National Cancer Institute Method Research Articles

Estimating the dietary and health impact of implementing front-of-pack nutrition labeling in Canada: A macrosimulation modeling study.

Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy diets. Health Canada has recently published FOPL regulations that will require food and beverages that meet or exceed set thresholds for sodium, sugars, or saturated fat to display a 'high in' symbol on the front of the package. Although a promising measure, its potential impact on dietary intakes and health have not yet been estimated in Canada. This study aims to estimate (1) the potential dietary impact of implementing a mandatory FOPL among Canadian adults; and (2) the number of diet-related non-communicable disease (NCD) deaths that could be averted or delayed due to these estimated dietary changes. Baseline and counterfactual usual intakes of sodium, total sugars, saturated fats, and calories were estimated among Canadian adults (n = 11,992) using both available days of 24 h recalls from the 2015 Canadian Community Health Survey-Nutrition. The National Cancer Institute method was used to estimate usual intakes, and adjusted for age, sex, misreporting status, weekend/weekday, and sequence of recall. Estimated counterfactual dietary intakes were modeled from reductions observed in experimental and observational studies that examined changes in sodium, sugars, saturated fat, and calorie content of food purchases in the presence of a 'high in' FOPL (four counterfactual scenarios). The Preventable Risk Integrated ModEl was used to estimate potential health impacts. Estimated mean dietary reductions were between 31 and 212 mg/day of sodium, 2.3 and 8.7 g/day of total sugars, 0.8 and 3.7 g/day of saturated fats, and 16 and 59 kcal/day of calories. Between 2,183 (95% UI 2,008-2,361) and 8,907 (95% UI 8,095-9,667) deaths due to diet-related NCDs, mostly from cardiovascular diseases (~70%), could potentially be averted or delayed by implementing a 'high in' FOPL in Canada. This estimation represents between 2.4 and 9.6% of the total number of diet-related NCD deaths in Canada. Results suggest that implementing a FOPL could significantly reduce sodium, total sugar, and saturated fat intakes among Canadian adults and subsequently prevent or postpone a substantial number of diet-related NCD deaths in Canada. These results provide critical evidence to inform policy decisions related to implementing FOPL in Canada.

Meeting the Healthy People 2030 Added Sugars Target

Many Americans exceed the dietary recommendations for added sugars. Healthy People 2030 set a population target mean of 11.5% calories from added sugars for persons aged ≥2 years. This paper describes the reductions needed in population groups with varying added sugars intake to meet this target using four different public health approaches. Data from the 2015-2018 National Health and Nutrition Examination Survey (n=15,038) and the National Cancer Institute method were used to estimate the usual percentage calories from added sugars. Four approaches investigated lowering intake among (1) the general U.S. population, (2) people exceeding the 2020-2025 Dietary Guidelines for Americans recommendation for added sugars (≥10% calories/day), (3) high consumers of added sugars (≥15% calories/day), or (4) people exceeding the Dietary Guidelines for Americans recommendation for added sugars with two different reductions on the basis of added sugars intake. Added sugars intake was examined before and after reduction by sociodemographic characteristics. To meet the Healthy People 2030 target using the 4 approaches, added sugars intake needs to decrease by an average of (1) 13.7 calories/day for the general population; (2) 22.0 calories/day for people exceeding the Dietary Guidelines for Americans recommendation; (3) 56.6 calories/day for high consumers; or (4) 13.9 and 32.3 calories/day for people consuming 10 to <15% and ≥15% calories from added sugars, respectively. Differences in added sugars intake were observed before and after reduction by race/ethnicity, age, and income. The Healthy People 2030 added sugars target is achievable with modest reductions in added sugars intake, ranging from 14 to 57 calories/day depending on the approach.

Low bioavailability of dietary iron among Brazilian children: Study in a representative sample from the Northeast, Southeast, and South regions.

Despite all efforts, iron deficiency anemia remains a serious public health problem among Brazilian children. To evaluate dietary iron intake and dietary practices that interfere with the absorption of this nutrient from three regions of Brazil. Brazil Kids Nutrition and Health Study is a cross-sectional dietary intake study in children aged 4-13.9 years old designed to investigate nutrient intakes and gaps of Brazilian children in a representative sample of households from Northeast, Southeast and South regions. Nutrient intake was assessed based on multiple-pass 24-h dietary recall and U.S. National Cancer Institute method was used to estimate usual micronutrients intakes and compliance with Dietary Reference Intakes. Five hundred sixteen individuals participated in the study (52.3% male). The top three most consumed food sources of iron were products of plant origin. Food sources of animal origin contributed with <20% of the total iron intake. Vitamin C intake was adequate, but the concomitant consumption of food sources of vitamin C with plant food sources of iron was not common. On the other hand, the concomitant intake of plant food sources of iron with food sources of iron chelators (e.g., coffee and teas) was frequent. Adequate iron intake was observed in all three regions in Brazil. Children's diet showed low iron bioavailability and insufficient consumption of food sources of iron absorption stimulants. Frequent presence of iron chelators and inhibitors of iron absorption might help to explain the high prevalence of iron deficiency in the country.

Dairy Food Consumption Is Associated with Reduced Risk of Heart Disease Mortality, but Not All-Cause and Cancer Mortality in US Adults.

Previous evidence has linked animal protein intake, including dairy foods, 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 total dairy consumption with mortality from all-causes, cancer, and heart disease. 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 usual intake for dairy foods 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 usual intakes of dairy. 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 animal protein. No associations were seen between dairy food intake and mortality risk from all-causes [HR = 0.97; confidence intervals (CI): 0.85-1.11; p = 0.67], and cancer [HR = 0.95; CI: 0.75-1.20; p = 0.65] when comparing the lowest quartile to the highest quartile of consumption. Dairy food consumption was associated with a 26% reduced risk for heart disease mortality when comparing the lowest quartile to the highest quartile [HR = 0.74; CI: 0.54-1.01; p = 0.05]. Further analyses in different age groups showed that dairy food consumption was associated with 39% and 31% reduced risk for heart disease mortality in older adults 51-70 and ≥51 y, respectively [adults 51-70 y: HR = 0.61; CI: 0.41-0.91; p = 0.01; adults ≥51 y: HR = 0.69; CI: 0.54-0.89; p = 0.004]. These results contradict previous findings that have linked dairy foods to increased mortality risk. Further, dairy foods as part of a healthy dietary pattern, may help lower heart disease mortality risk.

Dietary iron intake over two post-fortification periods in Brazil: data from the National Dietary Surveys 2008-2009 and 2017-2018.

We aimed to assess the dietary Fe intake and the prevalence of inadequate Fe intake over two post-fortification periods in Brazil. The intake was analysed according to sex, life stage, geographic region and stratum of family income per capita. Excluding pregnant and lactating women, this population-based study included 32749 and 44744 participants aged ≥ 10 years from the National Dietary Survey-Brazilian Household Budget Surveys 2008-2009 and 2017-2018, respectively. The National Cancer Institute method was used to predict usual dietary Fe intakes. The prevalence of Fe intake inadequacy was estimated following a probabilistic approach for women of childbearing age or with the Estimated Average Requirement cut-off point method. Over an interval of 10 years, the mean Fe intake remained almost unchanged for most sex-age groups, except for women of childbearing age. In this specific group, the prevalence of Fe intake inadequacy was > 20 % in 2008-2009 and have increased to > 25 % in 2017-2018, with the highest reductions in mean Fe intake found in the highest income strata and richest Brazilian regions. Meanwhile, the highest prevalence of Fe intake inadequacy (> 40 %) occurred among the poorest women aged 31-50 years from the lowest family income stratum, irrespective of the study period. Beans were the main Fe source, while fortified breads, pastas, pizzas, cakes and cookies contributed approximately 40 % of the Fe intake. The results provide important insights into the long-standing dietary impacts of food fortification, which can guide future (re)formulation of effective public health strategies to combat Fe deficiency.

Children and Adolescents in the United States with Usual High Added Sugars Intake: Characteristics, Eating Occasions, and Top Sources, 2015-2018.

Background: High consumption of added sugars is related to adverse health consequences. Objective: The objective of this study was to examine characteristics of US youth who report high intakes of added sugars, as well as the eating occasions and top sources of added sugars that contributed to intakes among consumers with high added sugars intake. Design and participants/setting: We conducted a cross-sectional study using 2015−2018 NHANES data among 5280 US youths (2−19 years). Main outcome measures: Outcome measure was usual percent of calories from added sugars using 2 days of dietary recall based on the National Cancer Institute method. High consumers were defined as consuming greater than 15% of total daily calorie intake from added sugars (1.5 times higher than the 2020−2025 Dietary Guidelines for Americans recommendation of <10% of total daily calorie intake). Explanatory measures were selected sociodemographics (e.g., age, sex, race/ethnicity). Eating occasions were breakfast, lunch, dinner, and snack. Statistical analyses performed: We used t-tests to compare mean differences between sociodemographic groups. Results: Overall, 34% of US youths were classified as high consumers of added sugars. The prevalence of high consumers of added sugars significantly varied by some sociodemographics (i.e., age, race/ethnicity, and head of household’s education level). The prevalence of high added sugars consumers was significantly greater among 12−19-year-olds (41%) and 6−11-year-olds (37%) compared to 2−5-year-olds (19%), non-Hispanic Black (42%) and non-Hispanic White (42%) persons compared to Hispanic persons (19%), and those with a head of household’s education level of high school/some college (40%) compared to households with college degree or higher (29%). The prevalence of high consumers did not differ by sex, income, or weight status. Of eating occasions, the amount of added sugars youths consumed was highest during snack occasions among high consumers. Top five sources of added sugars among high consumers on a given day were sweetened beverages, sweet bakery products, candy, other desserts, and ready-to-eat cereals. Conclusion: One in three US youths consumed more than 15% of total calories from added sugars. High added sugars intake was more prevalent among certain subgroups such as 12−19-year-olds and non-Hispanic Black or non-Hispanic White youth. Our findings can provide information for intervention efforts to decrease added sugars intake to promote child health.

Adding Walnuts to the Usual Diet Can Improve Diet Quality in the United States: Diet Modeling Study Based on NHANES 2015-2018.

The under-consumption of calcium, potassium, fiber, and vitamin D is considered a U.S. public health concern. Shifts in eating patterns that increase the consumption of vegetables, fruits, whole grains, nuts/seeds, and dairy products can help achieve the recommended intakes of these nutrients, leading to healthier diets. We assessed the impact of adding 1 ounce (28.35 g) of walnuts to usual diets on diet quality and nutrients of concern, including magnesium, fiber, and potassium. We utilized 24 h dietary recalls obtained from the What We Eat in America, National Health and Nutrition Examination Survey (NHANES) and modeled the addition of 1 ounce (28.35 g) of walnuts to the usual diets of no-nut consumers. No-nut consumers aged ≥4 years (n = 7757) from the 2015-2018 NHANES study were included. Population percentages with intakes below the estimated average requirement (EAR) values for calcium, magnesium, folate, and vitamin E and above the adequate intake (AI) values for potassium and fiber were examined. Diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015). The National Cancer Institute method was used to estimate the usual and modeled intakes. Significant differences between usual (current) and modeled intakes were determined using non-overlapping 95% confidence intervals. All analyses included sample weights to account for the NHANES survey design. Adding 1 ounce (28.35 g) of walnuts to the usual diet resulted in significant reductions in the percentages of adults with intakes below the EAR for magnesium and folate (69.6% vs. 52.0%; 49.2% vs. 40.6%, respectively), and increased the percentage of adults above the AI for potassium (22.8% vs. 26.5%). A similar trend was observed among children (4-18 years). HEI scores improved significantly from 49.1 (95% CI: 48.0-50.4) to 58.5 (95% CI: 57.5-59.6) in children and from 52.4 (95% CI: 51.0-53.8) to 59.2 (95% CI: 58.0-60.5) in adults. Adding 1 ounce (28.35 g) of walnuts to the usual diet of no-nut consumers improved the diet quality and adequacy of some under-consumed nutrients.

High Added Sugars Intake among US Adults: Characteristics, Eating Occasions, and Top Sources, 2015-2018.

The 2020−2025 Dietary Guidelines for Americans (DGA) recommends less than 10% of total daily calories come from added sugars. However, many adults overconsume added sugars putting them at risk for poor health outcomes. We examined characteristics of high added sugars consumers among US adults (≥20 years) and described their top 10 sources of added sugars intake using National Health and Nutrition Examination Survey 2015−2018 data (n = 9647). We defined high consumers as consuming >15% of daily calories from added sugars (1.5 times higher than the DGA). We used the National Cancer Institute method to estimate usual intake of energy and percent of calories from added sugars. Top 10 sources were identified based on their percentage contribution to total added sugars intake on a given day. T-tests were used to examine differences by age, sex, race/ethnicity, education, income, marital status, and weight status. Overall, mean usual total energy intake and added sugars intake was 2068 kcal/day and 264 kcal/day, respectively, and 30% of adults were classified as high consumers. The prevalence of high added sugars consumers was significantly higher among 20−30-year-olds (29%), 31−50-year-olds (33%), and 51−70-year-olds (29%) than those aged ≥70 years (22%); non-Hispanic Black (39%) and non-Hispanic White (31%) adults than Hispanics (26%); adults with <high school (37%), high school/GED (38%), or some college (34%) than adults with college or higher (15%); adults living in lower-income households (39% for federal poverty income ratio < 130% and 35% for 130%−<350%) than high-income households (21%). The prevalence of high consumers did not differ by sex or weight status. Top sources of added sugars were sweetened beverages (42%), tea (12%), sweet bakery products (11%), and jams/syrups/sugars (7%). Our findings can inform intervention efforts to decrease added sugars intake to support health.

Effect of Animal Protein Intake on Meeting Recommendations for Nutrient Intake among US Adults, What We Eat in America, NHANES 2015–2018

BackgroundReplacing some animal sources of protein with plant foods is encouraged. Nutrient intake may reflect changes in the protein source. The adequacy of habitual nutrient intake among US adults has not been evaluated by the level of animal protein (AP) intake. ObjectivesThe objective of this study was to compare food consumption and nutrient intake and adequacy among quintiles of percent AP intake. MethodsDietary intake data of adults 19+ y (N = 9706) from What We Eat in America, National Health and Nutrition Examination Survey 2015–2018 were used. Proportions of protein from animal and plant sources were estimated from ingredients in the Food and Nutrient Database for Dietary Studies 2015–2018, and then applied to dietary intakes. Intakes were classified by Q of percent AP. Food intake was described using the United States Department of Agriculture Food Patterns components. Usual nutrient intakes were estimated using the National Cancer Institute Method and compared with age and gender-specific Dietary Reference Intakes (DRIs). Comparisons between quintiles were made using t-tests. Results were considered significant at P < 0.01. ResultsTotal protein intake was higher as the Q of AP intake increased. Among the higher quintiles of percent AP, <1% did not meet their DRIs for protein than 17% in Q1 and 5% in Q2 (P < 0.01). In quintiles with lower compared with higher percent AP, there were significantly higher percentages not meeting DRIs for vitamins A, B12, choline, zinc, and calcium but meeting recommendations for folate, vitamin C, saturated fat, cholesterol, and fiber (P < 0.01). Among all quintiles, over one-third did not meet DRIs for fiber, vitamins A, C, D, E, K, choline, calcium, and potassium. ConclusionsReplacing protein from animal sources with plant foods may result in lower intakes of protein and some nutrients but a better intake of dietary components associated with reducing chronic disease risk. The current intake of US adults indicates dietary improvements are needed, regardless of protein source.

Dietary inadequacies overestimate the blood deficiencies of magnesium, zinc, and vitamins A, C, E, and D among residents of Sao Paulo

We aimed to estimate the prevalence of the inadequate intake and status of magnesium, zinc, and vitamins A, C, E, and D and identify factors associated with micronutrient deficiency in serum/plasma among residents of São Paulo, Brazil. Data from 824 individuals aged ≥14 years were obtained from the 2015 ISA-Nutrition, a population-based, cross-sectional survey. Dietary and supplement intakes were assessed using two 24-h dietary recalls, and the micronutrient inadequacies were estimated using the National Cancer Institute method. Micronutrient status was measured in serum or plasma, and deficiency was established according to the lower limit of the reference values. Receiver operating characteristic curve analysis was used to identify the effect of intake on the micronutrient status in serum/plasma. Logistic regression analysis was applied to assess the association between micronutrient status and individual characteristics. More than 80% of the population had an inadequate dietary intake of magnesium, vitamin E, and vitamin D. Males had a high prevalence of inadequate dietary intake of vitamin A and zinc. A high-to-moderate prevalence of inadequate vitamin C intake was observed. Vitamin D was the only nutrient with a deficient status comparable to its dietary inadequacy. The other nutrients demonstrated a lower deficiency prevalence compared to dietary inadequacy, and vitamin A demonstrated the lowest prevalence of deficiency in plasma. Generally, dietary intake showed a non-notable association with micronutrient deficiency in serum/plasma. Individuals with fasting glucose concentrations ≥100mg/dL and those using diuretic drugs had a higher risk of serum magnesium deficiency. Those using lipid-lowering drugs and those with high plasma adiponectin concentrations had a higher risk of serum zinc deficiency. Individuals who smoked and those with hypertension showed a higher risk of plasma vitamin C deficiency. Individuals with average leptin concentrations had a higher risk of plasma vitamin E deficiency. Finally, those with sufficient leisure-time physical activity had a lower risk of serum vitamin D deficiency. Residents of the urban areas of São Paulo demonstrated substantially inadequate intakes of most of the assessed micronutrients; however, micronutrient deficiency in serum/plasma was not associated with dietary inadequacy, and it usually demonstrated a lower prevalence than dietary indicators. Thus, using micronutrient intake to determine the serum/plasma profile should be done with caution. The status of the micronutrients varied according to individual characteristics, indicating the interplay of complex mechanisms underlying micronutrient balance.

An ensemble method based on marginal-effect models (EMM) for estimating usual food intake from single-day dietary data and internal/external two-day dietary data.

With collection of repeated 24-hour recalls, there exist challenges in usual intake estimation, including infeasibility of multiple dietary assessments, and shortage of non-zero intakes for episodically consumed foods. We developed an ensemble method based on marginal-effect models (EMM), which estimates usual intake distribution using single-day data with internal or external two-day data. The performance of the EMM was evaluated and compared with the National Cancer Institute (NCI) method and NCI 1-d method, via simulations with various scenarios and real data analyses of red meat, fish, and protein from Korea National Health and Nutrition Examination Survey (KNHANES). Simulations indicated the EMM (maximum bias of 1.67, 3.17, 8.57, 11.63 for average, median, 75%-tile, 95%-tile, respectively) provided more accurate estimation than the NCI method (maximum bias of 4.18, 9.43, 7.56, 37.43) across various scenarios on intake probability and within-person variation. The EMM showed robust estimation when an insufficient number of people have positive consumption on two days. In simulations with various external variance ratios, the EMM showed similar or superior performance to the NCI 1-d method. The EMM produced more stable estimates of usual intake distributions for red meat, fish, and protein than the two NCI methods. The proposed EMM showed substantial improvement over the NCI methods when data contain a relatively small number of people with positive consumption on two days; is robust when food intake probability is very low or high; and estimates an external variance ratio with relatively low bias.

Usual Intake of Micronutrients and Prevalence of Inadequate Intake among Chinese Adults: Data from CNHS 2015-2017.

Previous studies have used the traditional average-value method to calculate the usual dietary intake of a population, but the results may be biased due to the measurement errors. The aim of this study was to provide an assessment of the usual micronutrient intake and estimate the prevalence of inadequate intake among Chinese adults. Data from the Chinese Nutrition and Health Surveillance 2015-2017 as well as a total of 72,231 subjects aged 18 years and older were included in the analysis. The 24 h recall method combined with the condiment weighing method were used for three consecutive days to collect daily food and condiments intake. The daily intake of 16 micronutrients was calculated based on the Chinese Food Component Tables. The National Cancer Institute (NCI) method was used to estimate the usual intake of micronutrients, and the prevalence of inadequate intake was estimated using the estimated average requirement (EAR) cut-point method. The results showed that, except for sodium, copper, iron (only for males), vitamin E, and phosphorus, the usual intake of micronutrients in Chinese adults was low, and the prevalence of inadequate intake ranged from 38.67 to 97.63%. The prevalence of inadequate calcium and riboflavin intake was more than 90%, and the proportion of individuals with a usual intake of thiamine, vitamin A, potassium, and selenium below EAR also reached 80%. Manganese, magnesium, vitamin C, and zinc were potentially deficient micronutrients, with the prevalence of inadequate intake ranging from 38.67% to 77.09%. However, usual sodium intake was extremely high with an average of 5139.61 mg/day, and only a quarter of Chinese adults were below the World Health Organization (WHO) recommended value. For most micronutrients, the usual dietary intake declined with age and the prevalence of inadequate intake increased with age. Except for zinc, vitamin A, and B-vitamins, the prevalence of micronutrient deficiencies was higher in females than in males in the same age group (p &lt; 0.05). Therefore, Chinese adults do not receive enough micronutrients. Effective nutrition supplementary strategies and measures are needed to address these problems.

Advanced Dietary Analysis and Modeling: A Deep Dive into the National Cancer Institute Method

The National Cancer Institute (NCI) method has been used widely by researchers to make inferences about usual dietary intake distributions of foods and nutrients based on a limited number of 24-h dietary recalls (24-HRs). Although the NCI method does not provide individual estimates of usual intake, it can be used to address many research questions, including modeling effects of nutrition interventions on population distributions of usual intake. Software for implementing the NCI method, and corresponding code examples, is publicly available in the form of SAS macros but little formal guidance exists for conducting advanced analyses. We aim to present advanced techniques for working with NCI macros to conduct both basic and advanced dietary analyses and modeling. We first present the 3 basic building blocks of analyses using the NCI method: 1) data set preparation, 2) application of the MIXTRAN macro to estimate parameters of the usual intake distribution, including effects of covariates, after transformation of 24-HRs to approximate normality, and 3) application of the DISTRIB macro to estimate the distribution of usual nutrient intake. Then, we illustrate how researchers can employ these building blocks to answer questions beyond typical descriptive analyses. Researchers can adapt the building blocks to: 1) account for factors such as demographic changes or nutrition interventions such as food fortification, 2) estimate the prevalence of dietary inadequacy via the full probability method, 3) incorporate nutrient intake from sources not always captured by 24-HRs, such as dietary supplements and human milk, and 4) carry out multiple subgroup analyses. This article describes the theoretical basis and operational guidance for these techniques. With this article as a detailed resource, researchers can leverage the basic NCI building blocks to investigate a wide range of questions about usual dietary intake distribution.

Usual nutrient intake and dietary quality of low‐income U.S. older adults

AbstractWe estimate nutrient intake from diet and total sources including dietary supplements (DS), and dietary quality of low‐income U.S. older adults (60+ years) using the 2007–2016 National Health and Nutrition Examination Survey. We apply the National Cancer Institute method to determine usual/habitual nutrient intake distributions. Our results reveal that low‐income older adults have poor nutrient intake and dietary quality. DS use reduces the risk of nutrient inadequacy but is not associated with statistically significantly better dietary quality. Future policies that would change access to nutrients through DS should consider the current DS contributions to nutrient intake among the low‐income, older population.

Prediabetes awareness is not associated with lower consumption of self-reported added sugar in U.S. adults

AimsAdults aware of having prediabetes report engaging in dietary risk-reduction behavior changes. However, no studies have assessed if prediabetes awareness influences self-reported consumption of added sugar. MethodsCross-sectional data from 3314 adults, 20 years and older, with prediabetes were analyzed from 2013-2018 National Health and Nutrition Examination Survey data. Survey-weighted ordinary least squares regression was used to test whether prediabetes awareness was associated with usual intake of added sugar (g/day) using the National Cancer Institute Method by age, sex, and race/Hispanic origin after controlling for sociodemographic covariates. ResultsAmong 3314 adults with prediabetes, 528 reported being aware and 2786 reported being unaware of their condition. Prediabetes awareness was not significantly associated with added sugar consumption (estimated difference 1.7 g; 95% CI: - .80, 4.20; P = .18). There were no significant differences in added sugar consumption among those aware of their condition for age, sex, or race/Hispanic origin (Type 3 test for age: P = .15, male: P = .86, race, and Hispanic origin: P = .89). ConclusionAdults with prediabetes, aware of their condition, do not consume significantly lower quantities of added sugar compared to unaware adults, including no differences observed by age, sex, and race/Hispanic origin.

A Preliminary Study on a Form of the 24-h Recall That Balances Survey Cost and Accuracy, Based on the NCI Method.

The 24-h recall (24HR) is a short-term dietary assessment instrument that is widely used in large-scale nutrition surveys. The number of survey days is critical in the accuracy of estimates. The multiple, repeated collection of 24HRs can yield reliable dietary intakes, whereas that is not always feasible due to staffing, equipment, financial, and temporal constraints. The NCI (National Cancer Institute) method was developed to address this limitation by using only within-person variance to calculate usual dietary intake. However, the performance of different forms of 24HRs based on the NCI method remains unclear. The aim of this study was to explore a form of 24HR based on the NCI method that can balance accuracy and survey cost. A total of 595 subjects completed 7 consecutive 24HRs in each season, for a total of 28 24HRs. The averages of the 28 collection days were defined as the reference value to compare the performance of 24HRs for two consecutive days (C2), three consecutive days (C3), two non-consecutive days (NC2), and three non-consecutive days (NC3) for estimating the dietary intakes of Chinese adults. The equivalence test was used to evaluate whether the estimates of scenarios NC2 and NC3 were equivalent. Additionally, the accuracy of a scenario of NC2 which included a weekend was compared to that of a scenario of NC2 which included two weekdays. All results of the 24HRs in each scenario were corrected by the NCI method. Bias/relative bias and mean bias/mean relative bias were used as measures of precision and accuracy, respectively. The results showed that the precision was similar among the four scenarios, while the accuracy relationship varied among the different dietary components. In general, scenario NC3 was the most accurate, followed by scenario NC2, which was close to the former. The form using non-consecutive days was more accurate than that using consecutive days, and the main factor affecting the accuracy of the 24HRs was the continuity between multiple survey days rather than the number of days. The means and major percentiles of energy, nutrients, and frequently consumed food in scenarios NC2 and NC3 were functionally identical. The accuracy of the scenario of NC2 which included a weekend was higher than that of scenario NC2, which consisted of only weekdays. The above results indicated that the adoption of two, non-consecutive 24HRs consisting of a weekend and a weekday to collect dietary data prior to correction by the NCI method, is a feasible approach to balancing survey costs and accuracy in large-scale nutrition surveys.

Decreased Vitamin C Intake from Food and Supplements in the US Pregnant and Non-Pregnant Population: From NHANES 1999–2018

ObjectivesTo examine how vitamin C intake among women of reproductive age changed from 1999 to 2018 using data from 10 cycles of the National Health and Nutrition Examination Survey (NHANES) from 1999–2000 to 2017–2018.MethodsUsual vitamin C intake and prevalence of inadequate intake were estimated among pregnant and non-pregnant women 20–44 y who participated in NHANES 1999–2018 (n = 11,129), using the National Cancer Institute Method. Covariates included dietary recall sequence, intake day of the week, and dietary supplement use. Regression models were used to test for trends in vitamin c intake from foods, supplements, foods and supplements combined, and prevalence of inadequate vitamin C intake over 10 cycles of NHANES.Results1,392 were pregnant at the time of the exam. Vitamin C intake from foods alone in pregnant women decreased from 125 ± 6.7 mg in 1999–2000 to 103 ± 5.3 mg in 2017–2018 (p for trend = .0003). Supplemental vitamin c intake among pregnant women decreased from 140 ± 2.8 mg in 1999–2000 to 56 ± 0.9 mg in 2009–2010, followed by an apparent plateau between 2011–2018 (p for trend = .02). Consequently, intake foods and supplements combined decreased from 265 ± 31.9 mg in 1999–2000 to 158 ± 16.7 mg in 2017–2018 (p for trend = .0001). Inadequate intake (% < EAR) increased from 10.5 ± 2.2% in 2001–2002 to 17.2 ± 3.1% in 2017–2018 (p for trend = .015). Vitamin C intake from foods alone in non-pregnant women (n = 9,737) decreased from 84 ± 3.9 mg in 1999–2000 to 71 ± 2.5 mg in 2017–2018 (p for trend < .0001). Supplemental vitamin C intake among non-pregnant women decreased from 101 ± 1.3 mg in 1999–2000 to 41 ± 0.5 mg in 2009–2010 followed by an increase to 86 ± 2.7 mg in 2017–2018 (p for trend = .0075). Consequently, intake from foods and supplements combined decreased from 186 ± 15.4 mg in 1999–2000 to 119 ± 5.9 mg in 2009–2010 followed by an increase to 157 ± 28.4 mg in 2017–2018 (p for trend = .0045). Inadequate intake increased from 27.5 ± 2.5% in 1999–2000 to 38.6 ± 2.4% in 2017–2018 (p for trend < .0001).ConclusionsOver the past 2 decades, decreases in vitamin C intake from foods has outpaced the more recent increases in supplemental vitamin C intake among women 20–44 y. Pregnant women's vitamin C intake from both foods and supplements decreased during this time, which may result in an increased risk of infections, premature birth, and eclampsia.Funding SourcesFunded by the Reckitt|Mead Johnson Nutrition.

Lower Intakes of Key Nutrients Are Associated with More Workplace Absenteeism: NHANES 2003–2008

ObjectivesWhile the literature supports the importance of nutrition in physical health, the role of nutritional status, especially nutrient consumption, on work absenteeism in the United States population is largely unknown. The objective of this study was to determine whether dietary intake is associated with absenteeism in the workplace in US adults (19–64 years).MethodsData from NHANES 2003–08 cycles were used to estimate intakes of nutrients from food and food + supplements. Usual dietary intake was derived using the National Cancer Institute method with data from two valid 24-hr dietary recalls and a 30-day supplement use questionnaire. The mean of workplace absenteeism per year was estimated using negative binomial regression models with absenteeism data from the Medical Conditions Questionnaire.ResultsOut of 8,252 subjects, 3,919 reported missing workdays due to illness/injury (51%). The predicted mean of missed workdays was 4.79 days per year. Adults with absent days higher than 4.79 days had statistically significant lower intakes of nutrients including protein, vitamin E, thiamine, niacin, B6, folate, vitamin C, selenium, vitamin K, total choline, potassium, dietary fiber, alpha-Linolenic acid, alpha-carotene, and lycopene from food only. This association persisted for protein, selenium, vitamin K, total choline, potassium, dietary fiber, alpha-Linolenic acid, alpha-carotene, and lycopene when analyzed with usual intakes from both food and supplements.ConclusionsLower intakes of protein and several essential micronutrients are associated with higher workplace absenteeism due to illness/injury. This negative association may be corrected by increasing fortified foods and/or adding supplements. Future studies are needed to ascertain whether more nutrient intakes from food and supplements, particularly for nutrients not commonly found in the typical American diet or supplements, is an effective intervention to reduce workplace absenteeism to improve work productivity.Funding SourcesThis study was funded by Pharmavite LLC.

Adding Walnuts to the Diet of Children and Adolescents Improved the Diet Quality: Results of an NHANES Modeling Study

ObjectivesTo assess the impact of adding one ounce of walnuts on nutrients of public health concern and diet quality. MethodsFood modeling was implemented in the nationally representative 2015–2018 National Health and Examination Survey (NHANES) in a population of 4,756 children and adolescents of no-nut consumers. One ounce of walnuts was added to the usual dietary intake in this modeling study. The Healthy Eating Index-2015 was used as a summary measure of diet quality. Outcomes of interest were intakes of fiber, protein, potassium, folate, magnesium, and omega 3. Nutrient intake was analyzed using the National Cancer Institute method (NCI), while the HEI-2015 score was estimated using the population ratio method. Significant differences were determined using non-overlapping 95% CIs. ResultsHEI-2015 scores were significantly higher in Modeled diet compared to usual diets (58.5 ± 0.5 vs. 49.1 ± 0.6) out of 100 total points. Adding walnuts increased the energy density per 1,000 calories of the total protein, seafood and plant proteins, and polyunsaturated fatty acids, thus increasing the individual component HEI scores in these areas. Compared to usual diet, modeled diet significantly improved inadequacy for magnesium (48.3% to 34.6%), folate (28.3 to 22.0%), Copper (16.2%to 0.2%), and zinc (21.1% to 14.7%). Further, mean fiber intake significantly increased from 13.6 ± 0.2 to 15.4 ± 0.2 grams. ConclusionsPublic health messages targeted at no-nut consumers should emphasize the benefits of nut consumption, specifically walnuts, to improve diet quality. Further, adding walnuts to the diet improves the inadequacy of folate, magnesium, and trace minerals. Food pattern modeling using NHANES data can be used to assess nutritional impacts of compliance to current dietary guidance. Funding SourcesThis study was funded by the California Walnut Commission.

Increased Adherence to Added Sugars Recommendation Among Americans: What We Eat In America, NHANES, 2005–2008 and 2015–2018

ObjectivesThe Dietary Guidelines for Americans, 2020–2025 recommends limiting intake of added sugars to 10% of daily energy. This research presents results on the usual intake of added sugars among Americans by age and gender in 2005–2008 and 2015–2018.MethodsThe study included nationally representative data from children and adults ages 2 + years (y) participating in the What We Eat in America, National Health and Nutrition Examination Survey 2005–2008 (14,851 respondents) and 2015–2018 (16,588 respondents). Dietary intake data, obtained from in-person 24-hour recalls, were collected using an interviewer-administered 5-step USDA Automated Multiple-Pass Method. Added sugars (added in preparation, processing, or at table) were estimated using the USDA Food Patterns Equivalents Databases 2005–2008 and 2015–2018. Usual intake of added sugars and percentage of energy from added sugars were estimated from up to two 24-hour recalls using the National Cancer Institute Method. Age groups were: 2–5 y, 6–11 y, 12–19 y, 20–39 y, 40–59 y, and 60 + y; age groups 12 + y were separated by gender. A t test was used to compare results among age/gender groups and over time; statistical significance for differences was P < 0.01.ResultsThe mean usual intake of daily added sugars for respondents 2 + years old decreased from 19.2 ± 0.4 teaspoon equivalents (tsp eq) in 2005–2008 to 16.5 ± 0.3 tsp eq in 2015–2018. This corresponds to 27% and 36% of respondents consuming a usual intake of ≤ 10% of energy from added sugars in 2005–2008 and 2015–2018, respectively. Consumption of ≤ 10% of added sugars from energy significantly increased in the following groups: children 2–5 y and 6–11 y and males and females 20–39 y. In 2015–2018, a greater percentage of children 2–5 y (36%) consumed ≤ 10% of energy from added sugars than those 6–11 y (14%) and 12–19 y (males: 16%, females: 14%). For both males and females, a lesser percentage of 12–19 year-olds consumed ≤ 10% of energy as added sugars compared to older age groups (20 + y: 39 to 44%).ConclusionsOverall, almost two-thirds of Americans did not meet the recommendation to limit added sugars to 10% of energy. However, over a decade, an increase in adherence to the recommendation occurred in children 2–11 y and adults 20–39 y.Funding SourcesUS Department of Agriculture, Agricultural Research Service.