Objective: To design and develop a literature-derived, population-based dietary inflammatory index (DII) to compare diverse populations on the inflammatory potential of their diets. Design: Peer-reviewed primary research articles published through December 2010 on the effect of diet on inflammation were screened for possible inclusion in the DII scoring algorithm. Qualifying articles were scored according to whether each dietary parameter increased (+1), decreased (-1) or had no (0) effect on six inflammatory biomarkers: IL-1 beta, IL-4, IL-6, IL-10, TNF-alpha and C-reactive protein. Setting: The Dietary Inflammatory Index Development Study was conducted in the Cancer Prevention and Control Program of the University of South Carolina in Columbia, SC, USA from 2011 to 2012. Results: A total of approximate to 6500 articles published through December 2010 on the effect of dietary parameters on the six inflammatory markers were screened for inclusion in the DII scoring algorithm. Eleven food consumption data sets from countries around the world were identified that allowed individuals' intakes to be expressed relative to the range of intakes of the forty-five food parameters observed across these diverse populations. Qualifying articles (n 1943) were read and scored based on the forty-five pro-and anti-inflammatory food parameters identified in the search. When fit to this composite global database, the DII score of the maximally pro-inflammatory diet was +7.98, the maximally anti-inflammatory DII score was -8.87 and the median was +0.23. Conclusions: The DII reflects both a robust literature base and standardization of individual intakes to global referent values. The success of this first-of-a-kind attempt at relating intakes of inflammation-modulating foods relative to global norms sets the stage for use of the DII in a wide variety of epidemiological and clinical studies.
Objective: To update previous meta-analyses of cohort studies that investigated the association between the Mediterranean diet and health status and to utilize data coming from all of the cohort studies for proposing a literature-based adherence score to the Mediterranean diet. Design: We conducted a comprehensive literature search through all electronic databases up to June 2013. Setting: Cohort prospective studies investigating adherence to the Mediterranean diet and health outcomes. Cut-off values of food groups used to compute the adherence score were obtained. Subjects: The updated search was performed in an overall population of 4172 412 subjects, with eighteen recent studies that were not present in the previous meta-analyses. Results: A 2-point increase in adherence score to the Mediterranean diet was reported to determine an 8% reduction of overall mortality (relative risk = 0.92; 95% CI 0.91, 0.93), a 10% reduced risk of CVD (relative risk = 0.90; 95% CI 0.87, 0.92) and a 4% reduction of neoplastic disease (relative risk = 0.96; 95% CI 0.95, 0.97). We utilized data coming from all cohort studies available in the literature for proposing a literature-based adherence score. Such a score ranges from 0 (minimal adherence) to 18 (maximal adherence) points and includes three different categories of consumption for each food group composing the Mediterranean diet. Conclusions: The Mediterranean diet was found to be a healthy dietary pattern in terms of morbidity and mortality. By using data from the cohort studies we proposed a literature-based adherence score that can represent an easy tool for the estimation of adherence to the Mediterranean diet also at the individual level.
Given evident multiple threats to food systems and supplies, food security, human health and welfare, the living and physical world and the biosphere, the years 2016-2025 are now designated by the UN as the Decade of Nutrition, in support of the UN Sustainable Development Goals. For these initiatives to succeed, it is necessary to know which foods contribute to health and well-being, and which are unhealthy. The present commentary outlines the NOVA system of food classification based on the nature, extent and purpose of food processing. Evidence that NOVA effectively addresses the quality of diets and their impact on all forms of malnutrition, and also the sustainability of food systems, has now accumulated in a number of countries, as shown here. A singular feature of NOVA is its identification of ultra-processed food and drink products. These are not modified foods, but formulations mostly of cheap industrial sources of dietary energy and nutrients plus additives, using a series of processes (hence ultra-processed'). All together, they are energy-dense, high in unhealthy types of fat, refined starches, free sugars and salt, and poor sources of protein, dietary fibre and micronutrients. Ultra-processed products are made to be hyper-palatable and attractive, with long shelf-life, and able to be consumed anywhere, any time. Their formulation, presentation and marketing often promote overconsumption. Studies based on NOVA show that ultra-processed products now dominate the food supplies of various high-income countries and are increasingly pervasive in lower-middle- and upper-middle-income countries. The evidence so far shows that displacement of minimally processed foods and freshly prepared dishes and meals by ultra-processed products is associated with unhealthy dietary nutrient profiles and several diet-related non-communicable diseases. Ultra-processed products are also troublesome from social, cultural, economic, political and environmental points of view. We conclude that the ever-increasing production and consumption of these products is a world crisis, to be confronted, checked and reversed as part of the work of the UN Sustainable Development Goals and its Decade of Nutrition.
Objective: To present the Mediterranean diet (MD) pyramid: a lifestyle for today. Design: A new graphic representation has been conceived as a simplified main frame to be adapted to the different nutritional and socio-economic contexts of the Mediterranean region. This review gathers updated recommendations considering the lifestyle, dietary, sociocultural, environmental and health challenges that the current Mediterranean populations are facing. Setting and Subjects: Mediterranean region and its populations. Results: Many innovations have arisen since previous graphical representations of the MD. First, the concept of composition of the 'main meals' is introduced to reinforce the plant-based core of the dietary pattern. Second, frugality and moderation is emphasised because of the major public health challenge of obesity. Third, qualitative cultural and lifestyle elements are taken into account, such as conviviality, culinary activities, physical activity and adequate rest, along with proportion and frequency recommendations of food consumption. These innovations are made without omitting other items associated with the production, selection, processing and consumption of foods, such as seasonality, biodiversity, and traditional, local and eco-friendly products. Conclusions: Adopting a healthy lifestyle and preserving cultural elements should be considered in order to acquire all the benefits from the MD and preserve this cultural heritage. Considering the acknowledgment of the MD as an Intangible Cultural Heritage of Humanity by UNESCO (2010), and taking into account its contribution to health and general well-being, we hope to contribute to a much better adherence to this healthy dietary pattern and its way of life with this new graphic representation.
Objective: To perform construct validation of the population-based Dietary Inflammatory Index (DII) using dietary data from two different dietary assessments and serum high-sensitivity C-reactive protein (hs-CRP) as the construct validator. Design: Using data derived from (i) three 24 h dietary recalls (24HR) at baseline and at the end of each subsequent quarter (i. e. up to fifteen over a year) and (ii) a 7 d dietary recall (7DDR) measured at baseline and then quarterly, regression analyses were conducted to test the effect of the DII score on serum hs-CRP as dichotomous (3mg/l), while controlling for important potential confounders. Setting: Existing data from the Seasonal Variation of Blood Cholesterol Study (SEASONS), a longitudinal observational study of healthy participants recruited in Worcester, MA, USA and participants were followed for 1 year. Subjects: Participants who had at least one hs-CRP measurement over her/his 1-year participation (n 495 for 24HR, n 559 for 7DDR). Results: Higher DII scores were associated with values of hs-CRP >3mg/l (OR = 1.08; 95% CI 1.01, 1.16, P = 0.035 for the 24HR; and OR = 1.10; 95% CI 1.02, 1.19, P = 0.015 for the 7DDR). Conclusions: The population-based DII was associated with interval changes in hs-CRP using both the 24HR and 7DDR. The success of this first-of-a-kind attempt at relating individuals' intakes of inflammation-modulating foods using this refined DII, and the finding that there is virtually no drop-off in predictive capability using a structured questionnaire in comparison to the 24HR standard, sets the stage for use of the DII in a wide variety of other epidemiological and clinical studies.
Objective: To provide Current global and regional estimates of anaemia prevalence and number of persons affected in the total population and by population subgroup. Setting and design: We used anaemia prevalence data from the WHO Vitamin and Mineral Nutrition Information System for 1993-2005 to generate anaemia prevalence estimates for countries with data representative at the national level or at the first administrative level that is below the national level. For Countries without eligible data, we employed regression-based estimates, Which used the UN Human Development Index (HDI) and other health indicators. We combined country estimates, weighted by their Population, to estimate anaemia prevalence at the global level, by UN Regions and by category of human development. Results: Survey data covered 48-8% of the global Population, 76-1% of preschool- aged, children, 69-0% of pregnant women and 73-5% of non-pregnant women. e estimated global anaemia prevalence is 24-8% (95% C1 22-9, 26-7%), affecting 1-62 billion people (95% Cl 1-50, 1-74 billion). Estimated anaemia prevalence is 47-4% (95% CI 45-7, 49-10/6) in preschool-aged children, 41-8% (95% Cl 39-9, 43-8%) in pregnant women and 30-2% (95% CI 28-7, 31-6%) in non-pregnant women. In numbers, 293 million (95% CI 282, 303 million) preschool-aged children, 56 million (95 % Cl 54, 59 million) pregnant women and 468 million (95 % Cl 446, 491 million) non-pregnant women are affected. Conclusion: Anaemia affects one-quarter of the world's population and is concentrated in preschool-aged children and women, making it a global public health problem. Data on relative contributions of causal factors are lacking, however, which makes it difficult to effectively address the problem.
Objective: To review research on consumer use and understanding of nutrition labels, as well as the impact of labelling on dietary habits. Design: A systematic review was conducted by searching electronic databases. Relevant articles were screened by two reviewers and included if they met inclusion criteria, including eight methodological criteria. A total of 120 articles were included in the review, including cross-sectional surveys (n 96), experimental designs (n 17), 'natural experiments' (n 7) and longitudinal population-based surveys (n 2). Setting: Articles covered seven jurisdictions: USA (n 88), Europe (n 12), Canada (n 9), Australia and New Zealand (n 4), Norway (n 2), Thailand (n 1) and Trinidad (n 1). Subjects: Participants were from a wide range of age groups, socio-economic strata and geographical regions. Results: Nutrition labels on pre-packaged foods are among the most prominent sources of nutrition information. Nutrition labels are perceived as a highly credible source of information and many consumers use nutrition labels to guide their selection of food products. Evidence also shows a consistent link between the use of nutrition labels and healthier diets. However, the use of labels varies considerably across subgroups, with lower use among children, adolescents and older adults who are obese. Research also highlights challenges in terms of consumer understanding and appropriate use of labelling information. Conclusions: Nutrition labels on pre-packaged foods are a cost-effective population-level intervention with unparalleled reach. However, to capitalize on their potential, governments will need to explore new formats and different types of information content to ensure that nutrition information is accessible and understandable.
Objective: The US Food and Drug Administration and Institute of Medicine are currently investigating front-of-package (FOP) food labelling systems to provide science-based guidance to the food industry. The present paper reviews the literature on FOP labelling and supermarket shelf-labelling systems published or under review by February 2011 to inform current investigations and identify areas of future research. Design: A structured search was undertaken of research studies on consumer use, understanding of, preference for, perception of and behaviours relating to FOP/shelf labelling published between January 2004 and February 2011. Results: Twenty-eight studies from a structured search met inclusion criteria. Reviewed studies examined consumer preferences, understanding and use of different labelling systems as well as label impact on purchasing patterns and industry product reformulation. Conclusions: The findings indicate that the Multiple Traffic Light system has most consistently helped consumers identify healthier products; however, additional research on different labelling systems' abilities to influence consumer behaviour is needed.
Objective: To assess time trends in the contribution of processed foods to food purchases made by Brazilian households and to explore the potential impact on the overall quality of the diet. Design: Application of a new classification of foodstuffs based on extent and purpose of food processing to data collected by comparable probabilistic household budget surveys. The classification assigns foodstuffs to the following groups: unprocessed/minimally processed foods (Group 1); processed culinary ingredients (Group 2); or ultra-processed ready-to-eat or ready-to-heat food products (Group 3). Setting: Eleven metropolitan areas of Brazil. Subjects: Households; n 13 611 in 1987-8, n 16 014 in 1995-5 and n 13 848 in 2002-3. Results: Over the last three decades, the household consumption of Group 1 and Group 2 foods has been steadily replaced by consumption of Group 3 ultra-processed food products, both overall and in lower- and upper-income groups. In the 2002-3 survey, Group 3 items represented more than one-quarter of total energy (more than one-third for higher-income households). The overall nutrient profile of Group 3 items, compared with that of Group 1 and Group 2 items, revealed more added sugar, more saturated fat, more sodium, less fibre and much higher energy density. Conclusions: The high energy density and the unfavourable nutrition profiling of Group 3 food products, and also their potential harmful effects on eating and drinking behaviours, indicate that governments and health authorities should use all possible methods, including legislation and statutory regulation, to halt and reverse the replacement of minimally processed foods and processed culinary ingredients by ultra-processed food products.
Objective: To investigate consumption of ultra-processed products in Canada and to assess their association with dietary quality. Design: Application of a classification of foodstuffs based on the nature, extent and purpose of food processing to data from a national household food budget survey. Foods are classified as unprocessed/minimally processed foods (Group 1), processed culinary ingredients (Group 2) or ultra-processed products (Group 3). Setting: All provinces and territories of Canada, 2001. Subjects: Households (n 5643). Results: Food purchases provided a mean per capita energy availability of 8908 (SE 81) kJ/d (2129 (SE 19) kcal/d). Over 61.7% of dietary energy came from ultra-processed products (Group 3), 25.6% from Group 1 and 12.7% from Group 2. The overall diet exceeded WHO upper limits for fat, saturated fat, free sugars and Na density, with less fibre than recommended. It also exceeded the average energy density target of the World Cancer Research Fund/American Institute for Cancer Research. Group 3 products taken together are more fatty, sugary, salty and energy-dense than a combination of Group 1 and Group 2 items. Only the 20% lowest consumers of ultra-processed products (who consumed 33.2% of energy from these products) were anywhere near reaching all nutrient goals for the prevention of obesity and chronic non-communicable diseases. Conclusions: The 2001 Canadian diet was dominated by ultra-processed products. As a group, these products are unhealthy. The present analysis indicates that any substantial improvement of the diet would involve much lower consumption of ultra-processed products and much higher consumption of meals and dishes prepared from minimally processed foods and processed culinary ingredients.
Objective: To compare the relative validity of food group intakes derived from a comprehensive self-administered diet history questionnaire (DHQ) and a brief-type DHQ (BDHQ) developed for the assessment of Japanese diets during the previous month using semi-weighed dietary records (DR) as a reference method. Design: Between November 2002 and September 2003, a 4 d DR (covering four non-consecutive days), a DHQ (150-item semi-quantitative questionnaire) and a BDHQ (fifty-eight-item fixed-portion-type questionnaire) were completed four times (once per season) at 3-month intervals. Setting: Three areas in Japan: Osaka, Nagano and Tottori. Subjects: Ninety-two Japanese women aged 31-69 years and ninety-two Japanese men aged 32-76 years. Results: Median food group intakes were estimated well for approximately half of the food groups. No statistically significant differences were noted between a 16 d DR and the first DHQ (DHQ1) or between the DR and the first BDHQ (BDHQ1) in fifteen (44%) and fifteen (52%) food items for women and in fourteen (41%) and sixteen (55%) food items for men, respectively, indicating that both questionnaires estimated median values reasonably well. Median Spearman's correlation coefficients with the DR were 0.43 (range: -0.09 to 0.77) for DHQ1 and 0.44 (range: 0.14 to 0.82) for BDHQ1 in women, with respective values of 0.44 (range: 0.08 to 0.87) and 0.48 (range: 0.22 to 0.83) in men, indicating reasonable ranking ability. Similar results were observed for mean values of the four DHQ and BDHQ. Conclusions: In terms of food intake estimates, both the DHQ and the BDHQ showed reasonable validity.
Objective: To quantify the prevalence and trends of stunting among children using the WHO growth standards. Design: Five hundred and seventy-six nationally representative surveys, including anthropometric data, were analysed. Stunting was defined as the proportion of children below -2SD from the WHO length- or height-for-age standards median. Linear mixed-effects modelling was used to estimate rates and numbers of affected children from 1990 to 2010, and projections to 2020. Setting: One hundred and forty-eight developed and developing countries. Subjects: Boys and girls from birth to 60 months. Results: In 2010, it is estimated that 171 million children (167 million in developing countries) were stunted. Globally, childhood stunting decreased from 39.7 (95% CI 38.1, 41.4) % in 1990 to 26.7 (95% CI 24.8, 28.7) % in 2010. This trend is expected to reach 21.8 (95% CI 19.8, 23.8) %, or 142 million, in 2020. While in Africa stunting has stagnated since 1990 at about 40% and little improvement is anticipated, Asia showed a dramatic decrease from 49% in 1990 to 28% in 2010, nearly halving the number of stunted children from 190 million to 100 million. It is anticipated that this trend will continue and that in 2020 Asia and Africa will have similar numbers of stunted children (68 million and 64 million, respectively). Rates are much lower (14% or 7 million in 2010) in Latin America. Conclusions: Despite an overall decrease in developing countries, stunting remains a major public health problem in many of them. The data summarize progress achieved in the last two decades and help identify regions needing effective interventions.
Objective To examine and quantify the potential dose-response relationship between red and processed meat consumption and risk of all-cause, cardiovascular and cancer mortality. Design We searched MEDLINE, Embase, ISI Web of Knowledge, CINHAL, Scopus, the Cochrane library and reference lists of retrieved articles up to 30 November 2014 without language restrictions. We retrieved prospective cohort studies that reported risk estimates for all-cause, cardiovascular and cancer mortality by red and/or processed meat intake levels. The dose-response relationships were estimated using data from red and processed meat intake categories in each study. Random-effects models were used to calculate pooled relative risks and 95 % confidence intervals and to incorporate between-study variations. Results Nine articles with seventeen prospective cohorts were eligible in this meta-analysis, including a total of 150 328 deaths. There was evidence of a non-linear association between processed meat consumption and risk of all-cause and cardiovascular mortality, but not for cancer mortality. For processed meat, the pooled relative risk with an increase of one serving per day was 115 (95 % CI 111, 119) for all-cause mortality (five studies; P<0001 for linear trend), 115 (95 % CI 107, 124) for cardiovascular mortality (six studies; P<0001) and 108 (95 % CI 106, 111) for cancer mortality (five studies; P<0001). Similar associations were found with total meat intake. The association between unprocessed red meat consumption and mortality risk was found in the US populations, but not in European or Asian populations. Conclusions The present meta-analysis indicates that higher consumption of total red meat and processed meat is associated with an increased risk of total, cardiovascular and cancer mortality.
Objectives: To review associations between the family environment and young people's fruit and vegetable consumption. Design: A systematic review. Published English-language (n 60) papers were identified using electronic databases and manual searches of personal files and reference lists. Observational research reporting a measure of fruit/vegetable intake for children (aged 6-11 years) and/or adolescents (aged 12-18 years) and at least one potential family correlate of dietary intake was included. Results: Parental modelling and parental intake were consistently and positively associated with children's fruit and fruit, juice and vegetable (FJV) consumption. There were also positive associations between home availability, family rules and parental encouragement and children's fruit and vegetable consumption. Parental intake was positively associated with adolescents' fruit and vegetable consumption. There were also positive associations between parental occupational status and adolescent fruit consumption and between parental education and adolescents' FJV consumption. Conclusions: Our findings highlight the importance of targeting the family environment for the promotion of healthy eating behaviours among children and adolescents. Future interventions Should encourage parents to be positive role models by targeting parental intake and to create a supportive home environment through increased encouragement and availability of fruits and vegetables and employing rules to govern eating behaviours. For adolescents, indicators of family circumstances (e.g. parental education) should be used to identify target groups for interventions aimed at promoting healthy eating.
Objective: To describe the worldwide implementation of the WHO Child Growth Standards ('WHO standards'). Design: A questionnaire on the adoption of the WHO standards was sent to health authorities. The questions concerned anthropometric indicators adopted, newly introduced indicators, age range, use of sex-specific charts, previously used references, classification system, activities undertaken to roll out the standards and reasons for non-adoption. Setting: Worldwide. Subjects: Two hundred and nineteen countries and territories. Results: By April 2011, 125 countries had adopted the WHO standards, another twenty-five were considering their adoption and thirty had not adopted them. Preference for local references was the main reason for non-adoption. Weight-forage was adopted almost universally, followed by length/height-for-age (104 countries) and weight-for-length/height (eighty-eight countries). Several countries (thirty-six) reported newly introducing BMI-for-age. Most countries opted for sex-specific charts and the Z-score classification. Many redesigned their child health records and updated recommendations on infant feeding, immunization and other health messages. About two-thirds reported incorporating the standards into pre-service training. Other activities ranged from incorporating the standards into computerized information systems, to providing supplies of anthropometric equipment and mobilizing resources for the standards' roll-out. Conclusions: Five years after their release, the WHO standards have been widely scrutinized and implemented. Countries have adopted and harmonized best practices in child growth assessment and established the breast-fed infant as the norm against which to assess compliance with children's right to achieve their full genetic growth potential.
Objective: To characterize the trends, distribution, potential determinants and public health implications of meat consumption within the USA. Design: We examined temporal trends in meat consumption using food availability data from the FAO and US Department of Agriculture (USDA), and further evaluated the meat intake by type (red, white, processed) in the National Health and Nutrition Examination Surveys (NHANES) linked to the MyPyramid Equivalents Database (MPED). Results: Overall meat consumption has continued to rise in the USA and the rest of the developed world. Despite a shift towards higher poultry consumption, red meat still represents the largest proportion of meat consumed in the USA (58%). Twenty-two per cent of the meat consumed in the USA is processed. According to the NHANES 2003-2004, total meat intake averaged 128 g/d. The type and quantities of meat reported varied by education, race, age and gender. Conclusions: Given the plausible epidemiological evidence for red and processed meat intake in cancer and chronic disease risk, understanding the trends and determinants of meat consumption in the USA, where meat is consumed at more than three times the global average, should be particularly pertinent to researchers and other public health professionals aiming to reduce the global burden of chronic disease.
Objective: To present and discuss the dietary guidelines issued by the Brazilian government in 2014. Design: The present paper describes the aims of the guidelines, their shaping principles and the approach used in the development of recommendations. The main recommendations are outlined, their significance for the cultural, socioeconomic and environmental aspects of sustainability is discussed, and their application to other countries is considered. Setting: Brazil in the twenty-first century. Subjects: All people in Brazil, now and in future. Results: The food- and meal-based Brazilian Dietary Guidelines address dietary patterns as a whole and so are different from nutrient-based guidelines, even those with some recommendations on specific foods or food groups. The guidelines are based on explicit principles. They take mental and emotional well-being into account, as well as physical health and disease prevention. They identify diet as having cultural, socio-economic and environmental as well as biological and behavioural dimensions. They emphasize the benefits of dietary patterns based on a variety of natural or minimally processed foods, mostly plants, and freshly prepared meals eaten in company, for health, well-being and all relevant aspects of sustainability, as well as the multiple negative effects of ready-to-consume ultra-processed food and drink products. Conclusions: The guidelines' recommendations are designed to be sustainable personally, culturally, socially, economically and environmentally, and thus fit to face this century. They are for foods, meals and dietary patterns of types that are already established in Brazil, which can be adapted to suit the climate, terrain and customs of all countries.
Objective: Results of studies on fish consumption and CHD mortality are inconsistent. The present updated meta-analysis was conducted to investigate the up-to-date pooling effects. Design: A random-effects model was used to pool the risk estimates. Generalized least-squares regression and restricted cubic splines were used to assess the possible dose-response relationship. Subgroup analyses were conducted to examine the sources of heterogeneity. Setting: PubMed and ISI Web of Science databases up to September 2010 were searched and secondary referencing qualified for inclusion in the study. Subjects: Seventeen cohorts with 315 812 participants and average follow-up period of 15.9 years were identified. Results: Compared with the lowest fish intake (5 servings/week). The dose-response analysis indicated that every 15 g/d increment of fish intake decreased the risk of CHD mortality by 6% (RR = 0.94; 95% CI 0.90, 0.98). The method of dietary assessment, gender and energy adjustment affected the results remarkably. Conclusions: Our results indicate that either low (1 serving/week) or moderate fish consumption (2-4 servings/week) has a significantly beneficial effect on the prevention of CHD mortality. High fish consumption (>5 servings/week) possesses only a marginally protective effect on CHD mortality, possibly due to the limited studies included in this group.
Objective: To describe the relative validity and reliability of the FFQ used for assessing nutrient intakes of participants in the Tehran Lipid and Glucose Study (TLGS). Design: A total of 132 subjects (sixty-one males and seventy-one females) were included in the study. Dietary data were collected monthly by means of twelve 24 h dietary recalls (24hDR). Subjects completed two, 168-item semi-quantitative FFQ. Blood and urine samples were taken every season for measurement of plasma biomarkers and urinary N and K. Results: Mean age and BMI of the participants were 35.5 (SD 16.8) years and 25.5 (SD 5.2) kg/m(2), respectively. The mean energy-adjusted and dattenuated correlation coefficients for overall nutrient intake between the 24hDR and FFQ2 were 0-44 and 0.37 in 35-year-olds, respectively, and for individual nutrients ranged from 0.24 to 0.71 in men (mean r=0.53) and from 0.11 to 0.60 in women (mean r=0.39). The mean energy-adjusted reliability coefficients varied from 0.48 in 35-year-olds, and ranged from 0.41 to 0.79 in men (mean r=0.59) and from 0.39 to 0.74 in women (mean r=0.60). The FFQ2 and 24hDR produced exact agreement rates ranging between 39.6% and 68.3% in men and between 39.6% and 54.1% in women. The ranges of questionnaire validity coefficients, with the sample correlation between the questionnaires and biochemical marker as the lower limit and the estimate obtained by the method of triads as the upper limit, were 0.21-0.56 (protein) and 0.37-0.61 (K). Conclusions: The FFQ developed for the TLGS has reasonable relative validity and reliability for nutrient intakes in Tehranian adults.
Objective: Adherence to a Mediterranean diet is associated with significant improvements in health status. However, to date no systematic review and meta-analysis has summarized the effects of Mediterranean diet adherence on the risk of type 2 diabetes mellitus. Design: Electronic searches for randomized controlled trials and cohort studies were performed in MEDLINE, SCOPUS, EMBASE and the Cochrane Trial Register until 2 April 2014. Pooled effects were calculated by an inverse-variance random-effect meta-analysis using the statistical software Review Manager 5.2 by the Cochrane Collaboration. Setting: Meta-analysis of randomized controlled trials and cohort studies. Subjects: Eligibility criteria: 19+ years of age. Results: One randomized controlled trial and eight prospective cohort studies (122 810 subjects) published between 2007 and 2014 were included for meta-analysis. For highest v. lowest adherence to the Mediterranean diet score, the pooled risk ratio was 0.81 (95 % CI 0.73, 0.90, P < 0.0001, I-2 = 55 %). Sensitivity analysis including only long-term studies confirmed the results of the primary analysis (pooled risk ratio = 0.75; 95 % CI 0.68, 0.83, P < 0.00001, I-2 = 0 %). The Egger regression test provided no evidence of substantial publication bias (P = 0.254). Conclusions: Greater adherence to a Mediterranean diet is associated with a significant reduction in the risk of diabetes (19 %; moderate quality evidence). These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of type 2 diabetes mellitus.