The Glycaemic Index-Food-Frequency Questionnaire: Development and validation of a food frequency questionnaire designed to estimate the dietary intake of glycaemic index and glycaemic load:An effort by the PREVIEW Consortium

Dietary glycaemic index (GI) and glycaemic load (GL) are indices used to quantify the effect of carbohydrate quality and quantity on postprandial glycaemia. GI/GL-health associations are widely studied but data on the validity of integrated GI/GL measurements are scarce. We evaluated the performance of a food-frequency questionnaire (FFQ) specifically developed to assess GI/GL. In total, 263 Dutch men and 212 women (aged 55 ± 11 years) completed a 58-item GI-FFQ, an 183-item general-FFQ and a 2-day 24 h-recall and donated blood for glycated haemoglobin (HbA1c) determination. The level of agreement between these methods was evaluated by (1) cross-classification, (2) correlations and (3) Bland and Altman plots. The three dietary assessment methods provided comparable mean intake estimates for total carbohydrates (range: 214–237 g/day), mono/disaccharides (100–107 g/day), polysaccharides (114–132 g/day), as well as bread, breakfast cereals, potatoes, pasta, rice, fruit, dairy, cakes/cookies and sweets. Mean (±SD) GI estimates were also comparable between the GI-FFQ (54 ± 3), general-FFQ (53 ± 4) and 24 h-recalls (53 ± 5). Mean (±SD) GI-FFQ GL (117 ± 37) was slightly lower than the general-FFQ GL (126 ± 38) and 24 h-recalls GL (127 ± 37). Classification of GI in quartiles was identical for the GI-FFQ and general-FFQ for 43% of the population (r = 0.58) and with 24 h-recalls for 35% of the population (de-attenuated r = 0.64). For GL, this was 48% (r = 0.65) and 44% (de-attenuated r = 0.74). Correlations between GI and HbA1c were low (r = −0.09 for GI-FFQ, r = −0.04 for general-FFQ and r = 0.07 for 24 h-recalls). In conclusion, compared to a general-FFQ and 24 h-recalls, the GI-FFQ showed a moderate to good relative validity for carbohydrates, carbohydrate-rich foods and GI/GL. No metric predicted HbA1c

Demographic and Social-Cognitive Factors Associated with Weight Loss in Overweight, Pre-diabetic Participants of the PREVIEW Study

PurposeWeight loss has been demonstrated to be a successful strategy in diabetes prevention. Although weight loss is greatly influenced by dietary behaviors, social-cognitive factors play an important role in behavioral determination. This study aimed to identify demographic and social-cognitive factors (intention, self-efficacy, outcome expectancies, social support, and motivation with regard to dietary behavior and goal adjustment) associated with weight loss in overweight and obese participants from the PREVIEW study who had pre-diabetes.MethodProspective correlational data from 1973 adult participants were analyzed. The participants completed psychological questionnaires that assessed social-cognitive variables with regard to dietary behavior. Stepwise multiple regression analyses were performed to identify baseline demographic and social-cognitive factors associated with weight loss.ResultsOverall, being male, having a higher baseline BMI, having a higher income, perceiving fewer disadvantages of a healthy diet (outcome expectancies), experiencing less discouragement for healthy eating by family and friends (social support), and lower education were independently linked to greater weight loss. When evaluating females and males separately, education was no longer associated with weight loss.ConclusionThe results indicate that a supportive environment in which family members and friends avoid discouraging healthy eating, with the application of a strategy that uses specific behavior change techniques to emphasize the benefits of outcomes, i.e., the benefits of a healthy diet, may support weight loss efforts. Weight loss programs should therefore always address the social environment of persons who try to lose body weight because family members and friends can be important supporters in reaching a weight loss goal.Peer reviewe

A Protein Diet Score, Including Plant and Animal Protein, Investigating the Association with HbA1c and eGFR-The PREVIEW Project

Higher-protein diets have been advocated for body-weight regulation for the past few decades. However, the potential health risks of these diets are still uncertain. We aimed to develop a protein score based on the quantity and source of protein, and to examine the association of the score with glycated haemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR). Analyses were based on three population studies included in the PREVIEW project (PREVention of diabetes through lifestyle Intervention and population studies in Europe and around the World): NQplus, Lifelines, and the Young Finns Study. Cross-sectional data from food-frequency questionnaires (n = 76,777 subjects) were used to develop a protein score consisting of two components: 1) percentage of energy from total protein, and 2) plant to animal protein ratio. An inverse association between protein score and HbA1c (slope -0.02 +/- 0.01 mmol/mol, p <0.001) was seen in Lifelines. We found a positive association between the protein score and eGFR in Lifelines (slope 0.17 +/- 0.02 mL/min/1.73 m(2), p <0.0001). Protein scoring might be a useful tool to assess both the effect of quantity and source of protein on health parameters. Further studies are needed to validate this newly developed protein score.Peer reviewe

Objectively Measured Physical Activity and Sedentary Time Are Associated With Cardiometabolic Risk Factors in Adults With Prediabetes: The PREVIEW Study

OBJECTIVE The aim of the present cross-sectional study was to examine the association among physical activity (PA), sedentary time (ST), and cardiometabolic risk in adults with prediabetes.RESEARCH DESIGN AND METHODS Participants (n = 2,326; 25–70 years old, 67% female) from eight countries, with a BMI >25 kg ⋅ m−2 and impaired fasting glucose (5.6–6.9 mmol ⋅ L−1) or impaired glucose tolerance (7.8–11.0 mmol ⋅ L−1 at 2 h), participated. Seven-day accelerometry objectively assessed PA levels and ST.RESULTS Multiple linear regression revealed that moderate-to-vigorous PA (MVPA) was negatively associated with HOMA of insulin resistance (HOMA-IR) (standardized β = −0.078 [95% CI −0.128, −0.027]), waist circumference (WC) (β = −0.177 [−0.122, −0.134]), fasting insulin (β = −0.115 [−0.158, −0.072]), 2-h glucose (β = −0.069 [−0.112, −0.025]), triglycerides (β = −0.091 [−0.138, −0.044]), and CRP (β = −0.086 [−0.127, −0.045]). ST was positively associated with HOMA-IR (β = 0.175 [0.114, 0.236]), WC (β = 0.215 [0.026, 0.131]), fasting insulin (β = 0.155 [0.092, 0.219]), triglycerides (β = 0.106 [0.052, 0.16]), CRP (β = 0.106 [0.39, 0.172]), systolic blood pressure (BP) (β = 0.078 [0.026, 0.131]), and diastolic BP (β = 0.106 [0.39, −0.172]). Associations reported between total PA (counts ⋅ min−1) and all risk factors were comparable or stronger than for MVPA: HOMA-IR (β = −0.151 [−0.194, −0.107]), WC (β = −0.179 [−0.224, −0.134]), fasting insulin (β = −0.139 [−0.183, −0.096]), 2-h glucose (β = −0.088 [−0.131, −0.045]), triglycerides (β = −0.117 [−0.162, −0.071]), and CRP (β = −0.104 [−0.146, −0.062]).CONCLUSIONS In adults with prediabetes, objectively measured PA and ST were associated with cardiometabolic risk markers. Total PA was at least as strongly associated with cardiometabolic risk markers as MVPA, which may imply that the accumulation of total PA over the day is as important as achieving the intensity of MVPA

Alcohol consumption and mortality in individuals with diabetes mellitus

Studies have suggested that moderate alcohol consumption is associated with a reduced risk of CVD and premature mortality in individuals with diabetes mellitus. However, history of alcohol consumption has hardly been taken into account. We investigated the association between current alcohol consumption and mortality in men and women with diabetes mellitus accounting for past alcohol consumption. Within the European Prospective Investigation into Cancer and Nutrition (EPIC), a cohort was defined of 4797 participants with a confirmed diagnosis of diabetes mellitus. Men and women were assigned to categories of baseline and past alcohol consumption. Hazard ratios (HR) and 95% CI for total mortality were estimated with multivariable Cox regression models, using light alcohol consumption (>0-6 g/d) as the reference category. Compared with light alcohol consumption, no relationship was observed between consumption of 6 g/d or more and total mortality. HR for >6.12 g/d was 0.89(95% CI 0.61, 1.30) in men and 0.86(95% CI 0.46, 1.60) in women. Adjustment for past alcohol consumption did not change the estimates substantially. In individuals who at baseline reported abstaining from alcohol, mortality rates were increased relative to light consumers: HR was 1.52 (95% CI 0.99, 2.35) in men and 1.81 (95% CI 1.04, 3.17) in women. The present study in diabetic individuals showed no association between current alcohol consumption >6 g/d and mortality risk compared with light consumption. The increased mortality risk among non-consumers appeared to be affected by their past alcohol consumption rather than their current abstinence

associations between general and abdominal adiposity and mortality in individuals with diabetes mellitus

Individuals with diabetes mellitus are advised to achieve a healthy weight to prevent complications. However, fat mass distribution has hardly been investigated as a risk factor for diabetes complications. The authors studied associations between body mass index, waist circumference, waist/hip ratio, and waist/height ratio and mortality among individuals with diabetes mellitus. Within the European Prospective Investigation into Cancer and Nutrition, a subcohort was defined as 5,435 individuals with a confirmed self-report of diabetes mellitus at baseline in 1992-2000. Participants were aged 57.3 (standard deviation, 6.3) years, 54% were men, the median diabetes duration was 4.6 (interquartile range, 2.0-9.8) years, and 22% of the participants used insulin. Body mass index, as indicator of general obesity, was not associated with higher mortality, whereas all measurements of abdominal obesity showed a positive association. Associations generally were slightly weaker in women. The strongest association was observed for waist/height ratio: In the fifth quintile, the hazard rate ratio was 1.88 (95% confidence interval: 1.33, 2.65) for men and 2.46 (95% confidence interval: 1.46, 4.14) for women. Measurements of abdominal, but not general, adiposity were associated with higher mortality in diabetic individuals. The waist/height ratio showed the strongest association. Respective indicators might be investigated in risk prediction models

Lebensstilfaktoren und Mortalitätsrisiko bei Diabetikern. Unterscheiden die Beziehungen sich zu denen von Nicht-Diabetikern?

Diabetes mellitus ist weltweit eine der häufigsten nicht-übertragbaren Erkrankungen. Dabei handelt es sich um eine chronische Erkrankung, die eine kontinuierliche medizinische und Selbstbeobachtung erfordert, um eine Normalisierung des Blutzuckerspiegels zu erreichen und das Risiko für Herz-Kreislauferkrankungen und vorzeitige Mortalität zu senken. Die Diabetestherapie ist gut etabliert: das Hauptziel der Behandlung ist die Einstellung des Blutzuckerspiegels, was in erster Linie durch Medikamente, aber auch zum Teil durch die Änderung des Lebensstils erreicht werden soll. Jedoch ist die wissenschaftliche Evidenz der langfristigen positiven Effekte straffe Einstellung des Blutzuckerspiegels nicht endgültig gesichert. Aus diesem Grund sollte die Lebensstiländerung die Grundlage der Diabetesbehandlung und primäre Prävention von Komplikationen das Hauptziel bilden. Infolge des Mangels an wissenschaftlicher Evidenz sind die Ernährungs- und Lebensstilempfehlungen für Diabetiker jedoch ähnlich denen der Allgemeinbevölkerung. Somit war das erste Ziel dieser Arbeit, eine wissenschaftliche Grundlage evidenzbasierter Lebensstilempfehlungen für Diabetiker zu liefern. Das zweite Ziel war, zu untersuchen, ob sich die Beziehungen zwischen Lebensstilfaktoren und dem Mortalitätsrisiko bei Diabetikern zu denen von Nicht-Diabetikern unterscheiden, und damit, ob Diabetiker spezielle Empfehlungen erhalten sollten. Methoden Innerhalb der “European Prospective Investigation into Cancer and Nutrition (EPIC)-Studie” wurde eine Subkohorte von 6384 prävalenten Diabetikern, für die verifizierte Diagnosen vorlagen, gebildet. Anschließend wurden aus den Studienteilnehmern der restlichen Kohorte ohne Diabetes willkürlich 19152 Personen ausgewählt und den Diabetikern in einem Verhältnis von 1:3 zugeordnet, wobei für Alter, Geschlecht und Studienzentrum kontrolliert wurde. Ernährungs- und Lebensstilgewohnheiten der letzten 12 Monate wurden zu Studienbeginn mit Hilfe von Fragenbögen erfasst. Die Assoziationen der folgenden Faktoren mit dem Gesamtmortalitätsrisiko wurde mittels multivariater Cox Regression untersucht: Body-Mass-Index, Bauchumfang, Verhältnis Bauch-/Hüftumfang, Verhältnis Bauchumfang/ Körpergröße, 26 Lebensmittelgruppen, Alkoholkonsum, körperliche Aktivität - insgesamt und in der Freizeit - sowie Spazierengehen. Basierend auf der Idee des ‚Competing risk‘-Modells wurde ein kombiniertes Cox Regressionsmodell von Diabetikern und Nicht-Diabetikern gebildet. Mit diesem Modell wurde mittels Likelihood-Ratio-Test geprüft ob sich die Assoziationen statistisch unterschieden.   Ergebnisse Während einer mittleren Nachbeobachtungszeit von 9,5 Jahren sind 830 (13%) Diabetiker und 1338 (7%) Nicht-Diabetiker verstorben. Diabetes war unabhängig mit einem 54% erhöhten Mortalitätsrisiko verbunden (Hazard Ratio: 1.54; 95%-Konfidenzintervall: 1.41-1.70). Abdominale Adipositas war positiv mit dem Mortalitätsrisiko assoziiert. Eine gesunde Ernährung - einschließlich eines moderaten Alkoholkonsums - ging mit einem gesenkten Mortalitätsrisiko einher. Das waren im Genaueren: ein erhöhter Gemüse-, Nüsse und Samen-, Nudeln-, Reis- und Brotverzehr sowie ein erhöhter Kaffeekonsum, ein moderater Konsum von Käse, Pflanzenöl und Säften sowie ein eingeschränkter Genuss von Butter, Margarine und Limonade. Weiterhin war körperliche Aktivität, insgesamt und in der Freizeit, mit einem niedrigeren Gesamtmortalitätsrisiko assoziiert. Im Vergleich zu den Nicht-Diabetikern, traten die beobachteten günstigen Beziehungen hinsichtlich körperlicher Aktivität in der Freizeit und Kaffeekonsum bei den Diabetikern besonders stark zutage. Diabetes hatte jedoch keinen substantiellen Einfluss auf die Beziehungen der anderen untersuchten Ernährungs- und Lebensstilfaktoren zum Mortalitätsrisiko. Diskussion Diabetes war unabhängig mit einem erhöhten Mortalitätsrisiko verbunden, aber insgesamt wurden keine Hinweise darauf gefunden, dass sich Ernährungs- und Lebensstilempfehlungen für Diabetikern von denen für Nicht-Diabetikern unterscheiden sollten. Ein gesunder Lebensstil, wie er für die Allgemeinbevölkerung empfohlen wird, war auch in Diabetiker mit einem niedrigeren Mortalitätsrisiko assoziiert. In Bezug auf die primäre Prävention von Herz-Kreislauferkrankungen und einer vorzeitige Mortalität ist es somit nicht notwendig zu wissen, ob eine Person an Diabetes erkrankt ist oder nicht. Schlussfolgernd hat diese Studie gezeigt, dass Diabetiker und Nicht-Diabetiker, aber auch Prä-Diabetiker und Personen mit einem noch unerkannten Diabetes, gleichartige Ernährungs- und Lebensstilempfehlungen erhalten sollten. Damit sind diese Empfehlungen für eine größere Fraktion als nur der Allgemeinbevölkerung gültig. Eine gesunde Ernährung und ein gesunder Lebensstil ermöglichen Personen mit oder ohne Diabetes länger und gesünder zu leben.Diabetes mellitus is one of the most common non-communicable diseases globally. It is a chronic disease that requires continuing medical care and patient self-management education to achieve glycemic control and to reduce the risk of cardiovascular diseases (CVD) and premature mortality. When a patient is diagnosed with diabetes, treatment measures which need to be taken by general practitioners are well-established: glycemic control is the main objective of diabetes management, generally achieved by medication and to less extent by lifestyle interventions. Because conclusive evidence on long-term benefits of tight glycemic control are lacking, diabetes management should be an overall intervention strategy including lifestyle modification and aimed at primary prevention of CVD and premature mortality. Due to a lack of epidemiological studies in persons with diabetes, diet and lifestyle advices in diabetes to prevent complications are appropriate for people with and without diabetes. Therefore, it was firstly aimed to provide proof for evidence-based diet and lifestyle recommendations to prevent premature mortality in diabetes. The second objective was to investigate whether the associations between lifestyle factors and mortality were different from individuals without diabetes. Methods Within the European Prospective Investigation into Cancer and Nutrition (EPIC), a cohort was formed of 6,384 persons with a confirmed diagnosis of diabetes at baseline. Subsequently, EPIC participants without a verified or self-reported diabetes diagnosis were randomly selected and matched 1:3 to the persons with diabetes by age, sex, and study center. Diet and lifestyle during the previous 12 months were assessed at baseline with questionnaires. Associations between the following factors and overall mortality risk were studied using multivariable Cox regression models: body mass index, waist circumference, waist/hip ratio, waist/height ratio, 26 food groups, alcohol consumption, total and leisure-time physical activity, and walking. Next, using a competing risk approach, joint Cox proportional hazard regression models of persons with and without diabetes were built for the selected lifestyle factors and overall mortality risk. Likelihood ratio tests for heterogeneity assessed statistical differences in associations. Results After a median follow-up of 9.5 years, 830 (13%) persons with diabetes and 1,338 (7%) persons without diabetes died. Diabetes conferred an independent increased mortality risk with a hazard ratio of 1.54 (95% confidence interval 1.41, 1.70). Measures of abdominal, but not general, adiposity were positively associated with mortality. A healthy diet including an alcohol consumption within the recommended limits, a high consumption of vegetables, nuts and seeds, pasta, rice, bread, and coffee, a moderate consumption of cheese, vegetable oil, and juices and a low consumption of butter and margarine and soft drinks was associated with reduced mortality risks. Furthermore, higher levels of physical activity were related to reduced mortality. The favorable associations of leisure-time physical activity and coffee consumption and mortality were stronger in persons with diabetes compared with diabetes-free individuals. Diabetes status did not substantially influence the associations between the other studied lifestyle factors and mortality risk, including adiposity, other food groups, and alcohol consumption. Discussion Overall, although diabetes confers an independently increased mortality risk, no indications were found that diet and lifestyle recommendations should be different in persons with diabetes compared with persons without diabetes. A healthy lifestyle as recommended to the general population was also in persons with diabetes associated with lower mortality risk. Thus, in terms of primary prevention of CVD and premature mortality by diet and lifestyle, it is not necessary to know whether a person has been diagnosed with diabetes. Our study has shown that persons with and without diabetes, but also persons with pre-diabetes or undiagnosed diabetes should receive similar diet and lifestyle recommendations from their health care providers. A healthy diet and lifestyle allows people with and without diabetes to live healthier and longer; this should be advised and communicated to an even larger proportion than the general population

Total, Free, and Added Sugar Consumption and Adherence to Guidelines: The Dutch National Food Consumption Survey 2007–2010

A high sugar intake is a subject of scientific debate due to the suggested health implications and recent free sugar recommendations by the WHO. The objective was to complete a food composition table for added and free sugars, to estimate the intake of total sugars, free sugars, and added sugars, adherence to sugar guidelines and overall diet quality in Dutch children and adults. In all, 3817 men and women (7–69 years) from the Dutch National Food Consumption Survey 2007–2010 were studied. Added and free sugar content of products was assigned by food composition tables and using labelling and product information. Diet was assessed with two 24-h recalls. Diet quality was studied in adults with the Dutch Healthy Diet-index. Total sugar intake was 22% Total Energy (%TE), free sugars intake 14 %TE, and added sugar intake 12 %TE. Sugar consumption was higher in children than adults. Main food sources of sugars were sweets and candy, non-alcoholic beverages, dairy, and cake and cookies. Prevalence free sugar intake &lt;10 %TE was 5% in boys and girls (7–18 years), 29% in women, and 33% in men. Overall diet quality was similar comparing adults adherent and non-adherent to the sugar guidelines, although adherent adults had a higher intake of dietary fiber and vegetables. Adherence to the WHO free sugar guidelines of &lt;5 %TE and &lt;10 %TE was generally low in the Netherlands, particularly in children. Adherence to the added and free sugar guidelines was not strongly associated with higher diet quality in adults

Alcoholic Beverage Preference and Dietary Habits in Elderly across Europe: Analyses within the Consortium on Health and Ageing: Network of Cohorts in Europe and the United States (CHANCES) Project

Introduction The differential associations of beer, wine, and spirit consumption on cardiovascular risk found in observational studies may be confounded by diet. We described and compared dietary intake and diet quality according to alcoholic beverage preference in European elderly. Methods From the Consortium on Health and Ageing: Network of Cohorts in Europe and the United States (CHANCES), seven European cohorts were included, i.e. four sub-cohorts from EPIC-Elderly, the SENECA Study, the Zutphen Elderly Study, and the Rotterdam Study. armonized data of 29,423 elderly participants from 14 European countries were analyzed. Baseline data on consumption of beer, wine, and spirits, and dietary intake were collected with questionnaires. Diet quality was assessed using the Healthy Diet Indicator (HDI). Intakes and scores across categories of alcoholic beverage preference (beer, wine, spirit, no preference, non-consumers) were adjusted for age, sex, socio-economic status, self reported prevalent diseases, and lifestyle factors. Cohort-specific mean intakes and scores were calculated as well as weighted means combining all cohorts. Results In 5 of 7 cohorts, persons with a wine preference formed the largest group. After multivariate adjustment, persons with a wine preference tended to have a higher HDI score and intake of healthy foods in most cohorts, but differences were small. The weighted estimates of all cohorts combined revealed that non-consumers had the highest fruit and vegetable intake, followed by wine consumers. Non-consumers and persons with no specific preference had a higher HDI score, spirit consumers the lowest. However, overall diet quality as measured by HDI did not differ greatly across alcoholic beverage preference categories. Discussion This study using harmonized data from similar to 30,000 elderly from 14 European countries showed that, after multivariate adjustment, dietary habits and diet quality did not differ greatly according to alcoholic beverage preference