Certain dietary patterns are associated with GLIM criteria among Chinese community-dwelling older adults: a cross-sectional analysis.

Disease-related malnutrition is prevalent among older adults; therefore, identifying the modifiable risk factors in the diet is essential for the prevention and management of disease-related malnutrition. The present study examined the cross-sectional association between dietary patterns and malnutrition in Chinese community-dwelling older adults aged ≥65 years in Hong Kong. Dietary patterns, including Diet Quality Index International (DQI-I), Dietary Approaches to Stop Hypertension (DASH), the Mediterranean Diet Score, 'vegetable-fruit' pattern, 'snack-drink-milk product' pattern and 'meat-fish' pattern, were estimated and generated from a validated food frequency questionnaire. Malnutrition was classified according to the modified Global Leadership Initiative on Malnutrition (GLIM) criteria based on two phenotypic components (low body mass index and reduced muscle mass) and one aetiologic component (inflammation/disease burden). The association between the tertile or level of adherence of each dietary pattern and modified GLIM criteria was analysed using adjusted binary logistic regression models. Data of 3694 participants were available (49 % men). Malnutrition was present in 397 participants (10⋅7 %). In men, a higher DQI-I score, a higher 'vegetable-fruit' pattern score and a lower 'meat-fish' pattern score were associated with a lower risk of malnutrition. In women, higher adherence to the DASH diet was associated with a lower risk of malnutrition. After the Bonferroni correction, the association remained statistically significant only in men for the DQI-I score. To conclude, a higher DQI-I score was associated with a lower risk of malnutrition in Chinese older men. Nutritional strategies for the prevention and management of malnutrition could potentially be targeted on dietary quality.

Protein and physical activity in older persons.

PURPOSE OF REVIEW: The aim of this study was to highlight recent evidence on protein requirement and physical activity recommendations in older adults and their interrelationship. RECENT FINDINGS: Higher protein intake in older adults is beneficial for better physical function, reduced fracture risk, healthy ageing and lower mortality. However, the association between protein quality and health remains inconsistent. Higher physical activity is associated with a lower risk of physical dependence, frailty, cognitive impairment and mortality. Prospectively increasing or even sustaining physical activity can be protective against adverse health outcomes compared with decreasing physical activity. There is a synergistic protective effect of protein intake and physical activity on health. Data on the bidirectional link between protein intake and physical activity are scarce. Whether increasing physical activity can help to increase energy intake (and thus protein intake) and vice versa require further research. SUMMARY: The key role of protein intake and physical activity in optimizing health in older adults is well established. The synergistic effects of these two modifiable lifestyle factors strengthen the need to consider dietary and physical activity recommendations together. Future research may examine the bidirectional link between diet and physical activity, which could potentially be one of the strategies to increase the uptake of recommendations for protein intake and physical activity in older adults.

Malnutrition According to GLIM Criteria and Adverse Outcomes in Community-Dwelling Chinese Older Adults: A Prospective Analysis.

OBJECTIVES: The Global Leadership Initiative on Malnutrition (GLIM) has proposed a consensus scheme for classifying malnutrition. This study examined the prevalence of malnutrition according to GLIM criteria and evaluated if these criteria were associated with adverse outcomes in community-dwelling older adults. DESIGN: This was a prospective cohort study. SETTING AND PARTICIPANTS: Community-dwelling Chinese men and women aged ≥65 years in Hong Kong. METHODS: A health check including questionnaire interviews and physical measurements was conducted at baseline and 14-year follow-up. Participants were classified as malnourished at baseline according to the GLIM criteria based on 2 phenotypic components (low body mass index and reduced muscle mass) and 1 etiologic component (inflammation). Adverse outcomes including sarcopenia, frailty, falls, mobility limitation, hospitalization, and mortality were assessed at 14-year follow-up. Adjusted multiple logistic regression and Cox proportional hazards model were performed to examine the associations between malnutrition and adverse outcomes and presented as odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI). RESULTS: Data of 3702 participants [median age: 72 years (IQR 68-76)] were available at baseline. Malnutrition was present in 397 participants (10.7%). Malnutrition was significantly associated with higher risk of sarcopenia (n = 898, OR 2.25; 95% CI 1.04-4.86), frailty (Fried (n = 971, OR 2.83; 95% CI 1.47-5.43), FRAIL scale (n = 985, OR 2.30; 95% CI 1.06-4.98)) and all-cause mortality (n = 3702, HR: 1.62; 95% CI 1.39-1.89). There was no significant association between malnutrition and falls (n = 987, OR 1.09; 95% CI 0.52-2.31), mobility limitation (n = 989, OR 0.98; 95% CI 0.36-2.67), and hospitalization (n = 989, OR 1.37; 95% CI 0.67-2.77). CONCLUSIONS AND IMPLICATIONS: Among community-dwelling Chinese older adults, malnutrition according to selected GLIM criteria was a predictor of sarcopenia, frailty, and mortality at 14-year follow-up; whereas no association was found for falls, mobility limitation, and hospitalization. Clinicians may consider applying the GLIM criteria to identify malnourished community-dwelling older adults.

Evaluation of dietary pattern in early pregnancy using the FIGO Nutrition Checklist compared to a food frequency questionnaire.

OBJECTIVE: To evaluate the reliability and utility of the FIGO Nutrition Checklist to identify dietary and nutritional inadequacy in early pregnancy by comparing it against nutritional indicators and dietary quality indices (Dietary Approaches to Stop Hypertension [DASH] score, Mediterranean Diet Score [MDS], and Dietary Quality Index-International [DQI-I]), derived by a locally validated food frequency questionnaire (FFQ). METHODS: A prospective cohort study of healthy Chinese pregnant women randomly recruited between September 2017 and April 2018 at their first antenatal appointment. Women completed the FIGO Nutrition Checklist (translated into Chinese) and the FFQ. Spearman correlation was performed to examine association between the Checklist and dietary quality indices or food and nutrient intakes, calculated based on dietary data from the FFQ. RESULTS: Of 160 participants, 156 (97.5%) completed both the FIGO Nutrition Checklist and FFQ and were included. There were 148 (95%) women who reported at least one suboptimal dietary behavior using the Checklist. Checklist score was significantly associated with dietary quality indices (DASH ρ=0.344, P<0.001; DQI-I ρ=0.304, P<0.001; MDS ρ=0.164, P=0.041). The Checklist question on fruit/vegetables was significantly associated with fiber, vitamin C, and fruit and vegetable intake as calculated from the FFQ (0.325 ≤ ρ ≤0.441, P<0.001). The question on dairy intake was significantly associated with intake of calcium, milk and dairy products captured via FFQ (0.576 ≤ ρ ≤0.655, P<0.001). CONCLUSION: This study supports the use of the FIGO Nutrition Checklist to identify women with suboptimal dietary quality in early pregnancy.

Psychological Factors of Long-Term Dietary and Physical Activity Adherence among Chinese Adults with Overweight and Obesity in a Community-Based Lifestyle Modification Program: A Mixed-Method Study.

There is a paucity of research on factors influencing long-term adherence to lifestyle modification. We conducted a mixed-method study to explore the psychological factors of dietary and physical activity (PA) adherence among Chinese adults with overweight and obesity at 10 months after enrollment of a community-based lifestyle modification program in Hong Kong. We recruited Chinese adults newly enrolled in a culturally adapted lifestyle modification program and followed them for 10 months. For the quantitative study, primary outcomes were dietary and PA adherence scores while secondary outcomes included knowledge, self-efficacy, motivation and stage of change. For the qualitative study, data were collected using semi-structured interviews and observation. A total of 140 participants completed the 10-month follow-up. They reported moderate level of dietary adherence but low level of PA adherence at 10 months. Multivariable regression analyses revealed that greater improvement in nutrition knowledge and diet stage of change predicted higher dietary adherence while greater improvement in PA self-efficacy and PA stage of change predicted higher PA adherence. Qualitative data on 26 participants suggest that participants' knowledge and self-efficacy but not motivation were enhanced during the program. The findings of this study enhanced our understanding on factors influencing long-term adherence to lifestyle changes.

Dietary Intake of Anti-Oxidant Vitamins A, C, and E Is Inversely Associated with Adverse Cardiovascular Outcomes in Chinese-A 22-Years Population-Based Prospective Study.

Background: Conflicting and population-dependent findings have been reported from epidemiological studies on the associations of dietary intake of anti-oxidant vitamins with cardiovascular events. We investigated the prospective relationship between dietary intake of anti-oxidant vitamins and incident adverse cardiovascular outcomes amongst Hong Kong Chinese. Methods: In this prospective population-based study, baseline dietary intake of anti-oxidant vitamins (A, C, and E) were assessed using a food frequency questionnaire in 875 Chinese participants from the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS) in 1995⁻1996. The adjusted hazard ratio (HR) of incident adverse cardiovascular outcomes, defined as the first recorded diagnosis of cardiovascular deaths, non-fatal myocardial infarction or non-fatal stroke, and coronary or other arterial revascularizations, was calculated per unit intake of each vitamin using multivariable Cox regression. Results: Over a median follow-up of 22 years, 85 participants (9.7%) developed adverse cardiovascular outcomes. Dietary intakes of vitamin A, C, and E were independently and inversely associated with incident adverse cardiovascular outcomes (HR 0.68, 95%CI 0.53⁻0.88, p = 0.003 for vitamin A; HR 0.66, 95%CI 0.52⁻0.85, p = 0.001 for vitamin C; and HR 0.57, 95%CI 0.38⁻0.86, p = 0.017 for vitamin E) after adjustments for conventional cardiovascular risk factors at baseline. Conclusions: Dietary intakes of anti-oxidant vitamins A, C, and E reduced the risk of adverse cardiovascular outcomes in Hong Kong Chinese.

Diet quality is inversely associated with obesity in Chinese adults with type 2 diabetes.

BACKGROUND: Diet quality has been linked to obesity, but this relationship remains unclear in individuals with type 2 diabetes (T2D). The aim of this study is to examine the association between diet quality and obesity in Chinese adults with T2D. METHODS: Between April and November 2016, a total of 211 Chinese T2D adults who underwent assessment of diabetes-related treatment goals and metabolic control were recruited into two groups based on their body mass index (BMI): obese group (BMI ≥30 kg/m2) and non-obese group (BMI = 18.5-24.9 kg/m2). Diet quality indices including Alternate Healthy Eating Index-2010 (AHEI-2010), Diet Quality Index-International (DQI-I), and Dietary Approach to Stop Hypertension (DASH) score, were derived from a validated food frequency questionnaire. RESULTS: Obese T2D patients had significantly lower AHEI-2010 (P < 0.001), DQI-I (P < 0.001), and DASH total scores (P = 0.044) than their non-obese counterparts, independent of age and sex. They also had higher total energy (P < 0.001), protein percentage of energy (P = 0.023), and meat, poultry and organ meat (P < 0.001), but lower vegetable (P = 0.014) intakes. Our multivariate logistic regression analyses demonstrated that the AHEI-2010, but not DQI-I and DASH, total score had an inverse association with obesity, independent of sociodemographics, anti-diabetic medication use, physical activity level and total energy intake (odds ratio [OR] per standard deviation (1-SD) increase: 0.95, 95% confidence interval [CI]: 0.91-0.99, P = 0.020). This association remained significant after further adjustment for glycemic control. Inverse associations were also found between obesity and multivariate-adjusted component scores, including AHEI-2010 red/processed meat (OR per 1-SD: 0.71, 95% CI: 0.51-0.99, P = 0.044), DQI-I variety (OR per 1-SD: 0.63, 95% CI: 0.46-0.86, P = 0.004), and DASH red/processed meat (OR per 1-SD: 0.57, 95% CI: 0.38-0.84, P = 0.005). CONCLUSIONS: Better diet quality, as characterized by higher AHEI-2010 scores, was associated with lower odds of obesity in Chinese adults with T2D. Dietary patterns reflecting high consumption of plant-based foods and low consumption of animal-based, high-fat, and processed foods may be imperative to optimize nutritional guidance for obesity management in this population.

An Overview of Factors Associated with Adherence to Lifestyle Modification Programs for Weight Management in Adults.

This review aims to provide an overview of the factors associated with adherence reported in existing literature on lifestyle modification programs for weight management among the adult population. An electronic search was performed using PubMed, Medline, PsycINFO and PsycARTICLE to identify studies that examined the factors of adherence to lifestyle modification programs with explicit definition of adherence indicators. We identified 19 studies published between 2004 and 2016. The most commonly used indicator of adherence was attrition, followed by attendance, self-monitoring and dietary adherence. A broad array of factors has been studied but only few studies exploring each factor. Limited evidence suggested older age, higher education, healthier eating and physical activity behaviours, higher stage of change at baseline and higher initial weight loss may predict better adherence. On the other hand, having depression, stress, strong body shape concern and full-time job may predict poor adherence. Inconsistent findings were obtained for self-efficacy, motivation, male gender and previous weight loss attempt. This review highlights the need for more rigorous studies to enhance our knowledge on factors related to adherence. Identification of the factors of adherence could provide important implication for program improvement, ultimately improving the effectiveness and the cost-effectiveness of lifestyle modification program.

A Randomized Controlled Study to Examine the Effect of a Lifestyle Modification Program in OSA.

BACKGROUND: Obesity is an important risk factor for OSA. This study aimed to assess the effect of weight reduction through a lifestyle modification program (LMP) on patients with moderate to severe OSA. METHODS: This was a parallel group, randomized controlled trial. Altogether, 104 patients with moderate to severe OSA diagnosed on portable home sleep monitoring were randomized to receive a dietician-led LMP or usual care for 12 months. The primary outcome was reduction of apnea-hypopnea index (AHI) at 12 months as assessed by portable home sleep monitoring. RESULTS: In the intention-to-treat analysis (ITT), LMP (n = 61) was more effective in reducing AHI from baseline (16.9% fewer events in the LMP group vs 0.6% more events in the control group, P = .011). LMP was more effective in reducing BMI (-1.8 kg/m2, 6.0% of the initial BMI; -0.6 kg/m2, 2.0% of the initial BMI in control group; P < .001). The reduction in daytime sleepiness as assessed by Epworth Sleepiness Scale was not significant in ITT but was more in the LMP group (-3.5 in the LMP group vs -1.1 in the control group, P = .004) by treatment per protocol analysis. There was modest improvement in mental health in the Short Form Health Survey. Eating behavior was improved with increased intake of protein and fiber. These changes were observed 4 months after the initial intensive diet counseling and persisted at 12 months. CONCLUSIONS: LMP was effective in reducing the severity of OSA and daytime sleepiness. The beneficial effect was sustained in 12 months. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01384760; URL: www.clinicaltrials.gov.

A randomized controlled trial to investigate the impact of a low glycemic index (GI) diet on body mass index in obese adolescents.

BACKGROUND: The role of a low glycemic index (GI) diet in the management of adolescent obesity remains controversial. In this study, we aim to evaluate the impact of low GI diet versus a conventional Chinese diet on the body mass index (BMI) and other obesity indices of obese adolescents. METHODS: Obese adolescents aged 15-18 years were identified from population-recruited, territory-wide surveys. Obesity was defined as BMI ≥95th percentile of Hong Kong local age- and sex-specific references. Eligible subjects were randomized to either an intervention with low GI diet (consisting of 45-50% carbohydrate, 30-35% fat and 15-20% protein) or conventional Chinese diet as control (consisting of 55-60% carbohydrate, 25-30% fat and 10-15% protein). We used random intercept mixed effects model to compare the differential changes across the time points from baseline to month 6 between the 2 groups. RESULTS: 104 obese adolescents were recruited (52 in low GI group and 52 in control group; 43.3% boys). Mean age was 16.7 ± 1.0 years and 16.8 ±1.0 years in low GI and control group respectively. 58.7% subjects completed the study at 6 months (65.4% in low GI group and 51.9% in control group). After adjustment for age and sex, subjects in the low GI group had a significantly greater reduction in obesity indices including BMI, body weight and waist circumference (WC) compared to subjects in the control group (all p <0.05). After further adjustment for physical activity levels, WC was found to be significantly lower in the low GI group compared to the conventional group (p = 0.018). CONCLUSION: Low GI diet in the context of a comprehensive lifestyle modification program may be an alternative to conventional diet in the management of obese adolescents. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Ref. No: NCT01278563.

Current evidence on dietary pattern and cognitive function.

With global aging population, age-related cognitive decline becomes epidemic. Lifestyle-related factor is one of the key preventative measures. Dietary pattern analysis which considers dietary complexity has recently used to examine the linkage between nutrition and cognitive function. A priori approach defines dietary pattern based on existing knowledge. Results of several dietary pattern scores were summarized. The heterogeneity of assessment methods and outcome measurements lead to inconsistent results. Posteriori approach derives a dietary pattern independently of the existing nutrition-disease knowledge. It showed a dietary pattern abundant with plant-based food, oily fish, lower consumption of processed food, saturated fat, and simple sugar which appears to be beneficial to cognitive health. Despite inconclusive evidence from both approaches, diet and exercise, beneficial for other diseases, remains to be the two key modifiable factors for cognitive function. Large-scale prospective studies in multiethics population are required to provide stronger evidence in the future.

Food additives and behavior in 8- to 9-year-old children in Hong Kong: a randomized, double-blind, placebo-controlled trial.

OBJECTIVES: To test the individual effect of artificial food colorings (AFCs) and a preservative on the behavior of the general Chinese population. METHOD: One hundred thirty children (70 boys and 60 girls) in Hong Kong with a mean age of 8.64 years were enlisted to the study with a within-subject crossover between AFCs, a preservative (sodium benzoate), and a placebo capsule. Two behavior scores were used including the strengths and weaknesses of attention deficit hyperactivity disorder and normal behavior rating scale and the child behavior checklist-teacher report form. RESULTS: Capsule A containing AFCs and Capsule B containing sodium benzoate had no significant adverse effect compared with placebo in both behavior scores. This result persisted when analysis was restricted to children with 85% consumption of capsule (per protocol analysis). CONCLUSION: There seem to be no significant associations between AFCs and a preservative on Chinese children's behavior at the age of 8 to 9 years. Future directions and implications of this research are discussed.

Nutritionist's variation in counseling style and the effect on weight change of patients attending a community based lifestyle modification program.

Information concerning the nature of nutritionist-patient relationships is very limited. This qualitative and quantitative study examined nutritionist's skills, attributes, and beliefs towards nutrition counseling during a lifestyle modification intervention program, and whether this affected the patient's weight outcome. 24 nutrition consultations were observed during the program and the nutritionists were interviewed for their perception on practice (n = 4). A statistically significant difference was observed between the nutritionists in regard to patient's weight change after adjustment for age and baseline weight (p < 0.001). Key nutritionist skills identified that influenced weight outcome were meticulous investigation of the underlying obesity cause, identification of the subject's stage of change, and psychological support.

Prevention of overweight and obesity: how effective is the current public health approach.

Obesity is a public health problem that has become epidemic worldwide. Substantial literature has emerged to show that overweight and obesity are major causes of co-morbidities, including type II diabetes, cardiovascular diseases, various cancers and other health problems, which can lead to further morbidity and mortality. The related health care costs are also substantial. Therefore, a public health approach to develop population-based strategies for the prevention of excess weight gain is of great importance. However, public health intervention programs have had limited success in tackling the rising prevalence of obesity. This paper reviews the definition of overweight and obesity and the variations with age and ethnicity; health consequences and factors contributing to the development of obesity; and critically reviews the effectiveness of current public health strategies for risk factor reduction and obesity prevention.

Clients' experiences of a community based lifestyle modification program: a qualitative study.

There is little information about how clients attending lifestyle modification programs view the outcomes. This qualitative study examined the clients' experience of a community based lifestyle modification program in Hong Kong. Semi-structured interviews were conducted with 25 clients attending the program. Clients perceived the program had positive impacts on their health and nutrition knowledge. They experienced frustration, negative emotion, lack of motivation, and pressure from others during the program. Working environment and lack of healthy food choices in restaurants were the major perceived environmental barriers for lifestyle modification. Clients valued nutritionists' capability of providing professional information and psychological support in the program. Our results suggest that nutritionist's capability of providing quality consultations and patient-centered care are important for empowering clients achieve lifestyle modification.

Bone mineral status and its relation with dietary estimates of net endogenous acid production in Hong Kong Chinese adolescents.

Diet composition influences net endogenous acid production (NEAP), which may affect bone health. No studies are available to relate dietary estimate of NEAP to bone health in Chinese adolescents. This study examined the association of dietary estimates of NEAP with bone mineral status in Hong Kong Chinese adolescents. Baseline data on 171 boys and 180 girls aged 10-12 years from the Hong Kong Adolescent Bone Health Cohort Study were presented. Weight, height, Tanner stage and dietary intakes by FFQ were collected. NEAP was estimated from diet using Frassetto's method. Bone area (BA), bone mineral content (BMC) and bone mineral apparent density (BMAD) of total hip, lumbar (L1-L4) spine and whole body were estimated by dual-energy X-ray absorptiometry (DXA). No significant association was observed between BMC or BMAD and energy-adjusted NEAP or other nutrients. BA was significantly and positively associated with BMC at all sites in both sexes. Weight was significantly and positively associated with BMC in hip and spine in both sexes. Height was negatively correlated with hip BMC for boys and whole body BMC for girls. Pubertal stage was significantly and positively associated with BMC in all sites in both sexes. Weight and height contributed most of the variability in BMAD at different sites. The results suggest that anthropometric characteristics and pubertal stage are more influential than dietary NEAP in determining bone mineral status of Hong Kong Chinese adolescents. However, the methodological weaknesses regarding the use of DXA and FFQ in the present sample require attention.