Stability of the Framingham Nutritional Risk Score and its component nutrients over 8 years: the Framingham Nutrition Studies.

BACKGROUND/OBJECTIVES: Diet quality indices are increasingly used in nutrition epidemiology as dietary exposures in relation to health outcomes. However, literature on the long-term stability of these indices is limited. We aimed to assess the stability of the validated Framingham Nutritional Risk Score (FNRS) and its component nutrients over 8 years, as well as the validity of the follow-up FNRS. SUBJECTS/METHODS: Framingham Offspring/Spouse Study women and men (n=1734) aged 22-76 years were evaluated over 8 years. Individuals' nutrient intake and nutritional risk scores were assessed using 3-day dietary records administered at baseline (1984-1988) and at follow-up (1992-1996). Agreement between baseline and follow-up FNRS and nutrient intakes was evaluated by Bland-Altman method; stability was assessed using intra-class correlation (ICC) and weighted Kappa statistics. The effect of diet quality (as assessed by the FNRS) on cardiometabolic risk factors was evaluated using analysis of covariance. RESULTS: Modest changes from baseline (15%) were observed in nutrient intake. The stability coefficients for the FNRS (ICC: women, 0.49; men, 0.46; P<0.0001) and many nutrients (ICC 0.3) were moderate. Over half of the women and men (58%) remained in the same or contiguous baseline and follow-up quartile of the FNRS and few (3-4%) shifted >1 quartile. The FNRS was directly associated with body mass index in women (P<0.01) and high-density lipoprotein cholesterol among both women (P<0.001) and men (P<0.01). CONCLUSIONS: The FNRS and its constituent nutrients remained relatively stable over 8 years of follow-up. The stability of diet quality has implications for prospective epidemiological investigations.

The internal validity of a dietary pattern analysis. The Framingham Nutrition Studies.

STUDY OBJECTIVES: To examine the internal validity of a dietary pattern analysis and its ability to discriminate clusters of people with similar dietary patterns using independently assessed nutrient intakes and heart disease risk factors. DESIGN AND PARTICIPANTS: Population based study characterising dietary patterns using cluster analysis applied to data from the semiquantitative Framingham food frequency questionnaire collected from 1942 women ages 18-76 years, between 1984-88. SETTING: Framingham, Massachusetts. MAIN RESULTS: Of 1942 women included in the cluster analysis, 1828 (94%) were assigned to one of the five dietary pattern clusters: Heart Healthy, Light Eating, Wine and Moderate Eating, High Fat, and Empty Calorie. Dietary patterns differed substantially in terms of individual nutrient intakes, overall dietary risk, heart disease risk factors, and predicted heart disease risk. Women in the Heart Healthy cluster had the most nutrient dense eating pattern, the lowest level of dietary risk, more favourable risk factor levels, and the lowest probability of developing heart disease. Those in the Empty Calorie cluster had a less nutritious dietary pattern, the greatest level of dietary risk, a heavier burden of heart disease risk factors, and a relatively higher probability of developing heart disease. Cluster reproducibility using discriminant analysis showed that 80% of the sample was correctly classified. The cluster technique was highly sensitive and specific (75% to 100%). CONCLUSIONS: These findings support the internal validity of a dietary pattern analysis for characterising dietary exposures in epidemiological research. The authors encourage other researchers to explore this technique when investigating relations between nutrition, health, and disease.

Nutritional risk in an urban homebound older population. The nutrition and healthy aging project.

PURPOSE: To establish the prevalence of nutritional problems and their related socio-demographic and health-related risk factors in the homebound elderly population. METHODS: Subjects included 239 men and women, ages 65 to 105 years. Trained, two-person field teams conducted comprehensive in-home assessments. Medical record reviews assessed co-morbidity and medication use. RESULTS: The majority of these urban study subjects are of very advanced age (mean age 81 years), female (72%), non-white (73%), living alone (51%), of low income (76%), and somewhat socially isolated (26% had no weekly social contact). More older women than men were widowed (60 vs. 33%, respectively) and poor (80 vs. 67%). The disease burden and functional dependency were both high in men and women; 77% had three or more chronic medical conditions; 76% were functionally dependent in one or more ADL's and 95% in one or more IADL's. Poor dietary quality was universal in these older men and women; half or more consumed diets that deviated from recommended standards for at least 13 of the 24 nutritional guidelines studied. Five percent of subjects were underweight (Body Mass Index (BMI) <18.5); 22% were overweight (BMI 25.0-29.9); and 33% were obese (BMI >30.0). Fasting albumin, hemoglobin, and absolute lymphocyte concentrations were borderline to very low in 18-32%. Dyslipidemia was more common in women; however, men and women had similar Total:HDL cholesterol ratios. CONCLUSIONS: Nutritional status is poor in homebound persons of very advanced age with substantial co-morbidity and functional dependency. The complexities of nutritional risk necessitate multi-disciplinary and individualized nutritional intervention strategies.

Nutritional research within the Framingham Heart Study.

Fifty years of research at the Framingham Heart Study have made important contributions to the diagnosis and treatment of cardiovascular disease (CVD). Within the scope of this prospective population-based cohort study, research investigations from the Framingham Nutrition Studies have developed and advanced nutritional epidemiologic methods, many of which are highlighted here. Ongoing nutrition research explores relationship between diet, nutritional status, and the development of chronic diseases, including CVD. This paper summarizes key findings from decades of nutrition research within the Framingham Heart Study. Cross-sectional and longitudinal investigations are described, including recent research on dietary patterns and coronary heart disease risk among women. Implications for the development of national nutrition policy, population-based dietary guidance for chronic disease prevention, and nutrition-related health promotion campaigns for CVD risk reduction are discussed.

Validation of a dietary pattern approach for evaluating nutritional risk: the Framingham Nutrition Studies.

OBJECTIVE: To validate the use of cluster analysis for characterizing population dietary patterns. DESIGN: Cluster analysis was applied to a food frequency questionnaire to define dietary patterns. Independent estimates of nutrient intake were derived from 3-day food records. Heart disease risk factors were assessed using standardized protocols in a clinic setting. SETTING: Adult women (n = 1,828) participating in the Framingham Offspring-Spouse study. STATISTICAL ANALYSES: Age-adjusted mean nutrient intakes were determined for each cluster. Analysis of covariance was used to evaluate pairwise differences in intake across clusters. Compliance with published recommendations was determined for selected heart disease risk factors. Differences in age-adjusted compliance across clusters were evaluated using logistic regression. RESULTS: Cluster analysis identified 5 distinct dietary patterns characterized by unique food behaviors and significantly different nutrient intake profiles. Patterns rich in fruits, vegetables, grains, low-fat dairy, and lean protein foods resulted in higher nutrient density. Patterns rich in fatty foods, added fats, desserts, and sweets were less nutrient-dense. Women who consumed an Empty Calorie pattern were less likely to achieve compliance with clinical risk factor guidelines in contrast to most other groups of women. CONCLUSIONS: Cluster analysis is a valid tool for evaluating nutrition risk by considering overall patterns and food behaviors. This is important because dietary patterns appear to be linked with other health-related behaviors that confer risk for chronic disease. Therefore, insight into dietary behaviors of distinct clusters within a population can help to design intervention strategies for prevention and management of chronic health conditions including obesity and cardiovascular disease.

[Preventive nutritional services for the elderly]. / Präventive Ernährungsdienste für ältere Populationen.

Population aging is a global. These demographic transitions have brought about dramatic changes in the world's health needs and status. Chronic diseases of aging account for nearly half of population morbidity and mortality in the developing regions of the world 85% of deaths and disability in developed regions. Chronic diseases in the elderly is, in over 60%, associated with malnutrition. Malnutrition is one of the few preventable risk factors for chronic diseases. Carefully planned population-based nutrition interventions can lower risk malnutrition and thus for chronic diseases and as well as for their adverse outcomes. Nutrition interventions can also be used to reach particularly vulnerable segments of the population, such as extremely frail elders, to reduce the prevalence of nutrient deficiencies. Clearly, the prevention of nutrition-related problems in the population, including older persons, has important global health implications.

Health status and practices of urban Caribbean Latinos with diabetes mellitus.

Although Caribbean Latinos are more likely than non-Hispanic whites to develop diabetes, their health status has been poorly characterized. Information on diabetes management, metabolic control, dietary habits, and diabetes knowledge was gathered from a group of urban Caribbean Latinos with diabetes in order to characterize the nutritional behaviors, diabetes attitudes, health perceptions, and metabolic control of this high risk group. Interviews and medical record reviews were conducted among seventy low-income urban Caribbean Latinos with type 2 diabetes mellitus. Patients attending outpatient clinics were interviewed by bilingual interviewers. Medical records were reviewed to ascertain prevalence of diabetes-related complications, medications, and metabolic parameters. Participants were primarily Spanish-speaking and of Puerto Rican origin. Eighty-one percent were unemployed, and only 27% had completed high school or higher educational levels. Average hemoglobin A1c was 10.6%. Among those with hypertension and hyperlipidemia, many were not receiving treatment. Participants' estimation of their own degree of metabolic control was poor, as was their understanding of desirable blood glucose and weight goals. A second evening meal was common. Diets were higher in fat and sugar content than currently recommended. More effective treatment strategies for both patients and providers are needed to improve glycemic control and cardiovascular risk factors among indigent urban Caribbean Latinos. Essential features of such strategies for patient programs include culturally appropriate dietary counseling and low literacy materials to better communicate glycemic and weight goals and dietary guidelines. Provider education is needed regarding established guidelines and cultural influences on diabetes-related practices.

Buena Alimentacion, Buena Salud: a preventive nutrition intervention in Caribbean Latinos with type 2 diabetes.

A culturally sensitive 3-month intervention was provided to 18 Caribbean Latino men and women with non-insulin-dependent (type 2) diabetes mellitus. Compared to the randomly assigned control group, the intervention group showed statistically significant decreases in total calories, fat calories, percent of calories from fat, saturated fat calories, and percent of calories from saturated fat The intervention group showed increases in calories from carbohydrates and in the percent of calories from fiber.

Population nutrient intake approaches dietary recommendations: 1991 to 1995 Framingham Nutrition Studies.

OBJECTIVE: To estimate population nutrient intake levels and to assess adherence to current dietary recommendations for health promotion and disease prevention. DESIGN: Cross-sectional analysis of nutrient intake estimated from 3-day food records. Median macronutrient and micronutrient intake levels for men, women, and the total population are reported along with the proportions of men and women who achieved intakes compatible with nutrient goals defined by published guidelines. SETTING: Adult participants (2,520: 1,375 women and 1,145 men) in the Framingham Offspring-Spouse Study surveyed between 1991 and 1995. STATISTICAL ANALYSES: chi 2 Analyses were used to test for gender differences in the proportions of persons who had intakes that met nutrient guidelines. RESULTS: Population intake levels of certain key nutrients, including total and saturated fat, appear to be approaching recommended levels. High proportions of the Framingham population (70% or more) met current recommendations for intakes of protein, polyunsaturated and monounsaturated fat, cholesterol, alcohol, vitamins C and B-12, and folacin. About half or fewer met guidelines for carbohydrate; total and saturated fat; fiber; beta carotene; vitamins A, E, and B-6; calcium; and sodium. Important gender differences in the proportion of those meeting nutrient guidelines were observed for 12 of the 18 nutrients examined, including carbohydrate; total, saturated, and monounsaturated fat; cholesterol; fiber; sodium; calcium; and several vitamins. CONCLUSIONS: Although progress has been made toward achieving population adherence to preventive nutrition recommendations, large proportions of adults fall short of guidelines for some key nutrients. Differences in adherence rates between men and women suggest areas for gender-specific, targeted nutrition messages and behavioral interventions.

Margarine intake and subsequent coronary heart disease in men.

Margarine is a major source of trans fatty acids, the intake of which has risen since the early 20th century. Some data indicate that consumption of trans fatty acids increases the risk of coronary heart disease (CHD). In 1966-1969, 832 men from the Framingham Study, age 45-64 years and free of CHD, were administered a single 24-hour dietary recall, from which we estimated total daily margarine intake. We calculated CHD cumulative incidence rates and, using proportional hazards regression, CHD incidence rate ratios over 21 years of follow-up. Mean energy intake was 2,619 kcal; mean margarine intake was 1.8 (range 0-12) tsp per day. There were 267 incident cases of CHD. Age-adjusted CHD cumulative incidence rose over categories of margarine intake, but the increased risk was apparent only in the second half of the follow-up period. Adjusted for age and energy intake, the risk ratio for CHD for each increment of 1 teaspoon per day of margarine was 0.98 [95% confidence interval (CI) = 0.91-1.05] for the first 10 years of follow-up and 1.10 (95% CI = 1.04-1.17) for follow-up years 11-21. Adjustment for total fat intake and for cigarette smoking, glucose intolerance, left ventricular hypertrophy, body mass index, blood pressure, physical activity, and alcohol intake did not materially change the results. Butter intake did not predict CHD incidence. These data offer modest support to the hypothesis that margarine intake increases the risk of coronary heart disease.

Inverse association of dietary fat with development of ischemic stroke in men.

CONTEXT: A few ecological and cohort studies in Asian populations suggest an inverse association of the intake of both fat and saturated fat with risk of stroke. However, data among western populations are scant. OBJECTIVE: To examine the association of stroke incidence with intake of fat and type of fat among middle-aged US men during 20 years of follow-up. DESIGN AND SETTING: The Framingham Heart Study, a population-based cohort study. PARTICIPANTS: A total of 832 men, aged 45 through 65 years, who were free of cardiovascular disease at baseline (1966-1969). MEASUREMENTS AND DATA ANALYSIS: The diet of each subject was assessed at baseline by a single 24-hour dietary recall, from which intakes of energy and macronutrients were estimated. In Kaplan-Meier analyses, we calculated age-adjusted cumulative incidence rates of stroke. Using Cox regression, we estimated stroke incidence relative risks during 20 years of follow-up. MAIN OUTCOME MEASURE: Incidence of ischemic stroke, which occurred in 61 subjects during the follow-up period. RESULTS: Mean intakes were 10975 kJ for energy; 114 g (39% of energy) for total fat; 44 g (15%) for saturated fat; 46 g (16%) for monounsaturated fat; and 16 g (5%) for polyunsaturated fat. Risk of ischemic stroke declined across the increasing quintile of total fat (log-rank trend P=.008), saturated fat (P=.002), and monounsaturated fat (P=.008) but not polyunsaturated fat (P=.33). The age- and energy-adjusted relative risk for each increment of 3% of energy from total fat was 0.85 (95% confidence interval [CI], 0.78-0.94); for an increment of 1% from saturated fat, 0.91 (95% CI, 0.85-0.98); and for 1% from monounsaturated fat, 0.89 (95% CI, 0.83-0.96). Adjustment for cigarette smoking, glucose intolerance, body mass index, blood pressure, blood cholesterol level, physical activity, and intake of vegetables and fruits and alcohol did not materially change the results. Too few cases of hemorrhagic stroke (n=14) occurred to draw inferences. CONCLUSION: Intakes of fat, saturated fat, and monounsaturated fat were associated with reduced risk of ischemic stroke in men.

Dietary patterns of men and women suggest targets for health promotion: the Framingham Nutrition Studies.

PURPOSE: The goal of the study was to characterize the dietary patterns of adult men and women. DESIGN: The study used a cross-sectional analysis of food consumption behaviors and nutrient intake measured from 1984 through 1988. SETTING: The Framingham Offspring/Spouse Study, Framingham, Massachusetts. SUBJECTS: The population-based sample comprised 1831 men and 1828 women between 20 and 70 years of age. MEASURES: Dietary patterns were defined by cluster analyses, which used the estimates of usual daily food intake from food frequency questionnaires, and the patterns were compared with Food Guide Pyramid recommendations. Nutrient intakes were independently estimated from 24-hour recalls and compared with Year 2000 nutrition recommendations. RESULTS: Cluster analyses identified five groups of men and five groups of women with distinctive dietary patterns. Men differed on intakes of all food groups except vegetables and snacks plus sweetened beverages. Specific dietary behaviors, including low intakes of whole grains, fruits, vegetables, and other complex carbohydrates; high intakes of beer and liquor; and high intakes of high-fat animal foods warrant targeted intervention messages for men. Women's patterns differed across all food groups except red meats and fattier poultry and beer. Dietary behaviors of women that deserve attention include low fruit, vegetable, starch, and dietary intakes; chronic dieting; high alcohol intake; and sources of hidden fats. No cluster met the current recommendations for food and nutrient intake. CONCLUSIONS: Distinct dietary patterns in Framingham men and women vary in compliance with national nutrition and health policy objectives and provide insights for developing behavioral interventions to improve food and nutrient intake.

Diet and plasma lipids in women. I. Macronutrients and plasma total and low-density lipoprotein cholesterol in women: the Framingham nutrition studies.

This study examined relationships between diet and plasma total and LDL cholesterol levels in a population-based sample of 695 premenopausal and 727 postmenopausal women participating in the Framingham Offspring/Spouse Study. Regression analyses controlled for age, caloric intake, apolipoprotein E isoform type, estrogen use, and important CVD risk factors indicated that plasma total and LDL-cholesterol levels were directly associated with consumption of saturated fat and inversely associated with total calorie intake. In contrast, dietary cholesterol was not a predictor of plasma total or LDL cholesterol levels. Total cholesterol levels were also directly associated with total fat, oleic acid, and animal fat, and inversely associated with carbohydrate intake. Stepwise regressions with key nutrients indicated that saturated fat was consistently associated with total and LDL cholesterol levels in Framingham women. These analyses suggest that diet explains 2% of the variability in these lipid levels in a cross-sectional sample of women; the full model explains 22-27%.

Diet and plasma lipids in women. II. Macronutrients and plasma triglycerides, high-density lipoprotein, and the ratio of total to high-density lipoprotein cholesterol in women: the Framingham nutrition studies.

This study examined relationships between macronutrients and plasma triglycerides, HDL, and the total-to-HDL cholesterol ratio (T/H ratio) in a population-based sample of 695 premenopausal and 727 postmenopausal women participating in the Framingham Offspring/Spouse Study. Multivariate regression analyses revealed that plasma triglycerides were inversely related to protein, fiber, and polyunsaturated fat and directly related to saturated fat and oleic acid. Alcohol intake was directly related to HDL cholesterol and inversely related to the T/H ratio in all subgroups of women, except for postmenopausal women with the 3/2 or 2/2 apolipoprotein E phenotype. Similarly, a direct relationship between dietary fat and HDL cholesterol was limited to this single subgroup of postmenopausal women. Since dietary fat and alcohol do not appear to have consistent effects on plasma lipids in all groups of women, it is important to consider the genetic contribution to diet/lipid relationships in epidemiological studies and when evaluating lipid-lowering interventions.

Fission of crypts in the small intestine of the irradiated mouse.

Following 1600 R of X-rays there was a reduction in the number of crypts in the small intestine of the mouse by 77% as measured 5 days later. However, by 21 days the number had increased steadily to levels approaching normal. The number of villi did not change following irradiation. The mechanism of increase in crypt number was by budding and fission of repopulated crypts which had become larger than normal. Some aspects of crypt organization are discussed.