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Nutrient Density As a Dimension of Dietary Quality

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Nutrient Density As a Dimension of Dietary Quality 138 NUTRIENT DENSITY AS A DIMENSION OF DIETARY QUALITY Nutient Densit as a Dimension of Dietary Qualit Part II: Harmonizaton of the invesigatonal protocol in a multcenter evaluaton Marieke Vossenaar, Noel W Solomons Center for Studies of Sensory Impairment, Aging Key messages and Metabolism (CeSSIAM), Guatemala City, Guatemala > The concepts and calculations of ‘nutrient density’ Siti Muslimatun, Helda Khusun and ‘critical nutrient density’ provide valuable tools for Food Science and Nutrition Department, Indonesia identifying, evaluating and resolving problems of International Institute for Life Sciences (i3L), Jakarta, micronutrient inadequacy. Indonesia; Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition > When micronutrient intakes are low because energy (SEAMEO RECFON) – Pusat Kajian Gizi Regional intake is low, consumption of usual foods in higher Universitas Indonesia, Jakarta, Indonesia amounts may restore adequacy; but without energy defcit, micronutrient gaps require greater consumption of Mieke Faber nutrient-rich or enriched foods. Non-Communicable Diseases Research Unit, South Afican Medical Research Council, Cape Town, > In the midst of a worldwide obesity epidemic, the South Afica; Centre of Excellence for Nutrition, dietary energy requirements and intakes associated with North-West University, Potchefstroom, South Afica ‘normal’ and ‘excessive’ weight status interact with micronutrient considerations. Cornelius M Smuts Centre of Excellence for Nutrition, North-West > This multicenter evaluation will serve to illustrate University, Potchefstroom, South Afica the principles of nutrient density across diverse populations. It was designed to recruit a target population with similar Olga Patricia Garcia Obregon, Jorge Luis Rosado nutrient requirements (i.e., nonpregnant, nonlactating School of Natural Sciences, Universidad Autónoma women of reproductive age), but varying energy require- de Querétaro, Querétaro, Mexico ments (i.e., normal weight women versus obese women). Eva Monterrosa, Kesso Gabrielle van Zutphen Sight and Life, Basel, Switzerland SIGHT AND LIFE | VOL. 33 (1) | 2019 NUTRIENT DENSITY AS A DIMENSION OF DIETARY QUALITY 139 Background and context count for total energy consumed. Nutrient density (defned in This paper is part two of our ‘Density as a Dimension of Dietary Box 1) brings energy into the equation. Our companion paper, Quality’ series published in Sight and Life magazine.1 We de- entitled ‘Nutrient Density as a Dimension of Dietary Quality. scribe here the harmonization of an investigational protocol in Part I: Theoretical considerations of the nutrient-density ap- a multicenter evaluation to illustrate the principles of nutrient proach in a multicenter evaluation’ sets out the principles of the density across diverse populations. nutrient-density approach.1 The double burden of malnutrition BOX 1: Defnition of nutrient density Many people in deprived settings consume a monotonous diet based on nutrient-poor starchy staples, which may have suf- Nutrient density is the ratio of the amount of a nutrient in the fcient calories but do not provide the micronutrients needed diet to the energy provided by the same diet. It is frequently for good health.2–4 As a consequence of a global food supply expressed as the amount of the nutrient per 1,000 kcal or MJ that maximizes inexpensive calories fom staple grains, vegeta- of energy. ble oils and sugar crops5 and energy-dense processed foods,6–9 people around the globe sufer fom the double burden of mal- nutrition, which is characterized by the coexistence of under- The nutrient density of the observed diet refers to the ratio of nutrition with overweight and obesity, or with nutrition-related estimated nutrient intakes to estimated energy intake (for exam- noncommunicable disease, throughout the life course.10,11 The ple, assessed by means of 24-hour dietary recalls). The ‘critical double burden of nutritional disease adds an additional layer of nutrient density’, by contrast, is a reference value that consists of complexity but raises the possibility that double-duty actions a recommended daily intake for a specifc nutrient as the numer- could simultaneously reduce obesity and undernutrition.12–14 ator and daily energy requirements as the denominator (Box 2). It is the amount of nutrients, typically per 1,000 kcal, that would Shifing fom energy-dense to nutrient-dense diets achieve the nutrient requirements. In other words, when a diet Increasing the nutrient content of the diet, while maintaining an is constituted with at least the critical nutrient density, one is adequate and appropriate energy content, is critical for wellbe- assured that the requisite amount of a nutrient of interest will ing along the life course as well as for the prevention of over- be consumed when energy needs are met. weight and obesity.15 It has been demonstrated that consuming nutrient-dense foods – such as green leaf vegetables, eggs and BOX 2: Calculations to compute the observed nuts – is associated with a modestly lower risk of cardiovascular and critical nutrient densities disease, diabetes and all-cause mortality.16 Shifing diets fom energy-dense to nutrient-dense will have a signifcant benef- cial efect on the risk of developing noncommunicable diseases Observed nutrient density Observed nutrient density = x 1,000 along the life course, helping to keep a high life expectancy and observed energy intake (kcal) quality of life. daily nutrient requirement (units) Critical nutrient density = x 1,000 “ Shiftng diets fom energy-dense daily energy requirement (kcal) to nutient-dense will have a signifcant benefcial efec on the The nutrient-density approach has shown itself to be a valu- able tool for nutrition education, dietary guidance and meal ris of developing noncommunicable planning.18,19 Almost half a century ago, the FAO and WHO diseases along the life course” proposed the use of nutrient densities as a means to account for known diferences in the energy and nutrient requirements of specifc population subgroups.20 Two decades ago, a consul- Nutrient density as a dimension of dietary quality tancy to the FAO suggested replacing the traditional measures The nutrient adequacy of a diet is typically assessed by com- of diet quality with the nutrient-density approach.21 The nutri- paring nutrient intakes with nutrient requirements, such as the ent-density concept was applied to the development of food- 2004 Food and Agriculture Organization of the United Nations based dietary guidelines in which foods that made a greater (FAO) and the World Health Organization (WHO) Recommended contribution to nutrient intakes were prioritized over meeting Nutrient Intakes (RNI).17 However, these measures do not ac- total energy needs.21 140 NUTRIENT DENSITY AS A DIMENSION OF DIETARY QUALITY table 1: Critical nutrient density for a ‘normal’ weight woman versus an ‘obese’ woman* Recommended nutrient intakes Critical nutrient density, unit/1,000 kcal (RNI),** unit/day Woman with a daily energy Woman with a daily energy requirement of 1,850 kcal *** requirement of 2,250 kcal **** Folate DFE (µg DFE) 400.0 216.2 17 7 .8 Pantothenate (mg) 5.0 2.7 2.2 Thiamine (mg) 1.1 0.6 0.5 Ribofavin (mg) 1.1 0.6 0.5 Niacin (mg NE) 14.0 7.6 6.2 Vitamin B₆ (mg) 1.3 0.7 0.6 Vitamin B₁₂ (µg) 2.4 1.3 1.1 Biotin (µg) 30.0 16.2 13.3 Vitamin C (mg) 45.0 24.3 20.0 Vitamin A (µg RE) 500.0 27 0.3 222.2 Vitamin D (µg) 5.0 2.7 2.2 Vitamin E (mg α-TE) 7.5 4.1 3.3 Vitamin K (µg) 55.0 29.7 24.4 Calcium (mg) 1,000.0 540.5 444.4 Iron (mg) 15% bioavailability 19.6 10.6 8.7 10% bioavailability 29.4 15.9 13.1 Magnesium (mg) 220.0 118.9 97 .8 Selenium (µg) 26.0 14.1 11.6 Zinc (mg) Medium bioavailability 4.9 2.7 2.2 Low bioavailability 9.8 5.3 4.4 Iodine (µg) 150.0 81.1 66.7 DFE = dietary folate equivalent, NE = niacin equivalents, RE = retinol equivalents, TE = tocopherol equivalents * Normal weight is defned as body mass index (BMI) of 18.5–25 kg/m² and obese is defned as BMI > 30 kg/m² ** Recommended Nutrient Intakes for women *** Energy requirement for a woman aged 30–59.9 years, with a mean weight of 55 kg and a sedentary lifestyle; assuming a height of 158 cm, her BMI would be 22.0 kg/m2, which is classifed as ‘normal’ **** Energy requirement for a woman aged 30–59.9 years, with a mean weight of 85 kg and a sedentary lifestyle; assuming a height of 158 cm, her BMI would be 34.0 kg/m2, which is classifed as ‘obese’ day diets requires the combination of nutrient-profiling meth- “ Designing food paterns that ods with other strategies for improving food habits and health. Designing food patterns that are simultaneously nutrient-rich, are simultaneousy nutient-ric, low-cost, culturally acceptable and environmentally fiendly is 22 low-cos, cultrally acceptable challenging. Several studies have shown that ‘empty’ calories tend to be cheap, whereas diets that include more nutrient-rich and environmentally fiendly foods are generally more expensive.9,23–25 is callenging” Investigational protocol in a multicenter evaluation Challenges of nutrient-dense diets A multinational survey protocol is currently being implemented Translating the concept of nutrient density into healthier every- in three diverse regions with fnding fom Sight and Life to fr- SIGHT AND LIFE | VOL. 33 (1) | 2019 NUTRIENT DENSITY AS A DIMENSION OF DIETARY QUALITY 141 ther explore the applications of the nutrient-density and critical- Characteristics of the survey sites in Asia, nutrient-density approaches in public health epidemiology. Afica and North America The aim of the investigation is to assess the dietary ad- Three distinct survey sites across three continents were chosen; equacy of the diet of normal weight (body mass index [BMI] these include Indonesia in Asia, Mexico in North America and of 18.5–25 kg/m²) and obese (BMI > 30 kg/m²) women in each South Afica in Afica (see Figure 1).
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