Progress in Nutrition 2018; Vol. 20, N. 3: 473-482 DOI: 10.23751/pn.v20i3.5314 © Mattioli 1885 Original Article Is the design of dietary based studies enough with a quantitative description? Ismael San Mauro Martín, Sara Bermejo de las Heras, Elena Garicano-Vilar Research department, Research Centers of Nutrition and Health (CINUSA group), Madrid, Spain E-mail: [email protected] Summary. Objective: A proper diet, from a macronutrients quantitative point of view, does not imply it is qualitatively correct. We demonstrate that quantitative dietary advice may be qualitatively deficient. Design and setting: A search for suitable recommendations of macronutrients contribution to total energy intake was performed. Two similar quantitative (15-25% proteins, 45-60% carbohydrates and 20-35% fat) but qualita- tively different weekly menus were designed using DIAL software. Menu A provides more fibre, MUFAs, vitamins, minerals and minor components of the diet than menu B and PUFAs/SFA index is higher. In menu B, SFA, cholesterol, glucose and sucrose levels are higher. Results: Menu A has better qualitative contribution of carbohydrates, fat, vitamins and minerals; it is better adjusted to the dietary reference values, and provides more phytochemicals components. It also has more fibre and less simple sugar. Menu B provides plenty of fructose mainly from soft drinks. Conclusions: Diet may be deficient if only planned taking in consideration the quantitative aspect. All of this can generate wrong study analyses and conclusions. Key words: diet habit, nutrients, qualitative evaluation, quantitative evaluation Introduction Spain and Europe have been selected: Spanish Society for the Study of Obesity (SEEDO), Fundación Espa- The analysis of the populations’ dietary patterns ñola de la Nutrición (FEN) and European Food Safety is a topical issue. The traditional Mediterranean diet Authority (EFSA). (MD) pattern (1), and somewhat less known, Japanese SEEDOs recommendations are collected in the model (2), arouse interest of experts for their protec- Federación Española de Sociedades de Nutrición, Ali- tive action against chronic diseases (cardiovascular mentación y Dietética (FESNAD)-SEEDO Consen- diseases (CVD) (1, 2), cancer (3), diabetes (4, 5), neu- sus (2011) (10), gathered after the review of existing ronal and degenerative diseases (6). However, it must scientific data to make recommendations to the maxi- be kept in mind that the key to these two dietary pat- mum evidence, and whose principal objective is to pre- terns is part of a healthy lifestyle (7, 8). Thus, efforts vent obesity and its co-morbidities. In the document, over the past 50 years have led to set of science-based it is recommended that consumption of carbohydrates nutritional requirements and dietary guidelines, in or- equals or exceeds 50% of total energy intake (recom- der to be transmitted to professionals in the field and mendation grade C, according to the SIGN system) society. Scientific authorities are responsible for issu- (11); most of complex carbohydrates type (more than ing these nutritional recommendations, understood by 25g/day fibre, and less than 10% of simple sugars). Mataix-Verdú (2009) (9) as a series of mainly quanti- Regarding the lipids, the document recognizes as tative parameters, which if followed by individuals, al- rigorous limit the one issued by the EFSA: between lows them have an “optimal” health. In this case, three 20-35% (if olive oil is consumed) of total energy in- recommendations of organisms of great recognition in take (12). It adds the recommendation to limit con- 474 I. San Mauro Martín, S. Bermejo de las Heras, E. Garicano-Vilar sumption of trans fats. As for proteins, the evidence are not static, they may vary through stages of life, es- regarding their consumption is insufficient to draw any pecially during first years (16) and old age (17, 18). recommendation, but limits the consumption of meat These recommendations are used by professionals and meat products to prevent weight gain (recommen- in nutrition and health for setting standards in the cor- dation grade C) (10). rect nutrition, through food and health, of the popula- El libro blanco de la nutrición en España (13), pro- tion they serve, either in public health services, private duced by the FEN, issues recommendations based services or managing quality control of scientific stud- on reviews of sources of information concerning the ies and recommendations of public health and com- nutritional status of the Spanish population. As a munity nutrition (9). recommendation for carbohydrates, it states that they Despite all this, a study has shown that the quan- should contribute between 55-60% of total energy titative character of a diet (proportion of energy pro- intake, preferably being of complex type. It empha- vided by each macronutrient) is not comparable to its sizes the importance of dietary fibre, counselling the qualitative nature (quality of macronutrients) (16). A consumption of 25-30 g/day of non-absorbable car- diet based on whole grains, as opposed to a refined bohydrates and increase the consumption of products grain-based diet is an example. Empirical evidence made of whole wheat flour, legumes, vegetables, fruit has shown that increasing obesity is associated with and vegetables, and decrease the consumption of pas- increased consumption of foods based on refined prod- tries. Lipids should provide between 20-35% of total ucts. This is due to the 50% decrease of postprandial energy intake, less than 10% of saturated fatty acids energy expenditure compared to whole grain foods, ac- (SFA), and less than 7% of polyunsaturated fatty ac- cording to Barr and Wright (19), while consumption ids (PUFAs). As for proteins, it recommends provid- of whole grains has been linked in several studies with ing 0.8 g of protein/Kg of body weight/day, repre- a decrease in weight and body mass index (BMI) (20, senting 8-15% of the contribution to the total energy 21); getting itself to manifest, in some cases, a decrease intake. It is important to obtain proteins through of up to 22% probability of becoming overweight just high biological value proteins. with a regular consumption of whole grain breakfast Finally, the EFSA sets dietary reference values cereals (22). Some authors suggest (23, 24) that these (DRV), providing a recommendation for carbohy- whole grains protective actions versus refined grains, drates of 45-60% of total energy intake, with impor- owing to grains fibre, contains, along with fibre from tant fibre intake (25 g/day) (14). However, the expert fruits, vegetables and legumes, phytochemicals ex- committee considers that there is insufficient evidence tracts that are responsible for important antioxidant, to set a minimum limit of carbohydrate intake, so this anticancer and anti-inflammatory functions beneficial is an illustrative percentage (14). As for proteins and for health. The amount of plentiful and varied phyto- lipids, it recommends the consumption of 13-20% chemicals in grains could be the reason of the many of proteins of total energy intake (15), and 20-35% protective effects of whole grains versus refined grains, of lipids (12). It stresses the importance of limiting and one of the reasons that could explain the differ- consumption of SFA (less than 10% of total energy ences between the quantitative and the qualitative diet. intake) and trans fats, because it claims that there is However, such protection is attributed to a synergis- sufficient evidence to confirm that a high consumption tic effect of the complex mixture of phytochemicals in of both causes an increase in plasma cholesterol and, plant foods and/or whole grain foods, and not to a spe- consequently, the risk of CVD. Adults must pay atten- cific isolated phytochemical. Its mechanism and even tion to consumption of omega-3 (ω3) polyunsaturated interactions remains a challenge (25). fatty acids, consuming 250 mg/day, to reduce the risk In order to establish indicative of the quality val- of CVD. ues of the diet, Diet Quality Index (DQI) algorithms Some studies (16-18) have gone into more detail have been developed to evaluate their overall qual- within these official recommendations. The contribu- ity (based on quantities of certain nutrients, foods, or tions of each macronutrient to the total energy values both) and to categorize individuals according to their Is the design of dietary based studies enough with a quantitative description? 475 more or less healthy eating pattern, and in that way Results determine risk factors for non-communicable chron- ic diseases (26). It is important to use accepted and Table 1 lists the nutritional evaluations of menu A validated methods by the international community to (Table 2) and menu B (Table 3, according to the EFSA estimate food consumption as accurately as possible recommendations (12) and the DRV of the FESNAD and avoid biases (for invalidity) and random errors (for (29). These two menus, despite being normocaloric and inaccuracy) (27). having a quantitative profile according to the EFSAs It is hypothesized that studies based on dietary guidelines, have some notable qualitative differences. treatments, and/or based on diets with different char- According to the results obtained through the DIAL acteristics, show incomplete information to under- software, the amounts of sugars in both cases are much stand the study’s design and results. higher than recommended (less than 10% of total Due to the emergence of important studies in energy intake). However, it is noteworthy that this the field of nutrition, we believe that a more detailed recommendation applies, according to World Health methodology conducted in such studies is necessary to Organization (WHO), to all added sugars and sugars avoid bias in future studies and for better understand- naturally present in foods such as honey, syrups and ing. A quantitative diet is not enough to understand fruit concentrates, but not fruits as such. The software and determine whether a dietary treatment or a food also incorporates mono- and disaccharides in these pattern is appropriate or not.