NuVal™ & the Overall Nutritional Quality Index (ONQI) -knowledge to power-David L. Katz, MD, MPH, FACPM, FACP Associate Professor, adjunct, Public Health Practice Director, Prevention Research Center Yale University School of Medicine www.davidkatzmd.com Webinar 6/4/10
we live where good advice… “Eat food, not too much, mostly plants.” Michael Pollan …can be hard to swallow!-
Even when clear where “there” is- -it may seem… you can’t get there from here:
The case for skill power, not just will power.
Because people need to know things-they never knew they never knew!… Sodium content per 100 calories?
With what…FDA or IOM should have done: July, 2003 Katz DL. A food supply for dummies. Op-Ed: Hartford Courant; NY Newsday; etc. 10/03 Feb, 2006: If you want something done… and the rest is history…
ONQI Scientific Expert/Development Panel Chair: Dr. David Katz, Yale University School of Medicine Dr Keith Ayoob, Albert Einstein College of Medicine Dr Leonard Epstein, University of Buffalo; inventor, Traffic Light Diet Dr David Jenkins, University of Toronto; inventor, Glycemic Index Dr Francine Kaufman, USC; Past President, American Diabetes Association Dr Robert Kushner, Northwestern University Dr Ronald Prior, Arkansas Children’s Nutrition Center, USDA HNRC Dr Rebecca Reeves, Past President, American Dietetic Association Dr Barbara Rolls, Pennsylvania State University Dr Sachiko St. Jeor, University of Nevada Dr John Seffrin, President & CEO, American Cancer Society Dr Walter Willett, Harvard University 16 invitations extended; 14 acceptances Project Coordinators: Debbie Kennedy, PhD; Zubaida Faridi, MD, MPH: PRC Statistician/Data Analyst: Valentine Njike, MD, MPH: PRC Dietitians: Judy Treu, MS, RD; Lauren Rhee, MS, RD: PRC Others consulted
The ONQI Algorithm- •Macronutrient Adjustors Numerator Denominator Fat quality Protein quality Fiber Saturated fat Glycemic load Folate Trans fat Energy density Vitamin A Sodium Vitamin C Sugar Vitamin D Cholesterol •Trajectory Scores Vitamin E •Weighting Coefficients Vitamin B12 Vitamin B6 Potassium Categorical stipulations Calcium Zinc • Pure foods vs. Omega-3 fatty acids processed Total bioflavanoids • Intrinsic vs. added Total carotenoids sugars Magnesium • Artificial sweeteners Iron • Etc.
ONQI formula Something like: (1+UA1)×(1+UA2)×(1+ WP1×WS1×WR1×(adjustedTS1)+ ------------------ +WP16× WS16× WR16×(adjustedTS16 )) __________________________________________________________________ GL×ED×(1+WP1×WS1×WR1×(adjustedTS1)+ ---- +WP5×WS5×WR5×(adjustedTS5)) Variables in Formula TS = trajectory score Wp = weighting coefficient, prevalence Ws = weighting coefficient, severity Wr= weighting coefficient, relative impact UA1= adjuster for biological quality of fat UA2= adjustor for biological quality of protein ED= energy density adjuster GL= glycemic load adjuster Adjusted= pertinent mathematical transformations And in all its (gore or) glory: 20 pages of mind-numbing computer programming
Vrrrooommm- Under the Hood: undeniable (& distinctly advantageous) complexity At the User Interface: turnkey simplicity
A Sampling of Scores Beef & PoultryTurkey Breast (skinless) 48Chicken Breast (boneless) 39 SeafoodPork Tenderloin 35 Atlantic Salmon Fillet 87Bottom Round Roast (Beef) 34 Atlantic Halibut Fillet 82Flank Steak (Beef) 34 Catfish Fillet 82Breast 31 Cod Fillet 82Veal Chop 31 Tilapia Fillet 82Veal Leg Cutlet 31 Oysters 81Beef Tenderloin 30 Swordfish Steak 81Chicken Drumstick 30 Prawns 75Ground Sirloin (Beef 90/10) 30 Shrimp 75Pork Chop (boneless center) 28 Clams 71Chicken Wings 28 Monkfish Fillet 64Ground Round (Beef 85/15) 28 Bay Scallops 51Lamb Chops (loin) 28 Turbot Fillet 51Leg of Lamb 28 Lobster 36Ham (whole) 27Ground Chuck (Beef 80/20) 26Pork Ribs, Country Style 25Beef Spareribs 24Pork Baby Back Ribs 24
Canned Vegetables Del Monte Fresh Cut French Style Green Beans No Salt 100 Del Monte Fresh Cut Whole Leaf Spinach 76 Del Monte Fresh Cut Sweet Corn Cream Style No Salt Added 67 Produce Del Monte Fresh Cut Whole Green Beans Green Giant Extra Long Tender Green Asparagus Spears 59 56Apricots 100 Green Giant Cut Green Beans 52Asparagus 100 Del Monte Organic Whole Kernel Corn 50Beans 100 Green Giant Sweet Peas 50% Less Sodium 48Blueberries 100 Le Sueur Very Young Small Sweet Peas 43Broccoli 100 Green Giant Super Sweet Yellow & White Whole Kernel Corn 42Cabbage 100 Del Monte Organic Sweet Peas 39Cauliflower 100 Veg-All Homestyle Large Cut Vegetables 35Kiwi 100 Del Monte Fresh Cut Sweet Corn Cream Style 32Lettuce 100 Green Giant Niblets Whole Sweet Corn 27Mustard Greens 100 Progresso Artichoke Hearts 18Okra 100 Aunt Nellies Whole Ruby Red Pickled Beets 3Orange 100Spinach 100StrawberriesTurnip 100 100 Frozen VegetablesCarrots 99 Birds Eye Frozen Cauliflower Floret plastic bag 100Grapefruit 99 Birds Eye Frozen Chopped Spinach box 100Pineapple 99 Green Giant Frozen Broccoli Cuts steamable bag 100Plums 99 Green Giant Frozen Cut Green Beans steamable bag 100Mango 93 Birds Eye Frozen Peas polybag 96Potatoes 93 La Choy Frozen Snow Pea Pods box 96Red onions 93 Birds Eye Steamfresh Frozen Brussels Sprouts steamable bag 94Tangerines 93 Birds Eye Frozen Cooked Winter Squash box 91Bananas 91 Green Giant Frozen Mixed Vegetables steamable bag 87Corn 91 Birds Eye Frozen Asparagus Stir Fry plastic bag 82Grapes 91 Birds Eye Frozen Green Beans & Lightly Toasted Almonds box 68Honeydew Melon 91 Green Giant Frozen Cauliflower & 3 Cheese Sauce plastic bag 42Rhubarb 91 Green Giant Frozen Creamed Spinach in Low-Fat Sauce box 34Iceberg Lettuce 82 Birds Eye Steamfresh Specially Seasoned Southwestern Corn 33Bok Choy 81 Green Giant Frozen Sweet Baby Peas and Low-Fat Butter Sauce 30Passion Fruit 78 Green Giant Frozen Honey Glazed Carrots box 26Coconut 24 Green Giant Frozen Green Bean Casserole box 23
Cereal Salty SnacksHodgson Mill Unprocessed Wheat Bran 100 Garden of Eatin No Salt Blue Tortilla Chips 52Post Shredded Wheat Original 91 Terra unsalted potato chips barbecue 41Kashi 7 Whole Grain Puffs 91 Garden of Eatin Blue Tortilla Chips 40Kelloggs All-Bran 76 Terra Gold Original Potato Chips 33Kelloggs Special K Protein Plus 60 Snyders Multigrain Pretzel Sticks Lightly Salted 31Quaker Shredded Wheat 56 Guiltless Gourmet Chili Lime Tortilla Chips 30General Mills Fiber One 52 Tostitos Light Restaurant Style 28Kashi Golean High Protein & High Fiber 47 Utz Baked Potato Crisps Original 27General Mills Cinnamon Toast Crunch 40 Good health peanut butter filled pretzels 26Quaker Instant Oatmeal Original 39 Doritos Baked Nacho Cheese 25General Mills Cheerios 34 Frito-Lay Sun Chips Harvest Cheddar 25Post Shredded Wheat Frosted 31 Lays Baked Potato Crisps 25Kelloggs All-Bran 31 Baked Ruffles Cheddar & Sour Cream 24Post HealthyClassics Grape-Nuts 30 Newmans Own Organic Pretzel Rounds Unsalted 24Post Honey Bunches Of Oats with Almonds 29 Ruffles Thick Cut Original 24Kashi 7 Whole Grain Flakes 29 Doritos Cool Ranch 23General Mills Kix 29 Lays Potato Chips Classic 23General Mills Wheaties 28 Snyders Pretzels Honey Wheat o 23General Mills Whole Grain Total Raisin Bran 27 Sunshine cheez-it party mix 20Post Healthy Classics Raisin Bran 26 Newmans Own Organic Pretzel Rounds Salted 19Kelloggs Frosted Flakes 26 Fritos Corn Chips Original 16Kelloggs Corn Flakes 25 Cheetos Puffs 14Post Fruity Pebbles 24 Rold Gold Petzels Rods 14Kelloggs Mueslix 24 Chex Mix Traditional 13General Mills Corn Chex 24 Doritos Nacho Cheese 10Cream Of Wheat Instant Hot Cereal 24 Rold Gold Pretzel Sticks Fat Free 10Quaker Natural Granola Oats, Honey & Raisins 23 Pringles Reduced Fat Original 9Kelloggs Rice Krispies 23 Ruffles Cheddar & Sour Cream 9General Mills Basic 4 23 Cheetos Crunchy 5General Mills Lucky Charms 23 Utz Potato Chips Barbecue 4Kelloggs Corn Pops 20 Combos Pretzel Cheddar Cheese 3Kelloggs Froot Loops 17 Bugles Original Corn Snack 2Kashi Strawberry Fields 11 Glutino Pretzel Twists Gluten Free 1Capn Crunch 10Quaker Instant Grits Butter Flavor 6
NuVal con tempo >45,000 foods scored and audited in 600 supermarkets in 21 states; rolling out to hundreds more this year Recently adopted by Kroger, largest independent grocer in U.S. Searchable on-line database in May, 2010
NuVal is going to school… Independence School District, MO New Haven, CT Palm Beach County, FL
…But has already been tested: proof in the pudding (and everywhere else)
A quick DASH toward validation- 7 days of DASH study meal plan at 2300mg Na level Composite recipe scoring technique Mean ONQI score: 46* (95% CI: 40 to 53) NHANES 2003-2006 cohort (n = 15,900) Composite recipe scoring technique Mean ONQI score: 26.5* (95% CI: 26.4 to 26.6) Correlation with quartiles of HEI-2005: R = 0.52; p<0.0001 *p<0.01 Katz DL, Njike VY, Rhee LQ, Reingold A, Ayoob KT. Performance characteristics of NuVal and the Overall Nutritional Quality Index (ONQI). Am J Clin Nutr. 2010 Feb 24. [Epub ahead of print]
Do nutrition rating systems promote a healthy diet? An evaluation of the Overall Nutritional Quality Index (ONQI) and risk of chronic disease Laura Sampson1, Stephanie E. Chiuve1,3 and Walter C. Willett1,2,4 Departments of Nutrition1 and Epidemiology2, Harvard School of Public Health; Division of Preventive Medicine3 and Channing Laboratory4, Department of Medicine, Brigham and Womens Hospital and Harvard Medical School, Boston, MA BACKGROUND RESULTS SUMMARYNutrient profiling is a system of ranking or classifying foods based on nutrient Food Category* FFQ Foods (number) The mean (SD) of the ONQI score was 23.0 (7.3) in the composition. These profiles can be used to communicate the nutritional men and 24.3 (6.9) in the women quality of a food product to consumers. Vegetable 22, no added salt Women: 20,005 chronic disease events (4,433 CVD, Nearly Pure Vegetable 1, added salt 11,249 cancer, 5,265 diabetes and 2,994 deaths)Symbols aim to rank foods on the basis of health effects, however they have not been evaluated with respect to chronic disease risk. Milk & Nearly Pure Dairy 4, no added salt or hydrogenated oil (H) Men: 13,532 chronic disease events (4,195 CVD, 4,939 Nearly Milk 4, added salt, no H cancer, 2,407 diabetes and 1,928 deaths) OBJECTIVE Cooking Oil 2 excluding trans oils ONQI scores were inversely associated with risk of totalTo develop the Overall Nutritional Quality Index (ONQI) score for two large chronic disease and mortality among men and women Grains 6 including 5 cereals ongoing prospective cohorts, the Nurses Healthy Study’s (NHS) and Health (Table 1, Figure 2) Professional Follow Up Study’s (HPFS) 1986 food frequency questionnaires Pure Meats 12 The ONQI score was most strongly associated with lower (FFQ) and test the ability of ONQI to predict major chronic disease risk. Nearly Pure Meats 2, added salt risk of CVD and diabetes among women and men (Figure Cold Beverages 3, sugar substituted 2) NuVal™ SCORING SYSTEM Fruits 9 men, 11 women LIMITATIONS Figure1. The components of the Overall Nutritional Quality Index *Remaining ONQI categories are not applicable ONQI algorithm and NuVal system designed to measure nutritional quality at the food level, and not for an overall Numerator Denominator NuVal™ Score diet evaluation Folate, Potassium, Saturated Fat Figure 2. Multivariate- adjusted relative risk of disease comparing the highest to FFQ is not brand specific and does not distinguish food Fiber, Calcium, lowest quintile of the Overall Nutritional Quality Index Zinc, Magnesium, ● Trans Fat 1.2 WOMEN * p<0.05 comparing quintile 5 to quintile 1 preparation (ie canned, frozen, fresh) Analysis based on single measure of diet at baseline Sodium ● Omega-3 Fat, MEN 1.02 1.04 These limitations lead to non-differential misclassification Flavonoids, Iron, 1 Sugar 0.91* 0.89* of the ONQI score and bias the results towards the null Carotenoids 0.88* Relative risk of disease 0.85* 0.80* 0.79* VitaminsA/C/D/E/ Cholesterol 0.8 STRENGTHS B6/B12The NuVal™ Nutritional Scoring System, based on the Overall Nutritional 0.6 Quality Index (ONQI) algorithm is found in 6 supermarket chains, and over Use of an aggregate total chronic disease outcome, which is a valuable measure to evaluate the healthfulness of 550 stores, in the US currently 0.4 nutrient profiling systemsONQI algorithm includes >30 nutrients and food properties ONQI algorithm is a single summative score that balancesThe algorithm also incorporates measures of energy density and 0.2 complex trade-offs between the beneficial and detrimental macronutrient quality and coefficients are weighted based on strength of nutrients within a food association disease risk 0 ONQI algorithm is applied to all foods, which allows for METHODS comparison within and across food groups CVD Diabetes Cancer Total Mortality CONCLUSIONSStudy populations: 62,287 women from the NHS and 42,559 men from HPFS, free of disease at baseline in 1986, were followed for 20 years Diets comprised of foods with higher average ONQIOutcome Measurement: Total major chronic disease: initial occurrence of scores, which incorporates over 30 nutrients, food CVD, diabetes or cancer or non-trauma-related death from 1986 to 2006 Risk factors associated with ONQI score properties and magnitude of association with disease, isONQI score assessment: Dietary data collected through food frequency associated with lower risk of total chronic disease and questionnaires at baseline (1986) , categorized according to 24 different food Direct association with: Inverse association with: total mortality categories. 100 point scale was applied, multiplied by frequency of - Exercise - BMI Future research on nutrient profiles should use similar consumption, summed for all foods and then weighted by total servings. - Alcohol intake - Smoking techniques to validate the healthfulness of scoringStatistical Analysis - Hypertension - Regular aspirin use schemes against health outcomesMultivariate Cox proportional hazard models - Hypercholesterolemia Any scoring scheme regulated or adopted by the FDA for Acknowledgements standardized front-of-package labeling on supermarket This study was supported by research grants HL34594, HL60712, CA87969, and CA58895 from the NIH - Menopausal hormone use shelves should be based upon the best available scientific CONTACT: firstname.lastname@example.org evidence and predict risk of chronic disease
Eating to live… RR of all-cause mortality, top vs. bottom quintile of NuVal scores NHS: RR = 0.88; p<0.001 (n ~ = 70,000) HPFS: RR = 0.87; p = 0.001 (n ~ = 40,000) Chiuve S, Willett WC et al. Harvard School of Public Health Experimental Biology 2010
Money where mouths are? It’s aSNAP Directly link measure of nutritional quality to purchasing power of food stamps In any given food category (e.g., bread), use NuVal scores to stratify into quartiles For foods purchased in bottom quartile of overall nutritional quality, $1 of vouchers would be worth $1 $1.25 in next quartile $1.50 in next quartile $2 in top quartile Concept applicable to any assistance program or to public at large via public/private partnership involving retailers and loyalty card programs
Thank you! David L. Katz, MD, MPH, FACPM, FACP Director, Yale Prevention Research Center President, Turn the Tide Foundation, Inc. 130 Division St. Derby, CT 06418 (203) 732-1265 David.email@example.com www.davidkatzmd.com