nu val making good nutrition easy
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View Dr. Katz full webinar archive at: http://healthpromotionlive.comTRANSCRIPT
NuVal™& the Overall Nutritional Quality Index (ONQI)
-knowledge to power-
David L. Katz, MD, MPH, FACPM, FACPAssociate Professor, adjunct, Public Health Practice
Director, Prevention Research Center
Yale University School of Medicinewww.davidkatzmd.com
Webinar6/4/10
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?
Sodium
73 mg
Sodium
131 mg
Sodium
242 mg
Sodium
100 mg
Added sugar per 100kcal?
Sugar 12 G
Sugar 11 G
Which one of these products is the more nutritious choice?
Nutrition Quiz – Peanut Butter
Nutrition Quiz – Peanut Butter
Answer: Regular Peanut Butter
A little nutty…
NutrientPeanut Butter Reduced Fat
Peanut Butter
Sodium 150mg 250mg
Total Carbohydrate/sugar 7g 15g
Added Sugar* 3g 4g
Saturated Fat/Trans Fat 3g/0g 2.5g/0g
Fiber 2g 1g
Calories 190/32g 190/36g
NuVal SCORE 23 17
Power & Responsibility, but backwards…
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-
Numerator Denominator
FiberFolateVitamin AVitamin CVitamin DVitamin EVitamin B12Vitamin B6PotassiumCalciumZincOmega-3 fatty acidsTotal bioflavanoidsTotal carotenoidsMagnesiumIron
Saturated fatTrans fatSodiumSugarCholesterol
•Macronutrient AdjustorsFat quality
Protein quality
Glycemic load
Energy density
•Trajectory Scores
•Weighting Coefficients
Categorical stipulations
• Pure foods vs.
processed
• Intrinsic vs. added
sugars
• Artificial sweeteners
• Etc.
ONQI formulaSomething 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 & Poultry
SeafoodTurkey Breast (skinless) 48Chicken Breast (boneless) 39Pork Tenderloin 35Bottom Round Roast (Beef) 34Flank Steak (Beef) 34Breast 31Veal Chop 31Veal Leg Cutlet 31Beef Tenderloin 30Chicken Drumstick 30Ground Sirloin (Beef 90/10) 30Pork Chop (boneless center) 28Chicken Wings 28Ground Round (Beef 85/15) 28Lamb Chops (loin) 28Leg of Lamb 28Ham (whole) 27Ground Chuck (Beef 80/20) 26Pork Ribs, Country Style 25Beef Spareribs 24Pork Baby Back Ribs 24
Atlantic Salmon Fillet 87Atlantic Halibut Fillet 82Catfish Fillet 82Cod Fillet 82Tilapia Fillet 82Oysters 81Swordfish Steak 81Prawns 75Shrimp 75Clams 71Monkfish Fillet 64Bay Scallops 51Turbot Fillet 51Lobster 36
Birds Eye Frozen Cauliflower Floret plastic bag 100Birds Eye Frozen Chopped Spinach box 100Green Giant Frozen Broccoli Cuts steamable bag 100Green Giant Frozen Cut Green Beans steamable bag 100Birds Eye Frozen Peas polybag 96La Choy Frozen Snow Pea Pods box 96Birds Eye Steamfresh Frozen Brussels Sprouts steamable bag 94Birds Eye Frozen Cooked Winter Squash box 91Green Giant Frozen Mixed Vegetables steamable bag 87Birds Eye Frozen Asparagus Stir Fry plastic bag 82Birds Eye Frozen Green Beans & Lightly Toasted Almonds box 68Green Giant Frozen Cauliflower & 3 Cheese Sauce plastic bag 42
Green Giant Frozen Creamed Spinach in Low-Fat Sauce box 34Birds Eye Steamfresh Specially Seasoned Southwestern Corn 33Green Giant Frozen Sweet Baby Peas and Low-Fat Butter Sauce 30Green Giant Frozen Honey Glazed Carrots box 26Green Giant Frozen Green Bean Casserole box 23
Apricots 100
Asparagus 100
Beans 100
Blueberries 100Broccoli 100Cabbage 100Cauliflower 100Kiwi 100Lettuce 100Mustard Greens 100Okra 100
Orange 100Spinach 100Strawberries 100Turnip 100Carrots 99Grapefruit 99Pineapple 99Plums 99Mango 93Potatoes 93Red onions 93Tangerines 93Bananas 91Corn 91Grapes 91Honeydew Melon 91Rhubarb 91Iceberg Lettuce 82Bok Choy 81Passion Fruit 78Coconut 24
Produce
Canned Vegetables
Frozen Vegetables
Del Monte Fresh Cut French Style Green Beans No Salt 100Del Monte Fresh Cut Whole Leaf Spinach 76Del Monte Fresh Cut Sweet Corn Cream Style No Salt Added 67Del Monte Fresh Cut Whole Green Beans 59Green Giant Extra Long Tender Green Asparagus Spears 56Green Giant Cut Green Beans 52Del Monte Organic Whole Kernel Corn 50Green Giant Sweet Peas 50% Less Sodium 48Le Sueur Very Young Small Sweet Peas 43Green Giant Super Sweet Yellow & White Whole Kernel Corn 42Del Monte Organic Sweet Peas 39Veg-All Homestyle Large Cut Vegetables 35Del Monte Fresh Cut Sweet Corn Cream Style 32Green Giant Niblets Whole Sweet Corn 27Progresso Artichoke Hearts 18Aunt Nellie's Whole Ruby Red Pickled Beets 3
Hodgson Mill Unprocessed Wheat Bran 100Post Shredded Wheat Original 91Kashi 7 Whole Grain Puffs 91Kellogg's All-Bran 76Kellogg's Special K Protein Plus 60Quaker Shredded Wheat 56General Mills Fiber One 52Kashi Golean High Protein & High Fiber 47General Mills Cinnamon Toast Crunch 40Quaker Instant Oatmeal Original 39General Mills Cheerios 34Post Shredded Wheat Frosted 31Kellogg's All-Bran 31Post HealthyClassics Grape-Nuts 30Post Honey Bunches Of Oats with Almonds 29Kashi 7 Whole Grain Flakes 29General Mills Kix 29General Mills Wheaties 28General Mills Whole Grain Total Raisin Bran 27Post Healthy Classics Raisin Bran 26Kellogg's Frosted Flakes 26Kellogg's Corn Flakes 25
Post Fruity Pebbles 24Kellogg's Mueslix 24General Mills Corn Chex 24Cream Of Wheat Instant Hot Cereal 24Quaker Natural Granola Oats, Honey & Raisins 23Kellogg's Rice Krispies 23General Mills Basic 4 23General Mills Lucky Charms 23Kellogg's Corn Pops 20Kellogg's Froot Loops 17Kashi Strawberry Fields 11
Cap'n Crunch 10Quaker Instant Grits Butter Flavor 6
Garden of Eatin No Salt Blue Tortilla Chips 52
Terra unsalted potato chips barbecue 41
Garden of Eatin Blue Tortilla Chips 40
Terra Gold Original Potato Chips 33
Snyder's Multigrain Pretzel Sticks Lightly Salted 31
Guiltless Gourmet Chili Lime Tortilla Chips 30
Tostitos Light Restaurant Style 28
Utz Baked Potato Crisps Original 27
Good health peanut butter filled pretzels 26
Doritos Baked Nacho Cheese 25
Frito-Lay Sun Chips Harvest Cheddar 25
Lay's Baked Potato Crisps 25
Baked Ruffles Cheddar & Sour Cream 24
Newman's Own Organic Pretzel Rounds Unsalted 24
Ruffles Thick Cut Original 24
Doritos Cool Ranch 23
Lay's Potato Chips Classic 23
Snyder's Pretzels Honey Wheat o 23
Sunshine cheez-it party mix 20
Newman's Own Organic Pretzel Rounds Salted 19
Fritos Corn Chips Original 16
Cheetos Puffs 14
Rold Gold Petzels Rods 14
Chex Mix Traditional 13
Doritos Nacho Cheese 10
Rold Gold Pretzel Sticks Fat Free 10
Pringles Reduced Fat Original 9
Ruffles Cheddar & Sour Cream 9
Cheetos Crunchy 5
Utz Potato Chips Barbecue 4
Combos Pretzel Cheddar Cheese 3
Bugles Original Corn Snack 2
Glutino Pretzel Twists Gluten Free 1
Cereal Salty Snacks
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)
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]
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
*Remaining ONQI categories are not applicable
The NuVal™ Nutritional Scoring System, based on the Overall Nutritional
Quality Index (ONQI) algorithm is found in 6 supermarket chains, and over
550 stores, in the US currently
ONQI algorithm includes >30 nutrients and food properties
The algorithm also incorporates measures of energy density and
macronutrient quality and coefficients are weighted based on strength of
association disease risk
Study 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
Outcome Measurement: Total major chronic disease: initial occurrence of
CVD, diabetes or cancer or non-trauma-related death from 1986 to 2006
ONQI score assessment: Dietary data collected through food frequency
questionnaires at baseline (1986) , categorized according to 24 different food
categories. 100 point scale was applied, multiplied by frequency of
consumption, summed for all foods and then weighted by total servings.
Statistical Analysis
Multivariate Cox proportional hazard models
Do nutrition rating systems promote a healthy diet?An evaluation of the Overall Nutritional Quality Index (ONQI) and risk of chronic disease
CONCLUSIONS
BACKGROUND
Figure1. The components of the Overall Nutritional Quality Index
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 Women's Hospital and Harvard Medical School, Boston, MA
Diets comprised of foods with higher average ONQI
scores, which incorporates over 30 nutrients, food
properties and magnitude of association with disease, is
associated with lower risk of total chronic disease and
total mortality
Future research on nutrient profiles should use similar
techniques to validate the healthfulness of scoring
schemes against health outcomes
Any scoring scheme regulated or adopted by the FDA for
standardized front-of-package labeling on supermarket
shelves should be based upon the best available scientific
evidence and predict risk of chronic disease
The mean (SD) of the ONQI score was 23.0 (7.3) in the
men and 24.3 (6.9) in the women
Women: 20,005 chronic disease events (4,433 CVD,
11,249 cancer, 5,265 diabetes and 2,994 deaths)
Men: 13,532 chronic disease events (4,195 CVD, 4,939
cancer, 2,407 diabetes and 1,928 deaths)
ONQI scores were inversely associated with risk of total
chronic disease and mortality among men and women
(Table 1, Figure 2)
The ONQI score was most strongly associated with lower
risk of CVD and diabetes among women and men (Figure
2)
SUMMARY
Nutrient profiling is a system of ranking or classifying foods based on nutrient
composition. These profiles can be used to communicate the nutritional
quality of a food product to consumers.
Symbols aim to rank foods on the basis of health effects, however they have
not been evaluated with respect to chronic disease risk.
RESULTS
METHODS
1.02 1.04
0.91*0.88*
0.80*
0.89*0.85*
0.79*
0
0.2
0.4
0.6
0.8
1
1.2
CVD Diabetes Cancer Total
Mortality
Re
lati
ve
ris
k o
f d
ise
as
eWOMEN
MEN
* p<0.05 comparing quintile 5 to quintile 1
NuVal™ SCORING SYSTEM
OBJECTIVE
To develop the Overall Nutritional Quality Index (ONQI) score for two large
ongoing prospective cohorts, the Nurses Healthy Study’s (NHS) and Health
Professional Follow Up Study’s (HPFS) 1986 food frequency questionnaires
(FFQ) and test the ability of ONQI to predict major chronic disease risk.
Figure 2. Multivariate- adjusted relative risk of disease comparing the highest to
lowest quintile of the Overall Nutritional Quality Index
Risk factors associated with ONQI score
Direct association with:
- Exercise
- Alcohol intake
- Hypertension
- Hypercholesterolemia
- Menopausal hormone use
Inverse association with:
- BMI
- Smoking
- Regular aspirin use
Acknowledgements
This study was supported by research grants HL34594, HL60712, CA87969, and CA58895 from the NIH
CONTACT: [email protected]
LIMITATIONS
ONQI algorithm and NuVal system designed to measure
nutritional quality at the food level, and not for an overall
diet evaluation
FFQ is not brand specific and does not distinguish food
preparation (ie canned, frozen, fresh)
Analysis based on single measure of diet at baseline
These limitations lead to non-differential misclassification
of the ONQI score and bias the results towards the null
NumeratorFolate, Potassium,
Fiber, Calcium,
Zinc, Magnesium,
Omega-3 Fat,
Flavonoids, Iron,Carotenoids
VitaminsA/C/D/E/
B6/B12
Denominator
Saturated Fat
Trans Fat
Sodium
SugarCholesterol
●●
NuVal™ Score
STRENGTHS
Use of an aggregate total chronic disease outcome, which
is a valuable measure to evaluate the healthfulness of
nutrient profiling systems
ONQI algorithm is a single summative score that balances
complex trade-offs between the beneficial and detrimental
nutrients within a food
ONQI algorithm is applied to all foods, which allows for
comparison within and across food groups
Food Category* FFQ Foods (number)
Vegetable 22, no added salt
Nearly Pure Vegetable 1, added salt
Milk & Nearly Pure Dairy 4, no added salt or hydrogenated oil (H)
Nearly Milk 4, added salt, no H
Cooking Oil 2 excluding trans oils
Grains 6 including 5 cereals
Pure Meats 12
Nearly Pure Meats 2, added salt
Cold Beverages 3, sugar substituted
Fruits 9 men, 11 women
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 a
SNAP 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, FACPDirector, Yale Prevention Research Center
President, Turn the Tide Foundation, Inc.
130 Division St.
Derby, CT 06418
(203) 732-1265
www.davidkatzmd.com