NuVal-& the Overall Nutritional Quality Index (ONQI)-
David L. Katz, MD, MPH, FACPM, FACPDirector, Prevention Research Center
Yale University School of Medicine
Principal Inventor, ONQIChief Science Officer, NuVal, LLC
www.davidkatzmd.com
IOMPublic Forum
Washington, D.C.4-9-10
And clearly isn’t going down:
Blanck HM, Gillespie C, Kimmons JE, Seymour JD, Serdula MK. Trends in fruit and vegetable consumption among U.S. men and women, 1994-2005. Prev Chronic Dis. 2008;5:A35. Epub 2008 Mar 15
Katz DL. Plant foods in the American diet? As we sow... Medscape J Med. 2009;11(1):25. Epub 2009 Jan 26
What…FDA or IOM might have done:
n July, 2003q Katz DL. A food supply for dummies. Op-Ed: Hartford Courant;
NY Newsday; etc. 10/03
n Feb, 2006: If you want something done…§ and the rest is history…
ONQI Scientific Expert/Development Panel
n Chair: Dr. David Katz, Yale University School of Medicine
n Dr Keith Ayoob, Albert Einstein College of Medicinen Dr Leonard Epstein, University of Buffalo; inventor, Traffic Light Dietn Dr David Jenkins, University of Toronto; inventor, Glycemic Indexn Dr Francine Kaufman, USC; Past President, American Diabetes Associationn Dr Robert Kushner, Northwestern Universityn Dr Ronald Prior, Arkansas Children’s Nutrition Center, USDA HNRCn Dr Rebecca Reeves, Past President, American Dietetic Associationn Dr Barbara Rolls, Pennsylvania State Universityn Dr Sachiko St. Jeor, University of Nevadan Dr John Seffrin, President & CEO, American Cancer Societyn Dr Walter Willett, Harvard University
q 16 invitations extended; 14 acceptances
q Project Coordinators: Debbie Kennedy, PhD; Zubaida Faridi, MD, MPH: PRCq Statistician/Data Analyst: Valentine Njike, MD, MPH: PRCq Dietitians: Judy Treu, MS, RD; Lauren Rhee, MS, RD: PRC
n Others consulted
Q1
n Which scientific and authoritative statements/guidance documents were considered in developing the system? Which ones were eventually used in setting criteria and why? Which ones were not used and why?
A1n Dietary Reference Intakes, IOM
q http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=2&tax_subject=256&topic_id=1342
n Dietary Guidelines for Americans (2005)q http://www.health.gov/dietaryguidelines/
n NFP q http://www.fda.gov/Food/LabelingNutrition/ConsumerInformation/U
CM078889.htm
n WHO Dietary Recommendationsq http://www.who.int/nutrition/topics/nutrecomm/en/index.html
n Peer Reviewed LiteratureKatz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The stratification of foods on the basis of overall nutritional quality: the overall nutritional quality index. Am J Health Promot. 2009 Nov-Dec;24(2):133-43
The ONQI Algorithm-Numerator DenominatorFiberFolateVitamin AVitamin CVitamin DVitamin EVitamin B12Vitamin B6PotassiumCalciumZincOmega-3 fatty acidsTotal bioflavanoidsTotal carotenoidsMagnesiumIron
Saturated fatTrans fatSodiumSugarCholesterol
•Macronutrient FactorsFat qualityProtein qualityGlycemic loadEnergy density
•Trajectory Scores•Weighting Coefficients
Categorical stipulations
• Pure foods vs. processed
• Intrinsic vs. added sugars
• Artificial sweeteners• Etc.
A2
n Initial Considerations: Convention & Theory
q Inclusion on NFPq Strong support in peer-reviewed literatureq Highly relevant to public healthq Vital feature of some commonly consumed foodq Translation of ‘food level’ guidancen e.g.- whole grains; dark green/orange vegetables
Katz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The stratification of foods on the basis of overall nutritional quality: the overall nutritional quality index. Am J Health Promot. 2009 Nov-Dec;24(2):133-43
A2, cont.
n Final Decisions: Empiricismq Correlation with expert consensusq Diet stratificationq Correspondence to HEI-2005q Association with health outcomes
q Katz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The stratification of foods on the basis of overall nutritional quality: the overall nutritional quality index. Am J Health Promot. 2009 Nov-Dec;24(2):133-43
q 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 Apr;91(4):1102S-1108S
Harvard Study
n FFQs from ~110,000 men and women
n NuVal scores assigned to every food
n NuVal scores were aggregated to the level of total diet, dividedinto quintiles
n Multivariate models adjusted for: q age, calories, smoking, BMI, aspirin use, exercise, vitamin E
supplementation, menopausal status, menopausal hormone use, family history of MI or cancer, and history of high cholesterol or blood pressure
Nurses Health Study: NuVal vs. HEI-2005; n = ~70,000
NuVal, Quintile 5
HEI-2005, Quintile 5
RR of chronic disease 0.86 (0.82-0.90) 0.88 (0.83-0.92)
RR of CVD 0.77 (0.69-0.86) 0.83 (0.75-0.93)
RR of diabetes 0.79 (0.71-0.87) 0.90 (0.81-1.00)
Chiuve S, Willett WC et al. Harvard School of Public Health
HPFS: NuVal vs. HEI-2005; n = ~40,000
NuVal, Quintile 5
HEI-2005, Quintile 5
RR of chronic disease 0.85 (0.81-0.90) 0.86 (0.81-0.92)
RR of CVD 0.77 (0.69-0.85) 0.80 (0.72-0.89)
RR of diabetes 0.77 (0.67-0.88) 0.94 (0.82-1.08)
Chiuve S, Willett WC et al. Harvard School of Public Health
NuVal & mortality, n = 110,000
n RR of all-cause mortality, top vs. bottom quintile of NuVal scores
q NHS: RR = 0.88; p<0.001 (n ~ = 70,000)q HPFS: RR = 0.87; p = 0.001 (n ~ = 40,000)
Chiuve S, Willett WC et al. Harvard School of Public Health
Q3
n What factors were involved in determining any food categories that are used in the system and the definition of these categories? If categories are not used, why?
A3n Initial Considerations: Convention & Theoryq The supermarket ‘aisle’q Nielsen IRIq Fundamental nutritional distinctions: e.g., direct-from-
nature vs. processed/fortified; ‘artificially’ sweetened
n Final Decisions: Empiricism
q Katz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The stratification of foods on the basis of overall nutritional quality: the overall nutritional quality index. Am J Health Promot. 2009 Nov-Dec;24(2):133-43
q 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 Apr;91(4):1102S-1108S
A4n Unrestricted credit for nutrients in pure, direct-
from-nature foodsn Capping applied* to nutrient credit in fortified
foodsq TS capped at 4 following range testing / sensitivity analysisq ‘functional food’ exceptions, e.g., vitamin D in dairy
n Empirical confirmation
q Katz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The stratification of foods on the basis of overall nutritional quality: the overall nutritional quality index. Am J Health Promot. 2009 Nov-Dec;24(2):133-43
q 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 Apr;91(4):1102S-1108S
Q5
n In cases where nutrients are included that are not part of the Nutrition Facts Panel (e.g., added sugars), what factored into the decision to include these nutrients, and how is compliance measured?
A5n Derivation from dietary guidelines
q e.g., added sugar
n Translation of ‘food level’ guidance into quantifiable, algorithm entryq e.g., whole grains; ‘brightly colored’ fruits and vegetables
n Food supply reality checks:q diet soda vs. waterq salmon vs. chickenq dark chocolate vs. milk chocolate
n Empirical confirmationq Katz DL, Njike VY, Faridi Z, Rhee LQ, Reeves RS, Jenkins DJ, Ayoob KT. The stratification of
foods on the basis of overall nutritional quality: the overall nutritional quality index. Am J Health Promot. 2009 Nov-Dec;24(2):133-43
q 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 Apr;91(4):1102S-1108S
WHEAT FLOURNIACINREDUCED IRONTHIAMINERIBOFLAVINFOLIC ACIDSOYBEAN OILSUGARCOTTONSEED OILSALTBAKING SODAHF CORN SYRUPSOY LECITHINNATURAL FLAVORCORNSTARCH
10 g1 mg2 mg1 mg
.5 mg24 mg1 g
.75 g.5 g
135 mg120 mg100 mg
70 mg40 mg10 mg
INGREDIENTS: ENRICHED FLOUR (WHEAT FLOUR, NIACIN, REDUCED IRON, THIAMINE MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC ACID), SOYBEAN OIL, SUGAR, PARTIALLY HYDROGENATED COTTONSEED OIL, SALT, LEAVENING (BAKING SODA AND/OR CALCIUM PHOSPHATE), HIGH FRUCTOSE CORN SYRUP, SOY LECITHIN (EMULSIFIER), NATURAL FLAVOR, CORNSTARCH.
“Recipe”Development(imputation)
NutrientProfile
A5, cont.NuVal Nutrient String Generation-GCRC, Massachusetts Institute of TechnologyImputational Software: NCC, U Minn
RECIPE
Q6
n How will the system be updated with advances in science and changes in authoritative statements/guidance?
2010 Dietary
Guidelines
2010 Dietary
Guidelines
SAB Suggested
Topics from on-going lit review
SAB Suggested
Topics from on-going lit review
Finalize Review Areas
Finalize Review Areas
Assign ResearchAssign
ResearchPresent FindingsPresent Findings
DeterminePotential Changes
DeterminePotential Changes
Modify AlgorithmModify
Algorithm
Review Scores;
validation testing
Review Scores;
validation testing
Approve version 2.0Approve
version 2.0Update
ONQI DocUpdate
ONQI Doc
22Repeat as neededRepeat as needed
SAB / PRC ProcessSAB / PRC Process
1 of 3
Develop Comm. Plan
Develop Comm. Plan
Retailer Notification
Retailer Notification Develop PlanDevelop Plan Execute PlanExecute Plan
22Develop
Consumer Communication
Develop Consumer
Communication
Influencer Communication
Influencer Communication
Store Communication
Store Communication Execute PlanExecute Plan
Social Media CommunicationSocial Media
Communication Execute PlanExecute Plan
Develop PlanDevelop Plan Execute PlanExecute Plan
NuVal ProcessNuVal Process
2 of 3
Time Line & ConstraintsTime Line & ConstraintsRelative Calendar
SAB / PRCSAB / PRC NuValNuVal
NuValNuVal RetailerRetailer
Blackout Times – Retailer Rollout
Typical Blackout Period
3 of 3
ONQI Scientific Advisory Board
q Dr. David Katz, Ex Officio, Yale University
n Dr. Keith Ayoob, Chair, Albert Einstein College of Medicine
n Dr. Leonard Epstein, University of Buffalo; inventor, Traffic Light Dietn Dr. David Jenkins, University of Toronto; inventor, Glycemic Indexn Dr. Sonia Caprio, Yale Universityn Dr. Rebecca Reeves, Past President, American Dietetic Associationn Dr. Gail Frank, California State Universityn Dr. Eric Decker, University of Massachusetts; food science
NuVal conclusions:
n Uniquely independent, at inception & forevern We trusted (the SEP), but verified
q Founded in convention & theoryq Proven empirically:
n NuVal scores better predicted total chronic disease & all-cause mortality in 110,000 people over 20 yrs than the HEI-2005
n Early returns from PoP: the needle is movingn Designed to evolven Not hypothetical: >45,000 foods scored, matched to UPCs,
more dailyn Rapidly increasing uptake indicative of appeal/utility
Thank you!
David L. Katz, MD, MPH, FACPM, FACPDirector, Yale Prevention Research CenterPresident, Turn the Tide Foundation, Inc.
130 Division St.Derby, CT 06418(203) 732-1265
www.nuval.com