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Most nutrition answers are not simple, and few issues in science are settled by a single study. The public is also affected. Most members of the public are not experts and want clear advice. Among other sorts of information, they listen to advertising and true believers. Neither source is always accurate, especially when issues are multifaceted and complex. The public is not equipped to sort through contradictory messages. In science, one speaks of provisional hypotheses that can be overturned given new evidence.

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For our society to move beyond the limitations of nutrient-based dietary guidelines, we need much more information about foods and health. This will require a different way of thinking as well as a change in funding priorities. On the other hand, some scientists are beginning to recognize the importance of a shift in focus away from nutrients to foods and dietary patterns 34 , Set-aside or required moneys for food and dietary pattern studies are simply not there in anything like the magnitude needed to support nutrition research that would provide a truly adequate base for policy making about food.

The amount of such needed funds is not clear but could be substantial.

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One of the most consistent findings in nutritional epidemiology is reduced chronic disease risk with various dietary patterns 6 , 7 , 36 , In general, these dietary patterns are plant-centered, including vegetarian diets 3 , 4. Therefore, a focus on dietary patterns may advance nutrition science and favorably affect the political cascade. The A Priori Diet Quality Score, initially introduced in 38 , is based entirely on foods and furthers this idea. This score has commonalities with the Recommended Food Score 39 , 40 , but the A Priori Diet Quality Score incorporates quantity as well as variety of foods.

The score follows a set of principles but with slightly varying implementation between studies. Moderately detailed food groups, expressed either in grams or servings per day, are selected. The food groups are placed in quantiles. In the IWHS, each food group contributes 0—3 points to the sum score. Sijtsma et al 10 described in an online table the food groups included and the agreement among ratings as the A Priori Diet Quality Score was implemented in 4 studies.

The score was shown to have considerable predictive power for health outcomes, including total, CVD, cancer, and inflammatory-related mortality 41 ; myocardial infarction 38 ; diabetes 42 ; oxidative stress 11 ; body fatness and metabolic variables 12 ; and subclinical disease, including common carotid intima media thickness and albuminuria Information included periodic questionnaires and record linkage for disease ascertainment. Among 29, women with no heart disease, diabetes, or cancer at baseline in and adequate food-frequency questionnaire information, there were 10, deaths through In Table 1 , we describe the diet score in terms of food groups in women with a score of 25 fifth percentile and at the other extreme in women with a score of 51 95th percentile ; findings are consistent with a previously reported quantitative analysis of food group levels by quartiles of the diet score Those with the higher score ate substantially more of many favorably rated foods, such as green vegetables, other vegetables, fruit, seeds and nuts, whole-grain foods, poultry, fish, oil in salad dressing, and low-fat dairy, and tended toward higher but still moderate alcohol consumption.

However, legumes, tomatoes, coffee, and tea were only modestly higher. Among adversely rated foods, the women consumed substantially less red meat, processed meat, fried foods, butter, whole-fat dairy, soft drinks, and nonchocolate sweets. Among neutrally rated foods, they ate less refined-grain foods.

Thus, a high score reflects phytochemical-rich plant foods; limits meat and favors fish and poultry; favors low-fat milk, coffee, tea, and moderate alcohol consumption; and favors less-processed foods. Description of the A Priori Diet Quality Score: food group values at the fifth percentile score 25 and the 95th percentile score 51 1. The same diet categories are given for positively rated, negatively rated, and neutrally rated foods. Where there is not a food group within a given diet category, the row is left blank. Mursu et al 41 showed that it was unrelated to energy intake and inversely related to trans fat.

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We performed new analyses for a few more nutrients of interest, with adjustment for age and energy intake. An area for investigation is whether the a priori score could be improved by further consideration of nutrient associations; however, it is also possible that the success of this dietary score could inform our concepts about specific nutrients. Although diet is notorious for measurement variability 44 — 47 , dietary patterns are not as subject to within-person variability as are nutrients or foods.

Dietary patterns track strongly over long periods of time Table 2 10 , 11 , 41 , 48 — 51 , at within-person correlation levels comparable to those for measured variables such as blood pressure. The lack of correlation over 8 y of the traditional Iranian pattern 48 may reflect nutrition transition. Tracking correlation of dietary pattern scores in several studies 1. Rates were Some new analyses were performed on meat intake, the lack of which defines most forms of vegetarianism. Meat intake in these IWHS women was typical of the general population: Servings per week were 5.

Only 3. Within each quartile of the A Priori Diet Quality Score, there was no association of total meat intake with total death. It is highly correlated with other dietary patterns that successfully predict chronic disease outcomes 41 in prospective epidemiologic study but is based only on foods. In this sense, it is directly applicable to food choice.

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It favors less-processed, varied plant food: a plant-centered diet. Some lessons can be learned from this score. A palatable diet is a mixture of many foods, prepared in different ways, and dependent on factors such as taste, meal composition, and social aspects of food. A range of diets with high scores is healthful, but less healthful diets are sorted out by virtue of their low scores.

A high score can be achieved with substantial flexibility in food choice but tends to minimize meat, salt, added sugar, and heavily processed foods while emphasizing phytochemical-rich foods. It does not forbid any food. Although a lot is known about nutrition and chronic disease associations from dietary pattern scores, Kant 52 sounded a discouraging note.

Dietary scores have been much more successful and consistent in their predictions of chronic disease than have individual dietary elements, whether foods or nutrients. Further investigation in nutrition would do well to consider the successful dietary scores as a starting point. The A Priori Diet Quality Score works well as a whole, but the nature of its predictive ability is only partially understood.

Not every element of the score has equal certainty in its rating. Furthermore, the score seems to be robust to small changes in food group ratings across studies. A correlation of 0.


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Breaking meat out of the IWHS dietary score did not provide much new information. Nettleton et al 43 attempted to deconstruct the A Priori Diet Quality Score in the Multi-Ethnic Study of Atherosclerosis by forming a Simplified Healthy Dietary Pattern composed of sums of quartile ranks of 3 favorably rated foods whole grains, fruit, and seeds and nuts and subtracting quartile ranks from 3 unfavorably rated foods added fats and oils, processed meats, and fried potatoes.

This method of looking for a less-complex solution was fairly successful in its predictions. An example of a partially deconstructed diet pattern score is the Southern European Atlantic Diet SEAD 53 , which was studied in hospitalized patients with incident, nonfatal, acute myocardial infarction and population-based controls in Porto, Portugal.

The SEAD score ranged from 0 to 9 points, giving 1 point for being above the median 0 points for below the median in cod, fresh fish excluding cod, red meat and pork products, dairy products, legumes and vegetables, vegetable soup, potatoes, and whole-grain bread and 1 point for moderate wine intake.

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Additionally reverse scoring potatoes reduced the OR further. Ideas such as these for deconstructing successful scores should be pursued in an effort to use such scores as a stepping stone for an even better score. Thus, whereas diet scores may be robust to certain minor changes, they are also sensitive to the correct classification of certain foods as more beneficial or detrimental, such as red meats and pork products in this example. The optimal specification of diet scores should result in maximal predictive ability and thus in greater utility as the basis for dietary recommendations.

Several principles derived from the theory of food synergy and from studies of the A Priori Diet Quality Score can be phrased as simple rules. It also refers to enjoyment of eating. We should not waste the intake allotment with low-nutritional-quality foods—for example, because of detrimental processing ie, processing that reduces the nutritional value of food.

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