National Cancer Institute Dietary Patterns Methods Project: Examining multi-level patterns to support policy for cancer control Jill Reedy, PhD, MPH, RD

Disclosures: none

Acknowledgements: Dietary Patterns Methods Project US National Cancer Institute Jill Reedy Susan Krebs-Smith Amy Subar Stephanie George Paige Miller TusaRebecca Schap Maggie Wilson University of Hawaii Carol Boushey Reynolette Ettienne Brook Harmon Fred Hutchinson Cancer Research Center Marian Neuhouser University of South Carolina Angela Liese

Outline Dietary patterns background Progress in dietary patterns research and need for standardization Dietary Patterns Methods Project Dietary patterns across the food stream Summary

Dietary patterns background

Nutritional factors and cellular processes Food, nutrition, obesity, and physical activity Proliferation Hormone regulation Differentiation Inflammation/immunity Apoptosis Cell cycle Carcinogen metabolism DNA repair Mayne ST, Rock C, Playdon M. Diet, nutrition, and cancer: past, present and future. Nat Rev Clin Oncol, 2006.

Diet and cancer prevention May decrease risk May increase risk Cancer Risk Possible synergism & interactions Multicollinearity Source: Miller PE. 2012

Dietary patterns and cancer prevention Totality of diet

Why study dietary patterns? Complexity of diet Correlation among dietary constituents Clinical trials show positive health outcomes with changes in total diet Relevance for policy and guidance Complexity of diet Background on dietary patterns People eat foods (and meals), not nutrients Correlation among dietary constituents Analysis of single nutrients may be confounded by the effect of dietary patterns Clinical trials show positive health outcomes with changes in “total diet” Dietary Approaches to Stop Hypertension (DASH) Lyon Diet Heart Study Relevance for policy and guidance (low fat diet associated with fruits/vegetables, fiber, whole grains, and folate)

Progress in dietary patterns research and need for standardization

Progress in dietary patterns research 2010 Dietary Guidelines for Americans

Progress in dietary patterns research 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop

Progress in dietary patterns research 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project

Progress in dietary patterns research 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project 2015 Dietary Guidelines for Americans

Progress in dietary patterns research 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project 2015 Dietary Guidelines for Americans 2016 Extending Methods in Dietary Patterns Research Workshop Ex

Progress in dietary patterns research 1997 WCRF/AICR Report 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project 2015 Dietary Guidelines for Americans 2016 Extending Methods in Dietary Patterns Research Workshop Ex

Progress in dietary patterns research 1997 WCRF/AICR Report 2007 WCRF/AICR Report 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project 2015 Dietary Guidelines for Americans 2016 Extending Methods in Dietary Patterns Research Workshop Ex

Progress in dietary patterns research 1997 WCRF/AICR Report 2007 WCRF/AICR Report 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project 2015 Dietary Guidelines for Americans 2016 Extending Methods in Dietary Patterns Research Workshop 2017 WCRF/AICR Report Ex

Progress in dietary patterns research 1997 WCRF/AICR Report 2007 WCRF/AICR Report 2010 Dietary Guidelines for Americans 2011 Nutrition Evidence Library Workshop 2013 Dietary Patterns Methods Project 2015 Dietary Guidelines for Americans 2016 Extending Methods in Dietary Patterns Research Workshop 2017 WCRF/AICR Report 2027 Ex

Dietary Patterns Methods Project

Dietary Patterns Methods Project: Aims Aim 1: Systematic analysis of index-based dietary patterns and associations with mortality Aim 2: Explore the issue of measurement error in all models Aim 3: Apply these methods to other US and international cohorts, perhaps with other dietary assessment tools and/or databases

How does the project define dietary patterns? Methods to derive dietary patterns Data-driven approaches Investigator-driven approaches Hybrid approaches Factor analysis Cluster analysis Diet quality index scores Reduced rank regression

Are diet quality indices associated with reduced mortality?

Are diet quality indices associated with reduced mortality? NIH-AARP Multiethnic Cohort Women’s Health Initiative

Are diet quality indices associated with reduced mortality? NIH-AARP Multiethnic Cohort Women’s Health Initiative Adjusted for age, race/ethnicity, education, marital status, physical activity, smoking, energy, BMI, diabetes, alcohol (HEI & DASH), HRT (women only). Liese AD et al, J Nutr, 2015

Findings A dietary pattern that achieves a high diet quality index score is associated with lower risk of mortality in men and women in the US Findings were consistent across cohorts and across indexes Associations with mortality may tend to converge because scores are derived from many of the same core tenets Potential to inform both policy makers and those developing guidelines as to the role of dietary patterns and health Provides evidence regarding the benefit of an overall healthy eating pattern and suggests the need to optimize the US food environment to support whole grains, vegetables, fruit, and plant-based proteins

Dietary patterns across the food stream

Levels of the food stream Food supply Market/Community Individual

Dietary patterns at multiple levels of the food stream Food supply Market/Community Individual

Dietary patterns at multiple levels of the food stream How does adherence to dietary recommendations relate to health? Individual Liese AD, Krebs-Smith SM, George SM, Harmon BE, Neuhouser ML, Boushey CJ, Subar AF, Schap T, Reedy J. The Dietary Patterns Methods Project: Synthesis of findings across cohorts and relevance to dietary guidance. Journal of Nutrition, 2015.

Dietary patterns at multiple levels of the food stream Does the food supply align with current dietary recommendations? Food supply Miller PE, Reedy J, Kirkpatrick SI, Krebs-Smith SM. Healthfulness of the food supply: 1970-2010. Journal of the Academy of Nutrition and Dietetics, 2014.

US Food Supply: 55/100 points, not a very good grade Sue will have showed the video by this time, so they’ll know where this is from… Video at http://nccor.org/resources/nccor/videos.php

Findings US food supply is not consistent with federal dietary recommendations Little improvement over decades: fruit, vegetables, whole grains Efforts needed to target the architects of the food environment

Summary

Summary There are inter-related mechanisms regarding the biological effects of individual dietary constituents and the totality of diet, or dietary patterns To best understand these relationships and interpret findings it is important to consider how diet is measured, defined, and modeled: each of these aspects influences the ability to examine relationships between diet patterns and cancer Efforts to standardize, harmonize, and synthesize the growing literature related to dietary patterns and cancer is critical Guidance related to dietary patterns can further extend efforts to target the architects of the food environment across the food stream