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: schiuve@hsph.harvard.edu

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

David.katz@yale.edu

www.davidkatzmd.com