Medical nutritional therapy, an evidence-based application of the nutrition care process guided by a registered dietitian nutritionist, is an integral part of diabetes management, with emerging evidence suggesting distinct nutritional requirements in this population. A thorough review of the existing literature reveals an imperative to address the specific requirements for vitamins and minerals in this population. Current guidelines have given limited attention to micronutrients, despite the higher prevalence of deficiencies and the altered patterns of association between serum micronutrient concentrations and multiple health outcomes among individuals with type 2 diabetes (T2D). To enhance diabetes management, an international multidisciplinary panel of 20 experts from 12 countries participated in a modified Delphi process, which was informed by a narrative review conducted by the research team, to reach consensus on 18 statements, encompassing 11 nutrient-specific recommendations and 7 statements outlining future directions in diabetes nutrition therapy research. The plan for this consensus has been registered on the Practice Guideline Registration for Transparency (registration number: PREPARE-2025CN1178). The expert panel proposed potential target serum concentrations, screening strategies, and micronutrient supplementation for people with T2D and that personalized nutritional strategies integrating individual characteristics, genetic information, and gut microbiota represent key areas for future research.

Canada's Food Guide (CFG) was revised in 2019 to emphasize food quality through a balanced diet rich in fruits, vegetables, whole grains, and plant-based proteins. Although the Canadian Food Scoring System (CFSS) was developed to assess the alignment of individual foods and beverages with CFG 2019, no validated tool exists to evaluate multi-ingredient recipes. In this study, we modified the CFSS to create the CFSS for recipes (CFSSr), a nutrient profiling model that classifies recipes into five alignment categories ("very poor" to "excellent") based on food group composition and nutrient-of-concern thresholds from Canadian front-of-package labelling regulations. The CFSSr was applied to 93 021 unique generic recipes from the 2015 Canadian Community Health Survey-Nutrition. The majority (64%) of recipes were rated "poor" or "very poor" according to CFG 2019, with dessert and dessert topping recipes scoring lowest and nuts and seeds and snack recipes scoring highest. A sub-analysis of home-prepared recipes (n = 21 774) showed a similar pattern, with 57.6% rated "poor" or "very poor". Home-prepared recipes showed statistically significantly better alignment than otherwise-prepared recipes (median CFSSr: 45.0 vs. 43.8, p < 0.001), though the effect size was negligible, suggesting that preparation location alone does not ensure dietary quality but rather the cooking method (e.g., frying or added ingredients like salt and fats during preparation). These findings underscore a persistent gap between the nutritional quality of common recipes and CFG recommendations, highlighting the need for targeted policies, food literacy initiatives, and tools to promote healthier recipe choices and preparation methods.

Background: Literature on omega-3s and T2D risk has been heterogenous; however, most prior studies have used self-reported dietary intake or short-term supplementation regimens. Thus, further investigation is needed to assess longitudinal associations of circulating omega-3 with early T2D risk phenotypes. Objective: Assess longitudinal associations of circulating omega-3s with changes in insulin sensitivity (IS) and β-cell function (BCF) in the PROMISE cohort. Methods: Adults at-risk for T2D underwent four assessments over 9 years (n=472); blood samples were collected to determine insulin and glucose concentrations, and an OGTT was conducted. Baseline serum omega-3s (ALA, EPA, DPAn-3, DHA) were measured using gas chromatography-flame ionization detection. OGTT values were used to calculate validated IS (HOMA2-%S, ISI) and BCF (IGI/IR, ISSI-2) indices. Generalized estimating equations (GEE) analysis assessed the association between baseline omega-3s (mol%) with longitudinal change in IS and BCF indices after covariate adjustment. Results: Significant positive correlations were shown between EPA and DHA with IS measures (HOMA2-%S: EPA, r=0.18, DHA, r=0.23, all p<0.001; ISI: EPA, r=0.15, p<0.01, DHA, r=0.19, p<0.001) and between DHA and BCF indices (IGI/IR, r=0.14, p<0.01; ISSI-2, r=0.1, p<0.05). In adjusted GEE models, baseline EPA and DHA were positively associated with longitudinal change in IS (HOMA2-%S, p<0.001; ISI , p<0.01), and BCF (IGI/IR, p<0.05) ( Figure ) . Conclusions: Circulating omega-3s (specifically EPA and DHA) were positively associated with IS and BCF, which are important early T2D risk phenotypes. These findings add to growing evidence of the potential role omega-3s have in T2D primary prevention.

National school food programs (SFPs) have been implemented in several countries and can provide numerous benefits to children across the world. In June 2024, Canada released a National School Food Policy to support the development of a national SFP in Canada. As the enthusiasm to develop a national SFP grows, policymakers need evidence to inform a national SFP that can meet the needs of diverse communities in Canada. There is a paucity of recent information about the perceptions and needs of parents and caregivers in Canada regarding SFPs from various regions across the nation. To close this knowledge gap and gain insight into preferred program attributes, we conducted a mixed-methods study involving focus groups/interviews and surveys with parents and caregivers in the Greater Toronto Area and examined perceptions about the cultural aspects of SFPs among ethnic-specific sub-groups (South Asian, East Asian, and Southeast Asian households). The perceptions and needs identified from all parents and caregivers in the study were used to develop a framework that highlights attributes of a holistic and multicomponent SFP. This framework can be tested and modified with additional information from other locations and can validate other frameworks to inform policymakers on the most important objectives, attributes, and cultural considerations for a national SFP grounded in the perceptions and needs of parents and caregivers.

Background The Portfolio Diet, a dietary pattern of cholesterol-lowering foods, has been shown to reduce cardiovascular disease (CVD) risk factors in clinical trials and lower CVD risk in observational cohorts of mainly white men and women. However, evidence on mortality outcomes in diverse populations is limited. Objective To examine the association of the Portfolio dietary pattern with CVD mortality in a racially diverse cohort. Methods A total of 14,835 US adults from the National Health and Nutrition Examination Survey, NHANES (1988–1994), were included. Diet was assessed by a 24-h dietary recall which was supplemented with a food frequency questionnaire at baseline using the Portfolio Diet Score (PDS), with positive points for nuts, plant protein, viscous fiber, phytosterols, and plant monounsaturated fatty acid sources, and negative points for foods high in saturated fat and cholesterol (range, 6–30 points). The primary outcome was CVD mortality. Other mortality outcomes included coronary heart disease (CHD), stroke, and all-cause mortality. Results During 22 years of follow-up, 2300 CVD deaths, including 1887 CHD deaths, 413 stroke deaths, and 6238 all-cause deaths were documented. Greater adherence was inversely associated with risk factors including blood lipids, glycemia, and inflammation. Treated as a continuous variable, an increase in PDS by 8 points was associated with a 12% (hazard ratio 0.88 [95% confidence intervals:0.78, 0.99]), 14% (0.86 [0.78, 0.96]), and 12% (0.88 [0.82, 0.95]) lower risk of CVD, CHD, and all-cause mortality after adjustments for known CVD risk factors. Comparing the highest to lowest tertiles of the PDS, higher PDS was associated with 16% (0.84 [0.73, 0.98]), 18% (0.82 [0.72, 0.95]) and 14% (0.86 [0.78, 0.96]) lower risk of CVD, CHD, and all-cause mortality, respectively. As part of exploratory analyses, an interaction between PDS and race/ethnicity was observed, emphasizing the necessity of future research involving underserved groups. Conclusions Among a national cohort of racially diverse adults in the US, greater adherence to the Portfolio dietary pattern was inversely and prospectively associated with CVD, CHD, and all-cause mortality.

Ultra-processed food (UPF) contributes to nearly 50

While the potential of school food programs (SFPs) to influence healthy eating behaviors and improve child health outcomes is recognized globally, Canada currently lacks a well-established nationally coordinated and funded SFP. Instead, the fragmented nature of SFPs across Canada has resulted in a limited understanding of their nutritional quality. This study builds upon prior research assessing the characteristics of Canadian SFPs and aims to provide a baseline of SFP nutritional quality before federal policy implementation to identify priority areas for improvement in the current school food landscape. SFP menu data was collected from a diverse sample of school food providers. The mean content of nutrients of public health concern was calculated and two indices of dietary quality representing adherence to national nutrition guidelines were applied to SFP menu data: Healthy Eating Food Index 2019 (HEFI-2019) and Healthy Eating Index Canada (HEI-C) 2010. Nutritional quality results from 67 SFPs serving over 20% of Canadian schools revealed approximately 51% adherence to the 2019 and 2007 Canada's Food Guides, indicating similar adherence to national dietary guidelines as in the broader population. Snacks tended to be high in total sugars but low in protein and sodium was high across all meal types. Given the limited resources available to SFPs in Canada, these findings indicate that although school food providers are serving relatively healthful choices, a federally harmonized school food policy and program (including the development of national school food guidelines) can further improve the state of school food in Canada and its nutritional quality.

Objective biomarkers of diet, such as metabolomics, may improve dietary assessment and provide additional insight into how diet influences disease risk. The portfolio diet, a cholesterol-lowering plant-based diet, is recommended for lowering low-density lipoprotein cholesterol (LDL-C). This diet is low in saturated fat and includes nuts, plant protein (legumes), viscous fiber, and phytosterols. We examined metabolomic profiles in response to the portfolio diet in two randomized controlled trials (RCTs), where all foods were provided to the participants, compared to a control vegetarian diet and the same control diet with a statin. The first RCT included 34 adults (age 58.4 ± 8.6 y) and the second RCT included 25 adults (age 61.0 ± 9.6 y), all with high LDL-C (>4.1 mmol/L). Plasma samples were obtained at baseline, week 2, and week 4 in both RCTs for metabolomics analysis using liquid chromatography–tandem mass spectrometry. Linear mixed models were used to examine effects of the interventions on the metabolites in each RCT, applying a Bonferroni correction. Of 496 known metabolites, 145 and 63 metabolites significantly changed within the portfolio diet interventions in the first and second RCT, respectively. The majority were glycerophosphocholines (32

Canada's newly released National School Food Policy (NSFP) and its associated federal funding commitments mark significant progress toward a more coordinated school food system in Canada. However, significant gaps remain that could undermine the policy's effectiveness and longevity. Current bilateral agreements between federal and provincial/territorial governments highlight disparities in per-student funding, raising concerns about whether the allocated resources are adequate to achieve universally accessible, high-quality meal provision. Additionally, while the NSFP encourages school food programs to adhere to Canada's Food Guide and provincial nutrition guidelines, ambiguous language and the absence of enforceable standards leave room for inconsistent nutritional quality across programs. Furthermore, without a structured framework for monitoring and evaluation, there is no mechanism to assess program effectiveness, track nutritional outcomes, or ensure program accountability. To maximize the NSFP's impact, we urge policymakers to establish transparent funding rationales, develop clear and evidence-based national guidelines, and implement robust monitoring systems. Strengthening these policy components is essential to ensuring an equitable, effective, and sustainable approach to NSFP implementation in Canada.

BackgroundThe Portfolio Diet is a dietary pattern for cardiovascular disease (CVD) risk reduction with 5 key categories including nuts and seeds; plant protein from specific food sources; viscous fiber sources; plant sterols; and plant-derived monounsaturated fatty acid sources. To enhance implementation of the Portfolio Diet, we developed the PortfolioDiet.app, an automated, web-based, multicomponent, patient-facing health app that was developed with psychological theory. ObjectiveWe aimed to evaluate the effect of the PortfolioDiet.app on dietary adherence and its acceptability among adults with a high risk of CVD over 12 weeks. MethodsPotential participants with evidence of atherosclerosis and a minimum of one additional CVD risk factor in an ongoing trial were invited to participate in a remote web-based ancillary study by email. Eligible participants were randomized in a 1:1 ratio using a concealed computer-generated allocation sequence to the PortfolioDiet.app group or a control group for 12 weeks. Adherence to the Portfolio Diet was assessed by weighed 7-day diet records at baseline and 12 weeks using the clinical Portfolio Diet Score, ranging from 0 to 25. Acceptability of the app was evaluated using a multifaceted approach, including usability through the System Usability Scale ranging from 0 to 100, with a score >70 being considered acceptable, and a qualitative analysis of open-ended questions using NVivo 12. ResultsIn total, 41 participants were invited from the main trial to join the ancillary study by email, of which 15 agreed, and 14 were randomized (8 in the intervention group and 6 in the control group) and completed the ancillary study. At baseline, adherence to the Portfolio Diet was high in both groups with a mean clinical Portfolio Diet Score of 13.2 (SD 3.7; 13.2/25, 53%) and 13.7 (SD 5.8; 13.7/25, 55%) in the app and control groups, respectively. After the 12 weeks, there was a tendency for a mean increase in adherence to the Portfolio Diet by 1.25 (SD 2.8; 1.25/25, 5%) and 0.19 (SD 4.4; 0.19/25, 0.8%) points in the app and control group, respectively, with no difference between groups (P=.62). Participants used the app on average for 18 (SD 14) days per month and rated the app as usable (System Usability Scale of mean 80.9, SD 17.3). Qualitative analyses identified 4 main themes (user engagement, usability, external factors, and added components), which complemented the quantitative data obtained. ConclusionsAlthough adherence was higher for the PortfolioDiet.app group, no difference in adherence was found between the groups in this small ancillary study. However, this study demonstrates that the PortfolioDiet.app is considered usable by high-risk adults and may reinforce dietitian advice to follow the Portfolio Diet when it is a part of a trial for CVD management. Trial RegistrationClinicalTrials.gov NCT02481466; https://clinicaltrials.gov/study/NCT02481466

Introduction: Cardiovascular disease (CVD) is a leading cause of death in Canada. A healthy diet plays an integral role in CVD prevention. In 2019, Canada’s Food Guide (CFG) was updated to reflect current evidence on healthy eating. The Healthy Eating Food Index (HEFI) was developed as a tool to measure adherence to CFG. However, the extent to which adherence to CFG influences CVD remains unexplored within Canada. Objective: 1.) Assess the association between HEFI scores and the risk of CVD in a population-based cohort. 2.) Estimate the number of preventable CVD-related deaths from improvements in HEFI scores. 3.) Estimate potential healthcare cost savings from improvements in HEFI scores. Methods: Data linkages between the Canadian Community Health Survey – Nutrition (2004) and the Canadian Vital Statistics Death and Discharge Abstract Database (2017) will be used, with over 80% of CCHS respondents successfully linked to these databases. Weighted Cox proportional hazards models will be used to examine the prospective association between HEFI scores and CVD outcomes. Analyses will be stratified by sex to account for potential differences in associations between males and females. Multivariate models will be adjusted for dietary recall-related factors (e.g. weekday/weekend, sequence of recall), sociodemographic factors (e.g., age, education) and lifestyle-related factors (e.g., alcohol consumption, physical activity, smoking). The population attributable fraction (PAF) will be estimated for the number of preventable CVD deaths attributable to improvements in HEFI scores. To estimate the potential economic impact of HEFI improvements, the PAF will be multiplied by direct and indirect costs of CVD. Significance: This study will be the first to explore the prospective association between HEFI scores and CVD risk in a Canadian population as well as to quantify the number of preventable deaths and potential economic savings associated with improvements in HEFI scores. Analyses are currently underway, and results are forthcoming. Findings will inform dietary guidance and shape Canadian health and economic policy strategies, enhancing both public health and financial outcomes.

IntroductionThe Portfolio Diet combines cholesterol-lowering plant foods for the management of cardiovascular disease risk. However, the translation of this dietary approach into clinical practice necessitates a user-friendly method for patients to autonomously monitor their adherence.ObjectiveThis study aimed to develop and validate the clinical-Portfolio Diet Score (c-PDS) as a food-based metric to facilitate self-tracking of the Portfolio Diet.MethodsUsing a simulation model to estimate the c-PDS, the validity was assessed in a secondary analysis of a completed trial of the Portfolio Diet in 98 participants with hyperlipidemia over 6 months. Concurrent and predictive validity of the estimated c-PDS were assessed against the reference measure (weighed 7-day diet records) and concomitant changes in LDL-C from baseline to 6 months. Bland–Altman analysis was used to assess the limits of agreement between the two methods.ResultsThe c-PDS was positively correlated with dietary adherence as measured using the 7-day diet records (r = 0.94, p < 0.001). The c-PDS was negatively correlated with change in LDL-C (r = −0.43, p < 0.001) with a 1-point increase in the c-PDS being associated with a − 0.04 mmol/L (CI:−0.06,−0.03; p < 0.001) or a 1.09% reduction in LDL-C. Visual evaluation of the Bland–Altman plots showed reasonable agreement.ConclusionThese findings indicate good validity of the c-PDS for primary prevention in adults with hyperlipidemia. The predictive validity findings have informed the goals and messaging within the PortfolioDiet.app, a digital health application for delivering the Portfolio Diet. Future research will assess the effectiveness of the intended combination of the c-PDS and the PortfolioDiet.app in supporting behavior change.

Misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths, with their total costs in trillions of dollars. Progress in reducing such deaths has been slow and difficult. To address this challenge, this review introduces the definition of market-driven epidemics (MDEs), which arise when companies aggressively market products with proven harms, deny these harms, and resist mitigation efforts. MDEs are a specific within the broader landscape of commercial determinants of health. We selected three illustrative MDE products reflecting different consumer experiences: cigarettes (nicotine delivery product), sugar (food product), and prescription opioids (medical product). Each met the MDE case definition with proven adverse health impacts, well-documented histories, longitudinal product consumption and health impact data, and sustained reduction in product consumption. Based on these epidemics, we describe five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation. From the peak of consumption to the most recent data, U.S. cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. For each, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice and/or public mobilization overcame corporate marketing and resistance efforts. The gap between suspicion of harm and the consumption tipping point ranged from one to five decades-much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative and positive impacts. To our knowledge, this is the first comparative analysis of three successful efforts to change the product consumption patterns and the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time to effective mitigation provides a new method to reduce the impacts of harmful products.

Canada remains one of few Organisation for Economic Co-operation and Development (OECD) countries without a well-established nationally harmonized and funded school food program (SFP); however, the Canadian federal government recently announced the development and implementation of a national SFP that might supersede the uncoordinated patchwork of SFPs currently delivered across Canada. We designed and conducted novel survey research to systematically identify the characteristics of organization-led SFPs, building on previous research that focused on the characteristics of provincial and territorial government involvement in school food programming. An electronic survey was developed to include items deemed most relevant based on applicable literature and expert content validation, and distributed to organizations involved in the purchasing, planning, and/or preparation of school foods. Responses were categorized post hoc into the RE-AIM categories to assess SFP Reach, Effectiveness, Adoption, Implementation, and Maintenance. Analysis identified key SFP implementation characteristics (including funding source, payment model, and student eligibility), program components, SFP goals/mandates, and factors that determine what foods are served; and assessed correlations among key characteristics. Results from 67 SFPs across 10 provinces indicate considerable variability in SFP characteristics. SFP-delivering organizations reported a predominant goal of reducing student food insecurity, while nutrition and cost were cited as the main factors determining food served. Collectively, organizations were found to rely primarily on donations, while provincial funding accounted for only 30% of total funding. These findings reveal strengths and areas for improvement within Canada's current school food landscape and highlight important gaps that could be addressed with federal involvement.