Background: The health benefits and risks of dietary supplementation use remain controversial. Objective: To evaluate the association between dietary supplement use, levels of nutrient intake from foods and supplements, and mortality among US adults. Design: Prospective cohort study. Setting: National Health and Nutrition Examination Survey (NHANES) 1999–2010 linked to National Death Index Mortality Data. Patients: 30,899 US adults aged 20+ years who answered questions on dietary supplement use. Measurements: Dietary supplement use in the past 30 days and nutrient intake from foods and supplements. Outcomes included mortality from all causes, cardiovascular disease (CVD), and cancer. Results: During a median follow-up of 6.1 years, a total of 3,613 total deaths occurred, including 945 CVD deaths and 805 cancer deaths. Ever use of dietary supplements was not associated with mortality outcomes. Adequate nutrient intake (≥ Estimated Average Requirement or Adequate Intake) of vitamin A, vitamin K, magnesium, and zinc was associated with reduced all-cause or CVD mortality, but the associations were confined to nutrient intake from foods not supplements. Excess nutrient intake (> Tolerable Upper Intake Level) of calcium was associated with an increased risk of cancer mortality (> vs. ≤ Tolerable Upper Intake Level: multivariable-adjusted mortality rate ratio = 1.62, 95% CI: 1.07, 2.45; multivariable-adjusted mortality rate difference = 1.7, 95% CI: −0.1, 3.5 per 1,000 person-years), and the association appeared to be related to calcium intake from supplements (≥1000 mg/d vs. non-users: multivariable-adjusted mortality rate ratio=1.53, 95% CI: 1.04, 2.25; multivariable-adjusted mortality rate difference = 1.5, 95% CI: −0.1, 3.1 per 1,000 person-years) not foods. Limitations: Results from observational data may be affected by residual confounding. Reporting of dietary supplement use is subject to recall bias. Conclusion: Use of dietary supplements is not associated with mortality benefits among US adults. Primary Funding Source: National Institutes of Health

Background: Considerable attention has recently focused on dietary protein's role in the mature skeleton, prompted partly by an interest in nonpharmacologic approaches to maintain skeletal health in adult life. Objective: The aim was to conduct a systematic review and metaanalysis evaluating the effects of dietary protein intake alone and with calcium with or without vitamin D (Ca6D) on bone health measures in adults. Design: Searches across 5 databases were conducted through October 2016 including randomized controlled trials (RCTs) and prospective cohort studies examining 1) the effects of "high versus low" protein intake or 2) dietary protein's synergistic effect with Ca6D intake on bone health outcomes. Two investigators independently conducted abstract and full-text screenings, data extractions, and risk of bias (ROB) assessments. Strength of evidence was rated by group consensus. Random-effects meta-analyses for outcomes with $4 RCTs were performed. Results: Sixteen RCTs and 20 prospective cohort studies were included in the systematic review. Overall ROB was medium. Moderate evidence suggested that higher protein intake may have a protective effect on lumbar spine (LS) bone mineral density (BMD) compared with lower protein intake (net percentage change: 0.52%; 95% CI: 0.06%, 0.97%, I2 : 0%; n = 5) but no effect on total hip (TH), femoral neck (FN), or total body BMD or bone biomarkers. Limited evidence did not support an effect of protein with Ca6D on LS BMD, TH BMD, or forearm fractures; there was insufficient evidence for FN BMD and overall fractures. Conclusions: Current evidence shows no adverse effects of higher protein intakes. Although there were positive trends on BMD at most bone sites, only the LS showed moderate evidence to support benefits of higher protein intake. Studies were heterogeneous, and confounding could not be excluded. High-quality, long-term studies are needed to clarify dietary protein's role in bone health. This trial was registered at www.crd.york.ac.uk as CRD42015017751.Am J Clin Nutr 2017;105:1528-43.

IMPORTANCEThe childhood obesity rate has been steadily rising among US youths during the past 2 decades. Increasing evidence links consumption of ultraprocessed foods to excessive calorie consumption and weight gain, but trends in the consumption of ultraprocessed foods among US youths have not been well characterized. OBJECTIVETo characterize trends in the consumption of ultraprocessed foods among US youths. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional analysis using 24-hour dietary recall data from a nationally representative sample of US youths aged 2-19 years (n = 33 795) from 10 cycles of the National Health and Nutrition Examination Survey (NHANES) from 1999-2000 to 2017-2018. EXPOSURES Secular time.MAIN OUTCOMES AND MEASURES Percentage of total energy consumed from ultraprocessed foods as defined by NOVA, an established food classification system that categorizes food according to the degree of food processing.RESULTS Dietary intake from youths were analyzed (weighted mean age, 10.7 years; 49.1% were girls). From 1999 to 2018, the estimated percentage of total energy from consumption of ultraprocessed foods increased from 61.4% to 67.0% (difference, 5.6% [95% CI, 3.5% to 7.7%]; P < .001 for trend), whereas the percentage of total energy from consumption of unprocessed or minimally processed foods decreased from 28.8% to 23.5% (difference, −5.3% [95% CI, −7.5% to −3.2%]; P < .001 for trend). Among the subgroups of ultraprocessed foods, the estimated percentage of energy from consumption of ready-to-heat and -eat mixed dishes increased from 2.2% to 11.2% (difference, 8.9% [95% CI, 7.7% to 10.2%]) and from consumption of sweet snacks and sweets increased from 10.7% to 12.9% (difference, 2.3% [95% CI, 1.0% to 3.6%]), but the estimated percentage of energy decreased for sugar-sweetened beverages from 10.8% to 5.3% (difference, −5.5% [95% CI, −6.5% to −4.5%]) and for processed fats and oils, condiments, and sauces from 7.1% to 4.0% (difference, −3.1% [95% CI, −3.7% to −2.6%]) (all P < .05 for trend). There was a significantly larger increase in the estimated percentage of energy from consumption of ultraprocessed foods among non-Hispanic Black youths (from 62.2% to 72.5%; difference, 10.3% [95% CI, 6.8% to 13.8%]) and Mexican American youths (from 55.8% to 63.5%; difference, 7.6% [95% CI, 4.4% to 10.9%]) than the increase among non-Hispanic White youths (from 63.4% to 68.6%; difference, 5.2% [95% CI, 2.1% to 8.3%]) (P = .04 for trends). CONCLUSIONS AND RELEVANCEBased on the NHANES cycles from 1999 to 2018, the estimated proportion of energy intake from consumption of ultraprocessed foods has increased among youths in the US and has consistently comprised the majority of their total energy intake.

Background Diet is an important risk factor for cancer that is amenable to intervention. Estimating the cancer burden associated with diet informs evidence-based priorities for nutrition policies to reduce cancer burden in the United States. Methods Using a comparative risk assessment model that incorporated nationally representative data on dietary intake, national cancer incidence, and estimated associations of diet with cancer risk from meta-analyses of prospective cohort studies, we estimated the annual number and proportion of new cancer cases attributable to suboptimal intakes of seven dietary factors among US adults ages 20 years or older, and by population subgroups. Results An estimated 80 110 (95% uncertainty interval [UI] = 76 316 to 83 657) new cancer cases were attributable to suboptimal diet, accounting for 5.2% (95% UI = 5.0% to 5.5%) of all new cancer cases in 2015. Of these, 67 488 (95% UI = 63 583 to 70 978) and 4.4% (95% UI = 4.2% to 4.6%) were attributable to direct associations and 12 589 (95% UI = 12 156 to 13 038) and 0.82% (95% UI = 0.79% to 0.85%) to obesity-mediated associations. By cancer type, colorectal cancer had the highest number and proportion of diet-related cases (n = 52 225, 38.3%). By diet, low consumption of whole grains (n = 27 763, 1.8%) and dairy products (n = 17 692, 1.2%) and high intake of processed meats (n = 14 524, 1.0%) contributed to the highest burden. Men, middle-aged (45–64 years) and racial/ethnic minorities (non-Hispanic blacks, Hispanics, and others) had the highest proportion of diet-associated cancer burden than other age, sex, and race/ethnicity groups. Conclusions More than 80 000 new cancer cases are estimated to be associated with suboptimal diet among US adults in 2015, with middle-aged men and racial/ethnic minorities experiencing the largest proportion of diet-associated cancer burden in the United States.

Objective To examine the association between consumption of ultra-processed foods and risk of colorectal cancer among men and women from three large prospective cohorts. Design Prospective cohort study with dietary intake assessed every four years using food frequency questionnaires. Setting Three large US cohorts. Participants Men (n= 46 341) from the Health Professionals Follow-up Study (1986-2014) and women (n=159 907) from the Nurses’ Health Study (1986-2014; n=67 425) and the Nurses’ Health Study II (1991-2015; n=92 482) with valid dietary intake measurement and no cancer diagnosis at baseline. Main outcome measure Association between ultra-processed food consumption and risk of colorectal cancer, estimated using time varying Cox proportional hazards regression models adjusted for potential confounding factors. Results 3216 cases of colorectal cancer (men, n=1294; women, n=1922) were documented during the 24-28 years of follow-up. Compared with those in the lowest fifth of ultra-processed food consumption, men in the highest fifth of consumption had a 29% higher risk of developing colorectal cancer (hazard ratio for highest versus lowest fifth 1.29, 95% confidence interval 1.08 to 1.53; P for trend=0.01), and the positive association was limited to distal colon cancer (72% increased risk; hazard ratio 1.72, 1.24 to 2.37; P for trend<0.001). These associations remained significant after further adjustment for body mass index or indicators of nutritional quality of the diet (that is, western dietary pattern or dietary quality score). No association was observed between overall ultra-processed food consumption and risk of colorectal cancer among women. Among subgroups of ultra-processed foods, higher consumption of meat/poultry/seafood based ready-to-eat products (hazard ratio for highest versus lowest fifth 1.44, 1.20 to 1.73; P for trend<0.001) and sugar sweetened beverages (1.21, 1.01 to 1.44; P for trend=0.013) among men and ready-to-eat/heat mixed dishes among women (1.17, 1.01 to 1.36; P for trend=0.02) was associated with increased risk of colorectal cancer; yogurt and dairy based desserts were negatively associated with the risk of colorectal cancer among women (hazard ratio 0.83, 0.71 to 0.97; P for trend=0.002). Conclusions In the three large prospective cohorts, high consumption of total ultra-processed foods in men and certain subgroups of ultra-processed foods in men and women was associated with an increased risk of colorectal cancer. Further studies are needed to better understand the potential attributes of ultra-processed foods that contribute to colorectal carcinogenesis.