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A high-quality diet is associated with a decreased risk for hip fractures in elderly Chinese

Fang-fang Zeng 1, Wen-qiong Xue1, Wen-ting Cao 1, Bao-hua Wu 2, Hai-li Xie 1, Fan Fan 1, Hui-lian Zhu 1,*, Yu-ming Chen 1,*

1 Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China

2 Guangzhou Orthopaedics Trauma Hospital, Guangzhou, People's Republic of China.

Appendix A Diet-quality index components and scoring criteriaa

Diet quality index and components / Scoring criteria (daily intake) / Point(s)
Healthy Eating Index-2005 (HEI-2005)
Total fruit (included juice) / 0 to ≥ 1.6 servings/1000 kcal / 0-5
Whole fruit (except juice) / 0 to ≥ 0.8 servings/1000 kcal / 0-5
Total Vegetables (included potatoes) / 0 to ≥ 2.2 servings/1000 kcal / 0-5
Dark Green and Orange Vegetables and Legumes / 0 to ≥ 0.8 servings/1000 kcal / 0-5
Total Grains / 0 to ≥ 85 g/1000 kcal / 0-5
Whole Grains / 0 to ≥ 40 g/1000 kcal / 0-5
Milk / 0 to ≥ 1.3 servings/1000 kcal / 0-10
Meat and Beans / 0 to ≥ 70 g/1000 kcal / 0-10
Oils / 0 to ≥ 12 g/1000 kcal / 0-10
Saturated Fat / ≤ 7% to ≥ 15% of total energy / 10-0
Calories from solid fat, alcohol, and added sugar (SoFAAS) / ≤ 20% to ≥ 50% of total energy / 20-0
Sodium (taste) / Light / 10
Moderate / 5
Heavy / 0
Alternate Healthy Eating Index (aHEI)
Vegetables (except potatoes) / 0 to ≥ 5 servings / 0-10
Fruit (included juice) / 0 to ≥ 4 servings / 0-10
Nuts and soy protein / 0 to ≥ 1 servings / 0-10
Cereal fiber / 0 to ≥ 15 g / 0-10
Ratio of white to red meat / 0 to ≥ 4 / 0-10
Ratio of polyunsaturated to saturated fat / 0 to ≥ 1 / 0-10
Long-term multivitamin regular use / ≥ 5 years / 7.5
Otherwise / 2.5
Alcohol / Women:
0.5 to 1.5 drinks / 10
0 to < 0.5, >1.5 to >2.5 drinks / 0-9, 9-0
Men:
1.5 to 2.5 drinks / 10
0 to < 1.5, > 2.5 to > 3.5 drinks / 0-9, 9-0
Diet Quality Index-International (DQI-I)
(1)Variety / 0-20
Overall food group variety (meat/poultry/fish/eggs; dairy/beans; grain; fruit; vegetable) / ≥ 1 serving from each food group / 15
Any 1 food group missing / 12
Any 2 food groups missing / 9
Any 3 food groups missing / 6
≥ 4 food groups missing / 3
None from any food groups / 0
Within-group variety for protein source (meat, poultry, fish, dairy, beans, eggs) / ≥ 0.5 serving from any 3 different sources / 5
Any 2 different sources / 3
Any 1 source / 1
None from sources / 0
(2)Adequacy / 0-40
Vegetable (RNI: ≥ 2-5 servings/d)b / ≥ 100% RNI / 5
< 100–50% RNI / 3
< 0-50% RNI / 1
0% RNI / 0
Fruit (RNI: ≥ 1-4 servings/d)b / ≥ 100% RNI / 5
< 100–50% RNI / 3
< 0-50% RNI / 1
0% RNI / 0
Grains (RNI: ≥ 3-11 servings/d)b / ≥ 100% RNI / 5
< 100–50% RNI / 3
< 0-50% RNI / 1
0% RNI / 0
Fiber (RNI: 15-30 g/d)b / ≥ 100% RNI / 5
< 100–50% RNI / 3
< 0-50% RNI / 1
0% RNI / 0
Protein (RNI: ≥10% of energy) / ≥ 100% RNI / 5
< 100–50% RNI / 3
< 0-50% RNI / 1
0% RNI / 0
Iron (AI = 15 mg/d (men) or 20 mg/d (women) for Chinese) / ≥ 100% AI / 5
< 100–50% AI / 3
< 0-50% AI / 1
0% AI / 0
Calcium (AI = 800 mg/d for Chinese) / ≥ 100% AI / 5
< 100–50% AI / 3
< 0-50% AI / 1
0% AI / 0
Vitamin C (AI = 100 mg/d for Chinese) / ≥ 100% RNI / 5
< 100–50% RNI / 3
< 0-50% RNI / 1
0% RNI / 0
(3)Moderation / 0-30
Total fat / ≤ 20% of total energy / 6
> 20-30% of total energy / 3
> 30% of total energy / 0
Saturated fat / ≤ 7% of total energy / 6
> 7-10% of total energy / 3
> 10% of total energy / 0
Cholesterol / ≤ 300 mg / 6
300-400 mg / 3
> 400 mg / 0
Sodium (taste) / Light / 6
Moderate / 3
Heavy / 0
Empty calorie foods (oils, alcohol, starch) / ≤ 3% of total energy / 6
> 3-10% of total energy / 3
> 10% of total energy / 0
(4)Overall balance / 0-10
Macronutrient ratio (carbohydrate:protein:fat) / 55-65:10-15:15-25 / 6
52-68:9-16:13-27 / 4
50-70:8-17:12-30 / 2
Otherwise / 0
Fatty acid ratio (PUFA:MUFA:SFA) / PUFA/SFA = 1-1.5 and MUFA/SFA = 1-1.5 / 4
PUFA/SFA = 0.8-1.7 and MUFA/SFA = 0.8-1.7 / 2
Otherwise / 0
Alternate Mediterranean Diet Score (aMed)c
Whole grains / < or ≥ Median intake / 0 or 1
Vegetables (except potatoes) / < or ≥ Median intake / 0 or 1
Fruits (included juices) / < or ≥ Median intake / 0 or 1
Legumes / < or ≥ Median intake / 0 or 1
Nuts / < or ≥ Median intake / 0 or 1
Fish / < or ≥ Median intake / 0 or 1
Ratio of monounsaturated to saturated fat / < or ≥ Median intake / 0 or 1
Red and processed meats / < or ≥ Median intake / 1 or 0
Alcohol / Women: 5-15 g or otherwise / 1 or 0
Men: 15-25 g or otherwise / 1 or 0

aRNI, recommended nutrient intake; AI, adequate intake; PUFA, polyunsaturated fatty acid; MUFA, monounsaturated fatty acid; SFA, saturated fatty acid. For ranges, all diet scores are calculated by adding the number of points awarded proportionally.

bThe recommended intake of fruits, vegetables, grains and fiber is dependent on energy intake. Kim et al. have defined three energy intake categories: 7,118 kJ (1,700 kcal), 9,211 kJ (2,200 kcal) and 11,304 kJ (2,700 kcal). However, energy intake of many participants in the present study did not fall into these categories, and then we did some modification. See Appendix B.

cSex-specific median according to cutoff of controls.

Appendix BOriginal and revised version of energy intake and thecorresponding recommended intake of fruits, vegetables, grains and fiber

Original version / Revised version / Original version / Revised version / Original version / Revised version / Original version / Revised version
Energy intake (kcal/d) / - / ~1,450 / 1,700 / 1,451~1,950 / 2,200 / 1,950~2,450 / 2,700 / 2,451~
Fruit (servings/d) / - / 1 / 2 / 2 / 3 / 3 / 4 / 4
Vegetable (servings/d) / - / 2 / 3 / 3 / 4 / 4 / 5 / 5
Grains (servings/d) / - / 3 / 6 / 6 / 9 / 9 / 11 / 11
Fiber (g/d) / - / 15 / 20 / 20 / 25 / 25 / 30 / 30

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Appendix C Foods, food groups or nutrients intakes of study population by gender in Guangzhou, China

Men (177 pairs) / Women (549 pairs)
Cases / Controls / p / Cases / Controls / p
Total fruit included juice (g/d) / 35.5 (20.3, 61.3) / 60.0 (35.0, 102.9) / <0.001 / 42.1 (20.8, 73.6) / 64.0 (33.1, 108.9) / <0.001
Whole fruit excluded juice (g/d) / 35.5 (17.7, 59.4) / 57.0 (30.5, 101.3) / <0.001 / 40.2 (18.1, 71.1) / 60.2 (31.8, 105.4) / <0.001
Vegetables included potatoes (g/d) / 231 (135, 311) / 267 (170, 386) / <0.001 / 217 (140, 294) / 278 (196, 366) / <0.001
Vegetables excluded potatoes (g/d) / 216 (126, 300) / 252 (165, 359) / <0.001 / 198 (132, 276) / 257 (179, 345) / <0.001
Dark Vegetables (g/d) / 110 (61, 189) / 125 (68, 190) / 0.007 / 97 (63, 153) / 127 (86, 174) / <0.001
Total Grains (g/d)a / 203 (158, 252) / 191 (156, 251) / 0.227 / 181 (149, 221) / 175 (147, 221) / 0.425
Whole Grains (g/d)a / 0.28 (<0.01, 2.94) / 0.69 (<0.01, 3.43) / 0.284 / 0.06 (<0.01, 2.94) / 0.56 (<0.01, 5.83) / 0.012
Red meat (g/d) / 74.0 (52.6, 114.6) / 61.1 (47.3, 91.4) / <0.001 / 56.6 (40.5, 98.0) / 58.0 (40.0, 86.1) / 0.010
White meat (g/d) / 48.8 (26.4, 65.4) / 52.4 (29.1, 77.9) / 0.046 / 37.6 (21.4, 56.4) / 51.1 (31.1, 77.0) / <0.001
Fish and shellfish (g/d) / 21.8 (14.3, 36.8) / 30.9 (17.4, 55.6) / <0.001 / 20.4 (9.1, 35.5) / 31.9 (15.4, 53.0) / <0.001
Soybean and its products (g/d)a / 4.26 (1.97, 7.49) / 8.29 (4.11, 14.57) / <0.001 / 3.25 (1.20, 7.49) / 6.66 (2.08, 11.90) / <0.001
Diary products (g/d)a / 1.43 (<0.01, 7.29) / 4.99 (2.59, 11.74) / 0.001 / 1.56 (<0.01, 10.01) / 7.22 (1.70, 17.15) / <0.001
Nuts (g/d) / 6.0 (0.7, 12.9) / 9.0 (3.0, 13.5) / 0.002 / 3.00 (0.20, 6.40) / 6.40 (1.50, 12.90) / <0.001
Eggs (g/d) / 15.1 (7.5, 22.6) / 17.0 (11.3, 30.2) / 0.001 / 15.1 (7.5, 22.6) / 22.6 (11.3, 30.2) / <0.001
Oils (g/d) / 12.5 (10.0, 15.0) / 10.0 (5.0, 10.0) / <0.001 / 10.0 (7.5, 12.5) / 7.5 (5.0, 10.0) / <0.001
Sodium (taste), N(%) / <0.001 / 0.002
Light / 48 (27.1) / 27 (15.3) / 110 (20.0) / 91 (16.6)
Moderate / 100 (56.5) / 75 (42.4) / 236 (43.0) / 210 (38.3)
Heavy / 29 (16.4) / 75 (42.4) / 203 (37.0) / 248 (45.2)
Multivitamin regular use, N(%) / 1.000 / 0.005
≥ 5 years / 2 (1.1) / 3 (1.7) / 13 (2.4) / 32 (5.8)
Otherwise / 175 (98.9) / 174 (98.3) / 536 (97.6) / 517 (94.2)
Alcohol use, N(%) / 0.727 / 0.629
Moderateb / 5 (2.8) / 4 (2.3) / 7 (1.3) / 11 (2.0)
Otherwise / 172 (97.2) / 173 (97.7) / 542 (98.7) / 538 (98.0)
Protein (g/d) / 55.8 (42.8, 69.2) / 59.7 (47.6, 72.0) / 0.004 / 49.2 (40.2, 61.2) / 57.2 (46.7, 70.4) / <0.001
Carbohydrate (g/d) / 202 (170, 252) / 213 (180, 264) / 0.025 / 189 (156, 231) / 201 (165, 241) / <0.001
Total fat (g/d) / 41.5 (33.8, 51.0) / 37.3 (30.5, 44.6) / <0.001 / 32.7 (25.7, 42.6) / 34.5 (27.6, 43.4) / 0.256
Saturated fat (g/d) / 12.2 (9.3, 15.3) / 10.4 (8.1, 13.5) / <0.001 / 9.7 (7.1, 12.8) / 9.9 (7.7, 12.9) / 0.475
Monounsaturated fat (g/d) / 17.9 (14.4, 22.8) / 15.2 (13.0, 19.1) / <0.001 / 14.1 (10.9, 18.9) / 14.2 (11.4, 18.0) / 0.418
Polyunsaturated fat (g/d) / 10.3 (8.8, 12.3) / 10.2 (8.2, 12.2) / 0.805 / 8.3 (6.6, 10.7) / 9.1 (7.2, 11.6) / <0.001
Cholesterol (mg/d) / 236 (170, 344) / 265 (185, 346) / 0.025 / 236 (163, 333) / 274 (195, 401) / <0.001
Fiber (g/d) / 6.90 (4.85, 8.75) / 8.80 (7.15, 11.15) / <0.001 / 6.60 (5.10, 8.40) / 8.30 (6.50, 10.35) / <0.001
Iron (mg/d) / 18.6 (15.6, 23.3) / 20.4 (17.3, 25.2) / <0.001 / 17.6 (14.3, 21.5) / 19.5 (16.1, 23.3) / <0.001
Calcium (mg/d) / 359 (231, 444) / 441 (316, 572) / <0.001 / 344 (234, 463) / 456 (331, 581) / <0.001
Vitamin C (mg/d) / 78.3 (39.7, 105.2) / 100.9 (54.9, 125.0) / <0.001 / 75.4 (46.3, 105.1) / 99.4 (67.6, 130.8) / <0.001

Continuous variables were described by median (interquartile range).

a Moderate alcohol intake was defined as drinking 5-15 g alcohol for women or 15-25 g for men.