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© 2006 American Society for Nutrition J. Nutr. 136:2243-2248, August 2006

Nutritional Epidemiology

Dietary Energy Density Is Associated with Overweight Status among 5 Ethnic Groups in the Multiethnic Cohort Study1,2

Nancy C. Howarth*, Suzanne P. Murphy, Lynne R. Wilkens, Jean H. Hankin and Laurence N. Kolonel

Cancer Epidemiology Program, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, HI

* To whom correspondence should be addressed. E-mail: nhowarth{at}crch.hawaii.edu.


   ABSTRACT
TOP
 ABSTRACT
Introduction
 Subjects and Methods
 Results
 Discussion
 LITERATURE CITED
 
Differences in BMI among ethnic groups may be partially explained by the consumption of energy-dense foods, which influences energy intake in controlled laboratory studies. However, the role of dietary energy density (ED, kJ/g) in free-living persons is less understood. Our objective was to determine whether ED is related to current BMI and the risk for overweight and obesity and whether these relations are consistent among ethnic groups. We calculated ED from responses to a quantitative food frequency questionnaire and validated the measures against multiple 24-h recalls. Subjects consisted of 191,023 participants in the Hawaii-Los Angeles Multiethnic Cohort who were African American, Native Hawaiian, Japanese American, Latino, or Caucasian. Mean ED varied from a low of 4.62 kJ/g in Japanese American men to a high of 5.08 kJ/g in African American men. Mean BMI was lowest in Japanese Americans of both sexes and highest in Native Hawaiian men and African American women. After adjusting for the amount of food consumed per day, age, current smoking status, physical activity, chronic disease, and education, a 1 kJ/g increase in ED was associated with an increase in BMI of ~1 kg/m2 in each ethnic sex group. This same increase in ED was associated with a significantly increased risk of being overweight in all ethnic sex groups, varying from 4% in African American men to 34% in Japanese American women. Our findings suggest that consumption of an energy dense diet is a risk factor for higher BMI in both men and women across ethnic groups.


   Introduction
TOP
 ABSTRACT
 Introduction
Subjects and Methods
 Results
 Discussion
 LITERATURE CITED
 
Excess weight is a risk factor for several chronic diseases (1), and the prevalence of overweight and obesity is estimated at 65% in U.S. adults ≥20 y (2). However, there is considerable variation among sex and ethnic groups: in Caucasians the prevalence is 57% in women and 67% in men; in African Americans it is 78% in women and 60% in men; and in Latinos it is 72% in women and 74% in men (3). There are no national statistics for Asian or Pacific Island groups.

Energy density (ED)3 is defined as the amount of energy per unit weight of food (kJ/g) (4). Differences in BMI among ethnic groups can be partially explained by the overall ED of their customary diets (4,5). In an analysis of dietary patterns, Native Hawaiians and Latinos had high scores for the high ED fat and meat pattern, whereas Japanese Americans had high scores for the vegetable and fruit pattern (6). The fat and meat pattern was also associated with a lower BMI, whereas the vegetable and fruit pattern was associated with a higher BMI.

Studies show that people have little innate ability to downregulate the amount of food consumed to compensate for high ED (7–9), at least in the short term. In addition, energy dense foods tend to be high in fat and/or sugar, and highly palatable (10), possibly leading to overconsumption. Short-term feeding interventions show that people regularly ingest more energy when offered higher rather than lower ED foods. Results have been consistent when test foods of the same energy content but different ED were ingested as preloads (11) or incorporated into one or several meals (8,12,13). However, longer-term studies (14–16) have found that greater consumption of energy from energy-dense foods may be compensated for by decreased intake at subsequent meals, resulting in no net effect on body size.

Few epidemiologic studies have examined dietary ED among free-living persons, and only one, to our knowledge, has compared ED among men and women of different ethnic groups (5). We used the baseline data from participants in the Hawaii-Los Angeles Multiethnic Cohort (MEC), a large prospective study of 5 ethnic groups (17), to determine whether groups that habitually consume a diet higher in ED have a higher BMI.


   Subjects and Methods
TOP
 ABSTRACT
 Introduction
 Subjects and Methods
Results
 Discussion
 LITERATURE CITED
 
Study population.

The MEC includes over 215,000 participants, aged 45–75 y in 1993, and consists predominantly of 5 ethnic groups: African American (AA), Caucasian (CS), Latino (LT), Native Hawaiian (NH) and Japanese American (JA). Participants completed a 26-page mailed self-administered questionnaire that included a comprehensive quantitative food frequency questionnaire (QFFQ). The questionnaire also asked about demographics, medical history, and lifestyle factors, such as physical activity, smoking status, and self-reported height and weight. The analysis excluded cohort members outside of the 5 major ethnic groups (n = 13,959), individuals with implausible diets (energy intake >3 SEM or macronutrient intake >3.5 SEM) (n = 8265), and subjects with missing data for height or weight (n = 2549). The final analysis included 191,023 cohort members (86,713 men and 104,310 women). The investigation was approved by the University of Hawaii and University of Southern California Institutional Review Boards.

Dietary data.

As previously described (17,18), the QFFQ was developed specifically for the study population, and asked about consumption of >180 food items during the preceding year. Drinking water consumption was not assessed. ED (kJ/g) was calculated for each individual by dividing reported daily energy intake by the total grams of food consumed. We compared 3 calculation methods: 1) food and all beverages, 2) food and energy-containing beverages (excluding diet soda, tea, and plain coffee), and 3) food only.

A calibration substudy was conducted where ~230 MEC members in each of the 10 ethnic sex groups provided one unannounced 24-h recall per month by telephone for 3 mo, followed by a QFFQ ~3 mo later. The same ED variables were calculated for the QFFQ and for each 24-h recall in the calibration substudy, and the mean ED for each individual across recalls was used in analyses.

Other measures.

BMI was calculated as weight in kilograms divided by height in meters squared (kg/m2). Subjects were also classified as normal weight (BMI <25) or overweight/obese (BMI ≥25). Responses to questions on hours spent, on average, each day in sleeping, five sitting activities, strenuous sports, vigorous work, and moderate activity were aggregated into overall metabolic equivalents of activity (METs) (19). Smokers were defined as individuals who reported having smoked at least 20 packs of cigarettes in their lifetime and were currently smoking. The medical history included a self-report for diagnoses of the following conditions that may alter dietary habits: breast, colon, cervical, melanoma, prostate, stomach, uterine, and other cancers; hypertension, previous heart attack, stroke, diabetes, tuberculosis, gout, ulcers, partial removal of the stomach, gallstones, and removal of the gallbladder. A summary chronic disease variable reflected a diagnosis of any of these conditions.

Statistical analyses.

The validity of ED measures was investigated by computing Pearson's correlation coefficients between the mean ED across multiple 24-h recalls and the ED from the QFFQ in the MEC calibration substudy. The correlation was corrected for within-subject variability across the recalls.

Separate linear regression models of BMI on ED were evaluated for each of the 10 ethnic sex groups. BMI was log transformed to meet model assumptions. The following covariates were included in each model: age, current smoking status (yes/no), chronic disease, total METs of activity, and years of school completed. Our primary research question was whether ED was related to BMI. However, energy intake, amount of food consumed, and ED are related, and ED may be related to BMI simply because individuals who consume a diet with a high ED also tend to have high food and/or energy intakes. To address this, the following models were run: model A) excluding both the amount of food and energy as covariates; B) including amount of food as a covariate; C) including energy intake as a covariate; and D) including both covariates. The slope for ED, adjusted for energy and food amount, is the change in log BMI expected from a unit change in ED at a mean level of food amount and energy. Energy intake has been hypothesized to mediate the influence of ED on weight (that is, act as an intermediate variable). Therefore, its inclusion in the model allowed us to determine the influence of ED beyond its association with energy intake. Additional models were adjusted for men and women, with interaction terms between ethnic groups and energy density, and global F tests of all interaction terms were performed to test for differences in slope across groups.

Logistic regression was performed to determine the odds ratio and 95% CI of being overweight or obese associated with a one-unit increase in daily ED. Separate models were adjusted for each of the 10 ethnic sex groups. Nondietary covariates were the same as those for the linear regression models. Additionally, models including interaction terms were compared within each sex (through the likelihood ratio test) to models with main effects to determine whether energy density exhibited a different relation to overweight status across ethnic groups.

We used ethnic sex-specific correlations for ED between the QFFQ and recalls in the calibration substudy to correct the slopes from linear regression and the odds ratios from logistic regression by the method of moments (20,21). The variances were adjusted to account for the variability in the correlation by the delta method. The corrected parameters were compared across ethnic groups via a chi-square test, assuming normality of the parameters. All statistical analyses were performed using SAS, version 9.1. Comparisons with P < 0.05 were considered significant.


   Results
TOP
 ABSTRACT
 Introduction
 Subjects and Methods
 Results
Discussion
 LITERATURE CITED
 
Correlations from the calibration substudy (Table 1) comparing mean measures from the 24-h intakes to corresponding values from the QFFQ, corrected for within-subject variability, are given for each of the 3 methods of calculating ED. In all groups except AA men, the correlations for food and energy-containing beverages were highest and were ≥0.45. Thus, we considered this QFFQ measure of ED acceptable.


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  		TABLE 1 Correlations for 3 energy density calculation methods among Multiethnic Cohort subjects in the calibration substudy1

 
The ED of diets varied among the ethnic groups and ranged from 4.62 kJ/g in JA men to 5.08 kJ/g in AA men (Table 2). The magnitude and the variation in means were generally smaller among women, with values ranging from 4.64 kJ/g in JA and LT to 4.89 kJ/g in AA. Ethnic groups were significantly different within each sex group. AA, CS, and LT men had higher mean ED than women in those ethnic groups. Among men, weight and BMI were highest in NH and lowest in JA, but among women, these variables were highest in AA and lowest in JA (Table 2). BMI varied significantly among ethnic groups within each sex (P < 0.001). When we removed possible under- and over-reporters, by including only participants reporting 500–5000 kcal/d (2.092–209.2 MJ/d), the results did not differ. Mean adjusted BMI and body weight were both significantly higher across increasing quartiles of ED in each ethnic sex group (Table 3). Correlations were 0.04 for ED and energy intake, –0.38 for ED and food amount, and 0.89 for energy intake and food amount for all subjects combined, and were similar in magnitude and direction within all ethnic sex groups.


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  		TABLE 2 Subject characteristics by ethnicity and sex, Multiethnic Cohort1

 

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  		TABLE 3 Mean BMI and weight by quartiles of energy density in 5 ethnic groups1

 
    Regression models. In multivariate models, ED was positively and significantly associated with BMI in men and women in all ethnic groups. Adjusting for age, METs, smoking status, presence of chronic disease, and years of school completed, a 1 kJ/g increase in ED, approximately equivalent to a change of 1 SD, was associated with a significant increase of slightly more than 1 kg/m2 of BMI in all ethnic sex groups [Table 4, models A, B (also adjusted for food amount), C (also adjusted for total energy)]. With both food amount and total energy in the model (Table 4, model D), ED was significantly related to BMI in CS, JA, and LT of both sexes and NH men, indicating that ED is associated with BMI, even when adjusted for energy intake.


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  		TABLE 4 BMI associations with energy density (kJ/g) of all food and energy-containing beverages in 5 ethnic groups.

 
Adjusted odds ratios (Table 5) show that higher ED was associated with a significantly greater likelihood of being overweight in all ethnic sex groups (model A). After correcting for measurement error, the odds ratios became deattenuated, varying between 1.05 and 1.54 for men and between 1.14 and 1.48 for women, for a 1 kJ/g increase in ED. The corrected odds ratios differed across ethnic groups for men and women (P < 0.0001). When total amount of food (g) was added to the model (model B), associations of overweight with ED were higher in all groups. For this model, a 1 kJ/g increase in ED raised the likelihood of being overweight least in AA men (4%) and most in JA men (31%) and, in women, it ranged from 11% in AA to 34% in JA. The odds ratios differed between ethnic sex groups (P < 0.0001) in models A, B, and C. The addition of both food amount and total energy to the model (Table 5, model D) caused the association of ED with risk of overweight to become nonsignificant in AA and NH men and women, and to become weaker, but still significant, in the other groups. Controlling for fiber in all analyses attenuated the associations slightly, but ED generally remained significantly associated with BMI and risk of overweight.


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  		TABLE 5 Odds ratios of overweight status by daily energy density (kJ/g) of all food and energy-containing beverages in 5 ethnic groups.

 

   Discussion
TOP
 ABSTRACT
 Introduction
 Subjects and Methods
 Results
 Discussion
LITERATURE CITED
 
To our knowledge, this is the first study to analyze the association of ED with BMI in a multiethnic population-based cohort. It is also one of the few investigations of ED in free-living persons and, to our knowledge, the only study to calculate ED from QFFQ data. We found that ED was acceptably measured using QFFQ data, with a correlation of 0.50 between the QFFQ value and the mean of multiple 24-h recalls. ED was positively associated with BMI in all ethnic sex groups, and higher ED was associated with a greater likelihood of being overweight. Our findings suggest a possible role for ED in weight regulation.

Across the ethnic sex groups a 1 kJ/g higher ED was associated with ~1 kg/m2 higher BMI, and the association was highly significant. One kJ/g is larger than the greatest mean difference across ethnic sex groups (0.46 kJ/g), but is not unreasonable to attain through dietary changes. Although the association of ED with BMI was not large in absolute terms, it is most likely attenuated by the measurement error inherent in all dietary assessment instruments, including QFFQs (22). Thus, the true associations between ED and body size may be much stronger.

The 2 most important determinants of dietary ED are water and fat (4), and both vary considerably among foods. Fiber may also influence ED because of its relatively low energy content. It may be possible to reduce ED enough to affect weight gain through simple dietary changes, such as incorporating water into foods by making soups (11), adding vegetables to mixed dishes, using fiber-rich whole grains rather than refined grains, and reducing fat content (23,24). Beverages such as soda and sweetened juices are energy-dilute but may not be associated with a reduction of energy intake (25,26).

Various methods have been used to calculate ED (5,27–29), but we found that correlations between the QFFQ and 24-h recalls were the highest for the measure that includes food and energy-containing beverages. This variable also had the strongest relation with BMI in regression models. Ledikwe et al. (5) found that the day-to-day variation was high when all caloric beverages were included in an analysis of the Continuing Survey of Food Intake by Individuals (CSFII) and recommended against their inclusion in the calculation of ED. However, the MEC used a QFFQ whereas the CSFII used two 24-h recalls. The QFFQ method assesses intake over a year's time and should not be influenced by day-to-day variability. EDs calculated from our QFFQ data are slightly lower than those calculated from 24-h recall data in other studies (5,30). However, within our calibration study, mean ED from QFFQ data were slightly higher (4.81 ± 1.01 kJ/g) than from 24-h recall data (4.47 ± 1.41 kJ/g).

The differences in ED were reflected in corresponding variations in BMI for some but not all of the 10 ethnic sex groups (Table 2). JA exhibited the lowest ED, as well as the lowest BMI;. AA reported diets with the highest ED, and AA women had the highest BMIs. NH and LT of both sexes were anomalies, with low ED and high BMI. Although the reasons for these anomalies are unclear and require further study, they may be due in part to different meal patterns.

The magnitude of the association between ED and overweight status varied among ethnic groups, perhaps reflecting a dissimilarity in the accuracy of reporting energy intakes by ethnic group (18) and by weight status (31,32). AA men showed the lowest risk of being overweight from a more energy dense diet and also reported the lowest energy intake. Furthermore, the correlation between ED on the QFFQ and the recalls was notably lower for AA men in the calibration substudy. By comparison, the risk of overweight from a more energy dense diet was much higher in JA of both sexes, and the correlation of the 2 energy density measures for JA was above the mean in the calibration substudy.

The association of ED with BMI remained when the model was adjusted for energy and food amounts. This implies that ED has an association with BMI independent of its 2 components. Because of a likely correlated measurement error in energy and amount of food, it is possible that ED is a better predictor of actual intake than energy intake alone. More study of the errors in reporting these dietary variables would be useful.

A primary strength of this study is the large representative sample of participants from 5 diverse ethnic groups. However, this analysis involved cross-sectional data and causation could not be determined. Anthropometric variables were self-reported, but other researchers have found good concordance between self-reported and measured weight and height in the National Health and Nutrition Examination Surveys (33,34) and the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition (35). Participants in the MEC are presently responding to a repeat of the baseline questionnaire, where both weight and dietary information, in addition to waist and hip circumference, are being collected. Thus, longitudinal analyses will be possible in the future.

In conclusion, our results, combined with those of previous intervention studies, strongly suggest that a less energy dense diet is associated with a lower BMI in both men and women across ethnic groups. These preliminary cross-sectional results indicate a need for prospective epidemiological studies to delineate the link between ED and obesity risk, as well as intervention trials to further examine possible disparities in the associations of ED with BMI across ethnic groups. If our findings are confirmed, they provide another potential avenue for public health education.


   ACKNOWLEDGMENTS
 
We appreciate the contributions of Dr. Brian Henderson and Dr. Kristine Monroe, who conducted the data collection for the California portion of the MEC, and Jennifer Yamamoto, who provided statistical advice.


   FOOTNOTES
 
1 Presented in abstract form at NAASO, The Obesity Society, 2005 Vancouver BC [Howarth NC, Murphy SP, Wilkens LR, Hankin JH, Kolonel, LN. Dietary energy density is associated with overweight status among five ethnic groups: the Multiethnic Cohort Study (abstract). Obes Res. 2005;13:A17]. Back

2 The Multiethnic Cohort Study was funded by grant R37CA054281 from the National Cancer Institute, U.S. Department of Health and Human Services; additional support was provided by postdoctoral grant no. R25 CA90956, NIH/NCI. Back

3 Abbreviations used: AA, African American; CS, Caucasian; ED, energy density; JA, Japanese American; LT, Latino; MEC, Multiethnic Cohort; METs, metabolic equivalents of activity; NH, Native Hawaiian; QFFQ, quantitative food frequency questionnaire. Back

Manuscript received 23 January 2006. Initial review completed 23 February 2006. Revision accepted 23 May 2006.


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 ABSTRACT
 Introduction
 Subjects and Methods
 Results
 Discussion
 LITERATURE CITED
 

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