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1. NuVal™
& the Overall Nutritional Quality Index (ONQI)
-knowledge to power-
David L. Katz, MD, MPH, FACPM, FACP
Associate Professor, adjunct, Public Health Practice
Director, Prevention Research Center
Yale University School of Medicine
www.davidkatzmd.com
Webinar
6/4/10

2. we live where good advice…
 “Eat food, not too much, mostly plants.”
 Michael Pollan
…can be hard to swallow!-

7. Even when clear where “there” is-
-it may seem…
 you can’t get there from here:

8. The case for skill power,
 not just will power.

9. Because people need to know things-
they never knew they never knew!…
Sodium content per 100 calories?

10. Sodium Sodium Sodium Sodium
242 mg 100 mg 73 mg 131 mg

11. Added sugar per 100kcal?

12. Sugar Sugar
12 G 11 G

13. Nutrition Quiz – Peanut Butter
Which one of these products is the more nutritious choice?

14. Nutrition Quiz – Peanut Butter
Answer: Regular Peanut Butter

15. A little nutty…
Peanut Butter Reduced Fat
Nutrient
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

16. Power & Responsibility, but backwards…

19. 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…

20. 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

21. The ONQI Algorithm-
•Macronutrient Adjustors
Numerator Denominator Fat quality
Protein quality
Fiber Saturated fat Glycemic load
Folate Trans fat Energy density
Vitamin A Sodium
Vitamin C Sugar
Vitamin D Cholesterol •Trajectory Scores
Vitamin E •Weighting Coefficients
Vitamin B12
Vitamin B6
Potassium Categorical stipulations
Calcium
Zinc • Pure foods vs.
Omega-3 fatty acids processed
Total bioflavanoids • Intrinsic vs. added
Total carotenoids sugars
Magnesium • Artificial sweeteners
Iron • Etc.

22. ONQI formula
Something 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

23. Vrrrooommm-
 Under the Hood:
 undeniable (& distinctly advantageous) complexity
 At the User Interface:
 turnkey simplicity

24. A Sampling of Scores
Beef & Poultry
Turkey Breast (skinless) 48
Chicken Breast (boneless) 39
Seafood
Pork Tenderloin 35 Atlantic Salmon Fillet 87
Bottom Round Roast (Beef) 34 Atlantic Halibut Fillet 82
Flank Steak (Beef) 34 Catfish Fillet 82
Breast 31 Cod Fillet 82
Veal Chop 31 Tilapia Fillet 82
Veal Leg Cutlet 31 Oysters 81
Beef Tenderloin 30 Swordfish Steak 81
Chicken Drumstick 30 Prawns 75
Ground Sirloin (Beef 90/10) 30 Shrimp 75
Pork Chop (boneless center) 28 Clams 71
Chicken Wings 28 Monkfish Fillet 64
Ground Round (Beef 85/15) 28 Bay Scallops 51
Lamb Chops (loin) 28 Turbot Fillet 51
Leg of Lamb 28 Lobster 36
Ham (whole) 27
Ground Chuck (Beef 80/20) 26
Pork Ribs, Country Style 25
Beef Spareribs 24
Pork Baby Back Ribs 24

25. Canned Vegetables
Del Monte Fresh Cut French Style Green Beans No Salt 100
Del Monte Fresh Cut Whole Leaf Spinach 76
Del Monte Fresh Cut Sweet Corn Cream Style No Salt Added 67
Produce Del Monte Fresh Cut Whole Green Beans
Green Giant Extra Long Tender Green Asparagus Spears
59
56
Apricots 100 Green Giant Cut Green Beans 52
Asparagus 100 Del Monte Organic Whole Kernel Corn 50
Beans 100 Green Giant Sweet Peas 50% Less Sodium 48
Blueberries 100 Le Sueur Very Young Small Sweet Peas 43
Broccoli 100 Green Giant Super Sweet Yellow & White Whole Kernel Corn 42
Cabbage 100 Del Monte Organic Sweet Peas 39
Cauliflower 100 Veg-All Homestyle Large Cut Vegetables 35
Kiwi 100 Del Monte Fresh Cut Sweet Corn Cream Style 32
Lettuce 100 Green Giant Niblets Whole Sweet Corn 27
Mustard Greens 100 Progresso Artichoke Hearts 18
Okra 100 Aunt Nellie's Whole Ruby Red Pickled Beets 3
Orange 100
Spinach 100
Strawberries
Turnip
100
100
Frozen Vegetables
Carrots 99 Birds Eye Frozen Cauliflower Floret plastic bag 100
Grapefruit 99 Birds Eye Frozen Chopped Spinach box 100
Pineapple 99 Green Giant Frozen Broccoli Cuts steamable bag 100
Plums 99 Green Giant Frozen Cut Green Beans steamable bag 100
Mango 93 Birds Eye Frozen Peas polybag 96
Potatoes 93 La Choy Frozen Snow Pea Pods box 96
Red onions 93 Birds Eye Steamfresh Frozen Brussels Sprouts steamable bag 94
Tangerines 93 Birds Eye Frozen Cooked Winter Squash box 91
Bananas 91 Green Giant Frozen Mixed Vegetables steamable bag 87
Corn 91 Birds Eye Frozen Asparagus Stir Fry plastic bag 82
Grapes 91 Birds Eye Frozen Green Beans & Lightly Toasted Almonds box 68
Honeydew Melon 91 Green Giant Frozen Cauliflower & 3 Cheese Sauce plastic bag 42
Rhubarb 91 Green Giant Frozen Creamed Spinach in Low-Fat Sauce box 34
Iceberg Lettuce 82 Birds Eye Steamfresh Specially Seasoned Southwestern Corn 33
Bok Choy 81 Green Giant Frozen Sweet Baby Peas and Low-Fat Butter Sauce 30
Passion Fruit 78 Green Giant Frozen Honey Glazed Carrots box 26
Coconut 24 Green Giant Frozen Green Bean Casserole box 23

26. Cereal Salty Snacks
Hodgson Mill Unprocessed Wheat Bran 100 Garden of Eatin No Salt Blue Tortilla Chips 52
Post Shredded Wheat Original 91 Terra unsalted potato chips barbecue 41
Kashi 7 Whole Grain Puffs 91 Garden of Eatin Blue Tortilla Chips 40
Kellogg's All-Bran 76 Terra Gold Original Potato Chips 33
Kellogg's Special K Protein Plus 60 Snyder's Multigrain Pretzel Sticks Lightly Salted 31
Quaker Shredded Wheat 56 Guiltless Gourmet Chili Lime Tortilla Chips 30
General Mills Fiber One 52 Tostitos Light Restaurant Style 28
Kashi Golean High Protein & High Fiber 47 Utz Baked Potato Crisps Original 27
General Mills Cinnamon Toast Crunch 40 Good health peanut butter filled pretzels 26
Quaker Instant Oatmeal Original 39 Doritos Baked Nacho Cheese 25
General Mills Cheerios 34 Frito-Lay Sun Chips Harvest Cheddar 25
Post Shredded Wheat Frosted 31 Lay's Baked Potato Crisps 25
Kellogg's All-Bran 31 Baked Ruffles Cheddar & Sour Cream 24
Post HealthyClassics Grape-Nuts 30 Newman's Own Organic Pretzel Rounds Unsalted 24
Post Honey Bunches Of Oats with Almonds 29 Ruffles Thick Cut Original 24
Kashi 7 Whole Grain Flakes 29 Doritos Cool Ranch 23
General Mills Kix 29 Lay's Potato Chips Classic 23
General Mills Wheaties 28 Snyder's Pretzels Honey Wheat o 23
General Mills Whole Grain Total Raisin Bran 27 Sunshine cheez-it party mix 20
Post Healthy Classics Raisin Bran 26 Newman's Own Organic Pretzel Rounds Salted 19
Kellogg's Frosted Flakes 26 Fritos Corn Chips Original 16
Kellogg's Corn Flakes 25 Cheetos Puffs 14
Post Fruity Pebbles 24 Rold Gold Petzels Rods 14
Kellogg's Mueslix 24 Chex Mix Traditional 13
General Mills Corn Chex 24 Doritos Nacho Cheese 10
Cream Of Wheat Instant Hot Cereal 24 Rold Gold Pretzel Sticks Fat Free 10
Quaker Natural Granola Oats, Honey & Raisins 23 Pringles Reduced Fat Original 9
Kellogg's Rice Krispies 23 Ruffles Cheddar & Sour Cream 9
General Mills Basic 4 23 Cheetos Crunchy 5
General Mills Lucky Charms 23 Utz Potato Chips Barbecue 4
Kellogg's Corn Pops 20 Combos Pretzel Cheddar Cheese 3
Kellogg's Froot Loops 17 Bugles Original Corn Snack 2
Kashi Strawberry Fields 11 Glutino Pretzel Twists Gluten Free 1
Cap'n Crunch 10
Quaker Instant Grits Butter Flavor 6

27. 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

29. NuVal is going to school…
 Independence School District, MO
 New Haven, CT
 Palm Beach County, FL

30. …But has already been tested:
proof in the pudding
(and everywhere else)

31. 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
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]

32. Do nutrition rating systems promote a healthy diet?
An evaluation of the Overall Nutritional Quality Index (ONQI) and risk of chronic disease
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
BACKGROUND RESULTS SUMMARY
Nutrient profiling is a system of ranking or classifying foods based on nutrient Food Category* FFQ Foods (number) The mean (SD) of the ONQI score was 23.0 (7.3) in the
composition. These profiles can be used to communicate the nutritional men and 24.3 (6.9) in the women
quality of a food product to consumers. Vegetable 22, no added salt Women: 20,005 chronic disease events (4,433 CVD,
Nearly Pure Vegetable 1, added salt 11,249 cancer, 5,265 diabetes and 2,994 deaths)
Symbols aim to rank foods on the basis of health effects, however they have
not been evaluated with respect to chronic disease risk. Milk & Nearly Pure Dairy 4, no added salt or hydrogenated oil (H) Men: 13,532 chronic disease events (4,195 CVD, 4,939
Nearly Milk 4, added salt, no H cancer, 2,407 diabetes and 1,928 deaths)
OBJECTIVE
Cooking Oil 2 excluding trans oils ONQI scores were inversely associated with risk of total
To develop the Overall Nutritional Quality Index (ONQI) score for two large chronic disease and mortality among men and women
Grains 6 including 5 cereals
ongoing prospective cohorts, the Nurses Healthy Study’s (NHS) and Health (Table 1, Figure 2)
Professional Follow Up Study’s (HPFS) 1986 food frequency questionnaires Pure Meats 12
The ONQI score was most strongly associated with lower
(FFQ) and test the ability of ONQI to predict major chronic disease risk. Nearly Pure Meats 2, added salt risk of CVD and diabetes among women and men (Figure
Cold Beverages 3, sugar substituted 2)
NuVal™ SCORING SYSTEM Fruits 9 men, 11 women LIMITATIONS
Figure1. The components of the Overall Nutritional Quality Index *Remaining ONQI categories are not applicable
ONQI algorithm and NuVal system designed to measure
nutritional quality at the food level, and not for an overall
Numerator Denominator NuVal™ Score diet evaluation
Folate, Potassium, Saturated Fat
Figure 2. Multivariate- adjusted relative risk of disease comparing the highest to
FFQ is not brand specific and does not distinguish food
Fiber, Calcium,
lowest quintile of the Overall Nutritional Quality Index
Zinc, Magnesium, ● Trans Fat 1.2 WOMEN * p<0.05 comparing quintile 5 to quintile 1
preparation (ie canned, frozen, fresh)
Analysis based on single measure of diet at baseline
Sodium
●
Omega-3 Fat, MEN 1.02 1.04 These limitations lead to non-differential misclassification
Flavonoids, Iron, 1
Sugar
0.91* 0.89* of the ONQI score and bias the results towards the null
Carotenoids 0.88*
Relative risk of disease
0.85*
0.80* 0.79*
VitaminsA/C/D/E/
Cholesterol 0.8
STRENGTHS
B6/B12
The NuVal™ Nutritional Scoring System, based on the Overall Nutritional 0.6
Quality Index (ONQI) algorithm is found in 6 supermarket chains, and over
Use of an aggregate total chronic disease outcome, which
is a valuable measure to evaluate the healthfulness of
550 stores, in the US currently
0.4 nutrient profiling systems
ONQI algorithm includes >30 nutrients and food properties
ONQI algorithm is a single summative score that balances
The algorithm also incorporates measures of energy density and 0.2 complex trade-offs between the beneficial and detrimental
macronutrient quality and coefficients are weighted based on strength of nutrients within a food
association disease risk
0 ONQI algorithm is applied to all foods, which allows for
METHODS comparison within and across food groups
CVD Diabetes Cancer Total
Mortality CONCLUSIONS
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
Diets comprised of foods with higher average ONQI
Outcome Measurement: Total major chronic disease: initial occurrence of scores, which incorporates over 30 nutrients, food
CVD, diabetes or cancer or non-trauma-related death from 1986 to 2006 Risk factors associated with ONQI score
properties and magnitude of association with disease, is
ONQI score assessment: Dietary data collected through food frequency associated with lower risk of total chronic disease and
questionnaires at baseline (1986) , categorized according to 24 different food Direct association with: Inverse association with:
total mortality
categories. 100 point scale was applied, multiplied by frequency of - Exercise - BMI
Future research on nutrient profiles should use similar
consumption, summed for all foods and then weighted by total servings. - Alcohol intake - Smoking techniques to validate the healthfulness of scoring
Statistical Analysis - Hypertension - Regular aspirin use schemes against health outcomes
Multivariate Cox proportional hazard models - Hypercholesterolemia Any scoring scheme regulated or adopted by the FDA for
Acknowledgements standardized front-of-package labeling on supermarket
This study was supported by research grants HL34594, HL60712, CA87969, and CA58895 from the NIH - Menopausal hormone use
shelves should be based upon the best available scientific
CONTACT: schiuve@hsph.harvard.edu
evidence and predict risk of chronic disease

33. 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

34. 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

35. Thank you!
David L. Katz, MD, MPH, FACPM, FACP
Director, 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