BACKGROUND: Dietary energy density, or energy available in relation to gram intake, can inform disease risk. OBJECTIVE: The objective of this study was to investigate the association between baseline dietary energy density and risk of incident type 2 diabetes in postmenopausal women. DESIGN: Dietary energy density, weight status, and type 2 diabetes incidence were prospectively characterized in a large cohort of postmenopausal women participating in one or more clinical trials or an observational study. PARTICIPANTS/SETTING: The study involved 161,808 postmenopausal women recruited to the Women's Health Initiative observational study or clinical trials at 40 centers across the United States between 1993 and 1998. MAIN OUTCOME MEASURES: The primary outcome was incident type 2 diabetes. STATISTICAL ANALYSES PERFORMED: The association between dietary energy density quintiles and incident diabetes was tested using Cox proportional hazards regression. RESULTS: A total of 143,204 participants without self-reported diabetes at enrollment completed baseline dietary assessment and were followed for 12.7+/-4.6 years. Risk of diabetes developing was 24% greater for women in the highest dietary energy density quintile compared with the lowest after adjusting for confounders (95% CI 1.17 to 1.32). Body mass index (calculated as kg/m2) and waist circumference mediated the relationship between dietary energy density and diabetes. In waist circumference-stratified analysis, women in dietary energy density quintiles 2 to 5 with waist circumferences > 88 cm were at 9% to 12% greater risk of diabetes developing compared with women with waist circumference CONCLUSIONS: In this prospective study, a higher baseline dietary energy density was associated with higher incidence of type 2 diabetes among postmenopausal women, both overall, and in women with elevated waist circumference.

Purpose: Spirituality has been associated with better cardiac autonomic balance, but its association with cardiovascular risk is not well studied. We examined whether more frequent private spiritual activity was associated with reduced cardiovascular risk in postmenopausal women enrolled in the Women’s Health Initiative Observational Study. Methods: Frequency of private spiritual activity (prayer, Bible reading, and meditation) was selfreported at year 5 of follow-up. Cardiovascular outcomes were centrally adjudicated, and cardiovascular risk was estimated from proportional hazards models. Results: Final models included 43,708 women (mean age: 68.9±7.3; median follow-up: 7.0 years) free of cardiac disease through year 5 of follow-up. In age-adjusted models private spiritual activity was associated with increased cardiovascular risk (HR: 1.16; CI 1.02, 1.31, weekly vs. never; 1.25; CI 1.11, 1.40, daily vs. never). In multivariate models adjusted for demographics, lifestyle, risk factors, and psychosocial factors, such association remained significant only in the group with daily activity (HR 1.16; CI: 1.03, 1.30). Subgroup analyses indicate this association may be driven by the presence of severe chronic diseases. Conclusion: In aging women, higher frequency of private spiritual activity was associated with increased cardiovascular risk, likely reflecting a mobilization of spiritual resources in order to cope with aging and illness.

Underreporting of energy consumption by self-report is well-recognized, but previous studies using recovery biomarkers have not been sufficiently large to establish whether participant characteristics predict misreporting. In 2004-2005, 544 participants in the Women's Health Initiative Dietary Modification Trial completed a doubly labeled water protocol (energy biomarker), 24-hour urine collection (protein biomarker), and self-reports of diet (assessed by food frequency questionnaire (FFQ)), exercise, and lifestyle habits; 111 women repeated all procedures after 6 months. Using linear regression, the authors estimated associations of participant characteristics with misreporting, defined as the extent to which the log ratio (self-reported FFQ/nutritional biomarker) was less than zero. Intervention women in the trial underreported energy intake by 32% (vs. 27% in the comparison arm) and protein intake by 15% (vs. 10%). Younger women had more underreporting of energy (p = 0.02) and protein (p = 0.001), while increasing body mass index predicted increased underreporting of energy and overreporting of percentage of energy derived from protein (p = 0.001 and p = 0.004, respectively). Blacks and Hispanics underreported more than did Caucasians. Correlations of initial measures with repeat measures (n = 111) were 0.72, 0.70, 0.46, and 0.64 for biomarker energy, FFQ energy, biomarker protein, and FFQ protein, respectively. Recovery biomarker data were used in regression equations to calibrate self-reports; the potential application of these equations to disease risk modeling is presented. The authors confirm the existence of systematic bias in dietary self-reports and provide methods of correcting for measurement error.