Associations of dietary patterns and abdominal obesity in the adult population. Results of the Russian epidemiological ESSE-RF study

is directly prevalence and amount of drinking dry and fortified wines, as well as strong alcoholic drinks. Men with AO drinks higher amount of beer. In addition, men with AO showed a positive association with alcohol consumption ( χ =53,64, p<0,0001), while women with AO had a negative association ( χ =28,64, p<0,0001). Cardioprotective eating habits are more often (17%) present among people with AO without sex differences. Conclusion. The study revealed significant differences in dietary patterns of persons with AO compared with those without AO, most pronounced in women.

Medical Research Center, and all other participating centers. All subjects signed an informed consent. The response rate was ~80% [22].
To assess nutrition and dietary habits, a standard questionnaire was used on consumption of the main food groups (red meat, poultry, fish and seafood, sausages and meat delicacies, pickles, cereals and pasta, raw vegetables and fruits, legumes, confectionery and sweets, dairy products: milk, kefir, yoghurt, sour cream/cream, cottage cheese, cheese) with 4 criteria -"not consume/rarely"; "1-2 times a month"; "1-2 times a week" and "daily/almost daily". Dairy products by fat content were grouped according to the criteria of Russian regulatory documents [23]. The criteria for assessing a diet were determined in accordance with the World Health Organization criteria [24].
Daily consumption of confectionery, sweets, and/or consumption >12 tsp/raw sugar lumps were considered "consuming too much added sugar". Excessive salt intake was determined when there were simultaneously 2 out of 3 following items in the diet: daily consumption of sausages and meat delicacies; daily consumption of pickles and marinades; adding more salt to cooked dishes. The protective dietary pattern included the 4 following items: daily consumption of vegetables and fruits, fish consumption at least 1-2 times a week, consuming only vegetable oils, and the consumption of low-fat dairy products.
Alcohol consumption was assessed by the frequency and intensity of its usual intake once and per week. The following types of alcoholic beverages were evaluated: beer, dry wines and champagne, fortified wines, house wines and liqueurs, spirits (vodka, cognac, etc.). Additionally, the calculation of ethanol consumption per day was carried out in total from each type of alcoholic beverages. The "high consumption" category included women consuming 84 g and men consuming 168 g of pure ethanol per week; "moderate consumption"women consuming 42 g and men consuming 84 g of pure ethanol per week; "low consumption"women consuming <42 g and men consuming <84 g ethanol per week.
AO was recorded at waist circumference (WC) ≥102 cm in men and WC ≥88 cm in women. Anthropometric measurements were carried out using standard techniques and is described in the study protocol [22].
Statistical analysis was carried out on a cohort of respondents who have complete data on dietary pattern (n=19297; men, 7342; women, 11955).
There were gaps in the answers about alcohol consumption. To recover the missing data in the answers to the questions "How often do you drink Obesity is a significant global problem, rapidly growing in modern society and becoming an epidemic [1]. In Russia, according to the ESSE-RF  large-scale epidemiological study, the prevalence of  general obesity is 30,8% among women and 26,9%  among men, while abdominal obesity (AO) -38,4% and 24,3%, respectively [2]. Over the decade of 2003-2013, the obesity rate among women increased by 30%, and among men -2,5 times [2]. The increase in obesity is noted both among the urban and rural population, which, given the difference in physical activity, indicates the increasing role of inadequate nutrition in obesity development. AO is a nutrition-dependent risk factor, the development and prognosis of which is directly determined by the diet. AO is a key risk factor for metabolic syn drome, forming a whole cluster of metabolic disorders and increasing the adverse effect on the patient prognosis.
At the moment, the numerous studies in this area are a topic for active scientific discussion, since they are multidirectional in nature and have significant differences depending on the dietary structure in the population.
The aim was to study the associations of dietary patterns and AO among the adult Russian population.

Material and methods
The material was representative samples of male and female population aged 25- alcohol?" and "How much do you usually drink in one meal?" data recovery algorithm was used.
For each category of alcoholic beverages, a table was formed with the columns "sex", "age group", "education status", "type of residence", "average consumption frequency per week", "average quantity in ml per one meal". Every possible combination of values in the first four columns identified a subgroup to which the respondents might belong. For each subgroup, the mean values indicated in the last two columns were calculated. In the case when the respondent missed the answer to the question "How  often do you drink alcohol?" or "How much do you usually drink in one meal?", the missing value was restored by the average of the column "Average consumption frequency per week" or "average quantity in ml per one meal", respectively, from the subgroup to which the respondent belonged. Statistical analysis was performed using the Scipy 1.1.0, NumPy 1.14.3 libraries for Python 3.6.5 (Python Software Foundation, Delware, USA) and free R 3.6.1 environment. We calculated the mean and 95% lower and upper confidence intervals (CI) of the mean. The significance of differences between two independent samples was assessed using the Z-test for proportions in the case of binary data and the nonparametric Mann-Whitney U-test in the case of continuous one. The association between categorical data was assessed using the Pearson chi-squared test. The significance of differences between groups with different frequency of consuming a particular product was assessed using the Kruskal-Wallis test. For univariate and multivariate logistic regression, the glm function of the R 3.6.1 environment was used with an estimation of odds ratio (OR) and a 95% CI. The continuous variable "Age" was divided into 4 groups by decades ("25 years -34 years" -the reference group, "35 years -44 years", "45 years -54 years", "55 years -64 years") and was considered as a categorical. The results were considered significant at p<0,05.

Results
The central socio-demographic characteri stics of subjects have already been presented in detail in previous publications [2].
The characteristics of the daily dietary patterns are presented in Table 1. There are significant dif ferences in the dietary pattern of persons with AO, compared with those without AO. Thus, per sons with AO, both men and women, more often con sume red meat, fish and seafood, fruits and ve getables, less often sweets and confectionery, ce reals and pasta. Also, persons with AO without sex differences are less likely to consume raw sugar. Sugar consumption per day among women with and without AO is 4,1 (4,0-4,2) vs 4,6 (4,5-4,7) tsp (p<0,0001), while among men: 5,4 (5,2-5,6) vs 6,2 (6,1-6,4), respectively (p<0,0001). Differences in consumption of other foods are observed only in women. So, Russian women with AO more often consume poultry, sausages and meat delicacies, pickles, liquid dairy pro ducts (milk, kefir, yogurt) and cottage cheese. Excessive salt intake among women with AO is observed significantly more often. It is noticeable that the diet of women with AO often contains foods with a high salt content (processed meat products, pickles), which form an excessive salt intake. There are no differences in the prevalence of adding more salt to cooked food among women with AO. Among men, these features are not observed. However, in the general population, the consumption of processed products among men is higher and is one of the population characteristics of dietary pattern [25].
Among people with AO, the consuming too much sugar is lower, and the pattern of excessive intake of salt, sugar and milk fat is less common. There is also a higher rate of people adhering to a healthy diet (adequate consumption of vegetables and fruits, fish products, using only vegetable oils and consumption of low-fat dairy products).
The logistic regression made it possible to detail the differences in the diet of individuals with AO, as well as to demonstrate sex differences. The results of the analysis are presented in Table 2. Thus, among the differences in the dietary pattern of men with AO compared with those without AO, only a higher consumption of red meat and fruit and vegetable products remained, while rarer -cereals, pasta, sweets, including confectionery, cottage cheese and high-fat dairy products (sour cream and cream). In the diet of women with AO, a wider range Table 3 Comparison between groups of subjects with and without AO, depending on the level of alcohol consumption  sumption" and higher in the categories "moderate consumption" and "high consumption" (Table 3). Among men with AO, the percentage of people with a high alcohol consumption significantly higher than in those without AO (OR, 1,72 (95% CI 1,42-2,09), p<0,0001). In women, the situation is the opposite: persons with AO are less likely to consume alcoholic beverages. Thus, the indices in "non-users" group are higher, and in the group of "low consumption" -lower in comparison with similar indices in women without AO (p<0,0001). There are no significant differences in the categories "moderate consumption" and "high consumption". The characteristics of alcohol consumption by persons with and without AO are presented in Table 4.
of differences is noted. There was more common consumption of not only red meat, but fish products, poultry, meat and sausage products, and liquid dairy products, as well as fruits and vegetables, while there is a rarer presence in the diet of cereals, pasta, sweets, and high-fat dairy products (sour cream, cream). However, in this analysis, there are no longer any differences in excessive salt intake among women with AO. Of the positive aspects of the diet, both among men and women with AO, there is a rarer excessive consumption of sugar, salt, milk fat, and a more common use of cardioprotective diet. Significant differences are observed in the level of alcohol consumption. So, among men with AO, the indicator is lower in the category "low con- regarding higher consumption of milk, kefir and yogurt in women with AO were also noted in another Russian study [11], carried out using the "Selective observation of the diet of the population" conducted in 2013 [27]. However, after standardization for age, educational status and income level, association was observed only in men, in contrast to the present study. The consumption of cottage cheese in women was associated with a decrease in obesity risk [11]; in the present study, no significant associations were found. It should be noted that the cited and present studies differed in anthropometric measurements and, accordingly, determining the body weight category.
In the present study, anthropometric measurements were carried out according to standard methods by physician investigators, and in "Selective observation of the diet of the population" − by the respondents themselves. However, despite some differences in the results obtained, in general, there were positive associations between the consumption of liquid dairy products (in particular, kefir) and the obesity.
In the present study, no associations of consuming too much added sugar, confectionery and other sweets with the AO were observed, which may be related to the assessment of consumption frequency, but not intensity, as in other studies [19]. However, results similar to the present ones were obtained in another study [6], which included 2043 persons of both sexes from Moscow, Kaluga, Michurinsk and Tambov. The study demonstrated that, despite the overall high intake of added sugar from various foods, there was no association with obesity among the respondents [6].
The positive association of high consumption of red meat and the obesity [9] is confirmed in almost all studies on this topic. The present analysis also noted a higher consumption of red meat in both men and women with AO.
The positive association noted by many re searchers of the common consumption of pro cessed red meat (sausages and meat delicacies) and the presence of general and AO [6,19] is also observed in this analysis among women. Alcohol use has also been positively associated with obesity in studies [14], whereas in the current analysis this has been confirmed among men.
In general, the analysis demonstrates both unfavorable accents in the nutritional pattern of persons with AO, and at the same time, protective ones in comparison with persons without AO. Among persons with AO of both sexes, along with a higher consumption of red meat, a higher presence of vegetables and fruits in the diet is also noted. Also, among persons with AO without sex differences, the cardioprotective nutrition pattern is more common. Among the unfavorable dietary characteristics Men with AO, compared with men without AO, have a higher frequency and intensity of consuming dry and fortified wines, strong drinks (vodka, cognac). Differences were also observed in the form of greater intensity of beer consumption by men with AO. Among women, the situation is the opposite: persons with AO are less likely to consume alcoholic beverages. There was a lower frequency and intensity of beer and dry wine consumption among women with AO compared to those without AO. However, the frequency of drinking spirits among women with AO is higher, but without significant differences in intensity. In general, men with AO showed a positive association with alcohol consumption (χ=53,64, p<0,0001), while women with AO had a negative association (χ=28,63, p<0,0001).
The average WC values depending on the consumption of a particular food product are presented in Table 5. There are significant differences in WC among men between groups with different frequency of consumption of most food products analyzed in the study (red meat, fish, poultry, pickles, vegetables/fruits, cereals, sweets), with the exception of meat and sausage products, legumes, and dairy products, except for sour cream/cream. Among women, significant differences in WC are observed with different frequency of consumption of all analyzed food products.

Discussion
The performed analysis demonstrates differences in dietary pattern of persons with AO in comparison with Russians without AO. These differences are observed both in men and women with AO. In women, there are more differences than in the diets of men, which is reflected in the more frequent consumption of animal and processed products. Sex differences can also be traced in the level of alcohol consumption. Thus, men with AO more often and with higher intensity consume alcoholic beverages, in contrast to women with AO, in whom these indicators are lower than in those without AO.
It is also noticeable that persons with AO are more likely to consume energy-intensive foodsred meat, as well as men with AO -also alcoholic beverages, and women with AO -processed meat and sausages, liquid dairy products, fish and poultry.
The habit of consuming dairy products, even at the population level, is very widespread [25,26]. Therefore, the analysis of association between consuming dairy products and the obesity is of interest in many studies [10][11][12][13][14][15][16][17][18]. However, the results of analyzes are very different: from AO risk reduction [10,12,[14][15][16] and the absence of differences [9,10] to positive associations with certain types of dairy products [17]. Results similar to those obtained in this study individual diets is not always reflected in the population analysis. However, this analysis demonstrates a lot of emphasis on disorders in the eating habits of people with AO, which forms a scientifically grounded basis for preventive and rehabilitative measures. The research results can be used in developing preventive population-based programs aimed at preventing obesity, in estimating public health indicators and in making targeted management decisions.
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of persons with AO, the consumption of energyintensive foods without significant nutritional value -alcoholic beverages for both sexes, as well as processed meat -for women. One should also take into account the general dietary disturbances: low daily consumption of fruits and vegetables, cereals, legumes; high consumption of red meat, processed meat, and confectionery [25,26].
This analysis clearly demonstrated the dietary characteristics of individuals with AO and revealed sex differences. The nutritional imbalance observed in