RESEARCH
Original Research: Brief
American Diet Quality: Where It Is, Where It Is Heading, and What It Could Be Magdalena M. Wilson, MPH; Jill Reedy, PhD, MPH, RD; Susan M. Krebs-Smith, PhD, MPH ARTICLE INFORMATION Article history: Submitted 23 June 2015 Accepted 29 September 2015 Available online 21 November 2015
Keywords: Diet quality Healthy Eating Index Healthy People 2020 2010 Dietary Guidelines for Americans
Supplementary materials: Table 3 is available online at www.andjrnl.org 2212-2672/Published by Elsevier Inc. on behalf of the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2015.09.020
ABSTRACT Background Diet quality is critically important to the prevention of many types of chronic disease. The federal government provides recommendations for optimal diet quality through the Dietary Guidelines for Americans, and sets benchmarks for progress toward these recommendations through the Healthy People objectives. Objective This analysis estimated recent trends in American diet quality and compared those trends to the quality of diets that would meet the Healthy People 2020 objectives and the 2010 Dietary Guidelines for Americans in order to measure progress toward our national nutrition goals. Design This analysis used 24-hour recall data from the cross-sectional National Health and Nutrition Examination Survey, between the years of 1999-2000 and 2011-2012, to determine mean intakes of various dietary components for the US population over time. Mean intakes were estimated using the population ratio method, and diet quality was assessed using the Healthy Eating Index 2010 (HEI-2010). Results The mean HEI-2010 total score for the US population has increased from 49 in 1999-2000 to 59 in 2011-2012; continuing on that trajectory, it would reach a score of 65 by 2019-2020. A diet that meets the Healthy People 2020 objectives would receive a score of 74 and, by definition, a diet that meets the 2010 Dietary Guidelines for Americans would receive a score of 100. Trends in HEI-2010 component scores vary; all HEI-2010 component scores except sodium have increased over time. Conclusions Diet quality is improving over time, but not quickly enough to meet all of the Healthy People 2020 objectives. Whole fruit and empty calories are the only HEI-2010 components on track to meet their respective Healthy People 2020 targets. Furthermore, the country falls short of the 2010 Dietary Guidelines for Americans by a large margin in nearly every component of diet quality assessed by the HEI-2010. J Acad Nutr Diet. 2016;116:302-310.
N
EARLY HALF OF ALL AMERICAN ADULTS HAVE ONE or more chronic diseases that are related to poorquality diet.1-4 The burden of these diet-related diseases in this country, including associated morbidities, mortality, health care costs, and lost wages, is enormous,5-8 and suggests dietary improvements should be an imperative. The federal government provides recommendations for optimal diet quality through the Dietary Guidelines for Americans (DGA) and sets benchmarks for progress toward these recommendations through the Healthy People objectives. In 2010, the US Department of Health and Human Services set the most recent objectives, Healthy People 2020, as a benchmark for progress in this decade.9 Healthy People 2020 is a comprehensive set of objectives across many domains of health; included in these are seven objectives related to diet quality in the category of Nutrition and Weight Status. Also in 2010, the US Departments of Agriculture and Health and Human Services developed the 2010 DGA (released in January of 2011),10 which provide comprehensive evidence-based information on healthy diets.11 These two sets of national standards differ in that the 302
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
DGA enumerate the elements of an optimal diet, and the Healthy People 2020 objectives set targets that are “challenging but achievable” relative to baseline dietary intake in 2010.12 The Healthy Eating Index 2010 (HEI-2010) is a way to operationalize diet quality in relation to these benchmarks.13 The HEI-2010 is a density-based measure of diet quality, meaning that relative rather than absolute intakes are scored (generally as amounts per 1,000 kcal).13 It has 12 components: the 9 adequacy components are total fruit, whole fruit, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, and fatty acids; and the and 3 moderation components are refined grains, sodium, and empty calories. Component scores increase with increasing quantity for the adequacy components, and decrease with increasing quantity for the moderation components, so that a higher score on all components indicates better diet quality. Each component is worth 5, 10, or 20 points, for a total of 100 points. The development, complete methodology for scoring, and evaluation of the HEI-2010 has been described in detail elsewhere.13,14
RESEARCH This analysis used the HEI-2010 to evaluate the diet quality of Americans from 1999-2000 to 2011-2012 based on national dietary intake surveillance data from the National Health and Nutrition Examination Survey (NHANES). These recent dietary intake data and trends over time were then compared with diet quality scores for diets that meet the Healthy People 2020 objectives and the 2010 DGA in order to measure progress toward federal dietary benchmarks and identify components of diet most in need of improvement.
METHODS Describing the Current Trajectory of American Diet Quality and Creating a Projection to 2019-2020 This analysis used 1-day 24-hour recall dietary data from NHANES, a cross-sectional nationally representative survey of the noninstitutionalized US population conducted by the National Center for Health Statistics and the Centers for Disease Control and Prevention.15 This analysis included participants aged 2 years and older in NHANES cycles 19992000 to 2011-2012, the most recent year of dietary data available. Participants younger than 2 years of age were excluded from this analysis because the DGA and the Healthy People 2020 objectives are written as guidance for Americans aged 2 years and older. In addition, participants were excluded from the analysis if they did not have reliable dietary data determined using the dietary recall status variable in NHANES, or if they were breastfed children because they are not considered to have complete dietary intake data. The final analytic sample size for each cycle of NHANES is shown in Table 1. Further information regarding NHANES is available elsewhere.15 This study protocol was exempt from
Institutional Review Board approval, as all data used were drawn from existing publically available sources. Mean HEI-2010 scores for the population were estimated using the population ratio method,16 with a Monte Carlo simulation step included to calculate standard errors.17 In the population ratio method, weighted means of each nutrient or food group in the HEI-2010 are derived and then divided by the weighted mean of total calories to create density ratios for each food group or nutrient. These ratios are then compared with the relevant HEI-2010 component standard to calculate HEI-2010 scores. Examples and further details of using this method in NHANES are provided by the National Cancer Institute.17 All analyses to calculate mean HEI-2010 scores and standard errors were conducted using SAS Software (version 9.3, 2012, SAS Institute Inc). These HEI-2010 scores were exported to Excel (2010, Microsoft) and used to derive linear regression trend lines for both the total and component scores. These trend lines were then used to project the current diet quality trends out to the year 2020. The year 2020 was chosen to allow comparison with the Healthy People 2020 objectives, which were set to be achievable by that year.
Calculating HEI-2010 Score for a Diet that Would Meet the Healthy People 2020 Objectives Six of the Healthy People 2020 Nutrition and Weight Status objectives or sub-objectives include targets that align with 7 of the 12 components of the HEI-2010, as listed in Table 2. To calculate an HEI-2010 score for a diet that would meet the Healthy People 2020 objectives, each of the Healthy People
Table 1. Trends in Healthy Eating Index-2010 total and component scores Yearsa HEI-2010 component
Maximum points
1999-2000 (n[8,074)
2001-2002 (n[9,033)
2003-2004 (n[8,273)
2005-2006 (n[8,549)
2007-2008 (n[8,529)
2009-2010 (n[9,042)
2011-2012 (n[7,933)
mean score (standard error)! Total Fruit
5
2.9 (0.2)
3.1 (0.1)
2.9 (0.1)
2.8 (0.1)
3.0 (0.1)
3.3 (0.1)
3.0 (0.1)
Whole Fruit
5
3.2 (0.2)
3.4 (0.1)
3.1 (0.2)
3.3 (0.1)
4.1 (0.2)
4.4 (0.1)
4.0 (0.2)
Total Vegetables
5
3.3 (0.1)
3.3 (0.1)
3.3 (0.0)
3.2 (0.1)
3.3 (0.1)
3.3 (0.1)
3.4 (0.1)
Greens and Beans
5
2.2 (0.3)
2.1 (0.2)
2.1 (0.1)
2.3 (0.1)
2.5 (0.2)
2.7 (0.1)
3.0 (0.1)
Whole Grains
10
1.7 (0.1)
2.1 (0.1)
1.8 (0.1)
2.1 (0.1)
2.1 (0.1)
2.5 (0.1)
2.9 (0.1)
Dairy
10
6.2 (0.1)
6.3 (0.1)
6.2 (0.2)
6.4 (0.1)
6.3 (0.1)
6.8 (0.1)
6.4 (0.1)
Total Protein Foods
5
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
Seafood and Plant Proteins
5
3.0 (0.2)
3.1 (0.2)
3.3 (0.1)
3.5 (0.2)
3.2 (0.1)
3.8 (0.2)
3.7 (0.2)
Fatty Acids
10
3.9 (0.1)
4.1 (0.1)
4.2 (0.1)
3.8 (0.1)
4.0 (0.1)
4.1 (0.1)
4.7 (0.1)
Refined Grains
10
6.0 (0.1)
5.7 (0.1)
5.6 (0.1)
6.0 (0.1)
6.1 (0.1)
6.1 (0.1)
6.2 (0.2)
Sodium
10
4.7 (0.2)
5.1 (0.1)
5.0 (0.1)
4.5 (0.1)
4.3 (0.1)
3.7 (0.1)
4.2 (0.1)
Empty Calories Total Score
20
6.9 (0.5)
8.6 (0.3)
9.1 (0.2)
11.1 (0.2)
11.1 (0.3)
12.1 (0.2)
12.6 (0.2)
100
49.1 (1.3)
51.9 (0.8)
51.4 (0.7)
54.1 (0.6)
55.1 (1.1)
57.8 (0.7)
59.0 (0.9)
a
Data source: National Health and Nutrition Examination Survey, 1999-2000 to 2011-2012.
February 2016 Volume 116 Number 2
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
303
RESEARCH Table 2. Healthy Eating Index-2010 scoring standards and the Healthy People 2020 targets that align with each Healthy Eating Index-2010 component HEI-2010a component
HEI-2010 scoring standardsb
Healthy People 2020 target
Total Fruit
Max: 0.8 cup equivalent per 1,000 kcal Min: No Fruit
0.90 cup equivalent per 1,000 kcal
Whole Fruit
Max: 0.4 cup equivalent per 1,000 kcal Min: No Whole Fruit
0.45 cup equivalent per 1,000 kcalc
Total Vegetables
Max: 1.1 cup equivalent per 1,000 kcal Min: No Total Vegetables
1.14 cup equivalent per 1,000 kcal
Greens and Beans
Max: 0.2 cup equivalent per 1,000 kcal Min: No Greens and Beans
0.55 cup equivalent per 1,000 kcald
Whole Grains
Max: 1.5 oz equivalent per 1,000 kcal Min: No Whole Grains
0.60 oz equivalent per 1,000 kcal
Dairy
Max: 1.3 cup equivalent per 1,000 kcal Min: No Dairy
None
Total Protein Foods
Max: 2.5 oz equivalent per 1,000 kcal Min: No Protein Foods
None
Seafood and Plant Proteins
Max: 0.8 oz equivalent per 1,000 kcal Min: No Seafood or Plant Proteins
None
Fatty Acids
Max: (PUFAseþMUFAsf)/SFAsg 2.5 Min: (PUFAsþMUFAs)/SFAs 1.2
None
Refined Grains
Max: 1.8 oz equivalent per 1,000 kcal Min: 4.3 ounce equivalent per 1,000 kcal
None
Sodium
Max: 1,100 mg per 1,000 kcal Min: 2,200 mg per 1,000 kcal
2,300 mg/day
Empty Calories
Max: 19% of energy Min: 50% of energy
29.8% of energyh
a
HEI-2010¼Healthy Eating Index 2010. Intakes between the minimum (Min) and maximum (Max) standards are scored proportionately.13 c This is not a Healthy People 2020 target, but is derived from the assumption that half of total fruit intake comes from whole fruit. d This target includes red and orange vegetables in addition to the dark green vegetables, beans, and peas that are included in the HEI-2010 component. e PUFAs¼polyunsaturated fatty acids. f MUFAs¼monounsaturated fatty acids. g SFAs¼saturated fatty acids. h This target is for solid fats and added sugars only, and does not include the empty calories from alcohol, which are included in the HEI-2010 component. b
2020 targets that align with an HEI-2010 component was scored using the HEI-2010 standards. For the components with no respective Healthy People 2020 targets (ie, dairy, total protein foods, seafood and plant proteins, fatty acids, and refined grains), the projected HEI-2010 component score for 2019-2020 based on current trends was used. A detailed methodology for scoring each component follows.
Total and Whole Fruits. The Healthy People 2020 target for total fruit, Nutrition and Weight Status objective 14, does not specify the type of fruit consumed. This analysis assumes that at least half of total fruit intake would come from whole fruit, because for every year between 1999-2000 and 2011-2012, whole fruit has been greater than half of total fruit consumption. Accordingly, meeting the Healthy People 2020 targets would require a population to have a mean intake of 0.9 cup equivalents per day for total fruit and 0.45 cup 304
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
equivalents for whole fruit—both are above the respective HEI-2010 scoring standards—resulting in a maximum HEI-2010 score for these components.
Total Vegetables and Greens and Beans. The Healthy People 2020 target for total vegetables, Nutrition and Weight Status objective 15.1, exceeds the respective HEI-2010 standard, resulting in a maximum score for this component. The Healthy People 2020 target for vegetable subtypes, Nutrition and Weight Status objective 15.2, includes red and orange vegetables in addition to the dark green vegetables, beans, and peas that comprise the HEI2010 greens and beans component. This analysis assumes that at least 0.2 cups of the Healthy People 2020 vegetable subtype target of 0.55 cups are met with dark green vegetables, beans, and peas, based on usual dietary intake data for the US population18; therefore, this target meets the February 2016 Volume 116 Number 2
RESEARCH HEI-2010 greens and beans standard and receives the maximum score.
Whole Grains. The Healthy People 2020 target for whole grains, Nutrition and Weight Status objective 16, is 0.60 ounce equivalents per 1,000 kcal, significantly lower than the HEI-2010 standard for a maximum score, resulting in a HEI-2010 component score of 4 of 10. This analysis assumes that an increase in whole grains would not affect the consumption of refined grains and includes a sensitivity analysis testing this assumption.
Sodium. The Healthy People 2020 target for sodium, Nutrition and Weight Status objective 19, is an absolute limit of 2,300 mg. The HEI-2010 sodium component standard for a maximum score is a density of 1,100 mg per 1,000 kcal, but it is based on the 2010 DGA of an absolute limit of 2,300 mg per day, assuming average caloric intake.13 Because the Healthy People 2020 target and the HEI-2010 standard are derived from the same absolute standard, this analysis assumes the Healthy People 2020 target for sodium receives the maximum score.
Empty Calories. Healthy People 2020 target Nutrition and Weight Status objective 17.3 aligns most closely with the HEI2010 empty calories component, presenting recommendations for calories from solid fats and added sugars combined (as opposed to Nutrition and Weight Status objectives 17.1 and 17.2, which provide targets for solid fats and added sugars separately). When scored against the HEI-2010 standards for empty calories, the Healthy People 2020 target for solid fats and added sugars receives a score of 13 of 20. The HEI-2010 component for empty calories includes alcohol consumption >13 g per 1,000 kcal. The Healthy People 2020 objectives do not provide specific targets for general alcohol consumption, although topics related to alcohol consumption, such as binge drinking and driving under the influence of alcohol, are included in the Healthy People 2020 objectives related to substance abuse. For all NHANES cycles 2001-2002 to 2011-2012, mean alcohol consumption by men and women aged 20 years and older was
Original Research: Brief
American Diet Quality: Where It Is, Where It Is Heading, and What It Could Be Magdalena M. Wilson, MPH; Jill Reedy, PhD, MPH, RD; Susan M. Krebs-Smith, PhD, MPH ARTICLE INFORMATION Article history: Submitted 23 June 2015 Accepted 29 September 2015 Available online 21 November 2015
Keywords: Diet quality Healthy Eating Index Healthy People 2020 2010 Dietary Guidelines for Americans
Supplementary materials: Table 3 is available online at www.andjrnl.org 2212-2672/Published by Elsevier Inc. on behalf of the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2015.09.020
ABSTRACT Background Diet quality is critically important to the prevention of many types of chronic disease. The federal government provides recommendations for optimal diet quality through the Dietary Guidelines for Americans, and sets benchmarks for progress toward these recommendations through the Healthy People objectives. Objective This analysis estimated recent trends in American diet quality and compared those trends to the quality of diets that would meet the Healthy People 2020 objectives and the 2010 Dietary Guidelines for Americans in order to measure progress toward our national nutrition goals. Design This analysis used 24-hour recall data from the cross-sectional National Health and Nutrition Examination Survey, between the years of 1999-2000 and 2011-2012, to determine mean intakes of various dietary components for the US population over time. Mean intakes were estimated using the population ratio method, and diet quality was assessed using the Healthy Eating Index 2010 (HEI-2010). Results The mean HEI-2010 total score for the US population has increased from 49 in 1999-2000 to 59 in 2011-2012; continuing on that trajectory, it would reach a score of 65 by 2019-2020. A diet that meets the Healthy People 2020 objectives would receive a score of 74 and, by definition, a diet that meets the 2010 Dietary Guidelines for Americans would receive a score of 100. Trends in HEI-2010 component scores vary; all HEI-2010 component scores except sodium have increased over time. Conclusions Diet quality is improving over time, but not quickly enough to meet all of the Healthy People 2020 objectives. Whole fruit and empty calories are the only HEI-2010 components on track to meet their respective Healthy People 2020 targets. Furthermore, the country falls short of the 2010 Dietary Guidelines for Americans by a large margin in nearly every component of diet quality assessed by the HEI-2010. J Acad Nutr Diet. 2016;116:302-310.
N
EARLY HALF OF ALL AMERICAN ADULTS HAVE ONE or more chronic diseases that are related to poorquality diet.1-4 The burden of these diet-related diseases in this country, including associated morbidities, mortality, health care costs, and lost wages, is enormous,5-8 and suggests dietary improvements should be an imperative. The federal government provides recommendations for optimal diet quality through the Dietary Guidelines for Americans (DGA) and sets benchmarks for progress toward these recommendations through the Healthy People objectives. In 2010, the US Department of Health and Human Services set the most recent objectives, Healthy People 2020, as a benchmark for progress in this decade.9 Healthy People 2020 is a comprehensive set of objectives across many domains of health; included in these are seven objectives related to diet quality in the category of Nutrition and Weight Status. Also in 2010, the US Departments of Agriculture and Health and Human Services developed the 2010 DGA (released in January of 2011),10 which provide comprehensive evidence-based information on healthy diets.11 These two sets of national standards differ in that the 302
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
DGA enumerate the elements of an optimal diet, and the Healthy People 2020 objectives set targets that are “challenging but achievable” relative to baseline dietary intake in 2010.12 The Healthy Eating Index 2010 (HEI-2010) is a way to operationalize diet quality in relation to these benchmarks.13 The HEI-2010 is a density-based measure of diet quality, meaning that relative rather than absolute intakes are scored (generally as amounts per 1,000 kcal).13 It has 12 components: the 9 adequacy components are total fruit, whole fruit, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, and fatty acids; and the and 3 moderation components are refined grains, sodium, and empty calories. Component scores increase with increasing quantity for the adequacy components, and decrease with increasing quantity for the moderation components, so that a higher score on all components indicates better diet quality. Each component is worth 5, 10, or 20 points, for a total of 100 points. The development, complete methodology for scoring, and evaluation of the HEI-2010 has been described in detail elsewhere.13,14
RESEARCH This analysis used the HEI-2010 to evaluate the diet quality of Americans from 1999-2000 to 2011-2012 based on national dietary intake surveillance data from the National Health and Nutrition Examination Survey (NHANES). These recent dietary intake data and trends over time were then compared with diet quality scores for diets that meet the Healthy People 2020 objectives and the 2010 DGA in order to measure progress toward federal dietary benchmarks and identify components of diet most in need of improvement.
METHODS Describing the Current Trajectory of American Diet Quality and Creating a Projection to 2019-2020 This analysis used 1-day 24-hour recall dietary data from NHANES, a cross-sectional nationally representative survey of the noninstitutionalized US population conducted by the National Center for Health Statistics and the Centers for Disease Control and Prevention.15 This analysis included participants aged 2 years and older in NHANES cycles 19992000 to 2011-2012, the most recent year of dietary data available. Participants younger than 2 years of age were excluded from this analysis because the DGA and the Healthy People 2020 objectives are written as guidance for Americans aged 2 years and older. In addition, participants were excluded from the analysis if they did not have reliable dietary data determined using the dietary recall status variable in NHANES, or if they were breastfed children because they are not considered to have complete dietary intake data. The final analytic sample size for each cycle of NHANES is shown in Table 1. Further information regarding NHANES is available elsewhere.15 This study protocol was exempt from
Institutional Review Board approval, as all data used were drawn from existing publically available sources. Mean HEI-2010 scores for the population were estimated using the population ratio method,16 with a Monte Carlo simulation step included to calculate standard errors.17 In the population ratio method, weighted means of each nutrient or food group in the HEI-2010 are derived and then divided by the weighted mean of total calories to create density ratios for each food group or nutrient. These ratios are then compared with the relevant HEI-2010 component standard to calculate HEI-2010 scores. Examples and further details of using this method in NHANES are provided by the National Cancer Institute.17 All analyses to calculate mean HEI-2010 scores and standard errors were conducted using SAS Software (version 9.3, 2012, SAS Institute Inc). These HEI-2010 scores were exported to Excel (2010, Microsoft) and used to derive linear regression trend lines for both the total and component scores. These trend lines were then used to project the current diet quality trends out to the year 2020. The year 2020 was chosen to allow comparison with the Healthy People 2020 objectives, which were set to be achievable by that year.
Calculating HEI-2010 Score for a Diet that Would Meet the Healthy People 2020 Objectives Six of the Healthy People 2020 Nutrition and Weight Status objectives or sub-objectives include targets that align with 7 of the 12 components of the HEI-2010, as listed in Table 2. To calculate an HEI-2010 score for a diet that would meet the Healthy People 2020 objectives, each of the Healthy People
Table 1. Trends in Healthy Eating Index-2010 total and component scores Yearsa HEI-2010 component
Maximum points
1999-2000 (n[8,074)
2001-2002 (n[9,033)
2003-2004 (n[8,273)
2005-2006 (n[8,549)
2007-2008 (n[8,529)
2009-2010 (n[9,042)
2011-2012 (n[7,933)
mean score (standard error)! Total Fruit
5
2.9 (0.2)
3.1 (0.1)
2.9 (0.1)
2.8 (0.1)
3.0 (0.1)
3.3 (0.1)
3.0 (0.1)
Whole Fruit
5
3.2 (0.2)
3.4 (0.1)
3.1 (0.2)
3.3 (0.1)
4.1 (0.2)
4.4 (0.1)
4.0 (0.2)
Total Vegetables
5
3.3 (0.1)
3.3 (0.1)
3.3 (0.0)
3.2 (0.1)
3.3 (0.1)
3.3 (0.1)
3.4 (0.1)
Greens and Beans
5
2.2 (0.3)
2.1 (0.2)
2.1 (0.1)
2.3 (0.1)
2.5 (0.2)
2.7 (0.1)
3.0 (0.1)
Whole Grains
10
1.7 (0.1)
2.1 (0.1)
1.8 (0.1)
2.1 (0.1)
2.1 (0.1)
2.5 (0.1)
2.9 (0.1)
Dairy
10
6.2 (0.1)
6.3 (0.1)
6.2 (0.2)
6.4 (0.1)
6.3 (0.1)
6.8 (0.1)
6.4 (0.1)
Total Protein Foods
5
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
5.0 (0.0)
Seafood and Plant Proteins
5
3.0 (0.2)
3.1 (0.2)
3.3 (0.1)
3.5 (0.2)
3.2 (0.1)
3.8 (0.2)
3.7 (0.2)
Fatty Acids
10
3.9 (0.1)
4.1 (0.1)
4.2 (0.1)
3.8 (0.1)
4.0 (0.1)
4.1 (0.1)
4.7 (0.1)
Refined Grains
10
6.0 (0.1)
5.7 (0.1)
5.6 (0.1)
6.0 (0.1)
6.1 (0.1)
6.1 (0.1)
6.2 (0.2)
Sodium
10
4.7 (0.2)
5.1 (0.1)
5.0 (0.1)
4.5 (0.1)
4.3 (0.1)
3.7 (0.1)
4.2 (0.1)
Empty Calories Total Score
20
6.9 (0.5)
8.6 (0.3)
9.1 (0.2)
11.1 (0.2)
11.1 (0.3)
12.1 (0.2)
12.6 (0.2)
100
49.1 (1.3)
51.9 (0.8)
51.4 (0.7)
54.1 (0.6)
55.1 (1.1)
57.8 (0.7)
59.0 (0.9)
a
Data source: National Health and Nutrition Examination Survey, 1999-2000 to 2011-2012.
February 2016 Volume 116 Number 2
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
303
RESEARCH Table 2. Healthy Eating Index-2010 scoring standards and the Healthy People 2020 targets that align with each Healthy Eating Index-2010 component HEI-2010a component
HEI-2010 scoring standardsb
Healthy People 2020 target
Total Fruit
Max: 0.8 cup equivalent per 1,000 kcal Min: No Fruit
0.90 cup equivalent per 1,000 kcal
Whole Fruit
Max: 0.4 cup equivalent per 1,000 kcal Min: No Whole Fruit
0.45 cup equivalent per 1,000 kcalc
Total Vegetables
Max: 1.1 cup equivalent per 1,000 kcal Min: No Total Vegetables
1.14 cup equivalent per 1,000 kcal
Greens and Beans
Max: 0.2 cup equivalent per 1,000 kcal Min: No Greens and Beans
0.55 cup equivalent per 1,000 kcald
Whole Grains
Max: 1.5 oz equivalent per 1,000 kcal Min: No Whole Grains
0.60 oz equivalent per 1,000 kcal
Dairy
Max: 1.3 cup equivalent per 1,000 kcal Min: No Dairy
None
Total Protein Foods
Max: 2.5 oz equivalent per 1,000 kcal Min: No Protein Foods
None
Seafood and Plant Proteins
Max: 0.8 oz equivalent per 1,000 kcal Min: No Seafood or Plant Proteins
None
Fatty Acids
Max: (PUFAseþMUFAsf)/SFAsg 2.5 Min: (PUFAsþMUFAs)/SFAs 1.2
None
Refined Grains
Max: 1.8 oz equivalent per 1,000 kcal Min: 4.3 ounce equivalent per 1,000 kcal
None
Sodium
Max: 1,100 mg per 1,000 kcal Min: 2,200 mg per 1,000 kcal
2,300 mg/day
Empty Calories
Max: 19% of energy Min: 50% of energy
29.8% of energyh
a
HEI-2010¼Healthy Eating Index 2010. Intakes between the minimum (Min) and maximum (Max) standards are scored proportionately.13 c This is not a Healthy People 2020 target, but is derived from the assumption that half of total fruit intake comes from whole fruit. d This target includes red and orange vegetables in addition to the dark green vegetables, beans, and peas that are included in the HEI-2010 component. e PUFAs¼polyunsaturated fatty acids. f MUFAs¼monounsaturated fatty acids. g SFAs¼saturated fatty acids. h This target is for solid fats and added sugars only, and does not include the empty calories from alcohol, which are included in the HEI-2010 component. b
2020 targets that align with an HEI-2010 component was scored using the HEI-2010 standards. For the components with no respective Healthy People 2020 targets (ie, dairy, total protein foods, seafood and plant proteins, fatty acids, and refined grains), the projected HEI-2010 component score for 2019-2020 based on current trends was used. A detailed methodology for scoring each component follows.
Total and Whole Fruits. The Healthy People 2020 target for total fruit, Nutrition and Weight Status objective 14, does not specify the type of fruit consumed. This analysis assumes that at least half of total fruit intake would come from whole fruit, because for every year between 1999-2000 and 2011-2012, whole fruit has been greater than half of total fruit consumption. Accordingly, meeting the Healthy People 2020 targets would require a population to have a mean intake of 0.9 cup equivalents per day for total fruit and 0.45 cup 304
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
equivalents for whole fruit—both are above the respective HEI-2010 scoring standards—resulting in a maximum HEI-2010 score for these components.
Total Vegetables and Greens and Beans. The Healthy People 2020 target for total vegetables, Nutrition and Weight Status objective 15.1, exceeds the respective HEI-2010 standard, resulting in a maximum score for this component. The Healthy People 2020 target for vegetable subtypes, Nutrition and Weight Status objective 15.2, includes red and orange vegetables in addition to the dark green vegetables, beans, and peas that comprise the HEI2010 greens and beans component. This analysis assumes that at least 0.2 cups of the Healthy People 2020 vegetable subtype target of 0.55 cups are met with dark green vegetables, beans, and peas, based on usual dietary intake data for the US population18; therefore, this target meets the February 2016 Volume 116 Number 2
RESEARCH HEI-2010 greens and beans standard and receives the maximum score.
Whole Grains. The Healthy People 2020 target for whole grains, Nutrition and Weight Status objective 16, is 0.60 ounce equivalents per 1,000 kcal, significantly lower than the HEI-2010 standard for a maximum score, resulting in a HEI-2010 component score of 4 of 10. This analysis assumes that an increase in whole grains would not affect the consumption of refined grains and includes a sensitivity analysis testing this assumption.
Sodium. The Healthy People 2020 target for sodium, Nutrition and Weight Status objective 19, is an absolute limit of 2,300 mg. The HEI-2010 sodium component standard for a maximum score is a density of 1,100 mg per 1,000 kcal, but it is based on the 2010 DGA of an absolute limit of 2,300 mg per day, assuming average caloric intake.13 Because the Healthy People 2020 target and the HEI-2010 standard are derived from the same absolute standard, this analysis assumes the Healthy People 2020 target for sodium receives the maximum score.
Empty Calories. Healthy People 2020 target Nutrition and Weight Status objective 17.3 aligns most closely with the HEI2010 empty calories component, presenting recommendations for calories from solid fats and added sugars combined (as opposed to Nutrition and Weight Status objectives 17.1 and 17.2, which provide targets for solid fats and added sugars separately). When scored against the HEI-2010 standards for empty calories, the Healthy People 2020 target for solid fats and added sugars receives a score of 13 of 20. The HEI-2010 component for empty calories includes alcohol consumption >13 g per 1,000 kcal. The Healthy People 2020 objectives do not provide specific targets for general alcohol consumption, although topics related to alcohol consumption, such as binge drinking and driving under the influence of alcohol, are included in the Healthy People 2020 objectives related to substance abuse. For all NHANES cycles 2001-2002 to 2011-2012, mean alcohol consumption by men and women aged 20 years and older was
