Trends in Dietary Quality Among US Adults
Original Investigation Research
45. Leung CW, Hoffnagle EE, Lindsay AC, et al. A qualitative study of diverse experts’ views about barriers and strategies to improve the diets and health of Supplemental Nutrition Assistance Program (SNAP) beneficiaries. J Acad Nutr Diet. 2013;113(1):70-76.
48. Wardle J, Parmenter K, Waller J. Nutrition knowledge and food intake. Appetite. 2000;34(3): 269-275.
52. Wolongevicz DM, Zhu L, Pencina MJ, et al. Diet quality and obesity in women: the Framingham Nutrition Studies. Br J Nutr. 2010;103(8):1223-1229.
49. Ford ES, Dietz WH. Trends in energy intake among adults in the United States: findings from NHANES. Am J Clin Nutr. 2013;97(4):848-853.
46. Blumenthal SJHE, Willett W, Leung C, et al. SNAP to Health: A Fresh Approach to Strengthening the Supplemental Nutrition Assistance Program. Washington, DC: Center for the Study of the Presidency and Congress; 2012.
50. Carlson SA, Densmore D, Fulton JE, Yore MM, Kohl HW III. Differences in physical activity prevalence and trends from 3 US surveillance systems: NHIS, NHANES, and BRFSS. J Phys Act Health. 2009;6(suppl 1):S18-S27.
53. Boggs DA, Rosenberg L, Rodríguez-Bernal CL, Palmer JR. Long-term diet quality is associated with lower obesity risk in young African American women with normal BMI at baseline. J Nutr. 2013; 143(10):1636-1641.
47. Popkin BM, Zizza C, Siega-Riz AM. Who is leading the change? US dietary quality comparison between 1965 and 1996. Am J Prev Med. 2003;25(1):1-8.
51. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235-241.
54. Johansson G, Wikman A, Ahrén A-M, Hallmans G, Johansson I. Underreporting of energy intake in repeated 24-hour recalls related to gender, age, weight status, day of interview, educational level, reported food intake, smoking habits and area of living. Public Health Nutr. 2001;4(4):919-927.
Invited Commentary
The Growing Socioeconomic Disparity in Dietary Quality Mind the Gap Takehiro Sugiyama, MD, PhD; Martin F. Shapiro, MD, PhD
Disparity in dietary quality is a public health concern in the United States. Excess caloric intake induces obesity and diabetes mellitus, which in turn cause cardiovascular diseases. Similarly, poorer dietary quality has been shown to affect health outcomes, whether directly or via intermediate chronic Related article page 1587 conditions such as hypertension and dyslipidemia. The link between lower socioeconomic status (SES) and unhealthful diet is multifactorial. People of lower SES tend to have less access to healthful food; “food deserts” denote areas where residents may have difficulty getting nutritious food, mostly in poorer communities.1 Higher prices keep poorer people from buying more healthful food. Lower-SES individuals also may have limited knowledge about the effect of an unhealthful diet on their health. Federal and state governments have attempted to address the issue of dietary disparity mostly through the Supplemental Nutrition Assistance Program (SNAP, formerly known as the Food Stamp Program).2 More than 47 million SNAP participants receive benefits averaging $133 per person per month (nearly $80 billion per year in total). Currently, there is neither any incentive to buy healthful food nor restriction of benefits for unhealthful food; households can use SNAP benefits to buy “junk food” such as soft drinks, candy, and potato chips. This issue has provoked multiple debates in Congress and elsewhere.3-5 Several studies have investigated the effect of SNAP participation on dietary quality, but the results have been inconclusive. For example, the recently published study from the US Department of Agriculture (USDA) comparing SNAP participants and nonparticipants of equivalent SES using data from the National Health and Nutrition Examination Survey (NHANES) showed that SNAP participants had slightly lower overall Healthy Eating Index scores but also that SNAP participants consumed less saturated fat and sodium.6 Whereas these studies provided important information about individual-level associations of SNAP, we also have needed bird’s-
eye national-level evaluation of whether these governmental efforts have affected the nationwide temporal trend in dietary quality. In this context, the new study by Wang et al7 successfully illustrates the trend from 1999 to 2010 in discrepancy of dietary quality by SES in the United States, using the Alternate Healthy Eating Index 2010 (AHEI-2010) to measure dietary quality by SES category, defined on the basis of education and income level. Scores on the AHEI-2010 improved for the population as a whole, but the gap in scores (excluding the trans fat component, which was not measured in NHANES) between higher-SES and lower-SES groups widened during the observed period. The growing chasm in dietary quality by SES confronts us with the possibility that the governmental efforts to mind this gap have been insufficient. It is disappointing that the improvement seen in those of higher SES was not seen in the lower-SES group. How could we close the dietary quality gap? First, we could restrict benefits to more healthful foods, as has been done by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which restricts purchasable foods with the benefit. There have been proposals to adopt a pilot state-specific restriction on soft drinks. For example, New York state asked the federal government to waive SNAP rules to permit a pilot project excluding SNAP benefits for sugar-sweetened beverages in New York, New York, but the USDA denied this request for the reasons that “the scale and scope of the proposed demonstration is too large and complex”3 and that unresolved operational challenges could greatly affect the food retailers accepting SNAP benefits.3,4 Instead, the USDA conducted a large randomized controlled study, the Healthy Incentives Pilot (HIP), which provided financial incentives for more healthful foods (30 cents for every SNAP dollar spent on fruits or vegetables).8 Interim findings from the study suggest that HIP changed
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/09/2015
1595
Research Original Investigation
Trends in Dietary Quality Among US Adults
dietary quality toward a more healthful diet. The final report should contribute to future discussions about dietary quality. Other strategies to improve dietary quality include providing healthful foods to students and residents in underserved areas. For example, programs such as the School Breakfast Program and the National School Lunch Program have contributed to provide healthful breakfast and lunch to students at little or no cost. Conversely, reimbursable after-school snacks have been provided only for the students in after-school programs. Providing more healthful snacks and fruits for all students after school would discourage them from purchasing unhealthful snacks; the subsidy in this regard would be effective. These experiences would accustom students to healthful foods, and hopefully they would try to make full use of limited food budgets for healthful foods even after they become adults. We note a limitation of the AHEI-2010 as a measure of dietary quality. The total score is the sum of 11 components ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Clinical Study and Informatics, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan (Sugiyama); Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (Sugiyama); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles (Shapiro); Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (Shapiro).
1. Ver Ploeg M, Breneman V, Farrigan T, et al. Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences. Report to Congress. Washington, DC: US Department of Agriculture, Economic Research Service; 2009.
Corresponding Author: Takehiro Sugiyama, MD, PhD, Department of Clinical Study and Informatics, Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan ([email protected]). Published Online: September 1, 2014. doi:10.1001/jamainternmed.2014.3048. Conflict of Interest Disclosures: None reported.
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scored on a scale ranging between 0 and 10, summed up to a maximum of 110. Because each component contributes the same proportion to the total AHEI-2010 score, this may project an image that each component contributes equally to the eater’s health, which may not be true. Some aspects of dietary composition, such as binge drinking and trans fat intake, may affect health outcomes more than others. In the extreme, excessive intake or deficiency of a particular nutritional component may have a substantial detrimental effect on health that can undermine all the efforts on the other components. A score calculated in a more complex manner than a simple summation may correlate better with health outcomes. Future studies should consider such an alternate scoring system including an appropriate weighting or interactions among components. We urgently need to support multipronged initiatives to improve dietary quality for persons of lower SES.
2. US Department of Agriculture Food and Nutrition Service. Supplemental Nutrition Assistance Program (SNAP). http://www.fns.usda .gov/snap/supplemental-nutrition-assistance -program-snap. Accessed June 19, 2014. 3. Jessica Shan, Associate Administrator, Supplemental Nutrition Assistance Program, USDA, to Elizabeth Berlin, Executive Deputy Commissioner, New York State Office of Temporary and Disability Assistance. August 19, 2011. http://www.foodpolitics .com/wp-content/uploads/SNAP-Waiver-Request -Decision.pdf. Accessed June 19, 2014. 4. US Department of Agriculture Food and Nutrition Service. Implications of restricting the use of food stamp benefits—summary. 2007.
http://www.fns.usda.gov/sites/default/files/arra /FSPFoodRestrictions.pdf. Accessed June 19, 2014. 5. Barnhill A. Impact and ethics of excluding sweetened beverages from the SNAP program. Am J Public Health. 2011;101(11):2037-2043. 6. Gregory C, Ver Ploeg M, Andrews M, Coleman-Jensen A. Supplemental Nutrition Assistance Program (SNAP) Participation Leads to Modest Changes in Diet Quality. Washington, DC: US Department of Agriculture, Economic Research Service; 2013. Economic Research Report 147. 7. Wang DD, Leung CW, Li Y, et al. Trends in dietary quality among adults in the United States, 1999 through 2010 [published online September 1, 2014]. JAMA Intern Med. doi:10.1001 /jamainternmed.2014.3422. 8. US Department of Agriculture Food and Nutrition Service. HIP Healthy Incentives Pilot. 2014. http://www.fns.usda.gov/hip/healthy -incentives-pilot. Accessed June 19, 2014.
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/09/2015
jamainternalmedicine.com
Original Investigation Research
45. Leung CW, Hoffnagle EE, Lindsay AC, et al. A qualitative study of diverse experts’ views about barriers and strategies to improve the diets and health of Supplemental Nutrition Assistance Program (SNAP) beneficiaries. J Acad Nutr Diet. 2013;113(1):70-76.
48. Wardle J, Parmenter K, Waller J. Nutrition knowledge and food intake. Appetite. 2000;34(3): 269-275.
52. Wolongevicz DM, Zhu L, Pencina MJ, et al. Diet quality and obesity in women: the Framingham Nutrition Studies. Br J Nutr. 2010;103(8):1223-1229.
49. Ford ES, Dietz WH. Trends in energy intake among adults in the United States: findings from NHANES. Am J Clin Nutr. 2013;97(4):848-853.
46. Blumenthal SJHE, Willett W, Leung C, et al. SNAP to Health: A Fresh Approach to Strengthening the Supplemental Nutrition Assistance Program. Washington, DC: Center for the Study of the Presidency and Congress; 2012.
50. Carlson SA, Densmore D, Fulton JE, Yore MM, Kohl HW III. Differences in physical activity prevalence and trends from 3 US surveillance systems: NHIS, NHANES, and BRFSS. J Phys Act Health. 2009;6(suppl 1):S18-S27.
53. Boggs DA, Rosenberg L, Rodríguez-Bernal CL, Palmer JR. Long-term diet quality is associated with lower obesity risk in young African American women with normal BMI at baseline. J Nutr. 2013; 143(10):1636-1641.
47. Popkin BM, Zizza C, Siega-Riz AM. Who is leading the change? US dietary quality comparison between 1965 and 1996. Am J Prev Med. 2003;25(1):1-8.
51. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235-241.
54. Johansson G, Wikman A, Ahrén A-M, Hallmans G, Johansson I. Underreporting of energy intake in repeated 24-hour recalls related to gender, age, weight status, day of interview, educational level, reported food intake, smoking habits and area of living. Public Health Nutr. 2001;4(4):919-927.
Invited Commentary
The Growing Socioeconomic Disparity in Dietary Quality Mind the Gap Takehiro Sugiyama, MD, PhD; Martin F. Shapiro, MD, PhD
Disparity in dietary quality is a public health concern in the United States. Excess caloric intake induces obesity and diabetes mellitus, which in turn cause cardiovascular diseases. Similarly, poorer dietary quality has been shown to affect health outcomes, whether directly or via intermediate chronic Related article page 1587 conditions such as hypertension and dyslipidemia. The link between lower socioeconomic status (SES) and unhealthful diet is multifactorial. People of lower SES tend to have less access to healthful food; “food deserts” denote areas where residents may have difficulty getting nutritious food, mostly in poorer communities.1 Higher prices keep poorer people from buying more healthful food. Lower-SES individuals also may have limited knowledge about the effect of an unhealthful diet on their health. Federal and state governments have attempted to address the issue of dietary disparity mostly through the Supplemental Nutrition Assistance Program (SNAP, formerly known as the Food Stamp Program).2 More than 47 million SNAP participants receive benefits averaging $133 per person per month (nearly $80 billion per year in total). Currently, there is neither any incentive to buy healthful food nor restriction of benefits for unhealthful food; households can use SNAP benefits to buy “junk food” such as soft drinks, candy, and potato chips. This issue has provoked multiple debates in Congress and elsewhere.3-5 Several studies have investigated the effect of SNAP participation on dietary quality, but the results have been inconclusive. For example, the recently published study from the US Department of Agriculture (USDA) comparing SNAP participants and nonparticipants of equivalent SES using data from the National Health and Nutrition Examination Survey (NHANES) showed that SNAP participants had slightly lower overall Healthy Eating Index scores but also that SNAP participants consumed less saturated fat and sodium.6 Whereas these studies provided important information about individual-level associations of SNAP, we also have needed bird’s-
eye national-level evaluation of whether these governmental efforts have affected the nationwide temporal trend in dietary quality. In this context, the new study by Wang et al7 successfully illustrates the trend from 1999 to 2010 in discrepancy of dietary quality by SES in the United States, using the Alternate Healthy Eating Index 2010 (AHEI-2010) to measure dietary quality by SES category, defined on the basis of education and income level. Scores on the AHEI-2010 improved for the population as a whole, but the gap in scores (excluding the trans fat component, which was not measured in NHANES) between higher-SES and lower-SES groups widened during the observed period. The growing chasm in dietary quality by SES confronts us with the possibility that the governmental efforts to mind this gap have been insufficient. It is disappointing that the improvement seen in those of higher SES was not seen in the lower-SES group. How could we close the dietary quality gap? First, we could restrict benefits to more healthful foods, as has been done by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which restricts purchasable foods with the benefit. There have been proposals to adopt a pilot state-specific restriction on soft drinks. For example, New York state asked the federal government to waive SNAP rules to permit a pilot project excluding SNAP benefits for sugar-sweetened beverages in New York, New York, but the USDA denied this request for the reasons that “the scale and scope of the proposed demonstration is too large and complex”3 and that unresolved operational challenges could greatly affect the food retailers accepting SNAP benefits.3,4 Instead, the USDA conducted a large randomized controlled study, the Healthy Incentives Pilot (HIP), which provided financial incentives for more healthful foods (30 cents for every SNAP dollar spent on fruits or vegetables).8 Interim findings from the study suggest that HIP changed
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/09/2015
1595
Research Original Investigation
Trends in Dietary Quality Among US Adults
dietary quality toward a more healthful diet. The final report should contribute to future discussions about dietary quality. Other strategies to improve dietary quality include providing healthful foods to students and residents in underserved areas. For example, programs such as the School Breakfast Program and the National School Lunch Program have contributed to provide healthful breakfast and lunch to students at little or no cost. Conversely, reimbursable after-school snacks have been provided only for the students in after-school programs. Providing more healthful snacks and fruits for all students after school would discourage them from purchasing unhealthful snacks; the subsidy in this regard would be effective. These experiences would accustom students to healthful foods, and hopefully they would try to make full use of limited food budgets for healthful foods even after they become adults. We note a limitation of the AHEI-2010 as a measure of dietary quality. The total score is the sum of 11 components ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Clinical Study and Informatics, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan (Sugiyama); Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (Sugiyama); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles (Shapiro); Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (Shapiro).
1. Ver Ploeg M, Breneman V, Farrigan T, et al. Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences. Report to Congress. Washington, DC: US Department of Agriculture, Economic Research Service; 2009.
Corresponding Author: Takehiro Sugiyama, MD, PhD, Department of Clinical Study and Informatics, Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan ([email protected]). Published Online: September 1, 2014. doi:10.1001/jamainternmed.2014.3048. Conflict of Interest Disclosures: None reported.
1596
scored on a scale ranging between 0 and 10, summed up to a maximum of 110. Because each component contributes the same proportion to the total AHEI-2010 score, this may project an image that each component contributes equally to the eater’s health, which may not be true. Some aspects of dietary composition, such as binge drinking and trans fat intake, may affect health outcomes more than others. In the extreme, excessive intake or deficiency of a particular nutritional component may have a substantial detrimental effect on health that can undermine all the efforts on the other components. A score calculated in a more complex manner than a simple summation may correlate better with health outcomes. Future studies should consider such an alternate scoring system including an appropriate weighting or interactions among components. We urgently need to support multipronged initiatives to improve dietary quality for persons of lower SES.
2. US Department of Agriculture Food and Nutrition Service. Supplemental Nutrition Assistance Program (SNAP). http://www.fns.usda .gov/snap/supplemental-nutrition-assistance -program-snap. Accessed June 19, 2014. 3. Jessica Shan, Associate Administrator, Supplemental Nutrition Assistance Program, USDA, to Elizabeth Berlin, Executive Deputy Commissioner, New York State Office of Temporary and Disability Assistance. August 19, 2011. http://www.foodpolitics .com/wp-content/uploads/SNAP-Waiver-Request -Decision.pdf. Accessed June 19, 2014. 4. US Department of Agriculture Food and Nutrition Service. Implications of restricting the use of food stamp benefits—summary. 2007.
http://www.fns.usda.gov/sites/default/files/arra /FSPFoodRestrictions.pdf. Accessed June 19, 2014. 5. Barnhill A. Impact and ethics of excluding sweetened beverages from the SNAP program. Am J Public Health. 2011;101(11):2037-2043. 6. Gregory C, Ver Ploeg M, Andrews M, Coleman-Jensen A. Supplemental Nutrition Assistance Program (SNAP) Participation Leads to Modest Changes in Diet Quality. Washington, DC: US Department of Agriculture, Economic Research Service; 2013. Economic Research Report 147. 7. Wang DD, Leung CW, Li Y, et al. Trends in dietary quality among adults in the United States, 1999 through 2010 [published online September 1, 2014]. JAMA Intern Med. doi:10.1001 /jamainternmed.2014.3422. 8. US Department of Agriculture Food and Nutrition Service. HIP Healthy Incentives Pilot. 2014. http://www.fns.usda.gov/hip/healthy -incentives-pilot. Accessed June 19, 2014.
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/09/2015
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