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Original Investigation |

Trends in Dietary Quality Among Adults in the United States, 1999 Through 2010

Dong D. Wang, MD, MSc1; Cindy W. Leung, ScD2; Yanping Li, PhD1; Eric L. Ding, ScD1,3; Stephanie E. Chiuve, ScD1,4; Frank B. Hu, MD, PhD1,3,5; Walter C. Willett, MD, DrPH1,3,5
[+] Author Affiliations
1Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
2Center for Health and Community, School of Medicine, University of California, San Francisco
3Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
4Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
5Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2014;174(10):1587-1595. doi:10.1001/jamainternmed.2014.3422.
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Importance  Many changes in the economy, policies related to nutrition, and food processing have occurred within the United States since 2000, and the net effect on dietary quality is not clear. These changes may have affected various socioeconomic groups differentially.

Objective  To investigate trends in dietary quality from 1999 to 2010 in the US adult population and within socioeconomic subgroups.

Design, Setting, and Participants  Nationally representative sample of 29 124 adults aged 20 to 85 years from the US 1999 to 2010 National Health and Nutrition Examination Survey.

Main Outcomes and Measures  The Alternate Healthy Eating Index 2010 (AHEI-2010), an 11-dimension score (range, 0-10 for each component score and 0-110 for the total score), was used to measure dietary quality. A higher AHEI-2010 score indicated a more healthful diet.

Results  The energy-adjusted mean of the AHEI-2010 increased from 39.9 in 1999 to 2000 to 46.8 in 2009 to 2010 (linear trend P < .001). Reduction in trans fat intake accounted for more than half of this improvement. The AHEI-2010 component score increased by 0.9 points for sugar-sweetened beverages and fruit juice (reflecting decreased consumption), 0.7 points for whole fruit, 0.5 points for whole grains, 0.5 points for polyunsaturated fatty acids, and 0.4 points for nuts and legumes over the 12-year period (all linear trend P < .001). Family income and education level were positively associated with total AHEI-2010, and the gap between low and high socioeconomic status widened over time, from 3.9 points in 1999 to 2000 to 7.8 points in 2009 to 2010 (interaction P = .01).

Conclusions and Relevance  Although a steady improvement in AHEI-2010 was observed across the 12-year period, the overall dietary quality remains poor. Better dietary quality was associated with higher socioeconomic status, and the gap widened with time. Future efforts to improve nutrition should address these disparities.

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Figure 1.
Alternate Healthy Eating Index 2010 Score Among Adults Aged 20 to 85 Years by National Health and Nutrition Examination Survey Cycle

Data are presented as energy-adjusted means.

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Figure 2.
Alternate Healthy Eating Index 2010 Component Score Among Adults Aged 20 to 85 Years by National Health and Nutrition Examination Survey Cycle

Data are presented as energy-adjusted means. For fruits, vegetables, whole grains, nuts and legumes, long-chain (ω-3) fats, and polyunsaturated fatty acids (PUFAs), a higher score corresponded to higher intake. For trans fat, sugar-sweetened beverages, red and/or processed meat, and sodium, a higher score corresponded to lower intake. For alcohol, we assigned the highest score to moderate, and the lowest score to heavy, alcohol consumers. Nondrinkers received a score of 2.5. DHA indicates docosahexaenoic acid; EPA, eicosapentaenoic acid; and PUFA, polyunsaturated fatty acid.

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Figure 3.
Alternate Healthy Eating Index 2010 Score Without the trans Fat Component According to Socioeconomic Status (SES) by National Health and Nutrition Examination Survey Cycle

Symbols indicate covariate-adjusted means, and error bars, 95% confidence intervals. Participants with more than 12 completed years of education attainment and a poverty income ratio of at least 3.5 were categorized as high SES; participants with less than 12 years educational attainment and a poverty income ratio of less than 1.30 were categorized as low SES; and others were classified as medium SES. Values were estimated from multivariate linear regression analysis by adjusting for total energy intake (continuous), sex (male, female), age group (20-39, 40-64, ≥65 y), race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American, other), and household size.

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