This presentation was supported, in part, by the University of Utah, where Patricia Guenther has an adjunct appointment.

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2 Like the 2005 version, the Healthy Eating Index-2010 is a result of a collaboration among staff at the USDA Center for Nutrition Policy and Promotion and the National Cancer Institute. This presentation was supported, in part, by the University of Utah, where Patricia Guenther has an adjunct appointment. The diligent work of many in the National Nutrient Database Conference community in creating and supporting food composition databases made this work possible. 2

3 The Healthy Eating Index is a diet quality index that measures conformance to the Dietary Guidelines for Americans. The original HEI, which was published in 1995, assessed diets in terms of absolute amounts of food groups and nutrients. When the 2005 Dietary Guidelines for Americans were published, a revision of the HEI was in order. One new feature of the HEI-2005 was that is assessed diets on a density basis; that is, according to amounts consumed per 1,000 calories, rather than on the basis of absolute amounts. The HEI-2010 is not a total revision like the 2005 version was. It s more of an update to reflect the 2010 Dietary Guidelines for Americans. 3

4 The purposes of this project were to update the HEI to reflect the 2010 Dietary Guidelines and to estimate HEI-2010 scores for the US population. 4

5 The HEI rests on the nutrition science that is the basis of the Institute of Medicine s Dietary Reference Intakes and the Dietary Guidelines for Americans. The 2010 Dietary Guidelines Advisory Committee used the DRI reports (the blue books here), as well as their own analyses and evidence-based, systematic reviews of the scientific literature, to develop their advisory report to the Secretaries of Agriculture and Health and Human Services (the orange book). That report was the basis of the 2010 Dietary Guidelines for Americans, which is the current US federal nutrition policy. The USDA Food Patterns are found in the Guidelines. They provide quantitative, food-based recommendations at 12 calorie levels for complying with both the Dietary Guidelines and the Dietary Reference Intakes. Finally, then, the HEI-2010 measures diet quality, using the quantitative recommendations found in the Guidelines and in the USDA Food Patterns. 5

6 Key features of the HEI are that it assesses diet, including foods and beverages, and nutrients from them but not supplements, primarily by capturing the balance among the various food groups; it uncouples dietary quality from quantity by using a density approach; it employs a least restrictive approach to setting standards, which is to say that among dietary recommendations that vary by sex, age, and/or activity level, it uses the one that is easiest to achieve; and it is designed so that it does not require any single food or commodity to be consumed, in order for the maximum score to be attained. 6

7 The components of the 2005 version of the HEI listed here. They serve to assess diet quality from two perspectives. The adequacy components in the blue boxes represent dietary components to increase; and the moderation components in the red boxes represent components to decrease. The components highlighted in yellow were carried over into the 2010 version. The HEI still has Total Fruit, which includes 100% juice; Whole Fruit; Total Vegetables, Whole Grains; Meat and Beans, which has been renamed Total Protein Foods ; and Milk, which has been renamed Dairy. And the HEI-2010 still has Sodium as well as Calories from Solid Fats, Alcohol, and Added Sugars, which has been renamed Empty Calories. 7

8 Some specific points found in the 2010 Dietary Guidelines that we captured in new components of the HEI-2010 include: increase the intake of dark green vegetables, and beans and peas (which are sometimes called legumes); increase seafood by replacing some meat and poultry with fish and shellfish; increase intake of poly- and monounsaturated fatty acids; and decrease saturated fatty acids; and decrease intake of refined grains. 8

9 All 12 components of the HEI-2010 are shown here. The new component called Greens and Beans is the same as the previous one called Dark Green and Orange Vegetables and Legumes, except that orange vegetables are no longer included. The Greens in the name refers to dark green vegetables such as broccoli, spinach, and kale; and the Beans in the name refers to the beans and peas that are counted as vegetables, but this component does not include any beans and peas that are needed to meet the Total Protein Foods standard. The 2010 Guidelines have quantitative recommendations for seafood, which led to a new HEI component for seafood. To acknowledge the benefits of vegetarian diets, this component also includes plant protein foods, such as soy products, nuts, and seeds, as well as any beans and peas that are needed to meet the Total Protein Foods standard. A new adequacy component, called Fatty Acids, is the ratio of poly- plus monounsaturated fatty acids to saturated fatty acids. The Fatty Acids component is classified as an adequacy component to reflect the health benefits of poly- and monounsaturated fatty acids. We also have a new moderation component for refined grains because the 2010 Dietary Guidelines point out that people eat far more refined grains than are recommended. 9

10 We still have an empty calories component, but we modified the scoring a bit. The 2010 USDA Food Patterns include limits on calories from solid fats and added sugars, but do not specifically mention limits on alcohol. The text of the Dietary Guidelines, on the other hand, notes that calories from alcohol reduce the calories from solid fats and added sugars that can be accommodated; however, the Guidelines also acknowledge that moderate drinking has some potential beneficial effects. Therefore, in the HEI- 2010, calories from alcohol are considered to be empty calories, but only when alcohol is consumed beyond moderate amounts. 10

11 Three of the major food groups Fruits, Vegetables, and Protein Foods each have two components that get a maximum of 5 points each, as shown at the top of this slide. Dairy and Fatty Acids have maximums of 10 points, as do the first two moderation components, Refined Grains and Sodium. The third moderation component, Empty Calories, gets up to 20 points, and is weighted twice as heavily as any of the other components to emphasize the importance of their over-consumption, given the high rates of obesity in the US. The HEI-2010 still has a total, summation score with a maximum of 100 points, but most applications will benefit from considering the individual component scores as well. 11

12 Any index involves not just its components and point system, but also standards against which to score dietary intake. We use a density approach to set the standards; that is, they are amounts per 1000 calories of energy intake, except in the case of fatty acids where the standard is based on the ratio of poly- and monounsaturated fatty acids to saturated fatty acids. So the HEI assesses the quality of the mix of foods consumed. Advantages of this approach are that it doesn t require us to estimate an individual s appropriate energy intake level, which is difficult to do; and it allows assessment at other levels, such as USDA food assistance packages and various aspects of the food environment, such as menus and the US food supply. 12

13 This slide shows each of the components and the standards for the minimum and maximum scores and is taken from the fact sheet. Assigning HEI-2010 scores to any set of foods requires a database that translates them into amounts of food groups that are consistent with the USDA Food Patterns. Mixed foods need to be disaggregated, and any solid fats and added sugars are counted separately. 13

14 The HEI has been used in a variety of ways: to examine relationships between dietary patterns and health; to examine the cost of dietary patterns; to evaluate the food environment; to evaluate the effect of dietary interventions; and to assess and monitor diet quality of populations and subpopulations. This last application is the one that s most important for the USDA Center for Nutrition Policy and Promotion. 14

15 For this study, we used the HEI-2010 to assess the diet quality of Americans age 2 years and older in and by using the 24-hour dietary recall data collected in the National Health and Nutrition Examination Survey. We estimated the population s average daily, long-term intakes of all the dietary components that comprise the HEI-2010, by using the population ratio method. 15

16 Intakes of energy, fatty acids, sodium, and alcohol were calculated using the USDA Agricultural Research Service s, Food and Nutrient Database for Dietary Studies (FNDDS) created for the respective surveys. 16

17 Creating the food group variables was more complicated. For , we used the first version of the USDA Agricultural Research Service s MyPyramid Equivalents Database (MPED); but that database doesn t separate whole fruit from fruit juice. For that purpose, staff at the Center for Nutrition Policy and Promotion had created a fruit database, which we used. 17

18 Then for , we started with the second version of the MPED, which was created for NHANES, and added the second version of the fruit database. 18

19 Finally, we added the addendum to the MPED, also created at the Center for Nutrition Policy and Promotion, for 900 food codes that had been created since

20 Here you see the results with the scores expressed as a percent of their maximum values. In , average HEI-2010 scores, shown in the dark blue bars, were below the maximum for all components, except Total Protein Foods. Scores were below 50% of their maximums for Greens and Beans; Whole Grains; Sodium; and Empty Calories. Scores for remaining components were also substantially below their maximums in most cases. The scores that differed significantly, at the.05 level, between and are starred. Starting at the top of the chart, the score improved for Whole Fruit. Closer to the bottom, you can see that the score declined for sodium, which indicates that the amount of sodium consumed, relative to energy, increased; but the score improved for Empty Calories; and that means that a smaller proportion of energy came from what we call empty calories the calories provided by solid fats, alcohol, and added sugars. The total HEI-2010 score did not change significantly, between the two time periods, remaining at about

21 The diet quality of Americans is far from optimal, and did not improve overall between and Improvements in HEI scores would provide substantial health benefits for Americans by ensuring nutrient adequacy and reducing the risk of chronic diseases. According to the 2010 Dietary Guidelines, supporting such change will require comprehensive approaches that engage every segment of society individuals, families, schools, industry, government, and nongovernmental organizations; and the food environment needs to be reshaped so that the healthy choices become the easy, accessible, and desirable choices for everyone. 21

22 You can find additional information about the HEI-2010 on the CNPP and NCI websites, including a fact sheet with more details on the scoring system and sample SAS code for calculating scores. 22

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