PANEL 6.1 TRENDS IN DIETARY QUALITY AMONG ADULTS IN THE UNITED STATES
DANIEL WANG AND WALTER WILLETT E
vidence on trends in dietary quality pro- vides essential feedback and guidance for public policy. To investigate trends in US dietary quality over time and within socioeco- nomic subgroups, we used a nationally rep- resentative population of 29,124 adults aged 20–85 years from the US 1999–2010 National Health and Nutrition Examination Surveys (Wang et al. 2014). We measured dietary qual- ity by the Alternate Healthy Eating Index 2010 (AHEI-2010), an 11-dimension score based on a combination of food and nutrient vari- ables that have established relationships with important health outcomes. Over the 12 years, the mean AHEI-2010 increased from 39.9 to 46.8, suggesting a steady improvement in dietary quality. This improvement reflected favorable changes in both consumers’ food choices and food pro- cessing motivated by public policy and nutrition education. Reduction of trans fat, from 4.6 grams per person per day in the late 1990s to 1.3 grams per person per day by 2010, accounted for more than half of the improve- ment in dietary quality.
Public policy efforts were largely responsi- ble for this reduction in trans fat consumption.
Because of strong scientific evidence of adverse effects, since 2006 the US Food and Drug Administration (FDA) has required that trans fat be included in nutrition labels. Many states and cities have taken legislative and regula- tory actions to limit trans fat use in restaurants and other locations. Most manufacturers have reformulated products to reduce trans fat. More recently, the FDA proposed an action to eliminate trans fat from the food supply. Signif- icant improvements were also found for other components of AHEI-2010, including whole fruit, whole grains, sugar-sweetened beverages, nuts and legumes, and polyunsaturated fatty acids, whereas sodium intake increased signifi- cantly over time. Although modestly improved, overall dietary quality remains far from optimal, and huge room exists for further improvements, but only a small further gain can be made by reducing intake of trans fats.
Dietary quality in the high socioeconomic
group was consistently higher than in the lower socioeconomic groups, and that gap widened from 3.9 points in 1999–2000 to 7.8 points in 2009–2010. Higher prices for healthy foods and limited access to them may help explain this gap. Among ethnic groups, Mexican Americans
had a higher AHEI-2010 than non-Hispanic white and black groups, possibly owing to their dietary traditions and culture. Non- Hispanic blacks had the lowest AHEI-2010 scores largely because of differences in income and education.
Our findings highlight the need for pub- lic health researchers and policymakers to generate further scientific evidence to inform dietary guidelines and to design strategies for addressing the socioeconomic disparities in dietary quality. Some lessons can be learned from the process of trans fat elimination, which resulted from a combination of evolving scientific evidence, increasing consumer con- sciousness of the harmful effects of trans fat, regulatory actions, and reformulation of foods by manufacturers. The trans fat experience also shows that collective actions, such as legisla- tion and taxation, that create an environment that supports individuals’ healthy choices are more effective and efficient than actions that depend solely on consumers’ individual per- sonal responsibility. Populations with low socio- economic status are likely to benefit most from these kinds of collective actions.
Middle Africa and 42 percent in Southern Asia. Rates of open defecation, thought to be a particularly important factor in nutrition status (Spears et al. 2013 as reported on by Bhutta et al. 2013a), are above 10 percent in Eastern, Middle, Northern, and Western Africa and in South-Eastern Asia. The rate of open defecation is extremely high in Southern Asia at 38 percent, although it is falling rapidly.
Female secondary education enrollment
Girls’ education is important for nutrition because it tends to delay girls’ first pregnancy and is an important part of em- powering girls in general. All regions are making progress in enrolling girls in secondary school, converging on a rate just above 100,6 although the rate is still at only about 50 percent in Africa (Figure 6.5).
Population density of health workers
Access to knowledgeable health workers is important for many nutrition-specific interventions. Figure 6.6 shows the number
of health workers per 1,000 people by region. Europe has the most physicians (3.5) and Africa the fewest (0.5). Northern America has the most nurses and midwives (9.8) and Africa the fewest (1.3). Although Asia has twice as many community health workers as Africa per 1,000 people (not shown in graph), the numbers are very low in both regions (0.7 versus 1.4). No trend data are available. Moreover, these data say nothing about the distribution of health workers; the ratios are likely to be much lower in more remote, rural areas. Clearly, efforts to scale up nutrition programs in the health sector will be ham- pered by low numbers of health workers, particularly in Africa.
WHERE ARE COUNTRIES MOST VULNERABLE TO LOW LEVELS OF UNDERLYING DETERMINANTS?
How many countries are relatively vulnerable to low levels of more than one of these underlying drivers, and which ones are they most vulnerable to? These are important questions to address because they have the potential to contribute to accelerating improvements in nutrition (as Panel 6.2 shows for Bangladesh).
ACTIONS & ACCOUNTABILITY TO ACCELERATE THE WORLD’S PROGRESS ON NUTRITION 41
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