A National

Nutrition Agenda
for the Public’s
Health
Chapter 7

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National Nutrition Policy in the United
States
• National nutrition policy – nationwide guidelines
which specify how nutritional needs of the
American people will be met
• Address issues of:
• Food insecurity and malnutrition
• Food safety
• Food labeling and menu labeling
• Food fortification
• Sustainable agricultural practices
• Nutrition research

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National Nutrition Policy in the United
States (cont’d.)
• Does the U.S. have a national nutrition policy?
• The answer is both yes and no
• No – no single federal agency has mandate to
handle national nutrition policy as its sole function
• Yes – a decentralized system divides responsibility
among congressional committees, federal agencies,
and major departments

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National Nutrition Policy in the United
States (cont’d.)

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Elements of Nutrition Policy

• Food assistance programs

• National nutrition and health objectives
• Healthy People 2020 initiative
• Regulations to safeguard food supply and ensure
proper handling of food
• Dietary guidance systems
• Dietary Reference Intakes, the Dietary Guidelines for
Americans, and the MyPlate Food Guide
• Monitoring and surveillance programs
• Food labeling legislation
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National Nutrition Monitoring

• Methods of deriving data to apply in national

nutrition policies include:
• Nutrition screening
• Nutrition assessment
• Nutrition monitoring,
• Nutrition surveillance
• Nutrition monitoring analyzes relationship between
diet and health in the population
• Tracking of food supply and food consumption
began in 1909

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National Nutrition Monitoring (cont’d.)

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The National Nutrition Monitoring and
Related Research Program (NNMRRP)
• NNMRRP was established by Congress in 1990
• USDA and DHHS jointly implement and coordinate
activities of the NNMRRP
• Monitoring data are used to assess the dietary,
nutritional, and related health status of the
population
• More than 50 surveillance systems are operative

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NNMRRP (cont’d.)

• Activities associated with NNMRRP grouped into

five measurement components:
• Nutritional status and nutrition-related health
measurements
• Food and nutrient consumption
• Knowledge, attitudes, and behavior assessments
• Food composition and nutrient databases
• Food supply determinations

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NNMRRP (cont’d.)

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NNMRRP (cont’d.)

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NNMRRP (cont’d.)

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NNMRRP (cont’d.)

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Nutritional Status and Nutrition-
Related Health Measurements
• National Health and Nutrition Examination Survey
(NHANES) series
• The target population of NHANES I (1971–1974) was
civilian, noninstitutionalized persons aged 1–74 years
• NHANES II (1976–1980) targeted civilian,
noninstitutionalized persons aged six months–74 years

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NHANES (cont’d.)

• NHANES I and NHANES II both measured:

• Dietary intake (one 24-hour recall)
• Body composition
• Hematologic tests, urine tests
• X-rays of the hand and wrist
• Dental examinations and other measurements
• Hispanic Health and Nutrition Examination Survey
(HHANES) was conducted in 1982–1984
• Target population consisted of “eligible” Hispanics aged
six months to 74 years

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NHANES (cont’d.)

• NHANES III was conducted in 1988–1994

• A nationwide sample of about 34,000 persons aged two
months and over
• Survey divided into two three-year surveys
• Target population: civilian, non-institutionalized, persons
aged 2 months and over
• Collected (1) 24-hour recall and FFQ
• Added environmental data
• NHANES is considered a keystone in national
nutrition policymaking decisions

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NHANES (cont’d.)

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NHANES Mobile Examination Centers

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Summary of the Health Exams That
Are Part of NHANES

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Food and Nutrient Consumption

• Various surveys over the years, including:

• The 5-a-Day for Better Health Baseline Survey
• The Nationwide Food Consumption Survey
• The Vitamin and Mineral Supplement Survey
• “What We Eat in America Survey”
• This is the dietary interview component of NHANES
• Participants are asked questions about their health
status, disease history, and diet
• Dietary 24-hour recalls

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Food and Nutrient Consumption
(cont’d.)
• Total Diet Study (TDS)
• Assesses for nutrients and contaminants in foods
• Estimates levels of 11 essential minerals
• Targets eight age groups, infant through older persons
• Collects and analyzes 234 foods from retail markets in
urban areas 4 times per year

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Knowledge, Attitudes, and Behavior
Assessments
• Behavioral Risk Factor Surveillance System
(BRFSS) is the main source of information on risk
behaviors among adult populations

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Knowledge, Attitudes, and Behavior
Assessments (cont’d.)
• The BRFSS collects data related to:
• Health status
• Access to health care; tobacco and alcohol use
• Injury control (e.g., use of seat belts)
• Use of prevention services such as immunization and
breast cancer screening
• HIV and AIDS
• Weight management practices
• Treatment for high blood cholesterol
• Frequency of intake of dietary fat, fruits, and vegetables

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Food Composition and Nutrient
Databases
• Food Label and Package Survey (FLAPS)
• Monitors labeling practices of food manufacturers
• USDA’s National Nutrient Database for Standard
Reference
• The foundation of most food and nutrition databases in
the United States, and is used in food policy, research,
and nutrition monitoring

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Food Supply Determinations

• Food Supply Series surveys (annually) – U.S. total

population
• Quantities of food available for consumption on a per
capita basis
• Quantities of food energy, nutrients, and food
components provided by these foods (calculated)

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Uses of National Nutrition-Monitoring
Data
• Uses of NNMRRP surveys are listed in Table 7-5
• Uses are categorized as:
• Assessment of dietary intake
• Monitoring and surveillance
• Regulatory
• Food programs and guidance
• Scientific research
• Historic

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Nutrient Intake Standards

• Dietary Reference Intakes (DRIs)

• Used in planning and assessing the diets of individuals
and groups
• Are major shift from prevention of nutrient deficiencies
to prevention of chronic disease
• Include change in role of dietary supplements in
achieving good health

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Nutrient Intake Standards (cont’d.)

• Dietary recommendations of other countries and

groups
• The Food and Agriculture Organization (FAO) and the
World Health Organization (WHO) recommendations
are considered sufficient for the maintenance of health
in nearly all people

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Nutrition Survey Results: How Well
Do We Eat?
• We are well nourished
• We are also generally overfat, underexercised,
and beset to some extent with nutrient deficiencies
• Caution must be exercised in interpreting the
NHANES data
• When average nutrient intakes are examined, severe
deficiencies in individuals can be missed
• However, findings based on one or two days of dietary
intake can overestimate the extent of undernutrition

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The National Agenda for Improving
Nutrition and Health
• Almost no progress was made toward the Healthy
People 2010 targets for objectives in the nutrition
and overweight focus area
• The focus of the nutrition and weight status
objectives for Healthy People 2020 was expanded
• Includes a broader range of policies and environmental
factors that support eating a healthful diet and
maintaining a healthy body weight

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Dietary Guidance Systems

• Dietary Guidelines for Americans

• Were developed to promote health and reduce chronic
disease risks
• Includes basic guidelines for healthy eating and physical
activity
• Must be revised every 5 years; newest revision 2015–
2020
• DGAs 2020-2025 still under review

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USDA Food Guides

USDA: https://www.choosemyplate.gov/resources/myplate-graphic-resources
USDA Food Guides

USDA: https://www.choosemyplate.gov/resources/myplate-graphic-resources
The 2015–2020 Dietary Guidelines for
Americans
• The 2015–2020 Dietary Guidelines for Americans
are built around five Guidelines
1. Follow a healthy eating pattern across the lifespan
2. Focus on variety, nutrient density, and amount
3. Limit calories from added sugars and saturated fats
and reduce sodium intake
4. Shift to healthier food and beverage choices
5. Support healthy eating patterns for all

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A Social–Ecological Model for Food
and Physical Activity Decisions

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Themes of the 2015–2020 Dietary
Guidelines for Americans
• https://health.gov/dietaryguidelines/2015/guideline
s/executive-summary/
• The nation has high chronic disease rates
• A significant gap exists between actual and
optimal eating patterns
• The common characteristics of healthy eating
patterns are based on current scientific evidence

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Themes of the 2015–2020 Dietary
Guidelines for Americans (cont’d.)
• Healthy lifestyle changes are possible at the
individual and population level
• Public policy impacts population-wide outcomes
• Food choices impact the environment

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Impact of Dietary Guidance Systems

• Other government dietary programs impacted by

the Dietary Guidelines:
• National School Lunch Program
• The Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC)
• Nongovernment dietary recommendations are
issued by nonprofit health organizations
• American Heart Association
• American Cancer Society

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Food Intake Patterns

• Food Group Plans have been provided to the U.S.

population since the turn of the century
• In 2011, MyPlate replaced MyPyramid
• MyPlate was developed to help consumers obtain the
nutrients and substances needed for good health by
eating a variety of foods

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Understanding the Nutrition Gap

• Most recent NHANES survey shows gap between

current recommendations and consumers’
practices
• Eating away from home
• Increased portion sizes
• USDA Healthy Eating Index (HEI) was developed
jointly by the USDA and the National Cancer
Institute
• Measures the degree to which a person’s diet conforms
to federal dietary guidelines

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Understanding the Nutrition Gap
(cont’d.)

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Understanding the Nutrition Gap
(cont’d.)

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HEI 2015 Components
Standard for maximum Standard for minimum
Component Maximum points
score score of zero

Adequacy:
Total Fruits 2 5 ≥0.8 cup equiv. per 1,000 No Fruit
kcal
Whole Fruits 3 5 ≥0.4 cup equiv. per 1,000 No Whole Fruit
kcal
Total Vegetables 4 5 ≥1.1 cup equiv. per 1,000 No Vegetables
kcal
Greens and Beans4 5 ≥0.2 cup equiv. per 1,000 No Dark Green Vegetables
kcal or Legumes

Whole Grains 10 ≥1.5 oz equiv. per 1,000 No Whole Grains

kcal
Dairy 5 10 ≥1.3 cup equiv. per 1,000 No Dairy
kcal
Total Protein Foods6 5 ≥2.5 oz equiv. per 1,000 No Protein Foods
kcal
Seafood and Plant 5 ≥0.8 oz equiv. per 1,000 No Seafood or Plant
Proteins 6,7 kcal Proteins
Fatty Acids 8 10 (PUFAs + MUFAs)/SFAs (PUFAs + MUFAs)/SFAs
≥2.5 ≤1.2

Moderation:
Refined Grains 10 ≤1.8 oz equiv. per 1,000 ≥4.3 oz equiv. per 1,000
kcal kcal
Sodium 10 ≤1.1 gram per 1,000 kcal ≥2.0 grams per 1,000 kcal

Added Sugars 10 ≤6.5% of energy ≥26% of energy

Saturated Fats 10 ≤8% of energy ≥16% of energy

https://epi.grants.cancer.gov/hei/developing.html
Understanding the Nutrition Gap
(cont’d.)

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Implementing the Recommendations:
From Guidelines to Groceries
• Helping consumers to put guidelines into practice
requires translating recommendations into food-
specific guides
• Program directors can use policy tools for
implementing programs
• https://www.fns.usda.gov/usda-food-patterns

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Implementing the Recommendations
(cont’d.)

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Policymaking Does Not Stand Still

• Community nutritionists can serve as liaisons

between policymakers and the general public
• Legislation related to health care reform
• Third-party reimbursement for medical nutrition therapy
• Food and supplement labeling requirements
• New evidence-based dietary guidelines
• Healthy People 2020 objectives with a focus on the
social and environmental determinants of health
• The increasing use of social media
• Market forces in the health care field and the food
industry
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Policymaking Does Not Stand Still
(cont’d.)
• Formulating a national nutrition agenda is a
daunting task
• Government must make a commitment to develop and
promote a coordinated plan to improve the nation’s
nutrition and health status
• Scientists must reach a consensus on the interpretation
of scientific findings and appropriate dietary advice for
all Americans
• Sufficient financial resources must be allocated to
implementing the policy

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