Advertisement

Diet Quality: The Key to Healthy Eating

      The role of good nutrition in health and well-being has been established since early times, as far back as 1747, when the fact that scurvy could be prevented by eating citrus fruits was discovered. Historically, researchers have focused on the effects of individual nutrients or foods in isolation, as they relate to nutrition and chronic diseases. However, more recently nutrition scientists and researchers have looked at a more inclusive approach to diet and health using diet quality, because overall diet patterns may be a better predictor of disease risk than specific nutrients or individual foods.
      • Wrobleski M.M.
      • Parker E.A.
      • Hurley K.M.
      • Oberlander S.
      • Merry B.C.
      • Black M.M.
      Comparison of the HEI and HEI-2010 diet quality measures in association with chronic disease risk among low-income, African American urban youth in Baltimore, Maryland.
      Diet quality focuses on the totality of what one eats and drinks; it examines healthy eating patterns as a whole, with the aim to bring about lasting improvements in individual and population health. In the literature, diet quality is used to investigate the association between foods and nutrients and chronic disease incidence and mortality.
      • Kant A.K.
      Dietary patterns: biomarkers and chronic disease risk.
      The federal government provides recommendations for optimal diet quality through the Dietary Guidelines for Americans. The 2015-2020 Dietary Guidelines for Americans provides guidance for choosing a healthy diet and focuses on preventing the diet-related chronic diseases that continue to affect our population.
      Its recommendations are ultimately intended to help individuals improve and maintain overall health and reduce the risk of chronic disease. Its focus is disease prevention, not treatment.
      Healthy eating is not about a list of “don’t eats” or depriving oneself of favorite foods. Rather, it is about a healthful lifestyle of consuming nutritious foods and beverages to improve the quality of the diet and health outcomes, such as to help reduce risk of diet-related chronic disease, including heart disease, type 2 diabetes, and cancer.
      Evaluating the healthfulness of the diet is a great way that registered dietitian nutritionists (RDNs) can help to design suitable nutrition education materials appropriate for specific settings. To facilitate this process, the US Department of Agriculture’s (USDA’s) Center for Nutrition Policy and Promotion (CNPP) developed the original Healthy Eating Index (HEI). Subsequently, CNPP collaborated with the National Cancer Institute to provide various updates of the HEI to reflect the newest scientific evidence on diet and health, which resulted in three revisions, such as the HEI-2005, HEI-2010, and the current HEI-2015. Similarities among these three versions of the HEI are noted at: https://epi.grants.cancer.gov/hei/comparing.html.
      The HEI-2015 measures how well people’s dietary behavior aligns with key dietary recommendations in the 2015-2020 Dietary Guidelines for Americans. The HEI-2015, an index that assesses the multidimensional components of the diet across the lifecycle, is useful in describing the diet quality of Americans and in identifying where focused efforts for improvements are warranted. Additional information on the HEI-2015 can be found on the CNPP website at: www.cnpp.usda.gov/healthyeatingindex. CNPP will offer continuing education credit for completing a self-study of this website.
      To help RDNs understand how efforts in nutrition education may result in better HEI scores, describing factors relevant to the scoring of the HEI would be helpful. Thus, this article describes the characteristics of the HEI dietary components that impact the scoring system. It also summarizes how the HEI scores relate to diet quality and health outcomes.

      Food Patterns and HEI Scoring

      The USDA Food Patterns Are the Foundation of the HEI Scoring Standards

      An eating pattern represents the totality of all foods and beverages consumed. The USDA Food Patterns are a set of eating patterns that exemplify healthy eating. They include recommended intakes for the five food groups and for the subgroups within vegetables, grains, and protein foods. They also recommend an allowance for intake of oils. The USDA Food Patterns are used to determine the scoring standards for the HEI. Assigning HEI scores to a set of foods requires translating them into amounts of food groups that are consistent with the USDA Food Patterns. The Food Patterns Equivalents Database

      US Department of Agriculture, Agricultural Research Service. Food Patterns Equivalents Database 2013-2014. Food Surveys Research Group Home Page. https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/food-surveys-research-group/docs/fped-databases/. Accessed May 16, 2018.

      converts the foods and beverages in the Food and Nutrient Database for Dietary Studies

      US Department of Agriculture, Agricultural Research Service. USDA Food and Nutrient Database for Dietary Studies, 7.0. Food Surveys Research Group Home Page. http://www.ars.usda.gov/nea/bhnrc/fsrg. Accessed May 16, 2018.

      to the USDA Food Patterns components. To calculate the HEI score, all foods are broken down into their respective food groups and subgroups (Total Fruit, Whole Fruit, Total Vegetables, Greens and Beans, Whole Grains, Dairy, Total Protein Foods, Seafood and Plant Proteins, Fatty Acids, Refined Grains, Sodium, Empty Calories). Any solid fats and added sugars are counted separately.

      HEI Components and Scoring Standards

      Improving Food Patterns Can Increase HEI Scores

      The HEI comprises food group components identified in the USDA Food Patterns. These patterns are based on the types and proportions of foods Americans typically consume, but in nutrient-dense forms and appropriate amounts. They are designed to meet nutrient needs while not exceeding calorie requirements and while staying within limits for overconsumed dietary components. The HEI is divided into:
      • adequacy components (to increase), such as fruits, vegetables, whole grains, dairy products, total protein foods, and fats; and
      • moderation components (to limit), such as refined grains, sodium, added sugars, and saturated fats.
      The HEI components can be considered as a set of scores, each of which measures alignment with a different aspect of the Dietary Guidelines. For adequacy components, intakes at the level of the set standard or higher receive the maximum number of points, because higher intakes are desirable. For moderation components, intakes at the level of the set standard or lower receive the maximum number of points, because lower intakes are more desirable. Scores for intakes between the minimum and maximum standards are scored proportionately.
      Most HEI food components are weighted equally at 10 points. Foods with two subgroups, such as fruits, vegetables, and protein foods, are allotted 5 points each to total 10 (Table). The component scores are summed to derive a total maximum score of 100. The component scores indicate the makeup of the dietary patterns, and the total maximum score is an indication of the overall quality of the diet. The CNPP/HEI website provides more detailed information on how the HEI is scored at: www.cnpp.usda.gov/how-hei-scored.
      TableHealthy Eating Index (HEI)-2015
      Intakes between the minimum and maximum standards are scored proportionately.
      components and scoring standards
      Reprinted from: US Departement of Agriculture, Center for Nutrition Policy and Promotion. How the HEI is Scored. https://www.cnpp.usda.gov/how-hei-scored. Accessed July 2, 2018.
      ComponentMaximum pointsStandard for maximum scoreStandard for minimum score of 0
      Adequacy:
      Total fruits
      Includes 100% fruit juice.
      5≥0.8 c equivalent per 1,000 kcalNo fruit
      Whole fruits
      Includes all forms except juice.
      5≥0.4 c equivalent per 1,000 kcalNo whole fruit
      Total vegetables
      Includes legumes (beans and peas).
      5≥1.1 c equivalent per 1,000 kcalNo vegetables
      Greens and beans
      Includes legumes (beans and peas).
      5≥0.2 c equivalent per 1,000 kcalNo dark-green vegetables or legumes
      Whole grains10≥1.5 oz equivalent per 1,000 kcalNo whole grains
      Dairy
      Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages.
      10≥1.3 cup equivalent per 1,000 kcalNo dairy
      Total protein foods
      Includes legumes (beans and peas).
      5≥2.5 oz equivalent per 1,000 kcalNo protein foods
      Seafood and plant proteins
      Includes legumes (beans and peas).
      Includes seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas).
      5≥0.8 oz equivalent per 1,000 kcalNo seafood or plant proteins
      Fatty acids
      Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs).
      10(PUFAs+MUFAs)/SFAs ≥2.5(PUFAs+MUFAs)/SFAs ≤1.2
      Moderation:
      Refined grains10≤1.8 oz equivalent per 1,000 kcal≥4.3 oz equivalent per 1,000 kcal
      Sodium10≤1.1 g per 1,000 kcal≥2.0 g per 1,000 kcal
      Added sugars10≤6.5% of energy≥26% of energy
      Saturated fats10≤8% of energy≥16% of energy
      a Intakes between the minimum and maximum standards are scored proportionately.
      b Reprinted from: US Departement of Agriculture, Center for Nutrition Policy and Promotion. How the HEI is Scored. https://www.cnpp.usda.gov/how-hei-scored. Accessed July 2, 2018.
      c Includes 100% fruit juice.
      d Includes all forms except juice.
      e Includes legumes (beans and peas).
      f Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages.
      g Includes seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas).
      h Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs).

      Nutrient Density

      Nutrient Density Matters

      Healthy eating styles are based on choosing a variety of nutrient-dense foods across the food groups that contain vitamins, minerals, fiber, and other healthful nutrients or components while staying within appropriate calorie level limits. Nutrient-dense foods and beverages include vegetables, fruits, 100% vegetable/fruit juices, whole grains, seafood, eggs, beans and peas, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats and poultry with little or no saturated fats, sodium, refined starches, and added sugars.

      HEI and Density Scoring

      Increasing Nutrient Density Results in Improved HEI Scores

      The HEI captures the nutritional balance among the various food groups. It uncouples dietary quality from quantity by using a density approach, (ie, each of the components is scored per 1,000 calories, with the exception of fatty acids, which is a ratio of unsaturated to saturated fatty acids).
      Using a density approach for scoring allows the HEI to be used across food patterns of different calorie levels. Density standards are useful not only because they allow common standards to be used, but also because they are independent of an individual’s energy requirement.

      US Department of Agriculture, Agricultural Research Service. Food Patterns Equivalents Database 2013-2014. Food Surveys Research Group Home Page. https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/food-surveys-research-group/docs/fped-databases/. Accessed May 16, 2018.

      The USDA Food Patterns show recommended amounts of food from each food group at 12 calorie levels that meet the needs of individuals across the lifespan. Dietary recommendations vary by sex, age, and activity level.

      How Nutrition and Dietetics Practitioners Can Help to Improve HEI Scores

      The Work of RDNs Has Focused on Improving the Quality of the American Diet

      Through the application of various efficacious and cost-effective interventions, RDNs can positively impact public health as well as health outcomes for the individuals they counsel. A better understanding of how the HEI relates to diet quality can help RDNs adapt nutrition intervention strategies. RDNs can tailor healthy eating patterns to individuals in varied settings where food is obtained and consumed. These efforts could help to improve diet quality of their individual target audience. RDNs can find detailed information on key elements of healthy eating patterns and shifts needed to align with healthy eating patterns in the 2015-2020 Dietary Guidelines for Americans. The ChooseMyPlate.gov website has a number of resources to help RDNs create and support healthful eating patterns in their respective settings, including home, school, work, and communities, such as:

      A Holistic Approach

      In light of the role that food plays in health, we need to think about the totality of all food and beverage choices. Details on the relationship between dietary patterns and health outcomes can be found in “A Series of Systematic Reviews on the Relationship between Dietary Patterns and Health Outcomes.”

      US Department of Agriculture, Center for Nutrition Policy and Promotion. A series of systematic reviews on the relationship between dietary patterns and health outcomes. www.cnpp.usda.gov/sites/default/files/usda_nutrition_evidence_flbrary/DietaryPatternsReport-FullFinal.pdf. Published March 2014. Accessed July 2, 2018.

      A holistic approach is needed to make eating patterns healthy, because all of what individuals habitually eat and drink may affect health. Making healthy and wise choices across the food groups is a step to forming healthy eating patterns to help improve diet quality and health outcomes, as well as reduce diet-related chronic disease risks.

      References

        • Wrobleski M.M.
        • Parker E.A.
        • Hurley K.M.
        • Oberlander S.
        • Merry B.C.
        • Black M.M.
        Comparison of the HEI and HEI-2010 diet quality measures in association with chronic disease risk among low-income, African American urban youth in Baltimore, Maryland.
        J Am Coll Nutr. 2018; 37: 201-208
        • Kant A.K.
        Dietary patterns: biomarkers and chronic disease risk.
        Appl Physiol Nutr Metab. 2010; 35: 199-206
      1. 2015-2020 Dietary Guidelines for Americans. 8th ed. US Government Printing Office, Washington, DC2015
      2. US Department of Agriculture, Agricultural Research Service. Food Patterns Equivalents Database 2013-2014. Food Surveys Research Group Home Page. https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/food-surveys-research-group/docs/fped-databases/. Accessed May 16, 2018.

      3. US Department of Agriculture, Agricultural Research Service. USDA Food and Nutrient Database for Dietary Studies, 7.0. Food Surveys Research Group Home Page. http://www.ars.usda.gov/nea/bhnrc/fsrg. Accessed May 16, 2018.

      4. US Department of Agriculture, Center for Nutrition Policy and Promotion. A series of systematic reviews on the relationship between dietary patterns and health outcomes. www.cnpp.usda.gov/sites/default/files/usda_nutrition_evidence_flbrary/DietaryPatternsReport-FullFinal.pdf. Published March 2014. Accessed July 2, 2018.