Public Health and

Community Nutrition

Public Health and

Community Nutrition
Elizabeth Eilender

MOMENTUM PRESS, LLC, NEW YORK

Public Health and Community Nutrition

Copyright Momentum Press, LLC, 2016.
All rights reserved. No part of this publication may be reproduced,
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First published in 2016 by
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ISBN-13: 978-1-60650-869-5 (paperback)
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For My Parents
No man is an island.
- John Donne

Abstract
Poor quality dietary habits are one of the most pressing public health
concerns of our time. As a society, we are faced with the paradox of
malnutrition and overconsumption existing side-by-side. Many people
in our communities deal with the stark reality of food insecurity coupled
with a reliance on inexpensive, nutrient-poor calories that contribute to
the nationwide prevalence of obesity, type 2 diabetes, heart disease, and
other chronic conditions.
As a resource for both students and practitioners, Public Health and
Community Nutrition provides an overview of how social determinants of
healthsocioeconomic factors that influence a populations or an individuals well-beingcontribute to the existence of health disparities in
the United States. Now more than ever, diet and health experts are needed
to address these 21st-century public health challenges that require specific
professional competencies related to nutritional assessment, knowledge of
food assistance and support options, and nutrition education skills that
are appropriate for targeted audiences.

Keywords
community nutrition, cultural competence, Dietary Guidelines for
Americans, food assistance, food deserts, health disparities, health equity,
health literacy, Healthy People 2020, hunger, NHANES, nutrition
education, public health, SNAP, social determinants of health, WIC

Contents
Prefacexi
Acknowledgmentsxiii
Introduction xv
Chapter 1 Assessing the Nutrition Status of Americans......................1
Chapter 2 Food Insecurity in the United States................................15
Chapter 3 Health Literacy................................................................27
Chapter 4 Cultural Competence......................................................37
Chapter 5 Federal Food and Nutrition Assistance Programs.............51
Chapter 6 Nutrition Education........................................................67
Additional Resources79
Key Terms81
Index85

Preface
Poor quality dietary habits are one of the most pressing public health
concerns of our time. As a society, we are faced with the paradox of malnutrition and overconsumption existing side-by-side. Many people in our
communities deal with the stark reality of food insecurity coupled with
a reliance on inexpensive, nutrient-poor calories that contribute to the
nationwide prevalence of obesity, type 2 diabetes, heart disease, and other
chronic conditions.
In the United States, one-third of adults are obese, while another third
are overweight. At the same time, about 25 percent of the U.S. population participates in at least one federal food and nutrition assistance
program including 47 million people who receive Supplemental Nutrition Assistance Program benefits, and 30 million children who receive
low-cost or free lunches each school day through the National School
Lunch Program.
Nutritional status largely depends on social determinants of health
factors that influence a populations or an individuals well-being such
as income, education, literacy level, language, and cultural perceptions
of health. Today, the U.S. poverty rate is close to 15 percent including
20 million Americans who are coping with extreme poverty, while many
communities find it difficult to procure healthy foods for their households
because of geographical location, inadequate transportation, low income,
and knowledge gaps in sound nutrition practices among other hurdles.
Furthermore, demographic data continues to reflect the diversity of
the nations population with minorities expected to account for more
than 50 percent of the total population by 2043. As the ethnic and racial
makeup of the United States changes, so too does the mix of languages
people speak. Currently, 21 percent of the U.S. population speaks another
language at home, creating linguistic barriers to high-quality health care
and information. Moreover, 20 percent of U.S. adults read at or below a
fifth-grade level, presenting additional issues with access to care for vulnerable segments of the population.

xii Preface

Now more than ever, diet and health experts are needed to address
these 21st-century public health challenges that require specific professional competencies related to nutrition assessment, knowledge of food
assistance and support options, and nutrition education skills that are
appropriate for targeted audiences.
Public Health and Community Nutrition is an excellent introduction
to the key concepts that characterize the nutrition-related problems seen
today in the public health and community setting. As a resource, this
book outlines the socioeconomic factors and other barriers to health
equity that influence nutritional status, and provides information on
tools and resources needed by nutrition experts working to solve these
pervasive problems amid an increasingly complex and diverse population.

Acknowledgments
It takes a village to raise a child, a community to create hope, and a loving
family to write a book. Thank you to my wonderful husband Nicholas,
who was so encouraging every step of the way, and to my beautiful and
ever-patient children Nicole and Benjamin, who put up with a distracted
mother for many months.
To Katie Ferraro and Peggy Williams at Momentum Press, a tremendous thank you for tolerating my changing deadlines, and for contacting
me in the first placeI so enjoyed the opportunity to research and write
this book.

Introduction
Many Americans are not eating as healthfully as they should. For the past
25 years as the countrys prevalence of overweight, obesity, and chronic
disease has increased, the Healthy Eating Index (HEI)an assessment
of how our food habits nutritionally measure up to guidelineshas
remained consistently low (Dietary Advisory Committee Report 2015a).
This mismatch between established science-based dietary standards and
the way Americans actually eat presents an enormous public health
challenge for both policymakers and health care providers.
The problem is a serious one, as poor quality dietary habits as well as
a sedentary lifestyle are associated with preventable chronic diseases such
as obesity, high blood pressure, cardiovascular disease, type 2 diabetes,
certain cancers, and bone problems (Dietary Advisory Committee Report
2015b). In fact, at least six out of the top 10 leading causes of death in
the United States have an etiology that is related to diet and nutrition
(Healthy People 2020).
In order to address these issues, every five years the U.S. government
releases an important set of national guidelines known as The Dietary
Guidelines for Americans, which provides evidence-based recommendations for diet and physical activity to all healthy Americans aged two
years and older. The guidelines are published jointly by the U.S. Department of Health and Human Services (DHSS) and the U.S. Department
of Agriculture (USDA), and is a document that provides the bases for
creating and implementing health promotion and disease prevention
programs for local, state, and national initiatives, as well as private and
nonprofit organizations. It is within these settings that nutrition professionals and other health care providers are best able to assist individuals
and communities in making recommended dietary choices and meeting
physical activity goals for better health (Dietary Advisory Committee
Report 2015a).

xvi Introduction

Healthy People 2020

The 2015 Dietary Guidelines for Americans is the most recent version of
federal dietary recommendations and it supports the public health principles outlined in Healthy People 2020the nations 10-year goals and
objectives for health promotion and disease prevention. Developed by
the DHSS, Healthy People 2020 calls for the establishment of social and
physical environments that promote good health for all Americans based
on equal access to health information and resources.
A climate of such health equity is dependent on key social determinants of healthfactors that influence a populations or an individuals
well-being. These determinants include issues related to food security and
barriers to a nutritious diet; access to health information that is congruent
with literacy level; and the availability of culturally sensitive health care
providers and information.

Disparities
Healthy People 2020 defines a health disparity as
a particular type of health difference that is closely linked with
social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically
experienced greater obstacles to health based on their racial or
ethnic group; religion; socioeconomic status; gender; age; mental
health; cognitive, sensory, or physical disability; sexual orientation
or gender identity; geographic location; or other characteristics
historically linked to discrimination or exclusion (Healthy People
2020).
In response to this problem, the federal government is seeking to
eliminate health disparities and achieve health equity by including the
following new Healthy People 2020 objectives:
Improve the health literacy of the population.
Increase the proportion of persons who report that their
health care provider always gave them easy-to-understand

 Introduction

xvii

instructions about what to do to take care of their illness or

health condition.
Increase the proportion of persons who report that their
health care provider always asked them to describe how they
will follow specific health instructions once given.
Increase the proportion of schools that offer nutritious foods
and beverages outside of school meals.
Increase the proportion of school districts that require schools
to make fruits or vegetables available whenever other food is
offered or sold.
Increase the number of states that have state-level policies
that incentivize food retail outlets to provide foods that are
encouraged by the Dietary Guidelines for Americans.
Increase the proportion of Americans who have access to a
food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans.

Source: Healthy People (2020a); Healthy People (2020b); Healthy People (2020c).

The Role of the Public Health and

CommunityNutritionist
Many people are familiar with the words dietitian and nutritionist, but
not everyone understands the distinction between the two terms. Dietitians are health professionals who have earned either a four-year bachelors
degree in nutrition and dietetics or a three-year science degree followed
by a masters degree in nutrition and dietetics from a regionally accredited
college or university, and have completed 1,200 hours of supervised practical training in various hospital and community settings (Accreditation
Council for Education in Nutrition and Dietetics [n.d.]).
Candidates for the Registered Dietitian (RD) credential must pass a
national examination administered by the Commission on Dietetic Registration (CDR), and fulfill continuing professional education requirements in five-year cycles to maintain their registration. Some RDs hold
additional certifications in specialized areas of practice such as pediatrics,
geriatrics, sports, nutrition support, oncology, renal disease, and diabetes. The title dietitian is a legally protected term in the United States,

xviii Introduction

Canada, the United Kingdom, Australia, and other countries (Accreditation Council for Education in Nutrition and Dietetics [n.d.]).
In contrast, a nutritionist is a nonaccredited title that anybody can
assume whether they have pursued advanced study in nutrition and
dietetics or not, and the term is not legally protected in most countries
so many individuals with different levels of knowledge can call themselves a nutritionist (Accreditation Council for Education in Nutrition
and Dietetics [n.d.]). However, there are indeed qualified nutritionists
who have completed a rigorous course of study, have earned at least a
bachelors degree or a masters degree in nutrition science, and therefore
can serve as reliable experts.
In the United States, many states have regulatory laws that confer
licensure or certification to practitioners who have completed an accredited
curriculum in nutrition and dietetics as well as supervised practiceRDs
automatically meet this criteria, but other nutrition practitioners can as
well based on their education and work experience, and they therefore
can also work as state-licensed dietitian nutritionists (LDNs) or state-
certified dietitian nutritionists (CDNs).
To avoid confusion between those who are dietitians and those who
call themselves nutritionists, CDR now provides the Registered Dietitian
Nutritionist (RDN) credential, which is interchangeable with the RD
credential. Practitioners may use either according to personal preference.
The purpose of this newer version of the credential is to communicate to
the public that based on education and training, all dietitians are nutritionists, but not all nutritionists are dietitians. This book will use the terms
RDN, nutritionist, and dietitian interchangeably.
RDNs who work in public health and community nutrition face
professional challenges associated with nationwide food insecurity, low
health literacy, and the need for cultural competence among health care
providers. The role of public health nutritionists in particular is to focus
on population assessment, program creation and evaluation, and public
policy development. They often work for local, state, and federal departments of health, university extension programs, and other related entities.
Meanwhile, community nutritionists work directly with individuals and
families in community-based settings, participate in program development and nutrition education, and often work closely with social service
agencies (Bruening et al. 2015).

 Introduction

xix

In their capacity as educators, nutritionists have many interventional

approaches they can pursue in both public health and community-level
settings. As a resource for both students and practitioners, Public Health
and Community Nutrition provides an overview of how social determinants of health and nutrition status are assessed and contribute to the
existence of health disparities; the role that food assistance programs
and nutrition education initiatives play in helping groups and individuals achieve health equity; and how practitioners can apply principles of
dietary health promotion and disease prevention in their work as public
health and community nutritionists to reach these goals.

References
Accreditation Council for Education in Nutrition and Dietetics. n.d.
Registered Dietitian (RD)ACEND Fact Sheet: Educational and
Professional Requirements. www.eatrightacend.org/ACEND/content.
aspx?id=6442485467
Bruening, M., A.Z. Udarbe, E.Y. Jimenez, P.S. Crowley, D.C. Fredericks, L.A.E.
Hall. 2015. Academy of Nutrition and Dietetics: Standards of Practice and
Standards of Professional Performance for Registered Dietitian Nutritionists
(Competent, Proficient, and Expert) in Public Health and Community
Nutrition. Journal of the Academy of Nutrition and Dietetics 115, no. 10.
Dietary Advisory Committee Report. 2015a. Scientific Report of the 2015
Dietary Guidelines Advisory Committee: Part A. Executive Summary. www.
health.gov/dietaryguidelines/2015-scientific-report/02-executive-summary.
asp (accessed February 27, 2016).
Dietary Advisory Committee Report. 2015b. Scientific Report of the 2015
Dietary Guidelines Advisory Committee: Part B. Chapter 1: Introduction.
www.health.gov/dietaryguidelines/2015-scientific-report/03-introduction.
asp (accessed February 28, 2016).
Healthy People. 2020. Disparities. www.healthypeople.gov/2020/about/
foundation-health-measures/Disparities
Healthy People. 2020a. Social Determinants of Health. www.healthypeople.
gov/2020/topics-objectives/topic/social-determinants-of-health/objectives
Healthy People. 2020b. Communication and Health Information
Technology. www.healthypeople.gov/2020/topics-objectives/topic/healthcommunication-and-health-information-technology/objectives
Healthy People. 2020c. Nutrition and Weight Status. www.healthypeople.
gov/2020/topics-objectives/topic/nutrition-and-weight-status/objectives

CHAPTER 1

Assessing the Nutrition

Status of Americans
What Is a Healthy Diet?
There is no perfect diet. Every individual chooses what they eat based on
many factors, including habit, taste preference, convenience, cost, culture, family traditions, time constraints, and physical health. To maintain
a desirable weight and general well-being, a diet that works for one does
not necessarily work for all. However, convincing evidence demonstrates
that certain long-term dietary patterns significantly reduce the risk of
many chronic conditions we see so much of in the United States today.
The adoption of lifelong healthy patterns of eating ultimately sets the
stage for well-being, because what people routinely eat and drink confers
a positive cumulative effect on health over time. To promote not just better choices of specific foods but also better eating habits overall, the federal governments latest set of Dietary Guidelines for Americans (issued in
2015) emphasizes the importance of variety in what individuals consume
rather than on specific nutrients or foods in isolationhealthy eating
patterns (U.S. Department of Health and Human Services and U.S.
Department of Agriculture 2015).
Research shows that a healthy eating pattern includes a high intake of:

Fruits
Vegetables
Whole grains
Fat-free or low-fat dairy
Seafood
Legumes
Nuts

PUBLIC HEALTH AND COMMUNITY NUTRITION

A healthy eating pattern also includes less intake of:

Meat
Processed meat
Sugar-sweetened food
Refined grains

In order to apply this information to daily food choices, the Dietary

Guidelines suggest that Americans focus on any one of three broad eating
styles:
The Healthy U.S.-Style Eating Pattern
An eating pattern that is based on the types and proportions of foods
Americans typically eat, but in nutrient-dense and appropriate amounts.
An example of a Healthy U.S.-Style Eating Pattern based on a 2,000-calorie
daily diet is: 2 cups of vegetables, 2 cups of fruit, 6 ounces of grains (half
should be whole grains), 3 cups of dairy, 5 ounces of protein foods
(8ounces of seafood per week; 26 ounces of meat, poultry, and eggs per
week; 5 ounces of nuts, seeds, soy products per week), and 5 teaspoons of
healthy oils per day.
Note: The DASH dietary pattern (known as Dietary Approaches to
Stop Hypertension) is an example of a healthy eating pattern that has
many of the same features as the Healthy U.S.-Style Eating Pattern.
Research on DASH has shown that it significantly lowers blood pressure
and low-density lipoprotein (LDL-cholesterol) levels, thereby reducing
the risk for cardiovascular disease compared to diets that are similar to a
typical American diet.
DASH is high in vegetables, fruits, low-fat dairy products, whole
grains, poultry, fish, beans, and nuts and is therefore rich in potassium,
calcium, magnesium, fiber, and protein. The diet is low in sweets,
sugar-sweetened beverages, and red meats, and therefore low in saturated fats. It is also lower in sodium than the typical American diet.
For more information, visit www.nhlbi.nih.gov/health/health-topics/
topics/dash

Assessing the Nutrition Status of Americans 3

The Healthy Mediterranean-Style Eating Pattern

An eating pattern that contains more fruits and seafood and less dairy
than does the Healthy U.S.-Style Eating Pattern. An example of a daily
2,000-calorie diet includes 2 cups of vegetables, 2 cups of fruits, 6ounces
of grains (half of which are whole grains), 2 cups of dairy, 6 ounces of
protein foods, which include a combination of meat, poultry, and eggs (26
ounces per week), seafood (15 ounces per week), a combination of nuts, seeds,
and soy products (5 ounces per week), and 5 teaspoons of healthy oils per day.
The Healthy Vegetarian Eating Pattern
When compared to the Healthy U.S.-Style Eating Pattern, the Healthy
Vegetarian pattern includes more legumes (beans and peas), soy products,
nuts and seeds, and whole grains. It contains no meats, poultry, or seafood.
An example of a daily 2,000-calorie diet includes 2 cups of vegetables,
2 cups of fruit, 6 ounces of grains (3 of which is whole grains), 3 cups
of dairy substitute, 3 ounces of protein foods, including eggs (3ounces
per week); legumes (6 ounces per week); soy products (8ounces per week);
nuts and seeds (7 ounces per week); and 5 teaspoons of healthy oils per day.
While the above suggested eating patterns differ somewhat in specific food choices and combinations, they all align with key principles
of the Dietary Guidelines, which are evidence-based and support good
health and reduced disease risk. Within appropriate calorie limits for age,
gender, and physical activity level, the Dietary Guidelines recommend
choosing a dietary pattern consisting of the following components:
A Variety of Vegetables
Vegetables are important sources of many nutrients, including dietary
fiber, potassium, vitamin A, vitamin C, vitamin K, copper, magnesium,
vitamin E, vitamin B6, folate, iron, manganese, thiamin, niacin, and
choline. They should come from all of the vegetable subgroups, which
include dark green, red, and orange, legumes (beans and peas), starchy,
and other; and include all fresh, frozen, canned, and dried options in
cooked or raw forms, as well as vegetable juices.

PUBLIC HEALTH AND COMMUNITY NUTRITION

Adhering to weekly amounts from each vegetable subgroup ensures

variety and the likelihood of meeting nutrient needs. Vegetables should
be consumed in a nutrient-dense form, with limited additions of salt,
butter, or creamy sauces; and canned versions should be low in sodium.
A Variety of Fruits, Especially Whole Fruits
The fruits food group refers to whole fruits, including fresh, canned, frozen, and dried forms, as well as 100 percent fruit juice, if without added
sugar counts as one cup of fruit. Although fruit juice can be part of a
healthy eating pattern, it is lower than whole fruit in dietary fiber and
can contribute extra calories when consumed excessively. Therefore, at
least half of the recommended amount of fruits should come from whole
fruits. Similar to juice, an excessive intake of dried fruits may contribute
too many calories to the overall diet, so a half-cup of dried fruit counts as
a one-cup equivalent of fruit.
Grains (At Least Half of Which Are Whole Grains)
This food group includes grains as single foods such as rice, oatmeal, and
popcorn as well as products that include grains as an ingredient, such as
breads, cereals, crackers, and pasta.
Whole grains such as brown rice, quinoa, and oats contain the entire
kernel, including the endosperm, bran, and germ, and are a natural source
of many nutrients such as dietary fiber, iron, zinc, manganese, folate, magnesium, copper, thiamin, niacin, vitamin B6, phosphorus, selenium, riboflavin, and vitamin A. Refined grains are those that have been processed to
remove the bran and germ, which takes away dietary fiber, iron, and other
nutrients. Most refined grains are enriched, a process that adds back the iron
as well as four of the B vitamins (thiamin, riboflavin, niacin, and folic acid).
Many grain products such as cookies, cakes, and some snack foods are
high in added sugars and saturated fats and therefore should be limited.
Fat-free or Low-fat Dairy and Fortified Soy Products
This category includes milk, yogurt, cheese, or fortified soy beverages
(commonly known as soymilk). Soy beverages fortified with calcium,

Assessing the Nutrition Status of Americans 5

vitamin A, and vitamin D, are included as part of the dairy group because
they are similar to milk with respect to nutrient composition. Other products sold as milks but made from plants such as almond, rice, coconut,
and hemp, may contain calcium but are not included as part of the dairy
group because their overall nutritional content is not similar to dairy milk
and fortified soymilk.
In addition to calcium, the dairy group contributes phosphorus,
vitamin A, vitamin D (in products that are fortified with it), riboflavin,
vitamin B12, protein, potassium, zinc, choline, magnesium, and selenium.
Fat-free and low-fat (1 percent) dairy products provide the same
nutrients but less fat (and fewer calories) than higher fat options, such
as 2 percent and whole milk and regular cheese. Fat-free or low-fat milk
and yogurt, in comparison to cheese, contain less saturated fats and
sodium, and have more potassium, vitamin A, and vitamin D. Increasing
consumption of fat-free or low-fat milk or yogurt and lowering the proportion of cheese products would decrease saturated fat and sodium consumption, while increasing potassium, vitamin A, and vitamin D intake.
A Variety of Protein Food
The protein foods group comprises a broad selection of foods from both
animal and plant sources and includes several subgroups: seafood; meats,
poultry, and eggs; nuts, seeds, and soy products; and legumes (beans and
peas), which may also be considered as part of the vegetables group. Protein is also found in some foods from other food categories, such as dairy.
Different types of protein foods contain varying amounts of certain
nutrients. Meats, for example, offer the most zinc, while poultry provides
the most niacin. Meats, poultry, and seafood provide heme iron, which is
a form of iron more bioavailable than the nonheme type found in plant
sources. Seafood provides the most vitamin B12 and vitaminD, inaddition to almost all of the polyunsaturated omega-3 fatty acids, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Eggs contain the
most choline; nuts and seeds provide the most vitamin E; and soy products and legumes are a source of copper, manganese, and iron.
When selecting protein foods, nuts and seeds should be unsalted, and
meats and poultry should be consumed in lean forms. Processed meat

PUBLIC HEALTH AND COMMUNITY NUTRITION

and poultry are sources of salt and saturated fats, and can be eaten as
long as sodium, saturated fats, added sugars, and total calories are within
recommended limits.
Note: Seafood, which includes fish and shellfish, has been shown to
confer health benefits for the general population, as well as for women
who are pregnant or breastfeeding. Strong evidence shows that eating patterns that include seafood are associated with reduced risk of cardiovascular disease, and moderate evidence indicates that these eating patterns are
associated with reduced risk of obesity.
Since mercury is a heavy metal found in the form of methyl mercury
in seafood, in varying levels, seafood choices higher in EPA and DHA but
lower in methyl mercury can include salmon, anchovies, herring, shad,
sardines, Pacific oysters, trout, and Atlantic and Pacific mackerel (not king
mackerel, which is high in methyl mercury). Some canned seafood, such
as anchovies, may be high in sodium. Women who are pregnant or breastfeeding should consume at least 8 and up to 12 ounces of a variety of
seafood per week from choices that are lower in methyl mercury.
Healthy Oils
Although they are not a food group, the Dietary Guidelines emphasizes
oils as part of a healthy eating pattern because these types of lipids are a
major source of essential fatty acids and vitamin E. Oils are fats that are
extracted from plants and are liquid at room temperature. Typical dietary
oils include canola, corn, olive, peanut, safflower, soybean, and sunflower
oils. Oils are also naturally present in nuts, seeds, seafood, olives, and
avocados. The fat in some tropical plants such as coconut oil, palm kernel
oil, and palm oil, are not included in the oils category because they are
significantly higher in saturated fat content. Oils should replace solid fats
rather than being added to the diet.
Less Than 10 Percent of Calories Per Day Should Come from
Added Sugars
When sugars are added to foods and beverages it increases the calorie content without contributing essential nutrients, so consuming these items

Assessing the Nutrition Status of Americans 7

can make it difficult to meet nutrient needs while staying within energy
limits. Naturally occurring sugars, such as those in fruit or milk, are not
added sugars. Specific examples of added sugars that can be listed as an
ingredient include brown sugar, corn sweetener, corn syrup, dextrose,
fructose, glucose, high-fructose corn syrup, honey, invert sugar, lactose,
malt syrup, maltose, molasses, raw sugar, sucrose, trehalose, and turbinado sugar.
The recommendation to limit calories from added sugars is consistent with research examining eating patterns and health, where strong
evidence suggest that lower intakes of added sugars are associated with
reduced risk of cardiovascular disease in adults, and moderate evidence
indicates an association with reduced risk of obesity, type 2 diabetes, and
some types of cancer in adults.
Less Than 10 Percent of Calories Per Day Should Come from
Saturated Fats
Saturated fats should be limited to less than 10 percent of calories per day
by replacing them with unsaturated fats, while keeping total dietary fats
within the recommended range appropriate for age (20 to 35 percent of
total calories for adults). Individuals two years and older have no dietary
requirement for saturated fats, which the body can make to meet its physiological needs.
Strong and consistent evidence shows that replacing saturated fats
with unsaturated fats, especially polyunsaturated fats, is associated with
reduced blood levels of total cholesterol and LDL-cholesterol, and is associated with a reduced risk of heart attacks and deaths related to cardiovascular disease.
Some evidence has shown that replacing saturated fats with plant
sources of monounsaturated fats, such as olive oil and nuts, may be
associated with a reduced risk of cardiovascular disease, but the data is
not as strong. Evidence has also shown that replacing saturated fats with
carbohydrates reduces blood levels of total and LDL-cholesterol, but
increases blood levels of triglycerides and reduces high-density lipoproteins (HDL-cholesterol). Replacing total fat or saturated fats with carbohydrates is not associated with reduced risk of cardiovascular disease.

PUBLIC HEALTH AND COMMUNITY NUTRITION

Limit Trans Fats

Individuals should limit their intake of trans fats to as low as possible by
minimizing the amount of foods they eat containing synthetic sources
such as products made with partially hydrogenated oils. A number of
studies have demonstrated an association between increased intake of
trans fats and increased risk of cardiovascular disease, partly attributed to
its ability to raise blood levels of LDL-cholesterol.
Trans fats occur naturally in some foods and also are produced in a
process called hydrogenation, which is used by food manufacturers to
make products containing unsaturated fatty acids solid at room temperature (i.e., more saturated) and therefore more resistant to becoming
spoiled or rancid. Partial hydrogenation means that only some unsaturated fatty acids are converted to saturated fatty acids. Artificial trans fatty
acids are found in the partially hydrogenated oils used in some margarines, snack foods, and prepared desserts.
Limit Dietary Cholesterol
The body uses cholesterol for physiological and structural functions but
makes more than enough to meet its needs, and therefore it is not essential to the diet. However, foods that are higher in dietary cholesterol, such
as fatty meats and high-fat dairy products, are also higher in saturated
fats.
Strong evidence shows that lower intakes of dietary cholesterol are
associated with reduced risk of cardiovascular disease, and moderate evidence indicates that these eating patterns are associated with reduced risk
of obesity. Nevertheless, more research is needed regarding the dose
response relationship between dietary cholesterol and blood cholesterol
levels, and adequate evidence is not available for a specified limit for
dietary cholesterol with respect to the Dietary Guidelines. Dietary cholesterol is found only in animal foods such as egg yolk, dairy products,
shellfish, meats, and poultry.
Consume Less Than 2,300 Milligrams Per Day of Sodium
Sodium is an essential nutrient and is needed by the body in relatively small
quantities, except in cases of substantial sweating. Sodium is primarily

Assessing the Nutrition Status of Americans 9

consumed as salt (sodium chloride), and the recommendation for adults and
children ages 14 years and older is to limit sodium intake to less than 2,300
mg per day based on evidence showing a doseresponse relationship between
increased sodium intake and increased blood pressure in adults. In addition,
moderate evidence suggests an association between increased sodium intake
and a higher risk of cardiovascular disease in adults, and individuals with
prehypertension and hypertension should aim for a further reduction in
sodium intake to 1,500 mg per day for even greater blood pressure control.
Alcohol (If Consumed, Should Be in Moderation)
The Dietary Guidelines recommend that individuals who do not drink
alcohol should not start to do so for any reason. If alcohol is consumed,
it should be in moderationup to one drink per day for women and up
to two drinks per day for menand only by adults of legal drinking age.
There are also many circumstances in which individuals should not drink,
such as during pregnancy.
Caffeiness
Caffeine is not a nutrient but a dietary component that functions in the
body as a stimulant. It occurs naturally in plants such as coffee beans, tea
leaves, cocoa beans, kola nuts, and is also added to foods and beverages
such as caffeinated soda and energy drinks. If caffeine is added to a food,
it must be included in the listing of ingredients on the food label. Most
intake of caffeine in the United States comes from coffee, tea, and soda.
Much of the available evidence on caffeine focuses on coffee intake.
Moderate coffee consumption (three to five 8-oz cups per day or providing up to 400 mg per day of caffeine) can be included in a healthy eating
pattern, and is not associated with an increased risk of major chronic
diseases or premature death. However, people who do not consume caffeinated coffee or other caffeinated beverages are not encouraged to start
incorporating them into their diet. Those who choose to drink alcohol
should be cautious about mixing caffeine and alcohol together or consuming them at the same time.
Source: U.S. Department of Health and Human Services and U.S. Department of Agriculture
(2015).

10

PUBLIC HEALTH AND COMMUNITY NUTRITION

How Well Do Americans Eat?

For decades, scientific inquiry has resulted in a large and evolving body of
evidence that underscores the characteristics of a healthy diet. While the key
recommendations outlined in the Dietary Guidelines are subject to change
based on the accumulation of additional evidence, the current guidelines
are based on the strongest available data. Given our current understanding of how dietary habits impact disease prevalence, it is important for
health officials and public health experts to have a method of evaluation
of both individual and population-based dietary habits, lifestyle behavior,
and health, so as to better direct future guidelines and recommendations.
In order to assess the food choices people make, the quality of their
diet, and the nutrition status of the population, nutritional epidemiologists must collect information by conducting detailed surveys. These
questionnaires gather information about individual medical histories,
diet, and lifestyle. The survey results are then used to identify connections
between dietary habits and nutrition-related diseases or conditions. In
turn, various government agencies use this data to develop national health
priorities and goals; federal legislators use the information to develop
public policy related to food assistance programs, nutrition education
initiatives, food labeling, and food safety; and scientists use the results to
establish research priorities.
To that end, the National Nutrition Monitoring and Related Research
Program (NNMRRP) coordinates and oversees several national food
consumption surveys carried out by the United States Department of
Agriculture (USDA) and the Department of Health and Human Services (DHHS). These surveys include, the National Health and Nutrition
Examination Survey (NHANES), What We Eat in America (WWEIA,
formerly known as CSFII), and the Healthy Eating Index (HEI).
National Health and Nutrition Examination Survey
The NHANES program is comprised of a series of cross-sectional, nationally representative health examination surveys conducted in mobile examination units or clinics; and conducted by the National Center for Health
Statistics (NCHS) to assess the health and nutrition status of adults and
children in the United States. The surveys combine interviews and physical examinations and monitor changes over time by gathering information

Assessing the Nutrition Status of Americans 11

on dietary intake, biochemical tests, physical measurements (anthropometric data), and clinical assessments for evidence of nutritional deficiencies (National Center for Health Statistics [n.d.]).
The medical examinations and laboratory tests follow very specific
protocols and are as standard as possible to ensure comparable data across
sites and providers. The survey results are then used to determine the
prevalence of major diseases as well as risk factors for them, and to assess
nutritional status and its association with health promotion and disease prevention. In addition, the findings serve as the basis for national
standards for such measurements as height, weight, and blood pressure
(National Center for Health Statistics [n.d.]).
A total of seven national examination surveys have been conducted
from 1960 to 1994 in distinct cycles encompassing several years, but
since 1999, it has become a continuous annual survey. Data are collected
every year from a representative sample of the civilian, noninstitutionalized U.S. population, newborns and older via in-home personal interviews, and physical examinations in mobile clinics (National Center for
Health Statistics [n.d.]).
What We Eat in America
WWEIA is the dietary intake interview component of NHANES, and represents the integration of two nationwide surveys: the USDAs Continuing
Survey of Food Intakes by Individuals (CSFII) and NHANES. WWEIA
is conducted as a partnership between the USDA and the DHHS. The
latter is responsible for the sample design and data collection, while the
USDA oversees the maintenance of the databases used to code and process the information, and data review. The two surveys were integrated in
2002 with the most recent version covering 2009 to 2010 (United States
Department of Agriculture, Agricultural Research Service [n.d.]).
The Healthy Eating Index
The HEI is a measure of diet quality that assesses how well people adhere
to the Dietary Guidelines, using data that is collected through 24-hour
dietary recalls in national surveys. The original HEI was created by the
Center for Nutrition Policy and Promotion (CNPP) in 1995, and has

12

PUBLIC HEALTH AND COMMUNITY NUTRITION

been updated to reflect the 2010 Dietary Guidelines, with plans to

eventually update the index to align with the 2015 Dietary Guidelines
(United States Department of Agriculture, Center for Nutrition Policy
and Promotion [n.d.]).
Like its previous version, the 2010 HEI can be used to assess changes
in diet quality over time; examine the relationship between diet cost and
diet quality; evaluate the diets of subpopulations; assess the quality of
foods provided through USDA nutrition assistance programs, and the
impact of nutrition interventions. It can also be used in research to better understand relationships between nutrients, foods, dietary patterns,
and health-related outcomes (United States Department of Agriculture,
Center for Nutrition Policy and Promotion [n.d.]).
On account of its assessment purposes, the HEI is a diet quality index
of major significance to public health. The original 1995 index had 10
components that measured five major food groups and four nutrients that
should be consumed in moderation and variety, with a score of 100 being
as close to adherence to guidelines as possible (Guenther et al. 2013).
The most recent version of the HEI is also based out of a score from
0to 100 and has 12 components:
Adequacy (higher consumption results in a higher score)
Total fruit (5 points)
Whole fruit (5 points)
Total vegetables (5 points)
Greens and beans (5 points)
Whole grains (10 points)
Dairy (10 points)
Total protein (5 points)
Seafood and plant proteins (5 points)
Fatty acids (10 points)
Moderation (lower consumption results in a higher score)
Refined grains (10 points)
Sodium (10 points)
Empty calories and added sugar (20 points)
Source: National Collaborative on Childhood Obesity Research (n.d.).

Assessing the Nutrition Status of Americans 13

A diet with a score greater than 80 is considered good, one with a

score of 51 to 80 is considered fair, and one with a score of less than
51 is considered poor (Snetselaar 2015). Based on the 2009 to 2010
NHANES, the average HEI for Americans aged 2 and older was 57 (U.S.
Department of Health and Human Services, Office of Disease Prevention and Health Promotion [n.d.]). The most recent HEI-2010 scores
for the Total U.S. Population Aged Two or Older, Children 2 to 17 years,
and Older Adults Aged 65 or Older based on data from NHANES 2011
to 2012 are summarized in Table 1.1. The average score for the total U.S.
population was 59a small increase from the previous result, indicating
that Americans have not made much progress in improving the quality
of their diets.
Table 1.1 Healthy Eating Index 2010
Total and component scores1 for the U.S. total population, children and older adults,
NHANES 20112012.

HEI-2010 dietary
component
(maximum score)

Total
population
2 years
(n = 7,933)

Children
217 years
(n = 2,857)

Older adults
65 years
(n = 1,032)

Mean score (standard error)

Total fruit (5)

3.00 (0.11)

3.91 (0.18)

3.84 (0.22)

Whole fruit (5)

4.01 (0.17)

4.78 (0.22)

4.99 (0.05)

Total vegetables (5)

3.36 (0.08)

2.10 (0.09)

4.16 (0.19)

Greens and beans (5)

2.98 (0.15)

0.70 (0.09)

3.58 (0.47)

Whole grains (10)

2.86 (0.13)

2.50 (0.10)

4.23 (0.34)

Dairy (10)

6.44 (0.14)

9.03 (0.22)

5.99 (0.16)

Total protein foods (5)

5.00 (0.00)

4.44 (0.13)

5.00 (0.00)

Seafood and plant proteins(5)

3.74 (0.20)

3.05 (0.17)

4.91 (0.18)

Fatty acids (10)

4.66 (0.14)

3.29 (0.18)

5.60 (0.36)

Refined grains (10)

6.19 (0.15)

4.91 (0.16)

7.34 (0.31)

Sodium (10)

4.15 (0.06)

4.85 (0.25)

3.66 (0.26)

Empty calories (20)

12.60 (0.23)

11.50 (0.28)

14.99 (0.44)

Total HEI score (100)

59.00 (0.95)

55.07 (0.72)

68.29 (1.76)

Calculated using the population ratio method.

Source: United States Department of Agriculture, Center for Nutrition Policy and Promotion
(n.d.).

14

PUBLIC HEALTH AND COMMUNITY NUTRITION

References
Guenther, P.M., K.O. Casavale, S.I. Kirkpatrick, H.A.B. Hiza, K.J. Kuczynski,
L.L. Kahle, and S.M. Krebs-Smith. 2013. Update of the Healthy Eating
Index: HEI-2010. Journal of the Academy of Nutrition and Dietetics 113,
no.4, pp. 56980.
National Center for Health Statistics. n.d. National Health and Nutrition
Examination Survey (NHANES). www.healthindicators.gov/Resources/
DataSources/NHANES_91/Profile
National Collaborative on Childhood Obesity Research. n.d. The Healthy
Eating Index 2010: Fact Sheet. http://nccor.org/downloads/NCCOR_HEIfactsheet_v8.pdf
Snetselaar, L. March 2, 2015. Are American Following the US Dietary Gudielines?
Check thge Healthy Eating Index. www.elsevier.com/connect/are-americansfollowing-us-dietary-guidelines-check-the-healthy-eating-index
United States Department of Agriculture, Center for Nutrition Policy and
Promotion. n.d. Healthy Eating Index. www.cnpp.usda.gov/healthy
eatingindex
U.S. Department of Health and Human Services and U.S. Department of
Agriculture. December 2015. 20152020 Dietary Guidelines for Americans.
8th ed. http://health.gov/dietaryguidelines/2015/guidelines/
U.S. Department of Health and Human Services, Office of Disease Prevention
and Health Promotion. n.d. Scientific Report of the 2015 Dietary Guidelines
Advisory Committee. Appendix E-2.25: Average Healthy Eating Index-2010
Scores for Americans ages 2 years and older (NHANES 20092010). https://
health.gov/dietaryguidelines/2015-scientific-report/data-table-23.asp
United States Department of Agriculture, Agricultural Research Service. n.d.
What We Eat In America. www.ars.usda.gov/News/docs.htm?docid=13793

Index
Agency for Healthcare Research and
Quality, 47
Alcohol, 9

Culturally competent food and

nutrition professional, 46
Cultural skill, 46

CACFP. See Child and Adult Care

Food Program
Caffeine, 9
Campinha-Bacote Model for cultural
competence, 4446
CDR. See Commission on Dietetic
Registration
Centers for Disease Control and
Prevention Health Literacy
website, 34
Child and Adult Care Food Program
(CACFP), 52
Commission on Dietetic Registration
(CDR), xvii, 69
Commodity Supplemental Food
Program (CSFP), 52
Community-based interventions,
6768
Community programs
Feeding America, 63
Meals on Wheels, 6364
Cooperative extensions, 75
CSFP. See Commodity Supplemental
Food Program
Cultural awareness, 44
Cultural competence
Campinha-Bacote Model, 4446
definition, 39
diverse nation, 3738
language, 38
National CLAS Standards, 4041
need for, 3840
resources, 4748
self-assessment checklist statements,
4344
Cultural desire, 46
Cultural encounter, 46
Cultural knowledge, 46

Diet, 3031. See also Healthy diet

Dietary Approaches to Stop
Hypertension (DASH)
pattern, 2
Dietary cholesterol, 8
Dietitian, xviixviii
Diet quality, food insecurity, 1920
Disparities, xvixvii
Economic access, 24
EFNEP. See Expanded Food and
Nutrition Education Program
Elderly Nutrition Program, 53
Expanded Food and Nutrition
Education Program (EFNEP),
7778
Farmers Market Nutrition Program
(FMNP), 53, 62
Fat-free dairy, 45
FDPIR. See Food Distribution
Program on Indian
Reservations
Federal food and nutrition assistance
programs, 5253
Feeding America, 63
FFVP. See Fresh Fruit Vegetable
Program
FMNP. See Farmers Market Nutrition
Program
FNS. See Food and Nutrition Service
Food access, 1516
Food Access Research Atlas, 22
Food and Nutrition Act, 2008, 56
Food and Nutrition Service (FNS),
51
Food bank, 63
Food deserts, 2122

86 Index

Food Distribution Program on Indian

Reservations (FDPIR), 52
Food guidance, 7072
Food insecurity
diet quality, 1920
food access, 1516
health consequences, 2021
income and education, 2324
poverty, 1516
spending on food, 1819
USDA definitions, 18
USDAs annual food security
survey, 17
very low, 16
Food literacy, 31
Food measurement, 40
Food swamps, 23
Fresh Fruit Vegetable Program
(FFVP), 52
Fruits food group, 4
Grains food group, 4
Health beliefs and practices, cultural/
ethnic groups, 45
Health communication, 3133
Health disparity, xvixvii
Health literacy
communication, 3133
definitions of, 27
diet and, 3031
health outcomes and, 28
literacy data, 2930
overview of, 2728
PIAAC literacy, 2930
professionals, 3133
training resources, 3334
Health professionals, 3133
Healthy diet
alcohol, 9
caffeine, 9
dietary cholesterol, 8
fat-free and low-fat dairy, 45
fortified soy products, 45
fruits food group, 4
grains food group, 4
oils, 6
protein food group, 56

saturated fats, 7
sodium, 89
sugars, 67
trans fats, 8
vegetables, 34
Healthy Eating Index (HEI), xv,
1113
Healthy eating patterns
high intake of, 1
less intake of, 2
Mediterranean-style, 3
U.S.-style, 2
vegetarian, 3
Healthy People 2020, xvi
HEI. See Healthy Eating Index
High food security, 18
Households, food insecurity, 1619
ICE. See Industry Collaboration
Effort
Industry Collaboration Effort (ICE),
47
Language, 38
Lets Move!, 7374
Literacy, definition of, 28
Low-fat dairy, 45
Marginal food security, 18
Meals on Wheels, 6364
Mediterranean-style healthy eating
pattern, 3
MyPlate, 7172
National Bureau of Economic
Research, 23
National Center for Cultural
Competence (NCCC), 42,
48
National Center for Health Statistics
(NCHS), 10
National Health and Nutrition
Examination Survey
(NHANES), 1011
National Institutes of Health (NIH)
Plain Language Training, 33
National School Lunch Program
(NSLP), 52, 57

 Index 87

National Standards for Culturally and

Linguistically Appropriate
Services in Health and
Health Care (National CLAS
Standards), 4041
NCCC. See National Center for
Cultural Competence
NCHS. See National Center for
Health Statistics
NHANES. See National Health and
Nutrition Examination Survey
NSIP. See Nutrition Services Incentive
Program
NSLP. See National School Lunch
Program
Numeracy, definition of, 28
Nutrition education
community-based interventions,
6768
EFNEP, 7778
food guidance, 7072
Lets Move!, 7374
professional competencies, 6870
SNAP, 7475
WIC, 7577
Nutrition educators, 47
Nutritionist, xviii
Nutrition resilience, 19
Nutrition risk requirement, 61
Nutrition Services Incentive Program
(NSIP), 53
Oils, 6
PIAAC. See Program for International
Assessment of Adult
Competencies
Plain Writing Act, 33
Poverty, 1516
Professional competencies, 6870
Program for International Assessment
of Adult Competencies
(PIAAC), 2930
Protein food group, 56
Psychological stress, 2021
Racial groups, 37
RD. See Registered Dietitian

RDN. See Registered Dietitian

Nutritionist
Registered Dietitian (RD), xvii
Registered Dietitian Nutritionist
(RDN), xviii
Sample self-assessment checklist
statements, 4344
Saturated fats, 7
SBP. See School Breakfast Program
School Breakfast Program (SBP),
5253, 58
Senior Farmers Market Nutrition
Program (SFMNP), 53
SFMNP. See Senior Farmers Market
Nutrition Program
SFSP. See Summer Food Service
Program
SMP. See Special Milk Program
SNAP. See Supplemental Nutrition
Assistance Program
SNEB. See Society for Nutrition
Education and Behavior
Social determinants of health, xvi
Society for Nutrition Education and
Behavior (SNEB), 70
Sodium, 89
Soy products, 45
Special Milk Program (SMP), 53
Sugars, 67
Summer Food Service Program
(SFSP), 53, 58
Supplemental Nutrition Assistance
Program (SNAP), 53, 5456
food purchases, 5657
households, 56
nutrition education, 7475
TEFAP. See The Emergency Food
Assistance Program
The Emergency Food Assistance
Program (TEFAP), 52
Training resources, health literacy,
3334
Trans fats, 8
United States Department of
Agriculture (USDA), xv, 11, 16

88 Index

USDA. See United States Department

of Agriculture
U.S. Department of Health and
Human Services (DHHS)
Health Literacy Online,
3334
U.S.-style healthy eating pattern, 2
Vegetables, 34
Very low food security, 16, 18
What We Eat in America (WWEIA),
11

WIC. See Women, Infants and

Children
WIC Learning Online (WLOL),
76
WLOL. See WIC Learning Online
Women, Infants and Children (WIC),
53, 5860
eligibility, 60
nutrition education, 7577
nutrition risk requirement, 61
program administration, 6162
WWEIA. See What We Eat in
America