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Sources of Food Group Intakes among the US Population, 2001-2002
RESEARCH Current Research
Sources of Food Group Intakes among the US Population, 2001-2002 JESSICA L. BACHMAN, MS, MPH, RD; JILL REEDY, PhD, MPH, RD; AMY F. SUBAR, PhD, MPH, RD; SUSAN M. KREBS-SMITH, PhD, MPH, RD
ABSTRACT Background Food guides are typically built around a system of food groups. Accordingly, the US Department of Agriculture’s MyPyramid includes both food groups and subgroups, as well as an allowance for discretionary calories, in its guidance. Objective To identify the major dietary contributors to food group intake in the US population. Methods This cross-sectional study used 2001-2002 National Health and Nutrition Examination Survey data to determine weighted population proportions for the contribution of each subgroup to its MyPyramid food group (ie, proportion), and the contribution of specific foods to the subgroups oils, solid fats, and added sugars (ie, major contributors). Food codes associated with each food were sorted into 96 categories, termed specific foods, and were linked to the MyPyramid Equivalents Database to obtain food group equivalents. Results In regard to proportion, dark green vegetables (6%), orange vegetables (5%), and legumes (6%) fell well short of recommended levels. Intake of whole grains (10% of total) was far below the recommendation that at least half of all grains be whole. In regard to major contributors, top sources of oils were potato chips, salad dressing, and nuts/seeds; major contributors of solid fats were grain-based desserts, cheese, and sausages. Sweetened carbonated beverages provided 37% of added sugars. Conclusions Americans do not, in general, consume the most nutrient-dense forms of basic food groups, instead consuming foods that are high in solid fats and added J. L. Bachman is a graduate student, Department of Nutrition, The University of Tennessee, Knoxville. J. Reedy and A. F. Subar are nutritionists and S. M. KrebsSmith is chief, Risk Factor Monitoring and Methods Branch, Applied Research Program, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD. Address correspondence to: Jill Reedy, PhD, MPH, RD, Risk Factor Monitoring and Methods Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, MSC 7344, EPN 4005, Bethesda, MD 20892-7344. E-mail: [email protected] Manuscript accepted: October 22, 2007. Copyright © 2008 by the American Dietetic Association. 0002-8223/08/10805-0008$34.00/0 doi: 10.1016/j.jada.2008.02.026
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sugars. The main culprits—the foods that contribute most to discrepancies between recommendations and actual intake—are sweetened carbonated beverages and other sweetened beverages, grain-based desserts, nonskim dairy products, and fatty meats. J Am Diet Assoc. 2008;108:804-814.
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n 2005, the US Department of Agriculture (USDA) released MyPyramid (1), a food guide aimed at the general population and designed to provide nutrient adequacy while limiting commonly overconsumed foods, such as those containing solid fats (ie, saturated and trans-fatty acids) and added sugars (ie, energy-containing sweeteners). Using 12 patterns at varying energy levels, it recommends amounts of different food groups— grains, vegetables, fruit, milk, meat and beans, and oils (eg, nonhydrogenated vegetable oils and oils in fish, nuts, and seeds)—for individuals to consume, depending on their age, sex, and activity level. It also allows an additional small amount of calories beyond those coming from the food groups, referred to as “discretionary calories.” This energy may come from intake of solid fat, added sugar, alcohol, or additional food group foods. The MyPyramid food intake recommendations are in accordance with those from a number of other health-related organizations, including the American Heart Association’s guidelines for “making healthy food and lifestyle choices,” the National Heart, Lung, and Blood Institute’s Dietary Approaches to Stop Hypertension Eating Plan, and the American Dietetic Association’s and American Diabetes Association’s Exchange List for Meal Planning (2). Data presented in the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines) and elsewhere make clear that the population is not following current dietary advice (3-6). In particular, Americans need to eat more fruits, vegetables, and fat-free milk, and much less solid fats and added sugars. At the same time, they need to change the types of vegetables and grains they consume to include more dark green vegetables, orange vegetables, legumes, and whole grains. What is not clear is which foods contribute most to the discrepancies between recommendations and actual intake. The purpose of this research was to examine the ways in which Americans are actually consuming foods and beverages from the MyPyramid food groups and the subgroups oils, solid fats, and added sugars. Our intent was to examine the actual source of servings from these food groups to better understand current intake compared to recommendations and to provide context for necessary changes in the food environment and
© 2008 by the American Dietetic Association
crafting nutrition education messages about individual food groups. METHODS The source of dietary intake data for this study was the 2001-2002 National Health and Nutrition Examination Survey (NHANES) (7). NHANES used a nationally representative, complex multistage, stratified probability sample. It included oversampling of persons with low income, individuals aged 12 to 19 years and older than age 60 years, African Americans, and Mexican Americans. Trained interviewers conducted in-person 24-hour dietary recalls with all eligible persons, using automated data collection systems that included multiple passes. Dietary data included detailed descriptions of all food and quantities eaten. In 2002, a second 24-hour recall was obtained from respondents via telephone, but only the Day 1 recalls are included in this analysis for several reasons: a single day’s recall is sufficient for group mean usual intake estimation, Day 1 recalls are generally considered to be more valid than subsequent recalls because of the possibility of interviewer fatigue, and reweighting is not necessary if all respondents have the same number of recalls. This cross-sectional analysis includes all persons aged 2 years and older with dietary recalls deemed reliable by the data developers (n⫽9,033). To adjust for differential probabilities of selection and various sources of nonresponse, appropriate weighting factors were applied. These factors allow inference to the total civilian, noninstitutionalized US population. Further information regarding the design of the 2001-2002 NHANES, including sampling and weighting procedures can be found elsewhere (7). The dietary intake data collected in the survey were catalogued according to 4,069 discrete food codes. For this analysis, food codes representing similar foods—for example the various types of pasta dishes such as ziti, manicotti, and lasagna—were combined to provide an indication of the contribution of distinct food items to the intake of the MyPyramid groups being studied. That is, the 4,069 codes were sorted into 96 mutually exclusive food categories, which are hereafter referred to as specific foods to distinguish them from the food groups used in guidance. The list of specific foods (see the Figure) was adapted from a previous project (8,9). The foods reported in the survey were also the source of data for servings from the MyPyramid groups/subgroups. The MyPyramid food groups are measured in cups, ounces, cup or ounce equivalents, or teaspoons; for the purposes of this analysis, all these units of measure are referred to collectively as servings. The 4,069 food codes were linked to USDA’s MyPyramid Equivalents Database (MPED) (version 1.0, 2006, http://www.ars.usda.gov/research/ publications/publications.htm?seq_no_115⫽201058) to obtain the number of servings of each MyPyramid group and subgroup corresponding to the amount of each food reported. The MPED incorporates data from a recipe file, which disaggregates all foods reported in the survey to individual ingredients, and assigns those ingredients to MyPyramid groupings. For example, yogurt with fruit is separated into yogurt, fruit, and sweetener in the recipe
file and assigned corresponding cup equivalents of milk, grams of solid fat, cups of fruit, and teaspoons of added sugar, respectively, in the MPED. The MPED was used to assess all the MyPyramid food groups, including grains (with subgroups whole grains and nonwhole/refined grains), vegetables (with subgroups dark green vegetables, orange vegetables, legumes, starchy vegetables, and other vegetables), fruit, milk, meat and beans, and oils. For the purposes of this analysis, discretionary calories were considered to include only solid fat, added sugars and alcohol, all of which are accounted for in the MPED. The MPED includes data on other groups of foods that are not specifically mentioned in MyPyramid, but were still of interest and so included in this analysis, including tomatoes, potatoes, meat, poultry, fish, eggs, soy, nuts and seeds, fluid milk, yogurt, and cheese. Because the meat and poultry groups are not complete in the MPED, the servings from the two groups defined as “organ meats” and “frankfurters, sausage, luncheon meats” were reassigned to meat and/or poultry based on descriptions and amounts in the recipe files. Similarly, because Americans are encouraged to get most of their fruit from whole fruits rather than juice (4), the fruit group was further categorized into whole fruits and juices. The contribution of each subgroup to its respective MyPyramid food group (ie, proportion) was examined as well as the contribution of specific foods to each of the subgroups, and to oils, solid fats and added sugars (ie, major contributors). The contribution of each food (as subgroup or specific food) to the intake of each group/ subgroup was obtained by summing the number of servings provided by the food for all individuals and dividing by the total intake of that group/subgroup from all foods for all individuals. Thus, the weighted percentage contribution is given by n
兺 (F · w ) * 100 兺 (T · w ) i
i
i
i
i⫽1 n
i⫽1
Where n ⫽ the sample size, Fi ⫽ the number of servings contributed by the particular food for the ith individual, Ti ⫽ the total number of servings from all foods for the ith individual, and wi ⫽ the sample weight for the ith individual. This formula provides the percentage contributed by each food to the population’s total consumption of each group. The results differ from those that would be obtained if a mean proportion, rather than a population proportion, were used (10). Legumes (comprised of dried beans and peas, but not including peanuts) can be included in either the vegetable or meat and beans groups of MyPyramid; therefore, their contribution to the total intake of both groups was examined. RESULTS Distribution of Subgroups within MyPyramid Food Groups (Proportion) The distribution of servings among subgroups within each of the MyPyramid food groups is shown in Table 1, along with the recommended distribution, where applicable.
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Beverages Whole milk Reduced-fat milk Skim milk Vegetable juice 100% fruit juice, not orange/grapefruit juice 100% orange/grapefruit juice Fruit drinks Soda Milk substitute and evaporated milk Alcoholic beverages Coffee Tea Bakery/breads Hot cereal Pancakes/waffles/French toast Quickbreads Ready-to-eat cereals Grain-based dessertsa Yeast breads Dressings, spreads, other additionsb Butterc Cream Margarinec Mayonnaise Miscellaneous solid fats Nondairy creamer/cream substitutes Oilsc Salad dressing Sauces Sour cream Condiments Gelatins Jams and jelly Sugars/honey Syrups/toppings
Produce Broccoli Carrots Coleslaw Corn Fried white potatoes Lettuce Onions Other cruciferous Other white potatoes Peas Spinach String beans Sweet potatoes Tomatoes Tomato sauces Vegetable medleys and other vegetables Vegetable mixed dishes Apples and pears Avocado Bananas Citrus fruits Dried fruit Grapes Melon Peaches/plums/apricots/nectarines Strawberries Other fruit and fruit salad Snacks Potato/corn/other chipsd Popcorn Pretzels Nuts/seeds and nut/seed mixed dishes Candy Crackers
Entrees Chili Mexican mixed dishes Pizza Soups Meal replacements Pasta and pasta dishes Rice and rice mixed dishes Egg rolls Refrigerator/frozen Yogurt Cottage/ricotta/cream cheese Dairy desserts Frozen meals Deli Regular cheese Reduced-fat cheese Dried beans Burgers Cold cuts Eggs and egg mixed dishese Tuna and tuna mixed dishes Shrimp and shrimp mixed dishes Other fish and fish mixed dishes Liver and other organ meats Beef and beef mixed dishes Chicken and chicken mixed dishes Duck and duck mixed dishes Other meat and meat mixed dishes Pork and pork mixed dishes Turkey and turkey mixed dishes Sausage, franks, bacon, and ribs Tofu and meat substitutes
a
Includes cakes, cookies, donuts, pies, crisps, cobblers, and granola bars. Includes low-fat items such as low-fat salad dressings, cream cheese, and sour cream. c Butter, margarines, and oils do not include those used in yeast breads, grain-based desserts, quickbreads, pancakes/waffles/French toast, dairy desserts, salad dressing, mayonnaise, pasta and pasta mixed dishes, Mexican mixed dishes, ready-to-eat cereal, crackers, pretzels, potato/corn/other chips, or candy. d Includes low-fat versions. e Excludes eggs found in grain-based desserts, pancakes/waffles/french toast, yeast breads, quickbreads, dairy desserts, egg rolls, and pasta and pasta mixed dishes. b
Figure. List of specific foods used to provide an indication of the contribution of distinct food items to the intake of select MyPyramid groups. Specific foods listed are the result grouping like foods reported in the 2001-2002 National Health and Nutrition Examination Survey.
Slightly more than half of the fruit group servings were from whole (non-juice) fruit, a distribution that is consistent with recommendations in the 2005 Dietary Guidelines (4). Vegetable intakes were derived almost entirely from starchy and other vegetables (83% combined), in large part because potatoes and tomatoes contributed 24% and 22%, respectively (data not shown). Dark green vegetables (6%), orange vegetables (5%), and legumes (6%) fell well short of recommended levels (17%, 11%, and 17%, respectively). Likewise, consumption of whole grains (10% of total grains) was far below the recommendation that half or more of all grain servings come from whole grains. Meat accounted for more than 40% of the servings from
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the meat and beans group, followed by poultry (24%), fish (9%), nuts/seeds (9%), eggs (7%), legumes (7%), and soy (1%). More than 60% of the milk group servings came from fluid milk, about one third from cheese (36%), and the remaining from yogurt (2%). Added sugars (47%) contributed slightly more discretionary calories than solid fat (44%), and only a small amount was derived from alcohol (8%). Distribution of Specific Foods within MyPyramid Food Groups (Major Contributors) The specific foods used in this analysis are listed in the Figure, and findings for the specific food sources of se-
Table 1. Distribution of servings among subgroups within MyPyramid major food groups Food group Fruit Whole fruit Juice Vegetables Dark greenb Orangec Legumesde Starchyf Otherg Grains Whole Nonwhole Meat and beans Meat Poultry Fish Egg Nuts/seeds Legumese Soy Milk Milk Yogurt Cheese Discretionary calories Solid fat Added sugars Alcohol
% Current intake
% Recommendeda
53.5 46.5
ⱖ50 ⱕ50
5.8 4.7 6.5 29.3 53.7
17 11 17 17 37
9.5 90.5
ⱖ50 ⱕ50
43.1 24.4 8.7 7.4 8.4 7.1 0.9
NAh NAh NAh NAh NAh NAh NAh
61.6 2.2 35.7
NAh NAh NAh
44.3 47.3 8.4
NAh NAh NAh
a
From the Dietary Guidelines for Americans 2005 (4). For example broccoli, romaine, and spinach. For example carrots, pumpkin, and sweet potatoes. d For example lentils, cooked dried peas, and beans. e Legumes are included in both the vegetable group and the meat and beans group so that the relative proportion can be determined within both food groups. In the meat and beans group, servings are adjusted as defined in the MyPyramid Equivalents Database so that 1⁄4 c vegetables⫽1 oz equivalent meat and beans. f For example white potatoes, corn, and green peas. g For example tomatoes, onions, and iceburg lettuce. h NA⫽not applicable. No specific recommendations provided. b c
lected subgroups are found in Table 2. Foods are listed in descending order by percentages of their contribution to intake for the group. Table 2 includes all foods that contribute at least 2% of intake from that group, and foods contributing between 1% and 2% are footnoted. Whole Fruit and Fruit Juice. Apples and pears combined represented more than a quarter of the whole fruit consumed, with bananas (including plantains) contributing another 19%. Other major contributors of whole fruit included melon (15%), other fruit and fruit salad (8%), citrus fruits (7%), and grapes (6%). Grain-based desserts such as pies, crisps, and cobblers contributed more than 3% of the whole fruit, representing a high-fat and highsugar means of obtaining fruit. Pure orange and grapefruit juices combined accounted for fully half of the fruit juice consumed. All other kinds
of pure fruit juice contributed just 29% of the fruit juice servings, whereas fruit-flavored drinks, which generally contain a large amount of added sugars, contributed 14%. Vegetable Subgroups. Broccoli reported separately contributed more than one third of the dark green vegetables, and additional broccoli was likely contributed by mixed dishes and soups. Lettuce (including romaine) and spinach reported separately each contributed another 25% of the dark green vegetables. Carrots alone supplied the majority of orange vegetables, with 50% coming from those reported separately and undoubtedly additional contributions from mixed dishes and soups. Sweet potatoes were the only other single vegetable source contributing a sizeable proportion (9%) of orange vegetables. The list of top sources of other vegetables was long, with 20 specific foods contributing at least 1%, but the top five sources—lettuce, vegetable medley and other vegetables, condiments, tomatoes, and pizza— contributed about half of these vegetables. The specific foods that contributed to the intake of potatoes and tomatoes (data not shown) were also examined, because these two vegetables represented such a large proportion of vegetable intake. Five specific foods accounted for virtually all of the potatoes consumed: other white potatoes (37%), fried white potatoes (32%), potato/corn/other chips (19%), soups (6%), and beef and beef mixed dishes (3%). The major sources of tomatoes were tomatoes reported separately (22%), pizza (16%), pasta and pasta mixed dishes (13%), condiments (10%), tomato sauces (10%), and soups (5%). Whole and Nonwhole Grains. Ready-to-eat cereals and hot cereals made up more than 40% of all whole grains consumed. Yeast breads supplied an additional 35%, and popcorn (12%) and crackers (6%) were the next biggest sources. Yeast breads contributed 26% of the nonwhole grains. Grain-based desserts contributed an additional 10%, and pizza, pasta and pasta dishes, and Mexican dishes rounded out the top five sources of nonwhole grains, supplying 8% to 9% each. Meat and Bean Subgroups. Burgers; sausage, franks, bacon, and ribs; and cold cuts together supplied more than half the meat intake. Beef and beef mixed dishes from other sources contributed an additional 29%, and pork and pork mixed dishes provided 12%. Tuna and tuna mixed dishes supplied 17% and shrimp and shrimp mixed dishes supplied 15% of the fish consumed, and all other fish and fish mixed dishes contributed 62%. The proportion of fish that was high vs low in n-3 fatty acids (data not shown) was also examined. Of all fish consumed, 25% were high in these fatty acids and 75% were low. Chicken and chicken mixed dishes constituted 72% of the poultry consumed, not counting the chicken in cold cuts, soups and Mexican mixed dishes. Eggs and eggbased mixtures constituted 83% of the eggs consumed; beans reported separately provided 73% of the legumes, and nuts/seeds reported separately and nut/seed mixed dishes (mainly peanut butter sandwiches) provided 76% of the nuts and seeds. Milk and Cheese. Milk servings were primarily reported as fluid milk consumed as a beverage, with reduced-fat milk
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 Rank
Food item
Contribution to intake a
1 2 3 4 5 6 7 8 9 10 1 2 3 4 1 2 3 4 5 6 1 2 3 4 5 6 7 8 1 2 3 4 5 1 2 3 4 5 6 7 1 2 3 4 5 6
Whole fruit Apples and pears Bananas Melon Other fruit and fruit salad Citrus fruits Grapes Peaches/plums/apricots/nectarines Grain-based desserts Dried fruit Strawberries Fruit juiceb 100% orange/grapefruit juice 100% fruit juice, not orange/grapefruit Fruit drinks Peaches/plums/apricots/nectarines Dark green vegetablesc Broccoli Lettuce Spinach Vegetable medleys and other vegetables Chicken and chicken mixed dishes Soups Orange vegetablesd Carrots Sweet potatoes Vegetable medleys and other vegetables Soups Chicken and chicken mixed dishes Beef and beef mixed dishes Vegetable juice Grain-based desserts Legumese Beans Mexican mixed dishes Rice and rice mixed dishes Chili Soups Starchy vegetablesf Other white potatoes Fried white potatoes Potato/corn/other chips Corn Soups Peas Beef and beef mixed dishes Other vegetablesg Lettuce Vegetable medleys and other vegetables Condiments Tomatoes Pizza Pasta and pasta dishes
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 26.0 26.0 19.0 45.1 14.9 59.9 8.1 68.0 7.1 75.1 5.8 80.9 5.4 86.3 3.3 89.6 2.6 92.2 2.4 94.6 50.1 29.3 13.6 2.1
50.1 79.4 93.0 95.1
35.7 25.2 25.0 3.0 2.8 2.2
35.7 60.9 85.8 88.8 91.6 93.8
50.4 9.0 8.9 8.5 5.2 4.6 4.0 2.3
50.4 59.4 68.3 76.8 82.0 86.6 90.6 92.9
73.0 8.7 6.4 6.3 4.2
73.0 81.7 88.2 94.5 98.6
30.4 26.6 15.9 8.4 6.7 3.2 2.9
30.4 57.0 72.9 81.3 88.0 91.3 94.2
13.1 9.2 9.0 8.9 8.9 7.0
13.1 22.3 31.3 40.2 49.0 56.1 (continued)
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 (continued) Rank
Food item
Contribution to intake g
7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 1 2 3 4 5 6 1 2
Other vegetables Soups Tomato sauces String beans Other cruciferous Beef and beef mixed dishes Mexican mixed dishes Burgers Rice and rice mixed dishes Chicken and chicken mixed dishes Onions Chili Whole grainsh Ready-to-eat cereals Yeast breads Hot cereal Popcorn Crackers Grain-based desserts Pancakes/waffles/French toast Rice and rice mixed dishes Nonwhole grainsi Yeast breads Grain-based desserts Pizza Pasta and pasta dishes Mexican mixed dishes Rice and rice mixed dishes Potato/corn/other chips Chicken and chicken mixed dishes Quickbreads Burgers Crackers Ready-to-eat cereals Pretzels Meatj Beef and beef mixed dishes Burgers Sausage, franks, bacon, and ribs Pork and pork mixed dishes Cold cuts Mexican mixed dishes Pasta and pasta dishes Poultryk Chicken and chicken mixed dishes Cold cuts Turkey and turkey mixed dishes Sausage, franks, bacon, and ribs Soups Mexican mixed dishes Fishl Other fish and fish mixed dishes Tuna and tuna mixed dishes
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 4.2 60.3 4.2 64.4 4.0 68.5 3.7 72.2 3.3 75.5 2.9 78.4 2.8 81.2 2.6 83.8 2.4 86.2 2.2 88.4 2.2 90.5 28.7 25.3 13.7 12.4 6.4 3.5 2.9 2.8
28.7 54.0 67.7 80.1 86.5 90.1 93.0 95.8
26.4 9.7 9.2 7.7 7.5 5.3 4.5 3.9 3.6 3.4 3.1 3.0 2.0
26.4 36.2 45.4 53.1 60.6 65.9 70.4 74.3 77.9 81.4 84.5 87.4 89.5
28.6 17.4 14.3 12.2 11.6 4.0 2.2
28.6 46.0 60.3 72.5 84.1 88.1 90.3
72.0 10.1 4.9 3.0 2.9 2.0
72.0 82.1 87.0 90.1 93.0 95.0
62.4 17.3
62.4 79.7 (continued)
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 (continued) Rank
Food item l
3 4 5 1 2 3 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 5 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4
Fish Shrimp and shrimp mixed dishes Soups Pasta and pasta dishes Eggsm Eggs and egg mixed dishes Rice and rice mixed dishes Pasta and pasta dishes Soyn Tofu and meat substitutes Milk substitute and evaporated milk Pasta and pasta dishes Grain-based desserts Soups Meal replacements Nuts/seeds and nut/seed mixed dishes Nuts and seedso Nuts/seeds and nut/seed mixed dishes Candy Grain-based desserts Ready-to-eat cereals Milkp Reduced-fat milk Whole milk Skim milk Dairy desserts Meal replacements Cheeseq Regular cheese Pizza Mexican mixed dishes Reduced-fat cheese Pasta and pasta dishes Burgers Eggs and egg mixed dishes Oilsrs Potato/corn/other chips Salad dressing Nuts/seeds and nut/seed mixed dishes Chicken and chicken mixed dishes Mayonnaise Candy Yeast breads Margarine Grain-based desserts Burgers Popcorn Pasta and pasta dishes Fried white potatoes Solid fatst Grain-based desserts Regular cheese Sausage, franks, bacon, and ribs Pizza
Contribution to intake
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 14.5 94.2 2.3 96.5 2.1 98.6 82.6 2.5 2.1
82.6 85.0 87.2
59.0 14.7 5.5 4.8 3.8 3.5 2.8
59.0 73.7 79.2 84.1 87.9 91.4 94.2
75.9 9.4 5.8 2.1
75.9 85.3 91.1 93.2
39.5 26.1 15.9 7.9 2.0
39.5 65.6 81.5 89.4 91.3
44.0 21.1 8.5 7.9 7.2 3.6 2.5
44.0 65.1 73.6 81.6 88.8 92.4 94.9
16.3 13.0 10.2 7.5 6.5 4.6 4.5 3.8 3.1 3.0 2.7 2.3 2.1
16.3 29.4 39.5 47.0 53.5 58.2 62.7 66.5 69.6 72.6 75.2 77.5 79.6
10.9 7.7 7.1 5.9
10.9 18.7 25.8 31.7 (continued)
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 (continued) Rank
Food item t
5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Solid fats Fried white potatoes Dairy desserts Whole milk Mexican mixed dishes Pasta and pasta dishes Burgers Chicken and chicken mixed dishes Eggs and egg mixed dishes Reduced-fat milk Beef and beef mixed dishes Added sugarsu Soda Grain-based desserts Fruit drinks Dairy desserts Candy Ready-to-eat cereals Sugars/honey Tea Syrups/toppings Yeast breads
Contribution to intake
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 5.5 37.2 5.1 42.4 4.6 46.9 4.4 51.3 4.2 55.6 4.1 59.7 4.0 63.7 3.9 67.6 3.6 71.1 2.6 73.7 36.6 11.7 11.5 6.4 6.2 4.0 3.9 3.2 2.7 2.0
36.6 48.3 59.8 66.3 72.5 76.5 80.3 83.5 86.2 88.1
a
Specific food contributing at least 1% of whole fruit: avocado. There are no additional specific foods contributing at least 1% of fruit juice. c Specific foods contributing at least 1% to dark green vegetables in descending order: vegetable mixed dishes, pasta and pasta dishes, beef and beef mixed dishes. d Specific foods contributing at least 1% to orange vegetables in descending order: vegetable mixed dishes, coleslaw, frozen meals. e Specific foods contributing at least 1% to legumes in descending order: tofu and meat substitutes. f Specific foods contributing at least 1% to starchy vegetables in descending order: vegetable medley and other vegetables, chicken and chicken mixed dishes. g Specific foods contributing at least 1% of other vegetables in descending order: coleslaw, vegetable mixed dishes, vegetable juice. h There are no additional specific foods contributing at least 1% of whole grains. i Specific foods contributing at least 1% of nonwhole grains in descending order: pancakes/waffles/French toast, soups, beef and beef mixed dishes. j Specific foods contributing at least 1% of meat in descending order: 0ther meat and meat mixed dishes, pizza, chili, and soups. k Specific foods contributing at least 1% of total poultry in descending order: beef and beef mixed dishes. l There are no additional specific foods contributing at least 1% of fish. m Specific foods contributing at least 1% of eggs in descending order: pancakes/waffles/French toast, other fish and fish mixed dishes, chicken and chicken mixed dishes. n Specific food contributing at least 1% of soy: reduced-fat cheese. o Specific foods contributing at least 1% of nuts and seeds in descending order: other fruit and fruit salad, crackers. p Specific foods containing at least 1% of milk in descending order: pasta and pasta dishes, candy, eggs and egg mixed dishes, soups. q There are no additional specific foods contributing at least 1% of cheese. r Includes nonhydrogenated vegetable oils and fatty portions of fish, nuts, and seeds. s Specific foods contributing at least 1% of oils in descending order: tuna and tuna mixed dishes, oils, rice and rice mixed dishes, coleslaw, pizza, condiments, other white potatoes, eggs and egg mixed dishes. t Specific foods contributing at least 1% of solid fats in descending order: butter, quickbreads, crackers, yeast breads, soups, candy, beans, other white potatoes, other fish and fish mixed dishes, and cold cuts. u Specific food contributing at least 1% of added sugars: yogurt. NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation. b
supplying 40%, whole milk 26%, and skim milk 16%. Cheese reported separately represented more than half the cheese consumed, with regular cheese contributing 44% and reduced-fat cheese another 8%. Other major contributors of Cheese were pizza (21%), Mexican mixed dishes (8%), and pasta and pasta dishes (7%). Oils. The list of food sources of oils was relatively long, with more than 20 specific foods contributing at least 1% of intake. The major suppliers were potato chips (16%),
salad dressing (13%), nuts/seeds and nut/seed mixed dishes (10%), chicken and chicken mixed dishes (8%), and mayonnaise (6%). Solid Fats and Added Sugars. Solid fats were derived from a long list of specific foods, as well. Major contributors included grain-based desserts (11%); regular cheese (8%); sausage, franks, bacon, and ribs (7%); pizza (6%); fried white potatoes (6%); dairy desserts (5%); and whole milk (5%). Added sugars, on the other hand, were concentrated in
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fewer specific foods. Beverages comprised more than half of these, with sweetened carbonated beverages providing 37%, fruit drinks 11%, and tea 3%. Other substantial contributors included grain-based desserts (12%), dairy desserts, and candy (6% each). DISCUSSION This research builds on previous research by providing results from more recent data, across a range of food groups. It highlights key foods in the American diet that contribute both to food groups that are encouraged and those that are meant to be curtailed. A limitation of the study is that some foods were grouped together for ease of presentation that would have been of interest to examine separately. These include 1% and 2% milks, and apples and pears. Furthermore, these data are subject to the same vagaries and issues of measurement error as all self-reported dietary data, such as random error associated with writing or processing mistakes or systematic error associated with under- or overreporting by certain population groups (11). This study follows a methodology used in numerous studies examining food sources of nutrients (8,9,12-22) but applies it to investigate the food sources of guidancebased food groups. Researchers at USDA conducted similar analyses looking at a range of food groups, but given the objective to evaluate the MyPyramid patterns, the food groupings used were more commoditybased, whereas ours were more as-purchased or asconsumed (23). In addition, USDA considered only the leanest forms of various foods and did not present sources of milk, eggs, oils, solid fats, or added sugars (24). Other investigators have examined food sources of individual food groups. Cleveland and colleagues (25) examined the food sources of whole grains among adults, using data from the 1994-1996 Continuing Survey of Food Intakes by Individuals, and Harnack and colleagues (26) using the same data, conducted a similar analysis among children and adolescents. According to these investigators, the proportion of all grains consumed as whole grains were 15% and 14%, respectively, in the mid-1990s. This analysis suggested that the proportion was only 10% in 2001-2002, but at least some of that difference may be due to methodologic discrepancies. The current MPED does not consider the corn in corn chips to be a whole grain, as did the Pyramid Servings Database that the other authors used. Still, other analyses, using only the Pyramid Servings Database and covering the same time period suggest that the proportion of grains eaten as whole has declined slightly: average intake of total grains for all persons aged 2 years and older remained at 6.8 servings between 1994-1996 and 19992002, whereas average intake of whole grains decreased from one serving to 0.8 servings (27,28). Methodologic discrepancies could account for differences in sources of whole grains, as well. Using the Pyramid Servings Database, Cleveland and colleagues (25) and Harnack and colleagues (26) estimated that, in 1994-1996, breakfast cereals provided 30% and 38% of the whole grains consumed among adults (25) and youth (26), respectively. It was estimated that breakfast cereal contributed 43% of the whole grains among the total population using the
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MPED, but only 34% using the Pyramid Servings Database (for 1999-2002, data not shown). Guthrie and colleagues (29), also using the 1994-1996 Continuing Survey of Intakes by Individuals data, analyzed food sources of added sweeteners (comparable to what are called added sugars in our research). They reported that beverages accounted for 46% of the added sweeteners, with 33% of added sugars coming from sweetened carbonated drinks and 10% coming from fruit-based drinks. We found more than half of the added sugars (51%) were derived from beverages in 2001-2002, including a more substantial contribution from sweetened carbonated beverages (37%). Because the methodology and databases are similar between the two studies, differences in our results probably reflect real differences. Consumption of added sugars was estimated to have increased 14.5% between 1994-1996 and 1999-2002 (27,28). The 2005 Dietary Guidelines and MyPyramid demonstrate that, even when the most nutrient-dense forms of each food group are selected, only a very small amount of discretionary calories can be consumed to stay within energy limits. Our research makes clear that Americans do not, in general, consume the most nutrient-dense forms of basic food groups, instead consuming large amounts of foods that are high in solid fats and added sugars. For example, reduced-fat milk (not skim), whole milk, and regular cheese are major sources of the milk group and are also top sources of solid fat. In addition, burgers and sausage, franks, bacon, and ribs were major contributors to the intakes of both the meat group and solid fats. These patterns of eating make it difficult to stay within energy guidelines while achieving nutrient adequacy. Furthermore, within some basic food groups, more targeted choices could be made. The vegetable group includes a wide range of items of varying nutrient content, yet only two vegetables—white potatoes and tomatoes— account for 46% of the servings from that group. About half of all white potatoes in 2001-2002 were consumed as either fried potatoes or potato chips. A similar finding for 1994-1996 had been reported before (30), suggesting potatoes continue to be consumed in high-energy-dense ways and displace other important vegetable subgroups such as dark green vegetables, orange vegetables, and legumes. A low proportion of grains consumed as whole grains was anticipated, but due to modifications in the Pyramid Servings Database, these results are even more alarming. Stated another way, nonwhole grains are too high a proportion of total grains. Yeast breads are the major contributor of grains, and substituting whole-grain yeast breads for their nonwhole grain counterparts would go a long way toward remedying this situation. However, that change alone would not be sufficient to bring intakes into compliance with current guidance. Grain-based desserts—which, unlike yeast breads, contribute substantial added sugars and solid fat— constitute a full 10% of nonwhole grains and would need to be substantially reduced. Popcorn’s contribution to overall whole-grain intake may seem quite high, but it may be primarily a reflection of how minimal whole-grain intake is. The 2005 Dietary Guidelines recommend that consumers obtain most of their fats from “sources of polyunsaturated and monounsaturated fatty acids, such as fish,
nuts, and vegetable oils.” This study did not estimate the proportion of total fat derived from these sources, but it is of interest that only a fraction of the fish consumed is high in n-3 fatty acids. The top source of oils, according to our study, was potato/corn/other chips. Although the oil in chips may not be high in trans-fatty acids (31), chips are typically high in energy and salt, and a small serving could exhaust an entire day’s discretionary calorie allowance. One unique feature of our study was the derivation of a variable—meat—to capture what are commonly referred to as red meats. The meat variable includes all beef, pork, and other meats, as well as sausages and cold cuts made from them, and excludes all poultry and fish. Red meat consumption has been implicated as a potential risk factor for some chronic diseases (32-34), so this metric may prove useful in other studies as well. Data summarized in the 2005 Dietary Guidelines suggest that most of the solid fats and added sugars would need to be eliminated from Americans’ diets for diets to be in compliance with the Dietary Guidelines (4). Results of this study implicate the major contributors to these highenergy-dense foods are sweetened carbonated and other sweetened beverages, grain-based desserts, nonskim dairy products, and fatty meats. Although these have been noted even in the popular press for some time, this study provides much needed quantified evidence regarding the degree to which these types of foods contribute to dietary imbalances. CONCLUSIONS The discrepancy between actual and recommended consumption is due to many factors. These include individual-level behaviors, such as lack of consumer awareness of foods associated with beneficial health outcomes and the difficulties related to changing shopping and consumption patterns, as well as system-level factors related to the food environment. System-level factors include the increase in prevalence of eating away from home, the higher energy and fat content of foods consumed away from home, the higher costs of more healthful options, the proportion of less healthful compared to more healthful options, the overall increase in per capita energy available in the food supply, expanding portion sizes, as well as differences in the advertising, pricing, and promotion of healthful foods compared to their less healthful counterparts in the media (35-40). Both individualized nutrition interventions as well as environmental and policy interventions are needed to influence US consumption patterns (35-40). According to these findings, food and nutrition professionals would do well to educate individuals about appropriate choices within food groups rather than focusing on achieving a certain number of servings from each food group. The intricate balance between intake of discretionary calories—from solid fat and added sugars—and intake of food group foods is particularly important to highlight, especially because it appears to be difficult to achieve in the existing food environment. Food and nutrition professionals can also advocate for a food environment that provides health information, increases the availability of healthful foods, uses pricing strategies, and implements incentive programs to influence food choices.
The authors thank Lisa Kahle for expert programming. References 1. MyPyramid. US Department of Agriculture Web site. www. mypyramid.gov. Accessed September 25, 2007. 2. Krebs-Smith SM, Kris-Etherton P. How does MyPyramid compare to other population-based recommendations for controlling chronic disease? J Am Diet Assoc. 2007;107:830-837. 3. Buzby J, Wells HF, Vocke G. Possible implications for US agriculture from adaptation of select dietary guidelines. US Department of Agriculture, Economic Research Service Web site. http://www.ers.usda.gov/ Publications/ERR31/. Accessed February 19, 2008. 4. US Departments of Agriculture and Health and Human Services. Dietary Guidelines for Americans 2005. US Department of Health and Human Services Web site. http://www.healthierus.gov/ dietaryguidelines. Accessed September 25, 2007. 5. Guenther PM, Dodd KW, Reedy J, Krebs-Smith SM. Most Americans eat much less than recommended amounts of fruits and vegetables. J Am Diet Assoc. 2006;106:1371-1379. 6. Basiotis P, Guenther PM, Lino M, Britten P. Americans consume too many calories from solid fat, alcohol, and added sugars. US Dept of Agriculture Center for Nutrition Policy and Promotion Web site. http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight33. pdf. Accessed February 19, 2008. 7. Dietary interview, NHANES 2001-2002. Centers for Disease Control and Prevention, National Center for Health Statistics Web site. http:// www.cdc.gov/nchs/about/major/nhanes/nhanes01-02.htm. Accessed September 25, 2007. 8. Cotton PA, Subar AF, Friday JE, Cook A. Dietary sources of nutrients among US adults, 1994 to 1996. J Am Diet Assoc. 2004;104:921-930. 9. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US adults, 1989 to 1991. J Am Diet Assoc. 1998;98: 537-547. 10. Krebs-Smith SM, Kott PS, Guenther PM. Mean proportion and population proportion: Two answers to the same question? J Am Diet Assoc. 1989;89:671-676. 11. Trabulsi J, Schoeller DA. Evaluation of dietary assessment instruments against doubly labeled water, a biomarker of habitual energy intake. Am J Physiol Endocrinol Metab. 2001;281:E891-E899. 12. Krebs-Smith SM, Cronin FJ, Haytowitz DB, Cook DA. Food sources of energy, macronutrients, cholesterol, and fiber in diets of women. J Am Diet Assoc. 1992;92:168-174. 13. Thompson FE, Sowers MF, Frongillo EA Jr, Parpia BJ. Sources of fiber and fat in diets of US women aged 19 to 50: Implications for nutrition education and policy. Am J Public Health. 1992;82:695-702. 14. Fox MK, Reidy K, Novak T, Ziegler P. Sources of energy and nutrients in the diets of infants and toddlers. J Am Diet Assoc. 2006;106(suppl 1):S28-S42. 15. Stroehla BC, Malcoe LH, Velie EM. Dietary sources of nutrients among rural Native American and white children. J Am Diet Assoc. 2005;105:1908-1916. 16. Subar AF, Block G, James LD. Folate intake and food sources in the US population. Am J Clin Nutr. 1989;50:508-516. 17. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in food locations and sources among adolescents and young adults. Prev Med. 2002;35:107113. 18. Gordon AR, McKinney P. Sources of nutrients in students’ diets. Am J Clin Nutr. 1995;61(suppl):232S-240S. 19. Ma J, Betts NM. Zinc and copper intakes and their major food sources for older adults in the 1994-96 continuing survey of food intakes by individuals (CSFII). J Nutr. 2000;130:2838-2843. 20. Kant AK, Block G. Dietary vitamin B-6 intake and food sources in the US population: NHANES II, 1976-1980. Am J Clin Nutr. 1990;52:707716. 21. Murphy SP, Subar AF, Block G. Vitamin E intakes and sources in the United States. Am J Clin Nutr. 1990;52:361-367. 22. Block G, Norris JC, Mandel RM, DiSogra C. Sources of energy and six nutrients in diets of low-income Hispanic-American women and their children: Quantitative data from HHANES, 1982-1984. J Am Diet Assoc. 1995;95:195-208. 23. Britten P, Marcoe K, Yamini S, Davis C. Development of food intake patterns for the MyPyramid food guidance system. J Nutr Educ Behav. 2006;38(suppl):S78-S92. 24. Marcoe K, Juan W, Yamini S, Carlson A, Britten P. Development of food group composites and nutrient profiles for the MyPyramid food guidance system. J Nutr Educ Behav. 2006;38(suppl 2):S93-S107.
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25. Cleveland LE, Moshfegh AJ, Albertson AM, Goldman JD. Dietary intake of whole grains. J Am Coll Nutr. 2000;19(suppl):331S-338S. 26. Harnack L, Walters SA, Jacobs DR Jr. Dietary intake and food sources of whole grains among US children and adolescents: Data from the 1994-1996 Continuing Survey of Food Intakes by Individuals. J Am Diet Assoc. 2003;103:1015-1019. 27. Cook A, Friday J. CNRG Table Set 3.0: Pyramid servings intakes in the United States, 1999-2002, 1 day. US Department of Agriculture, Agricultural Research Service Web site. http://www.ars.usda.gov/ Services/docs.htm?docid⫽8503. Accessed September 25, 2007. 28. Cook A, Friday J. CNRG Table Set 1.1: Pyramid servings intakes in the United States, 1994-96, 1998, 2 day. US Department of Agriculture, Agricultural Research Service Web site. http://www.ars.usda. gov/Services/docs.htm?docid⫽8503. Accessed September 25, 2007. 29. Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc. 2000;100:43-51. 30. Krebs-Smith SM. Progress in improving diet to reduce cancer risk. Cancer. 1998;83:1425-1432. 31. Cho E, Chen WY, Hunter DJ, Stampfer MJ, Colditz GA, Hankinson SE, Willett WC. Red meat intake and risk of breast cancer among premenopausal women. Arch Intern Med. 2006;166:2253-2259. 32. Fung TT, Schulze M, Manson JE, Willett WC, Hu FB. Dietary pat-
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33. 34. 35. 36. 37. 38. 39. 40.
terns, meat intake, and the risk of type 2 diabetes in women. Arch Intern Med. 2004;164:2235-2240. Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. Diet, nutrition, and the prevention of cancer. Public Health Nutr. 2004;7:187-200. Kantor LS, Variyam JN, Allshouse JE, Putnam JJ, Lin BH. Choose a variety of grains daily, especially whole grains: A challenge for consumers. J Nutr. 2001;131(suppl):473S-486S. Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Prev Chronic Dis. 2006;3:A76. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health. 2001;22:309-335. Egger G. Swinburn B. An “ecological” approach to the obesity pandemic. BMJ. 1997;315:477-480. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: A review. Prev Med. 2004;39(suppl 2):S108-S136. Young LR. Nestle M. Expanding portion sizes in the US marketplace: Implications for nutrition counseling. J Am Diet Assoc. 2003;103:231-234. Jeffery RW, Utter J. The changing environment and population obesity in the United States. Obes Res. 2003;11(suppl):12S-22S.
Sources of Food Group Intakes among the US Population, 2001-2002 JESSICA L. BACHMAN, MS, MPH, RD; JILL REEDY, PhD, MPH, RD; AMY F. SUBAR, PhD, MPH, RD; SUSAN M. KREBS-SMITH, PhD, MPH, RD
ABSTRACT Background Food guides are typically built around a system of food groups. Accordingly, the US Department of Agriculture’s MyPyramid includes both food groups and subgroups, as well as an allowance for discretionary calories, in its guidance. Objective To identify the major dietary contributors to food group intake in the US population. Methods This cross-sectional study used 2001-2002 National Health and Nutrition Examination Survey data to determine weighted population proportions for the contribution of each subgroup to its MyPyramid food group (ie, proportion), and the contribution of specific foods to the subgroups oils, solid fats, and added sugars (ie, major contributors). Food codes associated with each food were sorted into 96 categories, termed specific foods, and were linked to the MyPyramid Equivalents Database to obtain food group equivalents. Results In regard to proportion, dark green vegetables (6%), orange vegetables (5%), and legumes (6%) fell well short of recommended levels. Intake of whole grains (10% of total) was far below the recommendation that at least half of all grains be whole. In regard to major contributors, top sources of oils were potato chips, salad dressing, and nuts/seeds; major contributors of solid fats were grain-based desserts, cheese, and sausages. Sweetened carbonated beverages provided 37% of added sugars. Conclusions Americans do not, in general, consume the most nutrient-dense forms of basic food groups, instead consuming foods that are high in solid fats and added J. L. Bachman is a graduate student, Department of Nutrition, The University of Tennessee, Knoxville. J. Reedy and A. F. Subar are nutritionists and S. M. KrebsSmith is chief, Risk Factor Monitoring and Methods Branch, Applied Research Program, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD. Address correspondence to: Jill Reedy, PhD, MPH, RD, Risk Factor Monitoring and Methods Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, MSC 7344, EPN 4005, Bethesda, MD 20892-7344. E-mail: [email protected] Manuscript accepted: October 22, 2007. Copyright © 2008 by the American Dietetic Association. 0002-8223/08/10805-0008$34.00/0 doi: 10.1016/j.jada.2008.02.026
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sugars. The main culprits—the foods that contribute most to discrepancies between recommendations and actual intake—are sweetened carbonated beverages and other sweetened beverages, grain-based desserts, nonskim dairy products, and fatty meats. J Am Diet Assoc. 2008;108:804-814.
I
n 2005, the US Department of Agriculture (USDA) released MyPyramid (1), a food guide aimed at the general population and designed to provide nutrient adequacy while limiting commonly overconsumed foods, such as those containing solid fats (ie, saturated and trans-fatty acids) and added sugars (ie, energy-containing sweeteners). Using 12 patterns at varying energy levels, it recommends amounts of different food groups— grains, vegetables, fruit, milk, meat and beans, and oils (eg, nonhydrogenated vegetable oils and oils in fish, nuts, and seeds)—for individuals to consume, depending on their age, sex, and activity level. It also allows an additional small amount of calories beyond those coming from the food groups, referred to as “discretionary calories.” This energy may come from intake of solid fat, added sugar, alcohol, or additional food group foods. The MyPyramid food intake recommendations are in accordance with those from a number of other health-related organizations, including the American Heart Association’s guidelines for “making healthy food and lifestyle choices,” the National Heart, Lung, and Blood Institute’s Dietary Approaches to Stop Hypertension Eating Plan, and the American Dietetic Association’s and American Diabetes Association’s Exchange List for Meal Planning (2). Data presented in the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines) and elsewhere make clear that the population is not following current dietary advice (3-6). In particular, Americans need to eat more fruits, vegetables, and fat-free milk, and much less solid fats and added sugars. At the same time, they need to change the types of vegetables and grains they consume to include more dark green vegetables, orange vegetables, legumes, and whole grains. What is not clear is which foods contribute most to the discrepancies between recommendations and actual intake. The purpose of this research was to examine the ways in which Americans are actually consuming foods and beverages from the MyPyramid food groups and the subgroups oils, solid fats, and added sugars. Our intent was to examine the actual source of servings from these food groups to better understand current intake compared to recommendations and to provide context for necessary changes in the food environment and
© 2008 by the American Dietetic Association
crafting nutrition education messages about individual food groups. METHODS The source of dietary intake data for this study was the 2001-2002 National Health and Nutrition Examination Survey (NHANES) (7). NHANES used a nationally representative, complex multistage, stratified probability sample. It included oversampling of persons with low income, individuals aged 12 to 19 years and older than age 60 years, African Americans, and Mexican Americans. Trained interviewers conducted in-person 24-hour dietary recalls with all eligible persons, using automated data collection systems that included multiple passes. Dietary data included detailed descriptions of all food and quantities eaten. In 2002, a second 24-hour recall was obtained from respondents via telephone, but only the Day 1 recalls are included in this analysis for several reasons: a single day’s recall is sufficient for group mean usual intake estimation, Day 1 recalls are generally considered to be more valid than subsequent recalls because of the possibility of interviewer fatigue, and reweighting is not necessary if all respondents have the same number of recalls. This cross-sectional analysis includes all persons aged 2 years and older with dietary recalls deemed reliable by the data developers (n⫽9,033). To adjust for differential probabilities of selection and various sources of nonresponse, appropriate weighting factors were applied. These factors allow inference to the total civilian, noninstitutionalized US population. Further information regarding the design of the 2001-2002 NHANES, including sampling and weighting procedures can be found elsewhere (7). The dietary intake data collected in the survey were catalogued according to 4,069 discrete food codes. For this analysis, food codes representing similar foods—for example the various types of pasta dishes such as ziti, manicotti, and lasagna—were combined to provide an indication of the contribution of distinct food items to the intake of the MyPyramid groups being studied. That is, the 4,069 codes were sorted into 96 mutually exclusive food categories, which are hereafter referred to as specific foods to distinguish them from the food groups used in guidance. The list of specific foods (see the Figure) was adapted from a previous project (8,9). The foods reported in the survey were also the source of data for servings from the MyPyramid groups/subgroups. The MyPyramid food groups are measured in cups, ounces, cup or ounce equivalents, or teaspoons; for the purposes of this analysis, all these units of measure are referred to collectively as servings. The 4,069 food codes were linked to USDA’s MyPyramid Equivalents Database (MPED) (version 1.0, 2006, http://www.ars.usda.gov/research/ publications/publications.htm?seq_no_115⫽201058) to obtain the number of servings of each MyPyramid group and subgroup corresponding to the amount of each food reported. The MPED incorporates data from a recipe file, which disaggregates all foods reported in the survey to individual ingredients, and assigns those ingredients to MyPyramid groupings. For example, yogurt with fruit is separated into yogurt, fruit, and sweetener in the recipe
file and assigned corresponding cup equivalents of milk, grams of solid fat, cups of fruit, and teaspoons of added sugar, respectively, in the MPED. The MPED was used to assess all the MyPyramid food groups, including grains (with subgroups whole grains and nonwhole/refined grains), vegetables (with subgroups dark green vegetables, orange vegetables, legumes, starchy vegetables, and other vegetables), fruit, milk, meat and beans, and oils. For the purposes of this analysis, discretionary calories were considered to include only solid fat, added sugars and alcohol, all of which are accounted for in the MPED. The MPED includes data on other groups of foods that are not specifically mentioned in MyPyramid, but were still of interest and so included in this analysis, including tomatoes, potatoes, meat, poultry, fish, eggs, soy, nuts and seeds, fluid milk, yogurt, and cheese. Because the meat and poultry groups are not complete in the MPED, the servings from the two groups defined as “organ meats” and “frankfurters, sausage, luncheon meats” were reassigned to meat and/or poultry based on descriptions and amounts in the recipe files. Similarly, because Americans are encouraged to get most of their fruit from whole fruits rather than juice (4), the fruit group was further categorized into whole fruits and juices. The contribution of each subgroup to its respective MyPyramid food group (ie, proportion) was examined as well as the contribution of specific foods to each of the subgroups, and to oils, solid fats and added sugars (ie, major contributors). The contribution of each food (as subgroup or specific food) to the intake of each group/ subgroup was obtained by summing the number of servings provided by the food for all individuals and dividing by the total intake of that group/subgroup from all foods for all individuals. Thus, the weighted percentage contribution is given by n
兺 (F · w ) * 100 兺 (T · w ) i
i
i
i
i⫽1 n
i⫽1
Where n ⫽ the sample size, Fi ⫽ the number of servings contributed by the particular food for the ith individual, Ti ⫽ the total number of servings from all foods for the ith individual, and wi ⫽ the sample weight for the ith individual. This formula provides the percentage contributed by each food to the population’s total consumption of each group. The results differ from those that would be obtained if a mean proportion, rather than a population proportion, were used (10). Legumes (comprised of dried beans and peas, but not including peanuts) can be included in either the vegetable or meat and beans groups of MyPyramid; therefore, their contribution to the total intake of both groups was examined. RESULTS Distribution of Subgroups within MyPyramid Food Groups (Proportion) The distribution of servings among subgroups within each of the MyPyramid food groups is shown in Table 1, along with the recommended distribution, where applicable.
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Beverages Whole milk Reduced-fat milk Skim milk Vegetable juice 100% fruit juice, not orange/grapefruit juice 100% orange/grapefruit juice Fruit drinks Soda Milk substitute and evaporated milk Alcoholic beverages Coffee Tea Bakery/breads Hot cereal Pancakes/waffles/French toast Quickbreads Ready-to-eat cereals Grain-based dessertsa Yeast breads Dressings, spreads, other additionsb Butterc Cream Margarinec Mayonnaise Miscellaneous solid fats Nondairy creamer/cream substitutes Oilsc Salad dressing Sauces Sour cream Condiments Gelatins Jams and jelly Sugars/honey Syrups/toppings
Produce Broccoli Carrots Coleslaw Corn Fried white potatoes Lettuce Onions Other cruciferous Other white potatoes Peas Spinach String beans Sweet potatoes Tomatoes Tomato sauces Vegetable medleys and other vegetables Vegetable mixed dishes Apples and pears Avocado Bananas Citrus fruits Dried fruit Grapes Melon Peaches/plums/apricots/nectarines Strawberries Other fruit and fruit salad Snacks Potato/corn/other chipsd Popcorn Pretzels Nuts/seeds and nut/seed mixed dishes Candy Crackers
Entrees Chili Mexican mixed dishes Pizza Soups Meal replacements Pasta and pasta dishes Rice and rice mixed dishes Egg rolls Refrigerator/frozen Yogurt Cottage/ricotta/cream cheese Dairy desserts Frozen meals Deli Regular cheese Reduced-fat cheese Dried beans Burgers Cold cuts Eggs and egg mixed dishese Tuna and tuna mixed dishes Shrimp and shrimp mixed dishes Other fish and fish mixed dishes Liver and other organ meats Beef and beef mixed dishes Chicken and chicken mixed dishes Duck and duck mixed dishes Other meat and meat mixed dishes Pork and pork mixed dishes Turkey and turkey mixed dishes Sausage, franks, bacon, and ribs Tofu and meat substitutes
a
Includes cakes, cookies, donuts, pies, crisps, cobblers, and granola bars. Includes low-fat items such as low-fat salad dressings, cream cheese, and sour cream. c Butter, margarines, and oils do not include those used in yeast breads, grain-based desserts, quickbreads, pancakes/waffles/French toast, dairy desserts, salad dressing, mayonnaise, pasta and pasta mixed dishes, Mexican mixed dishes, ready-to-eat cereal, crackers, pretzels, potato/corn/other chips, or candy. d Includes low-fat versions. e Excludes eggs found in grain-based desserts, pancakes/waffles/french toast, yeast breads, quickbreads, dairy desserts, egg rolls, and pasta and pasta mixed dishes. b
Figure. List of specific foods used to provide an indication of the contribution of distinct food items to the intake of select MyPyramid groups. Specific foods listed are the result grouping like foods reported in the 2001-2002 National Health and Nutrition Examination Survey.
Slightly more than half of the fruit group servings were from whole (non-juice) fruit, a distribution that is consistent with recommendations in the 2005 Dietary Guidelines (4). Vegetable intakes were derived almost entirely from starchy and other vegetables (83% combined), in large part because potatoes and tomatoes contributed 24% and 22%, respectively (data not shown). Dark green vegetables (6%), orange vegetables (5%), and legumes (6%) fell well short of recommended levels (17%, 11%, and 17%, respectively). Likewise, consumption of whole grains (10% of total grains) was far below the recommendation that half or more of all grain servings come from whole grains. Meat accounted for more than 40% of the servings from
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the meat and beans group, followed by poultry (24%), fish (9%), nuts/seeds (9%), eggs (7%), legumes (7%), and soy (1%). More than 60% of the milk group servings came from fluid milk, about one third from cheese (36%), and the remaining from yogurt (2%). Added sugars (47%) contributed slightly more discretionary calories than solid fat (44%), and only a small amount was derived from alcohol (8%). Distribution of Specific Foods within MyPyramid Food Groups (Major Contributors) The specific foods used in this analysis are listed in the Figure, and findings for the specific food sources of se-
Table 1. Distribution of servings among subgroups within MyPyramid major food groups Food group Fruit Whole fruit Juice Vegetables Dark greenb Orangec Legumesde Starchyf Otherg Grains Whole Nonwhole Meat and beans Meat Poultry Fish Egg Nuts/seeds Legumese Soy Milk Milk Yogurt Cheese Discretionary calories Solid fat Added sugars Alcohol
% Current intake
% Recommendeda
53.5 46.5
ⱖ50 ⱕ50
5.8 4.7 6.5 29.3 53.7
17 11 17 17 37
9.5 90.5
ⱖ50 ⱕ50
43.1 24.4 8.7 7.4 8.4 7.1 0.9
NAh NAh NAh NAh NAh NAh NAh
61.6 2.2 35.7
NAh NAh NAh
44.3 47.3 8.4
NAh NAh NAh
a
From the Dietary Guidelines for Americans 2005 (4). For example broccoli, romaine, and spinach. For example carrots, pumpkin, and sweet potatoes. d For example lentils, cooked dried peas, and beans. e Legumes are included in both the vegetable group and the meat and beans group so that the relative proportion can be determined within both food groups. In the meat and beans group, servings are adjusted as defined in the MyPyramid Equivalents Database so that 1⁄4 c vegetables⫽1 oz equivalent meat and beans. f For example white potatoes, corn, and green peas. g For example tomatoes, onions, and iceburg lettuce. h NA⫽not applicable. No specific recommendations provided. b c
lected subgroups are found in Table 2. Foods are listed in descending order by percentages of their contribution to intake for the group. Table 2 includes all foods that contribute at least 2% of intake from that group, and foods contributing between 1% and 2% are footnoted. Whole Fruit and Fruit Juice. Apples and pears combined represented more than a quarter of the whole fruit consumed, with bananas (including plantains) contributing another 19%. Other major contributors of whole fruit included melon (15%), other fruit and fruit salad (8%), citrus fruits (7%), and grapes (6%). Grain-based desserts such as pies, crisps, and cobblers contributed more than 3% of the whole fruit, representing a high-fat and highsugar means of obtaining fruit. Pure orange and grapefruit juices combined accounted for fully half of the fruit juice consumed. All other kinds
of pure fruit juice contributed just 29% of the fruit juice servings, whereas fruit-flavored drinks, which generally contain a large amount of added sugars, contributed 14%. Vegetable Subgroups. Broccoli reported separately contributed more than one third of the dark green vegetables, and additional broccoli was likely contributed by mixed dishes and soups. Lettuce (including romaine) and spinach reported separately each contributed another 25% of the dark green vegetables. Carrots alone supplied the majority of orange vegetables, with 50% coming from those reported separately and undoubtedly additional contributions from mixed dishes and soups. Sweet potatoes were the only other single vegetable source contributing a sizeable proportion (9%) of orange vegetables. The list of top sources of other vegetables was long, with 20 specific foods contributing at least 1%, but the top five sources—lettuce, vegetable medley and other vegetables, condiments, tomatoes, and pizza— contributed about half of these vegetables. The specific foods that contributed to the intake of potatoes and tomatoes (data not shown) were also examined, because these two vegetables represented such a large proportion of vegetable intake. Five specific foods accounted for virtually all of the potatoes consumed: other white potatoes (37%), fried white potatoes (32%), potato/corn/other chips (19%), soups (6%), and beef and beef mixed dishes (3%). The major sources of tomatoes were tomatoes reported separately (22%), pizza (16%), pasta and pasta mixed dishes (13%), condiments (10%), tomato sauces (10%), and soups (5%). Whole and Nonwhole Grains. Ready-to-eat cereals and hot cereals made up more than 40% of all whole grains consumed. Yeast breads supplied an additional 35%, and popcorn (12%) and crackers (6%) were the next biggest sources. Yeast breads contributed 26% of the nonwhole grains. Grain-based desserts contributed an additional 10%, and pizza, pasta and pasta dishes, and Mexican dishes rounded out the top five sources of nonwhole grains, supplying 8% to 9% each. Meat and Bean Subgroups. Burgers; sausage, franks, bacon, and ribs; and cold cuts together supplied more than half the meat intake. Beef and beef mixed dishes from other sources contributed an additional 29%, and pork and pork mixed dishes provided 12%. Tuna and tuna mixed dishes supplied 17% and shrimp and shrimp mixed dishes supplied 15% of the fish consumed, and all other fish and fish mixed dishes contributed 62%. The proportion of fish that was high vs low in n-3 fatty acids (data not shown) was also examined. Of all fish consumed, 25% were high in these fatty acids and 75% were low. Chicken and chicken mixed dishes constituted 72% of the poultry consumed, not counting the chicken in cold cuts, soups and Mexican mixed dishes. Eggs and eggbased mixtures constituted 83% of the eggs consumed; beans reported separately provided 73% of the legumes, and nuts/seeds reported separately and nut/seed mixed dishes (mainly peanut butter sandwiches) provided 76% of the nuts and seeds. Milk and Cheese. Milk servings were primarily reported as fluid milk consumed as a beverage, with reduced-fat milk
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 Rank
Food item
Contribution to intake a
1 2 3 4 5 6 7 8 9 10 1 2 3 4 1 2 3 4 5 6 1 2 3 4 5 6 7 8 1 2 3 4 5 1 2 3 4 5 6 7 1 2 3 4 5 6
Whole fruit Apples and pears Bananas Melon Other fruit and fruit salad Citrus fruits Grapes Peaches/plums/apricots/nectarines Grain-based desserts Dried fruit Strawberries Fruit juiceb 100% orange/grapefruit juice 100% fruit juice, not orange/grapefruit Fruit drinks Peaches/plums/apricots/nectarines Dark green vegetablesc Broccoli Lettuce Spinach Vegetable medleys and other vegetables Chicken and chicken mixed dishes Soups Orange vegetablesd Carrots Sweet potatoes Vegetable medleys and other vegetables Soups Chicken and chicken mixed dishes Beef and beef mixed dishes Vegetable juice Grain-based desserts Legumese Beans Mexican mixed dishes Rice and rice mixed dishes Chili Soups Starchy vegetablesf Other white potatoes Fried white potatoes Potato/corn/other chips Corn Soups Peas Beef and beef mixed dishes Other vegetablesg Lettuce Vegetable medleys and other vegetables Condiments Tomatoes Pizza Pasta and pasta dishes
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 26.0 26.0 19.0 45.1 14.9 59.9 8.1 68.0 7.1 75.1 5.8 80.9 5.4 86.3 3.3 89.6 2.6 92.2 2.4 94.6 50.1 29.3 13.6 2.1
50.1 79.4 93.0 95.1
35.7 25.2 25.0 3.0 2.8 2.2
35.7 60.9 85.8 88.8 91.6 93.8
50.4 9.0 8.9 8.5 5.2 4.6 4.0 2.3
50.4 59.4 68.3 76.8 82.0 86.6 90.6 92.9
73.0 8.7 6.4 6.3 4.2
73.0 81.7 88.2 94.5 98.6
30.4 26.6 15.9 8.4 6.7 3.2 2.9
30.4 57.0 72.9 81.3 88.0 91.3 94.2
13.1 9.2 9.0 8.9 8.9 7.0
13.1 22.3 31.3 40.2 49.0 56.1 (continued)
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 (continued) Rank
Food item
Contribution to intake g
7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 1 2 3 4 5 6 1 2
Other vegetables Soups Tomato sauces String beans Other cruciferous Beef and beef mixed dishes Mexican mixed dishes Burgers Rice and rice mixed dishes Chicken and chicken mixed dishes Onions Chili Whole grainsh Ready-to-eat cereals Yeast breads Hot cereal Popcorn Crackers Grain-based desserts Pancakes/waffles/French toast Rice and rice mixed dishes Nonwhole grainsi Yeast breads Grain-based desserts Pizza Pasta and pasta dishes Mexican mixed dishes Rice and rice mixed dishes Potato/corn/other chips Chicken and chicken mixed dishes Quickbreads Burgers Crackers Ready-to-eat cereals Pretzels Meatj Beef and beef mixed dishes Burgers Sausage, franks, bacon, and ribs Pork and pork mixed dishes Cold cuts Mexican mixed dishes Pasta and pasta dishes Poultryk Chicken and chicken mixed dishes Cold cuts Turkey and turkey mixed dishes Sausage, franks, bacon, and ribs Soups Mexican mixed dishes Fishl Other fish and fish mixed dishes Tuna and tuna mixed dishes
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 4.2 60.3 4.2 64.4 4.0 68.5 3.7 72.2 3.3 75.5 2.9 78.4 2.8 81.2 2.6 83.8 2.4 86.2 2.2 88.4 2.2 90.5 28.7 25.3 13.7 12.4 6.4 3.5 2.9 2.8
28.7 54.0 67.7 80.1 86.5 90.1 93.0 95.8
26.4 9.7 9.2 7.7 7.5 5.3 4.5 3.9 3.6 3.4 3.1 3.0 2.0
26.4 36.2 45.4 53.1 60.6 65.9 70.4 74.3 77.9 81.4 84.5 87.4 89.5
28.6 17.4 14.3 12.2 11.6 4.0 2.2
28.6 46.0 60.3 72.5 84.1 88.1 90.3
72.0 10.1 4.9 3.0 2.9 2.0
72.0 82.1 87.0 90.1 93.0 95.0
62.4 17.3
62.4 79.7 (continued)
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 (continued) Rank
Food item l
3 4 5 1 2 3 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 5 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4
Fish Shrimp and shrimp mixed dishes Soups Pasta and pasta dishes Eggsm Eggs and egg mixed dishes Rice and rice mixed dishes Pasta and pasta dishes Soyn Tofu and meat substitutes Milk substitute and evaporated milk Pasta and pasta dishes Grain-based desserts Soups Meal replacements Nuts/seeds and nut/seed mixed dishes Nuts and seedso Nuts/seeds and nut/seed mixed dishes Candy Grain-based desserts Ready-to-eat cereals Milkp Reduced-fat milk Whole milk Skim milk Dairy desserts Meal replacements Cheeseq Regular cheese Pizza Mexican mixed dishes Reduced-fat cheese Pasta and pasta dishes Burgers Eggs and egg mixed dishes Oilsrs Potato/corn/other chips Salad dressing Nuts/seeds and nut/seed mixed dishes Chicken and chicken mixed dishes Mayonnaise Candy Yeast breads Margarine Grain-based desserts Burgers Popcorn Pasta and pasta dishes Fried white potatoes Solid fatst Grain-based desserts Regular cheese Sausage, franks, bacon, and ribs Pizza
Contribution to intake
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 14.5 94.2 2.3 96.5 2.1 98.6 82.6 2.5 2.1
82.6 85.0 87.2
59.0 14.7 5.5 4.8 3.8 3.5 2.8
59.0 73.7 79.2 84.1 87.9 91.4 94.2
75.9 9.4 5.8 2.1
75.9 85.3 91.1 93.2
39.5 26.1 15.9 7.9 2.0
39.5 65.6 81.5 89.4 91.3
44.0 21.1 8.5 7.9 7.2 3.6 2.5
44.0 65.1 73.6 81.6 88.8 92.4 94.9
16.3 13.0 10.2 7.5 6.5 4.6 4.5 3.8 3.1 3.0 2.7 2.3 2.1
16.3 29.4 39.5 47.0 53.5 58.2 62.7 66.5 69.6 72.6 75.2 77.5 79.6
10.9 7.7 7.1 5.9
10.9 18.7 25.8 31.7 (continued)
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Table 2. Food sources of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other vegetables, whole grains, nonwhole grains, meat, poultry, fish, eggs, soy, nuts and seeds, milk, cheese, oils, solid fats, and added sugars listed in descending order by percentages of their contribution to intake for the group, based on data from the National Health and Nutrition Examination Survey 2001-2002 (continued) Rank
Food item t
5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Solid fats Fried white potatoes Dairy desserts Whole milk Mexican mixed dishes Pasta and pasta dishes Burgers Chicken and chicken mixed dishes Eggs and egg mixed dishes Reduced-fat milk Beef and beef mixed dishes Added sugarsu Soda Grain-based desserts Fruit drinks Dairy desserts Candy Ready-to-eat cereals Sugars/honey Tea Syrups/toppings Yeast breads
Contribution to intake
Cumulative contribution
4™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™™™™™™™3 5.5 37.2 5.1 42.4 4.6 46.9 4.4 51.3 4.2 55.6 4.1 59.7 4.0 63.7 3.9 67.6 3.6 71.1 2.6 73.7 36.6 11.7 11.5 6.4 6.2 4.0 3.9 3.2 2.7 2.0
36.6 48.3 59.8 66.3 72.5 76.5 80.3 83.5 86.2 88.1
a
Specific food contributing at least 1% of whole fruit: avocado. There are no additional specific foods contributing at least 1% of fruit juice. c Specific foods contributing at least 1% to dark green vegetables in descending order: vegetable mixed dishes, pasta and pasta dishes, beef and beef mixed dishes. d Specific foods contributing at least 1% to orange vegetables in descending order: vegetable mixed dishes, coleslaw, frozen meals. e Specific foods contributing at least 1% to legumes in descending order: tofu and meat substitutes. f Specific foods contributing at least 1% to starchy vegetables in descending order: vegetable medley and other vegetables, chicken and chicken mixed dishes. g Specific foods contributing at least 1% of other vegetables in descending order: coleslaw, vegetable mixed dishes, vegetable juice. h There are no additional specific foods contributing at least 1% of whole grains. i Specific foods contributing at least 1% of nonwhole grains in descending order: pancakes/waffles/French toast, soups, beef and beef mixed dishes. j Specific foods contributing at least 1% of meat in descending order: 0ther meat and meat mixed dishes, pizza, chili, and soups. k Specific foods contributing at least 1% of total poultry in descending order: beef and beef mixed dishes. l There are no additional specific foods contributing at least 1% of fish. m Specific foods contributing at least 1% of eggs in descending order: pancakes/waffles/French toast, other fish and fish mixed dishes, chicken and chicken mixed dishes. n Specific food contributing at least 1% of soy: reduced-fat cheese. o Specific foods contributing at least 1% of nuts and seeds in descending order: other fruit and fruit salad, crackers. p Specific foods containing at least 1% of milk in descending order: pasta and pasta dishes, candy, eggs and egg mixed dishes, soups. q There are no additional specific foods contributing at least 1% of cheese. r Includes nonhydrogenated vegetable oils and fatty portions of fish, nuts, and seeds. s Specific foods contributing at least 1% of oils in descending order: tuna and tuna mixed dishes, oils, rice and rice mixed dishes, coleslaw, pizza, condiments, other white potatoes, eggs and egg mixed dishes. t Specific foods contributing at least 1% of solid fats in descending order: butter, quickbreads, crackers, yeast breads, soups, candy, beans, other white potatoes, other fish and fish mixed dishes, and cold cuts. u Specific food contributing at least 1% of added sugars: yogurt. NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation. b
supplying 40%, whole milk 26%, and skim milk 16%. Cheese reported separately represented more than half the cheese consumed, with regular cheese contributing 44% and reduced-fat cheese another 8%. Other major contributors of Cheese were pizza (21%), Mexican mixed dishes (8%), and pasta and pasta dishes (7%). Oils. The list of food sources of oils was relatively long, with more than 20 specific foods contributing at least 1% of intake. The major suppliers were potato chips (16%),
salad dressing (13%), nuts/seeds and nut/seed mixed dishes (10%), chicken and chicken mixed dishes (8%), and mayonnaise (6%). Solid Fats and Added Sugars. Solid fats were derived from a long list of specific foods, as well. Major contributors included grain-based desserts (11%); regular cheese (8%); sausage, franks, bacon, and ribs (7%); pizza (6%); fried white potatoes (6%); dairy desserts (5%); and whole milk (5%). Added sugars, on the other hand, were concentrated in
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fewer specific foods. Beverages comprised more than half of these, with sweetened carbonated beverages providing 37%, fruit drinks 11%, and tea 3%. Other substantial contributors included grain-based desserts (12%), dairy desserts, and candy (6% each). DISCUSSION This research builds on previous research by providing results from more recent data, across a range of food groups. It highlights key foods in the American diet that contribute both to food groups that are encouraged and those that are meant to be curtailed. A limitation of the study is that some foods were grouped together for ease of presentation that would have been of interest to examine separately. These include 1% and 2% milks, and apples and pears. Furthermore, these data are subject to the same vagaries and issues of measurement error as all self-reported dietary data, such as random error associated with writing or processing mistakes or systematic error associated with under- or overreporting by certain population groups (11). This study follows a methodology used in numerous studies examining food sources of nutrients (8,9,12-22) but applies it to investigate the food sources of guidancebased food groups. Researchers at USDA conducted similar analyses looking at a range of food groups, but given the objective to evaluate the MyPyramid patterns, the food groupings used were more commoditybased, whereas ours were more as-purchased or asconsumed (23). In addition, USDA considered only the leanest forms of various foods and did not present sources of milk, eggs, oils, solid fats, or added sugars (24). Other investigators have examined food sources of individual food groups. Cleveland and colleagues (25) examined the food sources of whole grains among adults, using data from the 1994-1996 Continuing Survey of Food Intakes by Individuals, and Harnack and colleagues (26) using the same data, conducted a similar analysis among children and adolescents. According to these investigators, the proportion of all grains consumed as whole grains were 15% and 14%, respectively, in the mid-1990s. This analysis suggested that the proportion was only 10% in 2001-2002, but at least some of that difference may be due to methodologic discrepancies. The current MPED does not consider the corn in corn chips to be a whole grain, as did the Pyramid Servings Database that the other authors used. Still, other analyses, using only the Pyramid Servings Database and covering the same time period suggest that the proportion of grains eaten as whole has declined slightly: average intake of total grains for all persons aged 2 years and older remained at 6.8 servings between 1994-1996 and 19992002, whereas average intake of whole grains decreased from one serving to 0.8 servings (27,28). Methodologic discrepancies could account for differences in sources of whole grains, as well. Using the Pyramid Servings Database, Cleveland and colleagues (25) and Harnack and colleagues (26) estimated that, in 1994-1996, breakfast cereals provided 30% and 38% of the whole grains consumed among adults (25) and youth (26), respectively. It was estimated that breakfast cereal contributed 43% of the whole grains among the total population using the
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MPED, but only 34% using the Pyramid Servings Database (for 1999-2002, data not shown). Guthrie and colleagues (29), also using the 1994-1996 Continuing Survey of Intakes by Individuals data, analyzed food sources of added sweeteners (comparable to what are called added sugars in our research). They reported that beverages accounted for 46% of the added sweeteners, with 33% of added sugars coming from sweetened carbonated drinks and 10% coming from fruit-based drinks. We found more than half of the added sugars (51%) were derived from beverages in 2001-2002, including a more substantial contribution from sweetened carbonated beverages (37%). Because the methodology and databases are similar between the two studies, differences in our results probably reflect real differences. Consumption of added sugars was estimated to have increased 14.5% between 1994-1996 and 1999-2002 (27,28). The 2005 Dietary Guidelines and MyPyramid demonstrate that, even when the most nutrient-dense forms of each food group are selected, only a very small amount of discretionary calories can be consumed to stay within energy limits. Our research makes clear that Americans do not, in general, consume the most nutrient-dense forms of basic food groups, instead consuming large amounts of foods that are high in solid fats and added sugars. For example, reduced-fat milk (not skim), whole milk, and regular cheese are major sources of the milk group and are also top sources of solid fat. In addition, burgers and sausage, franks, bacon, and ribs were major contributors to the intakes of both the meat group and solid fats. These patterns of eating make it difficult to stay within energy guidelines while achieving nutrient adequacy. Furthermore, within some basic food groups, more targeted choices could be made. The vegetable group includes a wide range of items of varying nutrient content, yet only two vegetables—white potatoes and tomatoes— account for 46% of the servings from that group. About half of all white potatoes in 2001-2002 were consumed as either fried potatoes or potato chips. A similar finding for 1994-1996 had been reported before (30), suggesting potatoes continue to be consumed in high-energy-dense ways and displace other important vegetable subgroups such as dark green vegetables, orange vegetables, and legumes. A low proportion of grains consumed as whole grains was anticipated, but due to modifications in the Pyramid Servings Database, these results are even more alarming. Stated another way, nonwhole grains are too high a proportion of total grains. Yeast breads are the major contributor of grains, and substituting whole-grain yeast breads for their nonwhole grain counterparts would go a long way toward remedying this situation. However, that change alone would not be sufficient to bring intakes into compliance with current guidance. Grain-based desserts—which, unlike yeast breads, contribute substantial added sugars and solid fat— constitute a full 10% of nonwhole grains and would need to be substantially reduced. Popcorn’s contribution to overall whole-grain intake may seem quite high, but it may be primarily a reflection of how minimal whole-grain intake is. The 2005 Dietary Guidelines recommend that consumers obtain most of their fats from “sources of polyunsaturated and monounsaturated fatty acids, such as fish,
nuts, and vegetable oils.” This study did not estimate the proportion of total fat derived from these sources, but it is of interest that only a fraction of the fish consumed is high in n-3 fatty acids. The top source of oils, according to our study, was potato/corn/other chips. Although the oil in chips may not be high in trans-fatty acids (31), chips are typically high in energy and salt, and a small serving could exhaust an entire day’s discretionary calorie allowance. One unique feature of our study was the derivation of a variable—meat—to capture what are commonly referred to as red meats. The meat variable includes all beef, pork, and other meats, as well as sausages and cold cuts made from them, and excludes all poultry and fish. Red meat consumption has been implicated as a potential risk factor for some chronic diseases (32-34), so this metric may prove useful in other studies as well. Data summarized in the 2005 Dietary Guidelines suggest that most of the solid fats and added sugars would need to be eliminated from Americans’ diets for diets to be in compliance with the Dietary Guidelines (4). Results of this study implicate the major contributors to these highenergy-dense foods are sweetened carbonated and other sweetened beverages, grain-based desserts, nonskim dairy products, and fatty meats. Although these have been noted even in the popular press for some time, this study provides much needed quantified evidence regarding the degree to which these types of foods contribute to dietary imbalances. CONCLUSIONS The discrepancy between actual and recommended consumption is due to many factors. These include individual-level behaviors, such as lack of consumer awareness of foods associated with beneficial health outcomes and the difficulties related to changing shopping and consumption patterns, as well as system-level factors related to the food environment. System-level factors include the increase in prevalence of eating away from home, the higher energy and fat content of foods consumed away from home, the higher costs of more healthful options, the proportion of less healthful compared to more healthful options, the overall increase in per capita energy available in the food supply, expanding portion sizes, as well as differences in the advertising, pricing, and promotion of healthful foods compared to their less healthful counterparts in the media (35-40). Both individualized nutrition interventions as well as environmental and policy interventions are needed to influence US consumption patterns (35-40). According to these findings, food and nutrition professionals would do well to educate individuals about appropriate choices within food groups rather than focusing on achieving a certain number of servings from each food group. The intricate balance between intake of discretionary calories—from solid fat and added sugars—and intake of food group foods is particularly important to highlight, especially because it appears to be difficult to achieve in the existing food environment. Food and nutrition professionals can also advocate for a food environment that provides health information, increases the availability of healthful foods, uses pricing strategies, and implements incentive programs to influence food choices.
The authors thank Lisa Kahle for expert programming. References 1. MyPyramid. US Department of Agriculture Web site. www. mypyramid.gov. Accessed September 25, 2007. 2. Krebs-Smith SM, Kris-Etherton P. How does MyPyramid compare to other population-based recommendations for controlling chronic disease? J Am Diet Assoc. 2007;107:830-837. 3. Buzby J, Wells HF, Vocke G. Possible implications for US agriculture from adaptation of select dietary guidelines. US Department of Agriculture, Economic Research Service Web site. http://www.ers.usda.gov/ Publications/ERR31/. Accessed February 19, 2008. 4. US Departments of Agriculture and Health and Human Services. Dietary Guidelines for Americans 2005. US Department of Health and Human Services Web site. http://www.healthierus.gov/ dietaryguidelines. Accessed September 25, 2007. 5. Guenther PM, Dodd KW, Reedy J, Krebs-Smith SM. Most Americans eat much less than recommended amounts of fruits and vegetables. J Am Diet Assoc. 2006;106:1371-1379. 6. Basiotis P, Guenther PM, Lino M, Britten P. Americans consume too many calories from solid fat, alcohol, and added sugars. US Dept of Agriculture Center for Nutrition Policy and Promotion Web site. http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight33. pdf. Accessed February 19, 2008. 7. Dietary interview, NHANES 2001-2002. Centers for Disease Control and Prevention, National Center for Health Statistics Web site. http:// www.cdc.gov/nchs/about/major/nhanes/nhanes01-02.htm. Accessed September 25, 2007. 8. Cotton PA, Subar AF, Friday JE, Cook A. Dietary sources of nutrients among US adults, 1994 to 1996. J Am Diet Assoc. 2004;104:921-930. 9. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US adults, 1989 to 1991. J Am Diet Assoc. 1998;98: 537-547. 10. Krebs-Smith SM, Kott PS, Guenther PM. Mean proportion and population proportion: Two answers to the same question? J Am Diet Assoc. 1989;89:671-676. 11. Trabulsi J, Schoeller DA. Evaluation of dietary assessment instruments against doubly labeled water, a biomarker of habitual energy intake. Am J Physiol Endocrinol Metab. 2001;281:E891-E899. 12. Krebs-Smith SM, Cronin FJ, Haytowitz DB, Cook DA. Food sources of energy, macronutrients, cholesterol, and fiber in diets of women. J Am Diet Assoc. 1992;92:168-174. 13. Thompson FE, Sowers MF, Frongillo EA Jr, Parpia BJ. Sources of fiber and fat in diets of US women aged 19 to 50: Implications for nutrition education and policy. Am J Public Health. 1992;82:695-702. 14. Fox MK, Reidy K, Novak T, Ziegler P. Sources of energy and nutrients in the diets of infants and toddlers. J Am Diet Assoc. 2006;106(suppl 1):S28-S42. 15. Stroehla BC, Malcoe LH, Velie EM. Dietary sources of nutrients among rural Native American and white children. J Am Diet Assoc. 2005;105:1908-1916. 16. Subar AF, Block G, James LD. Folate intake and food sources in the US population. Am J Clin Nutr. 1989;50:508-516. 17. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in food locations and sources among adolescents and young adults. Prev Med. 2002;35:107113. 18. Gordon AR, McKinney P. Sources of nutrients in students’ diets. Am J Clin Nutr. 1995;61(suppl):232S-240S. 19. Ma J, Betts NM. Zinc and copper intakes and their major food sources for older adults in the 1994-96 continuing survey of food intakes by individuals (CSFII). J Nutr. 2000;130:2838-2843. 20. Kant AK, Block G. Dietary vitamin B-6 intake and food sources in the US population: NHANES II, 1976-1980. Am J Clin Nutr. 1990;52:707716. 21. Murphy SP, Subar AF, Block G. Vitamin E intakes and sources in the United States. Am J Clin Nutr. 1990;52:361-367. 22. Block G, Norris JC, Mandel RM, DiSogra C. Sources of energy and six nutrients in diets of low-income Hispanic-American women and their children: Quantitative data from HHANES, 1982-1984. J Am Diet Assoc. 1995;95:195-208. 23. Britten P, Marcoe K, Yamini S, Davis C. Development of food intake patterns for the MyPyramid food guidance system. J Nutr Educ Behav. 2006;38(suppl):S78-S92. 24. Marcoe K, Juan W, Yamini S, Carlson A, Britten P. Development of food group composites and nutrient profiles for the MyPyramid food guidance system. J Nutr Educ Behav. 2006;38(suppl 2):S93-S107.
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25. Cleveland LE, Moshfegh AJ, Albertson AM, Goldman JD. Dietary intake of whole grains. J Am Coll Nutr. 2000;19(suppl):331S-338S. 26. Harnack L, Walters SA, Jacobs DR Jr. Dietary intake and food sources of whole grains among US children and adolescents: Data from the 1994-1996 Continuing Survey of Food Intakes by Individuals. J Am Diet Assoc. 2003;103:1015-1019. 27. Cook A, Friday J. CNRG Table Set 3.0: Pyramid servings intakes in the United States, 1999-2002, 1 day. US Department of Agriculture, Agricultural Research Service Web site. http://www.ars.usda.gov/ Services/docs.htm?docid⫽8503. Accessed September 25, 2007. 28. Cook A, Friday J. CNRG Table Set 1.1: Pyramid servings intakes in the United States, 1994-96, 1998, 2 day. US Department of Agriculture, Agricultural Research Service Web site. http://www.ars.usda. gov/Services/docs.htm?docid⫽8503. Accessed September 25, 2007. 29. Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc. 2000;100:43-51. 30. Krebs-Smith SM. Progress in improving diet to reduce cancer risk. Cancer. 1998;83:1425-1432. 31. Cho E, Chen WY, Hunter DJ, Stampfer MJ, Colditz GA, Hankinson SE, Willett WC. Red meat intake and risk of breast cancer among premenopausal women. Arch Intern Med. 2006;166:2253-2259. 32. Fung TT, Schulze M, Manson JE, Willett WC, Hu FB. Dietary pat-
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33. 34. 35. 36. 37. 38. 39. 40.
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