An evidence-based definition of nutrition security: disparities in sociodemographic characteristics, dietary intake and cardiometabolic risk using the US Healthy Eating Index

BackgroundRising rates of diet-related chronic diseases and disparities in disease prevalence by sociodemographic factors highlight the need to improve the diet quality of Americans. Understanding how the Healthy Eating Index-2020 (HEI-2020) can be used as a measure of diet quality to create benchmarks for national nutrition monitoring can assist in surveillance and improve the design of nutrition programs and policies. ObjectiveTo examine the utility of the HEI-2020 to create benchmarks for national diet quality monitoring. MethodsThis serial cross-sectional study used data from the 2009-2018 National Health and Nutrition Examination Surveys (NHANES). Nationally representative data for 22,168 US adults ([&ge;]20 years) who completed two 24-hour recalls were analyzed. We derived HEI-2020 scores (0-100) from participants two 24-hour dietary recalls. Diet quality categories were established: high diet quality (>70-100), marginal (>60-70), low (>50-60), and very low (0-50). ResultsOnly 13% of US adults had high diet quality while nearly two-thirds had low or very low diet quality. Diet quality was higher for older adults, female, "Other" race or ethnicity, born outside of the US, have higher education attainment, higher income, and food security. Compared to adults with high diet quality, adults with very low diet quality had lower intakes of unprocessed or minimally processed foods, fruits, vegetables, whole grains, and seafood and the highest intakes of ultra-processed foods, refined grains, and red and processed meats (all P-trends <0.01). Adults with very low diet quality were more likely to have elevated adiposity, lower HDL cholesterol, and higher triglycerides, fasting glucose, and hemoglobin A1c (all P-trends [&le;]0.01). ConclusionsThe HEI-2020 is a robust measure of diet quality that can be directly linked to biological measures associated with chronic disease risk. Using evidence-based HEI categories could allow policymakers, public health practitioners, and nutrition professionals to set benchmarks and nationwide targets for achieving improved diet quality.