At the Intersection of Health, Health Care and Policy Cite this article as: Sara N. Bleich, Jessica Jones-Smith, Julia A. Wolfson, Xiaozhou Zhu and Mary Story The Complex Relationship Between Diet And Health Health Affairs, 34, no.11 (2015):1813-1820 doi: 10.1377/hlthaff.2015.0606

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Health: An Overview

By Sara N. Bleich, Jessica Jones-Smith, Julia A. Wolfson, Xiaozhou Zhu, and Mary Story 10.1377/hlthaff.2015.0606 HEALTH AFFAIRS 34, NO. 11 (2015): 1813–1820 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.

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The Complex Relationship Between Diet And Health

Sara N. Bleich is an associate professor in health policy and management at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland.

The relationship between food and health is complex. Everyone needs food to live, but too little food, too much food, or the wrong type of food has negative consequences for health. To increase understanding of this relationship, we describe trends and patterns in food-related diseases among both adults and children. Using an ecological framework, we then describe why food intake is complex with a discussion of three broad levels—macro (including policy and social-cultural norms), local community, and individual environments—and their relationship to food consumption. Given the strong relationship between an individual’s food choice and his or her surrounding environment, we end with examples of policy responses that aim to help people overcome environmental disincentives toward healthy eating. Finding ways to make eating healthfully easier and affordable for all populations is essential to shifting the average American diet toward one that promotes health. ABSTRACT

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ore than 2,500 years ago, Hippocrates said: “Let food be thy medicine and medicine be thy food.” Healthy diets can optimize both short- and longterm health and can help reduce risk for many health conditions. Poor nutrition is a primary contributor to morbidity globally1 and is associated with more than one in four US deaths.2 About half of US adults have one or more preventable chronic diseases related to poor-quality dietary patterns or physical inactivity, which disproportionately affect low-income and underserved communities.3,4 Simply put, food can help people live healthier and longer lives, and food can help people die prematurely. The relationship between people and food is complex. Food is generally abundant in the United States,5 and overconsumption of calories is a key driver of the nation’s obesity epidemic, as well as a host of diet-related diseases.6 Yet not all food is equally accessible, and healthier items (for example, fruit and vegetables) are typically more expensive than energy-dense, high-sugar,

7

Jessica Jones-Smith is an assistant professor in international health at the Johns Hopkins Bloomberg School of Public Health. Julia A. Wolfson is a PhD candidate in health policy and management at the Johns Hopkins Bloomberg School of Public Health. Xiaozhou Zhu is a graduate student at the Johns Hopkins Bloomberg School of Public Health.

high-sodium, or high-fat items. For households with food insecurity (that is, limited consistent access to nutritionally adequate and safe food acquired via socially acceptable means), food is often scarce.8 Consumption of food is stressful for the 40 percent of adults and 48 percent of adolescents trying to lose weight9,10 and the roughly 2–4 percent of adolescents and young adults with eating disorders.11 Modifying food consumption is difficult because individual eating behaviors are hard to change.12 Eating behavior is also complicated by the fact that food is essential to life, is a core part of cultural identity, and is important for social relationships, but people lack full control over what they eat. The purpose of this overview article is to describe the complex relationship between food and health. We describe trends and patterns in overall nutrition quality in the United States and trends and patterns in food-related diseases for adults and children. We focused this article primarily on diet and its relationship to health, while recognizing that physical inactivity is also an important contributor to the chronic diseases N ov e m b e r 2 0 1 5

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Mary Story (mary.story@duke .edu) is a professor in community and family medicine and global health at Duke University, in Durham, North Carolina.

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Health: An Overview discussed here. Using an ecological framework— an approach that emphasizes the linkages and relationships among multiple factors affecting health—we describe why food intake is complex and discuss policy alternatives that work within that framework (particularly via environmental change) to help improve food choices and, subsequently, the relationship between food and health.

Trends And Patterns In Dietary Quality Diet quality can be assessed using the Healthy Eating Index (HEI).13 The HEI is a twelve-dimension dietary quality index based on a combination of food and nutrient variables that are associated with obesity and chronic disease.14,15 It is scored on a scale from 0 (nonadherence) to 100 (perfect adherence). Limitations of the HEI have been documented16 and include the reliance on twenty-four-hour dietary recall data that rely on accurate memory and may be affected by social desirability bias, both of which may affect the accuracy or completeness of the information. The average dietary quality of US adults improved modestly from 1999 to 2010, increasing from 46.6 to 49.6 on the HEI.17 However, overall diet quality is poor, and adults with a college degree have higher dietary quality compared to those with a high school education (54.5 versus 47.9) (see online Appendix Figure A1).18 Furthermore, over time, adults with a college education demonstrated greater improvements in their dietary quality compared to adults with a high school education, thus widening the disparity in dietary quality by education from 5.6 points in 1999 to 6.6 points in 2010 (see Appendix Figure A1).18 Generally, poor diet quality in the HEI is attributable to underconsumption of the adequacy components such as vegetables or whole grains (foods that should be eaten in enough quantity to get the needed nutrients and for overall good health) and overconsumption of the moderation components such as sodium and refined grains (dietary components that should be limited or consumed in small amounts). Consistent with the average score of roughly 50 of 100 total points, adult Americans scored approximately half of all the total possible points for each of the component food groups, with the exception of protein foods (4.2 of a maximum score of 5.0), where Americans get much closer to the goal, and leafy greens and legumes (1.2 of a maximum score of 5.0), where scores are particularly inadequate.16 The diet quality of children and adolescents also falls short of recommendations, with average HEI scores ranging from 47 to 50 points 1814

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between 2003 and 2008.19 A similar story emerged from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee.4 Generally, among children, adolescents, and adults, intake of fruit, vegetables, whole grains, and dairy are too low, while intake of refined grains, added sugars, sodium, and saturated fats are too high.20 Most Americans overconsume sodium,4 which is strongly associated with hypertension and other cardiovascular risk factors.21 However, some improvements in total daily energy intake have been observed. For example, caloric intake by children declined from 2000 to 2010 (boys: 2,258 calories to 2,100 calories; girls: 1,831 calories to 1,755 calories).20 Over the same period, consumption of sugary beverages declined by 68 calories (from 233 calories to 155 calories) for youth (ages 2–19 years) and by 45 calories (196 calories to 151 calories) for adults (ages twenty and older).22 Although these declines vary by race/ethnicity and income, overall levels remain high.23,24

Trends And Patterns In Food-Related Diseases Food-related diseases are prevalent, persistent, and present across the lifespan. Exhibits 1 and 2 present age-adjusted trends in food-related diseases for adults and children using the National Health and Nutrition Examination Survey (NHANES) 1999–2012. The NHANES is a population-based survey designed to collect information on the health and nutrition of the US population. A complete description of data collection procedures and analytic guidelines are available elsewhere.25 Detailed estimates for each disease, overall and by demographic characteristics, can be found in the Appendix18 (Table A2 for adults and Table A3 for children), along with a description of the methods of analysis. The prevalence of obesity in adults and children is high and increased from 1999 to 2012 (adults: 30–35 percent; children: 14–17 percent). Exhibit 1 presents data on adults, and Appendix Figure A4 presents data on children.18 However, these averages mask important differences. For all age groups, the level of obesity is higher among black and Hispanic populations compared to whites. Among adults, the rate of increase of obesity has been higher among black and Hispanic groups, widening the disparity in prevalence (Exhibit 1). Obesity has increased steadily across the lifespan for all age groups, with the exception of children ages 2–5, who have experienced a decline in prevalence (see Appendix Table A3).18 Concurrently, diabetes among adults and prediabetes and diabetes among children increased

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between 1999 and 2012 (adults: 9–12 percent; children and adolescents: 8–18 percent). Exhibit 2 presents data on adults, and Appendix Figure A5 presents data on children.18 Similar to the patterns observed for obesity, the prevalence of diabetes for adults is disproportionately higher among blacks and Hispanics compared to whites (Exhibit 2). Much of the increase in diabetes is concentrated among older adults (ages sixty-five and older) (see Appendix Table A2).18 Hypertension among adults and prehypertension and hypertension among children modestly increased over the same period among adults (32–33 percent) and remained relatively stable among children at 11 percent. Among both adults and children, prevalence is considerably higher among blacks relative to whites (see Appendix).18

Complexity Of Food Intake The complex set of determinants of eating behavior described below paired with the current food environment helps explain why diet quality is poor and food and nutrition-related diseases are so prevalent in the United States. An individual’s eating behaviors are shaped by determinants at three broad levels: macro (including policy and social-cultural norms); local community; and individual behavior, including the family environment, as illustrated in Exhibit 3.26 Food choices are sensitive to environmental cues and constrained by what is available in the food supply, at both the macro and local levels. The food supply is directly and indirectly shaped by agricultural, economic, and political systems.27 Within these systems, food manufacturers aim to maximize profits and demonstrate continual market growth.27 Advances in food processing have resulted in a cheap supply of calorically dense and nutrient-poor sweeteners and fats that are used to produce foods that are palatable at a low cost.28 Merely having more food choices has been associated with increased caloric consumption.29 In 2010 more than 21,500 new food and beverage products were introduced in the United States—up from nearly 20,000 in 2006.30 As a result, the food supply is dominated by a staggering number of everincreasing, relatively low-cost, highly processed, highly palatable, and quick-to-prepare foods. Food manufacturers spend $11 billion per year in the United States marketing these foods, many of which are high in sugar, fats, and salt.31 Approximately $1.8 billion per year is directed toward food marketing to youth.32 Marketing of snack food and high-calorie beverages coincides with dramatic increases in the intake of these foods.33,34 During children’s television program-

Exhibit 1 Obesity Trends Overall And By Race And Ethnicity Among US Adults Ages Twenty And Older, 1999–2012

SOURCE Authors’ analysis of National Health and Nutrition Examination Survey data, 1999–2012.

ming, nearly 60 percent of advertisements show food eaten outside of mealtime; 34 percent of all advertisements are for candy and snacks, and 9 percent are for soda and other soft drinks.35 Mass marketing has also been implicated in promoting a beauty ideal of being dangerously thin that promotes eating disorders36 by simultaneously inducing demand for foods that make it difficult to reach desired weight goals and placing a high social value on thinness.37 Local community, individual, and family environments modify the extent of exposure and susceptibility to these macro-level factors. Nationwide, low-income neighborhoods are less likely to have a large supermarket38 and more likely to have fast food restaurants compared to higher-income neighborhoods.39 Although the evidence on the degree to which local community food environments influence food intake is mixed, the few studies that have robust designs (using either individual fixed effects, instrumental variables, or natural experiments to account for selection into neighborhoods) suggest that easy access to unhealthy food is more robustly Exhibit 2 Diabetes Trends Overall And By Race And Ethnicity Among Adults Ages Twenty And Older, 1999–2912

SOURCE Authors’ analysis of National Health and Nutrition Examination Survey data, 1999–2012. NOTE Estimated among fasting subsample.

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Health: An Overview Exhibit 3 A Framework For Understanding The Complexity Of Food Intake

SOURCE Authors’ analysis.

associated with poor diet than access to healthy food is associated with healthful diet.40,41 In addition, susceptibility to these local environment exposures is modulated by individual and family resources. Those with adequate monetary resources have more choice in determining their local neighborhood, can prioritize healthfulness of food over the price, and are better positioned to adapt their diet in response to special health needs or preferences. Social norms and cultural practices also contribute to food habits by influencing the composition and quantity of food in an individual’s diet.42 At the individual decision-making level, taste, price, and convenience are cited as the top three factors considered in food choices.43 Directly incorporating these factors, food manufacturers have created a food supply that is dominated by less healthful products that are tasty, cheap, and convenient. Beyond just catering to an innate preference for sweet, salty, and fatty tastes, food science is used to create products that are difficult to resist and keep consumers coming back for more.44 Marketing (described above) is heavily used to increase desire for less healthful products.45 Regarding price incentives, on a cost per calorie basis, energy-dense foods such as salty and sweet processed products, sugar, carbonated beverages, fats, and oils are among the cheapest sources of calories while fruit and vegetables are among the most expensive.46 Because of its widespread availability, affordability, and association with poor health, sodium was recently designated as a nutrient of public health concern for overconsumption across the entire US population.4 Related to preferences for convenience, time 1816

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constraints have increased for the average American. For example, the percentage of women in the labor force with children younger than age eighteen has increased from 47 percent to 71 percent since the 1970s.47 Finally, although health is an additional consideration when making food choices, behavioral economics has shown that humans consistently display “time-inconsistent preferences,” meaning a disproportionate attraction to the short-term pleasures of eating unhealthy food at the expense of long-term negative health consequences.48 Lastly, eating behavior is influenced by biology. Evidence suggests that feedback mechanisms trigger intense hunger signals when people lose weight, making sustained caloric decreases difficult.49 Additionally, significant gene-by-environment interactions demonstrate that food consumption can potentiate or attenuate genetic predispositions toward obesity and other chronic conditions.50

Policy Alternatives To Improve Food Choices Policies aimed at addressing the complex determinants of food intake and the wide variety of environmental disincentives toward healthy eating are critical for improving the relationship between food and health (Exhibit 3).51 This section focuses on policy responses that aim to help people overcome environmental disincentives toward healthy eating.We describe examples relevant to improving diet quality or reducing caloric intake as a result of the substantial policy response in this area and because these are key determinants of food-related illness. For

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the three environments identified in Exhibit 4 (macro, local community, and individual), we describe how each promotes food-related illness (such as obesity or hypertension), selected policy alternatives to address these environmental disincentives at each level, evidence of impact on disease or behavior change, and what is known about this evidence base from formal evaluations or the relevant literature. We outline two policy

alternatives for each level below. More detail for other selected policy alternatives is provided in the Appendix.18 Macro Level At the macro level, mandatory labeling of trans fat (manufactured fat created during a process called hydrogenation, which is commonly found in fried food, commercial baked goods, and margarine and is strongly associated with coronary heart disease)52 on pack-

Exhibit 4 Policy Responses To Overcome Environmental Disincentives Toward Healthy Eating How the environment promotes disease Macro level

Policy alternatives to change the environment

Evidence of impact on disease or behavior change

What is known (from formal evaluations or relevant literature)

Shapes preferences and consumption patterns through the food supply and marketing

Mandatory labeling of trans fat on packaged goods (2006)

The FDA requires that trans fat be listed on nutrition labels

Yes

Associated with food manufacturers’ product reformulation to eliminate or decrease trans fat in food supplya

Mandatory posting of calories in chain restaurants (2010)

The menu labeling provision of the Affordable Care Act requires that calorie information be posted in food outlets that have more than twenty locations

Mixed

A locality with mandatory menu labeling observed significant decrease in energy, saturated fat, and sodium for entrees eighteen months postimplementation because of changes in the nutrient content of restaurant menu offeringsb Limited to no impact on consumer behaviorc

Food package change in the WIC program (2009)

The WIC food package was revised to better align with dietary recommendations

Yes

Healthy Hunger Free Kids Act of 2010

Sets limits on calories, salt, sugar, and fat contained in all food and beverages sold in schools

Not evaluated

Improves diet quality (decreases in total fat and saturated fat; increases in dietary fiber and overall diet quality)d Stronger meal nutrition standards may improve student weight statuse

Sugary beverage tax in Berkeley, California (2014)

Places a one-cent-per-ounce excise tax on beverages with added sugar

Not evaluated

Economic modeling predicts that a one-cent-per-ounce tax would decrease consumption and reduce diabetesf

Double Up Food Bucks program (started in Detroit in 2009)

Increases the value of SNAP dollars when they are spent on fresh fruit and vegetables

Yes

Financial incentives targeting the purchase of fruit and vegetables among SNAP participants increased spending and consumptiong

Brief description of the policy

Local community level Influences physical and financial access to healthy food

Individual level Caters to strong preferences for low-cost, palatable, and convenient food

SOURCE Authors’ analysis of data from the following sources. aUnnevehr LJ, Jagmanaite E. Getting rid of trans fats in the US diet: policies, incentives, and progress (see Note 53 in text). bBruemmer B, et al. Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in King County, Washington (see Note 54 in text). cKiszko KM, et al. The influence of calorie labeling on food orders and consumption: a review of the literature (see Note 55 in text). dKong A, et al. The 18-month impact of special Supplemental Nutrition Program for Women, Infants, and Children food package revisions on diets of recipient families (see Note 57 in text). eTaber DR, et al. Association between state laws governing school meal nutrition content and student weight status implications for new USDA school meal standards (see Note 59 in text). fWang YC, et al.. A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes (see Note 61 in text). gFood and Nutrition Service, Office of Policy Support. Evaluation of the Health Incentives Pilot (HIP) final report—summary (see Note 60 in text). NOTES Staple foods are items intended for home preparation and consumption. The four staple food categories include meat, poultry, or fish; bread or cereal; vegetables or fruit; and dairy products. See the online Appendix for more examples (see Note 18 in text). FDA is Food and Drug Administration. SNAP is Supplemental Nutrition Assistance Program. WIC is Special Supplemental Nutrition Program for Women, Infants, and Children.

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Health: An Overview aged goods and mandatory posting of calories in chain restaurants are two examples of policy approaches to improve the food supply and promote healthier diets. The labeling policies may affect Americans’ diets by creating an incentive for food manufacturers and restaurant chains to change their products. Evidence suggests that these disclosure requirements have in fact stimulated product reformulations that have improved the nutrient profile of products on the market.53,54 In addition to influencing the food supply, disclosure requirements could also affect diet by modifying consumers’ behavior, although evidence of impact in this area is weak.55 Local Community Level At the local community level, the 2009 food package change in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Healthy Hunger Free Kids Act of 2010 are two examples of policies to address increasing access to healthy food in low-income populations and underserved communities. In 2009 the WIC food packages, which provide nutrition assistance to roughly nine million women, infants, and children each month, were revised to better align with dietary recommendations.56 For example, fruit and vegetables were substituted for juice and lower-fat milk for whole milk. Studies suggest that the revised WIC packages improved diet quality, particularly among Hispanic children.57,58 The Healthy Hunger Free Kids Act sets limits on calories, salt, sugar, and fat contained in all food and beverages sold in schools (both in the National School Lunch Program and in “competitive foods”). There is evidence that stronger school meal nutrition standards may improve students’ weight status.59 Individual Level At the individual level, the recent sugary beverage tax in Berkeley, California, and the Double Up Food Bucks program60 (included in the 2014 Farm Bill) are two examples of policies that use financial strategies to address price barriers and are facilitators to healthy eating. In November 2014 Berkeley became the first US city to pass a law taxing sugary beverages. The measure will place an excise tax of one cent per ounce on beverages with added sugar. Economic modeling predicts that such a tax would decrease consumption and reduce diabetes.61 The Double Up Food Bucks program is designed to boost Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) dollars when they are spent on fresh fruit and vegetables; for example, $10 of benefits at a farmers market is worth $20 dollars of produce.62 Evidence suggests that financial incentives for purchasing fruit and vegetables among SNAP participants increase spending for and consumption of them.60 The latter policy is especially

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It is unlikely that any one of these policy responses alone will eliminate food-related diseases.

relevant for decreasing well-documented price barriers to fruit and vegetable consumption for lower-income Americans, who are also at increased risk for diet-related diseases. Choosing The Right Policy Given the complex relationship between food and health, it is unlikely that any one of these policy responses alone will eliminate food-related diseases. It is also unlikely that any one policy response will fully address the myriad barriers to a healthy diet that vary among population subgroups and cluster among disadvantaged populations. To maximize effectiveness, policies seeking to improve diet should be comprehensive and address the multilevel factors that drive consumption. Prioritizing upstream policy alternatives (such as those focusing on the macro environment instead of influencing individual food choices) might have larger effects and be more sustainable.27 To attenuate the well-documented inequities in diet-related illness, policies also should be tailored to better address the barriers faced by specific target populations. Going forward, more research is needed to increase understanding of the impact of policy alternatives on eating behavior and diet-related disease. Only a few evaluations of the policies presented in this article examined those outcomes. Improved knowledge in this area will help maximize the impact of policies aimed at addressing environmental disincentives toward healthy eating.

Conclusion The famous words from the influential food writer Jean Anthelme Brillat-Savarin are perhaps more relevant today than when he wrote them in 1825: “Tell me what you eat, and I’ll tell you who you are.”63 With nearly 70 percent of adults overweight or obese and average diet quality scoring just 49 out of a total of 100 points, it is clear that the current US food environment engenders weight gain and consumption of an unhealthful diet, particularly among lower-income

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populations.While much of food-related diseases are preventable, eating a healthful diet today in America is often a resource-intensive task requiring knowledge, money, access, time, and willpower, among many other factors. The relationship people have with food is incredibly complex. Effective policy solutions must include comprehensive actions by the public and private sectors that focus on addressing the wide

variety of environmental disincentives toward healthy eating. They should also be targeted to more effectively address the specific barriers experienced by different subgroups, particularly disadvantaged populations. Finding ways to make eating healthfully easier for all populations is essential to shifting the average American diet toward one that promotes health. ▪

NOTES 1 Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980– 2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766– 81. 2 Murray CJ, Atkinson C, Bhalla K, Birbeck G, Burstein R, Chou D, et al. The state of US health, 1990–2010 burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591– 608. 3 Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11:E62. 4 Department of Agriculture. Scientific report of the 2015 Dietary Guidelines Advisory Committee. Washington (DC): USDA; 2015. 5 Barnard ND. Trends in food availability, 1909–2007. Am J Clin Nutr. 2010;91(5):1530S–6S. 6 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806– 14. 7 Monsivais P, Aggarwal A, Drewnowski A. Are socio-economic disparities in diet quality explained by diet cost? J Epidemiol Community Health. 2012;66(6):530–5. 8 Coleman-Jensen A, Gregory C, Singh A. Household food security in the United States in 2013. Washington (DC): Department of Agriculture; 2014 Sep. (Economic Research Report No. 173). 9 Bleich SN, Wolfson JA. Weight loss strategies: association with consumption of sugary beverages, snacks, and values about food purchases. Patient Educ Couns. 2014; 96(1):128–34. 10 Kann L, Kinchen S, Shanklin SL, Flint KH, Kawkins J, Harris WA, et al. Youth risk behavior surveillance—United States, 2013. MMWR Surveill Summ. 2014;63 (Suppl 4):1–168. 11 Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch

Gen Psychiatry. 2011;68(7):714–23. 12 Janz NK, Champion VL, Strecher VJ. The health belief model. In: Glanz K, Rimer BK, Lewis FM, editors. Health behavior and health education: theory, research, and practice. Third edition. San Francisco (CA): JosseyBass; 2002. p. 45–65. 13 Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hiza HA, Kuczynski KJ, et al. Update of the Healthy Eating Index: HEI–2010. J Acad Nutr Diet. 2013;113(4):569–80. 14 Gao SK, Beresford SA, Frank LL, Schreiner PJ, Burke GL, Fitzpatrick AL. Modifications to the Healthy Eating Index and its ability to predict obesity: the Multi-Ethnic Study of Atherosclerosis. Am J Clin Nutr. 2008;88(1):64–9. 15 Basiotis PP, Carlson A, Gerrior SA, Juan WY, Lino M. The Healthy Eating Index: 1999–2000. Washington (DC): Department of Agriculture, Center for Nutrition Policy and Promotion; 2002. (Report No. CNPP-12). 16 Wang DD, Leung CW, Li Y, Ding EL, Chiuve SE, Hu FB, et al. Trends in dietary quality among adults in the United States, 1999 through 2010. JAMA Intern Med. 2014;174(10): 1587–95. 17 Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and evaluation of the Healthy Eating Index–2005: technical report. Washington (DC): Department of Agriculture, Center for Nutrition Policy and Promotion; 2007 Nov. 18 To access the Appendix, click on the Appendix link in the box to the right of the article online. 19 Department of Agriculture. Diet quality of children age 2–17 years as measured by the Healthy Eating Index–2010. Washington (DC): Department of Agriculture, Center for Nutrition Policy and Promotion; 2013 Jul. 20 Ervin RB, Ogden CL. Trends in intake of energy and macronutrients in children and adolescents from 1999– 2000 through 2009–2010. NCHS Data Brief. 2013(113):1–8. 21 Institute of Medicine. Sodium intake in populations: assessment of evidence. Washington (DC): National Academies Press; 2013.

22 Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL. Trends in sugarsweetened beverage consumption among youth and adults in the United States: 1999–2010. Am J Clin Nutr. 2013;98(1):180–8. 23 Sanger-Katz M. Americans are finally eating less. New York Times [serial on the Internet]. 2015 Jul 24 [cited 2015 Sep 2]. Available from: http://www.nytimes.com/2015/07/ 25/upshot/americans-are-finallyeating-less.html 24 Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. J Acad Nutr Diet. 2013;113(1):43–53. 25 Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey analytic guidelines, 2011–2012 [Internet]. Atlanta (GA): CDC; 2013 Sep [cited 2015 Sep 10]. Available for download from: http://www.cdc .gov/nchs/nhanes/analytic_guide lines.htm 26 Story M, Kaphingst KM, RobinsonO’Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29: 253–72. 27 Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011; 378(9793):804–14. 28 Cutler D, Glaeser E, Shapiro J. Why have Americans become more obese? J Econ Perspect. 2003;17(3):93–118. 29 Kahn BE, Wansink B. The influence of assortment structure on perceived variety and consumption quantities. J Consum Res. 2004;30(4):519–33. 30 Economic Research Service. Processing and marketing: new products [Internet]. Washington (DC): Department of Agriculture; last updated 2014 Oct 30 [cited 2015 Sep 2]. Available from: http:// www.ers.usda.gov/topics/foodmarkets-prices/processingmarketing/new-products.aspx 31 Zimmerman FJ. Using marketing muscle to sell fat: the rise of obesity in the modern economy. Ann Rev Public Health. 2011;32:285–306. 32 Federal Trade Commission. Review of food marketing to children and

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