Part D. Chapter 1: Food and Nutrient Intakes, and Health: Current Status and Trends - Continued
Eating BehaviorsCurrent status and trends
Diet quality and energy balance directly affect health and weight status. Eating behaviors, such as when people eat (e.g., patterns of meals and snacks, meal and snack frequency), meal skipping, and the locations where food is obtained and consumed (e.g., retail and restaurants) influence dietary intake and quality. Assessing and understanding eating behaviors of the U.S. population can shed light on ways to improve food choices, weight status, and health outcomes of Americans.
Question 13: What are the current status and trends in the number of daily eating occasions and frequency of meal skipping? How do diet quality and energy content vary based on eating occasion?
Source of evidence: Data analysis
The majority of the U.S. population consumes three meals a day plus at least one snack. Children ages 2 to 5 years are most likely to consume three meals a day and adolescent females, young adult males, non-Hispanic Blacks, Hispanics, and individuals with lower incomes are least likely to consume three meals a day. Trend data from 2005-2006 to 2009-2010 show little change in meal and snack intake patterns.
Breakfast tends to have a higher overall dietary quality because of its higher nutrient density compared to other meals and snacks. Adolescents and young adults are the least likely to eat breakfast. Snacks contribute about one-fourth of daily energy intake for the U.S. population and are lower in nutrients of concern relative to energy intake than are meals. For young children ages 2 to 5 years, 29 percent of daily energy is from snacks.
Understanding eating behaviors is important for designing and implementing strategies to reduce obesity and other diet-related chronic diseases and for improving overall health. Breakfast eating is associated with more favorable nutrient intakes compared to nutrient intakes from other meals or snacks. Adolescents and young adults are the least likely to eat breakfast, and targeted promotion efforts are needed to reach these groups. For children and adolescents, the school breakfast program is an important venue for promoting breakfast consumption and efforts are needed to increase student participation rates.
Americans are frequent snackers and snacks contribute substantially to daily energy intake and tend to be lower than meals in shortfall nutrients of public health concern relative to energy intake. Because snack foods and beverages are readily available and accessible in multiple settings throughout the day, both population-level environmental changes and individual behavioral interventions and communications are needed to ensure that healthy choices are available in these settings and to minimize their contribution to excess energy intake.
Individuals with lower incomes are less likely to eat three meals a day compared to higher income individuals and low-income households are more likely to be food insecure. The federal nutrition programs play a key role in reducing food insecurity and improving nutritional health.
Review of the Evidence
These conclusions were reached by examining existing WWEIA NHANES data tables,5 from NHANES 2009-2010 for current intakes, and WWEIA, NHANES 2003-2004, 2005-2006 and 2007-2008 data for trends. Respondents self-identified the specific meal or snack occasion for each food and beverage consumed.
Eating Occasions: Meals. Three meals a day is the current norm for most of the U.S. population ages 2 years and older, with almost two-thirds (63 percent) eating breakfast, lunch, and dinner (Figure D1.39). However, there are differences by age, sex, racial/ethnicity group, and income level. By age group, consuming three meals a day follows a modest U-shaped curve where it is most likely for children ages 2 to 5 years (84 percent). It then declines, and reaches its lowest point during adolescence and young adulthood, and then increases with age through the adult years. Adolescent females (12 to 19 years) and young adult males (20 to 29 years) are the most likely to not eat three meals a day (49 percent). For all other age/sex groups, eating three meals a day is reported by 59 to 73 percent of respondents. Eating only one meal a day is most likely for young adult males (12 percent) and adolescent females (10 percent). However, all but 1 percent of these respondents, consumed at least two or more snacks a day (Table D1.13).
Among the U.S. population ages 2 years and older, 15 percent do not eat breakfast, 20 percent do not eat lunch, and 7 percent do not eat dinner. Breakfast is most likely to be skipped by young adults ages 20 to 29 years (28 percent of males, 22 percent of females) and adolescents (25 percent of females, 26 percent of males). Breakfast skipping declines sharply with advancing age. Lunch is not eaten by 25 percent of adolescent females and from 17 to 28 percent of all adult age groups (Table D1.14).
Non-Hispanic whites are most likely to report consuming three meals a day, across all age/sex/racial/ethnic groups, with 68 percent reporting breakfast, lunch, and dinner consumption. For non-Hispanic Blacks, slightly less than half (48 percent) consumed all three meals, and for all Hispanics, slightly more than half (52 percent). Non-Hispanic Blacks ages 12 to 19 years and 20 years and older, and Hispanics ages 12 to 19 years, were least likely to consume three meals a day (42 percent, 45 percent, and 45 percent, respectively) and most likely to consume only one meal a day (18 percent, 11 percent, and 10 percent).66
The percent of individuals consuming three meals a day increases with higher income levels. For those below 131 percent and from 131 to 185 percent of the poverty threshold, 53 percent and 56 percent report three meals a day, while for those above 185 percent of the threshold, 70 percent report three meals a day. For lower income individuals, the lower number of meals consumed per day is much more evident for older children and adults. Among children ages 2 to 5 years in the three income groupings, 81 percent, 82 percent, and 88 percent, respectively, report consuming three meals a day, while for adults ages 20 years and older, the corresponding percentages are 48 percent, 54 percent, and 70 percent, respectively.67
Eating Occasions: Snacks. Nearly all of the U.S. population ages 2 years and older consume at least one snack a day (96 percent). The most common snacking pattern for most age, sex, racial/ethnic and income groups is two to three snacks per day. Females and males ages 70 years and older are most likely to report eating one or fewer snacks per day (26 percent), and children ages 2 to 5 years are the least likely (10 percent). Children ages 2 to 5 years are most likely of any age group to report four or more snacks per day, across all racial/ethnic groups.68
The number of individuals reporting one or fewer snacks per day is highest (25 percent) for those below 131 percent of the poverty threshold, and lowest (17 percent) for those above 185 percent of the threshold. Consumption of four or more snacks per day is lowest (25 percent) for those below 131 percent of the poverty threshold and highest (35 percent) for those above 185 percent of the threshold. However, for all income groups, 2 to 3 snacks per day is the modal number and similar across income groups (51 percent, 48 percent, 48 percent).67
Trends. Trend data from NHANES from 2005-2006 to 2009-2010 show little change in number of daily eating occasions or frequency of meal skipping (Table D1.15).
Diet Quality and Energy content by Eating Occasion. For this analysis, diet quality is defined as a comparison of nutrient or food group content to energy content of a specified set of foods or beverages. In this question, diet quality compares the proportion of total nutrient intake at a given eating occasion to the proportion of energy intake at that eating occasion.
This analysis is summarized in Figure D1.40 and described below. In looking at this Figure, it should be noted that percent of total intake of nutrients of concern are shown in comparison to percent of total energy. If a nutrient is above the energy line, the meal/snack is a relatively higher source of that nutrient. If it is below the energy line, it is a relatively lower source.
Breakfast has a higher overall diet quality compared to lunch, dinner or snacks. Breakfast consists of 15 to 20 percent of the days total energy intake (Table D1.16) but has a higher percent of nutrients. For all the shortfall nutrients of public health concern (fiber, folate, vitamin D, calcium, iron, and potassium), a higher percent of the days total intake was consumed compared to the percent of energy consumed (Figure D1.40)
Among the U.S. population ages 2 years and older, about one fourth (24 percent) of daily energy intake is consumed at lunch and about one-third (35 percent) is consumed at dinner (Table D1.16). In terms of dietary quality, lunch is neutral, with similar percents of total nutrients and energy intakes for most nutrients. Dinner, which provides the greatest amount of daily total energy intake, has a higher percent of fiber, and potassium in comparison to percent energy, but calcium and several other nutrients are lower in comparison to percent energy. Sodium and saturated fat are higher as a percent of their total intakes than is energy intake. Further, the percent of total daily intake of sodium and saturated fat consumed at dinner is higher compared to other meals and snacks (Figure D1.40).
About one-fourth (24 percent) of daily energy intake comes from snacks. For young children ages 2 to 5 years, 29 percent of daily energy is from snacks (Table D1.17). Snacks provide the lowest percent of key nutrients (protein, iron, vitamin D, fiber, and potassium) relative to the percent of energy provided. Snacks provide 42 percent of the daily intake of added sugars. A lower percent of total sodium than of energy is provided by snacks. Snacks provide roughly the same percent of total intake of calcium as they do energy. This is also true of saturated fat for females (Table D1.17).
For additional details on this body of evidence, visit:
- Percent of the U.S. population consuming or skipping meals and snacks, 2001-2002, 2005-2006, 2007-2008, and 2009-2010 by age/sex groups, race/ethnicity, and percent of the poverty threshold. Available from: http://seprl.ars.usda.gov/Services/docs.htm?docid=18349.
- Percent of total energy and nutrient intake by meal/snack, 2001-2002, 2005-2006, 2007-2008 and 2009-2010 by age/sex groups, race/ethnicity, and percent of the poverty threshold. Available from: http://seprl.ars.usda.gov/Services/docs.htm?docid=18349.
Question 14: What are the current status and trends in the location of meal and snack consumption and sources of food and beverages consumed at home and away from home? How do diet quality and energy content vary based on the food and beverage source?
Source of evidence: Data analysis
About two-thirds of the calories consumed by the U.S. population are purchased at a store (69 percent), such as a grocery store or supermarket, and consumed in the home. The percent of calories eaten away from home (32 percent) has remained about the same since 2003-2004.
Food group and nutrient quality as measured by the Healthy Eating Index (HEI) vary by where food is obtained. Despite this, no matter where the food is obtained, diet quality of the U.S. populations does not meet recommendations for fruit, vegetables, dairy, whole grains, and exceeds recommendations for sodium, saturated fats, refined grains, solid fats, and added sugars.
The overall diet quality of the U.S. populations dietary patterns, regardless of where the food is purchased and eaten, is of major public health concern. Given that fruit, vegetables, dairy, and whole grains are consumed in less than recommended amounts and that sodium, saturated fats, refined grains, solid fats, and added sugars exceed recommended levels, urgent action is needed at individual and population levels to alter food purchasing and consumption habits.
Efforts are needed by the food industry and food retail (food stores and restaurants) sectors to market and promote healthy foods. The general public needs to be encouraged to purchase these healthier options. Making healthy options the default choice in restaurants (e.g., fat-free/low-fat milk instead of sugar-sweetened beverages, and fruit and non-fried vegetables in Childrens Meals, whole wheat buns instead of refined grain buns for sandwich meals) would facilitate the consumption of more nutrient dense diets. Food manufacturers and restaurants should reformulate foods to make them lower in overconsumed nutrients (sodium, added sugars and saturated fat) and calories and higher in whole grains, fruits and vegetables.
In addition, Federal regulations for food labeling need to be updated. Food labels are an important tool to enable the public to follow the Dietary Guidelines and to make healthy food choices. They provide consumers with quick, easy to use information about the food they are purchasing. They also lead food companies to reformulate their food products to meet consumer demand. As recently proposed by the FDA, updates are needed in the Nutrition Facts label on packaged foods to emphasize calories, serving sizes, and nutrients of concern (including overconsumed nutrients such as sodium). Consumers also may benefit from a standardized Front of Pack label that gives clear guidance such as proposed by the IOM panel on FOP labeling.69
In addition to regulatory, policy, environmental and organizational changes, individual behavioral strategies are also needed to help Americans improve dietary behaviors. Comprehensive lifestyle interventions in a variety of settings and nutrition counseling by professionals in health care settings can modify dietary behaviors and improve health outcomes.
Review of the Evidence
This conclusion was reached by examining a new analysis of WWEIA, NHANES food intake data, from WWEIA NHANES 2009-2010 for current status, and WWEIA NHANES 2003-2004, 2005-2006 and 2007-2008 for trends (see Appendix E-2.13: Percent of energy intake from major points of purchase and location of eating, 2003-2004, 2005-2006, 2007-2008, 2009-2010, for the U.S. population ages 2 years and older and Appendix E-2.14: Food group and nutrient content of foods per 1000 calories obtained from major points of purchase, 2003-2004, 2005-2006, 2007-2008, 2009-2010, for the U.S. population ages 2 years and older). This analysis was requested by the DGAC to answer the question. In addition, the DGAC reviewed the ERS publication Nutritional Quality of Food Prepared at Home and Away from Home, 1977-200870 to ascertain longer-term trends.
Respondents self-identified the food source (point of purchase) for each food or beverage they reported. For this analysis, food sources were grouped into the following categories: stores (grocery, supermarket, convenience/corner stores), full-service restaurants (defined as table service restaurants), quick-serve restaurants (includes fast food, counter service, and vending machines), school (includes child care). The location of eating, either at home or away from home, also was examined (Figure D1.41).
Americans increased their away-from-home share of caloric intake from 18 percent in 1977-1978 to 32 percent in 2005-2008, mainly from full service and fast food restaurants.70 The percent of calories eaten away from home has remained roughly the same since 2003-2004. In 2009-2010, 69 percent of calories consumed by Americans were purchased from a store and 58 percent were eaten at home. This is about the same percent from 2003-2008 (Figure D1.41).
Diet quality was assessed using a density approach expressed as the amount of food group or nutrient per 1000 calories consumed, for each source from which food is obtained. The point of purchase (e.g., food store) is used as a proxy for where the food is consumed (e.g., home) because most food from stores are consumed at home, and most foods from other points of purchase are consumed away from home. Diet quality for a food group or nutrient for each food source obtained/consumed was then compared to the standard for a optimal HEI score per 1000 calories.71 For saturated fat intake, the amount from each source was compared to the 2010 Dietary Guidelines limit for saturated fat intake.
Fruit. Fruit group density (cups per 1000 calories) is well below the HEI standard regardless of where the food is obtained or consumed. Amounts of fruit obtained and consumed differ by source, with full service and fast-food restaurants providing much less fruit per 1000 calories compared to other sources. This changed little from 2003-2004 to 2009-2010. Amount of fruit per 1000 calories is highest from schools/day care, and increased from 2003-2004 to 2009-2010, especially from 2007-2008 on (Figure D1.42).
Vegetables. Density for vegetables (cups per 1000 calories) falls below recommended intakes regardless of where food is obtained (Figure D1.43). Amounts of total vegetables and the starchy and other vegetable subgroups are shown in Figures D1.43 and D1.44. (Other vegetables are those not in the dark green, red orange, or starchy subgroups, such as green beans, iceberg lettuce, onions, cabbage, cucumbers.) Amounts of total vegetables and other vegetables per 1000 calorie are highest for restaurants, especially full service restaurants, with a slight downward trend from 2007-2008 to 2009-2010 (Figures D1.43 and D1.44). Amounts of total vegetables and starchy vegetables per 1000 calories from schools/daycare show a suggestive decrease in 2009-2010 compared to earlier years. Density for all vegetable subgroups by source for 2003-2004 through 2009-2010 are listed in Table D1.18.
Dairy. Amounts of total dairy products (fluid milk, cheese, and yogurt) are highest from schools/day care sources and are above the HEI standard, with an increase from 2007-2008. Amounts from other sources are far below recommendations (Figure D1.45).
Whole and refined grains. Whole grain density per 1000 calories is far below the HEI standard and is low for all food sources with little change since 2003-2004. On the other hand, refined grains exceed the HEI limit for all food sources, with the highest amount coming from quick serve restaurants (Figure D1.46).
Protein foods. Amounts of total protein foods per 1000 calories are above the HEI standard for full service restaurants and fast food restaurants (Figure D1.47).
Sodium. Amounts of sodium per 1000 calories are well above the HEI limit and do not differ greatly across sources. However, the density from full service and fast food restaurants are somewhat higher than from stores. There has been little change from 2003-2004 to 2009-2010 (Figure D1.48).
Saturated fats. Amounts of saturated fat per 1000 calories is well above the Dietary Guidelines limit and do not differ greatly across sources. However, the density from fast food restaurants is somewhat higher than from stores. There has been little change from 2003-2004 to 2009-2010 (Figure D1.49).
Empty calories. (defined as the total calories from solid fats and added sugars). Empty calories are well above the HEI limit (190 calories per 1000 calories) for all food sources, with the highest amount from fast food restaurants, but no large differences among sources. Empty calories have trended downward since 2003-2004 (Figure D1.50). The HEI does not have a separate HEI standard for added sugars and solid fats. Both added sugars and solid fats have decreased since 2003-2004. (Figures D1.51, D1.52) The highest amounts of added sugars are obtained from stores and the highest amounts of solid fats are obtained from fast food restaurants.
Food group density by age group. For children ages 2 to 5 years, fruit group density per 1000 calories from schools and stores reaches the HEI standard. School foods provide the highest fruit density among all food sources for 6-11 year olds, with an increase since 2007-2008. All other age groups do not reach the HEI standard for fruit from any source, although the store location is consistently the top source for adults. Vegetable density from full service restaurants reaches the HEI standard for ages 51-70 and 71 years and older. All sources of vegetables are below the standard for children, adolescents and adults under age 50. Dairy product density from child care and stores meet the HEI standard for children ages 2-5 and from schools for children ages 6-19. School foods provide the highest dairy product density among all food sources in childrens diets. For school age children and adolescents, school foods are the only food source that meets the recommended amount of dairy products. Among adults, dairy product density is low for all sources. For children ages 6-11, there is a difference in the added sugars density by source, with schools having less added sugars per 1000 calories than other sources. This difference is not as clear for younger children or adolescents. For adults the highest amount of added sugars per 1000 calories is from stores. For most age groups, there is a slight downward trend, especially in the density of added sugars from stores (see Appendix E-2.15: Amount of key nutrients and food groups by age group per 1000 calories from each point of purchase, 2003-2004, 2005-2006, 2007-2008, and 2009-2010).
For additional details on this body of evidence, visit:
- Appendix E-2.13: Percent of energy intake from major points of purchase and location of eating, 2003-2004, 2005-2006, 2007-2008, and 2009-2010, for the U.S. population ages 2 years and older
- Appendix E-2.14: Food group and nutrient content of foods per 1000 calories obtained from major points of purchase, 2003-2004, 2005-2006, 2007-2008, and 2009-2010, for the U.S. population ages2 years and older
- Appendix E-2.15: Amount of key nutrients and food groups by age group per 1000 calories from each major point of purchase, 2003-2004, 2005-2006, 2007-2008, and 2009-2010
- ERS report, Nutritional Quality of Food Prepared at Home and Away from Home, 1977-2008. Available from: http://www.ers.usda.gov/publications/eib-economic-information-bulletin/eib105.aspx.