Consideration of nutrition and sustainability in public definitions of 'healthy' food: an analysis of submissions to the US FDA

OBJECTIVE

To better understand how the public defines 'healthy' foods and to determine whether the public considers sustainability, implicitly and explicitly, in the context of healthy eating.

DESIGN

We conducted a content analysis of public comments submitted to the US FDA in 2016 and 2017 in response to an invitation for feedback on use of the term 'healthy' on food labels. The analysis explored the ways in which commenters' definitions of 'healthy' aligned with the 2015-2020 Dietary Guidelines for Americans and whether their definitions considered sustainability.

SETTING

The US Government's Regulations.gov website.

PARTICIPANTS

All 1125 unique comments from individuals and organisations.

RESULTS

Commenters' definitions of 'healthy' generally mirrored the recommendations that the Dietary Guidelines for Americans put forth to promote a 'healthy eating pattern'. Commenters emphasised the healthfulness of fruit, vegetables, whole grains, fish and other minimally processed foods and the need to limit added sugars, sodium, saturated and trans fats and other ingredients sometimes added during processing. One-third of comments (n 374) incorporated at least one dimension of sustainability, mainly the environmental dimension. Commenters who mentioned environmental considerations primarily expressed concerns about synthetic chemicals and genetic modification. Less than 20 % of comments discussed social or economic dimensions of sustainability, and less than 3 % of comments (n 30) used the word 'sustainability' explicitly.

CONCLUSIONS

This novel analysis provides new information about the public's perceptions of 'healthy' foods relative to nutrition and sustainability considerations. The findings can be used to advance policy discussions regarding nutrition labelling and guidance.

Home and wild food procurement were associated with improved food security during the COVID-19 pandemic in two rural US states

Both food insecurity and home and wild food procurement (HWFP), including gardening, increased in many countries during the COVID-19 pandemic; yet little evidence has demonstrated what impact HWFP had on food security. Using data from a representative sample of nearly 1000 residents in the two most rural US states (Vermont and Maine) conducted via an online survey in Spring/Summer 2021, as well as matching techniques, we compare food security outcomes among households who did and did not participate in HWFP in the first year of the pandemic. Nearly 60% of respondents engaged in HWFP in some way during the first year of the pandemic, with food insecure households more likely to do HWFP. Furthermore, HWFP early in the COVID-19 pandemic is associated with improved food security in the 9-12 months later, though these improvements were primarily associated with newly, not chronically, food insecure households. Newly and chronically food insecure households were more likely to want to continue these activities in the future, but also exhibited greater barriers to land access and costs associated with these activities. These results suggest that HWFP may provide food security improvements for certain households that utilize them, especially during crisis situations. Future research about HWFP should continue to explore multiple HWFP strategies, their barriers, and their potentially myriad relationships to food security, diet, and health outcomes, especially with longitudinal data.

Perceptions and knowledge of protein in dairy and plant-based alternatives among stakeholders in the US marketplace

This study explores beliefs about protein in dairy and plant-based (PB) alternatives among stakeholders in the US marketplace and whether beliefs are associated with product preferences. Eight thousand and fifty-two unique comments submitted to the US Food and Drug Administration (FDA) in response to a request for public input on the labelling of PB dairy alternatives (FDA-2018-N-3522) were coded. Of these, 383 (4.8%) discussed protein and were analysed for protein-specific themes. Themes were examined in relation to the submitter's product preference. Most comments that discussed protein focused on protein content and/or health outcomes believed to be associated with intake. Only one commenter who preferred dairy demonstrated an inaccurate understanding of protein content in dairy and PB alternatives, although nearly all failed to identify fortified soy beverage as an appropriate protein replacement; meanwhile, 14.2% who preferred PB alternatives demonstrated an inaccurate understanding regarding protein content in dairy and PB products. The results suggest knowledge gaps exist regarding protein in PB dairy alternatives, especially among those who prefer non-dairy options.

Personal bias in nutrition advice: A survey of health professionals' recommendations regarding dairy and plant-based dairy alternatives

Objective

To examine the association between health professionals' personal dietary behaviors and their professional nutrition recommendations on dairy and plant-based dairy alternatives.

Methods

A cross-sectional survey of 331 U.S. health professionals examined willingness to recommend dairy and/or plant-based dairy alternatives to patients across personal milk preference, and dietary pattern.

Results

Plant-based milk preference (OR 4.52; p < 0.001) and following a vegetarian dietary pattern (OR 1.91; p = 0.019) were associated with greater odds of recommending plant-based dairy alternatives to patients. Plant-based milk preference (OR 0.16; p < 0.001), following a vegetarian dietary pattern (OR 0.45; p = 0.009), and considering one's diet to be "plant-based" (OR 0.41; p = 0.005) were associated with lessor odds of recommending dairy to patients. Dietetics professionals were more likely than all other health professionals to recommend both dairy and plant-based dairy alternatives to patients.

Conclusion

Health professionals' nutrition recommendations may reflect their personal nutrition choices. Improved nutrition training, focusing on evidence-based recommendations, reducing personal bias in practice, and routinely including registered dietitians on interprofessional healthcare teams may improve the quality of nutrition advice given to U.S. consumers.

Innovation

This paper is the first to examine if health professionals' personal health behaviors are associated with their health advice on dairy and/or plant-based dairy alternatives.

Investigating Knowledge on Calcium and Preferences for Dairy vs. Plant-Based Alternatives

Calcium is a nutrient of public health concern and commonly associated with dairy foods. In recent years, plant-based alternatives to dairy products have grown in popularity. This study examines public understanding of dietary calcium in dairy products and plant-based alternatives and explores whether knowledge is associated with product preference. In 2018, the U.S. Food and Drug Administration (FDA) solicited comments on the labeling of plant-based dairy alternatives (FDA-2018-N-3522), including input on consumer understanding of the nutritional content of dairy foods and plant-based products. All 11,906 submissions were obtained and 8,052 were retained after duplicate and near-duplicate comments were removed. Comments were coded for major nutrition themes and those that mentioned calcium and were analyzed for three calcium-specific themes: knowledge and beliefs about calcium content, calcium bioavailability, and health outcomes associated with intake. Submissions were examined in relation to each commenter's preference for dairy products or plant-based alternatives. 244 unique submissions (3.0%) mentioned calcium. Over half (51.2%) of commenters who mentioned calcium preferred plant-based alternatives. Comments mentioning calcium often reflected preference. Most commenters had an accurate understanding of calcium content in dairy and plant-based products. However, several commenters-especially those who preferred plant-based alternatives-misunderstood calcium metabolism and health outcomes related to calcium. Given declining consumption of fluid dairy milk-a key source of dietary calcium-and increasing consumption of plant-based alternatives, addressing gaps in nutrition knowledge and misunderstanding related to dairy and calcium intake is critical and has implications for nutrition education and policy.

Perspectives from healthcare professionals on the nutritional adequacy of plant-based dairy alternatives: results of a mixed methods inquiry

BACKGROUND

Healthcare professionals are important sources of nutrition and health information for Americans. As plant-based (PB) dairy alternative products increase in popularity, concerns have been raised about their nutritional adequacy, and whether consumers understand nutritional differences to dairy. Healthcare professionals directly advise consumers on dietary choices, therefore we sought to examine their understanding and opinions of PB dairy alternatives.

METHODS

We analyzed comments submitted to the U.S. Food and Drug Administration (FDA) by health professionals (n = 191) in 2018-2019 in response to a request for public comment on the nutrition of PB dairy alternatives and the use of dairy terms like "milk", "cheese", and "yogurt" on their labels. Survey data from healthcare professionals (n = 417) was collected in 2020-2021. Comments and survey responses to open-ended questions were coded using template analysis and thematically analyzed. Logistic regression models examined perceptions across health professional characteristics for close-ended survey responses.

RESULTS

Three-fourths of health professionals believe consumers are confused about the nutritional differences between dairy and PB dairy alternatives. Over half (53%) do not believe either product is nutritionally superior to the other. Many believe dairy products have higher nutrient value, but also believe PB dairy alternatives can be part of a healthful diet. Compared to other types of health professionals, dietetics professionals demonstrated a more accurate understanding of the nutritional value of both products and were more likely to believe nutrients like protein (OR 2.02; 95% CI 1.22-3.34, p = 0.006) and vitamin D (OR 2.46; 95% CI 1.48-4.09, p = 0.001) may be nutrients of concern for PB dairy alternative consumers. They were also more likely to believe consumers are confused about these products (OR 3.44; 95% CI 1.65-7.21; p = 0.001). Health professionals who submitted comments to the FDA showed stronger opinions in favor of PB dairy alternatives.

CONCLUSIONS

Although PB dairy alternatives have nutritional value in certain diets, responses from health professionals suggest that changing their labeling to be different than dairy may reduce confusion. Improved nutrition education among health professionals may also be necessary.

Food Security Impacts of the COVID-19 Pandemic: Longitudinal Evidence from a Cohort of Adults in Vermont during the First Year

This study assessed changes in household food insecurity throughout the first year of the COVID-19 pandemic in a cohort of adults in the state of Vermont, USA, and examined the socio-demographic characteristics associated with increased odds of experiencing food insecurity during the pandemic. We conducted three online surveys between March 2020 and March 2021 to collect longitudinal data on food security, use of food assistance programs, and job disruptions during the COVID-19 pandemic. Food security was measured using the USDA six-item module. Among the 441 respondents, food insecurity rates increased significantly during the pandemic and remained above pre-pandemic levels a year after the start of the pandemic. Nearly a third (31.6%) of respondents experienced food insecurity at some point during the first year of the pandemic, with 53.1% of food-insecure households being classified as newly food-insecure. The odds of experiencing food insecurity during the pandemic varied based on socio-demographic factors. Households with children (OR 5.5, 95% CI 1.782−16.936, p < 0.01), women (OR 8.1, 95% CI 1.777−36.647, p < 0.05), BIPOC/Hispanic respondents (OR 11.8, 95% CI 1.615−85.805, p < 0.05), and households experiencing a job disruption (OR 5.0, 95% CI 1.583−16.005, p <0.01) had significantly higher odds of experiencing food insecurity during the first year of the COVID-19 pandemic, while respondents with a college degree (OR 0.08; 95% CI 0.025−0.246; p < 0.001) and household income of ≥USD 50,000 (OR 0.01; 95% CI 0.003−0.038; p < 0.001) had lower odds of experiencing food insecurity. These findings indicate that food insecurity continued to be a significant challenge one year after the start of the pandemic, which is important, given the adverse health impacts associated with food insecurity and health disparities among certain socio-demographic groups.

Diaper Need During the COVID-19 Pandemic Associated with Poverty, Food Insecurity, and Chronic Illness: An Analysis of a Representative State Sample of Caretakers with Young Children

Objectives: Diaper need is an important form of material hardship for families with young children. This study quantified diaper need during the COVID-19 pandemic and examined factors associated with diaper need.

Methods: Using a representative statewide sample of adults in Massachusetts, diaper need was assessed during the COVID-19 pandemic among respondents with at least one child 0–4 years of age in diapers (n=353). Bivariate tests examined associations between diaper need and individual and household factors. Multivariable regression was used to examine associations between diaper need and demographic factors, job loss, and mental health during the pandemic.

Results: More than one in three respondents reported diaper need (36.0%). Demographic factors associated with diaper need were age <25 years, Latino ethnicity, having less than a high school degree, unemployment before the pandemic, household income <$50,000, household food insecurity, or having a household member with a chronic disease. Diaper need was higher among respondents who utilized a nutrition assistance program or a food pantry during the pandemic. In multivariable analyses considering job loss and mental health during the pandemic, diaper need was associated with household income <$50,000 (odds ratio [OR] 3.61; confidence interval [95% CI] 1.40–9.26) and a chronic disease diagnosis within the household (OR 4.26; 95% CI 1.77–10.29).

Conclusions: This study indicates a level of diaper need similar to what was documented before the COVID-19 pandemic despite federal stimulus payments and increased distributions by local diaper banks. The findings identify groups at increased risk and suggest opportunities to reach those at risk through food assistance programs.

Growing Opportunities for Equitable, Interdisciplinary Undergraduate Food Systems Education: A Review of Food Systems Education at Land-Grant Institutions and Development of Open-Access Materials

Post-secondary coursework related to agriculture and the food supply has been at the core of the United States' land-grant system for more than 150 years. However, as the complexity of food systems has grown, so too have critiques that the education provided in these programs is too narrow to adequately prepare graduates to address pressing food systems issues. In response, some higher education institutions have developed degrees in food systems. To support development of this burgeoning field, we created, tested, and refined four evidence-informed, interdisciplinary, equity-oriented, open-access teaching modules. These modules are based on our experience conducting a multi-site, multi-year transdisciplinary investigation of subsidized, or “cost-offset”, community supported agriculture and a survey asking instructors at land-grant institutions (n = 66) about topic offerings and current unmet needs for instructional materials. Our collaboration illuminated the potential and challenges of food systems research; underscored the value of transdisciplinary research teams; and identified several equity-oriented topics related to the design, implementation, and evaluation of local food initiatives suitable for advancing sustainable foods systems education. Instructors reported that the most helpful teaching aids would be case studies, lesson plans with active learning components, and reference lists with relevant peer-reviewed publications. The final modules seek to shed light on the complexity of food systems projects and build knowledge, vocabularies, and skills across disciplines engaged with food systems. Per instructor-defined needs, each module features a case study, active-learning activities, and references. We anticipate that the adaptable modules will be suitable for a wide range of students and courses.

A Multi-Site Analysis of the Prevalence of Food Insecurity in the United States, before and during the COVID-19 Pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic profoundly affected food systems including food security. Understanding how the COVID-19 pandemic impacted food security is important to provide support and identify long-term impacts and needs.

OBJECTIVE

The National Food Access and COVID research Team (NFACT) was formed to assess food security over different US study sites throughout the pandemic, using common instruments and measurements. This study presents results from 18 study sites across 15 states and nationally over the first year of the COVID-19 pandemic.

METHODS

A validated survey instrument was developed and implemented in whole or part through an online survey of adults across the sites throughout the first year of the pandemic, representing 22 separate surveys. Sampling methods for each study site were convenience, representative, or high-risk targeted. Food security was measured using the USDA 6-item module. Food security prevalence was analyzed using ANOVA by sampling method to assess statistically significant differences.

RESULTS

Respondents (n = 27,168) indicate higher prevalence of food insecurity (low or very low food security) since the COVID-19 pandemic, compared with before the pandemic. In nearly all study sites, there is a higher prevalence of food insecurity among Black, Indigenous, and People of Color (BIPOC), households with children, and those with job disruptions. The findings demonstrate lingering food insecurity, with high prevalence over time in sites with repeat cross-sectional surveys. There are no statistically significant differences between convenience and representative surveys, but a statistically higher prevalence of food insecurity among high-risk compared with convenience surveys.

CONCLUSIONS

This comprehensive study demonstrates a higher prevalence of food insecurity in the first year of the COVID-19 pandemic. These impacts were prevalent for certain demographic groups, and most pronounced for surveys targeting high-risk populations. Results especially document the continued high levels of food insecurity, as well as the variability in estimates due to the survey implementation method.

Community supported agriculture plus nutrition education improves skills, self-efficacy, and eating behaviors among low-income caregivers but not their children: a randomized controlled trial

Background

Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a ‘share’ of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children.

Methods

The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016–2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children’s diet quality, body mass index (BMI), and physical activity; caregivers’ nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed.

Results

No significant net effects on children’s dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers’ cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security.

Conclusions

Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security.

Trial registration

ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01168-x.

The Food Bank and Food Pantries Help Food Insecure Participants Maintain Fruit and Vegetable Intake During COVID-19

Charitable food services, including food banks and pantries, support individual and households' food access, potentially maintaining food security and diet quality during emergencies. During the COVID-19 pandemic, the use of food banks and pantries has increased in the US. Here we examine perceptions of food banks and food pantries and their relationship to food security and fruit and vegetable (FV) intake during the first 6 months of the COVID-19 pandemic, using a statewide representative survey (n = 600) of residents of Vermont. The utilization of food pantries was more common among food insecure households and households with children. Among food insecure respondents, those who did not use a food pantry were significantly more likely to report consuming less FV during the pandemic. Further, we find respondents who are food insecure and using a food pantry report consuming more FV since the onset of the COVID-19 pandemic. We found that respondents who were both food insecure and reported not using a food pantry were significantly more likely to report both a reduction in fruit consumption (b = −0.58; p = 0.001) and a reduction in vegetable consumption (b = −0.415; p = 0.012). These results indicate that these services may support food access and one important dimension of diet quality (FV intake) for at-risk populations during emergencies.

Home food procurement impacts food security and diet quality during COVID-19

Background

Home food procurement (HFP) (i.e. gardening, fishing, foraging, hunting, backyard livestock and canning) have historically been important ways that people obtain food. Recently, some HFP activities have grown (e.g. gardening), while other activities (e.g. hunting) have become less common in the United States. Anecdotally, COVID-19 has sparked an increase in HFP evidenced by increased hunting licenses and shortages in seeds and canning supplies. HFP may have positive benefits for food security and diet quality, though research beyond gardening is especially limited in high-income countries.

Methods

We examine HFP activities since the COVID-19 pandemic began, and their relationship to food security and dietary quality using multivariable logit models and matching analysis with a statewide representative survey (n = 600) of residents of Vermont, United States.

Results

We find 29% of respondent households classified as food insecure since COVID-19, and higher prevalence of food insecurity among those experiencing a negative job change since COVID-19, households earning less than $50,000 annually, Hispanic and multi-race respondents. Nearly 35% of respondents engaged in HFP activities since the COVID-19 pandemic began; the majority of those gardened, and more than half pursued HFP activities more intensely than before the pandemic or for the first time. Food insecure households were more likely to pursue HFP more intensely, including more gardening, fishing, foraging, and hunting. Respondents who were food insecure, Black, Indigenous, People of Color, those with a negative job disruption, and larger households all had greater odds of increased intensity of HFP during the COVID-19 pandemic. HFP was significantly associated with eating greater amounts of fruits and vegetables; however, this effect was only significant for food secure households.

Conclusion

Overall, these results suggest that HFP activities have increased since the start of the COVID-19 pandemic, and may be an important safety net for food insecure households. However, HFP for food insecure households does not translate into the same higher fruit and vegetable intake as found among food secure HFP households, suggesting this population may be trying to maintain intake, or that they may have potential important resource or technical assistance needs. Long-term, HFP activities may have important food security and diet quality impacts, as well as conservation implications, which should be more thoroughly explored. Regardless, the increased interest and intensity of HFP demonstrates opportunities for educational and outreach efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10960-0.

Fruit and Vegetable Intake Assessed by Repeat 24 h Recalls, but Not by A Dietary Screener, Is Associated with Skin Carotenoid Measurements in Children

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute’s All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2–12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/−1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

The Early Food Insecurity Impacts of COVID-19

COVID-19 has disrupted food access and impacted food insecurity, which is associated with numerous adverse individual and public health outcomes. To assess these challenges and understand their impact on food security, we conducted a statewide population-level survey using a convenience sample in Vermont from March 29 to April 12, 2020, during the beginning of a statewide stay-at-home order. We utilized the United States Department of Agriculture six-item validated food security module to measure food insecurity before COVID-19 and since COVID-19. We assessed food insecurity prevalence and reported food access challenges, coping strategies, and perceived helpful interventions among food secure, consistently food insecure (pre-and post-COVID-19), and newly food insecure (post COVID-19) respondents. Among 3219 respondents, there was nearly a one-third increase (32.3%) in household food insecurity since COVID-19 (p < 0.001), with 35.5% of food insecure households classified as newly food insecure. Respondents experiencing a job loss were at higher odds of experiencing food insecurity (OR 3.06; 95% CI, 2.114-0.46). We report multiple physical and economic barriers, as well as concerns related to food access during COVID-19. Respondents experiencing household food insecurity had higher odds of facing access challenges and utilizing coping strategies, including two-thirds of households eating less since COVID-19 (p < 0.001). Significant differences in coping strategies were documented between respondents in newly food insecure vs. consistently insecure households. These findings have important potential impacts on individual health, including mental health and malnutrition, as well as on future healthcare costs. We suggest proactive strategies to address food insecurity during this crisis.