Letter to the Editor - Journal of Nutrition

Nutrition Research 21 (2001) 1411–1423 www.elsevier.com/locate/nutres

Healthy eating index of black and white older adults Christy C. Tangneya,*, Denis A. Evansb, Julia L. Bieniasb, Martha Clare Morrisb a

Department of Clinical Nutrition, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL, USA Rush Institute for Healthy Aging, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL, USA

b

Received 14 March 2001; revised 9 October 2001; accepted 25 October 2001

Abstract The Healthy Eating Index (HEI) is a measure of dietary quality that was developed to capture the multi-dimensional aspects of eating patterns and to track diet quality over time. We computed HEI scores based on responses to food frequency questionnaires among 4,932 participants in the Chicago Health and Aging Project (CHAP), an ongoing population-based study of adults aged 65 years and older (61% black; 39% white). The average HEI score for the CHAP population was 70.7, below the range of 80 –100 defined as a “good” diet by the USDA. Scores varied significantly by race and gender. White women had the highest HEI scores (mean, 73.5;n ⫽ 1198) followed by black women (mean, 71.5; n ⫽ 1797) and white men (mean, 70.5;n ⫽ 744). Black men had the lowest scores (mean, 66.8; n ⫽ 1193). Many older urban adults, and in particular, older black men, may have diets that are inadequate according to USDA dietary recommendations. © 2001 Elsevier Science Inc. All rights reserved. Keywords: Healthy Eating Index; food consumption; diet quality; diet variety; CSFII

1. Introduction The Healthy Eating Index (HEI) is a summary measure of diet quality that was designed by the United States Department of Agriculture’s Center for Nutrition Policy and Promotion in order to monitor changes in patterns of food consumption over time [1]. The index measures how well diets conform to the recommendations of the Dietary Guidelines and the

* Corresponding author. Tel.: ⫹1-312-942-5995; fax: ⫹1-312-942-5203. E-mail address: [email protected] (C.C. Tangney). 0271-5317/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved. PII: S 0 2 7 1 – 5 3 1 7 ( 0 1 ) 0 0 3 7 6 – 1

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C.C. Tangney et al. / Nutrition Research 21 (2001) 1411–1423

Food Guide Pyramid. The index was first applied to 24-hour recall data from the 1989 –1990 Continuing Survey of Food Intake by Individuals (CSFII), and then subsequently revised for use with 1994 –1996 CSFII data [2,3]. This score has also been adapted for use with food frequency questionnaires (FFQs) from participants in the Nurses Health Study [4] and the Male Health Professionals Study [5]. Other dietary scores have been developed to capture the multi-dimensional nature of food selection patterns. Both 24-hour recalls and FFQs have been used to construct scores for NHANES II, the National Health Interview Survey, and the Breast Cancer Detection and Demonstration Project [6 – 8]. In the latter study, the Recommended Food Score was inversely related to 6-year all-cause mortality among 43,000 women screened [8]. Improvement in another composite diet score based on FFQ data from the Nurses Health Study was associated with the 14-year decline in coronary heart disease incidence [9,10]. The present study describes the HEI scores of a large population of black and white older adults (65 years and older) residing in the Chicago area based upon responses from a 156-item FFQ. To the best of our knowledge, this is one of the first reports of diet quality of black and white older adults. HEI scores have been reported for black CSFII participants [11] though not separately for older adults, nor are there data for older Americans stratified according to ethnic groups [12].

2. Materials and methods 2.1. Population The dietary data are on participants of the Chicago Health and Aging Project (CHAP), a longitudinal study of risk factors for Alzheimer’s disease and other chronic health problems of older residents. In 1993 to 1997, a door-to-door census identified all residents aged 65 years and older of three contiguous neighborhoods on the south side of Chicago. All age-eligible residents were asked to participate in home interviews about their health and lifestyles, and 78% or 6,158 persons complied. The response rate was somewhat higher among black (81%) than white residents (75%). The interviews included questions about education, income, employment, smoking behavior, height and measured weight. A more detailed description of the study was published previously [13]. The study was approved by the Rush Presbyterian St. Luke’s Medical Center Institutional Review Board. 2.2. Dietary assessment Dietary assessment of the CHAP population began in February 1996 and concluded in April 1999. Of the 6,158 CHAP participants, 721 died before a dietary assessment could be completed, and 5,192 of the survivors (95%) completed a FFQ. The FFQs were either mailed or hand-delivered to the participants along with a stamped, addressed envelope for their return. Study staff made personal visits to collect unreturned FFQs, and in some cases, administered the FFQ as an interview (30% of completed questionnaires). Excluded from these analyses are 157 FFQs that had entire food sections or more than half


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the food items left blank, or with energy intakes ⬍ 700 kcal or ⬎ 4000 kcal for men and ⬍ 500 kcal or ⬎ 3800 kcal for women. We eliminated another 92 FFQs that were completed by persons with low cognitive scores (⬍10) on the Mini-Mental Status Examination, leaving a total of 4,943 FFQs. An additional 11 FFQs were removed prior to analyses because participants were neither black or white. 2.3. CHAP FFQ The CHAP FFQ [14] is a modified version of the Youth/Adolescent Questionnaire (YAQ [15], which was adapted from the Harvard FFQ [16] for self-administration by children aged 8 to 18 years. The 156-item questionnaire contains questions regarding the usual consumption of 139 food items and vitamin and/or mineral supplements over the last year plus additional questions about dietary behaviors. Compared to adult versions of the Harvard FFQ, the modified FFQ has fewer food items per page, non-quantitative portion sizes (e.g. 1 slice), fewer and shorter response options listed directly below each food item, and the inclusion of whole dishes, such as macaroni and cheese. Prior to the CHAP food survey, we conducted a pilot study on 185 randomly selected CHAP participants to evaluate the acceptability of the FFQ by this older, biracial population, many of whom migrated from the rural south. The pilot FFQ included 4 additional foods particular to the southern rural diet (pig’s feet, hog’s headcheese, chittlins, and sausage) that were not already included on the FFQ (e.g. greens, collards, grits, macaroni and cheese). In the pilot study, sausage was the only one of the 4 foods that was consumed with sufficient frequency and therefore added to the modified CHAP FFQ for the larger study. The FFQ also has questions concerning the fat content of dairy products consumed, removal of fat or poultry skin, special diets, meal preparation, consumption of ready made meals (e.g. frozen or microwave dinners), frequency of meals eaten away from home, and specific brand names of cereals, margarines, oils and multivitamins. 2.4. FFQ validation A validation study comparing the CHAP FFQ to repeated 24-hour dietary recalls was conducted among 232 randomly selected CHAP participants. Pearson’s correlation coefficients (r) for total intakes of selected dietary components for black (b) and white (w) participants were: for total fat (b: r ⫽ 0.45, w: r ⫽ 0.40), saturated fat (b: r ⫽ 0.44, w: r ⫽ 0.51), polyunsaturated fat (b: r ⫽ 0.37, w: r ⫽ 0.34), vitamin E (b: r ⫽ 0.46, w: r ⫽ 0.76), vitamin C (b: r ⫽ 0.35, w: r ⫽ 0.75), vitamin B6 (b: r ⫽ 0.51, w: r ⫽ 0.49), calcium (b: r ⫽ 0.44, w: r ⫽ 0.60) and iron (b: r ⫽ 0.39, w: r ⫽ 0.46). All correlations were highly significant (p ⬍ 0.001). 2.5. Nutrient analyses The FFQs were optically scanned and analyzed using the Harvard nutrient database, which is continually updated using the USDA Handbook No. 8 series with additional updates supplemented from manufacturers and McCance and Widdowson’s The Composition of

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Foods [17]. For some of the food items, natural portion sizes (e.g. 1 slice of bread, 1 egg, 1 banana) were used to determine nutrient content. Otherwise, nutrient content was based on mean portion sizes reported by the oldest participants (aged 65–74 and 75⫹ years) of the National Food Consumption Surveys, 1977–1978 [18,19] and 1987–1988 (personal communication). Daily intake of each dietary component was computed by multiplying the nutrient content of the food item by reported frequency of intake, and summing over all food items. 2.6. CHAP HEI scores Scores for the HEI range from 0 to 100 (perfect) and are based on USDA guidelines [1,3,20 –22]. The score is the sum of 10 components based on servings of grains, vegetables, fruits, milk, and meats, energy contribution from total fat, energy contribution from saturated fat, cholesterol intake, sodium intake, and food variety. Component scores for the first five components (food groups) reflect the total number of servings for that food group as recommended for men and women of specific age groups. For our population, recommended numbers of servings are those for men and women aged 51 years and older. A maximum score of 10 was assigned if the reported servings or intake level met or exceeded the recommendation. Scores of 0 were assigned if no food item in a particular food group was consumed (the 5 food groups), if less than 10 different foods were consumed more than once per month (variety) or if intake exceeded specified levels (45% of energy as total fat, 15% of energy as saturated fat, 450 mg dietary cholesterol, and 4800 mg dietary sodium). Scores less than 10 were assigned proportionately to the number of servings or intake level. For example, a score of 5 was assigned if half the number of recommended servings was consumed. Variety scores were computed on the basis of the total number of food items consumed more than once a month. For the computation of the variety scores, similar foods (e.g., hamburger and cheeseburger) were grouped together and counted only once. Combination foods, such as macaroni and cheese were broken down into their component ingredients and assigned to relevant food groups. The CHAP FFQ contains 79 questions pertaining to the variety component including 13 dairy or egg, 6 fish or poultry, 10 meat, 12 fruit, 21 vegetable, and 17 grain items. Any participant reporting consumption of 50 or more foods more than once per month (the 75th percentile of this distribution) was assigned the maximum variety component score of 10. 2.7. Demographic and other variables Non-dietary information on all CHAP participants was obtained from in-home interviews. Age was computed on the basis of self-reported birth date and date of returned FFQ. Race questions and categories were the same as those used by the 1990 US Census. Years of education were based on responses to a question on the highest grade or year of regular schooling. Smoking status was based on responses to a question regarding whether the participant currently smoked or not. Height was self-reported. Interviewers measured the participant’s weight on a digital free-standing scale placed on a flat surface with participant’s


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Table 1 Characteristics of the CHAP population stratified by race and gender within race, 1996 –1999* Characteristic

Age 65–74 y 75–84 y 85⫹ Education ⬍8 y 8–11 y 12⫹ Income $0–14,999 $15,000– 29,999 $30,000– 49,999 $50,000– 74,999 $75,000⫹ Smoking Current Former Never BMI ⬍⫽25 ⬎25 Working? Yes No

Total Blacks Whites (n ⫽ 4932) All Women Men All Women Men (n ⫽ 2990) (n ⫽ 1797) (n ⫽ 1193) (n ⫽ 1942) (n ⫽ 1198) (n ⫽ 744) 63*,a 29 8

70 25 5

67b 26 7

73 23 4

52 36 12

47 39 14

60 33 7

9 26 65

13 36 51

11 35 54

16 36 48

2 12 86

2 13 85

1 10 89

40 34

51 35

63 29

37 42

25 34

34 36

11 30

18

11

7

16

26

20

35

5

3

1

4

10

7

13

3

1

⬍1

⬍1

5

3

11

13 39 46

16 39 45

14 31 55

21 50 29

12 39 49

10 31 59

11 53 36

34 66

23 77

30 70

38 62

46 54

52 48

38 62

12 88

10 90

11 89

7 93

13 87

12 88

17 83

* All values are percentages. The proportion of individuals in that column with the characteristic specified in that row, e.g., a63% of the total CHAP population who were between 65 and 74 years of age; b67% of Black women are between the ages 65 to 74 years of age. a,b

shoes removed. Body mass index was calculated from these measurements (weight[kg]/ height[m]2). 2.8. Statistics All data were examined for normality and transformed if necessary. Analyses were performed using SAS, version 8 (Cary, NC). Comparisons in scores among categories of age (65–74, 75– 84, and 85⫹ years), race (black and white), gender (female and male), education (less than 8, 8 –11, 12⫹ years), income (levels specified in Table 1), smoking status (current, former, never), body mass index (ⱕ25, ⬎25) or employment status (working? yes or no) were performed with ANOVA tests. Comparisons in HEI and component scores between race and gender groups were also performed with ANOVA tests. If significant differences

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were observed for the ANOVAs, the least significant difference test was used to detect in which groups those differences existed. Pearson product moment correlations were used, unless otherwise indicated. When the HEI scores were compared to selected nutrient estimates or nutrient estimates from recalls and FFQs, estimates for individual nutrients were always energy adjusted according to the regression residual method of Willett and Stampfer [23].

3. Results 3.1. Population characteristics Population characteristics of 2,990 black and 1,942 white CHAP participants are presented in Table 1. A greater proportion of white adults was older and had more years of education as compared to black participants. The highest income category of $75,000 or more per annum was reported by 3% of participants and 13% of the participants were smokers. Only the proportion of black men currently smoking was markedly higher. Nearly 40% reported an annual income of less than $15,000 (many of whom were black). From 10% to 17% of the study population were working at the time of the interview. 3.2. HEI scores of CHAP participants HEI scores ranged from 33 to 96 with a mean of 70.7 (SD, 10.6), and a median score of 71.5. Because a significant race by gender interaction (p ⬍ 0.0001) was observed for HEI scores, all data are reported for the total group and for each of the four race-gender groups. When the distribution of total HEI scores for each of the four race-gender groups are depicted graphically (Figure 1), these differences become apparent. Black men had the lowest scores (mean 66.8) as shown by the leftmost curve. White women had the highest HEI scores (mean, 73.5) followed by black women (71.5) and white men (70.5). In the total population (Table 2), the lowest proportions of perfect scores occurred for grains, vegetables, milk and meat. The highest proportions with perfect scores occurred for total and saturated fat (as a percentage of energy), and cholesterol and sodium intakes. White women had significantly higher vegetable scores than any other group (p ⬍ 0.05) and black men had the poorest scores for this component (p ⬍ 0.05). Fruit scores of black and white women were significantly greater than those of their male counterparts (p ⬍ 0.05). White men and women had significantly higher milk scores than their black counterparts (p ⬍ 0.05). Moreover, perfect milk scores were observed in fewer black women (10.9%) and black men (10.5%) than in white women (22.2%) and men (20.7%). Among the four race-gender groups, black women had the best scores for total fat, saturated fat and sodium (though nonsignificant), and white women had the highest scores for grains, cholesterol, and vegetables (with only the latter component were scores significantly difference, p ⬍ 0.05). There were no significant differences in HEI scores across three age groups (65–74, 75– 84 and 85⫹ years), but participants with 12 or more years of education (mean ⫾ SD, 71.7 ⫾ 10.7) had significantly higher HEI scores (p ⬍ 0.0001) than those with less education


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Fig. 1. Frequency distributions of HEI scores for four groups: black men, white men, black women, and white women.

(mean ⫾ SD, 68.8 ⫾ 10.5), except for black men in whom there was no discernible trend with educational level. Among women of both races, HEI scores increased with increasing income categories; there were no differences among income categories of men, however. HEI scores were significantly higher (p ⬍ 0.0001) among non-smokers (mean ⫾ SD, 71.2 ⫾ 10.5) compared to current smokers (mean ⫾ SD, 67.6 ⫾ 10.7). 3.3. Comparison of HEI component scores and total HEI scores with dietary estimates HEI scores were positively correlated with the total number of different foods consumed per month (r ⫽ 0.51), with the number of servings of grains (r ⫽ 0.40), vegetables (r ⫽ 0.61), and fruits (r ⫽ 0.63), and negatively associated with total fat (r ⫽ ⫺0.46), and saturated fat (r ⫽ ⫺0.46). More moderate correlations with total HEI score were observed for milk (r ⫽ 0.32), meats (r ⫽ 0.26), and cholesterol (r ⫽ 0.26). HEI scores also rose concordantly with many of the macronutrients and micronutrients targeted by the Food Guide Pyramid and Dietary Guidelines. For example, the HEI scores were positively correlated with dietary fiber (r ⫽ 0.66), folate (r ⫽ 0.64), vitamin C (r ⫽ 0.55), vitamin A (r ⫽ 0.55), vitamin E (r ⫽ 0.34), protein (r ⫽ 0.47), calcium (r ⫽ 0.45), and vitamin D (r ⫽ 0.40) intakes. All of these relationships were statistically significant at p ⬍ 0.0005 except for dietary sodium intakes (p ⫽ 0.12). The total HEI scores of participants had good internal consistency with its specific components and external validity with the intakes of specific nutrients or dietary components

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Table 2 Total and component HEI scores by race and sex, CHAP 1996 –1999 Component score

Total (n ⫽ 4932)

Black women (n ⫽ 1797)

Black men (n ⫽ 1193)

White women (n ⫽ 1198)

White men (n ⫽ 744)

Total HEI

70.7 ⫾ 10.6a (0)b 5.2 ⫾ 2.3a (5.5)b 5.9 ⫾ 2.8 (15.9) 6.7 ⫾ 3.0 (29.2) 5.0 ⫾ 3.1 (15.0) 6.0 ⫾ 2.4 (10.8) 8.4 ⫾ 2.2 (44.4) 8.2 ⫾ 2.7 (50.6) 9.0 ⫾ 2.4 (78.3) 8.7 ⫾ 2.4 (59.0) 7.7 ⫾ 2.2 (26.9)

71.5 ⫾ 10.6c (0) 5.3 ⫾ 2.4 (6.5) 6.0 ⫾ 2.8c (17.8) 7.1 ⫾ 3.1c (36.3) 4.4 ⫾ 3.0c (10.9) 6.1 ⫾ 2.4 (11.8) 8.6 ⫾ 2.0 (48.7) 8.6 ⫾ 2.4 (57.8) 9.1 ⫾ 2.3 (80.2) 8.8 ⫾ 2.3 (64.7) 7.7 ⫾ 2.3 (28.5)

66.8 ⫾ 9.8d (0) 4.8 ⫾ 2.2 (4.4) 4.8 ⫾ 2.7d (8.8) 5.7 ⫾ 3.1d (18.2) 4.3 ⫾ 2.9c (10.5) 6.0 ⫾ 2.5 (12.7) 8.3 ⫾ 2.1 (42.7) 8.3 ⫾ 2.5 (49.5) 8.5 ⫾ 2.9 (70.3) 8.6 ⫾ 2.5 (58.9) 7.6 ⫾ 2.2 (25.3)

73.5 ⫾ 10.9e (0) 5.8 ⫾ 2.2 (7.2) 6.8 ⫾ 2.7c (24.5) 7.5 ⫾ 2.7c (37.4) 6.0 ⫾ 3.0d (22.2) 5.8 ⫾ 2.3 (8.4) 8.1 ⫾ 2.4 (40.8) 7.7 ⫾ 3.1 (44.7) 9.4 ⫾ 2.0 (84.0) 8.6 ⫾ 2.3 (56.4) 7.9 ⫾ 2.1 (27.0)

70.5 ⫾ 9.6c (0) 5.0 ⫾ 2.0 (1.9) 5.7 ⫾ 2.5c (8.6) 6.2 ⫾ 2.7d (16.1) 6.1 ⫾ 2.9d (20.7) 5.9 ⫾ 2.3 (9.4) 8.3 ⫾ 2.2 (42.2) 7.7 ⫾ 3.0 (44.4) 9.1 ⫾ 2.2 (77.4) 8.5 ⫾ 2.2 (49.5) 7.9 ⫾ 2.0 (25.5)

1. Grains 2. Vegetables 3. Fruits 4. Milk 5. Meats 6. Total fat 7. Saturated fat 8. Cholesterol 9. Sodium 10. Variety

Scores are reported as means ⫾ SD. Within each column, the proportion of participants with a perfect score of 10 for that specified component. None of the participants had a total HEI score of 100. c,d,e Values with different superscripts are significantly different (p ⬍ 0.05). a

b

(Table 3). We divided individuals according to their HEI score into categories used by the USDA [1,3] to define a “good” diet (HEI ⬎ 80), a diet that “needs improvement” (HEI 51 to 80), and a “poor” diet (HEI ⬍⫽50). To provide better inspection, we arbitrarily divided those with scores between 51 and 80 into two groups: a group with scores between 41 and 65, and one with scores of 66 – 80. The percent of energy from total fat and saturated fat decreased with increasing HEI scores, as did the cholesterol intakes.

4. Discussion There is surprisingly little dietary information for black and white older adults, and in particular, older black adults. We found that only 22% of adults from this older bi-racial community population had HEI scores indicating a “good” diet. The participants consumed diets that were low in total fat, saturated fat, cholesterol, and sodium but they appeared to be less successful in meeting recommendations for vegetables, milk, grains, and meats. There were distinct ethnic and gender differences in HEI scores, as shown in Figure 1 and Table


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Table 3 Relationship of HEI scores with daily number of foods, number of food group servings, energy and select dietary intake estimates and the distribution of foods, energy and dietary variables according to HEI rankings of 4932 CHAP participants Variable

HEI ranking “Poor” diet HEI scores (0–50) (n ⫽ 148)

Number of foods: 50⫹a Number of servings Grains: 7.4/9.1a Vegetables: 3.5/4.2 Fruits: 2.5/3.2 Milk: 2/2 Meats: 2.2/2.5 Total fat, % energy: ⱕ30a Saturated fat, % energy: ⬍10 Cholesterol, mg (energy-adjusted): ⱕ300 mg Sodium, mg (energy-adjusted): ⱕ2400 mg

Diet “needs improvement” HEI scores 51–65 (n ⫽ 1209)

HEI scores 66–80 (n ⫽ 2477)

“Good” diet HEI scores (80⫹) (n ⫽ 1098)

25.7 ⫾ 8.8c 2c

35.6 ⫾ 10.9 100

44.5 ⫾ 10.6 683

49.2 ⫾ 7.9 542

2.5 ⫾ 1.4c 2c 0.8 ⫾ 0.6 0 0.6 ⫾ 0.6 0 0.7 ⫾ 0.8 11 1.1 ⫾ 0.9 4 38.8 ⫾ 5.6 13.9 ⫾ 2.8 261.1 ⫾ 92.6

3.3 ⫾ 1.7 18 1.4 ⫾ 0.8 21 1.2 ⫾ 0.7 43 0.8 ⫾ 0.8 99 1.2 ⫾ 0.7 84 33.0 ⫾ 5.8 11.1 ⫾ 2.7 235.2 ⫾ 80.7

4.4 ⫾ 2.0 150 2.3 ⫾ 1.2 277 2.2 ⫾ 1.2 642 1.1 ⫾ 0.9 317 1.5 ⫾ 0.7 287 30.1 ⫾ 5.0 9.8 ⫾ 2.1 215.1 ⫾ 63.4

5.3 ⫾ 1.9 99 3.6 ⫾ 1.2 484 3.3 ⫾ 1.2 753 1.6 ⫾ 1.0 313 1.7 ⫾ 0.7 160 27.4 ⫾ 4.0 8.7 ⫾ 1.6 193.9 ⫾ 50.6

1975 ⫾ 494

2112 ⫾ 433

2231 ⫾ 392

2195 ⫾ 337

a The number of servings for women/men or proportion of energy or amount that constitutes a perfect score for that component, i.e., 7.4/9.1 servings of grains would equal a 10 for the grain score for women/men, respectively. b Values represent mean ⫾SD. c The average number of foods, number of servings or amount observed for participants with a HEI score that falls in either the “poor,” “needs improvement” or “good” category. The lower number reflects the proportion of participants in that HEI category with a perfect score for that component, i.e., 2 participants with a “poor” HEI had a score for 10 for variety (number of different foods) and 2 participants with a “poor” HEI had a score of 10 for grains.

2. Men of both races consumed fewer servings of fruits than did women, and whites consumed more milk and milk products than blacks. Total calcium (diet and supplements) intake in the CHAP population was far below the dietary reference intake of 1200 mg per day [24], ranging from a mean of 680 mg among black men to a mean of 921 mg among white females. All groups consumed fewer grains than recommended. There are no published reports of HEI scores in older populations to compare to the CHAP population other than one of the CSFII [12], in which data were not presented separately for black and white adults. Therefore, we examined HEI scores for persons 65 years and older from the 1994 –1996 CSFII, a nationally representative survey, and downloaded data for analysis on CSFII black and white participants aged 65 years and older from the Center for Nutrition Policy and Promotion (CNPP) web site www.usda.gov/cnpp. HEI scores were

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Table 4 HEI scores of adults aged 65 years or more from CSFII 1994 –1996 Component score

Total (n ⫽ 4475)

Black women (n ⫽ 231)

Black men (n ⫽ 200)

White women (n ⫽ 1939)

White men (n ⫽ 2105)

Total HEI 1. Grains 2. Vegetables 3. Fruits 4. Milk 5. Meats 6. Total Fat 7. Saturated Fat 8. Cholesterol 9. Sodium 10. Variety

64.6 ⫾ 13.4a 6.6 ⫾ 2.8 5.9 ⫾ 3.5 4.2 ⫾ 4.0 5.6 ⫾ 3.7 6.4 ⫾ 3.2 6.9 ⫾ 3.5 6.3 ⫾ 4.0 7.9 ⫾ 3.8 6.7 ⫾ 3.8 7.6 ⫾ 3.0

66.1 ⫾ 13.8 6.6 ⫾ 2.7 6.1 ⫾ 3.4 4.6 ⫾ 4.1 5.7 ⫾ 3.6 6.2 ⫾ 3.2 7.1 ⫾ 3.5 6.8 ⫾ 3.7 8.0 ⫾ 3.7 7.0 ⫾ 3.7 8.0 ⫾ 2.9

65.8 ⫾ 13.0 6.9 ⫾ 2.7 6.3 ⫾ 3.5 4.2 ⫾ 4.2 5.8 ⫾ 3.8 6.5 ⫾ 3.2 7.1 ⫾ 3.4 6.6 ⫾ 3.9 7.6 ⫾ 3.9 6.9 ⫾ 3.6 7.8 ⫾ 2.8

64.2 ⫾ 13.3 6.7 ⫾ 2.8 5.9 ⫾ 3.5 4.1 ⫾ 4.0 5.5 ⫾ 3.7 6.5 ⫾ 3.2 7.0 ⫾ 3.4 6.3 ⫾ 3.9 7.8 ⫾ 3.8 6.7 ⫾ 3.8 7.6 ⫾ 3.0

64.0 ⫾ 13.4 6.6 ⫾ 2.7 5.8 ⫾ 3.5 4.1 ⫾ 4.0 5.7 ⫾ 3.7 6.3 ⫾ 3.2 6.8 ⫾ 3.5 6.2 ⫾ 4.0 8.0 ⫾ 3.6 6.7 ⫾ 3.8 7.6 ⫾ 3.0

a

Values represent mean ⫾ SD.

computed by the CNPP for all CSFII participants with complete data on the first day of the two-day survey. Total HEI scores among the 4,475 CSFII older participants were lower than HEI scores of CHAP participants (mean HEI ⫽ 64.6 in CSFII versus 70.7 in CHAP) (Tables 2 and 4). In contrast to the CHAP study, in which significant differences existed in total HEI scores by race and gender, no such differences were observed in the CSFII participants. HEI scores of whites and of black females in the CSFII survey appeared lower than those of the CHAP study participants, but HEI scores for black males were similar in the two studies (mean, 66.8 in CHAP versus mean, 65.8 in CSFII). The CHAP participants also had lower grain scores of the CSFII participants and higher fruit, total fat, saturated fat, cholesterol and sodium scores. In the CSFII, variety scores for persons 70 – 85 years of age were significantly higher than either older (⬎85 years) or younger 65–70 years) participants (p ⬍ .0001, data not shown) but there were no differences by age in HEI scores in the CHAP study. In both studies, HEI scores differed significantly with income (p ⬍ 0.0001), being lower among persons in the lowest income categories. One explanation for the observed differences in scores between the two survey groups is the different methods of dietary assessment used by the two studies. HEI scores for the CSFII sample were derived from in-person 24-hour recall interviews, while the CHAP scores were based on responses to self-administered FFQs. Dietary methodology can be particularly important to the quantification of variety or any component. The variety scores for the CSFII and CHAP participants were quite similar. Because variety has been shown to increase markedly between days 1 and 3 of 14 consecutive days of recording [25], the CHAP FFQ may be better suited to assess dietary variety of groups than the single recall of the CSFII. The manner in which we scored responses for the variety component may be less conservative than that used by others [26,27]. For example, one study [26] that also used the FFQ to quantify diversity of food choices, defined a “limited”diet as one that contained less than 49 of 118 possible food items. Another group defined dietary variety as the number of nutrient-dense foods consumed more than once a month, excluding high fat desserts and snacks [27]. Alternatively, the higher total HEI scores in the CHAP study may be due to


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regional differences in the diet of our urban mid-western population compared to the national CSFII sample. As a tool to evaluate the multi-dimensional nature of diet, the HEI has some limitations. It does not discriminate between refined and unrefined grains/grain products or between complex versus simple carbohydrate-rich foods [2]. Because there are no restrictions concerning the maximum number of servings for the food group components, a perfect score for grains would be assigned when the individual consumes many servings of grain products that are almost exclusively refined carbohydrates. Nor does it attempt to evaluate choices made between meats, fish, or meat alternatives or when one’s diet consists of many servings of regular soft drinks. Other studies have related indices of diet quality to health outcomes. A high score on the Healthy Diet Indicator was associated with reduced prevalence of mild cognitive impairment [28] and lower mortality [29]. As stated earlier, the Recommended Food Score was inversely related to all cause mortality in a large cohort of women screened for breast cancer [8]. On the other hand, the HEI calculated from FFQs of men in the Health Professionals Follow-up Study was only weakly associated with risk of major chronic disease [5] and not associated with such risk in women from the Nurses Health Study [4]. In a similar manner, the longitudinal design of the CHAP study will allow for the study of dietary quality in relation to chronic disease, disability and death. Based on the work presented herein as well as that of others [4,5], the HEI, as estimated through the use of validated FFQs, reflects dietary patterns concordant with those from the Dietary Guidelines and the Food Guide Pyramid. At a minimum, assessments of overall dietary quality such as the HEI can be used for evaluating the effectiveness of nutritional guidelines and recommendations and for targeting segments of the population for further educational efforts. At present, it appears further work is needed to educate older black men concerning the selections of foods from vegetable, fruit, and milk groups. Many urban adults must be encouraged to consume more grains and to emphasize food selections that promote dietary variety. Acknowledgments The authors wish to thank Cheryl Bibbs for study coordination and Woojeong Bang for programming, and especially the CHAP interviewers. References [1] US Department of Agriculture, Center for Nutrition Policy, and Promotion. 1995. The Healthy Eating Index. CNPP-1. [2] Chung SJ, et al. Letter to the Editor: the Healthy Eating Index needs further work. J Am Diet Assoc 1996;16:751–2. [3] US Department of Agriculture, Center for Nutrition Policy, and Promotion. 1998. The Healthy Eating Index 1994 –1996. CNPP-5. [4] McCullough ML, Feskanich D, Stampfer MJ, Rosner BA, Hu FB, Hunter DJ, Variyam JN, Colditz GA, Willett WC. Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in women. Am J Clin Nutr 2000;72:1214 –22.

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[5] McCullough ML, Feskanich D, Rimm EB, Giovannucci EL, Ascherio A, Variyam JN Spiegelman D, Stampfer MJ, Willett WC. Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in men. Am J Clin Nutr 2000;72:1223–31. [6] Kant AK, Block G, Schatzkin A, Ziegler RG, Nestle M. Dietary diversity in the US population, NHANES II, 1976 –1980. J Am Diet Assoc 1991:91;1526 –31. [7] Kant A, Thompson FE. Measures of overall dietary quality from a food frequency questionnaire: The National Health Interview Survey, 1992. Nutr Res 1997;17:1443–56. [8] Kant AK, Schatzkin A, Graubard BI, Schairer C. A prospective study of diet quality, and mortality in women. JAMA 2000;83:2109 –15. [9] Hu FB, Stampfer MJ, Manson JE, Grodstein F, Colditz GA, Speizer FE, Willett WC. Trends in the incidence of coronary heart disease and changes in diet and lifestyle. N Engl J Med 2000;343:530 –7. [10] Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343:16 –22. [11] U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. Report card on the diet quality of African Americans. Nutrition Insights, number 6. 1998. [12] U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. A focus on nutrition for the elderly: it’s time to take a closer look. Nutrition Insights, number 14. 1999. [13] Wilson RS, Bennett DA, Beckett LA, Morris MC, Gilley DW, Bienias JL, Scherr PA, Evans DA. Cognitive activity in older persons from a geographically defined population. J Gerontol: Psych Sci 1999;54B:155– 60. [14] Morris MC, Colditz GA, Evans DA. Response to a mail nutritional survey in an older bi-racial community population. Am J Epidemiol 1998;8:342– 6. [15] Rockett H, Wolf A, Colditz G. Development and reproducibility of a FFQ to assess diets of older children and adolescents. J Am Diet Assoc 1995;95:336 – 40. [16] Willett WC, Sampson L, Stampfer MJ, Rosner B, Bain C, Witschi J, Hennekens C, Speizer FE. Reproducibility and validity of a semi-quantitative food frequency questionnaire. Am J Epidemiol 1985;122:51– 65. [17] Holland B, Welch AA, Unwin ID, Buss DH, Paul AA, Southgate DAT. McCance, and Widdowson’s The Composition of Foods, 5th Ed. Cambridge, UK: The Royal Chemistry, Ministry of Agriculture, Fisheries & Food, 1991. [18] Pao EM, Fleming KH, Guenther PM, Mickle SJ. Foods commonly eaten by individuals: amounts per day, and per eating occasion. Home Economics Research Report 44. Hyattsville, MD: USDA, 1982. [19] Nutritionist, Clinical Nutrition Branch. Documentation for determining reference amounts customarily consumed per eating occasion (memo to file). Washington DC: Food and Drug Administration, 10/30/91. [20] National Research Council, Committee on Diet, and Health, Food, and Nutrition Board,. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press, 1989. [21] US Department of Agriculture, Human Nutrition Information Service. The Food Guide Pyramid. Home and Garden Bulletin Number 1992:252. [22] Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans. US Department of Agriculture, Agricultural Research Service, and US Department of Health, and Human Services, 2000. [23] Willett W, Stampfer MJ. Total energy intake: implications for epidemiologic analyses. Am J Epidemiol 1986;124:17–29. [24] Yates AA, Schlicker S, Suitor CW. Dietary reference intakes: the new basis for recommendation for calcium and related nutrients, B vitamins and choline. J Am Diet Assoc 1998;98:699 –706. [25] Drewnowski A, Henderson SA, Driscoll SA, Rolls BJ. The dietary variety score: Assessing dietary quality in healthy young and older adults. J Am Diet Assoc 1997;97:266 –71. [26] Krondl M, Yurkiw MA, Coleman PH. Food use and perceived food meanings of the elderly. J Am Diet Assoc 1982;80:23–9. [27] Randall E, Marshall J, Graham S, Brasure J. Frequency of food use data and the multidimensionality of diet. J Am Diet Assoc 1989;89:1070 –5.


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[28] Huijbregts PPCW, Feskens EJM, Rasanen L, Fidanza F, Alberti-Fidanza A, Nissinen A, Giampaoli S, Kromhout D. Dietary patterns and cognitive function in elderly men in Finland, Italy, and Netherlands. Eur J Clin Nutr 1998;52:826 –31. [29] Huijbregts PPCW, Feskens EJM, Rasanen L, Fidanza F, Nissinen A, Menotti A, Kromhout D. Dietary pattern and 20 year mortality of elderly men in Finland, Italy, and the Netherlands: longitudinal study. BMJ 1997;315:13–7.