An evidence-based definition of nutrition security: disparities in sociodemographic characteristics, dietary intake and cardiometabolic risk using the US Healthy Eating Index
Authors: Sheinberg Elise , Schmidt Laura A. , Mande Jerold R. , Martinez-Steele Euridice , Tobias Deirdre K. , Leung Cindy W. 
Published: June 2024

ABSTRACTImportanceEstablishing a universal metric for nutrition security, defined as, “consistent and equitable access to healthy, safe, affordable foods essential to optimal health and well-being,” is a national priority. Understanding how the Healthy Eating Index-2020 (HEI-2020) could be used to measure and monitor nutrition security in the population can assist in surveillance and improve the design of nutrition programs and policies.ObjectiveTo examine the utility of the HEI-2020 as an evidence-based measure of nutrition security.DesignThis serial cross-sectional study used data from the 2009-2018 National Health and Nutrition Examination Surveys (NHANES).SettingNationally representative, population-based surveyParticipantsData for N=22,168 US adults (≥20 years) were analyzed.Main outcomeWe derived HEI-2020 scores (0-100), commonly used to capture overall diet quality, from participants’ two 24-hour dietary recalls. Nutrition security categories were established: high nutrition security (>70-100), marginal (>60-70), low (>50-60), and very low (0-50).ResultsOnly 13% of US adults had high nutrition security while nearly two-thirds had low or very low nutrition security. Nutrition security was higher for adults who were older, female, “Other” race or ethnicity, born outside of the US, have higher education attainment, higher income, and food security. Compared to adults with high nutrition security, adults with very low nutrition security had the lowest intakes of unprocessed or minimally processed foods, fruits, vegetables, whole grains, and seafood and the highest intakes of ultra-processed foods, refined grains, and red and processed meats (allP-trends <0.01). Similarly, adults with very low nutrition security were more likely to have elevated adiposity, lower HDL cholesterol, higher triglycerides, higher fasting glucose, and higher hemoglobin A1c (allP-trends ≤0.01).ConclusionsThe HEI is a robust measure of nutrition security that can be directly linked to the construct of nutrition security. Using evidence-based HEI cut-points as nutrition security categories would allow policy makers, public health practitioners and nutrition professionals to set benchmarks and nationwide targets for achieving nutrition security.KEY POINTSQuestionCan the Healthy Eating Index (HEI)-2020 be used as an evidence-based measure of nutrition security?FindingsUsing nationally representative data, we created four categories of nutrition security using HEI-2020 scores: high (≥70), marginal (>60-70, low (>50-60), and very low (≤50). Less than 1 in 6 US adults had high nutrition security. High nutrition security was less prevalent among adults with greater socioeconomic disadvantage. High nutrition security was also associated with more favorable cardiometabolic risk profiles.MeaningThe HEI can be directly linked to categories of nutrition security and used for national program and policy setting.