[Skip to Content]
[Skip to Content Landing]

Trends in Dietary Carbohydrate, Protein, and Fat Intake and Diet Quality Among US Adults, 1999-2016

Educational Objective
To understand the components of a healthy diet and trends in dietary intake among US adults.
1 Credit CME
Key Points

Question  What were the trends in carbohydrate, fat, and protein intake among US adults from 1999 to 2016?

Findings  In this nationally representative serial cross-sectional study that included 43 996 adults, there were decreases in low-quality carbohydrates (primarily added sugar) and increases in high-quality carbohydrates (primarily whole grains), plant protein (primarily whole grains and nuts), and polyunsaturated fat. However, 42% of energy intake was still derived from low-quality carbohydrates and the intake of saturated fat remained above 10% of energy.

Meaning  The macronutrient composition of diet among US adults has improved, but continued high intake of low-quality carbohydrates and saturated fat remain.

Abstract

Importance  Changes in the economy, nutrition policies, and food processing methods can affect dietary macronutrient intake and diet quality. It is essential to evaluate trends in dietary intake, food sources, and diet quality to inform policy makers.

Objective  To investigate trends in dietary macronutrient intake, food sources, and diet quality among US adults.

Design, Setting, and Participants  Serial cross-sectional analysis of the US nationally representative 24-hour dietary recall data from 9 National Health and Nutrition Examination Survey cycles (1999-2016) among adults aged 20 years or older.

Exposure  Survey cycle.

Main Outcomes and Measures  Dietary intake of macronutrients and their subtypes, food sources, and the Healthy Eating Index 2015 (range, 0-100; higher scores indicate better diet quality; a minimal clinically important difference has not been defined).

Results  There were 43 996 respondents (weighted mean age, 46.9 years; 51.9% women). From 1999 to 2016, the estimated energy from total carbohydrates declined from 52.5% to 50.5% (difference, −2.02%; 95% CI, −2.41% to −1.63%), whereas that of total protein and total fat increased from 15.5% to 16.4% (difference, 0.82%; 95% CI, 0.67%-0.97%) and from 32.0% to 33.2% (difference, 1.20%; 95% CI, 0.84%-1.55%), respectively (all P < .001 for trend). Estimated energy from low-quality carbohydrates decreased by 3.25% (95% CI, 2.74%-3.75%; P < .001 for trend) from 45.1% to 41.8%. Increases were observed in estimated energy from high-quality carbohydrates (by 1.23% [95% CI, 0.84%-1.61%] from 7.42% to 8.65%), plant protein (by 0.38% [95% CI, 0.28%-0.49%] from 5.38% to 5.76%), saturated fatty acids (by 0.36% [95% CI, 0.20%-0.51%] from 11.5% to 11.9%), and polyunsaturated fatty acids (by 0.65% [95% CI, 0.56%-0.74%] from 7.58% to 8.23%) (all P < .001 for trend). The estimated overall Healthy Eating Index 2015 increased from 55.7 to 57.7 (difference, 2.01; 95% CI, 0.86-3.16; P < .001 for trend). Trends in high- and low-quality carbohydrates primarily reflected higher estimated energy from whole grains (0.65%) and reduced estimated energy from added sugars (−2.00%), respectively. Trends in plant protein were predominantly due to higher estimated intake of whole grains (0.12%) and nuts (0.09%).

Conclusions and Relevance  From 1999 to 2016, US adults experienced a significant decrease in percentage of energy intake from low-quality carbohydrates and significant increases in percentage of energy intake from high-quality carbohydrates, plant protein, and polyunsaturated fat. Despite improvements in macronutrient composition and diet quality, continued high intake of low-quality carbohydrates and saturated fat remained.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Authors: Zhilei Shan, MD, PhD, Department of Nutrition, Harvard T. H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 (zshan@hsph.harvard.edu); Fang Fang Zhang, MD, PhD, Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Ave, Boston, MA 02111 (fang_fang.zhang@tufts.edu).

Accepted for Publication: August 12, 2019.

Author Contributions: Drs Zhang and Bhupathiraju had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Zhang and Bhupathiraju contributed equally.

Concept and design: Shan, Rehm, Hu, Mozaffarian, Zhang, Bhupathiraju.

Acquisition, analysis, or interpretation of data: Shan, Rehm, Rogers, Ruan, Wang, Hu, Zhang, Bhupathiraju.

Drafting of the manuscript: Shan, Rehm, Rogers.

Critical revision of the manuscript for important intellectual content: Rehm, Ruan, Wang, Hu, Mozaffarian, Zhang, Bhupathiraju.

Statistical analysis: Shan, Rehm, Rogers, Ruan, Wang.

Obtained funding: Hu, Zhang.

Administrative, technical, or material support: Hu, Zhang.

Supervision: Hu, Mozaffarian, Zhang, Bhupathiraju.

Conflict of Interest Disclosures: Dr Rehm reported receipt of personal fees from Nestec Ltd and the Dairy Management Institute. Dr Hu reported receipt of grants from the California Walnut Commission and personal fees from Metagenics, Standard Process, and Diet Quality Photo Navigation. Dr Mozaffarian reported receipt of grants from the Gates Foundation; receipt of personal fees from GOED, Nutrition Impact, Pollock Communications, Bunge, Indigo Agriculture, Amarin, Acasti Pharma, Cleveland Clinic Foundation, America’s Test Kitchen, and Danone; scientific advisory board membership from Elysium Health (with stock options), Omada Health, and DayTwo; and receipt of publication royalties from UpToDate; in addition, Dr Mozaffarian reported holding patents US8889739 and US9987243 listing Dr Mozaffarian as a coinventor for use of transpalmitoleic acid to prevent and treat insulin resistance, type 2 diabetes, and related conditions as well as reduce metabolic risk factors. No other disclosures were reported.

Funding/Support: This work is supported by National Institutes of Health grant R01 MD011501 to Drs Shan, Rehm, and Zhang; National Institutes of Health grant K01 DK107804 to Dr Bhupathiraju; and the Young Scientists Fund of the National Natural Science Foundation of China grant 81703214 to Dr Shan.

Role of the Funder/Sponsor: The study funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

References
1.
GBD 2016 Risk Factors Collaborators.  Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.  Lancet. 2017;390(10100):1345-1422. doi:10.1016/S0140-6736(17)32366-8PubMedGoogle ScholarCrossref
2.
Pan  A, Lin  X, Hemler  E, Hu  FB.  Diet and cardiovascular disease: advances and challenges in population-based studies.  Cell Metab. 2018;27(3):489-496. doi:10.1016/j.cmet.2018.02.017PubMedGoogle ScholarCrossref
3.
Ley  SH, Hamdy  O, Mohan  V, Hu  FB.  Prevention and management of type 2 diabetes: dietary components and nutritional strategies.  Lancet. 2014;383(9933):1999-2007. doi:10.1016/S0140-6736(14)60613-9PubMedGoogle ScholarCrossref
4.
Mokdad  AH, Ballestros  K, Echko  M,  et al; US Burden of Disease Collaborators.  The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states.  JAMA. 2018;319(14):1444-1472. doi:10.1001/jama.2018.0158PubMedGoogle ScholarCrossref
5.
Trumbo  P, Schlicker  S, Yates  AA, Poos  M; Food and Nutrition Board of the Institute of Medicine, the National Academies.  Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids.  J Am Diet Assoc. 2002;102(11):1621-1630. doi:10.1016/S0002-8223(02)90346-9PubMedGoogle ScholarCrossref
6.
Sacks  FM, Lichtenstein  AH, Wu  JHY,  et al; American Heart Association.  Dietary fats and cardiovascular disease: a presidential advisory from the American Heart Association.  Circulation. 2017;136(3):e1-e23. doi:10.1161/CIR.0000000000000510PubMedGoogle ScholarCrossref
7.
Bernstein  AM, Sun  Q, Hu  FB, Stampfer  MJ, Manson  JE, Willett  WC.  Major dietary protein sources and risk of coronary heart disease in women.  Circulation. 2010;122(9):876-883. doi:10.1161/CIRCULATIONAHA.109.915165PubMedGoogle ScholarCrossref
8.
Ludwig  DS, Hu  FB, Tappy  L, Brand-Miller  J.  Dietary carbohydrates: role of quality and quantity in chronic disease.  BMJ. 2018;361:k2340. doi:10.1136/bmj.k2340PubMedGoogle ScholarCrossref
9.
Song  M, Fung  TT, Hu  FB,  et al.  Association of animal and plant protein intake with all-cause and cause-specific mortality.  JAMA Intern Med. 2016;176(10):1453-1463. doi:10.1001/jamainternmed.2016.4182PubMedGoogle ScholarCrossref
10.
Reynolds  A, Mann  J, Cummings  J, Winter  N, Mete  E, Te Morenga  L.  Carbohydrate quality and human health: a series of systematic reviews and meta-analyses.  Lancet. 2019;393(10170):434-445. doi:10.1016/S0140-6736(18)31809-9PubMedGoogle ScholarCrossref
11.
Berryman  CE, Lieberman  HR, Fulgoni  VL  III, Pasiakos  SM.  Protein intake trends and conformity with the dietary reference intakes in the United States: analysis of the National Health and Nutrition Examination Survey, 2001-2014.  Am J Clin Nutr. 2018;108(2):405-413. doi:10.1093/ajcn/nqy088PubMedGoogle ScholarCrossref
12.
Cohen  E, Cragg  M, deFonseka  J, Hite  A, Rosenberg  M, Zhou  B.  Statistical review of US macronutrient consumption data, 1965-2011: Americans have been following dietary guidelines, coincident with the rise in obesity.  Nutrition. 2015;31(5):727-732. doi:10.1016/j.nut.2015.02.007PubMedGoogle ScholarCrossref
13.
Centers for Disease Control and Prevention.  Trends in intake of energy and macronutrients—United States, 1971-2000.  MMWR Morb Mortal Wkly Rep. 2004;53(4):80-82.PubMedGoogle Scholar
14.
Centers for Disease Control and Prevention. About the National Health and Nutrition Examination Survey. https://www.cdc.gov/nchs/nhanes/about_nhanes.htm. Accessed June 2, 2019.
15.
Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey response rates and population totals. https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx. Accessed June 2, 2019.
16.
Centers for Disease Control and Prevention. Information about dietary variables in National Health and Nutrition Examination Survey. https://www.cdc.gov/nchs/tutorials/dietary/AdditionalResources/Info_DietaryVariables.htm. Accessed June 2, 2019.
17.
Moshfegh  AJ, Rhodes  DG, Baer  DJ,  et al.  The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes.  Am J Clin Nutr. 2008;88(2):324-332. doi:10.1093/ajcn/88.2.324PubMedGoogle ScholarCrossref
18.
Blanton  CA, Moshfegh  AJ, Baer  DJ, Kretsch  MJ.  The USDA Automated Multiple-Pass Method accurately estimates group total energy and nutrient intake.  J Nutr. 2006;136(10):2594-2599. doi:10.1093/jn/136.10.2594PubMedGoogle ScholarCrossref
19.
Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey: measuring guides for the dietary recall interview. https://www.cdc.gov/nchs/nhanes/measuring_guides_dri/measuringguides.htm. Accessed June 2, 2019.
20.
Centers for Disease Control and Prevention. Key concepts about the NHANES sample weights. https://www.cdc.gov/nchs/tutorials/nhanes/SurveyDesign/SampleDesign/Info1.htm. Accessed June 2, 2019.
21.
Pasiakos  SM, Agarwal  S, Lieberman  HR, Fulgoni  VL  III.  Sources and amounts of animal, dairy, and plant protein intake of US adults in 2007-2010.  Nutrients. 2015;7(8):7058-7069. doi:10.3390/nu7085322PubMedGoogle ScholarCrossref
22.
Reedy  J, Lerman  JL, Krebs-Smith  SM,  et al.  Evaluation of the Healthy Eating Index–2015.  J Acad Nutr Diet. 2018;118(9):1622-1633. doi:10.1016/j.jand.2018.05.019PubMedGoogle ScholarCrossref
23.
Willett  WC.  Nutritional Epidemiology. 3rd ed. Oxford, England: Oxford University Press; 2013.
24.
Tooze  JA, Midthune  D, Dodd  KW,  et al.  A new statistical method for estimating the usual intake of episodically consumed foods with application to their distribution.  J Am Diet Assoc. 2006;106(10):1575-1587. doi:10.1016/j.jada.2006.07.003PubMedGoogle ScholarCrossref
25.
La Berge  AF.  How the ideology of low fat conquered America.  J Hist Med Allied Sci. 2008;63(2):139-177. doi:10.1093/jhmas/jrn001PubMedGoogle ScholarCrossref
26.
US Department of Health and Human Services; US Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 8th ed. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/. Accessed June 2, 2019.
27.
Lloyd-Jones  DM, Hong  Y, Labarthe  D,  et al; American Heart Association Strategic Planning Task Force and Statistics Committee.  Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond.  Circulation. 2010;121(4):586-613. doi:10.1161/CIRCULATIONAHA.109.192703PubMedGoogle ScholarCrossref
28.
Wang  DD, Leung  CW, Li  Y,  et al.  Trends in dietary quality among adults in the United States, 1999 through 2010.  JAMA Intern Med. 2014;174(10):1587-1595. doi:10.1001/jamainternmed.2014.3422PubMedGoogle ScholarCrossref
29.
Rehm  CD, Peñalvo  JL, Afshin  A, Mozaffarian  D.  Dietary intake among US adults, 1999-2012.  JAMA. 2016;315(23):2542-2553. doi:10.1001/jama.2016.7491PubMedGoogle ScholarCrossref
30.
Kelemen  LE, Kushi  LH, Jacobs  DR  Jr, Cerhan  JR.  Associations of dietary protein with disease and mortality in a prospective study of postmenopausal women.  Am J Epidemiol. 2005;161(3):239-249. doi:10.1093/aje/kwi038PubMedGoogle ScholarCrossref
31.
Farvid  MS, Cho  E, Chen  WY, Eliassen  AH, Willett  WC.  Dietary protein sources in early adulthood and breast cancer incidence: prospective cohort study.  BMJ. 2014;348:g3437. doi:10.1136/bmj.g3437PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements