Trends in Dietary Carbohydrate, Protein, and Fat Intake and Diet Quality Among US Adults, 1999-2016 | Nutrition | JAMA | JAMA Network
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Original Investigation
September 24, 2019

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

Author Affiliations
  • 1Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 2Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
  • 3Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 4Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
  • 5Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
  • 6School of Medicine, Tufts University, Boston, Massachusetts
  • 7Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 8Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
JAMA. 2019;322(12):1178-1187. doi:10.1001/jama.2019.13771
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.


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.