A Food Systems Perspective for Helping to Achieve AHA Dietary Goals

“Tug on anything in [food] and you will find it connected to everything else”

--A dietary twist substituted into a quote about nature attributed to naturalist John Muir

Food and health are interconnected in many complex ways. Unraveling the complexities involves looking at these connections from multiple perspectives. Nutrients important for health are usually consumed in the context of foods. A characteristic combination of foods can be identified as a food pattern (e.g., Mediterranean). For decades the American Heart Association’s Nutrition Committee has offered evidence-based dietary guidelines that have evolved from 1) an original focus on nutrients to include or avoid ^{(Chait et al., 1993)}, to 2) foods to include or avoid ^{(Krauss 2000, Lichtenstein 2006)} to 3) optimal food patterns (e.g., Mediterranean, DASH)^{(Eckel 2014).}

Over the span of time that dietary recommendations have evolved and shifted from nutrients to foods to patterns, the overall healthfulness of food choices in the US has not increased—many would argue it has declined (AHA – simple 7). This is likely a reflection of how challenging it can be for individuals to make food choice behavior changes that are aligned with recommendations. A follow-up issue to address is to what extent the responsibility and accountability for failing to be able to follow dietary recommendations lies with the individual vs. with the food environment and food system in which individuals live.

In this Science Advisory the AHA writing group has moved beyond food patterns to opening a discussion of the role of food systems. Here food systems is described as:

“…all the processes and resources involved in producing, processing, distributing, preparing and consuming food, … interconnected with food supply chains, farm production practices, food waste, natural resources, health, consumer behavior, food culture, social justice, and policies”.^{(Finley, 2017)}

If availability of and access to healthy foods is limited then shifting social norms to healthier dietary choice behaviors will be constrained. Taking a step further upstream, if foods grown and raised in the agricultural sector are not aligned with healthy human nutrition, then this will contribute to limited healthy choice availability. Adding to this, if farmers and ranchers do not believe there is sufficient consumer demand for healthier choices, and if government policies don’t support transitioning to healthier agricultural products, there will be low motivation to shift agricultural practice. Collectively these are system-level issues.

Current average US dietary intakes fall short of many of the nutrients and foods that are promoted by national guidelines, and exceed the amounts of many nutrients and foods recommended to be limited or avoided. In this AHA Scientific Advisory, the writing group suggests that food system issues are at play that preclude healthy foods as the default. This speaks to the extent to which accountability for dietary choices lies with the individual vs. society. It challenges us to evolve of our understanding of nutrition and health from nutrients, foods, and food patterns, to now consider a food systems perspective. If the food environment created by the current food system doesn’t support healthy choices, then this points to external factors that need to be addressed that are beyond the control of the individual consumer.

With the stated objective of having a healthy and sustainable food system, the writing group provides separate definitions of a healthy food system and a sustainable food system. The bulk of the advisory then describes four different domains of a food system, and provides tables of innovative examples of efforts to implement positive changes to this system. The four areas include 1) the Policy level (with subcategories of global, national, state and local), 2) the Private Sector, 3) Public Health Agencies and Healthcare, and 4) the more granular level of Communities, Families and Individuals. As a whole the writing group has done an excellent job of finding a critical mass of helpful examples that already exist, although published examples were not available or not identified for inclusion for some subcategories. Sodium reduction, in particular, is used as a case example of a multi-level approach where food system inputs are described across all levels; policy, private sector, public health and healthcare, and the community/family/individual.

Most importantly, after providing this helpful framework and the inspiring examples of innovation, the advisory ends with a discussion of gaps in evidence and future directions. The current situation in the US is that there is substantial opportunity for our food system to be healthier and more environmentally sustainable. The advice offered is directed internally to the AHA itself to partner with the food and agricultural industry to promote transparency and availability of data regarding food products and consumption patterns. The writing group concludes that impactful innovation in creating a healthier and more sustainable food system will require engaging stakeholders at every level of the food system, and suggests that the American Heart Association itself has the opportunity and a responsibility to play a leadership role and take actions in these areas. Beyond the value of defining and discussing a healthier and more sustainable food system, this scientific advisory points out the direct role the AHA can have in making positive changes in the food system. This would then support the ability of individuals to more closely align their dietary choice behaviors with improving their cardiovascular health.