Circulation

AHA SCIENCE ADVISORY

Innovation to Create a Healthy and

Sustainable Food System
A Science Advisory From the American Heart Association

ABSTRACT: Current dietary intakes of North Americans are inconsistent Cheryl A.M. Anderson,
with the Dietary Guidelines for Americans. This occurs in the context PhD, MPH, MS, FAHA,
of a food system that precludes healthy foods as the default choices. Chair
To develop a food system that is both healthy and sustainable requires Anne N. Thorndike, MD,
innovation. This science advisory from the American Heart Association MPH, FAHA, Vice Chair
describes both innovative approaches to developing a healthy and Alice H. Lichtenstein, DSc,
sustainable food system and the current evidence base for the FAHA
associations between these approaches and positive changes in dietary Linda Van Horn, PhD, RD,
FAHA
behaviors, dietary intakes, and when available, health outcomes.
Penny M. Kris-Etherton,
Innovation can occur through policy, private sector, public health,
PhD, RD, FAHA
medical, community, or individual-level approaches and could ignite Randi Foraker, PhD, MA,
and further public-private partnerships. New product innovations, FAHA
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reformulations, taxes, incentives, product placement/choice architecture, Colleen Spees, PhD, MEd,
innovative marketing practices, menu and product labeling, worksite RD, FAHA
wellness initiatives, community campaigns, nutrition prescriptions,
mobile health technologies, and gaming offer potential benefits. Some
innovations have been observed to increase the purchasing of healthy
foods or have increased diversity in food choices, but there remains
limited evidence linking these innovations with health outcomes. The
demonstration of evidence-based improvements in health outcomes is
challenging for any preventive interventions, especially those related to
diet, because of competing lifestyle and environmental risk factors that
are difficult to quantify. A key next step in creating a healthier and more
sustainable food system is to build innovative system-level approaches
that improve individual behaviors, strengthen industry and community
efforts, and align policies with evidence-based recommendations. To
enable healthier food choices and favorably impact cardiovascular health,
immediate action is needed to promote favorable innovation at all levels
of the food system.

Key Words: AHA Scientific Statements

◼ diet ◼ disease prevention, primary
◼ food intake ◼ nutrition

© 2019 American Heart Association, Inc.

https://www.ahajournals.org/journal/circ

Circulation. 2019;139:e1025–e1032. DOI: 10.1161/CIR.0000000000000686 June 4, 2019 e1025

 Anderson et al Nutrition Innovation

A
food system includes all the processes and re- the recommended amounts of meat, sodium, satu-
CLINICAL STATEMENTS

sources involved in producing, processing, dis- rated fats, refined grains, partially hydrogenated fats,
AND GUIDELINES

tributing, preparing, and consuming food and is and added sugar.2 Contemporary lifestyle recommen-
interconnected with food supply chains, farm produc- dations from the American Heart Association, Ameri-
tion practices, food waste, natural resources, health, can College of Cardiology, and the Dietary Guidelines
consumer behavior, food culture, social justice, and for Americans focus on the individual2,6,7 (Supplemental
policies.1 We define a healthy food system as one that Table 1). Practical advice has also been provided for
promotes and maintains nutrient-dense dietary patterns practitioners aiming to implement evidence-based di-
that optimize health individually and cross-culturally. We etary recommendations in the clinical setting.8 How-
define a sustainable food system as a food system that ever, more comprehensive strategies to improve adher-
meets current population needs without compromising ence to dietary recommendations, address barriers to
the needs of future generations. Developing a healthy healthy lifestyles, and ultimately promote cardiovascu-
and sustainable food system requires a multilevel inno- lar health are needed.
vative approach that includes global, federal, state, and There are significant gaps in the literature document-
local policies; the food industry; the agricultural indus- ing the impacts of innovations in food systems on car-
try; public health and medicine; communities, worksites, diovascular health factors such as dyslipidemia, excess
and schools; and individuals and families. body weight gain, high blood pressure, and insulin resis-
Our rationale for focusing on the food system is that tance. Despite these limitations, we identified evidence
current dietary patterns of Americans are inconsistent that innovations can favorably alter eating behaviors.
with the Dietary Guidelines for Americans,2 and this is This may be a promising first step toward improving
hypothesized to be associated with a food system that health outcomes. Innovation can occur through policy,
precludes healthy foods as the default choices.2–5 Cur- private sector, public health, medicine, community, and
rently, dietary patterns in the United States include less individual-level approaches. The multiple stakeholders
than the recommended amounts of fruits, vegetables, that contribute to a healthy and sustainable food sys-
dairy, whole grains, beans, and legumes and more than tem are shown in the Figure.
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Figure. Multiple stakeholders contribute to a healthy, sustainable food system.

e1026 June 4, 2019 Circulation. 2019;139:e1025–e1032. DOI: 10.1161/CIR.0000000000000686

 Anderson et al Nutrition Innovation

Table 1. Policy Approaches at Global, Federal, State, and Local Levels Table 2. Approaches by Food Suppliers/Producers/Distributors,

CLINICAL STATEMENTS
to Create a Healthier Food System Retailers, Restaurants, and Worksites to Create a Healthier Food
System

AND GUIDELINES
Level of Findings Regarding
Action Approach Effectiveness on Health Evidence for
Effectiveness on Food
Global/federal Incentivize agriculture and Potential to increase
Level of Choice Behaviors and
food supply chain to increase consumption of
Action Approach Health
supply and decrease cost of vegetables and fruits
nutritious foods and other healthy foods Food New product formulation Reductions in caloric
globally, but no current suppliers, (eg, reduction in amounts consumption25
research evidence producers, of trans fatty acids, sodium;
and food items with fewer
Ban trans fatty acids from the Reduces intake of trans
distributors calories; foods packaged
food supply fatty acids9
into smaller portion sizes)
Mandated national calorie May reduce calories
Retailers Product placement (choice Increases healthier
menu labeling for chain purchased or consumed,
(supermarkets, architecture) food and beverage
restaurants but data are mixed10
superstores, purchases26
Change WIC program to Results in healthier food convenience
Pricing strategies to Increases purchase
include additional healthy purchases and dietary stores)
promote healthy foods and and consumption of
foods, including vegetables intake by families using
discourage unhealthy foods healthy foods (eg,
and fruits WIC11–13
vegetables/fruits) and
Implement nutrition Beneficially influences reduces purchase
standards for food and diet and weight14,15 and consumption of
beverages in schools unhealthy foods (eg,
SSBs)27
Provide SNAP incentives May lead to healthier
for vegetables/fruits and diets and reduced Food and shelf labeling Small increases in
restrictions of sugary foods CVD16–18 strategies healthier purchases28,29

Restrict food and beverage May reduce childhood Online shopping strategies Potential to increase
marketing to youth obesity19 to promote healthier healthier food
purchases purchases, but research
State and Tax SSBs (Berkeley, CA) Decreases consumption is limited30
local of SSBs17,20
Restaurants Menu labeling Increases healthier food
Implement competitive Reduces obesity/ choices31
school food policies overweight and
improves dietary intake Restrictions on children’s May reduce children’s
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among children21,22 meals with toys intake of calories,

sodium, and fat32,33
SNAP incentives for farmers’ Increases access to and
markets (eg, “Health Bucks” purchase of vegetables Healthy default choices (eg, Potential to reduce
programs) and fruits in low-income no SSBs in children’s meals, intake of calories and
communities23 smaller portion sizes, whole unhealthy nutrients, but
grain rather than refined no research has been
Offer healthy foods and City more likely to sell grains in breads/rolls) published
beverages on government low-calorie beverages24
property (eg, ban sales of SSBs) Worksites Cafeteria programs and Increases healthier
healthy worksite food worksite food
CVD indicates cardiovascular disease; SNAP, Supplemental Nutrition procurement purchases34–36
Assistance Program; SSBs, sugar-sweetened beverages; and WIC, Women,
Infants, and Children. Worksite wellness programs Improves diet and
with nutrition counseling results in weight loss37

INNOVATIVE POLICY APPROACHES SSBs indicates sugar-sweetened beverages.

TO CREATE A HEALTHY AND

Although federal, state, and local policies restricting
SUSTAINABLE FOOD SYSTEM unhealthy fats, reducing purchases of sugar-sweetened
Table 1 highlights selected innovative food system poli- beverages, and promoting consumption of vegetables
cies that currently have documented evidence of favor- and fruit are proven effective for changing dietary be-
able impact on dietary behaviors and, in some cases, haviors, documenting quantifiable effects on health
health outcomes. For example, policies banning trans outcomes of these policies remains a challenge.
fatty acids from the food supply as well as national
calorie menu labeling have recently been implemented
with the goal of reducing the prevalence of cardiovas- INNOVATIVE APPROACHES FOR
cular disease and obesity.9,10 Such policies could stimu-
THE PRIVATE SECTOR THAT COULD
late development of new food items containing fewer
calories; food packaged or sold in smaller portion sizes; PROMOTE HEALTHIER DIETARY INTAKE
increases in vegetable and fruit consumption; and re- Private sector approaches are voluntary but, when
ductions in the consumption of sugar-sweetened bev- practiced widely, can favorably impact health behaviors
erages and other unhealthy foods and beverages.11–24 and outcomes population wide (Table 2). Research is

Circulation. 2019;139:e1025–e1032. DOI: 10.1161/CIR.0000000000000686 June 4, 2019 e1027

 Anderson et al Nutrition Innovation

needed, but formulation of new food products in align- Table 3. Innovative Public Health and Healthcare Approaches to
CLINICAL STATEMENTS

Create a Healthier Food System

ment with the Dietary Guidelines for Americans could
AND GUIDELINES

reduce population-wide calorie consumption.25 In ad- Evidence for

Effectiveness on Food
dition, retailers, restaurants, institutions, and work- Choice Behaviors and
sites, by increasing healthy choices among consumers Level of Action Approach Health
through marketing and nudging strategies, can system- International public Access to Nutrition Comprehensive rating/
atically achieve healthier intakes.26–37 Point-of-purchase health foundation Foundation’s Index: US ranking of 10 large
interventions promoting healthier food choices in res- Spotlight Index 201838 US food companies’
corporate and product
taurants, supermarkets, worksites, and schools have profiles for addressing
produced changes in food selection behavior but no obesity and diet-
related diseases; no
data on health outcomes. When modeled statistically, a
research examining
reduction in cardiovascular disease can be expected as diet or health
a result of vegetable/fruit incentives in the Supplemen- outcomes
tal Nutrition Assistance Program (SNAP) and taxes on EAT-Lancet
sugar-sweetened beverages. A summary of food inno- Commission on
healthier diets from
vations by selected food companies is shown in Supple- sustainable food
mental Table 2. systems; international
collaboration of 37
scientific experts39

INNOVATIVE APPROACHES BY PUBLIC National and local

coalitions
National Salt
Reduction Initiative
Modest progress for
voluntary sodium
HEALTH AGENCIES, NATIONAL (national coalition reduction by food
of city/state health companies40; research
COALITIONS, AND HEALTH CARE departments and is needed for health
organizations) effects
Public health and healthcare interventions have improved
food choices among low-income and medically ill popu- Community campaign Reduces purchases of
to reduce SSBs SSBs41
lations (Table 3). The Access to Nutrition Foundation has
Health care Medically tailored Reduce emergency
advocated for changes in food industry approaches by meals (eg, low department visits and
publishing a report ranking the 10 largest US food com- sodium, diabetic diet) hospitalizations of
panies on their nutritional policies, practices, and prod-
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Medicaid/Medicare
participants42
ucts by evaluating 7 categories: governance, products,
accessibility, marketing, lifestyles, labeling, and engage- Limit options in Strong evidence that
hospital foods for hospitals’ healthy
ment.38 Although it does not evaluate health outcomes, patients, employees, beverage initiatives
this report highlights food industry practices that could and visitors to those reduce purchase
consistent with the of SSBs by hospital
improve diet quality and reduce obesity worldwide. The
Dietary Guidelines for employees and
international EAT-Lancet Commission recently published Americans visitors34,43
a report outlining an integrated food system framework Nutrition prescriptions Research evaluating
that provides quantitative scientific targets for healthier outcomes is limited;
diets and sustainable food production to improve hu- small studies show
increased vegetable/
man health worldwide.39 fruit consumption and
awareness of diet-
related messages44–47
INNOVATIVE COMMUNITY-, SSBs indicates sugar-sweetened beverages.
FAMILY-, AND INDIVIDUAL-BASED
wearable tracking and assessment devices, and gaming
APPROACHES approaches, to improve healthy food choice behaviors
Community-based approaches offer potential to im- among adults and children.
prove healthier food selection, purchase, and con-
sumption48–55 (Table 4). For example, community orga-
nizations and school districts have implemented traffic ACHIEVING A HEALTHY AND
light labels and choice architecture to increase healthy SUSTAINABLE FOOD SYSTEM WITH A
choices of food pantry customers and students. Some
MULTILEVEL INNOVATIVE APPROACH:
schools have tested the effectiveness of increasing wa-
ter availability and have shown that students increase THE EXAMPLE OF SODIUM
consumption of water at school.50 There is growing For 5 decades, Americans have consumed more than
interest in implementing and testing smart technolo- the recommended amount of dietary sodium,56–58 de-
gies, including nutrition and health applications (apps), spite recommendation reductions from authoritative

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 Anderson et al Nutrition Innovation

Table 4. Innovative Community-, Family-, and Individual-Based Table 5. Multilevel Approaches to Innovations That Reduce Sodium

CLINICAL STATEMENTS
Approaches to Creating a Healthier Food System Intake

AND GUIDELINES
Evidence for Effectiveness Innovation Description
on Food Choice Behaviors
Policy FDA should modify the “generally regarded as safe”
Level of Action Approach and Health
status of sodium57
Community Food pantry healthy Potential to increase healthy
Private sector Potassium chloride substitution for sodium chloride57
and nonprofit food initiatives (eg, food purchases, but research
organizations traffic light labeling) is limited48 Technology to enhance taste with less sodium (eg, salt
crystals,62 spices and herbs63)
School districts Chef-enhanced Increases student
meals consumption of healthier Public health/ Reduction of sodium in hospital and institutional
meals49 health care foods64
Raising physician awareness and counseling about the
Product placement Increases student selection of
health risks of high sodium intake65
in cafeterias healthier foods50
Community, Campaigns to raise awareness of health consequences
Increasing water Increases student consumption
family, individual of excessive sodium intake57
availability and of water at school, but no
convenience evidence for decreased Sodium tracking apps57
consumption of SSBs51–53
FDA indicates US Food and Drug Administration.
Individual/family Mobile health apps Some evidence for weight
to improve food loss and improved dietary on eating behavior and health. We advise the
selection intake, but research is
limited54 American Heart Association to partner with the
Gaming to improve Behavior change strategies
food and agricultural industry to promote trans-
children’s dietary (eg, vegetable and fruit parency and availability of data regarding food
intake consumption) can be products and consumption patterns. This will
incorporated into a video
game55; research is needed to
increase important knowledge about the impact
determine whether behavior of product reformulation and marketing strategies
and health can be influenced on behavior and health.
SSBs indicates sugar-sweetened beverages. • Lastly, innovation in creating a healthy and sustain-
able food system requires engaging stakeholders
public health agencies.59–61 Improving adherence re- at every level of the food system. The American
quires innovations that effectively reduce the ubiqui- Heart Association is advised to partner with policy
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tous use of sodium in the food supply that is highly makers, the private sector, and community pub-
processed commercially. Innovative policy, private sec- lic health agencies to facilitate the integration
tor, public health, medical, community, and individual- of strategies that affect marketing and product
level approaches are needed (Table 5). development. This will accelerate progress toward
a healthier and more sustainable food system that
is expected to improve dietary intake and health
GAPS IN KNOWLEDGE AND FUTURE outcomes of all people.
There is a need for immediate action to promote and
DIRECTIONS fund innovative food systems approaches and their
This science advisory from the American Heart Asso- evaluation, especially given recent debates in highly
ciation describes innovative approaches needed to cre- respected research journals, by prominent scientists,
ate a healthier and more sustainable food system and about the promises and pitfalls of nutrition research.66,67
the existing evidence base for linking these approaches Innovation throughout all levels of the food system is
with positive changes anticipated in population-wide necessary to see improvements in the public’s health.
dietary behavior and health outcomes. Three key issues
inform future directions:
ARTICLE INFORMATION
• First, although some evidence suggests that recent
The American Heart Association makes every effort to avoid any actual or po-
innovations in the food system can change dietary tential conflicts of interest that may arise as a result of an outside relationship or
behaviors, evidence directly linking innovations to a personal, professional, or business interest of a member of the writing panel.
health outcomes is lacking. It is well known that Specifically, all members of the writing group are required to complete and
submit a Disclosure Questionnaire showing all such relationships that might be
demonstrating improvement in health outcomes perceived as real or potential conflicts of interest.
is challenging for innovative preventive programs, This science advisory was approved by the American Heart Association Sci-
especially those involving diet. We advise that ence Advisory and Coordinating Committee on March 6, 2019, and the Amer-
ican Heart Association Executive Committee on March 21, 2019. A copy of
partnerships be created to generate sponsored the document is available at https://professional.heart.org/statements by using
research in this important area. either “Search for Guidelines & Statements” or the “Browse by Topic” area.
• Second, there are major gaps in the literature To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@
wolterskluwer.com.
regarding the impact of previous innovations by The online-only Data Supplement is available with this article at https://
the food industry and the agricultural industry www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000000686.

Circulation. 2019;139:e1025–e1032. DOI: 10.1161/CIR.0000000000000686 June 4, 2019 e1029

 Anderson et al Nutrition Innovation

The American Heart Association requests that this document be cited as development, visit https://professional.heart.org/statements. Select the “Guide-
CLINICAL STATEMENTS

follows: Anderson CAM, Thorndike AN, Lichtenstein AH, Van Horn L, Kris- lines & Statements” drop-down menu, then click “Publication Development.”
AND GUIDELINES

Etherton PM, Foraker R, Spees C. Innovation to create a healthy and sustainable Permissions: Multiple copies, modification, alteration, enhancement, and/
food system: a science advisory from the American Heart Association. Circula- or distribution of this document are not permitted without the express permis-
tion. 2019;139:e1025–e1032. doi: 10.1161/CIR.0000000000000686. sion of the American Heart Association. Instructions for obtaining permission
The expert peer review of AHA-commissioned documents (eg, scientific are located at https://www.heart.org/permissions. A link to the “Copyright Per-
statements, clinical practice guidelines, systematic reviews) is conducted by the missions Request Form” appears in the second paragraph (https://www.heart.
AHA Office of Science Operations. For more on AHA statements and guidelines org/en/about-us/statements-and-policies/copyright-request-form).

Disclosures
Writing Group Disclosures

Other Speakers’ Consultant/

Writing Group Research Bureau/ Expert Ownership Advisory
Member Employment Research Grant Support Honoraria Witness Interest Board Other
Cheryl A.M. University of California None None None None None None None
Anderson at San Diego
Anne N. Thorndike Massachusetts General NIH† None None None None None None
Hospital
Randi Foraker Washington University None None None None None None None
in St Louis, School of
Medicine
Penny M. Pennsylvania State None None None None None None None
Kris-Etherton University
Alice H. Lichtenstein Tufts University None None None None None None None
Colleen Spees Ohio State University Abbott Labs*; Beef None None None None None None
Cattleman’s Association*
Linda Van Horn Northwestern University None None None None None None None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives
$10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity,
or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
Downloaded from http://ahajournals.org by on March 16, 2021

*Modest.
†Significant.

Reviewer Disclosures

Other Consultant/
Research Speakers’ Bureau/ Expert Ownership Advisory
Reviewer Employment Research Grant Support Honoraria Witness Interest Board Other
Mary E. University of None None None None None None Institute of Food
Camire Maine Technologists
(scientific editor
stipend)*
Brenda M. Virginia NIH (CO-I on NIH R21)* None Academy of Nutrition None None None California
Davy Polytechnic and Dietetics Walnut
Institute and (honorarium for Commission
State University research presentation (grant reviewer,
for weight summer 2018)*
management practice
group)*
Victor L. Nutrition Numerous members of the food None None None None Several None
Fulgoni Impact, LLC industry (as Senior Vice President members of
of Nutrition Impact, we conduct the food/
data analyses for numerous beverage
members of the food/beverage/ industry†
dietary supplement industries)†
Christopher Stanford None None None None None None None
Gardner University
Maha Tahiri Tufts University None None None None General ilSI*; IFIC*; None
Mills† EUFIC*

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more
during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

e1030 June 4, 2019 Circulation. 2019;139:e1025–e1032. DOI: 10.1161/CIR.0000000000000686

 Anderson et al Nutrition Innovation

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