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Consideration of nutrition and sustainability in public definitions of ‘healthy’ food: an analysis of submissions to the US FDA

Published online by Cambridge University Press:  04 April 2024

Emily H Belarmino*
Department of Nutrition and Food Sciences, University of Vermont, 109 Carrigan Drive, Burlington, VT 05405, USA Gund Institute for Environment, University of Vermont, 210 Colchester Ave, Burlington, VT 05405, USA
Michelle Carfagno
Division of Nutritional Sciences, Cornell University, Savage Hall, Ithaca, NY 14853, USA
Lauren Kam
Division of Nutritional Sciences, Cornell University, Savage Hall, Ithaca, NY 14853, USA
Kene-Chukwu Ifeagwu
Division of Nutritional Sciences, Cornell University, Savage Hall, Ithaca, NY 14853, USA
Miriam E Nelson
Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Avenue, Boston, MA 02111, USA
Rebecca A Seguin-Fowler
Institute for Advancing Health through Agriculture, Texas A&M AgriLife Research, 1500 Research Parkway, Centeq Building B, College Station, TX 77845, USA
*Corresponding author: Email
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To better understand how the public defines ‘healthy’ foods and to determine whether the public considers sustainability, implicitly and explicitly, in the context of healthy eating.


We conducted a content analysis of public comments submitted to the US FDA in 2016 and 2017 in response to an invitation for feedback on use of the term ‘healthy’ on food labels. The analysis explored the ways in which commenters’ definitions of ‘healthy’ aligned with the 2015–2020 Dietary Guidelines for Americans and whether their definitions considered sustainability.


The US Government’s website.


All 1125 unique comments from individuals and organisations.


Commenters’ definitions of ‘healthy’ generally mirrored the recommendations that the Dietary Guidelines for Americans put forth to promote a ‘healthy eating pattern’. Commenters emphasised the healthfulness of fruit, vegetables, whole grains, fish and other minimally processed foods and the need to limit added sugars, sodium, saturated and trans fats and other ingredients sometimes added during processing. One-third of comments (n 374) incorporated at least one dimension of sustainability, mainly the environmental dimension. Commenters who mentioned environmental considerations primarily expressed concerns about synthetic chemicals and genetic modification. Less than 20 % of comments discussed social or economic dimensions of sustainability, and less than 3 % of comments (n 30) used the word ‘sustainability’ explicitly.


This novel analysis provides new information about the public’s perceptions of ‘healthy’ foods relative to nutrition and sustainability considerations. The findings can be used to advance policy discussions regarding nutrition labelling and guidance.

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© The Author(s), 2024. Published by Cambridge University Press on behalf of The Nutrition Society

Historically, federal dietary guidance and recommendations have focused on the promotion of nutritionally adequate diets and healthy lifestyles(Reference Magni, Racagni and Agostoni1). However, the consideration of food system sustainability as a component of nutrition policies has been proposed(Reference Lawrence, Burlingame and Caraher2) in recognition of the complex ways in which sustainability challenges may threaten nutrition security – or the ability of all members of the population to have ‘consistent and equitable access to healthy, safe, affordable foods essential to optimal health and well-being’(3). Modern food systems are critical to meeting population food and nutrition needs, but also stress the natural resources upon which human nutrition and health depend. They are key consumers of land(Reference Behrens, Kiefte-de Jong and Bosker47), water(Reference Canning, Rehkamp and Hitaj5,6) and raw materials(Reference Canning, Rehkamp and Hitaj5); can contribute positively or negatively to air quality(Reference Behrens, Kiefte-de Jong and Bosker4,Reference Behrer and Lobell8) , water quality(Reference Behrens, Kiefte-de Jong and Bosker4,Reference Brandes, McNunn and Schulte9) and biodiversity(7,Reference Tilman, Clark and Williams10) and employ millions across diverse sectors including agriculture, processing, manufacturing and food service(11). Beyond nutrition and health, the literature on food system sustainability typically considers three dimensions: environmental sustainability (the protection of natural resources), social sustainability (the protection of human resources and pursuit of social equity) and economic sustainability (the generation of human prosperity)(Reference Ahmed, Downs and Fanzo12Reference Mazac14). Perturbations in any or all these dimensions have the potential to compromise human nutrition and health by reducing agricultural output(Reference Challinor, Watson and Lobell15), increasing food contamination(Reference Liu, Hofstra and Franz16), disrupting food supply chains(7), reducing food quality(Reference Ahmed and Stepp17,Reference Myers, Zanobetti and Kloog18) , increasing food prices(7) and limiting food choices(Reference Toussaint, Cabanelas and González-Alvarado19).

Dietary guidelines are one policy tool through which health considerations and food system sustainability goals have an opportunity to align. The US Department of Health and Human Services and the US Department of Agriculture update and publish the Dietary Guidelines for Americans (DGA) every 5 years, informed by a review of the research by the Dietary Guidelines Advisory Committee (DGAC), an expert scientific panel. Based on its review, the DGAC recommended, for the first time in 2015, that food system sustainability be incorporated into the DGA(20). This suggestion generated considerable public engagement; more than 29 000 comments were submitted to the federal government about the DGAC report, about half of which addressed the issue of including sustainability in the DGA(Reference Merrigan, Griffin and Wilde21,22) . Following review of these comments, the two US government Cabinet Secretaries that oversee the writing of the DGA released a statement that sustainability was beyond the scope of the mandate for the DGA and ultimately opted not to include sustainability language in the 2015–2020 DGA(Reference Vilsack and Burwell23). The 2020 and 2025 DGAC were not charged with updating the review of research on links between dietary patterns and sustainability. Although there remains debate about how synergies across food-related policies, programmes and guidelines can be achieved(Reference Finley, Dimick and Marshall24,Reference Muller, Tagtow and Roberts25) , some countries such as Brazil, Germany, Qatar and Sweden have expanded the scope of their dietary guidance in recent years to incorporate aspects of sustainability following stakeholder input and consultation on how to effectively encourage to better food choices(Reference Ahmed, Downs and Fanzo12,Reference Mazac14,Reference Gonzalez Fischer and Garnett26) . For example, the Brazilian guidelines discuss the sustainability impacts of different dietary patterns and provide health, environmental, social and economic rationale for their recommendations(Reference Gonzalez Fischer and Garnett26).

Food labels, primarily found on packaged foods, represent another policy instrument that can potentially help address challenges related to both human health and food system sustainability. Packaged foods tend to be higher in sodium, added sugars and refined grains, and they often carry the burden of sustainability impacts as well(Reference Orlando, Rebellato and Siquerira Silva27Reference Anastasiou, Baker and Hadjikakou30). For example, highly processed, packaged foods have been associated with intensive resource use(Reference Anastasiou, Baker and Hadjikakou30), greenhouse gas emissions(Reference Anastasiou, Baker and Hadjikakou30), biodiversity loss(Reference Anastasiou, Baker and Hadjikakou30) and food and plastic waste(Reference Anastasiou, Baker and Hadjikakou30) and some there are some concerns that their supply chains may redirect food spending away from small producers(31). Health- and nutrition-related claims are widely used on packaged food labels; yet research suggests some may be misleading(Reference Andrews, Burton and Netemeyer32,Reference Harris, Thompson and Schwartz33) , and some advocates have called for changes to labelling regulation(Reference Lytton34,Reference Nestle and Ludwing35) . In the USA, the present regulatory definition allows a packaged food to bear a ‘healthy’ nutrient content claim if it is low in fat and low in saturated fat as defined by the US FDA, meets certain criteria for cholesterol and sodium content, and serves as a good source of vitamin A, vitamin C, calcium, iron, protein or fibre(36).

This formal definition of ‘healthy’ was formulated 30 years ago when nutrition science and policy focused on limiting fat intake. In September 2016, in an effort to increase policy coherence and respond to a citizen petition requesting changes to the regulation on the use of ‘healthy’ on labelling, the FDA issued a request for information and public comments on use of the term ‘healthy’ to describe foods, especially in the context of food labelling, and whether the term ‘healthy’ may be false or misleading (FDA-2016-D-2335)(37). A broad set of questions was posed including ‘Are there current dietary recommendations (e.g. the Dietary Guidelines for Americans) or nutrient intake requirements… that should be reflected in criteria for use of the term “healthy?” What is consumers’ understanding of the meaning of the term “healthy” as it relates to food? What are consumers’ expectations of foods that carry a “healthy” claim?’ The deadline initially was set to January 2017 but was later extended to April 2017. Federal agencies must publish notices of proposed rulemaking in the Federal Register and provide the opportunity for any person or organisation to share insights and information in a comment before final rules can be put into effect. Agencies are required to consider public comments prior to publishing the final rule(Reference Carey38). The FDA has proposed new labelling guidance but has not published its final rule on this issue. Under the new proposed definition, manufacturers can label their products ‘healthy’ only if they contain a meaningful amount of food from at least one of the recommended food groups or subgroups as outlined in the DGA and adhere to specific limits for saturated fats, sodium and added sugars(39). Currently, and within the proposed definition as of August 2023, the ‘healthy’ label regulation does not include any sustainability dimensions.

Using data collected as part of the FDA solicitation in 2016 and 2017, we examined commenters’ definitions of ‘healthy.’ The aim of the research presented herein was to examine how commenters defined healthy with respect to the DGA and elucidate if there were implied or explicit mentions of the dimensions of sustainability.



Submissions to the Federal Register are publicly available at We downloaded each comment submitted during the comment period (September 2016 – April 2017) and created a database that included the submitter’s name, location and category (e.g. individual consumer, food industry and academia). A total of 1136 public comments were submitted by the final deadline (Fig. 1). One submission was composed of sixteen distinct comments and was therefore divided. About 2 % (n 26) were determined to be duplicates (i.e. identical comments submitted > 1 time by the same person) and excluded. The final sample included 1125 unique comments. All data were imported into the NVivo qualitative data analysis software (QSR International Pty Ltd. Version 11) for coding.

Fig. 1 Flow diagram of comments submitted to FDA-2016-D-2335


A three-member team trained by the first author coded the data in a two-step process. First, to index and explore the data with respect to nutrition, we coded all comments for alignment with recommendations from the 2015–2020 DGA by identifying each reference to the main food groups (or foods in those groups) as well as sodium, added sugars, saturated fats and trans fats. We organised these codes into dietary factors that are ‘included’ or ‘limited’ in a healthy eating pattern as defined by the DGA(40). Included dietary factors are vegetables, fruits, grains, low-fat and fat-free dairy, protein foods and oils, while sodium, added sugars, saturated fats and trans fats are defined as dietary factors to limit. To simplify our coding scheme, we considered all dairy products together (regardless of whether they were fat-free, low fat or had a higher fat content) and considered plant-based proteins (nuts, seeds and soya products) separate from animal-source protein foods (meat, fish and eggs). Additionally, we coded for references to food processing and serving sizes, as sodium, added sugars and saturated fats are often found in highly processed foods and eating within appropriate energy levels is recommended in the DGA(40). Relevant codes are presented in Supplementary File 1.

Next, the first author developed a structural coding framework relevant to the three non-health dimensions of sustainability typically addressed in the literature on food systems: environmental, social and economic sustainability(Reference Ahmed, Downs and Fanzo12Reference Mazac14). Sub-codes were created based on how the environmental, social and economic dimensions are defined in the United Nation’s Sustainability Assessment of Food and Agriculture Systems Guidelines(41) and ideas that emerged in the first stage of coding. In line with Béné et al.(Reference Béné, Prager and Achicanoy13), we considered issues related to governance and power dynamics as part of social sustainability. The members of the coding team piloted the framework with twenty-five randomly selected comments and met to review coding decisions, discuss discrepancies and revise the codebook. To assess and ensure consistency before applying the codebook to the full dataset, we applied the updated codebook to another twenty-five randomly selected comments and compared coding decisions. The aspects of the final coding framework relevant to this analysis are presented in Supplementary File 1.

One member of the coding team coded each comment with the final codebook, and a second member of the team reviewed the coding decisions. For each code, we resolved disagreements by discussion. We analysed the data by reviewing each code and co-produced a corresponding summary report with information on themes and ideas in the data. We used matrix coding queries to compare comments between those who identified themselves as individual consumers and those who identified as another category of respondent. To complement the qualitative analysis, we generated code frequency reports based on the number of comments that included information related to each dimension of sustainability. To identify explicit mentions of sustainability, we conducted word searches for the terms ‘sustainable,’ ‘sustainably’ and ‘sustainability.’ Quotes from the comments are presented verbatim.


Two-thirds of comments were submitted by individual consumers (Fig. 1). The next most common types of commenters were those from academia, health professions or the food industry. As with individual consumers, most academic and health professional commenters were responding as private citizens. A substantial minority of those from academia were students submitting position papers. Responses were received from across the country and two came from individuals who specified a location outside of the US. Although 62·0 % of commenters did not report their location, of those based in the USA that did report (n 425): 18·1 % came from the Midwest Census division, 8·7 % from the Northeast Census division, 32·5 % from the South Census division and 26·4 % from the West Census division (data not shown).

Alignment between comments and the recommendations in the 2015–2020 DGA

Submissions generally aligned with the key recommendations for foods and ingredients to include and limit in a healthy dietary pattern as defined in the 2015–2020 DGA (Table 1). Commenters identified vegetables, fruits, whole grains, nuts, seeds, legumes and naturally occurring oils (especially those present in plant foods, fish and seafood) as central to a healthy diet. Comments on meat tended to highlight either the perceived benefits of consuming minimally processed meats, lean meats, poultry, fish and seafood or the perceived risks associated with intake of red and processed meats. Comments on dairy revealed diverse views, particularly with respect to beneficial levels of fat (e.g. full fat v. low-fat or fat-free) and processing. A small number of commenters did not view any animal-source foods as part of a healthy diet.

Table 1 Perspectives on foods included and limited in a healthy dietary pattern as defined in the 2015–2020 DGA

Reflecting the intent of the request for comment to gather feedback to inform labelling rules, almost half of commenters discussed food processing (n 542, data not shown), largely emphasising the healthfulness of unprocessed or minimally processed ‘whole’ foods. For example, one individual consumer (location not specified) noted that healthy food is ‘natural, made up of ingredients that came from nature and are as raw and unaltered as possible.’ Another individual consumer (location not specified) shared ‘Any food products that are processed and packaged in any way should be disqualified… from using the “healthy” label.’

Over one-third of commenters (n 493) shared that healthy foods contain limited or no added sugars, sodium, saturated fats and/or trans fats. Some commenters (n 297, data not shown) also were concerned about the inclusion of food additives, including preservatives, sweeteners and dyes during processing. These comments were more common among individual consumers than respondents from other reporting categories. A few commenters (n 43, data not shown) mentioned the importance of understanding what constitutes a serving and selecting an appropriate amount based on dietary needs to reduce overconsumption. For example, one individual consumer (location not specified) wrote, ‘[S]erving sizes need to be reevaluated, so that people get their nutrition facts based on a realistic portion size.’

Consideration of sustainability in comments

Fewer than 3 % of submissions (n 30) included the terms ‘sustainable,’ ‘sustainably’ or ‘sustainability,’ but approximately one-third of commenters referenced one or more dimensions of sustainability. For example, although they did not mention sustainability, one individual consumer (location not specified) articulated how their understanding of ‘healthy’ extends far beyond nutrition content: ‘Healthy food means much more than what food does for you after you consume it. Truly healthy food is the finished product of a healthy process. This means the health of the producers, processors, distributors, retailers and consumers is added to the definition. A food may contain high amounts of vitamins, fibre or whole grain, but if the process in which it got from farm to fork excludes the health of the workers and the planet, can it be healthy in the true sense of the word?’ We present the frequency with which commenters addressed issues aligned with each dimension of sustainability in Table 2 and describe the nature of the comments below. Of the three dimensions of sustainability, aspects of environmental sustainability were referenced the most frequently.

Table 2 Public submissions to FDA-2016-D-2335 that address environmental, social and economic dimensions of sustainability

Environmental sustainability

About one in five commenters (n 252), most commonly individual consumers, described considerations aligned with the environmental dimension of sustainability. These commenters primarily shared concerns with conventional farming. Their concerns centered on agrochemical use and GM organisms (GMO) and often took the form of appeals for organic agriculture. Commenters advocated for an end to the use of pesticides, herbicides, antibiotics, hormones, other ‘chemicals’ and GMO in food production and felt strongly that any products that were not organic and GMO-free should not bear a ‘healthy’ label.

Commenters expressed worries about contamination of the food supply and compromised food safety. One concern related to agrochemical ‘residues’ making their way into people’s diets, as articulated by an individual consumer (location not specified): ‘The level of pesticide and chemical residues present in non-organic produce and processed foods is a problem. We don’t have enough scientific information yet on the long term consequences of their presence let alone how they will interact with each other – but it can’t be good. Unnatural chemicals floating into your body… also the impact on ground water and our soil is not fully understood or given enough consideration.’ Another concern pertained to the inclusion of GM ingredients in the food supply and lack of labelling as such. For example, a health professional (location not specified) wrote, ‘The word ‘Healthy’ or ‘Natural’ should only be allowed to be used when it is healthy or natural, or in other words only ORGANIC foods such as organic grains and produce, wild caught fish, grass fed meat or raw dairy/produce etc… Anything else sprayed or treated or especially GM is not healthy nor natural and does not qualify as food.’ At the time of the request for comment, no national standard existed for disclosing foods that are GM or may contain GM material. Mandatory compliance for the National Bioengineered Food Disclosure Standard (established in December 2018) began 1 January 2022(42).

Other comments raised by a smaller number of commenters considered (1) whether the living conditions, diets and well-being of livestock should be considered as part of the definition of ‘healthy’ and (2) if knowing a food’s origin is pertinent to determining its healthfulness. Although, as noted above, numerous submissions emphasised the benefits of eating a diet rich in plant-based foods and a few recommended reducing or eliminating meat intake; only two commenters explicitly mentioned links between dietary pattern and environmental sustainability.

Social sustainability

About one in six comments (n 187) addressed themes relevant to social sustainability. Most of these focused on the power of the food industry, especially producers of processed and packaged foods, and the ways in which this may affect the healthfulness of the food supply. Some commenters raised concerns about the influence of the food industry within government policymaking and rulemaking and/or stated that they believe there is a conflict between food industry profits and public health goals. An illustrative quote from an individual consumer in Colorado was, ‘It’s time the FDA listened to the nutritionists who work on behalf of the public instead of agri-giants, chemical companies and food processors.’ Another stated, ‘It is the job of the government to protect its people and their rights. How can a nation be expected to make wise choices when it comes to eating if they are falsely informed or if the information is simply disregarded or stretched for the benefit of large industries and companies?’ A small number of submitters shared an alternative opinion, expressing the belief that the government should not regulate the food supply, emphasising the benefits of individual judgement about what is healthy.

Other submissions relevant to social sustainability addressed the need to protect and promote the well-being of people involved in the food system from primary production through final consumption. These comments came primarily from individual consumers and academic submitters. Comments on the well-being of food and farm workers stated the importance of decent livelihoods and safe working conditions, as well as support for food systems that bring value to communities. For example, one individual consumer in Connecticut shared, ‘Healthy food is produced sustainably, using methods that neither deplete resources nor exploit farmers and farm workers.’ Comments related to consumer well-being considered food as a basic human right. These primarily emphasised the need to ensure all people have access to accurate nutrition information and affordable, nutritious food that meets their preferences. For example, an individual consumer from Maryland wrote, ‘Healthy food means that the individual is receiving a sufficient level of energy and a full array of macro- and micronutrients needed to thrive physically. At the same time, the individual is eating foods that align with their culture, preferences, values and means.’

Economic sustainability

Only seven comments raised issues related to economic sustainability. These addressed two topics: how local food systems can contribute to ‘a strong local economy’ and how labelling rules may affect the bottom line of food businesses.


Similar to the definition of a ‘healthy eating pattern’ as outlined in the DGA(40), this study found individuals that submitted comments to the FDA widely recognised vegetables, fruits, whole grains and other unprocessed or minimally processed ‘whole’ foods as ‘healthy’ and identified added sugars, sodium and saturated and trans fats as ingredients to limit. Notably, one-third of commenters addressed one or more dimensions of sustainability beyond nutrition when defining ‘healthy,’ even when the term ‘sustainability’ was not specifically used.

Public comments that did address sustainability primarily alluded to environmental issues. Among these, concerns about food safety, specifically contamination of the food supply by agricultural inputs, GMO or ingredients introduced during the processing of packaged foods were mentioned most frequently. Commenters rarely mentioned other environmental aspects of food system sustainability, such as food waste, long-distance distribution networks and/or single-use packaging waste. National attention on recent federal proposals and rulemaking on bioengineered/GMO and ‘natural’ labelling could be one reason for commenters’ focus on organic production and unprocessed or minimally-processed foods(Reference Lucht43). Non-environmental dimensions of sustainability were less frequently mentioned, suggesting that the prioritisation of environmental sustainability in research and advocacy on food systems(Reference Garnett44) has contributed to greater public awareness of this dimension. Of the comments that did raise non-environmental dimensions of sustainability, comments noted the potential influence of larger agri-food businesses in the policy process. The fact that social and economic issues were less commonly mentioned by commenters suggests that these commenters consider a food’s environmental impacts more relevant to its healthfulness than its social and economic impacts and/or that more work is needed to understand and illuminate all dimensions of food system sustainability, especially those related to economic resilience and social well-being. Prior research indicates that sustainability considerations – especially environmental considerations – ‘largely left out’ of national dietary guidelines, including the DGA(Reference Ahmed, Downs and Fanzo12,Reference Mazac14) .

The findings of this study as well as public comments submitted in response to the 2015 DGAC scientific report(22) suggest that some members of the public believe that policy makers should consider sustainability dimensions when developing nutrition policies and regulation designed to promote healthier food choices, including the DGA. To date, a common proposed solution to the challenges of unhealthy diets and diet-related chronic disease has been individual-level behaviour change through education and guidelines, including food labelling efforts. While labelling may empower some consumers(Reference Cecchini and Warin45), it also has the potential to reinforce socio-economic inequities in purchasing and consuming behaviours, as a myriad of social, economic and system factors can influence food choice and dietary patterns. There is accumulating evidence that interventions that require less effort on the part of consumers may be more effective and equitable(Reference Adams, Mytton and White46). With consideration of current and cumulative evidence, policy measures designed to support ease of healthy dietary purchase and consumption patterns aligned with achieving one or more dimensions of food system sustainability could be considered. Since the DGA underpins many federal food, nutrition and health policies and programs in the USA that is one among the clear opportunities to consider.

The dataset used in this study may limit the external validity of the findings; the portion of the population that was aware of this docket and motivated to submit a comment is unlikely to be representative of the US population. Documented barriers to participation in federal rulemaking by ordinary citizens include lack of awareness that rulemakings of interest are going on, difficulty reviewing rulemaking materials and limited understanding of how to participate effectively(Reference Mendelson47). Additionally, poor/limited internet access among some population subgroups, including socioeconomically under-resourced and geographically isolated populations, could hinder participation(48). However, commenters to this proposed rule came from across the country and expressed a broad range of views, suggesting that the sample captured some of the diversity of the US population. A distinctive aspect of this sample is that it was comprised primarily of individual consumers and contained few form letters. With few exceptions, each submission was unique. Prior research has found that federal agencies place little value on form letters, but appreciate original, substantive comments(Reference Mendelson49,Reference Schlosberg, Zavestoski and Shulman50) . In fact, government guidance specifies that ‘one well supported comment is often more influential than a thousand form letters’(51). This suggests that unique submissions like those reviewed for this study will carry greater weight with agency rule makers. Future research should explore how views expressed by individuals who submitted comments to the Federal Register differ from those of individuals who did not submit a comment and investigate the source and quality of evidence used to support claims made by commenters.

Internal validity of perceptions regarding sustainability may have been limited by the focus of this request for comment. In particular, some submissions may have overlooked issues related to sustainability because participation may have been prompted by a citizen petition, which focused on the nutrient content claim ‘healthy,’ not overall diet quality(37). However, we believe that the questions asked by FDA were sufficiently broad to welcome diverse submissions on the topic, evidenced by our finding that one in three comments considered at least one dimension of sustainability.

This paper adds to recent evidence suggesting that public comments can provide useful data for policy-relevant public health nutrition research(Reference Clark, Pope and Belarmino52Reference Schlepphorst, Clark and Pope57). Such data provide one potential pathway to understand public perceptions and may be useful to complement other methods such as survey research and social media data mining. Triangulation across multiple types of data may help overcome each method’s limitations and present a more complete view of public opinion on if and how health and food system sustainability are connected. Several strengths of the present study are worth noting. First, this research is extremely timely. The FDA has not yet finalised the new definition of the term ‘healthy’ and is actively developing a symbol that the food industry can voluntarily use to label food products that meet the updated definition of ‘healthy’(39). Second, we applied a rigorous approach to coding and analysis that involved training all coders in person, establishing consistent application of the codebook prior to full coding and collaborative reviews and discussion of all coding and code memos. Third, unlike some previous public health nutrition studies using Federal Register data(Reference Dinour and Pole53,Reference Haynes-Maslow, Andress and Jilcott Pitts55) , we analysed all submitted comments and thus were able to observe the full breadth of submissions and examine a large dataset. Finally, we adopted a team-based process, which is both more inclusive and supports more comprehensive interpretation than if the final analysis was conducted by only one or two authors.


This research sheds light on salient population-level nutrition and food sustainability perspectives and considerations. Specifically, those who participated in this invitation for public comment generally defined ‘healthy’ foods and ingredients in a manner similar to how a healthy eating pattern is defined by the DGA, suggesting that the FDA’s proposal to better align labelling regulation for ‘healthy’ with the DGA reflects public opinion. However, of note, one in three individuals who shared their views with the FDA also consider ‘healthy’ foods to embody certain attributes of sustainability, particularly environmental aspects, and consider these factors in their own purchasing and eating behaviours. Thus, further discussion and policy consideration is warranted, as it is not currently represented in how the DGA and FDA currently conceptualise ‘healthy’ food.



Financial support


Conflict of interest

MEN was a member of the 2010 and 2015 Dietary Guidelines Advisory Committees. RASF is the owner of StrongPeople, LLC. The authors have no other financial or personal interests to disclose.


E.H.B.: Conceptualisation, methodology, formal analysis, writing – original draft, writing – review and editing; M.C.: methodology, formal analysis, writing – review and editing; L.K.: methodology, formal analysis, writing – review and editing; K-C.I.: methodology, formal analysis, writing – review and editing; M.E.N.: methodology, writing – review and editing; R.A.S-F.: conceptualisation, methodology and writing – review and editing.

Ethics of human subject participation

Institutional Review Board (IRB) approval was not required because the US Federal Register is a publicly available database. Commenters agree prior to submission that their comments may be disclosed on a publicly accessible website.

Supplementary material

For supplementary material accompanying this paper visit


Magni, P, Racagni, G, Agostoni, C et al. (2017) Perspective: improving nutritional guidelines for sustainable health policies: current status and perspectives. Adv Nutr 8, 532545. doi: 10.3945/an.116.014738.Google Scholar
Lawrence, M, Burlingame, B, Caraher, M et al. (2015) Public health nutrition and sustainability. Public Health Nutr 18, 22872292. doi: 10.1017/S1368980015002402.CrossRefGoogle ScholarPubMed
U.S. Department of Agriculture (2023) Food and Nutrition Security. (accessed 05 September 2023).Google Scholar
Behrens, P, Kiefte-de Jong, JC, Bosker, T et al. (2017) Evaluating the environmental impacts of dietary recommendations. Proc Natl Acad Sci 114, 1341213417. doi: 10.1073/pnas.1711889114.CrossRefGoogle Scholar
Canning, P, Rehkamp, S, Hitaj, C et al. (2020) Resource Requirements of Food Demand in the United States. U.S. Department of Agriculture, Economic Research Service. (accessed 05 September 2023).Google Scholar
FAO (2021) Land Use Statistics and Indicators Statistics. Global, Regional and Country Trends 1990–2019. FAOSTAT Analytical Brief Series No 28. Rome. (accessed 05 September 2023).Google Scholar
Intergovernmental Panel on Climate Change (IPCC) (2019) Summary for Policymakers. In Climate Change and Land: IPCC Special Report on Climate Change, Desertification, Land Degradation, Sustainable Land Management, Food Security, and Greenhouse Gas Fluxes in Terrestrial Ecosystems. pp. 1–36. Cambridge: Cambridge University Press. (accessed 14 April 2024).CrossRefGoogle Scholar
Behrer, AP & Lobell, D (2022) Higher levels of no-till agriculture associated with lower PM2.5 in the Corn Belt. Environ Res Lett 17, 094012. doi: 10.1088/1748-9326/ac816f.CrossRefGoogle Scholar
Brandes, E, McNunn, GS, Schulte, LA et al. (2017) Targeted subfield switchgrass integration could improve the farm economy, water quality, and bioenergy feedstock production. GCB Bioenergy 10, 199212. doi: 10.1111/gcbb.12481.CrossRefGoogle Scholar
Tilman, D, Clark, M, Williams, D et al. (2017) Future threats to biodiversity and pathways to their prevention. Nature 546, 7381. doi: 10.1038/nature22900.CrossRefGoogle ScholarPubMed
U.S. Department of Agriculture Economic Research Service (2023) Ag and Food Sectors and the Economy. (accessed 05 September 2023).Google Scholar
Ahmed, S, Downs, S & Fanzo, J (2019) Advancing an integrative framework to evaluate sustainability in national dietary guidelines. Front Sustain Food Syst 3, 120. doi: 10.3389/fsufs.2019.00076.CrossRefGoogle Scholar
Béné, C, Prager, SD, Achicanoy, HAE et al. (2019) Global map and indicators of food system sustainability. Sci Data 6, 115. doi: 10.1038/s41597-019-0301-5.CrossRefGoogle ScholarPubMed
Mazac, R (2016) Examining Sustainability in Food-Based Dietary Guidelines: An International Comparison and Systems Thinking Framework for Sustainable Dietary Guideline Development. MS Thesis. University of British Columbia. (accessed 24 August 2023).Google Scholar
Challinor, AJ, Watson, J, Lobell, D et al. (2014) A meta-analysis of crop yield under climate change and adaptation. Nat Clim Change 4, 287291. doi: 10.1038/nclimate2153.CrossRefGoogle Scholar
Liu, C, Hofstra, N & Franz, E (2013) Impacts of climate change on the microbial safety of pre-harvest leafy green vegetables as indicated by Escherichia coli O157 and Salmonella spp. Int J Food Microbiol 163, 119128. doi: 10.1016/j.ijfoodmicro.2013.02.026.CrossRefGoogle ScholarPubMed
Ahmed, S & Stepp, JR (2016) Beyond yields: climate change effects on specialty crop quality and agroecological management. Elem Sci Anth 4, 000092. doi: 10.12952/journal.elementa.000092.CrossRefGoogle Scholar
Myers, SS, Zanobetti, A, Kloog, I et al. (2014) Increasing CO2 threatens human nutrition. Nature 510, 139142. doi: 10.1038/nature13179.CrossRefGoogle ScholarPubMed
Toussaint, M, Cabanelas, P & González-Alvarado, TE (2021) What about consumer choice? The influence of social responsibility on consumer’s purchasing behavior in the food value chain. Eur Res Manage Bus Econ 27, 100134. doi: 10.1016/j.iedeen.2020.100134.CrossRefGoogle Scholar
Dietary Guidelines Advisory Committee (2015) Scientific report of the 2015 Dietary Guidelines Advisory Committee. Washington, DC: U.S. Department of Agriculture, Agricultural Research Service. doi: 10.1017/CBO9781107415324.004.Google Scholar
Merrigan, K, Griffin, T, Wilde, P et al. (2015) Designing a sustainable diet. Science 350, 165166. doi: 10.1126/science.aab2031.CrossRefGoogle ScholarPubMed
Office of Disease Prevention and Health Promotion. (2019) Public Comments on the Scientific Report of the 2015 Dietary Guidelines Advisory Committee. (accessed 05 September 2023).Google Scholar
Vilsack, T & Burwell, S (2015) 2015 Dietary Guidelines: Giving you the Tools you Need to Make Healthy Choices. (accessed 26 September 2018).Google Scholar
Finley, JW, Dimick, D, Marshall, E et al. (2017) Nutritional sustainability: aligning priorities in nutrition and public health with agricultural production. Adv Nutr 8, 780788. doi: 10.3945/an.116.013995.CrossRefGoogle Scholar
Muller, M, Tagtow, A, Roberts, SL et al. (2009) Aligning food systems policies to advance public health. J Hunger Environ Nutr 4, 225240. doi: 10.1080/19320240903321193.CrossRefGoogle ScholarPubMed
Gonzalez Fischer, C & Garnett, T (2016) Plates, Pyramids, Planet: Developments in National Healthy and Sustainable Dietary Guidelines: A State of Play Assessment. Rome; Oxford: Food and Agriculture Organization of the United Nations and The Food Climate Research Network at The University of Oxford; available at (accessed 08 June 2022).Google Scholar
Orlando, EA, Rebellato, AP, Siquerira Silva, JG et al. (2020) Sodium in different processed and packaged foods: method validation and an estimative on the consumption. Food Res Int 129, 108836. doi: 10.1016/j.foodres.2019.108836.CrossRefGoogle Scholar
Steele, EM, Baraldi, LG, de Costa Louzada, ML et al. (2016) Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ Open 6, e009892. doi: 10.1136/bmjopen-2015-009892.CrossRefGoogle Scholar
Dunford, EK, Miles, DR, Popkin, B et al. (2022) Whole and refined grains: an examination of US household grocery store purchases. J Nutr 152, 550558. doi: 10.1093/jn/nxab382.CrossRefGoogle ScholarPubMed
Anastasiou, K, Baker, P, Hadjikakou, M et al. (2022) A conceptual framework for understanding the environmental impacts of ultra-processed foods and implications for sustainable food systems. J Cleaner Prod 368, 133155. doi: 10.1016/j.jclepro.2022.133155.CrossRefGoogle Scholar
Oxfam (2013) Behind the Brands: Food Justice and the ’big 10’ Food and Beverage Companies. Oxford: Oxfam; available at (accessed 05 September 2023).Google Scholar
Andrews, JC, Burton, S & Netemeyer, RG (2000) Are some comparative nutrition claims misleading? The role of nutrition knowledge, ad claim type and disclosure conditions. J Advert 29, 2842. doi: 10.1080/00913367.2000.10673615.CrossRefGoogle Scholar
Harris, JL, Thompson, JM, Schwartz, MB et al. (2011) Nutrition-related claims on children’s cereals: what do they mean to parents and do they influence willingness to buy? Public Health Nutr 14, 22072212. doi: 10.1017/S1368980011001741.CrossRefGoogle ScholarPubMed
Lytton, TD (2010) Banning front-of-package food labels: first amendment constraints on public health policy. Public Health Nutr 14, 11231126. doi: 10.1017/S1368980010002843.CrossRefGoogle ScholarPubMed
Nestle, M & Ludwing, DS (2010) Front of package food labels: public health or propaganda? JAMA 303, 771772. doi: 10.1001/jama.2010.179.CrossRefGoogle ScholarPubMed
US Food and Drug Administration (2018) 21 C.F.R. 101.65(d)(2). Code Fed Regul 21(2). (accessed 09 June 2022).Google Scholar
US Food and Drug Administration (2016) Use of the Term ‘“healthy”’ in the Labeling of Human Food Products; Request for Information and Comments. (accessed 25 June 2017).Google Scholar
Carey, MP (2013) The Federal Rulemaking Process: An Overview. CRS Report for Congress RL32240. (accessed 14 April 2024).Google Scholar
US Food and Drug Administration (2022) Use of the Term Healthy on Food Labeling. (accessed 2023).Google Scholar
U.S. Department of Health and Human Services & U.S. Department of Agriculture (2015) 2015–2020 Dietary Guidelines for Americans. 8th Edition. (accessed 05 September 2023).Google Scholar
Food and Agriculture Organization of the United Nations (2014) Sustainability Assessment of Food and Agriculture Systems (SAFA) Guidelines. Version 3. (accessed 18 May 2022).Google Scholar
Agricultural Marketing Service (2022) BE Disclosure. (accessed 09 June 2022).Google Scholar
Lucht, JM (2015) Public acceptance of plant biotechnology and GM crops. Viruses 7, 42544281. doi: 10.3390/v7082819.CrossRefGoogle ScholarPubMed
Garnett, T (2016) Plating up solutions. Science 353, 12021204. doi: 10.1126/science.aah4765.CrossRefGoogle ScholarPubMed
Cecchini, M & Warin, L (2016) Impact of food labelling systems on food choices and eating behaviours: a systematic review and meta-analysis of randomized studies. Obes Rev 17, 201210. doi: 10.1111/obr.12364.CrossRefGoogle ScholarPubMed
Adams, J, Mytton, O, White, M et al. (2016) Why are some population interventions for diet and obesity more equitable and effective than others? The role of individual agency. PLoS Med 13, 17. doi: 10.1371/journal.pmed.1001990.Google ScholarPubMed
Mendelson, NA (2012) Should mass comments count? Michigan J Environ Adm Law 173, 173184.Google Scholar
Pew Research Center (2021) Internet/Broadband Fact Sheet. (accessed 05 September 2023).Google Scholar
Mendelson, NA (2011) Rulemaking, democracy, and torrents of e-mail. George Wash Law Rev 79, 13431380.Google Scholar
Schlosberg, D, Zavestoski, S & Shulman, S (2009) Deliberation in e-rulemaking? The problem of mass participation. In Online Deliberation: Design, Research and Practice, pp. 133–148 [T Davies & SP Gangadharan, editors]. San Francisco: CSLI Publications; available at (accessed 09 June 2022).Google Scholar (2018) Tips for Submitting Effective Comments. (accessed 13 May 2022).Google Scholar
Clark, BE, Pope, L & Belarmino, EH (2022) Perspectives from healthcare professionals on the nutritional adequacy of plant-based dairy alternatives: results of a mixed methods inquiry. BMC Nutr 8, 46. doi: 10.1186/s40795-022-00542-7.CrossRefGoogle ScholarPubMed
Dinour, LM & Pole, A (2017) Potato chips, cookies, and candy oh my! Public commentary on proposed rules regulating competitive foods. Heal Educ Behav 44, 867875. doi: 10.1177/1090198117699509.CrossRefGoogle Scholar
Geller, SG, Clark, BE, Pope, L et al. (2022) Investigating knowledge on calcium and preferences for dairy v. plant-based alternatives. J Heal Eat Act Living 2, 60. doi: 10.51250/jheal.v2i2.42.CrossRefGoogle Scholar
Haynes-Maslow, L, Andress, L, Jilcott Pitts, S et al. (2018) Arguments used in public comments to support or oppose the U.S. Department of Agriculture’s minimum stocking requirements: a content analysis. J Acad Nutr Diet 118, 16641672. doi: 10.1016/j.jand.2017.12.005.CrossRefGoogle ScholarPubMed
Pomeranz, J & Pertschuk, M (2019) Key drivers of state preemption of food, nutrition, and agriculture policy: a thematic analysis of public testimony. Am J Heal Promot 33, 894902. doi: 10.1177/0890117118823163.CrossRefGoogle ScholarPubMed
Schlepphorst, KI, Clark, BE, Pope, L et al. (2023) Perceptions and knowledge of protein in dairy and plant-based alternatives among stakeholders in the US marketplace. Nutr Bull 00, 110. doi: 10.1111/nbu.12628.Google Scholar
Figure 0

Fig. 1 Flow diagram of comments submitted to FDA-2016-D-2335

Figure 1

Table 1 Perspectives on foods included and limited in a healthy dietary pattern as defined in the 2015–2020 DGA

Figure 2

Table 2 Public submissions to FDA-2016-D-2335 that address environmental, social and economic dimensions of sustainability

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