Workshop summary: building an NHANES for the future

The American Society for Nutrition's (ASN) Committee on Advocacy and Science Policy (CASP) organized a workshop, "Building a National Health and Nutrition Examination Survey (NHANES) for the Future," held during NUTRITION 2023, which took place in Boston, MA in July 2023. CASP had already identified an urgent need for increased support and modernization to ensure that a secure future for NHANES is achievable. The survey faces challenges associated with data collection, stagnant funding, and a need for more granular data for subpopulations and groups at risk. The workshop provided an overview of NHANES, including the nutrition component, and the many other uses for the survey's data, which extend beyond nutrition. Speakers highlighted NHANES's current and emerging challenges, as well as possible solutions to address these challenges, especially with regard to response rates of underrepresented groups, linkage of survey data to other resources, incorporation of new survey methodologies, and emerging data needs. The workshop also included a "Town Hall" component to gather additional feedback on NHANES' challenges and proposed solutions from audience members. The workshop provided many possible action items that ASN will explore and use to inform effective continued advocacy in support of NHANES and to find possible opportunities for ASN and others to partner with the Centers for Disease Control and Prevention National Center for Health Statistics to strengthen this vital survey and maintain its robust and relevant data moving forward.

UK Chickpea Consumption Doubled from 2008/09-2018/19

Background: Only 9% of individuals in the United Kingdom (UK) meet the recommendation for dietary fibre intake. Little is known about chickpea consumption in the UK. Methods: Chickpea intake trends and sociodemographic patterns were analysed using the National Diet and Nutrition Survey Rolling Programme data collected from 2008/09 to 2018/19 among 15,655 individuals ≥1.5 years completing a four-day food diary. Chickpea consumers were identified based on a list of chickpea-containing foods, with the most consumed foods being hummus, boiled chickpeas, chickpea flour, and low/reduced-fat hummus. Micronutrient and food group intakes were compared between chickpea consumers and non-consumers; the Modified Healthy Dietary Score was also assessed, which measures adherence to UK dietary recommendations. Results: Chickpea consumption increased from 6.1% (2008-2012) to 12.3% (2016-2019). Among 1.5-3 years, consumption increased from 5.7% to 13.4%, and among 19-64 years, consumption increased from 7.1% to 14.4%. The percentage of individuals eating chickpeas was higher among individuals with higher incomes and more education. Healthy-weight adults were more likely to consume chickpeas compared to those who were overweight or obese. Compared to both bean and non-bean consumers, chickpea consumers ate significantly more dietary fibre, fruits and vegetables, pulses, nuts, and less red meat and processed meat products. Chickpea consumers also had a higher Modified Healthy Dietary Score. Conclusions: In the UK, chickpea consumption more than doubled from 2008/09 to 2018/19. Chickpea consumers had a higher diet quality than non-consumers.

South African Consumers' Knowledge, Opinions and Awareness of Whole Grains and Their Health Benefits: A Cross-Sectional Online Survey

Evidence indicates that whole-grain food consumption reduces the risk of cardiovascular disease, type-2 diabetes, and some cancers. Increasing whole-grain consumption in developing countries is likely to significantly benefit the health of the population. However, there is very limited information on consumer whole-grain knowledge, attitudes, and behaviors in developing countries. An online cross-sectional survey was conducted among 1000 South African consumers with sufficient income to make food purchase choices and who were generally representative in terms of gender, age, and ethnicity. Most respondents (64%) were confident of their whole-grain knowledge. However, 60% of all participants selected incorrect definitions of whole grains. Whilst most correctly identified common cereals as whole grains, at most 50% of participants correctly identified common whole-grain foods. Also, whilst most (67%) thought that they were consuming enough whole grains, the majority (62%) underestimated the recommended level of consumption. Furthermore, respondent knowledge regarding whole-grain food attributes and the health benefits of whole-grain consumption was generally poor. Clearly, consumer-focused strategies are needed in developing countries to increase whole-grain food consumption to help the broader population achieve a healthy and sustainable diet. Actions proposed include: simple-to-understand information on whole-grain content relative to recommendations on food product labels, the provision of whole-grain foods in school nutrition schemes, and coordinated social and behavior change communication initiatives.

Trends and patterns of chickpea consumption among U.S. adults: analyses of NHANES data

BACKGROUND

Chickpeas are an affordable and nutrient-dense legume, but there is limited U.S. data on consumption patterns and the relationship between chickpea consumption and dietary intakes.

OBJECTIVE

This study examined trends and socio-demographic patterns among chickpea consumers and the relationship between chickpea consumption and dietary intake.

METHODS

Adults consuming chickpeas or chickpea-containing foods on one or both of the 24-hour dietary recalls were categorized as chickpea consumers. Data from National Health and Nutrition Examination Surveys 2003-2018 were used to evaluate trends and socio-demographic patterns in chickpea consumption (n=35,029). The association between chickpea consumption and dietary intakes was compared to other legume consumers and non-legume consumers from 2015-2018 (n=8,342).

RESULTS

The proportion of chickpea consumers increased from 1.9% in 2003-2006 to 4.5% in 2015-2018 (p-value for trend<0.001). This trend was consistent across age group, gender, race/ethnicity, education, and income. In 2015-2018, chickpea consumption was highest among individuals with higher incomes (2.4% among those with incomes <185% of the federal poverty guideline vs. 6.4% with incomes ≥300%), education levels (1.0% for <high school vs. 10.2% for college graduates), physical activity levels (1.9% for no physical activity vs. 7.7% for ≥430min of moderate-equivalent physical activity per week), and those with better self-reported health (1.7% fair poor vs. 6.5% for excellent/very good, p-trend<0.001 for each). Chickpea consumers had greater intakes of whole grains (1.48 oz/d for chickpea consumers vs. 0.91 for non-legume consumers) and nuts/seeds (1.47 vs. 0.72 oz/d), less intake of red meat (0.96 vs. 1.55 oz/d), and higher Healthy Eating Index scores (62.1 vs. 51.2) compared to both non-legume and other legume consumers (p-value<0.05 for each).

CONCLUSIONS

Chickpea consumption among U.S. adults has doubled between 2003 and 2018, yet intake remains low. Chickpea consumers have higher socioeconomic status and better health status, and their overall diets are more consistent with healthy eating.

Balanced Hybrid Nutrient Density Score Compared to Nutri-Score and Health Star Rating Using Receiver Operating Characteristic Curve Analyses

Background

Nutrient profiling (NP) models that are used to assess the nutrient density of foods can be based on a combination of key nutrients and desirable food groups.

Objective

To compare the diagnostic accuracy of a new balanced hybrid nutrient density score (bHNDS) to Nutri-Score and Health Star Rating (HSR) front-of-pack systems using receiver operating characteristic (ROC) curve analyses. The diet-level bHNDS was first validated against Healthy Eating Index (HEI-2015) using data from the 2017–18 National Health and Nutrition Examination Survey (2017–18 NHANES). Food-level bHNDS values were then compared to both the Nutri-Score and HSR using ROC curve analyses.

Results

The bHNDS was based on 6 nutrients to encourage (protein, fiber, calcium, iron, potassium, and vitamin D); 5 food groups to encourage (whole grains, nuts and seeds, dairy, vegetables, and fruit), and 3 nutrients (saturated fat, added sugar, and sodium) to limit. The algorithm balanced components to encourage against those to limit. Diet-level bHNDS values correlated well with HEI-2015 (r = 0.67; p &lt; 0.001). Food-level correlations with both Nutri-Score (r = 0.60) and with HSR (r = 0.58) were significant (both p &lt; 0.001). ROC estimates of the Area Under the Curve (AUC) showed high agreement between bHNDS values and optimal Nutri-Score and HSR ratings (&gt;0.90 in most cases). ROC analysis identified those bHNDS cut-off points that were predictive of A-grade Nutri-Score or 5-star HSR. Those cut-off points were highly category-specific.

Conclusion

The new bHNDS model showed high agreement with two front-of-pack labeling systems. Cross-model comparisons based on ROC curve analyses are the first step toward harmonization of proliferating NP methods that aim to “diagnose” high nutrient-density foods.

Estimated Sweetness in US Diet Among Children and Adults Declined From 2001 to 2018: A Serial Cross-Sectional Surveillance Study Using NHANES 2001–2018

An agreed-upon measure of total dietary sweetness is lacking hindering assessments of population-level patterns and trends in dietary sweetness. This cross-sectional study used 24-h dietary recall data for 74,461 participants aged ≥ 2 y from nine cycles (2001–2018) of the National Health and Nutrition Examination Survey (NHANES) to evaluate trends in the sweetness of the diet in the United States (US). LCS-containing items were matched to a sugar-sweetened counterpart (e.g., diet cola–regular cola or sucralose sugar). The matched pair was used to estimate the sugar equivalents from LCS-sweetened foods or beverages to estimate dietary level sweetness, which was described as grams of approximate sugar equivalent (ASE) per day. Trends in ASE were estimated overall and by subgroup, and trends were further disaggregated by food or beverage category. Overall, LCS sources contributed about 10.5% of ASE. Total ASE declined from 152 g/d to 117 g/d from 2001–2002 to 2017–2018 (p-trend < 0.001), with comparable declines in children and adults. Declines in total ASE were predominantly driven by beverages (−36.7% from 2001–2002 to 2017–2018) and tabletop sweeteners (−23.8%), but not food (−1.5%). Observed trends were robust to sensitivity analyses incorporating random, systematic, and sensory trial informed estimates of sweetness and also an analysis excluding possible under-reporters of dietary energy. This practical approach and underlying data may help researchers to apply the technique to other dietary studies to further these questions.

The association between social needs and chronic conditions in a large, urban primary care population

There is consensus that social needs influence health outcomes, but less is known about the relationships between certain needs and chronic health conditions in large, diverse populations. This study sought to understand the association between social needs and specific chronic conditions using social needs screening and clinical data from Electronic Health Records. Between April 2018-December 2019, 33,550 adult (≥18y) patients completed a 10-item social needs screener during primary care visits in Bronx and Westchester counties, NY. Generalized linear models were used to estimate prevalence ratios for eight outcomes by number and type of needs with analyses completed in Summer 2020. There was a positive, cumulative association between social needs and each of the outcomes. The relationship was strongest for elevated PHQ-2, depression, alcohol/drug use disorder, and smoking. Those with ≥3 social needs were 3.90 times more likely to have an elevated PHQ-2 than those without needs (95% CI: 3.66, 4.16). Challenges with healthcare transportation was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. For example, those with transportation needs were 84% more likely to have an alcohol/drug use disorder diagnosis (95% CI: 1.59, 2.13) and 41% more likely to smoke (95% CI: 1.25, 1.58). Specific social needs may influence clinical issues in distinct ways. These findings suggest that health systems need to develop strategies that address unmet social need in order to optimize health outcomes, particularly in communities with a dual burden of poverty and chronic disease.

Impact of sociodemographic factors on the consumption of tubers in Brazil

Background

Although tubers play a significant role in Brazilian agriculture, very little is known about the intake of tubers among the Brazilian population. The objective of this study was to characterize the intake of tubers across Brazil. The types of tubers consumed were quantified, and the impact of geographic and sociodemographic factors was assessed.

Methods

This cross-sectional study is based on dietary intake data of 33,504 subjects obtained from the Brazilian National Dietary Survey. All tuber containing foods were identified, and the contribution of different tubers to overall tuber consumption in Brazil was quantified. Descriptive analyses assessed the impact of macroregion and sociodemographic characteristics on tuber consumption, and differences in intake were assessed using statistical tests. Lastly, the dietary intakes of tuber consumers and non-consumers were compared after adjusting for energy and covariates to determine if there were any major differences in dietary intakes between the two groups.

Results

Fifty-five percent of the Brazilian population consumed tubers, which differed by macroregion. The intake of tubers among consumers also differed between macroregions. Overall, rural areas reported significantly higher mean daily intakes of tubers (122 g/day) among tuber consumers than urban areas (95 g/day). Mandioca and potato were the most commonly consumed tubers (59 and 43% prevalence, respectively, on any of the 2 days), while the highest daily intakes amongst tuber consumers across Brazil were noted for sweet potato (156 g/day) and potato (95 g/day). On a macroregion level, among tuber consumers, mandioca had the highest prevalence of consumption in the North (94%), Northeast (83%), and Central-West (68%), while consumption of potatoes was most prevalent in the Southeast (63%) and South (62%). Compared to women, small but significantly higher tuber intakes were noted for males (108 vs. 85 g/day). There were no significant differences in intakes among income quintiles. After adjusting for energy and other covariates, nutrient intakes between tuber and non-tuber consumers were not meaningfully different, with the exception of sodium (+ 6.0% comparing non-tuber to tuber consumers), iron (+ 6.1%), zinc (+ 5.7%), vitamin C (+ 8.3%), riboflavin (+ 9.0%), and folate (+ 7.9%).

Conclusions

Tuber consumption is influenced by regional and sociodemographic characteristics of the Brazilian population. When looking at energy-adjusted nutrient intakes, diets of tuber consumers have resulted in somewhat lower intakes of some micronutrients, namely riboflavin, folate, vitamin C, iron, sodium, and zinc.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00709-1.

Trends in Vitamin C Consumption in the United States: 1999-2018

Low intakes of fruits and vegetables have resulted in suboptimal intakes of several micronutrients, including vitamin C. This cross-sectional study used data from 84,902 children/adults (≥1 y) who completed a 24-h dietary recall as part of the United States National Health and Nutrition Examination Survey (1999-2018). Mean vitamin C intakes from foods/beverages were calculated as were trends in major food/beverage sources of vitamin C. Percentages below the Estimated Average Requirement (EAR) were estimated. Overall, mean vitamin C consumption declined by 23% (97-75 mg/d; p-value for trend < 0.001). 100% fruit juice was the leading source of vitamin C (25.6% of total or 21.7mg/d), but this declined by 48% (25-13 mg/d; p-value for trend < 0.001). Whole fruit increased among children/adolescents (+75.8%;10-17 mg/d; p-value for trend < 0.001), but not adults, while the vegetable contribution was generally unchanged. The proportion of the population below the EAR increased by 23.8% on a relative scale or 9 percentage points on an absolute scale (38.3-47.4%). Declines in vitamin C intake is driven largely by decreases in fruit juice coupled with modest increases in whole fruit. Due to associations between vitamin C intake and numerous health outcomes these trends warrant careful monitoring moving forward.

Opposing Consumption Trends for Sugar-Sweetened Beverages and Plain Drinking Water: Analyses of NHANES 2011-16 Data

Background: Choosing water in place of sugar-sweetened beverages (SSB) can reduce added sugars while maintaining adequate hydration. The present goal was to examine 2011–16 time trends in SSB vs. water consumption across US population subgroups.

Methods: Dietary intake data for 22,716 persons aged >4 years came from two 24-h dietary recalls in successive cycles of the National Health and Examination Survey (NHANES 2011–16). Water intakes (in mL/d) from plain water (tap and bottled) and from beverages (SSB and not-SSB) were the principal outcome variables. Intakes were analyzed by age group, income to poverty ratio (IPR), and race/ethnicity. Time trends by demographics were also examined.

Results: SSB and water intakes followed distinct social gradients. Most SSB was consumed by Non-Hispanic Black and lower-income groups. Most tap water was consumed by Non-Hispanic White and higher-income groups. During 2011–16, water from SSB declined from 322 to 262 mL/d (p < 0.005), whereas plain water increased (1,011–1,144 mL/d) (p < 0.05). Groups aged <30 years reduced SSB consumption (p < 0.0001) but it was groups aged >30 years that increased drinking water (p < 0.001). Non-Hispanic White groups reduced SSB and increased tap water consumption. Non-Hispanic Black and lower income groups reduced SSB and increased bottled water, not tap.

Conclusion: The opposing time trends in SSB and water consumption were not uniform across age groups or sociodemographic strata. Only the non-Hispanic White population reduced SSB and showed a corresponding increase in tap water. Lower-income and minority groups consumed relatively little plain drinking water from the tap.

Chronic pediatric health conditions among youth living in public housing and receiving care in a large hospital system in Bronx, NY

This study compared the prevalence of chronic pediatric health conditions for youth in public housing with youth not in public housing using clinical electronic health record (EHR) and housing data. Youth (ages 2-17 years) in a large urban health system were identified and categorized into two housing types—public housing (n = 10 770) and not in public housing (n = 84 883) by age (young childhood, middle childhood, young adolescence). The prevalence of some pediatric conditions was higher in public housing but varied by age. Disparities in health conditions among youth in public housing were more common in early adolescence: asthma (26.4 vs 18.6; P < .001); obesity (28.5 vs 24.6; P < .001); depression/anxiety (19.2 vs 17.3; P = .008); behavioral disorders (8.1 vs 5.3; P < .001). These results show that chronic pediatric conditions like asthma and obesity that lead to significant morbidity into adulthood are more common among youth living in public housing. However, this pattern is not consistent across all chronic conditions.

Flavonoid Intakes in the US Diet Are Linked to Higher Socioeconomic Status and to Tea Consumption: Analyses of NHANES 2011-16 Data

BACKGROUND

Many of the health benefits of tea have been attributed to its flavonoid content. Tea consumption in US adults varies by socioeconomic status (SES).

OBJECTIVES

The present objective was to explore intakes of total flavonoids and flavonoid subclasses by participant sociodemographics and by patterns of tea consumption.

METHODS

The present analyses were based on 2 d of dietary recalls for 17,506 persons aged >9 y in the 2011-2016 NHANES. The What We Eat in America nutrient composition database was merged with the USDA Expanded Flavonoid database, which included total flavonoids and flavan-3-ols (including catechins), flavanones, flavonols, anthocyanidins, flavones, and isoflavones. Flavonoid intakes were compared by sex, age, race/ethnicity, education, and income-to-poverty ratio (IPR) in univariate analyses. Flavonoid intakes of children and adults were also compared by tea consumption status. Time trends in flavonoid intakes were also examined.

RESULTS

Mean total flavonoid intake was 219 mg/d, of which flavan-3-ols provided 174 mg/d, or 79%. The highest total flavonoid intakes were found in adults aged 51-70 y (293 mg/d), non-Hispanic whites (251 mg/d) and in groups with college education (251 mg/d) and higher income (IPR >3.5: 249 mg/d) (P < 0.001 for all). The socioeconomic gradient was significant for anthocyanidins, flavonols, and flavones (P < 0.001 for all) but not for flavan-3-ols, and persisted across 3 cycles of NHANES. Adult tea consumers had higher intakes of total flavonoids (610 mg/d compared with 141 mg/d) and flavan-3-ols (542 mg/d compared with 97.8 mg/d) than did nonconsumers (P < 0.001). Time trend analyses showed that both tea consumption and flavonoid intakes were unchanged from 2011 to 2016.

CONCLUSIONS

Flavonoid intakes in children and adults in the NHANES 2011-16 sample were associated with higher SES and were largely determined by tea consumption. Studies of diet and disease risk need to take sociodemographic gradients and eating and drinking habits into account.

Unmet Social Needs and No-Show Visits in Primary Care in a US Northeastern Urban Health System, 2018-2019

Objectives. To characterize the association between social needs prevalence and no-show proportion and variation in these associations among specific social needs.Methods. In this study, we used results from a 10-item social needs screener conducted across 19 primary care practices in a large urban health system in Bronx County, New York, between April 2018 and July 2019. We estimated the association between unmet needs and 2-year history of missed appointments from 41 637 patients by using negative binomial regression models.Results. The overall no-show appointment proportion was 26.6%. Adjusted models suggest that patients with 1 or more social needs had a significantly higher no-show proportion (31.5%) than those without any social needs (26.3%), representing an 19.8% increase (P < .001). We observed a positive trend (P < .001) between the number of reported social needs and the no-show proportion-26.3% for those with no needs, 30.0% for 1 need, 32.1% for 2 needs, and 33.8% for 3 or more needs. The strongest association was for those with health care transportation need as compared with those without (36.0% vs 26.9%).Conclusions. We found unmet social needs to have a significant association with missed primary care appointments with potential implications on cost, quality, and access for health systems.

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program

Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.

A comparison of different practical indices for assessing carbohydrate quality among carbohydrate-rich processed products in the US

Healthier carbohydrate (carb)-rich foods are essential for health, but practical, validated indices for their identification are not established. We compared four pragmatic metrics, based on, per 10g of carb:(a) ≥1g fiber (10:1 carb:fiber), (b) ≥1g fiber and <1g free sugars (10:1:1 carb:fiber:free sugars), (c) ≥1g fiber and <2g free sugars (10:1:2 carb:fiber:free sugars); and (d) ≥1g fiber and, per each 1 g of fiber, <2g free sugars (10:1 carb:fiber, 1:2 fiber:free sugars; or 10:1|1:2). Using 2013-2016 National Health and Nutrition Examination Survey /Food and Nutrient Database for Dietary Studies, we assessed, overall and for 12 food categories, whether each metric discriminated carb-rich products higher or lower (per 100g) in calories, total fat, saturated fat, protein, sugar, fiber, sodium, potassium, magnesium, folate, and 8 vitamins/minerals. Among 2,208 carb-rich products, more met 10:1 (23.2%) and 10:1|1:2 (21.3%), followed by 10:1:2 (19.2%) and 10:1:1 (16.4%) ratios, with variation by product sub-categories. The 10:1 and 10:1|1:2 ratios similarly identified products with lower calories, fat, free sugars, and sodium; and higher protein, fiber, potassium, magnesium, iron, vitamin B6, vitamin E, zinc and iron. The 10:1:2 and 10:1:1 ratios identified products with even larger differences in calories and free sugars, but smaller differences in other nutrients above and lower folate, thiamine, riboflavin, and niacin; the latter findings were attenuated after excluding breakfast cereals (~9% of products). These novel findings inform dietary guidance for consumers, policy, and industry to identify and promote the development of the healthier carb-rich foods.

Quality of Meals Consumed by US Adults at Full-Service and Fast-Food Restaurants, 2003-2016: Persistent Low Quality and Widening Disparities

BACKGROUND

Meals from full-service restaurants (FS) and fast-food restaurants (FF) are an integral part of US diets, but current levels and trends in consumption, healthfulness, and related sociodemographic disparities are not well characterized.

OBJECTIVES

We aimed to assess patterns and nutritional quality (using validated American Heart Association [AHA] diet scores) of FS and FF meals consumed by US adults.

METHODS

Serial cross-sectional investigation utilizing 24-h dietary recalls in survey-weighted, nationally representative samples of 35,015 adults aged ≥20 y from 7 NHANES cycles, 2003-2016.

RESULTS

Between 2003 and 2016, American adults consumed ∼21 percent of energyfrom restaurants (FS: 8.5% in 2003-2004, 9.5% in 2015-2016, P-trend = 0.38; FF: 10.5%; 13.4%, P-trend = 0.31). Over this period, more FF meals were eaten for breakfast (from 4.4% to 7.6% of all breakfasts, P-trend <0.001), with no changes for lunch (15.2% to 15.3%) or dinner (14.6% to 14.4%). In 2015-2016, diet quality of both FS and FF were low, with mean AHA diet scores of 31.6 and 27.6 (out of 80). Between 2003 and 2016, diet quality of FF meals improved slightly, (the percentage with poor quality went from 74.6% to 69.8%; and with intermediate quality, from 25.4% to 30.2%; P-trend <0.001 each). Proportions of FS meals of poor (∼50%) and intermediate (∼50%) quality were stable over time, with <0.1% of consumed FS or FF meals meeting ideal quality. Disparities in FS meal quality persisted by race/ethnicity, obesity status, and education and worsened by income; whereas disparities in FF meal quality persisted by age, sex, and obesity status and worsened by race/ethnicity, education, and income.

CONCLUSIONS

Between 2003 and 2016, FF and FS meals provided 1 in 5 calories for US adults. Modest improvements occurred in nutritional quality of FF, but not FS, meals consumed, and the average quality for both remained low with persistent or widening disparities. These findings highlight the need for strategies to improve the nutritional quality of US restaurant meals.

Trends in Diet Quality Among Youth in the United States, 1999-2016

Importance

Prior studies of dietary trends among US youth have evaluated major macronutrients or only a few foods or have used older data.

Objective

To characterize trends in diet quality among US youth.

Design, Setting, and Participants

Serial cross-sectional investigation using 24-hour dietary recalls from youth aged 2 to 19 years from 9 National Health and Nutrition Examination Survey (NHANES) cycles (1999-2016).

Exposures

Calendar year and population sociodemographic characteristics.

Main Outcomes and Measures

The primary outcomes were the survey-weighted, energy-adjusted mean consumption of dietary components and proportion meeting targets of the American Heart Association (AHA) 2020 continuous diet score (range, 0-50; based on total fruits and vegetables, whole grains, fish and shellfish, sugar-sweetened beverages, and sodium). Additional outcomes were the AHA secondary score (range, 0-80; adding nuts, seeds, and legumes; processed meat; and saturated fat) and Healthy Eating Index (HEI) 2015 score (range, 0-100). Poor diet was defined as less than 40% adherence (scores, <20 for primary and <32 for secondary AHA scores); intermediate as 40% to 79.9% adherence (scores, 20-39.9 and 32-63.9, respectively); and ideal, as at least 80% adherence (scores, ≥40 and ≥64, respectively). Higher diet scores indicate better diet quality; a minimal clinically important difference has not been quantified.

Results

Of 31 420 youth aged 2 to 19 years included, the mean age was 10.6 years; 49.1% were female. From 1999 to 2016, the estimated AHA primary diet score significantly increased from 14.8 (95% CI, 14.1-15.4) to 18.8 (95% CI, 18.1-19.6) (27.0% improvement), the estimated AHA secondary diet score from 29.2 (95% CI, 28.1-30.4) to 33.0 (95% CI, 32.0-33.9) (13.0% improvement), and the estimated HEI-2015 score from 44.6 (95% CI, 43.5-45.8) to 49.6 (95% CI, 48.5-50.8) (11.2% improvement) (P < .001 for trend for each). Based on the AHA primary diet score, the estimated proportion of youth with poor diets significantly declined from 76.8% (95% CI, 72.9%-80.2%) to 56.1% (95% CI, 51.4%-60.7%) and with intermediate diets significantly increased from 23.2% (95% CI, 19.8%-26.9%) to 43.7% (95% CI, 39.1%-48.3%) (P < .001 for trend for each). The estimated proportion meeting ideal quality significantly increased but remained low, from 0.07% (95% CI, 0.01%-0.49%) to 0.25% (95% CI, 0.10%-0.62%) (P = .03 for trend). Persistent dietary variations were identified across multiple sociodemographic groups. The estimated proportion of youth with a poor diet in 2015-2016 was 39.8% (95% CI, 35.1%-44.5%) for ages 2 to 5 years (unweighted n = 666), 52.5% (95% CI, 46.4%-58.5%) for ages 6 to 11 years (unweighted n = 1040), and 66.6% (95% CI, 61.4%-71.4%) for ages 12 to 19 years (unweighted n = 1195), with persistent differences across levels of parental education, household income, and household food security status.

Conclusions and Relevance

Based on serial NHANES surveys from 1999 to 2016, the estimated overall diet quality of US youth showed modest improvement, but more than half of youth still had poor-quality diets.

Trends in tap and bottled water consumption among children and adults in the United States: analyses of NHANES 2011-16 data

BACKGROUND

Dietary Guidelines for Americans 2015-20 recommend choosing water in place of sugar-sweetened beverages (SSB). This study examined water consumption patterns and trends among children and adults in the US.

METHODS

Dietary intake data for 7453 children (4-18y) and 15,263 adults (>19y) came from two 24 h dietary recalls in three cycles of the National Health and Nutrition Examination Survey (NHANES 2011-2016). Water was categorized as tap or bottled (plain). Other beverages were assigned to 15 categories. Water and other beverage intakes (in mL/d) were analyzed by sociodemographic variables and sourcing location. Consumption time trends from 2011 to 2016 were also examined. Total water intakes from water, other beverages and moisture from foods (mL/d) were compared to Dietary Reference Intakes (DRI) for water.

RESULTS

Total dietary water (2718 mL/d) came from water (1066 mL/d), other beverages (1036 mL/d) and from food moisture (618 mL/d). Whereas total water intakes remained stable, a significant decline in SSB from 2011 to 2016 was fully offset by an increase in the consumption of plain water. The main sources of water were tap at home (288 mL/d), tap away from home (301 mL/d), and bottled water from stores (339 mL/d). Water and other beverage consumption patterns varied with age, incomes and race/ethnicity. Higher tap water consumption was associated with higher incomes, but bottled water was not. Non-Hispanic whites consumed most tap water (781 mL/d) whereas Mexican Americans consumed most bottled water (605 mL/d). Only about 40% of the NHANES sample on average followed US recommendations for adequate water intakes.

CONCLUSION

The present results suggest that while total water intakes among children and adults have stayed constant, drinking water, tap and bottled, has been replacing SSB in the US diet.

The Timing of Water and Beverage Consumption During the Day Among Children and Adults in the United States: Analyses of NHANES 2011-2016 Data

Dietary Guidelines for Americans 2015–20 recommend replacing sugar sweetened beverages (SSBs) with plain water in order to promote adequate hydration while reducing added sugar intake. This study explored how water intakes from water, beverages, and foods are distributed across the day. The dietary intake data for 7453 children (4–18 y) and 15,263 adults (>19 y) came from the National Health and Nutrition Examination Survey (NHANES 2011–2016). Water was categorized as tap or bottled. Beverages were assigned to 15 categories. Water intakes (in mL/d) from water, beverages, and food moisture showed significant differences by age group, meal occasion, and time of day. Plain water was consumed in the morning, mostly in the course of a morning snack and between 06:00 and 12:00. Milk and juices were consumed at breakfast whereas SSBs were mostly consumed at lunch, dinner, and in the afternoon. Children consumed milk and juices, mostly in the morning. Adults consumed coffee and tea in the morning, SSBs in the afternoon, and alcohol in the evening. Relatively little drinking water was consumed with lunch or after 21:00. Dietary strategies to replace caloric beverages with plain water need to build on existing drinking habits by age group and meal type.

Tea Consumption Patterns in Relation to Diet Quality among Children and Adults in the United States: Analyses of NHANES 2011-2016 Data

Flavonoid-rich tea offers an alternative to sugar-sweetened beverages. The present analyses, based on 2 24-hour dietary recalls for 17,506 persons aged ≥9 years old in the 2011–2016 National Health and Nutrition Examination Survey database (NHANES 2011–2016), explored tea consumption patterns in relation to demographics, diet quality, cardiovascular disease (CVD) biomarkers (lipids and blood pressure), and body weight. Beverage categories were unsweetened tea, other tea (herbal and presweetened tea), coffee, milk, 100% juice, water and other high-calorie (HC) and low-calorie (LC) beverages. Tea consumption (18.5% of the sample) was highest among older adults (51–70 years old), non-Hispanic Asians and Whites, and those with college education and higher incomes. The effects of age, gender, education, income, and race/ethnicity were all significant (p < 0.001 for all). Adult tea consumers had diets with more protein, fiber, potassium, iron, and magnesium, and less added sugars and alcohol. Their diets contained fewer HC beverages and coffee but had more total and citrus fruit, more total dark green and orange vegetables, and more seafood, eggs, soy and milk. Tea consumers had higher Healthy Eating Index (HEI-2015) and higher Nutrient-Rich Foods (NRF9.3) nutrient density scores. Few children drank tea and no differences in diet quality between consumers and non-consumers were observed. Adult tea consumers had slightly higher high-density lipoprotein (HDL) cholesterol and lower body mass index (BMI) values. Tea consumption was associated with higher socioeconomic status and better diets.

The Reach of an Urban Hospital System-Based Diabetes Prevention Program: Patient Engagement and Weight Loss Characteristics

PURPOSE

The purpose of this study was to identify patient and program delivery characteristics associated with engagement and weight loss in a Diabetes Prevention Program (DPP) implemented in an urban hospital system.

METHODS

Patient and program delivery data were collected between July 2015 and December 2017. DPP eligibility was determined based on age, body mass index (BMI), and hemoglobin A1C data via the electronic health record. Engagement was measured at 3 levels: ≤3 sessions, 4 to 8 sessions, and ≥9 sessions. Weight was measured at each DPP session.

RESULTS

Among the eligible patients (N = 31 524), referrals and engagement were lower in men than women, in Spanish speakers than English speakers, in younger (18-34 years) and middle-aged (35-54 years) than older adults, and in patients receiving Medicaid than other patients. Referral and engagement were higher in patients with higher BMIs and those prescribed ≥5 medications. Current smokers were less frequently engaged. Prior health care provider contact was associated with higher engagement. Overall, 28% of DPP participants achieved ≥5% weight loss; younger and middle-aged patients and those who gained weight in the prior 2 years were less likely to lose weight.

CONCLUSION

This assessment identified characteristics of patients with lower levels of referral and engagement. The DPP staff may need to increase outreach to address barriers to referral and during all points of engagement among men, younger patients, and Spanish speakers. Future research is needed to increase understanding with regard to why referrals and engagement are lower among these groups.

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

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.

Consumption Patterns of Milk and 100% Juice in Relation to Diet Quality and Body Weight Among United States Children: Analyses of NHANES 2011-16 Data

Background: The American Academy of Pediatrics (AAP) has recommended placing limits on the consumption of milk and 100% juice by children. Methods: Consumption data for 9,069 children aged 2-19 years came from three cycles of the nationally representative National Health and Nutrition Examination Survey (NHANES 2011-2016). Beverages were classified into 100% juices, milk (whole, reduced fat, and skim), caloric sugar sweetened beverages (SSB), low calorie beverages (LCB), and drinking water. The Healthy Eating Index 2015 and Nutrient Rich Food Index NRF9.3 were two measures of diet quality. Analyses examined consumption patterns for milk and 100% juice in relation to diet quality, AAP recommendations, and BMI z-scores across time and for different age groups. Results: Intakes of milk and 100% juice declined sharply with age, whereas SSB and water increased. Top quartiles of HEI 2015 and NRF9.3 diet quality scores were associated with higher intakes of water, milk, and 100% juice and with lower intakes of SSB. Lower-income groups drank less skim milk and water and more whole milk and SSB. Only 30% of the children consumed any 100% juice. There was no association between the consumption of milk or 100% juice and BMI z-scores for any age group. Conclusions: Top quartiles of diet quality were associated with more milk, 100% juice, and water, and less SSB. Higher quality diets were associated with lower compliance with the AAP 100% juice recommendations. Compliance with the AAP 100% juice recommendations was not associated with lower body weights. Attempts to limit the consumption of milk and 100% juice by children might have the unintended consequence of increasing consumption of SSB and may have limited value for obesity prevention.

Replacing Dairy Fat With Polyunsaturated and Monounsaturated Fatty Acids: A Food-Level Modeling Study of Dietary Nutrient Density and Diet Quality Using the 2013-16 National Health and Nutrition Examination Survey

Recent dietary guidelines have become more food-based, as opposed to purely nutrient-based. By contrast, assessing the impact of dietary changes on chronic disease risk continues to rely on single-nutrient substitutions. To assess the real-world implications of a nutrient-for-nutrient swap, this study examined dietary nutrient density and healthy diet scores following removal of food sources of dairy fat from diets of 15,260 individuals age ≥4 y in the National Health and Nutrition Examination Survey (NHANES 2013–2016). Those foods were then replaced with foods containing a comparable amount of non-dairy polyunsaturated fatty acids (PUFA) and monounsaturated fatty acids (MUFA). The present food-level substitution model was based on 576 diverse eating patterns of US population subgroups. Diet quality measures were the Nutrient Rich Food (NRF 9.3) Index and the 2015-Healthy Eating Index (HEI-2015). Removing 5% of dietary energy from dairy fat led to lower levels of multiple micronutrients and to lower NRF 9.3 scores. These deficits were not remedied by the modeled replacements. Although swapping dairy fat for foods containing non-dairy MUFA/PUFA did alter the fatty acid ratios, the resulting food patterns were still significantly lower in some key micronutrients. Nutrient-based dietary guidance is prone to ignore the complexity of food patterns and the recommended dietary change may have unintended nutritional consequences.

Diet quality among US-born and foreign-born non-Hispanic blacks: NHANES 2003-2012 data

Background

Non-Hispanic blacks in the United States are less likely to not meet national dietary recommendations than non-Hispanic whites; however, most studies do not consider nativity of US blacks.

Objective

With the use of the Alternative Healthy Eating Index-2010 (AHEI-2010) and the Dietary Approach to Stop Hypertension (DASH) scores, this cross-sectional study compared diet quality between US-born (n = 3,911) and foreign-born (n = 408) non-Hispanic black adults aged 22-79 y, based on pooled nationally representative data (NHANES 2003-2012) as well as by length of US residency.

Design

The association between nativity and diet quality was determined by using multivariable-adjusted linear regression for the continuous total diet quality scores and their components or multinomial (polytomous) logistic regression for categorical tertiles (low, medium, or high) of the total scores and their components.

Results

Foreign-born blacks had significantly higher AHEI-2010 (β: 9.3; 95% CI: 7.5, 11.0) and DASH (β: 3.1; 95% CI: 2.5, 3.8) scores compared with US-born blacks and more favorable intakes for many of the score components. Among foreign-born blacks, diet quality did not significantly differ by length of residency. Foreign-born blacks were more likely to be in the high than in the low tertile for vegetables [excluding starchy vegetables; relative risk ratio (RRR): 1.68; 95% CI: 1.24, 2.29], fruit [excluding and including fruit juice-RRR: 2.42 (95% CI: 1.69, 3.47) and RRR: 2.95 (95% CI: 1.90, 4.59), respectively], percentage of whole grains (RRR: 2.39; 95% CI: 1.64, 3.49), and omega-3 (ω-3) fatty acids (RRR: 2.03; 95% CI: 1.38, 2.97).

Conclusions

Foreign-born blacks have better diet quality than their US-born counterparts. In nutrition research and public health efforts, considering the place of birth among US blacks may improve the accuracy of characterizing dietary intakes and facilitate the development of targeted nutrition interventions to reduce diet-related diseases in the diverse black population in the United States.

Brief Report: Characterizing the Burden of Cardiometabolic Disease among Public Housing Residents Served by an Urban Hospital System

Objective

Housing status is a primary social determinant of health that is not typically not collected in clinical settings. Residential address data collected during clinical visits can identify patients at high-risk for cardiometabolic disease (CMD) residing in public housing.

Design

This study examined CMD and related risk factors among patients living in public housing and a comparison group not living in public housing.

Setting

All patients (n=173,568) were receiving primary care in a large hospital system in the Bronx, New York between January 1, 2016 and December 31, 2017.

Results

Patients in public housing were more likely to be women, to be Black or Hispanic, and to be on Medicaid compared with patients not living in public housing. Women in public housing were more likely than men to have had a higher prevalence of CMD and related risk factors.

Conclusion

The burden of CMD among public housing residents shows sex disparities where women have a higher prevalence of CMD and related risk factors than men.

Protocol for a cluster-randomized controlled trial of a technology-assisted health coaching intervention for weight management in primary care: The GEM (goals for eating and moving) study

INTRODUCTION

Over one-third of American adults have obesity with increased risk of chronic disease. Primary care providers often do not counsel patients about weight management due to barriers such as lack of time and training. To address this problem, we developed a technology-assisted health coaching intervention called Goals for Eating and Moving (GEM) to facilitate obesity counseling within the patient-centered medical home (PCMH) model of primary care. The objective of this paper is to describe the rationale and design of a cluster-randomized controlled trial to test the GEM intervention when compared to Enhanced Usual Care (EUC).

METHOD

We have randomized 19 PCMH teams from two NYC healthcare systems (VA New York Harbor Healthcare System and Montefiore Medical Group practices) to either the GEM intervention or EUC. Eligible participants are English and Spanish-speaking primary care patients (ages 18-69 years) with obesity or who are overweight with comorbidity (e.g., arthritis, sleep apnea, hypertension). The GEM intervention consists of a tablet-delivered goal setting tool, a health coaching visit and twelve telephone calls for patients, and provider counseling training. Patients in the EUC arm receive health education materials. The primary outcome is mean weight loss at 1 year. Secondary outcomes include changes in waist circumference, diet, and physical activity. We will also examine the impact of GEM on obesity-related provider counseling competency and attitudes.

CONCLUSION

If GEM is found to be efficacious, it could provide a structured approach for improving weight management for diverse primary care patient populations with elevated cardiovascular disease risk.

Designing Optimal Breakfast for the United States Using Linear Programming and the NHANES 2011-2014 Database: A Study from the International Breakfast Research Initiative (IBRI)

The quality of dietary patterns can be optimized using a mathematical technique known as linear programming (LP). LP methods have rarely been applied to individual meals. The present LP models optimized the breakfast meal for those participants in the nationally representative National Health and Nutrition Examination Survey 2011-2014 who ate breakfast (n = 11,565). The Nutrient Rich Food Index (NRF9.3) was a measure of diet quality. Breakfasts in the bottom tertile of NRF9.3 scores (T1) were LP-modeled to meet nutrient requirements without deviating too much from current eating habits. Separate LP models were run for children and for adults. The LP-modeled breakfasts resembled the existing ones in the top tertile of NRF9.3 scores (T3), but were more nutrient-rich. Favoring fruit, cereals, and dairy, the LP-modeled breakfasts had less meat, added sugars and fats, but more whole fruit and 100% juices, more whole grains, and more milk and yogurt. LP modeling methods can build on existing dietary patterns to construct food-based dietary guidelines and identify individual meals and/or snacks that need improvement.

Preventable Cancer Burden Associated With Poor Diet in the United States

BACKGROUND

Diet is an important risk factor for cancer that is amenable to intervention. Estimating the cancer burden associated with diet informs evidence-based priorities for nutrition policies to reduce cancer burden in the United States.

METHODS

Using a comparative risk assessment model that incorporated nationally representative data on dietary intake, national cancer incidence, and estimated associations of diet with cancer risk from meta-analyses of prospective cohort studies, we estimated the annual number and proportion of new cancer cases attributable to suboptimal intakes of seven dietary factors among US adults ages 20 years or older, and by population subgroups.

RESULTS

An estimated 80 110 (95% uncertainty interval [UI] = 76 316 to 83 657) new cancer cases were attributable to suboptimal diet, accounting for 5.2% (95% UI = 5.0% to 5.5%) of all new cancer cases in 2015. Of these, 67 488 (95% UI = 63 583 to 70 978) and 4.4% (95% UI = 4.2% to 4.6%) were attributable to direct associations and 12 589 (95% UI = 12 156 to 13 038) and 0.82% (95% UI = 0.79% to 0.85%) to obesity-mediated associations. By cancer type, colorectal cancer had the highest number and proportion of diet-related cases (n = 52 225, 38.3%). By diet, low consumption of whole grains (n = 27 763, 1.8%) and dairy products (n = 17 692, 1.2%) and high intake of processed meats (n = 14 524, 1.0%) contributed to the highest burden. Men, middle-aged (45-64 years) and racial/ethnic minorities (non-Hispanic blacks, Hispanics, and others) had the highest proportion of diet-associated cancer burden than other age, sex, and race/ethnicity groups.

CONCLUSIONS

More than 80 000 new cancer cases are estimated to be associated with suboptimal diet among US adults in 2015, with middle-aged men and racial/ethnic minorities experiencing the largest proportion of diet-associated cancer burden in the United States.

Use of dietary supplements in relation to urinary phthalate metabolite concentrations: Results from the National Health and Nutrition Examination Survey

BACKGROUND

Research suggests that dietary supplements may be a source of exposure to phthalates, given that diethyl phthalate (DEP) or di-n-butyl phthalate (DBP) can be components of coatings that facilitate extended release or encapsulate dietary supplements.

METHODS

Using nationally representative data on a population of 12,281 adults ages 20 y + surveyed between 1999 and 2014 from the National Health and Nutrition Examination Survey (NHANES), we evaluated the association between dietary supplement use in relation to urinary phthalate metabolites of DEP (monoethyl phthalate, MEP) and DBP (mono-n-butyl phthalate, MBP). We examined associations pertaining to regular use of multivitamin/multimineral (MVMM) supplements, as well as regular use of any other non-MVMM supplement products, the number of non-MVMM supplement products used, as well as individual supplements potentially containing phthalates (exclusive of MVMM). For each urinary phthalate metabolite, results are presented as the minimally-adjusted and multivariable-adjusted ratio, comparing the geometric mean among users to non-users.

RESULTS

In multivariable models, we observed a significant positive association between regular use of MVMM use and MEP, with persons using MVMM supplements having 11% higher geometric mean MEP than non-users (Ratio: 1.11; 95% CI: 1.04-1.20); no association was observed for MVMM in relation to MBP. No other significant multivariable-adjusted associations were observed, although power was limited in analyses of individual supplements. Associations did not markedly vary by gender; however, the associations of garlic supplement use with MEP and MBP varied by calendar time, with statistically significant positive associations observed in later years.

CONCLUSIONS

A modest significant association was observed between MVMM use and MEP. No other significant associations were observed in our overall multivariable models. Follow-up on the positive association observed between garlic and urinary phthalate metabolite concentrations observed in later years in a well-powered, prospective study would further clarify study findings.

Preference option randomized design (PORD) for comparative effectiveness research: Statistical power for testing comparative effect, preference effect, selection effect, intent-to-treat effect, and overall effect

Comparative effectiveness research trials in real-world settings may require participants to choose between preferred intervention options. A randomized clinical trial with parallel experimental and control arms is straightforward and regarded as a gold standard design, but by design it forces and anticipates the participants to comply with a randomly assigned intervention regardless of their preference. Therefore, the randomized clinical trial may impose impractical limitations when planning comparative effectiveness research trials. To accommodate participants' preference if they are expressed, and to maintain randomization, we propose an alternative design that allows participants' preference after randomization, which we call a "preference option randomized design (PORD)". In contrast to other preference designs, which ask whether or not participants consent to the assigned intervention after randomization, the crucial feature of preference option randomized design is its unique informed consent process before randomization. Specifically, the preference option randomized design consent process informs participants that they can opt out and switch to the other intervention only if after randomization they actively express the desire to do so. Participants who do not independently express explicit alternate preference or assent to the randomly assigned intervention are considered to not have an alternate preference. In sum, preference option randomized design intends to maximize retention, minimize possibility of forced assignment for any participants, and to maintain randomization by allowing participants with no or equal preference to represent random assignments. This design scheme enables to define five effects that are interconnected with each other through common design parameters-comparative, preference, selection, intent-to-treat, and overall/as-treated-to collectively guide decision making between interventions. Statistical power functions for testing all these effects are derived, and simulations verified the validity of the power functions under normal and binomial distributions.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk-outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk-outcome pairs, and new data on risk exposure levels and risk-outcome associations.

METHODS

We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017.

FINDINGS

In 2017, 34·1 million (95% uncertainty interval [UI] 33·3-35·0) deaths and 1·21 billion (1·14-1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6-62·4) of deaths and 48·3% (46·3-50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39-11·5) deaths and 218 million (198-237) DALYs, followed by smoking (7·10 million [6·83-7·37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6·53 million [5·23-8·23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4·72 million [2·99-6·70] deaths and 148 million [98·6-202] DALYs), and short gestation for birthweight (1·43 million [1·36-1·51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3-6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low.

INTERPRETATION

By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning.

FUNDING

Bill & Melinda Gates Foundation.

Medicare underpayment for Diabetes Prevention Program: implications for DPP suppliers

OBJECTIVES

To examine if Medicare reimbursements for the Diabetes Prevention Program (DPP) cover program costs.

STUDY DESIGN

A retrospective modeling study.

METHODS

A microcosting approach was used to calculate the costs of delivering DPP in 2016 to more than 300 patients from Montefiore Health System (MHS), a large healthcare system headquartered in Bronx, New York. Attendance and weight loss outcomes were used to estimate Medicare reimbursement. We also modeled revenue assuming that our program outcomes had been similar to those observed in national data.

RESULTS

The 1-year cost of delivering DPP to 322 participants in 2016 was $177,976, or $553 per participant. The costliest components of delivery were direct instruction (28% of total cost) and patient outreach, enrollment, and eligibility confirmation (24%). Based on our program outcomes (14.3% lost ≥5% of their initial weight and 50% attended ≥4 sessions), MHS would be reimbursed $34,625 ($108/patient). If outcomes were in line with national CDC reports (eg, better attendance and weight loss outcomes), MHS would have been reimbursed $61,270 ($190/patient).

CONCLUSIONS

In a large urban health system serving a diverse population, the costs of delivering DPP far outweighed Medicare reimbursement amounts. Analyzing and documenting the costs associated with delivering the evidence-based DPP may inform prospective suppliers and payers and aid in advocacy for adequate reimbursement.

Trends and Disparities in Diet Quality Among US Adults by Supplemental Nutrition Assistance Program Participation Status

IMPORTANCE

Unhealthful diet is a top contributor to chronic diseases in the United States. There are growing concerns about disparities in diet among US adults, especially for those who participate in the Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program. It remains unclear how these disparities may have changed over time.

OBJECTIVE

To assess whether disparities in key food groups and nutrients according to participation and eligibility for SNAP have persisted, improved, or worsened over time among US adults.

DESIGN SETTING AND PARTICIPANTS

This survey study examined a nationally representative sample of 38 696 adults aged 20 years or older: 6162 SNAP participants, 6692 income-eligible nonparticipants, and 25 842 higher-income individuals from 8 cycles of the National Health and Nutrition Examination Survey (1999-2014). Data analysis was conducted between January 1, 2017, and December 31, 2017.

EXPOSURES

Survey-weighted, energy-adjusted diet by SNAP participation status.

MAIN OUTCOMES AND MEASURES

Mean diet scores and proportions of US adults meeting poor, intermediate, or ideal diet scores based on the American Heart Association (AHA) 2020 Strategic Impact Goals for diet, including 8 components (fruits and vegetables; whole grains; fish and shellfish; sugar-sweetened beverages; sodium; nuts, seeds, and legumes; processed meats; and saturated fat).

RESULTS

The survey included 38 696 respondents (20 062 female [51.9%]; 18 386 non-Hispanic white [69.8%]; mean [SD] age, 46.8 [14.8] years). Participants of SNAP were younger (mean [SD] age, 41.4 [15.6] years) than income-eligible nonparticipants (mean [SD] age, 44.9 [19.6] years) or higher-income individuals (mean [SD] age, 47.8 [13.6] years); more likely to be female (3552 of 6162 [58.6%] vs 3504 of 6692 [54.8%] and 13 006 of 25 842 [50.4%], respectively); and less likely to be non-Hispanic white (2062 of 6162 [48.2%] vs 2594 of 6692 [56.0%] and 13 712 of 25 842 [75.8%], respectively). From surveys conducted in 2003 and 2004 to those conducted in 2013 and 2014, SNAP participants had less improvement in AHA diet scores than both income-eligible nonparticipants and higher-income individuals (change in mean score = 0.57 [95% CI, -2.18 to 0.33] vs 2.56 [95% CI, 0.36-4.76] and 3.84 [95% CI, 2.39-5.29], respectively; P = .04 for interaction). Disparities persisted for most foods and nutrients and worsened for processed meats, added sugars, and nuts and seeds. In 2013 to 2014, a higher proportion of SNAP participants had poor diet scores compared with income-eligible nonparticipants and higher-income individuals (461 of 950 [53.5%] vs 247 of 690 [38.0%] and 773 of 2797 [28.7%]; P < .001 for difference), and a lower proportion had intermediate diet scores (477 of 950 [45.3%] vs 428 of 690 [59.8%] and 1933 of 2797 [68.7%]; P < .001 for difference). The proportion of participants with ideal diet scores was low in all 3 groups (12 of 950 [1.3%] vs 15 of 690 [2.2%] and 91 of 2797 [2.6%]; P = .26 for difference).

CONCLUSIONS AND RELEVANCE

Dietary disparities persisted or worsened for most dietary components among US adults. Despite improvement in some dietary components, SNAP participants still do not meet the AHA goals for a healthful diet.

Beverage consumption patterns among 4-19 y old children in 2009-14 NHANES show that the milk and 100% juice pattern is associated with better diets

BACKGROUND

Patterns of beverage consumption among children and adolescents can be indicative of food choices and total diet quality.

METHODS

Analyses of beverage consumption patterns among 8119 children aged 4-19 y were based on the first 24-h recall of the National Health and Nutrition Examination Survey (2009-14 NHANES). Four pre-defined beverage patterns were: 1) milk pattern; 2) 100% juice pattern; 3) milk and 100% juice pattern; and 4) other caloric beverages. Food- and nutrient-based diet quality measures included the Healthy Eating Index 2010.

RESULTS

Most children drank other caloric beverages, as opposed to milk (17.8%), 100% juice (5.6%), or milk and 100% juice (13.5%). Drinkers of milk and 100% juice had diets that did not differ from each other in total calories, total and added sugars, fiber, or vitamin E. Milk drinkers consumed more dairy and had higher intakes of calcium, potassium, vitamin A and vitamin D as compared to all other patterns. Juice drinkers consumed more total fruit, same amounts of whole fruit, and had higher intakes of vitamin C as compared to the other consumption patterns. Drinkers of both milk and 100% juice had the highest HEI 2010 scores of all the consumption patterns.

CONCLUSIONS

Beverage consumption patterns built around milk and/or 100% juice were relatively uncommon. Promoting the drinking of milk and 100% juice, in preference to other caloric beverages, may be an effective strategy to improve children's diet quality. Restricting milk and 100% juice consumption may encourage the selection of other caloric beverages.

Reductions in national cardiometabolic mortality achievable by food price changes according to Supplemental Nutrition Assistance Program (SNAP) eligibility and participation

BACKGROUND

Suboptimal diets are a major contributor to cardiometabolic disease (CMD) mortality, and substantial disparities exist for both dietary quality and mortality risk across income groups in the USA. Research is needed to quantify how food pricing policies to subsidise healthy foods and tax unhealthy foods could affect the US CMD mortality, overall and by Supplemental Nutrition Assistance Program (SNAP) eligibility and participation.

METHODS

Comparative risk analysis based on national data on diet (National Health and Nutrition Examination Survey, 2003-2012) and mortality (mortality-linked National Health Interview Survey) and meta-analyses of policy-diet and diet-disease relationships.

RESULTS

A national 10% price reduction on fruits, vegetables, nuts and whole grains was estimated to prevent 19 600 CMD deaths/year, including 2.6% (95% UI 2.4% to 2.8%) of all CMD deaths among SNAP participants, 2.7% (95% UI 2.4% to 3.0%) among SNAP-eligible non-participants and 2.6% (95% UI 2.4% to 2.8%) among SNAP-ineligible non-participants. Adding a national 10% tax on sugar-sweetened beverages (SSBs) and processed meats would prevent a total of 33 700 CMD deaths/year, including 5.9% (95% UI 5.4% to 7.4%) of all CMD deaths among SNAP participants, 4.8% (95% UI 4.4% to 5.2%) among SNAP-eligible non-participants and 4.1% (95% UI 3.8% to 4.5%) among SNAP-ineligible non-participants. Adding a SNAP-targeted 30% subsidy for the same healthy foods would offer the largest reductions in both CMD mortality and disparities.

CONCLUSION

National subsidies for healthy foods and taxes on SSBs and processed meats would each reduce CMD mortality; taxes would also reduce CMD mortality more steeply for SNAP participants than for non-participants.

The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States

Introduction

Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state.

Objective

To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016.

Design and Setting

A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year.

Main Outcomes and Measures

Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed.

Results

Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).

Conclusions and Relevance

There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

The potential impact of food taxes and subsidies on cardiovascular disease and diabetes burden and disparities in the United States

BACKGROUND

Fiscal interventions are promising strategies to improve diets, reduce cardiovascular disease and diabetes (cardiometabolic diseases; CMD), and address health disparities. The aim of this study is to estimate the impact of specific dietary taxes and subsidies on CMD deaths and disparities in the US.

METHODS

Using nationally representative data, we used a comparative risk assessment to model the potential effects on total CMD deaths and disparities of price subsidies (10%, 30%) on fruits, vegetables, whole grains, and nuts/seeds and taxes (10%, 30%) on processed meat, unprocessed red meats, and sugar-sweetened beverages. We modeled two gradients of price-responsiveness by education, an indicator of socioeconomic status (SES), based on global price elasticities (18% greater price-responsiveness in low vs. high SES) and recent national experiences with taxes on sugar-sweetened beverages (65% greater price-responsiveness in low vs. high SES).

RESULTS

Each price intervention would reduce CMD deaths. Overall, the largest proportional reductions were seen in stroke, followed by diabetes and coronary heart disease. Jointly altering prices of all seven dietary factors (10% each, with 18% greater price-responsiveness by SES) would prevent 23,174 (95% UI 22,024-24,595) CMD deaths/year, corresponding to 3.1% (95% UI 2.9-3.4) of CMD deaths among Americans with a lower than high school education, 3.6% (95% UI 3.3-3.8) among high school graduates/some college, and 2.9% (95% UI 2.7-3.5) among college graduates. Applying a 30% price change and larger price-responsiveness (65%) in low SES, the corresponding reductions were 10.9% (95% UI 9.2-10.8), 9.8% (95% UI 9.1-10.4), and 6.7% (95% UI 6.2-7.6). The latter scenario would reduce disparities in CMD between Americans with lower than high school versus a college education by 3.5 (95% UI 2.3-4.5) percentage points.

CONCLUSIONS

Modest taxes and subsidies for key dietary factors could meaningfully reduce CMD and improve US disparities.

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

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.

FINDINGS

Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.

INTERPRETATION

Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.

FUNDING

The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

Replacing American Breakfast Foods with Ready-To-Eat (RTE) Cereals Increases Consumption of Key Food Groups and Nutrients among US Children and Adults: Results of an NHANES Modeling Study

Replacing the typical American breakfast with ready-to-eat cereals (RTECs) may improve diet quality. Our goal was to assess the impact of RTECs on diet quality measures for different age groups, using substitution modeling. Dietary intakes came from the 2007-2010 National Health and Examination Surveys (NHANES; n = 18,112). All breakfast foods, excluding beverages, were replaced on a per calorie basis, with frequency-weighted and age/race specific RTECs. Model 1 replaced foods with RTECs alone; Model 2 replaced foods with RTECs and milk. Diet quality measures were based on desirable food groups and nutrients, Healthy Eating Index (HEI)-2010 scores, and estimated diet costs. Model 1 diets were significantly higher in whole grains (+84.6%), fiber (+14.3%), vitamin D (+14.0%), iron (+54.5%) and folic acid (+104.6%), as compared to observed diets. Model 2 diets were additionally higher in dairy (+15.8%), calcium (+11.3%) and potassium (+3.95%). In Model 1, added sugar increased (+5.0%), but solid fats declined (-10.9%). Energy from solid fats and added sugars declined (-3.2%) in both models. Model 2 offered higher diet quality (57.1 vs. 54.6, p-value < 0.01) at a lower cost ($6.70 vs. $6.92; p < 0.01), compared to observed diets. Substitution modeling of NHANES data can assess the nutritional and economic impact of dietary guidance.

Comparing effectiveness of mass media campaigns with price reductions targeting fruit and vegetable intake on US cardiovascular disease mortality and race disparities

Background: A low intake of fruits and vegetables (F&Vs) is a major risk factor for cardiovascular disease (CVD) in the United States. Both mass media campaigns (MMCs) and economic incentives may increase F&V consumption. Few data exist on their comparative effectiveness.Objective: We estimated CVD mortality reductions potentially achievable by price reductions and MMC interventions targeting F&V intake in the US population.Design: We developed a US IMPACT Food Policy Model to compare 3 policies targeting F&V intake across US adults from 2015 to 2030: national MMCs and national F&V price reductions of 10% and 30%. We accounted for differences in baseline diets, CVD rates, MMC coverage, MMC duration, and declining effects over time. Outcomes included cumulative CVD (coronary heart disease and stroke) deaths prevented or postponed and life-years gained (LYGs) over the study period, stratified by age, sex, and race.Results: A 1-y MMC in 2015 would increase the average national F&V consumption by 7% for 1 y and prevent ∼18,600 CVD deaths (95% CI: 17,600, 19,500), gaining ∼280,100 LYGs by 2030. With a 15-y MMC, increased F&V consumption would be sustained, yielding a 3-fold larger reduction (56,100; 95% CI: 52,400, 57,700) in CVD deaths. In comparison, a 10% decrease in F&V prices would increase F&V consumption by ∼14%. This would prevent ∼153,300 deaths (95% CI: 146,400, 159,200), gaining ∼2.51 million LYGs. For a 30% price decrease, resulting in a 42% increase in F&V consumption, corresponding values would be 451,900 CVD deaths prevented or postponed (95% CI: 433,100, 467,500) and 7.3 million LYGs gained. Effects were similar by sex, with a smaller proportional effect and larger absolute effects at older ages. A 1-y MMC would be 35% less effective in preventing CVD deaths in non-Hispanic blacks than in whites. In comparison, price-reduction policies would have equitable proportional effects.Conclusion: Both national MMCs and price-reduction policies could reduce US CVD mortality, with price reduction being more powerful and sustainable.

Reducing US cardiovascular disease burden and disparities through national and targeted dietary policies: A modelling study

BACKGROUND

Large socio-economic disparities exist in US dietary habits and cardiovascular disease (CVD) mortality. While economic incentives have demonstrated success in improving dietary choices, the quantitative impact of different dietary policies on CVD disparities is not well established. We aimed to quantify and compare the potential effects on total CVD mortality and disparities of specific dietary policies to increase fruit and vegetable (F&V) consumption and reduce sugar-sweetened beverage (SSB) consumption in the US.

METHODS AND FINDINGS

Using the US IMPACT Food Policy Model and probabilistic sensitivity analyses, we estimated and compared the reductions in CVD mortality and socio-economic disparities in the US population potentially achievable from 2015 to 2030 with specific dietary policy scenarios: (a) a national mass media campaign (MMC) aimed to increase consumption of F&Vs and reduce consumption of SSBs, (b) a national fiscal policy to tax SSBs to increase prices by 10%, (c) a national fiscal policy to subsidise F&Vs to reduce prices by 10%, and (d) a targeted policy to subsidise F&Vs to reduce prices by 30% among Supplemental Nutrition Assistance Program (SNAP) participants only. We also evaluated a combined policy approach, combining all of the above policies. Data sources included the Surveillance, Epidemiology, and End Results Program, National Vital Statistics System, National Health and Nutrition Examination Survey, and published meta-analyses. Among the individual policy scenarios, a national 10% F&V subsidy was projected to be most beneficial, potentially resulting in approximately 150,500 (95% uncertainty interval [UI] 141,400-158,500) CVD deaths prevented or postponed (DPPs) by 2030 in the US. This far exceeds the approximately 35,100 (95% UI 31,700-37,500) DPPs potentially attributable to a 30% F&V subsidy targeting SNAP participants, the approximately 25,800 (95% UI 24,300-28,500) DPPs for a 1-y MMC, or the approximately 31,000 (95% UI 26,800-35,300) DPPs for a 10% SSB tax. Neither the MMC nor the individual national economic policies would significantly reduce CVD socio-economic disparities. However, the SNAP-targeted intervention might potentially reduce CVD disparities between SNAP participants and SNAP-ineligible individuals, by approximately 8% (10 DPPs per 100,000 population). The combined policy approach might save more lives than any single policy studied (approximately 230,000 DPPs by 2030) while also significantly reducing disparities, by approximately 6% (7 DPPs per 100,000 population). Limitations include our effect estimates in the model; these estimates use interventional and prospective observational studies (not exclusively randomised controlled trials). They are thus imperfect and should be interpreted as the best available evidence. Another key limitation is that we considered only CVD outcomes; the policies we explored would undoubtedly have additional beneficial effects upon other diseases. Further, we did not model or compare the cost-effectiveness of each proposed policy.

CONCLUSIONS

Fiscal strategies targeting diet might substantially reduce CVD burdens. A national 10% F&V subsidy would save by far the most lives, while a 30% F&V subsidy targeting SNAP participants would most reduce socio-economic disparities. A combined policy would have the greatest overall impact on both mortality and socio-economic disparities.

Factors in Placement and Enrollment of Primary Care Patients in YMCA's Diabetes Prevention Program, Bronx, New York, 2010-2015

Introduction

The reach of the New York State YMCA’s Diabetes Prevention Program (DPP) to at-risk populations may be increased through integration with primary care settings. Although considerable effort has been made in the referral and retention of patients, little is known about the factors associated with the placement of potential participants into YMCA’s DPP.

Methods

Among Montefiore Health System (MHS) patients referred to YMCA’s DPP (n = 1,249) from July 10, 2010, through November 11, 2015, we identified demographic factors (eg, age, preferred language) and primary care practice-level factors (eg, time between referral and start of session, session season) associated with placement into a session and subsequent drop-out. We also evaluated factors associated with weight loss.

Results

Patients were predominantly female (71%) and aged 45 years or older (71%). Patients preferring sessions in Spanish were less often placed in sessions. Patients aged 18 to 44 years were less often placed (P = .01) and enrolled (P = .001) than patients aged 60 years or older. Sessions conducted in the summer and spring had higher enrollment than fall and winter months. Patients who started the YMCA’s DPP within 2 months of their referral date were more often enrolled (54.4%) than patients who waited 4 or more months (21.6%) to start their sessions. Patients aged 45 to 59 years lost marginally less weight than those aged 60 years or older (−3.1% vs −3.8%; P = .07).

Conclusion

Although this evaluation gives some insight into the barriers to placement and enrollment in YMCA’s DPP, challenges remain. Efforts are under way to increase referral of patients to community-based DPPs.

Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States

IMPORTANCE

In the United States, national associations of individual dietary factors with specific cardiometabolic diseases are not well established.

OBJECTIVE

To estimate associations of intake of 10 specific dietary factors with mortality due to heart disease, stroke, and type 2 diabetes (cardiometabolic mortality) among US adults.

DESIGN, SETTING, AND PARTICIPANTS

A comparative risk assessment model incorporated data and corresponding uncertainty on population demographics and dietary habits from National Health and Nutrition Examination Surveys (1999-2002: n = 8104; 2009-2012: n = 8516); estimated associations of diet and disease from meta-analyses of prospective studies and clinical trials with validity analyses to assess potential bias; and estimated disease-specific national mortality from the National Center for Health Statistics.

EXPOSURES

Consumption of 10 foods/nutrients associated with cardiometabolic diseases: fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages (SSBs), polyunsaturated fats, seafood omega-3 fats, and sodium.

MAIN OUTCOMES AND MEASURES

Estimated absolute and percentage mortality due to heart disease, stroke, and type 2 diabetes in 2012. Disease-specific and demographic-specific (age, sex, race, and education) mortality and trends between 2002 and 2012 were also evaluated.

RESULTS

In 2012, 702 308 cardiometabolic deaths occurred in US adults, including 506 100 from heart disease (371 266 coronary heart disease, 35 019 hypertensive heart disease, and 99 815 other cardiovascular disease), 128 294 from stroke (16 125 ischemic, 32 591 hemorrhagic, and 79 578 other), and 67 914 from type 2 diabetes. Of these, an estimated 318 656 (95% uncertainty interval [UI], 306 064-329 755; 45.4%) cardiometabolic deaths per year were associated with suboptimal intakes-48.6% (95% UI, 46.2%-50.9%) of cardiometabolic deaths in men and 41.8% (95% UI, 39.3%-44.2%) in women; 64.2% (95% UI, 60.6%-67.9%) at younger ages (25-34 years) and 35.7% (95% UI, 33.1%-38.1%) at older ages (≥75 years); 53.1% (95% UI, 51.6%-54.8%) among blacks, 50.0% (95% UI, 48.2%-51.8%) among Hispanics, and 42.8% (95% UI, 40.9%-44.5%) among whites; and 46.8% (95% UI, 44.9%-48.7%) among lower-, 45.7% (95% UI, 44.2%-47.4%) among medium-, and 39.1% (95% UI, 37.2%-41.2%) among higher-educated individuals. The largest numbers of estimated diet-related cardiometabolic deaths were related to high sodium (66 508 deaths in 2012; 9.5% of all cardiometabolic deaths), low nuts/seeds (59 374; 8.5%), high processed meats (57 766; 8.2%), low seafood omega-3 fats (54 626; 7.8%), low vegetables (53 410; 7.6%), low fruits (52 547; 7.5%), and high SSBs (51 694; 7.4%). Between 2002 and 2012, population-adjusted US cardiometabolic deaths per year decreased by 26.5%. The greatest decline was associated with insufficient polyunsaturated fats (-20.8% relative change [95% UI, -18.5% to -22.8%]), nuts/seeds (-18.0% [95% UI, -14.6% to -21.0%]), and excess SSBs (-14.5% [95% UI, -12.0% to -16.9%]). The greatest increase was associated with unprocessed red meats (+14.4% [95% UI, 9.1%-19.5%]).

CONCLUSIONS AND RELEVANCE

Dietary factors were estimated to be associated with a substantial proportion of deaths from heart disease, stroke, and type 2 diabetes. These results should help identify priorities, guide public health planning, and inform strategies to alter dietary habits and improve health.

Replacing American snacks with tree nuts increases consumption of key nutrients among US children and adults: results of an NHANES modeling study

Background

Replacing typical American snacks with tree nuts may be an effective way to improve diet quality and compliance with the 2015–2020 Dietary Guidelines for Americans (DGAs).

Objective

To assess and quantify the impact of replacing typical snacks with composite tree nuts or almonds on diet metrics, including empty calories (i.e., added sugars and solid fats), individual fatty acids, macronutrients, nutrients of public health concern, including sodium, fiber and potassium, and summary measures of diet quality.

Methods

Food pattern modeling was implemented in the nationally representative 2009–2012 National Health and Examination Survey (NHANES) in a population of 17,444 children and adults. All between-meal snacks, excluding beverages, were replaced on a per calorie basis with a weighted tree nut composite, reflecting consumption patterns in the population. Model 1 replaced all snacks with tree nuts, while Model 2 exempted whole fruits, non-starchy vegetables, and whole grains (>50% of total grain content). Additional analyses were conducted using almonds only. Outcomes of interest were empty calories (i.e., solid fats and added sugars), saturated and mono- and polyunsaturated fatty acids, fiber, protein, sodium, potassium and magnesium. The Healthy Eating Index-2010, which measures adherence to the 2010 Dietary Guidelines for Americans, was used as a summary measure of diet quality.

Results

Compared to observed diets, modeled food patterns were significantly lower in empty calories (−20.1% and −18.7% in Model 1 and Model 2, respectively), added sugars (−17.8% and −16.9%), solid fats (−21.0% and −19.3%), saturated fat (−6.6% and −7.1%)., and sodium (−12.3% and −11.2%). Modeled patterns were higher in oils (65.3% and 55.2%), monounsaturated (35.4% and 26.9%) and polyunsaturated fats (42.0% and 35.7%), plant omega 3 s (53.1% and 44.7%), dietary fiber (11.1% and 14.8%), and magnesium (29.9% and 27.0%), and were modestly higher in potassium (1.5% and 2.9%). HEI-2010 scores were significantly higher in Model 1 (67.8) and in Model 2 (69.7) compared to observed diets (58.5). Replacing snacks with almonds only produced similar results; the decrease in sodium was more modest and no increase in plant omega-3 fats was observed.

Conclusion

Replacing between-meal snacks with tree nuts or almonds led to more nutrient-rich diets that were lower in empty calories and sodium and had more favorable fatty acid profiles. Food pattern modeling using NHANES data can be used to assess the likely nutritional impact of dietary guidance.

Cardiometabolic Mortality by Supplemental Nutrition Assistance Program Participation and Eligibility in the United States

OBJECTIVES

To investigate total and cause-specific cardiometabolic mortality among Supplemental Nutrition Assistance Program (SNAP) participants, SNAP-eligible nonparticipants, and SNAP-ineligible individuals overall and by age, gender, race/ethnicity, and other characteristics.

METHODS

We performed a prospective study with nationally representative survey data from the National Health Interview Survey (2000-2009), merged with subsequent Public-Use Linked Mortality Files (2000-2011). We used survey-weighted Cox proportional hazards models adjusted for age and gender to estimate hazard ratios of total and cause-specific cardiometabolic mortality for 499 741 US adults aged 25 years or older.

RESULTS

Over a mean of 6.8 years of follow-up (maximum 11.9 years), 39 293 deaths occurred, including 7408 heart disease, 2185 stroke, and 1376 diabetes deaths. Individuals participating in SNAP exhibited higher total and cardiovascular disease mortality, largely limited to non-Hispanic Whites and non-Hispanic Blacks, than both SNAP-eligible nonparticipants and SNAP-ineligible individuals, and higher diabetes mortality across races/ethnicities (P < .01).

CONCLUSIONS

Participants in SNAP require greater focus to understand and further address their poor health outcomes. Public Health Implications. Low-income Americans require even greater efforts to improve their health than they currently receive, and such efforts should be a priority for public health policymakers.

Lessons from Launching the Diabetes Prevention Program in a Large Integrated Health Care Delivery System: A Case Study

There is urgent need for health systems to prevent diabetes. To date, few health systems have implemented the evidence-based Diabetes Prevention Program (DPP), and the few that have mostly partnered with community-based organizations to implement the program. Given the recent decision by the Centers for Medicare & Medicaid Services to reimburse for diabetes prevention, there is likely much interest in how such programs can be implemented within large health systems or how community partnerships can be expanded to support DPP implementation. Beginning in 2010, Montefiore Health System (MHS), a large health care system in the Bronx, NY, partnered with the Young Men's Christian Association (YMCA) of Greater New York to deliver the YMCA's DPP. Over 4 years, 1390 referrals to YMCA's DPP were made; 287 participants attended ≥3 classes, and average weight loss was 3.4%. Because of increased patient demand and internal capacity, MHS assumed responsibility for DPP implementation in May 2015. Fully integrating the program within the health system took 5–6 months, including configuring electronic health record templates/reports, hiring a coordinator, and creating clinical referral workflows/training guides. Billing workflows were designed for risk-based contracts. In the first 11 months of implementation, 1277 referrals were made, and referrals increased over time. Twenty-four class cycles were initiated, and 282 patients began attending classes. Average weight loss among 61 graduates from the Summer/Fall 2015 wave of MDPP classes was 3.8%. Additional opportunities for expansion include training allied health staff, providing patient incentives, increasing master trainer capacity, offering DPP to employees, and securing reimbursement.

Trends in Consumption of Solid Fats, Added Sugars, Sodium, Sugar-Sweetened Beverages, and Fruit from Fast Food Restaurants and by Fast Food Restaurant Type among US Children, 2003-2010

Energy intakes from fast food restaurants (FFRs) have declined among US children. Less is known about the corresponding trends for FFR-sourced solid fats, added sugars, and sodium, and food groups of interest, such as fruit and sugar-sweetened beverages (SSBs). Using data from a single 24-h dietary recall among 12,378 children aged 4–19 years from four consecutive cycles of the nationally-representative National Health and Nutrition Examination Survey (NHANES), 2003–2010 a custom algorithm segmented FFRs into burger, pizza, sandwich, Mexican cuisine, chicken, Asian cuisine, fish restaurants, and coffee shops. There was a significant population-wide decline in FFR-sourced solid fats (−32 kcal/day, p-trend < 0.001), added sugars (−16 kcal/day; p-trend < 0.001), SSBs (−0.12 servings (12 fluid ounces or 355 mL)/day; p-trend < 0.001), and sodium (−166 mg/day; p-trend < 0.001). Declines were observed when restricted to fast food consumers alone. Sharp declines were observed for pizza restaurants; added sugars, solid fats, and SSBs declined significantly from burger restaurants. Fruit did not change for fast food restaurants overall. Temporal analyses of fast food consumption trends by restaurant type allow for more precise monitoring of the quality of children’s diets than can be obtained from analyses of menu offerings. Such analyses can inform public health interventions and policy measures.

Trends in Dietary Supplement Use Among US Adults From 1999-2012

IMPORTANCE

Dietary supplements are commonly used by US adults; yet, little is known about recent trends in supplement use.

OBJECTIVE

To report trends in dietary supplement use among US adults.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional study using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) collected between 1999 and 2012. Participants include noninstitutionalized adults residing in the United States, surveyed over 7 continuous 2-year cycles (sample size per cycle, 4863 to 6213).

EXPOSURES

Calendar time, as represented by NHANES cycle.

MAIN OUTCOMES AND MEASURES

In an in-home interview, participants were queried on use of supplements in the preceding 30 days to estimate the prevalence of use within each NHANES cycle, and trends were evaluated across cycles. Outcomes included use of any supplements; use of multivitamins/multiminerals (MVMM; defined as a product containing ≥10 vitamins and/or minerals); and use of individual vitamins, minerals, and nonvitamin, nonmineral supplements. Data were analyzed overall and by population subgroup (including age, sex, race/ethnicity, and educational status), and were weighted to be nationally representative.

RESULTS

A total of 37 958 adults were included in the study (weighted mean age, 46.4 years; women, 52.0% ), with an overall response rate of 74%. Overall, the use of supplements remained stable between 1999 and 2012, with 52% of US adults reporting use of any supplements in 2011-2012 (P for trend = .19). This trend varied by population subgroup. Use of MVMM decreased, with 37% reporting use of MVMM in 1999-2000 and 31% reporting use in 2011-2012 (difference, -5.7% [95% CI, -8.6% to -2.7%], P for trend < .001). Vitamin D supplementation from sources other than MVMM increased from 5.1% to 19% (difference, 14% [95% CI, 12% to 17%], P for trend  < .001) and use of fish oil supplements increased from 1.3% to 12% (difference, 11% [95% CI, 9.1% to 12%], P for trend < .001) over the study period, whereas use of a number of other supplements decreased.

CONCLUSIONS AND RELEVANCE

Among adults in the United States, overall use of dietary supplements remained stable from 1999-2012, use of MVMM decreased, and trends in use of individual supplements varied and were heterogeneous by population subgroups.