Whose Plate Is It? Awareness of MyPlate Among US Adults Over Time Since Implementation

BACKGROUND

MyPlate is a tool designed to educate the general US population on how to eat in alignment with the Dietary Guidelines for Americans; yet, there is a lack of data on who has heard of MyPlate over time.

OBJECTIVE

The objective of this analysis was to examine the prevalence of awareness of MyPlate within the US population and if awareness changes differentially over time.

DESIGN

This study was a serial, cross-sectional survey.

PARTICIPANTS/SETTING

Three survey waves of data (2013-2018) were used from the National Health and Nutrition Examination Survey of adults aged 20 years or older (n = 17,023).

MAIN OUTCOME MEASURES

Percentage of the US adult population who had heard of MyPlate was measured and stratified by sex, age, citizenship status, education, household food security status, income, receipt of Supplemental Nutrition Assistance Program (SNAP) benefits, and receipt of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits.

STATISTICAL ANALYSES PERFORMED

Global Wald tests were used to assess whether prevalence of awareness of MyPlate differed by sociodemographic characteristics. Tests of homogeneity using likelihood ratio tests of nested logistic regression models were used to assess whether differences in awareness of MyPlate by various sociodemographic characteristics changed over time from 2013 to 2018.

RESULTS

Twenty percent (19.5%) (n = 875) of the analytic sample of participants aged 20 years and older had heard of MyPlate in 2013-2014, 24.5% (n = 1,020) in 2015-2016, and 24.6% (n = 1,086) in 2017-2018. Awareness of MyPlate changed differentially over time (P value < .1) from 2013 to 2018 by income, household food security status, and receipt of SNAP benefits, with slower increases in awareness for households with lowest income over time, narrowing of differences in awareness by household food security status over time, and persistent differences in awareness by receipt of SNAP benefits over time.

CONCLUSIONS

These results highlight the current low awareness of MyPlate, disparities in awareness of MyPlate immediately after implementation by sociodemographic characteristics, and increases in awareness over time at differential rates within levels of income, food security status, and ever receipt of SNAP benefits. Given that the Dietary Guidelines for Americans 2025-2030 are currently in development, new strategies should be considered to disseminate tools that translate the updated Dietary Guidelines in such a way that reach the general population equitably upon implementation within the United States.

Risk Management of COVID-19 in the Residential Educational Setting: Lessons Learned and Implications for Moving Forward

With limited COVID-19-guidelines for institutions of higher education (IHEs), colleges and universities began the 2020-2021 academic year with varying approaches. We present a comprehensive COVID-19 prevention and mitigation approach at a residential university during the 2020-2021 academic year, along with campus SARS-CoV-2 transmission during this time. Risk management of COVID-19 was facilitated through (1) a layered approach of primary, secondary, and tertiary prevention measures; (2) a robust committee structure leveraging institutional public health expertise; (3) partnerships with external health entities; and (4) an operations system providing both structure and flexibility to adapt to changes in disease activity, scientific evidence, and public health guidelines. These efforts collectively allowed the university to mitigate SARS-CoV-2 transmission on campus and complete the academic year offering in-person learning on a residential campus. We identified 36 cases of COVID-19 among the 2037 in-person learners during the fall semester, 125 cases in the inter-semester break, and 169 cases among 2095 in-person learners during the spring semester. SARS-CoV-2 infection during the academic year was associated with gender (p = 0.04), race/ethnicity (p = 0.01), and sorority/fraternity membership (p < 0.01). Infection was not associated with undergraduate vs. graduate student status, Division I athlete status, or housing type (all p > 0.05). A multi-faceted public health approach was critical for reducing the impact of COVID-19 while carrying out the university's educational mission.

Association between diet quality indices and arterial stiffness in youth with type 1 diabetes: SEARCH for Diabetes in Youth Nutrition Ancillary Study

AIMS

We studied the association of three distinct diet quality indices and two measures of arterial stiffness in youth and young adults (YYA) aged 10 to 30 with T1D.

METHODS

Cross-sectional (n = 1421) and longitudinal (n = 520) analyses were conducted in T1D YYA participating in the SEARCH for Diabetes in Youth Study. The diet quality indices included the Dietary Approaches to Stop Hypertension (DASH) index, the Healthy Eating Index 2015 (HEI-2015), and a modified Mediterranean Diet Quality Index (mKIDMED). Arterial stiffness was measured with pulse wave velocity (PWV) and augmentation index (AIx) obtained using a SphygmoCor-Vx device and tonometer.

RESULTS

Average diet quality was moderate to poor, with mean scores of 41 (DASH, range 0-80), 55 (HEI-2015, range 0-100), 3.7 (mKIDMED, range - 3-12). None of the diet quality scores was associated with the central PWV or Aix, independent of demographic, clinical and lifestyle factors, body mass index and HbA1c. Longitudinal data yielded consistent findings with cross-sectional results.

CONCLUSIONS

This study suggests that diet quality may not function as an independent risk factor for arterial stiffening in YYA with T1D. These findings do not diminish the importance of consuming a quality diet for the management of diabetes, as demonstrated in previous work.

Dietary strategies to manage diabetes and glycemic control in youth and young adults with youth-onset type 1 and type 2 diabetes: The SEARCH for diabetes in youth study

AIMS

Examine associations of dietary strategies used to manage diabetes over time with hemoglobin A1c in youth-onset type 1 or type 2 diabetes.

METHODS

The SEARCH for Diabetes in Youth observational study assessed dietary strategies used by 1814 participants with diabetes (n = 1558 type 1, n = 256 type 2) at two to three research visits over 5.5 years (range 1.7-12.2). Participants reported often, sometimes, or never using 10 different dietary strategies, and use over time was categorized into five mutually exclusive groups: often using across visits; started using at later visits; sometimes using across visits; stopped using at later visits; or never using across visits. General multivariable linear models evaluated most recent A1c by use category for each strategy.

RESULTS

In type 1 diabetes, A1c was lower among those who starting tracking calories (-0.4%, Tukey P < .05), often counted carbs (-0.8%, Tukey P < .001), or sometimes chose low glycemic index foods (-0.5%, Tukey P = .02) vs those with less use, while participants who never drank more milk had the lowest A1c (-0.5%, Tukey P = .04). In type 2 diabetes, A1c was lower among those who often limited high fat foods (-2.0%, Tukey P = .02) or started counting carbohydrates (-1.7%, Tukey P = .07) than those who did so less.

CONCLUSIONS

For several dietary strategies, more frequent use over time was related to lower A1c in youth-onset type 1 and type 2 diabetes, suggesting these strategies can likely support diabetes management for this population. Investigation into factors predicting receipt of advice for specific strategies and corresponding impact on intake might be considered.

An Approach for Examining the Impact of Food Group-Based Sources of Nutrients on Outcomes with Application to PUFAs and LDL in Youth with Type 1 Diabetes

Traditionally, nutritional epidemiologists have utilized single nutrient or dietary pattern approaches to examine diet-health relationships. However, the former ignores that nutrients are consumed from foods within dietary patterns, and, conversely, dietary patterns may provide little information on mechanisms of action. Substitution provides a framework for estimating diet-health relationships while holding some nutrient intakes constant. We examined substitution effects of polyunsaturated fatty acids (PUFAs) in the SEARCH Nutrition Ancillary Study in the context of food group source. PUFAs were calculated from fatty acids 18:3, 20:5, and 22:6 (n-3), and 18:2 and 20:4 (n-6) from a food frequency questionnaire, quantified by food group. Models were adjusted for other fat intake, carbohydrates, protein, age, race, gender, and diabetes duration. Participants (n = 1441) were 14 years old on average, 51% female, with type 1 diabetes for 3.6 years. Mean intake of PUFAs was 14.9 g/day, and the highest PUFA sources were nonsolid fats, nuts, grains, red/processed meats, sweets/desserts, and high-fat chicken. PUFAs from nuts were inversely associated with low-density lipoprotein cholesterol (LDL) (p = 0.03) and PUFAs from high-fat chicken were positively associated with LDL (p < 0.01). Substituting nuts for chicken was associated with -7.4 mg/dL in LDL. These findings illustrate the importance of considering food group-based sources of nutrients when examining diet-health relationships.

Dietary quality and markers of inflammation: No association in youth with type 1 diabetes

BACKGROUND

Systemic inflammation is a key process underlying cardiovascular disease (CVD) development, and CVD risk is significantly elevated in persons with type 1 diabetes (T1D). Youth with T1D exhibit increased levels of inflammation. Studies in persons without diabetes suggest that dietary quality influences inflammation, yet little is known about dietary influences on inflammation in youth with T1D.

METHODS

This study evaluated the association of four distinct dietary quality indices (Dietary Approaches to Stop Hypertension (DASH), Healthy Eating Index 2010 (HEI2010), modified KIDMED and Total Antioxidant Capacity (TAC)) with biomarkers of inflammation (C-reactive protein (CRP), fibrinogen and interleukin-6 (IL-6)) in a sample of 2520 youth with T1D participating in the SEARCH for Diabetes in Youth Study.

RESULTS

Average diet quality was moderate to poor, with mean scores of 43 (DASH, range 0-80), 55 (HEI2010, range 0-100), 3.7 (mKIDMED, range 3-12) and 7237 (TAC). None of the four diet quality scores was associated with the selected biomarkers of inflammation in any analyses. Evaluation of a non-linear relationship or interactions with BMI or levels of glycemic control did not alter the findings. Replication of analyses using longitudinal data yielded consistent findings with our cross-sectional results.

CONCLUSIONS

Biomarkers of inflammation in youth with T1D may not be directly influenced by dietary intake, at least at the levels of dietary quality observed here. More work is needed to understand what physiologic mechanisms specific to persons with T1D might inhibit the generally beneficial influence of high dietary quality on systemic inflammation observed in populations without diabetes.

Association of adherence to a Mediterranean diet with glycemic control and cardiovascular risk factors in youth with type I diabetes: the SEARCH Nutrition Ancillary Study

Background/Objectives

This study aimed to determine the association between a Mediterranean diet and glycemic control and other cardiovascular risk factors among youth with type 1 diabetes (T1D).

Subjects/Methods

Incident T1D cases aged <20 years at diagnosis between 2002 and 2005 were included. Participants were seen at baseline (N=793), 1-year (N=512) and 5-year follow-up visits (N=501). Mediterranean diet score was assessed using a modified KIDMED index (mKIDMED). Multivariate linear regression and longitudinal mixed model were applied to determine the association between mKIDMED score and log-HbA1c, lipids, blood pressure (BP), and obesity.

Results

In cross-sectional analyses using baseline data, for individuals with an HbA1c of 7.5%, a two-point higher mKIDMED score (one standard deviation) was associated with 0.15% lower HbA1c (P=0.02). A two-point higher mKIDMED score was associated with 4.0 mg/dL lower total cholesterol (TC) (P=0.006), 3.4 mg/dL lower low-density lipoprotein (LDL)-C (P=0.004), 3.9 mg/dL lower non-high-density lipoprotein (non-HDL)-C (P=0.004), and 0.07 lower LDL-C/HDL-C ratio (P=0.02). Using longitudinal data, a two-point increase in mKIDMED score was associated with 0.01% lower log-HbA1c (P=0.07), 1.8 mg/dL lower TC (P=0.05), 1.6 mg/dL lower LDL-C (P=0.03), and 1.8 mg/dL lower non-HDL-C (P=0.03) than would otherwise have been expected. HbA1c mediated about 20% of the association for lipids in both cross-sectional and longitudinal models. An unexpected positive association between mKIDMED score and systolic BP was found among non-Hispanic white youth in cross-sectional analyses (P=0.009). Mediterranean diet was not associated with obesity.

Conclusions

Mediterranean diet may improve glycemic control and cardiovascular health in T1D youth.

Vitamin D in youth with Type 1 diabetes: prevalence of insufficiency and association with insulin resistance in the SEARCH Nutrition Ancillary Study

AIMS

To determine the prevalence of plasma vitamin D (25-dihydroxyvitamin D) insufficiency in individuals with Type 1 diabetes and to determine the cross-sectional and longitudinal associations of plasma vitamin D with insulin resistance.

METHODS

Participants from the SEARCH for Diabetes in Youth Study [n = 1426; mean age 11.2 years (sd 3.9)] had physician-diagnosed Type 1 diabetes [diabetes duration mean 10.2 months (sd 6.5)] with data available at baseline and follow-up (approximately 12 and 24 months after baseline). Insulin resistance was estimated using a validated equation. Cross-sectional and longitudinal multivariate logistic regression models were used to determine the association of plasma vitamin D with insulin resistance, adjusting for potential confounders.

RESULTS

Forty-nine per cent of individuals had plasma vitamin D < 50 nmol/l and 26% were insulin resistant. In cross-sectional multivariate analyses, participants who had higher plasma vitamin D (65 nmol/l) had lower odds of prevalent insulin resistance than participants with lower plasma vitamin D (25 nmol/l) (odds ratio 0.70, 95% CI 0.57-0.85). This association was attenuated after additional adjustment for BMI z-score, which could be a confounder or a mediator (odds ratio 0.81, 95% CI 0.64-1.03). In longitudinal multivariate analyses, individuals with higher plasma vitamin D at baseline had lower odds of incident insulin resistance, but this was not significant (odds ratio 0.85, 95% CI 0.63-1.14).

CONCLUSIONS

Vitamin D insufficiency is common in individuals with Type 1 diabetes and may increase risk for insulin resistance. Additional prospective studies are needed to determine the association between plasma vitamin D and insulin resistance, and to further examine the role of adiposity on this association.

Correlates of medical nutrition therapy and cardiovascular outcomes in youth with type 1 diabetes

OBJECTIVES

To examine whether the types of medical nutrition therapies (MNTs) taught to and used by youth with type 1 diabetes (T1D) vary by sociodemographic characteristics and cardiovascular (CVD) risk factors.

DESIGN

Cross-sectional study.

SETTING

The SEARCH for Diabetes in Youth study is a population-based cohort of individuals with clinical diagnosed diabetes.

PARTICIPANTS

A total of 1,191 individuals with T1D.

MAIN OUTCOME MEASURES

Types of MNTs and frequency of use.

ANALYSIS

Bivariate analysis and multivariate linear regression (P < .05) RESULTS: More race/ethnic minorities (vs whites), individuals with parents with less than a high school education (vs high school or higher education), and overweight/obese (vs underweight/normal weight) were taught additional MNTs. For underweight/normal weight individuals exclusively taught carbohydrate counting, those who used this approach "often" had lower hemoglobin A1c (8.6% vs 8.9%) and triglycerides (73.5 vs 84.1 mg/dL) than those who used it "sometimes/never." "Often" use of additional MNTs beyond carbohydrate counting was not associated with better mean values for CVD risk factors.

CONCLUSIONS AND IMPLICATIONS

In individuals with T1D, race/ethnic minorities, individuals with parents with less than a high school education, and overweight/obese individuals are taught more MNTs. Further research is needed to understand the effectiveness of the various MNTs on CVD risk factors, and to identify how to translate nutrition knowledge to behavior and metabolic status.

Timing and duration of obesity in relation to diabetes: findings from an ethnically diverse, nationally representative sample

OBJECTIVE

The influence on diabetes of the timing and duration of obesity across the high-risk period of adolescence to young adulthood has not been investigated in a population-based, ethnically diverse sample.

RESEARCH DESIGN AND METHODS

A cohort of 10,481 individuals aged 12-21 years enrolled in the U.S. National Longitudinal Study of Adolescent Health (1996) was followed over two visits during young adulthood (18-27 years, 2001-2002; 24-33 years, 2007-2009). Separate logistic regression models were used to examine the associations of diabetes (A1C ≥6.5% or diagnosis by a health care provider) in young adulthood with 1) obesity timing (never obese, onset <16 years, onset 16 to <18 years, onset ≥18 years) and 2) obesity duration over time (never obese, incident obesity, fluctuating obesity, and persistent obesity), testing differences by sex and race/ethnicity.

RESULTS

Among 24- to 33-year-old participants, 4.4% had diabetes (approximately half were undiagnosed), with a higher prevalence in blacks and Hispanics than whites. In multivariable analyses, women who became obese before age 16 were more likely to have diabetes than women who became obese at or after age 18 (odds ratio 2.77 [95% CI 1.39-5.52]), even after accounting for current BMI, waist circumference, and age at menarche. Persistent (vs. adult onset) obesity was associated with increased likelihood of diabetes in men (2.27 [1.41-3.64]) and women (2.08 [1.34-3.24]).

CONCLUSIONS

Diabetes risk is particularly high in individuals who were obese as adolescents relative to those with adult-onset obesity, thus highlighting the need for diabetes prevention efforts to address pediatric obesity.

Association of adolescent obesity with risk of severe obesity in adulthood

CONTEXT

Although the prevalence of obesity has increased in recent years, individuals who are obese early in life have not been studied over time to determine whether they develop severe obesity in adulthood, thus limiting effective interventions to reduce severe obesity incidence and its potentially life-threatening associated conditions.

OBJECTIVE

To determine incidence and risk of severe obesity in adulthood by adolescent weight status.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of 8834 individuals aged 12 to 21 years enrolled in 1996 in wave II of the US National Longitudinal Study of Adolescent Health, followed up into adulthood (ages 18-27 years during wave III [2001-2002] and ages 24-33 years during wave IV [2007-2009]). Height and weight were obtained via anthropometry and surveys administered in study participants' homes using standardized procedures.

MAIN OUTCOME MEASURES

New cases of adult-onset severe obesity were calculated by sex, race/ethnicity, and adolescent weight status. Sex-stratified, discrete time hazard models estimated the net effect of adolescent obesity (aged <20 years; body mass index [BMI] ≥95th percentile of the sex-specific BMI-for-age growth chart or BMI ≥30.0) on risk of severe obesity incidence in adulthood (aged ≥20 years; BMI ≥40.0), adjusting for race/ethnicity and age and weighted for national representation.

RESULTS

In 1996, 79 (1.0%; 95% confidence interval [CI], 0.7%-1.4%) adolescents were severely obese; 60 (70.5%; 95% CI, 57.2%-83.9%) remained severely obese in adulthood. By 2009, 703 (7.9%; 95% CI, 7.4%-8.5%) non-severely obese adolescents had become severely obese in adulthood, with the highest rates for non-Hispanic black women. Obese adolescents were significantly more likely to develop severe obesity in young adulthood than normal-weight or overweight adolescents (hazard ratio, 16.0; 95% CI, 12.4-20.5).

CONCLUSION

In this cohort, obesity in adolescence was significantly associated with increased risk of incident severe obesity in adulthood, with variations by sex and race/ethnicity.

A study of the birth weight-obesity relation using a longitudinal cohort and sibling and twin pairs

Sibling and twin study designs provide control for confounding factors that are typically unmeasured in traditional cohort studies. Using nationally representative data from the National Longitudinal Study of Adolescent Health collected at 3 visits during 1994-2002, the authors evaluated the longitudinal association between birth weight and later obesity in a traditional cohort study (n = 13,763; ages 11-21 years at baseline), controlling for sex, age, race/ethnicity, and parental education. Among persons with a nonobese mother, high birth weight (>4 kg) participants were more likely than normal birth weight (>/=2.5-</=4 kg) participants to become obese later in life (incidence rate ratio = 1.46, 95% confidence interval: 1.28, 1.67). In a matched sibling pair sample (full siblings: n = 513; monozygotic twins: n = 207; dizygotic twins: n = 189), the authors examined longitudinal within-pair differences. Birth weight difference was positively associated with body mass index difference later in life for female monozygotic pairs only (beta = 2.67, 95% confidence interval: 0.99, 4.35). Given the null associations observed in the sibling sample, the commonly observed positive association between birth weight and later obesity from cohort analyses may be attributed to confounding by maternal characteristics. Further research is needed to identify specific factors that contribute to the birth weight-obesity relation.

Longitudinal trends in obesity in the United States from adolescence to the third decade of life

No longitudinal analyses using national data have evaluated the increase in obesity from adolescence into early adulthood. We examined obesity incidence, persistence, and reversal in a nationally representative cohort of US teens followed into their early 30s, using measured height and weight data, in individuals enrolled in wave II (1996; 12-21 years), wave III (2001; 17-26 years), and wave IV (2008 early release data; 24-32 years) of the National Longitudinal Study of Adolescent Health (N = 8,675). Obesity was defined as a BMI >or=95th percentile of the 2000 Centers for Disease Control/National Center for Health Statistics growth charts or >or=30 kg/m(2) for individuals <20 years and >or=30 kg/m(2) in individuals >or=20 years. In 1996, 13.3% of adolescents were obese. By 2008, obesity prevalence increased to 36.1%, and was highest among non-Hispanic black females (54.8%). Ninety percent of the obese adolescents remained obese in 2008. While annual obesity incidence did not decline in the total sample across the two study intervals (2.3% per year 1996-2001 vs. 2.2% per year 2001-2008), rates among white females declined (2.7 to 1.9% per year) and were highest among non-Hispanic black and Hispanic females (3.8 and 2.7% per year, 1996-2001 vs. 3.0 and 2.6% per year, 2002-2008, respectively). Obesity prevalence doubled from adolescence to the early 20s, and doubled again from the early to late 20s or early 30s, with strong tracking from adolescence into adulthood. This trend is likely to continue owing to high rates of pediatric obesity. Effective preventive and treatment efforts are critically needed.

Entry into romantic partnership is associated with obesity

BMI is highly correlated between spouses; however, less is understood about the underlying mechanism(s) by which the development of obesity in one individual increases the risk of obesity in his/her spouse. The objective of this study is to investigate whether romantic partnership and duration of cohabitation are related to incident obesity and obesity-promoting behaviors. We used two data sets from the National Longitudinal Study of Adolescent Health: (i) 6,949 US adolescents (wave II, 1996) followed into adulthood (wave III, 2001-2002) and (ii) 1,293 dating, cohabiting, and married romantic couples from wave III, including measured anthropometry and self-report behavior data. In the longitudinal cohort, we used sex-stratified logistic regression models to examine the risk of incident obesity by longitudinal romantic relationship status and duration of time spent living with a romantic partner. In the Couples Sample, we used multinomial logistic regression to predict concordance in outcomes: obesity, moderate-to-vigorous physical activity, and screen time by romantic partnership and duration of time living with a romantic partner. Individuals who transitioned from single/dating to cohabiting or married were more likely to become obese than those who were dating at both waves. Partner concordance for negative, obesity-related behaviors was strongest for married couples and couples who lived together > or =2 years. The shared household environment may increase the likelihood of becoming obese, influence partner concordance, and may be an important target for obesity intervention.

Risk factors for isolated biliary atresia, National Birth Defects Prevention Study, 1997–2002

Biliary atresia is a rare birth defect that affects 1 in 12,000 to 1 in 19,500 live births. We used data from the National Birth Defects Prevention Study, a multistate case-control study, to identify potential risk factors for isolated biliary atresia (no additional unrelated major birth defects diagnosed). Infants were identified from eight states from 1997 to 2002, with clinical information abstracted from medical records. Potential risk factors assessed include: demographic factors, seasonality, preterm birth, maternal smoking, maternal alcohol use, maternal illicit drug use, maternal health, maternal medication use, maternal vitamin use, and maternal nutrition. Infants of non-Hispanic black mothers were more likely to have biliary atresia than infants of non-Hispanic white mothers (adjusted odds ratio (aOR) = 2.29, 95% confidence interval (CI) 1.07-4.93) and infants conceived during the spring season were more likely to have biliary atresia than infants conceived in winter (aOR = 2.33, 95%CI 1.05-5.16). Low intakes of vitamin E, copper, phosphorus, and beta tocopherol were associated with the occurrence of isolated biliary atresia (borderline significance). Low iron intake had a borderline inverse association with biliary atresia. While this analysis provides support for previous reports of a possible association between seasonal variation and the occurrence of biliary atresia, more data are needed to evaluate whether the seasonal variation is related to infectious agents. The role of nutrients in the development of biliary atresia remains unclear. Further studies of genetic, infectious, and nutrient exposures and the association of biliary atresia are warranted.