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Purpose Food service guidelines (FSG) policies can impact the nutritional quality of millions of meals sold or served to government employees, citizens in public places, or institutionalized persons. This study examines state FSG policies adopted January 1, 2015 to April 1, 2019, and uses a FSG Classification Tool (FSG Tool) to quantify alignment with nutrition recommendations for public health impact. Design Quantitative Content Analysis Setting State Government Worksites and Facilities Participants 50 states and District of Columbia (D.C.) in the United States. Measures Frequency of policies and percent alignment to FSG tool. Analysis FSG policies were identified using legal databases to assess state statutes, regulations, and executive orders. Content analysis and coding determined attributes of policies across 4 FSG Tool domains, (1) nutrition standards referenced; (2) behavioral design strategies encouraging selection of healthier offerings; (3) facility efficiency and environmental sustainability; and (4) FSG implementation supports. Results From 2015-2019, 5 FSG policies met study inclusion criteria. Four out of 5 policies earned a perfect nutrition score (100%) by referencing nutrition standards that align with the Dietary Guidelines for Americans (DGA) and are operationalized for use in food service venues. Four out of 5 policies included at least 1 implementation supports provision, such as naming an implementing agency, and 2 included provisions that encourage local food sourcing. Conclusion From 2015-2019, overall FSG policy comprehensiveness scores ranged from 24% to 73%, with most policies referencing food and nutrition standards that align to national nutrition recommendations. Public health practitioners can educate decision makers on the potential impact of FSG policies on diet-related health outcomes and associated cost savings, as well as other important co-benefits that support locally grown products and environmental sustainability practices.

This study aimed to assess the association of BMI with inpatient care cost, duration, and acute complications among patients hospitalized for COVID-19 at 273 US hospitals.Children (aged 2-17 years) and adults (aged ≥18 years) hospitalized for COVID-19 during March 2020-July 2021 and with measured BMI in a large electronic administrative health care database were included. Generalized linear models were used to assess the association of BMI categories with the cost and duration of inpatient care.Among 108,986 adults and 409 children hospitalized for COVID-19, obesity prevalence was 53.4% and 45.0%, respectively. Among adults, overweight and obesity were associated with higher cost of care, and obesity was associated with longer hospital stays. Children with severe obesity had higher cost of care but not significantly longer hospital stays, compared with those with healthy weight. Children with severe obesity were 3.7 times (95% CI: 1.4-9.5) as likely to have invasive mechanical ventilation and 62% more likely to have an acute complication (95% CI: 39%-90%), compared with children with healthy weight.These findings show that patients with a high BMI experience significant health care burden during inpatient COVID-19 care.

There have been conflicting reports concerning weight gain among adults during the COVID-19 epidemic. Although early studies reported large weight increases, several of these analyses were based on convenience samples or self-reported information. The objective of the current study is to examine the pandemic-related weight increase associated with the pandemic through May 2021.A total of 4.25 million adults (18 to 84 years) in an electronic health record database who had at least two weight measurements between January 2019 and February 2020 and one after June 2020 were selected. Weight changes before and after March 2020 were contrasted using mixed-effects regression models.Compared with the pre-pandemic weight trend, there was a small increase (0.1 kg) in weight in the first year of the pandemic (March 2020 through March 2021). Weight changes during the pandemic varied by sex, age, and initial BMI, but the largest mean increase across these characteristics was 1.3 kg. Weight increases were generally greatest among women, adults with BMI of 30 or 35 kg/mThe results indicate that the mean weight gain among adults during the COVID-19 pandemic may be small.

Background: Sugar-sweetened beverage (SSB) intake is associated with adverse health outcomes. Objective: We examined associations between the knowledge of health risks related to SSB and SSB intake among adolescents. Design: A cross-sectional study using 2021 YouthStyles survey data. Participants/settings: 831 US adolescents (12–17 years old). Main outcome measures: The outcome variable was SSB intake (none, 1–6 times/week, and ≥1 time/day). Exposure variables were knowledge of seven SSB-related health risks. Statistical analyses performed: Seven multinomial regressions were used to estimate adjusted odds ratios (AOR) for drinking SSB, according to knowledge of SSB-related health risks and after controlling for sociodemographics. Results: Overall, 29% of adolescents consumed SSB ≥1 time/day. Although most adolescents identified cavities (75.4%), weight gain (74.6%), and diabetes (69.7%) as being related to drinking SSB, fewer adolescents identified related conditions such as high blood pressure (31.7%), high cholesterol (25.8%), heart disease (24.6%), and some cancers (18.0%). Compared to non-SSB consumers, drinking SSB ≥1 time/day was significantly higher among adolescents who lacked knowledge of associations between SSB intake and weight gain (AOR = 2.0), heart disease (AOR = 1.9), or some cancers (AOR = 2.3) after controlling for covariates. Conclusions: Among US adolescents, knowledge of SSB-related health risks varied by condition, ranging from 18% (some cancers) to 75% (cavities and weight gain). There were increased odds of drinking SSB among those unaware that weight gain, heart disease, and some cancers are associated with SSB intake. Intervention could evaluate whether increasing certain types of knowledge may influence youth SSB intake.

Background: The COVID-19 pandemic impacted some dietary habits of Americans. Objective: We examined characteristics associated with a high intake of sweet foods and sugar-sweetened beverages (SSB) during the COVID-19 pandemic among US adults. Design: This was a cross-sectional study. Participants/settings: The SummerStyles survey data were collected in 2021 among 4034 US adults (≥18 years). Main outcome measures: The frequencies were measured of consuming various sweet foods (chocolate/candy, doughnuts/sweet rolls/Danish/muffins/Pop-Tarts, cookies/cake/pie/brownies, and ice cream/frozen desserts) and SSB (regular sodas, sweetened coffee/tea drinks fruit drinks, sports drinks, and energy drinks) during the COVID-19 pandemic. The responses were categorized into 0, >0 to

Objective To examine factors associated with water filter use (WFU) for drinking tap water at home and its association with consuming plain water and sugar-sweetened beverages (SSBs). Design Quantitative, cross-sectional study. Setting The 2018 SummerStyles survey data. Subjects U.S. adults (≥18 years; N=4042). Measures Outcomes were intake of plain water (tap/bottled water) and SSBs. Exposure was WFU (yes, no, not drinking tap water at home). Covariates included sociodemographics, weight status, Census regions, and home ownership status. Analysis We used multivariable logistic regressions to estimate adjusted odds ratios (AOR) and 95% confidence interval (CI) for consuming tap water, bottled water, or total plain water >3 cups/day (vs. ≤3 cups) and SSBs ≥1 time/day (vs. Results Overall, 36% of adults reported using a filter for drinking tap water at home; 14% did not drink tap water at home. Hispanics had significantly higher odds of using a water filter (AOR=1.50, 95% CI=1.14-1.98) vs non-Hispanic White. Factors significantly associated with lower odds of WFU were lower education (AOR=.69, 95% CI=.55-.86 for ≤high school; AOR=.78, 95% CI=.64-.95 for some college, vs college graduate), not being married (AOR=.81, 95% CI=.66-.98, vs married/domestic partnership), and lower household income (AOR=.68, 95% CI=.68-.90 for 3 cups/day of tap water (AOR=1.33, 95% CI=1.13-1.56) and lower odds of SSBs ≥1 time/day (AOR=.76, 95% CI=.62-.92). Not drinking tap water at home was associated with higher odds of drinking >3 cups/day bottled water (AOR=3.46, 95% CI=2.70-4.44). Conclusions WFU was associated with higher tap water intake and lower SSB intake among U.S. adults. WFU was higher among Hispanics, but lower among those with lower education and income and not married adults. Although WFU was associated with healthful beverage habits, additional considerations for WFU may include source water quality, oral health, cost, and proper use.

The 2020-2025 Dietary Guidelines for Americans* advise incorporating more fruits and vegetables into U.S. residents' diets as part of healthy dietary patterns. Adults should consume 1.5-2 cup-equivalents of fruits and 2-3 cup-equivalents of vegetables daily.

Frequent intake of sugar-sweetened beverages (SSBs) is associated with adverse health outcomes such as obesity, type 2 diabetes, and cardiovascular disease. Little is known about when, where, and why U.S. adults consume SSBs. This study, using data from an online survey distributed in 2021, examined the occasions, locations, and reasons for consuming SSBs and the characteristics of the adults who consume them. Nearly 7 of 10 adults reported consuming a SSB (1–6 times) in the past 7 days, and more than a third (38%) reported doing so once or more per day (on average). For comparative purposes, the sample was limited to adults who reported consuming SSBs within the last 7 days. Mealtimes were reported as the most frequent occasion for the intake of SSBs (43%) and SSBs were most often consumed at home (70%). Over half of respondents (56%) reported they consume SSBs because they enjoy the taste. Younger adults (18–34 years old) were more likely to consume SSBs in social settings than older adults (≥50 years old). Hispanic adults were less likely to consume SSBs at the beginning of the day compared to non-Hispanic White adults. Younger (18–34 years old) and middle-aged (35–49 years old) adults were more likely to consume SSBs in restaurants, at work, and in cars than older adults (≥50 years old). Women were less likely to consume SSBs at work than men. Hispanic adults were less likely to consume SSBs in cars than non-Hispanic White adults, while those earning USD 50,000&ndash

Background: High consumption of added sugars is related to adverse health consequences. Objective: The objective of this study was to examine characteristics of US youth who report high intakes of added sugars, as well as the eating occasions and top sources of added sugars that contributed to intakes among consumers with high added sugars intake. Design and participants/setting: We conducted a cross-sectional study using 2015–2018 NHANES data among 5280 US youths (2–19 years). Main outcome measures: Outcome measure was usual percent of calories from added sugars using 2 days of dietary recall based on the National Cancer Institute method. High consumers were defined as consuming greater than 15% of total daily calorie intake from added sugars (1.5 times higher than the 2020–2025 Dietary Guidelines for Americans recommendation of

Many U.S. youth experienced accelerated weight gain during the early COVID-19 pandemic. Using an ambulatory electronic health record dataset, we compared children's rates of BMI change in three periods: prepandemic (January 2018-February 2020), early pandemic (March-December 2020), and later pandemic (January-November 2021).We used mixed-effects models to examine differences in rates of change in BMI, weight, and obesity prevalence among the three periods. Covariates included time as a continuous variable; a variable indicating in which period each BMI was taken; sex; age; and initial BMI category.In a longitudinal cohort of 241,600 children aged 2-19 years with ≥4 BMIs, the monthly rates of BMI change (kg/mIn this large geographically-diverse cohort of U.S. youth, accelerated rates of BMI change observed during 2020 were largely attenuated in 2021. Positive rates indicate continued weight gain rather than loss, albeit at a slower rate. Childhood obesity prevalence remained high, which raises concern about long-term consequences of excess weight and underscores the importance of healthy lifestyle interventions. This article is protected by copyright. All rights reserved.

BACKGROUND: Infants and young children with high weight-for-length are at increased risk for obesity in later life. This study describes prevalence of high weight-for-length and examines changes during 2010–2018 among 11,366,755 infants and young children 3–23 months of age in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: Children’s weights and lengths were measured. High weight-for-length was defined as ≥2 standard deviations above sex and age-specific median on World Health Organization growth charts. Adjusted prevalence differences (APDs) between years were calculated as 100 times marginal effects from logistic regression models. APD was statistically significant if 95% confidence interval did not include 0. RESULTS: Adjusted prevalence of high weight-for-length decreased from 2010 to 2014, and leveled off through 2018 overall, in boys and girls, those 6–11 and 18–23 months of age, and non-Hispanic whites, non-Hispanic blacks, Hispanics, and Asians/Pacific Islanders. For 12–17 months old and American Indian/Alaska Native infants and young children, adjusted prevalence decreased from 2010 to 2014, and then increased slightly through 2018. Among 56 WIC state or territorial agencies, 33 had significant decreases between 2010 and 2018, whereas 8 had significant increases. Between 2014 and 2018, prevalence decreased significantly in 12 agencies and increased significantly in 23. CONCLUSIONS: The results indicate overall declines in prevalence of high weight-for-length from 2010 to 2018, with a prevalence stabilization since 2014. Continued surveillance is needed. Obesity prevention strategies in WIC and multiple settings are important for ensuring healthy child growth.

Background: Obesity remains a significant public health issue in the United States. Each week, millions of infants and children are cared for in early care and education (ECE) programs, making it an important setting for building healthy habits. Since 2010, 39 states promulgated licensing regulations impacting infant feeding, nutrition, physical activity, or screen time practices. We assessed trends in ECE regulations across all 50 states and the District of Columbia (D.C.) and hypothesized that states included more obesity prevention standards over time. Methods: We analyzed published ratings of state licensing regulations (2010-2018) and describe trends in uptake of 47 high-impact standards derived from Caring for Our Children's, Preventing Childhood Obesity special collection. National trends are described by (1) care type (Centers, Large Care Homes, and Small Care Homes); (2) state and U.S. region; and (3) most and least supported standards. Results: Center regulations included the most obesity prevention standards (∼13% in 2010 vs. ∼29% in 2018) compared with other care types, and infant feeding and nutrition standards were most often included, while physical activity and screen time were least supported. Some states saw significant improvements in uptake, with six states and D.C. having a 30%-point increase 2010-2018. Conclusions: Nationally, there were consistent increases in the percentage of obesity prevention standards included in ECE licensing regulations. Future studies may examine facilitators and barriers to the uptake of obesity prevention standards and identify pathways by which public health and health care professionals can act as a resource and promote obesity prevention in ECE.

Obesity* is a recognized risk factor for severe COVID-19 (1,2), possibly related to chronic inflammation that disrupts immune and thrombogenic responses to pathogens (3) as well as to impaired lung function from excess weight (4). Obesity is a common metabolic disease, affecting 42.4% of U.S. adults (5), and is a risk factor for other chronic diseases, including type 2 diabetes, heart disease, and some cancers.† The Advisory Committee on Immunization Practices considers obesity to be a high-risk medical condition for COVID-19 vaccine prioritization (6). Using data from the Premier Healthcare Database Special COVID-19 Release (PHD-SR),§ CDC assessed the association between body mass index (BMI) and risk for severe COVID-19 outcomes (i.e., hospitalization, intensive care unit [ICU] or stepdown unit admission, invasive mechanical ventilation, and death). Among 148,494 adults who received a COVID-19 diagnosis during an emergency department (ED) or inpatient visit at 238 U.S. hospitals during March-December 2020, 28.3% had overweight and 50.8% had obesity. Overweight and obesity were risk factors for invasive mechanical ventilation, and obesity was a risk factor for hospitalization and death, particularly among adults aged

Background Childhood obesity is linked with adverse health outcomes and associated costs. Current information on the relationship between childhood obesity and inpatient costs is limited. Objective The objective of this study was to describe trends and quantify the link between childhood obesity diagnosis and hospitalization length of stay (LOS), costs, and charges. Research design We use the National Inpatient Sample data from 2006 to 2016. Subjects The sample includes hospitalizations among children aged 2-19 years. The treatment group of interest includes child hospitalizations with an obesity diagnosis. Measures Hospital LOS, charges, and costs associated with a diagnosis of obesity. Results We find increases in obesity-coded hospitalizations and associated charges and costs during 2006-2016. Obesity as a primary diagnosis is associated with a shorter hospital LOS (by 1.8 d), but higher charges and costs (by $20,879 and $6049, respectively); obesity as a secondary diagnosis is associated with a longer LOS (by 0.8 d), and higher charges and costs of hospitalizations (by $3453 and $1359, respectively). The most common primary conditions occurring with a secondary diagnosis of obesity are pregnancy conditions, mood disorders, asthma, and diabetes; the effect of a secondary diagnosis of obesity on LOS, charges, and costs holds across these conditions. Conclusions Childhood obesity diagnosis-related hospitalizations, charges, and costs increased substantially during 2006-2016, and obesity diagnosis is associated with higher hospitalization charges and costs. Our findings provide clinicians and policymakers with additional evidence of the economic burden of childhood obesity and further justify efforts to prevent and manage the disease.

Summary Background and Objective As obesity among children and adolescents is associated with major health risks, including the persistence of obesity into adulthood, there has been interest in targeting prevention efforts at children and adolescent. The longitudinal tracking of BMI and obesity, as well as the effects of initial age and duration of follow‐up on this tracking, were examined in a large electronic health record (EHR) database. Methods The data consisted of 2.04 million children who were examined from 2006 through 2018. These children were initially examined between ages 2 and 9 years and had a final examination, on average, 4 years later. Results Overall, children with obesity at one examination were 7.7 times more likely to have obesity at a subsequent examination than children with a BMI ≤ 95th percentile. Further, 71% of children with obesity at one examination continued to have obesity at re‐examination. Although 2‐year‐olds had a relative risk of 5.5 and a positive predictive value of 54%, then sensitivity of obesity at younger ages was low. Of the children who were re‐examined after age 10 y and found to have obesity, only 22% had a BMI ≥ 95th percentile at age 2 years. Conclusions Despite the tracking of obesity at all ages, these results agree with previous reports that have found that an elevated BMI at a very young age will identify only a small proportion of older children with obesity.

Purpose: To examine factors associated with frequency of plain water (ie, tap, bottled, and unflavored sparkling water) intake among US high school students. Design: Quantitative, cross-sectional study. Setting: The 2017 national Youth Risk Behavior Survey data. Subjects: US high school students with plain water intake data (N = 10 698). Measures: The outcome was plain water intake. Exposure variables were demographics, academic grades, and behavioral characteristics. Analysis: We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for factors associated with infrequent plain water intake (Results: Overall, 48.7% of high school students reported drinking plain water Conclusions: Infrequent plain water intake was associated with younger age, poor academic grades, poor dietary behaviors, and physical inactivity. These findings can inform intervention efforts to increase water intake to promote healthy lifestyles among adolescents.

Background: The COVID-19 pandemic has triggered stress, anxiety, and disruption to many individuals’ daily lives, which might impact eating habits. Objective: To examine changes in eating habits related to less healthy foods and beverages during the early phase of the COVID-19 pandemic among US adults. Design: Cross-sectional study. Participants/setting: Authors used SummerStyles data gathered in June 2020 among 3916 US adults (≥18 years). Main outcome measures: The outcome of interest was the reported frequency of consuming more (1) unhealthy snacks and desserts including chips, cookies, and ice cream and (2) sugar-sweetened beverages (SSBs) like regular soda, fruit drinks, sports/energy drinks, sweetened coffee/teas during the COVID-19 pandemic. Responses were categorized as Never/Rarely, Sometimes, or Often/Always. Explanatory variables were sociodemographics, weight status, and census regions. Statistical analyses performed: We used multinomial regressions to calculate adjusted odds ratios (AOR) for Sometimes or Often/Always consuming more unhealthy snacks/desserts (vs. Never/Rarely); and Sometimes or Often/Always more SSBs (vs. Never/Rarely). Results: Overall, 36% of adults reported sometimes consuming more unhealthy snacks/desserts; 16% did so often/always. Twenty-two percent of adults reported sometimes drinking more SSBs; 10% did so often/always. Factors significantly associated with higher odds of reporting often/always consuming more unhealthy snacks/desserts were younger adults (AOR range = 1.51–2.86 vs. adults ≥65 years), females (AOR = 1.58 vs. males), non-Hispanic Black (AOR = 1.89 vs. non-Hispanic White), lower household income (AOR = 2.01 for

Purpose: The high intake of added sugars from foods or beverages increases the risk of obesity, hypertension, dyslipidemia, and cardiovascular disease. Because state-level data are lacking, we estimated dietary intake of added sugars by state and factors associated with intake among US adults. Design: Nationally representative, cross-sectional, in-person, household survey. Setting: 50 states and DC. Sample: 52,279 US adults from pooled data from 2010 and 2015 National Health Interview Surveys. Measures: Estimated total added sugars intake (tsp/day) using the National Cancer Institute’s scoring algorithm that converts responses from the Dietary Survey Questionnaire screener to estimated total added sugars intake (tsp/day). Analysis: Mean dietary-added sugars intake estimates and standard error were calculated for adults’ characteristics and by state for all 50 states and the District of Columbia. Differences by adult’s characteristics were assessed by pairwise t-tests (p < 0.05). All analyses accounted for complex survey design and sampling weights. Results: Overall, US adults consumed 17.0 tsp of added sugars/day (range: 14.8 tsp/day in Alaska to 1.2 tsp/day in Kentucky). Added sugars intake varied by states and sociodemographic characteristics. Conclusion: Findings may inform efforts to reduce added sugars intake to lower the high burden of chronic disease.

Obesity is a serious health concern in the United States, affecting more than one in six children (1) and putting their long-term health and quality of life at risk.* During the COVID-19 pandemic, children and adolescents spent more time than usual away from structured school settings, and families who were already disproportionally affected by obesity risk factors might have had additional disruptions in income, food, and other social determinants of health.† As a result, children and adolescents might have experienced circumstances that accelerated weight gain, including increased stress, irregular mealtimes, less access to nutritious foods, increased screen time, and fewer opportunities for physical activity (e.g., no recreational sports) (2,3). CDC used data from IQVIA's Ambulatory Electronic Medical Records database to compare longitudinal trends in body mass index (BMI, kg/m2) among a cohort of 432,302 persons aged 2-19 years before and during the COVID-19 pandemic (January 1, 2018-February 29, 2020 and March 1, 2020-November 30, 2020, respectively). Between the prepandemic and pandemic periods, the rate of BMI increase approximately doubled, from 0.052 (95% confidence interval [CI] = 0.051-0.052 to 0.100 (95% CI = 0.098-0.101) kg/m2/month (ratio = 1.93 [95% CI = 1.90-1.96]). Persons aged 2-19 years with overweight or obesity during the prepandemic period experienced significantly higher rates of BMI increase during the pandemic period than did those with healthy weight. These findings underscore the importance of efforts to prevent excess weight gain during and following the COVID-19 pandemic, as well as during future public health emergencies, including increased access to efforts that promote healthy behaviors. These efforts could include screening by health care providers for BMI, food security, and social determinants of health, increased access to evidence-based pediatric weight management programs and food assistance resources, and state, community, and school resources to facilitate healthy eating, physical activity, and chronic disease prevention.

Purpose: During a pandemic, persons might experience worry because of threats (real or perceived), or as part of stress-related reactions. We aimed to provide insight into Americans’ worry about food during COVID-19. Design, Subjects, Measures: Online survey data from June 2020 (n = 4,053 U.S. adults; 62.7% response rate) was used to assess 2 outcomes: worry about food availability (FA); food safety (FS). Adults with missing information about FA and FS were excluded from analysis (final n = 3,652). Analysis: We used descriptive statistics and multivariable logistic regression to examine characteristics associated with the outcomes and estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for associations between sociodemographic variables and outcomes. Results: 58.3% of respondents reported worry about FA; 57.5% about FS, with higher odds of worry for FA and FS (versus referents) in lower income households (FA: aOR = 1.76 95%CI [1.30, 2.39]; FS: 1.84[1.35, 2.51]); unemployed (1.54[1.05, 2.28]; 1.90[1.26,2.81]); non-Hispanic Black (1.55[1.14,2.12]); 2.25[1.65,3.07]); Hispanic (1.39[1.06,1.82]; 1.94[1.46,2.56]). Conclusion: Findings highlight the importance of strategies to reduce consumer worry about FA and FS and negative food behaviors, and the need for continued access to hunger safety net programs, which could have positive effects on nutrition security.

Obesity negatively affects children's health because of its associations with cardiovascular disease risk factors, type 2 diabetes, asthma, fatty liver disease, victimization stemming from social stigma and bullying, and poor mental health (e.g., anxiety and depression) (1). Children who have overweight or obesity in early childhood are approximately four times as likely to have overweight or obesity in young adulthood as their normal weight peers (2). Obesity prevalence is especially high among children from low-income families (3). In 2010, the overall upward trend in obesity prevalence turned downward among children aged 2-4 years enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a program of the U.S. Department of Agriculture (USDA); prevalence decreased significantly in all racial/ethnic groups and in 34 of the 56 WIC state or territory agencies during 2010-2014 (4). A more recent study among young children enrolled in WIC reported that the overall obesity prevalence decreased from 15.9% in 2010 to 13.9% in 2016 and statistically significant decreases were observed in all age, sex, and racial/ethnic subgroups (3). However, this study did not provide obesity trends at the state level. In collaboration with USDA, CDC used data from the WIC Participant and Program Characteristics (WIC PC) to update state-specific trends through 2016. During 2010-2016, modest but statistically significant decreases in obesity prevalence among children aged 2-4 years enrolled in WIC occurred in 41 (73%) of 56 WIC state or territory agencies. Comprehensive approaches that create positive changes to promote healthy eating and physical activity for young children from all income levels,* strengthen nutrition education and breastfeeding support among young children enrolled in WIC, and encourage redemptions of healthy foods in WIC food packages could help maintain or accelerate these declining trends.

Purpose: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent attitudes about limiting SSB and junk food (SSB/JF) intake. Design: Quantitative, cross-sectional study. Setting: The 2014 Family Life, Activity, Sun, Health, and Eating study. Sample: Parent–adolescent dyads (N = 1555). Measures: The outcome was adolescent SSB intake. Exposure variables were parent SSB intake, sociodemographics, and parent and adolescent attitudes about SSB/JF intake (responses: agree, neither, or disagree). Analysis: Multinomial logistic regressions estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs). Results: Half (49.5%) of adolescents and 33.7% of parents consumed SSB ≥1 time/day. Parent daily SSB intake was associated with adolescent daily SSB intake (aOR = 8.9; CI = 4.6-17.3) [referent: no consumption]. Adolescents who disagreed on having confidence to limit SSB/JF intake had higher odds of daily SSB intake (aOR = 3.5; CI = 1.8-6.8), as did those who disagreed they felt bad about themselves if they did not limit SSB/JF intake (aOR = 1.9; CI=1.1-3.3), compared to adolescents who agreed with these attitudes. No parental attitudes were significant. Conclusion: Higher odds of daily SSB intake among adolescents was associated with parent SSB intake and adolescent attitudes about confidence in, and feeling bad about, limiting SSB/JF intake. Parent attitudes were not associated with daily adolescent SSB intake. Efforts to reduce adolescent SSB intake could consider strategies geared toward improving adolescent attitudes and dietary behaviors and parental SSB intake.

OBJECTIVES: During the COVID-19 pandemic, U.S. retailers have reported few major, sustained disruptions in food availability (FA); the risk of contracting COVID-19 from eating or handling food is low. Some consumer food behaviors related to FA and food safety (FS), such as panic buying, stockpiling, bleaching food have occurred. During emergencies, assessing consumer nutrition beliefs and developing intervention can prevent unintended negative behaviors. We examined self-reported worry about FA and FS during the pandemic. METHODS: Survey data was collected online in June 2020 from a representative panel of US adults (n = 4,053). Outcome variables (worry about FA and FS) were assessed using collapsed response options (‘Worried at any level’ and ‘Not at all worried) to the question, “How worried are you and your household about each of the following as it relates to the COVID-19 pandemic?” Multivariable logistic regression analyses were used to estimate adjusted odds ratios (aORs) for the associations between sociodemographic variables and worry about FA and FS. RESULTS: Over half of respondents reported worry about FA (58.3%) or FS (57.5%). The highest reported worry about FA were among those not employed (74%), those with household income ≤$34,999 (70%), Black adults (68%), adults aged 35–49 years (64%), those with a high school education or less (62%), and those in the South (61%). The highest reported worry about FS was among those not employed (78%), Black adults (73%), household income ≤$34,999 (74%), aged 35–49 years (61%), and those in the Northeast (61%). Compared with their respective referent groups, significantly higher worry for FA and FS respectively were found among lower income households (aOR [CI] = 1.76 [1.30–2.39]; 1.84 [1.35–2.51]), those who were unemployed (1.54 [1.05–2.28]; 1.90 [1.26–2.81]), non-Hispanic Black (1.55 [1.14–2.12]; 2.25 [1.65–3.07]), and Hispanic (1.39 [1.06–1.82]; 1.94 [1.46–2.56]). CONCLUSIONS: Findings highlight the importance of strategies and communications that reduce fears and prevent unintended negative behaviors, and stress increasing consumer awareness of food access options during emergencies, including promotion of hunger safety net programs, especially among disproportionately affected groups. FUNDING SOURCES: Solely for author's time from their institutions.

Frequent intake of sugar-sweetened beverages (SSBs) is associated with adverse health outcomes, including obesity, type 2 diabetes, and cardiovascular disease. We used combined data from the 2010 and 2015 National Health Interview Survey to examine the prevalence of SSB intake among US adults in all 50 states and the District of Columbia. Approximately two-thirds of adults reported consuming SSBs at least daily, including more than 7 in 10 adults in Hawaii, Arkansas, Wyoming, South Dakota, Connecticut, and South Carolina, with significant differences in sociodemographic characteristics. Efforts to decrease SSB consumption could consider the sociodemographic and geographic differences in SSB intake when designing equitable interventions.

Frequent sugar-sweetened beverage (SSB) intake is associated with weight gain in women, and pre-pregnancy overweight and excessive gestational weight gain are linked to adverse pregnancy outcomes. SSB intake information for women of reproductive age (WRA) is limited. We described SSB intake among non-pregnant and pregnant WRA and identified correlates of daily intake. Using 2017 Behavioral Risk Factor Surveillance System data, we analyzed SSB intake (regular soda, fruit drinks, sweet tea, sports/energy drinks) for 11,321 non-pregnant and 392 pregnant WRA (18–49 years) in 12 states and D.C. Adjusted odds ratios (aOR) for daily (≥ 1 time/day) SSB intake (reference

The objective of this study was to describe the prevalence of sugar-sweetened beverage (SSB) intake among US adults (n = 68,896) residing in metropolitan and nonmetropolitan counties, by state, using data from the Behavioral Risk Factor Surveillance System. We used multinomial logistic regression to calculate adjusted prevalence ratios for daily (≥1 time per day) SSB intake. Overall, 26.0% of respondents reported daily SSB intake, with significantly higher prevalence in nonmetropolitan counties (30.9%) than in metropolitan counties (24.8%) (adjusted prevalence ratio = 1.32, 95% confidence interval, 1.26-1.39). This same pattern was significant in 5 of 11 states with metropolitan and nonmetropolitan counties. These findings could inform efforts to reduce frequent SSB intake in nonmetropolitan areas.

Approximately 46 million persons (14%) in the United States live in nonmetropolitan counties.* Compared with metropolitan residents, nonmetropolitan residents have a higher prevalence of obesity-associated chronic diseases such as diabetes (1), coronary heart disease (1), and arthritis (2). The 2005-2008 National Health and Nutrition Examination Survey (NHANES) found a significantly higher obesity prevalence among adults in nonmetropolitan (39.6%) than in metropolitan (33.4%) counties (3). However, this difference has not been examined by state. Therefore, CDC examined state-level 2016 Behavioral Risk Factor Surveillance System (BRFSS) data and found that the prevalence of obesity (body mass index [BMI] ≥30 kg/m2) was 34.2% among U.S. adults living in nonmetropolitan counties and 28.7% among those living in metropolitan counties (p

Purpose: To examine associations between knowledge of health conditions and sugar-sweetened beverage (SSB) intake among Hispanic adults. Design: Quantitative, cross-sectional study. Setting: The 2015 Estilos survey data. Participants: One thousand US Hispanic adults (≥18 years). Measures: The outcome variable was frequency of SSB intake (regular soda, fruit drink, sports/energy drink, and sweetened coffee/tea drink). Exposure variables were knowledge of 6 SSB-related health conditions (weight gain, diabetes, dental caries, high cholesterol, heart disease, and hypertension). Analysis: Six multinomial logistic regression models were used to estimate adjusted odds ratios for consuming SSBs ≥3 times/day (high intake), in relation to knowledge of SSB-related health conditions. Results: Overall, 58% of Hispanic adults consumed SSBs ≥2 times/day and 36% consumed SSBs ≥3 times/day. Although most identified that weight gain (75%) and diabetes (76%) were related to drinking SSBs, only half identified this relation with dental caries (57%) and hypertension (41%). Even fewer identified high cholesterol (32%) and heart disease (32%) as related. In crude analyses, SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, dental caries, and heart disease; however, after adjusting for sociodemographics and acculturation, associations were no longer significant. Conclusions: Although SSB intake was very high, knowledge of SSB-related health conditions was low and was not related to high SSB intake among US Hispanic adults. Education efforts alone may not be adequate for Hispanic adults to change their behaviors.

Purpose: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent knowledge of SSB-related health risks. Design: Quantitative, cross-sectional. Setting: 2014 SummerStyles survey. Subjects: Nine hundred and ninety parent and adolescent (12-17 years) pairs. Measures: The outcome was self-reported adolescent intake (0, >0 to 0 to Analysis: Separate multinomial logistic regression models were used to estimate adjusted odds ratios (aORs) for adolescent SSB intake ≥1 time/day (ref: 0 times/day), according to (1) parent SSB intake and (2) parent and (3) adolescent knowledge. Results: About 31% of adolescents consumed SSBs ≥1 time/day, and 43.2% of parents consumed SSBs ≥2 times/day. Adolescent and parent knowledge that SSB intake is related to health conditions ranged from 60.7% to 80.4%: weight gain (75.0% and 80.4%, respectively), diabetes (60.7% and 71.4%, respectively), and dental caries (77.5% and 72.9%, respectively). In adjusted models, adolescent SSB intake ≥1 time/day was associated with parent intake ≥2 times/day (aOR = 3.30; 95% confidence interval = 1.62-6.74) but not with parent or adolescent knowledge of health risks. Conclusion: Parental SSB intake may be an important factor in understanding adolescent behavior; knowledge of SSB-related health conditions alone may not influence adolescent SSB behavior.

Purpose: To compare the performance of a 1-question survey screener measuring total sugar-sweetened beverage (SSB) intake to a screener measuring SSB types separately using 4 questions. Design: Cross-sectional. Setting: Web-based 2014 SummerStyles survey. Participants: A total of 4167 US adults (≥18 years). Measures: Frequency of SSB intake measured using a 1-question screener was compared to frequency using a 4-question screener (regular soda, fruit drinks, sports/energy drinks, sweetened coffee/tea). SSB intake (number of time/day) was categorized as 0, >0 to Analysis: Paired t tests were used, and agreement was evaluated using weighted κ and Lin’s concordance correlation coefficient (CCC). Results: Mean SSB intake was 1.7 (95% confidence interval [CI]: 1.65-1.79) times/day using 4 questions and 0.6 (95% CI: 0.56-0.62) times/day using 1 question ( P < .001). Intake frequency based on 4 questions versus 1 was 16.0% versus 38.5% for 0 time/day, 15.6% versus 42.5% for >0 to Conclusion: Daily SSB intake was significantly lower using a 1-question screener versus a 4-question screener. Researchers should assess SSB types separately or consider that daily SSB intake is likely underestimated with 1 question.

Objective Although the Centers for Disease Control and Prevention (CDC) growth charts are widely used, BMI-for-age z-Scores (BMIz) are known to be uninformative above the 97th percentile. This study compared the relations of BMIz and other BMI metrics (%BMIp95, percent of 95th percentile, and ΔBMIp95, BMI minus 95th percentile) to circumferences, skinfolds, and fat mass. We were particularly interested in the differences among children with severe obesity (%BMIp95 ≥ 120). Methods Data was used from 30,003 2- to 19-year-olds who were examined from 1999-2000 through 2013-2014 in the National Health and Nutrition Examination Survey (NHANES). Results The theoretical maximum BMIz based on the growth charts varied by more than threefold across ages. The BMI metrics were strongly intercorrelated, but BMIz was less strongly related to the adiposity measures than were ΔBMIp95 and %BMIp95. Among children with severe obesity, circumferences and triceps skinfold showed almost no association with BMIz (r ≤ 0.10), whereas associations with %BMIp95 and ΔBMIp95 ranged from r = 0.32 to 0.79. Corresponding associations with fat mass ÷ height2 ranged from r = 0.40 (BMIz) to r =0.82 (%BMIp95) among 8- to 19-year-olds. Conclusions Among children with severe obesity, BMIz is only weakly associated with other measures of body fatness. Very high BMIs should be expressed relative to the CDC 95th percentile, particularly in studies that evaluate obesity interventions.

Objective Although the CDC growth charts are widely used, BMIz is known to be uninformative above the 97th percentile. We compared the relations of BMIz and other BMI metrics (%BMIp95, percent of 95th percentile, and ΔBMIp95, BMI minus 95th percentile) to circumferences, skinfolds and fat mass. We were particularly interested in the differences among children with severe obesity (%BMIp95 ≥ 120). Methods We used data from 30,003 2- to 19-year-olds who were examined from 1999-2000 through 2013-14 in NHANES. Results The theoretical maximum BMIz based on the growth charts varied by more than 3-fold across ages. The BMI metrics were strongly intercorrelated, but BMIz was less strongly related to the adiposity measures than were ΔBMIp95 and %BMIp95. Among children with severe obesity, circumferences and triceps skinfold showed almost no association with BMIz (r ≤ 0.10), whereas associations with %BMIp95 and ΔBMIp95 ranged from r=0.32 to 0.79. Corresponding associations with fat mass ÷ height2 ranged from r=0.40 (BMIz) to r=0.82 (%BMIp95) among 8- to 19-year-olds. Conclusions Among children with severe obesity, BMIz is only weakly associated with other measures of body fatness. Very high BMIs should be expressed relative to the CDC 95th percentile, particularly in studies that evaluate obesity interventions.

We described sociodemographic differences in perceptions of drinking water safety and examined associations between perceptions and plain water intake. We used the 2015 Estilos survey of 1,000 US Hispanic adults conducted in both Spanish and English. Outcome was water intake. Exposures were the level of agreement about water perceptions (My tap water is safe to drink; Community tap water is safe to drink; Bottled water is safer; I would buy less bottled water if my tap water was safe). Covariates were sociodemographics, region, Hispanic heritage, and acculturation. We used chi-square tests and multinomial logistic regression to examine associations of water perceptions and intake. Overall, 24% of Hispanic adults consumed water ≤1 time/day. Although 34% disagreed their home tap water was safe to drink, and 41% disagreed their community tap water was safe to drink, 65% agreed bottled water is safer than tap water, and 69% agreed they would buy less bottled water if they knew their tap water was safe. Perceptions differed by some covariates but were not significantly associated with plain water intake. In conclusion, negative perceptions of tap water were common among US Hispanic adults, which can inform efforts to increase awareness about safe public water systems.

Added sugars intake increases risk of obesity, hypertension, dyslipidemia, and cardiovascular diseases (CVD) and may impact disease management. We examined factors related to added sugars intake among US adults with or without CVD and risk factors using 2015 National Health Interview Survey (NHIS) (n=30616). NHIS used the National Cancer Institute (NCI) Dietary Screener Questionnaire (DSQ) to assess individual’s dietary intake. The DSQ used 8 questions to assess added sugar intake over the last 30 days. We used the NCI’s scoring algorithm to convert screener responses to estimate total added sugars intake (tsp/day) by characteristics within 3 strata—adults with a history of heart disease/stroke (CVD, n=4658), adults with hypertension/high cholesterol but without CVD (HTHC, n=10476), and adults without CVD or HTHC (no CVD, n=15482). Because our goal was not to look at association between added sugar and CVD risk, comparisons among the groups were not made. Characteristics included age, sex, race/ethnicity, education, income, marital status, smoking, and weight status. We used multiple linear regression to assess independent associations between intake and characteristics. Added sugars intake was similar in magnitude across all 3 strata (CVD 16.9, HTHC 17.0, and no CVD 17.3 tsp, respectively). We found increased added sugars intake with younger age, lower education, lower income, and smoking among adults regardless of CVD status. Having obesity was positively related to increased intake for adults without CVD, but no association was found between the weight status and intake in adults with CVD or HTHC. Improving diet may prevent CVD and aid disease self-management. Product reformulation to reduce added sugars and strategies to counsel and support individuals to reduce dietary added sugars may be needed to optimize heart health.