Trends in Food Sources and Diet Quality Among US Children and Adults, 2003-2018

Key Points Question What are the trends in nutritional quality of foods consumed from major US sources? Findings In this survey study of 20 905 children and 39 757 adults from 2003-2004 to 2017-2018, modest improvements were found in diet quality for foods from grocery stores and small improvements for foods from restaurants, each with disparities. Diet quality for foods from schools improved significantly, especially after 2010, and equitably across subgroups; by 2017-2018, food consumed at schools had the highest quality, followed by food from grocery stores, other sources, worksites, and restaurants. Meaning By 2017-2018, foods consumed at schools provided the best mean quality of major sources, without disparities, although further improvements are needed in all sources, especially restaurants, with a focus on reducing disparities.


eAppendix 1. National Health and Nutrition Examination Survey, Dietary Assessment, Dietary American Heart Association (AHA) scores and Healthy Eating Index scores
NHANES uses a complex, multistage, probability sampling design to select a nationally representative population of civilian, non-institutionalized participants. 1,2 The National Center for Health Statistics ethics review board approved the study protocol, and all participants provided written informed consent. Because data are publicly available and de-identified, institutional review board approval was not required for the current investigation.
The US Department of Agriculture (USDA) Automated Multiple-Pass Method was used for collecting 24-hour dietary recalls using "What We Eat In America," the dietary interview component of NHANES. The USDA Food Patterns Equivalents Database, which disaggregates mixed foods into their components parts, was used to assess changes in food groups. Nutrients were derived from cycle-specific versions of the USDA Food and Nutrient Database for Dietary Studies.

The American Heart Association (AHA) Diet Scores
To assess a summary diet score, we constructed a continuous diet score based on the AHA 2020 Strategic Impact Goal dietary targets, which have been significantly associated with cardiovascular and metabolic outcomes in multiple analyses. 4 The primary dietary targets are fruits/vegetables, whole grains, fish and shellfish, nuts/legumes/seeds, sugar-sweetened beverages, processed meat, sodium, and saturated fat (eTable 1). To best assess changes, we constructed a continuous score. Intake of each dietary item was scored from 0-10 (beneficial components) or 10-0 (harmful components) depending on whether consumption was encouraged or discouraged, respectively. For beneficial dietary components, individuals with zero intake received the lowest score (0). For harmful dietary components, the lowest score (0) was assigned to a higher level approximately equivalent to the 80th to 90th percentile of intake

Dietary Components of the American Heart Association (AHA) 2020 Strategic Impact Goals and Scoring Standards Points Range
Scoring Standard a Component Max Min AHA Score b 0-80 Fruits and vegetables c 0-10 ≥4.5 cups equiv. per day 0 Whole grains 0-10 ≥3 oz equiv. per day 0 Fish and shellfish 0-10 ≥1 oz equiv. per day 0 Nuts, seeds and legumes d 0-10 ≥4 servings per day 0 Sugar-sweetened beverages 10-0 ≤ 5.14 fl oz per day >16 fl per day Processed meat 10-0 ≤ 0.5 oz equiv. per day >1.764 oz equiv. per day Sodium 10-0 ≤ 1500 mg per day >4500 mg per day Saturated fat 10-0 ≤7% energy >15% energy a Intakes between the minimum and maximum standards are scored proportionately. b All AHA dietary variables were energy-adjusted to 2000kcal/d prior to analysis. c According to the AHA 2020 Goals, up to 3 cups/wk (0.42 cups/d) of starchy vegetables (e.g., potatoes, peas, corn) could be included; this maximum was incorporated into the analysis, with higher intake not contributing toward the score. 100% fruit juice could also be included; while its contribution was not capped in the original AHA 2020 Goals and thus not in our score, some organizations recommend no more than 1 serving/d of 100% fruit juice. d A serving of nuts, seeds and legumes is 1-oz equivalent of nuts and seeds or ½ cup of legume.

HEI-2015 Moderation
Refined Grains 0-10 ≤1.8 oz equiv. per 1,000 kcal ≥4.3 oz equiv. per 1,000 kcal Sodium 0-10 ≤1.1 grams per 1,000 kcal ≥2.0 grams per 1,000 kcal Added Sugars 0-10 ≤6.5% of energy ≥26% of energy Saturated Fats 0-10 ≤8% of energy ≥16% of energy a Intakes between the minimum and maximum standards are scored proportionately. b Includes 100% fruit juice. c Includes all forms except juice. d Includes legumes (beans and peas) e Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages. f Includes legumes (beans and peas) g Includes seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas). h Ratios of poly-and monosaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs). Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Percentages and CIs were estimated using survey weights to be nationally representative.

Worksites
7.05 (6.72-7.38) 6.53 (6.02-7.05) 6.73 (6.39-7.08) 6.93 (6.60-7.27) 7.20 (6.79-7.61) 7.33 (6.66-8.0) 6.96 (6.44-7.48) 6.51 (5.93-7.08) .85 -0.54 (-1.20, 0.12) Other sources 6.60 (6.34-6.86) 6.13 (5.86-6.40) 6.28 (5.99-6.57) 6.43 (6.21-6.64) 5.89 (5.65-6.13) 5.46 (5.12-5.79) 5.42 (5.08-5.76) 5.18 (4.91-5.44) <.001 -1.40 (-1.80, -1.0) Added sugars .09) 6.16 (5.92-6.4) 6.10 (5.76-6.45) 6.39 (6.24-6.54) 6.54 (6.33-6.74) 6.58 (6.38-6.78) 6.80 (6.58-7.02) 6.63 (6.37-6.88 (5.33-5.97) 6.01 (5.77-6.26) 5.85 (5.49-6.22) .03 -0.11 (-0.55, 0.34) Abbreviations: NHANES, National Health and Nutrition Examination Survey; HEI, Healthy Eating Index. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Percentages and CIs were estimated using survey weights to be nationally representative. b Includes legumes (beans and peas). c Includes 100% fruit juice. d Includes all forms except juice. e Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages. f Includes seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas). g Ratio of poly-and monounsaturated fatty acids (PUFAs and MUFAs) to saturated. Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Percentages and CIs were estimated using survey weights to be nationally representative. b Poor die quality was defined as being less than 40% adherent (<32 points Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Sensitivity analysis refers to diet quality based on the AHA score excluding fish/shellfish with a total score multiplied by 80/70. b Percentages and CIs were estimated using survey weights to be nationally representative. c Poor die quality was defined as being less than 40% adherent (<32 points). Intermediate was defined as adherence of 40%-79.9% (32-63.9 points). Ideal was defined as 80% adherence or greater (≥64 points). Abbreviations: NHANES, National Health and Nutrition Examination Survey. full-service restaurants refer to food/beverages consumed from "restaurant with waiter/waitress"; and fast-food restaurants refer to food/beverages consumed from "restaurant fast food/pizza". a Percentages and CIs were estimated using survey weights to be nationally representative. b Poor die quality was defined as being less than 40% adherent (<32 points). Intermediate was defined as adherence of 40%-79.9% (32-63.9 points). Ideal was defined as 80% adherence or greater (≥64 points). Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. .08 Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. c Represents the ratio of family income to the federal poverty threshold, adjusting for household size. For reference, the federal threshold in 2016 for a family of 4 was $24,300/y. A family of 4 earning $33,534/y would have a ratio of 1.38. d Indicates a lower level of income. e Indicates a higher level of income.  4 (24.4-26.4) 26.7 (25.8-27.5) 25.2 (24. 3-26.2) 26. 6 (24.8-28.4) 26. 4 (25.3-27.6) 26.0 (24.7-27.2) 25. 3 (24.2-26.4) 25.0 (24.0-26.1)