Cindy W. Leung

Trends in Dietary Quality Among Adults in the United States, 1999 Through 2010

IMPORTANCE Many changes in the economy, policies related to nutrition, and food processing have occurred within the United States since 2000, and the net effect on dietary quality is not clear. These changes may have affected various socioeconomic groups differentially. OBJECTIVE To investigate trends in dietary quality from 1999 to 2010 in the US adult population and within socioeconomic subgroups. DESIGN, SETTING, AND PARTICIPANTS Nationally representative sample of 29 124 adults aged 20 to 85 years from the US 1999 to 2010 National Health and Nutrition Examination Survey. MAIN OUTCOMES AND MEASURES The Alternate Healthy Eating Index 2010 (AHEI-2010), an 11-dimension score (range, 0-10 for each component score and 0-110 for the total score), was used to measure dietary quality. A higher AHEI-2010 score indicated a more healthful diet. RESULTS The energy-adjusted mean of the AHEI-2010 increased from 39.9 in 1999 to 2000 to 46.8 in 2009 to 2010 (linear trend P < .001). Reduction in trans fat intake accounted for more than half of this improvement. The AHEI-2010 component score increased by 0.9 points for sugar-sweetened beverages and fruit juice (reflecting decreased consumption), 0.7 points for whole fruit, 0.5 points for whole grains, 0.5 points for polyunsaturated fatty acids, and 0.4 points for nuts and legumes over the 12-year period (all linear trend P < .001). Family income and education level were positively associated with total AHEI-2010, and the gap between low and high socioeconomic status widened over time, from 3.9 points in 1999 to 2000 to 7.8 points in 2009 to 2010 (interaction P = .01). CONCLUSIONS AND RELEVANCE Although a steady improvement in AHEI-2010 was observed across the 12-year period, the overall dietary quality remains poor. Better dietary quality was associated with higher socioeconomic status, and the gap widened with time. Future efforts to improve nutrition should address these disparities.

Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors

BACKGROUND The Supplemental Nutrition Assistance Program (SNAP) is the largest federal nutrition assistance program. In recent years, SNAP participation rates increased during times of economic hardship. OBJECTIVE We examined whether household SNAP participation was associated with adiposity and metabolic risk factors in a representative sample of low-income US adults. DESIGN A cross-sectional analysis was performed with the use of data from the 2003-2006 National Health and Nutrition Examination Surveys. The study population was restricted to nonelderly adults whose household incomes fell to or <130% of the federal poverty level. Multinomial logistic and Poisson regression models were fit to examine the associations between SNAP participation and BMI, waist circumference, and metabolic risk factors among 2250 low-income adults. RESULTS In the previous 12 mo, 32.8% of adults received household SNAP benefits. SNAP participation was positively associated with obesity [prevalence ratio (PR): 1.58; 95% CI: 1.08, 2.31], waist circumference in men (PR for top compared with bottom quartile: 2.04; 95% CI: 1.15, 3.62; P = 0.02), and waist circumference in women (PR: 2.95; 95% CI: 1.51, 5.77; P = 0.003; P-interaction with sex = 0.11), independent of sociodemographic characteristics. SNAP participation was also related to elevated triglycerides (PR: 1.71; 95% CI: 1.33, 2.20), lower HDL cholesterol (PR: 1.23; 95% CI: 1.08, 1.41), elevated fasting glucose (≥110 mg/dL; PR: 1.63; 95% CI: 1.05, 2.52), and metabolic syndrome (PR: 1.49; 95% CI: 1.13, 1.95). Associations with triglycerides and HDL cholesterol persisted after adjustment for BMI. CONCLUSION Household SNAP participation was positively associated with BMI, waist circumference, and metabolic risk factors among low-income adults. These associations may be mediated by dietary intake and warrant further investigation.

Household Food Insecurity Is Positively Associated with Depression among Low-Income Supplemental Nutrition Assistance Program Participants and Income-Eligible Nonparticipants

BACKGROUND Food insecurity is associated with adverse mental health outcomes. Given that federal food assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), aim to alleviate food insecurity, there may be heterogeneity in the association between food insecurity and depression by SNAP participation status. OBJECTIVE With the use of data from the 2005-2010 NHANES, we examined the associations between household food security and depression and whether these differed by SNAP participation. METHODS The study population was restricted to 3518 adults with household incomes ≤130% of the federal poverty level. Food insecurity was assessed with the 18-item US Household Food Security Survey Module; a score of ≥3 was considered food insecure. Depression was assessed with the 9-item Patient Health Questionnaire and was defined as a score of ≥10. Multivariate logistic regression models examined the associations between food insecurity and depression, adjusting for sociodemographic and health characteristics. RESULTS The overall prevalence of depression was 9.3%, ranging from 6.7% among SNAP nonparticipants to 12.8% among SNAP participants. For every depressive symptom, there was a dose-response relation, such that a higher prevalence was observed with worsening food insecurity. After multivariate adjustment, food insecurity was positively associated with depression (P-trend < 0.0001), but SNAP participation modified this relation (P-interaction = 0.03). Among low-income, eligible nonparticipants, very low food security was significantly associated with higher odds of depression (OR: 5.10; 95% CI: 3.09, 8.41). Among SNAP participants, very low food security was also associated with higher odds of depression but at a lower magnitude (OR: 2.21; 95% CI: 1.54, 3.17). CONCLUSION The complex relation between food insecurity and mental health may vary on the basis of SNAP participation status. Programmatic efforts to address the risk of depression among their beneficiaries may positively affect the mental health of low-income adults.

Associations of Food Stamp Participation With Dietary Quality and Obesity in Children

OBJECTIVE: To determine if obesity and dietary quality in low-income children differed by participation in the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program. METHODS: The study population included 5193 children aged 4 to 19 with household incomes ≤130% of the federal poverty level from the 1999–2008 NHANES. Diet was measured by using 24-hour recalls. RESULTS: Among low-income US children, 28% resided in households currently receiving SNAP benefits. After adjusting for sociodemographic differences, SNAP participation was not associated with a higher rate of childhood obesity (odds ratio = 1.11, 95% confidence interval [CI]: 0.71–1.74). Both SNAP participants and low-income nonparticipants were below national recommendations for whole grains, fruits, vegetables, fish, and potassium, while exceeding recommended limits for processed meat, sugar-sweetened beverages, saturated fat, and sodium. Zero percent of low-income children met at least 7 of 10 dietary recommendations. After multivariate adjustment, compared with nonparticipants, SNAP participants consumed 43% more sugar-sweetened beverages (95% CI: 8%–89%), 47% more high-fat dairy (95% CI: 7%, 101%), and 44% more processed meats (95% CI: 9%–91%), but 19% fewer nuts, seeds, and legumes (95% CI: –35% to 0%). In part due to these differences, intakes of calcium, iron, and folate were significantly higher among SNAP participants. Significant differences by SNAP participation were not evident in total energy, macronutrients, Healthy Eating Index 2005 scores, or Alternate Healthy Eating Index scores. CONCLUSIONS: The diets of low-income children are far from meeting national dietary recommendations. Policy changes should be considered to restructure SNAP to improve children’s health.

Is participation in food and income assistance programmes associated with obesity in California adults? Results from a state-wide survey

OBJECTIVE Public assistance programmes may increase risk of obesity among adults. The current study assessed whether participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program), Supplemental Security Income (SSI) or California Work Opportunities and Responsibilities to Kids (CalWorks) was associated with obesity, independent of socio-economic status and food insecurity. DESIGN A cross-sectional analysis of the 2007 Adult California Health Interview Survey. Outcome measures included BMI and obesity. Distribution of BMI and prevalence of obesity were compared by participation in each programme, using weighted linear and binomial regression models in which BMI or obesity was the outcome, respectively, and programme participation was the predictor. SETTING A population survey of various health measures. SUBJECTS Non-institutionalized adults (n 7741) whose household income was ≤130% of the federal poverty level. RESULTS The prevalence of obesity was 27.4%. After adjusting for sociodemographic characteristics, food insecurity and participation in other programmes, the prevalence of obesity was 30% higher in SNAP participants (95% CI 6%, 59%; P=0.01) than in non-participants. This association was more pronounced among men than women. SSI participation was related to an adjusted 50% higher prevalence of obesity (95% CI 27%, 77%; P<0.0001) compared with no participation. SNAP and SSI participants also reported higher soda consumption than non-participants of any programme. CalWorks participation was not associated with obesity after multivariable adjustment. CONCLUSIONS Participation in SNAP or SSI was associated with obesity independent of food insecurity or socio-economic status. The suggestion that these associations may be mediated by dietary quality warrants further investigation among low-income populations.

Soda and Cell Aging: Associations Between Sugar-Sweetened Beverage Consumption and Leukocyte Telomere Length in Healthy Adults From the National Health and Nutrition Examination Surveys

OBJECTIVES We tested whether leukocyte telomere length maintenance, which underlies healthy cellular aging, provides a link between sugar-sweetened beverage (SSB) consumption and the risk of cardiometabolic disease. METHODS We examined cross-sectional associations between the consumption of SSBs, diet soda, and fruit juice and telomere length in a nationally representative sample of healthy adults. The study population included 5309 US adults, aged 20 to 65 years, with no history of diabetes or cardiovascular disease, from the 1999 to 2002 National Health and Nutrition Examination Surveys. Leukocyte telomere length was assayed from DNA specimens. Diet was assessed using 24-hour dietary recalls. Associations were examined using multivariate linear regression for the outcome of log-transformed telomere length. RESULTS After adjustment for sociodemographic and health-related characteristics, sugar-sweetened soda consumption was associated with shorter telomeres (b = -0.010; 95% confidence interval [CI] = -0.020, -0.001; P = .04). Consumption of 100% fruit juice was marginally associated with longer telomeres (b = 0.016; 95% CI = -0.000, 0.033; P = .05). No significant associations were observed between consumption of diet sodas or noncarbonated SSBs and telomere length. CONCLUSIONS Regular consumption of sugar-sweetened sodas might influence metabolic disease development through accelerated cell aging.

A Qualitative Study of Diverse Experts' Views about Barriers and Strategies to Improve the Diets and Health of Supplemental Nutrition Assistance Program (SNAP) Beneficiaries

The Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program, currently serves 44.7 million Americans with a budget of

Public support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP)

75 billion in 2011. This study engaged leading experts for in-depth, semi-structured interviews to explore their opinions concerning the existing challenges and barriers to eating nutritiously in SNAP. Experts also proposed strategies for improving nutritional status among SNAP recipients. Twenty-seven individuals were interviewed from advocacy, government, industry, and research organizations. Interviews were recorded, transcribed, coded, and analyzed for thematic content. The high cost of nutrient-rich foods, inadequate SNAP benefits, limited access to purchasing healthy foods, and environmental factors associated with poverty were identified as barriers that influence nutrition among low-income households in the United States. Six themes emerged among respondents from diverse sectors about how to address these challenges, including providing SNAP participants with incentives to purchase nutrient-rich food consistent with the 2010 Dietary Guidelines for Americans, restricting the purchase of nutrient-poor foods and beverages with program benefits, modifying the frequency of SNAP benefit distribution, enhancing nutrition education, improving the SNAP retailer environment, and increasing state and federal level coordination and consistency of program implementation. Given the recent dramatic increase in SNAP enrollment, policymakers must address existing barriers as well as consider new strategies to improve nutrition policies in SNAP so that the program can continue to address food insecurity needs as well as provide a healthful diet for SNAP beneficiaries.

Very low food security predicts obesity predominantly in California Hispanic men and women

OBJECTIVE To determine public attitudes towards federal spending on nutrition assistance programmes and support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP). DESIGN Participants answered survey questions by telephone assessing support for SNAP spending and proposed programme policy changes. SETTING USA SUBJECTS Survey of 3024 adults selected by random digit dialling conducted in April 2012, including 418 SNAP participants. RESULTS A majority (77%; 95% CI 75, 79%) of all respondents supported maintaining or increasing SNAP benefits, with higher support among Democrats (88%; 95% CI 86, 90%) than Republicans (61%; 95% CI 58, 65%). The public supported policies to improve the nutritional impact of SNAP. Eighty-two per cent (95% CI 80, 84%) of respondents supported providing additional benefits to programme participants that can only be used on healthful foods. Sixty-nine per cent (95% CI 67, 71%) of respondents supported removing SNAP benefits for sugary drinks. A majority of SNAP participants (54%; 95% CI 48, 60%) supported removing SNAP benefits for sugary drinks. Of the 46% (95% CI 40, 52%) of SNAP participants who initially opposed removing sugary drinks, 45 % (95% CI 36, 54%) supported removing SNAP benefits for sugary drinks if the policy also included additional benefits to purchase healthful foods. CONCLUSIONS The US public broadly supports increasing or maintaining spending on SNAP. The majority of respondents, including SNAP participants, supported policies to improve the nutritional impact of SNAP by restricting the purchase of sugary drinks and incentivizing purchase of healthful foods with SNAP benefits.

Improving the Nutritional Impact of the Supplemental Nutrition Assistance Program:: Perspectives From the Participants.

OBJECTIVE A high prevalence of food insecurity has persisted in the USA for the past two decades. Previous studies suggest that the association between food insecurity and obesity may vary by gender and race/ethnicity. We examined whether food insecurity was associated with BMI and obesity within gender and racial/ethnic groups in a large, diverse sample of low-income adults. DESIGN A cross-sectional analysis of a large population-based health survey. We compared the distribution of BMI and obesity by food security levels within gender and racial/ethnic categories. SETTING Data were derived from the 2003-2009 waves of the California Health Interview Survey. SUBJECTS The study sample included 35 747 non-elderly adults with households ≤200 % of the federal poverty level. RESULTS Among Hispanic men, very low food security was associated with a 1.0 kg/m2 higher BMI (95 % CI 0.3, 1.7 kg/m2) and a 36 % higher prevalence of obesity (95 % CI 17, 58 %) after multivariate adjustment. Among Hispanic women, very low food security was associated with a 1.1 kg/m2 higher BMI (95 % CI 0.4, 1.9 kg/m2) and a 22 % higher prevalence of obesity (95 % CI 8, 38 %). Positive associations were also observed for Asian women and multi-racial men. No significant associations were observed for non-Hispanic whites, African Americans, Asian men or multi-racial women. CONCLUSIONS Our results suggest that the association of food insecurity and obesity is limited to individuals of certain low-income, minority racial/ethnic groups. Whether targeted interventions to address food insecurity in these individuals may also decrease obesity risk deserves further investigation.