Contribution of moderation foods to total energy intake by sociodemographic characteristics in U.S. adults: National Health and Nutrition Examination Survey, 2017 – 2020

Background U.S. adults exceed recommended intakes of multiple nutrients of concern

This study uses a recently-developed food-level classification method for identifying foods exceeding thresholds for nutrients of concern to investigate sociodemographic differences in their contribution to total energy intake among U.S. adults. Design Cross-sectional. Participants/setting Participants 20 – 80 years of age in the 2017–2020 National Health and Nutrition Examination Survey (n=7706). Main outcome measures Data from 24-hour dietary recalls were used to identify “moderation foods” meeting at least one threshold for high content of nutrients of concern: added sugar >20% energy, sodium >460mg per serving, refined grains >50% of total grains or >10:1 ratio of carbohydrate to fiber content, saturated fat >20% energy, total fat >9% by weight (applied only to vegetables, sweets, and snacks), and all alcoholic beverages. The percentage of energy intake from moderation foods in total and from foods meeting each of the moderation food thresholds were calculated and compared across age, education, income-to-poverty ratio (IPR), and race/ethnicity. Statistical analyses performed Linear regression models with multiplicative interaction terms tested whether race/ethnicity or education modified relationships of IPR with moderation food intake.

Moderation foods contributed 76% (95%CI:75%-77%) of energy intake overall. Intake was higher in younger adults (mean=79%) versus older (72%-75%) adults, males (77%) versus females (74%), and adults in the lowest (79%) vs. highest (74%) income quartile. Moderation food intake was lowest in Non-Hispanic Asian adults (66%) and among adults with the highest education (mean=71%). Foods meeting thresholds for sodium, refined grains, and fat contributed the most to overall energy intake. Foods meeting thresholds for added sugar, sodium, and refined grains contributed a smaller share of energy intake in non-Hispanic Asians versus other racial/ethnic groups and in older versus younger adults. Income was inversely associated with moderation food intake only among high school graduates (second highest education group; β = - 1.1 95%CI = -2.1 to -0.2) and modestly inversely associated with moderation food intake in all race/ethnic groups except Mexican Americans/Other Hispanic adults.

High intake of moderation foods across all subgroups of U.S. adults, with only modest between-group differences in the contributions of different categories of moderation foods, suggest a need for population-wide changes in food selection to align with dietary guidelines. In particular, interventions and policies to assist in identifying foods high in sodium, refined grains, and fat may help consumers improve food choices. Competing Interest Statement The authors have declared no competing interest. Funding Statement This work was funded in part by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The funder had no involvement or restrictions regarding publication. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study used ONLY openly available human data that were originally located at https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/default.aspx?Cycle=2017-2020 I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes Funding: This work was funded in part by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The funder had no involvement or restrictions regarding publication. revised to address concerns raised by editors about unclear impact. added analyses of the contribution of individual types of moderation foods to overall energy intake. Data Availability All data are available online at: https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/default.aspx?Cycle=2017-2020 https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/default.aspx?Cycle=2017-2020 Abbreviations - HEI - Healthy Eating Index - IPR - Income-Poverty Eatio - NHANES - National Health and Nutrition Examination Survey - NCHS - National Center for Health Statistics