Factors Associated with Sugar-Sweetened Beverage Intake Among Young Children - United States, 2021.

Introduction: Because limited data exist about factors related to sugar-sweetened beverage (SSB) intake among younger children, we investigated factors associated with SSB intake among US children aged 1 to 5 years. Methods: We examined SSB intake (0, 1-3, or ≥4 times/week) by using data from the 2021 National Survey of Children's Health. We performed a multinomial logistic regression to calculate adjusted odds ratios (aORs) for select sociodemographic and household factors associated with moderate (1-3 times/week) and high (≥4 times/week) SSB intake. Results: Overall, 36% of children consumed SSBs 1 to 3 times/week and 21% consumed 4 or more times/week. Both moderate and high SSB intake were associated with child's age, child's race and ethnicity, highest caregiver education level, household income, primary household language, and frequency of family meals. For example, children who lived in households with caregiver education level of high school graduate or less were significantly more likely to have moderate (aOR, 2.06) and high (aOR, 2.81) SSB intake than those who lived in households with caregiver education level of college degree or higher. High SSB intake was also associated with marginal household food sufficiency, nonmetropolitan statistical area status, and receipt of government food benefits. Conclusion: Several sociodemographic and household factors were significantly associated with SSB intake among children aged 1 to 5 years. Public health initiatives designed to address SSB intake among young children in various settings including pediatric health care, early care and education, and the child's home could consider key associated factors.

Factors Associated with Daily Fruit and Vegetable Intakes among Children Aged 1-5 Years in the United States.

To describe child, caregiver, and household characteristics associated with fruit and vegetable intakes among US children aged 1-5 years, we examined fruit and vegetable intakes (less than daily vs. daily) using data from the 2021 National Survey of Children's Health among children aged 1-5 years. Multiple logistic regression provided adjusted odds ratios for factors associated with (1) daily fruit and (2) daily vegetable intakes. Among children aged 1-5 years, 68% (n = 11,124) consumed fruit daily, and 51% (n = 8292) consumed vegetables daily. Both daily fruit and daily vegetable intake were associated with child age, child race and ethnicity, and frequency of family meals. For example, children who ate a family meal 4-6 days/week (aOR 0.69; 95% CI 0.57, 0.83) or 0-3 days/week (aOR 0.57; 95% CI 0.46, 0.72) were less likely to consume fruit daily compared to children who had a family meal every day. Participation in food assistance programs, food insufficiency, and household income were not significantly associated with odds of daily fruit or daily vegetable intake in the adjusted models. Several factors were associated with daily fruit and vegetable intake among children aged 1-5. Strategies aimed at increasing fruit and vegetable consumption in early childhood may consider these child, caregiver, and household characteristics. Pediatric healthcare providers, early childhood education centers, and families of young children may be important partners in this work.

Time Playing Outdoors Among Children Aged 3-5 Years: National Survey of Children's Health, 2021.

INTRODUCTION: Federal guidelines recommend physical activity throughout the day for preschool-aged children. Time playing outdoors can support physical activity participation, health, and development. Estimates of time playing outdoors among U.S. children aged 3-5 years have not been published. METHODS: Parent/caregiver-reported data on children aged 3-5 years from the 2021 National Survey of Children's Health were analyzed in 2022-23. Chi-square tests were used to identify differences in time playing outdoors by sociodemographic and neighborhood characteristics. Multiple logistic regression analyses were conducted with significant characteristics for weekdays and weekend days. RESULTS: Among 11,743 children aged 3-5 years, 37% played outdoors for ≤1 hour on weekdays, and 24% played outdoors for ≤1 hour on weekend days. In 9 states, ≥40% of children played outdoors for ≤1 hour on weekdays. Adjusted models for weekdays and weekend days showed a greater likelihood of ≤1 hour playing outdoors among those in all racial/ethnic groups compared to non-Hispanic White, those who lived in metropolitan statistical areas, those who did not participate in child care, and those whose adult proxy disagreed with "we watch out for each other's children in this neighborhood." The weekday model showed additional differences by sex, with girls more likely to have ≤1 hour of time playing outdoors. CONCLUSIONS: Nearly 40% of preschool-aged children play outdoors for ≤1 hour per day on weekdays, with differences by sociodemographic and neighborhood characteristics. Further study and interventions focused on building supportive, equitable communities might increase the amount of time preschool-aged children spend playing outdoors.

Disaggregation of Breastfeeding Initiation Rates by Race and Ethnicity - United States, 2020-2021.

Introduction: Although breastfeeding is the ideal source of nutrition for most infants, racial and ethnic disparities exist in its initiation. Surveillance rates based on aggregated data can challenge the understanding and monitoring of effective, culturally appropriate interventions among racial and ethnic subgroups. Aggregated data have historically estimated breastfeeding rates among a few large racial and ethnic groups. We examined differences in breastfeeding initiation rates by disaggregation of data to finer subgroups of race and ethnicity. Methods: We analyzed births from January 1, 2020, through December 31, 2021, in 48 states and the District of Columbia by using National Vital Statistics System birth certificate data. Data indicate whether an infant received any breast milk during birth hospitalization and include self-reported maternal race and ethnicity. Cross-tabulations of race and ethnicity by breastfeeding initiation were calculated and compared across aggregated and disaggregated categories. Results: The overall prevalence of breastfeeding initiation was 84.0%, ranging from 74.5% (mothers identifying as Black) to 94.0% (mothers identifying as Japanese). The aggregated prevalence of breastfeeding initiation among mothers identifying as Hispanic was 86.8%; disaggregated estimates by Hispanic origin ranged from 82.2% (Puerto Rican) to 90.9% (Cuban). Conclusion: Substantial variation in the prevalence of breastfeeding initiation across disaggregated racial or ethnic categories exists. Disaggregation of racial and ethnic data unmasked differences that could reflect variations in cultural practices or systemic barriers to breastfeeding. Understanding why these differences exist could guide public health practitioners' efforts to improve and tailor breastfeeding support.

Early introduction of complementary foods/drinks and milk feeding type in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

Infants younger than 4 months are not ready for complementary foods/drinks (any solid or liquid other than breast milk or infant formula). Almost half of US infants participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which provides nutrition education and support to low-income families. We describe the prevalence of early introduction (<4 months) of complementary foods/drinks and examine the association of milk feeding type (fully breastfed, partially breastfed or fully formula fed) with early introduction of complementary foods/drinks. We used data from 3310 families in the longitudinal WIC Infant and Toddler Feeding Practices Study-2. We described the prevalence of early introduction of complementary foods/drinks and modeled the association of milk feeding type at Month 1 with early introduction of complementary foods/drinks using multi-variable logistic regression. Thirty-eight percent of infants were introduced early to complementary foods/drinks (<4 months). In adjusted models, infants who were fully formula fed or partially breastfed at Month 1 were 75% and 57%, respectively, more likely to be introduced early to complementary foods/drinks compared with fully breastfed infants. Almost two in five infants were given complementary foods/drinks early. Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks. There are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health.

Timing of Introduction of Complementary Foods - United States, 2016-2018.

The American Academy of Pediatrics (AAP) recommends introducing complementary foods (i.e., any solid or liquid other than breast milk or infant formula) to infants at approximately age 6 months (1). Although a consensus on ideal timing is lacking, most experts agree that introduction of complementary foods before age 4 months is too early because of infant gastrointestinal and motor immaturity (1,2). In addition, early introduction prevents exclusively breastfed infants from reaching the recommended 6 months of exclusive breastfeeding (1) and might be associated with increased risk for overweight and obesity (3). Nationally representative data on complementary feeding are limited; state-level estimates have been previously unavailable. CDC analyzed 2016-2018 data from the National Survey of Children's Health (NSCH) (N = 23,743) to describe timing of complementary feeding introduction and prevalence of early introduction of complementary foods before age 4 months (early introduction) among children aged 1-5 years. Prevalence of early introduction was 15.6% nationally and varied geographically and across sociodemographic and infant feeding characteristics. These estimates suggest that approximately one in six infants are introduced to complementary foods before they are developmentally ready. Efforts by health care providers and others who might influence infant feeding practices could help decrease the number of infants who are introduced to complementary foods too early.

Meeting the Healthy People 2030 Added Sugars Target.

INTRODUCTION: Many Americans exceed the dietary recommendations for added sugars. Healthy People 2030 set a population target mean of 11.5% calories from added sugars for persons aged ≥2 years. This paper describes the reductions needed in population groups with varying added sugars intake to meet this target using four different public health approaches. METHODS: Data from the 2015-2018 National Health and Nutrition Examination Survey (n=15,038) and the National Cancer Institute method were used to estimate the usual percentage calories from added sugars. Four approaches investigated lowering intake among (1) the general U.S. population, (2) people exceeding the 2020-2025 Dietary Guidelines for Americans recommendation for added sugars (≥10% calories/day), (3) high consumers of added sugars (≥15% calories/day), or (4) people exceeding the Dietary Guidelines for Americans recommendation for added sugars with two different reductions on the basis of added sugars intake. Added sugars intake was examined before and after reduction by sociodemographic characteristics. RESULTS: To meet the Healthy People 2030 target using the 4 approaches, added sugars intake needs to decrease by an average of (1) 13.7 calories/day for the general population; (2) 22.0 calories/day for people exceeding the Dietary Guidelines for Americans recommendation; (3) 56.6 calories/day for high consumers; or (4) 13.9 and 32.3 calories/day for people consuming 10 to <15% and ≥15% calories from added sugars, respectively. Differences in added sugars intake were observed before and after reduction by race/ethnicity, age, and income. CONCLUSIONS: The Healthy People 2030 added sugars target is achievable with modest reductions in added sugars intake, ranging from 14 to 57 calories/day depending on the approach.

Fruit, Vegetable, and Sugar-Sweetened Beverage Intake Among Young Children, by State - United States, 2021.

Good nutrition in early childhood supports optimal growth, development, and health (1). Federal guidelines support a dietary pattern with daily fruit and vegetable consumption and limited added sugars, including limited consumption of sugar-sweetened beverages (1). Government-published dietary intake estimates for young children are outdated at the national level and unavailable at the state level. CDC analyzed data from the 2021 National Survey of Children's Health (NSCH)* to describe how frequently, according to parent report, children aged 1-5 years (18,386) consumed fruits, vegetables, and sugar-sweetened beverages, nationally and by state. During the preceding week, approximately one in three (32.1%) children did not eat a daily fruit, nearly one half (49.1%) did not eat a daily vegetable, and more than one half (57.1%) drank a sugar-sweetened beverage at least once. Estimates of consumption varied by state. In 20 states, more than one half of children did not eat a vegetable daily during the preceding week. In Vermont, 30.4% of children did not eat a daily vegetable during the preceding week, compared with 64.3% in Louisiana. In 40 states and the District of Columbia, more than one half of children drank a sugar-sweetened beverage at least once during the preceding week. The percentage of children drinking sugar-sweetened beverages at least once during the preceding week ranged from 38.6% in Maine to 79.3% in Mississippi. Many young children are not consuming fruits and vegetables daily and are regularly consuming sugar-sweetened beverages. Federal nutrition programs and state policies and programs can support improvements in diet quality by increasing access to and availability of fruits and vegetables and healthy beverages in places where young children live, learn, and play.

High Added Sugars Intake among US Adults: Characteristics, Eating Occasions, and Top Sources, 2015-2018.

The 2020−2025 Dietary Guidelines for Americans (DGA) recommends less than 10% of total daily calories come from added sugars. However, many adults overconsume added sugars putting them at risk for poor health outcomes. We examined characteristics of high added sugars consumers among US adults (≥20 years) and described their top 10 sources of added sugars intake using National Health and Nutrition Examination Survey 2015−2018 data (n = 9647). We defined high consumers as consuming >15% of daily calories from added sugars (1.5 times higher than the DGA). We used the National Cancer Institute method to estimate usual intake of energy and percent of calories from added sugars. Top 10 sources were identified based on their percentage contribution to total added sugars intake on a given day. T-tests were used to examine differences by age, sex, race/ethnicity, education, income, marital status, and weight status. Overall, mean usual total energy intake and added sugars intake was 2068 kcal/day and 264 kcal/day, respectively, and 30% of adults were classified as high consumers. The prevalence of high added sugars consumers was significantly higher among 20−30-year-olds (29%), 31−50-year-olds (33%), and 51−70-year-olds (29%) than those aged ≥70 years (22%); non-Hispanic Black (39%) and non-Hispanic White (31%) adults than Hispanics (26%); adults with

Children and Adolescents in the United States with Usual High Added Sugars Intake: Characteristics, Eating Occasions, and Top Sources, 2015-2018.

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 <10% of total daily calorie intake). Explanatory measures were selected sociodemographics (e.g., age, sex, race/ethnicity). Eating occasions were breakfast, lunch, dinner, and snack. Statistical analyses performed: We used t-tests to compare mean differences between sociodemographic groups. Results: Overall, 34% of US youths were classified as high consumers of added sugars. The prevalence of high consumers of added sugars significantly varied by some sociodemographics (i.e., age, race/ethnicity, and head of household's education level). The prevalence of high added sugars consumers was significantly greater among 12−19-year-olds (41%) and 6−11-year-olds (37%) compared to 2−5-year-olds (19%), non-Hispanic Black (42%) and non-Hispanic White (42%) persons compared to Hispanic persons (19%), and those with a head of household's education level of high school/some college (40%) compared to households with college degree or higher (29%). The prevalence of high consumers did not differ by sex, income, or weight status. Of eating occasions, the amount of added sugars youths consumed was highest during snack occasions among high consumers. Top five sources of added sugars among high consumers on a given day were sweetened beverages, sweet bakery products, candy, other desserts, and ready-to-eat cereals. Conclusion: One in three US youths consumed more than 15% of total calories from added sugars. High added sugars intake was more prevalent among certain subgroups such as 12−19-year-olds and non-Hispanic Black or non-Hispanic White youth. Our findings can provide information for intervention efforts to decrease added sugars intake to promote child health.

Human milk expression in the first year postpartum among persons with low incomes.

BACKGROUND: Expressing milk (i.e., human milk) is common in the USA, but practices are unknown among families in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This study of a WIC population explores the practice of and reasons for expressing milk in the first year postpartum. METHODS: We analysed data from a longitudinal study to examine milk expression at 1, 3, 5, 7, 9, 11, and 13 months postpartum among breastfeeding persons enrolled in WIC with term singletons. We cross-sectionally analysed the weighted prevalence of milk expression at each survey month and report reasons for milk expression in the first 7 months. RESULTS: Among the study participants who reported feeding human milk at Month 1, 70.4% expressed milk in the first 13 months postpartum. The prevalence of milk expression was 56.8% at Month 1 and decreased to 13.9% at Month 13 among those feeding any human milk that month. Reasons for expressing milk changed over time; in the first month, increasing milk supply, relieving engorgement, and having an emergency supply of milk were common. In later months, having a supply of milk available so that someone else could feed their infant was common. CONCLUSIONS: Clinicians, health educators, WIC staff, and others working with WIC families can promote optimal expressed milk feeding and storage practices. Extra attention and support may be especially important in the first months postpartum when milk expression is common. Support for persons who are expressing milk can be tailored for reasons of milk expression.

Patterns in Mothers' Recollection of Health Care Providers' Young Child Feeding Recommendations.

OBJECTIVE: Characterize feeding guidance mothers recall receiving from their child's health care provider (HCP). DESIGN: Cross-sectional study of mothers participating in the 2017-2019 National Survey of Family Growth. PARTICIPANTS: US mothers reporting (n = 1,302) information about their youngest child (aged 6 months to 5 years). VARIABLES MEASURED: Weighted percentage of mothers who recalled their child's HCP discussing 6 different feeding topics by demographic characteristics. ANALYSIS: Logistic regression assessing the relationship between recall of feeding guidance and demographics. RESULTS: In this sample, 36.9% of mothers (95% confidence interval, 32.3-41.4) recalled HCPs recommending solid food before 6 months old (34.6% at 4-5 months, and 2.3% before 4 months). Mothers who were older or had a higher education level were more likely than their counterparts to recall their HCP discussing several of the feeding topics examined. CONCLUSION AND IMPLICATIONS: Mothers reported high recollection of early childhood nutrition guidance from their HCP; however, certain topics (eg, appropriate timing of solid food introduction) could be prioritized, and some subpopulations may need additional focus to improve receipt of messages. A better understanding of variability in recall of feeding guidance could provide information for interventions to address barriers to receiving and retaining guidance.

Iron Deficiency in the United States: Limitations in Guidelines, Data, and Monitoring of Disparities.

Iron deficiency and the more severe sequela, iron deficiency anemia, are public health problems associated with morbidity and mortality, particularly among pregnant women and younger children. The 1998 Centers for Disease Control and Prevention recommendations for prevention and control of iron deficiency in the United States is old and does not reflect recent evidence but is a foundational reference for many federal, clinical, and program guidelines. Surveillance data for iron deficiency are sparse at all levels, with critical gaps for pregnant women and younger children. Anemia, iron deficiency, and iron deficiency anemia are often conflated but should not be. Clinical guidelines for anemia, iron deficiency, and iron deficiency anemia give inconsistent recommendations, causing nonsystematic assessment of iron deficiency. Screening for iron deficiency typically relies on identifying anemia, despite anemia's low sensitivity for iron deficiency. In the National Health and Nutrition Examination Survey, more than 70% of iron deficiency is missed among pregnant women and children by relying on hemoglobin for iron deficiency screening. To improve assessment and diagnosis and strengthen surveillance, better and more complete data and updated foundational guidance on iron deficiency and anemia are needed that consider new evidence for measuring and interpreting laboratory results. (Am J Public Health. 2022;112(S8):S826-S835. https://doi.org/10.2105/AJPH.2022.306998).

Improving Nutrition in the First 1000 Days in the United States: A Federal Perspective.

The first 1000 days begins with pregnancy and ends at the child's second birthday. Nutrition throughout the life course, and especially during the first 1000 days, supports maternal health and optimal growth and development for children. We give a high-level summary of the state of nutrition in the first 1000 days in the United States. We provide examples where continued efforts are needed. We then discuss select opportunities to strengthen federal research and surveillance, programs, and communication and dissemination efforts aimed at improving nutrition and positively, and equitably, influencing the health and well-being of mothers and children. (Am J Public Health. 2022;112(S8):S817-S825. https://doi.org/10.2105/AJPH.2022.307028).

Anemia Among Pregnant Women Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children - United States, 2008-2018.

Among pregnant women, anemia, a condition of low hemoglobin concentration, can increase risk for maternal and fetal morbidity and mortality, including premature delivery, and other adverse outcomes (1). Iron deficiency is a common cause of anemia, and during pregnancy, iron requirements increase (2). Surveillance of anemia during pregnancy in the United States is limited. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participant and Program Characteristics (PC) data provide an opportunity to establish national and WIC state agency-level* anemia surveillance for WIC participants. National and state agency anemia prevalences among pregnant WIC participants at enrollment were examined using 2008-2018 WIC-PC data. Across all 90 WIC agencies (50 states, the District of Columbia [DC], five territories, and 34 Indian Tribal Organizations), anemia prevalence among pregnant WIC participants at enrollment increased significantly, from 10.1% in 2008 to 11.4% in 2018 (13% increase). Anemia prevalence increased significantly in 36 (64%) of the 56 agencies in states, DC, and territories, and decreased significantly in 11 (20%). Prevalence of anemia overall and by pregnancy trimester were higher among non-Hispanic Black or African American (Black) women than among other racial or ethnic groups. Anemia prevalence was higher among women assessed during the third trimester of pregnancy than among those assessed during first or second trimesters. Routine anemia surveillance using WIC enrollment anemia data can identify groups at higher risk for iron deficiency. Findings from this report indicate that anemia continues to be a problem among low-income women and reinforces the importance of efforts that ensure these women have access to healthier, iron-rich foods before and during pregnancy. This includes ensuring that eligible women are enrolled in WIC early during pregnancy.

Maternity Care Practices and Breastfeeding Intentions at One Month Among Low-Income Women.

BACKGROUND: Maternity care practices have been linked with higher chances of meeting breastfeeding intentions, but this relationship has not been examined using national data on US low-income women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: Using data from the WIC Infant and Toddler Feeding Practices Study-2 on 1080 women who intended to breastfeed, we estimated risk ratios for associations between (1) each of 6 maternity care practices supportive of breastfeeding (breastfeeding within 1 hour of birth, showing mothers how to breastfeed, giving only breast milk, rooming-in, breastfeeding on demand, no pacifiers), (2) each practice adjusted for all other practices, and (3) total number of practices experienced with whether women met their intention to feed only breast milk at 1 month old. Models were adjusted for demographics. RESULTS: In adjusted models (1), breastfeeding within 1 hour of birth, giving only breast milk, and no pacifiers were associated with higher likelihood of meeting prenatal breastfeeding intentions. Adjusting for all other practices (2), initiating breastfeeding within 1 hour of birth (risk ratio: 1.3; 95% confidence interval: 1.0-1.6) and giving only breast milk (risk ratio: 4.4; 95% confidence interval: 3.4-5.7) remained associated with meeting breastfeeding intention. There was a dose-response relationship between number of steps experienced and higher likelihood of meeting prenatal breastfeeding intentions (3). CONCLUSIONS: Women who experienced maternity care practices supportive of breastfeeding were more likely to meet their prenatal breastfeeding intentions, underscoring the importance of breastfeeding support during the birth hospitalization in enabling mothers to achieve their breastfeeding goals.

Food Preparation Practices for Infants Aged From 7 to 13 Months.

OBJECTIVE: To examine infant food preparation practices at age 7, 9, 11, and 13 months overall and by sociodemographic characteristics. DESIGN: Data from a longitudinal study from the US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infant and Toddler Feeding Practices Study-2 (ITFPS-2) were used. PARTICIPANTS: A sample of 1,904 infants (970 males and 934 females) enrolled in WIC who had been introduced to solid foods and were consuming food prepared at home. MAIN OUTCOME MEASURES: Food preparation practices included pureeing, mashing, chopping/dicing, and prechewing. Estimates were provided overall and by sociodemographics. ANALYSIS: Prevalence estimates were calculated for each survey month overall and by sociodemographics. Chi-square tests for independence were used to test for differences. RESULTS: Food preparation practices changed as infants aged. Pureeing and mashing were common in month 7 (57.8% and 59.6%, respectively), but chopping/dicing were the most prevalent by month 13 (85.4%). Food preparation practices did not vary by education status, but statistical differences were consistently observed by race and ethnicity and inconsistently observed by maternal age at birth. CONCLUSIONS AND IMPLICATIONS: Exposing children to a range of food textures at an appropriate age is important for developmental progress. Continued culturally relevant efforts by WIC educators and health care providers can emphasize the importance of early experiences with food textures.