Workshop summary: building an NHANES for the future.

The American Society for Nutrition's (ASN) Committee on Advocacy and Science Policy (CASP) organized a workshop, "Building a National Health and Nutrition Examination Survey (NHANES) for the Future," held during NUTRITION 2023, which took place in Boston, MA in July 2023. CASP had already identified an urgent need for increased support and modernization to ensure that a secure future for NHANES is achievable. The survey faces challenges associated with data collection, stagnant funding, and a need for more granular data for subpopulations and groups at risk. The workshop provided an overview of NHANES, including the nutrition component, and the many other uses for the survey's data, which extend beyond nutrition. Speakers highlighted NHANES's current and emerging challenges, as well as possible solutions to address these challenges, especially with regard to response rates of underrepresented groups, linkage of survey data to other resources, incorporation of new survey methodologies, and emerging data needs. The workshop also included a "Town Hall" component to gather additional feedback on NHANES' challenges and proposed solutions from audience members. The workshop provided many possible action items that ASN will explore and use to inform effective continued advocacy in support of NHANES and to find possible opportunities for ASN and others to partner with the Centers for Disease Control and Prevention National Center for Health Statistics to strengthen this vital survey and maintain its robust and relevant data moving forward.

UK Chickpea Consumption Doubled from 2008/09-2018/19.

Background: Only 9% of individuals in the United Kingdom (UK) meet the recommendation for dietary fibre intake. Little is known about chickpea consumption in the UK. Methods: Chickpea intake trends and sociodemographic patterns were analysed using the National Diet and Nutrition Survey Rolling Programme data collected from 2008/09 to 2018/19 among 15,655 individuals ≥1.5 years completing a four-day food diary. Chickpea consumers were identified based on a list of chickpea-containing foods, with the most consumed foods being hummus, boiled chickpeas, chickpea flour, and low/reduced-fat hummus. Micronutrient and food group intakes were compared between chickpea consumers and non-consumers; the Modified Healthy Dietary Score was also assessed, which measures adherence to UK dietary recommendations. Results: Chickpea consumption increased from 6.1% (2008-2012) to 12.3% (2016-2019). Among 1.5-3 years, consumption increased from 5.7% to 13.4%, and among 19-64 years, consumption increased from 7.1% to 14.4%. The percentage of individuals eating chickpeas was higher among individuals with higher incomes and more education. Healthy-weight adults were more likely to consume chickpeas compared to those who were overweight or obese. Compared to both bean and non-bean consumers, chickpea consumers ate significantly more dietary fibre, fruits and vegetables, pulses, nuts, and less red meat and processed meat products. Chickpea consumers also had a higher Modified Healthy Dietary Score. Conclusions: In the UK, chickpea consumption more than doubled from 2008/09 to 2018/19. Chickpea consumers had a higher diet quality than non-consumers.

South African Consumers' Knowledge, Opinions and Awareness of Whole Grains and Their Health Benefits: A Cross-Sectional Online Survey.

Evidence indicates that whole-grain food consumption reduces the risk of cardiovascular disease, type-2 diabetes, and some cancers. Increasing whole-grain consumption in developing countries is likely to significantly benefit the health of the population. However, there is very limited information on consumer whole-grain knowledge, attitudes, and behaviors in developing countries. An online cross-sectional survey was conducted among 1000 South African consumers with sufficient income to make food purchase choices and who were generally representative in terms of gender, age, and ethnicity. Most respondents (64%) were confident of their whole-grain knowledge. However, 60% of all participants selected incorrect definitions of whole grains. Whilst most correctly identified common cereals as whole grains, at most 50% of participants correctly identified common whole-grain foods. Also, whilst most (67%) thought that they were consuming enough whole grains, the majority (62%) underestimated the recommended level of consumption. Furthermore, respondent knowledge regarding whole-grain food attributes and the health benefits of whole-grain consumption was generally poor. Clearly, consumer-focused strategies are needed in developing countries to increase whole-grain food consumption to help the broader population achieve a healthy and sustainable diet. Actions proposed include: simple-to-understand information on whole-grain content relative to recommendations on food product labels, the provision of whole-grain foods in school nutrition schemes, and coordinated social and behavior change communication initiatives.

Trends and Patterns of Chickpea Consumption among United States Adults: Analyses of National Health and Nutrition Examination Survey Data.

BACKGROUND: Chickpeas are an affordable and nutrient-dense legume, but there is limited United States data on consumption patterns and the relationship between chickpea consumption and dietary intakes. OBJECTIVES: This study examined trends and sociodemographic patterns among chickpea consumers and the relationship between chickpea consumption and dietary intake. METHODS: Adults consuming chickpeas or chickpea-containing foods on 1 or both of the 24-h dietary recalls were categorized as chickpea consumers. Data from NHANES 2003-2018 were used to evaluate trends and sociodemographic patterns in chickpea consumption (n = 35,029). The association between chickpea consumption and dietary intakes was compared to other legume consumers and nonlegume consumers from 2015-2018 (n = 8,342). RESULTS: The proportion of chickpea consumers increased from 1.9% in 2003-2006 to 4.5% in 2015-2018 (P value for trend < 0.001). This trend was consistent across age group, sex, race/ethnicity, education, and income. In 2015-2018, chickpea consumption was highest among individuals with higher incomes (2.4% among those with incomes <185% of the federal poverty guideline compared with 6.4% with incomes ≥300%), education levels (1.0% for less than high school compared with 10.2% for college graduates), physical activity levels (1.9% for no physical activity compared with 7.7% for ≥430 min of moderate-equivalent physical activity per week), and those with better self-reported health (1.7% fair/poor compared with 6.5% for excellent/very good, P-trend < 0.001 for each). Chickpea consumers had greater intakes of whole grains (1.48 oz/d for chickpea consumers compared with 0.91 for nonlegume consumers) and nuts/seeds (1.47 compared with 0.72 oz/d), less intake of red meat (0.96 compared with 1.55 oz/d), and higher Healthy Eating Index scores (62.1 compared with 51.2) compared with both nonlegume and other legume consumers (P value < 0.05 for each). CONCLUSIONS: Chickpea consumption among United States adults has doubled between 2003 and 2018, yet intake remains low. Chickpea consumers have higher socioeconomic status and better health status, and their overall diets are more consistent with a healthy dietary pattern.

Vitamin D status of the Russian adult population from 2013 to 2018.

Vitamin D deficiency is widespread globally, however available data for the Russian adult population is fragmented. This cross-sectional study used secondary data for individuals undergoing testing for vitamin D concentrations from 2013 to 2018 by InVitro laboratory. 25(OH)D serum concentration was determined using chemiluminescent microparticle immunoassay. The mean, median, and proportion with severe, deficient, insufficient and sufficient 25-hydroxyvitamin D (25(OH)D) concentrations were estimated. Splines examined the effect of latitude on 25(OH)D concentrations. Data were available for 30,040 subjects age ≥ 18 years. 24.2% of the sampled population had sufficient (30-< 150 25(OH)D ng/mL), 34% deficient (10-19.9 ng/mL) and 5.6% severely deficient (< 10 ng/mL) status. Average 25(OH)D concentrations were highest among 30-44 years and lowest amongst older adults; females had modestly higher values. Concentrations were 15% higher in fall/summer vs. winter/spring. A non-linear relationship was observed by latitude; the highest 25(OH)D concentrations were observed near 54°N, decreasing at more southern latitudes for women and more northern latitudes for both sexes. These results are comparable to other Northern European publications and limited Russian samples demonstrating low concentrations. Acknowledging that nationally-representative and randomly sampled data are needed, the present data suggest the burden may be high and identifies some population sub-groups and geographic areas with a higher potential deficiency of vitamin D.

Potential for Front of Pack Labeling Exposure to Impact US Dietary Choices: A Population-Based Cross-Sectional Study Using NHANES 2017-2018.

In recent years, front-of-pack nutrition labeling (FOPL) schemes have proliferated, but the components of the diet subject to FOPL have not been described. This study quantified the proportion and elements of the diet that would be subject to FOPL in the US. The 2017-2018 National Health and Nutrition Examination Survey (n = 7121; age ≥2 year) 24-h dietary recalls were used to identify foods/beverages subject to FOPL. The proportion of dietary energy and additional dietary constituents subject to FOPL was estimated. Overall, 57% of dietary energy would be subject to FOPL. Individuals consuming more away-from-home meals had lower exposure to FOPL. Adults with a healthy-weight and those consuming a more healthful diet had more exposure to FOPL. Protein, sodium, potassium, whole fruit, vegetables, and unprocessed meats were less subject to FOPL as compared to total sugars, added sugars, calcium, fruit juice, milk, yogurt, nuts/seeds and whole grains. Because less than 60% of the diet would be impacted by FOPL, implementation of such a policy may have limited reach for the US diet and demonstrates some inconsistencies with current dietary guidance regarding the under- and over-representation of key food groups and nutrients.

Balanced Hybrid Nutrient Density Score Compared to Nutri-Score and Health Star Rating Using Receiver Operating Characteristic Curve Analyses.

Background: Nutrient profiling (NP) models that are used to assess the nutrient density of foods can be based on a combination of key nutrients and desirable food groups. Objective: To compare the diagnostic accuracy of a new balanced hybrid nutrient density score (bHNDS) to Nutri-Score and Health Star Rating (HSR) front-of-pack systems using receiver operating characteristic (ROC) curve analyses. The diet-level bHNDS was first validated against Healthy Eating Index (HEI-2015) using data from the 2017-18 National Health and Nutrition Examination Survey (2017-18 NHANES). Food-level bHNDS values were then compared to both the Nutri-Score and HSR using ROC curve analyses. Results: The bHNDS was based on 6 nutrients to encourage (protein, fiber, calcium, iron, potassium, and vitamin D); 5 food groups to encourage (whole grains, nuts and seeds, dairy, vegetables, and fruit), and 3 nutrients (saturated fat, added sugar, and sodium) to limit. The algorithm balanced components to encourage against those to limit. Diet-level bHNDS values correlated well with HEI-2015 (r = 0.67; p < 0.001). Food-level correlations with both Nutri-Score (r = 0.60) and with HSR (r = 0.58) were significant (both p < 0.001). ROC estimates of the Area Under the Curve (AUC) showed high agreement between bHNDS values and optimal Nutri-Score and HSR ratings (>0.90 in most cases). ROC analysis identified those bHNDS cut-off points that were predictive of A-grade Nutri-Score or 5-star HSR. Those cut-off points were highly category-specific. Conclusion: The new bHNDS model showed high agreement with two front-of-pack labeling systems. Cross-model comparisons based on ROC curve analyses are the first step toward harmonization of proliferating NP methods that aim to "diagnose" high nutrient-density foods.

Corrigendum: Estimated Sweetness in US Diet Among Children and Adults Declined From 2001 to 2018: A Serial Cross-Sectional Surveillance Study Using NHANES 2001-2018.

[This corrects the article DOI: 10.3389/fnut.2021.777857.].

The association between social needs and chronic conditions in a large, urban primary care population.

There is consensus that social needs influence health outcomes, but less is known about the relationships between certain needs and chronic health conditions in large, diverse populations. This study sought to understand the association between social needs and specific chronic conditions using social needs screening and clinical data from Electronic Health Records. Between April 2018-December 2019, 33,550 adult (≥18y) patients completed a 10-item social needs screener during primary care visits in Bronx and Westchester counties, NY. Generalized linear models were used to estimate prevalence ratios for eight outcomes by number and type of needs with analyses completed in Summer 2020. There was a positive, cumulative association between social needs and each of the outcomes. The relationship was strongest for elevated PHQ-2, depression, alcohol/drug use disorder, and smoking. Those with ≥3 social needs were 3.90 times more likely to have an elevated PHQ-2 than those without needs (95% CI: 3.66, 4.16). Challenges with healthcare transportation was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. For example, those with transportation needs were 84% more likely to have an alcohol/drug use disorder diagnosis (95% CI: 1.59, 2.13) and 41% more likely to smoke (95% CI: 1.25, 1.58). Specific social needs may influence clinical issues in distinct ways. These findings suggest that health systems need to develop strategies that address unmet social need in order to optimize health outcomes, particularly in communities with a dual burden of poverty and chronic disease.

Impact of sociodemographic factors on the consumption of tubers in Brazil.

BACKGROUND: Although tubers play a significant role in Brazilian agriculture, very little is known about the intake of tubers among the Brazilian population. The objective of this study was to characterize the intake of tubers across Brazil. The types of tubers consumed were quantified, and the impact of geographic and sociodemographic factors was assessed. METHODS: This cross-sectional study is based on dietary intake data of 33,504 subjects obtained from the Brazilian National Dietary Survey. All tuber containing foods were identified, and the contribution of different tubers to overall tuber consumption in Brazil was quantified. Descriptive analyses assessed the impact of macroregion and sociodemographic characteristics on tuber consumption, and differences in intake were assessed using statistical tests. Lastly, the dietary intakes of tuber consumers and non-consumers were compared after adjusting for energy and covariates to determine if there were any major differences in dietary intakes between the two groups. RESULTS: Fifty-five percent of the Brazilian population consumed tubers, which differed by macroregion. The intake of tubers among consumers also differed between macroregions. Overall, rural areas reported significantly higher mean daily intakes of tubers (122 g/day) among tuber consumers than urban areas (95 g/day). Mandioca and potato were the most commonly consumed tubers (59 and 43% prevalence, respectively, on any of the 2 days), while the highest daily intakes amongst tuber consumers across Brazil were noted for sweet potato (156 g/day) and potato (95 g/day). On a macroregion level, among tuber consumers, mandioca had the highest prevalence of consumption in the North (94%), Northeast (83%), and Central-West (68%), while consumption of potatoes was most prevalent in the Southeast (63%) and South (62%). Compared to women, small but significantly higher tuber intakes were noted for males (108 vs. 85 g/day). There were no significant differences in intakes among income quintiles. After adjusting for energy and other covariates, nutrient intakes between tuber and non-tuber consumers were not meaningfully different, with the exception of sodium (+ 6.0% comparing non-tuber to tuber consumers), iron (+ 6.1%), zinc (+ 5.7%), vitamin C (+ 8.3%), riboflavin (+ 9.0%), and folate (+ 7.9%). CONCLUSIONS: Tuber consumption is influenced by regional and sociodemographic characteristics of the Brazilian population. When looking at energy-adjusted nutrient intakes, diets of tuber consumers have resulted in somewhat lower intakes of some micronutrients, namely riboflavin, folate, vitamin C, iron, sodium, and zinc.

Trends in Vitamin C Consumption in the United States: 1999-2018.

Low intakes of fruits and vegetables have resulted in suboptimal intakes of several micronutrients, including vitamin C. This cross-sectional study used data from 84,902 children/adults (≥1 y) who completed a 24-h dietary recall as part of the United States National Health and Nutrition Examination Survey (1999-2018). Mean vitamin C intakes from foods/beverages were calculated as were trends in major food/beverage sources of vitamin C. Percentages below the Estimated Average Requirement (EAR) were estimated. Overall, mean vitamin C consumption declined by 23% (97-75 mg/d; p-value for trend < 0.001). 100% fruit juice was the leading source of vitamin C (25.6% of total or 21.7mg/d), but this declined by 48% (25-13 mg/d; p-value for trend < 0.001). Whole fruit increased among children/adolescents (+75.8%;10-17 mg/d; p-value for trend < 0.001), but not adults, while the vegetable contribution was generally unchanged. The proportion of the population below the EAR increased by 23.8% on a relative scale or 9 percentage points on an absolute scale (38.3-47.4%). Declines in vitamin C intake is driven largely by decreases in fruit juice coupled with modest increases in whole fruit. Due to associations between vitamin C intake and numerous health outcomes these trends warrant careful monitoring moving forward.

Estimated Sweetness in US Diet Among Children and Adults Declined From 2001 to 2018: A Serial Cross-Sectional Surveillance Study Using NHANES 2001-2018.

An agreed-upon measure of total dietary sweetness is lacking hindering assessments of population-level patterns and trends in dietary sweetness. This cross-sectional study used 24-h dietary recall data for 74,461 participants aged ≥ 2 y from nine cycles (2001-2018) of the National Health and Nutrition Examination Survey (NHANES) to evaluate trends in the sweetness of the diet in the United States (US). LCS-containing items were matched to a sugar-sweetened counterpart (e.g., diet cola-regular cola or sucralose sugar). The matched pair was used to estimate the sugar equivalents from LCS-sweetened foods or beverages to estimate dietary level sweetness, which was described as grams of approximate sugar equivalent (ASE) per day. Trends in ASE were estimated overall and by subgroup, and trends were further disaggregated by food or beverage category. Overall, LCS sources contributed about 10.5% of ASE. Total ASE declined from 152 g/d to 117 g/d from 2001-2002 to 2017-2018 (p-trend < 0.001), with comparable declines in children and adults. Declines in total ASE were predominantly driven by beverages (-36.7% from 2001-2002 to 2017-2018) and tabletop sweeteners (-23.8%), but not food (-1.5%). Observed trends were robust to sensitivity analyses incorporating random, systematic, and sensory trial informed estimates of sweetness and also an analysis excluding possible under-reporters of dietary energy. This practical approach and underlying data may help researchers to apply the technique to other dietary studies to further these questions.

Opposing Consumption Trends for Sugar-Sweetened Beverages and Plain Drinking Water: Analyses of NHANES 2011-16 Data.

Background: Choosing water in place of sugar-sweetened beverages (SSB) can reduce added sugars while maintaining adequate hydration. The present goal was to examine 2011-16 time trends in SSB vs. water consumption across US population subgroups. Methods: Dietary intake data for 22,716 persons aged >4 years came from two 24-h dietary recalls in successive cycles of the National Health and Examination Survey (NHANES 2011-16). Water intakes (in mL/d) from plain water (tap and bottled) and from beverages (SSB and not-SSB) were the principal outcome variables. Intakes were analyzed by age group, income to poverty ratio (IPR), and race/ethnicity. Time trends by demographics were also examined. Results: SSB and water intakes followed distinct social gradients. Most SSB was consumed by Non-Hispanic Black and lower-income groups. Most tap water was consumed by Non-Hispanic White and higher-income groups. During 2011-16, water from SSB declined from 322 to 262 mL/d (p < 0.005), whereas plain water increased (1,011-1,144 mL/d) (p < 0.05). Groups aged <30 years reduced SSB consumption (p < 0.0001) but it was groups aged >30 years that increased drinking water (p < 0.001). Non-Hispanic White groups reduced SSB and increased tap water consumption. Non-Hispanic Black and lower income groups reduced SSB and increased bottled water, not tap. Conclusion: The opposing time trends in SSB and water consumption were not uniform across age groups or sociodemographic strata. Only the non-Hispanic White population reduced SSB and showed a corresponding increase in tap water. Lower-income and minority groups consumed relatively little plain drinking water from the tap.

Chronic pediatric health conditions among youth living in public housing and receiving care in a large hospital system in Bronx, NY.

This study compared the prevalence of chronic pediatric health conditions for youth in public housing with youth not in public housing using clinical electronic health record (EHR) and housing data. Youth (ages 2-17 years) in a large urban health system were identified and categorized into two housing types-public housing (n = 10 770) and not in public housing (n = 84 883) by age (young childhood, middle childhood, young adolescence). The prevalence of some pediatric conditions was higher in public housing but varied by age. Disparities in health conditions among youth in public housing were more common in early adolescence: asthma (26.4 vs 18.6; P < .001); obesity (28.5 vs 24.6; P < .001); depression/anxiety (19.2 vs 17.3; P = .008); behavioral disorders (8.1 vs 5.3; P < .001). These results show that chronic pediatric conditions like asthma and obesity that lead to significant morbidity into adulthood are more common among youth living in public housing. However, this pattern is not consistent across all chronic conditions.

Coffee Consumption among Adults in the United States by Demographic Variables and Purchase Location: Analyses of NHANES 2011-2016 Data.

Coffee, obtained from various sources, is consumed by most United States adults. The present analyses of one and two 24-h dietary recalls for 14,865 persons aged ≥20 years in the 2011-2016 National Health and Nutrition Examination Survey (NHANES 2011-2016) aimed to identify socio-demographic predictors of coffee consumption and to examine whether coffee purchase locations differed by population sub-group. Given the emphasis on food and beverage consumption patterns, the relation between coffee consumption and compliance with the Dietary Guidelines of Americans was also examined. Coffee was consumed by 59% of the sample (n = 8551). Survey-adjusted mean intake among consumers was 544.7 g/day. Percent consumers and mean amounts consumed were highest among adults aged 51-70 years (p < 0.001), higher income groups (p < 0.001), and non-Hispanic Whites (p < 0.001). About 74% of coffee consumers obtained their coffee from stores, 9.8% from fast food restaurants, 4.3% from convenience stores, and 4.2% from someone else. Coffee source locations also varied by age, education, income, and race/ethnicity. Coffee consumers had significantly higher Healthy Eating Index (HEI-2015) and higher Nutrient-Rich Foods (NRF9.3) scores in energy-adjusted models and significantly higher HEI 2015 scores in multivariable models. In multivariable models, coffee consumers had diets with less added sugar (p < 0.001) but slightly more fat (of all types, including monounsaturated (MUFA), polyunsaturated (PUFA), saturated and solid fats), cholesterol, and alcohol. Their diets had more potassium and magnesium (p < 0.001) but less vitamin C (p < 0.001). Mean caffeine consumption was 233 mg/day for consumers and 72.3 mg/day for non-consumers. Coffee consumption patterns in the US vary across socio-demographic groups.

Unmet Social Needs and No-Show Visits in Primary Care in a US Northeastern Urban Health System, 2018-2019.

Objectives. To characterize the association between social needs prevalence and no-show proportion and variation in these associations among specific social needs.Methods. In this study, we used results from a 10-item social needs screener conducted across 19 primary care practices in a large urban health system in Bronx County, New York, between April 2018 and July 2019. We estimated the association between unmet needs and 2-year history of missed appointments from 41 637 patients by using negative binomial regression models.Results. The overall no-show appointment proportion was 26.6%. Adjusted models suggest that patients with 1 or more social needs had a significantly higher no-show proportion (31.5%) than those without any social needs (26.3%), representing an 19.8% increase (P < .001). We observed a positive trend (P < .001) between the number of reported social needs and the no-show proportion-26.3% for those with no needs, 30.0% for 1 need, 32.1% for 2 needs, and 33.8% for 3 or more needs. The strongest association was for those with health care transportation need as compared with those without (36.0% vs 26.9%).Conclusions. We found unmet social needs to have a significant association with missed primary care appointments with potential implications on cost, quality, and access for health systems.

A comparison of different practical indices for assessing carbohydrate quality among carbohydrate-rich processed products in the US.

Healthier carbohydrate (carb)-rich foods are essential for health, but practical, validated indices for their identification are not established. We compared four pragmatic metrics, based on, per 10g of carb:(a) ≥1g fiber (10:1 carb:fiber), (b) ≥1g fiber and <1g free sugars (10:1:1 carb:fiber:free sugars), (c) ≥1g fiber and <2g free sugars (10:1:2 carb:fiber:free sugars); and (d) ≥1g fiber and, per each 1 g of fiber, <2g free sugars (10:1 carb:fiber, 1:2 fiber:free sugars; or 10:1|1:2). Using 2013-2016 National Health and Nutrition Examination Survey /Food and Nutrient Database for Dietary Studies, we assessed, overall and for 12 food categories, whether each metric discriminated carb-rich products higher or lower (per 100g) in calories, total fat, saturated fat, protein, sugar, fiber, sodium, potassium, magnesium, folate, and 8 vitamins/minerals. Among 2,208 carb-rich products, more met 10:1 (23.2%) and 10:1|1:2 (21.3%), followed by 10:1:2 (19.2%) and 10:1:1 (16.4%) ratios, with variation by product sub-categories. The 10:1 and 10:1|1:2 ratios similarly identified products with lower calories, fat, free sugars, and sodium; and higher protein, fiber, potassium, magnesium, iron, vitamin B6, vitamin E, zinc and iron. The 10:1:2 and 10:1:1 ratios identified products with even larger differences in calories and free sugars, but smaller differences in other nutrients above and lower folate, thiamine, riboflavin, and niacin; the latter findings were attenuated after excluding breakfast cereals (~9% of products). These novel findings inform dietary guidance for consumers, policy, and industry to identify and promote the development of the healthier carb-rich foods.

Flavonoid Intakes in the US Diet Are Linked to Higher Socioeconomic Status and to Tea Consumption: Analyses of NHANES 2011-16 Data.

BACKGROUND: Many of the health benefits of tea have been attributed to its flavonoid content. Tea consumption in US adults varies by socioeconomic status (SES). OBJECTIVES: The present objective was to explore intakes of total flavonoids and flavonoid subclasses by participant sociodemographics and by patterns of tea consumption. METHODS: The present analyses were based on 2 d of dietary recalls for 17,506 persons aged >9 y in the 2011-2016 NHANES. The What We Eat in America nutrient composition database was merged with the USDA Expanded Flavonoid database, which included total flavonoids and flavan-3-ols (including catechins), flavanones, flavonols, anthocyanidins, flavones, and isoflavones. Flavonoid intakes were compared by sex, age, race/ethnicity, education, and income-to-poverty ratio (IPR) in univariate analyses. Flavonoid intakes of children and adults were also compared by tea consumption status. Time trends in flavonoid intakes were also examined. RESULTS: Mean total flavonoid intake was 219 mg/d, of which flavan-3-ols provided 174 mg/d, or 79%. The highest total flavonoid intakes were found in adults aged 51-70 y (293 mg/d), non-Hispanic whites (251 mg/d) and in groups with college education (251 mg/d) and higher income (IPR >3.5: 249 mg/d) (P < 0.001 for all). The socioeconomic gradient was significant for anthocyanidins, flavonols, and flavones (P < 0.001 for all) but not for flavan-3-ols, and persisted across 3 cycles of NHANES. Adult tea consumers had higher intakes of total flavonoids (610 mg/d compared with 141 mg/d) and flavan-3-ols (542 mg/d compared with 97.8 mg/d) than did nonconsumers (P < 0.001). Time trend analyses showed that both tea consumption and flavonoid intakes were unchanged from 2011 to 2016. CONCLUSIONS: Flavonoid intakes in children and adults in the NHANES 2011-16 sample were associated with higher SES and were largely determined by tea consumption. Studies of diet and disease risk need to take sociodemographic gradients and eating and drinking habits into account.

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program.

Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.

Social Risks Among Primary Care Patients in a Large Urban Health System.

INTRODUCTION: Health systems are increasingly interested in addressing the social determinants of health via social risk screening. The objective of this study is to understand the variability in the number and types of social risks overall and in population subgroups among primary care patients routinely screened in a large urban health system. METHODS: Between April and December 2018, a total of 24,633 primary care patients completed a 10-item screener across 19 ambulatory sites within a health system in the Bronx, NY. The prevalence of any social risk and specific social risks was estimated overall and for population subgroups. Wald tests were used to determine statistically significant differences by subgroup. Data were analyzed in winter/spring 2019. RESULTS: Twenty percent of patients presented with at least 1 social risk. The most frequently reported risks included housing quality (6.5%) and food insecurity (6.1%). Middle-aged (30-59 years) respondents (24.7%, 95% CI=23.6%, 25.7%) compared with those aged 18-29 years (17.7%, 95% CI=16.4%, 19.2%, p<0.001), and Medicaid patients (24.8%, 95% CI=24.0%, 25.5%) compared with commercially insured patients (11.8%, 95% CI=11.1%, 12.5%, p<0.001), were more likely to report social risks. The strongest predictor of housing quality risk was residing in public housing (15.1%, 95% CI=13.8%, 16.6%) compared with those not in public housing (5.6%, 95% CI=5.3%, 5.9%, p<0.001). Housing quality was the most frequently reported risk for children (aged <18 years) and older adults (aged ≥70 years), whereas, for middle-aged respondents (30-69 years), it was food insecurity. CONCLUSIONS: There are important differences in the prevalence of overall and individual social risks by subgroup. These findings should be considered to inform clinical care and social risk screening and interventions.