Americans with Diet-Related Chronic Diseases Report Higher Diet Quality Than Those Without These Diseases1–3

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Supplemental Material can be found at: http://jn.nutrition.org/content/suppl/2011/07/20/jn.111.14003 8.DC1.html The Journal of Nutrition Nutritional Epidemiology

Americans with Diet-Related Chronic Diseases Report Higher Diet Quality Than Those without These Diseases1–3

Xiaoli Chen,4 Lawrence J. Cheskin,5 Leiyu Shi,6 and Youfa Wang4*

4Center for Human Nutrition, Department of International Health, 5Department of Health, Behavior and Society; and 6Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205

Abstract Downloaded from Large health disparities exist in the U.S. across ethnic and socioeconomic status groups. Using nationally representative data, we tested whether American patients with diet-related chronic diseases had higher diet quality than nonpatients. We also tested whether nutrition knowledge and beliefs (NKB) and food label (FL) use were associated with the observed differences. The 1994–1996 Continuing Survey of Food Intake by Individuals, and the Diet and Health Knowledge Survey

were examined for 4356 U.S. adults. Dietary intakes were assessed using 2 nonconsecutive 24-h recalls and diet quality jn.nutrition.org was assessed by using the USDA 2005 Healthy Eating Index (HEI). Patients’ mean HEI was higher than that of nonpatients (mean 6 SE: 53.6 6 0.5 vs. 51.8 6 0.4; P , 0.001). Among patients, blacks were 92% more likely to report low diet quality (HEI , 20th percentile) than whites. The positive association between chronic diseases and HEI was observed only for

patients with good NKB [OR = 1.80 (95% CI = 1.34, 2.43)]. The diabetes-HEI association was stronger among FL users at JOHNS HOPKINS UNIVERSITY on March 7, 2012 [OR = 2.24 (95% CI = 1.08, 4.63)] than non-FL users [OR = 1.33 (95% CI = 0.65, 2.73)]. Hypertensive patients’ and nonpatients’ diet quality did not signiﬁcantly differ; linear regression models showed no difference in their HEI (b 6 SE: 0.6 6 0.6; P . 0.05) or sodium intake (218.6 6 91.4 g/d; P . 0.05) between them. In conclusion, U.S. adults with diet- related chronic diseases reported somewhat higher diet quality than nonpatients, especially among those patients with good NKB and use of FL. Efforts are needed to promote healthy eating among Americans with diet-related chronic diseases; nutrition education and promotion of FL use may help. J. Nutr. 141: 1543–1551, 2011.

Introduction People with chronic diseases may be more aware of nutrition Unhealthful dietary practices, including high intakes of energy, information and make use of information on food labels (FL) sodium, and sugar and low intakes of fruits and vegetables more often than people without such conditions (6). The recent 7 (FV), increase the risks of chronic diseases such as obesity, NHANES data showed that patients with chronic diseases who hypertension, cardiovascular disease, and some types of cancer were advised by a health professional were more likely to read FL (1–3). Many Americans have been diagnosed with diet-related than those not receiving such advice, and patients who read FL . chronic diseases (4,5). For example, 50 million Americans consumed less energy, saturated fat, and sugar and more fiber than have hypertension (4) and 24 million children and adults have non-FL users (7). Few studies to date have examined whether U.S. diabetes (5). Improvements in dietary intakes can help patients patients with diet-related chronic diseases alter their diet after prevent and/or control many chronic conditions. Given the diagnosis and what factors may affect their likelihood of doing so. enormous public health costs of diet-related chronic diseases, National data show large disparities in U.S. chronic disease improving dietary behaviors is urgently warranted (6). prevalence across racial/ethnic and socioeconomic status (SES) groups (8,9). It is unclear whether the association between chronic diseases and diet quality varies across these groups. Dietary 1 Supported by the NIH/The National Institute of Diabetes and Digestive and behavior may be driven by individuals’ nutrition knowledge and Kidney Diseases (R01DK81335-01A1). beliefs (NKB). Previously, we found that Americans who were less 2 Author disclosures: X. Chen, L. J. Cheskin, L. Shi, and Y. Wang, no conflicts of interest. knowledgeable about nutrition had poorer diets (10), which is 3 Supplemental Text 1 and Supplemental Tables 1 and 2 are available from the consistent with other findings (11). “Online Supporting Material” link in the online posting of the article and from the Using nationally representative data, we examined whether U.S. same link in the online table of contents at jn.nutrition.org. adults with diet-related chronic diseases reported higher diet quality 7 Abbreviations used: CSFII, Continuing Survey of Food Intakes by Individuals; than other Americans and whether the association varied by their DHKS, Diet and Health Knowledge Survey; FL, food label; FV, fruits and vegetables; HEI, Healthy Eating Index; NH, non-Hispanic; NKB, nutrition knowledge and beliefs; race/ethnicity, SES, NKB, and FL use. Because it is well documented PIR, poverty income ratio; SES, socioeconomic status. that low diet quality is a risk factor for various chronic diseases, * To whom correspondence should be addressed. E-mail: [email protected]. adults who initially have worse dietary intakes than average

ã 2011 American Society for Nutrition. Manuscript received February 16, 2011. Initial review completed March 16, 2011. Revision accepted May 22, 2011. 1543 First published online June 22, 2011; doi:10.3945/jn.111.140038. Americans would be more likely to develop the targeted chronic cut up; 1/2 cup cooked or canned legumes (such as beans and peas); 1 cup diseases. Thus, if individuals diagnosed with chronic diseases (pa- of raw, leafy vegetables (such as lettuce and spinach); or 1/4 cup dried fruit tients) are found to have similar to or healthier intakes than those (such as raisins, apricots, mango). without these diseases (nonpatients) based on cross-sectional survey NKB. data, this would suggest (though not prove) that they may have DHKS participants were asked to rate on a Likert-type scale the degree of importance they were assigned to 11 specific dietary behavior/ improved their diet after diagnosis. If the patients are not found choices (Supplemental Text 1): 1) use salt or sodium only in moderation; 2) having a healthier diet than the average American, this would choose a diet low in saturated fat; 3) choose a diet with plenty of FV; 4)use suggest the need for greater efforts to promote their eating more sugars only in moderation; 5) choose a diet with adequate fiber; 6)eata healthfully, e.g. for managing their diet-related health conditions. variety of foods; 7) maintain a healthy weight; 8) choose a diet low in fat; 9) choose a diet low in cholesterol; 10) choose a diet with plenty of breads, cereals, rice, and pasta; and 11) eat at least 2 servings of dairy products daily. Methods We calculated an overall NKB score (range: 11–44) to summarize participants’ answers to these questions. First, answers of “not at all im- Study design and data. Data from the USDA Continuing Survey of portant,” “not too important,” “somewhat important,” or “very im- Food Intakes by Individuals (CSFII) and the Diet and Health Knowledge portant” were assigned scores of 1, 2, 3, and 4, respectively; then the total Survey (DHKS) 1994–1996 were used to ascertain dietary intakes (12). score was summed. Higher scores indicated better NKB. A NKB score $ Note that although these are cross-sectional data, they could allow us to 80th percentile (score = 42) was considered a good NKB. assess whether Americans who have been diagnosed with diet-related chronic diseases tend to adopt an improved diet (e.g. due to self-education, FL use. Participants were asked 5 questions about FL use when buying awareness, family support, or their health professionals’ advice). foods, e.g. “Now think about food labels. When you buy foods, do you use: Downloaded from The CSFII included a nationally representative, multi-stage stratified the list of ingredients: often, sometimes, rarely, or never?” FL users for sample of 16,103 noninstitutionalized individuals aged 0–90 y residing in ingredients were defined as those who answered “often” or “sometimes,” the US. Information about dietary intakes by 1 or 2 nonconsecutive, whereas answering “rarely,” “never,” or “never seen” were categorized as multiple-pass, 24-h recalls collected 3–10 d apart were used. Information non-FL users. Similar questions were asked about the short phrases on the on demographics, SES, and lifestyle factors were also collected. A sample FL such as “low-fat;” the nutrition panel that lists the amount of energy, $ protein, fat, and such in a serving of the food; the serving size; and statements of CSFII participants (one adult aged 20 y/household) completed the jn.nutrition.org DHKS to answer questions about knowledge and attitudes toward dietary on the label that describe health benefits of nutrients or foods. Participants guidance and health. who answered all 5 questions with answers “often” or “sometimes” were categorized as FL users and others were categorized as non-FL users. Study population. Among CSFII participants, 9872 were aged $20 y Overweight and obesity. BMI (kg/m2) was calculated based on self- and had data on d 1 of recall. Of these, 5765 participated in the DHKS. at JOHNS HOPKINS UNIVERSITY on March 7, 2012 reported weight and height in the CSFII. BMI cutoffs of $25 and $30 We further excluded those aged .65 y (n = 1319) to include relatively were used to classify overweight and obesity, respectively. Those with healthy individuals without special dietary needs and those with only one BMI , 25 were categorized as normal weight. 24-h dietary recall (n = 90). A final sample of 4356 individuals (2219 men and 2137 women) was included. Sociodemographic characteristics. Participants were categorized as non-Hispanic (NH) whites, NH blacks, Hispanics, and others based on Chronic diseases. Participants were asked to report whether they had self-reported information. Education level was grouped into 3 cate- chronic disease(s) diagnosed by a physician during the survey period gories: ,high school (,12 y), high school, and .high school. Household (1994–1996), including diabetes, high blood pressure, heart disease, income levels were assessed using poverty income ratio (PIR), and were cancer, osteoporosis, high blood cholesterol, and stroke. Participants categorized as 0–130% (poor: food stamp eligible), 131–350% (middle), who reported having 1 or more of the 7 chronic diseases were categorized and $350% (high income). as patients and those without these diseases were called nonpatients. We focused on diabetes, hypertension, heart disease, and hypercholesterole- Other covariates. All models were adjusted for survey year, 1990 mia, which are common highly diet-related chronic diseases. Census geographic regions (Northeast, Midwest, South, and West), and degree of urbanization of the geographical area (metropolitan statistical Dietary intakes and diet quality. Averaged dietary intakes of foods area-central city, suburban, and rural). and nutrients were analyzed based on the two 24-h recalls, including total energy, fat (as percent of total energy intake), cholesterol, sodium, Statistical analysis. The primary exposure variables were chronic calcium, fiber, sugar, and FV. diseases diagnosed by doctors, whereas the outcome variables were To assess the overall diet quality, we applied the USDA’s new 2005 dietary intakes, including diet quality. x2 tests tested the differences in the Healthy Eating Index (HEI) (13–16). The USDA developed it to help percentages of chronic diseases across sociodemographics. The Wald F assess how well American diets comply with the 2005 Dietary Guidelines tests for continuous variables (e.g. HEI) and x2 tests for categorical for Americans. It consists of 12 components. Diets are scored on a variables (e.g. high HEI) were used to examine the distributions of these density basis [amounts are expressed per 1000 kcal (1 kcal = 4.18 kJ) or variables by sociodemographics and disease status. as a percent of energy]. Six components (total fruit; whole fruit; total Multivariable linear and logistic regression models were conducted to vegetable; dark green and orange vegetable and legume; total grain; and examine the associations of chronic diseases with dietary intakes as con- whole grain) are assigned 0–5 points; 5 components (milk, meat and tinuous or categorical variables, respectively. OR and 95% CI were cal- beans, oil, saturated fat, and sodium) are worth 0–10 points; the last culated. Covariates, including age, gender, race/ethnicity, income, education, component of solid fat, alcohol, and added sugar is allocated 0–20 survey year, region, urbanization, and overweight/obesity, were adjusted for points. HEI scores were calculated proportionally. in all models. HEI scores ranged from 0 to 100 (best) (17). Because a very small Stratified analyses were conducted by sex, race/ethnicity, income, percentage of people had a HEI $80 (1.2%), a “good” diet as education, NKB, and FL use to test whether the associations varied by these recommended by the USDA (18), we defined high diet quality as being characteristics. Interaction terms were included and tested in separate models. HEI $80th percentile (HEI = 64) and low diet quality as HEI ,20th Moreover, we examined whether the association varied by the number and percentile (HEI = 41). type of chronic diseases. Note that in general, 1 serving of FV consists of either of the following: All analyses were conducted using survey-related commands in SAS 1 medium-sized fruit (such as apples, oranges, bananas, pears), 1/2 cup (1 (version 9.2; SAS Institute) to take complex sampling design into account to cup equivalent = 0.000237 m3) of raw, cooked, canned, or frozen fruits or produce nationally representative estimates and to correct estimates of SE. vegetables; 3/4 cup (6 oz.) of 100% fruit or vegetable juice; 1/2 cup fruit, Significance was set at P , 0.05.

1544 Chen et al. Results Patients with multiple diseases were more likely to have high diet quality. For example, people with 3 chronic diseases were 81% Supplemen- The overall prevalence of chronic diseases was 28% ( more likely to have high HEI and 46% less likely to have low tal Table 1 ). Older, NH black, lower SES, and obese Americans HEI. Compared with people with only hypertension (the most had a higher prevalence than average. common chronic disease reported), those diagnosed with $ Americans with high diet quality (HEI 80th percentile) were diabetes were 87% less likely to report low diet quality. There more likely to be older, women, NH white or Hispanic, better was no significant difference in diet quality between hyperten- educated, and FL users and have a higher income, higher NKB sive patients and those without chronic diseases. Table 1 scores, and normal weight ( ). Compared with nonpatients, We also compared the predictors of high and low HEI patients had higher HEI scores, lower energy intake, and higher between patients and nonpatients (Table 5). Among patients, FV intake. Only 1.7% of patients and 1.1% of nonpatients NH blacks were 92% more likely to have low HEI than were $ overall, however, had a HEI 80. Patients and nonpatients did NH whites. Good NKB was significantly associated with high $ not differ in the percentage consuming 5servings/dofFVorthe HEI among both patients and nonpatients. Patients with better $ $ percentage consuming 2servings/doffruitsor 3servings/dof NKB were 57% less likely to have a low HEI than those with vegetables. Similar results were found for patients reporting dia- worse NKB. FL users were 43% less likely to have a low HEI betes and high blood cholesterol. There was no significant than non-FL users, again among both patients and nonpatients. difference in HEI or FV intake between people with and without Similar results were observed for hypertension and diabetes. heart disease or hypertension, although these patients reported Diabetes and heart disease patients with higher income were less lower energy intake. likely to have a low HEI. Downloaded from Linear regression models with adjustment for potential con- founders showed that compared with nonpatients, patients had higher HEI (Table 2). Overall, patients had relatively lower energy intake (P . 0.05), but this was only significant for diabetes Discussion patients (P , 0.05). Patients with hypercholesterolemia had a Using nationally representative data, we detected several associ- lower fat intake and higher fiber intake than those without ations of note. First, we found that U.S. adults with diet-related jn.nutrition.org hypercholesterolemia. Cholesterol and sodium intake did not chronic diseases reported higher diet quality, lower energy intake, differ between patients and nonpatients. No significant differ- and higher FV intake than other Americans. Diabetes patients ences were found in HEI, sodium, or other dietary intakes by were most likely to have higher HEI and consume less sugar than hypertensive status (all P . 0.05). Patients with diabetes and heart nondiabetes patients. These patients may be benefitting from the at JOHNS HOPKINS UNIVERSITY on March 7, 2012 disease consumed less sugar. In general, FV intakes were higher advice commonly offered by health professionals to improve their among patients (P , 0.01), but this difference was not significant diet by limiting energy-dense food consumption and consuming when each disease was examined separately (all P . 0.05). more nutrient-dense foods (19). Stratified analyses show that NH blacks with and without Second, we found that the differences in diet between patients any disease had higher intakes of cholesterol and fat than did and nonpatients were relatively small and, although better than NH whites (Table 3). Hispanics had a lower sodium intake than nonpatients’, patients’ dietary intakes were far from nutritional NH whites with hypertension (b 6 SE: 2343 6 136 mg/d; P , recommendations. For example, the average HEI was 52.3 and 0.05) and those without hypertension (b 6 SE: 2780 6 194 mg/d; only 1.2% had a HEI .80, much lower on average than the diet P , 0.001). recommended by the USDA (18). There was no significant We fit multivariable logistic regression models to examine the difference in cholesterol or sodium intake between patients and association between chronic diseases and diet quality (Table 4). nonpatients. We found no substantial differences in diet quality Patients were 30% more likely to have high HEI than nonpatients. between hypertensive patients and nonpatients. Diabetes patients were 65% more likely to report a high diet Compared with people with only hypertension, however, quality than nondiabetes patients. The significant associations of those with only diabetes were 87% less likely to report low diet overall chronic diseases and diabetes with high HEI were observed quality. In other words, patients with hypertension were less among men but not among women. The disease-diet association likely to have high diet quality than diabetes patients. Thus, the was slightly stronger among people with middle SES, but the diagnosis of diet-related chronic diseases may not be associated interaction terms were not significant. The significant association with healthier dietary behavior among certain populations (e.g. between chronic diseases and high HEI was observed for people hypertensive patients). Previous research also indicates that only with good NKB ($80th percentile) but not for those with an NKB one-third of hypertensive patients have received their doctors’ ,80th percentile. Hypercholesterolemia patients were 68% more advice to reduce salt intake (20). Health professionals should likely to have high HEI among those with better NKB but only encourage people with chronic diseases to adopt a healthier diet 3% more likely if with an NKB ,80th percentile (P-interaction = for control of blood pressure and other diet-related chronic 0.18). A significant association for high HEI was observed for health conditions. diabetes among FL users but not in nonusers. We also conducted Third, we found considerable racial/ethnic differences. Among similar models for FV (FV $ 5vs.FV,5 servings/d) and low diet patients with 1 or more chronic diseases, NH blacks were 92% quality (HEI ,20th percentile) and found similar results (data not more likely than NH whites to have low diet quality; NH blacks shown). Our further combined analysis showed no association had higher intakes of fat and cholesterol regardless of their among people with poor NKB and no FL use; the association was chronic disease status. Reducing dietary and health disparities is a significant among people with good NKB but no FL use. Similar high priority in the US (21). Diet-related health disparities often results were found for hypertension (P-interaction = 0.006). A reflect differences in chronic diseases. NH blacks have higher significant association between hypercholesterolemia was only mortality from diet-related chronic diseases than NH whites (21). observed among people with good NKB and FL use. NH blacks are less likely to meet USDA guidelines than NH We found a dose-response relationship between the number whites and have the lowest FV consumption among U.S. racial/ of chronic diseases and high HEI (Supplemental Table 2). ethnic groups (22). We found that only 36% of NH blacks

Chronic diseases and diet quality in U.S. adults 1545 TABLE 1 Diet quality [Healthy Eating Index (HEI)] and dietary intakes [energy and fruits and vegetables (FV)] among U.S. adults aged 20–65 y by sociodemographic characteristics and chronic diseases1

F $2 and Characteristic n HEI Energy, MJ/d FV, g/d HEI $ 80 HEI ,20th HEI $80th FV $55 V $35

All 4356 52.3 6 0.4 8.72 6 0.11 372 6 6.9 1.2 (0.2) 19.9 (1.1) 20.8 (0.9) 42.1 (1.2) 15.2 (0.8) Age, y 20–34 1165 50.4 6 0.6*** 9.46 6 0.17*** 359 6 9.8*** 0.4 (0.2)*** 24.2 (2.3)*** 16.3 (1.6)*** 42.1 (1.7) 14.1 (1.3) 35–49 1507 52.2 6 0.5 8.65 6 0.23 364 6 11.7 1.2 (0.4) 20.7 (1.7) 20.5 (1.4) 41.4 (2.1) 14.8 (1.2) 50–65 1684 55.2 6 0.4 7.73 6 0.09 403 6 9.8 2.6 (0.4) 12.3 (1.0) 27.9 (1.5) 43.1 (1.7) 17.4 (1.0) Sex Men 2219 50.7 6 0.4*** 10.5 6 0.19*** 399 6 8.4*** 1.1 (0.2) 23.8 (1.7)*** 16.9 (1.1)*** 48.6 (1.5)*** 17.3 (1.2)** Women 2137 53.8 6 0.5 6.98 6 0.06 347 6 8.5 1.4 (0.3) 16.1 (1.2) 24.6 (1.4) 35.8 (1.5) 13.2 (1.0) Race/ethnicity NH white 3285 52.3 6 0.4*** 8.71 6 0.09*** 368 6 7.4** 1.2 (0.2) 19.6 (1.3)*** 19.8 (1.1)*** 42.0 (1.3)* 15.2 (0.8) NH black 512 47.6 6 0.6 8.97 6 0.71 348 6 17.7 1.3 (0.6) 30.1 (2.8) 11.6 (2.3) 36.1 (3.5) 10.9 (1.6) Hispanic 411 54.4 6 1.0 8.40 6 0.24 388 6 22.9 1.5 (0.8) 17.0 (3.0) 26.1 (3.3) 43.6 (3.3) 16.7 (2.5) Other 148 59.3 6 1.7 8.88 6 0.55 461 6 24.9 0.8 (0.5) 6.3 (1.4) 45.6 (7.6) 53.8 (5.9) 21.6 (6.0) Education Downloaded from ,High school 731 49.4 6 0.6*** 8.46 6 0.59*** 306 6 19.4*** 1.5 (0.6) 30.5 (2.7)*** 18.2 (2.0)*** 33.4 (3.1)*** 8.6 (1.3)*** High school 1552 49.9 6 0.5 8.56 6 0.14 326 6 7.1 0.7 (0.3) 25.6 (1.9) 17.0 (1.3) 34.6 (1.8) 11.6 (1.1) .High school 2073 54.5 6 0.4 8.87 6 0.10 417 6 8.3 1.5 (0.2) 13.7 (1.0) 23.8 (1.2) 48.9 (1.5) 19.0 (1.0) Income2 Low 1079 49.5 6 0.7*** 8.80 6 0.54* 322 6 14.4*** 1.1 (0.4) 26.7 (2.5)*** 15.4 (2.1)*** 33.2 (2.9)*** 8.7 (1.3)*** jn.nutrition.org Middle 1543 51.0 6 0.5 8.69 6 0.12 357 6 8.3 0.9 (0.3) 22.7 (1.4) 17.8 (1.1) 39.9 (1.4) 13.7 (1.0) High 1734 54.4 6 0.5 8.71 6 0.12 401 6 9.8 1.5 (0.3) 15.2 (1.5) 25.1 (1.2) 46.8 (1.8) 18.6 (1.3) NKB ,80th percentile 3451 51.3 6 0.4*** 8.90 6 0.14*** 364 6 7.2*** 0.7 (0.2)*** 21.8 (1.4)*** 18.0 (0.9)*** 41.7 (1.4) 14.6 (0.9) $ 6 6 6 80th percentile 896 56.2 0.7 7.99 0.18 403 11.7 3.3 (0.7) 12.5 (1.6) 31.8 (2.3) 43.9 (1.9) 17.7 (1.6) at JOHNS HOPKINS UNIVERSITY on March 7, 2012 FL use3 Non-FL use 3143 50.9 6 0.4*** 9.07 6 0.15*** 359 6 7.7*** 0.9 (0.2)* 23.3 (1.4)*** 17.9 (1.0)*** 41.1 (1.3) 13.8 (0.9)** FL use 1211 55.8 6 0.5 7.81 6 0.12 406 6 11.2 2.2 (0.5) 11.2 (1.1) 28.3 (1.8) 44.7 (1.9) 18.9 (1.5) Weight status BMI ,25 1803 53.0 6 0.6*** 8.49 6 0.12*** 378 6 10.3*** 1.2 (0.2) 18.4 (1.7) 22.7 (1.5)* 41.2 (1.8)** 16.7 (1.3)** BMI 25–29.9 1540 52.2 6 0.5 9.33 6 0.24 391 6 11.2 1.2 (0.3) 20.1 (1.7) 20.2 (1.4) 45.8 (1.8) 15.6 (1.0) BMI $30 916 50.5 6 0.6 8.31 6 0.17 326 6 11.6 1.4 (0.5) 23.4 (1.6) 16.6 (2.1) 37.5 (2.1) 11.4 (1.2) Chronic diseases4 No 2830 51.8 6 0.4*** 8.95 6 0.14*** 367 6 8.1* 1.1 (0.2) 21.4 (1.3)** 19.4 (1.1)** 42.1 (1.5) 15.1 (1.0) Yes 1526 53.6 6 0.5 8.11 6 0.14 386 6 7.9 1.7 (0.3) 16.0 (1.4) 24.5 (1.5) 41.9 (1.5) 15.4 (1.1) Diabetes No 4100 52.1 6 0.4*** 8.77 6 0.11*** 371 6 7.3* 1.2 (0.2) 20.3 (1.1)*** 20.4 (0.9)* 42.4 (1.3) 15.2 (0.8) Yes 252 56.1 6 1.0 7.33 6 0.26 401 6 25.7 1.6 (0.7) 8.4 (1.9) 30.1 (4.7) 35.4 (4.1) 15.6 (2.6) Heart disease No 4046 52.3 6 0.4 8.75 6 0.31*** 372 6 7.1 1.3 (0.2)* 20.0 (1.1) 20.5 (0.9) 42.1 (1.3) 15.3 (0.8) Yes 310 53.1 6 0.8 7.95 6 0.27 380 6 19.5 0.4 (0.2) 16.6 (3.0) 27.7 (4.0) 41.6 (4.2) 13.2 (2.2) Hypercholesterolemia No 3735 52.0 6 0.4*** 8.79 6 0.12*** 368 6 7.1** 1.1 (0.2)* 20.8 (1.2)*** 20.2 (1.0) 41.9 (1.2) 15.0 (0.9) Yes 615 54.8 6 0.7 8.16 6 0.20 407 6 16.9 2.2 (0.6) 12.6 (1.7) 25.2 (2.6) 43.3 (3.0) 16.4 (1.9) Hypertension No 3460 52.2 6 0.4 8.82 6 0.12*** 370 6 7.5 1.2 (0.2) 20.4 (1.2) 20.3 (1.0) 42.0 (1.3) 15.5 (0.9) Yes 890 52.8 6 0.6 8.17 6 0.19 386 6 10.8 1.5 (0.5) 16.9 (1.7) 23.7 (2.0) 42.6 (2.1) 13.8 (1.4)

1 Values are mean 6 SEM for continuous variables and percentage (SE) for categorical variables. *P , 0.05, **P , 0.01, ***P , 0.001 for between-group differences. 2 Household income levels were assessed using poverty income ratio (PIR) and were categorized as 0–130% (low income: food stamp eligible), 131–350% (middle income), and $350% (high income). 3 FL use was deﬁned as using all of FL information for ingredient, short phrase, nutrition panel, serving size, and health beneﬁts of nutrients/foods. 4 Selected health condition(s), including 1 or more of these chronic diseases: diabetes, heart disease, hypercholesterolemia, hypertension, or cancer. 5 Unit: servings/d. In general, 1 serving of FV consists of 1 of the following: 1 medium-sized fruit (such as apples, oranges, bananas, pears); 1/2 cup (1 cup equivalent = 0.000237 m3) of raw, cooked, canned, or frozen FV; 3/4 cup (6 oz.) of 100% fruit or vegetable juice; 1/2 cup fruit, cut up; 1/2 cup cooked or canned legumes (such as beans and peas); 1 cup of raw, leafy vegetables (such as lettuce and spinach); or 1/4 cup dried fruit (such as raisins, apricots, mango). reported consuming $5servings/dofFVcomparedwith42%for greater likelihood of meeting dietary guidelines (22). Our study NH whites and 54% for other groups. The effects of SES on found that patients with higher education and/or incomes were health disparities have been suggested to be stronger than that of more likely to have high diet quality. Overall, these data support race/ethnicity (24), with higher SES being associated with a the need for greater efforts to promote healthy eating targeting

1546 Chen et al. TABLE 2 Linear regression models for the associations between chronic diseases and diet quality and average daily dietary intakes among U.S. adults aged 20–65 y1

Outcome/disease Model 1: Chronic diseases2 Model 2: Diabetes Model 3: Heart disease Model 4: Hypercholesterolemia Model 5: Hypertension

HEI 1.1 (0.5)* 3.9 (1.0)*** 0.3 (0.9) 1.8 (0.7)* 0.6 (0.6) Energy, kJ/d 2283 (193) 2884 (342)* 2346 (324) 2107 (162) 2291 (205) Total fat intake, % energy 0.0 (0.4) 1.3 (0.8) 20.2 (0.6) 21.0 (0.5)* 0.3 (0.4) Cholesterol intake, mg/d 29.4 (10.1) 24.7 (19.0) 1.3 (11.9) 210.3 (12.3) 21.3 (10.9) Sodium intake, mg/d 210.8 (83.6) 2169 (144) 282.2 (127) 84.3 (100) 218.6 (91.4) Calcium intake, mg/d 1.6 (20.9) 224.3 (41.9) 217.5 (31.5) 27.1 (21.7) 238.9 (20.5) Fiber intake, g/d 0.4 (0.4) 20.7 (0.7) 0.2 (0.7) 1.3 (0.6)* 0.1 (0.5) Sugar intake, g/d 22.0 (1.9) 212.7 (2.3)*** 25.1 (1.9)* 20.2 (2.1) 23.3 (2.4) FV intake, g/d 23.1 (8.3)** 37.4 (28.6) 5.1 (18.1) 34.3 (17.4) 21.7 (11.9)

1 Values are b 6 SEE, which showed the adjusted differences in intakes between patients vs. nonpatients. *P , 0.05, **P , 0.01, ***P , 0.001. Separate models were ﬁt for each dietary outcome. Each model adjusted for survey year, sex, age, education, poverty income ratio (PIR), race/ethnicity, BMI, region, and urbanization. 2 Selected health condition(s), including 1 or more of these chronic diseases: diabetes, heart disease, hypercholesterolemia, hypertension, or cancer. racial/ethnic minorities, particularly NH blacks and lower SES cardiovascular disease (29,30). Consuming adequate FV among Downloaded from groups, especially among those with diet-related chronic diseases. patients may help control their health conditions. However, only Fourth, the disease-diet association was only signiﬁcant a small proportion of Americans meet the USDA guidelines for among people with good NKB. Those with good NKB were FV intake (22,31). More vigorous efforts are needed to promote more likely to report high diet quality, and this association was FV consumption. Health professionals can and should play a somewhat stronger among patients than among nonpatients. more active role in encouraging their patients to consume ade- jn.nutrition.org Patients with good NKB were 57% less likely to have low diet quate FV. quality than patients with poor NKB. Previous research has also Our study has several important strengths. First, it is based shown a positive association of NKB with diet and health (25,26). on nationally representative data collected from a large sam- NKB may affect whether patients adopt desirable dietary changes. ple. To our knowledge, these data are the only available data-

Fifth, we observed a stronger association between diabetes sets that provide comprehensive, nationally representative at JOHNS HOPKINS UNIVERSITY on March 7, 2012 and high HEI among FL users than among non-FL users. FL data on the variables studied. Some of the measures were not users reported higher diet quality than non-FL users, both collected in other, more recent national surveys, such as the among patients and nonpatients. A signiﬁcant association be- NHANES. Furthermore, recent NHANES data show that tween hypercholesterolemia and high diet quality was ob- Americans’ diet quality has changed little since the mid-1990s, served only among people with good NKB and FL use. This when the CSFII data were gathered (13–15). Second, it indicates that NKB and FL use may modify the disease-diet included rich data regarding participants’ nutrition knowledge association. and behaviors. Third, we used HEI-2005 to assess overall diet Sixth, we found that patients did not consume more FV than quality. These ﬁndings may help shed light on the underlying nonpatients. Only 42% of them had $5 FV servings/d and only causes of health disparities in the US and help guide future 15% had $2 servings/d of fruits and $3 servings/d of vegeta- intervention efforts. bles. Low FV consumption is associated with increased risks of Our study also has some limitations. First, cross-sectional diet-related chronic diseases, such as diabetes (27,28) and data cannot ascertain when and how much the patients changed

TABLE 3 Linear regression models for the associations of chronic diseases with diet among U.S. adults aged 20–65 y, stratiﬁed by race/ethnicity1

Chronic diseases2 Diabetes Heart disease Hypercholesterolemia Hypertension Characteristic Without With Without With Without With Without With Without With

HEI NH black 22.9 (0.8)*** 23.4 (1.4)* 23.6 (0.9)*** 0.5 (2.3) 23.1 (0.8)*** 23.2 (2.3) 23.1 (0.7)*** 22.7 (2.1) 23.2 (0.8)*** 22.7 (1.8) Hispanic 3.9 (1.0)*** 3.9 (2.0) 3.5 (0.9)*** 3.5 (3.4) 3.7 (0.9)*** 7.4 (5.1) 3.7 (1.0)*** 6.0 (2.0)** 3.9 (0.9)*** 3.5 (3.0) Other 6.5 (1.7)*** 4.9 (2.8) 6.3 (1.4)*** 5.6 (4.5) 6.3 (1.4)*** 16.6 (6.2)* 6.4 (1.6)*** 6.3 (5.1) 6.5 (1.5)*** 4.6 (2.2)* Cholesterol intake NH black 57.5 (29.9) 92.2 (19.0)*** 59.7 (22.9)* 143 (40.7)*** 60.8 (21.1)*** 158 (34.7)*** 60.8 (21.7)** 110 (32.4)** 68.5 (27.8)* 71.6 (24.4)** Hispanic 6.1 (13.8) 15.0 (28.8) 11.7 (12.3) 237.9 (38.1) 7.2 (13.4) 27.1 (47.2) 5.2 (11.9) 51.4 (49.3) 10.3 (13.8) 23.5 (37.8) Other 35.5 (28.9) 211.5 (25.9) 30.2 (26.1) 275.9 (46.3) 29.5 (25.4) 2264 (49.3)*** 29.5 (25.6) 29.3 (48.0) 33.6 (28.2) 237.5 (27.9) Total fat intake NH black 1.9 (0.7)* 1.2 (0.8) 1.8 (0.6)** 20.9 (1.3) 1.7 (0.7)* 1.3 (1.2) 1.6 (0.6)* 1.6 (1.4) 2.2 (0.7)** 20.1 (1.1) Hispanic 20.2 (0.6) 21.7 (1.2) 20.3 (0.7) 27.3 (2.6)** 20.6 (0.7) 1.8 (3.2) 20.4 (0.7) 23.5 (1.8) 20.3 (0.7) 22.8 (1.5) Other 23.4 (1.0)*** 24.1 (1.6)* 23.7 (0.9)*** 24.1 (2.5) 23.6 (0.9)*** 29.2 (2.1)*** 23.4 (0.9)*** 26.6 (2.2)** 23.6 (1.0)** 24.1 (1.7)*

1 Values are b (SEE). Each model adjusted for survey year, sex, age, education, poverty income ratio (PIR), race/ethnicity, BMI, region, and urbanization. NH whites served as the reference. *P , 0.05, **P , 0.01, ***P , 0.001. 2 Selected health condition(s), including 1 or more of these chronic diseases: diabetes, heart disease, hypercholesterolemia, hypertension, or cancer.

Chronic diseases and diet quality in U.S. adults 1547 TABLE 4 Logistic regression models for the association between chronic diseases and high diet quality (HEI $ 80th vs. HEI , 80th percentile) among U.S. adults aged 20–65 y1

Model 1: Model 2: Model 3: Model 4: Model 5: Characteristic Chronic diseases4 Diabetes Heart disease Hypercholesterolemia Hypertension

Total, for whole sample1 1.30 (1.07, 1.58)* 1.65 (1.02, 2.64)* 1.42 (0.89, 2.28) 1.19 (0.88, 1.61) 1.22 (0.96, 1.55) Stratified by sex2 Men 1.57 (1.10, 2.24)* 2.73 (1.38, 5.39)* 1.88 (0.98, 3.58) 1.27 (0.84, 1.92) 1.25 (0.80, 1,95) Women 1.14 (0.88, 1.47) 1.08 (0.56, 2.09) 1.18 (0.63, 2.23) 1.19 (0.85, 1.69) 1.25 (0.92, 1.71) Percent change in OR 37.7 152.8 59.3 6.7 0.0 P-interaction 0.166 0.074 0.296 0.813 0.989 Stratified by race/ethnicity2 NH white 1.36 (1.06, 1.73)* 1.55 (0.92, 2.63) 1.44 (0.84 2.49) 1.26 (0.93, 1.72) 1.18 (0.92, 1.51) NH black 1.47 (0.64, 3.40) 4.24 (1.58, 11.4)** 1.15 (0.33, 3.97) 1.02 (0.39, 2.66) 1.64 (0.72, 3.72) Hispanic 1.79 (0.78, 4.10) 2.00 (0.57, 7.05) 5.04 (1.45, 17.5)* 2.00 (0.79, 5.06) 2.25 (0.84, 6.06) Other 0.67 (0.22, 2.02) 1.67 (0.33, 8.41) 3.65 (0.53, 25.2) 1.55 (0.18, 13.6) 0.36 (0.11, 1.21) Percent change in OR (white and black) 8.1 173.5 338.3 23.5 39.0 Percent change in OR (all) 167.2 173.5 25.2 96.1 525.0 P-interaction 0.380 0.789 0.579 0.980 0.010 Downloaded from Stratified by food stamp program2 Nonparticipants 1.24 (1.00, 1.53)* 1.62 (0.92, 2.86) 1.28 (0.71, 2.33) 1.19 (0.88, 1.61) 1.17 (0.91, 1.51) Participants 7.64 (3.09, 18.9)*** 3.17 (0.66, 15.3) 2.28 (0.50, 10.5) 1.06 (0.36, 3.11) 2.42 (0.97, 6.04) Percent change in OR 516.1 95.7 78.1 12.3 106.8 P-interaction 0.045 0.402 0.205 0.500 0.147 jn.nutrition.org Stratified by FL use2,3 Non FL use 1.23 (0.94, 1.61) 1.33 (0.65, 2.73) 1.36 (0.70, 2.64) 1.00 (0.74, 1.35) 1.39 (0.99, 1.93) FL use 1.35 (0.92, 1.96) 2.24 (1.08, 4.63)* 1.54 (0.87, 2.73) 1.46 (0.93, 2.28) 1.04 (0.66, 1.64) Percent change in OR 9.8 68.4 13.2 46.0 33.7

P-interaction 0.939 0.634 0.862 0.256 0.207 at JOHNS HOPKINS UNIVERSITY on March 7, 2012 Stratified by NKB2 Score ,80th percentile 1.13 (0.89, 1.42) 1.61 (0.87, 2.97) 1.31 (0.72, 2.38) 1.03 (0.76, 1.40) 1.13 (0.84, 1.53) Score $80th percentile 1.80 (1.34, 2.43) 1.58 (0.85, 2.95) 1.43 (0.74, 2.74) 1.68 (1.09, 2.60)* 1.62 (0.99, 2.66)* Percent change in OR 59.3 1.9 9.2 63.1 43.4 P-interaction 0.243 0.727 0.970 0.181 0.574 Stratified by NKB and FL use2 Poor NKB and non-FL use 1.07 (0.78, 1.46) 1.03 (0.43, 2.46) 1.31 (0.59, 2.91) 0.89 (0.64, 1.25) 1.11 (0.73, 1.68) Poor NKB and FL use 1.21 (0.76, 1.94) 2.90 (1.26, 6.65) 1.20 (0.62, 2.36) 1.23 (0.69, 2.18) 1.22 (0.72, 2.06) Good NKB and non-FL use 2.16 (1.25, 3.74) 2.20 (0.78, 6.19) 1.04 (0.37, 2.96) 1.24 (0.67, 2.30) 3.52 (1.66, 7.48) Good NKB and FL use 1.64 (0.95, 2.81) 1.07 (0.46, 2.51) 1.91 (0.68, 5.34) 2.30 (1.25, 4.23) 0.82 (0.37, 1.80) Percent change in OR 102.7 180.4 83.8 157.0 331.9 P-interaction 0.131 0.089 0.995 0.218 0.006

1 Values are OR (95% CI). Each model adjusted for survey year, sex, age, education, poverty income ratio (PIR), race/ethnicity, BMI, region, and urbanization. *P , 0.05, **P , 0.01, ***P , 0.001. 2 Adjusted for all above covariates, except for the variables stratified by (e.g. sex, education). 3 FL use was defined as using all of label information for ingredient, short phrase, nutrition panel, serving size, and health benefits of foods. 4 Selected chronic disease(s), including at least 1 of diseases: diabetes, heart disease, hypercholesterolemia, hypertension, or cancer. their diet because of the disease diagnosis. Second, the data were their cholesterol and sodium intakes are similar to those of collected 10 y ago. However, they are the only available national nonpatients. Patients with better nutrition knowledge or FL use surveys that provided all the measures we were interested in (e.g. are more likely to report high diet quality. The protective effects NKB), which were not collected in other, more recent national of nutrition knowledge and FL use are stronger among patients surveys, such as the NHANES. Third, two 24-h recalls may not than among nonpatients. Further, patients’ dietary intakes re- be adequate to assess individuals’ usual diet (32). Fourth, the main far from desirable compared with the Dietary Guidelines lack of healthcare information would not allow us to adjust for for Americans. The importance of nutrition knowledge and FL its potential effect, although our analysis controlled for income use should be highlighted in health promotion programs, and education. Fifth, diet is not the only risk factor for the especially among patients with or at increased risk of chronic, chronic diseases examined. Other factors, such as genetics and diet-related diseases. Health professionals can and should play a environmental factors, also affect chronic disease but were not more active role in encouraging their patients to adopt a more available in the datasets. Finally, self-reported medical diagnoses healthful diet. and dietary intakes are subject to reporting errors. In conclusion, Americans diagnosed with diet-related chronic Acknowledgments diseases have somewhat higher diet quality than those without We thank Dr. May Beydoun for her technical assistance in these diagnoses. However, many of the differences are small, and working on the data sets. X.C. and Y.W. had full access to the

1548 Chen et al. TABLE 5 Logistic regression models for the predictors of high diet quality (HEI $ 80th vs. HEI , 80th percentile) and low diet quality (HEI , 20th vs. HEI $20th percentile) among U.S. adults aged 20–65 y with and without chronic disease(s)1

High diet quality, $ 80th vs. HEI , 80th percentile Low diet quality, HEI , 20th vs. HEI $ 20th percentile Characteristic Without disease(s): Model 1 With disease(s): Model 2 Without disease(s): Model 3 With disease(s): Model 4

Chronic diseases2 Women (ref: men) 1.75 (1.36, 2.24)*** 1.06 (0.78, 1.45) 0.63 (0.46, 0.85)** 0.74 (0.52, 1.06) Age (ref: 20–34 y) 35–49 1.59 (1.14, 2.23)** 0.76 (0.43, 1.37) 0.95 (0.66, 1.36) 0.55 (0.30, 1.00)* 50–65 2.33 (1.62, 3.36)*** 1.35 (0.75, 2.42) 0.47 (0.31, 0.71)*** 0.28 (0.16, 0.51)*** Education (ref: ,high school) High school 0.95 (0.55, 1.64) 0.81 (0.54, 1.21) 0.72 (0.48, 1.08) 0.72 (0.44, 1.19) .High school 1.60 (0.95, 2.67) 0.88 (0.54, 1.43) 0.31 (0.21, 0.46)*** 0.46 (0.27, 0.80)** Household income (ref: low)3 Middle 0.95 (0.63, 1.42) 1.67 (1.01, 2.76)* 0.98 (0.71, 1.36) 0.92 (0.52, 1.61) High 1.24 (0.80, 1.91) 2.03 (1.21, 3.41)** 0.81 (0.49, 1.33) 0.73 (0.40, 1.32) Race/ethnicity (ref: NH white) NH black 0.52 (0.27, 1.02) 0.74 (0.36, 1.54) 1.34 (0.85, 2.10) 1.92 (1.09, 3.36)* Downloaded from Hispanic 1.69 (1.07, 2.67)* 1.74 (0.78, 3.87) 0.51 (0.31, 0.84)*** 0.96 (0.37, 2.45) Other 3.83 (2.00, 7.32)*** 1.62 (0.74, 3.54) 0.17 (0.08, 0.37)*** 1.33 (0.39, 4.52) Good NKB vs. other4 1.59 (1.18, 2.12)** 2.05 (1.51, 2.79)*** 0.76 (0.50, 1.16) 0.43 (0.26, 0.71)** FL use5 1.44 (1.07, 1.93)* 1.36 (0.93, 2.00) 0.50 (0.38, 0.66)*** 0.57 (0.38, 0.84)** Diabetes

Women (ref: men) 1.61 (1.31, 1.98)*** 0.45 (0.16, 1.21) 0.66 (0.52, 0.83)** 0.58 (0.15, 2.28) jn.nutrition.org Age (ref: 20–34 y) 35–49 1.42 (1.06, 1.91)* 1.51 (0.18, 12.98) 0.87 (0.65, 1.17) 1.74 (0.19, 15.65) 50–65 2.25 (1.66, 3.07)*** 2.82 (0.27, 29.71) 0.39 (0.29, 0.51)*** 6.29 (0.71, 55.84) Education (ref: ,high school)

High school 0.90 (0.66, 1.22) 1.63 (0.58, 4.56) 0.72 (0.51, 1.01) 1.70 (0.46, 6.23) at JOHNS HOPKINS UNIVERSITY on March 7, 2012 .High school 1.38 (0.99, 1.94) 0.95 (0.29, 3.16) 0.33 (0.24, 0.46)*** 0.56 (0.09, 3.63) Income (ref: low) Middle 1.04 (0.73, 1.48) 2.80 (0.84, 9.35) 1.02 (0.78, 1.35) 0.33 (0.11, 0.97)* High 1.35 (0.95, 1.90) 1.88 (0.52, 6.75) 0.86 (0.57, 1.30) 0.06 (0.01, 0.35)** Race/ethnicity (ref: NH white) NH black 0.55 (0.29, 1.05) 0.97 (0.37, 2.56) 1.51 (1.00, 2.28)* 1.29 (0.22, 7.52) Hispanic 1.56 (1.07, 2.29)* 3.01 (0.77, 11.7) 0.61 (0.40, 0.94)* 0.95 (0.09, 9.84) Other 3.21 (1.81, 5.68)*** 10.4 (1.0, 106.5)* 0.27 (0.17, 0.41)*** 16.3 (1.9, 143.6)* Good NKB vs. other4 1.75 (1.36, 2.25)*** 1.88 (0.69, 5.10) 0.66 (0.46, 0.95)* 1.26 (0.36, 4.46) FL use5 1.39 (1.09, 1.77)** 1.68 (0.69, 4.08) 0.50 (0.40, 0.62)*** 0.93 (0.28, 3.07) Heart disease Women (ref: men) 1.57 (1.28, 1.93)*** 0.97 (0.43, 2.18) 0.66 (0.51, 0.84)* 0.71 (0.26, 1.94) Age (ref: 20–34 y) 35–49 1.47 (1.11, 1.94)* 0.30 (0.12, 0.80)* 0.85 (0.63, 1.15) 0.46 (0.13, 1.66) 50–65 2.41 (1.80, 3.23)*** 0.77 (0.33, 1.82) 0.38 (0.28, 0.50)** 0.15 (0.05, 0.41)*** Education (ref: ,high school) High school 0.85 (0.61, 1.17) 1.41 (0.51, 3.91) 0.71 (0.51, 1.00) 0.84 (0.32, 2.18) .High school 1.31 (0.94, 1.82) 0.99 (0.30, 3.25) 0.33 (0.24, 0.46)** 0.70 (0.24, 2.02) Income (ref: low) Middle 1.03 (0.73, 1.45) 2.32 (0.60, 8.88) 1.02 (0.76, 1.36) 0.47 (0.19, 1.12) High 1.31 (0.94, 1.84) 3.37 (0.84, 13.6) 0.86 (0.57, 1.29) 0.30 (0.09, 0.97)* Race/ethnicity (ref: NH white) NH black 0.62 (0.35, 1.12) 0.32 (0.06, 1.65) 1.52 (1.02, 2.25) 0.45 (0.15, 1.37) Hispanic 1.59 (1.10, 2.31)* 4.73 (0.85, 26.23) 0.60 (0.39, 0.92)* 1.30 (0.05, 33.12) Other 3.27 (1.84, 5.81)*** 18.2 (2.39, 138.8)** 0.30 (0.20, 0.46)** NA6 Good NKB vs. other4 1.72 (1.32, 2.23)*** 1.91 (0.88, 4.17) 0.66 (0.46, 0.95)* 0.70 (0.31, 1.57) FL use5 1.43 (1.11, 1.84)** 2.56 (1.17, 5.58)* 0.50 (0.40, 0.62)** 1.10 (0.40, 3.03) Hypercholesterolemia Women (ref: men) 1.59 (1.28, 1.96)*** 1.15 (0.69, 1.91) 0.66 (0.51, 0.86)* 0.58 (0.28, 1.18) Age (ref: 20–34 y) 35–49 1.43 (1.08, 1.91)* 1.18 (0.41, 3.36) 0.94 (0.70, 1.28) 0.22 (0.09, 0.50)*** 50–65 2.16 (1.57, 2.96)*** 3.02 (1.11, 8.25)* 0.43 (0.32, 0.59)** 0.12 (0.05, 0.29)***

(Continued)

Chronic diseases and diet quality in U.S. adults 1549 TABLE 5 Continued

Education (ref: ,high school) High school 1.01 (0.72, 1.43) 0.45 (0.20, 1.01) 0.73 (0.52, 1.03) 0.42 (0.16, 1.09) .High school 1.48 (1.02, 2.14)* 0.69 (0.32, 1.49) 0.33 (0.24, 0.45)*** 0.32 (0.13, 0.78)** Income (ref: low) Middle 1.04 (0.71, 1.52) 2.49 (1.09, 5.69)* 1.04 (0.79, 1.36) 0.31 (0.12, 0.83)** High 1.38 (0.94, 2.03) 2.55 (1.24, 5.24)* 0.85 (0.56, 1.30) 0.42 (0.14, 1.31) Race/ethnicity (ref: NH white) NH black 0.59 (0.34, 1.03) 0.48 (0.14, 1.66) 1.46 (0.98, 2.19) 1.48 (0.48, 4.58) Hispanic 1.70 (1.14, 2.52)** 2.05 (0.82, 5.10) 0.57 (0.37, 0.88)** 0.45 (0.07, 2.98) Other 3.29 (1.80, 5.99)*** 3.50 (0.82, 14.9) 0.22 (0.12, 0.40)*** 1.42 (0.33, 6.10) Good NKB vs. other4 1.69 (1.29, 2.20)*** 2.63 (1.58, 4.36)*** 0.70 (0.49, 1.01) 0.42 (0.17, 1.08) FL use5 1.38 (1.06, 1.80)* 1.74 (1.05, 2.90)* 0.49 (0.39, 0.62)** 0.91 (0.45, 1.82) Hypertension

Women (ref: men) 1.57 (1.23, 2.00)*** 1.43 (0.97, 2.12) 0.63 (0.48, 0.84)** 0.67 (0.43, 1.05) Downloaded from Age (ref: 20–34 y) 35–49 1.51 (1.12, 2.05)** 0.72 (0.32, 1.65) 0.86 (0.62, 1.18) 0.91 (0.39, 2.12) 50–65 2.50 (1.84, 3.39)*** 1.12 (0.47, 2.65) 0.38 (0.27, 0.53)*** 0.44 (0.21, 0.94)* Education (ref: ,high school) High school 0.98 (0.65, 1.48) 0.73 (0.44, 1.20) 0.68 (0.48, 0.98)* 0.95 (0.51, 1.77)

.High school 1.51 (0.99, 2.31) 0.93 (0.51, 1.71) 0.31 (0.21, 0.44)*** 0.55 (0.28, 1.09) jn.nutrition.org Income (ref: low) Middle 1.11 (0.75, 1.65) 1.29 (0.67, 2.46) 0.89 (0.67, 1.17) 1.46 (0.76, 2.82) High 1.40 (0.94, 2.08) 1.58 (0.78, 3.17) 0.81 (0.52, 1.26) 0.71 (0.32, 1.59) Race/ethnicity (ref: NH white) NH black 0.47 (0.23, 0.92)* 1.03 (0.50, 2.09) 1.41 (0.95, 2.11) 1.78 (0.95, 3.34) at JOHNS HOPKINS UNIVERSITY on March 7, 2012 Hispanic 1.57 (1.03, 2.38)* 2.91 (1.07, 7.89)* 0.53 (0.32, 0.86)* 1.00 (0.37, 2.68) Other 3.69 (2.01, 6.79)*** 1.01 (0.44, 2.35) 0.28 (0.18, 0.42)*** 0.46 (0.06, 3.29) Good NKB vs. other4 1.67 (1.30, 2.14)*** 2.20 (1.33, 3.63)** 0.71 (0.49, 1.04) 0.43 (0.22, 0.88)* FL use5 1.56 (1.19, 2.06)** 0.95 (0.56, 1.63) 0.49 (0.39, 0.61)* 0.53 (0.31, 0.93)*

1 Values are OR (95% CI). Variables mutually adjusted for. Further adjusted variables included BMI, survey year, region, and urbanization. *P , 0.05, **P , 0.01, ***P , 0.001. 2 Selected chronic disease(s), including at least 1 of diseases: hypertension, diabetes, heart diseases, hypercholesterolemia, or cancer. 3 Household income levels were assessed using poverty income ratio (PIR) and were categorized as 0–130% (low income: food stamp eligible), 131–350% (middle income), and $350% (high income). 4 NKB score $ 80th percentile was treated as good NKB. 5 FL use was deﬁned as using all of label information for ingredient, short phrase, nutrition panel, serving size, and health beneﬁts of foods. 6 NA, not available.

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