INTRODUCTION: Acute kidney injury (AKI) is associated with increased mortality. AKI-related mortality trends by US urban and rural counties were assessed. METHODS: In the cross-sectional study, based on the Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) Multiple Cause of Death data, age-standardized mortality with AKI as the multiple cause was obtained among adults aged ≥25 years from 2001-2020, by age, sex, race and ethnicity, stratified by urban-rural counties. Joinpoint regressions were used to assess trends from 2001-2019 in AKI-related mortality rate. Pairwise comparison was used to compare mean differences in mortality between urban and rural counties from 2001-2019. RESULTS: From 2001-2020, age-standardized AKI-related mortality was consistently higher in rural than urban counties. AKI-related mortality (per 100,000 population) increased from 18.95 in 2001 to 29.46 in 2020 in urban counties and from 20.10 in 2001 to 38.24 in 2020 in rural counties. In urban counties, AKI-related mortality increased annually by 4.6% during 2001-2009 and decreased annually by 1.8% until 2019 (p<0.001). In rural counties, AKI-related mortality increased annually by 5.0% during 2001-2011 and decreased by 1.2% until 2019 (p<0.01). The overall urban-rural difference in AKI-related mortality was greater after 2009-2011. AKI-related mortality was significantly higher among older adults, men, and non-Hispanic Black adults than their counterparts in both urban and rural counties. Higher mortality was concentrated in rural counties in the Southern United States. CONCLUSIONS: Multidisciplinary efforts are needed to increase AKI awareness and implement strategies to reduce AKI-related mortality in rural and high-risk populations.

BACKGROUND: To improve the healthfulness of foods offered while accelerating the use of environmental sustainability practices, it is important to engage hospital food service operators in the adoption of such practices. The purpose of this study was to explore barriers, facilitators and best practices for implementing environmental sustainability standards in food service among veterans affairs (VA) hospitals in the United States. METHODS: We conducted an online survey with 14 VA hospital food service directors and then 11 qualitative interviews. The survey assessed motivations for initiating sustainability standards and included a self-rating of implementation for each of five standards: increasing plant-forward dishes, procuring and serving sustainable foods that meet organic/fair trade and other certifications, procuring and serving locally produced foods, reducing food waste and reducing energy consumption. Interviews were transcribed verbatim. Qualitative analysis, including coding of themes and subthemes, was conducted by two coders to determine barriers, facilitators and best practices for each of these five standards. Quantitative methods (counts and frequencies) were used to analyse the survey data. RESULTS: Participants had an average of 5 years of experience implementing sustainability standards. The top three motivators cited were reducing food waste, serving healthier foods and increasing efficiency or cost savings. Barriers revolved around patient preferences, contractual difficulties and costs related to reducing waste. Facilitators included taste testing new recipes that include more sustainable food options and easy access to sustainable products from the prime vendor. Best practices included making familiar dishes plant-forward and plate waste studies to prevent overproduction. CONCLUSIONS: Although there were many barriers to implementation, food service directors had solutions for overcoming challenges and implementing food service sustainability standards, which can be tested in future sustainability initiatives.

INTRODUCTION: Physical activity (PA) can reduce morbidity and mortality among adults with diabetes. While rural disparities in PA exist among the general population, it is not known how these disparities manifest among adults with diabetes. METHODS: Data from the 2020 and 2022 National Health Interview Survey were analyzed in 2023 to assess prevalence of meeting aerobic and muscle-strengthening recommendations according to the 2018 Physical Activity Guidelines for Americans during leisure time. PA prevalence was computed by diabetes status, type of PA, and urban/rural residence (large central metro, large fringe metro, medium/small metro, and non-metro). Logistic regression models were used to estimate prevalence and prevalence ratios of meeting PA recommendations by urban/rural residence across diabetes status. RESULTS: Among adults with diabetes in non-metro counties, only 23.8% met aerobic, 10.9% met muscle-strengthening, and 6.2% met both PA recommendations. By contrast, among adults with diabetes in large fringe metro counties, 32.1% met aerobic, 19.7% met strengthening, and 12.0% met both guidelines. Multivariable adjusted prevalence of meeting muscle-strengthening recommendations was higher among participants with diabetes in large fringe metro compared to large central metro counties (PR=1.27; 95% CI 1.03-1.56). Among those without diabetes, adjusted prevalence of meeting each recommendation or both was lower in non-metro and small/medium metro compared to large central metro counties. CONCLUSIONS: Adults with diabetes are less likely to meet the PA recommendations than those without, and differences exist according to urban/rural status. Improving PA among rural residents with diabetes may mitigate disparities in diabetes-related mortality.

Although diabetes and cardiovascular disease account for substantial disease prevalence among adults in the United States, their prevalence among racial and ethnic subgroups is inadequately characterized. To fill this gap, CDC described the prevalence of diagnosed cardiometabolic diseases among U.S. adults, by disaggregated racial and ethnic subgroups, among 3,970,904 respondents to the Behavioral Risk Factor Surveillance System during 2013-2021. Prevalence of each disease (diabetes, myocardial infarction, angina or coronary heart disease, and stroke), stratified by race and ethnicity, was based on self-reported diagnosis by a health care professional, adjusting for age, sex, and survey year. Overall, mean respondent age was 47.5 years, and 51.4% of respondents were women. Prevalence of cardiometabolic diseases among disaggregated race and ethnicity subgroups varied considerably. For example, diabetes prevalence within the aggregated non-Hispanic Asian category (11.5%) ranged from 6.3% in the Vietnamese subgroup to 15.2% in the Filipino subgroup. Prevalence of angina or coronary heart disease for the aggregated Hispanic or Latino category (3.8%) ranged from 3.1% in the Cuban subgroup to 6.3% in the Puerto Rican subgroup. Disaggregation of cardiometabolic disease prevalence data by race and ethnicity identified health disparities among subgroups that can be used to better help guide prevention programs and develop culturally relevant interventions.

BACKGROUND: Household food insecurity has been linked to adverse health outcomes, but pathways driving these associations are not well understood. The stress experienced by those in food insecure households and having to prioritize between food and other essential needs could lead to physiological dysregulations (i.e., allostatic load [AL]) and, as a result, adversely impact their health. OBJECTIVE: To assess the association between household food security status and AL and differences by gender, race and ethnicity, and Supplemental Nutrition Assistance Program (SNAP) participation. METHODS: We used data from 7640 US adults in the 2015-2016 and 2017-March 2020 National Health and Nutrition Examination Survey to estimate means and prevalence ratios (PR) for AL scores (based on cardiovascular, metabolic, and immune biomarkers) associated with self-reported household food security status from multivariable linear and logistic regression models. RESULTS: Adults in marginally food secure (mean = 3.09, SE = 0.10) and food insecure households (mean = 3.05, SE = 0.08) had higher mean AL than those in food secure households (mean = 2.70, SE = 0.05). Compared to adults in food secure households in the same category, those more likely to have an elevated AL included: SNAP participants (PR = 1.12; 95% confidence interval, CI = 1.03, 1.22) and Hispanic women (PR = 1.20; 95% CI = 1.05, 1.37) in marginally food secure households; and non-Hispanic Black women (PR = 1.14; 95% CI = 1.03, 1.26), men (PR = 1.13; 95% CI = 1.02, 1.26), and non-SNAP non-Hispanic White adults (PR = 1.22; 95% CI = 1.08, 1.39) in food insecure households. CONCLUSIONS: AL may be one pathway by which household food insecurity affects health and may vary by gender, race and ethnicity, and SNAP participation.

OBJECTIVE: Race and ethnicity data disaggregated into detailed subgroups may reveal pronounced heterogeneity in diabetes risk factors. We therefore used disaggregated data to examine the prevalence of type 2 diabetes risk factors related to lifestyle behaviors and barriers to preventive care among adults in the U.S. RESEARCH DESIGN AND METHODS: We conducted a pooled cross-sectional study of 3,437,640 adults aged ≥18 years in the U.S. without diagnosed diabetes from the Behavioral Risk Factor Surveillance System (2013-2021). For self-reported race and ethnicity, the following categories were included: Hispanic (Cuban, Mexican, Puerto Rican, Other Hispanic), non-Hispanic (NH) American Indian/Alaska Native, NH Asian (Chinese, Filipino, Indian, Japanese, Korean, Vietnamese, Other Asian), NH Black, NH Pacific Islander (Guamanian/Chamorro, Native Hawaiian, Samoan, Other Pacific Islander), NH White, NH Multiracial, NH Other. Risk factors included current smoking, hypertension, overweight or obesity, physical inactivity, being uninsured, not having a primary care doctor, health care cost concerns, and no physical exam in the past 12 months. RESULTS: Prevalence of hypertension, lifestyle factors, and barriers to preventive care showed substantial heterogeneity among both aggregated, self-identified racial and ethnic groups and disaggregated subgroups. For example, the prevalence of overweight or obesity ranged from 50.8% (95% CI 49.1-52.5) among Chinese adults to 79.8% (73.5-84.9) among Samoan adults. Prevalence of being uninsured among Hispanic subgroups ranged from 11.4% (10.9-11.9) among Puerto Rican adults to 33.0% (32.5-33.5) among Mexican adults. CONCLUSIONS: These findings underscore the importance of using disaggregated race and ethnicity data to accurately characterize disparities in type 2 diabetes risk factors and access to care.

Aim: This study assessed changes in testing for blood glucose in the United States (US) from 2019 to 2021. Methods: We conducted a serial cross-sectional analysis of the 2019–2021 National Health Interview Survey by including adults aged ≥ 18 years without reported diagnosed diabetes. We estimated the prevalence of testing for blood glucose within 12 months and the difference in the testing prevalence between 2019 and 2021. Results: The study sample included 82,594 respondents without diabetes in 2019––2021, with a mean age between 46.4 and 46.8 years. Overall, the prevalence of testing for blood glucose decreased significantly from 64.2 % (95 % confidence interval [CI] 63.3 %, 65.1 %) in 2019 to 60.0 % (95 % CI 59.1 %, 60.9 %) in 2021. Among adults who met the United States Preventive Services Task Force's 2015 screening recommendation, the prevalence decreased from 73.4 % (95 % CI 72.2 %, 74.6 %) to 69.5 % (95 % CI 68.3 %, 70.6 %). Although decreases in testing were observed in most groups, the extent of the decline differed by subgroups. Conclusions: Testing for blood glucose decreased in the US during the COVID-19 pandemic. This may have delayed diagnosis and treatment of prediabetes and diabetes, underscoring the importance of continued access to diabetes screening during pandemics. © 2023

BACKGROUND: Frequent intake of sugar-sweetened beverages (SSBs) among U.S. adults is a public health concern, because it has been associated with increased risks for adverse health outcomes such as obesity, type 2 diabetes, and cardiovascular disease. In contrast, drinking plain water (such as tap, bottled, or unsweetened sparkling water) instead of drinking SSBs might provide health benefits by improving diet quality and helping prevent chronic diseases. However, there is limited information on estimated expenditures on SSBs or bottled water among U.S. households. OBJECTIVE: This study examined differences in SSB and bottled water purchasing according to household and geographic area characteristics and estimated costs spent on purchasing SSB and bottled water from retail stores among a nationally representative sample of U.S. households. DESIGN: This study is a secondary analysis of the 2015 Circana (formerly Information Resources Inc. [IRI]) Consumer Network Panel (CNP) data, which were merged with the USDA nutrition data using the USDA Purchase-to-Plate Crosswalk-2015 (PPC) dataset (the latest available version of the PPC at the time the study began), and the Child Opportunity Index 2.0 (COI) data. PARTICIPANTS/SETTINGS: A total of 63,610 households, representative of the contiguous U.S. population, consistently provided food and beverage purchase scanner data from retail stores throughout 2015. EXPLANATORY VARIABLES: The included demographic and socioeconomic variables were household head's age, marital status, highest education level, race and ethnicity of the primary shopper in the household, family income relative to the federal poverty level, and presence of children in the household. Additionally, descriptors of households' residential areas were included, such as the county-level poverty prevalence, urbanization, census region, and census tract level Child Opportunity Index. MAIN OUTCOME MEASURES: Annual per capita spending (USD) on SSB and bottled water and daily per capita SSB calories purchased. STATISTICAL ANALYSIS: Unadjusted and multivariable adjusted mean values of the main outcome measures were compared by household demographic, socioeconomic, and geographic characteristics using linear regression analysis including Circana's household projection factors. RESULTS: Nearly all households reported purchasing SSBs at least once during 2015 and spent on average $47 (interquartile range [IQR]: $20) per person per year on SSBs, which corresponded to 211 kcal (IQR: 125 kcal) of SSBs per person per day. About 7 in 10 households reported purchasing bottled water at least once during 2015 and spent $11 (IQR: $5) per person on bottled water per year. Both annual per capita SSB and bottled water spending, and daily per capita SSB calories purchased was highest for households whose heads were between 40-59 years of age, had low household income, or lived in poor counties, or counties with a low Child Opportunity Index. Annual per capita spending was also higher for households with never married/widowed/divorced head, or at least one non-Hispanic Black head, and households without children, or those living in the South. Daily per capita SSB calorie purchases were highest for households where at least one head had less than a high school degree, households with at least one Hispanic or married head, and households with children or those living in the Midwest. CONCLUSIONS: These findings suggest that households that had lower socioeconomic status had higher annual per capita spending on SSBs and bottled water and higher daily per capita total SSB calories purchased than households with higher socioeconomic status.

INTRODUCTION: Policies and practices at the local level can help reduce chronic disease risk by providing environments that facilitate healthy decision-making about diet. METHODS: We used data from the 2014 and 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living to examine prevalence among US municipalities of policies to support access to healthier food in supermarkets, convenience stores, and farmers markets, as well as policies to support breastfeeding among government employees. Chi-square tests were conducted to compare prevalence estimates from 2021 to 2014 overall and according to municipal characteristics. RESULTS: In 2021, 29% of municipalities had at least 1 policy to encourage full-service grocery stores to open stores, which was not significantly different from 31% in 2014. Prevalence of having at least 1 policy to help corner stores sell healthier foods declined significantly from 13% in 2014 to 9% in 2021. Prevalence of policies providing all local government employees who were breastfeeding breaktime and space to pump breast milk increased significantly from 25% in 2014 to 52% in 2021. The percentage of municipalities that provided 8 or more weeks of paid maternity leave for employees increased significantly from 16% in 2014 to 19% in 2021. CONCLUSION: Prevalence of supports for supermarkets, convenience stores, and farmers markets generally did not increase among US municipalities from 2014 to 2021, while some supports for breastfeeding among municipal employees increased during this time. Opportunities exist to improve municipal-level policies that support healthy eating and breastfeeding among community residents and employees.

OBJECTIVES: Examine differences in perceptions of tap water (TW) and bottled water (BW) safety and TW taste and their associations with plain water (PW) and sugar-sweetened beverage (SSB) intake. DESIGN: Quantitative, cross-sectional study. SETTING: United States. SUBJECTS: 4,041 U.S. adults (≥18 years) in the 2018 SummerStyles survey data. MEASURES: Outcomes were intake of TW, BW, PW (tap and bottled water), and SSB. Exposures were perceptions of TW and BW safety and TW taste (disagree, neutral, or agree). Covariates included sociodemographics. ANALYSIS: We used chi-square analysis to examine sociodemographic differences in perceptions and multivariable logistic regressions to estimate adjusted odds ratios (AOR) for consuming TW ≤ 1 cup/day, BW > 1 cup/day, PW ≤ 3 cups/day, and SSB ≥ 1 time/day by water perceptions. RESULTS: One in 7 (15.1%) of adults did not think their home TW was safe to drink, 39.0% thought BW was safer than TW, and 25.9% did not think their local TW tasted good. Adults who did not think local TW was safe to drink had higher odds of drinking TW ≤ 1 cup/day (AOR = 3.12) and BW >1 cup/day (AOR = 2.69). Adults who thought BW was safer than TW had higher odds of drinking TW ≤1 cup/day (AOR = 2.38), BW > 1 cup/day (AOR = 5.80), and SSB ≥ 1 time/day (AOR = 1.39). Adults who did not think TW tasted good had higher odds of drinking TW ≤ 1 cup/day (AOR = 4.39) and BW > 1 cup/day (AOR = 2.91). CONCLUSIONS: Negative perceptions of TW safety and taste and a belief BW is safer than TW were common and associated with low TW intake. Perceiving BW is safer than TW increased the likelihood of daily SSB intake. These findings can guide programs and services to support water quality to improve perceptions of TW safety and taste, which might increase TW intake and decrease SSB intake.

The benefits of physical activity to health and obesity prevention are well established. However, attributes of the built environment influence participation in physical activity. The purpose of this study is to assess differences in perceptions of neighborhood walkability across demographic characteristics and social environment factors among rural residents. In a telephone survey, adult respondents (N = 448) across nine rural counties in a southeastern state answered questions about perceived neighborhood walkability, demographic characteristics, and their neighborhood social environment. Study recruitment for a convenience sample occurred through collaborations with local community organizations. Prevalence of destinations and barriers were estimated according to demographic and neighborhood social environment characteristics. Multiple logistic regression models assessed the association of demographic and neighborhood social environment characteristics with neighborhood walkability and calculated adjusted prevalence. Relaxing places to walk were the most often reported destinations (62.0%), followed by retail destinations (45.7%), and communal destinations (42.6%). Traffic was the most reported barrier to safe walking (40.4%), followed by animals (37.5%), and crime (30.5%). Perceptions of retail and communal destinations varied by age and race. Perceptions of traffic and crime as barriers varied by race, weight status, and income. Community belonging and social cohesion were associated with lower perceptions of barriers. Study findings present demographic characteristics and social environment attributes as key factors that shape perceived neighborhood walkability. Findings can help inform programmatic efforts and environmental change strategies to improve walking in rural areas.

Practitioners in health departments, university extension programs, and nonprofit organizations working in public health face varied challenges to publishing in the peer-reviewed literature. These practitioners may lack time, support, skills, and efficacy needed for manuscript submission, which keeps them from sharing their wisdom and experience-based evidence. This exclusion can contribute to literature gaps, a failure of evidence-based practice to inform future research, reduced ability to educate partners, and delays in advancing public health practice. Our article describes the writing workshops offered to Division of Nutrition, Physical Activity, and Obesity (DNPAO), Centers for Disease Control and Prevention (CDC) funded programs in 2021. This project consisted of three 60-minute introductory writing webinars open to all recipients, followed by a Writing for Publications workshop, an 8- to 9-week virtual learning/writing intensive for selected writing team applicants. The Society for Public Health Education staff, consultants, and CDC/DNPAO staff developed, refined, and presented the curriculum. The workshop for public health practitioner writing teams was offered to two cohorts and included extensive coaching and focused on potential submission to a Health Promotion Practice supplement, "Reducing Chronic Disease through Physical Activity and Nutrition: Public Health Practice in the Field" (see Supplemental Material), which was supported by CDC/DNPAO. We describe the webinars, the workshop design, modifications, evaluation methods and results.

PURPOSE: Food service guidelines (FSG) policies can impact the nutritional quality of millions of meals sold or served to government employees, citizens in public places, or institutionalized persons. This study examines state FSG policies adopted January 1, 2015 to April 1, 2019, and uses a FSG Classification Tool (FSG Tool) to quantify alignment with nutrition recommendations for public health impact. DESIGN: Quantitative Content Analysis. SETTING: State Government Worksites and Facilities. PARTICIPANTS: 50 states and District of Columbia (D.C.) in the United States. MEASURES: Frequency of policies and percent alignment to FSG tool. ANALYSIS: FSG policies were identified using legal databases to assess state statutes, regulations, and executive orders. Content analysis and coding determined attributes of policies across 4 FSG Tool domains, (1) nutrition standards referenced; (2) behavioral design strategies encouraging selection of healthier offerings; (3) facility efficiency and environmental sustainability; and (4) FSG implementation supports. RESULTS: From 2015-2019, 5 FSG policies met study inclusion criteria. Four out of 5 policies earned a perfect nutrition score (100%) by referencing nutrition standards that align with the Dietary Guidelines for Americans (DGA) and are operationalized for use in food service venues. Four out of 5 policies included at least 1 implementation supports provision, such as naming an implementing agency, and 2 included provisions that encourage local food sourcing. CONCLUSION: From 2015-2019, overall FSG policy comprehensiveness scores ranged from 24% to 73%, with most policies referencing food and nutrition standards that align to national nutrition recommendations. Public health practitioners can educate decision makers on the potential impact of FSG policies on diet-related health outcomes and associated cost savings, as well as other important co-benefits that support locally grown products and environmental sustainability practices.

OBJECTIVE: To examine factors associated with water filter use (WFU) for drinking tap water at home and its association with consuming plain water and sugar-sweetened beverages (SSBs). DESIGN: Quantitative, cross-sectional study. SETTING: The 2018 SummerStyles survey data. SUBJECTS: U.S. adults (≥18 years; N=4042). MEASURES: Outcomes were intake of plain water (tap/bottled water) and SSBs. Exposure was WFU (yes, no, not drinking tap water at home). Covariates included sociodemographics, weight status, Census regions, and home ownership status. ANALYSIS: We used multivariable logistic regressions to estimate adjusted odds ratios (AOR) and 95% confidence interval (CI) for consuming tap water, bottled water, or total plain water >3 cups/day (vs. ≤3 cups) and SSBs ≥1 time/day (vs. <1 time) by WFU. RESULTS: Overall, 36% of adults reported using a filter for drinking tap water at home; 14% did not drink tap water at home. Hispanics had significantly higher odds of using a water filter (AOR=1.50, 95% CI=1.14-1.98) vs non-Hispanic White. Factors significantly associated with lower odds of WFU were lower education (AOR=.69, 95% CI=.55-.86 for ≤high school; AOR=.78, 95% CI=.64-.95 for some college, vs college graduate), not being married (AOR=.81, 95% CI=.66-.98, vs married/domestic partnership), and lower household income (AOR=.68, 95% CI=.68-.90 for <$35,000, vs ≥$100,000). Using a water filter was associated with higher odds of drinking >3 cups/day of tap water (AOR=1.33, 95% CI=1.13-1.56) and lower odds of SSBs ≥1 time/day (AOR=.76, 95% CI=.62-.92). Not drinking tap water at home was associated with higher odds of drinking >3 cups/day bottled water (AOR=3.46, 95% CI=2.70-4.44). CONCLUSIONS: WFU was associated with higher tap water intake and lower SSB intake among U.S. adults. WFU was higher among Hispanics, but lower among those with lower education and income and not married adults. Although WFU was associated with healthful beverage habits, additional considerations for WFU may include source water quality, oral health, cost, and proper use.

INTRODUCTION: Local governments can address access to healthy food and transportation through policy and planning. This study is the first to examine municipal-level transportation supports for food access. METHODS: We used a nationally representative sample of US municipalities with 1,000 or more persons from the 2014 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living (N = 2,029) to assess 3 outcomes: public transit availability, consideration of food access in transportation planning, and presence of demand-responsive transportation (DRT). We used χ(2) tests to compare prevalences by municipal characteristics including population size, rurality, census region, median educational attainment, poverty prevalence, racial and ethnic population distribution, and low-income low-access to food (LILA) status. RESULTS: Among municipalities, 33.7% reported no public transit and 14.8% reported having DRT. Both public transit and DRT differed by population size (both P < .001) and census region (both P < .001) and were least commonly reported among municipalities with populations less than 2,500 (46.9% without public transit; 6.6% with DRT) and in the South (40.0% without public transit; 11.1% with DRT). Of those with public transit, 33.8% considered food access in transportation planning; this was more common with greater population size (55.9% among municipalities of ≥50,000 persons vs 16.8% among municipalities of <2,500 persons; P < .001), in the West (43.1% vs 26.8% in the Northeast, 33.7% in the Midwest, 32.2% in the South; P = .003), and municipalities with 20% or more of the population living below federal poverty guidelines (37.4% vs 32.2% among municipalities with less than 20% living in poverty; P = .07). CONCLUSION: Results suggest that opportunities exist to improve food access through transportation, especially in smaller and Southern communities, which may improve diet quality and reduce chronic disease.

Food policy councils (FPCs) are one form of community coalition that aims to address challenges to local food systems and enhance availability, accessibility, and affordability of healthy foods for local residents. We used data from the 2014 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living, a nationally representative survey of US municipalities (n = 2029), to examine the prevalence of FPCs and cross-sectional associations between FPCs and four types of supports for healthy food access (approaches to help food stores, practices to support farmers markets, transportation-related supports, and community planning documents). Overall, 7.7% of municipalities reported having a local or regional FPC. FPCs were more commonly reported among larger municipalities with ≥50,000 people (29.2%, 95% Confidence Interval (CI): 21.6, 36.8) and western region municipalities (13.2%, 95% CI: 9.6, 16.8). After multivariable adjustment, municipalities with FPCs had significantly higher odds of having all four types of supports, compared to those without FPCs (adjusted odds ratio (aOR) range: 2.4–3.4). Among municipalities with FPCs (n = 156), 41% reported having a local government employee or elected official as a member, and 46% had a designated health or public health representative. Although FPCs were uncommon, municipalities that reported having a local or regional FPC were more likely to report having supports for healthy food access for their residents.

PURPOSE: To examine factors associated with frequency of plain water (ie, tap, bottled, and unflavored sparkling water) intake among US high school students. DESIGN: Quantitative, cross-sectional study. SETTING: The 2017 national Youth Risk Behavior Survey data. SUBJECTS: US high school students with plain water intake data (N = 10 698). MEASURES: The outcome was plain water intake. Exposure variables were demographics, academic grades, and behavioral characteristics. ANALYSIS: We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for factors associated with infrequent plain water intake (<3 vs >/=3 times/day). RESULTS: Overall, 48.7% of high school students reported drinking plain water <3 times/day. Factors associated with infrequent plain water intake were younger age (</=15 years; aOR = 1.20, CI = 1.05-1.37); earning mostly D/F grades (aOR = 1.37, CI = 1.07-1.77); consuming regular soda 1 to 6 times/week (aOR = 1.92, CI = 1.67-2.20) or >/=1 time/day (aOR = 3.23, CI = 2.65-3.94), sports drinks 1 to 6 times/week (aOR = 1.30, CI = 1.14-1.49), milk <2 glasses/day (aOR = 1.51, CI = 1.31-1.73), fruits <2 times/day (aOR = 1.92, CI = 1.66-2.22), and vegetables <3 times/day (aOR = 2.42, CI = 2.04-2.89); and being physically active >/=60 minutes/day on <5 days/week (aOR = 1.83, CI = 1.60-2.08). Students with obesity were less likely to have infrequent water intake (aOR = 0.63, CI = 0.53-0.74). CONCLUSIONS: Infrequent plain water intake was associated with younger age, poor academic grades, poor dietary behaviors, and physical inactivity. These findings can inform intervention efforts to increase water intake to promote healthy lifestyles among adolescents.

PURPOSE: To provide a nationally representative description on the prevalences of policies, practices, programs, and supports relating to worksite wellness in US hospitals. DESIGN: Cross-sectional, self-report of hospitals participating in Workplace Health in America (WHA) survey from November 2016 through September 2017. SETTING: Hospitals across the United States. PARTICIPANTS: Random sample of 338 eligible hospitals participating in the WHA survey. MEASURES: We used previous items from the 2004 National Worksite Health Promotion survey. Key measures included presence of Worksite Health Promotion programs, evidence-based strategies, health screenings, disease management programs, incentives, work-life policies, barriers to health promotion program implementation, and occupational safety and health. ANALYSIS: Independent variables included hospital characteristics (eg, size). Dependent characteristics included worksite health promotion components. Descriptive statistics and chi(2) analyses were used. RESULTS: Eighty-two percent of hospitals offered a wellness programs during the previous year with larger hospitals more likely than smaller hospitals to offer programs (P < .01). Among hospitals with wellness programs, 69% offered nutrition programs, 74% offered physical activity (PA) programs, and 84% had a policy to restrict all tobacco use. Among those with cafeterias or vending machines, 40% had a policy for healthier foods. Only 47% and 25% of hospitals offered lactation support or healthy sleep programs, respectively. CONCLUSION: Most hospitals offer wellness programs. However, there remain hospitals that do not offer wellness programs. Among those that have wellness programs, most offer supports for nutrition, PA, and tobacco control. Few hospitals offered programs on healthy sleep or lactation support.

BACKGROUND: Nutrition interventions are a common component of worksite wellness programs and have been recognized as an effective strategy to change employee dietary behaviors. However, little is known about worksite food behaviors or the foods that are obtained at workplaces at the national level. OBJECTIVE: The aims were to examine the frequency of and the amount of money spent obtaining foods at work among employed US adults, to determine the foods most commonly obtained at work, and to assess the dietary quality of these foods. DESIGN: This is a cross-sectional analysis of data from the US Department of Agriculture Food Acquisition and Purchasing Survey, a nationally representative household survey conducted from April 2012 through January 2013 on food purchases and acquisitions during a 7-day study period. PARTICIPANTS: The study included 5,222 employed adult Americans. MAIN OUTCOME MEASURES: The study assessed the prevalence of obtaining any foods at work overall and according to sociodemographic subgroups, number of acquisitions and calories obtained, most commonly obtained foods and leading food sources of calories, and 2010 Healthy Eating Index (HEI) scores that represent dietary quality. STATISTICAL ANALYSES PERFORMED: Prevalence estimates of obtaining >/=1 foods at work were compared according to sociodemographic characteristic using chi(2) tests. RESULTS: Nearly a quarter (23.4%) of working adults obtained foods at work during the week, and the foods they obtained averaged 1,292 kcal per person per week. The leading food types obtained included foods typically high in solid fat, added sugars, or sodium, such as pizza, regular soft drinks, cookies or brownies, cakes and pies, and candy. HEI scores suggest that work foods are high in empty calories, sodium, and refined grains and low in whole grains and fruit. CONCLUSIONS: Working adults commonly obtain foods at work, and the foods they obtain have limited dietary quality. Future research should examine the role worksites can play to help ensure access to and promote healthier options.

PURPOSE: Local governments can implement food service guideline (FSG) policies, which, in large cities, may reach millions of people. This study identified FSG policies among the 20 largest US cities and analyzed them for key FSG policy attributes. DESIGN: Quantitative research. SETTING: Local government facilities. PARTICIPANTS: Twenty largest US cities. MEASURES: Frequency of FSG policies and percent alignment to tool. ANALYSIS: Using municipal legal code libraries and other data sources, FSG policies enacted as of December 31, 2016, were identified. Full-text reviews were conducted of identified policies to determine whether they met inclusion criteria. Included policies were analyzed for key policy attributes specific to nutrition, behavioral design, implementation, and facility efficiency. RESULTS: Searches identified 469 potential FSG policies, of which 6 policies across 5 cities met inclusion criteria. Five policies met a majority of criteria assessed by the classification tool. Overall alignment to the tool ranged from 17% to 88%. Of the 6 policies, 5 met a majority of the nutrition attributes and 5 met at least 50% of attributes associated with implementation. No policies met the attributes associated with facility efficiency. CONCLUSION: The FSG policies were identified in 5 of the 20 US cities. Policy alignment was high for nutrition and implementation attributes. This analysis suggests that when cities adopt FSG policies, many develop policies that align with key policy attributes. These policies can serve as models for other jurisdictions to create healthier food access through FSGs.

We described sociodemographic differences in perceptions of drinking water safety and examined associations between perceptions and plain water intake. We used the 2015 Estilos survey of 1,000 US Hispanic adults conducted in both Spanish and English. Outcome was water intake. Exposures were the level of agreement about water perceptions (My tap water is safe to drink; Community tap water is safe to drink; Bottled water is safer; I would buy less bottled water if my tap water was safe). Covariates were sociodemographics, region, Hispanic heritage, and acculturation. We used chi-square tests and multinomial logistic regression to examine associations of water perceptions and intake. Overall, 24% of Hispanic adults consumed water </=1 time/day. Although 34% disagreed their home tap water was safe to drink, and 41% disagreed their community tap water was safe to drink, 65% agreed bottled water is safer than tap water, and 69% agreed they would buy less bottled water if they knew their tap water was safe. Perceptions differed by some covariates but were not significantly associated with plain water intake. In conclusion, negative perceptions of tap water were common among US Hispanic adults, which can inform efforts to increase awareness about safe public water systems.

Background: Both excessive sodium intake and obesity are risk factors for hypertension and cardiovascular disease. The association between sodium intake and obesity is unclear, with few studies assessing sodium intake using 24-h urine collection. Objectives: Our objective was to assess the association between usual 24-h sodium excretion and measures of adiposity among US adults. Methods: Cross-sectional data were analyzed from a sample of 730 nonpregnant participants aged 20-69 y who provided up to 2 complete 24-h urine specimens in the NHANES 2014 and had data on overweight or obesity [body mass index (kg/m2) >/=25] and central adiposity [waist circumference (WC): >88 cm for women, >102 cm for men]. Measurement error models were used to estimate usual sodium excretion, and multiple linear and logistic regression models were used to assess its associations with measures of adiposity, adjusting for sociodemographic, health, and dietary variables [i.e., energy intake or sugar-sweetened beverage (SSB) intake]. All analyses accounted for the complex survey sample design. Results: Unadjusted mean +/- SE usual sodium excretion was 3727 +/- 43.5 mg/d and 3145 +/- 55.0 mg/d among participants with and without overweight/obesity and 3653 +/- 58.1 mg/d and 3443 +/- 35.3 mg/d among participants with or without central adiposity, respectively. A 1000-mg/d higher sodium excretion was significantly associated with 3.8-units higher BMI (95% CI: 2.8, 4.8) and a 9.2-cm greater WC (95% CI: 6.9, 11.5 cm) adjusted for covariates. Compared with participants in the lowest quartile of sodium excretion, the adjusted prevalence ratios in the highest quartile were 1.93 (95% CI: 1.69, 2.20) for overweight/obesity and 2.07 (95% CI: 1.74, 2.46) for central adiposity. The associations also were significant when adjusting for SSBs, instead of energy, in models. Conclusions: Higher usual sodium excretion is associated with overweight/obesity and central adiposity among US adults.

PURPOSE:: As part of wellness efforts, employers may seek to improve the nutritional quality of foods offered and consumed in cafeterias and vending machines. However, little is known about who consumes food from these venues and the types and dietary quality of the foods consumed. DESIGN:: Cross-sectional. SETTING:: Nonschool cafeterias and vending machines. PARTICIPANTS:: US adults >/=20 years old. MEASURES:: Prevalence of consuming foods, most common foods eaten, leading calorie sources, 2010 Healthy Eating Index. ANALYSIS:: Using 24-hour dietary recall data from NHANES 2005-2014 (N = 25,549 adults), we estimated the prevalence of consuming foods, assessed the most commonly consumed foods, and calculated dietary quality of foods. RESULTS:: On a given day, 3.1% of adults consumed foods from cafeterias and 3.9% from vending machines. Consumers averaged 692 kcal from cafeterias and 264 kcal from vending machines. Cafeteria consumers had higher income and education, while vending consumers were more likely to be male and younger adults. Common cafeteria foods included vegetables and fruits, but cafeteria foods were generally high in sodium and low in whole grains. Sugar-sweetened beverages and candies accounted for approximately half of all vending calories. CONCLUSION:: Foods chosen from cafeterias and vending machines do not align well with the Dietary Guidelines for Americans. Improving the dietary quality of foods consumed from these venues could impact millions of adults.

We examined community-level characteristics associated with free drinking water access policies in U.S. municipalities using data from a nationally representative survey of city managers/officials from 2,029 local governments in 2014. Outcomes were 4 free drinking water access policies. Explanatory measures were population size, rural/urban status, census region, poverty prevalence, education, and racial/ethnic composition. We used multivariable logistic regression to test differences and presented only significant findings. Many (56.3%) local governments had at least one community plan with a written objective to provide free drinking water in outdoor areas; municipalities in the Northeast and South regions and municipalities with </= 50% of non-Hispanic whites were less likely and municipalities with larger population size were more likely to have a plan. About 59% had polices/budget provisions for free drinking water in parks/outdoor recreation areas; municipalities in the Northeast and South regions were less likely and municipalities with larger population size were more likely to have it. Only 9.3% provided development incentives for placing drinking fountains in outdoor, publicly accessible areas; municipalities with larger population size were more likely to have it. Only 7.7% had a municipal plumbing code with a drinking fountain standard that differed from the statewide plumbing code; municipalities with a lower proportion of non-Hispanic whites were more likely to have it. In conclusion, over half of municipalities had written plans or a provision for providing free drinking water in parks, but providing development incentives or having a local plumbing code provision were rare.

PURPOSE: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent knowledge of SSB-related health risks. DESIGN: Quantitative, cross-sectional. SETTING: 2014 SummerStyles survey. SUBJECTS: Nine hundred and ninety parent and adolescent (12-17 years) pairs. MEASURES: The outcome was self-reported adolescent intake (0, >0 to <1, or >/=1 time/day) of SSBs (soda, fruit drinks, sports/energy drinks, other SSBs). The exposures were self-reported parent SSB intake (0, >0 to <1, >/=1 to <2, or >/=2 times/day) and parent and adolescent knowledge of SSB-related health risks (weight gain, diabetes, and dental caries). ANALYSIS: Separate multinomial logistic regression models were used to estimate adjusted odds ratios (aORs) for adolescent SSB intake >/=1 time/day (ref: 0 times/day), according to (1) parent SSB intake and (2) parent and (3) adolescent knowledge. RESULTS: About 31% of adolescents consumed SSBs >/=1 time/day, and 43.2% of parents consumed SSBs >/=2 times/day. Adolescent and parent knowledge that SSB intake is related to health conditions ranged from 60.7% to 80.4%: weight gain (75.0% and 80.4%, respectively), diabetes (60.7% and 71.4%, respectively), and dental caries (77.5% and 72.9%, respectively). In adjusted models, adolescent SSB intake >/=1 time/day was associated with parent intake >/=2 times/day (aOR = 3.30; 95% confidence interval = 1.62-6.74) but not with parent or adolescent knowledge of health risks. CONCLUSION: Parental SSB intake may be an important factor in understanding adolescent behavior; knowledge of SSB-related health conditions alone may not influence adolescent SSB behavior.

PURPOSE: To examine differences in students' access to school salad bars across sociodemographic groups and changes in availability over time. DESIGN: Nonexperimental. SETTING: Nationally representative 2011 and 2014 YouthStyles surveys. PARTICIPANTS: A total of 833 (2011) and 994 (2014) US youth aged 12 to 17 years. MEASURES: Youth-reported availability of school salad bars. ANALYSIS: Multivariable logistic regression models were used to assess differences in school salad bar availability by sociodemographics and changes in availability from 2011 to 2014. RESULTS: Youth-reported salad bar availability differed by age in 2011 and race/ethnicity in 2014, but not by sex, income, metropolitan residence, or region in either year. Salad bars were reported by 62% of youth in 2011 and 67% in 2014; the increase was not statistically significant ( P = .07). Significant increases from 2011 to 2014 were noted among youth aged 12 to 14 years (56%-69%; P < .01), youth of non-Hispanic other races (60%-85%; P < .01), and youth in the Midwest (58%-72%; P = .01). CONCLUSION: These results suggest that youth-reported access to school salad bars does not differ significantly across most sociodemographic groups. Although overall salad bar availability did not increase significantly from 2011 to 2014, some increases were observed among subgroups. Continued efforts to promote school salad bars through initiatives such as Let's Move Salad Bars to Schools could help increase access for the nearly one-third of US youth reporting no access.

The ability to make healthy choices is influenced by where one lives, works, shops, and plays. Locally enacted policies and standards can influence these surroundings but little is known about the prevalence of such policies and standards that support healthier behaviors. In this paper, we describe the development of a survey questionnaire designed to capture local level policy supports for healthy eating and active living and findings and lessons learned from a 2012 pilot in two states, Minnesota and California, including respondent burden, survey sampling and administration methods, and survey item feasibility issues. A 38-item, web-based, self-administered survey and sampling frame were developed to assess the prevalence of 22 types of healthy eating and active living policies in a representative sample of local governments in the two states. The majority of respondents indicated the survey required minimal effort to complete with half taking < 20 min to complete the survey. A non-response follow-up plan including emails and phone calls was required to achieve a 68% response rate (versus a 37% response rate for email only reminders). Local governments with larger residential populations reported having healthy eating and active living policies and standards more often than smaller governments. Policies that support active living were more common than those that support healthy eating and varied within the two states. The methods we developed are a feasible data collection tool for estimating the prevalence of municipal healthy eating and active living policies and standards at the state and national level.

INTRODUCTION: The Institute of Medicine and Centers for Disease Control and Prevention have recommended that government agencies use nutrition standards for foods and beverages sold and provided at their facilities. In this study, we examine written nutrition standards for foods sold or served in local government buildings or worksites among US municipalities. METHODS: We used data from a 2014 national survey of 1,945 municipal governments serving populations of 1,000 or more to assess the presence of written nutrition standards, the food groups or nutrients addressed by standards, and the populations served by facilities where standards are applied. The prevalence of standards was estimated by municipality population size, rural-urban status, census region, poverty prevalence, education level, and racial/ethnic composition. RESULTS: Overall, 3.2% of US municipalities reported nutrition standards with greater prevalence observed among large municipalities (12.8% of municipalities with ≥50,000 people vs 2.2% of municipalities with <2,500 people, P < .001). Prevalence differed by region, and standards were most common in the West (6.6%) and least common in the Midwest (2.0%, P = .003).The most common nutrition topics addressed in standards were offering low-calorie beverages, fruits and vegetables, and free drinking water. Most standards applied to facilities serving government employees (67%) or the general public (66%), with fewer serving institutionalized populations (23%). CONCLUSION: Few municipal governments reported having written nutrition standards for foods and beverages sold in their facilities in 2014. Implementing nutrition standards for foods sold or served by local governments is a strategy for increasing access to healthier foods and beverages among municipal employees and local residents.

PURPOSE: Low availability and affordability of healthier foods in food stores on the Navajo Nation (NN) may be a community-level risk factor for the high prevalence of obesity among the Navajo people. This study assessed the availability and pricing of foods and beverages in supermarkets and convenience stores throughout the NN. DESIGN: Descriptive study design using the Nutrition Environment Measurement Survey in Stores audit tool. SETTING: Supermarkets (n = 13) and convenience stores (n = 50) on NN and border-town supermarkets (n = 9). SUBJECTS: Not applicable. MEASURES: Availability and pricing of healthy and less-healthy foods. ANALYSIS: Descriptive and chi(2) analyses. RESULTS: Navajo convenience stores offered fewer healthier food options compared to Navajo supermarkets. In Navajo convenience stores, 100% whole grain products, reduced-fat cheese, lean meats, reduced-fat chips, and fat-free or light hot dogs were available in fewer stores than their corresponding less-healthy versions (all with p < .05). In both Navajo supermarkets and convenience stores, 100% whole wheat bread, lean cold cuts, and reduced-fat cheese were all more expensive per unit than their corresponding less-healthy versions (all with p < .05). CONCLUSIONS: According to this study, healthier foods are not as readily available in Navajo convenience stores as they are in Navajo supermarkets. Improving access to and affordability of healthier foods in reservation stores of all sizes may support healthy eating among Navajo residents.

PURPOSE: We assessed public support for required water access in schools and parks and perceived safety and taste of water in these settings to inform efforts to increase access to and consumption of tap water. DESIGN: Cross-sectional survey of the US public collected from August to November 2011. SETTING: Random digit-dialed telephone survey. PARTICIPANTS: Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states. MEASURES: Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings. ANALYSIS: Survey-adjusted perceived safety and taste as well as support for required access were estimated. RESULTS: There was broad support for required access to water throughout the day in schools (96%) and parks (89%). Few participants believed water was unsafe in schools (10%) or parks (18%). CONCLUSION: This study provides evidence of public support for efforts to increase access to drinking water in schools and parks and documents overall high levels of perceived taste and safety of water provided in these settings.