Table 3. Trends in Diet Quality of Foods From Different Sources Among US Adults (≥20 Years of Age), NHANES 2003-2018a.
| Diet components (scoring range) | Survey-weighted AHA mean score (95% CI) | P value for trend | Difference (95% CI) for 2017-2018 vs 2003-2004 | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2003-2004 (n = 4448) | 2005-2006 (n = 4520) | 2007-2008 (n = 5420) | 2009-2010 (n = 5762) | 2011-2012 (n = 4801) | 2013-2014 (n = 5047) | 2015-2016 (n = 5017) | 2017-2018 (n = 4742) | |||
| AHA diet score (0-80) | ||||||||||
| Grocery stores | 35.8 (34.6 to 36.9) | 37.6 (36.5 to 38.7) | 37.7 (36.3 to 39.0) | 38.4 (37.7 to 39.1) | 39.5 (38.6 to 40.3) | 39.1 (38.2 to 39.9) | 38.5 (37.5 to 39.5) | 38.3 (37.0 to 39.5) | <.001 | 2.51 (0.85 to 4.17) |
| Restaurants | 28.5 (27.8 to 29.2) | 28.4 (27.8 to 28.9) | 28.1 (27.6 to 28.6) | 28.6 (27.8 to 29.3) | 29.1 (28.3 to 29.9) | 29.5 (28.9 to 30.2) | 29.0 (28.1 to 29.9) | 29.0 (28.2 to 29.7) | .02 | 0.42 (−0.60 to 1.43) |
| Worksites | 33.5 (32.3 to 34.7) | 32.7 (31.9 to 33.6) | 33.1 (32.3 to 33.9) | 34.3 (33.5 to 35.1) | 33.8 (32.2 to 35.3) | 34.3 (32.8 to 35.9) | 34.6 (33.4 to 35.9) | 33.4 (32.1 to 34.7) | .13 | −0.07 (−1.90 to 1.72) |
| Other sources | 36.1 (35.3 to 37.0) | 35.5 (34.7 to 36.3) | 35.1 (34.3 to 35.9) | 35.5 (34.7 to 36.3) | 35.6 (35.0 to 36.1) | 34.7 (34.2 to 35.3) | 35.0 (34.2 to 35.7) | 34.7 (33.9 to 35.6) | .02 | −1.40 (−2.60 to −0.19) |
| Fruits and vegetables (0-10) | ||||||||||
| Grocery stores | 4.87 (4.57 to 5.16) | 4.97 (4.73 to 5.21) | 5.01 (4.73 to 5.29) | 5.11 (4.99 to 5.23) | 5.17 (4.94 to 5.40) | 5.00 (4.77 to 5.23) | 4.99 (4.72 to 5.26) | 4.74 (4.50 to 4.97) | .58 | −0.13 (−0.51 to 0.25) |
| Restaurants | 4.30 (4.13 to 4.47) | 4.22 (4.02 to 4.41) | 3.93 (3.77 to 4.09) | 3.97 (3.81 to 4.14) | 3.83 (3.68 to 3.98) | 3.67 (3.53 to 3.81) | 3.50 (3.36 to 3.65) | 3.47 (3.25 to 3.70) | <.001 | −0.82 (−1.10 to −0.54) |
| Worksites | 2.53 (2.14 to 2.92) | 2.44 (1.95 to 2.93) | 1.81 (1.44 to 2.19) | 2.76 (2.37 to 3.14) | 2.93 (2.16 to 3.70) | 2.70 (2.20 to 3.20) | 3.12 (2.54 to 3.70) | 2.70 (2.23 to 3.17) | .03 | 0.17 (−0.45 to 0.78) |
| Other sources | 3.74 (3.36 to 4.12) | 4.08 (3.64 to 4.51) | 3.98 (3.65 to 4.31) | 4.02 (3.71 to 4.33) | 3.62 (3.27 to 3.97) | 3.11 (2.88 to 3.34) | 3.34 (3.01 to 3.68) | 3.24 (2.75 to 3.73) | <.001 | −0.50 (−1.10 to 0.12) |
| Whole grains (0-10) | ||||||||||
| Grocery stores | 2.60 (2.40 to 2.79) | 2.98 (2.80 to 3.15) | 2.95 (2.72 to 3.18) | 3.37 (3.22 to 3.52) | 3.50 (3.34 to 3.67) | 3.43 (3.28 to 3.58) | 3.33 (3.13 to 3.53) | 3.04 (2.78 to 3.30) | <.001 | 0.44 (0.11 to 0.77) |
| Restaurants | 0.36 (0.28 to 0.44) | 0.42 (0.34 to 0.51) | 0.44 (0.36 to 0.52) | 0.40 (0.32 to 0.48) | 0.68 (0.58 to 0.78) | 0.76 (0.64 to 0.88) | 0.81 (0.60 to 1.02) | 0.53 (0.38 to 0.67) | <.001 | 0.16 (0.002 to 0.33) |
| Worksites | 0.84 (0.32 to 1.37) | 0.60 (0.36 to 0.85) | 0.64 (0.39 to 0.89) | 0.99 (0.68 to 1.29) | 1.09 (0.66 to 1.51) | 1.10 (0.89 to 1.31) | 0.88 (0.47 to 1.30) | 0.63 (0.36 to 0.89) | .53 | −0.22 (−0.80 to 0.37) |
| Other sources | 0.67 (0.53 to 0.81) | 0.77 (0.62 to 0.92) | 0.78 (0.62 to 0.93) | 0.76 (0.62 to 0.91) | 0.95 (0.83 to 1.07) | 0.82 (0.73 to 0.90) | 0.98 (0.84 to 1.12) | 0.81 (0.68 to 0.93) | .02 | 0.14 (−0.05 to 0.32) |
| Fish and shellfish (0-10) | ||||||||||
| Grocery stores | 1.43 (1.20 to 1.65) | 1.48 (1.31 to 1.65) | 1.45 (1.31 to 1.59) | 1.58 (1.38 to 1.79) | 1.60 (1.37 to 1.82) | 1.50 (1.30 to 1.70) | 1.35 (1.13 to 1.57) | 1.37 (1.16 to 1.59) | .48 | −0.05 (−0.36 to 0.26) |
| Restaurants | 1.22 (1.01 to 1.44) | 1.28 (1.11 to 1.44) | 1.24 (1.04 to 1.44) | 1.29 (1.12 to 1.47) | 1.09 (0.92 to 1.25) | 1.24 (1.07 to 1.42) | 1.14 (0.99 to 1.29) | 1.28 (1.10 to 1.47) | .76 | 0.06 (−0.22 to 0.34) |
| Worksites | 0.26 (0.15 to 0.37) | 0.19 (0.09 to 0.29) | 0.30 (0.12 to 0.47) | 0.46 (0.13 to 0.79) | 0.47 (0.27 to 0.67) | 0.43 (0.15 to 0.71) | 0.48 (0.12 to 0.84) | 0.46 (0.15 to 0.78) | .02 | 0.21 (−0.13 to 0.54) |
| Other sources | 0.57 (0.36 to 0.78) | 0.86 (0.64 to 1.09) | 0.40 (0.30 to 0.50) | 0.71 (0.52 to 0.90) | 0.33 (0.23 to 0.43) | 0.43 (0.29 to 0.58) | 0.37 (0.29 to 0.45) | 0.37 (0.24 to 0.50) | <.001 | −0.20 (−0.45 to 0.05) |
| Nuts, seeds, and legumes (0-10) | ||||||||||
| Grocery stores | 3.93 (3.59 to 4.27) | 4.12 (3.79 to 4.44) | 4.04 (3.71 to 4.37) | 4.23 (4.01 to 4.46) | 4.43 (4.25 to 4.61) | 4.42 (4.15 to 4.69) | 4.55 (4.23 to 4.87) | 4.52 (4.20 to 4.84) | <.001 | 0.59 (0.12 to 1.06) |
| Restaurants | 1.01 (0.81 to 1.22) | 1.05 (0.88 to 1.22) | 1.07 (0.84 to 1.30) | 1.0 (0.80 to 1.19) | 1.32 (1.11 to 1.52) | 1.28 (1.14 to 1.41) | 1.46 (1.24 to 1.69) | 1.29 (1.06 to 1.52) | <.001 | 0.28 (−0.03 to 0.59) |
| Worksites | 1.30 (1.00 to 1.61) | 1.42 (1.05 to 1.78) | 1.21 (0.93 to 1.49) | 1.42 (1.16 to 1.67) | 1.67 (1.17 to 2.17) | 1.21 (0.81 to 1.61) | 1.25 (0.78 to 1.72) | 1.60 (0.98 to 2.22) | .56 | 0.30 (−0.40 to 0.99) |
| Other sources | 1.80 (1.61 to 1.98) | 1.72 (1.46 to 1.99) | 1.55 (1.35 to 1.75) | 1.45 (1.20 to 1.70) | 1.95 (1.70 to 2.21) | 2.01 (1.78 to 2.23) | 1.93 (1.74 to 2.12) | 1.92 (1.69 to 2.15) | .007 | 0.12 (−0.17 to 0.42) |
| Sugar-sweetened beverages (0-10) | ||||||||||
| Grocery stores | 6.06 (5.70 to 6.42) | 6.51 (6.21 to 6.81) | 6.41 (6.07 to 6.75) | 6.75 (6.59 to 6.91) | 6.96 (6.65 to 7.26) | 7.30 (7.00 to 7.59) | 7.35 (7.10 to 7.60) | 7.33 (6.93 to 7.73) | <.001 | 1.27 (0.73 to 1.81) |
| Restaurants | 7.08 (6.82 to 7.35) | 7.39 (7.16 to 7.62) | 7.44 (7.18 to 7.70) | 7.46 (7.25 to 7.66) | 7.41 (7.18 to 7.64) | 7.72 (7.41 to 8.02) | 7.59 (7.24 to 7.94) | 8.0 (7.62 to 8.38) | <.001 | 0.92 (0.46 to 1.38) |
| Worksites | 6.71 (6.27 to 7.15) | 6.84 (6.26 to 7.43) | 6.94 (6.39 to 7.49) | 7.19 (6.75 to 7.62) | 6.38 (5.88 to 6.88) | 6.78 (6.11 to 7.44) | 7.87 (7.33 to 8.41) | 7.17 (6.50 to 7.83) | .10 | 0.46 (−0.34 to 1.25) |
| Other sources | 8.41 (8.17 to 8.65) | 8.82 (8.57 to 9.06) | 8.78 (8.64 to 8.92) | 8.80 (8.65 to 8.95) | 8.47 (8.33 to 8.61) | 8.25 (8.07 to 8.43) | 8.38 (8.13 to 8.63) | 8.41 (8.18 to 8.65) | .006 | 0.005 (−0.33 to 0.34) |
| Processed meat (0-10) | ||||||||||
| Grocery stores | 6.88 (6.67 to 7.09) | 6.94 (6.61 to 7.27) | 7.03 (6.81 to 7.26) | 6.93 (6.71 to 7.15) | 7.13 (6.91 to 7.36) | 7.17 (6.97 to 7.38) | 7.06 (6.89 to 7.23) | 7.31 (7.15 to 7.46) | .003 | 0.43 (0.17 to 0.68) |
| Restaurants | 7.85 (7.61 to 8.08) | 7.80 (7.60 to 8.01) | 7.99 (7.84 to 8.14) | 7.90 (7.65 to 8.16) | 7.66 (7.31 to 8.01) | 7.90 (7.72 to 8.09) | 7.99 (7.79 to 8.18) | 8.09 (7.90 to 8.27) | .10 | 0.24 (−0.06 to 0.54) |
| Worksites | 9.13 (8.94 to 9.31) | 9.10 (8.85 to 9.35) | 9.48 (9.30 to 9.66) | 9.33 (9.10 to 9.56) | 9.02 (8.58 to 9.45) | 9.24 (9.00 to 9.48) | 9.07 (8.65 to 9.49) | 9.04 (8.81 to 9.27) | .40 | −0.09 (−0.38 to 0.20) |
| Other sources | 8.96 (8.79 to 9.13) | 8.78 (8.54 to 9.02) | 8.70 (8.55 to 8.85) | 9.02 (8.87 to 9.17) | 9.01 (8.82 to 9.20) | 8.93 (8.65 to 9.20) | 9.06 (8.86 to 9.26) | 8.99 (8.76 to 9.21) | .10 | 0.03 (−0.26 to 0.31) |
| Sodium (0-10) | ||||||||||
| Grocery stores | 4.48 (4.34 to 4.63) | 5.15 (4.94 to 5.36) | 5.09 (4.94 to 5.24) | 4.55 (4.43 to 4.68) | 4.66 (4.57 to 4.74) | 4.65 (4.54 to 4.77) | 4.65 (4.46 to 4.84) | 4.98 (4.85 to 5.11) | .83 | 0.50 (0.30 to 0.69) |
| Restaurants | 2.98 (2.81 to 3.15) | 2.57 (2.45 to 2.68) | 2.58 (2.44 to 2.71) | 2.53 (2.39 to 2.67) | 2.93 (2.76 to 3.09) | 2.79 (2.68 to 2.91) | 2.61 (2.49 to 2.73) | 2.73 (2.55 to 2.90) | .62 | −0.25 (−0.50 to −0.01) |
| Worksites | 5.97 (5.56 to 6.38) | 6.0 (5.50 to 6.49) | 6.33 (5.94 to 6.73) | 5.61 (5.16 to 6.07) | 5.43 (4.78 to 6.08) | 5.88 (5.43 to 6.33) | 5.34 (4.74 to 5.94) | 5.67 (5.08 to 6.25) | .04 | −0.30 (−1.0 to 0.41) |
| Other sources | 5.86 (5.45 to 6.26) | 4.73 (4.49 to 4.96) | 5.06 (4.85 to 5.26) | 4.72 (4.48 to 4.96) | 5.24 (4.97 to 5.51) | 5.43 (5.16 to 5.69) | 5.14 (4.85 to 5.42) | 5.46 (5.16 to 5.75) | .44 | −0.40 (−0.90 to 0.10) |
| Saturated fat (0-10) | ||||||||||
| Grocery stores | 5.51 (5.25 to 5.76) | 5.45 (5.28 to 5.61) | 5.69 (5.45 to 5.94) | 5.87 (5.68 to 6.06) | 6.01 (5.77 to 6.25) | 5.58 (5.39 to 5.77) | 5.19 (4.99 to 5.39) | 4.97 (4.77 to 5.17) | <.001 | −0.54 (−0.86 to −0.21) |
| Restaurants | 3.74 (3.49 to 4.0) | 3.64 (3.42 to 3.85) | 3.41 (3.23 to 3.58) | 4.00 (3.75 to 4.25) | 4.16 (3.90 to 4.41) | 4.16 (3.95 to 4.38) | 3.88 (3.65 to 4.11) | 3.57 (3.35 to 3.78) | .16 | −0.17 (−0.51 to 0.16) |
| Worksites | 6.72 (6.39 to 7.04) | 6.12 (5.59 to 6.65) | 6.38 (6.02 to 6.74) | 6.56 (6.20 to 6.92) | 6.78 (6.33 to 7.23) | 7.01 (6.31 to 7.70) | 6.63 (6.07 to 7.18) | 6.13 (5.50 to 6.76) | .84 | −0.59 (−1.30 to 0.12) |
| Other sources | 6.11 (5.86 to 6.36) | 5.70 (5.44 to 5.96) | 5.86 (5.54 to 6.18) | 6.03 (5.77 to 6.30) | 6.01 (5.82 to 6.20) | 5.77 (5.45 to 6.08) | 5.76 (5.41 to 6.11) | 5.55 (5.27 to 5.83) | .03 | −0.56 (−0.93 to −0.18) |
Abbreviations: AHA, American Heart Association; NHANES, National Health and Nutrition Examination Surveys.
a
All meals, snacks, and beverages consumed from these sources. To account for varying serving sizes and amounts as well as facilitate interpretation of the overall nutritional quality of different sources of food compared with diet quality scores and national dietary recommendations, we adjusted all intakes to 2000 kcal/d. The AHA diet scores ranged from 0 (worse) to 10 (better) and were summed to range from 0 to 80 (with higher scores indicating healthier diets) (see eAppendix 1 in the Supplement for details of the AHA diet score). All analyses incorporate the NHANES complex sampling design and survey weights to provide nationally representative estimates. The test for P trend across cycles evaluates the monotonic trend across the whole period. Food sources were grouped as grocery stores (consumed food items obtained from grocery or supermarket), restaurants (restaurant fast food/pizza, restaurant with servers, or restaurant no additional information), schools (kindergarten through 12th grade school cafeteria or childcare center), worksites (cafeteria not in a kindergarten through 12th grade school, vending machine, common coffee pot, or snack tray), and other sources refer to food items obtained from elsewhere (sports, recreation, or entertainment facility, street vendor, vending truck, from someone else or gift, and others).