1. LV Moore, Kirsten Grimm, Sonia Kim, Kelley Scanlon Estimating Percent Meeting Fruit & Vegetable Recommendations from BRFSS data

2. These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home. 1) How often do you drink fruit juices such as orange, grapefruit, or tomato? 2) Not counting juice, how often do you eat fruit? 3) How often do you eat green salad? 4) How often do you eat potatoes not including French fries, fried potatoes, or potato chips? 5) How often do you eat carrots? 6) Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? BRFSS FV Screener (1994-2009)

3. Revised FV Screener (2011-) During the past month, how many times per day, week or month did you [drink] or [eat] 1)…100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice. 2)…fruit? Count fresh, frozen, or canned fruit. 3)…cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans. 4)…dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach? 5)…orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots? 6)…OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.

4. Healthy People – Food and Nutrition Consumption objectives Healthy People 2010 ≥2 servings of fruit (target of 75%) ≥3 servings of vegetables (target of 50%) Healthy People 2020 Increase the contribution of fruits to the diets of the population aged 2 years and older from 0.5 cup equivalents per 1,000 calories to 0.9 cup equivalents per 1,000 calories. Increase the variety and contribution of vegetables to the diets of the population aged 2 years and older from 0.8 cup equivalents per 1,000 calories to 1.1 cup equivalents per 1,000 calories.

5.  Median fruit intake (times/day)  Median vegetable intake (times/day)  Percent meeting minimum recommendations for fruit intake (age- & sex-specific)  Percent meeting minimum recommendations for vegetable intake (age- & sex-specific) Proposed Fruit &Vegetable Indicators

6. Percent meeting minimum recommendations requires 2 parts –Developing linear equations to convert BRFSS times per day into cup equivalents –Comparing estimated cup equivalents against minimum fruit and vegetable intake recommendations based on Dietary Guidelines

7. Part 1: Developing linear equations to convert BRFSS times per day into cup equivalents NCI developed a protocol for converting times per day into cup equivalents* Four steps –Develop a food coding scheme to aggregate 24 hr recall foods into food groups that parallel screener questions –Estimate mentions: # times each food group mentioned –Estimate portion sizes: median amount consumed, when a food group was eaten –Model cup equivalents by portion sizes x mentions to get the conversion equation *Available at http://appliedresearch.cancer.gov/surveys/chis/dietscreener/scoring.html

8. NCI equation for converting times per day into cup equivalents E(Fruits and Vegetables 1/2 ) = β 0 + β 1 (N FG1 P 1 + N FG2 P 2 +... + N FGk P k ) 1/2 Independent variable: mentions x portion sizes of food groups Dependent variable: cup equivalents of fruits and vegetables from all sources Where: –k = 6 mutually exclusive fruit and vegetable food groups (NCI: 100% fruit juice, Fruit, Salad, Fried potatoes, Other white potatoes, Dried beans, Other vegetables) –N FGk = number of times/mentions per day a participant consumed food group k –P k = estimated median age- and sex-specific portion sizes for each food group k (cup equivalents) E(Fruits and Vegetables 1/2 ) = β 0 + β 1 ( N FG1 P 1 + N FG2 P 2 +... + N FGk P k ) 1/2 –Estimates from NHANES and above equation – BRFSS times per day

9. Recalculation Rationale Portion sizes may have changed over time –NCI used 1994-96 Continuing Survey of Food Intakes of Individuals dietary recall data –DNPAO using 24 hour dietary recall data from 2003-2004 NHANES 7 NCI food groups ≠ 2011 6 BRFSS questions Need estimates for fruit alone and vegetable alone as well as combined Portion sizes are age and sex specific but other important sociodemographic variation to consider (race/ethnicity, socioeconomic status, etc.)

10. Step 1:Develop food coding scheme and estimate cup equivalents Scheme must –Be consistent with BRFSS 2011 questions –Have extensive documentation/rationale for transparency My Pyramid Equivalents Database (MPED) food groups –MPED translates the amounts of foods eaten in NHANES into the number of cup equivalents –32 MyPyramid major groups and subgroups –extensively documented –correlate well with 2011 BRFSS items except for other vegetables

11. Cup equivalents DayDescriptionFruit juiceFruitLegumes Dark-green vegetables Orange vegetables All vegetables excl legumes 1White potato, chips000000.882 1Potato salad with egg000000.51338 1Fruit drink0.2332800000 1Fruit drink0.2332800000 2White potato, french fries000000.37819 2Tomatoes, raw000000.2224 2Tomatoes, raw000000.1112 2Tomato catsup000000.04245 2Tomato catsup000000.0849 2Lettuce, raw000000.0469 2Lettuce, raw000000.07272 2Onions, mature, raw000000.0625 2Onions, mature, raw000000.075 2Cucumber pickles, dill000000.08388 Fruit and vegetable food records of participant 21005 (n=14/42; ~ 3 cup equivalents of FV)

12. Cup equivalents DayDescriptionFruit juiceFruitLegumes Dark-green vegetables Orange vegetables All vegetables excl legumes 1White potato, chips000000.882 1Potato salad with egg000000.51338 1Fruit drink0.2332800000 1Fruit drink0.2332800000 2White potato, french fries000000.37819 2Tomatoes, raw000000.2224 2Tomatoes, raw000000.1112 2Tomato catsup000000.04245 2Tomato catsup000000.0849 2Lettuce, raw000000.0469 2Lettuce, raw000000.07272 2Onions, mature, raw000000.0625 2Onions, mature, raw000000.075 2Cucumber pickles, dill000000.08388 Fruit and vegetable food records of participant 21005 (n=14/42; ~ 0.75 cup equivalents of FV)

13. Step 1:Develop food coding scheme MPED Con’td –No corresponding aggregation scheme to say what food should count –Does not help distinguish what is typically reported in a screener USDA Food Survey Research Group (FSRG) defined groups –has extensive documentation –Consistent with 2011 BRFSS categories –FSRG aggregates foods based on main ingredients; Ex. fruit juice in canned fruit does not count towards total fruit juice

14. Step 1:Develop food coding scheme 1st digit identifies one of 9 major food groups 1.milk and milk products 2.meat, poultry, fish, and mixtures 3.eggs 4.legumes, nuts, and seeds 5.grain products 6.fruits 7.vegetables 8.fats, oils, and salad dressings 9.sugars, sweets, and beverages Subsequent digits identify increasingly more specific subgroups including –5 fruit subgroups –8 vegetable subgroups –4 legumes/nuts/seeds subgroups Mixtures disaggregated into single foods per standard recipes Each 7,174 different types of food NHANES participants report assigned 8 digit food code Certain foods excluded from groups to make consistent with BRFSS screener Baby foods Dried fruit Condiments Fruits and vegetables on sandwiches (lettuce, tomato onion)

15. Food coding scheme for aggregating foods from NHANES 2003-04 into BRFSS 2011 comparable categories 2011 BRFSS QuestionUSDA FSRG variables Corresponding FSRG 8 Digit Food Codes* 1.During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice. (FRUIT JUICE) FRUIT11 + FRUIT35 (611 or 612 01- 612 13 or 612 16) + (612 0050 or 612 14 or 612 19-612 26 or 641 0011-642 2101) *Online search tool for USDA food codes : http://www.ars.usda.gov/services/docs.htm?docid=17032

17. Step 1:Develop food coding scheme MPED should be used in conjunction with FSRG For each NHANES participant –Each food eaten disaggregated –Only foods classified as one of the 6 FSRG food groups contributes to mentions & portion sizes (independent variables) –All foods except fried potatoes and non 100% fruit juice contribute cup equivalents (dependent variables)

18. Cup equivalents DayDescriptionFruit juiceFruitLegumes Dark-green vegetables Orange vegetables All vegetables excl legumes 1White potato, chips000000.882 1Potato salad with egg000000.51338 1Fruit drink0.2332800000 1Fruit drink0.2332800000 2White potato, french fries000000.37819 2Tomatoes, raw000000.2224 2Tomatoes, raw000000.1112 2Tomato catsup000000.04245 2Tomato catsup000000.0849 2Lettuce, raw000000.0469 2Lettuce, raw000000.07272 2Onions, mature, raw000000.0625 2Onions, mature, raw000000.075 2Cucumber pickles, dill000000.08388 Fruit and vegetable food records of participant 21005 (n=14/42)

19. Cup equivalents DayDescriptionFruit juiceFruitLegumes Dark-green vegetables Orange vegetables All vegetables excl legumes 1Potato salad with egg000000.51338 2Tomatoes, raw000000.2224 Fruit and vegetable food records of participant 21005 (n=2/42)

20. Step 2: Estimate mentions per day (N FGk ) Count the number of times each fruit and vegetable group mentioned in 24 hr recall data No minimum threshold to count as a mention Sum times per day each BRFSS food group mentioned and average over 2 days

21. Cup equivalents DayDescriptionFruit juiceFruitLegumes Dark-green vegetables Orange vegetables All vegetables excl legumes 1Potato salad with egg000000.51338 2Tomatoes, raw000000.2224 Fruit and vegetable food records of participant 21005 (n=2/42)

22. Mentions DayDescriptionFruit juiceFruitLegumes Dark-green vegetables Orange vegetables All vegetables excl legumes 1Potato salad with egg000001 2Tomatoes, raw000001 Total000002 Fruit and vegetable food records of participant 21005 (n=2/42) 1 mention per day

23. Step 3: Estimate portion sizes (P k ) When participants ate a food group, what was median amount eaten? Portion size = Total amount eaten (cup equivalents) of each food group / number of times each food group was mentioned Explore variation in portion sizes by various demographic characteristics –Age groups –Race/ethnicity –Socioeconomic status –Others

24. Median portion sizes (P k )* Food group Selected Demographic CharacteristicsLegumesOther vegetables Sex Male0.749961.31522 Female0.500181.312 Race/Ethnicity Non-Hispanic White 0.500031.52617 Non-Hispanic Black 0.562381.04206 Mexican American 0.750270.99242 Other Hispanic 0.751.06501 Other Race 0.322581.45222 *For illustration purposes only

25. Conversion equation E(Fruits and Vegetables 1/2 ) = β 0 + β 1 ( N FG1 P 1 + N FG2 P 2 +... + N FGk P k ) 1/2 –Estimates from NHANES and above equation – BRFSS times per day Where: –k = 6 mutually exclusive fruit and vegetable food groups (NCI: 100% fruit juice, Fruit, Salad, Fried potatoes, Other white potatoes, Dried beans, Other vegetables) –N FGk = number of times/mentions per day a participant consumed food group k –P k = estimated median age- and sex-specific portion sizes for each food group k (cup equivalents)

26. Proposed Fruit &Vegetable Indicators Percent meeting minimum recommendations requires 2 parts –Developing linear equations to convert BRFSS times per day into cup equivalents –Comparing estimated cup equivalents against minimum fruit and vegetable intake recommendations based on Dietary Guidelines

27. Step 4: Calculate percent meeting minimum requirement Conversion and estimating percent meeting the minimum requirements done simultaneously NCI developed 1- or 2-part nonlinear mixed models to account for usual intake Model depends on whether or not the food in question was consumed daily by almost everyone –If food group episodically consumed, 2-part model used to account for probability food consumed and amount eaten –If food group ubiquitously consumed, 1-part model used to account for only amount eaten

28. Estimating the percentage of population exceeding recommendation threshold No single set of recommendations in Dietary Guidelines Varies by each person’s appropriate level of energy intake based on sex, age, and activity level Estimate minimum recommendations based on age, sex, and sedentary behavior (<30 minutes of PA) Daily recommendations* SexAge (yearsVegetablesFruit Women 19-302½ cups2 cups 31-502½ cups1 ½ cups 51+ 2 cups 1 ½ cups Men19-303 cups2 cups 31-503 cups2 cups 51+2½ cups2 cups

29. Questions and Feedback