Fast food intake in Canada: differences among Canadians with diverse demographic, socio-economic and lifestyle characteristics.

Black, Jennifer L. ; Billette, Jean-Michel

Over the past 40 years, Canadians have substantially changed how and where they prepare, purchase and consume meals. (1,2) Evidence from the United States suggests that fast food consumption in particular is rising rapidly, contributing to increased intake of calories, saturated fat, sodium and sugar-sweetened beverages. (3,4) In 2007-2008, fast food contributed on average to 10%, 17% and 13% of daily caloric intake among US children, adolescents and adults respectively (5) and has been associated with lower intake of nutritious foods, such as fruits, vegetables and milk, and of several essential micronutrients, including calcium, iron and vitamin C. (3,4,6) As a result, fast food intake is thought to contribute to lower total dietary quality and higher body mass index (BMI), (6-8) and has become a topic of growing public health interest on both sides of the border.

While more than one third of Canadians aged 14-30 years reported consuming fast food on the day prior to a national survey in 2004, (9) no studies have examined the contribution of fast food to caloric intake or dietary quality at the population level in Canada. Canadian studies have documented meaningful geographic differences in the availability of fast food outlets relative to schools and diverse neighbourhoods; (10-12) however, little is known about whether patterns of intake vary across geographic regions or among socio-demographically diverse groups.

Findings from the United States, where fast food intake has received more empirical attention, suggest that intake is more prevalent among men, adolescents and young adults, and varies among groups with differing ethnic identities, educational attainment and income. (3,13,14) Intake may also cluster with health-related lifestyle characteristics including sedentary activities and substance use, (15,16) but more nuanced understanding about fast food behaviours is needed to inform Canadian health promotion approaches aimed at improving dietary quality. This study therefore examines national levels of fast food intake, contributions to average daily caloric intake, and differences among Canadians with varied demographic, socioeconomic and lifestyle characteristics.

METHODS

Data sources

Nationally-representative dietary data were drawn from the master files of the Canadian Community Health Survey (CCHS), cycle 2.2., which used a multistage strategy to sample respondents of all ages in private households in all provinces (n = 35,107, response rate = 76.5%). (17) Respondents completed a 24-hour dietary recall applying the Automated Multiple-Pass Method (18) and a second recall was obtained from a subsample (n = 10,786) 3-10 days later to take within-person variance into account when deriving usual intake distributions. All items consumed the previous day (from midnight to midnight) were described, including serving sizes and locations where items were prepared (e.g., home, fast food outlet, cafeteria, etc.).

Analyses included respondents aged [greater than or equal to] 2 years, who were not pregnant or breastfeeding, with at least one valid 24-hr dietary recall with reported intake greater than zero calories. Since evidence suggests that some respondents likely under-reported total daily energy intake, (19) 'implausible' dietary recalls were excluded to avoid potential underestimation from reporting bias. (20) The approach for identifying implausible respondents parallels a previous method for estimating daily energy requirements based on respondents' sex, age, BMI and physical activity levels and compares them with reported energy intake from 24-hr recalls (19) used previously to examine national intake of fruits and vegetables. (21) Consequently, about 40% of the recalls were dropped due to either under- or over-reporting and the final analytic sample included 17,509 'plausible respondents', of whom 3,628 completed a second dietary recall.

Variables of interest

Key outcomes were mean usual daily caloric intake measured in kilocalories (kcal), and mean usual proportion of daily caloric intake from foods/beverages purchased from a fast food outlet. Fast food outlets were conceptualized as limited service restaurants where customers order and pay before eating, based on standard industrial classifications. (22) To operationalize this construct, foods likely purchased at fast food outlets were identified when an item's reported location of preparation was a fast food outlet or pizzeria, similar to approaches used in previous studies (6); or if the item was coded as fast food in the Nutrition Survey System (NSS) database. (17) The corresponding location of preparation of NSS-defined fast foods was a fast food outlet in 70% of cases, while other locations, such as school cafeterias or take-out facilities, were reported in the remaining instances. The resulting definition of fast food is therefore more inclusive than if it had been solely based on participant-reported locations of preparation.

Demographic, socio-economic, health and lifestyle variables were obtained from the CCHS General Health Component questionnaire. Demographic characteristics included sex, age groups, province and rural/urban residential location. Urban areas were defined as population concentration [greater than or equal to] 1,000 and population density [greater than or equal to] 400/per square kilometre based on the 1996 Census of Canada. (23) Age groupings were similar to Canada's Food Guide's age-based dietary recommendations, with a finer breakdown for adult groupings and no distinctions among children aged 2-8 years due to small sample sizes. Socioeconomic characteristics included household income adequacy (a four-group classification based on household size and annual before-tax income), educational attainment (among respondents [greater than or equal to] 25 yrs), and household food security status adapted from the U.S. Department of Agriculture module. (23)

Health and lifestyle-related variables included physical activity and sedentary behaviours, fruit and vegetable intake, vitamin/ mineral supplement use, smoking, binge drinking, BMI, self-rated health and dietary quality. Only younger (6-11 yrs) and older children (12-17 yrs) completed (two different) age-based instruments pertaining to physical and sedentary activities. Physical activity was categorized as active, moderate or inactive for respondents aged [greater than or equal to] 12 yrs, and [less than or equal to] 12 versus >12 hrs/week for respondents aged 6-11. Sedentary activities such as reading, television or video game time were defined as <2 versus [greater than or equal to] 2 hrs/ day for younger children, whereas older children were coded into four categories based on hours of weekly sedentary time. BMI categories were based on the World Health Organization cut-offs for adults (24) and on the Cole et al. cut-offs for children. (25) Daily fruit and vegetable consumption (defined as <5 versus [greater than or equal to] 5 times/day) was based on reported intake from the CCHS questionnaire. Vitamin/mineral supplement use was assessed separately for children/adolescents and adults due to varying patterns of use between age groups, (26) and frequency of binge drinking was defined as consuming [greater than or equal to] 5 drinks on one occasion. Smoking and self-rated health were also examined.

Dietary quality was estimated using the Canadian adaptation of the Healthy Eating Index (HEI)-2005 which examines dietary intake relative to national recommendations in Canada's Food Guide. (27) The HEI is based on 11 criteria (maximum score = 100), with higher scores allocated for increased intake of fruits, vegetables, whole grains, total grain products, milk and alternatives, meat and alternatives and unsaturated fats, and lower intake of saturated fat, sodium and "other foods" that did not fit into any food group category. (27) HEI scores were calculated based on respondents' first 24-hr dietary recall and categorized by quartiles (Q = 22-48; Q2 = 49-57; Q3 = 58-66; and Q4 = 67-97).

Statistical analysis

Usual daily caloric intake from fast food was estimated using the National Cancer Institute (NCI) method, which aims to estimate long-term average daily intake using a mixed model composed of both a logistic and a linear part that jointly estimate the probability of consumption of foods on non-consumption days and the usual amount consumed on consumption days. (28) Within-person variance was taken into account using the second dietary recalls. To better predict both the probability and amount parts of the model, age, sex, BMI, ethnicity (French/ British/Canadian, other), consumption day (weekend/weekday), frequency of fruit/vegetable intake, recall sequence (1st or 2nd recall) and household income were modelled as independent variables.

With only one or two dietary recalls, it is difficult to accurately estimate usual intakes for individuals. (29) However, differences in fast food intake between groups can be examined using standard pairwise techniques. Therefore, Student's t-tests compared mean usual fast-food intake of each variable category against reference categories, defined as either the lowest/first category for continuous and ordinal variables (e.g., income adequacy, BMI) or the group comprising the largest relative proportion of the sample (e.g., age groups, province). Multiple comparisons were handled using the Dunn-Sidak correction for significance (new [alpha] = 1 - [(1 - [alpha]).sup.1/n] where n is the number of comparisons). (30) Missing data were handled with casewise deletion, except for income where a dummy variable was created to account for the 8% of respondents with missing data. Therefore, analytical sample sizes may vary from one variable to another depending on the number of missing cases.

Sensitivity analyses compared reported fast food-related caloric intake among plausible respondents to that of the full sample to estimate the degree of fast food under-reporting among implausible energy reporters. SAS 9.3 (SAS Institute, Cary, NC) was used for all analyses and sampling weights adjusted for design effects. The 500 sets of bootstrap weights supplied by Statistics Canada were used to derive robust standard errors for the calculation of t-tests.

RESULTS

Table 1 shows that mean fast food intake contributed to 146 kcal/ day and 6.3% of total daily energy intake at the national level. Among respondents who reported fast food intake on the first dietary recall, average daily fast food intake was 744 kcal and average energy intake was 206 calories higher than among those who did not consume any fast food. Figure 1 further illustrates how consumption varied widely across age-sex groups, from a peak of 9.3% of intake (248 kcal) among adolescent males to a low of 1.9% (32 kcal) among older females. While both absolute and relative fast food intake declined steadily across adult age groups, absolute intake was higher among males than females throughout the life-course (177 kcal vs. 111 kcal). However, the contribution of fast food to daily energy intake was not significantly different between males and females. Moreover, Table 1 shows that although residents in Newfoundland and Labrador (164 kcal) had the highest and Quebecers (128 kcal) had the lowest intake, neither provincial location nor living in an urban area was significantly associated with intake.

[FIGURE 1 OMITTED]

Socio-economic characteristics, including income adequacy, education and food security status, were not significant predictors of fast food consumption. However, intake was significantly associated with several health and lifestyle factors (Table 2). Children and adolescents (age 2-17 yrs) classified as obese (263 kcal) or overweight (220 kcal) had significantly higher mean usual fast food intakes than normal/underweight respondents (179 kcal). Results were similar for adults, where higher intake was reported by those with higher BMI. However, respondents with higher BMI also reported higher total daily caloric intake, and overall the proportion of intake did not vary significantly between obese respondents and those with BMI < 25 kg/[m.sup.2]. Further, overweight adults reported a small but significantly lower proportion of fast food intake compared to normal/underweight adults (4.8% versus 6.0%).

Individuals who consumed fruits and vegetables at least five times/day had significantly lower fast food intake than those who did not (101 kcal vs. 171 kcal). Higher intake was also associated with significantly lower dietary quality scores assessed from 24-hr dietary recalls. Compared to respondents with HEI scores in the lowest quartile, persons scoring in highest or second highest quartiles consumed significantly less fast food both in absolute and relative terms.

Vitamin/mineral supplement use was significantly associated with lower fast food intake among adults (111 kcal vs. 149 kcal) but not among children or adolescents. Respondents who reported binge drinking (compared to those who reported never binge drinking) consumed significantly more fast food, regardless of binge drinking frequency. However, level of physical activity, sedentary activities, smoking status and perceived health status were not significantly associated with intake.

Sensitivity analyses found that when the full sample of respondents aged [greater than or equal to] 2 yrs was used to estimate usual daily fast food intake, average intake for the population was 128 kcal. This is approximately 18 calories lower, and statistically significant (p < 0.05), compared to the estimate derived from the sample of plausible respondents. However, the contribution of fast food to usual daily energy intake did not significantly differ between the full sample and the subsample of plausible respondents, likely because both intakes were similarly under-reported by implausible respondents.

DISCUSSION

Findings revealed that 6.3%, or approximately 1 in every 16 calories consumed by Canadians, is derived from fast food. This is the first Canadian study to estimate usual fast food intake using nationally representative dietary data, making it impossible to gauge changes over time in Canada. Still, the magnitude of intake is not surprising given previous estimates that one in four Canadians consumed food prepared in a fast food outlet on the day prior to CCHS 2.2. data collection. (9) Moreover, Statistics Canada estimated that during the 6 years preceding the CCHS 2.2., Canadian spending on foods purchased from restaurants, including fast food outlets, increased by 27% (2) and totaled $37 billion in 2004. (31) Canada currently houses approximately 35,000 fast food outlets, and both the number of outlets and national sales are forecast by industry analysts to rise further in the near future. (31)

Overall, Canadians reported consuming less fast food than Americans did (per US national estimates), where fast food contributed to 10% of caloric intake among children (2-11 yrs), 17% among adolescents (12-19 yrs) and 13% among adults (20-64 yrs) in 2007-2008. (5) This study cannot address the cultural, economic or fast food price differences that explain the apparent lower proportion of fast food intake in Canada. However, Canadian young people, especially younger adult and adolescent males, reported notably higher intakes than the national average. These age- and sex-based findings are consistent with previous estimates that one third of teenagers and 39% of young men consumed food prepared at a fast food outlet on the day prior to the CCHS 2.2 interview. (1) Moreover, recent findings suggest that over 50% of students in grades 5-8 and 70% in grades 9-12 from Ontario, Quebec and Prince Edward Island report consuming food from a fast food outlet weekly. (32) The current findings further highlight that the ratio of young children's fast food intake to energy intake is comparable with that of older adolescents. Even the youngest age group of boys examined (ages 2-8) consumed 231 calories and 8.8% of usual caloric intake from fast food, suggesting that regular fast food consumption begins at very early ages.

Age and sex were the only socio-demographic variables examined that were significantly associated with fast food intake, suggesting that in Canada, neither socio-economic status nor urban/rural residential location nor provincial context are consistent predictors of fast food intake. While some international evidence suggests that fast food consumption varies with level of educational attainment and income (albeit in inconsistent directions), (3,6) recent national findings from the US (5) and these Canadian results do not support claims of a clear socio-economic gradient in the patterning of fast food intake. Findings therefore counter public discourse about healthy eating that sometimes portrays marginalized and lower income groups as more likely to make unhealthy food choices, such as frequently purchasing fast food. (33)

Current findings suggest however that fast food intake is associated with health-related lifestyle factors. For example, Canadians reporting higher fruit and vegetable consumption and vitamin/mineral supplement use (among adults) had lower usual fast food intake. Results are consistent with previous studies reporting that people aiming to adopt a healthy lifestyle may also avoid eating large quantities of fast food. (7) There is further evidence (at least among children in the US) that fast food consumers are more likely to consume a 'Western' style dietary pattern, with lower nutritional quality when choosing foods both inside and outside of restaurants. (34) Moreover, binge drinkers had higher fast food intakes than those who reported never having [greater than or equal to] 5 drinks on a single occasion. Binge drinking may reflect a pattern of risk behaviours associated with fast food consumption, particularly among youth. (35) However, associations between fast food and health practices did not extend to smoking, sedentary activities or physical activity.

Findings are consistent with previous studies outside Canada showing that higher fast food intake is associated with lower dietary quality and increased BMI. (6,7) Given that fast food intake is associated with increased caloric intake, it is likely that frequent consumption contributes to weight gain over time. However, due to the cross-sectional nature of this survey, it was not possible to disentangle whether fast food itself increases BMI or whether individuals with higher BMI were more likely to consume fast foods. Nonetheless, fast food consumption was significantly associated with lower diet quality, and individuals who scored below the national median on the Healthy Eating Index also had significantly higher usual fast food intake than those with the highest quality HEI scores.

A notable strength of this study was the use of a large nationally representative survey which included detailed dietary data for all age groups and is novel in the Canadian context. Estimates were also substantially improved by applying the NCI method to 24-hr dietary recall data to examine usual food intake from more than one day of reported intake because this method incorporates covariates and jointly estimates both the amount consumed and the probability of eating irregularly consumed foods. Estimates were also improved by excluding 'implausible respondents' to adjust for potential under-reporting of total energy and fast food intake. Still, a larger number of dietary recalls would likely have increased the estimated proportion of fast food consumers and better reflected people's day-to-day variation in fast food intake. (36)

While there is no universal definition of fast food, we applied the best possible operational definition available from this dataset to reflect standard industrial classifications of limited service establishments where customers order and pay before eating. (22) This operational definition, however, paid closer attention to the reported location of preparation than to the nutritional composition of foods. This definition therefore implied that, for example, a cup of coffee or salad purchased from a limited service outlet was counted as fast food, while homemade deep-fried onion rings were not. We attempted to improve this definition by considering both location of preparation and the NSS list of fast foods, but inclusion of the latter made little impact on usual intake estimates. We also lacked detailed information about the specific locations where foods were purchased, and future research is needed to buttress current understandings of how consumption is shaped by local food environment exposures surrounding Canadian schools, workplaces and homes.

Overall, this study confirms that fast food outlets play a notable role in feeding the Canadian population and particularly so for children, teenagers and young adults. Moreover, age and sex appear to be more strongly associated with fast food consumption than either socio-economic background or level of physical activity. Consequently, research and intervention strategies should focus on dietary practices of children and adolescents, whose fast food intakes are among the highest in Canada. Given recent evidence that full service restaurants in Canada also commonly supply meals with alarmingly high levels of calories, saturated fat and sodium, (37,38) clearer evidence is needed regarding the collective implications of wider food environment exposures on dietary practices. Such insight is needed to inform recent debates about the potential efficacy of population-level approaches, including menu labelling, zoning and regulatory restrictions to reduce availability of fast food outlets, and other proposed health promotion approaches for improving nutritional outcomes.

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Received: July 10, 2014

Accepted: December 26, 2014

Jennifer L. Black, PhD, RD, [1] Jean-Michel Billette, PhD [2]

Author Affiliations

[1.] Food, Nutrition and Health Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC

[2.] Microdata Access Division, Statistics Canada, Ottawa, ON

Correspondence: Jennifer L. Black, Food, Nutrition and Health Program, Faculty of Land and Food Systems, University of British Columbia, 2205 East Mall, Vancouver, BC V6T1Z4, Tel: 604-822-6869, E-mail: j.black@ubc.ca

Disclaimers: While the research and analyses were based on data from Statistics Canada, the views and opinions expressed in this paper do not necessarily reflect those of Statistics Canada. Additionally, all errors and omissions remain the sole responsibility of the authors.

Acknowledgements of sources of support: Jennifer Black has received prior support from the Centre for Science in the Public Interest, Canada and the University of British Columbia Food, Nutrition and Health Vitamin Research Fund to support analyses of the Canadian Community Health Survey version 2.2. However, the study described in this manuscript was not directly supported by any funding agency.

Conflict of Interest: None to declare.

Table 1. Sample characteristics and estimated mean daily intake
of fast food in calories and proportion of total estimated daily
energy intake accounted for by fast food among Canadians aged
[greater than or equal to] 2 years, by demographic and socio-economic
characteristics from the Canadian Community Health
Survey, Cycle 2.2, 2004

                                   Percent           Mean usual fast
                                 distribution        food intake in
                                                      kcal (95% CI)

Overall                     Total (n = 17,509) 100    146 (122-169)
Sex                           Total (n = 17,509)
  Male                               51.3             177 (130-225)
  Female (ref.)                      48.7             111 (91-131)
Age group, years              Total (n = 17,509)
  2-8                                6.1              192 (157-227)
  9-13                               6.8              202 (171-232)
  14-18                              7.1              210 (171-249)
  19-34                              22.1             193 (154-233)
  35-50 (ref.)                       27.5             140 (115-166)
  51-69                              21.1              88 (66-110)
  [greater than or                   9.3               46 (32-59)
    equal to] 70
Province                      Total (n = 17,509)
  Newfoundland                       1.8              164 (139-189)
    and Labrador
  Prince Edward Island               0.5              159 (122-196)
  Nova Scotia                        3.3              152 (126-177)
  New Brunswick                      2.5              150 (85-216)
  Quebec                             27.6             128 (108-150)
  Ontario (ref.)                     35.3             149 (124-175)
  Manitoba                           3.1              159 (114-204)
  Saskatchewan                       3.1              158 (129-187)
  Alberta                            8.8              159 (127-192)
  British Columbia                   13.9             143 (114-172)
Place of residence            Total (n = 17,509)
  Urban (ref.)                       81.5             148 (125-171)
  Rural                              18.5             143 (118-168)
Household income adequacy     Total (n = 17,509)
  Low income (ref.)                  8.3              127 (84-169)
  Lower middle income                19.9             131 (106-156)
  Upper middle income                32.2             150 (118-181)
  Upper income                       31.5             152 (128-175)
  Missing income                     8.2              151 (129-173)
Education *                       (n = 9855)
  Up to and including                36.9             110 (84-137)
    high school (ref.)
  Trades/certificate/                40.1             130 (101-160)
    some post-secondary
  University degree                  23.0             122 (99-144)
Household food security          (n = 17,422)
    status ([dagger])
  Food secure (ref.)                 93.6             143 (119-167)
  Food insecure                      4.5              165 (118-213)
    without hunger
  Food insecure                      1.9              177 (118-238)
    with hunger

                             t-test       % of usual     t-test *
                            ([double    energy intake
                            dagger])    from fast food
                                           (95% CI)

Overall                                 6.3 (5.3-7.3)
Sex
  Male                      p < 0.001   6.9 (5.1 -8.5)      ns
  Female (ref.)                         5.6 (4.5-6.6)
Age group, years
  2-8                       p < 0.01    8.2 (6.8-9.7)    p < 0.01
  9-13                      p < 0.001   8.4 (7.1 -9.7)   p < 0.001
  14-18                     p < 0.001   8.8 (7.1-10.4)   p < 0.001
  19-34                     p < 0.01    7.9 (6.4-9.4)    p < 0.05
  35-50 (ref.)                          6.0 (4.9-7.1)
  51-69                     p < 0.001   4.0 (3.0-4.9)    p < 0.01
  [greater than or          p < 0.001   2.3 (1.6-2.9)    p < 0.001
    equal to] 70
Province
  Newfoundland                 ns       6.9 (6.0-7.8)       ns
    and Labrador
  Prince Edward Island         ns       6.8 (5.3-8.3)       ns
  Nova Scotia                  ns       6.5 (5.4-7.6)       ns
  New Brunswick                ns       6.4 (3.9-9.0)       ns
  Quebec                       ns       5.5 (4.7-6.4)       ns
  Ontario (ref.)                        6.5 (5.4-7.6)
  Manitoba                     ns       6.9 (4.9-8.9)       ns
  Saskatchewan                 ns       6.8 (5.5-8.1)       ns
  Alberta                      ns       6.8 (5.5-8.2)       ns
  British Columbia             ns       6.3 (5.0-7.5)       ns
Place of residence
  Urban (ref.)                          6.4 (5.4-7.4)
  Rural                        ns       6.1 (5.2-7.0)       ns
Household income adequacy
  Low income (ref.)                     6.6 (5.4-7.7)
  Lower middle income          ns       5.7 (3.8-7.5)       ns
  Upper middle income          ns       5.6 (4.5-6.7)       ns
  Upper income                 ns       6.3 (5.0-7.6)       ns
  Missing income               ns       6.7 (5.7-7.7)       ns
Education *
  Up to and including                   4.9 (3.8-6.1)
    high school (ref.)
  Trades/certificate/          ns       5.6 (4.4-6.9)       ns
    some post-secondary
  University degree            ns       5.3 (4.4-6.2)       ns
Household food security
    status ([dagger])
  Food secure (ref.)                    6.2 (5.2-7.2)
  Food insecure                ns       7.2 (5.1 -9.2)      ns
    without hunger
  Food insecure                ns       7.6 (5.2-9.9)       ns
    with hunger

CI = Confidence Interval; ns = non-significant.

* Education variable defined only for persons age 25 years and
older without missing education data.

([dagger]) N = 17,422 owing to missing data on food security
module.

([double dagger]) The Dunn-Sidak correction was used to adjust
for multiple comparisons; all p-values are two-tailed.

Table 2. Estimated mean daily intake of fast food in calories and
proportion of total estimated daily energy intake accounted for
by fast food among Canadians aged ([greater than or equal to] 2
years, by key lifestyle characteristics from the Canadian
Community Health Survey, Cycle 2.2, 2004

                         Percent *     Mean usual fast    t-test
                        distribution   food intake in    ([double
                                        kcal (95% CI)    dagger])

Physical activity        (n = 1451)
    (age 6-11)
  0-12 hrs/week             43.1        202 (171-232)
    (ref.)
  > 12 hrs/week             56.9        197 (153-240)       ns
Physical activity       (n = 14,343)
    (age 12 and
    older)
  Active (ref.)             19.0        149 (145-153)
  Moderate                  24.9        141 (115-167)       ns
  Inactive                  56.1        140 (113-167)       ns
Sedentary                (n = 1451)
    activities
    (age 6-11)
  < 2 hours/day             40.4        193 (165-222)
    (ref.)
  [greater than             59.6        207 (164-250)       ns
    or equal to]
    2 hrs/day
Sedentary activities     (n = 2855)
    (age 12-17)
  < 10 hrs/week             14.1        200 (169-231)
    (ref.)
  10-19 hrs/week            27.8        206 (171-242)       ns
  20-29 hrs/week            34.7        205 (167-243)       ns
  [greater than or          23.5        216 (176-257)       ns
    equal to] 30
    hrs/week
BMI cut-offs             (n = 5848)
    (age 2-17)
  Normal/                   62.5        179 (155-202)
    underweight
    (ref.)
  Overweight                24.5        220 (178-262)    p < 0.05
  Obese                     13.0        263 (191-335)    p < 0.01
BMI cut-offs (age       (n = 10,780)
    [greater than
    or equal to] 18)
  Normal/underweight        46.0        113 (95-130)
    (ref.)
  Overweight                34.7        131 (105-157)       ns
  Obese                     19.4        174 (124-223)    p < 0.01
Fruit and vegetable     (n = 17,509)
    consumption
  < 5 times/day             65.3        171 (140-204)
    (ref.)
  [greater than or          34.7        101 (82-120)     p < 0.001
    equal to] 5
    times/day
Vitamin and mineral     (n = 11,485)
    supplement use
    (age [greater
    than or equal
    to] 18)
  No (ref.)                 66.5        149 (120-177)
  Yes                       33.5        111 (89-133)     p < 0.01
Vitamin and mineral      (n = 6023)
    supplement use
    (age 2-17)
  No (ref.)                 58.2        206 (174-238)
  Yes                       41.8        199 (168-231)       ns
Frequency of binge      (n = 14,330)
    drinking (age
    [greater than
    or equal to] 12)
  Never (ref.)              64.3        123 (106-139)
  Less than                 17.6        162 (132-193)    p < 0.01
    once/month
  1 to 3                    11.2        185 (146-224)    p < 0.001
    times/month
  At least once/week        6.9         190 (138-243)    p < 0.001
Current smoking         (n = 14,337)
    status (age
    [greater than
    or equal to] 12)
  Non-smoker (ref.)         77.3        134 (112-157)
  Occasional smoker         4.3         159 (108-209)       ns
  Daily smoker              18.4        153 (111-197)       ns
Self-rated health       (n = 14,340)
    (age [greater
    than or equal
    to] 12)
  Excellent/very            58.9        139 (114-164)
    good (ref.)
  Good                      30.0        142 (114-170)       ns
  Fair/poor                 11.1        134 (116-153)       ns
Healthy Eating Index    (n =14,615)
  1st quartile (ref.)       24.5        169 (142-197)
  2nd quartile              24.4        142 (116-168)       ns
  3rd quartile              23.8        132 (112-152)    p < 0.01
  4th quartile              27.3        113 (94-131)     p < 0.001

                          % of usual      t-test
                        energy intake    ([double
                          from fast      dagger])
                        food (95% CI)

Physical activity
    (age 6-11)
  0-12 hrs/week         8.7 (7.5-9.9)
    (ref.)
  > 12 hrs/week         8.2 (6.5-9.9)       ns
Physical activity
    (age 12 and
    older)
  Active (ref.)         6.3 (6.1-6.5)
  Moderate              6.1 (5.0-7.1)       ns
  Inactive              6.1 (4.9-7.3)       ns
Sedentary
    activities
    (age 6-11)
  < 2 hours/day         8.4 (6.7-10.2)
    (ref.)
  [greater than         8.1 (7.0-9.2)       ns
    or equal to]
    2 hrs/day
Sedentary activities
    (age 12-17)
  < 10 hrs/week         8.7 (7.5-9.9)
    (ref.)
  10-19 hrs/week        8.3 (6.9-9.8)       ns
  20-29 hrs/week        8.7 (6.9-10.4)      ns
  [greater than or      8.3 (6.8-9.8)       ns
    equal to] 30
    hrs/week
BMI cut-offs
    (age 2-17)
  Normal/               8.7 (7.3-10.2)
    underweight
    (ref.)
  Overweight            7.3 (6.3-8.3)       ns
  Obese                 8.6 (6.9-10.3)      ns
BMI cut-offs (age
    [greater than
    or equal to] 18)
  Normal/underweight    6.0 (4.7-7.3)
    (ref.)
  Overweight            4.8 (4.0-5.5)    p < 0.05
  Obese                 5.2 (4.3-6.2)       ns
Fruit and vegetable
    consumption
  < 5 times/day         7.4 (6.0-8.7)
    (ref.)
  [greater than or      4.4 (3.7-5.2)    p < 0.001
    equal to] 5
    times/day
Vitamin and mineral
    supplement use
    (age [greater
    than or equal
    to] 18)
  No (ref.)             6.3 (5.1-7.4)
  Yes                   5.0 (4.0-6.0)    p < 0.05
Vitamin and mineral
    supplement use
    (age 2-17)
  No (ref.)             8.7 (7.3-10.0)
  Yes                   8.4 (7.1-9.7)       ns
Frequency of binge
    drinking (age
    [greater than
    or equal to] 12)
  Never (ref.)          5.5 (4.8-6.3)
  Less than             6.8 (5.6-7.9)    p < 0.05
    once/month
  1 to 3                7.4 (5.9-8.9)    p < 0.001
    times/month
  At least once/week    7.4 (5.4-9.4)    p < 0.001
Current smoking
    status (age
    [greater than
    or equal to] 12)
  Non-smoker (ref.)     5.9 (4.9-6.8)
  Occasional smoker     6.7 (4.9-8.6)       ns
  Daily smoker          6.5 (4.7-8.4)       ns
Self-rated health
    (age [greater
    than or equal
    to] 12)
  Excellent/very        6.0 (5.0-7.0)
    good (ref.)
  Good                  6.1 (4.9-7.3)       ns
  Fair/poor             5.9 (5.1-6.7)       ns
Healthy Eating Index
  1st quartile (ref.)   7.2 (6.0-8.3)
  2nd quartile          6.1 (4.9-7.4)       ns
  3rd quartile          5.8 (5.0-6.7)    p < 0.01
  4th quartile          5.1 (4.3-6.0)    p < 0.001

CI = Confidence Interval; ns = non-significant.

* Some sample sizes are reduced owing to missing data.

([double dagger]) The Dunn-Sidak correction was used to adjust
for multiple comparisons; all p-values are two-tailed.