- Email: [email protected]
Vegetable Consumption and Selected Nutrient Intakes of Women of Childbearing Age
Research Article Vegetable Consumption and Selected Nutrient Intakes of Women of Childbearing Age Maureen L. Storey, PhD1,y; Patricia A. Anderson, MPP2,y ABSTRACT Objective: To examine intake of selected nutrients and vegetable consumption of women of childbearing age (WCBA) from 19–50 years of age, across race/ethnicities, and annual household incomes. Design: Dietary data from the National Health and Nutrition Examination Survey 2009–2012 and the Food Pattern Equivalents Database 2009–2012. Participants: The study sample included 3,058 WCBA who were non-Hispanic white (NHW), nonHispanic black (NHB), Mexican American (MA), and of other races/ethnicities (ORE) with annual household incomes of < $25,000, $25,000–75,000 or > $75,000. Variables Measured: Average daily consumption of vegetables and mean intakes of nutrients of concern from foods, including potassium (K), dietary fiber (DF), calcium, magnesium, iron, vitamin C, and folates. Analysis: The analysis compared mean vegetable consumption and nutrient intake from food to current recommendations across race/ethnicity and household income categories. Results: On average, WCBA consumed 1.43 cup equivalents/d of total vegetables and NHB WCBA consumed fewer vegetables than did NHW (P < .01), MA (P < .01), and ORE (P < .01) WCBA. Mean consumption of starchy vegetables, including white potatoes (WP), by WCBA was also below the recommended 5–6 cups of starchy vegetables per week. Average intake of K was 2,364 mg, or about half of the recommended 4,700 mg. Mean DF intake, 15.4 g, was about 60% of the recommended 25 g. In general, NHB WCBA consumed fewer vegetables than did NHW (P < 0.01), MA (P < 0.01), and ORE (P < 0.01) WCBA. On average, WCBA in households with incomes < $25,000 consumed fewer vegetables and had lower intakes of K, DF, calcium, and iron than did WCBA with household incomes > $75,000 (P < .05). Conclusions and Implications: These results showed that WCBA had low vegetable consumption, including starchy vegetables, compared with recommendations in the Dietary Guidelines for Americans, 2015–2020. Potassium and DF intakes were low among WCBA, but especially so for NHB WCBA and WCBA with limited financial resources. Government-sponsored food assistance programs should consider policies that encourage WCBA to consume more vegetables, including starchy vegetables, such as WP and lima beans that are rich in K and an important source of DF. Key Words: vegetable, shortfall nutrients, low-income, women, ethnicity, NHANES (J Nutr Educ Behav. 2016;-:1-6.) Accepted July 17, 2016.
INTRODUCTION It is well known that a mother's health and dietary choices before and during pregnancy, particularly during the first trimester, influence the health of ba-
bies.1,2 According to the Academy of Nutrition and Dietetics, Pregnancy is a critical period during which maternal nutrition and lifestyle choices are major influ-
1
Maureen Storey, LLC, Gainesville, VA Monroe, WA † Dr Storey and Ms Anderson were affiliated with the Alliance for Potato Research and Education at the time this study was completed. Conflict of Interest Disclosure: The authors’ conflict of interest disclosures can be found online with this article on www.jneb.org. Address for correspondence: Maureen L. Storey, PhD, Maureen Storey, LLC, 6362 Bold Venture Way, Gainesville, VA 20155; Phone: (703) 489-9815; E-mail: maureenstoreyllc@ gmail.com Ó2016 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jneb.2016.07.014 2
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ences on mother and child health. Inadequate levels of key nutrients during crucial periods of fetal development may lead to reprogramming within fetal tissues, predisposing the infant to chronic conditions in later life.3 Since 1980, the US Department of Health and Human Services and the US Department of Agriculture (USDA) jointly publish the Dietary Guidelines for Americans (DGAs) every 5 years.4 The DGAs encourage Americans to focus on eating a healthful diet and are the basis for USDA's multi–billion dollar nutrition assistance programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children
1
2 Storey and Anderson (WIC) that serves more than 8 million at-risk, low-income, pregnant, breastfeeding, and postpartum women, infants, and young children aged < 5 years.5 For most women of childbearing age (WCBA), and regardless of the eating pattern (healthy US-style, Mediterranean-style, and healthy vegetarian eating patterns), the 2015– 2020 DGAs recommend about 2.5–3 cups of vegetables each day, including 5–6 cups of starchy vegetables per week.6 Among adults, including WCBA, dietary intakes of vitamins A, C, and E, calcium, magnesium, potassium (K), and dietary fiber (DF) are low enough to be of concern.7 Specific recommendations for iron and folic acid intake were developed for WCBA because research showed that these are critical nutrients during pregnancy and WCBA tend to have inadequate iron and folic acid intakes.8 In 2007, the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine published a report that recommended that the USDA encourage greater fruit and vegetable consumption by issuing a cash value voucher to WIC participants for the purchase of fruits and vegetables, except for white potatoes (WP).8 The rationale of the HMD committee was that WIC participants ate enough WP, but that recommendation was based on 10year-old data from the Continuing Survey of Food Intake by Individuals 1994–1996 and 1998 and the 2005 DGAs. The USDA implemented the HMD's recommendation through regulations that prohibited WIC participants from using the cash value voucher to buy any type of WP, including fresh WP, in the grocery store. Nevertheless, WIC participants were allowed to use the cash value voucher to purchase WP at a farmers' market. In 2014, the USDA sponsored another HMD review of the WIC food package with an expedited review of WP in the WIC program. The HMD committee published a letter report to the USDA on February 3, 2015, recommending that WP be included in the WIC program like any other vegetable.9 The recommendation was based on the finding that overall, the nutrient profile of white potatoes is similar to that of
Journal of Nutrition Education and Behavior Volume -, Number -, 2016 other starchy vegetables that are currently permitted for purchase with the cash value voucher. Because white potatoes are so widely consumed, they contribute useful quantities of potassium and fiber to Americans' diets.9 The objective of this study was to examine vegetable consumption, and specifically WP consumption, of WCBA across race/ethnicity and household income, compared against the DGAs. Average intakes of select nutrients from foods, including K, DF, calcium, magnesium, iron, vitamin C, and folates, were compared against the Dietary Reference Intakes to better understand current vegetable and nutrient gaps for this subpopulation.
METHODS This study examined nutrient intakes from foods and vegetable consumption of WCBA aged 19–50 years using dietary data from the National Health and Nutrition Examination Survey (NHANES) 2009–2010 and 2011– 2012 and the Food Pattern Equivalents Database (FPED) 2009–2010 and 2011–2012. The National Center for Health Statistics of the Centers for Disease Control and Prevention conducts NHANES and survey data are released in 2-year cycles. All NHANES data collections receive approval from the National Center for Health Statistics Research Ethics Review Board. These data are publicly available and represent all non-institutionalized persons living in the US. This analysis used data from the first day of the 24hour dietary recall (24HR) and the total nutrient intake files. Dietary intake was measured using a multipass 24HR instrument that has been thoroughly tested for accuracy. Methods of collecting these data are explained on the USDA's Web site.10 Only day 1 dietary recall data were used because, according to the NHANES documentation, the mean of the population's distribution of usual intake can be estimated from a sample of individuals' 24-hour recalls, without sophisticated statistical adjustment.11 In addition, day 1 dietary recall data were collected in person whereas
day 2 data were collected on a much smaller subsample by phone interview. Dietary data from NHANES 2011–1212 were the most recent data available to the public; these data were not available for the HMD report. The FPED converts foods and beverages in the Food and Nutrient Database for Dietary Studies to cup equivalents of fruit, vegetables, and dairy; ounce equivalents of grains and protein foods; teaspoon equivalents of added sugars; gram equivalents of solid fats and oils; and number of alcoholic drinks.12,13 For purposes of this study, vegetables included all foods and food combinations coded as primarily vegetables (codes 71000100–79999999) in the Food and Nutrient Databases for Dietary Studies 2009–2010 and 2011–2012.14 White potatoes included the following: baked, boiled, fried, hash-browned, home-fried, mashed, roasted, salad, scalloped, stuffed, with sauce, and potato chips. Oven-baked and deep-fried french-fried potatoes were combined and included in the total WP means. This analysis did not include dietary supplements. The analysis used appropriate survey weights to calculate average daily nutrient intakes from foods and consumption of total vegetables, WP, and other starchy vegetables (sweet corn, green peas, and lima beans) for females aged 19–50 years.15 Mean intakes of select nutrients of concern for this population, including K, DF, calcium, magnesium, iron, vitamin C, and folates, were calculated from foods and beverages. The FPED was used to convert grams of vegetables and vegetable combinations, including WP, to cup equivalents. This study used an analysis of NHANES 2009-2010 and 2011–2012 dietary data by the USDA Agricultural Research Service as the basis for the design.16 Means of vegetable consumption and nutrient intake were compared across race/ethnicity, which included WCBA who were non-Hispanic black (NHB), nonHispanic white (NHW), Mexican American (MA), and of other race/ ethnicity (ORE), and household income categories < $25,000, $25,000– 75,000, and > $75,000. Group means were estimated in STATA 8 using the svyreg procedure to adjust for the
Journal of Nutrition Education and Behavior Volume -, Number -, 2016 complex design of the survey and the subpop option to calculate the group means for the age group (Release 8.0, Stata Statistical Software, StataCorp, College Station, TX, 2004). This procedure used a Taylor linearization approach to correct the estimated SEs for survey design effects.17 The statistical significance of differences of intakes between subpopulation means (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another.
RESULTS Average age of this sample of WCBA was 35.3 years; mean body mass index was 28.6 kg/m2 (Table 1). In general, NHW and ORE WCBA had lower body mass index than did NHB and MA WCBA. Approximately one third of the sample had the equivalent of a high school degree or less, and differences in educational attainment across race/ethnicity were significantly different. WCBA who were NHW and ORE had higher levels of education than did NHB and MA WCBA (P < .05). Nearly two thirds of MA WCBA had a high school education or less, and less than 10% were college educated. In contrast, NHB WCBA had higher levels of education than did MA WCBA (P < .05). About 27% of WCBA lived in a household with an annual income of < $25,000. Fewer NHW WCBA lived in households making < $25,000/y (P < .05). Approximately 45% of NHB WCBA had annual household income of < $25,000. Total energy intake for the sample was 1,897 kcal, on average (Table 2). In general, NHB women consumed more total energy than did NHW (P < .05) and ORE (P < .01) WCBA.
Vegetable Consumption Average total vegetable consumption by WCBA was about half of that recommended by DGAs, 2015–2020: 1.43 cup equivalents per day (CE/d) (Table 2). On average, NHB consumed fewer vegetables than did NHW (P < .01), MA (P < .01), and ORE (P < .01) WCBA.
The DGAs recommend that WCBA consume 5–6 cups of starchy vegetables per week, or about 0.75 cups/d. This nationally representative sample of WCBA consumed about one third of a cup (0.38 CE/d) of starchy vegetables, including WP. Women of childbearing age who were NHB consumed 0.45 CE/d of starchy vegetables, about 60% of the recommended 0.75 CE/d. On average, NHW and ORE WCBA consumed significantly fewer starchy vegetables than did NHB WCBA, 0.37 (P < .01) and 0.37 (P < .05) CE/d, respectively. The WCBA consumed an average of 0.31 CE/d of total WP. In general, NHB consumed more total WP than did NHW (P < .05) and ORE (P < .01) WCBA; ORE WCBA also tended to consume fewer WP than did NHW women (P < .05). Mean consumption of french-fried potatoes was low, about 0.07 CE/d, among WCBA, but NHB women tended to consume more french-fried potatoes than did women of all other races/ethnicities (P < .05).
Nutrient Intakes Mean intakes of K, DF, calcium, magnesium, iron, and folates were lower than current recommendations for women aged 19–50 years (Table 2). Average intake of K was 2,364 mg, or about half of the recommended 4,700 mg. Mean DF intake, 15.4 g/d, was about 60% of the recommended 25 g/d. With the exception of vitamin C, NHB women's mean intake of every nutrient examined in this study was lower than the intake of their NHW (P < .05) and MA (P < .05) counterparts. In general, ORE WCBA consumed more K, DF, calcium, magnesium, and folates than did NHB women (P < .05). Mean K and DF intakes among NHB women in this sample were about 50% of the adequate intakes (AI).
Income Analysis In general, WCBA living in households in the highest income category (> $75,000) consumed more vegetables (P < .05) and had higher average intakes of DF, calcium, magnesium, and iron than did WCBA in the lowest
Storey and Anderson 3 (< $25,000) and middle ($25,000– 75,000) household income categories (P < .05) (Table 3). Women in the lowest family income category consumed an average of 1.28 CE/d of total vegetables—approximately half of the 2.5 CE/d recommendation. Mean consumption of starchy vegetables was lower than the 0.75 CE/d recommendation across all income categories. Mean intake of K was also lower for WCBA with incomes < $25,000 than for women in the highest family income category (P < .05). Although women with higher household incomes tended to have higher intakes of folates, the differences were not statistically significant.
DISCUSSION This study confirmed that mean total vegetable consumption by WCBA remains low9—about half of the 2.5 CE/d recommended in the 2015– 2020 DGAs. Contrary to perception, mean starchy vegetable consumption, including WP, by WCBA was also below the recommended 5–6 cups of starchy vegetables per week.6 Mean vegetable consumption was significantly lower among NHB WCBA and WCBA in the lowest household income category. Average intakes of K, DF, magnesium, iron, and folates by WCBA were lower than current dietary recommendations across all races/ethnicities. These findings of this study agreed with previously published studies that found WCBA did not meet dietary recommendations for micronutrients that are particularly important before and during pregnancy.18 The 2015–2020 DGA identified K and DF as nutrients of concern because most Americans do not consume sufficient amounts of these nutrients to meet their needs. A USDA analysis using NHANES 2009– 2010 found that < 1% of females had K intakes that met the AI of 4,700 mg/d for individuals aged $ 14 years.19 A similar USDA analysis reported that mean DF intake for women was about 15 g/d and that NHB had significantly lower DF intakes, on average.20 In this sample of WCBA, average K intake was about half of the recommendation and mean intake of DF was also well below
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4 Storey and Anderson
Table 1. Description of Sample Population of Women of Childbearing Aged 19–50 y Using National Health and Nutrition Examination Survey 2009–2012
Parameters Age, y
Non-Hispanic Non-Hispanic Mexican Other Race/ All White (n ¼ 1,220) Black (n ¼ 664) American (n ¼ 492) Ethnicity (n ¼ 682) 35.3 (0.4) 35.5 (0.5)a 33.5 (0.7)b 33.6 (0.5)b 34.1 (0.6)a,b
Body mass index, kg/m2
28.6 (0.2)
27.9 (0.3)a
31.8 (0.4)b
Education (weighted %) High school degree or less Some college College or more
32.7 (2.0) 34.7 (1.4) 32.5 (2.2)
27.7 (2.6)a 34.9 (2.0)a,c 37.3 (3.1)a
40.5 (3.5)b 41.4 (3.1)a 18.2 (2.7)b
64.0 (3.7)c 27.1 (2.9)b,c 8.8 (1.6)c
30.1 (2.9)a 31.9 (2.8)c 37.9 (3.7)a
22.8 (2.1)a 35.6 (2.4)a 39.7 (2.8)a
45.3 (4.2)b 34.7 (2.6)a 13.6 (2.0)b
34.0 (3.0)c 45.1 (3.0)b 14.6 (4.3)b
29.7 (2.9)c 43.0 (3.0)b 24.0 (2.9)c
Annual income ($), % weighted < 24,999 27.4 (2.0) 25,000–74,999 38.0 (1.6) > 75,000 31.5 (1.9)
29.6c (0.5)
27.1 (0.4)a
a–c Values presented are weighted means SE. The statistical significance of differences of mean intakes across race/ethnicity categories (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another. Means with different superscripts are significantly different (P < .05).
the AI of 25 g/d for adult women. Furthermore, race/ethnicity and low income were associated with significantly lower intakes of K and DF among NHB and women with the lowest household income.
Previous studies found that WCBA in lower-income households consumed significantly fewer vegetables and had significantly lower intakes of nutrients of concern.18,21 Poor diet quality and low vegetable consumption have been
associated with lower income, in part owing to the relatively high cost of nutrient-dense foods such as fresh vegetables and fruits. Inadequate nutrition education and limited access to nutritious foods have also
Table 2. Mean Energy Intake, Vegetable Consumption, and Nutrient Intakes of Women of Childbearing Age (Aged 19–50 y) by Race/Ethnicity Using National Health and Nutrition Examination Survey 2009–2012
All Races (n ¼ 3,058)
Non-Hispanic White (n ¼ 1,220)
Non-Hispanic Black (n ¼ 664)
1,897 (14.0)
1,883 (18.6)a
2,009 (44.3)b
1,920 (43.3)a,b
1,835 (33.9)a
Total vegetables, CE/d (DGA recommendation: 2.5 CE/d)
1.43 (0.04)
1.44 (0.05)a
1.23 (0.05)b
1.53 (0.07)a
1.50 (0.08)a
Total starchy, CE/d (DGA recommendation: 5–6 cups/wk [about 0.75 CE/d])
0.38 (0.01)
0.37 (0.02)a
0.45 (0.03)b
0.37 (0.03)a,b
0.37 (0.03)a
Total white potatoes including french fries, CE/d
0.31 (0.01)
0.31 (0.02)a
0.38 (0.03)b
0.29 (0.04)a,b,c
0.24 (0.02)c
Total french-fried potatoes, CE/d
0.07 (0.005)
0.07 (0.01)a
0.11 (0.01)b
0.05 (0.01)a
0.06 (0.01)a
2,387 (39.8)a
2,185 (41.6)b
2,423 (56.2)a
2,394 (59.8)a
Variables Total energy, kcal/d
Potassium, mg/d (AI, 4,700 mg/d)
2,364 (26.3)
a
Dietary fiber, g/d (AI, 25 g/d)
15.4 (0.3)
15.4 (0.4)
Calcium, mg/d (RDA, 1,000 mg/d)
908 (10.4)
950 (16.1)a
Magnesium, mg/d (RDA, 310–320 mg/d) Iron, mg/d (RDA, 18 mg/d) Vitamin C, mg/d (RDA, 75 mg/d) Folates, mg/d (RDA, 400 mg/d)
271.7 (3.4) 13.6 (0.2)
275.3 (4.9)
a
13.8 (0.2)a,c
12.9 (0.3)
b
789 (19.9)b 245.2 (4.2)
b
17.5 (0.5)
c
278.2 (5.7)
a
14.6 (0.6)c 95 (7.1)b
72 (3.4)a
89 (4.6)b
367 (6.6)
a
b
318 (7.6)
Other Race/ Ethnicity (n ¼ 682)
16.4 (0.6)a,c
899 (25.3)a,c
12.6 (0.3)b
79 (2.7)
373 (9.6)
Mexican American (n ¼ 492)
854 (21.2)c 276.9 (8.6)a 13.0 (0.4)a,b 84 (3.5)b
a
385 (13.8)
378 (14.3)a
AI indicates Adequate Intake; CE/d, cup equivalents/d; DGA, Dietary Guidelines for Americans; RDA, Recommended Dietary Allowance. a–c Values presented are weighted means SE. The statistical significance of differences of mean intakes across race/ethnicity categories (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another. Means with different superscripts are significantly different (P < .05).
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Storey and Anderson 5
Table 3. Mean Energy Intake and Vegetable Consumption of Women of Childbearing Age (WCBA) (Aged 19–50 y) by Annual Income Level Using National Health and Nutrition Examination Survey 2009–2012 WCBA All Incomes 1,896.7 (14.0)
< $25,000 (n ¼ 1,063) 1,980.0 (44.1)a
$25,000–74,999 (n ¼ 1,110) 1,842.9 (36.0)b
Total vegetables, CE/d (DGA recommendation, 2.5 CE/d)
1.43 (0.04)
1.28 (0.04)a
1.37 (0.05)a
1.61 (0.06)b
Total starchy, CE/d (DGA recommendation, 5–6 CE/wk [about 0.75 CE/d])
0.38 (0.01)
0.41 (0.05)a
0.39 (0.03)a
0.35 (0.03)a
Total white potatoes, CE/d
0.31 (0.01)
0.33 (0.02)a
0.32 (0.02)a
0.28 (0.03)a
0.07 (0.07)
a
b
0.06 (0.01)b
Variables Total energy, kcal/d
Total french fries, CE/d Potassium, mg/d (AI, 4,700 mg/d)
2,364 (26.3)
Dietary fiber, g/d (AI, 25 g/d)
15.4 (0.3)
Calcium, mg/d (RDA, 1,000 mg/d)
908 (10.4)
Magnesium, mg/d (RDA, 310–320 mg/d) Iron, mg/d (RDA, 18 mg/d) Vitamin C, mg/d (RDA, 75 mg/d) Folates, mg/d (RDA, 400 mg/d)
271.7 (3.4)
0.09 (0.01)
2,280.9 (43.7)a 14.3 (0.4)
a
892.1 (22.2)a 260.3 (6.1)
a
0.06 (0.01)
2,333.4 (51.5)a,b 14.9 (0.4)
a
890.2 (17.9)a 265.5 (6.4)
$ $75,000 (n ¼ 659) 1,897.9 (32.8)a,b
2,474.9 (53.4)b 16.8 (0.4)b 958.4 (21.0)b
a
291.2 (6.4)b
13.6 (0.2)
13.2 (0.3)a
13.1 (0.3)a
14.5 (0.3)b
78.8 (2.7)
78.9 (4.8)
a
a
77.4 (3.1)a
367.4 (6.6)
360.5 (11.8)a
78.5 (3.7)
357.3 (9.2)a
382.5 (10.4)a
AI indicates Adequate Intake; CE/d, cup equivalents per day; DGA, Dietary Guidelines for Americans; RDA, Recommended Dietary Allowance. a,b Values presented are weighted means SE. The statistical significance of differences of mean intakes across income categories (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another. Means with different superscripts are significantly different (P < .05). been barriers to greater consumption of vegetables and fruit by women living in lower-income households.21 A recent meta-analysis concluded that: Socioeconomic disparities in diet quality may be explained by the higher cost of healthy diets. Identifying food patterns that are nutrient rich, affordable, and appealing should be a priority to fight social inequalities in nutrition and health.22 Using the Nutrient Rich Foods Index, studies showed that potatoes, tomato juices and tomato soups, carrots, and broccoli were the most affordable vegetables and were widely accepted across race/ethnicities and income levels.22-25 Continuous NHANES is a large, well-executed, nationally representative survey that is widely used in health research. Like any data set, however, it has certain limitations. The 24HR used in NHANES has been extensively tested but it is likely to have some measurement error for the variables used in this analysis. Dietary intake may be underestimated because respondents fail to remember or choose not to report certain foods or
beverages. However, the multi-pass system attempts to minimize underreporting. A small amount of vegetables as part of combinations may have been missed, but the researchers used the Agricultural Research Service data to validate the data and no differences were found. The statistical analysis used in this study did not account for the disproportionate racial/ethnic composition of the income categories. In addition, the middle-income category, $25,000–75,000, was heterogeneous, and using the poverty to income ratio may be another approach to assess the effect of income on food consumption and nutrient intake.
IMPLICATIONS FOR RESEARCH AND PRACTICE This analysis was designed to inform policy makers about current vegetable consumption patterns and nutrient needs of WCBA. Using a nationally representative sample from the most current federal dietary data, these results showed that on average, key nutrient intakes and vegetable consumption of WCBA were significantly
lower than current recommendations. Although frequently characterized as America's most popular or most frequently consumed vegetable, mean consumption of starchy vegetables, including WP, was below recommendations for WCBA. This study showed significant racial/ethnic and income disparities in total and starchy vegetable consumption and intakes of nutrients of concern such as K and DF. Moreover, NHB WCBA and low-income WCBA were at greatest risk for low nutrient intake and vegetable consumption, including starchy vegetables. More research is needed to understand better how to change vegetable consumption habits of all WCBA, especially those with the lowest intake, such as NHB WCBA and lowincome WCBA. Encouraging consumption of all vegetables, including WP, in any form (fresh, frozen, dried, canned, or dehydrated) can help address the vegetable gap.
ACKNOWLEDGMENTS At the time this study was conducted and submitted for publication, M. L. Storey was a paid employee of the
6 Storey and Anderson Alliance for Potato Research and Education; P. A. Anderson was a paid consultant for the Alliance for Potato Research and Education.
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Health Statistics. Vital Health Stat 2; 2013:1-17. US Department of Agriculture, Agricultural Research Service. What we eat in America. NHANES 2011-2012 data tables. http://www.ars.usda.gov/SP2User Files/Place/80400530/pdf/fped/Table_3_ FPED_INC_1112.pdf. Accessed April 23, 2016. Hazewinkel M, ed. Encyclopedia of Mathematics. New York, NY: Springer; 2001. Blumfield ML, Hure AJ, MacdonaldWicks L, Smith R, Collins CE. A systematic review and meta-analysis of micronutrient intakes during pregnancy in developed countries. Nutr Rev. 2013;71:118-132. Hoy MK, Goldman JD. Potassium intake of the U.S. population: what we eat in America. NHANES 2009–2010. Food Surveys Research Group dietary data brief no. 10. http://ars.usda.gov/ Services/docs.htm?docid¼19476. Accessed December 20, 2015. Hoy MK, Goldman JD. Fiber intake of the U.S. population: what we eat in America. NHANES 2009–2010. Food Surveys Research Group dietary data brief no. 12. https://www.ars.usda.gov/SP2 UserFiles/Place/80400530/pdf/DBrief/ 12_fiber_intake_0910.pdf. Accessed December 20, 2015. Bhargava A. Socio-economic and behavioural factors are predictors of food use in the National Food Stamp Program Survey. Br J Nutr. 2004;92:497-506. Darmon N, Drewnowski A. Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis. Nutr Rev. 2015;73:643. Fulgoni VL III, Keast DR, Drewnowski A. Development and validation of the nutrient-rich foods index: a tool to measure nutritional quality of foods. J Nutr. 2009;139:1549-1554. Stewart H, Hyman J, Fraz~ao E, Buzby JC, Carlson A. Can low-income Americans afford to satisfy MyPyramid fruit and vegetable guidelines? J Nutr Educ Behav. 2011;43:173-179. Drewnowski A, Rehm CD. Vegetable cost metrics show that potatoes and beans provide most nutrients per penny. PLoS One. 2013;8:e63277.
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CONFLICT OF INTEREST The authors have not stated any conflicts of interest.
Storey and Anderson 6.e1
INTRODUCTION It is well known that a mother's health and dietary choices before and during pregnancy, particularly during the first trimester, influence the health of ba-
bies.1,2 According to the Academy of Nutrition and Dietetics, Pregnancy is a critical period during which maternal nutrition and lifestyle choices are major influ-
1
Maureen Storey, LLC, Gainesville, VA Monroe, WA † Dr Storey and Ms Anderson were affiliated with the Alliance for Potato Research and Education at the time this study was completed. Conflict of Interest Disclosure: The authors’ conflict of interest disclosures can be found online with this article on www.jneb.org. Address for correspondence: Maureen L. Storey, PhD, Maureen Storey, LLC, 6362 Bold Venture Way, Gainesville, VA 20155; Phone: (703) 489-9815; E-mail: maureenstoreyllc@ gmail.com Ó2016 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jneb.2016.07.014 2
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ences on mother and child health. Inadequate levels of key nutrients during crucial periods of fetal development may lead to reprogramming within fetal tissues, predisposing the infant to chronic conditions in later life.3 Since 1980, the US Department of Health and Human Services and the US Department of Agriculture (USDA) jointly publish the Dietary Guidelines for Americans (DGAs) every 5 years.4 The DGAs encourage Americans to focus on eating a healthful diet and are the basis for USDA's multi–billion dollar nutrition assistance programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children
1
2 Storey and Anderson (WIC) that serves more than 8 million at-risk, low-income, pregnant, breastfeeding, and postpartum women, infants, and young children aged < 5 years.5 For most women of childbearing age (WCBA), and regardless of the eating pattern (healthy US-style, Mediterranean-style, and healthy vegetarian eating patterns), the 2015– 2020 DGAs recommend about 2.5–3 cups of vegetables each day, including 5–6 cups of starchy vegetables per week.6 Among adults, including WCBA, dietary intakes of vitamins A, C, and E, calcium, magnesium, potassium (K), and dietary fiber (DF) are low enough to be of concern.7 Specific recommendations for iron and folic acid intake were developed for WCBA because research showed that these are critical nutrients during pregnancy and WCBA tend to have inadequate iron and folic acid intakes.8 In 2007, the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine published a report that recommended that the USDA encourage greater fruit and vegetable consumption by issuing a cash value voucher to WIC participants for the purchase of fruits and vegetables, except for white potatoes (WP).8 The rationale of the HMD committee was that WIC participants ate enough WP, but that recommendation was based on 10year-old data from the Continuing Survey of Food Intake by Individuals 1994–1996 and 1998 and the 2005 DGAs. The USDA implemented the HMD's recommendation through regulations that prohibited WIC participants from using the cash value voucher to buy any type of WP, including fresh WP, in the grocery store. Nevertheless, WIC participants were allowed to use the cash value voucher to purchase WP at a farmers' market. In 2014, the USDA sponsored another HMD review of the WIC food package with an expedited review of WP in the WIC program. The HMD committee published a letter report to the USDA on February 3, 2015, recommending that WP be included in the WIC program like any other vegetable.9 The recommendation was based on the finding that overall, the nutrient profile of white potatoes is similar to that of
Journal of Nutrition Education and Behavior Volume -, Number -, 2016 other starchy vegetables that are currently permitted for purchase with the cash value voucher. Because white potatoes are so widely consumed, they contribute useful quantities of potassium and fiber to Americans' diets.9 The objective of this study was to examine vegetable consumption, and specifically WP consumption, of WCBA across race/ethnicity and household income, compared against the DGAs. Average intakes of select nutrients from foods, including K, DF, calcium, magnesium, iron, vitamin C, and folates, were compared against the Dietary Reference Intakes to better understand current vegetable and nutrient gaps for this subpopulation.
METHODS This study examined nutrient intakes from foods and vegetable consumption of WCBA aged 19–50 years using dietary data from the National Health and Nutrition Examination Survey (NHANES) 2009–2010 and 2011– 2012 and the Food Pattern Equivalents Database (FPED) 2009–2010 and 2011–2012. The National Center for Health Statistics of the Centers for Disease Control and Prevention conducts NHANES and survey data are released in 2-year cycles. All NHANES data collections receive approval from the National Center for Health Statistics Research Ethics Review Board. These data are publicly available and represent all non-institutionalized persons living in the US. This analysis used data from the first day of the 24hour dietary recall (24HR) and the total nutrient intake files. Dietary intake was measured using a multipass 24HR instrument that has been thoroughly tested for accuracy. Methods of collecting these data are explained on the USDA's Web site.10 Only day 1 dietary recall data were used because, according to the NHANES documentation, the mean of the population's distribution of usual intake can be estimated from a sample of individuals' 24-hour recalls, without sophisticated statistical adjustment.11 In addition, day 1 dietary recall data were collected in person whereas
day 2 data were collected on a much smaller subsample by phone interview. Dietary data from NHANES 2011–1212 were the most recent data available to the public; these data were not available for the HMD report. The FPED converts foods and beverages in the Food and Nutrient Database for Dietary Studies to cup equivalents of fruit, vegetables, and dairy; ounce equivalents of grains and protein foods; teaspoon equivalents of added sugars; gram equivalents of solid fats and oils; and number of alcoholic drinks.12,13 For purposes of this study, vegetables included all foods and food combinations coded as primarily vegetables (codes 71000100–79999999) in the Food and Nutrient Databases for Dietary Studies 2009–2010 and 2011–2012.14 White potatoes included the following: baked, boiled, fried, hash-browned, home-fried, mashed, roasted, salad, scalloped, stuffed, with sauce, and potato chips. Oven-baked and deep-fried french-fried potatoes were combined and included in the total WP means. This analysis did not include dietary supplements. The analysis used appropriate survey weights to calculate average daily nutrient intakes from foods and consumption of total vegetables, WP, and other starchy vegetables (sweet corn, green peas, and lima beans) for females aged 19–50 years.15 Mean intakes of select nutrients of concern for this population, including K, DF, calcium, magnesium, iron, vitamin C, and folates, were calculated from foods and beverages. The FPED was used to convert grams of vegetables and vegetable combinations, including WP, to cup equivalents. This study used an analysis of NHANES 2009-2010 and 2011–2012 dietary data by the USDA Agricultural Research Service as the basis for the design.16 Means of vegetable consumption and nutrient intake were compared across race/ethnicity, which included WCBA who were non-Hispanic black (NHB), nonHispanic white (NHW), Mexican American (MA), and of other race/ ethnicity (ORE), and household income categories < $25,000, $25,000– 75,000, and > $75,000. Group means were estimated in STATA 8 using the svyreg procedure to adjust for the
Journal of Nutrition Education and Behavior Volume -, Number -, 2016 complex design of the survey and the subpop option to calculate the group means for the age group (Release 8.0, Stata Statistical Software, StataCorp, College Station, TX, 2004). This procedure used a Taylor linearization approach to correct the estimated SEs for survey design effects.17 The statistical significance of differences of intakes between subpopulation means (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another.
RESULTS Average age of this sample of WCBA was 35.3 years; mean body mass index was 28.6 kg/m2 (Table 1). In general, NHW and ORE WCBA had lower body mass index than did NHB and MA WCBA. Approximately one third of the sample had the equivalent of a high school degree or less, and differences in educational attainment across race/ethnicity were significantly different. WCBA who were NHW and ORE had higher levels of education than did NHB and MA WCBA (P < .05). Nearly two thirds of MA WCBA had a high school education or less, and less than 10% were college educated. In contrast, NHB WCBA had higher levels of education than did MA WCBA (P < .05). About 27% of WCBA lived in a household with an annual income of < $25,000. Fewer NHW WCBA lived in households making < $25,000/y (P < .05). Approximately 45% of NHB WCBA had annual household income of < $25,000. Total energy intake for the sample was 1,897 kcal, on average (Table 2). In general, NHB women consumed more total energy than did NHW (P < .05) and ORE (P < .01) WCBA.
Vegetable Consumption Average total vegetable consumption by WCBA was about half of that recommended by DGAs, 2015–2020: 1.43 cup equivalents per day (CE/d) (Table 2). On average, NHB consumed fewer vegetables than did NHW (P < .01), MA (P < .01), and ORE (P < .01) WCBA.
The DGAs recommend that WCBA consume 5–6 cups of starchy vegetables per week, or about 0.75 cups/d. This nationally representative sample of WCBA consumed about one third of a cup (0.38 CE/d) of starchy vegetables, including WP. Women of childbearing age who were NHB consumed 0.45 CE/d of starchy vegetables, about 60% of the recommended 0.75 CE/d. On average, NHW and ORE WCBA consumed significantly fewer starchy vegetables than did NHB WCBA, 0.37 (P < .01) and 0.37 (P < .05) CE/d, respectively. The WCBA consumed an average of 0.31 CE/d of total WP. In general, NHB consumed more total WP than did NHW (P < .05) and ORE (P < .01) WCBA; ORE WCBA also tended to consume fewer WP than did NHW women (P < .05). Mean consumption of french-fried potatoes was low, about 0.07 CE/d, among WCBA, but NHB women tended to consume more french-fried potatoes than did women of all other races/ethnicities (P < .05).
Nutrient Intakes Mean intakes of K, DF, calcium, magnesium, iron, and folates were lower than current recommendations for women aged 19–50 years (Table 2). Average intake of K was 2,364 mg, or about half of the recommended 4,700 mg. Mean DF intake, 15.4 g/d, was about 60% of the recommended 25 g/d. With the exception of vitamin C, NHB women's mean intake of every nutrient examined in this study was lower than the intake of their NHW (P < .05) and MA (P < .05) counterparts. In general, ORE WCBA consumed more K, DF, calcium, magnesium, and folates than did NHB women (P < .05). Mean K and DF intakes among NHB women in this sample were about 50% of the adequate intakes (AI).
Income Analysis In general, WCBA living in households in the highest income category (> $75,000) consumed more vegetables (P < .05) and had higher average intakes of DF, calcium, magnesium, and iron than did WCBA in the lowest
Storey and Anderson 3 (< $25,000) and middle ($25,000– 75,000) household income categories (P < .05) (Table 3). Women in the lowest family income category consumed an average of 1.28 CE/d of total vegetables—approximately half of the 2.5 CE/d recommendation. Mean consumption of starchy vegetables was lower than the 0.75 CE/d recommendation across all income categories. Mean intake of K was also lower for WCBA with incomes < $25,000 than for women in the highest family income category (P < .05). Although women with higher household incomes tended to have higher intakes of folates, the differences were not statistically significant.
DISCUSSION This study confirmed that mean total vegetable consumption by WCBA remains low9—about half of the 2.5 CE/d recommended in the 2015– 2020 DGAs. Contrary to perception, mean starchy vegetable consumption, including WP, by WCBA was also below the recommended 5–6 cups of starchy vegetables per week.6 Mean vegetable consumption was significantly lower among NHB WCBA and WCBA in the lowest household income category. Average intakes of K, DF, magnesium, iron, and folates by WCBA were lower than current dietary recommendations across all races/ethnicities. These findings of this study agreed with previously published studies that found WCBA did not meet dietary recommendations for micronutrients that are particularly important before and during pregnancy.18 The 2015–2020 DGA identified K and DF as nutrients of concern because most Americans do not consume sufficient amounts of these nutrients to meet their needs. A USDA analysis using NHANES 2009– 2010 found that < 1% of females had K intakes that met the AI of 4,700 mg/d for individuals aged $ 14 years.19 A similar USDA analysis reported that mean DF intake for women was about 15 g/d and that NHB had significantly lower DF intakes, on average.20 In this sample of WCBA, average K intake was about half of the recommendation and mean intake of DF was also well below
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4 Storey and Anderson
Table 1. Description of Sample Population of Women of Childbearing Aged 19–50 y Using National Health and Nutrition Examination Survey 2009–2012
Parameters Age, y
Non-Hispanic Non-Hispanic Mexican Other Race/ All White (n ¼ 1,220) Black (n ¼ 664) American (n ¼ 492) Ethnicity (n ¼ 682) 35.3 (0.4) 35.5 (0.5)a 33.5 (0.7)b 33.6 (0.5)b 34.1 (0.6)a,b
Body mass index, kg/m2
28.6 (0.2)
27.9 (0.3)a
31.8 (0.4)b
Education (weighted %) High school degree or less Some college College or more
32.7 (2.0) 34.7 (1.4) 32.5 (2.2)
27.7 (2.6)a 34.9 (2.0)a,c 37.3 (3.1)a
40.5 (3.5)b 41.4 (3.1)a 18.2 (2.7)b
64.0 (3.7)c 27.1 (2.9)b,c 8.8 (1.6)c
30.1 (2.9)a 31.9 (2.8)c 37.9 (3.7)a
22.8 (2.1)a 35.6 (2.4)a 39.7 (2.8)a
45.3 (4.2)b 34.7 (2.6)a 13.6 (2.0)b
34.0 (3.0)c 45.1 (3.0)b 14.6 (4.3)b
29.7 (2.9)c 43.0 (3.0)b 24.0 (2.9)c
Annual income ($), % weighted < 24,999 27.4 (2.0) 25,000–74,999 38.0 (1.6) > 75,000 31.5 (1.9)
29.6c (0.5)
27.1 (0.4)a
a–c Values presented are weighted means SE. The statistical significance of differences of mean intakes across race/ethnicity categories (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another. Means with different superscripts are significantly different (P < .05).
the AI of 25 g/d for adult women. Furthermore, race/ethnicity and low income were associated with significantly lower intakes of K and DF among NHB and women with the lowest household income.
Previous studies found that WCBA in lower-income households consumed significantly fewer vegetables and had significantly lower intakes of nutrients of concern.18,21 Poor diet quality and low vegetable consumption have been
associated with lower income, in part owing to the relatively high cost of nutrient-dense foods such as fresh vegetables and fruits. Inadequate nutrition education and limited access to nutritious foods have also
Table 2. Mean Energy Intake, Vegetable Consumption, and Nutrient Intakes of Women of Childbearing Age (Aged 19–50 y) by Race/Ethnicity Using National Health and Nutrition Examination Survey 2009–2012
All Races (n ¼ 3,058)
Non-Hispanic White (n ¼ 1,220)
Non-Hispanic Black (n ¼ 664)
1,897 (14.0)
1,883 (18.6)a
2,009 (44.3)b
1,920 (43.3)a,b
1,835 (33.9)a
Total vegetables, CE/d (DGA recommendation: 2.5 CE/d)
1.43 (0.04)
1.44 (0.05)a
1.23 (0.05)b
1.53 (0.07)a
1.50 (0.08)a
Total starchy, CE/d (DGA recommendation: 5–6 cups/wk [about 0.75 CE/d])
0.38 (0.01)
0.37 (0.02)a
0.45 (0.03)b
0.37 (0.03)a,b
0.37 (0.03)a
Total white potatoes including french fries, CE/d
0.31 (0.01)
0.31 (0.02)a
0.38 (0.03)b
0.29 (0.04)a,b,c
0.24 (0.02)c
Total french-fried potatoes, CE/d
0.07 (0.005)
0.07 (0.01)a
0.11 (0.01)b
0.05 (0.01)a
0.06 (0.01)a
2,387 (39.8)a
2,185 (41.6)b
2,423 (56.2)a
2,394 (59.8)a
Variables Total energy, kcal/d
Potassium, mg/d (AI, 4,700 mg/d)
2,364 (26.3)
a
Dietary fiber, g/d (AI, 25 g/d)
15.4 (0.3)
15.4 (0.4)
Calcium, mg/d (RDA, 1,000 mg/d)
908 (10.4)
950 (16.1)a
Magnesium, mg/d (RDA, 310–320 mg/d) Iron, mg/d (RDA, 18 mg/d) Vitamin C, mg/d (RDA, 75 mg/d) Folates, mg/d (RDA, 400 mg/d)
271.7 (3.4) 13.6 (0.2)
275.3 (4.9)
a
13.8 (0.2)a,c
12.9 (0.3)
b
789 (19.9)b 245.2 (4.2)
b
17.5 (0.5)
c
278.2 (5.7)
a
14.6 (0.6)c 95 (7.1)b
72 (3.4)a
89 (4.6)b
367 (6.6)
a
b
318 (7.6)
Other Race/ Ethnicity (n ¼ 682)
16.4 (0.6)a,c
899 (25.3)a,c
12.6 (0.3)b
79 (2.7)
373 (9.6)
Mexican American (n ¼ 492)
854 (21.2)c 276.9 (8.6)a 13.0 (0.4)a,b 84 (3.5)b
a
385 (13.8)
378 (14.3)a
AI indicates Adequate Intake; CE/d, cup equivalents/d; DGA, Dietary Guidelines for Americans; RDA, Recommended Dietary Allowance. a–c Values presented are weighted means SE. The statistical significance of differences of mean intakes across race/ethnicity categories (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another. Means with different superscripts are significantly different (P < .05).
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Storey and Anderson 5
Table 3. Mean Energy Intake and Vegetable Consumption of Women of Childbearing Age (WCBA) (Aged 19–50 y) by Annual Income Level Using National Health and Nutrition Examination Survey 2009–2012 WCBA All Incomes 1,896.7 (14.0)
< $25,000 (n ¼ 1,063) 1,980.0 (44.1)a
$25,000–74,999 (n ¼ 1,110) 1,842.9 (36.0)b
Total vegetables, CE/d (DGA recommendation, 2.5 CE/d)
1.43 (0.04)
1.28 (0.04)a
1.37 (0.05)a
1.61 (0.06)b
Total starchy, CE/d (DGA recommendation, 5–6 CE/wk [about 0.75 CE/d])
0.38 (0.01)
0.41 (0.05)a
0.39 (0.03)a
0.35 (0.03)a
Total white potatoes, CE/d
0.31 (0.01)
0.33 (0.02)a
0.32 (0.02)a
0.28 (0.03)a
0.07 (0.07)
a
b
0.06 (0.01)b
Variables Total energy, kcal/d
Total french fries, CE/d Potassium, mg/d (AI, 4,700 mg/d)
2,364 (26.3)
Dietary fiber, g/d (AI, 25 g/d)
15.4 (0.3)
Calcium, mg/d (RDA, 1,000 mg/d)
908 (10.4)
Magnesium, mg/d (RDA, 310–320 mg/d) Iron, mg/d (RDA, 18 mg/d) Vitamin C, mg/d (RDA, 75 mg/d) Folates, mg/d (RDA, 400 mg/d)
271.7 (3.4)
0.09 (0.01)
2,280.9 (43.7)a 14.3 (0.4)
a
892.1 (22.2)a 260.3 (6.1)
a
0.06 (0.01)
2,333.4 (51.5)a,b 14.9 (0.4)
a
890.2 (17.9)a 265.5 (6.4)
$ $75,000 (n ¼ 659) 1,897.9 (32.8)a,b
2,474.9 (53.4)b 16.8 (0.4)b 958.4 (21.0)b
a
291.2 (6.4)b
13.6 (0.2)
13.2 (0.3)a
13.1 (0.3)a
14.5 (0.3)b
78.8 (2.7)
78.9 (4.8)
a
a
77.4 (3.1)a
367.4 (6.6)
360.5 (11.8)a
78.5 (3.7)
357.3 (9.2)a
382.5 (10.4)a
AI indicates Adequate Intake; CE/d, cup equivalents per day; DGA, Dietary Guidelines for Americans; RDA, Recommended Dietary Allowance. a,b Values presented are weighted means SE. The statistical significance of differences of mean intakes across income categories (P < .05) was calculated using the STATA test postestimation procedure that performed Wald tests to estimate the probability that any 2 means were equal to one another. Means with different superscripts are significantly different (P < .05). been barriers to greater consumption of vegetables and fruit by women living in lower-income households.21 A recent meta-analysis concluded that: Socioeconomic disparities in diet quality may be explained by the higher cost of healthy diets. Identifying food patterns that are nutrient rich, affordable, and appealing should be a priority to fight social inequalities in nutrition and health.22 Using the Nutrient Rich Foods Index, studies showed that potatoes, tomato juices and tomato soups, carrots, and broccoli were the most affordable vegetables and were widely accepted across race/ethnicities and income levels.22-25 Continuous NHANES is a large, well-executed, nationally representative survey that is widely used in health research. Like any data set, however, it has certain limitations. The 24HR used in NHANES has been extensively tested but it is likely to have some measurement error for the variables used in this analysis. Dietary intake may be underestimated because respondents fail to remember or choose not to report certain foods or
beverages. However, the multi-pass system attempts to minimize underreporting. A small amount of vegetables as part of combinations may have been missed, but the researchers used the Agricultural Research Service data to validate the data and no differences were found. The statistical analysis used in this study did not account for the disproportionate racial/ethnic composition of the income categories. In addition, the middle-income category, $25,000–75,000, was heterogeneous, and using the poverty to income ratio may be another approach to assess the effect of income on food consumption and nutrient intake.
IMPLICATIONS FOR RESEARCH AND PRACTICE This analysis was designed to inform policy makers about current vegetable consumption patterns and nutrient needs of WCBA. Using a nationally representative sample from the most current federal dietary data, these results showed that on average, key nutrient intakes and vegetable consumption of WCBA were significantly
lower than current recommendations. Although frequently characterized as America's most popular or most frequently consumed vegetable, mean consumption of starchy vegetables, including WP, was below recommendations for WCBA. This study showed significant racial/ethnic and income disparities in total and starchy vegetable consumption and intakes of nutrients of concern such as K and DF. Moreover, NHB WCBA and low-income WCBA were at greatest risk for low nutrient intake and vegetable consumption, including starchy vegetables. More research is needed to understand better how to change vegetable consumption habits of all WCBA, especially those with the lowest intake, such as NHB WCBA and lowincome WCBA. Encouraging consumption of all vegetables, including WP, in any form (fresh, frozen, dried, canned, or dehydrated) can help address the vegetable gap.
ACKNOWLEDGMENTS At the time this study was conducted and submitted for publication, M. L. Storey was a paid employee of the
6 Storey and Anderson Alliance for Potato Research and Education; P. A. Anderson was a paid consultant for the Alliance for Potato Research and Education.
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9.
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CONFLICT OF INTEREST The authors have not stated any conflicts of interest.
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