Healthy Eating Index-2020: Review and Update Process to Reflect the Dietary Guidelines for Americans,2020-2025.

The purpose of this review is to share the process for reviewing, updating, and developing the most recent version of the Healthy Eating Index-2020 (HEI-2020) for ages 2 and older, following the release of the Dietary Guidelines for Americans (DGA), 2020-2025. The overall review process included: 1) gathering information from the updated DGA, experts, and federal stakeholders; 2) considering substantive changes and needs for new development, keeping in mind the HEI's key features and guiding principles, the US Department of Agriculture's Dietary Patterns that serve as the foundation for the HEI, and scoring considerations; and 3) completing evaluation analyses, including the examination of content validity. The review process led to the development of the HEI-2020; a separate HEI-Toddlers-2020 was developed for ages 12 through 23 months. The 13 components and scoring standards of the HEI-2020 fully align with the HEI-2015, although the index was renamed to clarify that it aligned with the most recent 2020-2025 DGA. As the evidence informing the DGA continues to evolve, various aspects of the HEI may need to evolve in the future as well. Further methodological research is encouraged to add to the scientific evidence base on dietary patterns, to examine needs specific to each life stage, and to model optimal trajectories of healthy dietary patterns over the lifespan.

Evaluation of the Healthy Eating Index-Toddlers-2020.

BACKGROUND: With the addition of new guidance for children from birth to 24 months in the Dietary Guidelines for Americans, 2020-2025 (DGA), a Healthy Eating Index (HEI) was developed for toddlers. OBJECTIVE: To evaluate the psychometric properties of the HEI-Toddlers-2020, 5 analyses relevant to construct and concurrent validity and 2 related to reliability were examined. DESIGN: Twenty-four-hour diet recall data from the cross-sectional National Health and Nutrition Examination Survey (2011-2018) were used. In addition, exemplary menus were analyzed. PARTICIPANTS/SETTING: The main analytic sample included toddlers aged 12 through 23 months (n = 838), with additional analyses of toddlers aged 12 through 35 months (n = 1,717) from the United States. Included participants had valid diet recalls and available weight-for-age data. MAIN OUTCOME MEASURES: Outcomes measures included HEI-Toddlers-2020 total and component scores on menus, population distributions, and correlations. STATISTICAL ANALYSES: HEI total and component scores were calculated using menus from the American Academy of Pediatrics and Healthy Eating Research. Score means and distributions were estimated using a Markov Chain Monte Carlo approach with National Health and Nutrition Examination Survey data (2011-2018). Principal component analysis explored dimensions and Pearson correlations examined components, energy, and Cronbach α. In addition, HEI-Toddlers-2020 and HEI-2020 scores were compared for identical intakes at age 24 months. RESULTS: For validity, exemplary menus received high scores with the HEI-Toddlers-2020. The mean ± SE total HEI-Toddlers-2020 score for toddlers aged 12 through 23 months was 62.9 ± 0.78 and ranged from 40.1 to 84.4 (1st to 99th percentile). Correlation between diet quality and diet quantity was low (-0.15); the scree plot revealed multiple factors. In addition, total scores for identical intakes were approximately 1.5 points higher for HEI-Toddlers-2020 compared with HEI-2020 (difference range for component scores, -4.97 to 4.89). For reliability, most of the intercorrelations among components were low to moderate (0 to 0.49), with a few exceptions among related components. Cronbach α was .48. These results indicate that the index is multidimensional, with no single component driving the total score, and no unnecessary components that are highly correlated with another component. CONCLUSIONS: The results demonstrated evidence supportive of validity and reliability. The HEI-Toddlers-2020 can be used to assess alignment with the DGA for toddlers.

Continuity, Considerations, and Future Directions for the Healthy Eating Index-Toddlers-2020.

The Dietary Guidelines for Americans, 2020-2025 includes guidance for infants and toddlers aged birth to 24 months. To assess alignment with this new guidance, the Healthy Eating Index (HEI)-Toddlers-2020 was developed for toddlers 12 through 23 months old. This monograph focuses on the continuity, considerations, and future directions of this new index for toddlers in the context of evolving dietary guidance. There is considerable continuity between the HEI-Toddlers-2020 and previous versions of the HEI. The same process, guiding principles, and features (with caveats) are repeated in the new index. However, there are unique considerations for measurement, analysis, and interpretation for the HEI-Toddlers-2020 that this article addresses, while identifying future directions for the HEI-Toddlers-2020. The continued evolution of dietary guidance for infants, toddlers, and young children will provide additional opportunities for index-based metrics: considering inclusion of multidimensional layers in dietary patterns, defining a healthy eating trajectory, bridging healthy eating across different life stages, and communicating the constructs of balance among dietary constituents.

Development of the Healthy Eating Index-Toddlers-2020.

The Healthy Eating Index-Toddlers-2020 (HEI-Toddlers-2020) is a measure for assessing how well a set of foods aligns with new guidance in the Dietary Guidelines for Americans, 2020-2025 (DGA) for toddlers aged 12 through 23 months. This new tool was developed using consistent features and the guiding principles of the HEI. The HEI-Toddlers-2020, like HEI-2020, has 13 components reflecting all constituents of dietary intake, except for human milk or infant formula. These components include the following: Total Fruits, Whole Fruits, Total Vegetables, Greens and Beans, Whole Grains, Dairy, Total Protein Foods, Seafood and Plant Proteins, Fatty Acids, Refined Grains, Sodium, Added Sugars, and Saturated Fats. Healthy dietary patterns for toddlers have unique considerations reflected in the scoring standards for Added Sugars and Saturated Fats. Toddlers have lower energy intake relative to high nutrient needs and added sugars should be avoided. Another distinctive difference is that there is no recommendation to limit saturated fats to <10% of energy intake in this age group; however, saturated fats cannot be unlimited without displacing the energy available to achieve other food group and subgroup goals. Calculations using the HEI-Toddlers-2020, like the HEI-2020, result in a total score and a set of individual component scores that reveal a dietary pattern. The release of a HEI-Toddlers-2020 will enable assessment of diet quality that aligns with the DGA and support additional methodological research to examine needs specific to each life stage and how to model trajectories of healthy dietary patterns.

Dietary contributions of food outlets by urbanization level in the US population aged 2 years and older-NHANES 2013-2018.

BACKGROUND: Differences in food access, availability, affordability, and dietary intake are influenced by the food environment, which includes outlets where foods are obtained. These differences between food outlets within rural and urban food environments in the United States are not well understood. OBJECTIVES: The aim of this analysis is to describe the contribution of foods and beverages from 6 outlets-grocery stores, convenience stores, full-service restaurants, quick-service restaurants, schools, and other outlets-to the total energy intake and Healthy Eating Index (HEI)-2015 scores in the United States population, by urbanization level (nonmetropolitan statistical areas [MSAs], small-to-medium MSAs, and large MSAs). METHODS: Data from the National Health and Nutrition Examination Survey 2013-2018 were used. Dietary intake from one 24-h dietary recall was analyzed by the outlet where a food or beverage was obtained and by urbanization. Linear regression, adjusted for sex, age, race and Hispanic origin, and family income, was used to predict the contribution of each food outlet to the total energy intake and HEI-2015 total and component scores by urbanization level. RESULTS: During 2013-2018, foods and beverages from grocery stores and quick-service and full-service restaurants contributed to 62.1%, 15.1%, and 8.5% of the energy intake, respectively. The percentage of energy intake from full- and quick-service restaurants increased with increasing urbanization level. HEI-2015 total scores increased with the increasing urbanization level overall (48.1 non-MSAs, 49.2 small-to-medium MSAs, and 51.3 large MSAs) for grocery stores (46.7 non-MSAs, 48.0 small-to-medium MSAs, and 50.6 large MSAs) and for quick-service restaurants (35.8 non-MSAs, 36.3 small-to-medium MSAs, and 37.5 large MSAs). CONCLUSIONS: Grocery stores and restaurants were the largest contributors of energy intake in urban and rural areas. Diet quality improved with increasing urbanization overall and for grocery stores and quick-service restaurants.

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children and Dietary Intake in Children: Associations With Race and Ethnicity.

INTRODUCTION: Establishing healthy dietary intake in pediatric populations is important for prevention of chronic disease across the lifespan. Federal nutrition assistance programs can support the dietary intake of U.S. children. The objective of this study was to assess the relationship between Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation status and dietary intake within racial and ethnic groups. METHODS: Dietary intake of children aged 2-4 years in the cross-sectional National Health and Nutrition Examination Survey 2011-2016 was analyzed in 2021. Multivariable linear regression was used to compare stratum-specific mean estimates for nutrient and food group intake of children participating in Special Supplemental Nutrition Program for Women, Infants, and Children (reference group) with those of nonparticipants who were income eligible and income ineligible (i.e., above income limits) for the WIC program. Significance was set to Bonferroni-corrected p-values. RESULTS: Hispanic WIC participants consumed less added sugar (8.9 [SE=0.5] teaspoons) than their higher-income counterparts (14.6 [SE=1.5] teaspoons, p<0.001). Hispanic WIC participants also consumed more fiber (13.0 [SE=0.6] grams) than income-eligible (11.4 [SE=0.7] grams, p=0.032) and income-ineligible (i.e., higher-income, 9.4 [SE=1.3] grams, p=0.019) nonparticipants, but this was not significant at the Bonferroni-adjusted p-value of 0.01. No differences in dietary intake were observed by WIC participation status for non-Hispanic White and non-Hispanic Black children. CONCLUSIONS: Participation in WIC was associated with healthier dietary outcomes among Hispanic children; however, dietary intake of White and Black children was comparable by WIC participation status. Federal nutrition assistance programs should support sound nutrition, an important factor in reducing the risk of chronic disease, in all groups.

Healthy Eating Index-2015 Scores Vary by Types of Food Outlets in the United States.

Diet quality in the United States is improving over time but remains poor. Food outlets influence diet quality and represent the environments in which individuals make choices about food purchases and intake. The objective of this study was to use the Healthy Eating Index-2015 (HEI-2015) to evaluate the quality of foods consumed from the four major outlets where food is obtained-stores, full-service restaurants, quick-services restaurants, and schools-and to assess changes over time. This cross-sectional study used 24 h dietary recall data from eight cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey (NHANES). Linear trend estimation was used to test for changes in HEI scores over time, and balanced repeated replicate weighted linear regression was used to test for differences in total and component scores between types of food outlets. Overall, Americans are not consuming a mix of foods from any major category of food outlet that aligns with dietary guidelines. The total score for schools (65/100 points) and stores (62/100 points) was significantly higher than full-service (51/100 points) and quick-service (39/100 points) restaurants (p < 0.0001). HEI scores significantly improved over time for schools (p < 0.001), including an increase in whole grains from less than 1 point in 2003-2004 to 7 out of 10 points in 2017-2018. In 2017-2018, schools received the maximum score for total fruits, whole fruits, and dairy. Continued research on strategies for improving the quality of foods consumed from restaurants and stores is warranted.

Feasibility and Acceptability of a "Click & Collect" WIC Online Ordering Pilot.

BACKGROUND: Barriers to shopping for foods in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) have been reported. Online ordering options may improve the WIC shopping experience but are understudied. OBJECTIVE: The objective of this study was to test feasibility and acceptability of a "Click & Collect" model for WIC online ordering from the perspective of WIC participants. DESIGN: A Click & Collect online ordering model was adapted to the WIC program and implemented at 1 grocery store. In the Click & Collect model, WIC participants placed an online order ("click"), then completed payment and pickup at the store ("collect"). PARTICIPANTS/SETTING: Twenty-five WIC participants in East Tennessee were included. MAIN OUTCOME MEASURES: Feasibility was assessed by examining online order summaries and store receipts to determine whether WIC transactions were completed successfully. Acceptability was assessed by qualitative semi-structured interviews conducted with WIC participants after participating in the pilot. ANALYSES PERFORMED: Descriptive statistics were used to analyze sociodemographic and purchase data in SPSS software, version 27. Qualitative interviews were transcribed and analyzed for themes using directed content analysis in NVivo, version 12.0. RESULTS: All WIC participants in the study placed an online order, and 96% picked up the order, indicating a high degree of feasibility. In follow-up qualitative interviews, WIC participants reported interest in the Click & Collect model, and provided suggestions to improve practicality across the following 4 primary themes: website experience, curbside pickup, online shopping fee, and shopping preferences. CONCLUSIONS: The pilot was successfully implemented at 1 store. Click & Collect online ordering was feasible and acceptable to WIC participants, although additional work is needed to make it practical. Online shopping options for the WIC program should be further explored to expand access to nutritious WIC foods in families with low income.

A Qualitative Exploration of Predominantly White Non-Hispanic Tennessee WIC Participants' Food Retail and WIC Clinic Experiences During COVID-19.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has widened many existing nutrition disparities. In response, federal nutrition assistance programs have introduced flexibility waivers in programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), to rapidly respond to support the nutritional health status of income-eligible participants during COVID-19. Waivers were approved that permitted flexibilities in the WIC food package, WIC vendor guidelines, and WIC clinic experience. The impact of these waivers on WIC participants' retail and clinic experiences remains unknown. OBJECTIVES: Our aims were to understand the experiences of WIC participants in food retail settings and with WIC clinics during the COVID-19 pandemic and to explore WIC participants' perceptions of the impact of COVID-19 on their family's overall health, well-being, and daily lives. DESIGN: We conducted semi-structured phone interviews between April 30 and May 7, 2020. PARTICIPANTS/SETTING: Participants were 24 adults in WIC-enrolled families residing in Tennessee. ANALYSIS: Using grounded theory as the analytical framework, 2 coders completed an iterative, data-driven analytic process within NVivo, version 12. Hierarchical maps, coding matrices, and concept maps were used to aid direct content analysis for theme detection. RESULTS: Five primary themes emerged, including shopping barriers (existing compounded with new), coping strategies, impact on mental and emotional health, social comparison, and unintended consequences of COVID-19 on WIC families. CONCLUSIONS: COVID-19 created additional barriers to food security among WIC families and negatively affected their health and well-being. To meet the needs of this vulnerable population during and beyond the pandemic, the carryover of WIC flexibilities (ie, physical presence and food package substitution waivers) after COVID-19 may improve the ease of overall program participation.

WIC Participants' Perspectives About Online Ordering and Technology in the WIC Program.

OBJECTIVE: The objective of this study was to assess the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants' perceptions about ordering WIC groceries online. METHODS: Qualitative semistructured interviews were conducted with 24 WIC participants in East Tennessee from May to October 2019. Interviews were transcribed verbatim and analyzed using a grounded theory approach. RESULTS: Participants were interested in online ordering and spoke favorably about delivery and pickup options. Participants were willing to pay $2-5 to order online, though they were more willing to pay for a home or curbside delivery than an in-store pickup. Participants suggested additional ways to integrate technology into WIC food retail operations, such as providing benefit balances via text message and developing a mobile phone application for Tennessee WIC. CONCLUSIONS AND IMPLICATIONS: Findings can inform pilot tests for WIC online ordering.

WIC Participants' Perspectives of Facilitators and Barriers to Shopping With eWIC Compared With Paper Vouchers.

OBJECTIVES: (1) To describe facilitators and barriers to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food shopping via electronic benefits transfer (eWIC) compared with paper vouchers. (2) To explore suggestions that WIC participants had for modifying the program to enhance their overall WIC experience. DESIGN: Qualitative, semistructured, in-depth interviews. SETTING: WIC participants in East Tennessee. PARTICIPANTS: Twenty-four primary food shoppers of WIC-participating households aged at least 18 years were recruited using a purposive sampling strategy. PHENOMENON OF INTEREST: Perceived facilitators and barriers to use of eWIC as compared with paper vouchers. ANALYSIS: Interview transcripts were analyzed using a grounded theory approach to identify emergent themes. RESULTS: Participants identified several ways eWIC has improved their food shopping experience, including ad hoc redemption of WIC benefits and a quicker, more discrete checkout. Participants' chief complaint about eWIC was transaction errors at checkout. Participants identified other barriers to shopping for WIC foods that cannot be addressed by the card alone, such as difficulty identifying WIC items in-store. Participants reported changes to their benefit tracking behaviors and provided suggestions to improve WIC further. CONCLUSIONS AND IMPLICATIONS: The transition to eWIC was viewed favorably among WIC participants, although participants identified a need for additional support in addressing transaction errors. This finding presents an opportunity to modify messages delivered to WIC participants by WIC nutrition educators and enhance collaboration between WIC agencies, retailers, and e-commerce technology providers.

Select Food Group Intake of US Children Aged 2 to 4 Years by WIC Participation Status and Income.

BACKGROUND: Food group and nutrient priorities for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Package IV for children aged 2 to 4 years were described in the 2017 review of the WIC Food Package. Research has evaluated priority nutrient intake, but priority food group intake remains unknown. OBJECTIVES: To compare mean intake of priority food groups/subgroups of WIC children to WIC-eligible nonparticipants and higher income children. Further, we hoped to assess differences in percent contribution of food subgroups to total food group intake by WIC participation status and income. DESIGN: Cross-sectional study conducted using data from the 2011-14 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: One thousand forty-seven children aged 2 to 4 years. MAIN OUTCOME MEASURES: Mean intake reported in cup equivalents and ounce equivalents. We also looked at mean percent that food subgroups contributed to total intake within a food group. Analyses were performed for high and low priority food groups/subgroups: high = seafood, total vegetables, dark green vegetables, red/orange vegetables, whole grains, and nuts/seeds/soy; low = total starchy vegetables, other vegetables, legumes computed as vegetables, total dairy, and total protein foods. STATISTICAL ANALYSES PERFORMED: Multivariable linear regression analysis was used evaluate the relationship between income/WIC participation and mean intake/percent food subgroups contributed to total food group intake. RESULTS: Among low-income WIC-eligible children, participation in WIC was associated with greater mean intake of red/orange vegetables (0.18 ± 0.03 vs 0.01 ± 0.06 c equivalents; P < 0.05) and legumes (0.07 ± 0.01 vs 0.01 ± 0.02 c equivalents; P < 0.01). No differences in mean intake were observed between WIC children and higher income children. Grain intake of WIC children was composed of a higher percentage of whole grains (19.1% ± 1.6% vs 13.2% ± 1.5%; P < 0.01) compared with higher income children. The percent vegetable subgroups contributed to total vegetable intake varied by income; no differences were observed for dairy or protein subgroups. CONCLUSIONS: Among low-income children, participation in WIC was associated with greater intake of certain vegetables. Participation in WIC may also help close the diet quality gap between low-income and higher income children for priority foods targeted by the WIC food package. Future research should explore socioeconomic disparities in intake of nutrient-poor foods.

Differences in Consumption of NASEM Priority Nutrients and Food Groups by Race/Ethnicity Among Women Living in WIC-Participating Households.

PURPOSE: To examine racial/ethnic differences in dietary intake of women in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN: Cross-sectional study. SETTING: Data from the US National Health and Nutrition Examination Survey. PARTICIPANTS: Women 19 to 50 years of age living in WIC-participating households. MEASURES: Nutrient/food group intake from one 24-hour dietary recall. ANALYSIS: Multivariable linear regression was used to evaluate the relationship between race/ethnicity and nutrient/food group intake. RESULTS: Compared to non-Hispanic white women, Hispanic women had lower dietary energy density (1.7 ± 0.1 vs 2.2 ± 0.1 kcal/g, P < .001), and better nutrient intake, including more folate (429 ± 20 vs 364 ± 29 µg, P = .024), fiber (20.1 ± 0.9 vs 13.6 ± 0.9 g, P ≤ .001), and potassium (2575 ± 78 vs 2251 ± 66 mg, P = .012). This may be related to greater consumption of total vegetables (1.67 ± 0.16 vs 1.17 ± 0.17 cup equivalents [c-eq], P = .029), including more red and orange vegetables (0.64 ± 0.11 vs 0.32 vs 0.09 c-eq, P = .013) and more legumes (0.17 ± 0.04 vs 0.07 ± 0.02 c-eq, P = .006). Both Hispanic and non-Hispanic black women consumed more sodium (Hispanic: P = .015; non-Hispanic black: P = .008), but less added sugars (Hispanic: P ≤ .001; non-Hispanic black: P = .015), than non-Hispanic white women. CONCLUSION: These findings highlight differences in dietary intake by race/ethnicity and can inform nutrition messages of WIC nutrition educators and dietitians.

Appalachian Store Owners' and Managers' Perspectives on the Role of Their Store in the Community and in Providing Healthier Food to the Community.

Appalachian communities have lower access to healthier food sources like grocery stores. Through semi-structured interviews with owner/managers of convenience stores in Appalachian communities, this qualitative study explored perceived roles and business practices of small food retailers using a grounded theory approach. Five themes emerged including strong relationships between stores and customers, the role of the store in community, food and beverage stocking decisions, store owner/managers' perceived demand for healthier options, and federal food assistance program participation. The themes provide insight to store owner/manager perspectives on community-focused and business-focused priorities in Appalachian convenience stores and can inform healthy retail interventions.

Racial/Ethnic Disparities in Dietary Intake of U.S. Children Participating in WIC.

Recent studies have assessed diet quality of low-income U.S. children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but differences by race/ethnicity remain unknown. We assessed racial/ethnic disparities in nutrient intake from dietary sources (not supplements) among children participating in WIC, with a focus on priority nutrients and food groups for future WIC food package revisions, as described in a recent report by the National Academies of Sciences, Engineering, and Medicine (NASEM). We used data from the 2011-2014 National Health and Nutrition Examination Surveys (NHANES) and multivariable linear regression analysis to evaluate relationships between race/ethnicity and nutrient/food group intake of children participating in WIC. All data were analyzed using SAS 9.4 survey procedures, accounting for the complex survey design of the NHANES. Compared to non-Hispanic White children, Hispanic children had diets with better nutrient distribution and lower dietary energy density, while non-Hispanic Black children had diets with poorer nutrient intake. Hispanic children had higher potassium and fiber intake, and consumed more legumes, while non-Hispanic Black children had lower calcium and vitamin D intake, higher sodium intake, and lower total dairy intake, compared to non-Hispanic White children. These findings can inform WIC nutrition education messages and future food package revisions.

Changes in nutrient and food group intakes among children and women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children: findings from the 2005-2008 and 2011-2014 National Health and Nutrition Examination Surveys.

OBJECTIVE: To use nationally representative data to evaluate changes in nutrient and food intakes among children and women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) before v. after implementation of the 2009 food package revisions. DESIGN: Cross-sectional study using National Health and Nutrition Examination Survey (NHANES) data. NHANES survey cycles were pooled to assess nutrient/food group intakes among household WIC participants pre- (2005-2008) v. post- (2011-2014) implementation of the 2009 food package revisions. SETTING: Information regarding WIC participation and 24 h diet recalls were collected at NHANES examination. PARTICIPANTS: Children 24-59 months old and women 19-50 years of age in households receiving WIC benefits in the NHANES 2005-2008 and 2011-2014. RESULTS: Comparison of WIC participants' dietary intake pre- and post-revision demonstrated changes in mean population intakes of both nutrients and food groups. The food package revisions were associated with increased intakes of fibre (P = 0·004 children, P = 0·013 women) and whole grains (P = 0·001 children, P = 0·087 women). For children only, vegetable intake shifted to higher consumption of legumes (P = 0·013) and decreased intake of starchy vegetables (P = 0·042). No significant changes were observed for dairy or fruit intake of children or women. CONCLUSIONS: The study provides insight to what goals of the package revisions were achieved. The findings can inform future food package revisions.

Quality of depression care and its impact on health service use and mortality among veterans.

OBJECTIVE: Little is known about the effects of quality of depression care on patient outcomes other than depression status. This study examined Veterans Health Administration (VHA) data over a six-year period to determine whether quality of depression care was related to patients' health service use and mortality. METHODS: Using a national VHA database, the authors identified 205,165 veterans with a new-onset depressive disorder and at least one filled prescription for an antidepressant medication between October 1, 1999, and September 30, 2005. Quality of depression care was assessed with antidepressant medication possession ratios and adequacy of follow-up care (three or more depression-related visits during the 84 days after a depression diagnosis). Logistic regression modeling was used to predict inpatient service use and all-cause mortality. RESULTS: Of the cohort 48% received an adequate supply of antidepressant medication and 31% had three or more follow-up visits during the 84-day profiling period. Rates of adequate medication supply did not change over the six-year period, but there were improvements in adequate follow-up care over the study period (p=.03). Adequate follow-up depression care was associated with increased health service use and decreased likelihood of 12-month all-cause mortality. CONCLUSIONS: According to the quality indicators, less than half of patients with newly diagnosed depression received high-quality care. Notably, adequate follow-up care for depression was significantly related to reduction in odds of patient mortality at the 12-month follow-up. These findings suggest that quality of depression care may significantly affect patient outcomes, including mortality, and that further efforts to improve quality appear warranted.