Fruit juice consumption is associated with improved nutrient adequacy in children and adolescents: the National Health and Nutrition Examination Survey (NHANES) 2003-2006.

OBJECTIVE: To examine the contribution of 100 % fruit juice (FJ) consumption to dietary adequacy of shortfall nutrients by children and adolescents. DESIGN: Cross-sectional. SETTING: Secondary analysis of data from the 2003-2006 National Health and Nutrition Examination Survey (NHANES). SUBJECTS: Children and adolescents aged 2-18 years (n 7250). Usual intake, determined from two 24 h dietary recalls, was calculated using the National Cancer Institute method. The population was dichotomized into consumers or non-consumers of 100 % FJ. The age/gender-specific percentage of the two consumption groups with intakes less than the Estimated Average Requirement or that exceeded the Adequate Intake for selected nutrients was determined. A Z-statistic for differences in population proportions was used to determine significance (P < 0.05). RESULTS: Children aged 2-5 years had the highest percentage of 100 % FJ consumers (71.1 %), followed by children aged 6-12 years (57.0 %) and adolescents aged 13-18 years (44.5 %). Compared with 100 % FJ consumers, a significantly higher percentage of non-consumers had intakes below the Estimated Average Requirement for vitamin A (24.4 (SE 2.5) % v. 42.2 (SE 2.5) %), vitamin C (0.1 (SE 0.2) % v. 38.9 (SE 4.1) %), folate (8.8 (SE 1.5) % v. 22.1 (SE 2.4) %), P (11.6 (SE 2.1) % v. 21.3 (SE 2.6) %) and Mg (25.8 (SE 1.7) % v. 46.1 (SE 2.0) %). A greater percentage of 100 % FJ consumers exceeded the Adequate Intake for K (2.4 (SE 0.5) v. 0.5 (SE 0.2) %) compared with non-consumers. CONCLUSIONS: Consumption of 100 % FJ is associated with improved nutrient adequacy and can contribute to a healthy diet.

Diet quality is positively associated with 100% fruit juice consumption in children and adults in the United States: NHANES 2003-2006.

BACKGROUND: One hundred percent fruit juice (100% FJ) has been viewed by some as a sweetened beverage with concerns about its effect on weight. Little regard has been given to the contribution of 100% FJ to diet quality. METHODS: In this study data from the 2003-2006 National Health and Nutrition Examination Survey were used to examine the association of 100% FJ consumption with diet quality in participants 2-5 years of age (y) (n = 1665), 6-12 y (n = 2446), 13-18 y (n = 3139), and 19+y (n = 8861). Two 24-hour dietary recalls were used to determine usual intake using the National Cancer Institute method. Usual intake, standard errors, and regression analyses (juice independent variable and Healthy Eating Index-2005 [HEI-2005] components were dependent variables), using appropriate covariates, were determined using sample weights. RESULTS: The percentage of participants 2-5 y, 6-12 y, 13-18 y, and 19+y that consumed 100% FJ was 71%, 57%, 45%, and 62%, respectively. Usual intake of 100% FJ (ounce [oz]/day) among the four age groups was: 5.8 ± 0.6, 2.6 ± 0.4, 3.7 ± 0.4, and 2.4 ± 0.2 for those in age groups 2-5 y, 6-12 y, 13-18 y, and 19+y, respectively. Consumption of 100% FJ was associated with higher energy intake in 6-12 y, 13-18 y, and 19+y; and higher total, saturated, and discretionary fats in 13-18 y participants. Consumption of 100% FJ was associated with higher total HEI-2005 scores in all age groups (< 0.0001). In 100% FJ consumers, total and whole fruit consumption was higher and intake of added sugars was lower in all age groups. CONCLUSIONS: Usual intake of 100% FJ consumption exceeded MyPyramid recommendations for children 2-5 y, but was associated with better diet quality in all age groups and should be encouraged in moderation as part of a healthy diet.

Quantitative ultrasound normative reference data for community-dwelling white and black females in the United States.

Quantitative ultrasound (QUS) race-specific normative reference data are not available for accurate calculation of Z-scores. The primary aims of this study were (1) to develop a race-specific QUS reference database for white and black females and to compare estimated fracture risk between these 2 racial groups and (2) to compare stiffness index (SI) values of white females in this study to manufacturer-obtained values. Subjects included 1111 females (31% black), aged 20-85 yr (52 ± 19 yr), with a mean SI score of 93.7 ± 20.1. White females, aged 20-39 yr (n=213), were used to calculate T-scores, whereas Z-scores were age and race specific. Black females had significantly higher SI scores than white females (p<0.001). White females aged 50+ yr in this study had significantly higher SI scores compared with manufacturer-derived values. Results highlight the need for population- and race-specific normative data when using QUS as a screening tool for identifying high fracture risk.

Consumption of whole grains is associated with improved diet quality and nutrient intake in children and adolescents: the National Health and Nutrition Examination Survey 1999-2004.

OBJECTIVE: To examine the association of consumption of whole grains (WG) with diet quality and nutrient intake in children and adolescents. DESIGN: Secondary analysis of cross-sectional data. SETTING: The 1999-2004 National Health and Nutrition Examination Survey. SUBJECTS: Children aged 2-5 years (n 2278) and 6-12 years (n 3868) and adolescents aged 13-18 years (n 4931). The participants were divided into four WG consumption groups: ≥ 0 to < 0·6, ≥ 0·6 to < 1·5, ≥ 1·5 to < 3·0 and ≥ 3·0 servings/d. Nutrient intake and diet quality, using the Healthy Eating Index (HEI)-2005, were determined for each group from a single 24 h dietary recall. RESULTS: The mean number of servings of WG consumed was 0·45, 0·59 and 0·63 for children/adolescents at the age of 2-5, 6-12 and 13-18 years, respectively. In all groups, HEI and intakes of energy, fibre, vitamin B6, folate, magnesium, phosphorus and iron were significantly higher in those consuming ≥ 3·0 servings of WG/d; intakes of protein, total fat, SFA and MUFA and cholesterol levels were lower. Intakes of PUFA (6-12 years), vitamins B1 (2-5 and 13-18 years), B2 (13-18 years), A (2-5 and 13-18 years) and E (13-18 years) were higher in those groups consuming ≥ 3·0 servings of WG/d; intakes of added sugars (2-5 years), vitamin C (2-5 and 6-12 years), potassium and sodium (6-12 years) were lower. CONCLUSIONS: Overall consumption of WG was low. Children and adolescents who consumed the most servings of WG had better diet quality and nutrient intake.

A cafeteria-based tasting program increased liking of fruits and vegetables by lower, middle and upper elementary school-age children.

This study aimed to increase 1st, 3rd, and 5th grade children's liking for fruits and vegetables by offering repeated opportunities to taste selected items. Tastes of four fruits or four vegetables were offered to children (51% boys; 32% 1st graders and 34% 3rd graders) on alternate weeks for 8 weeks. Two-week follow-up tastings occurred 4 months and 10 months post-intervention. Children who began the program disliking the targeted fruits and vegetables improved liking for all items after 8 weeks and maintained higher scores at both follow-up assessments. Grade and gender differences in liking were observed but were not consistent at each time point.

Relationship between whole grain and fiber consumption and body weight measures among 6- to 18-year-olds.

OBJECTIVES: To examine the relationship between whole grain and fiber consumption and body weight measures in children 6 to 12 (n=3868) and adolescents 13 to 18 (n=4931) years old. STUDY DESIGN: Combined 1999 to 2004 National Health and Nutrition Examination Survey data were analyzed. Mean body mass index (BMI), BMI percentile, BMI z-score, waist circumference, and prevalence of overweight/obesity were compared across categories of whole grain consumption (0 to <0.6, >or=0.6 to <1.5, >or=1.5 to <3, and >or=3 servings) with (1) a sex, ethnicity, and total energy intake-adjusted model and (2) a cereal fiber plus model 1 covariates profile. RESULTS: Mean whole grain intake was 0.59 and 0.63 servings/d among children 6 to 12 years and adolescents 13 to 18 years, respectively. In children, consumption of >or=3 servings of whole grain was not associated with body weight measures; however, consumption of 1.5 to <3 servings was positively associated with all weight measures. In adolescents, BMI z-score was significantly lower in the highest whole grain consumption group compared with the lowest 2 groups; BMI percentile and waist circumference (model 1 only) were also significantly lower in the highest whole grain consumption group. CONCLUSIONS: Overall consumption of whole grain was below current recommendations of at least 3 servings per day. Only in adolescents was this level of whole grain intake associated with lower BMI z-scores.

Repeated taste exposure increases liking for vegetables by low-income elementary school children.

Children's food preferences play a major role in their food choices and consumption. The objective of the present study was to examine if repeated tastings of selected vegetables in a school setting increased children's liking of these items. A total of 360 fourth- and fifth-grade students attending four low-income, public elementary schools in southeastern Louisiana volunteered to participate. During the spring of 2008, children were offered a taste of carrots, peas, tomatoes, and bell peppers once a week for 10 weeks. At each tasting session children recorded whether they swallowed each of the vegetables, spit it into the napkin, or did not put it in their mouth and indicated their liking for each vegetable using a Likert-type response scale. Approximately one-half of the children tasted eight of ten times during the program (46.5% for those who began disliking and 68.5% for those who began liking the vegetables). Proc Glimmix analyses indicated that for children who began the program disliking the vegetables, repeated tasting improved liking scores for carrots, peas, and tomatoes; liking for bell peppers did not change. The number of children who reported liking or liking a lot for previously disliked vegetables was greater after eight or nine taste exposures. Repeated tasting of less-liked vegetables by children in a cafeteria-based setting is a strategy to promote liking of these items and is effective in approximately half of the participants.

"Smart Bodies" school wellness program increased children's knowledge of healthy nutrition practices and self-efficacy to consume fruit and vegetables.

Diets rich in fruit and vegetables are important for long-term health yet children frequently do not like these foods. The "Smart Bodies" school wellness program sought to increase children's knowledge of healthy nutritional practices, improve psychosocial variables associated with eating fruit and vegetables, and develop preferences for these foods. A randomized controlled intervention trial was conducted in 14 low-income, urban, public elementary schools (seven pairs). Data from 278 fourth and 282 fifth graders (234 boys, 326 girls; 82% Black, 10% White, 1% Hispanic, 5% Asian, 2% Other) were examined using multi-level modeling. The 12-week intervention program included participation in an interactive wellness exhibit and a classroom curriculum that emphasized consumption of fruit and vegetables. After the intervention, children that participated in the "Smart Bodies" program had greater nutrition knowledge and expressed more confidence that they could eat fruit instead of a favorite dessert, drink fruit juice and consume the recommended number of fruits and vegetables servings each day. Preferences for fruit and vegetables did not change as a result of participating in the program. These findings demonstrate that the "Smart Bodies" school-based wellness intervention positively impacted children's nutrition knowledge and psychosocial variables associated with consuming fruit and vegetables.

Black children with high preferences for fruits and vegetables are at less risk of being at risk of overweight or overweight.

Food preferences play a central role in food choices and consumption. The primary objective of this study was to examine the relationship between children's preferences for fruits and vegetables and their weight status. A total of 341 black children (43% boys; 68% fourth graders) attending low-income, public elementary schools in southeastern Louisiana volunteered to participate. Children were measured for height and weight and completed a survey that sought their preferences for 38 different fruits and vegetables during the fall of 2005. Results indicated that children preferred fruits more than vegetables and that there was a negative association between children's mean fruit and vegetable preference score and their body mass index for age percentile (r=-0.26; P=0.01). Children who reported a very low preference for fruits and vegetables were 5.5 times more likely to be categorized as at risk for overweight or overweight than were those who reported a high preference for fruits and vegetables (odds ratio: 5.5; confidence interval: 1.97 to 15.44; P<0.01). It is believed that food preferences are established early in life; therefore, nutritionists and other health care professionals should promote children's acceptance and intake of fruits and vegetables as a measure to reduce the prevalence of overweight among children.

Development and comparison of two field-based body fat prediction equations: NHANES 1999 - 2004.

Clinical guidelines define obesity in terms of excess body weight adjusted for height (i.e., bodymass index [BMI] categories) and/or gender-specific waist circumference (WC) cut-point values. Since body composition, particularly fat mass, is the most variable among individuals due to differences by gender, age, and race, and total percent body fat (%BF) can be estimated accurately using dual-energy X-ray absorptiometry (DXA), the purpose of this study was to develop and compare two field-based body fat prediction equations suitable for a nationally representative sample of the US adult population. Data were analyzed from subjects 20+ years of age (n = 11,907) with BMI and WC values, and that participated in DXA scans as part of the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Multiple linear regression was used to develop and compare DXA-estimated %BF as the dependent variable versus BMI or WC, gender, age, and race as predictor variables. Mean values for age, BMI, WC, and %BF among the sample were 46.84 ± 0.30 years, 28.17 ± 0.11 kg/m2, 96.69 ± 0.27 cm, and 34.19 ± 0.14 %, respectively. Both equations were similar in terms of explained variance, with R2 values of 0.82 for the BMI and WC equations, respectively. Both equations are easy to use, and could easily be developed as an application on a smartphone or other handheld device, or simply integrated into a spreadsheet for use as an additional tool for health professionals to assess the current health status of individuals based on predicted body fat from BMI, WC, and demographics.

Contribution of beef consumption to nutrient intake, diet quality, and food patterns in the diets of the US population.

This study examined the association between the nutrient contribution of beef, in its lowest and highest fat forms, and diet quality and food patterns in individuals 4+years of age. Beef consumers were categorized into three groups (lowest lean/highest fat [LLHF]; middle lean/middle fat content; and highest lean/lowest fat [HLLF]) based on the lean and fat content of beef consumed. Compared to non-beef consumers, HLLF consumers had higher intakes of vitamins B(6) and B(12), iron, zinc, and potassium. Non-beef consumers had higher intakes of thiamin, folate, calcium, and magnesium than HLLF beef consumers. The HLLF group had significantly higher intakes of vitamins A, C, B(6), and B(12); niacin; phosphorus; magnesium; iron; zinc; and potassium, protein and lower intakes of total energy; total fat; SFA; MUFA; total carbohydrates. There was no difference in diet quality between HLLF beef consumers and non-beef consumers. Moderate consumption of lean beef contributes to intakes of selected nutrients and diet quality was similar to non-beef consumers.

Endurance and resistance training lowers C-reactive protein in young, healthy females.

The purpose of this study was to determine whether endurance (E) or endurance + resistance (ER) training affects C-reactive protein (CRP) and if these changes are related to alterations in fitness and (or) body composition in young females. Thirty-eight females (aged 18-24 years) were assigned to 1 of 3 groups: (1) E, (2) ER or (3) active control (AC). The E and ER groups completed 15 weeks of marathon training. The ER group performed additional resistance training and the AC group maintained their usual exercise routine. Primary outcomes were measured pre- and post-training and included anthropometric indices, dual-energy x-ray absorptiometry, plasma CRP, time to complete 1.5 miles (in minutes), and upper and lower body strength tests (i.e., 8 repetition max on bench and leg press (ER group only)). There were no differences in any variable among the groups at baseline. After training, the E group decreased time to complete 1.5 miles (p < 0.05). The AC group decreased percent and absolute body fat while the E group decreased percent body fat, absolute body fat, and android and gynoid body fat (p < 0.05). The ER group significantly improved strength (p < 0.001) and reduced plasma CRP from 2.0 ± 1.1 to 0.8 ± 0.3 mg·L(-1) (p = 0.03). No significant associations were observed between CRP and measures of body composition or aerobic capacity. Combined endurance and resistance training may be an effective modality for reducing plasma CRP in young adult females independent of changes in aerobic capacity or body composition.

Nutrient contribution of total and lean beef in diets of US children and adolescents: National Health and Nutrition Examination Survey 1999-2004.

This study examined the nutritional contribution of total beef and lean beef (LB) to the diet of US children and adolescents using the US Department of Agriculture definition of LB as defined in MyPyramid. Twenty-four hour dietary recall data from children 4-8 years of age [y] (n=2474), 9-13 y (n=3273), and adolescents 14-18 y (n=4044) participating in the NHANES 1999-2004 were assessed. LB was defined as beef with ≤9.28 grams [g] fat/100 g (excess was discretionary fat). Means and standard errors were determined using appropriate sample weights. Consumption of LB contributed significantly to intake of protein and many key nutrients such as vitamins B6 and B12, zinc, iron, niacin, phosphorus, and potassium by US children and adolescents without providing significantly to intakes of total fat, saturated fatty acids, or sodium.

Whole-grain consumption is associated with diet quality and nutrient intake in adults: the National Health and Nutrition Examination Survey, 1999-2004.

BACKGROUND: The consumption of whole grains and its association with nutrient intake has not been assessed in a recent nationally representative population. OBJECTIVE: To examine the association of consumption of whole grains, using the new whole-grain definition, with diet quality and nutrient intake in a recent, nationally representative sample of adults. DESIGN: Secondary analysis of cross-sectional data from 1999-2004 National Health and Nutrition Examination Survey. PARTICIPANTS AND METHODS: Adults aged 19 to 50 years (n=7,039) and aged 51 years and older (n=6,237). MAIN OUTCOME MEASURES: Participants were divided into four whole-grain consumption groups: ≤0 to <0.6, ≥0.6 to <1.5, ≥1.5 to <3.0, and ≥3.0 servings (ounce equivalents)/day. Macro- and micronutrient intakes and diet quality, using the Healthy Eating Index, were determined for each group. STATISTICAL ANALYSES: Sample weights were applied. The percentages of adults in whole-grain consumption groups were calculated. The covariates used were energy, ethnicity, sex, and age. Least-square means were calculated. P for linear trend analysis was determined using whole-grain intake as a linear covariate. A P value of ≤0.05 was considered significant. RESULTS: Adults aged 19 to 50 and 51+ years consumed a mean of 0.63 and 0.77 servings of whole grains per day, respectively. For both age groups, diet quality and intake of energy, fiber, and polyunsaturated fatty acids were significantly higher in those consuming the most servings of whole grains. Intake of total sugars (19 to 50 year age group only), added sugars, saturated fatty acids, monounsaturated fatty acids, and cholesterol was significantly lower in those consuming the most servings of whole grains. Intake of all micronutrients, except vitamin B-12 and sodium, was higher among individuals who consumed the most servings of whole grains. CONCLUSIONS: Overall consumption of whole grains in the US population was low using the recently updated whole-grain definition. Adults who consumed the most servings of whole grains had better diet quality and nutrient intakes.

Whole grain and fiber consumption are associated with lower body weight measures in US adults: National Health and Nutrition Examination Survey 1999-2004.

This study examined the association of whole grain consumption with body weight measures and prevalence of overweight/obesity in a recent, nationally representative sample of adults. A secondary analysis of 1999-2004 National Health and Nutrition Examination Survey (NHANES) data was conducted using adults 19 to 50 years of age (y) (n = 7,039) and 51+ y (n = 6,237). Participants were categorized by whole grain consumption: ≥ 0 to <0.6, ≥ 0.6 to <1.5, ≥ 1.5 to <3.0, and ≥ 3.0 servings/day. Main outcome measures included body mass index (BMI), waist circumference (WC), and prevalence of overweight/obesity. Sample weights were applied and the number and percentages of adults in whole grain consumption groups were determined. Least-square means and standard errors were calculated for body weight measures. Two regression models were developed and compared. Model 1 covariates included age, gender, ethnicity, and total energy intake; Model 2 was extended to include cereal fiber. Trend analysis was conducted to test for differences between least-square means. Significance was set at P ≤ .05. Adults 19-50 and 51+ y consumed a mean of 0.63 and 0.77 servings of whole grains/day, respectively. A significant trend was observed in both age groups for increased consumption of whole grains with lower BMI, WC, and percentage overweight/obese (Model 1); however, a significant trend was not observed when cereal fiber was added as a covariate (Model 2). Results confirm overall whole grain intake well below recommendations, and adults who consumed the most servings of whole grains had lower body weight measures. Results also suggest that fiber in whole grain foods may mediate associations with weight measures in adults. Intake of whole grain foods should be encouraged by health professionals.

Lean beef contributes significant amounts of key nutrients to the diets of US adults: National Health and Nutrition Examination Survey 1999-2004.

Consumption of lean meat is a valuable addition to a healthy diet because it provides complete protein and is a rich source of vitamin B(12), iron, and zinc. The objective of this study was to examine the nutritional contribution of total beef and lean beef (LB) to the American diet using the USDA definition of LB as defined in MyPyramid. Twenty-four-hour dietary recall data from adults 19 to 50 years of age (n = 7049) and 51+ years (n = 6243) participating in the National Health and Nutrition Examination Survey 1999-2004 were assessed. Lean beef was defined as beef with <9.28 g fat per 100 g (excess was discretionary fat). Fifty percent of adults 19 to 50 years and 41% of adults 51+ years consumed beef on the day of the dietary recall. Total beef consumed among adults 19 to 50 and 51+ years was 49.3 +/- 1.4 g (1.74 oz/d) and 37.1 +/- 1.2 g (1.31 oz/d), respectively. In adults 19 to 50 and 51+ years, LB contributed 3.9% and 3.7% to total energy; 4.5% and 4.1% to total fat, 3.8% and 3.6% to saturated fatty acids; 13% and 11% to cholesterol intake; 15% and 14% to protein; 25% and 20% to vitamin B(12); 23% and 20% to zinc; and 8% and 7% to iron, respectively. Beef was also an important food source of many other nutrients, including niacin, vitamin B(6), phosphorus, and potassium. In addition, beef provided only 1% of total sodium intake. Consumption of beef contributed significantly to intake of protein and other key nutrients by US adults.

Physical Activity is Associated with Percent Body Fat and Body Composition but not Body Mass Index in White and Black College Students.

The objective of this study was to examine the association of self-reported physical activity (PA) with body composition in 290 college students (49% male, 60% White) 18-25 years of age. Outcome measures included: self-reported PA levels calculated in MET-hrs·wk-1 from the International Physical Activity Questionnaire (IPAQ); body mass index (BMI; in kg·m-2); and body composition variables estimated by dual-energy X-ray absorptiometry (DXA). Mean activity levels of the sample were 39.8 ± 23.8 MET-hrs·wk-1. Participants were divided into quartiles of PA levels: ≥0 to <24.0, ≥24.0 to <34.0, ≥34.0 to <51.25, and ≥51.25 MET-hrs ·wk-1 and body composition variables were compared by group. Chi-square analyses revealed a significant difference for gender by PA quartile [χ2 (3, N=290) = 32.42, p < 0.0001], and for gender by race by PA quartile [χ2 (9, N=290) = 37.82, p < 0.0001]. MET-hrs·wk-1 was inversely correlated with %BF (r = -0.40, p < 0.0001) but not BMI (r = 0.05, p = 0.43). When comparing body composition variables across PA quartiles, no significant differences were observed for BMI; however, subjects in the highest quartile of PA had a lower percent body fat (%BF) and fat mass (FM), and a higher lean-tissue mass (LTM) compared to subjects in the other three groups. In this cohort of young adults, participants in the highest activity group had a more fit body composition profile (e.g., lower %BF, lower FM, and higher LTM) which was not reflected in BMI and was independent of gender and race.

Self-reported physical activity improves prediction of body fatness in young adults.

PURPOSE: To examine self-reported physical activity levels from the International Physical Activity Questionnaire (IPAQ) as an independent predictor of dual-energy x-ray absorptiometry (DXA)-measured percent body fat (%BF) from body mass index (BMI), gender, and race. METHODS: Two hundred and seventy-eight students, aged 18-24 yr, volunteered to participate. There were 133 males (85 white and 48 black) and 145 females (77 white and 68 black). Total activity levels were quantified in MET hours per week (MET h wk(-1)) using the IPAQ short form. Height and weight were measured, and BMI values were calculated (kg m(-2)). %BF was assessed using DXA. Linear regression analysis was used to develop and compare a body fat prediction equation with (full) and without (reduced) the variable MET-h.wk. Both models included BMI, gender, and race as predictor variables. The prediction sum of squares (PRESS) statistic was used to cross-validate both models, and the individual predictive accuracy was compared using modified Bland-Altman plots. RESULTS: Mean +/- SD values were as follows: BMI = 24.4 +/- 4.1 kg m(-2), %BF = 24.5 +/- 9.3%, and MET h wk(-1) = 37.4 +/- 21.9. Gender, BMI, and race explained 81% of the variance in %BF, with a root mean square error (RMSE) of 4.07. The full model with MET-h.wk improved the prediction of %BF by 2% (R2 = 0.83, RMSE = 3.87). When cross-validated, the corresponding PRESS statistics for the reduced and full model were 4.10 and 3.90, respectively. Bland-Altman limits of agreement were greater for the reduced model compared with the full model (-8.09, 8.10 vs -7.67, 7.68). CONCLUSION: These results suggest that %BF can be predicted with greater precision and accuracy in a young adult population when MET-h.wk are included in addition to BMI, gender, and race.