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

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. 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). 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. 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). 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.