Data, Trends, and Maps Definitions and Sources

Obesity and weight status

Adult obesity is defined as body mass index (BMI) ≥ 30.0. Adult overweight is defined as BMI ≥25.0 but <30.0.

For both obesity and overweight, BMI was calculated from self-reported weight and height (weight [kg]/ height [m²). Respondents who reported the following were excluded:

• Weight < 50 pounds or ≥ 650 pounds.
• Height < 3 feet or ≥ 8 feet.
• BMI: <12 or ≥ 100.
• Pregnant respondents.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

For teens, obesity is defined as BMI-for-age and sex ≥95th percentile. For this age, overweight is defined as BMI-for-age and ≥85th percentile but <95th percentile.

For both obesity and overweight, percentiles are based on the 2000 CDC growth chart. BMI was calculated from self-reported weight and height (weight [kg]/ height [m²]).

Data Source: Youth Risk Behavior Surveillance System (YRBSS)

WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children. For children, obesity is defined as BMI-for-age and sex ≥95th percentile. Overweight is defined as BMI-for-age and sex ≥85th but <95th percentile.

Percentiles are based on the 2000 CDC growth chart. BMI was calculated from measured weight and height (weight [kg]/ height [m²]).

Children with missing values of height, weight, and BMI were excluded. Children with biologically implausible values for height, weight, and BMI were also excluded. Excluded values defined as the following z-scores values:

• Height-for-age < 5.0 or >4.0.
• Weight-for-age <-5.0 or >8.0.
• BMI-for-age <-4.0 or >8.0.

Data Source: Women, Infants, and Children Participant and Program Characteristics

High weight-for-length is defined as ≥2 standard deviations (SDs) above the sex and age-specific median. This is specific to the World Health Organization (WHO) growth standards.

Weight was measured to the nearest one-quarter pound, and length to the nearest one-eighth inch. This was done by using an infant measuring board according to CDC surveillance standards.

Children were excluded with missing values of sex, weight, or length. Children were also excluded or who had a length outside the range (45–110 cm) in the WHO growth standards. In addition, children with biological implausible values were excluded from analyses defined as:

• Weight-for-age < -6 or >5 SDs.
• Length-for-age < -6 or >6.
• Weight-for-length < -5 or >5 based on WHO growth standards cutpoints.

Data Source: Women, Infants, and Children Participant and Program Characteristics (WIC)

Breastfeeding – behavior

Ever breastfed is defined by the question "was [child] ever breastfed or fed breast milk?"

Breastfed at 6 and 12 months is defined as breastfeeding to any extent with or without the addition of complementary liquids or solids.

Data Source: National Immunization Survey. See note.A

Exclusive breastfeeding is defined as only breast milk—no solids, no water, and no other liquids

Data Source: National Immunization Survey. See note.A

Formula supplementation is defined as supplementation of breast milk with formula among infants breastfed at 2 days. This is with or without other supplementary liquids or solids.

Data Source: National Immunization Survey. See note.A

Formula supplementation is defined as supplementation of breast milk with formula among infants breastfed at 3 months or 6 months. This can be with or without other supplementary liquids or solids.

Data Source: National Immunization Survey. See note.A

Breastfeeding - environmental or policy

This score is from six categories of support that hospitals can provide for breastfeeding. Score can range from 0 to 100, with higher scores indicating better maternity care practices and policies. A state's score represents the average score across participating hospitals in the state.

Data Source: CDC Maternity Practices in Infant Nutrition and Care Survey

Numerator: Number of live births at hospitals designated as "baby friendly." Denominator: Number of live births.

Data Source: Breastfeeding Report Card

Fruit and vegetables – behaviors

Adults were asked via a telephone survey how many times per day, week, or month they consumed the following fruits and vegetables:

• 100% pure fruit juices.
• Fruit.
• Green salad.
• Fried potatoes.
• Other potatoes.
• Other vegetables.

Total daily fruit consumption was calculated based on responses to questions about fruit juices and fruit. Total daily vegetable consumption was calculated based on answers to the remaining questions.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Data came from the Youth Risk Behavior Survey (YRBS) fruit and vegetable module. Data include consumption of both fruit and 100% fruit juice.

Vegetable consumption data include all vegetables. Survey questions ask about consumption of green salad, potatoes (not including French fries, fried potatoes, or potato chips), carrots, and other vegetables.

Data Source: Youth Risk Behavior Surveillance System (YRBSS)

Fruits and vegetables – environmental or policy supports

Numerator: Total number of farmers markets per state. Source: United States Department of Agriculture (USDA), Agricultural Marketing Services. USDA National Farmers Market Directory.

Denominator: Estimated number of residents/100,000. United States Census Bureau.

Data Source: State Indicator Report on Fruits and Vegetables, 2018.

Numerator: Number of farmers markets that accept Supplemental Nutrition Assistance Program (SNAP) benefits. Denominator: Total number of farmers markets.

Data Source: State Indicator Report on Fruits and Vegetables, 2018.

Numerator: Number of farmers markets that accept WIC Farmers Market Nutrition Program coupons. Denominator: Total number of farmers markets.

Data Source: State Indicator Report on Fruits and Vegetables, 2018.

The number of food hubs by state includes multiple models of food hubs: farm-to-consumer, farm-to-business/institution, and a combination of the two. Food hubs may be cooperative, nonprofit, publicly held, or privately held business.

Data Source: State Indicator Report on Fruits and Vegetables, 2018.

State and local food policy councils included in this national directory are identified by ongoing self-registration. Councils are verified through an annual survey of food policy councils.

Data Source: State Indicator Report on Fruits and Vegetables, 2018.

State farm-to-school/preschool policies include adopted or enacted state legislation during January 1, 2002–March 31, 2017. Included legislation supported any of the three core elements of a farm-to-school program or initiative. Policies targeted grades K–12 or childcare or early care and education. Core elements include:

• Serving fruit and vegetables purchased from local/regional farms.
• Providing agriculture and nutrition education opportunities.
• School gardens.

Data Source: State Indicator Report on Fruits and Vegetables, 2018.

This analysis assessed the degree to which state childcare regulations reflected national nutrition standards for serving fruits and vegetables. State childcare regulations were assessed for licensed childcare centers, large or group family childcare homes, and small family childcare homes. Standards were from Caring for Our Children: National Health and Safety Performance Standards for Early Care and Education Programs, 3rd Edition.

The standards specify that children be served a variety of fruits, especially whole fruits and vegetables. Standards specifically mention dark green, orange, deep yellow, and root vegetables. States whose regulations scored 4 (regulation fully addresses standard) across all three childcare types were designated as "yes." States that received a score of less than 4 in any childcare type were designated as "no."

Data Source: National Resource Center for Health and Safety in Child Care and Early Education. See note.B

This indicates the degree to which state childcare regulations reflected national nutrition standards for serving fruits and vegetables. State childcare regulations were assessed for licensed childcare centers, large or group family childcare homes, and small family childcare homes.

Standards were from Caring for Our Children: National Health and Safety Performance Standards for Early Care and Education Programs, 3rd Edition. The standards specify that children be served a variety of fruits, especially whole fruits and vegetables. Standards specifically mention dark green, orange, deep yellow, and root vegetables.

States whose regulations scored 4 (regulation fully addresses standard) across all three child care types were designated as "yes." States that received a score of less than 4 in any child care type were designated as "no."

Data Source: National Resource Center for Health and Safety in Child Care and Early Education. See note.B

This indicator used one question from the Profiles Principal Questionnaire. The question was "During this school year, has your school... offered a self-serve salad bar to students?" Schools with principals who answered "Yes" were classified as having a salad bar.

Data Source: School Health Profiles (Profiles)

Physical activity - behavior

Adults 18 and older were asked "During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?" Respondents were classified as participating in no leisure-time physical activity if they responded "no." Respondents with missing data were excluded.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Adults 18 and older were classified as active if they reported:

• At least 150 minutes per week of moderate-intensity activity, or
• At least 75 minutes per week of vigorous-intensity activity, or
• A combination of moderate-intensity and vigorous-intensity activity (multiplied by two) totaling at least 150 minutes per week.

Respondents whose physical activity level could not be categorized due to missing physical activity data were excluded.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Adults 18 and older were classified as highly active if they reported:

• More than 300 minutes per week of moderate-intensity activity, or
• More than 150 minutes per week of vigorous-intensity activity, or
• A combination of moderate-intensity and vigorous-intensity activity (multiplied by two) totaling more than 300 minutes per week.

Respondents whose physical activity level could not be categorized due to missing physical activity data were excluded.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

This indicator is for adults 18 and older. Muscle-strengthening includes activities such as yoga, sit-ups, push-ups, and those using weight machines, free weights, or elastic bands. Respondents with missing data were excluded.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Percent of adults 18 and older classified as active or highly active according to the above indicators who also engaged in muscle-strengthening activities on 2 or more days a week. Respondents whose physical activity level could not be categorized due to missing physical activity data were excluded.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

The U.S. Census Bureau's American Community Survey asks, "How did this person usually get to work last week?" People 16 and older who worked and reported they "bicycle" or "walked" were classified as usually biked or walked to work.

Data Source: U.S. Census Bureau's American Community Survey

Respondents were asked: "During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)" Respondents were classified as active if they answered, "7 days."

Data Source: Youth Risk Behavior Surveillance System (YRBSS)

Respondents were asked: "In an average week in school when you go to school, how many days do you attend physical education classes?" Respondents were classified as participating in daily physical education if they answered, "5 days." Numerator: Number of students who answered “5 days.” Denominator: Students surveyed in grades 9-12.

Data Source: Youth Risk Behavior Surveillance System (YRBSS)

Physical activity - environmental or policy supports

Numerator: Number of youth whose parents answered, "yes" to all of the following questions. Questions were preceded by, "Please tell me if the following places and things are available to children in your neighborhood, even if [CHILD'S NAME] does not actually use them:

1. Park or playground area?
2. A recreation center, community center, or boys' or girls' club?
3. Sidewalks or walking paths?"

Denominator: Youth 17 and younger.

Data Source: National Survey of Children's Health

Numerator: Estimated number of each census tract's population within ½-mile buffer around local parks and beaches. This assessment used Esri StreetMap Premium/HERE and state and national parks from the Protected Areas Database of the United States. The estimated population living within ½ mile of a park was summed over all census tracts in a state. This helped estimate the total state-level population residing within ½ mile of a park.

Denominator: Census tract and state population from the American Community Survey 5-Year Estimates.

Data Source: National Environmental Public Health Tracking Network

States that have a state-level Complete Streets policy were given a "Yes." An ideal Complete Streets policy includes 10 elements. State policy did not have to include all 10 elements to be counted as a "yes." A list of Complete Streets policies, including state-level policies.

Data Source: National Complete Streets Coalition

State childcare regulations were assessed for licensed childcare centers, large or group family childcare homes, and small family childcare homes.

Standards were from Caring for Our Children: National Health and Safety Performance Standards for Early Care and Education Programs, 3rd Edition. Standards specify that preschoolers should be allowed 90 to 120 minutes of moderate-to vigorous-intensity physical activity per eight-hour day. States with regulations fully addressing standards for all three licensed childcare types were designated as "yes." States with regulations that did not fully address standards in any childcare type were designated as "no."

Data Source: National Resource Center for Health and Safety in Child Care and Early Education. See note.B

Sugar drinks - behavior

Respondents were asked, "During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop.)" Responses ranged from "I did not drink soda or pop during the past 7 days" to "4 or more times per day."

Data Source: Youth Risk Behavior Surveillance System (YRBSS)

Sugar drinks - environmental or policy supports

This indicator used one question from the Profiles Principal Questionnaire. The question was "Can students purchase each of the following snack foods or beverages from vending machines or at the school store, canteen, or snack bar: Soda pop or fruit drinks that are not 100% juice?" Schools with principals who answered "Yes" were classified as allowing students to purchase soda pop or fruit drinks.

Data Source: School Health Profiles (Profiles)

This indicator used one question from the Profiles Principal Questionnaire. The question was "Can students purchase each of the following snack foods or beverages from vending machines or at the school store, canteen, or snack bar: Sports drinks (e.g., Gatorade)?" Schools with principals who answered "Yes" were classified as allowing students to purchase sports drinks.

Data Source: School Health Profiles (Profiles)

State childcare regulations were assessed for licensed childcare centers, large or group family childcare homes, and small family childcare homes. Standards were from Caring for Our Children: National Health and Safety Performance Standards for Early Care and Education Programs, 3rd Edition.

States whose regulations scored 4 (regulation fully addresses standard) across all three childcare types were designated as "yes." States that received a score of less than 4 in any childcare type were designated as "no."

Data Source: National Resource Center For Health and Safety In Child Care and Early Education. See note.B

Television viewing - behavior

Respondents were asked, "On an average school day, how many hours do you watch TV?" Responses ranged from "I do not watch TV on an average school day" to "5 or more hours per day."

Data Source: Youth Risk Behavior Surveillance System (YRBSS)

Television viewing - environmental or policy supports

Media viewing includes watching television, videos, DVDs, and computers. State childcare regulations were assessed for licensed childcare centers, large or group family childcare homes, and small family childcare homes. Data assessed how well facilities reflected national standards for prohibiting the use of media viewing.

Standards were from Caring for Our Children: National Health and Safety Performance Standards for Early Care and Education Programs, 3rd Edition. States whose regulations scored 4 (regulation fully addresses standard) across all 3 childcare types were designated as "yes." States that received a score of less than 4 in any childcare type were designated as "no".

Data Source: National Resource Center For Health and Safety In Child Care and Early Education. See note.B

State childcare regulations were assessed for licensed childcare centers, large or group family childcare homes, and small family childcare homes. Standards were from Caring for Our Children: National Health and Safety Performance Standards for Early Care and Education Programs, 3rd Edition.

States whose regulations scored 4 (regulation fully addresses standard) across all three childcare types were designated as "yes." States that received a score of less than 4 in any childcare type were designated as "no".

Data Source: National Resource Center For Health and Safety In Child Care and Early Education. See note.B