key: cord-0962895-s32keaz0
authors: Liu, Junxiu; Micha, Renata; Li, Yan; Mozaffarian, Dariush
title: Trends in Food Sources and Diet Quality Among US Children and Adults, 2003-2018
date: 2021-04-12
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2021.5262
sha: 2fe14f40aedc548f30436b0483b37a621d382cab
doc_id: 962895
cord_uid: s32keaz0

IMPORTANCE: Time trends and population disparities in nutritional quality of foods from major US sources, including grocery stores, restaurants, schools, worksites, and other sources, are not well established. OBJECTIVE: To investigate patterns and trends in diet quality by food sources among US children and adults overall and in sociodemographic subgroups. DESIGN, SETTING, AND PARTICIPANTS: This serial, cross-sectional survey study included respondents from 8 National Health and Nutrition Examination Survey cycles (2003-2018) with valid dietary recalls. Data were analyzed from April 16, 2020, to July 20, 2020. EXPOSURES: Survey cycle, food source, and key sociodemographic subgroups. MAIN OUTCOMES AND MEASURES: Mean diet quality of foods (meals, snacks, and beverages) consumed per person, characterized by the American Heart Association diet score (range, 0-80, with higher scores indicating healthier diets), the Healthy Eating Index 2015 (range, 0-100, with higher scores indicating healthier diets), and their components. For the American Heart Association diet score, poor diet was defined as less than 40.0% adherence (score, <32.0), intermediate diet as 40.0% to 79.9% adherence (score, 32.0-63.9), and ideal as 80.0% or greater adherence (score, ≥64.0). RESULTS: The study included 20 905 children 5 to 19 years of age (mean [SD] age, 12.1 [5.24] years; 51.0% male) and 39 757 adults 20 years or older (mean [SD] age, 47.3 [15.1] years; 51.9% female). Diet quality of foods consumed from grocery stores increased modestly in children (53.2% to 45.1% with poor diet quality; P = .006 for trend) and adults (40.1% to 32.9% with poor diet quality; P = .001 for trend), with smaller changes for restaurants among children (84.8% to 79.6% with poor diet quality; P = .003 for trend). Changes for restaurants among adults were not statistically significant (65.4% to 65.2% with poor diet quality; P = .07 with poor diet quality); the same was true of worksites (adults: 55.6% to 50.7% with poor diet quality; P = .25 for trend). Food quality from other sources worsened (children: 40.0% to 51.7% with poor diet quality; adults: 33.8% to 43.8% with poor diet quality; P < .001 for trend each). The largest improvement in diet quality was in schools, with the percentage with poor diet quality decreasing from 55.6% to 24.4% (P < .001 for trend), mostly after 2010, and with equitable improvements across population subgroups. Findings were similar for Healthy Eating Index 2015. Significant disparities in diet quality trends were seen by sex, race/ethnicity, educational level, and household income for food consumed from grocery stores. For example, the proportion of foods consumed from grocery stores that were of poor diet quality decreased among high-income adults (from 36.9% to 26.5%; P = .001 for trend) but not among low-income adults (from 45.8% to 41.3%; P = .09 for trend). CONCLUSIONS AND RELEVANCE: By 2017-2018, foods consumed at schools improved significantly and provided the best mean diet quality of major US food sources, without population disparities. Additional improvements are needed from all major US food sources, with particular attention on equity.

NHANES uses a complex, multistage, probability sampling design to select a nationally representative population of civilian, non-institutionalized participants. 1,2 The National Center for Health Statistics ethics review board approved the study protocol, and all participants provided written informed consent. Because data are publicly available and de-identified, institutional review board approval was not required for the current investigation.

The US Department of Agriculture (USDA) Automated Multiple-Pass Method was used for collecting 24-hour dietary recalls using "What We Eat In America," the dietary interview component of NHANES. The USDA Food Patterns Equivalents Database, which disaggregates mixed foods into their components parts, was used to assess changes in food groups. Nutrients were derived from cycle-specific versions of the USDA Food and Nutrient Database for Dietary Studies.

To assess a summary diet score, we constructed a continuous diet score based on the AHA 2020 Strategic Impact Goal dietary targets, which have been significantly associated with cardiovascular and metabolic outcomes in multiple analyses. 4 The primary dietary targets are fruits/vegetables, whole grains, fish and shellfish, nuts/legumes/seeds, sugar-sweetened beverages, processed meat, sodium, and saturated fat (eTable 1). To best assess changes, we constructed a continuous score. Intake of each dietary item was scored from 0-10 (beneficial components) or 10-0 (harmful components) depending on whether consumption was encouraged or discouraged, respectively. For beneficial dietary components, individuals with zero intake received the lowest score (0). For harmful dietary components, the lowest score (0) was assigned to a higher level approximately equivalent to the 80th to 90th percentile of intake

Scoring Standard a Component Max Min AHA Score b 0-80 Fruits and vegetables c 0-10 ≥4.5 cups equiv. per day 0

Whole grains 0-10 ≥3 oz equiv. per day 0 Fish and shellfish 0-10 ≥1 oz equiv. per day 0 Nuts, seeds and legumes d 0-10 ≥4 servings per day 0

Sugar-sweetened beverages 10-0 ≤ 5.14 fl oz per day >16 fl per day Processed meat 10-0 ≤ 0.5 oz equiv. per day >1.764 oz equiv. per day Sodium 10-0 ≤ 1500 mg per day >4500 mg per day Saturated fat 10-0 ≤7% energy >15% energy a Intakes between the minimum and maximum standards are scored proportionately. b All AHA dietary variables were energy-adjusted to 2000kcal/d prior to analysis. c According to the AHA 2020 Goals, up to 3 cups/wk (0.42 cups/d) of starchy vegetables (e.g., potatoes, peas, corn) could be included; this maximum was incorporated into the analysis, with higher intake not contributing toward the score. 100% fruit juice could also be included; while its contribution was not capped in the original AHA 2020 Goals and thus not in our score, some organizations recommend no more than 1 serving/d of 100% fruit juice. d A serving of nuts, seeds and legumes is 1-oz equivalent of nuts and seeds or ½ cup of legume. 

Refined Grains 0-10 ≤1.8 oz equiv. per 1,000 kcal ≥4.3 oz equiv. per 1,000 kcal Sodium 0-10 ≤1.1 grams per 1,000 kcal ≥2.0 grams per 1,000 kcal Added Sugars 0-10 ≤6.5% of energy ≥26% of energy Saturated Fats 0-10 ≤8% of energy ≥16% of energy a Intakes between the minimum and maximum standards are scored proportionately. b Includes 100% fruit juice. c Includes all forms except juice. d Includes legumes (beans and peas) e Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages. f Includes legumes (beans and peas) g Includes seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas). h Ratios of poly-and monosaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs). Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Percentages and CIs were estimated using survey weights to be nationally representative.

b Poor die quality was defined as being less than 40% adherent (<32 points). Intermediate was defined as adherence of 40%-79.9% (32-63.9 points). Ideal was defined as 80% adherence or greater (≥64 points). 13. 6 (11.5-15.6) 19.9 (15.1-24.7) 19.7 (15. 3-24.0) 19.6 (16. 6-22.6) 19.2 (16. 0-22.4) 18. 8 (16.8-20.9) 0.001 Abbreviations: NHANES, National Health and Nutrition Examination Survey. full-service restaurants refer to food/beverages consumed from "restaurant with waiter/waitress"; and fast-food restaurants refer to food/beverages consumed from "restaurant fast food/pizza". a Percentages and CIs were estimated using survey weights to be nationally representative. b Poor die quality was defined as being less than 40% adherent (<32 points). Intermediate was defined as adherence of 40%-79.9% (32-63.9 points). Ideal was defined as 80% adherence or greater (≥64 points). 5.42 (5.18-5.67) 5.37 (5.18-5.57) 5.23 (5.05-5.4) 5.23 (5.04-5.43) 5.17 (4.96-5.38) .005 -0.34 (-0.60, -0.08)

5.01 (4.43-5.59) 4.58 (4.27-4.90) 4.80 (4.29-5.32) 4.88 (4.37-5.39) 5.20 (4.75-5.64) 4.93 (4.44-5.41) 4.85 (4.33-5.37) 5.05 (4.56-5.55) .49 0.04 (-0.72, 0.81)

5.87 (5.60-6.14) 5.32 (5.07-5.56) 5.47 (5.15-5.80) 5.43 (5.25-5.60) 4.80 (4.49-5.11) 4.42 (4.18-4.65) 4.59 (4.27-4.9) 4.40 (4.23-4.57) <.001 -1.50 (-1.80, -1.10) Moderation components Sodium 5.61 (5.36-5.86) 5.54 (5.38-5.7) 4.87 (4.72-5.03) 5.05 (4.92-5.17) 5.04 (4.90-5.18) 5.08 (4.86-5.3) 5.48 (5.32-5. .31 -0.40 (-0.70, -0.10)

6.05 (5.62-6.47) 6.14 (5.59-6.7) 6.50 (6.06-6.94) 5.77 (5.29-6.25) 5.46 (4.75-6.17) 5.97 (5.40-6.54) 5.44 (4.77-6.11) 5.77 (5.07-6.47) .06 -0.28 (-1.1, 0.54)

6.36 (6.02-6.69) 4.78 (4.51-5.06) 5.20 (5.0-5.40) 4.74 (4.45-5.02) 4.72 (4.41-5.02) 4.84 (4.57-5.12) 4.46 (4.12-4.80) 4.73 (4.37-5.10) <.001 -1.60 (-2.10, -1.10) Refined grains 6.74 (6.56-6.91) 6.62 (6.44-6.8) 6.60 (6.44-6.76) 6.66 (6.47-6.86) 6.86 (6.71-7.01) 6.97 (6.78-7.16) 6.78 (6.64-6.92 

Grocery 6.33 (6.09-6.57) 6.23 (6.07-6.39) 6.54 (6.32-6.75) 6.70 (6.50-6.90) 6.83 (6.60-7.07) 6.42 (6.24-6.59) 6.07 (5.87-6.27) 5.81 (5.61-6.01) <.001 -0.52 (-0.84, -0.21)

4.51 (4.25-4.77) 4.40 (4.18-4.62) 4.15 (3.97-4.32) 4.73 (4.47-4.99) 4.88 (4.63-5.13) 4.86 (4.65-5.06) 4.57 (4.32-4.81) 4.25 (4.01-4.49) .54 -0.26 (-0.62, 0.10)

7.05 (6.72-7.38) 6.53 (6.02-7.05) 6 .73 (6.39-7 .08) 6 .93 (6.60-7.27) 7.20 (6.79-7.61) 7.33 (6.66-8.0) 6.96 (6.44-7.48) 6.51 (5.93-7.08) .85 -0.54 (-1.20, 0.12) Other sources 6.60 (6.34-6.86) 6.13 (5.86-6.40) 6.28 (5.99-6.57) 6.43 (6.21-6.64) 5.89 (5.65-6.13) 5.46 (5.12-5.79) 5.42 (5.08-5.76) 5.18 (4.91-5.44) <.001 -1.40 (-1.80, -1.0) Added sugars .09) 6.16 (5.92-6.4) 6.10 (5.76-6.45) 6 .39 (6.24-6.54) 6.54 (6.33-6.74) 6.58 (6.38-6.78) 6.80 (6.58-7.02) 6.63 (6.37-6.88 (5.33-5.97) 6.01 (5.77-6.26) 5.85 (5.49-6.22) .03 -0.11 (-0.55, 0.34) Abbreviations: NHANES, National Health and Nutrition Examination Survey; HEI, Healthy Eating Index. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Percentages and CIs were estimated using survey weights to be nationally representative. b Includes legumes (beans and peas). c Includes 100% fruit juice. d Includes all forms except juice. e Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages. f Includes seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas). g Ratio of poly-and monounsaturated fatty acids (PUFAs and MUFAs) to saturated. Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Percentages and CIs were estimated using survey weights to be nationally representative. b Poor die quality was defined as being less than 40% adherent (<32 points Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a Sensitivity analysis refers to diet quality based on the AHA score excluding fish/shellfish with a total score multiplied by 80/70. b Percentages and CIs were estimated using survey weights to be nationally representative. c Poor die quality was defined as being less than 40% adherent (<32 points). Intermediate was defined as adherence of 40%-79.9% (32-63.9 points). Ideal was defined as 80% adherence or greater (≥64 points). Abbreviations: NHANES, National Health and Nutrition Examination Survey. full-service restaurants refer to food/beverages consumed from "restaurant with waiter/waitress"; and fast-food restaurants refer to food/beverages consumed from "restaurant fast food/pizza". a Percentages and CIs were estimated using survey weights to be nationally representative. b Poor die quality was defined as being less than 40% adherent (<32 points). Intermediate was defined as adherence of 40%-79.9% (32-63.9 points). Ideal was defined as 80% adherence or greater (≥64 points). Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. .08

Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. c Represents the ratio of family income to the federal poverty threshold, adjusting for household size. For reference, the federal threshold in 2016 for a family of 4 was $24,300/y. A family of 4 earning $33,534/y would have a ratio of 1.38. d Indicates a lower level of income. e Indicates a higher level of income. 4 (24.4-26.4) 26.7 (25.8-27.5) 25.2 (24. 3-26.2) 26. 6 (24.8-28.4) 26. 4 (25.3-27.6) 26.0 (24.7-27.2) 25. 3 (24.2-26.4) 25.0 (24.0-26.1)

.30 -0.39 (-1.80, 1.05) Hispanics 25.8 (24.7-27) 26.7 (25.5-27.8) 25.2 (24.3-26) 25. 6 (24.7-26.6) 27.1 (25.7-28.5) 26.7 (25.9-27.5) 26.0 (25.2-26.7) 26.1 (24. 6-27.6) . 6 (23.8-25.4) 25. 5 (24.5-26.6) 25.9 (24.9-26.9) 26.1 (25.4-26.9) 25.2 (23.9-26.6) 25.1 (23.7-26.5) .67 -0.63 (-2.30, 1.05) 1. 30-3.49 23.8 (22.9-24.8) 26.4 (25.5-27.3) 24.9 (23.8-26.1) 25.9 (24.8-27) 6-34.4) 36. 5 (35.5-37.6) 38. 3 (37.0-39.6) 38.9 (37.9-39.9) <.001 8.37 (6.78, 9.97 ) P for interaction .06

Non-Hispanic white 31. 6 (29.8-33.3) 31.2 (29.7-32.6) 29.1 (27. 3-30.9) 31. 3 (29.2-33.4) 32.2 (30.1-34.4) 35.9 (34.3-37.6) 37.0 (35. 4-38.5) 38.1 (36.7-39.5) <.001 6.55 (4.31, 8.80) Non-Hispanic black 31.5 (30.2-32.9) 30.2 (27.9-32.6) 32. 3 (30.6-33.9) 33.0 (31. 3-34.7) 33. 4 (32.0-34.9) 37.9 (36.4-39.4) 38. 4 (36.6-40.3) 39.1 (37. 5-40.7) <.001 7.54 (5.42, 9. 34.0 (32. 5-35.5) 34. 5 (33.5-35.4) 33.4 (31.9-34.9) 32.7 (31. 5-33.8) 33.4 (32.3-34.5) 33.9 (32. 4-35.4) . Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. c Represents the ratio of family income to the federal poverty threshold, adjusting for household size. 3 (36.1-46.5) .09 .09

Weighted Mean (95% CI) a P for trend 2017

Weighted Mean (95% CI) a P for trend 2017

Weighted Mean (95% CI) a P for trend 2017

Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). the ratio of family income to the federal poverty threshold, adjusting for household size

Standard definitions: final disposition of case codes and outcome rates for surveys

Standard definitions: final disposition of case codes and outcome rates for surveys

Heart disease and stroke statistics--2015 update: a report from the American Heart Association

Dietary Intake Among US Adults

Healthy Eating Index (HEI)

1. 30-3.49 40.1 (35.8-44.4) 38.7 (34. 35. 4 (30.2-40.7) 36. 3 (32.7-39.9) 31.4 (28. 6-34.2) 32. 8 (30.2-35.4) 35.9 (32. 6-39.3) 36.0 (31. 1-41.0) .07≥3.50 e 36.9 (32.7-41. 4) 30.7 (25.7-36.2) 31.0 (26.8-35.6) 25.7 (23.1-28. 5) 23.1 (18. 6-28.4) 23. 6 (20.7-26.8) 26.8 (23.0-31.0) 26. 5 (22.4-31.1) .001

Age group, y 20-49 52.9 (48. 6-57. 4-64.9) 61.2 (56.9-65. 6) .01Race/ethnicity b Non-Hispanic white 58.5 (54.9-62.0) 62. 5 (58.4-66.7) 63.0 (57. 3-68.8) 64. 3 (62.3-66.4) 67.9 (65.8-69.9) 66.1 (63. 6-68.5) 63.8 (59. 4-68.2) 64.0 (59. 4-68.5) .04 .21Non-Hispanic black 48. 5 (40.7-56.2) 50. 6 (43.3-57.9) 53.9 (49. 4-58.4) 54. 5 (49.0-60.0) 58. 3 (52.5-64.2) 57.2 (52. 6-61.8) 57.0 (52. 4-61.7) 57. 5 (51.1-63.9) .01Hispanics 66.6 (60. 5-72.7) 65. 3 (60.1-70.4) 64.0 (60. 4-67.6) 68. 6 (62.9-74.3) 63.7 (58. 6-68.8) 66.0 (60. 5-71.5) 5 (28.5-40.4) 40.6 (36. 6-44.6) 40. 6 (36.7-44.5) 43.0 (39. 5-46.5) 44. 4 (39.9-49. Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion.Abbreviations: NHANES, National Health and Nutrition Examination Survey. Food sources were grouped as grocery stores (consumed food items obtained from "grocery or supermarket"), restaurants ("restaurant fast food/pizza, restaurant with waiter/waitress, restaurant no additional information"), schools ("K-12 school cafeteria, childcare center"), worksites ("cafeteria not in a K-12 school, vending machine, common coffee pot or snack tray) and other sources refer to food items obtained from elsewhere ("sport, recreation, or entertainment facility, street vendor, vending truck, from someone else/gift, and others). a All percentages were survey-weighted; %, proportion. b Trends in diet for the other race or mixed race group are not presented in the race/ethnicity-stratified results due to their small sample sizes. c Represents the ratio of family income to the federal poverty threshold, adjusting for household size. For reference, the federal threshold in 2016 for a family of 4 was $24,300/y. A family of 4 earning $33,534/y would have a ratio of 1.38. d Indicates a lower level of income. e Indicates a higher level of income.High school graduate or GED