we used data from the 2006 brazos valley community health assessment ( bvha ) , which was developed by a collaboration of local and regional academic and community - based organizations in the brazos valley of central texas . participants were recruited from adult community residents who resided in one of six rural and one urban county by a professional independent survey research firm that identified 9,940 valid telephone numbers through random digit dialing . of these telephone numbers , more than 2,500 adults ( 19.4% minority , 71% female , and 61% rural residents ) who resided in the seven counties returned the mailed survey ; the response rate was 73.8% ( 25 ) . this study used data from 1,878 adult participants in the bvha who had complete responses for demographic characteristics , eating behaviors , and household food - related hardship ( experience of running out of food , without money to obtain more ) ( 26 , 27 ) ; 649 participants ( 25.7% ) were excluded due to missing data . there were no statistically significant differences between included and excluded participants with regards to demographic characteristics or rural residence . the texas a&m university institutional review board approved the study protocol and all participants provided informed consent . demographic characteristics included age ( 1844 years , 4564 years , and 65 years ) , race / ethnicity ( non - hispanic white vs. all others ) , household income ( poverty : 100% fpl [ federal poverty level ] , low income : 101199% fpl , and above low income : 200% fpl ) , employment status ( employed full - time outside the home for wages vs. not employed full - time outside the home ) , marital status ( married vs. not married ) , 1 child under the age of 18 years living in the household , and body mass index ( bmi ) , which was calculated from self - reported height and weight ( kg / m ) . the bmi was categorized as normal ( bmi < 25 kg / m ) , overweight ( bmi 2529.9 kg / m ) , and obese ( bmi 30 kg / m ) . eating behaviors were selected based on prior community - based work in north carolina and included prevalence and consumption of ssbs , frequency of fast food meals , frequency of eating a regular breakfast meal , and daily intake of fruit and vegetables ( 25 , 28 , 29 ) . ssb consumption was assessed with the following question :  how many cans of regular soda ( not diet ) or glasses of sweet tea do you drink on an average day? six response categories included 0 , 1 , 2 , 3 , 4 , 5 , or 6 ; and more than 6 . the prevalence of ssb consumption was defined as the proportion of adults who reported any consumption of ssb ( 1 can or glass per day ) . based on a distribution of responses , a dichotomized variable for a high level of ssb consumption was defined as 3 cans or glasses per day versus <3 cans or glasses . frequency of fast food meals was determined from the question :  how many times a week do you eat fast food meals? the same six response categories were provided as above ; and a similar approach for a dichotomized variable for frequent fast food meal consumption was defined ( 3 times / week vs. <3 times / week ) . the following question was used to describe breakfast meals frequency :  how many days a week do you eat a regular breakfast meal? from the six possible responses , a dichotomized breakfast meal variable was constructed as <3 days / week versus 3 days / week . two questions from a validated , self - reported two - item screener were combined to describe fruit and vegetable intake : ( 1 ) how many servings of fruit do you usually eat each day ( a serving= cup of fruit or  cup of fruit juice ) ? and ( 2 ) how many servings of vegetables do you usually eat each day ( a serving= cup of cooked or one cup raw vegetables ) ? ( 30 , 31 ) . a three - category variable was constructed for total daily intake of fruit and vegetables : 02 servings , 34 servings , and 5 servings . the first quantitative food depletion item in the household hunger dimension of the radimer - cornell measure of hunger and food insecurity was used to determine the presence of household food insecurity in the past 30 days ( 27 , 3235 ) . respondents were asked to choose the frequency ( often true , sometimes true , or never true ) that the following occurred for their household in the past 30 days :  the food that we bought did n't last and we did n't have enough money to buy more. responses of often true and sometimes true were combined to indicate food - related hardship ( often true or sometimes true ) versus no food - related hardship ( never true ) . this measure describes the household experience of running out of food without money to obtain more ( 26 , 27 ) . release 11 of stata statistical software was used for all statistical analyses ; p<0.05 was considered statistically significant . descriptive statistics were estimated for demographic characteristics , eating behaviors , and food - related hardship . the difference between rural and urban adults was assessed with contingency tables by using the  statistic . bivariate correlations between theoretically selected variables ( demographic characteristics , eating behaviors , and food - related hardship shown in table 1 ) and ssb intake were estimated . correlations at p<0.10 were retained for inclusion in the logistic regression model that included rural and urban respondents ; excluded variables included sex , overweight , ages 4564 years , and employment status . using backward elimination of all variables with p>0.05 , a combined multivariable logistic regression model ( n=1,878 ) was estimated for high level of ssb consumption ( 3 cans / glasses per day vs. <3 cans / glasses ) . using the final model for the combined sample , separate multivariable logistic regression models were estimated for the 734 urban respondents and the 1,144 rural respondents . difference in demographic characteristics , eating behaviors , and household food - related hardship between urban and rural adults ( n=1,878)a comparisons were performed using  test . statistically significant after using bonferroni correction for multiple comparison ( bonferroni - corrected p=0.002 ) . 1 can or glass of regular soda or sweet tea on an average day , compared with < 1 on an average day . 3 cans or glasses of regular soda or sweet tea on an average day , compared with <3 on an average day . we used data from the 2006 brazos valley community health assessment ( bvha ) , which was developed by a collaboration of local and regional academic and community - based organizations in the brazos valley of central texas . participants were recruited from adult community residents who resided in one of six rural and one urban county by a professional independent survey research firm that identified 9,940 valid telephone numbers through random digit dialing . of these telephone numbers , more than 2,500 adults ( 19.4% minority , 71% female , and 61% rural residents ) who resided in the seven counties returned the mailed survey ; the response rate was 73.8% ( 25 ) . this study used data from 1,878 adult participants in the bvha who had complete responses for demographic characteristics , eating behaviors , and household food - related hardship ( experience of running out of food , without money to obtain more ) ( 26 , 27 ) ; 649 participants ( 25.7% ) were excluded due to missing data . there were no statistically significant differences between included and excluded participants with regards to demographic characteristics or rural residence . the texas a&m university institutional review board approved the study protocol and all participants provided informed consent . demographic characteristics included age ( 1844 years , 4564 years , and 65 years ) , race / ethnicity ( non - hispanic white vs. all others ) , household income ( poverty : 100% fpl [ federal poverty level ] , low income : 101199% fpl , and above low income : 200% fpl ) , employment status ( employed full - time outside the home for wages vs. not employed full - time outside the home ) , marital status ( married vs. not married ) , 1 child under the age of 18 years living in the household , and body mass index ( bmi ) , which was calculated from self - reported height and weight ( kg / m ) . the bmi was categorized as normal ( bmi < 25 kg / m ) , overweight ( bmi 2529.9 kg / m ) , and obese ( bmi 30 kg / m ) . eating behaviors were selected based on prior community - based work in north carolina and included prevalence and consumption of ssbs , frequency of fast food meals , frequency of eating a regular breakfast meal , and daily intake of fruit and vegetables ( 25 , 28 , 29 ) . ssb consumption was assessed with the following question :  how many cans of regular soda ( not diet ) or glasses of sweet tea do you drink on an average day? six response categories included 0 , 1 , 2 , 3 , 4 , 5 , or 6 ; and more than 6 . the prevalence of ssb consumption was defined as the proportion of adults who reported any consumption of ssb ( 1 can or glass per day ) . based on a distribution of responses , a dichotomized variable for a high level of ssb consumption was defined as 3 cans or glasses per day versus <3 cans or glasses . frequency of fast food meals was determined from the question :  how many times a week do you eat fast food meals? the same six response categories were provided as above ; and a similar approach for a dichotomized variable for frequent fast food meal consumption was defined ( 3 times / week vs. <3 times / week ) . the following question was used to describe breakfast meals frequency :  how many days a week do you eat a regular breakfast meal? from the six possible responses , a dichotomized breakfast meal variable was constructed as <3 days / week versus 3 days / week . two questions from a validated , self - reported two - item screener were combined to describe fruit and vegetable intake : ( 1 ) how many servings of fruit do you usually eat each day ( a serving= cup of fruit or  cup of fruit juice ) ? and ( 2 ) how many servings of vegetables do you usually eat each day ( a serving= cup of cooked or one cup raw vegetables ) ? ( 30 , 31 ) . a three - category variable was constructed for total daily intake of fruit and vegetables : 02 servings , 34 servings , and 5 servings . the first quantitative food depletion item in the household hunger dimension of the radimer - cornell measure of hunger and food insecurity was used to determine the presence of household food insecurity in the past 30 days ( 27 , 3235 ) . respondents were asked to choose the frequency ( often true , sometimes true , or never true ) that the following occurred for their household in the past 30 days :  the food that we bought did n't last and we did n't have enough money to buy more. responses of often true and sometimes true were combined to indicate food - related hardship ( often true or sometimes true ) versus no food - related hardship ( never true ) . this measure describes the household experience of running out of food without money to obtain more ( 26 , 27 ) . demographic characteristics included age ( 1844 years , 4564 years , and 65 years ) , race / ethnicity ( non - hispanic white vs. all others ) , household income ( poverty : 100% fpl [ federal poverty level ] , low income : 101199% fpl , and above low income : 200% fpl ) , employment status ( employed full - time outside the home for wages vs. not employed full - time outside the home ) , marital status ( married vs. not married ) , 1 child under the age of 18 years living in the household , and body mass index ( bmi ) , which was calculated from self - reported height and weight ( kg / m ) . the bmi was categorized as normal ( bmi < 25 kg / m ) , overweight ( bmi 2529.9 kg / m ) , and obese ( bmi 30 kg / m ) . eating behaviors were selected based on prior community - based work in north carolina and included prevalence and consumption of ssbs , frequency of fast food meals , frequency of eating a regular breakfast meal , and daily intake of fruit and vegetables ( 25 , 28 , 29 ) . ssb consumption was assessed with the following question :  how many cans of regular soda ( not diet ) or glasses of sweet tea do you drink on an average day? six response categories included 0 , 1 , 2 , 3 , 4 , 5 , or 6 ; and more than 6 . the prevalence of ssb consumption was defined as the proportion of adults who reported any consumption of ssb ( 1 can or glass per day ) . based on a distribution of responses , a dichotomized variable for a high level of ssb consumption was defined as 3 cans or glasses per day versus <3 cans or glasses . frequency of fast food meals was determined from the question :  how many times a week do you eat fast food meals? the same six response categories were provided as above ; and a similar approach for a dichotomized variable for frequent fast food meal consumption was defined ( 3 times / week vs. <3 times / week ) . the following question was used to describe breakfast meals frequency :  how many days a week do you eat a regular breakfast meal? from the six possible responses , a dichotomized breakfast meal variable was constructed as <3 days / week versus 3 days / week . two questions from a validated , self - reported two - item screener were combined to describe fruit and vegetable intake : ( 1 ) how many servings of fruit do you usually eat each day ( a serving= cup of fruit or  cup of fruit juice ) ? and ( 2 ) how many servings of vegetables do you usually eat each day ( a serving= cup of cooked or one cup raw vegetables ) ? ( 30 , 31 ) . a three - category variable was constructed for total daily intake of fruit and vegetables : 02 servings , 34 servings , and 5 servings . the first quantitative food depletion item in the household hunger dimension of the radimer - cornell measure of hunger and food insecurity was used to determine the presence of household food insecurity in the past 30 days ( 27 , 3235 ) . respondents were asked to choose the frequency ( often true , sometimes true , or never true ) that the following occurred for their household in the past 30 days :  the food that we bought did n't last and we did n't have enough money to buy more. responses of often true and sometimes true were combined to indicate food - related hardship ( often true or sometimes true ) versus no food - related hardship ( never true ) . this measure describes the household experience of running out of food without money to obtain more ( 26 , 27 ) . release 11 of stata statistical software was used for all statistical analyses ; p<0.05 was considered statistically significant . descriptive statistics were estimated for demographic characteristics , eating behaviors , and food - related hardship . the difference between rural and urban adults was assessed with contingency tables by using the  statistic . bivariate correlations between theoretically selected variables ( demographic characteristics , eating behaviors , and food - related hardship shown in table 1 ) and ssb intake were estimated . correlations at p<0.10 were retained for inclusion in the logistic regression model that included rural and urban respondents ; excluded variables included sex , overweight , ages 4564 years , and employment status . using backward elimination of all variables with p>0.05 , a combined multivariable logistic regression model ( n=1,878 ) was estimated for high level of ssb consumption ( 3 cans / glasses per day vs. <3 cans / glasses ) . using the final model for the combined sample , separate multivariable logistic regression models were estimated for the 734 urban respondents and the 1,144 rural respondents . difference in demographic characteristics , eating behaviors , and household food - related hardship between urban and rural adults ( n=1,878)a comparisons were performed using  test . statistically significant after using bonferroni correction for multiple comparison ( bonferroni - corrected p=0.002 ) . servings of fruit and vegetables usually eaten each day . 1 can or glass of regular soda or sweet tea on an average day , compared with < 1 on an average day . 3 cans or glasses of regular soda or sweet tea on an average day , compared with <3 on an average day . rural respondents were older than urban counterparts ; a larger proportion were women , reported a household income 101199% fpl , and were obese ; and a smaller proportion were employed full - time outside the home for wages or had at least one child under the age of 18 years living in the household . compared with urban respondents , the prevalence and high level of ssb consumption ( 3 cans or glasses of ssb / day ) was greater among rural adults . a greater proportion of rural adults ate a regular breakfast meal less than three times a week and consumed fewer servings of fruit and vegetables . on the other hand , a larger proportion of urban adults ate fast food meals at least three times a week . finally , a larger proportion of rural adults reported household food - related hardship than urban counterparts ( 23.7% vs. 17.2% ) . several differences between urban and rural adults remained significant after correcting for multiple comparisons with a bonferroni - corrected level of statistical significance . several demographic variables were not correlated with ssb consumption ; namely sex , overweight status ( bmi 2529.9 kg / m ) , age category of participants 4564 years , and employment status . although statistically significant , the strength of individual correlations was weak ( r  0.15 ) . age category of participants 1844 years ( r=0.11 , p<0.001 ) , minority status ( r=0.10 , p<0.001 ) , poverty - level household income ( r=0.15 , p<0.001 ) , presence of 1 child in the household ( r=0.14 , p<0.001 ) , and obesity ( r=0.07 , p=0.005 ) were positively correlated with ssb consumption ; older age category ( 65 years ) was negatively correlated . among the variables for eating behaviors , frequency of fast food meals ( r=0.09 , p<0.001 ) , low fruit and vegetable intake ( r=0.15 , p<0.001 ) , and consuming <3 breakfast meals / week ( r=0.17 , p<0.001 ) were positively correlated with ssb consumption ; high fruit and vegetable intake of 5 servings / day was negatively correlated with ssb consumption ( r=0.12 , p<0.001 ) . food - related hardship was positively associated with ssb consumption ( r=0.21 , p<0.001 ) . minority status ( p=0.64 ) , employment status ( p=0.57 ) , age ( p=0.19 ) , and obesity ( p=0.17 ) were sequentially removed from the final model for the combined rural and urban sample , which adjusted for demographic characteristics , eating behavior , and household food - related hardship . independent of demographic characteristics , eating behaviors , and food - related hardship , rural residence was associated with greater odds for reporting a high level consumption of ssbs ( or 1.8 ; 95% ci 1.3 , 2.4 ; p<0.001 ) than urban residence . among all adults having a poverty - level household income ( or 2.2 ; 95% ci 1.6 , 3.1 ) , children in the household ( 1.8 ; 95% ci 1.3 , 2.3 ) , frequent consumption of fast - food meals ( 1.6 ; 95% ci 1.2 , 2.2 ) , infrequent breakfast meals ( 1.7 ; 95% ci 1.3 , 2.3 ) , low fruit and vegetable intake ( or 2.1 ; 95% ci 1.4 , 3.3 ) , and food - related hardship ( or 1.9 ; 95% ci 1.4 , 2.6 ) table 2 shows the results from the multivariable regression model for rural adults . among rural adults , a higher level of ssb consumption was associated with greater odds for respondents with poverty - level household income , presence of child in the household , frequent consumption of fast - food meals , infrequent consumption of regular breakfast , low fruit and vegetable intake , and food - related hardship . among urban adults ( table 3 ) , one eating behavior ( infrequent consumption of a regular breakfast meal ) , household food - related hardship , and one demographic characteristic ( children in the home ) were associated with ssb consumption . interestingly , frequency of fast - food meals and low fruit and vegetable intake were not associated with a high level of ssb consumption among urban adults . odds ratios and 95% ci from multiple variable logistic regression models correlating demographic characteristics , eating behaviors , and household food - related hardship with consumption of sugar - sweetened beverages among 1,144 rural adultsa dependent variable is consumption of 3 cans / glasses of regular soda or sweet tea on an average day compared with <3 cans / glasses . 1 child under 18 years living in the household with the adult respondent compared with no children . eat a regular breakfast meal <3 days a week compared with 3 days a week . in the last month , food bought did n't last and there was not enough money to buy more compared with food did last . odds ratios and 95% ci from multiple variable logistic regression models correlating demographic characteristics , eating behaviors , and household food - related hardship with consumption of sugar - sweetened beverages among 734 urban adultsa dependent variable is consumption of 3 cans / glasses of regular soda or sweet tea on an average day compared with <3 cans / glasses . 1 child under 18 years living in the household with the adult respondent compared with no children . eat a regular breakfast meal <3 days a week compared with 3 days a week . in the last month , food bought did n't last and there was not enough money to buy more compared with food did last . although research findings suggest a link between consumption of ssbs and health outcomes ( 1 , 2 , 12 ) , there are few studies that have examined the influence of less - healthy eating behaviors and food - related hardship on the consumption of high levels of ssb , especially among rural adults . this is critical considering the dramatic increase in prevalence of overweight and obesity ( 36 , 37 ) , ssb consumption ( 3 , 9 , 3840 ) , frequency of fast - food meal consumption ( 41 ) , and nutrition and health disparities associated with rural residence ( 25 , 4246 ) . however , studies of ssb consumption rarely have considered eating behaviors and adequacy of household food supplies as contributing factors . findings from this study of 1,878 rural and urban adults extend our understanding of the influence of less - healthy eating behaviors and household food - related hardship on higher levels of ssb consumption . first , the prevalence and high level of consumption of ssb were significantly greater among rural adults compared with urban counterparts . second , a high level of ssb consumption was associated with less - healthy eating behaviors , especially among rural adults . to our knowledge , this is apparently the first study that simultaneously evaluated the association of multiple eating behaviors and household food - related hardship among a large sample of rural adults . unlike primarily urban studies that used a single definition of ssb consumption such as once or more a week ( 17 ) , one 12-ounce serving of sugar - sweetened soda per day ( 6 ) , 1 ssb / day ( 47 ) , and > 1 bottle / day ( 48 ) , this study considered prevalence ( 1 can or glass of ssb / day ) and a high level of ssb consumption ( 3 cans or glasses of ssb / day ) . more than 52% of rural adults , compared with 43.7% of urban adults , consumed at least one ssb per day . this appears to be higher than a similar size study of rural adults ( n=1,817 ) in wyoming , montana , and idaho that defined ssb consumption as less than once / week versus once or more per week ( 17 ) or the large , primarily urban nurses health study ii that found that 9.5% of the sample consumed 1 ssb / day ( 47 ) . compared with previous studies of ssb consumption , our finding that rural adults consumed higher levels of ssb than urban adults is apparently new . one possible explanation may be that previous studies did not attempt to examine high levels of ssb consumption ; but chose lower levels of consumption , such as at least one ssb per day or week ( 6 , 17 , 47 , 48 ) . another explanation may be that rural residents have greater access to convenience and non - traditional food stores and fast - food opportunities where ssb are more available and affordable ( 43 , 45 , 4951 ) . preference and greater household availability for ssb such as regular soft drinks or sugar - sweet tea , which has been identified through household food inventories , may provide another explanation for high levels of ssb consumption ( 52 , 53 ) . in addition to consumption of ssb , three additional less - healthy eating behaviors that are associated with poor diet quality were examined ; namely , infrequent breakfast meals ( 28 , 54 , 55 ) , frequent consumption of fast - food meals ( 56 ) , and fewer portions of fruit and vegetables ( 57 , 58 ) . rural adults compared less favorably with urban adults in two of these three eating behaviors . a greater proportion of rural adults infrequently consumed a regular breakfast meal and ate less than three daily servings of fruit and vegetables . lower fruit and vegetable intake among rural adults may be the result of limited access to food stores that market fruit and vegetables  store availability and transportation infrastructure ( 46 , 59 , 60 ) . in the united states , there has been an overall decline in breakfast consumption ( 61 ) . one explanation for less frequent breakfast meal consumption among rural adults may be that rural adults travel a greater distance in the morning to work and do not have the time for a regular breakfast . in both urban and rural areas , there are increased opportunities for fast food through traditional fast - food restaurants and marketing of fast food through convenience and other retail stores , often referred to as an explanation for greater utilization of fast - food meals by urban adults may be greater accessibility and availability . inadequate household food supplies or household food - related hardship are known to influence food choice and dietary intake ( 46 , 51 , 63 ) . we identified great nutritional disparity between rural and urban adults , which has been absent from the literature . more than 23% of rural adults compared with 17.2% of urban adults reported that in the past 30 days purchased food did not last and there was no money to buy more , which is supported by secondary analysis of national surveys ( 64 ) . one explanation for the higher prevalence of both household food - related hardship and ssb consumption for rural adults may be related to the coping strategies food - insecure individuals employ to mitigate the consequences of food - related hardship ( 6568 ) such as consuming inexpensive and inflationary - resistant energy - dense foods ( 69 ) . findings from multiple variable regression models confirmed geographic differences and similarities in the association of demographic characteristics , eating behaviors , and food - related hardship with high levels of ssb consumption . although poverty - level household income increased the odds for ssb consumption among rural adults and not urban adults , in both geographic groups the presence of a child in the household was associated with a high level of ssb consumption . all three eating behaviors  frequent fast - food meals , infrequent breakfast , and low intakes of fruit and vegetables  were associated with ssb consumption among rural adults , but only infrequent consumption was significant among urban residents . food - related hardship was associated with ssb consumption among both rural and urban adults ; the effect size was greater among the urban sample . thus , multiple less - healthy eating behaviors have a greater association with ssb consumption among rural adults than among urban adults . interestingly , two less - healthy eating behaviors were not independently associated with ssb consumption in our urban subsample . a prior rural study found an increased likelihood of overweight or obesity associated with greater frequency of ssb and fast food ( 17 ) . thus , it is critically important to understand individual and household contextual influences on high levels of ssb consumption . our findings revealed linkages among multiple less - healthy eating behaviors , which enhance results from a similar study of rural adults ( 25 ) . adults , especially rural adults who frequently ate fast - food meals , infrequently consumed a breakfast meal , or had fewer daily servings of fruit and vegetables were also more likely to consume high levels of ssb . just as healthier food patterns are associated with healthier beverage patterns ( 70 ) , the present study shows that consumption of ssb appears to be closely linked to less - healthy eating patterns ( 71 , 72 ) . as such , ssb consumption may serve as a marker of other less - healthy eating behaviors and overall poor nutrition . first , the self - reported measure of ssb consumption may understate actual frequency and amount of ssb consumed on a usual day . future work will include specific prompts for calorically sweetened beverages to include carbonated and non - carbonated soft drinks , fruit punch , fruit drinks , lemonade , sweetened powder drinks , bottled coffees , and coffees or teas with added sugar ( 73 ) . third , data were not available on the type and amount of fast - food items consumed or the source of fast - food meals or ssb . finally , measures on sedentary behaviors ( e.g. television viewing , computer use , video gaming ) should be included ( 74 ) . despite these limitations , this study advances our knowledge about less - healthy eating behaviors and household food - related hardship . results from this study provide impetus for understanding interactions among multiple eating behaviors especially among economically and geographically disadvantaged adults . considering that americans are consuming more total calories per day , with much coming from ssb and fast food ( 75 ) , new strategies are needed for educating consumers not only about how to moderate their ssb intake , but also how to simultaneously disrupt the co - occurrence of undesirable eating behaviors ( e.g. fast - food consumption and skipping breakfast ) and promote healthful behaviors ( e.g. eating a regular breakfast and increasing fruit and vegetable intake ) . challenges include the perception and observation that ssb are priced and promoted preferentially with meal deals at fast - food outlets and other venues that market fast - food items ( 49 , 76 ) , and that energy - dense foods are not only least expensive but also most resistant to inflation ( 69 ) . given the economic disincentive for consumers to make healthier selections at fast - food restaurants and other venues ( 49 , 76 , 77 ) and the reality of low - cost accessible energy - dense foods , strategies must consider convenience and cost ( 69 ) especially for low - income and/or rural families ( 51 ) . supported in part by the national institutes of health ( nih)/national center on minority health and health disparities ( # 5p20md002295 ) and by cooperative agreement # 1u48dp001924 from the centers for disease control and prevention , prevention research centers program through core research project and special interest project nutrition and obesity policy research and evaluation network . the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih and cdc .