JOURNAL OFTHE AMERICAN DIETETICASSOCIATION LaRowe, et al.

J Am Diet Assoc. 107(7). July 2007.

Introduction

• The increase in childhood obesity together with current trends in beverage consumption has led to questions of whether specific beverages are impacting diet quality and obesity among children.

• The purpose of this study was to evaluate diet quality and body mass index (BMI) by beverage patterns in preschool and school-aged children.

• Beverage patterns were identified, using cluster analysis, in preschool (aged 2-5 years) and school-aged children (aged 6-11 years) in the National Health and Nutrition Examination Survey (NHANES) 2001-02 sample.

• Diet quality was assessed using the USDA’s Healthy Eating Index (HEI), total energy, and specific micronutrient intakes.

Beverage Patterns, Diet Quality, and Body Mass Index of US Preschool and School-aged Children

Children (2-5 y)

Cluster 1:

mix/

light drinkers

(n=249)

Cluster 2:

high-fat milk

(n=91)

Cluster 3:

water

(n=128)

Cluster 4:

fruit juices

(n=73)

P

Measure HEIc 70.9 ± 0.8 2 70.9 ± 1.6 2 71.0 ± 1.12 79.0 ± 1.1 1 <0.0001 Grains c 7.8 ± 0.1 2 7.9 ± 0.2 2 8.3 ± 0.2 1, 2 8.8 ± 0.2 1 <0.01 Vegetables c 5.0 ± 0.2 2 6.4 ± 0.4 1 5.5 ± 0.3 1, 2 3.6 ± 0.4 3 <0.0001 Fruitc 5.9 ± 0.3 2, 3 6.3 ± 0.4 2 4.9 ± 0.4 3 9.9 ± 0.1 1 <0.0001 Dairy c 7.0 ± 0.2 2 10.0 ± 0.0 1 7.8 ± 0.3 2 7.7 ± 0.3 2 <0.0001 Meat c 5.6 ± 0.2 5.7 ± 0.3 5.4 ± 0.3 5.5 ± 0.4 --- Total fat c 7.5 ± 0.2 2 6.5 ± 0.3 2 7.4 ± 0.3 2 9.1 ± 0.2 1 <0.0001 Saturated fat c 6.5 ± 0.2 1, 2 2.9 ± 0.3 3 6.1 ± 0.4 2 7.5 ± 0.4 1 <0.0001 Cholesterol c 9.2 ± 0.2 9.2 ± 0.3 9.0 ± 0.2 9.3 ± 0.3 --- Sodiumc 8.8 ± 0.1 8.5 ± 0.3 8.9 ± 0.2 8.9 ± 0.2 --- Varietyc 7.5 ± 0.2 2 7.8 ± 0.3 2 7.7 ± 0.3 2 8.7 ± 0.3 1 <0.05 Energy (kcals) d 1510 ± 28 2 1694 ± 45 1 1507 ± 35 2 1763 ± 50 1 <0.0001 Protein (% kcals) d 13.1 ± 0.2 2, 3 15.7 ± 0.4 1 14.4 ± 0.3 1, 2 13.1 ± 0.4 3 <0.0001 Riboflavin (mg) d 1.7 ± 0.04 3 2.5 ± 0.06 1 1.9 ± 0.04 2 1.9 ± 0.07 2 <0.0001 Folate (µg) d 309 ± 11 3 352 ± 17 2 352 ± 13 2, 3 419 ± 19 1 <0.0001 Vitamin A (µg RAE) d 447 ± 18 3 673 ± 29 1 557 ± 23 2 515 ± 33 2 <0.0001 Vitamin C (mg) d 82 ± 4.4 2 74 ± 7.0 2 69 ± 5.4 2 171 ± 7.8 1 <0.0001 Fiber (g) d 10.3 ± 0.3 9.8 ± 0.4 11.2 ± 0.3 10.4 ± 0.5 --- Calcium (mg) d 774 ± 223 1312 ± 36 1 895 ± 28 2 899 ± 40 2 <0.0001 Iron (mg) d 11.7 ± 0.3 2 11.8 ± 0.5 2 12.7 ± 0.4 1, 2 13.5 ± 0.6 1 <0.05 Zinc (mg) d 8.4 ± 0.2 2 10.2 ± 0.3 1 9.1 ± 0.3 2 8.5 ± 0.4 2 <0.01

Healthy Eating Index scores and daily nutrient intakes by beverage patterns among children aged 2-5 y in

NHANES 2001-02a, b

a National Health and Nutrition Examination Survey.b Values in the same row with different superscript numbers are significantly different, P <0.05 (Tukey-Kramer adjustment for multiple comparisons). c Mean ± SE.d For total energy intake, mean ± SE, adjusted for age, gender, and ethnicity; for nutrient intakes, mean ± SE, adjusted for total energy intake, age, gender, and ethnicity.

LaRowe, et al. J Am Diet Assoc. 107(7). July 2007.

Healthy Eating Index scores and daily nutrient intakes by beverage patterns among children aged 6-11 y in

NHANES 2001-02a, b Children (6-11 y)

Cluster 1:

mix/

light drinker

(n=266)

Cluster 2:

high-fat milk

(n=156)

Cluster 3:

water

(n=147)

Cluster 4:

sweetened drinks

(n=100)

Cluster 5:

soda

(n=124)

P

Measure

HEIc 66.1 ± 0.81, 2 68.1 ± 0.9 1 67.1 ± 1.2 1, 2 69.9 ± 0.9 1 63.2 ± 1.02 <0.005 Grainsc 7.5 ± 0.4 7.8 ± 0.2 7.6 ± 0.2 7.7 ± 0.2 7.5 ± 0.2 --- Vegetablesc 4.4 ± 0.2 2 4.8 ± 0.3 1,2 4.9 ± 0.3 1, 2 5.9 ± 0.3 1 5.1 ± 0.3 1, 2 <0.01 Fruitc 4.7 ± 0.2 1 4.8 ± 0.3 1 4.2 ± 0.3 1 4.1 ± 0.4 1 2.6 ± 0.3 2 <0.0001 Dairyc 6.8 ± 0.2 3 9.7 ± 0.06 1 7.8 ± 0.2 2 6.3 ± 0.3 3 6.5 ± 0.3 3 <0.0001 Meatc 5.6 ± 0.2 5.4 ± 0.3 5.8 ± 0.3 6.1 ± 0.3 5.5 ± 0.3 --- Total fatc 7.1 ± 0.2 2 7.4 ± 0.2 2 7.3 ± 0.3 2 8.5 ± 0.2 1 7.3 ± 0.3 2 <0.01 Saturated fatc 6.4 ± 0.2 2 5.1 ± 0.3 3 6.2 ± 0.3 2, 3 8.1 ± 0.3 1 6.5 ± 0.3 2 <0.0001 Cholesterolc 8.9 ± 0.2 8.7 ± 0.3 8.9 ± 0.2 8.9 ± 0.3 8.9 ± 0.3 --- Sodiumc 7.5 ± 0.2 1 6.6 ± 0.3 1, 2 6.6 ± 0.3 1, 2 6.1 ± 0.4 2 6.4 ± 0.3 1, 2 <0.01 Varietyc 7.2 ± 0.2 2 7.7 ± 0.2 1, 2 7.9 ± 0.2 1, 2 8.4 ± 0.2 1 7.0 ± 0.3 2 <0.005 Energy (kcals) d 1815 ± 32 3 2028 ± 46 1, 2 1943 ± 42 2, 3 2134 ± 57 1 2074 ± 44 1, 2 <0.0001 Protein (% energy) d 13.8 ± 0.2 2 15.0 ± 0.3 1 14.4 ± 0.3 1, 2 12.1 ± 0.4 3 11.8 ± 0.3 3 <0.0001 Riboflavin (mg) d 2.1 ± 0.04 3 2.7 ± 0.05 1 2.3 ± 0.05 2 1.8 ± 0.07 3 1.7 ± 0.05 3 <0.0001 Folate (µg) d 362 ± 10 2 428 ± 13 1 371 ± 12 2 353 ± 17 2 316 ± 13 2 <0.0001 Vitamin A (µg RAE) d 601 ± 32 2, 3 755 ± 44 1 671 ± 40 1, 2 485 ± 55 2, 3 407 ± 42 3 <0.0001 Vitamin C (mg) d 78 ± 4.7 2 78 ± 6.4 2 78 ± 5.9 2 117 ± 8.1 1 59 ± 6.2 2 <0.0001 Fiber (g) d 12.4 ± 0.3 2 12.8 ± 0.4 1 12.5 ± 0.4 1, 2 12.1 ± 0.5 1 11.0 ± 0.4 1, 2 <0.01 Calcium (mg) d 958 ± 23 3 1239 ± 313 1 1026 ± 29 2 770 ± 39 3 793 ± 30 3 <0.0001 Iron (mg) d 14.2 ± 0.3 2 14.5 ± 0.4 1 14.6 ± 0.4 1, 2 13.7 ± 0.6 1 12.6 ± 0.4 1, 2 <0.01 Zinc (mg) d 10.4 ± 0.3 3 11.7 ± 0.4 1 11.0 ± 0.3 1, 2 9.1 ± 0.4 2, 3 9.4 ± 0.3 2, 3 <0.0001

a National Health and Nutrition Examination Survey.b Values in the same row with different superscript numbers are significantly different, P <0.05 (Tukey-Kramer adjustment for multiple comparisons). c Mean ± SE.d For total energy intake, mean ± SE, adjusted for age, gender, and ethnicity; for nutrient intakes, mean ± SE, adjusted for total energy intake, age, gender, and ethnicity.

LaRowe, et al. J Am Diet Assoc. 107(7). July 2007.

Adjusted mean (± SE) body mass index (BMI kg/m2) by beverage pattern among children aged 2-5 years

Cluster 1:Mix/light drinker

Cluster 2:High-fat milk

Cluster 3:Water

Cluster 4:Fruit juices

15

15.5

16

16.5

17

17.5

18

BM

I (kg

/m2 )

Figure 1. Adjusted mean (± SE) body mass index (BMI kg/m2) by beverage pattern among children aged 2-5 years. Overall significance of pattern, after adjusting for age, gender, ethnicity, household income, Healthy Eating Index, physical activity, and birth weight: P = 0.30.

LaRowe, et al. J Am Diet Assoc. 107(7). July 2007.

Adjusted mean (± SE) body mass index (BMI kg/m2) by beverage pattern among children aged 6-11 years

b

b

a

a a

17

17.5

18

18.5

19

19.5

20

20.5B

MI (k

g/m

2 )

Cluster 1: Cluster 2: Cluster 3: Cluster 4: Cluster 5:Mix/light High-fat milk Water Sweetened Sodadrinker drinks

Figure 2. Adjusted mean (± SE) body mass index (BMI kg/m2) by beverage pattern among children aged 6-11 years. Overall significance of pattern, after adjusting for age, gender, ethnicity, household income, Healthy Eating Index, physical activity, and birth weight: P < 0.0001. Bars with different letters are significantly different, P < 0.05 by comparison using the Tukey-Kramer option to correct for multiple comparisons in general linear models.

LaRowe, et al. J Am Diet Assoc. 107(7). July 2007.

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Summary of Results

• In the four beverage patterns identified in preschool aged children, mean HEI scores differed significantly between the high-fat milk group and the fruit juice group; however, both these beverage patterns had the highest micronutrient intakes.

• Mean HEI scores differed significantly across five beverage patterns in school-aged children and the high-fat milk group had the highest diet quality, as measured by HEI scores and micronutrient intakes.

• Adjusted mean BMI differed significantly across beverage clusters only in school-aged children.

• Regardless of beverage patterns, diet quality needs improvement and all children in this sample could benefit by consuming fewer calorically sweetened beverages and increasing micronutrient-dense foods.

Beverage Patterns, Diet Quality, and Body Mass Index of US Preschool and School-aged Children

LaRowe, et al. J Am Diet Assoc. 107(7). July 2007.