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Journal of the American College of Nutrition, Vol. 17, No. 6, 579-585 (1998)
Published by the American College of Nutrition

Nutrient Intake and Food Group Consumption of 10-Year-Olds by Sugar Intake Level: The Bogalusa Heart Study

Rosanne P. Farris, MS Hyg, Theresa A. Nicklas, Dr PH, Leann Myers, PhD and Gerald S. Berenson, MD

Tulane Center for Cardiovascular Health, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana (R.P.F., L.M., G.S.B.)
Department of Food and Nutrition, North Dakota State University, Fargo, North Dakota (T.A.N.)

Address reprint requests to: Gerald S. Berenson, MD, Tulane Center for Cardiovascular Health, Tulane School of Public Health and Tropical Medicine, 1501 Canal Street, 14th Floor, New Orleans, LA 70112-2824


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Objective: The effect of total sugar intake on nutrient intake and food group consumption was examined in children.

Methods: Twenty-four hour dietary recalls were collected on a sample of 568 ten-year-olds from two cross-sectional surveys. The population was stratified according to total sugar intake quartiles: <=25th (46 g/1000 kcal), 25–50th (67 g/1000 kcal), 50–75th (81 g/1000 kcal) and >=75th (106 g/1000 kcal).

Results: No significant difference was shown in energy intakes across the quartiles and no significant race or gender differences were observed in mean total sugar intakes. However, with increasing total sugar intake, there was a significant linear decrease in mean intakes of protein, fat, saturated fat, starch, cholesterol, sodium, vitamins B6 and E, thiamin, niacin, iron, and zinc; and a significant linear increase in mean intakes of carbohydrate, fructose, lactose, sucrose, vitamin D, and calcium. Eating patterns reflected the differing nutrient intakes, with high sugar consumers having significantly higher intakes of total g of candy, beverages and milk and lower intakes of total g of meats, and cheese than lower sugar consumers. The nutritional quality of children’s diets high in total sugar appear to be adequate regarding vitamin and mineral intakes and are closer to meeting current dietary fat recommendations.

Key words: dietary intakes, eating patterns, childhood nutrition


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The nutritional and health consequences of children’s eating patterns have received considerable attention in the research literature. Particular areas of interest have included dietary quality with regard to vitamin and mineral intakes [1], excess fat, saturated fat, sodium and sugar [2], and possible influences of nutrition on health conditions such as diabetes [3], cardiovascular disease (CVD) [4,5], and obesity [6].

The influence of sugars on the diets of children remains controversial. A recent workshop reviewed current scientific evidence related to nutritional and health aspects of sugars on overweight and obesity [7,8], physical and mental performance [9,10], lipid metabolism [11], blood glucose control [12], oral health [13], and biological aging [14]. A considerable amount of new information has accumulated on the health effects of increased intake of total sugar. Evidence suggests that intake of sugars are not an independent risk factor for any particular disease [15]. However, it has been suggested that high intakes of sugar could potentially replace nutrient-rich foods in the diet and lead to deficiencies [16,17]. In addition, the significant inverse relationship between the percentage of energy from sugars and fats has been well documented [18,19].

Dietary recommendations for the general public include consuming sugars or sweets in moderation [2]. Published recommendations have suggested limiting the amount of energy from added sugars to approximately 10 to 15% of total energy [20]. The average daily intake of total sugar minus lactose is 80 g/day or 18% of total energy [21,22]. The basic issues concerning the nutritional impact of sugar intake at various levels remains controversial.

The purpose of this report is to examine nutrient adequacy and food sources at various levels of total sugar intake in a population of children.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Population
The Bogalusa Heart Study is an epidemiologic investigation of cardiovascular risk factor variables and environmental determinants of cardiovascular disease risk in children from a biracial (black-white) population that has been ongoing for 25 years [23,24]. The population of this study was obtained from two cross-sectional surveys of 10 year olds (n=568) who were surveyed either in 1984–85 (n=284; 40% black, 60% white, 51% female, 49% male) or 1987–88 (n=284; 42% black, 58% white, 50% female, 50% male).

Dietary Methods
Twenty-four-hour dietary recalls, adapted for interviewing children, were conducted. Each child was interviewed privately for 30 to 40 minutes to obtain an hour-by-hour recall of all foods and beverages consumed during the previous 24-hour period [25,26].

Quality controls included a standardized protocol for the collection, calculation, and editing of 24-hour dietary recalls; [27], graduated food models for quantification of amounts of foods and beverages consumed; [28], a product identification notebook for snack probing; a school lunch [29], and family recipe collection of actual food preparation, recipes, brand names of foods, and actual serving sizes of school meal food items served; and the Moore Extended Nutrients (MENu), formerly known as the Extended Table of Nutrient Values (ETNV), for nutrient composition [30]. All interviewers participated in rigorous training sessions and pilot studies before the field surveys to minimize interviewer effects [31]. Details of the dietary methodology procedures and quality controls have been referenced in previous publications [26]. The Bogalusa dietary data are comparable with national dietary survey data [32,33].

Nutrient Database
The MENu is a nutrient database including 5,000 core foods and recipes, with values for 97 dietary components. The data bank is a flexible system permitting continuous updating of existing values and additions for new single or composite foods. Nutrient values include US Department of Agriculture data, other published references, manufacturers’ information, and recipe calculation by ingredients [30]. In this database, naturally occurring sugars and sugars added to foods are not distinguished. Total sugar from all food sources are included. The resultant sugars database contains values for sucrose, maltose, glucose, fructose, and lactose, the sum of which is called total sugar. The percent missing values for total number of foods and recipes reported in the 24-hour dietary recalls was calculated. Only about 7% of the foods reported contained missing values for total sugar. The total sugar used for analysis reflects the sugar content of foods consumed by the 10-year-olds at the time of the survey.

Statistical Analyses
Total sugar intake in the 10-year-old children was normally distributed, ranging from 10 to 183 g/1000 kcal of total sugar, with a mean intake of 75 g/1000 kcal. Based on this distribution and differences in energy intake, the 568 children were stratified according to four different quartiles of total sugar intake: <=25th ( value of sugar intake=46 g/1000 kcal), 25 to 50th (=67 g/1000 kcal, 50 to 75th (=81 g/1000 kcal) and >=75th (=106 g/1000 kcal). The mean percent of total energy from total sugar in the lowest intake group was 9%, and mean percent of total energy from total sugar in the highest intake group was 19%. No secular trend was noted in the percentage of children in the four total sugar intake groups from 1984 to 1988; thus the two cross-sectional surveys of 10-year-old children were grouped together and then stratified by total sugar intake levels. Furthermore, since the overall significance level in mean energy intakes across the total sugar intake quartiles was close to significance (p<0.05) all nutrients were adjusted per 1000 kcal for the analyses. The race and gender distribution across all four total sugar intake quartiles was similar, reflecting 29% white males, 21% black males, 30% white females, and 20% black females. Sixty-one percent of the sample reported that the recall day eating pattern was typical, 19% reported they usually ate more and 13% reported that they usually ate less. No significant differences were noted by quartile for the recall day reflecting typical or atypical eating pattern.

All analyses were performed with the Statistical Analysis System [34]. Analysis of variance techniques were used to test statistical significance for nutrient intake levels across the four total sugar intake groups. For trend analysis coefficients and sums of squares for each contrast were generated using a program described in Dunlap [35]. A p value less than 0.05 denoted statistical significance.

Determination of Nutrient Adequacy
Mean nutrient intake was assessed for each total sugar intake group. Nutrient adequacy was determined by comparison of selected vitamins and minerals with the Recommended Dietary Allowances (RDA) [36] for each category of total sugar intake. The RDAs were devised as standards or guides of acceptable daily nutrient intake levels and are used as a basis for assessing dietary intakes of populations. For each recommended level given for vitamins and minerals, total daily intake was divided into the percentage of children less than one-third of the RDA, from one-third to two-thirds of the RDA, from two-thirds to 100% of the RDA, or greater than the RDA.

Food Group Intake
A food grouping program was designed as an adjunct to the Bogalusa Heart Study nutrition data system to provide the opportunity to examine major food group sources of nutrients consumed and amounts of food groups consumed. All foods or entries (core and recipe) appearing in the MENu and containing the food type identifying the group, e.g., cheese, as a major ingredient, were included in the food group list. Twenty-one major food groups were established and based, where feasible, on similar source characteristics. For example, "fruit and fruit juices" formed one major group, and "rice, biscuits, and cereals" were included in the breads and grains category.

Composite food items such as recipes were assigned to food groups according to primary ingredients. If no single type of food (other than water) accounted for at least 60% of the weight, the item was classified as a mixed dish. Total nutrients and the nutrient contribution from each food group were calculated for each dietary recall. For this report, the recalls were analyzed to determine the percent contribution from each food group to total sugar intake, as well as g of foods consumed from each food group by total sugar intake quartile.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Nutrient Intake by Total Sugar Intake Quartiles
No significant difference was shown in energy intakes across the four total sugar intake groups. With increasing total sugar intake, there was a significant linear decrease in mean intakes of protein, fat, saturated fat, starch, cholesterol, and sodium. In addition, the percentage of energy from protein, fat, and saturated fat significantly decreased with increasing total sugar intake. Intakes of total carbohydrate, fructose, lactose, and sucrose, significantly increased with higher total sugar intake (Table 1). For vitamins and minerals, mean intakes of vitamins B6 and E, niacin, iron, and zinc significantly decreased, while mean intake of vitamin D and calcium increased with increasing total sugar intake (Table 2).


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  		Table 1. Total Sugar Intake (g/1000 kcal) and Nutrient Intake in 10-Year Olds

 

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  		Table 2. Total Sugar Intake (g/1000 kcal) and Vitamin/Mineral Intake of 10-Year Olds

 
Comparison with Recommended Dietary Allowances
Intakes of vitamins and minerals were compared across quartiles for significant differences in the number of 10-year-olds with inadequate intakes. Inadequate intake was defined as <2/3 RDA.

More children in the upper quartile of total sugar intake had inadequate intakes of vitamin B, niacin, vitamin E, and iron, while more children in the lowest total sugar quartile had inadequate intakes of vitamins D and C, and calcium (Table 2). There were no significant differences in the proportion of children with inadequate intakes by total sugar intake quartiles for magnesium, phosphorus, riboflavin, vitamins A and B12, thiamin, or folacin.

Food Groups of Total Sugar Intake
In 10-year-old children, the major food group of total sugar was milk, which contributed 22 g of total sugar in the lowest total sugar intake quartile to 53 g in the highest total sugar intake quartile; and beverages, contributing 25 g of daily total sugar intake in the lowest quartile, and 52 g of total sugar in the highest quartile. The third highest contributor of total sugar was candy, ranging from 13 g of daily total sugar intake (lowest total sugar intake quartile) to 45 g of total sugar intake (highest total sugar intake quartile). There were also significant differences in the amount of total sugar contributed from desserts, and fruit juices, with children in the upper quartile consuming greater quantities of total sugar from these food groups than children in lower total sugar quartiles (data not shown).

Ten-year-olds in the highest total sugar consumption category (>=75th percentile) consumed significantly greater quantities of beverages, milk, and candy, while children in the lowest total sugar consumption quartile consumed significantly greater amounts of beef, poultry, pork, mixed meats and cheese (Table 3).


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  		Table 3. Contribution of the Mean Total Grams per 10-Year-Old Child from the Major Food Groups* by Total Sugar Intake Levels (g/1000 kcal)

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
The mean percent energy from total sugar in this study was 15.2%; ranging from 9.2% for children in the lowest total sugar intake quartile to 22.8% for children in the highest total sugar intake quartile. These results are somewhat lower than those reported in the 1987–88 Nationwide Food Consumption Survey (NFCS), where the mean percent energy from total sugar in diets of 7 to 10 year olds was 25% [38]. Although this percent may seem high, one needs to be reminded that it includes percent energy from all sugars. According to NFCS, the percent energy from added sugars contributed only 11% [38] which is close to the published recommendation of 10% [2,20,37]. The differences in results may reflect methodologic differences in the two studies.

Nutrient adequacy is a concern related to high intakes of sugar and "empty calories" i.e., sources of energy without micronutrients in the diet [6,17]. This is of particular concern for certain population subgroups including children and adolescents [17]. However, data from this study and NFCS showed no consistent or nutritionally meaningful variation of micronutrient intake across the range of total sugar intakes [38]. Furthermore, consumers of high amounts of total sugar had diets that approached the current dietary recommendations for fat, saturated fat, and cholesterol, and RDA’s for most vitamins and minerals [8,18–19].

An analysis of food consumption patterns of subpopulations with high and low intakes of total sugar (as percent of energy) will likely be confounded by percent of energy from fat. Subpopulations selected on the basis of a high percentage of energy from total sugar will automatically be those with a low percent energy from fat. This inverse relation between intakes of total sugar and fat has been consistently observed in comparison of groups within countries, between countries, and in selected subgroups [38–40]. Similarly, well-supervised intervention programs have documented that when fat was reduced in the diet there was a concomitant increase in energy from dessert items and total sugar intake [40,41].

Observations from this study and others [40,42] show there is considerable variation in the distribution of energy intake from carbohydrates, total sugar, and fat among children. This variation is reflected in energy consumption as well as dietary composition and vitamins and minerals. It is not possible to classify a child as a high or low consumer of specific nutrients based on the results of a single 24-hour recall. Rather, these data comparing groups at different total sugar intake levels indicate that children consuming 23% of energy from total sugar, more closely approach the current dietary recommendations for total fat, saturated fat, and cholesterol. It is important to note that the increased total sugar intake resulted from an increase in consumption of all sugars, including those naturally occurring in fruits, fruit juices, and milk, as well as those added to desserts, candy, and beverages.

Children who had a high total sugar intake also consumed less meats during the 24-hour period studied than those with lower total sugar intake. This finding is consistent with previous studies [43–45], and could explain the lower intakes of vitamins B6 and E, niacin, iron and zinc noted in children with high total sugar intake. It was interesting that children with high total sugar intake met 2/3 RDA for a variety of vitamins and minerals. In fact, their intake of vitamin D and calcium was higher than those children with low total sugar intake, primarily reflecting an increase in milk consumption. This has implications for prevention of osteoporosis, particularly during an age when attainment of peak bone mass is critical [46,47]. Additionally, data from this study and others [40,42] have shown that increased total sugar intake reflects not only an increase in variety of foods containing specific sugars, namely lactose and fructose, but also a substitution of meats for less nutrient dense foods (i.e., candy, beverages, desserts).

Educational efforts are needed to provide the public with adequate information on how to achieve an optimum diet that meets current dietary recommendations. The USDA Food Guide Pyramid [37] is an excellent tool that can be used to promote the current dietary recommendations for Americans [48]. Until these guidelines are revisited, the scientific community needs to move forward with their efforts to assess the impact of the current dietary recommendations on total sugar intake, and its ultimate health consequences. This is of particular importance with the rapidly growing market of "fat-free" desserts and snack items where the fat content has been replaced by various sugars, without changes in the total energy content of those products. Finally, with the upsurge of new diet regimens promoting a diet low in total sugar as the "cure all" for overweight [49–51], issues related to micronutrient density and how well these diets adhere to the established dietary guidelines need to be investigated.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The nutritional quality of diets high in total sugar as consumed by 10-year-old children, appear to be adequate with regard to intakes of most vitamins and minerals [36] and close to meeting the current dietary recommendations [2,20]. The consistent inverse relation between fat and sugar and the large number of children exceeding the current dietary recommendations for fat, saturated fat, and cholesterol [32,33] raises important questions on the practical application of those guidelines.



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   ACKNOWLEDGMENTS
 
This research is supported by funds from the National Heart, Lung, and Blood Institute of the United States Public Health Service (USPHS), #RO1-HL-38844, and a grant from the Sugar Association.

Received January 1, 1997. Accepted April 1, 1998.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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