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Beverage Consumption Patterns in Elementary School Aged Children across a Two-Year Period

Human Performance Laboratory, University of Nebraska-Kearney, Kearney, Nebraska (J.W.B., D.J.J., J.E.D.)
Department of Sports Medicine, University of Southern Maine, Gorham, Maine (J.W.B.)
Center for Physical Activity and Weight Management, Schiefelbusch Life Span Institute, University of Kansas, Lawrence, Kansas (D.J.J., J.E.D.)

Address reprint requests to: Janet Whatley Blum, Sc.D., Department of Sports Medicine, 37 College Ave, University of Southern Maine, Gorham, ME 04038. E-mail: jwblum{at}usm.maine.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS CONCLUSION REFERENCES

 
Objective: Existing data was reexamined to determine changes in beverage consumption and associations between beverages consumed and BMI Z-score in children (n = 164) across two years.

Methods: Beverages (milk, 100% juice, diet soda or sugar sweetened) and total caloric intake were calculated from a 24-hour diet recall. Height and weight were measured to calculate BMI. Subjects were categorized by BMI Z-score as normal weight, overweight, gained weight and lost weight. Data was collected at baseline and year 2.

Results: Significant decreases in milk and increases in diet soda were found over two years in all subjects and normal weight, whereas overweight had a significant increase in diet soda consumption and a decrease in milk consumption that did not reach significance. Change in milk consumption was inversely correlated with sugar-sweetened beverage consumption. Increases in diet soda consumption were significantly greater for overweight and subjects who gained weight as compared to normal weight subjects. Baseline BMI Z-score and year 2 diet soda consumption predicted 83.1% of the variance in year 2 BMI Z-score.

Conclusion: Shifts in beverage consumption were found in this convenient sample across two years. Diet soda consumption was the only type of beverage associated with year 2 BMI Z-score, and consumption was greater in overweight subjects and subjects who gained weight as compared to normal weight subjects at two years. Additional longitudinal data examining associations between beverage consumption and BMI is needed in children and adolescents, as consumption of regular and diet soda has become more of a social norm.

Key words: body mass index, children, beverage consumption

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS CONCLUSION REFERENCES

 
Shifts in beverage consumption have been examined using national surveys such as the National Food Consumption Survey [1], National Health and Nutrition Examination Surveys [2] and the Continuing Survey of Food Intakes by Individuals (CSFII) [3]. There is clear evidence suggesting secular increases in soft drink consumption and decreases in milk consumption among US children and adolescents. A recent estimate by Yen and Ling [4] using CSFII 1994–1996 data suggests that for each ounce reduction in milk a concomitant increase of 4.2 ounces of soft drinks is found which also results in an increase in 31 calories. This type of shift in beverage consumption patterns has been shown to affect diet quality and total caloric intake in children and adolescents.

Studies have shown that soft drink consumption is associated with lower dietary intakes of vitamin A and C, calcium, magnesium and riboflavin in children and adolescents [3,5]. Increases in soft drinks and fruit drinks in the diet are also linked to an increase in caloric intake in children [6,7]. Harnack and colleagues [7] found that mean adjusted caloric intake was 1830 kcal/d for school aged children ages 6–12 who did not consume soft drinks compared with 2018 kcal/d for children of the same age who consumed an average of 9 oz/d or more of soft drinks. Troiano and colleagues [8] found that soft drinks contributed a significantly higher proportion (2%) of daily caloric intake for overweight than non-overweight children or adolescents.

Little data exist that examine the association between beverage consumption patterns and body mass index (BMI). Forshee and Storey [9] examined CSFI 1994–96, 98 data and found age, race and gender as the most significant predictors of BMI among children and adolescents aged 6–19 years. Weak positive relationships were found between diet soda consumption and increased BMI in both boys and girls whereas a weak negative relationship between milk consumption and BMI was found in girls only. Similarly, Nicklas and colleagues [11] reported that sweetened beverages specifically regular soda explained only 1% of the variance of BMI in children who participated in the Bogalusa Heart Study. Giammattei and colleagues [12] reported a positive association between diet soda consumption and/or regular soda consumption and BMI Z-score in a group of 6th and 7th grade students in a school based study. Finally, a recent Canadian study [13] showed a positive although weak relationship between sugar-sweetened beverage consumption and % body fat in a group of children and adolescents.

Ludwig and colleagues [14] reported the first longitudinal data that suggested sugar-sweetened beverage consumption was an independent risk factor for obesity in adolescents. The authors found the odds of becoming obese increased by 60% for each additional serving of a sugar-sweetened beverage consumed per day across a 19-month period whereas increased diet soda consumption was found to be negatively associated with incidence of obesity [14]. No description of beverage consumption patterns in adolescents who decreased their overweight status was reported. Nevertheless, to our knowledge no other longitudinal data exists that examines beverage consumption patterns and incidence of obesity in children or adolescents.

Thus, the aims of this study were to reexamine existing longitudinal data to 1) determine differences in beverage consumption from baseline to year 2 follow-up in all subjects and based on body mass index (BMI) Z-scores; 2) examine the relationship between change in milk consumption and change in sugar-sweetened beverage consumption; and, 3) identify predictors of BMI Z-score at year 2.

	METHODS

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Design
The study used data from a convenience sample of elementary school children in grades 3 through 6 who had participated in a previously described study [15,16]. The data were collected from the fall of 1992 to the spring of 1996. The total eligible sample size was approximately 830 children in grades 3 through 5. This longitudinal cohort consisted of only those subjects (n = 166) who were measured at baseline and again two years later. Subjects were mainly Caucasian (94%) and included 92 girls and 74 boys. The research protocol was approved by the University of Nebraska-Kearney Institutional Review Board. Subjects and parents signed informed assent/consent prior to any data collection.

Measures
Beverage Consumption.
A 24-hour diet recall was used to determine total caloric intake and beverage consumption at baseline and year two. Diet recalls represented intakes only on school days. The 24-hour diet recall procedure included interviewing the subject two times during the 24-hour period. The first interview occurred at noon following the lunch meal. Subjects were interviewed to obtain all foods eaten from the morning through the noon meal. To aid in the recall of the noon meal, a sample meal tray was available for reference. For those subjects that participated in the school breakfast program a sample meal tray was also available for reference. The second interview occurred the following morning prior to the start of school. Subjects were interviewed to obtain all foods eaten since the previous noon meal. In addition, three dimensional food models were used to aid in recall. For a random sub-sample of subjects, parents were called to verify foods and beverages consumed at home during the 24-hour recall period. Caloric intake was quantified using the Nutritionist IV diet analysis program (ESHA Research, Salem, OR). Reliability was established repeatedly between the research nutritionists that conducted the 24-hour recalls and the interclass coefficient was always greater than 0.95.

All beverages were reported in fluid ounces. Beverages were classified as milk (skim, 1%, 2%, whole, chocolate, milkshakes), 100% juice, diet soda and sugar sweetened drinks (regular soda, HI-C, sports drinks, kool-ade, fruit flavored drinks, ice tea, hot chocolate).

Body Mass Index Z Score.
Subjects were weighed to the nearest 0.1 kg and height was measured without shoes to the nearest 0.1 cm one time at baseline and year two. These values were used to compute age and gender specific Z scores of BMI using the EpiInfo Program (version 6.02, Centers for Disease Control and Prevention). Subjects were classified as overweight if the calculated age and gender specific BMI Z-score was 1.0 and classified as normal weight if the calculated age and gender specific BMI Z-score was < 1.0 [17].

Statistics.
Means and standard deviations (SD) were calculated for all variables. Two subjects had outlier values (greater than 2.5 standard deviations) on the change in BMI Z-score variable and were excluded from the analysis. Subjects were categorized into four groups based on BMI Z-score at baseline and year 2. The four groups were 1) normal weight, BMI Z-score of < 1.0 at both baseline and year 2 (n = 99); 2) overweight, BMI Z-score of 1.0 at both baseline and year 2 (n = 48); 3) gained weight, BMI Z-score of < 1.0 at baseline and a BMI Z-score of 1.0 at year 2 (n = 11), and; 4) lost weight, BMI Z- score of 1.0 at baseline and a BMI Z-score of < 1.0 at year 2 (n = 6).

No gender differences in consumption of any type of beverage at baseline, year 2, or change from baseline to year 2 were found using independent t-tests, thus results for changes in beverage consumption are presented for boys and girls combined. Paired t-tests were used to determine differences between baseline and year 2 for milk, 100% juice, diet soda, sugar-sweetened beverage consumption and total caloric intake in all subjects and each BMI Z-score group. Repeated measures ANOVA with least significance difference post hoc tests were used to determine differences among BMI Z-score groups for milk, 100% juice, diet soda, sugar-sweetened beverage consumption and total caloric intake from baseline to year 2. Pearson product movement correlation was used to determine the relationship between change in milk consumption and change in sugar-sweetened beverage consumption in all subjects and in BMI Z-score groups.

Regression analysis was used to determine predictors of the dependent variable BMI Z-score at year 2. The 1st block included in the regression model was BMI Z-score at baseline. The 2nd block of potential variables considered for inclusion were age, gender, and age by gender interaction variable (baseline age * gender, where gender was 1 = girls, 0 = boys). The 3rd block of potential variables considered for inclusion were baseline consumption of milk, 100% juice, diet soda, sugar sweetened beverages (oz/d) and total caloric intake. The 4th block of potential predictor variables considered for inclusion were year 2 consumption of milk, 100% juice, diet soda, sugar-sweetened beverages (oz/d) and total caloric intake. For each block, all predictor variables were entered together into the model. Type I error rate was p = 0.05 for all analysis and data analysis was completed using SPSS (v11.2, Chicago, IL.).

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS CONCLUSION REFERENCES

 
Table 1 shows the physical characteristics of all subjects, normal weight, overweight, gained weight and lost weight subjects at baseline and year 2. Approximately, 60% (n = 99) of subjects were normal weight, 29.3% (n = 48) of subjects were overweight, 6.7% (n = 11) of subjects gained weight and 3.7% (n = 6) of the subjects lost weight.

View this table: [in this window] [in a new window]   Table 2. Beverage Consumption (oz/d and %) and Total Caloric Intake (kcal/d) of All, Normal Weight, Overweight, Gained Weight and Lost Weight Subjects at Baseline, Year Two and Change from Baseline to Year 2 ()

Table 3 shows results of regression analysis to identify predictors of year 2 BMI Z-score. All references to R² uses the more conservative adjusted R square formula. Regression analysis indicated that baseline BMI Z-score and year 2 diet soda consumption accounted for 83.1% of the variance in year 2 BMI Z-score (model, R² = 0.83; p < 0.001). Higher baseline BMI Z-scores and greater consumption of diet soda consumption at year 2 were associated with a higher year 2 BMI Z-score.

	DISCUSSION

The longitudinal design of this study allowed us to further examine the patterns of beverage consumption based on BMI Z-score from baseline to year 2. Normal weight subjects (n = 99, 60%) decreased milk and total caloric intake while increasing diet soda consumption over the two-year period. Overweight subjects (n = 48, 29%) significantly increased diet soda consumption over the two-year period and showed the same magnitude of decrease in milk consumption as compared to all and normal weight subjects but was not statistically significant. Increases in diet soda consumption approached significance for subjects who gained weight (n = 11, 6.7%) while subjects who lost weight (n = 6, 3.7%) showed no changes in beverage consumption patterns across the two-year period. Differences in beverage consumption among subjects were found only for diet soda consumption. The overweight subjects and subjects who gained weight had significantly higher consumption of diet soda as compared to normal weight subjects at year 2.

Controversy exists in the literature and it is unclear if type of beverage consumption is a major factor influencing overweight status of children and adolescent. Recent cross-sectional studies suggest little to no relationship between type of beverages consumed and BMI in children and adolescents [9–14]. Specifically, cross-sectional studies show that sugar-sweetened and regular or diet soda is weakly associated with increased BMI of children and adolescents [9–14].

In contrast, the only longitudinal study to our knowledge reports an independent effect of sugar-sweetened beverages to predict change in BMI over a 19-month period with the odds of becoming overweight among 11 and 12 year olds increasing by approximately 60% for each additional serving of sugar-sweetened beverage per day [14]. Furthermore, a negative association between increased diet soda consumption and incidence of obesity was reported. Our results do not support the association between sugar-sweetened beverages and BMI nor find a negative relationship between diet soda consumption and BMI. However, several differences exist between our study and Ludwig and colleagues [14] such as age of subjects and diet intake methodology for assessing beverage consumption and may explain the differences in findings.

To our knowledge, this is the first longitudinal data in school aged children to report a positive association between diet soda consumption and BMI. Our results support the findings from two recent cross-sectional studies [9,12] that find a positive but weak relationship between diet soda consumption and BMI. Our results show that baseline BMI Z-score was the strongest predictor of the variance in year-two BMI Z-score and was expected whereas, diet soda consumption explained 3.5% of the variance in year-two BMI Z-score. Our results suggest that for each 12 oz serving of diet soda consumption per day you would predict a year-two BMI Z-score as being 0.156 higher than what you would predict based on baseline BMI Z-score. Although we did not find any gender differences in beverage consumption it should be noted that it was mainly girls who consumed diet soda. The mechanism for increased diet soda consumption and increased BMI is unclear. Making an assumption that overweight subjects or those gaining weight may have preferred [14] or switched [12] to diet soda because they wanted to avoid calories and thus further weight gain is speculative. However, it is interesting to note the change in total caloric intake among our BMI Z-score groups. That is, the subjects who lost weight showed an increase in total caloric intake whereas the subjects who gained weight and overweight subjects showed a decrease in total caloric intake from baseline to year 2. Although, underreporting by overweight subjects is well-known [19] these results may support an avoidance of calories by consuming diet soda for the overweight subjects and subjects who gained weight, but also indicates that other factors are involved in BMI Z-score change. Thus, a plausible explanation may be that as children and adolescents become more overweight they may tend to engage in more sedentary behaviors [10,12]. Sedentary behavior such as watching television has been associated with changes in food and beverage consumption [12,20]. Thus, as suggested by Giammattei and colleagues [12] an increase in diet soda consumption in our convenience sample of children may be reflective of behaviors such as decreased physical activity that are associated with weight gain.

Several study limitations need to be considered. First, these findings are observational from previously collected data in a small convenience sample of school-aged children. Our sample was mainly Caucasian and from one rural Midwestern state; thus, the generalizability of this study is limited. Second, our data were collected for only one school day and did not include weekend days. Third, our data were collected during the fall of 1992 through the spring of 1996 and thus limits comparisons to beverage consumption intake of children since 1996. However, to our knowledge limited longitudinal data exist that describe associations between beverage consumption and incidence of overweight in children and adolescents.

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS CONCLUSION REFERENCES

 
Our findings in a convenience sample of elementary school- aged children show a shift in type of beverage consumed with milk consumption decreasing and diet soda consumption increasing over a two-year period. In this sample, milk appears to be displaced by sugar-sweetened beverages. These findings support both longitudinal and cross-sectional data showing shifts in beverage consumption of children during the same time period of 1992–1996 [1–3,18]. Increased diet soda consumption was the only type of beverage associated with an increased BMI Z-score at year 2 for all subjects. All subjects significantly increased diet soda consumption from baseline to year 2 and both the overweight and subjects who gained weight had higher diet soda consumption as compared to the normal weight subjects at year 2. The small sample size, the young age group studied and the dietary intake methodology may have limited the power to predict associations between beverage consumption and BMI. The findings of this study however, indicate that additional longitudinal studies are needed to determine if type of beverage consumption are associated with increased BMI in children since consumption of both regular and diet soda have become more of a social norm since 1996.

Received November 4, 2003. Accepted May 7, 2003.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS CONCLUSION REFERENCES

 

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