“leNHNHNIMWW|H1||l|N|flH|W| r} LII;m ARY Michigan State University This is to certify that the thesis entitled ADDED SUGAR AND DIET QUALITY IN RURAL NATIVE AMERICAN AND NON-HISPANIC WHITE CHILDREN presented by STEPHANIE DEANNE BLISS has been accepted towards fulfillment of the requirements for the MASTER OF SCIENCE degree in EPIDEMIOLOGY (7 C, c - A6 Major Professor’s Signature 4/1/2/0 7— Date MSU is an Affirmative Action/Equal Opportunity Institution _ .4 _._ —.—.—A—.—.-o-.---o-u-u-o-u----o-o-o-u-s-o-~- PLACE IN RETURN BOX to remove this checkout from your record. To AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/07 p:/ClRC/DateDueindd-p.1 ADDED SUGAR AND DIET QUALITY IN RURAL NATIVE AMERICAN AND NON-HISPANIC WHITE CHILDREN By Stephanie Deanne Bliss A THESIS Submitted to Michigan State University In partial fulfillment of the requirements For the degree of Master of Science Department of Epidemiology 2007 ABSTRACT ADDED SUGAR AND DIET QUALITY IN RURAL NATIVE AMERICAN AND NON-HISPANIC WHITE CHILDREN By Stephanie Deanne Bliss Intake of added sugar in the American diet increased approximately 40 percent from 1950-59 to 2000 and children are increasingly becoming overweight. Added sugar intake may also negatively affect diet quality by replacing nutrient-dense foods. The Institute of Medicine recommends that intake of added sugar not exceed 25 percent of total energy intake, whereas, the World Health Organization recommends that intake not exceed 10 percent. In this study we examined the association between added sugar intake and diet quality among a representative sample of Native American and non-Hispanic white children aged 1-6 (n=329), living in rural Oklahoma. Nutritional data were collected by two 85-item food frequency questionnaire given in-person to caregivers of 1-3 and 4-6 year old children. Median intakes of foods and nutrients and percent meeting recommendations were calculated across categories of added sugar intake. Children who were older, male, not enrolled in Women Infants and Children, and white were more likely to be in the highest categories of added sugar intake. Intakes of all micronutrients except for iron, vitamins C and E, as well as dairy and grain food groups, significantly decreased as added sugar intake increased in both age groups (p<0.05). Meeting recommendations for nutrients, however, did not vary significantly across added sugar intake. In conclusion, increased intake of added sugar substantially negatively affected diet quality in this population of rural Native American and white 1-6 year old children. This project along with future work is in honor of my niece, April Michelle Sullivan, who taught me the true meaning of perseverance and to my grandfather, Earl Wesley Bliss, who taught me the importance of working hard. iii TABLE OF CONTENTS LIST OF TABLES .................................................................................... v LIST OF FIGURES ................................................................................... vii CHAPTER 1 * INTRODUCTION INCLUDING SPECIFIC AIMS ............................................. 1 CHAPTER 2 LITERATURE REVIEW SUMMARY ............................................................ 14 REVIEW TABLES .................................................................................... 16 Added Sugar and Nutrient Intake,.Food Group Servings, Diet Quality in Children Aged 1-6 ....................................................... 16 Sugar Sweetened beverages and Nutrient Intake, Food Group Servings, Diet Quality in Children Aged 1-6 ............................................. 23 Added Sugar and Weight in Children Aged 1-6 ....................................... 27 Nutrient Intake, Food Group Servings and Diet Quality in Young Low-Income, Native Americans Living in Rural America ............................................ 30 CHAPTER 3 RESULTS ............................................................................................ 35 CHAPTER 4 CONCLUSIONS/PUBLIC HEALTH IMPLICATIONS ...................................... 60 APPENDICES ....................................................................................... 64 iv LIST OF TABLES Chapter 1 Table 1. Definitions of Dietary Reference Intakes ...................................... 5 Chapter 2 Table 2.1 Added Sugar and Nutrient Intake, Food Group Servings, Diet Quality in Children Aged 1-6 ......................................................... 16 Table 2.2 Sugar Sweetened beverages and Nutrient Intake, Food Group Servings, Diet Quality in Children Aged 1-6 ............................................. 23 Table 2.3 Added Sugar and Weight in Children Aged 1-6... 27 Table 2.4 Nutrient Intake, Food Group Servings and Diet Quality in Young, Low-Income, Native Americans Living in Rural America .................. 30 Chapter 3 Table 3.1 Selected Characteristics of the Study Population of Rural Native American and Non-Hispanic White Children, 1-6 years, OK 1997 (n=329) ...... 50 Table 3.2 Median Intakes of Beverage Groups that Are Contributors To Total Added Sugar By Age Group (a=1-3 year olds, b=4-6 year olds)of Study Population of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar, OK 1997 (N=329) .................................... 51 Table 3.3 Sociodemographic and Health Behavior Characteristics of Rural Native American and Non-Hispanic White Children,1-6 Years, Within Each Category of Added Sugar, OK 1997 (n=329) .......................................... 52 Table 3.4 Median Intakes of Nutrients of Study Population of Rural Native American and Non-Hispanic White Children, 1-6 Years, Within Each Category of Added Sugar, OK 1997 (N=329) ......................................................... 53 Table 3.5 Median Intakes of Servings of Food Guide Pyramid Food Groups of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar, OK 1997(2-6 year olds only n=276) ................................ 54 Table 3.6 Percent of Study Population of Rural Native American and Non- Hispanic White Children, 1-6 years, Meeting the DRIs for Nutrients Within Each Category of Added Sugar, OK 1997 (N=329) .......................................... 55 Table 3.7 Percent of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar Meeting The Recommended Servings of the Food Guide Pyramid for Young Children, OK 1997 (2-6 year olds only n=276) ....................................................................................... 56 Appendices . Table 3.4.1 P-values for Median Intakes of Nutrients of Study Population of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar by Race/Ethnicity, OK 1997, (N=329) ................................................... 65 Table 3.4.2 P-values for Median Intakes of Nutrients of Study Population of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar by Gender, OK 1997, (N=329) ............................................................ 66 Table 3.5.1 P-values for Median Intakes of Servings of Food Guide Pyramid Food Groups of Rural Native American and Non-Hispanic White Children, 2-6 Years Olds, Within Each Category of Added Sugar by Race/Ethnicity, OK 1997 (n=276) ............. 67 Table 3.5.2 P-Values for Median Intakes of Servings of Food Guide Pyramid Food Groups of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar by Gender, OK 1997, n=276 ....................................... 68 vi LIST OF FIGURES Chapter 1 Figure 1. Contributors of added sugars to Americans diet ................................. 2 vii CHAPTER 1 INTRODUCTION Based on food supply data, intake of added sugar increased 39% from 1950-59 to 2000 to an estimate of 149 pounds per year for each American (1). Intake of added sugar reached a peak in 1999 and has since slightly decreased (1). Even with the slight decrease the 2000 average of 32 teaspoons of added sugar intake per day is still greatly above the United States Departments of Agriculture (USDA) recommendation of 8 teaspoons per day (approximately 6% of total energy) for a 2,000 calorie diet (1, 2). Using national data, intakes of added sugar were reported (Guthrie 2000) at 15.2 teaspoons (15.9% of total energy) per day for children aged 2-5 years and 22.5 teaspoons (18.6% of total energy) per day in adolescence aged 6-11 years living in United States (3). These estimates were consistent with another study using national data published in 2005 that reported children aged 2-3 years consumed an average of 13.5 teaspoons (14.9% of total energy) per day and children aged 4-5 years consumed 17.2 teaspoons (16.5% of total energy) per day (4). Both studies report an intake of added sugar in children at nearly twice the amount that is recommended by the USDA. More specific literature review information regarding added sugar intake is available in chapter 2 of this thesis (see chapter 2, sections 1-4). The term added sugar was developed by the USDA and refers to sugar that does not naturally occur in foods such as fruit or milk; it is sugar that is used for processing and preparing food and that is added to foods directly before consuming (2). A few names of added sugar that are found in the food supply include: white sugar, brown sugar, corn syrup, dextrose, glucose, honey, high fructose corn syrup, molasses, raw sugar. It is found in many items such as breads, milk products, soft drinks, candy and ice cream (1). Data from the United States Department of Agriculture (USDA) 1994-96 Continuing Surveys of Food Intakes by Individuals (CSFII) found that the top contributor of added sugar in all Americans is soft drinks (33%) followed by sugars and candy (16%), other major contributors are depicted below (3). In children aged 2-5 years sugars/sweets (20.9%) was the top contributor followed by soft drinks (14.6%) in adolescences aged 6-1 1 years sofi drinks was the number one contributor at 21.9% of total added sugar (3). I Regular soft rinks I Sugars and candy El Cakes, cookies, pies El Frult drinks I Dairy desserts 8. milk products Other grains Figure 1. Contributors of added sugar to the diets of all Americans using national data (Guthrie and Morton 2000). The key to the pie chart starts with regular soft drinks as the largest section then follows clockwise going down the list. Potential Consequences of A dded Sugar Intake According to the 2005 Dietary Guidelines Advisory Committee Report, people with a high intake of added sugar consume more calories and less nutrients than people with a low intake of added sugar (2). The report also states that sugar-sweetened beverage are associated with weight gain.. The increased intake of added sugar in children living in the United States is concurrent with the dramatic rise in childhood obesity and type 2 diabetes (5,6). Among children aged 2-5 years the prevalence of overweight (defined as at or above the 95th percentile of body mass index for age and gender) was 5.0% in 1971-74 and has increased to 13.9% in 2003-2004 (6,7). The prevalence of overweight for children aged 6-11 years has increased fiom 4% to 18.8% (6,7). In addition, the prevalence of persons at-risk of overweight (defined as at or above the 85th percentile and less than the 95th percentile for age and gender) aged 2—19 years was 33.6 in 2003-04, children aged 2-5 years was 26.2 and for 6-11 years 37.2 (5). Even though a direct association between total added sugar intake and weight status in young children is still lacking it is important to investigate this possibility. Moreover, Native American children have been shown to be more likely than all US children combined to be overweight and at-risk of overweight (8). Another concern is the increase in Type 2 diabetes among young children with Native Americans experiencing a disproportionate number of cases (6,9). Recommendations and Guidelines To monitor intakes of nutrients and food groups as well as to promote a healthy diet, recommendations and guidelines have been developed by organizations such as the Institute of Medicine (10M) and the USDA, in the US and by the World Health Organization, internationally. The USDA Food Guide MyPyrarnid (10) and the Institute of Medicine (IOM) Dietary Reference Intakes (DRIs) are current recommendations used in the United States (11). Due to increases in added sugar intake and overweight/obesity recommendations for sugar and added sugar have been debated (12). Scientists argue that since the body cannot distinguish between the two sugars a specific recommendation for added sugar may be misleading (13). However, according to the Dietary Guidelines for Americans 2005 foods high in added sugar should be limited because usually they lack nutrients whereas foods such as fruit and milk that contain naturally occurring sugar provide many nutrients (2, 13). Research has noted that consuming foods high in added sugar and calories replace more nutrient dense foods in the diet, thus causing a nutrient dilution effect (14). Another argument for distinguishing between sugar and added sugar is that added sugar is in many processed and ready to eat foods and consumers may not be aware of how much they are consuming. Furthermore, a group of health experts petitioned the FDA in 1999 to include information on food labels regarding total added sugars (15). The group also wanted the FDA to provide consumers with a guide similar to that of the USDA’s Food Guide for added sugar. DRIs & Added Sugar Dietary Reference Intakes were more recently developed by the Institute of Medicine (IOM). They are a modified version of the Recommended Dietary Allowance (RDA) developed by the Food and Nutrition Board of the National Academy of Sciences/National Research Council in 1941 (I l). DRIs consist of four values that may be used for assessing nutrient intake adequacy in individuals and groups (Table l). The Estimated Average Requirement (EAR) and Adequate Intake (A1) are used to measure adequacy in groups, RDA is used to measure individual intake and the Tolerable Upper Intake Level (UL) is the highest average nutrient intake level that will not cause harm to an individual. The official definitions are noted below. Table 1. Definitions of Dietary Reference Intakes "‘ Estimated Average Intake The average daily nutn'ent intake level estimated to meet (EAR) the requirement of half the healthy individuals in a particular life stage and gender group. Recommended Dietary The average daily nutrient intake level sufficient to meet Allowance (RDA) the nutrient requirement of nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group. Adequate Intake (A1) A recommended average daily nutrient intake level based on observed or experimentally determined approximation or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate-used when an RDA cannot be determined. Tolerable Upper Intake The highest average daily nutrient intake level likely to Level (UL) pose no risk of adverse health effects to almost all individuals in the general population. As intake increases above the UL, the potential risk of adverse effects increases. *These definitions were taken directly from the Institute of Medicine (National Academy Press; 2000 (11) In 2002 the IOM released the Dietary Reference Intakes for macronutrients including a recommendation for added sugar. The recommendation states that the daily intake of added sugar should not exceed 25% of total energy because of potential adverse health effect such as dental caries, obesity and inadequate intakes of nutrients. However, a tolerable upper intake level (UL) for added sugar was not set (16). This recommendation came shortly afier a request by The Dietary Guidelines Advisory Committee (DGAC) for more research to be conducted on the potential adverse health effects of intakes of sugar and added sugar (17). Other groups such as The World Health Organization (WHO) (18) and the USDA Food Guide MyPyramid (10) have recommended limits much lower than the IOM recommendation, <10% of total energy and between 6-10% of total energy, respectively. The American Heart Association Dietary Guidelines recommends reducing intake of added sugar (12). Food Group Servings The Food group servings defined by the USDA have changed slightly over the past ten years. MyPyramid formerly known as The Food Guide Pyramid is a tool used to promote healthy eating (www.MyPra_mid.gg\_r ). The six food categories and the suggested servings for the MyPyramid are: Grains (6 ounces), Vegetable (2 1/2 cups), Fruit (2 cups), Milk (2 cups for children aged 2-8 years), Meat and beans (5 V2 ounces), and Oils (3-7 teaspoons depending on age and gender) (10). However, since this is a secondary data analysis and the data was collected in 1997 the study collaborators used the Food Guide Pyramid for Young Children. The suggest servings for five main food groups are slightly different, and are as follows: Grains (6 servings i.e. one serving equals 1 slice of bread or 1/2 cup of rice), Vegetable (3 servings i.e. one serving equals V2 cup raw or cooked), Fruit (2 servings i.e. one serving equals 1 piece of fruit or 3A cup of juice), Milk (2 servings i.e. one serving equals 1 cup milk or 2 ounces of cheese), and Meat (2 servings i.e. one serving equals 2 to 3 ounces of cooked meat or 1/2 cup of dry beans)(10). Brief Summary of Literature Added Sugar and Nutrient Intake, Food Group Servings, Diet Quality Recent data has suggested an association of added sugar and nutrient intake in children living in Australia, Germany, Great Britain, Norway and the United States (4,19- 25). Mean intake of added sugars as percent of total energy of children aged 2-18 years range from 12.4% to 18.4% (4, 21, 22, 24). The range for children less than 18 years old living in the United States is 5.6% to 26.7% (4, 13, 21, 24). Significant decreases in intakes of calcium, fiber, folate, iron, and vitamin A were found as total added sugar intake increased (4, 20, 21). Food groups such as vegetables and fruits showed a significant decrease with increasing intakes of total added sugar (4, 20, 21, 23). When reporting total added sugar and nutrient intake for children, six out of seven articles reviewed for this thesis reported that the category with the highest added sugar intake had the lowest intake of all micronutrients, except for vitamin C (4, 20-23, 25). Sugar Sweetened Beverages and Nutrient Intake, Food Group Servings, Diet Quality According to Morton and Guthrie using national data, the consumption of soft drink (including carbonated water and carbonated juice drinks) increased from 198 grams in 1998-91 to 279 grams in 1994-95 (26). Many studies have examined the association between beverages and nutrient intake due to the dramatic increase in consumption of non-diet soft drinks (27-31). Of five studies that investigated the affect of beverage consumption on nutrient intake in children four showed a negative association between non-diet soft drinks and calcium (28-30). Two studies that examined the association between adequacy of nutrients or diet quality and sugar-sweetened beverages found a negative association (28, 30). Added Sugar and Weight Little research has been reported on added sugar intake and weight in young children. However, reports on sugar-sweetened beverages and weight in children (aged 1-6 years) has not shown consistent results (32-34). Two prospective cohort studies that examined children found associations between small changes in BMI and sugar- sweetened beverages (33,34). A 2006 literature review that examined 30 publications found that epidemiologic evidence does indicate an association between sugar-sweetened beverages and weight gain/obesity (32). More specifically, soda was shown in the promotion of overweight and weight gain in children and adolescents (3 2). Nutrient Intake, Food Group Servings and Diet Quality in Young, Low-Income, Native Americans Living in Rural America The increasing intakes of added sugar in children living in the United States coincide with reports of inadequate intakes of important nutrients and food groups among low-income and minority populations (35 -3 7). Calcium is an important nutrient for growth especially in children and has been reported to be below recommended levels (26,27). Knol et a1. examined dietary patterns of children from low-income families living in the United States and concluded that out of 2,748 children aged 2-8 years not one child had a dietary pattern that followed a balanced diet as recommended by the USDA Food Guide Pyramid (F GP) (35). Munoz et al. reported that of a representative sample of 3,307 youth aged 2-19, years only 1% met the recommendations of the F GP (34). In addition, among the 2-11 year olds meeting recommendations for vegetable and fruit intake ranged fi'om 17.8% to 35.4% (37). Specific Aims Most studies that have reported on diet/diet quality involving children use national data and very few studies report on low-income, rural, or Native American children. Meanwhile these populations experience a disproportionately higher prevalence of overweight and many diseases (5, 9). To my knowledge, no study has yet examined the intake of total added sugar and nutrient and food group servings among Native American children. The purpose of this study is to examine the potential association of total added sugar on diet quality (defined in this study as meeting recommendations) and health behaviors (median intake of nutrients, food groups, and beverages, Blvfl-for-age, and hours played outside) of Native American and non-Hispanic white children from low- income families living in rural United States. The specific aims of this study are the following: Aim 1) To examine the association between sociodemographic and health behavior characteristics with added sugar intake as percent of total energy among Native American and non-Hispanic white children aged 1-6 in rural Oklahoma. Given differences in added sugar recommendations between IOM (525% of total energy) and WHO (<10% of total energy) we will categorize the data into 4 groups (<10%, 10-<16%, 16-525%, >25%). Aim 2) To examine the potential association between intake of added sugar and measures of diet quality among Native American and non-Hispanic white children aged 1-6 in rural Oklahoma. We will report median intake as well as the percent of children meeting the DRIs for macronutrients (carbohydrate, protein, fat and fiber), micronutrients (calcitun, iron, folate, zinc, vit. A, vit BI, vit B6, vit C, and vit E) and food groups (grains, meat, vegetable, fruit and dairy) within each category of added sugar. This introduction (chapter 1) is followed by a literature review (brief summary followed by literature review summary tables) (chapter 2), manuscript for publication (chapter 3), conclusions/public health implications (chapter 4) and appendices. Some of the information may be repeated due to chapter 3 (manuscript). 10 References 1. 10. 11. 12. 13. United States Department of Agriculture. Agriculture Fact Book 2001-2002. Chapter 2. Assessed online at http://www.usda.gov/factbook/chapter2.htrn. Department of Health & Human Services: 2005 Dietary Guidelines Advisory Committee Report, website: http://www.healtheirus.go_v/dietary&idelines/ . Guthrie IF, & Morton IF. Food Sources of added sweeteners in the diets of Americans. I Am Diet Assoc 2000; 100:43-48. Kranz S, Smiciklas-Wright H, Siega-Riz A, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr 2005; 146:105-11. . Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obestiy in the United States, 1999-2004. JAMA 2006; 295: 1549-55. http://www.cdc.go_v/. Centers for Disease Control website. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002; 288: 1 728-1732. . Zephier E, Himes JH, Story M, Zhou X. Increasing prevalences of overweight and obesity in northern plains American Indian children. Arch Pediatr Adolesc Med 2006; 106:34-39. Lee ET, Begum M, Wang W, Blackett PR, Blevins KS, Stoddart M, Tolbert B, Alaupovic P. Type 2 Diabetes and impaired fasting glucose in American Indians aged 5-40 years: The Cherokee Diabetes Study. Ann Epidemi012004; 14:696- 704. http://www.usdagov/cnpp/KidsPyra. United States Department of Agriculture’s MyPramid. Assessed in September 2006. Institute of Medicine of the National Academy of Sciences. Dietary Reference Intakes, Applications in dietary assessment. National Academy Press; 2000. Murphy SP, Johnson RK. The scientific basis of recent US guidance on sugars intake. Am J Clin Nutr 2003; 78(suppl):827S-33S. Bowman SA. Diets of individuals based on energy intakes from added sugars. Family Economics and Nutrition Review 1999; 12, 2: 31-8. 11 14. Charlton KE, Boume LT, Steyn K, Laubscher JA. Poor nutritional status in older black South Africans. Asia Pacific Journal of Clinical Nutrition 2001; 10 (l):31- 8. 15. Putnam J. US. Food Supply Providing More Food and Calories. Food Review 1999; 22:2-12. 16. Institute of Medicine of the National Academy of Sciences. Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Report. Washington, DC: National Academy Press; 2002. 17. US. Department of Health & Human Services: The Report on the Dietary Guidelines Committee on Dietary Guidelines for Americans. Report. 2000. 18. World Health Organization/Food and Agriculture Organization of the United Nations Expert Consultation. Diet, nutrition, and the prevention of chronic diseases. Technical Support Series 916. Geneva, Switzerland: World Health Organization; 2003. 19. Frary CD, Johnson RK, Wang MQ. Children and Adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. Journal of Adolescent Health 2004; 34:56-63 20. Alexy U, Sichert-Hellert W, Kersting M. Associations between intake of added sugars and intakes of nutrients and food groups in the diets of German children and adolescents. British Journal of Nutrition 2003; 90:441-447. 21. Overby NC, Lillegaard IT, Johansson L, Anderson LF. High intake of added sugar among Norwegian children and adolescents. Public Health Nutrition 2003; 7(2):285-293. 22. Somerset SM. Refined sugar intake in Australian children. Public Health Nutrition 2003; 6(8), 809-813. 23. F orshee RA, Storey ML. The role of added sugars in the diet quality of children and adolescents. Journal of the American College of Nutrition 2001; 20 (l):32- 43. 24. Farris RP, Nicklas TA, Myers L, Berenson GS. Nutrient intake and food group consumption of 10-year-olds by sugar intake level: The Bogalusa Heart Study. Journal of the American College of Nutrition 1998; 17 (6):579-585. 25. Gibson SA. Do diets high in sugars compromise micronutrient intakes? Journal of Human Nutrition and Dietetics 1997; 10:125-133. 12 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. Morton JF, Guthrie J F. Changes in children’s total fat intakes and their food group sources of fat, 1998-91 versus 1994-95: Implications for diet quality. Family Economics and Nutrition Review 1998; 11 (3):44-57. F orshee RA, Anderson PA, Storely ML. Changes in calcium intake and association with beverage consumption and demographics: comparing data from CSFII 1994-1996, 1998 and NHANES 1999-2002. Journal of the American College of Nutrition 2006; 25 (2):]08-116. Marshall TA, Gilmore JM, Broffitt B, Stumbo PJ, Levy SM. Diet quality in young children is influenced by beverage consumption. Journal of the American College of Nutrition 2005; 24 (1):65-75. Rodriguz-Artalejo F, Garcia EL, Gorgojo L, Carces C, Royo MA, Moreno MM, Banavente M, Macias A, Oya M. Consumption of bakery products, sweetened soft drinks and yogurt among children aged 6-7 years: association with nutrient intake and overall diet quality. British Journal of Nutrition 2003; 89:419-428. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med 2000; 154:1148-1152. Hamack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc 1999; 99:436-441. Malik VS, Schulze MB, Hu F B. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006; 84:274-88. Berkey CS, Rockett HR, Field AE, Gilhnan MW, Colditz GA. Sugar-added beverages and adolescent weight change. Obestiy Research 2004; 12 (5):778- 788. Ludwig DS, Peterson KE, Gortrnaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001; 357:505-08. Knol LL, Haughton B, F itzhugh EC. Dietary patterns of young, low-income US children. Journal of the American Dietetic Association 2005; 105:1765-73. Brady LM, Lindquist CH, Herd SL, Goran MI. Comparison of children’s dietary intake patterns with US dietary guidelines. British Journal of Nutrition 2000; 84:361-67. Munoz KA Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and adolescents compared with recommendations. Pediatrics 1997; 100:323-329. 13 CHAPTER 2 BACKGROUND & LITERATURE REVIEW Relevant articles that examined the relationship between added sugar intake, nutrient intake and food group servings in children were identified for this literature review. Using Medline, the following key words and phrases were used to obtain articles: “added sugars and children,” “added sugars and CSFII,” “added sugars and NHANES,” “added sugar and diet quality,” “sweetened beverages and children,” “soft drinks and children,” “DRI and children,” “sweetened beverages and weight,” “diet quality and children,” “nutrients and children,” and “Food Guide Pyramid and children.” Additional articles were found by cross-checking the references of key articles. Inclusion criteria were: published in English, published between 1990 and 2006, the study population had to be of children, exposure variable of “added” sugar (defined as sugars not naturally occurring in foods) and meeting nutrient or food group recommendations. In addition to the main exposure (added sugar) and outcome (diet quality), I also used the key words: sugar sweetened beverages and weight. Most identified articles were based on data fiom United States national data (Continuing Survey of Food Intake in Individuals (CSFII) or The National Health and Nutrition Examination Survey, (NHANES), use only two days of diet data which may not be accurate, are cross-sectional in design and include a wide range of children’s ages. Few articles report nutrient intake, food group servings or diet quality in low-income, rural and Native American children. 14 In total I identified twenty-three articles that examined the association between added sugar and nutrient or food group intake, diet quality and weight in children. Twenty-one of these studies are cross-sectional and four are cohorts. This literature review is divided into four sections, articles may be used in more than one section: 1. Association of added sugar in children (ages 1-6 years) with nutrient intake, food servings and diet quality (8 articles) 11. Association of sweetened beverage consumption in children (ages 1-6 years) with nutrient intake, food servings and diet quality (5 articles) 111. Association of sweetened beverage/added sugar with weight in children (ages 1-6 years) (6 articles, 2 are reviewed in another section also) IV. Nutrient intake/food servings/diet quality in rural, low-income and/or Native American in children (ages 1-6 years) (6 articles). 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Kranz S, Smiciklas-Wright H, Siega-Riz A, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr 2005; 146:105- 11. 2. Frary CD, Johnson RK, Wang MQ. Children and Adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. Journal of Adolescent Health 2004; 34:56-63. 3. Alexy U, SicheIt-Hellert W, Kersting M. Associations between intake of added sugars and intakes of nutrients and food groups in the diets of German children and adolescents. British Journal of Nutrition 2003; 90:441-447. 4. Overby NC, Lillegaard IT, Johansson L, Anderson LF. High intake of added sugar among Norwegian children and adolescents. Public Health Nutrition 2003; 7(2):285-293. 5. Forshee RA, Storey ML. The role of added sugars in the diet quality of children and adolescents. Journal of the American College of Nutrition 2001; 20 (l):32-43. 6. Bowman, SA. Diets of individuals based on energy intakes from added sugars. Family Economics and Nutrition Review 1999; 12, 2: 31-8 7. Farris RP, Nicklas TA, Myers L, Berenson GS. Nutrient intake and food group consumption of lO-year-olds by sugar intake level: The Bogalusa Heart Study. Journal of the American College of Nutrition 1998; 17 (6):579-585. 8. Gibson SA. Do diets high in sugars compromise micronutrient intakes? Journal of Human Nutrition and Dietetics 1997; 10:125-133. 9. F orshee RA, Anderson PA, Storely ML. Changes in calcium intake and association with beverage consumption and demographics: comparing data from CSFII 1994-1996, 1998 and NHANES 1999-2002. Journal of the American College of Nutrition 2006; 25 (2): 108-1 16. 10. Marshall TA, Gilmore JM, Broffitt B, Stumbo PJ, Levy SM. Diet quality in young children is influenced by beverage consumption. Journal of the American College of Nutrition 2005; 24 (l):65-75. 11. Rodriquez-Artalejo F, Garcia EL, Gorgojo L, Carces C, Royo MA, Moreno MM, Banavente M, Macias A, Oya M. Consumption of bakery products, sweetened soft drinks and yogurt among children aged 6-7 years: association with nutrient intake and overall diet quality. British Journal of Nutrition 2003; 89:419-428. 33 12. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med 2000; 154:1148-1152. 13. Hamack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc 1999; 99:436-441. 14. O’Connor TM, Yang S, Nicklas TA. Beverage intake among preschool children and its effect of weight status. Pediatrics 2006; 118 (4):]010-1018. 15. Welsh JA, Cogswell ME, Rogers S, Rockett H, Met Z, Grummer-Strawn LM. Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999-2002. Pediatrics 2005; 115:223-229. 16. Newby PK, Peterson KE, Berkey CS, Leppert J, Willett WC, Colditz GA. Beverage consumption is not associated with changes in weight and body mass index among low- income preschool children in North Dakota. Journal of The American Dietetic Association 2004; 104: 1086-1094. 17. Forshee RA, Storey ML. Total beverage consumption and beverage choices among children and adolescents. International Journal of Food Sciences and Nutrition 2003;54:297-307. 18. Knol LL, Haughton B, Fitzhugh EC. Dietary patterns of young, low-income US children. Journal of the American Dietetic Association 2005; 105:1765-73. 19. Stroehla BC, Malcoe LH, Velie EM. Dietary sources of nutrient among rural Native American and white children. Journal of the American Dietetic Association 2005; 105:1908-16. 20. Champagne CM, Bogle ML, McGee BB, Yadrick K, Allen R, Kramer TR, Simpson P, Gossett J, Weber J. Dietary intake in the lower Mississippi Delta region: results from the foods of our delta study. Journal of the American Dietetic Association 2004; 104:199-207. 21 . Kranz S, Siega—Riz AM, Herring AH. Changes in diet quality of American preschoolers between 1977 and 1998. Am J Public Health 2004;94:1524-30. 22. Brady LM, Lindquist CH, Herd SL, Goran Ml. Comparison of children’s dietary intake patterns with US dietary guidelines. British Journal of Nutrition 2000; 84:361-67. 23. Munoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and adolescents compared with recommendations. Pediatrics 1997; 100:323-329. 34 CHAPTER 3 MANUSCRIPT Introduction Based on food supply data intake of added sugar increased 39% from 1950-59 to 2000 to an estimate of 149 pounds per year for each American (1). Intake of added sugar reached a peak in 1999 and has since slightly decreased. Even with this slight decrease the 2000 average of 32 teaspoons of added sugar intake per day is still greatly above the United States Departments of Agriculture (USDA) recommendation of 8 teaspoons per day (approximately 6% of total energy) for a 2,000 calorie diet (1,2). Using national data intakes of added sugar were reported (Guthrie 2000) at 15.2 teaspoons (15.9% of total energy) per day for children aged 2-5 years and 22.5 teaspoons (18.6% of total energy) per day in adolescence aged 6-11 years living in United States (3). These estimates were consistent with another study using national data published in 2005 that reported children aged 2-3 years consumed an average of 13.5 teaspoons (14.9% of total energy) per day and children aged 4-5 years consumed 17.2 teaspoons (16.5% of total energy) per day (4). Both studies report an intake of added sugar in children at nearly twice the amount that is recommended by the USDA. Added sugar intake has also been associated with inadequate intakes of important nutrients and food groups among children (4-7). “Added sugar” refers to sugar that does not naturally occur in foods, such as fruit or milk; it is sugar used for processing and preparing food and sugar added to foods at the table (8). Added sugar includes white sugar, brown sugar, cane sugar, corn syrup, honey, 35 high fructose corn syrup and is found in items such as soft drinks, candy, ice cream, and syrup. The top contributors of added sugar to children’s diet have been found to be soft drinks, fi'uit drinks and desserts (2, 4). Data from the United States Department of Agriculture (USDA) 1994-96 Continuing Surveys of Food Intakes by Individuals (CSFII) demonstrate that consumption of soft drinks was the number one contributor to total added sugar intake in children aged 2-5 years at 14.6% and 21.9% of total added sugar in children aged 6-11 years (2). Multiple studies have shown that added sugar intake and consumption of sweetened beverages, are associated with inadequate micronutrient intake and diet quality in children (4, 5, 9-12). Using national data Kranz et al. reported that for most micronutrients mean intake significantly decreased as added sugar consumption increased in American children aged 2-5 years. This was also true of the fruit and dairy food groups (4). Results similar to the above study were found in children living in Germany, Australia, Great Britain and Norway (6, 7,13,14). Similar negative associations between soft drinks and most micronutrients, fi'uits, vegetables and dairy have been observed with increased intake of soft drinks (9-12). To monitor intakes of nutrients and food groups of children in the United States researchers, nutritionists and public health officials depend on guidelines developed by the USDA Food Guide Pyramid for young children (15) and the Institute of Medicine (IOM) Dietary Reference Intakes (DRIs) (16). In 2002 the IOM released DRIs for macronutrients, where the recommendation for added sugar is for intake to not exceed 25% of total energy, and a tolerable upper intake level (UL) for sugars was not set (16). This recommendation was developed in response to a request by The Dietary Guidelines 36 Advisory Committee (DGAC) for more research to be conducted on the potential adverse health effects on intakes of sugar and added sugar (17). The World Health Organization (WHO) (18) and the USDA Food Guide Pyramid (19) have recommended limits much lower than the DRI, <10% of total energy and between 6-10% of total energy, respectively. The 2000 American Heart Association Dietary Guidelines recommended avoiding foods that contain a lot of sugar; no limit was set (19). Recommendations were made due to possible adverse health effects of a high consumption of added sugar such as increased incidence of obesity and dental caries, inadequate intakes of calcium, hit and vegetables (16, 18). Due to the established association between childhood nutrition and adverse health outcomes in both childhood and adulthood (20) the DR] currently set for added sugar needs to be evaluated. In addition, most data reported on nutrient intake, food group servings and diet quality involving children use national data, very few studies report on low-income, rural, or Native American children who experience disproportionately higher prevalence’s of overweight and diseases (23, 24). Further, to our knowledge no study has yet examined the intake of added sugar on nutrient and food group servings in Native American children. The purpose of this research is to examine the association of increasing intake of added sugar on medium intakes of nutrient and food group servings as well as diet quality (defined as meeting recommendations for DRIs and food group servings) among Native American and non-Hispanic white children. Methods 37 Stuabr population Data were collected in 1997 as part of a community-based lead intervention study conducted in northeastern rural Oklahoma (25). The data are from a representative cross- sectional sample of Native American and non-Hispanic white caregivers of children aged 1 to 6 years that were living in Miami, OK. Families were eligible for the study if they had a white or Native American child aged 1-6 years and lived in one of the 31 census block groups that were part of the study area. To recruit the desired number of Native American families, researchers tried a variety of tactics including attending tribally—sponsored events and visiting tribal housing. Teams visited 5,572 residences and identified 550 eligible families. Out of 550 families 137 refirsed to participate, 77 families could not be interviewed, and 5 did not give complete information, leaving 331 families, of which one child was randomly selected per family for a response rate of 60.2%. Of the final sample that agreed to participate, 43.5% were Native American (n=144) and 56.5% were non-Hispanic white (n=187). Two children were considered ineligible for from these nutritional analyses because one child ate exclusively baby food and another had Phenylketonuria and were excluded from analyses. The final sample size for this study included 329 children aged 1-6. The research protocol was approved by the University of Oklahoma Health Sciences Center Institutional Review Board, and for this analysis the Institutional Review Board at Michigan State University. Nutritional Data An extensive questionnaire to assess sociodemographic, physical activity, height, weight and diet was administered in-person at the child’s home by trained interviewers. 38 To determine average daily dietary intake, an 85-item modified Block/NCI Food Frequency Questionnaire (FFQ) was administered to caregivers of study children. The questionnaire collected information on the child’s “usual” intake of food in the month prior to the interview as the time We The FFQ was modified to include certain foods and exclude others (not on the original Block/NCI) after consultation with key study informants and dieticians from the local population concerning dietary habits of these rural children. An open-ended section was also included in the questionnaire so that the caregivers could add any foods that were not listed. Specific brand names of breakfast cereals consumed were also recorded. To assess portion-size, two questionnaires were developed: one for the 1 and 2-year-old children and another for the 3 to 6 year-old children. For each food item, small, medium, large, and extra-large portions were developed. These portion sizes were estimated fi'om existing national data as well as information collected from local key informants including local dieticians. Added Sugar Intake Information on each food items added sugar content was added to the FF Q software DIET SYS nutritional database by a study investigator (Berrit Stroehla). Values were estimated by the software “THE FOODPROCESSER” ( http://www.esha.com/ ) to come up with the added sugar content of each food (grams per day). Primary contributors to ‘added sugar intake’ included items such as non-diet soft drinks, Kool- Aid, candy, sweetened fruit drinks, cakes and cookies. For these analyses, to standardize on total energy intake, added sugar intake was examined as percent of energy fiom added sugar, calculated by taking the total gram intake, multiplied by four to obtain energy intake (26). This quotient was then divided by total calories and multiplied by 100. 39 Percent of energy fi'om added sugar intake was categorized as follows: <10%, lO-<16%, 16-525%, >25%. These categories were chosen to reflect the recommendations made by the WHO (World Health Organization; 2003) and the IOM (National Academy Press; 2002) Variables We examined the median intakes of each nutrient from foods within each category of percent of energy fi'om added sugar, vitamin supplement intake was not examined. Next, we examined the median intake of food group servings from the USDA Food Guide Pyramid for Young Children. (http://www.us®gov/cnpp/KidsPyra) within each category of percent of energy from added sugar. To determine diet quality we looked at the percent meeting the recommendations for the following nutrients and food group servings. For iron, folate, zinc, magnesium, vitamin A, vitamin B6, vitamin C and vitamin B we used the Estimated Average Requirements (EAR) cut-point method (16). Simply, the EAR cut-point method is the percent of the population that meets the requirement and that percent is reported. For fiber and calcium we used the Adequate Intake (AI), this measurement examines the mean intake of the group for each nutrient and if that is not met than the group intake is inadequate. For fat, carbohydrate and protein the acceptable macronutrient distribution ranges, these ranges are used to assess adequacy, were examined. The recommendations for food group servings are from the United States Department of Agriculture Food Guide Pyramid for Young Children (15). To examine nutrient intakes we standardized the diets of the study population to 1000 kcal. 4O Sociodemographic and health behavior variables, including body mass index were examined. BMI was examined using the Centers for Disease Control gender specific growth charts; (http://www.cdc.gov/growthcharts). The following health behaviors were assessed: the number of months the child was breastfed (three categories 0, 51, >1), BMI-for-age (two categories <85’h, 85th percentile and above) and hours played outside per day (three categories 0-3, > 3). These cut-points were established after reviewing the distribution of data. The following demographic information was also assessed: federal poverty threshold (<100, 100-185 and >185), primary caregiver enrolled in the federal program for Women, Infants and Children (WIC) (yes, no) and race/ethnicity (Native American or non-Hispanic white). Statistical analyses For all analyses Statistical Analysis System (SAS) version 9.1was used. We first examined the distribution of each variable to identify outliers. Descriptive statistics were computed and reported for sociodemographic variables and health. Given differences in added sugar recommendations between IOM (525% of total energy) and WHO (<10% of total energy) we analyzed the data by 4 categories (<10%, 10-<16%, 16-525%, >25%). To test for trend between mean and median intakes of macro and micronutrients as well as food groups and added sugar intake (% of total energy) we used the nonparametric Kendall test (data retained as continuous variables). To determine if there was a trend between added sugar and diet quality (defined here as meeting recommendations either DRIs or USDA) we used the Cochran Armitage test for trend (2-sided test). Where sample size permitted we also examined results stratified by gender and race/ethnicity using the Wilcoxon-Mann—Whitney test for median intakes and Chi-square for diet 41 quality. Analyses are reported separately for two age groups, 1-3 and 4-6 year olds to align with the recommended DRIs, except where specified and 2-6 year olds are grouped for analyses of BMI-for-age and the USDA Food Guide Pyramid (F GP) for Young Children. Results The total study population had approximately an equal number of males and females 50.8% (n=167) and 49.8% (n=162), respectively, comparable number of children in each age group (1-3 years =50.8% and 4-6 years=49.8%, respectively) and slightly more non-Hispanic white children (56.8%) than Native American children (43.2 %) (Table l): A total of 54.5% and 53.1% of caretakers of 1-3 and 4-6 year olds, respectively, were living at < 100% of poverty ($16,400 in 1997, http://www.census.gov ). Over half of the population was enrolled in the Federal program for Women, Infants and Children (WIC) (73.6% 1-3 and 42.0% 4-6 year olds) and 15.5% of 2-6 year olds in the study population was either at-risk of overweight or overweight (85th percentile and above) at the time of the questionnaire administration. Added Sugar and Beverages Due to sweetened beverages being identified as one of the major contributors to added sugar intake in children (Guthrie 2000, 2), we examine the association between added sugar categorist and median intake of groups of beverages (Table 2). We examined three overlapping groups of beverages: group 1 (juices and soft drinks, not including diet), group 2 (Kool-Aid and soft drinks), and group 3 (carbonated drinks, both diet and regular). The highest intake reported was for 1-3 year olds at 1954.3 grams/day 42 of group 1 (juices and soft drinks) in the highest category of added sugar. While this estimate seems very high it is consistent with a previously reported intake of 2036.2 grams/day that used national data (F orshee 2003, 35). Added Sugar and Covariates Overall, the median percent of energy from added sugar in the children aged 1-3 years was 9.8% (10.1% in females, 9.1% in males) and in children aged 4-6 years was 14.1% (12.9% in females, 14.2% in males). Children that consumed < 10% of their calories from added sugar and therefore were least likely to consume added sugar were more likely to be aged 1-3 years (50.9% vs. 29.0% 4-6 year olds), female (43.2% vs. 37.1% males), < 100 % federal poverty (44.1% vs. 34.5% in 100-185% and 30.8% in >185%), enrolled in WIC (48.7% vs. 27.7% not enrolled), played less outside (50.0% vs. 34.4% in >3 hours), Native American (43.7% vs. 37.5% in non-Hispanic white.) (see Table 3). Children enrolled in WIC were also less likely to be in the highest two categories of added sugar consumption (20.4% combined) then those who were not enrolled (38.7% combined). Added Sugar and Median Nutrient Intake Next we examined median nutrient intake within categories of added sugar intake (percent of total energy) (Table 4). With the exception of carbohydrates (% of total energy), energy (kcal) and vitamin C median intakes of all other nutrients decreased with increasing intake of added sugar for both age groups (Table 4). Nutrients except energy (kcal), fiber and vitamin B were significantly negatively associated with increasing added sugar intake for the 1-3 year olds. For 4-6 year olds the only non-significant negative associations were for energy (kcal) and vitamin C. Most notable in this study was the 43 intake of calcium, which decreased by almost half fi'om the lowest to highest added sugar category in both age groups (p=<0.0001). We also looked at median intakes of nutrients within each age group by intake of added sugar and by race/ethnicity and gender (appendices 4.1 and 4.2). Native Americans consumed more energy in both age groups then did non-Hispanic white children as intake of added sugar increased the same was true for males in the 1-3 age group, whereas females consumed more energy in the older age group (4-6 years). Significant differences were seen in the 1-3 year olds for total calories (p=0.02),iron (p=0.03) and for 4-6 year olds calcium (p=0.04) phosphorus (p=0.04), vitamin A (p=0.01), protein (p=0.01), vitamin B1 (p=0.01), for gender (appendix 4.2). No significant differences were noted between race/ethnicities. Added Sugar and Median Intake of Food Groups Next we examined the median intake of servings from the USDA Food Guide Pyramid for Young Children with increasing intakes of added sugar (Table 5). Negative associations were significant for grains (p=0.047), total fruit (p=0.001) and dairy =<0.001). Only median intakes of dairy and meat met the recommended servings of 2/day in any category of added sugar for all children aged 2-6 years. The only significant differences by race/ethnicity was for servings of meat (p=0.04) (appendix 5.1). Gender was significantly associated with servings of vegetables (p=0.05) (appendix 5.2). Added Sugar and Diet Quality To determine diet quality we examined the percent of children meeting recommendations for nutrients and servings of food groups within category of added sugar intake. The percent of children meeting recommendations in the group of 4-6 year olds experienced a 44 significant decrease for folate and magnesium as the intake of added sugar increased (Table 6). The mean intake in each category of added sugar for fiber and calcium were compared to the Al to determine if the DRI was met. Not one category of added sugar in either age group had a mean intake that met the Al for fiber (data not shown). The mean intake for calcium in the 1-3 year olds in the highest two categories of added sugar did not meet the AI, and in the older children not one category of added sugar had a mean intake that was adequate (data not shown). Due to small numbers in each category of added sugar and meeting or not meeting recommendations statistics for race/ethnicity and gender were not available. Next we looked at the percent of children meeting national FGP recommendations. For each food group there was a reduction in those meeting recommendations as intake of added sugar increased (Table 7). Not one food group had 100% of the children meeting recommendations. In the highest category of added sugar (25 % or more of total energy) zero percent of the children met recommendations for grains, vegetables and fruit. Due to small numbers in each category of added sugar and meeting or not meeting recommendations statistics for race/ethnicity and gender were not available. Discussion We identified significant decreases in median intake of almost all micronutrients with increasing intake of added sugar in this population of rural Native American and non-Hispanic white children aged 1-6 years. Calcium, folate, phosphorus and vitamins A 45 and E intake were particularly at risk of decreasing with increasing added sugar intake. Median servings of every food group were lowest in the highest category of added sugar compared to the lowest; this was most true for dairy and fruit. Median intakes of some beverages in the highest added sugar category were approximately 8 times that of the lowest category. Children in the youngest age group (1-3 years) did not meet adequate intakes fiber in category of added sugar and for calcium when intake of added sugar was greater than 16% of total energy. The percent population of 4-6 year olds meeting national DRI recommendations significantly decreased as added sugar increased for folate and magnesium and the percent meeting recommendations for the food groups dairy and total fi'uit significantly decreased as added sugar increased. Among older children group intakes were inadequate for calcium and fiber in every added sugar category. Among the 4-6 year olds energy decreased slightly as added sugar increased (a similar finding was reported by Overby et al. 2003, 14). Fat significantly decreased in both age groups as intake of added sugar increased, this finding is consistent with published research (4, 13, 14). Overall, very few children are consuming the recommended number of servings for grains, vegetables and fruit regardless of which added sugar category they were in. The negative association found between added sugar and key nutrients such as calcium, fiber, folate, iron, and vitamin A in this study are similar to other research (4, 9, 13, 14). Kranz et al. stratified data from the Continuing Survey of Food Intake by Individuals (CSFII), 1994-96 and 1998 into 5 categories of added sugar with the highest category >25% of total energy from added sugar. They found that among 2-5-year-olds mean intakes of all the micronutrients examined (calcium, iron, folate, vitamin A, B12, C) 46 were the lowest in the highest category of added sugar (4). Bowman et al. using national data also reported that intake of all micronutrients were the lowest in the highest category of added sugar (>18% of total energy)(9). Research has also shown decreases in servings of food groups such as grains, vegetables and fruit as total added sugar consumption increased (4, 9,14,). National data showed that hit decreased by at least one whole serving (recommended amount is 2 servings) from the lowest to the highest category of added sugar in 2-5 year olds (4). This is very important since these foods are believed to offer health benefits beyond the positive health effects of vitamins. Studies that examine consumption of sugar sweetened beverages and diet have also found a negative association between sweetened beverages and calcium, milk, folate and vitamin A (10, 11, 27). National data from 1994-96 showed a negative association with carbonated soda consumption and intakes of calcium and vitamin A in children aged 2-5 years (12). Hamack et al using national data reported that of children aged 2-18 years those who consumed the most soft drinks compared to those who consumed the least had the lowest intake of milk and fruit juice (27). Fortification of foods such as cereal may also have an impact on added sugar and diet quality. Alexy et al.reported a positive association between intakes of added sugar and fortified foods (28). Relying on vitamin supplements or fortification is not recommended by the Dietary Guidelines 2005 for two reasons (8). First of all, foods have benefits other than nutrients such as phytochemicals that may be important to health. Secondly, consuming vitamin supplements or fortified foods may increase risk for over consumption of certain micronutrients, which can be harmful (8). 47 Research has also identified a potential relationship between consuming sugar- sweetened beverages and weight gain in children (29). However, a study that examined children aged 2-5 years using data from Nutritional Health and Nutrition Examination Survey (NHANES) 1999-2002 did not find an association of consumption of soda and BMI (30). They concluded that prospectively studying these children may provide a clearer answer since overweight is a result of consuming more calories than is exerted over time and the age of these children may be too young for conclusive results (30). We found that the prevalence of children in this study population at or above the 85th percentile (BMI-for-age) was nearly 15.5 % at the time of the study. Our data does not show a significant number of overweight children in the highest two added sugar categories. An important strength of this study is that it is the first to our knowledge to examine the association between added sugar consumption and nutrient intake, servings of food and diet quality in rural Native American children. The use of a F FQ in this study is a strength because it has the ability to capture the total ‘usual’ diet of an individual rather than their diet on one day. The FF Q was modified for this study population and was administered in the participant’s home by two trained interviewers. Children’s height and weight were also measured, not self-reported. Limitations in this study must also be considered. Recall bias may be present here since the data collected by the FF Q used a month prior for the interview tirneframe; caregivers may not be able to remember everything that the child ate. Studies have validated the use of the F FQ in capturing diets of young children by comparing multiple FFQ’s with diet records and biomarkers (33, 34). Although interviewers were trained 48 and monitored to insure the accurate collection of data there is a possibility of foods left out because a participant may have had more than one caregiver. Our study, along with others that examined national data, does show an association between intake of added sugar and decreased intakes of micronutrients, servings of fruit, vegetables and dairy. We also found that children did not have an adequate intake of calcium when intake of added sugar was greater than 16%. In addition, median intakes of all micronutrients with the exception of vitamin C were lowest in the highest category of added sugar. Due to the ubiquitous nature of added sugar in our society and the significant decreases in intakes of nutrients and food groups, the DRI for added sugar should be evaluated. Due to the significant negative associations between intake of nutrients and food groups and added sugar the DRI of 25% may need to be lowered. Other organizations such as the WHO and the American Heart Associations recommend limits lower than the DR]. According to the data reported here limiting sugar to 10% of total energy would assist in keeping nutrient levels at maximum intake. 49 Table 3.1 Selected Characteristics of the Study Population of Rural Native American and Non-Hispanic White Children, 1-6 years, OK 1997 (n=329) Characteristics Gender Female Male Race/Ethnicity Native American White, non-Hispanic Federal poverty threshold (%) <100 100-185 >185 Missing Enrolled in WICb Yes No Missing Vitamin supplement use month prior to interview Yes No Hours played outside /day 0-3 >3 Breastfed (months) Never _<_1 >1 Received Commodities in past 12 months Yes No Missing BMI-for-age (CDC) Less than 5% (underweight) 5 to less than 85% (healthy weight) 85 to less than 95% (at risk of overweight) 95% and above (overweight) 1-3 yr olds 4-6 yr olds N=167 N=162 N %" N % ' 87 52.1 75 46.3 80 47.9 87 53.7 69 41.3 73 45.1 98 58.7 89 54.9 91 54.5 86 53.1 58 34.7 58 35.8 12 7.2 14 8.6 6 3.6 4 2.5 123 73.6 68 42.0 44 26.4 93 57.4 - - 1 0.6 55 32.9 55 33.9 112 67.1 107 66.1 86 51.5 34 21.0 81 48.5 128 79.0 111 66.5 111 68.5 11 6.6 12 7.4 45 26.9 39 24.1 20 12.0 24 14.8 147 88.00 137 84.6 - - 1 0.6 2-6 yr olds N % 57 20.7 176 63.8 21 7.6 22 7.9 a Column percents add to 100, bFederal program for Women, Infants and Children 50 Table 3.2 Median Intakes of Beverage Groups That Are Contributors To Total Added Sugar by Age Group (1-3 years and 4-6 years), of Study Population of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar, OK 1997 (N=329) Added Sugar (% of total energy) o-<1o% 10%-25% Evan“; 1-3 year olds 1-3 1-3 1-3 1-3 Sample size (n=85) (n=50) (n=22) (n=10) Beverage groupsb Juices & soft drinks 251.9 440.0 700.0 1954.3 <.0001 Sugar drinks 99.0 388.4 595.8 1904.3 <.0001 Carbonated drinks 26.6 159.5 372.0 651.0 <.0001 4-6 year olds (n=47) (n=55) (n=47) (n=13) Juices & soft drinks 240.0 400.2 755.3 1368.9 <.0001 Sugar drinks 124.0 276.7 684.5 1368.9 <.0001 Carbonated drinks 66.4 132.9 248.0 620.0 <.0001 aKendall test for trend (data retained as continuous) bGroups are not mutually exclusive 51 Table 3.3 Sociodemographic and Health Behavior Characteristics of Rural Native American and Non-Hispanic White Children,1-6 Years, OK 1997 (Within Each Category of Added Sugar, n=329) Added Sugar (% of total energy) 0-<10% 10-<16% 16-525% >25% N N N N Total sample 13 %a 105 % a 69 % a 23 % a 2 Age in years 1-3 85 50.9 50 29.9 22 13.2 10 6.0 4-6 47 29.0 55 34.0 47 29.0 13 8.0 Gender Female 70 43.2 54 33.3 32 19.8 6 3.7 Male 62 37.1 51 30.5 37 22.2 17 10.2 Race/Ethnicity Native American 62 43 .7 44 31.0 28 19.7 8 5.6 Non-Hispanic White 70 37.5 61 32.6 41 21.9 15 8.0 Federal poverty threshold % <100 78 44.1 56 31.6 32 18.1 11 6.2 100-185 40 34.5 39 33.6 27 23.3 10 8.6 >185 8 30.8 8 30.8 9 34.6 1 3.8 Enrolled in WIC” Yes 93 48.7 59 30.9 28 14.7 11 5.7 No 38 27.7 46 33.6 41 29.9 12 8.8 Vitamin supplement use month prior to interview Yes 46 41.8 34 30.9 23 20.9 7 6.4 No 86 39.3 71 32.4 46 21.0 16 7.3 Hours played outside per day 1-3 60 50.0 36 30.0 17 14.2 7 5.8 >3 72 34.4 69 33.0 52 24.9 16 7.7 Breastfed (months) Never 85 38.3 73 32.9 48 21.6 16 7.2 51 9 39.2 10 43.5 3 13.0 1 4.3 >1 38 45.3 22 26.2 18 21.4 6 7.1 BMI-for-agec 98 92 64 22 0-<85% 82 35.2 81 34.8 52 22.3 18 7.7 85th and above 16 37.2 11 25.6 12 27.9 4 9.3 aRow percents add to 100, bFederal program for Women, Infants and Children cAnalayses subset to 2-6 year olds (n=276) 52 Table 3.4 Median Intakes of Nutrients of Study Population of Rural Native American and Non-Hispanic White Children, 1-6 Years, Within Each Category of Added Sugar, OK 1997 (N=329) 1-3 year olds Macronutrients Energy (kcal) Carbohydrate (% energy) Protein (% energy) Fat (% energy) Added sugar (% energy) Fiber (g/1000kca1) Micronutrients Calcirun (mg/1000kcal) Iron (mg/1000kca1) F olate (11g! 1 000kcal) Zinc (mg/1000kcal) Magnesium (mg/1000kcal) Phosphorus (mg/ 1 000kcal) Vitamin A (pg/1000kcal) Vitamin B1 (pg/ 1000kca1) Vitamin B6 (pg/1000kcal) Vitamin C (mg/1000kcal) Vitamin E (mg/1000kcal) 4-6 year olds Macronutrients Energy (kcal) Carbohydrate (% energy) Protein (% energy) Fat (% energy) Added sugar (% energy) Fiber (g/1000kcal) Micronutrients Calcium (mg/1000kcal) Iron (mg/1000kcal) Folate (pg/1 000kcal) Zinc (mg/ 1000kcal) Magnesium (mg/1000kcal) Phosphorus (mg/1000kcal) Vitamin A (pg/1000kcal) Vitamin Bl (pg/1000kcal) Vitamin B6 (11g 1000kcal) Vitamin C (mg/1000kcal) Vitamin E (mg/1000kcal) 0%-<10% (N=85) 1507.1 40.3 15.9 42.7 6.6 4.4 656.5 4.8 96.5 5.1 120.6 743.7 379.4 0.5 0.6 30.1 3 1 (N=47) 2133.0 41.2 16.0 43.8 7.4 5.0 630.9 5.7 109.5 5.3 119.5 744.3 418.9 0.6 0.6 29.2 3.6 16% 525% (N=50) (N=22) Median Intake 1763.3 1893.5 42.8 48.3 14.2 12.3 44.0 40.8 12.4 19.8 4.1 3.7 514.7 464.4 5.1 4.4 82.6 81.9 4.9 4.2 100.6 99.4 648.3 592.2 348.4 286.3 0.5 0.4 0.6 0.6 26.9 25.5 3.1 3.2 (N=55) (N=47) 1919.5 1916.0 44.1 48.0 14.7 13.2 41.3 39.8 13.3 20.4 4.6 4.5 471.2 442.0 5.3 4.7 92.5 95.3 5.0 4.4 106.4 97.0 618.8 560.0 326.6 338.0 0.5 0.5 0.6 0.6 26.0 33.4 3.4 3.8 Added Sugar (% of total energy) 10%-46% >25% (N=10) 2262.5 54.9 1 1.6 34.8 31.4 3.6 321.7 4.1 74.8 4.1 84.9 457.8 219.1 0.4 0.5 26.6 2.4 (N=13) 1827.8 56.9 1 1.2 34.4 28.5 3.6 374.9 4.6 72.7 4.3 74.4 497.7 242.5 0.4 0.5 29.3 2.8 P-valuea 0.014 <.0001 <.0001 0.0003 <.0001 0.029 <.0001 0.419 0.0003 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 0.1743 0.248 0.395 <.0001 <.0001 <.0001 <.0001 0.0009 <.0001 <.0001 0.0002 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 0.560 0.426 a P-value test for trend, Kendall (data retained as continuous variable) 53 Table 3.5 Median Intakes of Servings of Food Guide Pyramid Food Groups of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar, OK 1997(2-6 year olds only n=276) Added sugar (% of total energy) 0°/o-<10% 10%-<16% 16%-525% >25% Total Sample 01:93) (IF-92) (11:64) (11:22) Median Intakes (servings) Food Groupsb Grains (servings/day) 3.30 3.55 3.15 2.50 Vegetable (servings/day) 0.80 0.80 0.80 0.50 Fruit (servings/day) not including fruit juice 0.50 0.50 0.50 0.40 Total Fruit (servings/day) 1.40 1.00 1.20 0.75 Dairy (servings/day) 4.35 3.30 3.20 2.85 Meat (servings/day) 2.60 2.50 2.30 2.25 a p-value 0.047 0.177 0.484 0.001 <.0001 0.232 aP-value test for trend, Kendall (data retained as continuous variable) bFood Guide Pyramid Recommendations for Young Children (2-6 year olds), grains= 6 servings; vegetables—=3 servings; fi'uit=2 servings; dairy=2 servings; meat-=2 servings 54 Table 3.6 Percent of Study Population of Rural Native American and Non-Hispanic White Children, 1-6 years, Meeting the DRIs for Nutrients Within Each Category of Added Sugar, OK 1997 (N=329) Added Sugar (% of energy) 0%-<10% 10%-<16% 16%-525% >25% 1'3 year olds Percent Meeting Recommendationsa Macronutrients NC ”/0 N° % Nc % N° % Carbohydmted (% energy) 15 17.7 18 36.0 16 72.7 10 100.0 Protein d (% energy) 84 98.8 49 98.0 22 100.0 10 100.0 Micronutrients Iron (mg/d) 80 94.1 48 96.0 21 95.5 10 100.0 Folate (pg/d) 57 67.1 34 68.0 16 72.7 7 70.0 Zinc (mg/d) 81 95.3 48 96.0 22 100.0 10 100.0 Magnesium (mg/d) 83 97.6 50 100.0 22 100.0 10 100.0 Phosphorus (mg/d) 83 97.6 48 96.0 22 100.0 10 100.0 Vitamin A (pg/d) 85 100.0 50 100.0 22 100.0 10 100.0 Vitamin B6 (pg/d) 81 95.3 48 96.0 22 100.0 10 100.0 Vitamin C (mg/d) 82 96.5 50 100.0 22 100.0 10 100.0 Vitamin E (mg/d) 37 43.5 27 54.0 13 59.1 6 60.0 4-6 year olds Macronutrients Carbohydrate d (% energy) 1 1 23.4 22 40.0 36 76.6 12 92.3 Protein d (% energy) 47 100.0 55 100.0 47 100.0 13 100.0 Micronutrients Iron (mg/d) 46 97.9 55 100.0 44 93.6 13 100.0 Folate(1rg/d) 37 78.7 34 61.8 30 63.8 4 30.8 Zinc (mg/d) 46 97.9 55 100.0 44 93.6 13 100.0 Magnesium (mg/d) 45 95.7 53 96.4 41 87.2 9 69.2 Phosphorus (mg/d) 47 100.0 55 100.0 45 95.7 13 100.0 Vitamin A (pg/d) 47 100.0 54 98.2 46 97.9 13 100.0 Vitamin B6 (pg/d) 46 97.9 55 100.0 45 95.7 12 92.3 Vitamin C (mg/d) 45 95.7 54 98.2 46 97 .9 13 100.0 Vitamin E (mg/d) 29 61.7 38 69.1 28 59.6 6 46.2 value <.001 0.026 0.436 0.665 0.258 0.242 0.586 0.523 0.258 0.150 0.108 <.001 0.042 0.462 0.005 0.462 0.004 0.202 0.235 0.202 0.374 0.367 aEstimated Average Requirement bCochran-Arrnitage Trend Test, 2-sided P-value cNumber of children not meeting the recommendation within each category of added sugar consumption d Acceptable Macronutrient Distribution Ranges 55 Table 3.7 Percent of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar Meeting The Recommended Servings of the Food Guide Pyramid for Young Children, OK 1997 (2-6 year olds only n=276) Total Sample Food Groupsc Grains (servings/day) Vegetable (servings/day) Fruit (servings/day)not including juice Total Fruit(servings/day) Dairy (servings/day) Meat (servings/day) 5 3 1 93 66 0%-<10°/o (n=98) Added Sugar (% of Total Energy) 10%25% (n=22) % 0 0 O 9.1 63.6 54.6 a value 0.323 0.829 0.450 0.016 <.0001 0.209 References 10. 11. 12. . United States Department of Agriculture. Agriculture Fact Book 2001-2002. Chapter 2. Assessed online at http://www.usda.gov/factbook/chapterZ.htm in March 2007. Guthrie JF, & Morton JF. Food Sources of added sweeteners in the diets of Americans. J Am Diet Assoc 2000; 100:43-48. . http://www.cdc.gov/. Centers for Disease Control website. Assessed in September 2006. Kranz S, Smiciklas-Wright H, Siega-Riz A, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr 2005; 146:105-11. . Frary CD, Johnson RK, Wang MQ. Children and Adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. Journal of Adolescent Health 2004; 34:56—63. Somerset SM. Refined sugar intake in Australian children. Public Health Nutrition 2003; 6(8), 809-813. Gibson SA. Do diets high in sugars compromise micronutrient intakes? Journal of Human Nutrition and Dietetics 1997; 10:125-133. Department of Health & Human Services: 2005 Dietary Guidelines Advisory Committee Report, website: http://www.healtheirus.gov/dietaryguidelines/ Assessed in September 2006. Bowman SA. Diets of individuals based on energy intakes from added sugars. Family Economics and Nutrition Review 1999; 12, 2: 31-8. F orshee RA, Anderson PA, Storely ML. Changes in calcium intake and association with beverage consumption and demographics: comparing data from CSFII 1994-1996, 1998 and NHANES 1999-2002. Journal of the American College of Nutrition 2006; 25 (2):108-116. Marshall TA, Gilmore JM, Broffitt B, Stumbo PJ, Levy SM. Diet quality in young children is influenced by beverage consumption. Journal of the American College of Nutrition 2005; 24 (l):65-75.et al., 2005. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med 2000; 154:1148-1152. 57 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Alexy U, Sichert-Hellert W, Kersting M. Associations between intake of added sugars and intakes of nutrients and food groups in the diets of German children and adolescents. British Journal of Nutrition 2003; 90:441-447. Overby NC, Lillegaard IT, Johansson L, Anderson LF. High intake of added sugar among Norwegian children and adolescents. Public Health Nutrition 2003; 7(2):285-293. http://www.usda.gov/cnpp/KidsPyra. United States Department of Agriculture’s MyPramid. Assessed in September 2006. Institute of Medicine of the National Academy of Sciences. Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Report. Washington, DC: National Academy Press; 2002. ' US. Department of Health & Human Services: The Report on the Dietary Guidelines Committee on Dietary Guidelines for Americans. Report. 2000. World Health Organization/Food and Agriculture Organization of the United Nations Expert Consultation. Diet, nutrition, and the prevention of chronic diseases. Technical Support Series 916. Geneva, Switzerland: World Health Organization; 2003. Murphy SP, Johnson RK. The scientific basis of recent US guidance on sugars intake. Am J Clin Nutr 2003; 78(suppl):827S-33S. Ogden CL, F legal KM Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents,1999-200. JAMA 2002; 288: 1728-1732. Michels KB, Rosner BA, Chumlea C, Colditz GA, Willett WC. Preschool diet and adult risk of breast cancer. Int. J. Cancer 2006; 118: 749-754. Forshee RA, Storey ML. The role of added sugars in the diet quality of children and adolescents. Journal of the American College of Nutrition 2001; 20 (l):32- 43. Lee ET, Begum M, Wang W, Blackett PR, Blevins KS, Stoddart M, Tolbert B, Alaupovic P. Type 2 Diabetes and impaired fasting glucose in American Indians aged 5-40 years: The Cherokee Diabetes Study. Ann Epidemiol 2004; 14:696- 704. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obestiy in the United States, 1999-2004. JAMA 2006; 295: 1549-55. 58 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. Stroehla BC, Malcoe LH, Velie EM. Dietary sources of nutrient among rural Native American and white children. Journal of the American Dietetic Association 2005; 105: 1908-16. Atwater. Modern nutrition in health and disease 7th edition Philadelphia: Lea & Fediger, 1988. Hamack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc 1999; 99:436-441. Alexy U, Sichert-Hellert W, Kersting M. Fortification masks nutrient dilution due to added sugars in the diet of children and adolescents. J Nutr 2002; 132:2785-91. Ludwig DS, Peterson KE, Gortrnaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lance 2001; 357:505-08. O’Connor TM, Yang S, Nicklas TA. Beverage intake among preschool children and its effect of weight status. Pediatrics 2006; 118 (4):1010-1018. Berkey CS, Rockett HR, Field AE, Gillman MW, Colditz GA. Sugar-added beverages and adolescent weight change. Obestiy Research 2004; 12 (5):778- 788. Kwan ML, Block G, Selvin S, Month S, Buffler PA. Food consumption by children and the risk of childhoos acute leukemia. American Journal of Epidemiology 2004; 160:1098-1107. Khole DM, Clarke KK, George GC, Milani TJ, Hanss-Nuss H, Freeland-Graves J. Relative validity and relaiability of a food frequency questionnaire for a triethnic population of 1-year-old to 3-year-old children from low-income families. J Am Diet Assoc 2005; 105:727-734. Parish LA, Marshall JA, Krebs NF, Rewers M, Norris JM. Validation of a food frequency questionnaire in preschool children. Epidemiology 2003; 14:213-217. Forshee RA, Storey ML. Total beverage consumption and beverage choices among children and adolescents. International Journal of Food Sciences and Nutritio 2003; 54:297-307. 59 CHAPTER 4 CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS In conclusion, this research is consistent with published reports that examine intakes of added sugar and diet in children. This population of young, rural, Native Americans and non-Hispanic white children does not differ fiom national data (1-3). High intakes of added sugar have been shown to be associated with decreased intakes of micronutrients and servings of major food groups in children (1-3). Nutrients such as calcium, fiber, magnesium and vitamin E are important for the health of children and in this study these nutrients were the lowest in the highest added sugar category which is consistent with other research (1,4). It is also important that children consume a sufficient amount of food fiom each major food group in the MyPyramid and in this study servings of all food groups were lowest in the highest added sugar category. Attention has been focused on beverage intake specifically sugar-sweetened beverages or regular soft drinks and nutrition. This is due to the major role regular soft drinks play on total added sugar intake in the diets of Americans (5). It has been reported that sugar-sweetened beverages are associated with intakes of nutrients and diet quality (6,7). A significant association is seen between total added sugar intake and sugar drinks (including Kool-Aid and regular soft drinks) in this population. The percent of children meeting the EAR for nutrients was not associated with intakes of added sugar. This may be because of the measurement itself, even if the 60 Estimated Average Requirement is 100% in a group this means that only approximately half of the population is getting the required amount of that nutrient. This measurement may not be the best way to measure adequacy of a nutrient intake among groups. The participants of WIC had a lower overall intake of added sugar than those children who did not participate in the federal program. In this study population we can conclude that WIC had a negative affect on added sugar intake and therefore may be beneficial to nutrition. This relationship needs to be evaluated further to say with certainty that there is an association. Demographic variables associated with lower intakes of added sugar in this study were: younger age (1-3 vs. 4-6), female, Native American, and <100% federal poverty (vs. 100-185%, >185%). The association between added sugar intake with younger age and lower percent federal poverty have been reported elsewhere (1). Public Health Implications To reduce the risk of adverse health outcomes such as overweight and type 2 diabetes intake of added sugar may need to be limited. The prevalence of overweight in children is already much higher than it was twenty years ago and if the contributing factors to overweight are not identified and prevented this trend may continue. Type 2 diabetes has also risen considerably in children, especially Native Americans (8,9). Chronic diseases that are associated with poor nutrition and becoming overweight may continue to rise as the prevalence of overweight increases, resulting in an economical, as well as a psychological burden on the American people. I believe that food labels should 61 clearly list the amount of total added sugar in the product as well as provide a guide to how much should be consumed as was suggested to the FDA in 1999. Future Research Future research is needed to find out ways to encourage children to limit their intake of added sugar and sugar-sweetened beverages. Research that focuses on different ways to educate parents/caregivers and the children the benefits of consuming a healthy diet and what a healthy diet is, are necessary. Further ways to educate target populations on how to grow fi'uits and vegetables in different communities, the importance of exercise and the adverse effects of a poor diet may aid in the reduction of intake of total added sugar. 62 References l. Kranz S, Smiciklas-Wright H, Siega-Riz A, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr 2005; 146:105-11. Overby NC, Lillegaard IT, J ohansson L, Anderson LF. High intake of added sugar among Norwegian children and adolescents. Public Health Nutrition 2003; 7(2):285-293. Frary CD, Johnson RK, Wang MQ. Children and Adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. Journal of Adolescent Health 2004; 34:56-63. Bowman SA. Diets of individuals based on energy intakes from added sugars. Family Economics and Nutrition Review 1999; 12, 2: 31-8. Guthrie JF, & Morton JF. Food Sources of added sweeteners in the diets of Americans. J Am Diet Assoc 2000; 100:43-48. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med 2000; 154:1148-1152. Marshall TA, Gilmore JM, Broffitt B, Stumbo PJ, Levy SM. Diet quality in young children is influenced by beverage consumption. Journal of the American College of Nutrition 2005; 24 (1):65-75.et al., 2005. Bloomgarden ZT. Type 2 diabetes in the young. Diabetes Care 2004; 27:998- 1010. Lee ET, Begum M, Wang W, Blackett PR, Blevins KS, Stoddart M, Tolbert B, Alaupovic P. Type 2 Diabetes and impaired fasting glucose in American Indians aged 5-40 years: The Cherokee Diabetes Study. Ann Epidemi012004; 14:696- 704, 63 APPENDICES 64 Table 3.4.1 P-values for Median Intakes of Nutrients of Study Population of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar by Race/Ethnicity, OK 1997, (N=329) 0%-<10% 10%-<16% 16% 525% >25% 1-3 year olds Macronutrients P-valuea Energy (kcal) 0.72 0.19 0.80 0.32 Carbohydrate (% of energy) 0.52 0.30 0.36 0.50 Protein (% of energy) 0.48 0.54 0.95 0.50 Fat (% of energy) 0.92 0.23 0.40 0.50 Added sugar (%of energy) 0.92 0.84 0.90 1.00 Fiber(g/1000kcal) 0.82 0.37 0.33 0.74 Micronutrients Calcium (mg/ 1000kca1) 0.64 0.31 0.30 0.20 Iron (mg/ 1000kca1) 0.43 0.48 0.20 0.20 Folate (ug/ 1000kca1) 0.98 0.48 0.95 0.74 Zinc (mg/ 1000kca1) 0.34 0.65 0.60 1.00 Magnesium (mg/1000kcal) 0.56 0.73 0.69 0.32 Phosphorus (mg/1000kcal) 0.64 0.35 0.43 0.32 Vitamin A (pg/1000kca1) 0.11 0.30 0.20 1.00 Vitamin B1 (ug/ 1000kcal) 0.82 0.87 0.95 0.32 Vitamin B6 (pg/1000kcal) 0.80 0.33 0.84 1.00 Vitamin C (mg/1000kca1) 0.80 0.97 0.55 1.00 Vitamin E (mg/1000kcal) 0.49 0.15 1.00 0.20 4-6 year olds Macronutrients Energy (kcal) 0.13 0.07 0.10 0.83 Carbohydrate (% of energy) 0.33 0.78 0.64 0.37 Protein (% of energy) 0.22 0.33 0.64 0.53 Fat (% of energy) 0.40 0.64 0.72 0.45 Added sugar (%of energy) 0.33 0.86 0.11 0.83 Fiber (g/1000kcal) 0.32 1.00 0.46 1.00 Micronutrients Calcium (mg/ 1000kcal) 0.57 0.61 0.72 0.83 Iron (mg/ 1000kca1) 0.09 0.76 0.74 0.63 Folate (pg/1000kca1) 0.56 0.83 0.61 0.73 Zinc (mg/ 1000kcal) 0.74 0.68 0.58 0.63 Magnesium (mg/1000kcal) 0.11 0.82 0.58 0.73 Phosphorus (mg/ 1000kca1) 0.29 0.71 0.60 1.00 Vitamin A (pg/1000kcal) 0.74 0.10 0.53 0.73 Vitamin B1 (ug/ 1000kca1) 0.71 0.73 0.42 0.20 Vitamin B6 (ug/ 1000kca1) 0.86 0.54 0.89 0.63 Vitamin C (mg/ 1000kcal) 0.74 0.82 0.18 0.31 Vitamin E (mg/1000kcal) 0.23 0.42 0.51 0.16 aWilcoxon-Mann-Whitney, reporting 2-sided P-value 65 Table 3.4.2 P-values for Median Intakes of Nutrients of Study Population of Rural Native American and Non-Hispanic White Children Within Each Category of Added Sugar by Gender, OK 1997, (N=329) 0%-<10% 10%-<16% 16% 325% >25% 1-3 year olds Macronutrients P-valuea Energy (kcal) 0.02 0.75 0.84 0.27 Carbohydrate (% of 0.55 0.53 0.18 0.76 energy) Protein (% of energy) 0.90 0.98 0.84 0.76 Fat (% of energy) 0.45 0.74 0.12 0.61 Added sugar (%of energy) 0.34 0.45 0.27 0.20 Fiber(g/1000kcal) 0.33 0.28 0.40 0.36 Micronutrients Calcium (mg/1000kcal) 0.33 0.45 0.74 0.76 Iron (mg/1000kcal) 0.36 0.03 0.80 0.14 Folate (pg/ 1000kcal) 0.25 0.16 0.60 0.14 Zinc (mg/1000kcal) 1.00 0.80 0.43 0.36 Magnesium (mg/1000kcal) 0.19 0.80 0.74 0.27 Phosphorus (mg/ 1000kca1) 0.38 0.77 0.95 0.61 Vitamin A (pg/1000kcal) 0.94 0.50 0.22 0.20 Vitamin B1 (pg/1000kcal) 0.79 0.30 0.84 0.07 Vitamin B6 (pg/ 1000kcal) 0.26 0.16 0.08 0.76 Vitamin C (mg/1000kcal) 0.12 0.43 0.27 0.92 Vitamin E (mg/1000kcal) 0.36 0.34 0.36 0.20 4-6 year olds Macronutrients Energy (kcal) 0.77 0.58 0.91 1.00 Carbohydrate (% of 0.88 0.91 0.78 0.63 energy) Protein (% of energy) 0.66 0.31 0.01 0.16 Fat (% of energy) 0.94 0.49 0.25 0.39 Added sugar (%of energy) 0.12 0.93 0.49 0.50 Fiber (g/1000kcal) 0.51 0.42 0.97 0.39 Micronutrients Calcium (mg/1000kcal) 0.13 0.04 0.37 0.50 Iron (mg/1000kcal) 0.81 0.90 0.25 0.50 Folate (pg/1000kcal) 0.24 0.06 0.78 0.22 Zinc (mg/1000kcal) 0.79 0.51 0.12 1.00 Magnesium (mg/1000kcal) 0.62 0.09 0.24 0.30 Phosphorus (mg/1000kcal) 0.28 0.04 0.16 0.50 Vitamin A (ug/ 1000kcal) 0.16 0.01 0.97 0.50 Vitamin B1 (pg/1000kcal) 0.76 0.11 0.01 0.30 Vitamin B6 (pg/1000kcal) 0.92 0.31 0.18 0.77 Vitamin C (mg/1000kcal) 0.84 0.12 0.53 0.63 Vitamin E (mg/1000kcal) 0.19 0.62 0.96 1.00 aWilcoxon-Mann-Whitney, reporting 2-sided p-value 66 Table 3.5.1 P-values for Median Intakes of Servings of Food Guide Pyramid Food Groups of Rural Native American and Non-Hispanic White Children, 2-6 Years Olds, Within Each Category of Added Sugar by Race/Etlmicity, OK 1997 (n=276) Added Sugar (% of total energy) 0%—25% p-valuea Food Groupsb Grains (servings/day) 0.75 0.08 0.90 0.65 Vegetable (servings/day) 0.09 0.70 0.56 0.48 Fruit (servings/day) not including fruit juice 0.99 0.14 0.68 0.84 Total Fruit (servings/day) 0.80 0.46 0.44 0.77 Dairy (servings/day) 0.90 0.79 0.52 0.75 Meat (servings/day) 0.09 0.04 0.82 0.77 IWilcoxon Mann-Whitney l)Food Guide Pyramid Recommendations for Young Children (2-6 year olds), grains= 6 servings; vegetables=3 servings; fi'uit=2 servings; dairy=2 servings; meat=2 servings 67 Table 3.5.2 P-values for Median Intakes of Servings of Food Guide Pyramid Food Groups of Rural Native American and Non-Hispanic White Children, 2-6 Year Olds, Within Each Category of Added Sugar by Gender, OK 1997, (n=276) Added Sugar (% of total energy) 0%-<10% 10%-<16% 16%-S25% >25% p—valuea Food Groupsb Grains (servings/day) 0.09 1.0 0.46 0.12 Vegetable (servings/day) 0.72 0.08 0.05 0.40 Fruit (servings/day) not including fi'uit juice 0.62 0.31 0.22 0.62 Total Fruit (servings/day) 0.80 0.98 0.37 0.60 Dairy (servings/day) 0.72 0.50 0.29 0.65 Meat (servings/day) 0.06 0.98 0.86 0.40 I'Wilcoxon Mann-Whitney bFood Guide Pyramid Recommendations for Young Children (2-6 year olds), grains= 6 servings; vegetables=3 servings; fruit=2 servings; dairy=2 servings; meat=2 servings 68 IIIIIIIIIIIIII 11111111111111}ij1111mm