American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics

Age of juice introduction and cardiometabolic outcomes in middle childhood

BACKGROUND

The American Academy of Pediatrics recommends juice introduction after 12 months of age. Juice consumption has been linked to childhood obesity and cardiometabolic risk. We examined the prospective relationship between the age of juice introduction and primary and secondary cardiometabolic outcomes in middle childhood.

METHODS

Parents reported the age of juice introduction on Upstate KIDS questionnaires completed between 4-18 months of age. The quantity and type of juice introduced was not measured. Anthropometry, blood pressure (BP), and arterial stiffness by pulse wave velocity (PWV) were measured for 524 children at study visits between 8-10 years old (2017-2019). Age- and sex-adjusted z-scores were calculated for anthropometrics using the Centers for Disease Control and Prevention reference. Plasma lipids, hemoglobin A1c (HbA1c), and C-reactive protein (CRP) in a subset of children were also measured (n=248). Associations between age at juice introduction (categorized as <6, 6 to <12, ≥ 12 months) and outcomes were estimated using mean differences and odds ratios, applying generalized estimating equations to account for correlations between twins.

RESULTS

Approximately 18% of children were introduced to juice at < 6 months old, 52% between 6 to <12 months, and 30% ≥ 12 months of age. Children who were introduced to juice prior to 6 months had higher systolic BP (3.13 mmHg; 95% confidence interval 0.52, 5.74), heart rate (4.46 bpm; 1.05, 7.87), and mean arterial pressure (2.08 mmHg; 0.15, 4.00) compared to those introduced ≥ 12 months after covariate adjustment including sociodemographic factors and maternal pre-pregnancy body mass index. No adjusted differences in anthropometry, lipids, HbA1c, and CRP levels were found.

CONCLUSION

Early juice introduction during infancy was associated with higher systolic BP, heart rate, and mean arterial pressure in middle childhood.

CLINICAL TRIAL REGISTRY

This trial was registered at clinicaltrials.gov as NCT03106493 (https://clinicaltrials.gov/study/NCT03106493?term=upstate%20KIDS&rank=1).

School-based intervention impacts availability of vegetables and beverages in participants' homes

As rates of metabolic syndrome rise, children consume too few vegetables and too much added sugar. Because children tend to eat what is available at home, the home environment plays a key role in shaping dietary habits. This secondary analysis evaluated the effects of a school-based gardening, cooking, and nutrition education intervention (TX Sprouts) compared to control on the availability of vegetables, fruit juice, and sugar-sweetened beverages (SSBs) at home. In the TX Sprouts cluster-randomized trial, 16 schools were randomized to TX Sprouts (n = 8 schools) or control (n = 8 schools) for one academic year. All schools served predominately Hispanic families with low incomes. TX Sprouts built school gardens and taught 18 lessons to all 3rd-5th grade students at intervention schools. TX Sprouts also offered monthly caregiver lessons before and/or after school. Caregivers completed questionnaires pre and post, providing demographics and information about home availability of vegetables, fruit juice, and SSBs. Summary statistics were used to describe the sociodemographic characteristics of participants. Linear regression assessed the change in scores (pre to post) for the food/ beverage availability question. The model was adjusted for the caregiver's education, employment status, child's grade, and free or reduced-price lunch eligibility. The analytic sample included 895 participants. Compared to control, the intervention positively changed the home availability of targeted foods and beverages, largely by improving the availability of vegetables and vegetable juice. This study showed that a school gardening, nutrition, and cooking program delivered to elementary children may positively influence the home food environment.

Age of Juice Introduction and Child Anthropometry at 2-3 and 7-9 Years

OBJECTIVES

To assess the association between age of juice introduction and child anthropometry after the American Academy of Pediatrics changed their guidelines in 2017 to recommend delaying juice introduction until at least 12 months of age (previously 6 months), citing concerns of weight gain.

STUDY DESIGN

Upstate KIDS is a prospective birth cohort with follow-up through 9 years of age. Juice introduction was assessed on parental questionnaires at 4-18 months and categorized as <6, 6-<12, and ≥12 months. Child height and weight were recorded at 2-3 and 7-9 years of age. Weight-, height-, and body mass index (BMI)-for-age and sex z scores were calculated using the Centers for Disease Control and Prevention reference. Overweight/obese and obese status were categorized as BMI-for-age z score ≥85th and ≥95th percentiles. Controlling for sociodemographic characteristics and parental BMI, we assessed the associations of age of juice introduction with child anthropometry.

RESULTS

Prevalence of childhood obesity was 16.4% at 2-3 (n = 1713) and 22.8% at 7-9 years of age (n = 1283). Juice introduction at <6 vs ≥12 months was associated with higher weight-for-age z score at 2-3 years of age (mean difference = 0.21; 95% CI 0.04-0.37). At 7-9 years of age, juice introduction at <6 vs ≥12 months was related to higher BMI-for-age (0.38; 0.12-0.64) and weight-for-age z scores (0.27; 0.06-0.49). Risk of developing overweight/obesity and obesity was 1.54 (0.99-2.38) and 2.17 (1.11-4.23) times higher among children with juice introduced at <6 months. No associations were found with juice introduced at 6-<12 vs ≥12 months.

CONCLUSIONS

Risk of developing overweight/obesity or obesity is higher among children introduced to juice before 6 months of age compared with ≥12 months.

Predictors of Age at Juice Introduction and Associations with Subsequent Beverage Intake in Early and Middle Childhood

BACKGROUND

The American Academy of Pediatrics recommends that if parents choose to introduce juice, they wait until ≥12 months, citing concerns of obesity and dental caries.

OBJECTIVES

We sought to identify correlates of early juice introduction (<6 months) and determine whether early introduction establishes a pattern of sugary beverage intake in childhood.

METHODS

Upstate KIDS is a prospective birth cohort study with follow-up through 7 years (n = 4989). The age of juice introduction was assessed from responses on periodic questionnaires from 4-18 months and categorized as <6,  6 to <12, and ≥12 months. Sociodemographic information was reported using vital records or maternal questionnaires. At 24, 30, and 36 months and 7 years, mothers reported their child's regular juice, soda, water, and milk intakes. The analysis was restricted to singletons and 1 randomly selected twin from each pair with information on juice introduction (n = 4067). We assessed associations of sociodemographic correlates with juice introduction using Cox proportional hazard models. The relations of juice introduction with beverage intake were evaluated using Poisson or logistic regression for adjusted risk ratios (aRR) or ORs, adjusting for sociodemographic covariates and total beverage intake.

RESULTS

Of the mothers, 25% and 74% introduced juice prior to 6 and 12 months, respectively. Younger maternal age; black or Hispanic race/ethnicity; lower educational attainment; Special Supplemental Nutrition Program for Women, Infants, and Children participation (yes); smoking during pregnancy; a higher pre-pregnancy BMI; a lower household income; and living in a townhouse/condominium or mobile home were associated with earlier juice introduction. Earlier juice introduction was related to a higher childhood juice intake, any soda intake, and lower water intake, holding total beverage intake constant [aRR, 1.5 (95% CI: 1.3-1.7; P-trend < 0.0001); adjusted OR 1.6 (95% CI: 1.0-2.4; P-trend = 0.01); aRR 0.9 (95% CI: 0.8-0.9; P-trend < 0.0001), respectively].

CONCLUSIONS

Markers of lower socioeconomic status are strongly associated with earlier juice introduction, which, in turn, relates to sugary beverage intake in childhood, potentially replacing water.

Associations of mothers' source of feeding information with longitudinal trajectories of sugar-sweetened beverage intake, 100% juice intake and adiposity in early childhood

BACKGROUND

There remains a need to understand how information sources can promote young children's healthy beverage consumption and prevent obesity.

OBJECTIVES

To examine associations of mothers' primary feeding information source with children's sugar-sweetened beverage (SSB) intake, 100% juice intake and adiposity between ages 3 and 7 years.

METHODS

We analyzed data from a prospective cohort study (n = 371 children; 13 visits). Mothers reported their primary feeding information source at baseline and completed child 3-day dietary records each visit. Child adiposity indicators were calculated from repeated height/weight measurements and dual-energy X-ray absorptiometry. Longitudinal models examined beverage intakes and adiposity over time by source.

RESULTS

Primary feeding information sources included doctors (48.2%), mothers (17.5%), grandmothers (13.5%), other healthcare professionals (11.3%) and other family/friends (9.4%). Children's juice intake with age differed by source (P interaction = 0.03), with steepest and slightest intake decreases in the doctor (-19.7% each year; 95% CI: -23.7%, -15.5%) and grandmother (-5.0%; -14.5%, 5.5%) subgroups, respectively. Children's SSB intake did not differ by source, but increased annually by 7.1% (4.5%, 9.8%) overall. The grandmother subgroup had the greatest child adiposity over time.

CONCLUSIONS

Mothers' primary feeding information source may have important, yet heterogeneous, influences on young children's beverage intakes and adiposity over time. Consistent evidence-based messages are likely needed.

Consumption of 100% Orange Juice in Relation to Flavonoid Intakes and Diet Quality Among US Children and Adults: Analyses of NHANES 2013-16 Data

This study explored consumption patterns of 100% orange juice by socio-demographics among US children and adults. Dietary intakes data for 15,983 persons aged >2 y came from the nationally representative National Health and Nutrition Examination Survey (NHANES 2013-2016). The What We Eat in America nutrient composition database was merged with the USDA Expanded Flavonoid Database to assess flavonoid intakes. Diet quality measures were the Healthy Eating Index (HEI-2015) and Nutrient Rich Food (NRF9.3) Index. Orange juice consumption accounted for a mean of 14 kcal/d and varied with age, incomes, and race/ethnicity. Orange juice consumption was associated with higher intakes of bioactive flavonoids, lower added sugars, and higher-quality diets overall. Diets of consumers were higher in vitamin C, potassium, calcium, vitamin D (adults), flavanones, and total flavonoids (children) as compared to non-consumers. Consumers had significantly higher HEI-2015 and NRF9.3 scores and lower body mass index values (adults). However, only 15.9% of the NHANES sample consumed any orange juice at all; of these 11.8% had <1 serving/day and only 3.4% had 1 serving/day or more.

Cross-linked polydimethylsiloxane colloid as novel contrast agent for gastrointestinal magnetic resonance imaging: Transient nuclear Overhauser effect within the interface

With good contrast in T₁ and T₂ weighted imaging as well as low toxicity in 3- (4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay, this work proposes the cross-linked polydimethylsiloxane colloids as a novel non-ionic contrast agent for gastrointestinal magnetic resonance imaging. The experiments of nuclear magnetic resonance spectra and relaxation show that within the interface of the colloids, there are nuclear Overhauser effect and transient nuclear Overhauser effect (cross-relaxation). Regarding the longitudinal relaxation experiments of CH₂CH₂O segments of Tween 80, a two spins system is found and modeled well by the equation IZ-I0= S0((1-X) e-tD1 -(1+X) e-tT1) which is deduced based on the transient nuclear Overhauser effect proposed by Solomon. The arbitrary constant X is additionally added with the initial conditions (I_z - I₀)_t=0 = -2XS₀ and (S_z - S₀)_t=0 = -2S₀. For the two spins system, D₁ and T₁ are corresponding to longitudinal relaxation times of the bound water and the CH₂CH₂O respectively. Concerning the transverse relaxation experiments of the CH₂CH₂O, they agree with the equation with three exponential decays, defined by three relaxation times, likely corresponding to three mechanisms. These mechanisms possibly are intramolecular and intermolecular dipole-dipole (DD) interactions and scalar coupling. Within the interface, hydrogen bonding causes the positive nuclear Overhauser effect of the CH₂CH₂O's nuclear magnetic resonance spectra, the transient nuclear Overhauser effect of the CH₂CH₂O's longitudinal relaxation experiments and the intermolecular dipole-dipole interactions of the CH₂CH₂O's transverse relaxation experiments.

Association between early childhood caries and feeding practices among 3-5-year-old children of Indore, India

BACKGROUND

The impact of early childhood caries (ECC) seen in infants and young children to the society is enormous. Most studies on ECC have been focused on specific ethnic and lower socioeconomic communities, however fewer studies are conducted in India as compared to other developed countries.

AIMS

The study investigates the association between selected feeding practices and the presence of early ECC among 3-5 year-old children of Indore city.

METHODOLOGY

A cross-sectional sample consisted of 640 preschool children of different socioeconomic status (SES). A self-administered questionnaire was used to obtain information about demographic backgrounds and feeding history of the child. The caries experience of children was recorded.

STATISTICAL ANALYSIS

The data were evaluated using Chi-square and multivariate logistic regression.

RESULTS

The prevalence of ECC was found to be 64%. ECC was found to be significantly associated with age, SES, breastfeeding for more than 1 year, bottle feeding, bottle content used other than water, feeding at night, and cup drinking after 1 year.

CONCLUSION

The present study indicates that ECC and feeding habits have a significant relationship. The content of the bottle feed and feeding practices at night are the strongest factors among all feeding habits associated with ECC.

Modelling the Effects of Beverage Substitution during Adolescence on Later Obesity Outcomes in Early Adulthood: Results from the Raine Study

High sugar-sweetened beverage (SSB) consumption has been linked with obesity. The present study examined the associations between adolescent SSB intake and body mass index (BMI), waist circumference (WC), and overweight status in early adulthood, and modelled the association of alternative beverage substitution with BMI and WC. Data of offspring from the Western Australian Pregnancy Cohort (Raine) Study at ages 14 and 22 years were used (n = 667). SSB intake at 14 years (100 g/day) was associated with higher BMI (β = 0.19 kg/m², 95% CI 0.04, 0.33), WC (β = 0.41cm, 95% CI 0.04, 0.78), and being overweight at 22 years (OR 1.10, 95% CI 1.02, 1.18). Every 100g modelled substitution of SSB with milk at age 14 years was associated with lower BMI (−0.19 kg/m²) and WC (−0.52 cm) at age 22 years. Replacement of SSB with diet drink was associated with higher BMI and WC. No association was found for substitutions of SSB with water, tea/coffee, or 100% fruit juice with BMI or WC. SSB intake during adolescence was associated with higher BMI, WC, and being overweight in early adulthood. Milk as an alternative to SSB was associated with less adiposity. Caution is necessary in recommending diet drinks as a SSB alternative.

Consumption Patterns of Milk and 100% Juice in Relation to Diet Quality and Body Weight Among United States Children: Analyses of NHANES 2011-16 Data

Background: The American Academy of Pediatrics (AAP) has recommended placing limits on the consumption of milk and 100% juice by children. Methods: Consumption data for 9,069 children aged 2-19 years came from three cycles of the nationally representative National Health and Nutrition Examination Survey (NHANES 2011-2016). Beverages were classified into 100% juices, milk (whole, reduced fat, and skim), caloric sugar sweetened beverages (SSB), low calorie beverages (LCB), and drinking water. The Healthy Eating Index 2015 and Nutrient Rich Food Index NRF9.3 were two measures of diet quality. Analyses examined consumption patterns for milk and 100% juice in relation to diet quality, AAP recommendations, and BMI z-scores across time and for different age groups. Results: Intakes of milk and 100% juice declined sharply with age, whereas SSB and water increased. Top quartiles of HEI 2015 and NRF9.3 diet quality scores were associated with higher intakes of water, milk, and 100% juice and with lower intakes of SSB. Lower-income groups drank less skim milk and water and more whole milk and SSB. Only 30% of the children consumed any 100% juice. There was no association between the consumption of milk or 100% juice and BMI z-scores for any age group. Conclusions: Top quartiles of diet quality were associated with more milk, 100% juice, and water, and less SSB. Higher quality diets were associated with lower compliance with the AAP 100% juice recommendations. Compliance with the AAP 100% juice recommendations was not associated with lower body weights. Attempts to limit the consumption of milk and 100% juice by children might have the unintended consequence of increasing consumption of SSB and may have limited value for obesity prevention.

Dental caries and related risk factors in Saudi cerebral palsy children

Objective:

To determine caries experience and related risk factors in cerebral palsy (CP) children.

Methods:

Random sample of CP children was examined for dental caries and oral hygiene. Questionnaire was utilized for information about caries risk factors. This cross-sectional study was conducted in Riyadh from December 2014 to May 2015.

Results:

Fifty-two CP children were examined with mean age of 6.3±2.7 years. Only one (1.9%) child out of the 52 had no clinical caries. Combined (dmft plus DMFT) mean caries score among study sample was 9.98±3.99. Older children had significantly higher mean caries scores (11.5±3.34) than younger children (8.86±4.1, p=0.017). The CP children with good oral hygiene had lowest mean caries score (5.8±7.32) as compared to those with fair (9.72±3.3) and poor (11.55±3.05) oral hygiene (p=0.012). Those children whose first dental visit was for routine check-up had significantly (p=0.02) lower mean caries scores (7.33±4.65) than those who made their first visit due to dental problem (11.57±4.15). Similarly, those who had topical fluoride applications by dentist had significantly (p=0.003) lower mean caries scores (8.67±4.14) than those with no topical fluoride application (11.9±2.89).

Conclusion:

The studied CP children had very high caries experience and poor oral hygiene. There was strong association between the high caries experience and poor oral hygiene.

Are Liquid Sugars Different from Solid Sugar in Their Ability to Cause Metabolic Syndrome?

OBJECTIVE

Intake of sugary drinks, especially soft drinks, carries increased risk for obesity and diabetes. This article reviews whether sugary drinks carry different risks for metabolic syndrome compared with foods that contain natural or added sugars.

METHODS

A narrative review was performed to evaluate differences between liquid and solid sugars in their ability to induce metabolic syndrome and to discuss potential mechanisms to account for the differences.

RESULTS

Epidemiological studies support liquid added sugars, such as soft drinks, as carrying greater risk for development of metabolic syndrome compared with solid sugar. Some studies suggest that fruit juice may also confer relatively higher risk for weight gain and insulin resistance compared with natural fruits. Experimental evidence suggests this may be due to differences in how fructose is metabolized. Fructose induces metabolic disease by reducing the energy levels in liver cells, mediated by the concentration of fructose to which the cells are exposed. The concentration relates to the quantity and speed at which fructose is ingested, absorbed, and metabolized.

CONCLUSIONS

Although reduced intake of added sugars (sucrose and high-fructose corn syrup) remains a general recommendation, there is evidence that sugary soft drinks may provide greater health risks relative to sugar-containing foods.

Mothers' Facebook posts about infant health: findings from the Grow2Gether study

BACKGROUND

Social media is a common way for mothers to seek advice about their infants. However, little is known about how low-income urban mothers use social media to obtain infant health information and whether this information is consistent with expert pediatric recommendations.

OBJECTIVES

(1) identify the types of health questions asked by low-income mothers of infants in a social media parenting group; (2) describe whether peer answers are consistent with or contradict AAP guidelines; (3) identify the practices that mothers post about that are inconsistent with AAP guidelines.

METHODS

Forty-three low-income mothers were enrolled in Grow2Gether, a private Facebook group intervention focused on infant care and moderated by a psychologist. All health questions posted by mothers were coded thematically; answers to questions from the group were assessed for consistency with American Academy of Pediatrics (AAP) guidelines related to infant feeding, sleep, screen time, and safety. Additionally, all unique posts that contained practices inconsistent with these AAP guidelines were thematically coded.

RESULTS

In total, 215 posts were coded. Participants posted 61 questions related to infant health, most commonly solid food introduction (8/61), teething (8/61), and breastfeeding (7/61). Of the 77 answers given by peers, 6 contradicted guidelines. Separately, mothers had 73 posts demonstrating practices inconsistent with AAP guidelines [safe sleep (43/73) and screen time (21/73)].

CONCLUSIONS

Mothers' Facebook group interactions in the context of an infant care intervention revealed that when mothers posed direct questions regarding infant health, their peers generally gave answers that did not contradict AAP guidelines. In contrast, mothers' posts simply describing sleep and screen time practices commonly contradicted guidelines.

Food Consumption Patterns of Infants and Toddlers: Findings from the Feeding Infants and Toddlers Study (FITS) 2016

Background

The prevalence of obesity and type 2 diabetes continues to increase. These conditions disproportionately affect minorities and are associated with poor nutrition early in life. Current food-consumption patterns can inform pending dietary guidelines for infants and toddlers.

Objective

The aim of this study was to describe infant feeding, complementary feeding, and food and beverage consumption patterns of 0- to 23.9-mo-olds in the general population.

Methods

The Feeding Infants and Toddlers Study 2016 is a cross-sectional survey of caregivers of children aged <4 y. Dietary data were collected from a national random sample by using a 24-h dietary recall (n = 3235). The percentage of children consuming foods from >400 food groups was calculated. Differences in the percentage consuming between Hispanic, non-Hispanic white, and non-Hispanic black children aged 0-23.9 mo were evaluated with the use of ORs and 95% CIs.

Results

Eighty-three percent of 0- to 23.9-mo-olds (n = 2635) were ever breastfed, 34% of 0- to 3.9-mo-olds (n = 305) and 15% of 4- to 5.9-mo-olds (n = 295) were exclusively breastfed, and 24% of 12- to 14.9-mo-olds (n = 412) consumed breast milk on the day of the recall. Complementary foods were more likely to be introduced before 4 mo in formula-fed infants (27%) than in infants who did not consume formula (5%). Half of 4- to 5.9-mo-olds consumed iron-fortified infant cereal, but few consumed iron-rich meats. Among toddlers (12-23.9 mo; n = 1133), >20% consumed no servings of fruit or vegetables on the day of the recall, approximately half consumed 100% fruit juice, and one-quarter to one-third consumed a sugar-sweetened beverage (SSB).

Conclusions

Breastfeeding initiation and duration have improved, but exclusivity remains low. Low consumption of iron-rich foods, fruit, and vegetables and lack of variety in vegetable consumption are problems. Efforts to reduce the consumption of SSBs and 100% fruit juice are warranted in early childhood.

Ethnic disparities of beverage consumption in infants and children 0-5 years of age; National Health and Nutrition Examination Survey 2011 to 2014

BACKGROUND

Dietary patterns, including beverage consumption, that are developed during a child's first few years of life have been shown to impact dietary choices made later in life. Authoritative sources provide beverage recommendations for infants and children; however, it is unclear if these guidelines are followed and what, if any, the differences are among races/ethnicities. The objective of this study was to examine beverage consumption to recommendations among children 0-5 months, 6-11 months, 12-23 months, 2-3 years, and 4-5 years. Additionally, examine how these beverage patterns associate with nutrient intake and to determine if differences exist in beverage consumption among race/ethnic groups (Non-Hispanic White, Non-Hispanic Black, Hispanic, and Asian) in children aged 0-23 months, 2-3 years, and 4-5 years.

METHODS

Data from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) for children 0-5 years were analyzed (n = 2445). Beverages were classified as follows; milk, 100% juice, diet beverages, sugar sweetened beverages (SSB), and water.

RESULTS

Our results show that regardless of race/ethnicity, dietary recommendation were not always followed. Prior to 6 months, 10% of infants consumed any amount of 100% juice; from 6 to 11 months, 17% of young children were drinking any amount of milk. SSB consumption rapidly increased with age, whereas intake of milk and 100% juice declined after 2 to 3 years of age. Non-Hispanic Black young children consumed the most 100% juice from 2 to 3 years and up, exceeding recommended amounts, and throughout all age groups they consumed the least milk and most SSBs. The decreased intake of nutrient-rich beverages with age was associated with lower intakes of under-consumed nutrients of public health concern. By 4-5 years, 32.7% and 93.8% of children were consuming

CONCLUSIONS

Dietary recommendations for both the introduction of beverages and amounts consumed were not consistently followed for American infants and children 0-5 years. Race/ethnic disparities exist in beverage consumption with Non-Hispanic Black children consuming the least amount of milk and most SSBs. Improving beverage consumption patterns could help improve overall diet quality which directly contributes to overall childhood health.

Collapse

Key Words

• 100% juice
• Beverage
• Children
• Ethnic disparities
• Infants
• Milk
• Nutrient intake
• Recommendations
• Sugar sweetened beverage

Collapse

MESH Headings

• Black or African American/statistics & numerical data
• Animals
• Beverages/statistics & numerical data
• Child, Preschool
• Diet/methods
• Ethnicity/statistics & numerical data
• Female
• Fruit and Vegetable Juices/statistics & numerical data
• Humans
• Infant
• Infant, Newborn
• Male
• Milk/statistics & numerical data
• Nutrition Surveys/statistics & numerical data
• United States
• White People/statistics & numerical data

Collapse

Grants

• National Dairy Council

Collapse

Affiliation(s)

Elieke Demmer National Dairy Council, 10255 West Higgins Road, Suite 900, Rosemont, IL 60018-5616 USA
Christopher J. Cifelli National Dairy Council, 10255 West Higgins Road, Suite 900, Rosemont, IL 60018-5616 USA
Jenny A. Houchins National Dairy Council, 10255 West Higgins Road, Suite 900, Rosemont, IL 60018-5616 USA
Victor L. Fulgoni Nutrition Impact, LLC, Battle Creek, MI 49014 USA

Collapse

Beverage consumption patterns among 4-19 y old children in 2009-14 NHANES show that the milk and 100% juice pattern is associated with better diets

BACKGROUND

Patterns of beverage consumption among children and adolescents can be indicative of food choices and total diet quality.

METHODS

Analyses of beverage consumption patterns among 8119 children aged 4-19 y were based on the first 24-h recall of the National Health and Nutrition Examination Survey (2009-14 NHANES). Four pre-defined beverage patterns were: 1) milk pattern; 2) 100% juice pattern; 3) milk and 100% juice pattern; and 4) other caloric beverages. Food- and nutrient-based diet quality measures included the Healthy Eating Index 2010.

RESULTS

Most children drank other caloric beverages, as opposed to milk (17.8%), 100% juice (5.6%), or milk and 100% juice (13.5%). Drinkers of milk and 100% juice had diets that did not differ from each other in total calories, total and added sugars, fiber, or vitamin E. Milk drinkers consumed more dairy and had higher intakes of calcium, potassium, vitamin A and vitamin D as compared to all other patterns. Juice drinkers consumed more total fruit, same amounts of whole fruit, and had higher intakes of vitamin C as compared to the other consumption patterns. Drinkers of both milk and 100% juice had the highest HEI 2010 scores of all the consumption patterns.

CONCLUSIONS

Beverage consumption patterns built around milk and/or 100% juice were relatively uncommon. Promoting the drinking of milk and 100% juice, in preference to other caloric beverages, may be an effective strategy to improve children's diet quality. Restricting milk and 100% juice consumption may encourage the selection of other caloric beverages.

Food sources of free sugars in children's diet and identification of lifestyle patterns associated with free sugars intake: the GRECO (Greek Childhood Obesity) study

OBJECTIVE

Excessive free sugars consumption has a possible role in health issues, diet quality and obesity development. The present cross-sectional study aimed to identify the major food sources of free sugars in Greek children's diet and investigate possible associations of dietary patterns with free sugars intake.

DESIGN

Anthropometric measurements and information on dietary and physical activity habits were obtained. Energy and free sugars intake coming from foods were estimated and principal components analysis was applied to identify dietary patterns.

SETTING

The GRECO (Greek Childhood Obesity) study.

SUBJECTS

Nationwide sample of 3089 children (aged 10-12 years).

RESULTS

Adopting WHO criteria, 44·2 % of participants were categorized as having free sugars intake above 10 % of total energy intake. Mean contribution of free sugars to energy intake was 11·2 %, and the major food sources of free sugars differed from those of other childhood populations. Free sugars intake was not associated with overweight/obesity. Multiple linear regression analysis revealed that two lifestyle and dietary patterns, characterized by higher consumption of sweets, fast foods, fries, sugared drinks, frequently ordering/eating outside home and having meals in front of a screen (pattern 1) and higher consumption of whole fruits, 100 % fruit juices, vegetables, legumes and honey/jam (pattern 2), were positively associated with free sugars intake.

CONCLUSIONS

A large proportion of children exceeded the recommended cut-off and free sugars intake was associated with lifestyle patterns rather than single foods. Public health programmes aiming to reduce free sugars consumption should be tailored on promoting the correct dietary habits of specific childhood populations.

Beverage intake of Australian children and relationship with intake of fruit, vegetables, milk and body weight at 2, 3.7 and 5 years of age

AIM

Describe the type and amount of beverages consumed by Australian children at age 2, 3.7 and 5; investigate the longitudinal relationship between intake of sweet beverages with fruits and vegetables or milk/alternatives, and body mass index (BMI) z-score.

METHODS

Mothers in the NOURISH trial completed a single 24-hour recall of their child's intake, at age 2 (n = 515), 3.7 (n = 426) and 5 (n = 405). Anthropometry was measured by study staff. At each time point, proportion of children consuming at least one beverage on 24-hour recall from the following groups was determined; essential-cow's milk/alternatives, breast milk; non-essential-formula, sweet beverages. For consumers, intake (grams) of each beverage and proportion total estimated energy intake was calculated. The longitudinal relationship between intake of sweet beverages, and fruit and vegetable intake (g/kg body weight), with BMI z-score at 2, 3.7 and 5 years was examined using structural equation modelling. A second model investigated relationship with intake of milk/alternatives.

RESULTS

Sweet beverages were consumed by 38, 55 and 47% of children at each time point. Intake of sweet beverages strongly correlated between two and five years; however, intake was not associated with BMIz and did not appear to displace fruit and vegetable intake. Intake of cow's milk declined over time and was negatively associated with intake of sweet beverages at two and five years.

CONCLUSIONS

Tracking of intake over time supports the notion that children's early experience of sweet tastes is a strong predictor of future intake. Limiting exposure to sweet beverages in early childhood remains an important strategy in the development of healthy food preferences and promotion of dietary quality.

Prenatal and Early Life Fructose, Fructose-Containing Beverages, and Midchildhood Asthma

RATIONALE

Cross-sectional studies have linked intake of high-fructose corn syrup-sweetened beverages with asthma in schoolchildren.

OBJECTIVES

To examine associations of maternal prenatal and early childhood intake of sugar-sweetened beverages and fructose with current asthma in midchildhood (median age, 7.7 yr).

METHODS

We assessed maternal pregnancy (first- and second-trimester average) and child (median age, 3.3 yr) intake of sugar-sweetened beverages and total fructose using food frequency questionnaires in 1,068 mother-child pairs from Project Viva, a prospective prebirth cohort. In a multivariable analysis, we examined associations of quartiles of maternal and child sugar-sweetened beverage, juice, and total fructose intake with child current asthma in midchildhood, assessed by questionnaire as ever having doctor-diagnosed asthma plus taking asthma medications or reporting wheezing in the past 12 months.

RESULTS

Higher maternal pregnancy sugar-sweetened beverage consumption (mean, 0.6 servings/d; range, 0-5) was associated with younger maternal age, nonwhite race/ethnicity, lower education and income, and higher prepregnancy body mass index. Adjusting for prepregnancy body mass index and other covariates, comparing quartile 4 with quartile 1, higher maternal pregnancy intake of sugar-sweetened beverages (odds ratio, 1.70; 95% confidence interval, 1.08-2.67) and total fructose (odds ratio, 1.58; 95% confidence interval, 0.98-2.53) were associated with greater odds of midchildhood current asthma (prevalence, 19%). Higher early childhood fructose intake (quartile 4 vs. quartile 1) was also associated with midchildhood current asthma in models adjusted for maternal sugar-sweetened beverages (odds ratio, 1.79; 95% confidence interval, 1.07-2.97) and after additional adjustment for midchildhood body mass index z-score (odds ratio, 1.77; 95% confidence interval, 1.06-2.95).

CONCLUSIONS

Higher sugar-sweetened beverage and fructose intake during pregnancy and in early childhood was associated with childhood asthma development independent of adiposity.

Breakfast Quality Varies by Location among Low-Income Ethnically Diverse Children in Public Urban Schools

OBJECTIVE

To evaluate breakfast location and children's food choices.

METHODS

Cross-sectional analysis of 1,371 fourth- through sixth-grade students in 2013. Foods and beverages in 17 categories characterized breakfast choices: (1) ≥ 1 fruits or vegetables, (2) ≥ 1 foods high in saturated fats and added sugars (SFAS), and (3) meeting School Breakfast Program (SBP) requirements.

RESULTS

Among breakfast eaters (n = 1,133; 82.6%), 46.0% ate at home, 13.1% ate at school, 41.0% ate at multiple locations; and 21.8% ate at a corner store. Those eating at school were more likely to consume ≥1 fruit or vegetable (odds ratio [OR] = 1.90; 95% confidence interval [CI], 1.26-2.87), less likely to eat ≥1 SFAS food (OR = 0.46; 95% CI, 0.22-0.94), and more likely to meet SBP requirements (OR = 2.47; 95% CI, 1.42-4.29). Those eating at corner stores (n = 247) were more likely to consume high-SFAS foods (63.9% vs 9.2%; P < .001).

CONCLUSIONS AND IMPLICATIONS

Eating school breakfast increased the odds of consuming fruit, choosing lower SFAS, and meeting nutritional requirements of the SBP relative to other locations.

Parental Knowledge of AAP Juice Guidelines Is Associated With Parent and Children's Consumption of Juice and Sugar-Sweetened Beverages in an Underserved Population

This study tested whether parental knowledge of the American Academy of Pediatrics' (AAP) recommendations on juice limits for children is associated with decreased consumption of juice and sugar-sweetened beverages (SSBs) among parents and children. Fifty-two parents with children 2 to 12 years old in a resident continuity clinic in East Harlem, New York, completed a survey asking about children's and parent's practice and quantitative consumption of juice and SSBs as well as parental knowledge of the AAP recommendations on juice limits. Parent's total daily consumption of juice and SSBs ( P < .01), parent's score on the test of AAP guidelines ( P = .04), and parent's post-high school education ( P = .01) were associated with children's juice and SSB consumption in a multivariable linear regression model. Children's consumption of juice and SSBs is positively associated with parental consumption of juice and SSBs and negatively associated with parental formal education and knowledge of the AAP recommendations on juice limits.

Open Up and Let Us In: An Interprofessional Approach to Oral Health

Dental caries is the single most common chronic disease of childhood in the United States. Access to dental care is one of the barriers to improved oral health for children. Primary care providers who routinely treat children have an established role in prevention and early identification of health problems; thus, they are ideal front-line providers who can detect oral health discrepancies and begin the process of care and prevention.

Diet Quality among Preschool-Age Children of Latino Migrant and Seasonal Farmworkers in the United States

Dietary quality has been linked to obesity in children. Obesity among children of farmworker families exceeds that of other US Hispanic children. Knowledge of their dietary quality is needed to understand the origins and prevention of this obesity. Mothers (n = 237) of 3-year old children in farmworker families completed 3 24-hour recalls with trained interviewers using the Nutrition Data System for Research (NDS-R). Output was used to calculate total and component scores of the Revised Children's Diet Quality Index (RC-DQI). Mean total score was 62 (range 36-86) of an optimal score of 90. Scores for total fat, total grains, excess juice and iron were >80 % of the optimum, but scores for added sugar, whole grains, fruits, and vegetables were considerably lower. Children in farmworker families have low overall dietary quality. Intervention targeted to specific food issues may be an efficient way to addressing the problem.

Sugar in Infants, Children and Adolescents: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

The consumption of sugars, particularly sugar-sweetened beverages (SSBs; beverages or drinks that contain added caloric sweeteners (ie, sucrose, high-fructose corn syrup, fruit juice concentrates), in European children and adolescents exceeds current recommendations. This is of concern because there is no nutritional requirement for free sugars, and infants have an innate preference for sweet taste, which may be modified and reinforced by pre- and postnatal exposures. Sugar-containing beverages/free sugars increase the risk for overweight/obesity and dental caries, can result in poor nutrient supply and reduced dietary diversity, and may be associated with increased risk of type 2 diabetes mellitus, cardiovascular risk, and other health effects. The term "free sugars," includes all monosaccharides/disaccharides added to foods/beverages by the manufacturer/cook/consumer, plus sugars naturally present in honey/syrups/unsweetened fruit juices and fruit juice concentrates. Sugar naturally present in intact fruits and lactose in amounts naturally present in human milk or infant formula, cow/goat milk, and unsweetened milk products is not free sugar. Intake of free sugars should be reduced and minimised with a desirable goal of <5% energy intake in children and adolescents aged ≥2 to 18 years. Intake should probably be even lower in infants and toddlers <2 years. Healthy approaches to beverage and dietary consumption should be established in infancy, with the aim of preventing negative health effects in later childhood and adulthood. Sugar should preferably be consumed as part of a main meal and in a natural form as human milk, milk, unsweetened dairy products, and fresh fruits, rather than as SSBs, fruit juices, smoothies, and/or sweetened milk products. Free sugars in liquid form should be replaced by water or unsweetened milk drinks. National Authorities should adopt policies aimed at reducing the intake of free sugars in infants, children and adolescents. This may include education, improved labelling, restriction of advertising, introducing standards for kindergarten and school meals, and fiscal measures, depending on local circumstances.

Metabolic syndrome in children and adolescents

Prevalence of metabolic syndrome in children and adolescents is increasing, in parallel with the increasing trends in obesity rates. Varying definitions of this syndrome have hindered the development of a consensus for the diagnostic criteria in the pediatric population. While pathogenesis of metabolic syndrome is not completely understood, insulin resistance and subsequent inflammation are thought to be among its main mechanistic underpinnings. Overweight and obesity are cardinal features, along with abnormal glucose metabolism, dyslipidemia, and hypertension. Other disorders associated with metabolic syndrome include fatty liver, polycystic ovarian syndrome (PCOS), and pro-inflammatory states. Prevention and management of this condition can be accomplished with lifestyle modifications, behavioral interventions, pharmacological and surgical interventions as needed.

Randomized Controlled Trial of a Clinic-Based Intervention to Promote Healthy Beverage Consumption Among Latino Children

The objective of this study was to evaluate an educational module for Latino parents about the health effects of sweet beverages. Latino parents were randomized to receive the beverage module or a control module. Child beverage consumption was assessed at baseline, 2 weeks, 2 months, and 3 months via a beverage recall survey. At 2-week follow-up, children of intervention participants had a mean reduction in 7-day total sugar-sweetened beverage and 100% fruit juice consumption of 16 ounces while controls had a mean increase of 4 ounces ( P = .01). At 2-month and 3-month follow-up, there was a reduction in mean total sugar-sweetened beverage and 100% fruit juice consumption among both intervention and control children. An educational module on beverages for Latino parents reduced child consumption of sweet beverages at 2-week follow-up. However, study participation appears to have also reduced controls' beverage consumption suggesting that frequent intensive surveys of beverage intake may be an intervention unto itself.

A Socio-Ecological Examination of Weight-Related Characteristics of the Home Environment and Lifestyles of Households with Young Children

Home environment and family lifestyle practices have an influence on child obesity risk, thereby making it critical to systematically examine these factors. Thus, parents (n = 489) of preschool children completed a cross-sectional online survey which was the baseline data collection conducted, before randomization, in the HomeStyles program. The survey comprehensively assessed these factors using a socio-ecological approach, incorporating intrapersonal, interpersonal and environmental measures. Healthy intrapersonal dietary behaviors identified were parent and child intakes of recommended amounts of 100% juice and low intakes of sugar-sweetened beverages. Unhealthy behaviors included low milk intake and high parent fat intake. The home environment’s food supply was found to support healthy intakes of 100% juice and sugar-sweetened beverages, but provided too little milk and ample quantities of salty/fatty snacks. Physical activity levels, sedentary activity and the home’s physical activity and media environment were found to be less than ideal. Environmental supports for active play inside homes were moderate and somewhat better in the area immediately outside homes and in the neighborhood. Family interpersonal interaction measures revealed several positive behaviors, including frequent family meals. Parents had considerable self-efficacy in their ability to perform food- and physical activity-related childhood obesity protective practices. This study identified lifestyle practices and home environment characteristics that health educators could target to help parents promote optimal child development and lower their children’s risk for obesity.

Exploring infant feeding practices: cross-sectional surveys of South Western Sydney, Singapore, and Ho Chi Minh City

BACKGROUND

Infant feeding practices are known to influence the child's long-term health. Studies have associated obesity and other diseases with reduced breastfeeding and early introduction of high calorie beverages (HCBs). The rising prevalence of obesity is already a problem in most developed countries, especially Australia, but cultural differences are influential. Our aim is to examine and compare infant feeding practices and educational levels of respondents through questionnaires in three culturally different sites: Campbelltown (South Western Sydney), Australia, Singapore and Ho Chi Minh City, Vietnam (HCMC).

METHODS

Consenting parents and carers (aged ≥18 years old) of at least one child (≤6 years old) were recruited from paediatric clinics in Campbelltown, Singapore and HCMC. Participants completed an infant feeding practices questionnaire regarding breastfeeding, beverage and solid initiation in addition to the parent's ethnicity, age, and educational level. Data was analysed quantitatively using SPSS.

RESULTS

Two hundred eighty-three participants were recruited across the three sites, HCMC (n = 84), Campbelltown (n = 108), and Singapore (n = 91). 237 (82.6%) children were breastfed but in all only 100 (60.2%) were exclusively breastfed for five months or more. There was a statistical difference in rates of breast feeding between each region. HCMC (n = 18, 21.4%) had the lowest, followed by Campbelltown (n = 35, 32.4%), and then Singapore (n = 47, 51.7%). There was also a difference in rates of introduction of HCBs by 3 years of age, with those in HCMC (n = 71, 84.5%) were higher than Campbelltown (n = 71, 65.8%) and Singapore (n = 48, 52.8%). The educational level of respondents was lower in Vietnam where only 46.4% (n = 39) had completed post-secondary education, compared to 75.0% (n = 81) in Campbelltown and 75.8% (n = 69) in Singapore.

CONCLUSIONS

Rates of breast feeding were inversely correlated with rates of introduction of HCB and positively related to educational achievement. Vietnam had lowest rates of breast feeding, higher rates of introduction of HCBs, and lower rates of education. Given rising rates of obesity, there is a need for more effective programmes to promote breast feeding and restrict false advertising of HCBs.

Satisfying America's Fruit Gap: Summary of an Expert Roundtable on the Role of 100% Fruit Juice

The 2015 to 2020 Dietary Guidelines for Americans (DGAs) recognize the role of 100% fruit juice in health and in helping people meet daily fruit recommendations and state that 100% fruit juice is a nutrient-dense beverage that should be a primary choice, along with water and low-fat/fat-free milk. The DGAs note that children are consuming 100% fruit juice within recommendations (that is, 120 to 180 mL/d for children aged 1 to 6 y and 236 to 355 mL/d for children aged 7 to 18 y). Evidence shows that compared to nonconsumers, those who consume 100% fruit juice come closer to meeting daily fruit needs and have better diet quality. In children, 100% fruit juice is associated with increased intakes of nutrients such as vitamin C, folate, and potassium. When consumed within the DGA recommendations, 100% fruit juice is not associated with overweight/obesity or childhood dental caries and does not compromise fiber intake. Preliminary data suggest that polyphenols in some 100% fruit juices may inhibit absorption of naturally occurring sugars. Given its role in promoting health and in helping people meet fruit needs, experts participating in a roundtable discussion agreed that there is no science-based reason to restrict access to 100% fruit juice in public health nutrition policy and programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Reducing or eliminating 100% fruit juice could lead to unintended consequences such as reduced daily fruit intake and increased consumption of less nutritious beverages (for example, sugar-sweetened beverages).

District Policies and Practices Vary in Their Association With Adolescents' Consumption of Milk and 100% Fruit Juice

PURPOSE

Researchers previously examined the relationship between school beverage policies and sugar-sweetened beverage (SSB) consumption. This study addressed a research gap by examining cross-sectional associations between district-level policies and practices and U.S. high school students' consumption of milk and 100% fruit juice.

METHODS

Data from the 2012 School Health Policies and Practices Study and 2013 Youth Risk Behavior Surveillance System were linked for 12 large urban school districts. Outcome variables were daily milk consumption (≥1 glass/day) and 100% fruit juice consumption (≥1 time/day). Exposure variables were five district policies (i.e., restrict SSB sales, maintain closed campuses, offer/sell healthful alternatives, restrict promotional products, and require nutrition education). Logistic regression models estimated the odds of consuming milk or 100% fruit juice daily, conditional on the policies and adjusting for sex, race/ethnicity, grade level, weight status, and district free/reduced-price lunch eligibility (n = 23,173).

RESULTS

Students in districts that required/recommended restricting the times of SSB sales had 55% higher (adjusted odds ratio [AOR], 1.55; 95% confidence interval [CI], 1.28-1.87) odds of consuming ≥1 glass/day of milk than students in districts without this policy. Closed campus policies were associated with lower odds of consuming milk (AOR, .72; 95% CI, .63-.82) and higher odds of consuming juice (AOR, 1.27; 95% CI, 1.07-1.50). Policies requiring/recommending that districts offer/sell healthful alternatives were associated with lower odds of consuming 100% fruit juice daily.

CONCLUSIONS

Results suggest that restricting SSB sales may support adolescents' milk consumption. Future studies should assess whether the implementation of federal standards that further restrict SSB sales in school leads to increased milk consumption.

Perspective: A Historical and Scientific Perspective of Sugar and Its Relation with Obesity and Diabetes

Fructose-containing added sugars, such as sucrose and high-fructose corn syrup, have been experimentally, epidemiologically, and clinically shown to be involved in the current epidemics of obesity and diabetes. Here we track this history of intake of sugar as it relates to these epidemics. Key experimental studies that have identified mechanisms by which fructose causes obesity and diabetes are reviewed, as well as the evidence that the uricase mutation that occurred in the mid-Miocene in ancestral humans acted as a "thrifty gene" that increases our susceptibility for fructose-associated obesity today. We briefly review recent evidence that obesity can also be induced by nondietary sources of fructose, such as from the metabolism of glucose (from high-glycemic carbohydrates) through the polyol pathway. These studies suggest that fructose-induced obesity is driven by engagement of a "fat switch" and provide novel insights into new approaches for the prevention and treatment of these important diseases.

Does the early introduction of solids promote obesity?

Childhood obesity is a major public health challenge across the developed world, and it is vital to understand the modifiable factors that contribute to it. The influence of early-life nutrition on predisposition to later obesity and metabolic disease is now well established. Much research has concentrated on the preventative effects of breastfeeding in relation to childhood obesity risk, but the optimal timing of introducing solid foods has received far less attention. This remains a much-debated and contentious issue, and differing guidelines from international bodies have caused confusion among parents. There is no conclusive evidence from current research that introducing solids before six months of age is associated with an increased risk of obesity in infancy or childhood. Current studies suggest that the most clearly established risk factor for childhood obesity is maternal body mass index. There is a need for continued research in this area.

Fruit Juice and Change in BMI: A Meta-analysis

CONTEXT

Whether 100% fruit juice consumption causes weight gain in children remains controversial.

OBJECTIVE

To determine the association between 100% fruit juice consumption and change in BMI or BMI z score in children.

DATA SOURCES

PubMed, Embase, CINAHL, and Cochrane databases.

STUDY SELECTION

Longitudinal studies examining the association of 100% fruit juice and change in BMI measures were included.

DATA EXTRACTION

Two independent reviewers extracted data using a predesigned data collection form.

RESULTS

Of the 4657 articles screened, 8 prospective cohort studies (n = 34 470 individual children) met the inclusion criteria. Controlling for total energy intake, 1 daily 6- to 8-oz serving increment of 100% fruit juice was associated with a 0.003 (95% CI: 0.001 to 0.004) unit increase in BMI z score over 1 year in children of all ages (0% increase in BMI percentile). In children ages 1 to 6 years, 1 serving increment was associated with a 0.087 (95% confidence interval: 0.008 to 0.167) unit increase in BMI z score (4% increase in BMI percentile). 100% fruit juice consumption was not associated with BMI z score increase in children ages 7 to 18 years.

LIMITATIONS

All observational studies; studies differed in exposure assessment and covariate adjustment.

CONCLUSIONS

Consumption of 100% fruit juice is associated with a small amount of weight gain in children ages 1 to 6 years that is not clinically significant, and is not associated with weight gain in children ages 7 to 18 years. More studies are needed in children ages 1 to 6 years.

Beverage Consumption among U.S. Children Aged 0-24 Months: National Health and Nutrition Examination Survey (NHANES)

Data on beverage consumption patterns in early life are limited. The aim of this study was to describe beverage consumption by sociodemographic characteristics, along with water intake and sources of water among U.S. children aged 0-24 months. Data from 2740 children in the 2005-2012 NHANES were analysed. Food intake was determined via one 24-h dietary recall. Beverages were categorised according to What We Eat In America groups. Poverty-Income ratio was used to define household income. During infancy (0-5.9 months and 6-11.9 months) infant formulas were the most commonly consumed beverage, 74.1% and 78.6% of children consuming, respectively. Comparatively fewer children, 41.6% and 24.3%, consumed breast milk. In toddlers (12-24 months), the most commonly consumed beverages were plain milk (83.6% of children consuming), water (68.6%), 100% fruit juice (51.8%) and sweetened beverages (31.2%). Non-Hispanic black and Mexican-American children were more likely to consume sweetened beverages, 100% fruit juice and infant formula than Non-Hispanic white children. Children from lower income households were more likely to consume sweetened beverages and 100% fruit juice and less likely to consume breast milk than children from higher income households. Total water intake increased with age and the contribution of water from food and beverage sources was ~20% and ~80% for all children, respectively. Disparities in beverage consumption by race/ethnicity and income level are apparent in early life.

Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline

COSPONSORING ASSOCIATIONS

The European Society of Endocrinology and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.

OBJECTIVE

To formulate clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity.

PARTICIPANTS

The participants include an Endocrine Society-appointed Task Force of 6 experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The Task Force commissioned 2 systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and co-sponsoring organizations reviewed and commented on preliminary drafts of this guideline.

CONCLUSION

Pediatric obesity remains an ongoing serious international health concern affecting ∼17% of US children and adolescents, threatening their adult health and longevity. Pediatric obesity has its basis in genetic susceptibilities influenced by a permissive environment starting in utero and extending through childhood and adolescence. Endocrine etiologies for obesity are rare and usually are accompanied by attenuated growth patterns. Pediatric comorbidities are common and long-term health complications often result; screening for comorbidities of obesity should be applied in a hierarchal, logical manner for early identification before more serious complications result. Genetic screening for rare syndromes is indicated only in the presence of specific historical or physical features. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated. The prevention of pediatric obesity by promoting healthful diet, activity, and environment should be a primary goal, as achieving effective, long-lasting results with lifestyle modification once obesity occurs is difficult. Although some behavioral and pharmacotherapy studies report modest success, additional research into accessible and effective methods for preventing and treating pediatric obesity is needed. The use of weight loss medications during childhood and adolescence should be restricted to clinical trials. Increasing evidence demonstrates the effectiveness of bariatric surgery in the most seriously affected mature teenagers who have failed lifestyle modification, but the use of surgery requires experienced teams with resources for long-term follow-up. Adolescents undergoing lifestyle therapy, medication regimens, or bariatric surgery for obesity will need cohesive planning to help them effectively transition to adult care, with continued necessary monitoring, support, and intervention. Transition programs for obesity are an uncharted area requiring further research for efficacy. Despite a significant increase in research on pediatric obesity since the initial publication of these guidelines 8 years ago, further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions. Also needed are more studies to better understand the genetic and biological factors that cause an obese individual to manifest one comorbidity vs another or to be free of comorbidities. Furthermore, continued investigation into the most effective methods of preventing and treating obesity and into methods for changing environmental and economic factors that will lead to worldwide cultural changes in diet and activity should be priorities. Particular attention to determining ways to effect systemic changes in food environments and total daily mobility, as well as methods for sustaining healthy body mass index changes, is of importance.

Mitigating dietary arsenic exposure: Current status in the United States and recommendations for an improved path forward

Inorganic arsenic (iAs) is a well-characterized carcinogen, and recent epidemiologic studies have linked chronic exposures to non-cancer health outcomes, including cardiovascular disease, diabetes, skin lesions and respiratory disorders. Greater vulnerability has been demonstrated with early life exposure for health effects including lung and bladder cancer, immunotoxicity and neurodevelopment. Despite its well-known toxicity, there are important gaps in the regulatory oversight of iAs in food and in risk communication. This paper focuses on the US regulatory framework in relation to iAs in food and beverages. The state of existing regulatory agency toxicological assessments, monitoring efforts, standard setting, intervention policies and risk communication are explored. Regarding the approach for standard setting, risk-based evaluations of iAs in particular foods can be informative but are insufficient to create a numeric criterion, given current uncertainties in iAs toxicology and the degree to which traditional risk targets can be exceeded by dietary exposures. We describe a process for prioritizing dietary exposures for different lifestages and recommend a relative source contribution-based approach to setting criteria for arsenic in prioritized foods. Intervention strategies begin with an appropriately set criterion and a monitoring program that documents the degree to which this target is met for a particular food. This approach will promote improvements in food production to lower iAs contamination for those foods which initially do not meet the criterion. Risk communication improvements are recommended to ensure that the public has reliable information regarding sources and alternative dietary choices. A key recommendation is the consideration of meal frequency advice similar to what is currently done for contaminants in fish. Recent action level determinations by FDA for apple juice and infant rice cereal are evaluated and used as illustrations of how our recommended approach can further the goal of exposure mitigation from key sources of dietary iAs in the US.

100% citrus juice: Nutritional contribution, dietary benefits, and association with anthropometric measures

Citrus juices such as 100% orange (OJ) and grapefruit juice (GJ) are commonly consumed throughout the world. This review examines the contributions of OJ and GJ to nutrient intake, diet quality, and fruit intake, and supports citrus juices as nutrient-dense beverages. This review also explores the research examining associations between OJ and GJ intake and anthropometric measures. Citrus juices are excellent sources of vitamin C and contribute other key nutrients such as potassium, folate, magnesium, and vitamin A. OJ intake has been associated with better diet quality in children and adults. OJ intake has not been associated with adverse effects on weight or other body measures in observational studies in children and adults. In adults, some observational studies report more favorable body mass index or body measure parameters in OJ consumers compared to nonconsumers. Intervention studies in adults report no negative impacts of OJ or GJ consumption on anthropometric measures, although these measures were typically not the primary outcomes examined in the studies. Moderate consumption of citrus juices may provide meaningful nutritional and dietary benefits and do not appear to negatively impact body weight, body composition, or other anthropometric measures in children and adults.

Are Diet and Constipation Related in Children?

Constipation is a common complaint in childhood, and the etiology of many healthcare referrals. Despite literature documenting the high frequency of this problem, there is little research directly relating the food consumed and the eventual stool consistency. There is literature suggesting the importance of adequate fiber intake in children to maintain soft stools. Other dietary modifications actually have not been shown to be helpful or are not based on actual clinical studies. The presence of dietary allergies may also contribute to etiology of constipation. More studies to provide further linkages between diet and constipation are clearly needed.

Design and methods for a community-based intervention to reduce sugar-sweetened beverage consumption among youth: H2GO! study

Background

Reducing sugar-sweetened beverage (SSB) intake is an important dietary target among underserved children at high risk for obesity and associated morbidities. Community-based approaches to reduce SSB intake are needed. The use of narrative-based approaches (presenting messages within the context of a story) can facilitate connection with target health messages and empower children as behavior change agents within their families. The H₂GO! program is a community-based behavioral intervention that integrates narrative-based strategies to reduce SSB consumption and promote water intake among school-age youth and parents.

Methods

Guided by the Social Cognitive Theory and the Social Ecological Model, the H₂GO! intervention consists of 6 weekly sessions that target beverage knowledge, attitudes, and behaviors through youth-produced messages and narratives to reduce SSB intake and encourage water intake and parent–child activities. To reach underserved youth and families, we identified Boys & Girls Clubs (B&GC) (youth-based community centers that serve an ethnically diverse and predominantly low socioeconomic status population) as a community partner and study setting. Participants (children ages 9–12 years and their parents) will be recruited from B&GC sites in Massachusetts, USA. Intervention efficacy will be assessed through a site-randomized trial (N = 2 youth-based community sites, pair-matched for size and racial/ethnic composition) with 54 parent–child pairs (N = 108) enrolled per site (N = 216 total). The comparison site will carry on with usual practice. Child and parental SSB and water consumption (primary outcomes) and parent and child beverage knowledge and attitudes (secondary outcomes) will be measured via self-report surveys. Additional outcomes include children’s anthropometric data, additional dietary behaviors, and physical activity. Measures will be collected at baseline, 2 and 6 months follow-up. With an estimated 20 % dropout rate, the study will have 80 % power to detect a group difference of 3.9 servings of SSBs per week.

Discussion

Community-based approaches hold potential for decreasing SSB consumption among youth and families, particularly among underserved populations who are at greater obesity risk. This article describes the design and methods of a community-based behavioral intervention designed to reduce SSB consumption among youth and parents/caregivers.

Trial registration

ClinicalTrials.gov NCT02890056. Date of Registration: August 31, 2016

Badly Behaving Noses in Children: Rhinitis, Sinusitis, or Neither?

Every pediatrician has likely experienced frustration with cases of chronic nasal symptoms that either do not seem to get better or do show improvement but then worsen again. Often, this leads to the diagnosis of allergic rhinitis or sinusitis and subsequent prescription of medication(s) that may or may not be warranted. This article discusses the various causes of rhinitis, both allergic and nonallergic. Recommendations for treatment place special focus on nasal irrigation and the role that a child's diet can have on chronic nasal symptoms, with the hope of reducing excessive and sometimes unnecessary medication use. [Pediatr Ann. 2016;45(11):e384-e387.].

Compliance of Parenting Magazines Advertisements with American Academy of Pediatrics Recommendations

This study examined 3218 advertisements from the two parenting magazines with highest circulation in the United States. The authors compared each advertisement for a product for use by children, against all the published recommendations of the American Academy of Pediatrics (AAP) on topics such as toy safety, helmet use, age-defined choking hazards, infant sleep safety, and others. Any advertisement with images or products which went against a published AAP recommendation was deemed as non-adherence and was categorized according to the statement it contradicted. Nearly one in six (15.7%) of the advertisements contained example(s) of non-adherence to AAP recommendations, with twelve categories of offense represented. Categories ranked by overall share from most to least include: non-Food and Drug Administration (FDA) approved medical treatments, age-defined choking hazards, vitamins, cold medicine, formula, oral care, screen time, toy/playground safety, infant sleep, nutrition, water safety, and fall risk. Given that repeated exposure to messages in advertisements has been associated with changes in health decision-making, and parents often turn to parenting magazines for advice and ideas regarding their children, the publishers might consider screening the content in order to prevent confusing and potentially dangerous messages from being disseminated in the media.

The Sweet Path to Metabolic Demise: Fructose and Lipid Synthesis

Epidemiological studies link fructose consumption with metabolic disease, an association attributable in part to fructose-mediated lipogenesis. The mechanisms governing fructose-induced lipogenesis and disease remain debated. Acutely, fructose increases de novo lipogenesis through the efficient and uninhibited action of ketohexokinase and aldolase B which yields substrates for fatty-acid synthesis. Chronic fructose consumption further enhances the capacity for hepatic fructose metabolism by activating several key transcription factors (i.e., SREBP1c and ChREBP) which augment the expression of lipogenic enzymes, increasing lipogenesis and further compounding hypertriglyceridemia and hepatic steatosis. Hepatic insulin resistance develops from diacylglycerol-PKCɛ-mediated impairment of insulin signaling and possibly additional mechanisms. Initiatives that decrease fructose consumption and therapies that block fructose-mediated lipogenesis will be necessary to avert future metabolic pandemics.

Dietary and economic effects of eliminating shortfall in fruit intake on nutrient intakes and diet cost

Background

Children in the United States do not consume the recommended amounts of fruit. The economic and dietary consequences of meeting the shortfall in fruit consumption have not been evaluated.

Methods

Analyses were based on a nationally representative sample of 4–18 year-old children (n = 2,647) from the 2009–2010 National Health and Nutrition Examination Survey (NHANES). The shortfall in total fruit consumption for each child was estimated based on the USDA MyPlate recommendations. The potential impact of filling the shortfall in total fruit consumption was projected with whole fruit alone (WF model) or a combination of 100 % fruit juice and whole fruit (FJ + WF model). Juice consumption was capped using American Academy of Pediatrics (AAP) standards. The USDA national food prices database was used to estimate the cost of meeting the dietary recommendations for fruit. Selected nutrient and mineral intakes, as well as daily diet cost were estimated after eliminating the shortfall in fruit consumption.

Results

Among all children, vitamin C (+22.8 mg [95 % CI 21.4, 24.1] in the WF model and +48.1 mg [95 % CI 45.2, 51.1] in the FJ + WF model) and potassium intakes (+203 mg [95 % CI 190, 215] in WF and +263 mg [95 % CI 248, 280] in FJ + WF) were increased in both models. The FJ + WF model resulted in a marginal increase in dietary fiber (e.g., a relative change less than 10 %), while the WF model resulted in a meaningful increase in dietary fiber (e.g., a relative change greater than 10 %; +2.2 g [95 % CI 2.1, 2.3]). Conversely, the WF model resulted in only a marginal increase in calcium, while the FJ + WF model resulted in a meaningful increase in calcium (+85 mg [95 % CI 79, 89]). Calories were increased in all models (+4.5 % [95 % CI 4.1, 4.9 %] for FJ + WF and +3.5 % [95 % CI 3.2, 3.7 %] for WF). Meeting the fruit shortfall with whole fruit alone increased estimated diet costs by 9.9 % (+$0.44/d [95 % CI 0.42, 0.47]), while the fruit juice/whole fruit combination increased diet costs by 5.2 % (+$0.23/d [95 % CI 0.22, 0.25]).

Conclusions

Meeting fruit consumption guidelines without a substantial increase in diet costs may be a challenge. Combining whole fruit with 100 % fruit juice capped at AAP standards may be one approach to meeting fruit recommendations within cost constraints. Identifying approaches to increasing whole fruit consumption in as cost-neutral a fashion as possible should be a priority.