Dairy Council November | December 2008 Volume 79 ® Number 6

SUMMARY A review of the scientific literature indicates that flavored milk such as chocolate milk Flavored milk is white cow’s milk consumed in moderation does not cause (whole, low-fat, fat-free) with added overweight/obesity, tooth decay, or flavoring (chocolate, strawberry, etc.) hyperactivity and other behavioral disorders and sweetener(s). This highly preferred, in children. Also, chocolate milk contains a nutrient-rich beverage is just as nutritious negligible amount of caffeine and the little as unflavored (white) milk. Both flavored amount of oxalic acid in chocolate milk does and white milk provide several nutrients not impair calcium absorption. Emerging (i.e., calcium, potassium, and magnesium) research indicates that chocolate milk that are low in children’s and adults’ diets. may help adults recover from strenuous, energy-depleting resistance exercise. Currently, more than half of children ages 2 to 8 and three-quarters of adolescents Several health professional organizations fail to consume recommended servings of including the American Academy of low-fat or fat-free milk or milk products. Pediatrics and the American Academy of Therefore, it is important not to limit Pediatric Dentistry support consumption children’s and adolescents’ access to of flavored milk, a nutrient-rich beverage, in flavored milk due to its sugar content. moderation. The 2005 Dietary Guidelines FLAVORED Doing so may have the undesirable effect for Americans state that small amounts MILK: of further reducing intakes of many of sugars added to nutrient-dense foods, essential nutrients provided by milk. such as reduced-fat milk, may increase QUESTIONS & consumption by enhancing palatability, Children’s consumption of flavored milk thus improving nutrient intake without ANSWERS has been shown to increase their total contributing excessive calories. milk and nutrient intakes and reduce their intake of soft drinks and other Flavored milk contains both natural (lactose) energy-dense, nutrient-poor beverages. and added sugars. On average, flavored Moreover, a recent study found that milk contains an additional 4 teaspoons drinking flavored or white milk was not of sugar and 60 calories per 8 ounces due associated with adverse effects on children’s to the addition of sucrose and/or other and adolescents’ body mass index. nutritive sweeteners. Flavored milk contains less added sugar than other beverages consumed by children, such as fruit drinks and soft drinks. There is no current consensus on a national school nutrition standard for flavored milk, however, suggestions have been made to reduce the amount of sugar in foods and beverages in schools. The dairy industry, through new product innovation, is developing reduced sugar flavored milk formulations that will appeal to children. D

The Dairy Council Digest® is available on-line. www.nationaldairycouncil.org 31 A N I N T E R P R E T I V E R E V I E W O F R E C E N T N U T R I T I O N R E S E A R C H INTRODUCTION November | December 2008 Q. How does flavored milk impact the quality Flavored milk is white cow’s milk (whole, of children’s and low-fat, fat-free) with added flavoring adolescents’ diets? (e.g., chocolate, strawberry, vanilla, banana, root beer, etc.) and sweetener(s). Among A. Studies show that consuming low-fat flavored milks, chocolate milk is the most or fat-free flavored milk can help children popular (1,2). Despite the wide variety Flavored milk – and adolescents meet the 2005 Dietary and popularity of flavored milks, some a nutrient-rich Guidelines for Americans’ recommendations questions about their nutritional and health beverage providing for dairy foods and increase their intake of benefits continue to be raised, especially milk nutrients (6-8). The Dietary Guidelines by some parents/care providers and the same recommend that children ages 2 to 8 years school nutrition policy makers. This Digest essential nutrients consume 2 cups per day of low-fat or addresses some of the questions related as unflavored fat-free milk or equivalent milk products to the consumption of flavored milk, (i.e., cheese, yogurt), and that all people particularly chocolate milk, and presents (white) milk – 9 years and older consume 3 cups per day recommendations offered by health is a well-accepted, of low-fat or fat-free milk or equivalent milk professional organizations. nutritious products (4). However, many Americans, alternative to both children and adults, are not consuming Q. Is flavored milk as nutritious recommended daily servings of dairy foods as unflavored (white) milk? the wide array of (9,10). More than half (53%) of children beverages available ages 2 to 8 and more than three-quarters A. Flavored milk is a nutrient-rich beverage to children and (77%) of adolescents do not consume the recommended daily servings of milk providing the same nine essential nutrients adolescents. as white milk, including calcium, potassium, products (9). Approximately 60% to 80% phosphorus, protein, vitamin D, vitamin A, of total dairy servings consumed by children and adolescents are consumed as milk, vitamin B12, riboflavin, and niacin (niacin equivalents) (3). Milk, flavored and either as a beverage or as an ingredient unflavored, provides three of the five in mixtures such as pudding or soup (11). nutrients that fall short in children’s diets As children enter adolescence their milk (i.e., calcium, potassium, and magnesium) consumption often decreases, while their and four of the seven nutrients (i.e., vitamin intake of soft drinks increases (12-15). A, calcium, magnesium, and potassium) Children’s diets are low in several essential low in adults’ diets (4). Each 8-ounce nutrients such as calcium, potassium, and serving of flavored or white milk provides magnesium (4). Many children also have 300mg of calcium, which is 37% of the diets inadequate in vitamin D (16). These 800mg of calcium recommended for nutrients, especially calcium and vitamin D, children 4 through 8 and 23% of the are necessary for developing strong 1,300mg of calcium recommended for bones and teeth (17-20). The early years, individuals 9 through 18 years (3,5). particularly during adolescence, are a critical The major difference between flavored and time to build bone mass (20). Studies have unflavored milk is the higher carbohydrate shown that consuming an adequate intake and calorie content of flavored milk due of milk and other dairy foods during to the addition of sucrose and/or other childhood benefits adolescents’ bone health nutritive sweeteners (3). In general, (21) and that low intake of milk during chocolate flavored milks provide about childhood and adolescence is associated 60 more calories per 8-ounce serving than with low bone mass and increased risk of do their unflavored counterparts (3). An fractures in adulthood (19). 8-ounce serving of low-fat (1%) chocolate Children’s consumption of flavored milk milk provides 158 calories, whereas its has been shown to increase their milk and unflavored counterpart provides 102 nutrient intakes (6-8). Using data from calories (3). nearly 4,000 school-aged children and adolescents who participated in the 1994- 96 and 1998 USDA Continuing Survey of Food Intakes by Individuals, researchers 32 found that those who drank flavored milk November | December 2008 200 I.U. per day to 400 I.U. per day) (16). consumed more total milk and fewer soft The report recognizes the importance drinks and fruit drinks compared with of vitamin D-fortified milk as a source of children who did not drink flavored milk (6). vitamin D for children and adolescents. In addition, flavored milk consumers had While optional, nearly all fluid milk, flavored higher calcium and phosphorus intakes, but and plain, marketed in the U.S. is fortified a similar percent of energy from total fat with vitamin D to obtain the standard and added sugars compared with children amount of 400 I.U. per quart (100 I.U. per who did not consume flavored milk (6). A cup) (5). The Food and Drug Administration retrospective analysis of diets of more than recently released a health claim for calcium 3,000 children ages 6 to 17 years found a and vitamin D and osteoporosis that can be positive effect on children’s overall diets used on packages of reduced-fat, low-fat, when they chose flavored milks and yogurts and fat-free milks (22). Consuming vitamin instead of sodas and sweetened drinks (7). D-fortified flavored milk could help improve The researchers suggested that children and vitamin D status, especially for those who adolescents can enhance the quality of their drink little or no white milk. diets by consuming flavored dairy products such as flavored milk in moderation as an Q. What about the amount and alternative to energy-dense, nutrient poor type of added sweeteners beverages (7). in flavored milk? A recent study found that children and adolescents who included flavored milk A. Flavored milk contains both natural in their diets had significantly higher total (mostly in the form of lactose) and added milk intakes than those who exclusively sugars, either nutritive (e.g., sucrose, consumed white (unflavored) milk (8). high fructose corn syrup [HFCS]) or Also, energy-adjusted intakes of vitamin A, non-nutritive, depending on the brand. calcium, phosphorus, magnesium, and Because each manufacturer has a unique potassium were significantly higher for formula, the ingredients, including the children who drank flavored or white milk amount and type of added sweetener(s), than for non-milk drinkers (8). Among vary somewhat among flavored milk females 12-18 years of age, calcium intakes products. On average, an 8-ounce serving by flavored milk drinkers and exclusively of low-fat chocolate milk contains about white milk drinkers were nearly double 4 teaspoons of added sugar, while an the calcium intakes of non-milk drinkers. equivalent amount of soft drinks contains Drinking flavored or white milk was not New research 7 teaspoons. Flavored milk has less sugar associated with adverse effects on body shows that and more nutrients than soft drinks. mass index. This study used data from 7,557 children and Despite allegations linking HFCS with children and adolescents ages 2-18 years adolescents obesity, scientific evidence indicates that who participated in the 1999-2002 National HFCS does not appear to contribute more Health and Nutrition Examination Surveys who drink either to obesity or other chronic diseases than (8). Based on their findings, the researchers flavored or white other nutritive (caloric) sweeteners (23,24). concluded that “limiting children and milk have higher The American Medical Association (AMA), adolescents’ access to flavored milk due to intakes of nutrients based on a review of the scientific literature, its higher added sugars or energy content concluded that, because the composition of may only have the undesirable effect of low in their diets HFCS and sucrose is so similar, particularly further reducing intakes of many essential and similar or with regard to absorption by the body, it nutrients provided by milk,” while having no lower body mass is unlikely that HFCS contributes more to impact on body fat (8). obesity or other conditions than sucrose indexes compared (24). However, the AMA calls for additional Recognizing the importance of adequate to non-milk vitamin D for bone and overall health and research on the health effects of HFCS and the prevalence of vitamin D deficiency drinkers. other sweeteners. among children and adolescents, the The Food and Drug Administration American Academy of Pediatrics (AAP) (FDA) has approved five non-nutritive recently issued a clinical report calling for sweeteners (e.g., saccharin, aspartame, doubling the amount of vitamin D (i.e., from acesulfame-K, sucralose, neotame) (25). 33 Although extensive testing by the FDA November | December 2008 that adhere to tooth surfaces. Also, has shown that these sugar-substitutes studies have demonstrated that several are safe for adults and children, many components in chocolate milk such as consumers who are aware of these calcium, phosphorus, protein, and cocoa sweeteners report that they are trying to may protect teeth from decay (28). The consume less of them (26). The School author of a paper on milk, flavored milk Nutrition Association recommends that products, and caries concluded that the beverages containing non-nutritive Offering low-fat cariogenicity (cavity-forming potential) sweeteners be allowed only in high and fat-free of flavored milks is “negligible to low” schools and only after the end of the flavored milk in and, when consumed in moderation, school day (27). flavored milks are a preferable alternative schools can to similarly sweetened soft drinks (29). Q. Does consumption of help children The American Academy of Pediatric flavored milk cause and adolescents Dentistry states that “chocolate milk is weight gain? meet the Dietary OK for children’s teeth” (30). A. A recent study of 7,557 children and Guidelines for Q. What other concerns adolescents ages 2 to 18 years found that Americans’ have been raised about drinking flavored or white milk did not recommended flavored milk? increase body mass index (BMI) (8). Average daily energy intakes of milk servings for milk A. Scientific evidence does not support drinkers (flavored or white milk) were and other the suggestion that added sugars in significantly greater than daily energy dairy foods. flavored milk cause hyperactivity intakes of those who did not consume in children. Reports that sugars cause milk for all groups except boys ages 6 to hyperactivity (i.e., a cluster of symptoms 11 years. Yet despite higher daily energy including excitability, learning difficulties, intakes, the BMI of milk drinkers was and short attention span), other either comparable (children 2-5 years behavioral disorders, or interfere with and 6-11 years) or lower (males 12-18 academic performance in children have years) than that of milk non-drinkers (8). been based on anecdotal observations, There was no difference in intake of not adequately controlled experiments added sugars between flavored milk (25,31,32). drinkers and non-milk drinkers. With respect to the amount of caffeine in The key to maintaining a healthy body chocolate milk, each cup contains about weight is to balance calories consumed 2 to 7mg (33). Soft drinks, on the other from foods and beverages with calories hand, may contain up to ten times more expended by physical activities (4). caffeine than chocolate milk (33). An Added sugar, when used in moderation examination of food sources and intakes and with concern for overall caloric of caffeine found that soft drinks are the balance, can increase the appeal of major source of caffeine in the diets of nutrient-rich beverages such as flavored children ages 2 to 17 years, whereas a milk and provide additional choices for negligible amount of caffeine is provided children and adolescents, thus improving by flavored dairy products (34). nutrient intake without contributing Chocolate milk contains a negligible excessive calories (4). amount of oxalic acid, a compound occurring naturally in cocoa beans Q. Does flavored milk and other plants. Although oxalic acid consumption cause can combine with calcium to form tooth decay? an insoluble salt, there is no scientific evidence that oxalic acid in chocolate A. There is no scientific evidence that milk impairs calcium absorption. One consumption of flavored milk such as study found that the absorption of chocolate milk causes tooth decay. calcium from chocolate milk was similar Because flavored milk is a beverage, it to that from unflavored milk and other is less likely to cause cavities than many calcium-containing foods (35). other foods such as raisins or candies 34 Q. Why is it important November | December 2008 Q. Do health professional to offer flavored milk to organizations support children at school? flavored milk?

A. Offering flavored milk in schools can A. Several health professional help children and adolescents meet the organizations and nutrition experts Dietary Guidelines’ recommendations recognize the importance of flavored for dairy foods. Research shows that milk in helping children and adolescents students drink more milk when flavored meet their recommended daily intakes of milk is offered in schools. A School Milk dairy foods and dairy food nutrients such Pilot Test, co-sponsored by the School as calcium. The 2005 Dietary Guidelines Nutrition Association and the National for Americans, which identify low-fat and Dairy Council, found that children drank fat-free milk and milk products as one of more milk when schools offered ice-cold the “Food Groups to Encourage,” state milk in various flavors (strawberry, that small amounts of sugars added to chocolate, etc.) in plastic, re-sealable nutrient-dense foods, such as reduced- containers, in different sizes, and different fat milk, may increase consumption by merchandising locations (e.g., vending enhancing palatability, thus improving machines, a la carte cafeteria, school nutrient intake without contributing stores) (36). Children who participate excessive calories (4). Although not in the National School Lunch Program identifying flavored milk specifically, are more likely than non-participants to the American Dietetic Association consume flavored milk (50% vs. 9%) states that “by increasing the palatability and total milk (75% vs. 19%) at lunch of nutrient-dense foods/beverages, as well as over a 24-hour period (15). sweeteners can promote diet The importance to children’s health of healthfulness” (25). The AAP, in a offering low-fat and fat-free flavored policy statement discouraging soft milk in schools, as part of child nutrition drinks in schools (14) and in its report programs and/or outside these programs on optimizing children’s and adolescents’ (e.g., vending machines), is recognized Health bone health and calcium intakes (20), by the AAP (14) and the Institute professional encourages consumption of nutritious of Medicine (IOM), Committee on organizations such beverages including low-fat or fat-free Nutrition Standards for Foods in flavored milks. The IOM recognizes the Schools (37). as the American nutritional value of flavored milk with Academy of modest amounts of sugar for school Q. Is there a national Pediatrics and children (37). nutrition standard for the American Two members of the AAP Committee flavored milk offered Academy of on Nutrition state “given the importance in schools? of calcium, vitamin D and other key Pediatric Dentistry ingredients in the diet of children and A. Currently there is no consensus on have issued adolescents, flavored milks could be a a national school nutrition standard for nice alternative [to unflavored milk] since foods and beverages, including flavored statements the contribution of added sugars to the milk. However, Congress may support supporting and overall diet of young children is minimal” national nutrition standards in 2009 recommending (40). Researchers at Pennsylvania State when it reauthorizes the Child Nutrition flavored milk for University, recognizing the low dairy Act. In the meantime, restrictions on the and calcium intakes of children ages 4 calorie and sugar content of low-fat and children and to 18 years, recommend that nutrition fat-free flavored milks offered in schools adolescents. guidance be focused on increasing have been proposed (27,37,38). The children’s intake of low-fat dairy products dairy industry, through new product “with special emphasis on increasing innovation, is developing reduced sugar calcium intake in school-age children and flavored milk formulations that will adolescents through flavored low-fat milk appeal to children (39). products” (41). Similarly, researchers at the University of Saskatchewan, Canada,

35 suggest adding chocolate milk November | December 2008 34. Frary, C.D., R.D. Johnson, and M.Q. Wang. J. Am. Diet. Assoc. 105: 110, 2005. to school vending machines as a 10. Wells, H.F., and J.C. Buzby. Dietary Assessment 35. Recker, R.R., A. Bammi, M.J. Barger-Lux, et al. of Major Trends in U.S. Food Consumption, Am. J. Clin. Nutr. 47: 93, 1988. strategy to increase children’s and 1970-2005. Economic Information Bulletin No. adolescents’ milk intake (42). The (EIB-33). U.S. Department of Agriculture, 36. National Dairy Council and School Nutrition Economic Research Service, March 2008. Association. The School Milk Pilot Test. Beverage American Academy of Pediatric www.ers.usda.gov/Publications/EIB33/ Marketing Corporation for National Dairy Council and School Nutrition Association. 2002. Dentistry states that chocolate milk 11. Cook, A.J., and J.E. Friday. Pyramid Servings www.nationaldairycouncil.org Intakes in the United States 1999-2002, 1 Day. is OK for children’s teeth, is a highly U.S. Department of Agriculture, Agricultural 37. National Academy of Sciences, Institute of nutritious beverage, is preferable to Research Service, Community Nutrition Medicine, Committee on Nutrition Standards for Research Group, CNRG Table Set 3.0. Foods in Schools. V.A. Stallings and A.L. Yaktine many popular snacks that provide www.ars.usda.gov/sp2UserFiles/Place/12355000/ (Eds). Nutrition Standards for Foods in Schools: foodlinks/ts_3-0.pdf Leading the Way Toward Healthier Youth. calories but few nutrients, and Washington, D.C.: National Academies Press, 2007. 12. Striegel-Moore, R.H., D. Thompson, and S.G. because children like flavored milk Affenito, et al. J. Pediatr. 148: 183, 2006. 38. Alliance for Healthier Generation. Alliance School Beverage Guidelines. they drink more of it (30). 13. Nielsen, S.J., and B.M. Popkin. www.healthiergeneration.org/schools.aspx?id=108. Am. J. Preventative Med. 27: 205, 2004. 39. Dairy Management Inc. New lower-calorie flavored 14. American Academy of Pediatrics, Committee on milk formulations address nutrition issues and win Q. Is it true that School Health. Pediatrics 113: 152, 2004. kids’ approval. March 19, 2008. consuming chocolate 15. U.S. Department of Agriculture, Food and Nutrition www.innovatewithdairy.com. Service. School Nutrition Dietary Assessment 40. Bhatia, J.J.S., and F.R. Greer. AAP News 28 (June), milk helps adult Study – III. Alexandria, VA: Food and Nutrition 2007. www.aapnews.org Service, USDA, November 2007. www.fns.usda.gov athletes recover from (under Research). 41. Kranz, S., P.-J. Lin, and D.A. Wagstaff. J. Pediatr. 151: 642, 2007. strenuous exercise? 16. Wagner, C.L., F.R. Greer, and the Section on Breastfeeding and Committee on Nutrition. 42. Vatanparast, H., E. Lo, C.J. Henry, et al. Nutr. Res. 26: 325, 2006. A. Pediatrics 122: 1142, 2008. Preliminary findings from a 17. U.S. Department of Health and Human Services. 43. Karp, J.R., J.D. Johnston, S. Tecklenburg, et al. single-blind, randomized study of Bone Health and Osteoporosis: A Report of Int. J. Sport Nutr. Exerc. Met. 16: 78, 2006. D nine male endurance-trained cyclists the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, RELATED RESOURCES found that those who drank low-fat Office of the Surgeon General, 2004. chocolate milk after an intense bout www.surgeongeneral.gov/library. www.nationaldairycouncil.org 18. Miller, G.D., J.K. Jarvis, and L.D. McBean. ■ Flavored Milk in Perspective (under Nutrition & of exercise (i.e., glycogen-depleting Handbook of Dairy Foods and Nutrition. Product Information, Dairy Foods, Supportive Boca Raton, FL: CRC Press, 2007, pp. 181-244. exercise) were able to bike about Science) 19. Kalkwarf, H.J., J.C. Khoury, and B.P. Lanphear. ■ A Perspective on Sugars & Health. Dairy twice as long during a second Am. J. Clin. Nutr. 77: 257, 2003. Council Digest 78(4), 2007 (under Health workout before reaching exhaustion 20. Greer, F.R., and N.R. Krebs for the American Professional Resources, Dairy Council Digest Academy of Pediatrics Committee on Nutrition. than those who consumed a Pediatrics 117: 578, 2006. Archives) www.nutritionexplorations.org carbohydrate replacement sports 21. Moore, L.L., M.L. Bradlee, D. Gao, et al. ■ J. Pediatr. 153: 667, 2008. All About Flavored Milk (information for drink, and as long as those who parents and educators) 22. U.S. Department of Health and Human Services, consumed a fluid replacement Food and Drug Administration. Fed. Regist. drink (43). Additional research is 73(189):1, September 29, 2008. 23. International Food Information Council Foundation. Coming Next Issue: needed to support this benefit of What science says about fructose. Food Insight chocolate milk. D July/August: 2, 2008. http://ific.org. SPOTLIGHT ON 24. American Medical Association, Council on Science and Public Health. The Health Effects of High DAIRY FOODS, REFERENCES Fructose Syrup. Report 3 of the Council on Science DAIRY NUTRIENTS, & and Public Health (A-08). June 19, 2008. 1. Conners, P., C. Bednar, and S. Klammer. www.ama-assn.org/ama/pub/category/18641.html BLOOD PRESSURE J. Nutr. Educ. 33: 31, 2001. 25. American Dietetic Association. J. Am. Diet. Assoc. 2. Thompson, J.L., P.D. Gerard, and M.A. Drake. 104: 255, 2004. ACKNOWLEDGMENTS J. Food Sci. 72: 666s, 2007. 26. International Food Information Council (IFIC) 3. U.S. Department of Agriculture, Agricultural Foundation. 2008 Food & Health Survey. Consumer National Dairy Council® assumes the responsibility Research Service. National Nutrient Database Attitudes Toward Food, Nutrition & Health. for this publication. However, we would like to for Standard Reference, Release 21. 2008. Washington, D.C.: IFIC, 2008. http://ific.org acknowledge the help and suggestions of the Nutrient Data Laboratory Home Page. 27. School Nutrition Association. National Nutrition following reviewers in its preparation: www.ars.usda.gov/ba/bhnrc/ndl. Standards Recommendations. June 5, 2008. ■ Rachel K. Johnson, PhD, MPH, RD www.schoolnutrition.org/uploadedFiles/School_ 4. U.S. Department of Health and Human Services Professor of Nutrition Dietary Nutrition/16_LegislativeAction/SNA_National_ and U.S. Department of Agriculture. University of Vermont Guidelines for Americans, 2005. Washington, D.C.: Nutrition_Standards.pdf. US Government Printing Office, 2005. 28. Miller, G.D., J.K. Jarvis, and L.D. McBean. Burlington, VT ■ www.healthierus.gov/dietaryguidelines. Handbook of Dairy Foods and Nutrition. 3rd Ed. Janey Thornton, PhD, SNS 5. Institute of Medicine. Dietary Reference Intakes for Boca Raton, FL: CRC Press, 2007, pp. 245-265. School Nutrition Director Calcium, Phosphorus, Magnesium, Vitamin D, and 29. Levine, R.S. Br. Dent. J. 191: 20, 2001. Hardin County Schools Fluoride. Washington, D.C.: National Academy 30. American Academy of Pediatric Dentistry. Elizabethtown, KY Press, 1997. AAPD Fast Facts. Diet and dental health. 2008. The Dairy Council Digest® is written and edited by 6. Johnson, R.K., C. Frary, and M.Q. Wang. www.aapd.org/media/fastfacts08.pdf. Lois D. McBean, MS, RD. J. Am. Diet. Assoc. 102: 853, 2002. 31. White, J.W., and M. Wolraich. 7. Frary, C.D., R.K. Johnson, and M.Q. Wang. Am. J. Clin. Nutr. 62(suppl): 242, 1995. J. Adol. Health 34: 56, 2004. 32. Wolraich, M.L., D.B. Wilson, and J.D. White. COPYRIGHT NOTICE 8. Murphy, M.M., J.S. Douglass, R.K. Johnson, et al. JAMA 274: 1617,1995. ® J. Am. Diet. Assoc. 108: 631, 2008. Copyright © 2008, NATIONAL DAIRY COUNCIL, 33. Pennington, J.A.T., and J.S. Douglass. Bowes and O’Hare International Center, 10255 West Higgins Road, 9. National Dairy Council. Unpublished data based on Church’s Food Values of Portions Commonly Used. Suite 900, Rosemont, IL 60018-5616. the National Health and Nutrition Survey 18th Ed. Philadelphia: Lippincott, Williams, and (NHANES), 1999-2002. Wilkins, 2005. ISSN 0011-5568 36 Flavored Milk in PERSPECTIVE INTRODUCTION Nutrient-rich flavored milk comes in a variety of flavors and offers the same unique nutrient package of nine essential nutrients as unflavored milk. Flavored milk is available in traditional flavors such as chocolate as well as innovative flavors including strawberry, vanilla, mocha and root beer. As the most popular milk choice in schools, flavored milk is a highly palatable, nourishing beverage that can help Americans, particularly children, meet current daily dairy food and calcium intake recommendations. Despite the important nutrient contributions flavored milk makes to the diet, concerns about the potential effects of the added sugar and flavorings in flavored milk have raised questions regarding the role of flavored milk in a healthy diet. This review highlights flavored milk’s valuable contributions to nutrient intake and health, presents recommendations offered by health professional organizations and nutrition experts regarding flavored milk consumption, addresses questions about the consumption of this nutrient-rich beverage and provides data that demonstrates the importance of flavored milk in the school environment.

Flavored Milk’s Nutrients and Health Benefits The 2005 Dietary Guidelines for Americans (DGA) recommends 2 cups of low-fat or fat-free milk or equivalents (i.e., cheese, yogurt) daily for children aged 2 to 8 years, and 3 cups or equivalents daily for people aged 9 years and older because of milk’s important nutrient contributions to the diet (1). Flavored milk is a nutrient-rich beverage providing the same nine essential nutrients as unflavored milk,

Flavored Milk in Perspective – 1 including calcium, potassium, phosphorus, protein, vitamins A, D and B12, riboflavin, and niacin (niacin equivalents) (2). Milk, flavored and unflavored, whole, reduced-fat, low-fat or fat-free, provides three of the five nutrients that fall short in children’s diets (i.e., calcium, potassium, and magnesium) and four of the seven nutrients limiting in adults’ diets (i.e., vitamin A, calcium, magnesium, and potassium) (1). Each 8 ounce (1 cup) serving of flavored or unflavored milk provides 300 mg of calcium or 30% of the Daily Value (1000 mg) for calcium.

Milk’s nutrients play an important role in bone development and maintenance and overall nutrient adequacy throughout childhood and adulthood (1). The U.S. Surgeon General’s Report on Bone Health and Osteoporosis recognizes that milk’s nutrients, including calcium, magnesium, phosphorus, potassium, protein, and vitamin D, work together to help build and strengthen bone and are important for both fracture and osteoporosis prevention (3). The 2005 DGA acknowledges milk and dairy foods’ contribution to bone health and improvement of diet quality (1). In addition to improving bone health, milk and dairy foods, when consumed as part of a healthy diet, may help to reduce the risk of osteoporosis (3-5), hypertension (6-9), obesity (10-14), colon cancer (15-18) and metabolic syndrome (19-22), a cluster of conditions that can lead to heart disease and type 2 diabetes.

Flavored Milk Helps Meet Nutrient Needs Flavored milk is Many Americans, both children and adults, are not a nutrient-rich consuming recommended daily servings of dairy foods (23). Approximately 60% to 80% of total dairy servings consumed beverage providing by children and adolescents are consumed as milk, either as the same nine a beverage or as an ingredient in mixtures such as pudding essential nutrients or soup (24). As children enter adolescence, their milk consumption often decreases, while their intake of soft drinks as unflavored increases (25-28). milk, including Studies show that consuming low-fat or fat-free flavored calcium, potassium, milk can help children and adolescents meet the 2005 DGA phosphorus, recommendations for dairy foods and increase their intake of milk nutrients (29-31). In one study, children who drank protein, vitamins flavored milk consumed more total milk and fewer soft drinks A, D and B12, and fruit drinks compared with children who did not drink riboflavin, and flavored milk, based on data from nearly 4,000 school-aged children and adolescents who participated in the 1994-96 and niacin (niacin 1998 USDA Continuing Survey of Food Intakes by Individuals equivalents) (2). (29). In addition, flavored milk consumers had higher calcium

Flavored Milk in Perspective – 2 and phosphorus intakes, but a similar percent of energy from total fat and added sugars compared with children who did not consume flavored milk (29). A retrospective analysis of diets of more than 3,000 children ages 6 to 17 years found a positive effect on children’s overall diets when they chose flavored milks and yogurts instead of sodas and sweetened drinks (30). The researchers suggest that children and adolescents can enhance the quality of their diets by consuming milk such as flavored milk in moderation as an alternative to energy-dense, nutrient poor beverages (30). A more recent study found that children and adolescents who included flavored milk in their diets had significantly higher total milk intakes than those who exclusively consumed unflavored milk (31). Also, energy-adjusted intakes of vitamin A, calcium, phosphorus, magnesium, and potassium were significantly higher for children who drank flavored or unflavored milk than for non-milk drinkers (31). Among females 12-18 years of age, calcium intakes by flavored milk drinkers and exclusively white milk drinkers were nearly double the calcium intakes of non-milk drinkers. This study used data from 7,557 children and adolescents ages 2-18 years who participated in the 1999-2002 National Health and Nutrition Examination Surveys (31). Based on their findings, the researchers conclude that “limiting children and adolescents’ access to flavored milk due to its higher added sugars or energy content may only have the undesirable effect of further reducing intakes of many essential nutrients provided by milk” (31).

Flavored Milk’s Nutrients are Important for Bone Health The nutrients in unflavored and flavored milk including calcium, magnesium, phosphorus, potassium, protein, and vitamin D, are necessary for developing strong bones and teeth as well as for overall health (3, 5, 32-33). Childhood, particularly adolescence, is the most critical time to build bone mass (5). Studies have shown that consuming an adequate intake of milk and other dairy foods during childhood benefits adolescents’ bone health (34) and that low intake of milk during childhood and adolescence is associated with low bone mass and increased risk of fractures in adulthood (33).

In addition to the 2005 DGA “nutrients of concern” that dairy provides including calcium, potassium and magnesium, recent studies suggest that vitamin D is also lacking in the diets of children (35). Recognizing the importance of adequate vitamin D for bone and the prevalence of vitamin D deficiency among children and adolescents, the American Academy of Pediatrics (AAP) issued a clinical report calling for doubling the amount of vitamin D they recommend (i.e., from 200 I.U. per day to 400 I.U. per day) (36). The report recognizes the importance of vitamin D-fortified milk as a source of vitamin D for children and adolescents. Nearly all fluid milk, flavored and unflavored, marketed in the U.S. is fortified with vitamin D to obtain the standard amount of 400 I.U. per quart (100 I.U. per cup) (37). Therefore, consuming vitamin D-fortified flavored milk may help improve children’s and adolescents’ vitamin D status, especially for those who drink little or no unflavored milk. A recent study showed that drinking vitamin D-fortified milk improved the vitamin D status in adults (38).

Flavored Milk in Perspective – 3 HEALTH PROFESSIONAL RECOMMENDATIONS In addition to the 2005 DGA recommendations of 2 cups or equivalents of low-fat or fat-free milk daily for children aged 2 to 8 years and 3 cups for those aged 9 years and older, the DGA has also highlighted low-fat and fat-free milk and milk products as one of the “Food Groups to Encourage” since most Americans are not consuming enough of these foods and the nutrients they provide (1). The AAP recommends children consume 3 servings of dairy foods and adolescents consume 4 servings daily (5) to meet calcium intake recommendations. Additionally, the American Academy of Family Physicians (AAFP), the American Dietetic Association (ADA), the National Medical Association (NMA), the National Hispanic Medical Association (NHMA) and the School Nutrition Association (SNA) all support and promote 3 daily servings of dairy foods among their members and the public. To help meet recommendations, many health professional organizations and nutrition experts recognize the importance of consuming flavored milk in helping children and adolescents meet their recommended daily intakes of dairy foods and dairy food nutrients such as calcium. The ADA states that “by increasing the palatability of nutrient-dense foods/beverages, sweeteners can promote diet healthfulness” (39). This The American Dietetic concept is also supported by the 2005 DGA which states that enhancing the palatability of nutrient-dense Assocation states that foods, such as milk, may improve nutrient intake (1). “by increasing the The AAP, in a policy statement discouraging soft drinks palatability of nutrient- in schools (27) and in its report on optimizing children’s and adolescents’ bone health and calcium intakes dense foods/beverages, (5), encourages consumption of nutritious beverages sweeteners can promote diet including low-fat or fat-free flavored milks. The Institute of Medicine (IOM) recognizes the nutritional value of healthfulness” (39). This flavored milk with modest amounts of sugar for school concept is also supported by children (40). the 2005 Dietary Guidelines for Lastly, the American Heart Association (AHA) supports Americans which states that a positive role for added sugars to help increase intakes enhancing the palatability of nutrient-rich foods including dairy foods. Specifically, in their scientific statement onDietary Sugar Intake and of nutrient-dense foods, Cardiovascular Health, the AHA states, “when sugars are such as milk, may improve added to otherwise nutrient-rich foods, such as sugar- sweetened dairy products like flavored milk and yogurt nutrient intake (1). and sugar-sweetened cereals, the quality of children’s

Flavored Milk in Perspective – 4 and adolescents’ diet improves, and in the case of flavored milks, no adverse effects on weight status were found”(41).

Two members of the AAP’s Committee on Nutrition, in an article on clearing up confusion on the role of dairy products in children’s diets, state “given the importance of calcium, vitamin D and other key ingredients in the diet of children and adolescents, flavored milks could be a nice alternative [to unflavored milk] since the contribution of added sugars to the overall diet of young children is minimal” (42). Researchers at Pennsylvania State University, recognizing the low dairy and calcium intakes of children ages 4 to 18 years, recommend that nutrition guidance be focused on increasing children’s intake of low-fat dairy products “with special emphasis on increasing calcium intake in school-age children and adolescents through flavored low- fat milk products” (43). Similarly, researchers at the University of Saskatchewan, Canada, recommend adding chocolate milk to school vending machines as a strategy to increase children’s and adolescents’ milk intake (44). The American Academy of Pediatric Dentistry states that “chocolate milk is OK for your teeth,” is a highly nutritious beverage, is preferable to many popular snacks that provide calories but few nutrients, and because children like flavored milk, they drink more of it (45).

SWEETENERS IN FLAVORED MILK Flavored milk — whole, reduced-fat, low-fat or fat-free - provides the nutrients calcium, potassium, phosphorus, protein, vitamins A, D and B12, riboflavin and niacin (niacin equivalents). Flavored milk contains both natural sugar (12 gm of lactose per 8 ounce serving) and added sweeteners. Sweeteners can be nutritive (caloric) such as sucrose, commonly known as table sugar, or high fructose corn syrup (HFCS), or non-nutritive, depending on the brand. Because each manufacturer has a unique formula, including the amount and type of added sweetener(s), added sugar content may vary among flavored milk products. On average, an 8 ounce serving of low-fat chocolate milk contains about 4 teaspoons of added sugar, while an equivalent amount of soft drink contains 7 teaspoons. An 8 ounce serving of low-fat (1%) chocolate milk provides 158 calories, whereas its unflavored counterpart provides 102 calories (2).

HFCS is a type of nutritive sweetener that can be added to flavored milk. The composition of HFCS is very similar to the sweetener sucrose. Sucrose molecules are composed of one molecule of glucose and one of fructose, thus sucrose contains 50% glucose and 50% fructose, while HFCS is composed of 55% glucose and 45% fructose with these two sugar molecules existing separately. The similar content may explain the lack of metabolic differences between the two sweeteners (46). Based on a review of

Flavored Milk in Perspective – 5 the scientific literature, the American Medical Association concluded that, because the composition of HFCS and sucrose is so similar, particularly with regard to absorption by the body, it is unlikely that HFCS contributes more to obesity or other conditions than sucrose (47). Therefore, despite some studies linking fructose consumption with obesity, overall, the scientific evidence indicates that HFCS does not appear to contribute more to obesity or other chronic diseases than other nutritive (caloric) sweeteners (47-48). Body weight The key to maintaining a healthy body weight is to balance Studies found calories consumed from foods and beverages with calories that flavored milk expended by physical activities (1). Added sugar, when used in moderation and with concern for overall caloric balance, drinkers had higher can increase the appeal of nutrient-rich beverages such as calcium and nutrient flavored milk and provide additional choices for children and intakes compared to adolescents, thus improving nutrient intake without contributing excessive calories (1). Although flavored milk contains some nondrinkers but did added calories from sugar, there is no evidence that milk, not have higher flavored or unflavored, adversely affects body mass index (BMI) added sugar or in youth. A study by Murphy et al. found that the BMI of milk drinkers was comparable to or lower than that of non-milk total fat intakes. drinkers, in children 2-5 years and 6-11 years, and in males 12-18 years, respectively (31). There was no difference in total intake of added sugars between flavored milk drinkers and non- milk drinkers. Similarly, an earlier study found that flavored milk drinkers had higher calcium and nutrient intakes compared to nondrinkers but did not have higher added sugar or total fat intakes, both important considerations for weight control (29).

Dental Caries It is known that sugar consumption can contribute to tooth decay, however experts agree that flavored milk is a good choice for healthy teeth. Studies have demonstrated that several components in chocolate milk such as calcium, phosphorus, protein, and cocoa may protect teeth from decay (32). Because flavored milk is a liquid, it may be less likely to cause cavities than other foods such as raisins or candies that adhere to tooth surfaces. A briefing paper on milk, flavored milk products, and dental caries concluded that the cariogenicity (cavity-forming potential) of flavored milks is “negligible to low” and, when consumed in moderation, flavored milks are a preferable alternative to similarly sweetened soft drinks (49). The American Academy of Pediatric Dentistry states that “chocolate milk is OK for your teeth” (45).

Flavored Milk in Perspective – 6 Hyperactivity Hyperactivity is defined as a cluster of symptoms including excitability, learning difficulties, and short attention span. Claims that sugar consumption can lead to hyperactivity or interfere with academic performance in children were popular during the 1990s but several reviews on the subject state that this notion is scientifically unsubstantiated (39, 50). For example, a meta-analysis of 23 studies performed over a 12-year period concluded that sugar intake does not affect children’s behavior (51).

OTHER QUESTIONS ABOUT FLAVORED MILK Caffeine in Chocolate Milk Chocolate milk contains a small amount of caffeine per serving compared to many other caffeinated beverages (52). The 2 to 7 mg of caffeine in an 8 ounce serving of chocolate milk is similar to that in one cup of decaffeinated coffee and 5 times less than an equal amount of iced tea or some regular soft drinks (52). The amount of caffeine in a serving of chocolate milk is relatively small compared to the average total daily caffeine intake by children of 14-22 mg or about 0.8 - 0.85 mg/kg body weight (52-53).

Caffeine’s effects on behavior depend on an individual’s usual intake and tolerance or sensitivity to caffeine (53). At lower doses, caffeine is associated with positive subjective effects such as mild stimulation, whereas at higher intakes, negative effects are reported such as a delay of sleep onset (53). A meta-analysis of double blind, placebo-controlled studies of dietary caffeine and/or supplementary caffeine treatment and behavior in children and adolescents led to the conclusion that caffeine has no adverse cognitive or behavioral effects in children (54). However, very high caffeine intakes (>3mg/kg) in children whose usual caffeine intake is low led to negative subjective reports of nervousness, stomach aches, and nausea (54). While possible adverse behavioral effects of caffeine have been cited as a reason for restricting or eliminating chocolate milk from children’s diets, there is no persuasive scientific evidence to justify this concern (52, 54). Consuming the recommended amount of daily servings of low-fat or fat-free dairy foods, including flavored milk, can help children meet nutrient needs without contributing to excessive caffeine intake.

Calcium Absorption Chocolate milk contains a small amount of oxalic acid (0.5-0.6%), a compound occurring naturally in cocoa beans and other plants. In some instances, oxalic acid can combine with calcium in the intestine to form calcium oxalate, which is fairly insoluble. Scientific evidence indicates that the oxalic acid in chocolate milk does not impair calcium absorption, and calcium absorption from chocolate milk has been found to be similar to that from unflavored milk and other calcium- containing foods (55-56).

Flavored Milk in Perspective – 7 Lactose Intolerance People with lactose maldigestion may tolerate chocolate milk more easily than unflavored milk (57-58). Lactose maldigestion is the limited ability to digest lactose, the main carbohydrate in milk, due to insufficient levels of the intestinal enzyme lactase. Lactose maldigestion may manifest into gastrointestinal symptoms, known as lactose intolerance, with excess lactose intake. Most individuals with lactose maldigestion can comfortably drink 2 cups of any type of milk a day when consumed in small servings with foods at separate meals (e.g., breakfast and dinner) (59-60). Because most individuals drink flavored milk such as chocolate milk with meals (61), this beverage is likely to be well tolerated by lactose maldigesters. Also, the cocoa in chocolate milk may slow gastric emptying (58-59). In one study of 16 individuals with lactose maldigestion who consumed chocolate and other milks, chocolate milk significantly reduced breath hydrogen production compared to fat-free unflavored milk (58).

FLAVORED MILK IN SCHOOLS Flavored milk is an important part of school nutrition programs and its inclusion can help children meet nutrient needs to support bone development during peak bone building years. Flavored milk is the most popular milk choice among school children and accounts for 66% of all milk sold in schools according to a Since flavored milk recent report based on the U.S. Department of Agriculture’s is the most popular School Nutrition Dietary Assessment Studies I and III (28, 62). A study among northern Texas elementary school students aged 6 to choice among school 11 years found that milk’s flavor was the most important factor children, it is an influencing children’s milk drinking, with the majority of children important part of choosing chocolate milk at school (63). A credit to its popularity, the study reported that children’s typical advice to new students school nutrition included “get chocolate milk” (63). programs and its Capitalizing on flavored milk’s popularity and encouraging inclusion can help availability of flavored milk in schools is an important way to children meet nutrient help children meet daily calcium and other essential nutrient recommendations at a time when milk intake typically declines. needs to support The percentage of students consuming milk (flavored and bone development unflavored) at lunch progressively decreases from elementary school to middle school to high school (28). As milk intake during peak bone decreases, particularly between the ages of 10 to 18 years building years. which overlaps with the peak bone building years, intake of

Flavored Milk in Perspective – 8 carbonated beverages dramatically rises with total daily consumption more than three times higher than total daily milk consumption by age 18 (64). The consequences of not consuming adequate amounts of milk or milk products can be detrimental to bone development and overall health (5, 32).

A School Milk Pilot Test, co-sponsored by SNA and National Dairy Council (NDC), found that children drank more milk when schools offered ice-cold milk in various flavors (strawberry, chocolate, etc.) and in plastic, re-sealable containers, in different sizes and different merchandising locations (e.g., vending machines, a la carte cafeteria, school stores) (65). Participating schools consisted of 47 elementary and 99 secondary schools in eight states across the country including school districts in Utah, California, Florida Virginia, Pennsylvania, Massachusetts, New York and West Virginia. This pilot study demonstrated that simple improvements to school milk, including offering a variety of flavors served cold and in plastic containers, not only increased milk consumption in primary and secondary schools by an average of 37%, but also increased average daily school lunch participation at the secondary level by 5% (65).

Offering flavored milk in schools as part of the National School Lunch Program (NSLP) and the School Breakfast Program (SBP) can increase milk and nutrient intake and can help children and adolescents meet the DGA recommendations for milk and dairy foods (66-68). Children who participate in the NSLP are more likely than non-participants to consume more total milk (75% vs. 19%) and more flavored milk (50% vs. 9%) at lunch. Moreover, this trend has been shown to persist over 24 hours (28). When approximately 400 elementary school Since 90% of flavored children in Pennsylvania were provided with an option of having chocolate milk included in school meals, more milk milks sold were low- was consumed and intake of nutrients such as calcium and fat or fat-free its riboflavin increased (66). Likewise, when 6th grade students in an elementary school in New York City were provided with inclusion in the school low-fat (1%) chocolate milk as part of the NSLP, children’s nutrition programs is milk and nutrient (e.g., calcium, riboflavin, phosphorus) likely encouraging the intakes increased (68). consumption of low- The inclusion of flavored milk in school meal programs fat and fat-free milk may help students consume more low-fat or fat-free milk. A report on the U.S. Department of Agriculture’s School (61), a component of Nutrition Dietary Assessment Studies I and III found a significant the Dietary Guidelines shift in milk consumption from the early 1990s when approximately three-quarters of students chose whole-fat for Americans “Food or reduced-fat (2%) milk in school to the 2004/2005 school Groups to Encourage.” year when more than three-quarters of students chose low-

Flavored Milk in Perspective – 9 fat (1%) or fat-free (62). Since 90% of flavored milks sold were low-fat or fat-free (62) and flavored milk was the most popular choice among students (28), its inclusion in the school nutrition programs is likely encouraging the consumption of low-fat and fat-free milk (62), a component of the DGA “Food Groups to Encourage.” The AAP and the IOM Committee on Nutrition Standards for Foods in Schools acknowledge key nutrient contributions that milk, including low-fat and fat-free flavored milk, makes to children’s diets (27, 40).

FLAVORED MILK IN SCHOOL NUTRITION POLICY Increasing rates of childhood and adult obesity have resulted in greater efforts to address the epidemic by changing the school environment. Excess intake of macronutrients such as sugar and fat can lead to increased caloric intake and weight gain. Some groups have called for a reduction of added sugars in sweetened foods and beverages, including flavored milk, particularly within the school environment (40, 69-70). Currently there is no consensus on national school nutrition standards for foods and beverages, including sugar and caloric content of flavored milks. However, Congress is expected to address national school nutrition standards in 2009 when it reauthorizes the 2004 Child Nutrition Act. The SNA has called for the adoption of a uniform national, science-based nutrition standard for all foods served in schools, including no more than 28 grams of sugar per 8 ounce serving of milk and offering only low-fat or fat-free milk (70).

The Alliance for a Healthier Generation recommends that low-fat and fat-free flavored milks contain no more than 150 calories per 8 ounce serving (69). The IOM’s report, Nutrition Standards for Foods in Schools, recommended that low-fat and fat-free flavored milks contain up to 22 grams of total sugar (naturally occurring and added) per 8 ounce serving (40). The IOM beverage guidelines recommend that only milk, water and 100% fruit juice be available in schools, and that non-nutritive sweeteners only be allowed in beverages sold in high schools, outside of the school day hours. In debating nutrition policy, some lawmakers have also proposed specific nutrient parameters. For example, U.S. Senator Tom Harkin, chairman of the Senate Committee on Agriculture, Nutrition & Forestry, proposed legislation in the 2008 session of Congress that would mandate national school nutrition standards, including a cap on flavored milk at 170 calories per 8 ounce serving.

The AAP, in their policy statement on soft drinks in schools, recommends reducing intake of sweetened beverages such as soft drinks, and replacing them with healthful offerings such as real fruit and vegetable juices, water, and low-fat white or flavored milk (27).

To help children meet Milk Group recommendations, the acceptability and availability of nutrient-rich flavored milk in schools is critical. When used in moderation and with consideration of overall caloric balance, sugars can increase the appeal of nutrient-dense foods and beverages, thereby providing

Flavored Milk in Perspective – 10 additional choices to meet nutritional needs in the context of a healthful diet (1). Flavored milk is the most popular milk choice in schools and may even help children choose low-fat or fat-free milk options more often since 90% of flavored milks consumed are low-fat or fat-free (62). For a product to be acceptable, it must also taste good since no one wins when children throw away their nutrient-rich milk because they don’t enjoy the taste.

NDC recognized that having acceptable and palatable flavored milk formulations containing reduced levels of added sugar to offer in schools is a priority in the school environment. The dairy industry conducted research among children aged 8 to 17 years to determine the palatability of new lower sugar formulations for flavored milk. This research suggests that flavored milk of 150 to 170 calorie range per 8 ounces — depending on brand — meets children’s taste approval (71). However, while these flavored milks may be acceptable, palatable and meet lower-calorie and sugar recommendations, these formulations have limited availability and can cost more to produce. Higher costs may further reduce availability for cost-conscious schools. Limited product availability of the most popular milk choice in school may reduce consumption of milk and the nutrients it contains during the peak bone- building years.

Flavored milk remains an important component of school meals, and all types can help school-aged children meet intake recommendations for the calcium, potassium and other nutrients they need for proper growth and development. The dairy industry is working to continue to expand and diversify milk choices including a range of reduced sugar formulations to help meet the varied needs (including taste, nutrition and overall acceptability) of today’s schools and their milk drinkers.

ATTITUDES TOWARD FLAVORED MILK Parents and health professionals both support offering flavored milk to children. A review of qualitative consumer research conducted in 2005 by NDC suggests both health professionals and parents would encourage their child to drink flavored milk when away from home because the overall goodness of milk simply outweighs any concerns with sugar (72). A quantitative survey of more than 4,000 moms found that 92% are comfortable with their child drinking chocolate or flavored milk with their school lunch (73). Within the same survey, 83% of moms would prefer for their children to drink flavored milk as opposed to soft drinks at school and 84% knew that flavored milk and unflavored milk have approximately the same nutritional value (73). A more recent survey also found that a majority of moms do not feel that the sugar in chocolate milk is excessive (74). In a survey of more than 400 family practitioners, dietitians and pediatricians, a majority thought it was important that children drink more milk, regardless of whether it was flavored or unflavored (75). The positive attitudes of both parents and health professionals toward flavored milk and encouragement of its consumption can be conducive to helping children meet dairy food intake recommendations.

Flavored Milk in Perspective – 11 SUMMARY AND CONCLUSIONS Flavored milks are well liked and health professionals support intake of this beverage. The availability of flavored milk can increase overall milk and nutrient intake in schools. Research indicates that health and behavior concerns about flavored milk and weight gain or hyperactivity are unfounded. This review addresses various nutritional and health topics related to flavored milk and indicates the following:

• The 2005 DGA encourages the consumption of 3 servings of low-fat or fat-free dairy foods each day for those age 9 and older, and flavored milk is a nutrient- rich and appealing beverage choice for children that can help them meet nutrient recommendations.

• Flavored milks — whole, reduced-fat, low-fat or fat-free — contain the same essential nutrients as unflavored milks. Chocolate milk, for example, provides calcium, potassium, phosphorus, protein, vitamin A, D and B12, riboflavin and niacin (as niacin equivalents) and contains 2 to 4 teaspoons of added sugar that accounts for about 60 more calories per serving than unflavored milk.

• When used in moderation and with concern for overall caloric balance, sugars can increase the appeal of nutrient-rich foods and provide additional choices for children to meet nutritional needs in the context of a healthful diet.

• Research shows that children who drink flavored milk can increase milk and nutrient intake without increasing added sugar or total fat intake and without adversely affecting BMI, a measure of weight status.

• Intake of sugar may contribute to dental caries, but it is unlikely that flavored milks cause this condition. Components in flavored milk including calcium, phosphorus, and cocoa in chocolate milk may protect teeth from decay.

• Flavored milk is a healthful, nutrient-rich product for schools and wellness policies and is the most popular milk choice among school children. Since most of the flavored milk consumed in schools is low-fat or fat-free, its presence in schools may be helping children transition to consuming lower fat milk.

• A variety of reduced sugar formulations may help meet the varied needs of schools, including taste, nutrition, and overall acceptability.

©2010 National Dairy Council®

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Flavored Milk in Perspective – 15

When it comes to NUTRITION, THINK YOUR not all drinks are created equal!

MILK CHOCOLATE MILK 100% FRUIT LOWFAT 1% LOWFAT 1% ORANGE JUICE PUNCH

Calories 100 % Daily Value Calories 160 % Daily Value Calories 110 % Daily Value Calories 120 % Daily Value Total Fat 4% Total Fat 4% Total Fat 1% Total Fat 0% Total Carbohydrates 4% Total Carbohydrates 9% Total Carbohydrates 8% Total Carbohydrates 10% Protein 16% (includes 3 tsp Protein 4% (includes 3 tsp added sugar) added sugar) Vitamin A 10% Vitamin A 4% Protein 16% Protein 0% Vitamin C 0% Vitamin C 140% Vitamin A 10% Vitamin A 0% Vitamin D 25% Vitamin D 0% Vitamin C 4% Vitamin C 1% Calcium 30% Calcium 2% Vitamin D 25% Vitamin D 0% Calcium 30% Calcium 2%

COLA SOY BEVERAGE, BOTTLED SPORTS

Calories 90 % Daily Value PLAIN* WATER DRINK Total Fat 0% Calories 100-130 % Daily Value Calories 0 % Daily Value Calories 70 % Daily Value Total Carbohydrates 8% Total Fat 6-7% Total Fat 0% Total Fat 0% (includes 6 tsp Total Carbohydrates 3-4% Total Carbohydrates 0% Total Carbohydrates 6% added sugar) Protein 14-22% Protein 0% (includes 3 tsp added sugar) Protein 0% Vitamin A 10-30% Vitamin A 0% Protein 0% Vitamin A 0% Vitamin C 0% Vitamin C 0% Vitamin A 0% Vitamin C 0% Vitamin D 10-30% Vitamin D 0% Vitamin D 0% Vitamin C 2% Calcium 10-30% Calcium 0% Calcium 0% Vitamin D 0% Calcium 0%

*Nutrient ranges for soy beverage reflect the differences between unfortified soy beverages as reported by USDA National Nutrient Database for Standard Reference, www.NutritionExplorations.org Release 19 and a large-distribution fortified soy beverage. Unlike milk, there is no federal standard of identity for soy beverages, and nutritional data will vary by brand. Consumers must carefully check the nutrition panel.

Sources: USDA National Nutrient Database for Standard Reference, Release 19; USDA database for the added sugars content of selected foods, Release 1, February, 2006. Percent Daily Values are based on a 2,000 calorie diet. All nutrients quoted for 8 oz. portion.

Copyright © 2007, NATIONAL DAIRY COUNCIL,® Rosemont, IL 60018-5616. All rights reserved. Printed in U.S.A. Milk provides nutrients essential for 1 good health and kids will drink more when it’s flavored. Flavored milk contains the same nine 2 essential nutrients as white milk and is a healthful alternative to soft drinks. Drinking low-fat or fat-free white or 3 flavored milk helps kids get the 3 daily servings* of milk recommended by the Dietary Guidelines for Americans, and provides three of the five “nutrients of concern” that children do not get enough of – calcium, potassium and magnesium as well as vitamin D. Children who drink flavored milk meet 4 more of their nutrient needs; do not 3-A-Day of Dairy is a comprehensive science-based nutrition education program designed to provide clear guidance for consumers about how to meet dietary recommendationsconsume for dairy more foods (low-fat added and fat-free sugar, milk, yogurtfat or and cheese). On average, Americans consume only about half of the three servings of dairy each day recommended by the 2005 Dietary Guidelines for Americans. The 3-A-Day of Dairy program is guided and supported by leading health and nutritioncalories; professional organizations and are including not the heavier American Academy than of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Dietetic Association (ADA), National Hispanic Medical Association (NHMA), National Medical Association (NMA), and School Nutrition Association (SNA). non-milk drinkers. Low-fat chocolate milk is the most 5 popular milk choice in schools and kids drink less milk (and get fewer nutrients) if it’s taken away.

Read about the science behind these reasons on www.NationalDairyCouncil.org

These health and nutrition organizations support 3-Every-Day™ of Dairy, a science-based nutrition education program encouraging Americans These health and nutrition organizations support 3-A-Day of Dairy, a science-based nutrition education program encouraging Americans to to consume the recommended three daily servings of nutrient-rich low-fat or fat-free milk and milk products to improve overall health. consume the recommended three daily servings of nutrient-rich low-fat or fat-free milk and milk products to improve overall health.

Supporting Health & Nutrition Organizations of 3-A-Day of Dairy 1. Milk provides nutrients essential for • The AAP recommends that children consume three good health and kids will drink more servings of dairy foods daily and that adolescents consume when it’s flavored. four servings a day to meet calcium recommendations.8 • Milk drinkers, in general, consume more calcium, • Flavored milk drinkers consume more milk phosphorus, magnesium, potassium and vitamin A than than exclusively white milk drinkers.1 Offering non-milk drinkers.9 flavored low-fat or fat-free milk can help increase milk consumption and boost overall participation 4. Children who drink flavored milk meet in school meal programs.2 more of their nutrient needs; do not consume • Two government programs, the National more added sugar, fat or calories; and are not Institute of Child Health and Human heavier than non-milk drinkers. Development’s Milk Matters3 and the U.S. Department of Health and Human Services’ Best • The American Heart Association states that “when sugars Bones Forever,4 recommend low-fat and fat-free are added to otherwise nutrient-rich foods, such as sugar- flavored milk as a good option for children. sweetened dairy products like flavored milk and yogurt and sugar-sweetened cereals, the quality of children’s and 2. Flavored milk contains the same nine essential adolescents’ diets improves, and in the case of flavored nutrients as white milk and is a healthful milks, no adverse effects on weight status were found.”10 alternative to soft drinks. • According to the 2005 Dietary Guidelines for Americans, • Low-fat and fat-free flavored milk contains — calcium, adding a small amount of sugar to nutrient-dense potassium, phosphorous, protein, vitamins A, D and B12, foods such as reduced-fat milk products helps enhance riboflavin and niacin (niacin equivalents) — and can help their palatability and improves nutrient intake without kids meet their calcium recommendations.5 contributing excessive calories.7 • Flavored milk drinkers have lower intakes of soft drinks • Flavored milk drinkers do not have higher total fat or compared to those who do not drink flavored milk.1 calorie intakes than non-milk drinkers.1 • The American Academy of Pediatrics policy statement • Children who drink flavored and white milk don’t have Soft Drinks in Schools encourages schools to offer low-fat higher body mass index (BMI) than those who do not or fat-free white or flavored milk, water or real fruit or drink milk.9 vegetable juice as healthful alternatives to soft drinks.6 5. Low-fat chocolate milk is the most popular milk 3. Drinking low-fat or fat-free white or flavored choice in schools and kids drink less milk (and get milk helps kids get the 3 daily servings of fewer nutrients) if it’s taken away. milk recommended by the Dietary Guidelines • According to 2005 USDA data, 66% of the milk chosen for Americans, and provides three of the five by children in schools is flavored; most (60%) of which is “nutrients of concern” that children do not get low-fat (1%) or fat-free.11 enough of – calcium, potassium and magnesium as • Removing flavored milk from schools has been shown to well as vitamin D. result in a 62-63 percent reduction in milk consumption • The 2005 Dietary Guidelines for Americans acknowledges by kids in kindergarten through 5th grade, a 50 percent milk and dairy foods’ contribution to bone health and reduction in milk consumption by adolescents in 6th improvement of diet quality.7 through 8th grades, and a 37 percent reduction in milk consumption in adolescents in 9th through 12th grades.12

www.nationaldairycouncil.org/childnutrition ©National Dairy Council 2010®

* Daily recommendations - 3 cups of low-fat or fat-free milk or equivalent milk products for those 9 years of age and older and 2 cups of low-fat and fat-free milk or equivalent milk products for children 2-8 years old. References 1. Johnson RK, Frary C, Wang MQ. The nutritional consequences of flavored milk consumption by school-aged children and adolescents in the United States. J Am Diet Assoc. 2002; 102(6):853-856. 2. National Dairy Council and School Nutrition Association. The School Milk Pilot Test. Beverage Marketing Corporation for National Dairy Council and School Nutrition Association. 2002. http://www.nutritionexplorations.org/sfs/schoolmilk_pilottest.asp (Accessed January 4, 2009). 3. NICHD. For Stronger Bones….for Lifelong Health…Milk Matters! Accessed Sept 7, 2009 via http://www.nichd.nih.gov/publications/pubs/upload/strong_bones_lifelong_ health_mm1.pdf 4. HHS, Best Bones Forever. Accessed Sept 7, 2009 via http://www.bestbonesforever.gov/ 5. 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. J Adolesc Health 2004;34(1):56-63. 6. American Academy of Pediatrics, Committee on School Health. Soft drinks in schools. Pediatrics 2005; 113152-154. 7. United States Dept. of Health and Human Services, United States Dept. of Agriculture and United States Dietary Guidelines Advisory Committee, 2005 Dietary Guidelines for Americans. (6th ed. HHS publications, 2005, Washington D.C.) 8. Greer FR, Krebs NF and the Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children and adolescents. Pediatrics 2006; 117:578-585. 9. Murphy MM, Douglas JS, Johnson RK, Spence LA. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in U.S. children and adolescents. J Am Diet Assoc. 2008; 108:631-639. 10. Johnson RK, et al. Dietary Sugars Intake and Cardiovascular Health. A Scientific Statement From the American Heart Association. Circulation. 2009; 120:1011-1020. 11. ENVIRON International Corporation. School Milk: Fat Content Has Declined Dramatically since the Early 1990s. 2008. 12. Patterson J, Saidel M. The Removal of Flavored Milk in Schools Results in a Reduction in Total Milk Purchases in All Grades, K-12. J Am Diet Assoc. 2009; 109,(9): A97.