Beverage Patterns and Diet Quality in US Children

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of

Science in the Graduate School of The Ohio State University

By

Andrea Marie Lane B.S.

Graduate Program in Allied Medicine

The Ohio State University

2017

Master’s Examination Committee:

Dr. Christopher A. Taylor, Advisor

Dr. Colleen K. Spees

Dr. Keeley J. Pratt

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Copyrighted by

Andrea Marie Lane

2017

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Abstract

The purpose of this study was to investigate the beverage patterns and the potential differences between sugar-sweetened beverage (SSB) intake and diet quality in different weight categories of US children aged 2-18 years old. A cross-sectional study design was used to examine the dietary and anthropometric data collected from the National Health and Nutrition Examination

Survey 2005-2012. Diet quality was measured using the Healthy Eating Index

(HEI) 2010. Beverage pattern data was divided into groups based on age and weight categorization. Diet quality was analyzed by SSB consumption, which was broken down into non-consumer, limited consumers, and high consumers within each age and weight group. The most reported beverages and those consumed highest by volume were: water, milk, and soda for children and adolescents 6-18 years old in all three weight groups. While in young children 2-5 years old in all three weight groups, these were water, milk, and juice. The quantity of SSB children drink was associated with a difference in HEI scores more so than their weight status. Higher SSB intake was associated with lower overall HEI scores, as well as lower fruit, whole grains, and empty calorie scores compared to non- consumption. Pediatric healthy diet and lifestyle interventions should focus on limiting the consumption of SSB in youth regardless of weight status.

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Vita

October 27, 1992 ...... Born - Columbus, Ohio

May 2015 ...... B.S. Human Nutrition, The Ohio State University

2015-2017 ...... MS/DI Program in Medical Dietetics The Ohio State University

Field of Study

Major Field: Allied Medicine

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Table of Contents

Abstract ...... ii

Vita ...... iii

List of Tables ...... vii

List of Figures ...... viii

Chapters:

1. Introduction ...... 1

Beverage Choices and Diet Quality in US Children ...... 1

Statement of Problem ...... 2

Purpose of Study ...... 2

Research Questions ...... 3

Definition of Terms ...... 4

List of Abbreviations ...... 6

2. Review of Literature ...... 7

Overview ...... 7

Causes and Consequences of Overweight and Obesity in Youth ... 9

Dietary Recommendations ...... 10

Diet Quality and Current Trends ...... 12

Factors of Diet Quality and Energy Intake ...... 15

Beverage Trends ...... 16

Sugar-sweetened Beverages and Obesity ...... 19 iv Sugar-sweetened Beverages Interventions ...... 22

Beverages and Diet Quality ...... 25

Summary ...... 27

3. Methodology ...... 28

Overview of the Study ...... 28

Research Questions ...... 29

Overview of NHANES ...... 29

Subjects ...... 30

Data Sources ...... 31

Data Preparation ...... 32

Data Analysis ...... 36

Protection of Human Rights ...... 37

4. Results and Discussion ...... 38

Demographics ...... 38

Beverages Consumed by US Children Across Age and Weight

Status ...... 38

Diet Quality by Sugar-sweetened Beverages Consumption in US

Children ...... 43

Diet Quality by Weight Status and SSB Consumption in the 2-5

Year Olds ...... 44

Diet Quality by Weight Status and SSB Consumption in the 6-11

Year Olds ...... 46

v Diet Quality by Weight Status and SSB Consumption in the 12-18

Year Olds ...... 48

Overall Trends and Conclusion ...... 49

5. Beverage Patterns and Diet Quality by Weight in US Children ...... 52

Abstract ...... 52

Introduction ...... 53

Methods ...... 54

Results ...... 57

Discussion ...... 59

Conclusion ...... 62

References ...... 63

Appendix A: Tables and Figure ...... 73

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List of Tables

Table 1: Healthy Eating Index 2010 Scales and Scoring Procedures ...... 34

Table 2: Sample sizes of weight status by age group for analysis...... 74

Table 3: Volume of Beverages Consumed in Grams by Age and Weight Status 76

Table 4: Calories from Beverages by Age and Weight Status ...... 77

Table 5: Calories from Added Sugars in Beverages by Age and Weight Status 78

Table 6: Diet Quality by Weight and SSB Consumption for 2-5 year olds ...... 79

Table 7: Diet Quality by Weight and SSB Consumption for 6-11 year olds ...... 80

Table 8: Diet Quality by Weight and SSB Consumption for 12-18 year olds ...... 81

Table 9: Proportion of children in the three levels of SSB Consumption by Age

and Weight ...... 82

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List of Figures

Figure 1: Prevalence of Obesity and Extreme Obesity in US Children

and Adolescents Aged 2 to 19 Years From 1988-1994 Through

2013-2014 ...... 8

Figure 2: Proportion of children 2-5 years old who reported consumption of each

beverage in their 24-hour dietary recall...... 74

Figure 3: Proportion of children 6-11 years old who reported consumption of each

beverage in the 24-hour dietary recall ...... 75

Figure 4: Proportion of children 12-18 years old who reported consumption of

each beverage in the 24-hour dietary recall ...... 75

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Chapter 1: Introduction

Beverage Choices and Diet Quality in US Children

Throughout the last few decades childhood obesity trends have risen causing many negative immediate and long-term health consequences for those youth dealing with the excess weight. Childhood obesity puts children and adolescents at higher risk for obesity later in life and diseases such as type 2 diabetes, atherosclerosis, and sleep apnea1. The type of foods and beverages a child consumes are key contributing factors of weight management. Children in the United States are not following the dietary guidelines for a healthy lifestyle and disease prevention2. Beverages choices and their contribution to energy intake have changed over time. The role of beverages, especially SSB, in childhood obesity has been investigated for its potential contribution of empty calories and effects on satiety and often-poor energy compensation. There is limited research on a potential connection between the beverages a child drinks and their diet quality based on age and weight status.

The objective of this study is to determine the beverage intake patterns of

US children and if there is, within weight status groups, a difference in diet quality based on sugar-sweetened beverage consumption using data from the 2005-

2012 National Health and Nutrition Examination Survey. It is critical for further

1 research to investigate the potential relationships between the factors contributing to obesity to help develop effective weight management interventions in the youth population.

Statement of the Problem

Childhood obesity is a concern for healthcare and public health officials globally. Obesity and poor diet quality in children put them at higher risk for chronic diseases such as type 2 diabetes mellitus, atherosclerosis, and nonalcoholic fatty liver disease1. Additionally, being overweight during childhood can put one at higher risk for severe obesity in adulthood3. These health risks demonstrate the need for further research and development of interventions to prevent and reduce the rates of childhood obesity. Energy balance, therein diet and beverage choices, is a factor of the etiology of obesity. There is limited up to date research on the interaction of beverage intake, diet quality, and weight status within the pediatric US population.

Purpose of the Study

The purpose of this study is to describe the potential differences between beverage choices and diet quality in different weight categories of US children aged 2-18 years old. Knowledge of such a difference could help healthcare providers develop appropriate interventions to promote a healthy weight in children. Analysis of data from the National Health and Nutrition Examination

Survey will be used to determine diet quality and beverage patterns. There is a gap in the literature on the associations between quantity of SSB consumption and diet quality based on weight status in children and youth in the US.

2 Research Questions

The aim of this study is to determine if there is a difference between youths beverage consumption and diet quality. In this study these research questions were answered:

1. What are the amounts and types of beverages consumed by US

children across three age groups (2-5, 6-11, and 12-18 years old) and

three weight status categories?

a. Quantified in grams, total energy and kcals of added sugars

b. Assess differences across weight status categories:

i. Healthy weight (5th - 84th BMI-for-age percentile)

ii. Overweight (85th - 94th BMI-for-age percentile)

iii. Obese (≥95th BMI-for-age percentile)

2. Is there a difference in diet quality by HEI-2010 scores between sugar-

sweetened beverage consumption patterns in US children? Broken

down into:

a. No consumption (<16 kcals of added sugar)

b. Limited consumption (≤140 kcals from added sugar)

c. High consumption (>140 kcals from added sugar)

3 Definition of Terms

Body Mass Index A measure of weight adjusted for height, determined

by weight in kilograms divided by height in meters

squared, used as a proxy measure of obesity4.

BMI-for-age Percentile An indicator for relative position of a child’s BMI

value among children of the same age and gender5.

Childhood Overweight A child’s weight between the 85th and 94th percentile

on their age and gender growth chart4.

Childhood Obesity A child’s weight greater than or equal to the 95th

percentile on their age and gender growth chart 4.

Diet Quality A measure of the value or healthfulness of a person’s

food consumption compared to a set standard. The

higher the score (from 0-100) the better the quality of

a persons diet using HEI6.

Growth Chart A tool used by clinicians to track the growth of infants

and children based on percentile curves of

distribution of measurements of healthy US children

2 years and older7.

Healthy Eating Index A scale that quantifies a score that compares diet

intake to the recommendations in the Dietary

Guidelines for Americans. This tool scores a person’s

diet based on intake of 12 food components such as

4 whole fruit or total vegetable, this score can be used

to determine diet quality6.

Sugar Sweetened Beverages sweetened with added sugars

Beverages including sodas, fruit flavored juices, energy drinks,

and sports drinks8.

US Dietary Guidelines National dietary recommendations based on

scientific evidence to promote a healthy lifestyle and

prevent diet-related diseases9.

5 List of Abbreviations

AI Adequate Intake

BMI Body Mass Index

CDC Centers for Disease Control and Prevention

CSFII Continuing Survey of Food Intake by Individuals

DASH Dietary Approaches to Stop Hypertension

DRI Dietary Reference Intake

GI Gastrointestinal

HEI Healthy Eating Index

LCB Low Calorie Beverages

NHANES National Health and Nutrition Examination Survey

NYPANS National Youth Physical Activity and Nutrition Study

RDA Recommended Daily Allowance

SSB Sugar-Sweetened Beverages

UL Upper Limit

USDA United States Department of Agriculture

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Chapter 2: Review of Literature

Overview

Traditionally, obesity is a term for excess adiposity, which can be hard to measure in the clinical setting. So often weight is used to determine body fatness, but the term is now used to stress the seriousness of a child’s weight status4. Current guidelines for categorizing weight status in children and adolescents are based on the categorization percentiles of body mass index

(BMI) for age on the gender-specific Center for Disease Control (CDC) growth charts4. In children, a BMI-for-age below the 5th percentile is classified as underweight and those in between the 5th to 84th percentile are classified as healthy weight10. A child’s BMI-for-age between the 85th and 95th percentile is considered overweight, while those at or above the 95th percentile are being considered obese4. The American Heart Association defines severe obesity in children as ≥120% of the 95th percentile on the age and gender specific CDC growth chart11.

Overweight and obesity in children is a concern internationally and within the US Between 1988-1994 obesity rates for children 2-19 years of age in the US were close to 10%, the rate increased steadily until 2003-2004 when it reached

17.1% and has since fluctuated12. Adolescents in the age range of 12-19 years

7 old had a higher prevalence of obesity at 20.5% than compared to children ages

2-5 years old with 8.9%12. Some of the most recent prevalence rates estimates

17% of the children in the US are obese13. The high rates have become a concern due to the negative health consequences that are associated with childhood obesity, including metabolic, gastrointestinal, and cardiovascular complications1. Due to the current rates and negative consequences of obesity an objective of the US Healthy People 2020 is to reduce the portion of children and adolescents who are obese to 14.5%14.

Figure 1: Prevalence of Obesity and Extreme Obesity in US Children and

Adolescents Aged 2 to 19 Years From 1988-1994 Through 2013-201412

8 Causes and Consequences of Overweight and Obesity in Youth

Weight status and obesity in early childhood have multiple influences; some are environmental, such as maternal gestational diabetes, maternal obesity, race, and dietary intake11. Hispanic and African American youth in the

US have been shown to be at a higher risk of obesity than compared to the white or Asian American population12. Family income level was found to be a predictor of a weight status in children, particularly with low income families being three times more likely than high income families to have an overweight or obese child

15. According to the Surgeon General Dr. Regina Benjamin (2010), eating too many calories along with inadequate activity, genetics, culture, and environment all are contributing factors for becoming overweight and obese16.

Having a positive energy balance over time can cause children to gain excess weight that may pose potential health problems. Environmental factors such as abundant access to energy dense food and a sedentary lifestyles contribute to the energy imbalance17. The increase in the prevalence of obesity has occurred faster than would be possible for a genetic change, therefore pointing to energy balance and allocation of energy stores as the affect on body composition17. A parent’s perception on their child’s weight may be an influencing factor in the weight of their children. Parent’s who believe diet rather than physical activity are the cause of excess weight in children were shown to be more likely to have an overweight child 15. Suggesting the feeding habits and activity beliefs of the parents have a role in the energy balance of the child.

9 Overweight and obesity in childhood places children at a higher risk for cardiovascular, pulmonary, skeletal, gastrointestinal (GI), metabolic and psychosocial problems1,11. Poor health outcomes can occur in these areas in childhood and continue into adulthood if one’s BMI remains elevated. During childhood and adolescence being overweight or obese puts you at higher risk of remaining overweight or obese as an adult18. Intake of healthy food choices like fruits, vegetables, and whole grains and vigorous physical activity were seen to decrease while BMI increased as adolescents transitioned into adulthood 19. The higher risk for hypertension, insulin resistance, obstructive sleep apnea, and nonalcoholic fatty liver disease that obese children have can impact their health and leave them vulnerable to chronic disease later in life1. Due to these risks health initiatives, such as those by Healthy People 2020 and the Academy of

Nutrition and Dietetics, include a focus on maintaining a healthy weight and prevention of obesity in childhood14,20.

Dietary Recommendations

The 2015-2020 Dietary Guidelines for Americans focuses on the whole diet as an eating pattern that should include variety for nutrient adequacy and be based on proper calorie level for weight management9. The dietary recommendations for children in the US are met by incorporating more vegetables, fruits, and whole grains21,14. Including vegetables of a variety of colors, such as dark leafy greens, red and orange, and legumes into the daily diet will help to accomplish the goals for a healthy diet9. Whole fruits are recommended for their contribution of fiber and lower energy density9. There is

10 also a push for children and adolescents to limit their intake of saturated fats, added sugar, and sodium for cardiovascular health, energy balance, and weight management9,20,21. Other foods to incorporate in a child’s diet include lean meats, beans, fish, low-fat dairy for their provision of protein, vitamins, and minerals important for growth and reduced saturated fats contribution21. Specific calorie and serving size recommendations for the different food groups are based on age and sex of the children.

It is recommended that children 2-8 years old consume 1- 1.5 cups of vegetables, 1-1.5 cups of fruit, 3-5 oz of grains, 2-2.5 cups of dairy, and 2-4oz of protein foods, and only 15-17g of oils a day 9. Nutrients of concern for growing children are calcium, vitamin E, folate, iron, potassium, magnesium and fiber because the historical inadequate consumption of foods rich in these nutrients and their importance for growth20. Fiber consumption is associated with lower

BMI and lower percent body fat in adolescent girls 22. Promotion of this dietary component is beneficial for satiety, GI health, and serum cholesterol maintenance. There are many benefits to following a healthy diet: helps to maintains an appropriate weight, and prevents development and progression of diseases like type 2 diabetes, cardiovascular disease, and hypertension that may cause morbidities 8.

In the promotion of energy balance and healthy weight maintenance in children, limiting foods and beverages that are a concentrated source of energy is a key element of the dietary recommendation. SSB and fruit juice should be limited to 4-6 oz/day for kids 1-6 years old while kids 7-18 years old should aim

11 for 8 to 12 oz/day 21. It is also recommended to limit SSB and juices as snacks between meals21. For children over the age of two year old low fat milk is recommended over the use of whole milk21. Water should be the first choice for children to drink because of its importance in rehydration without contributing to energy intake.

Diet Quality and Current Trends

The overall quality of one’s diet can be assessed in many ways based on adherence to diet and or nutrient intake recommendations. One of the tools that is used in the US to assess diet quality is the Healthy Eating Index (HEI), which compares a person’s intake with the US Dietary Guidelines. The original HEI scored a person’s diet based on 10 components including grains, vegetables, fruits, milk, meat, total fat, saturated fats, cholesterol, sodium, and variety with a score range of 0-10023. The tool compares consumption of these components with the recommendations for the individual’s RDA for energy level23. HEI-2005 was an update to the original index that included 5 additional components for scoring whole fruit, dark greens/orange vegetables/legumes, whole grains, oils, and calories from solid fats/alcohol/added sugars and removed total fat and cholesterol based on recommendations per 1000kcal24. The newest update is the

HEI-2010, which includes total fruit, whole fruit, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, and empty calorie categories for scoring25. These scores help health care members and researchers understand the overall

12 nutritional quality of the diet of a person as well as see to the extent to which someone follows the recommendations for a healthy diet.

The diet quality of US citizens of all ages was reported to be 59 in 2010, increasing from 49.1 in 199926. Empty calorie scores were at 12.6 out of a maximum of 20, dairy scores at 6.4 out of 10, and total fruit and total vegetables scores at 3.0 and 3.4 out of 526. The overall diet quality of US children from 4-18 years old was reported to be poor at a score of 502. At the national level youth ages 4-18 years old are ultimately not following the USDA Dietary Guidelines based on NHANES 2005-2010 data using the HEI-20102. The guidelines promoting for more vegetables, fruits, and whole grains while limiting saturated fats, refined grains, and sodium. Contributing factors to the poor diet quality scores are that children are not meeting even half of the recommended amounts of whole grains, greens, or total vegetables2.

Children who were not apple product consumers had low HEI 2010 scores in total fruit (1.9/5), whole fruit (1.5/5), whole grains (1.7/10), sodium (4.9/10), and empty calories (8.6/20), these score being significantly lower then apple product consumers27. On average US youth eat 1.25 cup equivalents of total fruit a day, which includes 100% fruit juices, whole fruit, and mixed fruit dishes, with whole fruit accounting for close to 53% of total fruit intake 28. Total fruit intake recommendations include whole fruit and 100% fruit juice. At least half of one’s total fruit intake should come from whole fruit rather than from 100% fruit juice sources for the fiber contribution and prevention of excess energy intake9. This

13 distinction is incorporated into the assessment of diet quality. Overall, youth who ate apple products had higher diet quality compared to non-consumers27.

Adolescents 14-18 years old had the lowest score of all the youth population when it came to whole-grains, whole fruit, and dairy, but were the highest when it came to total vegetables and fatty acids2. In adolescents the decreased consumption of dairy, grains, total fruit and vegetables is associated with central adiposity; dairy and total grains were found to be inversely associated with central adiposity measured by waist circumference 29. The youngest group of 4-8 year olds had the lowest score for empty calories and sodium2. Younger children 4-8 years old had the highest HEI-2010 score of 52 compared to 46 and 43 for 9-13 year olds and 14-18 year olds respectively2. The trends from this study suggest that perhaps the younger children have a better diet quality and that as children age they develop poor eating habits. Younger children typically have better diets because of the increased involvement of the caregivers in food selection and preparation than compared to older youth as they develop more independence in food decisions. Preschool aged children’s usual intakes were found to not meet the Adequate Intake (AI) for potassium, vitamin E, and fiber but were exceeding the Upper Limit (UL) for zinc and sodium30. Although, overall nutrient intakes were adequate, based on Dietary

Reference Intakes (DRI’s), for preschoolers 30. 76% of the children 2-4 years old were found to consume more saturated fats than recommended 30.

14 Factors of Diet Quality and Energy Intake

From 1989 to 2010 children 2-5 years old have had an increase in daily caloric intake, +305kcal/day, which became significantly higher than the intakes reported before the obesity rates increased in the 1980s 31. An overall increase in energy intake was seen between 1989-2003, followed by a decline from in 2004-

2008 and stabilization in 2009-2010 in US children 2-18 years old 31. Top food energy sources between 1989-2010 were pizza, grain based desserts, bread, pasta dishes, and savory snacks 31. These are foods that are not typically considered healthy options because of their energy density and could potentially be a factor into the overall diet quality of our youth. Portion sizes have also increased since 1977 for US children and in some cases increasing energy intakes during the eating occasion 32.

Meal and snack frequency are considerations when looking into a persons diet quality. It is important to not just examine what a person eats, but when and how often. In a recent study meal frequency was found to have a positive association with diet quality in children and adolescents, not dependent on the variations of what constitutes a meal33. Anderson et. al (2016), suggested that the intake of healthy food was not negatively correlated with the consumption of unhealthy food in preschool aged children34. Just because children may eat what is recommend as part of a healthy lifestyle does not prevent or deter them from eating the foods that should be limited.

A small study in Boston found that a majority of school-aged children consume at least three meals per day 35. Evans et. al (2015) also found that 91%

15 of children in 5th through 8th grade eat dinner at home35. Location of eating an occasion is an important indicator for diet quality in children. Home food availability is associated with diet quality; there was a positive association between healthy food availability and Dietary Approaches to Stop Hypertension

(DASH) score which is a measure of diet quality 36. That is why researchers and clinicians need to take into account the type of food available due to the number of children who are eating meals from home. Physical activity in adolescent girls was shown to be positively associated with diet quality and recommended as a focus for interventions to help set physical activity as part of their lifestyle while behaviors are being established to increase diet quality later in life 22. A cohort study following high school students had similar finds; vigorous physical activity was associated with increased fruit, vegetable, and whole grain consumption and decreased soda consumption which are positive factors in diet quality 19.

Beverage Trends

Classification of sugar-sweetened beverages has varied between studies, but typically drinks containing added sugar are considered in this category.

Mesirow & Welsh (2014) classified sodas, fruit flavored drinks, sports drinks, energy drinks, and sweetened fruit juices as SSBs37. Another source considered drinks with 9% or more sugar by volume sugar-sweetened beverages38. While other sources provide broader inclusion characteristics such as energy- containing soft drinks, sugar-sweetened fruit drinks, and colas39. Drinks that are sweetened by sugars, including sucrose and high fructose corn syrup, that add calories are defined as sugar-sweetened beverages by the 2010 Dietary

16 Guidelines for Americans8. A standard definition may need to be set in further research to provide consistent analysis and recommendation. The theme throughout research into beverage consumption is considering drinks that provide calories, with added sugars, and often poor nutritional value are considered SSBs.

Beverage choice trends have changed in children throughout the last few decades. Sugar-sweetened beverages and high fat milk were part of the top sources of energy intake in US children between 1989-2010 31. The consumption of high fat milk has changed, in 1989-1991 high fat milk provided 11% of total calorie intake for US children and by 2010 dropped down to 6.9% 31. Fruit drinks, soda, and milk provided the largest contribution of beverage-sourced calories in

US children40,41. According to the 2010 National Youth Physical Activity and

Nutrition Study (NYPANS) by the CDC, the top three beverage choices of high school students are water, milk, and 100% fruit juices 42. With these beverages being favorable options compared to drinks that offer empty calories.

In 1989-1991, SSB provided about 6.3% daily caloric intake while in

2003-2004 SSB provided 9.1% daily caloric intake and has since dropped down to 6.1% in 2010 31. Energy intake from SSB had significantly decreased in US youth between 1999-2010 from 223kcal/day to 155kcal/day43. Overall, the total percent energy coming from beverages had decreased from 24.2% to 21.1% in

US children between 2001-201037. While other studies reported percentages as low as 18.7% of daily caloric intake from beverages in 2005-201041. Even though the results of these studies were from a national representative sample using

17 data from National Health and Nutrition Examination Survey (NHANES), there is a risk for possible under-reporting of intakes by self-reported diets. 1 in 5 children, ages 6 months to 12 years old, had excessive calorie consumption defined as greater than 200 calories from beverages, with the highest contributor being fruit juice 44. Youth obtain close to 34% of their total fruit intake as 100% juices, with kids between the ages of 2-5 years old drinking significantly more

100% juice than the older age groups 28. Children who were 100% fruit juice drinkers consumed between 147-164kcal/day of juice between 2005 and 201041.

Milk consumers took in around 245kcal/day from dairy41.

Between 2001 and 2010, consumption of sports drinks, energy drinks, and sweetened coffee/tea increased37. In 2010, 24% of high school students drank a serving of soda a day and 16% drank a serving of sport drinks a day42. Close to

65% of high school students drink a serving of SSB at least once a day, with the most common SSB being regular soda45. Older children 12-18 years old had double the amount of soda drinkers compared to younger 2-5 year olds41. The energy contribution of SSB was shown to increase with age in German children, as well as the amount of added sugar in the diet46. A longitudinal study in 2005 showed that 1 in 3 preschool aged children drank SSBs daily34. Mesirow and

Welsh (2014), also indicated that the intake prevalence of sodas, fruit drinks, and sugar sweetened fruit juices have decreased37. Those who were non-consumers of SSB has increased from 1999-2010, while those who consume one SSB/day and two or more SSB/day have decreased 43. This is a positive trend suggesting

18 that health promotion guidelines may be effective in helping with certain empty calorie drink options while others, such as soda, could be reduced.

Eating fast food one or more times a week was associated with higher odds of drinking SSB three or more times a day in adolescents45. Another observational study of high school students found an association with fast food consumption and increased frequency of soda consumption 19. Between 2000-

2012 children consumed close to 40 grams of added sugar a day from beverages

47. In some studies there have been gender differences in SSB consumption, with male adolescents being more likely than female adolescents to drink SSB45.

Sugar-sweetened Beverages and Obesity

It has been hypothesized that the consumption of SSB may contribute to obesity because of the high sugar content, higher glycemic load and a lack of energy compensation48. Although this is a reoccurring hypothesis the research data into a possible association between SSB and obesity have been inconsistent. A cross-sectional study of beverage consumption found that obese children were more likely to drink soda compared to healthy weight children 41. A study by Ludwig, Peterson, and Gortmaker (2001) identified the possibility that with each additional serving of SSB consumed per day the more the risks of becoming obese increased49.

Obtaining calories from liquid sources without compensating further energy intake from foods can cause a positive energy balance. Liquids satiety expectation can affect how much a person eats following beverage consumption; a person may feel less satiated after drinking a beverage with the same caloric

19 density as a solid food item due to lower expected satiety from a liquid50. The orosensory effect of oral liquids led to a smaller rise in hormones that are part of satiety and a smaller reduction in hormone involved in hunger50. This could potentially explain the difficulty regulating caloric compensation. This caloric compensation may be key when it comes to weight management. A reduction in liquid calorie consumption was more strongly associated with weight loss than with a reduction in solid calorie consumption 51. Sugar intakes were lower in adults who were low calorie beverage (LCB) consumers compared to SSB consumers, which the researchers suggest it is due to the LCB not compensating with sugary food the calories missed from the beverages 52.

Along with the rates of obesity increasing in both adults and youth so have the serving sizes of SSB. The portion sizes of soft drinks increased by about

100ml between 1977 and 2006 in the US 32. Eating occasions containing the larger portions of soft drinks had higher energy intakes 32. So not only do the larger volumes of beverages in and of themselves increase caloric intake but also they can also affect the consumption of meals as well. Looking at discretionary food intake along with beverages, participants compensated for

SSB with lower incremental total calorie intake, while diet beverage consumers took in more calories than the calories from the drinks themselves 53. Per capita, the average calorie contribution of SSBs per day for children increased between

1989-2008 from 130kcal/d to 209kcal/day40. The empty calories, or beverages that provide energy but not a lot of nutrients, coming from SSBs can have negative health consequences. SSB consumption in children was found to have

20 a significant association with cardiometabolic markers, such as serum lipid levels, waist circumference, and CRP concentrations39. These are health markers that were historically not a problem for children, but rather problems seen in adults indicating potential cardiovascular issues. A meta-analysis of the literature exploring SSB consumption and specific disease risks found that higher consumption of these sugary beverages were significantly associated with type 2 diabetes and metabolic syndrome 54.

Systematic reviews of the literature surrounding an association between

SSB consumption and obesity or BMI have found inconsistent results for both children and adolescents 55. After adjusting for total energy intake, in children some studies were unable to find a significant association between SSB and obesity status 39,56,57. A significant association between SSB consumption and obesity was reported in non-Hispanic whites and Mexican Americans but not in non-Hispanic blacks after total energy intake was adjusted58. A longitudinal study of children in Germany saw that an increase in water consumption did not have an association with changes in BMI, but rather the increased consumption of sugar-containing beverages, by one glass/d, increased the risk for obesity by about 22% 59.

A different meta-analysis of the literature completed in 2006, containing cross-sectional studies and prospective cohorts of children, adolescents, and adults, found that there was a link between the risk for overweight or obesity with the consumption of SSB 60. The same leading author found similar results in

2013 with SSBs consumption being positively associated with weight gain in

21 children; one serving a day of SSB was associated with a 0.06-unit increase in

BMI61. LaRowe et al (2007), reported an association between BMI and beverage choices in children 6-11 years old62. A double-blind randomized control trial in school-aged children determined that there was a significant increase in mean

BMI z-score, mean weight gain, and fat mass in the sugar sweetened beverage group compared to those children given sugar-free beverages63. Soft drink consumers had a greater risk for increased wait circumference and waist for height ratio64. These results provide more evidence to suggest targeting SSBs in weight management interventions. Malik et. al, (2013) suggests those who may benefit the most from targeted SSBs interventions are those children who are already overweight to prevent further weight gain61.

An unexpected trend indicated that close to 43% of the children that drank mostly water daily were overweight, which could possibly be explained by reverse causation, that overweight children may be trying to make healthier food and drink choices 62. An observational cohort of adolescents who were obese at baseline drank soda less frequently compared to healthy weight adolescents 19.

Similarly, overweight and obese adults were more likely to drink diet beverages53.

The trajectory of low calorie beverage choices and weight classification needs further investigation.

Sugar-sweetened Beverage Interventions

In recent years there have been many interventions developed to reduce the consumption of SSB because of the caloric contributions they provide with minimal nutritional value. An intervention that is school based and student lead

22 were able to see behavioral change in Appalachian high school students when it came to reducing daily and weekly SSB consumption 65. Student formed and directed messages that were focused on reducing SSB intake rather then avoidance or replacement; the interventions decreased SSB consumption of the student participants by close to one serving per day and increased water consumption 65.

Another school-based intervention, that provided three educational sessions discouraging carbonated beverages in children 7 to 11 years old was effective at reducing the total intake of carbonated beverages66. This cluster randomized control trial also saw that after 12 months the control group had an increase in overweight and obese children while the intervention had a small reduction in students in these weight categories66. A randomized control trial that replaced SSB with zero calorie drinks in overweight or obese SSB consumers in the home setting. In this study there was a significant decrease in total energy intake and sugar intake between the experimental and control groups after the one year intervention and second year follow up 67. The group that received non- caloric drinks experienced a significant reduction after the one year intervention but did not maintain significance after year 2 follow up 67. There was an ethnic variance in the study results, with Hispanic participants significantly reducing their BMI both 1 and 2 years after the intervention 67.

Strategies targeting SSB have shown to affect more than just beverage consumption; a 20% tax increase on SSBs did reduce the number of calories coming from sugary beverages but also had a negative impact on overall diet

23 quality in pre-school children38. In a longitudinal study of adults with hypertension that promoted the DASH diet, a one serving/d reduction in SSB was associated with a 0.5kg weight loss after 6 months and 0.7kg weight loss after 18 months 51.

Showing an intervention promoting an overall diet improvement can also help reduce SSB intake and weight loss. A randomized control trial using the theory of planned behavior and focusing on health literacy SIPsmartER intervention that provided three classes and phone calls to deliver education on either decreasing

SSB or physical activity promotion was able to significantly decrease SSB consumption in adults who received the beverage education 68.

A secondary analysis of a longitudinal study promoting water consumption showed that increased water consumption lead to a reduction in sugar-containing beverages in children 59. Strategies to promote SSB reduction in children should include interventions in the primary care setting, with parents more likely to follow recommendations from their doctor or nurse than an health educator 44. Changes in the environment may be one answer to reducing the intake of SSB, specifically regular soda, with 21% of homes having soda available at all times 44. The availability of unhealthy foods, including regular soda and sports drinks, in the home is associated with high calorie beverages consumption36. Many of the approaches are focused on behavior and lifestyle changes including messages on abstaining, reducing, or replacing SSB in the diet with variable efficacy.

24 Beverages and Diet Quality

Not as much is known when it comes to beverage choices and diet quality in US children, and the literature out is inconsistent. A cross-sectional study analyzing data from Continuing Survey of Food Intake by Individuals (CSFII)

1994-1996 and 1998 reported that beverages did not have a significant association with diet quality based on the original HEI scores in children or adults

69. However, an association between beverages and diet quality was shown to exist in children based on a cross-sectional study from a nationally representative sample in 2001-200262. Young children, 2-5 years old, who were frequent fruit juice drinkers, were found to have the highest diet quality and highest energy intake62. High fat milk consumers had lower diet quality scores compared to fruit juice consumers ages 2-5 years old, possibly due to displacement of other nutrient dense foods 62. However, other research has shown that consumption of milk and dairy products are associated with adequate intakes of calcium and vitamin D70. Milk consumption was positively associated with the probability of reaching vitamin A, folate, vitamin B12, calcium, and magnesium recommended intakes in youth 2-17 years old based on the CSFII 1994-199671. 100% fruit juice consumption was positively associated with the likelihood of meeting vitamin C, folate, and magnesium recommendation in children 6-17 years old71.

The 6-11 year old soda consumers had lower micronutrient intakes and lower HEI scores compared to the other beverage consumer clusters 62.

Carbonated sodas were inversely associated with nutrient intakes in kids 2-17 years old71. One German study reported that the consumption of SSB was

25 associated with poorer diet quality in 2-19 year olds according to the nutritional quality index based on German reference values46. Fruit juice and beverages with added sugar were inversely associated with diet quality and the intake of multiple nutrients, such as calcium and vitamin D, in young children based on nutrient adequacy ratios70. This association is thought to be from a decreased intake of nutrient dense foods with the consumption of nutrient poor SSB70. In a

Canadian study of 8-10 year olds, high intakes of beverage-sourced added sugars were associated with lower diet quality using the HEI-C72. Low-fat milk consumers had a higher diet quality compared to whole-fat milk consumers based on KIDMED index, which measures adherence to a Mediterranean diet on a 12 point scale64. For each point on the scale was associated with 14% increase in odds of being a low-fat milk consumer and a 11% decrease in odds of being a soft drink consumer compared to whole-fat milk consumers64.

A study analyzing the NHANES data from 2003 through 2012 found that in adults, SSBs consumption was associated with the biggest reduction in diet quality score when compared to the effects of other beverage categories53. In

European adults non-consumers of soft drinks and low calorie beverage (LCB) consumers had better diet qualities and lower energy intakes than compared to consumers of SSB and consumers of both SSB and LCB 52. Diet beverages with low calorie sweeteners consumption as a replacement for caloric sweetened beverages in adults caused a significant decrease in dessert consumption, total energy intake, energy from total sugars and added sugars73. Study participants who were assigned to consume water in the place of caloric beverages had a

26 significant increase in fruits and vegetables and a decrease in protein foods and grains intake after 6 months post intervention73. Adults were 62% more likely to be snack and high fat food consumers if they are SSB drinkers then compared to water, coffee, and tea drinkers74. Fruit and vegetable consumers were less likely to be soda consumers compared to water, coffee, and tea drinkers74. A person in an unhealthy food consumption group had higher probability of being in an unhealthy drink group, proposing a connection beverage and food choices74. The possible connection between beverage type and overall diet quality in children needs to be further investigated based on the more recent national data.

Summary

There are many factors that contribute to the causes of childhood obesity and the multiple health consequences associated with it. A gap remains in the scientific literature over the possible association between sugar-sweetened beverage consumptions and diet quality based on weight status in children and adolescents. Beverage consumption, in relation to type and caloric intake, and diet quality were the contributing factors investigated in this paper. Further analysis of poor diet quality and changes in beverage choices needs examined to better understand the relationship between them and obesity in children.

27

Chapter 3: Methodology

Overview of the Study

This research study was quantitative in nature, specifically examining cross-sectional data. Previously collected anonymous data from the 2005-2012

National Health and Nutrition Examination Survey data was downloaded from public access files that were then coded and analyzed to determine if a difference between the variables, beverage consumption and diet quality existed.

Trained professionals collected 24-hour diet recalls using a multiple pass method during the NHANES process. After reviewing the diet recall data beverages and food was coded and categorized. Beverages were classified into eight categories: water, soda, fruit drinks and ades, milk, diet/low calorie drinks, coffee/teas, 100% fruit juices, and other. Diet quality was measured using HEI-

2010 from the categorized foods. The type and amount of beverages consumed from each category was then analyzed.

Consumer-only data, meaning beverage consumption information was only indicated for those who drank from that category, was analyzed from the initial 24 hour diet recall and used to describe the amounts of the beverages consumed. Sugar-sweetened beverages included the combination of beverages from soda, fruit drinks and ades, milk, and coffee/tea that were sweetened with

28 added sugar. The SSB consumers and non-consumers diet quality were computed and compared based on weight status. Weight status was determined from anthropometric data, including height and weight that was collected at the mobile examination center for NHANES participants.

Research Questions

In this study these research questions were answered:

1. What are the amounts and types of beverages consumed by US

children across three age groups (2-5, 6-11, and 12-18 years old) and

three weight status categories?

a. Quantified in grams, total energy and kcals of added sugars

b. Assess differences across weight status categories:

i. Healthy weight (5th - 84th BMI-for-age percentile)

ii. Overweight (85th - 94th BMI-for-age percentile)

iii. Obese (≥95th BMI-for-age percentile)

2. Is there a difference in diet quality by HEI-2010 scores between sugar-

sweetened beverage consumption patterns in US children? Broken

down into:

a. No consumption (<16 kcals of added sugar)

b. Limited consumption (≤140 kcals from added sugar)

c. High consumption (>140 kcals from added sugar)

Overview of NHANES

The NHANES is a program of the National Center of Health Statistics that samples the US population to assess their health and nutritional status75. The

29 NHANES collects data on demographic, socioeconomic, dietary, and health information as well as medical, dental, and anthropometric measurements of adults and children75. Data is analyzed from these surveys to help provide a picture of the health status of the US population. The surveys and examinations are done continuously with data collected from about 5,000 citizens annually, while releasing the data every two years75.

Subjects

The target population was youth ages 2-18 years old in the US The

National Health and Nutrition Examination Survey 2005-2012 data was used, providing nationally representative stratified sample of approximately 20,000 US citizens randomly selected. The NHANES sample population was stratified by race, income, and age, to account for the elderly, African-American, Hispanic, and low income US population75. The sample frame of this study consisted of

NHANES participants, ages 2-18 years old. The initial sample contained 14,307 participants of NHANES 2005-2012 between the ages 2-18 years of age. The final sample size of this study was 13,185 children, after excluding participants with missing dietary data and those classified as underweight. Participants who were underweight were excluded due to small sample size and the complex etiologies behind this weight status.

Dietary data collected by NHANES was through interviews by trained professionals using a validated automated multi-pass method. The information for participants younger than 6 years old was obtained from a proxy. Those who were between 6-11 years old were interviewed along with a proxy, and those

30 over 11 years old were interviewed without a proxy. Dietary recalls, which includes food and beverage intakes, weight, and age data from the NHANES

2005-2012 sample were used in this study. Diet quality and beverage patterns were analyzed from this data.

Data Sources

Demographics

Non-institutionalized US citizens were sampled and demographic information, such as age, gender, race, socioeconomic status, and education, was obtained. The data obtained from NHANES is stratified and weighted to be nationally representative to the US population. In this study age and gender were used to assess weight status in appropriate CDC growth charts. Age was also used to categorize the results.

Dietary Intakes

The USDA Automated Multiple-Pass Method, a computer program with standardized questions to guide the 24-hour diet recall of participants, was used to collect the dietary data. The Automated Multiple-Pass Method (AMPM) is a validated procedure used to obtain a 24-hour dietary recall76. This computer- based questionnaire guides the trained interviewers as they go over the participant’s intake over the past 24-hours multiple times by asking questions several times to get complete data. More detail is often gathered each time the interviewer goes over the previous day’s intake. Questions asked include: description and types of foods, serving sizes, and the type of meal eaten in the last 24 hours. Two non-consecutive days of recalls are collected with one in

31 person at the mobile examination center and the other over the telephone. In this study the one day in person dietary recalls were used to follow the trend in the surrounding literature analyzing dietary data from NHANES2,31,43,62.

The USDA Food and Nutrient Database for Dietary Studies (FNDDS) was used to code foods and beverages and analyze the nutrients in the data. This food database was used because of its large variety of food and nutrient values to reference. The database program was helpful in coding the beverages and food that was collected from the diet recalls. The data was then imputed into the

Food Patterns Equivalents Database (FPED). FPED is a program that converts foods and beverages from FNDDS to food patterns that can be used to compare to the US dietary Guidelines77.

Body Measurements

Weight was measured by trained investigators on an electronic scale in kilograms recorded to two decimal places during the NHANES study data collection visit. Children and adults wore underwear and light paper clothing provided by the examination center78(p2). Height was measured using a stadiometer for children and adults 3 years and older79(p3). Children less than 3 years old were measured recumbently on a length board. Height was measured in centimeters and was recorded to the nearest millimeter.

Data Preparation

Age

Citizens of all ages, starting from birth, were included in the NHANES

2005-2012. In this study data from participants ages 2 to 18 years old was

32 examined. Based on the cut off point trends in the current body of literature age was broken down into 3 groups: 2-5 years old, 6-11 years old, and 12-18 years old13,28,31,41,62.

Weight status

Weight status was determined after calculating BMI from the participants’ height and weight in kg/m2. The BMI was then compared to age and gender specific CDC growth charts to determine BMI-for-age percentile of the child.

Weight categories in this study were based on the CDC guidelines which included underweight as a child below the 5th percentile, healthy weight as a child in the 5th to 84th percentile, overweight as a child in the 85th to 94th percentile, and obese as a child in the 95th or higher percentile for their gender specific BMI-for- age10,80.

Demographic and anthropometric data, including age, gender, height, and weight, from study sample was imputed into SPSS. That file data was then exported into a Microsoft Excel document to be imported into Microsoft Access.

The file in that format was through Epi Info v3.5.4 from the CDC to generate BMI percentiles. Once percentiles are added to the file it was then exported into

Microsoft Excel and opened in SPSS. The percentile data was then recoded into weight categories based on the CDC Guidelines.

Diet Quality

Healthy Eating Index (HEI) 2010 was used to determine diet quality of the participants from the food patterns data and the nutrient data. This is a validated tool to measure diet quality when compared to the 2010 US Dietary Guidelines.

33 Shown in the table below: the index takes into account total fruit, whole fruit, total vegetable, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, and empty calorie consumption to produce a score25. This score, from 0-100, can be used to determine the quality of someone’s diet.

HEI- 20101 Maximum Standard for maximum score Standard for minimum score of component zero ▲ Adequacy (higher score indicates higher consumption) Total Fruit2 5 ≥ 0.8 cup equiv. / 1,000 kcal10 No fruit Whole Fruit3 5 ≥ 0.4 cup equiv. / 1,000 kcal No whole fruit Total Vegetables4 5 ≥ 1.1 cup equiv. / 1,000 kcal No vegetables Greens and Beans4 5 ≥ 0.2 cup equiv. / 1,000 kcal No dark-green vegetables, beans, or peas Whole Grains 10 ≥ 1.5 ounce equiv. / 1,000 kcal No whole grains Dairy5 10 ≥ 1.3 cup equiv. / 1,000 kcal No dairy Total Protein Foods6 5 ≥ 2.5 ounce equiv. / 1,000 kcal No protein foods Seafood and Plant 5 ≥ 0.8 ounce equiv. / 1,000 kcal No seafood or plant proteins Proteins6,7 Fatty Acids8 10 (PUFAs + MUFAs) / SFAs > 2.5 (PUFAs + MUFAs) / SFAs < 1.2

▼ Moderation (higher score indicates lower consumption) Refined Grains 10 ≤ 1.8 ounce equiv. / 1,000 kcal ≥ 4.3 ounce equiv. / 1,000 kcal Sodium 10 ≤ 1.1 gram / 1,000 kcal ≥ 2.0 grams / 1,000 kcal Empty Calories9 20 ≤ 19% of energy ≥ 50% of energy

1 Intakes between the minimum and maximum standards are scored proportionately. 2 Includes 100% fruit juice. 3 Includes all forms except juice. 4 Includes any beans and peas not counted as Total Protein Foods. 5 Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages. 6 Beans and peas are included here (and not with vegetables) when the Total Protein Foods standard is otherwise not met. 7 Includes seafood, nuts, seeds, soy products (other than beverages) as well as beans and peas counted as Total Protein Foods. 8 Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs). 9 Calories from solid fats, alcohol, and added sugars; threshold for counting alcohol is > 13 grams/1,000 kcal. 10 Equiv. = equivalent, kcal = kilocalories.

Table 1: Healthy Eating Index 2010 Scales and Scoring Procedures81

34 Beverage Consumption

Beverage consumption data was collected from the 24-hour dietary recall information of NHANES 2005-2012. Beverages were coded in the FNDDS and clustered into eight groups: water, milk, 100% juice, coffee/tea, fruit drinks and ades, soda, diet/low calorie drinks, and other. Non-food combination beverages were manually coded into the eight beverage groups, categorized based on the beverage that contributed the highest amount in grams in the combination.

Consumption of each type and amount of beverage were grouped and analyzed as consumer-only clusters. Fruit drinks and ades included sports drinks, lemonades, and other fruit flavored drinks. Beverages included in the other category were those that do not typically fall into the previous groups, such as meal replacement drinks, alcohol, and cultural beverages.

Sugar sweetened beverages were defined as beverages containing added sugars such as sucrose or fructose that contributes calories8. Beverages included in the SSB category: soda, fruit drinks and ades, sugar-sweetened teas, sweetened/flavored milk, sugar-sweetened coffee drinks, sports drinks, energy drinks, and sweetened juices. Beverages from the eight beverage groups that fell into the SSB definition and contributed Calories from added sugars were combined into the SSB cluster. The diet quality score of consumers and non- consumers of the SSB cluster were investigated to determine a potential difference between the two groups broken down by weight categories and age.

The SSB cluster was also further broken down into three groups based on the amount of consumption: non-consumption (<16 kcals of added sugars from

35 beverages), limited consumption (≤140 kcals of added sugar from beverages), and high consumption (>140 kcals of added sugar from beverages). The consumption cut off points were determined by the recommendations from the

US Dietary Guidelines to obtain less than 10% of daily calories from added sugars9. On average a child, ages 2-8 years of age, needs 1200-1600kcal/d depending on age, gender, and activity level, with 10% of this range being 120-

160kcal/d and a serving size of soda providing an estimated 140 kcals82. In SSB consumers, children who obtained more than the recommended limit of calories, based on the average 140 kcals were considered high consumers while those falling below were classified as limited consumers. The diet quality total scores and subcomponent scores of the participants in each group were compared to determine if a difference exists.

Data Analysis

Descriptive statistics were used to determine the frequency and mean quantities of consumption of the beverages by age and weight categories.

Descriptive statistics provided consumer trends based on the percentage of sample reported consumption, grams consumed, energy provided from beverage, and energy from added sugar in the 8 beverage categories. Analysis of variance (ANOVA) was used to analyze the difference between the variables; sugar-sweetened beverage consumption and diet quality in the three weight categories and three SSB consumption levels. The data was coded and clustered based on the type and amount of beverage consumed. SSB consumption was also clustered by quantity for further analysis with HEI 2010

36 scores. For statistical analysis of the data, SSPS Complex Samples (version 24,

IBMS SPSS) was used to create population-based estimates and statistical analyses that account for the complex sampling strategy of NHANES. Statistical significance was assed by the overlapping of 95% confidence intervals.

Protection of Human Rights

This study used anonymous de-identifiable data previously collected, resulting in minimal risk for corruption of privacy or harm on the participants.

Therefore the data and procedures are exempt from the need of review by the

Institutional Review Board.

37

Chapter 4: Results and Discussion

Demographics

Dietary and anthropometric data for 2-18 year old US citizens from the

2005-2012 National Health and Nutrition Examination Survey was used in this study. After excluding participants who did not have complete dietary information or were classified as underweight the total sample size was 13,185. The sample was broken down by age groups and by weight classification: 65% (n=8,590) were healthy weight, 16% (n=2,055) were overweight, and 19% (n=2,540) were obese. The distribution of sample across age and weight status groups are presented in Table 2.

Beverages Consumed by US Children Across Age and Weight Status

Percent Consuming

Differences among the three age categories in beverage consumption patterns are presented in Figures 2-4. Within the youngest age group, milk, water, and juice were consumed by the most children, with 73.7%, 73.4%, and

54.0%, respectively, consuming these beverages on the day of recall. The top three beverages among 6-11 year olds were water (77.2%), milk (61.8%), and soda (39.4%). In the 12-18 year old age group water, soda, and milk were the most reported beverages at 76.0%, 48.9%, and 40.8%, respectively.

38 The proportion of 12-18 year old children that drank milk (40.8%) was nearly half of the youngest group (73.7%), while soda consumption was reported twice as much in the oldest group (48.9%) than in the youngest group (24.2%).

The percentage of those that were juice consumers was lower in the older age groups; the largest disparity in fruit juice intakes was between the 2-5 year olds group at (54.0%) and the 6-11 year old group at (33.5%). Fruit drinks and ades consumption was also higher than juice consumption in the 6-11 and 12-18 year old groups.

Grams of Intakes from Beverages

By volume, water consumption was the highest in 12-18 year olds (Table

2). The older children drank more soda and less milk than the youngest children surveyed. Children in the 2-5 year old age group with obesity reported significantly more fruit drink and ade and coffee/tea consumption in grams compared to those of a healthy weight. Children ages 6-11 years old with obesity consumed significantly more low calorie beverages in grams compared to those in the healthy weight group. Youth ages 12-18 years old in the obese category drank significantly more water in grams than those in the healthy weight category.

Total Energy from Beverages

In the 2-5 year olds and 6-11 year olds the leading source of energy from beverages was milk, while in the 12-18 year olds it was soda (Table 3). Obese

12-18 year olds consumed significantly more energy (142 kcal/d) from soda compared to the obese 2-5 (27 kcal/d) and 6-11 year olds (74 kcal/d); 6-11 year

39 olds consumed more energy from soda than 2-5 year olds. Obese 12-18 year olds consumed significantly less energy from milk and juice than obese 2-5 year olds. Fruit drinks and ades were a part of the top three energy providing beverages for all three age groups.

Calories from Added Sugar from Beverages

Fruit drinks and ades provided the most added sugars from beverages in the

2-5 year olds (Table 4). In the 6-11 and 12-18 year old groups soda was the highest contributor of beverage sourced added sugars. Obese 12-18 year olds consumed significantly more added sugars from soda (131kcals/d) compared to the obese 2-5 (25 kcal/d) and 6-11 year olds (66 kcals/d); 6-11 year olds consumed more added sugars from soda than 2-5 year olds. The largest source of added sugars from beverages came from soda in the 6-11 and 12-18 years old age groups. Fruit drinks and ades were also a part of the top sources of beverage sourced added sugars in all three age groups. Differences were not significant between weight categories within the same age groups.

Discussion on Beverage Patterns

The results of this study, milk, juice, and water the being highest reported beverages consumed, are in line with similar findings from Watowicz et al

(2015)41. The energy contribution of soda, fruit drinks and ades, and milk reported in this study support the beverage-sourced energy findings of the literature. Sugar-sweetened beverages, including fruit drinks and soda, and milk have been the top beverage-sourced energy contributors in children’s diets31,40,41. The largest source of added sugars from beverages were those,

40 which are in this study and in the surrounding literature, classified as sugar- sweetened beverages. The majority of the calories from soda are empty calories from added sugars. The risk of drinking large quantities of empty calories is the potential to displace the consumption of healthy foods and beverages that provide needed nutrients. Soda consumption was associated with lower micronutrient intakes in children62,83. One study suggests a diluting effect from

SSB on children’s diet quality because of a negative association with the consumption of these beverages and the intake of micronutrients46.

Milk was one of the most consumed beverages volumetrically and provided a higher amount of beverage-sourced energy in the younger age groups. A study of children’s beverage consumption patterns found that young children ages 2-5 years old were more likely to drink milk and 100% juice than compared to adolescents ages 12-18 years old41. Younger children age 2-5 years old consume more juice than compared to children 6-18 years old28. The amount of 100% fruit juice reported in this study (33.5%) is much lower than other estimates for 6-11 year olds. In 2007-2008 around 50% of 6-11 year olds reported drinking 100% fruit juice40.

The most frequently consumed beverages of the youngest age group are those that are recommended as healthy beverage choices. Although milk and juice provide calories, these drinks also provide vitamins and minerals that a growing child needs, such as calcium, vitamin D, potassium, and folate. Studies have shown that milk and 100% juice consumption is associated with adequate intakes of those key nutrients in youth70,83. In the surrounding literature, milk and

41 juice consumption is higher in young children and lower in adolescents, while soda consumption is higher in older children than in the younger children41,84.

The oldest age group surveyed reported the highest proportion of soda consumption, as well as the highest volume of soda consumed in grams. In the

6-11 year old age group, soda and fruit drinks, both considered SSB, were reportedly consumed more than in the younger age group. Children 6-11 years old were reported to have consumed around 231kcal/d from SSB, which included soda, fruit drinks, high sugar milk, and sports drinks in 2007-200840. The amount of energy obtained from soda was higher in each ascending age group, supporting the literature that indicates SSB intake is higher in adolescents than in young children43,46,85. The proportion of children drinking soda was higher by each ascending age group from 2-5 year olds to 12-18 year olds by which the amount nearly doubled41. Energy from SSB and intake of added sugar was found to increase with age in German youth 2-19 year olds46.

Water and low-calorie beverages are recommended substitutions for SSB because of the potential benefit in weight management86. The substitution of non- caloric beverages for SSB was found to reduce weight gain in frequent SSB consuming children63. Efforts to reduce SSB consumption have promoted the consumption of non-caloric or reduced calorie beverages63,66,86, especially among those with overweight or obesity67,87. Larger quantities of low calorie beverages in the obese 6-11 year olds may be due to an effort to reduce energy intake from beverages following recommendations from healthcare providers that target those who are obese more so than healthy weight individuals. Close to

42 43% of adolescents, ages 6-11 years old, whose beverage consumption was predominantly water were overweight or obese62. The same explanation may account for the trend of higher water intake by obese 12-18 year olds than to those of a healthy weight. Although overall the larger volumes of water consumed by the 12-18 year old group compared to the younger groups may be due to higher fluid requirements.

Diet Quality by Sugar-sweetened Beverage Consumption in US Children

In each age group, differences in diet quality scores were found between consumers of sugar-sweetened beverage and non-consumers (Tables 5-7). Total

HEI 2010 scores were significantly lower in those who consumed more than 140

Calories from added sugar in beverages (high consumers) compared to those who consumed less than 1 teaspoon of added sugars from beverages (non- consumers) in all 3 age groups, with the exception of the overweight 6-11 year olds. Total HEI 2010 scores were significantly lower in the high SSB consumer group compared to those who consumed ≤140 Calories from added sugar from beverages (limited consumer) in all age groups with the exception of overweight

12-18 year olds. As expected high SSB consumers had lower empty calorie component scores compared to the limited and non-consumers of SSB in all age groups. The quantity of SSB a child drinks was associated with a difference in diet quality more so than their weight status. Higher SSB consumption was associated with poorer total fruit, whole grains, and empty calorie diet quality scores.

43 Discussion on Diet Quality and Sugar-Sweetened Beverage Patterns

Consumption of sugar-sweetened beverages in German youth was found to be associated with poorer total diet quality46. Although children with the greatest amount of SSB consumption had the poorest total diet quality, overall the children in this study had poor total diet quality scores, especially in total vegetable, greens and beans, seafood and plant proteins component scores.

These results are agreement with overall diet quality of children in the US reported with HEI-2010 score of 50 and subcategories greens and beans, whole grains, fatty acids, and total vegetables being the most problematic2. When taking into account SSB beverage consumption from similar data, using

NHANES 2005-2010, fruit and dairy scores were lower and sodium scores were higher with high SSB consumption in this study2. If diet quality is already below ideal levels than this data suggests that consumption of SSB only contributes to an even poorer overall diet and should be a focus for health promotion to reduce consumption.

Diet Quality by Weight Status and SSB Consumption in the 2-5 Year Olds

Of the 2-5 year olds (21%), (21%), and (27%) were high SSB consumers for healthy weight, overweight, and obese weight categories, respectively (Table

8). Total protein foods, seafood and plant protein, fatty acid, and refined grains scores were not significantly different between the SSB consumption categories in the 2-5 year old age group. Within the 2-5 year olds whole fruit, total fruit, and whole grain scores were significantly lower in high SSB consumers compared to non-consumers. Obese high consumers had lower greens and beans scores

44 (0.2) compared to the overweight (0.6) and healthy weight (0.6) high SSB consumers of the 2-5 year olds, as well as the score being lower than the obese non-consumer (0.8). Dairy scores for the healthy weight high SSB consumers were significantly lower than the non-consumers in the 2-5 year old group, but a difference was not found in the other weight categories. Whole grain scores were significantly lower for the healthy weight and overweight limited consumers compared to the non-consumers in the same weight categories. Total fruit scores for healthy weight and obese limited consumers were significantly lower than non-consumers in those weight categories. Healthy and obese limited consumers had significantly lower total HEI 2010 scores compared to non-consumers.

Obese high SSB consumers had significantly lower sodium scores than healthy weight high consumers, although healthy weight high consumers had significantly higher scores than the limited and non-consumers of the healthy weight group.

Discussion on Diet Quality by Weight Status and SSB Intake in the 2-5 Year Olds

The consensus is that younger children, those 2-8 years old, have higher diet qualities than adolescents 12-18 years old2,88. It has also been speculated that SSB consumption may displace nutritious foods in children based on the negative effect on total intake of multiple nutrients associated with intake of these beverages46. Possibly, the substitution of fruits and 100% juices for SSB could account for the lower scores in total and whole fruit associated with high SSB consumption. Even drinking a limited amount of SSB could have an association with decreased consumption of fruit and 100% juices in this study. High soft drink

45 consumption was suggested to displace fruit juice consumption in children and adolescents89. Although an association was found in the current data, an older study investigating the diets of young children did not find an association between fruit and juice consumption with SSB consumption34. The obese high consumers reported the lowest greens and beans food intake, which are foods that are typically lower calories and high in fiber that can be helpful in weight control. Consumption of fruits and vegetables may help prevent an increase in adiposity in children90. The association between poor greens and beans consumption and obesity may be attributed to the effects of fruits and vegetables in body composition and weight.

Diet Quality by Weight Status and SSB Consumption in the 6-11 Year Olds

Of the children in this age group (48%) of the obese fell within the high

SSB consumption category, while it was close to (36%) in the healthy weight children (Table 8). Less than a quarter of these children were non-consumers in each weight group. Within the 6-11 year olds total fruit, whole fruit, and whole grains scores were lower significantly in the healthy weight and obese high SSB consumers compared to non-consumers. Although within the healthy weight and overweight high SSB consumers total fruit and whole fruit scores were significantly lower than the limited SSB consumers. In the 6-11 year old age group sodium component scores were higher in the healthy weight and overweight high SSB consumers compared to those who were non-consumers.

Sodium component scores were also higher for the healthy weight and obese high consumers compared to the limited consumers in the same weight

46 categories. Obese limited SSB consumers and non-consumers had significantly higher protein foods scores compared to the healthy weight limited consumers and non-consumers. Overweight non-consumers had lower refined grains scores than healthy weight non-consumers.

Discussion on Diet Quality by Weight Status and SSB Intake in the 6-11 Year

Olds

Total diet quality scores were much lower in this study, especially for those who are high SSB consumers, ranging from 38.4 to 43.1, than compared to a similar study a decade ago. Children who were SSB consumers had total HEI scores of 69.9 in 2001-200262. Similar to the results of this study, fruit consumption was lower in fourth through sixth grade students who were high soft drink and SSB consumers91. A cross-sectional study of Canadian children 8-10 years old found a similar association between higher intakes of added sugars from beverages and lower diet quality measured using HEI-C72. The consumption of SSB was also associated with decreased consumption of healthy food choices. Every 10g of added sugars from beverages was associated with

0.4serving/d reduction of fruits and vegetables72.

The higher sodium scores, meaning children consuming less sodium, associated with high SSB consumption in this study contradicts the results from one study that found a significant association between SSB and salt intakes in children92. The weight of a child may have more of an association with protein consumption more so than SSB consumption, with obese children eating more protein foods than those of a healthy weight. One study had a small association

47 between meat consumption and overweight/obesity in children, but more research is needed to understand if this association with weight status is a significant dietary pattern93.

Diet Quality by Weight Status and SSB Consumption in the 12-18 Year Olds

Over 50% of adolescents were high SSB consumers regardless of weight status (Table 8). Healthy weight non-consumers had higher total fruit, whole fruit, total vegetable, greens and beans, whole grain and dairy component scores compared to high SSB consumers of the same weight category in the 12-18 year old age group. Total fruit and whole grain scores were lower in the high SSB consumers compared to the non-consumers. Total fruit scores were lower than the limited consumers. Whole fruit scores were lower for the healthy weight and obese high consumers compared to the non-consumers and limited consumers of the same weight categories. Dairy scores were significantly lower for healthy and overweight high SSB consumers compared to non-consumers. Obese limited SSB consumers had higher refined grain scores than the overweight and healthy weight limited consumers. Overweight non-consumers had higher protein food scores compared to obese non-consumers. Healthy weight limited consumers had higher seafood and plant protein scores than the overweight and obese limited consumers. Obese high consumers had lower total vegetable intakes than obese limited consumers. Sodium scores were significantly higher in the high SSB consumers when compared to the non-consumers.

48 Discussion on Diet Quality by Weight Status and SSB Intake in the 12-18 Year

Olds

In the adolescent group, especially those of a healthy weight, not consuming SSB was associated with better diet quality based on multiple areas of consumption that are aspects of a high diet quality. A high amount of sugar- sweetened beverages, which have low nutrient densities, was associated with decreased consumption of nutrient dense foods in children70. The results of this study support those findings with the pattern of decreased diet quality scores within the higher SSB consumption levels. Suggesting poorer nutrient density of the diet. Another study reported that a high intake of added sugars was associated with lower micronutrient density and more inadequacies of the diet in

Irish children and teenagers94. Spanish adolescent soft drink consumers were also reported to have low intakes of folic acid, magnesium, vitamin C, and fiber64.

Although whole grains, fruit, and dairy have been known to be problem components for adolescents, these results show that high SSB consumption is associated with scores even lower for fruit, dairy, and protein foods than previously reported for this age2.

Overall Trends and Conclusion

Poorer overall diet quality scores could be attributed to the lower fruit, whole fruit, whole grain, and empty calorie scores that are associated with higher

SSB consumption. Consumption quantity was more associated with the differences in diet quality component scores than weight overall. Higher consumption of SSB was associated with lower HEI-2010 scores in US youth.

49 Although an assessment of adolescents and young adults from 1994-1998 did not find an association with beverage intakes and HEI scores69, the results from the present study coincide with prior reports of the deleterious association between beverages, specifically SSB, and diet quality46,53,62,70,72.

Sugar-sweetened beverages not only contribute to obesity because of the empty calories and lack of calorie compensation associated with these beverages but also, based on these results, contribute based on their association with decreased fruit and whole grain consumption which are recommended for weight maintenance9,90 and better diet quality. Diet quality has previously been shown to be inversely associated with BMI in children95. Diet quality is not only important because of its association with weight, but also because of its relation to overall health and mortality. The core measure of diet quality used in this study, the Healthy Eating Index-2010, is a quantitative approach to measure adherence to US Dietary Guidelines. The HEI-2010 has been associated with significantly lower risk in mortality;96 therefore, emphasizing the need interventions to improve diet quality in the US population.

The results of this study do have limitations to take into consideration. This study being observational in nature does not allow a casual relationship to be produced. Excluding underweight participants from the study’s sample may limit potential discoveries of unknown trends for this segment of the population. The data is collected from a one-day snapshot of the children’s diets, which may not be representative of their usual intake. The reliance of memory for the diet recall and the accuracy of intake estimations of the participants and proxies do provide

50 limitations to this study. There may be differences in the accuracy of the diet recall between what the child consumed and what the child’s proxy reports in the younger groups. The cross sectional nature of the study did not investigate the changes of diet and weight longitudinally. Currently, the US Department of

Agriculture has not release the HEI-2015 to evaluate diet quality based on the most recent Dietary Guidelines 2015-2020. Therefore, these analyses evaluate dietary intakes based on concordance with the 2010 Dietary Guidelines. One of the strengths of this study design is from the large nationally representative sample size, which increases the external validity.

Because of SSB consumption was noted across all weight categories in this study, it indicates that health and weight management interventions should focus on limiting the consumption of SSB in youth no matter the weight status.

Future research in the determinants of beverage choices in children based on age and weight is needed to better understand what behaviors and influencing factors to target healthy beverage interventions. Future research should investigate the factors contributing to the association between the consumption of sugar-sweetened beverages and lower intakes of whole grains and fruit.

51

Chapter 5: Beverage Patterns and Diet Quality by Weight in US Children

Abstract

Objective: The purpose of this study was to investigate the beverage patterns and the potential differences between sugar-sweetened beverage (SSB) intake and diet quality in different weight categories of US children aged 2-18 years old.

Methods: A cross-sectional study design was used to examine the dietary and anthropometric data collected from the National Health and Nutrition Examination

Survey 2005-2012. Diet quality was measured using the Healthy Eating Index

(HEI) 2010. Beverage pattern data was divided into groups based on age and weight categorization. Diet quality was analyzed by SSB consumption, which was broken down by consumption levels, non-consumer, limited consumers, and high consumers, within each age and weight group.

Results: The most reported beverages and those consumed highest by volume were: water, milk, and soda for children and adolescents 6-18 years old in all three weight groups. While for young children 2-5 years old in all three weight groups, these were water, milk, and juice. The quantity of SSB children drink

SSB was associated with a difference in HEI-2010 scores more so than their weight status. Higher SSB intake was associated with lower overall HEI-2010

52 scores, as well as lower HEI 2010 scores for fruit, whole grains, and added calorie compared to non-consumption.

Conclusions: Pediatric healthy diet and lifestyle interventions should focus on limiting the consumption of SSB in youth who consume them regardless of weight status.

Introduction

Overweight and obesity in children are continued concerns internationally and within the US. Some of the most recent prevalence rates estimate that 17% of the youth in the US are obese13. These high rates have become a concern due to the negative health consequences that are associated with childhood obesity, including metabolic, gastrointestinal, and cardiovascular complications1. A positive energy balance over time can lead to excess weight gain in children.

Environmental factors such as abundant access to energy-dense food and sedentary lifestyles were suggested to contribute to energy imbalance17. It has been hypothesized that the consumption of sugar-sweetened beverages may contribute to obesity because of their high sugar content, higher glycemic load, and lack of energy compensation48. What children drink matters, because the nutrients (or lack thereof) in the beverages and calorie contribution impact not only weight management, but also diet quality.

Limiting foods and beverages that are concentrated sources of energy is recommended for the promotion of energy balance and healthy weight maintenance in children. The US 2010 Dietary Guidelines recommend patterns that promote a healthy lifestyle and focus on prevention of diseases such as

53 obesity8, and was reinforced in the new US 2015 Dietary Guidelines9.

Compliance to these recommendations is one way to measure diet quality. It has been suggested that beverage consumption was associated with diet quality46,62,70. Sugar-sweetened beverages have been associated with rising rates of obesity due to the contribution of empty calories and effects on energy balance, but little is known of their role in diet quality when it comes to quantity consumed and weight status in children. The aim of this study was to investigate beverage patterns and the potential differences between SSB intakes and diet quality in different weight categories of US children.

Methods

Study Population

Data from the National Health and Nutrition Examination Survey

(NHANES) 2005-2012 for youth 2-18 years of age was analyzed. The NHANES provides a nationally-representative, stratified sample of randomly selected US non-institutionalized citizens75. Weight categories were based on the CDC guidelines which include: underweight, a child below the 5th percentile; healthy weight, a child being in the 5th to 84th percentile; overweight, a child in the 85th to

94th percentile; and obese, a child being in the 95th or higher percentile for their sex and age80. Participants who provided complete and valid dietary data, as well as who were ≥5 percentile of BMI-for-age were included in this study. Those who were underweight were excluded due to the small sample size and the complex etiologies behind this weight status. Age was also used to categorize the results;

54 participants were broken down into three groups: 2-5 years old, 6-11 years old, and 12-18 years old.

Dietary Data

The NHANES collected dietary data through interviews completed by trained professionals using a validated automated multi-pass method. The information for participants younger than 6 years old was obtained from a proxy.

Those who were between 6-11 years old were interviewed along with a proxy, and those over 11 years old were interviewed without a proxy. Two non- consecutive days of recalls were collected, one in person at the mobile examination center and the other over the telephone. The one day in person 24- hour dietary recall data was analyzed for 13,185 individuals in this study. Dietary information collected included the types of foods and beverages, serving sizes, and the type of meal that were consumed in the last 24 hours. The Healthy

Eating Index (HEI) 2010 was used to determine diet quality of the participants from the food patterns data and the nutrient data.

Food and Beverage Coding

The USDA Food and Nutrient Database for Dietary Studies (FNDDS) was used to code foods and beverages and analyze the nutrients in the data. The data was then imputed into the Food Patterns Equivalents Database (FPED).

FPED is a program that converts foods and beverages from FNDDS to food patterns that can be used to compare to the US Dietary Guidelines77. Beverages were clustered into eight groups: water, milk, 100% juice, coffee/tea, fruit drinks and ades, soda, diet/low calorie drinks, and other. Fruit drinks and ades included

55 sports drinks, lemonades, and other fruit flavored drinks. Beverages included in the cluster labeled “other” were ones that do not typically fall into the previous groups, such as meal replacement drinks, alcohol, and cultural beverages. Non- food combination beverages were manually coded into the eight beverage groups. They were categorized by the beverage with the highest contribution, in grams, to the mixture. This included beverage additions, such as syrups and sugar, which were mixed into the consumed beverage. Consumption of each type and amount of beverage were grouped and analyzed as consumer-only clusters.

Sugar sweetened beverages were defined as beverages containing added sugars, such as sucrose or fructose, that contribute calories8. Beverages included in the SSB category: soda, fruit drinks and ades, sugar-sweetened teas, sweetened/flavored milk, sugar-sweetened coffee drinks, sports drinks, energy drinks, and sweetened juices. Beverages from the eight beverage groups that fell into the SSB definition and contributed calories from added sugars were combined into the SSB cluster. The SSB cluster was also further broken down into three groups based on the amount of consumption: non-consumption (<16 kcals of added sugars from beverages), limited consumption (≤140 kcals of added sugar from beverages), and high consumption (>140 kcals of added sugar from beverages).

Statistical Analysis

Descriptive statistics were used to determine the frequency and mean quantities of consumption of the beverages by age and weight categories.

56 Descriptive statistics provided consumer trends based on the percentage of sample reported consumption, grams consumed, energy provided from beverage, and energy from added sugar in the eight beverage categories.

Analysis of variance (ANOVA) was used to analyze the difference between the variables: sugar-sweetened beverage consumption and diet quality in the three weight categories and three SSB consumption levels. SSPS Complex Samples

(version 24, IBMS SPSS) was used to create population-based estimates and statistical analyses that account for the complex sampling strategy of NHANES.

Statistical significance was assed by the overlapping of 95% confidence intervals.

Results

Beverage Patterns

Within the youngest age group, 2-5 year olds, milk, water, and juice were the highest consumed beverages reported. The most consumed beverages in the 6-11 and 12-18 year old age groups were water, milk, and soda. The proportion of 12-18 year old children that drank milk (40.8%) was nearly half of the youngest group (73.7%), while soda consumption was reported twice as much in the oldest group (48.9%) than in the youngest group (24.2%). In the 2-5 year olds and 6-11 year olds, the leading source of energy from beverages was milk, while in the 12-18 year olds it was soda. Obese 12-18 year olds consumed significantly more energy (142 kcal/d) and added sugars from soda compared to the obese 2-5 (27 kcal/d) and 6-11 year olds (74 kcal/d). Fruit drinks and ades were a part of the top three energy-providing beverages for all three age groups.

57 Diet Quality by SSB Consumption

In each age group, differences in diet quality scores were found between consumers of sugar-sweetened beverage and non-consumers (Tables 5-7). Total

HEI 2010 scores were significantly lower in those who consumed more than 140

Calories from added sugar in beverages (high consumers) compared to those who consumed less than 16 kcals from added sugars from beverages (non- consumers) in all three age groups, with the exception of the overweight 6-11 year olds. The amount of SSB a child drinks was associated with a difference in diet quality more so than their weight status. Higher SSB consumption was associated with lower HEI scores for fruit, whole grains, and added calories, which contributed to poorer overall diet quality. In all three age groups, high SSB consumption was significantly associated with higher sodium scores than compared to the consumption of ≤140 Calories from added sugar from beverages (limited consumption) and non-consumption in the healthy weight groups.

Within the 2-5 year olds whole fruit, total fruit, and whole grain scores were significantly lower in high SSB consumers compared to non-consumers.

High consumption of SSB was associated with lower total fruit, whole fruit, and whole grain intakes within the overweight and obese 6-11 year olds. Similarly, total fruit and whole grain consumption was lower in high SSB consumers compared to those who were non-consumers in the adolescents, those who were

12-18 years old, while whole fruit was only significantly lower in the healthy weight and obese groups.

58 In the youngest age group healthy and obese limited consumers had significantly lower total HEI 2010 scores compared to non-consumers. Obese high SSB consumers had lower greens and beans scores compared to the overweight and healthy weight children in the 2-5 year old age group. Healthy weight non-consumers had higher total fruit, whole fruit, total vegetable, greens and beans, whole grain and dairy component scores compared to high SSB consumers of the same weight category in the 12-18 year old age group.

Discussion

Patterns of beverage intakes differed across age groups, as well as across weight status groups. The most frequently consumed beverages of the youngest age group were those that are recommended as healthy beverage choices; milk and 100% juice consumption was associated with adequate intakes of those key nutrients in youth70,83. In the surrounding literature, milk and juice consumption was higher in young children and lower in adolescents, while soda consumption was higher in older children than in the younger children41,84. Sugar- sweetened beverages, including fruit drinks and soda, and milk have been the top beverage-sourced energy contributors in children’s diets31,40,41. The majority of the calories from soda are empty calories from added sugars. The risk from drinking large quantities of empty calories is the potential to displace the consumption of healthy foods and beverages that provide needed nutrients46,62,83.

In the adolescent group, especially those of a healthy weight, not consuming SSB was associated with better diet quality based on multiple areas

59 of consumption. A high amount of sugar-sweetened beverages, which have low nutrient densities, was associated with decreased consumption of nutrient dense foods in children. These results support prior work that showed decreased diet quality scores within those youth consuming higher amounts SSB70,72. Similarly, a high intake of added sugars was associated with lower micronutrient density and more inadequacies of the diet in Irish children and teenagers94. Spanish adolescent soft drink consumers were also reported to have low intakes of folic acid, magnesium, vitamin C, and fiber64. Total diet quality scores were much lower in this study, especially for those who are high SSB consumers, ranging from 38.4 to 43.1, than compared to a similar study a decade ago which reported that children who were SSB consumers had total HEI scores of 69.9 in 2001-

200262. Consistent with some of the findings in the surrounding literature, younger children 2-8 years old, were found to have higher diet qualities than adolescents 12-18 years old2,88.

The consumption of SSB was also associated with decreased consumption of healthy food choices. Wang et. al (2014) reported that every 10g of added sugars from beverages was associated with 0.4 serving/d reduction of fruits and vegetables72. Similar to the results of the current study, fruit consumption was lower in fourth through sixth grade students who were high soft drink and SSB consumers91. The results from the present study coincide with prior reports of the deleterious association between beverages, specifically SSB, and diet quality46,53,62,70,72. Sugar-sweetened beverages not only contribute to obesity because of the empty calories and lack of calorie compensation

60 associated with these beverages but also, based on these results, contribute based on their association with decreased fruit and whole grain consumption which are recommended for weight maintenance9,90 and better diet quality. Diet quality was shown to be inversely associated with BMI in children95. Diet quality is not only important because of its association with weight, but also because of its relation to overall health and mortality. Adherence to US Dietary Guidelines was associated with lower risk in mortality, therefore emphasizing the need interventions to improve diet quality in the US population96. Health promotions should therefore focus on healthy diet patterns overall with SSB reduction as a portion of the intervention.

The results of this study do have limitations to take into consideration. This study being observational in nature does not allow a casual relationship to be produced. The data is collected from a one-day snapshot of the children’s diets, which may not be representative of their usual intake. The reliance of memory for the diet recall and the accuracy of intake estimations of the participants and proxies do provide limitations to this study. There may be differences in the accuracy of the diet recall between what the child consumed and what the child’s proxy reports in the younger groups. Currently, the US Department of Agriculture has not release the HEI-2015 to evaluate diet quality based on the most recent

Dietary Guidelines 2015-2020. Therefore, these analyses evaluate dietary intakes based on concordance with the 2010 Dietary Guidelines.

61 Conclusions

Higher consumption of SSB was associated with poorer diet quality scores in US youth. Consumption quantity was more associated with the differences in diet quality component scores than weight overall. Health and weight management interventions should focus on limiting the consumption of SSB in all youth who consume SSB, no matter the weight status. However, SSB consumption was associated with poorer diet quality in many other facets of healthy eating, requiring an emphasis on the total diet and not just beverage consumption patterns. Future research in the determinants of beverage choices in children based on age and weight is needed to better understand what behaviors and influencing factors to target in healthy beverage interventions and how they relate to promoting broader healthy eating patterns.

62

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72

Appendix A: Tables and Figures

73 Age group Weight Status n Population % 2-5 year olds Healthy weight 2427 76.6% Overweight 420 13.0% Obese 393 10.4% 6-11 year olds Healthy weight 2696 65.4% Overweight 687 16.6% Obese 899 18.0% 12-18 year olds Healthy weight 2904 64.3% Overweight 818 15.8% Obese 1070 19.9% Table 2. Sample sizes of weight status by age group for analysis

2-5 Year Olds

80% 70% 60% 50% 40% 30% 20% 10% 0% Water Milk 100% Coffee/tea Fruit Soda Low Cal Other Juice Drinks and and Diet Ades

Normal weight Overweight Obese Total

Figure 2: Proportion of children 2-5 years old who reported consumption of each beverage in their 24-hour dietary recall.

74 6-11 Year Olds

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Water Milk 100% Coffee/tea Fruit Soda Low Cal Other Juice Drinks and Diet and Ades

Normal weight Overweight Obese Total

Figure 3: Proportion of children 6-11 years old who reported consumption of each beverage in the 24-hour dietary recall.

12-18 Year Olds

80% 70% 60% 50% 40% 30% 20% 10% 0% Water Milk 100% Coffee/tea Fruit Soda Low Cal Other Juice Drinks and Diet and Ades

Normal weight Overweight Obese Total

Figure 4: Proportion of children 12-18 years old who reported consumption of each beverage in the 24-hour dietary recall.

75

Mean grams (95% confidence intervals) Beverage Age Healthy weight Overweight Obese Water 2-5 years 306 (287, 326) 316 (270, 361) 331 (275, 386) 6-11 years 428 (390, 466) 535 (469, 602) 541 (445, 638) 12-18 years 758 (683, 832) 824 (706, 943) 934 (833, 1034) Milk 2-5 years 305 (283, 326) 348 (292, 404) 293 (249, 337) 6-11 years 231 (217, 244) 232 (196, 268) 227 (199, 256) 12-18 years 190 (166, 214) 168 (132, 204) 186 (148, 225) Juice 2-5 years 171 (155, 188) 162 (125, 200) 167 (135, 199) 6-11 years 90 (80, 99) 84 (67, 101) 98 (79, 117) 12-18 years 87 (73, 100) 92 (74, 110) 80 (63, 97) Coffee/Tea 2-5 years 13.6 (9.4, 17.7) 15.3 (9.6, 21) 27.6 (17.9, 37.4) 6-11 years 31.5 (22.6, 40.3) 42.2 (22.9, 61.5) 41.7 (28.4, 55) 12-18 years 121 (85.6, 155) 129 (86, 172) 99.6 (77.1, 122) Fruit drinks 2-5 years 102 (92, 112) 115 (85, 145) 140 (113, 168) and ades 6-11 years 141 (128, 154) 136 (104, 167) 165 (138, 193) 12-18 years 194 (168, 219) 176 (122, 231) 166 (131, 201) Soda 2-5 years 54.7 (46.2, 63.3) 45.5 (28.1, 62.9) 70.5 (42.8, 98.2) 6-11 years 141 (126, 156) 174 (147, 202) 185 (153, 218) 12-18 years 321 (280, 363) 344 (290, 399) 364 (305, 424) Lowcal 2-5 years 28.9 (21.1, 36.7) 30.6 (14.3, 46.9) 50.9 (12.7, 89.2) 6-11 years 39.5 (31.9, 47.1) 73 (31.6, 114.4) 78.6 (53.7, 103.4) 12-18 years 67.1 (51.8, 82.5) 42.3 (21.2, 63.5) 98.2 (64.5, 131.9) Other 2-5 years 5.3 (2.3, 8.2) 5.2 (0.6, 9.8) 1.8 (-0.4, 4.1) 6-11 years 7.1 (3.5, 10.7) 5.3 (0.2, 10.4) 4.9 (1.2, 8.6) 12-18 years 30.5 (21.8, 39.2) 15.6 (6.1, 25.2) 56.4 (9.1, 103.7) Table 3: Volume of Beverages Consumed in Grams by Age and Weight Status

76

Mean Calories (95% confidence intervals) Beverage Age Healthy weight Overweight Obese Water 2-5 years 0.31 (0.03, 0.6) 0.02 (0, 0.03) 0.03 (-0.02, 0.09) 6-11 years 0.11 (0.01, 0.21) 0.58 (-0.26, 1.42) 0.72 (-0.13, 1.57) 12-18 years 0.74 (0.34, 1.14) 0.06 (-0.05, 0.16) 0.06 (-0.04, 0.16) Milk 2-5 years 182 (168, 195) 199 (165, 232) 170 (141, 199) 6-11 years 139 (131, 147) 137 (114, 160) 138 (121, 156) 12-18 years 107 (93, 120) 89 (71, 106) 104 (83, 125) Juice 2-5 years 75.5 (68.3, 82.7) 74.9 (57.5, 92.2) 75.4 (58.1, 92.6) 6-11 years 42.5 (38.3, 46.6) 40.5 (32.2, 48.9) 45 (36.3, 53.8) 12-18 years 41.8 (34.6, 48.9) 41.9 (34.2, 49.7) 38.5 (30.4, 46.5) Coffee/Tea 2-5 years 2.6 (1.8, 3.4) 3.1 (1.9, 4.3) 6.2 (3.8, 8.6) 6-11 years 6.8 (5.1, 8.6) 9.4 (3.7, 15.1) 8.5 (5.7, 11.3) 12-18 years 24.7 (18.5, 30.8) 25.8 (16, 35.6) 20.1 (14.7, 25.5) Fruit drinks 2-5 years 42.8 (38.4, 47.1) 48.2 (36.1, 60.3) 54.3 (42.9, 65.7) and ades 6-11 years 56.9 (51.9, 62) 54.3 (42.1, 66.5) 67.5 (55.6, 79.5) 12-18 years 73.3 (63.1, 83.4) 65.3 (47.5, 83.2) 60.9 (48.7, 73.1) Soda 2-5 years 21.2 (17.8, 24.5) 17.9 (11.1, 24.7) 27 (16.6, 37.4) 6-11 years 54.9 (48.9, 61) 71 (58.5, 83.5) 73.8 (60.3, 87.3) 12-18 years 124 (108, 140) 133 (112, 154) 143 (119, 166) Lowcal 2-5 years 4.2 (2.6, 5.8) 5.5 (1.5, 9.6) 8.5 (0.8, 16.2) 6-11 years 4.6 (3, 6.1) 8.1 (5.7, 10.6) 4.9 (3, 6.8) 12-18 years 3.1 (2.2, 4) 2 (0.8, 3.2) 3.1 (1.8, 4.5) Other 2-5 years 3.8 (1.7, 6) 4.3 (0.4, 8.2) 2.4 (-1.3, 6.1) 6-11 years 5.5 (3, 7.9) 4.2 (0.7, 7.6) 4.4 (1.1, 7.7) 12-18 years 17.8 (12.8, 22.8) 13.5 (3.3, 23.6) 25.4 (9, 41.7) Table 4: Calories from Beverages by Age and Weight Status

77 Mean Calories (95% confidence intervals) Beverage Age Healthy Weight Overweight Obese Water 2-5 years 0.29 (0.02, 0.57) 0 (0, 0) 0 (0, 0) 6-11 years 0.08 (-0.01, 0.18) 0.43 (-0.17, 1.03) 0.31 (-0.07, 0.68) 12-18 years 0.69 (0.3, 1.08) 0.05 (-0.05, 0.16) 0.05 (-0.05, 0.14) Milk 2-5 years 22.1 (17.7, 26.4) 17.8 (11.4, 24.2) 17.7 (12.7, 22.8) 6-11 years 20.6 (18.3, 22.9) 21.4 (15.2, 27.6) 20.5 (16.5, 24.4) 12-18 years 10.9 (8.5, 13.2) 7.4 (4.8, 10) 11.8 (8.4, 15.3) Juice 2-5 years 0.37 (0.1, 0.63) 0.24 (-0.09, 0.58) 0.56 (-0.44, 1.56) 6-11 years 0.29 (0.05, 0.52) 0.22 (-0.1, 0.54) 0.16 (-0.03, 0.35) 12-18 years 0.59 (0.16, 1.03) 0.6 (0.03, 1.16) 0.36 (0.02, 0.69) Coffee/Tea 2-5 years 2.1 (1.4, 2.9) 2.3 (1.3, 3.3) 4.9 (2.9, 7) 6-11 years 5.1 (3.6, 6.7) 6.9 (2.4, 11.3) 6.1 (3.3, 8.8) 12-18 years 16.8 (11.8, 21.9) 19.9 (11.6, 28.1) 13.1 (9.5, 16.6) Fruit drinks 2-5 years 33.6 (30.1, 37.1) 35.7 (26.5, 44.8) 42.7 (33.3, 52.1) and ades 6-11 years 45.1 (41, 49.3) 43 (32.7, 53.3) 54.4 (44.9, 63.8) 12-18 years 57.1 (49, 65.2) 53.3 (38.2, 68.4) 48.4 (38.6, 58.3) Soda 2-5 years 19.1 (16.1, 22.1) 16.3 (10, 22.5) 24.5 (15, 34.1) 6-11 years 49.9 (44.3, 55.5) 62.3 (52.1, 72.6) 66.4 (54.2, 78.5) 12-18 years 114 (98.9, 128) 122 (102, 142) 131 (109, 153) Lowcal 2-5 years 3.2 (1.8, 4.6) 4.4 (0.9, 7.9) 6.9 (0.3, 13.6) 6-11 years 3.4 (2.1, 4.7) 5.7 (3.9, 7.5) 3.1 (1.5, 4.6) 12-18 years 1.4 (0.8, 1.9) 1 (0.1, 1.9) 1 (0.2, 1.9) Other 2-5 years 1.1 (0.2, 2) 1.3 (0.1, 2.5) 0.1 (0, 0.1) 6-11 years 2.3 (1.1, 3.5) 1.3 (0.4, 2.3) 1.7 (0.5, 2.9) 12-18 years 5.5 (3.4, 7.7) 2.8 (0.8, 4.8) 6.6 (3.4, 9.9) Table 5: Calories from Added Sugars in Beverages by Age and Weight Status

78 HEI-2010 score (95% confidence interval) <1 tsp added sugar <=140 kcals >140 kcals Total Fruit Healthy weight 4.1 (3.9, 4.2) 3.5 (3.4, 3.7)a 2.8 (2.5, 3.0)ab Overweight 3.9 (3.3, 4.4) 3.2 (2.9, 3.6) 2.6 (2.1, 3.2)a Obese 4.1 (3.6, 4.6) 3.2 (2.9, 3.6)a 2.8 (2.3, 3.3)a Whole Fruit Healthy weight 3.4 (3.2, 3.7) 3.0 (2.8, 3.3) 2.4 (2.0, 2.7)ab Overweight 3.4 (2.8, 3.9) 2.7 (2.3, 3.1) 2.0 (1.4, 2.6)a Obese 3.3 (2.7, 3.8) 2.6 (2.1, 3.2) 2.1 (1.6, 2.6)a Total Vegetables Healthy weight 2.2 (2.0, 2.3) 1.9 (1.8, 2.1) 1.8 (1.6, 2.1) Overweight 2.4 (2.0, 2.8) 2.2 (2.0, 2.5) 1.6 (1.3, 2.0)a Obese 2.2 (1.8, 2.5) 2.0 (1.6, 2.3) 1.8 (1.5, 2.1) Greens and beans Healthy weight 0.7 (0.5, 0.9) 0.6 (0.5, 0.8) 0.6 (0.4, 0.9) Overweight 0.8 (0.4, 1.2) 0.7 (0.5, 1.0) 0.6 (0.3, 1.0) Obese 0.8 (0.4, 1.2) 0.4 (0.2, 0.5) 0.2 (0.0, 0.3)axy Whole Grains Healthy weight 3.3 (2.9, 3.6) 2.3 (2.1, 2.6)a 1.8 (1.5, 2.0)ab Overweight 3.6 (2.8, 4.3) 1.7 (1.1, 2.2)a 1.7 (1.0, 2.4)a Obese 2.7 (2.0, 3.4) 2.3 (1.7, 3.0) 1.2 (0.8, 1.7)a Dairy Healthy weight 6.8 (6.5, 7.2) 6.5 (6.2, 6.8) 6.0 (5.5, 6.5)a Overweight 7.5 (6.9, 8.1) 6.6 (5.9, 7.4) 6.6 (5.5, 7.7) Obese 6.4 (5.5, 7.4) 7.1 (6.4, 7.8) 4.8 (3.7, 5.9)

Total Protein Healthy weight 3.3 (3.2, 3.5) 3.5 (3.3, 3.6) 3.2 (3.0, 3.4) Foods Overweight 3.4 (3.0, 3.8) 3.5 (3.2, 3.9) 3.2 (2.8, 3.5) Obese 3.6 (3.1, 4.0) 3.3 (2.9, 3.7) 3.4 (3.0, 3.8)

Seafood and Plant Healthy weight 1.6 (1.4, 1.8) 1.5 (1.3, 1.6) 1.2 (0.9, 1.5) Proteins Overweight 1.9 (1.4, 2.4) 1.4 (1.0, 1.8) 1.3 (0.7, 1.9) Obese 1.7 (1.0, 2.3) 1.0 (0.7, 1.4) 1.0 (0.6, 1.4) Fatty Acids Healthy weight 3.1 (2.5, 3.6) 3.5 (3.2, 3.9) 3.4 (3.0, 3.8) Overweight 2.9 (2.1, 3.6) 3.6 (2.7, 4.4) 2.4 (1.6, 3.2) Obese 3.3 (2.4, 4.2) 3.5 (2.8, 4.1) 3.4 (2.8, 4.1) Refined Grains Healthy weight 6.1 (5.7, 6.5) 6.0 (5.7, 6.3) 6.8 (6.4, 7.3) Overweight 6.4 (5.8, 7.1) 6.4 (5.9, 7.0) 6.8 (5.8, 7.7) Obese 6.6 (5.8, 7.4) 6.2 (5.3, 7.0) 5.5 (4.4, 6.5) Sodium Healthy weight 5.7 (5.4, 6.1) 5.8 (5.5, 6.2) 6.8 (6.5, 7.2)ab Overweight 5.2 (4.4, 6.0) 5.6 (4.9, 6.3) 6.5 (5.5, 7.4) Obese 5.8 (5.0, 6.6) 5.9 (5.3, 6.5) 5.6 (5.0, 6.3)x Empty Calories Healthy weight 15.4 (14.9, 15.9) 12.8 (12.4, 13.2)a 7.9 (7.2, 8.6)ab Overweight 15.1 (14.0, 16.1) 13.2 (12.0, 14.3) 8.3 (6.8, 9.7)ab Obese 15.8 (14.8, 16.7) 13.0 (12.0, 14.0)a 8.6 (7.5, 9.7)ab a ab Total HEI2010 Healthy weight 55.7 (54.2, 57.2) 51.1 (49.7, 52.4) 44.6 (42.6, 46.6) Score Overweight 56.4 (53.5, 59.3) 51.0 (48.0, 54.1) 43.6 (41.0, 46.2)ab Obese 56.0 (53.5, 58.5) 50.5 (48.0, 53.1)a 40.4 (37.2, 43.5)ab Table 6: Diet Quality by Weight and SSB Consumption for 2-5 year olds aSignificantly different from non-consumption. bSignificantly different from limited consumption. xSignificantly different from healthy weight. ySignificantly different from overweight. 79 HEI-2010 score (95% confidence interval) <1 tsp added sugar <=140 kcals >140 kcals Total Fruit Healthy weight 3.1 (2.9, 3.4) 3.0 (2.9, 3.2) 2.1 (1.9, 2.3)ab Overweight 2.4 (1.8, 2.9) 3.2 (2.8, 3.6) 1.8 (1.5, 2.1)b Obese 3.1 (2.6, 3.7) 2.7 (2.4, 3.1) 2.2 (1.9, 2.5)a Whole Fruit Healthy weight 2.9 (2.5, 3.2) 2.8 (2.7, 3.0) 2.1 (1.9, 2.3)ab Overweight 2.3 (1.6, 2.9) 3.0 (2.6, 3.5) 1.7 (1.4, 2.1)b Obese 2.9 (2.3, 3.5) 2.4 (2.1, 2.7) 1.9 (1.6, 2.2)a Total Vegetable Healthy weight 2.2 (2.0, 2.4) 2.0 (1.8, 2.1) 1.8 (1.7, 2.0)a Overweight 2.1 (1.6, 2.5) 2.0 (1.6, 2.4) 1.8 (1.6, 2.0) Obese 2.3 (2.0, 2.7) 2.0 (1.8, 2.3) 2.0 (1.8, 2.3) Greens and Beans Healthy weight 0.8 (0.5, 1.0) 0.6 (0.5, 0.8) 0.5 (0.4, 0.6) Overweight 0.6 (0.3, 1.0) 0.9 (0.5, 1.3) 0.6 (0.3, 0.8) Obese 0.7 (0.4, 1.0) 0.7 (0.4, 0.9) 0.5 (0.3, 0.7) Whole Grains Healthy weight 2.8 (2.3, 3.3) 2.2 (1.9, 2.5) 1.5 (1.4, 1.7)ab Overweight 2.0 (1.4, 2.6) 2.1 (1.5, 2.6) 1.7 (1.2, 2.1) Obese 3.2 (2.2, 4.2) 2.1 (1.6, 2.6) 1.5 (1.2, 1.9)a Dairy Healthy weight 4.9 (4.4, 5.3) 5.8 (5.5, 6.1)a 4.7 (4.4, 4.9) Overweight 4.9 (4.1, 5.7) 5.5 (4.7, 6.3) 4.6 (4.0, 5.3) Obese 4.7 (3.7, 5.8) 5.6 (5.0, 6.3) 4.6 (4.2, 5.0) Total Protein Healthy weight 3.6 (3.5, 3.8) 3.4 (3.3, 3.6) 3.3 (3.2, 3.4)a Foods Overweight 4.0 (3.8, 4.3) 3.4 (3.0, 3.8) 3.5 (3.2, 3.9) Obese 4.2 (3.9, 4.5)x 3.8 (3.6, 4.0)x 3.5 (3.3, 3.7) Seafood Plant Healthy weight 2.0 (1.6, 2.4) 1.4 (1.2, 1.6) 1.3 (1.1, 1.4)a Proteins Overweight 1.6 (1.1, 2.1) 1.3 (0.8, 1.9) 1.6 (1.1, 2.1) Obese 1.4 (0.9, 1.9) 1.5 (1.1, 1.8) 1.2 (0.9, 1.4) Fatty Acids Healthy weight 3.9 (3.5, 4.3) 4.0 (3.6, 4.3) 3.6 (3.3, 3.9) Overweight 3.4 (2.7, 4.1) 3.9 (3.1, 4.7) 4.1 (3.5, 4.6) Obese 3.9 (3.1, 4.8) 3.7 (3.1, 4.2) 3.8 (3.3, 4.4) R efined Grains Healthy weight 4.7 (4.2, 5.2) 4.7 (4.4, 5.0) 5.4 (5.2, 5.7)b Overweight 3.5 (2.9, 4.1)x 4.7 (3.9, 5.5) 5.4 (4.8, 6.0)a Obese 4.1 (3.1, 5.0) 4.1 (3.5, 4.7) 5.4 (4.9, 6.0)b Sodium Healthy weight 4.4 (3.9, 5.0) 5.2 (4.9, 5.5) 5.9 (5.6, 6.2)ab Overweight 3.7 (2.7, 4.8) 4.8 (3.9, 5.7) 6.1 (5.6, 6.6)a Obese 4.2 (3.2, 5.2) 4.2 (3.6, 4.8)x 5.4 (4.9, 5.8)b Empty Calories Healthy weight 13.4 (12.7, 14.0) 12.0 (11.4, 12.5)a 7.6 (7.0, 8.1)ab Overweight 13.8 (12.4, 15.2) 12.2 (10.7, 13.7) 7.9 (7.2, 8.7)ab Obese 14.7 (13.0, 16.4) 12.4 (11.7, 13.1) 8.2 (7.5, 8.9)ab Total HEI2010 Healthy weight 48.7 (46.4, 51.1) 47.2 (46.0, 48.4) 39.8 (38.6, 41.0)ab Score Overweight 44.2 (40.6, 47.8) 47.1 (43.2, 51.0) 40.9 (38.6, 43.1)b Obese 49.4 (45.0, 53.8) 45.2 (43.6, 46.9) 40.3 (38.4, 42.1)ab Table 7: Diet Quality by Weight and SSB Consumption for 6-11 year olds aSignificantly different from non-consumption. bSignificantly different from limited consumption. xSignificantly different from healthy weight. ySignificantly different from overweight.

80 HEI-2010 score (95% confidence interval) <1 tsp added sugar <=140 kcals >140 kcals Total Fruit Healthy weight 2.6 (2.3, 2.9) 2.1 (1.9, 2.4) 1.6 (1.5, 1.8)ab Overweight 2.7 (2.1, 3.3) 2.4 (2.0, 2.7) 1.6 (1.3, 1.9)ab Obese 2.8 (2.3, 3.2) 2.4 (2.1, 2.7) 1.5 (1.2, 1.7)ab Whole Fruit Healthy weight 2.2 (1.9, 2.6) 1.9 (1.7, 2.2) 1.5 (1.3, 1.7)ab Overweight 2.3 (1.7, 2.9) 1.7 (1.4, 2.1) 1.5 (1.2, 1.8) Obese 2.4 (1.9, 2.8) 2.0 (1.6, 2.3) 1.3 (1.1, 1.5)ab Total Vegetable Healthy weight 2.5 (2.2, 2.8) 2.3 (2.2, 2.5) 2.0 (1.9, 2.1)ab Overweight 2.5 (2.0, 2.9) 2.2 (1.9, 2.6) 2.2 (2.0, 2.4) Obese 2.5 (2.2, 2.8) 2.8 (2.4, 3.1) 2.1 (1.9, 2.3)b a Greens and Healthy weight 1.1 (0.8, 1.3) 0.7 (0.5, 0.9) 0.5 (0.4, 0.6) Beans Overweight 0.7 (0.3, 1.0) 0.7 (0.4, 0.9) 0.6 (0.4, 0.8) Obese 0.8 (0.5, 1.1) 0.8 (0.4, 1.1) 0.5 (0.3, 0.7) Whole Grains Healthy weight 2.6 (2.1, 3.0) 2.2 (1.9, 2.6) 1.4 (1.3, 1.6)ab Overweight 2.6 (1.9, 3.3) 2.0 (1.4, 2.6) 1.5 (1.1, 1.9)a Obese 2.2 (1.7, 2.7) 2.0 (1.4, 2.7) 1.3 (1.0, 1.7)a Dairy Healthy weight 4.6 (4.0, 5.2) 4.8 (4.3, 5.2) 3.2 (2.9, 3.6)ab Overweight 5.7 (4.4, 7.0) 3.8 (3.1, 4.5) 3.2 (2.7, 3.7)a Obese 4.4 (3.6, 5.2) 4.7 (3.7, 5.6) 3.5 (3.1, 4.0)

Total Protein Healthy weight 3.8 (3.6, 4.0) 3.6 (3.4, 3.7) 3.6 (3.5, 3.8) Foods Overweight 4.2 (3.9, 4.4) 3.6 (3.2, 4.0) 3.5 (3.3, 3.8)a Obese 3.6 (3.3, 3.9)y 3.8 (3.5, 4.2) 3.8 (3.6, 4.0)

Seafood and Plant Healthy weight 1.8 (1.4, 2.1) 1.6 (1.4, 1.8) 1.4 (1.1, 1.6) Proteins Overweight 1.7 (1.1, 2.3) 1.1 (0.8, 1.4)x 1.1 (0.8, 1.3) Obese 1.4 (0.9, 1.9) 1.0 (0.7, 1.3)x 1.0 (0.7, 1.2) Fatty Acids Healthy weight 4.1 (3.6, 4.6) 4.0 (3.6, 4.4) 4.0 (3.8, 4.3) Overweight 4.3 (3.3, 5.3) 4.2 (3.5, 5.0) 4.1 (3.7, 4.5) Obese 5.0 (4.1, 5.8) 4.5 (3.7, 5.3) 4.3 (3.8, 4.8) Refined Grains Healthy weight 4.3 (3.9, 4.8) 4.2 (3.9, 4.5) 5.3 (5.1, 5.6)ab Overweight 4.6 (3.7, 5.6) 4.7 (4.1, 5.4) 5.3 (4.8, 5.9) Obese 4.1 (3.1, 5.0) 5.4 (4.7, 6.1)x 5.5 (5.0, 6.0) Sodium Healthy weight 3.6 (3.2, 4.0) 4.3 (3.9, 4.7)a 5.4 (5.0, 5.8) Overweight 3.0 (2.3, 3.7) 4.4 (3.7, 5.1) 5.8 (5.4, 6.2)ab Obese 3.3 (2.7, 4.0) 4.3 (3.4, 5.1) 5.0 (4.6, 5.4)a Empty Calories Healthy weight 14.9 (14.3, 15.5) 11.9 (11.3, 12.4)a 7.6 (7.1, 8.1)ab Overweight 15.8 (14.7, 16.9) 11.2 (10.0, 12.4)a 8.0 (7.1, 8.8)ab Obese 15.5 (14.6, 16.5) 13.4 (12.1, 14.8) 8.2 (7.5, 8.9)ab a ab Total HEI2010 Healthy weight 48.1 (46.4, 49.7) 43.6 (42.1, 45.1) 37.7 (36.8, 38.6) Score Overweight 50.0 (46.9, 53.2) 42.1 (39.4, 44.7)a 38.3 (36.8, 39.8)a Obese 48.0 (44.7, 51.2) 47.1 (44.2, 49.9) 38.0 (36.6, 39.5)ab Table 8: Diet Quality by Weight and SSB Consumption for 12-18 year olds aSignificantly different from non-consumption. bSignificantly different from limited consumption. xSignificantly different from healthy weight. ySignificantly different from overweight.

81 Healthy Age group Consumption Weight Overweight Obese 2-5 Year-olds Non-Consumers 35.9% 35.8% 25.7% Limited Consumers 42.8% 43.6% 47.1% High Consumers 21.3% 20.7% 27.3% 6-11 Year-olds Non-Consumers 18.7% 21.4% 16.8% Limited Consumers 45.5% 40.8% 35.2% High Consumers 35.9% 37.8% 48.0% 12-18 Year-olds Non-Consumers 22.1% 21.4% 19.1% Limited Consumers 25.8% 21.0% 25.4% High Consumers 52.1% 57.6% 55.5% Table 9: Proportion of children in the three levels of SSB Consumption by Age and Weight

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