Sugar-sweetened beverages (SSB) consumption patterns among school-age children from rural Quetzaltenango, Content

1. Introduction 2. Presentation summary 3. Objectives 4. Methodology 5. Results and Discussion 6. Conclusions 7. Acknowledgments 8. References 1. Introduction

o José Alfonso Castillo Miranda o Nutrition Bachelor´s degree Thesis o Rafael Landívar University o Quetzaltenango, Guatemala 2020 2. Presentation Summary

Eating Sugar-sweetened School-age (Consumption) beverages children pattern

Nutrition Double burden San José Chiquilajá, transition of malnutrition Quetzaltenango School-Age Children

• Period during the life cycle, which includes children between 6 to 11 years old • In this period, the ability to classify and understand opinions is developed ü Close relationship with food practices and nutrition. ü The child acquires knowledge about which foods are beneficial for their health and which are pleasant to consume • Characterized by the influence of the school environment: school authorities, teachers, classmates, friends, school breaks, games and dynamics in classroom

Krause, M. 2017; Noriega, R. 2018; Rivera, J. 2018 Eating (consumption) pattern

• Represents the totality of all foods and beverages consumed. • It generates important data about eating practices or behaviors of a determined group ü Studies have shown that school-age children’s eating patterns may reflect the general population’s eating patterns ü This study focused on Sugar-Sweetened Beverages consumption patterns

Popkin, 2001; Rivera, J. 2008; Barquera, S. 2010 Sugarly-sweetened beverages (SSB)

• Beverages with addition of sugar during their formulation and preparation. • Bevareges that usually use marketing strategies • A significant increase of SBB consumption has been observed among school children: ü Guatemalan urban areas: 77 grams of sugar from usual diet come from SSB ü Urban area of Quetzaltenango: 20% from SSB. ü SSB high consumption can generate health problems, such as excess weight and chronic non-comnunicable diseases in adulthood

Healthy NYC, 2018; Montenegro, G. 2010 Nutrition transition

• Refers to eating behaviors changes due to preference and consumption modifications • Cheap, high-energy, free sugars and saturated fats in foods are consumed especially among developing countries rural áreas where nutrition transition is more evident • Children are exposed to food environments in which the consumption of unhealthy food items is promoted

WHO 2020; Rivera, J. 2014; Díaz, L. 2015 Double burden of malnutrition

• Is the coexistence of “undernutrition along with overweight and obesity, or diet-related noncommunicable diseases, within individuals, households and populations, and across the lifecourse” (WHO,2020)

• Countries with lower incomes present higher prevalences: ü According to The Lancet, the prevalence of the double burden of malnutrition in Guatemala is 40%

• The rural area population in Guatemala is more vulnerable and has a higher food and nutritional insecurity prevalence than urban peers

WHO 2020; Rivera, J. 2014; The Lancet. 2020 San José Chiquilajá, Quetzaltenango

• Rural community located in the northwest of Quetzaltenango municipality, 2357 meters above sea level

• General data from Quetzaltenango municipality: • 56% live in poverty. • 38% live in rural areas • 31% are between 0 -14 years old

• 47% of the children under 5 suffer stunting

INE, 2018 3. Objectives

To determine the sugar-sweetened beverages (SSB) consumption patterns among school- age children from a rural area of Quetzaltenango, Guatemala Specific objectives

1. To characterize the study population according to the research variables

2. To establish the caloric and macronutrients intake from diet

3. To establish children´s SSB constumption and their contribution to the total volumen of beverages consumed

4. To identify the caloric consumption from sugar-sweetened beverages and total beverages and their contribution to the energy intake

5. To estimate the energy density from sugar-sweetened beverages according to their classification 4. Methods

Type of study: Participants: Children between 8 and 11 years old, Quantitative, descriptive who attend EORM José Martí School; San José and cross-sectional. Chiquilajá, Quetzaltenango

Sample: No sample was applied, all Data Analysis: children who met the inclusion criteria were enrolled Microsoft Excel® (115 participants) SPSS® Process

Approval of Reviewing CESSIAM Researchers pictorical 24 Human Studies trainning hours recall with Committee children

Obtaining Coordination with Informed standard recipes the EORM José Consent and average Martí administration weights

Completion of the Instrument Analysis of data pictorial 24-hour preparation recall collected Data Collection

• Approval was obtained from the Human Studies Committee of CESSIAM

• Informed Consent was obtained from parents and children

• A team of 4 trained nutritionists from CESSIAM provided participants with pictorial 24h recalls and office materials to fill out

• Instructions were given and doubts were solved

• Incomplete instruments were filled in next day with the help of nutritionists, teachers and parents

• The food and beverages consumed were confirmed, establishing recipes, preparations, and products brands Data Analysis

• The data input was done using in Excel®

• The food composition tables from the United States Department of Agriculture (USDA) and INCAP, thus nutritional information from product labels, were used to establish calories and macronutrients total intake

• The energy density of the SSB consumed by the children was estimated, according to 100 mL or g of product

• A comparison of beverage consumption patterns in the population was made using two reference systems (Rivera, J. et al. And Barquera, S. et al.) To establish sweetened consumption, all beverages were classified as follows:

Sugar-sweetened beverages (SSB) No sweetened drinks

Infusions (coffee and tea) Atoles () Natural drinks and smoothies Juices and drinks with added sugar Simple whole, skim, or low-fat milk (liquid or powdered) Plain water Soft drinks 5. Results

• Demographics • Energy and macronutrient intake • Diversity and frequency of beverages consumed • Energy intake from Sugarly-sweetened beverages (SSB) • Nutrient (energy) density • Comparison of volume and energy intake School-Age Children Characteristics N = (115) % Demographics Sex of the Boys 57 49.6 Girls 58 50.4 participants Age (years) according to 8 40 34.8 9 37 32.2 age and sex 10 17 14.8 11 21 18.3 Energy intake from all foods

Age Sex 8 – 9 years old 10 – 11 years old Boys Girls Energy and n = 77 n = 38 n = 57 n = 58 Nutrients Average ± DE Average ± DE p value Average ± DE Average ± DE p value Median Median Median Median Min– Max Min– Max Min – Max Min – Max 2016 ± 575 2015 ± 444 2033 ± 551 2018 ± 535 Calories (Kcal) 2023 1985 0.950 1985 2045 0.998 613 – 2993 1172 – 2860 928 – 3075 613 – 2993

64 ± 22 63 ± 16 63 ± 21 65 ± 21 Protein (g) 61 65 0.814 61 65 0.664 23 – 121 29 – 98 25 – 112 23 – 121

53 ± 26 49 ± 20 51 ± 24 53 ± 25 Fat (g) 49 41 0.632 47 48 0.935 5 – 120 23 – 107 5 – 120 12 – 119

332 ± 95 341 ± 90 343 ± 95 331 ± 93 Carbohydrates 330 339 0.475 333 331 0.601 (g) 105 – 536 190 – 587 168 – 540 105 – 587 Results Analysis Energy Adecuacy •Girls and younger participants have a higher energy consumption than the recommended for their age and sex by the World Health Organization (WHO). Gupta N. and WHO recommend that energy intake should be adequate according to sex and age in order to reduce risk of overweight and obesity and their comorbidities •In contrast, Díaz L. in a research conducted in Amatitlán, Guatemala presented adequate results regarding energy and macronutrients intake among school-age children

Protein Adecuacy •Regarding protein, the school-age children reported a much higher intake than the WHO and the Institute of Nutrition of Central America and Panama (INCAP) recommendations •According to Pysz et al. the excessive protein intake among children has been associated to metabolic disorders and overweight as adults

Gupta, N. 2012; Pysz, M. 2014; Díaz, L. 2015 Type of Clasification Beverage beverage Arroz en leche ( and milk) Atol de fécula de maíz (cornstarch) Atol de elote (corn) Atol de (corn dough) Atol de plátano (plantain) Corazón de trigo® ( semola) Atoles (gruels) Incaparina® without milk Incaparina® with milk Atol de avena / mosh (oats) Sugar- Atol de maíz tostado (Toasted corn) Diversity of Vitacereal® (multi-cereal) sweetened Atol de maíz quebrantado (craked corn) beverages (SSB) Atol de cereales (multi-cereal) beverages Coffee with sugar Infusions Coffee with sugar and milk (Coffee and tea) Barley with sugar consumed Tea Artisan chocolate Juices and drinks with added sugar Powdered drink mix (liquid or powdered) Boxed juice Milk with sugar Soft drinks Soft drinks Plain Water Plain water Non- sweetened Milk without sugar Plain milk Natural smoothie drinks Natural drinks and smoothies Lemonade SSB consumption frecuency

No 24 hour Lunch Dinner Snack

1 Coffee with sugar Coffee with sugar Powdered drink mix Coffee with sugar Coffee with sugar

Incaparina® without Vitacereal (wheat Incaparina® without 2 Milk with sugar Coffee with sugar milk semola gruel) milk

Incaparina® without Atol de plátano Arroz en leche (milk 3 Powdered drink mix Tea with sugar milk gruel (platain gruel) and rice gruel)

Arroz en leche (Milk Vitacereal (wheat Atol de cereales Coffee with sugar and Incaparina® with milk 4 and rice gruel) semola gruel) (multicereal gruel) milk gruel

Incaparina® with milk Corazón de trigo® Arroz en leche (Milk Atol de plátano Atol de avena (oats 5 gruel (wheat germ gruel) and rice gruel) (platain gruel) gruel) Results Analysis

SBB Diversity • The largest number of beverages consumed by the participants were atoles (gruels) and coffee, drinks rooted in the food intake patterns in Guatemala, especially among rural areas

SBB Intake Frequency • The consumption of instant coffee with sugar in early age does not have health benefits for children. • The second more consumed beverage was Incaparina® without milk, which is promoted by the Ministry of Education’s school feeding programs and the Ministry of Health, due to its nutrient content • Regarding the intake schedule, Montenegro and Vossennar identified the importance of temperature in the drinks consumed during the day, having hot drinks consumed at mornings and nights, while cold drinks are consumed at noon.

Montenegro, G. 2010; Vossenaar, M. 2015; DIGEFOCE. 2020 Energy contribution (Top ten beverages)

Percentage Cumulative No. Beverages (%) Percentage (%) 1 Incaparina® with milk gruel 17.5 17.5 2 Coffee with sugar 16.9 34.4 3 Incaparina® without milk gruel 14.6 49 4 Plain Milk 7.6 56.6 5 Arroz en leche (rice and milk gruel) 7.2 63.8 6 Powdered drink mix 7.1 70.9 7 Milk simple with sugar 4.1 75 8 Vitacereal (wheat semola gruel) 3.6 78.6 9 Artisan chocolate with sugar 3.4 82 10 Atol de avena (oats gruel) 3.4 85.4 Beverage Percentage Cumulative Beverage energy (Kcal) (%) percentage (%)

Atoles 31754 62.2 62.2 Energy intake (Gruels) Infusions 12509 24.5 86.7 according to (coffee and tea) the Juices and drinks with classification of added sugar, (liquid 5788 11.3 98 SSB or powdered) Soft drinks 990 2.0 100 Results Analysis

Atole (Gruel) Consumption •The consumption of atoles (gruels) is influenced by various factors, such as social and family environment and the school environment •Liza Díaz concludes that atoles are recommended for their nutritional value and that in the context investigated they are substitutes for milk

Enery intake •There is only one unsweetened drink among the 10 drinks with the highest caloric intake, which provide 85% of the energy value from the drinks consumed •The top 3 beverages which provide 49% of the energy consumed. This is an indicator that coffee and Incaparina® are consumed in large quantities

Rivera, J. 2018; Díaz, L. 2015; Makkes, L. 2011 Energy intake from total beverages and SSB

Age Sex

8 – 9 years 10 – 11 years Boys Girls n = 77 n = 38 n = 57 n = 58 General Energy p value p value average Average ± DE Average ± DE Average ± DE Average ± DE Median Median Median Median Min– Max Min– Max Min – Max Min – Max

All drinks 561 ± 223 546 ± 213 586 ± 242 527 ± 191 571 492 0.71 587 505 0.15 555 kcal (Kcal) 116 – 1190 1 140 – 958 1 116 – 1190 1 120 – 1019 1

SSB 504 ± 227 484 ± 220 538 ± 254 457 ± 183 488 448 0.62 523 457 0.10 479 kcal (Kcal) 116 – 1190 1 112 – 958 1 116 – 1190 1 112 – 1019 1 Results Analysis

Energy intake

•Participants have a similar energy intake from total beverages and SSB •All beverages contribute 27% (555 kcal) of the total energy intake reported in 24 hours recalls •Of those 555 kcal, 479 kcal are from SSB, constituting 24% of total diet energy •Studies in Uruguay, Argentina, , Guatemala City and Amatitlán (Guatemala), conclude that high caloric intake from SSB are demonstrable

Rivera, J. 2018; Díaz, L. 2015; Makkes, L. 2011; Barquera, S. 2010 Beverages volume intake comparisons

1374 ml 1721 ml 1253 ml Results Analysis

The research conducted in Mexico by Rivera J. and Barquera S. were used as references for the analysis due to their importance, rigor and similar context to Guatemala

Total beverage intake volume • Plain water intake does not comply with those recommended by the WHO and is significantly lower than the Mexican results • Popkin and Stanhope mention that the low consumption of plain water generates a high energy intake, due to the difference in caloric density intake. • Vossennar highlighted that the intake of foods with low energy density promotes healthier eating patterns, since satiating amounts of food and beverages are consumed • Rivera and Barquera established that the consumption of plain water is the best method for guarantee hydration and hydro-electrolyte balance

Stanhope, K. 2008 ; Rivera, J. 2018; Vossenaar, M 2019; Popkin, B. 2013 Barquera, S. 2010 Caloric intake from beverages comparisons

504 kcal 411 kcal 323 kcal Results Analysis Energy intake from all beverages

The consumption of atoles (gruels) is potentially beneficial for the growth and mental and physical development of school-age children, due to the amount of vitamins and minerals they have in their formulation or preparation.

Nevertheless, the addition of a high amount of sugar to the atoles makes them a SSB that increased their energy density.

In contrast, the findings in Mexico suggested that the energy intake is higher given the high soft drinks and sugary juices intake

Rivera, J. 2018; Díaz, L. 2015; Barquera, S. 2010 6. Conclusions

• The study participants general characteristics are similar to those observed in the general population

• The energy and protein intake was higher than the recommended for age and sex by WHO. These may become into a predisposition factor for overweight and obesity in childhood and chronic non-communicable diseases in adult age

• The SSB most frequently consumed were coffee with sugar and atoles (gruels), which are SSB with cultural importance throughout Guatemala due to their perceived nutritional benefits, especially for the latter • The atoles (gruels) are the SSB which the higher contribution to the total energy given their quantity of nutrients and the added sugars used for their preparation, altougth this type of beverage is an important vehicle for nutrients among Guatemalan children • The SBB frequently reported by schoolchildren have a high energy density

• There are differences between the consumption patterns of reported beverages by Mexico and Quetzaltenango. The latter reported higher SBB intake thorughout preprations like infusions and atoles, and lower pure water intake which does not comply with the WHO recomendations 7. Acknowledgments

Many thanks for the support and guidence to:

● Dr. Noel Solomons, Scientific Director, CESSIAM Guatemala

● Marta Escobar BA. Nutritionist, CESSIAM Quetzaltenango

● Rosario García-Meza MA. Msc. Research Coordinator, CESSIAM Quetzaltenango 9. References 1. Krause M. Dietoterapia de Krause. 14th ed. España: Elsevier Masson; 2017. 2. Cerezo R, Noriega L. Prácticas óptimas de alimentación infantil en los servicios de salud. INCAP. Ciudad de Guatemala: INCAP; 2015. 3. Rivera J, Colchero A, Fuentes M, González T, Aguilar C, Hernández G, et al. La obesidad en México: Estado de la política pública y recomendaciones para su prevención y control. Instituto Nacional de Salud Pública. 2018 México. 4. Healthy NYC. Bebidas azucaradas. Boletín de Salud. Nueva York. 2018; 18(6). 5. Rivera J, Pedraza L, Martorell R, Gil A. Introduction to the double burden of undernutrition and excess weight in Latin America. The American Journal of Clinical Nutrition. 2014; 100(6). 6. The Lancet. Serie Lancet 2019: Doble Carga Malnutrición. Edición en español. (Traducido de The Lancet Serie 2019 en inglés). INCAP, Guatemala. Julio, 2020. 7. Díaz L. Patrón de consumo de bebidas azucaradas en niños de primaria que asisten a escuelas públicas en Amatitlán, Guatemala. Tesis de grado. Licenciatura en nutrición - URL. 2015. 8. Rivera J, et al. Consumo de bebidas para una vida saludable: Recomendaciones para la población mexicana. Medigraphic Artemisa. Bol Med Hosp Infant Mex. 2008; 65. 9. Barquera S, et.al. Caloric beverage consumption patterns in Mexican children. Nutrition Journal. 2010; 9(47). 10. Pinetta C, Vossenaar M, Solomons N. Validación de un método pictórico para el Registro de un Día de Consumo de Alimentos en niños en edad escolar. CESSIAM. 2011 diciembre; 22(2). 11. Makkes S, Montenegro G, Groeneveld I, Doak C, Solomons N. Beverage consumption and anthropometric outcomes among schoolchildren in Guatemala. Maternal & Child Nutrition. 2011; 7. 12. Montenegro G, Vossenar M, Doak C, Solomons N. Contribution of beverages to energy, macronutrient and micronutrient intake of third and fourth grade schoolchildren in Quetzaltenango, Guatemala. Maternal & Child Nutrition. 2010 13. Vossenar M, Escobar M, Bonorden M, Solomons N. Developing Food-Based Recommendations to complement distribution of a poultry-based fortified food for school-aged children form rural. Center for Studies of Sensory Impairment, Aging and Metabolism - CESSIAM. 2015; 28(891.11). 14. Gupta N, Goel K, Shah P, et al. Childhood Obesity in Developing Countries: Epidemiology, Determinants, and Prevention. Endocrine Rev. 2012;33(1):48- 70 15. Pysz M, Leszczyńska T, Cieślik E, Kopeć A, Wielgos B, Piątkowska E. Relationship between the intake of energy and basic nutrients and the BMI values in group of children aged 10-12. Rocz Panstw Zakl Hig. 2014; 65:345-52. 16. DIGEFOCE. Menús de alimentación escolar 2020: Quetzaltenango. Ministerio de Educación. 2020. 17. Kiyah J, Duffey P, Barry M, Popkin D. Causes of increased energy intake among children in the US, 1977 – 2010. American Journal of Preventive Medicine. Elsevier. 2013. 18. Malik V, Popkin B, Bray G, Depres J-P, Willett W, Hu F. Sugar Sweetened Beverages and Cardiometabolic Risk: A Meta-analysis. Nutr Rev 68: 439- 458,2010. 6 19. Stanhope KL, Havel PJ. Endocrine and metabolic effects of consuming beverages sweetened with fructose, glucose, sucrose, or high-fructose . Am J Clin Nutr 2008; 88:1733–1737 THANK YOU