Council November | December 2008 Volume 79 ® Number 6

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

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

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

35 suggest adding chocolate milk November | December 2008 34. Frary, C.D., R.D. Johnson, and M.Q. Wang. J. Am. Diet. Assoc. 105: 110, 2005. to school vending machines as a 10. Wells, H.F., and J.C. Buzby. Dietary Assessment 35. Recker, R.R., A. Bammi, M.J. Barger-Lux, et al. of Major Trends in U.S. Food Consumption, Am. J. Clin. Nutr. 47: 93, 1988. strategy to increase children’s and 1970-2005. Economic Information Bulletin No. adolescents’ milk intake (42). The (EIB-33). U.S. Department of Agriculture, 36. National Dairy Council and School Nutrition Economic Research Service, March 2008. Association. The School Milk Pilot Test. Beverage American Academy of Pediatric www.ers.usda.gov/Publications/EIB33/ Marketing Corporation for National Dairy Council and School Nutrition Association. 2002. Dentistry states that chocolate milk 11. Cook, A.J., and J.E. Friday. Pyramid Servings www.nationaldairycouncil.org Intakes in the United States 1999-2002, 1 Day. is OK for children’s teeth, is a highly U.S. Department of Agriculture, Agricultural 37. National Academy of Sciences, Institute of nutritious beverage, is preferable to Research Service, Community Nutrition Medicine, Committee on Nutrition Standards for Research Group, CNRG Table Set 3.0. Foods in Schools. V.A. Stallings and A.L. Yaktine many popular snacks that provide www.ars.usda.gov/sp2UserFiles/Place/12355000/ (Eds). Nutrition Standards for Foods in Schools: foodlinks/ts_3-0.pdf Leading the Way Toward Healthier Youth. calories but few nutrients, and Washington, D.C.: National Academies Press, 2007. 12. Striegel-Moore, R.H., D. Thompson, and S.G. because children like flavored milk Affenito, et al. J. Pediatr. 148: 183, 2006. 38. Alliance for Healthier Generation. Alliance School Beverage Guidelines. they drink more of it (30). 13. Nielsen, S.J., and B.M. Popkin. www.healthiergeneration.org/schools.aspx?id=108. Am. J. Preventative Med. 27: 205, 2004. 39. Dairy Management Inc. New lower-calorie flavored 14. American Academy of Pediatrics, Committee on milk formulations address nutrition issues and win Q. Is it true that School Health. Pediatrics 113: 152, 2004. kids’ approval. March 19, 2008. consuming chocolate 15. U.S. Department of Agriculture, Food and Nutrition www.innovatewithdairy.com. Service. School Nutrition Dietary Assessment 40. Bhatia, J.J.S., and F.R. Greer. AAP News 28 (June), milk helps adult Study – III. Alexandria, VA: Food and Nutrition 2007. www.aapnews.org Service, USDA, November 2007. www.fns.usda.gov athletes recover from (under Research). 41. Kranz, S., P.-J. Lin, and D.A. Wagstaff. J. Pediatr. 151: 642, 2007. strenuous exercise? 16. Wagner, C.L., F.R. Greer, and the Section on and Committee on Nutrition. 42. Vatanparast, H., E. Lo, C.J. Henry, et al. Nutr. Res. 26: 325, 2006. A. Pediatrics 122: 1142, 2008. Preliminary findings from a 17. U.S. Department of Health and Human Services. 43. Karp, J.R., J.D. Johnston, S. Tecklenburg, et al. single-blind, randomized study of Bone Health and Osteoporosis: A Report of Int. J. Sport Nutr. Exerc. Met. 16: 78, 2006. D nine male endurance-trained cyclists the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, RELATED RESOURCES found that those who drank low-fat Office of the Surgeon General, 2004. chocolate milk after an intense bout www.surgeongeneral.gov/library. www.nationaldairycouncil.org 18. Miller, G.D., J.K. Jarvis, and L.D. McBean. ■ Flavored Milk in Perspective (under Nutrition & of exercise (i.e., glycogen-depleting Handbook of Dairy Foods and Nutrition. Product Information, Dairy Foods, Supportive Boca Raton, FL: CRC Press, 2007, pp. 181-244. exercise) were able to bike about Science) 19. Kalkwarf, H.J., J.C. Khoury, and B.P. Lanphear. ■ A Perspective on Sugars & Health. Dairy twice as long during a second Am. J. Clin. Nutr. 77: 257, 2003. Council Digest 78(4), 2007 (under Health workout before reaching exhaustion 20. Greer, F.R., and N.R. Krebs for the American Professional Resources, Dairy Council Digest Academy of Pediatrics Committee on Nutrition. than those who consumed a Pediatrics 117: 578, 2006. Archives) www.nutritionexplorations.org carbohydrate replacement sports 21. Moore, L.L., M.L. Bradlee, D. Gao, et al. ■ J. Pediatr. 153: 667, 2008. All About Flavored Milk (information for drink, and as long as those who parents and educators) 22. U.S. Department of Health and Human Services, consumed a fluid replacement Food and Drug Administration. Fed. Regist. drink (43). Additional research is 73(189):1, September 29, 2008. 23. International Food Information Council Foundation. Coming Next Issue: needed to support this benefit of What science says about fructose. Food Insight chocolate milk. D July/August: 2, 2008. http://ific.org. SPOTLIGHT ON 24. 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Washington, D.C.: IFIC, 2008. http://ific.org acknowledge the help and suggestions of the Nutrient Data Laboratory Home Page. 27. School Nutrition Association. National Nutrition following reviewers in its preparation: www.ars.usda.gov/ba/bhnrc/ndl. Standards Recommendations. June 5, 2008. ■ Rachel K. Johnson, PhD, MPH, RD www.schoolnutrition.org/uploadedFiles/School_ 4. U.S. Department of Health and Human Services Professor of Nutrition Dietary Nutrition/16_LegislativeAction/SNA_National_ and U.S. Department of Agriculture. University of Vermont Guidelines for Americans, 2005. Washington, D.C.: Nutrition_Standards.pdf. US Government Printing Office, 2005. 28. Miller, G.D., J.K. Jarvis, and L.D. McBean. Burlington, VT ■ www.healthierus.gov/dietaryguidelines. Handbook of Dairy Foods and Nutrition. 3rd Ed. Janey Thornton, PhD, SNS 5. Institute of Medicine. Dietary Reference Intakes for Boca Raton, FL: CRC Press, 2007, pp. 245-265. 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National Dairy Council. Unpublished data based on Church’s Food Values of Portions Commonly Used. Suite 900, Rosemont, IL 60018-5616. the National Health and Nutrition Survey 18th Ed. Philadelphia: Lippincott, Williams, and (NHANES), 1999-2002. Wilkins, 2005. ISSN 0011-5568 36