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Beverage Patterns, Diet Quality, and Body Mass Index of US Preschool and School-Aged Children
TARA L. LAROWE, PhD; SUZEN M. MOELLER, PhD; ALEXANDRA K. ADAMS, MD, PhD ters had the highest micronutrient intakes. Mean HEI differed significantly across beverage patterns for schoolaged children (from 63.2 to 69.9, PϽ0.01), with the highfat milk cluster having the best diet quality, reflected by HEI and micronutrient intakes. Adjusted mean BMI differed significantly across beverage clusters only in schoolaged children (from 17.8 to 19.9, PϽ0.05). Conclusions Beverage patterns were related to diet quality among preschool and school-aged children, but were only related to BMI in school-aged children. Children from all clusters could benefit by consuming fewer calorically sweetened beverages and increasing micronutrient-dense foods. J Am Diet Assoc. 2007;107:1124-1133. ABSTRACT Objective To evaluate diet quality and body mass index (BMI) by beverage patterns in children aged 2 to 11 years. Design Beverage patterns were formed using 24-hour dietary recall diet variables from the 2001-2002 National Health and Nutrition Examination Survey. Diet quality was assessed using energy, micronutrient intakes, and Healthy Eating Index (HEI) scores (a 100-point scale that measures adherence to the Dietary Guidelines for Americans). Subjects/setting Children, aged 2 to 5 years (nϭ541) and 6 to 11 years (nϭ793), were selected from 2001-2002 National Health and Nutrition Examination Survey data. Statistical analysis Cluster analysis was used to identify beverage patterns in preschool and school-aged children. General linear models were used to compare HEI scores, energy, micronutrient intakes, and BMI across beverage clusters. Results Four and five beverage clusters were identified for preschool and school-aged children, respectively. In preschool children, mean HEI differed between the fruit juice cluster (79.0) vs the high-fat milk cluster (70.9, PϽ0.01); however, both fruit juice and high-fat milk clus-

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T. L. LaRowe is a postdoctoral fellow, Department of Family Medicine, University of Wisconsin-Madison. S. M. Moeller is a scientist, Department of Science, Quality, and Public Health, American Medical Association, Chicago, IL; at the time of the study, she was an assistant scientist, Departments of Ophthalmology and Visual Science and Nutritional Sciences, University of Wisconsin-Madison. A. K. Adams is an assistant professor, Department of Family Medicine, University of Wisconsin-Madison, Madison, WI. Address correspondence to: Tara L. LaRowe, PhD, Postdoctoral Fellow, Department of Family Medicine, University of Wisconsin-Madison, 777 S Mills St, Madison, WI 53715. E-mail: Tara.larowe@fammed.wisc.edu Copyright © 2007 by the American Dietetic Association. 0002-8223/07/10707-0017$32.00/0 doi: 10.1016/j.jada.2007.04.013
1124 Journal of the AMERICAN DIETETIC ASSOCIATION

he increasing prevalence of childhood obesity is a significant public health concern. Fourteen percent of children aged 2 to 5 years and 19% of children aged 6 to 11 years are now obese (1). Children with overweight or obesity are more likely to stay overweight or obese into adulthood (2), which may increase their risk for hypertension, cardiovascular disease, and diabetes (3). During the past decade, the prevalence of type 2 diabetes has increased among children (4) and respiratory diseases are also more common in overweight children (5,6). In a large study of children and adolescents aged 5 to17 years, 58% of overweight children were found to have at least one cardiovascular disease risk factor (7). Efforts to reduce the burden of pediatric obesity are needed and require identifying modifiable risk factors, including diet, for prevention. Trends in beverage consumption during the past several decades (8) suggest that the overall nutrition profile of children is changing. Total energy intake from beverages is increasing in children (8) leading to the hypothesis that excess energy from calorically sweetened beverages may be related to the increased prevalence of overweight among children (1). Some studies have supported this hypothesis (9-12); others have not (13-15). Overall diet quality in children might also be compromised with changing beverage trends, with less nutritious beverages replacing micronutrient dense drinks, including milk and 100% fruit juices (16-19). © 2007 by the American Dietetic Association

The overall HEI score is a composite of 10 equally weighted diet components. SUBJECTS AND METHODS Study Population NHANES 2001-2002 is a complex. fruit drinks (eg. Therefore. including water and diet sodas. Recommended July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1125 . fruit punch. and spring water High-fat milk Reduced-fat milk Soda Diet soda Sweetened beverages Coffee and tea Water Figure 1. and whether beverage patterns in preschool and school-aged children were related to body mass index (BMI).992). and Mexican Americans. we selected children aged 2 to 11 years. African Americans. and variety. including tap water. For this study sample. Of the 13. Diet Quality Measure To assess overall diet quality within each beverage cluster. vegetables. fruit. or absolute weight in grams (21). 80% (nϭ10. total cholesterol and sodium intakes. a score of 10 reflects perfect compliance. lemonade. We also excluded children with missing age. Two hundred twelve children were further excluded because breastmilk or infant formula was reported or because there were missing covariate data. we used the USDA HEI (22). Assisted interviews (proxy and child) were conducted in children aged 6 to 11 years. Beverage Pattern Formation Before entering beverages into a cluster analysis. including household income. apple. reduced-fat milk. coffee and tea. We considered using percentage total daily energy from each beverage group. respectively. We determined whether specific beverage patterns were associated with overall diet quality. The final sample available for analysis consisted of 541 children aged 2 to 5 years and 793 children aged 6 to 11 years. nectars. media screen time. condensed. other 100% fruit juices or unsweetened fruit juices) Whole or 2% (white or chocolate) fluid milk. but because many beverages. Components six through 10 measure dietary fat and saturated fat as total percentages of food energy intake. For each component.700 kcal for children aged 2 to 5 years and Ͻ900 kcal or Ͼ 3. bottled water.900 g for children aged 6 to 11 years) (nϭ251). water from water cooler. or buttermilk Skim or 1% (white or chocolate) fluid milk.399 g for children aged 2 to 5 years and Ͻ400 g or Ͼ 2. and birth weight. skim or 1% evaporated. water from drinking fountain. We excluded children whose reported energy intake was implausible (Ͻ800 kcal or Ͼ 2. as well as a summary of daily energy and nutrient intake. We also did not choose the number of servings of beverages because the information for servings was not available in the NHANES data. with complete dietary data (nϭ1. were oversampled to allow for precise estimates from each group. Beverage groups (nϭ8) used in cluster analysis of data on children aged 2 to 11 years in the 2001-2002 National Health and Nutrition Examination Survey. Beverage intake may be measured in one of the following ways: percentage energy intake from each beverage group. with and without caffeine Fruit juice sweetened with sugar. For each participant. The HEI measures diet quality based on both foods and nutrients consumed by individuals aged 2 years and older.701) had completed reliable dietary interview data. each worth 10 points. Dietary intake was conducted for children aged Ͻ6 years by a proxy interview of the parent/caregiver. sweetened beverages.500 kcal for children aged 6 to 11 years) or whose reported total beverage consumption in grams was implausible (Ͻ200 g or Ͼ 2. The Human Subjects Review Board at the University of Wisconsin-Madison granted approval for this study. with and without caffeine Diet or sugar-free cola and noncola. using a 100-point scale to measure how well an individuals diet complies with specific recommendations of the Dietary Guidelines for Americans (22). powdered orange-flavor drink). physical activity. whole or 2% evaporated. do not contribute significant amounts of energy. and water (see Figure 1). we decided against this method. multistage probability sample of the noninstitutionalized population of the United States. Beverage group Fruit juices Beverages in the group Includes 100% fruit juices and unsweetened fruit juices (grapefruit.This article presents a food-based approach to identify predominant beverage intake patterns among preschool (aged 2 to 5 years) and school-aged children (aged 6 to 11 years) in the 2001-2002 National Health and Nutrition Examination Survey (NHANES) sample. including adolescents aged 12 to 19 years. orange. coffee and tea sweetened with sugar or low-cal sweetener Coffee and tea. we used absolute weight in grams and used this method of measurement for subsequent analyses.and sex-specific BMI percentiles or who were classified as underweight (Յ5th percentile) (nϭ195). Certain population subgroups. milk. condensed. soda. diet soda. fruit juices.477) participated in the physical exams at the mobile examination center and 74% (nϭ9. number of servings. or buttermilk Cola and noncola. individual beverages were aggregated into eight beverage groups: high-fat milk.156 persons eligible in the 2001-2002 sample. The first five components measure adherence for the five major food groups of the Food Guide Pyramid: grains. individual foods and beverages were reported during a 24hour period. and meat (23). unsweetened Total plain water. measured by the US Department of Agriculture’s (USDA’s) Healthy Eating Index (HEI). whereas a score of 0 to 9 is less than perfect. Dietary Assessment Dietary intake was assessed using a single 24-hour dietary recall at the mobile examination center interviews (20).

and physical activity. sex.7Ϯ3. Statistical Analysis Cluster analysis was used to identify different beverage patterns among eight previously defined beverage groups (Figure 1).2 11Ϯ5.9 2.1* 86Ϯ19 87Ϯ23 88Ϯ7. and micronutrient intakes of riboflavin. race/ ethnicity.4 12Ϯ5. NC). PϽ0. were determined by examining Scree plots. . the mean percentage of total energy from beverages. by total energy intake. and average percentage of total energy from beverages across beverage patterns in US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002 Children (2-5 y) Cluster 1: mix/light drinker (n‫؍‬249) Cluster 2: high-fat milk (n‫؍‬91) Cluster 3: water (n‫؍‬128) Cluster 4: fruit juices (n‫؍‬73) Beverage Beverage group High-fat milk (g) Reduced-fat milk (g) Fruit juices (g) Other sweetened juices and drinks (g) Regular soda (g) Low-energy and diet soda (g) Unsweetened coffee and tea (g) Water (g) Total beverage consumption (g) Total percentage of energy from beverages (%kcal) 4™™™™™™™™™™™™™™™™™™™™ meanϮstandard error ™™™™™™™™™™™™™™™™™™™™3 155Ϯ10 786Ϯ27* 206Ϯ20 217Ϯ24 55Ϯ8. and the means and frequencies of sample characteristics. least-square means of BMI were compared across all beverage patterns using the Tukey-Kramer adjustment for multiple comparisons. iron.2Ϯ1. sex. birth weight. separately for children aged 2 to 5 years and 6 to 11 years. between 51 and 80 as “needs improvement. the mean HEI and component scores. A four-cluster solution. For comparisons across categorical variables. We also ran the FASTCLUS procedure with a predefined number of 20 clusters and removed individuals in clusters with fewer than five subjects. 2002-2003. vitamin A. percent energy from protein. we separately calculated the mean grams of each beverage group and total beverage consumption. Using a general linear model and adjusting for age.8 5. USDA computed HEI scores for each participant aged Ն2 years using NHANES 2001-2002 dietary data (25). and a five-cluster solution.05. Before this study.225Ϯ48 18.8Ϯ2. ␹2 tests were used. SAS Inc. physical activity (number of times per week play or exercise hard enough to sweat or breathe hard) and media screen time (total number of hours per day of television watching and computer time). we ran two to eight clusters to determine the best solution.1* 17. and zinc. Outliers that were previously identified and removed were reassigned to the nearest cluster. birth weight. we removed individuals whose intake from any beverage group was Ն5 standard deviations away from the mean absolute weight in grams for that group. ethnicity.5Ϯ2. From this sample.9 28.Table 1. fiber. diet quality (HEI). for children aged 6 to 11 years. vitamin C. the means of macroand micronutrient intakes. we regressed BMI onto the categorical beverage pattern variable. The process of cluster analysis is sensitive to outliers. folate. household income. HEI criteria classifies diet quality with scores of 81 or higher as “good” scores. and by examining the clusters for meaningful separation of beverage patterns.8 338Ϯ24 753Ϯ25* 200Ϯ22 853Ϯ25* 1.0 97Ϯ14 59Ϯ10 585Ϯ29* 249Ϯ19* 101Ϯ18 132Ϯ18 76Ϯ18 106Ϯ10* 78Ϯ15 99Ϯ17 58Ϯ15 5.4 9.6 35. F statistics.9Ϯ0.5Ϯ6.0 5. household income.2Ϯ2. average gram intake of total beverage consumption.8Ϯ1. Other covariate data were collected via questionnaires or medical exams at household interviews or at mobile examination center exams and included age. for children aged 2 to 5 years. To describe variables across the four (children aged 2 to 5 years) and five (children aged 6 to 11 years) beverage clusters.1. Body Size and Covariate Measures Anthropometric data were collected at the medical portions of the mobile examination center exams (26). The USDA HEI 2001-2002 database was merged with the rest of the NHANES 2001-2002 database using the corresponding respondent identification number. This procedure uses the K-means 1126 July 2007 Volume 107 Number 7 method to classify subjects into nonoverlapping groups in an iterative process by comparing Euclidean distances between each subject and each cluster set.6Ϯ1. To evaluate if beverage patterns were related to BMI in children aged 2 to 5 and 6 to 11 years separately. Cary.8 0 189Ϯ9.” and scores under 50 as “poor” (24). We further assessed diet quality. Height and weight were used to calculate BMI and BMI percentiles for age and sex according to Centers for Disease Control and Prevention growth reference charts (26).352Ϯ39 1.1* *Significantly different than most other groups by comparisons using general linear models. therefore. calcium. in addition to the HEI.0 2. Beverage patterns were generated using the FASTCLUS procedure in SAS (version 9. Average total gram intake from beverage groups.422Ϯ39 1.8Ϯ0. General linear models (PROC GLM) with Tukey-Kramer’s adjustment for multiple comparisons were used to test differences across beverage patterns.

Non-Hispanic African-American children made up a larger proportion of the mix/light drinker pattern (17. and the average percentage of total energy from beverages across beverage patterns.3 11Ϯ3. Tables 1 and 2 describe each beverage pattern by showing the following for each beverage group: average weight in grams of beverage groups that made significant contributions. We named this pattern as the mix/light drinker because none of the eight individual beverage groups in that pattern significantly contributed to the uniqueness of that pattern (ie. and 24. A higher proportion of male children were in the fruit juice cluster (56. water. Based on the number of children in each cluster.4 6. respectively.257Ϯ33* 332Ϯ30 270Ϯ23 934Ϯ21* 1.8 years in the water cluster.6%) and a smaller proportion of the high-fat milk cluster (5.3 4Ϯ2. aged 2 to 5 years (Table 3).1 13Ϯ8. respectively.1 337Ϯ13 316Ϯ19 1.1 years in the July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1127 . Age. and fruit juices.4 1. Children aged 2 to 5 and 6 to 11 years in the high-fat milk pattern had significantly higher total percent energy intakes from beverages (35.6%) and a smaller proportion of the water cluster (9.943Ϯ43 1.9 22. physical activity. and relatively smaller contributions from other beverages.0Ϯ1. and average percentage of total energy from beverages across beverage patterns in US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002 Children (6-11 y) Cluster 1: mix/light drinker (n‫؍‬266) Cluster 2: high-fat milk (n‫؍‬156) Cluster 3: water (n‫؍‬147) Cluster 4: sweetened drinks (n‫؍‬100) Cluster 5: soda (n‫؍‬124) Beverage Beverage group High-fat milk (g) Reduced-fat milk (g) Fruit juices (g) Other sweetened juices and drinks (g) Regular soda (g) Low-energy and diet soda (g) Unsweetened coffee and tea (g) Water (g) Total beverage consumption (g) Total percentage of energy from beverages (%kcal) 4™™™™™™™™™™™™™™™™™™™™™™™™™™ meanϮstandard error ™™™™™™™™™™™™™™™™™™™™™™™™™™3 91Ϯ7.1 years in the high-fat milk and fruit juice clusters to 3.0001) and ranged from a mean of 3.0001). Compared to other clusters. the average total beverage consumption in grams. sweetened drinks.1) and used sample weights so that findings were representative of US children aged 2 to 11 years. and media screen time did differ significantly (PϽ0. both preschool (Table 1) and school-aged (Table 2) children in the mix/light drinker pattern differed from all other patterns by reporting significantly lower total beverage consumption in grams compared to other beverage clusters (PϽ0. We labeled the four beverage patterns among children aged 2 to 5 years as mix/ light drinker. and media screen time did not differ across beverage patterns for children. PϽ0.7 *Significantly different than most other groups by comparisons using general linear models. Ages ranged from a mean of 8. and soda.6 25. the mix/light drinker pattern was the predominant beverage pattern. water.8% of total daily energy intake came from beverages in the sweetened drinks and soda clusters. children drank a little of each beverage listed in Tables 1 and 2). average gram intake of total beverage consumption. Average total gram intake from beverage groups. a higher proportion of children in the water cluster had a higher household income and a lower proportion of children in the mix/light drinker cluster were at risk for overweight. birth weight and physical activity did not differ significantly across beverage clusters. Several differences were seen across the identified beverage patterns.8%).2Ϯ0.7Ϯ0.Table 2.354Ϯ44 14.305Ϯ35 1. overweight.1 133Ϯ13* 128Ϯ17 129Ϯ19* 70Ϯ15 57Ϯ11 117Ϯ92 84Ϯ10 100Ϯ16 861Ϯ31* 103Ϯ16 120Ϯ9.7% of energy. for school-aged children.3Ϯ0. respectively.9 24.7Ϯ0.5 27Ϯ13 3Ϯ1. All analyses were conducted using SAS (version 9.8 6.0Ϯ3. whereas Mexican-American children made up a larger proportion of the high-fat milk cluster (18.2 131Ϯ13 149Ϯ18 116Ϯ20 717Ϯ24* 26Ϯ6. sex.05. We named the beverage clusters based on the predominant beverage group in the cluster. Birth weight. in both age groups. household income.5%). derived more of their total beverage consumption from high-fat milk and water. Household income and at risk for overweight also differed significantly across beverage patterns. Characteristics of children by beverage patterns are illustrated in Table 3 (aged 2 to 5 years) and Table 4 (aged 6 to 11 years).8Ϯ0. Similar beverage patterns were also observed for children aged 6 to 11 years. Age did differ significantly across beverage clusters (PϽ0.0 624Ϯ22* 164Ϯ17 187Ϯ17 143Ϯ16 107Ϯ12* 18Ϯ6. Children in the high-fat milk and water patterns.2% of energy and 25.7* 16. we labeled the five beverage patterns as mix/light drinker. For children aged 6 to 11 years (Table 4). RESULTS Four and five beverage clusters were identified for children aged 2 to 5 and 6 to 11 years. respectively) compared to other beverage clusters.617Ϯ53 1.05).0Ϯ3. In addition.0%) compared to the water cluster (40.6%). high-fat milk. high-fat milk.5 15Ϯ6. Twenty-nine percent of energy came from beverages in the fruit juice cluster for preschool children.4 126Ϯ16* 32Ϯ12 29Ϯ9. ethnicity.3% and 22. The average percentage of total en- ergy from beverages differed significantly across beverage clusters.

Weighted estimates.2 Characteristic Age (y) Sex (%) Male Female Ethnicity (%) Non-Hispanic white Non-Hispanic African American Mexican American Other Household income (%) Յ$35.04 For continuous variables.0 41.8Ϯ0. for categorical variables.8 3.9 11.1 48.1 Cluster 2: high-fat milk (n‫؍‬156) 8.5 67.0001 0.2 11.379Ϯ66 6. significance tested on the basis of general liner models.9 7.2 49.6 3.323Ϯ59 7.0001 0.0 53.8 67.0001 0.8 26. BMI >85th percentile (%) Birth weight (g) Physical activity (times/wk) Media screen time (h/d) a b P value 0.1Ϯ0.1 65.9 51.3 13.6 10.1Ϯ0.1Ϯ0.1 10. Characteristics of each beverage pattern among US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002ab Children (2-5 y) Cluster 1: mix/light drinker (n‫؍‬249) 3.2 48.3 63.4Ϯ0.2 Cluster 3: water (n‫؍‬128) 3.5 11.2 22.2 60.2 33.1Ϯ0. significance tested on the basis of general liner models.9 51.0Ϯ0.0001 0.2 2.0 57.2 3.2 61.5 15. 1128 July 2007 Volume 107 Number 7 .5Ϯ0.10 0.6 42.8 35.1Ϯ0.2 25.359Ϯ67 7.15 0.8 18.9Ϯ0.1 Cluster 2: high-fat milk (n‫؍‬91) 3. significance tested on basis of ␹2 comparisons. Weighted estimates.1 50.7Ϯ0.0001 0.1 9.0 13.0 3.4 19.1 47.1 40.9 6.1 14.5 58.3Ϯ0.2Ϯ0.7Ϯ0.0001 0.307Ϯ66 5.5 15.198Ϯ63 6.5 41.9 55.3 40.3Ϯ0.6 59.26 For continuous variables.3 5.0001 0.8Ϯ0.0 44.6 14.11 0.305Ϯ35 5.4 69.426Ϯ50 6.2 8.1 36. Table 4.000 Ͼ$35.2 17.2 2.5 30.4 3.0 10.9 3.3 3.1 67.2 Cluster 4: sweetened drinks (n‫؍‬100) 8.2 Cluster 3: water (n‫؍‬147) 8. Characteristics of each beverage pattern among US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002ab Children (6-11 y) Cluster 1: mix/light drinker (n‫؍‬266) 8.8 57.6Ϯ0.0Ϯ0.2 61.0001 0.9 28.9 38.6 59.0 15.4Ϯ0.1 3.302Ϯ47 6.1 13.0001 0. significance tested on basis of ␹2 comparisons.1Ϯ0.3 2.0 3.4 2.1Ϯ0.1 63.1 56.2 Cluster 4: fruit juices (n‫؍‬73) 3.9Ϯ0.10 0.8 12.000 Overweight.8 11.5Ϯ0.1 52.8Ϯ0.5 2.8 17.1 17. meanϮstandard error.6Ϯ0. BMI >85th percentile (%) Birth weight (g) Physical activity (times/wk) Media screen time (h/d) a b P value 0.000 Overweight.6 3.9Ϯ0.8 69.2 58.2 Characteristic Age (y) Sex (%) Male Female Ethnicity (%) Non-Hispanic white Non-Hispanic African American Mexican American Other Household income (%) Յ$35.000 Ͼ$35.2 2.Table 3.8 35.2 59.4 3.4 2.6 22.5 11. meanϮstandard error.7 39.9Ϯ0.9 9.2 33. for categorical variables.4 66.2 Cluster 5: soda (n‫؍‬124) 8.1 42.1 40.249Ϯ37 6.4 54.9 45.0001 0.

7Ϯ0.4 9.6Ϯ0. The high-fat milk pattern had the best dairy score.05 (Tukey-Kramer adjustment for multiple comparisons). folate.2y 6.3y 1.3y 5.8Ϯ0. Male children made up a larger proportion of the high-fat milk cluster (63.2 8.9Ϯ0.9Ϯ0. A larger proportion of non-Hispanic African-American children were in the sweetened drinks cluster (22.3 7.1Ϯ0. The sweetened drinks pattern had the best vegetable score and the mix/light drinker pattern had the worst.3y 1.2 8.5 899Ϯ40y 13.01 MeanϮstandard error.3Ϯ0. xyz Values in the same row with different superscripts are significantly different at PϽ0.07y 419Ϯ19x 515Ϯ33y 171Ϯ7.04z 309Ϯ11z 447Ϯ18z 82Ϯ4.2Ϯ0. but had the worst total fat and saturated fat scores compared with the other beverage clusters.04y 352Ϯ13yz 557Ϯ23y 69Ϯ5.9Ϯ0.5Ϯ0.2Ϯ0. The mean HEI scores across beverage patterns ranged from 70.8Ϯ0. Beverage patterns also differed significantly on diet quality in children aged 6 to 11 years (Table 6).4 1312Ϯ36x 11. meanϮstandard error.3 895Ϯ28y 12. compared to other beverage clusters (PϽ0.3 7.0001 Ͻ0.7Ϯ0.2Ϯ0.7Ϯ0.5y 10. vitamin C.1x 8.9Ϯ0. and iron) and the sweetened July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1129 .8%).9Ϯ0.9 for the sweetened drinks pattern.6Ϯ0.0Ϯ0.1y 8. Variety scores were best for the sweetened drinks cluster and worst for the soda and mix/light drinker clusters.4Ϯ0. Healthy Eating Index (HEI) scores and daily nutrient intakes by beverage patterns among US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002 Children (2-5 y) Cluster 1: mix/light drinkers (n‫؍‬249) 70.2 7.7Ϯ0.8Ϯ0.4z 7.0001).7Ϯ0.6 hours per day) (PϽ0.05) Diet quality differed significantly by beverage patterns in children aged 2 to 5 years (Table 5).7Ϯ0.4y 10.org as part of a PowerPoint presentation featuring additional online-only content.4Ϯ0.763Ϯ50x 13.Table 5.3y 2. The high-fat milk pattern had the highest percentage of energy from protein. vitamin A.6y 7.0Ϯ1.3x 1. For micronutrients.2x 3.9Ϯ1.0001 — Ͻ0.4y 10.0Ϯ1.0001 Ͻ0.2Ϯ0.1x 7. The range for HEI scores was 63.0001 Ͻ0. The best vegetable score was in the high-fat milk group. the mix/light drinker pattern had the lowest total energy intake. Percent energy from protein was highest in the high-fat milk pattern and lowest in the fruit juice and mix/light drinker patterns. along with the mix/light drinker cluster.8Ϯ0.4Ϯ0.2 7.8Ϯ0. The soda pattern had the worst fruit score and the sweetened drinks pattern had the best total fat and saturated fat scores compared with the other beverage clusters.5Ϯ0.4y 9.5Ϯ0. beverage patterns with the highest micronutrient intakes were the high-fat milk cluster (riboflavin.3y 5. vitamin A. and ethnicity. meanϮstandard error. sex.2xy 9.0001 Ͻ0.9 years in the sweetened drinks cluster.5Ϯ0. The water cluster had the largest proportion of children at risk for overweight (42.3xy 1. fiber.0%) compared to a smaller proportion in the soda cluster (7. HEI component scores also varied across beverage patterns. age. sex.2 for the soda pattern to 69.4x 6.7Ϯ0.0001 Ͻ0.1 7.0001 Ͻ0. adjusted for age.0001 — Ͻ0.2%). The fruit juice pattern had the best fruit score.5Ϯ0.6x 8.4z 9.8y 7.1Ϯ0.3x Cluster 3: water (n‫؍‬128) 71. mix/light drinker and high-fat milk clusters to 8.8Ϯ0.2x 7.3 8.8Ϯ0. calcium.01 Ͻ0.2xy 5.4 hours per day) compared with the mix/light drinker cluster (2.4Ϯ0.0 in the fruit juice pattern.2 8. After adjusting for energy intake. and iron).5Ϯ0. for nutrient intakes.2y 5. NOTE: Information from this table is available online at www.4y Measure HEIa Grainsa Vegetablesa Fruita Dairya Meata Total fata Saturated fata Cholesterola Sodiuma Varietya Energy (kcal)b Protein (% kcal)b Riboflavin (mg)b Folate (␮g)b Vitamin A (␮g retinal activity equivalents)b Vitamin C (mg)b Fiber (g)b Calcium (mg)b Iron (mg)b Zinc (mg)b a b P value Ͻ0.0y 9.4y 11.0Ϯ0. Energy intakes were highest among the high-fat milk and fruit juice patterns and were lowest for mix/light drinker and water patterns.3xy 4. vitamin C.4x 9. adjusted for total energy intake. For total energy intake.9Ϯ0.510Ϯ28y 13.2y 6.4Ϯ0.2y 1.1Ϯ0. sex.507Ϯ35y 14.3yz 7.3 6.9Ϯ0. age.4xy 9.0Ϯ0.5Ϯ0.05 Ͻ0. Compared to most other beverage clusters.9Ϯ0. the fruit juice pattern had the worst.4x 2. the sweetened drinks and soda patterns had the lowest.1y 5.1Ϯ0.4Ϯ0.5Ϯ0.3y Cluster 4: fruit juices (n‫؍‬73) 79.5Ϯ0.0001 Ͻ0. whereas the water pattern had the worst.adajournal.3y 8.05 Ͻ0.694Ϯ45x 15.2y 5. the beverage clusters with the lowest intake of micronutrients were the soda cluster (riboflavin. and ethnicity. and zinc) and fruit juice cluster (folate. Mean hours per day of media screen time was higher in the sweetened drinks cluster (3.3z 9.5Ϯ0.4z 1.9Ϯ0.3y 6.9Ϯ0.0x 5.0001 Ͻ0.2y Cluster 2: high-fat milk (n‫؍‬91) 70.7Ϯ0.0001 — — Ͻ0.3 8.1Ϯ0.9 in the mix/light drinker and high-fat milk patterns to 79.1%) and a smaller proportion of the mix/light drinker cluster (42.3Ϯ0.3Ϯ0.3 774Ϯ22z 11.3Ϯ0.0001 Ͻ0. and ethnicity.8x 10.0001 Ͻ0.06x 352Ϯ17y 673Ϯ29x 74Ϯ7.6%) and also had higher household income.2yz 1.5Ϯ0.0Ϯ0.

2x 7.7Ϯ0.2y 2. household income.6x 9.3Ϯ0.2y 4.8Ϯ0.4Ϯ0.5Ϯ0.8xy 7.05z 316Ϯ13y 407Ϯ42z 59Ϯ6.8Ϯ0.3yz 8.4Ϯ0.5 Cluster 1: Mix/light drinker Cluster 2: High-fat milk Cluster 3: Water Cluster 4: Fruit juices 17 Cluster 1: Cluster 2: Cluster 3: Cluster 4: Cluster 5: Beverage pattern Mix/light High-fat milk drinker Water Sweetened drinks Soda Figure 2.5 b b 16.0001 Ͻ0.5Ϯ0. Healthy Eating Index score.4 4.3xy Cluster 4: sweetened drinks (n‫؍‬100) 69.026Ϯ29y 14.8Ϯ0.3Ϯ0.1Ϯ0.9Ϯ0.0001 Ͻ0. NOTE: Information from this table is available online at www.4Ϯ0.6Ϯ0.2xy 2.5 a a a BMI 19 18.3 6.2z 5.3 7. Overall significance of pattern.4y 6.3 6.9y 12.0001 MeanϮstandard error.07z 353Ϯ17y 485Ϯ55yz 117Ϯ8.0001 Ͻ0.7Ϯ0.2 4.0001.005 Ͻ0.04z 362Ϯ10y 601Ϯ32yz 78Ϯ4.3y 958Ϯ23z 14. (Information from this figure is available online at www.2y 1.5Ϯ0.9Ϯ0.3xy 4. For total energy intake.815Ϯ32z 13.2 7. by comparison using the Tukey-Kramer option to correct for multiple comparisons in general linear models. ethnicity.4yz Cluster 5: soda (n‫؍‬124) 63.3Ϯ0.1Ϯ0.05.3x 4.2x 8.01 Ͻ0.8Ϯ0.3xy 7.3xy 7.01 Ͻ0.4x 11.5 15 18 17. Adjusted mean (Ϯstandard error) body mass index (BMI kg/m2) by beverage pattern among US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002.3x 8. Healthy Eating Index score. adjusted for age.943Ϯ42yz 14.7Ϯ0.5Ϯ0.5Ϯ0.7Ϯ0.3x 7. ethnicity.4xy 1.org as part of a PowerPoint presentation featuring additional online-only content.0001 Ͻ0.4Ϯ0.5 20 19.028Ϯ46xy 15.9x 7.2 6.1Ϯ0.3xy 7.0001 Ͻ0.6Ϯ0. meanϮstandard error. meanϮstandard error. and birth weight determined at PϽ0.7Ϯ0. age.0Ϯ0.074Ϯ44xy 11.0001 — Ͻ0. and birth weight determined at Pϭ0.0001 Ͻ0.5Ϯ0.1Ϯ0.6Ϯ0.4xy 11. sex.) Beverage pattern Figure 3.0y 7.org as part of a PowerPoint presentation featuring additional online-only content.3y 10.3x 9.2 5.2 4.4Ϯ0.3 6.2xy 1.005 — Ͻ0.2y 8.3y 8.239Ϯ313x 14. and ethnicity. xyz Values in the same row with different superscripts are significantly different at PϽ0.4Ϯ0.5Ϯ0.4x Cluster 3: water (n‫؍‬147) 67.2x 2.3z 6.2 7.2 5.9x 7. Healthy Eating Index (HEI) scores and daily nutrient intakes by beverage patterns among US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002 Children (6-11 y) Cluster 1: mix/light drinker (n‫؍‬266) 66.4Ϯ0.2Ϯ0.8Ϯ0.1Ϯ0.5x 770Ϯ39z 13.2Ϯ0.5Ϯ0. sex.adajournal.9Ϯ0.5 17 BMI 20.3z 1.1Ϯ0.3y 2.2Ϯ0.9Ϯ0.7Ϯ0.9Ϯ0.7Ϯ0. PϽ0.8Ϯ0.adajournal.0001 Ͻ0.7Ϯ0.2Ϯ1.05x 428Ϯ13x 755Ϯ44x 78Ϯ6.7y 12.8Ϯ0.7Ϯ0. Bars with different letters are significantly different. sex.5 16 15.9Ϯ0.) 1130 July 2007 Volume 107 Number 7 .6Ϯ0.4x 1.1Ϯ0. for nutrient intakes.3y 6.4Ϯ0.0Ϯ0.01 Ͻ0.2y 6.8Ϯ0.3xy 2. 18 17.01 Ͻ0.2x 6. physical activity.3 7.05 (Tukey-Kramer adjustment for multiple comparisons). adjusted for total energy intake. and ethnicity.0001 — Ͻ0.3z 5. after adjusting for age.30.4Ϯ0.2y 11.1Ϯ0.6Ϯ0.1Ϯ0.1Ϯ0.4xy 793Ϯ30z 12.adajournal.8Ϯ0.3x 2.0Ϯ0.4z 1.4y 8.6Ϯ0.1x 12.3xy 4. Overall significance of pattern.2Ϯ0.1Ϯ1.3y 6. (Information from this figure is available online at www.3Ϯ0.4y 12.2y 5.0001 Ͻ0.1Ϯ0.2xy 7.3z Cluster 2: high-fat milk (n‫؍‬156) 68.3y 6. physical activity.9Ϯ0.8Ϯ0.org as part of a PowerPoint presentation featuring additional online-only content.6Ϯ0.0Ϯ0.4Ϯ0.1Ϯ0. sex.3 8.3xy 2. after adjusting for age.06x 5.4xy 9.134Ϯ57x 12.9Ϯ0.Table 6.2y 5. household income.3z 8.01 Ͻ0.05y 371Ϯ12y 671Ϯ40xy 78Ϯ5. Adjusted mean (Ϯstandard error) body mass index (BMI kg/m2) by beverage pattern among US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002.3yz Measure HEIa Grainsa Vegetablesa Fruita Dairya Meata Total fata Saturated fata Cholesterola Sodiuma Varietya Energy (kcal)b Protein (% energy)b Riboflavin (mg)b Folate (␮g)b Vitamin A (␮g retinal activity equivalent)b Vitamin C (mg)b Fiber (g)b Calcium (mg)b Iron (mg)b Zinc (mg)b a b P value Ͻ0.5Ϯ0.1Ϯ0.3 7.

However. mainly high-fat milk. in contrast to the high-fat milk pattern. where HEI scores ranged from 68. and 18. DISCUSSION The changes in beverage consumption patterns during the past several decades (8) have increased interest in whether or not children are meeting nutrient requirements and whole food recommendations and if beverage intake. unlike the preschool children. diet quality was similar to or worse than most other groups. Beverage intake patterns from preschool to school-aged children could also be affected by several environmental factors. specifically calorically sweetened beverages. Regardless of beverage pattern. The relatively high HEI score for the fruit juice pattern reflects in part the variety and fruit component scores. No formal guidelines have been established for beverage consumption in children or adults. perhaps as a result of parental encouragement and influence on eating healthful foods and beverages (32). The high-fat milk pattern in school-aged children. This emphasizes the need for appropriate food selection to July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1131 .2 and 17.6 across dietary patterns in children aged 2 to 3 years and 4 to 8 years. measured by HEI.8.8 to 78.7. Diet quality. that can influence food choices and preferences including socialcognitive cues (33). Among preschoolers in the high-fat milk cluster. This is consistent with a study of low-income US children. across beverage patterns ranged from 70. this may reflect the total and saturated fat scores. sweetened drinks.drinks cluster (calcium and zinc). followed by unsweetened coffee and tea. as the majority of milk consumed in this pattern came from higher-fat varieties of milk (whole and 2%). however. and zinc). and school food environment (35). respectively. the beverage patterns we identified were not consistent with what has been proposed by the Beverage Guidance Panel. The fruit juice pattern. among children and to identify if BMI in children was associated with different beverage patterns.9 in children aged 6 to 11 years. respectively) (PϽ0. In this study. in the 2001-2002 NHANES sample using cluster analysis.9 to 79. noncalorically sweetened beverages. We also observed that diet quality was poorer among school-aged compared to preschool children. BMI was not significantly different across beverage patterns for children aged 2 to 5 years. First. However. In general. measured by the HEI. respectively) compared to the mix/light drinker and high-fat milk patterns (adjusted mean BMIϭ18. respectively (28). BMI was significantly higher in the water. which counts fruit servings from both whole foods as well as juices (23). Although the mix/light drinker pattern in both age groups had combinations of all beverage groups.8 to 69. 18. This may also reflect that children in the high-fat milk cluster were taking in more energy from milk. such as milk and fruit juice.0 in children aged 2 to 5 years and from 63.1 and from 65.30). we derived four and five nonoverlapping beverage patterns among children aged 2 to 5 and 6 to 11 years. Total energy intake for the mix/light drinker pattern in both age groups was lower than most other beverage clusters and was more consistent with the energy requirements for their age group (36).8) score compared to most other beverage clusters. our results showed that diet quality differed significantly across beverage patterns for both age groups of children. The high-fat milk pattern had the highest micronutrient intake (riboflavin. a recent guidance system has been proposed for beverage consumption in persons Ͼ6 years of age.7. calcium. and alcohol (with some nutrients). The Beverage Guidance Panel recommends water as the most preferable beverage. peers (34). Whereas the preschool children may be displacing other micronutrient-dense foods and comprising dietary variety (29. suggesting consumption of calorically sweetened beverages displaces important nutrients. Under the new HEI 2005 construct (31). this criterion will change so that no more than half of one’s daily fruit requirement is derived from fruit juice. in the diets of children (16-19). Comparisons of BMI across beverage patterns are shown for children aged 2 to 5 years (Figure 2) and for children aged 6 to 11 years (Figure 3). For children aged 6 to 11 years. we observed that more than one third of their total daily energy intake came from beverages. the HEI score for this cluster was among the lowest compared to the fruit juice pattern. and soda patterns (adjusted mean BMIϭ19. fiber. fruit juices. We suspect that most of these children’s fruit intake may come from fruit juices.2 to 69.9. This may be due to several factors. children in the high-fat milk pattern had the highest micronutrient intakes whereas micronutrient intake was the lowest for children in the soda and sweetened drinks pattern. suggesting that these children may still be transitioning from infant to toddler feeding patterns. as reflected by HEI scores and micronutrient intakes. are related to the increased prevalence of childhood obesity. in addition to family. In our sample of children aged 2 to 11 years. displaces more nutritious beverages. Similar findings were seen among children aged 6 to 11 years. Previous research has suggested that consumption of some beverages. We observed. which ranks beverages based on energy and nutrient content and related health benefits and risks (27). folate. that the total percentage of energy coming from beverages decreased from approximately 36% in children aged 2 to 5 years to approximately 26% in children aged 6 to 11 years. and calorically sweetened beverages (without nutrients). Our data also suggests this trend.05). vitamin A. Although we observed higher micronutrient intakes in the high-fat milk pattern. In children aged 2 to 5 years. older children appear to be eating more micronutrientdense foods. had a higher HEI (68. in the high-fat milk clusters. low-fat milk. the diet quality of children in this sample needs improvement (24). which can supply excess sugar and energy. a large proportion of this pattern was made up of calorically sweetened beverages. The objectives were to understand the association of different beverage patterns with overall diet quality. the high-fat milk cluster emerged with the highest micronutrient intakes compared to the other clusters. thus displacing other micronutrient-dense foods resulting in reduced dietary variety (29. had the highest HEI score and also had higher micronutrient intakes of folate and vitamin C compared to other clusters. beverage patterns were only related to BMI for children aged 6 to 11 years. rather than whole fruit because we did not observe differences in fiber intake across the different beverage clusters.30). Overall. including calorically sweetened beverages.

4. which may misclassify children according to food.29:343-349. We expected children’s BMI would be reflective of total energy intake from each beverage pattern. and nutrient intake. Ludwig DS. Changes in beverage intake between 1977 and 2001.27:205-210. Our study has several limitations. 17. for assistance with data processing. prospective studies are needed to assess beverage patterns over time that lead to overweight. Pediatrics. Further research using prospective studies is needed to better assess the influence of beverage consumption on diet quality and its influence on overweight in children. 2005. the relationship between beverage clusters and BMI may be subject to reverse causation.24:187-194. Pediatrics. Lancet. Thomas P. Ultimately. which may lead to overweight. Skinner JD. 2003. Nielsen SJ. Schoch G. 1999. Dockery DW. 2005. Gortmaker SL. Whitaker RC. mean HEI scores among children in all beverage clusters were below 81 (a score of 81 or greater representing a “good” diet). Regardless of beverage pattern. 9. 24-hour recalls were performed in young children by use of a proxy and mothers and/or caregivers may not have complete knowledge of what their child ate on a given day (ie. Peterson KE. J Am Diet Assoc. and critique of the manuscript. Our data did not support this in children aged 2 to 5 years. 2004. Ferraro KF. 1997. This project was supported by National Institutes of Health grants Nos. Soft drink consumption among US children and adolescents: Nutritional consequences. 2001. 3. Tabak CJ. Ogden CL. Damokosh AI.104:1086-1094. Our data 1132 July 2007 Volume 107 Number 7 suggest that beverages are associated with diet quality in children. Pediatr Pulmonol. statistical support. beverage. Wilkinson JA. However. Because of the cross-sectional nature of NHANES. Houck K. Cavan D. McDowell MA. 6. 14. or patterns. We also observed that children in the high-fat milk cluster had the lowest BMI. Only one 24-hour dietary recall was collected from NHANES participants. J Am Diet Assoc. Dietz WH. Dolan LM. Welsh JA. 12. we tried to increase the likelihood that real and distinct beverage patterns among children emerged by using criteria such as Scree plots and F statistics. Marshall TA. 1996. 1997.58:S110-S119. Seidel KD. Dortmund Nutritional and Anthropometrical Longitudinally Designed. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective. observational analysis. Pediatrics. Preventing childhood obesity by reducing consumption of carbonated drinks: Cluster randomised controlled trial.24:65-75. Preschool children may have a better ability to self-regulate food intake and energy (37) for both liquid and solid foods (38. 7. We observed that the sweetened drinks and soda patterns children consumed roughly one quarter of their daily energy intakes from beverages. The authors thank David Brown. Harnack L. Popkin BM.36:514-521. Kerr D. and 5-K23HL068827-03. Mei Z.39). The cross-sectional design of NHANES limited our ability to fully evaluate the relationships between BMI and beverage patterns because the choice of diet may not necessarily reflect weight. Rockett H.328:1237. Curtin LR. Stang J. Fruit juice intake is not related to children’s growth. Prevalence of overweight and obesity in the United States. 2004. Gold DR. Fruit juice consumption and the prevalence of obesity and short stature in German preschool children: Results of the DONALD Study. Beverage consumption is not associated with changes in weight and body mass index among low-income preschool children in North Dakota. 13. Newby PK. the large sample of children allowed us to identify certain beverage patterns and how they may influence overall diet quality during certain stages in childhood. Daniels SR. We did not anticipate that children in the water cluster would have significantly higher BMI. 15. Rockwell HL. Khoury PR. James J. Pediatrics. Colditz G. Diet quality in young children is influenced by beverage consumption. 11. Effects of body fat on ventilatory function in children and adolescents: Cross-sectional findings from a random population sample of school children. 1999-2002. Willett WC. 2. Excess Fruit Juice Consumption by preschool-aged children is associated with short stature and obesity. Sichert-Hellert W. Berkey CS. if the child was in school or daycare) and recalling the amounts of liquids may be more difficult than solids. those in the water. Thorpe RJ Jr. 5. but among the best overall diet quality as reflected by the HEI and micronutrient intakes. J Pediatr Gastroenterol Nutr. Story M. Pinhas-Hamiel O. These findings might also suggest that there is more parental control over a preschooler’s food intake compared to older children. Pediatr Pulmonol. The life course of severe obesity: Does childhood overweight matter? J Gerontol B Psychol Sci Soc Sci.99:436-441. 1999. Leppert J. PhD. Srinivasan SR. Carroll MD. Kersting M. Rogers S. JAMA. mostly from calorically sweetened beverages. Zeitler P. Berkey CS. Wright JA. References 1. Broffitt B. CONCLUSIONS We observed that diet quality differed across distinct beverage patterns among children aged 2 to 5 and 6 to 11 years. For children aged 6 to 11 years. Manz F. which supports the concept that children with better overall diet quality would have lower BMIs. Dennison BA. 2004. Am J Prev Med. Moran J 3rd. 2006. GrummerStrawn LM. sweetened drinks. The benefit of cluster analysis is to identify people and group them by similar beverage intakes. Standiford D. which may fluctuate from day to day. 8.103:1175-1182. Speizer FE. Consuming high amounts of calorically sweetened beverages might lead to excessive energy intake. T32-HP-10010-10. Baker SL.295:1549-1555.103:58-64. . Dietz WH. DK07665. after adjusting for other covariates. Although cluster analysis is a data-driven process that requires subjective decisions of the investigator and has no gold standard for determining the number of clusters (44). Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. Coletta F. 1997.357:505-508. Predicting obesity in young adulthood from childhood and parental obesity. 1999. Stumbo PJ. in which diet may be modified because of weight (40). all children could benefit by decreasing their intake of soda and other calorically sweetened beverages that may displace important micronutrient-dense foods needed for growth and development. Moreover.337:869-873. Pepe MS. and soda patterns had the highest BMI.99:15-22. BMJ. N Engl J Med. 16. 19992004. J Pediatr.115:e223-e229. Flegal KM. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. In addition. Body-mass index as a predictor of incident asthma in a prospective cohort of children. Berkey CS. J Am Coll Nutr. indicating that diets of children aged 2 to 11 years need improvement. Berenson GS. Peterson KE. 10. Freedman DS. Eichenberger Gilmore JM.128:608-615. Alexy U. Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri. Cogswell ME. Lazarus R. but BMI was only significantly associated with beverage patterns of children aged 6 to 11 years. Colditz GA. This is supported by research that shows children with higher BMIs report higher levels of dieting (41-43). 2003. 1999. Carruth BR. Levy SM.improve diet quality even in children that are meeting recommended energy requirements.

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