The Contribution of Major Food Categories and Companies to Household Purchases of Added Sugar in Australia

BackgroundThe Australian Government will soon be releasing a series of sugar reformulation targets for packaged foods.ObjectiveTo estimate the amount of added sugar purchased from packaged food and beverages and the relative contribution that food categories and food companies made to these purchases in 2018. The secondary objective was to examine differences in purchases of added sugar across income levels.DesignCross-sectional study.Participants/settingWe used 1 year of grocery purchase data from a nationally representative panel of Australian households (the NielsenIQ Homescan panel), combined with a packaged food and beverage database (FoodSwitch).Main outcome measuresAdded sugar purchases (grams per day per capita), purchase-weighted added sugar content (grams per 100 g) and total weight of products (with added sugar) purchased (grams per day per capita).Statistical analyses performedFood categories and food companies were ranked according to their contribution to added sugar purchases. Differences in added sugar purchases by income levels were assessed by 1-factor analysis of variance.ResultsAdded sugar information was available from 7188 households and across 26,291 unique foods and beverages. On average, the amount of added sugar acquired from packaged foods and beverages was (mean ± SE) 35.9 ± 0.01 g/d per capita. Low-income households purchased 11.0 g/d (95% CI: 10.9-11.0 g/d, P < .001) more added sugar from packaged products than high-income households per capita. The top 10 food categories accounted for 82.2% of added sugar purchased, largely due to purchases of chocolate and sweets, soft drinks, and ice cream and edible ices. Out of 994 food companies, the top 10 companies contributed to 62.1% of added sugar purchases.ConclusionsThe Australian Government can strengthen their proposed sugar reduction program by adding further category-specific targets, prioritizing engagement with key food companies and considering a broader range of policies to reduce added sugar intakes across the Australian population.     

Decreasing the Consumption of Foods with Sugar Increases Their Reinforcing Value: A Potential Barrier for Dietary Behavior Change

BackgroundThe Dietary Guidelines for Americans (DGA) have recommended reducing added sugar intake since its inception in 1980. Nearly 40 years later, added sugar consumption still exceeds 2015-2020 DGA recommendations among most of the population. The reinforcing value of food influences eating behaviors, and foods high in added sugars are highly reinforcing. Restricting intake of foods high in added sugars as part of a low-sugar diet may increase their reinforcing value such that reducing consumption may be difficult to maintain. If so, this would present a mechanistic barrier to making the necessary dietary changes to meet 2015-2020 DGA recommendations.PurposeTo determine whether the relative reinforcing value of foods high in added sugars is altered when reducing intake of all foods high in sugars.MethodsObese (n=19) and normal weight (n=23) men and woman who habitually consumed over 10% of their calories from added sugars completed the study. Reinforcing value of foods high in added sugars was measured via progressive ratio schedules of reinforcement before and on day 7 of a weeklong controlled feeding intervention where added sugars comprised 2.5% to 4.0% of daily calories and total sugars 7.3% to 8.6% of daily calories.ResultsThe reinforcing value of foods high in added sugars increased (P<0.01) after consuming a diet low in total added sugars for 1 week in both obese and normal weight participants.ConclusionAdhering to a low-sugar diet for 1 week increases the reinforcing value of foods high in added sugars. Future studies should examine whether consuming a diet low in added sugars, but not other sugar, increases reinforcing value of foods high in added sugars and whether high–added sugar food reinforcement returns to baseline after longer-term reductions in added sugars.     

Foods Served in Child Care Programs Participating in the Child and Adult Care Food Program and Alignment with Program Meal Patterns

ObjectiveAssess Child and Adult Care Food Program (CACFP) program compliance with meal component requirements for children aged 3-5 years by program type, and describe foods and beverages most commonly served.DesignCross-sectional analysis of 1-week menu surveys during winter/spring 2017.SettingUS CACFP-participating child care programs.ParticipantsNationally representative multistage cluster sample of 664 programs: 222 child care centers, 247 Head Start programs, 195 family child care homes.Main Outcome Measure(s)Percentage of meals including required components; frequently served foods and beverages.AnalysisMean percentages; 2-tailed t tests; alpha = 0.05 significance level.ResultsMost breakfasts (97%), lunches (88%), and afternoon snacks (97%) included all required CACFP meal components. Most breakfasts included fruits (96%), but not vegetables; 16% included a meat/meat alternate. Most lunches (81%) included both fruits and vegetables. Afternoon snacks were mostly grains/breads (80%) and fruits (57%). Most frequently served foods included 1% unflavored milk and fresh fruits such as apples and bananas. Most menus limited juice, offered low-sugar cereal, and did not include flavored milk; very few menus included noncreditable foods with added sugar.Conclusions and ImplicationsMost CACFP meals provided required components, but there is room for improvement, particularly for increasing vegetables served and limiting foods high in added sugar and fat.     

Participation in the CACFP Ensures Availability but not Intake of Nutritious Foods at Lunch in Preschool Children in Child-Care Centers

BackgroundThe US Department of Agriculture Child and Adult Care Food program (CACFP) recently (October 2017) updated requirements for meal reimbursement and best practice recommendations for serving nutritious meals and beverages, and minimum age-specific serving sizes for five food groups. It is not known whether CACFP-funded child-care centers are meeting the updated meal pattern requirements and best practice recommendations, and whether children are meeting nutrition recommendations based on the current 2015-2020 Dietary Guidelines for Americans (DGA).ObjectiveThis study assessed whether the recruited CACFP-funded child-care centers in this study were meeting the updated (2017) CACFP requirements regarding foods served for lunch and whether children attending these child-care centers were meeting age- and sex-specific DGA recommendations regarding foods consumed.DesignThis was a cross-sectional study using the Dietary Observation for Child Care method. Participants and settingsChildren aged 3 to 5 years (n=108) from 10 classrooms in three CACFP-funded child-care centers in Lincoln, NE, were recruited by convenience sampling during spring 2018.Measurable outcomesFood served and consumed during observed lunches in comparison with updated CACFP requirements and DGA, respectively.Statistical analysisAdjusted mean amounts of foods served from each food group were compared with age specific minimum CACFP serving size requirements. Adjusted mean amounts of foods consumed from each food group were then compared with age- and sex-specific DGA recommendations.ResultsThe recruited child-care centers were meeting the updated CACFP requirements regarding foods served but showed limited adherence to the best practice recommendations during the observed lunches. However, the overall mean intake for grains, fruits, and vegetables was significantly lower (P<0.01) than DGA recommendations. In addition, approximately 25% of the children did not consume any vegetables during their meal. ConclusionsAlthough child-care centers were meeting the updated CACFP requirements by serving the recommended amounts of foods, children were not meeting DGA-recommended intakes. Future studies are needed to explore ways to improve adherence to best practice recommendations to improve children’s consumption of healthy foods in child-care centers.     

Added sugar and sugar-sweetened foods and beverages and the risk of pancreatic cancer in the National Institutes of Health-AARP Diet and Health Study

BACKGROUND: Although it has been hypothesized that hyperglycemia, hyperinsulinemia, and insulin resistance are involved in the development of pancreatic cancer, results from epidemiologic studies of added sugar intake are inconclusive. OBJECTIVE: Our objective was to investigate whether the consumption of total added sugar and sugar-sweetened foods and beverages is associated with pancreatic cancer risk. DESIGN: In 1995 and 1996, we prospectively examined 487 922 men and women aged 50-71 y and free of cancer and diabetes. Total added dietary sugar intake (in tsp/d; based on the US Department of Agriculture's Pyramid Servings Database) was assessed with a food-frequency questionnaire. Relative risks (RRs) and 95% CIs were calculated with adjustment for total energy and potential confounding factors. RESULTS: During an average 7.2 y of follow-up, 1258 incident pancreatic cancer cases were ascertained. The median intakes for the lowest and highest quintiles of total added sugar intake were 12.6 (3 tsp/d) and 96.2 (22.9 tsp/d) g/d, respectively. No overall greater risk of pancreatic cancer was observed in men or women with high intake of total added sugar or sugar-sweetened foods and beverages. For men and women combined, the multivariate RRs of the highest versus lowest intake categories were 0.85 (95% CI: 0.68, 1.06; P for trend = 0.07) for total added sugar, 1.01 (0.82,1.23; P for trend = 0.58) for sweets, 0.98 (0.82,1.18; P for trend = 0.49) for dairy desserts, 1.12 (0.91,1.39; P for trend = 0.35) for sugar added to coffee and tea, and 1.01 (0.77,1.31; P for trend = 0.76) for regular soft drinks. CONCLUSION: Our results do not support the hypothesis that consumption of added sugar or of sugar-sweetened foods and beverages is associated with overall risk of pancreatic cancer.     

Prevalence of Low-Calorie Sweeteners and Related Front-of-Package Claims in the Brazilian Packaged Food Supply

BackgroundLow-calorie sweeteners (LCSs) are increasingly being used worldwide, including in foods and beverages commonly consumed by children.ObjectiveTo examine the prevalence of LCSs in packaged foods and beverages sold in Brazil, whether LCSs are added to products with advertising directed to children, and whether foods and beverages with LCSs include front-of-package (FoP) LCS-related health and nutrition claims.DesignCross-sectional study.SettingA sample (n = 11,434) of packaged foods and beverages sold by the top 5 largest Brazilian food retailers was examined to identify LCSs and added sugars, and a subsample (n = 3491) was examined to determine the presence of advertising directed to children and FoP LCS-related claims in foods and beverages with LCSs.Main outcome and measuresThe prevalence of foods and beverages with different types of LCSs in the Brazilian food supply, among ultra-processed foods and beverages and among foods and beverages with added sugars, were measured. Foods and beverages with advertising directed to children were checked to see if these products had LCSs and how many products with LCSs had FoP labels with LCS-related claims.Statistical analysesMean and 95% CIs were used to determine the overall prevalence of foods and beverages with LCSs and in the different assessed stratifications.ResultsThe prevalence of LCSs was 9.3% (95% CI 8.8-9.9) in Brazilian packaged foods and beverages, 14.6% (95% CI 13.8-15.4) in ultra-processed products alone, and 5.7% (95% CI 4.2-7.7) in foods and beverages with advertising directed to children. About 83% of food and beverage with LCSs were also sweetened with added sugars. LCSs were most frequently added to nonalcoholic sweetened beverages, breakfast cereals, and granola bars. Forty percent of foods and beverages with LCS did not present any FoP LCS-related claim.ConclusionThis study shows that LCSs are present in 15% of ultra-processed foods and beverages in Brazil, largely used in combination with added sugars, and are found in foods and beverages with advertising directed to children. Clearer FoP information regarding the presence of LCSs, in particular in products with advertising directed to children, can help consumers make more informed choices regarding LCS consumption.     

Sugar intakes from snacks and beverages in Japanese children

While sugar intake is an important factor for obesity, diabetes and dental caries, sugars are also important energy sources, especially for rapidly growing children. Children like sugar-rich sweet foods. However, intake for Japanese children is not known due to a lack of studies and sugar composition data. This study was designed to determine sugar intakes from snacks and beverages in Japanese school children. A nutrition survey was conducted for 3 weekdays for 283 Japanese school children (7, 10 and 13 y old) in 8 prefectures from different areas of Japan. The methods for the survey were the weighing method for school lunches and the 24-h recall method for other foods. To estimate sugar intakes, the sugar composition table that was recently compiled by us for 135 beverages, cakes and other sweets was used. Height and weight were measured. They were similar to Japanese averages. Energy intakes were also similar to the results of the Japanese National Health and Nutrition Surveys. Sugar eaten outside meals was 24.7±15.5 g/d. From the National Health and Nutrition Surveys conducted in 2009, the mean sucrose intake from meals including some home-made cookies for 7-14-y-old children was 5.5 g/d, suggesting the mean total sugar intake of these children was about 30 g/d. This was within the range of FAO/WHO recommendation (less than 10% of energy intake, 49 g for these children. Mean intakes among age groups were not significantly different (p>0.05), but the intake for girls was lower than for boys in the oldest age group (p<0.05). Contributions of each sugar to total intake were sucrose 64%, fructose 14%, glucose 13% and lactose 9%. Fructose and glucose were mainly from isomerized sugar. Contributions of food groups to total intake were beverages 25%, baked goods 19% and ice cream 17%, respectively, covering 61% of all. In conclusion, we revealed that the average sugar intake of Japanese children was within the range of the FAO/WHO recommendation, though the effects of the kind of sugars on health remain to be clarified.     

Dietary sugar intake and dietary behaviors in Korea: a pooled study of 2,599 children and adolescents aged 9-14 years

BACKGROUND/OBJECTIVESDietary sugar intake, particularly added sugar and sugar-sweetened beverages, has received worldwide attention recently. Investigation of dietary behaviors may facilitate understanding of dietary sugar intakes of children and adolescents. However, the relationship between dietary sugar intake and dietary behaviors in the Korean population has not been investigated. Thus, this study aimed to estimate dietary sugar intake and food sources according to sex as well as examine the relationship of dietary sugar intake with frequent snacking and dietary patterns among Korean children and adolescents.SUBJECTS/METHODSWe pooled data from five studies involving Korean children and adolescents conducted from 2002 to 2011. A total of 2,599 subjects aged 9-14 years were included in this study. Each subject completed more than 3 days of dietary records.RESULTSMean daily total sugar intake was 46.6 g for boys and 54.3 g for girls. Compared with boys, girls showed higher sugar intakes from fruits (7.5 g for boys and 8.8 g for girls; P = 0.0081) and processed foods (27.9 g for boys and 34.9 g for girls; P < 0.0001). On average, 95.4% of boys and 98.8% of girls consumed snacks during the study period, and total sugar intake showed a significantly increasing trend with increasing energy intake from snacks (P < 0.0001 for both sexes). Two dietary patterns were identified by cluster analysis: Traditional and Westernized patterns. Total sugar intake was higher in the Westernized pattern (56.2 g for boys and 57.2 g for girls) than in the Traditional pattern (46.5 g for boys and 46.3 g for girls).CONCLUSIONSThese results suggest that multilateral and practical development of a nutrition education and intervention program that considers dietary behaviors as well as absolute sugar intake is required to prevent excessive sugar intake in Korean children and adolescents.     

Frequency of Sweet and Salty Snack Food Consumption Is Associated with Higher Intakes of Overconsumed Nutrients and Weight-For-Length z Scores During Infancy and Toddlerhood

BackgroundCurrent dietary guidelines recommend avoiding foods and beverages with added sugars and higher sodium before age 2 years.ObjectiveThe aim was to describe daily snack food intake (frequency and total energy) and the associations with overconsumed nutrients (added sugars, sodium, and saturated fats) and child weight-for-length z scores.DesignA cross-sectional, secondary analysis of baseline data from an ongoing longitudinal intervention was conducted.Participants and settingA sample of 141 caregivers with infants (aged 9 to 11 months) and toddlers (aged 12 to 15 months) was recruited in Buffalo, NY, between 2017 and 2019.Main outcome measuresThree 24-hour dietary recalls were used to categorize 'sweet and salty snack foods' or 'commercial baby snack foods' based on the US Department of Agriculture What We Eat in America food group classifications and estimate nutrient intakes. Child recumbent length and weight were measured by trained researchers.Statistical analysisDaily frequency (times/day), energy (kcal/day), and overconsumed nutrients from snack food intake were calculated. Multivariable regression models examined associations between the frequency of and energy from snack food intake with overconsumed nutrients and child weight-for-length z scores.ResultsInfants consumed snack foods on average 1.2 times/day contributing 5.6% of total daily energy, 19.6% of added sugars, and 6.8% of sodium. Toddlers consumed snack foods on average 1.4 times/day contributing 8.9% of total daily energy, 40.0% of added sugars, and 7.2% of sodium. In adjusted models including all children, greater frequency of sweet and salty snack food intake, but not commercial baby snack foods, was associated with higher weight-for-length z scores.ConclusionsSnack foods are frequently consumed by infants and toddlers and contribute to the intake of overconsumed nutrients such as added sugars and sodium. Given the current guidelines to avoid added sugars and higher sodium before age 2 years, additional recommendations related to nutrient-dense snack intake may be beneficial.     

Fortified Foods Are Major Contributors to Nutrient Intakes in Diets of US Children and Adolescents

BackgroundEven in an era of obesity and dietary excess, numerous shortfall micronutrients have been identified in the diets of US children and adolescents. To help tailor strategies for meeting recommendations, it is important to know what foods contribute greatly to micronutrient intakes. Data are lacking on specific contributions made by added nutrients.ObjectiveOur aims were to examine the impact of fortification on nutrient adequacy and excess among US children and adolescents and to rank food sources of added nutrient intake and compare rankings with those based on total nutrient intake from foods.Design and statistical analysesData were from 7,250 respondents 2 to 18 years old in the National Health and Nutrition Examination Survey 2003-2006. Datasets were developed that distinguished nutrient sources: intrinsic nutrients in foods; added nutrients in foods; foods (intrinsic plus added nutrients); and total diet (foods plus supplements). The National Cancer Institute method was used to determine usual intakes of micronutrients by source. The impact of fortification on the percentages of children having intakes less than the Estimated Average Requirement and more than the Upper Tolerable Intake Level was assessed by comparing intakes from intrinsic nutrients to intakes from intrinsic plus added nutrients. Specific food sources of micronutrients were determined as sample-weighted mean intakes of total and added nutrients contributed from 56 food groupings. The percentage of intake from each grouping was determined separately for total and added nutrients.ResultsWithout added nutrients, a high percentage of all children/adolescents had inadequate intakes of numerous micronutrients, with the greatest inadequacy among older girls. Fortification reduced the percentage less than the Estimated Average Requirement for many, although not all, micronutrients without resulting in excessive intakes. Data demonstrated the powerful influence of fortification on food-source rankings.ConclusionsKnowledge about nutrient intakes and sources can help put dietary advice into a practical context. Continued monitoring of top food sources of nutrients and nutrient contributions from fortification will be important.     

The Contribution of Discrete Vegetables,Mixed Dishes,and Other Foods to Total Vegetable Consumption: US Ages 2 Years and Over, 2017-2018

BackgroundThe 2020-2025 Dietary Guidelines for Americans recommend intake of a variety of vegetables, including dark green, red, and orange vegetables and starchy and other vegetables.ObjectivesThis study aims to describe sociodemographic differences in the contribution of different categories of vegetables and the form in which they are consumed (ie, discrete vegetables, mixed dishes, and other foods such as savory snacks to total vegetable intake on a given day).DesignThis is a cross-sectional, secondary analysis of the 2017-2018 National Health and Nutrition Examination Survey.Participants/settingThis study included the data of 7122 persons aged 2 years with reliable day 1 24-hour dietary recalls.Main outcome measuresServing equivalents of vegetables from 20 discrete categories of vegetables and from mixed dishes and other foods as a percentage of total vegetables.Statistical analysesPairwise differences by age, sex, race, Hispanic origin, and family income were examined using univariate t statistics, and trends by age and income were examined using orthogonal polynomials.ResultsMean serving equivalents of vegetables was 1.4 cups. The serving equivalents increased with age among youth, was higher among non-Hispanic Asian (NHA) persons than other subgroups, and increased with increasing family income. Overall, discrete vegetables contributed 55.2% of total vegetable intake, and the contribution increased with age in adults and with increasing family income. The top 5 discrete vegetable contributors were other vegetables and combinations, french fries and other fried white potatoes, lettuce and lettuce salads, mashed potatoes and white potato mixtures, and baked or boiled white potatoes. Nonstarchy discrete vegetables contributed more to total vegetables for adults (37.6%) than youth (28.0%), and the contribution increased with increasing family income. On the other hand, the contribution of mixed dishes and other foods decreased with increasing family income.ConclusionsDiscrete vegetables only contributed 55.2% of total vegetable intake, and the top sources were not varied. Three of them potato based, which may explain the reported low vegetable intake, relative to the 2020-2025 Dietary Guidelines for Americans. More than one-third of vegetables consumed were nonstarchy discrete vegetables, many of which are high in vitamins. Nonstarchy discrete vegetable intake was higher in adults than youth and increased with family income.     

Dietary Intakes of Children Enrolled in US Early Child-Care Programs During Child-Care and Non-Child-Care Days

BackgroundEarly-child-care (ECE) programs may substantially influence child diet quality.ObjectiveThe Study of Nutrition and Activity in Child Care Settings describes the usual food group intake of preschool-aged children attending ECE programs relative to Dietary Guidelines for Americans (DGA) recommendations, comparing intakes during child-care and non-child-care days.DesignMeal observations and parent-completed food diaries in a cross-sectional nationally representative multistage cluster sample of Child and Adult Care Food Program-participating ECE programs.Participants/settingOne thousand four hundred sixty-eight children aged 3 to 5 years attending 217 Child and Adult Care Food Program-participating ECE programs (eg, child-care centers and Head Start) during 2017.Main outcome measuresDaily energy intake, daily US Department of Agriculture Food Pattern Food Group intakes, and percentage of daily intakes meeting 2015-2020 DGA Food Pattern recommendations.Statistical analyses performedRegression-adjusted usual intakes and percentage of children meeting recommendations were estimated using the National Cancer Institute method. Single-day mean intakes were used to test for statistical differences between child-care and non-child-care days.ResultsMean usual energy intake was 1,524 ± 19.3 kcal during child-care days and exceeded the recommended range at 1,702 ± 30.2 kcal during non-child-care days; single-day means indicated significantly lower energy intake on child-care days (P < 0.001). The percent of children meeting DGA recommendations on a child-care day varied by DGA food group: fruits (51.4%), grains (50.1%), dairy (42.5%), vegetables (6.5%), whole grains (4.6%), and protein foods (0.1%). Recommended limits on calories from added sugar and solid fats were met by 28.2% and 14.6% of children, respectively. Compared with mean food group intakes during a single child-care day, non-child-care day intakes were similar for fruits and vegetables, lower for dairy and whole grains, and higher for total grains, protein foods, and calories from added sugars and solid fats.ConclusionsAlthough there is room to increase nutrient density inside and outside of child care, intakes on child-care days more closely align to DGAs.     

Diet quality in young children is influenced by beverage consumption

BACKGROUND: Replacement of milk with sugar-containing beverages could affect calcium intake and overall diet quality. OBJECTIVE: To describe dairy food, 100% juice and added sugar beverage intakes, contributions of dairy foods to diet quality, and effects of beverages on diet quality in young children. METHODS: We surveyed participants in the Iowa Fluoride Study (n = 645) at ages 1, 2, 3, 4 and 5 years and calculated intakes for 1-5 years (i.e. weighted averages). Nutrient, dairy food and beverage intakes were obtained from 3-day diaries; nutrient adequacy ratios were calculated as the nutrient intake to Recommended Dietary Allowance/Adequate Intake ratio; and dairy-dependent percentages were calculated as fractions of total diet nutrient adequacy ratios (truncated at 1) not met by non-dairy foods. RESULTS: Milk intakes were inversely associated with intakes of juice drinks (2, 4, 5 and 1-5 years), soda pop (2, 3, 4, 5 and 1-5 years) and added sugar beverages (2, 3, 4, 5 and 1-5 years). Dairy dependent fractions of 1-5 year nutrient adequacy ratios were 68% for calcium and 61% for vitamin D. Higher 1-5 year calcium adequacy was predicted by higher energy, higher other dairy and lower added sugar beverage intakes while higher vitamin D adequacy was predicted by higher energy and higher other dairy intakes. Overall diet quality was predicted by higher energy, higher other dairy, lower 100% juice and lower added sugar beverage intakes. CONCLUSIONS: Dairy foods remain an important source of calcium and vitamin D, while added sugar beverages and, to a lesser extent, 100% juice decrease diet quality of young children.     

The Contribution of Snacking to Overall Diet Intake among an Ethnically and Racially Diverse Population of Boys and Girls

BackgroundChildren in low-income and minority populations are at risk for poor dietary quality. At least one-third of the calories consumed by children are eaten between meals (ie, snacks). The contribution of snacking to diet quality among children is poorly understood.ObjectiveThe current study examined associations between snacking and children’s diet quality along with differences across ethnicity or race, sex, and weight status.DesignCross-sectional data came from Phase I of the Family Matters Study, an observational study.Participants/settingThis study included 150 families with children aged 5 to 7 years old from six ethnic or racial groups (n=25 from each: African American, Hispanic, Hmong, Native American, Somali, non-Hispanic white); data were collected in Minneapolis–Saint Paul, MN in 2017-2018.Main outcome measuresTotal daily energy (kilocalories), overall diet quality using the Healthy Eating Index (HEI-2010), and food group intakes (eg, fruit, vegetables, refined grains, sugar-sweetened beverages [SSB]) were assessed using three 24-hour dietary recalls.Statistical analyses performedConditional fixed effects estimators (within-child variation) were used in regression analyses to characterize the relationship between daily snacking and dietary intake relative to dietary intake at all other daily meal occasions. Mean (±standard deviation) overall dietary intake including all meals and snacks was compared with mean (±standard deviation) intake of meals only.ResultsAmong boys, snacking was found to contribute positively to HEI-2010 scores (HEI-2010=57.6, HEI-2010 without snacks=55.0; effect size [ES]=0.28, P=0.03). Snacking was an important source of fruit (ES=0.71) and dairy (ES=0.53), but also contributed to children’s consumption of refined grains (ES=0.68) and SSB (ES=0.31). Very few vegetables were consumed as snacks. Furthermore, snacks contributed more to the overall diet quality (HEI-2010) of Native American (ES=0.30) and Somali (ES=0.35) youth as compared with youth from other ethnic or racial backgrounds.ConclusionsFindings suggest that snacks have the potential to improve diet quality in children. Future research should examine influences on children’s food choices at snack times and barriers to serving more healthful foods as snacks that are faced by ethnically or racially diverse families.     

Consumption of Beverages Containing Low-Calorie Sweeteners,Diet, and Cardiometabolic Health in Youth With Type 2 Diabetes

BackgroundLow-calorie sweetened beverages (LCSBs) are commonly used as a lower-calorie alternative to sugar-sweetened beverages (SSBs) by individuals with type 2 diabetes. However, little is known about how intake of LCSBs is related to dietary intake and cardiometabolic health, particularly among youth.ObjectiveTo test the hypothesis that having higher baseline LCSB intake and increasing LCSB intake over 2 years of follow-up are associated with poorer dietary intake and higher cardiometabolic risk factors among youth enrolled in the Treatment Option for Type 2 Diabetes in Adolescents and Youth (TODAY) study.DesignSecondary, exploratory, analysis of baseline and longitudinal data from the TODAY study, which was a randomized, multisite trial conducted from 2004 to 2012, to compare effects of 3 interventions (metformin alone, metformin + rosiglitazone, and metformin + intensive lifestyle intervention) on glycemic control in youth with type 2 diabetes.Participants/settingThe study included 476 children and adolescents (10-17 years, mean body mass index 34.9 ± 7.8 kg/m²), who were participants in the multicenter (n = 15) TODAY study.Main outcome measuresDiet was assessed using a food frequency questionnaire. Differences in energy intake, macronutrients, food group intakes, and cardiometabolic biomarkers were evaluated in 3 groups of LCSB consumers at baseline (low [1-4 servings/wk], medium [5-11 servings/wk], and high [≥12 servings/wk]), each compared with nonconsumers, and between 4 groups of change in LCSB intake (nonconsumption at start of study and nonconsumption after 2 years, increase in consumption after 2 years, decrease in consumption after 2 years, and high consumption at start of study and high consumption after 2 years).Statistical analyses performedMultivariable linear regression was performed at baseline and longitudinally over 2 years of follow-up.ResultsEnergy (kilocalories), fiber, carbohydrate, total fat, saturated fat, and protein intake (grams) were higher among high LCSB consumers compared with nonconsumers at baseline. No associations were observed between LCSB consumption and cardiometabolic risk factors at baseline. Change in LCSB intake between baseline and follow-up was not associated with change in energy intake or cardiometabolic risk factors. Participants who decreased LCSB consumption reported greater increases in sugar intake (18.4 ± 4.8 g) compared with those who increased LCSB consumption (5.7 ± 4.9 g) or remained high LCSB consumers (5.9 ± 7.4 g), but this trend was not statistically significant after a correction for multiple testing.ConclusionsLCSB consumption was associated with higher energy intake in youth with type 2 diabetes, with the highest energy intakes reported in high LCSB consumers. Those who reduced LCSB consumption tended to report greater increases in sugar intake during follow-up, but further studies are needed to better understand this trend.     

Where Are Kids Getting Their Empty Calories? Stores,Schools, and Fast-Food Restaurants Each Played an Important Role in Empty Calorie Intake among US Children During 2009-2010

Consumption of empty calories, the sum of energy from added sugar and solid fat, exceeds recommendations, but little is known about where US children obtain these empty calories. The objectives of this study were to compare children's empty calorie consumption from retail food stores, schools, and fast-food restaurants; to identify food groups that were top contributors of empty calories from each location; and to determine the location providing the majority of calories for these key food groups. This cross-sectional analysis used data from 3,077 US children aged 2 to 18 years participating in the 2009-2010 National Health and Nutrition Examination Survey. The empty calorie content of children's intake from stores (33%), schools (32%), and fast-food restaurants (35%) was not significantly different in 2009-2010. In absolute terms, stores provided the majority of empty calorie intake (436 kcal). The top contributors of added sugar and solid fat from each location were similar: sugar-sweetened beverages, grain desserts, and high-fat milk1 from stores; high-fat milk, grain desserts, and pizza from schools; and sugar-sweetened beverages, dairy desserts, french fries, and pizza from fast-food restaurants. Schools contributed about 20% of children's intake of high-fat milk and pizza. These findings support the need for continued efforts to reduce empty calorie intake among US children aimed not just at fast-food restaurants, but also at stores and schools. The importance of reformed school nutrition standards was suggested, as prior to implementation of these changes, schools resembled fast-food restaurants in their contributions to empty calorie intake.     

What's in Your Drink? Poster Educates Families About Sugar Content and Fatty Liver Disease

ObjectiveDrinking sugar-sweetened beverages is a risk factor for developing childhood obesity and nonalcoholic fatty liver disease (NAFLD). This study investigated the impact of an educational poster in pediatric offices on family's knowledge of sugar content in beverages and assessed awareness of NAFLD.DesignPreclinic visit surveys asked patients’ caregivers about the sugar content in beverages and awareness of NAFLD. Postclinic visit surveys assessed improvement in knowledge of sugar content and willingness to change dietary habits.SettingOutpatient visits in a single center in Houston between September and November 2019.ParticipantsOne hundred and forty-nine caregivers were surveyed, and patients’ median age was 5.5 years (range, 0–18 years) with 57% males.InterventionEducational posters displayed the sugar content of common beverages in each clinic room.Main Outcome MeasuresOutcomes measured included pre-post clinic visit change and predictors of change in (1) knowledge of sugar content in beverages and (2) intent to change beverage consumption. Baseline awareness of NAFLD and associated predictors were also assessed.AnalysisLogistic regression identified factors associated with an intended change in beverage consumption, change in survey score, and NAFLD awareness.ResultsIncreased knowledge of sugar content with median scores of 25% preclinic to 50% postclinic (P < 0.001). Eighty-eight percent of caregivers were very/moderately likely to provide their children fewer sugar-sweetened beverages. Sixty percent of caregivers were aware of NAFLD, but only 32.8% were concerned.Conclusions and ImplicationsPosters in clinics increased awareness of the sugar content in beverages, and most caregivers reported intent to decrease children's sugary beverage consumption.     

Exploring Mothers’ Perspectives About Why Grandparents in Appalachia Give Their Grandchildren Cariogenic Foods and Beverages: A Qualitative Study

BackgroundDental caries is the most common chronic childhood disease. Past studies revealed that grandparents provide their grandchildren with cariogenic foods and beverages (eg, those with free sugars and/or modified starches). Qualitative research can help identify what drives this phenomenon.ObjectiveOur aim was to examine mothers’ explanations for why grandparents in north central and central Appalachia give their grandchildren cariogenic foods and beverages.DesignA qualitative study on children’s oral health in Pennsylvania and West Virginia from 2018 through 2020 was performed. In-person, semi-structured interviews were conducted. Qualitative data from interviews were recorded, transcribed, and then coded using NVivo. Data analysis for this study was performed using thematic analysis with iterative theme development.Participants/settingThe participants were 126 mothers of children aged 3-5 years from West Virginia (n = 66) and Pittsburgh, PA (n = 60).Main outcome measuresMothers’ perspectives about why grandparents give their grandchildren cariogenic foods and beverages were analyzed.ResultsIn the study sample, 85% of mothers (n = 107/126) named at least 1 of their children’s grandparents as a member of their social network responsible for their children’s oral health. From these interviews, 85% of mothers (n = 91/107) discussed that grandparents gave their grandchildren cariogenic foods and beverages. The mothers described the following 4 themes to explain why grandparents gave their grandchildren cariogenic foods and beverages: privilege of the grandparent role; responsibilities of the grandparent role; symbol of care and affection; and limited consideration or understanding of the detrimental impact.ConclusionsGrandparents play a role in giving their grandchildren cariogenic foods and beverages, which could potentially contribute to childhood caries. Research is needed to develop effective social interventions to help some grandparents understand the implications of a cariogenic diet on their grandchildren’s oral health and/or decrease their provision of cariogenic foods and beverages.     

Availability of Lower-Sodium School Lunches and the Association with Selection and Consumption among Elementary and Middle School Students

BackgroundDuring 2010, the US Department of Agriculture updated the school meals standards, including three progressively decreasing sodium targets. The Target 1 standards went into effect in 2014, but during 2018, the US Department of Agriculture delayed the Target 2 standards until 2024 and eliminated the Target 3 standards citing concerns regarding the availability and acceptability of lower-sodium foods. In addition, there are currently no sugar standards, and it is unknown whether sugar is substituted for salt in lower-sodium school foods.ObjectiveTo examine the availability, selection, and consumption of school lunches already in alignment with the Target 2 and 3 sodium levels and the association between sodium and sugar.DesignAn observational cafeteria-based study conducted during fall 2018.Participants and settingStudents (n = 1985) in grades three through eight attending 13 elementary/kindergarten through eighth-grade schools in a large, urban school district in New England.Main outcome measuresAvailability, selection, and consumption were examined using plate waste methodology.Statistical analyses performedMixed-model analysis of variance accounting for student demographic characteristics with schools/students as a random effect (students nested within schools) were used to examine differences in availability, selection, and consumption. Linear regression was used to examine the association between sodium and sugar in the school foods.ResultsThe majority of meals selected (87%) and consumed (98%) were already in alignment with the Target 2 standards. There were significant inverse associations between sodium levels and consumption; each 100-mg increase in sodium was associated with a decrease in consumption by 2% for entrées (P = 0.002) and 5% for vegetables (P = 0.01). When examining the association between sodium and sugar, each 10-mg reduction in sodium was associated with 1-g increase in sugar among entrées (P < 0.0001), whereas there was a significant positive association between sodium and sugar with vegetables and condiments.ConclusionsThis study provides some evidence that schools may already have the ability to provide lower-sodium meals that are acceptable to students, and therefore the recent rollbacks to the sodium standards may be unwarranted. Study findings suggest that the US Department of Agriculture should take under consideration policies that would limit added sugar for school meals as sugar may be substituted for salt.