National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages

Methods 

The CSFII is a nationally representative survey of noninstitutionalized individuals in the United States. The 1994-1996, 1998 CSFII data set ((9)) (including the 1998 Supplemental Children's Survey of 5,559 children aged birth through 9 years old) was used for this evaluation and consists of 24-hour-recall food intake data for one (n=21,662) or two (n=20,607) nonconsecutive days. Two-day average food group records (response rate = 77.5%) and appropriate weighting factors were used to calculate the mean daily beverage intake for individuals aged birth through 18 years of age. The beverage categories included: 100% fruit juice (citrus juice plus noncitrus juices and nectars), total fluid milk, total carbonated beverages (regular and low-calorie), and total fruit drinks and ades (not 100% juice; regular and low-calorie). Infants and children who were breastfeeding were excluded from the analysis, leaving a final sample size of 10,648 (50.5% male, 49.5% female; 70% white, 15% black; 17% of the total sample were of Hispanic origin). Descriptive statistics were computed using SPSS (Version 10.1, 2000, SPSS Inc, Chicago, IL). Statistical comparisons of mean intakes were performed using t tests. Gender differences were not evaluated.

Results and discussion 

Mean daily intakes of beverages for selected age groups are presented in the Table. tableThe mean daily intakes of 100% fruit juice for children aged <6 months, 6 months to 6 years, and 7 to 18 years were 0.9, 4.6, and 3.4 oz, respectively. Except for children aged <6 months, mean intakes did not exceed AAP recommendations. For infants less than 6 months old, 22% consumed some amount of 100% fruit juice. Three percent and 1% consumed >6 and >12 oz/day, respectively. The AAP recommends against introduction of fruit juice into the diets of children less than 6 months old. For children aged 6 months to 6 years, 73% fell within the AAP recommendations and 9% consumed >12 oz/day. For children and adolescents aged 7 to 18 years, 94% fell within AAP recommendations.

Table. Daily intake of selected beverage categories by age group, Continuing Survey of Food Intakes by Individuals 1994-1996, 1998

	Age group	n	100% fruit juice (oz)a	Fruit drinks and ades (oz)b	Fluid milk (oz)c	Carbonated soft drinks (oz)d	AAP fruit juice recommendation (oz)	Within AAP recommendation (%)
			←Mean (SEM) [25th-75th percentile]→
	AAP-defined age groups
	<6 mo	492	0.9 (0.08)f	e	e	e	0	78
	6 mo-6 y	7,552	4.6 (0.25)	4.0 (0.18)	11.2 (0.01)	2.9 (0.06)	4-6	73
			[0-7.3]	[0-6.2]	[4.1-16.3]	[0-4.1]
	7-18 y	2,604	3.4 (0.10)	5.1 (0.47)	9.0 (0.34)	12.4 (0.58)	8-12	94
			[0-5.2]	[0-8.0]	[2.0-14.2]	[0-18.5]
	Other age groups
	6-11 mo	573	2.8 (0.12)	0.9 (0.25)	4.0 (0.31)	e	4-6	87
			[0-4.2]	g	[0-0.3]
	1-3 y	3,777	5.5 (0.33)	3.6 (0.17)	12.6 (0.08)	2.1 (0.009)	4-6	67
			[0-8.3]	[0-5.2]	[5.3-17.8]	[0-3.1]
	4-8 y	3,769	3.6 (0.24)	4.7 (0.26)	10.5 (0.04)	4.5 (0.22)	4-6h, 8-12i	77h, 97i
			[0-5.7]	[0-7.8]	[4.1-14.3]	[0-6.2]
	9-13 y	1,149	3.2 (0.10)	4.6 (0.02)	9.7 (0.74)	9.7 (0.77)	8-12	95
			[0-5.2]	[0-7.5]	[4.1-14.2]	[0-14.4]
	14-18 y	888	3.7 (0.01)	5.7 (0.92)	7.8 (0.13)	18.0 (0.88)	8-12	92
			[0-6.2]	[0-8.0]	[0-12.2]	[6.1-26.8]

AAP=American Academy of Pediatrics. aCalculated by adding together intakes of citrus juices (fresh, frozen, canned, or bottled grapefruit, lemon, lime, orange, and other citrus juices, sweetened or unsweetened; mixtures of citrus juices; and baby-food citrus juices) and noncitrus juices and nectars (fruit juices, nectars, and baby-food juices other than citrus; and mixtures of citrus and noncitrus juices). bIncludes regular and low-calorie fruit drinks, punches, and ades, including those from powdered mix or frozen concentrates. Excludes 100% fruit juices and carbonated fruit drinks. cIncludes fluid whole, lowfat, skim, and acidophilus milk; buttermilk; reconstituted dry milk; evaporated milk; and sweetened condensed milk. Does not include breast milk (breastfeeding infants excluded from the analysis). dIncludes regular and low-calorie carbonated soft drinks, such as colas, fruit-flavored and cream sodas, ginger ale, root beer, and carbonated soft drinks containing fruit juice; carbonated fruit juice drinks; and sweetened and unsweetened carbonated water. Contribution of unsweetened carbonated water to total carbonated soft drink category is 1.1% and 0.4% for age groups 6 months to 6 years and 7 to 18 years, respectively. eComputed mean<0.1 oz/day. Result not statistically reliable because of the small number of individuals in this age group consuming the beverage. f78% of children in this age group consumed no 100% fruit juice; 95th percentile is 5.2 oz. g85% of children in this age group consumed no fruit drinks and ades; 95th percentile is 4.6 oz. hAge 4-6 years. iAge 7-8 years.

Mean daily beverage intakes for children ages 1 through 18 years are depicted in the Figure.Mean 100% fruit juice intakes for all ages do not exceed AAP recommendations (shaded area). One hundred percent fruit juice consumption peaks at 2 years, declines steadily, and plateaus around age 7 years. Mean intake of fluid milk is highest (2 cups/day) at age 1, but by age 18 it decreases to cup/day. Intake of carbonated soft drinks increases as children age, with a dramatic increase beginning around age 8. Mean daily intake of fruit drinks and ades exceeds that of 100% fruit juice (P=.009) at 5 years, and mean intake of carbonated soft drinks exceeds 100% fruit juice (P =.035) and milk (P =.029) at ages 5 and 13, respectively. At age 13, intake of carbonated soft drinks exceeds the AAP recommendations for 100% fruit juice consumption.

View Large Image Download to PowerPoint

Fig. 1. Daily intake of selected beverage categories by age group (mean and SEM), Continuing Survey of Food Intakes by Individuals 1994-1996, 1998.

Analysis of the most recent CSFII survey data indicates that most children's and adolescents' 100% fruit juice intake does not exceed AAP recommendations. Although 9% of children 6 months to 6 years old and 6% of children 7 to 18 years old consumed >12 oz/day 100% fruit juice, an amount defined as excessive ((4)), there are no consistent data to suggest that these amounts negatively impact children's growth. A potentially greater concern to children's health relates to the intake of beverages not considered to be as nutrient-dense as 100% fruit juice. At age 5 years and older, intake of fruit drinks and ades exceeds that of 100% fruit juice. Many fruit drinks and ades are fortified with vitamins or minerals (eg, vitamin C, calcium) but may not offer the variety of nutrients or the nutritional benefits found in 100% fruit juice. Most fruit drinks and ades contain 10% or less real fruit juice, have added sweeteners, and may not supply amounts of particular nutrients or food components equivalent to 100% fruit juice. For instance, an 8-oz serving of 100% orange juice contains no added sweeteners, is an excellent source of vitamin C, and contains a variety of phytochemicals, food components that may contribute to reduced risk for chronic diseases [10], [11], [12]. An 8-oz serving of orange juice is also a good source of folate and potassium, important nutrients not concentrated in fruit drinks and ades because many of these beverages contain 10% or less of 100% juice. United States Food and Drug Administration rules do not allow for these beverages to be fortified with folate and potassium. Evidence suggests that a high intake of added sugars, especially of sugar-sweetened beverages, is associated with a reduction in diet quality and reduces the chances for achieving nutrient adequacy ((13)).

Although much of the research regarding 100% fruit juice intake and growth has focused on younger children, of greater concern may be the beverage intakes of older children and adolescents. The data in this report indicate that intake of carbonated soft drinks is significantly greater than intake of 100% fruit juice and milk at ages 5 and 13, respectively. After age 8, intake of carbonated soft drinks increases dramatically and exceeds the AAP fruit juice recommendations after age 12. Older children and adolescents (>12 years) drink more carbonated soft drinks than milk, 100% fruit juice, or fruit drinks and ades (Figure). Carbonated soft drinks provide little or no nutritional value beyond calories and represent the largest contributor of added sugars in the diets of adolescents ((14)). Intakes of carbonated soft drinks have been negatively associated with intakes of calcium, riboflavin, vitamin A, and vitamin C in preschool and school-aged children ((15)) and teenagers ((16)). Nondiet soft drink intake also has been positively associated with energy intake in children ((15)), which may contribute to the increased frequency of obesity and its comorbidities (eg, type 2 diabetes) observed in children [17], [18]. Because the present analysis uses cross-sectional data, it could not be concluded whether carbonated soft drinks displace 100% fruit juice or fluid milk from the diet, although other studies suggest this may be the case ((15)). More longitudinal studies are needed to better define beverage consumption patterns in children and adolescents and how these patterns impact health.

Applications 

■There is no conclusive evidence to suggest that in most cases intake of 100% fruit juice should be restricted in children and adolescents; however, practitioners should discourage consumption of beverages other than breast milk, infant formula, and water in children less than 6 months old. For the majority of children and adolescents, 6 oz of 100% fruit juice is considered one fruit serving ((19)) and promotion of moderate intakes of 100% fruit juice as part of a healthful and varied diet is consistent with public health recommendations for increasing fruit and vegetable intake to optimize health and reduce risk for chronic disease [19], [20], [21], [22]. Practitioners should be aware that consumption of beverages with added sweeteners may increase after 4 years of age and may displace more nutrient-dense beverages from the diet. Nutrition professionals who work with children or parents can play an important role in educating their clients about the nutritional advantages of 100% fruit juice, and the nutritional differences between 100% fruit juice, fruit drinks and ades, and carbonated soft drinks.

■Health professionals should encourage replacement of less nutritious beverages with those that are more nutrient-dense or represent more healthful choices such as milk, water, or 100% fruit juice. Continued encouragement of healthful beverage choices should extend into adolescence, when consumption of carbonated soft drinks is particularly high.