Download A Perspective on Sugars and Health

Dairy Council
July | August 2007
Volume 78
Number 4
®
SUMMARY
However, there is no conclusive evidence
that sugars per se are associated with
any of these disorders, with the exception
of dental caries, a disease in which multiple
factors in addition to sugars are involved.
Nevertheless, excess energy intake
from sugars, particularly added sugars,
is associated with weight gain and
displacement of more nutrient-dense
foods. For this reason, health professional
organizations and government agencies
recommend reduced intake of added sugars.
Nutritive or caloric sweeteners (sugars)
increase the palatability of foods and add
to the pleasure of eating. Sugars are present
naturally in foods such as fructose in fruits
and lactose in milk and are added to a
variety of foods and beverages during
processing or preparation. Added sugars
typically include sucrose (table sugar) and
high fructose corn syrup (HFCS).
A PERSPECTIVE
ON SUGARS
& HEALTH
Added sugars are digested and metabolized
the same as their naturally occurring
sugar counterparts. In general, foods and
beverages with naturally containing sugars
tend to be nutrient-dense (i.e., high in
nutrients in relation to their calories),
whereas many foods and beverages with
added sugars (e.g., non-diet soft drinks, fruit
drinks, candy) typically provide calories but
few or no micronutrients. However, there
are nutrient-dense foods such as flavored
milks, flavored yogurts, and some cereals
that have small amounts of added sugars.
According to the American Dietetic
Association (ADA), people can safely
enjoy sugars “when consumed in a diet
that is guided by current federal nutrition
recommendations, such as the Dietary
Guidelines for Americans and the Dietary
Reference Intakes, as well as individual
health goals.” The ADA adds that “by
increasing the palatability of nutrient-dense
foods/beverages, sweeteners can promote
diet healthfulness.” Likewise, the 2005
Dietary Guidelines for Americans states that
“in some cases, small amounts of sugars
added to nutrient-dense foods, such as
breakfast cereals and reduced-fat milk
products, may increase a person’s intake of
such foods by enhancing the palatability
of these products, thus improving nutrient
intake without contributing excessive
calories.” Studies show that intake of
flavored milk improves children’s nutrient
intake without contributing to weight gain.
Americans’ “sweet tooth”
is evidenced by their high
consumption of sugars,
particularly added sugars,
which has increased over
the years. Soft drinks are
a major source of added
sugars in the diet. These
beverages contain HFCS,
which has replaced sucrose
as an added sweetener
in these and many other
products. HFCS is similar
in its composition and
metabolism to sucrose.
Because milk and other dairy products are
a major source of calcium in the U.S. and
because milk consumption has declined,
it is important to ensure that nutrition
education messages regarding intake
of sugars not inadvertently discourage
consumption of foods and beverages of
high nutrient density such as flavored
D
milks and yogurts.
Poor diet quality, obesity,
dental caries, diabetes
mellitus, heart disease,
and behavioral disorders
in children have been
blamed on intake of sugars.
The Dairy Council Digest® is available on-line.
www.nationaldairycouncil.org
21
A
N
I
N
T
E
R
P
R
E
T
I
V
E
R
E
V
I
E
W
O
F
R
E
C
E
N
T
N
U
T
R
I
T
I
O
N
R
E
S
E
A
R
C
H
INTRODUCTION
Nutritive or caloric sweeteners (sugars)
impart sweetness to the diet, increase a
food’s energy content (4 kcal/g), and confer
certain functional properties to foods (1,2).
Sugars are present naturally in foods such as
fructose in fruits and lactose in milks and are
added to a variety of foods and beverages
during processing or preparation. Despite
sugars’ importance in adding to the pleasure
of eating, increased consumption of sugars,
particularly added sweeteners such as
sucrose (table sugar) and high fructose
corn syrup (HFCS), has raised concerns
regarding sugars’ possible detrimental
effects on health and behavior (3-5). A
recent survey of consumers’ most pressing
food and health issues found that 63% of
respondents were extremely or somewhat
concerned about sugars and 70% reported
trying to consume less added sugars (6).
This Digest reviews types and sources of
sugars; the relationship between sugars
and health and behavior; and guidance
from health professional organizations
and government agencies regarding
intake of sugars. For information on sugar
alcohols (e.g., sorbitol, mannitol, xylitol)
and non-nutritive sweeteners (sugar
substitutes), such as those approved by
the Food and Drug Administration (e.g.,
saccharin, aspartame, acesulfame K,
neotame, and sucralose), readers can
refer to several publications (1,7-9).
TYPES OF NUTRITIVE
SWEETENERS
The use of different terminologies to define
sugars has led to some confusion about the
types of sweeteners (10). Based on their
chemical composition, the term “sugars”
generally refers to monosaccharides and
disaccharides. Monosaccharides consist
of one sugar unit and include glucose,
fructose, and galactose. Disaccharides are
made up of two sugar units and include
sucrose (glucose + fructose), lactose
(glucose + galactose), and maltose (glucose
+ glucose).
A further distinction is made between
“naturally occurring” sugars such as lactose
in milk and fructose in fruits and “added
sugars” which are added to foods at the
22
July | August 2007
Sugars add to the
pleasure of eating.
However, a high
intake of added
sugars, especially
from foods and
beverages of low
nutrient-density
(e.g., non-diet
soft drinks, fruit
drinks, candy), can
lead to excessive
calorie intake and
displacement of
essential nutrients.
table or during processing or preparation
(1,2,10). Some examples of added sugars
include sucrose, corn syrup, HFCS, honey,
molasses, and raw sugar (1,11). Added sugars
are digested and metabolized the same as
their naturally occurring sugar counterparts.
However, foods with naturally occurring
sugars tend to be nutrient-rich in relation to
their calories (i.e., nutrient-dense), whereas
many foods and beverages high in added
sugars supply calories but few or no
nutrients (11-13). Concern centers on the
presence of added sugars in foods of low
nutrient density (e.g., soft drinks). However,
there is a growing perception that any food
with added sugars, whether nutrient dense
or not, should be avoided.
Because of its name, HFCS is often confused
with pure fructose or incorrectly assumed
to be much higher in fructose than other
sweeteners such as sucrose. Yet, HFCS is
similar in its composition and metabolism
to sucrose (14,15). Sucrose is composed
of 50% glucose and 50% fructose.
Commercially available HFCS 55 (55%
fructose) contains approximately the same
percentage of glucose and fructose as
sucrose, while HFCS 42 (42% fructose) has
less fructose than sucrose. Once absorbed
by the digestive system, the human body
cannot distinguish between HFCS and
sucrose (14,15).
CHANGING INTAKE
OF SWEETENERS AND
THEIR SOURCES
Data from food availability and food
intake (primarily dietary recalls) surveys
provide information about consumption
of sugars (10). Availability of sugars used as
sweeteners has increased over the years,
peaking in the late 1990s, and slightly
declining thereafter (14,16-20). However,
the increase in sugars availability has not
contributed disproportionately to the
increase in total energy availability that
has occurred over the same time (16).
During the past several decades, a shift in
the availability of sugars has occurred, with
a decrease in table sugar and an increase
in HFCS (16).
Food intake surveys reveal that
consumption of added sugars has not
only increased over the years, but differs
among age groups with the highest intake
for adolescents (20,21). Data from the
National Health and Nutrition Examination
Survey (NHANES) 1999-2002 indicate that
for all individuals aged 2 years and over,
added sugars contributed 16.6% of total
calorie intake (20). Although this average
estimated intake of added nutritive
sweeteners falls below the Institute of
Medicine (IOM)’s suggested maximal intake
level of 25%, nearly one-third of adolescent
females aged 14 to 18 years exceed this
level (1,2).
Non-diet soft drinks and other sweetened
beverages are the major source of added
sugars in the diet (12,19,22). According
to an analysis of data from more than
10,000 Americans ages 4 and older who
participated in NHANES 1999-2000 and
2001-2002, 49% of added sugars in the
diet were contributed by a combination
of regular soft drinks, fruit drinks and
presweetened teas (22). Soft drinks
contributed 36% of added sugars in the
diet (22), a percentage similar to that
reported in an earlier study (i.e., 33%) (12).
The Nutrition Facts Panel on foods and
beverages lists the amount of total sugars
per serving, but does not distinguish
between sugars naturally present and those
added. USDA’s Nutrient Data Laboratory
has recently developed a database that
provides the added sugars content of
selected foods and beverages (23).
SUGARS & HEALTH
Sugars, particularly added sugars, and
health has been the subject of several
scientific evaluations over the past 20 years
(1-3,11,24-27). With the exception of
sugars’ contribution to dental caries, there
is no conclusive evidence that intake of
sugars per se is associated with the many
alleged adverse health effects attributed to
them (1-3,5). Nevertheless, excess energy
intake from added sugars can potentially
lead to nutrient shortcomings, due to
displacement of more nutrient-dense
foods/beverages, and to weight gain (13).
Diet Quality. The relationship between
added sugars intake and diet quality is
complex and depends on the nutrient
composition of the food containing added
sugars and whether nutrient-dense foods
July | August 2007
No conclusive
evidence indicates
that consumption
of sugars per se is
associated with
the many alleged
adverse health
effects attributed
to them. An
exception is dental
caries, a disease
in which sugars
are not the
sole offender.
are displaced (2). Increased consumption of
sugars from energy dense, nutrient-poor
foods (e.g., soft drinks) can result in
decreased intakes of certain micronutrients,
whereas added sugars in nutrient-dense
foods (e.g., flavored milk, sweetened yogurt,
presweetened breakfast cereals) can
improve diet quality (2).
An analysis of data from NHANES III,
1988-1994 conducted by the IOM
identified reduced intakes of calcium,
vitamin A, iron, and zinc with increasing
intake of added sugars, particularly at intake
levels exceeding 25% of energy (2). To
ensure diet quality, the IOM recommends
a maximal intake level of added sugars of
25% of energy or less. The IOM also reports
that micronutrient inadequacies may occur
in diets with very low levels of total sugars
(<4% of energy) because nutrient-rich
foods such as fruits and dairy products
may be avoided due to their natural sugars
content (2).
Several other reports link high intakes of
added sugars with low intakes of some
nutrients (27-29). For example, the 2005
Dietary Guidelines Advisory Committee
identified 19 studies supporting this
finding (27). A recent study of low-income
households found that greater use of added
sugars significantly reduced intakes of
protein, iron, vitamins A, C, B6, B12,
and potassium (29). A meta-analysis of
88 studies of the effect of soft drinks (a
major source of added sugars) on nutrition
and health found that soft drink intake
was associated with lower intakes of milk,
calcium, and other nutrients (30).
On the other hand, when sugars are added
to nutrient-rich foods they can increase the
palatability and consumption of these foods,
thereby improving nutrient intake (1,11).
Studies show that when children and
adolescents consume flavored milks
(i.e., milks with small amounts of added
sweeteners), their intake of milk and milk’s
nutrients such as calcium increases (31-33).
Using data from the CSFII 1994-96 and
1998, researchers found that children
and adolescents who drank flavored milks
not only had higher calcium intakes, but
also higher total milk intakes, and lower
consumption of soft drinks, without
increased intake of percent calories from
total fat or added sugar, compared with
23
children who were non-consumers of
flavored milk (31).
A subsequent study by these researchers
showed that consumption of sweetened
dairy products (e.g., flavored milks,
flavored yogurts) and presweetened
cereals had a positive effect on children’s
and adolescents’ diet quality (e.g.,
increased calcium, folate, and iron) (32).
In contrast, intake of sugar-sweetened
beverages (e.g., soft drinks), sugars and
sweets, and sweetened grains (e.g., cakes,
cookies, pies) negatively impacted their
diet quality (32). Flavored milk’s positive
impact on children’s nutrient intake is also
demonstrated in an investigation of 7557
children and adolescents aged 2 to 18
years who participated in NHANES 19992002 (33). Flavored milk consumers had
higher total milk intakes than those who
consumed exclusively plain milk (33).
Also, compared to milk non-drinkers,
flavored milk consumers had higher
energy-adjusted intakes of several
nutrients (33), including those limiting
in children’s diets (i.e., calcium, potassium,
magnesium) (11). In addition, intake of
added sugars and body weights were
similar for flavored milk drinkers and milk
non-drinkers (33).
The importance of flavored dairy
products such as flavored milks
and yogurts in helping children and
adolescents meet their recommended
daily intakes of dairy foods and dairy food
nutrients such as calcium is recognized
by the 2005 Dietary Guidelines for
Americans (11), the American Academy
of Pediatrics (34,35), and the National
Academy of Sciences (NAS)’ Committee
on Nutrition Standards for Foods in
Schools (36). As stated in the Dietary
Guidelines, “in some cases, small
amounts of sugars added to nutrientdense foods such as breakfast cereals
and reduced-fat milk products, may
increase a person’s intake of such foods
by enhancing the palatability of these
products, thus improving nutrient
intake without contributing excessive
calories” (11). The American Academy
of Pediatrics, in a policy statement
discouraging soft drinks in schools
(34) and in its report on optimizing
children’s and adolescents’ bone health
July | August 2007
Research indicates
that children
and adolescents
who consume
sweetened dairy
products (e.g.,
flavored milks,
flavored yogurts)
not only improve
their intake of
essential nutrients
(e.g., calcium), but
also increase milk
intake and reduce
consumption of
soft drinks, without
increasing intake
of percent calories
from total fat,
added sugars,
or body weight.
and calcium intakes (35), encourages
intake of nutritious beverages including
low-fat or fat-free flavored milk. The
NAS, in its newly released nutrition
standards for competitive foods in schools
(i.e., foods and beverages served a la
carte in cafeterias, in vending machines,
or in school stores), recognizes the
nutritional value of flavored milk and
yogurt with modest amounts of added
sugars (36).
Obesity. Obesity results from excess
energy intake in relation to energy
expended (primarily by physical activity).
Sugars alone do not cause obesity
(1,2,5,13,37). Rather, over-consumption
of any energy-yielding nutrient –
carbohydrate (complex or refined sugars),
fat, or protein – can result in weight gain
(27). Current evidence does not support
a direct link between increasing intake
of sugars and obesity independent of
energy intake (2,13).
Because sugars-sweetened beverages
(e.g., soft drinks, fruit drinks) are the
largest source of added sugars (12,19)
and their consumption has increased
dramatically in past decades in parallel
with the rise in overweight and
obesity, researchers have sought to
determine whether consumption of
sugars-sweetened beverages, particularly
nondiet soft drinks, contributes to
weight gain and obesity (27,30,38-42).
Although the weight of epidemiological
and experimental evidence indicates
that greater consumption of sugarssweetened beverages is associated with
an increase in energy intake and weight
gain or obesity, the findings are not
entirely consistent (2,39-42).
Proposed mechanisms to explain
the association between sweetened
beverages and obesity include excess
calorie intake (30,38), the concept that
liquid calories may be less satiating
than solid foods (43,44), sugars-induced
stimulation of satiety mechanisms (45),
and displacement of milk from the
diet (41).
The strongest evidence supports the
excess calorie hypothesis (30,38,41).
With regard to potential biological
mechanisms, a critical review led to
24
the conclusion that “the associations
between sugars-sweetened beverages
and obesity must be viewed as
circumstantial because biological
plausibility, based on known physiologic
mechanisms regulating food intake
and energy balance, and short-term
experimental studies, does not support
cause and effect conclusions” (46). Other
researchers suggest that the effect of
sugars-sweetened beverages on body
weight may be influenced by behavioral
factors such as how sugars are used in
the diet and the availability and cost of
sweetened beverages (47). Intake of
sugars-sweetened beverages may
displace milk from the diet (40,41).
Emerging scientific evidence suggests
that consuming adequate amounts of
dairy foods such as milk, yogurt, and/or
cheese and their components (i.e.,
calcium, protein) may play a beneficial
role in achieving and maintaining a
healthy body weight (48-50).
July | August 2007
Researchers have suggested that the
increase in HFCS in the food supply has
played a significant role in America’s
obesity epidemic (51). However, evidence
is insufficient to conclude that HFCS
alters metabolism to uniquely promote
deposition of body fat or increase food
intake (1,15,52-54).
The 2005 Dietary
Guidelines for
Americans states
that “small
amounts of
sugars added to
nutrient-dense
foods, such as
breakfast cereals
and reduced-fat
milk products, may
increase a person’s
intake of such
foods by enhancing
the palatability
of these
products, thus
improving nutrient
intake without
contributing
excessive calories.”
Dental Caries (Tooth Decay).
Sugars are fermentable carbohydrates
that can contribute to the risk of dental
caries (1,2,11,27,55,56). However,
multiple factors influence this risk
(55,56). Sucrose in a retentive or sticky
form (e.g., dried fruits) and eaten
between meals is potentially more
cariogenic than sugars that are rapidly
cleared from the mouth (e.g., in liquids
such as flavored milk). The longer
sugars remain in the mouth or on tooth
surfaces where they are exposed to
microorganisms, the greater the risk
of dental caries. Also, protective factors
in some foods, such as protein (casein,
whey), lipids, calcium, and phosphorus
in milk and cheese, may reduce the
caries-potential of sugars (56,57).
Because of soft drinks’ high content of
sugars, acidogenic potential (which can
result in enamel erosion), and frequent
consumption, which can increase the risk
of dental caries, the American Academy
of Pediatrics encourages intake of more
healthful alternatives including low-fat
flavored milk (58). The most effective
way to reduce dental caries is to practice
good oral hygiene (i.e., regular brushing
and flossing of teeth) and use topical
fluorides, fluoridated toothpaste, and
fluoridated water (1,2,11,55-57).
Other Disorders. There is no
conclusive evidence that sugars per se
cause other disorders such as diabetes
mellitus (1,2,4,5,27,53,59-63), heart
disease (1,2,5,64-66), or behavior
problems in children (1,2,67-69). The
American Diabetes Association, in its
nutrition recommendations for diabetes,
does not provide specific guidelines
for sugars intake other than pointing
out that sugars can be substituted
for other carbohydrate sources on a
calorie-for-calorie basis (59,60).
With respect to heart disease, short-term
studies show that high intake of sugars,
particularly sucrose and fructose, can
adversely affect blood triglyceride and
low density lipoprotein (LDL) cholesterol
levels under certain conditions
(1,2,5,64,65). However, this effect is not
observed in long-term studies. Although
no dietary trials link sugars consumption
with cardiovascular disease, the American
Heart Association recommends that high
sugars intake be avoided because sugars
have no nutritional value other than
providing calories (64,66).
A persistent myth is that sugars intake
is related to hyperactivity and other
behavioral disorders in children.
However, scientific evidence does
not support the suggestion that sugars
cause hyperactivity or adversely affect
attention span or cognitive performance
in children (1,2,67-69).
CONCLUSION
High intake of foods and beverages with
added sugars, especially those of low
nutrient-density (e.g., non-diet soft
drinks, candy, fruit drinks), can contribute
excess calories, which in turn can lead to
weight gain and nutrient displacement.
For this reason, health professional
organizations and government agencies
25
call for a reduced intake of added
sugars (1,2,11,70). When used in
moderation and with consideration
of overall caloric balance, sugars can
increase the appeal of nutrient-dense
foods and beverages, thereby
providing additional choices to
meet nutritional needs in the
D
context of a healthful diet (2).
REFERENCES
1. American Dietetic Association. J. Am. Diet. Assoc.
104: 255, 2004.
2. Institute of Medicine of the National Academies.
Dietary Reference Intakes for Energy, Carbohydrate,
Fiber, Fat, Fatty Acids, Cholesterol, Protein, and
Amino Acids. Washington, D.C.: The National
Academies Press, 2002.
3. Lineback, D.R., and J.M. Jones. Am. J. Clin. Nutr.
78(4 suppl): 814s, 2003.
4. Coulston, A.M., and R.K. Johnson. J. Am. Diet.
Assoc. 102: 351, 2002.
5. Anderson, G.H. Nutr. Res. 17(9): 1485, 1997.
6. International Food Information Council (IFIC)
Foundation. Food & Health Survey: Consumer
Attitudes toward Food, Nutrition & Health.
Washington, D.C.: International Food Information
Council Foundation, 2006. http:/ific.org
7. Kroger, M., K. Meister, and R. Kava. Comprehensive
Rev. Food Sci. Food Safety 5: 35, 2006.
8. Meister, K. Sugar-Substitutes and Your Health. April
2006. American Council on Science and Health.
www.acsh.org.
9. International Food Information Council.
Sugars & Low-Calorie Sweeteners. May 2004.
www.ific.org/nutrition/sugars/index.cfm.
10. Sigman-Grant, M., and J. Morita. Am. J. Clin. Nutr.
78(suppl): 815s, 2003.
11. U.S. Department of Health and Human Services,
U.S. Department of Agriculture. Dietary Guidelines
for Americans 2005. 6th ed. Washington, D.C.:
U.S. Government Printing Office, 2005.
www.healthierus.gov/dietaryguidelines.
12. Guthrie, J.F., and J.F. Morton. J. Am. Diet. Assoc.
100: 43, 2000.
13. Murphy, S.P., and R.K. Johnson. Am. J. Clin. Nutr.
78(suppl): 827s, 2003.
14. Schorin, M.D. Nutr. Today 40: 248, 2005.
15. White, J.S., and J.P. Foreyt. Food Technol. 60: 96,
2006.
16. U.S. Department of Agriculture, Economic
Research Service. Food availability (per capita)
data system (updated February 15, 2007).
www.ers.usda.gov/Data/FoodConsumption/
17. Hiza, H.A.B., and L. Bente. Nutrient Content of the
U.S. Food Supply, 1909-2004. A Summary Report.
Home Economics Research Report No. 57,
February 2007.
18. Putnam, J., J. Allshouse, and L.S. Kantor. FoodRev.
25(3): 2, 2002.
19. Popkin, B.M., and S.J. Nielsen. Obes. Res. 11:
1325, 2003.
20. Cook, A.J., and J.E. Friday. Pyramid Servings Intakes
in the United States 1999-2002, 1 Day. Beltsville,
MD: USDA, Agricultural Research Service,
Community Nutrition Research Group, 2005.
www.ba.ars.usda.gov/cnrg.
21. Block, G. J. Food Compost. Anal. 17: 439, 2004.
22. Murphy, M.M., and J.S. Douglas for ENVIRON
International Co. What America Drinks. How
Beverages Relate to Nutrient Intakes and Body
Weight. Study commissioned by the Milk Processor
Education Program. 2007.
26
July | August 2007
23. U.S. Department of Agriculture, Agricultural
Research Service. USDA Database for the Added
Sugars Content of Selected Foods. Release 1.
www.ars.usda.gov/nutrientdata.
24. Glinsmann, W.H., H. Irausquin, and Y.K. Park.
J. Nutr. 116(11s): 1s, 1986.
25. Clydesdale, F.M. Am. J. Clin. Nutr. 62(suppl. 1):
vii, 1995.
26. Glinsmann, W.H., and Y.K. Park. Am. J. Clin. Nutr.
62: 161s, 1995.
27. 2005 Dietary Guidelines Advisory Committee.
Report of the Dietary Guidelines Advisory
Committee on the Dietary Guidelines for
Americans, 2005. August 2004.
www.health.gov/dietaryguidelines/
dga2005/report/.
28. Bowman, S.A. Fam. Econ. Nutr. Rev. 12(3):
31, 1999.
29. Bhargava, A., and A. Amialchuk. J. Nutr. 137:
453, 2007.
30. Vartanian, L.R., M.B. Schwartz, and K.D. Brownell.
Am. J. Public Health 97: 667, 2007.
31. Johnson, R.K., C. Frary, and M.Q. Wang.
J. Am. Diet. Assoc. 102: 853, 2002.
32. Frary, C.D., R.K. Johnson, and M.Q. Wang.
J. Adol. Health 34: 56, 2004.
33. Murphy, M.M., J.S., Douglass, R.K. Johnson, et al.
Nutrient intakes and body measures of children and
adolescents in the United States drinking flavored,
plain or no milk. 2007 Experimental Biology
meeting abstracts [on CD-ROM]. Abst. # 833.3.
34. American Academy of Pediatrics, Committee on
School Health. Pediatrics 113: 152, 2004.
35. Greer, F.R., N.K. Krebs, and the Committee on
Nutrition. Pediatrics 117: 578, 2006.
36. National Academy of Sciences, Institute of
Medicine, Committee on Nutrition Standards for
Foods in Schools. V.A. Stallings and A.L. Yaktine
(Eds). Nutrition Standards for Foods in Schools:
Leading the Way Toward Healthier Youth.
Washington, D.C.: National Academies Press, 2007.
37. Saris, W.H.M. Am. J. Clin. Nutr. 78(suppl):
850s, 2003.
38. Schulze, M.B., J.E. Manson, D.S. Ludwig, et al.
JAMA 292: 927, 2004.
39. Centers for Disease Control and Prevention, Division
of Nutrition and Physical Activity. Research to
Practice Series No. 3. Does Drinking Beverages with
Added Sugars Increase the Risk of Overweight?
Atlanta: Centers for Disease Control and Prevention,
2006. www.cdc.gov/nccdphp/
40. Malik, V.S., M.B. Schulze, and F.B. Hu. Am. J. Clin.
Nutr. 84: 274, 2006.
41. Bachman, C.M., T. Baranowksi, and T.A. Nicklas.
Nutr. Rev. 64: 153, 2006.
42. Pereira, M.A. Int. J. Obesity 30(suppl): 28s, 2006.
43. DiMeglio, D.P., and R.D. Mattes. J. Obes. Rel. Met.
Disord. 24: 794, 2000.
44. Bell, E.A., L.S. Roe, and B.J. Rolls. Physiol. Behav.
78(4-5): 593, 2003.
45. Anderson, G.H., and D. Woodend. Am. J. Clin.
Nutr. 78(suppl): 843s, 2003.
46. Anderson, G.H. Int. J. Obes. 30(suppl. 3):
52s, 2006.
47. Drewnowski, A., and F. Bellisle. Am. J. Clin. Nutr.
85: 651, 2007.
48. Zemel, M.B. J. Am. Coll. Nutr. 24: 537s, 2005.
49. Moore, L.L., M.L. Bradlee, D. Gao, et al. Obesity
14: 1010, 2006.
50. National Dairy Council. Dairy Council Digest 77(6):
31, 2006.
51. Bray, G.A., S.J. Nielsen, and B.M. Popkin. Am. J.
Clin. Nutr. 79: 537, 2004.
52. Hein, G.L., J.S. White, M.L. Storey, et al.
Nutr. Today 40: 253, 2005.
53. Schorin, M.D. Nutr. Today 41: 70, 2006.
54. Melanson, K.J., L. Zukley, J. Lowndes, et al.
Nutrition 23: 103, 2007.
55. Touger-Decker, R., and C. van Loveren. Am. J. Clin.
Nutr. 78(suppl): 881s, 2003.
56. DePaola, D.P., R. Touger-Decker, D. Rigassio-Radler,
et al. In: Modern Nutrition in Health and Disease,
10th ed. M.E. Shils, M. Shike, A.C. Ross, et al (Eds).
Philadelphia: Lippincott Williams & Wilkens, 2006,
pp. 1151-1178.
57. Miller, G.D., J.K. Jarvis, and L.D. McBean.
Handbook of Dairy Foods and Nutrition. 3rd ed.
Boca Raton, FL: CRC Press, 2006. pp. 245-265.
58. American Academy of Pediatrics, Committee on
School Health. Pediatrics 113: 152, 2004.
59. American Diabetes Association. Diabetes Care 29:
2140, 2006.
60. Franz, M.J., J.P. Bantle, C.A. Beebe, et al. Diabetes
Care 25: 148, 2002.
61. Janket, S.J., J.E. Manson, H. Sesso, et al. Diabetes
Care 26: 1008, 2003.
62. Daly, M. Am. J. Clin. Nutr. 78(suppl): 865s, 2003.
63. Kelley, D.E. Am. J. Clin. Nutr. 78(suppl):
858s, 2003.
64. Howard, B.V., and J. Wylie-Rosett. Circulation 106:
523, 2002.
65. Fried, S.K., and S.P. Rao. Am. J. Clin. Nutr.
78(suppl): 873s, 2003.
66. Lichtenstein, A.H., L.J. Appel, M. Brands, et al.
Circulation 114: 82, 2006.
67. American Medical Association, International Life
Sciences Institute, and the Nutrition Foundation.
Nutr. Rev. 44(suppl): 1, 1986.
68. White, J.W., and M. Wolraich. Am. J. Clin. Nutr.
62(suppl): 242, 1995.
69. Wolraich, M.L., D.B. Wilson, and J.D. White. JAMA
274: 1617, 1995.
70. U.S. Department of Agriculture, Center for Nutrition
Policy and Promotion. MyPyramid. Steps to A
D
Healthier You. www.mypyramid.gov.
RELATED RESOURCE
■
Flavored Milk in Perspective.
www.nationaldairycouncil.org
(under Health Professional Resources,
then Research Summaries).
Coming Next Issue:
MAKING NUTRIENT RICH
FOOD CHOICES FIRST:
KEY TO A HEALTHY DIET
ACKNOWLEDGMENTS
National Dairy Council® assumes the responsibility
for this publication. However, we would like to
acknowledge the help and suggestions of the
following reviewers in its preparation:
■ G. Harvey Anderson, Ph.D.
Professor and Director
Program in Food Safety,
Nutrition and Regulatory Affairs
University of Toronto, Toronto, Ontario, Canada
■ Rachel K. Johnson, PhD, RD, MPH
Dean, College of Agriculture & Life Sciences
Professor of Nutrition
University of Vermont, Burlington, VT
The Dairy Council Digest® is written and edited by
Lois D. McBean, M.S., R.D.
COPYRIGHT NOTICE
Copyright © 2007, NATIONAL DAIRY COUNCIL,®
O’Hare International Center, 10255 West Higgins Road,
Suite 900, Rosemont, IL 60018-5616.
ISSN 0011-5568