Download adverse effect of high added sugar consumption on

ADVERSE EFFECT OF HIGH ADDED SUGAR CONSUMPTION ON DIETARY
INTAKE IN AMERICAN PRESCHOOLERS
SIBYLLE KRANZ, PHD, RD, HELEN SMICIKLAS-WRIGHT, PHD, ANNA MARIA SIEGA-RIZ, PHD, RD, AND DIANE MITCHELL, MSRD
Objectives To assess the effect of Dietary Reference Intakes (DRI)-recommended added sugar intake levels on nutrient and
food group consumption by preschoolers.
Study design This was a cross-sectional study of 2- to 5-year-olds in the United States Department of Agriculture
Continuing Survey of Food Intake by Individuals (CSFII), 1994 to 1996, and 1998 (n = 5437). Main food sources of added
sugar were established. For five categories (#10% energy from added sugar, 11% to 15%, 16% to 20%, 21% to 25%, and >25%),
mean nutrient and food group consumption and proportion of children not meeting the DRI were ascertained. The
nonparametric test for trend indicated significance of changes. Analysis was stratified by age (2- to 3-year-olds versus 4- to
5-year-olds), and survey design corrected to maintain the nationally representative character of the data.
Results The majority of children consumed less than 25% of energy from added sugar; the main sources were fruit and or
soft drinks and desserts. Increasing added sugar consumption was paralleled by decreasing nutrient and food group intakes and
increasing proportions of children with intakes below the DRI. Calcium intake was insufficient in large proportions of children
consuming 16% or more from added sugar.
Conclusions In preschoolers, the new DRI for added sugar are reason for concern. Further research is needed to investigate the effects of the DRI on diet quality, body weight, and health status in young children. (J Pediatr 2005;146:105-11)
ational and international groups have issued recommendations for added sugar intake. In the United States Department
of Agriculture’s (USDA) Food Guide Pyramid, added sugar consumption is suggested to range between 6% to 10% of
total energy.1 The World Health Organization recommends limiting added sugar intake to <10% of total energy and in
the 2003 report states that a reduction of sugar-sweetened drinks for children is a strategy to reduce chronic diseases.2 In contrast
to these guidelines, the National Academy of Sciences (NAS) released the
From the Department of Nutritional
recommendations for energy and macronutrient intakes, which included a Dietary
Sciences, College of Health and HuReference Intake (DRI) of 25% or less of total energy from added sugar. This cut-point was
man Development, Pennsylvania State
based on evidence of potentially adverse consequences on outcomes including biomarkers
University, State College, Pennsylvania; and the Departments of Nutrition
(eg, blood lipids), behavior, dental caries, obesity, coronary heart disease, and nutrient
and Maternal and Child Health, School
3
intakes.
of Public Health, University of North
Carolina, Chapel Hill.
The differentiation between total sugar and added sugar is important4; total sugars
Supported by a Seed Grant by the
include all sugars in the diet, including those in nutrient-dense foods, such as lactose in
College of Health and Human Demilk or fructose in fruits. Consequently, diets high in total sugar would not necessarily be
velopment, Pennsylvania State University.
expected to result in lower diet quality. Added sugar is a component in foods that might not
Submitted for publication Jan 29,
be related to the nutrient density of any food, for example, pastries containing low levels of
2004; last revision received Aug 5,
micronutrients could be just as high in added sugar as a fortified cereal, which might
2004; accepted Aug 30, 2004.
contain not only high sugar but also have high micronutrient density. Thus,
Reprints are not available from the
authors.
recommendations on added sugar intake in the American population should be based
Correspondence to: Dr Sibylle Kranz,
solely on research distinguishing those two kinds of sugar in the diet.
Department of Nutritional Sciences,
The new DRI are of great public health importance. They are used by health proCollege of Health and Human Development, Pennsylvania State Unifessionals in providing dietary guidance or serve as guides in planning and delivering federal
versity, Henderson Building 5G, State
nutrition programs. Assessment of dietary adequacy is often based on DRI cut-points.
College, PA 16802. E-mail: sxk72@
N
AI
CSFII
DRI
EAR
Adequate intake
Continuing Survey of Food Intakes by Individuals
Dietary reference intakes
Estimated average requirement
NHANES
USDA
National Health and Nutrition Examination
Survey
United States Department of Agriculture
psu.edu.
0022-3476/$ - see front matter
Copyright ª 2005 Elsevier Inc. All rights
reserved.
10.1016/j.jpeds.2004.08.077
105
Table I. Selected sociodemographic characteristics
of the sample from the CSFII 1994 to 1996 and 1998
(in percentage of total population in each age group)
CSFII 1994 to 1996
and 1998
Characteristics
Sex
Ethnicity
Income
Education*
Employment
status*
213y
(n = 2805)
415y
(n = 2632)
51.9
61.1
50.7
61.7
16.7
16.7
16.0
16.7
6.2
30.2
4.9
31.5
14.4
14.2
29.2
30.7
26.2
23.6
16.7
18.0
31.5
51.8
33.5
48.5
59.4
61.8
Boys
Non-Hispanic
white
Non-Hispanic
black
Non-Hispanic
other
Hispanic
,130% of
poverty
130%–184%
of poverty
185%–350%
of poverty
.350% of
poverty
Less than
high school
High school
More than
high school
Employed
*Of female head of household.
Policy-makers use them to design dietary guidelines, such as
the Food Guide Pyramid. Thus, the recommendations are
a powerful tool and have great potential to aid in the effort to
limit nutrition related health problems.
The purpose of this study was to investigate the effect
of added sugar intake on diet quality in preschool children
by using dietary data available subsequent to NHANES
(National Health and Nutrition Examination Survey) III
(1988 to 1992), which was used by the DRI macronutrients
committee. Given the relation between chronic diseases and
demographic variables,5-7 we investigated intakes of added
sugar by children from various sociodemographic groups.
Finally, we examined associations between intake of added
sugars and food group as well as nutrients. This approach
recognizes that diets are complex and that food group analysis
reflects interactions of nutrients and other dietary components.
METHODS
Estimates of dietary intakes were based on data for children 2 through 5 years of age who provided 2 days of dietary
106
Kranz et al
intake information in the Continuing Survey of Food Intakes
by Individuals (CSFII), 1994 to 1996 and 1998 (n = 5437).
The 1994 to 1996 USDA CSFII survey data were collected
through the use of a stratified, multistage, area probability
sample to obtain a nationally representative sample of noninstitutionalized persons living in households. Interviewers
followed preset protocols to complete the survey. Detailed
description of the study design can be found in the study by
Tippet and Cypel.8 Dietary intake data were collected through
the use of a standardized multiple pass approach. Day 1 of
dietary intake was collected by means of a household interview,
whereas day 2, which was collected 3 to 10 days after day 1 but
not on the same day of the week, could be reported during a
phone interview. Interview respondents reported 24-hour
recalls for children younger than age 6. In 1998, the same
methods were used for a supplemental survey in children. All
survey waves (CSFII, 1994 to 1996 and 1998) were combined
and used in this study. The data set provides sociodemographic
information as well as number of servings from the Food Guide
Pyramid food groups and teaspoons of added sugar for all
individuals who reported dietary intake (n = 21,662). Sociodemographic information, such as age, race, and sex of the children as well as years of education and employment status of the
female head of household, was ascertained during the survey.
As described by Welsh et al,1 an added sugar category
was developed for the CSFII Pyramid Servings data set to
capture all caloric carbohydrate sweeteners (monosaccharides,
disaccharides, and higher saccharides). Included were all sugars
and sugar-containing ingredients added during processing or
preparation, and sugars eaten separately (candy) or added at the
table (syrups, white or brown sugar, and so forth) but excluding
all naturally occurring sugars (such as fructose in fruits).9
Descriptive analysis, means and standard errors, were
ascertained to describe the sample. Main sources of added
sugar consumption were acquired by using the food grouping
system developed by a group of researchers at the University
of North Carolina at Chapel Hill (UNC food grouping
system).10 We calculated average daily consumption contributed from each UNC food group and retained a list of the
highest 10. We then ranked this list in descending order.
Analysis was stratified by 5 added sugar intake levels:
(1) meeting the recommendation of #10% of energy from
added sugar (25% of the sample), (2) between 11% and 15%
of energy (26%), (3) 16% to 20% (24%), (4) 21% to 25% (14%),
and (5) in excess of the new recommendation (>25% of energy)
(12%). Intakes were analyzed by income and ethnicity groups.
Mean and standard error of average nutrient and food group
consumption as well as nutrient density (nutrient consumption
per 1000 kcal average energy intake) were calculated. The
proportions of children not meeting the Adequate intake (AI)
for calcium or Estimated Average Requirement (EAR) for
other nutrients were ascertained. A nonparametric test for
trend across ordered groups was conducted to obtain a z-score
and P value to assess significance of the changes of dietary
intakes with increasing levels of added sugar consumption.11
The statistical package used for analysis was STATA
(version 7.0), which allows adjustment for sample design effect
The Journal of Pediatrics January 2005
Table II. Main food sources* of added sugar consumption in preschoolers using the University of North Carolina
food grouping systemy for 2- to 3-year-olds and 4- to 5-year-olds (in percentage of total added sugar
consumption within each age group)
UNC Category
Fruit drinks
High-fat desserts
Regular soft drinks
Sugars and jellies
Candy
Low-fiber, ready-to-eat cereal
Low-fat desserts
Low-fat milk§
Low-fiber other fruits
Medium-fat milk
Total
Example foods
2- to 3-year-olds
4- to 5-year-olds
%z
20.3
%z
18.9
15.2
16.2
13.9
10.1
6.9
6.4
6.3
2.9
16.0
9.5
6.5
7.0
6.4
2.7
2.4
1.7
86.1
2.1
1.6
86.9
Lemonades, juices
with 10% fruit juice
Ice cream,
pies, cookies, cakes
Cola type
Cornflakes, Special K
Gelatin desserts
2% milk,
skim milk
Fruit salad/cocktail, applesauce
Whole milk, milkshakes
*Main food sources of added sugar are similar except for the candy and low-fiber cereal categories, which are reversed for the 4- to 5-year-olds.
yUNC food groups, Grouping of foods into 75 categories with similar nutrition profiles.10
zPercentage of total added sugar consumption of children in this age group.
§Includes flavored milk and items prepared with low-fat milk powder.
Table III. Proportion of preschoolers at different levels of added sugar intake by income and ethnicity for (a) 2- to
3-year-olds and (b) 4- to 5-year-olds (in percentage of individuals within each income or ethnicity group)
Sugar consumption (% of total energy)
(a)
Sample size
(percentage of total sample)
Income level (% poverty)
,130
130–184
185–350
.350
Ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic
Non-Hispanic other
(b)
Income level (% poverty)
,130
130–184
185–350
.350
Ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic
Non-Hispanic other
0%–10%
11%–15%
16%–20%
21%–25%
>25%
n = 781 (28%)
n = 743 (26%)
n = 618 (22%)
N = 367 (13%)
n = 296 (11%)
33.5
26.5
26.5
27.1
26.6
26.4
25.2
30.9
19.9
19.5
23.5
22.1
12.5
13.1
12.5
9.8
7.6
14.5
12.3
10.1
26.3
26.3
34.9
44.2
n = 547 (21%)
28.5
23.2
27.0
27.3
n = 682 (26%)
21.3
27.9
19.1
11.8
n = 662 (25%)
12.4
13.7
9.1
9.0
N = 412 (16%)
11.5
9.0
9.9
7.7
N = 329 (12%)
27.3
18.6
15.8
18.9
26.7
24.3
23.0
21.0
24.2
21.7
26.9
33.2
13.2
17.0
19.5
14.5
8.6
18.3
14.8
12.4
17.7
18.2
30.4
32.3
22.1
28.6
23.9
30.8
28.9
24.8
22.9
19.3
17.7
15.8
11.5
9.5
13.6
12.5
11.3
8.1
Adverse Effect Of High Added Sugar Consumption On Dietary Intake In American
Preschoolers
107
Table IV. Trends of energy, nutrient, and food group intakes (mean ± SEM) by added sugar consumption levels
for 2- to 3-year-olds (a) and 4- to 5-year-olds (b)
Sugar consumption (% total energy)
(a)
0%–10%
(n = 781)
11%–15%
(n = 743)
16%–20%
(n = 618)
21%–25%
(n = 367)
>25%
(n = 296)
Mean ± SEM
Macronutrients
Energy (kcal)
Carbohydrate*
Protein*
Fat*
Fiber (g)
Micronutrients
Calcium (mg)
Iron (mg)
Folate (mg)
Vitamin A (RAE)
Vitamin B12 (mg)
Vitamin C (mg)
Food groups2
Grains (6)
Vegetable (3)
Fruit (2)
Dairy (2)
(b)
Macronutrients
Energy (kcal)
Carbohydrate*
Protein*
Fat*
Fiber (g)
Micronutrients
Calcium (mg)
Iron (mg)
Folate (mg)
Vitamin A (RAE)
Vitamin B12 (mg)
Vitamin C (mg)
Food groupsy
Grains (6)
Vegetable (3)
Fruit (2)
Dairy (2)
Test for trend
z score
P value
±
±
±
±
±
18.34
0.34
0.12
0.29
0.24
1462.8
53.8
14.9
32.9
10.5
± 20.28
± 0.29
± 0.11
± 0.27
± 0.19
1464.6 ±
55.7 ±
13.7 ±
32.1 ±
9.8 ±
19.73
0.32
0.12
0.28
0.21
1484.9
57.9
12.8
31.0
9.2
± 26.35
± 0.32
± 0.14
± 0.28
± 0.23
1418.9 ±
62.9 ±
11.1 ±
27.8 ±
8.0 ±
33.75
0.49
0.19
0.45
0.27
2.54
19.74
225.96
211.30
28.43
.01
,.001
,.001
,.001
,.001
889.1 ±
11.9 ±
242.2 ±
800.3 ±
3.4 ±
109.0 ±
17.04
0.23
4.70
21.34
0.08
3.58
831.0
11.6
238.1
774.4
3.3
99.1
± 15.76
± 0.22
± 4.86
± 21.06
± 0.08
± 2.94
744.3
11.6
235.7
730.6
3.0
97.4
±
±
±
±
±
±
15.00
0.23
4.59
20.52
0.07
3.10
712.87
11.4
225.1
683.6
3.2
98.0
± 18.09
± 0.30
± 6.14
± 29.91
± 0.23
± 4.15
611.2 ±
9.9 ±
191.9 ±
583.1 ±
2.6 ±
96.3 ±
23.19
0.33
5.93
23.99
0.15
4.39
212.15
24.75
25.95
26.87
28.46
21.68
,.001
,.001
,.001
,.001
,.001
.09
0.19
0.10
0.13
0.07
21.8
21.79
213.79
212.37
,.07
,.07
,.001
,.001
1414.8
52.4
15.8
33.1
10.5
6.8 ±
2.5 ±
3.7 ±
2.2 ±
0.13
0.08
0.13
0.05
(n = 547)
7.2
2.6
3.1
2.0
± 0.13
± 0.07
± 0.10
± 0.05
(n = 682)
7.0 ±
2.5 ±
2.6 ±
1.8 ±
0.13
0.09
0.10
0.05
(n = 662)
6.9
2.5
2.2
1.7
± 0.16
± 0.10
± 0.10
± 0.06
(n = 412)
6.0 ±
2.1 ±
2.0 ±
1.4 ±
(n = 329)
1608.2 ±
50.9 ±
16.0 ±
34.4 ±
12.7 ±
27.81
0.39
0.14
0.33
0.30
1692.2
52.8
15.0
33.6
12.0
± 23.91
± 0.28
± 0.12
± 0.24
± 0.21
1692.6 ±
55.0 ±
14.0 ±
32.6 ±
11.6 ±
23.10
0.27
0.11
0.24
0.26
1694.6
57.3
13.0
31.3
10.7
± 28.18
± 0.38
± 0.14
± 0.33
± 0.26
1622.6 ±
61.3 ±
11.7 ±
28.8 ±
8.9 ±
32.21
0.37
0.16
0.35
0.24
0.37
21.52
225.78
213.43
213.28
,.71
,.001
,.001
,.001
,.001
944.2 ±
13.6 ±
287.9 ±
952.4 ±
4.6 ±
101.7 ±
21.93
0.32
6.91
53.07
0.45
3.65
906.7
13.7
287.8
878.0
4.2
95.8
± 16.61
± 0.29
± 6.81
± 31.67
± 0.31
± 2.82
850.8
13.3
271.5
822.8
3.6
94.8
±
±
±
±
±
±
16.32
0.26
5.60
25.14
0.09
3.67
774.4
12.9
260.5
744.1
3.5
93.9
± 17.64
± 0.31
± 6.59
± 25.10
± 0.21
± 3.87
675.9
10.8
212.2
688.5
3.0
100.0
±
±
±
±
±
±
19.15
0.29
7.07
34.12
0.10
4.65
211.96
28.07
210.09
27.55
28.99
22.30
,.001
,.001
,.001
,.001
,.001
.02
0.12
0.08
0.08
0.06
26.43
25.77
211.61
212.14
,.001
,.001
,.001
,.001
5.8 ±
2.1 ±
2.2 ±
2.3 ±
0.15
0.07
0.08
0.07
6.0
2.0
1.9
2.2
± 0.12
± 0.06
± 0.07
± 0.05
5.7 ±
1.9 ±
1.8 ±
2.0 ±
0.11
0.06
0.08
0.05
5.6
1.8
1.5
1.7
± 0.15
± 0.07
± 0.08
± 0.05
4.7 ±
1.7 ±
1.2 ±
1.5 ±
*In percentage of total energy.
yIn the Food Guide Pyramid for Young Children (2 to 6 years old) servings, in parenthesis are the recommended number of servings.
and weighting to maintain the nationally representative
character of the data. All analysis was conducted for two
separate age groups of children (2- and 3-year-olds compared
with 4- and 5-year-olds).
RESULTS
Half of the children in the sample were girls and approximately half was in each age group (Table I). Approximately
108
Kranz et al
one third were in the lowest income group and one quarter
were in the highest income group. The majority of children
was non-Hispanic white and had an employed female head of
household.
Average added sugar intake was lower in 2- and 3year-olds compared with 4- and 5-year-olds: 14.9% and
16.5% of total energy, respectively (equivalent to 13.5 ± 0.19
and 17.2 ± 0.24 teaspoons per day). In younger children,
The Journal of Pediatrics January 2005
average added sugar intake represented in teaspoons per day
was 4.4 tsp in the 0% to 10% group, 11.9 tsp in the 11% to
15%, 16.5 tsp in the 16% to 20%, 21.3 tsp in the 21% to
25%, and 23.1 tsp in the highest added sugar consumption
group. Consumption was higher in the older children: 5.0
tsp in the 0% to 10% group, 13.7 tsp in the 11% to 15%,
19.0 tsp in the 16% to 20%, 24.4 tsp in the 21% to 25%, and
26.4 tsp in the highest added sugar consumption group.
Main sources of added sugar in preschoolers are provided in
Table II. The rank order of the top-10 categories were the
same in both age groups, with the exception of the candy
and low-fiber cereal category. Half of the added sugar
consumption was contributed by the top three items: fruit
drinks, high-fat desserts, and regular soft drinks.
Eleven percent and 12% of the younger and older
children, respectively, consumed more than 25% of energy
from added sugar. Consumption levels differed between income and ethnic groups. Proportionally fewer children at the
lowest income level and those classified as ‘‘non-Hispanic
other’’ consumed the highest level of added sugar. More
children in the younger age group than in the older age group
had 10% or less of added sugar intake. Higher proportions of
non-Hispanic white and black children consumed more than
15% of energy from added sugar (Table III).
With the exception of carbohydrates and vitamin C,
average consumption of macronutrients and micronutrients
significantly decreased with increasing added sugar level
(Table IV). In addition to the nutrients listed in Table IV,
this trend was also observed for saturated fat, zinc, magnesium,
vitamin B6, and sodium (data not shown).
On average, children consuming above 25% of energy
from added sugar consumed a significantly lower proportion of
energy from protein, fat, and less fiber but increased percentage
of energy from carbohydrates than children at lower levels of
added sugar intake. Absolute intakes of micronutrients were
also lower in this group, with the exception of vitamin C.
Investigation of nutrient density (intake per 1000 kcal)
indicated that micronutrient density significantly decreased
with increasing level of added sugar intake, whereas carbohydrate density significantly increased (data not shown).
The proportion of children with intakes below the AI
for calcium and EAR for other nutrients increased for most
nutrients with increasing level of added sugar intake (data not
shown). The data were most striking for calcium. Forty
percent of the 2- and 3-year-olds and approximately 70% of 4and 5-year-olds in the highest added sugar intake group fell
below the AI for calcium. Almost one quarter of the younger
children and one-half of the older children were below the AI
at added sugar intakes of 16% to 25%. Even at the lowest
added sugar intake level, a large proportion of children,
especially 4- and 5-year-olds did not meet the AI for calcium.
For most nutrients, the proportion of children consuming less than the EAR was highest at sugar intakes of more
than 25% of energy, but for several nutrients the percentage of
older children not reaching the EAR was close to 5% for
vitamins A and C and 13% for folate at an added sugar intake
of 11% to 15% of total energy.
Intake of servings of Food Guide Pyramid food groups
changed as well. Grains, vegetables, fruits, and dairy decreased
with increasing added sugar levels below the recommended
intakes in the older children. The decline was steady across all
added sugar categories. Especially noteworthy was the
reduction in intake of fruit and dairy foods in both age
groups. The number of servings of meat did not change
significantly between groups (data not shown).
DISCUSSION
This study has shown a significant trend toward
decreasing intakes of nutrients and food groups by preschool
children with increasing added sugar levels. Children with the
highest level of added sugar intake (25% of energy or more)
had the lowest consumption of most nutrients and servings of
grains, vegetables, fruits, and dairy. One exception to the
decline in nutrient intake was carbohydrates, which increased
with increasing added sugar intake, whereas fat consumption
decreased. This reciprocal relation between sugar and fat
consumption has been described previously12-15 and is thought
to be one reason for the lack of consistent evidence for
a parallel relation between increasing added sugar consumption and higher body weight.
The dilution of nutrients with increasing added sugar
intake levels as described in this study has been shown by others
as well.16-18 Thus, the new recommendation for added sugar
intake might be a reason for concern. Decreasing micronutrient
intakes with higher added sugar consumption probably are
observed because the main food source of added sugar intake
are foods with low micronutrient profiles,14,19 such as sweetened soft drinks and juices. Hence, limitation of added sugar
intake could result in higher nutrient dense diets. This was also
demonstrated by a study limiting the amount of added sugar in
the diet of federal School Breakfast Program participants to
<10% of total energy.20 Nutrient density in that study increased
when added sugar intake was decreased. Calcium, an important
nutrient in growing children, had been inadequate in a large
proportion of children before the study. The number of
servings of dairy had been below the recommended amounts;
thus, the inadequate calcium levels had been paralleled by the
low consumption of dairy, probably because sweetened
beverages replaced milk and dairy products as beverages.21-23
After reflecting on data from other studies, some
researchers concluded that the change in nutrient and food
group consumption, although statistically significant, was so
small as to bear no clinical importance.18 However, we believe
that even a reduction of one-half serving of a food group
intake in children with high added sugar levels measured in
a nationally representative data set is an alarming result. In this
study, we found that children with the lowest added sugar level
consumed approximately one serving more of grains, fruits,
and dairy compared with children in the highest added sugar
intake group. This is especially alarming when the intake
reduction occurs in food groups that are currently not consumed at the recommended intake levels, such as dairy, fruits,
and vegetables.
Adverse Effect Of High Added Sugar Consumption On Dietary Intake In American
Preschoolers
109
A further point to consider in this discussion is the effect
of food fortification. Many foods in the food supply that are
high in added sugar are also fortified, such as sweetened cereals
and breads. As our results indicated, the effect of added sugar
intake level on nutrient consumption might be modified by the
fortification of foods. Consumption of most micronutrients
decreases to a much weaker extent, as could be expected with
increasing added sugar intake. Although increased added sugar
consumption leads to decreased nutrient density, the magnitude of this effect is lowered after controlling for fortification in
the food supply.17 Hence, fortification masks the potentially
adverse effects of the high added sugar content in the diet.
Dietary intake behaviors established in childhood track
over time, thus establishing that a diet high in added sugar
during childhood might affect the development of chronic
diseases later in life.24 Also, added sugar consumption is
predicted by a number of sociodemographic variables, for
example, that income and social status affect added sugar
intakes25 and that non-Hispanic children consume higher
levels of added sugar than Hispanic children.26 Consequently,
the recommendation for added sugar intake for the overall
American population might not be appropriate for some
subgroups of the population. The growth and development of
children with a high likelihood of consuming increased levels
of added sugar might be negatively affected by the DRI.
Rather than being encouraged by health professionals and
caretakers to decrease added sugar consumption, they will
maintain a diet that puts them at high risk for calcium
inadequacy and low intakes of fruits and vegetables.
One limitation to our study was that children’s diets
were reported by proxy and were therefore prone to incomplete or biased information. This limitation in the data
collection in preschool children has been acknowledged by the
research community and will have to be tolerated until
accurate measurement methods have been developed for freeliving children.27 However, we used a large, nationally
representative sample of American preschoolers to investigate
the relation between added sugar intake levels and nutrient
consumption. We included children with 2 days of dietary
intake and are confident that the resulting mean intakes are
good estimates of the average consumption in American
preschoolers. NHANES data provides dietary intake information, biomarkers, and measured height and weight;
however, this data set has been used in the development of the
DRI. Consequently, we decided to use the other large
nationally representative data set, the CSFII, which provided
us with more updated information than NHANES III.
Debates about sugars and health are longstanding. The
Joint World Health Organization/Food and Agriculture
Organization Expert Consultation on Diet, Nutrition, and
Prevention of Chronic Disease recommended that intake of
free sugars be no more than 10% of total energy consumed.2 In
the USDA’s Food Guide Pyramid, ‘‘moderate’’ added sugar
consumption was defined as 6% to 10% of total energy.1 These
ongoing debates argue for continued evaluations of the effect of
sugars on dietary intakes, metabolism, and chronic diseases. In
addition, the point has been raised that most added sugars are
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Kranz et al
not visible in foods and are not listed on the food label, making
it difficult for the consumer to estimate consumption.28
Our results indicate reasons for concern. The DRI for
added sugar intake might not be appropriate for American
preschoolers. In contrast to others,29 we found that although
the most dramatic decreases in micronutrient intakes were
observed at added sugar intake levels of more than 25% of total
energy, food group consumption and the proportion of
children meeting the AI for calcium was also very low at
added sugar intakes of less than 10% of calories.
More research is needed to investigate the appropriateness of the DRI with respect to overall diet quality as well as
measurable health outcomes, such as body weight. Nationally
representative data collecting information on added sugar
consumption as well as biomarkers and body weight status will
be helpful in determining a relation. Also, large, longitudinal
studies examining the long-term effect of high added sugar
diets in young children might help elucidate the causality of
increased body weight and risk factors for chronic diseases and
diet patterns. However, until more data are available, the DRI
for added sugar might adversely affect young children in the
long run. The consequences of high added sugar diets must be
considered with reference to sociodemographic factors and the
relations to overall diet quality and health status.
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The Journal of Pediatrics January 2005
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sugars. J Am Diet Assoc 1992;92:708-13.
16. Murphy SP, Johnson RK. The scientific basis of recent US guidance on
sugars intake. Am J Clin Nutr 2003;78:827S-33S.
17. Alexy U, Sichert-Hellert W, Kersting M. Fortification masks nutrient
dilution due to added sugars in the diet of children and adolescents. J Nutr
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50 Years Ago in The Journal of Pediatrics
SOME PECULIARITIES OF AMINO ACID METABOLISM IN INFANCY AND EARLY CHILDHOOD
Schreier K. J Pediatr 1955:46;86-106
In January 1955, Kurt Schreier of Heidelberg, Germany, and Rochester, New York, provided a comprehensive review of
normal amino acid metabolism and the relation of amino acids with growth rate during gestation and early life. He also
proposed a classification of inborn errors of protein metabolism. Many of his observations remain true, whereas others have
been revised or discarded. At the time, much of the renewed interest in amino acid metabolism was sparked by new
technologies such as column chromatography and stable isotopes, which allowed investigators to examine normal and
aberrant amino acid metabolic pathways.
Still valid are his observations that the placenta and fetal cells actively concentrate amino acid from the maternal
circulation and that the amino nitrogen concentration is highest in the youngest and smallest fetus. In his review of the
relations of anabolic hormones with growth, he noted the work of several investigators ‘‘that testosterone benefits the
growth and general condition of premature infants has not been confirmed.’’ What is the chance that those trials would be
approved today? Regarding the protein-sparing action of carbohydrates and fats, he wrote ‘‘For this reason, milk is
a wonderful food for the growing organism, not only because it supplies proteins, but also carbohydrate and fat,
simultaneously to the tissues.’’ Mother Nature still knows best!
Although most of his observations on normal amino acid metabolism still hold true, his classification of inborn errors of
metabolism has undergone significant evolution. Disorders of impaired kidney function would today include the
aminoacidurias secondary to renal tubular transport disorders. His second group included generalized metabolic
disturbances, citing cystinosis as an example. The third group was inborn errors in which a portion or an entire protein was
missing such as hemophilia, Wilson hepatolenticular degeneration, and hypophophatasia. Fourth were the idiopathic
hypoproteinemias such as agammaglobulinemia or hypoalbuminemia. His final group included disorders of phenylalanine
and tyrosine metabolism such as PKU, albinism, alkaptonuria, and tyrosinosis. He concluded by agreeing with basic
researchers that ‘‘often fatal pathological changes during adult life may have their origin in a very short period of dietary
abnormality in infancy.’’ Although this statement might still ignite vigorous discussion, clearly understanding the role of
metabolic pathways in growth and development is as critical today as it was 50 years ago.
Paul M. Fernhoff, MD, FAAP, FACMG
Division of Medical Genetics
Department of Human Genetics
Emory University School of Medicine
Atlanta, GA 30322
YMPD1220
10.1016/j.jpeds.2004.09.015
Adverse Effect Of High Added Sugar Consumption On Dietary Intake In American
Preschoolers
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