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Beverage Patterns, Diet Quality, and Body Mass Index of US Preschool and School-Aged Children
TARA L. LAROWE, PhD; SUZEN M. MOELLER, PhD; ALEXANDRA K. ADAMS, MD, PhD ters had the highest micronutrient intakes. Mean HEI differed signicantly across beverage patterns for schoolaged children (from 63.2 to 69.9, P0.01), with the highfat milk cluster having the best diet quality, reected by HEI and micronutrient intakes. Adjusted mean BMI differed signicantly across beverage clusters only in schoolaged children (from 17.8 to 19.9, P0.05). Conclusions Beverage patterns were related to diet quality among preschool and school-aged children, but were only related to BMI in school-aged children. Children from all clusters could benet by consuming fewer calorically sweetened beverages and increasing micronutrient-dense foods. J Am Diet Assoc. 2007;107:1124-1133. ABSTRACT Objective To evaluate diet quality and body mass index (BMI) by beverage patterns in children aged 2 to 11 years. Design Beverage patterns were formed using 24-hour dietary recall diet variables from the 2001-2002 National Health and Nutrition Examination Survey. Diet quality was assessed using energy, micronutrient intakes, and Healthy Eating Index (HEI) scores (a 100-point scale that measures adherence to the Dietary Guidelines for Americans). Subjects/setting Children, aged 2 to 5 years (n541) and 6 to 11 years (n793), were selected from 2001-2002 National Health and Nutrition Examination Survey data. Statistical analysis Cluster analysis was used to identify beverage patterns in preschool and school-aged children. General linear models were used to compare HEI scores, energy, micronutrient intakes, and BMI across beverage clusters. Results Four and ve beverage clusters were identied for preschool and school-aged children, respectively. In preschool children, mean HEI differed between the fruit juice cluster (79.0) vs the high-fat milk cluster (70.9, P0.01); however, both fruit juice and high-fat milk clus-

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

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

This article presents a food-based approach to identify predominant beverage intake patterns among preschool (aged 2 to 5 years) and school-aged children (aged 6 to 11 years) in the 2001-2002 National Health and Nutrition Examination Survey (NHANES) sample. We determined whether specic beverage patterns were associated with overall diet quality, measured by the US Department of Agricultures (USDAs) Healthy Eating Index (HEI), and whether beverage patterns in preschool and school-aged children were related to body mass index (BMI). SUBJECTS AND METHODS Study Population NHANES 2001-2002 is a complex, multistage probability sample of the noninstitutionalized population of the United States. Certain population subgroups, including adolescents aged 12 to 19 years, African Americans, and Mexican Americans, were oversampled to allow for precise estimates from each group. Of the 13,156 persons eligible in the 2001-2002 sample, 80% (n10,477) participated in the physical exams at the mobile examination center and 74% (n9,701) had completed reliable dietary interview data. For this study sample, we selected children aged 2 to 11 years, with complete dietary data (n1,992). We excluded children whose reported energy intake was implausible (800 kcal or 2,700 kcal for children aged 2 to 5 years and 900 kcal or 3,500 kcal for children aged 6 to 11 years) or whose reported total beverage consumption in grams was implausible (200 g or 2,399 g for children aged 2 to 5 years and 400 g or 2,900 g for children aged 6 to 11 years) (n251). We also excluded children with missing age- and sex-specic BMI percentiles or who were classied as underweight (5th percentile) (n195). Two hundred twelve children were further excluded because breastmilk or infant formula was reported or because there were missing covariate data, including household income, physical activity, media screen time, and birth weight. The nal sample available for analysis consisted of 541 children aged 2 to 5 years and 793 children aged 6 to 11 years. The Human Subjects Review Board at the University of Wisconsin-Madison granted approval for this study. Dietary Assessment Dietary intake was assessed using a single 24-hour dietary recall at the mobile examination center interviews (20). Dietary intake was conducted for children aged 6 years by a proxy interview of the parent/caregiver. Assisted interviews (proxy and child) were conducted in children aged 6 to 11 years. For each participant, individual foods and beverages were reported during a 24hour period, as well as a summary of daily energy and nutrient intake. Beverage Pattern Formation Before entering beverages into a cluster analysis, individual beverages were aggregated into eight beverage groups: high-fat milk, reduced-fat milk, fruit juices, soda,

Beverage group Fruit juices

Beverages in the group Includes 100% fruit juices and unsweetened fruit juices (grapefruit, orange, apple, nectars, other 100% fruit juices or unsweetened fruit juices) Whole or 2% (white or chocolate) uid milk; whole or 2% evaporated, condensed, or buttermilk Skim or 1% (white or chocolate) uid milk; skim or 1% evaporated, condensed, or buttermilk Cola and noncola, with and without caffeine Diet or sugar-free cola and noncola, with and without caffeine Fruit juice sweetened with sugar, fruit drinks (eg, fruit punch, lemonade, powdered orange-avor drink); coffee and tea sweetened with sugar or low-cal sweetener Coffee and tea, unsweetened Total plain water, including tap water, water from drinking fountain, water from water cooler, bottled water, and spring water

High-fat milk Reduced-fat milk Soda Diet soda Sweetened beverages

Coffee and tea Water

Figure 1. Beverage groups (n8) used in cluster analysis of data on children aged 2 to 11 years in the 2001-2002 National Health and Nutrition Examination Survey.

diet soda, sweetened beverages, coffee and tea, and water (see Figure 1). Beverage intake may be measured in one of the following ways: percentage energy intake from each beverage group, number of servings, or absolute weight in grams (21). We considered using percentage total daily energy from each beverage group, but because many beverages, including water and diet sodas, do not contribute signicant amounts of energy, we decided against this method. We also did not choose the number of servings of beverages because the information for servings was not available in the NHANES data. Therefore, we used absolute weight in grams and used this method of measurement for subsequent analyses. Diet Quality Measure To assess overall diet quality within each beverage cluster, we used the USDA HEI (22). The HEI measures diet quality based on both foods and nutrients consumed by individuals aged 2 years and older, using a 100-point scale to measure how well an individuals diet complies with specic recommendations of the Dietary Guidelines for Americans (22). The overall HEI score is a composite of 10 equally weighted diet components, each worth 10 points. For each component, a score of 10 reects perfect compliance, whereas a score of 0 to 9 is less than perfect. The rst ve components measure adherence for the ve major food groups of the Food Guide Pyramid: grains, vegetables, fruit, milk, and meat (23). Components six through 10 measure dietary fat and saturated fat as total percentages of food energy intake, total cholesterol and sodium intakes, and variety, respectively. Recommended
July 2007 Journal of the AMERICAN DIETETIC ASSOCIATION 1125

Table 1. Average total gram intake from beverage groups, average gram intake of total beverage consumption, and average percentage of total energy from beverages across beverage patterns in US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002 Children (2-5 y) Cluster 1: mix/light drinker (n249) Cluster 2: high-fat milk (n91) Cluster 3: water (n128) Cluster 4: fruit juices (n73)

Beverage Beverage group High-fat milk (g) Reduced-fat milk (g) Fruit juices (g) Other sweetened juices and drinks (g) Regular soda (g) Low-energy and diet soda (g) Unsweetened coffee and tea (g) Water (g) Total beverage consumption (g) Total percentage of energy from beverages (%kcal)

4 meanstandard error 3 15510 78627* 20620 21724 558.4 9.56.1* 8619 8723 887.0 9714 5910 58529* 24919* 10118 13218 7618 10610* 7815 9917 5815 5.61.9 2.82.4 125.0 2.52.0 5.22.2 115.8 5.73.8 0 1899.8 33824 75325* 20022 85325* 1,42239 1,35239 1,22548 18.80.6 35.21.1* 17.90.9 28.81.1*

*Signicantly different than most other groups by comparisons using general linear models, P0.05.

HEI criteria classies diet quality with scores of 81 or higher as good scores, between 51 and 80 as needs improvement, and scores under 50 as poor (24). Before this study, USDA computed HEI scores for each participant aged 2 years using NHANES 2001-2002 dietary data (25). The USDA HEI 2001-2002 database was merged with the rest of the NHANES 2001-2002 database using the corresponding respondent identication number. We further assessed diet quality, in addition to the HEI, by total energy intake; percent energy from protein; and micronutrient intakes of riboavin, folate, vitamin A, vitamin C, ber, calcium, iron, and zinc. Body Size and Covariate Measures Anthropometric data were collected at the medical portions of the mobile examination center exams (26). Height and weight were used to calculate BMI and BMI percentiles for age and sex according to Centers for Disease Control and Prevention growth reference charts (26). Other covariate data were collected via questionnaires or medical exams at household interviews or at mobile examination center exams and included age, sex, race/ ethnicity, household income, birth weight, physical activity (number of times per week play or exercise hard enough to sweat or breathe hard) and media screen time (total number of hours per day of television watching and computer time). Statistical Analysis Cluster analysis was used to identify different beverage patterns among eight previously dened beverage groups (Figure 1), separately for children aged 2 to 5 years and 6 to 11 years. Beverage patterns were generated using the FASTCLUS procedure in SAS (version 9.1, 2002-2003, SAS Inc, Cary, NC). This procedure uses the K-means
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method to classify subjects into nonoverlapping groups in an iterative process by comparing Euclidean distances between each subject and each cluster set. The process of cluster analysis is sensitive to outliers; therefore, we removed individuals whose intake from any beverage group was 5 standard deviations away from the mean absolute weight in grams for that group. We also ran the FASTCLUS procedure with a predened number of 20 clusters and removed individuals in clusters with fewer than ve subjects. From this sample, we ran two to eight clusters to determine the best solution. A four-cluster solution, for children aged 2 to 5 years, and a ve-cluster solution, for children aged 6 to 11 years, were determined by examining Scree plots, F statistics, and by examining the clusters for meaningful separation of beverage patterns. Outliers that were previously identied and removed were reassigned to the nearest cluster. To describe variables across the four (children aged 2 to 5 years) and ve (children aged 6 to 11 years) beverage clusters, we separately calculated the mean grams of each beverage group and total beverage consumption, the mean percentage of total energy from beverages, the mean HEI and component scores, the means of macroand micronutrient intakes, and the means and frequencies of sample characteristics. General linear models (PROC GLM) with Tukey-Kramers adjustment for multiple comparisons were used to test differences across beverage patterns. For comparisons across categorical variables, 2 tests were used. To evaluate if beverage patterns were related to BMI in children aged 2 to 5 and 6 to 11 years separately, we regressed BMI onto the categorical beverage pattern variable. Using a general linear model and adjusting for age, sex, ethnicity, household income, birth weight, diet quality (HEI), and physical activity, least-square means of BMI were compared across all beverage patterns using the Tukey-Kramer adjustment for multiple comparisons.

Table 2. Average total gram intake from beverage groups, average gram intake of total beverage consumption, and average percentage of total energy from beverages across beverage patterns in US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002 Children (6-11 y) Cluster 1: mix/light drinker (n266) Cluster 2: high-fat milk (n156) Cluster 3: water (n147) Cluster 4: sweetened drinks (n100) Cluster 5: soda (n124)

Beverage Beverage group High-fat milk (g) Reduced-fat milk (g) Fruit juices (g) Other sweetened juices and drinks (g) Regular soda (g) Low-energy and diet soda (g) Unsweetened coffee and tea (g) Water (g) Total beverage consumption (g) Total percentage of energy from beverages (%kcal)

4 meanstandard error 3 917.0 62422* 16417 18717 14316 10712* 186.4 12616* 3212 299.1 13313* 12817 12919* 7015 5711 11792 8410 10016 86131* 10316 1209.2 13113 14918 11620 71724* 266.4 1.01.5 156.1 138.5 2713 31.3 113.3 42.4 6.03.8 6.03.1 33713 31619 1,25733* 33230 27023 93421* 1,30535 1,94343 1,61753 1,35444 14.70.6 25.70.7* 16.20.9 24.30.9 22.80.7

*Signicantly different than most other groups by comparisons using general linear models, P0.05.

All analyses were conducted using SAS (version 9.1) and used sample weights so that ndings were representative of US children aged 2 to 11 years. RESULTS Four and ve beverage clusters were identied for children aged 2 to 5 and 6 to 11 years, respectively. We named the beverage clusters based on the predominant beverage group in the cluster. We labeled the four beverage patterns among children aged 2 to 5 years as mix/ light drinker, high-fat milk, water, and fruit juices. Similar beverage patterns were also observed for children aged 6 to 11 years; we labeled the ve beverage patterns as mix/light drinker, high-fat milk, water, sweetened drinks, and soda. Tables 1 and 2 describe each beverage pattern by showing the following for each beverage group: average weight in grams of beverage groups that made signicant contributions, the average total beverage consumption in grams, and the average percentage of total energy from beverages across beverage patterns. Several differences were seen across the identied beverage patterns. Children in the high-fat milk and water patterns, in both age groups, derived more of their total beverage consumption from high-fat milk and water, respectively, and relatively smaller contributions from other beverages. Based on the number of children in each cluster, the mix/light drinker pattern was the predominant beverage pattern. We named this pattern as the mix/light drinker because none of the eight individual beverage groups in that pattern signicantly contributed to the uniqueness of that pattern (ie, children drank a little of each beverage listed in Tables 1 and 2). In addition, both preschool (Table 1) and school-aged (Table 2) children in the mix/light drinker pattern differed from all other patterns by reporting signicantly lower total beverage consumption in grams compared to other beverage clusters (P0.0001). The average percentage of total en-

ergy from beverages differed signicantly across beverage clusters. Children aged 2 to 5 and 6 to 11 years in the high-fat milk pattern had signicantly higher total percent energy intakes from beverages (35.2% of energy and 25.7% of energy, respectively) compared to other beverage clusters. Twenty-nine percent of energy came from beverages in the fruit juice cluster for preschool children, and 24.3% and 22.8% of total daily energy intake came from beverages in the sweetened drinks and soda clusters, respectively, for school-aged children. Characteristics of children by beverage patterns are illustrated in Table 3 (aged 2 to 5 years) and Table 4 (aged 6 to 11 years). Birth weight, physical activity, and media screen time did not differ across beverage patterns for children, aged 2 to 5 years (Table 3). Age did differ signicantly across beverage clusters (P0.0001) and ranged from a mean of 3.1 years in the high-fat milk and fruit juice clusters to 3.8 years in the water cluster. A higher proportion of male children were in the fruit juice cluster (56.0%) compared to the water cluster (40.6%). Non-Hispanic African-American children made up a larger proportion of the mix/light drinker pattern (17.6%) and a smaller proportion of the high-fat milk cluster (5.8%), whereas Mexican-American children made up a larger proportion of the high-fat milk cluster (18.6%) and a smaller proportion of the water cluster (9.5%). Household income and at risk for overweight also differed signicantly across beverage patterns. Compared to other clusters, a higher proportion of children in the water cluster had a higher household income and a lower proportion of children in the mix/light drinker cluster were at risk for overweight. For children aged 6 to 11 years (Table 4), birth weight and physical activity did not differ signicantly across beverage clusters. Age, sex, ethnicity, household income, overweight, and media screen time did differ signicantly (P0.05). Ages ranged from a mean of 8.1 years in the
July 2007 Journal of the AMERICAN DIETETIC ASSOCIATION 1127

Table 3. Characteristics of each beverage pattern among US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002ab Children (2-5 y) Cluster 1: mix/light drinker (n249) 3.60.1 47.0 53.0 57.8 17.6 14.1 10.5 41.5 58.5 15.0 3,30535 5.90.2 2.40.1 Cluster 2: high-fat milk (n91) 3.10.1 48.9 51.1 65.3 5.8 18.6 10.3 40.2 59.8 26.9 3,35967 7.10.5 2.10.2 Cluster 3: water (n128) 3.80.1 40.6 59.4 69.1 9.9 9.5 11.5 30.8 69.2 25.8 3,19863 6.50.4 2.50.2 Cluster 4: fruit juices (n73) 3.10.1 56.0 44.5 67.1 14.8 11.9 6.1 40.6 59.4 19.6 3,37966 6.10.4 2.30.2

Characteristic Age (y) Sex (%) Male Female Ethnicity (%) Non-Hispanic white Non-Hispanic African American Mexican American Other Household income (%) $35,000 $35,000 Overweight, BMI >85th percentile (%) Birth weight (g) Physical activity (times/wk) Media screen time (h/d)
a b

P value 0.0001 0.0001 0.0001

0.0001 0.0001 0.11 0.10 0.26

For continuous variables, meanstandard error, signicance tested on the basis of general liner models; for categorical variables, signicance tested on basis of 2 comparisons. Weighted estimates.

Table 4. Characteristics of each beverage pattern among US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002ab Children (6-11 y) Cluster 1: mix/light drinker (n266) 8.10.1 42.8 57.2 61.5 15.0 10.3 13.2 33.1 67.9 28.0 3,24937 6.70.2 2.60.1 Cluster 2: high-fat milk (n156) 8.10.1 63.1 36.9 55.2 17.0 15.9 11.9 45.4 54.6 22.1 3,30247 6.30.2 2.90.2 Cluster 3: water (n147) 8.70.1 50.2 49.8 67.1 13.2 8.5 11.2 33.4 66.6 42.6 3,32359 7.00.4 3.00.2 Cluster 4: sweetened drinks (n100) 8.90.2 48.9 51.1 52.2 22.0 13.8 12.0 41.2 58.8 35.4 3,30766 5.90.3 3.40.2 Cluster 5: soda (n124) 8.80.2 60.7 39.3 63.9 7.2 11.1 17.9 38.2 61.8 35.2 3,42650 6.20.3 2.80.2

Characteristic Age (y) Sex (%) Male Female Ethnicity (%) Non-Hispanic white Non-Hispanic African American Mexican American Other Household income (%) $35,000 $35,000 Overweight, BMI >85th percentile (%) Birth weight (g) Physical activity (times/wk) Media screen time (h/d)
a b

P value 0.0001 0.0001 0.0001

0.0001 0.0001 0.10 0.15 0.04

For continuous variables, meanstandard error, signicance tested on the basis of general liner models; for categorical variables, signicance tested on basis of 2 comparisons. Weighted estimates.

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Table 5. Healthy Eating Index (HEI) scores and daily nutrient intakes by beverage patterns among US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002 Children (2-5 y) Cluster 1: mix/light drinkers (n249) 70.90.8y 7.80.1y 5.00.2y 5.90.3yz 7.00.2y 5.60.2 7.50.2y 6.50.2xy 9.20.2 8.80.1 7.50.2y 1,51028y 13.10.2yz 1.70.04z 30911z 44718z 824.4y 10.30.3 77422z 11.70.3y 8.40.2y Cluster 2: high-fat milk (n91) 70.91.6y 7.90.2y 6.40.4x 6.30.4y 10.00.0x 5.70.3 6.50.3y 2.90.3z 9.20.3 8.50.3 7.80.3y 1,69445x 15.70.4x 2.50.06x 35217y 67329x 747.0y 9.80.4 131236x 11.80.5y 10.20.3x Cluster 3: water (n128) 71.01.1y 8.30.2xy 5.50.3xy 4.90.4z 7.80.3y 5.40.3 7.40.3y 6.10.4y 9.00.2 8.90.2 7.70.3y 1,50735y 14.40.3xy 1.90.04y 35213yz 55723y 695.4y 11.20.3 89528y 12.70.4xy 9.10.3y Cluster 4: fruit juices (n73) 79.01.1x 8.80.2x 3.60.4z 9.90.1x 7.70.3y 5.50.4 9.10.2x 7.50.4x 9.30.3 8.90.2 8.70.3x 1,76350x 13.10.4z 1.90.07y 41919x 51533y 1717.8x 10.40.5 89940y 13.50.6x 8.50.4y

Measure HEIa Grainsa Vegetablesa Fruita Dairya Meata Total fata Saturated fata Cholesterola Sodiuma Varietya Energy (kcal)b Protein (% kcal)b Riboavin (mg)b Folate (g)b Vitamin A (g retinal activity equivalents)b Vitamin C (mg)b Fiber (g)b Calcium (mg)b Iron (mg)b Zinc (mg)b
a b

P value 0.0001 0.01 0.0001 0.0001 0.0001 0.0001 0.0001 0.05 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.05 0.01

Meanstandard error. For total energy intake, meanstandard error, adjusted for age, sex, and ethnicity; for nutrient intakes, meanstandard error, adjusted for total energy intake, age, sex, and ethnicity. xyz Values in the same row with different superscripts are signicantly different at P0.05 (Tukey-Kramer adjustment for multiple comparisons). NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation featuring additional online-only content.

mix/light drinker and high-fat milk clusters to 8.9 years in the sweetened drinks cluster. A larger proportion of non-Hispanic African-American children were in the sweetened drinks cluster (22.0%) compared to a smaller proportion in the soda cluster (7.2%). Male children made up a larger proportion of the high-fat milk cluster (63.1%) and a smaller proportion of the mix/light drinker cluster (42.8%). The water cluster had the largest proportion of children at risk for overweight (42.6%) and also had higher household income, along with the mix/light drinker cluster, compared to other beverage clusters (P0.0001). Mean hours per day of media screen time was higher in the sweetened drinks cluster (3.4 hours per day) compared with the mix/light drinker cluster (2.6 hours per day) (P0.05) Diet quality differed signicantly by beverage patterns in children aged 2 to 5 years (Table 5). The mean HEI scores across beverage patterns ranged from 70.9 in the mix/light drinker and high-fat milk patterns to 79.0 in the fruit juice pattern. HEI component scores also varied across beverage patterns. The best vegetable score was in the high-fat milk group; the fruit juice pattern had the worst. The fruit juice pattern had the best fruit score, whereas the water pattern had the worst. The high-fat milk pattern had the best dairy score, but had the worst total fat and saturated fat scores compared with the other beverage clusters. Energy intakes were highest among

the high-fat milk and fruit juice patterns and were lowest for mix/light drinker and water patterns. Percent energy from protein was highest in the high-fat milk pattern and lowest in the fruit juice and mix/light drinker patterns. After adjusting for energy intake, age, sex, and ethnicity, beverage patterns with the highest micronutrient intakes were the high-fat milk cluster (riboavin, vitamin A, calcium, and zinc) and fruit juice cluster (folate, vitamin C, and iron). Beverage patterns also differed signicantly on diet quality in children aged 6 to 11 years (Table 6). The range for HEI scores was 63.2 for the soda pattern to 69.9 for the sweetened drinks pattern. The sweetened drinks pattern had the best vegetable score and the mix/light drinker pattern had the worst. The soda pattern had the worst fruit score and the sweetened drinks pattern had the best total fat and saturated fat scores compared with the other beverage clusters. Variety scores were best for the sweetened drinks cluster and worst for the soda and mix/light drinker clusters. Compared to most other beverage clusters, the mix/light drinker pattern had the lowest total energy intake. The high-fat milk pattern had the highest percentage of energy from protein; the sweetened drinks and soda patterns had the lowest. For micronutrients, the beverage clusters with the lowest intake of micronutrients were the soda cluster (riboavin, folate, vitamin A, vitamin C, ber, and iron) and the sweetened
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Table 6. Healthy Eating Index (HEI) scores and daily nutrient intakes by beverage patterns among US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002 Children (6-11 y) Cluster 1: mix/light drinker (n266) 66.10.8xy 7.50.4 4.40.2y 4.70.2x 6.80.2z 5.60.2 7.10.2y 6.40.2y 8.90.2 7.50.2x 7.20.2y 1,81532z 13.80.2y 2.10.04z 36210y 60132yz 784.7y 12.40.3y 95823z 14.20.3y 10.40.3z Cluster 2: high-fat milk (n156) 68.10.9x 7.80.2 4.80.3xy 4.80.3x 9.70.06x 5.40.3 7.40.2y 5.10.3z 8.70.3 6.60.3xy 7.70.2xy 2,02846xy 15.00.3x 2.70.05x 42813x 75544x 786.4y 12.80.4x 1,239313x 14.50.4x 11.70.4x Cluster 3: water (n147) 67.11.2xy 7.60.2 4.90.3xy 4.20.3x 7.80.2y 5.80.3 7.30.3y 6.20.3yz 8.90.2 6.60.3xy 7.90.2xy 1,94342yz 14.40.3xy 2.30.05y 37112y 67140xy 785.9y 12.50.4xy 1,02629y 14.60.4xy 11.00.3xy Cluster 4: sweetened drinks (n100) 69.90.9x 7.70.2 5.90.3x 4.10.4y 6.30.3z 6.10.3 8.50.2x 8.10.3x 8.90.3 6.10.4y 8.40.2x 2,13457x 12.10.4z 1.80.07z 35317y 48555yz 1178.1x 12.10.5x 77039z 13.70.6x 9.10.4yz Cluster 5: soda (n124) 63.21.0y 7.50.2 5.10.3xy 2.60.3y 6.50.3z 5.50.3 7.30.3y 6.50.3y 8.90.3 6.40.3xy 7.00.3y 2,07444xy 11.80.3z 1.70.05z 31613y 40742z 596.2y 11.00.4xy 79330z 12.60.4xy 9.40.3yz

Measure HEIa Grainsa Vegetablesa Fruita Dairya Meata Total fata Saturated fata Cholesterola Sodiuma Varietya Energy (kcal)b Protein (% energy)b Riboavin (mg)b Folate (g)b Vitamin A (g retinal activity equivalent)b Vitamin C (mg)b Fiber (g)b Calcium (mg)b Iron (mg)b Zinc (mg)b
a b

P value 0.005 0.01 0.0001 0.0001 0.01 0.0001 0.01 0.005 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.01 0.0001 0.01 0.0001

Meanstandard error. For total energy intake, meanstandard error, adjusted for age, sex, and ethnicity; for nutrient intakes, meanstandard error, adjusted for total energy intake, age, sex, and ethnicity. xyz Values in the same row with different superscripts are signicantly different at P0.05 (Tukey-Kramer adjustment for multiple comparisons). NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation featuring additional online-only content.

18 17.5 17
BMI

20.5 20 19.5

BMI

19 18.5
b b

16.5 16 15.5 15

18 17.5
Cluster 1: Mix/light drinker Cluster 2: High-fat milk Cluster 3: Water Cluster 4: Fruit juices

17
Cluster 1: Cluster 2: Cluster 3: Cluster 4: Cluster 5:

Beverage pattern

Mix/light High-fat milk drinker

Water

Sweetened drinks

Soda

Figure 2. Adjusted mean (standard error) body mass index (BMI kg/m2) by beverage pattern among US children aged 2 to 5 years in the National Health and Nutrition Examination Survey 2001-2002. Overall signicance of pattern, after adjusting for age, sex, ethnicity, household income, Healthy Eating Index score, physical activity, and birth weight determined at P0.30. (Information from this gure is available online at www.adajournal.org as part of a PowerPoint presentation featuring additional online-only content.)

Beverage pattern

Figure 3. Adjusted mean (standard error) body mass index (BMI kg/m2) by beverage pattern among US children aged 6 to 11 years in the National Health and Nutrition Examination Survey 2001-2002. Overall signicance of pattern, after adjusting for age, sex, ethnicity, household income, Healthy Eating Index score, physical activity, and birth weight determined at P0.0001. Bars with different letters are signicantly different, P0.05, by comparison using the Tukey-Kramer option to correct for multiple comparisons in general linear models. (Information from this gure is available online at www.adajournal.org as part of a PowerPoint presentation featuring additional online-only content.)

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drinks cluster (calcium and zinc). The high-fat milk pattern had the highest micronutrient intake (riboavin, folate, vitamin A, ber, calcium, and zinc). Comparisons of BMI across beverage patterns are shown for children aged 2 to 5 years (Figure 2) and for children aged 6 to 11 years (Figure 3). BMI was not signicantly different across beverage patterns for children aged 2 to 5 years. For children aged 6 to 11 years, BMI was signicantly higher in the water, sweetened drinks, and soda patterns (adjusted mean BMI19.9, 18.7, and 18.7, respectively) compared to the mix/light drinker and high-fat milk patterns (adjusted mean BMI18.2 and 17.8, respectively) (P0.05). DISCUSSION The changes in beverage consumption patterns during the past several decades (8) have increased interest in whether or not children are meeting nutrient requirements and whole food recommendations and if beverage intake, specically calorically sweetened beverages, are related to the increased prevalence of childhood obesity. In this study, we derived four and ve nonoverlapping beverage patterns among children aged 2 to 5 and 6 to 11 years, respectively, in the 2001-2002 NHANES sample using cluster analysis. The objectives were to understand the association of different beverage patterns with overall diet quality, measured by HEI, among children and to identify if BMI in children was associated with different beverage patterns. Overall, our results showed that diet quality differed signicantly across beverage patterns for both age groups of children. However, beverage patterns were only related to BMI for children aged 6 to 11 years. No formal guidelines have been established for beverage consumption in children or adults. However, a recent guidance system has been proposed for beverage consumption in persons 6 years of age, which ranks beverages based on energy and nutrient content and related health benets and risks (27). The Beverage Guidance Panel recommends water as the most preferable beverage, followed by unsweetened coffee and tea, low-fat milk, noncalorically sweetened beverages, fruit juices, and alcohol (with some nutrients), and calorically sweetened beverages (without nutrients). In our sample of children aged 2 to 11 years, the beverage patterns we identied were not consistent with what has been proposed by the Beverage Guidance Panel. Although the mix/light drinker pattern in both age groups had combinations of all beverage groups, a large proportion of this pattern was made up of calorically sweetened beverages. Diet quality, measured by the HEI, across beverage patterns ranged from 70.9 to 79.0 in children aged 2 to 5 years and from 63.2 to 69.9 in children aged 6 to 11 years. Regardless of beverage pattern, the diet quality of children in this sample needs improvement (24). We also observed that diet quality was poorer among school-aged compared to preschool children. This is consistent with a study of low-income US children, where HEI scores ranged from 68.8 to 78.1 and from 65.8 to 69.6 across dietary patterns in children aged 2 to 3 years and 4 to 8 years, respectively (28). Previous research has suggested that consumption of some beverages, including calorically sweetened beverages, displaces more nutritious beverages, such as milk

and fruit juice, in the diets of children (16-19). Our data also suggests this trend. In children aged 2 to 5 years, the high-fat milk cluster emerged with the highest micronutrient intakes compared to the other clusters. Although we observed higher micronutrient intakes in the high-fat milk pattern, the HEI score for this cluster was among the lowest compared to the fruit juice pattern. This may be due to several factors. First, this may reect the total and saturated fat scores, as the majority of milk consumed in this pattern came from higher-fat varieties of milk (whole and 2%). This may also reect that children in the high-fat milk cluster were taking in more energy from milk, thus displacing other micronutrient-dense foods resulting in reduced dietary variety (29,30). Among preschoolers in the high-fat milk cluster, we observed that more than one third of their total daily energy intake came from beverages, mainly high-fat milk, suggesting that these children may still be transitioning from infant to toddler feeding patterns. The fruit juice pattern, in contrast to the high-fat milk pattern, had the highest HEI score and also had higher micronutrient intakes of folate and vitamin C compared to other clusters. The relatively high HEI score for the fruit juice pattern reects in part the variety and fruit component scores, which counts fruit servings from both whole foods as well as juices (23). We suspect that most of these childrens fruit intake may come from fruit juices, rather than whole fruit because we did not observe differences in ber intake across the different beverage clusters. Under the new HEI 2005 construct (31), this criterion will change so that no more than half of ones daily fruit requirement is derived from fruit juice, which can supply excess sugar and energy. Similar ndings were seen among children aged 6 to 11 years. In general, children in the high-fat milk pattern had the highest micronutrient intakes whereas micronutrient intake was the lowest for children in the soda and sweetened drinks pattern, suggesting consumption of calorically sweetened beverages displaces important nutrients. The high-fat milk pattern in school-aged children, unlike the preschool children, had a higher HEI (68.8) score compared to most other beverage clusters. We observed, in the high-fat milk clusters, that the total percentage of energy coming from beverages decreased from approximately 36% in children aged 2 to 5 years to approximately 26% in children aged 6 to 11 years. Whereas the preschool children may be displacing other micronutrient-dense foods and comprising dietary variety (29,30), older children appear to be eating more micronutrientdense foods, perhaps as a result of parental encouragement and inuence on eating healthful foods and beverages (32). Beverage intake patterns from preschool to school-aged children could also be affected by several environmental factors, in addition to family, that can inuence food choices and preferences including socialcognitive cues (33), peers (34), and school food environment (35). Total energy intake for the mix/light drinker pattern in both age groups was lower than most other beverage clusters and was more consistent with the energy requirements for their age group (36); however, diet quality was similar to or worse than most other groups, as reected by HEI scores and micronutrient intakes. This emphasizes the need for appropriate food selection to
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improve diet quality even in children that are meeting recommended energy requirements. We expected childrens BMI would be reective of total energy intake from each beverage pattern. Our data did not support this in children aged 2 to 5 years, after adjusting for other covariates. Preschool children may have a better ability to self-regulate food intake and energy (37) for both liquid and solid foods (38,39). These ndings might also suggest that there is more parental control over a preschoolers food intake compared to older children. For children aged 6 to 11 years, those in the water, sweetened drinks, and soda patterns had the highest BMI. Consuming high amounts of calorically sweetened beverages might lead to excessive energy intake, which may lead to overweight. We observed that the sweetened drinks and soda patterns children consumed roughly one quarter of their daily energy intakes from beverages, mostly from calorically sweetened beverages. We did not anticipate that children in the water cluster would have signicantly higher BMI. Because of the cross-sectional nature of NHANES, the relationship between beverage clusters and BMI may be subject to reverse causation, in which diet may be modied because of weight (40). This is supported by research that shows children with higher BMIs report higher levels of dieting (41-43). We also observed that children in the high-fat milk cluster had the lowest BMI, but among the best overall diet quality as reected by the HEI and micronutrient intakes, which supports the concept that children with better overall diet quality would have lower BMIs. Our study has several limitations. Only one 24-hour dietary recall was collected from NHANES participants, which may misclassify children according to food, beverage, and nutrient intake, which may uctuate from day to day. In addition, 24-hour recalls were performed in young children by use of a proxy and mothers and/or caregivers may not have complete knowledge of what their child ate on a given day (ie, if the child was in school or daycare) and recalling the amounts of liquids may be more difcult than solids. The benet of cluster analysis is to identify people and group them by similar beverage intakes, or patterns. Although cluster analysis is a data-driven process that requires subjective decisions of the investigator and has no gold standard for determining the number of clusters (44), we tried to increase the likelihood that real and distinct beverage patterns among children emerged by using criteria such as Scree plots and F statistics. The cross-sectional design of NHANES limited our ability to fully evaluate the relationships between BMI and beverage patterns because the choice of diet may not necessarily reect weight. However, the large sample of children allowed us to identify certain beverage patterns and how they may inuence overall diet quality during certain stages in childhood. Ultimately, prospective studies are needed to assess beverage patterns over time that lead to overweight. CONCLUSIONS We observed that diet quality differed across distinct beverage patterns among children aged 2 to 5 and 6 to 11 years, but BMI was only signicantly associated with beverage patterns of children aged 6 to 11 years. Our data
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suggest that beverages are associated with diet quality in children. Moreover, mean HEI scores among children in all beverage clusters were below 81 (a score of 81 or greater representing a good diet), indicating that diets of children aged 2 to 11 years need improvement. Regardless of beverage pattern, all children could benet by decreasing their intake of soda and other calorically sweetened beverages that may displace important micronutrient-dense foods needed for growth and development. Further research using prospective studies is needed to better assess the inuence of beverage consumption on diet quality and its inuence on overweight in children. This project was supported by National Institutes of Health grants Nos. T32-HP-10010-10, DK07665, and 5-K23HL068827-03. The authors thank David Brown, PhD, for assistance with data processing, statistical support, and critique of the manuscript. References
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