The purpose of this study was to evaluate current sugar-sweetened beverage (SSB) consumption trends and their association with insulin resistance-related metabolic parameters and anthropometric measurements by performing a cross-sectional analysis of the NHANES data during the years 1988–1994 and 1999–2004. Main outcome measures included SSB consumption trends, a homeostasis model assessment of insulin resistance, blood pressure, waist circumference, body mass index, and fasting concentrations of total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides. Although overall SSB consumption has increased, our data suggest that this increase was primarily due to an increase in the amount of SSBs consumed by males in the high-SSB intake group alone. Multivariate linear regression analyses also showed that increased SSB consumption was independently associated with many adverse health parameters. Factors other than SSB consumption must therefore be contributing to the increasing prevalence of obesity and metabolic syndrome in the majority of US children.
The increased consumption of sugar-sweetened beverages (SSBs) over the past two decades has been implicated in the increased incidence of obesity and metabolic syndrome (MetS), a group of conditions associated with insulin resistance, including hypertension, dyslipidemia, central adiposity, and impaired glucose metabolism [
As in the adult population, the prevalence of obesity and MetS in the US pediatric population is increasing [
In order to evaluate the current consumption trends of SSBs and the association of SSB intake with insulin resistance-associated metabolic parameters and anthropometric measurements in the US pediatric population, we reviewed the National Health and Nutrition Examination Survey (NHANES) and performed these analyses in each available time period. We report our findings using data from US adolescents aged 12–19 years from NHANES III (1988–1994), NHANES 1999-2000, NHANES 2001-2002, and NHANES 2003-2004.
The NHANES is conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC), and is designed to monitor the health and nutritional status of the US civilian, noninstitutionalized population. NHANES III covered the years 1988–1994, and can be divided into two phases (1988–1991 and 1991–1994). Since 1999, NHANES has been planned and conducted as continuous annual surveys, and data are released in 2-year periods. A nationally representative sample is selected every year using a stratified multistage probability cluster sample design [
The NHANES protocol consists of a home interview performed by a trained interviewer, followed by a visit to an examination center, where participants undergo physical examinations, provide blood and urine samples, and complete additional questionnaires. The details of the participant examinations and laboratory assessments are available on the NHANES website (
The NHANES III Dietary Data Collection system and the United States Department of Agriculture (USDA) Survey Nutrient Database (SND) were used for dietary intake data Coding [
Outcome variables included glucose levels, insulin levels, a homeostasis model assessment of insulin resistance (HOMA-IR), total cholesterol (TC) levels, high-density lipoprotein cholesterol (HDL-C) levels, low-density lipoprotein cholesterol (LDL-C) levels, triglyceride (TG) levels, the TG/HDL-C ratio, systolic blood pressure (SBP), diastolic blood pressure (DBP), waist circumference (WC), and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) percentile for age and sex (per the National Center for Health Statistics references) [
Sugar-sweetened beverage information was obtained through a 24-hour dietary recall interview. (In NHANES 2003-2004, the 24-hour recall was assessed on two separate days; the first day was an in-person interview comparable to the previous NHANES study periods’ primary interview mode, whereas the second day was a telephone interview 3–10 days later. For consistency in the methodology of data collection among the study periods, only the first day of the NHANES 2003-2004 24-hour recall was used in our analyses.) Sugar-sweetened beverages were defined as caloric soft drinks, colas, sugar-sweetened fruit drinks, or other sugar-sweetened beverages; pure fruit juices and diet soft drinks were not included. Sugar-sweetened beverage intake in grams (g) for each reported beverage was divided by 250 g (a serving equivalent; approximately 8 ounces [oz] or a cup of beverage) and summed for each adolescent. In each NHANES analyzed, low SSB intake was defined as the lowest quintile (≤20th percentile) of the sum of the number of SSB serving equivalents a subject consumed per day; medium was defined as the 2nd–4th quintiles (
Statistical analyses were performed with SUDAAN, version 9.0 (Research Triangle Institute, Research Triangle Park, NC) using techniques appropriate for the complex NHANES survey design. All of the analyses used the NHANES-provided sampling weights that were calculated to take into account unequal probabilities of selection resulting from the sample design, nonresponse, and planned oversampling of selected subgroups, so that results are representative of the US community-dwelling population. Dietary variables were analyzed both as continuous variables and in quintiles to minimize the chance that a small number of extreme observations would have undue influence on the results. The data are presented as NHANES III (1988–1994) versus NHANES 1999–2004, both in their individual components (i.e., NHANES III, Phase I 1988–1991; NHANES III, Phase II 1991–1994; NHANES 1999-2000; NHANES 2001-2002; and NHANES 2003-2004) as well as in their entirety (NHANES 1988–1994 and NHANES 1999–2004) since both trend and aggregate analyses were performed. Descriptive statistics summarize the data and are expressed as the mean ± the standard error (SE). Mean differences in outcomes comparing 1988–1994 to 1999–2004 in aggregate were tested for significance using
The characteristics of the study participants are shown in Table
Characteristics of US adolescents aged 12–19 years: NHANES III (1988–1994) and complete NHANES 1999–2004 cohorts.
NHANES III | NHANES III | ||||||
Phase I | Phase II | NHANES | NHANES | NHANES | NHANES III | NHANES | |
1988–1991 | 1991–1994 | 1999-2000 | 2001-2002 | 2003-2004 | 1988–1994 | 1999–2004 | |
Number of Participants ( | 1531 | 1703 | 2308 | 2417 | 2242 | 3234 | 6967 |
Age in years (mean) | 15.7 | 15.2 | 15.4 | 15.5 | 15.4 | 15.4 | 15.5 |
Sex (%) | |||||||
Male | 50.9 | 50.6 | 51.5 | 50.6 | 51.1 | 50.7 | 51.1 |
Female | 49.1 | 49.4 | 48.5 | 49.4 | 48.9 | 49.3 | 48.9 |
Race/ethnicity (%) | |||||||
Non-Hispanic white | 66.9 | 65.1 | 56.8 | 63.8 | 64.9 | 66.0 | 62.1 |
Non-Hispanic black | 15.4 | 15.6 | 14.9 | 13.9 | 15.7 | 15.5 | 14.8 |
Mexican American | 8.2 | 8.3 | 13.0 | 9.0 | 11.1 | 8.3 | 10.9 |
Other race–including multiracial | 4.8 | 4.8 | 7.3 | 5.3 | 3.6 | 4.8 | 5.3 |
Other Hispanic | 4.7 | 6.2 | 8.0 | 8.0 | 4.7 | 5.4 | 6.9 |
The overall number of SSB serving equivalents consumed per day by each NHANES study period as well as the number of SSB serving equivalents consumed per day by the low-, medium-, and high-SSB intake groups from each cohort is shown in Table
Trends in SSB intake among adolescents aged 12–19 years: NHANES III (1988–1994), NHANES 1999-2000, NHANES 2001-2002, and NHANES 2003-2004. Low SSB intake defined as lowest quintile based on NHANES III cutoffs; medium defined as 2nd–4th quintiles; high defined as highest quintile. Mean indicates mean number of serving equivalents of sugar-sweetened beverages reported during 24 hour dietary recall.
NHANES III | NHANES III | ||||||||
Phase I | Phase II | NHANES | NHANES | NHANES | NHANES III | NHANES | |||
1988–1991 | 1991–1994 | 1999-2000 | 2001-2002 | 2003-2004 | Trends | 1988–1994 | 1999–2004 | ||
Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | |||
SSB intake | |||||||||
Overall | |||||||||
Low (0–0.7 serving equivalents) | 0.04 (.01) | 0.08 (0.03) | 0.05 (0.01) | 0.04 (0.01) | 0.06 (0.01) | .96 | 0.06 (0.01) | .05 (0.01) | .52 |
Medium (0.8–4.5 serving equivalents) | 2.5 (0.1) | 2.4 (0.1) | 2.5 (0.1) | 2.4 (0.04) | 2.6 (0.1) | .17 | 2.4 (0.1) | 2.5 (0.03) | .12 |
High (4.6-24.2 serving equivalents) | 6.5 (0.3) | 6.7 (0.2) | 7.2 (0.2) | 7.1 (0.2) | 6.9 (0.2) | .12 |
(a)
Since the number of SSBs consumed per day may be different between males and females, we also performed sex-specific subgroup analyses; these results are shown in Table
Trends in SSB Intake among adolescents aged 12–19 years by sex: NHANES III (1988–1994), NHANES 1999-2000, NHANES 2001-2002, and NHANES 2003-2004. Low SSB intake defined as lowest quintile based on NHANES III cutoffs; medium defined as 2nd–4th quintiles; high defined as highest quintile. Mean indicates mean number of serving equivalents of sugar-sweetened beverages reported during 24 hour dietary recall.
NHANES III | NHANES III | ||||||||
Phase I | Phase II | NHANES | NHANES | NHANES | NHANES III | NHANES | |||
1988–1991 | 1991–1994 | 1999-2000 | 2001-2002 | 2003-2004 | Trends | 1988–1994 | 1999–2004 | ||
Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | Mean (SE) | |||
SSB intake | |||||||||
Overall | 3.3 (0.1) | 3.6 (0.1) | . 51 | ||||||
Low (0-0.7 serving equivalents) | 0.02 (0.01) | 0.09 (0.06) | .03 (0.01) | 0.04 (0.01) | 0.05 (0.02) | .99 | 0.05 (0.03) | 0.04 (0.01) | .57 |
Medium (0.8-4.5 serving equivalents) | 2.6 (0.1) | 2.4 (0.1) | 2.6 (0.1) | 2.6 (0.04) | 2.7 (0.1) | .18 | 2.5 (0.1) | 2.6 (0.04) | .08 |
High (4.6-24.2 serving equivalents) | 6.6 (0.2) | 6.9 (0.3) | 7.5 (0.3) | 7.3 (0.3) | 7.2 (0.2) | .08 | |||
SSB intake | |||||||||
Overall | 2.1 (0.2) | 2.5 (0.1) | 2.5 (0.2) | 2.3 (0.1) | 2.4 (0.1) | .35 | 2.3 (0.1) | 2.5 (0.1) | .30 |
Low (0–0.7 serving equivalents) | 0.05 (0.01) | 0.08 (0.03) | 0.07 (0.01) | 0.05 (0.01) | 0.06 (0.01) | .92 | 0.06 (0.02) | 0.06 (0.01) | .93 |
Medium (0.8–4.5 serving equivalents) | 2.4 (0.1) | 2.4 (0.1) | 2.5 (0.04) | 2.3 (0.1) | 2.5 (0.1) | .44 | 2.4 (0.1) | 2.4 (0.03) | .47 |
High (4.6–24.2 serving equivalents) | 6.1 (0.5) | 6.2 (0.3) | 6.6 (0.3) | 6.7 (0.2) | 6.3 (0.3) | .52 | 6.2 (0.3) | 6.5 (0.1) | .26 |
(a)
The multivariate linear regression analyses evaluating the relationship between SSB intake and insulin resistance-associated metabolic parameters and anthropometric measurements are shown in Table
Regression analyses of metabolic parameters and anthropometric Measurements associated with SSB intake among US adolescents aged 12–19 years: NHANES III (1988–1994), NHANES 1999-2000, NHANES 2001-2002, NHANES 2003-2004, and complete NHANES 1999–2004 cohorts. Beta (SE) represents the number of SSBs consumed per day, adjusting for amount of physical activity performed per day, age, sex, ethnicity, and energy intake per day (in kilocalories). Abbreviations: HOMA-IR, homeostasis model assessment of insulin resistance; TC, total cholesterol; TG, triglyceride; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; WC, waist circumference; SE, standard error.
NHANES III | NHANES III | ||||||
Phase I | Phase II | NHANES | NHANES | NHANES | NHANES III | NHANES | |
1988–1991 | 1991–1994 | 1999-2000 | 2001-2002 | 2003-2004 | 1988–1994 | 1999–2004 | |
Beta (SE) | Beta (SE) | Beta (SE) | Beta (SE) | Beta (SE) | Beta (SE) | Beta (SE) | |
HOMA-IR# | — | — | 0.08 (0.04) | 0.03 (0.02) | — | ||
TC (mg/dL) | 0.04 (.30) | 0.17 (0.50) | |||||
HDL-C (mg/dL) | |||||||
LDL-C (mg/dL)# | 0.93 (0.79) | 0.70 (0.71) | 0.79 (0.39) | 0.72 (0.51) | 0.13 (0.29) | ||
TG (mg/dL)# | 1.41 (1.15) | 0.04 (1.87) | 1.53 (1.14) | 1.02 (0.84) | |||
TG/HDL-C ratio# | 0.02 (0.04) | 0.05 (0.04) | 0.05 (0.03) | 0.001 (0.03) | 0.03 (0.02) | ||
SBP (mmHg) | 0.08 (0.16) | 0.12 (0.17) | 0.11 (0.12) | 0.15 (0.17) | 0.10 (0.14) | ||
DBP (mmHg) | 0.13 (0.16) | 0.01 (0.07) | |||||
WC (cm) | 0.42 (0.23) | 0.07 (0.25) | 0.22 (0.18) | ||||
BMI (kg/m2) percentile for age-sex | 0.70 (0.42) | 0.04 (0.67) | 0.38 (0.45) |
#morning & fasting subsample.
As has been reported elsewhere [
Given the strong association between SSB intake and altered metabolism [
Nevertheless, as shown by our linear regression analyses, SSB consumption is associated with adverse metabolic parameters [
Moreover, our data show that SSB intake in the top quintile of SSB consumers from each of the NHANES 1999–2004 study periods has begun to decline (7.2 SSB serving equivalents per day in 1999-2000, to 7.1 SSB serving equivalents per day in 2001-2002, to 6.9 SSB serving equivalents per day in 2003-2004) after increasing dramatically from the amount of SSB consumption in NHANES III (6.5 SSB serving equivalents per day in 1988–1991, and 6.7 SSB serving equivalents per day in 1991–1994). Whether this trend continues, and whether it is associated with changes in the prevalence of pediatric obesity and MetS, warrants further investigation.
One limitation to this study is that the data are cross-sectional, and thus cannot infer causality; another is that the analyses are confined to adolescents aged 12–19 years. We can also not exclude the possibility that significant differences in either the age at which children begin consuming SSBs and/or the amounts of SSBs consumed among children in the pre-teen years increase the rate of obesity and MetS in adolescents, as both of these scenarios would not be captured by our analyses. Moreover, since the pubertal status of subjects participating in NHANES has not been documented since NHANES III, we are unable to longitudinally adjust for the subjects’ degree of pubertal maturation. Studies such as ours that utilize questionnaires also have other inherent limitations: (i) the recall method is subject to inaccuracy and bias, especially with behaviors such as dietary habits [
Although the mean overall amount of SSB consumption in US adolescents has increased over the past 16 years, paralleling the increase in pediatric obesity and MetS, our data suggest that this observation is primarily due to increased SSB intake in the top quintile of male SSB consumers. Thus, increased consumption of SSBs is not solely responsible for the increasing prevalence of obesity and MetS for the majority of US adolescents. Public health efforts aimed at addressing other factors linked with adverse metabolic parameters and anthropometric measurements, such as decreasing physical activity and increasing consumption of fast foods and other calorie-dense and nutritionally-poor foods, are therefore needed to adequately address the ongoing epidemic of pediatric obesity and MetS.
The authors thank Dr. Daphne Carlson Bremer and Dr. Daniel Tancredi for their assistance in the preparation of this manuscript. All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. This work was supported by Grant nos. KL2 RR024144 and UL1 RR024146 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at