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 inves-

tigate the effects of the DRI on diet quality, body weight, and health status in young children. (J Pediatr 2005;146:105-11)

National and international groups have issued recommendations for added sugar intake. In the United States Departmentof Agriculture’s (USDA) Food Guide Pyramid, added sugar consumption is suggested to range between 6% to 10% oftotal 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 contrastto these guidelines, the National Academy of Sciences (NAS) released therecommendations for energy and macronutrient intakes, which included a DietaryReference Intake (DRI) of 25% or less of total energy from added sugar. This cut-point wasbased on evidence of potentially adverse consequences on outcomes including biomarkers(eg, blood lipids), behavior, dental caries, obesity, coronary heart disease, and nutrientintakes.3

The differentiation between total sugar and added sugar is important4; total sugarsinclude all sugars in the diet, including those in nutrient-dense foods, such as lactose inmilk or fructose in fruits. Consequently, diets high in total sugar would not necessarily beexpected to result in lower diet quality. Added sugar is a component in foods that might notbe related to the nutrient density of any food, for example, pastries containing low levels ofmicronutrients could be just as high in added sugar as a fortified cereal, which mightcontain not only high sugar but also have high micronutrient density. Thus,recommendations on added sugar intake in the American population should be basedsolely on research distinguishing those two kinds of sugar in the diet.

The new DRI are of great public health importance. They are used by health pro-fessionals in providing dietary guidance or serve as guides in planning and delivering federalnutrition programs. Assessment of dietary adequacy is often based on DRI cut-points.

From the Department of NutritionalSciences, College of Health and Hu-man Development, Pennsylvania StateUniversity, State College, Pennsylva-nia; and the Departments of Nutritionand Maternal and Child Health, Schoolof Public Health, University of NorthCarolina, Chapel Hill.

Supported by a Seed Grant by theCollege of Health and Human De-velopment, Pennsylvania State Uni-versity.Submitted for publication Jan 29,2004; last revision received Aug 5,2004; accepted Aug 30, 2004.

Reprints are not available from theauthors.

Correspondence to: Dr Sibylle Kranz,Department of Nutritional Sciences,College of Health and Human De-velopment, Pennsylvania State Uni-versity, Henderson Building 5G, StateCollege, PA 16802. E-mail: sxk72@psu.edu.0022-3476/$ - see front matter

Copyrightª 2005 Elsevier Inc. All rightsreserved.

10.1016/j.jpeds.2004.08.077

AI Adequate intakeCSFII Continuing Survey of Food Intakes by IndividualsDRI Dietary reference intakesEAR Estimated average requirement

NHANES National Health and Nutrition ExaminationSurvey

USDA United States Department of Agriculture

105

Policy-makers use them to design dietary guidelines, such asthe Food Guide Pyramid. Thus, the recommendations area powerful tool and have great potential to aid in the effort tolimit nutrition related health problems.

The purpose of this study was to investigate the effectof added sugar intake on diet quality in preschool childrenby using dietary data available subsequent to NHANES(National Health and Nutrition Examination Survey) III(1988 to 1992), which was used by the DRI macronutrientscommittee. Given the relation between chronic diseases anddemographic variables,5-7 we investigated intakes of addedsugar by children from various sociodemographic groups.Finally, we examined associations between intake of addedsugars and food group as well as nutrients. This approachrecognizes that diets are complex and that food group analysisreflects interactions of nutrients and other dietary components.

METHODSEstimates of dietary intakes were based on data for chil-

dren 2 through 5 years of age who provided 2 days of dietary

Table I. Selected sociodemographic characteristicsof the sample from the CSFII 1994 to 1996 and 1998(in percentage of total population in each age group)

CSFII 1994 to 1996and 1998

Characteristics2 1 3 y

(n = 2805)4 1 5 y

(n = 2632)

Sex Boys 51.9 50.7Ethnicity Non-Hispanic

white61.1 61.7

Non-Hispanicblack

16.7 16.7

Non-Hispanicother

16.0 16.7

Hispanic 6.2 4.9Income ,130% of

poverty30.2 31.5

130%–184%of poverty

14.4 14.2

185%–350%of poverty

29.2 30.7

.350% ofpoverty

26.2 23.6

Education* Less thanhigh school

16.7 18.0

High school 31.5 33.5More thanhigh school

51.8 48.5

Employmentstatus*

Employed 59.4 61.8

*Of female head of household.

106 Kranz et al

intake information in the Continuing Survey of Food Intakesby Individuals (CSFII), 1994 to 1996 and 1998 (n = 5437).The 1994 to 1996 USDA CSFII survey data were collectedthrough the use of a stratified, multistage, area probabilitysample to obtain a nationally representative sample of non-institutionalized persons living in households. Interviewersfollowed preset protocols to complete the survey. Detaileddescription of the study design can be found in the study byTippet and Cypel.8 Dietary intake data were collected throughthe use of a standardized multiple pass approach. Day 1 ofdietary intake was collected by means of a household interview,whereas day 2, which was collected 3 to 10 days after day 1 butnot on the same day of the week, could be reported during aphone interview. Interview respondents reported 24-hourrecalls for children younger than age 6. In 1998, the samemethods were used for a supplemental survey in children. Allsurvey waves (CSFII, 1994 to 1996 and 1998) were combinedand used in this study. The data set provides sociodemographicinformation as well as number of servings from the Food GuidePyramid food groups and teaspoons of added sugar for allindividuals who reported dietary intake (n = 21,662). Sociode-mographic information, such as age, race, and sex of the chil-dren as well as years of education and employment status of thefemale head of household, was ascertained during the survey.

As described by Welsh et al,1 an added sugar categorywas developed for the CSFII Pyramid Servings data set tocapture all caloric carbohydrate sweeteners (monosaccharides,disaccharides, and higher saccharides). Included were all sugarsand sugar-containing ingredients added during processing orpreparation, and sugars eaten separately (candy) or added at thetable (syrups, white or brown sugar, and so forth) but excludingall naturally occurring sugars (such as fructose in fruits).9

Descriptive analysis, means and standard errors, wereascertained to describe the sample. Main sources of addedsugar consumption were acquired by using the food groupingsystem developed by a group of researchers at the Universityof North Carolina at Chapel Hill (UNC food groupingsystem).10 We calculated average daily consumption contrib-uted from each UNC food group and retained a list of thehighest 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 fromadded 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 groupconsumption as well as nutrient density (nutrient consumptionper 1000 kcal average energy intake) were calculated. Theproportions of children not meeting the Adequate intake (AI)for calcium or Estimated Average Requirement (EAR) forother nutrients were ascertained. A nonparametric test fortrend across ordered groups was conducted to obtain a z-scoreand P value to assess significance of the changes of dietaryintakes 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 Carolinafood grouping systemy for 2- to 3-year-olds and 4- to 5-year-olds (in percentage of total added sugarconsumption within each age group)

UNC Category Example foods 2- to 3-year-olds 4- to 5-year-olds

%z %z

Fruit drinks Lemonades, juiceswith 10% fruit juice

20.3 18.9

High-fat desserts Ice cream,pies, cookies, cakes

15.2 16.2

Regular soft drinks Cola type 13.9 16.0Sugars and jellies 10.1 9.5Candy 6.9 6.5Low-fiber, ready-to-eat cereal Cornflakes, Special K 6.4 7.0Low-fat desserts Gelatin desserts 6.3 6.4Low-fat milk§ 2% milk,

skim milk2.9 2.7

Low-fiber other fruits Fruit salad/cocktail, applesauce 2.4 2.1Medium-fat milk Whole milk, milkshakes 1.7 1.6Total 86.1 86.9

*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- to3-year-olds and (b) 4- to 5-year-olds (in percentage of individuals within each income or ethnicity group)

Sugar consumption (% of total energy)

0%–10% 11%–15% 16%–20% 21%–25% >25%

(a) Sample size(percentage of total sample)

n = 781 (28%) n = 743 (26%) n = 618 (22%) N = 367 (13%) n = 296 (11%)

Income level (% poverty),130 33.5 26.6 19.9 12.5 7.6130–184 26.5 26.4 19.5 13.1 14.5185–350 26.5 25.2 23.5 12.5 12.3.350 27.1 30.9 22.1 9.8 10.1

EthnicityNon-Hispanic white 26.3 28.5 21.3 12.4 11.5Non-Hispanic black 26.3 23.2 27.9 13.7 9.0Hispanic 34.9 27.0 19.1 9.1 9.9Non-Hispanic other 44.2 27.3 11.8 9.0 7.7

(b) n = 547 (21%) n = 682 (26%) n = 662 (25%) N = 412 (16%) N = 329 (12%)Income level (% poverty)

,130 27.3 26.7 24.2 13.2 8.6130–184 18.6 24.3 21.7 17.0 18.3185–350 15.8 23.0 26.9 19.5 14.8.350 18.9 21.0 33.2 14.5 12.4

EthnicityNon-Hispanic white 17.7 22.1 28.9 17.7 13.6Non-Hispanic black 18.2 28.6 24.8 15.8 12.5Hispanic 30.4 23.9 22.9 11.5 11.3Non-Hispanic other 32.3 30.8 19.3 9.5 8.1

Adverse Effect Of High Added Sugar Consumption On Dietary Intake In AmericanPreschoolers 107

Table IV. Trends of energy, nutrient, and food group intakes (mean ± SEM) by added sugar consumption levelsfor 2- to 3-year-olds (a) and 4- to 5-year-olds (b)

Sugar consumption (% total energy)

0%–10% 11%–15% 16%–20% 21%–25% >25%Test for trend(a) (n = 781) (n = 743) (n = 618) (n = 367) (n = 296)

Mean ± SEM z score P valueMacronutrientsEnergy (kcal) 1414.8 ± 18.34 1462.8 ± 20.28 1464.6 ± 19.73 1484.9 ± 26.35 1418.9 ± 33.75 2.54 .01Carbohydrate* 52.4 ± 0.34 53.8 ± 0.29 55.7 ± 0.32 57.9 ± 0.32 62.9 ± 0.49 19.74 ,.001Protein* 15.8 ± 0.12 14.9 ± 0.11 13.7 ± 0.12 12.8 ± 0.14 11.1 ± 0.19 225.96 ,.001Fat* 33.1 ± 0.29 32.9 ± 0.27 32.1 ± 0.28 31.0 ± 0.28 27.8 ± 0.45 211.30 ,.001Fiber (g) 10.5 ± 0.24 10.5 ± 0.19 9.8 ± 0.21 9.2 ± 0.23 8.0 ± 0.27 28.43 ,.001

MicronutrientsCalcium (mg) 889.1 ± 17.04 831.0 ± 15.76 744.3 ± 15.00 712.87 ± 18.09 611.2 ± 23.19 212.15 ,.001Iron (mg) 11.9 ± 0.23 11.6 ± 0.22 11.6 ± 0.23 11.4 ± 0.30 9.9 ± 0.33 24.75 ,.001Folate (mg) 242.2 ± 4.70 238.1 ± 4.86 235.7 ± 4.59 225.1 ± 6.14 191.9 ± 5.93 25.95 ,.001Vitamin A (RAE) 800.3 ± 21.34 774.4 ± 21.06 730.6 ± 20.52 683.6 ± 29.91 583.1 ± 23.99 26.87 ,.001Vitamin B12 (mg) 3.4 ± 0.08 3.3 ± 0.08 3.0 ± 0.07 3.2 ± 0.23 2.6 ± 0.15 28.46 ,.001Vitamin C (mg) 109.0 ± 3.58 99.1 ± 2.94 97.4 ± 3.10 98.0 ± 4.15 96.3 ± 4.39 21.68 .09

Food groups2

Grains (6) 6.8 ± 0.13 7.2 ± 0.13 7.0 ± 0.13 6.9 ± 0.16 6.0 ± 0.19 21.8 ,.07Vegetable (3) 2.5 ± 0.08 2.6 ± 0.07 2.5 ± 0.09 2.5 ± 0.10 2.1 ± 0.10 21.79 ,.07Fruit (2) 3.7 ± 0.13 3.1 ± 0.10 2.6 ± 0.10 2.2 ± 0.10 2.0 ± 0.13 213.79 ,.001Dairy (2) 2.2 ± 0.05 2.0 ± 0.05 1.8 ± 0.05 1.7 ± 0.06 1.4 ± 0.07 212.37 ,.001

(b) (n = 547) (n = 682) (n = 662) (n = 412) (n = 329)MacronutrientsEnergy (kcal) 1608.2 ± 27.81 1692.2 ± 23.91 1692.6 ± 23.10 1694.6 ± 28.18 1622.6 ± 32.21 0.37 ,.71Carbohydrate* 50.9 ± 0.39 52.8 ± 0.28 55.0 ± 0.27 57.3 ± 0.38 61.3 ± 0.37 21.52 ,.001Protein* 16.0 ± 0.14 15.0 ± 0.12 14.0 ± 0.11 13.0 ± 0.14 11.7 ± 0.16 225.78 ,.001Fat* 34.4 ± 0.33 33.6 ± 0.24 32.6 ± 0.24 31.3 ± 0.33 28.8 ± 0.35 213.43 ,.001Fiber (g) 12.7 ± 0.30 12.0 ± 0.21 11.6 ± 0.26 10.7 ± 0.26 8.9 ± 0.24 213.28 ,.001

MicronutrientsCalcium (mg) 944.2 ± 21.93 906.7 ± 16.61 850.8 ± 16.32 774.4 ± 17.64 675.9 ± 19.15 211.96 ,.001Iron (mg) 13.6 ± 0.32 13.7 ± 0.29 13.3 ± 0.26 12.9 ± 0.31 10.8 ± 0.29 28.07 ,.001Folate (mg) 287.9 ± 6.91 287.8 ± 6.81 271.5 ± 5.60 260.5 ± 6.59 212.2 ± 7.07 210.09 ,.001Vitamin A (RAE) 952.4 ± 53.07 878.0 ± 31.67 822.8 ± 25.14 744.1 ± 25.10 688.5 ± 34.12 27.55 ,.001Vitamin B12 (mg) 4.6 ± 0.45 4.2 ± 0.31 3.6 ± 0.09 3.5 ± 0.21 3.0 ± 0.10 28.99 ,.001Vitamin C (mg) 101.7 ± 3.65 95.8 ± 2.82 94.8 ± 3.67 93.9 ± 3.87 100.0 ± 4.65 22.30 .02

Food groupsy

Grains (6) 5.8 ± 0.15 6.0 ± 0.12 5.7 ± 0.11 5.6 ± 0.15 4.7 ± 0.12 26.43 ,.001Vegetable (3) 2.1 ± 0.07 2.0 ± 0.06 1.9 ± 0.06 1.8 ± 0.07 1.7 ± 0.08 25.77 ,.001Fruit (2) 2.2 ± 0.08 1.9 ± 0.07 1.8 ± 0.08 1.5 ± 0.08 1.2 ± 0.08 211.61 ,.001Dairy (2) 2.3 ± 0.07 2.2 ± 0.05 2.0 ± 0.05 1.7 ± 0.05 1.5 ± 0.06 212.14 ,.001

*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 representativecharacter of the data. All analysis was conducted for twoseparate age groups of children (2- and 3-year-olds comparedwith 4- and 5-year-olds).

RESULTSHalf of the children in the sample were girls and approx-

imately half was in each age group (Table I). Approximately

108 Kranz et al

one third were in the lowest income group and one quarterwere in the highest income group. The majority of childrenwas non-Hispanic white and had an employed female head ofhousehold.

Average added sugar intake was lower in 2- and 3-year-olds compared with 4- and 5-year-olds: 14.9% and16.5% of total energy, respectively (equivalent to 13.5 ± 0.19and 17.2 ± 0.24 teaspoons per day). In younger children,

The Journal of Pediatrics � January 2005

average added sugar intake represented in teaspoons per daywas 4.4 tsp in the 0% to 10% group, 11.9 tsp in the 11% to15%, 16.5 tsp in the 16% to 20%, 21.3 tsp in the 21% to25%, and 23.1 tsp in the highest added sugar consumptiongroup. Consumption was higher in the older children: 5.0tsp 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%, and26.4 tsp in the highest added sugar consumption group.Main sources of added sugar in preschoolers are provided inTable II. The rank order of the top-10 categories were thesame in both age groups, with the exception of the candyand low-fiber cereal category. Half of the added sugarconsumption was contributed by the top three items: fruitdrinks, high-fat desserts, and regular soft drinks.

Eleven percent and 12% of the younger and olderchildren, respectively, consumed more than 25% of energyfrom added sugar. Consumption levels differed between in-come and ethnic groups. Proportionally fewer children at thelowest income level and those classified as ‘‘non-Hispanicother’’ consumed the highest level of added sugar. Morechildren in the younger age group than in the older age grouphad 10% or less of added sugar intake. Higher proportions ofnon-Hispanic white and black children consumed more than15% of energy from added sugar (Table III).

With the exception of carbohydrates and vitamin C,average consumption of macronutrients and micronutrientssignificantly 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 energyfrom added sugar consumed a significantly lower proportion ofenergy from protein, fat, and less fiber but increased percentageof energy from carbohydrates than children at lower levels ofadded sugar intake. Absolute intakes of micronutrients werealso lower in this group, with the exception of vitamin C.Investigation of nutrient density (intake per 1000 kcal)indicated that micronutrient density significantly decreasedwith increasing level of added sugar intake, whereas carbohy-drate density significantly increased (data not shown).

The proportion of children with intakes below the AIfor calcium and EAR for other nutrients increased for mostnutrients with increasing level of added sugar intake (data notshown). The data were most striking for calcium. Fortypercent of the 2- and 3-year-olds and approximately 70% of 4-and 5-year-olds in the highest added sugar intake group fellbelow the AI for calcium. Almost one quarter of the youngerchildren and one-half of the older children were below the AIat added sugar intakes of 16% to 25%. Even at the lowestadded 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 consum-ing less than the EAR was highest at sugar intakes of morethan 25% of energy, but for several nutrients the percentage ofolder children not reaching the EAR was close to 5% forvitamins A and C and 13% for folate at an added sugar intakeof 11% to 15% of total energy.

Adverse Effect Of High Added Sugar Consumption On Dietary Intake In AmerPreschoolers

Intake of servings of Food Guide Pyramid food groupschanged as well. Grains, vegetables, fruits, and dairy decreasedwith increasing added sugar levels below the recommendedintakes in the older children. The decline was steady across alladded sugar categories. Especially noteworthy was thereduction in intake of fruit and dairy foods in both agegroups. The number of servings of meat did not changesignificantly between groups (data not shown).

DISCUSSIONThis study has shown a significant trend toward

decreasing intakes of nutrients and food groups by preschoolchildren with increasing added sugar levels. Children with thehighest level of added sugar intake (25% of energy or more)had the lowest consumption of most nutrients and servings ofgrains, vegetables, fruits, and dairy. One exception to thedecline in nutrient intake was carbohydrates, which increasedwith increasing added sugar intake, whereas fat consumptiondecreased. This reciprocal relation between sugar and fatconsumption has been described previously12-15 and is thoughtto be one reason for the lack of consistent evidence fora parallel relation between increasing added sugar consump-tion and higher body weight.

The dilution of nutrients with increasing added sugarintake levels as described in this study has been shown by othersas well.16-18 Thus, the new recommendation for added sugarintake might be a reason for concern. Decreasing micronutrientintakes with higher added sugar consumption probably areobserved because the main food source of added sugar intakeare foods with low micronutrient profiles,14,19 such as sweet-ened soft drinks and juices. Hence, limitation of added sugarintake could result in higher nutrient dense diets. This was alsodemonstrated by a study limiting the amount of added sugar inthe diet of federal School Breakfast Program participants to<10% of total energy.20 Nutrient density in that study increasedwhen added sugar intake was decreased. Calcium, an importantnutrient in growing children, had been inadequate in a largeproportion of children before the study. The number ofservings of dairy had been below the recommended amounts;thus, the inadequate calcium levels had been paralleled by thelow consumption of dairy, probably because sweetenedbeverages replaced milk and dairy products as beverages.21-23

After reflecting on data from other studies, someresearchers concluded that the change in nutrient and foodgroup consumption, although statistically significant, was sosmall as to bear no clinical importance.18 However, we believethat even a reduction of one-half serving of a food groupintake in children with high added sugar levels measured ina nationally representative data set is an alarming result. In thisstudy, we found that children with the lowest added sugar levelconsumed approximately one serving more of grains, fruits,and dairy compared with children in the highest added sugarintake group. This is especially alarming when the intakereduction occurs in food groups that are currently not con-sumed at the recommended intake levels, such as dairy, fruits,and vegetables.

ican109

A further point to consider in this discussion is the effectof food fortification. Many foods in the food supply that arehigh in added sugar are also fortified, such as sweetened cerealsand breads. As our results indicated, the effect of added sugarintake level on nutrient consumption might be modified by thefortification of foods. Consumption of most micronutrientsdecreases to a much weaker extent, as could be expected withincreasing added sugar intake. Although increased added sugarconsumption leads to decreased nutrient density, the magni-tude of this effect is lowered after controlling for fortification inthe food supply.17 Hence, fortification masks the potentiallyadverse effects of the high added sugar content in the diet.

Dietary intake behaviors established in childhood trackover time, thus establishing that a diet high in added sugarduring childhood might affect the development of chronicdiseases later in life.24 Also, added sugar consumption ispredicted by a number of sociodemographic variables, forexample, that income and social status affect added sugarintakes25 and that non-Hispanic children consume higherlevels of added sugar than Hispanic children.26 Consequently,the recommendation for added sugar intake for the overallAmerican population might not be appropriate for somesubgroups of the population. The growth and development ofchildren with a high likelihood of consuming increased levelsof added sugar might be negatively affected by the DRI.Rather than being encouraged by health professionals andcaretakers to decrease added sugar consumption, they willmaintain a diet that puts them at high risk for calciuminadequacy and low intakes of fruits and vegetables.

One limitation to our study was that children’s dietswere reported by proxy and were therefore prone to in-complete or biased information. This limitation in the datacollection in preschool children has been acknowledged by theresearch community and will have to be tolerated untilaccurate measurement methods have been developed for free-living children.27 However, we used a large, nationallyrepresentative sample of American preschoolers to investigatethe relation between added sugar intake levels and nutrientconsumption. We included children with 2 days of dietaryintake and are confident that the resulting mean intakes aregood estimates of the average consumption in Americanpreschoolers. NHANES data provides dietary intake in-formation, biomarkers, and measured height and weight;however, this data set has been used in the development of theDRI. Consequently, we decided to use the other largenationally representative data set, the CSFII, which providedus with more updated information than NHANES III.

Debates about sugars and health are longstanding. TheJoint World Health Organization/Food and AgricultureOrganization Expert Consultation on Diet, Nutrition, andPrevention of Chronic Disease recommended that intake offree sugars be no more than 10% of total energy consumed.2 Inthe USDA’s Food Guide Pyramid, ‘‘moderate’’ added sugarconsumption was defined as 6% to 10% of total energy.1 Theseongoing debates argue for continued evaluations of the effect ofsugars on dietary intakes, metabolism, and chronic diseases. Inaddition, the point has been raised that most added sugars are

110 Kranz et al

not visible in foods and are not listed on the food label, makingit difficult for the consumer to estimate consumption.28

Our results indicate reasons for concern. The DRI foradded sugar intake might not be appropriate for Americanpreschoolers. In contrast to others,29 we found that althoughthe most dramatic decreases in micronutrient intakes wereobserved at added sugar intake levels of more than 25% of totalenergy, food group consumption and the proportion ofchildren meeting the AI for calcium was also very low atadded sugar intakes of less than 10% of calories.

More research is needed to investigate the appropriate-ness of the DRI with respect to overall diet quality as well asmeasurable health outcomes, such as body weight. Nationallyrepresentative data collecting information on added sugarconsumption as well as biomarkers and body weight status willbe helpful in determining a relation. Also, large, longitudinalstudies examining the long-term effect of high added sugardiets in young children might help elucidate the causality ofincreased body weight and risk factors for chronic diseases anddiet patterns. However, until more data are available, the DRIfor added sugar might adversely affect young children in thelong run. The consequences of high added sugar diets must beconsidered with reference to sociodemographic factors and therelations to overall diet quality and health status.

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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

2002;132:2785-91.

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children and adolescents. J Am Coll Nutr 2001;20:32-43.

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reducing refined sugar intake. Int J Food Sci Nutr 1999;50:391-7.

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consumption predicts the tradeoff between milk and soft drinks in young girls’

diets. J Nutr 2000;131:246-50.

50 Years Ago in The Journal of PediaSOME PECULIARITIES OF AMINO ACID METABOLISM

Schreier K. J Pediatr 1955:46;86-106

In January 1955, Kurt Schreier of Heidelberg, Germany, a

normal amino acid metabolism and the relation of amino ac

proposed a classification of inborn errors of protein metabolis

been revised or discarded. At the time, much of the renew

technologies such as column chromatography and stable is

aberrant amino acid metabolic pathways.

Still valid are his observations that the placenta and fe

circulation and that the amino nitrogen concentration is hig

relations of anabolic hormones with growth, he noted the

growth and general condition of premature infants has not b

approved today? Regarding the protein-sparing action of

a wonderful food for the growing organism, not only b

simultaneously to the tissues.’’ Mother Nature still knows b

Although most of his observations on normal amino acid m

metabolism has undergone significant evolution. Disorde

aminoacidurias secondary to renal tubular transport diso

disturbances, citing cystinosis as an example. The third group

missing such as hemophilia, Wilson hepatolenticular dege

hypoproteinemias such as agammaglobulinemia or hypoalbu

and tyrosine metabolism such as PKU, albinism, alkapton

researchers that ‘‘often fatal pathological changes during adu

abnormality in infancy.’’ Although this statement might stil

metabolic pathways in growth and development is as critica

Adverse Effect Of High Added Sugar Consumption On Dietary Intake In AmPreschoolers

22. Harnack L, Stang J, Story M. Soft drink consumption among US children

and adolescents: nutritional consequences. J Am Diet Assoc 1999;99:436-41.

23. Guenther PM. Beverages in the diets of American teenagers. J Am Diet

Assoc 1986;86:493-9.

24. Zive MM, Berry CC, Sallis JF, Grank GC, Nader PR. Tracking dietary

intake in white and Mexican-American children from age 4 to 12. J Am Diet

Assoc 2002;102:683-9.

25. Brady LM, Lindquist CH, Herd SL, Goran MI. Comparison of

children’s dietary intake patterns with US dietary guidelines. Br J Nutr 2000;

84:361-7.

26. Kranz S, Siega-Riz AM. Sociodemographic determinants of added

sugar intake in preschoolers 2 to 5 years old. J Pediatr 2002;140:667-72.

27. Serdula MK, Alexander MP, Scanlon KS, Bowman BA. What are

preschool children eating? A review of dietary assessment. Annu Rev Nutr

2001;21:475-98.

28. American Dietetic Association. Position paper: dietary guidance for

healthy children ages 2 to 11. J Am Diet Assoc 2004;104:660-77.

29. Lineback DR, Jones JM. Sugars and health workshop: summary and

conclusions. Am J Clin Nutr 2003;78:893S-7S.

tricsIN INFANCY AND EARLY CHILDHOOD

nd Rochester, New York, provided a comprehensive review of

ids with growth rate during gestation and early life. He also

m. Many of his observations remain true, whereas others have

ed interest in amino acid metabolism was sparked by new

otopes, which allowed investigators to examine normal and

tal cells actively concentrate amino acid from the maternal

hest in the youngest and smallest fetus. In his review of the

work of several investigators ‘‘that testosterone benefits the

een confirmed.’’ What is the chance that those trials would be

carbohydrates and fats, he wrote ‘‘For this reason, milk is

ecause it supplies proteins, but also carbohydrate and fat,

est!

etabolism still hold true, his classification of inborn errors of

rs of impaired kidney function would today include the

rders. His second group included generalized metabolic

was inborn errors in which a portion or an entire protein was

neration, and hypophophatasia. Fourth were the idiopathic

minemia. His final group included disorders of phenylalanine

uria, and tyrosinosis. He concluded by agreeing with basic

lt life may have their origin in a very short period of dietary

l ignite vigorous discussion, clearly understanding the role of

l 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 30322YMPD1220

10.1016/j.jpeds.2004.09.015

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