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Beverage Intake Guidelines Applicable to Young Children

The second session, moderated by Esa Davis, associate professor of medicine at the University of Pittsburgh, focused on prominent national-level guidelines that offer beverage intake guidance applicable to children 5 years of age and younger. In the first presentation, Rafael Pérez-Escamilla, professor of epidemiology and public health at the Yale School of Public Health, discussed the scientific report of the 2015 Dietary Guidelines Advisory Committee (DGAC) (HHS/USDA, 2015b). Next, Stephen Daniels, professor and chair of the Department of Pediatrics at the University of Colorado School of Medicine and chair of the American Academy of Pediatrics (AAP) Committee on Nutrition, discussed existing AAP guidelines for beverage intake. In addition to discussing the recommendations for beverage intake, both presentations also provided insight into the evidence informing the guidelines. Following Daniels’s presentation, he and Pérez-Escamilla took part in a facilitated discussion, moderated by Davis.

SCIENTIFIC REPORT OF THE 2015 DIETARY GUIDELINES ADVISORY COMMITTEE¹

The Dietary Guidelines for Americans (DGA) provides food-based recommendations for individuals 2 years of age and older, and have “an enormous impact on all food and nutrition policy in the country, especially at the federal level, with very strong permeation to the state, all the way

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¹ This section summarizes information presented by Rafael Pérez-Escamilla.

down to the local level,” stated Pérez-Escamilla. He noted that the DGA affects various sectors, including the food industry (e.g., product formulation, reformulation), nutrition education policies, and food assistance programs. The DGA is developed through what he described as a three-step process: (1) scientific report of the DGAC, (2) translation of the DGAC’s report into policy, known as the DGA, and (3) design and dissemination of DGA related products. Pérez-Escamilla, a member of the 2015 DGAC, focused his comments on the topics, recommendations, and implication statements made by the 2015 DGAC relevant to the workshop.

Intake of Added and Free Sugars in Relation to Chronic Disease

The 2015 DGAC approached the evidence by conducting original systematic reviews, reviewing existing expert reports, performing food pattern modeling, and commissioning data analyses. The 2015 DGAC defined sugar-sweetened beverages as “liquids that are sweetened with various forms of added sugars,” which include, but are not limited to, soda, fruitades, and sports drinks, stated Pérez-Escamilla. The DGAC primarily found moderate to strong evidence of the detrimental health effects of sugar-sweetened foods and beverages and refined grains, which included links to obesity, type 2 diabetes, heart disease, and dental caries. Echoing sentiments expressed by Anna Maria Siega-Riz in the first session, Pérez-Escamilla cautioned that the evidence was predominantly from studies on adults, as very few studies have been conducted on cohorts of children. Based on dietary pattern models and the scientific evidence on chronic disease risk, the 2015 DGAC concluded that added sugars intake should make up less than 10 percent of total energy consumed in the diet. Pérez-Escamilla emphasized that “added sugars should be replaced in the diet by selecting healthier options rather than replacing them with low-calorie sweeteners.” He added, “there was absolutely no reason for [the 2015 DGAC] to endorse the use of low-calorie sweeteners in children.” The 2015 DGAC also found moderate evidence to suggest that free sugars intake below 10 percent of total energy intake was associated with fewer dental caries, a conclusion that aligns with a systematic review by the World Health Organization (WHO, 2015).

Dietary Patterns

Recognizing that each individual nutrient, food, and food group does not independently affect chronic disease risk, the 2015 DGAC elected to consider the total diet in the context of dietary patterns. Pérez-Escamilla explained that low intakes of vegetables, whole fruit, and whole grains have resulted in markedly inadequate intakes of fiber in the U.S. population, which has implications for recommendations regarding the contribution of

100 percent fruit juice toward fruit intake. Pérez-Escamilla indicated that available evidence suggested energy-dense, low-fiber dietary patterns with higher intakes of “sweets, refined grains, and processed meats, as well as sugar-sweetened beverages, whole milk, fried potatoes, certain fats and oils, and fast food increase the risk of obesity later in life.”

Food pattern modeling revealed that “it is very difficult to achieve a healthful food pattern when added sugars in food and beverages are consumed above 10 percent [of total energy intake],” said Pérez-Escamilla. He described the 10 percent limit on added sugars as “lenient.” The analysis suggested lower limits were needed to achieve the goals set by the U.S. Department of Agriculture (USDA) food patterns over the course of a lifetime, as represented by different calorie levels (see Table 3-1). Pérez-Escamilla noted that other national and international organizations have arrived at similar findings regarding limiting added sugars (i.e., American Academy of Pediatrics, American Diabetes Association, American Heart Association, Centers for Disease Control and Prevention, World Health Organization), and he suggested that scientific consensus across organizations has had an effect on U.S. food labeling policy.

In the American diet, 19 percent of total energy intake comes from beverages, with 35 percent of beverage energy coming from sugar-sweetened beverages. Beverages (excluding milk and 100 percent fruit juice) make up 47 percent of the added sugars in the U.S. diet, with 39 percent of added sugars coming from sugar-sweetened beverages. Accordingly, the 2015 DGAC stated, “Dramatically reducing the intake of sugar-sweetened beverages and limiting sweets and desserts would help lower intakes of the food component added sugars” (HHS/USDA, 2015b).

Evidence-Based Policies

Pérez-Escamilla explained that very few policies are specifically directed at children 5 years of age and younger. Given that a 5-year-old is on the cusp of school age, Pérez-Escamilla mentioned that there is strong evidence for implementing school policies for nutrition standards to improve the availability, accessibility, and consumption of healthy foods and beverages sold outside the school meal programs. Reducing or eliminating unhealthy foods and beverages can help improve purchasing behavior and higher-quality dietary intake by children while at school, continued Pérez-Escamilla. From an implementation standpoint, he emphasized the role of schools and early child care and education settings. The 2015 DGAC recommended policies and programs in these settings be designed not only to limit unhealthy food and sugar-sweetened beverages and increase access to water, but also to support providers and teachers so sound nutrition education and physical activity is incorporated into the curriculum.

TABLE 3-1 Added Sugars Available in the U.S. Department of Agriculture Food Patterns (Healthy U.S.-Style, Healthy Mediterranean-Style, and Healthy Vegetarian Patterns) (in calories, teaspoons, and percent of total calories per day)

SOURCES: As presented by Rafael Pérez-Escamilla, June 21, 2017; HHS/USDA, 2015b.

The 2015 DGAC also highlighted the role of federal food assistance programs, recommending that programs be leveraged to support the purchase of healthier options, including foods and beverages low in added sugars. Pérez-Escamilla observed that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may be and can continue playing a role in the decline of not only sugar-sweetened beverages, but also 100 percent fruit juice consumption through revisions to the food packages offered by the program.

To help consumers make informed decisions, the 2015 DGAC specifically recommended that the Nutrition Facts label include added sugars, listed in grams and teaspoons, reported Pérez-Escamilla. He also noted that taxes are another factor that affects consumer decisions. While initially perceived as controversial when recommended by the 2015 DGAC, Pérez-Escamilla explained that sugar-sweetened beverage taxes, particularly the

tax implemented in Mexico, are effective policies for affecting intake and generating revenue.

Pérez-Escamilla noted that a disproportionate amount of marketing money is spent to promote unhealthy foods to children ($1.7 billion in 2009), as compared to healthy products ($80 million in 2009). Stating that racial disparities in marketing practices exist, he pointed out that 80 percent of foods and drinks advertised to children on Spanish television are unhealthy, and black children see more than twice as many television advertisements for sugar-sweetened beverages than their white counterparts. Websites and social media are also being used to promote food and beverages, particularly to children, Pérez-Escamilla remarked. The 2015 DGAC recommended that policies be implemented that limit exposure and marketing of foods and beverages high in added sugars and sodium to all age groups, particularly children and adolescents, specified Pérez-Escamilla.

Interface with Other Guidelines

Pérez-Escamilla concluded his presentation by noting that the Robert Wood Johnson Foundation’s Healthy Eating Research (HER) program had recently put forth healthy beverage recommendations for water, milk, and juice intake of children 2 to 4 years of age and 5 to 10 years of age, which were consistent with the 2010 DGA. Pérez-Escamilla explained that the recommendations offer a strong message regarding juice, and that children do not have to consume juice if they prefer whole fruit instead.

AMERICAN ACADEMY OF PEDIATRICS (AAP) GUIDELINES²

One of the major areas of focus for AAP is providing nutrition guidance for children and adolescents. Daniels explained that AAP develops and publishes several types of reports and statements that provide various depths of analyses of the evidence:

• Clinical practice guidelines represent the highest level of evidence review, including a comprehensive review of literature and data analyses.
• Policy statements are based on a review of literature and describe and/or drive AAP’s stance on a particular child health care and policy issue. They are considered “living documents” and are reviewed at least every 3 years, at which time the statement is “reaffirmed, revised, or retired,” depending on the evidence that has emerged in the meantime.
• Clinical reports, also a type of policy document, aim to help the pediatrician make the best practice decisions based on current evidence.
• Technical reports focus on issues underpinning either clinical decision making or other types of issues related to pediatrics.

Daniels also acknowledged two major AAP publications that provide nutrition guidance for children and adolescents—Nutrition: What Every Parent Needs to Know (AAP, 2011) and Pediatric Nutrition (AAP Committee on Nutrition, 2013). Both are in the process of being revised.

According to Daniels, AAP has not formally defined sugar-sweetened beverages and, at this time, does not have a specific statement on beverage intake or sugar-sweetened beverage intake among children 0 to 5 years of age. He explained that AAP is currently developing a policy statement with the American Heart Association on the health effects of added sugars. AAP

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² This section summarizes information presented by Stephen Daniels.

guidance, however, does note that a number of sugar-sweetened products (i.e., sports drinks, soft drinks, and energy drinks) are not appropriate beverages for young children.

AAP offers general feeding guidance for children younger than 5 years of age. During the first year of life (birth to 12 months of age), AAP recommends exclusive breastfeeding for approximately 6 months and continued breastfeeding throughout the first year of life, even after the introduction of iron- and zinc-rich complementary foods. Infant formula is the only acceptable substitute for breastmilk, noted Daniels, adding that cow’s milk should not be provided to infants in the first year of life. He also highlighted a recent AAP policy statement recommending that 100 percent fruit juice not be given in the first year of life (Heyman and Abrams, 2017), a revision of a previous recommendation that 100 percent fruit juice could be offered to infants beginning at 6 months of age.

For the second year of life (12 to 24 months of age), AAP recommends that breastfeeding can continue and cow’s milk can be introduced. Daniels noted that cow’s milk should be the primary beverage for young children, starting at 1 year of age. He also explained that whole fruit is preferred, but that AAP guidance allows for 100 percent fruit juice to be offered to children 12 months of age and older. Accompanying this guidance is an emphasis on portion size—no more than 4 ounces of 100 percent fruit juice per day for children 1 to 3 years of age. To avoid risk of dental caries, 100 percent fruit juice should not be given in a bottle or at bedtime, stated Daniels. He added that calorie-dense and nutrient-poor foods and beverages should be avoided.

For children 2 to 5 years of age, Daniels said that AAP guidance places an emphasis on low-fat milk. He also specified that 100 percent fruit juice can help children meet their fruit intake goals, but only with appropriate portion size. For this age range, AAP recommends no more than 4 ounces of 100 percent juice per day for children 1 to 3 years of age and no more than 6 ounces per day for children 4 to 6 years of age.

Sugar-sweetened beverages are one of the top contributors to total energy intake for children, stated Daniels. He added that soft drinks are a main source of added sugars intake for young children and have been shown to displace milk in the diet. To encourage and sustain milk consumption and achieve nutrition goals for vitamin D and calcium, AAP recognizes that flavored milk can be part of a healthy diet. Daniels noted there is evidence to suggest that flavored milk can increase milk intake among children.

Pediatricians play an important role in monitoring growth, development, and changes in body mass index percentiles, which are used to evaluate whether dietary intake is adequate and to assess a child’s progression toward obesity. Daniels thought that pediatricians should be tuned into

cultural preferences to guide families toward the healthiest possible diet and suggested that health promotion efforts should aim to remove sugar-sweetened beverages from children’s diets. He also believed that pediatricians should be asking parents about how they expose their children to media and help families develop a plan around media use. Outlining current media use recommendations, Daniels explained that pediatricians should discourage screen media for children 18 to 24 months of age, other than interactive applications, and, if media are to be introduced, high-quality programming and apps should be used. Children 2 years of age and older should be exposed to less than 1 hour per day of high-quality programing, with no screens during meals or 1 hour before bedtime, he continued. A family approach to sharing media should be used, noted Daniels.

To conclude his presentation, Daniels said that AAP is supportive of efforts to incentivize healthier eating and strongly supports WIC, the Supplemental Nutrition Assistance Program (SNAP), the school meal program, and policies that ultimately improve the diets of children. He stated, however, that AAP has not supported efforts to remove 100 percent fruit juice from WIC packages or efforts to disallow certain foods and beverages, including sugar-sweetened beverages, from the SNAP program.

FACILITATED DISCUSSION WITH THE AUDIENCE

To open the facilitated discussion, Davis asked Pérez-Escamilla and Daniels to discuss the strengths and limitations of different expert groups releasing guidelines on similar topics. Daniels noted that applying evidence is a challenging process that takes time, effort, and resources. He said that different groups may not arrive at the same conclusions because “there are major gaps in the evidence that require interpretation and, sometimes, insertion of expert opinion.” Daniels also indicated that evidence-based guidelines are not always implemented, and suggested that more work needs to be done to understand how to enhance uptake. In describing how the DGAC scientific report is translated to the DGA, Pérez-Escamilla discussed the need for the process by which policies are created to be transparent and evidence based. He offered his experience with the HER responsive parenting infant and young toddler feeding guidelines as an example of how the committee involved in the review of the evidence had input on the translation of the evidence.

An audience member noted that the National School Lunch and School Breakfast Programs allow for up to 50 percent of fruit requirements to be satisfied by 100 percent juice, and asked if the regulations should be changed to only allow whole fruit. Daniels acknowledged that 100 percent fruit juice is not identical to whole fruit in terms of nutrition (e.g., fiber). However, he was not supportive of completely eliminating 100 percent fruit juice, given its portability and shelf stability. Instead, Daniels emphasized

the role of the overall dietary pattern and how 100 percent fruit juice fits into the context of the total diet. Pérez-Escamilla suggested taking a life-course approach to developing preferences for unsweetened foods and beverages so that sugar-sweetened beverages, and perhaps even fruit juice, are not considered normative beverages for young children.

Davis posed a question from an audience member who asked about ways to restrict sugar-sweetened beverage purchases with SNAP benefits. Pérez-Escamilla explained that a few years ago he was part of an advisory panel asked to provide advice on whether USDA should administer SNAP more like WIC benefits (i.e., funds designated for the purchase of specific foods) or whether additional funds or incentives should be used to promote fruit and vegetable purchases. He noted there is opposition to imposing restrictions, particularly among civil society organizations working in very low-income communities. These organizations felt such limitations would target low-income communities and disallow choice. The advisory panel ultimately recommended launching the USDA Healthy Incentives Pilot to provide financial incentives for the purchase of fresh fruits and vegetables using SNAP benefits. Pérez-Escamilla also offered the idea of changing the definition of what qualifies as “food” so that sugar-sweetened beverages are no longer considered eligible. Daniels suggested leveraging SNAP Education to promote healthier food choices.

To conclude the facilitated discussion, Davis posed a series of audience questions related to milk. The first question asked whether the recommended alternative to sugar-sweetened beverages should be milk rather than water. Daniels repeated that, from AAP’s perspective, there is a hierarchy of beverages for children with milk as the primary beverage, followed by water. The second question challenged AAP’s position on flavored milk for young children, and suggested that unflavored whole milk should be recommended instead. Repeating a point made during his presentation, Daniels noted that when flavored milk is removed as an option, children who consumed flavored milk tended not to switch to unflavored milk. The final question Davis posed related to the sugar content in infant formulas. Daniels explained that both infant formula and breastmilk contain sugar. He said that infant formulas are designed to be compositionally close to breastmilk, and do not have the protein loads and other components of cow’s milk that promote iron deficiency in infants. This compositional difference underlies the recommendation that cow’s milk not be given to children younger than 1 year of age, stated Daniels. Pérez-Escamilla noted that emerging evidence suggests that one of the drivers behind the obesity risk difference between formula-fed and breastfed infants may be higher protein intake among formula-fed infants. Daniels suggested the obesity risk differences could also be caused by differences in hunger and satiety cues and mother–infant interactions.

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