Association Between 100% Juice Consumption and Nutrient Intake and Weight of Children Aged 2 to 11 Years

Objective  To investigate the associations between 4 categories of daily 100% juice consumption (0 fl oz, > 0 to ≤ 6 fl oz; > 6 to < 12 fl oz; and ≥ 12 fl oz) and nutrient and food group intake and weight in children.

Design  Cross-sectional study.

Setting  Secondary analysis of the 1999-2002 National Health and Nutrition Examination Survey data.

Participants  Children 2 to 11 years of age (N = 3618).

Main Exposure  Juice consumption.

Outcome Measures  The association between juice consumption, nutrient intake, food group consumption, and weight status was determined as was the likelihood of overweight with juice consumption.

Results  Mean daily juice consumption was 4.1 fl oz, which contributed a mean intake of 58 kcal (3.3% of total energy intake). Compared with nonconsumers, the overall nutritional profile of those consuming 100% juice had significantly higher intakes of energy, carbohydrates, vitamins C and B₆, potassium, riboflavin, magnesium, iron, and folate and significantly lower intakes of total fat, saturated fatty acids, discretionary fat, and added sugar. Children consuming 100% juice also consumed significantly more servings of total whole fruit than nonconsumers. No significant differences were found in weight status and the amounts of 100% juice consumed. There was no difference in the likelihood of being overweight between juice consumers and nonconsumers.

Conclusions  On average, children consumed less than the maximum amounts of 100% juice recommended by the American Academy of Pediatrics. One hundred percent juice consumption was associated with better nutrient intake than in the nonconsumption group and was not associated with weight status or the likelihood of being overweight in children 2 to 11 years of age.

The prevalence of overweight and obesity in the United States is increasing at alarming rates¹ in all age and ethnic groups compared with observations during the past 20 years.^2-4 According to the 1999-2002 National Health and Nutritional Evaluation Survey (NHANES), 22.6% of children aged 2 to 5 years and 31% of children aged 6 to 19 years were overweight or at risk of overweight² (body mass index [BMI] [calculated as weight in kilograms divided by height in meters squared] ≥ 85th percentile), and 10.3% were overweight (BMI ≥ 95th percentile).⁵ The percentage of overweight has increased compared with data from NHANES III (1988-1994), which showed that 7.2% of children 2 to 5 years of age and 11.3% of children 6 to 11 years of age were overweight.⁶ Overweight in children is associated with increased health problems, including hyperlipidemia,⁷ hypertension,⁷ metabolic syndrome,⁸ and type 2 diabetes.⁹ Overweight children also experience discrimination, stigmatization,¹⁰ and low self-esteem.¹¹ Furthermore, overweight tends to follow children into adulthood.¹²

Food-consumption patterns may play a role in the increasing prevalence of overweight in children. Dennison et al¹³ initially raised concerns about 100% fruit juice as a dietary factor associated with overweight in children when they showed that preschool-aged children consuming 12 fl oz or more of 100% fruit juice per day had a higher prevalence of overweight than those who consumed less than 12 fl oz a day (32% vs 9%). Later, this association with overweight held for apple juice only.¹⁴ Tanasescu et al¹⁵ also showed, in a small sample of 53 children in Connecticut, that overweight was associated with fruit juice consumption. Dennison et al¹³ found that the high–100% fruit juice consumers tended to have a short stature¹⁶; however, this was later shown for only apple juice and grape juice consumers.¹⁴ A major limitation of these studies^13-15 is that they included small, regional samples, possibly explaining why results have not been replicated in national surveys. Several national studies failed to show an association between 100% fruit juice and overweight or stature in children.^17-19 In studies using larger nationally representative populations, in 2- to 5-year-old children (N = 1160) O’Connor et al²⁰ showed that there was no significant association between 100% fruit juice and weight, and Field et al²¹ showed no association between weight and fruit juice in children aged 9 to 14 years (N = 14 918). This was confirmed in a study of children 6 to 19 years of age from the 1994-1996, 1998 Continuing Survey of Food Intake by Individuals for noncitrus juices; citrus juices were shown to be inversely associated with weight.²²

Welsh et al²³ looked at a possible association of consuming sweet drinks (100% fruit juices/drinks and sodas) with BMI during a 1-year period and found no association between sweet-drink consumption and development of overweight in preschool children of normal weights enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children. Children who were already overweight or at risk for overweight at the beginning of the study did have significantly higher odds of remaining overweight or becoming overweight if they drank more than 1 sweet drink per day, but analysis was not limited to 100% fruit juice. In another longitudinal study of preschool-aged children, no significant correlation between weight change and 100% fruit juice was found.²⁴ Thus, recent studies using national samples have shown no association between consumption of 100% fruit juice and weight. The 2 objectives of this study were to determine if, in a nationally representative sample of children 2 to 11 years of age, 100% juice consumption affected (1) nutrient intake and food groups and (2) weight status.

The NHANES is an ongoing data-collection initiative to obtain information about the health and diet of a cross-sectional, nationally representative US sample. For this study, data from 1999-2000 and 2001-2002 were combined. Procedures for selecting the sample and conducting the interviews and examinations for 1999-2002 NHANES were similar to those for previous surveys.¹⁶ (Additional information about 1999-2002 NHANES is available at http://www.cdc.gov/nchs/nhanes.htm.)

For NHANES, information is obtained from in-home interviews followed by medical evaluations and physical examinations at mobile examination centers. The latter included measurements of body weight and height. Race/ethnicity was based on self-reported data using census categories.²⁵

The types and amounts of foods and beverages consumed were determined using the multi-pass, 24-hour dietary interview method.²⁶ Caretakers reported dietary intakes for children younger than 6 years and the 6- to 12-year-old children reported their diets with adult assistance. For the 1999-2000 NHANES, the United States Department of Agriculture (USDA) 1994-1998 Survey Nutrient Database was used to code and report intake of energy and nutrients. The USDA Food and Nutrient Database for Dietary Studies, version 1, was used for processing dietary interview data for 2001-2002.²⁷ Only dietary interviews deemed “reliable and [that] met minimum criteria” were used. In the original release of 1999-2000 NHANES, data on vitamin A intake were only available in milligrams of retinol equivalents and vitamin E intake data were only available in milligrams of alpha-tocopherol equivalents. We used the special database released by the USDA to determine vitamin A in milligrams of retinol activity equivalents and vitamin E in milligrams of alpha-tocopherol equivalents.^28-30 Food group–servings data were obtained from the Pyramid Database for USDA Food Survey Food Codes, version 2.0.³¹

Added sugars are defined by the USDA as any sugar product that is eaten separately or used as an ingredient in processed or prepared foods. Discretionary fat includes amounts of fat above that consumed if the lowest fat choices were made in all food groups. We did not include 100% juice in the total whole fruit group.

The 1999-2000 NHANES Anthropometry Procedures Manual describes the protocol, equipment, and measurement of anthropometric data.³² The manual also provides information about equipment, calibration, methods, quality control, and survey procedures. Percentile and z scores of weight for age and percentile and z scores of BMI for age were calculated using growth chart programs available from the Centers for Disease Control and Prevention.³³

Children aged 2 to 11 years were separated into 4 groups: 3 groups of juice consumers (> 0 to ≤ 6 fl oz/d, > 6 to ≤ 12 fl oz/d, and > 12 fl oz/d) and nonconsumers, depending on whether any 100% juice was reported in the 24-hour recall. Juice groupings were chosen as the highest recommended levels for age groups by the American Academy of Pediatrics (AAP).³⁴ A list of 100% juice food codes were generated from the NHANES food files and were used to define a juice consumer. Participants were separated into 3 age groups (2-3, 4-8, and 9-11 years), similar to those used for dietary reference intakes³⁵ and the MyPyramid groupings.³⁶ There is a difference between age groupings for MyPyramid and the AAP recommendation for 100% juice intake; however, there was no difference between intake of children aged 4 to 8 years (9.52 fl oz) and children aged 7 to 8 years (9.51 fl oz); thus, we felt justified in combining these groups. Since this study used secondary data and no personal identifiers were available, it was exempted by the institutional review board of the Baylor College of Medicine.

Analyses were conducted for all children aged 2 to 11 years and for each age group separately. Least square means and standard errors of the mean are presented for food groups, nutrient intakes, and obesity measures for juice consumers and nonconsumers. Median values were also compared; because they were similar to the means, they are not presented in this article. Energy intake was adjusted for sex, ethnicity, and age. Food-group intake, nutrient intakes, and obesity measures were adjusted for sex, ethnicity, age, and energy intake. Logistic regression, after adjustment for sex, ethnicity, age, and energy intake, was used to assess the risk of overweight and the risk of being overweight. All analyses were weighted using the NHANES examination sample weights and adjusted for the complex sample design of NHANES with the statistical package SUDAAN, version 8 (RTI International, Research Triangle Park, North Carolina). Because multiple comparisons were conduced, a Bonferroni adjustment was made, and the effective P value was .0125.

Of the sample (N = 3618) of 2- to 11-year-old children, 24% were aged 2 to 3 years, 47% were aged 4 to 8 years, and 29% were aged 9 to 11 years (Table 1). Fifty-one percent were male; 33% were Hispanic, 29% were white, 29% were black, and 9% were of another race. Forty-three percent of the children consumed 100% juice the day of the recall: 55% of 2- to 3-year-old children, 41% of 4- to 8-year-old children, and 35% of 9- to 11-year-old children. The mean amount of 100% juice consumed daily was 4.1 fl oz, contributing a mean of 58 kcal (3.3% energy intake). Among 100% juice consumers, the mean amount of 100% juice consumed daily was 10.6 fl oz, which contributed a mean of 150 kcal or 8.5% of total energy intake (data not shown). The mean amount of 100% juice consumed was highest among 2- to 3-year-old children. Those who did not consume 100% juice consumed significantly more fluid ounces of fruit drinks (P < .001) and soft drinks (P < .001) than children who consumed 100% juice at all ages (data not shown). For nonconsumers, fruit drinks and soft drinks accounted for 9.4% of total energy intake.

Compared with children who did not consume 100% juice, children consuming more than 6 fl oz of 100% juice had significantly lower intakes of total fat and saturated fatty acids and significantly higher intakes of total carbohydrates, vitamins C and B₆, folate, potassium, magnesium, and iron (Table 2). Total energy intake was significantly higher in children who consumed more than 12 fl oz of 100% juice (2138 kcal) compared with children who did not consume 100% juice (1828 kcal).

Mean adjusted intake of food groups by amount of 100% juice consumed is presented in Table 3. Compared with children who did not consume 100% juice, children who consumed more than 6 fl oz of 100% juice consumed significantly less discretionary fat and added sugar (Figure) and significantly more servings of total whole fruits.

No significant differences were found in any weight parameter or the amount of 100% juice consumed (Table 4). Similar results were found when the analyses were conducted by the age categories (2-3, 4-8, and 9-11 years). There was no difference in the likelihood of being overweight among the 100% juice consumers compared with nonconsumers (Table 5) or in consumption of juice by weight category (Table 6).

This study showed that consumption of 100% juice was not associated with increased BMI or other measures of obesity in children aged 2 to 11 years and that children who drank 100% juice had improved nutrient and food-group intakes compared with those who did not. Most published studies that have evaluated the association between weight and 100% juice consumption have done so in preschool-aged children.^{13,14,17-20,37,38} Most of these studies showed no association between fruit juice consumption and weight in children.^17-20,37-39 Only Dennison and colleagues’^13,14,38 and Tanasescu and colleagues’¹⁵ groups found an association between consumption of juice and obesity. The study by Dennison et al¹³ has been criticized for its small biased sample and that it failed to account for other potential reasons for obesity.⁴⁰ Moreover, age- and sex-specific BMI cutoffs⁴¹ to define obesity were not the Centers for Disease Control and Prevention recommendations, making that study difficult to compare with others. Subsequently, the association between weight and fruit juice consumption was shown only in children aged 2 and 7 years who drank apple juice.¹⁴ Patients in the study by Tanasescu et al¹⁵ are also difficult to compare with current students, because obesity was defined as a BMI at or above the 85th percentile, a value that is defined as at risk of overweight. Faith et al³⁸ showed that the association between very high levels of fruit juice consumption (24-30 fl oz) and BMI z scores could be shown only in children 1 to 5 years of age who were already overweight or at risk of overweight.

Those studies, though flawed, demonstrated the need for additional studies assessing the association between juice consumption and weight in children; however, other studies, including ours, have failed to show a relationship between juice consumption and weight in children. In 9- to 14-year-old children, fruit juice consumption was not associated with weight.²¹ This was later confirmed in a national study of children and adolescents 6 to 19 years of age.²²

Our study did not show an association between juice consumption and BMI or other measures of obesity or the likelihood of overweight, but it did show increased energy intake in the group with the highest amounts of juice consumption. This has been shown previously²⁰ and warrants further investigation to determine the source and effect of the additional energy. It is facile and premature to suggest it is attributed solely to juice. To determine the effect of this increased energy intake on overweight later in life would require a longitudinal study conducted in a nationally representative sample with adequate statistical power.

The mean intake of vitamin C in this study met recommendations. It has been shown previously that among 7- to 12-year-old children, approximately 12% had low intakes of vitamin C (< 30 mg/d), and that the primary contributor to vitamin C intake was high–vitamin C fruit juice.⁴² Among younger children (aged 2 and 5 years), vitamin C intake was most strongly correlated at that time with consumption of citrus fruits and citrus juices.⁴³ Removing juices from the diet without replacement resulted in substantial decreases in vitamin C intake in all food patterns; replacement with fruit corrected this.³⁷ In this study, children in groups consuming any amount of 100% juice had higher intakes of vitamin C, suggesting that consumption of juice may be a good way to help children meet this recommendation, especially if they do not consume whole fruit.

Consumption of 100% juice was not associated with a decreased intake of other foods or beverages. Children who consumed more than 12 fl oz per day of 100% juice did not consume significantly less milk compared with the children who did not consume 100% juice. Children who consumed 100% juice also consumed significantly less total fat, saturated fatty acids, added sugar, and discretionary fat, which is an important step to meeting the 2005 Dietary Guidelines for Americans.⁴⁴ That 100% juice consumption was not associated with decreased intake of milk is consistent with findings reported by Dennison et al¹³ and Skinner et al¹⁹ and is important from a nutrient standpoint. It is also important that, on average, children who consumed 100% juice also consumed more servings of total whole fruits.

On average, young children are consuming 2.2 servings of fruit, which meets the current recommendation of 2 servings a day for 2- to 3-year-old children⁴⁵; however, as children get older, fruit consumption declines.⁴⁵ Among 4- to 8-year-old children, the mean intake of fruit was below the current recommended number of 2 servings per day.⁴⁵ Approximately 40% of children aged 2 to 5 years consumed less than 1 serving of fruit per day.⁴⁶ In our study, an alarming 57% of 2- to 11-year-old children reported not consuming any amount of 100% juice.

Good dietary habits should be encouraged in childhood, because it is the time when many adult-onset diseases linked to low intake of fruits or vegetables, such as cancer⁴⁷ and cardiovascular disease,⁴⁸ may begin. Few children meet the recommendations for fruit and vegetable intake. Since fruit and vegetable intake generally decreases with increased age in children,^45,49 it is important to encourage intake at a young age. It is not clear why some children drink more fruit juice and what the association is with increased intake of fruit in these individuals. Taste and availability are 2 generally recognized factors in increased intake of fruit and vegetables⁵⁰; usual food intake, subjective norms, parenting style,⁵¹ and visual benefits of eating fruit and vegetables⁵² are others.

The AAP advises that 100% fruit juice be limited to 4 to 6 fl oz per day for children 1 to 6 years of age and to 8 to 12 fl oz a day for children and adolescents 7 to 18 years of age. The AAP further recommends that in the evaluation of overnutrition in children, health care providers should determine the amount of 100% fruit juice consumed.³⁴ While the AAP suggests that consumption of whole fruits should be encouraged for meeting daily recommended fruit intake, they also state that 100% fruit juice can be part of a healthy diet when served in age-appropriate amounts.³⁴ The AAP policy statement does not include a rationale for their recommendations; thus, it is time that these recommendations are reassessed.

On average, the entire population of children in this survey consumed only 4.1 fl oz of 100% juice, which was well within the AAP's recommendations³⁴ and the 2005 Dietary Guidelines for Americans⁴⁴; however, of those children drinking juice, the intake was higher and exceeded recommendations. Excessive intake should be monitored by practitioners. Children 2 to 3 years of age had the highest juice consumption and the highest percentage of energy coming from juice. Overall, the mean energy intake of children consuming the highest amounts of juice was higher than children consuming no juice. This is consistent with another study²⁰ that found that with increased consumption of any type of beverage, including 100% fruit juice, total energy intake increased, though BMI did not increase. Although higher intakes of juice were not associated with increased weight, a longitudinal study is needed to understand the effect of the increased energy intake associated with increased 100% juice consumption on weight.

The USDA conducted a special analysis for the 2005 Dietary Guidelines for Americans Advisory Committee,³⁷ looking at the effect of removing fruit juice from the fruit recommendation and substituting the portion of the composite with whole fruit. Replacing 100% fruit juice with whole fruit did not result in nutrient shortfalls, with the exception of nutrients (ie, potassium and magnesium) that are already in shortfall amounts in most diets. However, replacing some of the 100% fruit juice with whole fruit could help meet the fiber recommendation. Thus, the current Dietary Guidelines for Americans recommend that the intake of no more than one-third of fruit servings should come from 100% fruit juice and no less than two-thirds should come from whole fruit.³⁷

This study looked only at 100% juice, as defined by the Food and Drug Administration,⁵³ and weight. Care must be taken by consumers to read labels and to not confuse 100% juice with juice drinks or ades. Two recent studies^20,22 failed to show a relationship between BMI and consumption of fruit drinks or ades; however, these products are high in added sugars and, though some are fortified with nutrients such as vitamin C, contribute few nutrients to children's diets.⁵⁴

This study has several limitations. First, the cross-sectional study design of NHANES does not provide the longitudinal data needed to determine if the increased energy intake associated with increased juice consumption would lead to increased weight over time. Furthermore, no cause-and-effect relationships can be determined. Second, a single dietary recall may not represent the typical intake⁵⁵ of the study population, and underreporting or overreporting of energy may have occurred.^56,57 Third, children of this age typically spend time away from their parents in child care or school and parents may be unaware of everything that they consumed the day before, resulting in reporting errors.⁵⁸ It is possible that foods other than 100% juice contributed to differences in nutrient intake of the participants. Given the multicolinearity in diet, there are a number of eating patterns that have been shown to be potentially associated with overweight⁵⁹ that warrant further investigation.

In conclusion, 100% juice intake, even in amounts exceeding recommendations, was not associated with obesity and provides valuable nutrients, including vitamins C and B₆, folate, potassium, and magnesium and is associated with decreased intake of total and saturated fat, added sugar, and discretionary fat. Furthermore, 100% juice consumption was associated with increased intake of fruit and was not associated with decreased intake of other nutrient-dense foods, such as milk, meat, or vegetables, in the children's diets. Consumption of 100% juice as part of an overall healthy diet should be encouraged based on its nutritional benefits. The weight of the current scientific evidence clearly supports the nutritional benefits of 100% juice consumption and does not support a relationship between overweight and 100% juice consumption in children.

Correspondence: Theresa A. Nicklas, DrPH, Department of Pediatrics, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Ave, Houston, TX 77030-2600 (tnicklas@bcm.tmc.edu).

Accepted for Publication: September 27, 2007.

Author Contributions: Dr Nicklas had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr O’Neil worked closely with her assessing data and writing the manuscript. Dr Kleinman was involved in the review of the literature and critical editing of the manuscript. Study concept and design: Nicklas, O’Neil, and Kleinman. Acquisition of data: Nicklas. Analysis and interpretation of data: Nicklas and O’Neil. Drafting of the manuscript: Nicklas, O’Neil, and Kleinman. Critical revision of the manuscript for important intellectual content: Nicklas, O’Neil, and Kleinman. Obtained funding: Nicklas. Administrative, technical, and material support: Nicklas. Study supervision: Nicklas and Kleinman.

Financial Disclosure: None reported.

Funding/Support: This work was supported in part by the USDA Hatch Projects (940-36-3104, Project No. 93673 and LAB 93676, Project No. 0199070), the Juice Products Association, and with federal funds from the USDA/Agricultural Research Service (under cooperative agreement No. 58-6250-6-003).

Role of the Sponsor: The sponsor had no role in the design or conduct of the study; the collection, management, analysis, or interpretation of the data; or the preparation or approval of the manuscript.

Disclaimer: This work is a publication of the USDA Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the US government.

Additional Contributions: Victor Fulgoni III, PhD, and Sally Fulgoni, BS, from Nutrition Impact LLC, Battle Creek, Michigan, helped in the statistical analysis of the NHANES data.