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• W2096483131 abstract "In an editorial accompanying the study by Mrdjenovic and Levitsky1Mrdjenovic G. Levitsky D.A. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children.J Pediatr. 2003; 142: 604-610Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar on the topic of sweetened drinks and childhood nutrition, Schwartz2Schwartz R.P. Soft drinks taste good, but the calories count.J Pediatr. 2003; 142: 599-601Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar proposed that Americans “reduce the availability and limit portion sizes of sugar-sweetened drinks sold at school and provided at home.” In the study, 30 children 7 to 13 years of age acted as their own controls, collecting daily diet records and weighing food to estimate intake from a baseline period through 4 to 8 weeks of follow-up. Body mass index was measured regularly. The data showed that not only were those children with the highest intake of sweetened drinks consuming greater daily energy, but also that sweet drinks displaced milk from their diet. The resulting trade-off resulted in lower daily protein, calcium, phosphorus, magnesium, and vitamin A. The authors concluded that excessive sweetened-drink consumption associated with decreased milk intake may be one important risk factor for childhood obesity and nutrient deficiencies.1Mrdjenovic G. Levitsky D.A. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children.J Pediatr. 2003; 142: 604-610Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar In his editorial, Schwartz2Schwartz R.P. Soft drinks taste good, but the calories count.J Pediatr. 2003; 142: 599-601Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar recommended teaching children to drink water for thirst, promoting healthier choices in vending machines in schools and communities, prohibiting advertising of sweetened beverages in schools and daycare centers, and even levying small taxes on soft drinks and snack foods to be used to educate children and fund extra-curricular activities. In light of the accumulating evidence, Schwartz's recommendations to limit sweetened drinks would seem reasonable. But have we gone too far in making soft drinks the fall guy for obesity?Some think so. Subsequent letters to the editor, as well as press releases from representatives of the soft drink industry, disagreed with the conclusions of the authors of the study.3Sutherland L.A. Soft drinks and obesity.J Pediatr. 2004; 144: 554-557Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 4Ginevan M.E. Soft drinks and obesity.J Pediatr. 2004; 144: 555-556Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 5Allport J.H. Soft drinks and obesity.J Pediatr. 2004; 144: 554-555Abstract Full Text Full Text PDF PubMed Google Scholar They objected to recommendations from the healthcare community that supported curbing soft drink consumption. The respondents felt that the designation of sweetened drinks as a cause for such a complex, multi-factorial problem as obesity was simplistic. They cited declining physical activity and increasing television and screen time as etiologies with a greater base of research evidence than that for soft drinks. Likewise, frequency of fast food, extreme portion sizes, and other unbalanced patterns of food consumption have had an equal or greater impact than that of soft drinks. They stated that the data on the increase in soft drink consumption are contradictory. Despite several studies based on the USDA's National Health and Nutrition Examination Survey and the Continuing Food Survey of Food Intakes by Individuals methodologies that showed an increasing trend,6Ballew C. Kuester S. Gillespie C. Beverage choices affect adequacy of children's nutrient intakes.Arch Pediatr Adolesc Med. 2000; 154: 1148-1152Crossref PubMed Scopus (141) Google Scholar, 7French S.A. Story M. Fulkerson J.A. Gerlach A.F. Food environment in secondary schools: a la carte, vending machines, and food policies and practices.Am J Public Health. 2003; 93: 1161-1167Crossref PubMed Google Scholar, 8French S.A. Lin B.H. Guthrie J.F. National trends in soft drink consumption among children and adolescents age 6 to 17 years: prevalence, amounts, and sources, 1977/1978 to 1994/1998.J Am Diet Assoc. 2003; 103: 1326-1331Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar, 9Guthrie J.F. Morton J.F. Food sources of added sweeteners in the diets of Americans.J Am Diet Assoc. 2000; 100 (quiz): 43-51Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar, 10Harnack L. Stang J. Story M. Soft drink consumption among US children and adolescents: nutritional consequences.J Am Diet Assoc. 1999; 99: 436-441Abstract Full Text Full Text PDF PubMed Scopus (581) Google Scholar, 11Borrud L. Enns W. Mickle S. What we eat in America: USDA surveys food consumption changes.Food Rev. 1996; Sept-Oct: 14-19Google Scholar, 12Krebs-Smith S.M. Choose beverages and foods to moderate your intake of sugars: measurement requires quantification.J Nutr. 2001; 131: 527S-535SPubMed Google Scholar not all studies demonstrated this trend.13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar In their public and private communications, representatives of the soft drink industry cited a study by Park et al13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar that suggests that carbonated soft drink consumption has not increased, nor has milk consumption fallen, over the past decade, whereas obesity has accelerated. In addition, they state that research has failed to confirm the displacement of milk intake with rising soft drink consumption. Ultimately, they cite evidence that consumption of carbonated soft drinks from vending machines at school is minimal, only 2.5 oz per week, certainly insufficient to account for the obesity crisis.3Sutherland L.A. Soft drinks and obesity.J Pediatr. 2004; 144: 554-557Abstract Full Text Full Text PDF PubMed Scopus (2) Google ScholarMany of their objections are valid. Certainly, soft drinks are not the root cause of obesity. The healthcare community has convinced Americans that there is an obesity epidemic. Now the public wants health professionals to identify the villain. Finding a single culprit would be convenient, but it will not happen with obesity. This disease is wrapped in genetics and culture, behavior and psychology. It is important to recognize that even if soft drink consumption was eliminated through a zealous, latter-day prohibition movement, it is unlikely to eliminate obesity, given the many factors that contribute.14American Academy of Pediatrics, Committee on Nutrition Prevention of pediatric overweight and obesity.Pediatrics. 2003; 112: 424-430Crossref PubMed Scopus (1022) Google Scholar However, among those many factors, soft drinks have a prominent place. Although obesity prevention will require many interventions that affect all aspects of children's lives, curbing the current intake of sugar consumed in the form of sweetened drinks will be one of the most important strategies. The objections of the soft drink industry sidestep the intent of the recommendations being made by pediatricians. And in doing so, the industry may miss an opportunity to play a central role in helping to unravel childhood obesity.In a Crowded Field, Why Are Soft Drinks Singled Out?Far from picking on soft drinks as the sole cause for obesity, the American Academy of Pediatrics (AAP) has issued several policy statements on a broad array of issues surrounding childhood obesity. The AAP Committee on Nutrition statement on “The Prevention of Pediatric Overweight and Obesity” was issued in August 2003, addressing genetics, family dynamics and the home environment, recent societal changes, the decline in physical activity and concomitant rise in television viewing, as well as dietary factors that promote obesity.14American Academy of Pediatrics, Committee on Nutrition Prevention of pediatric overweight and obesity.Pediatrics. 2003; 112: 424-430Crossref PubMed Scopus (1022) Google Scholar Previously, the AAP Committee on Nutrition recommended a limitation on juice intake by babies to lessen the risk of overweight.15American Academy of Pediatrics The use and misuse of fruit juice in pediatrics.Pediatrics. 2001; 107: 1210-1213Crossref PubMed Scopus (72) Google Scholar In a clinical report on the prevention and treatment of diabetes type II, the AAP cited the role of the community in helping to prevent the advent of obesity-related diabetes through improved physical activity and nutrition, especially among high-risk populations.16Gahagan S. Silverstein J. Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska Native children. American Academy of Pediatrics Committee on Native American Child Health.Pediatrics. 2003; 112: e328-e347Crossref PubMed Google Scholar The Committee on Sports Medicine called for healthy weight-management practices for children participating in athletics.17American Academy of Pediatrics Committee on Sports Medicine and Fitness. Promotion of healthy weight-control practices in young athletes.Pediatrics. 1996; 97: 752-753PubMed Google Scholar The Committee on School Health and the Committee on Sports Medicine jointly called on schools to increase opportunities for daily physical activity and recommended several ways to achieve it.18American Academy of Pediatrics Physical fitness and activity in schools.Pediatrics. 2000; 105: 1156-1157Crossref PubMed Scopus (74) Google Scholar The Committee on Public Education urged avoidance of television and media viewing for children under the age of 2 years and urged limiting viewing to 1 to 2 hours for all children above the age of 2 years.19American Academy of Pediatrics Children, adolescents, and television.Pediatrics. 2001; 107: 423-426Crossref PubMed Scopus (112) Google Scholar It was only in January 2004 that the Committee on School Health (COSH) issued the statement “Soft Drinks in Schools,” adding it to the list of statements on obesity.20American Academy of Pediatrics, Committee on School Health Soft drinks in schools.Pediatrics. 2004; 113: 152-154Crossref PubMed Scopus (158) Google ScholarWhy were soft drinks singled out in the AAP COSH statement? American children over-consume foods that constitute the tip of the USDA Food Guide Pyramid, the section labeled “discretionary fats and sugars,” a term that connotes fats and sugars added to the diet by choice, not inherent in the foods themselves.9Guthrie J.F. Morton J.F. Food sources of added sweeteners in the diets of Americans.J Am Diet Assoc. 2000; 100 (quiz): 43-51Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar, 12Krebs-Smith S.M. Choose beverages and foods to moderate your intake of sugars: measurement requires quantification.J Nutr. 2001; 131: 527S-535SPubMed Google Scholar, 21Kantor L.S. A dietary assessment of the US food supply: comparing per capita food consumption with food pyramid serving recommendations. Agricultural Economic Report 772. US Dept of Agriculture, Washington, DC1998Google Scholar, 22Johnson R.K. Frary C. Choose beverages and foods to moderate your intake of sugars: the 2000 dietary guidelines for Americans—what's all the fuss about?.J Nutr. 2001; 131: 2766S-2771SPubMed Google Scholar, 23Morton J.F. Guthrie J.F. Changes in children's total fat intakes and their food group sources of fat, 1989-91 versus 1994-95: implications for diet quality.Fam Econ Nutr Rev. 1998; 11: 44-57Google Scholar Currently, American children and adults consume nearly one third of their daily energy from this class of foods; ie, energy-dense, nutrient-poor foods, also termed snack foods.24Kant A.K. Reported consumption of low-nutrient-density foods by American children and adolescents: nutritional and health correlates, NHANES III, 1988 to 1994.Arch Pediatr Adolesc Med. 2003; 157: 789-796Crossref PubMed Scopus (134) Google Scholar, 25Brady L.M. Lindquist C.H. Herd S.L. Goran M.I. Comparison of children's dietary intake patterns with US dietary guidelines.Br J Nutr. 2000; 84: 361-367PubMed Google Scholar For the US population as a whole, added sweeteners account for 16% of total daily energy.9Guthrie J.F. Morton J.F. Food sources of added sweeteners in the diets of Americans.J Am Diet Assoc. 2000; 100 (quiz): 43-51Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar Soft drinks are the number one source of added sugars in the American diet and account for 33%. When the number two source, fruit drinks, is added, together they account for 43% of the total added sugars.12Krebs-Smith S.M. Choose beverages and foods to moderate your intake of sugars: measurement requires quantification.J Nutr. 2001; 131: 527S-535SPubMed Google Scholar For children, especially teens, the impact of soft drinks is even greater. As a food group, added sugars constitute 18% to 20% of a child's daily energy.9Guthrie J.F. Morton J.F. Food sources of added sweeteners in the diets of Americans.J Am Diet Assoc. 2000; 100 (quiz): 43-51Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar Sweetened soft drinks amount to 40% of all added sugars in a child's diet and with the addition of fruit drinks, more than 50%.9Guthrie J.F. Morton J.F. Food sources of added sweeteners in the diets of Americans.J Am Diet Assoc. 2000; 100 (quiz): 43-51Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar Americans have been warned to moderate their sugar intake.22Johnson R.K. Frary C. Choose beverages and foods to moderate your intake of sugars: the 2000 dietary guidelines for Americans—what's all the fuss about?.J Nutr. 2001; 131: 2766S-2771SPubMed Google Scholar A limit of 6% to 10% of daily calories from the combined added sugars in the diet has been recommended.12Krebs-Smith S.M. Choose beverages and foods to moderate your intake of sugars: measurement requires quantification.J Nutr. 2001; 131: 527S-535SPubMed Google Scholar, 26Diet, nutrition and the prevention of chronic diseases.World Health Organ Tech Rep Ser. 2003; 916 (i-149, backcover)PubMed Google Scholar With many common food products, such as ketchup and spaghetti sauce, containing added sugars, dietary recommendations are easily exceeded. For a child consuming 1300 kcal per day, this represents only 6 teaspoons of added sugars, and for a teenager consuming 2800 kcal per day, 18 teaspoons of sugars, excluding sugars inherent in fruits and dairy products. Such a modest amount can be consumed at a single sitting in the form of a large soft drink at a fast food restaurant. Daily adolescent intake of sweetened soft drinks averages nearly two 12-oz servings per day, or the equivalent of 20 teaspoons of sugar and 300 kcal.10Harnack L. Stang J. Story M. Soft drink consumption among US children and adolescents: nutritional consequences.J Am Diet Assoc. 1999; 99: 436-441Abstract Full Text Full Text PDF PubMed Scopus (581) Google Scholar, 27Gleason P, Suitor, C. Children's diets in the mid-1990s: dietary intake and its relationship with school meal participation. Available online at: http://ww2.fns.usda.gov/oane/menu/published/cnp/files/childdiet/pdf. 2001. Alexandria, VA: US Dept of Agriculture. Accessed June 2004.Google Scholar This would be less of a problem if soft drink intakes were offset by decreases in energy intake elsewhere in the diet. However, studies suggest that such calories are added to the daily total.28Mattes R.D. Dietary compensation by humans for supplemental energy provided as ethanol or carbohydrate in fluids.Physiol Behav. 1996; 59: 179-187Crossref PubMed Scopus (350) Google Scholar, 29Bellisle F. Rolland-Cachera M.F. How sugar-containing drinks might increase adiposity in children.Lancet. 2001; 357: 490-491Abstract Full Text Full Text PDF PubMed Scopus (43) Google ScholarIs the Proposed Connection Between Over-consumption of Soft Drinks and Obesity Supported by Research?Besides the study by Mrdjenovic and Levitsky already cited,1Mrdjenovic G. Levitsky D.A. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children.J Pediatr. 2003; 142: 604-610Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar two other longitudinal, randomized studies have been done using late elementary school and middle-school children. Both showed an effect of soft drink consumption on weight.30Ludwig D.S. Peterson K.E. Gortmaker S.L. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis.Lancet. 2001; 357: 505-508Abstract Full Text Full Text PDF PubMed Scopus (1760) Google Scholar, 31James J. Thomas P. Cavan D. Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial.BMJ. 2004; 328: 1237-1241Crossref PubMed Google Scholar In the first study, Ludwig et al30Ludwig D.S. Peterson K.E. Gortmaker S.L. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis.Lancet. 2001; 357: 505-508Abstract Full Text Full Text PDF PubMed Scopus (1760) Google Scholar followed 548 children 11 to 12 years of age prospectively for 19 months. Soft drink consumption increased 57% as obesity rose 9.3%. When diet, activity, television, and anthropometrics were controlled for, each soft drink consumed daily was shown to increase the child's risk of obesity by 60%. In the second study, James et al31James J. Thomas P. Cavan D. Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial.BMJ. 2004; 328: 1237-1241Crossref PubMed Google Scholar sought to determine whether reducing consumption of carbonated beverages had an impact on weight gain. The authors followed 644 children 7 to 11 years of age for 1 school year. Using a focused intervention program meant to promote alternate drinks, the control group increased 0.2 glasses (50 mL), whereas the treatment group decreased carbonated soft drink intake by 0.6 glasses per day (150 mL). At 12 months, the percent overweight and obese children among controls increased by 7.5% but decreased by 0.2% in the intervention group. Eliminating just a few ounces of sweetened drinks is likely to affect the risk of childhood obesity substantially. Investigators suggest that small alterations in daily energy consumption may have significant implications. Even small amounts of sweetened drinks consumed at home, at school, and in the community may have a cumulative effect. Hill and colleagues32Hill J.O. Wyatt H.R. Reed G.W. Peters J.C. Obesity and the environment: where do we go from here?.Science. 2003; 299: 853-855Crossref PubMed Scopus (1656) Google Scholar calculated that altering the energy gap by only 0.42 MJ/day (100 kcal/day)—which, ironically, is the equivalent of one 8-oz serving of sweetened soft drink—would prevent excessive weight gain in most Americans. In a review of sugar consumption in the American diet, Krebs-Smith12Krebs-Smith S.M. Choose beverages and foods to moderate your intake of sugars: measurement requires quantification.J Nutr. 2001; 131: 527S-535SPubMed Google Scholar concluded that even though added sugars are not the sole cause of obesity and that both energy intake and expenditure also are suspects, the fact that large segments of the population are experiencing an energy surplus makes it difficult to justify regular intake of soft drinks because of the additional, nutritionally empty calories.Soft drink industry representatives cite the National Family Opinion World Group Share of Intake Panel (SIP) study, which they funded, as evidence for their claim that soft drinks are not over-consumed and are rarely consumed in schools, certainly not in amounts that would contribute to obesity.3Sutherland L.A. Soft drinks and obesity.J Pediatr. 2004; 144: 554-557Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 4Ginevan M.E. Soft drinks and obesity.J Pediatr. 2004; 144: 555-556Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 5Allport J.H. Soft drinks and obesity.J Pediatr. 2004; 144: 554-555Abstract Full Text Full Text PDF PubMed Google Scholar, 13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar When children 1 to 5 years of age in the study were examined as a group, only 3.7 oz of carbonated soft drinks were consumed per child per day, a fall from 5.2 oz in the 1987-88 survey, according to their data. However, even the Park survey data showed that teen females consumed 16 oz per day and teen males 23 oz per day, amounts similar to those reported in other surveys.8French S.A. Lin B.H. Guthrie J.F. National trends in soft drink consumption among children and adolescents age 6 to 17 years: prevalence, amounts, and sources, 1977/1978 to 1994/1998.J Am Diet Assoc. 2003; 103: 1326-1331Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar, 10Harnack L. Stang J. Story M. Soft drink consumption among US children and adolescents: nutritional consequences.J Am Diet Assoc. 1999; 99: 436-441Abstract Full Text Full Text PDF PubMed Scopus (581) Google Scholar The SIP survey is a mail marketing survey that utilized 2-week family diaries from 12,000 persons per year to monitor total beverage intakes. The data were weighted quarterly to be representative of the US population, but it was not a randomized sampling. The study group was further biased by self-selection. Instructions were given in writing and not reviewed with participants by trained research assistants using multiple pass methodologies through onsite or phone contact, as was the case for larger, randomized national surveys. Park13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar cited a single decade of data, eliminating the acceleration of soft drink consumption that occurred in the 1970s and 1980s. Park's frequently cited statistics on consumption of carbonated soft drinks neglects other, faster growing segments of the sweetened drink market.13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar Park's data on fruit drinks, eg, showed an increase across all age groups and both genders.13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar Irrespective of the validity of the SIP study, the question for the AAP COSH was whether soft drink contracts in schools promoted further soft drink consumption by students. No study to date has examined the effects on student consumption patterns of introducing a soft drink contract into a school district. But current levels of consumption suggest that students do not need further encouragement.Are There Nutritional Consequences from Over-consumption of Soft Drinks?Besides excess sugar consumption as a source of unnecessary daily energy, the AAP COSH also considered the corresponding decline in milk consumption as soft drink intake increased and its effect on the daily nutrient profile of children. Milk is a nutrient-dense food. Its elimination from a child's diet is not without consequences. Risk of future osteoporosis and bone fractures because of inadequate daily calcium is only the most prominent clinical issue associated with declining milk consumption. Based on National Health and Nutrition Examination Survey data from 1999-2000, several nutrients have become “problem nutrients” because of consumption rates falling below the daily recommended intakes.33Institute of Medicine Dietary Reference Intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. National Academy Press, Washington, DC1997Google Scholar Corresponding to this phenomenon, milk intake also has fallen as the intake of sweetened drinks has risen. Several studies have shown that the two are closely connected.1Mrdjenovic G. Levitsky D.A. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children.J Pediatr. 2003; 142: 604-610Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar, 22Johnson R.K. Frary C. Choose beverages and foods to moderate your intake of sugars: the 2000 dietary guidelines for Americans—what's all the fuss about?.J Nutr. 2001; 131: 2766S-2771SPubMed Google Scholar, 34Johnson R. Panely C. Wang M.Q. The association between noon beverage consumption and the diet quality of school-age children.J Child Nutr Management. 1998; 22: 95-100Google Scholar, 35Cavadini C. Siega-Riz A.M. Popkin B.M. US adolescent food intake trends from 1965 to 1996.Arch Dis Child. 2000; 83: 18-24Crossref PubMed Scopus (307) Google Scholar, 36Lytle L.A. Seifert S. Greenstein J. McGovern P. How do children's eating patterns and food choices change over time? Results from a cohort study.Am J Health Promot. 2000; 14: 222-228Crossref PubMed Scopus (332) Google Scholar This reciprocal relationship suggests that displacement of milk by sweetened drinks is one of the principle factors that fuels some nutritional deficiencies noted in children.6Ballew C. Kuester S. Gillespie C. Beverage choices affect adequacy of children's nutrient intakes.Arch Pediatr Adolesc Med. 2000; 154: 1148-1152Crossref PubMed Scopus (141) Google Scholar, 37Rampersaud G.C. Bailey L.B. Kauwell G.P. National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages.J Am Diet Assoc. 2003; 103: 97-100Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 38Skinner J.D. Carruth B.R. A longitudinal study of children's juice intake and growth: the juice controversy revisited.J Am Diet Assoc. 2001; 101: 432-437Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar When soft drinks are chosen in place of milk in school lunches, intake of protein, calcium, zinc, vitamins A and C fall, a finding seen in several previous studies34Johnson R. Panely C. Wang M.Q. The association between noon beverage consumption and the diet quality of school-age children.J Child Nutr Management. 1998; 22: 95-100Google Scholar, 39Frary C.D. Johnson R.K. Wang M.Q. Children and adolescents' choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups.J Adolesc Health. 2004; 34: 56-63Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar and reiterated by Mrdjenovic and Levitsky.1Mrdjenovic G. Levitsky D.A. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children.J Pediatr. 2003; 142: 604-610Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar In addition, those with the highest soft drink intakes in the diet also have the highest energy intakes.40Forshee R.A. Storey M.L. Total beverage consumption and beverage choices among children and adolescents.Int J Food Sci Nutr. 2003; 54: 297-307Crossref PubMed Scopus (173) Google Scholar Guthrie et al9Guthrie J.F. Morton J.F. Food sources of added sweeteners in the diets of Americans.J Am Diet Assoc. 2000; 100 (quiz): 43-51Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar looked at the displacement phenomenon a different way. By examining women with adequate calcium intakes, they were able to show that these women had lower intakes of sweetened soft drinks and greater intakes of milk. Displacement can even be identified in the first 24 months of life. In the Feeding Infants and Toddler Study, Skinner et al41Skinner J.D. Ziegler P. Ponza M. Transitions in infants' and toddlers' beverage patterns.J Am Diet Assoc. 2004; 104: S45-S50Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar found that as fruit juice, fruit drink, and carbonated drinks increased, calcium density in the diet fell. So, rather than being a consolation that fruit drinks represent the second greatest source of vitamin C among children of all ages as Park suggests, this fact is disturbing.13Park Y.K. Meier E.R. Bianchi P. Song W.O. Trends in children's consumption of beverages: 1987 to 1998.Fam Econ Nutr Rev. 2003; 14: 69-79Google Scholar Fortification of a sugared drink is no substitute for fruit consumption.Is It the Drink or the Marketing That Is The Problem?When they wrote the policy statement, the members of the AAP COSH were faced with a new marketing strategy aimed at children termed “exclusive soft drink contracts,” contracts between representatives of the soft drink industry and school authorities. Fearing that one consequence of these lucrative school contracts was going to be the promotion of even greater over-consumption of sugar, the COSH recommended that pediatricians work with their local school districts to eliminate sweetened drinks from schools, substituting instead water, milk, and fruit and vegetable juices.20American Academy of Pediatrics, Committee on School Health Soft drinks in schools.Pediatrics. 2004; 113: 152-154Crossref PubMed Scopus (158) Google Scholar The committee's fears proved well founded. The recent School Health Policies and Programs Study, conducted in 2000, surveyed all 51 state education agencies, 523 school districts, 841 school food service representatives, and 927 schools about current policies. The survey showed that 49.9% of districts had a soft drink contract and that of these, nearly 80% received a specified percentage of the sales receip" @default.
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