Many factors influence the rising levels of obesity including changes in activity and dietary patterns. National dietary surveys are valuable tools for identifying sources of energy, including sugar, in a population. However, these surveys use diaries that aim to capture food intake rather than fluid intake and may underestimate beverage and therefore energy intakes. A study of 1456 children and adults was conducted in the United Kingdom using a 7-day fluid specific intake diary. Total daily intakes of beverages were higher in all ages compared with previous surveys. However, 30% of adults and more than 50% of children did not meet European adequate intake for total water. Children consumed on average 175 kcal/d as still or carbonated soft drinks. This fluid-specific survey raises concerns about the total and type of fluids consumed by both adults and children in the United Kingdom.
Joan Gandy, PhD, RD, is a dietetic consultant and fellow of the British Dietetic Association, Birmingham, England.
The author has declared that she is employed as a consultant for Danone.
Correspondence: Joan Gandy, PhD, RD, British Dietetic Association, 5th Floor Charles House, 148-9 Great Charles St, Queensway, Birmingham, B3 3HT, United Kingdom (firstname.lastname@example.org).
In 2009, nearly two-thirds of adults and 3 in 10 children were classified as either overweight or obese in the United Kingdom.1 By 2050, the prevalence of obesity is predicted to increase to 60% in adult men, 50% in women, and 25% in children.2 The United Kingdom is facing a major public health problem, and there is an urgent need to develop strategies to address this. Although there are many sources of sugar in the diet, the role of sweetened beverages (SSBs) in the development of obesity and associated conditions is becoming well recognized.3,4 In the United States, analysis of the National Health and Nutrition Examination Survey has shown that the amount of energy provided by SSBs significantly contributed to increased total daily energy intake and therefore obesity.5 Despite rising levels of obesity in the United Kingdom, there is a paucity of similar UK data. In the United States, increasing levels of obesity have been associated with upward trends in SSB consumption.6 However, the United Kingdom’s National Diet and Nutrition Survey (NDNS) reported relatively small intakes of SSBs in 2001 and 2008 for adults.7 No fluid-specific studies have been conducted in the United Kingdom, and the NDNS surveys use food diaries that may not record all drinking events. Therefore, a beverage intake survey reported here, which used a fluid-specific tool and aimed to capture all drinking events, was conducted to address these concerns about the ability of NDNS methodology to capture all drinking events.
BEVERAGE INTAKE SURVEY IN THE UNITED KINGDOM
During March and May 2010, a sample of 1456 people, including children aged 3 to 18 years and adults aged 19 to 75 years, was recruited throughout the United Kingdom. The recruitment was based on a precise quota method that was representative in terms of region, socioeconomic characteristics, and urban/rural classification. Quotas were also set for age, gender, and working status. Participants or an adult proxy who took care of the children younger than 15 years completed a fluid-specific diary for 7 days recording the volume consumed at every drinking occasion, time consumed, and additions to the beverage (milk, sugar). The beverages were categorized as follows: water and flavored water, milk and milk derivatives (plain milk, flavored milk, drinking yogurt, and other milk-based drinks), hot beverages (tea, coffee, chocolate, herbal fruit tea, etc), still soft drinks (dilutable squashes and cordials, fruit drinks, fruit juices, fruit-based smoothies, etc), carbonated soft drinks, functional drinks (energy drinks, sports drinks, and fortified waters), alcohol (spirits, beers, cider, alcopops, etc), and others (vegetable juices, etc).
TOTAL BEVERAGE INTAKE IN THE UNITED KINGDOM
The total volumes consumed by each age group are shown in the Table. Although the average intake for adults of 2.31 L was similar to the adequate intake (AI) of water recommended by the European Food Safety Authority (EFSA),8 30% of adults had inadequate intakes. Men were more likely to have inadequate intakes than were women, with 35% men and 25% women achieving the recommended AIs. Overall, less than 50% of children had AIs with the mean intakes for all age groups of children being below that recommended by the EFSA. However, these intakes were significantly higher than those observed by the NDNS survey in 2008.6 For adults, the intakes were approximately 30% higher than those in the NDNS survey. It is important to note that up to 70% of beverages were consumed outside meals and were therefore more likely to have not been recorded in the NDNS survey, which was designed to capture energy and nutrient intake rather than total fluid intake.
The apparent inadequate intakes of fluid within this population raise concerns about the hydration status of the population. However, it is important to consider the relationship between hydration status and fluid intake. Although few studies have looked at this relationship, it has been shown that children who drank more fluids and in particular more water9 were more likely to be euhydrated. The inadequate intakes observed suggest that some participants may be at risk of mild dehydration and its subsequent effects possibly including poorer cognitive function10 and associated morbidities.11
TYPES OF BEVERAGES CONSUMED IN THE UNITED KINGDOM
The Figure shows the quantities of each type of beverage consumed per day according to age and gender. There was a lot of variation in the types of beverages consumed by different groups. The amount of water consumed was relatively low with no age/gender group exceeding 600 mL. Adults drank more hot beverages (1.00–1.23 L/d) than any other drink. Predictably, 3-year-old children consumed more milk compared with other types of beverage and other groups.
Preliminary findings showed that children consumed the most regular (sweetened) carbonated and still soft drinks (430–640 mL/d), with children aged 15 to 17 years consuming more of these beverages and functional drinks than any other age group. On average, (sugar sweetened) beverages provided approximately 175 kcal/d in children, which is remarkably similar to that observed in 2- to 18-year-olds in the National Health and Nutrition Examination Survey study.5 Further analysis is ongoing, and the contribution of other beverages to energy intake has yet to be calculated.
The role of SSBs in the increasing levels of obesity and associated comorbidities is attracting more attention.3,4 Although the evidence is not equivocal, some studies have shown links between sugar SSBs (carbonated and soft drinks) and the development of type 2 diabetes and cardiovascular disease.3 Despite increasing levels of obesity, especially in children, in the United Kingdom it has been reported that SSB intake does not appear to be increasing.7 However, the reported intakes were considerably lower than those in the present study for all age and gender groups. The present study reported higher levels of intake in every age and gender groups compared with the NDNS data.
Attention is increasingly being given to the reduction of the consumption of SSBs as a viable strategy in both the prevention and management of obesity in adults12 and children.13,14 Despite the apparent lack of an increase in SSBs reported by the NDNS study, the present study emphasizes the need to reduce SSB consumption as a public health strategy to prevent and manage obesity. In addition, a reduction in SSBs may improve overall diet quality.15
IMPLICATIONS OF THE UK FLUID INTAKE STUDY
Undoubtedly, the levels of beverage intake in the present study raise concerns about the level of hydration in this population. The higher levels of intake compared with the NDNS survey may have implications for the validity of the EFSA recommendations.8 These recommendations used data from 13 European countries including the 2001 NDNS study from the United Kingdom.16 This study reported beverage intakes lower than both the 2008 NDNS survey7 and the present survey. The data from other countries were also collected as part of food- rather than fluid-specific studies and may also have underestimated fluid intake. It is therefore possible that the reference values have been set too low.
The apparent low levels of water consumption across the population and the amount of energy consumed by children in still and carbonated beverages offer opportunities for the development of public health strategies aimed at changing the drinking behavior of the population. A recent systematic review has highlighted the potential role of increased water consumption in reducing energy intake and managing obesity.17
There is a need for more research in this area, and it is essential that more surveys be conducted using fluid-specific methods. This will inform the debate on the recommendations in the United Kingdom and other countries and assist the development of obesity prevention and management programs.
The author thanks J. Griffin, C. Dale, L. Le Bellego, R. Monrozier, and S. Vergne.
1. National Health Service NHS The Information Centre for Health & Social Care Statistics on Obesity, Physical Activity and Diet
: England, 2010
. Accessed September 9, 2011.
2. Butland B, Jebb B, Kopelman P, et al. Foresight Tackling Obesities: Future Choices—Project Report
. 2nd ed. Government Office for Science 2007. www.bis.gov.uk/foresight
. Accessed September 11, 2011.
3. Malik VS, Popkin BM, Bray GA, Després JP, Hu FP. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010; 121: 1356–1364.
4. Malik SV, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006; 84: 274–288.
5. Reedy J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc. 2010; 110: 1477–1484.
6. Bleich SN, Wang YC, Wang Y, et al.. Increasing consumption of sugar-sweetened beverages among US adults: 1988–1994 to 1999–2004. Am J Clin Nutr. 2009; 89: 372–381.
7. Bates B, Lennox A, Swan G. The National Diet and Nutrition Survey: Headline Results From Year 1 of the Rolling Programme (2008/2009). London, UK: Food Standards Agency; 2010.
8. European Food Safety Authority Scientific Opinion on Dietary Reference Values for Water
. Parma, Italy: EFSA; 2010.
9. Stahl A, Kroke A, Bolzenius K, et al.. Relations between hydration status in children and their dietary profile—results from the DONALD study. Eur J Clin Nutr. 2007; 61: 1386–1392.
10. Ganio MS, Armstrong LE, Casa DJ, et al.. Mild dehydration impairs cognitive performance and mood of men. Br J Nutr. 2012; 106: 1535–1543.
11. Manz F. Hydration and disease. J Am Coll Nutr. 2007; 26: 535S–541S.
12. Chen L, Appel LJ, Loris C, et al.. Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial. Am J Clin Nutr. 2009; 89: 1299–1306.
13. Sichieri R, Trotte AP, de Souza RA, et al.. School randomised trial on prevention of excessive weight gain by discouraging students from drinking sodas. Public Health Nutr. 2009; 12: 197–202.
14. Sanigorsjki AM, Bell AC, Swinburn BA. Association of key foods and beverages with obesity in Australian school-children. Public Health Nutr. 2007; 10: 152–157.
15. Libuda L, Alexy U, Buyken AE, et al.. Consumption of sugar-sweetened beverages and its association with nutrient intakes and diet quality in German children and adolescents. Brit J Nutr. 2009; 101: 1549–1557.
16. Henderson L, Gregory J, Swan G. The National Diet And Nutrition Survey: Adults Aged 19 to 64 Years. London, UK: Her Majesty’s Stationery Office; 2002.
17. Daniels MC, Popkin BM. Impact of water intake on energy intake and weight status: a systematic review. Nutr Rev. 2010; 68: 505–521.