Fluid Intake of European Children and Adolescents
Moreno, Luis A. PhD; Iglesia-Altaba, Iris MSc; Santaliestra-Pasías, Alba M. MSc
Luis A. Moreno, PhD, is a member of the Growth, Exercise, Nutrition and Development (GENUD) Research Group of the Facultad de Ciencias de la Salud at Universidad de Zaragoza, Zaragoza, Spain. He is also a medical doctor, with PhD degree, and professor at the University of Zaragoza.
Iris Iglesia-Altaba, MSc, is a member of the Growth, Exercise, Nutrition and Development (GENUD) Research Group of the Facultad de Ciencias de la Salud at Universidad de Zaragoza, Zaragoza, Spain. She is also a nutritionist and a PhD student, is working at the University of Zaragoza for more than 6 years as a researcher in nutrition epidemiology, and is an expert in vitamins.
Alba M. Santaliestra-Pasías, MSc, is a member of the Growth, Exercise, Nutrition and Development (GENUD) Research Group of the Facultad de Ciencias de la Salud at Universidad de Zaragoza, Zaragoza, Spain, and is a nutritionist, with a food science degree, a PhD student, working at the University of Zaragoza for more than 6 years as a researcher in nutrition epidemiology, and an expert in sedentarism and dietary patterns.
The authors have no conflicts of interest to disclose.
Correspondence: Luis A. Moreno, PhD, Facultad de Ciencias de la Salud, Universidad de Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain (email@example.com).
Few studies have assessed total water intake in European children and adolescents, and fewer have evaluated the types of beverages being consumed in relation to childhood obesity and sedentary behaviors. Water intake and beverage consumption in the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-sectional Study, a large, pan-European study in adolescents aged 12.5 to 17.5 years, are described in terms of gender and age differences and in relation to screen-based sedentary behaviors. Dietary intake was measured in terms of fluids (milliliters) and energy (kilojoules) using two 24-hour recall assessments in 2741 adolescents. Sugar-sweetened beverages accounted for the largest amount of energy intake per person from beverages, and water, the largest amount of fluid. However, 12.1% of adolescents did not drink plain water at any time, with 69.4% of boys and 64.4% of girls having a total water intake below the levels currently recommended by the European Food Safety Authority. A causal link between sweetened beverage consumption and childhood obesity has not been definitively shown; however, the consumption of sugar-sweetened beverages during sedentary activities could contribute to the promotion of childhood obesity. In general, adolescents spending more than 4 h/d on sedentary behaviors were more likely to consume sweetened beverages than those spending fewer than 2 hours on the same activities. Efforts should be made to promote healthy foods and beverages in children and adolescents and to replace sedentary behaviors with physical activity.
Water comprises about 60% of human body weight and even higher percentages in children and adolescents.1 Current recommendations for total daily fluid intake (including water from all beverages and moisture content of foods) vary widely between countries and organizations, and to date, only a very limited number of studies have focused on water intake and beverage consumption in healthy children and adolescents. In the Dortmund Nutritional and Anthropometric Longitudinally Designed study,2 boys and girls aged 2 to 13 years had a total water intake (based on 3-day dietary records) that increased with age—from 1114 g/d in 2- to 3-year-olds to 1363 g/d in 4- to 8-year olds and 1801 g/d in 9- to 13-year old boys, driven mainly by an increase in beverage consumption. Milk (9%–17%) and mineral water (12%–15%) were the most important sources of total water intake.
Despite a recent leveling-off in the trends of obesity prevalence in children and adolescents, childhood obesity is still a major public health issue.3 Intervention studies aiming to prevent childhood obesity have proposed promoting water intake as a key message to prevent obesity.4 It is therefore important to assess not only water intake but also the type of beverages being consumed. In a 15-year study (1983–1997) of sugar sources in the diets of British children, a marked shift away from table sugar to a significant increase in sugar from soft drinks (and, to a lesser extent, fruit juices) was observed,5 suggesting sugar-sweetened beverages as a probable contributor to childhood obesity.
This article reviews 2 separate analyses of the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Cross-sectional Study (CSS), conducted between 2006 and 2007 in 10 European cities.6 Detailed information about the study has been published elsewhere.7,8 The aim of this review was to assess water intake and beverage consumption in European adolescents, together with other lifestyle correlates.
WATER AND BEVERAGE CONSUMPTION IN EUROPEAN ADOLESCENTS
Data on water intake and beverage consumption were collected using the HELENA–Dietary Assessment Tool, a self-administered, computer-based questionnaire based on the Young Adolescents’ Nutrition Assessment on Computer and reported as the mean of two 24-hour memory recall assessments.9 Validation of the Young Adolescents’ Nutrition Assessment on Computer in a sample of Flemish adolescents indicated good agreement (as measured by Cohen κ coefficient, a robust statistic for interrater agreement) between self-reported and dietician-administered 24-hour dietary recall, ranging from 0.82 for water to 0.92 for tea and coffee.10
Of the 3528 individuals enrolled in HELENA-CSS, 678 were excluded because of insufficient dietary intake data and 108 failed to complete the second 24-hour recall assessment, giving a sample size of 2741 adolescents from 8 European countries.9 The types of beverages imbibed were grouped into 10 categories (Table 1). Beverage consumption was calculated in terms of fluid intake (milliliters) and energy intake (kilojoules). Water accounted for the highest percentage of fluid intake per person, followed by fruit juice, other beverages, and low-fat milk. Sugar-sweetened beverages accounted for the highest percentage of energy intake, followed by sweetened milk beverages.9
Boys and older adolescents consumed more fluid and more energy than did girls and younger adolescents, respectively. Compared with girls, boys consumed more total energy from beverages and more energy from sweetened milk drinks, sugar-sweetened beverages, fruit juice, high-fat milk, and alcoholic beverages (P < .001 all comparisons). Among all gender and age subgroups, sugar-sweetened beverages contributed most to total energy intake from beverages, with sweetened milk drinks, low-fat milk, and fruit juice also being contributors.9 A subgroup of adolescents who did not drink any water, preferring beverages from the other 9 groups, was identified and accounted for 12.1% of the sample; this percentage was higher in boys (16.7%) than in girls (8.1%).9
In terms of geography, adolescents from Germany were found to consume the highest amount of energy from beverages, and Italian adolescents, the lowest (a between-country difference of 1086 kJ/person/day). In half of the countries, sugar-sweetened beverages were the largest contributors to total beverage energy intake. Sweetened milk drinks, low-fat milk, and fruit juice were the largest contributors in Spain, Sweden, and France and Greece, respectively. Spanish adolescents had the largest per person energy intake from sweetened milk drinks (548 kJ/person/day).
BEVERAGE CONSUMPTION AND SEDENTARY BEHAVIORS IN EUROPEAN ADOLESCENTS
An additional analysis of HELENA-CSS data provided information on sedentary behaviors and food and beverage intake in a subset of 2202 adolescents (45.5% male) and is described in more detail elsewhere.12 The frequency of sedentary behaviors such as watching television, playing computer and video games, using the Internet (for recreation or studying), and studying outside school hours was collected separately for weekdays and weekends via a standardized, self-reported questionnaire (validated in a subgroup of 183 adolescents from HELENA-CSS13). Participants were required to choose from 7 predefined responses for time spent on each activity (0, <30, 30–60, 60–120, 120–180, 180–240, and >240 minutes). On the basis of recommendations by the American Academy of Pediatrics,14 participants were subsequently classified into 1 of 3 groups for each behavior (<2, 2–4, and ≥4 h/d).12
Data on food and beverage consumption were collected using the HELENA–Dietary Assessment Tool, consistent with the analysis described previously. Binary logistic regression analyses were performed to obtain odds ratios and 95% confidence intervals (CIs) of food group consumption (above the median) by specified sedentary behaviors. Boys who spent more than 4 h/d playing video games on weekdays and weekends were 7.84 (95% CI, 2.55–24.10) and 3.04 (1.72–5.39) times more likely to drink sweetened beverages above the median amount, respectively, than those spending fewer than 2 h/d on the same activity; similar, but slightly lower, findings were observed in girls (Table 2). Odds ratios for consuming sweetened beverages above the median amount were consistently high for boys and girls reporting more than 4 h/d of watching television, playing computer games, and using the Internet for recreation on weekdays and weekends (odd ratios ranged from 1.60 to 2.26 in boys and from 1.57 to 2.38 in girls).12
Boys and girls spending 2 to 4 h/d on weekdays using the Internet for recreation were 1.34 (95% CI, 0.86–2.07) and 1.21 (0.78–1.87) times more likely to drink juices above the median amount; similar findings were observed for boys and girls studying for 2 to 4 h/d (weekdays) and for girls studying for more than 4 h/d (weekdays). The odds of milk consumption were highest in both boys (2–4 h/d) and girls (2–4 and >4 h/d) during studying (weekdays).12
The results of the HELENA-CSS provide important information about the pattern of beverage intake and sedentary behaviors in European adolescents. On the basis of the European Food Safety Authority reference values for total water intake for adolescents older than 14 years,15 69.4% of boys and 64.4% of girls in the HELENA-CSS have a total water intake below the recommended amount of 2.5 and 2.0 L/d, respectively (Figure 1). Consistent with the World Health Organization Health Behavior in School-aged Children survey, which has indicated poor dietary habits in adolescents,16,17 diet in boys and girls in the HELENA-CSS was characterized by a high consumption of sugar-sweetened beverages.9,12 These beverages accounted for the largest amount of energy intake per person from beverages, followed by sweetened milk drinks,9 and were consumed more frequently during certain sedentary activities, such as watching television and playing video and computer games.12
Over the past decade, consumption of sugar-sweetened beverages has emerged as the dietary factor most consistently associated with weight gain and has been identified by the World Health Organization as a “probable contributor” to the obesity epidemic.18 Whereas the European Food Safety Authority recommendations on fluid intake do not distinguish between types of beverage, more recently, the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee of Nutrition has recommended that plain water should be promoted as the main source of fluids for children to prevent the development of obesity.19 Given the increased likelihood of sweetened beverage consumption during certain sedentary behaviors observed in the second analysis,12 it is tempting to consider that promoting physical activity in adolescents would reduce intake. However, as another analysis of the HELENA-CSS population has concluded, in line with previous research, there is no relationship between time spent in moderate to vigorous physical activity and intake of sweetened beverages.20
The strengths and limitations of the HELENA-CSS have been described in detail elsewhere.9,12 One potential limitation concerns the use of repeated 24-hour recall assessments, which, although widely accepted as a method of assessing dietary intake in epidemiological studies, has not been validated for the assessment of beverage consumption. An indirect comparison with unpublished data from the Bahía 2010 study, in which 402 adolescents aged 14 to 17 years were assessed by means of a 3-day fluid intake diary, showed similar distribution of beverage types (particularly water) in the 2 studies (Figure 2). It should be noted that the HELENA-CSS cohort is not representative of the European population, and caution should be used in generalizing the results to other groups.12
Total fluid intake is unacceptably low in most adolescents in the HELENA-CSS population. A significant proportion of adolescents (especially boys) consume only beverages other than plain water, and sweetened beverage intake was markedly more likely in adolescents spending more than 4 h/d on screen-based sedentary behaviors. Although a causal link between sugar-sweetened beverage consumption and childhood obesity has not been definitively shown, it is a probable contributor. Thus, efforts to promote healthy foods and beverages and to replace sedentary behaviors with physical activity appear to offer a way forward in the short-term. Beverage intake should be assessed in the context of other obesity-related lifestyles, and the role of parents in creating an environment of healthy food and beverage consumption should be considered in public health strategies. Clustering of lifestyle behaviors should also be considered.
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