In recent years, the possible side effects of excessive fruit juice consumption by infants and young children has been the topic of several scientific publications. Apart from dental caries and gastrointestinal symptoms (1-3), obesity (4) and failure to thrive (4,5) were discussed. For the first time, failure to thrive was described in eight children aged 14 to 27 months, who consumed 12 to 30 fl oz fruit juice (340-850 g) per day, primarily apple juice. After nutritional intervention, dietary energy intake and weight gain increased. Two reasons contributing to failure to thrive were suggested: replacement of foods of higher energy and nutrient density by excessive fruit juice consumption or carbohydrate malabsorption, caused by fructose and sorbitol from fruit juice (5).
In a recent survey, an association between excessive consumption of fruit juice (≥12 fl oz/day) and short stature or obesity was reported in a sample of 223 2- through 5-year-old children (4). However, the findings were controversial (6-9). Among other responses to the report, a longitudinal rather than a cross-sectional study was demanded, to draw meaningful conclusions about the associations between fruit juice consumption and obesity or failure to thrive (6). Additionally, it was stated that besides the fruit juice consumption, the overall nutrition of the children should be considered (9).
The Dortmund Nutritional and Anthropometrical Longitudinally Designed (DONALD) Study provides the opportunity to investigate the possible associations between long-term fruit juice consumption, overall nutrition, and the development of body weight and height in healthy children, by using a longitudinal approach.
Details of the sample from the DONALD Study have been described previously (10). In short, the DONALD Study sample comprises families who are interested in the long-term nutrition and health of their children and have volunteered to take part. This report includes data from 205 preschool children (105 boys, 100 girls) each examined at the ages of 3, 4, and 5 years from 1990 through 1997. Sample characteristics are shown in Table 1. The DONALD Study is a purely observational noninvasive study approved by the International Scientific Committee of the Research Institute of Child Nutrition. An additional ethics committee review of our study protocol was considered unnecessary.
The subjects had their heights measured (to the nearest 1 mm) in a standing position, using a digital telescopic wall-mounted stadiometer (Harpenden, Rappenswil, Switzerland). For weight measurements (to the nearest 0.1 kg) and electronic scale (Model 753 E; Seca, Hamburg, Germany) was used. Body weight and height were compared with the data from the Netherlands' growth survey (11), because this survey is representative of a neighboring population and covers all age groups, closely meshed without gaps.
Details of the method have been published previously (10). In short, parents completed a 3-day weighed diet record of the amounts of all foods and beverages consumed by their child measured by electronic food scales (accuracy 1 g, 0-1000 g; Digita 8000; Soehnle, Mürrhardt, Germany). If weighing was not possible, semiquantitative amounts (household measures, numbers of portions) were accepted. However, on 72% of all recorded days, more than 90% of all reported food items were weighed, and on 21% of all recorded days, 50% to 90% of all reported food items were weighed.
Fruit juice was separated from all other drinks because this sort of drink had been considered in the context of child growth and health in the literature. Additionally, interactions between the consumption of fruit juice and the consumption of other beverages or fruit were examined. Other food groups were defined as fruit juice drinks (i.e., sweetened commercial mixtures of fruit juice and water), sweetened beverages (e.g., soda drinks and colas), milk to drink (exclusive of milk or milk products used as ingredients in foods), water (including tap water, mineral water, tea, and coffee), and fruit (the sum of all fresh and canned fruits).
Energy and nutrient intakes were calculated using our nutrient database LEBTAB, which is continuously updated by all new recorded food items. At present, LEBTAB contains about 3900 food items (2030 foods, composites, and commercial products; 1340 commercial infant food products; and 290 special preparations). Added sugars were defined as the sum of added monosaccharides, disaccharides, and oligosaccharides.
Statistical software (Version 6.11; SAS, Cary, NC, U.S.A.) was used for data analysis. Intakes of food groups and nutrients were calculated from the individual means of the 3 recorded days. The distribution of food group intake was skewed to the right; therefore, intakes are shown as percentiles (10th, 50th (median), and 90th) in addition to the mean values.
To validate records, the ratio of reported energy intake (EI) to estimated basal metabolic rate (BMR), taking into account age, sex, body weight, and height (12) was used (13). Excessive fruit juice consumption was defined as 12 fl oz or more per day (340 g/day) according to the definition of Dennison et al. (4) Obesity was defined as body mass index (BMI = weight in kilograms/height in square meters) more than that for the 90th age- and sex-specific percentile (14), as recommended by the European childhood obesity group (15). Short stature was defined as a height standard deviation score (HSDS = deviation of a child's body height from the median of the reference (11) as a multiple of the standard deviation) below -2.0 (16). Growth velocity was calculated as the difference between the first and the last of the three measurements divided by the exact number of days between the measurements. For the longitudinal approach, the average values from the measurements at ages 3, 4, and 5 years were calculated for each participant.
Pearson correlation coefficients were used to test interactions among fruit juice consumption and energy and nutrient intake or anthropometric indices. The Wilcoxon rank sum test was used to identify differences among groups. p < 0.05 was considered significant.
The mean EI/BMR ratio of the records from the 3-, 4-, and 5- year-old children was 1.42, 1.46, and 1.51, respectively, indicating the usual intake of healthy children (17). The EI/BMR ratio of the subgroup of obese children was not significantly lower (-5%) and the total food intake not significantly higher (+4%; 50 g/day) than that of nonobese children.
Mean food group intakes of the study sample corresponded well to the findings from a representative sample of German preschool children (18) (Table 2). In this study, the total fruit juice consumed comprised 40% to 50% apple, pear, or pear-apple juice; 23% to 33% mixed fruit juice; 5% to 28% orange juice; and other juices. In all age groups, at least 10% of the children did not consume any fruit juice. In the different age groups mean intraindividual variations of the intakes of fruit juice and fruit (coefficient of variation [CV], 67-87%) were higher than the intraindividual variations of the intake of fruit juice drinks (CV, 35%), milk (CV, 48-60%), water (CV, 55-65%), and sweetened beverages (CV, 40-60%).
In all age groups, consumption of fruit juice was inversely correlated with the consumption of all other beverages and the total consumption of all other food. In contrast, the correlations among the consumption of fruit juice and other groups of beverages were only significant in single age and food groups (Table 3).
In 9% of all diet records, reported fruit juice intake exceeded 12 fl oz/day (Table 4). Five children (2.4%) consumed excessive fruit juice repeatedly on all 3 observations, 10 children (4.9%) on 2 observations, and 23 (11.2%) children on 1 observation only. None of the five children with a repeatedly excessive fruit juice intake was obese or short (data not shown).
Neither the BMI, the HSDS, nor the growth velocity correlated with the consumption of fruit juice (Fig. 1). The children's BMI correlated positively with the intake of energy (r = 0.18; p < 0.05), but not with the intake of protein, fat, carbohydrate, or added sugars (calculated as percentage of energy intake = E%). No association was found between the HSDS and diet composition.
Total energy intake and diet composition of records with low versus excessive fruit juice consumption differed significantly (Table 5). Excessive fruit juice consumers had slightly higher intakes of energy and lower intakes of added sugars in single age groups only, but higher intakes of carbohydrates and lower intakes of fat in all age groups.
In the total sample, fruit juice and fruits each supplied on average 65 to 70 kcal/day (5% of total energy intake) and together reached the energy supply from milk (120-130 kcal/day; 9-11% of total energy intake). In contrast, the energy supply from sweetened beverages and fruit juice drinks was low (<2% of total energy intake). In the subgroup of children with excessive fruit juice consumption, energy supply from fruit juices was 19%, 17%, and 15% at 3, 4, and 5 years, respectively.
In the DONALD Study sample of 205 healthy pre-school children we found no indication of an association between the consumption of fruit juice and the occurrence of obesity or short stature. Even children with repeatedly excessive fruit juice consumption over 3 years were neither obese nor short, and their growth velocity was normal.
The sample size of our study comes close to the sample (n = 223) of Dennison et al. (4). Our study sample was part of the DONALD Study, a demanding longitudinal survey comprising voluntarily participating families with interest in long-term diet and health of their children. Nevertheless, the dietary habits of the DONALD Study sample mirror the overall dietary habits of German children. Mean food group intake of this sample of 3-, 4-, and 5-year-old children corresponded well to representative findings (cf. Table 2). Also other findings from the DONALD Study (e.g., food variety in the infant diet or nutrient intake of children and adolescents) were comparable to representative data (19,20).
Dennison et al. (4) defined excessive fruit juice consumption as more than 12 fl oz/day, which was approximately twice the mean and approximately three times the median of the daily intake of their 2- and 5-year-old sample and also the lower range of excessive fruit juice intakes of the younger subjects reported by Smith and Lifshitz (5). This cutoff was also appropriate for the distribution of consumption data in our sample. In the current study, an intake of 12 fl oz per day was more than the 90th percentile of fruit juice consumption.
A larger proportion of excessive fruit juice consumers defined by such an age-independent single limit might be expected in older children, because of an increasing total food intake, than in our 3- to 5-year-old sample. However, the effects of excessive fruit juice consumption on the overall diet and health might be less severe or undetectable in older groups. In our sample, energy supply from fruit juice decreased with increasing age in the excessive fruit juice consumers. Therefore, it may be more useful to recommend age-specific limits for fruit juice consumption, if any, rather than a single limit for all children.
In this study, the energy intake of children with excessive fruit juice consumption was slightly higher than the energy intake of children with low fruit juice consumption. Energy intake of both subgroups was in the range of energy requirements between light and moderate physical activity (17). In contrast to our findings, Smith and Lifshitz (5) reported a hypocaloric diet in 8 toddlers aged 14 to 27 months, who consumed 12 to 30 fl oz (340-850 g) fruit juice per day. In their sample, fruit juice supplied between 25% and 60% of total energy intake compared with 15% and 20% in our subgroup of excessive consumers.
Moreover, in the report from Smith and Lifshitz (5) the energy intake from fat (25 E%) and protein (7-13 E%) in the overall diet was much lower than in our sample (fat, 33 E%; protein, 11-13 E%). The effects of excessive fruit juice consumption on the overall diet may be more severe in younger children, as in the Smith and Lifshitz report (5) because of their lower total food intake, than in older children, as in our sample.
It has been stated, that a high consumption of fruit juice may lower the amount of milk drunk and thus lead to a decrease in calcium intake (21). In accordance with Dennison et al. (4), we did not find an inverse correlation between the consumption of fruit juice and milk drunk, and we cannot support this hypothesis.
In our sample, the diet composition of children with excessive fruit juice consumption was closer to the international dietary preventive guidelines (22-25) than the high-fat and low-carbohydrate diet of children with a low fruit juice consumption. Recent studies suggest that children with low fat intakes (< 30 E%) grow as satisfactory as children with higher fat intakes (26,27).
Although not directly comparable, the reported data from America and Germany give the impression that excessive fruit juice consumption is more critical in American than in German children and may mirror other differences of dietary habits as well.
The report of Dennison et al. (4) raised the question whether the reported association between high fruit juice intake and obesity could be an artifact and just one component of an overabundant diet or whether parents had attempted to correct their children's obesity by offering the perceived low-calorie fruit juice. In our sample, the total food intake tended to be higher in obese than in nonobese children, but fruit juice consumption was significantly inversely correlated with total food intake (excluding fruit juice), indicating that fruit juice replaced other foods at least partially, particularly other beverages. Because the EI/BMR ratio and total food intake did not differ significantly between obese and nonobese subjects, we suppose that both subgroups reported their food consumption with comparable reliability.
Failure to thrive may have organic (e.g., underlying diseases or abnormalities) or nonorganic causes. The most important reason for nonorganic failure to thrive is an inadequate dietary energy intake (28). Other possible factors are a low intake of protein, zinc, iron, copper, iodine, and vitamin A or simultaneous nutrient deficiencies (29). However, Dennison et al. (4) reported a higher energy intake in children with excessive fruit juice consumption than in children with low fruit juice consumption, and the protein intake did not differ in both subgroups. The short stature of 19 children in their sample may have been caused by other organic or nonorganic factors not recorded in the survey, rather than by an energy or protein deficiency.
Carbohydrate malabsorption after consumption of fruit juices is frequently observed in infants and young children and may be a contributing factor to nonorganic failure to thrive (2,5). This is a further argument for advising parents to be cautious about excessive use of fruit juice (3), but it should not hinder the promotion of balanced consumption of fruit juices along with fresh fruit as part of a balanced diet.
Especially in infants or young children, imbalance in the diet can severely impair health. However, we should be cautious in ascribing this to a single food item or a single food group. Failure to thrive was reported in children whose total food intake or food selection (e.g., sweets, full-fat dairy products, or fatty meat) was restricted, because of a misconception concerning a health diet for children (30,31). McCann et al. (32) reported that several mothers of children with failure to thrive restricted their children's intake of unhealthy foods despite their children's low weight. We agree with Smith and Lifshitz (5) that "any single food consumed in excess . . . can result in dietary imbalances and affect the weight gain and growth of children." Therefore, comprehensive nutrition education is necessary, because people must learn, that a single food (e.g., fruit juice) is not healthy or unhealthy, but that the total composition of a diet must be balanced. The food guide pyramid (33), used in the United States, or the Optimized Mixed Diet (34), a dietary preventive concept for children and adolescents used in Germany, are suitable tools to promote the current dietary recommendations.
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