American Journal of Epidemiology Copyright 2001 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved

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1 American Journal of Epidemiology Copyright 2001 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved Vol. 153, No. 10 Printed in U.S.A. Nutrient Intake in 10-Year-Old Children Nicklas et al. Trends in Nutrient Intake of 10-Year-Old Children over Two Decades ( ) The Bogalusa Heart Study Theresa A. Nicklas, 1 Abdalla Elkasabany, 2 Sathanur R. Srinivasan, 2 and Gerald Berenson 2 Dietary intakes of 10-year-old children were examined in seven cross-sectional surveys to observe secular trends in nutrient intake and food consumption patterns over 2 decades ( ). Total energy intake remained unchanged from 1973 to However, when expressed as energy per kilogram body weight, intake decreased from 65.5 kcal in 1973 to 55.4 kcal in 1994 because children s weight increased. A significant trend was noted in ponderal index, which increased from ( ) to ( ), with an actual weight gain of 1.45 kg from 1973 to 1979 and 2.71 kg from 1981 to Linear trends also were noted for total fat (negative), saturated fat (negative), dietary cholesterol (negative), polyunsaturated fat (positive), and total carbohydrate (positive). There was a significant increase in percent energy from protein and carbohydrate and a significant decrease in percent energy from fat, primarily saturated and monounsaturated fat. Trends in nutrient intakes of children reflected trends in food consumption. The percentage of total fat from fats/oils, mixed meats, eggs, milk, pork, and desserts decreased, while that from poultry, cheese, and snacks increased. Although more children met dietary recommendations for total fat, saturated fat, and dietary cholesterol, the vast majority continued to exceed prudent diet recommendations. Am J Epidemiol 2001;153: child nutrition; diet; energy intake; fats; nutrition surveys Although there has been a decline in heart disease over the past 2 decades, coronary heart disease remains the major cause of death in the United States (1). Coronary heart disease is, in part, considered a nutritional disease that could be prevented by prudent dietary habits (2 7). In addition, increasing obesity has occurred over the past 2 decades in both children and adults. Stephen and Wald (8) documented trends in individual consumption of dietary fat from 1920 to 1984 based on 171 reported studies. More recent population-based studies have documented changes in dietary intake and risk factors for cardiovascular disease over the past 3 decades (9 16). Results show a decline in dietary fat, saturated fat, dietary cholesterol, and serum total cholesterol. Changes in reported intake correspond to shifts observed in the sources of these nutrients in the food supply (17 21). The majority of these studies have focused on young adults, with limited data available on trends in the diets of children. Because altering dietary habits from childhood onward is considered prudent in delaying or preventing the development of coronary heart Received for publication February 3, 2000, and accepted for publication October 5, Abbreviation: MENu, Moore Extended Nutrients. 1 Children s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX. 2 Tulane Center for Cardiovascular Health, Tulane School of Public Health and Tropical Medicine, New Orleans, LA. Correspondence to Dr. Theresa A. Nicklas, Children s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX ( tnicklas@bcm.tmc.edu). disease, it is of special interest to examine the secular trends in dietary intake of children. The Bogalusa Heart Study (22, 23), a long-term epidemiology study, presents the opportunity to observe secular trends of nutrient intake over 21 years in a well-defined biracial (White-Black) pediatric population. While the nutrient intakes of infants (24, 25), children (26, 27), and adolescents (28) have been reported, national surveys have demonstrated that eating patterns are changing over time (12). In this report, secular trends are examined in the energy, macronutrient, cholesterol, and fatty acid intakes of 10-year-old children residing in Bogalusa, Louisiana, from 1973 to The results are compared with current dietary recommendations (2 7) and trends in several food-consumption patterns in the United States. MATERIALS AND METHODS Population Children attending the fifth grade (age 10 years) in the Bogalusa, Louisiana, school system were targeted for study during each of seven cross-sectional surveys from 1973 to Sample sizes and mean age of children by race (Black- White), gender, and survey year are shown in table 1. Varying proportions of children were selected randomly for dietary interview during each cross-sectional survey: (year 1), 50 percent; (year 4), 50 percent; (year 6), 75 percent; (year 9), 100 percent; (year 12), 72 percent;

2 970 Nicklas et al. TABLE 1. Sample size and mean age of 10-year-old children, by race, gender, and survey year in the Bogalusa Heart Study, Mean age (years) White Male Female No. % No. % Black Male Female No. % No. % (n = 185) (n = 158) (n = 224) (n = 304) (n = 284) (n = 284) (n = 216) Total (n = 1,655) (year 15), 90 percent; and, (year 20), 88 percent. The race and gender distributions of the seven cohorts were similar, with a White-Black composition of 65 and 35 percent, respectively, representative of the total population. Written informed consent was obtained from the children s parent or guardian before examination, and experimental plans, procedures, and consent forms for this study were reviewed and approved by the Louisiana State University and Tulane University medical centers ethics and research committees. Dietary methodology The 24-hour dietary recall method was adapted for use in interviewing children (29). Quality controls, which improved the reliability and validity, included 1) a standardized protocol that specified exact techniques for interviewing, recording, and calculating results (29); 2) standardized graduated food models for quantification of foods and beverages consumed (29); 3) a product identification notebook for probing of snack consumption; 4) school lunch assessment to identify all school lunch recipes, preparation methods, and average portion sizes of menu items reflected in each 24-hour recall (30); 5) follow-up telephone calls to parents to obtain information on brand names, recipes, and preparation methods of meals served at home; 6) products researched in the field to obtain updated information on product cost, ingredients, and their weights; primarily snack foods, candy, and fast foods; and, 7) the Moore Extended Nutrients (MENu), formerly known as the Extended Table of Nutrient Values, for nutrient composition (31). All interviewers participated in rigorous training sessions and pilot studies before the field surveys to minimize interviewer effects. Duplicate recalls were obtained from 10 percent random subsamples of each study population to assess interviewer variability (32, 33). Previous reports (24) have shown that the coefficients of variation for measurement error were relatively low (less than 20 percent), with iron, cholesterol, and vitamin C being the most difficult dietary components to estimate. One 24-hour dietary recall was collected on each study participant. Prior to lunch, students were escorted from the classroom to a designated area in the school to complete a recall interview. Each interview took minutes, and the recall period reflected the previous 24 hours. No more than six children were interviewed by any one interviewer on any given day to avoid interviewer fatigue. Nutrient database The MENu is a nutrient database that includes more than 5,000 core foods and recipes, with values for 97 dietary components (31). The data bank is a flexible system permitting continuous updates of existing values and additions of new single or composite foods. Periodic updates are made to the MENu to reflect nutrient changes in food products. Nutrient values include United States Department of Agriculture data, other published references, manufacturers information, and recipe calculation by ingredients. For each survey period, the 24-hour recalls were analyzed on the MENu, and the nutrient information was stored in a file. In addition, the version of the MENu used was saved on a tape. Analyses reflect data that were retrieved from stored information files specific to those time periods. Although the MENu is updated frequently as current information becomes available, we have the ability to store a version for each year. Measure of adiposity Trained examiners followed rigid protocols that changed little over time (23). Briefly, height was measured twice to the nearest 0.1 cm on a standard board, and weight was measured twice to the nearest 0.1 kg by using a balance beam metric scale. For both weight and height, the two readings were averaged. The children were clothed in only a hospital gown, underpants, and socks. Ponderal index (weight (kg)/height (m 3 )) was used as the measure of adiposity. Statistical analyses All analyses were performed with the Statistical Analysis System (34). Descriptive statistics summarized the data. Analyses of variance were used to test statistical signifi-

3 Nutrient Intake in 10-Year-Old Children 971 cance for each nutrient. Raw data and data adjusted per 1,000 kcal and per kilogram body weight were examined. Each nutrient was entered as a dependent variable in a model with race, gender, race gender interaction, and year entered as fixed main effects. The relation of the mean for each nutrient over time was examined by models with linear, quadratic, and cubic year terms in succession. Mantel- Haenszel χ 2 test was used to test for a linear trend in the percentage exceeding the current dietary recommendations for total fat, saturated fat, and cholesterol (2, 5). Ponderal index was used to assess whether a secular trend toward increased overweight occurred during the study period. This was done with a model that included race, gender, and race gender interaction in addition to year as independent variables. RESULTS Nutrient intake Intake of total energy, macronutrient, and cholesterol for each of the 7 survey years from 1973 to 1994 are presented in table 2. Total energy intake remained virtually the same over these years, ranging from 2,054 to 2,224 kcal. There were no detectable racial differences, but boys had consistently higher energy intake than did girls (data not shown). A significant negative trend was noted in energy intake relative to body weight. No significant trend was noted in total protein intake. A significant positive trend was noted for total carbohydrate and starch intake. Although total sugar (simple carbohydrates) intake remained similar over the study period, a significant decrease in sucrose intake and a significant increase in fructose intake occurred. A significant negative trend was observed with respect to intake of total fat, saturated fatty acid, and monounsaturated fatty acid. The trend was opposite for polyunsaturated fatty acid intake, with a significant shift toward higher ratios of polyunsaturated to saturated fatty acid (0.32 to 0.63). Cholesterol intake decreased significantly over the years, ranging from 324 mg ( ) to 246 mg ( ). Percent contribution of the macronutrients to energy intake is presented in table 3. The percent of energy from protein and carbohydrate increased significantly over the years. In contrast, the percent of energy from fat decreased significantly. This decrease was reflected in percent of energy from saturated and monounsaturated fatty acids. Percent energy from polyunsaturated fatty acid showed a significant positive trend. Fatty acid intakes are shown in table 4. There was a significant decrease in intakes of palmitic, myristic, stearic, and oleic fatty acids. Intake of stearic acid was significantly lower in than in previous surveys. Intakes of linoleic acid increased over the years. Consumption of food groups Trends were observed in the mean gram amounts of food groups consumed by 10-year-old children during versus (table 5). There was a decrease in the consumption of fats/oils, vegetables/soups, breads/grains, mixed meats, desserts, candy, and eggs. In contrast, children consumed increased amounts of fruits/fruit juices, beverages, poultry, snacks, condiments, and cheese. The percent of total dietary fat from fats/oils, mixed meats, pork, eggs, desserts, and milk decreased in compared with In contrast, the percent of fat from poultry, snacks, and cheese increased. Comparison with dietary recommendations There was an apparent decrease in the percentage of children who exceeded the dietary recommendations (2 5) for total fat and saturated fatty acid from 1973 to 1994 (figure 1). However, approximately 80 percent of the children still exceeded the recommended intake of total fat, and approximately 70 percent exceeded the recommended intake of saturated fat. Seventy-three percent of the 10-year-old children in exceeded the dietary cholesterol recommendation of 100 mg/1,000 kcal; the percentage decreased to 51 percent in (figure 1). This decrease in dietary cholesterol intake largely reflects a decrease in the consumption of eggs from 1973 to Secular trends in obesity To determine whether a secular trend toward increased overweight occurred during the study period, ponderal index (weight (kg)/height (m 3 ), a measure of adiposity) data were examined in the seven study cohorts. A significant positive trend was observed in the ponderal index, increasing from ( ) to ( ), with mean weight increasing from 1.45 ( ) to 2.71 kg ( ) (figure 2). DISCUSSION Dietary intake data have been collected from US children in large nationwide surveys and longitudinal studies (13, 26, 35 42). Despite some differences in design characteristics, findings regarding trends as well as current nutrient intakes and eating patterns of children are consistent with the longterm studies in Bogalusa. For more than 2 decades, the Bogalusa Heart Study has been collecting data on children s dietary intakes in a biracial community. However, no attempts have been made to change the eating habits of the inhabitants. Changes in food choices and nutrient intake reflect national changes in food consumption patterns and the influences of industry, mass communication, and commercial advertising in our society. Evaluation of diets of seven cross-sectional samples of 10-year-old children in Bogalusa revealed that the diets of children changed positively from 1973 to The percentage of energy intake from protein and carbohydrate increased. In contrast, the percentage of energy from total fat and saturated fat decreased. The decrease in fat intake reflects a decrease in intakes of palmitic, stearic, myristic, and oleic fatty acids. There is a possibility that the changes noted in this study reflect more available data on the change in fatty acid content of foods. Nutrient information on food products is more complete and available today than it was 20 years ago.

4 972 Nicklas et al. TABLE 2. Intake of selected nutrients of 10-year-old children in the Bogalusa Heart Study, by survey year, * Nutrient (g) (n = 185) p for trend (n = 158) (n = 224) (n = 304) (n = 284) (n = 284) (n = 216) Linear Quadratic Cubic Energy (kcal) (kcal/kg body weight) Protein Carbohydrate Starch Sugar Sucrose Fructose Fat Saturated Monounsaturated Polyunsaturated P:S Cholesterol (mg) (mg/1,000 kcal) Sodium (mg) (mg/1,000 kcal) 2,141 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 54 2,316 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 56 * Adjusted for race and gender. Mean ± standard deviation. P:S, ratio of polyunsaturated to saturated fatty acids. 2,145 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 82 2,054 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 86 2,145 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 60 2,224 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 76 2,116 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±

5 Nutrient Intake in 10-Year-Old Children 973 TABLE 3. Macronutrient composition of the diets of 10-year-old children in the Bogalusa Heart Study, by survey year, Nutrients (% energy) (n = 185) (n = 158) (n = 224) (n = 304) (n = 284) (n = 284) (n = 216) Linear p value for trend Quadratic Cubic Carbohydrate Fat Saturated Polyunsaturated Monounsaturated Protein 49.4 ± 9.5* 38.4 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± * Mean ± standard deviation. TABLE 4. Fatty acid intake* of 10-year-old children in the Bogalusa Heart Study, by survey year, Fatty acid (g) (n = 185) (n = 158) (n = 224) (n = 304) (n = 284) (n = 284) (n = 216) p value for trend Linear Quadratic Cubic Myristic Palmitic 2.8 ± ± ± ± ± ± ± ± ± ± ± ± ± ± Stearic Oleic 10.4 ± ± ± ± ± ± ± ± ± ± ± ± ± ± Linoleic Linolenic 11.4 ± ± ± ± ± ± ± ± ± ± ± ± ± ± 1.07 Arachidonic 0.14 ± ± ± ± ± ± ± 0.53 * Adjusted for race and gender. Mean ± standard deviation. TABLE 5. Consumption of food groups in terms of amount and percent of total fat by 10-year-old children during versus Food group Fats/oils Fruits/fruit juices Vegetables/soups Breads/grains Mixed meats Poultry Seafood Beef Pork Eggs Cheese Milk Beverages Candy Desserts Snacks Condiments Mean amount consumed ** 148.5* 104.7** 135.0**** 18.9* 53.4*** *** 31.8* * 35.4* 42.3**** 17.3*** 12.5*** % of total fat consumed * p < 0.05; ** p < 0.01; *** p < 0.001; **** p <. Nonalcoholic nondairy * **** 8.59**** * 1.24**** 6.59**** 10.53**** 0.01* **** 6.67*** 0.13 More than 26 million children participate in the National School Lunch Program daily, and 5 million participate in the National School Breakfast Program. For some 10-year-old children, approximately percent of their total daily intake of energy comes from school meals (43 47). Changes in the nutrient contribution of school meals to the dietary intakes of children are similar to the changes shown in children s reported intake (43 46). While the availability of school breakfast and lunch programs has a beneficial effect on nutrition, this program also may be contributing to the increasing adiposity observed in this study. Trends in nutrient intakes of these children are consistent with national trends in the food supply and trends in the types of foods consumed by children (10 18). There has been an overall decline in the total gram amount of fats/oils, vegetables/soups, breads/grains, mixed meats (combination dishes including meat), eggs, candy, and desserts. In contrast, consumption of fruit/fruit juices, poultry, beverages, cheese, condiments, and snacks has increased. These changes have resulted in a shift in the foods that contribute to the decrease of total fat intake in the diets of children. The percentage of total fat from fats/oils, milk, mixed meats, eggs, pork, and desserts has decreased, and the percentage of total fat from, poultry, cheese, and snacks has increased. Changes in children s food choices and nutrient intakes also reflect changes in several food consumption patterns in

6 974 Nicklas et al. FIGURE Percent of 10-year-old children who exceeded the current American Heart Association dietary guidelines, Bogalusa Heart Study, the United States. There has been an overall decline in the consumption of whole milk, for which an increase in consumption of 2 percent and skim milk has been substituted. Other shifts in food consumption include a decrease in egg consumption and substitutions of poultry and fish for red meat and margarine for butter (10, 17). Similarly, food companies have shifted away from using saturated fats in processed foods with the replacement of vegetable oils that are partially hydrogenated or contain trans fatty acids. It should be noted that despite a decrease in dietary fat intake and an essentially similar total energy intake from 1973 to 1994, there has been a significant and dramatic increase in adiposity of children. We previously documented a twofold increase in the prevalence of overweight among children (48, 49); the yearly increases in relative weight and obesity from 1983 to 1994 were 50 percent greater than those between 1973 and The lack of increase observed in total energy intakes may reflect the high degree of variability shown in reported energy intakes using a single 24- hour dietary recall (50). The mean energy intake in this study averaged 2,200 calories over the 2 decades with a standard deviation of 800 calories and may not be sensitive enough to detect a small increment in energy consumption. For any one child to gain 5 pounds (2.27 kg) over a year, he or she would only need to consume an additional 48 calories every day. This is considerably lower than the reported standard deviation for energy intake and potential increase of energy intake not detectable by a simple 24-hour dietary recall. Further, the observed secular trend toward increased adiposity may reflect changes in food consumption patterns. Dietary fat is being increasingly replaced with refined carbohydrates and high-energy, less nutrient-dense foods instead of whole-grain products, vegetables, and fruits. In addition to diet, physical activity also plays a role in achieving healthy weights (51 56). One study showed that children who watched 4 or more hours of television per day had greater body fat and body mass index than those who watched less than 2 hours per day (52). Although physical activity was not routinely assessed in the Bogalusa Heart Study, we documented a similar time spent in watching television, which could have contributed to obesity observed in Bogalusa children. These observations indicate that both diet and sedentary activity are contributing factors to the rampant obesity occurring in the United States. The secular trends observed in the nutrient intake and eating patterns of children are important to consider in the design and implementation of population-based educational strategies for the promotion of health and prevention of chronic diseases. Although the diets of children have changed favorably in the past 21 years, more than 75 percent of the Bogalusa children still exceed the current dietary recommendations for total fat and saturated fat, and adiposity has dramatically increased. There is an ongoing need for nutrition intervention and education with regard to the entire US pediatric population. We must begin such efforts with health education and health promotion for elementary

7 Nutrient Intake in 10-Year-Old Children 975 FIGURE 2. Mean ponderal index of 10-year-old children, Bogalusa Heart Study, (Health Ahead/Heart Smart) (57 61) and high school (Gimme 5) students (62). Equally important, private industry has the potential to change the eating habits and nutrient intake of our children. Industry must continue its efforts to provide healthier food choices and introduce innovative ways to market these new choices to appeal to the public. Finally, we need to continue to monitor the changes that are occurring in the food supply and in the diets of children. ACKNOWLEDGMENTS Supported by National Health, Lung, and Blood Institute of the US Public Health Service grant 5R01 HL This work is a publication of the US Department of Agriculture/Agricultural Research Service Children s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, and has been funded in part with federal funds from the US Department of Agriculture/Agricultural Research Service under Cooperative Agreement 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 by the US government. REFERENCES 1. American Heart Association Heart and Stroke Statistical Update. Dallas, TX: American Heart Association, Healthy People 2000: national health promotion and disease prevention objectives. Washington, DC: US GPO, (DHHS (PHS) publication no ). 3. The Surgeon General s report on nutrition and health. Washington, DC: US Department of Health and Human Services, (DHHS publication no ). 4. Weidman WJ, Kwiterovich P, Jesse MJ, et al. AHA committee report. Diet in the healthy child: Task Force Committee of the Nutrition Committee and the Cardiovascular Disease in the Young Council of the American Association. Circulation 1983; 67:1411A 14A. 5. Food and Nutrition Board. Diet and health: implications for reducing chronic disease risk. Washington, DC: National Academy Press, Ahrens EH Jr. Introduction to symposium. The evidence relating six dietary factors to the nation s health: consensus state-

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