INTRODUCTION. Key Words: child, overweight, sugar-sweetened beverages, racial/ethnic disparities (J Nutr Educ Behav. 2013;45:

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1 Research Article Disparities in Consumption of Sugar-Sweetened and Other Beverages by Race/Ethnicity and Obesity Status among United States Schoolchildren Allison Hedley Dodd, PhD 1 ; Ronette Briefel, DrPH, RD 1 ; Charlotte Cabili, MS, MPH 1 ; Ander Wilson, MS 2,y ; Mary Kay Crepinsek, MS, RD 3 ABSTRACT Objective: Identify disparities by race/ethnicity and obesity status in the consumption of sugar-sweetened (SSBs) and other among United States schoolchildren to help tailor interventions to reduce childhood obesity. Design: Secondary data analysis using beverage intake data from 24-hour dietary recalls and measured height and weight from the third School Nutrition Dietary Assessment Study, a nationally representative sample of school-aged children and schools. Setting: Schools participating in the National School Lunch Program (n ¼ 287). Participants: Children in grades 1-12 with a completed 24-hour dietary recall (n ¼ 2,314). Main Outcome Measure(s): Percentage of children consuming in 8 beverage categories by school level and consumption location. Analysis: Two-tailed t tests to determine significant differences (P <.05) between the proportions of children consuming by race/ethnicity and weight status. Results: Beverage consumption patterns did not substantially differ across weight status groups, but they differed by race/ethnicity in the home. black elementary schoolchildren consumed nonsoda SSBs more often and unflavored, low-fat milk less often at home than non-hispanic white schoolchildren. Conclusions and Implications: Higher consumption of SSBs coupled with a lower consumption of milk is disproportionately affecting non-hispanic black schoolchildren. Targeted interventions by racial/ethnic group are needed to promote more healthful beverage choices among schoolchildren, particularly at home. Key Words: child, overweight, sugar-sweetened, racial/ethnic disparities (J Nutr Educ Behav. 2013;45: ) INTRODUCTION Between 1977 and 1996, the percentage of children ages 2-18 years who consumed sugar-sweetened (SSBs) increased from 75% to 85%, as did the number of occasions in which they consumed these and the average calories consumed per occasion. 1 During this time period, the same measures of beverage consumption decreased significantly for children's consumption of milk. Additionally, the average SSB portion size for 2- to 18-year-olds increased from 13.1 ounces to 18.9 ounces, and the average milk portion decreased from 15.4 to 13.6 ounces. 1 As portion sizes and the proportion of children and adolescents consuming SSBs have increased, the contribution to total caloric intake from SSBs has increased as well. For children ages 2-19 years, average caloric intake 1 Mathematica Policy Research, Research Division, Washington, DC 2 Department of Statistics, North Carolina State University, Raleigh, NC 3 Mathematica Policy Research, Research Division, Cambridge, MA Mr Wilson was affiliated with the Mathematica Policy Research, Research Division, Cambridge, MA at the time this study was completed. Address for correspondence: Allison Hedley Dodd, PhD, st St, NE, 12th Floor, Washington, DC 20002; Phone: (202) ; Fax: (202) ; adodd@ mathematica-mpr.com Ó2013 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR from SSBs increased from 204 to 224 kcal/day, which corresponded to an increase from 9.8% to 10.7% of daily caloric intake from to The largest increase in caloric contributions from SSBs occurred among children ages 6-11 years. For all age groups, the increase in caloric consumption from SSBs was greater for black and Mexican American children than for white children. 2 During this same time period, childhood obesity rates increased from 10% to 17% across all children and became most prevalent among nonwhite populations, especially non-hispanic black girls and Mexican American boys. 3,4 The childhood obesity rate for was still at 17%. 5 Several studies have shown that a greater consumption of SSBs is associated with obesity among children and adolescents. 6,7 In recent years, there has been a push to focus public health 240 Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013

2 Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Dodd et al 241 interventions aimed at reducing childhood obesity on decreasing the consumption of caloric drinks, particularly SSBs, which are high in calories and low in nutritional value; reducing excessive consumption of 100% fruit juices; and switching from whole milk to low-fat or fat-free milk As a first step toward tailoring interventions, researchers have sought to characterize beverage intake among children by the location in which the were consumed. These studies have shown that most SSB consumption among school-aged children and adolescents occurred at home, rather than at school or away from home or school. 1,2,11 Participation in school lunch or breakfast has been found to be associated with consuming fewer calories from SSBs at school. 11 However, little research has been done to characterize differences in beverage consumption patterns by race and/or ethnicity. Identifying differences in beverage intake by factors such as race/ethnicity or weight status may be beneficial in tailoring future diet-related childhood obesity interventions. This study sought to characterize beverage consumption patterns among United States (US) schoolchildren by racial/ethnic group and by weight status. The consumption of SSBs (differentiating between soda and other SSBs), 100% fruit juice, milk, diet drinks, and bottled water among non-hispanic whites, non- Hispanic blacks, and Hispanics was analyzed by examining the percentage of school-aged children and adolescents who consumed a beverage on at least 1 occasion during a typical day in the school week, by consumption location. Given that many schools have implemented nutrition and beveragerelated policies, greater differences in beverage consumption by race/ ethnicity were expected at home than at school. Differences in daily beverage consumption between overweight, obese and non-obese, non-overweight children were also examined. METHODS Study Design and Sample Data from the third School Nutrition Dietary Assessment Study (SNDA-III) were used to analyze the beverage intake of US school-aged children and adolescents (hereafter referred to as school-aged children, schoolchildren, children, or students ). The SNDA-III is a nationally representative, cross-sectional sample of US public school food authorities participating in the National School Lunch Program (NSLP), schools within the food authorities, and children within those schools during school year. 12 (A school food authority is the local NSLP administrative unit for 1 or more school districts.) The final sample included 2,314 children in grades 1-12 (ages 6-18 years), distributed among 287 schools at the elementary (n ¼ 732), middle (n ¼ 787), and high school (n ¼ 795) levels who completed a 24-hour dietary recall and a parent interview. Field interviewers measured each child's height and weight using standardized equipment and procedures at school (n ¼ 2,228). Close to half of all school-aged children in NSLP schools in spring 2005 were from racial or ethnic minority populations: 22% were Hispanic, 17% were non-hispanic black, and 7% were other minorities or biracial. 12 Based on parent report of income, 42% of children were from families eligible for free or reduced-price school meals (income at or below 185% of the federal poverty level). Overall, 18% of children participated in the School Breakfast Program (SBP) and 62% participated in the NSLP on the intake day. 13 Although participation in the SBP was significantly higher for non- Hispanic black students (32%) than for Hispanic (21%) or non-hispanic white (13%) students, participation in the NSLP did not differ significantly by racial/ethnic group (70%, 67%, and 57%, respectively). 13 Measured height and weight were used to calculate body mass index (BMI), and each child's BMI was compared to the 2000 Centers for Disease Control and Prevention age- and sexspecific growth charts to determine BMI-for-age percentiles. 14 A child was classified as overweight if his or her BMI was greater than or equal to the 85th percentile but less than the 95th percentile for age and sex. A child with a BMI greater than or equal to the 95th percentile was classified as obese. 15 Approximately 40% of school-aged children were overweight or obese, and over 20% were classified as obese at each school level. 16 In elementary schools, the prevalence of obesity was higher among Hispanic boys (31%) than non-hispanic white boys (16%). black girls in middle schools had a substantially greater likelihood of being overweight or obese (66%) than their non- Hispanic white (31%) and Hispanic (46%) counterparts. Data on Beverage Consumption Beverage consumption data are based on a single day's intake per sampled student and estimated at the group level. Data were collected in person using 24-hour dietary recalls (Automated Multiple Pass Method software; version 2.3, US Department of Agriculture, Agricultural Research Service, Beltsville, MD, 2003). Elementary students completed the dietary recall in 2 parts. During the in-school interview, they reported what they had eaten since waking up until the time of the interview. The next day, they were interviewed with parental assistance to report their intake for the remainder of the target day. Middle and high school students reported what they had eaten during the day (from midnight to midnight) before the interview. 12 Information was collected on bottled water, but not tap water, to reduce respondent burden in asking additional drinking water questions. Dietary recalls were processed with the SurveyNet coding system (version 3.14, US Department of Agriculture, Agricultural Research Service, Beltsville, MD, 2004) and the Food and Nutrient Database for Dietary Studies (version 1.0, US Department of Agriculture, Agricultural Research Service, Beltsville, MD, 2004). All reported were grouped into 8 mutually exclusive categories: SSBs (soda, other), flavored milk, unflavored milk (whole/2%, skim/1%), 100% fruit juice, diet/lowcalorie drinks, and bottled water. To learn more about possible differences in SSB consumption patterns, SSBs were split into 2 categories soda and other SSBs, such as lemonade, fruit-flavored drinks, and sport drinks. Flavored milk was considered a milk product rather than an SSB because it is a significant source of protein, calcium, and vitamins A and D. 10 Further, flavored milk is not a main

3 242 Dodd et al Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 contributor of added sugars in US children and adolescents, whereas soda and fruit-flavored drinks are the top 2 contributors. 17 The 24-hour dietary recall interviews, conducted Tuesday-Saturday, captured the food and reported at each eating occasion on an average day that the child attended school (Monday-Friday). This analysis focuses on the location where a beverage was consumed (school, home, or all locations) rather than the location where a beverage was obtained. 18 Data on consumed away from school or home, such as at a restaurant, are not presented separately because few children consumed at these locations on school days, resulting in unreliable estimates among population subgroups for all beverage categories except sugarsweetened soda. The category all locations encompasses any beverage consumption throughout the day, regardless of the location where the beverage was consumed. Additional details on the SNDA-III study design, sample, and data collection have been described elsewhere. 12 All data collection instruments and procedures for the study were approved by the US Department of Agriculture's Food and Nutrition Service, which administers the school meal programs; the 2004 Education Information Advisory Committee of the Council of Chief State School Officers; and the Office of Management and Budget. In addition, the study worked with any institutional review process a school district required. Data analyses for this research were approved by an independent institutional review board (Public/Private Ventures, Philadelphia, PA). Statistical Analysis Descriptive analyses of the percentage of school-aged children consuming various beverage products were completed using Statistical Analysis Software (version 9.1, SAS Institute, Cary, NC, 2004) and SUDAAN (release 9, Research Triangle Institute, Research Triangle Park, NC, 2005). Appropriate sampling weights for public schoolchildren and the design effects of the complex SNDA-III sampling procedure were used. Twotailed t tests were conducted to determine whether there were statistically significant differences between the proportions of children consuming among population subgroups defined by race/ethnicity and weight status. Children in the other racial/ethnic group were excluded from these comparisons because the sample was too small to generate reliable estimates. Differences were considered statistically significant at a P <.05 level, with a Benjamini- Hochberg adjustment for multiple comparisons. 19 RESULTS Tables 1-3 show the differences in the percentage of school-aged children in each racial/ethnic group consuming by the location where the beverage was consumed, for each school level (elementary, middle, and high, respectively). The total quantities of consumed at each location did not differ by racial/ ethnic group (data not shown). That is, caloric differences in beverage consumption by race/ethnicity were driven by the choice of beverage rather than portion sizes or total quantities (ie, calories) consumed. As outlined below, more racial/ethnic group differences in beverage consumption occurred in the home compared to at school. Racial/Ethnic Differences in Beverage Consumption at Home Across all school levels, non-hispanic white students were significantly more likely to consume unflavored low-fat milk (1% or skim) at home than both non-hispanic black and Hispanic students. Among elementary school students (Table 1), non- Hispanic blacks were significantly less likely than non-hispanic whites to consume milk of any kind at home. A significantly higher percentage of non-hispanic black elementary school students (49%) consumed other (nonsoda) SSBs at home than non-hispanic white (30%) or Hispanic (26%) students. By middle school (Table 2), the difference in the percentage of children consuming other SSBs at home was no longer significant, because the percentage consuming other SSBs at home decreased among non-hispanic black children and increased among Hispanic children. black middle school children were less likely than non-hispanic whites to consume unflavored milk of any kind at home. At the high school level (Table 3), significantly fewer non- Hispanic black students consumed diet drinks at home (5%) than non- Hispanic white (16%) or Hispanic (13%) students. Racial/Ethnic Differences in Beverage Consumption at School Significantly more non-hispanic black than non-hispanic white students consumed 100% fruit juice at school. Hispanic elementary school students (56%) were significantly more likely than non-hispanic black elementary students (36%) to drink flavored milk at school (Table 1). The proportions of older students consuming flavored milk at school were lower and did not vary across racial/ ethnic groups. At the middle school level (Table 2), fewer non-hispanic black than non-hispanic white students consumed unflavored low-fat milk. Both Hispanic and non- Hispanic black high school students were significantly more likely than their non-hispanic white counterparts to consume 100% fruit juice at school (Table 3). Differences in Beverage Consumption by Weight Status Table 4 shows the differences in the percentage of school-aged children consuming at any location throughout the day by weight status, for each school level. At all school levels, as compared to children who were not overweight or obese, a significantly higher percentage of obese children consumed diet or lowcalorie drinks. Among elementary school students, this difference is the result of differences in consumption of diet drinks at home, whereas for high school students, this difference is the result of differences in consumption at school (Table 5). Only among middle school students were obese children (24%) significantly less likely to consume 100% fruit juice than children who were overweight

4 Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Dodd et al 243 Table 1. Racial/Ethnic Differences in Percentage of Elementary School Children Consuming Beverages by Consumption Location and Beverage Type All a (n ¼ 732) Whites (n ¼ 379) Blacks (n ¼ 128) Hispanics (n ¼ 184) % SE % SE % SE % SE All locations b Sugar-sweetened soda (nondiet) d c Flavored milk c d,e c Unflavored milk (whole/2%) Unflavored milk (1%/skim) % fruit juice c d,e c Diet/low-calorie drinks f Bottled water Sugar-sweetened soda (nondiet) f f f f c e,f Flavored milk d c Unflavored milk (whole/2%) f Unflavored milk (1%/skim) f % fruit juice c d,e c,f Diet/low-calorie drinks f f f f Bottled water d f e,f Sugar-sweetened soda (nondiet) c d,e c Flavored milk c e,f Unflavored milk (whole/2%) c d,e c Unflavored milk (1%/skim) c,d e,f e,f 100% fruit juice Diet/low-calorie drinks c d,e,f c Bottled water a All category includes children with racial/ethnic group other than non-hispanic white, non-hispanic black, or Hispanic in addition to these groups; b All locations category includes consumed at home, at school, or away from home and school (eg, in restaurants); c Significantly different from non-hispanic blacks; d Significantly different from Hispanics; e Significantly different from non-hispanic whites; f Indicates a coefficient of variation > 30%. Note: t tests with Benjamini-Hochberg adjustment were used to examine differences between racial/ethnic groups. All significance is at P ¼.05. Source: Third School Nutrition Dietary Assessment Study (SNDA-III), (39%) or not overweight or obese (37%). This difference was driven by differences in fruit juice consumption at home. Obese middle school students (6%) also had lower consumption of unflavored low-fat milk at home than normal (12%) or overweight (15%) middle school students (Table 5). DISCUSSION This analysis focused on the percentage of US public schoolchildren and adolescents who consumed sugar-sweetened and other at any point during the day by racial/ethnic group, consumption location, and weight status. Although programs such as those fostered by the Healthy Hunger-Free Kids Act of 2010 are being implemented to improve children's nutrition at school, the results of this study support the need for programs that educate parents and children so that they make healthy beverage choices outside of the school setting. 11,20,21 Previous research has shown that factors such as parental dietary intake and excessive media exposure can influence schoolchildren across developmental stages. 20 This analysis of beverage consumption patterns highlighted several important racial/ethnic group differences in children's consumption of varied milk products, SSBs other than soda, and 100% fruit juice. The majority of the differences between groups occurred in the home. Except for a higher prevalence of consumption of diet drinks among obese children, beverage consumption patterns did not differ substantially from overweight and normal-weight schoolchildren. Beverage Consumption at Home and at School Sugar-sweetened were divided into 2 categories (soda and other) to provide more detail on the types of SSBs than previously reported

5 244 Dodd et al Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Table 2. Racial/Ethnic Differences in Percentage of Middle School Children Consuming Beverages by Consumption Location and Beverage Type All a (n ¼ 787) Whites (n ¼ 389) Blacks (n ¼ 175) Hispanics (n ¼ 170) % SE % SE % SE % SE All locations b Sugar-sweetened soda (nondiet) Flavored milk Unflavored milk (whole/2%) c d,e c Unflavored milk (1%/skim) c e % fruit juice c,d e e Diet/low-calorie drinks Bottled water Sugar-sweetened soda (nondiet) f Flavored milk Unflavored milk (whole/2%) f f Unflavored milk (1%/skim) c e,f f 100% fruit juice c d,e c Diet/low-calorie drinks d,f f e Bottled water f f Sugar-sweetened soda (nondiet) Flavored milk f f Unflavored milk (whole/2%) c d,e c Unflavored milk (1%/skim) c,d e,f e,f 100% fruit juice Diet/low-calorie drinks Bottled water a All category includes children with racial/ethnic group other than non-hispanic white, non-hispanic black, or Hispanic in addition to these groups; b All locations category includes consumed at home, at school, or away from home and school (eg, in restaurants); c Significantly different from non-hispanic blacks; d Significantly different from Hispanics; e Significantly different from non-hispanic whites; f Indicates a coefficient of variation > 30%. Note: t tests with Benjamini-Hochberg adjustment were used to examine differences between racial/ethnic groups. All significance is at P ¼.05. Source: Third School Nutrition Dietary Assessment Study (SNDA-III), using SNDA-III data. 11,18 A previous study by Briefel and colleagues using SNDA-III data found that SSBs were consumed by 68% of students on a given school day, indicating that approximately 15% to 25% of students consumed both soda and other SSBs, depending on age and other factors. 11 The data from the SNDA-III 11 on the percentage of secondary school children consuming SSBs in 2005 appear to be comparable to the National Health and Nutrition Examination Survey (NHANES) data analyzed by Wang et al 2 approximately three quarters of children in both surveys consumed at least 1 SSB on a weekday. The percentage of elementary school-aged children in the SNDA-III who consumed an SSB on the study day (61%) appears to be slightly lower than in the previous study (80%). 2,11 Compared with the earlier study, the SNDA-III estimates of the percentage of elementary school children in 2005 consuming 100% fruit juice (47% vs 30%) and diet (11% vs 5%) at any consumption location were higher. 2 The percentage of children consuming fruit juice and diet drinks was higher for high school children as well. Among high school students, there was a similar decline in overall milk consumption compared to the younger students in middle and elementary schools. There was an apparent increase in the percentage of children consuming soda and other soft drinks (either diet or sugar sweetened) as they aged. Differences between the 2 national studies may relate to the timing of the surveys; NHANES was conducted during all months of the year, including summers, when children were not in school, and the SNDA-III was conducted in the spring, during the school year. The decline in overall milk consumption as children aged occurred at both school and home. However, the majority of differences in milk consumption by racial/ethnic group occurred at home. Compared to their

6 Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Dodd et al 245 Table 3. Racial/Ethnic Differences in Percentage of High School Students Consuming Beverages by Consumption Location and Beverage Type All a (n ¼ 795) Whites (n ¼ 412) Blacks (n ¼ 137) Hispanics (n ¼ 188) % SE % SE % SE % SE All locations b Sugar-sweetened soda (nondiet) f Flavored milk f Unflavored milk (whole/2%) Unflavored milk (1%/skim) c d,e c 100% fruit juice c e Diet/low-calorie drinks c d,e c Bottled water c e Sugar-sweetened soda (nondiet) f Flavored milk Unflavored milk (whole/2%) f f Unflavored milk (1%/skim) f f f 100% fruit juice c,d e e Diet/low-calorie drinks f f f Bottled water c d,e,f c Sugar-sweetened soda (nondiet) Flavored milk f f f Unflavored milk (whole/2%) f Unflavored milk (1%/skim) c,d d,e,f c,e 100% fruit juice Diet/low-calorie drinks c d,e,f c Bottled water f a All category includes children with racial/ethnic group other than non-hispanic white, non-hispanic black, or Hispanic in addition to these groups; b All locations category includes consumed at home, at school, or away from home and school (eg, in restaurants); c Significantly different from non-hispanic blacks; d Significantly different from Hispanics; e Significantly different from non-hispanic whites; f Indicates a coefficient of variation > 30%. Note: t tests with Benjamini-Hochberg adjustment were used to examine differences between racial/ethnic groups. All significance is at P ¼.05. Source: Third School Nutrition Dietary Assessment Study (SNDA-III), non-hispanic white counterparts, elementary-aged, non-hispanic black children had significantly lower milk consumption at home for all types of milk. As children got older, the differences in the percentage consuming certain types of milk disappeared as the consumption among non-hispanic whites fell closer to the consumption levels among non- Hispanic blacks. By middle school, the percentage consuming unflavored milk of any type was lower among non-hispanic blacks than non-hispanic whites. By high school, the only difference that remained was a lower percentage of non- Hispanic black students consuming low-fat (skim or 1%), unflavored milk at home. Across all school levels, non-hispanic whites were more likely than either non-hispanic blacks or Hispanics to consume low-fat, unflavored milk at home. Other research has found that adolescents' calcium intake is related to the availability of meals at home and higher socioeconomic status, and that calcium intake may be of concern, especially among girls ages 9-18 years. 22,23 There appears to be a need for interventions that are targeted to specific racial/ethnic groups to promote nonflavored, nonfat/low-fat milk as a healthy beverage choice, among school-aged children. 10,22 This study found that among elementary school children, a higher percentage of non-hispanic blacks consumed calories from nonsoda SSBs at home compared to non- Hispanic whites and Hispanics. Among middle and high school students, there were no significant differences in SSB consumption across racial/ethnic groups at either home or school. Based on consistent evidence of negative health effects, the American Academy of Pediatrics recommends limiting the consumption of SSBs and the amount of 100% fruit juice. 6,8,15,21 Previous research has suggested that discouraging the consumption of SSBs may be an

7 246 Dodd et al Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Table 4. Weight Status Differences in Percentage of Children Consuming Beverages at Any Point in the Day (All Locations) by School Level and Beverage Type important strategy for promoting a healthy diet and preventing excess caloric intake and weight gain among children. 2,7 A higher percentage of non- Hispanic black schoolchildren consumed 100% fruit juice while at school than non-hispanic white schoolchildren at all school levels. The difference in juice consumption Not Overweight or Obese Overweight Obese % SE % SE % SE Elementary school, n Sugar-sweetened soda (nondiet) Flavored milk Unflavored milk (whole/2%) Unflavored milk (1%/skim) % fruit juice Diet/low-calorie drinks b b a,c Bottled water Middle school, n Sugar-sweetened soda (nondiet) Flavored milk Unflavored milk (whole/2%) Unflavored milk (1%/skim) % fruit juice b b a,c Diet/low-calorie drinks b c Bottled water High school, n Sugar-sweetened soda (nondiet) Flavored milk Unflavored milk (whole/2%) Unflavored milk (1%/skim) d % fruit juice Diet/low-calorie drinks b c Bottled water a Significantly different from overweight; b Significantly different from obese; c Significantly different from not overweight or obese; d Indicates a coefficient of variation > 30%. Note: t tests with Benjamini-Hochberg adjustment were used to examine differences between racial/ethnic groups. All significance is at P ¼.05. Source: Third School Nutrition Dietary Assessment Study (SNDA-III), is likely a result of the higher participation in the SBP among non- Hispanic black children noted earlier. A previous study using SNDA-III data found that SBP participants were significantly more likely than nonparticipants to consume fruit juice at breakfast. 24 Both NSLP and SBP participants were more likely than nonparticipants to consume milk at school, although few racial/ethnic differences in milk intake were observed here. The paucity of other racial/ethnic differences in beverage consumption at school is consistent with the study by Finkelstein and colleagues, 25 who found very little variation in school food environments and practices by racial/ethnic mix or socioeconomic status of the children. Beverage Consumption and Obesity There was only 1 significant racial/ ethnic group difference in beverage consumption that occurred across all school levels: a higher percentage of obese school children consumed diet drinks than children who were not overweight or obese. This difference in diet beverage consumption among obese and non-overweight, non-obese children was seen across all school levels when assessing beverage consumption from all locations, and it has been observed in other studies In elementary school, these differences occur at home, whereas in high school, these differences occur at school. Data Limitations The SNDA-III data are cross-sectional. Therefore, the association between diet drink consumption and obesity is not clear. It may be that the parents who perceive their child to be obese are more likely to provide diet soda or other low-calorie at home. High school students who are obese may be more likely to select a diet soda as a beverage in an effort to control their weight or to appear as if they are trying to do so. 28 A prospective study of adolescents found that diet soda consumption was positively associated with weight gain during the adolescent years. 27 This association was explained by dieting behaviors, which have been shown to be ineffective and potentially promote weight gain in preadolescents and adolescents. 27,29 Water is a potential substitute for less-healthy. The omission of tap water from the 2005 dietary intake data likely results in an underestimate of the percentage of children consuming water. In NHANES

8 Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Dodd et al 247 Table 5. Weight Status Differences in Percentage of Children Consuming Beverages by School Level and Consumption Location Not Overweight or Obese Overweight Obese % SE % SE % SE Elementary school, n Sugar-sweetened soda (nondiet) d d d b a Flavored milk Unflavored milk (whole/2%) Unflavored milk (1%/skim) % fruit juice a b,c a Diet/low-calorie drinks d d d Bottled water d d Sugar-sweetened soda (nondiet) Flavored milk Unflavored milk (whole/2%) Unflavored milk (1%/skim) b d c,d 100% fruit juice Diet/low-calorie drinks b b,d a,c Bottled water a c,d Middle school, n Sugar-sweetened soda (nondiet) d Flavored milk d Unflavored milk (whole/2%) d Unflavored milk (1%/skim) d % fruit juice d Diet/low-calorie drinks d d d Bottled water d d Sugar-sweetened soda (nondiet) Flavored milk a c,d d Unflavored milk (whole/2%) Unflavored milk (1%/skim) b b a,c 100% fruit juice b b a,c Diet/low-calorie drinks Bottled water High school, n Sugar-sweetened soda (nondiet) b c Flavored milk Unflavored milk (whole/2%) d Unflavored milk (1%/skim) d 100% fruit juice Diet/low-calorie drinks b,d c,d Bottled water (continued) , bottled water contributed about half of total plain drinking water for adolescent females and about one third for younger children and adolescent males. 30 Given the difficulty of accurately reporting the intake of tap water and the fact that the beverage consumption categories in this study were not mutually exclusive, the overall impact of not including tap water in SNDA-III is likely minimal. Other limitations of this study include the use of self-reported, 1-day dietary intake data by children (and their parents, for elementary school children), which may result in under- or overreporting of intake. 31 In addition, the data reflect beverage intake patterns only from Monday through Friday (in the school year). Weekend beverage consumption is likely greater with the exception of milk, 2 and the types of consumed by racial/ethnic groups may differ compared to those consumed on school days. Finally, the SNDA-III findings reflect beverage consumption patterns at school in spring 2005, prior to widespread changes in competitive food policies and school meal standards. IMPLICATIONS FOR RESEARCH AND PRACTICE This study sought to characterize the beverage consumption patterns of US schoolchildren by racial/ethnic group and consumption location, and by weight status. As anticipated, the majority of racial/ethnic differences in the percentage of children consuming certain occurred in the home. Although the higher consumption of SSBs coupled with a lower consumption of milk is a trend that has been seen previously, 1 this study shows that it appears to be disproportionately affecting non- Hispanic black children. Although some of the differences among racial/ethnic groups disappeared as children got older, it was usually because 1 group moved toward the more negative behavior, such as reducing milk consumption. This nationally representative study of US public schoolchildren highlights the need

9 248 Dodd et al Journal of Nutrition Education and Behavior Volume 45, Number 3, 2013 Table 5. Continued for nutrition education and behavioral interventions to improve beverage choices that are tailored to specific racial/ethnic groups and to both parents and children. Familybased interventions and school home community partnerships aimed at helping parents and children select healthy and appropriate portion sizes are potential strategies to reduce calories and improve nutrition from. 21,22,32 ACKNOWLEDGMENTS The authors have no conflicts of interest to report. This research was supported by a grant from the Robert Wood Johnson Foundation (no ). The opinions expressed are those of the authors and do not necessarily represent the views or recommendations of Mathematica Policy Research or the Robert Wood Johnson Foundation. REFERENCES Not Overweight or Obese Overweight Obese % SE % SE % SE Sugar-sweetened soda (nondiet) Flavored milk a c,d d Unflavored milk (whole/2%) b c Unflavored milk (1%/skim) d d 100% fruit juice Diet/low-calorie drinks Bottled water a Significantly different from overweight; b Significantly different from obese; c Significantly different from not overweight or obese; d Indicates a coefficient of variation > 30%. Note: t tests with Benjamini-Hochberg adjustment were used to examine differences between racial/ethnic groups. All significance is at P ¼.05. Source: Third School Nutrition Dietary Assessment Study (SNDA-III), Nielsen SJ, Popkin BM. Changes in beverage intake between 1977 and Am J Prev Med. 2004;27: Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened and 100% fruit juices among US children and adolescents, Pediatrics. 2008; 121:e1604-e Ogden C, Carroll M. Prevalence of Obesity among Children and Adolescents: United States, Trends through Health e-stat. obesity_child_07_08/obesity_child_07_ 08.pdf. Published June Accessed January 2, Ogden CL, Carroll MD, Curtin LR, Lamb M, Flegal KM. Prevalence of high body mass index in US children and adolescents, JAMA. 2010;303: Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, JAMA. 2012;307: Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health. 2007;97: Robert Wood Johnson Foundation. The Negative Impact of Sugar-sweetened Beverages on Children s Health. A Research Synthesis. Princeton, NJ: Robert Wood Johnson Foundation; American Academy of Pediatrics. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107: Popkin BM, Armstrong LE, Bray GM, Caballero B, Frei B, Willet WC. A new proposed guidance system for beverage consumption in the United States. Am J Clin Nutr. 2006;83: Centers for Disease Control and Prevention. Effects of switching from whole to low-fat/fat-free milk in public schools New York City, Morb Mortal Wkly Rep. 2010;59: Briefel RB, Wilson A, Gleason PM. Consumption of low-nutrient, energydense foods and at school, home, and other locations among school lunch participants and nonparticipants. J Am Diet Assoc. 2009;109:S79-S Gordon AR, Cohen R, Crepinsek MK, Fox MK, Hall J, Zeidman E. The third School Nutrition Dietary Assessment Study: background and study design. J Am Diet Assoc. 2009;109:S20-S Gordon AR, Fox MK, Clark M, et al. School Nutrition Dietary Assessment Study-III: Vol. II: Student Participation and Dietary Intakes. Alexandria, VA: US Department of Agriculture, Food and Nutrition Service; Kuczmarski RJ, Ogden CL, Grummer- Strawn LM, et al. CDC growth charts: United States. Adv Data. 2000;314: Barlow SE, Expert committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S Gleason PM, Dodd AH. School Breakfast Program but not School Lunch Program participation is associated with lower body mass index. J Am Diet Assoc. 2009;109:S118-S 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: Briefel RB, Crepinsek MK, Cabili C, Wilson A, Gleason PM. School food environments and practices affect dietary behaviors of US public school children. J Am Diet Assoc. 2009;109:S91-S Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Ser B Stat Methodol. 1995; 57: Harrison K, Bost KK, McBride BA, et al. Toward a developmental conceptualization of contributors to overweight and obesity in childhood. Child Dev Persp. 2011;5: Princeton University Policy Workshop on Urban Food Systems. Tipping the Scales: Strategies for Changing How America s Children Eat. A Report to the Robert

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