Added sugar, macro-and micronutrient intakes and anthropometry of children in a developing world context

Objective The objective of this study was to determine the relationship between added sugar and dietary diversity, micronutrient intakes and anthropometric status in a nationally representative study of children, 1-8.9 years of age in South Africa. METHODS: Secondary analysis of a national survey of children (weighted n = 2,200; non weighted n = 2818) was undertaken. Validated 24-hour recalls of children were collected from mothers/caregivers and stratified into quartiles of percentage energy from added sugar (% EAS). A dietary diversity score (DDS) using 9 food groups, a food variety score (FVS) of individual food items, and a mean adequacy ratio (MAR) based on 11 micronutrients were calculated. The prevalence of stunting and overweight/obesity was also determined. RESULTS: Added sugar intake varied from 7.5-10.3% of energy intake for rural and urban areas, respectively. Mean added sugar intake ranged from 1.0% of energy intake in Quartile 1 (1-3 years) (Q1) to 19.3% in Q4 (4-8 years). Main sources of added sugar were white sugar (60.1%), cool drinks (squash type) (10.4%) and carbonated cool drinks (6.0%). Added sugar intake, correlated positively with most micronutrient intakes, DDS, FVS, and MAR. Significant negative partial correlations, adjusted for energy intake, were found between added sugar intake and intakes of protein, fibre, thiamin, pantothenic acid, biotin, vitamin E, calcium (1-3 years), phosphorus, iron (4-8 years), magnesium and zinc. The prevalence of overweight/obesity was higher in children aged 4-8 years in Q4 of %EAS than in other quartiles [mean (95%CI) % prevalence overweight 23.0 (16.2-29.8)% in Q4 compared to 13.0 (8.7-17.3)% in Q1, p = 0.0063]. CONCLUSION: Although DDS, FVS, MAR and micronutrient intakes were positively correlated with added sugar intakes, overall negative associations between micronutrients and added sugar intakes, adjusted for dietary energy, indicate micronutrient dilution. Overweight/obesity was increased with higher added sugar intakes in the 4-8 year old children

Pearson correlation coefficients of added sugar intake (AS) per day with nutrient intake values, micronutrient intakes per 4.18MJ, and Pearson’s partial correlation coefficients (adjusted for kilojoule intake).

<p>AS = Added sugar</p><p>†adjusted for kJ intake.</p><p>*Correlation/Partial correlation significant, p<0.05.</p><p>**Correlation/Partial correlation significant, p<0.01.</p><p>***Correlation/Partial correlation significant, p<0.0001.</p><p>Pearson correlation coefficients of added sugar intake (AS) per day with nutrient intake values, micronutrient intakes per 4.18MJ, and Pearson’s partial correlation coefficients (adjusted for kilojoule intake).</p

Mean dietary intake (24-hr recall) of South African children aged 1–3 and 4–8 years old according to quartiles of added sugar intake as a percentage of energy (%EAS).

<p>^#95% CI = 95% Confidence interval;</p><p>[A], [B], [C], [D]: Bonferroni, p<0.05. Values with different letters are significant differences between groups (%EAS quartile groups)</p><p>*Significant relationship between quartile groups of added sugar intake (%EAS) and whether or not food from the relevant food group / food item was consumed, Chi square p<0.05.</p><p>**Significant relationship between quartile groups of added sugar intake (%EAS) and whether or not food from the relevant food group / food item was consumed, Chi square p<0.01.</p><p>***Significant relationship between quartile groups of added sugar intake (%EAS) and whether or not food from the relevant food group / food item was consumed, Chi square p<0.0001.</p><p>Mean dietary intake (24-hr recall) of South African children aged 1–3 and 4–8 years old according to quartiles of added sugar intake as a percentage of energy (%EAS).</p

Sugar, macronutrient intakes and % contribution of main sources of sugar for children aged 4–8 years by categories of money spent by household on food weekly (SES).

<p>* 95% CI = 95% Confidence Intervals: LCI = Lower confidence interval; UCI = Upper confidence interval.</p><p>[A], [B],[C],[D]: Significant differences between SES groups when letters are different; Bonferroni, p<0.05.</p><p>CHO = carbohydrate; WS = White sugar; AS = Added sugar; CDC = Cool drink, carbonated; CDS = Cool drink, squash type</p><p>SES 1 = R0-50; SES 2 = R50-100; SES3 = R100-200; SES4 = R200-400+.</p><p>Sugar, macronutrient intakes and % contribution of main sources of sugar for children aged 4–8 years by categories of money spent by household on food weekly (SES).</p

Mean daily micronutrient intakes per 4.18MJ of 1–3 year and 4–8 year olds according to quartiles of added sugar intake as a proportion of energy (% EAS).

<p>*95% CI = 95% Confidence interval</p><p>[A], [B], [C] AND [D]: significant difference between groups (quartiles of sugar, EAS % of energy intake) when letters are different</p><p>Bonferroni, p<0.05.</p><p>Mean daily micronutrient intakes per 4.18MJ of 1–3 year and 4–8 year olds according to quartiles of added sugar intake as a proportion of energy (% EAS).</p

Sugar, macronutrient intakes and % contribution of main sources of sugar for children aged 1–8 years by geotype.

<p>* 95% CI = 95% Confidence Intervals: LCI = Lower confidence interval; UCI = Upper confidence interval</p><p>^###Significant difference between urban and rural values, t-test p<0.0001</p><p>^##Significant difference between urban and rural values, t-test p<0.01</p><p>^&&&Significant difference between urban and rural values, age 1–3 years, t-test p<0.0001</p><p>^&&Significant difference between urban and rural values, age 1–3 years, t-test p<0.01</p><p><sup>$Significant difference between urban and rural values, age 4–8 years, t-test p<0.0001

Significant difference between urban and rural values, age 4–8 years, t-test p<0.01</p><p>CHO = carbohydrate; WS = White sugar; AS = Added sugar; CDC = Cool drink, carbonated; CDS = Cool drink, squash type</p><p>Sugar, macronutrient intakes and % contribution of main sources of sugar for children aged 1–8 years by geotype.</p</sup>

Dietary diversity, food variety score and mean adequacy ratio of 1–3 and 4–8 year olds according to quartiles of added sugar intake per day as a percentage of energy (%EAS).

<p>*95% CI = 95% Confidence interval;</p><p>[A], [B], [C], [D]: Values with different letters are significant differences between groups (%EAS quartile groups), Bonferroni, p<0.05.</p><p>DDS = Dietary Diversity Score; FVS = Food Variety Score; MAR = Mean Adequacy Ratio.</p><p>Dietary diversity, food variety score and mean adequacy ratio of 1–3 and 4–8 year olds according to quartiles of added sugar intake per day as a percentage of energy (%EAS).</p

The anthropometric status of children aged 1–3 years old nationally and by quartiles of added sugar intake as a percentage of energy (%EAS) (mean z-score and prevalence with two-sided confidence limits), according to WHO 2006/2007 sex specific z-scores, (male and female combined).

<p>* for children aged 1–5 years</p><p>[A], [B]: significant differences between groups (quartiles of sugar intake %EAS) when letters are different; Bonferroni, p<0.05.</p><p>#Significant relationship between different groups of added sugar (%EAS) intake and stunting, Chi square p<0.05.</p><p>The anthropometric status of children aged 1–3 years old nationally and by quartiles of added sugar intake as a percentage of energy (%EAS) (mean z-score and prevalence with two-sided confidence limits), according to WHO 2006/2007 sex specific z-scores, (male and female combined).</p

Sugar, macronutrient intakes and % contribution of main sources of sugar for children aged 1–3 by categories of money spent by household on food weekly (SES).

<p>* 95% CI = 95% Confidence Intervals: LCI = Lower confidence interval; UCI = Upper confidence interval.</p><p>[A], [B],[C],[D]: Significant differences between SES groups when letters are different; Bonferroni, p<0.05.</p><p>CHO = carbohydrate; WS = White sugar; AS = Added sugar; CDC = Cool drink, carbonated; CDS = Cool drink, squash type</p><p>SES 1 = R0-50; SES 2 = R50-100; SES3 = R100-200; SES4 = R200-400+</p><p>Sugar, macronutrient intakes and % contribution of main sources of sugar for children aged 1–3 by categories of money spent by household on food weekly (SES).</p