Andrea J. Sharma

Consumption of added sugars is decreasing in the United States

BACKGROUND The consumption of added sugars (caloric sweeteners) has been linked to obesity, diabetes, and heart disease. Little is known about recent consumption trends in the United States or how intakes compare with current guidelines. OBJECTIVE We examined trends in intakes of added sugars in the United States over the past decade. DESIGN A cross-sectional study of US residents ≥2 y of age (n = 42,316) was conducted by using dietary data from NHANES 1999-2008 (five 2-y cycles) and data for added-sugar contents from the MyPyramid Equivalents Database. Mean intakes of added sugars (grams and percentage of total energy intake) were weighted to obtain national estimates over time across age, sex, and race-ethnic groups. Linear trends were tested by using Walds F tests. RESULTS Between 1999-2000 and 2007-2008, the absolute intake of added sugars decreased from a mean (95% CI) of 100.1 g/d (92.8, 107.3 g/d) to 76.7 g/d (71.6, 81.9 g/d); two-thirds of this decrease, from 37.4 g/d (32.6, 42.1 g/d) to 22.8 g/d (18.4, 27.3 g/d), resulted from decreased soda consumption (P-linear trend <0.001 for both). Energy drinks were the only source of added sugars to increase over the study period (P-linear trend = 0.003), although the peak consumption reached only 0.15 g/d (0.08, 0.22 g/d). The percentage of total energy from added sugars also decreased from 18.1% (16.9%, 19.3%) to 14.6% (13.7%, 15.5%) (P-linear trend <0.001). CONCLUSION Although the consumption of added sugars in the United States decreased between 1999-2000 and 2007-2008, primarily because of a reduction in soda consumption, mean intakes continue to exceed recommended limits.

Caloric Sweetener Consumption and Dyslipidemia Among US Adults

CONTEXT Dietary carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk. Added sugars (caloric sweeteners used as ingredients in processed or prepared foods) are an increasing and potentially modifiable component in the US diet. No known studies have examined the association between the consumption of added sugars and lipid measures. OBJECTIVE To assess the association between consumption of added sugars and blood lipid levels in US adults. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study among US adults (n = 6113) from the National Health and Nutrition Examination Survey (NHANES) 1999-2006. Respondents were grouped by intake of added sugars using limits specified in dietary recommendations (< 5% [reference group], 5%-<10%, 10%-<17.5%, 17.5%-<25%, and > or = 25% of total calories). Linear regression was used to estimate adjusted mean lipid levels. Logistic regression was used to determine adjusted odds ratios of dyslipidemia. Interactions between added sugars and sex were evaluated. MAIN OUTCOME MEASURES Adjusted mean high-density lipoprotein cholesterol (HDL-C), geometric mean triglycerides, and mean low-density lipoprotein cholesterol (LDL-C) levels and adjusted odds ratios of dyslipidemia, including low HDL-C levels (< 40 mg/dL for men; < 50 mg/dL for women), high triglyceride levels (> or = 150 mg/dL), high LDL-C levels (> or = 130 mg/dL), or high ratio of triglycerides to HDL-C (> 3.8). Results were weighted to be representative of the US population. RESULTS A mean of 15.8% of consumed calories was from added sugars. Among participants consuming less than 5%, 5% to less than 17.5%, 17.5% to less than 25%, and 25% or greater of total energy as added sugars, adjusted mean HDL-C levels were, respectively, 58.7, 57.5, 53.7, 51.0, and 47.7 mg/dL (P < .001 for linear trend), geometric mean triglyceride levels were 105, 102, 111, 113, and 114 mg/dL (P < .001 for linear trend), and LDL-C levels modified by sex were 116, 115, 118, 121, and 123 mg/dL among women (P = .047 for linear trend). There were no significant trends in LDL-C levels among men. Among higher consumers (> or = 10% added sugars) the odds of low HDL-C levels were 50% to more than 300% greater compared with the reference group (< 5% added sugars). CONCLUSION In this study, there was a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.

Prevalence Estimates of Gestational Diabetes Mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007–2010

Introduction The true prevalence of gestational diabetes mellitus (GDM) is unknown. The objective of this study was 1) to provide the most current GDM prevalence reported on the birth certificate and the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and 2) to compare GDM prevalence from PRAMS across 2007–2008 and 2009–2010. Methods We examined 2010 GDM prevalence reported on birth certificate or PRAMS questionnaire and concordance between the sources. We included 16 states that adopted the 2003 revised birth certificate. We also examined trends from 2007 through 2010 and included 21 states that participated in PRAMS for all 4 years. We combined GDM prevalence across 2-year intervals and conducted t tests to examine differences. Data were weighted to represent all women delivering live births in each state. Results GDM prevalence in 2010 was 4.6% as reported on the birth certificate, 8.7% as reported on the PRAMS questionnaire, and 9.2% as reported on either the birth certificate or questionnaire. The agreement between sources was 94.1% (percent positive agreement = 3.7%, percent negative agreement = 90.4%). There was no significant difference in GDM prevalence between 2007–2008 (8.1%) and 2009–2010 (8.5%, P = .15). Conclusion Our results indicate that GDM prevalence is as high as 9.2% and is more likely to be reported on the PRAMS questionnaire than the birth certificate. We found no statistical difference in GDM prevalence between the 2 phases. Further studies are needed to understand discrepancies in reporting GDM by data source.

Consumption of Added Sugars and Indicators of Cardiovascular Disease Risk Among US Adolescents

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among U.S. adults.1 While atherosclerosis and CVD occur later in life, their risk factors, including lipid disorders2, diabetes3, and obesity are increasingly being identified among adolescents and even children.4 Though CVD among children is rare,4 an increase in cardiometabolic risk factors at younger ages and their apparent tendency to track into adulthood5–7 highlights the need for early and effective prevention efforts. Lifestyle changes, including dietary change, have long been a central focus of efforts to reduce CVD risk. Since the 1950’s Americans have been advised to reduce their consumption of fats and cholesterol, and replace them with complex carbohydrates.8 It appears that, in part, Americans have followed this advice. But while food disappearance data suggests that fat consumption has decreased, it is refined rather than complex carbohydrates that have increased.9 While the overall health impact of this trend is unclear, several studies have shown a positive correlation between the consumption of carbohydrates – particularly some sugars - and the presence of CVD risk factors.10–12 A recent longitudinal study among women demonstrated that the incidence of CVD increased with higher consumption of sugar-sweetened beverages,13 the largest contributor of added sugars in the U.S. diet.14 Studies comparing the impact of different sugars have demonstrated that the monosaccharide fructose but not glucose, raises triglyceride levels and lowers HDL levels, suggesting that the metabolic impact may differ substantially by sugar type.12, 15 Added sugars are refined, calorie-containing sweeteners added to foods and beverages during processing or preparation. Consumption of these sugars has increased substantially in recent decades. Sugars used to sweeten soft drinks have become the largest single source of calories in the U.S. diet.16 In 1994–1996, Americans over the age of 2 y obtained nearly 16% of their total energy from added sugars; adolescents, the highest consumers, obtained more than 20% of their energy from sugars added to foods and beverages.17 Today in the U.S., the most commonly consumed added sugars are refined beet or cane sugar (sucrose) and high fructose corn syrup (HFCS),18 both of which contribute fructose and glucose, in approximately equal amounts, to the diet. Added sugars are estimated to contribute 74%–80% of the dietary fructose consumed.19, 20 Given the high consumption of added sugars among adolescents and the potential for long-term health risks associated with early diet, it is important to understand the impact of this dietary trend. The purpose of our study was to determine if there is an association between the consumption of added sugars and indicators of cardiometabolic health among U.S. adolescents.Background— Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. Methods and Results— In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated by added sugar consumption level (<10%, 10 to <15%, 15 to <20%, 20 to <25%, 25 to <30%, and ≥30% of total energy). Multivariable means were weighted to be representative of US adolescents and variances adjusted for the complex sampling methods. Daily consumption of added sugars averaged 21.4% of total energy. Added sugars intake was inversely correlated with mean high-density lipoprotein cholesterol levels (mmol/L) which were 1.40 (95% confidence interval [CI] 1.36 to 1.44) among the lowest consumers and 1.28 (95% CI 1.23 to 1.33) among the highest (P trend =0.001). Added sugars were positively correlated with low-density lipoproteins (P trend =0.01) and geometric mean triglycerides (P trend =0.05). Among the lowest and highest consumers, respectively, low-density lipoproteins (mmol/L) were 2.24 (95% CI 2.12 to 2.37) and 2.44 (95% CI 2.34 to 2.53), and triglycerides (mmol/L) were 0.81 (95% CI 0.74, 0.88) and 0.89 (95% CI 0.83 to 0.96). Among those overweight/obese (≥85th percentile body-mass-index), added sugars were positively correlated with the homeostasis model assessment (P linear trend =0.004). Conclusion— Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.

Is obesity still increasing among pregnant women? Prepregnancy obesity trends in 20 states, 2003-2009.

OBJECTIVE To estimate trends in prepregnancy obesity prevalence among women who delivered live births in the US during 2003-2009, by state, age, and race-ethnicity. METHODS We used Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2003, 2006, and 2009 to measure prepregnancy obesity (body mass index [BMI]≥30kg/m(2)) trends in 20 states. Trend analysis included 90,774 records from 20 US states with data for all 3 study years. We used a chi-square test for trend to determine the significance of actual and standardized trends, standardized to the age and race-ethnicity distribution of the 2003 sample. RESULTS Prepregnancy obesity prevalence increased by an average of 0.5 percentage points per year, from 17.6% in 2003 to 20.5% in 2009 (P<0.001). Obesity increased among women aged 20-24 (P<0.001), 30-34 (P=0.001) and 35 years or older (P=0.003), and among non-Hispanic white (P<.001), non-Hispanic black (P=0.02), Hispanic (P=0.01), and other women (P=0.03). CONCLUSION Overall, prepregnancy obesity prevalence continues to increase and varies by race-ethnicity and maternal age. These findings highlight the need to address obesity as a key component of preconception care, particularly among high-risk groups.

High pregnancy weight gain and risk of excessive fetal growth

OBJECTIVE The purpose of this study was too assess whether prepregnancy body mass index (BMI) modifies the relationship between pregnancy weight gain and large for gestational age (LGA; > 90% of birthweight for gestational age) or macrosomia (>or= 4500 g). STUDY DESIGN This was a population-based cohort study of 104,980 singleton, term births from 2000-2005. RESULTS Prepregnancy BMI modified the relationship between weight gain and LGA. Lean women had higher odds of LGA than overweight or obese women for weight gain >or= 36 lb. For macrosomia, prepregnancy BMI did not modify the association. Compared with women who gained 15-25 lb, the aOR for a gain of 26-35 lb was 1.5 (95% confidence interval [CI], 1.2-1.9), for a gain of 36-45 lb was 2.1 (95% CI, 1.7-2.7), and for a gain of >or= 46 lb was 3.9 (95% CI, 3.0-5.0). CONCLUSION Current pregnancy weight gain recommendations include weight gain ranges that are associated with increased risk of LGA and macrosomia.

Association of maternal body mass index, excessive weight gain, and gestational diabetes mellitus with large-for-gestational-age births.

OBJECTIVE: To estimate the percentage of large-for-gestational age (LGA) neonates associated with maternal overweight and obesity, excessive gestational weight gain, and gestational diabetes mellitus (GDM)—both individually and in combination—by race or ethnicity. METHODS: We analyzed 2004–2008 linked birth certificate and maternal hospital discharge data of live, singleton deliveries in Florida. We used multivariable logistic regression to assess the independent contributions of mothers prepregnancy body mass index (BMI), gestational weight gain, and GDM status on LGA (birth weight-for-gestational age 90th percentile or greater) risk by race and ethnicity while controlling for maternal age, nativity, and parity. We then calculated the adjusted population-attributable fraction of LGA neonates to each of these exposures. RESULTS: Large-for-gestational age prevalence was 5.7% among normal-weight women with adequate gestational weight gain and no GDM and 12.6%, 13.5% and 17.3% among women with BMIs of 25 or higher, excess gestational weight gain, and GDM, respectively. A reduction ranging between 46.8% in Asian and Pacific Islanders and 61.0% in non-Hispanic black women in LGA prevalence might result if women had none of the three exposures. For all race or ethnic groups, GDM contributed the least (2.0–8.0%), whereas excessive gestational weight gain contributed the most (33.3–37.7%) to LGA. CONCLUSION: Overweight and obesity, excessive gestational weight gain, and GDM all are associated with LGA; however, preventing excessive gestational weight gain has the greatest potential to reduce LGA risk. LEVEL OF EVIDENCE: III

Gestational weight gain in obese mothers and associations with fetal growth

BACKGROUND In 2009, the Institute of Medicine recommended gestational weight gains (GWGs) of 5-9 kg for all obese women. Recommendations by severity of obesity were not specified because of a lack of available data. OBJECTIVE Our objective was to examine associations between GWG and fetal growth in obese women and assess interactions with obesity severity. DESIGN We used 2004-2006 Pregnancy Nutrition Surveillance System data from 122,327 obese mothers [prepregnant body mass index (BMI; in kg/m(2)) ge 30]. We used logistic regression to estimate measures of fetal growth including small-for-gestational-age, which was defined as birth weight (BW) lt 2 SDs below the sex and race-ethnicity-specific mean BW (SGA(2SD)), and macrosomia (BW ge 4500 g). We tested for interactions between obesity severity (class I: BMI of 30-34.9; class II: BMI of 35.0-39.9; class III: BMI ge 40) and GWG. RESULTS Obesity severity modified associations between GWG and fetal growth. Compared with weight gains of 5-9 kg, weight loss in class I women significantly increased the odds of SGA(2SD), whereas a GWG from 0.1 to 4.9 kg was not associated with SGA(2SD) and did not decrease the odds of macrosomia. In class II and III women, compared with weight gains of 5-9 kg, a GWG from minus 4.9 to +4.9 kg was not associated with SGA(2SD) but did decrease the odds of macrosomia. CONCLUSIONS Our study suggests a GWG below the Institute of Medicine guidelines may be associated with more favorable BW for all obese women, and GWG may need to be further defined by obesity severity.

Adherence to Vitamin D Recommendations Among US Infants

OBJECTIVES: In November 2008, the American Academy of Pediatrics (AAP) doubled the recommended daily intake of vitamin D for infants and children, from 200 IU/day (2003 recommendation) to 400 IU/day. We aimed to assess the prevalence of infants meeting the AAP recommended intake of vitamin D during their first year of life. METHODS: Using data from the Infant Feeding Practices Study II, conducted from 2005 to 2007, we estimated the percentage of infants who met vitamin D recommendations at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 months (n = 1952–1633). RESULTS: The use of oral vitamin D supplements was low, regardless of whether infants were consuming breast milk or formula, ranging from 1% to 13%, varying by age. Among infants who consumed breast milk but no formula, only 5% to 13% met either recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation. Among those who consumed formula but no breast milk, 81% to 98% met the 2003 recommendation, but only 20% to 37% would have met the 2008 recommendation. CONCLUSIONS: Our findings suggest that most US infants are not consuming adequate amounts of vitamin D according to the 2008 AAP recommendation. Pediatricians and health care providers should encourage parents of infants who are either breastfed or consuming <1 L/day of infant formula to give their infants an oral vitamin D supplement.

Prevalence and characteristics associated with gestational weight gain adequacy.

OBJECTIVE: To estimate the prevalence of gestational weight gain adequacy according to the 2009 Institute of Medicine recommendations and examine demographic, behavioral, psychosocial, and medical characteristics associated with inadequate and excessive gain stratified by prepregnancy body mass index (BMI) category. METHODS: We used cross-sectional, population-based data on women delivering full-term (37 weeks of gestation or greater), singleton neonates in 28 states who participated in the 2010 or 2011 Pregnancy Risk Assessment Monitoring System. We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for inadequate and excessive compared with adequate gain, stratified by prepregnancy BMI. RESULTS: Overall, 20.9%, 32.0%, and 47.2% of women gained inadequate, adequate, and excessive gestational weight, respectively. Prepregnancy BMI was strongly associated with weight gain outside recommendations. Compared with normal-weight women (prevalence 51.8%), underweight women (4.2%) had decreased odds of excessive gain (adjusted OR 0.50, CI 0.40–0.61), whereas overweight and obese class I, II, and III (23.6%, 11.7%, 5.4%, and 3.5%, respectively) women had increased odds of excessive gain (adjusted OR range 2.07, CI 1.63–2.62 to adjusted OR 2.99, CI 2.63–3.40). Underweight and obese class II and III women had increased odds of inadequate gain (adjusted OR 1.25, CI 1.01–1.55 to 1.86, CI 1.45–2.36). Most characteristics associated with weight gain adequacy were demographic such as racial or ethnic minority status and education and varied by prepregnancy BMI. Notably, one behavioral characteristic—smoking cessation—was associated with excessive gain among normal-weight and obese women. CONCLUSION: Most women gained weight outside recommendations. Understanding characteristics associated with inadequate or excessive weight gain may identify potentially at-risk women and inform much-needed interventions. LEVEL OF EVIDENCE: III