- Email: [email protected]
Dietary Intake Patterns of Low-Income Urban African-American Adolescents
RESEARCH Research and Professional Briefs Meets Learning Need Codes 3000, 3020, 4070, and 4160. To take the Continuing Professional Education quiz for this article, log in to ADA’s Online Business Center at www.eatright.org/obc, click the “Journal Article Quiz” button, click “Additional Journal CPE Articles,” and select this article’s title from a list of available quizzes.
Dietary Intake Patterns of Low-Income Urban African-American Adolescents YOUFA WANG, MD, PhD, MS; LISA JAHNS, PhD, RD; LISA TUSSING-HUMPHREYS, PhD, RD; BIN XIE, MD, PhD; HELAINE ROCKETT, MS, RD, FADA; HUIFANG LIANG, MD, PhD; LUANN JOHNSON, MS
ABSTRACT Unhealthy eating increases risks for chronic disease. Few studies have examined the multifaceted aspects of diY. Wang is an associate professor, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. L. Jahns is a research nutritionist, Grand Forks Human Nutrition Research Center, US Department of Agriculture, Agricultural Research Service, Grand Forks, ND; at the time of the study, she was an assistant professor of public health nutrition, Department of Nutrition, The University of Tennessee, Knoxville. L. TussingHumphreys is a research nutritionist, US Department of Agriculture, Agricultural Research Service, Baton Rouge, LA; at the time of the study, she was project coordinator, Department of Kinesiology and Nutrition, University of Illinois at Chicago. B. Xie is an associate professor, School of Community and Global Health, Claremont Graduate University, San Dimas, CA; at the time of the study, he was an assistant research professor, Hamovitch Research Center/School of Social Work, University of Southern California, Los Angeles. H. Rockett is senior health analyst, Massachusetts General Hospital and a consultant, Harvard School of Public Health, Boston, MA; at the time of the study, she was nutrition research manager, Channing Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. H. Liang is a senior scientist, Pharmacoepidemiology, Takeda Global Research and Development Center, Inc, Deerfield, IL; at the time of the study, she was a research assistant, Department of Kinesiology and Nutrition, University of Illinois at Chicago. L. Johnson is a statistician, Grand Forks Human Nutrition Research Center, US Department of Agriculture, Agricultural Research Service, Grand Forks, ND. Address correspondence to: Youfa Wang, MD, PhD, MS, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St E2546, Baltimore, MD 21205. E-mail: [email protected] Drs Wang and Jahns contributed equally to this study. Manuscript accepted: January 8, 2010. Copyright © 2010 by the American Dietetic Association. 0002-8223/$36.00 doi: 10.1016/j.jada.2010.06.005
1340
Journal of the AMERICAN DIETETIC ASSOCIATION
etary intake of low-income, urban African-American adolescents. This study aimed to describe dietary patterns including energy, nutrients, food groups, and diet quality and to identify areas to guide future interventions. Baseline data for a school-based obesity prevention study were collected from 382 African-American adolescents (10- to 14-year-olds) from four Chicago, IL, public schools in 2003. Diet was assessed using a 152-item food frequency questionnaire. Diet quality was measured using a modified version of the US Department of Agriculture Healthy Eating Index (HEI) and compared to published estimates for a nationwide sample. Participants reported high energy intakes and several unhealthy eating patterns: 58.6% consumed one or more servings of sweetened beverages per day and 15.7% consumed three or more servings per day; average fried food consumption was high (1.4 servings/day), 58.4% consumed one or more serving per day; and 75% consumed three or more three snacks per day. Only 49% of participants met the recommended three servings of dairy foods per day. Compared to a national, mostly white sample, participants had lower HEI scores (P⬍0.05); mean score was 66.0⫾12.8 (100⫽ maximum HEI score) vs 70.3⫾13.0 in boys vs girls, one third had scores ⬍60 (“needs improvement”) and only 15% scored ⬎80 (“good”). This study reveals key areas of problematic dietary patterns for future interventions targeting low-income African-American adolescents, including frequent intakes of calorie-dense, low nutrientrich foods, such as fried foods, snacks, and sweetened beverages. J Am Diet Assoc. 2010;110:1340-1345.
U
nhealthy eating increases the risk of many chronic diseases, including obesity. Obesity has become a major public health concern in the United States, and low-income and minority adolescents are disproportionately affected, possibly because of unhealthy food choices and lack of adequate physical activity (1,2). Unhealthy adolescent dietary practices not only have immediate deleterious physical and psychological effects, but also could determine trajectories of eating habits that influence chronic disease risks through adulthood, such as obesity and cardiovascular disease (3). It is not well-
© 2010 by the American Dietetic Association
understood how low-income minority groups’ diets may differ from those of other groups (2,3). Because of the importance of diet in good health, national guidelines have been developed (3,4). Although most US youths have adequate micronutrient intakes (5), only a small proportion meet recommendations for vegetable and fruit intake, and many overconsume added sugars, including sweetened beverages (6,7). A national survey reported 84% of Americans’ diet scored as “poor” or “needs improvement” by the US Department of Agriculture’s (USDA) Healthy Eating Index (HEI) (8). African Americans and low-income groups had lower scores than other ethnic and income groups. However, few studies have examined dietary patterns of urban low-income African-American adolescents. Although several previous studies on adolescent’s dietary intake have included African Americans, most tend to focus on only selected aspects of dietary intake (9-18). Because low-income African-American adolescents have a high prevalence of obesity and risk factors for metabolic syndrome (2,19), it is important to identify key dietary risk factors. To date, no research has examined multifaceted aspects of dietary intake that can contribute to obesityrelated comorbidities among this underserved population. This study examined dietary intake patterns of lowincome, African-American adolescents, including intakes of energy, nutrients, and food groups, and diet quality. Adequacy of nutrient intake at the group level was assessed by comparing mean intakes of nutrients to the Dietary Reference Intakes; overall diet quality was assessed using the HEI and compared to a large nationwide sample. Findings from this study will identify dietary problem areas and help guide future interventions.
METHODS Participants and Study Design A randomized intervention trial was initiated to test the feasibility and effectiveness of an environmental obesity prevention program in urban low-income African-American adolescents. Four Chicago, IL, public schools were selected and randomly assigned to control and intervention groups. The intervention focused on the school environment and aimed at promoting healthy eating and physical activity. The study was named Health-Kids (Healthy Eating and Active Lifestyles from School to Home for Kids). This is a cross-sectional analysis of dietary intake of 382 participants aged 10 to 14 years at baseline (Fall 2003). The majority of participants (⬎72%) were from low-income families (20-22). Parental survey data (from 108 parents) confirmed only 13.5% had a household annual income ⬎US$40,000 (21,22). Study protocols were approved by the Institutional Review Board at the University of Illinois at Chicago (for data collection) and Johns Hopkins University School of Public Health (for data analysis). Informed consent was obtained from adolescents and their parents or legal guardians. Details about the study design and data collection are provided elsewhere (20).
Food Consumption Measures Dietary intake was assessed using a 152-item, semiquantitative food frequency questionnaire, the Harvard Youth/Adolescent Questionnaire. The instrument was self-administered in the classroom while research staff and teachers monitored participants. Reproducibility and validity among adolescents has been described in detail (9,23). The Harvard Youth/Adolescent Questionnaire asks participants how often, in the past year, they usually consume the listed food items. Consumption of discrete serving sizes is asked where appropriate (such as a cup of yogurt, a hamburger, or a piece of fruit); foods without a discrete serving size, such as vegetables, do not have a portion size listed. Additional questions ask about frequency of fried food consumption and number of snacks consumed per day on school and nonschool days. At baseline, 417 adolescents completed the Harvard Youth/Adolescent Questionnaire. Individuals with extreme energy intakes (⬍500 or ⬎7,000 kcal) or with ⬎70 missing items on the Harvard Youth/Adolescent Questionnaire were excluded (22), yielding a sample size of 382 (92%). Serving sizes were quantified by examining those used by the USDA Handbook No. 8 and the Nationwide Food Consumption Survey: Foods Commonly Eaten by Individuals (specifically for ages 9 to 18 years) (24). Energy and nutrient intakes were calculated using a nutrient database specifically designed for use with the Harvard Youth/Adolescent Questionnaire and presented as average daily intake per adolescent. Food items were first aggregated into five major categories based upon the US Food Guide Pyramid (meat and main dishes, baked goods/cereals, fruits, vegetables, and dairy) as adapted for use with the Harvard Youth/Adolescent Questionnaire by team members (18). Next, food items were aggregated into 21 groups to allow pattern assessment including additional dietary factors (eg, fat, sugar, and energy). Note that fried potatoes are included in the fried, not the vegetable group. Nutrient intakes were compared to the national Dietary Reference Intakes (25-27). Diet quality was assessed using the 1995 USDA HEI (28). The HEI has been used to assess the diets of children and adolescents (29). The 1995 HEI was used instead of the 2005 HEI (30) because a key aim of this research was to compare the diet quality scores of the study participants with those published for other national samples. HEI consists of 10 dietary components that represent various aspects of a healthy diet, including intakes of grains, vegetables, fruit, dairy, meat, and avoidance of overconsumption of total and saturated fat, cholesterol, and sodium. The 10th component is a measure of dietary variety consisting of the number of different food items consumed (28). These components were selected to help measure compliance with national dietary recommendations. For each component, individuals receive a score between 1 and 10. Component scores are summed to derive an overall score, which ranges from 0 to 100. An overall HEI score of 80 implies a “good” diet; a score between 51and 80 implies a diet that “needs improvement”; a score ⬍51 implies a “poor” diet. The Harvard Youth/Adolescent Questionnaire items were grouped into HEI components according to adapSeptember 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1341
Table 1. Average daily intakes of energy, nutrients, and food groups (servings/day) of low-income urban African-American adolescents All (nⴝ382)
Energy and nutrients Energy (kcal) Total fat (% energy) Saturated fat (% energy) Cholesterol (mg) Fiber (g) Calcium (mg) Iron (mg) Sodium (mg) Vitamin C (mg) Vitamin D (IU) Folate (g) Food groups Baked goods/cereals Vegetables and fruits Vegetables Fruits Dairy Meat and main dishes Snacks Fried foods Sweetened beverages Sugar (g)
4™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™3 3,144⫾1,575 3,204⫾1,570 3,100⫾1,581 31⫾4 30⫾4 32⫾4 12⫾2 11⫾2 12⫾2 341⫾181 340⫾168 342⫾190 24⫾13 25⫾14 23⫾13 1,338⫾768 1,402⫾774 1,291⫾762 19⫾10 19⫾10 19⫾10 3,764⫾1,925 3,831⫾1,937 3,714⫾1,920 183⫾108 189⫾110 178⫾107 245⫾179 263⫾178 231⫾180 521⫾285 537⫾291 510⫾281
0.52 0.001 0.001 0.91 0.40 0.16 0.40 0.56 0.34 0.09 0.36
7.9⫾4.8 4.7⫾3.5 2.2⫾1.9 2.5⫾2.1 3.5⫾2.4 3.2⫾1.8 5.4⫾4.4 1.4⫾1.0 1.5⫾1.3 116.9⫾67.4
0.66 0.52 0.83 0.20 0.15 0.94 0.86 0.86 0.62 0.37
a
Boys (nⴝ162)
8.0⫾4.8 4.8⫾3.5 2.2⫾1.8 2.6⫾2.2 3.7⫾2.4 3.2⫾1.7 5.4⫾4.4 1.4⫾1.0 1.6⫾1.2 120.5⫾67.5
Girls (nⴝ220)
Sex difference P valuea
Daily intakes
7.8⫾4.8 4.6⫾3.5 2.2⫾1.9 2.4⫾2.0 3.4⫾2.3 3.2⫾1.8 5.3⫾4.0 1.4⫾0.9 1.5⫾1.3 114.2⫾67.4
One-way analysis of variance.
tations used by Feskanich and colleagues (29). Study participants’ HEI scores were compared to those of the 1996 Growing Up Today Study cohort. The Growing Up Today Study also utilized the Harvard Youth/Adolescent Questionnaire, and included a national sample of approximately 14,000 middle to high socioeconomic status, mostly (95%) white adolescents aged 9 to 14 years old (29). Participants’ height and weight were directly measured at the schools by trained interviewers (21). Weight status was classified by comparing their body mass index (BMI; calculated as kg/m2) to the 2000 US Centers for Disease Control and Prevention Growth Charts (31): obese (BMI ⱖ95th percentile), overweight (85thⱖBMI⬍95th percentile), or nonoverweight (BMI ⬍85th percentile). Statistical Analysis No difference in the adolescents’ baseline dietary intake patterns between the control and intervention groups was detected. Thus, the data were pooled for analysis. Between-group differences were tested using t tests or one-way analysis of variance, or 2 (for categorical variables). Component and overall HEI scores of Health-Kids adolescents were compared to published scores for Growing Up Today Study adolescents (32). Unequal variances between the samples were assumed. The Smith-Satterthwaite procedure was used to approximate a t statistic. The procedure is robust for equal/unequal variances when the sample sizes are different, and provides conservative results. Significant differences were reported at P⬍0.05. Analyses were performed using Stata (version 10.1, 2009, Stata Corp, College Station, TX).
1342
September 2010 Volume 110 Number 9
RESULTS AND DISCUSSION Participants’ mean age was 11.5⫾1.1 years; 98.4% were African American, and 57.6% were girls. Overall prevalence of overweight and obesity was 40.3%. More girls than boys were obese (27.3% vs 16.1%), but fewer girls than boys were overweight (14.1% vs 22.8%; P⬍0.05). Mean energy intake was high in this sample (3,144⫾ 1,575 kcal), but high energy intake (2,904 kcal) has been reported previously in a similar population (33). There were no significant sex differences in overall energy intake, although sex differences were observed for a few nutrients (total and saturated fat). More than half of adolescents consumed ⬎300 mg cholesterol per day and sodium intake was high, with ⬎75% consuming ⱖ2,400 mg per day. Mean fiber intake was inadequate at 23 to 25 g/day, while the recommended intake is 31 g/day for boys aged 9 to 13 and 26 g/day for girls (25). All adolescents consumed well above the Estimated Average Requirement for vitamin C, folate, and iron (26). Mean calcium intake was 1,338⫾768 mg, but 55% consumed less than the recommend amount of 1,300 mg/day (27). About 50% of adolescents’ vitamin D intakes were less than the recommended 200 IU (27), with a median intake of 194 IU (Table 1). There were no substantial sex differences in food group intakes. On average, fruit and vegetable consumption was less than the recommended amounts, even when nonfried potatoes and fruit juices were included. Only 49% met the recommendation of three servings of dairy food/day; 59% consumed at least one serving of sweetened beverages each day, and 15.7% consumed at least three sweetened beverages per day. Overall, adolescents re-
Table 2. Comparison of US Department of Agriculture Healthy Eating Index scores between low-income urban African-American adolescents in the Health-Kids Study and a nationwide sample of mostly white adolescents in the Growing Up Today Studya Girls Component HEI total score (maximum score⫽100) HEI individual component Grains Vegetables Fruit Dairy Meat Total fat Saturated fat Cholesterol Sodium Variety
Health-Kids (nⴝ220)
Boys
Growing Up Today Study (nⴝ8,807)
Health-Kids (nⴝ162)
Growing Up Today Study (nⴝ7,645)
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™™™™™™™3 66.0⫾12.8 70.3⫾13.0c 67.1⫾13.4 68.9⫾12.3c 8.1⫾2.4 6.7⫾2.8 6.6⫾3.3 7.0⫾3.0 6.9⫾2.9 8.3⫾1.8 6.2⫾2.9 6.2⫾4.4 5.0⫾3.2 5.0⫾3.1
7.3⫾2.1c 5.3⫾2.4c 6.4⫾3.0 7.5⫾2.7 5.6⫾2.4c 8.7⫾1.9c 7.6⫾2.9c 9.7⫾1.4c 5.1⫾3.2 7.1⫾3.3c
8.0⫾2.6 6.2⫾3.0 6.4⫾3.2 7.5⫾2.8 6.7⫾2.9 8.8⫾1.6b 7.0⫾2.8 6.2⫾4.3 5.0⫾3.2 5.0⫾3.1
7.3⫾2.1c 4.6⫾2.2c 5.6⫾3.0c 8.2⫾2.5c 5.9⫾2.4c 8.5⫾1.9 7.1⫾3.1 9.1⫾2.3c 5.1⫾3.2 7.6⫾3.1c
a
Based on the 1995 US Department of Agriculture Healthy Eating Index (HEI) system (8,24). Results for Growing Up Today Study are based on Feskanich and colleagues (29). Different from Health-Kids girls; P⬍0.05. c Different from same-sex Health-Kids adolescents; P⬍0.05. b
ported consuming nearly 120 g of added sugar per day. Average intake of fried foods was high (1.4 servings/day), and 58.4% consumed at least one serving of fried food each day. Participants consumed many snacks (5.4 servings/day), of which most were sweet as opposed to savory snacks (4 vs 1.4 servings). Among Health-Kids adolescents, 13% had HEI scores ⬍51 (“poor”), one third had scores ⬍60, indicating a diet that “needs improvement,” and only 15% had HEI scores ⬎80, indicating “good” diet quality. Compared to Growing Up Today Study participants (29), who represent a more general US adolescent population although mostly (96%) white, Health-Kids adolescents had total HEI scores approximately 2 to 4 points lower (P⬍0.01, Table 2); HealthKids girls had better scores for grains, vegetables, and meat components, and lower scores for total and saturated fat, cholesterol, and overall dietary variety (a reflection of the number of different food items consumed); Health-Kids boys scored better for grains, vegetables, fruit, and meat, but worse for dairy, cholesterol, and variety. Health-Kids adolescents had few sex differences, although girls’ total fat intake score was worse than boys (8.3 vs 8.8; P⬍0.05). This study presents dietary patterns of low-income urban African-American adolescents in Chicago. The findings indicate a number of targeted areas for future dietary interventions. Participants reported high energy intakes, which is consistent with their high obesity prevalence. Participants consumed large amounts of sodium, cholesterol, added sugars, snack foods, sweetened beverages, and fried foods. Only a small proportion met recommendations for fruits or vegetables. Compared to a large national sample of mainly white adolescents, these African-American low-income adolescents had lower diet quality. Health-Kids Study participants reported high energy intakes compared to the Growing Up Today Study partici-
pants and a number of high-energy intake related eating patterns. At least two factors could contribute to the reported higher energy intake. First, Health-Kids participants had a high prevalence of overweight/obesity, and may require a higher energy intake to sustain excess adiposity. Second, the Harvard Youth/Adolescent Questionnaire might overestimate usual energy intake, and some adolescents might have over reported their dietary intake. Nevertheless, the Harvard Youth/Adolescent Questionnaire has been validated for use among a general population of youths including African-American adolescents (23) and is used in other studies, some of which reported lower (18) or similar energy intake levels (34). Several previous studies reported a lower energy intake in US adolescents of similar age. For example, mean energy intake in Growing Up Today Study participants was 2,063⫾652 kcal (girls) to 2,306⫾722 kcal (boys), but the prevalence of overweight in Growing Up Today Study was also lower (9). Another large multiethnic study using the Harvard Youth/Adolescent Questionnaire reported 1,854⫾759 kcal (girls) to 2,071⫾810 kcal (boys), while African-American adolescents reported higher energy intakes than others (18). However, the findings of several other studies were consistent with the present study. Using an FFQ, another study in inner-city school adolescents reported mean intakes of 3,136 kcal (in fourth to fifth graders [approximately 10 to 11 years old]) and 2,297 kcal (in sixth to seventh graders [approximately 12 to 13 years old]) (15). Two other studies of African-American adolescents reported high energy intake similar to what observed in this study, approximately 2,900 kcal (33) and 3,200 kcal (34), respectively. Thus, the present study and others show that African-American adolescents seem to report high energy intake, which puts them at higher risk for obesity and other chronic diseases. Second, 50% of adolescents’ calcium intake was less than the recommended 1,300 mg/day. Nearly half did not consume three servings of dairy food per day as recom-
September 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1343
mended. With dairy foods being the main dietary source, vitamin D intake was of particular concern. Nearly half consumed less than the recommended amount. African Americans have increased need for dietary vitamin D because their darker pigmentation reduces sunlight exposure for vitamin D synthesis in the skin (35,36). Third, study participants reported frequent consumption of snack foods, fried foods, and sweetened beverages, which contribute to total energy intake. The majority of snack foods are high in energy, sugar, sodium, and/or fat, but otherwise are a poor source of other nutrients. Fried food may be considered a proxy for high-energy density foods, as well as fast foods, which are associated with poorer diet quality and risk for overweight among adolescents (10,37,38). Participants reported consuming nearly 120 g added sugar per day. This is primarily because of the consumption of sugar-sweetened beverages, such as soft drinks and fruit juice. A previous study found that 60.3% of participants reporting consuming soft drinks two times or more per day on average, while 22.0% consumed four times or more per day (21). Note that 120 g is equivalent to close to 30 teaspoons of sugar or about three cans of soft drink. The sugar content per 12-oz can of cola is about 40 g. This study shows that these low-income urban African-American adolescents consumed more added sugar than the national average. The Continuing Survey of Food Intakes by Individuals 1994-1996 data show that, on average, US adults and children consumed 20.5 teaspoons of added sugar per day, 24.1 teaspoons by children, and 24.6 teaspoons by those aged 12 to 19 years old. These were mainly contributed by consumption of sugar-sweetened beverages and fruit juice (39). Another recent study shows that, based on the National Health and Nutrition Examination Survey (NHANES) 1999-2004 data, among US children and adolescent, per-capita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice in total was 270 kcal/day; from sugar-sweetened beverages intake, 224 kcal/day and 48 kcal/day from 100% fruit juice. Soda contributed approximately 67% of all sugarsweetened beverages calories among adolescents, whereas fruit drinks provided more than half of the sugar-sweetened beverage calories consumed by preschool-aged children. In this nationally representative sample, the ethnic difference between white and African-American adolescents in sugarsweetened beverages and 100% fruit juice consumption was small—the calories (kcal/per day) derived was 302 vs 297 (white vs African American) for sugar-sweetened beverages and 42 vs 48 (white vs African American) for 100% fruit juice. In total, they were equivalent to about 86 g added sugar (40). Overall HEI score was lower in this sample than the Growing Up Today Study adolescents’ (66.4 vs 69.7), but still higher than the national average for adolescents aged 11 to 14 in the NHANES 1999-2000 survey (60.8) (8). The discrepancies likely result from ethnic differences in the study samples and their dietary intakes, age in the case of the Growing Up Today Study adolescents, and dietary assessment methodology in the NHANES, which collected 24-hour recall data, while the Harvard Youth/Adolescent Questionnaire reflects usual intake. In addition to the many strengths of this study, including the use of a validated detailed Harvard Youth/Ado-
1344
September 2010 Volume 110 Number 9
lescent Questionnaire and a high-risk study population (20), it also has several limitations. Only a homogeneous sample was included. Direct comparison of income and ethnic differences is not possible. In addition, the 1995 USDA HEI does not consider energy intake. The high energy intake reported by participants contributed to the relatively high HEI scores, which may well underestimate problems with diet quality. CONCLUSIONS The present study found a number of unhealthy eating patterns among urban low-income African-American adolescents, which could put them at increased risk for obesity and other chronic diseases. Participants’ high intakes of energy, fat, added sugars, fried food, snack foods, and sweetened beverages are of particular concern. School-based interventions that also involve families and communities are needed to help improve diet quality and reduce risk factors for chronic diseases. STATEMENT OF POTENTIAL CONFLICT OF INTEREST: No potential conflict of interest was reported by the authors. FUNDING/SUPPORT: The study was supported in part by research grants from the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (1R01DK63383, R01DK81335-01A1) and National Institute of Child Health and Human Development (1R03HD058077-01A1). ACKNOWLEDGEMENTS: We are indebted to the participating schools, families, and students in the study for their cooperation and support. We also thank Ji Li for her assistance in conducting some statistical analysis. References 1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 19992004. JAMA. 2006;295:1549-1555. 2. Wang Y, Beydoun MA. The obesity epidemic in the United States— Gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6-28. 3. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2005. http://www.health. gov/dietaryguidelines/. Accessed June 29, 2009. 4. US Department of Health and Human Services. Healthy People 2010. http://www.healthypeople.gov/. Accessed June 29, 2009. 5. Moshfegh A, Goldman J, Cleveland L. What We Eat In America, NHANES 2001-2002: Usual nutrient intakes from food compared to Dietary Reference Intakes. US Department of Agriculture, Agricultural Research Service; 2005. 6. Berkey CS, Rockett HR, Field AE, Gillman MW, Colditz GA. Sugaradded beverages and adolescent weight change. Obes Res. 2004;12: 778-788. 7. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001;357:505-508. 8. Basiotis PP, Carlson A, Gerrior SA, Juan WY, Lino M. The Healthy Eating Index: 1999-2000. http://www.cnpp.usda.gov/publications/HEI/ HEI99-00report.pdf. Accessed June 10, 2009. 9. Rockett HR, Berkey CS, Field AE, Colditz GA. Cross-sectional measurement of nutrient intake among adolescents in 1996. Prev Med. 2001;33:27-37. 10. French SA, Story M, Neumark-Sztainer D, Fulkerson JA, Hannan P. Fast food restaurant use among adolescents: Associations with nutrient intake, food choices and behavioral and psychosocial variables. Int J Obes Relat Metab Disord. 2001;25:1823-1833. 11. Cullen KW, Baranowski T, Klesges LM, Watson K, Sherwood NE, Story M, Zakeri I, Leachman-Slawson D, Pratt C. Anthropometric,
12. 13. 14.
15.
16. 17.
18. 19.
20.
21. 22. 23. 24.
parental, and psychosocial correlates of dietary intake of AfricanAmerican girls. Obes Res. 2004;12(suppl):20S-31S. Matheson DM, Wang Y, Klesges LM, Beech BM, Kraemer HC, Robinson TN. African-American girls’ dietary intake while watching television. Obes Res. 2004;12(suppl):32S-37S. Lytle LA, Himes JH, Feldman H, Zive M, Dwyer J, Hoelscher D, Webber L, Yang M. Nutrient intake over time in a multi-ethnic sample of youth. Public Health Nutr. 2002;5:319-328. Granner ML, Sargent RG, Calderon KS, Hussey JR, Evans AE, Watkins KW. Factors of fruit and vegetable intake by race, gender, and age among young adolescents. J Nutr Educ Behav. 2004;36: 173-180. Field AE, Peterson KE, Gortmaker SL, Cheung L, Rockett H, Fox MK, Colditz GA. Reproducibility and validity of a food frequency questionnaire among fourth to seventh grade inner-city school children: Implications of age and day-to-day variation in dietary intake. Public Health Nutr. 1999;2:293-300. Cavadini C, Siega-Riz AM, Popkin BM. US adolescent food intake trends from 1965 to 1996. Arch Dis Child. 2000;83:18-24. Affenito SG, Thompson DR, Barton BA, Franko DL, Daniels SR, Obarzanek E, Schreiber GB, Striegel-Moore RH. Breakfast consumption by African-American and white adolescent girls correlates positively with calcium and fiber intake and negatively with body mass index. J Am Diet Assoc. 2005;105:938-945. Xie B, Gilliland FD, Li YF, Rockett HR. Effects of ethnicity, family income, and education on dietary intake among adolescents. Prev Med. 2003;36:30-40. Braunschweig CL, Gomez S, Liang H, Tomey K, Doerfler B, Wang Y, Beebe C, Lipton R. Obesity and risk factors for the metabolic syndrome among low-income, urban, African American schoolchildren: The rule rather than the exception? Am J Clin Nutr. 2005;81:970-975. Wang Y, Tussing L, Odoms-Young A, Braunschweig C, Flay B, Hedeker D, Hellison D. Obesity prevention in low socioeconomic status urban AfricanAmerican adolescents: Study design and preliminary findings of the HEALTH-KIDS Study. Eur J Clin Nutr. 2006;60:92-103. Wang Y, Liang H, Tussing L, Braunschweig C, Caballero B, Flay B. Obesity and related risk factors among low-socioeconomic status minority students in Chicago. Public Health Nutr. 2007;10:927-938. Li J, Wang Y. Tracking of dietary intake patterns is associated with baseline characteristics of urban low-income African-American adolescents. J Nutr. 2008;138:94-100. Rockett HR, Breitenbach M, Frazier AL, Witschi J, Wolf AM, Field AE, Colditz GA. Validation of a youth/adolescent food frequency questionnaire. Prev Med. 1997;26:808-816. Pao EM, Fleming KH, Guenther PM, Mickle SJ. Foods Commonly Eaten by Individuals: Amount per Day and per Eating Occasion Home Economics Research Report. Washington, DC: US Government Printing Office; 1982.
25. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002. 26. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academies Press; 2000. 27. Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academies Press; 1997. 28. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: Design and applications. J Am Diet Assoc. 1995;95:1103-1108. 29. Feskanich D, Rockett HR, Colditz GA. Modifying the Healthy Eating Index to assess diet quality in children and adolescents. J Am Diet Assoc. 2004;104:1375-1383. 30. US Department of Agriculture. Center for Nutrition Policy and Promotion. Healthy Eating Index. http://www.cnpp.usda.gov/HealthyEatingIndex. htm. Accessed June 29, 2009. 31. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC growth charts: United States. Adv Data. 2000:1-27. 32. Norman GR, Streiner DL. Biostatistics: The Bare Essentials. St Louis, MO: Mosby; 1994. 33. Cullen KW, Bishop RG, de Moor C. Fat practices and consumption among African-American adolescent Boy Scouts: The impact of meal source. Ethn Dis. 2002;12:193-198. 34. Dwyer JH, Dwyer KM, Scribner RA, Sun P, Li L, Nicholson LM, Davis IJ, Hohn AR. Dietary calcium, calcium supplementation, and blood pressure in African American adolescents. Am J Clin Nutr. 1998;68: 648-655. 35. Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency among healthy adolescents. Arch Pediatr Adolesc Med. 2004;158:531-537. 36. Harris SS. Vitamin D and African Americans. J Nutr. 2006;136:11261129. 37. Taveras EM, Berkey CS, Rifas-Shiman SL, Ludwig DS, Rockett HR, Field AE, Colditz GA, Gillman MW. Association of consumption of fried food away from home with body mass index and diet quality in older children and adolescents. Pediatrics. 2005;116:518-524. 38. Stewart H, Blisard N, Jolliffe D. Let’s eat out: Americans weigh taste, convenience, and nutrition. Economic Information Bulletin; No. 19. 2006. http://www.ers.usda.gov/publications/eib19/eib19.pdf. Accessed August 28, 2009. 39. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics. 2008;121:1604-1614. 40. Krebs-Smith SM. Choose beverages and foods to moderate your intake of sugars: Measurement requires quantification. J Nutr. 2001; 131(2S-1):527S-535S.
September 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1345
Dietary Intake Patterns of Low-Income Urban African-American Adolescents YOUFA WANG, MD, PhD, MS; LISA JAHNS, PhD, RD; LISA TUSSING-HUMPHREYS, PhD, RD; BIN XIE, MD, PhD; HELAINE ROCKETT, MS, RD, FADA; HUIFANG LIANG, MD, PhD; LUANN JOHNSON, MS
ABSTRACT Unhealthy eating increases risks for chronic disease. Few studies have examined the multifaceted aspects of diY. Wang is an associate professor, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. L. Jahns is a research nutritionist, Grand Forks Human Nutrition Research Center, US Department of Agriculture, Agricultural Research Service, Grand Forks, ND; at the time of the study, she was an assistant professor of public health nutrition, Department of Nutrition, The University of Tennessee, Knoxville. L. TussingHumphreys is a research nutritionist, US Department of Agriculture, Agricultural Research Service, Baton Rouge, LA; at the time of the study, she was project coordinator, Department of Kinesiology and Nutrition, University of Illinois at Chicago. B. Xie is an associate professor, School of Community and Global Health, Claremont Graduate University, San Dimas, CA; at the time of the study, he was an assistant research professor, Hamovitch Research Center/School of Social Work, University of Southern California, Los Angeles. H. Rockett is senior health analyst, Massachusetts General Hospital and a consultant, Harvard School of Public Health, Boston, MA; at the time of the study, she was nutrition research manager, Channing Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. H. Liang is a senior scientist, Pharmacoepidemiology, Takeda Global Research and Development Center, Inc, Deerfield, IL; at the time of the study, she was a research assistant, Department of Kinesiology and Nutrition, University of Illinois at Chicago. L. Johnson is a statistician, Grand Forks Human Nutrition Research Center, US Department of Agriculture, Agricultural Research Service, Grand Forks, ND. Address correspondence to: Youfa Wang, MD, PhD, MS, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St E2546, Baltimore, MD 21205. E-mail: [email protected] Drs Wang and Jahns contributed equally to this study. Manuscript accepted: January 8, 2010. Copyright © 2010 by the American Dietetic Association. 0002-8223/$36.00 doi: 10.1016/j.jada.2010.06.005
1340
Journal of the AMERICAN DIETETIC ASSOCIATION
etary intake of low-income, urban African-American adolescents. This study aimed to describe dietary patterns including energy, nutrients, food groups, and diet quality and to identify areas to guide future interventions. Baseline data for a school-based obesity prevention study were collected from 382 African-American adolescents (10- to 14-year-olds) from four Chicago, IL, public schools in 2003. Diet was assessed using a 152-item food frequency questionnaire. Diet quality was measured using a modified version of the US Department of Agriculture Healthy Eating Index (HEI) and compared to published estimates for a nationwide sample. Participants reported high energy intakes and several unhealthy eating patterns: 58.6% consumed one or more servings of sweetened beverages per day and 15.7% consumed three or more servings per day; average fried food consumption was high (1.4 servings/day), 58.4% consumed one or more serving per day; and 75% consumed three or more three snacks per day. Only 49% of participants met the recommended three servings of dairy foods per day. Compared to a national, mostly white sample, participants had lower HEI scores (P⬍0.05); mean score was 66.0⫾12.8 (100⫽ maximum HEI score) vs 70.3⫾13.0 in boys vs girls, one third had scores ⬍60 (“needs improvement”) and only 15% scored ⬎80 (“good”). This study reveals key areas of problematic dietary patterns for future interventions targeting low-income African-American adolescents, including frequent intakes of calorie-dense, low nutrientrich foods, such as fried foods, snacks, and sweetened beverages. J Am Diet Assoc. 2010;110:1340-1345.
U
nhealthy eating increases the risk of many chronic diseases, including obesity. Obesity has become a major public health concern in the United States, and low-income and minority adolescents are disproportionately affected, possibly because of unhealthy food choices and lack of adequate physical activity (1,2). Unhealthy adolescent dietary practices not only have immediate deleterious physical and psychological effects, but also could determine trajectories of eating habits that influence chronic disease risks through adulthood, such as obesity and cardiovascular disease (3). It is not well-
© 2010 by the American Dietetic Association
understood how low-income minority groups’ diets may differ from those of other groups (2,3). Because of the importance of diet in good health, national guidelines have been developed (3,4). Although most US youths have adequate micronutrient intakes (5), only a small proportion meet recommendations for vegetable and fruit intake, and many overconsume added sugars, including sweetened beverages (6,7). A national survey reported 84% of Americans’ diet scored as “poor” or “needs improvement” by the US Department of Agriculture’s (USDA) Healthy Eating Index (HEI) (8). African Americans and low-income groups had lower scores than other ethnic and income groups. However, few studies have examined dietary patterns of urban low-income African-American adolescents. Although several previous studies on adolescent’s dietary intake have included African Americans, most tend to focus on only selected aspects of dietary intake (9-18). Because low-income African-American adolescents have a high prevalence of obesity and risk factors for metabolic syndrome (2,19), it is important to identify key dietary risk factors. To date, no research has examined multifaceted aspects of dietary intake that can contribute to obesityrelated comorbidities among this underserved population. This study examined dietary intake patterns of lowincome, African-American adolescents, including intakes of energy, nutrients, and food groups, and diet quality. Adequacy of nutrient intake at the group level was assessed by comparing mean intakes of nutrients to the Dietary Reference Intakes; overall diet quality was assessed using the HEI and compared to a large nationwide sample. Findings from this study will identify dietary problem areas and help guide future interventions.
METHODS Participants and Study Design A randomized intervention trial was initiated to test the feasibility and effectiveness of an environmental obesity prevention program in urban low-income African-American adolescents. Four Chicago, IL, public schools were selected and randomly assigned to control and intervention groups. The intervention focused on the school environment and aimed at promoting healthy eating and physical activity. The study was named Health-Kids (Healthy Eating and Active Lifestyles from School to Home for Kids). This is a cross-sectional analysis of dietary intake of 382 participants aged 10 to 14 years at baseline (Fall 2003). The majority of participants (⬎72%) were from low-income families (20-22). Parental survey data (from 108 parents) confirmed only 13.5% had a household annual income ⬎US$40,000 (21,22). Study protocols were approved by the Institutional Review Board at the University of Illinois at Chicago (for data collection) and Johns Hopkins University School of Public Health (for data analysis). Informed consent was obtained from adolescents and their parents or legal guardians. Details about the study design and data collection are provided elsewhere (20).
Food Consumption Measures Dietary intake was assessed using a 152-item, semiquantitative food frequency questionnaire, the Harvard Youth/Adolescent Questionnaire. The instrument was self-administered in the classroom while research staff and teachers monitored participants. Reproducibility and validity among adolescents has been described in detail (9,23). The Harvard Youth/Adolescent Questionnaire asks participants how often, in the past year, they usually consume the listed food items. Consumption of discrete serving sizes is asked where appropriate (such as a cup of yogurt, a hamburger, or a piece of fruit); foods without a discrete serving size, such as vegetables, do not have a portion size listed. Additional questions ask about frequency of fried food consumption and number of snacks consumed per day on school and nonschool days. At baseline, 417 adolescents completed the Harvard Youth/Adolescent Questionnaire. Individuals with extreme energy intakes (⬍500 or ⬎7,000 kcal) or with ⬎70 missing items on the Harvard Youth/Adolescent Questionnaire were excluded (22), yielding a sample size of 382 (92%). Serving sizes were quantified by examining those used by the USDA Handbook No. 8 and the Nationwide Food Consumption Survey: Foods Commonly Eaten by Individuals (specifically for ages 9 to 18 years) (24). Energy and nutrient intakes were calculated using a nutrient database specifically designed for use with the Harvard Youth/Adolescent Questionnaire and presented as average daily intake per adolescent. Food items were first aggregated into five major categories based upon the US Food Guide Pyramid (meat and main dishes, baked goods/cereals, fruits, vegetables, and dairy) as adapted for use with the Harvard Youth/Adolescent Questionnaire by team members (18). Next, food items were aggregated into 21 groups to allow pattern assessment including additional dietary factors (eg, fat, sugar, and energy). Note that fried potatoes are included in the fried, not the vegetable group. Nutrient intakes were compared to the national Dietary Reference Intakes (25-27). Diet quality was assessed using the 1995 USDA HEI (28). The HEI has been used to assess the diets of children and adolescents (29). The 1995 HEI was used instead of the 2005 HEI (30) because a key aim of this research was to compare the diet quality scores of the study participants with those published for other national samples. HEI consists of 10 dietary components that represent various aspects of a healthy diet, including intakes of grains, vegetables, fruit, dairy, meat, and avoidance of overconsumption of total and saturated fat, cholesterol, and sodium. The 10th component is a measure of dietary variety consisting of the number of different food items consumed (28). These components were selected to help measure compliance with national dietary recommendations. For each component, individuals receive a score between 1 and 10. Component scores are summed to derive an overall score, which ranges from 0 to 100. An overall HEI score of 80 implies a “good” diet; a score between 51and 80 implies a diet that “needs improvement”; a score ⬍51 implies a “poor” diet. The Harvard Youth/Adolescent Questionnaire items were grouped into HEI components according to adapSeptember 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1341
Table 1. Average daily intakes of energy, nutrients, and food groups (servings/day) of low-income urban African-American adolescents All (nⴝ382)
Energy and nutrients Energy (kcal) Total fat (% energy) Saturated fat (% energy) Cholesterol (mg) Fiber (g) Calcium (mg) Iron (mg) Sodium (mg) Vitamin C (mg) Vitamin D (IU) Folate (g) Food groups Baked goods/cereals Vegetables and fruits Vegetables Fruits Dairy Meat and main dishes Snacks Fried foods Sweetened beverages Sugar (g)
4™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™3 3,144⫾1,575 3,204⫾1,570 3,100⫾1,581 31⫾4 30⫾4 32⫾4 12⫾2 11⫾2 12⫾2 341⫾181 340⫾168 342⫾190 24⫾13 25⫾14 23⫾13 1,338⫾768 1,402⫾774 1,291⫾762 19⫾10 19⫾10 19⫾10 3,764⫾1,925 3,831⫾1,937 3,714⫾1,920 183⫾108 189⫾110 178⫾107 245⫾179 263⫾178 231⫾180 521⫾285 537⫾291 510⫾281
0.52 0.001 0.001 0.91 0.40 0.16 0.40 0.56 0.34 0.09 0.36
7.9⫾4.8 4.7⫾3.5 2.2⫾1.9 2.5⫾2.1 3.5⫾2.4 3.2⫾1.8 5.4⫾4.4 1.4⫾1.0 1.5⫾1.3 116.9⫾67.4
0.66 0.52 0.83 0.20 0.15 0.94 0.86 0.86 0.62 0.37
a
Boys (nⴝ162)
8.0⫾4.8 4.8⫾3.5 2.2⫾1.8 2.6⫾2.2 3.7⫾2.4 3.2⫾1.7 5.4⫾4.4 1.4⫾1.0 1.6⫾1.2 120.5⫾67.5
Girls (nⴝ220)
Sex difference P valuea
Daily intakes
7.8⫾4.8 4.6⫾3.5 2.2⫾1.9 2.4⫾2.0 3.4⫾2.3 3.2⫾1.8 5.3⫾4.0 1.4⫾0.9 1.5⫾1.3 114.2⫾67.4
One-way analysis of variance.
tations used by Feskanich and colleagues (29). Study participants’ HEI scores were compared to those of the 1996 Growing Up Today Study cohort. The Growing Up Today Study also utilized the Harvard Youth/Adolescent Questionnaire, and included a national sample of approximately 14,000 middle to high socioeconomic status, mostly (95%) white adolescents aged 9 to 14 years old (29). Participants’ height and weight were directly measured at the schools by trained interviewers (21). Weight status was classified by comparing their body mass index (BMI; calculated as kg/m2) to the 2000 US Centers for Disease Control and Prevention Growth Charts (31): obese (BMI ⱖ95th percentile), overweight (85thⱖBMI⬍95th percentile), or nonoverweight (BMI ⬍85th percentile). Statistical Analysis No difference in the adolescents’ baseline dietary intake patterns between the control and intervention groups was detected. Thus, the data were pooled for analysis. Between-group differences were tested using t tests or one-way analysis of variance, or 2 (for categorical variables). Component and overall HEI scores of Health-Kids adolescents were compared to published scores for Growing Up Today Study adolescents (32). Unequal variances between the samples were assumed. The Smith-Satterthwaite procedure was used to approximate a t statistic. The procedure is robust for equal/unequal variances when the sample sizes are different, and provides conservative results. Significant differences were reported at P⬍0.05. Analyses were performed using Stata (version 10.1, 2009, Stata Corp, College Station, TX).
1342
September 2010 Volume 110 Number 9
RESULTS AND DISCUSSION Participants’ mean age was 11.5⫾1.1 years; 98.4% were African American, and 57.6% were girls. Overall prevalence of overweight and obesity was 40.3%. More girls than boys were obese (27.3% vs 16.1%), but fewer girls than boys were overweight (14.1% vs 22.8%; P⬍0.05). Mean energy intake was high in this sample (3,144⫾ 1,575 kcal), but high energy intake (2,904 kcal) has been reported previously in a similar population (33). There were no significant sex differences in overall energy intake, although sex differences were observed for a few nutrients (total and saturated fat). More than half of adolescents consumed ⬎300 mg cholesterol per day and sodium intake was high, with ⬎75% consuming ⱖ2,400 mg per day. Mean fiber intake was inadequate at 23 to 25 g/day, while the recommended intake is 31 g/day for boys aged 9 to 13 and 26 g/day for girls (25). All adolescents consumed well above the Estimated Average Requirement for vitamin C, folate, and iron (26). Mean calcium intake was 1,338⫾768 mg, but 55% consumed less than the recommend amount of 1,300 mg/day (27). About 50% of adolescents’ vitamin D intakes were less than the recommended 200 IU (27), with a median intake of 194 IU (Table 1). There were no substantial sex differences in food group intakes. On average, fruit and vegetable consumption was less than the recommended amounts, even when nonfried potatoes and fruit juices were included. Only 49% met the recommendation of three servings of dairy food/day; 59% consumed at least one serving of sweetened beverages each day, and 15.7% consumed at least three sweetened beverages per day. Overall, adolescents re-
Table 2. Comparison of US Department of Agriculture Healthy Eating Index scores between low-income urban African-American adolescents in the Health-Kids Study and a nationwide sample of mostly white adolescents in the Growing Up Today Studya Girls Component HEI total score (maximum score⫽100) HEI individual component Grains Vegetables Fruit Dairy Meat Total fat Saturated fat Cholesterol Sodium Variety
Health-Kids (nⴝ220)
Boys
Growing Up Today Study (nⴝ8,807)
Health-Kids (nⴝ162)
Growing Up Today Study (nⴝ7,645)
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™™™™™™™3 66.0⫾12.8 70.3⫾13.0c 67.1⫾13.4 68.9⫾12.3c 8.1⫾2.4 6.7⫾2.8 6.6⫾3.3 7.0⫾3.0 6.9⫾2.9 8.3⫾1.8 6.2⫾2.9 6.2⫾4.4 5.0⫾3.2 5.0⫾3.1
7.3⫾2.1c 5.3⫾2.4c 6.4⫾3.0 7.5⫾2.7 5.6⫾2.4c 8.7⫾1.9c 7.6⫾2.9c 9.7⫾1.4c 5.1⫾3.2 7.1⫾3.3c
8.0⫾2.6 6.2⫾3.0 6.4⫾3.2 7.5⫾2.8 6.7⫾2.9 8.8⫾1.6b 7.0⫾2.8 6.2⫾4.3 5.0⫾3.2 5.0⫾3.1
7.3⫾2.1c 4.6⫾2.2c 5.6⫾3.0c 8.2⫾2.5c 5.9⫾2.4c 8.5⫾1.9 7.1⫾3.1 9.1⫾2.3c 5.1⫾3.2 7.6⫾3.1c
a
Based on the 1995 US Department of Agriculture Healthy Eating Index (HEI) system (8,24). Results for Growing Up Today Study are based on Feskanich and colleagues (29). Different from Health-Kids girls; P⬍0.05. c Different from same-sex Health-Kids adolescents; P⬍0.05. b
ported consuming nearly 120 g of added sugar per day. Average intake of fried foods was high (1.4 servings/day), and 58.4% consumed at least one serving of fried food each day. Participants consumed many snacks (5.4 servings/day), of which most were sweet as opposed to savory snacks (4 vs 1.4 servings). Among Health-Kids adolescents, 13% had HEI scores ⬍51 (“poor”), one third had scores ⬍60, indicating a diet that “needs improvement,” and only 15% had HEI scores ⬎80, indicating “good” diet quality. Compared to Growing Up Today Study participants (29), who represent a more general US adolescent population although mostly (96%) white, Health-Kids adolescents had total HEI scores approximately 2 to 4 points lower (P⬍0.01, Table 2); HealthKids girls had better scores for grains, vegetables, and meat components, and lower scores for total and saturated fat, cholesterol, and overall dietary variety (a reflection of the number of different food items consumed); Health-Kids boys scored better for grains, vegetables, fruit, and meat, but worse for dairy, cholesterol, and variety. Health-Kids adolescents had few sex differences, although girls’ total fat intake score was worse than boys (8.3 vs 8.8; P⬍0.05). This study presents dietary patterns of low-income urban African-American adolescents in Chicago. The findings indicate a number of targeted areas for future dietary interventions. Participants reported high energy intakes, which is consistent with their high obesity prevalence. Participants consumed large amounts of sodium, cholesterol, added sugars, snack foods, sweetened beverages, and fried foods. Only a small proportion met recommendations for fruits or vegetables. Compared to a large national sample of mainly white adolescents, these African-American low-income adolescents had lower diet quality. Health-Kids Study participants reported high energy intakes compared to the Growing Up Today Study partici-
pants and a number of high-energy intake related eating patterns. At least two factors could contribute to the reported higher energy intake. First, Health-Kids participants had a high prevalence of overweight/obesity, and may require a higher energy intake to sustain excess adiposity. Second, the Harvard Youth/Adolescent Questionnaire might overestimate usual energy intake, and some adolescents might have over reported their dietary intake. Nevertheless, the Harvard Youth/Adolescent Questionnaire has been validated for use among a general population of youths including African-American adolescents (23) and is used in other studies, some of which reported lower (18) or similar energy intake levels (34). Several previous studies reported a lower energy intake in US adolescents of similar age. For example, mean energy intake in Growing Up Today Study participants was 2,063⫾652 kcal (girls) to 2,306⫾722 kcal (boys), but the prevalence of overweight in Growing Up Today Study was also lower (9). Another large multiethnic study using the Harvard Youth/Adolescent Questionnaire reported 1,854⫾759 kcal (girls) to 2,071⫾810 kcal (boys), while African-American adolescents reported higher energy intakes than others (18). However, the findings of several other studies were consistent with the present study. Using an FFQ, another study in inner-city school adolescents reported mean intakes of 3,136 kcal (in fourth to fifth graders [approximately 10 to 11 years old]) and 2,297 kcal (in sixth to seventh graders [approximately 12 to 13 years old]) (15). Two other studies of African-American adolescents reported high energy intake similar to what observed in this study, approximately 2,900 kcal (33) and 3,200 kcal (34), respectively. Thus, the present study and others show that African-American adolescents seem to report high energy intake, which puts them at higher risk for obesity and other chronic diseases. Second, 50% of adolescents’ calcium intake was less than the recommended 1,300 mg/day. Nearly half did not consume three servings of dairy food per day as recom-
September 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1343
mended. With dairy foods being the main dietary source, vitamin D intake was of particular concern. Nearly half consumed less than the recommended amount. African Americans have increased need for dietary vitamin D because their darker pigmentation reduces sunlight exposure for vitamin D synthesis in the skin (35,36). Third, study participants reported frequent consumption of snack foods, fried foods, and sweetened beverages, which contribute to total energy intake. The majority of snack foods are high in energy, sugar, sodium, and/or fat, but otherwise are a poor source of other nutrients. Fried food may be considered a proxy for high-energy density foods, as well as fast foods, which are associated with poorer diet quality and risk for overweight among adolescents (10,37,38). Participants reported consuming nearly 120 g added sugar per day. This is primarily because of the consumption of sugar-sweetened beverages, such as soft drinks and fruit juice. A previous study found that 60.3% of participants reporting consuming soft drinks two times or more per day on average, while 22.0% consumed four times or more per day (21). Note that 120 g is equivalent to close to 30 teaspoons of sugar or about three cans of soft drink. The sugar content per 12-oz can of cola is about 40 g. This study shows that these low-income urban African-American adolescents consumed more added sugar than the national average. The Continuing Survey of Food Intakes by Individuals 1994-1996 data show that, on average, US adults and children consumed 20.5 teaspoons of added sugar per day, 24.1 teaspoons by children, and 24.6 teaspoons by those aged 12 to 19 years old. These were mainly contributed by consumption of sugar-sweetened beverages and fruit juice (39). Another recent study shows that, based on the National Health and Nutrition Examination Survey (NHANES) 1999-2004 data, among US children and adolescent, per-capita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice in total was 270 kcal/day; from sugar-sweetened beverages intake, 224 kcal/day and 48 kcal/day from 100% fruit juice. Soda contributed approximately 67% of all sugarsweetened beverages calories among adolescents, whereas fruit drinks provided more than half of the sugar-sweetened beverage calories consumed by preschool-aged children. In this nationally representative sample, the ethnic difference between white and African-American adolescents in sugarsweetened beverages and 100% fruit juice consumption was small—the calories (kcal/per day) derived was 302 vs 297 (white vs African American) for sugar-sweetened beverages and 42 vs 48 (white vs African American) for 100% fruit juice. In total, they were equivalent to about 86 g added sugar (40). Overall HEI score was lower in this sample than the Growing Up Today Study adolescents’ (66.4 vs 69.7), but still higher than the national average for adolescents aged 11 to 14 in the NHANES 1999-2000 survey (60.8) (8). The discrepancies likely result from ethnic differences in the study samples and their dietary intakes, age in the case of the Growing Up Today Study adolescents, and dietary assessment methodology in the NHANES, which collected 24-hour recall data, while the Harvard Youth/Adolescent Questionnaire reflects usual intake. In addition to the many strengths of this study, including the use of a validated detailed Harvard Youth/Ado-
1344
September 2010 Volume 110 Number 9
lescent Questionnaire and a high-risk study population (20), it also has several limitations. Only a homogeneous sample was included. Direct comparison of income and ethnic differences is not possible. In addition, the 1995 USDA HEI does not consider energy intake. The high energy intake reported by participants contributed to the relatively high HEI scores, which may well underestimate problems with diet quality. CONCLUSIONS The present study found a number of unhealthy eating patterns among urban low-income African-American adolescents, which could put them at increased risk for obesity and other chronic diseases. Participants’ high intakes of energy, fat, added sugars, fried food, snack foods, and sweetened beverages are of particular concern. School-based interventions that also involve families and communities are needed to help improve diet quality and reduce risk factors for chronic diseases. STATEMENT OF POTENTIAL CONFLICT OF INTEREST: No potential conflict of interest was reported by the authors. FUNDING/SUPPORT: The study was supported in part by research grants from the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (1R01DK63383, R01DK81335-01A1) and National Institute of Child Health and Human Development (1R03HD058077-01A1). ACKNOWLEDGEMENTS: We are indebted to the participating schools, families, and students in the study for their cooperation and support. We also thank Ji Li for her assistance in conducting some statistical analysis. References 1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 19992004. JAMA. 2006;295:1549-1555. 2. Wang Y, Beydoun MA. The obesity epidemic in the United States— Gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6-28. 3. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2005. http://www.health. gov/dietaryguidelines/. Accessed June 29, 2009. 4. US Department of Health and Human Services. Healthy People 2010. http://www.healthypeople.gov/. Accessed June 29, 2009. 5. Moshfegh A, Goldman J, Cleveland L. What We Eat In America, NHANES 2001-2002: Usual nutrient intakes from food compared to Dietary Reference Intakes. US Department of Agriculture, Agricultural Research Service; 2005. 6. Berkey CS, Rockett HR, Field AE, Gillman MW, Colditz GA. Sugaradded beverages and adolescent weight change. Obes Res. 2004;12: 778-788. 7. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001;357:505-508. 8. Basiotis PP, Carlson A, Gerrior SA, Juan WY, Lino M. The Healthy Eating Index: 1999-2000. http://www.cnpp.usda.gov/publications/HEI/ HEI99-00report.pdf. Accessed June 10, 2009. 9. Rockett HR, Berkey CS, Field AE, Colditz GA. Cross-sectional measurement of nutrient intake among adolescents in 1996. Prev Med. 2001;33:27-37. 10. French SA, Story M, Neumark-Sztainer D, Fulkerson JA, Hannan P. Fast food restaurant use among adolescents: Associations with nutrient intake, food choices and behavioral and psychosocial variables. Int J Obes Relat Metab Disord. 2001;25:1823-1833. 11. Cullen KW, Baranowski T, Klesges LM, Watson K, Sherwood NE, Story M, Zakeri I, Leachman-Slawson D, Pratt C. Anthropometric,
12. 13. 14.
15.
16. 17.
18. 19.
20.
21. 22. 23. 24.
parental, and psychosocial correlates of dietary intake of AfricanAmerican girls. Obes Res. 2004;12(suppl):20S-31S. Matheson DM, Wang Y, Klesges LM, Beech BM, Kraemer HC, Robinson TN. African-American girls’ dietary intake while watching television. Obes Res. 2004;12(suppl):32S-37S. Lytle LA, Himes JH, Feldman H, Zive M, Dwyer J, Hoelscher D, Webber L, Yang M. Nutrient intake over time in a multi-ethnic sample of youth. Public Health Nutr. 2002;5:319-328. Granner ML, Sargent RG, Calderon KS, Hussey JR, Evans AE, Watkins KW. Factors of fruit and vegetable intake by race, gender, and age among young adolescents. J Nutr Educ Behav. 2004;36: 173-180. Field AE, Peterson KE, Gortmaker SL, Cheung L, Rockett H, Fox MK, Colditz GA. Reproducibility and validity of a food frequency questionnaire among fourth to seventh grade inner-city school children: Implications of age and day-to-day variation in dietary intake. Public Health Nutr. 1999;2:293-300. Cavadini C, Siega-Riz AM, Popkin BM. US adolescent food intake trends from 1965 to 1996. Arch Dis Child. 2000;83:18-24. Affenito SG, Thompson DR, Barton BA, Franko DL, Daniels SR, Obarzanek E, Schreiber GB, Striegel-Moore RH. Breakfast consumption by African-American and white adolescent girls correlates positively with calcium and fiber intake and negatively with body mass index. J Am Diet Assoc. 2005;105:938-945. Xie B, Gilliland FD, Li YF, Rockett HR. Effects of ethnicity, family income, and education on dietary intake among adolescents. Prev Med. 2003;36:30-40. Braunschweig CL, Gomez S, Liang H, Tomey K, Doerfler B, Wang Y, Beebe C, Lipton R. Obesity and risk factors for the metabolic syndrome among low-income, urban, African American schoolchildren: The rule rather than the exception? Am J Clin Nutr. 2005;81:970-975. Wang Y, Tussing L, Odoms-Young A, Braunschweig C, Flay B, Hedeker D, Hellison D. Obesity prevention in low socioeconomic status urban AfricanAmerican adolescents: Study design and preliminary findings of the HEALTH-KIDS Study. Eur J Clin Nutr. 2006;60:92-103. Wang Y, Liang H, Tussing L, Braunschweig C, Caballero B, Flay B. Obesity and related risk factors among low-socioeconomic status minority students in Chicago. Public Health Nutr. 2007;10:927-938. Li J, Wang Y. Tracking of dietary intake patterns is associated with baseline characteristics of urban low-income African-American adolescents. J Nutr. 2008;138:94-100. Rockett HR, Breitenbach M, Frazier AL, Witschi J, Wolf AM, Field AE, Colditz GA. Validation of a youth/adolescent food frequency questionnaire. Prev Med. 1997;26:808-816. Pao EM, Fleming KH, Guenther PM, Mickle SJ. Foods Commonly Eaten by Individuals: Amount per Day and per Eating Occasion Home Economics Research Report. Washington, DC: US Government Printing Office; 1982.
25. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002. 26. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academies Press; 2000. 27. Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academies Press; 1997. 28. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: Design and applications. J Am Diet Assoc. 1995;95:1103-1108. 29. Feskanich D, Rockett HR, Colditz GA. Modifying the Healthy Eating Index to assess diet quality in children and adolescents. J Am Diet Assoc. 2004;104:1375-1383. 30. US Department of Agriculture. Center for Nutrition Policy and Promotion. Healthy Eating Index. http://www.cnpp.usda.gov/HealthyEatingIndex. htm. Accessed June 29, 2009. 31. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC growth charts: United States. Adv Data. 2000:1-27. 32. Norman GR, Streiner DL. Biostatistics: The Bare Essentials. St Louis, MO: Mosby; 1994. 33. Cullen KW, Bishop RG, de Moor C. Fat practices and consumption among African-American adolescent Boy Scouts: The impact of meal source. Ethn Dis. 2002;12:193-198. 34. Dwyer JH, Dwyer KM, Scribner RA, Sun P, Li L, Nicholson LM, Davis IJ, Hohn AR. Dietary calcium, calcium supplementation, and blood pressure in African American adolescents. Am J Clin Nutr. 1998;68: 648-655. 35. Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency among healthy adolescents. Arch Pediatr Adolesc Med. 2004;158:531-537. 36. Harris SS. Vitamin D and African Americans. J Nutr. 2006;136:11261129. 37. Taveras EM, Berkey CS, Rifas-Shiman SL, Ludwig DS, Rockett HR, Field AE, Colditz GA, Gillman MW. Association of consumption of fried food away from home with body mass index and diet quality in older children and adolescents. Pediatrics. 2005;116:518-524. 38. Stewart H, Blisard N, Jolliffe D. Let’s eat out: Americans weigh taste, convenience, and nutrition. Economic Information Bulletin; No. 19. 2006. http://www.ers.usda.gov/publications/eib19/eib19.pdf. Accessed August 28, 2009. 39. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics. 2008;121:1604-1614. 40. Krebs-Smith SM. Choose beverages and foods to moderate your intake of sugars: Measurement requires quantification. J Nutr. 2001; 131(2S-1):527S-535S.
September 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1345