Beverage Consumption of Mother–Toddler Dyads in Families with Limited Incomes

Beverage Consumption of Mother–Toddler Dyads in Families with Limited Incomes Sharon L. Hoerr, RD, PhD, FACN Seung-Yeon Lee, PhD Rachel F. Schiffman, RN, PhD, FAAN Mildred Omar Horodynski, RN, PhD Lorraine McKelvey, PhD

Beverage intake and diet quality of toddlers from families with limited incomes were described and compared to their mother’s beverage intake. At both 2 and 3 years of age, the children’s average milk intake was adequate, the juice intake was twice that recommended, and the intake of sweetened beverages was high. Mothers who consumed more than 12 fl oz of soft drinks per day were nearly four times more likely to have a child with poor diet quality. Health practitioners should do focused screening of mothers’ and children’s beverage intakes to quickly assess those at high risk for poor diets. n 2006 Elsevier Inc. All rights reserved.

EALTH PROFESSIONALS HAVE become increasingly concerned about the shift in beverage intake away from milk to less nutrient dense beverages such as soft drinks and sweetened beverages. Cross-sectional national survey data have documented this shift in youth (French, Lin, & Guthrie, 2003; Rampersaud, Bailey, & Kauwell, 2003; Storey, Forshee, & Anderson, 2004). There have been a few studies of beverage intake for children as young as 2 years (Marshall, Levy, Broffitt, Eichenberger-Gilmore, & Strumbo, 2003; Skinner & Carruth, 2001; Skinner, Ziegler, & Ponza, 2004), but none have targeted families with limited incomes or examined the dietary relationships between the children and caregivers in such families. Young children in families with limited incomes are at a high risk of inadequate nutrient intakes because of insufficient food resources (Drewnowski & Specter, 2004) and caregivers’ limited knowledge of nutrients in foods (Baranowski, 1997). Early childhood is a critical period for physical, cognitive, and psychological development, as well as the formation of food preferences (Koivisto Hursti, 1999). The caregivers of young children determine the availability of foods and, based on the construct of role modeling from social learning theory, are role models for food intake (Baranowski, 1997; Koivisto Hursti, 1999). Fisher,

H

Journal of Pediatric Nursing, Vol 21, No 6 (December), 2006

Mitchell, Smiciklas-Wright, and Birch (2001) demonstrated that mothers’ beverage choices influenced the trade-off between milk and soft drinks in their 5-year-old daughters’ diets. It is not known if this modeling would be true for even younger children. The beverage and food consumption of the mother might well predict that of her child because it is the mother who typically purchases food, prepares meals, and feeds children (Baranowski, 1997; Fisher et al., 2001). A recent study found a high concordance between poor diet quality of mothers with that of their infants and toddlers (Lee, Hoerr, & Schiffman, 2005). The theoretical rationale for this study is based on the construct of role modeling from social learning theory (Baranowski, 1997).

From the Department of Food Science & Human Nutrition, Michigan State University, East Lansing, MI, College of Nursing, University of Wisconsin-Milwaukee, WI, College of Nursing, Michigan State University, East Lansing, MI and Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR. Address correspondence and reprint requests to Sharon L. Hoerr, RD, PhD, FACN, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI 48824. E-mail: [email protected] 0882-5963/$ - see front matter n 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2006.01.035

403

404

HOERR ET AL

The purposes of this study were (1) to investigate whether the diet quality of toddlers whose mothers were high consumers of soft drinks was poorer than the diet quality of children whose mothers consumed low amounts of or no soft drinks at all; (2) to examine the consumption of beverages such as milk, fruit juice, sweetened beverages, and soft drinks over 2 years in families with limited incomes; and (3) to explore how the beverage intake of mothers related to that of their children. The children in this study were at or near 24 and 36 months; these are important ages for the development of the child’s food preferences. LITERATURE REVIEW Beverage consumption can influence the adequacy of nutrient intakes in children and adults (Ballew, Kuester, & Gillespie, 2000; Fisher et al., 2001). Milk is a good source of vitamins A, B, and D, protein, calcium, and magnesium. Many 100% fruit juices can provide vitamins A and C and folate, as well as potassium and antioxidants (Rampersaud et al., 2003; Subar, Krebbs-Smith, Cook, & Kahle, 1998). Inversely, consumption of carbonated drinks has been negatively associated with intakes of vitamins A and C and calcium for 2- to 5-year-olds in national surveys (Ballew et al., 2000) and with reduced diet quality (Johnson & Frary, 2001). The replacement of beverages high in nutritional quality such as milk and 100% fruit juice with soft drinks and sugar-sweetened beverages is of special concern for the health of young children (Mrdjenovic & Levitsky, 2003; Rampersaud et al., 2003). Several studies have related the decline in milk intake and typical replacement by sweetened drinks to increased risk for obesity (Bray, Nielson, & Popkin, 2004; Drewnowski & Specter, 2004; Ludwig, Peterson, & Gortmaker, 2001; Mrdjenovic & Levitsky, 2003; Zemel, 2004), growth retardation, and diarrhea (Dennison, Rockwell, & Baker, 1997). Despite the health risks, families with limited resources might be likely to purchase soft drinks and sweetened beverages because these are generally less expensive by volume than more nutritious beverages (Drewnowski & Specter, 2004). Furthermore, children in families with limited incomes might be at higher risk for poor health than those in families with higher incomes due to limited resources and fewer opportunities for nutrition education (Baranowski, 1997; North, Emmett & ALSPAC Study Team, 2000).

The degree to which the consumption of soft drinks and sweetened beverages is a problem for nutrition and health of children remains controversial. In its update of nutrient recommendations for carbohydrate intake, the Food and Nutrition Board presented data that consumption of soft drinks did not begin to negatively influence the mineral intakes of children until added sugars exceed 25% of calories in the diet (Institute of Medicine, 2002). A recent analysis of national survey data demonstrated that the leading source of calories in the U.S. diet for adults is now soft drinks, replacing white bread for first place (Bermudez, 2005); thus, soft drinks are contributing higher amounts of empty calories to the diet than ever before. Not only did two thirds of this national sample from 1999 to 2000 report drinking soft drinks or sweet drinks on 1-day dietary recalls, but obesity rates were higher in this group as well (Bermudez, 2005). In a prospective study of children from the Harvard Nurses Health Study, dietary data from food frequencies demonstrated small but significant dose–response relationships between consumption of sugar-added beverages and increases in body mass index (BMI = weight in kilograms/ height in meters squared) (Berkey, Rocket, Field, Gillman, & Colditz, 2004). In a longitudinal study of preschool children in Tennessee, investigators found that calcium intake related negatively to children’s body fat and to intakes of sweetened beverages over time (Skinner, Bounds, Carruth, & Ziegler, 2003). Whatever the relationship of soft drinks and sweetened beverages to diet quality and health, it is clear that intakes are increasing among most age groups, especially youth. Data from national nutrition surveys averaging 2 days of dietary intakes showed the children 1–3 years consumed an average of 2.1 fluid ounces (fl oz) soft drinks and 3.6 fl oz sweetened beverages per day (Rampersaud et al., 2003). In a longitudinal study of infants’ beverage consumption during the transition stage of infant nutrition, investigators found that about 11.9% of 24-month-old children consumed soft drinks on a 24-hour dietary recall for an average of 5.5 fl oz per day, and 42.6% consumed fruit drinks (not 100% juice) for an average of 10.3 fl oz per day (Skinner et al., 2004). A survey conducted by the National Soft Drink Association found that nearly three fourths of children 1–5 years old drank soft drinks over a 2-week period, with a mean intake of less than 4 fl oz (Park, Meier, Bianchi, & Song, 2002). British

405

BEVERAGE CONSUMPTION OF MOTHER–TODDLER DYADS

investigators reported over half of the toddlers in their study consumed sugar-sweetened beverages (Hunty, Lader, & Clarke, 2000). Thus, various investigators using different sampling frames and different assessment techniques have reported different findings regarding the extent of soft drinks and sweetened beverages in diets of young children. In addition, very little is known about role modeling of beverage intake by young children in families with limited incomes. METHOD This study was based on data collected from one site in a midsize midwestern community participating in a multisite, national, longitudinal clinical trial of an early-childhood intervention program, Early Head Start (EHS), aimed at low-income families (Administration for Children and Families, 2002). EHS is an intervention for families of young children that aims to promote the optimal growth of infants and toddlers (Raikes & Love, 2002). The criteria for participation in the longitudinal study were as follows: (1) child born between September 1, 1995, and September 30, 1998, and under 12 months of age at enrollment (the focus child); (2) the family could not have 3 months’ participation or longer in any comprehensive child development program during the 5 years immediately preceding the birth of the focus child; and (3) the family income was at or less than 100% of the federal poverty income ratio (10% of families could be over income if the family had qualifying risk factors). Local health care and social service workers recruited families who satisfied these criteria and enrolled them in this study after informed consent. Early Head Start program staff at the local agency collected demographic and needs data during application to the program. Of the 196 families enrolled in the research and evaluation study at this site, investigators accepted and randomly assigned 189 families into the Early Head Start program group or into the comparison group that did not receive Early Head Start. There were no differences between the two study groups at or near enrollment for family demographic characteristics and family-related measures. The university’s review committee approved the study and participants gave informed consent for themselves and for their focus children. Trained data collectors interviewed families in their homes near the time of enrollment and at periodic intervals until the focus child (the youngest child

in the family) was 3 years of age. There were multiple waves of data collection; data for the current study were collected when the child was at or near 24 months of age (n=118) and again at 36 months of age (n=133).

Sample Data for this study come from 93 mother– toddler pairs for whom there were both 24- and 36-month dietary data available. Subjects were excluded because some mothers could not be contacted at one or both of the interview times and because caregivers other than mothers also fed the children, so these children’s food intakes were uncertain. There were no significant differences between program and comparison groups in demographics or dietary data, so the 93 children in this study were drawn from both the EHS group (n = 51) and the comparison group (n = 42). In addition, there were no significant differences in demographic characteristics at enrollment between the 93 dyads in this study versus those not in this study. At the 24-month birthday related interview, the average age of toddlers was 25.2 months, ranging from 23.1 to 28.7 months of age; at the 36-month birthday related interview, the average age was 38.4 months. At enrollment, use of other services by mothers was high; 75 received Medicaid and 75 received The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Whereas 50 mothers reported receiving food stamps (32%), nearly all were eligible. At 26 months after enrollment, 35% reported receiving WIC, 45% Medicaid, and 20% food stamps.

Procedures Trained interviewers obtained one 24-hour food recall from each mother about her and her child’s food intake when the child was at or near 24 months of age and again when the child was approximately 36 months old. The dietary data were collected through a single, standardized, 24-hour dietary recall based on U.S. Department of Agriculture’s multiple-pass method (Conway, Ingwersen, Vinyard, & Moshfegh, 2003). Interviewers trained in the dietary recall method used food models to help the caregivers provide information about the foods and the portion sizes that they and their toddler ate within the previous 24 hours. The five-step food recall method consisted of (1) the quick list, an uninterrupted listing of the foods and beverages consumed; (2) the forgotten foods list, queries on types of foods

406

typically overlooked; (3) the time and occasion at which foods and beverages were consumed; (4) the detail cycle to elicit descriptions of foods and amounts eaten aided by food models to help estimate portion sizes; and (5) the final probe review. Dietary information included the caregiver’s description of the food and drink, time of consumption, amount ingested, and location where the food or beverage was consumed. Researchers entered the interview data into a database by food or beverage and classified each into major food groups as appropriate, enumerating the number and type of food groups consumed. Adequate dietary quality was defined as eating at least one serving of food per day from each of the recommended five food groups (fruit, vegetable, dairy, meat, and grain) from the Food Guide Pyramid (U.S. Department of Agriculture, 1996). A Food Group Score (FGS) ranging from 0 (none) to 5 (all food groups) was previously validated against nutrient adequacy of the diet, where poor diet quality was due to consumption of less than one serving per day from at least one of the five food groups (Schuette, Song, & Hoerr, 1996). Beverage consumption in fluid ounces was estimated after categorizing all beverages consumed into six groups: (1) milk including flavored milks, (2) 100% fruit juice, (3) nondiet soft drinks, (4) sweetened beverages (not 100% fruit juice) and sports drinks, (5) noncarbonated caffeinated beverages, and (6) water. Diet beverages were not included because few participants consumed them and because they contribute neither calories nor nutrients to the diet.

Statistical Analysis Data were analyzed with the Statistical Package for the Social Sciences (SPSS, 2004). The total beverage consumption in fluid ounces for all six beverage categories was calculated for both the mothers and their children. Subjects were divided into two groups on the basis of their beverage consumption: nonconsumers and consumers. The average beverage consumption was calculated only for beverage consumers. Outliers were identified and truncated to the next nearest in range value, or Windsorized (Hoaglin, Mosteller, & Tukey, 1983). After exclusion of outliers because of nonnormal distributions, Spearman rank order correlation coefficients were calculated to examine the relationship for beverage consumption between mother–toddler dyads at both interviews. Finally, the odds ratio was calculated for a poor diet quality

HOERR ET AL

(FGS b5) of the child, for the mothers who consumed more than 12 fl oz of soft drinks compared to the mothers who consumed less than this amount at 36 months. RESULTS Demographic data for the mothers at enrollment are shown in Table 1. Only one family exceeded 100% of the poverty income ratio (PIR) and most were Caucasian, 78.6%. Forty-one percent of mothers had less than a high school education and about half were living without a partner. Mother–child pairs reported use of only four types of flavored milk but 15 types of soft drinks and over 60 kinds of sweetened beverages (data not shown). The volume of beverage intake for mothers and their children at two periods is shown in Table 2. On average, the children’s intakes of milk and of juice tended to be larger than their mothers’. Two thirds of children consumed at least the recommended 16 fl oz of milk; one third drank more than the recommended 6 fl oz of juice. Mothers’ soft drink intakes averaged about two 12-fl-oz cans per day, and about two thirds of the mothers drank soft drinks on the day reported. Mean intakes of sweetened beverages were high for both mothers and children who consumed them, ranging from 10 to 13 fl oz over the 2 time periods. Table 1. Characteristics of Mothers at Enrollment (N = 93)4 Characteristic

Educational level (n = 83) bHigh school graduate High school graduate Some college or more Marriage status (n = 83) Single Married Separated Divorced Widowed Cohabiting Race/ethnicity (n = 84) Caucasian African American Hispanic Other ethnicityy Yearly gross income (n = 72) $0 to 5000 $5001 to 10,000 $10,001 to 15,000 z$15,001

n (%)

34 (41.0) 32 (38.5) 17 (20.5) 33 19 3 11

(39.8) (22.9) (3.6) (13.3) 0 17 (20.4) 66 9 4 5

(78.6) (10.7) (4.8) (5.9)

15 26 15 16

(20.8) (36.1) (20.8) (22.3)

4Samples sizes vary for demographics because not all mothers answered each of the items. yAsian or mixed race/ethnicity.

407

BEVERAGE CONSUMPTION OF MOTHER–TODDLER DYADS

Table 2. Description of Beverage Consumption (in Fluid Ounces) of Mothers and Children from 24-Hour Dietary Recall (N = 93) Mothers 24 Months

Total beverage consumption Range (fl oz) 11–192 Mean F SD (fl oz) 47.6 F 30.4 Milk Nonconsumer, n (%) 49 (52.7) Consumers n = 44 Range (fl oz) 3 –29 Outliers (fl oz) 32, 36, 52 Mean F SD (fl oz) 12.5 F 7.9 75 Percentiles (fl oz) 16 100% Fruit/vegetable juice Nonconsumer, n (%) 66 (71.0) Consumers n = 27 Range (fl oz) 2 –16 Outliers (fl oz) 132 Mean F SD (fl oz) 9.7 F 4.1 75 Percentiles (fl oz) 12 Soft drinks (not including diet) Nonconsumer, n (%) 35 (37.6) Consumers n = 58 Range (fl oz) 1– 88 Outliers (fl oz) 112, 140 Mean F SD (fl oz) 30.3 F 22.6 75 Percentiles (fl oz) 45.3 Sweetened beverage Nonconsumer, n (%) 79 (84.9) Consumers n = 14 Range (fl oz) 2–24 Outliers (fl oz) NA Mean F SD (fl oz) 11.9 F 5.9 75 Percentiles (fl oz) 16 Caffeinated beverage (not including soft drinks) Nonconsumer, n (%) 69 (74.2) Consumers n = 24 Range (fl oz) 4 –100 Outliers (fl oz) 216 Mean F SD (fl oz) 36.1 F 31.2 75 Percentiles (fl oz) 57 Water Nonconsumer, n (%) 45 (48.4) n = 48 Consumers Range (fl oz) 4 –32 Outliers (fl oz) 40, 65, 136, 140, 272 Mean F SD (fl oz) 16.0 F 8.0 75 Percentiles (fl oz) 20

Children 36 Months

24 Months

36 Months

8–120 44.1 F 23.2

2 – 66 28.7 F 12.2

4 – 66 25.2 F 11.8

45 (48.4) n = 48 2–23 NA 10.6 F 5.4 16

11 (11.8) n = 82 2 – 36 58 13.5 F 8.9 19.3

5 (5.4) n = 88 2–32 34, 36, 37, 39 13.1 F 8.5 18

77 (82.8) n = 16 4 –24 48, 84 12.1 F 7.4 21

41 (44.1) n = 52 2 – 32 36, 64, 128 12.9 F 8.4 18

47 (50.5) n = 46 2 – 24 34, 60 10.8 F 6.8 14.5

29 (31.2) n = 64 2 – 41 60, 76, 101, 112 21.1 F 11.3 30

70 (75.3) n = 23 2 –14 46 6.7 F 4.0 12

64 (68.8) n = 29 0.25 –16 NA 7.4 F 4.1 12

77 (82.8) n = 16 7 – 24 32, 122 13.1 F 6.3 16

50 (53.8) n = 43 2 – 40 58 13.2 F 9.4 20

65 (69.9) n = 28 2–23 24, 64 10.4 F 6.2 13.5

69 (74.2) n = 24 3 – 80 96, 120, 132 32.9 F 25.3 46

92 (98.9) n=1 NA NA 6+0 NA

91 (97.8) n =2 4 –16 NA 6 F 8.49 NA

31 (33.3) n = 62 4 – 56 72, 84 23.2 F 16.8 32

25 (26.9) n = 68 2 –12 16, 24 6.6 F 3.3 9

19 (20.4) n = 74 2 –16 24, 27, 30 8.5 F 5.0 12

Outliers identified by box plot were not included in averages.

Mothers drank less than the recommended 16 fl oz of milk, only 11.2% of mothers drank 16 fl oz at the 24- and 14.2% at the 36-month interviews, respectively. The mothers’ soft drink intakes from one year to the next showed consistency, with a significant correlation of r = .39 ( p b .01). The child’s soft drink consumption was correlated from age 2 to 3 years (r = .38, p b .01).

Children’s beverage intakes were significantly correlated with that of their mothers at both times (Tables 3 and 4). Of special interest were the positive mother–child correlations for soft drinks at both 24 and 36 months. The mother’s soft drink intakes were associated with child’s intake of soft drinks, r = .25 ( p b .05) and 0.30 ( p b .01) at 24 and 36 months, respectively. However, the mothers’ soft

408

HOERR ET AL

Table 3. Spearman Rank Order Correlation Coefficient of Mother’s and Child’s Beverage Consumption at 24 Months (N = 93) Mother Milk

Juice

Soft drinks

Child Milk .12 .03 .02 Juice .05 .364 .06 Soft drinks .17 .15 .25y Sweetened .03 .16 .15 beverages Water .01 .04 .06

Sweetened Beverages

Caffeinated

Water

.18 .23y .14 .21y

.07 .09 .14 .09

.01 .11 .09 .02

.01

.06

.274

4p b .01. yp b .05.

drink intakes were not associated with the child’s fruit juice at 24 months; by 36 months there was an inverse correlation, r = .36 ( p b 0.01). Finally, mothers who consumed more than 12 fl oz of soft drinks at 36 months were 3.8 times more likely to have a child whose diet quality was poor (FGS b5) compared to mothers who did not consume soda or drank less than 12 fl oz per day (95% confidence interval, 1.12–13.0). DISCUSSION This is the first longitudinal study of beverage consumption of 2- and 3-year-olds in families living in poverty. These findings demonstrate that the intake of soft drinks and sweetened beverages was high for both mothers and children and the children’s intake of fruit juice was generally excessive. We also found that the mothers’ beverage consumption significantly related to that of their children, lending support to the importance of role modeling in the development of food preferences in young children. Finally, the mothers with high intakes of soft drinks were more likely to have children with poor diet quality. Compared to findings from a predominantly middle-income sample (Skinner et al., 2004), a higher percentage of children in this study at 24 months consumed soft drinks (11.9% vs. 31%), although the average intakes were similar (5.5 vs. 6.7 fl oz). Nearly one in four children at 24 months and one in three at 36 months consumed soft drinks the previous day; the average amount of those who drank them was about 7 fl oz. A survey by the National Soft Drink Association from 1997 to 1998 using 2 weeks of food diaries showed that children ages 1 to 5 years consumed, on

average, only 3.7 fl oz soft drinks (for both consumers and nonconsumers) and 72.1% consumed soft drinks over the 2 weeks (Park et al., 2002). Average intakes of soft drinks by young children were lower than our findings when nonconsumers were included. The finding in this study that the children had high average intakes of milk, fruit juice, and sweetened beverages (beverage consumers only) is consistent with national survey data for preschoolers (Rampersaud et al., 2003). As other studies have shown, toddlers’ intake of fruit juice was high in this study (Dennison, 1996; Marshall et al., 2003; Skinner et al., 2004). The high average intake of fruit juice reported in the current study of 12.9 fl oz at 24 months and 10.9 fl oz at 36 months was slightly higher than that reported by Skinner et al. (2004) — 9.5 fl oz at 24 months. Skinner and Carruth (2001) reported that the toddlers in a middle-income sample averaged 6.8 fl oz of fruit juice per day. This difference might be explained in part if more children in the present study were on WIC and receiving subsidies for the purchase of 100% fruit juice. Excessive juice intake by toddlers are of concern, in part because some studies have found high consumption of fruit juice to be related to short stature or overweight (Dennison, 1996; Dennison et al., 1997); however, research findings by Skinner and Carruth (2001) did not support excessive fruit juice consumption contributing to short stature or to overweight. Excessive juice intake certainly can contribute to excess calories. We found that the mother’s intake of soft drinks and juice, but not milk, was significantly related with her child’s intake. Few of these mothers drank

Table 4. Spearman Rank Order Correlation Coefficient of Mother’s and Child’s Beverage Consumption at 36 Months (N = 93) Mother Milk

Child Milk Juice Soft drinks Sweetened beverages Water 4p b .05. yp b .01.

Juice

.03 .04 .254 .03 .15 .14 .18 .15 .09

.12

Soft Drinks Sweetened Caffeinated

Water

.01 .36y .30y .01

.14 .19 .06 .17

.05 .11 .10 .13

.214 .10 .01 .05

.16

.01

.17

.09

409

BEVERAGE CONSUMPTION OF MOTHER–TODDLER DYADS

milk on the day reported, although nearly all the children did. Mothers who drank more than 12 fl oz of soft drinks per day were almost four times more likely to have children who had a poor diet quality. The high intake of soft drinks is of special concern in light of the possible links between high fructose corn syrup and obesity, especially in people living with limited incomes (Bray et al., 2004; Drewnowski & Specter, 2004). A recent study in primary schools in England demonstrated that an educational intervention resulted in reduction in soft drink consumption by children and a reduction in childhood obesity (James, Thomas, Cavan, & Kerr, 2004). The mother’s milk intake was strongly and positively associated with her child’s diet quality at 24 months. Although no other study was located that found the same relationship for this age, Fisher et al. (2001) did find that the soft drink intake of mothers was related negatively to their young children’s milk and calcium intake. National trends show reduced milk intake and increases in intake of soft drinks and sweetened beverages. There was a 25% to 30% decline in milk consumption by children and adolescents between 1977–1978 and 1994 –1995 (Borrud, Enns, & Mickle, 1997; Harnack, Stang, & Story, 1999). Morton and Guthrie (1998) reported a 41% increase in soft drink consumption between 1989– 1991 and 1994 –1995. We see the same patterns even in these families, many of whom have subsidies for milk and 100% fruit juice. This study was unique in having a sample composed of mother–child pairs almost all of whom were below the poverty level. Other strengths include the ability to follow beverage and food group patterns longitudinally over 2 years and mother–child comparisons of food and beverage intakes. Only 1-day food intake data were available; however, the year-to-year correlations in beverage intake were stable for mothers at these two times. Although, nutrient analysis was not reported in this article, other studies have shown that food group intakes are predictive of nutrient adequacy (Foote, Murphy, Wilkens, Basiotis, & Carlson, 2004; Kant, 1996; Schuette et al., 1996). Finally, it would have been desirable to have complete data on heights and weights of mothers and children at each measurement period in order to compare beverage intake with weight status. These data should become available for analysis when the children in the EHS study turn 5 years of age, and we are

interested in predicting 5-year-old body weights in future work. IMPLICATIONS This study suggests that it would be helpful for health professionals, especially nurses and nurse practitioners, to ask about the daily beverage intakes of mothers and children, especially soft drinks, fruit juice, sweetened beverages, and milk. Intakes should be compared to those recommended for both the mother and children at various ages. Practitioners can probe for average intake of fruit juice by toddlers and caution mothers that their children need only 6 fl oz of fruit juice per day. Nurses can encourage mothers to offer milk and then water when children are thirsty. Although sweetened beverages are less expensive than milk and fruit juice, pure water is still cheaper than both and better for children’s weight and teeth. Finally, mothers themselves should be encouraged to consume healthy foods and beverages because they serve as important models for their children. ACKNOWLEDGMENTS The findings reported here are based on research conducted as part of the national Early Head Start Research and Evaluation Project funded by the Administration on Children, Youth and Families, U.S. Department of Health and Human Services, through Grant 90YF0010, Pathways Project: Research into Directions for Family Health and Service Use, to Rachel F. Schiffman, RN, PhD FAAN, principal investigator (now at University of Wisconsin-Milwaukee), and Hiram E. Fitzgerald, PhD, coprincipal investigator (Michigan State University). The research is part of the independent research the Michigan State University conducted with the Community Action Agency in Jackson, Michigan, which is one of the 17 programs that participated in the national Early Head Start study. The content of this publication does not necessarily reflect the views or policies of the Early Head Start Research Consortium, Mathematica Policy Research Inc., or the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The Community Action Agency in Jackson, Michigan, and Applied Developmental Science Graduate Programs, Michigan State University, also provided supplemental funding for this research.

410

HOERR ET AL

REFERENCES Administration for Children and Families. (2002). Making a difference in the lives of infants and toddlers and their families. The impacts of Early Head Start: Executive summary. Washington, DC: U.S. Department of Health and Human Services. Ballew, C., Kuester, S., & Gillespie, C. (2000). Beverage choices affect adequacy of children’s nutrient intakes. Archives of Pediatric and Adolescent Medicine, 154, 1148 – 1152. Baranowski, T. (1997). Families and health actors: Personal and social determinants. In D. S., Gochmen, (Eds.), Handbook of health behavior research (pp. 179 - 206). New York: Kluwer. Berkey, C. S., Rockett, H. R., Field, A. E., Gillman, M. W., & Colditz, G. A. (2004). Sugar-added beverages and adolescent weight change. Obesity Research, 12, 778 – 788. Bermudez, O. I. (2005). Consumption of sweet drinks among American adults from the NHANES 1999 –2000. [Abstract] FASEB Journal, 19, A1464. Borrud, L., Enns, C. W., & Mickle, S. (1997). What we eat in America: USDA surveys food consumption changes. Food Review, 19, 4 – 5. Bray, G. A., Nielson, S. J., & Popkin, B. M. (2004). Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. American Journal of Clinical Nutrition, 79, 537 – 543. Conway, J. M., Ingwersen, L. A., Vinyard, B. T., & Moshfegh, A. J. (2003). Effectiveness of the U.S. Department of Agriculture 5-step multiple pass method in assessing food intake in obese and nonobese women. American Journal of Clinical Nutrition, 77, 1171 – 1178. Dennison, B. (1996). Fruit juice consumption by infants and children: A review. Journal of the American College of Nutrition, 15(Suppl. 5), 4S – 11S. Dennison, B. A., Rockwell, R. H., & Baker, S. L. (1997). Excess fruit juice consumption by pre-school-aged children is associated with short stature and obesity. Pediatrics, 99, 15 – 22. Drewnowski, A., & Specter, S. E. (2004). Poverty and obesity: The role of energy density and energy costs. American Journal of Clinical Nutrition, 79, 6 – 16. Fisher, J. O., Mitchell, D. C., Smiciklas-Wright, H., & Birch, L. L. (2001). Maternal milk consumption predicts the tradeoff between milk and soft drinks in young girls’ diets. Journal of Nutrition, 131, 246 – 250. Foote, J., Murphy, S., Wilkens, L., Basiotis, P., & Carlson, A. (2004). Dietary variety increases the probability of nutrient adequacy among adults. Journal of Nutrition, 134, 1779 – 1785. French, S. A., Lin, B. H., & Guthrie, J. F. (2003). National trends in soft drink consumption among children and adolescents aged 17 years: Prevalence, amounts and sources, 1978 to 1994 – 98. Journal of the American Dietetic Association, 103, 1326 – 1331. Harnack, L., Stang, J., & Story, M. (1999). Soft drink consumption among US children and adolescents: Nutritional consequences. Journal of the American Dietetic Association, 99, 436 – 441. Hoaglin, D. C., Mosteller, F., & Tukey, J. W. (1983). Understanding robust and exploratory data. New York: Wiley. Hunty, A., Lader, D., & Clarke, P. (2000). What British children are eating and drinking at age 12–18 months. Journal of Human Nutrition and Dietetics, 13, 83 – 86. Institute of Medicine, National Research Council, Food and Nutrition Board. (2002). Dietary carbohydrates, sugars and starches. (Chap. 6). Dietary reference intakes for energy and

carbohydrates, fat, protein and amino acids (macronutrients) (pp. 6-1 - 6-57). Washington, DC: National Academy Press. Available: http://www.iom.edu/report.asp.id=4340 (Retrieved June 13, 2005). James, J., Thomas, P., Cavan, D., & Kerr, D. (2004). Preventing childhood obesity by reducing consumption of carbonated drinks: Cluster randomized clinical trial. British Medical Journal, 1136, 1 – 5. Johnson, R. K., & Frary, C. (2001). Choose beverages and foods to moderate your intake of sugars: The 2000 dietary guidelines for Americans—What’s all the fuss about? Journal of Nutrition, 131(Suppl. 10), 2755S – 2771S. Kant, A. K. (1996). Indexes of overall diet quality: A review. Journal of the American Dietetic Association, 96, 785 – 791. Koivisto Hursti, U. K. (1999). Factors influencing children’s food choice. Annals of Medicine, 31(Suppl. 1), 26 – 32. Lee, S. Y., Hoerr, S. L., & Schiffman, R. F. (2005). Screening for infants’ & toddlers’ diet quality through maternal diet. MCN The American Journal of Maternal Child Nursing, 30, 60 – 66. Ludwig, D. S., Peterson, K. E., & Gortmaker, S. L. (2001). Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet, 357, 505 – 508. Marshall, T. A., Levy, S. M., Broffitt, B., EichenbergerGilmore, J. M, & Strumbo, P. J. (2003). Patterns of beverage consumption during transition stage of infant nutrition. Journal of the American Dietetic Association, 103, 1350 – 1353. Morton, J. F., & Guthrie, J. F. (1998). Changes in children’s total fat intakes and their food group sources of fat, 1989–91 versus 1995–96: Implications for diet quality. Economics and Nutrition Review, 11, 44 – 57. Mrdjenovic, G., & Levitsky, D. (2003). Nutritional and energetic consequences of sweetened drink consumption in 6-to-13 year-old children. Journal of Pediatrics, 142, 604 – 610. North, K., Emmet S., & the ALSPAC Study Team. (2000). Types of drinks consumed by infants at 4 and 8 months of age: Socio-demographic variations. Journal of Human Nutrition and Dietetics, 13, 71 – 82. Park, Y. K., Meier, E. R., Bianchi, P., & Song, W. O. (2002). Trends in children’s consumption of beverages. Family Economics and Nutrition Review, 14, 69 – 79. Rampersaud, G. C., Bailey, L. B., & Kauwell, G. P. (2003). National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages. Journal of the American Dietetic Association, 103, 97 – 100. Raikes, H., & Love, J. (2002). Early Head Start: A dynamic new program for infants and toddlers and their families. Infant Mental Health Journal, 23, 1 – 3. Schuette, L. K., Song, W. O., & Hoerr, S. L. (1996). Quantitative use of the food guide pyramid to evaluate dietary intake of college students. Journal of the American Dietetic Association, 96, 453 – 457. Skinner, J. D., Bounds, W., Carruth, B. R., & Ziegler, P. (2003). Longitudinal calcium intake is negatively related to children’s body fat intakes. Journal of the American Dietetic Association, 103, 1626 – 1637. Skinner, J. D., & Carruth, B. (2001). A longitudinal study of children’s juice intake and growth: The juice

BEVERAGE CONSUMPTION OF MOTHER–TODDLER DYADS

controversy revisited. Journal of the American Dietetic Association, 11, 432 – 437. Skinner, J. D., Ziegler, R., & Ponza, M. (2004). Transitions in infants’ and toddlers beverage patterns. Journal of the American Dietetic Association, 104(Suppl.1), S45 – S50. Statistical Package for the Social Sciences, Inc. (2004). SPSS version 12.01 for Windows. Chicago, IL: SPSS, Inc. Storey, M. L., Forshee, R. A., & Anderson, P. A. (2004). Associations of adequate intake of calcium with diet, beverage consumption, and demographic characteristics among children

411

and adolescents. Journal of the American College of Nutrition, 23, 18 – 33. Subar, A. E., Krebbs-Smith, S. M., Cook, A., & Kahle, L. L. (1998). Dietary sources of nutrients among U.S. children, 1989– 1991. Pediatrics, 102, 913 – 923. U. S. Department of Agriculture. (1996). Dietary guidelines for Americans. Available:http://www.usda.gov/cnpp/pyrabklt.pdf, (Retrieved November 9, 2004). Zemel, M. B. (2004). Role of calcium and dairy products in energy partitioning and weight management. American Journal of Clinical Nutrition, 79(Suppl. 5), S907 – S912.