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Soft drinks and obesity
age for persistent recurrent diarrhea. The typical facial and hair abnormalities were strongly suggestive of ‘‘syndromic diarrhea.’’ Intestinal biopsy and immunologic assessment were compatible with the diagnosis. She is now 17 years old and has growth delay (ÿ5 standard deviations for height and ÿ3 for weight) but normal pubertal development. A slight psychic impairment is also evident. She still has intermittent diarrhea and frequent upper respiratory tract infections. Despite an abnormal intestinal permeability and an elevation of serum immunoglobulin A (980 mg/dL), malabsorption is not clinically evident and intestinal histology is improved. The course of the presented cases adds clinical information about the long-term outcome of this rare syndrome. Intestinal failure can be reversible for a time-dependent spontaneous maturation of the intestinal mucosa, allowing discontinuation of PN. Further clinical observations are needed to confirm the prognosis of the disease that seems less severe than would have been expected. Arrigo V. Barabino, MD E-mail: [email protected] F. Torrenti, MD E. Castellano, MD D. Erba, MD A. Calvi, MD P. Gandullia, MD Pediatric Gastroenterology G. Gaslini Institute Genoa 16148 Italy YMPD735 10.1016/j.jpeds.2004.01.026
REFERENCES 1. Stankler L Lloyd D Pollitt RJ Gray ES, Thom H Russell G. Unexplained diarrhoea and failure to thrive in 2 siblings with unusual facies and abnormal scalp hair shafts: a new syndrome. Arch Dis Child 1982;57: 212-6. 2. Girault D Goulet O Le Deist F Brousse N Colomb V Cesarini JP et al. Intractable infant diarrhea associated with phenotypic abnormalities and immunodeficiency. J Pediatr 1994;125:36-42.
Soft drinks and obesity To the Editor: I read with great interest the report by Mrdjenovic and Levitsky, which was misleading.1 The author’s statement that sweetened drink consumption is a risk factor for childhood obesity is unfounded and has not been proven with any conclusive scientific or epidemiologic evidence. In fact, a number of recent studies have concluded that sweetened beverage consumption does not contribute to weight gain or displace milk consumption.2-4 Mrdjenovic and Levitsky describe an incomplete study design and lack consistency in their methods and reporting. First, the summer camp study setting and lack of beverage choice by the children is troubling. The authors report that milk was consumed at 96% of all meals when served 554 Letters
and ‘‘reduction in milk intake was the result of not serving milk.’’ This suggests milk was highly desirable to children and the study design may have been inappropriate to answer the question of whether sweetened beverages displace milk consumption. Second, dietary assessment is a complex issue; the small number of participants with dietary data included in the analyses is troubling. Further, Marshall et al recently reported that parents have difficulty estimating beverage intakes for their children.5 Third, reporting milk consumption in grams and sweetened drinks in ounces is misleading. Once converted, 42 to 52 grams of displaced milk equals only 1.5 to 1.8 ounces. Given the limited study sample and diet recall methods, I wonder if this is significant. Next, concluding that children at the highest quintile of sweetened beverage consumption gained the most weight is an interesting finding; at baseline an inverse relationship was reported. Last, to report weight gain without presenting data regarding changes in height or body mass index is misleading and incomplete. The impact of beverage consumption on total energy intake and obesity in children and adolescents is at best complex and deserving of further study. Conclusions from this study should be viewed with skepticism and in no way applied to the entire pediatric population. Lisa A. Sutherland, PhD Department of Nutrition University of North Carolina at Chapel Hill Chapel Hill, NC 27599 YMPD738 10.1016/j.jpeds.2004.01.029
REFERENCES 1. Mrdjenovic G, Levitsky DA. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J Pediatr 2003;142:604-10. 2. Weaver AR, Storey ML, Forshee RA, Woo RY, Clark KL. Beverage consumption among elementary and high school children. Abstract presented at the Federation of the American Society for Experimental Biology Annual Meeting, April 2000. 3. Forshee RA, Storey ML. Total beverage consumption and beverage choices among children and adolescents. Intl J Food Science Nutr 2003; 54:297-307. 4. Park YK, Meier ER, Bianchi P, Song WO. Trends in children’s consumption of beverages: 1987 to 1998. Fam Econ Nutr Rev 2003;14:69-79. 5. Marshall TA, Eichenberger-Gilmore JM, Broffitt B, Levy SM, Stumbo PJ. Relative validation of a beverage frequency questionnaire in children 6 months through 5 years using 3-day food and beverage diaries. J Am Diet Assoc 2003;103:714-20.
Soft drinks and obesity To the Editor: There is no question that obesity presents a major challenge to physicians and their patients. Youth and their parents are overwhelmed by the amount of nutritional information available and confused by the many contradictory messages published by the scientific community, the media, and advertisers. Mrdjenovic and Levitsky’s study1 and Robert Schwartz’s editorial2 address this serious health problem in a limited way by evaluating only one factor, the use of The Journal of Pediatrics
April 2004
sweetened drinks, for a multifactorial problem. In addition, their methodology is complicated and confusing: there was no control group, they enrolled only 30 children and of these, only 21 were weighed and only 20 had food records completed by their parents at the end of the study. What is most disconcerting about this article and the accompanying editorial is that they did not take into consideration the reality that the majority of consumers eat what pleases them or is most convenient. Although they may claim to read food labels, consumers usually cannot process this information into healthy food choices. However, there is no public debate or scientific controversy about the need for greater physical activity among Americans of all ages. Schwartz understates, and the original study does not even address, this serious public health problem. Lack of physical activity, not excessive caloric intake, needs to be evaluated and addressed far more extensively as a cause of adolescent obesity. Mrdjenovic and Levitsky’s conclusion1 that sweetened drinks have displaced milk is directly contradicted by a study by Park et al.3 They evaluated 9288 youth, ages 1 to 19 years, during three 2-year periods of 1987 to 1988, 1992 to 1993, and 1997 to 1998. This study showed no significant decline in the prevalence of milk consumption over the decade long survey period for all age groups. Specifically, they found that milk consumption increased significantly for the 1 to 5 year age group, from 11.6 oz /day to 13.5 oz/day, (P<.05) and remained stable for children in the five other age groups. It seems to me that there is little gained from studies that focus on one specific beverage or food group as the cause of obesity, because children and their parents are going to continue to consume these as long as they are available. Undoubtedly, the consumption of excessive quantities of the vast number of high-sugar and high-fat foods sold is contributing to the rise in overweight and obesity in this country. The big question is how to educate the public that this trend has serious lifelong consequences for both the physical and emotional health of these youth. Ideally in the near future, the food, beverage, fast-food restaurant chains, and sports products industries will use their considerable advertising influence to promote greater awareness among the public about the importance of preventing and reducing obesity through better nutritional choices, reduced portion sizes and increased physical activity. These efforts will benefit the participating companies by increasing their public image and goodwill. In addition, significantly increased emphasis needs to be placed upon creating an inspiring, and thus hopefully trend-setting, public awareness national campaign about the long-term health benefits gained by preventing the loss of aerobic fitness and muscle strength, similar to the campaigns to reduce cigarette use and to prevent substance abuse and drunk driving. Joanne H. Allport, MD, MPH CEO, Growing Up Well, LLC Novato, CA 94945-3501 YMPD749 10.1016/j.jpeds.2004.01.040
Letters
REFERENCES 1. Mrdjenovic G, Levitsky D. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J Pediatr 2003; 142:604-10. 2. Schwartz R. Soft drinks taste good, but the calories count. J Pediatr 2003;142:599-601. 3. Park YK, Meier ER, Bianchi P, Song W. Trends in children’s consumption of beverages: 1987 to 1998. Fam Econ Nutr Rev 2002;14: 69-77.
Soft drinks and obesity To the Editor: As concern over childhood overweight has grown, some have suggested that ‘‘sweetened drinks’’ may contribute significantly to the problem.1,2 Others have suggested that removing soft drink vending machines from middle schools and high schools might significantly affect overweight among students by discouraging carbonated soft drink (CSD) consumption.3 I agree that childhood overweight is a serious problem that must be addressed rationally and scientifically. The National Family Opinion (NFO) WorldGroup Share of Intake Panel (SIP) study is a mail sample of 12,000 persons per year. Participants keep two-week diaries of all beverages consumed, excluding tap water, and the location where these were consumed. In a survey conducted during the 2001-2002 school year, consumption of CSDs purchased from secondary school vending machines were estimated for a demographically balanced sample of 2716 students ages 12 to 18 years. Two-week consumption diaries were kept by students for the school year (September 2001 through May 2002). Seasonal shifts in beverage consumption were reflected by the data and are similar to NFO data from previous surveys.4 The study found that average per capita consumption of regular CSDs purchased from school vending machines was 2.5 ounces per week. Among students who drank beverages from vending machines, 20% of all students, the intake averaged only 12.5 ounces per week, about one 12-ounce can of soda. Eliminating all vending machines appears to be an overly broad policy response that will have a very limited impact, if any, on childhood overweight. The amount of CSDs consumed per week from vending machines does not appear to be excessive and can be easily balanced by even modest levels of physical activity. Re-establishing active, daily physical education classes would realistically expend the 140 calories of energy provided by 12 ounces of soda that may have been purchased from a school vending machine. Michael E. Ginevan, PhD BBL Sciences Reston, VA 20190 YMPD739 10.1016/j.jpeds.2004.01.030
Analysis of data cited in this letter was supported by the National Soft Drink Association. 555
REFERENCES 1. Stankler L Lloyd D Pollitt RJ Gray ES, Thom H Russell G. Unexplained diarrhoea and failure to thrive in 2 siblings with unusual facies and abnormal scalp hair shafts: a new syndrome. Arch Dis Child 1982;57: 212-6. 2. Girault D Goulet O Le Deist F Brousse N Colomb V Cesarini JP et al. Intractable infant diarrhea associated with phenotypic abnormalities and immunodeficiency. J Pediatr 1994;125:36-42.
Soft drinks and obesity To the Editor: I read with great interest the report by Mrdjenovic and Levitsky, which was misleading.1 The author’s statement that sweetened drink consumption is a risk factor for childhood obesity is unfounded and has not been proven with any conclusive scientific or epidemiologic evidence. In fact, a number of recent studies have concluded that sweetened beverage consumption does not contribute to weight gain or displace milk consumption.2-4 Mrdjenovic and Levitsky describe an incomplete study design and lack consistency in their methods and reporting. First, the summer camp study setting and lack of beverage choice by the children is troubling. The authors report that milk was consumed at 96% of all meals when served 554 Letters
and ‘‘reduction in milk intake was the result of not serving milk.’’ This suggests milk was highly desirable to children and the study design may have been inappropriate to answer the question of whether sweetened beverages displace milk consumption. Second, dietary assessment is a complex issue; the small number of participants with dietary data included in the analyses is troubling. Further, Marshall et al recently reported that parents have difficulty estimating beverage intakes for their children.5 Third, reporting milk consumption in grams and sweetened drinks in ounces is misleading. Once converted, 42 to 52 grams of displaced milk equals only 1.5 to 1.8 ounces. Given the limited study sample and diet recall methods, I wonder if this is significant. Next, concluding that children at the highest quintile of sweetened beverage consumption gained the most weight is an interesting finding; at baseline an inverse relationship was reported. Last, to report weight gain without presenting data regarding changes in height or body mass index is misleading and incomplete. The impact of beverage consumption on total energy intake and obesity in children and adolescents is at best complex and deserving of further study. Conclusions from this study should be viewed with skepticism and in no way applied to the entire pediatric population. Lisa A. Sutherland, PhD Department of Nutrition University of North Carolina at Chapel Hill Chapel Hill, NC 27599 YMPD738 10.1016/j.jpeds.2004.01.029
REFERENCES 1. Mrdjenovic G, Levitsky DA. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J Pediatr 2003;142:604-10. 2. Weaver AR, Storey ML, Forshee RA, Woo RY, Clark KL. Beverage consumption among elementary and high school children. Abstract presented at the Federation of the American Society for Experimental Biology Annual Meeting, April 2000. 3. Forshee RA, Storey ML. Total beverage consumption and beverage choices among children and adolescents. Intl J Food Science Nutr 2003; 54:297-307. 4. Park YK, Meier ER, Bianchi P, Song WO. Trends in children’s consumption of beverages: 1987 to 1998. Fam Econ Nutr Rev 2003;14:69-79. 5. Marshall TA, Eichenberger-Gilmore JM, Broffitt B, Levy SM, Stumbo PJ. Relative validation of a beverage frequency questionnaire in children 6 months through 5 years using 3-day food and beverage diaries. J Am Diet Assoc 2003;103:714-20.
Soft drinks and obesity To the Editor: There is no question that obesity presents a major challenge to physicians and their patients. Youth and their parents are overwhelmed by the amount of nutritional information available and confused by the many contradictory messages published by the scientific community, the media, and advertisers. Mrdjenovic and Levitsky’s study1 and Robert Schwartz’s editorial2 address this serious health problem in a limited way by evaluating only one factor, the use of The Journal of Pediatrics
April 2004
sweetened drinks, for a multifactorial problem. In addition, their methodology is complicated and confusing: there was no control group, they enrolled only 30 children and of these, only 21 were weighed and only 20 had food records completed by their parents at the end of the study. What is most disconcerting about this article and the accompanying editorial is that they did not take into consideration the reality that the majority of consumers eat what pleases them or is most convenient. Although they may claim to read food labels, consumers usually cannot process this information into healthy food choices. However, there is no public debate or scientific controversy about the need for greater physical activity among Americans of all ages. Schwartz understates, and the original study does not even address, this serious public health problem. Lack of physical activity, not excessive caloric intake, needs to be evaluated and addressed far more extensively as a cause of adolescent obesity. Mrdjenovic and Levitsky’s conclusion1 that sweetened drinks have displaced milk is directly contradicted by a study by Park et al.3 They evaluated 9288 youth, ages 1 to 19 years, during three 2-year periods of 1987 to 1988, 1992 to 1993, and 1997 to 1998. This study showed no significant decline in the prevalence of milk consumption over the decade long survey period for all age groups. Specifically, they found that milk consumption increased significantly for the 1 to 5 year age group, from 11.6 oz /day to 13.5 oz/day, (P<.05) and remained stable for children in the five other age groups. It seems to me that there is little gained from studies that focus on one specific beverage or food group as the cause of obesity, because children and their parents are going to continue to consume these as long as they are available. Undoubtedly, the consumption of excessive quantities of the vast number of high-sugar and high-fat foods sold is contributing to the rise in overweight and obesity in this country. The big question is how to educate the public that this trend has serious lifelong consequences for both the physical and emotional health of these youth. Ideally in the near future, the food, beverage, fast-food restaurant chains, and sports products industries will use their considerable advertising influence to promote greater awareness among the public about the importance of preventing and reducing obesity through better nutritional choices, reduced portion sizes and increased physical activity. These efforts will benefit the participating companies by increasing their public image and goodwill. In addition, significantly increased emphasis needs to be placed upon creating an inspiring, and thus hopefully trend-setting, public awareness national campaign about the long-term health benefits gained by preventing the loss of aerobic fitness and muscle strength, similar to the campaigns to reduce cigarette use and to prevent substance abuse and drunk driving. Joanne H. Allport, MD, MPH CEO, Growing Up Well, LLC Novato, CA 94945-3501 YMPD749 10.1016/j.jpeds.2004.01.040
Letters
REFERENCES 1. Mrdjenovic G, Levitsky D. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J Pediatr 2003; 142:604-10. 2. Schwartz R. Soft drinks taste good, but the calories count. J Pediatr 2003;142:599-601. 3. Park YK, Meier ER, Bianchi P, Song W. Trends in children’s consumption of beverages: 1987 to 1998. Fam Econ Nutr Rev 2002;14: 69-77.
Soft drinks and obesity To the Editor: As concern over childhood overweight has grown, some have suggested that ‘‘sweetened drinks’’ may contribute significantly to the problem.1,2 Others have suggested that removing soft drink vending machines from middle schools and high schools might significantly affect overweight among students by discouraging carbonated soft drink (CSD) consumption.3 I agree that childhood overweight is a serious problem that must be addressed rationally and scientifically. The National Family Opinion (NFO) WorldGroup Share of Intake Panel (SIP) study is a mail sample of 12,000 persons per year. Participants keep two-week diaries of all beverages consumed, excluding tap water, and the location where these were consumed. In a survey conducted during the 2001-2002 school year, consumption of CSDs purchased from secondary school vending machines were estimated for a demographically balanced sample of 2716 students ages 12 to 18 years. Two-week consumption diaries were kept by students for the school year (September 2001 through May 2002). Seasonal shifts in beverage consumption were reflected by the data and are similar to NFO data from previous surveys.4 The study found that average per capita consumption of regular CSDs purchased from school vending machines was 2.5 ounces per week. Among students who drank beverages from vending machines, 20% of all students, the intake averaged only 12.5 ounces per week, about one 12-ounce can of soda. Eliminating all vending machines appears to be an overly broad policy response that will have a very limited impact, if any, on childhood overweight. The amount of CSDs consumed per week from vending machines does not appear to be excessive and can be easily balanced by even modest levels of physical activity. Re-establishing active, daily physical education classes would realistically expend the 140 calories of energy provided by 12 ounces of soda that may have been purchased from a school vending machine. Michael E. Ginevan, PhD BBL Sciences Reston, VA 20190 YMPD739 10.1016/j.jpeds.2004.01.030
Analysis of data cited in this letter was supported by the National Soft Drink Association. 555