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Aug 10, 2011 - 1International Prevention Research Institute (iPRI), Ecully (Lyon), France; ... daily versus non-daily sugar-sweetened and artificially sweetened ...
European Journal of Clinical Nutrition (2012) 66, 150–155

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ORIGINAL ARTICLE

Demographic, socioeconomic and nutritional determinants of daily versus non-daily sugar-sweetened and artificially sweetened beverage consumption P Mullie1,2,3,4, D Aerenhouts4 and P Clarys4 1 International Prevention Research Institute (iPRI), Ecully (Lyon), France; 2Unit of Epidemiology and Biostatistics, Queen Astrid Military Hospital, Brussels, Belgium; 3Erasmus University College, Brussels, Belgium and 4Faculty of Physical Education and Physiotherapy, Department of Human Biometrics and Biomechanics, Vrije Universiteit Brussel, Brussels, Belgium

Objective: The aim of this study was to determine the impact of demographic, socioeconomic and nutritional determinants on daily versus non-daily sugar-sweetened and artificially sweetened beverage consumption. Methods: Cross-sectional design in 1852 military men. Using mailed questionnaires, sugar-sweetened and artificially sweetened beverage consumption was recorded. Principal component analysis was used for dietary pattern analysis. Results: Sugar-sweetened and artificially sweetened beverages were consumed daily by 36.3% and 33.2% of the participants, respectively. Age, body mass index (BMI), non-smoking and income were negatively related to sugar-sweetened beverage consumption. High BMI and trying to lose weight were related to artificially sweetened beverages consumption. Three major patterns were obtained from principal component analysis: first, the ‘meat pattern’, was loaded for red meats and processed meats; second, the ‘healthy pattern’, was loaded for tomatoes, fruit, whole grain, vegetables, fruit, fish, tea and nuts; finally, the ‘sweet pattern’ was loaded for sweets, desserts, snacks, high-energy drinks, high-fat dairy products and refined grains. The sugar-sweetened beverage consumption was strongly related with both the meat and sweet dietary patterns and inversely related to the healthy dietary pattern. The artificially sweetened beverage consumption was strongly related with the sweet and healthy dietary pattern. Conclusions: Daily consumption of sugar-sweetened beverages was inversely associated with a healthy dietary pattern. Daily consumption of artificially sweetened beverages was clearly associated with weight-loss intention.

European Journal of Clinical Nutrition (2012) 66, 150–155; doi:10.1038/ejcn.2011.138; published online 10 August 2011 Keywords: nutritional sciences; sugar-sweetened beverages; artificially sweetened beverages; nutritional assessment; public health

Introduction In Belgium, more than 50% of adults have a body mass index (BMI) of 25.0 kg/m2 or more, which emphasizes the public

Correspondence: Dr P Mullie, International Prevention Research Institute (iPRI), Espace Europe´en, Baˆtiment G, Chemin du Saquin, Ecully (Lyon) 69130, France. E-mail: [email protected] Contributors: PM conceived the original idea together with PC and DA, performed the study, analysed the data and wrote the first draft. All authors contributed to the final draft. Received 22 February 2011; revised 6 June 2011; accepted 22 June 2011; published online 10 August 2011

health problem of being overweight or obese (Devriese et al., 2004). Sugar-sweetened beverage consumption has been associated with the worldwide obesity epidemic (Malik et al., 2006). In their review, Malik et al. (2006) found clear epidemiological and experimental evidence that higher sugar-sweetened beverage consumption is associated with weight gain and obesity. The authors concluded that sufficient evidence exists for implementing public health strategies to discourage sugar-sweetened beverage consumption. In response to this epidemic, beverage industry created artificially sweetened beverages. Surprisingly, little is known about consumer’s profiles and determinants of sugarsweetened and artificially sweetened beverage consumption.

Sugar-sweetened and artificially sweetened beverages and dietary pattern analysis P Mullie et al

151 Moreover, and to our knowledge, limited data have been published relating sugar-sweetened and artificially sweetened beverage consumption to dietary patterns. The aim of this study was to describe the demographic, socio-economic and nutritional determinants of daily sugarsweetened and artificially sweetened beverage consumption. Knowledge of determinants can be useful in providing tailored, population-based health advice. This study was set up in a Belgian population, which implicates two groups with demographic very distinctive backgrounds (that is, French-speaking in the south of the country and Flemish speaking in the north), living in comparable commercial environments. It is to be expected that both cultures are exposed to the same intensity of marketing for sugarsweetened and artificially sweetened beverages. A demographic diversity in dietary patterns in Belgium has already been demonstrated in comprehensive epidemiological research (Devriese et al., 2004; Mullie et al., 2009b). Principal components analysis was carried out to study the association between sugar-sweetened and artificially sweetened beverages and specific dietary patterns.

Subjects and methods In February 2007, air and terrestrial components of the Belgian army totaled 33 053 men. A group of 5000 men was randomly selected after stratification for military rank and age, representative for the total army structure. The selection consisted of 598 officers; 2103 non-commissioned officers and 2299 soldiers. A semiquantitative food-frequency questionnaire with 150 food items was sent to the subjects using the following categories of consumption frequency: never, one to three times a month, once a week, two to four times a week, five to six times a week, once a day, two to three times a day, four to six times a day and more than six times a day. Portion sizes were predefined using familiar measuring devices (teaspoon, serving, cup, and so on). The validity of the questionnaire was tested on a sample of 100 men representative for our participants (Mullie et al., 2009b). Sugar-sweetened beverage consumption was defined as consumption of beverages with added sugar, such as soft drinks. Artificially sweetened beverage consumption was defined as consumption of beverages with added artificial sweeteners. For the first category, consumption of CocaCola, Pepsi, Fanta, Sprite and Icetea was recorded and for the second category, the consumption of Coca-Cola light, Pepsi max, Fanta light, Sprite light and Icetea light was recorded. Consumption was dichotomized for the binary logistic models in more than a serving daily versus less than a serving daily, based on frequency of consumption, consumed amount and usual household units. A serving was defined to deliver a volume of 150 ml sugar-sweetened or artificially sweetened beverages. A second more general questionnaire was used to register health-related and lifestyle characteristics such as smoking,

marital status, main occupation, age, weight, height, number of children and knowledge of cardiovascular risk factors (Autier et al., 2003). Yearly gross salary was obtained from administrative services, taking into account the rank and years of active duty. Physical activity was assessed with the validated International Physical Activity Questionnaire (Craig et al., 2003). For descriptive statistics, number and percentages were calculated for the specific individual characteristics: agecategory (20–29 years, 30–39 years, 40–49 years and 50–59 years); BMI classified according to the World Health Organization in normal weight, 18.5p BMI o 25.0 kg/m2, overweight, 25.0p BMI o 30.0 kg/m2 and obesity, BMI X30.0 kg/m2 (Magnusson, 2007); physical activity (stratified in low, moderate and high according to the International Physical Activity Questionnaire) (Craig et al., 2003); use of vitamin supplements (yes or no); actual smoking (yes or no); marital status (married versus single, divorced or widower); demographic background (French and Flemish speaking); educational level (low for vocational education, moderate for secondary level and high for bachelor or master level); income (low for lowest tertile of yearly gross income of the group, moderate for intermediate tertile of income and high for highest tertile of yearly income); and weight-loss intention (not trying to lose weight versus trying to lose weight). For sugar-sweetened and for artificially sweetened beverages consumption, odds ratios (OR) were calculated using logistic regression. The variables in the adjusted model were entered simultaneously to account for the effects of all covariates. Daily consumption (1) or non-daily consumption (0) of sugar-sweetened and artificially sweetened beverages was examined, taking into account the following predictors: age, BMI, physical activity, use of vitamin supplements, smoking, marital status, demographic background, educational level, income level and weight-loss intention. To identify dietary patterns, principal components analysis was applied to the data of the semiquantitative foodfrequency questionnaire. First, the 150 food items were classified into 34 predefined food groups with similar nutrient profiles, according to Hu et al. (2000). Principal components analysis was used to derive dietary patterns based on the 34 food groups. Varimax transformation was effectuated to achieve uncorrelated factors with a greater interpretability. Components with eigenvalues above 1.5, interpretability of the factors and Scree plot were used to determine the number of selected factors. The eigenvalues of the factors dropped after the second factor (from 2.44–1.77) and after the third factor (from 1.77–1.44). The remaining factors were more similar after the fourth factor (ranging from 1.38 for the fifth factor to 1.10 for the tenth factor). Three major dietary patterns were clearly identified for further analysis. The factor scores for each pattern were constructed by adding up the observed intakes of the component food items, weighted by the individual factor loadings. Those factor scores rank individuals according to European Journal of Clinical Nutrition

Sugar-sweetened and artificially sweetened beverages and dietary pattern analysis P Mullie et al

152 their agreement with each dietary pattern. Logistic regressions with consumption of sugar-sweetened and artificially sweetened beverages as dichotomic-dependent variables and dietary patterns as predictor variables were constructed. The variables in the model were entered simultaneously to account for the effects of all covariates. Daily consumption (1) or non-daily consumption (0) of sugar-sweetened and artificially sweetened beverages was examined, taking into account the three dietary patterns. SPSS 18.0 (SPSS Inc., Chicago, IL, USA) statistics software was used. A two-sided significance level of 0.05 was defined. The Bioethical Committee of the University of Leuven approved the complete research protocol. An informed consent was signed by all participants.

Results Table 1 presents the demographic and lifestyle characteristics of the subjects. The participation rate was 37.0%: of the 5000 potential participants, 1852 filled out the questionnaires and 3142 refused to participate. Men who refused to participate were contacted. The main reason for not participating was the time-consuming questionnaires. There was an overrepresentation of non-commissioned officers (50% versus 42% selected) and an underrepresentation of soldiers (38% versus 46% selected). The overrepresentation of noncommissioned officers was largely due to the age-category 40–49 years, and the underrepresentation of soldiers was due to the age-categories 20–29 and 30–39 years.

Table 1 Characteristics of the study participants Characteristics

Categorisation

Total Age (in years)

Body mass index (in kg/m2)a

Physical activityb

Regular use of vitamin supplementation Actual smoking Marital status

Demographic background Educational level

c

Incomed Weight-loss intentione Meals in a military restaurant

Sugar-sweetened beverage consumption Artificially sweetened beverage consumption a

20–29 30–39 40–49 50–59 Normal (o25.0) Overweight (X25.0 to o30.0) Obese (X30.0) Missing Low Moderate High Missing No Yes No Yes Single Divorced, widower Married Missing French Flemish Low Moderate High Low Moderate High Not trying to lose weight Trying to lose weight Four to five times a week Once to thrice a week Never A serving daily Less than a serving daily A serving daily Less than a serving daily

Responders

Non-responders

n

%

n

%

1852 119 358 1064 311 744 836 244 28 365 383 1016 88 1569 283 1405 447 207 209 1425 11 804 1048 789 811 252 618 616 618 1217 635 345 360 1148 673 1179 614 1238

100.0 6.4 19.3 57.5 16.8 40.2 45.1 13.2 1.5 19.7 20.7 54.9 4.8 84.7 15.3 75.9 24.1 11.2 11.3 76.9 0.6 43.4 56.6 42.6 43.8 13.6 33.4 33.3 33.4 65.7 34.3 18.6 19.4 62.0 36.3 63.7 33.2 66.8

3148 461 753 1439 495

100.0 14.6 23.9 45.7 15.7

1484 1664

47.1 52.9

Body mass index was classified according to the World Health Organization (Magnusson, 2007). Physical activity was stratified in low, moderate and high according to the International Physical Activity Questionnaire (Craig et al., 2003). c Educational level is low for vocational education, moderate for secondary level and high for bachelor or master level. d Income is low for lowest tertile of yearly income, moderate for intermediate tertile of income and high for highest tertile of yearly income. e Weight-loss intention was stratified in not trying to lose weight and trying to lose weight. b

European Journal of Clinical Nutrition

Sugar-sweetened and artificially sweetened beverages and dietary pattern analysis P Mullie et al

153 Table 2 Logistic regressions with consumption of sugar-sweetened and artificially sweetened beverages as dichotomic-dependent variables, and demographic and lifestyle characteristics as predictors (adjusted odds ratiosa)

Age (years) Body mass index (kg/m2) Physical activity (low, moderate, high) Regular use of vitamin supplementation (no as reference versus yes) Smoking (no as reference versus yes) Marital status (single or divorced as reference versus married) Demographic background (French as reference versus Flemish) Education categories (low as reference, moderate, high) Income-categories (low as reference, moderate, high) Weight-loss intention (not trying to lose versus trying to lose)

Sugar-sweetened beverages

Artificially sweetened beverages

Daily versus non-daily consumption

Daily versus non-daily consumption

Odds ratio

95% Confidence interval

Odds ratio

95% Confidence interval

0.97* 0.93* 0.93 0.81 1.58* 0.90 1.23* 0.88 0.81* 0.80

0.96–0.99 0.90–0.97 0.82–1.06 0.61–1.08 1.25–2.01 0.70–1.15 1.00–1.53 0.74–1.04 0.70–0.95 0.62–1.03

0.97* 1.08* 1.04 1.13 0.80 0.87 1.41* 0.80 0.91 1.55*

0.96–0.99 1.04–1.12 0.91–1.19 0.85–1.51 0.62–1.04 0.68–1.11 1.13–1.74 0.74–1.04 0.78–1.06 1.22–1.98

*Odds ratios within a column were statistically significant from 1.00 (Po0.05); for operationalization of variables, see subjects and methods section. a Odds ratios adjusted for age, body mass index, physical activity, supplement intake, smoking, marital status, demographic background, education, income and weight-loss intention.

About 58% had a BMI X25.0 kg/m2, 43% had French as first language and 57% was Flemish, while 42.6% had a low level of education. Responders to our mailing tended to be older than non-responders (74.3% were older than 40 years compared with 61.4% for the non-responders) and the responders had about the same distribution concerning demographic background as the non-responders. More than 60% of the participants never took a meal in a military restaurant. Daily consumption of sugar-sweetened and artificially sweetened beverages was 36.3% (n ¼ 673) and 33.2% (n ¼ 614), respectively (Table 1). Age, BMI, non-smoking and income were negatively related with sugar-sweetened beverage consumption (Table 2). The adjusted OR for smokers was 1.58 (95% CI: 1.25–2.01), which indicates a strong positive relation between sugar-sweetened beverage consumption and smoking. Physical activity, use of vitamin supplements, marital status, educational level and weight-loss intentions were not associated with sugar-sweetened beverage consumption. Sugar-sweetened beverage consumption was related to demographic background, with an OR of 1.23 (95% CI: 1.00–1.53) for Flemish-speaking subjects compared with French speaking. Age was negatively associated with artificially sweetened beverage consumption (Table 2). BMI, Flemish background and trying to lose weight were associated with artificially sweetened beverage consumption. The OR for trying to lose weight versus not trying to lose weight was 1.55 (95% CI: 1.22–1.98). Physical activity, use of vitamin supplements, smoking, marital status, educational level, and income were not related to artificially sweetened beverage consumption. Table 3 presents the factor-loading matrix for the three major factors identified by using food consumption data

Table 3 Factor-loading matrix for the major factors identified by using food consumption data from the food-frequency questionnairea Factor 1 (meat dietary pattern) Red meats Processed meats Beer Garlic Tomatoes Wine Eggs Poultry Liquor Organ meats Fruit Low-fat dairy products Whole grain Vegetables Cold breakfast cereals Fruit juice Fish Tea Nuts Sweets and desserts Snacks High-energy drinks High-fat dairy products Refined grains Mayonnaise Potatoes

0.60 0.58 0.47 0.43 0.43 0.40 0.38 0.37 0.37 0.33

0.35

Factor 2 (healthy dietary pattern)

Factor 3 (sweet dietary pattern) 0.30 0.46

0.41

0.58 0.47 0.43 0.39 0.38 0.37 0.36 0.32 0.30 0.53 0.45 0.42 0.40 0.36 0.30 0.30

a

Absolute values o0.30 were excluded from the table for simplicity. Foods or food groups with factor loadings o0.30 for three factors were excluded; see Table 2 for food groupings.

from the food-frequency questionnaire. The greater the factor loading for a specific food group, the bigger the impact of that food group to a specific factor. The first factor European Journal of Clinical Nutrition

Sugar-sweetened and artificially sweetened beverages and dietary pattern analysis P Mullie et al

154 Table 4 Logistic regressions with consumption of sugar-sweetened and artificially sweetened beverages as dichotomic-dependent variables and dietary patterns as predictor variables

Meat dietary pattern Healthy dietary pattern Sweet dietary pattern

Sugar-sweetened beverages

Artificially sweetened beverages

Daily versus non-daily consumption

Daily versus non-daily consumption

Odds ratio

95% Confidence interval

Odds ratio

95% Confidence interval

1.21* 0.54* 2.51*

1.07–1.36 0.48–0.61 2.21–2.86

1.01 1.25* 1.45*

0.90–1.12 1.30–1.61 1.30–1.62

*Odds ratios within a column were statistically significant from 1.00 (Po0.05); for operationalization of variables: the continuous dependent variable meat dietary pattern, healthy dietary pattern and sweet dietary pattern in factors scores.

was heavily loaded with red meats, processed meats, beer, garlic, tomatoes, wine, eggs, poultry, liquor, organ meats and vegetables. This factor explained 7.4% of the total variance and was labeled meat dietary pattern. The second factor, explaining 7.2% of the total variance, was more loaded for tomatoes, fruit, low-fat dairy products, whole grain, vegetables, cold breakfast cereals, fruit juice, fish, tea and nuts. This was labeled healthy dietary pattern. The last factor, explaining 6.2% of the total variance, was heavily loaded with red meats, processed meats, sweets, desserts, snacks, high-energy drinks, high-fat dairy products, refined grains, mayonnaise and potatoes. This was labeled sweet dietary pattern. The consumption of sugar-sweetened beverages was strongly related with the meat and sweet dietary pattern and inversely related to the healthy dietary pattern (Table 4). The probability of a healthy dietary pattern rich in plant foods was almost 50% lower for those with a daily sugar-sweetened beverage consumption (OR ¼ 0.54; 95% CI: 0.48–0.61). An increased consumption of artificially sweetened beverages was associated with a healthy and sweet dietary pattern.

Discussion The aim of this study was to identify determinants of regular sugar-sweetened and artificially sweetened beverage consumption. Age, BMI, income, and dietary patterns were strong indicators of consumption of both beverages. No association was found between physical activity, use of vitamin supplements, marital status, educational level and sugar-sweetened or artificially sweetened beverage consumption. Smoking was associated with high daily sugar-sweetened beverage consumption. This fact emphasized the clustering of unhealthy lifestyles associated with smoking. Earlier research in this population indicated that smoking was also associated with an unhealthy dietary pattern containing less fruits and vegetables (Mullie et al., 2009a, b). In a Chinese population, Ko et al. (2010) found also a positive association between smoking and consumption of sugar-sweetened beverages. BMI was not positively associated with high consumption of sugar-sweetened beverages; this is in European Journal of Clinical Nutrition

contrast with the review of Malik et al. (2006), which concluded that there was a positive association between soda consumption and obesity. A possible explanation for the inverse relationship present in this study is that being overweight or obese could make someone more receptive to negative energy-related messages concerning sugar-sweetened beverage consumption. This adaptation can make the relationship between sugar-sweetened consumption and BMI difficult to evaluate in a cross-sectional design. This view is supported by the fact that consumption of artificially sweetened beverages is distinctly greater in subjects with higher BMI and in subjects trying to lose weight. Bleich et al. (2009), using data from NHANES, found the same tendency: overweight or obese adults with weight-loss intentions were less likely to drink sugar-sweetened beverages. In New York City adults, Rehm et al. (2008) found a positive association between sugar-sweetened beverages and BMI for women only and not for men. This corroborates with the lack of association in our male population. Socioeconomic position, as measured by the income indicator, was related to daily sugar-sweetened beverage consumption: a lower income was associated with a higher consumption. Why a lower socioeconomic position is associated with higher consumption of sugar-sweetened beverage is not clear, but the low cost and aggressive marketing in low-income areas could be an explanation. In previous research, low socioeconomic position in this population has been associated with a clustering of unhealthy lifestyles, such as smoking, unhealthy dietary patterns and obesity (Mullie et al., 2010b). Drinking daily sugar-sweetened beverages can be seen as an unhealthy habit due to the high-energy content of the beverages and the low nutritional value. In this study, with a response of 37%, information was gathered about the non-responders. Our responders were older than non-responders; therefore, consumption of sugar-sweetened and artificially sweetened beverages might be underestimated, due to the age-dependent influence. This difference in participation can be explained by the fact that a lot of questions were related to cardiovascular diseases, hence younger people (usually soldiers) were less inclined to participate. A specific socioeconomic or health-related participation bias seems to be

Sugar-sweetened and artificially sweetened beverages and dietary pattern analysis P Mullie et al

155 modest, because (i) older soldiers between 40 and 60 years old participated normally to the study and (ii) BMI and total cholesterol in participants and non-participants were almost equal (Mullie et al., 2010a). A military population was selected for this study; this population has the advantage of limiting the influence of occupation as socioeconomic determinant, which allowed us to restrain our investigations to the influence of income and education as socioeconomic indicators. The sample can be seen as representative for Belgian army men. Because of the different manual and non-manual tasks and occupation and education levels present in an army, our sample can be seen as representative for men with an occupation. Moreover, our nutritional results match with the results of the most recent Belgian cross-sectional research (Devriese et al., 2004). In a representative sample of Belgian men aged between 20 and 55 years, daily sugar-sweetened beverage consumption was 38.6%, which is close to our 36.3%. In this national survey, a lower consumption was associated with increasing age, increasing income and a French background. There was no relation with educational level and BMI. Body weight was self-reported, which can be a limitation for the validity of the study. However, in a subsample, we were able to compare self-reported BMI with measured values. Categorical analyses revealed a good agreement between both, with 40% normal weight, 46% overweight and 14% obese individuals for self-reported BMI, and, respectively, 41%, 46% and 13% for measured BMI (Mullie et al., 2010a). The army food supply is very diverse; each canteen has its own menu’s. Moreover, the food supply in military restaurants is the same for soldiers and officers. Less than 15% of the military men visited the military restaurant every weekday. At different places in military settings, vending machines with sugar- and artificial-sweetened soft drinks are available, which is a comparable setting as in more general occupational situations. The soft drinks were assessed in group in the foodfrequency questionnaire. There is probably an underestimation of the consumption; however, those five soft drinks, Coca-Cola, Pepsi, Fanta, Sprite and Icetea, are by far the most consumed. In conclusion, a higher BMI was associated with a decreasing consumption of sugar-sweetened beverages and with an increase in consumption of artificially sweetened beverages. The same tendency was observed for weight-loss intention: trying to lose weight was associated with an increased consumption of artificially sweetened beverages. Both observations could indicate that being overweight or obese makes one more receptive for low-energy beverages in an attempt to lose weight. Sugar-sweetened beverage consumption was clearly associated with an unhealthy dietary pattern; due to the cross-sectional design of this study; however, one must be prudent with causality. Nevertheless, this emphasizes the

importance of discouraging consumption of sugar-sweetened beverages; the low nutritional benefit is clearly not compensated by a healthy dietary pattern.

Conflict of interest The authors declare no conflict of interest.

Acknowledgements We are indebted to the participants of this study. We wish to thank Ms Laura-Louise Fairley for the grammatical corrections of the manuscript.

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