Beverage Consumption Among High School Students—United States, 2010 FREE

MMWR. 2011;60:778-780

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Milk and 100% fruit juice are a source of water and provide key nutrients such as calcium and vitamin C.¹ Other beverages, referred to as sugar drinks or sugar-sweetened beverages (SSBs), also are a source of water but have poor nutritional value. SSBs are the largest source of added sugars in the diet of U.S. youths, and the increased caloric intake resulting from these beverages is one factor contributing to the prevalence of obesity among adolescents in the United States.^2- 3 To determine the extent to which U.S. adolescents consume different types of beverages and variations in consumption by sex and race/ethnicity, CDC analyzed data from the 2010 National Youth Physical Activity and Nutrition Study (NYPANS). NYPANS included a school-based survey conducted by CDC that measured physical activity and dietary behaviors among a nationally representative sample of students in grades 9-12. This analysis indicated that, although water, milk, and 100% fruit juice were the beverages consumed most commonly during the 7 days before the survey, 24.3% of high school students drank a serving (e.g., can, bottle, or glass) of regular soda or pop, 16.1% drank a serving of a sports drink, and 16.9% drank a serving of another SSB one or more times per day during the same period. For all SSBs, male students were more likely than female students, and black students were more likely than white students and Hispanic students to report drinking these beverages one or more times per day. Families, schools, and youth-oriented institutions should limit SSBs among all adolescents while ensuring their access to more healthful beverages. Targeted efforts are especially needed to reduce consumption of SSBs among male and black adolescents.

NYPANS measured the prevalence of behaviors and behavioral determinants related to physical activity and nutrition. The survey used a three-stage cluster sample design to obtain cross-sectional data representative of public- and private-school students in grades 9-12 in all 50 states and the District of Columbia. Students completed an anonymous, self-administered questionnaire in their classrooms during a regular class period during the spring of 2010. Data from 11,429 students were available for analysis. The school response rate was 82%, the student response rate was 88%, and the overall response rate* was 73%.

Respondents were asked how many times during the 7 days before the survey they drank the following beverages: 100% fruit juices; regular soda or pop; diet soda or pop; regular sports drinks; energy drinks; other SSBs†; coffee, coffee drinks, or any kind of tea; and plain water (i.e., water).‡ Respondents also were asked how many glasses of milk they drank per day during the 7 days before the survey.§ Responses were divided into less than one time or glass per day versus one or more times or glasses per day (i.e., daily consumption). To calculate the percentage of students who drank any combination of SSBs during the 7 days before the survey, responses to questions on regular soda or pop, regular sports drinks, and other SSBs that indicated consumption of less than once a day were divided by seven to determine daily intake and then responses were summed.

Race/ethnicity data are presented only for non-Hispanic black, non-Hispanic white, and Hispanic students (who might be of any race); the numbers of students from other racial/ethnic groups were too small for meaningful analysis. Data were weighted to provide national estimates. Statistical software that takes into account the complex sampling design was used to calculate prevalence estimates and 95% confidence intervals (CIs) and to conduct t tests for subgroup differences (P <0.01).

During the 7 days before the survey, 72.4% of high school students nationwide drank a serving of water daily, 42.0% drank one or more glasses of milk daily, and 30.2% drank 100% fruit juices daily. Although water consumption did not vary by sex, male students were more likely than female students to drink milk and 100% fruit juices daily. White students were more likely than black students and Hispanic students to drink both water and milk daily, and Hispanic students were more likely than black students to drink milk daily. White students were less likely than black students and Hispanic students to drink 100% fruit juices daily.

During the 7 days before the survey, 24.3% of high school students nationwide drank a serving of regular soda or pop, 16.1% drank a serving of a sports drink, and 16.9% drank a serving of another SSB daily. Male students were more likely than female students to drink soda or pop and sports drinks daily, but no sex differences were detected in the daily consumption of other SSBs. For all three types of drinks, black students were more likely than white students and Hispanic students to report daily consumption. In addition, Hispanic students were more likely than white students to drink sports drinks daily. In addition, 15.6% of high school students nationwide drank soda or pop two or more times per day, 9.2% drank sports drinks two or more times per day, and 9.8% drank other SSBs two or more times per day. During the 7 days before the survey, 62.8% of high school students drank any combination of these beverages daily, and 32.9% drank any combination of these beverages two or more times per day.

During the 7 days before the survey, 14.8% of high school students nationwide drank a serving of coffee, coffee drinks, or any kind of tea daily. Daily consumption of diet soda or pop (7.1%) and energy drinks (5.0%) was less common. Daily consumption of diet soda or pop and coffee, coffee drinks, or tea did not vary by sex, but male students were more likely than female students to drink energy drinks daily. White students were less likely than black students and Hispanic students to drink energy drinks daily.

Reported by:

Nancy D. Brener, PhD, Caitlin Merlo, MPH, Danice Eaton, PhD, Laura Kann, PhD, Div of Adolescent and School Health, Sohyun Park, PhD, Heidi M. Blanck, PhD, Div of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Nancy D. Brener, nbrener@cdc.gov, 770-488-6184.

CDC Editorial Note: The findings in this report indicate that water, milk, and 100% fruit juices were the beverages most commonly consumed daily by high school students. These are healthful beverages, and milk and 100% fruit juice are sources of key nutrients. According to this analysis, however, daily consumption of regular soda or pop, sports drinks, and other SSBs also is common in this population. Consumption of these beverages might be related to negative health outcomes. A recent meta-analysis found soft drink intake to be associated with increased energy intake and body weight, and with lower intakes of milk, calcium, and other nutrients.⁴ Among adolescents specifically, SSB consumption can contribute to weight gain, type 2 diabetes, and metabolic syndrome.^2- 3

Compared with results from 24-hour dietary recall interviews conducted among persons aged 12-19 years as part of the National Health and Nutrition Examination Survey, findings from NYPANS are higher for daily consumption of 100% fruit juice, but lower for SSBs.⁶ However, a study using a questionnaire similar to that used in NYPANS among a population-based sample of public-school students in Texas found results more similar to those of NYPANS for daily consumption of milk, 100% fruit juice, and soda.⁷ Results by sex and race/ethnicity from the Texas study also are similar to those in this report; both found that consumption of soda or pop, sports drinks, and other SSBs is highest among male and black students.⁷

The findings in this report are subject to at least two limitations. First, these data apply only to youths who attend school and, therefore, are not representative of all persons in this age group. Nationwide, in 2008, of persons aged 16-17 years, approximately 4% were not enrolled in a high school program and had not completed high school.⁸ Second, the data are self-reported, and although whether students were underreporting or overreporting their consumption of beverages cannot be determined, results did differ from those using 24-hour recall methods.⁶ CDC currently is conducting studies to determine the extent to which these survey data correspond to data collected from a subsample of students using 24-hour recall methods.

When selecting beverages, adolescents should be aware that water and low-fat or fat-free milk are the most healthful. In limited amounts, 100% fruit juice also has health benefits. Adolescents also should be aware that consuming regular soda or pop, sports drinks, and other SSBs can lead to weight gain and diabetes. According to the American Academy of Pediatrics, routine ingestion of sports drinks by children and adolescents should be avoided or restricted.⁹ In addition, a recommendation of the 2010 Dietary Guidelines for Americans is to reduce the intake of calories from solid fats and added sugars.∥ CDC works with state education and health agencies to implement multiple strategies for decreasing the intake of added sugars, with a specific emphasis on reduction of SSBs among all populations, including adolescents. One such strategy is to limit access to these drinks in schools through policy and environmental change. Such efforts have met with considerable success. A recent analysis of data from 34 states found significant increases in all of these states between 2006 and 2008 in the percentage of secondary schools in which students could not purchase soda pop or fruit drinks that were not 100% juice.¹⁰ CDC also is encouraging schools to improve access to free drinking water. Still, additional strategies are needed to reduce SSB consumption, especially among male and black students. Although changing school policy is an important first step, most calories from these drinks are consumed in the home.⁶ It is critical, therefore, to involve families, the media, and other institutions that interact with adolescents to increase their awareness of possible detrimental health effects and discourage their consumption of SSBs.

Sugar-sweetened beverages (SSBs) are the largest source of added sugars in the diet of U.S. youths; the increased caloric intake resulting from these beverages is one factor potentially contributing to the prevalence of obesity among adolescents nationwide.

What is added by this report?

Based on data from the 2010 National Youth Physical Activity and Nutrition Study, U.S. adolescents most commonly consumed water, milk, or 100% fruit juice during the 7 days before the survey, but daily consumption of regular soda or pop, sports drinks, and other SSBs is common in this population, especially among male and black students.

What are the implications for public health practice?

When selecting beverages, adolescents should be aware that water, low-fat or fat-free milk, and limited amounts of 100% fruit juice are the most healthful options, and that regular consumption of regular soda or pop, sports drinks, and other SSBs can lead to excess weight and diabetes. Families, schools, and youth-oriented institutions should limit access to SSBs while ensuring access to more healthful, low-calorie beverages.

*Overall response rate = (number of participating schools/number of eligible sampled schools) × ([number of usable questionnaires] /[number of eligible students sampled]).

†Such as lemonade, sweetened tea or coffee drinks, flavored milk, Snapple, or Sunny Delight, but not including soda or pop, sports drinks, energy drinks, or 100% fruit juice.

‡The NYPANS questions included the following: “During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.)”; “During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not count diet soda or diet pop.)”; “During the past 7 days, how many times did you drink a can, bottle, or glass of diet soda or pop, such as Diet Coke, Diet Pepsi, or Sprite Zero?”; “During the past 7 days, how many times did you drink a can, bottle, or glass of a sports drink such as Gatorade or PowerAde? (Do not count low-calorie sports drinks such as Propel or G2.)”; “During the past 7 days, how many times did you drink a can, bottle, or glass of an energy drink, such as Red Bull or Jolt? (Do not count diet energy drinks or sports drinks such as Gatorade or PowerAde.)”; “During the past 7 days, how many times did you drink a cup, can, or bottle of coffee, coffee drinks, or any kind of tea?”; “During the past 7 days, how many times did you drink a can, bottle, or glass of a sugar-sweetened beverage such as lemonade, sweetened tea or coffee drinks, flavored milk, Snapple, or Sunny Delight? (Do not count soda or pop, sports drinks, energy drinks, or 100% fruit juice.)”; and “During the past 7 days, how many times did you drink a bottle or glass of plain water? Count tap, bottled, and unflavored sparkling water.” For each question, the response options were as follows: “I did not drink (beverage) during the past 7 days,” “1 to 3 times during the past 7 days,” “4 to 6 times during the past 7 days,” “1 time per day,” “2 times per day,” “3 times per day,” and “4 or more times per day.”

§Participants were asked the following question: “During the past 7 days, how many glasses of milk did you drink? (Count the milk you drank in a glass or cup, from a carton, or with cereal. Count the half pint of milk served at school as equal to one glass.).” The fat content of the milk consumed was not specified.

∥Additional information is available at http://www.cnpp.usda.gov/dietaryguidelines.htm.