Sugar Consumption from Infancy to Adolescence

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Starting in the 1950’s there was concern between sugar intake and coronary heart disease (CHD)1.  The Sugar Research Foundation (SRF) quickly responded to these inquiries by funding a literature review that focused on how fat and cholesterol were the dietary causes of CHD, minimizing the concern of sugar consumption1,2.  The conclusions were published in the New England Journal of Medicine in 1967, yet the sugar industry did not initially disclose their funding of the project2.  However, when people realized this project was funded by the sugar industry there was skepticism about the validity of the findings2. 

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Subsequent research has concluded that excess sugar consumption can lead to metabolic syndrome, cardiovascular disease, type 2 diabetes, and a higher prevalence of overweight and obesity, leading to increased healthcare costs and premature deaths3,4.  It should be noted that the biggest change in children’s diets that have great consequences for health across the life span is the intense increase in sugar consumtion28.  Observing sugar consumption across the developing ages of childhood is important since eating behaviors evolve during the first years of life, including what to eat, when to eat and how much to eat5.  Subsequently these dietary patterns are reflected in the eating behaviors observed in adolescence and adulthood5. 

Humans are primed to like sweet foods; in fact, infants are born with a preference for sweet foods deeming them as “safe”5.  Usually when a food is “bitter” that means the food is rancid or toxic to the body; therefore it makes sense humans evolutionary evolved to prefer sweet foods5.  This innate preference is fulfilled when a child is born and the first substance ingested is milk, which contains sugar lactose as the primary carbohydrate5,6.  Mature human milk contains over 7 grams of carbohydrates per 100 grams of breast milk7; infants under 12 months consume over 650 grams of breast milk in a 24-hour period30.  Therefore, infants are consuming over 45 grams of carbohydrates mostly in the form of sugar.  During the first six months of life infants should be exclusively fed breast milk, (if not on formula), and after the American Academy of Pediatrics recommends infant, iron-fortified cereal7,8.  However many cereals are disguised as “breakfast foods” for infants when they are really boxes of sugar9. 

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Infants consume what their parents or caregiver(s) provide them, which is usually the mother, who is termed a proximal determinant10,28.  Although there are innate preferences for sweet foods, infants have an unlearned preference and predisposition about what foods they consume10.  There is some evidence to suggest infants can regulate the amount of volume they consume, but not what they consume10.  Therefore if a parent provides the infant with sugar-laden iron-fortified cereal, the infant will consume it.

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Once children are above one year old they are considered toddlers11.  Starting at two years old, children start requesting food products, and three-quarters of the time it is at the food-store12.  Most requests are in the brand-name form with breakfast cereal being the largest requests at 47%, and 65% of the requested cereals are sugar-sweetened12.  Nutrition analyses of breakfast cereals reveal children’s cereals are higher in sugar than nonchildren’s cereals13.  Often on these sugary cereal boxes are cartoon and licensed media characters used to promote products to children14. Characters have a positive influence on which foods children eat, especially for foods high in sugar14.

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This is of concern since most characters and advertisements geared towards children do not promote healthy foods15.  Children at this age do not have the developmental capacity to understand these seemingly fun food commercials are bias trying to enrapture kids with their characters, bright colors, and descriptive language12.  The majority of families purchase foods from the supermarket determined by marketing aimed at children rather than the food’s nutritional profile28.  The advertisements work in conjunction with parents often giving into children whining about what they prefer to eat and purchasing such foods with children’s “nag factor”17.  These events play a role in the increased sugar consumption of toddlers, even though 97% of parents believe eating habits in childhood predicts overall health17.

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When looking at the different developmental stages of infancy the age brackets that had the highest intake of sweet-foods fell in the age ranges of 15-18 months and 19-24 months, with the highest quartiles being 92% and 90%, respectively18.  Children at these ages are just starting to request foods; therefore, it is ultimately the caregiver that is providing them with the sugar-containing foods.  The caregiver often gives into the “nag factor” mentioned above which stems from unhealthy food advertisements geared toward children.

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Children recognize the association of food brand logos and characters more as they get older14.  However, when characters were used to advertise fruits and vegetables it did not have the same effect as when used for sugar-filled cereals14.  Perhaps children are used to seeing certain characters on sugary foods and associate them with only that one food product16.  High exposure of these foods at a young age and the powerful cognitive effect of food addiction may play a role in children not accepting characters displayed on other food products16. 

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It is not until pre-school when children start to self-regulate how much, and of, what they are eating, yet their eating behaviors are still strongly influenced by what the caregiver provides them10.  When children start attending childcare centers parents often pack lunch, and depending on what the caregiver puts in the children’s lunch determines what the child will eat19.  A cluster randomized control trial concluded consumption increments of various foods were relative to the amount of foods offered in the child’s lunch bag19.  Although children can start to regulate what they put in their mouth, it is predetermined by what is in their lunch bag, and filling a lunch bag with more food will stimulate the child to eat more19.  Another study conducted at the Department of Health Promotion/Behavioral Sciences at the University of Texas School of Public Health looked at 50 packed lunched at an Early Childcare Center20.  Twenty-eight percent of the lunches contained at least one food pouch20.  It was further analyzed that these food pouches contributed to 20% of the lunch’s total calorie content, and 41% total sugar20.  These convenient, pouches of food are often considered a small portion of the meal, such as a side-dish or snack, yet are contributing almost half of the sugar consumed in one meal.  Parents purchase pre-made snacks like these pouches out of convenience29, disregarding their sugar component.

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Once children enter primary school, and if not packing a lunch, they start to have autonomy about what they purchase in the school lunchroom.   This is an interesting age when parent’s restrictive talk seems to play a significant role in how children eat21.  A study conducted on maternal behaviors concluded restrictive feeding practices and setting limits on how many sweets a six-year old could eat increased the child’s intake of such foods21.  Therefore, limiting little Johnny on how many cookies he can purchase in the lunchroom may spur him to purchase, and eat, more than he would have if nothing were said.

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When looking across the lifespan, six years old is just the start of the incline of sweet-food consumption for males and females.  In both genders, the age ranges that consume the most foods and beverages with added sugars are 9-13 years old and 14-18 years old22.  Beverages, excluding milk and 100% fruit juices, contribute to 47% of sugar consumption and 31% of the sugar was coming from snacks and sweets23.  There is evidence from a study conducted on children at secondary school showing children between 10-18 years old believe the social norm of sugar-sweetened beverages (SSBs) consumption is greater than it is24.  In fact, 76% of children overestimated the daily norm in their school grade, and 24% thought the daily average SSB consumed was three or more per day per child24.  Although most students, (36%), in the study consumed one SSB per day, the overestimation of SSB consumption norms could play a role in the amount of SSB children are consuming24.  Ergo, adolescents thinking their peers are consuming more than their actual intake could spur them to consume more because of inflated perceived norms24.

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Peer pressure can greatly contribute to unhealthy eating habits25.  A study was done on secondary school students who left school for lunch after policies were enacted to ban the selling of SSBs and sweet snacks25.  Forty-four percent of children said they left school to buy lunch because their friends did, and 68.5% of students spent money on sweets throughout the week25.  The restriction of purchasing sweet foods in school contributed to adolescents purchasing them elsewhere; yet overwhelming more powerful was the strong social and cultural value in spending time with friends, and being persuaded by peers to consume certain items, particularly ones that contained high amounts of sugar25.

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After analyzing the sugar consumption at varying ages and taking into account the cognitive development at each age, I think it is most crucial to address sugar consumption with infants and toddlers.  At this age children have a preference for sweet foods and powerful purchasing power on what products their parents buy2,12.  This is especially of concern since most advertisements children see promote sugary food intake, and children at this age do not have the developmental capacity to understand food manufacturers are using bias information to lure them in to wanting their products12,15.  Children’s eating behaviors are established early in life and persist into adulthood, which is why a diet high in sugary food will most likely lead to a similar diet in adolescence and adulthood5.  This is consistent with the Life Course Development model highlighting nutritional habits formed early in life stay with the child as they progress in age26.

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I think the most challenging age to address sugar consumption would be with teenagers. They have perceived norms of their peers consuming more sugar than they actually do combined with the powerful effect of peer pressure to fit in24,25.  Additionally, sugar affects teenagers’ brains intensely; consumption of high sugar diets have reported to profoundly heighten the brain’s reward system in middle-late adolescence27.  During this time the reward hormone dopamine is extremely high spurring the brain to quickly learn about rewards and regulates certain aspects of neuroplasticity27.  Therefore teenagers have a vulnerability to consume a diet high in sugar with exhibited diminished behavioral control27.

In conclusion, middle-late adolescents would be the most challenging age to combat the overconsumption of sugar in foods.  This is due to a variety of aspects including: their brain’s greatly rewarding them after consumption, perceived norms that their peers consume more sugar-laden foods and beverages than they do, and the fact that they want to fit in with their peers regarding eating behaviors27,24,25.

 

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References:

1. Kearns, C.E., Schmidt, L.A., & Glants, S.A.  (2016).  Sugar Industry and Coronary heart Disease Research.  JAMA Intern Med, 176(11): 1680-1685.  doi: 10.1001/jamainternmed.2016.5394

2. Domonoske, C.  (2016).  50 Years Ago, Sugar Industry Quietly Paid Scientisits to Poiint Blame at Fat.  NPR.  Retreived from http://www.npr.org/sections/thetwo-way/2016/09/13/493739074/50-years-ago-sugar-industry-quietly-paid-scientists-to-point-blame-at-fat

3. Stanhope, K. L.  (2016).  Sugar consumption, metabolic disease and obesity: The state of the controversy. Critical Reviews in Clinical Laboratory Sciences, 53(1), 52–67.  doi: http://doi.org/10.3109/10408363.2015.1084990

4. Brownell, K.D., Farley, T., Willett, W.C., Popkin, B.M., Chaloupka, F.J., Thompson, J.W., & Ludwig, D.S.  (2009).  The Public Health and Economics Benefits of Taxing Sugar-Sweetened Beverages.  The New England Journal of Medicine, 361: 1599-1605.

5. Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the Development of Children’s Eating Behaviours: From Infancy to Adolescence. Canadian Journal of Dietetic Practice and Research : A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche En Dietetique : Une Publication Des Dietetistes Du Canada, 68(1), s1–s56.

6. Ballard, O., & Morrow, A. L. (2013). Human Milk Composition: Nutrients and Bioactive Factors. Pediatric Clinics of North America, 60(1), 49–74. http://doi.org/10.1016/j.pcl.2012.10.002

7. University of Michigan Medicine.  (2017).  Feeding your Baby and Toddler (Birth to Age Two).  University of Michigan: Michigan Medicine.  Retrieved from http://www.med.umich.edu/yourchild/topics/feedbaby.htm

8. American Academy of Pediatrics.  (2008).  Starting Solid Foods.  Healthy Children from the American Academy of Pediatrics.  Retrieved from https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx

9. Cicero, K.  (2013).  A box of sugar?  Pick the best cereal for you.  CNN.  Retrieved from http://www.cnn.com/2013/05/20/health/choose-right-cereal/index.html

10. Savage, J. S., Fisher, J. O., & Birch, L. L. (2007). Parental Influence on Eating Behavior: Conception to Adolescence. The Journal of Law, Medicine & Ethics : A Journal of the American Society of Law, Medicine & Ethics, 35(1), 22–34. http://doi.org/10.1111/j.1748-720X.2007.00111.x

11. CDC. (2017).  Toddlers (1-2 years old).  CDC.  Retrieved from https://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/toddlers.html

12. Story, M., & French, S. (2004). Food Advertising and Marketing Directed at Children and Adolescents in the US. The International Journal of Behavioral Nutrition and Physical Activity, 1, 3. http://doi.org/10.1186/1479-5868-1-3

13. Schwartz, M.B., Vartanian, L.R., Wharton, C.M., & Brownell, K.D.  (2008).  Examining the Nutritional Quality of Breakfast Cereals Marketed to Children.  The Journal of the Academy of Nutrition and Dietetics, 108(4): 702-705.  doi: http://dx.doi.org/10.1016/j.jada.2008.01.003

14. Kraak, V. I., & Story, M. (2015). Influence of food companies’ brand mascots and entertainment companies’ cartoon media characters on children’s diet and health: a systematic review and research needs. Obesity Reviews, 16(2), 107–126. http://doi.org/10.1111/obr.12237

15. Bernhardt, A.M., Wilking, C, Gilbert-Diamond, D., Emond, JA., & Sargent JD. (2015). Children’s recall of fast food television advertising testing the adequacy of food marketing regulation. Healthy Eating Research. Retrieved from

         http://healthyeatingresearch.org/research/childrens-recall-of-fast-food-television-advertising- testing-the-adequacy-of-food-marketing-regulation/

16.  Westwater, M. L., Fletcher, P. C., & Ziauddeen, H. (2016). Sugar addiction: the state of the science. European Journal of Nutrition, 55(Suppl 2), 55–69.

        http://doi.org/10.1007/s00394-016-1229-6

17.  Choi, J.  (2017).  Parents struggle to keep the junk food out of little mouths.  USAToday.  Retrieved from

        https://www.usatoday.com/story/news/nation/2017/02/23/american-parents-struggle-to-feed-healthy-food-to-children/98270318/

18.  Briefel, R.R., Reidy, K., Karwe, V., Jankowski, L., & Hendricks, K.  (2004).  Toddlers’ Transition to Table Foods: Impact on Nutrient Intakes and Food      

        Patterns.  Supplement to the Journal of the Academy of Nutrition and Dietetics.  Retrieved from

        http://jandonline.org/article/S0002-8223(03)01493-7/pdf

19.  Briley, M.E., Romo-Palafox, M., Sweitzer, S.J., Ranjit, N., Byrd-Williams, C.E., Roberts-Grey, C., & Hoelscher, D.M.  (2015).  Analysis of Preschooler’s                 Sack Lunches: If Parents Pack More Does the Child Eat More?  Jounral of the Academy of Nutrition and Dietetics, 115(9): A-46.  Retrieved from       

        http://jandonline.org/article/S2212-2672(15)00847-3/pdf

20.  Balderrama, J., Robbins, R., Sweitzer, S., Byrd-Williams, C.E., Roberts-Gray, C., Hoelscher, D., Briley, M.  (2017).  Prevalence of Food Squeeze Pouches           in Infant and Toddler Packed Lunches at Early Childcare Centers.  Journal of the Academy of Nutrition and Dietetics, 117(9): A93.            

        http://dx.doi.org/10.1016/j.jand.2017.06.086

21. Park, S., Li, R., & Birch, L.  (2015).  Mother’s Child-Feeding Practices Are Associated with Children’s Sugar-Sweetened Beverage Intake.  The Journal of          Nutrition, 145(4): 806-812.  Retrieved from http://jn.nutrition.org/content/145/4/806.long

22. Average Intakes of Added Sugars as a Percent of Calories per Day by Age-Sex Group, in Comparison to the Dietary Guidelines Maximum Limit of Less    

       Than 10 Percent of Calories.  [Figure describing average intake of added sugar by age-sex groups].  Retrieved from

       https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/#figure-2-9-average-intakes-of-added-sugars-as-a-percent-of-calor

23. Food Category Sources of added sugars in the U.S. population ages 2 years and older.  [Figure describing sources of sugary foods and beverages].    

       Retrieved from https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/#figure-2-10-food-category-sources-of-added-sugars-in-the-us-popu

24. Perkins, J.M., Perkins, H.W., & Craig, D.W.  (2010).  Misperceptions of peer norms as a risk factor for sugar-sweetened beverage consumption among    

       secondary school students.  Journal of the Academy of Nutrition and Dietetics, 110(12): 1916-1921.  doi: http://dx.doi.org/10.1016/j.jada.2010.09.008

25. Macdiarmid, J.I., Wills, W.J., Masson, L.F., Craig, L.C.A, Bromlet, C., & McNeill, G.  (2015).  Food and drink purchasing habits out of school at lunchtime:        a national survey of secondary school pupils in scotland.  International Journal of Behavioral Nutrition and Physical Activity, 12: 98.  Doi      

       https://doi.org/10.1186/s12966-015-0259-4

26. Wethington, E.  (2005).  An overview of the life course perspective: implications for health and nutrition.  Journal of Nutition Education and Behavior,           37(3): 115-120.  Doi: https://doi.org/10.1016/S1499-4046(06)60265-0

27. Reichelt, A. C. (2016). Adolescent Maturational Transitions in the Prefrontal Cortex and Dopamine Signaling as a Risk Factor for the Development of              Obesity and High Fat/High Sugar Diet Induced Cognitive Deficits. Frontiers in Behavioral Neuroscience, 10, 189.

       http://doi.org/10.3389/fnbeh.2016.00189

28. Coller, R. J., & Kuo, A. A. (2015).  Children families and communities-Chapter 3. In Kuo, A. A., Coller, R. J., Stewart-Brown, S., & Blair, M. (Eds.).  Child            Health: A Population Perspective. Oxford University Press.

29. Goldberg, E.  (2017, May 29).  Why you should stop feeding your baby trendy little food pouches.  Huffington Post.  Retrieved from

       http://www.huffingtonpost.com/entry/baby-food-pouches-plastic_us_59120da5e4b050bdca600cb0

30. Onyango, A.W., Receveur, O. & Esrey, S.A.  (2002).  The contribution of breast milk to toddler diets in western Kenya.  Bull World Health Organization,              80(4): 292-299.  Retrieved from http://www.scielosp.org/pdf/bwho/v80n4/a06v80n4.pdf