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NNNS: Nutrient Quality (2006)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
  • The purpose of this study was to determine differences between users of reduced sugar (RS) foods and beverages and those who use only the full sugar (FS) versions of the same products, who reported more than one day of food recalls.
  • HO: That there is a difference in intakes of energy and nutrients and in knowledge, practice and attitudes between consumers reporting any use of RS products and those who report use of only the FS versions of the same products.
Inclusion Criteria:
Records for adults, over 20 years old, providing two days of dietary intakes in the 1994-1996 CSFII (USDA 2002).
Exclusion Criteria:
Description of Study Protocol:

Recruitment

  • Records for adults greater 20 years old or older, providing two dietary intakes in the 1994-1996 CSFII (USDA 2002), were used.

Design

  • Food lists accompanying the CSFII data were scanned and categories for which both FS and RS versions were identified: These were yogurt, cocoa and other sweetened milk beverages, frozen and gelatin desserts, puddings, breads, cookies, cakes, fruit drinks, confectionary products, carbonated and non-carbonated drinks and sweeteners (syrups, sugar and sugar substitutes, jellies)
  • Dietary recalls were sorted for respondents reporting use of both FS and RS versions and those reporting no use of any of these foods. Only 2% of men and 3% of women did not report use of these products (either the FS or RS versions). Few respondents indicated exclusive use of RS products: Of consumers reporting RS, most chose a mix of some reduced calorie products.  

Statistical Analysis

  • Weighted data were used to describe demographics, whereas unweighted data were used for nutrient, food group and DHKS analyses
  • To compensate for the complex CSFII sampling, a restrictive P-value of less than 0.01 was used to determine significance, a method suggested by the US department of Agriculture
  • Comparisons were conducted using Chi-square for descriptive data and ANOVA with the Scheffe test (SAS version 6.12) for all other data.
Data Collection Summary:

Nutrient Densities

  • Calculated by dividing nutrient intake by energy intake and multiplying by 1,000 for protein, vitamin A, vitamin C, iron, calcium, zinc, vitamin B6, adjusted for protein, magnesium, vitamin E, vitamin B12, thiamin, riboflavin, niacin, folate and phosporus
  • Because vitamin E, vitamin B6, magnesium, and zinc intakes for men and calcium, vitamin E, vitamin B6, magnesium and zinc intakes for women are often below recommended levels, comparison to DRI were made
  • CSFII companion survey, the Diet and Health Knowledge Survey (DHKS) for 1994-1996 was used as the source of specific questions regarding attitudes, knowledge and practice.
Description of Actual Data Sample:
  • Number of respondents
    Males RS: 1,689; FS 2,957
    Females RS: 2,065; FS: 2,376
  • Age: Greater than 20 years
  • Anthropometrics: BMI were adjusted to compensate for over-reporting of height and under-reporting of weight.
Summary of Results:

Other Findings

  • Demographic Comparisons: RS users were significantly more likely to be female than male (22% compared with 17%) and white than non-white (45% compared with 25%). RS users reported significantly higher vitamin supplementation use than FS users (40% and 30%, respectively). Exclusive FS users were significantly younger (48±17 years) than RS (53±16 years) users. RS users were significantly more likely to have attained higher educational levels (13±3 years, compared with 12±3 years) and have higher incomes as a percentage of poverty than FS users (240%, compared with 208%).
    • Mean BMI values for all adults was greater than 25, overweight. Males and females reporting RS usuage were significantly more likely to have higher BMI values than those exclusively using FS.
  • Food Guide Pyramid Groupings: The average reported number of servings of milk and milk products was below recommended levels for all respondents, whereas reported average meat consumption was higher than recommeded. When compared with FS users, RS users consistently reported significantly higher intakes of fruit and lower intakes of discretionary fat and added sugars. Significantly lower intakes of potatoes and higher intakes of dark green and yellow vegetables for RS than FS.
Comparisons of Adults Consuming Any Reduced-Sugar (RS) Foods and Beverages, Compared with Those Consuming Only Full Sugar (FS) Versions of the Same Food a,b

  Males RSc Males FS
 Females RSc Females FS
Number of Respondents 1,689 2,957 2,065 2,376
Food Guide Number of Servings ±SD    
Grains 7.6±3.5 7.4±3.8 5.6±2.6a 5.2±2.5b
Fruits 1.9±2.1a 1.4±1.9b 1.7±1.9a 1.3±1.5b
Vegetables 4.1±2.5 4.0±2.5 3.2±1.8a 2.9±1.8b
Milk 1.5±1.3 1.4±1.3 1.1±0.9 1.1±0.9
Meat 62.5±32.7a 67.6±35.8b 43.2±23.9a 46.2±23.0b
Discetionary Fat (g) 62.5±32.7a 67.6±35.8b 43.2±23.9a 46.2±23.0b
Added Sugars (tsp) 17.2±14.0a 23.0±17.3b 12.6±9.3a 17.4±13.1b
Intake (Grams Consumed ±SD)    
Milk and Milk Products    
Yogurt 7±50a 0.4±12b 13±61a 0.7±14b
Cocoa, Milk Beverages, Instant Breakfast 7±47 5±43 9±56 5±43
Frozen, Desserts, Puddings 25±89a 6±44b 16±62a 4±29b
Grains    
Breads, Cookies, Cakes 81±80 82±89 57±62 54±60
Fruits    
Fruit Drinks 94±372  77±285  71±258  68±251 
Beverages    
Non-Carbonated 118±397  138±493  102±340  93±314 
Carbonated 721±925  665±922  569±690a   465±695b
Desserts, Gelatin 10±54a  6±43b   12±59a  6±38b
Sweeteners (Syrups, Jelly, Sugar Subsitutes) 18±39 21±41 13±25 16±31
Confectionary 13±46 11± 41 10±30 10±32
Nutrient Intake Compared with Dietary Reference Intakes    
Calcium (AI=1,200g per day for adults) 884 855 633 605
Zinc (EAR=9.4 mg per day in males; 6.8 mg per day in females) 13.3 13.2 9.0 8.6
Magnesium (EAR=350 mg per day in males; 265 mg per day in females) 319 308 236 217
Vitamin B6 (EAR=1.4mg per day in males; 1.3 mg per day in females) 2.1  2.0  1.5  1.4 
Vitamin E (EAR=12mg tocopherol per day for adults)  7.8 7.3  5.7  5.3 
Nutrient Densities    
Protein (g) 42±10a  40±10b   1±11a  39±10b
Vitamin A (RE) 583±532a 464±496b 647±597a 556±792b
Vitamin E (mg T) 8±6a 7±5b 6±4a 5±4b
Vitamin C (mg) 52±41a 42±37b 62±49a 52±42b
Thiamin (mg) 0.87±0.3a 0.80±0.3b 0.87±0.3a 0.78±0.3b
Riboflavin (mg) 1.0±0.4a 0.9±0.3b 1.1±0.4a 0.9±0.4b
Niacin (mg) 12.6±4.1a 13.4±3.7b 12.4±4.5a 11.3±3.9b
Vitamin B6 (mg) 1.01±0.4a 0.88±0.4b 1.02±0.5a 0.89±0.4b
Folate (ug) 144±82a 122±69b 151±84a 129±69b
Vitamin B12 (ug) 2.90±4.0 2.62±3.7 2.6±3.7 2.7±6.8
Calcium (mg) 401±161a 354±148b 421±175a 370±161b
Phosphorus (mg) 658±146a 602±131b 666±165a 601±138b
Magnesium (mg) 149±42a 134±42b 157±50a 137±42b
Iron (mg) 9±4a 8±3b 8±4a 7±3b
Zinc (mg) 6±3 6±3 6±3a 5±2b
Fiber (g) 9±4 8±3 10±4a 8±4b
Total Carbohydrates (g) 123±24  129±24  122±23  129±24 
Added Sugars (tsp) 1.6±4.2a  2.8±6.7b  1.6±3.8a 3.1±7.0b
Total Fat (g) 37±9  38±8  36±9a  37±9b 
Saturated Fat (g) 12.2±3.7a  12.7±36.6b  11.7±3.9a 12.4±3.7b
PUFA (g) 7.8±2.7a 7.4±3b 7.8±3.1a 7.6±3.1b
MUFA (g) 14.4±33.9  14.6±3.6  13.6±4.0a  14.1±3.7b
Cholesterol (mg) 140±75a 149±85b 134±82a  142±87b

  • A: Data source; self-reported intakes of adults in the combined 1994 to 1996 Continuing Survey of Food Intakes by Individuals; two days of records.
    • AI: Adequate intake
    • EAR: Estimated average requirement
    • MUFA: Monounsaturated fatty acids
    • PUFA: Polyunsaturated fatty acids
    • RE: Retinol equivalents.
  • B: Values followed by differing letters denote stataistically significant differences (P<0.01), as determined by analysis of variance (ANOVA)
  • C: Combined results of exclusive and mixed RS users. 

Food and Energy Intakes

  • RS users reported consuming equal or lower intakes of food (in grams), compared with FS users. Exceptions were users of RS yogurt and frozen and gelatin desserts, who reported eating significantly greater amounts of these products than did FS users.
  • Although women ate more of these products, this intake was accompanied by significantly lower energy intakes by the female RS users than the FS users (1,535±551kcal, compared with 1,618±575). There was a significantly lower intake for males (2,202±815kcal, compared with 2,353±935kcal).
  • Greater use of calcium and magnesium might explain the higher intakes of calcium and magnesium in RS users
  • Female RS users reported greater quantities of carbonated beverages.

Micronutrient Intake

  • Both male and female RS users tended to report similar or higher micronutrient intakes, compared with FSA-only users, although differences were not always significant (Table One) for all respondents; reported mean intakes of zinc and Vitamin B6 tended to meet or exceed DRI, whereas intakes for calcium, vitamin E and magnesium were below recommendations.

Nutrient Density

  • After adjusting nutrient intakes to account for differences in energy intake, significantly higher intakes were noted for males and females consuming RS foods and beverages (13 and 15 of 17 nutrients, respectively). Fat and sugar intakes were significantly more positive for males and females (four of six and all six parameters).

Consumer Beliefs and Knowledge Differences

  • Only significant differences between RS and FS users occured in label-reading practices. RS users were significantly more likely than FS users to read labels for calories, fats and sugars. No significant differences were detected in nutrition knowledge or attitudes.
Author Conclusion:
  • Users of RS products were different from those using only the FS versions of foods and beverages, in terms of demographic characteristics and food selection. Those reporting use of RS products generally reported diets that more closely met dietary guidance in terms of food patterns and micronutrient intakes, while reporting higher awareness of food choices through the use of label-reading. 
  • Users of RS products reflect a distinct consumer: One who may be more affluent, older, better informed and more aware of overall health
  • Physicians and health care specialists can be encouraged by these findings, despite the study limitations. Recommendations to substitute RS foods for full-calorie versions need not result in over-consumption of foods. Consumers do not necessarily have to omit all FS foods to achieve overall dietary goals. In this study, those reporting combined RS and FS products usage had favorable diets.
  • Health professionals should feel comfortable in encouraging the use of RS foods as one means of preventing weight gain, while achieving dietary quality
  • Limitations of study by author: Respondents reporting use of RS foods may have under-reported food intakes; overweight respondents might have under-reported weight as well as food intake or over-reported height; provides information for only one point of time (no clear way to identify which respondents were using RS products to try to lose or maintain weight or whether weight was increasing).
Funding Source:
Reviewer Comments:
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) No
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? No
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? No
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes