NNNS: High Fructose Corn Syrup (HFCS) (2010)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
To examine longitudinal changes in consumption of six types of beverages (milk, diet and regular soda, fruit juice, fruit-flavored drinks and coffee or tea) in girls and to determine the relationship between beverage intake, body mass index (BMI) and nutrient intake in the National Heart, Lung and Blood Institute Growth and Health Study.
Inclusion Criteria:
Part of multi-site National Heart, Lung and Blood Institute Growth and Health Study.
Exclusion Criteria:
Description of Study Protocol:


  • The University of Berkley recruited girls from public and parochial schools in the Richmond Unified School District
  • The University of Cincinnati and the Cincinnati Children's Hospital Medical Center recruited girls from all public and parochial schools in Hamilton County
  • Westat, Inc. and Group Association in Rockville, Maryland randomly selected girls from families who were enrolled in a large Washington, DC-area health maintenance organization and (because of an insufficient number of white families with age-eligible girls) recruited girls from several local Girl Scout troops in the same geographic area
  • Child assent and parental consent was obtained
  • The study was approved by the institutional review boards of all participating institutions.


  • Girls participated in 10 approximately annual assessment visits at participating sites or (when the girl was unable to travel to the site) at her home
  • Retention was high at Visits Two, Three and Four (96%, 94% and 91%, respectively), declined to 82% at Visit Seven and increased to 89% at Visit 10
  • Data collection: Commenced in 1987 and ended in 1997
  • Demographic data: Collected at study entry from girls and their parents (or guardians)
  • Race: Defined by self-report, using US Census categories
  • Age: Recorded as their age at last birthday
  • BMI: Calculated annually on the basis of the research staff's measures of girls' height and weight; weight (kg) divided by height (m), squared.

Statistical Analysis

  • To examine age- and race-related differences in average daily beverage consumption (in grams), a separate model was constructed for each type of beverage
  • The predictors were visit, race and visit-by-race interaction
  • All models were adjusted for site differences and daily total caloric intake
  • Beverage consumption reports at different visits were not independent, therefore mixed models (PROC MIXED) were used to account for the within-girl correlation
  • Separate mixed models were used to estimate the relationship between beverage consumption and each dependent variable: BMI and average daily intake of total calories, sucrose, fructose, total sugars and calcium.
Data Collection Summary:

Food Intake

  • A three-day food record, which was collected annually for Visits One through Five and then again at Visits Seven, Eight and 10
  • Dietitians were trained and certified by the University of Minnesota Nutrition Coordinating Center (NCC) and retrained in later years by staff at the Dietary Data Entry Center in Cincinnati. They used age-appropriate materials to instruct girls to record all food and drink for three consecutive days (two weekdays and one weekend day)
  • Dietitans reviewed the completed food records individually with the girls. Food records were coded and analyzed for nutrients using the Food Table, version 19, of the NCC nutrient database. The amount and type of beverages consumed were recorded in the food diaries.
  • Beverages were coded as follows:
    1. Milk: All kinds of cow's milk, including flavored varieties
    2. Regular soda: All non-diet carbonated beverages, excluding water
    3. Diet soda: All diet carbonated beverages
    4. Fruit juice: Fruit and vegetable juices
    5. Fruit drinks: Fruit-flavored drinks, punches and ades that contain less 100% juice
    6. Coffee and tea.
  • For each beverage category, average grams were determined by adding the daily amounts and dividing the total by the number of days associated with a visit.
Description of Actual Data Sample:
  • Initial N: 2,379 girls, nine or 10 years old at study entry, who identified themselves by using United States census categories for race and ethnicity
  • Attrition (final N): 2,371 girls, 99.7% of whom completed a food diary at one or more visits
  • Age: Nine to 10 years old at entry of study
  • Ethnicity: Black or white, non-Hispanic, with racially concordant parents or gaurdians
  • Location: California, USA.
Summary of Results:

Other Findings

  • Milk: At each visit, black girls had consumed less milk than white girls did. White girls' milk intake did not change between Visits One and Three (ages 9.5 to 11.5 years), but decreased steadily after Visit Three. From Visit Three until Visit Seven (ages 11.5 to 15.5 years), black girls' milk consumption decreased at a greater rate than white girls' consumption.
  • Regular soda: The rate of increase in regular soda consumption was greater among black girls than among white girls until Visit Eight (age 16.5 years), when black girls' soda intake leveled off, but white girls' soda intake continued to increase
  • Diet soda: Black girls' intake remained uniformly low across all visits (up to 11.5g per day, on average), whereas white girls' intake of diet soda increased steadily throughout the entire period
  • Fruit juice: Changed little between Visits One and Four (ages 9.5 to 12.5 years) and then increased slightly after Visit Five
  • Fruit drinks: At all visits, black girls consumed more than white girls. White girls' consumption changed little during the study, except for modest increases at Visits Four and Eight. In contrast, black girls' intake increased at a much greater rate between Visits Three and 10 (ages 11.5 to 18.6 years)
  • Coffee and tea: Black girls, on average, consumed less.

Mean Daily Consumption (Standard Error) of Each Type of Beverage (in Grams), by Race and Visit)

    Visit (Mean Age in Years at Visit)              
Race Beverage One (9.5) Two (10.5) Three (11.5) Four (12.5) Five (13.5) Seven (15.5) Eight (16.5) 10 (18.6)
White Regular Soda 135.45 (8.29) 164.33 (8.54) 201.70(8.63) 216.56 (9.32) 242.12 (9.13) 274.48 (9.74) 329.70 (9.90)  377.02 (9.09)
  Diet Soda 22.36 (4.52) 33.82 (4.66) 37.39 (4.71) 49.60 (5.09) 52.65 (4.99) 71.48 (5.32) 72.63 (5.41) 81.86 (4.96)
  Milk 352.04 (7.22) 340.00 (7.44) 348.83 (7.52) 320.07 (8.12) 306.28 (7.96) 290.20 (8.49) 262.24 (8.63) 241.99 (7.92)
  Coffee and Tea 19.78 (3.45) 20.09 (3.55) 22.74 (3.59) 22.35 (3.88) 27.90 (3.80) 53.31 (4.06) 67.44 (4.12) 105.60 (3.78)
  Fruit Juice 110.46 (4.94) 106.70 (5.09) 111.64 (5.15) 103.80 (5.56) 120.58 (5.45) 124.81 (5.81) 119.38 (5.91) 128.68 (5.42)
  Fruit Drinks 78.41 (4.39) 82.23 (4.53) 81.91 (4.57) 95.39 (4.94) 84.41 (4.84) 80.26 (5.17) 96.92 (5.25) 87.16 (4.82)
Black Regular Soda 134.53 (7.85) 173.15 (7.87) 210.44 (7.76) 244.96 (8.33) 299.41 (8.13) 326.06 (8.79) 347.19 (8.73) 338.48 (8.11)
  Diet Soda 7.20 (1.75) 11.53 (1.75) 8.38 (1.73) 10.28 (1.86) 8.59 (1.81) 10.21 (1.96) 8.65 (1.95) 9.46 (1.81)
  Milk 244.13 (5.36) 237.99 (5.37) 214.83 (5.30) 180.44 (5.68) 160.30 (5.55) 150.45 (6.00) 147.57 (5.96) 144.62 (5.53)
  Coffee and Tea 19.50 (2.61) 18.94 (2.61) 17.55 (2.58) 18.66 (2.77) 23.03 (2.70) 29.08 (2.92) 41.11 (2.90) 46.84 (2.69)
  Fruit Juice 108.36 (4.86) 103.91 (4.87) 105.43 (4.81) 93.32 (5.16) 110.02 (5.03) 115.38 (5.44) 105.80 (5.41) 119.81 (5.02)
  Fruit Drinks 134.68 (6.78) 144.47 (6.80) 169.44 (6.71) 173.27 (7.19) 159.73 (7.02) 212.74 (7.59) 202.34 (7.54) 204.41 (7.00)

  • Regular soda intake was associated with BMI [chi-square (1)=49.95 to 2,072.68; P<0.0001]. See table below.
  • Consumption of beverages was associated with an increase in average daily caloric intake [chi-square (1)=49.95 to 2,072.68; P<0.0001]
  • Drinking milk, soda, fruit drinks or coffee or tea was associated with increased average daily sucrose consumption [chi-squares (1)=5.85 to 469.34; P<0.05]
  • Diet soda consumption was asscociated with a significant decrease in average daily sucrose intake [chi-square (1)=6.63; P<0.01]
  • Fruit juice was not associated with average daily sucrose intake
  • Drinking soda, fruit juice or fruit drinks was strongly associated with increased average daily fructose consumption [chi-squares (1)=7,809.30 to 13,752.38; P<0.0001], whereas drinking milk or coffee or teas was associated with decreased average daily fructose intake [chi-squares (1)=22.79 and 8.25, respectively; P<0.05]
  • Diet soda was not associated with average daily fructose. All beverages except diet soda were associated with increased intake of average daily total sugar intake [chi-squares (1)=213.98 to 5,300.18; P<0.0001]
  • Diet soda consumption was not associated with average daily total sugar intake. Milk and diet soda consumption were associated with increased average daily calcium intake [chi-squares (1)=73.35 and 10,000.65, respectively; P<0.0001]
  • Regular soda, fruit drinks, or coffee or tea was associated with significant decreases in average daily calcium intake [chi-squares (1)=6.46 to 94.17; P<0.05]
  • Fruit juice was not associated with average daily calcium intake.

Relationship Among Beverage Consumption (in Units of 100g per Day) and Outcomes of Body Mass Index and Average Daily Intake of Total Energy, Sucrose, Fructose, Total Sugars and Calcium

  Beverage Parameter Estimate SE          
Outcomes Milk Regular Soda Diet Soda Fruit Juice Fruit Drinks Coffee or Tea
BMI -0.002 (0.006) 0.011 (0.0005)a -0.010 (0.013) 0.005 (0.007) 0.009 (0.007) 0.005 (0.013)
Daily Energy (kcal) 96.4 (2.2)d 81.5 (1.7)d 29.1 (4.1)d 81.3 (2.7)d 81.3 (2.3)d 46.3 (4.3)d
Daily Sucrose (g) 0.2 (0.1)a 0.6 (0.1)d -0.5 (0.2)b 0.2 (0.1) 2.3 (0.1)d 3.8 (0.2)d
Daily Fructose (g) -0.15 (0.03)d 3.99 (0.03)d -0.01 (0.06) 4.89 (0.04)d 3.43 (0.03)d -0.18 (0.06)b
Daily Total Sugar (g) 4.3 (0.1)d 7.8 (0.1)d -0.3 (0.2) 9.4 (0.1)d 8.9 (0.1)d 3.4 (0.2)d
Daily Calcium (mg) 103.1 (0.8)d -7.0 (0.7)d 13.7 (1.6)d 1.7 (1.1) -2.3 (0.9)a -6.7 (1.7)c 

a: P<0.05
b: P<.01
c: P<0.001
d: P <0.0001.

Author Conclusion:

Limitations or Biases

  • Dietary information was based on self-reporting and may therefore be subject to recall errors or under-reporting
  • Before data entry, food was reduced into main ingredients, making it impossible to relate beverage to consumption of specific foods or type of meals (fast food)
  • Because the NGHS started out with a limited age range of nine- to 10-year-old children and did not collect food diaries in every year, it was not possible to report beverage consumption for each age
  • The NGHS is not a national sample of girls
  • However, these limitations are offset by several strengths, such as large number of black girls, low drop-out rate and availability of three days of food intake data
  • Public health efforts are needed to help adolescents gain access to and choose healthful beverages and decrease intake of beverages of minimal nutritional value.
Funding Source:
Government: NHLBI
Reviewer Comments:
We retained the nomenclature of "black and white" rather than African-American and Caucasian because this is how it was described in the original article.
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? Yes
  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) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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? N/A
  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.) N/A
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  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? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  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? N/A
  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? N/A
  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? Yes
  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? No
  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? Yes
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