100% Fruit Juice, Vegetable, And Sweetened Beverage

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Validity and reliability of a behavior-based food coding system for

measuring fruit, 100% fruit juice, vegetable, and sweetened beverage

consumption: results from the Girls Health Enrichment Multisite Studies

Karen W. Cullen, Dr.P.H., R.D., L.D.,a,* John H. Himes, Ph.D., M.P.H.,b

Tom Baranowski, Ph.D.,a Janet Pettit,b Mary Stevens,b

Deborah Leachman Slawson, Ph.D., R.D., c Eva Obarzanek, Ph.D., R.D.,d

Maureen Murtaugh, Ph.D., R.D.,b Donna Matheson, Ph.D.,e

Wanjie Sun, M.S., f and James Rochon, Ph.D.g

aDepartment of Pediatrics, Childrens Nutrition Research Center, Baylo r College of Medicine, Houston, TX 77030-2600, USAbDivision of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA

cUniversity of Memphis, Memphis, TN 38152, USAdDivision of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, MD 20892, USA

eCenter for Research in Disease Prevention, Stanford University, Stanford, CA 94305, USAfGeorge Washington University Biostatistics Center, Rockville, MD 20852, USA

gDuke Clinical Research Institute, Durham, NC 27715, USA

Abstract

Background. This paper presents the rationale, reliability, and validity of a behavior-based food coding system for measuring fruit (F),

juice (J), vegetable (V), sweetened beverage, and water consumption in children.

Methods. Coding algorithms for FJV, sweetened beverages, and water were developed for use with the Nutrition Data System forResearch (NDS-R). Two hundred and ten 8- to 10-year-old African American girls at four field centers completed two 24-h dietary recalls at

baseline and at 12 weeks follow-up after a weight gain prevention intervention. Differences in mean baseline consumption of selected food

variables and other selected nutrients across the four field centers were analyzed. Intraclass correlation coefficients (ICCs) for reliability

across 2 days of food recalls and 12-week test retest reliability correlations were calculated. For the purposes of this paper, nutrient intake

estimates were considered construct validators of food intake, and validity was assessed by correlating the coded food variable servings with

nutrient intake.

Results. ICCs varied from zero (0.001 for beta carotene equivalents) to moderate (0.44 for sucrose), indicating substantial instability in

consumption or reporting. Twelve-week test retest correlations were slight to moderate (0.09 for lycopene to 0.49 for folate). FJV

consumption was negatively related to percent energy from fat (r = 0.28; P= 0.001) and positively related to other nutrients. Sweetened

beverage consumption was positively related to energy, sucrose, fructose, and vitamin C consumption.

Conclusions. This behavior-based food coding system demonstrated construct validity among 8- to 10-year-old African American girls

and can measure the desired food groups.

D2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Keywords: Obesity; Prevention; Female; African American; Children; Diet; Fruit; Vegetables; Juice; Sweetened beverages; Water; Validity; Reliability

Introduction

Healthy dietary behaviors such as increased consumption

of fruit (F), 100% fruit juice (J), and vegetable (V) and

reduced consumption of sweetened beverages have been

related to lower chronic disease risk [13] and lower body

weight [46]. Assessing the impact of behavior change

0091-7435/$ - see front matterD 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

doi:10.1016/j.ypmed.2003.05.001

* Corresponding author. Department of Pediatrics, Childrens Nutrition

Research Center, Baylor College of Medicine, 1100 Bates Street, Houston,

TX 77030-2600. Fax: +1-713-798-6764, +1-713-798-7098.

E-mail address: [email protected] (K.W. Cullen).

www.elsevier.com/locate/ypmed

Preventive Medicine 38 (2004) S24S33


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programs focusing on FJV or sweetened beverages requires

valid and reliable measurement of dietary intake. Several

coding systems currently exist for measuring FJV consump-

tion, and the inclusion of FJV items to summarize intakes

reflects the emphases of programs with which they are

associated [710]. Targeting particular fruits and vegetables

for inclusion in coding systems is appropriate and shoulddepend on the research question [8,9] because it can

influence whether the project is determined to be a success

[8,11]. Similarly, the coding procedure used for sweetened

beverages should reflect the research question and be clearly

defined.

Behavior-based coding systems are designed to measure

targeted dietary changes. Thus, a major difference between

food coding methods is the definition of particular foods

and preparatory practices reflected within composite cate-

gories of FJV. For example, the 5 A Day program, whose

goal is to encourage behavior change for healthy diets that

are lower in fats and sweets and higher in FJV, discounts

condiments (e.g., catsup), high-fat and sweetened fruits

(e.g., apple pie), and high-fat vegetables (e.g., potato chips

and French fries) [9]. Only 100% fruit juice was counted

within the juice composite. Other, especially analytic epi-

demiologic, studies measure total nutrient intake to assess

nutrient chronic disease relationships and thereby often

count all food sources of the nutrients of interest for

inclusion in coding systems.

The Girls Health Enrichment Multisite Studies (GEMS),

conducted at four field centers, was a collaborative effort

designed to develop and evaluate interventions to prevent

excessive weight gain among 8- to 10-year-old African

American girls. The major dietary goals of three of theGEMS interventions were to increase FJV and water

consumption and to decrease sweetened beverage consump-

tion. The other intervention primarily targeted physical

activity and had minimal emphasis on dietary change.

The GEMS investigators selected a behavior-based coding

system approximating the national 5 A Day guidelines [9]

and developed coding algorithms for FJV for use with the

Nutrition Data System for Research (NDS-R) software

(version 4.02_30, 1999, Nutrition Coordinating Center,

University of Minnesota, Minneapolis, MN). New coding

algorithms were also developed for sweetened beverages

and water.

This report describes the procedures used for developing

the coding system to define servings of FJV, sweetened

beverages, and water and examines these derived food

serving composite variables for their reliability and validity.

Methods

Study design

Pilot studies were conducted at four field centers, located

at Baylor College of Medicine, Houston; University of

Memphis; University of Minnesota, Minneapolis; and Stan-

ford University, Palo Alto. A coordinating center, located at

the George Washington University Biostatistics Center,

provided support and coordination for key study activities.

The National Heart, Lung, and Blood Institute sponsored the

program and their staff also participated. A total of 210

African American girls, age 8 10 years, were randomlyassigned to an active intervention (n = 115) or comparison

group (n = 95). Each field center designed and developed its

own 12-week intervention targeting a healthy diet and/or

engaging in physical activity. Girls assigned to comparison

groups were given health education materials or counseled

on topics other than diet and physical activity. All four field

centers had several common key measures, including die-

tary intake, which were measured the same way across field

centers. Outcome measurements were taken at baseline, just

before randomization, and at follow-up, soon after the 12-

week intervention period concluded. All parents or guard-

ians gave written informed consent, and girls gave their

assent to participate in the study. Each field centers study

was approved by its IRB. Other details of the design are

described elsewhere [11].

Dietary assessment methods

At baseline, each girl completed two 24-h dietary recalls

that were administered 12 weeks apart. Recalls covering

one weekend day and one weekday were encouraged but not

required. GEMS staff obtained the information and recorded

it using a laptop computer and NDS-R software. The first

interview was conducted in person with online interview

prompts and a food amounts booklet available to provide

dimensional and volume reporting aids for prompting thegirl to recall the foods and amounts eaten. The second

interview was conducted by telephone, also using NDS-R

along with a food amounts booklet given to the girls at the

first interview. The telephone interview method was used to

minimize participant burden of traveling to some data

collection place for the second recall. According to NDS-

R procedures, a multiple-pass approach was utilized to

provide the girls with several opportunities to recall food

and beverage consumption for the previous day. An initial

brief listing of meals and foods was entered into the

computer. This was followed by prompts for additional

foods not previously recalled and for more detailed infor-

mation regarding each food listed. Additional foods con-

sumed were often remembered and recorded during the

probing. After probing, the data collector read what was

recorded and queried for verification and completeness. At

each center, a lead nutritionist reviewed each recall and sent

all to NCC. Another review was conducted and questionable

values were marked and the data returned to each center.

The final data cleaning procedure was a reconciliation

between the NCC and each center and this data file was

used in all analyses. After the 12-week intervention was

concluded, the girls completed another pair of dietary recalls

using the same procedures as during baseline. For analyses,

K.W. Cullen et al. / Preventive Medicine 38 (2004) S24S33 S25


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Table 1

Description of GEMS behavior-based food groups

Category Group name Inclusion Exclusion Serving size Unit

Fruit 1. Fresh, frozen,

cooked, canned,

and dried

1. Baked goods, desserts,

and pies

2. Fruit other than raisins

1. Fresh, frozen, canned,

or cooked = 1/2 cup

chopped or default density

serving/day

2. Caramel apple

3. Fruit in recipes(e.g., salads)

in cereal

3. Avocado4. Maraschino cherries

2. One medium piece

when appropriate(e.g., apple, orange)

4. Raisins in cereal 5. Fruit in cookies 3. Dried = 1/4 cup

5. Jell-O with fruit 6. Granola bars with fruit

7. Trail mix

8. Banana chips

4. Cereal = to be determined

(e.g. 1 cup cereal = 1/4 cup raisin)

9. Fruit leather or fruit roll-ups

10. Fruit in candy

(e.g., chocolate or yogurt

covered raisins)

11. Fruit in ice cream and

ice cream recipes

12. Fruit in commercial

entrees

13. Fruit in jam, jelly, and

marmalade

Fruit juice 1. 100% juice

(sweetened or

unsweetened)

1. Drinks with


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the 2 days of collection were averaged for each assessment

period, baseline, and postintervention, respectively.

The University of Minnesota Nutrition Coordinating

Center staff trained at least one dietary assessment staff

from each field center centrally; subsequently, all other

measurement staff were trained by the NCC-trained staff

and certified by NCC after passing standard certification

tests.

Behavioral food coding system

Decisions regarding food grouping were based on the

content and intentions of the interventions. In this way,

changes in consumption could be linked to the intervention

effects.

Fruit. Only fruits that appeared like fruits when eaten, in

the fresh, canned, or frozen forms, were included in the

coding system. Fruits from high-fat and sugar-containing

dishes such as fruit in baked desserts and baked grain

products (e.g., pie, granola bar), fruits that had a high

concentration of added sugar (e.g., jam, roll-up, fruit leath-

er), and deep-fried fruit chips (e.g., apple chips, banana

chips) were not included (Table 1). Fruits suspended in

flavored gelatin and raisins in cereals were counted.

Juice. Only 100% fruit or vegetable juices in the fresh,

canned, or frozen forms were included (Table 1). Amounts

less than 100% dilute the nutritional value of fruits and

vegetables and were not targeted in this intervention.

Vegetables. Only vegetables that appear like vegetables, or

vegetable pieces, in the fresh, frozen, or canned forms, were

included (Table 1). Vegetables high in fat like olives and

avocados were excluded. Fried vegetables with high-fat

Category Group name Inclusion Exclusion Serving size Unit

Water-based

beverages

Sweetened

soft drinks

1. Sweetened

carbonated drink

1. Artificially sweetened

carbonated drinks

8 fluid ounces serving/day

2. Consumed as a

beverage

2. Ice

3. Not consumed as a

beverage (i.e., part of

a recipe)Water-based

beverages

Sweetened

fruit drinks

1. Sweetened

noncarbonated

drink

1. Artificially sweetened

noncarbonated drinks

2. Dry powder

8 fluid ounces serving/day

2.


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content were not counted (e.g., French fries, hash browns,

other fried potato products, fried onion rings). Tomato paste

and sauce in mixed dishes as well as vegetable condiments

were excluded because they are found mostly in foods that

were not promoted in the interventions (e.g., pizza, catsup).

Within mixed dishes, the amount of each component vege-

table was included to provide a total number of servings ofvegetable for the entire amount eaten (e.g., carrots, potatoes,

and onion in beef stew.) Legumes were defined as mature

beans and soy products and were considered vegetables.

However, they were categorized separately from the vegeta-

ble group and only included in the summary composite of all

fruits, juices, and vegetables. Textured vegetable protein

products (e.g., veggie burgers) were not counted as legumes

because they are processed protein products. Vegetables with

sauces and cheese (e.g., baked potato with toppings, broc-

coli-cheese casserole) were counted since the interventions

focused on substituting lower fat cheeses and sauces for the

typical higher fat versions.

Sweetened beverages. The sweetened beverages category

was operationalized as water-based beverages. The inter-

ventions encouraged girls to choose water and thereby

hopefully decrease sweetened beverage consumption (Table

1). The coding categories were soft drinks (carbonated),

fruit drinks (noncarbonated), sports drinks, sweetened tea,

sweetened coffee, and sweetened water.

Water. Noncarbonated, nonsweetened water from the tap

or in bottles that was consumed as a beverage was counted.

Hypotheses. Nutrients included in the analyses were se-lected to relate to the behavioral coding of food groups (F, J,

V, water, and sweetened beverages) in specific directions

and included total energy intake, percent energy from fat,

sucrose, fructose, dietary fiber, folate, vitamin C, beta

carotene equivalents, and lycopene. Support for the con-

struct validity of the food group coding system would be

provided in two ways: the presence of a significant corre-

lation between a food group and nutrients related to the food

group (e.g., between vegetables and beta carotene equiv-

alents; fruits and vitamin C) and by dietary displacement

(e.g., a negative relationship between water and sweetened

beverages or between F, J, V, and fat intake). The hypoth-

eses included the following: (1) F, J, and V consumption

would be positively related to consumption of energy,

dietary fiber, folate, vitamin C, beta carotene, and lycopene

(dietary correlation) and negatively related to percentage of

energy from fat (dietary displacement); (2) sweetened bev-

erage consumption would be positively related to energy

intake and the major components of the sugars, sucrose, and

fructose (dietary correlation) and negatively related to

dietary fiber, folate, vitamin C, beta carotene, and lycopene

(dietary displacement); and (3) water consumption would be

negatively related to energy, sucrose, fructose, and percent

energy from fat (dietary displacement).

Data analysis. Demographic characteristics were com-

pared between the four centers using chi-squares for cate-

gorical variables and ANOVA for continuous variables.

Mean daily nutrient totals for all girls at baseline were

calculated, averaged across the 2 days, and compared

between field centers using ANOVA. Mean daily consump-

tion of all food group servings for all girls at baseline wascalculated using GEMS behavior-based food coding system

and compared between field centers using ANOVA.

Intraclass correlation coefficients (ICCs) were calculat-

ed across the 2 days of baseline dietary intake for all food

categories to assess reliability across days of intake for

each girl. Differences among field centers were assessed

using Fishers Z transformation and chi-square test statistic

(n = 210 girls). Bivariate plots of Days 1 and 2 nutrient

and food group consumption values were examined for

outliers and potential bias between reporting days. Mean

daily nutrient totals and food group servings were calcu-

lated for girls in the comparison groups at follow-up.

Test retest reliability was assessed by calculating Spear-

man correlations for all food groups and nutrient variables

between the mean of the two recalls at baseline and mean

of the two recalls at follow-up for girls in the comparison

groups only. Spearman correlations were used because not

all variables were normally distributed. To assess con-

struct validity or how well the food coding system

worked, Spearman correlation coefficients were calculated

between all food group servings and nutrients at baseline.

Validity correlations were first conducted separately by

field center and compared between centers using Fishers

Z transformation and the chi-square test statistic. The

validity correlations did not consistently differ by fieldcenter. Therefore, data were pooled across the sites for

this report. Variables with significant site differences in

Table 2

Baseline characteristics of randomized girls

Baylor,

n = 35

Memphis,

n = 60

Minnesota,

n = 54

Stanford,

n = 61

Mean

(SE)

Mean

(SE)

Mean

(SE)

Mean

(SE)

Girl age*** 8.0

(0.1)

8.9

(0.1)

8.8

(0.1)

9.1

(0.1)

Parent education (%)***

Some high school 0.0 10.3 10.2 11.1

High-school graduate 3.0 17.2 26.5 25.9

Tech school or some

college

3.0 8.6 12.2 0.0

College or graduate

degree

93.9 63.8 51.0 63.0

Household income (%)

< US$20,000 12.1 35.6 26.0 31.5

US$20,000 $39,999 36.4 33.9 44.0 42.6

zUS$40,000 51.5 30.5 30.0 25.9

Body mass index

(kg/m2)***

23.8

(1.0)

23.7

(0.7)

20.4

(0.8)

21.3

(0.8)

***P < 0.001 for differences among field center.

K.W. Culle n et al. / Preventive Medicine 38 (2004) S24S33S28


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the pattern of validity correlations are described in the

text.

Results

Demographic characteristics of the GEMS participants byfield center are shown in Table 2. Significant differences for

age, body mass, and parental education were found between

centers. The girls randomized at Baylor were 8 years old; the

other three field centers enrolled 8, 9, and 10 year old girls.

The majority of parents at Baylor reported a college degree or

higher. Girls from Baylor and Memphis had significantly

higher body mass index than girls from Minnesota.

All girls completed the baseline assessment. Becausedifferences in BMI by field center were identified, analyses

Table 4

Intraclass correlation coefficients across 2 days of dietary intake at baseline and daily mean (SD) consumption for Days 1 and 2 recalls

Intraclass correlations Mean intakes

All girls,

n = 210

Baylor,

n = 35

Memphis,

n = 60

Minnesota,

n = 54

Stanford,

n = 61

Day 1,

n = 210

Day 2,

n = 210

Kilocaloriesa 0.43* 0.66 0.19 0.28 0.46 1,629 (737) 1,551 (647)

% Energy from fat 0.13 0.23 0.05 0.17 0.11 34.7 (7.7) 34.5 (7.8)

Sucrose (g)a 0.44*** 0.82 0.42 0.02 0.05 44.9 (39.3) 40.8 (33.3)

Fructose (g) 0.21 0.48 0.01 0.11 0.21 24.1 (15.6) 22.8 (14.5)

Fiber (g) 0.42 0.37 0.42 0.28 0.48 9.8 (5.4) 9.5 (5.3)

Folate (Ag) 0.38 0.43 0.55 0.31 0.34 258.0 (34.3) 274.0 (169.4)

Vitamin C (mg) 0.13 0.13 0.20 0.20 0.13 76.7 (66.9) 75.1 (81.4)

Beta carotene equivalents 0.001 0.12 0.10 0.16 0.05 1,114 (2,121) 1,523 (3,095)

Lycopene (Ag)a 0.22*** 0.06 0.69 0.01 0.04 4,225 (6,005) 3,540 (5,806)

Fruit (serving) 0.17 0.11 0.15 0.36 0.08 0.44 (0.88) 0.39 (0.88)

100% fruit juice (serving)a 0.16* 0.09 0.08 0.43 0.20 0.63 (0.86) 0.67 (0.83)

Vegetables (serving) 0.06 0.04 0.22 0.12 0.04 0.75 (0.89) 0.96 (1.31)

Legumes (serving) 0.05 0.11 0.08 0.10 0.02 0.08 (0.24) 0.04 (0.14)

Total FJV (serving) 0.20 0.26 0.0005 0.32 0.24 1.88 (1.71) 2.02 (1.92)

Water (serving) 0.38 0.45 0.38 0.41 0.21 0.74 (1.02) 0.86 (1.21)

Sweetened beverages (serving) 0.04 0.20 0.10 0.03 0.12 1.23 (1.25) 1.1 (1.1)

a ICCs different between field centers.

*P < 0.05.

***P < 0.001.

Table 3

Mean (SD) daily intakes at baseline by field center from 2 days of 24-h recalls

All girls,

n = 210

Baylor,

n = 35

Memphis,

n = 60

Minnesota,

n = 54

Stanford,

n = 61

Post hoc comparison

Total energy** 1,590 (590) 1,914 (831) 1,498 (472) 1,468 (448) 1,603 (583) Baylor > all

Energy from fat* 34.6 (5.9) 33.3 (5.7) 36.3 (5.1) 32.9 (6.1) 35.1 (6.1) Memphis > Minnesota

Sucrose (g)** 42.8 (31.1) 62.6 (55.7) 34.8 (19.8) 41 (16.4) 41 (26.3) Baylor > all

Fructose (g)** 23.5 (11.9) 29 (14.1) 19.4 (8.7) 23.9 (9.9) 23.9 (13.5) Baylor, Minnesota,Stanford > Memphis

Fiber (g) 9.7 (4.5) 11 (4.7) 9.1 (4.2) 8.7 (3.5) 10.3 (5.2)

Folate (Ag) 266 (127.1) 318.8 (185.2) 234.5 (117.7) 258.7 (95) 272.9 (112.1)

Vitamin C (mg) 75.9 (56.0) 93 (76.0) 68 (47.2) 81.9 (50.2) 68.5 (54.0)

Beta carotene

equivalents (Ag)

1,318 (1,885) 1,732 (2,025) 1,292 (1,857) 1,100 (1,710) 1,300 (1,985)

Lycopene (Ag) 3,883 (4,627) 5,790 (5,316) 3,293 (5,737) 3,290 (3,288) 3,893 (3,725)

Fruit (serving)** 0.4 (0.7) 0.3 (0.5) 0.3 (0.4) 0.5 (0.7) 0.6 (0.9) Minnesota and Stanford >

Baylor; Stanford > Memphis

100% fruit juice

(serving)**

0.7 (0.7) 0.6 (0.6) 0.5 (0.4) 0.9 (0.8) 0.6 (0.7) Minnesota > Baylor,

Memphis, Stanford

Vegetables (serving)* 0.9 (0.8) 1.2 (1.0) 0.8 (0.8) 0.7 (0.7) 0.8 (0.8) Baylor > all

Legumes (serving) 0.1 (0.1) 0.0 (0.1) 0.1 (0.1) 0.0 (0.1) 0.1 (0.2)

Total FJV (serving) 1.9 (1.4) 2.2 (1.5) 1.6 (1.1) 2.1 (1.4) 1.9 (1.7)

Water (serving) 0.8 (0.9) 0.9 (1.4) 0.9 (0.9) 0.8 (0.8) 0.7 (0.7)

Sweetened beverages

(serving)***

1.2 (0.9) 1.9 (1.1) 1.0 (0.8) 0.9 (0.7) 1.1 (0.8) Baylor > all

*P < 0.05 for differences among centers by ANOVA.

**P < 0.01 for differences among centers by ANOVA.

***P < 0.001 for differences among centers by ANOVA.



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nutrient. Sweetened beverage consumption was positively

correlated with energy (P < 0.001), sucrose (P < 0.001),

fructose (P < 0.001), and vitamin C (P < 0.05). Few

differences across field centers in correlations between

nutrients and food groups were found, and field center-

specific correlations were generally in the same direction as

the pooled data correlations.

Discussion

This report described the development of a coding

system to define servings of FJV, sweetened beverages,

and water from 24-h dietary recalls collected via NDS-R and

examined these derived food servings variables for their

reliability and validity. Two types of construct validity

(dietary correlation and dietary displacement) for the de-

rived food group variables were evident from the significant

correlations between specific nutrients and food groups

(Table 6).

Total FJV and juice consumption were negatively related

to the percentage of energy from fat, providing some

support for the dietary displacement hypothesis that eating

a greater amount of FJV may displace foods higher in fat

[12]. Alternatively, juice consumption may have increased

energy intake, but not fat, thereby reducing the percent

energy from fat without displacing high-fat foods. This

result also could reflect substitution of juice as a meal

beverage instead of milk. Mean daily juice intake, however,

was only 0.7 servings per day or about four fluid ounces,

perhaps minimizing the likelihood of the last two alterna-

tives to the dietary displacement hypothesis.The dietary correlation type of construct validity was

found for FJV. Fruit consumption was positively related to

nutrients found in fruits (fructose, fiber, and vitamin C),

with the exception of folate. The latter finding might reflect

alternative sources of folate, particularly from fortification

of grain products. Juice was positively correlated to all the

nutrients in FJV, plus sucrose. Vegetable consumption was

significantly correlated with nutrients commonly found in

vegetables (fructose, fiber, folate, vitamin C, beta carotene

equivalents, and lycopene).

Dietary correlation was also moderate for sweetened

beverages (Table 6). Significant positive correlations were

obtained between sweetened beverages and energy, sucrose,

fructose, and vitamin C. Because the major sweetener of

soft drinks and fruit drinks is high fructose corn syrup and

sucrose, and vitamin C is often added to fruit drinks, a

component of sweetened beverages, these correlations are

not surprising. The lack of a negative relationship between

sweetened beverages and percent energy from fat (dietary

displacement) may reflect a moderate consumption of

sweetened beverages by these girls, which ranged from

0.9 to 1.9 servings (7.215 fluid ounces) per day (Table 3).

Water consumption was very low and the data did not

indicate dietary displacement of other foods and beverages.

Low variability in water consumption may account for why

it was not related to consumption of any nutrient. Little is

known about water consumption by children in the United

States. Water consumption is an important area of research

because potential savings in energy may be an important

component of obesity prevention and weight management

programs [21].The poor to moderate ICCs revealed substantial vari-

ability in intake over 2 days, which may be particularly

evident for nutrients and food groups in which consump-

tion is very low (Table 4). Many of the recalls were

conducted on both a weekday and a weekend, that is,

Saturdays and Sundays. Because weekend consumption for

some foods may differ systematically from consumption

on week days [13], this may influence the ICC. For

example, sweetened beverages may only be allowed on

weekends in some homes. The reliability ICCs of sweet-

ened beverages, legumes, and vegetables were poor. The

low reliability of vegetable servings (r = 0.06) is consistent

with the low ICC for beta carotene equivalents (0.001)

because vegetables are a major source of this nutrient.

Higher ICCs would be expected with more days of

assessment. To achieve an ICC of 0.4, approximately 10

days of collection would be needed for vegetable intake.

An ICC of 0.32 was obtained for vegetables from 5 days

of food records completed by 137 African American,

Hispanic, and White 9- to 12-year-old girls [14], whereas

an ICC of 0.53 for vegetables was obtained for two 24-

h dietary recalls from 10- to 14-year-old African American

boy scouts [15]. The ICCs for fruit (0.17) and juice (0.16)

reported here were also lower than those obtained in

previous work with 9- to 12-year-old girls (0.65 for fruitand 0.51 for juice) [14] and 11- to 14-year-old boys (0.31

for fruit and 0.33 for juice) [15]. These results suggest that

this younger group of African American girls (mean age

about 9 years) may not provide reliable self-report of

dietary intake and that more than 2 days of dietary

assessment may be needed to provide more reliable esti-

mates of usual consumption from younger girls. Alterna-

tively, GEMS dietary intake was collected in 2002, 4 5

years after the previous studies [14,15]. Family dietary

patterns experienced by the GEMS participants may be

more variable from day to day, especially from weekday to

weekend day, than the dietary patterns from 5 years ago.

Reported dietary intake of FJV, sweetened beverages,

water, energy, percentage of energy from fat, and selected

nutrients varied among 8- to 10-year-old girls across the

four field centers in the GEMS program (Table 3). For

three of the field centers, total energy intake was lower than

the 1,812 energy reported by a large nationally representa-

tive sample of 6- to 11-year-old African American girls

[16]. The percentage of energy from fat exceeded the

recommended 30% but was similar to the 33.7% reported

by 611 years old, a large nationally representative sample

of African American girls [16]. Despite reporting one of the

lowest overall energy intake, girls from Memphis also



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reported the highest consumption of fat as a percent of total

energy.

The recommended intake of grams of dietary fiber for

children is 5 plus their age [17]. Girls from all field centers

reported about half the recommended value (9.7 g). These

fiber intakes were somewhat lower than the 12 g reported by

a national sample of 6- to 11-year-old African Americangirls via two in person 24-h dietary recalls [16]. Girls from

all field centers reported consumption of vitamin C (75.9

mg) beyond the recommended range of 25 mg for 8 year

olds and 45 mg for girls ages 910 but less than the 111 mg

reported by a national sample of 6- to 11-year-old African

American girls [16]. Folate intakes (266 Ag) were lower

than the 300 Ag recommended for 9- to 13-year-old girls but

similar to national data for 6- to 11-year-old African

American girls (233 Ag) [16].

In general, FJV consumption by GEMS girls (1.9 serv-

ing/day) was very low compared to national surveys.

However, the behavior-based food coding system excluded

high-fat vegetables, fruits in desserts, and juice in fruit

drinks that may account for the low consumption values.

Consumption of 2.13 servings of FJV was reported by 210

African American, Hispanic, and White 9- to 12-year-old

students in Houston using a behavior coding system and

student-completed food records [14]. Girls from Baylor

consumed the greatest amount of vegetables (1.2 servings

per day), which was still lower than the 2.4 servings

reported by a national sample of 6- to 11-year-old African

American girls [16]. However, 25% of vegetables were

French fries in the national data set, and our coding scheme

excluded fried potatoes [16] so our values are actually much

lower than national estimates. Memphis and Baylor girlsreported the lowest fruit consumption (0.3 serving/day), but

the other field centers also reported low consumption (0.5

0.6 serving/day) compared with the 1.4 serving reported by

a national sample of 6- to 11-year-old African American

girls [16]. The national data reflect an epidemiological FJV

coding system whereby all FJV counts are not directly

comparable to the current analyses. However, it is clear that

girls assessed in this study are consuming inadequate

amounts of fruits and vegetables and interventions are

needed to improve consumption of these important foods.

More 100% fruit juice was consumed by Minnesota girls

(about 5.3 fluid ounces) than the other three field centers.

About 2.1 fluid ounces of citrus juices were consumed by 6-

to 11-year-old African American girls [16]. Sweetened

beverage consumption varied from the highest amount

(1.9 servings or 15.2 fluid ounces) for the Baylor field

center to a low of 7.2 fluid ounces reported by girls in

Memphis. Previously published data reported consumption

of about 11.6 fluid ounces of sweetened beverages for 9- to

12-year-old African American boys and girls in Houston

[18] and 11.8 fluid ounces by a national sample of African

American girls [16]. The Houston data were obtained from

up to 7 days of food records completed daily in classrooms

and might have provided more reliable estimates of con-

sumption compared with other reported sweetened beverage

consumption data. Because sweetened beverages supply

only energy, consumption at any level may increase risk

for weight gain.

The variability in sweetened beverage consumption

across field centers may reflect true differences in con-

sumption and patterns, perhaps due to regional differ-ences in food amounts consumed and in region-specific

differences in reporting. Test retest correlations of aver-

age intake between baseline and conclusion of the inter-

vention for girls in the comparison condition were in the

poor to moderate range (Table 5). This could reflect

variation due to seasonal availability since up to 5

months elapsed between baseline and follow-up recalls.

Differences in the proportion of weekend versus weekday

meals between baseline and follow-up might have con-

tributed to the lower values.

There are several important limitations to these results.

The low reliability across the 2 days of recalls for some of

the food groups and nutrients may have reduced the ability

to detect real differences between the testretest measures.

Obtaining more days of dietary recall would reduce the

standard error and increase the likelihood of detecting

significant relationships in the data. Seasonality and day

of the week effects could impact the results. All data were

from self-report and are thereby subject to memory and

recall errors [19]. To minimize this problem, all data

collectors attended a rigorous training program and were

certified in using NDS-R to collect GEMS dietary recalls.

While some biomarkers would help to provide an objective

measure of some of the nutrients found in FJV [20],

measuring biomarkers is invasive, expensive, and difficultto justify with healthy young girls volunteering for a health

promotion program. Also, there is no biomarker adequate

for validating consumption of fruits or vegetables.

Conclusion

A behavior-based coding system for FJV, sweetened

beverages, and water for NDS-R was found to have con-

struct validity among 8- to 10-year-old African American

girls. Reliability across 2 days of recall was low for some

nutrients and food groups, suggesting that more than 2 days

of dietary recalls would be needed to provide more reliable

estimates of usual consumption. Use of the coding system

with children from other ethnic groups and adults and

further validation against observational or other procedures

are warranted.

Acknowledgments

This work is a publication of the USDA/ARS Depart-

ment of Pediatrics, Childrens Nutrition Research Center,

Baylor College of Medicine and Texas Childrens Hospital,

K.W. Culle n et al. / Preventive Medicine 38 (2004) S24S33S32


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Houston, TX. This study was sponsored by the National

Heart, Lung, and Blood Institute (U01 HL65160, U01

HL62662, U01 HL62663, U01 HL62732, and U01

HL62668). This project has also been funded in part by

federal funds from the USDA/ARS under Cooperative

Agreement No.58-6250-6001. The contents of this publica-

tion do not necessarily reflect the views or policies of theUSDA, nor does mention of trade names, commercial

products, or organizations imply endorsement by the U.S.

Government.

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100% Fruit Juice, Vegetable, And Sweetened Beverage