Intake of soft drinks and sugar sweetened beverages by Colombian children and adolescents

Oscar Fernando Herran Eduardo Villamor Doris Cristina Quintero-Lesmes About the authors

Abstract

Objectives:

to describe the consumption of sugar sweetened beverages in Colombia, South America and variables associated with this consumption.

Methods:

based on the Food Frequency Questionnaire applied in the National Survey of the Nutritional Situation of Colombia (2010), the prevalence and frequency/day of the consumption of sugar sweetened beverages by 10,070 subjects between 5 and 17 years old was estimated.

Results:

the prevalence of sugar sweetened beverages consumption in subjects between 5 and 17 years old was 85.3%, and the average frequency of consumption was 0.71 times/day. The relationship between age and the prevalence of consumption displayed a J form, and the association with frequency in times/day was linear. The highest consumption occurred at 16 years of age, with a prevalence of 90.4% and an average frequency of 0.83 times/day. Overweight and obesity were not associated with consumption (p>0.05).

Conclusions:

the prevalence and average frequency of consumption were positively associated with age, wealth, and level of urbanism and conversely associated with education and household food security. Children with stunting have a reduced prevalence but increased frequency of consumption. The consumption of sweetened-beverages is an expression of the stage of nutritional and food transitions.

Key words
Soft drinks; Diet; Child; Adolescent; Colombia

Resumo

Objetivos:

descrever o consumo de bebidas adoçadas com açúcar na Colômbia, América do Sul e as variáveis associadas a esse consumo.

Métodos:

embasados no Questionário de Frequência Alimentar aplicado na Pesquisa Nacional de Situação Nutricional da Colômbia (2010), foi estimada a prevalência e frequência/dia do consumo de bebidas adoçadas com açúcar por 10.070 indivíduos entre5 e 17 anos de idade.

Resultados:

a prevalência do consumo de bebidas adoçadas com açúcar em indivíduos entre 5 e 17 anos de idade foi de 85,3%, e a frequência média de consumo foi de 0,71 vezes/dia. A relação entre idade e prevalência de consumo demonstrou uma forma J, e a associação com a frequência em vezes/dia foi linear. O maior consumo ocorreu aos 16 anos de idade, com uma prevalência de 90,4% e uma frequência média de 0,83 vezes/dia. Sobrepeso e obesidade não foram associados ao consumo (p>0,05).

Conclusões:

a prevalência e a frequência média de consumo foram positivamente associadas com idade, condições financeiras e nível de urbanismo e inversamente associadas com educação e segurança alimentar doméstica. Crianças com déficit de crescimento têm prevalência reduzida, mas frequência de consumo aumentada. O consumo de bebidas adoçadas é uma expressão do estágio de transições nutricionais e alimentares.

Palavras-chave
Refrigerantes; Dieta; Criança; Adolescente; Colômbia

Introduction

In 2005, the National Nutrition Situation Survey (Encuesta Nacional de la Situación Nutricional, ENSIN-2005) in Colombia quantified the consumption of sugar-sweetened-beverages (SSB) through a 24-Hour Dietary Recall (r24h).11 Profamilia, Instituto Nacional de Salud, Universidad de Antioquia, OPS, Instituto Colombiano de Bienestar Familiar. Encuesta Nacional de la Situación Nutricional de Colombia, 2005. Ensin. 2006. p. 229-315. The prevalence of SSB consumption in the last 24 hours (PU24) was 21.8%, and the average amount consumed was 371 g. The PU24 for SSB was 11.3%, with an average amount of 31.5 g.11 Profamilia, Instituto Nacional de Salud, Universidad de Antioquia, OPS, Instituto Colombiano de Bienestar Familiar. Encuesta Nacional de la Situación Nutricional de Colombia, 2005. Ensin. 2006. p. 229-315. The report of this measurement was non-specific and did not differentiate whether the beverages contained sugar, or if, for example, the amount of SSB reported used powder or reconstituted liquid in their preparation.

Colombia, like Latin America, is not unfamiliar with 2 of the main phenomena associated with the development of chronic noncommunicable diseases (CND): nutrition and food transitions.22 Amigo H. Obesidad en el niño en América Latina: situación, criterios de diagnóstico y desafío. Cad Saude Publica. 2004;19(Suplemento 1): 163-70. As a consequence of the stages of transition, excess weight and obesity have increased in all groups. In the National Food Situation Survey (ENSIN-2010), the prevalence of overweight among children and adolescents between 5 and 17 years old was 17.5%.33 Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338. The nutrition transition continued in the period of 2005-2010, during which excess weight increased in the Colombian population by at least 5%.44 Kasper NM, Herrán OF, Villamor E. Obesity prevalence in Colombian adults is increasing fastest in lower socioeconomic status groups and urban residents: results from two nationally representative surveys. Public Health Nutr. 2014; 17: 1-9.

The habitual consumption (≥2 times/day) and excessive consumption (over 0.15 L/day) of SSB,55 Pollard CM, Meng X, Hendrie GA, Hendrie D, Sullivan D, Pratt IS, Kerr DA, Scott JA. Obesity, socio-demographic and attitudinal factors associated with sugar-sweetened beverage consumption: Australian evidence. Aust N Z J Public Health. 2016; 40: 71-7.

6 Alderete E, Bejarano I, Rodriguez A. Beverage intake and obesity in early childhood: evidence form primary health care clients in Northwest Argentina. J Dev Orig Health Dis. 2015;1-9.
-77 Park S, Akinbami LJ, McGuire LC, Blanck HM. Association of sugar-sweetened beverage intake frequency and asthma among U.S. adults, 2013. Prev Med. 2016; 91: 58-61. mainly refreshments and others such as soft drinks, tea and juices, have been associated with excess weight and are also attributed to other undesirable effects in the development of mediators of CND, such as caries, asthma, hypertension, kidney damage, metabolic syndrome, diabetes mellitus type II, osteopenia, increased visceral fat and resistance to insulin.88 Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M, Mozaffarian D. Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in 2010. Circulation. 2015; 132: 639-66.,99 Barrio-Lopez MT, Martinez-Gonzalez M a, Fernandez-Montero A, Beunza JJ, Zazpe I, Bes-Rastrollo M. Prospective study of changes in sugar-sweetened beverage consumption and the incidence of the metabolic syndrome and its components: the SUN cohort. Br J Nutr. 2013; 110: 1722-31. However, there is also contradictory evidence stating that SSB consumption does not cause excess weight.1010 Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: A systematic review. Am J Clin Nutr. 2006; 84: 274-88. The adequate measurement of consumption is complex, and many of these findings are attributed to a lack of rigor in the measurement of exposure to these beverages. A study that reviewed 32 reports evaluating SSB consumption and the risk of overweight in children and adolescents showed that only 9 studies were methodologically sound and that 5 of them positively confirmed this relationship.1111 Bucher Della Torre S, Keller A, Laure Depeyre J, Kruseman M. Sugar-Sweetened Beverages and Obesity Risk in Children and Adolescents: A Systematic Analysis on How Methodological Quality May Influence Conclusions. J Acad Nutr Diet. 2016; 116: 638-59.

According to Euromonitor International, an independent market research agency, the 2009-2014 per capita consumption of SSB decreased from 48.5 L in 2009 to 47.5 L in 2014 in Colombia. However, spending in the segment of SSB increased by 40%, with a greater emphasis on the market for tea, juice and soft drinks enriched with fiber and energy drinks.1212 Oliveros Forero G. En promedio, cada colombiano gasta $178.000 en gaseosas al año. [Internet]. La República. 2015 [cited 2016 Aug 1]. Available from: http://www.larepublica.co/en-promedio-cada-colombiano-gasta-178000-en-gaseosas-al-año_295226
http://www.larepublica.co/en-promedio-ca...
,1313 Bustamante Cristina. Los colombianos se toman $ 12,5 billones en gaseosas y jugos | Empresas | Negocios | Portafolio. Portafolio. 2014. Euromonitor also states that Colombia is among the countries with the lowest SSB consumption in the region. For example, in 2013 in Mexico, the annual consumption per capita was between 142 and 373.4 L, where it was only 47.2 L in Colombia.1313 Bustamante Cristina. Los colombianos se toman $ 12,5 billones en gaseosas y jugos | Empresas | Negocios | Portafolio. Portafolio. 2014.,1414 Los 10 países latinos que más gaseosas consumen. [Internet]. Dinero. 2014 [cited 2016 Aug 1]. Available from: http://www.dinero.com/pais/articulo/los-10-paises-latinos-mas-gaseosas-consumen/203039
http://www.dinero.com/pais/articulo/los-...
In addition, the Administrative Department of Statistics (Departamento Administrativo de Estadística, DANE) states that SSB consumption per capita in the period of 2009-2013 increased by 7% due to the country's economic growth and that the middle class reached 62% of market participation, with the lower class at 29% and the higher class at 9%.1515 LegisComex.com. BEBIDAS NO ALCOHÓLICAS EN COLOMBIA [Internet]. LegisComex.com. 2014 [cited 2016 Oct 1]. Available from: http://www.legiscomex.com/BancoMedios/DocumentosPDF/informe-sectorial-bebidas-no-alcoholicas-colombia-completo-rci285.pdf
http://www.legiscomex.com/BancoMedios/Do...

In Colombia, the Ministry of Public Health has proposed taxing the consumption of SSB, disseminating preventive messages on their consumption through mass media and other measures that aim at restricting and even prohibiting the sale and consumption of SSB in school settings.1616 Ortiz Castaño D. Impuesto a gaseosas en Colombia: Postobón responde - El Colombiano [Internet]. El Colombiano. 2016 [cited 2016 Jul 28]. Available from: http://m.elcolombiano.com/impuesto-a-gaseosas-en-colombia-postobon-responde-GF4502019
http://m.elcolombiano.com/impuesto-a-gas...
Complementarily, the beverage industry announced self-regulation measures that include not selling SSB in schools.1616 Ortiz Castaño D. Impuesto a gaseosas en Colombia: Postobón responde - El Colombiano [Internet]. El Colombiano. 2016 [cited 2016 Jul 28]. Available from: http://m.elcolombiano.com/impuesto-a-gaseosas-en-colombia-postobon-responde-GF4502019
http://m.elcolombiano.com/impuesto-a-gas...

The objective of this study was to describe the consumption of SSB and some variables associated with it.

Methods

Study population. The ENSIN-2010 was performed in Colombia, South America, by the Colombian Institute of Family Welfare (Instituto Colombiano de Bienestar Familiar, ICBF), the methodology of which has previously been published.33 Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338. In summary, participants were selected to represent 99% of the population through multi-stage stratified sampling. All municipalities of the 32 departments of the country were grouped in strata with similar sociodemographic characteristics. The strata were represented by randomly selected municipalities, maintaining the proportional probability of stratum size. Within each stratum, clusters were formed from 10 households that were randomly selected. Household members were invited to participate. In total, 50,670 households were included in the survey.

Measurement of consumption: prevalence and frequency of the consumption of SSB. The ENSIN- 2010, which utilized a food frequency questionnaire (FFQ) using 10 categories of response for the last month, estimated the frequency of consumption of 30 foods or food groups and 3 related practices. The details of the construction of the FFQ have previously been published.33 Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338. In this study, we analyzed the SSB (boxed, powdered, bottled?) item. The ENSIN- 2010 does not differ by the type of refreshments or soft drinks (i.e., light, sugared, gasified, etc.). The categories of FFQ responses were converted into a continuous variable (frequency/day), using appropriate dividers to express the frequency of consumption in units of "day" (time).33 Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338.,1717 Ardila MF, Herrán OF. Desarrollo de un instrumento para evaluar la dieta en niños y adolescentes colombianos. Rev Bras Saúde Mater Infant. 2012; 12: 365-74. The consumption calculation, prevalence (yes/no) and frequency/day (times/day), was performed for all subjects between 5 and 17 years of age, except for pregnant women and subjects who were practicing diets prescribed by health professionals, thus incorporating the complex sample design. The FFQ was applied through a direct interview by nutritionists-dietitians; when the children were between 5 and 10 years old or the adolescents were under 12 years old, the mothers or caregivers responded. The responses were recorded directly on laptops (PDAs). The FFQ used does not have reproducibility or validity studies, but the consumer frequency section is exhaustive, and it contains mutually exclusive and complementary response options, which rationally allows for a continuous timeline for this type of analysis.

Sample. The usual consumption of SSB was studied using the FFQ in a subsample of 17,897 subjects between 5 and 64 years old. For the present analysis, we chose children between 5 and 10 years old (3,842) and adolescents between 11 and 17 years old (6,345). We excluded those who were practicing a diet prescribed by a health professional (n=38) and pregnant adolescents (n=371). To ensure plausible data on body mass index [kg/m2] (BMI), we limited the analysis to subjects with a height >80 and <200 cm and a weight >12 and <200 kg. The subsample analyzed included 10,070 subjects.

Anthropometric measurements. Anthropometric measurements were obtained using standardized techniques and calibrated instruments. Size was measured with a stadiometer with a sensitivity of 1 millimeter (Diseños Flores SR Ltda, Lima, Peru); weight was measured using scales with a sensitivity of 100 g (SECA 872). Overweight in children and adolescents was defined according to the equivalent cut-off points for body mass index (BMI) for sex and age, ≥25, following the recommendations of the International Obesity Task Force (IOTF).1818 Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000; 320 (7244): 1240. Stunting was established based on Z scores on the Height/Age indicator (Z<2), using the World Health Organization benchmark. Excess weight was the sum of overweight and obesity, BMI ≥25.

Socioeconomic evaluation. Food security was determined based on a modified and validated Colombian version of the "Community Childhood Hunger Identification Project".1919 Álvarez MC, Estrada A, Montoya EC, Melgar-Quiñónez H. Validación de escala de la seguridad alimentaria doméstica en Antioquia, Colombia. Salud Publ Mex. 2006; 48: 474-81. Ethnicity was established through self-recognition of the subject. The wealth index was measured using the survey designed by the Demographic and Health Survey (DHS). This continuous index was categorized into quintiles and represents household wealth through various indicators, which are grouped based on the principal component analysis.2020 USAID. Rutstein SO. The DHS Wealth Index: Approaches for rural and urban areas. Demographic and Health Research [Internet]. 2008. No. 60. 2014 [cited 2016 Oct 19]. Available from: http://www.popline.org/node/209748
http://www.popline.org/node/209748...
The level of education of the subjects was established based on the years studied and approved; the reference categories are of interest for the programs of nutrition and public health in Colombia. The level of urbanism was established by the ICBF based on population density;33 Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338. regions are geospatial clusters that correspond to cultural identity and were pre-established by the Colombian state for all regional and national government agencies.

Statistical analysis. The main outcomes of interest were the prevalence of SSB (yes/no) and the average frequency of consumption (times/day). To quantify the associations between sociodemographic variables and outcomes, we estimated consumption prevalence ratios (PRs) and the differences between mean consumption frequencies by categories of predictors. All estimates and 95% confidence intervals (CI95%) were calculated by incorporating the complex sample design with Stata software version 14 (Stata Corporation, College Station, TX).2121 StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. 2015. The PRs and their 95% CIs were adjusted in a binomial regression model with the consumption prevalence as the dependent variable. The mean differences and their 95% CIs were adjusted in linear regression models with frequency/day as the dependent variable. For binomial and linear models, the predictors were some of the variables included in the survey: gender, age, ethnicity, stunting, overweight, head of household education, wealth index, household food insecurity, area and geographic regions. In addition, all p-values were calculated using the linear trend test for nominal, ordinal, or variance (ANOVA) predictors. The technical procedures for the ENSIN- 2010 were endorsed by the Research Ethics Committee of the National Institute of Health of Colombia, as recorded in Act 3 of April 8, 2010. The ICBF obtained informed consent from the participants prior to enrollment. The authors declare that the procedures performed in the development of this work met the ethical standards, revised in 2008, of the Helsinki Declaration. The Committee of Ethics in Health Research of the Industrial University of Santander is exempt from reviewing the analyses performed with public and anonymous information considered as secondary sources.

Results

The prevalence of SSB for children aged 5 to 10 years was 81.8%, and their mean frequency of consumption was 0.60 times/day (CI95%, 0.57 to 0.64). The prevalence of SSB consumption in adolescents aged between 11 and 17 years old was 87.4%, and their mean frequency of consumption was 0.77 times/day (CI95%, 0.74 to 0.80). In all the subjects studied, the prevalence was 85.3%, and the mean frequency of consumption was 0.71 times/day (CI95%, 0.69 to 0.74). The correlation between prevalence and frequency of consumption was r=0.80 (CI95%, 0.44 to 0.94).

The prevalence of overweight was 12.8%, and that of stunting was 10.6%. The highest consumption was in adolescents aged 16 years, with a prevalence of 90.4% and a mean frequency of 0.83 times/day. A direct association between consumption and frequency with age was found (p<0.0001 for both, Tables 1 and 2). Sex was not associated with consumption. Bogotá, the capital of the country, displayed the highest consumption prevalence (93.6%) and average frequency (0.73 times/day); the Pacific region displayed the lowest consumption prevalence (76.5%) and average frequency (0.57 times/day). The nutritional status based on the height/age indicator was associated with consumption: the prevalence of consumption was higher in subjects without stunting (PR=1.04 (CI95%, 1.02 to 1.05), p<0.0001), but the frequency of consumption was 0.06 (0.03 to 0.09) times/day greater in subjects with stunting (p<0.0001). Excess weight was not associated with consumption (p>0.05).

Table 1
Association between sociodemographic variables and the prevalence of sugar sweetened beverages in subjects between 5 and 17 years of age in Colombia, ENSIN-2010a.
Table 2
Association between sociodemographic variables and the frequency/day of consumption of sugar sweetened beverages in subjects between 5 and 17 years of age in Colombia, ENSIN-2010a.

All the variables representing socioeconomic level differently were directly associated with consumption. Table 1 shows the crude prevalence of consumption and adjusted PRs for the different variables studied. Table 2 shows the mean frequency and adjusted consumption differences (times/day).

Discussion

Based on the FFQ applied in the ENSIN-2010, we managed to establish that in Colombia, 8 out of 10 children and 9 out of 10 adolescents consume SSB. The prevalence of consumption in subjects is not differentiated by sex. The relationship between age and the prevalence of consumption had a J-shaped distribution (Figure 1). In addition, the relationship between age and frequency of consumption (times/day) was linear (Figure 1), and the highest prevalence was reached in adolescents aged 16 years. For both prevalence and frequency/day, the variables studied that approximate the socioeconomic level of subjects and households, such as food security, household head education, and the wealth index, were directly related to consumption. The consumption of SSB in Colombia is predominant in urban areas, which presupposes a direct relationship with the degree of urbanism, structural and economic development and human development. Neither the prevalence nor the frequency/day of consumption was related to excess weight. The relationship with ethnic groups was clear: indigenous groups had the lowest consumption, and the Afro-Colombian population had the highest prevalence and average frequency. The above findings are another expression of the stage of nutrition and food transitions in Colombia.

Figure 1
Prevalence and frequency (times/days) of sugar sweetened beverages in the Colombian population between 5 and 17 years old, ENSIN-2010, Colombia.

Based on a Consumer Frequency Questionnaire applied at ENSIN-2010, Colombia. Regression lines for prevalence, frequency/day and age in years (the area between the lines represents the 95% confidence interval).


According to the different theorists of the nutrition transition phenomenon,2222 López de Blanco M, Carmona A. La transición alimentaria y nutricional: Un reto en el siglo XXI. An Venez Nutr. 2005; 18: 90-104.

23 Popkin BM. Nutrition in transition: The changing global nutrition challenge. Asia Pac J Clin Nutr. 2001;10 Suppl:S13-8.
-2424 Popkin BM. The shift in stages of the nutrition transition in the developing world differs from past experiences! Public Health Nutr. 2002; 5: 205-14. based on the results presented here and other complementary results derived from the ENSIN, we can affirm that in the nutrition and alimentary transition that Colombia is experiencing, patterns 2 to 5 are observed: there is famine in some regions (pattern 2), whereas there is a high protein diet and accelerated migration of the traditional diet to the socalled western diet in the more developed regions and with higher levels of urbanism, with the subsequent appearance of CND (patterns 3 and 4). The transition follows the model of low- and middle-income countries; it is characterized by an accelerated nutrition transition in which the extremes of the nutritional status and the double load coexist.2525 Doak CM, Adair LS, Monteiro C, Popkin BM. Overweight and underweight coexist within households in Brazil, China and Russia. J Nutr. 2000; 130: 2965-71. The presence of different stages of the food and nutrition transition reflects different levels of structural, economic and all types of development in the interior of the country and results in differences in consumption reported here by the level of urbanism, region or index of wealth. As in the nutritional state, this is the result of complex interactions between the determinants.

Although it has been reported that the probability of SSB consumption in adults is higher in men than in women,55 Pollard CM, Meng X, Hendrie GA, Hendrie D, Sullivan D, Pratt IS, Kerr DA, Scott JA. Obesity, socio-demographic and attitudinal factors associated with sugar-sweetened beverage consumption: Australian evidence. Aust N Z J Public Health. 2016; 40: 71-7. this relationship is not present in those under 18. In Ecuadorian children and adolescents between 10 and 19 years of age, according to the National Health and Nutrition Survey conducted in 2012, men consume more SSB than women (83 versus 79.9%); however, these differences are not significant.2626 Freire WB, Ramírez-Luzuriaga MJ, Belmont P, Mendieta MJ, Silva-Jaramillo MK, Romero N, Sáenz K, Piñeiros P, Gómez LF, Monge R. Tomo I: Encuesta Nacional de Salud y Nutrición de la población ecuatoriana de cero a 59 años. ENSANUT-ECU 2012 [Internet]. Quito, Ecuador: Ministerio de Salud Pública/Instituto Nacional de Estadísticas y Censos.; 2014 [cited 2015 Oct 19]. Available from: http://www.ecuadorencifras.gob.ec/documentos/web-inec/Estadisticas_Sociales/ENSANUT/MSP_ENSANUT-ECU_06-10-2014.pdf
http://www.ecuadorencifras.gob.ec/docume...
A review of several studies on the determinants of SSB consumption in children and young adolescents concluded that sex is apparently not a determinant of consumption.2727 Mazarello Paes V, Hesketh K, O'Malley C, Moore H, Summerbell C, Griffin S, van Sluijs EM, Ong KK, Lakshman R. Determinants of sugar-sweetened beverage consumption in young children: A systematic review. Obes Rev. 2015;16: 903-13. However, in Mexico, studies in adolescents have reported that men consume more energy from SSB but also from general consumption.2828 Rodríguez-Burelo M del R, Avalos-García MI, López-Ramón C. Consumo de bebidas de alto contenido calórico en México: un reto para la salud pública. Salud en Tabasco. 2014; 20: 28-33. The differences that occur in consumption are particular to the stage of nutritional and food transitions and are also evident in other consumptions. For example, in Colombia, women consume more vegetables than men.33 Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338. These differences in consumption by sex, even in children and adolescents, can be explained by hypothesis, by the differential incorporation of the concept of health or by social pressure in the ideal of Western beauty.

It has previously been reported that adolescents and young adults most frequently consume SSB.1111 Bucher Della Torre S, Keller A, Laure Depeyre J, Kruseman M. Sugar-Sweetened Beverages and Obesity Risk in Children and Adolescents: A Systematic Analysis on How Methodological Quality May Influence Conclusions. J Acad Nutr Diet. 2016; 116: 638-59. However, even assuming that this consumption is exclusively at the expense of SSB, their theoretical consumption derived from the estimated amount in the ENSIN-2005 (approximately 400/day g), which corresponds to an estimated frequency of 0.80 times/day in the ENSIN-2010, still does not reach the level of exposure in which a causal association between excess weight and SSB consumption has been reported, which is the habitual consumption of more than 0.15 L/day, with a frequency of ≥2 times/day.55 Pollard CM, Meng X, Hendrie GA, Hendrie D, Sullivan D, Pratt IS, Kerr DA, Scott JA. Obesity, socio-demographic and attitudinal factors associated with sugar-sweetened beverage consumption: Australian evidence. Aust N Z J Public Health. 2016; 40: 71-7.

6 Alderete E, Bejarano I, Rodriguez A. Beverage intake and obesity in early childhood: evidence form primary health care clients in Northwest Argentina. J Dev Orig Health Dis. 2015;1-9.
-77 Park S, Akinbami LJ, McGuire LC, Blanck HM. Association of sugar-sweetened beverage intake frequency and asthma among U.S. adults, 2013. Prev Med. 2016; 91: 58-61. Of course, here only the consumption of SSB has been evaluated with some limitations rather than the total amount of SSB consumed.

There is abundant literature concluding that malnutrition in any form, stunting (height/age), acute malnutrition (weight/height) or overweight (weight/height or weight/age) can be promoted through an adequate intake of nutrients.2929 Wojcicki JM. Malnutrition and the role of the soft drink industry in improving child health in Sub-Saharan Africa. Pediatrics. 2010; 126: e1617-21.,3030 Brownell KD, Frieden TR. Ounces of prevention: the public policy case for taxes on sugared beverages. N Engl J Med. 2009; 360: 1805-8. The consumption of SSB, among other things, displaces the consumption of food dense in nutrients and provides "empty" energy; therefore, it is reasonable to think that there is a causal relationship between consumption and growth.2929 Wojcicki JM. Malnutrition and the role of the soft drink industry in improving child health in Sub-Saharan Africa. Pediatrics. 2010; 126: e1617-21.,3030 Brownell KD, Frieden TR. Ounces of prevention: the public policy case for taxes on sugared beverages. N Engl J Med. 2009; 360: 1805-8. Our results adjusted by the possible confounders show that although the subjects with delayed growth have a lower prevalence of consumption, they present a more average frequency/day value; therefore, it is possible that in Colombian children and adolescents, the displacement of food dense in nutrients by the consumption of SSB is a rational explanation for stunting. The cross-sectional data do not allow us to delve into a possible causal explanation between the consumption of SSB and stunting, which would justify conducting new studies.

Several of the aspects that deserve special care in analyzing these consumption outcomes are related to exposure measurement; a) the FFQ used in the ENSIN-2010 did not specifically ask for the type of beverage consumed, nor for its type of sweetener. In Colombia, according to industry and data from Euromonitor International, the market for sugar-free or artificially sweetened has grown rapidly and reached 30% of market shares in 2014. b) The dose here is a combined representation of prevalence and frequency; in populations with a high prevalence of consumption but a low frequency, this can be translated to subjects less exposed to the components of the beverage than in subjects of populations with a low relative prevalence and greater frequency of consumption. c) The FFQ applied in the ENSIN- 2010 did not measure the amount consumed or how to approach this measurement. However, using r24h, the ENSIN-2005 had complementarily established that in children between 4 and 8 years of age, the PU24 was 18.5% and the mean amount consumed was 273 g; in the group from 9 to 13 years old, the PU24 increased to 21.6% and the mean amount to 330 g; and in the group from 14 to 18 years old, the PU24 was 26.4% and the mean amount was 409 g. The PU24 of soft drinks was always smaller and varied widely with age. d) There was no difference between carbonated and non-carbonated beverages in how the consumption of SSB was measured. e) The ENSIN-2010 did not ask about the consumption of bottled water. f) FFQs are simplified methods that can lead to memory bias and dilution of the association by reverse causality. All of the above are limitations in the measurement of exposure and future challenges for ENSIN and other studies.

The interest in investigating excess weight as one of the main mediators in the development of CND and the consumption of SSB faces the challenges described above and many others. Here, we found no association between overweight and consumption, but the cross-sectional nature of the data, the limitations in measuring consumption as described above, the possible decrease in consumption in subjects with excess weight and others that we are not even aware of lead to a dilution of the association, if it existed, and do not allow any causal approach.

Finally, we could characterize the consumption of SSB in Colombian children and adolescents and can highlight some of the methodological challenges for future measurements. Studies must estimate the contribution made by SSB to the total energy intake. It is necessary to understand the consumption of SSB as an expression of the stage of nutritional and food transitions to make coherent public policies and preventive practices.

References

  • 1
    Profamilia, Instituto Nacional de Salud, Universidad de Antioquia, OPS, Instituto Colombiano de Bienestar Familiar. Encuesta Nacional de la Situación Nutricional de Colombia, 2005. Ensin. 2006. p. 229-315.
  • 2
    Amigo H. Obesidad en el niño en América Latina: situación, criterios de diagnóstico y desafío. Cad Saude Publica. 2004;19(Suplemento 1): 163-70.
  • 3
    Ministerio de la Protección Social. Encuesta Nacional de la Situación Nutricional en Colombia 2010. Ensin. p. 261-338.
  • 4
    Kasper NM, Herrán OF, Villamor E. Obesity prevalence in Colombian adults is increasing fastest in lower socioeconomic status groups and urban residents: results from two nationally representative surveys. Public Health Nutr. 2014; 17: 1-9.
  • 5
    Pollard CM, Meng X, Hendrie GA, Hendrie D, Sullivan D, Pratt IS, Kerr DA, Scott JA. Obesity, socio-demographic and attitudinal factors associated with sugar-sweetened beverage consumption: Australian evidence. Aust N Z J Public Health. 2016; 40: 71-7.
  • 6
    Alderete E, Bejarano I, Rodriguez A. Beverage intake and obesity in early childhood: evidence form primary health care clients in Northwest Argentina. J Dev Orig Health Dis. 2015;1-9.
  • 7
    Park S, Akinbami LJ, McGuire LC, Blanck HM. Association of sugar-sweetened beverage intake frequency and asthma among U.S. adults, 2013. Prev Med. 2016; 91: 58-61.
  • 8
    Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M, Mozaffarian D. Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in 2010. Circulation. 2015; 132: 639-66.
  • 9
    Barrio-Lopez MT, Martinez-Gonzalez M a, Fernandez-Montero A, Beunza JJ, Zazpe I, Bes-Rastrollo M. Prospective study of changes in sugar-sweetened beverage consumption and the incidence of the metabolic syndrome and its components: the SUN cohort. Br J Nutr. 2013; 110: 1722-31.
  • 10
    Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: A systematic review. Am J Clin Nutr. 2006; 84: 274-88.
  • 11
    Bucher Della Torre S, Keller A, Laure Depeyre J, Kruseman M. Sugar-Sweetened Beverages and Obesity Risk in Children and Adolescents: A Systematic Analysis on How Methodological Quality May Influence Conclusions. J Acad Nutr Diet. 2016; 116: 638-59.
  • 12
    Oliveros Forero G. En promedio, cada colombiano gasta $178.000 en gaseosas al año. [Internet]. La República. 2015 [cited 2016 Aug 1]. Available from: http://www.larepublica.co/en-promedio-cada-colombiano-gasta-178000-en-gaseosas-al-año_295226
    » http://www.larepublica.co/en-promedio-cada-colombiano-gasta-178000-en-gaseosas-al-año_295226
  • 13
    Bustamante Cristina. Los colombianos se toman $ 12,5 billones en gaseosas y jugos | Empresas | Negocios | Portafolio. Portafolio. 2014.
  • 14
    Los 10 países latinos que más gaseosas consumen. [Internet]. Dinero. 2014 [cited 2016 Aug 1]. Available from: http://www.dinero.com/pais/articulo/los-10-paises-latinos-mas-gaseosas-consumen/203039
    » http://www.dinero.com/pais/articulo/los-10-paises-latinos-mas-gaseosas-consumen/203039
  • 15
    LegisComex.com. BEBIDAS NO ALCOHÓLICAS EN COLOMBIA [Internet]. LegisComex.com. 2014 [cited 2016 Oct 1]. Available from: http://www.legiscomex.com/BancoMedios/DocumentosPDF/informe-sectorial-bebidas-no-alcoholicas-colombia-completo-rci285.pdf
    » http://www.legiscomex.com/BancoMedios/DocumentosPDF/informe-sectorial-bebidas-no-alcoholicas-colombia-completo-rci285.pdf
  • 16
    Ortiz Castaño D. Impuesto a gaseosas en Colombia: Postobón responde - El Colombiano [Internet]. El Colombiano. 2016 [cited 2016 Jul 28]. Available from: http://m.elcolombiano.com/impuesto-a-gaseosas-en-colombia-postobon-responde-GF4502019
    » http://m.elcolombiano.com/impuesto-a-gaseosas-en-colombia-postobon-responde-GF4502019
  • 17
    Ardila MF, Herrán OF. Desarrollo de un instrumento para evaluar la dieta en niños y adolescentes colombianos. Rev Bras Saúde Mater Infant. 2012; 12: 365-74.
  • 18
    Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000; 320 (7244): 1240.
  • 19
    Álvarez MC, Estrada A, Montoya EC, Melgar-Quiñónez H. Validación de escala de la seguridad alimentaria doméstica en Antioquia, Colombia. Salud Publ Mex. 2006; 48: 474-81.
  • 20
    USAID. Rutstein SO. The DHS Wealth Index: Approaches for rural and urban areas. Demographic and Health Research [Internet]. 2008. No. 60. 2014 [cited 2016 Oct 19]. Available from: http://www.popline.org/node/209748
    » http://www.popline.org/node/209748
  • 21
    StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. 2015.
  • 22
    López de Blanco M, Carmona A. La transición alimentaria y nutricional: Un reto en el siglo XXI. An Venez Nutr. 2005; 18: 90-104.
  • 23
    Popkin BM. Nutrition in transition: The changing global nutrition challenge. Asia Pac J Clin Nutr. 2001;10 Suppl:S13-8.
  • 24
    Popkin BM. The shift in stages of the nutrition transition in the developing world differs from past experiences! Public Health Nutr. 2002; 5: 205-14.
  • 25
    Doak CM, Adair LS, Monteiro C, Popkin BM. Overweight and underweight coexist within households in Brazil, China and Russia. J Nutr. 2000; 130: 2965-71.
  • 26
    Freire WB, Ramírez-Luzuriaga MJ, Belmont P, Mendieta MJ, Silva-Jaramillo MK, Romero N, Sáenz K, Piñeiros P, Gómez LF, Monge R. Tomo I: Encuesta Nacional de Salud y Nutrición de la población ecuatoriana de cero a 59 años. ENSANUT-ECU 2012 [Internet]. Quito, Ecuador: Ministerio de Salud Pública/Instituto Nacional de Estadísticas y Censos.; 2014 [cited 2015 Oct 19]. Available from: http://www.ecuadorencifras.gob.ec/documentos/web-inec/Estadisticas_Sociales/ENSANUT/MSP_ENSANUT-ECU_06-10-2014.pdf
    » http://www.ecuadorencifras.gob.ec/documentos/web-inec/Estadisticas_Sociales/ENSANUT/MSP_ENSANUT-ECU_06-10-2014.pdf
  • 27
    Mazarello Paes V, Hesketh K, O'Malley C, Moore H, Summerbell C, Griffin S, van Sluijs EM, Ong KK, Lakshman R. Determinants of sugar-sweetened beverage consumption in young children: A systematic review. Obes Rev. 2015;16: 903-13.
  • 28
    Rodríguez-Burelo M del R, Avalos-García MI, López-Ramón C. Consumo de bebidas de alto contenido calórico en México: un reto para la salud pública. Salud en Tabasco. 2014; 20: 28-33.
  • 29
    Wojcicki JM. Malnutrition and the role of the soft drink industry in improving child health in Sub-Saharan Africa. Pediatrics. 2010; 126: e1617-21.
  • 30
    Brownell KD, Frieden TR. Ounces of prevention: the public policy case for taxes on sugared beverages. N Engl J Med. 2009; 360: 1805-8.

Publication Dates

  • Publication in this collection
    Jul-Sep 2017

History

  • Received
    10 Nov 2016
  • Accepted
    16 June 2017
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