Abstract
Objective
Assess caregivers’ knowledge about juice and sugar-sweetened beverages (SSBs) and identify factors that contribute to their early introduction.
Methods
One hundred forty-four parents of young infants completed a 45-item questionnaire focused on infant nutrition.
Results
Seventy-two percent of parents plan to give juice to their babies starting in the first year of life; only 16% plan to introduce SSBs. Parents with some college education or more were significantly less likely to report an intention to introduce juice (P < .0001) and SSBs (P < .001) in their children’s diets. Education level was significantly associated with knowledge about juice and SSBs (P < .001). Parents with higher knowledge were significantly less likely to plan on introducing juice (P < .001) and SSBs (P < .001).
Conclusion
Parents of young infants lack enough knowledge about the detrimental effects of juice and sugary drinks. These knowledge gaps give pediatric providers a unique opportunity to provide anticipatory guidance starting in early infancy on the adverse health effects of juice and SSBs.
Introduction
The overwhelming rates of pediatric obesity in the United States are a major public health concern, with increasing rates of childhood hypertension, hyperlipidemias, type 2 diabetes, and fatty liver disease. 1 Dietary factors significantly contribute to the development of childhood obesity.2,3 The early introduction of juice and sugar-sweetened beverages (SSBs) in children’s diets plays an important role.4-7
SSBs are defined as drinks with added sugar, such as soda, iced tea, juice drinks (containing <100% juice), lemonade, and sports drinks. 8 SSB consumption in childhood is linked to unhealthy weight gain and excess adiposity. 9 Starting to drink SSBs at an early age is, therefore, particularly concerning. The Feeding Infants and Toddlers Study of 2016 found a 9% prevalence of SSB consumption in children aged 6 to 12 months old, with this number increasing to 29% of children 12 to 24 months old. The most common SSBs consumed at these ages are fruit-flavored drinks. 10
Although 100% fruit juice is not considered a SSB, it contains naturally occurring sugars in a concentrated form that pose health risks when consumed in excess. 11 The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides 128 ounces of 100% fruit juice per month to low-income children aged 1 to 5 years, which amounts to about 4 ounces of juice per day. 12 This is consistent with the American Academy of Pediatrics’ recommendation of limiting the consumption of 100% fruit juice to no more than 4 ounces per day for children ages 1 to 3 years. 13
Unfortunately, parents often report introducing juice and SSBs in their infants’ diets before 1 year of age and giving significantly more than the recommended 4 oz/day.
The aims of this study were as follows: (a) to assess infants’ caregivers’ knowledge about juice and SSBs and (b) to identify factors that contribute to the intended early introduction of juice and SSBs in children’s diets. Specifically, we investigated the parental knowledge, attitudes, and practices among parents of young infants regarding juice and SSBs. The overall goal of this work is to identify knowledge gaps and other risk factors for the early introduction of juice and SSBs in children’s diets so that intervention strategies targeting these may be implemented in primary care and other settings.
Methods
The study was conducted at the Hasbro Children’s Hospital Pediatric Primary Care clinic located in Providence, RI. Hasbro Children’s Hospital is the only children’s hospital in the state of RI. The clinic serves a low-income, multiethnic, and diverse patient population very similar to other urban academic teaching hospitals. The clinic is the continuity site for 48 categorical pediatric residents affiliated with the Warren Alpert Medical School of Brown University.
As part of a longitudinal randomized controlled trial on the prevention of obesity starting in early infancy, we consecutively enrolled 144 parent-infant dyads presenting for a well-child care visit. The study was approved by our institutional review board. In order to be enrolled, infants had to be healthy, full-term (>37 weeks gestation), and between 8 and 16 weeks old (±2 weeks). The parent or legal guardian had to provide written informed consent, speak English and/or Spanish, and be 18 years of age or older. Infants were excluded if they had a congenital and/or chromosomal anomaly or other significant chronic illness. A bilingual research assistant (RA) reviewed the clinic’s daily schedule in the electronic medical system and identified potentially eligible subjects. The RA consecutively approached potential study subjects, verified eligibility, and obtained informed consent. The RA provided a 45-item questionnaire on a tablet for the parent to complete. The questionnaire and the consent form were available in English and in Spanish.
The questionnaire took approximately 10 minutes to complete and included demographic information, parental dietary habits, and intention to introduce juice and SSBs in their baby’s diet, as well as a series of statements about juice and sugary drinks. The questionnaire was developed by the authors with guidance provided by experts in the field of childhood obesity and nutrition. It was translated into Spanish by the senior author who is a certified Spanish translator. The completed questionnaires and the babies’ anthropometric data were collected using Research Electronic Data Capture (REDCap). A $5 Walmart gift card was given to the participants as a token of appreciation.
We assessed parental knowledge about juice by presenting a series of 9 statements on a 5-point Likert-type scale. Parents could strongly agree (SA), agree (A), be neutral (N), disagree (D) or strongly disagree (SD) with each statement. We worded the statements so that some were “true,” and others were “false.” When parents agreed or strongly agreed with a “true” statement, their response was assessed as being correct. When they disagreed or strongly disagreed with a “false” statement, their answer was also assessed as being correct. Conversely, when parents agreed or strongly agreed with a “false” statement, or they disagreed or strongly disagreed with the “true” statement, their answers were marked as incorrect. Neutral responses were assessed as being incorrect for a particular statement, since they implied that the parent lacked sufficient knowledge. Each correct answer was given a score of 1. There were a total of 9 statements; therefore, the score ranged between 0 and 9 depending on how many statements they answered correctly. Answers were stratified into 3 groups: scores of 0 to 3 (poor knowledge), scores of 4 to 6 (fair knowledge), and scores of 7 to 9 (excellent knowledge).
Statistical Analysis
Descriptive statistics (frequencies) were calculated to summarize categorical variables including demographic information (eg, gender, race/ethnicity, education level, household income, marital status, baby’s medical insurance, household size, number of WIC recipients in the household, and intention to introduce juice and SSBs). Associations among categorical variables were analyzed using Fisher’s exact test as appropriate to assess infant caregivers’ knowledge about juice and SSBs. The major outcome of these analyses is to identify factors that contribute to the early introduction of juice and SSBs. All statistical analyses were performed using R version 3.6.1 with statistical significance accepted when P < .05 (2-tailed). 14
Results
Study participants included primarily poorly educated, low-income mothers of various ethnic backgrounds, who received WIC benefits and the state’s health insurance. Even though 48% of respondents identified themselves as Hispanic, 85% chose to complete the questionnaire in English (Table 1). Forty-two percent of caregivers reported keeping juice at home and 21% reported having sugary drinks at home every single day of the week.
Characteristics of Study Participants.
Percentages may not add up to 100% due to rounding.
When parents were asked about their intention to introduce juice in their children’s diet, 72% of parents planned to give juice to their babies starting in the first year of life. However, when they were asked about their intent to introduce SSBs, only 16% of parents planned to introduce SSBs in the first year of life (Table 2). Parents reported their intention to introduce juice significantly earlier than SSBs in their children’s diets (Figure 1).
Parental Intention to Introduce Juice and Sugar-Sweetened Beverages.
Age of intended introduction of juice and Sugar Sweetened-Beverages.
Parents with some college education or a higher degree were significantly less likely to report an intention to introduce juice (P < .0001) and sugary beverages (P < .001) in their children’s diets compared with parents with lower educational attainments (Figure 2).
Parental education level and intention to introduce juice and Sugar-Sweetened Beverages.
Participants were asked whether to agree or disagree with a series of 9 statements about juice and its effects on children’s health on a 5-point Likert-type scale (Table 3). As previously described, parents were given 1 point for each correct answer. Only 10% of parents demonstrated excellent knowledge responding correctly to at least 7 of the 9 statements. Fifty percent had fair knowledge with a score between 4 and 6, and 40% demonstrated poor knowledge with a score of only 0 to 3 points (Figure 3).
Parental Knowledge About Juice.
Parental Knowledge Score.
Education level was significantly associated with knowledge about juice and SSB (P < .001). Parents with higher education had more knowledge about the effects of juice and SSBs in their child’s health (Figure 4). In turn, parents with higher knowledge scores were significantly less likely to plan to introduce juice (P < .001) and SSBs (P < .001) in their children’s diet (Figure 5).
Parental Education level and knowledge scores.
Parental Knowledge Scores and intention to introduce juice and Sugar-Sweetened Bevarages.
Parents were asked to evaluate their perception of their baby’s weight at enrollment as underweight (BMI [body mass index] ≤15%), about the right weight (BMI 15% to 85%), or overweight (BMI ≥85%). Ninety-six percent of the healthy weight babies were perceived by their parents as having a healthy weight. However, 81% of the overweight babies were perceived by their parents as having a healthy weight. Only 17% of overweight babies were perceived correctly by their parents as being overweight.
Discussion
Studies on childhood obesity show that the trajectory of obesity is established during the child’s first 5 years of life. Poor eating habits like dining in front of a television, eating fast food for dinner, and consuming obesogenic foods begin at a young age.15,16 These habits contribute to the longitudinal risk of overweight and obesity throughout childhood. Once children become overweight, losing weight has proven highly challenging. 17
In the state of Rhode Island, the rates of childhood overweight (BMI percentile 85th to 95th) and obesity (BMI percentile ≥95th) are higher than in most other states. These rates are significantly higher among children from lower socioeconomic backgrounds. Children in Rhode Island are especially at risk, as the state is ranked 11th in the country overall for obesity prevalence among WIC participants aged 2 to 4 years.5,18 Nineteen percent of children enrolled in Head Start programs in RI are overweight, and 18% are obese, as compared with the national averages of 13% and 16%, respectively. 19
Despite the overwhelmingly high rates of childhood obesity in the United States and the role sugary drinks play, few studies have examined the knowledge that parents of young infants have about juice and SSBs and whether that knowledge affects their behavior.20-22
Our data suggest that parents have preconceived ideas about when and why they should introduce juice and SSBs in their children’s diet, even before an infant is ready to start eating solids. Although the majority of parents surveyed do not plan to introduce SSBs in their children’s diet until after the first year of life, most parents intend to start 100% fruit juice before their baby turns one. This suggests that parents perceive juice as a healthy and nutritious drink, whereas SSBs are thought to be less healthy for their babies.
The majority of parents living in poverty in the United States are eligible to receive WIC benefits for their children <5 years of age. Ninety-five percent of our study subjects reported having the state’s health insurance plan (RiteCare), making them eligible for WIC. This demographic makeup is consistent with our clinic population and that of other urban academic pediatric continuity clinics. The WIC program provides 128 ounces of 100% juice per month to families starting at 1 year of age. By including juice in the WIC package, parents might perceive juice as a healthy and important dietary item that should be included in their baby’s diet.20,23
In turn, parents receiving WIC benefits might be more likely to buy juice even before they start getting it from the program and also more likely to buy more to supplement what they receive from WIC once their baby turns one. Families in which there are older siblings receiving juice from WIC may also be more likely to introduce it in their baby’s diet at an earlier age. In fact, all parents in our study reported that they would buy it, get it from WIC, and/or would buy some more.
The early introduction of juice and sugary drinks results in children acquiring a taste and perhaps a preference for sugary flavors at a very young age, in lieu of healthier options such as milk or water.24,25 Our data show that almost 3 quarters of the parents plan to introduce juice in their baby’s diet before WIC starts giving them juice. About a quarter of the parents plan to give juice to their babies when starting baby foods, between 5 and 6 months of age. Therefore, for an intervention to be effective, it would have to be implemented in the first few months of life or even prenatally.
In 2009, WIC improved their food package for children ages 2 to 4 years. Changes included a reduction of more than half the amount of juice, more fresh fruits and vegetables, low-fat milk instead of whole milk, less cheese, and less refined white flour products. Following these changes, the overall national obesity rates in children ages 2 to 4 years decreased for the first time in decades, from 15% in 2008 to 14% in 2014, 26 and the quality of toddler’s diets improved.18,27,28 This reversal in toddler obesity rates reinforces the benefits of eating whole foods, and fewer refined foods and sugary drinks. 29
The United States Department of Agriculture (USDA) states, “Any fruit or 100% fruit juice counts as part of the Fruit Group.” 30 However, one serving of apple juice is nutritionally inferior to a serving of whole apple; juice has more calories, more sugar, and less fiber than the whole fruit. 18 In our study, over half of parents identified fruit juice as fruit by agreeing or strongly agreeing with the statement: “Juice is a way to provide fruit in my baby’s diet.” The USDA’s inclusion of juice as a fruit serving and its provision in the WIC package leads to the confusing notion that juice is a healthy drink choice for babies that can replace fruit in their diet.
In the state of RI, 40% of Hispanic children, 59% of Native American children, and 31% of Black children live in families with incomes below the federal poverty level, as compared with 15% of White children. 19 For most low-income families, fresh fruit is a luxury item, given the high cost and lack of accessibility in large urban areas. Instead, parents buy juice, which is inexpensive and highly palatable, leading to the early consumption of high volumes of juice in this vulnerable population.
Highly educated individuals are likely to be more knowledgeable about the nutrition facts of juice and SSBs.22,31 In our study, parents with some college education or higher demonstrated higher knowledge scores compared with parents with a high school education or less. As expected, parents with limited knowledge about juice and SSBs and their adverse health effects are more likely to introduce these unhealthy beverages in their children’s diets at a very young age.
In our study, one-half of parents thought that 100% juice contained no sugar, believing the common misconception that “no added sugar” means no sugar. Most parents are unaware that there is a correlation between drinking juice and adverse gastrointestinal distress, excess weight gain, and ear infections. These knowledge gaps provide an excellent opportunity for pediatric practitioners to educate families on the adverse health effects of juice and SSBs.
A few studies have looked at parents’ perceptions and knowledge of juice and SSBs at such an early age.20,21 Having an understanding of the knowledge and intended behaviors of parents, before they start giving drinks other than breastmilk or formula to their infants, is very important. The results of our study provide information that can help develop preventative interventions before unhealthy habits and taste preferences form and become ingrained in the parent-child dyad.
From a public health standpoint, removing juice from the WIC package, taking away its status as a fruit serving from the USDA recommendations, and taxing SSBs would have a tremendous impact on the health of our most vulnerable children. In 2015, Berkley, California, started a SSB tax of 1 penny per ounce that resulted in a 52% drop in sugary drink consumption in low-income families. Following the data on alcohol and tobacco taxation, this study on soda taxation demonstrates that it may be a very effective tool to help fight the obesity epidemic in the United States. 32
Our study has several limitations. Because the participants are inner-city, low-income parents, most of whom receive WIC benefits, our results might not be generalizable to other more affluent patient populations. However, our study population is the most vulnerable to poor nutrition choices and is similar to ones cared for by many pediatric residency programs located in large academic centers in the United States. The data were collected by parental self-report. Parents were given a tablet and asked to complete the questionnaire while they waited for their provider. Although we developed the questions at a fifth-grade reading level and excluded parents who were unable to read in English and/or Spanish, the literacy level of the respondents could have affected their ability to answer some of the questions confidently. It is also possible that parents could have answered some of the questions about their planned introduction of juice and SSBs in a way that was subject to social desirability response bias. However, we aimed to combat this bias by including many questions about infant nutrition that were unrelated to juice and SSBs.
Conclusion
Parents of young infants lack enough knowledge about the detrimental effects of juice and sugary drinks on their children’s health. Pediatricians are in a unique position to provide anticipatory guidance starting at a very young age regarding the negative health effects of juice and sugary drinks and to promote a healthy diet that includes water and milk as the best drink options for children and adolescents.
According to the US Department of Health and Human Services, diet-only interventions result in the most significantly favorable adiposity-related outcomes. 33 The excessive consumption of juice and SSBs leads to childhood overweight and obesity.4-6 Therefore, a focused intervention targeting the caregivers of infants prior to the introduction of juice and SSBs offers the opportunity to proactively prevent the development of obesogenic habits.
These data could guide the development of intervention strategies in order to delay, reduce, or eliminate the introduction of juice and SSBs in children’s diets. This, in turn, could potentially play a significant role in reducing the rates of childhood overweight and obesity in our country. In addition, policy stakeholders and health officials might benefit from having a better understanding of parents’ perceptions and behaviors surrounding these unhealthy beverages in order to make changes that would affect millions of children.
Our prospective randomized controlled trial will aim to answer whether a simple, inexpensive intervention will improve parental knowledge about juice and SSBs and whether that knowledge will have an impact on the child’s BMI.
Author Contributions
SM and NG were the main contributors to design of the project and writing of the manuscript. JFF provided vaulable consultation for the development of the project and statistical support. AA and ALM conducted the statistical analyses and graphs. JE, OS, and LR were the research assistants who collected the data and entered the anthropometric data onto REDCap. BB assisted with the IRB submission and training of the research assistants. All authors assisted with editing and have reviewed the final version submitted for publication.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Children’s Miracle Network award grant.
