《学术英语（医学）》拓展阅读资料：A new proposed guidance system for beverage consumption in the United States

Commentary A new proposed guidance system for beverage consumption in the United States1-3 Barry M Popkin, Lawrence E Armstrong, George M Bray, Benjamin Caballero, Balz Frei, and Walter C Willett ABSTRACT 2001, the proportion of energy obtained from calorically sweet The Beverage Guidance Panel was assembled to provide guidance ened soft drinks and fruit drinks, which-as defined later-are on the relative health and nutritional benefits and risks of various different from fruit juices, has increased 3-fold, from 2.8% to beverage categories. The beverage panel was initiated by the first 7.0%(50-144 kcal/d), with a concurrent reduction in milkintake author. The Panel's purpose is to attempt to systematically review (1). Portion sizes of calorically sweetened beverages for all ages the literature on beverages and health and provide guidance to the increased from 13.6 fl oz(402 mL)to 21.0 fl oz(621 mL) consumer. An additional purpose of the Panel is to develop a deeper between 1977 and 1996--a proportionately larger increase than dialog among the scientific community on overall beverage con- the increase in the number of servings(1). At the same time that o sumption patterns in the United Sates and on the great potential to portion sizes have increased, Americans have also increased the change this pattern as a way to improve health. Over the past several number of servings of calorically sweetened beverages from 1.96 a decades, levels of overweight and obesity have increased across all in 1977 to 2.39 in 1996. Servings are measured for beverages opulation groups in the United States. Concurrently, an increased according to US Department of Agriculture(USDA)standards laily intake of 150-300 kcal (for different age-sex groups)has Our proposed guidance thus focuses on obtaining as much of from the consumption of calorically sweetened beverages. Thepanel amounts of energy and an improved nutrient profile caloric and nutrient contents and related health benefits and risks The Beverage Guidance Panel was assembled to provide guid- 9 ance on the relative health and nutritional benefits and risks of Drinking water was ranked as the preferred beverage to fulfill daily various beverage categories. a healthy diet does not rely on s water needs and was followed in decreasing value by tea and coffee, fluids to provide energy or nutrient needs.Therefore, potable 5 low-fat(1.5% or 1%)and skim(nonfat)milk and soy beverages noncalorically sweetened beverages, beverages with some nutri- water could be used to fulfill almost all the fluid needs of health a tional benefits(fruit and vegetable juices, whole milk, alcohol, and individuals. However, to allow for variety and individual pref- The Panelrecommends that the consumption of beverages with noor cages. In fact, the other motivation for this Beverage Guidance a sports drinks ), and calorically sweetened, nutrient-poor beverages erences, healthful diets may include several other types of bev. S a few calories should take precedence over the consumption of bev. System was to help consumers select a variety of beverages erages with more calories. Am Clin Nutr 2006: 83: 529-42 There is evidence that beverages have weak satiety properties oo and elicit poor dietary compensation. Studies of appetitive sen- B KEY WORDS Water, tea, coffee, milk, fruit juice, alcohol, sations(eg, hunger, fullness, and prospective consumption)sup-RG calorically sweetened beverages, beverage guidance system port the view that fluids are less satiating than are solid foods (7-9). Dietary compensation(the adjustment in energy intake INTRODUCTION made by individuals in subsequent meals in response to earlier food intake) has been studied with solid, semisolid, and fluid The development of the Beverage Guidance System was mo- foods. For fluids, Mattes(10) reported a complete lack of ivated by the large increase in unhealthy weight patterns in the compensation, which suggests that fluid calories are not readily United States over the past 20y and the 5-15% increase in dietary nergy intake during that same period. Although the focus of the 1 from I From the University of North Carolina, Chapel Hill, NC(BMP);the US Dietary Guidelines for Americans has been on food, energy University of Connecticut Human Performance Laboratory, Storrs, CT intake from beverages currently represents 21% of the total en- (LEA); the Louisiana State University Medical Center and Pennington Bio- ergy intake for Americans aged >2 y(). This quantity of calo- medical Research Center, Baton Rouge, LA(GMB); the Johns Hopkins ries from fluids, which is predominantly from calorically sweet- University, Baltimore, MD(BC): Linus Pauling Institute, Oregon State Uni- ened beverages, adds to the energy intake from current foodstuffs versity, Corvallis, OR(BF); and the Harvard School of Public Health, Bos- in our diet and is a contributing factor to the energy excess needed ton, MA ( WCW) to produce obesity (2-4). Depending on the reference point, the 2 Supported by The Unilever Health Institute, Netherlands. Address reprint requests to BM Popkin, Carolina Population Center average calorie intake for all Americans aged >2y has increased University of North Carolina at Chapel Hill, 123 West Franklin Street, by 150-300 kcal/d for different age-sex groups (5,6). Data Chapel Hill, NC27516-3997 E-mail: popkin@ unc.edu also show that =% of this increase is contributed by the con- Received June 6. 2005 Imption of calorically sweetened beverages. Between 1977 and Accepted for publication October 3, 200 Am J Clin Nutr 2006: 83: 529-42 Printed in USA. o 2006 American Society for Nutrition

Commentary A new proposed guidance system for beverage consumption in the United States1–3 Barry M Popkin, Lawrence E Armstrong, George M Bray, Benjamin Caballero, Balz Frei, and Walter C Willett ABSTRACT The Beverage Guidance Panel was assembled to provide guidance on the relative health and nutritional benefits and risks of various beverage categories. The beverage panel was initiated by the first author. The Panel’s purpose is to attempt to systematically review the literature on beverages and health and provide guidance to the consumer. An additional purpose of the Panel is to develop a deeper dialog among the scientific community on overall beverage con￾sumption patterns in the United Sates and on the great potential to change this pattern as a way to improve health. Over the past several decades, levels of overweight and obesity have increased across all population groups in the United States. Concurrently, an increased daily intake of 150 –300 kcal (for different age-sex groups) has occurred, with approximately 50% of the increased calories coming from the consumption of calorically sweetened beverages. The panel ranked beverages from the lowest to the highest value based on caloric and nutrient contents and related health benefits and risks. Drinking water was ranked as the preferred beverage to fulfill daily water needs and was followed in decreasing value by tea and coffee, low-fat (1.5% or 1%) and skim (nonfat) milk and soy beverages, noncalorically sweetened beverages, beverages with some nutri￾tional benefits (fruit and vegetable juices, whole milk, alcohol, and sports drinks), and calorically sweetened, nutrient-poor beverages. The Panel recommends that the consumption of beverages with no or few calories should take precedence over the consumption of bev￾erages with more calories. Am J Clin Nutr 2006;83:529 – 42. KEY WORDS Water, tea, coffee, milk, fruit juice, alcohol, calorically sweetened beverages, beverage guidance system INTRODUCTION The development of the Beverage Guidance System was mo￾tivated by the large increase in unhealthy weight patterns in the United States over the past 20 y and the 5–15% increase in dietary energy intake during that same period. Although the focus of the US Dietary Guidelines for Americans has been on food, energy intake from beverages currently represents 21% of the total en￾ergy intake for Americans aged
2 y (1). This quantity of calo￾ries from fluids, which is predominantly from calorically sweet￾ened beverages, adds to the energy intake from current foodstuffs in our diet and is a contributing factor to the energy excess needed to produce obesity (2– 4). Depending on the reference point, the average calorie intake for all Americans aged
2 y has increased by 150 –300 kcal/d for different age-sex groups (5, 6). Data also show that 50% of this increase is contributed by the con￾sumption of calorically sweetened beverages. Between 1977 and 2001, the proportion of energy obtained from calorically sweet￾ened soft drinks and fruit drinks, which—as defined later—are different from fruit juices, has increased 3-fold, from 2.8% to 7.0% (50 –144 kcal/d), with a concurrent reduction in milk intake (1). Portion sizes of calorically sweetened beverages for all ages increased from 13.6 fl oz (402 mL) to 21.0 fl oz (621 mL) between 1977 and 1996—a proportionately larger increase than the increase in the number of servings (1). At the same time that portion sizes have increased, Americans have also increased the number of servings of calorically sweetened beverages from 1.96 in 1977 to 2.39 in 1996. Servings are measured for beverages according to US Department of Agriculture (USDA) standards. Our proposed guidance thus focuses on obtaining as much of the daily fluid needs as possible from beverages that have lower amounts of energy and an improved nutrient profile. The Beverage Guidance Panel was assembled to provide guid￾ance on the relative health and nutritional benefits and risks of various beverage categories. A healthy diet does not rely on fluids to provide energy or nutrient needs. Therefore, potable water could be used to fulfill almost all the fluid needs of healthy individuals. However, to allow for variety and individual pref￾erences, healthful diets may include several other types of bev￾erages. In fact, the other motivation for this Beverage Guidance System was to help consumers select a variety of beverages. There is evidence that beverages have weak satiety properties and elicit poor dietary compensation. Studies of appetitive sen￾sations (eg, hunger, fullness, and prospective consumption) sup￾port the view that fluids are less satiating than are solid foods (7–9). Dietary compensation (the adjustment in energy intake made by individuals in subsequent meals in response to earlier food intake) has been studied with solid, semisolid, and fluid foods. For fluids, Mattes (10) reported a complete lack of compensation, which suggests that fluid calories are not readily 1 From the University of North Carolina, Chapel Hill, NC (BMP); the University of Connecticut Human Performance Laboratory, Storrs, CT (LEA); the Louisiana State University Medical Center and Pennington Bio￾medical Research Center, Baton Rouge, LA (GMB); the Johns Hopkins University, Baltimore, MD (BC); Linus Pauling Institute, Oregon State Uni￾versity, Corvallis, OR (BF); and the Harvard School of Public Health, Bos￾ton, MA (WCW). 2 Supported by The Unilever Health Institute, Netherlands. 3 Address reprint requests to BM Popkin, Carolina Population Center, University of North Carolina at Chapel Hill, 123 West Franklin Street, Chapel Hill, NC 27516-3997. E-mail: popkin@unc.edu. Received June 6, 2005. Accepted for publication October 3, 2005. Am J Clin Nutr 2006;83:529 – 42. Printed in USA. © 2006 American Society for Nutrition 529 by guest on August 19, 2012 www.ajcn.org Downloaded from

registered"for appetite regulation. Another study found that served and consumed is larger. For instance, for soft drinks this gestion of 450 kcal of calorically sweetened fruit drink pro- was 19.9 fl oz for the average American aged 22 y in 1994-1996 duced a significant increase in body weight that was not found (23). The USDA food-composition table uses 8 fl oz(237 mL) when the same amount was consumed in solid form by the same We also recommend that calorically sweetened beverages move dividuals(l1). The mechanisms for this weaker compensatory back to the 8-oz beverage size. A set of definitions for all the key response to fluids are not known. concepts used in discussing beverages in this review is provided The Panel on Water and Electrolytes of the Institute of Med- in Table 1 icine(IOM) has recognized that fluid requirements vary widely mong individuals and populations(12). Therefore, no estimated average requirement(EAR) has been set for water, and an ade quate intake(Al)was defined instead. The Al, derived from the THE BEVERAGE GUIDANCE SYSTEM usual intake of total fluids in the general population, was set at This Beverage Guidance System ranks beverages in 6 levels, 125 fl oz(3.7 L)/d for men and 91 fl oz(2.7 L)d for women. from the least preferred by the Panel (Level 6-beverages that About 80% of those daily needs is contributed by beverages, should be consumed in limited quantities) to the most preferred including water, and the rest by solid foods(12). Conversely, the by the Panel (Level 1--those that should be consumed as the contribution of fluids to meeting the Recommended Dietary Al- major beverage, ie, water) lowance(RDA) for essential nutrients is minimal, except for Itis not possible to define a set amount of water for each person milk and fruit juices. This balance between energy and nutrient because the water needs depend partially on overall diet and the healthy diet. In this proposed guidance system, we have ranked water and electrolytes(12)of a healthy menu that fulfills all beverages with water at the bottom (level 1), to be consumed nutrient requirements, including fiber, for ahealthy man is shown frequently, and calorically sweetened beverages at the top (level in Table 2. In this example, beverages provide 76% of the total s o), which should be consumed sparingly fluid needs the remainder comes from solid foods This table can The focus of the proposed guidance system is on caloric and be viewed in terms of total fluid intake. This persons diet re- noncaloric sweeteners and other substances that affect the energy quires 96.3 fl oz(2849 mL)of beverage intake Of these bever on hunger and satiety responses; however, the concept is used by contribute only 14% of the total caloric intake some scholars for solid foods, soups, and bevera On the basis of the rationale outlined above. different combi whereas others do not use this concept in their measurement(18). nations of beverages can be used to fulfill the fluid needs of e Inthis article, we use a simple operational definition that is based healthy person. Potable water has the advantage that itisvirtually on caloric content per unit volume Relative to most foods, bev- devoid of adverse effects when consumed within the allowable a low energy density [<350 kcal/12 fl oz(355 mL) a because water is the item that reduces energy density the most 19-22). Thus, relative energy density within each beverage Level 1:water category was compared with other beverage categories ur recommendations are aimed at the population older tha development of taste preferences and early imprinting of food such as calcium, magnesium, and fluoride. For a detailed review 9 choices, that may affect beverage choice and intake and electrolytes(12). Despite the importance of water for human life, and because of our incomplete understanding of everyday TERMS AND DEFINITIONS water turnover, in recent years scientists have begun studies of We defined beverages as all fluids consumed by humans, human water requirements, of hydration, and of the relation ncluding water. However, we excluded liquid meal replacement between hydration status and human health(24-26). products aimed at weight management as well as soups In as- Acute dehydration results in impaired cognition, moodiness, sessing each beverage category, we considered the following poor thermoregulation, reduced cardiovascular function, and factors paired physical work capacity. These expenses can be charged to 1)Energy and nutrient density. Energy density was defined as an overhead or trust account (12). The effects of dehydration on cognitive function have been studied in several randomized con kcal/100 mL Nutrient density was defined as the nutrent trolled clinical trials, in which dehydration was achieved by fluid content(in nutrient-specific units)per 8 fl oz(237 mL)and per 100 mL (3.4 fl oz) restriction, heat exposure, exercise, or combinations thereof 2)Contribution to total energy intake and body weight (27). In healthy young adults, dehydration to 2. 8% body weight Contribution to the daily intake of essential nutrients. loss by heat exposure or exercise significantly decreased alert 4) Evidence for beneficial health effects ness, concentration, tracking performance, and short-term mem- 5) Evidence for adverse health effects ory and increased tiredness, headaches, and reaction time(28). In the only study performed in older subjects(healthy 50-82-y The Panel used 8 fl oz(237 mL) as the reference unit. Eight olds), dehydration by overnight fluid restriction was related to tion size used for food labels; however, the actual portion size minished memory (29 essing speed, poorer attention, and di- unces is the official FDA (Food and Drug Administration) por- slower psychomotor proc

“registered” for appetite regulation. Another study found that ingestion of 450 kcal of calorically sweetened fruit drink pro￾duced a significant increase in body weight that was not found when the same amount was consumed in solid form by the same individuals (11). The mechanisms for this weaker compensatory response to fluids are not known. The Panel on Water and Electrolytes of the Institute of Med￾icine (IOM) has recognized that fluid requirements vary widely among individuals and populations (12). Therefore, no estimated average requirement (EAR) has been set for water, and an ade￾quate intake (AI) was defined instead. The AI, derived from the usual intake of total fluids in the general population, was set at 125 fl oz (3.7 L)/d for men and 91 fl oz (2.7 L)/d for women. About 80% of those daily needs is contributed by beverages, including water, and the rest by solid foods (12). Conversely, the contribution of fluids to meeting the Recommended Dietary Al￾lowance (RDA) for essential nutrients is minimal, except for milk and fruit juices. This balance between energy and nutrient content is a critical factor to define the role of beverages in a healthy diet. In this proposed guidance system, we have ranked beverages with water at the bottom (level 1), to be consumed frequently, and calorically sweetened beverages at the top (level 6), which should be consumed sparingly. The focus of the proposed guidance system is on caloric and noncaloric sweeteners and other substances that affect the energy density (kcal/100 mL) and nutrient density of each beverage. It is recognized that the concept of “energy density” for solid and liquid foods may not be equivalent, particularly when focusing on hunger and satiety responses; however, the concept is used by some scholars for solid foods, soups, and beverages (13–17), whereas others do not use this concept in their measurement (18). In this article, we use a simple operational definition that is based on caloric content per unit volume. Relative to most foods, bev￾erages have a low energy density [350 kcal/12 fl oz (355 mL)] because water is the item that reduces energy density the most (19 –22). Thus, relative energy density within each beverage category was compared with other beverage categories. Our recommendations are aimed at the population older than 6 y. Below that age, there are many additional factors, such as development of taste preferences and early imprinting of food choices, that may affect beverage choice and intake. TERMS AND DEFINITIONS We defined beverages as all fluids consumed by humans, including water. However, we excluded liquid meal replacement products aimed at weight management as well as soups. In as￾sessing each beverage category, we considered the following factors: 1) Energy and nutrient density. Energy density was defined as kcal/100 mL. Nutrient density was defined as the nutrient content (in nutrient-specific units) per 8 fl oz (237 mL) and per 100 mL (3.4 fl oz). 2) Contribution to total energy intake and body weight. 3) Contribution to the daily intake of essential nutrients. 4) Evidence for beneficial health effects. 5) Evidence for adverse health effects. The Panel used 8 fl oz (237 mL) as the reference unit. Eight ounces is the official FDA (Food and Drug Administration) por￾tion size used for food labels; however, the actual portion size served and consumed is larger. For instance, for soft drinks this was 19.9 fl oz for the average American aged 2 y in 1994 –1996 (23). The USDA food-composition table uses 8 fl oz (237 mL). We also recommend that calorically sweetened beverages move back to the 8-oz beverage size. A set of definitions for all the key concepts used in discussing beverages in this review is provided in Table 1. THE BEVERAGE GUIDANCE SYSTEM This Beverage Guidance System ranks beverages in 6 levels, from the least preferred by the Panel (Level 6— beverages that should be consumed in limited quantities) to the most preferred by the Panel (Level 1—those that should be consumed as the major beverage, ie, water). It is not possible to define a set amount of water for each person because the water needs depend partially on overall diet and the water contained in the foods. An example from the IOM report on water and electrolytes (12) of a healthy menu that fulfills all nutrient requirements,including fiber, for a healthy manis shown in Table 2. In this example, beverages provide 76% of the total fluid needs; the remainder comes from solid foods. This table can be viewed in terms of total fluid intake. This person’s diet re￾quires 96.3 fl oz (2849 mL) of beverage intake. Of these bever￾ages, the main contributor is tea (33%), followed by potable water (25%), coffee (21%), milk (15%), and orange juice (6%). A key message in this example is that all beverages combined contribute only 14% of the total caloric intake. On the basis of the rationale outlined above, different combi￾nations of beverages can be used to fulfill the fluid needs of a healthy person. Potable water has the advantage that it is virtually devoid of adverse effects when consumed within the allowable intake. Level 1: water Water consumption is necessary for metabolism and for nor￾mal physiologic functions and may provide essential minerals such as calcium, magnesium, and fluoride. For a detailed review of the maintenance of water balance, see the IOM report on water and electrolytes (12). Despite the importance of water for human life, and because of our incomplete understanding of everyday water turnover, in recent years scientists have begun studies of human water requirements, of hydration, and of the relation between hydration status and human health (24 –26). Acute dehydration results in impaired cognition, moodiness, poor thermoregulation, reduced cardiovascular function, and im￾paired physical work capacity. These expenses can be charged to an overhead or trust account (12). The effects of dehydration on cognitive function have been studied in several randomized con￾trolled clinical trials, in which dehydration was achieved by fluid restriction, heat exposure, exercise, or combinations thereof (27). In healthy young adults, dehydration to 2.8% body weight loss by heat exposure or exercise significantly decreased alert￾ness, concentration, tracking performance, and short-term mem￾ory and increased tiredness, headaches, and reaction time (28). In the only study performed in older subjects (healthy 50 – 82-y￾olds), dehydration by overnight fluid restriction was related to slower psychomotor processing speed, poorer attention, and di￾minished memory (29). 530 POPKIN ET AL by guest on August 19, 2012 www.ajcn.org Downloaded from

PROPOSED BEVERAGE GUIDANCE SYSTEM 531 TABLE 1 Glossary of definitions of the key concepts and beverages Metabolic water Water formed during the metabolism of food Potable water Whether supplied from ground water or underground aquifers, water suitable for human consumption. free of pathogens and major pollutants, containing <50 mg nitrates/L(European standard), and not having toxic amounts of any mineral. Added caloric sweeteners All the composite sugars added to a food, including sucrose, high-fructose com syrup, honey, molasses, and other syrups. Naturally occur Sugars ing in food and not added in processing, preparation, or at the table Calorically sweetened beverages Any beverage to which a caloric sweetener has been added, including carbonated or noncarbonated soft drinks, fruit punch, fruit drinks, lemonade, sweetened powder drinks, or any other nonartificially sweetened beverages. Excluded from this definition are sugars naturally present in fluids and that are not added in processing, in preparation, or at the table. Soft drinks Nonalcoholic carbonated or noncarbonated beverages containing caloric sweeteners and flavorings. Fruit drinks Calorically sweetened beverages with a small percentage of a fruit juice or juice flavoring containing carbonated water and flavoring. Fruit and vegetable juices Beverages that are composed exclusively of an aqueous liquid or liquids extracted from one or more fruits or vegetables with no added caloric sweeteners. Noncalorically sweetened beverages Soft drinks(diet sodas)or fruit drinks sweetened with Food and Drug Administration-approved noncaloric sweeteners. Noncaloric sweeteners do not provide calories, but they do provide the sweet taste. Noncaloric sweeteners currently include aspartame(Equalor NutraSweet), acesulfame K(Sunett), saccharin or benzsulfamide(Sweet'n Low ), and sucralose(Splenda) sssEs<s99 All are many times sweeter than sugar per gram. Energy density Kilocalories per 8 fl oz(237 mL)of beverage. Amount of each nutrient in 8 fl oz(237 mL)of beverage. The health benefits and risks to be onsidered include noncommunicable diseases such as obesity, type 2 diabetes, heart disease, ous cancers. dental caries and bone health. I Merisant, Chicago, IL. 2 Nutrinova Inc, Somerset, NJ Cumberland Packing Corp, Brooklyn, NY 4 McNeil Nutritionals(Johnson Johnson). Washington, PA The adverse effects of acute dehydration on physical work Chronic dehydration increases the risk of bladder cancer(12) 卷 capacity and exercise performance are well established (30), However, some of the effects are not well established, because especially when dehydration exceeds 1-2% of body weight few studies have focused on chronic disease outcomes. Betwee 2001 and 2004, ll of 13 studies showed a significant association TABLE 2 Daily water intake from a diet providing 2200 kcal energy and adequate intake of all essential nutrients' Meal Food or beverage consumed Wate 95→N Total food Milk, 1%(8 fl oz) Orange juice(6 fl oz) 9&3 Coffee(12 fl oz) Total for meal 8 Snack Total food 8775285 ater(12 fl oz) Total for snack 443 Lunch Iced tea, brewed, decaffeinated(16 fl oz) 47 Total for meal Snack Total food 14 Milk, 1%(8 fl oz) 237 Total for snack Dinner 523 Iced tea, brewed, decaffeinated(16 fl oz) Coffee. decaffeinated (8 fl oz) 237 Total for meal Energy and water from food Total energy and total water(all sources) Data are from the Institute of Medicine Panel on Dietary Reference Intakes for Electrolytes and Water, 2004(12). 1 oz=29.574 mL

The adverse effects of acute dehydration on physical work capacity and exercise performance are well established (30), especially when dehydration exceeds 1–2% of body weight (31, 32). Chronic dehydration increases the risk of bladder cancer (12). However, some of the effects are not well established, because few studies have focused on chronic disease outcomes. Between 2001 and 2004, 11 of 13 studies showed a significant association TABLE 1 Glossary of definitions of the key concepts and beverages Metabolic water Water formed during the metabolism of food. Potable water Whether supplied from ground water or underground aquifers, water suitable for human consumption, free of pathogens and major pollutants, containing 50 mg nitrates/L (European standard), and not having toxic amounts of any mineral. Added caloric sweeteners All the composite sugars added to a food, including sucrose, high-fructose corn syrup, honey, molasses, and other syrups. Naturally occurring sugars Sugars occurring in food and not added in processing, preparation, or at the table. Calorically sweetened beverages Any beverage to which a caloric sweetener has been added, including carbonated or noncarbonated soft drinks, fruit punch, fruit drinks, lemonade, sweetened powder drinks, or any other nonartificially sweetened beverages. Excluded from this definition are sugars naturally present in fluids and that are not added in processing, in preparation, or at the table. Soft drinks Nonalcoholic carbonated or noncarbonated beverages containing caloric sweeteners and flavorings. Fruit drinks Calorically sweetened beverages with a small percentage of a fruit juice or juice flavoring containing carbonated water and flavoring. Fruit and vegetable juices Beverages that are composed exclusively of an aqueous liquid or liquids extracted from one or more fruits or vegetables with no added caloric sweeteners. Noncalorically sweetened beverages Soft drinks (diet sodas) or fruit drinks sweetened with Food and Drug Administration–approved noncaloric sweeteners. Noncaloric sweeteners do not provide calories, but they do provide the sweet taste. Noncaloric sweeteners currently include aspartame (Equal1 or NutraSweet1 ), acesulfame K (Sunett2 ), saccharin or benzosulfamide (Sweet’n Low3 ), and sucralose (Splenda4 ). All are many times sweeter than sugar per gram. Energy density Kilocalories per 8 fl oz (237 mL) of beverage. Nutrient density Amount of each nutrient in 8 fl oz (237 mL) of beverage. The health benefits and risks to be considered include noncommunicable diseases such as obesity, type 2 diabetes, heart disease, various cancers, dental caries, and bone health. 1 Merisant, Chicago, IL. 2 Nutrinova Inc, Somerset, NJ. 3 Cumberland Packing Corp, Brooklyn, NY. 4 McNeil Nutritionals (Johnson & Johnson), Washington, PA. TABLE 2 Daily water intake from a diet providing 2200 kcal energy and adequate intake of all essential nutrients1 Meal Food or beverage consumed Energy Water kcal mL Breakfast Total food 299 83 Milk, 1% (8 fl oz) 102 237 Orange juice (6 fl oz) 82 177 Coffee (12 fl oz) 13 355 Total for meal 496 852 Snack Total food 105 88 Water (12 fl oz) 0 355 Total for snack 105 443 Lunch Total food 534 190 Iced tea, brewed, decaffeinated (16 fl oz) 5 473 Total for meal 539 663 Snack Total food 314 7 Milk, 1% (8 fl oz) 102 237 Water (12 fl oz) 0 355 Total for snack 416 599 Dinner Total food 649 523 Iced tea, brewed, decaffeinated (16 fl oz) 5 473 Coffee, decaffeinated (8 fl oz) 9 237 Total for meal 663 1233 Total Energy and water from foods 1,901 891 Energy and water from beverages 318 2899 Total energy and total water (all sources) 2,219 3790 1 Data are from the Institute of Medicine Panel on Dietary Reference Intakes for Electrolytes and Water, 2004 (12). 1 oz  29.574 mL. PROPOSED BEVERAGE GUIDANCE SYSTEM 531 by guest on August 19, 2012 www.ajcn.org Downloaded from

53 between improved hydration status and reduced kidney stone cholesterol concentrations(56) compared with the equivalent occurrence(33, 34). amount of caffeine or hot water. In agreement with these studies. Excess water intake can occur; however, this is rare in healthy a recent double-blind crossover study found that acute consump persons with properly functioning kidneys because the kidneys tion of black tea improved coronary vessel function, as assessed can produce a large volume of urine in a relatively short period of by coronary flow velocity reserve (57). The beneficial effects of time to correct the disturbance. Only in exceptional circum- tea consumption on endothelium-dependent vasodilation may be ances does hyperhydration occur (ie, I out of 1000 ultraendur- explained by activation of endothelial nitric oxide synthase ance competitors), resulting in the dilution of body fluids and a(eNOS)by tea flavonoids, via an estrogen receptor a-dependent low serum sodium concentration (ie, <136 mEq Na"/L)(35). pathway (58). Despite these intriguing results, the potential Drinking water may contain different concentrations of Ca++ health benefits of flavonoids in tea and their antioxidant com- and Mg+, which contribute to meeting the recommended di- pared with nonantioxidant mechanisms of action remain to be etary intakes of these minerals(36). Calcium and magnesium fully explored (59). from bottled water are well absorbed and utilized (37-39). The fluoride content of bottled water is usually much lower than Cottee fluoridated tap water, but on occasion it may exceed advisable Several prospective cohort studies have observed significant concentrations (40). inverse associations between regular coffee consumption and the risk of type 2 diabetes(60-63). In a US cohort, a modest inverse Level 2 tea and cofifee association between decaffeinated coffee consumption and the risk of type 2 diabetes also was observed, which suggests that ≈ Te compounds other than caffeine may contribute to risk reduction E Black, green, and oolong tea are the 3 main categories of tea (61).High intakes of coffee have been associated with significant consumed in the world. Tea provides a variety of flavonoids and reductions in colorectal cancer risk in numerous case-control antioxidants as well as a few micronutrients, in particular fluo- studies, but prospective cohort studies have not generally ob- s ride(41). Although there is solid evidence that tea protects served such significant associations(64, 65). Coffee and caffeine remains unclear whether tea consumption lowers cancer risk in reductions in the risk of Parkinson disease in men(66)but not in 9 theanine. Recently, theanine was shown to enhance innate im- estrogen. In 2 large prospective cohort studies, coffee consump munity--the bodys ability to resist infections-by stimulating tion was inversely associated with the risk of Parkinson disease D 8 Tcells(43), and this effect has been replicated with regular in women who had never used estrogen postmenopausally, but (5-6 cups/d, or 1185-1422 mL/d) tea consumption in humans inverse associations were not observed in women who used e reduce tooth decay and cavities (47), and reduce kidney stones daily consumption of =6 cups of coffee was associated with a significant increase in Parkinson disease risk among postmen- Numerous epidemiologic studies have examined the associa- pausal estrogen users(68). Two prospective cohort studies in the 3 tion between tea consumption and the risk of cardiovascular United States found significant inverse associations between diseases. A meta-analysis that combined the data from 10 pro- coffee consumption and the risk of sui iy spective cohort studies and 7 case-control studies concluded that J-shaped relation between coffee consumption and the risk of mL)is associated with an 11% decrease in the risk of myocardial cups of coffee was associated with a significant increase in the s infarction(50). However, the results among prospective coho risk of suicide compared with more moderate consumption(71) studies are inconsistent. A 6-y study of Dutch men and women Most large prospective cohort studies have not found high found that those who drank 23 cups/d(=13 fl oz) had a signif- intakes of coffee or caffeine to be associated with a significantly icantly lower risk of myocardial infarction than did nondrinkers increased risk of coronary heart disease or myocardial infarction (51). A 7-y study of US women found that the risk of vascular (72-74). In contrast, coffee consumption has been associated events was significantly lower in a small number of women who with increases in several cardiovascular disease risk factors. The drank 24 cups black tea/d (52). Finally, a 15-y study of US men consumption of boiled unfiltered coffee has been found to in- found no association between tea consumption and cardiovas- crease plasma total and LDL-cholesterol concentrations, cular disease risk, but tea consumption in this population was whereas the consumption of filtered coffee does not appear to relatively low, averaging I cup/d(53).Overall, the current data have adverse effects on lipid profiles(75). The diterpenes caf suggest that consumption of 23 cups black tea/d may modestly estol and kahweol have been identified as cholesterol-raising decrease the risk of myocardial infarction. Although green tea factors in roasted coffee beans(76). Diterpenes are extracted by onsumption may confer a similar benefit(54), there is currently hot water when coffee is brewed, and they are trapped by paper not enough data to draw firm conclusion filters. Consequently, filtered coffee contains very little cafestol Recent evidence suggests that tea consumption improves and kahweol, whereas boiled coffee and espresso may contain endothelium-dependent vasodilation, which could explain, at significant amounts (77). Controlled clinical trials have found least in part, a reduction in cardiovascular disease risk (55). Two that high intakes of filtered and unfiltered coffee increase plasma linical studies found that the daily consumption of 4-5 cups homocysteine concentration-an independent risk factor for car- 30-40 fl oz) black tea for 4 wk significantly improved diovascular diseases (78, 79). In randomized controlled trials, endothelium-dependent vasodilation in patients with coronary caffeinated coffee consumption has been found to result in mod- artery disease (55)and in patients with mildly elevated serum est but significant increases in systolic (2.0-2. 4 mm Hg) and

between improved hydration status and reduced kidney stone occurrence (33, 34). Excess water intake can occur; however, this is rare in healthy persons with properly functioning kidneys because the kidneys can produce a large volume of urine in a relatively short period of time to correct the disturbance. Only in exceptional circum￾stances does hyperhydration occur (ie, 1 out of 1000 ultraendur￾ance competitors), resulting in the dilution of body fluids and a low serum sodium concentration (ie, 136 mEq Na/L) (35). Drinking water may contain different concentrations of Ca and Mg, which contribute to meeting the recommended di￾etary intakes of these minerals (36). Calcium and magnesium from bottled water are well absorbed and utilized (37–39). The fluoride content of bottled water is usually much lower than fluoridated tap water, but on occasion it may exceed advisable concentrations (40). Level 2: tea and coffee Tea Black, green, and oolong tea are the 3 main categories of tea consumed in the world. Tea provides a variety of flavonoids and antioxidants as well as a few micronutrients, in particular fluo￾ride (41). Although there is solid evidence that tea protects against chemically induced cancers in experimental animals, it remains unclear whether tea consumption lowers cancer risk in humans (42). Tea also provides some amino acids, primarily theanine. Recently, theanine was shown to enhance innate im￾munity—the body’s ability to resist infections— by stimulating
- T cells (43), and this effect has been replicated with regular (5– 6 cups/d, or 1185–1422 mL/d) tea consumption in humans (43– 45). Tea consumption may also increase bone density (46), reduce tooth decay and cavities (47), and reduce kidney stones (48, 49). Numerous epidemiologic studies have examined the associa￾tion between tea consumption and the risk of cardiovascular diseases. A meta-analysis that combined the data from 10 pro￾spective cohort studies and 7 case-control studies concluded that an increase in tea consumption of 3 large cups/d (24 fl oz, or 710 mL) is associated with an 11% decrease in the risk of myocardial infarction (50). However, the results among prospective cohort studies are inconsistent. A 6-y study of Dutch men and women found that those who drank 3 cups/d (13 fl oz) had a signif￾icantly lower risk of myocardial infarction than did nondrinkers (51). A 7-y study of US women found that the risk of vascular events was significantly lower in a small number of women who drank 4 cups black tea/d (52). Finally, a 15-y study of US men found no association between tea consumption and cardiovas￾cular disease risk, but tea consumption in this population was relatively low, averaging 1 cup/d (53). Overall, the current data suggest that consumption of 3 cups black tea/d may modestly decrease the risk of myocardial infarction. Although green tea consumption may confer a similar benefit (54), there is currently not enough data to draw firm conclusions. Recent evidence suggests that tea consumption improves endothelium-dependent vasodilation, which could explain, at least in part, a reduction in cardiovascular disease risk (55). Two clinical studies found that the daily consumption of 4 –5 cups (30 – 40 fl oz) black tea for 4 wk significantly improved endothelium-dependent vasodilation in patients with coronary artery disease (55) and in patients with mildly elevated serum cholesterol concentrations (56) compared with the equivalent amount of caffeine or hot water. In agreement with these studies, a recent double-blind crossover study found that acute consump￾tion of black tea improved coronary vessel function, as assessed by coronary flow velocity reserve (57). The beneficial effects of tea consumption on endothelium-dependent vasodilation may be explained by activation of endothelial nitric oxide synthase (eNOS) by tea flavonoids, via an estrogen receptor -dependent pathway (58). Despite these intriguing results, the potential health benefits of flavonoids in tea and their antioxidant com￾pared with nonantioxidant mechanisms of action remain to be fully explored (59). Coffee Several prospective cohort studies have observed significant inverse associations between regular coffee consumption and the risk of type 2 diabetes (60 – 63). In a US cohort, a modest inverse association between decaffeinated coffee consumption and the risk of type 2 diabetes also was observed, which suggests that compounds other than caffeine may contribute to risk reduction (61). High intakes of coffee have been associated with significant reductions in colorectal cancer risk in numerous case-control studies, but prospective cohort studies have not generally ob￾served such significant associations (64, 65). Coffee and caffeine consumption have been consistently associated with significant reductions in the risk of Parkinson disease in men (66) but not in women (67), which may be due to the modifying effects of estrogen. In 2 large prospective cohort studies, coffee consump￾tion was inversely associated with the risk of Parkinson disease in women who had never used estrogen postmenopausally, but inverse associations were not observed in women who used es￾trogen postmenopausally (67, 68). In the Nurses’ Health Study, daily consumption of 6 cups of coffee was associated with a significant increase in Parkinson disease risk among postmeno￾pausal estrogen users (68). Two prospective cohort studies in the United States found significant inverse associations between coffee consumption and the risk of suicide (69, 70). However, a J-shaped relation between coffee consumption and the risk of suicide was observed in Finland, where daily consumption of 8 cups of coffee was associated with a significant increase in the risk of suicide compared with more moderate consumption (71). Most large prospective cohort studies have not found high intakes of coffee or caffeine to be associated with a significantly increased risk of coronary heart disease or myocardial infarction (72–74). In contrast, coffee consumption has been associated with increases in several cardiovascular disease risk factors. The consumption of boiled unfiltered coffee has been found to in￾crease plasma total and LDL-cholesterol concentrations, whereas the consumption of filtered coffee does not appear to have adverse effects on lipid profiles (75). The diterpenes caf￾estol and kahweol have been identified as cholesterol-raising factors in roasted coffee beans (76). Diterpenes are extracted by hot water when coffee is brewed, and they are trapped by paper filters. Consequently, filtered coffee contains very little cafestol and kahweol, whereas boiled coffee and espresso may contain significant amounts (77). Controlled clinical trials have found that high intakes of filtered and unfiltered coffee increase plasma homocysteine concentration—an independent risk factor for car￾diovascular diseases (78, 79). In randomized controlled trials, caffeinated coffee consumption has been found to result in mod￾est but significant increases in systolic (2.0 –2.4 mm Hg) and 532 POPKIN ET AL by guest on August 19, 2012 www.ajcn.org Downloaded from

PROPOSED BEVERAGE GUIDANCE SYSTEM 533 diastolic (0.7-1. 2 mm Hg) blood pressure(75, 80). Although lactose content than does milk and may be preferred by individ coffee consumption was associated with small increases in sys- uals with reduced lactose tolerance. In general, low-fat dairy tolic and diastolic blood pressure in one prospective cohort study, beverages and fortified soymilk provide an important source of the risk of developing hypertension after an average of 33 y was protein, calcium, and other essential micronutrients not affected(81). Many beneficial, and some detrimental, health effects have been attributed to the consumption of cow milk. The role of milk Caffeine intake intake on weight control has been explored in many studies. A There are greater amounts of caffeine in coffee than in tea Teegarden and Zemel (96)found that a higher consumption of able 3). Although caffeine is a mild diuretic, human studies milk appeared to induce weight loss, but their study had a small indicate that caffeine consumption of up to 500 mg/d does not sample size and a high dropout rate. In larger randomized trials cause dehydration or chronic water imbalance(82, 83). A caf- those subjects assigned to a higher intake of low-fat milk expe- feinated beverage's fluid content compensates for an acute di- rienced a greater weight gain that was either statistically signif- uretic effect. At this time, the preponderance of evidence in icant(97)or not statistically significant(98). In a longitudinal healthy adults suggests that a moderate caffeine intake up to 400 study of many thousand adolescents, low-fat milk consumption mg/d is not associated with an increased risk of heart disease, was positively associated with a gain in body mass index;this hypertension, osteoporosis, or high cholesterol(84). Some peo- was accounted for by a higher energy intake among those whe ple are more sensitive to caffeine's effects than are others and consumed more milk(99). The 2005 Dietary Guidelines for may feel effects at lower doses. Pregnancy and aging may affect Americans Committee performed a detailed review of this topic I one's sensitivity to caffeine. Pregnant women are often advise and concluded that there was not sufficient evidence that milk s to limit caffeine consumption because caffeine intakes >300 consumption reduced, or prevented,weight gain(100).Subse- E mg/d have been associated with an increased risk of miscarriage quent published research has found that milk did not prevent 9 and low birth weight(85-87). It is unclear whether caffeine has weight gain, including one 48-wk clinical trial funded by the adverse effects in children, but concerns regarding its effects on National Dairy Council(101, 102) the developing nervous system have led torecommendations that A second issue relates to bone health.The Dietary Guidelines a daily caffeine intake by children should be limited to 2.5 mg/kg Committee also evaluated 7 randomized trials and 32observa- body weight (84). Interestingly, a variety of investigations report an"invertedU tional studies that explored the relation between milk intake and E relation when a physiologic or psychological response is plotted bone health. All 7 randomized trials and 25 of the observational versus caffeine intake. That is, the magnitude of caffeine's effect studies showed a positive relation between milk consumption s intakes. Such a relation has been reported for exercise perfor- However, the benefits of higher calcium intake on bone mineral mance time(88, 89), reaction time(90), vigilance(91), informa- density are not maintained if the high intake is reduced. In or tion processing(92), and mood state( 93)but may not exist for all trial with children, milk intake, but not calcium supplementation, physiologic and psychological responses. Furthermore, this had a continuing effect on bone mineral density 3.5 y after ter a graphic relation may shift left or right, with caffeine habituation mination of the intervention(104). The duration of the random-9 or naivete ized studies was too brief to validly assess fracture incidence Large prospective studies in adults have consistently shown no a Added calories ignificant relation between milk intake and risk of fractures. Addition of milk, cream, or caloric sweeteners to coffee and Milk is an important source of calcium and is the key source for ea increases the energy density of these beverages and would vitamin D due to fortification, particularly for persons aged6-18N lower their value in this guidance system. This might be partic ularly important for gourmet coffee users who consume a lot of also important contributors to the intake of essential nutrients in high-energy coffee drinks. For instance, Shields et al (94)found the diet of children and adolescents. Data from the National in one very small sample of college women that gourmet coffee Health and Nutrition Examination Survey(NHANES)and Con drinkers consumed 206 more calories per day than did ongour- tinuing Survey of Food Intakes by Individuals(CSFID) indicate met coffee drinkers. The high caloric content of some gourmet that as consumption of milk products increases, so does the intake coffee drinks is shown in Table 3. Sweetened tea provides of calcium, magnesium, potassium, zinc, iron, vitamin A, ribo- smaller amounts of energy than does gourmet coffee, as noted in flavin, and folate(105). Conversely, eliminating milk produc Table 3 from the USDa dietary pattern would substantially reduce in- takes of those essential nutrients(100). Nevertheless, although it Level 3: low fat(1.5% or 1%)and skim(nonfat)milk would require a careful selection of foods, milk products could be and soy beverages replaced with soy-based products and items from other food For children, milk is the current key source of vitamin D and groups, particularly fruit and vegetables--some of which are calcium and is an excellent source of high-quality protein Low also good sources of calcium. The essential micronutrients in fat and skim milks, including low-fat yogurt drinks, can contrib- milk products could also be replaced by daily multivitamin ute to a healthy diet but are not essential. Fortified soymilk is a mineral and calcium supplements. Fortification of milk with good alternative for individuals who prefer not to consume cow vitamin D has reduced the occurrence of rickets in children, but milk, although consumers should be aware that soymilk cannot other sources of supplemental vitamin D can be used be legally fortified with vitamin D and provides =% of the Some studies have reported a beneficial effect of milk con- calcium bioavailable from milk(95). Yogurt drinks have a lower mption in reducing the risk of the metabolic syndrome, a

diastolic (0.7–1.2 mm Hg) blood pressure (75, 80). Although coffee consumption was associated with small increases in sys￾tolic and diastolic blood pressurein one prospective cohort study, the risk of developing hypertension after an average of 33 y was not affected (81). Caffeine intake There are greater amounts of caffeine in coffee than in tea (Table 3). Although caffeine is a mild diuretic, human studies indicate that caffeine consumption of up to 500 mg/d does not cause dehydration or chronic water imbalance (82, 83). A caf￾feinated beverage’s fluid content compensates for an acute di￾uretic effect. At this time, the preponderance of evidence in healthy adults suggests that a moderate caffeine intake up to 400 mg/d is not associated with an increased risk of heart disease, hypertension, osteoporosis, or high cholesterol (84). Some peo￾ple are more sensitive to caffeine’s effects than are others and may feel effects at lower doses. Pregnancy and aging may affect one’s sensitivity to caffeine. Pregnant women are often advised to limit caffeine consumption because caffeine intakes
300 mg/d have been associated with an increased risk of miscarriage and low birth weight (85– 87). It is unclear whether caffeine has adverse effects in children, but concerns regarding its effects on the developing nervous system have led to recommendations that daily caffeine intake by children should be limited to 2.5 mg/kg body weight (84). Interestingly, a variety of investigations report an “inverted U” relation when a physiologic or psychological response is plotted versus caffeine intake. That is, the magnitude of caffeine’s effect is smaller at low and high intakes but greater at intermediate intakes. Such a relation has been reported for exercise perfor￾mance time (88, 89), reaction time (90), vigilance (91), informa￾tion processing (92), and mood state (93) but may not exist for all physiologic and psychological responses. Furthermore, this graphic relation may shift left or right, with caffeine habituation or naiveté. Added calories Addition of milk, cream, or caloric sweeteners to coffee and tea increases the energy density of these beverages and would lower their value in this guidance system. This might be partic￾ularly important for gourmet coffee users who consume a lot of high-energy coffee drinks. For instance, Shields et al (94) found in one very small sample of college women that gourmet coffee drinkers consumed 206 more calories per day than did nongour￾met coffee drinkers. The high caloric content of some gourmet coffee drinks is shown in Table 3. Sweetened tea provides smaller amounts of energy than does gourmet coffee, as noted in Table 3. Level 3: low fat (1.5% or 1%) and skim (nonfat) milk and soy beverages For children, milk is the current key source of vitamin D and calcium and is an excellent source of high-quality protein. Low fat and skim milks, including low-fat yogurt drinks, can contrib￾ute to a healthy diet but are not essential. Fortified soymilk is a good alternative for individuals who prefer not to consume cow milk, although consumers should be aware that soymilk cannot be legally fortified with vitamin D and provides 75% of the calcium bioavailable from milk (95). Yogurt drinks have a lower lactose content than does milk and may be preferred by individ￾uals with reduced lactose tolerance. In general, low-fat dairy beverages and fortified soymilk provide an important source of protein, calcium, and other essential micronutrients. Many beneficial, and some detrimental, health effects have been attributed to the consumption of cow milk. The role of milk intake on weight control has been explored in many studies. Teegarden and Zemel (96) found that a higher consumption of milk appeared to induce weight loss, but their study had a small sample size and a high dropout rate. In larger randomized trials, those subjects assigned to a higher intake of low-fat milk expe￾rienced a greater weight gain that was either statistically signif￾icant (97) or not statistically significant (98). In a longitudinal study of many thousand adolescents, low-fat milk consumption was positively associated with a gain in body mass index; this was accounted for by a higher energy intake among those who consumed more milk (99). The 2005 Dietary Guidelines for Americans Committee performed a detailed review of this topic and concluded that there was not sufficient evidence that milk consumption reduced, or prevented, weight gain (100). Subse￾quent published research has found that milk did not prevent weight gain, including one 48-wk clinical trial funded by the National Dairy Council (101, 102). A second issue relates to bone health. The Dietary Guidelines Committee also evaluated 7 randomized trials and 32 observa￾tional studies that explored the relation between milk intake and bone health. All 7 randomized trials and 25 of the observational studies showed a positive relation between milk consumption and bone mineral density in one or more skeletal sites (103). However, the benefits of higher calcium intake on bone mineral density are not maintained if the high intake is reduced. In one trial with children, milk intake, but not calcium supplementation, had a continuing effect on bone mineral density 3.5 y after ter￾mination of the intervention (104). The duration of the random￾ized studies was too brief to validly assess fracture incidence. Large prospective studies in adults have consistently shown no significant relation between milk intake and risk of fractures. Milkis animportant source of calcium andisthe key source for vitamin D due to fortification, particularly for persons aged 6 –18 y, for whom calcium requirements are higher. Milk products are also important contributors to the intake of essential nutrients in the diet of children and adolescents. Data from the National Health and Nutrition Examination Survey (NHANES) and Con￾tinuing Survey of Food Intakes by Individuals (CSFII) indicate that as consumption of milk productsincreases, so doestheintake of calcium, magnesium, potassium, zinc, iron, vitamin A, ribo￾flavin, and folate (105). Conversely, eliminating milk products from the USDA dietary pattern would substantially reduce in￾takes of those essential nutrients (100). Nevertheless, although it would require a careful selection of foods, milk products could be replaced with soy-based products and items from other food groups, particularly fruit and vegetables—some of which are also good sources of calcium. The essential micronutrients in milk products could also be replaced by daily multivitamin￾mineral and calcium supplements. Fortification of milk with vitamin D has reduced the occurrence of rickets in children, but other sources of supplemental vitamin D can be used. Some studies have reported a beneficial effect of milk con￾sumption in reducing the risk of the metabolic syndrome, a PROPOSED BEVERAGE GUIDANCE SYSTEM 533 by guest on August 19, 2012 www.ajcn.org Downloaded from

534 TAbLE 3 Beverage nutrient composition table Calories Total fat SFA Sugars Caffeine Sodium Potassium Vitamin A Vitamin C Calcium Vitamin D Folate Level 1: water, bottled water? Level 2: tea and coffee(unsweetened) Brewed black tea2 Decaffeinated black tea, brewed- Brewed green tea Decaffeinated green tea, brewed 021 000000000 000000000 000000041 000000000 Level 3: low-fat and skim milk and Reduced fat(1.5% and 1%)and skim milk sssEs<s99 Milk(1% fat, vitamin 1.51270 0290 12 A-fortified) Milk (skim, vitamin A-fortified) 83 0 0.312.5 14 Soy beverages Silk soy milk, plain 0.56 Silk soy milk, vanil 3.50.5 Silk live"mango 0.535 0120350 125015350 4404 Silk soy milk, chocolate 1403.50.519 100350 Level 4: noncalorically sweetened Lipton Green Tea to Go, 0000 卷 Diet pe 000 000 000 000 Level 5: caloric beverages with some nutnents Fruit and vegetable juices Orange juice(Minute Maid 0 0 0 010 1000 Concord grape juice(Welch's) 170 00 40 0 Apple juice (Minute Maid)? 95→N 0 026 Fruit medley(Minute Maid) 0 036 Cranberry juice cocktail- 0 031 Apple juice(ul 0 024 V8 Tomato Juice 0 0 590470 2000 Carrot juice 0 0 68689 4513021 57 Whole(3.25% fat)2 2% fat vitamin A-fortified Sports drinks Gatorade x factor 2 0 0 POWERade line 0 015 POWERade raize° 0 029 Alcoholic beverage 00000 Beer, regular(12 fl oz) 0 0 Light beer, Bud Light(12 fl oz) 110 00 Beer. ale 0 013 Red table wine(3.5 fl oz) 0 0 0 White table wine(3.5 fl oz) Level 6: calorically sweetened 0 0 Coca- Cola classic° 00(

TABLE 3 Beverage nutrient composition table1 Calories Total fat SFA Sugars Caffeine Sodium Potassium Vitamin A Vitamin C Calcium Vitamin D Folate kcal g1 g g mg mg mg IU mg mg IU g Level 1: water, bottled water2 Level 2: tea and coffee (unsweetened) Tea 0 0 0 0 0 1 0 0 0 0 0 0 Brewed black tea2 0 0 0 0 47 7 88 0 0 0 0 3 Decaffeinated black tea, brewed2 0 0 0 0 2.4 0 88 0 0 0 0 3 Brewed green tea2 0 0 0 0 30 0 0 0 0 0 0 0 Decaffeinated green tea, brewed2 00 00 3 0 0 0 0 0 0 0 Lipton original (unsweetend)3 0 0 0 0 35 0 0 0 0 0 0 0 Herbal tea2 00 00 0 0 0 0 0 0 0 0 Coffee2 Coffee, brewed 2 0 0 0 95 5 116 0 0 4.7 0 4.7 Coffee, brewed, espresso 1 0 0 0 64 0 34.5 0 0 1 0 0 Decaffeinated coffee, brewed 0 0 0 0 2.4 0 128 0 0 4.7 0 0 Level 3: low-fat and skim milk and soy beverages2 Reduced fat (1.5% and 1%) and skim milk Milk (1% fat, vitamin A–fortified) 102 2 1.5 12.7 0 103 366 478 0 290 127 12.2 Milk (skim, vitamin A–fortified) 83 0.2 0.3 12.5 0 103 448 499 0 352 98 14.8 Soy beverages4 Silk soy milk, plain 100 4 0.5 6 0 85 300 500 0 300 120 24 Silk soy milk, vanilla 100 3.5 0.5 7 0 130 300 500 0 300 120 24 Silk live “mango” 230 4 0.5 35 0 120 350 1250 15 350 100 100 Silk soy milk, chocolate 140 3.5 0.5 19 0 100 350 500 0 300 120 24 Level 4: noncalorically sweetened beverages Lipton Green Tea to Go, decaffinated3 0 0 0 0 0 70 0 0 0 0 0 0 Diet Pepsi5 0 0 0 0 24 25 20 0 0 0 0 0 Diet Coke6 0 0 0 0 31 70 0 0 0 0 0 0 Level 5: caloric beverages with some nutrients Fruit and vegetable juices Orange juice (Minute Maid)7 110 0 0 24 0 15 450 0 72 20 0 60 Tropicana Light’n Healthy8 50 0 0 10 0 10 450 1000 72 200 0 28 Concord grape juice (Welch’s)9 170 0 0 40 0 20 0 0 60 0 0 0 Apple juice (Minute Maid)7 110 0 0 26 0 0 0 0 72 0 0 0 Fruit medley (Minute Maid)7 170 0 0 36 0 20 340 0 60 0 0 0 Cranberry juice cocktail2 137 0 0 31 0 5 0 0 52 0 0 0 Apple juice (unsweetened)2 112 0 0 24 0 7 295 100 12 170 0 0 V8 Tomato Juice10 50 0 0 8 0 590 470 2000 60 20 0 0 Carrot juice2 94 0 0 9 0 68 689 45130 21 57 0 9 Milk Whole (3.25% fat)2 146 8 4.5 13 0 98 350 249 0 276 98 12 2% fat vitamin A–fortified2 122 4.8 3.1 13 0 100 366 461 0 285 105 12 Wendy’s Frosty11 217 5 4 27 0 129 0 520 0 12 0 0 Sports drinks Gatorade X Factor12 50 0 0 14 0 110 30 0 0 0 0 0 POWERade line6 64 0 0 15 0 53 32 0 0 0 0 0 POWERade Raize6 110 0 0 29 36 46 32 0 0 0 0 0 Alcoholic beverages2 Beer, regular (12 fl oz) 139 0 0 0 0 14 96 0 0 14 0 21 Light beer, Bud Light (12 fl oz) 110 0 0 0 0 11 92 0 0 11 0 0 Beer, ale 155 0 0 13 0 14 77 0 0 17 0 0 Red table wine (3.5 fl oz) 74 0 0 0 0 0 115 0 0 8 0 2 White table wine (3.5 fl oz) 70 0 0 0 0 5 82 0 0 9 0 0 Level 6: calorically sweetened beverages Pepsi Cola5 100 0 0 27 25 25 10 0 0 0 0 0 Coca-Cola Classic6 105 0 0 26 23 33 0 0 0 0 0 0 (Continued) 534 POPKIN ET AL by guest on August 19, 2012 www.ajcn.org Downloaded from

PROPOSED BEVERAGE GUIDANCE SYSTEM 535 TABLE 3 (Continued) Calories Total fat SFA Sugars Caffeine Sodium Potassium Vitamin A Vitamin C Calcium Vitamin D Folate g ng Tropicana Fruit Punch(3% juice) 110 00 29 0 50 0 Nestea cool Lipton Original Iced Te Arizona green tea s 0 0000005 000000 Kool-Aid Splash Grape Berry amba Juice, banana berry 0.50 Sweetened coffee drinks Starbucks Frappuccino, coffee 160 .51.725 flavored Starbucks Caffe Mocha. no 24010 0 whipped cream Amounts are per 8 fl oz, or 237 mL SFA, saturated fatty acid. 2 Data from the US Department of Agriculture, Agricultural Research Services, Nutrient Data Laboratory: National Nutrient Database for Standard ReferenceInternet:http://www.nal.usda.gov/fnic/foodcomp/search/. sssEs3fl oz dairy products/d, although the literature is not consistent analysis of 10 prospective studies also indicated a beneficial (112). It has been speculated that this adverse effect of milk may effect of milk consumption in reducing the risk of coronary heart be related to its well-documented effect on circulating concen- disease and ischemic stroke(107). In a short-term clinical trial, 2 trations of insulin-like growth factorI(110, 113, 114),which has dietary patterns were used-one emphasizing fruit and vegeta- been associated with increases of many cancers in both humans bles and the other emphasizing fruit and vegetables, low-fat dairy and animals(114). products, higher protein and fiber intakes, and a lower fat intal Dietary Approaches to Stop Hypertension; DASH diet). Both dietary patterns significantly reduced blood pressure in normo- Level 4: noncalorically sweetened beverages tensive or stage I hypertensive men and women of diverse ethnic Noncalorically sweetened beverages(diet sodas and other backgrounds. The daSh diet had a significantly greater effect diet"drinks) are preferable to calorically sweetened beverages on reducing blood pressure than did the fruit and vegetables diet because they provide water and sweetness but no calories. FDA and is one of the dietary patterns recommended by the recent US approved noncaloric sweeteners are considered safe, although Dietary Guidelines(108, 109). It is interesting that the daSH other than FDa surveillance data there is no evidence from long diet actually recommended more fruit and vegetables than did the term studies in humans available to this Panel and is most likely fruit and vegetable diet, so there might be confounding factors lacking involved. Moreover, in a carefully conducted multicenter trial Raben et al (3) showed that beverages sweetened with nona- an increase of 3 glasses of low-fat milk daily had no effect on loric sweeteners were associated with weight loss when ingested blood pressure(110) in amounts similar to calorically sweetened beverages where

cluster of disorders that includes insulin resistance, glucose in￾tolerance, hypertension, hypertriglyceridemia, and low concen￾trations of HDL. In the Coronary Artery Risk Development in Young Adults (CARDIA) Study, milk consumption was in￾versely associated with the 10-y cumulative incidence of the metabolic syndrome in overweight individuals (106). A pooled analysis of 10 prospective studies also indicated a beneficial effect of milk consumption in reducing the risk of coronary heart disease and ischemic stroke (107). In a short-term clinical trial, 2 dietary patterns were used— one emphasizing fruit and vegeta￾bles and the other emphasizing fruit and vegetables, low-fat dairy products, higher protein and fiber intakes, and a lower fat intake (Dietary Approaches to Stop Hypertension; DASH diet). Both dietary patterns significantly reduced blood pressure in normo￾tensive or stage I hypertensive men and women of diverse ethnic backgrounds. The DASH diet had a significantly greater effect on reducing blood pressure than did the fruit and vegetables diet and is one of the dietary patterns recommended by the recent US Dietary Guidelines (108, 109). It is interesting that the DASH diet actually recommended more fruit and vegetables than did the fruit and vegetable diet, so there might be confounding factors involved. Moreover, in a carefully conducted multicenter trial, an increase of 3 glasses of low-fat milk daily had no effect on blood pressure (110). Among the evidence for possible adverse effects of milk con￾sumption, a meta-analysis of case-control studies reported a 70% greater risk of prostate cancer in men with the highest milk consumption levels (111). Other studies have suggested an in￾creased risk of aggressive ovarian cancer in persons consuming
3 fl oz dairy products/d, although the literature is not consistent (112). It has been speculated that this adverse effect of milk may be related to its well-documented effect on circulating concen￾trations of insulin-like growth factor I (110, 113, 114), which has been associated with increases of many cancers in both humans and animals (114). Level 4: noncalorically sweetened beverages Noncalorically sweetened beverages (diet sodas and other “diet” drinks) are preferable to calorically sweetened beverages because they provide water and sweetness but no calories. FDA￾approved noncaloric sweeteners are considered safe, although other than FDA surveillance data there is no evidence from long￾term studies in humans available to this Panel and is most likely lacking. Raben et al (3) showed that beverages sweetened with nonca￾loric sweeteners were associated with weight loss when ingested in amounts similar to calorically sweetened beverages where TABLE 3 (Continued) Calories Total fat SFA Sugars Caffeine Sodium Potassium Vitamin A Vitamin C Calcium Vitamin D Folate kcal g1 g g mg mg mg IU mg mg IU g Tropicana Fruit Punch (3% juice)8 110 0 0 29 0 50 0 0 0 0 0 0 Fruitopia (10% juice varieties)13 110 0 0 29 0 75 0 0 100 0 0 0 Nestea Cool14 82 0 0 22 11 68 0 0 0 0 0 0 Lipton Original Iced Tea3 60 0 0 17 20 50 0 0 0 0 0 0 Arizona Green Tea15 70 0 0 17 10 20 0 0 0 0 0 0 Kool-Aid Splash Grape Berry Punch2 116 0 0 30 0 35 12 0 0 0 0 0 Jamba Juice, banana berry smoothie16 149 0.5 0 31 0 36 0 62 5 62 0 0 Sweetened coffee drinks17 Starbucks Frappuccino, coffee flavored 160 2.5 1.7 25 70 93 0 100 0 220 0 0 Starbucks Caffe Mocha, no whipped cream 240 10 5 24 65 125 0 0 0 0 0 0 1 Amounts are per 8 fl oz, or 237 mL. SFA, saturated fatty acid. 2 Data from the US Department of Agriculture, Agricultural Research Services, Nutrient Data Laboratory: National Nutrient Database for Standard Reference. Internet: http://www.nal.usda.gov/fnic/foodcomp/search/. 3 lipton.com. 4 silkissoy.com. 5 pepsi.com. 6 coca-cola.com. 7 minutemaid.com. 8 tropicana.com. 9 welchs.com. 10 v8juice.com. 11 wendys.com. 12 gatorade.com. 13 fruitopia.com. 14 nestea.com. 15 arizonabev.com. 16 jambajuice.com. 17 starbucks.com. PROPOSED BEVERAGE GUIDANCE SYSTEM 535 by guest on August 19, 2012 www.ajcn.org Downloaded from

536 OPKIN ET AI weight gain and increased blood pressure occurred. A new liter- TABLE 4 ature is emerging that seems to suggest that the high sweetness in Comparison of the energy contents of different alcoholic beverages these beverages may contribute to conditioning for a high pref- Beverage Energy Amount erence for sweetness(115, 116) and thus these noncaloricall sweetened beverages would be less desirable than water, tea, or fl oz(m coffee Beer 12 12(355) Level 5: caloric beverages with some nutrients 12(355) 5(148) Fruit juices (100% juice)provide most of the nutrients of their Spirits, 80 proof natural source, but they have a relatively high energy content and Standard alcoholic drink ly lack fiber and other beneficial nonnutrient compounds Soft drink 12(355) present in the whole produce. There is no specific need to con- sume fruit juices, and consumption of whole fruits should be encouraged for satiety and energy balance. The US Dietary oz of beer, and some coolers contain >250 kcal( compared with Guidelines Committee(100) recommended that no more than 4 kcal in a &-fl oz soft drink ). The health effect of coolers has one-third of the daily intake of fruit be in the form of juices. Fruit not been studied smoothies are usually high-calorie versions of fruit drinks and Although excessive alcohol(ethanol) consumption has been therefore are not recommended. linked to serious health and social problems, moderate alcohol Vegetable juices(eg tomato and multi-vegetable juices)are a consumption has been associated with some health benefits s healthy alternative to fruit juices. They have fewer calories per (122). The relation between alcohol consumption and mortality F 100 mL(3. 4 fl oz)than does orange juice but usually have is often described as J-shaped, meaning that light-to-moderate significant amounts of added sodium. For example, tomato juice consumption compared with abstention or high consumption is s and vegetable cocktails have over 975 mg of sodium per 12 oz associated with lower rates of mortality--mostly from coronary (357 mL). As with fruit juices, whole tomatoes and vegetables heart disease(23)and ischemic stroke(124)--whereas heavy nould be encouraged for satiety and energy balance rather than alcohol consumption is associated with higher rates of mortality getable juices from many causes. The benefits of moderate alcohol co Whole(full-fat)milk contains 236 kcal/12 fl oz (255 mL)and tion, which in addition to cardiovascular diseases may include a has a higher energy density and saturated fat content than do reduced risk of type 2 diabetes(125, 126) and gallstones(127, reduced-at milk(2% fat, 180kcal/12 fl oz), low-fat milk(1%, 150 128), appear to be derived mainly from alcohol itself. Although a adverse health effects of saturated fats have been well docu- blood pressure, platelet aggregation, and serum lipids, epidem e mented in numerous studies, especially with respect to an ologic evidence does not support added health benefits specific creased risk of cardiovascular diseases(117). Whole-fat dairy to flavonoids in red wine or dark beer(123, 129). Alcoholic s products are a significant source of saturated fat in the American beverages, even at moderate intakes, are linked with an increased diet.Whole-fat milk contributes significantly to the saturated fat risk of birth defects(130)and breast cancer(131, 132). The 9 intake in the United States, which has been found in NHANES II increased risk of breast cancer appears to be caused, at least in a data to be 20% higher than the desirable level of s10% of daily part, by the interference of alcohol with the absorption and me- s nergy intake. Sports drinks contain from 50% to 90% of the energy (75-140 alcoholic beverages, and other women who consume alcohol kcal/12fl oz, or 255 mL) contained in calorically sweetened soft should also consume adequate folate, preferentially from a sup- N drinks(158 kcal/12 fl oz)and provide small amounts of sodium, plement(400 ug/d)(133, 134). Heavy alcohol consumption IsN chloride, and potassium. Although a well-balanced nutritious associated with several cancers, in addition to breast cancer(135). diet provides the same ingredients, the carbohydrates, water, and and other significant health problems such as cirrhosis of the liver tivities(ie, when the sweat rate is >8 L/d, when strenuous exer- athy(138), atrial fibrillation(139), and dementia(l t diomyop- sodium in sports drinks are advantageous during endurance ac-(136), hypertension(137), hemorrhagic stroke(121), ise lasts >60 min, or when there is a deficiency of sodium or carbohydrates)(118). The Panel recommends sports drinks be Level 6: calorically sweetened beverages consumed sparingly, except by endurance athletes because these The least recommended beverages by the Panel are calorically les sweetened beverages with a high energy density and no, or very Alcoholic beverages consumed in moderation have some small amounts of, other nutrients. These include carbonated health benefits for adults. Moderate intake is defined as the daily (fizzy) and noncarbonated(still)beverages, which are usually consumption of no more than one drink for women and 2 for men sweetened with high-fructose corn syrup or sucrose. Our recom- 119, 120). Alcoholic beverages contain calories. A standard mendation is to consume calorically sweetened soft drinks an alcoholic drink is defined as one that contains =14 g alcohol juice drinks sparingly. Caloric sweeteners have been linked to (121). The amounts of a sample of alcoholic beverages and their dental caries, increased energy intake, weight gain, and type 2 energy contents are provided in Table 4. Alcohol provides =7 diabetes(2-4, 47, 100) kcal/g(100 kcal) per standard alcoholic drink. Wine-, malt In the quantities consumed today, soft drinks and and spirit-based coolers containing 3-7% alcohol are widely most likely contribute to the obesity epidemic by available and are often marketed to young peo y intake. As noted in the Introduction, to look like sodas. Many of these beverages contain added sugars. human literature show that these beverages are not sat An 8-floz(237-mLcooler may contain more alcohol than an 8-fl compensation in terms of reduction in the intake of other foods

weight gain and increased blood pressure occurred. A new liter￾ature is emerging that seems to suggest that the high sweetness in these beverages may contribute to conditioning for a high pref￾erence for sweetness (115, 116) and thus these noncalorically sweetened beverages would be less desirable than water, tea, or coffee. Level 5: caloric beverages with some nutrients Fruit juices (100% juice) provide most of the nutrients of their natural source, but they have a relatively high energy content and may lack fiber and other beneficial nonnutrient compounds present in the whole produce. There is no specific need to con￾sume fruit juices, and consumption of whole fruits should be encouraged for satiety and energy balance. The US Dietary Guidelines Committee (100) recommended that no more than one-third of the daily intake of fruit be in the form of juices. Fruit smoothies are usually high-calorie versions of fruit drinks and, therefore, are not recommended. Vegetable juices (eg tomato and multi-vegetable juices) are a healthy alternative to fruit juices. They have fewer calories per 100 mL (3.4 fl oz) than does orange juice but usually have significant amounts of added sodium. For example, tomato juice and vegetable cocktails have over 975 mg of sodium per 12 fl oz (357 mL). As with fruit juices, whole tomatoes and vegetables should be encouraged for satiety and energy balance rather than vegetable juices. Whole (full-fat) milk contains 236 kcal/12 fl oz (255 mL) and has a higher energy density and saturated fat content than do reduced-at milk (2% fat, 180 kcal/12 fl oz),low-fat milk (1%, 150 kcal/12 fl oz), and skim or nonfat milk (135 kcal/12 fl oz). The adverse health effects of saturated fats have been well docu￾mented in numerous studies, especially with respect to an in￾creased risk of cardiovascular diseases (117). Whole-fat dairy products are a significant source of saturated fat in the American diet. Whole-fat milk contributes significantly to the saturated fat intake in the United States, which has been found in NHANES III data to be 20% higher than the desirable level of 10% of daily energy intake. Sports drinks contain from 50% to 90% of the energy (75–140 kcal/12 fl oz, or 255 mL) contained in calorically sweetened soft drinks (158 kcal/12 fl oz) and provide small amounts of sodium, chloride, and potassium. Although a well-balanced nutritious diet provides the same ingredients, the carbohydrates, water, and sodium in sports drinks are advantageous during endurance ac￾tivities (ie, when the sweat rate is
8 L/d, when strenuous exer￾cise lasts
60 min, or when there is a deficiency of sodium or carbohydrates) (118). The Panel recommends sports drinks be consumed sparingly, except by endurance athletes because these beverages provide calories. Alcoholic beverages consumed in moderation have some health benefits for adults. Moderate intake is defined as the daily consumption of no more than one drink for women and 2 for men (119, 120). Alcoholic beverages contain calories. A standard alcoholic drink is defined as one that contains 14 g alcohol (121). The amounts of a sample of alcoholic beverages and their energy contents are provided in Table 4. Alcohol provides 7 kcal/g (100 kcal) per standard alcoholic drink. Wine-, malt-, and spirit-based coolers containing 3–7% alcohol are widely available and are often marketed to young people and packaged tolooklike sodas.Many ofthese beverages contain added sugars. An 8-fl oz (237-mL) cooler may contain more alcoholthan an 8-fl oz of beer, and some coolers contain
250 kcal (compared with 104 kcal in a 8-fl oz soft drink). The health effect of coolers has not been studied. Although excessive alcohol (ethanol) consumption has been linked to serious health and social problems, moderate alcohol consumption has been associated with some health benefits (122). The relation between alcohol consumption and mortality is often described as J-shaped, meaning that light-to-moderate consumption compared with abstention or high consumption is associated with lower rates of mortality—mostly from coronary heart disease (123) and ischemic stroke (124)—whereas heavy alcohol consumption is associated with higher rates of mortality from many causes. The benefits of moderate alcohol consump￾tion, which in addition to cardiovascular diseases may include a reduced risk of type 2 diabetes (125, 126) and gallstones (127, 128), appear to be derived mainly from alcohol itself. Although short-term studies have shown beneficial effects of red wine on blood pressure, platelet aggregation, and serum lipids, epidemi￾ologic evidence does not support added health benefits specific to flavonoids in red wine or dark beer (123, 129). Alcoholic beverages, even at moderate intakes, are linked with an increased risk of birth defects (130) and breast cancer (131, 132). The increased risk of breast cancer appears to be caused, at least in part, by the interference of alcohol with the absorption and me￾tabolism of folate. Therefore, pregnant women should not drink alcoholic beverages, and other women who consume alcohol should also consume adequate folate, preferentially from a sup￾plement (400 g/d) (133, 134). Heavy alcohol consumption is associated with several cancers, in addition to breast cancer (135), and other significant health problems such as cirrhosis of the liver (136), hypertension (137), hemorrhagic stroke (121), cardiomyop￾athy (138), atrial fibrillation (139), and dementia (140). Level 6: calorically sweetened beverages The least recommended beverages by the Panel are calorically sweetened beverages with a high energy density and no, or very small amounts of, other nutrients. These include carbonated (fizzy) and noncarbonated (still) beverages, which are usually sweetened with high-fructose corn syrup or sucrose. Our recom￾mendation is to consume calorically sweetened soft drinks and juice drinks sparingly. Caloric sweeteners have been linked to dental caries, increased energy intake, weight gain, and type 2 diabetes (2– 4, 47, 100). In the quantities consumed today, soft drinks and fruit drinks most likely contribute to the obesity epidemic by facilitating excess energy intake. As noted in the Introduction, animal and human literature show that these beverages are not satiating, and compensation in terms of reduction in the intake of other foods TABLE 4 Comparison of the energy contents of different alcoholic beverages Beverage Energy Amount kcal fl oz (mL) Beer 140 12 (355) Light beer 100 12 (355) Wine cooler 110–275 12 (355) Wine 115 5 (148) Spirits, 80 proof 100 1.5 (44) Standard alcoholic drink 98 14 (414) Soft drink 150 12 (355) 536 POPKIN ET AL by guest on August 19, 2012 www.ajcn.org Downloaded from

PROPOSED BEVERAGE GUIDANCE SYSTEM 537 Fluid Ounces Consumed Kilocalories Consumed TOTAL 114 fl oz TOTAL 464 kcal BEVERAGE5 (5 fl oz) LEVEL V LEVEL I (15 fl oz) CALORIC BEVERAGES LEVEL V LEVEL I (213 kcal) f。z) sssEs2 y was 21%. very-low-calorie beverages. Thus, the Panel suggests a distribu Hence, US adults aged 19 y consumed 464 calories/d from tion in which= 80% of beverages consist of water, unsweetened verges. A reduced intake of caloric beverages that provide no tea, and unsweetened coffee and only =% of low-fat milk

and beverages is poor, with the net effect being increased energy intake and obesity (2– 4, 8, 10, 141–144). It is possible that the fructose content has an added effect (145). There is also evidence linking calorically sweetened bever￾ages with an increased risk of type 2 diabetes. One recent pro￾spective study using data from the Nurses’ Health Study found that women consuming one or more servings of sugar-sweetened soft drinks per day had a significantly higher risk of developing type 2 diabetes than did those who consumed less than one serving per month (4). Others suggest that soft drinks are replac￾ing milk in the diet (1, 144). We note that soft drinks and fruit drinks are not the only high-calorie beverages. New drinks are constantly being offered that fit the same profile, eg, very-high-calorie smoothies. We did not systematically review these newer beverages. At the same time, the Panel recommends a significantly reduced intake of calorically sweetened beverages. What is the proportion of energy from beverages a person should consume? A summary of the beverage intake pattern of adults aged 19 y in the United States from the 1999 –2002 NHANES, conducted in a nationally representative population sample, is shown inFigure 1; the pattern of energy obtained from the different categories of beverages is also shown. The pattern for adults aged 19 y was selected. Water, tea, and coffee in￾takes—the unsweetened beverages—accounted for 70% of the total volume but contributed only 2% of the calories. In contrast, the calorically sweetened soft drinks and fruit drinks provided 46% of the calories. As noted earlier, the proportion of energy from beverages for the average American aged
2 y was 21%. Hence, US adults aged 19 y consumed 464 calories/d from beverages. A reduced intake of caloric beverages that provide no nutritional benefit is needed to reduce this high energy intake from beverages;these beverages are not neededto fulfillthe daily energy intake of any individual. Many IOM/Food and Nutrition Board dietary requirements panels, as well as the 2005 US Department of Health and Human Services–USDA Dietary Guidelines Advisory Committee have developed sample healthful menus that fulfill the recommended intakes for macronutrients, micronutrients, fiber, and water of average adults. The total beverage requirement is based on the overall composition of an individual’s diet and his or her phys￾iologic needs for water. Our review used one such sample menu (12) to estimate the contribution of beverages to nutrient intake (Table 2). In this and similar examples, the contribution of bev￾erages to total energy intake was 14%. These calories are con￾tributed primarily by low-fat milk (9%), which is a naturally nutrient-rich beverage. Excluding milk, the other caloric bever￾ages contributed 5% to the total caloric intake, or 114 kcal/d. The sample man described in Table 2 has an energy require￾ment of 2200 kcal, which requires a total beverage intake of 98 fl oz (2.9 L). In his diet, water contributed 25 fl oz (26%); an additional 52 fl oz (54%) came from tea and coffee, leaving 20 fl oz (21%) from milk and juice or other calorically sweetened beverages. This distribution is ideal for a man with low levels of activity, particularlythe high consumption of nonsweetened bev￾erages—water, tea, and coffee. This distribution of beverages could consist of 100% water or could represent any of many combinations, with the goal to get 80% of beverage intake from very-low-calorie beverages. Thus, the Panel suggests a distribu￾tion in which 80% of beverages consist of water, unsweetened tea, and unsweetened coffee and only 20% of low-fat milk, FIGURE 1. Average daily beverage intake patterns for US adults aged 19 y, 1999 –2002. 1 fl oz  29.57 mL. PROPOSED BEVERAGE GUIDANCE SYSTEM 537 by guest on August 19, 2012 www.ajcn.org Downloaded from

538 POPKIN ET AI TOTAL 98 fl oz TOTAL 98 fI Oz t0 toz)s LEVEL VI LEVEL V LOW- FAT MIL NONCALORICALLY LEVEL If ngg:0-16群oz ALLY SWEETEN LEVELⅣ nge:0.32n0 NSWEETENED 9e:0.32ol LEVEL Il LEVEL II Range: 0-40 n oz/d EA OR COFFEE LEVEL I Range: 0.40 N oz/d n owd (24 fl oz) LEVEL I ange: 1001 Water 102050o sSss之s FIGURE 3. Acceptable beverage consumption patterns(14% of energy o FIGURE 2. Suggested beverage consu patterns(10% of rom beverages)for a person with a 2200-kcal daily energy requirement. The from beverages)for a person with a 2200-kcal daily energy require values 24, 36, 6, 12, 8, and 12 fl oz are shown for illustrative purposes onl values 50, 28, 16, and 4 floz are shown for illustrative purposes only; the total Beverage Guidance Panel's suggested range for each beverage. " Range should sum to 98 fl oz, as shown at the top of the figure. I The Beverage caffeine is a limiting factor up to 400 mg/d, or 32fl oz coffee/d(can replace Guidance Panel's suggested range for each beverage. Range: caffeine is a limiting factor up to 400 mg/d, or 32 fl oz coffee/d(can replace water). Can ater)."Can substitute for tea and coffee with the same limitations regarding ubstitute for tea and coffee with the same limitations 100% fruit juices, 0-8 fl oz/d; alcoholic beverages, O-I drink/d for women women and 0-2 drinks/d for men: whole milk, Ofl/d. 1 fl oz 29.57 mL. and 0-2 drinks/d for men: whole milk. 0f oz/d. 1 fl oz 29.57 mL CONCLUSIONS AND RECOMMENDATIONS The obesity epidemic provides the rationale for developi a juice, alcohol, and calorically sweetened beverages (Figures 2 Beverage Guidance System. Because some beverages provide d3) The graphic design(Figure 2) developed by the Beverage energy balance, reducing their consumption is an important com- 9 Guidance Panel summarizes the relative importance of each bev- ponent of a broader strategy to reduce energy intake. Although a erage presented in this review. We suggest that the proportions of this Beverage Guidance System provides a sense of the relative 5 beverages shown in Figure 2 should be consumed by any person, energy density, nutrient density, health benefits, and health risks but the actual amounts of fluids shown are based on a person with linked with each category of beverages(and also the relative o an energy intake requirement of 2200 kcal and a dietary intake importance of each beverage), it is not possible to provide clear A pattern presented by the IOM in its publication and summarized guidance regarding specific quantities. However, in Table 2 we N in Table 2. The suggested pattern shown in Figure 2 would provide an example for adults who have an energy requirement provide at most 10% of total energy from beverages. An accer of 2200 kcal/d In this case, beverages provide 14% of the total able intake pattern(Figure 3)would provide 14% of energy from energy from calories. beverages. On the basis of this review and our knowledge of The current high intake of calorically sweetened beverages health and nutrition, the Panel recommends the following range contributes importantly to the excess caloric intake and is an of intake for beverages: important factor underlying the development of obesity in the Level I: water. 20-50 fl oz/d. United States. The evidence from nationally representative sur- Level 2: tea and coffee(unsweetened), 0-40 fl oz/d(can veys shows that both portion sizes and the number of servings of replace water; caffeine is a limiting factor up to 400 mg/d, 32 these beverages have increased. If the caloric intake is to be fl oz coffee/d) reduced, a decreased intake of these beverages should be part of Level 3: low-fat and skim milk and soy beverages, 0-16 fl the solution. Level 4: noncalorically sweetened beverages, 0-32 fl, The Beverage Guidance Panel has identified some research nd development issues that the food industry could address. For ould substitute for tea and coffee with the same limitations as example, the calorie content of sweetened beverages could be for caffeine reduced by 75-80% from current levels and low-calorie alter Level 5: caloric beverages with some nutrients, 0-8 fl oz natives could be developed. The Panel notes that evidence indi 100% fruit juices/d, 0-l alcoholic drink/d for women and 0-2 cates that calorically sweetened beverages have replaced milk in drinks/d for men(one drink 12 fl oz beer, 5 fl oz wine, or 1.5 the uS diet, which has resulted in a reduction in the net intake of fl oz distilled spirits), and o fl oz whole milk/d key essential nutrients. There is a need among children and ad- Level 6: calorically sweetened beverages, 0-8 fl oz/d. olescents to reverse this trend

juice, alcohol, and calorically sweetened beverages (Figures 2 and 3). The graphic design (Figure 2) developed by the Beverage Guidance Panel summarizes the relative importance of each bev￾erage presented in this review.We suggest that the proportions of beverages shown in Figure 2 should be consumed by any person, but the actual amounts of fluids shown are based on a person with an energy intake requirement of 2200 kcal and a dietary intake pattern presented by the IOM in its publication and summarized in Table 2. The suggested pattern shown in Figure 2 would provide at most 10% of total energy from beverages. An accept￾able intake pattern (Figure 3) would provide 14% of energy from beverages. On the basis of this review and our knowledge of health and nutrition, the Panel recommends the following range of intake for beverages: Level 1: water, 20 –50 fl oz/d. Level 2: tea and coffee (unsweetened), 0 – 40 fl oz/d (can replace water; caffeine is a limiting factor up to 400 mg/d, 32 fl oz coffee/d). Level 3: low-fat and skim milk and soy beverages, 0 –16 fl oz/d. Level 4: noncalorically sweetened beverages, 0 –32 fl oz/d (could substitute for tea and coffee with the same limitations as for caffeine). Level 5: caloric beverages with some nutrients, 0 – 8 fl oz 100% fruit juices/d, 0 –1 alcoholic drink/d for women and 0 –2 drinks/d for men (one drink  12 fl oz beer, 5 fl oz wine, or 1.5 fl oz distilled spirits), and 0 fl oz whole milk/d. Level 6: calorically sweetened beverages, 0 – 8 fl oz/d. CONCLUSIONS AND RECOMMENDATIONS The obesity epidemic provides the rationale for developing the Beverage Guidance System. Because some beverages provide primarily energy and can contribute significantly to a positive energy balance, reducing their consumption is an important com￾ponent of a broader strategy to reduce energy intake. Although this Beverage Guidance System provides a sense of the relative energy density, nutrient density, health benefits, and health risks linked with each category of beverages (and also the relative importance of each beverage), it is not possible to provide clear guidance regarding specific quantities. However, in Table 2 we provide an example for adults who have an energy requirement of 2200 kcal/d. In this case, beverages provide 14% of the total energy from calories. The current high intake of calorically sweetened beverages contributes importantly to the excess caloric intake and is an important factor underlying the development of obesity in the United States. The evidence from nationally representative sur￾veys shows that both portion sizes and the number of servings of these beverages have increased. If the caloric intake is to be reduced, a decreased intake of these beverages should be part of the solution. The Beverage Guidance Panel has identified some research and development issues that the food industry could address. For example, the calorie content of sweetened beverages could be reduced by 75– 80% from current levels and low-calorie alter￾natives could be developed. The Panel notes that evidence indi￾cates that calorically sweetened beverages have replaced milk in the US diet, which has resulted in a reduction in the net intake of key essential nutrients. There is a need among children and ad￾olescents to reverse this trend. FIGURE 3. Acceptable beverage consumption patterns (14% of energy from beverages) for a person with a 2200-kcal daily energy requirement. The values 24, 36, 6, 12, 8, and 12 fl oz are shown for illustrative purposes only; the total should sum to 98 fl oz, as shown at the top of the figure. 1 The Beverage Guidance Panel’s suggested range for each beverage. 2 Range: caffeine is a limiting factor up to 400 mg/d, or 32 fl oz coffee/d (can replace water). 3 Can substitute for tea and coffee with the same limitations regarding caffeine. 4 100% fruit juices, 0 – 8 fl oz/d, alcoholic beverages, 0 –1 drink/d for women and 0 –2 drinks/d for men; whole milk, 0 fl oz/d. 1 fl oz  29.57 mL. FIGURE 2. Suggested beverage consumption patterns (10% of energy from beverages) for a person with a 2200-kcal daily energy requirement. The values 50, 28, 16, and 4 fl oz are shown for illustrative purposes only; the total should sum to 98 fl oz, as shown at the top of the figure. 1 The Beverage Guidance Panel’s suggested range for each beverage. 2 Range: caffeine is a limiting factor up to 400 mg/d, or 32 fl oz coffee/d (can replace water). 3 Can substitute for tea and coffee with the same limitations regarding caffeine. 4 100% fruit juices, 0 – 8 fl oz/d; alcoholic beverages, 0 –1 drink/d for women and 0 –2 drinks/d for men; whole milk, 0 fl oz/d. 1 fl oz  29.57 mL. 538 POPKIN ET AL by guest on August 19, 2012 www.ajcn.org Downloaded from