Dietary and Health Correlates of Sweetened Beverage Intake: Sources of Variability in the National Health and Nutrition Examination Survey (NHANES).

Susan E Swithers,Allison C Sylvetsky,Jean A Welsh,Janet Figueroa,G R Bonanno

doi:10.3390/nu13082703

Abstract

Recent studies using data from the National Health and Nutrition Examination Survey (NHANES) have used inconsistent approaches to identify and categorize beverages, especially those containing low-calorie sweeteners (LCS), also referred to as low-calorie sweetened beverages (LCSBs). Herein, we investigate the approaches used to identify and categorize LCSBs in recent analyses of NHANES data. We reviewed published studies examining LCS consumption in relation to dietary and health outcomes and extracted the methods used to categorize LCS as reported by the authors of each study. We then examined the extent to which these approaches reliably identified LCSBs using the Internet Archive Wayback Machine to examine beverage ingredients lists across three NHANES cycles (2011–2016). None of the four general strategies used appeared to include all LCSBs while also excluding all beverages that did not contain LCS. In some cases, the type of sweetener in the beverage consumed could not be clearly determined; we found 9, 16, and 18 of such “mixed” beverage identifiers in the periods 2011–2012, 2013–2014, and 2015–2016, respectively. Then, to illustrate how heterogeneity in beverage categorization may impact the outcomes of published analyses, we compared results of a previously published analysis with outcomes when “mixed” beverages were grouped either all as LCSBs or all as sugary beverages. Our results suggest that caution is warranted in design and interpretation of studies using NHANES data to examine dietary and health correlates of sweetened beverage intake.

Highlights

There is general scientific consensus that excess consumption of sugary beverages (SBs) contributes to a variety of negative health outcomes including overweight, obesity, type II diabetes, and cardiovascular disease [1]
The number of foodcodes classified as low-calorie sweetened beverages (LCSBs) in papers that used one of the four general strategies described above spans at least the range of 14–148; for some analyses, the specific number of foodcodes cannot be determined with certainty (Table 1)
What We Eat in America (WWEIA)/National Health and Nutrition Examination Survey (NHANES) data have adopted heterogeneous approaches to categorize specific foodcodes into beverage groups, which has resulted in marked variability in the number of beverages that have been classified as LCSBs across analyses

Summary

Introduction

There is general scientific consensus that excess consumption of sugary beverages (SBs) contributes to a variety of negative health outcomes including overweight, obesity, type II diabetes, and cardiovascular disease [1]. One common approach to assess potential impacts of LCSB consumption on dietary (e.g., energy intake, sugar intake) and health-related (e.g., body mass index, glycemic responses) outcomes has been to compare these outcomes in people who report consuming LCSBs with those who do not report LCSB consumption. This approach has been used by several studies based on data from the National Health and Nutrition. NHANES is a survey of a nationally representative sample of approximately 5000 people in the United States each year and is widely used to investigate associations between dietary intake and a variety of diet- and health-related outcomes [2]. Since 1999, NHANES has been a continuous survey, with NHANES data collected in 2-year cycles, after which, results are released with a delay of approximately

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