Energy Density, Portion Size, and Eating Occasions: Contributions to Increased Energy Intake in the United States, 1977–2006

Causes of Increased Energy Intake Among Children in the U.S., 1977–2010

The relative effect of energy density (ED), the number of eating occasions (EO), and portion size (PS) to total energy (TE) intake are unknown. Using cross‐sectional nationally‐representative data from the Nationwide Food Consumption Survey (1977–78, n=17,464), Continuing Survey of Food Intake of Individuals (1989–91, n=8,340), and National Health and Nutrition Examination Surveys (1994–98 and 2003–06, n=9,460) for adults (aged ≥ 19 y) we mathematically decompose TE (kcal/d) to understand the relative contributions of each component ‐ PS (g/EO), ED (kcal/g/EO) and EO(#) ‐ to changes in TE over time. There was a steady increase in TE intake (+437 kcal, p<0.001) and the number of daily EO (+1.0 p<0.001) between 1977–78 and 2003–06. The average PS steadily increased between 1977–78 and 1994–98 then non‐significantly decreased between 1994–98 and 2003–06, while the average ED remained relatively stable over the 30‐year period. Between 1977–78 and 1989–91 changes in PS dominated (84.9% of the TE change), while changes in EO accounted for 37.1% of TE change. However, between 1994–98 and 2003–06 changes in EOs accounted for 88.2% and changes in PS accounted for just 22.6% of change in TE. While all three components contributed to the 30‐yr change, changes in EO and PS have consistently accounted for the greatest percent of change in total energy intake. These findings suggest a new focus for obesity prevention efforts.

[Purpose] This study aimed to investigate changes in physical activity and energy intake according to abdominal obesity in Korean adult men before and after COVID-19.[Methods] Using data from the 2019 and 2020 KNHANES, the physical activity level measured by the Global Physical Activity Questionnaire (GPAQ) the physical activity level by GPAQ, number of days of walking and strength training, aerobic exercise, and total energy, protein, fat, carbohydrate, dietary fiber, and sugar intake for a total of 2,799 participants were analyzed.[Results] There were no changes in energy intake during the pandemic. The number of days of weekly walking was higher (2019, p = 0.006; 2020, p = 0.012) and strength training was significantly higher (2019, p < 0.0001; 2020 p < 0.0001) in the non-abdominal obesity group than in the abdominal obesity group before and after COVID-19. Strength training at least once a week suppressed abdominal obesity (0.628 times in 2019, p < 0.0001; 0.605 times in 2020, p < 0.0001). In addition, even when the total energy intake and age were adjusted for, strength training influenced the suppression of abdominal obesity (0.634 times in 2019, p < 0.0001; 0.614 times in 2020, p < 0.0001).[Conclusion] Even with the change in the physical activity level, such as walking and aerobic exercise, due to the influence of social distancing measures, strength training influenced the suppression of abdominal obesity, regardless of the COVID-19 pandemic.

We examined the association between food insecurity and total daily energy intakes in American men and women. We estimated the number of daily snacks and meals consumed by individuals in different food security categories. Also, we calculated the energy contribution, energy density, and food group sources of those snacks and meals. Using the 1999-2002 National Health and Nutrition Examination Survey (NHANES), we examined the Food Security Survey Module (FSSM) and dietary information from the 24-h recall. Differences in energy intakes between groups were not significant. Women who were food insecure without hunger (FIWOH) and food insecure with hunger (FIWH) had significantly fewer meals than food secure (FS) women. The energy contribution of each meal and the total energy contributed from snacking were both significantly greater for FIWOH women than for FS women. The number of meals was significantly lower whereas the daily number of snacking occasions and the total energy from snacking were significantly increased for FIWOH men relative to FS men. FIWOH men consumed snack foods that had significantly lower energy density than those consumed by FS men. Among men and women, the major sources of meal energy were the grain group, the meat, poultry, and fish group, and the sugar, sweets, and beverages group whereas the major source of snacking energy was the sugar, sweets, and beverages group. Total energy intakes were not different for FI individuals; however, their meal and snack behaviors were different. Focusing solely on total energy intake would miss important consequences of food insecurity.

To estimate the net caloric impact from replacing sugar-sweetened beverages (SSBs) with alternatives in children and adolescents in naturalistic settings. Secondary analysis based on nationally representative cross-sectional study. Fixed-effect regression analysis of 2 nonconsecutive 24-hour dietary recalls from the 2003-2004 National Health and Nutrition Examination Survey data. Children and adolescents 2 to 19 years of age (N = 3098). Within-person beverage consumption between 2 surveyed days. The association between changes in the consumption of SSBs and other beverages and changes in total energy intake (TEI) of the same individual. Each additional serving (8 oz) of SSB corresponded to a net increase of 106 kcal/d (P < .001; 95% confidence interval [CI], 91 to 121 kcal/d), holding other beverages constant. Increases were also seen (all P < .001) for each additional serving of whole milk (169 kcal/d; 95% CI, 143 to 195 kcal/d), reduced-fat milk (145 kcal/d; 95% CI, 118 to 171 kcal/d), and 100% juice (123 kcal/d; 95% CI, 90 to 157 kcal/d). No net increases in TEI were seen for water (8 kcal/d; P = .27; 95% CI, -6 to 22 kcal/d) or diet drinks (47 kcal/d; P = .20; 95% CI, -23 to 117 kcal/d). Substituting SSBs with water was associated with a significant decrease in TEI, controlling for intake of other beverages, total beverage and nonbeverages, and fast-food and weekend effects. Each 1% of beverage replacement was associated with 6.6-kcal lower TEI, a reduction not negated by compensatory increases in other food or beverages. We estimate that replacing all SSBs with water could result in an average reduction of 235 kcal/d. Replacing SSB intake with water is associated with reductions in total calories for all groups studied.

Trends in Energy Intake among US Children by Eating Location and Food Source, 1977-2006

To the Editor

BACKGROUND/OBJECTIVESSince gain or loss of skeletal muscle mass is a gradual event and occurs due to a combination of lifestyle factors, assessment of dietary factors related to skeletal muscle is complicated. The aim of this study was to investigate the changes in total energy intake according to the level of skeletal muscle mass.SUBJECTS/METHODSA total of 8,165 subjects ≥ 30 years of age from the Korean National Health and Nutrition Examination Surveys (KNHANES) 2008–2011 were included in the analysis, and multivariate-adjusted regression analyses were performed to analyze the association of the quartiles of sarcopenia index (SI) with energy intake of the study population after adjusting for age and metabolic parameters.RESULTSThe increase in SI quartile was in proportion to the gradual decrease in systemic lipids and the anthropometric measurement of fat accumulation (P < 0.001). Subjects in higher SI quartiles tended to consume more total energy and energy-producing nutrients than those in lower quartiles (P < 0.001). After age, body weight, alcohol consumption, and metabolic parameters were adjusted in the analysis, total energy intake gradually increased according to the increase in SI quartile, and the association between total energy intake and SI was more pronounced in men. However, the risk (odd ratio) of having a low SI was not affected by any single macronutrient intake.CONCLUSIONSIn this study, total energy intake was positively associated with SI and relative skeletal mass in both men and women. However, no significant association or a weak association was observed between any single macronutrient intake and skeletal muscle mass. The data indicated that acquiring more energy intake within the normal range of energy consumption may help to maintain skeletal muscle mass.

[This corrects the article on p. 222 in vol. 12, PMID: 29854328.].

OBJECTIVE. The obesity epidemic in the United States continues to increase. Because obesity tends to track over time, the increase in overweight among young children is of significant concern. A number of eating patterns have been associated with overweight among preschool-aged children. Recently, 100% fruit juice and sweetened fruit drinks have received considerable attention as potential sources of high-energy beverages that could be related to the prevalence of obesity among young children. Our aim was to evaluate the beverage intake among preschool children who participated in the National Health and Nutrition Examination Survey 1999–2002 and investigate associations between types and amounts of beverages consumed and weight status in preschool-aged children. METHODS. We performed a secondary analysis of the data from the National Health and Nutrition Examination Survey 1999–2002, which is a continuous, cross-sectional survey of a nationally representative sample of the noninstitutionalized population of the United State. It included the collection of parent reported demographic descriptors, a 24-hour dietary recall, a measure of physical activity, and a standardized physical examination. The 24-hour dietary recall was obtained in person by a trained interviewer and reflected the foods and beverages that were consumed by the participant the previous day. The National Health and Nutrition Examination Survey food groups were classified on the basis of the US Department of Agriculture9s Food and Nutrient Database for Dietary Studies. We reviewed the main food descriptors used and classified all beverages listed. One hundred percent fruit juice was classified as only beverages that contained 100% fruit juice, without sweetener. Fruit drinks included any sweetened fruit juice, fruit-flavored drink (natural or artificial), or drink that contained fruit juice in part. Milk included any type of cow milk and then was subcategorized by percentage of milk fat. Any sweetened soft drink, caffeinated or uncaffeinated, was categorized as soda. Diet drinks included any fruit drink, tea, or soda that was sweetened by low-calorie sweetener. Several beverages were removed from the analysis because of low frequency of consumption among the sample. Water was not included in the analysis because it is not part of the US Department of Agriculture9s Food and Nutrient Database categories. For the purposes of this analysis, the beverages were converted and reported as ounces, rather than grams, as reported by the National Health and Nutrition Examination Survey, to make it more clinically relevant. The child9s BMI percentile for age and gender were calculated on the basis of Centers for Disease Control and Prevention criteria and used to identify children9s weight status as underweight ( RESULTS. All children who were aged 2 to 5 years were identified (N = 1572). Those with missing data were removed from additional analysis, resulting in a final sample of 1160 preschool children. Of the 1160 children analyzed, 579 (49.9%) were male. White children represented 35%, black children represented 28.3%, and Hispanic children represented 36.7% of the sample. Twenty-four percent of the children were overweight or at risk for overweight (BMI ≥85%), and 10.7% were overweight (BMI ≥95%). There were no statistically significant differences in BMI between boys and girls or among the ethnicities. Overweight children tended to be older (mean age: 3.83 years) compared with the normal-weight children (mean age: 3.48 years). Eighty-three percent of children drank milk, 48% drank 100% fruit juice, 44% drank fruit drink, and 39% drank soda. Whole milk was consumed by 46.5% of the children, and 3.1% and 5.5% of the children consumed skim milk and 1% milk, respectively. Preschool children consumed a mean total beverage volume of 26.93 oz/day, which included 12.32 oz of milk, 4.70 oz of 100% fruit juice, 4.98 oz of fruit drinks, and 3.25 oz of soda. Weight status of the child had no association with the amount of total beverages, milk, 100% fruit juice, fruit drink, or soda consumed. There was no clinically significant association between the types of milk (percentage of fat) consumed and weight status. In analysis of covariance, daily total energy intake increased with increased consumption of milk, 100% fruit juice, fruit drinks, and soda. However, there was not a statistically significant increase in BMI on the basis of quantity of milk, 100% fruit juice, fruit drink, or soda consumed. CONCLUSIONS. On average, preschool children drank less milk than the 2005 Dietary Guidelines for Americans recommendation of 16 oz/day. Only 8.6% drank low-fat or skim milk, as recommended for children who are older than 2 years. On average, preschool children drank

Dietary recommendations for adults with diabetes are to follow a healthy diet in appropriate portion sizes. We determined recent trends in energy and nutrient intakes among a nationally representative sample of US adults with and without type 2 diabetes. Participants were adults aged ≥20 years from the cross-sectional National Health and Nutrition Examination Surveys, 1988-2012 (N = 49 770). Diabetes was determined by self-report of a physician's diagnosis (n = 4885). Intake of energy and nutrients were determined from a 24-h recall by participants of all food consumed. Linear regression was used to test for trends in mean intake over time for all participants and by demographic characteristics. Among adults with diabetes, overall total energy intake increased between 1988-1994 and 2011-2012 (1689 kcal versus 1895 kcal; Ptrend < 0.001) with evidence of a plateau between 2003-2006 and 2011-2012. In 2007-2012, energy intake was greater for younger than older adults, for men than women, and for non-Hispanic whites versus non-Hispanic blacks. There was no change in the percentage of calories from carbohydrate, total fat or protein. Percentage of calories from saturated fat was similar across study periods but remained above recommendations (11.2% in 2011-2012). Fibre intake significantly decreased and remained below recommendations (Ptrend = 0.002). Sodium, cholesterol and calcium intakes increased. There was no change in energy intake among adults without diabetes and dietary trends were similar to those with diabetes. Future data are needed to confirm a plateau in energy intake among adults with diabetes, although the opportunity exists to increase fibre and reduce saturated fat.

We assessed the association between distribution of energy intake and total daily energy intake among individuals with type 2 diabetes, using data from 1219 men and women who completed the 1999–2004 National Health and Nutrition Examination Survey (NHANES). History of diabetes was self‐reported. Daily energy intake, overall and by meal (breakfast, lunch, dinner) and snack, was estimated from a 24‐h food frequency questionnaire. Multiple regression models were used to estimate the association between percent of daily energy intake at each meal and snack with daily energy intake. Models were controlled for sex, age, race/ethnicity, body mass index and physical activity. Intake of energy (mean ± standard deviation), as percent of total daily intake, at breakfast, lunch, dinner and snack was 22.9% ± 15.7%, 23.2% ± 20.0%, 35.2% ± 21.3%, and 12.4% ± 16.3%, respectively. A larger breakfast (≥ 20% vs. &lt;10% of total daily calories) was associated with 293 ± 104 (mean ± standard error) kilocalories lower total daily energy intake. No association was found between meal size at lunch, dinner or snack and total energy intake. The results suggest a possible role of food pattern in daily intake of energy. Consuming a higher energy breakfast may help decrease the overall daily intake of energy, which is critical for management of type 2 diabetes.

Children's energy intake has been reported to increase as a function of the portion size of foods offered to them. However, these studies have routinely used one “amorphous” entrée, macaroni and cheese, to test these effects. We investigated the effects of increasing the portion size of two entrees (one unit and one amorphous food; hotdogs and macaroni and cheese, respectively) on children's (3–6 y) energy intake at lunch. Entrées were provided in small or large portions along with fixed amounts of other foods. We measured entrée and total food intake (in g and kcal) across 5 presentations of each portion size of each entrée. A linear mixed model with repeated measures was used to test main effects for portion size and presentation and a portion*presentation interaction. Overall, the portion size of the entrée marginally influenced the amount of entrée consumed (kcal, p&lt;.12; g, p&lt;.01) however it did not impact total energy consumed at the meal (p&lt;.96). When examined by type of entrée, children ate significantly more (in kcal and g) of the large size of the amorphous entrée (p&lt;.02) but not of the unit entrée (p&lt;.15). Increases in portion size resulted in a large increase in entrée intake (25–34%) but only a 4% increase in total energy intake at the meal. Our findings suggest that children do not always respond to increases in portion size by increasing total energy intake.(Research Support: The National Cattlemen's Beef Association)

Late Evening Eating Patterns among US Adults Vary in Their Associations With, and Impact on, Energy Intake and Diet Quality: Evidence from What We Eat in America, National Health and Nutrition Examination Survey 2013-2016

To examine associations between consumption of low-calorie sweetened beverages (LCSBs), sugar, and total energy intake in children in the United States. We used 24-hour dietary recalls from 7026 children enrolled in the National Health and Nutrition Examination Survey (NHANES) 2011 to 2016 to assess energy and macronutrient intake among LCSB (≥4 oz LCSB, <4 oz SB), SB (≥4 oz SB, <4 oz LCSB), and LCSB + SB consumers (≥4 oz each) compared with water consumers (≥4 oz water, <4 oz LCSB and SBs). Sample weights and complex survey procedures were used for all analyses. Adjusting for body mass index (BMI) percentile, LCSB, SB, and LCSB + SB consumption was associated with 196, 312, and 450 more total calories and 15, 39, and 46 more grams of added sugar, which amounts to 60, 156, 184 more calories from added sugar, compared with water consumers (P < .05 for all pairwise comparisons). No differences in energy intake were observed between LCSB and SB consumers. [Correction added on 28 May 2019, after first online publication: In the preceding sentence, quantities of added sugar reported are in grams. The corresponding calories have also been specified in this version.] CONCLUSIONS: These findings challenge the utility of LCSB for weight management in children and adolescents.