Wojcicki and Heyman Respond

Abstract

We appreciate the thoughtful letter from Nicklas et al. In this response, we focus on their point that any association between 100% fruit juice consumption and childhood obesity is not supported by the scientific literature. First, Nicklas et al. comment that the article we cite by Dennison et al.,1 reporting an association between excess fruit juice consumption and short stature and obesity, was conducted in a small, regional sample of children from New York and used a nonstandard definition of obesity. They also note that the findings could not be reproduced in a subsequent article by another group.2 Although we appreciate these insights and critiques, we would like to note that a more recent study by Faith et al.,3 enrolling a larger sample of preschool children (n = 2801) from New York State than Dennison et al.,1 found an increased risk of adiposity gain for low income overweight or obese children participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Faith et al. found that each additional daily serving of fruit juice was associated with an excess adiposity gain of 0.009 z-score SD per month.3 This study is particularly significant because the children at greater risk were those low-income children who were already overweight or obese. A longitudinal study conducted in Missouri found a similar association between fruit juice consumption and increased risk for persistence of obesity among low-income WIC children who were already overweight or obese.4 As we have previously pointed out in another commentary,5 the prevalence of overweight and obesity in low income WIC children at two and three years of age is strikingly high, with non-Hispanic Black, Hispanic, and Mexican-American children all having a prevalence greater than 35%. Although we agree with Nicklas et al. that not all studies have shown a positive association between 100% fruit juice consumption and the development of overweight and obesity in young children, the studies we cite above suggest the urgent need to eliminate 100% fruit juice consumption particularly among the youngest and most vulnerable children—those already overweight and obese—in hopes of potentially reversing the epidemic. As we note in our commentary, the benefits of whole fruit in contrast to any fruit juice include the added fiber, which limits the insulin response and increases overall satiety.6 Although we agree with Nicklas et al. that 100% fruit juice does provide micronutrient benefits including vitamin C, folate, potassium, and magnesium, we point out that previous nationwide studies of dietary intake in toddlers and preschool children have found that micronutrient intakes meet or exceed requirements, whereas intake of dietary fiber was low in the majority of toddlers and preschoolers.7 Replacing fruit juice consumption with whole fruit among all young, vulnerable children would begin to address this problem of inadequate intake of fiber and follows the Institute of Medicine recommendation that whole fruit is the preferable option for children aged one year or older.8 Additionally, young preschool-aged children (both normal weight and overweight or obese) should become accustomed to drinking water and low fat milk, based on the health benefits associated with consuming these beverages. The Healthy Hunger Free Kids Act of 2010 requires potable water be available at all times in childcare facilities to encourage water consumption.9 Recent studies with older children have found that consumption of water may help with weight loss or maintenance10 and that provision of water in elementary schools can prevent the development of obesity.11 Although we appreciate the comments by Nicklas et al., the severity of the obesity epidemic among our nation’s youths, the existence of scientific data supporting the benefits of removing 100% fruit juice from young children’s diet, particularly among already overweight and obese children, and the concomitant existence of federal legislation mandating provision of water in childcare facilities sets the stage for elimination of fruit juice consumption in federally supported childcare facilities.