NUTR 551 Lecture Notes - Lecture 8: Apple Sauce, Apple Juice, Juice
29 Jun 2018
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Consumption of apples is associated with a better
diet quality and reduced risk of obesity in children:
National Health and Nutrition Examination Survey
(NHANES) 2003–2010
Carol E. O’Neil
1*
, Theresa A. Nicklas
2
and Victor L. Fulgoni III
3
Abstract
Background: Most children do not meet the recommendation for fruit consumption. Apples are the second most
commonly consumed fruit in the US; however, no studies have examined the association of total apple products,
apples, apple sauce, and 100 % apple juice consumption on diet quality and weight/adiposity in children.
Methods: The purpose of this study was to examine the association between various apple consumption forms
with diet quality and weight/adiposity in a nationally representative sample of children. Participants were children
2–18 years of age (N= 13,339) from the National Health and Nutrition Examination Survey 2003–2010. Intake was
determined using a single interview administered 24-h diet recall. Apple product consumption was determined
using the cycle-appropriate USDA Food and Nutrient Database for Dietary Studies food codes. Total diet quality
and component scores were determined using the Healthy Eating Index-2010 (HEI). Anthropometrics were
determined using standard methods. Covariate adjusted linear and logistic regressions were used to compare
apple product consumers with non-consumers; sample weights were used. Probability was set at <0.01.
Results: Approximately 26 % of the population (n= 3,482) consumed some form of apple products. Consumers
of apple products, whole apples, apple sauce, and 100 % apple juice had higher HEI scores than non-consumers:
50.4 ± 0.4 v 41.9 ± 0.3, 52.5 ± 0.5 v 42.7 ± 0.3, 52.1 ± 0.8 v 47.2 ± 0.4, and 51.4 ± 0.6 v 46.5 ± 0.4, respectively. Apple
products and whole apple consumers had lower BMI z-scores than non-consumers: 0.4 ± 0.04 v 0.5 ± 0.03 and
0.3 ± 0.1 v 0.5 ± 0.02, respectively. Apple products and whole apple consumers were 25 % (0.59–0.95 99
th
CI) and
30 % (0.52–0.95 99
th
CI), respectively, were less likely to be obese than non-consumers.
Conclusions: Consumption of any form of apples contributed to the fruit recommendation of children and improved
diet quality. Apples should be included in the diets of children as a component of an overall healthy diet.
Keywords: NHANES, Apple, Apple juice, Apple sauce, Children, Fruit, Weight, Diet quality
Introduction
Fruit, defined by the Dietary Guidelines for Americans
(DGA) [1] as a nutrient-dense food, has also been recog-
nized as part of a healthy eating pattern [1]. Eating
nutrient-dense foods, such as fruit helps Americans bal-
ance nutrient needs within their energy needs. The rec-
ommendation for fruit is age, gender, and physical activity
dependent, and for children ranges from 1 cup equivalent
for children 2–3 years of age (years) to 2 cup equivalents
for males 14–18 years [2]. Fresh, frozen, canned, or dried
fruit can be used to meet the fruit recommendation, as
can 100 % fruit juice [2, 3]. Approximately 35 % to 50 % of
total fruit intake by children 9 to 18 years [4] comes from
100 % fruit juice, which makes a positive contribution to
overall diet quality, and has been associated with increased
intake of whole fruit [5–7]. However, most children fail to
meet the fruit recommendation [8–14].
* Correspondence: [email protected]
1
Louisiana State University Agricultural Center, 261 Knapp Hall, Baton Rouge,
LA 70803, USA
Full list of author information is available at the end of the article
© 2015 O'Neil et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
O’Neil et al. Nutrition Journal (2015) 14:48
DOI 10.1186/s12937-015-0040-1
Eating a diet rich in fruit, as part of an overall healthy
diet may reduce the risk of cardiovascular disease [15–18],
type 2 diabetes [18–20], and some types of cancer [18, 21].
According to the DGA [1], eating fruit, which is a rela-
tively low-energy food, in place of higher energy foods
may help lower overall energy intake; however, the effect
of fruit consumption on weight or weight loss is contro-
versial [18, 22–24]. Fruit provides a wide array of nutri-
ents, including nutrients of public health concern [1],
such as dietary fiber and potassium, as well as other short-
fall nutrients, like vitamins A and C and folate [25]. Many
of the health benefits seen may be due to these nutrients
or to the phytochemicals found in fruit [26].
Apples (Malus domestica) are the second most com-
monly consumed fruit in the United States (US) [27],
with 65 % of the apple crop consumed as fresh fruit and
35 % as processed apple products (e.g. apple sauce or
apple juice) [28]. One medium raw apple (182 g), with
skin, provides approximately 95 kcals, 19 g total sugars,
4 g dietary fiber (22 % of the Daily Value [DV]), and
195 mg of potassium (6 % DV). In addition, raw apples
contain virtually no total fat, saturated fatty acids, or so-
dium; and they have no cholesterol. Processed apple
products have a slightly different nutrient profile than
raw apples. For example apple sauce may or may not
have added sugars and ½cup (122 g) has only 1.3 g diet-
ary fiber and ½cup of 100 % fruit juice (124 g) has 0.2 g
dietary fiber [25]. These processed apple products still
count toward the fruit recommendation [2]. Apples are
also especially rich in phenolics, especially hydroxycin-
namic acid derivatives and flavonoids [27].
No studies have examined the association of apple
product consumption and diet quality or weight/adiposity
parameters in children. The purpose of this study was to
examine the association between apple/apple product
consumption with diet quality and weight/adiposity pa-
rameters in a nationally representative sample of children
using the National Health and Nutrition Examination Sur-
vey (NHANES) 2003–2010 data.
Subjects and methods
The NHANES
The NHANES is a continual program designed to col-
lect data that can be used to assess the health and nu-
tritional status of free-living children and adults in the
US. One of major objectives of the NHANES is to pro-
vide the data for investigators to be able to examine
the relationship between diet, nutrition, and health
[29]. The survey is unique in that it collects data from
interviews, dietary intake, and physical examinations.
Details regarding the survey design, content, opera-
tions, procedures, and participation rates are available
online [29–32].
Study population and dietary intake
The study population consisted of children 2–18 years
(N= 13,339) who participated in the 2003–2004, 2005–
2006, 2007–2008, 2009–2010 NHANES. Intake data were
obtained from What We Eat in America which were col-
lected during an in-person automated multiple-pass 24-h
dietary recall interview and a telephone 24-h dietary recall
conducted three to ten days later [33, 34]. For these stud-
ies, only the first day of data collection was used. Detailed
descriptions of the dietary interview methods are provided
in the NHANES Dietary Interviewers Procedure Manuals
[35, 36]. Briefly, proxies, usually parents, provided the
24-h dietary recalls of children 2–5 years; children 6–11
years were assisted by a proxy; older children provided
their own recalls. Recall data deemed unreliable by the
USDA Food Surveys Research Group (n= 275), preg-
nant and lactating females (n= 83), and those children
consuming breast milk (n= 10) were excluded from the
analyses. This left a final analytical sample of 13,339.
The NHANES has stringent protocols and procedures
that ensure confidentiality and protect individual partic-
ipants from identification using federal laws [37] and
additional Institutional Review Board approval for these
secondary analyses was not required [38].
Determination of apple product consumption
Apple/apple product consumption was determined form
the 24-h dietary recall by using the cycle-appropriate
United States Department of Agriculture food codes [39]
for: 1) whole apples; 2) apple sauce (which includes cooked
apples); 3) 100 % apple juice; and, 4) total apples, which in-
cluded all food codes from the three groups above.
Healthy Eating Index (HEI-2010)
The HEI-2010 [40, 41] was used to determine diet qual-
ity as specified by the 2010 DGA [1]. For the HEI-2010 a
total score is determined, as are 12 component scores.
Of these, nine: total fruit, whole fruit, total vegetables,
greens and beans, whole grains, dairy, total protein foods,
seafood and plant proteins, and fatty acids measure ad-
equacy; and a higher score is better. Three of the compo-
nent scores: refined grains, sodium, and empty calories,
measure moderation; and higher scores indicate lower
consumption. The SAS code used to calculate HEI-2010
scores was downloaded from the Center for Nutrition Pol-
icy and Promotion website [42].
Anthropometric and physiological measures
Height, weight, and waist circumference were obtained
according to NHANES protocols [43]. Body mass index
(BMI) was calculated as kg/m
2
[44]. The SAS program
of the Centers for Disease Control and Prevention was
used to determine BMI z-score and placement of children
on the 2000 growth charts [45]. Children with a BMI ≥the
O’Neil et al. Nutrition Journal (2015) 14:48 Page 2 of 9
85
th
and <95
th
were considered overweight; and children ≥
the 95th percentile were considered obese [46]. Children
with a BMI ≥85
th
percentile were considered overweight
or obese.
Statistical analyses
Sampling weights and the primary sampling units and
strata information, as provided by NHANES [47], were
included in all analyses using SUDAAN v11.0 (Research
Triangle Institute; Raleigh, NC). Least-square means
(and the standard errors of the least-square means) were
calculated using PROC REGRESS of SUDAAN. Linear
regression was used to determine differences in total
and sub-component HEI-2010 scores between apple,
apple sauce, apple juice, and total apple consumers and
non-consumers, as well as differences in anthropometric
measures among these consumers and non-consumers.
Logistic regression was used to determine if apple, apple
sauce, apple juice, and total apple consumers had a lower
odds ratio (OR) of being overweight, obese, or overweight
or obese. For all linear and logistic regressions, covariates
were: age (continuous variable), gender (discrete variable),
and ethnicity (discrete variable), all of which were deter-
mined from the sample person questionnaire [31]; poverty
index ratio (<1.25, 1.25–3.24, >3.25), which was obtained
from the NHANES family questionnaire [48]; and phys-
ical activity level (sedentary, moderate, and vigorous),
which was also obtained from the sample person ques-
tionnaire [31, 49]. All covariates were self-reported. A
p value of <0.01 was considered significant to reduce
the likelihood of making a type one error.
Results
Apple consumption and demographic characteristics
Approximately 26 % of the population (n= 3,482) con-
sumed some form of apple products; 14 % (n= 1,891)
consumed whole apple; 5 % (n= 332) consumed apple
sauce, and ~12 % (n= 1,714) consumed 100 % apple juice.
Some children consumed more than one apple product in
one day; therefore, there was some overlap in the study
population. Among consumers, mean intake of any apple
products was 222.2 ± 3.9 g, whole apple was 143 ± 3.8 g
(~1 cup equivalent), apple sauce was 129.8 ± 5.7 g (~1/2
cup equivalent), and apple juice was 9.6 ± 0.24 fluid
ounces (272.5 ± 6.7 g; 1.2 cup equivalents). Total apple
product consumers, whole apples, apple sauce, or apple
juice were more likely to be younger and less likely to be
current smokers than non-consumers (Table 1). There
were also racial/ethnic differences among consumers of
whole apples and apple sauce, with fewer non-Hispanic
blacks and more Mexican-Americans consuming whole
apples and fewer Mexican-Americans consuming apple
sauce. Apple sauce consumers were less likely to be
sedentary and more likely to be moderately physically
active than non-consumers (Table 1).
HEI-2010
Although all HEI-2010 scores were relatively low, con-
sumers of any apple product had higher total HEI-2010
scores than non-consumers (Table 2). Total apple prod-
uct consumers also had higher HEI-2010 component
scores: total fruit, whole fruit, whole grains, sodium, and
empty calories than non-consumers. It is important to
remember that sodium, refined grains, and empty calo-
ries are reverse scored so a higher score indicates lower
consumption. Whole apple consumers had higher com-
ponent scores for total and whole fruit, whole grains,
and seafood & plant protein, as well as empty calories.
Apple sauce consumers also had higher component
scores for total and whole fruit, whereas apple juice con-
sumers had higher component scores for total fruit and
empty calories.
Weight and adiposity measures
Total apple product and apple consumers had lower
mean BMI z-scores than non-consumers (Table 3). Total
apple product consumers also had a lower prevalence of
obesity and overweight or obesity than seen in non-
consumers; whereas, whole apple consumers only had a
lower prevalence of obesity than non-consumers. No dif-
ferences in any measure of weight or adiposity were seen
between apple sauce and apple juice consumers, when
compared with non-consumers. Table 4 shows that chil-
dren consuming total apple products or whole apples
were 25 % and 30 %, respectively, less likely to be obese
than non-consumers. No significant differences were
seen when comparing the likelihood of overweight or
obesity among apple sauce or apple juice consumers and
non-consumers.
Discussion
This is the first study, that we are aware of, that has shown
that total apple product consumption, whole apples, and
apple sauce and apple juice were associated with higher
diet qualities than those seen in non-consumers of the
same food groups. It is also the first study to show that
total apple consumption and whole apple consumption is
associated with a lower prevalence of obesity and a lower
likelihood of obesity.
Recently, it was shown that more than three-quarters
(77.1 %) of all children 2–19 years consumed any fruit
on a given day [8]. There is a clear difference in age, with
younger children 2–5 years consuming more than older
children 12–19 years [8]. Fruit consumption among chil-
dren 2–18 years appears to have increased during the time
of this study (2003 to 2010) [9] from 0.55 in 2003–2004 to
0.62 in 2009–2010 cup equivalents/1,000 kcal (kcals)
O’Neil et al. Nutrition Journal (2015) 14:48 Page 3 of 9
Document Summary
Consumption of apples is associated with a better diet quality and reduced risk of obesity in children: National health and nutrition examination survey (nhanes) 2003 2010. Carol e. o"neil1*, theresa a. nicklas2 and victor l. fulgoni iii3. Background: most children do not meet the recommendation for fruit consumption. Apples are the second most commonly consumed fruit in the us; however, no studies have examined the association of total apple products, apples, apple sauce, and 100 % apple juice consumption on diet quality and weight/adiposity in children. Methods: the purpose of this study was to examine the association between various apple consumption forms with diet quality and weight/adiposity in a nationally representative sample of children. 2 18 years of age (n = 13,339) from the national health and nutrition examination survey 2003 2010. Intake was determined using a single interview administered 24-h diet recall.
