100% Orange juice consumption is associated with better diet quality, improved nutrient adequacy, decreased risk for obe...

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RESEARCHOpenAccess100%Orangejuiceconsumptionisassociatedwith betterdietquality,improvednutrientadequacy, decreasedriskforobesity,andimproved biomarkersofhealthinadults:NationalHealthand NutritionExaminationSurvey,2003-2006CarolEO ’ Neil1*,TheresaANicklas2,GailCRampersaud3andVictorLFulgoniIII4AbstractBackground: Consumptionof100%orangejuice(OJ)hasbeenpositivelyassociatedwithnutrientadequacyanddiet quality,withnoincreasedriskofoverweight/obesityinchildren;however,noonehasexaminedthesefactorsinadults. Thepurposeofthisstudywastoexaminetheassociationof100%OJconsumptionwithnutrientadequacy,diet quality,andriskfactorsformetabolicsyndrome(MetS)inanationallyrepresentativesampleofadults. Methods: Datafromadults19+yearsofage(n=8,861)participatingintheNationalHealthandNutritionExamination Survey2003-2006wereused.TheNationalCancerInstitutemethodwasusedtoestimatetheusualintake(UI)of100% OJconsumption,selectednutrients,andfoodgroups.PercentagesofthepopulationbelowtheEstimatedAverage Requirement(EAR)orabovetheAdequateIntake(AI)weredetermined.DietqualitywasmeasuredbytheHealthy EatingIndex-2005(HEI-2005).Covariateadjustedlogisticregressionwasusedtodetermineifconsumershadalower oddsratioofbeingoverweightorobeseorhavingriskfactorsofMetSorMetS. Results: Usual percapita intakeof100%OJwas50.3ml/d.Amongconsumers(n=2,310;23.8%),UIwas210.0ml/d. Comparedtonon-consumers,consumershadahigher(p<0.05)percentage(%SE)ofthepopulationmeetingthe EARforvitaminA(39.72.5vs54.01.2),vitaminC(0.00.0vs59.01.4),folate(5.80.7vs15.10.9),and magnesium(51.61.6vs63.71.2).ConsumerswerealsomorelikelytobeabovetheAIforpotassium(4.10.8vs 1.80.2).HEI-2005wassignificantly(p<0.05)higherinconsumers(55.00.4vs49.70.3).Consumersalsohadhigher intakesoftotalfruit,fruitjuice,wholefruit,andwholegrain.Consumershadalower(p<0.05)meanbodymassindex (27.60.2vs28.50.1),totalcholesterollevels(197.61.2vs200.80.75mg/dL),andlowdensity lipoprotein-cholesterollevels(112.51.4vs116.70.93mg/dL).Finally,comparedtonon-consumersof100%OJ, consumerswere21%lesslikelytobeobeseandmaleconsumerswere36%lesslikelytohaveMetS. Conclusion: Theresultssuggestthatmoderateconsumptionof100%OJshouldbeencouragedtohelpindividuals meettheUSDAdailyrecommendationforfruitintakeandasacomponentofahealthydiet. Keywords: Orangejuiceconsumption,100%fruitjuiceconsumption,Dietquality,Nutrients,Nutrientadequacy,Adults, Weight,Obesity,Metabolicsyndrome,NHANES *Correspondence: coneil1@lsu.edu1LouisianaStateUniversityAgriculturalCenter,261KnappHall,BatonRouge, Louisiana70803,USA Fulllistofauthorinformationisavailableattheendofthearticle 2012O'Neiletal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited.O ’ Neil etal.NutritionJournal 2012, 11 :107 http://www.nutritionj.com/content/11/1/107

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BackgroundConsumptionof100%fruitjuice(FJ)hasbeenassociated withhigherintakesofkeynutrients,includingvitamins CandB-6,folate,thiamin,magnesium,andpotassium, aswellasbetterdietquality,andincreasedintakeoftotal andwholefruitconsumptioninchildren[1-4]andadults [3]ascomparedtothosethatdonotconsume100%FJ. Therehavebeenconcernsaboutoverweight/obesityin consumersof100%FJ,especiallychildren[5-7].Most studieshavebeenconductedinchildrenandhavenot shownarelationshipbetween100%FJconsumptionand weight[8].Cross-sectionalstudiesthathavebeenconductedinadultshaveshownthatconsumptionof100% FJhasbeeninverselyassociatedwithbodymassindex (BMI)[9,10]andobesity[10];however,thelongitudinal Nurses ’ HealthStudyIIshowedthat100%FJconsumptionwaspositivelyassociatedwithweightgain[11]. Therelationshipbetweenconsumptionof100%FJand othermarkersofdiseaseamongadultsisinconsistent. PereiraandFulgoni[10],usingdatafromtheNational HealthandNutritionExaminationSurvey(NHANES) 1999-2004andYooetal.[12]usingdatafromthe BogalusaHeartStudy,showednoassociationofriskof metabolicsyndrome(MetS)among100%FJconsumers; anotherstudyshowedthat,inmiddleagedandolder adults,fastingglucose,butnotfastinginsulin[13]was lowerin100%FJconsumers.Indifferentstudies,diabetes riskwasshowntobeassociatedwith100%FJconsumption[14]ornot[11].DatafromtheCARDIAstudyhave shownanassociationofareducedriskofhypertension with100%FJconsumption[15].Sincedataontheeffects ofconsumptionof100%OJonadulthealthareconflicting,furtherstudiesareneeded. Fewstudieshaveexaminedtheeffectofspecificfruit juicesondietandhealth.Orangejuice(OJ)isthemost popular100%FJconsumedintheUS.In2009, per capita availabilityofOJwas14.84liters[16].Orange juiceisalsooneofthemostnutrientdense100%FJ,regardlessoftypeofdensitymeasuresusedintheevaluation[17].Twohundredandthirtysevenmlof100%OJ provides469kilojoules(kJ)(112kcal),21gtotalsugars, 124mgvitaminC,27mgmagnesium,0.10mgvitamin B-6,74 gDietaryFolateEquivalents,496mgpotassium,andonly0.06gsaturatedfattyacids(SFA)and 2.48mgsodium[18].Somebrandsofcommercially available100%OJarefortifiedwithfiber,calcium,or vitaminD;thesehavebeenidentifiedasnutrientsof publichealthconcerninthe2010DietaryGuidelinesfor Americans[19]. Invitro[20]andanimalstudies[21,22]havesuggested thatcitrusjuicesorcomponentsofthesejuices,including theflavanoneshesperidinandnaringin(ortheiraglycone formshesperetinandnaringenin),mayhavebeneficial effectsonbloodlipids.Clinicalstudiesconductedinadults haveshownthatconsumptionof100%OJhasbeenassociatedwithhealthbenefitsincludingpositiveeffectson bloodlipids[23-26] — especiallyinhypercholesterolemic individuals,lowerlevelsofseveraloxidativeorinflammatorystressbiomarkers[27-29],andlowerbloodpressure [30].Epidemiologicstudies,usinganationallyrepresentativesample,lookingattheassociationbetweenconsumptionof100%OJandhealthmarkersarelacking.The objectiveofthisstudywastoexaminetheassociationof 100%OJusualintakes(UI)onselectnutrients,foodgroup equivalents,dietquality,weightparameters,andriskfactorsassociatedwithcardiovasculardiseaseandmetabolic syndromeinadults.MethodsStudypopulationDatafromadults19+yrs(n=8,861)participatinginthe NHANES2003-2006werecombinedfortheseanalyses toincreasethesamplesize.Femaleswereexcludedfrom thestudyiftheywerepregnantorlactating.Demographicinformation[31]andphysicalactivitylevels[32] weredeterminedfromtheNHANESinterview.NHANES hasstringentconsentprotocolsandprocedurestoensure confidentialityandprotectionfromidentification[33]. Sincethiswasasecondarydataanalysiswithalackof personalidentifiers,thisstudywasexemptedbythe LouisianaStateUniversityAgriculturalCenterInstitutionalReviewBoard.DeterminationofdietaryintakedataDietarydatawerecollectedusingtwo24-hourdietary recallsusinganautomatedmultiple-passmethod[34,35]; thefirstrecallwasconductedinpersonbyatrained interviewerandthesecondrecallwasconducted310dayslaterviatelephone.Onlyrecalldatajudgedtobe completeandreliablebytheNationalCenterforHealth Statisticsstaffwereincludedinthisstudy.Detailed descriptionsofthedietaryrecallsanddatacollectionare availableintheNHANESDietaryInterviewer ’ sTraining Manual[36]. Inthisstudy,100%OJwasdefinedusingtheUnited StatesFoodandDrugAdministrationdefinition[37]for 100%FJ;thatistheproductcontained100%FJ — inthis case,OJ.Thisincludes100%FJmadefromconcentrate and100%FJwithaddednutrients,suchascalciumor vitaminD;butdoesnotincludejuicedrinksorother productsthatcontainlessthan100%fruitjuice.IndividualfoodcodesinNHANES2003-2004and2005-2006 wereusedtodetermineintakeof100%OJ.Consumers of100%OJweredefinedasthoseparticipantsconsuminganyamountof100%OJoneitherdayofthe24-hour recalls.Todeterminenutrientintake,theUSDAFood andNutrientDatabaseforDietaryStudies,versions2 [38]and3[39]wereusedforNHANES,2003-2004andO ’ Neil etal.NutritionJournal 2012, 11 :107 Page2of10 http://www.nutritionj.com/content/11/1/107

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2005-2006,respectively.Nutrientsexaminedincluded macronutrients,dietaryfiber,andsodiumandalsothose micronutrientslikelytobeprovidedby100%OJ:vitamins A,C,andB6;folate;magnesium;andpotassium.Intake fromsupplementswasnotconsidered.Foodgroupequivalentintakesandhealthyeatingindex (HEI-2005)Foodgroupequivalentintakes(formerlycalledMyPyramidequivalents)weredeterminedusingMyPyramid EquivalentsDatabase2.0;whennecessary,intakesfor NHANES2005-2006werehandmatchedtosimilar foods.TheHEI-2005wasusedtodeterminedietquality [40].TheSAScodeusedtocalculateHEI-2005scores wasdownloadedfromtheCenterforNutritionPolicy andPromotionwebsite[41].PhysiologicalmeasuresHeight,weight,andwaistcircumference(WC)were obtainedaccordingtoNHANESprotocols[42].Body massindexwascalculatedasbodyweight(kilograms) dividedbyheight(meters)squared[43].Fortheodds ratio(OR)assessments,overweight/obesityandhigh waistcircumferenceweredeterminedusingtheNational HeartLungandBloodInstitute(NHLBI)ClinicalGuidelines[43].Systolic(SBP)anddiastolicbloodpressures (DBP)weredeterminedusingthestandardNHANES protocol[44]andthemeanofallvaluesmeasuredwas used.Totalcholesterolandhighdensitylipoproteincholesterol(HDL-C)weredeterminedonnon-fastedindividuals[45]whilelowdensitylipoproteincholesterol (LDL-C)(46),triacylglycerides[46],bloodglucose[47], andinsulin[47]weredeterminedononlyfastedsubjects. Pertheseprotocols,notallindividualsmayhavevalues foralltests(seetablesforsamplenumbers).Metabolic syndromewasdefinedusingtheNHLBIAdultTreatment PanelIIIcriteria[48];thatishaving3ormoreofthefollowingriskfactors:abdominalobesity,WC>102cm (males),>88cm(females);hypertension,SBP 130mmHg orDBP 85mmHgortakinganti-hypertensivemedications;HDL-C,<40mg/dL(males),<50mg/dL (females);hightriacylglycerides, 150mg/dLortaking anti-hyperlipidemicmedications;highfastingglucose, 110mg/dLortakinginsulinorotherhypoglycemic agents.StatisticalanalysesSamplingweightsandthesamplingunitsandstratainformation,asprovidedbyNHANES,wereincludedinall analysesusingSUDAANv10.0(ResearchTriangle Institute;Raleigh,NC).Usualintakesweredetermined usingSASv9.2(SASInstitute,Cary,NC).Usualintake determinationsrepresentlongtermaveragedailyintakes andaredeterminedbyremovingexcessiveintra-person variationinintakes;thesearethebestestimatestocomparetodietaryrecommendationsassuggestedintakesare tobemetovertime,ratherthanmeasuredonasingleday. Usualintakeof100%OJconsumptionandselectednutrientswascalculatedusingtheNationalCancerInstitute (NCI)method[49].ForUIof100%OJ,whichisconsumedepisodically,thetwopartNCImodel(probability andamount)wasused;fornutrientswhichareconsumed dailybymostpeople,theonepartmodelwasused.The NCISASmacros(Mixtranv1.1andDistribv1.1)were usedtogenerateparametereffectsaftercovariateadjustmentsandtoestimatethedistributionofusualintakevia MonteCarlosimulationmethods,respectively[49].Covariatesinthisstudyweredayoftheweekofthe24-hrrecall[codedasweekend(Friday-Sunday)orweekday (Monday-Thursday)]andsequenceofdietaryrecall(first orsecond).SoftwareprovidedbyNCIwasusedwiththe twodaysofintakeusingone-daysamplingweightstoobtainappropriatevarianceestimates.Balancedrepeated replication(BRR)wasperformedtoobtainstandarderrors (SE)andconfidenceintervals(CI)forthepercentiles;BRR weightswereconstructedwithFayadjustmentfactor M=0.3(perturbationfactor0.7)andfurtheradjustedto matchtheinitialsampleweighttotalswithinspecificage/ gender/ethnicitygroupingsforthefulldataset.The DietaryReferenceIntake(DRI)agegroupswereusedto presentUIforeachofthenutrientsstudied. ToassesstheextentofinadequateintakeofvitaminsA andC,folate,andmagnesium,theEstimatedAverage Requirements(EAR)cut-pointmethodproposedbythe InstituteofMedicine[50]wasused.TheEARistheappropriateDRItousewhenassessingtheadequacyof groupintakes[50].TheEARcut-pointmethodprovides anestimateoftheproportionofindividualsinthegroup withinadequateintakesbyageandgender.Fornutrients withoutanEAR, i.e. sodiumandpotassium,thepercent abovetheAdequateIntake(AI)wasdetermined. Todetermineifthereweresignificantdifferences (p<0.05)forthepercentageof100%OJconsumersvs non-consumerswithintakeslessthantheEARorabove theAIaZ-statisticfordifferencesinpopulationproportionswasused.Linearregressionwasusedtodetermine differencesin100%OJconsumersandnon-consumers forphysiologicalmeasures.Logisticregressionwasused todetermineif100%OJconsumershadalowerORof beingoverweightorobeseorhadotherhealthriskfactors.Covariatesforlinearandlogisticregressionincluded energy(kcals),age,gender,ethnicity,povertyindexratio, andphysicalactivityforbodyweightandBMI;forother physiologicalmeasuresBMIwasalsoaddedasacovariate.Physicalactivitywasdeterminedfromphysicalactivityquestionnairesandseparatedsubjectsintothree categories:sedentary,moderateactivity,andvigorousactivity[51].O ’ Neil etal.NutritionJournal 2012, 11 :107 Page3of10 http://www.nutritionj.com/content/11/1/107

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ResultsUsualintakeoforangejuiceThesampleconsistedofadults19yearsofageandolder (n=8,861)ofwhich2,310(23.8%)consumed100%OJ. Percapitaconsumptionwas50.31.8ml/day,whereas amongconsumers,consumptionwas210.03.8ml/day. Percapitaconsumptionandconsumptionamongconsumerswashigherinmales(p<0.05)thaninfemales.The 75thpercentileamongconsumerswas259.36.8ml/day (Table1).Usualintakeofmacronutrients,andselected micronutrientsTheUIofcarbohydrates,totalsugars,anddietaryfiberwas higher(p<0.05)inconsumersthaninnon-consumers (Table2).Table3showsthatin100%OJconsumers,the UIofvitaminsA,B6,andC;folate;andmagnesiumwas higher(p<0.05)thannon-co nsumers,andconsumerswere lesslikelytobebelowtheEARthannonconsumers (p<0.05)(Table3).Thoseconsuming100%OJhadausual meanintakeofvitaminAof66015RetinolActivity Equivalents(RAE) g/dcomparedwith5808RAE g/d; approximately40%ofthoseconsuming100%OJwere belowtheEARforvitaminA,comparedwith54%ofnonconsumers(bothp<0.05).Orangejuiceconsumershada usualmeanintakeoffolateof60610DietaryFolate Equivalents(DFE) g/dcomparedwith5216DFE g/d; approximately6%of100%OJconsumerswerebelowthe EAR,comparedwith15%fornon-consumers(both p<0.05).Adultsconsuming100%OJhadameanusualintakeofvitaminCof1462.4mg/dcomparedwithapproximately671.3mg/dfornon-consumers.Onaverage, 100%OJconsumerswerenotbelowtheEAR,compared with59%ofnon-consumers(p<0.05).Adultsthatconsumed100%OJhadhigherus ualmeanintakeof313 4mg/dmagnesiumcomparedwith2833mg/dfornonconsumers.Approximately64%ofadultsthatconsumed 100%OJwerebelowtheEAR,comparedwith52%for non-consumers(bothp<0.05).Theusualmeanintakeof potassiumof100%OJconsumerswas302636mg/d, comparedwith262322mg/dfornon-consumers; approximately4%of100%OJconsumerswereabovethe AI,comparedwithonly2%ofnon-consumers(p<0.05).DietqualityandfoodgroupequivalentsusualintakeDietquality,asmeasuredbyHEI-2005,wassignificantly higher(p<0.05)inconsumersthaninnon-consumers (55.00.4vs49.70.3)(Table4).Totalfruit(1.80.05 vs0.70.02cupequivalents/d),fruitfromjuice(1.1 Table1Usualintakeoforangejuice(ml/d)inthetotalpopulationandconsumersTotalpopulationConsumersonlyPercentilesofintakeamongconsumers N=8,861n=2,310 GenderMeanSEPct.MeanSE25thSE50thSE75thSE Combined50.31.823.8210.03.8109.43.0468.64.7259.36.8 Male59.22.7a24.5235.65.3a118.34.1192.22.0286.98.3 Female41.42.1b23.1177.45.0b94.63.8147.97.4227.77.7Datasource:Adults19+yearsofageparticipatinginNHANES2003-2006withconsumersdefinedasorangejuiceconsumptiononeitheroftwodaysofinta ke assessment. Meanswithdifferentlettersindicateasignificantdifferencebetweengendersp<0.05. 1ml=0.0338USfluidoz. Table2Energyandmacronutrientusualintakesamong consumersandnon-consumersoforangejuiceUsualintakePercentile GroupMeanSE1025507590 Energy,Kcal/d Consumer22483314001702212626843569 Non-Consumer21851513391656208726223170 Protein,g/d Consumer84.91.352.262.579.8102.0125.3 Non-Consumer83.40.750.462.880.0100.6121.4 Carbohydrates,g/d Consumer2794a178214265330402 Non-Consumer2602b155194248314384 Totalsugars,g/d Consumer1332.3a77.496.9124160201 Non-Consumer1191.3b57.279.0110149192 Dietaryfiber,g/d Consumer16.60.3a9.612.215.820.124.7 Non-Consumer15.30.3b8.611.114.518.522.9 Totalfat,g/d Consumer83.11.447.760.878.7101.2124.6 Non-Consumer83.70.747.661.379.9102.1125.1 Saturatedfattyacids,g/d Consumer27.40.615.219.625.833.441.6 Non-Consumer27.80.315.019.726.334.342.8Datasource:Adults19+yearsofageparticipatinginNHANES2003-2006with consumersdefinedasorangejuiceconsumptiononeitheroftwodaysof intakeassessment. n:2,310OJconsumersand6,551non-consumers. Meanswithdifferentlettersaresignificantlydifferent,p<0.05.O ’ Neil etal.NutritionJournal 2012, 11 :107 Page4of10 http://www.nutritionj.com/content/11/1/107

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0.03vs0.20.01cupequivalents/d)andwholefruit (0.70.03vs0.50.02cupequivalents/d)wereallhigher forconsumersascomparedtonon-consumers.In addition,wholegrainconsumptionwashigher(p<0.05) inconsumers(0.80.03ounceequivalents)thaninnonconsumers(0.60.02ounceequivalents).AnthropometricandcardiovascularriskfactorsConsumersof100%OJhadalowermeanBMIthannonconsumers(27.60.18vs28.50.11kg/m2;p=0.0001) (Table5).Adultsthatconsumed100%OJalsohadlower totalcholesterol(197.61.2mg/dLv200.80.75mg/dL; p=0.0220)andlowerLDL-C(112.51.4mg/dLv116.7 0.93mg/dL;p=0.0110)levelsthanthosethatdidnotconsume100%OJ.SerumvitaminC(1.10.01vs0.9 0.01mg/dL;p<0.0001),redbloodcellfolate(309.33.6 vs285.32ng/mlRBC;p<0.0001),andserumfolate (14.80.24vs13.70.25ng/ml;p=0.0013)werehigher inconsumersof100%OJthaninnon-consumers(Table5). Therewerenodifferencesamongconsumersandnonconsumersinwaistcircumference,SBPorDBP,C-reactive protein,HDL-cholesterol,triacyglycerides,bloodglucose, insulin,orhomocysteinelevels.Riskofmetabolicsyndromeandriskfactorsformetabolic syndromeMalesthatconsumed100%OJshoweda36%reducedrisk [OR:0.62;95thCI:0.45-0.91]ofMetS;nodifferenceswere observedinfemales(OR:1.4195thCI:0.96-2.07)(Table6). Maleconsumersof100%OJalsoshoweda23%reduced risk(OR:0.7795thCI:0.61-0.99)oflowHDL-Clevels. Overalltherewasa21%reducedrisk(OR:0.79;95thCI: 0.65-0.95)ofobesityinadultsthatconsumed100%OJ comparedwithnon-consumers.DiscussionApproximately24%ofthepopulationconsumed100% OJoneitherofthedayswhena24hourrecallwastaken. Table3Selectedmicronutrientusualintakesamongconsumersandnon-consumersoforangejuiceandcomparisonto EstimatedAverageRequirements(EAR)orAdequateIntake(AI)UsualintakePercentileEAR GroupMeanSE1025507590%BelowSE VitaminA,RAEug/d Consumer66015a364471618802100939.72.5aNon-Consumer5808b26537352973096054.01.2bVitaminB-6,mg/d Consumer2.10.0a1.31.62.02.63.29.51.0aNon-Consumer1.90.0b1.11.41.82.32.916.71.4bFolate,DFEug/d Consumer60610a3584515787308905.80.7aNon-Consumer5216b28837148763479615.10.9bVitaminC,mg/d Consumer1462.4a1101251481671780.00.0aNon-Consumer66.61.3b26.138.958.585.4117.159.01.4bMagnesium,mg/d Consumer3134a19323829637244951.61.6aNon-Consumer2833b17021327033941163.71.2bUsualIntakePercentileAI GroupMeanSE1025507590%AboveSE Sodium,mg/d Consumer3483532066260433384213510798.40.3 Non-Consumer3501292137265433514194507498.80.2 Potassium,mg/d Consumer302636a197823962939356441954.10.8aNon-Consumer262322b161020092532314037561.80.2bDatasource:Adults19+yearsofageparticipatinginNHANES2003-2006withconsumersdefinedasorangejuiceconsumptiononeitheroftwodaysofinta ke assessment. n:2,310OJconsumersand6,551non-consumers. Meanswithdifferentlettersaresignificantlydifferent,p<0.05.O ’ Neil etal.NutritionJournal 2012, 11 :107 Page5of10 http://www.nutritionj.com/content/11/1/107

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Malesconsumedmore100%OJ,bothasapercentageof consumersandinamount.Thepercentofconsumers wassimilartothatofchildren[52]. Percapita UIconsumptionwas50.3ml/d;howevertheUIforconsumers was210.0ml/d.Unlikechildren,wherethereisaspecific recommendationforconsumptionof100%FJ[53],there isnorecommendationforconsumptionof100%FJby adults,otherthan “ themajorityofthefruitrecommendedshouldcomefromwholefruits,includingfresh, canned,frozen,anddriedforms,ratherthanfrom juice ” [19]. Therationaleforlimiting100%FJintakeisthatitlacks fiberandcancontributetoexcessenergyconsumption whenconsumedinexcess[19].Amodelingstudy,commissionedbythe2005DietaryGuidelinesAdvisory Committee[54]suggestedthatdietaryfiberwaslower whenwholefruitwasremovedfromthediet,whichledto therecommendationthatintakeofnomorethanonethirdoffruitservingsshouldcomefrom100%FJandtwothirdsshouldcomefromwholefruit.However,thisstudy andothers[1-4,52]haveshownthateitherconsumersof 100%FJhadhigherintakesofdietaryfiberthannonconsumersortherewasnodifferenceinfiberconsumptionbetweenthegroups.Since100%FJislowindietary fiber,itsuggeststhatotherhigherfiberfoods,including wholefruit,areconsumedbyconsumersof100%FJ;this wasshownnotonlyinthisstudyof100%OJconsumers, buthasbeenshowninotherstudiesaswell[1,2,52]. Asexpected,100%OJconsumershadincreasedintake ofnutrientstypicallyfoundin100%OJ(i.e vitaminC, folate,andpotassium).Consumerswerealsolesslikely tohaveintakesbelowtheEARforvitaminsA,B-6,and C;folate;andmagnesiumthannon-consumers.Thereductioninthepercentageofthepopulationwithinadequateintakesofthesenutrientsassociatedwith100% OJconsumptionindicatesthevalueofconsuminganutrientdensebeverage[17].MeanpotassiumUIwasalso higherinconsumersthannon-consumersandthepercentageofthepopulationabovetheAIwashigher.This isanimportantfindingsincepotassiumwasidentifiedas anutrientofpublichealthconcern[19].Toourknowledgethisisthefirstreportstudyingtheassociationbetweentheconsumptionof100%OJandnutrientadequacy inadultsusingtherecommendedUIprocedures. Dietquality,asmeasuredbyHEI-2005,wasapproximately10%higherin100%OJconsumers.Whiletheincreasewasdueinparttotheincreaseinwholefruitand FJconsumption,consumersalsohadahigherUIofwhole grains.Althoughintakeoftotalfruit,wholefruit,andFJ washigherin100%OJconsumers,overallintakefromthe fruitfoodgroupswaslow.Despiteextensive,coordinated publichealthcampaignsbygovernment,industry,and others[55],fruitconsumptioninadultsremainslow[56]. Sincea236.6mlservingof100%OJcountsaspartofthe recommendationforthefruitgroup,moderateconsumptionof100%OJcanhelpindividualsmeetfruitintake recommendations. Thepotentialassociationofconsumptionof100%FJ andweightinchildrenhasbeendebatedintheliterature formorethanadecade[1,2,5-8,57-62];however,lessis knownaboutthisrelationshipinadults.Participantsinthe Nurses ’ HealthStudyIIwithahigherconsumptionof 100%FJhadalargerweightgainthanthosewithlower fruit100%FJconsumption,althoughtheamountsand typesof100%FJconsumed,andspecificcovariatesused intheanalyses,werenotclear[11].Anotherstudy[9] showedthatselfreportedBMIwaslowerinconsumersof 100%FJ.Ourswasthefirststudythatusedanationally representativeadultpopulationthatshowedconsumersof Table4Dietquality,asmeasuredbyhealthyeating indexandselectusualintakesofMyPyramidfood componentsamongconsumersandnon-consumersof orangejuiceUsualintakePercentile GroupMeanSE1025507590 HealthyEatingIndex,score Consumer55.00.4a44.549.354.960.665.7 Non-Consumer49.70.3b38.443.549.455.661.4 Totaldairy,cupequivalents Consumer1.60.050.60.91.42.12.9 Non-Consumer1.50.0020.50.81.32.02.8 Totalfruit,cupequivalents Consumer1.80.05a1.11.41.82.12.3 Non-Consumer0.70.02b0.20.30.60.91.4 Fruitjuice,cupequivalents Consumer1.10.03a0.80.91.11.31.4 Non-Consumer0.20.01b0.00.00.10.20.4 Wholefruit,cupequivalents Consumer0.70.03a0.10.30.61.01.4 Non-Consumer0.50.02b0.10.20.40.71.1 Totalgrain,ounceequivalents Consumer7.00.14.25.36.78.410.0 Non-Consumer6.80.13.84.96.48.310.3 Wholegrain,ounceequivalents Consumer0.80.03a0.20.40.71.01.5 Non-Consumer0.60.02b0.10.20.50.91.3 Totalvegetables,cupequivalents Consumer1.70.030.91.21.62.02.5 Non-Consumer1.60.030.91.21.52.02.5Datasource:Adults19+yearsofageparticipatinginNHANES2003-2006with consumersdefinedasorangejuiceconsumptiononeitheroftwodaysof intakeassessment. n:2,310OJconsumersand6,551non-consumers. Meanswithdifferentlettersaresignificantlydifferent,p<0.05.O ’ Neil etal.NutritionJournal 2012, 11 :107 Page6of10 http://www.nutritionj.com/content/11/1/107

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Table5Physiologicalmeasuresamongconsumersandnon-consumersoforangejuiceConsumersNon-consumers VariablenLSMSEnLSMSEp-Value BodyWeight*(kg)213081.30.20615081.40.120.5072 BMI*(kg/m2)213027.60.18615028.50.11<0.0001 WaistCircumference*(cm)206997.10.17600597.30.100.4381 SystolicBloodPressure(mmHg)**1801124.00.535296123.80.300.7604 DiastolicBloodPressure(mmHg)**180170.80.42529671.30.230.2976 SerumVitaminC(mg/dL)**20221.10.0158130.910.01<0.0001 C-ReactiveProtein**(mg/dL)20410.430.0358740.410.010.5922 TotalCholesterol**(mg/dL)2034197.61.25857200.80.750.0220 HDL-Cholesterol**(mg/dL)203353.70.45585753.80.240.8230 Triglycerides**(mg/dL)954141.63.62833147.43.30.2246 LDL-Cholesterol**(mg/dL)939112.51.42746116.70.930.0110 PlasmaGlucose**(mg/dL)960103.01.42856102.40.620.6853 Insulin**(uU/mL)95111.60.38282311.30.250.4441 RBCFolate**(ng/mLRBC)2044309.33.65872285.32.0<0.0001 SerumFolate**(ng/mL)203714.80.24584913.70.250.0013 Homocysteine**(umol/L)19888.70.0857298.90.060.0853*Adjustedforenergy(kcal),age,gender,ethnicity,povertyincomeratio,andphysicalactivity.**Adjustedforenergy(kcal),age,gender,ethnicity,povertyincomeratio,BMI,andphysicalactivity. Abbreviations:LSM=leastsquaremean;SE=standarderror;BMI=bodymassindex;HDL-C=highdensitylipoprotein-cholesterol;LDL-C=low-density lipoproteincholesterol;RBC=redbloodcell. Table6Riskofmetabolicsyndrome,increasedriskofindividualmetabolicsyndromecomponentsandotherhealth factorsamongadult(19+yrs)consumersandnon-consumersoforangejuiceRiskORSELCL,UCLp-ValueORSELCL,UCLp-ValueORSELCL,UCLp-Value AllFemaleMale MetS0.93 0.130.71,1.220.57901.41 0.280.96,2.070.07950.64 0.120.45,0.910.0119 ElevatedBP0.980.070.85,1.130.75860.98 0.150.73,1.310.89480.95 0.120.75,1.220.7078 HighGlucose0.96 0.100.78,1.180.67721.08 0.170.79,1.470.61800.82 0.110.64,1.060.1361 HighTG1.11 0.130.89,1.390.35751.41 0.251.00,1.990.05030.91 0.110.72,1.150.4474 ElevatedWC0.98 0.150.73,1.330.90671.09 0.240.72,1.660.68900.83 0.150.59,1.180.3052 LowHDL-C0.92 0.080.78,1.090.35181.08 0.110.891.310.42710.77 0.100.61,0.990.0406 Obese0.79 0.080.65,0.950.01160.76 0.100.59,0.970.02890.79 0.090.64,0.970.0276 Overweight1.13 0.070.99,1.280.06991.18 0.100.99,1.390.05811.07 0.090.91,1.260.3976 OverweightorObese0.89 0.070.76,1.040.14370.88 0.090.73,1.080.22160.85 0.090.69,1.060.1461 HighLDL-C0.82 0.100.66,1.030.09080.76 0.120.57,1.030.07830.85 0.140.63,1.160.3163*Referencegroup:Non-consumersoforangejuicewithoddsratiosetat1.0. AllMetabolicSyndromeComponents:ElevatedWaistCircumference 102cminmenor 88cminwomen;ElevatedTriglycerides 150mg/dLortaking medicationforElevatedTriglycerides(AntihyperlipidemicAgentsorNicotinicAcidDerivatives);ReducedHDL-C<40mg/dLinmenor<50mg/dLinwom enor takingmedicationforReducedHDL-C(AntihyperlipidemicAgentsorNicotinicAcidDerivatives);ElevatedBP 130mmHgSystolicor 85mmHgDiastolicortaking medicationforElevatedBP(AntihypertensiveCombinations);ElevatedFastingGlucose 100mg/dLortakingmedicationforElevatedGlucose(Antidiabetic Agents);MetabolicSyndrome( 3riskfactorsabove).Otherriskfactors:ElevatedLDL-C 100mg/dL;OverweightBMI 25and<30;ObeseBMI 30;Overweightor ObeseBMI 25. Abbreviations:OR=oddsRatio;LCL=lowerconfidencelevel;UCL=upperconfidencelevel;SE=standarderror;MetS=metabolicsyndrome;BP=bloodpr essure; TG=triglycerides;WC=waistcircumference;HDL-C=highdensitylipoprotein-cholesterol;LDL-C=lowdensitylipoprotein-cholesterol.O ’ Neil etal.NutritionJournal 2012, 11 :107 Page7of10 http://www.nutritionj.com/content/11/1/107

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100%OJhadalowerBMIthannon-consumers.These findingsareimportantsince100%OJhasthehighest per capita consumption[16]amongthejuicesandtherefore hasthepotentialtobeanimportantcomponentofthe diet.Clinicalstudiesthatincorporatedhighlevelsof100% OJ(750ml[24]or500ml[30])asaninterventionhave reportednoincreasesinweightorotheranthropometric measuresoverthecourseofthestudy. TotalcholesterollevelsandLDL-Clevelswereboth significantlylowerinconsumersof100%OJthannonconsumers.Compoundsfoundin100%OJ,including hesperidin,naringin,orlimonoidsortheircirculating aglyconeforms,havebeenshowntolowertotalorLDLCinanimalmodels[63,64].Itwashypothesizedthatthese compoundsmayhaveinhibited3-Hydroxy-3-methylglutarylcoenzymeAreductaseandincreasedtheexpressionofLDL-Creceptorsintheliver,amechanism similartostatins.Thesecompoundshavealsobeenshown toreducethenetsecretionofapolipoproteinB,whichin turnmayhelpinhibitcholesterolestersynthesis[20,65]. Orangejuice,athigherintakeamounts(750ml)has alsobeenshowntolowerLDL-CandraiseHDL-Cina randomizedclinicaltrialofhypercholesterolemiaindividuals[24].Althoughthepresentstudydidnotlookseparatelyatindividualswithhypercholesterolemia,itdid showthatamorerealisticconsumptionof100%OJwas associatedwithreducedtotalcholesterolandLDL-C levels.Itisnotclearwhytherewasnodifferenceshown betweenHDL-Clevelsbetween100%OJconsumersand non-consumers,asmayhavebeensuggestedbyclinical trials;theresponsemaybedose-dependentordependent oncontinualconsumption.Therewasa23%lowerriskof lowHDL-Clevelsinmalesonly. Consumptionof100%OJwasassociatedwitha21% lowerriskofobesityinmenandwomen.ThiswassimilartothefindingsofPereiraandFulgoni[10]that lookedattheriskofobesityandconsumptionof100% FJinparticipantsofNHANES1999-2004.Theyalso showedasignificantlylowerriskofmetabolicsyndrome, whereasthisstudyshowedalowerriskinmalesonly. Thatstudyshowedamuchhigherintakeof100%FJ, comparedwiththeintakeof100%OJonly;butthere werealsootherdifferencesinthepopulation,sincethey showed,forexamplethatconsumersweremorelikelyto befemale.Ourstudyshowedthat100%OJconsumers weremorelikelytobemales.Consumptiondifferences of100%FJinadultsneedtobestudiedfurther. Strengthsofthisstudyincludethatitencompasseda largenationallyrepresentativesampleachievedthrough combiningseveralsetsofNHANESdatareleases.The studyalsousestheNCImethodtoassessUIandthepercentageofthepopulationbelowrecommendedlevelsin 100%OJconsumersandnon-consumers,aswellasadjustmentfornumerouscovariatesincludingphysicalactivity. Twenty-fourhourdietaryrecallshaveseveralinherent limitations.Participantsreliedonmemorytoself-report dietaryintakes;therefore,dataweresubjecttononsamplingerrors,includingunderreportingofenergyand examinereffects.Respondentsmaynothavedifferentiated between100%OJorafruitdrink/ade.Confusionover thesebeverageshasbeenreflectedinseveralstudiesthat assessedacombined100%FJandjuicedrinkorsweetened FJcategory[66-69].TheuseofAIcannotbeusedtodeterminetheprevalenceofinadequateintakeinagroup. Rather,ifthemeanintakeofagroupisatorabovetheAI, andthevarianceofintakeinthegroupofinterestissimilartothevarianceofintakeusedinthepopulationoriginallyusedtosettheAI,theprevalenceofinadequate nutrientintakesislikelytobelow[50].Finally,since causalinferencescannotbedrawnfromNHANESanalyses,andduetomulti-collinearityofdiet,foodsother than100%OJmayhavecontributedtodifferencesinnutrientintakeoftheparticipants.ConclusionsConsumptionof100%OJwasassociatedwithbetterdiet qualityandanincreasedprevalenceofmeetingtheEAR forkeynutrientsandotherbiomarkersofpositivehealth outcomes,includinglowertotalcholesterolandLDL levels.Consumersof100%OJhadlowermeanBMIanda decreasedriskofobesity.Inaddition,maleshada decreasedriskofmetabolicsyndrome.Theseresultssuggestedthat100%OJconsumptionshouldbeencouraged asacomponentofahealthydiettohelpindividualsmeet nutrientandfruitintakerecommendations.Abbreviations AI:Adequateintake;BMI:Bodymassindex;BRR:Balancedrepeated replication;CI:Confidenceinterval;DBP:Diastolicbloodpressure; DFE:Dietaryfolateequivalents;DRI:Dietaryreferenceintake;EAR:Estimated averagerequirements;FJ:100%Fruitjuice;HDL-C:Highdensitylipoproteincholesterol;HEI-2005:Healthyeatingindex-2005;LDL-C:Lowdensity lipoprotein-cholesterol;MetS:Metabolicsyndrome;NHANES:Nationalhealth andNutritionexaminationsurvey;NHLBI:Nationalheart,lung,andblood institute;OJ:100%Orangejuice;OR:Oddsratio;RAE:Retinolactivity equivalents;SBP:Systolicbloodpressure;SFA:Saturatedfattyacids;UI:Usual intake;WC:Waistcircumference. Competinginterests GailRampersaud ’ spositionattheUniversityofFloridaisco-fundedbythe FloridaDepartmentofCitrus.Noneoftheotherauthorsdeclareacompeting interest. Authors ’ contributions Allauthorscontributedequallytothiswork.Allauthorsreadandapproved thefinalmanuscript. Acknowledgements ThisworkisapublicationoftheUnitedStatesDepartmentofAgriculture (USDA/ARS)Children ’ sNutritionResearchCenter,DepartmentofPediatrics, BaylorCollegeofMedicine,Houston,Texas.Thecontentsofthispublication donotnecessarilyreflecttheviewsorpoliciesoftheUSDA,nordoes mentionoftradenames,commercialproducts,ororganizationsimply endorsementfromtheU.S.government.Thisresearchprojectwassupported bytheFloridaDepartmentofCitrus,andUSDA – AgriculturalResearchO ’ Neil etal.NutritionJournal 2012, 11 :107 Page8of10 http://www.nutritionj.com/content/11/1/107

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Servicethroughspecificcooperativeagreement58-6250-6-003.Partial supportwasreceivedfromtheUSDAHatchProjectLAB93951. Authordetails1LouisianaStateUniversityAgriculturalCenter,261KnappHall,BatonRouge, Louisiana70803,USA.2USDA/ARSChildren ’ sNutritionResearchCenter, DepartmentofPediatrics,BaylorCollegeofMedicine,Houston,Texas77030, USA.3FoodScienceandHumanNutritionDepartment,UniversityofFlorida, Gainesville,Florida32611,USA.4NutritionImpact,LLC,BattleCreek,Michigan 49014,USA. Received:9March2012Accepted:30November2012 Published:12December2012 References1.NicklasTA,O'NeilCE,KleinmanR: Associationbetween100%juice consumptionandnutrientintakeandweightinchildrenaged2to 11years. ArchPedAdolescMed 2008, 162: 557 – 565. 2.O ’ NeilCE,NicklasTA,KleinmanR: Relationshipbetween100%juice consumptionandnutrientintakeandweightofadolescents. 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AccessedJune21,2011. 45.NationalHealthandNutritionExaminationSurvey: 2003-2004Data documentation,codebook,andfrequencies.TotalcholesterolandHDL.Last revisedApril ;2010.http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/ l13_c.htm.AccessedJune21,2011. 46.NationalCenterforHealthStatistics: NHANESdocumentation,codebook,and frequencies:surveyyears2003-2004.MEClaboratorycomponent:triglycerides andLDL-cholesterol ;http://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/ l13am_c.pdf.AccessedJune12,2010. 47.NationalCenterforHealthStatistics: NHANESdocumentation,codebook,and frequencies:surveyyears2003-2004.MEClaboratorycomponent:plasma glucose,serumC-peptide,andinsulin ;http://www.cdc.gov/nchs/data/nhanes/ nhanes_03_04/l10am_c.pdf.AccessedJune12,2010. 48.NationalCholesterolEducationProgram: Nationalheart,lung,andblood institute.Nationalinstitutesofhealth.Detection,evaluation,andtreatmentof highbloodcholesterolinadults(adulttreatmentpanelIII) ;2002.NIH PublicationNo.02-5215. 49.UsualDietaryIntakes: SASmacrosforanalysisofasingledietarycomponent http://riskfactor.cancer.gov/diet/usualintakes/macros_single.html.Accessed June12,2010. 50.InstituteofMedicine.FoodandNutritionBoard: Dietaryreferenceintakes: applicationsindietaryassessment .WashingtonDC:NationalAcademy Press;2000. 51.NationalCenterforHealthStatistics: NHANESdocumentation,codebook,and frequencies:surveyyears2003-2004.Physicalactivity .http://www.cdc.gov/ nchs/nhanes/nhanes2005-2006/PAQ_D.htm.AccessedAugust29,2011. 52.O'NeilCE,NicklasTA,RampersaudGC,FulgoniVL3rd: Onehundred percentorangejuiceconsumptionisassociatedwithbetterdietquality, improvednutrientadequacy,andnoincreasedriskforoverweight/ obesityinchildren. NutrRes 2011, 31: 673 – 682. 53.AmericanAcademyofPediatrics: CommitteeonNutrition.Theuseand misuseoffruitjuiceinpediatrics. Pediatrics 2001, 107: 1210 – 1213. 54.USdepartmentofagriculture,2005dietaryguidelinesadvisorycommittee report(2004)fruitandfruitjuiceanalysis .http://www.health.gov/ dietaryguidelines/dga2005/report/HTML/G2_Analyses.htm#fruitjuice. AccessedSeptember30,2010. 55. Produceforbetterhealth .http://www.fruitsandveggiesmorematters.org. AccessedMay292010. 56.CentersforDiseaseControlandPrevention(CDC): State-specifictrends infruitandvegetableconsumptionamongadults – UnitedStates, 2000-2009. MMWRMorbMortalWklyRep 2010, 59: 1125 – 1130. 57.Melgar-QuinonezHR,KaiserLL: Relationshipofchild-feedingpracticesto overweightinlow-incomeMexican-Americanpreschool-agedchildren. JAmDietAssoc 2004, 104: 1110 – 1119. 58.AlexyU,Sichert-HellertW,KerstingM,ManzF,SchochG: Fruitjuice consumptionandtheprevalenceofobesityandshortstatureinGerman preschoolchildren:resultsoftheDONALD(DortmundNutritionaland AnthropometricalLongitudinallyDesignedStudy). PediatGastroenterol Nutr 1999, 29: 343 – 349. 59.SkinnerJD,CarruthBR,MoranJ3rd,HouckK,ColettaF: Fruitjuiceintakeis notrelatedtochildren'sgrowth. Pediatrics 1999, 103: 58 – 64. 60.SkinnerJD,CarruthBR: Alongitudinalstudyofchildren'sjuiceintakeand growth:thejuicecontroversyrevisited. AmDietAssoc 2001, 101: 432 – 437. 61.O'ConnorTM,YangSJ,NicklasTA: Beverageintakeamongpreschool childrenanditseffectonweightstatus. Pediatrics 2006, 118: e1010 – 8. 62.NewbyPK,PetersonKE,BerkeyCS,LeppertJ,WillettWC,ColditzGA: Beverageconsumptionisnotassociatedwithchangesinweightand bodymassindexamonglow-incomepreschoolchildreninNorth Dakota. 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JNutr 2000, 130: 1734 – 1742. 67.SanigorskiAM,BellAC,SwinburnBA: Associationofkeyfoodsand beverageswithobesityinAustralianschoolchildren. PublicHealthNutr 2007, 10: 152 – 157. 68.PaynterNP,YehHC,VoutilainenS,SchmidtMI,HeissG,FolsomAR,BrancatiFL, KaoWH: Coffeeandsweetenedbeverageconsumptionandtheriskoftype 2diabetesmellitus:theatherosclerosisriskincommunitiesstudy. AmJ Epidemiol 2006, 164: 1075 – 1084. 69.OdegaardAO,KohWP,ArakawaK,YuMC,PereiraMA: Softdrinkandjuice consumptionandriskofphysician-diagnosedincidenttype2diabetes: theSingaporeChineseHealthStudy. AmJEpidemiol 2010, 171: 701 – 708.doi:10.1186/1475-2891-11-107 Citethisarticleas: O ’ Neil etal. : 100%Orangejuiceconsumptionis associatedwithbetterdietquality,improvednutrientadequacy, decreasedriskforobesity,andimprovedbiomarkersofhealthinadults: NationalHealthandNutritionExaminationSurvey,2003-2006. Nutrition Journal 2012 11 :107. Submit your next manuscript to BioMed Central and take full advantage of: € Convenient online submission € Thorough peer review € No space constraints or color “gure charges € Immediate publication on acceptance € Inclusion in PubMed, CAS, Scopus and Google Scholar € Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit O ’ Neil etal.NutritionJournal 2012, 11 :107 Page10of10 http://www.nutritionj.com/content/11/1/107


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ui 1475-2891-11-107
ji 1475-2891
fm
dochead Research
bibl
title
p 100% Orange juice consumption is associated with better diet quality, improved nutrient adequacy, decreased risk for obesity, and improved biomarkers of health in adults: National Health and Nutrition Examination Survey, 2003-2006
aug
au id A1 ca yes snm O’Neilmi Efnm Carolinsr iid I1 email coneil1@lsu.edu
A2 NicklasATheresaI2 tnicklas@bcm.edu
A3 RampersaudCGailI3 gcr@ufl.edu
A4 Fulgoni IIILVictorI4 VIC3RD@aol.com
insg
ins Louisiana State University Agricultural Center, 261 Knapp Hall, Baton Rouge, Louisiana, 70803, USA
USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, 77030, USA
Food Science and Human Nutrition Department, University of Florida, Gainesville, Florida, 32611, USA
Nutrition Impact, LLC, Battle Creek, Michigan, 49014, USA
source Nutrition Journal
issn 1475-2891
pubdate 2012
volume 11
issue 1
fpage 107
url http://www.nutritionj.com/content/11/1/107
xrefbib pubidlist pubid idtype doi 10.1186/1475-2891-11-107pmpid 23234248
history rec date day 9month 3year 2012acc 30112012pub 12122012
cpyrt 2012collab O'Neil et al.; licensee BioMed Central Ltd.note This is an Open Access article distributed under the terms of the Creative Commons Attribution License (
http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
kwdg
kwd Orange juice consumption
100% fruit juice consumption
Diet quality
Nutrients
Nutrient adequacy
Adults
Weight
Obesity
Metabolic syndrome
NHANES
abs
sec
st
Abstract
Background
Consumption of 100% orange juice (OJ) has been positively associated with nutrient adequacy and diet quality, with no increased risk of overweight/obesity in children; however, no one has examined these factors in adults. The purpose of this study was to examine the association of 100% OJ consumption with nutrient adequacy, diet quality, and risk factors for metabolic syndrome (MetS) in a nationally representative sample of adults.
Methods
Data from adults 19+ years of age (n = 8,861) participating in the National Health and Nutrition Examination Survey 2003-2006 were used. The National Cancer Institute method was used to estimate the usual intake (UI) of 100% OJ consumption, selected nutrients, and food groups. Percentages of the population below the Estimated Average Requirement (EAR) or above the Adequate Intake (AI) were determined. Diet quality was measured by the Healthy Eating Index-2005 (HEI-2005). Covariate adjusted logistic regression was used to determine if consumers had a lower odds ratio of being overweight or obese or having risk factors of MetS or MetS.
Results
Usual it per capita intake of 100% OJ was 50.3 ml/d. Among consumers (n = 2,310; 23.8%), UI was 210.0 ml/d. Compared to non-consumers, consumers had a higher (p < 0.05) percentage (% ± SE) of the population meeting the EAR for vitamin A (39.7 ± 2.5 vs 54.0 ± 1.2), vitamin C (0.0 ± 0.0 vs 59.0 ± 1.4), folate (5.8 ± 0.7 vs 15.1 ± 0.9), and magnesium (51.6 ± 1.6 vs 63.7 ± 1.2). Consumers were also more likely to be above the AI for potassium (4.1 ± 0.8 vs 1.8 ± 0.2). HEI-2005 was significantly (p < 0.05) higher in consumers (55.0 ± 0.4 vs 49.7 ± 0.3). Consumers also had higher intakes of total fruit, fruit juice, whole fruit, and whole grain. Consumers had a lower (p < 0.05) mean body mass index (27.6 ± 0.2 vs 28.5 ± 0.1), total cholesterol levels (197.6 ± 1.2 vs 200.8 ± 0.75 mg/dL), and low density lipoprotein-cholesterol levels (112.5 ± 1.4 vs 116.7 ± 0.93 mg/dL). Finally, compared to non-consumers of 100% OJ, consumers were 21% less likely to be obese and male consumers were 36% less likely to have MetS.
Conclusion
The results suggest that moderate consumption of 100% OJ should be encouraged to help individuals meet the USDA daily recommendation for fruit intake and as a component of a healthy diet.
bdy
Background
Consumption of 100% fruit juice (FJ) has been associated with higher intakes of key nutrients, including vitamins C and B-6, folate, thiamin, magnesium, and potassium, as well as better diet quality, and increased intake of total and whole fruit consumption in children
abbrgrp
abbr bid B1 1
B2 2
B3 3
B4 4
and adults
3
as compared to those that do not consume 100% FJ. There have been concerns about overweight/obesity in consumers of 100% FJ, especially children
B5 5
B6 6
B7 7
. Most studies have been conducted in children and have not shown a relationship between 100% FJ consumption and weight
B8 8
. Cross-sectional studies that have been conducted in adults have shown that consumption of 100% FJ has been inversely associated with body mass index (BMI)
B9 9
B10 10
and obesity
10
; however, the longitudinal Nurses’ Health Study II showed that 100% FJ consumption was positively associated with weight gain
B11 11
.
The relationship between consumption of 100% FJ and other markers of disease among adults is inconsistent. Pereira and Fulgoni
10
, using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 and Yoo et al.
B12 12
using data from the Bogalusa Heart Study, showed no association of risk of metabolic syndrome (MetS) among 100% FJ consumers; another study showed that, in middle aged and older adults, fasting glucose, but not fasting insulin
B13 13
was lower in 100% FJ consumers. In different studies, diabetes risk was shown to be associated with 100% FJ consumption
B14 14
or not
11
. Data from the CARDIA study have shown an association of a reduced risk of hypertension with 100% FJ consumption
B15 15
. Since data on the effects of consumption of 100% OJ on adult health are conflicting, further studies are needed.
Few studies have examined the effect of specific fruit juices on diet and health. Orange juice (OJ) is the most popular 100% FJ consumed in the US. In 2009, per capita availability of OJ was 14.84 liters
B16 16
. Orange juice is also one of the most nutrient dense 100% FJ, regardless of type of density measures used in the evaluation
B17 17
. Two hundred and thirty seven ml of 100% OJ provides 469 kilojoules (kJ) (112 kcal), 21 g total sugars, 124 mg vitamin C, 27 mg magnesium, 0.10 mg vitamin B-6, 74 μg Dietary Folate Equivalents, 496 mg potassium, and only 0.06 g saturated fatty acids (SFA) and 2.48 mg sodium
B18 18
. Some brands of commercially available 100% OJ are fortified with fiber, calcium, or vitamin D; these have been identified as nutrients of public health concern in the 2010 Dietary Guidelines for Americans
B19 19
.
In vitro
B20 20
and animal studies
B21 21
B22 22
have suggested that citrus juices or components of these juices, including the flavanones hesperidin and naringin (or their aglycone forms hesperetin and naringenin), may have beneficial effects on blood lipids. Clinical studies conducted in adults have shown that consumption of 100% OJ has been associated with health benefits including positive effects on blood lipids
B23 23
B24 24
B25 25
B26 26
—especially in hypercholesterolemic individuals, lower levels of several oxidative or inflammatory stress biomarkers
B27 27
B28 28
B29 29
, and lower blood pressure
B30 30
. Epidemiologic studies, using a nationally representative sample, looking at the association between consumption of 100% OJ and health markers are lacking. The objective of this study was to examine the association of 100% OJ usual intakes (UI) on select nutrients, food group equivalents, diet quality, weight parameters, and risk factors associated with cardiovascular disease and metabolic syndrome in adults.
Methods
Study population
Data from adults 19+ yrs (n = 8,861) participating in the NHANES 2003-2006 were combined for these analyses to increase the sample size. Females were excluded from the study if they were pregnant or lactating. Demographic information
B31 31
and physical activity levels
B32 32
were determined from the NHANES interview. NHANES has stringent consent protocols and procedures to ensure confidentiality and protection from identification
B33 33
. Since this was a secondary data analysis with a lack of personal identifiers, this study was exempted by the Louisiana State University Agricultural Center Institutional Review Board.
Determination of dietary intake data
Dietary data were collected using two 24-hour dietary recalls using an automated multiple-pass method
B34 34
B35 35
; the first recall was conducted in person by a trained interviewer and the second recall was conducted 3-10 days later via telephone. Only recall data judged to be complete and reliable by the National Center for Health Statistics staff were included in this study. Detailed descriptions of the dietary recalls and data collection are available in the NHANES Dietary Interviewer’s Training Manual
B36 36
.
In this study, 100% OJ was defined using the United States Food and Drug Administration definition
B37 37
for 100% FJ; that is the product contained 100% FJ—in this case, OJ. This includes 100% FJ made from concentrate and 100% FJ with added nutrients, such as calcium or vitamin D; but does not include juice drinks or other products that contain less than 100% fruit juice. Individual food codes in NHANES 2003-2004 and 2005-2006 were used to determine intake of 100% OJ. Consumers of 100% OJ were defined as those participants consuming any amount of 100% OJ on either day of the 24-hour recalls. To determine nutrient intake, the USDA Food and Nutrient Database for Dietary Studies, versions 2
B38 38
and 3
B39 39
were used for NHANES, 2003-2004 and 2005-2006, respectively. Nutrients examined included macronutrients, dietary fiber, and sodium and also those micronutrients likely to be provided by 100% OJ: vitamins A, C, and B6; folate; magnesium; and potassium. Intake from supplements was not considered.
Food group equivalent intakes and healthy eating index (HEI-2005)
Food group equivalent intakes (formerly called MyPyramid equivalents) were determined using MyPyramid Equivalents Database 2.0; when necessary, intakes for NHANES 2005-2006 were hand matched to similar foods. The HEI-2005 was used to determine diet quality
B40 40
. The SAS code used to calculate HEI-2005 scores was downloaded from the Center for Nutrition Policy and Promotion website
B41 41
.
Physiological measures
Height, weight, and waist circumference (WC) were obtained according to NHANES protocols
B42 42
. Body mass index was calculated as body weight (kilograms) divided by height (meters) squared
B43 43
. For the odds ratio (OR) assessments, overweight/obesity and high waist circumference were determined using the National Heart Lung and Blood Institute (NHLBI) Clinical Guidelines
43
. Systolic (SBP) and diastolic blood pressures (DBP) were determined using the standard NHANES protocol
B44 44
and the mean of all values measured was used. Total cholesterol and high density lipoprotein cholesterol (HDL-C) were determined on non-fasted individuals
B45 45
while low density lipoprotein cholesterol (LDL-C) (46), triacylglycerides
B46 46
, blood glucose
B47 47
, and insulin
47
were determined on only fasted subjects. Per these protocols, not all individuals may have values for all tests (see tables for sample numbers). Metabolic syndrome was defined using the NHLBI Adult Treatment Panel III criteria
B48 48
; that is having 3 or more of the following risk factors: abdominal obesity, WC >102 cm (males), >88 cm (females); hypertension, SBP ≥130 mmHg or DBP ≥85 mmHg or taking anti-hypertensive medications; HDL-C, <40 mg/dL (males), <50 mg/dL (females); high triacylglycerides, ≥150 mg/dL or taking anti-hyperlipidemic medications; high fasting glucose, ≥110 mg/dL or taking insulin or other hypoglycemic agents.
Statistical analyses
Sampling weights and the sampling units and strata information, as provided by NHANES, were included in all analyses using SUDAAN v10.0 (Research Triangle Institute; Raleigh, NC). Usual intakes were determined using SAS v 9.2 (SAS Institute, Cary, NC). Usual intake determinations represent long term average daily intakes and are determined by removing excessive intra-person variation in intakes; these are the best estimates to compare to dietary recommendations as suggested intakes are to be met over time, rather than measured on a single day. Usual intake of 100% OJ consumption and selected nutrients was calculated using the National Cancer Institute (NCI) method
B49 49
. For UI of 100% OJ, which is consumed episodically, the two part NCI model (probability and amount) was used; for nutrients which are consumed daily by most people, the one part model was used. The NCI SAS macros (Mixtran v1.1 and Distrib v1.1) were used to generate parameter effects after covariate adjustments and to estimate the distribution of usual intake via Monte Carlo simulation methods, respectively
49
. Covariates in this study were day of the week of the 24-hr recall [coded as weekend (Friday-Sunday) or weekday (Monday-Thursday)] and sequence of dietary recall (first or second). Software provided by NCI was used with the two days of intake using one-day sampling weights to obtain appropriate variance estimates. Balanced repeated replication (BRR) was performed to obtain standard errors (SE) and confidence intervals (CI) for the percentiles; BRR weights were constructed with Fay adjustment factor M = 0.3 (perturbation factor 0.7) and further adjusted to match the initial sample weight totals within specific age/gender/ethnicity groupings for the full dataset. The Dietary Reference Intake (DRI) age groups were used to present UI for each of the nutrients studied.
To assess the extent of inadequate intake of vitamins A and C, folate, and magnesium, the Estimated Average Requirements (EAR) cut-point method proposed by the Institute of Medicine
B50 50
was used. The EAR is the appropriate DRI to use when assessing the adequacy of group intakes
50
. The EAR cut-point method provides an estimate of the proportion of individuals in the group with inadequate intakes by age and gender. For nutrients without an EAR, i.e. sodium and potassium, the percent above the Adequate Intake (AI) was determined.
To determine if there were significant differences (p < 0.05) for the percentage of 100% OJ consumers vs non-consumers with intakes less than the EAR or above the AI a Z-statistic for differences in population proportions was used. Linear regression was used to determine differences in 100% OJ consumers and non-consumers for physiological measures. Logistic regression was used to determine if 100% OJ consumers had a lower OR of being overweight or obese or had other health risk factors. Covariates for linear and logistic regression included energy (kcals), age, gender, ethnicity, poverty index ratio, and physical activity for body weight and BMI; for other physiological measures BMI was also added as a covariate. Physical activity was determined from physical activity questionnaires and separated subjects into three categories: sedentary, moderate activity, and vigorous activity
B51 51
.
Results
Usual intake of orange juice
The sample consisted of adults 19 years of age and older (n = 8,861) of which 2,310 (23.8%) consumed 100% OJ. Per capita consumption was 50.3 ± 1.8 ml/day, whereas among consumers, consumption was 210.0 ± 3.8 ml/day. Per capita consumption and consumption among consumers was higher in males (p < 0.05) than in females. The 75sup th percentile among consumers was 259.3 ± 6.8 ml/day (Table
tblr tid T1 1).
table
Table 1
caption
b Usual intake of orange juice (ml/d) in the total population and consumers
tgroup align left cols 7
colspec colname c1 colnum 1 colwidth 1*
center c2 2
c3 3
c4 4
c5 5
c6 6
c7
thead valign top
row rowsep
entry morerows
nameend namest
Total population
Consumers only
Percentiles of intake among consumers
N = 8,861
n = 2,310
tfoot
Data source: Adults 19+ years of age participating in NHANES 2003-2006 with consumers defined as orange juice consumption on either of two days of intake assessment.
Means with different letters indicate a significant difference between genders p < 0.05.
1 ml = 0.0338 US fluid oz.
tbody
Gender
Mean ± SE
Pct.
Mean ± SE
25th ± SE
50th ± SE
75th ± SE
Combined
50.3 ± 1.8
23.8
210.0 ± 3.8
109.4 ± 3.0
468.6 ± 4.7
259.3 ± 6.8
 Male
59.2 ± 2.7a
24.5
235.6 ± 5.3a
118.3 ± 4.1
192.2 ± 2.0
286.9 ± 8.3
 Female
41.4 ± 2.1b
23.1
177.4 ± 5.0b
94.6 ± 3.8
147.9 ± 7.4
227.7 ± 7.7
Usual intake of macronutrients, and selected micronutrients
The UI of carbohydrates, total sugars, and dietary fiber was higher (p < 0.05) in consumers than in non-consumers (Table
T2 2). Table
T3 3 shows that in 100% OJ consumers, the UI of vitamins A, B6, and C; folate; and magnesium was higher (p < 0.05) than non-consumers, and consumers were less likely to be below the EAR than non consumers (p < 0.05) (Table
3). Those consuming 100% OJ had a usual mean intake of vitamin A of 660 ± 15 Retinol Activity Equivalents (RAE) μg/d compared with 580 ± 8 RAE μg/d; approximately 40% of those consuming 100% OJ were below the EAR for vitamin A, compared with 54% of non-consumers (both p < 0.05). Orange juice consumers had a usual mean intake of folate of 606 ± 10 Dietary Folate Equivalents (DFE) μg/d compared with 521 ± 6 DFE μg/d; approximately 6% of 100% OJ consumers were below the EAR, compared with 15% for non-consumers (both p < 0.05). Adults consuming 100% OJ had a mean usual intake of vitamin C of 146 ± 2.4 mg/d compared with approximately 67 ± 1.3 mg/d for non-consumers. On average, 100% OJ consumers were not below the EAR, compared with 59% of non-consumers (p < 0.05). Adults that consumed 100% OJ had higher usual mean intake of 313 ± 4 mg/d magnesium compared with 283 ± 3 mg/d for non-consumers. Approximately 64% of adults that consumed 100% OJ were below the EAR, compared with 52% for non-consumers (both p < 0.05). The usual mean intake of potassium of 100% OJ consumers was 3026 ± 36 mg/d, compared with 2623 ± 22 mg/d for non-consumers; approximately 4% of 100% OJ consumers were above the AI, compared with only 2% of non-consumers (p < 0.05).
Table 2
Energy and macronutrient usual intakes among consumers and non-consumers of orange juice
Usual intake
Percentile
Data source: Adults 19+ years of age participating in NHANES 2003-2006 with consumers defined as orange juice consumption on either of two days of intake assessment.
n: 2,310 OJ consumers and 6,551 non-consumers.
Means with different letters are significantly different, p < 0.05.
Group
Mean ± SE
10
25
50
75
90
Energy, Kcal/d
 Consumer
2248 ± 33
1400
1702
2126
2684
3569
 Non-Consumer
2185 ± 15
1339
1656
2087
2622
3170
Protein, g/d
 Consumer
84.9 ± 1.3
52.2
62.5
79.8
102.0
125.3
 Non-Consumer
83.4 ± 0.7
50.4
62.8
80.0
100.6
121.4
Carbohydrates, g/d
 Consumer
279 ± 4a
178
214
265
330
402
 Non-Consumer
260 ± 2b
155
194
248
314
384
Total sugars, g/d
 Consumer
133 ± 2.3a
77.4
96.9
124
160
201
 Non-Consumer
119 ± 1.3b
57.2
79.0
110
149
192
Dietary fiber, g/d
 Consumer
16.6 ± 0.3a
9.6
12.2
15.8
20.1
24.7
 Non-Consumer
15.3 ± 0.3b
8.6
11.1
14.5
18.5
22.9
Total fat, g/d
 Consumer
83.1 ± 1.4
47.7
60.8
78.7
101.2
124.6
 Non-Consumer
83.7 ± 0.7
47.6
61.3
79.9
102.1
125.1
Saturated fatty acids, g/d
 Consumer
27.4 ± 0.6
15.2
19.6
25.8
33.4
41.6
 Non-Consumer
27.8 ± 0.3
15.0
19.7
26.3
34.3
42.8
Table 3
Selected micronutrient usual intakes among consumers and non-consumers of orange juice and comparison to Estimated Average Requirements (EAR) or Adequate Intake (AI)
8
c8
Usual intake
Percentile
EAR
Group
Mean ± SE
10
25
50
75
90
% Below ± SE
Data source: Adults 19+ years of age participating in NHANES 2003-2006 with consumers defined as orange juice consumption on either of two days of intake assessment.
n: 2,310 OJ consumers and 6,551 non-consumers.
Means with different letters are significantly different, p < 0.05.
Vitamin A, RAE ug/d
 Consumer
660 ± 15a
364
471
618
802
1009
39.7 ± 2.5a
 Non-Consumer
580 ± 8b
265
373
529
730
960
54.0 ± 1.2b
Vitamin B-6, mg/d
 Consumer
2.1 ± 0.0a
1.3
1.6
2.0
2.6
3.2
9.5 ± 1.0a
 Non-Consumer
1.9 ± 0.0b
1.1
1.4
1.8
2.3
2.9
16.7 ± 1.4b
Folate, DFE ug/d
 Consumer
606 ± 10a
358
451
578
730
890
5.8 ± 0.7a
 Non-Consumer
521 ± 6b
288
371
487
634
796
15.1 ± 0.9b
Vitamin C, mg/d
 Consumer
146 ± 2.4a
110
125
148
167
178
0.0 ± 0.0a
 Non-Consumer
66.6 ± 1.3b
26.1
38.9
58.5
85.4
117.1
59.0 ± 1.4b
Magnesium, mg/d
 Consumer
313 ± 4a
193
238
296
372
449
51.6 ± 1.6a
 Non-Consumer
283 ± 3b
170
213
270
339
411
63.7 ± 1.2b
Usual Intake
Percentile
AI
Group
Mean ± SE
10
25
50
75
90
% Above ± SE
Sodium, mg/d
 Consumer
3483 ± 53
2066
2604
3338
4213
5107
98.4 ± 0.3
 Non-Consumer
3501 ± 29
2137
2654
3351
4194
5074
98.8 ± 0.2
Potassium, mg/d
 Consumer
3026 ± 36a
1978
2396
2939
3564
4195
4.1 ± 0.8a
 Non-Consumer
2623 ± 22b
1610
2009
2532
3140
3756
1.8 ± 0.2b
Diet quality and food group equivalents usual intake
Diet quality, as measured by HEI-2005, was significantly higher (p < 0.05) in consumers than in non-consumers (55.0 ± 0.4 vs 49.7 ± 0.3) (Table
T4 4). Total fruit (1.8 ± 0.05 vs 0.7 ± 0.02 cup equivalents/d), fruit from juice (1.1 ± 0.03 vs 0.2 ± 0.01 cup equivalents/d) and whole fruit (0.7 ± 0.03 vs 0.5 ± 0.02 cup equivalents/d) were all higher for consumers as compared to non-consumers. In addition, whole grain consumption was higher (p < 0.05) in consumers (0.8 ± 0.03 ounce equivalents) than in non-consumers (0.6 ± 0.02 ounce equivalents).
Table 4
Diet quality, as measured by healthy eating index and select usual intakes of MyPyramid food components among consumers and non-consumers of orange juice
Usual intake
Percentile
Group
Mean ± SE
10
25
50
75
90
Data source: Adults 19 + years of age participating in NHANES 2003-2006 with consumers defined as orange juice consumption on either of two days of intake assessment.
n: 2,310 OJ consumers and 6,551 non-consumers.
Means with different letters are significantly different, p < 0.05.
Healthy Eating Index, score
 Consumer
55.0 ± 0.4a
44.5
49.3
54.9
60.6
65.7
 Non-Consumer
49.7 ± 0.3b
38.4
43.5
49.4
55.6
61.4
Total dairy, cup equivalents
 Consumer
1.6 ± 0.05
0.6
0.9
1.4
2.1
2.9
 Non-Consumer
1.5 ± 0.002
0.5
0.8
1.3
2.0
2.8
Total fruit, cup equivalents
 Consumer
1.8 ± 0.05a
1.1
1.4
1.8
2.1
2.3
 Non-Consumer
0.7 ± 0.02b
0.2
0.3
0.6
0.9
1.4
Fruit juice, cup equivalents
 Consumer
1.1 ± 0.03a
0.8
0.9
1.1
1.3
1.4
 Non-Consumer
0.2 ± 0.01b
0.0
0.0
0.1
0.2 0.4
Whole fruit, cup equivalents
 Consumer
0.7 ± 0.03a
0.1
0.3
0.6
1.0
1.4
 Non-Consumer
0.5 ± 0.02b
0.1
0.2
0.4
0.7
1.1
Total grain, ounce equivalents
 Consumer
7.0 ± 0.1
4.2
5.3
6.7
8.4
10.0
 Non-Consumer
6.8 ± 0.1
3.8
4.9
6.4
8.3
10.3
Whole grain, ounce equivalents
 Consumer
0.8 ± 0.03a
0.2
0.4
0.7
1.0
1.5
 Non-Consumer
0.6 ± 0.02b
0.1
0.2
0.5
0.9
1.3
Total vegetables, cup equivalents
 Consumer
1.7 ± 0.03
0.9
1.2
1.6
2.0
2.5
 Non-Consumer
1.6 ± 0.03
0.9
1.2
1.5
2.0
2.5
Anthropometric and cardiovascular risk factors
Consumers of 100% OJ had a lower mean BMI than non-consumers (27.6 ± 0.18 vs 28.5 ± 0.11 kg/m2; p = 0.0001) (Table
T5 5). Adults that consumed 100% OJ also had lower total cholesterol (197.6 ± 1.2 mg/dL v 200.8 ± 0.75 mg/dL; p = 0.0220) and lower LDL-C (112.5 ± 1.4 mg/dL v 116.7 ± 0.93 mg/dL; p = 0.0110) levels than those that did not consume 100% OJ. Serum vitamin C (1.1 ± 0.01 vs 0.9 ± 0.01 mg/dL; p < 0.0001), red blood cell folate (309.3 ± 3.6 vs 285.3 ± 2 ng/ml RBC; p < 0.0001), and serum folate (14.8 ± 0.24 vs 13.7 ± 0.25 ng/ml; p = 0.0013) were higher in consumers of 100% OJ than in non-consumers (Table
5). There were no differences among consumers and non-consumers in waist circumference, SBP or DBP, C-reactive protein, HDL-cholesterol, triacyglycerides, blood glucose, insulin, or homocysteine levels.
Table 5
Physiological measures among consumers and non-consumers of orange juice
Consumers
Non-consumers
*Adjusted for energy (kcal), age, gender, ethnicity, poverty income ratio, and physical activity.
**Adjusted for energy (kcal), age, gender, ethnicity, poverty income ratio, BMI, and physical activity.
Abbreviations: LSM = least square mean; SE = standard error; BMI = body mass index; HDL-C = high density lipoprotein-cholesterol; LDL-C = low-density lipoprotein-cholesterol; RBC = red blood cell.
Variable
n
LSM ± SE
n
LSM ± SE
p-Value
Body Weight* (kg)
2130
81.3 ± 0.20
6150
81.4 ± 0.12
0.5072
BMI* (kg/m2)
2130
27.6 ± 0.18
6150
28.5 ± 0.11
<0.0001
Waist Circumference* (cm)
2069
97.1 ± 0.17
6005
97.3 ± 0.10
0.4381
Systolic Blood Pressure (mmHg)**
1801
124.0 ± 0.53
5296
123.8 ± 0.30
0.7604
Diastolic Blood Pressure (mmHg)**
1801
70.8 ± 0.42
5296
71.3 ± 0.23
0.2976
Serum Vitamin C (mg/dL)**
2022
1.1 ± 0.01
5813
0.91 ± 0.01
<0.0001
C-Reactive Protein** (mg/dL)
2041
0.43 ± 0.03
5874
0.41 ± 0.01
0.5922
Total Cholesterol** (mg/dL)
2034
197.6 ± 1.2
5857
200.8 ± 0.75
0.0220
HDL-Cholesterol** (mg/dL)
2033
53.7 ± 0.45
5857
53.8 ± 0.24
0.8230
Triglycerides** (mg/dL)
954
141.6 ± 3.6
2833
147.4 ± 3.3
0.2246
LDL-Cholesterol** (mg/dL)
939
112.5 ± 1.4
2746
116.7 ± 0.93
0.0110
Plasma Glucose** (mg/dL)
960
103.0 ± 1.4
2856
102.4 ± 0.62
0.6853
Insulin** (uU/mL)
951
11.6 ± 0.38
2823
11.3 ± 0.25
0.4441
RBC Folate** (ng/mL RBC)
2044
309.3 ± 3.6
5872
285.3 ± 2.0
<0.0001
Serum Folate** (ng/mL)
2037
14.8 ± 0.24
5849
13.7 ± 0.25
0.0013
Homocysteine** (umol/L)
1988
8.7 ± 0.08
5729
8.9 ± 0.06
0.0853
Risk of metabolic syndrome and risk factors for metabolic syndrome
Males that consumed 100% OJ showed a 36% reduced risk [OR: 0.62; 95th CI: 0.45-0.91] of MetS; no differences were observed in females (OR: 1.41 95th CI: 0.96-2.07) (Table
T6 6). Male consumers of 100% OJ also showed a 23% reduced risk (OR: 0.77 95th CI: 0.61-0.99) of low HDL-C levels. Overall there was a 21% reduced risk (OR: 0.79; 95th CI: 0.65-0.95) of obesity in adults that consumed 100% OJ compared with non-consumers.
Table 6
Risk of metabolic syndrome, increased risk of individual metabolic syndrome components and other health factors among adult (19+ yrs) consumers and non-consumers of orange juice
10
c9 9
c10
Risk
OR ± SE
LCL, UCL
p-Value
OR ± SE
LCL, UCL
p-Value
OR ± SE
LCL, UCL
p-Value
All
Female
Male
* Reference group: Non-consumers of orange juice with odds ratio set at 1.0.
All Metabolic Syndrome Components: Elevated Waist Circumference ≥102 cm in men or ≥88 cm in women; Elevated Triglycerides ≥150 mg/dL or taking medication for Elevated Triglycerides (Antihyperlipidemic Agents or Nicotinic Acid Derivatives); Reduced HDL-C <40 mg/dL in men or <50 mg/dL in women or taking medication for Reduced HDL-C (Antihyperlipidemic Agents or Nicotinic Acid Derivatives); Elevated BP ≥130 mmHg Systolic or ≥85 mmHg Diastolic or taking medication for Elevated BP (Antihypertensive Combinations); Elevated Fasting Glucose ≥100 mg/dL or taking medication for Elevated Glucose (Antidiabetic Agents); Metabolic Syndrome (≥3 risk factors above). Other risk factors: Elevated LDL-C ≥100 mg/dL; Overweight BMI ≥25 and <30; Obese BMI ≥30; Overweight or Obese BMI ≥25.
Abbreviations: OR = odds Ratio; LCL = lower confidence level; UCL = upper confidence level; SE = standard error; MetS = metabolic syndrome; BP = blood pressure; TG = triglycerides; WC = waist circumference; HDL-C = high density lipoprotein-cholesterol; LDL-C = low density lipoprotein-cholesterol.
MetS
0.93 ± 0.13
0.71, 1.22
0.5790
1.41 ± 0.28
0.96, 2.07
0.0795
0.64 ± 0.12
0.45,0.91
0.0119
Elevated BP
0.98 ± 0.07
0.85, 1.13
0.7586
0.98 ± 0.15
0.73, 1.31
0.8948
0.95 ± 0.12
0.75, 1.22
0.7078
High Glucose
0.96 ± 0.10
0.78, 1.18
0.6772
1.08 ± 0.17
0.79, 1.47
0.6180
0.82 ± 0.11
0.64, 1.06
0.1361
High TG
1.11 ± 0.13
0.89, 1.39
0.3575
1.41 ± 0.25
1.00, 1.99
0.0503
0.91 ± 0.11
0.72, 1.15
0.4474
Elevated WC
0.98 ± 0.15
0.73, 1.33
0.9067
1.09 ± 0.24
0.72, 1.66
0.6890
0.83 ± 0.15
0.59, 1.18
0.3052
Low HDL-C
0.92 ± 0.08
0.78, 1.09
0.3518
1.08 ± 0.11
0.89 1.31
0.4271
0.77 ± 0.10
0.61, 0.99
0.0406
Obese
0.79 ± 0.08
0.65, 0.95
0.0116
0.76 ± 0.10
0.59, 0.97
0.0289
0.79 ± 0.09
0.64, 0.97
0.0276
Overweight
1.13 ± 0.07
0.99, 1.28
0.0699
1.18 ± 0.10
0.99, 1.39
0.0581
1.07 ± 0.09
0.91, 1.26
0.3976
Overweight or Obese
0.89 ± 0.07
0.76, 1.04
0.1437
0.88 ± 0.09
0.73, 1.08
0.2216
0.85 ± 0.09
0.69, 1.06
0.1461
High LDL-C
0.82 ± 0.10
0.66, 1.03
0.0908
0.76 ± 0.12
0.57, 1.03
0.0783
0.85 ± 0.14
0.63, 1.16
0.3163
Discussion
Approximately 24% of the population consumed 100% OJ on either of the days when a 24 hour recall was taken. Males consumed more 100% OJ, both as a percentage of consumers and in amount. The percent of consumers was similar to that of children
B52 52
. Per capita UI consumption was 50.3 ml/d; however the UI for consumers was 210.0 ml/d. Unlike children, where there is a specific recommendation for consumption of 100% FJ
B53 53
, there is no recommendation for consumption of 100% FJ by adults, other than “the majority of the fruit recommended should come from whole fruits, including fresh, canned, frozen, and dried forms, rather than from juice”
19
.
The rationale for limiting 100% FJ intake is that it lacks fiber and can contribute to excess energy consumption when consumed in excess
19
. A modeling study, commissioned by the 2005 Dietary Guidelines Advisory Committee
B54 54
suggested that dietary fiber was lower when whole fruit was removed from the diet, which led to the recommendation that intake of no more than one-third of fruit servings should come from 100% FJ and two-thirds should come from whole fruit. However, this study and others
1
2
3
4
52
have shown that either consumers of 100% FJ had higher intakes of dietary fiber than non-consumers or there was no difference in fiber consumption between the groups. Since 100% FJ is low in dietary fiber, it suggests that other higher fiber foods, including whole fruit, are consumed by consumers of 100% FJ; this was shown not only in this study of 100% OJ consumers, but has been shown in other studies as well
1
2
52
.
As expected, 100% OJ consumers had increased intake of nutrients typically found in 100% OJ (i.e. vitamin C, folate, and potassium). Consumers were also less likely to have intakes below the EAR for vitamins A, B-6, and C; folate; and magnesium than non-consumers. The reduction in the percentage of the population with inadequate intakes of these nutrients associated with 100% OJ consumption indicates the value of consuming a nutrient dense beverage
17
. Mean potassium UI was also higher in consumers than non-consumers and the percentage of the population above the AI was higher. This is an important finding since potassium was identified as a nutrient of public health concern
19
. To our knowledge this is the first report studying the association between the consumption of 100% OJ and nutrient adequacy in adults using the recommended UI procedures.
Diet quality, as measured by HEI-2005, was approximately 10% higher in 100% OJ consumers. While the increase was due in part to the increase in whole fruit and FJ consumption, consumers also had a higher UI of whole grains. Although intake of total fruit, whole fruit, and FJ was higher in 100% OJ consumers, overall intake from the fruit food groups was low. Despite extensive, coordinated public health campaigns by government, industry, and others
B55 55
, fruit consumption in adults remains low
B56 56
. Since a 236.6 ml serving of 100% OJ counts as part of the recommendation for the fruit group, moderate consumption of 100% OJ can help individuals meet fruit intake recommendations.
The potential association of consumption of 100% FJ and weight in children has been debated in the literature for more than a decade
1
2
5
6
7
8
B57 57
B58 58
B59 59
B60 60
B61 61
B62 62
; however, less is known about this relationship in adults. Participants in the Nurses’ Health Study II with a higher consumption of 100% FJ had a larger weight gain than those with lower fruit 100% FJ consumption, although the amounts and types of 100% FJ consumed, and specific covariates used in the analyses, were not clear
11
. Another study
9
showed that self reported BMI was lower in consumers of 100% FJ. Ours was the first study that used a nationally representative adult population that showed consumers of 100% OJ had a lower BMI than non-consumers. These findings are important since 100% OJ has the highest per capita consumption
16
among the juices and therefore has the potential to be an important component of the diet. Clinical studies that incorporated high levels of 100% OJ (750 ml
24
or 500 ml
30
) as an intervention have reported no increases in weight or other anthropometric measures over the course of the study.
Total cholesterol levels and LDL-C levels were both significantly lower in consumers of 100% OJ than non-consumers. Compounds found in 100% OJ, including hesperidin, naringin, or limonoids or their circulating aglycone forms, have been shown to lower total or LDL-C in animal models
B63 63
B64 64
. It was hypothesized that these compounds may have inhibited 3-Hydroxy-3-methyl-glutaryl coenzyme A reductase and increased the expression of LDL-C receptors in the liver, a mechanism similar to statins. These compounds have also been shown to reduce the net secretion of apolipoprotein B, which in turn may help inhibit cholesterol ester synthesis
20
B65 65
.
Orange juice, at higher intake amounts (750 ml) has also been shown to lower LDL-C and raise HDL-C in a randomized clinical trial of hypercholesterolemia individuals
24
. Although the present study did not look separately at individuals with hypercholesterolemia, it did show that a more realistic consumption of 100% OJ was associated with reduced total cholesterol and LDL-C levels. It is not clear why there was no difference shown between HDL-C levels between 100% OJ consumers and non-consumers, as may have been suggested by clinical trials; the response may be dose-dependent or dependent on continual consumption. There was a 23% lower risk of low HDL-C levels in males only.
Consumption of 100% OJ was associated with a 21% lower risk of obesity in men and women. This was similar to the findings of Pereira and Fulgoni
10
that looked at the risk of obesity and consumption of 100% FJ in participants of NHANES 1999-2004. They also showed a significantly lower risk of metabolic syndrome, whereas this study showed a lower risk in males only. That study showed a much higher intake of 100% FJ, compared with the intake of 100% OJ only; but there were also other differences in the population, since they showed, for example that consumers were more likely to be female. Our study showed that 100% OJ consumers were more likely to be males. Consumption differences of 100% FJ in adults need to be studied further.
Strengths of this study include that it encompassed a large nationally representative sample achieved through combining several sets of NHANES data releases. The study also uses the NCI method to assess UI and the percentage of the population below recommended levels in 100% OJ consumers and non-consumers, as well as adjustment for numerous covariates including physical activity.
Twenty-four hour dietary recalls have several inherent limitations. Participants relied on memory to self-report dietary intakes; therefore, data were subject to non-sampling errors, including underreporting of energy and examiner effects. Respondents may not have differentiated between 100% OJ or a fruit drink/ade. Confusion over these beverages has been reflected in several studies that assessed a combined 100% FJ and juice drink or sweetened FJ category
B66 66
B67 67
B68 68
B69 69
. The use of AI cannot be used to determine the prevalence of inadequate intake in a group. Rather, if the mean intake of a group is at or above the AI, and the variance of intake in the group of interest is similar to the variance of intake used in the population originally used to set the AI, the prevalence of inadequate nutrient intakes is likely to be low
50
. Finally, since causal inferences cannot be drawn from NHANES analyses, and due to multi-collinearity of diet, foods other than 100% OJ may have contributed to differences in nutrient intake of the participants.
Conclusions
Consumption of 100% OJ was associated with better diet quality and an increased prevalence of meeting the EAR for key nutrients and other biomarkers of positive health outcomes, including lower total cholesterol and LDL levels. Consumers of 100% OJ had lower mean BMI and a decreased risk of obesity. In addition, males had a decreased risk of metabolic syndrome. These results suggested that 100% OJ consumption should be encouraged as a component of a healthy diet to help individuals meet nutrient and fruit intake recommendations.
Abbreviations
AI: Adequate intake; BMI: Body mass index; BRR: Balanced repeated replication; CI: Confidence interval; DBP: Diastolic blood pressure; DFE: Dietary folate equivalents; DRI: Dietary reference intake; EAR: Estimated average requirements; FJ: 100% Fruit juice; HDL-C: High density lipoprotein-cholesterol; HEI-2005: Healthy eating index-2005; LDL-C: Low density lipoprotein-cholesterol; MetS: Metabolic syndrome; NHANES: National health and Nutrition examination survey; NHLBI: National heart, lung, and blood institute; OJ: 100% Orange juice; OR: Odds ratio; RAE: Retinol activity equivalents; SBP: Systolic blood pressure; SFA: Saturated fatty acids; UI: Usual intake; WC: Waist circumference.
Competing interests
Gail Rampersaud’s position at the University of Florida is co-funded by the Florida Department of Citrus. None of the other authors declare a competing interest.
Authors’ contributions
All authors contributed equally to this work. All authors read and approved the final manuscript.
bm
ack
Acknowledgements
This work is a publication of the United States Department of Agriculture (USDA/ARS) Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the U.S. government. This research project was supported by the Florida Department of Citrus, and USDA – Agricultural Research Service through specific cooperative agreement 58-6250-6-003. Partial support was received from the USDA Hatch Project LAB 93951.
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Abstract
Background
Consumption of 100% orange juice (OJ) has been positively associated with nutrient adequacy and diet quality, with no increased risk of overweight/obesity in children; however, no one has examined these factors in adults. The purpose of this study was to examine the association of 100% OJ consumption with nutrient adequacy, diet quality, and risk factors for metabolic syndrome (MetS) in a nationally representative sample of adults.
Methods
Data from adults 19+ years of age (n = 8,861) participating in the National Health and Nutrition Examination Survey 2003-2006 were used. The National Cancer Institute method was used to estimate the usual intake (UI) of 100% OJ consumption, selected nutrients, and food groups. Percentages of the population below the Estimated Average Requirement (EAR) or above the Adequate Intake (AI) were determined. Diet quality was measured by the Healthy Eating Index-2005 (HEI-2005). Covariate adjusted logistic regression was used to determine if consumers had a lower odds ratio of being overweight or obese or having risk factors of MetS or MetS.
Results
Usual per capita intake of 100% OJ was 50.3 ml/d. Among consumers (n = 2,310; 23.8%), UI was 210.0 ml/d. Compared to non-consumers, consumers had a higher (p < 0.05) percentage (% ± SE) of the population meeting the EAR for vitamin A (39.7 ± 2.5 vs 54.0 ± 1.2), vitamin C (0.0 ± 0.0 vs 59.0 ± 1.4), folate (5.8 ± 0.7 vs 15.1 ± 0.9), and magnesium (51.6 ± 1.6 vs 63.7 ± 1.2). Consumers were also more likely to be above the AI for potassium (4.1 ± 0.8 vs 1.8 ± 0.2). HEI-2005 was significantly (p < 0.05) higher in consumers (55.0 ± 0.4 vs 49.7 ± 0.3). Consumers also had higher intakes of total fruit, fruit juice, whole fruit, and whole grain. Consumers had a lower (p < 0.05) mean body mass index (27.6 ± 0.2 vs 28.5 ± 0.1), total cholesterol levels (197.6 ± 1.2 vs 200.8 ± 0.75 mg/dL), and low density lipoprotein-cholesterol levels (112.5 ± 1.4 vs 116.7 ± 0.93 mg/dL). Finally, compared to non-consumers of 100% OJ, consumers were 21% less likely to be obese and male consumers were 36% less likely to have MetS.
Conclusion
The results suggest that moderate consumption of 100% OJ should be encouraged to help individuals meet the USDA daily recommendation for fruit intake and as a component of a healthy diet.
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Nutrition Journal. 2012 Dec 12;11(1):107
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