Fluid intake of Latin American children and adolescents: results of four 2016 LIQ.IN 7 National Cross-Sectional Surveys

Fluid intake of Latin American children and adolescents: results of four 2016 LIQ.IN 7 National... Purpose The primary aim of this survey was to report total fluid intake (TFI) and different fluid types for children (4–9 years) and adolescents (10–17 years) in Mexico, Brazil, Argentina and Uruguay. The second aim was to compare TFI with the adequate intake (AI) of water from fluids as recommended by the USA Institute of Medicine. Methods Data were collected using a validated liquid intake 7-day record (Liq.In ). Participants’ characteristics, including age, sex and anthropometric measurements were recorded. Results A total of 733 children and 933 adolescents were recruited. Over 75% of children in Uruguay met the IOM’s recom- mended intake. Fewer children in Argentina (64–72%) and Brazil (41–50%) obtained AI and the lowest values were recorded in Mexico (33–44%), where 16% of boys and 14% girls drank 50% or less of the AI. More adolescents in Argentina (42%) met the AIs than other countries; the lowest was in Mexico (28%). Children and adolescents in Mexico and Argentina drank more sugar sweetened beverages than water. Conclusions Large numbers of children and adolescents did not meet AI recommendations for TFI, raising concerns about their hydration status and potential effects on mental and physical well-being. Given the negative effects on children’s health, the levels of SSB consumption are worrying. Keywords Beverages · Fluid intake · Water · Hydration · Liq.in  · Children · Adolescents · Mexico · Brazil · Uruguay · Argentina Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s0039 4-018-1728-8) contains supplementary material, which is available to authorized users. * J. Gandy CIBERobn (Centro de Investigación Biomédica en Red joan.gandy@btinternet.com Fisiopatología de la Obesidad y Nutrición), Institute of Health Carlos III, Madrid, Spain British Dietetic Association, Birmingham, UK Hydration Science Lab, University of Arkansas, Fayetteville, School of Life and Medical Services, University AR, USA of Hertfordshire, Hatfield AL10 9AB, UK Division of Endocrinology, University of Arkansas Hospital Infantil de México Federico Gómez, Mexico City, for Medical Sciences, Little Rock, AR, USA Mexico Human Nutrition Unit, Hospital Universitari de Sant Center of Studies on Infant Nutrition, Buenos Aires, Joan de Reus, Faculty of Medicine and Health Sciences, Argentina Institut d’Investigació Sanitària Pere Virgili, Biochemistry and Biotechnology Department, Universitat Rovira i Virgili, Unidad de Apoyo a la Investigación Clínica, Instituto C/Sant Llorenç, 21, 43201 Reus, Spain Nacional de Pediatría, Mexico City, Mexico GENUD (Growth, Exercise, NUtrition and Development) Research Group, Faculty of Health Sciences, Universidad de Zaragoza, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain Vol.:(0123456789) 1 3 S54 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 will influence the findings and conclusions. The study of Introduction Piernas et al. [4] used the recommendations for the USA IOM for total water. The Liq.In [6] was an interconti- Inadequate hydration in children and adolescents has been nental study; therefore, the EFSA recommendations [14] shown to affect both physical [1] and cognitive perfor- were used as they are more conservative than those of the mance [2, 3]. However, few studies have looked at children IOM [5] and less likely to overestimate non-adherence. or adolescents’ fluid intake in terms of total volume and There is no agreed methodology for the development of adequacy in Latin America. Piernas et al. [4] reported total recommendations on the adequate intake of water and water intakes (TWI) (sum of food moisture and fluid intake) different approaches to establishing such recommenda- in children and adolescents in the 2012 Mexican National tions have been taken [15]. For example, the IOM rec- Health and Nutrition survey. Alarmingly a high proportion ommendations are based on median intakes from national of the subjects, 71% of 4–6-year-old, 81–83% of 9–13-year- surveys while the EFSA recommendations are based on old and 83–87% of 14–18-year-old did not meet the USA population studies and other factors including desirable Institute of Medicine (IOM) recommendations [5] for the osmolarity values of urine and desirable water volumes adequate intake (AI) of total water. Information was not per unit energy consumed. Specific recommendations are collected on hydration status but given the high number of not available for Latin American countries; therefore, the participants not meeting the recommendations it is likely choice of recommendations for comparison is subjective. that some, if not most, were at risk of the effects of hypohy - The present study resurveyed samples of the child and dration. This was emphasized by data collected from a fluid adolescent populations from Argentina, Brazil, Mexico intake survey (Liq.In ) in Mexico that reported 54–65% of and Uruguay. Unlike the former survey [6], it was focused 4–9-year-old and 55 to greater than 70% of 10–17-year-old entirely on Latin American countries; therefore, the IOM as having fluid intakes less than the recommended adequate recommendations were used to assess adherence to AI of intakes [6]. While these levels are lower than the Piernas fluids in these populations in line with other studies as et al. study [4], they reinforce concerns about the potential discussed above. risk of the effects of low fluid intake on the health and well- Therefore, the primary objective of the present study was being of this population. This Liq.In study also reported to report total fluid intake (TFI) and intake of different fluid the percentages of children (4–9  years) and adolescents types of children (4–9 years) and adolescents (10–17 years) (10–17 years) in Brazil, Uruguay and Argentina not reaching in Mexico, Brazil, Argentina and Uruguay. The secondary the recommended intakes of fluids as 32, < 20 and < 37%, aim was to compare TFI with the AI recommendations set respectively, for children and 35–50, 15–23 and 45–70% for by the USA IOM [5]. adolescents, respectively. While these levels are lower than those observed in Mexico, there is still potential cause for concern especially in Argentina. Methods Several other studies have been conducted in Latin America assessing fluid intake of children and adoles- Design and study population cents. For example, total fluid intake and fluid types have been reported in Mexico [7], and Brazil [8]; however, the The present analysis reports cross-sectional surveys of emphasis has been on the energy content of fluids rather children aged 4–9 years (6–9 years old in Uruguay) and than adequate intakes. Other studies have only reported adolescents (10–17  years) in Argentina, Brazil, Mexico energy-containing fluids and have not included non-caloric and Uruguay. The age ranges were chosen as it was felt, fluids including water [9 ]. This emphasis on energy from after consultation with pediatricians, that children less than fluids is the result of concerns about the increasing levels 10 years of age could be considered prepubescent. One par- of overweight and obesity in this region [10–12] and the ent, or care giver, recorded data for children < 12 years old, need to develop effective interventions. A recent review while older adolescents self-reported the amount and types highlighted this and other negative effects of some bever - of beverage consumed. These surveys are part of a multi- ages on children [13]. Surveys of fluid intake, in terms of national project called Liq.In The primary objective of the both volume and type of fluid consumed, are a vital part Liq.In surveys is to assess the sources of fluid consumption, of the process of developing public health policies and including drinking water and different types of beverages. To interventions aimed at improving the health of these vul- ensure harmony across the surveys standard operating proce- nerable populations. This is particularly important in Latin dures related to the method of recruitment, the instruments America where there is a paucity of such data. for data collection and data treatment were developed by the It is important to recognize that the choice of recom- coauthors and a central research private organization, and mendations used for comparisons between survey results then distributed to local investigators of this private research 1 3 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S55 organization. The data collection was performed in 2016 accompanied by a booklet with pictures of standard fluid between March and May in different regions of Argentina, containers to assist the estimation of the amount of fluid Mexico, and Uruguay; and for operational reasons between consumed. November and December in Brazil. Before the survey began, the researcher explained use of Participants were recruited via a systematic door-to-door the record in an initial face-to-face interview in the partici- recruitment until suitable quotas for age, sex, region and pant’s home. After a period of 7 days, the record was col- socioeconomic characteristics, in relation to the total coun- lected by the researcher and checked for completion with the try population, were met. Only one individual per house- participant and/or parent/caregiver. Participants who did not hold was eligible to participate. If several individuals of complete the full 7 days of the fluid record, who reported a one household were eligible, the investigator selected the mean total daily fluid intake below 0.4 L/day or higher than individual based on whether or not the quotas had already 6 L/day for children aged 14–17 years and higher than 4 L/ been achieved. Inclusion criteria were apparently healthy day for children under the age of 14 years, were excluded individuals. Participants who had a parent or caregiver who from the analysis. was illiterate, or those working in any capacity in a com- pany in anyway associated with the manufacture, distribu- Classification and analysis of the fluid types tion and/or sale of water and any other kind of beverage were excluded from participation. Pregnancy and lactation were Fluids recorded were classified as water (tap and bottled not exclusion criteria. After receiving a detailed description water), milk and milk derivatives, hot beverages (coffee, tea of the study and its objectives, following the principles of and other), 100% fruit juices, sugar sweetened beverages informed consent, participants’ parent or guardian gave oral (SSB) (carbonated soft drinks (CSDs), juice-based drinks, approval of their willingness to be included. No monetary functional beverages such as energy and sports drinks, ready incentive was offered for taking part in the study. All data to drink tea and coffee and flavored water), artificial/non- were recorded anonymously. nutritive sweeteners beverages (A/NSB) (diet/zero/light soft drinks), alcoholic drinks and other beverages. The water and Ethical approval milk content of hot beverages, including “mate”, were not disaggregated. More details of the fluid categories can be The survey protocol was reviewed and approved by the Uni- found in supplementary Table S2. TFI was defined as the versity of Arkansas Review Board (ref. 14-12-376). sum of all these categories. In Uruguay and Argentina only, a specific code for the fluid type “mate” was included as Anthropometry previous surveys had indicated a significant daily intake of this traditional drink and this was considered of interest by Height (m) and weight (kg) were self-reported by partici- local collaborators. A participant was defined as a consumer pants or care givers depending on the participant’s age. The of a certain fluid type if this fluid type was consumed at least body mass index (BMI) z score was calculated (kg/m ). once during the 7-day period. Individual’s estimated daily TFI was compared with Assessment of total fluid intake and the different the AI for water from fluids (beverages including drinking fluid types water) set by the USA IOM [5]. To allow comparison with previously published data, the comparison between observed Participants aged 12–17 years of age or the parent or car- intakes and the recommendations set by  EFSA [14] is pro- egiver of children aged 4–11 years completed the Liq.In vided in the supplementary materials (Figure S1). The num- record in the official language of the country. The Liq.In bers of individuals drinking ≤ 1 serving (being 250 mL) of record is a 7-day fluid-specific record validated for accuracy SSB per week, 2–6 servings of SSB per week and ≥ 1 serv- and reliability [16]. The Liq.In record consists of a grid ing/day intake of SSB was recorded. These cut-offs were structured according to different times of the day from wak - obtained from meta-analyses associating such levels of ing, meal times (breakfast, lunch and dinner) and periods intake with potential risks for the development of obesity, between meals (morning, before lunch/aperitif, afternoon, type 2 diabetes and metabolic syndrome [17–19]. tea break, before dinner/aperitif, evening, just before going to bed) to during the night. The participants were instructed Statistical analysis to record on this grid all drinking events at any moment of the day with the following details; the fluid type, the vol- The demographic and anthropometric characteristics of the ume consumed, the size of the container from which it was study population are presented either as means and standard drunk, where it was drunk and whether food was also con- deviations (SD) for continuous variables, or numbers and sumed. Food consumption was not reported. The record was percentages for dichotomous variables. TFI are presented as 1 3 S56 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 median (25th–75th percentiles) and mean [standard error of and Argentinian girls the highest for girls (1594 mL/day). mean (SEM)]. Due to the skew in intakes (supplementary Overall Mexican children and adolescents had the lowest figure S2), the different fluid types are presented as median median TFI 1061 (751–1490) compared with the other coun- (50th percentile), 25th–75th percentiles and proportion tries. Uruguayan children and Argentinian adolescents had of consumers. The presented contribution (%) to TFI was the highest total fluid intakes. calculated from the mean intake of each fluid types. The median (25th–75th percentiles) and mean (SEM) of the Comparison with IOM recommendations different fluid types by sex and age group can be found as supplementary table S2 and S3, respectively. Between sex Figure 1 shows a comparison of TFI with the AI of water comparisons were made with a Wilcoxon rank test for con- from fluids set by the IOM [5 ]. Over 75% of 4–9-year-old tinuous variables. All statistical tests were two-tailed and in Uruguay and 64–72% in Argentina met the IOM’s rec- the significance level was set at P < 0.05. All analyses were ommended intake. This decreased to 41–50% in Brazil and performed using the SPSS software version 22.0 (SPSS Inc, 33–44% in Mexico. Less than 2% of Uruguayan children Chicago, IL) and were verified by a statistician. drank less than 50% of the AI; this rose to < 7% in Argen- tina. In Mexico, 16% of boys and 14% girls drank 50% or less of the AI. In the adolescent age group, there was an Results increase in the number of both males and females who were not drinking 50% of the recommended TFI. Fewer adoles- Participant characteristics cents, than children, in all countries met the AIs for water from fluids. Argentinian females and males, 48 and 38%, The characteristics of the populations surveyed are shown respectively, had the highest rates of participants meeting or in Table 1. A total of 733 children (4–9 years) and 933 ado- exceeding the AI. Mexicans again had the lowest rates; 37% lescents (10–17 years) were recruited. The sexes were rep- for females and 22% for males. resented evenly overall although there were some disparities within the countries and age groups. Type of fluid consumed Total fluid intake The type of fluid consumed by the younger children is shown in Table 3. It is interesting to note that in Brazil all The estimated total daily fluid (TFI) intakes per age cat- the children drank water, while only 84% of Argentinian egory, sex and country are shown in Table  2. There was children consumed water. In terms of volume of water con- no significant sex difference in any of the age groups or sumed, Uruguayan and Brazilian children consumed more countries apart from the Mexican children where boys water than all the other countries; 500 (250–768) and 369 had a significantly (P < 0.039) higher median (25–75th) (238–609) mL/day, respectively. In Mexico and Uruguay, intake 1155 (809–1540) mL/day compared with girls 994 the majority of the water consumed was bottled, whereas in (719–1452) mL/day. Mexican boys and girls had the lowest Argentina and Brazil it was tap water. The median intakes of median intakes, 994 and 1155 mL/day, respectively; Uru- tap water were 0 mL/day for Mexican and Uruguayan chil- guayan boys had the highest median TFI (1686 mL/day) dren and 266 and 138 mL/day for Brazilian and Argentinian Table 1 Demographic and anthropometric characteristics of the study population, by country and age group 4–9 years 6–9 years 10–17 years Mexico Brazil Argentina Uruguay Mexico Brazil Argentina Uruguay Sample size 293 146 173 121 376 194 219 144  Male 140 (48) 68 (47) 114 (66) 57 (47) 212 (56) 62 (32) 130 (59) 74 (51)  Female 153 (52) 78 (53) 59 (34) 64 (53) 164 (44) 132 (68) 89 (41) 70 (49) Age (years) 6.5 ± 1.7 6.6 ± 1.8 6.4 ± 1.7 7.7 ± 0.9 13.5 ± 2.4 13.6 ± 2.3 13.5 ± 2.2 12.3 ± 2.3 Weight (kg) 31.5 ± 13.3 27.4 ± 8.5 28.1 ± 10.6 35.0 ± 10.1 51.8 ± 13.2 53.3 ± 16.4 52.9 ± 13.6 46.7 ± 15.2 Height (m) 1.2 ± 0.2 1.2 ± 0.1 1.2 ± 0.2 1.4 ± 0.1 1.5 ± 0.2 1.6 ± 0.1 1.6 ± 0.1 1.5 ± 0.1 BMI z score 2.6 ± 3.2 1.2 ± 1.8 1.4 ± 2.1 1.1 ± 1.8 0.9 ± 1.3 0.5 ± 1.4 0.6 ± 1.2 0.5 ± 1.3 BMI body mass index Data presented as numbers (percentage) for dichotomous variables Data presented as mean ± standard deviation for continuous variables 1 3 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S57 Table 2 Daily total fluid Percentiles intake (mL/day) for children (4–9 years) and adolescents Country Sex N (%) Mean ± SEM 5 10 25 50 75 90 95 (10–17 years), by country and 4–9 years Mexico M 140 (48) 1301 ± 59 506 581 809 1155 1540 2178 2831 sex F 153 (52) 1169 ± 52 441 529 719 994 1452 2092 2493 Brazil M 68 (47) 1393 ± 88 495 622 860 1229 1633 2483 3124 F 78 (53) 1432 ± 72 615 766 1034 1314 1629 2359 2717 Argentina M 114 (66) 1843 ± 74 668 903 1203 1665 2414 3006 3401 F 59 (34) 1737 ± 108 492 875 1098 1594 2228 2872 3481 6–9 years Uruguay M 57 (47) 1804 ± 87 931 1106 1316 1686 2014 2885 3345 F 64 (53) 1594 ± 58 898 1011 1283 1519 1865 2191 2346 Mexico M 212 (56) 1687 ± 61 644 758 1052 1469 2121 2923 3521 F 164 (44) 1669 ± 75 628 737 934 1456 2166 3026 3376 Brazil M 62 (32) 1788 ± 142 494 659 1023 1407 2374 3757 4571 F 132 (68) 1678 ± 76 493 676 1027 1533 2223 2889 3346 Argentina M 130 (59) 1932 ± 66 797 966 1383 1876 2442 3020 3194 F 89 (41) 1845 ± 81 789 971 1335 1710 2291 2626 3323 Uruguay M 74 (51) 1745 ± 109 573 865 1170 1587 2176 2793 3668 F 70 (49) 1587 ± 80 637 770 984 1520 2043 2457 2819 4–9 years Mexico 293 1232 ± 39 488 562 751 1061 1490 2126 2622 Brazil 146 1414 ± 56 555 700 957 1297 1632 2359 2678 Argentina 173 1807 ± 61 632 886 1185 1633 2344 2930 3404 6–9 years Uruguay 121 1693 ± 52 905 1049 1311 1639 1904 2364 2978 10–17 years Mexico 376 1679 ± 47 641 747 1011 1462 2121 2988 3393 Brazil 194 1713 ± 69 497 673 1030 1491 2231 2971 3792 Argentina 219 1897 ± 51 864 967 1362 1780 2400 2850 3198 Uruguay 144 1668 ± 68 596 802 1088 1544 2115 2582 3114 SEM Standard error of the mean, M Males, F females Wilcoxon test was used for sex comparisons P < 0.039 children, respectively. Over three quarters of these children water daily in Argentina, Brazil and Mexico, which was consumed milk, or its derivatives, on a daily basis. The high- most marked in Brazil and Mexico where the median vol- est daily volume consumed was in Uruguay 429 mL/day; ume was > 130 mL/day. Brazilian adolescents (10–17 years) Mexico had the lowest milk consumption at 265 mL/day. had the highest water consumption 505 (278–778) mL/day With the exception of Brazil, where 70% of children con- of any country. As with the younger children, Mexicans and sumed 100% fruit juice, this drink was not a popular choice Uruguayans drank mainly bottled water while Argentinian within this age group. Uruguayan children consumed fewer and Brazilian adolescents drank mainly tap water. Uruguay hot beverages than children in the other countries. Only 1% had the lowest consumption of SSB with a median intake of of children in Uruguay drank hot beverages with a median 390 mL/day; CSDs were the major contributor to this vol- value of 0 mL/day due to the skewed nature of the data. ume. The largest consumers of SSB were Argentinian ado- Nearly all children (93–98%) in all four countries consumed lescents who had a daily intake of 686 mL/day with a 75th SSB; more SSB was consumed than milk and its deriva- percentile > 1 L; most of this being CSD and juice-based tives. A daily median of more than 500 mL was consumed drinks. As might be expected there was a lower intake of in Argentina (545 mL) and Uruguay (570 mL). In both these milk and its derivatives amongst these older children com- countries, the 75th percentile was greater than 1 L/day. In pared with the younger age groups and a subsequent increase Mexico and Brazil, the median intake was < 400 mL/day in the intake of hot beverages. As was observed in the chil- with 75th percentiles of approximately 600 mL/day. In all dren, Brazilian adolescents had the highest median intake of countries, the major contributor to SSB intake was carbon- 100% fruit juice (42 mL/day) with 60% consuming it daily. ated soft drinks (CSD), followed by juice-based drinks, The contribution of each type of fluid to TFI (%) is shown which were particularly popular in Brazil. in Fig. 2, and the same data by sex are shown in supplemen- Types of beverage consumed by the 10–17-year-old are tary figure S3. In all four countries, milk and its derivatives shown in Table 4. Adolescents drank a higher volume of represented about a quarter of TFI in the youngest age group. 1 3 S58 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 Total 15% 28% 19% 38% 14% 21% 21% 44% F 16% 35% 16% 33% Total 7% 18% 28% 47% M 7% 25% 26% 41% F 6% 13% 29% 51% Total 6% 7% 18% 69% M 5% 5% 18% 72% F 7% 10% 19% 64% Total 7% 16% 77% 11% 12% 77% ≤50% AI 3% 19% 77% Total 23% 25% 23% 28% 50-75% AI M 26% 28% 24% 22% 75-100% AI F 19% 21% 23% 37% ≥100% AI Total 18% 28% 17% 38% M 21% 39% 10% 31% F 16% 23% 20% 41% Total 11% 21% 26% 42% M 13% 25% 24% 38% 7% 17% 28% 48% Total 16% 23% 24% 37% M 18% 30% 19% 34% F 14% 16% 30% 40% 0% 10%20% 30%40% 50%60% 70%80% 90% 100% Distribution of participants (%) Fig. 1 Total fluid intake of children (4–9  years) and adolescents (10–17  years) expressed as a percentage (%) of the adequate intake of water from fluids set by the Institute of Medicine [7] based on 7-day mean of each participant by sex Children in Mexico and Brazil drank approximately a third and adolescents in Argentina, Brazil and Uruguay. It also of TFI as water and another third as SSB. In Argentina and presents more recent data for these age groups in Mexico. Uruguay, the largest contributor to TFI was SSB. Amongst In the present study, Mexican children had a lower median adolescents, milk and its derivatives contributed to 12–19% TFI than children in the other countries (1061 mL/day); of TFI. The contribution of CSD and water to TFI differed Uruguayan children had the highest daily intake of fluid at in the adolescents compared with the children. In Argentina 1639 mL/day. Amongst adolescents, Mexico, Uruguay and SSB contributed 43% to TFI compared with 24% for water. Brazil had similar TFIs (1462–1544 mL/day); Argentinian In the other three countries, the contribution of SSB and adolescents had the highest TFI (1780 mL/day). It is dic ffi ult water was similar, namely, 38 vs 40% in Mexico, 37 vs 35% to compare the results of the present survey with most of the in Brazil and 34 vs 31% in Uruguay. previous studies due to different age categories and meth- Over 75% of children and adolescents in Mexico, Brazil odological differences. The present study generally reported and Argentina drank at least one serving (250 mL/day) of fluid intakes higher than from the latest data reported from SSB per day (Fig. 3). In Mexico, Brazil and Argentina, the Mexico in 2012 [4] but lower than those from Brazil [8] number of children drinking ≥ 1 serving per day was slightly from 2008/9. No data are available for children and adoles- lower than for the corresponding adolescents. However, Uru- cents from Argentina or Uruguay apart from the in Liq.In guay had the most children and the lowest number of ado- surveys of 2012 [6]. Comparisons with the previous Liq.In lescents drinking ≥ 1 serving per day. study [6] are more appropriate as the same validated 7-day record and age categories were used. Intake by Mexican and Brazilian children and Brazilian adolescents in the present Discussion survey were similar to the earlier study; Argentinian chil- dren and Mexican and Argentinian adolescents increased The present study reports recent data for children (aged their TFI by approximately 260 mL/day. However, the TFIs 4–9 years) and adolescents (aged 10–17 years) on estimated for Uruguayan children and adolescents decreased mark- total fluid intake and types of fluid consumed in four Latin edly by approximately 300 and 500 mL/day, respectively. American countries. For the first time, comparisons with The reasons for the TFI differences between the two surveys the IOM recommendations [5] on adequate intake (AI) of are unclear although it may be due to sampling differences, water from fluids (20% of TWI) are reported for children despite the populations being selected according to the same 1 3 10-17 years 6-9 years 4-9 years Argentin Argentin Uruguay a Brazil Mexico Uruguay a Brazil Mexico (n=144) (n=219) (n=194) (n=376) (n=121) (n=173) (n=146) (n=293) European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S59 Table 3 Median (P25–P75) daily intake (mL/day) of different fluid types and the percentage of consumers among children (4–9 years), by coun- try 4–9 years 6–9 years Mexico (n = 293) Brazil (n = 146) Argentina (n = 173) Uruguay (n = 121) P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers Water 252 (90–505) 90 369 (238–609) 100 271 (79–607) 84 500 (250–768) 91  Bottled water 241 (61–468) 87 0 (0–170) 48 0 (0–64) 30 434 (0–706) 73  Tap water 0 (0–0) 16 266 (82–438) 83 138 (0–461) 68 0 (0–50) 26 Milk and 265 (111–451) 91 302 (152–468) 95 343 (154–517) 87 429 (232–500) 90 derivatives Hot beverages 0 (0–28) 33 0 (0–63) 47 54 (0–211) 59 0 (0–0) 1  Coffee 0 (0–0) 23 0 (0–34) 36 0 (0–0) 6 0 (0–0) 0  Tea 0 (0–0) 14 0 (0–0) 17 0 (0–35) 29 0 (0–0) 0  Maté ND ND ND ND 0 (0–139) 40 0 (0–0) 1  Other hot ND ND ND ND ND ND 0 (0–0) 0 beverages SSB 391 (185–607) 95 396 (197–603) 98 545 (254– 93 570 (275– 98 1062) 1026)  CSD 48 (0–200) 61 150 (47–267) 88 191 (39–378) 79 217 (200–484) 92  Juice-based 68 (0–216) 67 171 (71–297) 92 161 (0–514) 72 109 (0–595) 55 drinks  Functional 0 (0–0) 12 0 (0–0) 13 0 (0–0) 6 0 (0–0) 0 beverages  RTD tea and 0 (0–0) 13 0 (0–0) 14 0 (0–0) 3 0 (0–0) 0 coffee  Flavored 57 (0–191) 67 0 (0–0) 14 0 (0–54) 31 0 (0–0) 7 water 100% fruit 0 (0–0) 22 55 (0–158) 70 0 (0–0) 16 0 (0–0) 1 juices A/NSB 0 (0–0) 11 0 (0–0) 10 0 (0–156) 43 0 (0–0) 5 Alcoholic 0 (0–0) 0 0 (0–0) 0 0 (0–0) 1 0 (0–0) 0 beverages Other bever- 0 (0–0) 9 0 (0–0) 19 0 (0–0) 4 0 (0–0) 17 ages SSB Sugar sweetened beverages, CSD carbonated sweetened drinks, RTD ready to drink, A/NSB Artificial/non-nutritive sweeteners beverages, ND no data quota method. In particular, the sample size for Uruguay American countries appear to have adequate intakes, there doubled for children and increased by nearly 50% for the is still concern about the health and well-being of those chil- adolescents. dren who report intakes below the recommendation. While Over two-thirds of children in Argentina and Uruguay without biomarkers it is not possible to draw conclusions met the AIs [5], although in Mexico and Brazil fewer than about their hydration status, if their water intake is actually half of children met them. These rates are broadly compa- suboptimal it is possible that their cognitive and physical rable to the previous Liq.In study [6] for Mexico, Uruguay performances may be affected [1 , 3]. and Argentina; however, the percentage of Brazilian children An important issue that has emerged from the present not meeting the recommendations increased from 32% to study is that while these children and adolescents are more over 50% when either the IOM [5] or the EFSA [14] recom- likely to meet the recommendations on water intake from mendations were used. It has previously been shown that fluids, a significant proportion of the fluid was sweetened children and adolescents frequently do not meet to recom- beverages, especially CSD. This was consistent for all coun- mendations on adequate water intake of TFI [20–22] with tries but most marked in Uruguay. In a period of 4 years, up to 90% drinking less than the recommendations in some Uruguayan children increased their proportion of TFI from countries. While it is reassuring to note that a reasonable SSB from 25% in the earlier Liq.In study [23] to 41% in the proportion of children and adolescents in these four Latin present study. Both Uruguayan and Argentinian adolescents 1 3 S60 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 Table 4 Median (P25–P75) daily intake (mL/day) of different fluid types and the percentage of consumers among adolescents (10–17 years), by country Mexico (n = 376) Brazil (n = 194) Argentina (n = 219) Uruguay (n = 144) P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers Water 391 (180–963) 90 505 (278–778) 99 346 (93–675) 84 434 (155–798) 89  Bottled water 336 (111–721) 85 17 (0–179) 54 0 (0–100) 38 340 (0–684) 74  Tap water 0 (0–0) 23 314 (114–643) 88 146 (0–497) 68 0 (0–39) 29 Milk and 154 (9–320) 76 156 (36–265) 83 144 (0–361) 71 240 (63–498) 80 derivatives Hot beverages 0 (0–131) 49 31 (0–149) 61 179 (0–357) 75 0 (0–87) 29  Coffee 0 (0–107) 43 16 (0–98) 55 0 (0–73) 35 0 (0–0) 19  Tea 0 (0–0) 17 0 (0–0) 24 0 (0–71) 36 0 (0–0) 8  Maté ND ND ND ND 0 (0–179) 40 0 (0–0) 13  Other hot ND ND ND ND ND ND 0 (0–0) 1 beverages SSB 524 (258–908) 94 499 (262–811) 98 686 (388– 92 390 (194–749) 92 1147)  CSD 137 (0–393) 72 235 (107–459) 93 247 (86–599) 83 200 (64–411) 78  Juice-based 47 (0–200) 58 174 (54–344) 89 150 (0–463) 68 0 (0–215) 42 drinks  Functional 0 (0–0) 11 0 (0–0) 15 0 (0–0) 10 0 (0–0) 5 beverages  RTD tea and 0 (0–0) 19 0 (0–0) 16 0 (0–0) 1 0 (0–0) 0 coffee  Flavored 115 (0–292) 68 0 (0–0) 17 0 (0–71) 32 0 (0–0) 19 water 100% fruit 0 (0–0) 20 42 (0–157) 60 0 (0–0) 15 0 (0–0) 6 juices A/NSB 0 (0–0) 12 0 (0–36) 33 0 (0–100) 38 0 (0–0) 18 Alcoholic 0 (0–0) 3 0 (0–0) 7 0 (0–0) 6 0 (0–0) 2 beverages Other bever- 0 (0–0) 10 0 (0–0) 8 0 (0–0) 2% 0 (0–0) 19 ages SSB Sugar sweetened beverages, CSD carbonated sweetened drinks, RTD ready to drink, A/NSB Artificial/non-nutritive sweeteners beverages, ND no data Fig. 2 Contribution of the dif- Mexico 31% 26% 3% 37% ferent fluid types (%) to total fluid intake among children (4–9 years) and adolescents Brazil 32% 24% 3% 31% 8% (10–17 years), by country. SSB Water Sugar sweetened beverage, A/ Argentina 24% 20% 8% 39% 7% Milk & derivatives NSB Artificial/non-nutritive Hot beverages sweeteners, TFI Total fluid Uruguay 32% 25% 41% intake   SSB 100% fruit juices Mexico 38% 13% 6% 40% A/NSB Alcoholic beverages Brazil 37% 12% 6% 35% 7% Other beverages Argentina 24% 12% 13% 43% 7% Uruguay 34% 19% 10% 31% 3% 0% 20%40% 60%80% 100% Contribution of each fluid types to TFI (%) 1 3 6-9 10-17 years years 4-9 years European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S61 ≤ 1 serving per week 2-6 serving per day ≥ 1 serving per day Mexico 5% 26% 69% (n=293) Brazil 1% 19% 80% (n=146) Argentina 77% 5% 18% (n=173) Uruguay 1% 17% 82% (n=121) Mexico 6% 16% 78% (n=376) Brazil 2% 16% 82% (n=194) Argentina 8% 9% 84% (n=219) Uruguay 8% 28% 63% (n=144) 0% 10%20% 30%40% 50%60% 70%80% 90%100% Percentage of participants (%) Fig. 3 Percentage of children and adolescents drinking SSB on daily or less frequency, according to country also appear to have increased the proportion of fluid from in this region, is also experiencing the double burden of dis- SSB during this period. This comparison, however, should ease with undernutrition occurring alongside obesity [30], be made with caution due to differing classifications of which will further stretch limited public health resources. fruit juice between the studies. There is a tendency to snack One strategy that is increasingly being used to reduce in Latin American countries [24] with SSB being a snack SBB consumption in children is to increase plain water con- component amongst younger adults and children [25]. It is sumption [31]. Studies have shown that higher consump- interesting to note that the methodology used in this study, tion of plain water is associated with lower consumption and the previous Liq.In studies [6, 23] is more likely to of SSB [32–34]. In the present study, the median intake of have captured all drinking events including snacks [26] and, water ranged from 252 to 500 mL/day, with the Uruguayan therefore, may better reflect TFI and SSB intake. children drinking more than the other groups of children; These levels of SSB consumption raise concerns given Mexican children drank the lowest volume of water. As a the increasing body of evidence on the negative effects of proportion of TFI in children, water accounted for 24% in some drinks on children’s health [13]. The apparent increase Argentina and 31–32% in the other three countries. The in SSB consumption between the previous and present Liq. adolescents had a similar pattern when proportion of TFI In studies was most marked in Uruguayan children and ado- was considered. These results are broadly similar to the lescents, and Argentinian adolescents. Latin American has previous Liq.In surveys for Mexico, Argentina and Brazil. seen a rapid rise in obesity and overweight especially in chil- Although Uruguayan children and adolescents had markedly dren and adolescents [12, 27] and more public health poli- lower water intakes in this study than in the previous survey cies are urgently needed to halt, and hopefully, reverse this [6], this was accompanied by an increase in SSB consump- trend. In Mexico, several policies have been implemented tion, as discussed above. This finding suggests that action including a tax on SSB since 2014 [28] and the development is needed to reverse this trend in Uruguay. Plain water is of a healthy beverage guide [29]. While beyond the remit the drink of choice and healthy hydration strategies should of this analysis, comparison between countries, stratified be incorporated into public health policies and food-based for BMI status and socioeconomic status may yield further dietary guidelines [35]. An example of this is the Mexico insights into drinking behavior amongst children and adoles- healthy beverage guide, which includes a pictorial represen- cents in Latin America. Data from the present study are vital tation of a jug that represents daily fluid intake and shows in highlighting high consumption levels of different fluid the proportion of each fluid type that should be consumed types and for the development of health policies. This is par- [29]. ticularly important in a country such as Uruguay where fluid The strengths of this study include the use of a meth- consumption data are lacking. Uruguay, like other countries odology validated, albeit in adults, to assess fluid intake, 1 3 10-17 years 6-9 years 4-9 years S62 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 Acknowledgements Participant recruitment and data collection in all namely, the Liq.In dairy [16]. This methodology was previ- countries was performed by IPSOS. ously used by Iglesia [6] in the same Latin American coun- tries, so facilitating valid temporal comparisons. The large Compliance with ethical standards sample size also contributed to a fuller understanding of fluid intake in these countries. Nonetheless, there are limi- Ethical statement All the participants gave their consent prior the tations to this study including those inherent in any cross- inclusion in the study. All data were recorded anonymously. The pro- sectional study, such as how representative were the samples tocol of the surveys was reviewed and approved by the Institutional Review Board, Office of Research Compliance of the University of of the general populations in these age categories. In this Arkansas (IRB Protocol #14-12-376). study, a quota sampling system was used in terms of age, sex and SES. Data from Brazilian children and adolescents Conflict of interest CM and IG are full-time employee of Danone Re- were collected from only one city, while it is the largest city search. SAK was a scientific consultant for Quest Diagnostics. JS-S, and municipality in Brazil, it may not be representative of LAM, SAK, JG, HM are members of advisory board on fluid intake other areas of Brazil. Moreover, data collection in Brazil of Danone Research, and have received consultancies from Danone Research. SAK has received research grants from Danone Research. was performed during another a different period of the year J.S.-S, EC, and LAM has received consultancies from Danone S.A. for operational reasons. As all data collection was performed JLA and CP Report No. conflicts of interest. outside summer or winter, periods with larger temperature variations, the seasonal effect on fluid intake behavior was Open Access This article is distributed under the terms of the Crea- considered to be moderate. Recording dietary intake in tive Commons Attribution 4.0 International License (http://creat iveco mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- children requires a degree of parental assistance according tion, and reproduction in any medium, provided you give appropriate to age [36] and for all children under 12 years a parent or credit to the original author(s) and the source, provide a link to the care giver  completed the 7-day record. The validity of data Creative Commons license, and indicate if changes were made. of this age group, and adolescents, remains to be assessed. 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Fluid intake of Latin American children and adolescents: results of four 2016 LIQ.IN 7 National Cross-Sectional Surveys

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Chemistry; Nutrition
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Abstract

Purpose The primary aim of this survey was to report total fluid intake (TFI) and different fluid types for children (4–9 years) and adolescents (10–17 years) in Mexico, Brazil, Argentina and Uruguay. The second aim was to compare TFI with the adequate intake (AI) of water from fluids as recommended by the USA Institute of Medicine. Methods Data were collected using a validated liquid intake 7-day record (Liq.In ). Participants’ characteristics, including age, sex and anthropometric measurements were recorded. Results A total of 733 children and 933 adolescents were recruited. Over 75% of children in Uruguay met the IOM’s recom- mended intake. Fewer children in Argentina (64–72%) and Brazil (41–50%) obtained AI and the lowest values were recorded in Mexico (33–44%), where 16% of boys and 14% girls drank 50% or less of the AI. More adolescents in Argentina (42%) met the AIs than other countries; the lowest was in Mexico (28%). Children and adolescents in Mexico and Argentina drank more sugar sweetened beverages than water. Conclusions Large numbers of children and adolescents did not meet AI recommendations for TFI, raising concerns about their hydration status and potential effects on mental and physical well-being. Given the negative effects on children’s health, the levels of SSB consumption are worrying. Keywords Beverages · Fluid intake · Water · Hydration · Liq.in  · Children · Adolescents · Mexico · Brazil · Uruguay · Argentina Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s0039 4-018-1728-8) contains supplementary material, which is available to authorized users. * J. Gandy CIBERobn (Centro de Investigación Biomédica en Red joan.gandy@btinternet.com Fisiopatología de la Obesidad y Nutrición), Institute of Health Carlos III, Madrid, Spain British Dietetic Association, Birmingham, UK Hydration Science Lab, University of Arkansas, Fayetteville, School of Life and Medical Services, University AR, USA of Hertfordshire, Hatfield AL10 9AB, UK Division of Endocrinology, University of Arkansas Hospital Infantil de México Federico Gómez, Mexico City, for Medical Sciences, Little Rock, AR, USA Mexico Human Nutrition Unit, Hospital Universitari de Sant Center of Studies on Infant Nutrition, Buenos Aires, Joan de Reus, Faculty of Medicine and Health Sciences, Argentina Institut d’Investigació Sanitària Pere Virgili, Biochemistry and Biotechnology Department, Universitat Rovira i Virgili, Unidad de Apoyo a la Investigación Clínica, Instituto C/Sant Llorenç, 21, 43201 Reus, Spain Nacional de Pediatría, Mexico City, Mexico GENUD (Growth, Exercise, NUtrition and Development) Research Group, Faculty of Health Sciences, Universidad de Zaragoza, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain Vol.:(0123456789) 1 3 S54 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 will influence the findings and conclusions. The study of Introduction Piernas et al. [4] used the recommendations for the USA IOM for total water. The Liq.In [6] was an interconti- Inadequate hydration in children and adolescents has been nental study; therefore, the EFSA recommendations [14] shown to affect both physical [1] and cognitive perfor- were used as they are more conservative than those of the mance [2, 3]. However, few studies have looked at children IOM [5] and less likely to overestimate non-adherence. or adolescents’ fluid intake in terms of total volume and There is no agreed methodology for the development of adequacy in Latin America. Piernas et al. [4] reported total recommendations on the adequate intake of water and water intakes (TWI) (sum of food moisture and fluid intake) different approaches to establishing such recommenda- in children and adolescents in the 2012 Mexican National tions have been taken [15]. For example, the IOM rec- Health and Nutrition survey. Alarmingly a high proportion ommendations are based on median intakes from national of the subjects, 71% of 4–6-year-old, 81–83% of 9–13-year- surveys while the EFSA recommendations are based on old and 83–87% of 14–18-year-old did not meet the USA population studies and other factors including desirable Institute of Medicine (IOM) recommendations [5] for the osmolarity values of urine and desirable water volumes adequate intake (AI) of total water. Information was not per unit energy consumed. Specific recommendations are collected on hydration status but given the high number of not available for Latin American countries; therefore, the participants not meeting the recommendations it is likely choice of recommendations for comparison is subjective. that some, if not most, were at risk of the effects of hypohy - The present study resurveyed samples of the child and dration. This was emphasized by data collected from a fluid adolescent populations from Argentina, Brazil, Mexico intake survey (Liq.In ) in Mexico that reported 54–65% of and Uruguay. Unlike the former survey [6], it was focused 4–9-year-old and 55 to greater than 70% of 10–17-year-old entirely on Latin American countries; therefore, the IOM as having fluid intakes less than the recommended adequate recommendations were used to assess adherence to AI of intakes [6]. While these levels are lower than the Piernas fluids in these populations in line with other studies as et al. study [4], they reinforce concerns about the potential discussed above. risk of the effects of low fluid intake on the health and well- Therefore, the primary objective of the present study was being of this population. This Liq.In study also reported to report total fluid intake (TFI) and intake of different fluid the percentages of children (4–9  years) and adolescents types of children (4–9 years) and adolescents (10–17 years) (10–17 years) in Brazil, Uruguay and Argentina not reaching in Mexico, Brazil, Argentina and Uruguay. The secondary the recommended intakes of fluids as 32, < 20 and < 37%, aim was to compare TFI with the AI recommendations set respectively, for children and 35–50, 15–23 and 45–70% for by the USA IOM [5]. adolescents, respectively. While these levels are lower than those observed in Mexico, there is still potential cause for concern especially in Argentina. Methods Several other studies have been conducted in Latin America assessing fluid intake of children and adoles- Design and study population cents. For example, total fluid intake and fluid types have been reported in Mexico [7], and Brazil [8]; however, the The present analysis reports cross-sectional surveys of emphasis has been on the energy content of fluids rather children aged 4–9 years (6–9 years old in Uruguay) and than adequate intakes. Other studies have only reported adolescents (10–17  years) in Argentina, Brazil, Mexico energy-containing fluids and have not included non-caloric and Uruguay. The age ranges were chosen as it was felt, fluids including water [9 ]. This emphasis on energy from after consultation with pediatricians, that children less than fluids is the result of concerns about the increasing levels 10 years of age could be considered prepubescent. One par- of overweight and obesity in this region [10–12] and the ent, or care giver, recorded data for children < 12 years old, need to develop effective interventions. A recent review while older adolescents self-reported the amount and types highlighted this and other negative effects of some bever - of beverage consumed. These surveys are part of a multi- ages on children [13]. Surveys of fluid intake, in terms of national project called Liq.In The primary objective of the both volume and type of fluid consumed, are a vital part Liq.In surveys is to assess the sources of fluid consumption, of the process of developing public health policies and including drinking water and different types of beverages. To interventions aimed at improving the health of these vul- ensure harmony across the surveys standard operating proce- nerable populations. This is particularly important in Latin dures related to the method of recruitment, the instruments America where there is a paucity of such data. for data collection and data treatment were developed by the It is important to recognize that the choice of recom- coauthors and a central research private organization, and mendations used for comparisons between survey results then distributed to local investigators of this private research 1 3 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S55 organization. The data collection was performed in 2016 accompanied by a booklet with pictures of standard fluid between March and May in different regions of Argentina, containers to assist the estimation of the amount of fluid Mexico, and Uruguay; and for operational reasons between consumed. November and December in Brazil. Before the survey began, the researcher explained use of Participants were recruited via a systematic door-to-door the record in an initial face-to-face interview in the partici- recruitment until suitable quotas for age, sex, region and pant’s home. After a period of 7 days, the record was col- socioeconomic characteristics, in relation to the total coun- lected by the researcher and checked for completion with the try population, were met. Only one individual per house- participant and/or parent/caregiver. Participants who did not hold was eligible to participate. If several individuals of complete the full 7 days of the fluid record, who reported a one household were eligible, the investigator selected the mean total daily fluid intake below 0.4 L/day or higher than individual based on whether or not the quotas had already 6 L/day for children aged 14–17 years and higher than 4 L/ been achieved. Inclusion criteria were apparently healthy day for children under the age of 14 years, were excluded individuals. Participants who had a parent or caregiver who from the analysis. was illiterate, or those working in any capacity in a com- pany in anyway associated with the manufacture, distribu- Classification and analysis of the fluid types tion and/or sale of water and any other kind of beverage were excluded from participation. Pregnancy and lactation were Fluids recorded were classified as water (tap and bottled not exclusion criteria. After receiving a detailed description water), milk and milk derivatives, hot beverages (coffee, tea of the study and its objectives, following the principles of and other), 100% fruit juices, sugar sweetened beverages informed consent, participants’ parent or guardian gave oral (SSB) (carbonated soft drinks (CSDs), juice-based drinks, approval of their willingness to be included. No monetary functional beverages such as energy and sports drinks, ready incentive was offered for taking part in the study. All data to drink tea and coffee and flavored water), artificial/non- were recorded anonymously. nutritive sweeteners beverages (A/NSB) (diet/zero/light soft drinks), alcoholic drinks and other beverages. The water and Ethical approval milk content of hot beverages, including “mate”, were not disaggregated. More details of the fluid categories can be The survey protocol was reviewed and approved by the Uni- found in supplementary Table S2. TFI was defined as the versity of Arkansas Review Board (ref. 14-12-376). sum of all these categories. In Uruguay and Argentina only, a specific code for the fluid type “mate” was included as Anthropometry previous surveys had indicated a significant daily intake of this traditional drink and this was considered of interest by Height (m) and weight (kg) were self-reported by partici- local collaborators. A participant was defined as a consumer pants or care givers depending on the participant’s age. The of a certain fluid type if this fluid type was consumed at least body mass index (BMI) z score was calculated (kg/m ). once during the 7-day period. Individual’s estimated daily TFI was compared with Assessment of total fluid intake and the different the AI for water from fluids (beverages including drinking fluid types water) set by the USA IOM [5]. To allow comparison with previously published data, the comparison between observed Participants aged 12–17 years of age or the parent or car- intakes and the recommendations set by  EFSA [14] is pro- egiver of children aged 4–11 years completed the Liq.In vided in the supplementary materials (Figure S1). The num- record in the official language of the country. The Liq.In bers of individuals drinking ≤ 1 serving (being 250 mL) of record is a 7-day fluid-specific record validated for accuracy SSB per week, 2–6 servings of SSB per week and ≥ 1 serv- and reliability [16]. The Liq.In record consists of a grid ing/day intake of SSB was recorded. These cut-offs were structured according to different times of the day from wak - obtained from meta-analyses associating such levels of ing, meal times (breakfast, lunch and dinner) and periods intake with potential risks for the development of obesity, between meals (morning, before lunch/aperitif, afternoon, type 2 diabetes and metabolic syndrome [17–19]. tea break, before dinner/aperitif, evening, just before going to bed) to during the night. The participants were instructed Statistical analysis to record on this grid all drinking events at any moment of the day with the following details; the fluid type, the vol- The demographic and anthropometric characteristics of the ume consumed, the size of the container from which it was study population are presented either as means and standard drunk, where it was drunk and whether food was also con- deviations (SD) for continuous variables, or numbers and sumed. Food consumption was not reported. The record was percentages for dichotomous variables. TFI are presented as 1 3 S56 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 median (25th–75th percentiles) and mean [standard error of and Argentinian girls the highest for girls (1594 mL/day). mean (SEM)]. Due to the skew in intakes (supplementary Overall Mexican children and adolescents had the lowest figure S2), the different fluid types are presented as median median TFI 1061 (751–1490) compared with the other coun- (50th percentile), 25th–75th percentiles and proportion tries. Uruguayan children and Argentinian adolescents had of consumers. The presented contribution (%) to TFI was the highest total fluid intakes. calculated from the mean intake of each fluid types. The median (25th–75th percentiles) and mean (SEM) of the Comparison with IOM recommendations different fluid types by sex and age group can be found as supplementary table S2 and S3, respectively. Between sex Figure 1 shows a comparison of TFI with the AI of water comparisons were made with a Wilcoxon rank test for con- from fluids set by the IOM [5 ]. Over 75% of 4–9-year-old tinuous variables. All statistical tests were two-tailed and in Uruguay and 64–72% in Argentina met the IOM’s rec- the significance level was set at P < 0.05. All analyses were ommended intake. This decreased to 41–50% in Brazil and performed using the SPSS software version 22.0 (SPSS Inc, 33–44% in Mexico. Less than 2% of Uruguayan children Chicago, IL) and were verified by a statistician. drank less than 50% of the AI; this rose to < 7% in Argen- tina. In Mexico, 16% of boys and 14% girls drank 50% or less of the AI. In the adolescent age group, there was an Results increase in the number of both males and females who were not drinking 50% of the recommended TFI. Fewer adoles- Participant characteristics cents, than children, in all countries met the AIs for water from fluids. Argentinian females and males, 48 and 38%, The characteristics of the populations surveyed are shown respectively, had the highest rates of participants meeting or in Table 1. A total of 733 children (4–9 years) and 933 ado- exceeding the AI. Mexicans again had the lowest rates; 37% lescents (10–17 years) were recruited. The sexes were rep- for females and 22% for males. resented evenly overall although there were some disparities within the countries and age groups. Type of fluid consumed Total fluid intake The type of fluid consumed by the younger children is shown in Table 3. It is interesting to note that in Brazil all The estimated total daily fluid (TFI) intakes per age cat- the children drank water, while only 84% of Argentinian egory, sex and country are shown in Table  2. There was children consumed water. In terms of volume of water con- no significant sex difference in any of the age groups or sumed, Uruguayan and Brazilian children consumed more countries apart from the Mexican children where boys water than all the other countries; 500 (250–768) and 369 had a significantly (P < 0.039) higher median (25–75th) (238–609) mL/day, respectively. In Mexico and Uruguay, intake 1155 (809–1540) mL/day compared with girls 994 the majority of the water consumed was bottled, whereas in (719–1452) mL/day. Mexican boys and girls had the lowest Argentina and Brazil it was tap water. The median intakes of median intakes, 994 and 1155 mL/day, respectively; Uru- tap water were 0 mL/day for Mexican and Uruguayan chil- guayan boys had the highest median TFI (1686 mL/day) dren and 266 and 138 mL/day for Brazilian and Argentinian Table 1 Demographic and anthropometric characteristics of the study population, by country and age group 4–9 years 6–9 years 10–17 years Mexico Brazil Argentina Uruguay Mexico Brazil Argentina Uruguay Sample size 293 146 173 121 376 194 219 144  Male 140 (48) 68 (47) 114 (66) 57 (47) 212 (56) 62 (32) 130 (59) 74 (51)  Female 153 (52) 78 (53) 59 (34) 64 (53) 164 (44) 132 (68) 89 (41) 70 (49) Age (years) 6.5 ± 1.7 6.6 ± 1.8 6.4 ± 1.7 7.7 ± 0.9 13.5 ± 2.4 13.6 ± 2.3 13.5 ± 2.2 12.3 ± 2.3 Weight (kg) 31.5 ± 13.3 27.4 ± 8.5 28.1 ± 10.6 35.0 ± 10.1 51.8 ± 13.2 53.3 ± 16.4 52.9 ± 13.6 46.7 ± 15.2 Height (m) 1.2 ± 0.2 1.2 ± 0.1 1.2 ± 0.2 1.4 ± 0.1 1.5 ± 0.2 1.6 ± 0.1 1.6 ± 0.1 1.5 ± 0.1 BMI z score 2.6 ± 3.2 1.2 ± 1.8 1.4 ± 2.1 1.1 ± 1.8 0.9 ± 1.3 0.5 ± 1.4 0.6 ± 1.2 0.5 ± 1.3 BMI body mass index Data presented as numbers (percentage) for dichotomous variables Data presented as mean ± standard deviation for continuous variables 1 3 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S57 Table 2 Daily total fluid Percentiles intake (mL/day) for children (4–9 years) and adolescents Country Sex N (%) Mean ± SEM 5 10 25 50 75 90 95 (10–17 years), by country and 4–9 years Mexico M 140 (48) 1301 ± 59 506 581 809 1155 1540 2178 2831 sex F 153 (52) 1169 ± 52 441 529 719 994 1452 2092 2493 Brazil M 68 (47) 1393 ± 88 495 622 860 1229 1633 2483 3124 F 78 (53) 1432 ± 72 615 766 1034 1314 1629 2359 2717 Argentina M 114 (66) 1843 ± 74 668 903 1203 1665 2414 3006 3401 F 59 (34) 1737 ± 108 492 875 1098 1594 2228 2872 3481 6–9 years Uruguay M 57 (47) 1804 ± 87 931 1106 1316 1686 2014 2885 3345 F 64 (53) 1594 ± 58 898 1011 1283 1519 1865 2191 2346 Mexico M 212 (56) 1687 ± 61 644 758 1052 1469 2121 2923 3521 F 164 (44) 1669 ± 75 628 737 934 1456 2166 3026 3376 Brazil M 62 (32) 1788 ± 142 494 659 1023 1407 2374 3757 4571 F 132 (68) 1678 ± 76 493 676 1027 1533 2223 2889 3346 Argentina M 130 (59) 1932 ± 66 797 966 1383 1876 2442 3020 3194 F 89 (41) 1845 ± 81 789 971 1335 1710 2291 2626 3323 Uruguay M 74 (51) 1745 ± 109 573 865 1170 1587 2176 2793 3668 F 70 (49) 1587 ± 80 637 770 984 1520 2043 2457 2819 4–9 years Mexico 293 1232 ± 39 488 562 751 1061 1490 2126 2622 Brazil 146 1414 ± 56 555 700 957 1297 1632 2359 2678 Argentina 173 1807 ± 61 632 886 1185 1633 2344 2930 3404 6–9 years Uruguay 121 1693 ± 52 905 1049 1311 1639 1904 2364 2978 10–17 years Mexico 376 1679 ± 47 641 747 1011 1462 2121 2988 3393 Brazil 194 1713 ± 69 497 673 1030 1491 2231 2971 3792 Argentina 219 1897 ± 51 864 967 1362 1780 2400 2850 3198 Uruguay 144 1668 ± 68 596 802 1088 1544 2115 2582 3114 SEM Standard error of the mean, M Males, F females Wilcoxon test was used for sex comparisons P < 0.039 children, respectively. Over three quarters of these children water daily in Argentina, Brazil and Mexico, which was consumed milk, or its derivatives, on a daily basis. The high- most marked in Brazil and Mexico where the median vol- est daily volume consumed was in Uruguay 429 mL/day; ume was > 130 mL/day. Brazilian adolescents (10–17 years) Mexico had the lowest milk consumption at 265 mL/day. had the highest water consumption 505 (278–778) mL/day With the exception of Brazil, where 70% of children con- of any country. As with the younger children, Mexicans and sumed 100% fruit juice, this drink was not a popular choice Uruguayans drank mainly bottled water while Argentinian within this age group. Uruguayan children consumed fewer and Brazilian adolescents drank mainly tap water. Uruguay hot beverages than children in the other countries. Only 1% had the lowest consumption of SSB with a median intake of of children in Uruguay drank hot beverages with a median 390 mL/day; CSDs were the major contributor to this vol- value of 0 mL/day due to the skewed nature of the data. ume. The largest consumers of SSB were Argentinian ado- Nearly all children (93–98%) in all four countries consumed lescents who had a daily intake of 686 mL/day with a 75th SSB; more SSB was consumed than milk and its deriva- percentile > 1 L; most of this being CSD and juice-based tives. A daily median of more than 500 mL was consumed drinks. As might be expected there was a lower intake of in Argentina (545 mL) and Uruguay (570 mL). In both these milk and its derivatives amongst these older children com- countries, the 75th percentile was greater than 1 L/day. In pared with the younger age groups and a subsequent increase Mexico and Brazil, the median intake was < 400 mL/day in the intake of hot beverages. As was observed in the chil- with 75th percentiles of approximately 600 mL/day. In all dren, Brazilian adolescents had the highest median intake of countries, the major contributor to SSB intake was carbon- 100% fruit juice (42 mL/day) with 60% consuming it daily. ated soft drinks (CSD), followed by juice-based drinks, The contribution of each type of fluid to TFI (%) is shown which were particularly popular in Brazil. in Fig. 2, and the same data by sex are shown in supplemen- Types of beverage consumed by the 10–17-year-old are tary figure S3. In all four countries, milk and its derivatives shown in Table 4. Adolescents drank a higher volume of represented about a quarter of TFI in the youngest age group. 1 3 S58 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 Total 15% 28% 19% 38% 14% 21% 21% 44% F 16% 35% 16% 33% Total 7% 18% 28% 47% M 7% 25% 26% 41% F 6% 13% 29% 51% Total 6% 7% 18% 69% M 5% 5% 18% 72% F 7% 10% 19% 64% Total 7% 16% 77% 11% 12% 77% ≤50% AI 3% 19% 77% Total 23% 25% 23% 28% 50-75% AI M 26% 28% 24% 22% 75-100% AI F 19% 21% 23% 37% ≥100% AI Total 18% 28% 17% 38% M 21% 39% 10% 31% F 16% 23% 20% 41% Total 11% 21% 26% 42% M 13% 25% 24% 38% 7% 17% 28% 48% Total 16% 23% 24% 37% M 18% 30% 19% 34% F 14% 16% 30% 40% 0% 10%20% 30%40% 50%60% 70%80% 90% 100% Distribution of participants (%) Fig. 1 Total fluid intake of children (4–9  years) and adolescents (10–17  years) expressed as a percentage (%) of the adequate intake of water from fluids set by the Institute of Medicine [7] based on 7-day mean of each participant by sex Children in Mexico and Brazil drank approximately a third and adolescents in Argentina, Brazil and Uruguay. It also of TFI as water and another third as SSB. In Argentina and presents more recent data for these age groups in Mexico. Uruguay, the largest contributor to TFI was SSB. Amongst In the present study, Mexican children had a lower median adolescents, milk and its derivatives contributed to 12–19% TFI than children in the other countries (1061 mL/day); of TFI. The contribution of CSD and water to TFI differed Uruguayan children had the highest daily intake of fluid at in the adolescents compared with the children. In Argentina 1639 mL/day. Amongst adolescents, Mexico, Uruguay and SSB contributed 43% to TFI compared with 24% for water. Brazil had similar TFIs (1462–1544 mL/day); Argentinian In the other three countries, the contribution of SSB and adolescents had the highest TFI (1780 mL/day). It is dic ffi ult water was similar, namely, 38 vs 40% in Mexico, 37 vs 35% to compare the results of the present survey with most of the in Brazil and 34 vs 31% in Uruguay. previous studies due to different age categories and meth- Over 75% of children and adolescents in Mexico, Brazil odological differences. The present study generally reported and Argentina drank at least one serving (250 mL/day) of fluid intakes higher than from the latest data reported from SSB per day (Fig. 3). In Mexico, Brazil and Argentina, the Mexico in 2012 [4] but lower than those from Brazil [8] number of children drinking ≥ 1 serving per day was slightly from 2008/9. No data are available for children and adoles- lower than for the corresponding adolescents. However, Uru- cents from Argentina or Uruguay apart from the in Liq.In guay had the most children and the lowest number of ado- surveys of 2012 [6]. Comparisons with the previous Liq.In lescents drinking ≥ 1 serving per day. study [6] are more appropriate as the same validated 7-day record and age categories were used. Intake by Mexican and Brazilian children and Brazilian adolescents in the present Discussion survey were similar to the earlier study; Argentinian chil- dren and Mexican and Argentinian adolescents increased The present study reports recent data for children (aged their TFI by approximately 260 mL/day. However, the TFIs 4–9 years) and adolescents (aged 10–17 years) on estimated for Uruguayan children and adolescents decreased mark- total fluid intake and types of fluid consumed in four Latin edly by approximately 300 and 500 mL/day, respectively. American countries. For the first time, comparisons with The reasons for the TFI differences between the two surveys the IOM recommendations [5] on adequate intake (AI) of are unclear although it may be due to sampling differences, water from fluids (20% of TWI) are reported for children despite the populations being selected according to the same 1 3 10-17 years 6-9 years 4-9 years Argentin Argentin Uruguay a Brazil Mexico Uruguay a Brazil Mexico (n=144) (n=219) (n=194) (n=376) (n=121) (n=173) (n=146) (n=293) European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S59 Table 3 Median (P25–P75) daily intake (mL/day) of different fluid types and the percentage of consumers among children (4–9 years), by coun- try 4–9 years 6–9 years Mexico (n = 293) Brazil (n = 146) Argentina (n = 173) Uruguay (n = 121) P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers Water 252 (90–505) 90 369 (238–609) 100 271 (79–607) 84 500 (250–768) 91  Bottled water 241 (61–468) 87 0 (0–170) 48 0 (0–64) 30 434 (0–706) 73  Tap water 0 (0–0) 16 266 (82–438) 83 138 (0–461) 68 0 (0–50) 26 Milk and 265 (111–451) 91 302 (152–468) 95 343 (154–517) 87 429 (232–500) 90 derivatives Hot beverages 0 (0–28) 33 0 (0–63) 47 54 (0–211) 59 0 (0–0) 1  Coffee 0 (0–0) 23 0 (0–34) 36 0 (0–0) 6 0 (0–0) 0  Tea 0 (0–0) 14 0 (0–0) 17 0 (0–35) 29 0 (0–0) 0  Maté ND ND ND ND 0 (0–139) 40 0 (0–0) 1  Other hot ND ND ND ND ND ND 0 (0–0) 0 beverages SSB 391 (185–607) 95 396 (197–603) 98 545 (254– 93 570 (275– 98 1062) 1026)  CSD 48 (0–200) 61 150 (47–267) 88 191 (39–378) 79 217 (200–484) 92  Juice-based 68 (0–216) 67 171 (71–297) 92 161 (0–514) 72 109 (0–595) 55 drinks  Functional 0 (0–0) 12 0 (0–0) 13 0 (0–0) 6 0 (0–0) 0 beverages  RTD tea and 0 (0–0) 13 0 (0–0) 14 0 (0–0) 3 0 (0–0) 0 coffee  Flavored 57 (0–191) 67 0 (0–0) 14 0 (0–54) 31 0 (0–0) 7 water 100% fruit 0 (0–0) 22 55 (0–158) 70 0 (0–0) 16 0 (0–0) 1 juices A/NSB 0 (0–0) 11 0 (0–0) 10 0 (0–156) 43 0 (0–0) 5 Alcoholic 0 (0–0) 0 0 (0–0) 0 0 (0–0) 1 0 (0–0) 0 beverages Other bever- 0 (0–0) 9 0 (0–0) 19 0 (0–0) 4 0 (0–0) 17 ages SSB Sugar sweetened beverages, CSD carbonated sweetened drinks, RTD ready to drink, A/NSB Artificial/non-nutritive sweeteners beverages, ND no data quota method. In particular, the sample size for Uruguay American countries appear to have adequate intakes, there doubled for children and increased by nearly 50% for the is still concern about the health and well-being of those chil- adolescents. dren who report intakes below the recommendation. While Over two-thirds of children in Argentina and Uruguay without biomarkers it is not possible to draw conclusions met the AIs [5], although in Mexico and Brazil fewer than about their hydration status, if their water intake is actually half of children met them. These rates are broadly compa- suboptimal it is possible that their cognitive and physical rable to the previous Liq.In study [6] for Mexico, Uruguay performances may be affected [1 , 3]. and Argentina; however, the percentage of Brazilian children An important issue that has emerged from the present not meeting the recommendations increased from 32% to study is that while these children and adolescents are more over 50% when either the IOM [5] or the EFSA [14] recom- likely to meet the recommendations on water intake from mendations were used. It has previously been shown that fluids, a significant proportion of the fluid was sweetened children and adolescents frequently do not meet to recom- beverages, especially CSD. This was consistent for all coun- mendations on adequate water intake of TFI [20–22] with tries but most marked in Uruguay. In a period of 4 years, up to 90% drinking less than the recommendations in some Uruguayan children increased their proportion of TFI from countries. While it is reassuring to note that a reasonable SSB from 25% in the earlier Liq.In study [23] to 41% in the proportion of children and adolescents in these four Latin present study. Both Uruguayan and Argentinian adolescents 1 3 S60 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 Table 4 Median (P25–P75) daily intake (mL/day) of different fluid types and the percentage of consumers among adolescents (10–17 years), by country Mexico (n = 376) Brazil (n = 194) Argentina (n = 219) Uruguay (n = 144) P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers P50 (P25–P75) % consumers Water 391 (180–963) 90 505 (278–778) 99 346 (93–675) 84 434 (155–798) 89  Bottled water 336 (111–721) 85 17 (0–179) 54 0 (0–100) 38 340 (0–684) 74  Tap water 0 (0–0) 23 314 (114–643) 88 146 (0–497) 68 0 (0–39) 29 Milk and 154 (9–320) 76 156 (36–265) 83 144 (0–361) 71 240 (63–498) 80 derivatives Hot beverages 0 (0–131) 49 31 (0–149) 61 179 (0–357) 75 0 (0–87) 29  Coffee 0 (0–107) 43 16 (0–98) 55 0 (0–73) 35 0 (0–0) 19  Tea 0 (0–0) 17 0 (0–0) 24 0 (0–71) 36 0 (0–0) 8  Maté ND ND ND ND 0 (0–179) 40 0 (0–0) 13  Other hot ND ND ND ND ND ND 0 (0–0) 1 beverages SSB 524 (258–908) 94 499 (262–811) 98 686 (388– 92 390 (194–749) 92 1147)  CSD 137 (0–393) 72 235 (107–459) 93 247 (86–599) 83 200 (64–411) 78  Juice-based 47 (0–200) 58 174 (54–344) 89 150 (0–463) 68 0 (0–215) 42 drinks  Functional 0 (0–0) 11 0 (0–0) 15 0 (0–0) 10 0 (0–0) 5 beverages  RTD tea and 0 (0–0) 19 0 (0–0) 16 0 (0–0) 1 0 (0–0) 0 coffee  Flavored 115 (0–292) 68 0 (0–0) 17 0 (0–71) 32 0 (0–0) 19 water 100% fruit 0 (0–0) 20 42 (0–157) 60 0 (0–0) 15 0 (0–0) 6 juices A/NSB 0 (0–0) 12 0 (0–36) 33 0 (0–100) 38 0 (0–0) 18 Alcoholic 0 (0–0) 3 0 (0–0) 7 0 (0–0) 6 0 (0–0) 2 beverages Other bever- 0 (0–0) 10 0 (0–0) 8 0 (0–0) 2% 0 (0–0) 19 ages SSB Sugar sweetened beverages, CSD carbonated sweetened drinks, RTD ready to drink, A/NSB Artificial/non-nutritive sweeteners beverages, ND no data Fig. 2 Contribution of the dif- Mexico 31% 26% 3% 37% ferent fluid types (%) to total fluid intake among children (4–9 years) and adolescents Brazil 32% 24% 3% 31% 8% (10–17 years), by country. SSB Water Sugar sweetened beverage, A/ Argentina 24% 20% 8% 39% 7% Milk & derivatives NSB Artificial/non-nutritive Hot beverages sweeteners, TFI Total fluid Uruguay 32% 25% 41% intake   SSB 100% fruit juices Mexico 38% 13% 6% 40% A/NSB Alcoholic beverages Brazil 37% 12% 6% 35% 7% Other beverages Argentina 24% 12% 13% 43% 7% Uruguay 34% 19% 10% 31% 3% 0% 20%40% 60%80% 100% Contribution of each fluid types to TFI (%) 1 3 6-9 10-17 years years 4-9 years European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 S61 ≤ 1 serving per week 2-6 serving per day ≥ 1 serving per day Mexico 5% 26% 69% (n=293) Brazil 1% 19% 80% (n=146) Argentina 77% 5% 18% (n=173) Uruguay 1% 17% 82% (n=121) Mexico 6% 16% 78% (n=376) Brazil 2% 16% 82% (n=194) Argentina 8% 9% 84% (n=219) Uruguay 8% 28% 63% (n=144) 0% 10%20% 30%40% 50%60% 70%80% 90%100% Percentage of participants (%) Fig. 3 Percentage of children and adolescents drinking SSB on daily or less frequency, according to country also appear to have increased the proportion of fluid from in this region, is also experiencing the double burden of dis- SSB during this period. This comparison, however, should ease with undernutrition occurring alongside obesity [30], be made with caution due to differing classifications of which will further stretch limited public health resources. fruit juice between the studies. There is a tendency to snack One strategy that is increasingly being used to reduce in Latin American countries [24] with SSB being a snack SBB consumption in children is to increase plain water con- component amongst younger adults and children [25]. It is sumption [31]. Studies have shown that higher consump- interesting to note that the methodology used in this study, tion of plain water is associated with lower consumption and the previous Liq.In studies [6, 23] is more likely to of SSB [32–34]. In the present study, the median intake of have captured all drinking events including snacks [26] and, water ranged from 252 to 500 mL/day, with the Uruguayan therefore, may better reflect TFI and SSB intake. children drinking more than the other groups of children; These levels of SSB consumption raise concerns given Mexican children drank the lowest volume of water. As a the increasing body of evidence on the negative effects of proportion of TFI in children, water accounted for 24% in some drinks on children’s health [13]. The apparent increase Argentina and 31–32% in the other three countries. The in SSB consumption between the previous and present Liq. adolescents had a similar pattern when proportion of TFI In studies was most marked in Uruguayan children and ado- was considered. These results are broadly similar to the lescents, and Argentinian adolescents. Latin American has previous Liq.In surveys for Mexico, Argentina and Brazil. seen a rapid rise in obesity and overweight especially in chil- Although Uruguayan children and adolescents had markedly dren and adolescents [12, 27] and more public health poli- lower water intakes in this study than in the previous survey cies are urgently needed to halt, and hopefully, reverse this [6], this was accompanied by an increase in SSB consump- trend. In Mexico, several policies have been implemented tion, as discussed above. This finding suggests that action including a tax on SSB since 2014 [28] and the development is needed to reverse this trend in Uruguay. Plain water is of a healthy beverage guide [29]. While beyond the remit the drink of choice and healthy hydration strategies should of this analysis, comparison between countries, stratified be incorporated into public health policies and food-based for BMI status and socioeconomic status may yield further dietary guidelines [35]. An example of this is the Mexico insights into drinking behavior amongst children and adoles- healthy beverage guide, which includes a pictorial represen- cents in Latin America. Data from the present study are vital tation of a jug that represents daily fluid intake and shows in highlighting high consumption levels of different fluid the proportion of each fluid type that should be consumed types and for the development of health policies. This is par- [29]. ticularly important in a country such as Uruguay where fluid The strengths of this study include the use of a meth- consumption data are lacking. Uruguay, like other countries odology validated, albeit in adults, to assess fluid intake, 1 3 10-17 years 6-9 years 4-9 years S62 European Journal of Nutrition (2018) 57 (Suppl 3):S53–S63 Acknowledgements Participant recruitment and data collection in all namely, the Liq.In dairy [16]. This methodology was previ- countries was performed by IPSOS. ously used by Iglesia [6] in the same Latin American coun- tries, so facilitating valid temporal comparisons. The large Compliance with ethical standards sample size also contributed to a fuller understanding of fluid intake in these countries. Nonetheless, there are limi- Ethical statement All the participants gave their consent prior the tations to this study including those inherent in any cross- inclusion in the study. All data were recorded anonymously. The pro- sectional study, such as how representative were the samples tocol of the surveys was reviewed and approved by the Institutional Review Board, Office of Research Compliance of the University of of the general populations in these age categories. In this Arkansas (IRB Protocol #14-12-376). study, a quota sampling system was used in terms of age, sex and SES. Data from Brazilian children and adolescents Conflict of interest CM and IG are full-time employee of Danone Re- were collected from only one city, while it is the largest city search. SAK was a scientific consultant for Quest Diagnostics. JS-S, and municipality in Brazil, it may not be representative of LAM, SAK, JG, HM are members of advisory board on fluid intake other areas of Brazil. Moreover, data collection in Brazil of Danone Research, and have received consultancies from Danone Research. SAK has received research grants from Danone Research. was performed during another a different period of the year J.S.-S, EC, and LAM has received consultancies from Danone S.A. for operational reasons. As all data collection was performed JLA and CP Report No. conflicts of interest. outside summer or winter, periods with larger temperature variations, the seasonal effect on fluid intake behavior was Open Access This article is distributed under the terms of the Crea- considered to be moderate. Recording dietary intake in tive Commons Attribution 4.0 International License (http://creat iveco mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- children requires a degree of parental assistance according tion, and reproduction in any medium, provided you give appropriate to age [36] and for all children under 12 years a parent or credit to the original author(s) and the source, provide a link to the care giver  completed the 7-day record. The validity of data Creative Commons license, and indicate if changes were made. of this age group, and adolescents, remains to be assessed. 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Journal

European Journal of NutritionSpringer Journals

Published: Jun 1, 2018

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