Towards a Better Understanding of the Role of Early Life Sugar-containing Beverage Exposure in Modifying the Risk of Pediatric Obesity Restricted; Files Only
Chiang, Katelyn (Spring 2026)
Abstract
In recent years, there have been intensified efforts to reduce consumption of sugar-containing beverages during early childhood, but it is unclear if these recommendations are being met and how non-compliance may impact risk of later obesity. We characterized trends in sugar-containing beverage consumption in the United States and assessed the impact of updated recommendations on consumption. We also examined the association between early introduction to fruit juice and risk of childhood obesity in two cohorts, examining the role of later sugar-containing beverage consumption in mediating this association and the role of metabolically adverse prenatal environments in modifying the effect.
We found there have been significant improvements in fruit juice consumption practices during early childhood over the past decade in the United States, including reductions in the number of infants with any reported consumption of fruit juice on a given day and the number of toddlers and young children consuming fruit juice over the recommended daily limits.
In a cohort of low-income children in the United States, we found those introduced to fruit juice before 12 months of age had increased risk of overweight/obesity at 5 years compared to children introduced ≥12 months (RR=1.27, 95% CI: 1.02-1.58). This association was not attenuated by usual intake of sugar-containing beverages at 5 years or average sugar-containing beverage intake across early childhood from 1 to 5 years. In a British-based cohort, we found among children born to mothers with elevated cardiometabolic risk during pregnancy, early introduction to fruit juice <6 months was associated with increased risk of obesity at 7 years compared to children introduced ≥12 months (RR=1.70, 95% CI: 1.15-2.50). There was no significant increased risk among children born to mothers without elevated cardiometabolic risk during pregnancy.
Our findings suggest early life sugar-containing beverage intake patterns in the United States do not align with current recommendations and introduction to fruit juice before 12 months of age is associated with increased risk of childhood obesity. Pathways linking early introduction to fruit juice and obesity outside of increased later intake of sugar-containing beverages may exist, and children experiencing metabolic adversity in-utero may be particularly susceptible.
Table of Contents
1. Chapter 1: Introduction 13
1.1 References 15
2. Chapter 2: Background 19
2.1 Childhood obesity 19
2.2 Free sugars and sugar-containing beverages 19
2.3 Prevalence of sugar-containing beverage consumption during early childhood 21
2.4 Current early life sugar-containing beverage recommendations 22
2.5 Early life sugar containing-beverage consumption and health outcomes 24
2.6 Evidence gaps 25
2.7 References 27
3. Chapter 3: Expanded Methods 38
3.1 Overview of parent studies 38
3.1.1 NHANES 38
3.1.2 WIC ITFPS-2 39
3.1.3 ALSPAC 39
3.2 Nutrition assessment methods 40
3.2.1 Timing of introduction to sugar-containing beverages 40
3.2.2 Usual and given day intake of sugar-containing beverages 42
3.3 Obesity assessment methods 44
3.4 Statistical analyses 44
3.5 References 46
4. Chapter 4: Trends in early life sugar-containing beverage consumption in the United States and impact of updated expert guidelines – NHANES 2013-2023 50
4.1 Abstract 51
4.2 Introduction 52
4.3 Methods 55
4.3.1 Study Design 55
4.3.2 Dietary Intake 56
4.3.3 Sugar-containing Beverage Intake 56
4.3.4 Sociodemographic Characteristics 58
4.3.5 Statistical Analysis 58
4.4 Results 60
4.5 Discussion 65
4.6 Tables and Figures 71
4.7 References 83
5. Chapter 5: Early introduction to fruit juice is associated with increased risk of overweight/obesity at 5 years 88
5.1 Abstract 89
5.2 Introduction 91
5.3 Methods 93
5.3.1 Data Source 93
5.3.2 Timing of Introduction to Fruit Juice 93
5.3.3 Child Overweight/Obesity Status at 5 years 94
5.3.4 Sugar-containing Beverage Consumption 94
5.3.5 Other Measures 96
5.3.6 Statistical Analysis 97
5.4 Results 98
5.5 Discussion 102
5.6 Tables and Figures 109
5.7 References 114
6. Chapter 6: Early introduction to fruit juice is associated with increased risk of obesity at 7 years among children exposed to a metabolically adverse prenatal environment 121
6.1 Abstract 122
6.2 Introduction 123
6.3 Methods 124
6.3.1 Study Population 124
6.3.2 Exposure: Age at introduction to fruit juice 125
6.3.3 Outcome: Obesity at 7 and 15 years 125
6.3.4 Effect Modifier: Maternal cardiometabolic health during pregnancy 126
6.3.5 Maternal and Child Covariates 126
6.3.6 Statistical Analyses 128
6.4 Results 129
6.5 Discussion 132
6.6 Tables and Figures 136
6.7 References 140
7. Chapter 7: Expanded Discussion 146
7.1 Summary of key findings 146
7.2 Study strengths and limitations 148
7.3 Public health implications 150
7.4 Future directions for research 151
7.5 Conclusion 152
7.6 References 153
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