economic38ab.com

EuropeanJournalofNutrition(2018)57(Suppl3):S113–S123https://doi.
org/10.
1007/s00394-018-1725-yORIGINALCONTRIBUTIONFluidintakepatternsofchildrenandadolescents:resultsofsixLiq.
In7nationalcross-sectionalsurveysC.
Morin1·J.
Gandy2,3·R.
Brazeilles4·L.
A.
Moreno5,6·S.
A.
Kavouras7,8·H.
Martinez9·J.
SalasSalvadó6,10·J.
Bottin1·IsabelleGuelinckx1Received:23February2018/Accepted:18May2018/Publishedonline:1June2018TheAuthor(s)2018AbstractPurposeThisstudyaimedtoidentifyandcharacterizepatternsoffluidintakeinchildrenandadolescentsfromsixcountries:Argentina,Brazil,China,Indonesia,MexicoandUruguay.
MethodsDataonfluidintakevolumeandtypeamongstchildren(4–9years;N=1400)andadolescents(10–17years;N=1781)werecollectedusingthevalidated7-dayfluid-specificrecord(Liq.
In7record).
Toidentifyrelativelydistinctclus-tersofsubjectsbasedoneightfluidtypes(water,milkanditsderivatives,hotbeverages,sugar-sweetenedbeverages(SSB),100%fruitjuices,artificial/non-nutritivesweetenedbeverages,alcoholicbeverages,otherbeverages),aclusteranalysis(partitioningaroundk-medoidsalgorithm)wasused.
Clusterswerethencharacterizedaccordingtotheirsocio-demographicsandlifestyleindicators.
ResultsThesixinterpretableclustersidentifiedwere:lowdrinkers–SSB(n523),lowdrinkers–waterandmilk(n615),mediummixeddrinkers(n914),highdrinkers–SSB(n513),highdrinkers–water(n352)andveryhighdrinkers–water(n264).
Countryofresidencewasthedominantcharacteristic,followedbysocioeconomiclevel,inallsixpatterns.
ConclusionsThisanalysisshowedthatconsumptionofwaterandSSBweretheprimarydriversoftheclusters.
Inadditiontocountry,socio-demographicandlifestylefactorsplayedaroleindeterminingthecharacteristicsofeachcluster.
Thisinformationhighlightstheneedtotargetinterventionsinparticularpopulationsaimedatchangingfluidintakebehaviorandimprovinghealthinchildrenandadolescents.
KeywordsBeverages·Fluidintake·Water·Hydration·Liq.
In7·Children·Adolescents·ClusteringanalysisElectronicsupplementarymaterialTheonlineversionofthisarticle(https://doi.
org/10.
1007/s00394-018-1725-y)containssupplementarymaterial,whichisavailabletoauthorizedusers.
*IsabelleGuelinckxisabelle.
guelinckx@danone.
com1HydrationandHealthDepartment,DanoneResearch,RouteDépartemental128,91767Palaiseau,France2BritishDieteticAssociation,Birmingham,UK3SchoolofLifeMedicalServices,UniversityofHertfordshire,Hatfield,UK4BiometricsandDataScienceDepartment,DanoneResearch,Palaiseau,France5GENUD(Growth,Exercise,NutritionandDevelopment)ResearchGroup,FacultyofHealthSciences,UniversidaddeZaragoza,InstitutoAgroalimentariodeAragón(IA2),InstitutoInvestigaciónSanitariaAragón(IISAragón),Zaragoza,Spain6CIBERobn(CentrodeInvestigaciónBiomédicaenRedFisiopatologíadelaObesidadyNutrición),InstituteofHealthCarlosIII,Madrid,Spain7HydrationScienceLab,UniversityofArkansas,Fayetteville,AR,USA8DivisionofEndocrinology,UniversityofArkansasforMedicalSciences,LittleRock,AR,USA9HospitalInfantildeMéxicoFedericoGómez,MéxicoCity,Mexico10HumanNutritionUnit,HospitalUniversitarideSantJoandeReus,FacultyofMedicineandHealthSciences,Institutd'InvestigacióSanitàriaPereVirgili,BiochemistryandBiotechnologyDepartment,UniversitatRoviraiVirgiliReus,Reus,SpainS114EuropeanJournalofNutrition(2018)57(Suppl3):S113–S123IntroductionLowfluidintake,oritsbiomarkers,hasbeenassociatedwithanincreasedriskofdevelopingcardiometabolicdiseases[1,2],chronickidneydisease[3]andrecurrentkidneystones[4].
Adequatehydrationhasbeenshowntoimprovecognitioninchildren[5]andadults[6],improvemood[7,8]andattenuatebiologicalriskfactorsfortheabove-mentionedconditions.
Inaddition,consumingsugar-sweetenedbeverages(SSB)hasbeenlinkedwithanincreasedfutureriskofobesity[9],andcardiometa-bolicdiseases.
EachdailyservingincreaseinSSBhasbeenlinkedtoa21%increasedriskoftype2diabetes[10],7%increasedriskofhypertension[11]and7–18%increasedriskofstroke,heartfailureandcoronaryheartdisease[12].
Totalfluidintakehasbeenreportedformanycountries[13–20]togetherwithdataonthetypeoffluidconsumed[21–25].
Manystudieshaveshownthatahighproportionofchildrenandadolescentsdonotdrinkenoughtomeetwaterintakerecommendations[13,15,16,23].
Thisisespeciallyimportantinyoungchildrenwho,duetotheirrelativelyhighbodywatercontentandunderdevelopedregulatorysystems,arevulnerabletotheeffectsofnotdrinkingenough[26].
Itisapparentfromthese,andmanyotherstudies,thatwhileanindividualmaybedrinkingsufficientintermsofvolumetomeet,orexceedcurrentrecommendationsonfluidintake,theremaybeawidevarietyofcombinationsoffluidtypewithinthattotalvol-ume.
Consideringonlyoneortwovariablesatatimelim-itstheinterpretationofdata,andasaconsequence,theirusefulness[27].
Increasingly,dietarypatternsarebeingstudiedtoinvestigatetheseinteractions[28].
Therefore,itisnowpertinenttolookatpatternsoffluidconsump-tionasopposedtostudiesthatconsideronlyvolumeorindividualfluidtype.
Differentmethodsofanalyzingdietarypatternscanbeusedindiversepopulations,includingprincipalcompo-nentanalysis,clusteranalysesandmorerecently,reducedrankregression[29].
Fluidintakehasbeenevaluatedusingmultipleregressionanalysis[19],principalcomponentanalysis[30]andadynamicpanelmodel[31].
Anothermultivariatetechniquethatcanbeappliedtofluidintakeisclusteranalysis.
Themainadvantageofclusteranalysisisthatitcreatesgroupsofindividualsthatareashomo-geneousaspossible,minimizingthevariancewithineachgroupandmaximizingthevariancebetweengroups.
Thisallowstheidentificationoffluidintakepatterns,called'clusters',commontoagroupofpeoplethataredifferentfromeachoftheotherpatterns.
Suchclusterscanthenbeevaluatedthroughclassicalregressionmethods,inter-pretedandvalidatedfromafluidintakepointofview.
Clusteranalysishasbeenusedextensivelytoevaluatedietarypatterns[32],andisnowbeingappliedtofluidintakepatternsinadults[17,33,34]andchildren[35–39],althoughitsuseisstilllimited.
However,tothebestofourknowledgeclusteranalysisoffluidintakepatternsinchildrenandadolescentshasonlybeenperformedinsingle-countrypopulationgroups.
AglobalanalysisofFIpatternshasnotbeenpossibletodateduetovariationsinthemethodologyusedtocollectdata;therefore,theimportanceofthecountryofresidencepersehasnotbeeninvestigatedusingclusteranalysis.
Withtheavailabilityofavalidated7-dayfluidrecord[40]andahar-monizedmethodologyacrossvariouscountries[41–43]itisnowpossibletostudyglobalfluidintakepatternstakingintoconsiderationthisvariable.
Therefore,theprimaryaimofthisstudywastoidentifydifferentpatternsoffluidintakeinchildrenandadolescentsinsixcountries.
Thesecondaryaimwastocharacterizethesepatternsintermsofsocio-demographicsandlifestyleindicators.
MaterialsandmethodsSurveyandsurveysampleThispooledsecondaryanalysiswasperformedontheindi-vidualdataof3214participantsaged4–17.
9yearsfromsixcross-sectionalsurveys.
Theprimaryobjectiveofallsur-veyswastoassesstheintakeofdrinkingwateranddiffer-enttypesofbeverages.
ThesurveysincludedinthepooledanalysiswereconductedinLatinAmerica(Mexico,Brazil,Argentina,Uruguay),andAsia(China,Indonesia)in2016.
Therecruitmentofparticipantsandfurtherdetailsofthepopulationsincludedinthisanalysishavebeendescribedpreviously[41–43].
Participantsandparentswereselectedfromadatabaseofindividualsvolunteeringforpopulationsurveysorviaasystematicdoor-to-doorapproachwithaninvitationfortheirchildtoparticipate.
Allparticipants,includingparentsandchildren,willingtojoininthesurveyreceiveddetailedinformationaboutthesurveyobjectives,whatwasexpectedfromthem,aswellasadisclosureofthesurvey'sprovisionstopreserveconfidentiality,risksandbenefits,andaclearexplanationabouttheiroptiontoparticipatevoluntarilyornotinthesurvey.
Afterofferingadetaileddescriptionofthesurvey,parentswereaskedfororalapprovalfortheirchildtoparticipate.
Nomonetaryincentivewasofferedfortakingpartinthesurvey.
Alldatawererecordedanony-mously.
Therefore,participantscannotbeidentifieddirectly,orthroughidentifierslinkedtotheparticipants.
ThesurveyprotocolwasreviewedandapprovedbytheUniversityofArkansasReviewBoard(ref.
14-12-376).
S115EuropeanJournalofNutrition(2018)57(Suppl3):S113–S123FluidassessmentParticipantswereprovidedwiththeLiq.
In7record,a7-dayfluid-specificrecordvalidatedforaccuracyandreliability[40].
TheLiq.
In7recordwaspresentedintheofficialcountrylanguage.
Inallcountries,exceptChina,apaperversionoftherecordwasdeliveredandexplainedtotheparticipantsduringaninterviewathome.
Afteraperiodof7days,therecordwascollectedbytheresearcherandcheckedforcom-pletionwiththeparticipant.
InChina,participantscompletedanelectronicversionoftheLiq.
In7recordviaasmartphone.
Participantswereinstructedtoreportalldrinkingeventsatanymomentofthedaywithdetailssuchasthefluidtype,sizeofthecontainerfromwhichthefluidwasdrunkandtheactualvolumeconsumed.
Foodconsumptionwasnotrecorded.
Toassistparticipantsinestimatingtheprecisevol-umeoffluidconsumed,aphotographicbookletofstandardfluidcontainerssupportedtherecords.
Forchildrenyoungerthan12years,theprimarycaregiverwasresponsibleforcompletingtherecord.
AnthropometricandlifestylevariablesTheanthropometricandlifestyledatawerecollectedviaaquestionnaireduringaface-to-facevisitathome,exceptinChinawherethesedatawerecollectedviaaweb-basedquestionnaire.
Inallcountries,exceptforIndonesia,height(m)andweight(kg)wereself-reportedbyparticipantsorcaregiversdependingontheparticipant'sage.
InIndonesia,weightwasmeasuredbythesurveyresearchers.
Thebodymassindex(BMI)wascalculated(kg/m2);BMIclassifica-tionwasbasedonsex-andage-specificcut-offvaluesforindividualsaged≤18years[44].
Todeterminethesocioeconomicstatus(SES)ofeachparticipant,country-adaptedclassificationswereapplied.
InMexico,ArgentinaandUruguay,theAsociaciónMexi-canadeAgenciasdeInvestigacióndeMercadoyOpiniónPública(AMAI)systemwasusedandinBraziltheABEPclassification[45,46].
BothsystemsuseacombinationofthefollowingcriteriatodeterminetheSESofahousehold;workstatus,occupation,education,medicalcoverage,num-berofdomesticservants,numberofbathrooms,householdequipment,possessionofaninternationalcreditcardand/oraccesstopublicutilityservices.
InIndonesia,SESwasdeterminedbasedonthecombinedscoreofhouseholdexpenditure,electricityusage,householdcookingequipmentandthekindofsourceofdrinkingwater(e.
g.
,tapwater,wellwater,springwater)foruseinthehousehold.
InChina,SESwasdeterminedbasedonthehouseholdincomeofthepar-ticipant.
AnincomeofRMB≤5999wasclassifiedasSESDE,anincomebetweenRMB6000and11,999asSESCandanincome≥RMB12,000aslevelAB.
Forthisanalysis,SESclasseswereharmonizedasdetailedinTableS1oftheonlineresources.
Thenumberofhoursperdaytheparticipantspentwatch-ingTVoranycontentonascreen(≥2or2.
5L/dayasshowninapreviousanalysis[41].
Fromthepresentanalysis,itwouldappearthatintermsoffluidvolumeandtype,thereislittleofconcernthatrequiresinterventionintheselat-tertwoclusters.
ThiscouldbeduetoallproactiveactionsundertakeninIndonesiatoincreasetheaccesstosafewater[61]andtoencouragewaterconsumption[62].
However,withincreasinglevelsofobesity[63]andtype2diabetesTable2(continued)VariableModalityCluster/modality(%)RankingvtestBMIclassificationUnderweight204.
4Frequencyphysicalactivity2/monthto1/week123.
4Sedentarybehavior≥2h/day103.
4Sedentarybehavior<2h/day73.
4Lunchboxfrequency2to5/week43.
7Frequencyphysicalactivity2/weekto1/day63.
9Socio-economicstatusDE54AccesstofluidatschoolNo35.
1CountryUruguay15.
7CountryBrazil15.
7CountryMexico26.
3CountryArgentina16.
6CountryChina09.
5S120EuropeanJournalofNutrition(2018)57(Suppl3):S113–S123[64]inIndonesiathereareconcernsaboutincreasingSSBconsumption[65].
Publichealthpoliciesandinterventionsareneededtohaltandhopefullyreversethistrend[66].
FluidpatternanalysesinchildrenandadolescentshavebeenconductedintheUSA[30]andCanada[35].
Bougatsasetal.
identifiedsixclusters[30]includingonewhichwassimilartothelowdrinkers–waterandmilkcluster.
Othercomparisonsbetweenthetwoanalysesaredifficultduetothedifferencesinfluidtypeclassification.
TheanalysisbyDanyliwandcolleagues[35]identifiedfiveclustersinclud-ingmilkandhigh-fatmilk;however,waterwasexcludedfromtheanalysisasfluidswerecategorizedonthebasisoftheirenergyandnutrientcontent.
Otheranalyseshaveconcentratedentirelyonenergycontentratherthanvolumeoffluidtypes.
Thisisthefirststudytoincludedatafrommorethanonecountry;therefore,directcomparisonstootheranalysesaredifficultandreasonsforanysimilaritiesordifferencesarebeyondtheremitofthepresentanalysis.
However,whilesocietalandculturalinfluencesonfoodpat-ternsarewellrecognized[67],identificationofthefactorsthatinfluencedrinkingpatternsrequiresfurtherresearch.
SocioeconomiclevelwasasignificantcharacteristicinthreeoftheFIclusters.
Thelowdrinkers–milkandwaterclusterwasmorerepresentedbySESAB,highdrinkers–SSBwereassociatedwithSESDEandveryhighdrinkers–waterwereassociatedwithSESC.
DisparitiesinSESandhydra-tion[68],water[69]andtypeoffluidsconsumed[70]havebeenreportedalthoughevidencefromclusteranalysisislim-itedandcomplicatedbythelackofconsistentdefinitionsofSEL.
Danyliwetal.
[35]noteddifferencesinintakeaccord-ingtohouseholdsecurityandincome,butnospecificpat-ternswereestablished.
InarecentsystematicreviewlowerSESwasassociatedwithhigherSSBconsumption[71].
Inthepresentanalysis,alowerSESwasalsoasignificantchar-acteristicofthehighintake–SSBcluster.
Therefore,itwouldseemappropriateforinterventionsinthosecountriesthataimtodecreaseSSBconsumptionandreplaceSSBwithwater,targetchildrenandadolescentsinthelowerSELs.
Sedentarybehaviorand/orphysicalactivityweresignifi-cantcharacteristicsoffouroftheFIpatternclusters.
Par-ticipantswhoreportedlessthan2hofsedentarybehaviorwereover-representedinthelowdrinkers–waterandmilkcluster.
Childrenandadolescentswhoreportedmorethan2hofsedentarybehaviorwereover-representedinthehighdrinkerswithSSBcluster;thosewhoreportedbeingphysi-callyactiveonceaweektotwiceamonthwereunder-rep-resented.
ArecentclusteranalysisofdatafromtheELANAandHELENAstudiesinchildrenandadolescentsreportedclusterscharacterizedbysedentarybehaviorandSSBcon-sumption[72].
ThisisnotsurprisinggiventheestablishedlinksbetweensedentarybehaviorandlesshealthydietaryintakeincludingSSBconsumption[71,73,74].
Thosewhoreportedsedentarybehaviorgreaterthan2haweekand/orbeingphysicallyactiveonceaweektotwiceamonthwereover-representedintheveryhighdrinkers–watercluster.
Whilethismayappearcontradictory,thisphenomenonhasbeenreportedbeforeandisprobablyduetothosewhoreportbeingsedentaryfortwoormorehoursperdaycompensat-ingbybeingphysicallyactiveatothertimesoftheday[72].
Clearly,thepreventionandtreatmentofoverweightandobesityinchildrenandadolescentsrequiresamultifacetedapproach,whichfocusesonchangingdietaryhabits,includ-ingreducingSSBconsumption,andreducingsedentarybehaviorandorincreasingphysicalactivity.
Thecurrentstudyhasseveralstrengthsincludingtheuseofaharmonizedsamplinganddatacollectionmethodologyacrossthecountriesandofavalidatedassessmentmethodfortotalfluidintake[40],reflectingtheday-to-daybehavioroftheparticipantsovera7-dayperiod.
Thesamplesizeandtheuseofdatafromparticipantsinsixcountriesundoubt-edlystrengthenedtheanalysis.
Objectivestatisticalcrite-riasuchasusingthesilhouettecoefficienttoidentifythenumberofclusterscombinedwiththesubsequentuseofsubjectivecriteriarenderedtheselectedclustersinterpret-able.
However,itisimportanttorecognizethelimitationsofthisstudy.
Missingdataforsomeofthevariablesresultedinaslightlyreducedsamplesize;however,thisisinevitableinlargecross-sectionalstudiessuchastheLiq.
In7survey.
Theuseofbiomarkersforhydrationstatusorhealthout-comemeasureswouldhavestrengthenedthefindingsandpossibleimplicationsoftheanalysis.
Parentsorprimarycar-ersrecordedfluidintakeandrespondedtoquestionsaboutlifestyleandsocio-demographicsforyoungerparticipants,whilethismayhaveincreasedprecisiontheymayhavebeenbiasedtowardsdemonstratedhealthycharacteristics.
Inaddi-tion,adolescentswerenotaskediftheirparentsprovidedalunchboxforschoolnoraboutwateravailabilityinschools.
Whilethequestionsonsedentarybehaviorandphysicalactivityprovidevitalandinterestinginformation,itwouldhavebeenbettertohaveusedavalidatedphysicalactiv-ityquestionnairesuchastheInternationalPhysicalActivityQuestionnaire(IPAQ).
Toensureareliableandsensitiveapproximationofsocioeconomicstatus,country-specificmethodswereusedasaharmonizedclassificationsystemisnotcurrentlyavailable.
Thisanalysisisthefirsttoinvestigatefluidintakepatternsacrosscountriesandhasshownthatcountryofresidenceisanimportantdeterminantofclustermembership.
Therefore,itwouldbeinterestingtorepeattheanalysiswithineachcountryandextendthesurveytoothercountriesandregionsoftheworld.
Giventheinterestinestablishingguidanceandrecommendationsacrossregions,e.
g.
,LatinAmericancountries,orcontinents,e.
g.
,Europe,oncemoredataareavailableitwouldbeinterestingtorepeattheanalysisagainwithintheseregions.
ClusteranalysisoffluidintakepatternscouldbeausefultoolformonitoringinterventionsaimedatS121EuropeanJournalofNutrition(2018)57(Suppl3):S113–S123increasingwaterintakewhilereducingSSBconsumptionbyrepeatingtheanalysisoveraperiodoftime.
ConclusionsThisanalysisidentifiedsixclusterswithdifferingfluidintakepatterns,whichvariedintermsoftotalfluidintake.
TheconsumptionofwaterandSSBwastheprimarydriversoftheclusters.
Countryofresidenceprovedtobeanimpor-tantvariable,withsomecountriesbeingover-orunder-rep-resentedintheclusters.
Inaddition,socio-demographicandlifestylefactorsplayedaroleindeterminingthecharacteris-ticsofeachcluster.
Togetherthisinformationhighlightstheneedtotargetinterventionsinparticularpopulationsaimedatchangingfluidintakebehaviorandimprovinghealth,e.
g.
,increasingwaterintakeandreducingSSBconsumptioninMexico.
Thisanalysisemphasizestheneedformorelocalsurveystoprovidevaluabledataforthedevelopment,imple-mentationandevaluationofpoliciesandprogramsaimedatchangingfluidintakebehavior.
AcknowledgementsParticipantrecruitmentanddatacollectioninallcountrieswasperformedbyIPSOS.
CompliancewithethicalstandardsInformedconsentAlltheparticipantsgavetheirconsentpriortheinclusioninthestudy.
Alldatawererecordedanonymously.
EthicalstandardsTheprotocolofthesurveyswasreviewedandapprovedbytheInstitutionalReviewBoard,OfficeofResearchCom-plianceoftheUniversityofArkansas(IRBProtocol#14-12-376).
ConflictofinterestCM,RB,JBandIGarefull-timeemployeesofDanoneResearch.
JS-S,LAM,SAK,JGandHMaremembersoftheadvisoryboardonfluidintakeofDanoneResearch,andhavereceivedconsultanciesfromDanoneResearch.
SAKwasascientificconsultantforQuestDiagnosticsandhasactiveresearchgrantsfromDanoneRe-search.
JS-SandLAMhasreceivedconsultanciesfromDanoneS.
A.
OpenAccessThisarticleisdistributedunderthetermsoftheCrea-tiveCommonsAttribution4.
0InternationalLicense(http://creativecommons.
org/licenses/by/4.
0/),whichpermitsunrestricteduse,distribu-tion,andreproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinktotheCreativeCommonslicense,andindicateifchangesweremade.
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