Letters to the Editor
Statements appearing here are those of the writers and do not represent the official position of the American Academy of Pediatrics, Inc. or its Committees. Comments on any topic, including the contents of Pediatrics, are invited from all
members of the profession: those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.
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Letters should be submitted in duplicate in double-spaced typing on plain white paper with name and address of sender(s) on the letter. Send them to Jerold F. Lucey, MD, Editor, Pediatrics Editorial Office, Fletcher Allen Health Care, Burlington, VT 05401.
Fruit Juice Consumption
To the Editor.—
This letter is in response to the article “Excess Fruit Juice Consumption by Preschool-aged Children Is Associated With Short Stature and Obesity” published in the January 1997 issue of
Pediatrics.
After reviewing the study, I believe this is a classic example of conclusions drawn by statistical treatment of inadequate or incom-plete data. The study does not successfully establish cause and effect, does not reflect the activity level, genetic background or overall nutrition of the children, and does not distinguish between the nutritional content of the juices children are drinking. Addi-tionally, the sampling size for “excessive juice drinkers” is too small to be able to draw sound statistical conclusions.
Although the title states that excess fruit juice consumption is associated with short stature and obesity, it is only after statistical adjustments were made for “maternal height, child age, child sex, and child age-sex interaction” that the authors find an association between juice consumption and short stature.
Additionally, the study does not account for the paternal ge-netic background of the children or their overall nutrition. The authors suggest that some children may be substituting extra juice for more nutritious foods, but the study gives no evidence for this. In fact, the group consuming a high amount of juice had a total caloric intake that was higher on average and would be accounted for by an extra 1 to 2 glasses of fruit juice or sugar-based drink.
Finally, the study does not distinguish between the nutritional content of different juices. The study should have separated the juice types. And the authors show no concern that the consump-tion of soda significantly increased among 2- to 5-year-olds.
The fact is not all juices are created equal and orange juice provides a nutritional benefit to children and adults. It is fat-free and sodium-free, does not have any added sugar, and citrus fruits are especially recommended by the National Research Council for daily fruit servings.
The Food and Drug Administration (FDA) has established def-initions for use in nutrition labeling, and orange juice qualifies as being an excellent source of vitamin C and a good source of folate, thiamin, and potassium.
William Stinson, PhD
Scientific Research, Processed Products Florida Department of Citrus
Lakeland, FL 33802-0148
To the Editor.—
The recently published article entitled, “Excess Fruit Juice Con-sumption by Preschool-aged Children Is Associated With Short Stature and Obesity,”1raises some interesting questions.
How-ever, we believe clarification is needed on a number of points before any definitive conclusions can be drawn from the data. First, the cutoff points used throughout the paper are not the standards routinely used and we believe create some confusion. The authors classify stunting as less than 20% height for age and overweight as a body mass index (BMI) greater than the 75th percentile. However, the Third Report on Nutrition Monitoring in the
United States2uses the more commonly accepted standard of the
5th percentile of the National Center for Health Statistics growth reference to define shortness and the 95th percentile of BMI as the cutoff for overweight. If these more traditional cutoff points were used, would the authors still see differences in shortness and overweight in the two groups of children?
Also it is curious that “excessive” fruit juice consumers were defined as children drinking 12 ounces or more a day of juice. What is the scientific basis of deciding 12 ounces as the cutoff point for excessive?
The authors use the mother’s height as an independent variable to explain the child’s height. Why was the father’s height not recorded?
From the data presented in the paper, short children consumed adequate energy and a sufficient amount of protein. Therefore, it is unclear why the authors believe that dietary factors are contrib-uting to the short stature. What would be the presumed mecha-nism? This is unclear in the discussion.
Finally, we believe that researchers must be extremely cautious in making any strong statements about juice consumption and growth based on a sample of only 19 children— only 4 children were in the 5-year-old age category.
Eileen Kennedy, DSc, RD
Howard Riddick, PhD
Carol Kramer-LeBlanc, PhD
Carole Davis, MS, RD
US Department of Agriculture, Center for Nutrition Policy and Promotion
Washington, DC 20036
REFERENCES
1. Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics. 1997;99:15–22
2. Interagency Board for Nutrition Monitoring and Related Research. Third Report on Nutrition Monitoring in the United States, I. Washington, DC: Federal of American Societies for Experimental Biology, Life Sci-ences Research Office; 1995
To the Editor.—
The recent article by Dennison et al1 deals with potentially
important issues in child nutrition. However, the article provides insufficient evidence to support the conclusions that are mainly drawn by comparing only 19 children drinking fruit juice$12 fl oz per day (HF) vs 149 children drinking,12 fl oz fruit juice (LF). The results of this study raise several questions and also some possibilities for different interpretations of the data. The duration of fruit juice consumption is not reported. Is that duration suffi-ciently long in 2-year-old children (who form the majority of the HF group, N515) to have any meaningful association with their height and weight? Could this be a “true but unrelated” associa-tion? Greater energy intake of the HF group could also suggest increased intake of foods other than fruit juice alone. It is also conceivable that parents of shorter children overzealously include fruit juice in children’s diet as a “healthful food” to help them
grow better. The argument of the authors that fruit juice may cause malabsorption severe enough to impair growth is inconsis-tent with the occurrence of obesity that is associated with fruit juice consumption. Although statistically significant, are the body weight and height differences in HF and LF groups biologically significant? The height of the HF group was lower by only 3.3% than that of the LF group (34 inches vs 35 inches in 2-year-old children) and the mean body weight (calculated from the mean group height and body mass index) of the HF group was actually lower by about 0.5 lb than the LF group. In general, fruit juices provide plenty of vitamin C, some minerals and proteins, besides carbohydrates, and are not “empty calories” as implied by the authors. This study may unnecessarily steer parents away from feeding fruit juice to children. A better designed longitudinal rather than a cross-sectional study is needed to draw meaningful conclusions.
Nikhil V. Dhurandhar, PhD
University of Wisconsin—Madison Medical School Beers-Murphy Clinical Nutrition Center
Madison, WI 53706-1571
REFERENCE
1. Dennison BA, Rockwell HL, Baker SL. Excessive fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics. 1997;99:15–22
In Reply.—
The data presented in this paper were collected as part of a study to determine optimal methods to assess young children’s dietary intake. By using the mean of 7 days of dietary data, we were better able to describe an individual child’s “usual diet” than most studies that include fewer days of dietary data. However, we have no data regarding tracking of fruit juice consumption over time, age at which children started drinking fruit juice, or amounts of fruit juice consumed at younger ages. Child height was mea-sured using research caliber methods with a Harpenden Stadiom-eter (Cambridge, MD), which is accurate to 5 mm. Child body mass index (BMI) was calculated using the individual child’s height and weight, not the group’s mean height or mean weight. We did not inquire about the child’s father’s height or weight nor the child’s height or weight at birth as we did not anticipate a need for that information. We agree that future studies should consider these factors.
The relationship between children’s fruit juice intake and growth parameters was examined after we noted that a number of children in the study seemed to drink a lot of fruit juice. Please refer to page 16 of the journal article for our reasons for choosing 12 fl oz/day of fruit juice as a “cut point.” Common sense and dietary balance are two additional reasons. The US Department of Agriculture Food Guide Pyramid recommends two servings of fruit for those consuming 1600 kcal/day.1Although 12 fl oz of fruit
juice equals two fruit servings, most nutritionists recommend consumption of a variety of fruits and that not all fruit servings come from fruit juice. Twelve fl oz of fruit juice is about 180 kcal and represents approximately 15% of a 2-year-old child’s daily calorie intake. For comparison purposes, this is also, on average, the same number of calories contributed by dietary protein. Al-though we recognize that fruits and their respective juices differ in sugar content and concentration as well as nutritional value, we did not examine the relationship between growth parameters and different types of fruit juices.
As stated in the “Methods” section of the paper, definitions of obesity and short stature are relative and can be defined in a multitude of ways, all of which are somewhat arbitrary. Obesity definitions vary and include: weight.130% ideal body weight, triceps skinfolds thickness .85th percentile, BMI or ponderal index.95th,.85th, and/or.75th percentiles. The most widely accepted diagnostic criterion for the identification of obesity is a triceps skinfolds thickness in excess of the 85th percentile.2BMI
cutoff values corresponding to the 85th percentiles from the sec-ond NHANES (1976 –1980) have been selected for tracking the prevalence of overweight and monitoring the Healthy People 2000 objective 2.3.3The published BMI percentiles for children do not
include the 85th percentile; therefore, the published percentiles above and below the 85th percentiles were selected, ie, the 75th
and 90th percentiles.4We are not aware of any published
percen-tiles for ponderal index in children; therefore, the 90th age- and sex-specific percentiles from our own study population were used. Using these three definitions of obesity, the children who drank $12 fl oz/day of fruit juice were more likely to be overweight than children who drank less fruit juice (Figure 3).
Definitions of short (or tall) stature are less well-defined, and again, are relative and arbitrary. We did not use the word “stunt-ing,” which has certain connotations from research in child mal-nutrition, but rather referred to height in relative terms. Different cutpoints are appropriate for different purposes. It is quite com-mon to examine populations by quintiles, which is essentially what was done with height; children in the lowest height quintile were defined as “short.”
To avoid the use of cutpoints and arguments about their selec-tion, and to increase statistical power, multivariate models were used to examine the relationship between a child’s fruit juice consumption and his/her height and adiposity (Table 5). The children who drank$12 fl oz/day of fruit juice were significantly shorter. The adjusted mean height difference in the 2-year-old children was 2.8 cm (1.1 inches) and in the 5-year-old children was 4.7 cm (1.9 inches). These differences were statistically significant; whether they are clinically significant, or not, depends on one’s perspective. The children who drank$12 fl oz/day of fruit juice were significantly more overweight, especially as ascertained by ponderal index, which is thought to be a better measure of excess weight in growing children.5
We have reported an association of increased fruit juice con-sumption with short stature and with obesity. We have clearly stated in the paper that this is a cross-sectional study and that we
can not infer causality. Randomized, longitudinal studies are
needed to establish cause and effect. We agree with Dr Kennedy and colleagues that the reasons for the observed association be-tween excess fruit juice and short stature are not entirely clear and the mechanisms can only be postulated. It is certainly possible as Dr Dhurandhar suggests that parents of short children might give these children more fruit juice to drink than parents of taller children. Alternately, large amounts of fruit juice, which have been shown to cause malabsorption in some children, might con-tribute to decreased growth in some children. It is certainly possi-ble, even probapossi-ble, that overweight children, who consume rela-tively large amounts of fruit juice, might also consume excess amounts of other foods. The development of obesity is multifac-torial, with genetic, social, and environmental influences. We agree that additional longitudinal studies are needed to further evaluate these associations.
We concur that researchers need to be cautious. At the same time, this is the second study in young children to report an association between consumption of$12 fl oz/day of fruit juice and decreased height.6This study, however, puts the earlier case
report into perspective. In this population-based study, based on 7 days of dietary data, most children (89%) drank moderate amounts of fruit juice (,12 fl oz/day) and only a small fraction of children—16% (15/94) of 2-year-old children and 5% (4/74) of 5-year-old children— drank, on average,$12 fl oz/day of fruit juice. To suggest to parents, especially parents of young children, that .12 fl oz/day of fruit juice might be “too much” seems prudent, as well as cautious. We concur that additional research studies are needed to replicate these findings and to better under-stand the mechanisms involved. We would urge funding of lon-gitudinal dietary studies in young children.
Barbara A. Dennison, MD
Helen L. Rockwell, BS
Sharon Baker, MS
Bassett Healthcare
Cooperstown, NY 13326-1394
REFERENCES
1. US Department of Agriculture (USDA). Human Nutrition Information Service. The Food Guide Pyramid. (Home and Garden Bulletin No. 252). Washington, DC: US Department of Health and Human Services; 1992 2. Dietz WH. Nutrition and obesity. In: Grand RJ, Sutphen JL, Dietz WH, eds. Pediatric Nutrition: Theory and Practice. New York, NY: Butterworth; 1987:525
3. US Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington,
LETTERS TO THE EDITOR 729 at Viet Nam:AAP Sponsored on August 30, 2020
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4. Hammer LD, Kaemer HC, Wilson DM, et al. Standardized percentile curves of body mass index for children and adolescents. Am J Dis Child. 1991;145:259 –263
5. Ferichs RR, Harsha DW, Berenson GS. Equations for estimating per-centage of body fat in children 10 –14 years old. Pediatr Res. 1979;13: 170 –174
6. Smith MM, Lifshitz F. Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive. Pediatrics. 1994;93:438 – 443
The Case of the Missing Methylphenidate
To the Editor.—
Safer et al in their article “Increased Methylphenidate Usage for Attention Deficit Disorder in the 1990s,”1attempt to assuage
con-cerns that unprecedented increases in the production of methyl-phenidate in this country, as monitored by the Drug Enforcement Administration (DEA), do not reflect the actual increase in the use of the drug in American children. Dr Safer is acknowledged for his more than two-decade effort to assess the use of methylphenidate both on the local and national level. Unfortunately, we remain unconvinced by Dr Safer’s most recent data. We believe a signif-icant change has occurred in children’s use of methylphenidate in this country during the 1990s.
Any data about the prevalence and use of methylphenidate from the early 1990s must be viewed as already “dated.” As with any “epidemic,” prevalence rates can change rapidly. The 1992 aggregate production of methylphenidate was 3708 kg. The ap-proved level for 1997 is 13,824 kg, a 270% increase.2Very recent
data challenges the validity of extrapolating national trends of methylphenidate use from local or, for that matter, state surveys. As Safer noted there are 5-fold differences between states and within states greater than 10-fold variations by zip code have been documented.3
The United States produces 90% of the world’s methylpheni-date.4Australia has been the only other country to note a rise in
the use of methylphenidate.5In the United States the attention
deficit hyperactivity disorder (ADHD)/methylphenidate epi-demic appears to be concentrated within white middle- and upper middle-class America.6 All minorities, most notably
African-Americans, are underrepresented percentage-wise in recent sur-veys that have examined ethnicity as a factor.6,7 Thus, the data
from Baltimore County and Maryland Medicaid surveys—areas either more low-income or black—may be underestimating na-tional usage.
The question of whether methylphenidate is overprescribed based on presumed prevalence rates of ADHD may be impossible to answer and may not even be the right question to ask. Drawing from the analysis of zip code data and individual practitioners’ prescription rates, we believe that methylphenidate is both over-prescribed and underover-prescribed depending on local community standards. Despite attempts to standardize the diagnosis and treatment of ADHD,8the widely varying methylphenidate
pre-scription and usage patterns lead us to conclude that the ADHD diagnosis remains very much “in the eye of the beholder.” We are alarmed by well-documented reports of school districts where rates of elementary school-age boys taking methylphenidate are more than triple Safer’s national estimates of 3% to 4%.9
We believe such pockets of high usage and the overall increase in methylphenidate use represent a cultural shift in the acceptabil-ity of psychotropic medication to treat children’s performance and behavior problems.10We wish a similar effort to address these
problems with psychosocial interventions was as vigorous as treatment with methylphenidate. The large increase in methyl-phenidate use nationally also raises the always present liability of methylphenidate abuse.
Finally, we must ask where is all this methylphenidate going? Logic dictates the manufacturers will go to the effort and cost in producing the drug only if someone is willing to buy it. Similarly, why would most end purchasers of methylphenidate buy the drug if they didn’t intend to use it? Safer’s “guesstimate” of only a 2.5-fold increase of methylphenidate use in children between 1990 and 1995 leaves over six tons unaccounted for in 1995 alone. In-creased dosage frequency, longer duration of treatment, more teenagers and adults taking methylphenidate, illegal diversion,
and/or overseas shipments cannot account for all of this drug. Perhaps we should check in the Chesapeake Bay.
Lawrence Diller, MD
Private Practice
Walnut Creek, CA 94596 Department of Pediatrics
University of California, San Francisco San Francisco, CA 94143
Robert Morrow, MD
Private Practice Norfolk, VA 23508 Department of Pediatrics Eastern Virginia Medical School Norfolk, VA 23501
REFERENCES
1. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for atten-tion deficit disorder in the 1990s. Pediatrics 1996;98:1084 –1088 2. Federal Register. December 17, 1996;61FR66311
3. Drug Enforcement Administration. ARCOS Database 1995. Washington, DC: Department of Justice; 1996
4. UN International Narcotics Control Board. Report of the UN International Narcotics Control Board, 1994. New York, NY: Un Publication; 1995 5. Carmichael A. Improving diagnosis and management of attention
def-icit-hyperactivity disorder in Australia. Med J Australia. 1996;165: 464 – 465
6. Wilson P. IMS Report: Prescription Data. Presented at Stimulant Use in the Treatment of ADHD, Drug Enforcement Administration Conference; December, 1996; San Antonio, TX
7. Maurer P. African-American children less likely to get Ritalin. Clin Psychiatric News. 1996;24:1–2
8. American Academy of Pediatrics, Committee on Children with Disabil-ities and Committee on Drugs. Medication for children with attentional disorders. Pediatrics 1996;98:301–304
9. Morrow R, LeFever G. A Virginia Study. Presented at Stimulant Use in the Treatment of ADHD, Drug Enforcement Administration Conference; December, 1996; San Antonio, TX
10. Diller LH. The run on Ritalin: attention deficit disorder and stimulant treatment in the 1990s. Hastings Center Report. 1996;26:12–18
In Reply.—
We share Dr Diller and Dr Morrow’s concern about the sizable increase in methylphenidate use but their conclusions go beyond the data presented in our paper. We presented utilization data from several available sources, eg, school surveys, Medicaid and health maintenance organization settings, which contain patient-level data that yield population-based estimates on the prevalence of methylphenidate. We believe these estimates are more reliable measures of the extent of medication use than production quotas. Nevertheless, when viewed over 5 years, either measure reflects an important increase in utilization. What our data illustrate is that production quotas are appreciably overestimating the extent of the increase.
The 2.5-fold increase our data suggests cannot be used to sup-port either appropriate or inappropriate use. We have conjectured that the increase may be explained by increased treatment of females, longer duration of treatment, and by more favorable parental attitudes about drug therapy for behavioral problems. In addition, the DSM-IV criteria for attention deficit hyperactivity disorder (ADHD) are more inclusive than earlier versions of the DSM classification. Further, the expansion of disability criteria to include ADHD during the early 1990s may have led to increased utilization.
There are some points of inaccuracy and rhetoric in the letter to the editor to which we would like to respond. Whether methyl-phenidate’s increased use is justifiably called “an epidemic” re-mains to be seen. In the most recently published population-based prevalence estimate of this disorder and its pharmacotherapy, less than one-third of those diagnosed with ADHD were receiving stimulant therapy.1Second, we are unaware of published evidence
showing a concentration of the treatment among “middle- and upper middle-class” children, although African-Americans as a
DOI: 10.1542/peds.100.4.728
1997;100;728
Pediatrics
William Stinson
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