The Healthy Beverage Index Is Associated with Reduced Cardio-metabolic Risk in US Adults: A Preliminary Analysis Kiyah J. Duffey, PhD Brenda M. Davy, PhD, RD

Table 1: Description of the Healthy Beverage Index (HBI) score components Beverage Component Description Points 1. Water Water comprises at least 20% of fluid requirements 15   No water consumption Water <20% of fluid requirements Proportional points for intake > 0% - < 20%1 2. Coffee & Tea Unsweetened coffee and tea comprise 0-40% of fluid requirements 5 3. Low Fat Milk <1.5%, skim, and/or soy milk comprises 0-16% of fluid requirements 4. Diet Drinks Artificially sweetened beverages, including coffee & tea, comprise 0-16% of fluid requirements 5. 100% Fruit Juice 100% fruit juice comprises 0-8% of fluid requirements 6. Alcohol Between 0-1 drinks2 for women, 0-2 drinks for men 7. 2% or Whole Fat Milk 0% of fluid requirements come from 2% or whole fat milk 8. Sugar-sweetened beverages 0-8% of fluid requirements come from sugar-sweetened Soda, Fruit Drinks, Sweetened Coffee or Tea, Other Sweetened Beverages3, Other Beverages4 9. Total Beverage Energy Energy from beverages <10% of total energy 20 Energy from beverages ≥10% but <15% of total energy proportional points based on reported intake1 Energy from beverages ≥15% of total energy 10. Met Fluid Requirements Amount (mL) of beverages consumed was ≥ fluid requirements Amount (mL) of beverages consumed was < fluid requirements 1Proportional points were assigned as follows: Proportional Score for Water = ((mL of Water * 15) / (0.20 * Total Fluid Requirements)); Proportional Score for Total Beverage Energy, energy from beverages = ((15 – Percent energy from beverages)*3.3333333) where energy from beverages is ≥10% - ≤14%; Proportional score for Met Fluid requirements = ((mL of Water * 15) / (0.20 * Total Fluid Requirements)) where total fluid requirements = 1 mL per 1 kcal of food consumed. 2 One drink is defined as the following: beer - 12 oz, 354.84 grams/mL; wine - 5 oz, 147.85 grams/mL; liquor - 1.5 oz, 44.355 grams/mL 3 Includes beverages like sweetened coffee and tea, and Horchata (a Mexican/Spanish sugar-sweetened beverage). 4 Includes meal replacement and nutritional supplement drinks

Table 2: Examples1 of daily beverage intake from NHANES participants that would provide a healthy and typical Healthy Beverage Index (HBI) score for a US adult (≥ 19 years) with a daily energy requirement of 2000 kcal   “Healthy” Beverage Pattern “Typical” Beverage Pattern Category Beverage Consumed (kcal) Fluid (ml) per Component HBI Score Beverage Consumed (Amount) 1. Water Tap Water Bottled Water 1000 500 15 Tap water 250 9 2. Coffee & Tea Black Coffee Green Tea 5 237 3. Low Fat Milk Skim milk (90 kcal) None 4. Diet Drinks Diet Soda 5. 100% Fruit Juice 6. Alcohol Red wine (106 kcal) 148 7. Whole Fat Milk [Insert slide contents here] 1 These are examples of actual beverage intake drawn from observed consumption patterns in the NHANES sample and are based on individuals whose total daily energy requirements are 2,000 kcal. Values – including those of beverages and the HBI score – are rounded in this table for illustrative purposes. The “healthy” pattern represents consumption which would result in a very high HBI score; the “typical” pattern is more representative of the population’s reported intake. Data are drawn from adults, aged ≥19 years, from NHANES 2005-2010. 1 mL = 0.033814 fl oz.

“Healthy” Beverage Pattern “Typical” Beverage Pattern Table 2: Examples1 of daily beverage intake from NHANES participants that would provide a healthy and typical Healthy Beverage Index (HBI) score for a US adult (≥ 19 years) with a daily energy requirement of 2000 kcal (continued)   “Healthy” Beverage Pattern “Typical” Beverage Pattern Category Beverage Consumed (kcal) Fluid (ml) per Component HBI Score Beverage Consumed (Amount) 8. Sugar-Sweetened Beverages None 15 Soda (200 kcal) Vanilla Latte (290 kcal) 500 250 9. Total Beverage Energy < 10% total energy intake - 20 >14% total energy intake 10. Met Total Fluid Requirements (2000 ml needed) 17 Total Fluids Consumed 2648 ml 1737 ml Total Beverage Energy 196 kcal 490 kcal Total HBI Score 100 56 1These are examples or requirements of actual beverage intake drawn from observed consumption patterns in the NHANES sample and are based on individuals whose total daily energy are 2,000 kcal. Values – including those of beverages and the HBI score – are rounded in this table for illustrative purposes. The “healthy” pattern represents consumption which would result in a very high HBI score; the “typical” pattern is more representative of the population’s reported intake. Data are drawn from adults, aged ≥19 years, from NHANES 2005-2010. 1 mL = 0.033814 fl oz.

Table 3: Distribution of individual beverage components1 and means (SD) within Healthy Beverage Index (HBI) quartiles of US adults (≥ 19 years), NHANES 2005-2010.   HBI Quartile Component Full Sample 1 2 3 4 1. Water 11.80 (0.09) 3.83 (0.16) 12.89 (0.11) 12.83 (0.10) 14.10 (0.06) 2. Coffee & Tea 4.17 (0.03) 4.31 (0.05) 4.44 (0.03) 4.16 (0.04) 3.94 (0.04) 3. Low Fat Milk 4.67 (0.02) 4.74 (0.04) 4.66 (0.04) 4.53 (0.04) 4.73 (0.02) 4. Diet Drinks 4.43 (0.02) 4.72 (0.03) 4.70 (0.03) 4.47 (0.04) 4.10 (0.05) 5. 100% Fruit Juice 4.08 (0.02) 3.65 (0.06) 3.84 (0.05) 3.96 (0.04) 4.50 (0.03) 6. Alcohol 3.78 (0.04) 3.41 (0.07) 3.38 (0.06) 3.53 (0.06) 4.36 (0.03) 7. Whole Fat Milk 3.13 (0.04) 2.33 (0.06) 2.54 (0.07) 3.26 (0.05) 3.79 (0.04) 8. Sugar Sweetened Beverages 6.87 Su (0.12) 0.85 (0.09) 1.40 (0.11) 7.96 (0.18) 12.47 (0.10) 9. Total Beverage Energy 7.68 (0.12) 0.44 (0.03) 1.04 (0.07) 5.18 (0.16) 16.87 (0.11) 10. Met Total Fluid Requirements 17.55 (0.05) 15.31 (0.13) 18.20 (0.07) 17.56 (0.08) 18.16 (0.07) Total HBI 68.17 (0.24) 43.59 (0.13) 57.09 (0.05) 67.44 (0.06) 87.03 (0.15) 1 Values are mean (SD) for each component of the HBI. The HBI scores range from 0-100, with a higher score indicating a healthier beverage pattern. Data are drawn from NHANES 2005-2010 for adults, aged ≥ 19 years.

Odds Ratio (95% Confidence Interval) Table 4: Odds Ratios of cardio-metabolic outcomes1 associated with a 10-point higher Healthy Beverage Index (HBI) score among US adults (≥ 19 years), NHANES 2005-2010. Odds Ratio (95% Confidence Interval) Cardio-metabolic outcomes Males Females Normal Weight Overweight/Obese High Waist Circumference 0.64 (0.47, 0.87)* 1.03 (1.01, 1.04)* 0.96 (0.90, 1.03) 1.00 (0.99, 1.01) Hypertension 0.96 (0.92, 1.00)* 0.97 (0.93, 1.00)** High Fasting Glucose 1.01 (0.99, 1.04) 0.98 (0.95, 1.01) High Fasting Insulin 1.01 (0.92, 1.11) 0.96 (0.94, 0.99)* 0.96 (0.93, 0.99)* High Total Cholesterol 1.00 (0.96, 1.05) 0.97 (0.96, 0.99)* 1.00 (0.98, 1.01) High LDL-C 1.07 (0.99, 1.16) 0.96 (0.93, 1.00)* 0.97 (0.94, 1.00)* Low HDL-C 0.99 (0.97, 1.00) 0.95 (0.90, 1.00)* High Triglycerides 0.98 (0.94, 1.03) 0.89 (0.80, 1.00)* 1.00 (0.96, 1.06) Metabolic Syndrome 1.01 (0.97, 1.04) 1.01 (0.96, 1.05) High CRP 0.93 (0.86, 0.99)* 0.91 (0.83, 0.98)* 0.97 (0.94, 1.01) 1Estimates are from gender stratified multivariable poission regression models of a 10-point higher HBI score on each outcome of interest adjusting for age, race/ethnicity, total household income, highest level of educational achievement, marital status, total household size, total physical activity, total energy intake, and BMI (cardio-metabolic outcomes only where not stratified by overweight status). Models are further stratified by overweight/obese status when tests of interaction were statistically significant, p<0.10. Weight stratified models do not further control for BMI regardless of the outcome. Data are drawn from NHANES 2005-2010 for adults, aged ≥ 19 years. The HBI score ranges from 0-100, with a higher score indicating healthier overall beverage intake patterns. Abbreviations used: CRP, C-Reactive protein; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. The following dichotomous outcomes were used: High Waist Circumference, Men: >102 cm (40 inches), Women: >89 cm (35 inches); Hypertension, ≥ 140/90mmHg; High fasting glucose, ≥5.55 mmol/L (100mg/dL); High Fasting Insulin, >60 pmol/L; High total cholesterol, >5.18 mmol/L (200 mg/dL); High LDL-Cholesterol, >4.14 mmol/L (160 mg/dL); Low HDL- Cholesterol, Men: <1.04 mmol/L (40 mg/dL), Women: <1.295 mmol/L (50 mg/dL); High triglyceride, ≥1.695 mmol/L (150 mg/dL); High C-reactive protein, ≥ 0.6 mg/L (≥6 mg/dL). Metabolic Syndrome was considered present in anyone meeting three of the following five: high waist circumference, high triglycerides, low HDL-C, elevated blood pressure (≥ 130/85 mmHg), high fasting glucose. * Estimate is statistically significantly different from zero, p< 0.05. ** Estimate is statistically significantly different from zero, p< 0.10.

Table 5: Alternative specification models of the association between each 10-point higher Healthy Beverage Index (HBI) score and dichotomous cardio-metabolic outcomes1 among US adults (≥ 19 years), NHANES 2005-2010. Odds Ratio (95% Confidence Interval) Cardio-metabolic outcomes Males Females Normal Weight Overweight/Obese High Waist Circumference 0.65 (0.48, 0.88)* 1.02 (1.00, 1.04)* 0.96 (0.90, 1.03) 1.00 (0.99, 1.01) Hypertension 0.97 (0.94, 1.01) 0.98 (0.94, 1.01) High Fasting Glucose 1.02 (1.00, 1.05)* 0.99 (0.95, 1.02) High Fasting Insulin 1.02 (0.92, 1.13) 0.97 (0.95, 1.00)** 0.96 (0.94, 0.99)* High Total Cholesterol 1.00 (0.95, 1.05) 0.97 (0.95, 0.98)* 1.00 (0.98, 1.01) High LDL-C 1.07 (0.99, 1.16)** 0.97 (0.93, 1.00)** 0.97 (0.95, 1.01) Low HDL-C 1.01 (0.99, 1.02) 0.95 (0.90, 1.01) High Triglycerides 1.01 (0.97, 1.05) 0.90 (0.81, 1.01)** Metabolic Syndrome 1.05 (1.02, 1.08)* 1.02 (0.97, 1.07) High CRP 0.94 (0.88, 1.00)** 0.93 (0.87, 1.01)** 1.00 (0.96, 1.03) 1Estimates are from gender stratified multivariable poission regression models of a 10-point higher HBI score on each outcome of interest adjusting for age, race/ethnicity, total household income, highest level of educational achievement, marital status, total household size, and total physical activity. Models are further stratified by overweight/obesity status when tests of interaction indicated statistically significant different effects, p<0.10. Alternative model specifications, which further controlled for total energy intake and BMI (in cardio-metabolic outcomes only), can be found in the Table 3. Data are drawn from NHANES 2005-2010 for adults, aged ≥ 19 years. The HBI scores range from 0-100, with a higher score indicating a healthier diet pattern. Abbreviations used: CRP, C-Reactive protein; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. The following dichotomous outcomes were used: High Waist Circumference, Men: >102 cm (40 inches), Women: >89 cm (35 inches); Hypertension, ≥ 140/90mmHg; High fasting glucose, ≥5.55 mmol/L (100mg/dL); High Fasting Insulin, >60 pmol/L; High total cholesterol, >5.18 mmol/L (200 mg/dL); High LDL-Cholesterol, >4.14 mmol/L (160 mg/dL); Low HDL- Cholesterol, Men: <1.04 mmol/L (40 mg/dL), Women: <1.295 mmol/L (50 mg/dL); High triglyceride, ≥1.695 mmol/L (150 mg/dL); High C-reactive protein, ≥ 0.6 mg/L (≥6 mg/dL). Metabolic Syndrome was considered present in anyone meeting three of the following five: high waist circumference, high triglycerides, low HDL-C, elevated blood pressure (≥ 130/85 mmHg), high fasting glucose. * Estimated odds ratio is statistically significantly different from one, p< 0.05. ** Estimated odds ratio is statistically significantly different from one, p< 0.10.  

β coefficient (Standard Error) Table 6: Association of each 10-point higher Healthy Beverage Index (HBI) score with cardio-metabolic and anthropometric outcomes in healthy US adults (≥ 19 years)1, NHANES 2005-2010.   β coefficient (Standard Error) Males Females Normal weight Overweight/Obese Waist Circumference -0.07 (0.09) -0.11 (0.17) 0.20 (0.11)** 0.15 (0.11) Systolic BP 0.01 (0.09) 0.07 (0.09) Diastolic BP 0.01 (0.10) 0.19 (0.11) Fasting Glucose -0.23 (0.18) -0.24 (0.11)* Fasting Insulin 0.09 (0.14) -0.14 (0.13) Total Cholesterol -0.32 (0.49) -1.01 (0.29)* 0.37 (0.32) 0.40 (0.30) LDL-C -0.69 (0.64) -0.84 (0.37)* 0.23 (0.32) HDL-C -0.30 (0.16)** 0.28 (0.11) Triglycerides -0.99 (0.52)** -1.08 (0.56)** -1.12 (0.51)* High CRP -0.001 (0.001) 1 Estimated associations of continuous level of each cardio-metabolic outcome on 10-point higher HBI score are derived from gender and weight stratified (where appropriate, with significant interaction term p<0.10) linear regression models adjusting for age, race/ethnicity, total household income, highest level of educational achievement, marital status, total household size, and total physical activity. The HBI scores range from 0-100, with a higher score indicating a healthier diet pattern. Healthy individuals are those who do not meet the criteria to be classified using the dichotomous cut points for: High Waist Circumference, Men: >102 cm (40 inches), Women: >89 cm (35 inches); hypertension, ≥ 140/90mmHg; High fasting glucose concentration, ≥5.55 mmol/L (100mg/dL); High Fasting Insulin concentration, >60 pmol/L; High total cholesterol concentration (TC), >5.18 mmol/L (200 mg/dL); High LDL-Cholesterol concentration (LDL-C), >4.14 mmol/L (160 mg/dL); Low HDL- Cholesterol concentration (HDL-C), Men: <1.04 mmol/L (40 mg/dL), Women: <1.295 mmol/L (50 mg/dL); High triglyceride concentration, ≥1.695 mmol/L (150 mg/dL); High C-reactive protein concentration (CRP), ≥ 0.6 mg/L (≥6 mg/dL). * Estimated coefficient is significantly different from zero, p<0.05 ** Estimated coefficient is significantly different from zero, p<0.10