1. 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

2. 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)* ) 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, grams/mL; wine - 5 oz, grams/mL; liquor oz, 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

3. 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
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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 mL = fl oz.

4. “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 mL = fl oz.

5. Table 3: Distribution of individual beverage components1 and means (SD) within Healthy Beverage Index (HBI) quartiles of US adults (≥ 19 years), NHANES
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 for adults, aged ≥ 19 years.

6. 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
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 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.

7. 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
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< 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 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.

8. 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
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)
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