Sodium and Sugar in Complementary Infant and Toddler Foods Sold in the United States
- Mary E. Cogswell, DrPH, RNa,
- Janelle P. Gunn, RD, MPHa,
- Keming Yuan, MSa,
- Sohyun Park, PhDb, and
- Robert Merritt, MAa
OBJECTIVES: To evaluate the sodium and sugar content of US commercial infant and toddler foods.
METHODS: We used a 2012 nutrient database of 1074 US infant and toddler foods and drinks developed from a commercial database, manufacturer Web sites, and major grocery stores. Products were categorized on the basis of their main ingredients and the US Food and Drug Administration’s reference amounts customarily consumed per eating occasion (RACC). Sodium and sugar contents and presence of added sugars were determined.
RESULTS: All but 2 of the 657 infant vegetables, dinners, fruits, dry cereals, and ready-to-serve mixed grains and fruits were low sodium (≤140 mg/RACC). The majority of these foods did not contain added sugars; however, 41 of 79 infant mixed grains and fruits contained ≥1 added sugar, and 35 also contained >35% calories from sugar. Seventy-two percent of 72 toddler dinners were high in sodium content (>210 mg/RACC). Toddler dinners contained an average of 2295 mg of sodium per 1000 kcal (sodium 212 mg/100 g). Savory infant/toddler snacks (n = 34) contained an average of sodium 1382 mg/1000 kcal (sodium 486 mg/100 g); 1 was high sodium. Thirty-two percent of toddler dinners and the majority of toddler cereal bars/breakfast pastries, fruit, and infant/toddler snacks, desserts, and juices contained ≥1 added sugar.
CONCLUSIONS: Commercial toddler foods and infant or toddler snacks, desserts, and juice drinks are of potential concern due to sodium or sugar content. Pediatricians should advise parents to look carefully at labels when selecting commercial toddler foods and to limit salty snacks, sweet desserts, and juice drinks.
What’s Known on This Subject:
US children consume excessive amounts of sodium and substantial amounts of added sugars. Early life exposures to salt and sugar can set taste preferences and health trajectories.
What This Study Adds:
A substantial proportion of toddler meals and other commercial foods meant for children age ≥12 months are of potential concern because of their high sodium content or presence of ≥1 added sugar.
Approximately 79% of US children aged 1 to 3 years exceed the upper level of 1500 mg/d of sodium recommended by the Institute of Medicine (IOM) for this age group, and 23% of US children aged 2 to 5 years are overweight or obese.1–3 Obesity and excess sodium intake are associated with an increased risk of high blood pressure among children,2,4–6 and children with high blood pressure are more likely to develop hypertension as adults and, subsequently, cardiovascular disease.7,8 Because of the association of added sugar content to obesity and chronic diseases,9,10 the Dietary Guidelines for Americans, 2010, recommends limiting added sugar intake to no more than 5% to 15% of total energy intake.11 On average, 13% of total energy intake among US children aged 2 to 5 years is from added sugars.12
Pediatricians can play an important role in counseling parents about the appropriate foods to feed young children for a healthy diet and thus aid in the prevention of obesity, high blood pressure, and the subsequent increased risk of heart disease and stroke. Early life exposures to sodium and sugar can set taste preferences and determine health trajectories.13–15 Furthermore, the majority of US children visit pediatricians annually, thus providing opportunities for counseling parents about food choices for their children.16 According to the 2014 American Academy of Pediatrics Nutrition Handbook, “food choices to be encouraged, whether home or commercially prepared, are those with no added salt or sugar.”17
There are gaps in the data regarding the sodium and sugar content of commercial US foods marketed for infants and toddlers. Studies with information on the sodium and sugar content of complementary foods sold in the United States are outdated18–21 or include few or no toddler foods.18–24 Studies conducted in other countries22–26 may not apply to the nutrient content of foods sold in the United States. National intake recommendations and food regulations differ, for example, between the United States and Canada27,28; different types of food may be offered, and differences in the same type of food may exist.29 Nutrition information on added sugar content is not available, with previous studies relying on total sugar content.25,26,30 The sodium density of specific categories of foods marketed to infants and toddlers is unknown. Among US children aged 1 to 3 years, mean sodium intake density is ∼1400 mg of sodium per 1000 kcal compared with 550 mg/1000 kcal among infants, suggesting toddlers compared with infants consume foods that are significantly more sodium dense.1,31,32
The objectives of the present study were to determine the sodium and sugar content of commercial infant and toddler foods sold in the United States and to identify food products high in sodium or sugar content or containing added sugars.
We initially used the commercial Gladson Nutrition Database33 to identify the US infant and toddler foods and brands. The Gladson database includes package information (eg, Nutrition Facts label and full ingredient lists) for >200 000 products. In this database, 1495 infant and toddler food products were identified by searching for the terms “baby” or “toddler” in the category and description fields. Infant formulas, fortified milk, and oral electrolytes were excluded because they are regulated by the US Food and Drug Administration (FDA) for labeling and nutrition content.34
We confirmed or updated information from the Gladson database and added additional products through searching brand or manufacturer Web sites of the foods identified. Additional information was obtained through purchases from 5 metropolitan Atlanta retail/wholesale grocers (Kroger, Publix, Target, Costco, and Wal-Mart) listed among the top 10 food retailers and wholesalers in the United States and Canada in 2013.35 Purchases included private label products (n = 37) and products without information on manufacturer Web sites (n = 26). No private label infant or toddler products were found at Costco. As in a Canadian study,25,26 we identified food products for purchase from the section labeled as “baby” or “infant” foods and purchased a sample of each of unique product. Data were confirmed and/or collected from March through December 2012. Duplicates, and products that we could not confirm as being present in the marketplace during that period, were deleted; the result was a final sample of 1074 separate food products, some representing the same food type (eg, different brands of apple sauce). Information was entered from the Nutrition Facts label and the ingredient list to capture sodium and sugar content. The majority of the nutrition information came from manufacturer’s Web sites (n = 889 products), with the remainder from purchased products (n = 63) and the Gladson database (n = 122).
Food categories were based on those used to set the FDA’s reference amount customarily consumed per eating occasion (RACC) according to age for infant and toddler foods.36 Food products were categorized based on the food type, intended age or developmental stage, and manufacturer defined serving size (eg, stage 1 vegetables) (Table 1). Categories were further combined or split on the basis of the listed ingredients. For example, ready-to-serve fruits of the strained or junior type were combined and examined separately from ready-to-serve junior type dairy-based desserts and ready-to-serve junior type dinners, vegetables, or soups. The term “infant” was used for complementary food products aimed at children aged 4 to 12 months (stages 1‒3) and “toddler” foods for foods aimed at children aged 12 to 36 months (stage 4).
Currently, no standard guidelines exist for assessing sodium or sugar content of complementary infant and toddler foods. We identified the amount of sodium and sugar in selected foods from the Nutrition Facts label and used other information on the label to assess content by using 3 constructs: (1) per 100 g (concentration); (2) per serving; and (3) in relation to calories. The ingredient list was also examined to identify the presence of added sugars. Nutrient concentrations (milligrams per 100 g) account for variability in serving sizes across food categories. Nutrient content per standard serving (the assigned RACC provided in Table 1) allows comparison of the nutrient content across brands for the same food type or category and is meant to reflect the amount consumed. Examining the nutrient content in relation to calories (per 1000 calories or percentage of calories) allows comparisons in the nutrient content across foods adjusting for the caloric content. This adjustment is important because sugar is a source of calories and persons who consume more calories generally have higher sodium intake.
Sodium content was evaluated in 3 ways: (1) sodium concentration (milligrams per 100 g); (2) sodium per RACC; and (3) sodium density (milligrams per 1000 kcal). High sodium content was defined as >210 mg of sodium per RACC. After evaluating various approaches to define high sodium content,25,26,35–37 we used a similar approach to the Elliott study25,26 to define high sodium content for each food product but used the recommendations of the United States Department of Agriculture (USDA) MyPlate27 to determine the total recommended servings per day rather than Canada’s Food Guide.28 Sodium content was defined as high based on the IOM’s dietary reference intakes for sodium for children aged 1 to 3 years2 and 7 daily servings from the grains, protein, and dairy food groups to meet recommended intakes according to the USDA’s MyPlate for children aged 2 to 3 years.27 For sodium, this corresponds to 210 mg of sodium per serving (a tolerable upper intake level of 1500 mg divided by 7 servings). In addition, low-sodium products were identified as containing ≤140 mg/RACC (an adequate intake of 1000 mg divided by 7 servings). This level (≤140 mg/RACC) also corresponds with FDA regulations related to labeling a product as low in sodium, which is useful for those wanting to limit sodium intake.
Sugar content of the selected foods was evaluated in 4 ways: (1) sugar concentration (milligrams per 100 g); (2) sugar per RACC; (3) percentage of calories from sugar; and (4) presence of added sugars. High sugar content was defined as >35% of total calories from sugar. However, products high in fat or protein may be lower in the relative calories from sugar. Thus, we also defined products of potential concern as including ≥1 added sugar in the ingredient list. In lieu of information on the amount of added versus naturally occurring sugars, the IOM recommendations for Nutrition Standards for Food in Schools was used.38 These standards state that snacks, foods, and beverages should provide no more than 35% of calories from total sugars per portion as packaged. Exceptions are 100% fruits and fruit juices without added sugars, 100% vegetables and vegetable juices without added sugars, and unflavored nonfat and low-fat milk and yogurt. Thus, we did not report the proportion of products high in sugar content (>35% of calories from total sugars) for categories including these foods. All but 1 of the dairy-based dessert products were flavored, and we therefore included this category in our analysis. In addition, we identified whether a product may be of concern because it contained added sugars. Ingredients qualifying as added sugars were identified by using lists from the Dietary Guidelines for Americans, 2010,11 and USDA’s MyPlate27 recommendations and included sugar, sweetener, syrup, corn syrup, high-fructose corn syrup, honey, fructose, malt, maltose, molasses, dextrose, glucose, lactose, sucrose, turbinado, and trehalose. As other studies have done, the present study included “juice concentrate” or “cane” (juice, syrup, or sugar) as sources of added sugars.9,39 If a food product included ≥1 source of added sugars (as identified earlier) in the ingredients list, it was categorized as including added sugars. Products with at least 1 source of added sugars and >35% of total calories from sugar were also examined.
For each food category, mean and 95% confidence intervals were calculated for sodium content. We also estimated the proportion of products within a specific food category with the following: (1) low sodium content; (2) high sodium content; (3) high sugar content; (4) with ≥1 added sugar; or (5) with both high sugar content and containing ≥1 added sugar. All statistical analyses were performed by using SAS version 9.3 (SAS Institute, Inc, Cary, NC).
Regarding infant food products, all but 2 of the 657 infant vegetables, dinners, fruits, dry cereals, and ready-to-serve mixed grains and fruits were low in sodium content (≤140 mg/RACC) (Table 2), and none was high in sodium (>210 mg/RACC). Seventy-two percent of toddler dinners were high in sodium content (>210 mg/RACC). Toddler dinners contained an average of 2295 mg of sodium per 1000 kcal (sodium 212 mg/100 g). Savory infant/toddler snacks (n = 34) contained an average of 1382 mg of sodium per 1000 kcal (sodium 486 mg/100 g); 1 was high sodium.
The majority of the infant vegetables, dinners, fruits, and dry/instant cereals did not contain added sugars. However, 52% of infant ready-to-serve mixed grains and fruits contained ≥1 added sugar and 44% also contained >35% calories from sugar. On average, infant mixed grains and fruits contained 9 g of sugar per 100 g, 10 g of sugar per RACC, and 47% of calories from total sugars (Table 3).
Thirty-two percent of toddler dinners and the majority of toddler cereal bars/breakfast pastries, fruit, and dry fruit-based snacks contained ≥1 added sugar. Thirty-five percent of cereal bars/breakfast pastries contained >35% of calories from total sugars and ≥1 added sugar. On average, these products contained 29 g of sugar per 100 g, 6 g of sugar per RACC, and 31% of total calories from total sugars. Eighty-eight percent of dry fruit-based snacks contained ≥1 added sugar and >35% of calories from total sugars. On average dry fruit-based snacks contained 60 g sugar/100 g, 9 g sugar/RACC, and 66% of calories from total sugars (Table 3).
Most infant/toddler savory snacks, desserts, and juices/drinks contained ≥1 added sugars, and 61% of dairy-based desserts contained at least 1 added sugar and >35% of calories from total sugars. Dairy-based desserts contained 12 g of sugar per 100 g, 12 g of sugar per RACC, and 51% of total calories from sugars (Table 3). The most commonly used added sugars were fruit juice concentrate (56%), sugar (33%), cane (20%), syrup (15%), and malt (7%). High-fructose corn syrup, molasses, honey, dextrose, fructose, and glucose were listed as an ingredient in 2% to 4% of the products examined (data not shown). In products containing an added sugar, 74% included the added sugar among the first 4 ingredients listed on the product label.
A substantial proportion of commercial toddler dinners or meals sold in the United States are high in sodium content. Although infant/toddler savory snacks or sides are not generally high in sodium content per standard serving, they have the highest sodium concentration (ie, “saltiness”). In addition, the majority of products in categories with some toddler foods (ie, toddler cereal bars/breakfast pastries, fruits and dry fruit-based snacks, infant/toddler savory snacks, desserts, fruit drinks), contained ≥1 added sugar as an ingredient. In contrast, the majority of commercially prepared foods for infants only (ie, vegetables, dinners, fruit, dry/instant cereals) are generally low in sodium and total sugars and did not contain added sugars. The 1 exception was ready-to-serve, mixed grains and fruits, for which a substantial proportion of products were high in total sugars and contained at least 1 added sugar as an ingredient. Although “fruit juice concentrate” was the primary added sugar in the products evaluated in the present study, a substantial proportion of products also contained “sugar,” “cane,” or other types of sugars. These results are somewhat concerning, given the research suggesting that exposure to sodium and added sugars in early life can affect taste preferences, intake, and health later in life.13–15,40
Our study is the most recent and comprehensive research on the sodium and sugar content of US commercial infant and toddler food products. Despite differences in thresholds used to identify excess nutrient content, food products, and food categories, our overall findings on sodium and total sugar content are similar to the Canadian studies indicating25,26 many types of infant and toddler food products did not have low sugar or sodium content. In the present study, ∼7 of 10 toddler dinners or meals were high in sodium content and sodium dense. The concentration of sodium in infant/toddler savory snacks was comparable with plain salted potato chips sold to the general population (450-mg sodium/100 g for plain salted potato chips).41 The average amount of calories from sugar in toddler dry fruit-based snacks and cereal bars and breakfast pastries also did not differ from similar products meant for older children and adults, such as fruit leather pieces (62% of calories from total sugars) and strawberry toaster pastries (32% of calories from total sugars).
A substantial proportion of products contained ≥1 added sugar in their ingredient list, even foods not typically thought of as sweet. Approximately 1 in 3 toddler dinners and meals and 7 of 10 infant/toddler savory snacks contained ≥1 added sugar. Sugars are known to elicit a positive response at birth, and research shows that at an early age, the addition of sugar, even in small amounts, may enhance liking for products that are high in sodium per serving or high in sodium concentration (ie, salty).13
Our study is subject to limitations. First, sodium, sugar, and calorie content are based on the label, not laboratory analysis. According to FDA regulatory standards, the nutritional values on the label can vary from the actual value by as much as ±20%.42 Second, the Nutrition Facts label does not include the amount of added sugars, separate from total sugar. We included qualitative data from the ingredient list on the presence of added sugars in the products but could not quantify the amount. In addition, fruit juice concentrate is considered an added sugar only if not diluted to 100% juice, and we were unable to consistently evaluate these details from the package information. Third, when comparing the ratio of a nutrient to total calories, products high in total calories from sources other than those evaluated (eg, fat) may seemingly be lower in sugar and sodium and need to be interpreted with caution. Finally, we examined sales data to choose grocery stores and checked Web sites for top-selling brands of infant and toddler products, but our database lacks sales or market share data for individual food products, and it is possible we missed products.
Parents can be reassured that commercial foods for infants (eg, vegetables, dinners, plain fruit [without grains], dry cereals) sold in the United States in 2012 were generally acceptable in sodium and sugar content. However, the majority of snacks, desserts, or juice drinks for infants or toddlers, and many commercial foods meant for toddlers aged ≥12 months were either high in sodium content or contained ≥1 added sugar. Many types of commercial infant and toddler foods had higher or equivalent levels of sodium and sugars to products sold for older children or adults. As indicated in the American Academy of Pediatrics’s 2014 Pediatric Nutrition Handbook, parents and caregivers can be advised to read labels and choose products or food types lower in sodium.17 The proposed changes to the nutrition label to include information on added sugars30 may also help parents make better choices. Products high in naturally occurring sugars, such as plain pureed fruits are an important source of other required nutrients; however, some may be a significant source of added sugar. Key advice for parents includes limiting juice and avoiding sugar-sweetened beverages and energy-dense, nutrient-poor snacks; if purchasing commercial toddler foods, the labels should be checked for sodium and added sugar. Reducing excessive sodium and added sugar intake from birth to 24 months can help set taste preferences and lead to better health for children now and as they grow.
The authors thank Jennifer Seymour, PhD, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, for her thorough review of the original draft of the article and Joyce Maalouf for her work creating the database and earlier work on this study.
- Accepted November 25, 2014.
- Address correspondence to Mary E. Cogswell, DrPH, RN, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop F72, Atlanta, GA 30341. E-mail:
Dr Cogswell contributed to the study concept and design, categorized the foods, developed the analytic plan, and drafted and revised the manuscript; Ms Gunn assisted in the study design, helped with the development of the database and data interpretation, and revised the manuscript for critical content; Mr Yuan analyzed the data; Dr Park assisted in the study design and revised the manuscript for critical content; and Mr Merritt conceptualized and designed the study, and revised the manuscript for critical content. All authors approved the final manuscript as submitted.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
FINANCIAL DISCLOSURE: The authors have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Centers for Disease Control and Prevention.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 550, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2014-4028.
- Copyright © 2015 by the American Academy of Pediatrics