The Relationship between 100% Fruit Juice Consumption and Myopia in Adolescents and Young Adults: A Cross-Sectional Study Based on NHANES

doi:10.21203/rs.3.rs-4782382/v1

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The Relationship between 100% Fruit Juice Consumption and Myopia in Adolescents and Young Adults: A Cross-Sectional Study Based on NHANES

https://doi.org/10.21203/rs.3.rs-4782382/v1

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Objective

Given the increasing prevalence of myopia among the youth worldwide and the complex, unclear pathogenic mechanisms, this study delves into the potential connection between 100% fruit juice consumption and the risk of myopia. It aims to provide crucial scientific evidence for effective myopia prevention strategies, thus safeguarding visual health in this demographic.

Methods

This cross-sectional observational study is based on data from the 2003–2006 National Health and Nutrition Examination Survey (NHANES) in the United States. We included 906 adolescents and young adults, aged 12 to 25, who completed a non-cycloplegic vision examination. Participants were categorized into three groups based on their 100% fruit juice consumption: "never," "moderate," and "high" consumption groups. Using multivariable logistic regression models and adjusting for potential confounders such as age, gender, height, birthplace, family income, education level, race, and body mass index (BMI), we analyzed the association between 100% fruit juice consumption and the risk of myopia.

Results

Adjusted multivariate analysis revealed that both moderate and high consumption of 100% fruit juice were significantly associated with an increased risk of myopia (P < 0.05). Subgroup analysis indicated that this association was particularly significant among males and the 12–17 age group (P < 0.05). Additionally, interaction analysis suggested that birthplace, BMI, and race might be important moderators in the relationship between 100% fruit juice consumption and myopia risk (P < 0.05).

Conclusion

This study demonstrates a significant association between 100% fruit juice consumption and an increased risk of myopia in adolescents and young adults, with this link being more pronounced in specific populations such as males and younger age groups. These findings provide essential evidence for developing myopia prevention strategies, highlighting the impact of dietary factors on visual health and the necessity of targeted interventions for high-risk groups. The results underscore the importance of incorporating dietary guidance into comprehensive myopia prevention strategies.

100% fruit juice

myopia

National Health and Nutrition Examination Survey

In recent years, the incidence of myopia has shown an explosive growth trend globally. In urban areas of East Asia, the prevalence of myopia among adolescents has reached 80%-90%[1]. It is projected that by 2050, approximately half of the global population will be affected by myopia[2]. Early onset and rapid progression of myopia significantly increase the risk of high myopia[3]. High myopia is not merely a refractive error but can lead to a range of serious complications, such as glaucoma and retinal detachment[4], potentially causing permanent vision damage. Hence, the development and implementation of effective myopia prevention strategies are urgently needed. However, achieving this requires a deep understanding of the causes and mechanisms of myopia development. It is important to note that the etiology of myopia is highly complex and multifactorial. Despite extensive research in this field, the scientific community's understanding of the complete mechanisms and all related factors of myopia development remains incomplete. Therefore, continuing to explore this area and finding more effective prevention and treatment methods has become a critical task.

Fruits and vegetables are essential sources of vitamins and minerals for the human body[5]. Dietary guidelines worldwide have consistently recommended increasing the intake of fruits and vegetables. 100% fruit juice is a beverage made entirely from fruit, distinct from fruit-flavored drinks that may contain added sugars or other diluted ingredients. 100% fruit juice can be part of a healthy diet and help meet daily fruit intake requirements[6]. Currently, the debate continues on whether the consumption of 100% fruit juice is beneficial or harmful to human health. Compared to those who do not consume 100% fruit juice, regular consumers are more likely to develop late-stage age-related macular degeneration[7]. The natural sugars in 100% fruit juice may lead to weight gain similar to sugary beverages[8–10], although some studies do not support this result[11].

NHANES is a program conducted by the Centers for Disease Control and Prevention. It is a comprehensive, nationally representative survey designed to assess the health and nutritional status of the U.S. population. NHANES provides extensive data on various aspects of health and nutrition, making it a valuable resource for researchers and federal agencies both within the United States and internationally. Therefore, NHANES offers a high-quality, nationally representative sample for investigating the relationship between 100% fruit juice consumption and myopia among adolescents and young adults.

Currently, there is insufficient research on the relationship between 100% fruit juice intake and the risk of myopia. This study aims to explore the potential association between the consumption of 100% fruit juice and the incidence of myopia in adolescents and young adults, utilizing data from NHANES 2003–2006. This research hopes to provide new insights into the impact of 100% fruit juice on human health and potentially offer dietary recommendations for the young population to aid in myopia prevention.

1.1 Subjects

The NHANES program, initiated in the early 1960s, collects data through interviews covering demographic, socioeconomic, dietary, and health-related information. The NHANES survey protocol is approved by the National Center for Health Statistics Institutional Review Board, and informed consent is obtained from all participants. Detailed survey design and methods for the NHANES database are available on the website (https://wwwn.cdc.gov/nchs/nhanes/).

We included all participants from the 2003–2006 NHANES project who did not meet any exclusion criteria. Inclusion criteria were: (1) participants aged 12 to 25 years; (2) participants who underwent refractive examination. Exclusion criteria were: (1) history of cataract or refractive surgery; (2) missing data or responses of "refused" or "don't know" for the following variables: education level, BMI, race, family income, birthplace, 100% fruit juice consumption, height.

1.2 Methods

1.2.1 Definitions

NHANES conducts ophthalmic examinations for participants aged 12 years and older, which include prescription for glasses, visual acuity, and corneal curvature. Objective refractive measurements are obtained using the Nidek ARK-760 autorefractor. Spherical equivalent (SE) is calculated by summing the spherical error and half of the cylindrical error. Myopia is defined as a spherical equivalent of less than or equal to -1.0 diopters (D) in either eye, consistent with previous studies[12–14]. This conservative definition of myopia is used to avoid misclassification, given that NHANES refractive results are obtained without cycloplegia.

Data on 100% fruit juice consumption are derived from the food frequency questionnaire (FFQ) within the NHANES database, a collaborative effort between the National Institutes of Health and the National Cancer Institute. The FFQ was introduced in the 2003–2004 and 2005–2006 NHANES cycles to assess the frequency and timing of food consumption over the past 12 months. Regarding the frequency of 100% fruit juice consumption, participants answered the question: "How often do you drink other 100% fruit juices or 100% mixed fruit juices (such as pineapple, prune, etc.)?" Based on their responses, participants were categorized into three groups: "never," "moderate consumption" (defined as consuming at least once per month but less than once per day), and "high consumption" (defined as consuming once per day or more). This categorization method aligns with previous studies[7]. Detailed information on the categorization is provided in Table 1.

Table 1

The food frequency questionnaire:How often drink 100% fruit juice?
Code or Value	Value Description	Group
1	never	the "never-consuming" group
2	1 time per month or less	the "moderate-consuming" group
3	2–3 times per month
4	1–2 times per week
5	3–4 times per week
6	5–6 times per week
7	1 time per day	the "high-consuming" group
8	2–3 times per day
9	4–5 times per day
10	6 or more times per day

1.2.2 Covariates

We included variables that might influence the relationship between 100% fruit juice consumption and myopia in our model: age, race, BMI, gender, education level, family income, birthplace, and height. Race was categorized into White, Hispanic, Black, and Other. Birthplace was divided into three categories: born in the United States, Mexico, or elsewhere. Education level was grouped into three categories: less than high school, high school graduate or equivalent, and more than high school. BMI was classified into four levels: underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI < 30.0), and obese (BMI ≥ 30.0). Family income was categorized into four groups: $25,000-$54,999, $55,000-$74,999, ≤$24,999, and ≥$75,000.

1.3 Statistical Analysis

Data analysis was conducted according to the analytical guidelines provided by the National Center for Health Statistics. Collinearity was assessed by examining the variance inflation factor (VIF) for complex survey data, which is most suitable for NHANES research. A VIF value of 1 indicates no collinearity. Typically, a VIF less than 10 is recommended, with a more conservative suggestion of less than 2.5[15].

Normality was tested using the K-S test. Normally distributed data were expressed as mean ± standard deviation (x ± s) and analyzed using the Student t-test or one-way ANOVA; non-normally distributed data were expressed as median. The association between 100% fruit juice consumption and myopia was examined using multivariable logistic regression analysis. Three models were constructed: Model 1 without adjusting for confounders; Model 2 adjusted for age and gender; Model 3 adjusted for age, gender, height, birthplace, family income, education level, race, and BMI. Odds ratios (ORs) with P values and 95% confidence intervals (CIs) were calculated, with P < 0.05 considered statistically significant. All data analyses were performed using R (version 4.3.1).

2.1 Study Population Selection

We utilized publicly available data from two NHANES cycles (2003–2004, 2005–2006), encompassing a total of 20,470 participants who underwent health interviews and examinations, of which 5,600 were aged 12–25 years. Among them, 5,092 participants underwent non-cycloplegic autorefraction in both eyes. Subsequently, we excluded 13 participants with a history of refractive or cataract surgery, as these surgeries could significantly affect refractive error. Participants with missing data or responses of "refused," "don't know," or "missing" for variables such as age, gender, height, birthplace, family income, race, education level, BMI, and 100% fruit juice consumption were also excluded (n = 4,173). Ultimately, our analysis included data from 906 participants. The flowchart for participant selection is shown in Fig. 1.

Table 2 presents the characteristics of the 906 participants. Among them, 304 (33.55%) were myopic, while 602 (66.45%) were not. The most common level of 100% fruit juice consumption was moderate, with 578 participants (63.8%), followed by never consuming 100% fruit juice at 228 participants (25.2%) and high consumption at 100 participants (11%). Regarding education level, the most common was less than high school, with 534 participants (58.9%), followed by more than high school with 211 participants (23.3%), and the least common was high school diploma with 161 participants (17.8%). The median height was 66 inches.

Table 2

Baseline Characteristics of Participants
Variable	Nonmyopia (n = 602)	Myopia (n = 304)	Total (n = 906)	P
Age (years)	18(17.20)	18(17.20)	18(17.20)	0.055
BMI, kg/m2				0.398
Underweight(< 18.5)	40 (6.6%)	13 (4.3%)	53 (5.8%)
Normal(18.5 to < 25)	306 (50.8%)	151 (49.7%)	457 (50.4%)
Overweight(25 to < 30)	129 (21.4%)	66 (21.7%)	195 (21.5%)
Obesity(30 or greater)	127 (21.1%)	74 (24.3%)	201 (22.2%)
100% Fruit Juice Consumption				0.078
Never	165(27.4%)	63 (20.7%)	228 (25.2%)
Moderate	375 (62.3%)	203 (66.8%)	578 (63.8%)
High	62 (10.3%)	38 (12.5%)	100 (11%)
Gender				0.061
Female	319(53.0%)	181 (59.5%)	500 (55.5%)
Male	283 (47.0%)	123 (40.5%)	406 (44.8%)
Race				0.023
Mexican American	140(23.3%)	76 (25.0%)	216 (23.8%)
Other Hispanic	21(3.5%)	6(2.0%)	27 (3.0%)
Non-Hispanic White	215 (35.7%)	115 (37.8%)	330 (36.4%)
Non-Hispanic Black	209 (34.7%)	87 (28.6%)	296 (32.7%)
Other/Multiracial	17 (2.8%)	20 (6.6%)	37 (4.1%)
Education Level				0.028
Less than High School	371 (61.6%)	163 (53.6%)	534 (58.9%)
High School	106(17.6%)	55 (18.1%)	161 (17.8%)
More than High School	125 (20.8%)	86 (28.3%)	211 (23.3%)
Family Income				0.749
$25,000–54,999	190 (31.6%)	93 (30.6%)	283 (31.2%)
$55,000–74,999	68 (11.3%)	32(10.5%)	100 (11.0%)
<= $24,999	212 (35.2%)	118 (38.8%)	330 (36.4%)
>= 75,000	132 (21.9%)	63 (20.1%)	193 (21.3%)
Birthplace				0.270
U.S.	529 (87.9%)	265 (87.2%)	794 (87.6%)
Mexico	45 (7.5%)	18 (5.9%)	63 (7.0%)
Other	28 (4.7%)	21 (6.9%)	49 (5.4%)
Height	66(64.69)	66(64.69)	66(64.69)	0.9943

2.2 Relationship Between 100% Fruit Juice Consumption and Myopia

In this study, the variance inflation factor (VIF) for all variables was below 1.42, indicating minimal collinearity among the variables in the model. Analysis was conducted using three different models: univariate logistic regression (Model 1), a model adjusted for age and gender (Model 2), and a model further adjusted for height, birthplace, family income, education level, race, and BMI (Model 3).

In both Model 1, moderate consumption of 100% fruit juice was associated with an increased risk of myopia (P < 0.05), while high consumption was not significantly related to myopia risk (P>0.05). However, in Model 2 and Model 3, both moderate and high consumption of 100% fruit juice were associated with an increased risk of myopia (P < 0.05), as detailed in Table 3.

Table 3

Association between 100% fruit juice consumption and myopia in adolescents and young adults.
Characteristic	Model 1			Model 2			Model 3
	OR*	95% CI	P	OR*	95% CI	P	OR*	95% CI	P
100% fruit juice consumption			0.063			0.060			0.028
Never	Ref		-	Ref		-	Ref		-
Moderate	1.42	1.02, 2.00	0.043	1.42	1.02, 2.01	0.041	1.52	1.08, 2.17	0.019
High	1.61	0.97, 2.64	0.063	1.67	1.01, 2.76	0.045	1.83	1.08, 3.09	0.024

OR = Odds Ratio, CI = Confidence Interval.

Model 1: univariate logistic regression; Model 2 : adjusted the age, sex; Model 3 : adjusted the age, sex, height, country of birth, household income, level of education,race,and BMI.

2.3 Subgroup Analysis of the Relationship Between 100% Fruit Juice Consumption and Myopia

Subgroup analyses were conducted based on gender (male, female) and age group (12–17 years, 18–25 years). In models adjusted for height, birthplace, family income, education level, race, and BMI, moderate and high consumption of 100% fruit juice were significantly associated with an increased risk of myopia among male adolescents and young adults (P < 0.05). However, this association was not significant among females (P > 0.05).

In the 12–17 year age group, moderate and high consumption of 100% fruit juice were significantly associated with an increased risk of myopia (P < 0.05). In contrast, no significant association was found in the 18–25 year age group (P > 0.05). See Table 4. Interaction tests indicated that birthplace, BMI, and race may influence the relationship between 100% fruit juice consumption and myopia (P < 0.05), as detailed in Table 5.

Table 4

Subgroup Analysis of the Relationship Between 100% Fruit Juice Consumption and Myopia by Gender and Age
Group	Gender						Age
Group	Male			Female			12-17year			18-25year
	OR*	95% CI	P	OR*	95% CI	P	OR*	95% CI	P	OR*	95% CI	P
the "never-consuming" group	Ref		-	Ref		-	Ref		-	Ref		-
the "moderate-consuming" group	2.21	1.20, 4.25	0.014	1.26	0.81, 1.98	0.3	2.51	1.37, 4.80	0.004	1.15	0.74, 1.81	0.5
the "high-consuming" group	4.75	2.08, 11.2	<0.001	0.78	0.36, 1.66	0.5	2.67	1.10, 6.48	0.030	1.58	0.78, 3.11	0.2

Table 5

Interaction P-values for Subgroup Analysis of the Relationship Between 100% Fruit Juice Consumption and Myopia
Variable	Gender	Age	Birthplace	BMI	Race	Education Level	Family Income
P_interaction	0.094	0.157	0.003	< 0.001	< 0.001	0.099	0.702

In recent years, as the importance of myopia prevention and control has become increasingly evident, research into its associated factors has also become critical. Diet is a modifiable factor, and parents and schools can help prevent certain diseases by guiding adolescents in their dietary habits. The relationship between diet and myopia is gaining more attention. Our study aims to elucidate the connection between 100% fruit juice consumption and myopia, offering new avenues for myopia prevention and control. Juice is an integral part of daily dietary intake, and many adolescents and young adults prefer to consume 100% fruit juice to meet their fruit intake needs. Utilizing nationally representative data from the United States, this study is the first to identify an association between the consumption of 100% fruit juice and an increased risk of myopia.

Myopia is influenced by both genetic and environmental factors [16–17]. The underlying mechanism linking 100% fruit juice consumption to an increased risk of myopia remains unclear. One hypothesis is that 100% fruit juice may promote myopia development by elevating blood glucose levels. Since 100% fruit juice contains a significant amount of natural sugars and has a medium to high glycemic index [18], individuals consuming more 100% fruit juice might experience higher blood glucose levels.A study by Ho Sik Hwang and his team, utilizing data from the 2008–2012 Korean National Health and Nutrition Examination Survey, explored this relationship. The study included 11,703 participants aged 25 to 49 years who had not undergone refractive correction or cataract surgery. Using a multivariate logistic regression model that accounted for various covariates, including age, sex, education level, daily sunlight exposure, hypertension, serum 25(OH)D levels, and serum glucose levels, the study found a significant association between higher blood glucose levels and increased risk of high myopia [19].Another NHANES study involving 6,855 Americans aged 12 to 25 years from diverse racial backgrounds found a link between fasting blood glucose levels and refractive error or myopia [20]. A follow-up study by Nina Jacobsen and colleagues on 16-26-year-old type 1 diabetes patients attending the Steno Diabetes Center in Copenhagen between 1995 and 1997 revealed that poor blood glucose control is a risk factor for myopia [21].However, research on the impact of 100% fruit juice consumption on blood glucose control yields conflicting results. A meta-analysis by Mary M. Murphy and colleagues of randomized controlled trials found a neutral effect of 100% fruit juice on blood glucose control [22]. Recently, a two-sample Mendelian randomization study found no causal relationship between fasting blood glucose and myopia [23]. Notably, this Mendelian randomization study has certain limitations: sample overlap between the study results and exposure data, and the lack of multivariable Mendelian randomization methods to adjust for confounding factors such as BMI. Therefore, the study does not definitively negate the causal relationship between fasting blood glucose and myopia.

100% fruit juice is regarded as a high-sugar, high-calorie food with adverse health effects similar to those of sugary beverages. Sugary drinks can induce insulin resistance, leading to elevated levels of insulin and insulin-like growth factor 1 (IGF-1). IGF-1 in scleral fibroblasts promotes the elongation of the eye axis, which is closely associated with the development of myopia. However, a study by Li and colleagues found no correlation between the incidence of myopia and the intake of vegetables, fruits, or sugary beverages. Notably, the pathogenesis of myopia is highly complex, and further research is required to understand the specific mechanisms by which 100% fruit juice affects myopia.

This study found a more pronounced association between 100% fruit juice consumption and increased myopia risk in males and individuals aged 12–17. Factors such as country of birth, BMI, and ethnicity may influence the relationship between 100% fruit juice consumption and myopia. The exact mechanisms behind these results remain unclear, and no related studies have been reported. Previous research has explored the impact of age and gender on myopia risk. The findings of this study suggest a novel perspective on the influence of gender on myopia risk: adolescent males may consume more 100% fruit juice and thereby face a higher risk of myopia, which requires further validation. BMI is closely linked to insulin resistance, and as 100% fruit juice is a sweet beverage, it may induce insulin resistance, ultimately contributing to myopia. Thus, BMI may indirectly influence the relationship between 100% fruit juice consumption and myopia by affecting the onset of insulin resistance.

This study utilized a large, nationally representative sample and employed covariates to adjust for confounding factors affecting myopia. All NHANES data measurements adhered to explicit guidelines and were conducted by trained professionals, ensuring data reliability. Nonetheless, this study has certain limitations: (1) Some potential confounders affecting myopia, such as diabetes, outdoor activity duration, parental myopia, and other unknown factors, were not included in our model. (2) We relied on non-cycloplegic refraction data to assess myopia, which introduces measurement error and affects the precision of our study. (3) The NHANES data from 2003–2006 may not accurately reflect current conditions. (4) This study is cross-sectional, thus it cannot establish causality between myopia and 100% fruit juice consumption. (5) NHANES data only includes myopia information for individuals aged 12 and older, limiting our ability to explore the relationship between 100% fruit juice consumption and myopia in children under 12. (6) 100% fruit juice consumption was assessed through self-reported interviews, where participants were asked to recall their food consumption patterns over the past year, potentially leading to recall bias and inaccuracies in reported consumption frequency. (7) Although the prevalence of myopia is higher among Asian populations, this study did not include an Asian category in its racial classification.Despite these limitations, to our knowledge, this is the first study to report the relationship between 100% fruit juice consumption and the risk of myopia in adolescents and young adults.

In summary, after adjusting for various confounding factors, we found an association between 100% fruit juice consumption and increased myopia risk in adolescents and young adults. Future research should involve larger sample sizes and more comprehensive investigations. Our findings are significant for guiding dietary health and myopia prevention strategies for adolescents and young adults.

Author Contribution

ZC initiated the idea and designed the whole study. WH performed the main analyses and wrote the original manuscript. LY revised the manuscript and advised on statistical methods. CXL was responsible for the accuracy and integrity of this study. All authors contributed to the article and approved the submitted version.

Data Availability Statement: The data presented in this study are openly available in the U.S. National Health and Nutrition Examination Survey at [www.cdc.gov/nchs/nhanes/]

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No competing interests reported.

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22 Jul, 2024

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The Relationship between 100% Fruit Juice Consumption and Myopia in Adolescents and Young Adults: A Cross-Sectional Study Based on NHANES

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Subjects and Methods

1.1 Subjects

1.2 Methods

1.2.1 Definitions

1.2.2 Covariates

1.3 Statistical Analysis

Results

2.1 Study Population Selection

2.2 Relationship Between 100% Fruit Juice Consumption and Myopia

2.3 Subgroup Analysis of the Relationship Between 100% Fruit Juice Consumption and Myopia

Discussion

Declarations

Author Contribution

References

Additional Declarations

Status:

Version 1