Publications by authors named "Johanna T Dwyer"

156 Publications

Opportunities for Adding Undernutrition and Frailty Screening Measures in US National Surveys.

Adv Nutr 2021 May 19. Epub 2021 May 19.

Office of Dietary Supplements, NIH, Bethesda, MD, USA.

Both undernutrition and frailty adversely affect the health and functional outcomes of the older adult population. Timely and accurate national data are necessary to assess those at risk of these debilitating but often preventable conditions, to correct them and support healthy aging. The objective was to identify relevant measures in undernutrition and frailty screening tools and determine if these measures are collected in recent protocols for US national surveys sampling older adults and which measures could be added to be able to better assess risk of undernutrition and frailty. Commonly used undernutrition and frailty screening tools were evaluated to identify measures that were unique or common to both. US national surveys were examined to determine whether they included older adults in their survey sample, collected health measures from participants, in what form, and whether they were functional indexes or survey questions. A comparative analysis of survey protocols was performed to determine which surveys collected data related to the measures of undernutrition and frailty. Of the 8 national surveys, only 3 provided ≥1 physical measurement (i.e., height/weight, grip strength, balance). Most surveys included self-reported data on height/weight, physical functioning/mobility, disability, and psychological components. Whereas 6 included questions on food security/food program participation, only 1 collected data on dietary intake. Currently national surveys include only limited health measures that can be used to identify undernutrition and frailty risk in older adults. Adding a few simple screening measures already included in popular screening tools, such as grip strength, unintentional weight loss, and loss of appetite, to national surveys which monitor older Americans would facilitate estimation of the prevalence of undernutrition and frailty risk, better estimate those at risk, provide an opportunity to set national goals to reduce their risk, and help implement strategies for improved health outcomes.
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http://dx.doi.org/10.1093/advances/nmab056DOI Listing
May 2021

Association of food insecurity with dietary intakes and nutritional biomarkers among US children, National Health and Nutrition Examination Survey (NHANES) 2011-2016.

Am J Clin Nutr 2021 May 8. Epub 2021 May 8.

Department of Nutrition Science, Purdue University, West Lafayette, IN, USA.

Background: Food insecurity is associated with poorer nutrient intakes from food sources and lower dietary supplement use. However, its association with total usual nutrient intakes, inclusive of dietary supplements, and biomarkers of nutritional status among US children remains unknown.

Objective: The objective was to assess total usual nutrient intakes, Healthy Eating Index-2015 (HEI-2015) scores, and nutritional biomarkers by food security status, sex, and age among US children.

Methods: Cross-sectional data from 9147 children aged 1-18 y from the 2011-2016 NHANES were analyzed. Usual energy and total nutrient intakes and HEI-2015 scores were estimated using the National Cancer Institute method from 24-h dietary recalls.

Results: Overall diet quality was poor, and intakes of sodium, added sugars, and saturated fat were higher than recommended limits, regardless of food security status. Food-insecure girls and boys were at higher risk of inadequate intakes for vitamin D and magnesium, and girls also had higher risk for inadequate calcium intakes compared with their food-secure counterparts, when total intakes were examined. Choline intakes of food-insecure children were less likely to meet the adequate intake than those of their food-secure peers. No differences by food security status were noted for folate, vitamin C, iron, zinc, potassium, and sodium intakes. Food-insecure adolescent girls aged 14-18 y were at higher risk of micronutrient inadequacies than any other subgroup, with 92.8% (SE: 3.6%) at risk of inadequate intakes for vitamin D. No differences in biomarkers for vitamin D, folate, iron, and zinc were observed by food security status. The prevalence of iron deficiency was 12.7% in food-secure and 12.0% in food-insecure adolescent girls.

Conclusions: Food insecurity was associated with compromised intake of some micronutrients, especially among adolescent girls. These results highlight a need for targeted interventions to improve children's overall diet quality, including the reduction of specific nutrient inadequacies, especially among food-insecure children. This study was registered at clinicaltrials.gov as NCT03400436.
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http://dx.doi.org/10.1093/ajcn/nqab113DOI Listing
May 2021

Perspective: Framework for Developing Recommended Intakes of Bioactive Dietary Substances.

Adv Nutr 2021 May 7. Epub 2021 May 7.

Weaver & Associates Consulting, LLC, Colorado Springs, CO, USA.

Dietary bioactives are food substances that promote health but are not essential to prevent typical deficiency conditions. Examples include lutein and zeaxanthin, omega-3 fatty acids, and flavonoids. When quality evidence is available, quantified intake recommendations linking dietary bioactives with specific health benefits will enable health professionals to provide evidence-based information to consumers. Without evidence-based recommendations, consumers use information from available sources that often lack standards and rigor. This article describes a framework to develop guidance based on quality evidence fully vetted for efficacy and safety by qualified experts, and designed to communicate the amounts of specific dietary bioactive compounds with identified health benefits. The 4-step Framework described here can be adapted by credible health organizations to work within their guideline development process. Standards of practice used in clinical guidelines are adapted to quantify dietary bioactive intake recommendations from foods consumed by the general public, by taking into account that side effects and trade-offs are often needed for medical treatments but are not acceptable for dietary bioactives. In quantifying dietary bioactive recommendations, this Framework establishes 4 decision-making steps: 1) characterize the bioactive, determine amounts in specific food sources, and quantify intakes; 2) evaluate safety; 3) quantify the causal relation between the specific bioactive and accepted markers of health or normal function via systematic evidence reviews; and 4) translate the evidence into a quantified bioactive intake statement. This Framework provides a working model that can be updated as new approaches are advanced.
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http://dx.doi.org/10.1093/advances/nmab044DOI Listing
May 2021

Using the Google™ Search Engine for Health Information: Is There a Problem? Case Study: Supplements for Cancer.

Curr Dev Nutr 2021 Feb 3;5(2):nzab002. Epub 2021 Feb 3.

Frances Stern Nutrition Center, Tufts Medical Center and Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA.

We assessed the quality of online health and nutrition information using a Google™ search on "supplements for cancer". Search results were scored using the Health Information Quality Index (HIQI), a quality-rating tool consisting of 12 objective criteria related to website domain, lack of commercial aspects, and authoritative nature of the health and nutrition information provided. Possible scores ranged from 0 (lowest) to 12 ("perfect" or highest quality). After eliminating irrelevant results, the remaining 160 search results had median and mean scores of 8. One-quarter of the results were of high quality (score of 10-12). There was no correlation between high-quality scores and early appearance in the sequence of search results, where results are presumably more visible. Also, 496 advertisements, over twice the number of search results, appeared. We conclude that the Google™ search engine may have shortcomings when used to obtain information on dietary supplements and cancer.
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http://dx.doi.org/10.1093/cdn/nzab002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059196PMC
February 2021

Perspective: Measuring Sweetness in Foods, Beverages, and Diets: Toward Understanding the Role of Sweetness in Health.

Adv Nutr 2021 03;12(2):343-354

Monell Chemical Senses Center, Philadelphia, PA, USA.

Various global public health agencies recommend minimizing exposure to sweet-tasting foods or beverages. The underlying rationale is that reducing exposure to the perception of sweet tastes, without regard to the source of sweetness, may reduce preferences for sweetness, added sugar intake, caloric intake, and body weight. However, the veracity of this sequence of outcomes has yet to be documented, as revealed by findings from recent systematic reviews on the topic. Efforts to examine and document the effects of sweetness exposure are needed to support evidence-based recommendations. They require a generally agreed-upon methodology for measuring sweetness in foods, beverages, and the overall diet. Although well-established sensory evaluation techniques exist for individual foods in laboratory settings, they are expensive and time-consuming, and agreement on the optimal approach for measuring the sweetness of the total diet is lacking. If such a measure could be developed, it would permit researchers to combine data from different studies and populations and facilitate the design and conduct of new studies to address unresolved research questions about dietary sweetness. This narrative review includes an overview of available sensory techniques, their strengths and limitations, recent efforts to measure the sweetness of foods and diets across countries and cultures, and a proposed future direction for improving methods for measuring sweetness toward developing the data required to support evidence-based recommendations around dietary sweetness.
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http://dx.doi.org/10.1093/advances/nmaa151DOI Listing
March 2021

Dietary Assessment Methodology in Response to September 2020 Issue.

J Acad Nutr Diet 2021 Feb 24;121(2):213. Epub 2020 Nov 24.

Tufts University School of Medicine, Boston, MA.

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http://dx.doi.org/10.1016/j.jand.2020.10.020DOI Listing
February 2021

High folic acid or folate combined with low vitamin B-12 status: potential but inconsistent association with cognitive function in a nationally representative cross-sectional sample of US older adults participating in the NHANES.

Am J Clin Nutr 2020 12;112(6):1547-1557

Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ, USA.

Background: Potential safety concerns relative to impaired cognitive function may exist when high folic acid exposures are combined with low vitamin B-12 status.

Objectives: We aimed to examine the relation of the coexistence of high folate and low vitamin B-12 status with cognitive function, utilizing various definitions of "high" folate status.

Methods: Cross-sectional data from older adults (≥60 y; n = 2420) from the 2011-2014 NHANES were analyzed. High folate status was defined as unmetabolized serum folic acid (UMFA) > 1 nmol/L or serum total folate > 74.1 nmol/L, and low vitamin B-12 status as methylmalonic acid > 271 nmol/L or serum vitamin B-12 < 150 pmol/L. Logistic regression models estimated ORs of scoring low on 1 of 4 cognitive tests: the Digit Symbol Substitution Test (DSST), the Consortium to Establish a Registry for Alzheimer's Disease Delayed Recall (CERAD-DR) and Word Learning tests, and the Animal Fluency test (AF).

Results: A significant interaction was observed relative to scoring low on the DSST (<34; UMFA; P-interaction = 0.0071) and AF (serum folate; P-interaction = 0.0078) for low vitamin B-12 and high folate status. Among those with low vitamin B-12, high UMFA or high serum total folate was associated with higher risk of scoring low on the DSST (OR: 2.16; 95% CI: 1.05, 4.47) and the AF (OR: 1.93; 95% CI: 1.08, 3.45). Among those with "normal" vitamin B-12, higher UMFA or serum total folate was protective on the CERAD-DR. In noninteraction models, when high folate and normal vitamin B-12 status was the reference group, low vitamin B-12 combined with high UMFA was associated with greater risk based on the DSST (<34, OR: 2.87; 95% CI: 1.85, 4.45; <40, OR: 2.22; 95% CI: 1.31, 3.75) and AF (OR: 1.97; 95% CI: 1.30, 2.97); but low vitamin B-12 and lower UMFA (OR: 1.69; 95% CI: 1.16, 2.47) was also significantly associated for DSST < 40 risk.

Conclusions: Low vitamin B-12 was associated with cognitive impairment both independently and in an interactive manner with high folate for certain cognitive performance tests among older adults.
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http://dx.doi.org/10.1093/ajcn/nqaa239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184300PMC
December 2020

Older adults with obesity have higher risks of some micronutrient inadequacies and lower overall dietary quality compared to peers with a healthy weight, National Health and Nutrition Examination Surveys (NHANES), 2011-2014.

Public Health Nutr 2020 09 29;23(13):2268-2279. Epub 2020 May 29.

Department of Nutrition Science, Purdue University, West Lafayette, IN47907, USA.

Objective: To evaluate total usual intakes and biomarkers of micronutrients, overall dietary quality and related health characteristics of US older adults who were overweight or obese compared with a healthy weight.

Design: Cross-sectional study.

Setting: Two 24-h dietary recalls, nutritional biomarkers and objective and subjective health characteristic data were analysed from the National Health and Nutrition Examination Survey 2011-2014. We used the National Cancer Institute method to estimate distributions of total usual intakes from foods and dietary supplements for eleven micronutrients of potential concern and the Healthy Eating Index (HEI)-2015 score.

Participants: Older adults aged ≥60 years (n 2969) were categorised by sex and body weight status, using standard BMI categories. Underweight individuals (n 47) were excluded due to small sample size.

Results: A greater percentage of obese older adults compared with their healthy-weight counterparts was at risk of inadequate Mg (both sexes), Ca, vitamin B6 and vitamin D (women only) intakes. The proportion of those with serum 25-hydroxyvitamin D < 40 nmol/l was higher in obese (12 %) than in healthy-weight older women (6 %). Mean overall HEI-2015 scores were 8·6 (men) and 7·1 (women) points lower in obese than in healthy-weight older adults. In addition, compared with healthy-weight counterparts, obese older adults were more likely to self-report fair/poor health, use ≥ 5 medications and have limitations in activities of daily living and cardio-metabolic risk factors; and obese older women were more likely to be food-insecure and have depression.

Conclusions: Our findings suggest that obesity may coexist with micronutrient inadequacy in older adults, especially among women.
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http://dx.doi.org/10.1017/S1368980020000257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429309PMC
September 2020

Harmonizing Micronutrient Intake Reference Ranges for Dietary Guidance and Menu Planning in Complementary Feeding.

Curr Dev Nutr 2020 Mar 4;4(3):nzaa017. Epub 2020 Feb 4.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

There are no published harmonized nutrient reference values for the complementary feeding period. The aim of the study was to develop proposals on adequate and safe intake ranges of micronutrients that can be applied to dietary guidance and menu planning. Dietary intake surveys from 6 populous countries were selected as pertinent to the study and reviewed for data on micronutrients. The most frequently underconsumed micronutrients were identified as iron, zinc, calcium, magnesium, phosphorus, potassium, and vitamins A, B6, B12, C, D, E, and folate. Key published reference values for these micronutrients were identified, compared, and reconciled. WHO/FAO values were generally identified as initial nutrient targets and reconciled with nutrient reference values from the Institute of Medicine and the European Food Standards Authority. A final set of harmonized reference nutrient intake ranges for the complementary feeding period is proposed.
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http://dx.doi.org/10.1093/cdn/nzaa017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059853PMC
March 2020

Perspective: Time to Resolve Confusion on Folate Amounts, Units, and Forms in Prenatal Supplements.

Adv Nutr 2020 07;11(4):753-759

Office of Dietary Supplements, National Institutes of Health, Bethesda, MD, USA.

Folate-containing prenatal supplements are commonly consumed in the United States, but inconsistencies in units of measure and chemical forms pose challenges for providing authoritative advice on recommended amounts. New regulations require folate to be declared as micrograms of dietary folate equivalents (DFE) on product labels, whereas intake recommendations for reducing the risk of neural tube defects (NTDs) and the Tolerable Upper Intake Level are expressed as micrograms of folic acid. Today, >25% of prenatal supplements contain folate as synthetic salts of L-5-methyltetrahydrofolate (L-5-MTHF), but recommendations do not include this form of the vitamin. Harmonizing units of measure and addressing newer forms of folate salts in intake recommendations and in the prevention of NTDs would resolve the confusion.
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http://dx.doi.org/10.1093/advances/nmaa017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360441PMC
July 2020

Disintegration and Dissolution Testing of Green Tea Dietary Supplements: Application and Evaluation of United States Pharmacopeial Standards.

J Pharm Sci 2020 06 18;109(6):1933-1942. Epub 2020 Feb 18.

Office of Dietary Supplements, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20814.

Approved performance quality tests are lacking in the United States Pharmacopeia (USP) for dietary supplements (DSs) containing green tea extracts. We evaluated the applicability of USP <2040 > general chapter protocols for disintegration and dissolution testing of botanicals to GT DSs. Of 28 single-ingredient GT DSs tested in 2 to 4 lots, 9 (32.1%) always passed the disintegration test, 8 (28.6%) always failed, and 11 (39.3%) showed inconsistent results. Of 34 multi-ingredient DSs tested in 2 lots, 21 (61.8%) passed and 8 (23.5%) failed in both lots, and 5 (14.7%) exhibited inconsistent performance. When stronger destructive forces were applied (disk added), all of the capsules that had failed initially, but not the tablets, passed. In dissolution testing, for the release of epigallocatechin-3-gallate (EGCG), only 6 of 20 single-ingredient DSs passed. Unexpectedly, with the addition of pepsin (prescribed by USP), only one additional DS passed. These results raise concerns that EGCG was not released properly from GT DS dosage forms. However, the general USP protocols may be inadequate for this botanical. More biorelevant destructive forces may be needed to break down capsules and tablets strengthened by the EGCG's interaction with shell material and to overcome the inhibition of digestive enzymes by EGCG.
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http://dx.doi.org/10.1016/j.xphs.2020.02.005DOI Listing
June 2020

Dietary Supplement Use and Its Micronutrient Contribution During Pregnancy and Lactation in the United States.

Obstet Gynecol 2020 03;135(3):623-633

Department of Nutrition Science, Purdue University, West Lafayette, Indiana; the Office of Dietary Supplements, National Institutes of Health, Bethesda, Maryland; the Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah; and the Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado.

Objective: To estimate the prevalence of use and the micronutrient contribution of dietary supplements among pregnant, lactating, and nonpregnant and nonlactating women in the United States.

Methods: Cross-sectional data from 1,314 pregnant, 297 lactating, and 8,096 nonpregnant and nonlactating women (aged 20-44 years) in the 1999-2014 National Health and Nutrition Examination Survey were combined to produce statistically reliable, nationally representative estimates. Information about dietary supplements used in the past 30 days was collected through an interviewer-administered questionnaire and in-home inventory. The prevalence of nutrient-specific supplement use, mean daily nutrient intakes from supplements among users, and motivations for supplement use were assessed. Differences by age, income, and trimester within pregnant women were also tested.

Results: Seventy-seven percent of pregnant women and 70% of lactating women used one or more dietary supplements, whereas 45% of nonpregnant and nonlactating women used supplements. In particular, 64% of pregnant and 54% of lactating women used prenatal supplements. Mean intakes of thiamin, riboflavin, niacin, folic acid, vitamins B6, B12, and C, iron, and zinc from supplements alone were at or above their respective recommended dietary allowances (RDAs) among pregnant and lactating supplement users. About half of pregnant and 40% of lactating women took supplements based on the recommendation of a health care provider. Among pregnant women, those in their first trimester, aged 20-34 years, or in a lower-income family were less likely to use supplements compared with their counterparts.

Conclusion: The majority of pregnant and lactating women used dietary supplements, which contributed many nutrients in doses above the RDAs. Although inadequate Intakes of folate and iron are of concern among pregnant women who are not using supplements, supplement users often consumed high doses, suggesting a potential need of health care providers to discuss dietary supplement use and the recommended doses of nutrients during pregnancy and lactation.
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http://dx.doi.org/10.1097/AOG.0000000000003657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138460PMC
March 2020

Total Usual Micronutrient Intakes Compared to the Dietary Reference Intakes among U.S. Adults by Food Security Status.

Nutrients 2019 Dec 22;12(1). Epub 2019 Dec 22.

Interdepartmental Nutrition Program, Purdue University, 700 W. State Street, West Lafayette, IN 47907, USA.

This study examined total usual micronutrient intakes from foods, beverages, and dietary supplements (DS) compared to the Dietary Reference Intakes among U.S. adults (≥19 years) by sex and food security status using NHANES 2011-2014 data ( = 9954). DS data were collected via an in-home interview; the NCI method was used to estimate distributions of total usual intakes from two 24 h recalls for food and beverages, after which DS were added. Food security status was categorized using the USDA Household Food Security Survey Module. Adults living in food insecure households had a higher prevalence of risk of inadequacy among both men and women for magnesium, potassium, vitamins A, B6, B12, C, D, E, and K; similar findings were apparent for phosphorous, selenium, and zinc in men alone. Meanwhile, no differences in the prevalence of risk for inadequacy were observed for calcium, iron (examined in men only), choline, or folate by food security status. Some DS users, especially food secure adults, had total usual intakes that exceeded the Tolerable Upper Intake Level (UL) for folic acid, vitamin D, calcium, and iron. In conclusion, while DS can be helpful in meeting nutrient requirements for adults for some micronutrients, potential excess may also be of concern for certain micronutrients among supplement users. In general, food insecure adults have higher risk for micronutrient inadequacy than food secure adults.
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http://dx.doi.org/10.3390/nu12010038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019721PMC
December 2019

Comparison of 4 Methods to Assess the Prevalence of Use and Estimates of Nutrient Intakes from Dietary Supplements among US Adults.

J Nutr 2020 04;150(4):884-893

Department of Nutrition Science, Purdue University, West Lafayette, IN, USA.

Background: Accurate and reliable methods to assess prevalence of use of and nutrient intakes from dietary supplements (DSs) are critical for research, clinical practice, and public health monitoring. NHANES has been the primary source of DS usage patterns using an in-home inventory with a frequency-based DS and Prescription Medicine Questionnaire (DSMQ), but little is known regarding DS information obtained from 24-h dietary recalls (24HRs).

Methods: The objectives of this analysis were to compare results from 4 different methods for measuring DS use constructed from two data collection instruments (i.e., DSMQ and 24HR) and to determine the most comprehensive method for measuring the prevalence of use and estimating nutrient intakes from DS for selected nutrients. NHANES 2011-2014 data from US adults (aged ≥19 y; n = 11,451) were used to examine the 4 combinations of methods constructed for measuring the prevalence of use of and amount of selected nutrients from DSs (i.e., riboflavin, vitamin D, folate, magnesium, calcium): 1) DSMQ, 2) 24HR day 1, 3) two 24HRs (i.e., mean), and 4) DSMQ or at least one 24HR.

Results: Half of US adults reported DS use on the DSMQ (52%) and on two 24HRs (mean of 49%), as compared with a lower prevalence of DS use when using a single 24HR (43%) and a higher (57%) prevalence when combining the DSMQ with at least one 24HR. Mean nutrient intake estimates were highest using 24HR day 1. Mean supplemental calcium from the DSMQ or at least one 24HR was 372 mg/d, but 464 mg/d on the 24HR only. For vitamin D, the estimated intakes per consumption day were higher on the DSMQ (46 μg) and the DSMQ or at least one 24HR (44 μg) than those on the 24HR day 1 (32 μg) or the mean 24HR (31 μg). Fewer products were also classed as a default or reasonable match on the DSMQ than on the 24HR.

Conclusions: A higher prevalence of use of DSs is obtained using frequency-based methods, whereas higher amounts of nutrients are reported from a 24HR. The home inventory results in greater accuracy for products reported. Collectively, these findings suggest that combining the DSMQ with at least one 24HR (i.e., DSMQ or at least one 24HR) is the most comprehensive method for assessing the prevalence of and estimating usual intake from DSs in US adults.This trial was registered at clinicaltrials.gov as NCT03400436.
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http://dx.doi.org/10.1093/jn/nxz306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138661PMC
April 2020

Screening Community-Living Older Adults for Protein Energy Malnutrition and Frailty: Update and Next Steps.

J Community Health 2020 06;45(3):640-660

Abbott Nutrition Division of Abbott, Columbus, OH, 43219, USA.

Protein-energy malnutrition (PEM)/undernutrition and frailty are prevalent, overlapping conditions impacting on functional and health outcomes of older adults, but are frequently unidentified and untreated in community settings in the United States. Using the World Health Organization criteria for effective screening programs, we reviewed validity, reliability, and feasibility of data-driven screening tools for identifying PEM and frailty risk among community-dwelling older adults. The SCREEN II is recommended for PEM screening and the FRAIL scale is recommended as the most promising frailty screening tool, based on test characteristics, cost, and ease of use, but more research on both tools is needed, particularly on predictive validity of favorable outcomes after nutritional/physical activity interventions. The Malnutrition Screening Tool (MST) has been recommended by one expert group as a screening tool for all adults, regardless of age/care setting. However, it has not been tested in US community settings, likely yields large numbers of false positives (particularly in community settings), and its predictive validity of favorable outcomes after nutritional interventions is unknown. Community subgroups at highest priority for screening are those at increased risk due to prior illness, certain demographics and/or domiciliary characteristics, and those with BMI < 20 kg/m or < 22 if > 70 years or recent unintentional weight loss > 10% (who are likely already malnourished). Community-based health professionals can better support healthy aging by increasing their awareness/use of PEM and frailty screening tools, prioritizing high-risk populations for systematic screening, following screening with more definitive diagnoses and appropriate interventions, and re-evaluating and revising screening protocols and measures as more data become available.
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http://dx.doi.org/10.1007/s10900-019-00739-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188699PMC
June 2020

Characteristics and Challenges of Dietary Supplement Databases Derived from Label Information.

J Nutr 2018 08;148(suppl_2):1422S-1427S

Office of Dietary Supplements, National Institutes of Health, Bethesda, MD.

Launched in 2008, the Dietary Supplement Label Database (DSLD) permits the search of any term that appears anywhere on product labels. Since then, the database's search and download features have been periodically improved to enhance use for researchers and consumers. In this review, we describe how to customize searches and identify products and ingredients of interest to users in the DSLD, and provide the limitations of working with information derived from dietary supplement product labels. This article describes how data derived from information printed on product labels are entered and organized in the DSLD. Among the challenges are determining the chemical forms, types of extract, and amounts of dietary ingredients, especially when these are components of proprietary blends. The FDA announced new dietary supplement labeling regulations in May 2016. The 2017 DSLD has been updated to reflect them. These new regulations and examples cited in this article refer to this redesigned version of the DSLD. Search selection characteristics such as for product type and intended user group are as described in FDA guidance and regulations for dietary supplements. For this reason, some age groups (such as teens and seniors) and marketing recommendations for use (e.g., weight loss, performance, and other disease- or condition-specific claims) are not included in the search selections. The DSLD user interface features will be revised periodically to reflect regulatory and technologic developments to enhance user experience. A comprehensive database derived from analytically verified data on composition would be preferable to label data, but is not feasible for technical, logistic, and financial reasons. Therefore, a database derived from information printed on product labels is the only practical option at present for researchers, clinicians, and consumers interested in the composition of these products.
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http://dx.doi.org/10.1093/jn/nxy103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857608PMC
August 2018

Why Americans Need Information on Dietary Supplements.

J Nutr 2018 08;148(suppl_2):1401S-1405S

Office of Dietary Supplements, National Institutes of Health, Bethesda, MD.

Until a decade ago, no dietary supplement (DS) databases with open access for public use existed in the United States. They were needed by researchers, since half of American adults use dietary DSs and, without information on supplement use and composition, exposures could not be estimated. These articles on Challenges and Future Directions for Dietary Supplement Databases describe subsequent progress. They begin by describing why information on DSs is needed by the government and how it is used to ensure the health of the public. Current developments include: application of DS information to meet public health needs; research efforts on DS quality, efficacy, and safety (as conducted by the Office of Dietary Supplements and other federal agencies); enhanced regulatory activities implemented by the FDA Office of Dietary Supplement Programs, the FDA Office of Enforcement, and the Federal Trade Commission; and initiatives for broader development and dissemination of DS databases for commercial and public use. Other contributions in this journal supplement describe the challenges of working with DSs and the progress that has been made. Additional articles describe surveys of DS use among the general US population and also among special groups such as high supplement users, illustrating why there is a need in the United States for information on supplements. Likely directions for the future of DS science are summarized.
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http://dx.doi.org/10.1093/jn/nxy081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857605PMC
August 2018

Dietary Supplement Ingredient Database (DSID) and the Application of Analytically Based Estimates of Ingredient Amount to Intake Calculations.

J Nutr 2018 08;148(suppl_2):1413S-1421S

Consulting Statistician, Longmont, CO.

Objective: We describe the purpose of the Dietary Supplement Ingredient Database (DSID), the statistical methodology underlying online calculators of analytically verified supplement content estimates, and the application and significance of DSID label adjustments in nutritional epidemiology.

Background And History: During dietary supplement (DS) manufacturing, many ingredients are added at higher than declared label amounts, but overages are not standardized among manufacturers. As a result, researchers may underestimate nutrient intakes from DSs. The DSID provides statistical tools on the basis of the results of chemical analysis to convert label claims into analytically predicted ingredient amounts. These adjustments to labels are linked to DS products reported in NHANES.

Rationale: Tables summarizing the numbers of NHANES DS products with ingredient overages and below label content show the importance of DSID adjustments to labels for accurate intake calculations.

Recent Developments: We show the differences between analytically based estimates and labeled content for vitamin D, calcium, iodine, caffeine, and omega-3 (n-3) fatty acids and their potential impact on the accuracy of intake assessments in large surveys. Analytical overages >20% of label levels are predicted for several nutrients in 50-99% of multivitamin-mineral products (MVMs) reported in NHANES: for iodine and selenium in adult MVMs, for iodine and vitamins D and E in children's MVMs, and for iodine, chromium, and potassium in nonprescription prenatal MVMs. Predicted overages of 10-20% for calcium can be applied to most MVMs and overages >10% for folic acid in the vast majority of adult and children's MVMs.

Future Directions: DSID studies are currently evaluating ingredient levels in prescription prenatal MVMs and levels of constituents in botanical DSs.

Conclusions: We estimate that the majority of MVM products reported in NHANES have significant overages for several ingredients. It is important to account for nonlabeled additional nutrient exposure from DSs to better evaluate nutritional status in the United States.
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http://dx.doi.org/10.1093/jn/nxy092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857613PMC
August 2018

Perspective: Dietary Biomarkers of Intake and Exposure-Exploration with Omics Approaches.

Adv Nutr 2020 03;11(2):200-215

University of Colorado Anschutz Medical Campus, Denver, CO, USA.

While conventional nutrition research has yielded biomarkers such as doubly labeled water for energy metabolism and 24-h urinary nitrogen for protein intake, a critical need exists for additional, equally robust biomarkers that allow for objective assessment of specific food intake and dietary exposure. Recent advances in high-throughput MS combined with improved metabolomics techniques and bioinformatic tools provide new opportunities for dietary biomarker development. In September 2018, the NIH organized a 2-d workshop to engage nutrition and omics researchers and explore the potential of multiomics approaches in nutritional biomarker research. The current Perspective summarizes key gaps and challenges identified, as well as the recommendations from the workshop that could serve as a guide for scientists interested in dietary biomarkers research. Topics addressed included study designs for biomarker development, analytical and bioinformatic considerations, and integration of dietary biomarkers with other omics techniques. Several clear needs were identified, including larger controlled feeding studies, testing a variety of foods and dietary patterns across diverse populations, improved reporting standards to support study replication, more chemical standards covering a broader range of food constituents and human metabolites, standardized approaches for biomarker validation, comprehensive and accessible food composition databases, a common ontology for dietary biomarker literature, and methodologic work on statistical procedures for intake biomarker discovery. Multidisciplinary research teams with appropriate expertise are critical to moving forward the field of dietary biomarkers and producing robust, reproducible biomarkers that can be used in public health and clinical research.
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http://dx.doi.org/10.1093/advances/nmz075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442414PMC
March 2020

The Dietary Supplement Label Database: Recent Developments and Applications.

J Nutr 2018 08 3;148(Suppl 2):1428S-1435S. Epub 2018 Aug 3.

Division of Health and Nutrition Examination Surveys/Analysis Branch, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD.

Objective: To describe the history, key features, recent enhancements, and common applications of the Dietary Supplement Label Database (DSLD).

Background And History: Although many Americans use dietary supplements, databases of dietary supplements sold in the United States have not been widely available. The DSLD, an easily accessible public-use database was created in 2008 to provide information on dietary supplement composition for use by researchers and consumers.

Rationale: Accessing current information easily and quickly is crucial for documenting exposures to dietary supplements because they contain nutrients and other bioactive ingredients that may have beneficial or adverse effects on human health. This manuscript details recent developments with the DSLD to achieve this goal and provides examples of how the DSLD has been used.

Recent Developments: With periodic updates to track changes in product composition and capture new products entering the market, the DSLD currently contains more than 71,000 dietary supplement labels. Following usability testing with consumer and researcher user groups completed in 2016, improvements to the DSLD interface were made. As of 2017, both a desktop and mobile device version are now available. Since its inception in 2008, the use of the DSLD has included research, exposure monitoring, and other purposes by users in the public and private sectors.

Future Directions: Further refinement of the user interface and search features to facilitate ease of use for stakeholders is planned.

Conclusions: The DSLD can be used to track changes in product composition and capture new products entering the market. With over 71,000 DS labels it is a unique resource that policymakers, researchers, clinicians, and consumers may find valuable for multiple applications.
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http://dx.doi.org/10.1093/jn/nxy082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597011PMC
August 2018

The Chemical Forms of Iron in Commercial Prenatal Supplements Are Not Always the Same as Those Tested in Clinical Trials.

J Nutr 2019 06;149(6):890-893

Office of Dietary Supplements, NIH, Bethesda, MD.

In the US, 70% of pregnant women use an iron-containing prenatal supplement product; however, only 2.6% of pregnant women have iron-deficiency anemia and 16.3% are iron deficient. Yet, published data on the amounts and chemical forms of iron used in formulating these products are not available, although they are known to affect bioavailability. This information is especially important in comparing commercially available products with those that were tested in clinical trials. Our examination of nonprescription and prescription iron-containing prenatal supplement products in NIH's Dietary Supplement Label Database (DSLD) and DailyMed found the labeled amount of elemental iron ranged between 9 and 60 mg/serving in 148 nonprescription supplements and between 4.5 and 106 mg/serving in 101 prescription supplements. Ferrous fumarate was the preferred chemical form used in these products. In contrast, ferrous sulfate was the preferred chemical form of iron reported in the clinical trials summarized in a 2015 Cochrane Systematic review assessing the effects of daily oral iron supplements for pregnant women. Ferrous sulfate was not found on any prenatal supplement product label in the DSLD or DailyMed. The chemical forms of products on the market and those tested in clinical trials are dissimilar, and we believe this may have clinical implications. The findings raise several questions. Do outcomes in clinical trials correlate with the benefits and risks that might adhere to iron supplements with different iron formulations? Should the differences in chemical forms, their bioavailability, and safety profiles, be considered in greater depth when evaluating the effect of the various formulations on maternal iron nutriture? Should new clinical trials for pregnant and lactating women in the US use a form of iron not found in prenatal supplements sold in the US or should a more common form be used?
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http://dx.doi.org/10.1093/jn/nxz042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698632PMC
June 2019

Federal Monitoring of Dietary Supplement Use in the Resident, Civilian, Noninstitutionalized US Population, National Health and Nutrition Examination Survey

J Nutr 2018 08 3;148(Suppl 2):1436S-1444S. Epub 2018 Aug 3.

National Institutes of Health, Office of Dietary Supplements, Bethesda MD.

Objective: This review summarizes the current and previous data on dietary supplement (DS) use collected from participants in the National Health and Nutrition Examination Survey (NHANES), describes the NHANES dietary supplement database used to compute nutrient intakes from DSs, discussed recent developments and future direction, and describes many examples to demonstrate the utility of these data in informing nutrition research and policy.

Background And History: Since 1971, NHANES, has been collecting information on the use of DSs from participants. These data are critical to national nutrition surveillance and have been used to characterize usage patterns, examine trends over time, assess the percentage of the population meeting or exceeding nutrient recommendations, and to help elucidate the sources contributing nutrients to the diet of the US population.

Rationale: Over half of adults and about one-third of children in the United States use at least one dietary supplement in the past 30 days. Dietary supplements contribute to the dietary intake of nutrients and bioactive compounds in the US and therefore need to be assessed when monitoring nutritional status of the population and when studying diet-health associations.

Recent Developments: With the recent development and availability of the Dietary Supplement Label Database (DSLD), a comprehensive DS database that will eventually contain labels for all products marketed in the US, NHANES DS data will be more easily linked to product information to estimate nutrient intake from DS.

Future Directions: Over time, NHANES has both expanded and improved collection methods. The continued understanding of sources of error in collection methods will continue to be explored and is critical to improved accuracy.

Conclusions: NHANES provides a rich source of nationally representative data on the usage of dietary supplements in the US.
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http://dx.doi.org/10.1093/jn/nxy093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516064PMC
August 2018

Trends in Mean Nutrient Intakes of US Infants, Toddlers, and Young Children from 3 Feeding Infants and Toddlers Studies (FITS).

J Nutr 2019 07;149(7):1230-1237

Department of Nutrition Science, Purdue University, West Lafayette, IN.

Background: Many updates to young child feeding recommendations have been published over the past decade, but concurrent intake trends have not been assessed.

Objective: The aim of this study was to evaluate adequacy and trends in energy and nutrient intakes of US infants and children aged 0-47.9 mo through use of Feeding Infants and Toddlers Study (FITS) data from 2002, 2008, and 2016.

Methods: FITS are cross-sectional surveys of parents/caregivers of infants and young children (FITS 2002, n = 2962; FITS 2008, n = 3276; FITS 2016, n = 3235). Dietary intakes were assessed by telephone with trained interviewers using the Nutrition Data System for Research. Mean ± SE nutrient intakes were calculated. Diet adequacy was assessed with the nutrient adequacy ratio (NAR) for 17 nutrients and the corresponding mean adequacy ratio.

Results: Energy and macronutrient intakes were generally stable across surveys, but significant decreases for saturated fat and total sugars and an increase in fiber were observed among 6-11.9-mo-olds and 12-23.9-mo-olds (P-trend < 0.0001). Mean sodium intakes exceeded Adequate Intakes (AI) for all ages, whereas fiber intakes were universally below the AI. Nutrients with the lowest NAR values were vitamin D (range 0.41-0.67/1.00) and vitamin E (range 0.60-0.79/1.00 for 2008 and 2016). For iron, infants aged 6-11.9 mo had the lowest NAR values at 0.77-0.88/1.00, compared to 0.85-0.89/1.00 for 12-47.9-mo-olds. Potassium was low from 12 to 47.9 mo (NAR range 0.55-0.63/1.00 across survey years). The nutrients with the greatest decline in mean intakes were iron and vitamins D and E among 6-11.9-mo-olds, and vitamin D and potassium among 12-23.9-mo-olds in 2016 compared to 2002.

Conclusions: The diets of US infants and young children were generally adequate for most micronutrients and stable over time, but sodium intakes were too high, and nutrient gaps still existed, especially for vitamins D, E, and fiber across ages and for iron among infants.
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http://dx.doi.org/10.1093/jn/nxz054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602894PMC
July 2019

Best Practices for Dietary Supplement Assessment and Estimation of Total Usual Nutrient Intakes in Population-Level Research and Monitoring.

J Nutr 2019 02;149(2):181-197

School of Medicine, Wake Forest, Winston-Salem, NC.

The use of dietary supplements (DS) is pervasive and can provide substantial amounts of micronutrients to those who use them. Therefore when characterizing dietary intakes, describing the prevalence of inadequacy or excess, or assessing relations between nutrients and health outcomes, it is critical to incorporate DS intakes to improve exposure estimates. Unfortunately, little is known about the best methods to assess DS, and the structure of measurement error in DS reporting. Several characteristics of nutrients from DS are salient to understand when comparing to those in foods. First, DS can be consumed daily or episodically, in bolus form and can deliver discrete and often very high doses of nutrients that are not limited by energy intakes. These characteristics contribute to bimodal distributions and distributions severely skewed to the right. Labels on DS often provide nutrient forms that differ from those found in conventional foods, and underestimate analytically derived values. Finally, the bioavailability of many nutrient-containing DS is not known and it may not be the same as the nutrients in a food matrix. Current methods to estimate usual intakes are not designed specifically to handle DS. Two temporal procedures are described to refer to the order that nutrient intakes are combined relative to usual intake procedures, referred to as a "shrinking" the distribution to remove random error. The "shrink then add" approach is preferable to the "add then shrink" approach when users and nonusers are combined for most research questions. Stratifying by DS before usual intake methods is another defensible option. This review describes how to incorporate nutrient intakes from DS to usual intakes from foods, and describes the available methods and fit-for-purpose of different analytical strategies to address research questions where total usual intakes are of interest at the group level for use in nutrition research and to inform policy decisions. Clinical Trial Registry: NCT03400436.
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http://dx.doi.org/10.1093/jn/nxy264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374152PMC
February 2019

Dietary Supplement Use among Infants and Toddlers Aged <24 Months in the United States, NHANES 2007-2014.

J Nutr 2019 02;149(2):314-322

Office of Dietary Supplements, NIH, Bethesda, MD.

Background: Limited nationally representative data are available on dietary supplement (DS) use and resulting nutrient exposures among infants and toddlers.

Objective: This study evaluated DS use among US infants and toddlers to characterize DS use, estimate nutrient intake from DSs, and assess trends in DS use over time.

Methods: Using nationally representative data from NHANES (2007-2014) and trends over time (1999-2014), we estimated prevalence of DS use and types of products used for US infants and toddlers aged <2 y (n = 2823). We estimated median daily intakes of vitamins and minerals consumed via DSs for all participants aged <2 y, by age groups (0-11.9 mo and 12.0-23.9 mo), and by feeding practices for infants 0-5.9 mo.

Results: Overall, 18.2% (95% CI: 16.2%, 20.3%) of infants and toddlers used ≥1 DS in the past 30 d. Use was lower among infants (0-5.9 mo: 14.6%; 95% CI: 11.5%, 18.1%; 6-11.9 mo: 11.6%; 95% CI: 8.8%, 15.0%) than among toddlers (12-23.9 mo: 23.3%; 95% CI: 20.4%, 26.3%). The most commonly reported DSs were vitamin D and multivitamin infant drops for those <12 mo, and chewable multivitamin products for toddlers (12-23.9 mo). The nutrients most frequently consumed from DSs were vitamins D, A, C, and E for those <2 y; for infants <6 mo, a higher percentage of those fed breast milk than those fed formula consumed these nutrients via DSs. DS use remained steady for infants (6-11.9 mo) and toddlers from 1999-2002 to 2011-2014, but increased from 7% to 20% for infants aged 0-5.9 mo.

Conclusions: One in 5 infants and toddlers aged <2 y use ≥1 DS. Future studies should examine total nutrient intake from foods, beverages, and DSs to evaluate nutrient adequacy overall and by nutrient source.
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http://dx.doi.org/10.1093/jn/nxy269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6551282PMC
February 2019

The Feeding Infants and Toddlers Study (FITS) 2016: Moving Forward.

Authors:
Johanna T Dwyer

J Nutr 2018 09;148(suppl_3):1575S-1580S

Tufts University School of Medicine and Frances Stern Nutrition Center, Tufts Medical Center, Boston, MA.

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http://dx.doi.org/10.1093/jn/nxy159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126635PMC
September 2018

Dietary Supplement Use among U.S. Children by Family Income, Food Security Level, and Nutrition Assistance Program Participation Status in 2011⁻2014.

Nutrients 2018 Sep 1;10(9). Epub 2018 Sep 1.

Department of Nutrition Science, Purdue University, West Lafayette, IN 47907, USA.

This analysis characterizes use of dietary supplements (DS) and motivations for DS use among U.S. children (≤18 years) by family income level, food security status, and federal nutrition assistance program participation using the 2011⁻2014 National Health and Nutrition Examination Survey data. About one-third (32%) of children used DS, mostly multivitamin-minerals (MVM; 24%). DS and MVM use were associated with higher family income and higher household food security level. DS use was lowest among children in households participating in the Supplemental Nutrition Assistance Program (SNAP; 20%) and those participating in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC; 26%) compared to both income-eligible and income-ineligible nonparticipants. Most children who used DS took only one (83%) or two (12%) products; although children in low-income families took fewer products than those in higher income families. The most common motivations for DS and MVM use were to "improve (42% or 46%)" or "maintain (34 or 38%)" health, followed by "to supplement the diet (23 or 24%)" for DS or MVM, respectively. High-income children were more likely to use DS and MVM "to supplement the diet" than middle- or low-income children. Only 18% of child DS users took DS based on a health practitioner's recommendation. In conclusion, DS use was lower among children who were in low-income or food-insecure families, or families participating in nutrition assistance programs.
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http://dx.doi.org/10.3390/nu10091212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163871PMC
September 2018

Dietary Supplement Use Differs by Socioeconomic and Health-Related Characteristics among U.S. Adults, NHANES 2011⁻2014.

Nutrients 2018 Aug 17;10(8). Epub 2018 Aug 17.

Department of Nutrition Science, Purdue University, 700 W. State St., West Lafayette, IN 47907, USA.

The objective of this study was to estimate the prevalence of use and types of dietary supplements (DS) used by U.S. adults (≥19 years) by sociodemographic characteristics: family income-to-poverty ratio (PIR), food security status, and Supplemental Nutrition Assistance Program (SNAP) participation using NHANES 2011⁻2014 data ( = 11,024). DS use was ascertained via a home inventory and a retrospective 30-day questionnaire. Demographic and socioeconomic differences related to DS use were evaluated using a univariate statistic. Half of U.S. adults (52%) took at least one DS during a 30-day period; multivitamin-mineral (MVM) products were the most commonly used (31%). DS and MVM use was significantly higher among those with a household income of ≥ 350% of the poverty level, those who were food secure, and SNAP income-ineligible nonparticipants across all sex, age, and race/ethnic groups. Among women, prevalence of use significantly differed between SNAP participants (39%) and SNAP income-eligible nonparticipants (54%). Older adults (71+ years) remained the highest consumers of DS, specifically among the highest income group (82%), while younger adults (19⁻30 years), predominantly in the lowest income group (28%), were the lowest consumers. Among U.S. adults, DS use and the types of products consumed varied with income, food security, and SNAP participation.
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http://dx.doi.org/10.3390/nu10081114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116059PMC
August 2018

Total Usual Nutrient Intakes of US Children (Under 48 Months): Findings from the Feeding Infants and Toddlers Study (FITS) 2016.

J Nutr 2018 09;148(9S):1557S-1566S

Nestlé Research Center, Vers-Chez-les-Blanc, Lausanne, Switzerland.

Background: The US Dietary Guidelines will expand in 2020 to include infants and toddlers. Understanding current dietary intakes is critical to inform policy.

Objective: The purpose of this analysis was to examine the usual total nutrient intakes from diet and supplements among US children.

Methods: The Feeding Infants and Toddlers Study 2016 is a national cross-sectional study of children aged <48 mo (n = 3235): younger infants (birth to 5.9 mo), older infants (6-11.9 mo), toddlers (12-23.9 mo), younger preschoolers (24-36.9 mo), and older preschoolers (36-47.9 mo) based on the use of a 24-h dietary recall. A second 24-h recall was collected from a representative subsample (n = 799). Energy, total nutrient intake distributions, and compliance with Dietary Reference Intakes were estimated with the use of the National Cancer Institute method.

Results: Dietary supplement use was 15-23% among infants and toddlers and 35-45% among preschoolers. Dietary intakes of infants were adequate, with mean intakes exceeding Adequate Intake for all nutrients except vitamins D and E. Iron intakes fell below the Estimated Average Requirement for older infants (18%). We found that 31-33% of children aged 12-47.9 mo had low percentage of energy from total fat, and >60% of children aged 24-47.9 mo exceeded the saturated fat guidelines. The likelihood of nutrient inadequacy for many nutrients was higher for toddlers: 3.2% and 2.5% greater than the Adequate Intake for fiber and potassium and 76% and 52% less than the Estimated Average Requirement for vitamins D and E, respectively. These patterns continued through older ages. Intakes exceeded the Tolerable Upper Intake Level of sodium, retinol, and zinc across most age groups.

Conclusions: Dietary intakes of US infants are largely nutritionally adequate; concern exists over iron intakes in those aged 6-11.9 mo. For toddlers and preschoolers, high intake of sodium and low intakes of potassium, fiber, and vitamin D and, for preschoolers, excess saturated fat are of concern. Excess retinol, zinc, and folic acid was noted across most ages, especially among supplement users.
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http://dx.doi.org/10.1093/jn/nxy042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126633PMC
September 2018