Registered dietitians' perceptions and use of the plant-based recommendations in the 2019 Canada's Food Guide.

BACKGROUND: In 2019, Canada's Food Guide underwent its first transformation in over a decade. The change received considerable attention given the increased focus on plant-based proteins and the decision to eliminate the milk and alternatives food group. Yet little is known about health professionals' views of these updates. In response, the present study examined Canadian dietitians' attitudes and behaviours towards the guide's expanded plant-based recommendations. METHODS: A pan-Canadian cross-sectional online survey was administered from January to March 2020 to currently practicing registered dietitians. The study was pre-registered, piloted and received ethical approval. Descriptive and inferential statistics were performed and open-text responses underwent thematic analysis. RESULTS: In total, 411 dietitians from 10 provinces and various work settings participated. Most dietitians (82.8%) consider the food guide's recommendation to choose protein foods that come from plants more often is evidence-based. Compared to its predecessor, dietitians encourage their patients/clients to choose protein foods that come from plants (p < 0.001) and non-dairy sources of calcium (p < 0.001) significantly more frequently under the new guide. A slight majority of dietitians (57.7%) agree with the decision to omit the standalone milk and alternatives group in favour of bringing dairy into the protein category. CONCLUSIONS: Canadian dietitians generally look favourably upon the new plant-based recommendations and have adjusted their nutrition counselling in response. The findings are considered to be the first to characterise how dietitians view changes to the plant-based content of one of the most recognisable diet-related educational tools in Canada.

The barriers and enablers to achieving adequate calcium intake in young adults: a qualitative study using focus groups.

BACKGROUND: Despite the established benefits of calcium consumption, many young Australians are not meeting the recommendations for calcium intake. This is concerning because an adequate calcium consumption is important throughout young adulthood to reach peak bone mass and for the prevention of osteoporosis. Therefore, the present study aimed to explore the barriers and enablers to consuming calcium-rich foods with young adults. METHODS: Using a semi-structured question guide, five focus group discussions were conducted with 39 participants [mean (SD) age 22.5 (1.8) years]. Participants were mostly females (n = 29) and enrolled in tertiary education (n = 31). A deductive approach was used to group common ideas into themes. The findings from the focus groups were analysed using the COM-B framework, which examines the interactions between three key components (i.e. capability, opportunity and motivation). RESULTS: On examining the young adults' capability to consume a diet adequate in calcium, it was found that young adults had limited knowledge of sources, prevention of disease and recommended amounts. Some participants voiced physical barriers to consumption (lactose intolerance). Opportunity was reported as a physical (availability of calcium-rich foods), financial and social opportunity. Some participants reported motivation to include dairy as a result of the habit becoming engrained during their childhood under parental influence (automatic motivation), whereas others reflected on a lack of awareness relating to inadequacy and health consequences (reflective motivation). CONCLUSIONS: Although social media was seen to be an acceptable mode of intervention, concerns were raised about the source and credibility of the information. The findings may inform the development of future interventions targeting eating habits of young adults.

Pattern of beverage intake and milk and dairy products sufficiency among high-school students in Kuwait.

High consumption of soft drinks has been associated with lower intakes of milk and calcium-rich foods and higher body mass index (BMI). This study aimed to explore the pattern of beverage intake among Kuwaiti high-school students. A questionnaire on knowledge, attitudes and practices concerning beverages and milk and dairy products intake was completed by 190 Kuwaiti students aged 16-18 years and BMI was calculated for 181 of them. Intake of sweetened carbonated beverages and to a lesser extent packaged fruit juices affected the sufficiency of milk and dairy products intake among the sample of high-school students in Kuwait. Although BMI was not related to milk and dairy insufficiency, more of the overweight and obese students displayed incorrect practices. Nutritional education of high-school students on the importance of milk and dairy products as well as the hazards of excess sweetened carbonated beverages and packaged juice is recommended to prevent the obesity epidemic prevailing in Kuwait.

Regulatory and Policy-Related Aspects of Calcium Fortification of Foods. Implications for Implementing National Strategies of Calcium Fortification.

Daily calcium intake is well below current recommendations in most low- and middle-income countries (LMICs). Calcium intake is usually related to bone health, however an adequate calcium intake has also been shown to reduce hypertensive disorders of pregnancy, lower blood pressure and cholesterol values, and to prevent recurrent colorectal adenomas. Food fortification of foods has been identified as a cost-effective strategy to overcome micronutrient gaps in public health. This review summarizes regulatory aspects of fortification of commonly consumed foods with micronutrients, with an emphasis on calcium. We selected a convenient sample of 15 countries from different WHO regions and described the regulatory framework related to calcium fortification of staple foods. We assessed the relevant policies in electronic databases including the WHO Global database on the Implementation of Nutrition Action (GINA) for fortification policies and the Global Fortification Data Exchange Database, a fortification database developed and maintained by Food Fortification Initiative (FFI), Global Alliance for Improved Nutrition (GAIN), Iodine Global Network (IGN), and Micronutrient Forum. Food fortification with micronutrients is widely used in many of the selected countries. Most countries had national legislation for the addition of micronutrients to staple foods, especially wheat flour. These national legislations, that includes regulations and standards, can provide the framework to consider the implementation of adding calcium to the fortification strategies, including the selection of the adequate food vehicle to reach the targeted population at risk safely. The strategy to include calcium in the fortification mix in fortified staple foods seems promising in these countries. However, potential undesired changes on the organoleptic characteristics of fortified foods and products thereof, and operational feasibility at the manufacturing site should be evaluated by the stakeholders during the planning stage. Codex Alimentarius standards should be considered by regulators in order to assure adherence to international standards. While the selected countries already have established national regulations and/or standards for fortification of key staple food vehicles, and there are experiences in the implementation of fortification of some staple foods, national food intake surveys can help plan, design, and modify existing fortification programs as well as monitor food and nutrient consumption to assess risk and benefits.

Assessing calcium intake in postmenopausal women.

INTRODUCTION: Because foods fortified with calcium are increasingly available, the calcium content of calcium-fortified foods may not be adequately captured in traditional assessments of dietary intake, such as dietary records analyzed with commercially available software. The primary objective of our study was to design and test a calcium-focused food frequency questionnaire (CFFFQ) including foods naturally rich in calcium and calcium-fortified foods. Secondary objectives were to review calcium sources and adequacy of intake in black and in white postmenopausal women. METHODS: We studied a convenience sample of 46 black and 139 white postmenopausal women (mean [SD] age 69.4 [5.8] years). Participants completed a multiple-pass interview for 24-hour recall of foods eaten and the 46-item CFFFQ. RESULTS: The correlation between measures for total daily calcium intake was moderately strong (r = 0.53, P < .001). The CFFFQ estimated greater total daily calcium intake than did the 24-hour recall (mean [SD], 1,021 [624] mg/d vs 800 [433] mg/d, P < .001). As daily calcium intake increased, the 24-hour recall increasingly underreported calcium (r = 0.41, P < .001) compared with the CFFFQ. Cross-tabulation and Chi2 analyses found that the CFFFQ had greater specificity for lower calcium intakes. For calcium classified by food groups, there was moderate correlation for dairy (r = 0.56, P < .001) and fruits (r = 0.43, P < .001). The CFFFQ overestimated mean total calcium compared with the 24-hour recall by 221 mg/d (P < .001), including within racial groups (195 mg/d for black women, P = .04, and 229 mg/d for white women, P < .001). Dairy was the primary calcium source for both groups (55% of intake for black women and 57% of intake for white women). CONCLUSION: The CFFFQ can be used to identify postmenopausal women with inadequate calcium intakes (<800 mg/d) and to identify key sources of dietary calcium. Older black women consume less daily calcium than do older white women.

Comparison of Nutrient Reference Values for Food Labeling in Japan with CODEX Recommendations, Based on DRIs and Nutrient Intake in Japan.

To clarify the degree of consistency between the international recommendations and the national Japanese system, the nutrient reference values (NRVs) adopted by the CODEX were compared with current Japanese NRVs 2015, the dietary reference intakes for Japanese (DRIs-J) 2015, and actual nutrient intake levels by the Japanese population. The Japanese NRV for protein was high relative to CODEX NRV-R (i.e., NRV-Requirement). The Japanese NRVs for folate and calcium were low, and vitamin K was high, relative to each CODEX NRV-R. However, it was similar to the DRI-J values, and current intake levels for the Japanese population. For iron, calculation methods were different between the CODEX and Japan. Japanese iron NRV was calculated based on the RDA without menstruatating women, whereas CODEX NRV-R was calculated based on the INL98 of all adult men and women. Actual intake levels of iron for the Japanese population were similarly low. The Japanese NRV for sodium was high and potassium was low based on DRI-J values, relative to the CODEX NRV-NCD. For nutrients that show large discrepancies between the CODEX and Japanese NRVs, the values should be discussed further.

Intakes of Calcium and Phosphorus and Calculated Calcium-to-Phosphorus Ratios of Older Adults: NHANES 2005-2006 Data.

BACKGROUND: High intakes of dietary phosphorus (P), relative to calcium (Ca) intake, are associated with a lower calcium:phosphorus ratio (Ca:P) ratio which potentially has adverse health effects, including arterial calcification, bone loss, and death. A substantial percentage of older adults (50 to 70 and 71 plus years) who have a higher risk of fracture rate than younger adults typically have low intakes of dietary Ca that are dominated by higher intakes of dietary P from natural and fortified foods, and lower Ca:P ratios than desirable. OBJECTIVE: This investigation was undertaken to examine Ca and P intakes and the resulting Ca:P ratios (by mass) across gender and older adult age groups, using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2006. DESIGN: NHANES data are based on a cross-sectional sample of the non-institutionalized United States (US) population within various regions. This sample is selected to be representative of the entire US population at all ages. National Cancer Institute (NCI) methods and SAS survey procedures were used for analyses. Ca:P ratios were calculated using total Ca from both foods and supplements, whereas P intakes were calculated from food composition values and supplements. The amounts of P additives in processed foods are not available. RESULTS: Mean Ca and P intakes demonstrated lower intakes of Ca and higher intakes of P compared to current Recommended Dietary Allowances (RDAs). The Ca:P ratios in older male and female adults were influenced by both low-Ca and high-P dietary consumption patterns. CONCLUSIONS: Both low total Ca intakes and high P amounts contribute to lower Ca:P ratios, i.e., ~0.7:1.0, in the consumption patterns of older adults than is recommended by the RDAs, i.e., ~1.5:1.0. Whether Ca:P ratios lower than recommended contribute to increased risk of bone loss, arterial calcification, and all-cause mortality cannot be inferred from these data. Additional amounts of chemical P additives in the food supply may actually reduce even further the Ca:P ratios of older adults of both genders, but, without P additive data from the food industry, calculation of more precise ratios from NHANES 2005-2006 data is not possible.

Calcium requirements of physically active people.

Dietary calcium and physical activity have been independently, but inconsistently, associated with the development of increased peak bone mass and reduced bone loss later in life. An examination of the literature points to important effects of dietary calcium on bone health. During the development of peak bone mass, calcium intakes of <1 g/d are associated with lower bone mineral density. At intakes approaching calcium requirements, physical activity is a more important predictor of bone mineral density than is calcium intake. In studies of postmenopausal women, calcium intakes of 1 g (25 mmol/d) appear to be necessary to effect a positive impact of exercise on bone mineral density in the spine. Calcium intakes recommended for protecting bone health appear to be adequate to protect against other disorders with an etiology that includes inadequate dietary calcium. Calcium requirements as modified by physical activity need to be determined for each population subgroup according to sex, age, race, and cultural environment.

Overview of key nutrients: micronutrient aspects.

Micronutrients are the key to optimal macronutrient metabolism because of their essential role in metabolism. Invariably, metabolic steps require the concomitant involvement of one or more vitamins and minerals. Chronic degenerative disease etiology and rate of pathogenesis are intimately associated with micronutrient imbalances. Although precise mechanisms remain to be identified, antioxidant status is critical in atherosclerosis and cancer pathogenesis. While elucidating estimates and establishing "singular" values by sex and age for parameters such as estimated average requirements, RDA, and RDI, it is imperative to arrive at these estimates in the light of their interdependent role in metabolism.

Do dairy products improve bone density in adolescent girls?

Previous studied have shown that when calcium is supplemented in adolescents who normally consume less than 1000 mg calcium, bone mineral accretion improves between 1 and 5%. This increment in bone accretion is improved up to 10% when dairy products are used as a source of supplemental calcium in adolescent girls. Because the addition of dairy foods is a simple, inexpensive intervention that carries no risk and because it substantially increases bone accretion with potential long-term benefits, adolescents should be encouraged to include dairy products in their diet.

Blood pressure responses of white men with hypertension to two low-sodium metabolic diets with different levels of dietary calcium.

OBJECTIVE: To compare the blood pressure responses of men with hypertension consuming low-sodium (Na) metabolic diets differing in dietary calcium (Ca) for two 6-week periods. SUBJECTS: White men who had hypertension, were nonsmokers, and were sedentary. INTERVENTION: This study consisted of two separate 6-week metabolic feeding periods. In the first period, a high-Ca group (n = 6) was fed 1,400 mg Ca per day. In the second period, a low-Ca group (n = 5) was fed 400 mg Ca per day. Both groups were fed 1,500 mg Na per day. MAIN OUTCOME MEASURES: Blood pressure; urine and blood measured for electrolyte, calcitriol, renin, and parathyroid hormone (PTH) levels. To measure typical nutrient intakes, 3-day dietary records were collected before the beginning of each treatment period. STATISTICAL ANALYSES PERFORMED: Repeated-measures analysis of variance and split-plot analysis of variance were used to analyze, respectively, blood pressure responses and response variables over time. RESULTS: In both groups, serum Na level decreased (P < .05) over the 6-week period; urine Na decreased (P < .05) only in the low-Ca group. Serum PTH level decreased (P < .05) in the high-Ca group and increased (P < .05) in the low-Ca group; no change occurred in serum calcitriol level. Diastolic blood pressure decreased (8 mm Hg) in the low-Ca group (P < .05). The low-Ca group showed an 8% to 9% decrease in both systolic and diastolic blood pressure vs a 2% to 3% decrease in the high-Ca group. We also examined how the metabolic diet differed from subjects' typical diet. Results showed a positive correlation between the change in Na intake (usual to metabolic diet) and the change in systolic and diastolic blood pressure in both groups (P < .04). Results also showed a negative correlation between the change in the ratio of Na to Ca (usual to metabolic diet) and the change in diastolic blood pressure in the low-Ca group (P < .03). Directional change in blood pressure (either increase or decrease) could be predicted on the basis of how much the Na and Ca in the metabolic diet differed from subject's typical diet. APPLICATIONS: Results of this study suggest that in the dietary management of hypertension it may be more important to focus on specific changes in a person's diet (eg, decreasing Na intake by 1,000 mg/day and increasing Ca intake by 400 mg/day) rather than setting specific levels of Na and Ca to be consumed.

The nutrient content of the Italian food supply 1961-1992.

OBJECTIVE: To highlight the methodology used to determine nutrient per capita per day values, to report values for food energy and 12 nutrients and to compare these values with FAO nutrient per capita values and Recommended Dietary Intakes (RDIs) for Italy. DESIGN: The nutrient content of the Italian food supply was calculated using food per capita data from FAO and food composition data from the Italian National Nutrition Institute. RESULTS: All nutrient per capita values have increased since 1961 except carboyhdrate. Wheat-based products were important sources of thiamin, riboflavin, niacin, phosphorus, iron, and potassium; and vegetables were predominant sources of vitamin A, ascorbic acid, riboflavin, niacin, calcium, iron, and potassium. The increase in red meats has accounted for some of the increases in fat, protein, vitamin A, thiamin, riboflavin, niacin, phosphorus, and iron. FAO reported higher values for energy, fat and niacin and lower values for protein, ascorbic acid, riboflavin, thiamin, calcium in all years. The trends for vitamin A and iron were similar in both data sets; however, there were switches in which set reported higher values. The trends for niacin and calcium were not similar. When compared with the RDIs, most of the nutrients were adequate. The exceptions were iron for females ages 10-59 and calcium for adolescents. CONCLUSION: Different nutrient values and sometimes trends resulted when nutrient composition data and edible portion factors specific to Italy were used to determine nutrient per capita values. The nutrient content of the Italian food supply changed between 1961 and 1992, suggesting dietary patterns in Italy also changed.

[Calcium content in the whole-day food rations of primary school children in Bialystok and vicinity]. / Zawartosc wapnia w racjach pokarmowych dzieci szkól podstawowych z Bialegostoku i okolic.

Randomly selected 354 primary school pupils aged 9 and 14 from Bialystok and its vicinity gave a 24-hour feeding history. Calcium diet content was evaluated in the children. The values obtained were referred to the recommended standard of Ca intake according to age and sex. It was found that Ca supply in daily food rations of children in Bialystok and suburbs is most insufficient, and the 9-year-old children's place of living had a significant effect on the calcium content in diets.

Physicians underestimate calcium intake in women.

BACKGROUND AND OBJECTIVES: Personalized nutritional counseling about calcium intake during office encounters requires rapid estimation of calcium intake. We compared the accuracy of physician estimates to a validated calcium intake measure and characterized women whose intakes were incorrectly deemed inadequate by physicians. METHODS: As part of a controlled trial of brief, office-based calcium intake counseling of women, family physicians estimated calcium intake from patients' self-reported intake of dairy food/beverage intake and from their supplement use. We compared estimates to the Short Calcium Questionnaire (SCQ), a validated 7-day dietary recall measure completed by patients. Sensitivity/specificity of physician-estimated calcium intake was estimated by comparison with the SCQ. RESULTS: For 97 women, SCQ rated 32 (33%) as inadequate, 55 (57%) as adequate, and 10 (10%) as excessive. When compared to SCQ, the sensitivity of physician-estimated calcium intake inadequacy was 97% (95% confidence interval [CI]: 94%-100%), specificity was 51% (95% CI: 41%-61%), and positive predictive value was 49% (95% CI: 39%-59%). Women with underestimated intakes were more likely to report a family history of osteoporosis and take a daily multivitamin. The major source of physician underestimation of calcium intake was underestimate of dairy product contribution. CONCLUSIONS: More accurate estimates of dairy-based calcium intake will lead to greater specificity in identifying inadequate calcium intake.