Usual nutrient intakes and diet quality among United States older adults participating in the Supplemental Nutrition Assistance Program compared with income-eligible nonparticipants.

BACKGROUND: The proportion of older adults with food insecurity at 8% has increased faster than that of the general United States population from 2001 to 2017. Many low-income food-insecure older adults rely on food-assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), for meeting energy and nutrient needs, whereas others are eligible but do not participate. Neither updated nutrient intake estimates nor potential differences in meeting the Dietary Reference Intakes from foods alone and with dietary supplements (DS) among low-income older adults using or eligible for SNAP are known. OBJECTIVES: This study assessed and compared national estimates of usual nutrient adequacy and dietary quality of United States older adults using SNAP and income-eligible nonparticipants. METHODS: Usual dietary intake was estimated among older adults (≥60 y; n = 2582) in the 2007-2016 NHANES cross-sectional national survey. Data on food-assistance participation and eligibility (poverty-income-ratio ≤130%), DS use, and ≥24-h dietary recalls were used. The NCI method (Markov Chain Monte Carlo approach) was applied to estimate mean usual nutrient intakes, proportion of inadequate nutrient intake, and dietary quality using the 2015 Healthy Eating Index. RESULTS: Neither usual nutrient intake from dietary and total sources nor dietary quality differed between older adult SNAP participants and eligible nonparticipants. Low dietary quality and high percentage of inadequate intake for several nutrients were apparent among both groups, especially from food sources alone, including vitamins A (56%), C (55%), D (97%), E (99%), calcium (73%), and magnesium (74%), but rates were attenuated when DS were also considered (i.e., 36% reduced risk for vitamin D inadequacy). CONCLUSIONS: Diet quality and usual nutrient intake among older adult SNAP participants and eligible nonparticipants were poor, but DS lowered the risk of nutrient inadequacy. Future policies and programs should focus on improving the intake of vitamins A, C, D, E, calcium, and magnesium and dietary quality for all older adults.

Major Gaps in Understanding Dietary Supplement Use in Health and Disease.

Precise dietary assessment is critical for accurate exposure classification in nutritional research, typically aimed at understanding how diet relates to health. Dietary supplement (DS) use is widespread and represents a considerable source of nutrients. However, few studies have compared the best methods to measure DSs. Our literature review on the relative validity and reproducibility of DS instruments in the United States [e.g., product inventories, questionnaires, and 24-h dietary recalls (24HR)] identified five studies that examined validity (n = 5) and/or reproducibility (n = 4). No gold standard reference method exists for validating DS use; thus, each study's investigators chose the reference instrument used to measure validity. Self-administered questionnaires agreed well with 24HR and inventory methods when comparing the prevalence of commonly used DSs. The inventory method captured nutrient amounts more accurately than the other methods. Reproducibility (over 3 months to 2.4 years) of prevalence of use estimates on the questionnaires was acceptable for common DSs. Given the limited body of research on measurement error in DS assessment, only tentative conclusions on these DS instruments can be drawn at present. Further research is critical to advancing knowledge in DS assessment for research and monitoring purposes.

Trends in Overall and Micronutrient-Containing Dietary Supplement Use in US Adults and Children, NHANES 2007-2018.

BACKGROUND: Dietary supplement (DS) use is widespread in the United States and contributes large amounts of micronutrients to users. Most studies have relied on data from 1 assessment method to characterize the prevalence of DS use. Combining multiple methods enhances the ability to capture nutrient exposures from DSs and examine trends over time. OBJECTIVES: The objective of this study was to characterize DS use and examine trends in any DS as well as micronutrient-containing (MN) DS use in a nationally representative sample of the US population (≥1 y) from the 2007-2018 NHANES using a combined approach. METHODS: NHANES obtains an in-home inventory with a frequency-based dietary supplement and prescription medicine questionnaire (DSMQ), and two 24-h dietary recalls (24HRs). Trends in the prevalence of use and selected types of products used were estimated for the population and by sex, age, race/Hispanic origin, family income [poverty-to-income ratio (PIR)], and household food security (food-secure vs. food-insecure) using the DSMQ or ≥ 1 24HR. Linear trends were tested using orthogonal polynomials (significance set at P < 0.05). RESULTS: DS use increased from 50% in 2007 to 56% in 2018 (P = 0.001); use of MN products increased from 46% to 49% (P = 0.03), and single-nutrient DS (e.g., magnesium, vitamins B-12 and D) use also increased (all P < 0.001). In contrast, multivitamin-mineral use decreased (70% to 56%; P < 0.001). In adults (≥19 y), any (54% to 61%) and MN (49% to 54%) DS use increased, especially in men, non-Hispanic blacks and Hispanics, and low-income adults (PIR ≤130%). In children (1-18 y), any DS use remained stable (∼38%), as did MN use, except for food-insecure children, whose use increased from 24% to 31% over the decade (P = 0.03). CONCLUSIONS: The prevalence of any and MN DS use increased over time in the United States. This may be partially attributed to increased use of single-nutrient products. Population subgroups differed in their DS use.

A Randomized Intervention of Supplemental Nutrition Assistance Program-Education Did Not Improve Dietary Outcomes Except for Vitamin D Among Lower-Income Women in Indiana.

BACKGROUND: The goal of US Department of Agriculture Supplemental Nutrition Assistance Program-Education (SNAP-Ed) is to improve the likelihood that those eligible for SNAP will make healthy choices aligned with the Dietary Guidelines for Americans, 2020-2025. OBJECTIVE: The objective of the study was to evaluate the long-term effects of a direct SNAP-Ed intervention in which participants actively engage in learning with educator instruction about dietary quality and usual intake of key nutrient and food groups among Indiana SNAP-Ed-eligible women participants as an example sample in the context of no similar existing evaluation. DESIGN: The study design was a parallel-arm, randomized controlled, nutrition education intervention, with follow-up at 1 year. PARTICIPANTS/SETTING: Participants (18 years and older; n = 97 women) eligible for SNAP-Ed and interested in receiving nutrition education lessons were recruited from 31 Indiana counties from August 2015 to May 2016 and randomized to an intervention (n = 53) or control (n = 44) group. INTERVENTION: The intervention comprised core lessons of Indiana SNAP-Ed delivered between 4 and 10 weeks after baseline assessment. Each participant completed a baseline and 1-year follow-up assessment. Dietary intake was assessed using repeated 24-hour dietary recalls (up to 2). MAIN OUTCOME MEASURES: Mean usual nutrient, food group intake, diet quality (ie, Healthy Eating Index-2010 scores), and proportion of intervention and control groups meeting Dietary Guidelines for Americans, 2020-2025 recommendations and Dietary Reference Intake indicators of requirement or adequacy, were determined using the National Cancer Institute method and the simple Healthy Eating Index-2010 scoring algorithm method. Dietary changes between intervention and control groups were examined over time using mixed linear models. STATISTICAL ANALYSES PERFORMED: Bonferroni-corrected significance levels were applied to the results of the mixed linear models for comparisons of usual intake of nutrients and foods. RESULTS: No differences in diet quality, intake of food group components, food group intake, or nutrients were observed at 1-year follow-up, except that vitamin D intake was higher among those who received SNAP-Ed compared with the control group. CONCLUSIONS: A direct SNAP-Ed intervention did not improve diet quality, food group intake, or key nutrient intake, except for vitamin D, among Indiana SNAP-Ed-eligible women up to 1 year after the nutrition education.

A narrative review of nutrient based indexes to assess diet quality and the proposed total nutrient index that reflects total dietary exposures.

A priori dietary indices provide a standardized, reproducible way to evaluate adherence to dietary recommendations across different populations. Existing nutrient-based indices were developed to reflect food/beverage intake; however, given the high prevalence of dietary supplement (DS) use and its potentially large contribution to nutrient intakes for those that use them, exposure classification without accounting for DS is incomplete. The purpose of this article is to review existing nutrient-based indices and describe the development of the Total Nutrient Index (TNI), an index developed to capture usual intakes from all sources of under-consumed micronutrients among the U.S. population. The TNI assesses U.S. adults' total nutrient intakes relative to recommended nutrient standards for eight under-consumed micronutrients identified by the Dietary Guidelines for Americans: calcium, magnesium, potassium, choline, and vitamins A, C, D, E. The TNI is scored from 0 to 100 (truncated at 100). The mean TNI score of U.S. adults (≥19 y; n = 9,954) based on dietary data from NHANES 2011-2014, was 75.4; the mean score for the index ignoring DS contributions was only 69.0 (t-test; p < 0.001). The TNI extends existing measures of diet quality by including nutrient intakes from all sources and was developed for research, monitoring, and policy purposes.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2021.1967872.

Evaluating a Food Pantry-Based Intervention to Improve Food Security, Dietary Intake, and Quality in Midwestern Food Pantries.

BACKGROUND: Voices for Food was a longitudinal community, food pantry-based intervention informed by the social ecological model, and designed to improve food security, dietary intake, and quality among clients, which was carried out in 24 rural food pantries across 6 Midwestern states. OBJECTIVE: Our objective was to evaluate changes in adult food security, dietary intake, and quality from baseline (2014) to follow-up (2016), and to assess the role of adult food security on dietary outcomes. DESIGN: A multistate, longitudinal, quasi-experimental intervention with matched treatment and comparison design was used to evaluate treatment vs comparison group changes over time and changes in both groups over time. PARTICIPANTS/SETTING: Adult food pantry clients (n = 617) completed a demographic food security survey, and up to three 24-hour dietary recalls at baseline (n = 590) and follow-up (n = 160). INTERVENTION: Community coaching served as the experimental component, which only "treatment" communities received, and a food council guide and food pantry toolkit were provided to both "treatment" and matched "comparison" communities. MAIN OUTCOME MEASURES: Change in adult food security status, mean usual intakes of nutrients and food groups, and Healthy Eating Index-2010 scores were the main outcome measures. STATISTICAL ANALYSES PERFORMED: Linear mixed models estimated changes in outcomes by intervention group and by adult food security status over time. RESULTS: Improvements in adult food security score (-0.7 ± 0.3; P = .01), Healthy Eating Index-2010 total score (4.2 ± 1.1; P < .0001), and empty calories component score (3.4 ± 0.5; P <.0001) from baseline to follow-up were observed in treatment and comparison groups, but no statistically significant changes were found for adult food security status, dietary quality, and usual intakes of nutrients and food groups between the 2 groups over time. The intervention effect on dietary quality and usual intake changes over time by adult food security status were also not observed. CONCLUSIONS: Food pantry clients in treatment and comparison groups had higher food security and dietary quality at the follow-up evaluation of the Voices for Food intervention trial compared with baseline, despite the lack of difference among the groups as a result of the experimental coaching component.

US Department of Agriculture Food Composition Databases, the Food and Nutrient Database for Dietary Studies 2013-2014, and the National Nutrient Database for Standard Reference Version 28 Yield Significantly Different Nutrient Totals of Food Items from Eight Midwestern Food Pantry Inventories.

BACKGROUND: Food pantries are part of the food environment that serve as a resource to individuals having low or very low food security. Determining whether or not application of two US Department of Agriculture food composition databases to foods in the food pantry environment estimate nutrient means differently will inform interventions aimed to improve these food environments. OBJECTIVE: To quantify and compare amounts of key nutrients within the food items included in eight midwestern food pantry inventories and evaluate the quality of the match of these foods as assigned to two food composition databases, the Food and Nutrient Database for Dietary Studies 2013-2014 and the National Nutrient Database for Standard Reference version 28. DESIGN: This cross-sectional, secondary analysis used data from Voices for Food Clinical Trial (2014). SETTING: Food pantry inventories were recorded from four food pantries in Indiana and four in South Dakota from US Department of Agriculture-classified nonmetro counties with high poverty. MAIN OUTCOME MEASURES: Main outcomes measured were least square nutrient means for the total food pantry inventory and by food group. STATISTICAL ANALYSES PERFORMED: Ranked nutrient means and food-match scores that quantified how closely the recorded description matched the database food descriptions were estimated and compared between databases using the Wilcoxon unpaired two-sample test and Fisher exact test. Multiple one-way adjusted analysis of covariance tested for significant differences in least square mean nutrient values between databases. RESULTS: For the total pantry inventory, ranked least square means of total fiber; calcium; potassium; vitamins C, D, A, and B-12; choline; and sodium differed significantly between databases, whereas among all food groups, vitamins A and D differed. Food items in the total pantry inventory more closely matched with the National Nutrient Database for Standard Reference version 28 than the Food and Nutrient Database for Dietary Studies 2013-2014 (P < 0.0001). CONCLUSIONS: National Nutrient Database for Standard Reference version 28 more closely matches food items from Midwestern food pantry inventories compared with the Food and Nutrient Database for Dietary Studies 2013-2014.

The Total Nutrient Index is a Useful Measure for Assessing Total Micronutrient Exposures Among US Adults.

BACKGROUND: Most dietary indices reflect foods and beverages and do not include exposures from dietary supplements (DS) that provide substantial amounts of micronutrients. A nutrient-based approach that captures total intake inclusive of DS can strengthen exposure assessment. OBJECTIVES: We examined the construct and criterion validity of the Total Nutrient Index (TNI) among US adults (≥19 years; nonpregnant or lactating). METHODS: The TNI includes 8 underconsumed micronutrients identified by the Dietary Guidelines for Americans: calcium; magnesium; potassium; choline; and vitamins A, C, D, and E. The TNI is expressed as a percentage of the RDA or Adequate Intake to compute micronutrient component scores; the mean of the component scores yields the TNI score, ranging from 0-100. Data from exemplary menus and the 2003-2006 (≥19 years; n = 8861) and 2011-2014 NHANES (≥19 years; n = 9954) were employed. Exemplary menus were used to determine whether the TNI yielded high scores from dietary sources (women, 31-50 years; men ≥ 70 years). TNI scores were correlated with Healthy Eating Index (HEI) 2015 overall and component scores for dairy, fruits, and vegetables; TNI component scores for vitamins A, C, D, and E were correlated with respective biomarker data. TNI scores were compared between groups with known differences in nutrient intake based on the literature. RESULTS: The TNI yielded high scores on exemplary menus (84.8-93.3/100) and was moderately correlated (r = 0.48) with the HEI-2015. Mean TNI scores were significantly different for DS users (83.5) compared with nonusers (67.1); nonsmokers (76.8) compared with smokers (70.3); and those living with food security (76.6) compared with food insecurity (69.1). Correlations of TNI vitamin component scores with available biomarkers ranged from 0.12 (α-tocopherol) to 0.36 (serum 25-hydroxyvitamin D), and were significantly higher than correlations obtained from the diet alone. CONCLUSIONS: The evaluation of validity supports that the TNI is a useful construct to assess total micronutrient exposures of underconsumed micronutrients among US adults.

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

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.

Nutritional contributions of food pantries and other sources to the diets of rural, Midwestern food pantry users in the USA.

Food pantries provide free food to individuals at nutritional risk given lack of available foods. Frequent use of food pantries is associated with higher dietary quality; however, neither the nutrient contributions of food pantries to participant diets nor their relationship with household food security are known. This cross-sectional analysis used secondary data from rural food pantry participants, including sociodemographic characteristics, household food security and 24-h recalls. Mean intakes of selected food groups and nutrients from food pantries, supermarkets, other stores and restaurants, and other were compared by one-way ANCOVA. Interaction effects of household food security with food sources were evaluated by two-way ANCOVA. About 40 % of participants' dietary intake came from food pantries. Mean intakes of fibre (P < 0·0001), Na (P < 0·0001), fruit (P < 0·0001), grains (P < 0·0001) and oils (P < 0·0001) were higher from food pantries compared with all other sources, as were Ca (P = 0·004), vitamin D (P < 0·0001) and K (P < 0·0001) from food pantries compared with two other sources. Percentage total energy intake (%TEI) from added sugars (P < 0·0001) and saturated fat (P < 0·0001) was higher from supermarkets than most other sources. Significant interaction effects were observed between food sources and household food security for vegetables (P = 0·01), Na (P = 0·01) and %TEI from saturated fat (P = 0·004), with food-insecure participants having significantly higher intakes from food pantries and/or supermarkets compared with all other sources. Future interventions may incorporate these findings by providing education on purchasing and preparing healthy meals on limited budgets, to complement foods received from pantries, and by reducing Na in pantry environments.

Dietary Quality and Usual Intake of Underconsumed Nutrients and Related Food Groups Differ by Food Security Status for Rural, Midwestern Food Pantry Clients.

BACKGROUND: Food pantry users represent a predominantly food insecure population, yet dietary intake may differ among food secure (FS), low FS, and very low FS clients. Usual intake of food groups and nutrients by food security status has not previously been compared among food pantry clients. OBJECTIVE: This study aimed to estimate the usual intakes of underconsumed nutrients (ie, potassium; dietary fiber; choline; magnesium; calcium; vitamins A, D, E, and C; and iron) and related food groups (ie, vegetables, fruits, whole grains, and dairy) and dietary quality, and to evaluate their relationship with food security status. DESIGN: This cross-sectional, secondary analysis used baseline data from a prior intervention study (Clinical Trial Registry: NCT03566095). A demographic questionnaire, the US Household Food Security Survey Module, and up to three 24-hour dietary recalls on nonconsecutive days, including weekdays and weekends, were collected. PARTICIPANTS/SETTING: This community-based study included a convenience sample of adult, midwestern food pantry clients (N=579) recruited from August to November 2014. MAIN OUTCOME MEASURES: Main outcomes evaluated were Healthy Eating Index-2010 scores and usual intakes of underconsumed nutrients and related food groups. STATISTICAL ANALYSES PERFORMED: Linear regression models and the National Cancer Institute method, adjusting for confounders, were used to estimate associations of food security with diet quality and usual intake, respectively. RESULTS: Being FS was associated with a higher whole grains HEI-2010 score and higher mean usual intake of whole grains compared with being low FS. Being FS was associated with higher usual intakes of iron and dairy compared with being very low FS. Being FS was associated with a higher mean usual intake of dark green vegetables compared with being low FS and very low FS. Usual intakes were below federal guidance for all subgroups of food security. CONCLUSIONS: Although food security status may differentiate dietary intake among food pantry clients, improvements are needed among all clients.

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.

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.

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

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.

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

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 (n = 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.

Children's Dietary Quality and Micronutrient Adequacy by Food Security in the Household and among Household Children.

Children's food-security status has been described largely based on either the classification of food security in the household or among household children, but few studies have investigated the relationship between food security among household children and overall dietary quality. Our goal was to examine children's dietary quality and micronutrient adequacy by food-security classification for the household and among household children. Data from 5540 children (2-17 years) from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 were analyzed. Food-security status was assessed using the U.S. Household Food Security Survey Module and categorized into high, marginal, low, and very low food security for the households and among household children. Dietary quality and micronutrient adequacy were characterized by the Healthy Eating Index (HEI) 2015 and Mean Adequacy Ratio (MAR; based on total nutrient intakes from diet and dietary supplements), respectively. The HEI 2015 scores did not substantially vary by either food-security classification, but the MAR was greater in high compared to very low food security in households and among household children; a linear relationship was found only among household children. In general, very good agreement was observed between the classifications, but the strength of agreement differed by children's age, race/Hispanic origin, and family income. In conclusion, micronutrient adequacy, but not dietary quality, significantly differed by food-security status. While the agreement between food security in the household and among household children is very good, classification of food security among household children may be more sensitive to detecting differences in exposure to nutrients.

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

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.

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

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.

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

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 (n = 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 t 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.

Usual Nutrient Intakes from the Diets of US Children by WIC Participation and Income: Findings from the Feeding Infants and Toddlers Study (FITS) 2016.

Background: A recent report of the National Academies of Sciences, Engineering, and Medicine (NASEM) outlined priority nutrients for infants and children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Objective: The objective of this study was to assess usual nutrient intakes from foods and beverages (not supplements) among US children aged <4 y by WIC participation status. Methods: A national random sample of children aged <4 y (n = 3,235) from the Feeding Infants and Toddlers Study (FITS) 2016 was categorized by WIC participation status (participants, lower-income nonparticipants, or higher-income nonparticipants) and age (younger infants aged 0-5.9 mo, older infants aged 6-11.9 mo, toddlers aged 12-23.9 mo, or preschoolers aged 24-47.9 mo). All participants contributed one 24-h dietary recall, with a second recall from a representative subsample (n = 799). Usual intakes and compliance with federal dietary recommendations were estimated by using the National Cancer Institute method. Differences between WIC participants and either lower-income nonparticipants or higher-income nonparticipants were tested using t tests. Results: The diets of infants (aged <12 mo) were nutritionally adequate in general. Older infants participating in WIC had higher compliance with iron and vitamin D guidelines than either group of nonparticipants and greater compliance with calcium, zinc, and potassium guidelines than higher-income nonparticipants. WIC toddlers had a higher risk of inadequate calcium and excessive sodium intakes than higher-income nonparticipants. Eight percent of WIC toddlers exceeded added sugar guidelines compared with either nonparticipant group (∼2%). WIC toddlers and preschoolers had a lower risk of inadequate vitamin D intake than lower-income nonparticipants, but inadequacy was >75% across all subgroups. WIC preschoolers had higher compliance with saturated fat guidelines but lower compliance with sodium and added sugar guidelines than higher-income nonparticipants. Conclusions: WIC participants had better intakes of iron (ages 6-23.9 mo), zinc and potassium (ages 6-11.9 mo), saturated fat (ages 24-47.9 mo), and vitamin D (all ages). Regardless of WIC participation status, most infants and children met the calcium and zinc guidelines, but large proportions had intakes not meeting the recommendations for iron (ages 6-11.9 mo), vitamin D, potassium, fiber, saturated fat, and sodium.

B-vitamin status and bone mineral density and risk of lumbar osteoporosis in older females in the United States.

BACKGROUND: Previous data suggest that elevated serum total homocysteine (tHcy) may be a risk factor for bone fracture and osteoporosis. Nutritional causes of elevated tHcy are suboptimal B-vitamin status. To our knowledge, this is the first nationally representative report on the relation of B vitamins and bone health from a population with folic acid fortification. OBJECTIVE: The purpose of this analysis was to examine the relation between B-vitamin status biomarkers and bone mineral density (BMD), risk of osteoporosis, and biomarkers of bone turnover. DESIGN: We examined the relation of tHcy, methylmalonic acid (MMA), and serum/red blood cell folate and total-body and lumbar spine BMD in women aged ≥50 y participating in the NHANES 1999-2004 (n = 2806), a nationally representative cross-sectional survey. These are the only years with concurrent measurement of tHcy and whole-body dual-energy X-ray absorptiometry. We also examined B-vitamin biomarkers relative to bone turnover markers, bone alkaline phosphatase, and urinary N-terminal cross-linked telopeptide of type I collagen in a 1999-2002 subset with available data (n = 1813). RESULTS: In comparison with optimal concentrations, women with elevated tHcy were older with lower serum vitamin B-12, red blood cell folate, and dietary micronutrient intakes and had significantly higher mean ± SE markers of bone turnover (bone alkaline phosphatase: 15.8 ± 0.59 compared with 14.0 ± 0.25 µg/L; urinary N-terminal cross-linked telopeptide of type I collagen: 48.2 ± 2.9 compared with 38.9 ± 0.90 nmol bone collagen equivalents per mmol creatinine/L). Elevated MMA (OR: 1.88; 95% CI: 1.10, 3.18) and tHcy (OR: 2.17; 95% CI: 1.14, 4.15) were related to increased risk of lumbar osteoporosis. When examined as a continuous variable, tHcy was negatively associated, serum folates were positively associated, and MMA and vitamin B-12 were not significantly associated with lumbar and total-body BMD. CONCLUSION: In this nationally representative population of older US women with high exposure to B vitamins through food fortification and dietary supplements, only elevated tHcy and MMA were independently associated with risk of lumbar spine osteoporosis.