Victor L. Fulgoni

Foods, Fortificants, and Supplements: Where Do Americans Get Their Nutrients?

Limited data are available on the source of usual nutrient intakes in the United States. This analysis aimed to assess contributions of micronutrients to usual intakes derived from all sources (naturally occurring, fortified and enriched, and dietary supplements) and to compare usual intakes to the Dietary Reference Intake for U.S. residents aged ≥2 y according to NHANES 2003–2006 (n = 16,110). We used the National Cancer Institute method to assess usual intakes of 19 micronutrients by source. Only a small percentage of the population had total usual intakes (from dietary intakes and supplements) below the estimated average requirement (EAR) for the following: vitamin B-6 (8%), folate (8%), zinc (8%), thiamin, riboflavin, niacin, vitamin B-12, phosphorus, iron, copper, and selenium (<6% for all). However, more of the population had total usual intakes below the EAR for vitamins A, C, D, and E (34, 25, 70, and 60%, respectively), calcium (38%), and magnesium (45%). Only 3 and 35% had total usual intakes of potassium and vitamin K, respectively, greater than the adequate intake. Enrichment and/or fortification largely contributed to intakes of vitamins A, C, and D, thiamin, iron, and folate. Dietary supplements further reduced the percentage of the population consuming less than the EAR for all nutrients. The percentage of the population with total intakes greater than the tolerable upper intake level (UL) was very low for most nutrients, whereas 10.3 and 8.4% of the population had intakes greater than the UL for niacin and zinc, respectively. Without enrichment and/or fortification and supplementation, many Americans did not achieve the recommended micronutrient intake levels set forth in the Dietary Reference Intake.

Avocado consumption is associated with better diet quality and nutrient intake, and lower metabolic syndrome risk in US adults: results from the National Health and Nutrition Examination Survey (NHANES) 2001–2008

BackgroundAvocados contain monounsaturated fatty acids (MUFA) dietary fiber, essential nutrients and phytochemicals. However, no epidemiologic data exist on their effects on diet quality, weight management and other metabolic disease risk factors. The objective of this research was to investigate the relationships between avocado consumption and overall diet quality, energy and nutrient intakes, physiological indicators of health, and risk of metabolic syndrome.MethodsAvocado consumption and nutrition data were based on 24-hour dietary recalls collected by trained NHANES interviewers using the USDA Automated Multiple Pass Method (AMPM). Physiological data were collected from physical examinations conducted in NHANES Mobile Examination Centers. Diet quality was calculated using the USDA’s Healthy Eating Index-2005. Subjects included 17,567 US adults  ≥ 19 years of age (49% female), including 347 avocado consumers (50% female), examined in NHANES 2001–2008. Least square means, standard errors, and ANOVA were determined using appropriate sample weights, with adjustments for age, gender, ethnicity, and other covariates depending on dependent variable of interest.ResultsAvocado consumers had significantly higher intakes of vegetables (p < 0.05); fruit, diet quality, total fat, monounsaturated and polyunsaturated fats, dietary fiber, vitamins E, K, magnesium, and potassium (p < 0.0001); vitamin K (p = 0.0013); and lower intakes of added sugars (p < 0.0001). No significant differences were seen in calorie or sodium intakes. Body weight, BMI, and waist circumference were significantly lower (p < 0.01), and HDL-C was higher (p < 0.01) in avocado consumers. The odds ratio for metabolic syndrome was 50% (95th CI: 0.32-0.72) lower in avocado consumers vs. non-consumers.ConclusionsAvocado consumption is associated with improved overall diet quality, nutrient intake, and reduced risk of metabolic syndrome. Dietitians should be aware of the beneficial associations between avocado intake, diet and health when making dietary recommendations.

Nutrient profiling of foods: creating a nutrient-rich food index

Nutrient profiling of foods, described as the science of ranking foods based on their nutrient content, is fast becoming the basis for regulating nutrition labels, health claims, and marketing and advertising to children. A number of nutrient profile models have now been developed by research scientists, regulatory agencies, and by the food industry. Whereas some of these models have focused on nutrients to limit, others have emphasized nutrients known to be beneficial to health, or some combination of both. Although nutrient profile models are often tailored to specific goals, the development process ought to follow the same science-driven rules. These include the selection of index nutrients and reference amounts, the development of an appropriate algorithm for calculating nutrient density, and the validation of the chosen nutrient profile model against healthy diets. It is extremely important that nutrient profiles be validated rather than merely compared to prevailing public opinion. Regulatory agencies should act only when they are satisfied that the scientific process has been followed, that the algorithms are transparent, and that the profile model has been validated with respect to objective measures of a healthy diet.

Development and Validation of the Nutrient-Rich Foods Index: A Tool to Measure Nutritional Quality of Foods

Ranking and/or classifying foods based on their nutrient composition is known as nutrient profiling. Nutrition quality indices need to be tested and validated against quality of the total diet. A family of nutrient-rich foods (NRF) indices were validated against the Healthy Eating Index (HEI), an accepted measure of diet quality. All foods consumed by participants in NHANES 1999-2002 studies were scored using NRFn.3 (where n = 6-15) indices based on unweighted sums, means, and ratios of percent daily values (DV) for nutrients to encourage (n) and for nutrients to limit (LIM) (3). Individual food scores were calculated based on 100 kcal (418 kJ) and FDA serving sizes [reference amounts customarily consumed (RACC)]. Energy-weighted food-based scores per person were then regressed against HEI, adjusting for gender, age, and ethnicity. The measure of index performance was the percentage of variation in HEI (R2) explained by each NRF score. NRF indices based on both nutrients to encourage and LIM performed better than indices based on LIM only. Maximum variance in HEI was explained using 6 or 9 nutrients to encourage; index performance actually declined with the inclusion of additional vitamins and minerals. NRF indices based on 100 kcal (418 kJ) performed similarly to indices based on RACC. Algorithms based on sums or means of nutrient DV performed better than ratio-based scores. The NRF9.3 index, based on 9 nutrients to encourage and 3 LIM per RACC and per 100 kcal, explained the highest percentage of variation from HEI and could be readily expected to rank foods based on nutrient density.

Bean Consumption Is Associated with Greater Nutrient Intake, Reduced Systolic Blood Pressure, Lower Body Weight, and a Smaller Waist Circumference in Adults: Results from the National Health and Nutrition Examination Survey 1999-2002

Background: Epidemiological studies have shown positive findings associated with legume consumption and measures of cardiovascular disease and obesity. However, few observational trials have examined beans as a separate food variable when determining associations with health parameters. Objective: To determine the association of consuming beans on nutrient intakes and physiological parameters using the National Health and Examination Survey (NHANES) 1999-2002. Methods: Using data from NHANES 1999-2002, a secondary analysis was completed with a reliable 24-hour dietary recall where three groups of bean consumers were identified (N = 1,475). We determined mean nutrient intakes and physiological values between bean consumers and non-consumers. Least square means, standard errors and ANOVA were calculated using appropriate sample weights following adjustment for age, gender, ethnicity and energy. Results: Relative to non-consumers, bean consumers had higher intakes of dietary fiber, potassium, magnesium, iron, and copper (ps < 0.05). Those consuming beans had a lower body weight (p = 0.008) and a smaller waist size (p = 0.043) relative to non-consumers. Additionally, consumers of beans had a 23% reduced risk of increased waist size (p = 0.018) and a 22% reduced risk of being obese (p = 0.026). Also, baked bean consumption was associated with a lower systolic blood pressure. Conclusions: Bean consumers had better overall nutrient intake levels, better body weights and waist circumferences, and lower systolic blood pressure in comparison to non-consumers. These data support the benefits of bean consumption on improving nutrient intake and health parameters.

Food Sources of Energy and Nutrients among Adults in the US: NHANES 2003–2006

Identification of current food sources of energy and nutrients among US adults is needed to help with public health efforts to implement feasible and appropriate dietary recommendations. To determine the food sources of energy and 26 nutrients consumed by US adults the 2003–2006 National Health and Nutrition Examination Survey (NHANES) 24-h recall (Day 1) dietary intake data from a nationally representative sample of adults 19+ years of age (y) (n = 9490) were analyzed. An updated USDA Dietary Source Nutrient Database was developed for NHANES 2003–2006 using current food composition databases. Food grouping included ingredients from disaggregated mixtures. Mean energy and nutrient intakes from food sources were sample-weighted. Percentages of total dietary intake contributed from food sources were ranked. The highest ranked sources of energy and nutrients among adults more than 19 years old were: energy—yeast bread/rolls (7.2%) and cake/cookies/quick bread/pastry/pie (7.2%); protein—poultry (14.4%) and beef (14.0%); total fat—other fats and oils (9.8%); saturated fatty acids—cheese (16.5%) and beef (9.1%); carbohydrate—soft drinks/soda (11.4%) and yeast breads/rolls (10.9%); dietary fiber—yeast breads/rolls (10.9%) and fruit (10.2%); calcium—milk (22.5%) and cheese (21.6%); vitamin D—milk (45.1%) and fish/shellfish (14.4%); and potassium—milk (9.6%) and coffee/tea/other non-alcoholic beverages (8.4%). Knowledge of primary food sources of energy and nutrients can help health professionals design effective strategies to reduce excess energy consumed by US adults and increase the nutrient adequacy of their diets.

Dietary supplement use is associated with higher intakes of minerals from food sources

BACKGROUND Dietary supplement use is extensive in US adults. Some reports suggested that supplement users had higher nutrient intakes from the diet than did nonusers, but to our knowledge this finding has not been examined in nationally representative survey data. OBJECTIVE In this analysis, we examined mineral intakes from the diet by supplement-use categories and how these supplements contributed to meeting or exceeding Dietary Reference Intakes for selected minerals. DESIGN Data from adults (≥19 y of age; n = 8860) who participated in NHANES 2003-2006, a nationally representative, cross-sectional survey, were examined. Supplement use was defined as the participants self-reported use of a supplement that contained one or more selected minerals. RESULTS Dietary intakes of minerals from food sources were higher for magnesium, copper, potassium, and selenium in male supplement users than in nonusers. For women, dietary intakes of minerals from food sources were higher for users than for nonusers for each mineral examined except for selenium. In women, users of calcium-containing dietary supplements were much more likely to meet the Estimated Average Requirement (EAR) than were nonusers. Even after consideration of supplement use, >14% of adults had inadequate intakes for calcium and magnesium on the basis of the percentage of adults with usual intakes less than the EAR. The prevalence of adults who exceeded the tolerable upper intake level (UL) for calcium, zinc, iron, and magnesium was higher in users than in nonusers. CONCLUSIONS Individuals who used mineral-containing dietary supplements had higher mineral intakes from food sources in the diet than did nonusers. For all minerals examined, and particularly for calcium and magnesium in men and women and iron in women, supplement use decreased the prevalence of intake inadequacy for each respective mineral; however, supplements contributed to risk of potentially excessive intakes for calcium, iron, zinc, and magnesium.

The Role of Dairy in Meeting the Recommendations for Shortfall Nutrients in the American Diet

Background: The 2005 Dietary Guidelines Advisory Committee (DGAC) recognized calcium, potassium and magnesium, all found in high levels in dairy foods, among the shortfall nutrients in both children and adults’ diets. Objective: The objectives were to determine: 1) the percentage of the population with intakes greater than the Adequate Intakes (AI) for calcium and potassium and the percentage of the population with inadequate magnesium intake (based on Estimated Average Requirement [EAR]) and 2) the impact of various levels of dairy consumption on intake of calcium, potassium and magnesium. Design: Secondary analysis of data from the 1999-2004 NHANES. Subjects/Setting: Participants 2 years of age and older. Main Outcome Measures: Percentage of the population meeting current recommendations for calcium, potassium and magnesium. Statistical Analyses Performed: Percentage of EAR/AI for nutrients was calculated based on age/gender specific values. All analyses were weighted using the NHANES six-year sample weights and adjusted for the complex sample design of NHANES with the statistical package SUDAAN. Results: The most recent NHANES data demonstrated that a significant proportion of the American population did not meet recommendations for calcium, potassium, and magnesium. Less than 3% of the population consumed the recommended level or more of potassium. Only 30% of the US population 2 years of age and older obtained the recommended level of calcium or more and 55% consumed less than the EAR for magnesium. Recommending 3–4 servings from the dairy group for all people greater than 9 years of age may be necessary in order to ensure adequate intake of calcium and magnesium, assuming the current diet remains the same. More than 4 servings of dairy would be needed to meet the potassium recommendation at all ages. Conclusions: For those individuals who do not consume dairy products, we need to better understand the barriers to consuming specific dairy products. In addition, more research is needed to examine whether food-based recommendations are practical, feasible and cost effective to meet nutrient needs.

Examination of Vitamin Intakes among US Adults by Dietary Supplement Use

BACKGROUND More than half of US adults use dietary supplements. Some reports suggest that supplement users have higher vitamin intakes from foods than nonusers, but this observation has not been examined using nationally representative survey data. OBJECTIVE The purpose of this analysis was to examine vitamin intakes from foods by supplement use and how dietary supplements contribute to meeting or exceeding the Dietary Reference Intakes for selected vitamins using data from the National Health and Nutrition Examination Survey among adults (aged ≥19 years) in 2003-2006 (n=8,860). RESULTS Among male users, mean intakes of folate and vitamins A, E, and K from food sources were significantly higher than among nonusers. Among women, mean intakes of folate and vitamins A, C, D, and E from foods were higher among users than nonusers. Total intakes (food and supplements) were higher for every vitamin we examined among users than the dietary vitamin intakes of nonusers. Supplement use helped lower the prevalence of intakes below the Estimated Average Requirement for every vitamin we examined, but for folic acid and vitamins A, B-6, and C, supplement use increased the likelihood of intakes above the Tolerable Upper Intake Level. CONCLUSIONS Supplement use was associated with higher mean intakes of some vitamins from foods among users than nonusers, but it was not associated with the prevalence of intakes less than the Estimated Average Requirement from foods. Those who do not use vitamin supplements had significantly higher prevalence of inadequate vitamin intakes; however, the use of supplements can contribute to excess intake for some vitamins.

Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet.

Purpose. Model the potential national health benefits and medical savings from reduced daily intake of calories, sodium, and saturated fat among the U.S. adult population. Design. Simulation based on secondary data analysis; quantitative research. Measures include the prevalence of overweight/obesity, uncontrolled hypertension, elevated cholesterol, and related chronic conditions under various hypothetical dietary changes. Setting. United States. Subjects. Two hundred twenty-four million adults. Measures. Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports. Analysis. The simulation model predicts disease prevalence and medical expenditures under hypothetical dietary change scenarios. Results. We estimate that permanent 100-kcal reductions in daily intake would eliminate approximately 71.2 million cases of overweight/obesity and save