Women's diet quality in the UK

Women's diets are of interest as they not only impact on wellbeing and risk of chronic disease in women themselves, but also influence pregnancy outcomes and infant health. UK dietary surveys show that, while some improvements have occurred, intakes of key micronutrients, particularly iron, vitamin D, calcium and folate remain below recommended levels. Women's diets are also too high in saturated fat and salt, and low in fibre, oily fish and fruits and vegetables. Evidence suggests that certain chronic conditions are influenced by dietary components, e.g. inadequate calcium and vitamin D intakes reduce bone density, salt and saturated fat increase cardiovascular disease risk, excessive alcohol intakes increase cancer risk, low intakes of long chain n‐3 fatty acids may adversely affect fetal development and mental health, while adequate folic acid reduces the risk of birth defects. Focused health initiatives are needed to improve diet quality in women, particularly school‐aged girls, women planning a pregnancy, those living in areas of deprivation and elderly women. Vitamin and mineral supplements, and fortified foods may have a role to play alongside dietary improvements in helping women to achieve optimal diet quality.     

Long-term effects of nutrient intervention on markers of bone remodeling and calciotropic hormones in late-postmenopausal women

BACKGROUND: Adequate intakes of calcium and vitamin D reduce bone loss and fracture risk in the elderly. Other nutrients also affect bone health, and adequate intakes may influence bone turnover and balance. OBJECTIVE: We compared the long-term effects on bone turnover markers and calciotropic hormones of a multinutrient supplement, a calcium and vitamin D supplement, and dietary instruction aimed at increasing calcium intake through foods. DESIGN: Ninety-nine healthy postmenopausal women participated in a 3-y, randomized trial, receiving either 1) supplemental calcium (1450 mg/d) and vitamin D [10 microg (400 IU)/d], 2) calcium, vitamin D, and other nutrients (multinutrient supplement), or 3) dietary instruction (dietary control group). Data are from 83 subjects who completed the trial. RESULTS: Increases over baseline in calcium intakes and serum 25-hydroxyvitamin D concentrations were sustained over 3 y in all treatment groups. Circulating parathyroid hormone concentrations were reduced at year 1 in all treatment groups but trended toward baseline thereafter. Bone turnover markers followed a similar pattern, and none of the changes in biochemical concentrations differed significantly between groups. CONCLUSIONS: All 3 interventions offer long-term feasibility for increasing calcium intake and serum 25-hydroxyvitamin D concentrations. The dietary addition of micronutrients implicated in skeletal physiology confers no obvious bone-sparing effect in healthy postmenopausal women beyond that of calcium and vitamin D alone. The attenuation over time in suppression of parathyroid hormone and bone turnover might help explain why nutrient intervention tends to have less of a bone-sparing effect than do skeletally active medications such as estrogen or bisphosphonates.     

Amount and type of protein influences bone health

Many factors influence bone mass. Protein has been identified as being both detrimental and beneficial to bone health, depending on a variety of factors, including the level of protein in the diet, the protein source, calcium intake, weight loss, and the acid/base balance of the diet. This review aims to briefly describe these factors and their relation to bone health. Loss of bone mass (osteopenia) and loss of muscle mass (sarcopenia) that occur with age are closely related. Factors that affect muscle anabolism, including protein intake, also affect bone mass. Changes in bone mass, muscle mass, and strength track together over the life span. Bone health is a multifactorial musculoskeletal issue. Calcium and protein intake interact constructively to affect bone health. Intakes of both calcium and protein must be adequate to fully realize the benefit of each nutrient on bone. Optimal protein intake for bone health is likely higher than current recommended intakes, particularly in the elderly. Concerns about dietary protein increasing urinary calcium appear to be offset by increases in absorption. Likewise, concerns about the impact of protein on acid production appear to be minor compared with the alkalinizing effects of fruits and vegetables. Perhaps more concern should be focused on increasing fruit and vegetable intake rather than reducing protein sources. The issue for public health professionals is whether recommended protein intakes should be increased, given the prevalence of osteoporosis and sarcopenia.     

Calcium, vitamin D and involutional osteoporosis

PURPOSE OF REVIEW: Previous studies suggest that combined calcium and vitamin D supplementation decreases the risk of fractures in older people, particularly those living in care homes, but trials of vitamin D alone in fracture prevention have generated inconsistent results. This review examines the physiological functions of calcium and vitamin D, and the contrasting views of what constitutes an adequate dietary calcium intake and vitamin D sufficiency in adults, and highlights the results of recent large studies of calcium and vitamin D supplementation. RECENT FINDINGS: The RECORD study shows that calcium (1000 mg/day) and vitamin D (800 IU/day), either alone or in combination, are ineffective in the secondary prevention of osteoporotic fractures in older men and women living in the community. The Northern and Yorkshire Study also suggests that calcium (1000 mg/day) and vitamin D (800 IU/day) are of no benefit in the primary prevention of fractures in community-dwelling older women. Furthermore, the Wessex study demonstrated no reduction in fractures in older people living in the community treated with annual IM injections of vitamin D (300 000 IU). SUMMARY: The latest studies highlight that vitamin D, either alone or in combination with calcium supplementation, is ineffective in the primary or secondary prevention of fractures in community-dwelling older people. In contrast, calcium and vitamin D supplementation prevents fractures in institutionalized elderly people, who commonly have vitamin D deficiency and secondary hyperparathyroidism.     

Vitamin D and bone health in postmenopausal women

Osteoporosis, a disease of increased skeletal fragility, is becoming increasingly common as the U.S. population ages. Adequate vitamin D and calcium intake is the cornerstone of osteoporosis prevention and treatment. Age-related changes in vitamin D and calcium metabolism increase the risk of vitamin D insufficiency and secondary hyperparathyroidism. Although longitudinal data have suggested a role of vitamin D intake in modulating bone loss in perimenopausal women, studies of vitamin D and calcium supplementation have failed to support a significant effect of vitamin D and calcium during early menopause. There is a clearer benefit in vitamin D and calcium supplementation in older postmenopausal women. Vitamin D intake between 500 and 800 IU daily, with or without calcium supplementation, has been shown to increase bone mineral density (BMD) in women with a mean age of approximately 63 years. In women older than 65, there is even more benefit with vitamin D intakes of between 800 and 900 IU daily and 1200-1300 mg of calcium daily, with increased bone density, decreased bone turnover, and decreased nonvertebral fractures. The decreases in nonvertebral fractures may also be influenced by vitamin D-mediated decreases in body sway and fall risk. There are insufficient available data supporting a benefit from vitamin D supplementation alone, without calcium, to prevent osteoporotic fracture in postmenopausal women.     

Micronutrient status and intake in the UK – where might we be in 10 years' time?

Poor dietary choices not only manifest in obesity, which is currently the main public health focus in the UK, but can also lead to inadequate micronutrient intakes, with implications for health. Recent dietary survey data and measurements of status biomarkers have highlighted folate, vitamin D, calcium, iron and iodine to be amongst the micronutrients of most concern for particular subgroups of the UK population. Those most vulnerable to inadequate intakes of these micronutrients include adolescents, ethnic minorities and lower socio‐economic groups. Teenage girls and women of childbearing age are of particular concern because of their high requirements for some micronutrients and the impact poor micronutrient intakes can have on the health of their offspring. Yet, compared to other food concerns, relatively little importance seems to be given by consumers to the micronutrient density of foods. This review explores different factors that may influence micronutrient intakes and status over the following decade and beyond. Over the next few years, it is likely that the micronutrients of concern remain similar, although continuation of dietary trends could result in further decreases in iron and calcium intakes. In an obesogenic and sedentary environment, where many people are being encouraged to reduce their energy intakes, increasing the micronutrient density of the diet is essential to prevent a concurrent decrease in micronutrient intake. Investment in fortification policies/practices or sustained government programmes aimed at raising awareness of micronutrients of most concern or encouraging supplementation, for example focusing on folate and vitamin D, could considerably improve population micronutrient intakes. Over the longer term, with sufficient investment in research and support from healthcare professionals and the food industry, adequate micronutrient intakes could be achieved across the UK population. However, global food security issues, including retaining food supply in response to an increase in demand for food, energy and water, and changing climate, could potentially hamper these efforts.     

Nutrition and bone growth and development

The growth and development of the human skeleton requires an adequate supply of many different nutritional factors. Classical nutrient deficiencies are associated with stunting (e.g. energy, protein, Zn), rickets (e.g. vitamin D) and other bone abnormalities (e.g. Cu, Zn, vitamin C). In recent years there has been interest in the role nutrition may play in bone growth at intakes above those required to prevent classical deficiencies, particularly in relation to optimising peak bone mass and minimising osteoporosis risk. There is evidence to suggest that peak bone mass and later fracture risk are influenced by the pattern of growth in childhood and by nutritional exposures in utero, in infancy and during childhood and adolescence. Of the individual nutrients, particular attention has been paid to Ca, vitamin D, protein and P. There has also been interest in several food groups, particularly dairy products, fruit and vegetables and foods contributing to acid-base balance. However, it is not possible at the present time to define dietary reference values using bone health as a criterion, and the question of what type of diet constitutes the best support for optimal bone growth and development remains open. Prudent recommendations (Department of Health, 1998; World Health Organization/Food and Agriculture Organization, 2003) are the same as those for adults, i.e. to consume a Ca intake close to the reference nutrient intake, optimise vitamin D status through adequate summer sunshine exposure (and diet supplementation where appropriate), be physically active, have a body weight in the healthy range, restrict salt intake and consume plenty of fruit and vegetables.     

Nutrition and bone health projects funded by the UK Food Standards Agency: have they helped to inform public health policy?

The UK Food Standards Agency convened an international group of expert scientists to review the Agency-funded projects on diet and bone health in the context of developments in the field as a whole. The potential benefits of fruit and vegetables, vitamin K, early-life nutrition and vitamin D on bone health were presented and reviewed. The workshop reached two conclusions which have public health implications. First, that promoting a diet rich in fruit and vegetable intakes might be beneficial to bone health and would be very unlikely to produce adverse consequences on bone health. The mechanism(s) for any effect of fruit and vegetables remains unknown, but the results from these projects did not support the postulated acid-base balance hypothesis. Secondly, increased dietary consumption of vitamin K may contribute to bone health, possibly through its ability to increase the gamma-carboxylation status of bone proteins such as osteocalcin. A supplementation trial comparing vitamin K supplementation with Ca and vitamin D showed an additional effect of vitamin K against baseline levels of bone mineral density, but the benefit was only seen at one bone site. The major research gap identified was the need to investigate vitamin D status to define deficiency, insufficiency and depletion across age and ethnic groups in relation to bone health.     

Predictors of nutritional adequacy in mother-toddler dyads from rural families with limited incomes

OBJECTIVE: To predict the mean adequacy ratio (MAR) scores of mothers and toddlers from intakes of fruits, vegetables, and dairy group foods and being seated during mealtimes. DESIGN/SUBJECTS: This was a regression analysis of cross-sectional data of the diet quality and being seated during mealtimes of 100 rural mother-toddler dyads from limited-income families using two 24-hour dietary recalls. Children were 11 to 25 months of age and at or below 100% of the poverty index. MEASURES OF OUTCOME: Dietary quality for mothers and toddlers was assessed using a MAR score for eight different nutrients (vitamin A, vitamin C, vitamin D, folate, calcium, zinc, iron, and magnesium), and a score of 85 or above was considered nutritionally adequate. The main food groups of interest were servings from the fruits, vegetables, and dairy group foods. Mealtime sitting behavior was the percentage of times the toddler remained seated while eating. RESULTS: Servings of fruits, vegetables, and dairy foods predicted 0.62 of the variance in the mother's MAR score, whereas vegetable and dairy intakes along with being seated while eating indicated nutritional adequacy for toddlers. Mothers with low MAR scores were most likely to have toddlers with poor diets, although few toddlers had poor diet quality. CONCLUSIONS: Adequate intakes of dairy, vegetables, and whole fruits along with being seated while eating could be quick assessment tools to screen toddlers for nutritional risk. Mothers with poor diet quality were likely to have toddlers with poor diets; low intakes of fruits, vegetables, and dairy foods were markers for poor diet quality in mothers.     

Combined Calcium and Vitamin D Supplementation Reduces Bone Loss and Fracture Incidence in Older Men and Women

A recent supplementation study of 389 men and women over the age of 65 years was conducted to address the impact of combined calcium and vitamin D supplementation on nonvertebral fracture incidence and maintenance of bone mass. Daily supplementation with 500 mg calcium and 700 IU vitamin D for 3 years moderately reduced bone loss at several sites and significantly decreased the rate of nonvertebral fractures, compared with a placebo group. Optimal intake of both calcium and vitamin D may be an easily implemented strategy to maintain existing bone mass and reduce the risk of fracture in older men and women.     

Supplementation with vitamin D and calcium in long-term care residents

Vitamin D deficiency is a common finding in institutionalized older persons. Vitamin D-deficient elderly persons are at higher risk of falls and fractures. Long-term care residents should be considered at high risk of vitamin D deficiency and therefore vitamin D supplementation is highly recommended in this population. The minimal effective dose is 800 IU per day. It is recommended that vitamin D supplementation should be implemented in all patients in residential aged care facilities. In addition to vitamin D, calcium supplementation has shown to enhance the effect of vitamin D on bone. Calcium intake should be optimized (1200-1500 mg per day recommended) and supplementation offered to those with inadequate intake. The addition of calcium depends on tolerance, history of kidney stones, and emerging data regarding its cardiovascular safety.     

Hypovitaminosis D in the elderly: From bone to brain

Conclusion  There is a growing consensus that vitamin D recommended daily intakes for the elderly are far too low, and that all individuals should take as much vitamin D as needed to raise levels to between 32 to 40 ng/ml (80 to 100 nmol/L) (5, 108, 109). Supplementation will likely be necessary in most elderly, since according to current lifestyles, diet and sunlight alone are inadequate sources of vitamin D (17). We believe that to raise and maintain 25(OH) vitamin D levels at a minimum of 32 ng/ml (80 nmol/L), most elderly will require at least 2,000 IU of cholecalciferol per day. But many questions remain. Are other biological markers preferable to 25(OH) vitamin D to assess repletion? Do the current estimates of optimal serum levels provide health benefits for all conditions, or do optimal vitamin D levels differ depending on the target tissue? How much vitamin D, cholecalciferol, or ergocalciferol, should be given to maintain these levels? What are the molecular mechanisms by which vitamin D influences health and disease? Cross-sectional studies have suggested that low vitamin D levels not only predict nursing home admission but also are associated with increased mortality (1, 2). Further knowledge of the mechanisms of vitamin D action and prospective clinical trials designed to determine if supplementation resulting in vitamin D levels higher than those shown to reduce the risk of falls and fractures is also effective in reducing the burden of various medical conditions could help validate a cost-effective intervention that will provide greater quality of life and longevity and have a major public health impact.     

Nutritional Determinants of Bone Health

ABSTRACT

Osteoporosis is a major public health problem. The aging population will require vigilant prevention, education, and treatment to maintain bone density and reduce the risk of fractures and falls. Nutritional requirements of elderly persons can have a profound effect on bone health. Calcium, vitamin D, and protein are vital nutrients for optimal bone health. Adequate calcium is essential for bone maintenance. Vitamin D research shows a link between reduced falls and fractures. Related macro- and micronutrients play an important role in bone mass integrity and quality. Adequate nutrition for older adults needs to be encouraged to promote and maintain bone health.     

Effects of vitamin D in the elderly population: current status and perspectives

Besides its well-known effect on bone metabolism, recent researches suggest that vitamin D may also play a role in the muscular, immune, endocrine, and central nervous systems. Double-blind RCTs support vitamin D supplementation at a dose of 800 IU per day for the prevention of falls and fractures in the senior population. Ecological, case–control and cohort studies have suggested that high vitamin D levels were associated with a reduced risk of autoimmune diseases, type 2 diabetes, cardio-vascular diseases and cancer but large clinical trials are lacking today to provide solid evidence of a vitamin D benefit beyond bone health. At last, the optimal dose, route of administration, dosing interval and duration of vitamin D supplementation at a specific target dose beyond the prevention of vitamin D deficiency need to be further investigated.     

Nutrient Intake and Status in Adults Consuming Plant-Based Diets Compared to Meat-Eaters: A Systematic Review

Health authorities increasingly recommend a more plant-based diet, rich in fruits, vegetables, pulses, whole grains and nuts, low in red meat and moderate in dairy, eggs, poultry and fish which will be beneficial for both health and the environment. A systematic review of observational and intervention studies published between 2000 and January 2020 was conducted to assess nutrient intake and status in adult populations consuming plant-based diets (mainly vegetarian and vegan) with that of meat-eaters. Mean intake of nutrients were calculated and benchmarked to dietary reference values. For micronutrient status, mean concentrations of biomarkers were calculated and compared across diet groups. A total of 141 studies were included, mostly from Europe, South/East Asia, and North America. Protein intake was lower in people following plant-based diets compared to meat-eaters, but well within recommended intake levels. While fiber, polyunsaturated fatty acids (PUFA), folate, vitamin C, E and magnesium intake was higher, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) intake was lower in vegetarians and vegans as compared to meat-eaters. Intake and status of vitamin B12, vitamin D, iron, zinc, iodine, calcium and bone turnover markers were generally lower in plant-based dietary patterns compared to meat-eaters. Vegans had the lowest vitamin B12, calcium and iodine intake, and also lower iodine status and lower bone mineral density. Meat-eaters were at risk of inadequate intakes of fiber, PUFA, α-linolenic acid (ALA), folate, vitamin D, E, calcium and magnesium. There were nutrient inadequacies across all dietary patterns, including vegan, vegetarian and meat-based diets. As plant-based diets are generally better for health and the environment, public health strategies should facilitate the transition to a balanced diet with more diverse nutrient-dense plant foods through consumer education, food fortification and possibly supplementation.     

Longitudinal assessment of micronutrient intake among African-American and white girls: The National Heart, Lung, and Blood Institute Growth and Health Study

OBJECTIVE: Low intakes of micronutrients among adolescents may be linked to long-term health risks, especially in African-American girls. This report describes intake of key micronutrients relative to the Dietary Reference Intakes in a sample of African-American and white girls. DESIGN: Longitudinal analyses used data from 3-day food records collected in the National Heart, Lung, and Blood Institute Growth and Health Study. SUBJECTS/SETTING: Subjects included 1,166 white and 1,213 African-American girls (aged 9 to 18 years). MAIN OUTCOME MEASURES: Estimated usual daily intakes of vitamins A, E, C, D, B-6, B-12, magnesium, folate, calcium, and zinc were compared to the Adequate Intake (for vitamin D and calcium) or the Estimated Average Requirement (EAR) (all other micronutrients). STATISTICAL ANALYSES PERFORMED: Usual daily intake of each micronutrient was estimated. For nutrients with an EAR, the EAR cut-point method was used to assess the prevalence of low nutrient intakes. Mixed models were used to identify age and racial differences in usual daily intake of each nutrient. RESULTS: African-American girls consumed less vitamin A and D, calcium, and magnesium compared to white girls. Regardless of race, a substantial percentage of girls had intakes below the EAR: vitamin E (81.2% to 99.0%), magnesium (24.0% to 94.5%), folate (46.0% to 87.3%). Intakes of vitamins A, D, and C; calcium; and magnesium decreased across years. As girls aged, there was an increasing proportion with intakes below the EAR for vitamins A, C, B-6, and B-12. CONCLUSIONS: Food and nutrition professionals should continue to educate adolescent girls, especially those who are African American, about the importance of a nutrient-dense diet for optimum health.     

The influence of breakfast and dairy products on dietary calcium and vitamin D intake in postpubertal adolescents and young adults

Background: Given the importance of both calcium and vitamin D for bone health and the high prevalence of vitamin D from around the world, the present study aimed to evaluate calcium and vitamin D intake in a group of healthy Brazilian adolescents and young adults and to examine the influence of breakfast and dairy products in the total intake of these nutrients. Methods: One hundred and sixty adolescents and young adults, aged 16–20 years old, from a public school, participated in the present study. Three‐day dietary records were used to assess calcium and vitamin D intakes. Serum 25(OH)D levels were measured using a radioimmunoassay kit. The results were expressed as the mean (SD). Results: Only 3.8% of the subjects met the daily adequate intake recommendation for calcium, and none for vitamin D [682.2 (132.2) mg day^?1 and 124.0 (28.0) IU day^?1, respectively]. 25(OH)D serum levels were insufficient in 51.5% and deficient in 9.7% of the individuals [72.5 (22.3) nmol L^?1]. There was a significant positive correlation between dairy product intake with both calcium and vitamin D (r = 0.597 and r = 0.561, respectively; P = 0.000). Adolescents who ate breakfast had a significant higher mean calcium, vitamin D and dairy product intake than adolescents who did not report this meal. Conclusions: The majority of adolescents and young adults did not consume recommended intakes of calcium and vitamin D and also presented 25(OH)D insufficiency. The results indicate that a regular breakfast and the consumption of dairy products represent important strategies in improving calcium and vitamin D intake in the diet.     

Effects of a low-fat vegan diet and a Step II diet on macro- and micronutrient intakes in overweight postmenopausal women

OBJECTIVE: This study investigated the nutrient intake of overweight postmenopausal women assigned to a low-fat vegan diet or a Step II diet. METHODS: Fifty-nine overweight (body mass index, 26 to 44 kg/m2) postmenopausal women were randomly assigned to a self-selected low-fat vegan or a National Cholesterol Education Program Step II diet in a 14-wk controlled trial on weight loss and metabolism. Nutrient intake, which was measured per 1000 kcal, was the main outcome measure. Statistical analyses included within-group and between-group t tests examining changes associated with each diet. RESULTS: Consumption of a low-fat vegan diet was associated with greater decreases in fat, saturated fat, protein, and cholesterol intakes and greater increases in carbohydrate, fiber, beta-carotene, and total vitamin A intakes than was a Step II diet. The low-fat vegan group also increased thiamin, vitamin B6, and magnesium intakes more than the Step II group, and both groups increased folic acid, vitamin C, and potassium intakes. If considering only food sources of micronutrients, the low-fat vegan group decreased vitamin D, vitamin B12, calcium, selenium, phosphorous, and zinc intakes compared with baseline. However, with incidental supplements included, decreases were evident only in phosphorous and selenium intakes. No micronutrient decreases were found in the Step II group. CONCLUSIONS: Individuals on a low-fat vegan or Step II diet should take steps to meet the recommended intakes of vitamin D, vitamin K, folic acid, calcium, magnesium, and zinc. Individuals on a low-fat vegan diet should also ensure adequate intakes of vitamin B12, phosphorous, and selenium.     

Dietary determinants of bone mass and fracture risk: a review

There is considerable controversy concerning the relationships between nutrient intakes and both bone mass and fracture risk. This paper reviews the evidence for each of the dietary variables which have been suggested to be of relevance: calcium, vitamin D, phosphorus, protein, dietary fibre, fluoride, caffeine and alcohol. Most surveys have concentrated on calcium intake and other nutrients have been relatively neglected. Peak bone mass appears to be a critical factor in determining bone health in the postmenopausal years, and calcium intake in childhood and adolescence may be an important determinant of peak bone mass. Calcium intake may also affect the rate of bone loss in middle-aged and elderly subjects. However, further study is required in all these areas. Furthermore, few surveys have investigated the relative contributions of nutrition and other factors to bone loss, but it is likely that oestrogen concentrations and physical activity have a greater effect than diet in both middle-aged and elderly women.     

Should we be concerned about the vitamin D status of athletes?

A surprisingly high prevalence of vitamin D insufficiency and deficiency has recently been reported worldwide. Although very little is known about vitamin D status among athletes, a few studies suggest that poor vitamin D status is also a problem in athletic populations. It is well recognized that vitamin D is necessary for optimal bone health, but emerging evidence is finding that vitamin D deficiency increases the risk of autoimmune diseases and nonskeletal chronic diseases and can also have a profound effect on human immunity, inflammation, and muscle function (in the elderly). Thus, it is likely that compromised vitamin D status can affect an athlete's overall health and ability to train (i.e., by affecting bone health, innate immunity, and exercise-related immunity and inflammation). Although further research in this area is needed, it is important that sports nutritionists assess vitamin D (as well as calcium) intake and make appropriate recommendations that will help athletes achieve adequate vitamin D status: serum 25(OH)D of at least 75 or 80 nmol/L. These recommendations can include regular safe sun exposure (twice a week between the hours of 10 a.m. and 3 p.m. on the arms and legs for 5-30 min, depending on season, latitude, and skin pigmentation) or dietary supplementation with 1,000-2,000 IU vitamin D3 per day. Although this is significantly higher than what is currently considered the adequate intake, recent research demonstrates these levels to be safe and possibly necessary to maintain adequate 25(OH)D concentrations.