Journal of the American College of Nutrition, Vol. 23, No. 4, 341-350 (2004)
Published by the American College of Nutrition
Longitudinal Changes in Intake and Food Sources of Calcium from Childhood to Young Adulthood: The Bogalusa Heart Study
R. Rajeshwari, MS,
Theresa A. Nicklas, DrPH,
Su-Jau Yang, MS and
Gerald S. Berenson, MD
Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas (R.R., T.A.N., S.J.Y.)
Tulane Center for Cardiovascular Health, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana (G.S.B.)
Address reprint requests to: Theresa A. Nicklas, DrPH, Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates Avenue, Houston, Texas 77030. E-mail: tnicklas{at}bcm.tmc.edu
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ABSTRACT
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Objective. To examine changes in calcium intake and food sources of calcium from childhood to young adulthood in a longitudinal sample.
Methods. Information on food and nutrient intake was derived from a single 24-hour dietary recall collected on children who participated in a cross-sectional survey at age 10 and again in young adulthood. A cohort of 237 young adults who participated in the 1989–1991 young adult survey (ages 19 to 28 years) also participated in one of three cross-sectional surveys from 1973 to 1978 at 10 years of age. Repeated measures analysis of variance was applied to examine the longitudinal changes in intake of calcium and food sources from childhood to young adulthood.
Results. Total calcium intake at age 10 was not significantly different than total calcium intake of those same individuals when they were young adults. Gender and ethnic differences were observed within the two age groups. In both childhood (age 10 years) and young adulthood, African-American females had significantly lower total calcium intake than Euro-American males. However, this ethnic difference in total calcium intake did not exist after adjusting for energy intake. Calcium intake per 1000 kcal was significantly lower in females than males at age 10, but not in young adulthood. A large percentage of 10-year-olds did not meet the RDA or AI for calcium intake (54% and 88%, respectively), and this was also shown when they were young adults (77% and 75%, respectively).
Conclusions. More effective nutrition educational efforts are needed to emphasize the importance of adequate calcium intake and the major food sources of calcium, beginning early in childhood and continuing into young adulthood.
Key words: dietary intake, calcium, child nutrition, adult nutrition
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INTRODUCTION
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Osteoporosis and low bone mass are currently perceived major health threats for an estimated 44 million women and men over the age of 50. Osteoporosis, which is associated with low calcium intake, has been called the "pediatric disease with geriatric consequences" [1–3].
Calcium intake influences the risk of osteoporosis by effecting genetically determined peak bone mass, a state that is reached by age 30 or earlier [2–6]. Thus, childhood and adolescence are critical times to optimize peak bone mass [7,8]. Milk and other dairy products are among the best sources of calcium, they offer high calcium bioavailability, have a high calcium content, and may be obtained at low cost relative to their nutritional value [9,10]. In children, more than two-thirds of calcium intake is derived from consumption of milk and dairy products [11]. In contrast, only 22% of calcium intake in young adults is from dairy products.
Children and adolescents are drinking less milk and more sweetened beverages [12,13]. The decline in milk consumption may have a major impact on overall dietary quality and nutritional intake [12–14]; thus, having serious, long term detrimental effects on bone health later in life [15].
Dietary calcium intake declines as children get older and females consume less calcium than males. Data from the 1994–1996 Continuing Survey of Food Intakes (CSFII) showed that the majority of children have a usual intake of calcium that is less than 100% of the calcium Adequate Intake (AI) [16]. Seventy-one percent of girls and 62% of boys 6 to 11 years of age do not meet 100% of the AI for calcium [16]. Similar results were observed for 10-year old children in Bogalusa, Louisiana, where 69% did not meet the dietary recommendation of 1300 mg/day; the percentage was higher among females (76%) than males (62%) (p < 0.001) [17]. In two young adult surveys, more females than males did not meet the calcium AI recommendation. Among females and males 12 to 19 years, 88% and 68%, respectively, did not meet the calcium AI recommendation [16]. Nearly 9 out of 10 adolescent girls and 7 out of 10 adolescent boys failed to meet the AI recommendation for calcium. Caucasians and Hispanics had higher calcium intake levels than African-Americans and "others" [16,18,19]. Among young adults (19–28 years), 77% did not meet the AI recommendation for calcium; particularly females (82%) [17].
On average, school-aged children are consuming 2.2 servings of dairy products compared to only 1.7 servings in young adults [20]. The proportion of calcium contributed by milk and milk products decreased with age; 71% of girls and 62% of boys 6 to 11 years of age do not meet AI requirement for calcium [16]. Among young adults (19 to 28 years of age), 77% did not meet the AI for calcium particularly female (82%) [17,21]. In a more recent attempt to identify the major dietary sources of nutrients in children’s diets, Subar et al. reported that milk supplied greater than 51% of the calcium in children’s diets. However, milk intake decreased by 6 percent by 12 to 18 years of age. A limitation of these data is that they do not provide an accurate picture of how calcium intake and food sources of calcium change from childhood to young adulthood in a longitudinal sample.
In response to the nation’s critical shortfall in calcium consumption, a plethora of calcium-fortified food products and beverages have appeared on supermarket shelves [6]. Although the percentage of U.S. adults exceeding the recommended dietary intake for calcium is low (i.e., less than 5%) [22], this percentage may increase due to the availability of calcium-fortified foods and beverages, many of which are fortified at high levels [6]. This discrepancy between calcium intakes and recommendations has led to the marketing of an increasing number and variety of calcium-fortified foods and beverages. These current changes in the food supply may not be reflected in this 1989–1991 study of young adults.
It is well known that transition from childhood to young adulthood consists of great behavioral and physiological changes [23,24]. For example, during childhood, eating patterns are greatly influenced by participation in school meals [25] and parental control of foods served in the home [26–29]. As children age, they become increasingly reliant on fast-food sources [30]. One can reasonably hypothesize that during this transition from childhood to young adulthood, eating behaviors may change, resulting in inconsistent eating patterns across the age periods.
The Bogalusa Heart Study, [31,32] a long-term epidemiology study, provides the unique opportunity to examine changes in calcium intake from childhood to young adulthood in a longitudinal sample. In addition, the contribution of food groups to calcium intake from childhood to young adulthood can also be examined.
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METHODS
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Population
The Bogalusa Heart Study is an epidemiological investigation of cardiovascular risk factor variables and environmental determinants in a bi-racial (white-black) population that began in 1973 [31,32]. A cohort of 246 young adults who participated in the 1989–1991 young adult survey (ages 19 to 28 years) also participated in one of three cross-sectional surveys from 1973 to 1978 at 10 years of age. Nine subjects were excluded from the analysis because they were pregnant. The sample consisted of 43% males, 57% females, 70% Euro-Americans (EA) and 30% African-Americans (AA). The ethnic mix of the sample is comparable to the Bogalusa population [31,32], but the sample had a slightly higher percentage of females. Approximately 32% of the sample participated in the 1973–74 survey, 27% in the 1976–77 survey, and 41% in the 1978–79 survey (Table 1). The duration of follow-up for the 1973 survey was 14–18 years, for the 1976 survey it was 11–15 years, and, for the 1978 survey it was 9–13 years. Written informed consent was obtained and experimental plans, procedures, and consent forms were reviewed and approved by the Louisiana State University and Tulane University Medical Center ethics and research committees.
Dietary Methodology
The 24-hour dietary recall method was used in interviewing children [33,34]. Quality controls included 1) a standardized protocol that specified exact techniques for interviewing, recording, and calculating results; 2) standardized graduated food models for quantification of foods and beverages consumed; 3) a product identification notebook for probing of foods commonly forgotten; 4) school lunch assessment was conducted to identify and calculate all school lunch recipes, preparation methods, and average portion sizes of menu items reflected in each 24-hour recall [35]; 5) follow-up telephone calls to parents were conducted to obtain information on brand names, recipes, and preparation methods of meals served at home; 6) products were researched in the field to obtain updated information on product cost, ingredients, and their weights; primarily snack foods, candy, and fast foods; and, 7) the Moore Extended Nutrients (MENu), formerly known as the Extended Table of Nutrient Values, was used for nutrient composition [36]. A similar 24-hour dietary recall methodology was used when the children were young adults.
One 24-hour dietary recall was collected on each study participant at each time period. All interviewers participated in rigorous training sessions and pilot studies before the field surveys were conducted to minimize interviewer effects. Duplicate recalls were obtained from a 10 percent random sub-sample for each study population to assess interviewer variability [37].
Nutrient Database
The MENu is a nutrient database that includes more than 5,000 core foods and recipes, with values for 97 dietary components [36]. The database is a flexible system permitting continuous updates of existing values and additions of new single or composite foods. Periodic updates are made to the MENu to reflect nutrient changes in food products. Nutrient values include United States Department of Agriculture data, other published references, manufacturers’ information, and recipe calculation by ingredients.
For each survey period, the 24-hour recalls were analyzed on the MENu, and the nutrient information was stored in a file. In addition, the version of the MENu used was saved on a tape. Analyses reflect data that were retrieved from stored information files specific to those time periods. Although the MENu was updated frequently as current information became available, we were able to store a version for each year.
Food Groups and Meal Periods
The food-grouping scheme was designed as an adjunct to the Tulane University Medical Center Nutrition system Data. To allow for comparison across multiple survey years, the food-grouping scheme was not changed since its development in 1973. Twenty-one major food groups were established and based, where feasible on similar source characteristics. For example, "fruit and fruit juices" formed one major group, and "rice, biscuits, and cereals" were included in the breads and grains category. Composite food items such as recipes were assigned to food groups according to primary ingredients. If no single type of food (other than water) accounted for at least 60% of the weight, the item was classified as mixed meat. For those recipes that could be disaggregated (e.g. a hamburger with bun, lettuce and tomato), each of the foods was assigned to their corresponding food group. Consumption was defined as any individual who consumed a food in any of the food groups, including those individuals who reported tasting or taking a bite of a food item. However, mean food group consumption was determined across the whole population. Meal periods, as reported by the respondents, were categorized into breakfast, lunch, dinner, and snacks.
Statistical Analysis
The study sample included 246 subjects who were screened both at age 10 in 1973–1978 and again in young adulthood in 1989–1991. Nine subjects were excluded from the analysis because they were pregnant.
Analysis of variance was used to examine the ethnic, gender, and ethnic x gender differences in total calcium intake. The difference in total calcium intake from childhood to young adulthood was examined by repeated measures analysis of variance. Chi-square tests were employed to test for significant differences in percent meeting calcium intake recommendations by ethnicity, gender, and ethnicity x gender.
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RESULTS
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Calcium Intakes by 10-Year-Olds and Young Adults
Reported mean total calcium intakes by gender and ethnicity are presented in Table 1. Intakes of total calcium were significantly higher in males than females at age 10 (p < 0.0001) and in young adulthood (p < 0.01). No ethnic differences were found in total calcium intake at the two age periods. When calcium intakes were adjusted per 1,000 kcal, females had significantly lower calcium intakes than males (p < 0.01) at age 10. However, this gender difference did not exist when they became young adults, which may reflect the significant ethnic x gender interaction observed in young adulthood. EA males had significantly higher calcium intake per 1000 kcal and AA females had significantly lower calcium intakes per 1000 kcal than the other gender x ethnic groups. Total calcium intake among 10-year-olds in Bogalusa (Mean = 816 mg) is comparable to calcium intakes among 10-year-olds in NHANES (Mean = 882 mg). For young adults, however, calcium intakes are slightly lower (Mean = 732 mg) than the national average (Mean = 925 mg).
Percentage of Calcium Intake by Meal Period and Food Source
The percentage of calcium intake by meal period at age 10 and in young adulthood is presented in Fig. 1. At age 10, the percentage of calcium coming from breakfast and lunch was 55% compared to 45% in young adulthood. The percentage of calcium coming from dinner was 17% at age 10 and 31% in young adulthood.
The food source of calcium in the diets of 10-year-olds is presented in Fig. 2. At age 10, 60% of the calcium intake came from foods/beverages consumed at home and 25% from foods consumed at school. Two percent of calcium intake came from foods/beverages consumed at a restaurant. In young adulthood, 61% of the calcium intake came from foods/beverages consumed at home and 9% from foods consumed at the workplace. Twenty-one percent of calcium intake came from foods consumed at a restaurant.
Food Sources of Calcium
The major food sources of calcium by age and ethnicity are presented in Fig. 3. At both age 10 and in young adulthood, milk (54% and 23%, respectively) was the major source of calcium, followed by breads/grains (11% and 18%, respectively). The contribution of cheese to calcium intake increased from 3% to 15% during the transition from childhood (age 10) to young adulthood. Desserts, vegetables, nonalcoholic beverages contributed an additional 16% to 20% to calcium intake. In childhood, AA had higher percentage of calcium from salty snacks, compared to EA (1.4% vs. 0.6%, respectively). Similarly, in young adulthood AA (18.5%) had a higher percentage of calcium from alcoholic beverages compared to EA (7.2%).
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Fig. 3. Contribution of calcium from food groups consumed in childhood and young adulthood. At childhood AA had higher percentage of calcium from salty snacks, compared to EA: 1.4% vs. 0.6%, respectively. At young adulthood, AA had higher percentage of calcium from alcoholic beverages compared to EA: 18.5% vs. 7.2%, respectively.
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Percentage of Subjects Meeting Calcium Intake Recommendations
The percentage meeting the Recommended Dietary Allowances (RDA) and Adequate Intakes (AI) for calcium at age 10 and in young adulthood is presented in Table 2. At age 10, the percentage not meeting the RDA for calcium was 54% and this percentage increased to 77% when they were young adults, with a smaller percentage of AA females meeting the RDA for calcium intake at both age periods. If we compare intakes to the current AI calcium recommendations a higher percentage did not meet the recommendations at age 10 (88%) and in young adulthood (75%), particularly females.
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DISCUSSION
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Changes in calcium intake from childhood to young adulthood has been of interest for many years and is currently a focus of discussion [23,38]. Total calcium intake at age 10 was not significantly different than total calcium intake of those same individuals when they were young adults. Gender and ethnic differences were observed within the two age groups. In both childhood (age 10 years) and young adulthood, AA females had significantly lower total calcium intakes than EA males. However, this ethnic difference in total calcium intake did not exist after adjusting for energy intake. This could be partly explained by the significant correlation between intake of energy and calcium found in this study (r = 0.58, p < 0.0001). Calcium intake per 1000 kcal was significantly lower in females than males at age 10, but not in young adulthood. In contrast to our findings, CSFII data [39] showed that average daily intake of calcium was lower in young adults than in children. The difference found between our study and CSFII may reflect the type of study design that was used (e.g. longitudinal vs. cross-sectional, respectively). Other studies have shown that calcium intakes were lower among females [10] and African-Americans [40,41], even after adjusting for total energy intake.
Data from CSFII indicated that only 29% of females and 38% of males ages 6–11 met the RDA for calcium [42,43]. These percentages are similar to those found in this study for 10-year-old females, but the percentage of males meeting the RDA for calcium was higher in this study compared to national averages. According to Brady LM et al. [44], low intake of milk and other dairy foods by children and adolescents is the primary reason for their low calcium intakes [45].
The major food sources of calcium at both age 10 and in young adulthood was milk followed by breads/grains. The contribution of cheese to calcium intake increased during the transition from childhood to young adulthood. Desserts, vegetables, and nonalcoholic beverages contributed on additional 16% to 20% to calcium intake. Examples of desserts that contributed calcium included ice cream, pudding, cookies, cakes, pies and doughnuts. The calcium coming from vegetables included dark green leafy vegetables (e.g. collards, turnip greens), potatoes and spaghetti sauce, or vegetables that had butter or margarine added during food preparation (e.g. green beans, lima beans, corn, broccoli, cabbage). The two beverages that contributed calcium were fruit flavored and carbonated beverages, suggesting that the beverages were fortified with calcium. In light of the low calcium intakes in this longitudinal sample, it is disturbing that calcium is coming from low-nutrient dense foods, such as desserts and beverages. Consumption of milk and other dairy products appear to be an excellent way, not only to achieve more calcium, but also to reap the benefits of other nutrients they provide [46,47] compared to low-nutrient dense foods. It is generally argued that choosing calcium-fortified foods, particularly at the expense of foods naturally containing calcium, is not the best way to meet calcium recommendations. Another concern is that calcium bioavailability from calcium-fortified foods may vary, depending on the food [48]. For example one would need to consume 8 cups of spinach or 2 
cups of broccoli to obtain the same amount of calcium absorbed from one cup of milk [49,50].
In this study, 38% of the children reported taking a vitamin-mineral supplement everyday or occasionally. Whereas, when they were young adults only 27% reported supplement use everyday or occasionally. Data used in this study is 10–15 years old and may not reflect the increase in fortification and supplementation of foods [51–59], and soft drink consumption [13,60]. According to representative national surveys, approximately 40%–47% of the U.S. population reported taking a dietary supplement occasionally [61,62]. The percentage of supplement use increased when individuals reached their 20s and continued to increase throughout adulthood. Thirty-three percent of young adults and less than 10% of children reported taking two or more supplements. Females (44%) were more likely to take supplements than males (35%) [62]. In the CATCH study conducted in 1997, 17.6% of eighth grade students reported taking vitamin-mineral supplements [63]. Currently there are gaps in food and dietary supplement composition data because of limited resources, changing availability of foods and products and the emergence of new supplements of health interest [64]. Moreover, supplement use may be commonly inaccurately reported or under-reported [65]. As newer longitudinal and population-based samples become available, they could further extend our understanding on the impact of changes in the food supply on the diets of children and young adults.
It is well known that transition from childhood to young adulthood consists of behavioral and physiological changes [23,24]. For example, during childhood, eating patterns are greatly influenced by participation in school meals [25] and parental control of foods served in the home [26–30]. As children age, they become increasingly autonomous; there are decreased family influences on dietary habits, and children become increasingly reliant on fast food sources [30]. In this study, there were variations in the percentage of calcium intake by meal period and food source during the age transition from childhood to young adulthood. A larger percentage of the calcium intake by 10-year-olds came from lunch compared to a larger percentage of the calcium intake by young adults coming from dinner.
For 10-year-olds in this study, 25% of the calcium came from school meals. One study found that individuals who participated both in the School Breakfast Program (SBP) and National School Lunch Program (NSLP), the differences in calcium intake were striking. Mean calcium intake among participants in both meal programs was 75% of the AI compared to 37% among nonparticipants. For overall 24-hour dietary intake of calcium, participants met 109% of the AI compared to 73% among nonparticipants. Participants consumed 1.9 servings of milk from the two meals compared with 0.7 servings among nonparticipants. Instead of milk, nonparticipants consumed more soda and fruit drinks for breakfast and lunch (average of 0.9 servings for nonparticipants versus 0.2 servings for participants). For total amount of dairy products consumed, participants consumed 2.2 servings compared to 0.9 servings for nonparticipants. Similar differences were observed in overall 24-hour dietary intake of dairy products.
One study showed that there were age differences in dairy product consumption patterns. Mean consumption of milk decreased as children became young adults, while consumption of sweetened beverages and cheese increased [66]. In the Bogalusa Heart Study, 42% and 8% of the children who consumed milk or cheese, respectively, at age 10 consumed the same dairy products when they were young adults. When milk and cheese were combined into one dairy product group, only 62% of the children who consumed a dairy food/beverage at age 10 consumed the same dairy products when they were young adults.
A limitation of this study is the use of a single 24-hour dietary recall for characterizing changes in consumption of dairy products from childhood to young adulthood. However, the use of a single 24-hour dietary recall has been found to be acceptable in characterizing dietary intakes of groups of individuals in large epidemiological surveys [33]. It is also important to emphasize that the AI for calcium intake cannot be used to estimate the proportion of the population with inadequate intake, and the results presented in this study may in fact be an overestimation. Because of the potential overestimation we also generated median calcium intakes in addition to mean intakes (Data not shown). These data showed that calcium intakes were positively skewed as indicated by the higher means compared to the medians, particularly for AA and females.
A strength of this study is that it is longitudinal and provides the opportunity to look at changes in calcium intake from childhood to young adulthood and the contribution of food groups to calcium intake during this age transition. However, these data may not be generalizable to the broader population. Keeping this in mind, this study provides important findings that have implications on designing effective intervention strategies to promote healthier eating habits that may prevent osteoporosis later in life.
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APPLICATION
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The present study shows that calcium intakes are low during the period of dietary transition from early childhood to young adulthood, despite the increase in energy intakes. Furthermore, because of a considerable decrease in intake of total calcium from childhood to young adulthood, it is clear that despite the growing girth of America’s youth, there is a corresponding nutrient shortage among the generation. These findings argue strongly for the development of dietary guidance that not only addresses energy restriction, but also assists in selecting nutrient dense diets that support optimal growth and development in children and adults.
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ACKNOWLEDGMENTS
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This research was supported by grants from the National Heart, Lung, Blood Institute of the U.S. Public Health Service (USPHS), Early Natural History of Arteriosclerosis R01 HL 38844, National Institute of Aging AG16592, and the United States Department of Agriculture, Economic Research Service Cooperative Agreement No. 43-3AEM-0-80071. Partial support was received from the National Dairy Council.
This work is a publication of the United States Department of Agriculture (USDA/ARS) Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, in Houston, Texas. The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the U.S. government. We are grateful to Margaret Moore for development and Catherine Champagne, PhD for maintenance of the Moore Extended Nutrients (MENu) database. The authors wish to thank Pamelia Harris for help in preparing the manuscript.
The Bogalusa Heart Study represents the collaborative efforts of many people whose cooperation is gratefully acknowledged. We also thank the children and young adults of Bogalusa without whom this study would not have been possible.
Received December 10, 2003.
Accepted May 7, 2004.
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TOP
ABSTRACT
INTRODUCTION
