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In this secondary analysis of data from a double‐blind randomized controlled trial (clinicaltrials.gov identifier: NCT00133744) of micronutrient supplementation (multiple micronutrients [MMN], iron–folic acid [IFA] and folic acid [FA] alone), we examined the potential modifying effect of gestational age at enrolment on the association of antenatal supplementation and pregnancy‐induced hypertension (PIH). We included 18,775 nulliparous pregnant women with mild or no anaemia who were enrolled at 20 weeks of gestation or earlier from five counties of northern China. Women were randomly assigned to receive daily FA, IFA or MMN from enrolment until delivery. We used logistic regression to evaluate the association between PIH and timing of micronutrient supplementation. The incidence of PIH was statistically significantly lower among women who began MMN supplementation before 12 gestational weeks compared with women who began MMN supplementation at 12 weeks or later (RR = 0.74, 95% CI: 0.60–0.91). A similar protective effect was observed for both early‐onset (

Summary Background & aims Increasing evidence suggests that iron-containing multiple micronutrient may reduce the risk of pregnancy-induced hypertension including gestational hypertension or preeclampsia. We aimed to examine whether 30 mg iron plus folic acid or multiple micronutrients during pregnancy reduces the risk of pregnancy-induced hypertension. Methods We conducted a secondary data analysis by the dataset from a double-blind randomized controlled trial in China from 2006 to 2009 that was conducted to investigate the effects of multiple micronutrient supplements on adverse pregnancy outcomes when provided to pregnant women with no/mild anemia. We used logistic regression to estimate the adjusted odds ratio and 95% confidence interval and test for effect modification. Results The incidence of pregnancy-induced hypertension was 7.1% (423/5923), 6.3% (374/5933) and 6.3% (372/5914) among the pregnant women who took folic acid only, iron-folic acid and multiple micronutrient supplements, respectively. The adjusted odds ratios associated with iron-folic acid supplements and multiple micronutrient supplements for pregnancy-induced hypertension were both nearly 0.88 (95% confidence interval, 0.76–1.02), compared with folic acid supplements only. Among pregnant women aged 20–24 years, iron-folic acid (adjusted odds ratios: 0.81, 95% confidence interval: 0.67–0.96) or multiple micronutrient supplementation (adjusted odds ratios: 0.83, 95% confidence interval: 0.70–0.99) can significantly reduce the risk of pregnancy-induced hypertension compared to folic acid supplementation. Conclusions Overall, there were no significant differences in pregnancy-induced hypertension across supplement groups. However, among pregnant women aged 20–24 years, iron-containing multiple micronutrient supplementation was associated with a reduced risk of pregnancy-induced hypertension compared with folic acid supplements only. Trial registration ClinicalTrials.gov NCT00133744.

In 2009, the Ministry of Health of Kyrgyzstan launched a national Infant and Young Child Nutrition (IYCN) program which included point-of-use fortification of foods with micronutrient powders (MNP) containing iron, vitamin A, and other micronutrients. Caretakers of children aged 6–23 months were given 30 sachets of MNP every 2 months. Micronutrient surveys were conducted in 2009 and 2013. The objective of the study was to compare the prevalence of anemia and deficiencies of iron and vitamin A among children aged 6–29 months prior to the MNP program (2009) with those after full implementation (2013). Cross-sectional national surveys were conducted in 2009 (n = 666) and 2013 (n = 2150). Capillary blood samples were collected to measure hemoglobin, iron (ferritin and soluble transferrin receptor [sTfR]) and vitamin A (retinol binding protein [RBP]) status, and inflammation status (C-reactive protein [CRP] and α-1-acid glycoprotein [AGP]). Ferritin, sTfR, and RBP were adjusted for inflammation; hemoglobin was adjusted for altitude. The prevalence of anemia was non-significantly lower in 2013 compared to 2009 (32.7% vs. 39.0%, p = 0.076). Prevalence of inflammation-adjusted iron deficiency (54.8% vs. 74.2%, p

Although prenatal iron-containing supplements have been associated with lower anemia prevalence in later pregnancy, few trials have examined the effect of supplements on the anemia status of post-partum women and their infants. We compared the effects of folic acid alone (FA), iron-folic acid (IFA) and multiple micronutrients (MMN) when provided to pregnant women with no or mild anemia on the hemoglobin levels of post-partum women and their infants at 6 and 12 months of age. We also examined the potential modifying effect of maternal hemoglobin concentration at enrollment. A double-blind randomized controlled trial was conducted in China; 18,775 nulliparous women with a hemoglobin concentration > 100 g/L were randomly assigned to receive daily FA (400 μg); IFA (FA, Fe 30 mg), or MMN (FA, Fe and 13 micronutrients) from before 20 gestational weeks until delivery. Compared with daily prenatal FA, supplementation with IFA or MMN did not affect the prevalence of anemia at 4–6 weeks post-partum (27.2%, 26.8%, and 26.3%, respectively). At 6 months of age, the anemia prevalence in infants was 6.9%, 6.7%, and 6.7%, respectively. Findings were similar at 12 months of age. Among both post-partum women and infants, findings were similar across all levels of hemoglobin at enrollment. Compared to FA alone, prenatal IFA and MMN provided to women with no or mild anemia did not affect anemia in women post-partum or their infants regardless of baseline maternal hemoglobin concentration at enrollment.

In this secondary analysis of data from a double-blind randomized controlled trial carried out in northern China, we aimed to assess the effect of prenatal supplementation with multiple micronutrients (MMN) or iron + folic acid (IFA), versus folic acid (FA) alone, on risk of spontaneous preterm birth (SPB) and the impact of supplementation timing on SPB. A total of 18,775 nulliparous pregnant women enrolled between 2006 and 2009 were randomly assigned to receive daily FA, IFA, or MMN from the period before 20 weeks’ gestation to delivery. The incidences of SPB for women consuming FA, IFA, and MMN were 5.7%, 5.6% and 5.1%, respectively. Compared with women given FA, the relative risks of SPB for those using MMN and IFA were 0.99 (95% confidence interval: 0.85, 1.16) and 0.89 (95% confidence interval: 0.79, 1.05), respectively. SPB incidence in women who started consuming FA, IFA, and MMN before the 12th week of gestation (4.6%, 4.2%, and 3.9%, respectively) was significantly reduced compared with starting supplement use on or after the 12th gestational week (6.9%, 7.2%, and 6.4%, respectively). Starting use of FA, IFA, or MMN supplements before the 12th week of gestation produced a 41%–45% reduction in risk of SPB. Early prenatal enrollment and micronutrient use during the first trimester of pregnancy appeared to be of particular importance for prevention of SPB, regardless of supplement group.

Background Vitamin B-12 and folate deficiencies in women and children have important public health implications. However, the evidence is conflicting and limited on whether the influence of inflammation on biomarker concentrations may be sufficiently and consistently influenced by inflammation to require adjustment for interpreting concentrations or estimating population prevalence of deficiencies. Objective We examined correlations between concentrations of the inflammation biomarkers C-reactive protein (CRP) and α1-acid glycoprotein (AGP) and serum vitamin B-12 and serum and RBC folate among nonpregnant women of reproductive age (WRA; 15–49 yr) and preschool children (PSC; 6–59 mo). Methods We analyzed cross-sectional data from 16 nationally representative nutrition surveys conducted in WRA (n = 32,588) and PSC (n = 8,256) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project. Spearman correlations between CRP or AGP and vitamin B-12 or folate concentrations were examined, taking into account complex survey design effects. Results Correlations between inflammation and vitamin B-12 or folate were weak, with no clear pattern of association in either WRA or PSC. Correlation coefficients between CRP and vitamin B-12 for WRA and PSC ranged from −0.25 to 0.16, and correlations between AGP and vitamin B-12 ranged between −0.07 and 0.14. Similarly, correlations between CRP and serum folate ranged from −0.13 to 0.08, and correlations between AGP and serum folate between −0.21 and 0.02. Only 3 surveys measured RBC folate, and among them, correlations for WRA ranged from −0.07 to 0.08 for CRP and −0.04 for AGP (1 country). Conclusions Based on the weak and inconsistent correlations between CRP or AGP and vitamin B-12 or folate biomarkers, there is no rationale to adjust for inflammation when estimating population prevalence of vitamin B-12 or folate deficiencies in WRA or PSC.

As national flour fortification standards are one of the policy documents developed to guide food fortification, the objective was to compare national, mandatory wheat and maize flour fortification standards to World Health Organization (WHO) fortification guidelines. For each nutrient in 72 countries’ standards, the type of compound was noted as ‘yes’ if it was included in international guidelines or ‘no’ if it was not. Nutrient levels in standards were classified as lower than, equal to, or higher than those suggested by WHO. If another food (i.e. rice, oil, milk) was mass fortified with a nutrient categorized as “lower than,” the classification was changed to “less than recommendation and included in other mass fortified food”. At least 61% of standards included one or more recommended compounds for all nutrients in standards for wheat flour alone (iron, folic acid, vitamin A, zinc, vitamin B12,), wheat and maize flour together (iron, folic acid, vitamin A, zinc, vitamin B12) and maize flour alone (thiamin, riboflavin, niacin, pyridoxine); no country included pantothenic acid in its maize flour standard. For folic acid, vitamin A, thiamin, riboflavin, niacin and pyridoxine, at least 50% of standards (1) met or exceeded WHO suggested levels, or (2) were lower than suggested levels and another food was mass fortified with the specific nutrient in the country. For iron, zinc and vitamin B12, less than 50% of standards met (1) or (2). In conclusion, iron, zinc and vitamin B12 may require the most attention in national fortification standards.

This chapter provides an overview of monitoring and evaluation issues related to food fortification. It presents the foundational 2006 WHO/FAO monitoring and evaluation background for food fortification and briefly describes the principal components of regulatory and household/individual monitoring and evaluation (M&E). Additionally, these components are integrated within a systematic six step framework for M&E of food fortification programs. Ideally, the information generated by an M&E system should be regularly reviewed by a national multisector coalition of key stakeholders commonly known as a Food Fortification Alliance. M&E program performance is critical for determining whether foods are being fortified according to country standards and for estimating dietary and nutritional impact. Ultimately, a strong fortification M&E system is one that includes information from all M&E components and provides this information to decision makers so they can make adjustments to improve food fortification program effectiveness.

Concerns have been raised about the benefits of Fe-containing supplements on infant birth weight among women with normal/high Hb levels at baseline. Thus far, no clinical trials have examined whether the effects of prenatal Fe-containing supplements on birth weight vary by maternal Hb levels. We compared the effects of Fe–folic acid (IFA) or multiple micronutrients (MMN) with folic acid (FA) supplements on birth weight among pregnant women with mild/no anaemia or high Hb levels. A double-blind randomised controlled trial was conducted in 2006–2009. In total, 18 775 pregnant women with mild/no anaemia (145 g/l) baseline Hb levels, IFA and MMN supplements increased birth weight by 91·44 (95 % CI 3·37, 179·51) g and 107·63 (95 % CI 21·98, 193·28) g (P

Two national surveys were conducted in Jordan in 2002 and 2010 to investigate the micronutrient status in women and children. To determine the prevalence of anemia, iron and folate deficiency among women and children in 2010 and compare with the prevalence of anemia and iron deficiency in 2002. A nationally representative survey was conducted in 2002 (1023 women, 15–49 years of age; 1059 children, 12–59 months of age) and a second survey in 2010 (2035 women; 940 children). Venous blood samples were used to measure hemoglobin, ferritin and red blood cell folate (the latter on a subsample of 393 women). Among women in 2010, the prevalence of folate deficiency and insufficiency was 13.6% and 82.9%, respectively. Geometric mean serum ferritin was higher in 2010 compared with 2002 (21.3 ng/ml vs 18.3, P=0.01); there was no significant change in the prevalence of iron deficiency (35.1% vs 38.7%, P=0.17), iron deficiency anemia (19.1% vs 20.0%, P=0.61) or anemia (29.2% vs 29.3%, P=0.96). Among children, a significantly lower prevalence was observed in 2010 compared with 2002 for iron deficiency (13.7% vs 26.2% P

OBJECTIVES: To conduct a household and biomarker survey to assess the baseline prevalence of folate deficiency and insufficiency and vitamin B12 deficiency in women of reproductive age prior to the start of a wheat flour fortification program in the Ambala District in Haryana, India. METHODS: A multistage cluster probability household and biomarker survey was conducted. Participants were women of reproductive age (18–49 y) who were not pregnant and resided in rural areas of two subdistricts in Ambala District in Haryana. Venous blood samples were collected among 866 women. Plasma, serum, and red blood cells (RBC) were separated by centrifugation, processed, and stored at

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake. While wheat flour mills are often inspected by agencies affiliated with national ministries to ensure compliance with national fortification standards, few countries use data derived from these inspections to construct an external monitoring system for use in program management and evaluation. The primary objective of this paper is to assess the performance of the external monitoring system utilized in Jordan according to the US Centers for Disease Control and Prevention’s Updated Guidelines for Evaluating Public Health Surveillance Systems. A secondary objective is to present mill monitoring results from 2009 to 2010 in order to demonstrate the data generated by the system. The review concludes that the data required for the system is representative, simple to collect, and can be collected in a flexible manner. The external monitoring system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. Data on production of fortified flour and utilization of premix can be provided in a timely manner, but on-site mill monitoring and flour sample collection are more challenging due to resource constraints. The frequent collection of a small number of indicators can provide fortification program managers with timely information with which to base decisions. Jordan’s external monitoring system successfully documented the performance of each mill and the entire flour fortification program, and can serve as a model for other national fortification programs considering external monitoring approaches.

To combat iron and other micronutrient deficiencies, the Ministry of Health of the Kyrgyz Republic launched a regional Infant and Young Child Nutrition (IYCN) program in 2009, which included promotion of home fortification with micronutrient powder (MNP) containing iron (12.5 mg elemental iron), vitamin A (300 μg) and other micronutrients. Every 2 months children aged 6–24 months were provided 30 sachets to be taken on a flexible schedule. The objective was to assess biochemical indicators of iron and vitamin A status among children aged 6–24 months at the baseline and follow-up surveys. Cross-sectional representative cluster surveys were conducted in 2008 (n=571 children) and 2010 (n=541). Data collected included measurement of hemoglobin, serum ferritin, soluble transferrin receptor (sTfR), retinol-binding protein, C-reactive protein (CRP) and α1-glycoprotein acid (AGP). Among all children, declines were observed in the prevalence of: anemia, 50.6% versus 43.8% (P=0.05); total iron deficiency (either low ferritin or high sTfR), 77.3% versus 63.7% (P

BACKGROUND/OBJECTIVES: Vitamin D deficiency, a risk factor for osteomalacia and osteoporosis, is a re-emerging health problem globally. While sunlight is an important vitamin D source, previous investigations among women whose culture encourages skin covering have been small, not nationally representative, or both. We investigated serum 25–hydroxyvitamin D (25(OH)D(3)) status and factors associated with deficiency in a nationally representative survey of 2013 Jordanian women of reproductive age in Spring 2010. SUBJECTS/METHODS: We measured 25(OH)D(3) concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with skin covering and other factors. RESULTS: Results showed 60.3% (95% CI: 57.1–63.4%) deficiency (

Consuming an adequate amount of iodine during pregnancy is critical for fetal neurologic development. Even a mild deficiency can impair cognitive ability. Important sources of iodine in the United States include dairy products and iodized salt. Although the U.S. population has traditionally been considered iodine sufficient, median urinary iodine concentrations (UIC) have decreased 50% since the 1970s. We analyzed 2001-2006 NHANES data from urine iodine spot tests for pregnant (n = 326), lactating (n = 53), and nonpregnant, nonlactating (n = 1437) women of reproductive age (15-44 y). We used WHO criteria to define iodine sufficiency (median UIC: 150-249 microg/L among pregnant women; >or=100 microg/L among lactating women; and 100-199 microg/L among nonpregnant, nonlactating women). The iodine status of pregnant women was borderline sufficient (median UIC = 153 microg/L; 95% CI = 105-196), while lactating (115 microg/L; 95% CI = 62-162) and nonpregnant, nonlactating (130 microg/L; 95% CI = 117-140) women were iodine sufficient. Dairy product consumption was an important contributor to iodine status among both pregnant and nonpregnant, nonlactating women, and those who do not consume dairy products may be at risk for iodine deficiency. Although larger samples are needed to confirm these findings, these results raise concerns about the iodine status of pregnant women and women of reproductive age who are not consuming dairy products. Iodine levels among U.S. women should be monitored, particularly among subgroups at risk for iodine deficiency.

Objective: To determine associations between changes in obesity and vigorous physical activity (PA) status and depressive symptoms in a cohort aged 51 to 61 years at baseline. Method: Two waves (1992, 1998) of Health and Retirement Study data were used to divide participants into four obesity and four vigorous PA status categories based on change in or maintenance of their 1992 status in 1998. Depressive symptoms were defined as the upper quintile score (women ≥ 4, men ≥ 3) on the eight-item Center for Epidemiologic Studies—Depression Scale. Logistic regression determined adjusted odds ratios for depressive symptoms associated with obesity and vigorous PA status. Results: Among men, no significant associations were found. Among women, decreasing from high vigorous PA status and maintenance of obese status were independently associated with increased odds for depressive symptoms in 1998. Discussion: The findings illustrate the importance of examining gender differences in studies of risk factors for depression.

Relatively few studies have focused on who is at risk for weight regain after weight loss and how to prevent it. The objectives of this study were to determine the prevalence and predictors of weight regain in U.S. adults who had experienced substantial weight loss.Data were analyzed from the 1999-2002 National Health and Nutrition Examination Survey (NHANES). This study examined U.S. adults aged 20-84 years who were overweight or obese at their maximum weight (body mass index/=25) and had experienced substantial weight loss (weighed 10% less than their maximum weight 1 year before they were surveyed) (n=1310).Compared to their weight 1 year ago, 7.6% had continued to lose weight (5%), 58.9% had maintained their weight (within 5%), and 33.5% had regained weight (5%). Factors associated with weight regain (vs weight maintenance or loss) included Mexican American ethnicity (versus non-Hispanic white) (odds ratio [OR]=2.0; 95% confidence interval [CI]=1.3-3.1), losing a greater percentage of maximum weight (/=20% vs 10% to15%) (OR=2.8; 95% CI=2.0-4.1), having fewer years since reaching maximum weight (2-5 years vs10 years) (OR=2.1; 95% CI=1.2-3.7), reporting greater daily screen time (/=4 hours vs 0-1 hour) (OR=2.0; 95% CI=1.3-3.2), and attempting to control weight (OR=1.8; 95% CI=1.1-3.0). Finally, weight regain was higher in those who were sedentary (OR=1.8; 95% CI=1.0-3.0) or not meeting public health recommendations for physical activity (OR=2.0; 95% CI=1.2-3.5).How to achieve the skills necessary for long-term maintenance of weight loss in the context of an obesogenic environment remains a challenge.

OBJECTIVE: To examine the concentration of C-reactive protein (CRP) in relation to gestational weeks during pregnancy among Chinese women. METHODS: From a randomized control trial of prenatal supplementation with folic acid, iron-folic acid, and multiple micronutrients in China, we examined 834 pregnant women with CRP measured initially between 5 and 20 weeks and at follow-up between 28 and 32 weeks gestation. We calculated and plotted CRP geometric means by gestational weeks. The same analysis was repeated for women who had normal pregnancies (624 women) by excluding women with stillbirth, preterm, small for gestational age, body mass index 30 kg/m(2) at enrollment, and hypertension or anemia during pregnancy. RESULTS: We observed a significant positive trend between log-transformed CRP and gestational age from 5 to 20 weeks and from 28 to 32 weeks both in the full sample and in the subset of women who had normal pregnancies. CRP geometric mean was 0.81 mg/l at 5–7 weeks of gestation, 2.85 mg/l at 19–20 weeks of gestation, and 3.89 mg/l at 32 weeks of gestation. A similar increasing trend in the CRP median or percentage of elevated CRP were also observed. CONCLUSION: We concluded that CRP increased with gestational age among healthy Chinese women who delivered healthy infants. Am. J. Hum. Biol. 28:574–579, 2016.

Context. More than 80 countries fortify flour, yet the public health impact of this intervention on iron and anemia outcomes has not been reviewed. Objective. The objective of this systematic review was to review published and gray literature pertaining to the impact of flour fortification on iron and anemia. Data Sources. A systematic review was conducted by searching 17 databases and appealing for unpublished reports, yielding 1881 documents. Study Selection. Only studies of government-supported, widely implemented fortification programs in which anemia or iron status was measured prior to and ≥12 months after initiation of fortification were included. Data Extraction. Details about the design, coverage, compliance with national standards, and evaluation (e.g., anemia prevalence before and after fortification) of flour fortification programs were extracted from the reports. Data Synthesis. Thirteen studies describing 26 subgroups (n = 14 for children ≤15 y, n = 12 for women of reproductive age) were included. During the period from pre- to postfortification (and as difference-in-difference for those studies that included a control group), there were statistically significant decreases in the prevalence of anemia in 4 of 13 subgroups of children and in 4 of 12 subgroups of women of reproductive age as well as significant decreases in the prevalence of low ferritin in 1 of 6 subgroups of children and in 3 of 3 subgroups of women of reproductive age. Conclusions . Evidence of the effectiveness of flour fortification for reducing the prevalence of anemia is limited; however, evidence of effectiveness for reducing the prevalence of low ferritin in women is more consistent.

Background Nutrition counseling by physicians can improve patients' dietary behaviors and is affected by physicians' nutrition practices and attitudes, such as the perceived relevance of nutrition counseling. Objective The objective was to provide data on medical students' perceived relevance of nutrition counseling, reported frequency of nutrition counseling, and frequency of fruit and vegetable intakes. Design Students (n = 2316) at 16 US medical schools were surveyed and tracked at freshmen orientation, at the time of orientation to wards, and in their senior year. Results Freshmen students were more likely (72%) to find nutrition counseling highly relevant than were students at the time of ward orientation (61%) or during their senior year (46%; P for trend = 0.0003). Those intending to subspecialize had lower and declining perceptions of counseling relevance (P for trend = 0.0009), whereas the perceived relevance of counseling by primary care specialists remained high (P for trend = 0.5). Students were significantly more likely to find nutrition counseling highly relevant if they were female, consumed more fruit and vegetables, believed in primary prevention, had personal physicians who encouraged disease prevention, or intended to specialize in primary care. Only 19% of students believed that they had been extensively trained in nutrition counseling, and 17% of seniors reported that they frequently counseled their patients about nutrition. Students who consumed more fruit and vegetables, believed that they would be more credible if they ate a healthy diet, were not Asian or white, or intended to specialize in primary care counseled patients about nutrition more frequently. Medical students consumed an average of 3.0 fruit and vegetable servings/d, which declined over time. Conclusions The perceived relevance of nutrition counseling by US medical students declined throughout medical school, and students infrequently counseled their patients about nutrition. Interventions may be warranted to improve the professional nutritional practices of medical students.

Objective: To examine the prevalence and association of health-related quality of life (HRQOL) with trying to lose weight and with weight loss practices (eating fewer calories, physical activity, and both) among overweight and obese U.S. adults ≥ 20 years of age. Research Methods and Procedures: This study used data from the 2001 to 2002 National Health and Nutrition Examination Survey, a continuous annual survey of the civilian non-institutionalized U.S. population. This analysis included those ≥ 20 years of age with BMI ≥ 25 (n = 2578) who responded to four standard HRQOL measures that assessed general health status and recent physical health, mental health, and activity limitation. Results: Among obese men, but not women, there were significant increasing linear trends in the adjusted prevalence of trying to lose weight as physically unhealthy and activity limitation days increased. Regardless of BMI or HRQOL, reducing calories was a common weight loss practice (66% to 86%). Except for recent activity limitation, respondents with BMI ≥ 35 did not generally differ by HRQOL level in the attainment of recommended physical activity either alone or in combination with reduced calories, whereas those in the BMI 25 to 34.9 groups often differed significantly by HRQOL level. Specifically, increased unhealthy or activity limitation days were associated with reduced prevalence of attained physical activity. Discussion: Our findings indicate an association between trying to lose weight and a greater number of unhealthy days reported by obese men, suggesting that these men may be influenced by traditional clinical weight-loss counseling that is prompted by weight and comorbidity, whereas women had a high prevalence of trying to lose weight irrespective of weight and HRQOL. Assessment of HRQOL, especially measures that evaluate physical domains, could provide subjective information to assist with weight counseling.

Objective This study investigated food choices made by individuals consuming diets differing in energy density and explores relationships between energy density and diet quality. Design Cross-sectional, nationally representative survey. Subjects 7,500 adults (older than 19 years) in the 1994-1996 Continuing Survey of Food Intakes by Individuals. Statistical Analysis Energy density values were calculated from reported food intake. Subjects were classified as consuming a low-energy-density diet, medium-energy-density diet, or high-energy-density diet using tertile cutoffs. For each group, the percentage consuming various foods/beverages and the mean amount of foods/beverages they consumed was determined along with mean nutrient intakes. Results Compared with participants consuming a high-energy-density diet, those with a low-energy-density diet had a lower energy intake but consumed more food, by weight, from most food groups. A low-energy-density diet included a relatively high proportion of foods high in micronutrients and water and low in fat, such as fruits and vegetables. Subjects with a low-energy-density diet consumed fewer (nonwater) beverages such as caloric carbonated beverages. They also consumed less fat and had higher intakes of several important micronutrients, including vitamins A, C, and B-6, folate, iron, calcium, and potassium. Conclusions These analyses further demonstrate the beneficial effects of a low-energy-density diet, which was associated with lower energy intakes, higher food intakes, and higher diet quality than a high-energy-density diet. To achieve a low-energy-density diet, individuals should be encouraged to eat a variety of fruits and vegetables as well as low-fat/reduced-fat, nutrient-dense, and/or water-rich grains, dairy products, and meats/meat alternatives.

The prevalence of overweight and obese adults in the United States is at record levels. The primary purpose is to describe secular trends in desired weight among adults from 1994 to 2003, and secondarily, to examine the hypothetical impact of achieving desired weight on obesity prevalence. Data were from the Behavioral Risk Factor Surveillance System (1994, 1996, 1998, 2000, 2003), a random-digit-dialed telephone survey. Sample included respondents from 47 states and the District of Columbia. Non-institutionalized adults aged 18 years or older were included (N=703 286). Primary outcome measures included reported weight and desired weight. Means for desired weight increased 2.3 kg between 1994 and 2003, and reported weights increased 3.9 kg. The increased trend was observed across several subgroups for age, race/ethnicity and education. Within subgroups of weight status, the trend has remained relatively stable, particularly when examined in relation to the difference between reported and desired weight as a percentage of reported body weight. Generally, overweight men desired weights approximately 4.5% less than their reported weight, and obese men desired weights approximately 15% less than their reported weight for each corresponding year. For women, approximate values of desired weight were 12% less than reported weight for overweight women and 24% less for obese women. The prevalence of obesity would decrease to 4.4% if individuals weighed their desired weight. Americans are shifting their desired weight upward, concomitantly with an increase in their reported body weight.

Compared with younger adults, older people experience additional health, social, and environmental conditions that affect their dietary intake. To identify those additional dimensions and examine them in association with fruit and vegetable intake, data of 4,622 participants in NHANES III (1988–1994), ages 60 years and over, were analyzed using multivariate logistic regression modeling. Results showed that participants at highest risk of consuming fruits and vegetables in the lowest quartile were those socially isolated, with missing pairs of posterior teeth, with poor self-reported health and those who were obese. To prevent downward spiraling health, barriers must be addressed in intervention programs.

Objectives: The prevalence of childhood overweight in the United States has markedly increased over the last 30 years. We examined differences in the secular trends for BMI, weight, and height among white, black, and Mexican-American children. Research Methods and Procedures: Analyses were based on nationally representative data collected from 2 to 17 year olds in four examinations (1971–1974 through 1999–2002). Results: Overall, black children experienced much larger secular increases in BMI, weight, and height than did white children. For example, over the 30-year period, the prevalence of overweight increased ∼3-fold (4% to 13%) among 6- to 11-year-old white children but 5-fold (4% to 20%) among black children. In most sex-age groups, Mexican-American children experienced increases in BMI and overweight that were between those experienced by blacks and whites. Race/ethnicity differences were less marked among 2 to 5 year olds, and in this age group, white children experienced the largest increase in overweight (from 4% to 9%). In 1999–2002, the prevalence of extreme BMI levels (≥99th percentile) reached 6% to 7% among black girls and Mexican-American boys. Discussion: Because of the strong tracking of childhood BMI levels into adulthood, it is likely that the secular increases in childhood overweight will greatly increase the burden of adult disease. The further development of obesity interventions in different racial/ethnic groups should be emphasized.

Background Although walking is a popular leisure-time activity, a substantial amount of total daily walking occurs in nonleisure contexts (i.e., occupation, transportation, and household work). Because nonleisure walking is not assessed by traditional leisure-time activity surveys, total walking among U.S. adults may be underestimated. This study describes walking estimates obtained from a measure of leisure-time activity and a specific measure of total walking in all contexts. Methods A national sample of adults ( n =6626), selected by random-digit dialing, was surveyed between May 1999 and November 2000. Estimates of walking prevalence and of weekly time spent walking were examined from two separate modules: (1) an assessment restricted to leisure-time activity, and (2) an assessment of total walking. Results Walking prevalence based on the total walking module was nearly double that based on the leisure-time module (81% vs 43%, respectively). The median weekly minutes of walking also nearly doubled using the total walking module (239 vs 130 minutes, respectively). Among those with jobs involving substantial walking, median weekly walking minutes were more than three times greater with the total walking module (476 vs 130 minutes, respectively). Conclusions U.S. adults, particularly those with jobs involving walking, do a substantial amount of walking not captured by traditional leisure-time activity surveys. This may affect the appropriate targeting of physical activity interventions, as well as the evaluation of the effectiveness of physical activity promotions and policies. However, further characterization of nonleisure walking is needed to determine its contribution to health and meeting physical activity guidelines.

Objective.The authors examined vitamin/supplement (V/S) use and its relationship to sociodemographics, health behaviors, and health conditions among adults in 13 states.Methods.This investigation used 2001 data from a cross-sectional study of non-institutionalized adults aged ⩾18 years, the Behavioral Risk Factor Surveillance System.Results.Of 45,415 respondents with complete data (18,723 males and 26,692 females), 56.5% ( n=5,652) reported current V/S use. After adjusting for age, sex, race/ethnicity, and education, the authors found a statistically significant association between V/S use and positive health risk behavior (adjusted odds ratio [OR] = 1.46; pConclusions.People who used V/S in the states surveyed were more likely to demonstrate positive health risk behaviors than those who did not report V/S use. Thus it appears that individuals who are most likely to use V/S are least likely to need V/S. It is crucial that individuals report quantity and frequency of V/S use when providing medical or diet histories to health care providers.

Dietary energy density [kcal/g (kJ/g)] influences energy intake under controlled laboratory conditions. Little is known about the energy density of the diets of free-living persons. Because energy density investigations are a relatively new endeavor, there are neither standard calculation methods nor published nationally representative values. This paper examines the calculation of energy density based on systematic exclusion of beverage categories, presents data on variability, and compares values by sex, age, and race/ethnicity in a representative sample of U.S. adults. Mean daily dietary energy density values for adults (aged >19 y) were calculated using two 24-h recalls from the Continuing Survey of Food Intakes by Individuals 1994-1996 based on food, food and liquid meal replacements, food and alcohol, food and juice, food and milk, food and juice and milk, food and energy-containing beverages, and food and all beverages. Energy density varied by calculation method, ranging from 0.94 to 1.85 kcal/g (3.93-7.74 kJ/g). Intraindividual-to-interindividual CV ratios were highest for the food and energy-containing beverages calculation. Men reported diets with a higher energy density than women for all calculation methods (P < 0.0001). There were differences by race/ethnicity and an inverse linear trend for age. These data indicate that beverage inclusion schemes should be clearly defined when reporting energy density values. In epidemiologic studies, calculations based on food and all beverages and food and energy-containing beverages may diminish associations with outcome variables. These nationally representative data, which provide an important frame of reference for other studies, indicate that dietary energy density differs by sex, age, and race/ethnicity.

Objective. Although many studies have found that childhood levels of body mass index (BMI; kg/m2) are associated with adult levels, it has been reported that childhood BMI is not associated with adult adiposity. We further examined these longitudinal associations. Design. Cohort study based on examinations between 1973 and 1996. Setting. Bogalusa, Louisiana. Participants. Children (2610; ages 2-17 years old) who were followed to ages 18 to 37 years; the mean follow-up was 17.6 years. Main Outcome Measures. BMI-for-age and triceps skinfold thickness (SF) were measured in childhood. Subscapular and triceps SFs were measured among adults, and the mean SF was used as an adiposity index. Adult obesity was defined as a BMI ≥ 30 kg/m2 and adult overfat as a mean SF in the upper (gender-specific) quartile. Results. Childhood levels of both BMI and triceps SF were associated with adult levels of BMI and adiposity. The magnitude of these longitudinal associations increased with childhood age, but the BMI levels of even the youngest (ages 2-5 years) children were moderately associated (r = 0.33-0.41) with adult adiposity. Overweight (BMI-for-age ≥ 95th centile) 2- to 5-year-olds were >4 times as likely to become overfat adults (15 of 23 [65%]), as were children with a BMI < 50th centile (30 of 201 [15%]). Even after accounting for the triceps SF of children, BMI-for-age provided additional information on adult adiposity. Conclusions. Childhood BMI is associated with adult adiposity, but it is possible that the magnitude of this association depends on the relative fatness of children.

Background: Despite the popularity of antiobesity medications, there is a lack of population-based data on their use. In addition, response (termination of pill use and receipt of an echocardiogram) to the fenfluramine and dexfenfluramine market withdrawal among the public has not been described. Lessons learned from this event have implications for future withdrawals. Methods: We used data from the Behavioral Risk Factor Surveillance System (BRFSS) a random-digit telephone survey. In 1998, six states included detailed questions about the use of prescription weight loss pills in the previous 2 years, n = 16,460 noninstitutionalized adults aged 18 years or older. Results: Almost one third of prescription weight loss pills users were not obese before taking pills. Family and friends and other nonphysicians were reported as sources of medication by one in ten users. One third of users also reported taking nonprescription diet products. Among fenfluramine or dexfenfluramine users, one third continued pill use after the market withdrawal and only one quarter received echocardiograms. Conclusions: Despite enormous publicity, many persons continued to use fen-phen after the market withdrawal and most did not receive follow-up echocardiograms. Our study raises issues regarding the effectiveness of withdrawal warnings in a small but significant subset. Additional means of communicating risk to individuals are needed for future product withdrawals including special strategies for those lacking healthcare coverage.

Background Most persons with type 2 diabetes are overweight, and obesity worsens the metabolic and physiologic abnormalities associated with diabetes. Our objective was to assess the effectiveness of lifestyle and behavioral weight loss and weight control interventions in adults with type 2 diabetes. Methods Studies were obtained from searches of multiple electronic bibliographic databases, supplemented with hand searches of selected journals and consultation with experts in obesity research. Studies were included if they were published or unpublished randomized controlled trials in any language that examined weight loss or weight control strategies using one or more dietary, physical activity, or behavioral interventions, with a follow-up interval of at least 12 months. Effects were combined using a random-effects model. Results The 22 studies of weight loss interventions identified yielded a total of 4659 participants with a follow-up of 1 to 5 years. The pooled weight loss for any intervention in comparison with usual care among 585 subjects was 1.7 kg (95% confidence interval [CI]: 0.3 to 3.2 kg), or 3.1% of baseline body weight among 511 subjects. Among 126 persons who underwent a physical activity and behavioral intervention, those who also received a very low-calorie diet lost 3.0 kg (95% CI: −0.5 to 6.4 kg), or 1.6% of baseline body weight, more than persons who received a low-calorie diet. Among 53 persons who received identical dietary and behavioral interventions, those who received a more intense physical activity intervention lost 3.9 kg (95% CI: −1.9 to 9.7 kg), or 3.6% of baseline body weight, more than those who received a less intense or no physical activity intervention. Comparison groups often achieved substantial weight loss (up to 10.0 kg), minimizing between-group differences. Changes in glycated hemoglobin level generally corresponded to changes in weight and were not substantial when between-group differences were examined. Conclusion Weight loss strategies involving dietary, physical activity, or behavioral interventions were associated with small between-group improvements in weight. These results were minimized by weight loss in the comparison group, however, and examination of individual study arms revealed that multicomponent interventions, including very low-calorie diets or low-calorie diets, may hold promise for achieving weight loss in adults with type 2 diabetes.

Americans’ consumption of fruits and vegetables has increased slightly over the last 10 years, but most people still do not meet the Dietary Guidelines recommendation to consume 5 to 9 servings per day. New and innovative strategies are needed if we are to significantly increase the mean population intake of fruits and vegetables. To help formulate such strategies as well as to evaluate evidence and identify research gaps, the American Cancer Society and the Centers for Disease Control and Prevention convened the Fruit and Vegetable Environment, Policy, and Pricing Workshop, which brought together experts in how environmental change, policy, and pricing affect fruit and vegetable consumption. The papers in this supplement consist of a review of environmental interventions to improve nutrition and papers covering pricing and consumer value and how fruit and vegetable consumption can be promoted at worksites, restaurants, grocery stores and other community settings, and schools. Conclusions from the workshop were that existing intervention strategies need to be evaluated, promising example programs need to be disseminated, and new innovative interventions and programs need to be created and evaluated.

Background Arthritis is the leading cause of disability in the United States. Obesity is a risk factor for arthritis, but the relationship between arthritis and weight has not been well characterized at the population level in the United States. Previous research shows that physicians often fail to advise their obese patients to lose weight. Objectives To describe the relationship between body weight and arthritis in the United States, and to assess predictors of efforts to lose weight among obese adults with arthritis, including the impact of professional advice to lose weight. Methods Data from the 2000 Behavioral Risk Factor Surveillance System (a population-based survey of U.S. adults) from the 35 states that collected information on weight and height, arthritis, and efforts to lose weight. Arthritis was based on self-report of doctor diagnosis or chronic joint symptoms. Main outcome measures were arthritis and efforts to lose weight among adults with arthritis. Results Overall, 31.7% of respondents had self-reported arthritis. There was a strong relationship between body weight and arthritis. Specifically, the prevalence of arthritis was 25.9% among normal weight (18.5 to 24.9 body mass index [BMI]) adults; 32.1% among overweight (25 to 29.9 BMI) adults; and 43.5% among obese (>30 BMI) adults. This association persisted after adjusting for other factors (adjusted odds ratio [AOR] for having arthritis among obese individuals compared with healthy weight individuals, 3.6; 95% confidence interval [CI]=3.2–3.8). Among obese adults with arthritis who had a routine checkup within the past 12 months, only 43% were advised to lose weight by a health professional. However, recipients of such advice were more likely to try to lose weight than nonrecipients, and professional advice was the strongest independent predictor of weight loss efforts (AOR=2.8; 95% CI=2.5–3.1). Conclusions Body mass index (BMI) is an important independent risk factor for self-reported arthritis. Although physicians often fail to advise obese adults with arthritis to lose weight, adults who report receiving such advice were more likely to report weight-loss efforts. Improved awareness of the relationship between arthritis and weight might help motivate patients to lose weight, and physician advice to lose weight could contribute to the prevention and treatment of arthritis.

Background Americans spend over $33 billion annually on weight-loss products and services. Although weight-control methods are of considerable public health interest, few national data on weight-loss practices are available. This paper examines the prevalence of specific weight-loss practices among U.S. adults trying to lose weight. Methods Data from the 1998 National Health Interview Survey, which was conducted through face-to-face interviews of a nationally representative sample of U.S. adults ( n =32,440), were analyzed in 2003. Results Twenty-four percent of men and 38% of women were trying to lose weight. Attempting weight loss was less common among normal weight (body mass index [BMI] 2 ) people (6% men, 24% women) than overweight (BMI≥25 to 30 kg/m 2 ) people (28%, 49%) or obese (BMI≥30 kg/m 2 ) people (50%, 58%). Among those trying to lose weight, the most common strategies were eating fewer calories (58% men, 63% women); eating less fat (49%, 56%); and exercising more (54%, 52%). Less frequent strategies were skipping meals (11% men, 9% women); eating food supplements (5%, 6%); joining a weight-loss program (3%, 5%); taking diet pills (2%, 3%); taking water pills or diuretics (1%, 2%); or fasting for ≥24 hours (0.6%, 0.7%). Only one third of all those trying to lose weight reported eating fewer calories and exercising more. Conclusions Increased efforts are needed among all those trying to lose weight to promote effective strategies for weight loss, including the use of calorie reduction and increased physical activity.

Background Alcohol abuse is a major public health problem in the United States. Binge drinking and drinking among youth are of special concern. The purpose of this study is to examine trends in alcohol use and binge drinking and correlates of the behaviors with a focus on drinking among persons 18 to 20 years of age. Methods Data are from telephone interviews of 449,110 adults aged ≥18 years residing in the 19 states that participated in the Behavioral Risk Factor Surveillance System (BRFSS) from 1985 to 1999. The percentages reporting current alcohol use and binge use (≥5 drinks per occasion) were calculated by year, age, gender, race, and level of education. Data were analyzed in 2003. Results From 1985 to 1999, the prevalence of current alcohol use dropped 7.3%, and binge drinking dropped 3.3%. Among all age groups, most of the decline occurred before 1990. The greatest decline in both current (12.6%) and binge use (7.3%) occurred in the 18- to 20-year-old group. Between 1997 and 1999, however, respondents in this age group reported increases in these behaviors. Throughout the survey period, the proportion of current users who binge changed very little and remained highest among persons aged 18–20 years (52.1%). Conclusions Alcohol use leveled off in the 1990s, but may be increasing, especially among persons 18–20 years of age. Those who drink are about as likely to report binge drinking as were drinkers 15 years ago.

BACKGROUND The biological variability in serum retinol concentrations has never been examined in a large sample, and its effect on population distribution estimates and the clinical assessment of vitamin A status is unknown. OBJECTIVE We evaluated the biological CV of serum retinol and examined the effect of the CV on both population distribution estimates and clinical assessments of vitamin A status by using data from the third National Health and Nutrition Examination Survey, 1988-1994. DESIGN We described the biological CV [(SD/x) x 100] and examined associations between the CV and other factors via multivariate analysis of variance and linear regression. We used linear regression to predict the mean retinol concentration from a single concentration and established 95% CIs for each participant. We estimated the adjusted prevalence of inadequate vitamin A status (retinol < 1.05 micromol/L) on the basis of the CIs. We estimated an uncertainty range for serum retinol concentrations for which the CIs included the established cutoff. RESULTS The mean biological CV across all strata was 6.45%. The biological CV varied significantly between racial-ethnic groups (P < 0.05). Prevalence estimates of inadequate serum retinol concentrations were reduced after adjustment for the total variation, with an adjusted overall prevalence of 0.62% compared with an unadjusted prevalence of 2.63%. CONCLUSIONS The actual population prevalence of inadequate vitamin A status may be 75% lower than the estimates previously reported. Confirmation of vitamin A status may be needed for persons in the United States with observed serum retinol concentrations near the recognized cutoff.

Objective To examine trends in walking among adults in 31 states. Methods Trends by sociodemographic strata were analyzed from respondents who participated in the Behavioral Risk Factor Surveillance System (BRFSS). Results The prevalence of walking among men increased 3.8% (95% confidence interval [CI]=2.4–5.2), from 26.2% (95% CI=25.1–25.3) in 1987 to 30.1% (95% CI=29.4–30.8) in 2000. In women, walking increased 6.6% (95% CI=5.4–7.8), from 40.4% (95% CI=–39.4–41.1) to 46.9% (95% CI=46.2–47.6) during the same time period. However, the prevalence of walking three times a week for 30 minutes duration remained constant across all years. The largest increases occurred in minority subpopulations: 8.7% (95% CI=3.2–14.2) in Hispanic women, 8.5% (95% CI=4.4–12.6) non–Hispanic black women, and 7.0% (95% CI=2.3–11.7) in non–Hispanic black men. Walking was the most frequently reported activity among adults who met the national recommendations for regular physical activity (defined as five or more times a week for ≥30 minutes per session). Conclusions Given the acceptability of walking across all sociodemographic subgroups, efforts to increase the frequency of walking could markedly increase the percentage of U.S. adults who engage in regular physical activity, a national priority identified in the Healthy People 2010 objectives for the nation.

Objective: To describe weight-control practices and receipt of weight-loss advice among obese people with asthma. Research Methods and Procedures: We analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Results: Among 13,953 participants with current asthma, 27.3% had a body mass index of ≥30 kg/m2. Overall, 48.1% of participants with asthma reported trying to lose weight (64.1% among overweight or obese participants and 72.9% among obese participants). Among participants with asthma who were trying to lose or maintain weight, 74.7% reported trying to reduce their energy and/or fat intake, and 57.8% reported using physical activity. Approximately 29.7% were using the recommended combination of energy and/or fat intake reduction and physical activity of ≥150 min/wk. During the 12 months before the interview, 16.2% of overweight and 44.9% of obese participants with asthma reported receiving advice to lose weight. Among obese participants receiving weight-loss advice, 82.9% reported trying to lose weight compared to 63.8% of participants who did not receive such advice. Discussion: Health professionals can play an important role in educating their patients with asthma about the importance of weight control and assisting their overweight and obese patients in setting appropriate weight goals and helping them achieve those goals.

Background Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals. Methods Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated. Results By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use. Conclusions Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help.

Universal prenatal daily iron-folic acid (IFA) and multiple micronutrient (MM) supplements are recommended to reduce the risk of low birth weight, maternal anemia, and iron deficiency (ID) during pregnancy, but the evidence of their effect on iron status among women with mild or no anemia is limited. The aim of this study was to describe the iron status [serum ferritin (SF), serum soluble transferrin receptor (sTfR), and body iron (BI)] before and after micronutrient supplementation during pregnancy. We examined 834 pregnant women with hemoglobin > 100 g/L at enrollment before 20 wk of gestation and with iron measurement data from a subset of a randomized, double-blind trial in China. Women were randomly assigned to take daily 400 μg of folic acid (FA) (control), FA plus 30 mg of iron, or FA, iron, plus 13 additional MMs provided before 20 wk of gestation to delivery. Venous blood was collected in this subset during study enrollment (before 20 wk of gestation) and 28-32 wk of gestation. We found that, at 28-32 wk of gestation, compared with the FA group, both the IFA and MM groups had significantly lower prevalence of ID regardless of which indicator (SF, sTfR, or BI) was used for defining ID. The prevalence of ID at 28-32 wk of gestation for IFA, MM, and FA were 35.3%, 42.7%, and 59.6% by using low SF, 53.6%, 59.9%, and 69.9% by using high sTfR, and 34.5%, 41.2%, and 59.6% by using low BI, respectively. However, there was no difference in anemia prevalence (hemoglobin < 110 g/L) between FA and IFA or MM groups. We concluded that, compared with FA alone, prenatal IFA and MM supplements provided to women with no or mild anemia improved iron status later during pregnancy but did not affect perinatal anemia. This trial was registered at clinicaltrials.gov as NCT00137744.

BACKGROUND/OBJECTIVES: Vitamin D deficiency in children remains a global concern. Although literature exists on the vitamin D status and its risk factors among children in the Middle East, findings have yielded mixed results, and large, representative community studies are lacking. SUBJECTS/METHODS: In a nationally representative survey of 1077 Jordanian children of preschool age (12–59 months) in Spring 2010, we measured 25(OH)D(3) concentrations by liquid chromatography–tandem mass spectrometry and calculated prevalence ratios for deficiency associated with various factors. RESULTS: Results showed 19.8% (95% confidence interval (CI): 16.4–23.3%) deficiency (

Accurate assessment of dietary intake among preschool-aged children is important for clinical care and research, for nutrition monitoring and evaluating nutrition interventions, and for epidemiologic research. We identified 25 studies published between January 1976 and August 2000 that evaluated the validity of food recalls (n = 12), food frequency questionnaires (n = 9), food records (n = 2), or other methods (n = 2). We identified four studies that evaluated the reproducibility of food frequency questionnaires. Validity studies varied in validation standard and study design, making comparisons between studies difficult. In general, food frequency questionnaires overestimated total energy intake and were better at ranking, than quantifying, nutrient intake. Compared with the validation standard, food recalls both overestimated and underestimated energy intake. When choosing a method to estimate diet, both purpose of the assessment and practicality of the method must be considered, in addition to the validity and reproducibility reported in the scientific literature.

Background. Assessing the diets of children presents unique methodological challenges. Validity and reliability studies of recalls, records, food frequency questionnaires (FFQs), diet histories, and observations among children were reviewed. Methods. Forty-seven studies were published in peer-reviewed English journals between January 1970 and April 1999 of children 5–18 years of age with a sample size of at least 30. Results. Most of the 24-h recall validation studies assessed only a portion of the day, not a 24-h period, with higher agreements for meal versus complete day intake. Food records underestimated energy intake when compared to doubly labeled water. Few studies evaluated children's ability to complete records alone or to record an entire day. FFQs overestimated energy intake; however, validation standards may have over-or underestimated intake or used different referent periods. Reliability studies were identified for FFQs and diet history; results showed higher energy intake in first compared to subsequent administrations. Limited data were available on age, ethnicity, and gender effects. Conclusions. Correlations between the validation standard and dietary method were generally higher for recalls and records than FFQs. It was difficult to generalize the validity and reliability results of dietary assessment methods because of discrepancies in study design, referent periods, and validation standards.

To determine whether low fat intake is associated with increased risk of nutritional inadequacy in children 2 to 8 years old and to identify eating patterns associated with differences in fat intake.Using 2 days of recall from the Continuing Survey of Food Intake by Individuals (CSFII), 1994 to 1996, we classified 2802 children into quartiles of energy intake from fat (29%, 29% to 31.9% [defined as moderate fat], 32% to 34.9%, andor =35%) and compared nutrient intakes, the proportion of children at risk for inadequate intakes, Food Pyramid servings, and fat content per serving across quartiles.More children in quartile 2 were at risk for inadequate intakes of vitamin E, calcium, and zinc than children in higher quartiles (P.0001); more children in quartiles 3 and 4 were at risk for inadequate intakes of vitamins A and C and folate (P.001). Fruit intake decreased across quartiles (P.0001); whereas vegetable, meat, and fat-based condiment intakes increased (P.0001). Fat per serving of grain, vegetables, dairy, and meat increased across quartiles (P.0001).Moderate-fat diets were not consistently associated with an increased proportion of children at risk for nutritional inadequacy, and higher-fat diets were not consistently protective against inadequacy. Dietary fat could be reduced by judicious selection of lower-fat foods without compromising nutritional adequacy.

Background: Although body fat patterning has been related to adverse health outcomes in adults, its importance in children and adolescents is less certain. Objective: We examined the relation of circumference (waist and hip) and skinfold-thickness (subscapular and triceps) measurements to lipid and insulin concentrations among 2996 children and adolescents aged 5-17 y. Design: This was a community-based, cross-sectional study conducted in 1992-1994. Results: A central or abdominal distribution of body fat was related to adverse concentrations of triacylglycerol, LDL cholesterol, HDL cholesterol, and insulin: these associations were independent of race, sex, age, weight, and height. These associations were observed whether fat patterning was characterized by using I) waist circumference alone (after adjustment for weight and height), 2) waist-to-hip ratio, or 3) principal components analysis. Compared with a child at the 10th percentile of waist circumference, a child at the 90th percentile was estimated to have, on average, higher concentrations of LDL cholesterol (0.17 mmol/L). triacylglycerol (0.11 mmol/L), and insulin (6 pmol/L) and lower concentrations of HDL cholesterol (-0.07 mmol/L). These differences, which were independent of weight and height, were significant at the 0.001 level and were consistent across race-sex groups. Conclusions: These findings emphasize the importance of obtaining information on body fat distribution, waist circumference in particular. in children. Waist circumference, which is relatively easy to measure, may help to identify children likely to have adverse concentrations of lipids and insulin.