Regan Bailey, Ph.D., RD - FNCE

11/18/2010
Measuring Total Nutrient
Intakes
Purpose of NHANES
Regan Bailey, Ph.D., RD
ADA Food and Nutrition Conference & Exposition
November 7, 2010
Views expressed are my own and do not reflect the views of
ODS, NIH, HHS, or any other entity of the U.S. Government.
To assess the health
and nutritional status
of adults and children
in the United States.
Uses of NHANES Data
Eligible NHANES Population
• Surveillance and monitoring
• Research
• Setting nutritional requirements
• DRIs
• Comparison with biomarkers and biological intermediates.
• Public health recommendations
• Prevention initiatives
• Monitoring exposure levels—pollutants, chemicals
• Food safety and fortification
• Civilian, non-institutionalized population of the United
States
• Ages 2 months and older
• Residents of all 50 states and DC
• 5000 persons examined each year in 15 locations
• Survey design determines which populations are oversampled
Data Collection
Household Interview
1. Household interview (at home)
• Questions about individual participants, their families, and
their household
• Dietary Supplement Information
2. Mobile Exam Center (MEC)
• Physical exam, sensitive questions
• Laboratory/biochemical information
• Dietary recall
Interviewers ask participants about their use of dietary
supplements and also about their use of antacids.
“Have you used or taken any vitamins,
minerals, herbals or other dietary
supplements in the past 30 days?
Include prescription and non-prescription
supplements.”
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11/18/2010
Product Usage Questions
Supplement Containers
• For how long have you been taking the product or a similar
type of product?
• In the past 30 days, how many days did you take the
product?
• On the days that you took the product, how much did you
usually take on a single day?
If participant says that they have taken a dietary supplement,
then interviewer asks to see all supplement containers.
• Containers are seen 88% of the time
• It is very important that containers are seen so that
supplement names can be recorded accurately and
completely.
Dietary Supplements Flowchart
Household interviews
Field Office/WESTAT
What Information is in the
NHANES Dietary Supplement
Database?
Dietary Supplement data
released to public NHANES Web site
NCHS
Reported supplement
labels are found in our
internal database,
requested from
manufacturers/distributors,
or found on internet.
• Supplement name
• Source of information
• manufacturer, distributor, and other references (such as
the Internet and PDR).
• Product type (infant/pediatric, prenatal, geriatric, standard)
• Ingredient and dosage information
• Manufacturer and Distributor information
• Contact information
So what do we know?
Prevalence of Use of
Any Dietary Supplement (%)
65
71
39
43
29
26
39
49
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Age in Years
Bailey et al. Journal of Nutrition, in press.
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11/18/2010
Prevalence of use
of MVMM (%)
44
46
Prevalence of Selected Vitamins and Mineral: US
population ≥ 1 year (%)
31
29 29 29 28 27 26
26
32
20
16
27
35
19 19 18 17
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Age in Years
Bailey et al. Journal of Nutrition, in press.
Bailey et al. Journal of Nutrition, in press.
Users (%) of Botanical Supplements
20
18
17
13
%
Number of Dietary Supplements
Reported in the US
53
2
4
3
5
20
11
6
10
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Age in Years
Bailey et al. Journal of Nutrition, in press.
1 2 3 4 5 or more
Bailey et al. Journal of Nutrition, in press.
Supplement Use (%) by BMI
Supplement Use (%) by Education
56
57
*
*
37
50
61
48
< 25 25-30 ≥ 30
BMI
< HS HS > HS
Education
Bailey et al. Journal of Nutrition, in press.
Bailey et al. Journal of Nutrition, in press.
3

percent
percent
percent
11/18/2010
65
60
55
50
45
40
35
30
25
20
Adult Supplement Use by Gender
male
*
*
60
female 57
*
47 46 47
35
NH3 1999-2002 2003-2006
80
75
70
65
60
55
50
45
40
35
30
25
Supplement Use by Age
20-39 40-59 60+
70
64
55 55
47
43 42 41
37
NH3 1999-2002 2003-2006
*
Gahche et al. Unpublished Data.
Gahche et al. Unpublished Data.
Supplement Use Race/Ethnicity
70
* *
60
60
58
50 *
44
40
33 34
32
29
30
20
10
NH White
NH Black
Mex Am
36
34
NHANES 2003-2006
• More than half the US adult population use dietary
supplements (53%)
• Estimated 35% of children (1 -13 years) report use of
supplements
• The impact of dietary supplements can not be ignored!!!
0
NH3 1999-2002 2003-2006
Gahche et al. Unpublished Data.
Total Nutrient Intake
TOTAL Nutrient Intake
• Food
• Beverages
• Fortified Foods
• Dietary Supplements
• Some medications (e.g. antacids)
Important to evaluate total nutrient intake:
• For some nutrients, portion of intake from supplements may
be large (e.g., vitamin E)
• Adequacy and excess perhaps underestimated if only food
sources are considered
• Some ULs defined only for supplement-derived nutrient
intake (e.g., Mg)
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11/18/2010
Total vs Usual Nutrient Intakes
Usual total nutrient intake
• 24-hour recall are good daily measure, but not “usual” or
long-term
• Usual intakes of foods and nutrients are necessary to
characterize the role that nutrients play in disease
prevention and treatment
• Limited research exists
• contribution of dietary supplements to total usual
nutrient intakes among various segments of the U.S.
population
• Unobservable in practice
• Can be estimated as the mean of multiple daily intakes
• Varies from individual to individual
• Distribution of usual intakes is typically of interest
How do we incorporate
dietary supplements in
NHANES?
Original Scale
Transform
Transformed Scale
• Two days of 24-hour dietary recall - DAILY
• Day 1: MEC interview
• Day 2: Telephone 3 to 10 days after MEC
• Dietary data are collected using USDA’s dietary data
collection instrument
• Automated Multiple-Pass Method
• Supplement Data – MONTHLY
Back transform
Slide courtesy of Kevin Dodd NIH/NCI
Example: Vitamin B6
in Women 19-50 yrs
DS: Calcium 2003-2006
2,24 hr recalls &
adjustments with Iowa method
20% below EAR
• 53% of NHANES 2003-2006 participants reported DS use
• 43% used supplemental calcium
• Mean = 331 mg (SE 10)
• 8% (SE 0.7) met the AI through DS use alone
Single 24-hour recall-
37% below EAR
5

Calcium (mg)
mg/day
11/18/2010
Mean (SE) Calcium Intake by Gender
and Survey Years for Calcium Users
500
400
416.4
441.7
1200
1000
Calcium: Foods vs Total
US Population: Users and Non-Users
Foods
Total
332.6
800
300
200
188.5
216.8
239
600
400
100
200
0
NHANES III 1999-2002 2003-2006 NHANES III 1999-2002 2003-2006
0
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Males
Females
Bailey et al. Journal of Nutrition, 2010.
Percentiles of calcium intake from food alone and from all
sources (total: food, dietary supplements, antacids, and drinking
water) by females age 51-70 years in the United States 2003-2006
4000
3500
3000
2500
2000
1500
1000
500
0
Food-Alone
Total Intake
1 5 25 50 75 95 99
Total Calcium: % above the AI
100
90
96 97
Male
Female
83
80
70
67
65 64
60
50
42
44
38
39 39
40
32 31
30
23
20
15
13
10
0
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Percentiles of Intake
Bailey et al. Journal of Nutrition, 2010
Bailey et al. Journal of Nutrition, 2010
Issues with Calcium
Vitamin D
Consider all sources
• Water
• Antacids
Consider all forms
• Elemental calcium in what is important
• Very Few Reliable Food Sources
• 37% used supplemental vitamin D
• Sales increasing
• Mean = 8.6 µg (SE 0.3)
• Status also depends of sunlight exposure
• Serum 25 (OH) vitamin D
• Non-bone health
6

Vitamin D (µg)
11/18/2010
Percent of U.S. Population using Vitamin D Supplement
and Percent Meeting or Exceeding the Adequate Intake
Level
Mean intake for Vitamin D
from Foods and from All
Sources (Total)
14
12
Foods
Total
10
8
6
4
2
Adequate Intake levels: 14-50 years ≥ 5 mcg/day; 51-70 years ≥ 10 mcg/day; 71+ years ≥ 15 mcg/day
0
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Age Group
Bailey et al. Journal of Nutrition, 2010
100
90
80
70
60
50
40
30
20
10
0
Vitamin D
Females: % above the AI
Bailey et al. Journal of Nutrition, 2010
1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+
Foods
Total
Folate 2003-2006
39% of the US reported use of folic acid
Folic Acid vs Folate
Gender
• Females > Males
Race/ Ethnicity
• Whites > NH Black > Mexican Americans
Age Groups
• 71+ = 51-70 > 31-50 > 19-30 > 14-18
30
“At Risk”: Below EAR
Dietary Folate
Total Folate (Diet + DS)
FIGURE 1 Mean ({+/-}SE) percentiles of dietary and total folic acid
intake in the United States, 2003-2006
25
20
15
22 22
19
17
23 23
15
13
24
14
10
5
0
14-18 19-30 31-50 51-70 71+
Females, age in y
Bailey, R. L et al. Am J Clin Nutr 2010;91:231-237
Bailey et al. American Journal of Clinical Nutrition, 2010
Copyright ©2010 The American Society for Nutrition
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11/18/2010
FIGURE 2 The cumulative distribution of usual intake of folic acid for
US adults who consumed no supplements containing folic acid
[n = 5277]; 0.0% exceeded the tolerable upper intake level (UL)
Prevalence (percentage {+/-} SE) of folic acid intakes exceeding the Tolerable
Upper Intake Level by dietary supplement use categories
Bailey, R. L. et al. Am J Clin Nutr 2010;92:353-358
Yang, Q. et al. Am J Clin Nutr 2010;91:64-72
Copyright ©2010 The American Society for Nutrition
Copyright ©2010 The American Society for Nutrition
NHANES Data 2007-2008
• Two days of 24-hour dietary recall
• Day 1: MEC interview + DS
• Day 2: Telephone 3 to 10 days after MEC + DS
• 30 day frequency questionnaire
• Validation
• Motivations for use
50
45
40
35
30
25
20
15
10
5
0
Agreement between Methods
38
36
46
32
29 28
25 25
23 22 23
21
Any Use Calcium Vitamin D Folic Acid
Crombach α = 0.87
Crombach α = 0.88
Crombach α = 0.91
Crombach α = 0.88
Day 1
Day 2
DSQ
Issues with dietary
supplements
Take Home Messages
Moving targets
• Default values
No single comprehensive database
• DSLD
Very little known about reporting errors
Analytical vs labeled labels
Bioavailability
Reports accepted as “truth”
• Need validation
• Dietary supplements may add large amounts of nutrients to
dietary intake of nutrients.
• Several studies indicate the users of DS actually have higher
nutrient intakes and better quality diets than non-users of DS.
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11/18/2010
Regan Bailey, Ph.D., R.D.
baileyr@mail.nih.gov
ODS Web site: http://ods.od.nih.gov
• More than half the US population uses dietary supplements
• Must be included in nutrient intake estimates
• Must be accounted for when calculating prevalence of
inadequate and excessive intakes of nutrients in a group
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