Foods, fortificants, and supplements: Where do Americans get their nutrients?

Micronutrient Inadequacy in Short Sleep: Analysis of the NHANES 2005-2016

One third of U.S. adults report short sleep (<7 h), which has been linked to negative health outcomes. Inadequate intake of micronutrients across the U.S. adult population has been reported, and a relationship between sleep conditions and micronutrient intake is emerging. This cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES 2005–2016) (n = 26,211) showed that participants with short sleep duration had a lower usual intake (Food + Supplements) of calcium, magnesium, and vitamin D in all adults aged 19+ years, and vitamin K in adults aged 19–50 years, even after adjusting for covariates. In addition, participants reporting short sleep had a higher percentage of individuals with intake lower than the estimated average requirement (EAR) across multiple nutrients. Age and gender differences were observed in the prevalence of inadequate intake across multiple nutrients. Adults aged 51–99 years with short sleep duration had inadequate intake with respect to more nutrients. In females there was an association between short sleep and a higher prevalence of inadequate intake (Food + Spp) for calcium, magnesium, and vitamins A, C, D, E, and K (above adequate intake). Conversely, males reporting short sleep only had an inadequate intake of vitamin D. Overall, we demonstrate that short sleep is associated with increased nutrient inadequacy, emphasizing the possible need for dietary supplementation.

Dietary Whole Egg Reduces Body Weight Gain in a Dose-Dependent Manner in Zucker Diabetic Fatty Rats

BACKGROUND

We previously reported that a whole-egg-based diet attenuated weight gain in rats with type 2 diabetes (T2D) and more effectively maintained vitamin D status than an equivalent amount of supplemental cholecalciferol.

OBJECTIVES

The objective of this study was to determine the lowest dose of whole egg effective at maintaining vitamin D homeostasis and attenuating the obese phenotype in T2D rats.

METHODS

Zucker diabetic fatty (ZDF) rats (n = 40; age 6 wk; prediabetic) and their lean controls (n = 40; age 6 wk) were randomly assigned to a diet containing 20% casein (CAS) or 20%, 10%, 5%, or 2.5% protein from whole egg (20% EGG, 10% EGG, 5% EGG, and 2.5% EGG, respectively). All diets contained 20% total protein (wt:wt). All rats received their respective diets for 8 wk, at a stage of growth and development that translates to adolescence in humans, until 14 wk of age, a point at which ZDF rats exhibit overt T2D. Weight gain was measured 5 d/wk, and circulating 25-hydroxyvitamin D [25(OH)D] was measured by ELISA. Mean values were compared by 2-factor ANOVA.

RESULTS

The 20% EGG diet maintained serum 25(OH)D at 30 nmol/L in ZDF rats, whereas the 10%, 5%, and 2.5% EGG diets did not prevent insufficiency, resulting in mean serum 25(OH)D concentrations of 24 nmol/L in ZDF rats. Body weight gain was reduced by 29% (P < 0.001) and 31% (P < 0.001) in ZDF rats consuming 20% and 10% EGG diets, respectively, and by 16% (P = 0.004) and 12% (P = 0.030) in ZDF rats consuming 5% and 2.5% EGG diets, respectively, compared with CAS.

CONCLUSIONS

Whole-egg-based diets exerted a dose-dependent response with respect to attenuating weight gain. These data could support dietary recommendations aimed at body weight management in individuals predisposed to obesity and T2D.

Dietary intake and micronutrient deficiency in children with cancer

Data regarding micronutrient deficiencies in children with cancer are lacking. We measured micronutrients in a subset of children with cancer (n = 23) participating in a randomized trial of the neutropenic diet. Ninety-six percent of children had ≥1 micronutrient deficiency and 39% had ≥3 micronutrient deficiencies. Eighty-six percent of children had vitamin C deficiency, 87% had 25-hydroxyvitamin D deficiency, 50% had zinc deficiency, and 13% had vitamin A deficiency. Dietary intake did not correlate with micronutrient deficiency status. More data are needed regarding the prevalence and etiology of micronutrient deficiencies in children with cancer to further understand their implications and treatment.

Type of Sandwich Consumption Within a US Dietary Pattern Can Be Associated with Better Nutrient Intakes and Overall Diet Quality: A Modeling Study Using Data from NHANES 2013-2014

BACKGROUND

Previous research in adults has reported an association between sandwich consumers and increased daily energy, total fat, and sodium intakes and decreased dietary fiber intake. Additionally, sandwich consumers had a lower diet quality, as compared to non-sandwich consumers. However, the research failed to differentiate between the types of sandwiches consumed.

OBJECTIVES

The purpose of this study was to model different sandwiches, using both whole-grain bread (WGB), enriched-grain bread (EGB), and soft taco tortillas, to examine associations with energy (kcal), nutrient intakes, and diet quality, in comparison to the typically consumed sandwich (control).

METHODS

Data from the NHANES 2013-2014 was used to complete the analyses in adults ≥19 years old, and USDA food composites were used to create 5 sandwich types, using WGB, EGB, or soft corn tortillas.

RESULTS

In the modeling analysis, adults consuming the soft corn tortilla taco had lower energy, as compared to those eating the typical sandwich. Total fat intakes were lower in the WGB and EGB grilled chicken/cheese/vegetable sandwiches and in the soft taco tortilla, in comparison to the control sandwich. Sodium intakes were lower in the WGB and EGB grilled chicken/cheese/vegetable sandwiches and in the soft taco tortilla, in comparison to the typical sandwich consumed. All WGB sandwich models and the soft taco tortilla had greater daily dietary fiber intakes, in comparison to the control sandwich. WGB, EGB, and tortilla sandwiches were also associated with greater intakes of shortfall nutrients. All sandwich models, except EGB with meat/cheese/vegetables, had higher diet qualities, in comparison to the control.

CONCLUSIONS

The current data support the inclusion of certain WGB and EGB sandwiches/tortillas, within recommended dietary patterns, in American adults, and suggest that ingredients within a sandwich, rather than the just the bread component, can be an important contributor to overall nutrient intakes and nutrients to limit in the diet.

Recent advances and challenges on applications of nanotechnology in food packaging. A literature review

Nanotechnology applied to food and beverage packaging has created enormous interest in recent years, but in the same time there are many controversial issues surrounding nanotechnology and food. The benefits of engineered nanoparticles (ENPs) in food-contact applications are accompanied by safety concerns due to gaps in understanding of their possible toxicology. In case of incorporation in food contact polymers, the first step to consumer exposure is the transfer of ENPs from the polymer to the food. Hence, to improve understanding of risk and benefit, the key questions are whether nanoparticles can be released from food contact polymers and under which conditions. This review has two main goals. Firstly, it will presents the current advancements in the application of ENPs in food and beverage packaging sector to grant active and intelligent properties. A particular focus will be placed on current demands in terms of risk assessment strategies associated with the use ENPs in food contact materials (FCMs), i.e. up-to-date migration/cytotoxicity studies of ENPs which are partly contradictory. Food matrix effects are often ignored, and may have a pronounced impact on the behaviour of ENPs in the gastrointestinal tract (GIT). A standardized food model (SFM) for evaluating the toxicity and fate of ingested ENPs was recently proposed and herein discussed with the aims to offer an overview to the reader. It is therefore clear that further systematic research is needed, which must account for interactions and transformations of ENMs in foods (food matrix effect) and in the gastrointestinal tract (GIT) that are likely to determine nano-biointeractions. Secondly, the review provides an extensive analysis of present market dynamics on ENPs in food/beverage packaging moving beyond concept to current industrial applications.

A Diet High in Processed Foods, Total Carbohydrates and Added Sugars, and Low in Vegetables and Protein Is Characteristic of Youth with Avoidant/Restrictive Food Intake Disorder

Avoidant/restrictive food intake disorder (ARFID) is characterized in part by limited dietary variety, but dietary characteristics of this disorder have not yet been systematically studied. Our objective was to examine dietary intake defined by diet variety, macronutrient intake, and micronutrient intake in children and adolescents with full or subthreshold ARFID in comparison to healthy controls. We collected and analyzed four-day food record data for 52 participants with full or subthreshold ARFID, and 52 healthy controls, aged 9-22 years. We examined frequency of commonly reported foods by logistic regression and intake by food groups, macronutrients, and micronutrients between groups with repeated-measures ANOVA. Participants with full or subthreshold ARFID did not report any fruit or vegetable category in their top five most commonly reported food categories, whereas these food groups occupied three of the top five groups for healthy controls. Vegetable and protein intake were significantly lower in full or subthreshold ARFID compared to healthy controls. Intakes of added sugars and total carbohydrates were significantly higher in full or subthreshold ARFID compared to healthy controls. Individuals with full or subthreshold ARFID had lower intake of vitamins K and B12, consistent with limited vegetable and protein intake compared to healthy controls. Our results support the need for diet diversification as part of therapeutic interventions for ARFID to reduce risk for nutrient insufficiencies and related complications.

Nutrients in the US Diet: Naturally Occurring or Enriched/Fortified Food and Beverage Sources, Plus Dietary Supplements: NHANES 2009-2012

BACKGROUND

Nutrients are added to the diet through fortification/enrichment and dietary supplements (DSs). Meeting the US Dietary Reference Intakes (DRIs) varies by nutrient and population subsegments.

OBJECTIVE

The aim of this study was to assess the relative role of naturally occurring, enriched/fortified, and DS sources of 15 micronutrients with reference to the DRIs.

METHODS

We used the NHANES 2009-2012 (≥2 y old, n = 16,975) data, the ILSI North America Fortification database, and the National Cancer Institute usual intake method.

RESULTS

Prevalence of nutrient intake from naturally occurring sources below the Estimated Average Requirement (EAR) varied from 5% for vitamin B-12 to 100% for vitamin D, with ≥40% of the population below the EAR for 8 of the 14 nutrients (ages ≥2 y). With enrichment/fortification, the percentage below the EAR decreased to the following for vitamins A (35%), C (34%), and B-6 (7%), folate (8%), thiamin (5%), riboflavin (3%), niacin (1%), and iron (2%). Nutrients from DSs further improved intakes related to the EAR for 12 nutrients (ages ≥2 y). For 9-18-y-olds, the percentages of nutrient intakes below the EAR were 14-50% higher than for 2-8-y-olds. The Tolerable Upper Intake Level (UL) was exceeded among children aged 2-8 y for folate (41.7%), niacin (10.1%), and zinc (39.9%), whereas among ages ≥2 y and 9-18 y no prevalence of intakes over the UL exceeded 10%.

CONCLUSIONS

Fortification/enrichment constitutes a meaningful contribution to reducing the percentage of individuals with less than the EAR for their demographic. These data underscore the need to encourage better dietary patterns to improve the intake of nutrients at risk of low intake.

Weighing the risks of high intakes of selected micronutrients compared with the risks of deficiencies

Several intervention strategies are available to reduce micronutrient deficiencies, but uncoordinated implementation of multiple interventions may result in excessive intakes. We reviewed relevant data collection instruments and available information on excessive intakes for selected micronutrients and considered possible approaches for weighing competing risks of intake above tolerable upper intake levels (ULs) versus insufficient intakes at the population level. In general, population-based surveys in low- and middle-income countries suggest that dietary intakes greater than the UL are uncommon, but simulations indicate that fortification and supplementation programs could lead to high intakes under certain scenarios. The risk of excessive intakes can be reduced by considering baseline information on dietary intakes and voluntary supplement use and continuously monitoring program coverage. We describe a framework for comparing risks of micronutrient deficiency and excess, recognizing that critical information for judging these risks is often unavailable. We recommend (1) assessing total dietary intakes and nutritional status; (2) incorporating rapid screening tools for routine monitoring and surveillance; (3) addressing critical research needs, including evaluations of the current ULs, improving biomarkers of excess, and developing methods for predicting and comparing risks and benefits; and (4) ensuring that relevant information is used in decision-making processes.

Race/Ethnicity, Enrichment/Fortification, and Dietary Supplementation in the U.S. Population, NHANES 2009⁻2012

In the United States (U.S.), food fortification and/or enrichment and dietary supplement (DS) use impacts nutrient intakes. Our aim was to examine race/ethnicity and income (Poverty Income Ratio, PIR) differences in meeting the Dietary Reference Intakes based on estimated dietary intakes among the U.S. population age ≥2 years (n = 16,975). Two 24-hour recalls from the National Health and Nutrition Examination Survey (NHANES) cycles 2009-2012 were used to estimate the intake of 15 nutrients as naturally occurring, enriched/fortified, and plus DSs. Across racial/ethnic groups and within PIR categories, significant differences were observed in the %< Estimated Average Requirement (EAR) for vitamin A following enrichment/fortification (E/F) and for vitamin B12 and riboflavin following both E/F and DS use when comparing non-Hispanic blacks, Hispanics, and the other race/ethnicity group to non-Hispanic whites. The % Collapse

Key Words

• dietary reference intake
• socioeconomic status

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MESH Headings

• Dietary Supplements
• Ethnicity
• Food, Fortified
• Humans
• Income
• Micronutrients/administration & dosage
• Micronutrients/deficiency
• Nutrition Surveys
• Nutritional Requirements
• Nutritional Status/ethnology
• Race Factors
• Recommended Dietary Allowances
• United States

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Grants

• NA-MEDUNIVSCAROLINA-20170317 International Life Sciences Institute North America
• NA-MEDUNIVSCAROLINA-20170317 North American branch of the International Life Sciences Institute (ILSI North America)

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Affiliation(s)

Angela M Malek Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
Jill C Newman Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
Kelly J Hunt Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
Bernadette P Marriott Departments of Medicine and Psychiatry, Medical University of South Carolina, Charleston, SC 29425, USA.

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Maintenance dose of warfarin beyond time in therapeutic range for preventing vascular events

BACKGROUND

The quality of anticoagulation is closely associated with efficacy and safety in warfarin users. Although genetic polymorphisms have been related to warfarin dosages and vascular events(VE), genetic evaluations have not been recommended for all warfarin users. The aim is to evaluate the significance of the maintenance dose of warfarin (MDW) on VE, considering the time in therapeutic range (TTR).

METHODS

This retrospective study analyzed the data of patients who received warfarin for any reasons. A total of 11,835 patients with warfarin were divided into quartiles by MDW. We assessed TTR using the Rosendaal method and VE.

RESULTS

VE occurred in 9.1% of the warfarin users. The mean TTR level was 34.0 ± 25.7%, and the MDW was 3.38 ± 1.06 mg per day. Patients with VE were more likely to have a lower MDW and lower TTR levels. In moderate- or well-controlled TTR status, a lower MDW was significantly related to under-controlled anticoagulation and associated with higher risks of VE. Lower MDW had a higher risk of stroke or arterial/venous thromboembolism (Q1: OR, 1.57; 95% CI 1.25 to 1.96; Q2: OR, 1.40; 95% CI 1.12 to 1.75; Q3: OR, 1.35; 95% CI 1.08 to 1.68).

CONCLUSIONS

We suggest that patients with very low MDW might be at risk when using warfarin. Therefore, we propose that patients with a very low MDW might be alternatively considered for novel oral anticoagulants rather than warfarin.

Contribution of nutrition science to the vitamin D field-Clarity or confusion?

Recent opinion pieces have questioned whether nutrition science is fit for purpose, suggesting that the evidence-base for dietary recommendations is populated with poor quality science and unresolved controversy. Nutrition science is accused of not keeping up with the times and making little real-world progress to stem the growing global malnutrition crisis, by failing to apply cutting-edge techniques to nutrition problems. Nutritional epidemiology has been blamed for harming public health nutrition and the public perception of science itself, by selectively reporting biased, confounded data. Focussed on obesity and associated disorders and hunger, these articles do not refer to micronutrient deficiencies or advances in micronutrient research. There is a serious public health problem of low vitamin D status. Given that the field of vitamin D has experienced an exponential increase in peer-reviewed publications over the last 50 years, it seems timely that we take these cues to reflect upon whether the expanded body of scientific literature has contributed to a deeper knowledge of vitamin D in health and disease, leading to improved nutrition policy and patient care, or whether it has led to so much confusion and controversy that progress has been impeded. We consider whether the accusations of poor science and biased reporting levelled at nutrition science are evident within the vitamin D nutrition research area and whether they have compromised dietary recommendations for vitamin D. In evaluating whether reformation is required, we discuss the confusion and controversy within the field and signpost common ground within the vitamin D community. We outline vitamin D nutrition research that has presented strategies for vitamin D deficiency prevention within the population, particularly using food first approaches that could extend beyond high income settings to low- and middle-income countries. Finally, we encourage government and industry to implement technical advances and drive real-world progress.

Best Practices for Dietary Supplement Assessment and Estimation of Total Usual Nutrient Intakes in Population-Level Research and Monitoring

The use of dietary supplements (DS) is pervasive and can provide substantial amounts of micronutrients to those who use them. Therefore when characterizing dietary intakes, describing the prevalence of inadequacy or excess, or assessing relations between nutrients and health outcomes, it is critical to incorporate DS intakes to improve exposure estimates. Unfortunately, little is known about the best methods to assess DS, and the structure of measurement error in DS reporting. Several characteristics of nutrients from DS are salient to understand when comparing to those in foods. First, DS can be consumed daily or episodically, in bolus form and can deliver discrete and often very high doses of nutrients that are not limited by energy intakes. These characteristics contribute to bimodal distributions and distributions severely skewed to the right. Labels on DS often provide nutrient forms that differ from those found in conventional foods, and underestimate analytically derived values. Finally, the bioavailability of many nutrient-containing DS is not known and it may not be the same as the nutrients in a food matrix. Current methods to estimate usual intakes are not designed specifically to handle DS. Two temporal procedures are described to refer to the order that nutrient intakes are combined relative to usual intake procedures, referred to as a "shrinking" the distribution to remove random error. The "shrink then add" approach is preferable to the "add then shrink" approach when users and nonusers are combined for most research questions. Stratifying by DS before usual intake methods is another defensible option. This review describes how to incorporate nutrient intakes from DS to usual intakes from foods, and describes the available methods and fit-for-purpose of different analytical strategies to address research questions where total usual intakes are of interest at the group level for use in nutrition research and to inform policy decisions. Clinical Trial Registry: NCT03400436.

Food processing: criteria for dietary guidance and public health?

The NOVA food categorisation recommends 'avoiding processed foods (PF), especially ultra-processed foods (UPF)' and selecting minimally PF to address obesity and chronic disease. However, NOVA categories are drawn using non-traditional views of food processing with additional criteria including a number of ingredients, added sugars, and additives. Comparison of NOVA's definition and categorisation of PF with codified and published ones shows limited congruence with respect to either definition or food placement into categories. While NOVA studies associate PF with decreased nutrient density, other classifications find nutrient-dense foods at all levels of processing. Analyses of food intake data using NOVA show UPF provide much added sugars. Since added sugars are one criterion for designation as UPF, such a proof demonstrates a tautology. Avoidance of foods deemed as UPF, such as wholegrain/enriched bread and cereals or flavoured milk, may not address obesity but could decrease intakes of folate, calcium and dietary fibre. Consumer understanding and implementation of NOVA have not been tested. Neither have outcomes been compared with vetted patterns, such as Dietary Approaches to Stop Hypertension, which base food selection on food groups and nutrient contribution. NOVA fails to demonstrate the criteria required for dietary guidance: understandability, affordability, workability and practicality. Consumers' confusion about definitions and food categorisations, inadequate cooking and meal planning skills and scarcity of resources (time, money), may impede adoption and success of NOVA. Research documenting that NOVA can be implemented by consumers and has nutrition and health outcomes equal to vetted patterns is needed.

The balance between food and dietary supplements in the general population

In the past, vitamins and minerals were used to cure deficiency diseases. Supplements nowadays are used with the aim of reducing the risk of chronic diseases of which the origins are complex. Dietary supplement use has increased in the UK over recent decades, contributing to the nutrient intake in the population, but not necessarily the proportion of the population that is sub-optimally nourished; therefore, not reducing the proportion below the estimated average requirement and potentially increasing the number at risk of an intake above the safety limits. The supplement nutrient intake may be objectively monitored using circulation biomarkers. The influence of the researcher in how the supplements are grouped and how the nutrient intakes are quantified may however result in different conclusions regarding their nutrient contribution, the associations with biomarkers, in general, and dose-response associations specifically. The diet might be sufficient in micronutrients, but lacking in a balanced food intake. Since public-health nutrition guidelines are expressed in terms of foods, there is potentially a discrepancy between the nutrient-orientated supplement and the quality of the dietary pattern. To promote health, current public-health messages only advocate supplements in specific circumstances, but not in optimally nourished populations.

Vitamin E: Mechanism of transport and regulation in the CNS

Although vitamin E has been recognized as a critical micronutrient to neuronal health for more than half a century, vitamin E transport and regulation in the brain remain a mystery. Currently, the majority of what is known about vitamin E transport has been delineated in the liver. However, clues from the pathogenesis of neurological-related vitamin E deficient diseases point to compromised neuronal integrity and function, underlining the critical need to understand vitamin E regulation in the CNS. Additionally, most of the same molecular players involved in vitamin E transport in the liver are also found in CNS, including sterol SRB1, TTP, and ABCA/ABCG, suggesting similar intracellular pathways between these organ systems. Finally, based on chemical similarities, intracellular CNS shuttling of vitamin E likely resembles cholesterol's use of ApoE particles. Utilizing this information, this review will address what is currently known about trafficking vitamin E across the blood brain barrier in order to ensure an adequate supply of the essential nutrient to the brain. Although debatable, the health of the brain in relation to vitamin E levels has been demonstrated, most notably in oxidative stress-related conditions such as ataxias, Alzheimer's disease, and Parkinson's disease. Future vitamin E research is vital in understanding how the regulation of the vitamin can aid in the prevention, treatment, and curing of neurological diseases. © 2018 IUBMB Life, 71(4):424-429, 2019.

Daily Consumption of Oregon Hazelnuts Affects α-Tocopherol Status in Healthy Older Adults: A Pre-Post Intervention Study

Background

Inadequate vitamin E and magnesium intakes are of concern for older adults owing to the associated incidence of age-related diseases.

Objective

This study was designed to determine the extent to which a 16-wk intervention with hazelnuts alters vitamin E and magnesium status in a group of older men and women, and used a pre-post intervention design without a control group to adjust for temporal changes.

Methods

Participants (n = 32 including 22 women; mean ± SD age: 63 ± 6 y) consumed hazelnuts (∼57 g/d) for 16 wk. Blood and urine samples and anthropomorphic measures were taken at the start and end of the intervention to determine plasma concentrations of α-tocopherol and serum concentrations of magnesium, lipids, glucose, insulin, and high-sensitivity C-reactive protein along with urinary vitamin E metabolites; several other micronutrients were measured by a lymphocyte proliferation assay. There were 3 primary endpoints, calculated as the mean changes in measurements between baseline and the end of the 16-wk intervention for 1) plasma α-tocopherol, 2) urinary α-carboxyethyl hydroxychromanol (α-CEHC; an α-tocopherol metabolite), and 3) serum magnesium.

Results

Hazelnut consumption increased concentrations of the urinary α-tocopherol metabolite α-CEHC (mean ± SD: 0.84 ± 0.45 to 1.14 ± 0.50 µmol/g creatinine; P = 0.0006). In addition, hazelnut consumption increased serum concentrations of magnesium (+2.1%, P = 0.05), decreased concentrations of fasting glucose (-3.4%, P = 0.03) and LDL cholesterol (-6.0%, P = 0.02), and decreased total:HDL cholesterol ratios (-4.5%, P = 0.009). No significant changes were observed in blood pressure, lymphocyte proliferation assays, and serum concentrations of insulin, high-sensitivity C-reactive protein, triglyceride, α-tocopherol, or HDL cholesterol.

Conclusions

Consuming hazelnuts improves a biomarker of vitamin E status in older adults. Vitamin E is a shortfall micronutrient, as identified by the Dietary Guidelines for Americans 2015-2020, which frequently is consumed at levels less than the Estimated Average Requirement of 12 mg/d; thus, hazelnuts should be considered as part of a healthy dietary pattern. This trial was registered at clinicaltrials.gov as NCT03485989.

Current regulatory guidelines and resources to support research of dietary supplements in the United States

The U.S. Dietary Supplement Health and Education Act (DSHEA) established the regulatory framework for dietary supplements as foods through the Food and Drug Administration (FDA). DSHEA outlined the legal definition, labeling requirements, and process for adverse event reporting for dietary supplements. FDA also issued formal guidance on current Good Manufacturing Practice to ensure that processes for preparation, packaging, labeling, and storage of supplements and ingredients are documented and meet specifications to ensure purity, composition, and strength. However, efficacy of dietary supplements is not required under U.S. law. Despite regulations to improve the marketplace, many challenges remain; as a result, the quality and safety of products available can be highly variable, especially for botanical and herbal products. The ability of regulators to successfully carry out their mission is hampered by the sheer number of products and manufacturing facilities and a lack of analytical methods for all ingredients and products in the marketplace, this is especially difficult for herbal and botanical dietary supplements. Safety issues continue to exist such as adulteration and contamination, especially with specific product types (i.e. body building, sexual enhancement). Thus, a need remains for continued efforts and improved techniques to assess the quality of dietary supplements, especially with regard to purity, bioavailability, and safety. This review will highlight the existing American regulatory framework for dietary supplements and will describe the remaining regulatory barriers to ensuring that safe and high-quality dietary supplements are offered in the marketplace.

Nutrient Supplement Use among the Chinese Population: A Cross-Sectional Study of the 2010⁻2012 China Nutrition and Health Surveillance

Nutrient supplements play a key role in managing malnutrition/chronic diseases and are commonly used in the world, but few studies described the prevalence of nutrient supplement use at the national level in China. To our knowledge, this study provides the first detailed investigation of nutrient supplement use in a nationally representative sample of the Chinese population. This study aimed to describe the prevalence of the nutrient supplement use among the Chinese population aged 6 years or older in 2010⁻2012. A stratified multistage cluster sampling method was conducted to recruit participants from 150 surveillance sites. The demographic characteristics and information about nutrient supplement use were collected through an interview-administrative questionnaire. A total of 74,501 children and adults (excluding the pregnant women) were included in the study (mean age, 35.7 years; male, 47.0%, female, 53.5%). Only 0.71% of the participants reported using nutrient supplements in the previous month. Participants aged 6⁻11 years and 60 years and above, female, living in large urban, with higher education level and higher family incomes were more likely to use nutrient supplements than their counterparts (p < 0.05). The prevalence of nutrient supplement use increased with age in Chinese adults. The highest usage among the nutrient supplements was multi-vitamins and minerals with 0.37%. More females used single vitamin, multi-mineral, multi-vitamins and minerals than males (p < 0.05). The nutrient supplement use proportion was highest amongst the participants with a health problem, and the participants who had no idea about their health conditions were the least likely to use the nutrient supplements (p < 0.05). The prevalence of nutrient supplement use was low among the Chinese population in 2010⁻2012. Further research is required to understand the social cognition, usage reasons, dosage and consumption motivation of NS, and the relationships with health effects, to ensure that the nutrient supplements can be appropriately promoted in China.

Summary Outcomes of the ODIN Project on Food Fortification for Vitamin D Deficiency Prevention

Food-based solutions for optimal vitamin D nutrition and health through the life cycle (ODIN) was a cross-disciplinary, collaborative project, including 30 partners from 19 countries, which aimed to develop evidence-based solutions to prevent low vitamin D status (25-hydroxyvitamin D (25(OH)D) < 30 nmol/L) using a food-first approach. This paper provides a summary overview of some of the important ODIN outcomes and outlines some outstanding data requirements. In a study of almost 56,000 individuals, the first internationally standardised dataset of vitamin D status showed that 13% of EU residents overall, across a latitude gradient of 35° N to 69° N, had serum 25(OH)D < 30 nmol/L and 40% were < 50 nmol/L. The risk of low vitamin D status was several-fold higher among persons of ethnic minority. However, additional data from quality bio-banked sera would be required to improve these estimates. To address the question of dietary requirements for vitamin D among under-researched life-stage and population groups, four dose-response RCTs conducted in Northern Europe showed that vitamin D₃ intakes of 8 and 13 μg/day prevented 25(OH)D decreasing below 30 nmol/L in white children and adolescents and 20 and 30 μg/day, respectively, achieved ≥50 nmol/L. Among white women during pregnancy, 30 μg/day is required to prevent umbilical cord 25(OH)D, representing new-born vitamin D status, below 25 nmol/L. While 8 μg/day protected white women in Finland at the 30 nmol/L cut-off, 18 μg/day was needed by women of East African descent to prevent 25(OH)D decreasing below 30 nmol/L during wintertime. Replicate RCTs are needed in young children <5 years and in school-age children, teens and pregnant women of ethnic minority. Using a series of food production studies, food-based RCTs and dietary modelling experiments, ODIN research shows that diverse fortification strategies could safely increase population intakes and prevent low vitamin D status. Building on this solid technological platform, implementation research is now warranted to scale up interventions in real-world settings to eradicate vitamin D deficiency.

Prolonging healthy aging: Longevity vitamins and proteins

It is proposed that proteins/enzymes be classified into two classes according to their essentiality for immediate survival/reproduction and their function in long-term health: that is, survival proteins versus longevity proteins. As proposed by the triage theory, a modest deficiency of one of the nutrients/cofactors triggers a built-in rationing mechanism that favors the proteins needed for immediate survival and reproduction (survival proteins) while sacrificing those needed to protect against future damage (longevity proteins). Impairment of the function of longevity proteins results in an insidious acceleration of the risk of diseases associated with aging. I also propose that nutrients required for the function of longevity proteins constitute a class of vitamins that are here named "longevity vitamins." I suggest that many such nutrients play a dual role for both survival and longevity. The evidence for classifying taurine as a conditional vitamin, and the following 10 compounds as putative longevity vitamins, is reviewed: the fungal antioxidant ergothioneine; the bacterial metabolites pyrroloquinoline quinone (PQQ) and queuine; and the plant antioxidant carotenoids lutein, zeaxanthin, lycopene, α- and β-carotene, β-cryptoxanthin, and the marine carotenoid astaxanthin. Because nutrient deficiencies are highly prevalent in the United States (and elsewhere), appropriate supplementation and/or an improved diet could reduce much of the consequent risk of chronic disease and premature aging.

Intake of Vitamins and Minerals from Voluntarily Fortified Foods in School Children in Central-Eastern Poland

Objective: To estimate vitamin and mineral intakes from voluntarily fortified foods (VFFs) in relation to the Dietary Reference Intake (DRI) in children aged 6 - 12. Methods: The study was conducted among 677 school children from Central-Eastern Poland. Data on VFFs consumption were collected using a semi-quantitative food frequency questionnaire containing 58 food items available on the Polish market; the content of nutrients in VFFs was estimated using the producers labelling declaration. The amounts of nutrients consumed from VFFs were compared to DRI and Tolerable Upper Intake Levels (ULs). The distribution of nutrient intakes according to the percentage of DRI categories (<20%, 20 - 39.9%, 40 - 59.9%, 60 - 79.9%, 80 - 99.9%, 100 - 119%, and >120%) was investigated. Results: In our study, 78.3% (n = 530) of children were classified as VFF-consumers. The most often consumed groups of VFFs were cereal products and juices/non-alcoholic beverages (92.5% and 76.6% of children, respectively). The amounts of vitamin D intake were negligible (92.5% of children did not exceed 20% of DRI from VFFs); vitamins A, E, B12 and calcium were small (>60% did not exceed 40% of DRI); vitamins B1, B2, niacin, folic acid, pantothenic acid and iron were moderate (>25% consumed 80% of DRI or above); while vitamins C, B6 and biotin were high (>40% consumed 100% of DRI or above). Intake above ULs was observed for niacin and folic acid (2.6% and 1.1% of children, respectively). Conclusions: Substantial differences between the VFFs contribution of various micronutrients to the DRIs were observed. Consumption of VFFs may prevent inadequate intakes for the majority of nutrients. Keywords: children, DRI, inadequate intake, minerals, fortified foods, vitamins.

Perspective: Should Vitamin E Recommendations for Older Adults Be Increased?

Current vitamin E requirements are uniformly applied across the population for those >14 y of age. However, aging is associated with alterations in cellular and physiologic functions, which are affected by vitamin E. Therefore, it is questionable whether vitamin E requirements can be uniformly applied to all adult age categories. With aging, there is dysregulation of the immune system in which there are decreased cell-mediated and pathogen defense responses coupled with an overactive, prolonged inflammatory state. Both animal and human studies in the aged suggest that intake above currently recommended levels of vitamin E may improve immune and inflammatory responses and be associated with a reduced risk of infectious disease. We review the evidence that was considered in establishing the current requirements for vitamin E and highlight data that should be considered in determining the vitamin E requirements in older adults, particularly focusing on the evidence suggesting a benefit of increased vitamin E intake on immune function and inflammatory processes and resistance to infection. The main objective of this Perspective is to initiate the discussion of whether the current Dietary Reference Intake for vitamin E should be increased for the older population. We make this suggestion on the basis of mechanistic studies showing biological plausibility, correction of a major cellular dysfunction in older adults, and strong evidence from several animal and a few human studies indicating a reduction in risk and morbidity from infections.

Challenges in the Diagnosis of Magnesium Status

Magnesium is a critical mineral in the human body and is involved in ~80% of known metabolic functions. It is currently estimated that 60% of adults do not achieve the average dietary intake (ADI) and 45% of Americans are magnesium deficient, a condition associated with disease states like hypertension, diabetes, and neurological disorders, to name a few. Magnesium deficiency can be attributed to common dietary practices, medications, and farming techniques, along with estimates that the mineral content of vegetables has declined by as much as 80⁻90% in the last 100 years. However, despite this mineral's importance, it is poorly understood from several standpoints, not the least of which is its unique mechanism of absorption and sensitive compartmental handling in the body, making the determination of magnesium status difficult. The reliance on several popular sample assays has contributed to a great deal of confusion in the literature. This review will discuss causes of magnesium deficiency, absorption, handling, and compartmentalization in the body, highlighting the challenges this creates in determining magnesium status in both clinical and research settings.

Why Americans Need Information on Dietary Supplements

Until a decade ago, no dietary supplement (DS) databases with open access for public use existed in the United States. They were needed by researchers, since half of American adults use dietary DSs and, without information on supplement use and composition, exposures could not be estimated. These articles on Challenges and Future Directions for Dietary Supplement Databases describe subsequent progress. They begin by describing why information on DSs is needed by the government and how it is used to ensure the health of the public. Current developments include: application of DS information to meet public health needs; research efforts on DS quality, efficacy, and safety (as conducted by the Office of Dietary Supplements and other federal agencies); enhanced regulatory activities implemented by the FDA Office of Dietary Supplement Programs, the FDA Office of Enforcement, and the Federal Trade Commission; and initiatives for broader development and dissemination of DS databases for commercial and public use. Other contributions in this journal supplement describe the challenges of working with DSs and the progress that has been made. Additional articles describe surveys of DS use among the general US population and also among special groups such as high supplement users, illustrating why there is a need in the United States for information on supplements. Likely directions for the future of DS science are summarized.

Dietary Supplement Ingredient Database (DSID) and the Application of Analytically Based Estimates of Ingredient Amount to Intake Calculations

OBJECTIVE

We describe the purpose of the Dietary Supplement Ingredient Database (DSID), the statistical methodology underlying online calculators of analytically verified supplement content estimates, and the application and significance of DSID label adjustments in nutritional epidemiology.

BACKGROUND AND HISTORY

During dietary supplement (DS) manufacturing, many ingredients are added at higher than declared label amounts, but overages are not standardized among manufacturers. As a result, researchers may underestimate nutrient intakes from DSs. The DSID provides statistical tools on the basis of the results of chemical analysis to convert label claims into analytically predicted ingredient amounts. These adjustments to labels are linked to DS products reported in NHANES.

RATIONALE

Tables summarizing the numbers of NHANES DS products with ingredient overages and below label content show the importance of DSID adjustments to labels for accurate intake calculations.

RECENT DEVELOPMENTS

We show the differences between analytically based estimates and labeled content for vitamin D, calcium, iodine, caffeine, and omega-3 (n-3) fatty acids and their potential impact on the accuracy of intake assessments in large surveys. Analytical overages >20% of label levels are predicted for several nutrients in 50-99% of multivitamin-mineral products (MVMs) reported in NHANES: for iodine and selenium in adult MVMs, for iodine and vitamins D and E in children's MVMs, and for iodine, chromium, and potassium in nonprescription prenatal MVMs. Predicted overages of 10-20% for calcium can be applied to most MVMs and overages >10% for folic acid in the vast majority of adult and children's MVMs.

FUTURE DIRECTIONS

DSID studies are currently evaluating ingredient levels in prescription prenatal MVMs and levels of constituents in botanical DSs.

CONCLUSIONS

We estimate that the majority of MVM products reported in NHANES have significant overages for several ingredients. It is important to account for nonlabeled additional nutrient exposure from DSs to better evaluate nutritional status in the United States.

Challenges in Developing Analytically Validated Laboratory-Derived Dietary Supplement Databases

The Dietary Supplement Label Database (DSLD) is sponsored by the Office of Dietary Supplements (ODS) and the National Library of Medicine (NLM). It provides a searchable, free database of the contents of ∼65,000 supplement labels. A companion database of analytically verified product labels [the Dietary Supplement Ingredient Database (DSID)] was created by ODS, NLM, and the USDA. There are considerable challenges to populating both databases, but the DSID faces unique analytic chemistry challenges. This article describes the challenges to creating analytically verified marketplace surveys of dietary supplement (DS) product content claims for inclusion in public databases. Nutritionists and public health scientists require information on actual exposures to DS constituents because labeled content may not match labeled product content. Analytic verification of composition of DSs provides a link to actual exposure. A public database of analytically derived DS content was developed to provide more accurate estimates of dietary intake in population-based epidemiologic studies. The DSID has conducted surveys of several types of vitamin- and mineral-containing DSs. Results showing label content claims as analytically derived values are available in the current DSID. A recent pilot project explored the feasibility of adding botanical DS products to the DSID. Candidates for future botanical DSID studies will be based on sales volume, potential public health impacts, and the availability of validated analytic methods and reference materials. Databases like DSID and the DSLD are essential for researchers and clinicians to evaluate dietary ingredient intakes in population-based epidemiologic studies. Together, these databases provide a picture of the DS marketplace. The DSID provides an analytic survey of marketed DSs. However, selection of future botanical supplements for DSID evaluation involves analytic challenges. Even when appropriate resources are available, method selection and data evaluation are resource- and time-consuming.

Overfed but undernourished: recognizing nutritional inadequacies/deficiencies in patients with overweight or obesity

Overweight and obesity are highly prevalent throughout the world and can adversely affect the nutritional status of individuals. Studies have shown that many people with obesity have inadequate intake of iron, calcium, magnesium, zinc, copper, folate and vitamins A and B₁₂, likely as a result of poor diet quality. Nutritional inadequacies or deficiencies may also occur due to altered pharmacokinetics in the individual with obesity and due to interactions in those with overweight or obesity with various pharmaceuticals. However, it has been demonstrated that the adult population in the United States as a whole is deficient in certain micronutrients as a result of the availability and overconsumption of high-calorie, low-nutrient processed foods. Poor nutrition may contribute to the development of certain chronic conditions, such as type 2 diabetes, which is already more prevalent in those with obesity. Clinicians need to be aware of these gaps, particularly in those individuals with obesity who are undergoing bariatric surgery or taking pharmaceutical products long term to facilitate weight loss. Patients with overweight or obesity likely struggle to achieve a balanced diet and may benefit from consultation with a dietitian. Along with providing recommendations for healthy eating and exercise, supplementation with specific micronutrients or multivitamins should be considered for individuals at the highest risk for or with established deficiencies. Further research is needed to understand the factors underlying nutritional inadequacies in individuals with overweight or obesity, as well as the outcomes of treatment strategies employed to address them.

Vitamin D status in South Korean population: Seven-year trend from the KNHANES

Vitamin D deficiency has become one of the most prevalent health problems in modern society. However, there has been no study that has reported the trend of vitamin D status in Asia. We performed an observational study to investigate the trend of vitamin D status in South Korea based on a representative national database acquired from the Korea National Health and Nutrition Examination Surveys (KNHANES) conducted from 2008 to 2014. A total of 39,759 patients were included in the final analyses. Serum 25-hydroxyvitamin D (25 (OH)D) levels were measured by radioimmunoassay. The overall mean serum level of 25 (OH)D was 45.7 nmol/L in males and 40.9 nmol/L in females in KNHANES 2008 to 2014. There was a significant trend toward lower serum 25 (OH)D levels from 2008 to 2014 in males by -1.2 (95% confidence interval [CI] -1.5 to -0.9) nmol/L per year and in female by -0.7 (95% CI -0.9 to -0.4) nmol/L per year. The overall mean serum level of 25 (OH)D in 2008 was 53.0 nmol/L in males and 45.7 nmol/L in females. It decreased to 43.2 nmol/L in males and 39.2 nmol/L in females in 2014. Vitamin D deficiency, defined as the serum 25 (OH)D level of <50 nmol/L, was found in 65.7% of males and 76.7% of females in overall population. A significant increasing trend of vitamin D deficiency was also observed. The prevalence of vitamin D deficiency in 2008 was 51.8% in males and 68.2% in females, but rose to 75.2% and 82.5%, respectively, in 2014. The present study demonstrated that vitamin D status in South Koreans is still deteriorating. More extensive and proactive measures are needed to improve vitamin D status in South Korea.

An innate immune response and altered nuclear receptor activation defines the spinal cord transcriptome during alpha-tocopherol deficiency in Ttpa-null mice

Mice with deficiency in tocopherol (alpha) transfer protein gene develop peripheral tocopherol deficiency and sensory neurodegeneration. Ttpa^-/- mice maintained on diets with deficient α-tocopherol (α-TOH) had proprioceptive deficits by six months of age, axonal degeneration and neuronal chromatolysis within the dorsal column of the spinal cord and its projections into the medulla. Transmission electron microscopy revealed degeneration of dorsal column axons. We addressed the potential pathomechanism of α-TOH deficient neurodegeneration by global transcriptome sequencing within the spinal cord and cerebellum. RNA-sequencing of the spinal cord in Ttpa^-/- mice revealed upregulation of genes associated with the innate immune response, indicating a molecular signature of microglial activation as a result of tocopherol deficiency. For the first time, low level Ttpa expression was identified in the murine spinal cord. Further, the transcription factor liver X receptor (LXR) was strongly activated by α-TOH deficiency, triggering dysregulation of cholesterol biosynthesis. The aberrant activation of transcription factor LXR suppressed the normal induction of the transcription factor retinoic-related orphan receptor-α (RORA), which is required for neural homeostasis. Thus we find that α-TOH deficiency induces LXR, which may lead to a molecular signature of microglial activation and contribute to sensory neurodegeneration.

Effect of microencapsulated ferrous sulfate particle size on Cheddar cheese composition and quality

Iron-fortified Cheddar cheese was manufactured with large microencapsulated ferrous sulfate (LMFS; 700-1,000 µm in diameter) or small microencapsulated ferrous sulfate (SMFS; 220-422 µm in diameter). Cheeses were aged 90 d. Compositional, chemical, and sensory characteristics were compared with control cheeses, which had no ferrous sulfate added. Compositional analysis included fat, protein, ash, moisture, as well as divalent cations iron, calcium, magnesium, and zinc. Thiobarbituric acid reactive species assay was conducted to determine lipid oxidation. A consumer panel consisting of 101 participants evaluated the cheeses for flavor, texture, appearance, and overall acceptability using a 9-point hedonic scale. Results showed 66.0% iron recovery for LMFS and 91.0% iron recovery for SMFS. Iron content was significantly increased from 0.030 mg of Fe/g in control cheeses to 0.134 mg of Fe/g of cheese for LMFS and 0.174 mg of Fe/g of cheese for SMFS. Fat, protein, ash, moisture, magnesium, zinc, and calcium contents were not significantly different when comparing iron-fortified cheeses with the control. Iron fortification did not increase lipid oxidation; however, iron fortification negatively affected Cheddar cheese sensory attributes, particularly the LMFS fortified cheese. Microencapsulation of ferrous sulfate failed to mask iron's distinct taste, color, and odor. Overall, SMFS showed better results compared with LMFS for iron retention and sensory evaluation in Cheddar cheese. Results of this study show that size of the microencapsulated particle is important in the retention of the iron in the cheese and its sensory attributes. This study provides new information on the importance of particle size with microencapsulated nutrients.

Italian Association of Clinical Endocrinologists (AME) and Italian Chapter of the American Association of Clinical Endocrinologists (AACE) Position Statement: Clinical Management of Vitamin D Deficiency in Adults

Vitamin D deficiency is very common and prescriptions of both assay and supplementation are increasing more and more. Health expenditure is exponentially increasing, thus it is timely and appropriate to establish rules. The Italian Association of Clinical Endocrinologists appointed a task force to review literature about vitamin D deficiency in adults. Four topics were identified as worthy for the practicing clinicians. For each topic recommendations based on scientific evidence and clinical practice were issued according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) System. (1) What cut-off defines vitamin D deficiency: even though 20 ng/mL (50 nmol/L) can be considered appropriate in the general population, we recommend to maintain levels above 30 ng/mL (75 nmol/L) in categories at risk. (2) Whom, when, and how to perform screening for vitamin D deficiency: categories at risk (patients with bone, liver, kidney diseases, obesity, malabsorption, during pregnancy and lactation, some elderly) but not healthy people should be screened by the 25-hydroxy-vitamin D assay. (3) Whom and how to treat vitamin D deficiency: beyond healthy lifestyle (mostly sun exposure), we recommend oral vitamin D (vitamin D2 or vitamin D3) supplementation in patients treated with bone active drugs and in those with demonstrated deficiency. Dosages, molecules and modalities of administration can be profitably individually tailored. (4) How to monitor the efficacy of treatment with vitamin D: no routine monitoring is suggested during vitamin D treatment due to its large therapeutic index. In particular conditions, 25-hydroxy-vitamin D can be assayed after at least a 6-month treatment. We are confident that this document will help practicing clinicians in their daily clinical practice.

Vitamin D Requirements for the Future-Lessons Learned and Charting a Path Forward

Estimates of dietary requirements for vitamin D or Dietary Reference Values (DRV) are crucial from a public health perspective in providing a framework for prevention of vitamin D deficiency and optimizing vitamin D status of individuals. While these important public health policy instruments were developed with the evidence-base and data available at the time, there are some issues that need to be clarified or considered in future iterations of DRV for vitamin D. This is important as it will allow for more fine-tuned and truer estimates of the dietary requirements for vitamin D and thus provide for more population protection. The present review will overview some of the confusion that has arisen in relation to the application and/or interpretation of the definitions of the Estimated Average Requirement (EAR) and Recommended Dietary Allowance (RDA). It will also highlight some of the clarifications needed and, in particular, how utilization of a new approach in terms of using individual participant-level data (IPD), over and beyond aggregated data, from randomised controlled trials with vitamin D may have a key role in generating these more fine-tuned and truer estimates, which is of importance as we move towards the next iteration of vitamin D DRVs.

Fat-soluble vitamins A and E and health disparities in a cohort of pregnant women at delivery

The objective of the present study was to evaluate intakes and serum levels of vitamin A, vitamin E, and related compounds in a cohort of maternal-infant pairs in the Midwestern USA in relation to measures of health disparities. Concentrations of carotenoids and tocopherols in maternal serum were measured using HPLC and measures of socio-economic status, including food security and food desert residence, were obtained in 180 mothers upon admission to a Midwestern Academic Medical Center labour and delivery unit. The Kruskal-Wallis and independent-samples t tests were used to compare measures between groups; logistic regression models were used to adjust for relevant confounders. P < 0·05 was considered statistically significant. The odds of vitamin A insufficiency/deficiency were 2·17 times higher for non-whites when compared with whites (95 % CI 1·16, 4·05; P = 0·01) after adjustment for relevant confounders. Similarly, the odds of being vitamin E deficient were 3·52 times higher for non-whites (95 % CI 1·51, 8·10; P = 0·003). Those with public health insurance had lower serum lutein concentrations compared with those with private health insurance (P = 0·05), and living in a food desert was associated with lower serum concentrations of β-carotene (P = 0·02), after adjustment for confounders. Subjects with low/marginal food security had higher serum levels of lutein and β-cryptoxanthin compared with those with high food security (P = 0·004 and 0·02 for lutein and β-cryptoxanthin). Diet quality may be a public health concern in economically disadvantaged populations of industrialised societies leading to nutritional disadvantages as well.

Dietary Calcium Intake in Sample of School Age Children in City of Rabat, Morocco

Calcium is an important mineral playing a vital role to maintain bone health. Calcium intake is considered as one of the most important determinants to assess the calcium status and to evaluate the calcium deficiency in the human body. Our study aims at estimating calcium intake in a sample of children and adolescent to be used in the global strategy to reduce calcium deficiency disorders in Morocco. Thus, 131 children and adolescents were recruited from public schools at Rabat and its regions in the framework of a descriptive cross-sectional study. For each participant, anthropometric parameters were measured. Calcium status was assessed by 24 h dietary recall. Food frequency questionnaire was used to evaluate children's nutritional habits and to assess the consumption of calcium-rich food. Overall, the mean calcium intake was 522.0 ± 297.0 mg/day, and 85.5% of subjects highlighted calcium deficiency, with no significant difference between boys and girls. Calcium intake was significantly different according to age groups, and high consumption of calcium was found in subjects aged from 14 to 18 years (776.86 ±290.07 mg/day), giving evidence of the low calcium status of the studied population. Daily food intake and food frequency analysis showed that bread, vegetables, and fruits are the most consumed food and the main source of daily calcium intake. Consumption of dairy products, considered as the best source of calcium, is lower and represents only 14% of total calcium intake. Our study clearly showed that calcium status is very lower in Moroccan children and adolescents and a large proportion of this population have inadequate calcium intake. Hence, there's an urgent need of specific strategies, including children sensitisation and nutritional education, to increase calcium intake and therefore reduce calcium deficiency disorders impacting the whole body during childhood and in adult age.

The nutrition-gut microbiome-physiology axis and allergic diseases

Dietary and bacterial metabolites influence immune responses. This raises the question whether the increased incidence of allergies, asthma, some autoimmune diseases, cardiovascular disease, and others might relate to intake of unhealthy foods, and the decreased intake of dietary fiber. In recent years, new knowledge on the molecular mechanisms underpinning a 'diet-gut microbiota-physiology axis' has emerged to substantiate this idea. Fiber is fermented to short chain fatty acids (SCFAs), particularly acetate, butyrate, and propionate. These metabolites bind 'metabolite-sensing' G-protein-coupled receptors such as GPR43, GPR41, and GPR109A. These receptors play fundamental roles in the promotion of gut homeostasis and the regulation of inflammatory responses. For instance, these receptors and their metabolites influence Treg biology, epithelial integrity, gut homeostasis, DC biology, and IgA antibody responses. The SCFAs also influence gene transcription in many cells and tissues, through their inhibition of histone deacetylase expression or function. Contained in this mix is the gut microbiome, as commensal bacteria in the gut have the necessary enzymes to digest dietary fiber to SCFAs, and dysbiosis in the gut may affect the production of SCFAs and their distribution to tissues throughout the body. SCFAs can epigenetically modify DNA, and so may be one mechanism to account for diseases with a 'developmental origin', whereby in utero or post-natal exposure to environmental factors (such as nutrition of the mother) may account for disease later in life. If the nutrition-gut microbiome-physiology axis does underpin at least some of the Western lifestyle influence on asthma and allergies, then there is tremendous scope to correct this with healthy foodstuffs, probiotics, and prebiotics.

The Evolving Role of Multivitamin/Multimineral Supplement Use among Adults in the Age of Personalized Nutrition

Micronutrient deficiencies occur in segments of the adult population in the United States. Multivitamin/multimineral supplements (MVMS) are widely used by this population, which reduces inadequacies in micronutrient intake, but the potential for exceeding tolerable upper intake levels in others should be considered. There are concerns associated with the excessive intake of certain nutrients, particularly folic acid, and potential untoward consequences. The advent of nutrigenomics and the enhanced ability to directly study the interactions between nutrition and genetic variants and expression will allow for the conduct of more targeted studies with specific endpoints and may ultimately lead to progress in the field of personalized nutrition. The role of MVMS in health maintenance and chronic disease prevention remains controversial. Conducting studies in this area has been hampered by, among other factors, inconsistent definitions of MVMS, ranging from as few as three vitamins to broad-spectrum products containing more than two dozen vitamins and minerals. Results from some observational studies and large-scale, randomized, controlled trials suggest that MVMS may reduce the risk of some forms of cancer and, potentially, cardiovascular disease. The ongoing COcoa Supplement and Multivitamin Outcomes Study (COSMOS) is expected to build on this research and provide additional insights into these areas.

Challenges in conducting clinical nutrition research

Clinical nutrition research has played a pivotal role in establishing causality between diet or nutrient intake and health outcome measures and in the determination of dietary requirements and levels of supplementation to achieve specific outcomes. Because the studies are performed with humans, clinical nutrition research can be readily translated into public health messages. However, there are many challenges and considerations unique to the field, such as the baseline nutritional status of study participants, defining appropriate control groups, effective blinding of participants and investigators, the evolving ethics of randomized control trials, and a tension in a priori decisions regarding inclusion of nutritionally vulnerable participants versus representative samples of general populations. Regulatory approvals that place increasing burdens on the ability of investigators to carry out and complete research protocols have grown dramatically in recent years. There is much room for improved efficiency in the approval and reporting processes aimed at protecting volunteers and providing transparency to the public. Decreased redundancy would have a direct benefit to clinical nutrition research and investigators. Despite these challenges, the information to be gained and the rewards of clinical nutrition research remain high.

Development of Databases on Iodine in Foods and Dietary Supplements

Iodine is an essential micronutrient required for normal growth and neurodevelopment; thus, an adequate intake of iodine is particularly important for pregnant and lactating women, and throughout childhood. Low levels of iodine in the soil and groundwater are common in many parts of the world, often leading to diets that are low in iodine. Widespread salt iodization has eradicated severe iodine deficiency, but mild-to-moderate deficiency is still prevalent even in many developed countries. To understand patterns of iodine intake and to develop strategies for improving intake, it is important to characterize all sources of dietary iodine, and national databases on the iodine content of major dietary contributors (including foods, beverages, water, salts, and supplements) provide a key information resource. This paper discusses the importance of well-constructed databases on the iodine content of foods, beverages, and dietary supplements; the availability of iodine databases worldwide; and factors related to variability in iodine content that should be considered when developing such databases. We also describe current efforts in iodine database development in the United States, the use of iodine composition data to develop food fortification policies in New Zealand, and how iodine content databases might be used when considering the iodine intake and status of individuals and populations.

Vitamin and Mineral Supplement Use among Korean Adults: Baseline Data from the Trace Element Study of Korean Adults in Yeungnam Area

Although dietary supplement use is believed to improve health status, the efficacy and safety of its use remains controversial. This study aimed to investigate the contribution of consumption of vitamin and mineral supplements (VMS) to the total micronutrient intake. Study participants (n = 586) were selected from the ongoing prospective cohort study of the Korean population, and baseline information on current use of dietary supplements, types of supplements, frequency of use, dosage, duration, and brand name was collected. Dietary information was assessed using a 146-item semi-quantitative food frequency questionnaire. Approximately one-fourth of the participants were categorized as VMS users. The proportion of VMS use was significantly higher in women (p = 0.02), older participants (p = 0.002), and those with a higher income level (p = 0.03) than in non-users. All vitamin and mineral intakes of both groups met the recommended nutrient intake levels by food consumption alone, except for riboflavin, calcium, and magnesium. Approximately 0.7-3.4% of the VMS users had nutrient intake levels that exceeded the tolerable upper intake levels for vitamin A, E, C, iron, and iodine. Excessive use of VMS can lead to an increased risk for adverse health effects. The results of this study provide useful baseline data for establishing guidelines for the appropriate consumption and adequate intake levels of VMS.

Dietary Supplements: Regulatory Challenges and Research Resources

Many of the scientific and regulatory challenges that exist in research on the safety, quality and efficacy of dietary supplements are common to all countries as the marketplace for them becomes increasingly global. This article summarizes some of the challenges in supplement science and provides a case study of research at the Office of Dietary Supplements at the National Institutes of Health, USA, along with some resources it has developed that are available to all scientists. It includes examples of some of the regulatory challenges faced and some resources for those who wish to learn more about them.

Contribution of Dietary Supplements to Nutritional Adequacy by Socioeconomic Subgroups in Adults of the United States

Many Americans have inadequate intakes of several nutrients, and the Dietary Guidelines for Americans 2015–2020 identified vitamins A, C, D, and E, in addition to calcium, magnesium, iron, potassium, choline, and fiber as “underconsumed nutrients”. Based on nationally representative data on 10,698 adults from National Health and Nutrition Examination Surveys (NHANES), 2009–2012, assessments were made of socioeconomic differences, based on the Poverty Income Ratio (PIR), in terms of the association of dietary supplement use on nutrient intake and nutrient inadequacies. Compared to food alone, the use of any dietary supplement plus food was associated with significantly (p < 0.01) higher intakes of 15–16 of 19 nutrients examined in all socioeconomic groups; and significantly reduced rates of inadequacy for 10/17 nutrients in the subgroup PIR > 1.85 (not poor), but only 4–5/17 nutrients (calcium and vitamins A, C, D, E) for the poor and nearly poor subgroups (PIR < 1.35 and PIR 1.35 to ≤1.85, respectively). An increased prevalence of intakes above the Tolerable Upper Intake Level (UL) was seen for 3–9/13 nutrients, but all were less than 5% in the PIR subgroups. In conclusion, dietary supplement use was associated with an increased micronutrient intake, decreased inadequacies, and a slight increase in the prevalence of intakes above the UL, with greater benefits seen in the PIR > 1.85 subgroup.

Contribution of Dietary Supplements to Nutritional Adequacy in Various Adult Age Groups

Many Americans have inadequate intakes of several nutrients. The Dietary Guidelines for Americans 2015–2020 specifically identified vitamins A, C, D and E, calcium, magnesium, iron, potassium, choline and fiber as “underconsumed nutrients”. Based on nationally representative data in 10,698 adults from National Health and Nutrition Examination Surveys (NHANES), 2009–2012, assessments were made of age-group differences in the impact of dietary supplements on nutrient intake and inadequacies. Compared to food alone, use of any dietary supplement plus food was associated with significantly (p < 0.01) higher intakes of 15–16 of 19 nutrients examined in all age groups; and significantly reduced rates of inadequacy for 10/17, 8/17 and 6/17 nutrients examined among individuals age ≥71, 51–70 and 19–50 years, respectively. Compared to the other age groups, older adults (≥71 years) had lower rates of inadequacy for iron and vitamins A, C, D and E, but higher rates for calcium. An increased prevalence of intakes above the Tolerable Upper Intake Level was seen for 8–9 of 13 nutrients, but were mostly less than 5% of the population. In conclusion, dietary supplement use is associated with increased micronutrient intake, decreased inadequacies, and slight increases in prevalence above the UL, with greater benefits seen among older adults.

Vitamin D in adolescence: evidence-based dietary requirements and implications for public health policy

Vitamin D is a unique nutrient. First, it acts as a pro-hormone and secondly, the requirement for vitamin D can be met by both endogenous synthesis from sunlight and by dietary sources. This complicates the determination of dietary requirements for vitamin D, which along with the definition of optimal vitamin D status, have been highly controversial and much debated over recent years. Adolescents are a population group at high risk of low vitamin D status, which is concerning given the important role of vitamin D, and calcium, in promoting normal bone mineralisation and attainment of peak bone mass during this rapid growth phase. Dietary vitamin D recommendations are important from a public health perspective in helping to avoid deficiency and optimise vitamin D status for health. However limited experimental data from winter-based dose-response randomised trials in adolescents has hindered the development of evidence-based dietary requirements for vitamin D in this population group. This review will highlight how specifically designed randomised trials and the approach adopted for estimating such requirements can lead to improved recommendations. Such data indicate that vitamin D intakes of between 10 and about 30 µg/d may be required to avoid deficiency and ensure adequacy in adolescents, considerably greater than the current recommendations of 10-15 µg/d. Finally this review will consider the implications of this on public health policy, in terms of future refinements of vitamin D requirement recommendations and prioritisation of public health strategies to help prevent vitamin D deficiency.

Contribution of Dietary Supplements to Nutritional Adequacy in Race/Ethnic Population Subgroups in the United States

The U.S. Centers for Disease Control and Prevention has reported that nutritional deficiencies in the U.S. population vary by age, gender, and race/ethnicity, and could be as high as nearly one third of certain population groups. Based on nationally representative data in 10,698 adults from National Health and Nutrition Examination Surveys (NHANES) primarily from 2009-2012, assessments were made of race/ethnic differences in the impact of dietary supplements on nutrient intake and prevalence of inadequacies. Compared to food alone, use of any dietary supplement plus food was associated with significantly higher intakes of 14 to 16 of 19 nutrients examined in all race/ethnic groups; and significantly (p < 0.01) reduced rates of inadequacy for 8/17 nutrients examined in non-Hispanic whites, but only 3-4/17 nutrients (calcium, and vitamins A, D, and E) for other race/ethnic groups. Across race/ethnic groups an increased prevalence of intakes above the Tolerable Upper Intake Level (UL) was seen for 1-9/13 nutrients, but all were less than 5% of the population. In conclusion, use of dietary supplements is associated with increased micronutrient intake, decreased nutrient inadequacies, and slight increases in prevalence above the UL in all race/ethnicities examined, with greater benefits among non-Hispanic whites.