High Prevalence of Inadequate Calcium and Iron Intakes by Mexican Population Groups as Assessed by 24-Hour Recalls 1 4

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1 The Journal of Nutrition Supplement The Dietary Intake and Eating Habits of the Mexican Population: Results from the National Health and Nutrition Survey 2012 High Prevalence of Inadequate Calcium and Iron Intakes by Mexican Population Groups as Assessed by 24-Hour Recalls 1 4 Tania G Sánchez-Pimienta, 5 Nancy López-Olmedo, 5 Sonia Rodríguez-Ramírez, 5 Armando García-Guerra, 5 Juan A Rivera, 5 Alicia L Carriquiry, 6 and Salvador Villalpando 5 * 5 Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico; and 6 Department of Statistics, Iowa State University, Ames, IA Abstract Background: A National Health and Nutrition Survey (ENSANUT) conducted in Mexico in 1999 identified a high prevalence of inadequate mineral intakes in the population by using 24-h recall questionnaires. However, the 1999 survey did not adjust for within-person variance. The 2012 ENSANUT implemented a more up-to-date 24-h recall methodology to estimate usual intake distributions and prevalence of inadequate intakes. Objective: We examined the distribution of usual intakes and prevalences of inadequate intakes of calcium, iron, magnesium, and zinc in the Mexican population in groups defined according to sex, rural or urban area, geographic region of residence, and socioeconomic status (). Methods: We used dietary intake data obtained through the 24-h recall automated multiple-pass method for 10,886 subjects as part of ENSANUT A second measurement on a nonconsecutive day was obtained for 9% of the sample. Distributions of usual intakes of the 4 minerals were obtained by using the Iowa State University method, and the prevalence of inadequacy was estimated by using the Institute of MedicineÕs Estimated Average Requirement cutoff. Results: Calcium inadequacy was 25.6% in children aged 1 4 y and % in subjects >5 y old. More than 45% of subjects >5 y old had an inadequate intake of iron. Less than 5% of children aged <12 y and 25 35% of subjects aged >12 y had inadequate intakes of magnesium, whereas zinc inadequacy ranged from <10% in children aged <12 y to 21.6% in men aged $20 y. Few differences were found between rural and urban areas, regions, and tertiles of. Conclusions: Intakes of calcium, iron, magnesium, and zinc are inadequate in the Mexican population, especially among adolescents and adults. These results suggest a public health concern that must be addressed. JNutr2016;146(Suppl):1874S 80S. Keywords: Introduction calcium, iron, magnesium, zinc, usual intake, inadequate intakes, nutrition surveys, Mexico 1 Published in a supplement to The Journal of Nutrition. Presented at the 16th Public Health Research Congress, held in Cuernavaca, Morelos, Mexico, 4 6 March The congress was organized by the National Institute of Public Health (INSP), Mexico. Sponsors: Bloomberg Philanthropies and INSP, Mexico. The Supplement Coordinators for this supplement were Juan A Rivera, Center for Nutrition and Health Research, INSP, Cuernavaca, Mexico, and Lilia S Pedraza, Center for Nutrition and Health Research, INSP, Cuernavaca, Mexico. Supplement Coordinator disclosures: Juan A Rivera and Lilia S Pedraza reported no conflicts of interest. Publication costs for this supplement were defrayed in part by the payment of page charges. This publication must therefore be hereby marked "advertisement" in accordance with 18 USC section 1734 solely to indicate this fact. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors or the publisher, Editor, or Editorial Board of The Journal of Nutrition. 2 Supported by Bloomberg Philanthropies and INSP, Mexico. In Mexico, 4 nationally representative nutrition surveys have been conducted over the past few decades. The first 2, the National Nutrition Surveys 1988 and 1999, focused exclusively on nutritional assessment and estimated the prevalence of malnutrition and micronutrient deficiencies in children 5 11 y of age and females y of age and used 24-h recall questionnaires to collect amounts of food consumed (1, 2). The 2006 and 2012 nutrition surveys merged with the National Health Surveys, resulting in the National Health and Nutrition Surveys (ENSANUTs) and 2012, which collected information on all ages and both sexes. 3 Author disclosures: TG Sánchez-Pimienta, N López-Olmedo, S Rodríguez-Ramírez, A García-Guerra, JA Rivera, AL Carriquiry, and S Villalpando, no conflicts of interest. 4 Supplemental Methods, Supplemental Results, and Supplemental Tables 1 6 are available from the Online Supporting Material link in the online posting of the article and from the same link in the online table of contents at *To whom correspondence should be addressed. svillalp@insp.mx. 7 Abbreviations used: EAR, Estimated Average Requirement; ENSANUT, National Health and Nutrition Survey; INSP, National Institute of Public Health (Instituto Nacional de Salud Pública); IOM, Institute of Medicine; ISU, Iowa State University; NCI, National Cancer Institute;, socioeconomic status; 24HR, 24-h recall automated multiple-pass method. ã 2016 American Society for Nutrition. 1874S Manuscript received November 9, Initial review completed December 22, Revision accepted June 27, First published online August 10, 2016; doi: /jn

2 ENSANUT 2006 used a semiquantitative FFQ to collect information on foods consumed (3), whereas ENSANUT 2012 implemented a new 24-h recall questionnaire with the automated multiple-pass variant and with repeated measures in a subsample (4). Results from the 1999 and 2006 surveys reported high prevalence of inadequate intakes of minerals, especially calcium, iron, and zinc, and low serum concentrations of magnesium (5 14). For this analysis, we decided to focus on these 4 minerals. Estimated usual intake distributions and the prevalence of inadequate intakes of these minerals are essential pieces of information for health researchers and policy makers interested in the quality of the diet in Mexico and the effectiveness of food assistance programs over the past decades in Mexico. The goal of this article is to examine the distribution of usual intakes and to estimate the prevalence of inadequate intakes of calcium, iron, magnesium, and zinc in the Mexican population stratified by sex, rural and urban areas, region of residence, and socioeconomic status (). Methods Databases. We used food intake data from the ENSANUT Our group participated in the design, implementation, and analysis of ENSANUT 2012, a probabilistic, cross-sectional survey representative of the Mexican population at the national, state, regional, and rural or urban levels (4, 15). A stratified multistage sample design was used. The primary sampling units were basic geostatistical areas, the census units in Mexico (equivalent to census tracts in the United States). Detailed information on the sampling methodology was published elsewhere (16). The ENSANUT 2012 protocol was approved by the Mexican National Institute of Public Health [Instituto Nacional de Salud Pública (INSP by its Spanish acronym)] Research, Ethics, and Biosafety Committees. All subjects >18 y of age and parents or legal guardians of minors signed informed consents. In addition, children 5 17 y of age signed informed assents (4). Amounts of food consumed were collected by using the 24-h recall automated multiple-pass method (24HR; 17). The 24HR was applied by trained personnel to a random representative subsample of ;10% of the total sample of ENSANUT 2012 participants. Respondents were randomly selected individuals aged $15 y. Respondents for individuals aged <15 y were mothers or the person responsible for preparing and serving food or feeding the selected child. Foods consumed outside the home were declared by the children. In addition, a second 24HR was applied to a random subsample of 981 individuals, ;9% of the total sample, on nonconsecutive days, to adjust for day-to-day variability. A detailed description of the 24HR used is published elsewhere (4). The nutrient composition of foods was obtained from a foodcomposition database developed by the INSP. This database contains nutritional information for 1484 foods and recipes. More than one-third of the data come from the USDA National Nutrient Database. Other sources of information are food-composition tables from the National Institute of Medical Sciences and Nutrition Salvador Zubirán and the Institute of Nutrition of Central America and Panama. In addition, information from food labels and web pages of processed-food manufacturers were included. The food-composition database was updated for this survey and is available upon request (18). Information on sex, age, and was obtained from the ENSANUT 2012 database. Households were classified into tertiles of. Data from rural (<2500 inhabitants) and urban ($2500 inhabitants) areas and 3 geographic regions North, Central, and South were analyzed separately (15). Preparation of the analytic sample. Data cleaning to correct inconsistencies and implausible information was conducted by an INSP and University of North Carolina team. Correction for implausible or missing information on food quantities consumed was performed by imputing the average intake of the particular food item for the age group, meal time, area of residence, and region. Detailed information on the cleaning process and data imputation is provided in another publication (4). For this analysis, energy intakes out of the interval between 23 and +3 SDs of the log ratio of energy intake to estimated energy requirement were considered implausible and eliminated from the study. Children receiving partial or exclusive breastfeeding were excluded from the analysis because estimating the intake of total energy and nutrients was not possible due to a lack of information on breast-milk intake; pregnant and lactating women were also excluded due to their different energy and nutrient intakes relative to the rest of the women. We defined an upper boundary for plausible mineral intake by multiplying the 99th percentile of the intake for each mineral by 1.5. This value (1.5-fold) was selected on the basis of simulations that suggested that the probability that a legitimate intake value would exceed the upper bound was very low (7 of 10,000). When an intake value exceeded the upper boundary, we replaced it with a random value between the 95th percentile and the upper boundary of the observed distribution (4). At the end of data preparation, 10,096 individuals comprised the final sample. This sample was further categorized into 4 age groups, as follows: 1) children 1 4 y of age (n = 2113), children 5 11 y of age (n = 2753), adolescents y of age (n = 2056), and adults $20 y of age (n = 3174). Statistical analysis. We carried out the mineral intake analysis in subgroups defined by sex, age group, area and region of residence, and. Distributions of usual mineral intakes were estimated by using the Iowa State University (ISU) method through the Software for Intake Distribution Estimation (PC-SIDE, version 1.02) (4, 19). To estimate the usual intake of heme iron, the original intake distribution was smoothed due to the high proportion of zero intakes in the database. Adding a random value from a normal distribution truncated at zero and a very smallvariancetoeachhemeironintake was sufficient to eliminate the concentration of points at zero without significantly affecting the distribution of heme iron intakes. Given that heme iron is an episodically consumed nutrient in the studied population (27% of the population had zero intake on the day of the 24HR), an additional analysis that used the National Cancer Institute (NCI) method (20) is presented in the Supplemental Methods, Supplemental Results,andSupplemental Table 1. Except for iron, the prevalence of intakes below recommendations was estimated by using as cutoffs the Institute of MedicineÕs (IOMÕs) Estimated Average Requirement (EAR) for each particular mineral (21, 22). For iron, we estimated the prevalence of inadequacy with the use of the full-probability approach proposed by the IOM (21). Because there is no EAR for heme and nonheme iron, inadequacies for these nutrients are not presented. In the case of iron, we estimated inadequacy in each age category by using 2 iron bioavailability assumptions: a bioavailability of 18%, which is determined for the US population by the IOM (20), and a lower bioavailability based on the Mexican Dietary Recommendations (23). The 18% bioavailability is likely to be appropriate for the segment of the Mexican population with diets similar to diets in the US population. The Mexican bioavailability assumption based on the Mexican Dietary Recommendations corresponds to the traditional Mexican diet that is high in tortillas and beans and low in animal protein, which results in a high intake of phytates and other dietary inhibitors of iron absorption (23, 24). These diets are still common in certain sectors of the Mexican population. The estimated iron bioavailabilities of traditional diets were 5.5% in children <4 y of age and 7.5% in children $4 y of age (23, 24). Iron inadequacy was estimated under these 2 assumed bioavailability levels by estimating usual iron intakes computed with PC-SIDE. Age and sex groups used to derive the DRIs are different from the age category used in ENSANUT When necessary, we rescaled individual daily intake in order to use a single cutoff within each ENSANUT age category. This adjustment is described in detail in the Supplemental Methods and Supplemental Table 2. Differences in mineral intake between residents of urban and rural areas, regions, and were tested by using StudentÕs t tests. A null hypothesis was rejected at an a level that controls the overall type I error rate at 5% by using Bonferroni correction for multiple comparisons (North, Central, and South regions and tertiles) (25). Results presented are stratified by sex because DRIs for minerals are generally different between sexes, except for children aged 1 4 y. For all statistical Inadequate intakes of calcium and iron in Mexico 1875S

3 comparisons we used the Stata statistical package version 12.1 (Stata 12, 2011; StataCorp) with the use of the STATA SVY module for complex samples. Results Our sample included 10,096 individuals stratified by the 4 age categories and representing 111,312,097 persons at the national level. Approximately half of the sample (49.5%) were males and 73% lived in urban areas. Almost half of the sample (48.6%) lived in the Central region of Mexico and 31.6% lived in the South region. Approximately 37.6% were in the highest tertile and 32% were in the middle tertile (Table 1). Household characteristics were comparable to the 2010 Census (16). Results by urban or rural area and region are reported in Supplemental Tables 3 6. Usual intakes and prevalence of inadequacy by age and Children 1 4 y of age. Prevalence of inadequate intakes. Approximately onefourth (25.6%) of Mexican children consumed inadequate amounts of calcium and more than half (52.2%) did not consume sufficient iron when the Mexican bioavailability value is assumed. Magnesium and zinc intakes were adequate and almost all children (98%) met the requirements (Table 2). We found a significantly higher prevalence of iron inadequacy among children in the lowest tertile than in those in the middle and highest tertiles and in those in the middle tertile compared with the highest tertile (Table 2). Usual intakes. No significant differences in usual intakes of the 4 minerals were documented in this age group. Children 5 11 y of age. Prevalence of inadequate intakes. The prevalences of inadequate intakes in both sexes were >60% for calcium, ;46% for iron (Mexican bioavailability), and between 2.5% and 8.6% for magnesium and zinc. The proportion of girls with calcium TABLE 1 Characteristics of the study population Sample, n Expansion factor, n (in thousands) Percentage Sex Male , Female , Population group Children 1 4 y old Children 5 11 y old , Adolescents y old , Adults $20 y old , Area Urban , Rural , Region North , Central , South , Socioeconomic status Low , Medium , High , Total 10, , inadequacy was significantly higher (74.6%) in the lowest tertile of relative to the highest tertile (55.2%). The proportion of both boys and girls with iron inadequacy using the Mexican bioavailability value was significantly higher in the lowest tertile than in the highest tertile (boys: 43.7% compared with 50.1%; girls: 40.4% compared with 53.0%). In addition, iron inadequacy was significantly lower in girls in the middle tertile than in the lowest tertile when we assumed a bioavailability of 18% (Table 3). Usual intakes. In this group, significantly higher intakes of magnesium were observed in both sexes in the lowest tertile than in the medium and highest tertiles (Table 3). Adolescents y of age. Prevalence of inadequate intakes. Calcium inadequacy was higher in this age group relative to the other ages, reaching 88.1% in females and 71.8% in males. Prevalences of iron inadequacy, with the use of the Mexican bioavailability value, were 79.9% in females and 64.3% in males. Inadequacies for magnesium and zinc were ;34% and 15%, respectively, for both sexes. In male adolescents, we observed a significantly higher prevalence of iron inadequacies in the lowest tertile than in the middle tertile (Table 4). Usual intakes. In female adolescents, significantly lower intakes of total and nonheme iron were observed in the lowest and highest tertiles than in the medium tertile as well as significantly lower intakes of calcium and zinc in the highest tertile than in the medium tertile (Table 4). In male adolescents, magnesium intakes were significantly lower in the highest tertile than in the lowest and medium tertiles, whereas in female adolescents magnesium intakes were significantly lower in the medium and highest tertiles than in the lowest tertile and were also significantly lower in the highest relative to the medium tertile. Adults $20 y of age. Prevalence of inadequate intakes. In adults, calcium inadequacy exceeded 54%, and almost 90% of women had an inadequate intake of iron using the Mexican bioavailability value. Thirty-five percent of men and 25% of women had inadequate intakes of magnesium and ;25% of men and 10% of women showed inadequate intakes of zinc. Usual intakes. Men in the lowest tertile of had higher intakes of total and nonheme iron than did those in the highest tertile. Men and women in the lowest tertile of had higher intakes of magnesium than did those in the medium and highest tertiles. Meanwhile, women in the lowest tertile of had greater intakes of total and nonheme iron than women in the medium tertile (Table 5). Discussion To our knowledge, this is the first analysis of mineral dietary intakes collected through the 24HR in a representative sample of the Mexican population. Inadequate intakes of the 4 minerals studied in different age groups may result from high intakes of discretionary foods, mainly sugar-sweetened beverages and energydense nutrient-poor products, which contribute approximately one-quarter of total energy intake, resulting in diets low in mineral intakes. In addition, the intake of milk and dairy products was below recommendations (26, 27). Contrary to our expectations, few differences were found in inadequacies between urban and rural areas, regions, and tertiles of. The exception was the prevalence of inadequate iron 1876S Supplement

4 TABLE 2 Usual intakes and prevalences of inadequate intakes of minerals in Mexican children 1 4 y of age at the national level and by 1 National Low Medium High Expansion factor (in thousands), n 8,440,166 2,733,851 3,031,835 2,674,479 Sample, n Calcium Total Iron Heme iron Nonheme iron Magnesium Zinc Calcium With bioavailability by Mexican recommendations a b c With bioavailability by Institute of Medicine a b c Magnesium Zinc Labeled means in a row without a common superscript letter differ, P, EAR, Estimated Average Requirement;, socioeconomic status. intake based on the low availability assumption, which was found to be significantly higher in the lowest and medium tertiles in children and male adolescents but not in female adolescents and adults. Although the main sources of minerals (meat, milk, and dairy) are consumed in larger amounts in urban areas, in the North and Central regions, and in subjects in the highest tertile of (26), similar inadequacies of calcium, magnesium, and TABLE 3 Usual intakes and prevalences of inadequate intakes of minerals in Mexican boys and girls aged 5 11 y at the national level and by 1 Boys Girls National Low Medium High National Low Medium High Expansion factor (in thousands), n 9,050,967 3,198,880 3,005,332 2,846,756 8,852,300 3,057,124 3,249,514 2,545,661 Sample, n Calcium Total iron Heme iron Nonheme iron Magnesium a b b a b b Zinc Calcium a b With bioavailability by Mexican recommendations a b a b c With bioavailability by Institute of Medicine a a b Magnesium Zinc Labeled means in a row without a common superscript letter differ, P, EAR, Estimated Average Requirement;, socioeconomic status. Inadequate intakes of calcium and iron in Mexico 1877S

5 TABLE 4 Usual intakes and prevalences of inadequate intakes of minerals in Mexican male and female adolescents y of age at the national level and by 1 National Males Females Low Medium High National Low Medium High Expansion factor (in thousands), n 8,427,367 2,346,710 2,749,525 3,331,132 7,719,718 2,176,326 2,449,323 3,094,070 Sample, n Calcium a b Total iron a a b Heme iron Nonheme iron a a b Magnesium a a b a b c Zinc a b Calcium With bioavailability by Mexican recommendations a b With bioavailability by Institute of Medicine Magnesium Zinc Labeled means in a row without a common superscript letter differ, P, EAR, Estimated Average Requirement;, socioeconomic status. zinc, and to a lesser degree of iron, could be explained by alternative sources of minerals in subjects living in disadvantaged sectors of the population (rural areas and the South region as well as those in the lowest tertile of ). For example, corn tortillas, which contribute ;20% of total energy intake (26), are an important source of total calcium (103 g/d), iron (1.6 g/d), TABLE 5 Usual intakes and prevalences of inadequate intakes of minerals in Mexican men and women $20 y of age at the national level and by 1 National Men Women Low Medium High National Low Medium High Expansion factor (in thousands), n 33,378,333 10,561,851 10,353,864 12,462,618 35,443,245 9,751,804 10,834,469 14,856,973 Sample, n 1, , Calcium Total iron a b a b Heme iron Nonheme iron a a b a b Magnesium a b c a b b Zinc Calcium With bioavailability by Mexican recommendations a b With bioavailability by Institute of Medicine Magnesium Zinc Labeled means in a row without a common superscript letter differ, P, EAR, Estimated Average Requirement;, socioeconomic status. 1878S Supplement

6 magnesium (80 g/d), and zinc (1.4 g/d). Legumes are also a good source of iron (1.6 g/d), magnesium (44 g/d), and zinc (1 g/d). These foods are more highly consumed in rural areas, in the South region, and in subjects in the lowest tertile of than in urban areas, the North and Central regions, and in the highest tertile of (data not shown). Tortilla and beans, which are consumed in larger amounts by disadvantaged relative to the wealthiest populations, are good sources of nonheme iron but contain inhibitors of iron absorption (phytic acid and tannins), which contribute to the low availability of dietary iron in the Mexican traditional diet. This explains the association of total iron under the assumption of a lower iron bioavailability in certain age and sex subgroups. The purpose of this study was to characterize dietary mineral intakes among Mexicans; therefore, we focused on the evaluation of nutrient intakes from foods rather than from external sources. One limitation of this study is that we did not include information from mineral supplements consumed in pharmacologic form. Therefore, our results are probably an underestimation of the total mineral intake in the Mexican population. Another possible limitation pertains to the compilation of food-composition tables by the INSP. Like any study that uses food-composition tables, the analytical methods used, number of samples, representativeness (season, region, etc.), updating databases, compiler desitions such as merging data from different sources, etc., may involve errors in nutrient estimation (28). An additional limitation of the study is that the ISU method does not provide unbiased estimates of the usual intake distributions of episodically consumed dietary components unless every participant has the same number ($2) 24-h recalls. Thus, we used the NCI method in addition to the ISU for heme iron. The differences between the 2 methods are shown in Supplemental Table 1. Usual intakes of heme iron are lower in all age groups when the NCI method is used. This is expected given that to conduct the ISU method on heme iron we added a small random amount to all of the zero values. We cannot determine the difference in the percentage of the population with inadequate intakes of heme iron because there is no DRI for this nutrient. The main strength of this analysis is that it is based on a probabilistic national sample that is representative of the Mexican population. The use of the 24HR with a replicate 24HR collected for a subsample of participants is another strength. The use of the 24HR increases the accuracy with which daily intake information can be captured (29). The estimated distribution of the usual intakes of minerals after adjustment for within-person variance was done by using the ISU method implemented with the PC-SIDE software (19). The high prevalence of calcium inadequacy is consistent with data observed elsewhere but is concerning from a public health perspective. In Brazil, 84% of men and 90% of women (20 59 y of age) had inadequate calcium intakes and children aged y had an inadequacy of 95% (30, 31). In the United States and Europe, calcium intakes tend to be higher and inadequacies are lower thaninmexico(20 44%inmales and 37 58% in females) (32, 33). Low calcium intakes in Mexico may be partially explained by the low consumption of dairy products in the population. In Mexico, only ;35% of childrenaged1 4yand22%ofchildrenaged5 11ymeet international recommendations for dairy consumption of $2 portions/d; adolescents (12 19 y) and adults ($20 y) are even less compliant, with only 17% and 9% meeting recommendations, respectively (27). These observations are consistent with the high proportion of these populations with inadequate calcium intakes. In the case of iron, although intakes are high (twice the EAR for iron), the risk of inadequacy is high because dietary iron has low bioavailability in accordance with the Mexican Dietary Recommendations, mainly due to the high content of phytates and other iron absorption inhibitors in the diet (23, 24). However, the prevalence of iron inadequacy decreased in 2006 and 2012 (7, 8, 14). When we used the bioavailability value for the United States and Canada (18%) (21), iron inadequacy decreased to levels comparable to those observed elsewhere (30, 31, 34). In Mexico, traditional diets predominantly based on tortillas, beans, and vegetables coexist with Western-type diets, similar to those consumed in the United States and Canada; it is likely that the prevalence of inadequate iron intake is between the 2 estimates of iron bioavailability used. Further research is needed to estimate individual bioavailable iron intake on the basis of the characteristics of the diet (24). Dietary magnesium intake is evaluated here for the first time, to our knowledge, in a national survey in Mexico. This is important because, in 2006, we observed a high proportion of individuals with low serum concentrations of magnesium: 12% in children <5 y of age, 28% in children aged 5 11 y, and 37% in adolescents aged y (7). In this study there was a trend for lower magnesium inadequacy in rural areas, in the South region, and in the lowest tertile. Although these differences were significant only in adolescents aged y living in urban and rural areas and females y of age living in the North and South regions, this situation could be explained by the higher intakes of whole grains and legumes (magnesium-rich foods) in these populations (26). A low proportion of individuals showed usual intakes below the corresponding EARs for zinc. The important decrease in the prevalence of zinc inadequacy observed in 2012 compared with previous surveys may be due, in part, to the fact that we assumed that dietary zinc is highly bioavailable. If we adjusted the bioavailability value of dietary zinc, taking into account the presence of mineral absorption inhibitors in the Mexican diet, we would then obtain estimates of inadequacy more consistent with the estimates of serum zinc deficiency reported in 2006: 27.5% for children <5 y old, 23.6% for children aged 5 11 y, 26.4% in adolescents aged y, and 42.6% in adults aged $20 y (7 9). In conclusion, inadequacies of mineral intake were shown in the Mexican population. Specifically, we provide information on significant deficiencies in calcium and iron intakes among the Mexican population, which suggests a public health concern. It is important to analyze dietary data along with biological markers to provide reliable evidence because dietary data can be inaccurate for many reasons (35) and should be interpreted with caution. Mineral supplement use as well as other aspects of the diet that facilitate or hinder mineral absorption should be further examined. Acknowledgments We thank David Quezada, Eric Monterubio, Leticia Escobar, and Ignacio Mendez for collaboration in the development of the databases and suggestions on statistical analysis and Kevin Dodd for his collaboration in the analysis of heme iron with the NCI method. TGS-P, NL-O, SR-R, JAR, ALC, and SV designed the research; TGS-P wrote the first draft of the manuscript and analyzed the data; NL-O and ALC contributed to the data analysis; NL-O, SR-R, AG-G, JAR, ALC, and SV reviewed the manuscript; and TGS-P and SV had primary responsibility for the final content. All authors read and approved the final manuscript. Inadequate intakes of calcium and iron in Mexico 1879S

7 References 1. Sepúlveda-Amor J, Lezana-Hernandez M, Tapia-Conyer R, Valdespino J, Madrigal H, Kumate J. [Nutritional status of pre-school children and women in Mexico: results of a probabilistic national survey.] Gac Med Mex 1990;126: (in Spanish). 2. Rivera Dommarco J, Shamah Levy T, Villalpando S, González de Cossío T, Hernández Prado B, Sepúlveda J. Encuesta Nacional de Nutrición Estado nutricio de niños y mujeres en México. [National Nutrition Survey 1999.] Cuernavaca (Mexico): Instituto Nacional de Salud Pública; 2001 (in Spanish). 3. Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T, Rojas R, Villalpando-Hernández S, Hernández-Avila M, Sepúlveda- Amor J. Encuesta Nacional de Salud y Nutrición [National Health and Nutrition Survey 2006.] Cuernavaca, México. Cuernavaca (Mexico): Instituto Nacional de Salud Pública; 2006 (in Spanish). 4. López-Olmedo N, Carriquiry AL, Rodríguez-Ramírez S, Ramírez-Silva I, Espinosa-Montero J, Hernández-Barrera L, Campirano F, Martínez- Tapia B, Rivera JA. Usual intake of added sugars and saturated fats is high while dietary fiber intake is low in the Mexican population. J Nutr 2016;146(Suppl):1856S 65S. 5. Barquera S, Rivera J, Safdie M, Flores M, Campos-Nonato I, Campirano F. [Energy and nutrient intake in preschool and school age Mexican children: National Nutrition Survey 1999.] Salud Publica Mex 2003;45 (Suppl 4):S (in Spanish). 6. Barquera S, Rivera J, Espinosa-Montero J, Safdie M, Campirano F, Monterrubio E. [Energy and nutrient consumption in Mexican women years of age: analysis of the National Nutrition Survey 1999.] Salud Publica Mex 2003;45:S530 9 (in Spanish). 7. Morales-Ruán MC, Villalpando S, García-Guerra A, Shamah-Levy T, Robledo-Pérez R, Avila-Arcos MA, Rivera JA. [Iron, zinc, copper and magnesium nutritional status in Mexican children aged 1 to 11 years.] Salud Publica Mex 2012;54: (in Spanish). 8. De la Cruz-Góngora V, Gaona B, Villalpando S, Shamah-Levy T, Robledo R. [Anemia and iron, zinc, copper and magnesium deficiency in Mexican adolescents: National Health and Nutrition Survey 2006.] Salud Publica Mex 2012;54: (in Spanish). 9. Mejía-Rodríguez F, Shamah-Levy T, Villalpando S, García-Guerra A, Humarán I. [Iron, zinc, copper and magnesium deficiencies in Mexican adults from the National Health and Nutrition Survey 2006.] Salud Publica Mex 2013;55: (in Spanish). 10. Mundo-Rosas V, Rodríguez-Ramírez S, Shamah-Levy T. [Energy and nutrient intake in Mexican children 1 to 4 years old: results from the Mexican National Health and Nutrition Survey 2006.] Salud Publica Mex 2009;51(Suppl 4):S530 9 (in Spanish). 11. Flores M, Macías N, Rivera M, Barquera S, Hernández L, García- Guerra A, Rivera J. [Energy and nutrient intake among Mexican schoolaged children, Mexican National Health and Nutrition Survey 2006.] Salud Publica Mex 2009;51(Suppl 4):S (in Spanish). 12. Rodríguez-Ramírez S, Mundo-Rosas V, Shamah-Levy T, Ponce-Martínez X, Jiménez-Aguilar A, González-de Cossío T. [Energy and nutrient intake in Mexican adolescents: analysis of the Mexican National Health and Nutrition Survey 2006.] Salud Publica Mex 2009;51(Suppl 4):S (in Spanish). 13. Barquera S, Hernández-Barrera L, Campos-Nonato I, Espinosa J, Flores M, Barriguete A, Rivera J. [Energy and nutrient consumption in adults: analysis of the Mexican National Health and Nutrition Survey 2006.] Salud Publica Mex 2009;51(Suppl 4):S (in Spanish). 14. Shamah-Levy T, Villalpando S, Jáuregui A, Rivera J. [Overview of the nutritional status of selected micronutrients in Mexican children in 2006.] Salud Publica Mex 2012;54: (in Spanish). 15. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpando S, Franco A, Cuevas-Nasu L, Romero-Martínez M, Hernández-Ávila M. Encuesta Nacional de Salud y Nutrición Resultados Nacionales. Cuernavaca (Mexico): Instituto Nacional de Salud Pública; 2012 (in Spanish). 16. Romero-Martínez M, Shamah-Levy T, Franco-Núñez A, Villalpando S, Cuevas-Nasu L, Gutiérrez JP, Rivera-Dommarco JA. Encuesta Nacional de Salud y Nutrición 2012: diseño y cobertura. Salud Publica Mex 2013;55(Suppl 2):S (in Spanish). 17. Conway JM, Ingwersen LA, Vinyard BT, Mashfegh AJ. Effectiveness of the US Department of Agriculture 5-step multiple-pass method in assessing food intake in obese and nonobese women. Am J Clin Nutr 2003;77: Instituto Nacional de Salud Publica. Bases de datos del valor nutritivo de los alimentos. Compilación del Instituto Nacional de Salud Pública. Cuernavaca (Mexico): Instituto Nacional de Salud Publica; 2012 (in Spanish). 19. Nusser S, Carriquiry A, Dodd K, Fuller W. A semiparametric transformation approach to estimating usual daily intake distributions. J Am Stat Assoc 1996;91: Tooze JA, Midthune D, Dodd KW, Freedman LS, Krebs-Smith SM, Subar AF, Guenther PM, Carroll RJ, Kipnis V. A new method for estimating the usual intake of episodically-consumed foods with application to their distribution. J Am Diet Assoc 2006;106: Institute of Medicine. Dietary Reference Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington (DC): National Academies Press; Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D. Washington (DC): National Academies Press; Rivera J, Hotz C, Rodriguéz S, García A, Pérez A, Martínez H, González M. In: Bourges H, Casanueva E, Rosado JL, editors. [Nutrient Intake recommendations for the Mexican population, Physiological Bases.] 1st ed. Mexico City (Mexico): Editorial Médica Panamericana; 2008 (in Spanish). 24. Rodríguez SC, Hotz C, Rivera J. Bioavailable dietary iron is associated with hemoglobin concentration in Mexican preschool children. J Nutr 2007;137: Armstrong RA. When to use the Bonferroni correction. Ophthalmic Physiol Opt 2014;34: Aburto TC, Pedraza LS, Sánchez TG, Batis C, Rivera JA. Discretionary foods have a high contribution and fruits, vegetables, and legumes have a low contribution to the total energy intake of the Mexican population. J Nutr 2016;146(Suppl):1881S 7S. 27. Batis C, Aburto TC, Sánchez-Pimienta TG, Pedraza LS, Rivera JA. Adherence to dietary recommendations for food group intakes is low in the Mexican population. J Nutr 2016;146(Suppl):1897S 906S. 28. Merchant AT, Dehghan M. Food composition database development for between country comparisons. Nutr J 2006;5: Raper N, Perloff B, Ingwersen L, Steinfeldt L, Anand J. An overview of USDAÕs Dietary Intake Data System. J Food Compos Anal 2004;17: Araujo MC, Bezerra I, Barbosa F, Junger W, Yokoo E, Pereira R, Sichieri R. Macronutrient consumption and inadequate micronutrient intake in adults. Rev Saude Publica 2013;47(Suppl 1):177S 89S. 31. Veiga G, Costa R, Araújo M, Souza A, Bezerra I, Barbosa F, Sichieri R, Pereira R. Inadequate nutrient intake in Brazilian adolescents. Rev Saude Publica 2013;47(Suppl 1):212S 21S. 32. Bailey RL, Dodd K, Goldman J, Gahche J, Dwyer J, Moshfegh A, Sempos C, Picciano M. Estimation of total usual calcium and vitamin D intakes in the United States. J Nutr 2010;140: Roman Viñas B, Ribas L, Ngo J, Gurinovic M, Novakovic R, Cavelaars A, de Groot L, vanõt Veer P, Matthys C, Serra L. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab 2011;59: Health Canada. Canadian Community Health Survey, Cycle 2.2, Nutrition (2004) nutrient intakes from food. Provincial, regional and national summary data tables. Vol. 2. Ottawa (Canada): Health Canada; Subar AF, Freedman L, Tooze J, Kirkpatrick S, Boushey C, Neuhouser ML, Thompson FE, Potischman N, Guenther PM, Tarasuk V, et al. Addressing current criticism regarding the value of self-report dietary data. J Nutr 2015;145: S Supplement