Reflections of Dietary Studies With Children in the Ten- State Nutrition Survey of

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1 Ad Hoc Committee To Review the Ten-State Nutrition Survey Reflections of Dietary Studies With Children in the Ten- State Nutrition Survey of The dietary component of the Ten-State Nutrition Survey (TSNS) was designed to provide a description of food consumption for persons of many ages, including infants and small children 0 to 36 months old and adolescents 10 to 16 years old. Because the overall objective of the TSNS was to describe nutritional status of groups as contrasted to individuals, the 24-hour recall method was an acceptable technique; however, its value is obviously limited by the ability of the respondent (mothers in the case of infants and young children) to remember all food items consumed. The actual range of intake within groups of the TSNS was probably less than that reported because of both underestimation and overestimation of food consumption. Average intakes of some nutrients determined from 24- hour recalls may be some 10% greater than those found by other techniques, indicating that 24- hour intakes are more likely to be overestimated than underestimated.2 This fact does not invalidate use of 24-hour recall data for comparing intakes of groups of persons included in one survey if the assumption is made that erroneous data are randomly distributed among the subsets of groups. Examination of the detailed reports of the TSNS1 and of raw data#{176}indicated that erroneous data were randomly distributed. SOCIOECONOMIC STATUS AND FOOD CONSUMPTION Dietary intake data for all children 1 to 3 and 12 to 16 years old in the TSNS have been examined according to ethnicity, per capita income, sex (of adolescents), and geographic region. As previously reported,3 absolute intakes of energy (calories) and of all the nutrients examined reflected socioeconomic status. That is, when sex, race, and age were held constant, intakes of nutrients tended to increase with increase in income. This association of nutrient intakes with income, most striking for vitamin C, was particularly evident among adolescents. These observations for black and white children #{176}Provided by the Nutrition Program Center for Disease Control, Department of Health, Education, and Welfare, under contracts HSM and HSM DIETARY STUDIES WITH CHILDREN

2 are summarized in Tables I and II. When per capita income, sex, and age were held constant, black children had somewhat lower median intakes of energy and of most nutrients than did white children. Hispanic, Indian, and Oriental children were included in the TSNS. However, their numbers were small compared with black and white children, and it was difficult or impossible to stratify the subsamples by income, sex and age. In addition, among Spanish-American childrn,t there were substantial differences between Mexican-American (Southwest) and Puerto-Rican (Northeast), which further confounded interpretation. It was apparent that Mexican-American children in Texas were among the least wellnourished in the entire TSNS.35 NUTRITIONAL ADEQUACY: QUALITY VERSUS QUANTITY The nutritional adequacy of diets is at least in part determined by the total amount of food consurned. Calculation of the amount of individual nutrients for each 1,000 kcal consumed provides some indication of the degree to which nutritional adequacy of the diet is either a quantitative function of the total amount of food consumed or is a more qualitative function dependent on specific choices of food with high nutrient content. The nutritional quality of diets expressed as the mean amount of nutrients per 1,000 kcal showed little variation in relation to family income or ethnicity. Further examination of these data showed virtually no effects of sex, ethnic group, and per capita income on distribution of protein, iron, thiamin, riboflavin, niacin, and vitamin A content (units per 1,000 kcal) of diets. Calcium content (milligrams per 1,000 kcal) of diets of 1- to 3- year-old children was expectedly some 50% higher than that of diets consumed by adolescents. Densities of protein, riboflavin, and vitamin A were also somewhat greater in toddiers diets than in diets of adolescents; this probably reflected the proportionately greater contribution of fluid milk to diets of younger children. These data are summarized in Tables III and IV. Diets consumed by black children contained less calcium (milligrams per 1,000 kcal) than did those consumed by white children; however, the magnitude of the differences was less than that described in the Preschool Nutrition Survey.6 Only for vitamin C was there significant correlation between per capita income and nutrient density (milligrams per 1,000 kcal) of the diet. A strong association between plasma ascorbic acid content and socioeconomic status was clearly demonstrated among children in the Preschool Nutrition Survey and among persons of all ages in the TSNS.7 WEAKNESSES IN DIETARY COMPONENT OF SURVEYS Dietary studies in most nutrition surveys are designed to estimate energy and nutrient intakes of individuals participating in the survey and to obtain general information about food and food use in the community. Although dietary studies may seem to the physician to be the least rewarding component in the traditional tripartite (dietary, clinical, laboratory) approach to evaluation of nutritional status, such studies are essential to any comprehensive survey if changes in food policy (commercial or governmental) or modificalions of consumer behavior are to be achieved. Limitations of the dietary data in the TSNS are recognized and, although not unique to the TSNS, some are: (1) The use of standard food composition tables, particularly average values compiled for recipes rather than evaluation of individual (family) recipes as prepared in the home, ignored the remarkable variability in food preparation in different households. Data compiled in the Preschool Nutrition Survey6 on macaroni and cheese prepared in the home (the most commons casserole prepared for preschool children) showed four-fold differences in calcium content,s although the mean calcium content was virtually identical with that given in a standard food composition table.9 (2) Failure to include contribution of vitamin! mineral supplements to the total day s intake, or to identify those children receiving such supplements, made it difficult to examine correlations between nutrient intakes and biochemical indices, especially of water-soluble vitamins. tclassification used in detailed reports of the TSNS. Consumed by approximately 15% of children in PNS. AMERICAN ACADEMY OF PEDIATRICS 321

3 I PERcENTILES FOR Nummr.rr hrr.x FOR CHILDREN 1 TO 3 Y&ns OLD Per Capita Income ($) No , , , , , , , , Calories Protein (gm) Vitamin A(IU x 10) i0% 50% 90% 10% 50% 90% io% 50% 90% 627 1,409 2, ,333 2, ,437 2, ,324 2, ,482 2, ,316 2, ,174 1, ,327 2, ,310 2, ,101 1, ,180 1, ,170 2, Vitamin C (mg) 10% 50% 90i II PERCENTILES FOR NUTRIENT INTAXE FOR CHILDREN 12 TO 16 Y.ns OLD Per Capita Calories Income ($) No. 10% 50% 90% Protein (gm) 10% 50% 90% Vitamin A(IU x 10) 10% 50% 90i Vitamin C (mg) 10% 50% 90% ,297 2,199 3, , ,392 2,555 4,651 1, ,568 2,769 4, , ,106 1,839 2, , ,011 1,928 3,303 1, ,163 2,093 3, ,861 3, , ,092 2,106 4, ,112 2,503 4, , , , ,581 2, , ,042 1,794 3,352 1, ,210 2,311 3, , DIETARY STUDIES WITH CHILDREN

4 I (cor1ued) Iron(mg) Calcium (mg) Thiamine (mg) Riboflavin (mg) 10% 50% 90 10% 50% 90% 10% 50% 90% 10% 50% 9#{243}% , , , , , , , , , , , , II (corrnr med) r--- Iron(mg) -j,- Calcium (mg) Thiamin (mg) Riboflavin (mg) 10% 50% 90% 10% 50% 90% 10% 50% 90% 10% 50% 90% , ,129 2, ,274 2, , , , , , , , , , AMERICAN ACADEMY OF PEDIATRICS 323

5 III PERCENTILES FOR Nuriur DENSITY#{176} FOR CHILDREN 1 TO 3 Yrus OLD Per Capita. Protein Iron Calcium Income ($) No. 10% 50% 90i 10% 50% 90% 10% 50% 90% , , ,304 1, , , ,031 1, , , , ,053 1, , , , ,002 i:! ,266 IU/1,000 #{176}Nutrient density is expressed as mg/1,000 keal, except for protein which is gm/1,000 kcal and vitamin A which is kcal. N PERCENTILES FOR NUTRIENT DENSITY FOR CHILDREN 12 TO 16 Yr.is OLD Per Capita Protein Iron Calcium Income - J ($) No. 10% 50% % 50% 90% 10% 50% 90% , i_,c? , , , i_ , , #{176}Nutrient density is expressed as mg/1,000 kcal, except for protein which is gm/1,000 kcal and Vitamin A which is IU/1,000 kcal. 324 DIETARY STUDIES WITH CHILDREN

6 III (corrrinued) Thiamin Riboflavin Vitamin A Vitamin C 10% 50% 96i io% 50% 90 10% 50% 90% 10% 50% 90% ,852 2,104 2,096 4,055 4,800 5, ,538 1,497 2,109 4,827 4,035 5, ,791 2,028 1,925 4,151 4,713 4, ,061 2,000 1,690 2,041 9,499 5,168 4, IV (cor-rir med) 10% Thiamin 50% 90% l0% -a-vin 50% 90% Vitamin #{243}% 50% A 90i 10% Vitamin % C 90% ,088 3, ,274 3, ,305 3, ,345 4, ,304 4, ,321 3, ,431 8, ,184 5, ,277 5, ,346 7, ,150 4, ,243 3, AMERICAN ACADEMY OF PEDIATRICS 325

7 CONCLUSION Physical (anthropometric) and biochemical evidence of malnutrition or of nutritional risk among children in the Ten-State Nutrition Survey reflected primarily an inadequacy of total energy intake and not improper selection of foods or unbalanced diets. Thus, the quantity of food-not the quality-was the major dietary problem highlighted by the Ten-State Nutrition Survey. AD Hoc COMMITTEE To REVIEW THE TEN-STATE Nu riutlon SURVEY Ciiu.Es U. Lowi, M.D., Chairman GILBERT FoiwEs, M.D. STANLEY Gui, PH.D. GEORGE M. OWEN, M.D. NATHAN J. SMITH, M.D. WILLIAM B. WElL, JR., M.D. MILTON Z. NICHAMAN, M.D., LiaLcon Dietary history vs. seven-day record vs. 24-hour recall. J. Am. Diet. Assoc., 28:218, Committee to Review the Ten-State Nutrition Survey: The Ten-State Nutrition Survey: Pediatric perspective. Pediatrics, 51:1095, McGanity, W. J.: Nutrition survey in Texas. Texas Med., 65:40, Chase, H. P., Kumar, V., DOddS, J. M., Sauberlich, E. H., Hunter, R. M., Burton, R. S., and Spalding, V.: Nutritional status of preschool Mexican-American migrant farm children. Am. J. Dis. Child., 122:316, Owen, G. M., Kram, K. M., Garry, P. J., Lowe, J. E., and Lubin, A. H.: A study of nutritional status of preschool children in the United States Pediatrics, 53:597, Garn, S. M., Owen, G. M., and Clark, D. C.: Ascorbic acid: The vitamin of affluence. Ecol. Food Nutrient, 3:151, Kram, K. M., King, A. M., and Owen, G. M.: unpublished data. 9. Watt, B. K., and Merrill, A. L.: Composition of food raw, processed prepared. Handbook 8, revised. Washington, D.C.: U.S. Department of Agriculture, REFERENCES 1. U.S. Department of Health Education and Welfare, Health Services and Mental Health Administration, Center for Disease Control: The Ten-State Nutrition Survey, 1968, Atlanta: DHEW Publication No. (HSM) to , Young, C. M., Hagan, G. C., Tucker, R. E., and Foster, W. D. A comparison of dietary study methods: II. ACKNOWLEDGMENT The advice of Dr. Phyllis Acosta, University of Georgia, and Dr. Norge Jerome, University of Kansas, concerning analytical approaches to TSNS dietary data and the techmeal assistance of Ms. Sara Stinson in canying out some of these analyses at the University of Michigan Center for Human Growth and Development are gratefully acknowledged. 326 DIETARY STUDIES WITH CHILDREN

8 Reflections of Dietary Studies With Children in the Ten-State Nutrition Survey of Charles U. Lowe, Gilbert Forbes, Stanley Garn, George M. Owen, Nathan J. Smith, William B. Weil, Jr. and Milton Z. Nichaman Pediatrics 1975;56;320 Updated Information & Services Permissions & Licensing Reprints including high resolution figures, can be found at: Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Information about ordering reprints can be found online:

9 Reflections of Dietary Studies With Children in the Ten-State Nutrition Survey of Charles U. Lowe, Gilbert Forbes, Stanley Garn, George M. Owen, Nathan J. Smith, William B. Weil, Jr. and Milton Z. Nichaman Pediatrics 1975;56;320 The online version of this article, along with updated information and services, is located on the World Wide Web at: Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 1975 by the American Academy of Pediatrics. All rights reserved. Print ISSN: