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

Ad Hoc Committee To Review the Ten-State Nutrition Survey Reflections of Dietary Studies With Children in the Ten- State Nutrition Survey of 1968-1970 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 21-71-522 and HSM 21-71-526. 320 DIETARY STUDIES WITH CHILDREN

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

I PERcENTILES FOR Nummr.rr hrr.x FOR CHILDREN 1 TO 3 Y&ns OLD Per Capita Income ($) No. 0-500 30 500-1,000 74 1,000+ 166 0-500 25 500-1,000 70 1,000+ 170 0-500 133 500-1,000 82 1,000+ 31 0-500 130 500-1,000 82 1,000+ 34 Calories Protein (gm) Vitamin A(IU x 10) i0% 50% 90% 10% 50% 90% io% 50% 90% 627 1,409 2,046 29 51 100 100 285 610 845 1,333 2,260 35 58 90 115 283 721 927 1,437 2,216 34 57 88 143 279 724 620 1,324 2,292 22 51 72 48 211 586 800 1,482 2,288 27 59 104 95 261 721 877 1,316 2,101 31 53 86 126 281 751 688 1,174 1,817 22 45 77 81 199 504 831 1,327 2,210 34 53 91 118 266 605 812 1,310 2,445 31 59 103 134 271 660 542 1,101 1,883 23 46 78 71 232 993 601 1,180 1,674 24 46 76 58 209 703 781 1,170 2,089 36 50 97 119 228 541 Vitamin C (mg) 10% 50% 90i3 5 20 80 8 37 82 13 44 128 6 22 163 8 33 109 10 33 131 3 16 100 5 23 123 5 34 135 3 22 99 6 25 122 6 29 106 II PERCENTILES FOR NUTRIENT INTAXE FOR CHILDREN 12 TO 16 Y.ns OLD Per Capita Calories Income ($) No. 10% 50% 90% Protein (gm) 10% 50% 90% Vitamin A(IU x 10) 10% 50% 90i Vitamin C (mg) 10% 50% 90% 0-500 106 1,297 2,199 3,974 500-1,000 177 1,392 2,555 4,651 1,000+ 507 1,568 2,769 4,674 39 85 142 45 96 178 56 107 194 69 277 878 133 312 818 149 387 1,055 6 34 173 9 49 146 12 56 206 0-500 101 1,106 1,839 2,837 500-1,000 196 1,011 1,928 3,303 1,000+ 470 1,163 2,093 3,451 0-500 345 891 1,861 3,541 500-1,000 226 1,092 2,106 4,059 11000+ 110 1,112 2,503 4,354 36 67 108 32 75 134 43 77 139 31 69 127 38 81 158 39 99 171 81 281 823 71 258 891 109 293 820 67 262 1,393 65 271 1,221 96 321 1,223 6 33 155 6 44 169 12 50 169 6 31 170 5 36 157 7 50 180 0-500 438 825 1,581 2,910 500-1,000 260 1,042 1,794 3,352 1,000+ 118 1,210 2,311 3,879 28 59 104 35 70 128 46 83 154 56 227 1,216 55 233 945 61 300 936 4 30 141 4 33 140 8 51 169 322 DIETARY STUDIES WITH CHILDREN

I (cor1ued) Iron(mg) Calcium (mg) Thiamine (mg) Riboflavin (mg) 10% 50% 90 10% 50% 90% 10% 50% 90% 10% 50% 9#{243}% 2 6 16 409 945 1,624 1.7 1.5 2.7 3 8 18 467 999 1,503 1.6 1.0 1.8 2.7 4 7 14 441 689 1,538 1.4 1.7 2.7 3 6 10 334 689 1,538 1.4 1.4 2.4 3 8 13 275 905 1,775 1.5 1.6 3.4 3 7 13 456 880 1,619 1.5 1.6 2.9 3 6 11 149 647 1,474 1.4 2.6 3 6 13 309 799 1,469 1.5 1.7 2.8 4 7 15 378 911 1,742 1.7 1.7 3.0 2 5 12 247 735 1,519 1.4 3.0 3 5 10 211 655 1,352 2.4 2 5 10 438 903 1,405 1.5 2.6 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% 6 12 22 254 938 1,945 2.3 1.9 3.6 6 13 25 397 1,129 2,303 2.4 1.0 2.3 4.2 7 14 26 496 1,274 2,648 1.4 2.6 2.6 4.6 5 11 16 286 732 1,550 1.0 1.5 1.5 2.8 5 10 19 293 829 1,735 1.0 1.8 1.8 3.2 5 10 20 376 947 1,867 1.0 2.0 1.9 3.3 5 10 20 231 724 1,448 2.3 1.5 3.4 5 12 26 252 865 1,687 2.2 1.8 3.5 6 14 25 362 945 2,110 2.9 2.0 4.0 4 9 16 163 557 1,218 1.8 1.4 2.8 5 9 20 173 602 1,345 2.0 1.5 2.9 6 12 22 280 712 1,604 2.4 1.8 3.1 AMERICAN ACADEMY OF PEDIATRICS 323

III PERCENTILES FOR Nuriur DENSITY#{176} FOR CHILDREN 1 TO 3 Yrus OLD Per Capita. Protein Iron Calcium Income ($) No. 10% 50% 90i 10% 50% 90% 10% 50% 90% 0-500 30 28 40 50 3 5 7 310 677 1,058 500-1,000 174 33 43 54 3 6 15 409 712 1,304 1,000+ 166 30 39 52 3 5 8 374 644 1,203 0-500 25 25 36 52 3 5 6 251 587 999 500-1,000 70 28 42 50 3 5 7 294 603 1,031 1,000+ 170 29 41 51 3 5 7 372 671 1,173 0-500 133 29 41 51 3 5 8 180 535 1,010 500-1,000 82 30 43 52 3 5 7 219 609 1,053 1,000+ 31 30 40 51 3 5 8 273 562 1,125 0-500 130 29 43 55 3 5 8 265 664 1,264 500-1,000 82 29 39 51 3 5 7 199 523 1,002 i:!00+ 34 31 43 56 3 4 6 463 715 1,266 IU/1,000 #{176}Nutrient density is expressed as mg/1,000 keal, except for protein which is gm/1,000 kcal and vitamin A which is kcal. N PERCENTILES FOR NUTRIENT DENSITY FOR CHILDREN 12 TO 16 Yr.is OLD Per Capita Protein Iron Calcium Income - J ($) No. 10% 50% 90 116% 50% 90% 10% 50% 90% 0-500 106 23 37 49 4 5 8 141 418 747 500-1,000 177 25 37 48 4 5 7 215 437 714 i_,c?00+ 507 28 38 50 3 5 7 232 469 751 0-500 101 25 37 50 4 5 8 212 421 694 500-1,000 196 27 39 51 4 5 8 183 451 716 1,000+ 470 26 37 51 4 5 7 211 471 773 0-500 345 25 37 50 4 6 8 157 395 649 500-1,000 226 26 38 52 3 5 8 171 378 642 i_00+ 110 28 37 52 4 5 8 179 402 676-0-500 438 25 38 50 4 6 8 118 367 681 500-1,000 260 25 37 52 4 5 8 114 342 603 1,000+ 118 28 40 57 4 6 8 123 349 564 #{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

III (corrrinued) Thiamin Riboflavin Vitamin A Vitamin C 10% 50% 96i io% 50% 90 10% 50% 90% 10% 50% 90% 1.6 2.0 1.8 597 906 962 1,852 2,104 2,096 4,055 4,800 5,039 5 8 9 14 21 34 56 76 87 1.7 1.7 1.9 323 825 833 1,538 1,497 2,109 4,827 4,035 5,623 8 5 7 15 22 24 68 74 87 1.0 1.0 2.0 1.9 1.9 741 813 870 1,791 2,028 1,925 4,151 4,713 4,678 3 6 3 15 18 25 85 71 93 1.0 2.1 1.9 2.0 763 617 1,061 2,000 1,690 2,041 9,499 5,168 4,601 3 6 9 20 21 21 111 115 98 IV (cor-rir med) 10% Thiamin 50% 90% l0% -a-vin 50% 90% Vitamin #{243}% 50% A 90i 10% Vitamin --- 50% C 90%. 1.4 410 1,088 3,300 561 1,274 3,106 649 1,305 3,583 3 5 5 14 19 20 63 54 71 527 1,345 4,913 461 1,304 4,505 586 1,321 3,549 3 21 73 6 20 88 6 25 87 1.4 469 1,431 8,799 420 1,184 5,490 378 1,277 5,060 3 17 77 3 15 69 4 18 60 1.0 1.5 443 1,346 7,019 298 1,150 4,719 327 1,243 3,715 3 20 85 3 15 71 4 22 80 AMERICAN ACADEMY OF PEDIATRICS 325

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, 1952. 3. Committee to Review the Ten-State Nutrition Survey: The Ten-State Nutrition Survey: Pediatric perspective. Pediatrics, 51:1095, 1973. 4. McGanity, W. J.: Nutrition survey in Texas. Texas Med., 65:40, 1969. 5. 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, 1971. 6. 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. 1968-1970. Pediatrics, 53:597, 1974. 7. Garn, S. M., Owen, G. M., and Clark, D. C.: Ascorbic acid: The vitamin of affluence. Ecol. Food Nutrient, 3:151, 1974. 8. 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, 1963. 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, 1970. Atlanta: DHEW Publication No. (HSM) 72-8130 to 72-8134, 1972. 2. 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

Reflections of Dietary Studies With Children in the Ten-State Nutrition Survey of 1968-1970 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: http://pediatrics.aappublications.org/content/56/2/320 Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/permissions.xhtml Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Reflections of Dietary Studies With Children in the Ten-State Nutrition Survey of 1968-1970 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: http://pediatrics.aappublications.org/content/56/2/320 Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1975 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.