A Health Professional's Guide to Antioxidants, B Vitamins, Calcium

A Health Professional’s Guide to Antioxidants, B Vitamins, Calcium and Other Bone Health Nutrients 2002 National Nutrition Month Resource Manual for Health Professionals Produced by Dietitians of Canada Fall, 2001 Link to www.dietitians.ca (CHN Healthy Eating Affiliate) TABLE OF CONTENTS 2002 National Nutrition Month Campaign Campaign Theme Campaign Target Audience Campaign Objectives Key Messages and Contacts Nutrition Month Campaign Resources Resources for Health Professionals Resources for Consumers Nutrition Month Campaign Ideas 4 4 5 6 9 9 10 11 Keeping on Top of Nutrition Research and News Dietary Reference Intakes (DRIs) The ABCs of Healthy Eating Antioxidants…Vitamin C, E, Selenium and Carotenoids B - Vitamins Calcium and other related bone health nutrients 12 14 16 17 22 26 Acknowledgements References 31 32 2002 National Nutrition Month Campaign 3 Dietitians of Canada 2002 National Nutrition Month Campaign Campaign Theme Nutrition Month® is a registered trademark of Dietitians of Canada (DC). Since the early 1980’s, DC has successfully organized this annual campaign. The theme of the 2002 Nutrition Month campaign is: The ABCs of Healthy Eating L’ ABC d’une saine alimentation “The ABCs of Healthy Eating” will reinforce the principles of Canada’s Guidelines for Healthy Eating and will address consumer questions on three important nutrient groups: A - Antioxidants B - B vitamins C - Calcium and other related bone health nutrients. These nutrients are of interest and recent reports, including the latest scientific evidence, have been released by the National Academy of Sciences. These reports provide new Dietary Reference Intakes for Canadians and Americans. This campaign resource manual is designed to help you become better equipped to understand recent findings regarding some key nutrients so that you can guide consumers towards making healthy food choices. Campaign Target Audience This campaign is aimed at adults 19 years and older. The following consumer trends provide some background on this target group. Interest in Nutrition and its Relationship to Health Two-thirds of Canadians surveyed in a study by the National Institute of Nutrition felt that nutrition is very or extremely important in choosing the food they eat. Consistent with a decade of surveys, women are more likely than men to consider nutrition to be important (73% vs. 60%, respectively).1 Four in five Canadians believe that food and nutrition play a “great” role in maintaining or improving overall health. Women and Quebec consumers are particularly likely to believe that food and nutrition play a great role in maintaining and promoting health. Health food store shoppers and vitamin/supplement users are both more likely to believe in the great importance of food and nutrition 2002 National Nutrition Month Campaign 4 Dietitians of Canada to one’s health. Younger consumers (aged 18-24 years) are least likely to believe that food and nutrition play a great role in health.2 The top health concerns of Canadians are heart or circulatory health issues (28%), cancer (24%), nutrition/diet (24%), exercise (17%), weight (12%), and diabetes (8%). 2 Interest in and use of Vitamin/Mineral Supplements 44% of Canadians take supplements according to a survey of 1003 Canadians aged 18 and over. Of those who take supplements, women are more likely to do so than men, and those over 65 are more likely to do so than those in younger age groups.3 For those people taking supplements, multivitamins are the most popular choice (49.2%), followed by other vitamins/minerals (36.5%), vitamin C (31.6%), vitamin E (17.4%), vitamin B complex (11.7%), herbal/botanical preparations (7.4%), vitamin D (3.9%), vitamin A (2.6%), antioxidant combination (1.5%), and beta-carotene (0.6%).3 When asked the most important reason for taking vitamins, 44% of vitamin users said “to feel healthy/make me feel better”, 35% because they “don’t eat right”, 8% for energy/strength, and 7% to help prevent disease. 3 A study by the National Institute of Nutrition, found that when consumers were asked about the changes they make to their diet in an effort to improve or maintain their health, those most likely to report eating more vegetables are vitamin/supplement users and women. Those most likely to eliminate or restrict consumption of a food or food component are older consumers (55+), vitamin supplement users, and higher income households ($35,000+).2 Campaign Objectives • Reinforce the importance of healthy eating. • Provide consumers with current information on some key nutrients. • Get consumers to focus on tasty, quick/easy food selection as key route to achieving adequate nutrient intake. • Assist consumers to make informed decisions regarding supplements. • Provide an overall appreciation of principles of healthy eating; i.e. healthy eating is not determined by one nutrient or one food; reinforce Canada’s Guidelines for Healthy Eating (CGHE) and food guide selections. • Identify where to go to find trusted healthy eating information, and reinforce the dietitian as a key resource. 2002 National Nutrition Month Campaign 5 Dietitians of Canada Key Messages and Contacts Key messages are “talking points” that can be used in your Nutrition Month campaign, promotions, interviews, or articles. These are broad messages that can be used often throughout your campaign. Other consumer messages more specific to the three nutrient groups are provided later in this manual. Focus on key nutrition principles that stand the test of time Canada’s Food Guide to Healthy Eating is a useful tool to help plan and choose a healthy diet. The guide provides a framework for the kinds and amounts of foods to eat each day. Canada’s Guidelines for Healthy Eating (CGHE) provides broad guidelines aimed at helping consumers adopt healthy eating patterns: • Enjoy a variety of foods. • Emphasize cereals, breads, other grain products, vegetables and fruits. • Choose lower-fat dairy products, leaner meats and foods prepared with little or no fat. • Achieve and maintain a healthy body weight by enjoying regular physical activity and healthy eating. • Limit salt, alcohol, and caffeine. Eat a variety of foods to help improve your overall nutritional health When you include a variety of different foods in your daily meals and snacks you’ll benefit from the many different vitamins, minerals, antioxidants and fibre they provide. Vary your choices from each food group. Experiment with new varieties, flavours, colours and preparation methods for a change. Balance your intake of food according to your age, gender and activity level Eating the right amount of food is as important as what you choose to eat. For information on serving sizes refer to Canada’s Food Guide to Healthy Eating www.hcsc.gc.ca/hppb/nutrition/pube/foodguid/ index.html. If you need help planning a healthy diet contact a registered dietitian. To find a dietitian visit www.dietitians.ca or call the Consulting Dietitians of Canada Network at 1-888-901-7776. Achieve and maintain a healthy weight by eating well and keeping active For tips on healthy eating visit Dietitians of Canada website www.dietitians.ca. Canada’s Food Guide to Healthy Eating (www.hc-sc.gc.ca/hppb/nutrition/pube/foodguid/index.html) and Canada’s Physical Activity Guide to Healthy Active Living (www.paguide.com) can also help. Aim to include plenty of antioxidant-rich vegetables, fruits and whole grains in your meal plans each day Antioxidant nutrients including vitamins C, E and selenium play a role in promoting health and preventing disease. In addition, a number of other compounds with antioxidant potential (such as carotenoids, flavonoids, etc.) are currently being studied for their possible health benefits. All of these antioxidants are easy to get and enjoy in the foods you eat. Satisfy your requirement for B vitamins by eating a variety of different foods from each food group each day Grain products provide thiamin, riboflavin, niacin, and folate. Milk, cheese, and other milk products provide riboflavin. Vegetables and fruit, and legumes provide folate. The Meat & Alternatives group provides thiamin, riboflavin, niacin and vitamin B6. For vitamin B12, foods of animal origin including milk, cheese and other milk products, eggs and meats are key sources. 2002 National Nutrition Month Campaign 6 Dietitians of Canada For the health of your bones choose a variety of calcium-rich foods especially milk products, the highest of food sources Calcium works along with other nutrients - phosphorus, magnesium, and vitamin D to build strong bones. You can get these nutrients by eating a variety of different foods from each of the four food groups each day. Milk, cheese and other milk products provide the most readily available source of calcium and other bone-building nutrients. Focus on foods, rather than supplements, to satisfy your nutrient needs whenever possible Supplements will not provide everything your body needs to be healthy. Foods contain many active components in addition to vitamins and minerals. If you rely on supplements for your vitamins and minerals, you’ll miss out on some of these important active agents. If you do take supplements get advice from a registered dietitian. Remember that healthy eating tastes great Try some fast and easy recipes from Dietitians of Canada Great Food Fast (2000) or DC’s newest cookbook (2002) Cook Great Food – a collection of 450 delicious recipes that offer tasty choices for everyday family meals, entertaining, and quick, light meals. When you have nutrition questions…Registered Dietitians are your key source of reliable food and nutrition information and advice Dietitians have the skills and knowledge to translate nutrition science into practical, everyday food choices. No matter what your personal eating style or food preferences, dietitians can provide trusted, accurate and timely nutrition advice. For more information about the role of a dietitian or to find a dietitian in your community visit www.dietitians.ca or call the Consulting Dietitians of Canada Network at 1-888-901-7776. This Nutrition Month campaign is brought to you by Dietitians of Canada and thousands of Dietitians across the country, with support from the campaign Official Sponsors – Chatelaine magazine, Dairy Farmers of Canada and Kraft Canada Inc (Cracker Barrel, Singles, Peanut Butter, Jell-O Pudding and POST cereals). For more information visit the Dietitians of Canada website at www.dietitians.ca/eatwell 2002 National Nutrition Month Campaign 7 Dietitians of Canada Key Contacts National Nutrition Month Regional Representatives a local contact if you want to get involved or obtain information British Columbia Region Melodie Yong Lipid Clinic St. Paul’s Hospital 1081 Burrard Street Vancouver, BC V6Z 1Y6 Phone: (604) 806-8611 Fax: (604) 809-8590 myong@providencehealth.bc.ca Alberta and the Territories Region Susan Yoo #17, 11111 - 26 Avenue Edmonton, AB T6J 5M7 Phone : (780) 407-3460 semie_rue@hotmail.com Rory Hornstein #11 1720 11th Street SW Calgary, AB T2T 3L6 Phone (403) 229-1118 rhornstein@eleventhsheet.com Saskatchewan, Manitoba and North-Western Ontario Region Lora Montebruno-Myco (Manitoba) 174 James Carleton Drive Winnipeg, MB R2P 0T4 Phone: (204) 633-6228 correy@mb.sympatico.ca Tracy Everitt (Saskatchewan) Public Health Nutritionist North East, North Central and Pasquia Health Districts Melfort, SK S0E 1A0 Phone: (306) 752-6310 Fax: (306) 753-6353 tracye.nchd@shin.sk.ca Central and Southern Ontario Region Marci Cooper 194 Pineway Blvd. Toronto, ON M2H 1B2 Phone: (416) 813-5142 Fax: (416) 813-4972 mcooper@interlog.com Roselle Martino 560 Steeple Hill Pickering, ON L1V 5Z3 Phone: (905) 831-2569 Fax: (905) 831-8117 rosellemartino@sympatico.ca Quebec, North East and Eastern Ontario Region Renée C. Crompton Health Canada, First Nations and Inuit Health Branch Ontario Region 1547 Merivale Road, 3rd floor Postal locator 6103A Ottawa, ON K1A 0L3 Phone: (613) 952-8377 Fax: (613) 952-7733 renee_crompton@hc-sc.gc.ca Atlantic Region Nathalie Roy (Moncton NB) 217 Maplehurst Drive Moncton, NB E1C 9R7 mminr@nb.sympatico.ca Kelly Sullivan (St. John’s, NFLD) 17 Major Avenue St. John’s, NF A1C 4N4 Phone: (709) 576-3588 adam.kelly@nf.sympatico.ca Barb Matheson (PEI) 192a Cumberland Street Charlottetown, PEI C1A 5C6 Phone: (902) 465-4404 Fax: (902) 465-4429 barbmatheson@hotmail.com DC National Nutrition Month® Co-ordinator Anne Gagné (416) 642-9318 agagne@dietitians.ca 2002 National Nutrition Month Campaign 8 Dietitians of Canada Nutrition Month Campaign Resources Resources for Health Professionals Nutrition Month Resource Manual (Available in pdf format on Dietitians of Canada (DC) website) Includes: background information on campaign key nutrients; identification of resources for health professionals and consumers; campaign ideas for your work site and community events; key messages to use in your nutrition month campaign, promotions, media interviews or articles; and local contacts. Online professional development course on DRIs (Available on the Dietetics @ Work section of DC’s website www.dieteticsatwork.com) Includes detailed online learning courses on the Dietary Reference Intakes (DRIs). Take the “DQ Challenge” - an interactive opportunity to test your DRI knowledge. Dietitians of Canada Manual of Clinical Dietetics and Client Education Materials (Available to order online from the Dietetics @ Work section of DC’s website www.dieteticsatwork.com). Dietitians of Canada website (www.dietitians.ca) Download colourful PSAs from DC’s News Room. Download consumer 2002 campaign theme factsheets; as well as factsheets on a variety of other topics. 2000 Campaign Planner (Available in pdf format on “members” side of DC website www.dietitians.ca/diet/html/theme.asp) Provides ideas for cookbook promotions. Media Support Contact your Regional Representative (see key contacts pg. 8); news releases, radio and print PSAs (also available on DC website). Visit DC’s online News Room at www.dietitians.ca. See campaign profile in March issue of Chatelaine. 2002 National Nutrition Month Campaign 9 Dietitians of Canada Resources for Consumers Consumer Factsheets/Brochure Set of 4 factsheets, available on DC website, which include healthy food choices tips and recipes: 1) Do You Know Your ABCs? 2) Up the Anti-oxidants 3) “B” Smart with Your Food 4) Calcium Counts Registered Dietitians - Your professional for food, diet and nutrition information. Highlights dietitians services and qualifications as well as how to find a dietitian. Cookbooks Dietitians of Canada Cook Great Food published by Robert Rose (2002) - a collection of 450 delicious recipes that offer tasty choices for everyday family meals, entertaining and quick, light meals. Dietitians of Canada Great Food Fast written by Bev Callaghan RD and Lynn Roblin RD and published by Robert Rose (2000). Website (www.dietitians.ca/eatwell) Nutrition Challenge – invite your clients and colleagues to take the challenge and enter a draw to win a copy of DC’s newest cookbook Cook Great Food. Visit the Virtual Kitchen to sample recipes from DC’s newest cookbook Cook Great Food. Visit the Nutrition Profile, Meal Planner, and Healthy Body Quiz to assess your food choices, body weight and activity level. Visit FAQ’s and Factsheets for other healthy eating topics. 2002 National Nutrition Month Campaign 10 Dietitians of Canada Nutrition Month Campaign Ideas Here are some campaign ideas for planning Nutrition Month events in your worksite or community. Remember to post your events on the “Calendar of Events” form found on the members’ side of Dietitians of Canada (DC) website www.dietitians.ca and let your regional representative know. Goals: • Increase your community’s awareness of the 2002 Nutrition Month theme and messages on “The ABCs of Healthy Eating”. • Increase your community’s awareness of the importance of healthy eating and ways to achieve healthy eating. • Increase your community’s awareness of healthy eating resources and how to access a dietitian. • Promote www.dietitians.ca. • Profile campaign corporate partners that make this event possible each year. Strategies: • Email daily or weekly nutrition tips and recipes to clients or staff members. Attach consumer factsheets (available in pdf format on DC website). • Include healthy eating tips and recipes in staff newsletters, on bulletin boards, or as handouts. Distribute handouts to clients or make available in cafeteria or waiting areas. • Copy factsheets and/or recipes to include on patient trays or send out with pay cheques. • Feature Cook Great Food recipes in cafeteria and distribute recipes. • Connect with local media to encourage stories and coverage of your events. Your Regional Representative can offer guidance. • Cook up a recipe from Cook Great Food or Great Food Fast and deliver it to local radio DJ or television host in time for the dinnertime or rush hour news. • Host noon hour “Lunch & Learn” nutrition discussions. • Organize Nutrition Month proclamations with local politicians. Use the guide on DC web site. • Organize a contest for staff or community and offer an hour consultation with a dietitian as a prize. • Organize cooking demonstrations in your workplace or community. Invite local media personalities to do the cooking! • Plan grocery store information sessions, tours and tasting - highlight food sources and recipes for key nutrients. • Have a contest in your cafeteria - for example, name two items on today’s menu that provide certain key nutrients (i.e. calcium). Give away copies of Cook Great Food or Great Food Fast as prizes. • Post Nutrition Month posters in prominent places in cafeterias, waiting areas, community centres, schools, libraries, etc. • Look for opportunities to build partnerships with other health professionals to extend your reach in promoting healthy eating i.e. pharmacists, public health nurses, school teachers, community recreation leaders, etc. • Provide “skill-testing ABC’s questions” to local radio hosts to use on their morning program – callers get their name entered into a draw at the end of the month for a copy of Cook Great Food or Great Food Fast. • Include nutrition tips on pay stubs or email messages. • Copy consumer factsheets and deliver to libraries, schools and recreation facilities for their staff and community bulletin boards. Include information on dietitians in your community they can contact for more information, speakers, events, etc. • Set up a computer in waiting areas or cafeteria and introduce consumers to the public side of DC’s website – there’s lots to explore including the Nutrition Challenge, Virtual Kitchen, Nutrition Profile, Meal Planner, Healthy Body Quiz, FAQs and Factsheets, plus “Find a Dietitian”. 2002 National Nutrition Month Campaign 11 Dietitians of Canada Keeping on Top of Nutrition Research & News With advancements in technology and the increasing use of the Internet, consumers today have access to more sources of nutrition information than ever before. Health professionals and consumers alike recognize that the information they find is often inaccurate, confusing, or misleading. As a nutrition educator it is up to you to ensure that you are providing the most up-to-date and reliable information to consumers. Here are some ways to keep on top of current nutrition issues: Follow up on leading edge nutrition news and research • Find out what the media are reading on Dietitians of Canada website. Visit DC’s Newsroom at www.dietitians.ca/news/index.html • Find recent research on peer reviewed journals using the University of Bergen’s list of journals www.uib.no/isf/guide/journal.htm, New England Journal of Medicine www.nejm.org, or the Journal of the American Medical Association http://jama.ama-assn.org • Access research papers and track media health and nutrition news through U.S. National Library of Medicine’s Medline www.medportal.com • Search CIDAR at www.dietitians.ca/cfdrresearch to see what dietetic research has been published, or to post an abstract of your own research. • Get daily email updates from Nutrition News Focus www.nutritionnewsfocus.com • Get daily email health clips from Canadians newspapers and medical journals from the Health Services Utilization and Research Commission www.hsurc.sk.ca • Find out what’s new from Health Canada www.hc-sc.gc.ca/english/media/ • Participate in discussions with other dietitians and health professionals. • If you are a DC member, join member-to-member discussions on the “members” side of DC’s website www.dietitians.ca Use and refer consumers to reliable nutrition information web sites • Dietitians of Canada www.dietitians.ca • Canadian Health Network www.canadian-health-network.ca • American Dietetic Association www.eatright.com • Berkeley Nutrition Services – Are you eating right? www.nutritionquest.com/ • Food and Nutrition Internet Index www.fnii.ifis.org • Health Canada - Nutrition Program www.hc-sc.gc.ca/hppb/nutrition • Health Canada - Food Program www.hc-sc.gc.ca/datahpb/datafood • International Food and Information Council Foundation http://ificinfo.health.org • Medline Plus: Vitamins and Minerals www.nlm.nih.gov/medlineplus/vitaminandmineralsupplements.html • National Institute of Nutrition www.nin.ca • National Institute of Health - Office of Dietary Supplements http://ods.od.nih.gov/ • Tuft’s University Nutrition Navigator www.navigator.tufts.edu/index.html 2002 National Nutrition Month Campaign 12 Dietitians of Canada • U.S. National Institute of Health – Medline Plus www.medlineplus.com • USDA - Food and Nutrition Information Centre www.nal.usda.gov/fnic/ Keep current with your consumers • Find out where your consumers get their nutrition information, diets, supplements, herbal remedies, etc. • Check out consumer magazines, Internet sites, popular diets, nutrition fads, nutrition and weight control programs, television and radio shows. • Critique information and share your views with other dietitians through newsgroups or the member-to-member section on the “members” side of DC website www.dietitians.ca. Stay within your area of expertise • Use resources such as the Manual of Clinical Dietetics (6th edition) and Client Education Materials (available to order online on DC’s website www.dieteticsatwork.com). • If necessary, refer consumers/clients to a dietitian who specializes in a topic. Use the “Find a Dietitian” service at www.dietitians.ca. Be critical of your findings • Always check to see if the source of nutrition information is reliable (i.e. produced by accredited organizations, universities, or professionals, backed by valid research, etc.). • Look for websites that subscribe to the HON code principles of the Health on the Net Foundation www.hon.ch/HONcode 2002 National Nutrition Month Campaign 13 Dietitians of Canada Dietary Reference Intakes (DRIs) Background information on Dietary Reference Intakes (DRIs) is presented here so that you can better interpret some of the information being presented in the following sections on “The ABCs of Healthy Eating”. The DRIs are new nutrition recommendations, which expand and replace the RNIs used in Canada and the RDAs used in the United States. They are the most up-to-date scientifically based nutrient recommendations available. The DRIs were developed by the Food and Nutrition Board (FNB) of the National Academy of Sciences www.iom.edu/fnb. DRIs will be established for all nutrients. Some of those that have been examined to date include “Calcium and Bone Related Nutrients”, “Antioxidants”, and “B-Vitamins”. Detailed reports for all of the nutrients released thus far are available from the National Academy Press website http://www.nap.edu. The DRIs include four nutrient intake reference values: The Estimated Average Requirement (EAR) is the nutrient intake value that is estimated to meet the requirement defined by a specified indicator of adequacy in 50% of the individuals in a life stage and gender group. The EAR is not used as a recommended intake for individuals but can be used to assess adequacy of groups. The Recommended Dietary Allowance (RDA) is the average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group. The RDA can be used as an intake goal for individuals. Adequate Intake (AI) is a recommended average daily nutrient intake level based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate. It is used when the RDA cannot be determined and can be considered an intake goal for individuals. The Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. As intake increases above the UL, the risk of adverse effects increases. Because we cannot predict who will react adversely to high intakes, it’s safest if everyone maintains an intake below the UL. The DRIs are intended to apply to healthy populations and do not specifically consider the effects of disease or medication use on nutrient needs. Each DRI refers to the average daily nutrient intake of individuals over time (several days to a week, for example). In most cases, the amount taken daily may vary substantially from day-to-day. Intakes below the RDA or AI do not mean that an individual’s diet does not meet their individual requirement, because the RDA and AI are set at levels thought to exceed the requirement of almost all individuals in an age/sex group. 2002 National Nutrition Month Campaign 14 Dietitians of Canada Health Canada is establishing an advisory committee to evaluate DRI implementation issues from a public health perspective. Once all DRI reports have been published, policies which provide dietary guidance to Canadians will be reviewed. Dietitians and other health professionals are encouraged to become informed of both the science behind the establishment of the new reference values and their appropriate application. The online DRI course offered by Dietitians of Canada is highly recommended to all health professionals who wish to appropriately implement the DRIs in their practice. NEW! Dietitians of Canada’s online professional development course “Dietary Reference Intakes” is now available on the Dietetics @ Work section of DC’s website at www.dieteticsatwork.com. The DRI course includes detailed lessons on: 1) Introduction to DRIs 2) Application of DRIs in Dietary Assessment 3) DRIs for Calcium and Related Nutrients 4) DRIs for B Vitamins, and 5) DRIs for Antioxidants. Three other lessons in the DRI course are planned and will follow as new scientific reports are released. 2002 National Nutrition Month Campaign 15 Dietitians of Canada The ABC’s of Healthy Eating Consumers are interested in the foods they eat and expect health professionals to guide them in their choice of foods and nutrients. A growing interest in the use of vitamin/mineral supplements challenges health professionals to keep up to date in terms of their intended use and safety. The following information will provide health professionals with the information they need to advise clients about “The ABCs of Healthy Eating”. The focus of “The ABCs of Healthy Eating” campaign is on nutrients for which there have been recent Dietary Reference Intake reports published by the National Academy of Sciences http://www.nap.edu. These reports provide the most up-to-date reference for dietitians and other health professionals on nutrient requirements and safety. The reports used to develop the ABCs of Healthy Eating Campaign include: • Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids (2000). • Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998). • Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997). • Dietary Reference Intakes - Applications in Dietary Assessment (2000). The DRI report on Dietary Planning should be available soon and will be an important resource for health professionals. Dietary Reference Intake (DRI) tables which provide “Recommended Intakes for Individuals” and “Tolerable Upper Intake Levels” for all vitamins and minerals released to date can be found on the “members” side of the DC website at: www.dietitians.ca/members_only/drinew.asp The information provided in this manual is aimed at the health professional. The goal is not to educate consumers about DRIs, nor encourage them to start trying to calculate nutrient intakes. Consumers see and hear lots of information in the marketplace about antioxidants, calcium, specific vitamins and nutrients, and other food constituents. This manual is intended to provide background information on “The ABCs of Healthy Eating” so that you can provide consumers with clear and consistent messages, from a trusted source, and help consumers make wise food and supplement decisions. PLEASE NOTE: The RDAs and AIs presented in the following charts are intake goals for individuals. They should NOT be used to compare nutrient intake data in populations or groups! The EAR is the appropriate DRI to use when assessing the adequacy of group intakes, with the percentage below the EAR reflecting the prevalence of dietary inadequacy. For more information on the appropriate use of DRIs refer to the report Dietary Reference Intakes: Applications in Dietary Assessment (2000) published by the National Academy of Sciences www.nap.edu. Dietitians of Canada’s new online professional development course “Dietary Reference Intakes” will also help you learn how to apply the DRIs correctly in your practice. 2002 National Nutrition Month Campaign 16 Dietitians of Canada ANTIOXIDANTS…Vitamin C, E, Selenium and Carotenoids Antioxidants - RDAs and Tolerable Upper Intake Levels (UL) for Adults 19 + Nutrient Vitamin C Recommended Dietary Allowance (RDA) 75 mg/day females 90 mg/day males add 35 mg/day for smokers 15 mg/day Tolerable Upper Intake Level (UL) 2000 mg/day Vitamin E (as ∝-tocopherol) Selenium B-carotene 1000 mg/day* 55 µg No recommendation at this time due to contradictory data 400 µg/day No UL set at this time due to contradictory data Vitamin E: UL applies to synthetic forms of ∝-tocopherol obtained from supplements, fortified foods, or a combination of the two. * Source: Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals: Vitamins, Elements, and Tolerable Upper Intake Levels, National Academy of Sciences, 2001 and Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and B-carotene, and other Carotenoids. National Academy of Sciences, 2000. Key Consumer Messages on Antioxidant Nutrients: Aim to include plenty of antioxidant-rich vegetables, fruits and whole grains in your meal plans each day. Vitamins C, E and selenium have been identified as antioxidant nutrients which play an important role in health maintenance, and possibly, in disease prevention. In addition, other compounds with antioxidant potential, including B-carotene and carotenoids such as lycopene and lutein, are being studied for their roles in human health. All of these antioxidants are easy to get in the foods you enjoy eating. Antioxidants are substances that help counter the adverse effects of free radicals. Free radicals are formed as a result of oxidation at the cellular level in the body. Free radicals can cause damage to cell walls and structures within cells and are believed to play a role in the development of health problems such as heart disease, cancer, cataracts, and some deterioration associated with aging. This is an area of active research, and to date, conclusive evidence that antioxidant nutrients prevent these diseases has not been obtained. Currently, a large number of human intervention studies are underway, and the results of these studies may give rise to a new understanding of the role of antioxidants in chronic disease.4 A diet such as the DASH Diet (Dietary Approaches to Stop Hypertension ) that is high in vegetables and fruit (8-10 servings per day), but low in saturated and total fat, and cholesterol, in combination with 3 servings of low-fat dairy products has been shown to reduce risk of hypertension, reduce homocysteine levels, and reduce levels of total cholesterol and low-density lipoprotein.5 6 7 A recent study on the “Food Habits of Canadians” aged 18 to 65 years found that intake of servings from the Vegetables & Fruit group was low, particularly among women and men over 50. Average daily 2002 National Nutrition Month Campaign 17 Dietitians of Canada servings from Vegetables & Fruit group was 5.2 for men and 4.6 for women. Average intake of Grain Products was also low for women age 18-65 at 4.9 servings per day but men in the same age category were getting 6-9 servings per day.8 For more information on the function and food sources of antioxidants refer to the chart on page 21. Vitamin C Vitamin C is often taken in amounts higher than recommended for its perceived health benefits related to immunity and disease reduction. While it may have a positive effect on the duration and severity of symptoms, it does not prevent colds. Reviews of numerous studies generally conclude that mega doses of vitamin C have no significant effect on incidence of the common cold, but do provide a moderate benefit in terms of duration and severity in some groups. While several studies have reported an inverse correlation between vitamin C intake and cardiovascular disease, some types of cancer, and cataracts, other studies have failed to do so. To date, no experimental studies have demonstrated a clear role of vitamin C in the prevention of these diseases.9 For most Canadians vitamin C supplements do not appear to be necessary. The best way to get vitamin C is by eating plenty of vitamin C rich foods such as fruits and vegetables. Aim for 5 to 10 servings of fruits and vegetables daily. Some key sources of vitamin C include citrus fruits and their juices, kiwi fruit, strawberries, red and green peppers, broccoli and tomatoes. Canada’s Food Guide to Healthy Eating recommends 5-10 servings of fruits and vegetables a day. Five servings of most fruits and vegetables provide more than 200 mg of vitamin C per day.10 Vitamin C supplements can be found in amounts of 250 – 1000 mg/pill and even amounts as high as 5000 mg/pill. Consumers who supplement may forget to consider that they also get vitamin C from food sources as well. The Tolerable Upper Intake Level (UL) for vitamin C for adults is 2000 mg per day. Intakes of vitamin C above the UL may cause diarrhea and gastrointestinal problems.11 For more information about vitamin C supplements refer to the “Efficacy and Safety Summary Table for Dietary Supplements”. Manual of Clinical Dietetics (6th edition), American Dietetic Association Dietitians of Canada. Appendix 12. p. 841-852. 2000. Individuals who smoke require higher amounts of vitamin C. Research has shown that the metabolic turnover (and therefore recommended intake) of ascorbate in smokers is about 35 mg/day greater than in non smokers, apparently due to increased oxidative stress and other metabolic factors.12 Vitamin E Vitamin E has been promoted extensively to help improve heart health but research is not conclusive and high intakes are not warranted. Epidemiological research suggests that high intakes of vitamin E are associated with lower risk of some chronic diseases, especially heart disease. However limited and discordant clinical trial evidence precludes recommendations at this time of higher vitamin E intakes to reduce heart disease.13 2002 National Nutrition Month Campaign 18 Dietitians of Canada For most Canadians vitamin E supplements do not appear to be necessary. The best way to get vitamin E is by including foods containing vitamin E in your daily food choices such as vegetable oils, wheat germ, peanut butter, nuts, seeds and leafy greens. Deficiencies of vitamin E are very rare and are typically seen only in individuals unable to absorb the vitamin or with inherited abnormalities that prevent the maintenance of normal blood concentrations.14 The main dietary sources of vitamin E are edible vegetable oils. At least half of the tocopherol content of wheat germ oil, sunflower oils, cottonseed oil, safflower oil, canola oil, and olive oil is in the form of ∝tocopherol, which is the biologically active form of vitamin E.15 The RDA is now based only on the ∝-tocopherol form of vitamin E, which is a change from previous recommendations that included beta, gamma and other forms of vitamin E. It should be noted, however, that tables of food composition likely provide the latter value, called a TE (tocopherol equivalent) and thus overestimate the vitamin E content of the overall diet by 20%.16 The Tolerable Upper Intake Level (UL) for vitamin E is 1000 mg/day for adults 19 years and over. The UL applies to synthetic forms obtained from supplements, fortified foods of a combination of the two. The UL is based on the adverse effect of increased tendency to hemorrhage. There is no evidence of adverse effects from the consumption of vitamin E occurring in food.17 For more information about vitamin E supplements refer to the “Efficacy and Safety Summary Table for Dietary Supplements”. Manual of Clinical Dietetics (6th edition), American Dietetic AssociationDietitians of Canada. Appendix 12. p. 841-852. 2000. Selenium Canadians can get adequate amounts of selenium in their diet. High doses of supplements are toxic. Key food sources of selenium include Brazil nuts, meat, fish and poultry. Grains, dairy products and legumes provide moderate amounts. Individuals who eat vegetarian diets consisting of plants grown in areas where the soil contains little selenium are most at risk of low selenium intakes. In the United States and Canada the extensive transport of food from region to region prevents low-selenium geographic areas from having low dietary selenium intakes.18 The risk of selenium intake above the Tolerable Upper Intake Level (UL) from food by Canadian and U.S populations appears to be small. In North America the greater risk is for selenium toxicity from taking supplements above the UL.19 The Tolerable Upper Intake Level (UL) for selenium is 400 µg/day for adults 19 and over. The UL was based on selenosis as the adverse effect. The most frequently reported features of selenosis (chronic toxicity) are hair and nail brittleness and loss . Other signs include gastrointestinal disturbances, skin rash, garlic breath odor, fatigue, irritability, and nervous system abnormalities.20 There is a narrow range between beneficial and tolerable levels for selenium. For example, there is only an 8-fold range compared to ~66-fold range for vitamin E and 20-fold range for vitamin C (RDA vs UL). 2002 National Nutrition Month Campaign 19 Dietitians of Canada B-carotene and other carotenoids Carotenoids have been associated with various health effects including decreased risk of some cancers, heart disease, macular degeneration and cataracts. While there is consistent evidence for these potential health benefits, this may be due to other substances found in carotenoid-rich food or other behaviours associated with increased fruit and vegetable consumption. Numerous epidemiological studies have shown that individuals who consume a relatively large quantity of carotenoid-rich fruit and vegetables have a lower risk of cancer at several tumor sites, particularly lung cancer. Intakes of tomato-based foods (tomato sauce, tomatoes, and pizza) and lycopene, which is found predominantly in tomato products, was associated with significantly lower prostate cancer risk.21 Epidemiological studies suggest that carotenoid- and B-carotene-rich diets are associated with reduced risk of cardiovascular disease. 22 Dietary carotenoids have also been suggested to decrease the risk of age-related macular degeneration, the most common cause of irreversible blindness in people over age 65 in the United States, Canada and Europe. 23 Higher dietary intake of carotenoids or higher blood concentrations of carotenoids have been found to be inversely associated with the risk of various forms of cataract in some, but not all studies.24 A specific clear function of certain carotenoids that is firmly linked to health outcomes is the provitamin A activity of some dietary carotenoids (∝-carotene, B-carotene, and B-cryptoxanthin) and their role in prevention of vitamin A deficiency. These carotenoids can be converted into retinol and are referred to as provitamin A carotenoids.25 Lycopene, lutein, and zeaxanthin have no vitamin A activity and are referred to as nonprovitamin A carotenoids.26 Canadians can get adequate amount of B-carotene and other carotenoids from food . Foods rich in Bcarotene and other carotenoids include dark orange or red coloured vegetables and fruit such as carrots, sweet potatoes, pink grapefruit, and tomato sauce. Aiming for 5-10 servings of vegetables and fruit will increase intakes of B-carotene and other carotenoids. No DRIs are available for B-carotene and other carotenoids at this time due to contradictory data. However, existing recommendations for consumption of five or more servings of fruits and vegetables per day are supported because this would provide 3 to 6 mg/day of B-carotene.27 Nutrient analysis of menus adhering to the U.S. Dietary Guidelines and the National Cancer Institute’s Five-a-Day for Better Health Program, indicates that persons following these diets would be consuming approximately 5.2 to 6.0 mg/day provitamin A carotenes on average if a variety of fruits and vegetables were consumed.28 Similar levels would be obtained by following Canada’s Food Guide to Healthy Eating, which specifies a minimum of five servings of vegetables and fruit daily.29 Because B-carotene supplements have not been shown to confer any health benefits for the prevention of the major chronic diseases and because they can be harmful to some people, they are not recommended. Some research has shown that B-carotene supplements (not B-carotene rich foods) may cause adverse effects in smokers but the studies are conflicting. The results of ongoing studies may help resolve this issue. There also appears to be a relationship between the adverse effects of B-carotene and both 2002 National Nutrition Month Campaign 20 Dietitians of Canada smoking and alcohol consumption in the ATBC Cancer Prevention Study and Carotene and Retinol Efficacy Study (CARET), a multi-center lung cancer prevention trial.30 B-carotene in the form of supplements has a much higher bioavailability than B-carotene from foods.31 When food sources of carotenoids are consumed there are no adverse effects other than harmless carotenodermia (yellowish discoloration of the skin caused by high intakes of carotene) or lycopenodermia (deep orange discoloration of the skin from high intakes of lycopene-rich foods such as tomatoes).32 No Tolerable Upper Intake Level (UL) has been set at this time due to contradictory data. For more information about B-carotene supplements refer to the “Efficacy and Safety Summary Table for Dietary Supplements”. Manual of Clinical Dietetics (6th edition), American Dietetic AssociationDietitians of Canada. Appendix 12. p. 841-852. 2000. Functions and Food Sources of Antioxidants Nutrient Vitamin C Function • Acts as an antioxidant to help reduce oxidative stress. • Aids in iron absorption. • Maintains connective tissue (collagen) which holds muscles, bones and tissues together. • Helps heal cuts and wounds and keep gums healthy. • Maintains strong blood vessel walls. • Acts as an antioxidant to help reduce oxidative stress. Food Sources Oranges and orange juice, grapefruit and grapefruit juice, apple juice, kiwi fruit, strawberries, red, yellow and green peppers, broccoli, Brussels sprouts, potatoes, and tomatoes. Vitamin E Sunflower seeds, nuts, vegetable oils, sweet potato, papaya, peanut butter, avocados, sweet potatoes, and wheat germ. Brazil nuts, fish, shellfish, meat, poultry, eggs, beans, grain products and whole grains. Selenium • Functions as a component of selenoprotein oxidant defense enzymes. These defend against oxidative stress caused by oxygen derived compounds. • Regulation of thyroid hormone action. • Regulation of the redox status of vitamin C and other molecules. Carotenoids • ∝-carotene, B-carotene, and B-cryptoxanthin provide a source of ∝-carotene, B-carotene, B-cryptoxanthin, lycopene, vitamin A and help prevent vitamin A deficiency (which can increase lutein, and zeaxanthin susceptibility to infectious diseases and vision problems). Dark orange vegetables such as carrots, sweet potatoes, pumpkin, cantaloupe, pink grapefruit, tomatoes and tomato products, broccoli, and dark green leafy vegetables including spinach, beet greens, Swiss chard, and kale. Foods listed are all a source of nutrients (5% RNI) but in most cases provide 10% or more of the highest RDA/AI for adults. • Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, National Academy of Sciences, 2000. www.nap.edu • Nutrient Value of Some Common Foods, Health Canada, 1999. www.hc-sc.gc.ca/food-aliment/ • USDA Nutrient Database for Standard Reference, Release 14 www.nal.usda.gov/fnic/etext/000020.html 2002 National Nutrition Month Campaign 21 Dietitians of Canada B- VITAMINS Selected B-Vitamins - RDAs and Tolerable Upper Intake Levels (UL) for Adults 19+ Nutrient Thiamin Recommended Dietary Allowance (RDA) 1.1mg/day females 1.2 mg/day males 1.1mg/day females 1.3 mg/day males 14 mg/day females 16 mg/day males 1.3 mg/day 19-50 1.5 mg/day 51 + females 1.7 mg/day 51+ males 2.4 µg/day 400 µg/day Tolerable Upper Intake Level (UL) No UL established Riboflavin No UL established Niacin 35 mg/day Vitamin B6 100 mg/day as pyridoxine Vitamin B12 Folate No UL established 1000 µg/day Niacin: As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan. UL applies only to supplemental niacin or niacin in fortified foods. Folate: As dietary folate equivalents (DFE). 1 DFE= 1 µg food folate = 0.6 µg folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach. UL applies only to folic acid consumed as supplements or in fortified foods. In view of evidence linking folate intake with neural tube defect in the fetus, it is recommended that all women capable of becoming pregnant consume 400 ug from a multivitamins/multiminerals supplements in addition to intake of food folate from a varied diet. Vitamin B12: Because 10 to 30 percent of older people may malabsorb food-bound B12, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12. Source: Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals: Charts for Vitamins, Elements, and Tolerable Upper Intake Levels, National Academy of Sciences, 2001 and Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998). The DRI report focuses on the eight B-complex vitamins - thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, and biotin, and choline. This Nutrition Month manual does not address pantothenic acid, biotin and choline because there is no evidence to support issues of risk with these vitamins. Key Messages for Consumers on B-Vitamins: Thiamin, riboflavin, niacin, vitamin B6, vitamin B12 and folate are all B-vitamins, which perform a variety of essential functions in your body. B vitamins including thiamin, riboflavin, niacin, vitamin B6, vitamin B12, and folate are all enzyme cofactors involved in a variety of different metabolic functions (refer to chart on page 25). 2002 National Nutrition Month Campaign 22 Dietitians of Canada For example: folate and vitamin B12 act together in DNA synthesis which is important for cell development; riboflavin, vitamin B6, vitamin B12, folate are involved in normal blood cell formation; vitamins B6 and B12 are involved in neurological function. Most Canadians can get adequate amounts of B-vitamins from food. Each of the four food groups in Canada’s Food Guide to Healthy Eating provides different B-vitamins so include a variety of foods from each food group. Grain products provide thiamin, riboflavin, niacin and folate; vegetables and fruit, and grain products fortified with folic acid provide folate; milk, cheese, and other milk products provide riboflavin and vitamin B12; meat and alternatives provide thiamin, riboflavin, niacin and vitamins B6 and B12, and meat alternatives such as beans, lentils, nuts, and peanut butter provide folate (refer to chart of page25). Consumers can get the B-vitamins they need by consuming daily: 5-12 servings of Grain Products; 5-10 servings of Vegetables and Fruit; 2-4 servings of Milk Products; and 2-3 servings of Meat & Alternatives. B-vitamin supplements are not necessary for most Canadians with the exception of folic acid for pregnant women and women capable of becoming pregnant. People over the age of 50 and vegans who avoid animal products may need a Vitamin B12 supplement. Folic Acid To reduce risk of neural tube defects for women capable of becoming pregnant, the recommendation is to take a daily multi vitamin/mineral supplement containing 0.4 mg (400 ug) of folic acid and to eat a healthy diet that includes folate containing foods. The critical time for supplementation is at least one month prior to conception and continuing through the first trimester of pregnancy . Foods containing folate include cooked beans, chickpeas, lentils, dark leafy greens, cooked spinach, asparagus, broccoli, corn, green peas, oranges and orange juice, canned pineapple juice, honeydew melon, cantaloupe, nuts and sunflower seeds, peanut butter, wheat germ and fortified breads, cereals, and pasta. For more information about folic acid and pregnancy refer to: • Health Canada Update on Reducing the Risk of Neural Tube Defects http://www.hcsc.gc.ca/hppb/nutrition/factsheets/fs_folic_acid.html • Nutrition for a Healthy Pregnancy - National Guidelines for the Childbearing Years http://www.hcsc.gc.ca/hppb/nutrition/pube/pregnancy/e_index.html Addition of folic acid to white flour and pasta products labelled “enriched” became mandatory as of November 1998 in Canada (e.g. 0.15 mg folic acid/100mg white flour, enriched flour, enriched white flours; 0.27 mg folic acid/100 mg enriched pasta).33 As a result of fortification average intake of folate is expected to increase by about 80 to 100 µg/day (130 to 165 µg DFE/day) for women and by more for men.34 No adverse effects have been associated with the consumption of the amounts of folate normally found in fortified foods. The Tolerable Upper Intake Level (UL) for adults is set at 1,000 µg/day of folate from fortified food or as a supplement, exclusive of food intake. Intake at this level may mask a B12 deficiency (especially in those at risk of B12 deficiency e.g. older adults, vegans who eat no animal foods).35 2002 National Nutrition Month Campaign 23 Dietitians of Canada Thiamin There are no reports available of adverse effects from consumption of excess thiamin from ingestion of food and supplements. Because of inadequate data no Tolerable Upper Intake Level (UL) has been established. Supplements that contain up to 50 mg/day of thiamin are widely available but the possible occurrence of adverse effects resulting from this level or more of intake appears not to have been studied systematically.36 Niacin There is no evidence of adverse effects from the consumption of naturally occurring niacin in foods. The Tolerable Upper Intake Level (UL) was based on evidence concerning intake of niacin as a supplement, food fortificant or pharmacological agent. Flushing is the first adverse effect observed after excess niacin intake and this was used as a basis to set the UL for niacin at 35 mg/day.37 Riboflavin No adverse effects are associated with riboflavin consumption from food or supplements have been reported. Studies using large doses of riboflavin have not been designed to systematically evaluate adverse effects. Therefore evidence on adverse effects was not sufficient to set a Tolerable Upper Intake Level (UL).38 Vitamin B6 No adverse effects have been associated with high intake of vitamins B6 from food sources. Large oral supplemental doses of pyridoxine to treat conditions (e.g. carpal tunnel syndrome and premenstrual syndrome) have been associated with sensory neuropathy and dermatological lesions.39 Long term use of very high doses (500 to 5000 g/day) of vitamin B6 is associated with nerve damage.40 The Tolerable Upper Intake Level (UL) is set at 100 mg/day of vitamin B6 as pyridoxine. The UL was based on sensory neuropathy as the critical endpoint.41 Vitamin B 12 Ten to thirty percent of people older than older 50 years are estimated to have atrophic gastritis with low stomach acid secretion, and may have decreased bioavailability of vitamin B 12 from foods. Therefore, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12.42 43 Vegetarians who do not consume any animal products may be at risk of B12 deficiency.44 Vegans who eat no animal products may need a supplement. In Canada, there are very few vitamin B12 fortified foods, except those intended primarily for those on vegan diets. No adverse effects have been associated with excess vitamin B12 intake from food or supplements in healthy individuals. There was not sufficient scientific evidence to set a Tolerable Upper Intake level (UL) for vitamin B12 at this time.45 2002 National Nutrition Month Campaign 24 Dietitians of Canada Functions and Food Sources of Selected B-Vitamins Nutrient Thiamin (vitamin B1) Function • Plays a role in carbohydrates and energy metabolism • deficiency can cause weakness, nerve damage, and beriberi (characterized by polyneuritis, cardiovascular symptoms, and gastrointestinal disorders) • Functions as a catalyst in many reduction/oxidation (redox) reactions many of which are important in energy metabolism. • Involved in the metabolism of other B vitamins. • Deficiency can cause mouth, throat, skin and blood conditions, deficiency usually associated with other nutrient deficiencies. • Functions as a catalyst in many reduction/oxidation (redox) reactions many of which are important in energy metabolism. • Important in formation of DNA and cell growth, and mobilization of intracellular calcium. • Deficiency causes pellagra (characterized by skin and digestive problems and mental impairment) • Coenzyme in many chemical reactions involving amino acid metabolism. • Involved in hemoglobin synthesis. • Involved in neurotransmitter synthesis (which may account for finding that convulsions and depression are symptoms of deficiency). • Acts with folate in DNA synthesis and cell formation, including red blood cells. • Helps prevent demyelination of the nervous system. • Deficiency may cause pernicious anemia vegans (low intakes) and and the elderly (low absorption) are at risk. • Acts with Vitamin B12 in DNA synthesis and cell formation, including red blood cells. • Helps lower risk of birth defects such as spina bifida. • Deficiency may result in macrocytic anemia. • Inadequate intake of folate, vitamin B6 and vitamin B12 can contribute to an increase in homocysteine level which is associated with heart disease. 25 Food Sources Enriched breads, cereals and pasta, pork products, green peas, dried beans (kidney, navy and soybeans), lentils, and nuts. Riboflavin (vitamin B2) Milk, cheese and other milk products, meat, eggs, nuts, green peas and cooked spinach, beans (navy and soybeans), lentils, enriched breads, cereals and pasta. Niacin (vitamin B3) Meat, fish, poultry, milk, cheese, peanuts, peanut butter, beans (kidney, navy, soybeans, chick peas), corn, green peas, enriched breads, cereals, and pasta. Pyridoxin (vitamin B6) Meat, fish, poultry, organ meats, enriched cereals, beans (kidney, navy, soybeans, chick peas), lentils, potatoes, bananas, and watermelon. Cobalamin (vitamin B12) Found only in animal products such as meat, fish, poultry, eggs, milk, cheese and milk products. Foods fortified with B12, such as soy and rice beverages, and soy-based meat substitutes. Folate Liver, cooked beans (kidney, navy, soybeans, chick peas), lentils, asparagus, cooked spinach, romaine lettuce, Brussels sprouts, beets, broccoli, corn, green peas, oranges and orange juice, canned pineapple juice, honeydew melon and cantaloupe, sunflower seeds, nuts, peanut butter, wheat germ, and enriched bread, cereals and pasta. 2002 National Nutrition Month Campaign Dietitians of Canada Foods listed are all a source of nutrients (5% RNI) but in most cases provide 10% or more of the highest RDA/AI for adults. • Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, 1998. • Nutrient Value of Some Common Foods, Health Canada, 1999. . www.hc-sc.gc.ca/food-aliment/ • USDA Nutrient Database for Standard Reference, Release 14 www.nal.usda.gov/fnic/etext/000020.html CALCIUM AND OTHER RELATED BONE HEALTH NUTRIENTS Calcium and Other Related Bone Health Nutrients - RDAs/AIs and Tolerable Upper Intake Levels (UL) for Adults 19+ Nutrient Calcium RDA or Adequate Intake (AI) 1000 mg/day (ages 19-50) AI 1200 mg/day (ages 51+) AI 700 mg/day (ages 19 +) Tolerable Upper Intake Level (UL) 2500 mg/day Phosphorus 4 g/day (19-70y) 3 g/day (>70y) 350 mg/day Magnesium 310 mg/day (ages 19-30 females) 320 mg/day (ages 31+ females) 400 mg/day (ages 19-30 males) 420 mg/day (ages 31+ males) 5 µg/day (ages 31-50y) AI 10 µg/day (ages 51-70y) AI 15 µg/day (ages 70y +) AI 3 mg/day AI (females) 4 mg/day (males) Vitamin D 50 µg/day Fluoride 10 mg/day Calcium, Vitamin D and Fluoride are presented as Adequate Intake (AI). Vitamin D: Cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D Vitamin D recommendation in the absence of adequate exposure to sunlight. Magnesium: The UL for magnesium represents intake from a pharmacological agent only. Source: Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals: Charts for Vitamins, Elements, and Tolerable Upper Intake Levels, National Academy of Sciences, 2001.Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997). Key Consumer Messages on Calcium and Other Related Bone Health Nutrients Calcium works together with other bone-building nutrients (Vitamin D, phosphorus, magnesium, fluoride) to develop strong and healthy bones and teeth. Including a variety of foods that provide these bone-building nutrients is important. 2002 National Nutrition Month Campaign 26 Dietitians of Canada The role of these nutrients in the development and preservation of bone mass was key in terms of determining the criteria on which to base the new DRIs. Protein also works with these nutrients to build and maintain strong bones. For more information on the function and food sources of calcium and bone health nutrients refer to the chart on page 30. Calcium is an important bone-building nutrient. An adequate intake of calcium throughout life, along with regular activity, is essential to build and maintain strong bones and prevent osteoporosis. Osteoporosis is characterized by reduced bone mass, increased bone fragility, and increased risk of fracture. One in 4 women and 1 in 8 men suffer from osteoporosis in Canada.46 Women are at greater risk because they have less bone tissue and because diminished estrogen at menopause accelerates bone loss.47 Peak bone mass is achieved between the ages of 19 and 30, depending on which bone site is considered. Bone density and strength are highest at the time of peak bone mass, after which time the process is reversed and calcium is gradually lost from bone.48 Eating calcium-rich foods and regular physical activity, especially weight-bearing exercises, can help maintain bone mass and strength. Including milk and milk products in your daily diet is an easy way to ensure that you meet the recommended amount of calcium. Milk and milk products like cheese and yogurt provide the most readily available source of calcium and other bone-building nutrients. Other foods such as calcium-fortified beverages (soy, rice and orange juice), tofu made with calcium sulfate, salmon and sardines with bones, sesame seeds, and almonds also contribute to calcium intakes (see chart on page 30). Some vegetables such as bok choy, kale and broccoli provide calcium but in smaller amounts. Canada’s Food Guide to Healthy Eating recommends 2-4 servings of milk products per day. Two servings of milk and milk products provides approximately 600 mg calcium. With the revised recommended intake (AI) of 1000 mg for adults 19-50 years of age and 1200 mg for adults over 51 years, it is desirable to aim for the middle to upper end of the 2-4 servings range. As with all food choices it’s best to choose a variety of calcium-rich foods. A recent study on the “Food Habits of Canadians” aged 18 to 65 years found the average number of servings per day from the Milk Products group was 1.8 for men and 1.4 for women. Intake decreased in both sexes with age, more so in women than men.8 Canada’s Food Guide to Healthy Eating recommends 2-4 servings of Milk Products per day. Those individuals who consumed the most milk products met their requirement for calcium. Calcium can be poorly absorbed from some foods, particularly those high in oxalic acid (spinach, sweet potatoes, rhubarb, and beans) or phytic acid (unleavened bread, raw beans, seeds, nut and grains, and soy isolates). Soybeans contain large amounts of phytic acid, yet calcium absorption is relatively high from this food. 49 Calcium from fortified soy beverages was found to be 25% less bioavailable than calcium in milk.50 High intakes of sodium may increase calcium excretion. The DRI report determined that available evidence did not warrant different calcium intake requirements for individuals according to their salt consumption. 2002 National Nutrition Month Campaign 27 Dietitians of Canada Protein increases urinary calcium excretion, but its effect on calcium retention is controversial. The DRI report determined that available evidence did not warrant adjusting calcium intake recommendations based on dietary protein intake. It should be recognized that inadequate protein intakes (34g/day) have been associated with poor general health and poor recovery from osteoporotic hip fractures.51 Caffeine has a modest negative impact on calcium retention. The negative effect of caffeine on bone mass density can be offset by the addition of dietary calcium.52 Some Canadians, particularly people who have allergies or who do not regularly consume milk products may benefit from taking a calcium supplement. Consumers who do not include milk products in their diet should consult with a Registered Dietitian or physician. Food allergies, low intake of dairy products, and following a strict vegetarian diet prevent some individuals from getting the recommended calcium. Those who have been diagnosed by a physician with lactose intolerance can usually enjoy two cups of milk a day without side effects. Lactose free milk is also available. Some people with lactose intolerance can re-condition their digestive systems to accept dairy foods without discomfort by including smaller quantities of milk with meals or other foods and spread throughout the day.53 Excess calcium intake primarily concerns nutrient supplements. There is some evidence of a slightly increased risk of kidney stone formation with calcium supplements, but not food in both men and women. It is the binding of dietary calcium with oxalate in the intestine that reduces risk of kidney stones. When taken without food, calcium supplements might not benefit from this. The syndrome of hypercalcemia and renal insufficiency with and without alkalosis (milk-alkali syndrome MAS), and the interaction of calcium with the absorption of other essential minerals are some potential adverse effects of calcium intakes above the Tolerable Upper Intake Level.54 The Tolerable Upper Intake Level (UL) for calcium is set at 2500 mg/day for adults 19 and over. This UL was based on risk of MAS.55 Phosphorus Phosphorous is found in a variety of foods particularly those included in the Milk Products and Meat & Alternatives groups of Canada’s Food Guide to Healthy Eating. Supplements do not appear to be necessary. For food sources of phosphorus refer to the chart on page 30. No reports exist of untoward effects following high dietary phosphorus intakes in humans. Essentially all instances of dysfunction (and, hence, all instances of hyperphosphatemia) in humans occur for nondietary reasons (e.g. end-stage renal disease, vitamin D intoxication). Therefore, data on the normal adult range for serum Pi are used as the basis for deriving the UL for adults.56 The Tolerable Upper Intake Level (UL) for phosphorus is 4 g/day for adults 19-70 years of age and 3 g/day for adults over 70 years of age. Magnesium Foods from all four food groups in Canada’s Food Guide to Healthy Eating provide magnesium. Key sources include cooked beans and lentils, nuts and seeds, and leafy green vegetables. Food sources of magnesium are listed in the chart on page 30. 2002 National Nutrition Month Campaign 28 Dietitians of Canada Magnesium, when ingested as a naturally occurring substance in foods, has not been demonstrated to exert any adverse effect. However, adverse effects of excess magnesium intake have been observed with intakes from nonfood sources such as various magnesium salts used for pharmacologic purposes.57 While there is interest in how magnesium can prevent many chronic diseases, there is no evidence that Mg supplementation is necessary.57 Magnesium can be found in some calcium supplements but contrary to some promotional materials Mg is not required for calcium absorption.58 59 The Tolerable Upper Intake Level (UL) is set at 350 mg/day and is based on risk of diarrhea with high intakes. This represents acute intake from a pharmacological agent only and does not include intake from food and water.60 Vitamin D Vitamin D is found only in a few foods including fish liver oils, fatty fish, and foods fortified with vitamin D such as milk and margarine. Some people may benefit from vitamin D supplements especially the elderly who have little exposure to sunlight. The major source of vitamin D for humans is exposure of the skin to sunlight. Aging significantly decreases the capacity of human skin to produce vitamin D3. An increase in skin melanin pigmentation or the use of sunscreen will also reduce the production of vitamin D3 in the skin.61 Between the months of October and March in Canada vitamin D synthesis in the skin is very limited.62 Also, the elderly who do not get much exposure to sunlight, due to excess clothing or because they are house-bound, are at greater risk for vitamin D deficiency. There is strong evidence that the elderly are at high risk for vitamin D deficiency, which exacerbates osteoporosis, resulting in increased risk of fractures. Aging significantly decreases the capacity of human skin to produce vitamin D3 as well as decreases kidney function which is involved in converting 25(OH)D to1,25 (OH)2D, the hormone form. 63 64 The Tolerable Upper Intake Level (UL) for Vitamin D is 50 ug (2000 IU) per day for adults 19 and over. The UL is was based on risk of hypercalcemia.65 Fluoride People who live in areas with low water fluoride may need a supplemental intake of fluoride. Fluoride intake varies according to the fluoride content of the local drinking water. Naturally occurring concentrations range from <0.3 mg/L to over 4.0 mg/L. When fluoride is added to water a concentration of 1.0 mg/L is often used. Most foods have very low amounts of fluoride (< 0.05 mg/100g food).66 Sources of fluoride in the diet include fluoridated water and foods grown or cooked in it, canned fish with bones, and tea. The amount of fluoride in tea can vary from 1 to 6 mg/L depending on the amount of dry tea used, the water fluoride concentration, and brewing time.67 Fluoridated dental products can also contribute fluoride. Supplements are prescribed for children living in areas with low water fluoride levels but are rarely prescribed for adults. The Tolerable Upper Intake Level (UL) for fluoride is 10 mg/day. The primary adverse effects associated with excess fluoride intake are enamel and skeletal fluorosis.68 2002 National Nutrition Month Campaign 29 Dietitians of Canada Functions and Food Sources of Calcium and Other Related Bone Health Nutrients Nutrient Calcium Function • Helps build and maintain strong bones and teeth • Plays a major role in many body systems including vascular contraction and vasodilatation, contraction and relaxation of muscle, regulation of heartbeat , nerve transmission, blood clotting, and enzyme regulation. • Major component of bones and teeth. • Helps generate and regulate energy in the body. • Helps regulate enzymes in the body. • Involved in cell growth and repair. Food Sources Milk, cheese, yogurt, calcium fortified beverages (soy, rice and orange juice), canned salmon and sardines with bones, sesame seeds, cooked beans, tofu containing calcium sulfate, and almonds. Bok choy, kale and broccoli also provide calcium but in smaller amounts. Phosphorus Fish (halibut, salmon, sardines and salmon with bones), cooked beans, lentils, milk, cheese, yogurt, almonds, meat, poultry, cottage cheese, peanut butter, green peas, tofu containing calcium sulfate. Cooked beans and lentils, nuts and seeds, peanut butter, leafy green vegetables, brown rice, oat bran. Smaller amounts are found in most food groups including grain products, milk products and meat. Magnesium • Plays a major role in bone and mineral homeostasis. • Vital to many basic body functions including producing energy, making body protein, and muscle contractions. • Helps maintain normal muscle and nerve function. • Helps body maintain normal blood levels of calcium. • Plays a role in bone formation and maintenance. • Deficiency leads to rickets – rare in U.S and Canada. • Deficiency in older adults contributes to risk of osteoporosis (elderly not exposed to sunlight or a regular dietary source are at greater risk). • Primary role in protecting teeth from decay. • Helps form strong bones and teeth. Vitamin D Sunlight helps the body produce vitamin D. Food sources include fish liver oils, fish (salmon, mackerel, sardine, tuna), fortified milk and margarine. Fluoride Fluoridated water and foods grown or cooked in it, canned fish with bones, tea. Foods listed are all a source of nutrients (5% RNI) but in most cases provide 10% or more of the highest RDA/AI for adults. • Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997). • Nutrient Value of Some Common Foods, Health Canada, 1999. www.hc-sc.gc.ca/food-aliment/ • USDA Nutrient Database for Standard Reference, Release 14 www.nal.usda.gov/fnic/etext/000020.html 2002 National Nutrition Month Campaign 30 Dietitians of Canada Acknowledgements Dietitians of Canada (DC) would like to thank the many people who contributed to the development of this Resource Manual. Thank you to the DC members who critically reviewed the Resource Manual for nutrition content and accuracy: Susan Barr RDN PhD Professor of Nutrition University of British Columbia, BC Mary Bush, RD, MSc Marcia Cooper, MSc, RD, PhD Candidate NNMC Regional Representative for Central and Southern Ontario Linda Corby, MSc, MEd, RD, FDC Policy Communications Specialist Dietitians of Canada, MB Krista Esslinger, RD, MSc Tracy Everitt RD, SK NNMC Regional Representative for Saskatchewan Theresa Glanville, RD, PhD, Associate professor Department of Applied Human Nutrition Mount Saint Vincent University, NS Helen Haresign, RD, MSc, FDC Vice -President Development Dietitians of Canada Valerie Irvine PDt Public Health Services, Saskatoon District Health Saskatoon, Sk Janice MacDonald RDN, M.Ed. Dietitians of Canada Vesanto Melina, RD, MS, BC Lora Montebruno-Myco RD NNMC Regional Representative for Manitoba Jayne Thirsk, RD, PhD, Dietitians of Canada Cindy Thorvaldson, RD, MSc, AB Dairy Nutrition Council of Alberrta Susan Yoo, RD, MSc NNMC Regional Representative for Alberta and the Territories Thank you to the dietitians and staff of the 2002 National Nutrition Month Campaign sponsors for their input: Kerry Grady-Vincent, RD, MHSc and Gail Ewan, PDt - Dairy farmers of Canada Marilynn L. Small, RD, Sr. Manager Nutrition Affairs, Michi Furuya Chang, MHSc, RD, Gurjinder Gill, MHSc RD and Marquita JavierBrozo, RD - Kraft Canada Inc. Bonnie Cohen MSc, RD - Canadian Egg Marketing Agency This manual was written by DC member Lynn Roblin, RD, M.Sc. The coordination of this resource was done by Anne Gagné, RD, Co-ordinator, 2002 National Nutrition Month Campaign and Helen Haresign RD, M.Sc., FDC Vice-President Development Dietitians of Canada. National Nutrition Month Artwork: Anne Bouillon, AF &Naf Designs Filomena Vernace-Inserra, BASc, RD Sunnybrook & Women’s College Health Centre Inner Health Nutrition Consulting (private practice) Susan J. Whiting, PhD Professor of Nutrition University of Saskatchewan 2002 National Nutrition Month Campaign 31 Dietitians of Canada References 1 National Institute of Nutrition, Health Claims in Canada - Taking the Consumer Pulse, March 1999. 2 National Institute of Nutrition, Consumer Awareness and Attitudes toward Functional Foods, June 2000. 3 Vitamin Information Service – Roche Vitamins Canada Inc, 2001 Gallup Survey. 4 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids National Academy of Sciences, 2000. 5 Appel, LJ., et al. “A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure - DASH Collaborative Research Group” NEJM 336:1117-1124, 1997. 6 Appel LJ., et al. “Effect of Dietary Patterns on Serum Homocysteine: Results of a randomized, controlled feeding study.” Circulation 102:852-857, 2001. 7 Obarzanek, E., et al. “Effects Blood Lipids of a Blood Pressure Lowering Diet: The Dietary Approaches to Stop Hypertension (DASH) Trial”. Am J Clin Nut 74 (1)80-9, 2001. 8 Grey-Donald, K. Jacobs-Starkey L, and Johnson-Down L. “Food Habits of Canadians: Reduction in Fat Intake over a Generation”. Canadian Journal of Public Health p. 381-385, Sept-Oct. 2000. 9 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter 5 Vitamin C p.127 National Academy of Sciences, 2000. 10 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter 5 Vitamin C p.154 National Academy of Sciences, 2000. 11 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter 5 Vitamin C Chapter 5 Vitamin C p. 95 National Academy of Sciences, 2000. 12 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 5 Vitamin C p.154. National Academy of Sciences, 2000. 13 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 6 Vitamin E p. 187. National Academy of Sciences, 2000. 14 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 6 Vitamin E p. 186. National Academy of Sciences, 2000. 15 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 6 Vitamin E p. 245. National Academy of Sciences, 2000. 16 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 6 Vitamin E p.186-187, 224-225. National Academy of Sciences, 2000. 17 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 6 Vitamin E p.249-260. National Academy of Sciences, 2000. 18 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 7 Selenium p. 309. National Academy of Sciences, 2000. 19 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 7 Selenium p. 317 National Academy of Sciences, 2000. 20 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 7 Selenium p. 311 National Academy of Sciences, 2000. 21 Giovannucci et al, 1995 cited in Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and BetaCarotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p.342-346. National Academy of Sciences, 2000. 22 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter 8 B-Carotene and Other Carotenoids p.346. National Academy of Sciences, 2000. 2002 National Nutrition Month Campaign 32 Dietitians of Canada 23 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter 8 B-Carotene and Other Carotenoids p.348. National Academy of Sciences, 2000. 24 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter, Chapter 8 B-Carotene and Other Carotenoids p. 350-351. National Academy of Sciences, 2000. 25 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids Chapter, Chapter 8 B-Carotene and Other Carotenoids p.325 National Academy of Sciences, 2000. 26 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 339-251 National Academy of Sciences, 2000. 27 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 371 National Academy of Sciences, 2000. 28 Lachance, 1997 cited in Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 351-2 National Academy of Sciences, 2000. 29 Health Canada, 1997 cited in Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and BetaCarotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 351-2 National Academy of Sciences, 2000. 30 Albanes et al, 1996 and Omenn et al 1996a cited in Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 368 National Academy of Sciences, 2000. 31 Micozzi et al 1992 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 355 National Academy of Sciences, 2000. 32 Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta-Carotene, and other Carotenoids, Chapter 8 B-Carotene and Other Carotenoids p. 371 National Academy of Sciences, 2000. 33 Food and Drugs Acts and Regulations, November 5, 1998. 34 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 8 Folate p. 197. National Academy of Sciences, 1998. 35 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 8 Folate p. 273. National Academy of Sciences, 1998. 36 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline Chapter 4 Thiamin p. 81. National Academy of Sciences, 1998. 37 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 6 Niacin p.142. National Academy of Sciences, 1998. 38 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 5 Riboflavin p. 115. National Academy of Sciences, 1998. 39 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline Chapter 7 Vitamin B6. p. 182. National Academy of Sciences, 1998. 40 Manual of Clinical Dietetics (6th edition), “Efficacy and Safety Summary Table for Dietary Supplements”. American Dietetic Association-Dietitians of Canada. Appendix 12. p. 841-852. 2000. 41 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 7 Vitamin B6. p. 183. National Academy of Sciences, 1998. 42 Andrews et al., 1967; Hurwitz et al., 1997; Johnsen et al., 1991; Krasinski et al., 1986 cited in Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 9 Vitamin B 12 p. 338. National Academy of Sciences, 1998. 43 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 9 Vitamin B12. p 338. National Academy of Sciences, 1998. 44 Manual of Clinical Dietetics (6th edition), “Vegetarian Nutrition”, p.159-176, American Dietetic AssociationDietitians of Canada. 2000. 2002 National Nutrition Month Campaign 33 Dietitians of Canada 45 Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, Chapter 9 Vitamin B12 p. 346. National Academy of Sciences, 1998. 46 Osteoporosis Society of Canada www.osteoporosis.ca. 47 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p.115. National Academy of Sciences, 1997. 48 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p.106. National Academy of Sciences, 1997. 49 Heaney et al, 1991 cited in Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p. 73. National Academy of Sciences, 1997. 50 Heaney RP, Dowell MS, Rafferty K. et al. “Bioavailability of the Calcium in Fortified Soy Imitation Milk, with Some Observations on Method.” American Journal of Clinical Nutrition, 71:1166-9 2000. 51 Delmi et al, 1990 cited in Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p 76. National Academy of Sciences, 1997 52 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p 76. National Academy of Sciences, 1997 53 Suarez FL et al. “Lactose Maldigestion is Not an Impediment to the Intake of 1500mg Calcium Daily as Dairy Products.” Am J Clin Nutr 68:1118-1122, 1998. 54 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p. 134-143. National Academy of Sciences, 1997 55 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 4 Calcium p. 137-141. National Academy of Sciences, 1997 56 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 5 Phosphorus p. 186. National Academy of Sciences, 1997. 57 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 6 Magnesium, p 190-249. National Academy of Sciences, 1997. 58 Whiting SJ, Wood RJ, Kim K, “Pharmacology Update: Calcium supplements”. Journal of the American Academy of Nurse Practitioners. 9:187-192, 1997. 59 Osteoporosis Prevention, Diagnosis and Therapy. NIH Consensus Statement 2000 March 27-29:17(2) 1-36. 60 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 6 Magnesium, p. 242-249. National Academy of Sciences, 1997. 61 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D, p. 255-6. National Academy of Sciences, 1997. 62 Holick, 1994; Oliveri et al., 1993 cited in Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D p. 256. National Academy of Sciences, 1997. 63 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D p. 255. National Academy of Sciences, 1997 64 Norman, A.W. “Intestinal Calcium Absorption: A Vitamin D-hormone Mediated Adaptive Response.” Am. J. Clinical Nutrition 51:290-300, 1990. 65 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D p. 278-287. National Academy of Sciences, 1997. 66 Taves, 1983 cited in Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D Chapter 8 Fluoride p. 293. National Academy of Sciences, 1997. 67 Cremer and Buttner, 1970; Wei et al., 1989 cited in Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D, Chapter 8 Fluoride p 294. National Academy of Sciences, 1997. 68 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Chapter 7 Vitamin D, Chapter 8 Fluoride p. 306-313. National Academy of Sciences, 1997. 2002 National Nutrition Month Campaign 34 Dietitians of Canada Official Sponsors of the 2002 National Nutrition Month Campaign www.dairyfarmers.org www.kraftcanada.com 2002 National Nutrition Month Campaign 35 Dietitians of Canada