Download VitD Ca intakes Final

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Dietary sources and socio-demographic and economic factors affecting vitamin D and
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calcium intakes in Flemish preschoolers
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Inge Huybrechts1, Yi Lin1, Willem De Keyzer1,2, Isabelle Sioen1, Theodora Mouratidou3, Luis
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A. Moreno3, Nadia Slimani4, Mazda Jenab4, Stefanie Vandevijvere5, Guy De Backer1, Stefaan
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De Henauw1,2
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Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University,
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Ghent, Belgium
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Gent, Belgium
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Zaragoza, C/ Corona de Aragon 42, 50009, Zaragoza, Spain
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Lyon Cedex 08, France
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Department of Nutrition and dietetics, University College Ghent, Keramiekstraat 80, 9000
GENUD (Growth, Exercise, NUtrition and Development) Research Group, University of
International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, 69372
Unit of Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
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Running title: vitamin D and Calcium intake in preschoolers
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Funding: The Flanders preschool dietary survey was funded by the Belgian Nutrition
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Information Center (NICE)
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Authors:
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Inge Huybrechts (PhD), Unit nutrition and food safety, Department of Public Health, Faculty
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of Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent,
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Belgium
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[email protected]
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Yi Lin (MS, MPH), Unit nutrition and food safety, Department of Public Health, Faculty of
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Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium
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[email protected]
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Willem De Keyzer (MS), University College Ghent, department of Nutrition and dietetics,
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Faculty of Health Care Vesalius, Keramiekstraat 80, B-9000 Ghent, Belgium
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[email protected]
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Isabelle Sioen (PhD), Unit nutrition and food safety, Department of Public Health, Faculty of
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Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium
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[email protected]
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Theodora Mouratidou (PhD), GENUD (Growth, Exercise, NUtrition and Development)
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Research Group, University of Zaragoza, C/ Corona de Aragon 42, 50009, Zaragoza, Spain
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[email protected]
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Luis Moreno (Prof), GENUD (Growth, Exercise, NUtrition and Development) Research
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Group, University of Zaragoza, C/ Corona de Aragon 42, 50009, Zaragoza, Spain
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[email protected]
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Nadia Slimani (PhD), International Agency for Research on Cancer (IARC), 150 Cours
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Albert Thomas, 69372 Lyon Cedex 08, France
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[email protected]
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Mazda Jenab (PhD), International Agency for Research on Cancer (IARC), 150 Cours Albert
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Thomas, 69372 Lyon Cedex 08, France
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[email protected]
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Stefanie Vandevijvere
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Unit of Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
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[email protected]
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Guy De Backer (Prof), Unit nutrition and food safety, Department of Public Health, Faculty
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of Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent,
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Belgium
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[email protected]
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Stefaan De Henauw (Prof), Unit nutrition and food safety, Department of Public Health,
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Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent,
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Belgium
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[email protected]
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*Corresponding author: Inge Huybrechts, Department of Public Health, Faculty of Medicine
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and Health Sciences, Ghent University, UZ – 2 Blok A, De Pintelaan 185, B-9000 Ghent,
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Belgium. Tel: +32 (0)9 332 24 23, Fax: +32 (0)9 332 49 94, email: [email protected]
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Abstract
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Background/Objectives: Low calcium and vitamin D intakes have been associated with
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health risks in childhood and adulthood. This study aims to investigate dietary sources of
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calcium and vitamin D intake, and its associated socio-demographic, economic and lifestyle
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factors among preschoolers.
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Subjects/Methods: Three-day estimated diet records from 696 Flemish preschoolers 2.5-6.5
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years old (51% boys) were used (66% of 1052 collected diaries). Contribution of 58 food
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groups to calcium and vitamin D intake were computed. Multiple linear regression was used
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to examine associations of intakes with socio-demographic, economic and lifestyle factors.
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Results: Mean calcium intake (844 mg/d) was above, and mean vitamin D intake (2.0 µg/d)
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largely below the Belgian recommendations. Milk, sweetened milk drinks, and cheese were
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the main sources of calcium intakes (26%, 25% and 11%, respectively). Butter and margarine
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were the main vitamin D sources (26%), followed by growth milk (=fortified milk) (20%) and
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fish (15%). Calcium and vitamin D intake were negatively associated with participants’ age,
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and calcium positively with parental education and family size. The child’s gender,
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supplement use and physical activity level, and the employment status and smoking behaviour
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of the parents were not associated with calcium or vitamin D intake.
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Conclusions: Flemish preschoolers had too low vitamin D intakes while most had adequate
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calcium intakes. Milk (including sweetened, fortified/growth milk) was the main food source
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of calcium intake and the second important source of vitamin D intake after butter and
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margarine. Calcium intake was positively associated with parental education, while vitamin D
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intake not.
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Key words: dietary sources, vitamin D, calcium, preschool, child, socio-demographic,
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economic
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Introduction
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Even though clinical consequences of adverse bone health are predominantly seen in older
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age, accumulating evidence indicates that many predisposing factors arise in childhood
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(Davies et al, 2005). Bone mineral content at older age is determined by the peak bone mass
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attained in young adulthood and subsequent adult bone loss (Davies et al, 2005; Kalkwarf et
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al, 2003). Therefore, interventions designed to maximize bone health should start at an early
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age. While peak bone mass is mainly genetically controlled, calcium and vitamin D intake
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during childhood and adolescence are considered to play an important role in bone health
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(Davies et al, 2005; Johnston et al, 1992; Matkovic, 1992; Rizzoli et al, 2010).
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Previous findings on calcium and vitamin D intakes of Flemish preschoolers suggest that
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<70% of the children comply with the recommendations (Hoge Gezondheidsraad, 2003) for
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calcium intake and <15% with the recommendations for vitamin D intake (Huybrechts & De
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Henauw, 2007). These borderline calcium and inadequate vitamin D intakes, in comparison
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to the Belgian Superior Health Council (BSHC) recommendations (Hoge Gezondheidsraad,
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2003), are cause of concern for the health of Belgian preschool children, and provide evidence
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of dietary inadequacies in an understudied subgroup of the population. Therefore, it is
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important to examine the food sources contributing most to daily calcium and vitamin D
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intakes of Flemish preschoolers, and subpopulations most vulnerable of inadequate intakes in
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order to enable targeted interventions.
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The aim of this study is to investigate dietary sources of calcium and vitamin D intakes and its
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associated socio-demographic, economic and lifestyle factors among Flemish preschoolers.
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Methods
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Survey population
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The study used data from the Flanders preschool dietary survey (data collected from October
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2002 until February 2003), in which usual dietary intake was estimated from 3-day estimated
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dietary records (EDR) and a forty-seven item Food Frequency Questionnaire (FFQ),
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completed by a proxy (parent/caregiver). The sampling design, methods response rate (50%)
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and representativity of the study sample were described previously (Huybrechts et al, 2008b).
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In brief, schools were used as primary sampling units and classes as secondary sampling
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units. A total of 2095 children from forty-three schools were invited to participate. The
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percentage of under-reporters was low (< 2% of the children when using the individual
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Goldberg cut-offs adopted for children) and has been described in depth elsewhere
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(Huybrechts & De Henauw, 2007).
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Socio-demographic, economic and lifestyle information about the child and its family was
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collected via a parental questionnaire: employment status (employed or unemployed);
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educational attainment (lower secondary, secondary or higher education); and smoking status
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(currently smoking: yes/no) of the parents; family size (less or more than two children);
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children’s physical activity level (light, medium or high) and supplement use (yes/no) of the
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child. Level of physical activity was assessed via a short parental questionnaire asking about
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their subjective perception of the physical activity level of their child (very active (e.g.
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running, swimming, cycling), active (e.g. walking, actively playing) or less active (e.g. mainly
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sitting or screen activities), and the number of hours their child spends in organized sport
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activities (e.g. football, ballet, etc.).
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The Ethical Committee of the Ghent University Hospital granted ethical approval for the
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study. Informed written consent was obtained from all parents.
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Assessment of dietary calcium and vitamin D intake
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For the purposes of the current analysis only food diaries with three completed record days,
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were included resulting in a final sample of 696 (66% of the 1052 collected) diaries.
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Using a systematic procedure the following food composition tables (listed in order of
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priority) were used to perform nutrient calculations: the Belgian food composition tables
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NUBEL (NUBEL, 2004), Dutch food composition database NEVO (NEVO, 2001), food
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composition tables of the Belgian Institute Paul Lambin (IPL, 2004), and the McCance and
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Widdowson’s UK food composition tables (FSA, 2002). Within the context of this study,
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systematic procedure refers to the use of the Belgian food composition tables as the basic
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tables and thereafter when insufficient information was available in this Belgian database, the
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other databases were used.
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In total 936 foods and composite dishes were reported in the food diaries of the 696 children
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that were included in the study sample. All recipes described in depth as ingredients in the
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diaries were encoded as ingredients in the database. In order to enable classification of foods
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into food groups of the Flemish Food Based Dietary Guidelines (FBDG) (Vigez, 2004), eight
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extra composite dishes had to be disaggregated. After the disaggregating procedures, food
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items were divided into 58 food groups of similar nutrient content based on the classification
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of the Flemish FBDG and the expert opinion of the investigators (see table 2).
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The contribution of dietary supplements to total calcium and vitamin D intake was not
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considered in this study. However, in depth analysis reporting the frequency of consumption
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of dietary supplements among Flemish preschoolers is published elsewhere (Huybrechts et al,
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2010).
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Statistical analyses
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The Statistical Package for the Social Sciences for Windows version 14 (SPSS Inc., Chicago,
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IL, USA) was used to perform statistical analyses.
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Mean and median usual intakes of the population and the proportion below or above defined
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cut-offs (Hoge Gezondheidsraad, 2009), were calculated using statistical modeling (NUSSER
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method, developed at Iowa State University) in order to correct for day-to-day variability in
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the 3d EDR (Guenther et al, 1997; Nusser et al, 1996). The program used to calculate usual
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intakes was the Software for Intake Distribution Estimation (C-side) (Iowa State University,
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USA) (Iowa State University, 2006). Recommendations of the BSHC (revised version 2009)
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were used to evaluate total calcium and vitamin D intakes (Hoge Gezondheidsraad, 2009).
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The population proportion formula was used to determine the percentage contribution of each
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of food group to the intake of calcium and vitamin D (Krebs-Smith et al, 1989) which
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includes summing the amount of the component provided by the food for all individuals
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divided by the total intake of that component from all foods for the entire study population
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(Fox et al, 2006; Krebs-Smith et al, 1989; Royo-Bordonada et al, 2003).
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Multiple linear regression analysis was used to investigate the associations of mean calcium
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and vitamin D intake (dependent variables) with the socio-demographic, economic and
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lifestyle variables available from the parental questionnaires (independent variables).
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Associations were simultaneously controlled for all variables included in the models: total
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energy intake, sex, age, physical activity level, supplement use, household size, occupational
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status and educational level of the parents and smoking of the parents. Interactions of the
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independent variables with age and gender were also included. Only significant variables
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associated with calcium and vitamin D intake were included in the final model. All two-tailed
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statistical analyses were tested with a significance level set at P < 0.05.
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Results
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Characteristics of the study population
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The total study sample of 696 children included 51% boys and 49% girls. 30% of the children
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were between 2.5-3 years old and 70% between 4-6.5 years old (Table 1). The proportion of
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children studied in each province (30% in Antwerp, 24% in East-Flanders, 22% in West-
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Flanders, 15% in Flemish Brabant and 9% in Limburg), compared well with the proportions
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derived from the target population, namely preschool children in Flanders (28%, 23%, 18%,
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18% and 13% respectively). Mean calcium intake (95% CI) was 844 (821 – 868) mg per day
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and mean vitamin D intake was 2.0 (1.8 – 2.2) µg per day. Mean calcium intake was above
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and mean vitamin D intake largely below the age specific recommendations for children.
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Insert Table 1
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In total, 86% of the children 2-3 years old met the calcium recommendation of 500 mg per
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day and 64% of the children 4-6 years old met the recommendation of 700 mg per day. Only
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5% of the children met the vitamin D recommendation of 10 µg per day (4% in the children 2-
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3 years old and 1% in the children 4-6 years old).
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Dietary sources of calcium and vitamin D intake
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Table 2 lists food and beverage categories and their relative contributions to daily calcium and
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vitamin D intake in preschool children. Milk, sweetened milk drinks, and cheese were the
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main sources of calcium intakes (26%, 25% and 11%, respectively), followed by milk
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desserts, sweet snacks (e.g. child biscuits), cooked vegetables and fruit juice.
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Butter and margarine (26%), fortified milk drinks (growth milk) (20%) and fish (15%) were
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the main sources of vitamin D, followed by meat products, sweet snacks, milk, eggs and hard
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cheese. Very similar results were obtained, for what concerns the main food sources
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contributing to total calcium and vitamin D intakes, when stratifying for age or gender.
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Insert Table 2
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Associations of calcium and vitamin D intake with socio-demographic and economic
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factors
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Calcium and vitamin D intake were both negatively associated with age of the child, and
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calcium was positively associated with both maternal and paternal educational level and
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family size (Table 3). Gender, supplement use and physical activity level of the child, and ,
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employment status and smoking behaviour of the parents were not associated with calcium or
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vitamin D intake.
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Insert Table 3
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Discussion
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Main results
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Mean calcium intake was above and mean vitamin D intake largely below the
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recommendation for children (95% of the children had vitamin D intakes below the
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recommendation) (Hoge Gezondheidsraad, 2009). Milk, sweetened milk drinks (e.g.
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chocolate milk), and cheese were the main sources of calcium intakes (26%, 25% and 11%,
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respectively). Butter and margarine were the main sources of vitamin D (26%) probably due
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to the mandatory fortification of margarine in Belgium, followed by fortified milk drinks
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(20%) and fish (15%). Meat and poultry also contributed importantly to vitamin D intakes
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(11% for meat & poultry together). Both nutrients were negatively associated with
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participants’ age, and calcium was positively associated with parental educational level and
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family size, but not with the child’s gender, supplement use , the occupational status and
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smoking behaviour of the parents. The lower calcium and vitamin D intakes in the oldest age
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group are likely due to the reduced milk intakes in the oldest age group compared to the
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youngest children (Huybrechts et al, 2008a).
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It should be taken into consideration that our low estimated vitamin D intakes do not
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necessarily imply a problem of vitamin D deficiency given that vitamin D is also derived
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from the action of sunlight on the skin. Unfortunately, sun exposure was not assessed in this
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study, and also contributions from supplements have not been taken into account. However,
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studies conducted in similar geographical altitude have reported that the contribution of
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vitamin D derived from sunlight is insufficient to reach the vitamin D requirement (Stellinga-
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Boelen et al, 2007; Tylavsky et al, 2006). Previous research showed that the vitamin D intake
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provided via dietary supplements was about 1.3 µg/d for children < 4 years old and 0.9 µg/d
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for children at least 4 years old (Huybrechts et al, 2010). In that study, it was shown that the
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group of children taking dietary supplements had still mean vitamin D intakes below 5 µg/d.
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Therefore, young children in Belgium might risk having an inadequate vitamin D intake
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during winter months (Davies et al, 1999; Emmett et al, 2002).
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Comparison with the literature
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Differences in dietary intake assessment methods, study design and food grouping made it
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difficult to compare our calcium and vitamin D intakes, and food contributions to results
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derived from other studies. These limitations should be considered when interpreting the
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comparisons with other studies reported below.
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Low vitamin D intakes found in our preschool children, were similar to that observed in other
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European studies (Emmett et al, 2002; Lambert et al, 2004; Serra-Majem et al, 2006). For
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instance the results concerning vitamin D intake and compliance to the recommendations
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were comparable to those of Spanish children 2-5 years old (boys: 1.4 µg/d; girls: 1.2 µg/d)
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and children from the UK aged 1-3 years old (1.8 µg/d) (Emmett et al, 2002; Serra-Majem et
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al, 2006). In contrast, calcium intakes in the Spanish children (boys: 135 mg/1000 kcal;
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girls: 116 mg/1000 kcal) were much lower than those observed in our Belgian sample of
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children (Serra-Majem et al, 2006). Similarly, calcium intakes of the UK (boys: 796; girls:
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732 mg/d) were lower than those reported for Belgian children (Emmett et al, 2002; Serra-
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Majem et al, 2006).
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Similarly to our study, milk was the main calcium source in another survey among Spanish
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children, (26 % in Spain compared with 50 % in Belgium) (Royo-Bordonada et al, 2003).
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Fish was the main vitamin D source in Spanish children (43 %), while margarine/butter in
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Flemish preschoolers (9% in Spanish children) (Royo-Bordonada et al, 2003). Comparison
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with main vitamin D contributors among four year old Swedish children showed that in the
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Swedish preschoolers, the contribution of margarine, butter and oils (20%) and of fish (11%)
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to total vitamin D intakes was lower in comparison with our Flemish preschoolers (Garemo et
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al, 2007).
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Both calcium and vitamin D intakes derived from food intake alone was higher for children in
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the US (calcium: boys: (< 4y) 999 mg/d, (> 4y) 1058 mg/d; girls: (< 4y) 965 mg/d, (>4 y) 951
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mg/d; vitamin D: boys: (< 4y) 7.2 µg/d, (> 4y) 6.4 µg/d; girls: (< 4y) 6.9 µg/d, (>4 y) 5.5
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µg/d) than to those of our sample (Bailey et al, 2010). The main calcium food sources in US
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children 2-5 y old were milk and cheese and the percentage contribution for those two food
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groups (59% & 11% respectively) was very similar to the percentages reported for Belgian
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children (Table 2) (Subar et al, 1998).
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When considering the above comparison with European countries, it appears that the intakes
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of calcium and vitamin D are lower in European children than in children from the US. This
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could be attributed to differences in fortification policies or food composition. In addition,
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within Europe, differences in fortification policies might be causing differences in vitamin D
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and calcium intakes and in the main food sources contributing to these intakes (e.g. due to
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margarine fortification, the main vitamin D sources in Belgian children were margarine/butter
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compared to fish in Spain).
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Although no information was found of the influence of parental education on the intake of
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children’s calcium and vitamin D intakes, Galobardes et al. showed that calcium and vitamin
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D intakes were negatively associated with the educational level of the study subjects
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(Galobardes et al, 2001). A recent study in Polish children and adolescents (7-16 y old) also
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showed more frequent fish, fruit and vegetable intakes among children & adolescents of
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higher socio-economic status (SES) families (Suliga, 2010). Given the gap in data
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investigating the influence of socio-demographic and economic factors influencing calcium
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and vitamin D intakes among preschool aged children, future studies investigating
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preschoolers dietary intakes should look at possible socio-demographic and economic factors
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influencing these intakes to evaluate the results obtained in our study.
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Strengths & limitations
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Although, willingness to participate leads to some selection bias, these data represent a more
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general population of preschool children in Flanders compared to other food consumption
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surveys mostly restricted to local areas. Nonetheless, as shown previously (Huybrechts et al,
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2008b), the study sample was subject to some selection bias, with lower socio-economic
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classes being slightly underrepresented. Although this slight selection bias might have
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influenced our results concerning the association between calcium and vitamin D intakes and
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socio-economic factors, it is not possible to prevent such selection bias in large-scale surveys.
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Similarly, to other dietary assessment methodologies, diet records are prone to a degree of
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misreporting which possibly had an influence in the classification of compliance and non-
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compliance with the recommendations. However, the percentage of under-reporters in the
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final sample for analysis was less than 2%. In addition, a 3d diet record does not necessarily
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reflect individual’s usual intake. For this reason,, statistical modelling (NUSSER method) that
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accounts for within-individual variability (Iowa State University, 2006) was used in order to
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calculate usual calcium and vitamin D intake. Unfortunately, it was impossible to correct for
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seasonal variations, because the fieldwork was conducted only during autumn and wintertime.
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No data were found about potential seasonal influences on nutrient intake in this population
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group in Belgium. However, from the results of the National food consumption survey
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(2004), it could be concluded that seasonal variations have a small effect on nutrient and food
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intakes (De Vriese et al, 2006), likely due to the widespread availability of most foods all year
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round. In addition it should be noted that food composition data, used for calculating nutrient
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intake might also introduce some bias in dietary surveys reporting nutrient intake. Therefore,
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the authors would like to emphasize the growing requirement for good quality food composition
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data.
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Finally, it should also be mentioned that the SES and lifestyle variables used in the analyses
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were obtained via a parental questionnaire that included some basic questions about the
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family situation and some lifestyle habits of the child. These subjective SES and lifestyle
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measure could also introduce some bias (e.g. due to social desirable answers).
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Recommendations
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Our study findings and published literature indicate unfavourably low vitamin D intakes
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among childhood populations. Enhancing the daily amount of spreadable margarine/butter on
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preschool children’s bread and increasing fatty fish intake could contribute importantly to
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higher vitamin D intakes. While spreadable margarine for preschool children’s bread was
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under-consumed in comparison with the FBDG (Huybrechts et al, 2008a), it was still the main
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source of vitamin D intakes. Although spreadable fat is an item that might be more prone to
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underreporting in diaries, the results from the FFQ also revealed that more than one-third of
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the children never consume spreadable fat on their bread (Huybrechts et al, 2008a). However,
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in the battle against obesity one should keep in mind that the total energy intake should not be
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influenced by the enhancement of these fatty food groups what could necessitate a
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concomitant decrease in other (energy dense) foods containing invisible fat or sugar (e.g. soft
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drink and candy bars). In the Flemish FBDG children are recommended to use about 5g
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margarine per slice of bread (3-5 slices of bread per day are recommended in preschool aged
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children and margarine is recommended above butter because of its more advantage fatty acid
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contents).
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Also the consumption of fortified (growth) milk in children could be recommended to
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increase children’s vitamin D intake. However, most of these growth milks contain added
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sugar which makes them energy dense and less appropriate in the fight against obesity.
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If public health policies for the increase in vitamin D intake are to be effective, policy
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development and implementation needs to target the main sources of dietary vitamin D in
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various populations (including higher as well as lower educated populations). In addition to
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the mandatory fortification of margarines, manufacturers could also contribute by
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reformulating existing products to incorporate more calcium and/or vitamin D.
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Conclusion
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Flemish preschoolers surveyed between 2002 and 2003, had mean vitamin D intakes largely
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below the recommendation, whereas mean calcium intake was above the minimum
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recommended intake level. This situation could be improved by promoting the consumption
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of food categories with high vitamin D contents such as margarine, fish and fortified dairy
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products. Both calcium and vitamin D intakes were negatively associated with age, and
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calcium intake was positively associated with the educational level of the mother and the
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father and family size. This finding suggests that prevention strategies should especially focus
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on children from lower educated parents.
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Acknowledgements
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We thank all the parents and teachers who participated into this project and generously
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volunteered their time and knowledge. The Flanders preschool dietary survey was funded by
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the Belgian Nutrition Information Center (NICE).
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Contributors: Inge Huybrechts performed and interpreted statistical analyses and drafted the
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article. Yi Lin contributed to the statistical analyses and the interpretation of the results. All
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other authors helped in the evaluation of the results and the writing of the manuscript.
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Moreover, Inge Huybrechts and Stefaan De Henauw were responsible for the study protocol
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and the fieldwork. All authors have read and have approved the manuscript as submitted.
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Conflict of interest
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The authors declare no conflict of interest.
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Table 1. Characteristics of the children participating in the Flanders preschool dietary survey
Children with
3d diet record
n£
(%)
Boys
339
(51.2)
Girls
323
(48.8)
2.5-3 years old
197
(29.8)
4-6.5 years old
465
(70.2)
Antwerp
211
(30)
Limburg
62
(9)
East-Flanders
167
(24)
Flemish-Brabant
101
(15)
West-Flanders
155
(22)
Lower secondary education
26
(4.0)
Secondary education
250
(38.2)
Higher education
379
(57.9)
Gender:
Age:
Province:
Maternal education
19
Paternal education
Lower secondary education
49
(7.7)
Secondary education
279
(43.8)
Higher education
309
(48.5)
Two children or less in the family
480
(72.7)
More than 2 children in family
180
(27.3)
Smoker
98
(14.9)
Non-smoker
561
(85.1)
Smoker
160
(24.9)
Non-smoker
483
(75.1)
Employed
488
(74.5)
Unemployed
167
(25.5)
Employed
566
(88.9)
Unemployed
71
(11.1)
Brothers and sisters in the family
Smoking habits mother
Smoking habits father
Maternal employment
Paternal employment
Physical activity level of child
20
Less physically active
246
(37.7)
Moderate physically active
303
(46.5)
Highly physically active
103
(15.8)
Special diet for diabetes
0
-
Gluten-free diet (gluten-intolerance)
1
(0.1)
Lactose-free diet (lactose-intolerance)
3
(0.4)
Special diet for food-allergies
8
(1.1)
Energy-restricted diet
2
(0.3)
3
(0.4)
17
(2.4)
Vegetarian or semi-vegetarian (no red meat)
3
(0.4)
Lacto-ovo-vegeterian
1
(0.1)
Ovo-vegeterian
0
-
Lacto-vegeterian
0
-
Biological diet
6
(0.9)
Religious or other eating pattern
1
(0.1)
Total
11
(1.6)
9
(1.3)
Taking special diet:
Other diet (e.g. laxative diet, high energy
diet, fibre restricted diet)
Total
Following special eating pattern:
Used dietary supplements during previous
month:
Iron
21
Calcium
9
(1.3)
Fluor
0
-
Multiminerals
3
(0.4)
Vitamin C
34
(4.9)
Vitamin B-complex
0
(0.0)
Fat-soluble vitamins
3
(0.4)
Multi-vitamins
96
(13.8)
Multi-minerals & -vitamins
80
(11.5)
Echinacea
15
(2.2)
Total‡
226
(32.5)
Mean
95% CI
844.3
(820.6-868.0)
2.0
(1.8-2.2)
584.1
(569.5-598.6)
1.4
(1.3-1.5)
Nutrient intake*
Calcium (mg/d)
Vitamin D (μg/d)
Calcium(mg/1000kcal)
Vitamin D (µg/1000kcal)
£
n 696 (number of children who completed diet record)
404
*Distribution was corrected for within person variability and for day of the week using Cside
405
(Iowa State University, 2006)
406
†Belgian Superior Health Council (BSHC) (Adequate intake = AI)
407
‡ The total number of children using dietary supplements is not equal to the sum of the
408
children using the different types of dietary supplements as some of the children were using
409
more than one type of dietary supplement
22
Table 2 - Dietary sources of calcium and vitamin D intakes of Flemish preschoolers.
Food intake (g)
Food group
Subgroup
Beverages (incl. juices but no drinks from restgroup)
Water
Mean Median
Total Vitamin D
(SD)
486.2
%
order
0.7
6.0
2.2
0.0
(90.1)
0.0
0.2
8.2
0.0
(43.5)
0.0
0.0
172.8
150.0
(209.3)
0.0
2.6
Vegetable juice
0.2
0.0
(6.0)
0.0
0.0
Soup / bouillon
57.7
0.0
(101.7)
0.7
1.0
Fruit juice
Bread and cereals
Bread / rolls / crackers / rice cakes
23.1
order
0.0
Tea and coffee without sugar
150.0
%
(226.4)
Light beverages
224.2
Total Calcium
86.7
0.0
62.5
(46.8)
0.0
2.0
Sweetened bread
7.5
0.0
(22.5)
0.0
0.3
Breakfast cereals (ready-to-eat / hot)
8.9
0.0
(20.0)
0.0
2.1
Pasta / noodles
86.7
15.4
1.4
0.0
(41.0)
7
4.3
70.3
Potatoes and grains
9
10
1.2
0.0
0.2
23
Food intake (g)
Food group
Subgroup
Rice
Potatoes
Vegetables
Mean Median
Total Vitamin D
(SD)
%
order
6.3
0.0
(25.5)
0.0
65.0
50.0
(69.3)
1.4
66.5
Total Calcium
%
order
0.1
10
0.0
1.0
3.4
Cooked vegetables
53.7
40.0
(60.1)
0.0
3.1
Raw vegetables
12.8
0.0
(38.3)
0.0
0.3
Fruit (sweetened / unsweetened)
109.9
0.0
1.3
Fresh fruit
94.0
68.8
(102.7)
0.0
1.2
Canned fruit
15.4
0.0
(45.4)
0.0
0.1
Dried fruit
0.4
0.0
(3.7)
0.0
0.0
Olives
0.1
0.0
(1.5)
0.0
0.0
Milk, milk products and calcium enriched soy milk
433.9
24.9
Milka
170.3
112.5
(193.5)
Sweetened milk drinks (e.g. Fristi, chocolate
171.3
125.0
(195.7)
milk, …)
6
60.3
2.3
0.03
6
25.1
1
22.8
2
24
Food intake (g)
Food group
Subgroup
Growth milk (fortified with vitamins &
Mean Median
Total Vitamin D
(SD)
%
Total Calcium
order
%
2
order
19.7
0.0
(88.2)
19.7
2.4
4.5
0.0
(25.3)
0.0
0.8
Sweetened or aromatised yoghurt
14.2
0.0
(46.9)
0.0
2.3
Soy drinks
15.7
0.0
(82.5)
0.8
1.7
Milk desserts
19.9
0.0
(56.2)
1.4
Milk desserts based on soy
2.3
0.0
(19.1)
0.0
0.2
Probiotics (e.g. Actimel, Yakult, …)
0.7
0.0
(7.4)
0.0
0.0
15.3
0.0
(43.3)
0.7
1.7
minerals)
Yoghurt
White (fresh) cheese
Cheese
14.5
4.0
11.8
0.0
(22.6)
3.5
Cheese spread
2.7
0.0
(8.8)
0.6
8.6
Butter / margarine
8.3
7
(9.5)
4
25.9
11.1
3
1.1
25.9
6.0
3.3
12.2
Hard cheeseb
Fat & oilc
9
8
0.3
1
0.3
25
Food intake (g)
Food group
Subgroup
Mean Median
Total Vitamin D
(SD)
%
Total Calcium
order
%
order
Oil
0.3
0.0
(1.4)
0.0
0.0
Frying oil
0.0
0.0
(0.6)
0.0
0.0
Meat / poultry / fish / egg / meat alternates
90.3
Meat, game and meat products
37.2
20.0
(46.1)
7.7
4
0.9
Chicken / turkey
15.9
0.0
(34.7)
3.2
9
0.2
8.5
0.0
(28.7)
14.6
3
0.3
Cold cuts (from meat products)
20.7
6.8
(30.2)
3.3
8
0.3
Cold cuts (from fish products)
0.9
0.0
(6.8)
1.3
Eggsd
5.1
0.0
(18.2)
4.1
Meat substitutes (e.g. tofu, tempe, …)
1.7
0.0
(11.6)
0.0
0.2
Nuts and seeds
0.3
0.0
(3.4)
0.0
0.0
Fish / shellfish
Restgroup (snacks & desserts)
Brioches
Sweet snacks
34.2
201.8
2.4
0.0
6
9.2
0.3
8.3
3.5
0.0
(17.0)
0.0
43.6
32.0
(43.5)
7.5
0.2
5
3.3
5
26
Food intake (g)
Food group
Subgroup
Mean Median
Total Vitamin D
(SD)
%
Total Calcium
order
%
order
Salty snacks
2.1
0.0
(9.8)
0.0
0.1
Tea and coffee with sugar
3.2
0.0
(26.6)
0.0
0.0
Soft drinks
97.7
0.0
(169.4)
0.0
0.6
Salty sauces
12.5
0.0
(24.9)
0.6
0.9
Cream
0.3
0.0
(2.6)
0.1
0.0
Sweet sauces
0.1
0.0
(2.5)
0.0
0.0
Chocolate
3.1
0.0
(9.5)
0.0
0.7
Chocolate spread
9.4
0.0
(13.9)
0.0
1.3
Other sweet spread (e.g. jam, honey, …)
5.3
0.0
(11.6)
0.0
0.1
Sugar
0.1
0.0
(0.9)
0.0
0.0
Fried snacks
0.1
0.0
(2.6)
0.0
0.0
14.6
0.0
(37.7)
0.0
0.4
6.2
0.0
(23.2)
1.0
0.6
French fries / croquettes
Sweet desserts (e.g. ice cream, tiramisu, …)
Miscellaneous
4.2
0.5
0.4
27
Food intake (g)
Food group
Subgroup
Mean Median
(SD)
Total Vitamin D
%
order
Total Calcium
%
order
Pizza & quiches
2.2
0.0
(17.8)
0.3
0.3
Other miscellaneouse
2.0
0.0
(21.3)
0.2
0.1
The contributions of each food group are expressed in percentage of daily calcium and vitamin D intake.
a
Includes cow's milk and goat's milk
b
Excludes cream cheese
c
Includes lard / animal fats and regular / low-fat / fat-free versions of cream cheese / sour cream / half-and-half
d
includes only eggs reported separately and eggs included in disaggregated food mixtures
e
includes foods or components with negligible contributions to total nutrient intakes that could not be categorized in the above food
groups (e.g. herbs and spices / monosodium glutamate / starch / plain gelatin / artificial sweeteners / pectin / cocoa powder / etc.)
28
Table 3. Associations of calcium and vitamin D intake with socio-demographic and economic characteristics of participants.
β
Type I Wald
Dependent variable:
Coefficients
95% Confidence Interval
Lower
Upper
Bound
Bound
Chi-Square
P-value
β
SE
Intercept
0.503
0.435
-0.349
1.4
1.4
0.247
Energy
0.002
0.000
0.001
0.002
45
<0.001
-0.191 0.0071
-0.330
-0.051
7.2
0.007
Vitamin D (n=594)†
Age
Calcium (n=594) ‡
Intercept
Energy
Age
17.7
103
-184
220
0.030
0.863
0.495
0.040
0.417
0.572
156
<0.001
-28
12.0
-51
-4.0
5.3
0.022
29
β
Type I Wald
Dependent variable:
Coefficients
β
95% Confidence Interval
SE
Lower
Upper
Bound
Bound
Chi-Square
P-value
Secondary educated mother*
111
58
-3.5
225
3.6
0.057
Higher educated mother*
123
59
8.0
239
4.4
0.036
67
42
-15.3
149
2.6
0.110
Higher educated father*
139
44
53
225
10.0
0.002
Family size (>2children)§
61
25
12.0
5.9
0.015
Secondary educated father*
110
*Maternal and paternal educational level, using lower education as a reference.
§
Family size, using two children or less as a reference.
†Non-significant variables with standardized coefficients β for vitamin D intake.
Gender (girl) : β=-0.077, P=0.636;
30
Maternal education : secondary: β=-0.777, P=0.051; higher: : β=-0.702, P=0.073;
Paternal education : secondary: β=0.436, P=0.150; higher: : β=0.462, P=0.143;
Physical activity: moderate : β=0.045, P=0.794; higher; β=-0.023, P=0.923;
Family size (>2 children): β=0.005, P=0.977;
Maternal smoking status (no): β=-0.420, P=0.058;
Paternal smoking status (no): β=0.172, P=0.378;
Maternal employment (unemployed): β=-0.239, P=0.225;
Paternal employment (unemployed): β=0.196, P=0.449;
Supplement (no): β=-0.321, P=0.052
‡Non-significant variables with standardized coefficients β for calcium intake.
Gender (girl): β=13.7, P=0.5541;
31
Physical activity: moderate: β=12.4, P=0.618; higher β=47.1, P=0.176
Maternal smoking status (no): β=-27.6, P=0.415;
Paternal smoking status (no): β=3.6, P=0.898;
Maternal employment (unemployed): β=31.8, P=0.259;
Paternal employment (unemployed): β=21.4, P=0.563;
Supplement (no): β=-20.7, P=0.394
32
Reference List
Bailey RL, Dodd KW, Goldman JA, Gahche JJ, Dwyer JT, Moshfegh AJ et al. (2010):
Estimation of total usual calcium and vitamin D intakes in the United States. J Nutr.
140, 817-822
Davies JH, Evans BA and Gregory JW (2005): Bone mass acquisition in healthy children.
Arch.Dis.Child 90, 373-378
Davies PS, Bates CJ, Cole TJ, Prentice A and Clarke PC (1999): Vitamin D: seasonal and
regional differences in preschool children in Great Britain. Eur.J.Clin.Nutr. 53, 195198
De Vriese, S., Huybrechts, I., Moreau, M. and Van Oyen, H. (2006): The Belgian Food
Consumption Survey 1 - 2004: Report (Enquête de consommation alimentaire Belge 1
- 2004 : Rapport). D/2006/2505/16
Emmett P, Rogers I and Symes C (2002): Food and nutrient intakes of a population sample of
3-year-old children in the south west of England in 1996. Public Health Nutr. 5, 55-64
Fox MK, Reidy K, Novak T and Ziegler P (2006): Sources of energy and nutrients in the diets
of infants and toddlers. J.Am.Diet.Assoc. 106, S28-S42
FSA (2002): McCance and Widdowson's The Compostition of Foods. Cambridge. Royal
Society of Chemistry
Galobardes B, Morabia A and Bernstein MS (2001): Diet and socioeconomic position: does
the use of different indicators matter? Int J Epidemiol. 30, 334-340
Garemo M, Lenner RA and Strandvik B (2007): Swedish pre-school children eat too much
junk food and sucrose. Acta Paediatr. 96, 266-272
Guenther PM, Kott PS and Carriquiry AL (1997): Development of an approach for estimating
usual nutrient intake distributions at the population level. J Nutr. 127, 1106-1112
Hoge Gezondheidsraad. Dietary recommendations for Belgium: revised version 2003
(Voedingsaanbevelingen voor België: herziene versie 2003). 2003. Brussel.
Hoge Gezondheidsraad. Dietary recommendations for Belgium: revised version november
2009 (Voedingsaanbevelingen voor België: herziene versie 2009). nr. 8309. 2009.
Brussel.
Huybrechts I, Matthys C, Vereecken C, Maes L, Temme EHM, Van Oyen H et al. (2008a):
Food intakes by preschool children in Flanders compared with Dietary Guidelines.
Int.J.Environ.Res.Public Health 5, 243-257
33
Huybrechts I and De Henauw S (2007): Energy and nutrient intakes by pre-school children in
Flanders-Belgium. Br J Nutr 98, 600-610
Huybrechts I, Maes L, Vereecken C, De Keyzer W., De Bacquer D., De Backer G. et al.
(2010): High dietary supplement intakes among Flemish preschoolers. Appetite. 54,
340-345
Huybrechts I, Matthys C, Pynaert I, De Maeyer M, Bellemans M, De Geeter H et al. (2008b):
Flanders preschool dietary survey: rationale, aims, design, methodology and
population characteristics. The Archives of Public Health 66, 5-25
Iowa State University. C-side. http://www.cssm.iastate.edu/software/cside.html . 2006.
IPL (2004): Table de Composition des Aliments 2004. Bruxelles. Institut Paul Lambin
Johnston CC, Miller JZ, Slemenda CW, Reister TK, Hui S, Christian JC et al. (1992):
Calcium supplementation and increases in bone mineral density in children.
N.Engl.J.Med. 327, 82-87
Kalkwarf HJ, Khoury JC and Lanphear BP (2003): Milk intake during childhood and
adolescence, adult bone density, and osteoporotic fractures in US women. Am J Clin
Nutr 77, 257-265
Krebs-Smith SM, Kott PS and Guenther PM (1989): Mean proportion and population
proportion: two answers to the same question? J.Am.Diet.Assoc. 89, 671-676
Lambert J, Agostoni C, Elmadfa I, Hulshof K, Krause E, Livingstone B et al. (2004): Dietary
intake and nutritional status of children and adolescents in Europe. Br J Nutr 92,
S147-S211
Matkovic V (1992): Osteoporosis as a pediatric disease: role of calcium and heredity.
J.Rheumatol.Suppl 33, 54-59
NEVO (2001): NEVO-Table, Dutch Food Composition Table 2001. Zeist. NEVO Foundation
(in Dutch)
NUBEL (2004): Belgian Food Composition Table, 4th Edition. Brussels. Ministry of Public
Health (in Dutch)
Nusser SM, Carriquiry AL, Dodd KW and Fuller WA (1996): A semiparametric
transformation approach to estimating usual daily intake distributions.
J.Am.Stat.Assoc. 91, 1440-1449
Rizzoli R, Bianchi ML, Garabedian M, McKay HA and Moreno LA (2010): Maximizing
bone mineral mass gain during growth for the prevention of fractures in the
adolescents and the elderly. Bone 46, 294-305
Royo-Bordonada MA, Gorgojo L, de Oya M, Garces C, Rodriguez-Artalejo F, Rubio R et al.
(2003): Food sources of nutrients in the diet of Spanish children: the Four Provinces
Study. Br J Nutr 89, 105-114
34
Serra-Majem L, Ribas-Barba L, Perez-Rodrigo C and Bartrina JA (2006): Nutrient adequacy
in Spanish children and adolescents. Br J Nutr 96, S49-S57
Stellinga-Boelen AA, Wiegersma PA, Storm H, Bijleveld CM and Verkade HJ (2007):
Vitamin D levels in children of asylum seekers in The Netherlands in relation to
season and dietary intake. Eur J Pediatr. 166, 201-206
Subar AF, Krebs-Smith SM, Cook A and Kahle LL (1998): Dietary sources of nutrients
among US children, 1989-1991. Pediatrics. 102, 913-923
Suliga E (2010): Parental education and living environmental influence on physical
development, nutritional habits as well as level of physical activity in Polish children
and adolescents. Anthropol.Anz. 68, 53-66
Tylavsky FA, Cheng S, Lyytikainen A, Viljakainen H and Lamberg-Allardt C (2006):
Strategies to improve vitamin D status in northern European children: exploring the
merits of vitamin D fortification and supplementation. J Nutr. 136, 1130-1134
Vigez. The Active Food Guide Pyramid. Het Vlaams Instituut voor Gezondheidspromotie en
Ziektepreventie (VIGeZ) . 2004.
35