Spotlight on Calcium and Vitamin D


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Learn more about calcium and Vitamin D and their importance to your health.

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  • -Introduce yourself Vitamin D and calcium are extremely important nutrients Partly because of the critical roles they play in health, but also because they are often under-consumed in the U.S. We will touch on both of these points and more as we explore this Spotlight on Calcium & Vitamin D Note to Presenter:This presentation includes additional background information and research references related to the topics on the slides. This information is not necessarily to be presented, but rather it serves as additional reference material for you and may help you in answering your audience’s questions.This information will be denoted by a “Notes to Presenter” heading in the notes section beneath each slide.Presentation last updated 8/2012
  • Over the next 30 to 45 minutes, we will discuss the following…After each of the three sections I have made time for questions, so please write down any questions as they come to you and I will address them at a few specific times throughout the presentation.While this is a lot of information to cover in our short time together, I will attempt to provide a thorough overview of the current science on these nutrients. New science continues to emerge and I would encourage all of you to follow the current research on these topics.Note to Presenter:The last section, “Calcium and Vitamin D, Bringing It Home”, contains practical tips for increasing vitamin D and Calcium in the dietDepending on the audience and time allotted, this section may be omitted
  • - Let’s jump right in with a few fun facts about calcium…- Calcium is well known for its structural role in bones and teeth-99% of calcium in the body is found in the bones and teeth -remaining 1% is in the blood, lymph and other body fluids- It is the most abundant mineral in your body; women carry about 2.5 pounds worthAs part of every cell, calcium acts as a messenger, directing cell function, hormone action, and nerve impulses. Calcium also plays a role in muscle contractility, blood coagulation, and heart function.Throughout life, calcium is continually being removed from bones and replaced with more calcium. Consequently, the need for an adequate supply of dietary calcium is important throughout life, not only during the years of skeletal development.Notes to Presenter:Refer audience to the “How Much Calcium is in Your Bones?” activity located in the Health Fair Resources section of the Health and Nutrition tab on the Western Dairy Association’s website ( - The activity uses visual representations (bags of flour) to demonstrate the amount of calcium in bones at various life stages
  • These are the recommendations for daily calcium intake issued by the National Academy of SciencesNote: Pregnant women haveimproved efficiency of intestinal calcium absorption so recommendations are the same for other women their ageAmerica’s low calcium intake has been recognized as a major public health problemThe Dietary Guidelines for Americans and MyPlate recommend 2 to 3 cups (2 cups for 2-3 year olds, 2.5 cups for 4-8 year olds, 3 cups for everyone 9+ years old) of low-fat or fat-free milk (or equivalent milk products) per day, as they are excellent sources of calcium It is assumed that we pick up the rest of the calcium we need (the amount not met through these 2-3 servings) from other food groups1 cup of milk provides 300mg of calcium Different types of milk products provide varying amounts of calcium however, so individuals should be diligent about checking nutrition facts labels (for example, 1 cup of cottage cheese provides only 140 mg of calcium) Notes to Presenter:These recommendations are based on the assumption that individuals are consuming the RDA of vitamin D This is due to the fact the functions of calcium in the body are so interrelated with the functions of vitamin DFor infants: (Based on calcium content of human milk…)0-6 mo, adequate intake (AI) = 200 mg/day6-12 mo, AI – 260 mg/dayTolerable Upper Intake Levels*:Infants 0-6 mo = 1,000 mg/dayInfants 6-12 mo = 1,500 mg/dayChildren 1-8 yrs = 2,500 mg/dayAdults 9-18 yrs = 3,000 mg/dayAdults 19-50 yrs = 2,500 mg/dayAdults 51 yrs & older = 2,000 mg/day* Adult ULs are based on data related to kidney stone incidence among post-menopausal women using calcium supplementsInfant ULs are based on calcium excretion data from an infant feeding study9-18 yrs ULs were developed in consideration of the pubertal growth spurt
  • America’s low calcium intake has been recognized as a major public health problem… As you can see here, calcium made the 2010 Dietary Guidelines list of “nutrients of concern” for both children and adults. Calcium was also listed as a nutrient of concern in the 2005 Guidelines which highlights the fact that this is a chronic problemNotes to presenter:Dairy’s nutrient package includes three of the four of the nutrients we fall short on – calcium, potassium, and vitamin D– as well as protein, phosphorous, vitamin A, vitamin B12, riboflavin, and niacin
  • - This table depictsMean Daily Calcium Intake (in milligrams) from foodsAs you’ll recall from a previous slide, the National Academy of Sciences calcium recommendations for… 9-18 years old = 1,300 mg Females 50-59 years old, and everyone 70 & older = 1,200 mgYou can see from this graph that mean daily intake for these groups is falling below thatNotes to Presenter:Non-Hispanic Blacks have the lowest Mean Daily Intake of Calcium across the age-span
  • - Research has shown that calcium is the nutrient most likely to be deficient in the US diet - From the previous slides, we know that people are not meeting current recommendations. - This chart shows how the average American diet measures up with the recommendations put forth by the 2010 Dietary Guidelines. - You will notice that Americans are falling short on intake for both dairy and calcium- In general, Americans are consuming only half of the recommended 3 servings of dairy foods every day (approximately 1.7 servings daily) -This is significant because low intake of milk and other calcium-rich dairy foods has been associated with low calcium intakes, for obvious reasons.- We know that prolonged calcium deficiency is one of several risk factors contributing to osteoporosis, a disease characterized by low bone mass and increased risk of fractures.Note to presenter:Studies in children and adolescents show that consumption of milk (unflavored and flavored) and other dairy products increases calcium intake and improves the nutritional quality of their diets. One study found that children who drank milk were more likely to meet recommended intakes for calcium, magnesium, vitamin A, folate, and vitamin B12 than children who chose less nutrient-rich beverages.According to research published in 2011, after the release of the DRI report, a considerable percentage of Americans 2 years and older are not meeting the Estimated Average Requirement (EAR)* for calcium (38%).More than two-thirds of adolescent girls have calcium intakes below the EAR. 68% of females 9-13 years and 77% of females 14-18 years consume less than the EAR for calcium.A significant percentage of older adult have calcium intakes below the EAR. 40% of 51-70 year olds and 49% of adults 71 years and older have intakes below the EAR for calcium.*The EAR is used by the IOM and other experts to identify nutrient inadequacies of groups or populations, not individuals.The EAR is the median requirement of a population, or the intake that meets the needs of half the individuals in a population.According to the IOM, if more than half the population is consuming the EAR, the majority of the population is adequately nourished.
  • Bullet 1 - Throughout life, calcium is continually being removed from bones and replaced with more calcium. Consequently, the need for an adequate supply of dietary calcium is important throughout life. Nearly 40% of peak bone mass is accumulated during adolescence 85-90%of adult bone mass is formed by age 18 in girls and age 20 in boys. Increasing calcium intake during childhood and adolescence appears to result in a heavier and denser skeleton and, consequently a higher peak bone mass.After mid-30’s, bone loss beginsWomen lose bone mass faster after menopause.Bullet 2 – this process is necessary to help the body keep serum calcium within a normal range - If the diet is low in calcium, the body will steal it from the only source it has – BONES.Bullet 3 - Optimal calcium intake during childhood and adolescence is necessary to reduce the risk of frequent withdrawals and calcium-related conditions later in life. - Osteoporosis is considered a pediatric disease with geriatric consequences. - In other words, strong bones built during childhood and adolescence can help lower risk of osteoporosis later in life. Notes to Presenter:Bones continue to grow in density until about age 30. Density then gradually declines with age. Significant evidence suggests that consuming adequate amounts of calcium or foods naturally rich in calcium such as milk, cheese and yogurt throughout life may delay or minimize age-related bone loss and thereby decrease the risk for osteoporosis
  • - While dairy foods are best known for their role in bone health, there are several lesser-known benefits. The 2010 Dietary Guidelines for Americans noted that moderate evidence indicates the intake of milk and milk products is associated with a reduced risk of cardiovascular disease, type 2 diabetes and lower blood pressure in adults.Bullet 1 – Evidence from observational studies does not support an association between dairy intake (even full fat dairy) and CVD incidence (Kratz M, Eur J Nurtr, 2012; Otto, Mozzafarian et al, AJCN, 2012). Dairy saturated fatty acids show inverse association with CVD risk – in fact each 5% unit increase in energy from dairy lead to a 40% reduction in risk (Otto, Mozzafarian et al, AJCN, 2012).Bullet 2 – meta analysis of six prospective cohort studies – more dairy intake is association with a 14% lower risk of diabetes (Tong et al, EJCN, 2011)Bullet 3 - Studies indicate that achieving a daily calcium intake to 1,000-1,500 mg (the equivalent of 3-4 servings of dairy foods) may reduce the risk of hypertension.Researchsupports an inverse relationship between dietary calcium and blood pressure (G. Miller, J. Jarvis and L. McBean. Handbook of Dairy Foods and Nutrition, Third Edition. Taylor & Francis Group, Boca Raton, FL. 2007.)
  • Bullet 1 - A 2010 meta-analysisfound that women taking calcium supplements (usually 1,000 mg/day) had a 27% increased risk of heart attack. - Reanalysis of the data, revealed an increased risk of cardiovascular events among women who were not taking calcium supplements when they entered the study abrupt changes in plasma calcium concentrationsmight be to blameBullet 2 -Other research suggests that calcium from dairy products has a milder effect on plasma concentrations as compared to calcium from supplements Bullet 3 -The American Heart Association has stated that there is currently not enough scientific evidence available to determine whether or not calcium plays a role in the development of heart diseaseHowever, they support the national recommendations for calcium intake across the lifespan, and specifically recommend meeting calcium needs through fat-free milk and low-fat dairyBottom Line: Strive to meet the calcium recommendations set for your age and gender group, obtaining as much as you can from food rather than supplementsNotes to Presenter:Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, Reid IR.Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ. 2010 Jul 29;341:c3691. Bolland MJ, Grey A, Avenell A, Gamble GD, Reid IR. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women's Health Initiative limited access dataset and meta-analysis. BMJ. 2011 Apr 19;342:d2040.Calcium for prevention of weight gain, cardiovascular disease, and cancer Am J ClinNutr 2011 94: 5 1159-1160
  • - What are the food sources of calcium? - Dairy products - Dark green leafy vegetables such as kale, collards, turnip greens and broccoli - Canned sardines and salmon (b/c of the small bones) - Calcium fortified orange juice, soy beverages, etc.Experts often recommend foods such as milk and other dairy foods for meeting calcium needs. The American Academy of Pediatrics (AAP), in a report on optimizing bone health and calcium intakes of children and adolescents, identifies milk and other dairy foods as the preferred source of calcium. - 75% of calcium in the US food supply comes from dairy foods- Individuals 9 years of age and older need 3-4 servings of dairy foods a day to meet calcium recommendations (1,000 to 1,300 mg/day)Here’s a quick way to figure out the calcium content of a dairy product…Look at the percent daily value on the label and add a zero to it. - Example, if a product contains 35% of your daily value for calcium in one serving, it is providing 350mg of calcium (based on 1,000mg/day recommendation)Notes to Presenter:As far as fortified beverages (such as orange juice, soy, rice, and almond beverages), beverage companies use different methods to manufacture and fortify their products and there is no federal standard of identity for the nutrients included in or omitted from these products. The amount of calcium absorbed from soy beverages was, on average, 25% less than that absorbed from cow’s milk (Heaney, Am J ClinNutr, 2000). Not only does milk have greater bioavailability of calcium, it also has more protein and more phosphorus than soy beverages.Low fat dairy products contain slightly more calcium than their full-fat counterparts; the mineral is found in the nonfat portion of the food.
  • In general, calcium absorption decreases with increasing calcium intake (and vice versa). Bullet 1 – Calcium absorption and excretion (in urine) may be affected by the following… AGE -Calcium absorption decreases with advancing age (particularly after age 60) - Absorption decreases to about 15-20% in adulthood and declines further after that ESTROGEN STATUS - Decreases in estrogen (occurs in menopause and amenorrheic women) both increases bone resorption and decreases calcium absorption DISEASE – Some diseases decrease the body’s ability to digest and or absorb calcium ALCOHOLISM – Excessive alcohol intake interferes with the body’s ability to regulate calcium homeostasis Additionally, alcohol inhibits the activation of vitamin D, which is necessary for calcium absorption PREGNANCY - During pregnancy and after weaning, relative calcium absorption increases USE OF CERTAIN MEDICATIONS – can affect bioavailability as well as increase calcium excretion VITAMIN D - aids in the absorption and utilization of calcium – in the absence of 1,25-dihydroxyvitamin D (biologically active form), less than 10% of dietary calcium may be absorbed compared to the average 30% FIBER - Dietary fiber, with the exception of wheat bran, seems to have little effect on calcium absorption, especially when adequate calcium is consumed. Foods high in oxalates (cabbage, spinach, rhubarb) or phytates (cereal grains, wheat bran, nuts and legumes) have less available calcium than foods without these constituents- Humans absorb only about 5% of the calcium from spinach compared with almost 28% from milk.HIGH SODIUM - High sodium diets increase urinary calcium excretion CAFFEINE - Likewise, high levels of caffeine can increase urinary calcium excretion -this effect can be overcome by increasing the amount of calcium in the diet - Moderate intake (1 cup of coffee or 2 cups of tea per day) has shown no negative effects on bone in young women LACTOSE – enhances bioavailability of calcium in infants, however, in adults, lactose has little if any effect on calcium absorption
  • Bullet 1 - As we just talked about, many factors affect calcium bioavailability and absorption - This includes the type of calcium-containing food you’re eatingJust a reminder…this is just looking at calcium. Each food is unique in nutrient content (and bioavailability of those nutrients), and all foods should be included as part of a balance diet.Note to Presenter:This handout is available on the Western Dairy Association website: westerndairyassociation.orgClick on the “Health and Nutrition” tab > “Health Fair Resources” > Download the “Not All Calcium Sources Are Created Equal” handoutDirect link to handout:
  • - You often hear the question “Why can’t I just take a supplement to get the calcium I need?”Bullet 1 – Foods contain other essential nutrients in addition to calcium. - For example, together, milk, yogurt and cheese also contain eight other essential nutrients (potassium, phosphorus, protein, vitamins A and D, B12, riboflavin and niacin) - A calcium supplement may help you meet your daily calcium needs but you’ll miss out on these other important nutrients that dairy foods provide. Bullet 2 - Good nutrition depends on overall healthful eating - The Academy of Nutrition and Dietetics (The Academy), the National Institutes of Health and the American Academy of Pediatrics believe that individuals should attempt to meet their nutrient needs through food first.**For example consider the analogy of an orange… - An orange provides a healthy dose of a nutrient we need: vitamin C - We can get the vitamin C we need through supplements - However, eating an orange offers more than just vitamin C…  oranges contain fiber, folate, a variety of phytonutrients, and small amounts of other vitamins and minerals - Plus we get visual, taste, and texture pleasure from enjoying an orange that we wouldn’t get from swallowing a vitamin C supplement- It is easy to forget to take a supplement, but we rarely forget to eat! Note to Presenter: Available in MV/M supplement or single preparations; there are at least a dozen commonly prescribed calcium supplements and hundreds of different formulations – calcium carbonate is the most common preparation in calcium-fortified foods and supplements.Several factors such as solubility, dosage, timing of intake, and meal conditions can influence the bioavailability of calcium from calcium supplements.A study in postmenopausal women found no difference in the bioavailability of calcium from calcium carbonate or calcium citrate (Heaney, J. Am. Coll. Nutr. 2001). Calcium carbonate may be more likely to cause gas, bloating, and or constipation as compared to calcium citrate- Calcium carbonate is absorbed best when taken with food-Calcium from supplements may be absorbed as well as that from milk, but foods such as milk provide additional nutrients important for health.The NIH Consensus Statement reported that calcium absorption is most efficient at individual or divided doses of 500 mg or less and when taken between meals – may need supplemental vit. D to insure adequate calcium absorptionPurdue University Study (April 2009 – to be published in Aug. in Journal of Bone and Mineral Research) – showed that dairy has an advantage over calcium carbonate in promoting bone growth and strength - - they found that the bones of rats fed nonfat dry milk were longer, wider, more dense and stronger than those of rats fed a diet with calcium carbonate.
  • So that’s the end of the first section on calcium… - Does anyone have any questions on that content before we move into Vitamin D?
  • In the last decade, vitamin D has become a focus of renewed interest This attention stems from the unexpected finding of widespread vitamin D deficiency in children and adults and emerging evidence of an expanding beneficial role for vitamin D in human health (cancer, immune disorders, cardiovascular disease etc.) In 2010, the recommended daily intakes for vitamin D were increased, and further research into un-solidified potential health benefits of vitamin D continues
  • - Chances are you’ve heard or seen at least one news story, headline or product advertisementhighlighting the virtues of Vitamin D- Here are a few examples… click through and read each headline…
  • Bullets 1 & 2 - Vitamin D is known as the “sunshine vitamin” because with enough exposure to sunlight, the body can make all the vitamin D it needs. However, because people have variable and often limited exposure to sunlight, vitamin D is considered an essential nutrient.Bullet 3 - The effect of vitamin D on calcium absorption is similar to a locked door and a key. -Vitamin D is the key that unlocks the door and helps calcium to be absorbed. - Vitamin D also works in the kidneys to limit calcium loss in urine.Bullet 4 – We know for certain that Vitamin D regulates blood calcium levels, but vitamin D receptors have been identified in most cells and tissues of the body - This suggests that it may be involved in other regulatory functions as well
  • I just mentioned that the body can make it’s own Vitamin D I am going to take a few minutes to touch on that process…Vitamin D3 is produced when sunlight light reacts with cholesterol in the skinVitamin D3 is then converted into calcidiolin the liverCalcidiol circulates in serum (this is what is measured when you ask for a vitamin D blood test) Calcidiol is further convertedin the kidneys to produce the active form, calcitriolCalcitriol is the active form of vitamin D which acts to turn on and off your genes. It also circulates in the blood to maintain blood calcium levels.- Vitamin D that comes from the diet is converted in the same way- Season, geographic latitude, time of day, cloud cover, smog, skin melanin content, and sunscreen all affect UV radiation exposure and vitamin D synthesis. Note box - So why are more and more people becoming vitamin D deficient? - For most of history, humans got all the vitamin D they needed simply from being outdoors -What the body didn’t use right away, it stored in fat. - Over the years, we have switched from hunting and farming to indoor jobs - We also began slathering on the sunscreen to protect our skin from the UV rays and skin cancer
  • - As it has become more apparent that people are often vitamin D deficient, there is a renewed appreciation for this sunshine vitamin.Bullet 1 - In the early 1920s, vitamin D deficiency was identified as the cause of rickets - Rickets is a disease characterized by softening of the bones and skeletal deformities (bowed legs) in growing infants and children (pictured in the upper right-hand corner)). Bullet 2 - In the 1930s, implementation of the public health measure to fortify milk with vitamin D made rickets a rare disease in the U.S. - In fact, until the last decade it was assumed that vitamin D deficiency had been eliminated as a public health concern all together.Bullet 3 - Recent increased interest in vitamin D is attributed to several developments. These included: A re-appearance of vitamin D deficiency rickets in U.S. infants and young children (especially among African Americans)New findings of an epidemic of poor vitamin D status in both children and adultsIt is estimated that vitamin D deficiency affects 21% to 58% of adolescents and adults in the U.S. Research demonstrating that vitamin D deficiency no only adversely affects the skeleton, but also may be associated with increased risk of several chronic non-skeletal diseasesAll of this excitement led the Institute of Medicine to reconsider of the daily reference intakes for vitamin D.In 2010, the dietary recommendations for vitamin D were increased for most age groupsNote to Presenter:Though it is not the active form of vitamin D, the general consensus is that testing for serum 25-hydroxyvitamin D levels serves as the best indicator of vitamin D status (Serum 1,25(OH)2D does not offer accurate information about vitamin D status. It may appearnormal or even elevated due to secondary hyperparathyroidism that accompaniesvitamin D deficiency) - However, optimal serum concentrations of 25(OH)D have not been established- It is likely that they vary at each stage of life - The committee assigned to revise the DRIs did establish that nearly all individuals are vitamin D sufficient at serum 25(OH)D levels of 50 nmol/L - The committee also noted that there is a lack of systematic evidence available to establish serum 25OHD cut-offs that define vitamin D deficiency. - Review of the data suggested that some individuals are at risk for deficiency at levels below 30 nmol/L while others become at risk between 30 nmol/L and 50 nmol/L - The committee found that the daily median intake of vitamin D in the U.S. was below 400 IU/day - However, serum 25(OH)D concentrations were above 40 nmol/L (the level that has been established as reflecting an intake equal to the RDA)
  • - Vitamin D recommendations increase with age partly because the skin becomes less efficient at producing vitamin DAssumptions: The recommendations are based on the assumptions that… Individuals are getting minimal sun exposure (due to concerns about the known effects related to skin cancer) Individuals are meeting calcium intake recommendations (due to the known interplay of calcium and vitamin D)These recommendations are based on intakes necessary for adequate bone healthThey do no necessarily support vitamin D levels required to optimize all potential physiological roles of vitamin D When establishing these recommendations, experts concluded that there was not currently enough scientific evidence related to vitamin D’s roles in autoimmune disease, cancer, diabetes etc. to take them into accountNotes to Presenter:Recognizing the recent resurgence of vitamin D deficiency rickets in children and vitamin D’s possible link to chronic diseases, the AAP recommends that babies who are exclusively breastfed should receive a vitamin D supplement until they’re drinking at least 32 ounces of formula a day. Children 1 year of age and older, not consuming at least 400 IU of vitamin D from food sources, such as vitamin D fortified milk, should receive supplementation. NOTE: These AAP recommendations were issued in 2008 and need to be reevaluated with consideration for the new vitamin D RDA of 600IU/day for children over 1 year old Tolerable Upper Intake Levels: (Based on classictoxicity studies)Infants 0-6 mo = 1,000 IU/dayInfants 6-12 mo = 1,500 IU/dayChildren 1-3 yrs = 2,500 IU/dayChildren 4-8 yrs = 3,000 IU/dayChildren & Adults 9 yrs & older = 4,000 mg/dayRule of Thumb: serum 25(OH)D rises by ~ 1 nmol/L for each 40 IU of intakeSome controversial research suggests that ideal serum 25(OH)D levels are ≥75 nmol/L, and many experts still believe that children and adults require 800-1000 IU per(Vieth R, Bischoff-Ferrari H, Boucher BJ, Dawson-Hughes B, Garland CF, Heaney RP, et al. The urgent need to recommend an intake of vitamin D that is effective. Am J ClinNutr 2007;85:649-50. )
  • - As we saw with calcium, Vitamin D has made the 2010 Dietary Guidelines list of “nutrients of concern” for both children and adults.Note to presenter:Dairy’s nutrient package includes three of the four of the nutrients we fall short on – calcium, potassium, and vitamin D– as well as protein, phosphorous, vitamin A, vitamin B12, riboflavin, and niacinIn general, about 9 out of 10 individuals (or 88% of people) consume amounts below the RDA (Recommended Dietary Allowance – the intake level that will meet the needs of the majority – 97.5% - of individuals in a population) for vitamin D. This percentage is roughly the same when examining men, woman, children, and adults.96% of girls 14-18 years old consume amounts below the RDA for vitamin D.
  • While it appears that many individuals in the U.S. are vitamin D deficient, some groups are more at risk than others…BREASTFED INFANTS: The vitamin D content of breast milk is reflective of the mother’s vitamin D status Unless a woman is taking high doses of vitamin D, her breast milk alone usually cannot support her infants’ daily needsThe AAP recommends that exclusively and partially breastfed infants receive a vitamin D supplement of 400 IU/dayOLDER ADULTS: Older adults’ skin does not synthesize vitamin D as efficiently as younger individualsAlso, they often spend more time indoorsLIMITED SUN EXPOSURE: Individuals that are homebound, wear long robes or head coverings for religious reasons, and or have jobsthat limit sun exposure are not likely to get enough sunlight for endogenous vitamin D productionThe significance of sunscreen in relation to vitamin D deficiency is currently unclearINDIVIDUALS WITH DARK SKIN: Dark skin results from increased amounts of the pigment melanin in the skin - This decreases skin’s ability to synthesize Vitamin D from sunlightFAT MALABSORBERS: Vitamin D is a fat-soluble vitamin and therefore needs some dietary fat in the gut for adequate absorptionIndividuals with certain medical conditions such as liver disease, cystic fibrosis, and Crohn’s disease do not absorb dietary fat effectively and may need vitamin D supplementOBESE INDIVIDUALS/BARIATRIC SURGERY PATIENTS: Fat tissue sequesters vitamin D, altering it’s release into the body Obese individuals may need a higher amount of vitamin D than normal weight people to obtain normal blood levels- Some bariatric surgeries involves bypassing the portion of the intestine where vitamin D is absorbed People who have had such surgeries may be more vulnerable to deficiency if their intake from food or supplements is not adequate
  • Bullet 1 - The role of vitamin D in bone health is well establishedVitamin D helps maintain healthy blood levels of calcium and phosphorus (the key bone minerals) Bullet 2 & 3 - It helps the body absorb and use these minerals to form and maintain strong bones,thus playing a role in the prevention of rickets in children and osteomalacia and osteoporosis in adults. -Without vitamin D, only 10-15% of dietary calcium and about 60% of phosphorus is absorbed. According to the National Osteoporosis Foundation, people with low levels of vitamin D have lower bone density and are more likely to break bones when they are older.
  • - While vitamin D’s role in bone health is well recognized, new research suggests this can be thought of as just the tip of the “vitamin D iceberg” It is estimated that upwards of 2000 genes may be affected by vitamin D Some preliminary research suggests a potential connection between vitamin D and many diseases and conditions including… (Click to reveal other conditions)I will touch on just a few of these in the next slide.Note to Presenter:Obesity has also been associated with vitamin D deficiency. The reason is that the vitamin D is trapped within the fat and cannot easily exit. As a result, obese patients need at least twice as much vitamin D as normal weight individuals in order to maintain normal vitamin D status.
  • Bullet 1 – Researchindicates that vitamin D-deficient individuals (or those with low sun exposure) have an increased prevalence of various infectious and autoimmune diseases - E.g. tuberculosis, pneumonia, bacterial infections, gingivitis, multiple sclerosis, rheumatoid arthritis, type 1 diabetesBullet 2 – 70 years ago, scientists noticed that people living at higher latitudes with less sunlight were at higher risk of dying of cancer. - Today, evidence suggests that people with low vitamin D statustend to have higher rates of breast, colon, rectum, prostate and ovarian cancer - More recent evidence also links it to cancers of the esophagus and pancreas, as well as leukemia. - It is thought that upwards of 17 different types of cancers may be vitamin D sensitive.Bullet 3 – While more clinical trials are recommended, vitamin D shows promising results for helping prevent CVD… - Vitamin D deficiency has been associated with increased cardiovascular risk - Some studies show an inverse relationship between vitamin D levels and blood pressure - In some studies higher rates of CVD have been observed in those with hypertension and vitamin D deficiencyNOTE: It should be noted that the functions of vitamin D, outside of bone health, are still controversial - More research is neededNotes to Presenter:On Vitamin D & Autoimmune disorders:Vitamin D insufficiency has been linked to an increased risk of tuberculosis and pneumonia, bacterial infections of the lungs, and gingivitis. The active form of vitamin D3,calcitriol, is believed to mediate immunological effects by binding to nuclear vitamin D receptors present in most immune cells, which in tern increases expression of defensive genes. It was recently recognized that the immune cell known as the macrophage needs vitamin D in order to produce a peptide which is responsible for killing infectious agents such as tuberculosis. Bikle D. Nonclassic actions of vitamin D. J. ClinEndocrinMetab. 2008Holick MF. The vitamin D epidemic and its health consequences. J Nutr. 2005; 135: 2739S-48S.Munger et al. JAMA 2006; 296 (23): 2832-8Vitamin D controls T cell antigen receptor signaling and activation in human T cells, Nature, 2010On Vitamin D & CancerVitamin D insufficiency affects normal cellular proliferation and differentiation and may thus affect risk of cancer. It is thought that activated vitamin D inhibits cancer cell growth.Heaney RP. J Steroid Biochem Mol Biol. 2007; 103:635-641Lappe JM, et al. Am J ClinNutr. 2007; 85:1586-591; www.vitamindhealth.orgBritish Journal of Nutrition, Jan. 2010, Jenab et al.On Cardiovascular Disease & Vitamin DThe Role of Vitamin D and Calcium in Type 2 Diabetes. A Systematic Review and Meta-AnalysisJCEM 2007 92: 2017-2029; doi:10.1210/jc.2007-0298Krause R et al. Ultraviolet B and Blood Pressure. Lancet. 1998; 352:709-710Wang et al. Vitamin D Deficiency and Risk of CVD. Circulation. 2008Pittas AG, Dawson-Hughes B, Li T, Van Dam RM, Willett WC, Manson JE, et al. Vitamin D and calcium intake in relation to type 2 diabetes in women. Diabetes Care 2006;29:650-6. 
  • - This quote reinforces the thought that while we are still in the research stage, the alternative roles of vitamin D (outside of bone health) are likely very real, and very important
  • -Few foods naturally supply vitamin D. -Seafood, particularly fatty fish such as mackerel, tuna, salmon and herring, as well as cod liver oil, is the most significant natural source of vitamin D in the diet. - Small amounts of vitamin D are also naturally found in sun-exposed mushrooms, egg yolk and liver. - Many foods are fortified with vitamin D including milk, some yogurts and cheeses, breakfast cereals, breads and juices. - Fortified milk is the most significant source of vitamin D in the U.S. diet. (note: vitamin D in skim and whole milk are equally bioavailable regardless of the fact that vitamin D is a fat soluble vitamin)Most experts agree that many people will not be able to meet the RDA for vitamin D focusing solely on food sources A supplement may be necessaryBullet – “Sensible Sun Exposure” – According to Dr. Holick – a practitionerat the forefront of vitamin D research… - Spending a limited amount time outdoors with arms and legs uncovered (free of sunscreen), then applying clothing or sunscreen long before the danger of sunburn sets in; 5-15 min. 2-3x per week can provide 80-100% of the requirement for vitamin D - Some dermatologists disagree due to skin cancer concernsNotes to Presenter:Factors affecting cutaneous production of vitamin D3: increased melanin (skin pigment) sunscreen use glass (windows)Clothesaging (causes a decrease in the amount of 7-dehydrocholesterol)winter seasonnorthern latitudescloud coverSmogDr. Holick has indicated that one cannot make enough vitamin D if above Atlanta, Georgia…The skin has the ability to prevent vitamin D toxicity – once you make a certain amount of vitamin D, the same UV light that created it, begins to degrade it. The more you make, the more that is destroyed.
  • Bullet 1 – Vitamin D fortification in milk began commercially in 1932 - It was endorsed by the American Medical Association Council on Foods and Nutrition in 1933.Bullet 2 – Fortification of milk is optional - However, nearly all milk sold in the U.S. is fortified. - 8 oz of vitamin D fortified milk usually contains 115-124 IU of vitamin D, supplying about 20% of the RDABullet 3 – An analysis of NHANES (National Health and Nutrition Examination Survey) 1999-2002 data found that fluid milk was the largest single source of vitamin D
  • Bullet 1 – Vitamin D3 is produced in the skin upon exposure to UVB irradiation - D3 also occurs naturally in some animal products. Bullet 2 – Vitamin D2 is derived from ultraviolet B (UVB) irradiation of ergosterol, a yeast and plant sterol. Bullet 3 – There has been considerable debate over whether or not D3 and D2 are equally effective in raising serum 25(OH)D levels -vitamin D3 is currentlythe preferred and most common form of vitamin D used in food fortification and over-the-counter dietary supplements. - However, research shows that both forms effectively raise serum 25(OH)D levels.Notes to Presenter:A variety of multivitamin supplements contain either 200 IU or 400 IU of vitamin D2 or more commonly, D3. Also, vitamin D2 and D3 supplements are available in either 400, 1,000 or 2,000 IU capsules or tablets. Fish liver oils contain up to 1,300 IU but are also high in vitamin A, carrying risks of vitamin A toxicity. Popular calcium supplements also contain vitamin D.Relying on supplements raises concerns of long-term compliance as well as an incomplete “package” of nutrients for health benefits.
  • Does anyone have any questions?Note to Presenter:The following section, “Vitamin D & Calcium, Bringing It Home”, contains practical tips for increasing vitamin D and Calcium in the diet.- Depending on the audience and the time allotted, this section may be omitted. - If omitting this section, skip to the 2nd to last slide now
  • We know that Vitamin D & Calcium are important nutrientsWe also know that generally speaking, we’re not doing a great job getting enough of them in our dietsNow what?We’re going to spend the next few slides going over some practical tips for increasing the Vitamin D and Calcium content of your diet
  • Milk and milk products are a fundamental source of both vitamin D and calcium in the American dietRecognizing this, The Dietary Guidelines for Americans recommend 3 servings of low-fat or fat-free dairy every day for most age groups However, data from the 2007-2008 National Health and Nutrition Examination Survey (NHANES) indicate that most Americans are falling shortThe horizontal green lines on this chart represent the recommended daily dairy servings for the various age groups (2 cups for 2-3 year olds, 2.5 cups for 4-8 year olds, 3 cups for everyone 9+ years old) The vertical bars represent the average number of servings each age group is actually consumingOn average, people consume only about 1.7 servings of milk or milk products each day (half of what they should)So, what can we do about this?
  • Aneasy place to start is at breakfast…
  • - Another easy way to increase calcium & vitamin D is to sneak them in through snacksAdditional tip:- Take a brief walk outside during lunch breaks or on the weekend with your family - This is a good way to get “sensible sun exposure”
  • Bullet 1 – Experts agree that dairy foods deserve a special place in children’s diets - Kids who don’t consume dairy are unlikely to meet their calcium needs, putting them at greater risk for osteoporosis later in life. - Milk also contain 8 other essential nutrients needed for growth and development (including vitamin D)Bullet 2 – Flavored milk is a hot topic in the media lately with the childhood obesity epidemic at the forefront of national efforts - Research shows that children who consume flavored milk have greater total milk intake, and higher intakes of many key nutrients, compared with children who do not drink milk. - Flavored milk provides just 3% of the added sugar in children’s diets (soft drinks & fruit drinks contribute 45%) - Also, there has been no link between drinking flavored milk and obesity. - In fact, in one study, flavored milk drinkers had comparable or lower BMIs than those children who didn’t drink milk. (This is partly because children who drink flavored milk are choosing to drink milk – not soda or another high-calorie low-nutrient beverage.) - Flavored milk provides the same nine essential nutrients as unflavored milk and can help kids meet their calcium requirements. - Recent research indicates that when schools remove flavored milk from school cafeterias, overall milk consumption goes down - Given what we have already learned – that milk is a fundamental source of essential nutrients important for growth – this is a bad thingNOTE:Children 1 year of age and older, not consuming 400 IU of vitamin D from food sources, such as vitamin D fortified milk, should receive supplementation. Notes to Presenter:A study of 7 districts throughout the United States showed that when schools removed or limited flavored milk, Overall milk consumption dropped an average of 35%, and did not recover over time. Impact on Milk Consumption & Nutrient Intakes from Eliminating Flavored Milk in Elementary Schools, Prime Consulting Group, May 2011, a joint project of the MilkProcessor Education Program, the National Dairy Council and the School Nutrition Association.)Murphy MM et al. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in U.S. children and adolescents. JADA 2008; 108:631-639.
  • Bullet 1 - Meals eaten as a family increase the likelihood that milk intake will increase. - Adolescents who eat 6 or 7 family meals a week are 27% less likely to report poor dairy food intake compared to those who eat fewer family meals.Bullet 2 - Frequency of family meals is associated with increased intake of fruits, vegetables, grains, and calcium-rich foods and negatively associated with soft drink consumption. Bullet 3 - Mothers who drink milk more frequently tend to have daughters who drink milk more frequently and drink fewer soft drinks.Children are developing eating habits that will last a lifetime…this is the age at which they need to be shown how to make healthy food choicesNotes to Presenter:Videon T, et al 2003 J Adolesc Health 32:365-73. Fisher O, et al 2001 J Nutr 131:246-50.Neumark-Sztainer D, et al 2003 J Am Diet Assoc 103:317-22.
  • Whatever your life stage, getting adequate Vitamin D & Calcium is important Dairy foods are an easy way to do this- These pictures are examples of what a serving size of various dairy foods looks like… -One serving of milk is 8 ounces which is equal to 1 cup.  - One serving of cheese is 1 to 1 ½ ounces of cheese. - That is about the size of 4 dice -For shredded cheese, about 1/3 cup would be equivalent to one serving. - For cottage cheese, the serving size increases to 2 cups to meet nutrient requirements. - Cottage cheese contains less calcium than other dairy foods because of the way it is made  - One serving of yogurt is 8 ounces, which is 1 cup. - Most single serve yogurt containers are 6-8 ounces.
  • Some people experience digestive symptoms (e.g. gas, bloating, diarrhea) when they consume milk and other dairy products As we age, some of us produce less of the enzyme lactase, which is necessary to digest the lactose in dairy - This leads to lactose maldigestion or lactose intolerance, and the associated discomfortStudies suggest that many lactose intolerant people can handle moderate amounts of dairy foods Individuals with lactose intolerance should follow these simple tips to include nutrient-rich dairy in their diet… D: Solid food slows digestion. - Slower digestion allows the body more time to digest lactose, which helps reduce symptoms. - Some people are able to tolerate chocolate milk and whole milk better -There is some evidence that thecocoa in chocolate milk and the full fat in whole milk may help slow digestion. A: Natural cheeses are generally well-tolerated because most of the lactose is removed when it is made. -Cheddar, Colby, Monterey Jack, mozzarella and Swisscheeses are particularly low in lactose I: Determine how much lactose you can tolerate at a time by starting with a small amount of milk with meals (less than 1 cup) - Gradually increase the serving size until you start to experience symptoms. - Drink slightly less than this amount in order to tolerate lactose. -Try drinking small amounts more frequently to improve your tolerance for lactose. R: For those with a more serious response to lactose, lactose-free milk contains all the same nutrients as regular milk -Lactase enzymes can also be added to your first sip or bite of a dairy food, through drops, capsules, pills or chewable tablets. (Check your pharmacy for lactase enzymes.) Y: Most yogurt contains “live, active cultures.” - These friendly bacteria improve your gut micro flora which will help you digest lactose. -The semi-solid consistency of yogurt also helps delay gastric emptying – this means that the lactase your body does make has more time to digest the lactose present. - Sweet acidophilus milk, and fermented dairy foods, like kefir or yogurt milk, may be more tolerable. Bottom line: The goal for lactose intolerant individuals is to remain symptom free while meeting nutrient needs. - Constant exposure to lactose, in small amounts and combined with food, may improve tolerability and actually help relieve symptoms.Notes to Presenter:National Institutes of Health recently convened a consensus development conference to review the scientific evidence and develop objective statements about treating lactose intolerance. The panel concluded that their isn’t enough scientific evidence to answer many of the questions about lactose intolerance, including how many people have it, whether lactose intolerance or the related avoidance of dairy foods causes serious health effects, and how lactose intolerance should be treated. More research will be needed to answer these questions.
  • Follow this “ease of digestion” continuum when making dairy choices.  Those on the left are “easiest” to digest because they are lower in lactose or have characteristics that help slow the digestion process, giving lactase more time to digest lactose consumed. For example, natural cheeses are lower in lactose because most of it is removed in the process of making cheese; and chocolate milk may be easier to digest than regular milk because of the added cocoa that may help delay gastric emptying, just like the semi-solid consistency of yogurt. Regular white milk is listed as “more difficult” to digest but it can still be a part of your diet. Drink it in smaller amounts and with other foods. Remember, that the fat content of milk influences tolerance to milk. Milk that is higher in fat is often more tolerable because it may help slow gastric emptying. Note to Presenter:Kefir is like yogurt in that it contains live, active bacteria cultures, but it is a drinkable fermented dairy product. Many people with lactose intolerance find it tolerable.
  • Spotlight on Calcium and Vitamin D

    1. 1. SPOTLIGHT ON CALCIUM AND VITAMIN D Presenter Name Presenter Title Presenter Organization
    2. 2. OUTLINE  Calcium Recommendations - How are we doing?  Calcium and Bones  More Than Strong Bones  Sources, Absorption, Fortification, and Supplementation   Vitamin D      A New Appreciation for the Sunshine Vitamin Recommendations Vitamin D-ficiency The Role of Vitamin D – The Iceberg below the Surface Sources, Fortification and Supplementation 2  Calcium and Vitamin D, Bringing It Home
    3. 3. Structural role in bones and teeth 99% of calcium in the body is found in the skeleton Most abundant mineral in your body CALCIUM Part of every cell
    4. 4. CALCIUM RECOMMENDATIONS FROM THE NATIONAL ACADEMY OF SCIENCES, 2010 You Are Life-Stage Group 1-3 Years 4-8 Years 9-18 Years 19-50 Years 51- 70 Years (Men) 51- 70 Years (Women) 71+ You Need 700 mg 1,000mg 1,300 mg 1,000 mg 1,000 mg 1,200 mg 1,200 mg 4 **NOTE: The recommendations for pregnant and lactating women are the same as for other women their age
    5. 5. “NUTRIENTS OF CONCERN”  Calcium  Potassium  Fiber  Vitamin D 5
    6. 6. HOW ARE WE DOING? NOT SO GOOD. Mean Daily Calcium Intake (mg) from Food 1400 RDA 1200 1000 800 Males 600 Females 400 200 0 Ages 2-5 Ages 6-11 Ages 12-19 Ages 20-50 Ages 50-59 Ages 60-69 Ages 70 & Over 6 What we Eat in America: NHANES 2007-2008
    7. 7. THE CALCIUM GAP 7 2010 Dietary Guidelines for Americans
    8. 8. THE CALCIUM BONE BANK  Deposits are made early in life…   85-90% of bone mass is formed by age 18-20 When calcium is lacking in the diet, withdrawals are made …from BONES  Frequent withdrawals = fragile bones 8
    9. 9. DAIRY: MORE THAN STRONG BONES  Cardiovascular Disease   Type 2 Diabetes   Full fat dairy foods have not been associated with CVD; in fact, some studies show possible protective role of dairy foods risk of Type 2 Diabetes with adequate (3 daily servings) dairy intake – unclear if relation is strongest for low-fat, full-fat, or all types of dairy Blood Pressure Regulation  risk of high blood pressure with daily calcium intake of 1,000-1,500 mg/daily 9
    10. 10. A NOTE ON CALCIUM AND YOUR HEART…  2010 meta-analysis…  Increased risk of heart attack among women taking calcium supplements  Calcium from supplements, rather than calcium from food may be the most suspect  The jury is still out… The American Heart Association supports national calcium intake recommendations  Fat-free milk & low-fat dairy products encouraged  10
    11. 11. FOOD SOURCES OF CALCIUM Food Calcium (mg) Yogurt, plain, low-fat, 1 Cup 415 Yogurt, fruit-flavored, low-fat, 1 Cup 345 Sardines, canned in oil, with bones, 3 ounces 324 Milk, plain, flavored or lactose free, 1 Cup 300 Orange Juice, calcium-fortified, 8 ounces 300 Cheddar Cheese, 1 ounce 204 Cottage Cheese, low-fat, 1 Cup 138 Kale, cooked, 1 Cup 94 Broccoli, raw, ½ Cup 21 11
    12. 12. CALCIUM BIOAVAILABILITY  Calcium absorption and renal excretion may be affected by:            Age Estrogen status Some diseases of the small intestine, liver and pancreas Alcoholism Pregnancy Use of certain medications Vitamin D status Fiber and its components (oxalic acid or phytic acid) High-sodium diets Caffeine Lactose 12
    13. 13. NOT ALL CALCIUM SOURCES ARE CREATED EQUAL  To absorb the same amount of calcium as you get from ONE cup of milk, you would have to eat one of the following: 13
    14. 14. WHY CAN’T I JUST TAKE A SUPPLEMENT TO GET THE CALCIUM I NEED?  More than just calcium  The Academy, NIH, and AAP recommend we meet nutritional needs through food first “A fundamental premise of the Dietary Guidelines is that nutrients should come primarily from foods.” ~ 2010 Dietary Guidelines for Americans 14
    15. 15. QUESTIONS? 15
    16. 16. Widespread vitamin D deficiency Expanding role of vitamin D in human health VITAMIN D New dietary recommendations
    17. 17. VITAMIN D IN THE NEWS 17
    18. 18. VITAMIN D – THE “SUNSHINE” VITAMIN  Considered a hormone, vitamin, and essential nutrient  Synthesized in the skin as a result of exposure to sunlight  Most known for role in enhancing calcium absorption and increasing bone resorption  Vitamin D receptors present in most body cells and tissues 18
    19. 19. VITAMIN D SYNTHESIS Skin exposure to sunlight Vitamin D3 Liver Calcidiol Kidney Calcitriol (active form) 19
    20. 20. A NEW APPRECIATION FOR THE SUNSHINE VITAMIN  1920s – vitamin D deficiency identified as the cause of rickets in infants and young children  1930s –fortification of milk with vitamin D  Today – Renewed interest: Re-appearance of vitamin D deficiency rickets  New findings of an epidemic of poor vitamin D status  Research demonstrating adverse affects of deficiency beyond bones   New vitamin D recommendations 20
    21. 21. VITAMIN D RECOMMENDATIONS Age 0-12 mo 1-70 years >70 years Adequate Intake 400 IU/day - RDA 600 IU/day 800 IU/day **NOTE: The recommendations for pregnant and lactating women are the same as for other women their age  Assumptions: -Minimal sun exposure -Adequate calcium intake 21 National Academy of Sciences, Institute of Medicine, 2010
    22. 22. “NUTRIENTS OF CONCERN”  Calcium  Potassium  Fiber  Vitamin D 22
    23. 23. VITAMIN D-FICIENCY  Who’s at Risk? Breastfed Infants  Older Adults  Those Receiving Limited Sun Exposure  Individuals with Dark Skin  Fat Malabsorbers  Obese Individuals  Or, those who have undergone bariatric surgery  23
    24. 24. VITAMIN D AND BONE HEALTH  Helps maintain healthy blood levels of calcium and phosphorus  Aids in absorption of the key bone minerals  Plays a role in the prevention of rickets and severe bone loss “Studies show that people with low levels of vitamin D have lower bone density or bone mass. They are also more likely to break bones when they are older.” - National Osteoporosis Foundation 24
    25. 25. THE ROLE OF VITAMIN D: THE ICEBERG BELOW THE SURFACE Bone Health Metabolic syndrome Hypertension Muscle weakness/wasting Certain Cancers Heart Disease Type 1 Diabetes Falls Chronic pain/Fibromyalgia Autoimmune disorders AND MORE… 25
    26. 26. VITAMIN D AND…  Auto-immune disorders   Cancer   D-deficient individuals have an increased prevalence of various infectious and autoimmune diseases Inverse associations between vitamin D status and certain cancers Cardiovascular Disease  Inverse associations between vitamin D status and CVD risk, blood pressure, metabolic syndrome, type 2 diabetes 26
    27. 27. “Humans make thousands of units of vitamin D within minutes of whole body exposure to sunlight. From what we know of nature, it is unlikely such a system evolved by chance.” ~ Dr. John Cannell, Executive Director, Vitamin D Council. 27
    28. 28. BEST SOURCES OF THIS NUTRIENT? Food Vitamin D (IU) Salmon, 3 ½ ounces, cooked 360 Tuna, light, canned, drained, 3 ounces 200 Fortified Milk, all types, 8 ounces 120 Orange Juice, fortified, 8 ounces 100 Yogurt, fortified, 6 to 8 ounces 80-100 Cereal, ready-to-eat, fortified, ¾ to 1 Cup 40-60 Egg, 1 large, whole, cooked any way 20 Mushrooms, ½ Cup, cooked 11  “Sensible Sun Exposure” 28
    29. 29. VITAMIN D FORTIFICATION  Vitamin D fortification in milk – 1932  Optional, however…   Nearly all milk sold in the U.S. is fortified with vitamin D Fluid milk is the single largest source of vitamin D in the American diet  Some cheeses and yogurts are also being fortified 29
    30. 30. SUPPLEMENTATION: D2 OR D3?  Vitamin D3 (cholecalciferol)   Vitamin D2 (ergocalciferol)   Produced in the skin upon exposure to UVB irradiation Manufactured by yeast upon exposure to UV irradiation Vitamin D3 is the preferred, and most common form  Both D3 & D2 are effective in raising serum vitamin D levels 30
    31. 31. QUESTIONS? 31
    33. 33. VITAMIN D & CALCIUM, BRINGING IT HOME  Milk is the #1 dietary source of Vitamin D & Calcium in the American Diet What do we do? 33 NHANES 2007-2008, ages 2 years and older
    34. 34. TIPS FOR INCREASING CALCIUM & VITAMIN D START AT BREAKFAST…  Use low-fat milk in place of water when making oatmeal   Make scrambled eggs with low-fat milk and top with shredded cheese Pair low-fat cottage cheese with fresh fruit for a nutrient-rich breakfast • Top a whole-grain waffle with low-fat yogurt and mixed berries instead of syrup  Top off breakfast with a glass of calcium and vitamin D fortified orange juice 34
    35. 35. TIPS FOR INCREASING CALCIUM & VITAMIN D SNACK SMART…  Mix low-fat milk or vitamin D-fortified yogurt with fruit in a blender to make a fruit smoothie or licuado  When a craving strikes, enjoy a cup of steaming hot chocolate – mix fat-free milk with a little chocolate syrup  For a nutrient-rich snack, enjoy fruit and cheese kabobs, or skip the cheese and dip fruit kabobs in low-fat yogurt 35
    36. 36. TIPS FOR INCREASING CALCIUM & VITAMIN D …IN CHILDREN  Dairy foods supply 83% of the calcium in the diets of young children  Dairy’s unique nutrient package is an important source of nutrition for growing bodies • WHAT ABOUT FLAVORED MILK?  Greater total milk intake  Greater nutrient intake  No relationship with obesity 36
    37. 37. TIPS FOR INCREASING CALCIUM AND VITAMIN D IN CHILDREN EATING TOGETHER IS IMPORTANT  Meals eaten as a family increase likelihood of milk intake   More family meals means increased intake of encouraged food groups Moms who drink milk have daughters who drink more milk, less soft drinks 37
    38. 38. 3 EVERY DAY OF DAIRY One serving:  Milk 8 ounces = 1 cup  Cheese 1 – 1 ½ ounces  Yogurt 8 ounces = 1 cup 38
    39. 39. DO PEOPLE WITH LACTOSE INTOLERANCE NEED TO AVOID DAIRY? D A Drink milk with food. Add natural cheeses to your diet, such as Cheddar, Colby and Swiss, which are low in lactose. I Introduce dairy slowly. Gradually increase the amount. R Y Reduce it. Enjoy lactose-free milk and milk products. Yogurt with active cultures helps digest lactose. 39
    40. 40. Moderately Easy Easiest More Difficult Ease of digestion  Natural cheeses: Cheddar, Colby and Swiss  Yogurt with live and active cultures  Kefir  Lactose-free milk  Chocolate milk  Ice cream and frozen yogurt  Soft cheeses: Cottage, Feta, Rico tta  Whole milk  Reduced fat milk  Lowfat milk  Fat-free milk 40
    41. 41. For More Information: • Western Dairy Association: • National Dairy Council: • 2010 Dietary Guidelines for Americans and MyPlate: , • Office of Dietary Supplements: • NIH Osteoporosis and Related Bone Diseases National Resource Center: • American Academy of Pediatrics: Today’s presentation provided by: 41
    42. 42. QUESTIONS? 42