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Research Article
The Open Access Journal of Science and Technology
Vol. 2 (2014), Article ID 101020, 6 pages
doi:10.11131/2014/101020

Postpartum Nutrient Intakes and Beverage Patterns of American Indian Women

Teresa A. Marshall1, Katherine W. O. Kramer2, Brenna C. McMahon3, Delores E. Starr4, Kathy R. Phipps5, John J. Warren1, Deborah V. Dawson2, and David R. Drake2

1Department of Preventive and Community Dentistry, University of Iowa, Iowa City IA, USA

2Dows Institute for Dental Research, University of Iowa, Iowa City, IA, USA

3University of Wisconsin Hospital & Clinics, Madison, WI, USA

4Indian Health Service, Pine Ridge, SD, USA

5Oral Health Surveillance Consultant, Morro Bay, CA, USA

Received 14 August 2013; Accepted 17 April 2014

Academic Editor: Gustavo Pimentel

Copyright © 2014 Teresa A. Marshall et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives: American Indian (AI) children are at risk for chronic diseases associated with marginal early nutrition environments. We describe nutrient intakes and beverage patterns of AI women during the early postnatal period to identify nutritional adequacy and beverage habits. Methods: 24 hour recalls and beverage frequency questionnaires were administered to AI mothers (n = 239) from a Northern Plains Tribal community 1 month postpartum. 24 hour recalls were analyzed using Nutritionist PRO(R) software, and intakes were compared to Estimated Average Requirements (EAR). Results: The percentage of AI women reporting nutrient intakes below the EAR was 97% for vitamin D, 96% for vitamin E, 69% for vitamin A, 55% for vitamin C, 73% for calcium and 79% for magnesium. Median (25th, 75th percentile) beverage intakes reported by beverage consumers were 8.0(4.0, 16.0) oz milk, 8.0(3.4, 16.0) oz 100% juice, 8.0(4.0, 16.0) oz juice drinks, 18.6(7.4, 28.0) oz regular pop, 9.1(4.6, 18.3)oz sports drinks, 12.0(5.1, 22.0)oz sugared flavored water and 48.0(24.0, 96.0) oz water. Conclusions: The low nutrient and high sugared beverage intakes increased risk of chronic malnutrition. The nutritional environment predisposes AI children to chronic diseases including obesity and dental caries through early metabolic programming and later modeling behaviors.

1. Introduction

Dietary behaviors are a common denominator for both obesity and dental caries, which are chronic diseases particularly prevalent in American Indian (AI) children [1,2]. Obesity is defined as having excess body fat, and predisposes one to multiple comorbid conditions including type 2 diabetes, cardiovascular disease, hypertension, osteoarthritis and sleep apnea. Dental caries is defined as the process during which oral bacteria produce acid which destroys the enamel. While obesity is associated with excessive intake of energy from carbohydrate, protein, fat or alcohol, caries are associated with excessive exposure to fermentable carbohydrates. Highly processed foods and dietary behaviors that encourage frequent, prolonged eating have been associated with both obesity and caries.

Unfortunately, both disease processes are much more complex than is often suggested by the emphasis on excessive energy intake and eating frequency. Obesity has long been known to have a strong genetic predisposition with multiple environmental risk factors. Caries have historically been associated with environmental risk factors including oral hygiene and fluoride exposure; the genetic predisposition to caries is beginning to be explored. Furthermore, dietary influences, previously simplified to current eating practices, are now being explored as lifelong processes. Early nutrient exposure is thought to set the stage for subsequent disease risk through metabolic programming and tissue development [3,4]. In utero and early post-natal malnutrition is a risk factor for adult obesity and cardiovascular disease, while micronutrient deficiencies during tooth development are a risk factor for enamel hypoplasia which could increase susceptibility to caries [3,4][5][6]. Furthermore, Schroth et al. reported that children with severe early childhood caries had lower serum vitamin D and higher parathyroid hormone levels than children without caries [6].

Obesity and caries are each associated with low socioeconomic status; the relationship between socioeconomic status and access to adequate nutritional resources is called food security [7,8,9]. Early food insecurity has been associated with increased risk of poor oral health, increased hospitalizations, developmental concerns and obesity [10,11,12,13]. Diets of children from very low food secure households are often high in total energy, fat and added sugars and characterized by high sugared beverage intakes [14,15].

AI children have disproportionally high burdens of both obesity and caries, and little data are available on their early nutrition environments. Modeling of diets that provide inadequate nutrient intakes and/or beverages associated with caries during infancy could increase risk of obesity and caries in later childhood. The purpose of the present paper is to describe nutrient intakes and beverage patterns of AI women during the early postnatal period to identify nutritional adequacy and beverage habits.

2. Methods

2.1. Subjects

Mothers (n = 239) of newborn children living in a Northern Plains Tribal community were recruited for participation in a longitudinal investigation of early childhood caries with emphasis on transmission of cariogenic bacteria from mother to child [16]. The study was approved by the University of Iowa's Institutional Review Board, the Aberdeen Area Indian Health Service's Institutional Review Board and the Tribal Research Review Board.

2.2. Data collection

Baseline data including demographic, mothers' dietary and other caries-related variables were collected through interviews by study research assistants and exams by dental hygienists during in-home visits when the child was approximately one month of age (± 30 days). A dietary manual was developed to train research assistants to conduct 24 hour recalls and query dietary practices. The 24 hour recalls were analyzed by a registered dietitian using Nutritionist PRO(R) software, and nutrient intakes were compared to age and gender specific Estimated Average Requirements (EAR), the Dietary Recommended Intake (DRI) that defines the nutrient intake necessary to meet 50% of a population's needs, and Adequate Intakes (AI), the DRI that defines the nutrient intake meeting 100% of the population's needs [17,18]. A beverage intake questionnaire was used to ascertain frequencies and quantities of beverage consumption. Alcohol intake was not assessed due to sensitivity of alcohol use and the alcohol free nature of the community.

2.3. Statistical analyses

Statistical analyses were performed using SAS (Version 9.3, SAS Institute, Cary NC). Descriptive statistics are presented for demographic, nutrient and beverage intakes.

3. Results

The women in this study were 23.7 ± 5.6 years of age (mean ± standard deviation) and living in households with 7.0 ± 2.8 members at enrollment. The majority of women self-identified as AI alone. Most women had a high school education or less with few graduating from college. Of those reporting household income, most reported incomes less than $10,000. Specific demographic characteristics are provided in Table 1.

Table 1: AI women's (n = 239) demographic characteristics at enrollment

Women's 24 hour-recall reported nutrient intakes and the percentage of women whose nutrient intakes were below their age-specific EARs are listed in Table 2. More than 90% of women reported nutrient intakes below the EAR for vitamin D and vitamin E, while over 50% reported intakes below the EAR for vitamin A, vitamin C, calcium and magnesium. Median (25th, 75th percentiles) fiber intakes of 13 (8, 18) g were below the AI of 25 g. The median (25th, 75th percentiles) total sugar intakes were 78 (40, 123) g; the relative distribution of natural and added sugars is unknown.

Table 2: Median (25th, 75th %) daily nutrient intakes of AI women (n = 239) calculated from 24 hour recalls compared to age specific Estimated Average Requirements (EAR).

More women reported consumption of water or sugared beverages than of flavored sugar-free beverages (Table 3). Water, 100% juice and regular pop were consumed by over 80% of women, while milk and reconstituted powdered beverages were consumed by over half of women. Of those reporting consumption, median intakes were highest for water (48 oz), followed by regular pop (19 oz), milk (8 oz), 100% juice (8 oz) and reconstituted sugared beverages (8 oz). The most commonly consumed beverages at meals were water (36%) and regular pop or other sugared beverages (33%), with water (47%) and regular pop or other sugared beverages (29%) also being the most commonly consumed beverages between meals.

Table 3: Percent of AI women (n = 239) consuming beverages weekly, and median (25th, 75th %) daily intakes of consumers calculated from 24 hour recalls.

4. Discussion

Analyses of 24 hour recalls reported by AI women during the postnatal period suggest that their nutrient intakes are not consistent with EAR guidelines for adult women. The EAR is defined as the nutrient intake meeting 50% of a healthy population's requirements, and is used to identify nutritional adequacy [17]. An individual whose usual intake is less than the EAR is defined as having an inadequate intake. Using these criteria, the diets of AI women are not meeting their nutritional needs and place them at risk for nutrient deficiency related diseases.

Reported energy intakes are within normal ranges for adult women suggesting that inadequate nutrient intakes are associated with food choices rather than inadequate food consumption. Nutrients associated with grains (i.e., thiamin, niacin, riboflavin) and meats (i.e., protein, iron and zinc) were least likely to be deficient, while nutrients associated with dairy foods (i.e., calcium, vitamin D, and vitamin A) and fruits or vegetables (i.e., fiber, vitamin C, and folate) were more likely to be deficient. Low intakes of dairy products, fruits and vegetables have been reported previously amongst AI populations [19], and low intakes are certainly not unique to this population [20,21]. Ta et al. assessed fruit and vegetable intakes of adults living in Washington State as part of a cardiovascular risk factor study, and reported that approximately 22%, 15% and 6% of adults met the 2005 USDA Dietary Guidelines for fruits, vegetables or both fruits and vegetables, respectively [20]. Similarly Lutfiyya et al. reported that 79% of rural and 75% of non-rural adults participating in the 2009 Behavioral Risk Factor Surveillance Study failed to consume the recommended 5 servings of fruits and/or vegetables [21].

Low household incomes, particularly for the household size, were reported by AI women participating in this study. Although we did not assess food security, food insecurity is associated with the presence of children, low socioeconomic status, and black or Hispanic identity, and has previously been reported in AI populations [22,23,24,25,26]. According to the USDA, the geographical area studied is considered a food desert with 100% of residents having low food access [23]. With limited access to food stores and limited financial resources, which impact transportation to access food as well as purchasing power, the observed inadequate nutrient intakes are not surprising. Bauer et al. reported that AI children from very low food secure homes had more household barriers to healthy food consumption and consumed more foods from convenience stores than their food secure peers [24]. Mullany et al. reported that high food costs and transportation barriers increased the risk of food insecurity in AI families [25].

Over 50% of AI women participating in this study reported weekly consumption of regular pop, reconstituted powdered sugared beverages, 100% juice and other sugared beverages. Recommendations for sugared beverage intakes are limited, and generally suggest that sugared beverage, including 100% juice, intakes be decreased or limited to 8 oz per day [27,28]. Total daily sugared beverage intakes reported by AI consumers were high relative to suggested intakes for added sugars. According to the United States Department of Agriculture's MyPlate Guidelines, recommended empty calorie intakes (i.e., calories from solid fats and added sugars) for adult women with low activity levels range from 160–260 kcal [29]. Eight ounces of regular pop, reconstituted powdered sugared beverages and 100% juice contain 100, 110, and 130 kcal, respectively. Many AI women participating in this study who consume these beverages are exceeding these guidelines; again, these data are consistent with reported intakes from other populations [14,15][30].

We do not know if or how the diets of AI women might have changed since childbirth as our data were collected 1 month postpartum. However, the reported intakes are not consistent with adequate nutrition for optimal fetal development, nor are AI women modeling nutritionally healthy diets for their children. Most women are prescribed prenatal vitamins during pregnancy which, if consumed, would ensure adequate nutrient intake for fetal development. Should the dietary intakes reported 1 month postpartum reflect food insecurity and/or lack of access to healthy diets, one could assume that food nutrient intakes during pregnancy were not ideal. Prenatal, perinatal or postnatal malnutrition is considered a risk factor for subsequent chronic disease, including obesity and enamel hypoplasia associated dental caries [3,4][5]. Regardless of the in utero environment, modeling of dietary behaviors that provide inadequate nutrient and high sugared beverages intakes places the AI child at risk for both obesity and dental caries.

Self-reported dietary intakes are limited by the respondent's memory, willingness to divulge true behaviors and biased recall. A single 24 hour recall, which is a poor estimate of individual intake, was used to collect intake data in this study; multiple 24 hour recalls are preferred to identify usual nutrient intakes. A beverage frequency intake was used to quantify usual beverage intakes. Interview administered recalls and frequencies do not require literacy, have limit impact on food choices and have minimal response burden. Participants are aware that the current study is focused on oral health, and knowledge of associations between sugared beverage intakes and caries might have encouraged underreporting of sugared beverage intakes and exaggeration of sugar-free beverage intakes.

The low nutrient and high sugared beverage intakes reported by AI women are not uncommon for individuals with socioeconomic, racial and ethnic disparities. The reported intakes increase risk of chronic malnutrition which predisposes the women to chronic disease and early mortality. Furthermore, through early metabolic programming and later modeling behaviors, the nutritional environment predisposes the AI children to chronic diseases including obesity and dental caries.

Acknowledgements

This study was funded by NIH Grant RO1 DE017736. None of the authors have a conflict of interest.

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Research Article
The Open Access Journal of Science and Technology
Vol. 2 (2014), Article ID 101020, 6 pages
doi:10.11131/2014/101020

Postpartum Nutrient Intakes and Beverage Patterns of American Indian Women

Teresa A. Marshall1, Katherine W. O. Kramer2, Brenna C. McMahon3, Delores E. Starr4, Kathy R. Phipps5, John J. Warren1, Deborah V. Dawson2, and David R. Drake2

1Department of Preventive and Community Dentistry, University of Iowa, Iowa City IA, USA

2Dows Institute for Dental Research, University of Iowa, Iowa City, IA, USA

3University of Wisconsin Hospital & Clinics, Madison, WI, USA

4Indian Health Service, Pine Ridge, SD, USA

5Oral Health Surveillance Consultant, Morro Bay, CA, USA

Received 14 August 2013; Accepted 17 April 2014

Academic Editor: Gustavo Pimentel

Copyright © 2014 Teresa A. Marshall et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives: American Indian (AI) children are at risk for chronic diseases associated with marginal early nutrition environments. We describe nutrient intakes and beverage patterns of AI women during the early postnatal period to identify nutritional adequacy and beverage habits. Methods: 24 hour recalls and beverage frequency questionnaires were administered to AI mothers (n = 239) from a Northern Plains Tribal community 1 month postpartum. 24 hour recalls were analyzed using Nutritionist PRO(R) software, and intakes were compared to Estimated Average Requirements (EAR). Results: The percentage of AI women reporting nutrient intakes below the EAR was 97% for vitamin D, 96% for vitamin E, 69% for vitamin A, 55% for vitamin C, 73% for calcium and 79% for magnesium. Median (25th, 75th percentile) beverage intakes reported by beverage consumers were 8.0(4.0, 16.0) oz milk, 8.0(3.4, 16.0) oz 100% juice, 8.0(4.0, 16.0) oz juice drinks, 18.6(7.4, 28.0) oz regular pop, 9.1(4.6, 18.3)oz sports drinks, 12.0(5.1, 22.0)oz sugared flavored water and 48.0(24.0, 96.0) oz water. Conclusions: The low nutrient and high sugared beverage intakes increased risk of chronic malnutrition. The nutritional environment predisposes AI children to chronic diseases including obesity and dental caries through early metabolic programming and later modeling behaviors.