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PARENTAL INFLUENCES ON CALCIUM INTAKE IN CHILDREN AND THEIR
ROLE IN CHILD SUPPLEMENT AND CALCIUM-FORTIFIED FOOD USE

By

Stephanie Lyn Schoemer

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE
Department of Food Science and Human Nutrition

2005

ABSTRACT

PARENTAL INFLUENCES ON CALCIUM INTAKE IN CHILDREN AND THEIR
ROLE IN CHILD SUPPLEMENT AND CALCIUM-FORTIFIED FOOD USE

By

Stephanie Lyn Schoemer
Our objective was to understand how these influences of calcium intake relate to a
sample of preadolescent’s use of supplements and calcium-fortified foods.
Qualitative interviews and surveys were used to conduct a prospective study to assess
parental influences on preadolescent calcium supplement and fortified food use. The
study population was a convenience sample of Asian (n=56) Hispanic (n=6l), and
white (n= 74) parents (n=191) of children (10-13 years). Content analysis procedures
were used to identify and code interview comments as positive, neutral, or negative
parental influences. Cluster analysis was used to identify groups with similar patterns
of comments and chi-square analysis was used to determine associations between
groups and variables of interest. Two dominant patterns of responses defined the
clusters. Cluster 1 (n=128), consisted of positive parental influences for availability
of dairy foods, milk, and cheese, positive health benefit beliefs for dairy, and child
preference for dairy and cheese, whereas Cluster 2 (n=63) consisted of one positive
parental influence, availability of milk, while the rest remained neutral. No
relationship was found between cluster membership and child supplement use. Use
of calcium-fortified foods was significantly more likely to occur in children
represented in Cluster 1 compared to Cluster 2. Positive parental influences were
related to calcium-fortified food, but not supplement use, and will need to be

considered in nutrition education.

Copyright by
STEPHANIE LYN SCHOEMER
2005

ACKNOWLEDGMENTS

I would like to extend my gratitude to my advisor, Beth Olson. She has spent many
hours with me planning, reviewing, and discussing this project. I appreciate all of her
thoughtful comments and suggestions throughout the process. I have learned a
tremendous amount from her and feel so fortunate to have had her as an advisor. I
would also like to thank my committee members, Mark Reckase, Kimberly Chung
and Lorraine Weatherspoon. They have also spent a lot of time with me advising and
providing helpful suggestions with certain components of the project. Finally, I
would like to thank my parents and my boyfriend who have been extremely

supportive during this challenging process.

iv

TABLE OF CONTENTS

LIST OF FIGURES .......................................................................... viii

LIST OF APPENDICES ............................................................................................ ix

CHAPTER ONE

INTRODUCTION ................................................................................ 1

CHAPTER TWO

REVIEW OF LITERATURE ................................................................. 6
Importance of Calcium ................................................................. 6
Recommendations and Intake ........................................................ 15
Sources of Calcium .................................................................... 27
Parental Influences ..................................................................... 40

CHAPTER THREE

METHODS ...................................................................................... 49
Overview of Design ....................................................................... 49
Data Sources ........................................................................... 49
Transformation ofData53
Analysis .................................................................................. 61

CHAPTER FOUR

RESULTS ....................................................................................... 64

CHAPTER FIVE

DISCUSSION ................................................................................... 80

CHAPTER SIX

CONCLUSIONS AND IMPLICATIONS ................................................ 95

APPENDICES ................................................................................. 97

BIBLIOGRAPHY ........................................................................... 159

LIST OF TABLES

Chapter Two Page
Table 2.1 Recommended Calcium Intakes in US and UK ........................... 17

Table 2.2 NHANES l999-2000-Percentage of Children Not Meeting the AI
Calcium Recommendation ................................................................... 23

Table 2.3 Percent Nutrient Contribution of Dairy Foods to the US. Food Supply,

1997 ............................................................................. 28
Table 2.4 Calcium Contribution of Selected Foods ................................... 31
Table 2.5 Calcium Content of One Serving of Fortified Foods ..................... 32
Chapter Three
Table 3.1 Variables Representing Parental Influences on Calcium Intake
Identified through Content Analysis ....................................... 55
Table 3.2 Parental Influences, Sociodemographic, Supplement and Calcium-
Fortified Food Variables ..................................................... 60
Chapter Four
Table 4.1.1 Sociodemographic Characteristics for Parents and Children. . . . . . . . ....66
Table 4.1.2. Child Race/Ethnicity Differences by State of Residence ............... 67
Table 4.1.3 Child Race/Ethnicity Differences in free/reduced price School Lunch
Participation .................................................................... 67
Table 4.1.4 Child Race/Ethnicity Differences in Education Level ................... 67
Table 4.2.1 Positive Parental Influences Related to Child Dairy Intake ............. 69
Table 4.2.2 Negative Parental Influences Related to Child Dairy Intake. . ....70
Table 4.3.1 Cluster Patterns ............................................................... 71
Table 4.3.2 Child-Parent Sociodemographics by Cluster Pattern ..................... 71

vi

Table 4.4.1

Table 4.4.2

Table 4.4.3

Table 4.4.4

Child and Parent Calcium Supplement and Calcium-

Fortified Food Use ............................................................ 75
Child and Parent Calcium-Fortified Food Type .......................... 75
Sociodemographics of Children who used Supplements ................ 76

Sociodemographics of Children who used Calcium-Fortified
Foods ................................................................................................. 76

vii

LIST OF FIGURES

Chapter Four Page

Figure 4.5.1 Relationship between Cluster Membership and Child ................... 78
Calcium-Fortified Food Use

Figure 4.5.2 Relationship between Cluster Membership and Child Calcium-
Fortified Food Use, among Free/Reduced Price School Lunch
Program Participants .......................................................... 79

Figure 4.5.3 Relationship between Cluster Membership and Child Calcium-
Fortified Food Use, Among Parents with Less Education ............... 79

viii

Appendix A
Appendix B

Appendix C

Appendix D
Appendix E
Appendix F
Appendix G

Appendix H

LIST OF APPENDICES

Page
UCIHRS Informed Consent ................................................. 99
W1003 Qualitative Interview Guide ...................................... 102
W1003 Supplement and Calcium-Fortified Food Questionnaire
Interview Guide and Questionnaire ....................................... 108
Codebook ..................................................................... 133
Coding Form ................................................................. 147
Hierarchical Cluster Dendogram .......................................... 149
K-means Cluster Method ................................................... 154
Percent Prevalence of Positive, Negative and Neutral Parental
Influences ..................................................................... 158

ix

Chapter One

INTRODUCTION

1.1 Background

Inadequate calcium intake has reached crisis levels according to various
professional societies and health agencies that identify it as a major nutrition priority
in the United States. Data from the NHANES 1999-2000 survey estimated that 56
percent of 2 to 8 year olds and 80 percent of 9 to 18 year olds are not meeting the
current dietary recommendations for calcium (Ervin et al., 2004). Generally, boys
consume more calcium than girls. However, the average intakes for boys
documented in CSFII 1994—96 and 1998 and NHANES 1999-2000 are well below the
adequate intake (AI). Calcium is an essential nutrient involved in numerous
biochemical processes and inadequate intake during childhood and adolescence
increases the risk for several negative health consequences such as bone fractures and
osteoporosis later in life.

Calcium is the principal mineral of bone and teeth with greater than 99 percent of
the body’s calcium found in the skeleton. The majority of bone mass is accumulated
during the first two decades of life, thus childhood and adolescence are critical times
to obtain sufficient calcium to help ensure adequate mineralization of the skeleton
(Abrams et al., 2000). Recognition of the critical role of calcium in bone health
contributed to the Food and Nutrition Board’s (FNB) Standing Committee on the
Scientific Evaluation of Dietary Reference Intakes and specifically the Panel on

Calcium and Related Nutrients decision in 1997 to increase calcium intake

recommendations in adolescents and adults 51 + years (IOM, 1997). Unfortunately,
during this time of maximum bone accretion, the majority of American youth are not
consuming sufficient calcium to reach peak bone mass — potentially leaving
themselves vulnerable to increased risk for bone fiactures and osteoporosis later in
life (Lysen & Walker, 1997). Particularly susceptible are youth of Asian or Hispanic
heritage who have a higher risk of osteoporosis compared to whites (Siris et al.,
2001)

Osteoporosis -- a disease that gradually weakens bones and often leads to
painful and debilitating fractures — affects 15-28 million Americans, including half
the women over 45 years of age, and results in health care costs of $7-10 billion
(NOF, Accessed 2004). One in three women and one in eight men aged 50 years and
older will experience an osteoporosis-related fracture in their lifetime. Osteoporotic-
related fractures have serious consequences with 24 percent of hip fi'acture patients
aged 50 and older dying in the year following fracture (NOF, Accessed 2004).
Osteoporosis is the most readily identified health issue associated with inadequate
calcium throughout the lifespan and research suggests that optimal intake can help
delay or ameliorate the onset of this harmful condition.

1.2 Study Rationale

Multiple and diverse factors may negatively influence calcium nutrition in
preadolescents and adolescents. It has been suggested that some of these influences
include: displacement of milk as a beverage with soda, juices and sports drinks
(Ballew et al., 2000), eating away from home (Guthrie, 1999), the perception,

particularly among females, that milk and/or dairy products are fattening and

therefore intake is restricted or eliminated (Barr, 1995), lactose intolerance, and
psychosocial developmental changes. The role of the family, particularly the role of
the parent, is a factor of interest that may negatively or positively affect calcium
intake in children. Unfortunately, limited research has been completed in this area.
Parental influences play an important role in the development of children’s eating
patterns, eating behaviors and food preferences (Birch, 1998b). Focus group research
has identified positive parental influences such as modeling of milk consumption by
other family members, parental expectations that milk will be consumed regularly,
and availability of calcium-rich foods in the home as influences that may work to
improve intake (Novotny et al., 1999; Auld et al., 2002; Novotny et al., 2003). A
study that investigated calcium intake found that modeling of milk by mothers was
shown to positively influence milk consumption in girls 5 to 9 years old (Fisher et al. ,
2004). Further research, however, is needed to gain a clearer understanding of the
role of the parent, and will be addressed in this study.

Additionally, little information is available regarding psychosocial factors behind
child intake of dietary supplements and calcium-fortified foods. Over the past
decade, there has been an increase in calcium-fortified food and supplement use
(Miller et al., 2001; Nicklas, 2003). Over half of adults age 20 years or older, 45
percent of 3 to 5 year olds, and 33 percent of 6 to 11 year olds were reported to be
using vitamin/or mineral supplements (Radimer et al., 2004) Characteristics of adult
supplement users who have reported giving supplements to their children were more
likely to be married, with higher income and education levels, and were more likely

to consume a nutrient-rich diet (Y u at al., 1997). Popkin et a1 indicated that use of

fortified foods crossed socioeconomic lines, but there are no current analyses of
characteristics of fortified-food users on a large cross-section of the US. population
(Subar & Bowering, 1988; Popkin et al., 1996a). Furthermore, little is known about
why parents provide supplements and calcium-fortified foods to their child and which
are more likely to do so. This research study will be the first to explore the
relationship between parental influences related to calcium-rich foods and their role
in child use of supplements and calcium-fortified foods. Data obtained in this study
will lend itself to future strategies aimed at improving calcium nutriture through
calcium-fortified foods and/or supplements, consequently potentially reducing the
risk for osteoporosis.
1.2 Specific Aims and Hypotheses
The specific aims of this study are:
Aim 1. To identify positive and negative parental influences related to calcium intake
in preadolescents.
Hla: The most prevalent positive parental influence will be availability.
Hlb: The most prevalent negative parental influence will be lack of parental
modeling.
Aim 2. To identify patterns of parental influences within the sample population.
H2a: There will be one main positive and one main negative parental
influence pattern of parental influences.
Aim 3. To compare patterns of parental influences to preadolescent use of calcium-
fortified foods and supplements.

[Bar A positive parental influence pattern will be positively

associated with supplement and calcium-fortified food use.
H3b: A negative pattern will be negatively associated with
supplement and calcium-fortified food use.

Should the research findings demonstrate that specific parental influences that are
associated with the use or lack of use of supplements and calcium-fortified foods, the
long term goal of this research is to contribute to the development of effective
educational strategies aimed specifically at parents of preadolescents that address the

use of calcium-fortified foods and supplements.

Chapter 2

REVIEW OF LITERATURE

2.1 Importance of Calcium
2.1.1 Overview of Calcium

Calcium accounts for 1 to 2 percent of adult human body weight with 99
percent of total body calcium found in the teeth and bones. Calcium exists primarily
in the form of hydroxyapatite, and this bone mineral is almost 40 percent of the
weight of the bone. Adequate calcium is essential to bone health in adolescence to
ensure adequate mineralization of the skeleton, and throughout the lifespan to
optimize bone mass and prevent early bone loss (Heaney, 2000a). Although the
amount of calcium outside of bones and teeth is relatively small, it is required for
essential biochemical functions including contraction and relaxation of muscle
(including normal heart beat), coagulation of blood, transmission of nerve impulses,
activation of enzyme reactions, stimulation of hormone secretions, and cell
adhesiveness (Miller & Anderson, 1999; J avaid & Cooper, 2002). The level of
ionized calcium in the blood must be maintained within a narrow range to perform
biochemical functions. When the diet is low in calcium the bones release enough
calcium into the blood stream to meet the body’s needs.

In addition to bone health and essential biochemical functions, research has
demonstrated the potentially beneficial roles for calcium and/or dairy foods with
regard to a variety of disorders including chronic diseases such as hypertension, colon

cancer, and obesity, along with breast cancer, kidney stones, polycystic ovary

syndrome, ovarian cancer, premenstrual syndrome, insulin resistance, and lead
poisoning (IOM, 1997). The following sections will more extensively review the role
of calcium in bone health and chronic disease prevention.
2.1.2 Bone Health

Bone is a specialized connective tissue that provides mechanical support for
muscles, protects vital organs, and stores the calcium needed for essential
biochemical functions. Despite its static appearance, bone is a dynamic tissue
constantly being formed and broken down. This process, called remodeling, is the
resorption (breaking down) of existing bone tissue and deposition of new bone tissue
to replace that which has been broken down (IOM, 1997). Resorption of old bone
and formation of new bone are processes that continuously overlap. The importance
of these processes varies at different times throughout the life cycle. In general, from
birth until about age 20, the bones are in a phase of active growth. This stage is
characterized by an increase in bone length and bone width. Shaping and sculpting
the growing bones, called modeling, also occurs at this time. Between the ages of 12
and 30, the rapid phase of bone dimensional growth tapers off and consolidation
occurs with the attainment of peak bone mass. Although dimensional bone growth
ceases at maturity, adult bone is constantly being remodeled. It is generally accepted
that peak bone mass or maximum bone density and strength occurs by age 30
(Heaney et al., 2000). Recent studies indicate that peak bone mass at several skeletal
sites may be reached as early as late adolescence (Matkovic, 1996). Beginning in the
405 or later, resorption of existing bone starts to exceed formation of new bone,

resulting in a net loss.

A number of interrelated nutritional, genetic, and environmental factors contribute
to bone health. Bone has the same kind of nutrient needs as other tissues, including
energy, protein and micronutrients (Heaney, 2000a). Additionally, bone requires
dietary intake to supply the bulk materials needed for synthesis of the extracellular
material, which comprises more than 95 percent of the substance of bone and which
is largely responsible for its structural and mechanical properties (J avaid & Cooper,
2002). These bulk materials are mainly calcium, phosphorus and protein. During
growth, this structural material cannot be amassed if the bulk components of bone are
not present in adequate amounts in the diet. The need for dietary calcium persists
even after growth has ceased. Calcium is excreted daily from the body in
considerable quantity (4-8 mmol) requiring calcium replacement through the diet. In
absence of adequate calcium intake, regulating hormones cause bone to release
calcium to serve the essential fiinctions in other systems of the body. Chronic dietary
insufficiency can result in the formation of weak, poorly mineralized bone. The same
considerations apply to the other bulk constituents of bone, phosphorus and protein.
However, these nutrients are less likely to be present in limiting quantities in modern
diets in the developed world. In addition to dietary factors, twin and family studies
indicate that genetic factors have a strong influence on bone development. Heaney
and colleagues reported that about 75% of the variability in peak bone mass is
attributable to heredity (Heaney et al., 2000). Furthermore, physical activity patterns
including exercise and mobilization can also influence bone mass and strength
(J avaid & Cooper, 2002). Thus, modifiable factors, including dietary intake and

physical activity patterns, as well as genetic factors are related to bone development.

2.1.3 Calcium and Bone Health

Accumulating research, including epidemiological evidence, randomized clinical
trials, and metabolic balance studies, indicates that dietary calcium throughout life
helps to optimize peak bone mass achieved by age 30 or earlier, slow age-related
bone loss, and reduce osteoporosis fracture risk in later adult years (Matkovic &
Heaney, 1992; IOM, 1997; Ilich & Kerstetter, 2000; Wosje & Specker, 2000). An
analysis of 139 papers relating to calcium intake and bone health published since
1975 provides convincing evidence of the beneficial role of calcium and calcium-rich
foods in skeletal health. In 50 of the 52 investigator-controlled, calcium intervention
trials, increasing calcium intake positively affected bone gain during growth, reduced
bone loss in later years or lowered fracture risk (Heaney, 2000a). While most of the
investigator-controlled studies used calcium supplements, six used dairy sources of
calcium, which all demonstrated a positive relationship between calcium and bone
health. Similar beneficial effects of calcium were demonstrated in approximately
three-quarters of 86 observational studies, most of which used dairy sources of
calcium (Heaney, 2000a). There are several other nutritional and lifestyle factors,
such as the amount of protein in the diet, energy intake, body weight, alcohol
consumption, vitamin D intake, smoking, and exercise, which have been shown to
play a potential role in affecting bone mass. However, the scientifically reproducible
evidence showing a connection between these factors and bone mass is not as robust
as the calcium connection (Miller et al., 2001).

Peak bone mass is an important measure of bone health. Approximately 60-80

percent of the variance of peak bone mass is attributable to genetics (Weaver et al.,

1999a), leaving modifiable factors such as diet and physical activity to influence an
individual’s genetically programmed peak bone mass. The majority of peak bone
mass is laid down during the first two decades of life. Thus, childhood and
adolescence are critical times to optimize peak bone mass. By the time adolescents
finish their "growth spurt" around the age of 17 years, approximately 90 percent of
their adult bone mass will have been established. Children’s bodies need sufficient
calcium to support their accelerated growth spurt during the preteen and teenage
years. In addition, children going through puberty have a bone accretion rate
approximately twice that of children before or alter puberty (Weaver et al., 199%).
Therefore, obtaining sufficient calcium when the skeleton is most responsive to
dietary calcium during puberty helps to ensure adequate mineralization of the
skeleton to promote bone health later in life and decrease the risk for osteoporosis.
2.1.4 Osteoporosis

Osteoporosis has been described as a "pediatric disease that manifests itself in
old age" (Lysen & Walker, 1997). It is the most readily identifiable health issue
associated with inadequate calcium intake. Osteoporosis is a condition of skeletal
fragility characterized by decreases in bone mass and deterioration of the bone tissue,
with a consequent increase in fracture risk (Heaney, 2000a). The rate of osteoporosis
has reached epidemic proportions in the United States and is responsible for
considerable morbidity, mortality, and economic costs. The health care costs
associated with osteoporosis are estimated at $13.8 billion per year for osteoporosis-
related fractures alone (N OF, Accessed 2004). Oflen termed a silent disease,

osteoporosis usually goes unnoticed until back pain or spontaneous fracture occurs.

10

Because there often are no symptoms prior to most osteoporotic fractures, relatively
few people are medically diagnosed in time for effective therapy. Consequently,
many people experience unnecessary fracture-related pain, expense, and disability.
Osteoporosis is a major health problem that calls for comprehensive, national
preventive strategies aimed at adolescents, young adults, postmenopausal women, and
older adults. While no single nutrient can prevent osteoporosis, consuming adequate
calcium throughout life may play a critical role in reducing risk or complications of
the disease (Kalkwarf et al., 2003; Nicklas, 2003).
2.1.5 Inadequate Calcium During Childhood

In addition to osteoporosis, recent evidence suggests that effects of inadequate
calcium may occur in children as well as adults. There has been a dramatic increase
in the incidence of fractures over the last 30 years along with a general decline in
calcium intake in children and young adults (Khosla et al., 2003). Researchers have
speculated that these increases may be due to low bone density associated with low
calcium consumption (Khosla et al., 2003; Goulding et al., 2004). Subsequently, in
addition to entering adulthood with compromised bone mass, thereby increasing risk
for developing osteoporosis, children with low intakes may also be prone to bone
fractures during childhood.
2.1.6 Other Benefits of Calcium

In addition to bone health, research suggests there may be other positive
health effects associated with adequate calcium intake, particularly in the areas of

chronic disease including hypertension, colon cancer, and obesity.

11

Hypertension

Many studies have investigated a possible role of calcium in lowering the risk
of hypertension. In a review of 22 randomized intervention trials, calcium
supplementation was found to reduce systolic blood pressure modestly, by 1.68 mm
Hg in hypertensive adults, and had no significant effect in normotensive adults
(Allender et al., 1996). Diastolic blood pressure was not altered in either group.
More recently, the DASH (Dietary Approaches to Stop Hypertension) trial revealed
that intake of a low fat diet containing almost three servings of dairy foods
(predominately low fat milk) in combination with fruits and vegetables significantly
reduced blood pressure in persons with high normal blood pressure. In hypertensive
participants, the blood pressure lowering effects of the DASH diet were even greater,
evidenced by reductions of 11.4 mm HG in systolic and 5.5 mm HG in diastolic
pressure compared to the control diet (Appel et al., 1997). In this study, the increase
in dairy product consumption provided a mean dietary calcium increase from 443 to
1,265 mg/day. Since publication of the DASH diet, several health organizations have
issued support for the DASH diet to reduce the risk for or treat hypertension (Miller
et al., 2000). More research is needed, however, to understand the potential
similarities and/or differences of providing calcium through supplementation versus
calcium-rich food sources while controlling for other dietary factors on blood
pressure in greater segments of the population.

Little is known about the relationship of calcium intake and blood pressure in
children. A randomized trial on 101 boys and girls (mean age 11 years old) of

African American, Caucasian, Asian, and Hispanic descent showed that calcium

12

supplementation of 600 mg/day could reduce blood pressure, although the effect was
much larger in children who had lower baseline calcium intakes (150 to 347 mg)
(Gillrnan et al., 1995). No further reduction in blood pressure was observed in
children already consuming over 1,000 m/day of calcium by supplementing them
with 600 mg/day. More research is needed to fully understand the relationship
between calcium and blood pressure in children.
Colon Cancer

Several different types of studies support a beneficial role for calcium against
colon cancer (Lupton, 1997; Holt et al., 1998; Holt, 1999; Holt et al., 2001; Baron et
al., 2003; Wallace et al., 2004). Most research has been completed using calcium
supplements. However, more recent research with dairy foods has also shown
beneficial effects. In an investigation of 70 patients with a history of developing
polyps or noncancerous growths in the colon, increasing food sources of calcium,
specifically low fat dairy foods, reduced the risk for colon cancer (Holt et al., 1998).
The study participants were divided into two groups, one of which maintained its
baseline diet and the other which increased its dietary calcium intake to about 1,500
mg/day, mostly for diary foods. Compared to the control group, significant
reductions in cell proliferation and in two markers of cell differentiation occurred in
the group consuming additional dairy foods (Holt et al., 1998). A randomized,
double-blind trial of 930 adults with a recent history of colorectal adenomas found
that increasing calcium intake by 1,200 mg/day using a calcium supplement, reduced
the incidence of recurrent adenomatous polyps by 19% and the total number of

tumors by 24% in less than one year (Baron et al., 1999). Whether similar beneficial

l3

effects on the recurrence of colonic adenomatous polyps would be found following
intake of food sources of calcium such as dairy products is unknown.
Obesity

Although energy balance is the most critical factor in weight regulation, some
recent studies suggest that adequate calcium intake may contribute to shifiing the
energy balance and thus play a favorable role in weight regulation (Davies et al.,
2000; Carruth BR, 2001; Zemel, 2004). Dairy sources of calcium have been shown
to have greater favorable effects compared to supplemental sources of calcium in
attenuating weight and fat gain and accelerating fat loss (Zemel, 2003). This
augmented effect of dairy products relative to supplemental calcium is likely due to
additional bioactive compounds, including the angiotensin-converting enzyme
inhibitors and the rich concentration of branched-chain amino acids in whey, which
may act synergistically with calcium to decrease adiposity (Davies et al., 2000;
Zemel, 2004). These concepts have been supported by epidemiological data and
recent clinical trials. However, some research has also shown no beneficial effects of
added calcium or dairy in promoting weight loss (Barr, 2003; Lappe et al.,. 2004;
Berkey et al., 2005). More research is needed in larger trials with different subgroups
where other dietary factors are controlled for to clearly delineate the effects of

calcium on weight regulation.

14

2.2 Recommendations and Intake
2.2.1 Calcium Recommendations

Given the importance of calcium to bone health, the development and
maintenance of bone is the major determinant of calcium needs (IOM, 1997). Thus,
unlike other nutrients, the requirement for calcium relates not to the maintenance of
the metabolic function of the nutrient, but to the maintenance of an optimal reserve
for adequate skeletal support (Abrams et al., 2000). Calcium functions as a threshold
nutrient because the size of the body’s skeletal calcium reserve is genetically limited.
Therefore, at suboptimal intakes the ability of the body to store calcium as bone tissue
is limited by the intake of calcium, but increasing calcium intake above that required
as optimal for genetic or mechanical purposes does not result in further increases in
stores (Heaney, 2000a). Thus, calcium can only be stored as bone, and increasing
calcium intake above that which produces optimal bone mass will not result in more
bone. There is also no biochemical assay that accurately reflects calcium nutritional
status. Blood calcium concentration, for example, is not a good indicator because it is
tightly regulated. Scientific literature reveals numerous potential indirect indicators
of calcium adequacy, most of which are closely related to the skeletal calcium content

(Cashman, 2002).

Traditionally, daily calcium requirements have been estimated by a factorial
approach. This practice involves estimating the average physiological requirement
for absorbed calcium derived from balance data, adjusting for incomplete utilization,
individual variability, and (Heaney, 2000a) bioavailability of calcium among food

sources (Cashman, 2002). This approach is subject to considerable uncertainty, as is

15

evident from the wide variation in estimates of daily calcium requirements made by
different expert authorities. For example, the United States and United Kingdom have
established very different recommendations for calcium intake (IOM, 1997; 1998)
(Table 2.1). Much of this disagreement arose as a result of different interpretations
of available data, e. g. different estimates of absorption efficiencies and obligatory
losses of calcium were used by the three authorities (Cashman & Flynn, 1999).
Despite differences in estimating the requirements, significant proportions of the
population in a number of western countries fail to achieve recommendations for

calcium (Abrams & Stuff, 1994).

16

Table 2.1. Recommended Calcium Intakes in US and UK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UK RN] (1991) * US A] (1997) §
Age Group mg/d Age Group mg/d
(years) (years)

0-1 525 0-0.5 210

0.5-1 270
1-3 350 1-3 500
4-6 450 4-8 800
7-10 550
11-14M 1000 9-13M 1300
15-18M 1000 14-18M 1300
11-14F 800 9-13F 1300
15-18F 800 14-18F 1300
19-50 700 19-30 1000

30-50 1000
>50 700 >50 1200
Pregnancy 700 Pregnancy

S18 1300

19-50 1000
Lactation +550 Lactation

£18 1300

19-50 1000

 

 

 

 

 

" Reference nutrient intake (RN 1) (Department of Health, 1998)
§ Adequate Intake (AI) (10M, 1997)

More recently, the US Food and Nutrition Board established
recommendations for daily calcium intake for different population groups, principally
using data from metabolic balance studies to develop a non-linear regression model to
predict the lowest value of intake at which mean maximal calcium retention is
attained (IOM, 1997) (Table 2.1). This approach was based on the principle that
maximizing the calcium reserve in the skeleton is required in order to maximize
skeletal strength, and that an adequate calcium intake is needed to achieve these
genetically-determined upper limits of both skeletal size and density. A major
limitation of this approach is the limited balance data available, which resulted in the

establishment of an adequate intake (AI) rather than a recommended dietary

l7

allowance (RDA), since no estimate of the average requirement could be derived
(IOM, 1997; Heaney, 2000a). The recommended AI represents an approximation of
the calcium intake that, in the judgment of the Dietary Reference Intakes (DRI)
Committee, would appear to be sufficient to maintain calcium nutriture while
recognizing that lower intakes may be adequate for some. Additional studies on
calcium balance over broad ranges of intakes and long-term measures of calcium

sufficiency are needed to establish a more precise and accurate recommendations.

The AIs for calcium are higher than the 1989 RDAs for most age categories to
reflect current scientific information. Current dietary recommendations for calcium
are 500 mg for children aged 1 to 3 years, 800 mg for children aged 4 to 8 years,
1,300 mg for adolescents aged 9 to 18 years, 1000 mg for adults aged 19 to 50 years,
and 1,200 mg for adults aged 51 years and older (IOM, 1997)(Table 2.1). Calcium
needs vary throughout life with greater needs during periods of rapid grth in
childhood and adolescence, during pregnancy and lactation, and in later adult years to
compensate for age-related bone loss. The following will review age-specific
requirements for calcium in children 1 t018 years to understand specific differences in

the recommendations that were established.

2.2.2 Establishing Calcium Recommendations for Children I through 8 years
Children 1 through 8 years retain less calcium in the body than infants, but

need two to four times as much calcium per unit of body weight as adults (Miller et

al., 2001). Optimal calcium intake is important during these years in establishing

peak adult bone mass and for promoting healthy eating habits, which have been

18

shown to be established during this time period (Neumark-Sztainer et al., 1999). For
children 1 to 3 years of age, 500 mg of calcium/day is recommended to support a
calcium retention of 100 mg/day (IOM, 1997). For 4 through 8 year old children, a
calcium intake of 800 mg/day is recommended to support a maximal calcium
retention of 130 to 174 mg/day (IOM, 1997). As there are no balance studies
available in boys, the data for girls was applied to both sexes. More recent studies
have shown higher intakes of calcium to be more beneficial than current
recommendations. For example, when 6 to 10 year olds consumed 1,600 mg
calcium/day, bone mass accumulation was 3% to 5% higher than when calcium
intake was 1,000 mg/day or less (Wosje & Specker, 2000). Other intervention studies
have indicated that at least 1,200 mg calcium/day is needed to maximize calcium
retention in 6 to 10 year old children (Johnston et al., 1992; Slemenda et al., 1997;
Abrams et al., 1999). High levels of calcium intake, however, may also have
negative effects, such as decreasing their absorption of other minerals such as iron
and zinc. These minerals may be marginal in toddlers and preschool children,
especially in developing countries. Thus, there is substantial need for further
investigation regarding the risks and benefits of higher calcium intake in this age

group (Ilich-Ernst et al., 1998; Ames et al., 1999).

2.2.3 Establishing Calcium Recommendations for Children 9 through 18 years

In view of the importance of the pubertal growth spurt in determining ultimate
bone mass, this time period has become one of the most studied for evaluation of
calcium dietary requirements as well as bone mineral acquisition and turnover. Most,

but not all, studies have focused on girls, due to the greater incidence of osteoporosis

l9

in females and the shorter duration of pubertal bone growth in girls versus boys. As
children reach the adolescent growth spurt, skeletal accumulation of calcium (calcium
retention) increases dramatically. Between 140 mg and 165 mg calcium/day is
deposited in the skeleton during preadolescence and as much as 350 mg calcium/day
during adolescence (IOM, 1997). Compared to young adult women ages 19 to 30
years, teenage girls retain approximately four times more of the calcium they
consume, or on average calcium retention of 326 mg/day (Weaver et al., 1996).

At least 40% or more of the body’s total skeletal mass is formed during the
adolescent growth spurt (Heaney et al., 2000). Although bone mass may accumulate
through the third decade of life, peak adult bone mass may be reached as early as late
adolescence in certain bones (proximal femur and vertebrae). Recent research
indicates that the peak calcium accretion rate occurs at age 13 for girls and 14.5 for
boys (Heaney etal., 2000). In addition to the dramatic increase in skeletal mass
during adolescence, inefficient absorption of calcium during the teenage years may
contribute to an increased need for this mineral. Intestinal calcium absorption
previously presumed to be 40%, has shown to be closer to 30% in teens (Abrams et
al., 1997; Abrams et al., 2000; Badenhop-Stevens & Matkovic, 2004). Also,
adolescent girls are unable to adapt urinary calcium excretion to changes in calcium
intake. Very high urinary calcium levels have been detected in adolescent females
with low calcium intakes (Heaney et al., 2000). These factors have led to the calcium
A1 of 1,300 mg/day for children and adolescents ages 9 through 18 to maximize

calcium retention (IOM, 1997).

20

2.2.4 Racial Differences in Establishing Recommendations

Racial differences in calcium metabolism have been noted in children and
adults. In children and adolescents aged 9 to 18 years, Bell and colleagues (Bell et
al., 1993) found that African Americans had similar calcium absorption efficiency but
lower urinary calcium excretion. Abrams and colleagues (Abrams et al., 1996) found
absorption efficiency to be similar in prepubertal African American, Mexican-
American, and Caucasian girls, but significantly greater in Afiican American girls
after menarche. These metabolic differences may contribute to the widely observed
higher bone mass in African American children (Gilsanz et al., 1991; Bell et al.,
1993) and adults (Luckey et al., 1989). However, implications for the calcium intake
requirement are not clear, and observed differences in absorption have not resulted in
race-specific recommendations at this time.
2.2.5 Tolerable Upper Intake Recommendations

Currently, the available data on the adverse effects of excess intake in humans
primarily concerns calcium intake from nutritional supplements. Of many possible
adverse effects of excessive calcium intake, the most widely studied and biologically
important are: kidney stone formation, the syndrome of hypercalcemia and renal
insufficiency with and without alkalosis, milk-alkali syndrome (MAS), and the
interaction of calcium with the absorption of other essential minerals (IOM, 1997).
The adult upper limit (UL) for calcium is 2,500 mg per day. This level was generated
through adult research data to detect the lowest-observed-adverse-effect level
(LOAEL) for MAS or nephrolithiasis. Calcium intakes of 300 to 2,500 mg/day have

not been shown to cause MAS or nephrolithiasis and provide supportive evidence for

21

a UL of 2,500 mg/day for adults (IOM, 1997). Although the safety of excess calcium
intake in children 1 through 18 yr has not been studied, an UL of 2,500 mg (62.5
mmol)/day is also recommended for this life stage group based on adult data.
Although calcium supplementation in children may appear to pose minimal risk of
MAS or hypercalciuria, risk of depletion of other minerals associated with high
calcium intakes may be greater. Therefore a conservative UL is recommended for
children due to the lack of data.
2. 2. 6 Actual Intake in Children

Despite calcium’s expanding role in health, nationwide surveys indicate that
few Americans are meeting dietary recommendations for calcium (Alaimo et al.,
1994; Fleming & Heinback, 1994; Albertson et al., 1997; USDA, 2000). Many
population groups, particularly adolescents and older adults, consume diets
containing significantly less calcium than recommended. At all ages, males consume
more calcium than females, presumably because of their higher energy intake. Data
from the Continuing Survey of Food Intake 1994—96 (CSFII 1994-96) showed that
71% of girls and 62% of boys 6 to 11 years of age do not meet 100% of the Al for
calcium, with estimated mean intake in girls to be 865 mg/day and in boys to be 984
mg/day. Similar results were observed for lO-year old children in Bogalusa,
Louisiana, where 69% did not meet dietary recommendations; the percentage was
higher among females (76%) than males (62%) (p<0.001) (Raj eshwari et al., 2005).
Among older females and males 12 to 19 years of age, 88% and 68%, respectively,
did not meet the calcium recommendation with estimated mean intake in girls to be

773 mg/day and in boys to be 1,145 mg/day. Therefore nine out of ten adolescent

22

girls and seven out of ten adolescent boys failed to meet the Al for calcium. Data
from the more recent National Health and Nutrition Examination Survey (NHANES
1999-2000) leads to similar conclusions as with 67% of girls and 61% of boys ages 6-
11 and 84% of girls and 70% of boys ages 12-19 not meeting the Al for calcium. The
mean estimated intake in 6-11 year old girls was 860 mg/day and 915 mg/day in boys
and in 9-18 year old girls was estimated at 820 mg and 1,081 mg/day in boys (Ervin
et al., 2004). For all age groups, including adolescents (ages 12-19 years), males
consumed higher amounts of calcium than females of the same age. In males,
calcium intake peaked during adolescence and then declined in early adulthood. For
females, the calcium intake peaked during childhood (ages 6-11 years) and began to
decline in adolescence. For females, the average daily intake fell below the AI
recommendation beginning at the start of the adolescent period. Race/ethnic data was
collected which found similar results among groups with a lower percentage of
Hispanic girls (ages 6-11) and Hispanic boys (ages 12-19) not meeting the Al for
calcium compared to other groups (Table 2.2). Unfortunately, data from the
NHANES and CSFII national

Table 2.2. NHANES l999-2000-Percentage of Children Not Meeting the AI
Calcium Recommendation

 

 

 

 

 

 

 

 

 

 

 

 

All Non-Hispanic Hispanic (%) Non-
Race/Ethnic White (%) Hispanic
Groups Q/o) Black Q/o)

Boys 6-11 y 67 64 71 70

Boys 12-19 y 70 69 62 71

Girls 6-11 61 65 55 72

Girls 12-19 84 82 85 90

(Ervin et al., 2004)

23

surveys for assessing Asians, Native Hawaiians, or other Pacific Islanders intake were
considered "statistically unreliable" due to small sample size.

Race/ethnic differences in calcium intake are of potential importance, as low
bone density and osteoporosis occur in notable proportions among Asians, Hispanics,
and Non-Hispanic whites, with lower proportions in African Americans. One study
in high school students (n=900) found that more than half the students had intakes
below current recommendations (Barr, 1994). Ethnicity was revealed as a predictor
of total calcium intake with whites having significantly greater mean intakes (1,127
mg) than those of Asian origin (768 mg) (Barr, 1994). In another study (n=51) of
Asian and Caucasian adolescents mean calcium intakes (1113 i 491mg) were below
the recommendations, but greater than previous studies with no statistical differences
regarding ethnicity (Oshiro et al., 2003). Sample size, however, may have been too
small to demonstrate differences. A general limitation to assessing intake in different
race/ethnic groups is that the nutrition assessment tool most commonly used, a food
frequency questionnaire (FFQ), may not be culturally sensitive to identify important
sources of calcium other than dairy. Recently, a FF Q was developed specifically for
Asians, Hispanics and white youth which may provide a more comprehensive
assessment of calcium intake (Jensen, 2004). More research is needed to assess
intake in these subgroup populations to help target more effective intervention
strategies.

2.2.7 The Magnitude of problem
Americans’ inadequate calcium intake is recognized as a major public health

problem (Gerrior et al., 1998). In 1999, a calcium consensus conference supported

24

by the National Institutes of Health, (NIH), United States Department of Agriculture
(USDA), National Osteoporosis Foundation and many professional societies, food
producers and health agencies concluded that Americans’ inadequate calcium intake
had reached a level that required public health measures (Calcium Summit, 1999).
The consensus panel called for strategies to increase calcium intake across virtually
all segments of the population. Likewise, the federal government’s Healthy People
2010 objectives for the nation identified low calcium as one of the priority nutrition
problems in the US (Healthy People 2010, 2000). The inadequate dietary intake of
adolescents is of particular concern because it coincides with a period of rapid
skeletal growth, a critical time to maximize peak bone mass and protect against future
risk for osteoporosis (Teegarden et al., 1999).
2.2.8 Summary of Recommendations and Intake

The recommendations were established based on maximum bone retention
and are set at a level of consumption necessary for an individual to maximize
genetically determined peak adult bone mass, to maintain adult bone mass, and to
minimize bone loss in later years (Miller et al., 2001). There is considerable
disagreement between expert groups on the daily calcium intake levels that should be
recommended, reflecting the ambiguity in the data used for establishing calcium
requirements (Cashman, 2002). Despite disagreements on recommended intakes,
evidence indicates that dietary calcium intake is inadequate for the maintenance of
bone health in a substantial proportion of population age groups, particularly
adolescents. Optimizing calcium intake of the entire population cannot be expected

to completely eliminate the many multifactorial disorders in which a low calcium

25

intake is contributing factor. However, improving calcium status appears to be a
cost-effective approach to reducing the total disease burden associated with a
inadequate calcium intake (F ulgoni et al., 2004). For this reason, strategies to ensure
optimal calcium intake in Americans, especially from calcium-rich foods, deserve

attention.

26

2.3 Sources of Calcium
2.3.1 Dairy Foods as a Source of Calcium

In the United States, milk and other dairy products are the major source of
calcium, providing 72% of the calcium available in the food supply (Gerrior et al.,
1998) (Table 2.3). In an analysis of food sources of calcium, milk and other dairy
products provided 83% of the calcium in the diets of children (ages 6-12), 77% of the
calcium in adolescents (ages 13-19), and between 65% to 72% of the calcium in
adults’ diet (Fleming & Heinback, 1994). A more recent analysis of a longitudinal
study of 10-year olds in Bogalusa, Louisiana, supports earlier findings that at age 10
and in young adulthood, milk and other dairy products were the major source of
calcium (Raj eshwari et al., 2004). Few other foods provide such a concentrated
source of calcium, which is as readily available for absorption, as do milk and other
dairy products. Also, some food sources such as some vegetables contain phytates
and oxalates, which can reduce the intestinal absorption of calcium (Gueguen &
Pointillart, 2000). Without consuming dairy products, it is difficult to meet dietary
calcium recommendations through foods (Barr, 1994; Fleming & Heinback, 1994;
Neumark-Sztainer et al., 1997; F ulgoni et al., 2004).

Calcium-rich foods such as milk and other dairy foods provide, in many cases,
about 300 mg of calcium per serving and also contain other nutrients important to
health. As shown in Table 2.3, milk and other dairy foods provide substantial
amounts of vitamin D (if fortified), vitamin A, cobalamin, riboflavin, niacin,

potassium, phosphorus, and protein.

27

Table 2.3. Percent Nutrient Contribution of Dairy Foods to the US. Food Supply,
1997 (Gerrior et al., 1998)

 

 

 

 

 

Nutrient (%)
Energy 9.3
Protein 19.4
Fat 12.6
Carbohydrate 4.6
Minerals
Calcium 72.1
Phosphorus 32.4
Zinc 16.2
Magnesium 15.8
Iron 1.8
Vitamins
Riboflavin 26.1
Vitamin B12 21.6
Vitamin A 15.3
Vitamin B6 8.7
Folate 6.2
Thiamin 4.7
Vitamin E 2.8
Ascorbic Acid 2.5
Niacin 1.2

 

Vitamin D-fortified milk products provide almost all of American’s dietary intake of
vitamin D, which increases absorption of calcium (Matkovic et al., 2005). Nearly all
fluid milk marketed in the US. is fortified with vitamin D to obtain the standardized
amount of 400 IU (10 ug) per quart of milk. Other dairy foods such as cheese and
yogurt are not generally fortified with vitamin D.

Because milk and other dairy foods are excellent sources of calcium as well as
many other nutrients (Table 2.3), their intakes may improve the overall nutritional
quality of the diet (Fleming & Heinback, 1994; Devine, 1996; Heaney, 1999; Heaney,
2000a). A longitudinal study involving 64 postmenopausal women in Australia found

that the women who were randomly assigned to receive 1,000 mg of additional

28

calcium per day by consuming fat free milk powder increased not only their calcium
intake, but also their intake of other essential nutrients such as potassium,
phosphorus, magnesium, riboflavin, thiamin, and zinc, meeting their respective DRI
recommendations (Devine, 1996; Heaney, 1999). In contrast, the women who took
calcium supplements increased only their intake of calcium to meet the calcium DRI
recommendations (Devine, 1996). Although both milk and calcium supplements
improved calcium intake, consuming the milk improved the woman’s overall diet
quality as well. A more recent analysis of adults (agesl9-50) from NHANES 1999-
2000 found that higher intakes of total dairy and milk were associated with higher
intake of essential nutrients, including calcium, magnesium, potassirun, zinc, iron,
vitamin A, riboflavin, and folate relative to their DRI recommendations (Fulgoni et
al,2004)

Similarly, among children and adolescents, consumption of milk has been
demonstrated to increase both calcium intake and improve the overall nutrient
adequacy of their diet (Fleming & Heinback, 1994; Johnson, 1998). When children
(ages 6-10) included milk as part of their noon meal, intake of calcium as well as
other essential nutrients such as vitamin A, E, and zinc also increased to meet the DRI
recommendations (Johnson, 1998). These results reinforce not only the importance
of dairy foods and milk as key calcium sources but as foods associated with a
package of nutrients. A diet low in calcium is generally low in other essential

nutrients as well and is a marker for overall poor diet quality (Barger—Lux, 1992).

29

2.3.2 Nondairy Food Sources of Calcium

Consuming dairy foods with their high calcium bioavailability, high calcium
content and relative low cost is an efficient way to obtain adequate calcium.
However, for many who do not consume dairy foods, there are a variety of non-dairy
sources, including dark green leafy vegetables (particularly mustard greens and
collards), bok choy, beans, nuts and fish (e. g., salmon, sardines, oysters), (Weaver et
al., 1999b; Berdainer, 2002). For certain populations (e. g. Asians, vegetarians, those
with lactose intolerance) these foods can be a significant source of calcium (Novotny
et al., 2003; Oshiro et al., 2003).

Unfortunately, a number of these nondairy foods provide less calcium per
serving and are less bioavailable than milk and other dairy products (Table 2.4)
(USDA, 1998). Therefore, more servings of nondairy foods are needed to equal the
calcium intake from a typical serving of milk and other dairy foods. For example, an
individual would need to consume eight cups of spinach, nearly five cups of red
beans or 2 ‘A cups of broccoli to obtain the same amount of calcium absorbed from
one cup of milk (Weaver et al., 1999b). Components in some calcium-rich nondairy
foods such as phytates in unleavened bread, seeds, nuts and most cereals and oxalates
in spinach, rhubarb, sweet potatoes and walnuts can form insoluble complexes with
calcium, reducing its bioavailability (Weaver et al., 1999b). Consequently, it may be
difficult for Americans to meet their calcium needs exclusively from nondairy foods
naturally containing calcium (Weaver et al., 1999b). Despite these limitations,
calcium from nondairy foods is an important source and may be more useful for

people unlikely to or unable to consume dairy.

30

Table 2.4. Calcium Contribution of Selected Foods, (USDA, 1998)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Food Calcium (mg)
Yogurt, nonfat, plain (1 cup) 415
Cheese, Swiss (1 l/2 oz) 408
Yogurt, low fat, flavored (1 cup) 314
Cheese, cheddar (1 1/2 oz) 306
Milk, skim (1 cup) 302
Milk, 2% ( 1 cup) 297
Milk, whole ( 1 cup) 291
Sardines with bones (2 oz) 217
Salmon with bones (2 oz) 135
Tofu ( ‘/2 cup) 130
Ice cream, soft serve (1/2 cup) 118
Turnip greens, cooked (1/2 cup) 99
Almonds (1/4 cup) 94
Kale, frozen cooked (1/2 cup) 90
Okra, cooked (1/2 cup_ 50
Broccoli, cooked (1/2 cup) 36
Whole wheat bread (1 slice) 20

 

2.3.3 Calcium-Fortified Foods

In the United States fortification with low amounts of essential nutrients has
been in practice for over 60 years and has contributed substantially to nutrient intakes
and reduced risk for disease and nutrient deficiencies (Leveille, 1994; Nicklas et al.,
1995; Popkin et al., 1996b). For individuals who limit or avoid foods naturally rich
in calcium such as milk and other dairy foods, calcium-fortified foods can be a
reasonable option to help achieve adequate calcium intakes (ADA, 2001). Calcium
fortification has become widespread. It is now commonplace for many foods,
especially beverages and grain products, to be fortified with at least 100 mg of
calcium is provided in each serving. Significant calcium fortification began in the
late 19808 and early 19903 specifically with the introduction of fortified orange juice

and grapefruit juices. By early 1999, 234 foods and beverages “with added calcium”

31

had been introduced (Miller et al., 2001). These products include calcium fortified
breakfast cereals, breads, pastas, pancake and waffle mixes, juices, juice drinks,
spreads/margarines, bottled water, candy, energy bars and soy beverages (F ishbein,
2004). Table 2.5 lists a number of fortified foods in terms of their typical serving

size, calcium (mg), and their respective values (2000b).

Table 2.5. Calcium Content of One Serving of Fortified Foods (National Institute of
Child Health & Human Development, 2000)

 

 

Serving Calcium % Daily
Size FOOd Item (mg) Value

l/2 cup Frozen yogurt, fat-free, calcium added 450 45%

1 cup Calcium-fortified orange juice 300 30%

1 cup Soy milk, calcium added 250-300 25-30%

1/2 cup Tofu made with calcium 260 25%

 

2.3.3.1 Prevalence

The wider availability of fortified foods and beverages may be improving
calcium status in Americans; however, this has not been recently investigated. An
analysis of the CSFII 1989-1991, which quantified the contribution of the fortification
of nine nutrients including calcium (vitamin A, vitamin C, thiamin, riboflavin, niacin,
folate, calcium, iron, zinc) found that fortification substantially increased the intakes
of all nutrients examined except for calcium, in all age/ gender groups but especially
in children (Bemer et al., 2001). The USDA nutrient database was updated to reflect
the fortification of foods with the nine nutrients of interest and then the updated
values were applied to the 3-day diet record. The breakfast cereal category was
responsible for nearly all the intake of nutrients from fortified foods, except vitamin

C, for which juice-type beverages made a greater contribution. Because the number

32

and type of fortified foods (specifically calcium-fortified foods) have increased
dramatically in years after the CSFII 1989-1991 data was collected, total calcium
intake from calcium fortified foods may be increasing, however, no current data
exists on their current contribution. Furthermore, no data exists on how many
calcium-fortified foods have stayed in the market since their increases in the late
1990s, thus current nutrient databases may not accurately reflect their presence.
Calcium fortification may play a role in promoting bone health and decreasing
incidence of chronic diseases (osteoporosis, obesity, hypertension), similar to folate’s
beneficial effects on neural tube defects (NTDs) (Werler et al., 1993), thus the role of
calcium—fortification needs to be considered in further research investigations.
2.3.3.2 Characteristics of Calcium-Fortified Food Users

Sociodemographic characteristics of fortified product users have not been well
studied. Popkin et a1 (Popkin et al., 1996b) indicated that use of enriched and
fortified products crossed socioeconomic lines back in the 1970s, but there are no
current analyses on a large cross-section of the US. population. For calcium-fortified
foods, characteristics of users may differ based on the specific food of interest. For
example, widely consumed foods such as breads, rolls, bagels, rice, and noodles
which were the first type of foods used in enrichment and fortification may cross
sociodemographic barriers for consumption. Ready-to-eat-breakfast-cereal (RTEBC),
even though widely consumed, has been shown to be associated with more use by
Caucasians, those with higher income and education levels, and those with healthier
food patterns compared to nonusers (Siega-Riz et al., 2000). More specific foods

such as calcium-fortified orange juice or calcium-fortified cereal bars may be

33

purchased by people also concerned with their health, particularly in increasing their
calcium intake. A greater understanding of the characteristics of calcium-fortified
food users is needed to effectively target those most in need of calcium fortification.
2.3.3.3 Limitations of Calcium-Fortified Foods

The increased availability and use of calcium-fortified foods raises concerns,
including the potential for calcium toxicity, lower calcium absorbability than
expected and inadequate intakes of other essential nutrients. In 1997, the NAS set
2,500 mg calcium per day as the Tolerable Upper Limit for calcium (1997). Calcium
intakes in excess of this amount can potentially increase risk for milk-alkali syndrome
(MAS) (i.e. a condition of hypercalcemia and renal insufficiency), aggravate kidney
stone formation in stone-formers who hyper absorb calcium from the intestine and
inhibit the body’s absorption of iron and zinc (1997). Although calcium toxicity is
rare, excessive use of calcium-fortified foods, especially by individuals who are
already meeting their calcium needs, is a possibility (Whiting & Wood, 1997). The
bioavailability of calcium from calcium-fortified food products is another
consideration and may vary, depending on the food (F airweather-Tait & Teucher,
2002; Heaney et al., 2005). In a study of 16 healthy men, the calcium from soy
beverages was absorbed at only 75% the efficiency of calcium from cow’s milk
(Heaney, 2000b); thus, more servings of nondairy foods fortified with calcium may
be needed to meet calcium recommendations. Additionally, there is concern that
fortifying foods with large quantities of calcium, especially over the long term, may
adversely affect the utilization of iron, zinc and magnesium (Heaney et al., 2005).

Finally, the nutrient profile of calcium-fortified foods are usually not nutritionally

34

equivalent to dairy foods (Heaney, 2000b; Nicklas, 2003; F ishbein, 2004).
Individuals using calcium-fortified foods, particularly low nutrient foods, as a
replacement for dairy foods, may not consume other nutrients found in dairy, such as
vitamin D (if fortified), potassium, and riboflavin (Whiting & Wood, 1997; Sloan,
2000). Calcium-fortified foods can be used to enhance calcium intake, especially for
individuals whose intake of dairy foods is limited. However, there is need for
education about the appropriate use of calcium-fortified foods, excess intake of
calcium, and under consumption of other nutrients essential for health.
2.3.4 Calcium Supplements

For those unable to meet their calcium needs through diet, calcium
supplements may be effective in increasing calcium intake. With increases in
recommendation levels along with research supporting calcium’s numerous benefits
to health, calcium supplements are increasingly becoming an important source of
calcium (Berdainer, 2002; Fairweather-Tait & Teucher, 2002).
2.3.4.1 Prevalence in Adults

According to the NHANES l999-2000 approximately 52% of US adults aged
20 years or older took at least one dietary supplement some time during the preceding
month (Radimer etal., 2004). The most commonly reported supplement among
adults were multivitamin/multiminerals (35%) formulas which generally provide 10%
of the daily value (DV), or 100 mg of calcium. Approximately 30% of women and
19% of men take calcium supplements which generally provide 500 mg calcium per

serving (Radimer et al., 2004).

35

Comparison of NHANES 1999-2000 findings with those from previous
NHANES surveys, which used similar methodology, suggests that supplement use
has increased in the past 20 years. Results from the Third NHANES survey (1988-
1994) were approximately 40% of adults ages 20 years and older (Ervin et al.,
1999b), compared with 35% in the Second NHANES survey and 23% in the First
NHANES survey (Block et al., 1988). Supportive of NHANES data, the National
Health Interview Surveys of 1987, 1992, and 2000 found that the percentage of adults
who took a multivitamin/mineral supplement increased fiom about one in six to one
in four, and the trend in daily use of multivitamins, vitamin A, vitamin C, vitamin E,
and calcium supplements by US adults increased significantly (Millen et al., 2004).
Additionally, the trend analysis indicated that calcium supplementation decreased
from 1987 to 1992, but that from 1992 to 2000 it increased. The NHANES 1999-
2000 also noted an increase in calcium supplement use, in particular in middle-aged
and elderly adult females (Radimer et al., 2004). It has been speculated that these
increases may be due to media reports regarding therapeutic effects of calcium in
reducing the risk of other chronic diseases (6. g. hypertension, colon cancer, breast
cancer, and kidney stones) in addition to the prevention of osteoporosis (Millen et al.,
2004)
2.3.4.2 Prevalence in Children and Adolescents

Little is known about supplement use, particularly calcium supplement use in
preadolescents and adolescents. According to the CSFII 1994, approximately 33% of
adolescents (13-18 years) surveyed reported using supplements, with 16% using

supplements on a daily basis (Stang et al., 2000). Of the adolescents who used

36

supplements, only 4% used a calcium supplement (Stang et al., 2000). In the 1998
Child and Adolescent Trial for Cardiovascular Health Tracking Study (CATCH 111),
1,532 eighth-grade students were surveyed on their dietary intakes of supplements.
18% of the eighth graders surveyed reported using vitamin-mineral supplements on
the 24-hour recall. Of those users, 47% took multivitamin and/or multimineral
preparations, 37% used single nutrient supplements (mostly vitamin C) with 3.9%
using calcium (Dwyer et al., 2001). The CATCH III reported slightly lower use
which may have been due to the age, sample size or sociodemographic characteristics
of the population. Evidence indicates that few adolescents take calcium supplements.
However, the most commonly reported supplement for children and adolescents is a
multivitamin with minerals which generally provides some calcium and may improve
intake in this population.
2.3.4.3 Characteristics of Supplement Users

There have been certain demographic/lifestyle characteristics that have been
found to be associated with adult users of supplements. Analyses of previous
supplement surveys have found demographic/lifestyle characteristic associations
similar to NHANES l999-2000 (Slesinski et al., 1996) (Subar & Block, 1990; live et
al., 1996): higher usage rates among women, non-Hispanic white, older people, those
with higher income and education levels, former and/or non-smokers, those with
normal BMI, and higher rates of physical activity. Users were also shown to be more
likely to have higher nutrient intakes from foods and higher total intakes for several

micronutrients than nonusers (Radimer et al., 2004). These characteristics are all

37

indicative of a healthy lifestyle (Miller et al., 2003). Non-users were shown to be less
likely to have adequate nutrient intakes from foods and consume a healthy diet.

The characteristics of children and adolescent supplement users has not been
examined to the extent of adults and remains to be determined (Dwyer et al., 2001).
A study of mother and daughter (ages 5-7) pairs (n=192) found that mothers who
used multivitamin/multimineral (MVM) supplements were more likely to give MVM
supplements to their daughters (Lee et al., 2002). Additionally mothers who reported
giving MVM supplements to their children were more likely to have higher incomes
and education levels (Lee et al., 2002). Adolescent (13-18 years) supplement users
from the CSFII 1994 were found to be more likely to be female, non-Hispanic white,
from families of higher socioeconomic status, consume diets with higher nutrient
intakes from foods and had higher nutrition awareness than nonusers (Stang et al.,
2000). Similar to the CSFII 1994, adolescent supplement users fi'om the CATCH III
trial were more likely to be non Hispanic white and had significantly higher scores on
a measure of nutrition awareness (Dwyer et al., 2001). These results are similar to
adult findings (Eliason et al., 1997; Greger, 2001; Miller et al., 2003) suggesting the
important role of the parent on child supplement use.
2.3.4.4 Types of Calcium Supplements, Dosage, Timing

There are currently approximately two dozen commonly prescribed calcium
supplements and hundreds of different formulations (F ishbein, 2004). Calcium
supplements are generally readily available over-the counter, as various salts and salt
combinations, principally as carbonate, citrate, lactate and phosphate, and to a lesser

degree as the gluconate, glubionate, gluceptate in many oral forms which are

38

generally well absorbed. Calcium supplements vary in calcium content with the
largest percent of calcium (40%) in calcium carbonate (most cost effective and
readily available in some antacids), with other salts such as citrate, lactate and
gluconate fimrishing 21%,l4%, and 9.3% of calcium (Berdainer, 2002). Many of the
commercially available calcium supplements also contain vitamin D, magnesium,
potassium, and other minerals to help aid in absorption and promote bone health.
Physical properties such as solubility, interference from coingested
medications or food stuffs, dosage, and timing can affect the bioavailability of
calcium (Fairweather-Tait & Teucher, 2002). In terms of dosage and timing, calcium
is best absorbed in doses of 500 mg or less (Nicklas, 2003). Individuals requiring
more than 500 mg of elemental calcium from supplements should take in multiple
closes with meals for efficient utilization. Use of calcium supplements may contribute
to potential side effects including constipation and bloating, as well as nutrient
imbalances and toxicity of taken in doses above the UL (Heaney, 2000a). Also, if
calcium supplements are substituted for calcium-rich foods such as dairy products to
meet calcium needs, attention needs to be given to other nutrients provided by foods
(Heaney, 2000b; Fairweather—Tait & Teucher, 2002). Educational interventions are
needed for the general population to understand the risks/benefits and to more
effectively target those in need of calcium supplementation to optimize calcium

intake for those in need (Miller et al., 2001).

39

2.4 Parental Influences
2.4.1 Introduction

Numerous influences may negatively impact calcium nutrition in children. It
has been suggested that some of these influences include (1) displacement of milk as
a beverage by soda, juices and sports drinks (Hamack et al., 1999; Ballew et al.,
2000); (2) eating away from home (Guthrie, 1999; Lin B-H, 1999); (3) the perception,
particularly among females, that milk and/or dairy products are fattening and
therefore intake is restricted or eliminated (Barr, 1995; Neumark-Sztainer et al., 1999;
Smart et al., 1999); and (4) peer influences (Chapmen, 1993; Neumark-Sztainer et al.,
1999). In addition to these influences, the role of the parent may negatively or
positively impact calcium intake.

Parental influences play an important role in the development of childrens
eating patterns, eating behaviors and food preferences (Birch, 1998b; Birch &
Davison, 2001) not only by the foods they make available and accessible, but also by
serving as a role model, (Cutting et al., 1999) and by actively encouraging or
expecting them to eat certain foods at mealtimes (Drucker et al., 1999). Limited
research has been completed involving parental influence specific to calcium intake
in children. The next sections will address parental influence through availability,
accessibility, taste preference, modeling, parental expectation, knowledge, health
benefit beliefs, and their potential role in influencing calcium intake in children.

2.4.2 Parental Influence on Availability and Accessibility
Availability concerns whether foods of interest are present in an environment

(e. g. carrots in the refrigerator) (Cullen et al., 2000; Baranowski, 2002). A

40

longitudinal study evaluating calcium intake from 192 girls, ages 5 to 9 years old, as a
function of mother-daughter beverage choices , provided new evidence that the
mother-daughter similarity in milk intake was statistically mediated by the extent to
which the mothers made milk available to daughters, and that milk availability at
meals and snacks was the main influence in milk intake in young girls (Fisher et al.,
2004). Although both groups drank more sweetened beverages as they got older,
only the girls whose mothers were in the habit of frequently serving milk at meals and
snacks were still drinking significant amounts of milk, and were getting enough
calcium, at age 9 (Fisher et al., 2004). Another study of 902 adolescents (ages 13-18)
and their parents/ guardians that completed the Project EAT survey and the Youth
Adolescent Food Frequency Questionnaire (FFQ) found that while most parents
reported that fruits and were available at home (90.3%), fewer parents reported milk
was served at meals (66.6%) (Hanson et al., 2005). Intake of dairy in general was
less than recommended for adolescents as well as adults. However, similar to Fisher
and colleagues, for those parents who did make dairy foods available at meal and
snack times, their children had significantly higher calcium intakes than those who
did not (p < 0.05) (Hanson et al., 2005). These findings suggest that making milk and
other calcium-rich foods routinely available may help to ensure that such foods are
consumed in the amounts needed to achieve adequate calcium intakes. This
relationship is consistent with the findings of studies that showed a positive
association of children’s fruit and vegetable intakes with the availability of those

foods in the home (Domel et al., 1993; Krebs-Smith et al., 1995; Baranowski et al.,

41

1997; Gibson et al., 1998; Heam, 1998; Weber Cullen et al., 2000; Edmonds et al.,
2001; Cullen et al., 2003).

Accessibility concerns whether food is made available in a form and location
that is likely to increase its consumption (e. g. ready-to-eat carrot sticks in a plastic
bag at the front of a child-accessible refiigerator shelf next to the child’s favorite low-
fat dip) (Baranowski, 2002; Cullen et al., 2003). Accessibility has also been
positively associated with fruit and vegetable intake (Cullen et al., 2000; Baranowski,
2002). Fisher and Hanson et al illustrated the importance of accessibility by finding
that serving milk and dairy foods at meal and snack time, thereby making it easily
accessible, had a positive impact on overall calcium intake.

2.4.3 Parental Influence on Taste Preference

The term “preference” refers to the selection of one item over others. In
general usage, preference connotes that liking is the basis for selection (Birch,
1998a). The preference for sweet and salty tastes, and the rejection of sour and bitter
tastes are innate and unleamed (Beauchamp et al., 1994), but nearly all other food
preferences are learned via children’s experience with food and eating. Parents help
to shape children’s eating environment that is important in the formation of children’s
food preferences (Birch, 1998a; Birch, 1999). Children’s food preferences are shaped
by the quantity and quality of children’s experience with food, and as a result of many
eating occasions in which foods are associated with the social contexts of eating and
with the physiological consequences of indigestion, children come to accept some
foods and reject others, shaping their dietary intake (Birch, 1998b). By parents

providing experience with some foods and flavors and not others, their impact on the

42

feeding environment can influence individual differences in food preferences
established during childhood which may persist later in life (Birch, 1999).

Food preference is the primary factor influencing child and adult food choices
(Barr, 1994; Neumark-Sztainer et al., 1999; 2000a; Carruth BR, 2000). In research
with adolescents, taste preference for dairy foods was associated with calcium intake
(Barr, 1994; Novotny R, 1999; Smart et al., 1999; Lee & Reicks, 2003; Novotny et
al., 2003). Barr found among high school students (n=900) that taste enjoyment of
dairy foods was significantly lower among Asians than in Caucasians and other ethnic
groups (Barr, 1994). In the USDA regional project, “Factors Influencing the
Consumption of Calcium-Rich Foods among Adolescents,” (project W191) taste
enjoyment of dairy foods was identified as a key motivator and barrier with
Caucasians having the most positive comments towards milk while Asians and
Hispanics had more negative comments to the taste of milk. All groups liked cheese,
ice cream and pizza (Novotny et al., 1999; Auld et al., 2002). Data collected in the
regional project included focus groups of 2 age groups (11 to 12 and 16 to 17 years)
and two days of 24-hour recalls from 200 male and female Asian, Hispanic, and white
youth from 11 participating states (Auld et al., 2002). From the W191 project in
Asian focus groups in Hawaii, Novotny and colleagues found that taste was a
motivator by many if served at a certain temperature and with certain “matching”
foods (accompanying food type). “Milk has to be cold.” “I like plain milk when it’s
been sitting in Fruit Loops for a long time because it tastes really good, it gets

sugary.” (Novotny et al., 1999). More research is needed in understanding the factors

43

that influence children’s calcium-rich food preferences which may help to positively
impact calcium consumption in children and adolescents.
2.4.4 Parental Influence through Modeling

Modeling concerns a child observing parents’ food selection patterns and
eating behavior, and then imitating those behaviors (Birch, 1998a). In a study of 180
mothers and their 5 year-old girls, few mothers were modeling milk consumption, but
the mothers who drank milk frequently had daughters who drank milk more
frequently and drank fewer soft drinks. They concluded that maternal milk and soft
drink consumption predicted the apparent tradeoff between milk and soft drinks in the
diets of preschool-age girls (Fisher et al., 2001). Similarly, in the Project EAT study
(Hanson et al., 2005) although the majority of parents had inadequate intake of dairy
foods, those parents with higher dairy intakes were positively associated with dairy
intake in their children. Another study in adolescents (n=105), found that for girls
who reported often seeing their parents drink milk, their calcium intake was
significantly greater than for others (Lee & Reicks, 2003). Barr also found in high
school students (n=900), that modeling of milk use by a significant adult was
associated with improved calcium intake for both high school males and females
(Barr, 1994). These findings suggest that modeling of milk and other dairy foods by
parents, may be an important factor in promoting adequate calcium intake in children
and adolescents, although more research is needed.
2.4.5 Parental Influence through Expectation

Parental expectations concerns encouragement or enforcement of nutrient-rich

foods to be consumed at meals (Cullen et al., 2001). Parents’ “do as I say ” pressure

44

 

on children to “finish your vegetables” is one means of encouraging children to eat
nutrient-dense foods but has not been studied to a great extent (Cullen et al., 2001).
Some research has suggested that pressuring children to eat may diminish children’s
ability to self-regulate intake, (Fisher & Birch, 1999; Birch & Fisher, 2000; Francis et
al., 2001) which may result in lower nutrient intake and increased risk for overweight
and obesity. These studies did not look specifically at calcium intake. In the W191, a
key motivator and barrier was the expectation within families for drinking milk.
Limited expectation by parents was more common among older girls and Asian
groups (Auld et al., 2002). There may be differences, however, in how parental
expectation is interpreted. For example, parents that encourage calcium-rich food
consumption by discussing with their children the importance of having enough of
these foods and make an effort to provide them to consume at meal and snack times
may be different than parents who “force” their children to eat these foods during
meals. These differences may have varying impacts on calcium intake, thus more
research is needed to clearly defining parental expectation and develop measures to
accurately capture this parental factor.
2.4.6 Parental Influence through Knowledge

Although many parents and children understand the importance of calcium
intake to bone health during childhood and throughout the lifespan (N eumark-
Sztainer et al., 1997), inability to translate knowledge regarding the importance of
calcium and bone health to specific dietary recommendations may contribute to
inadequate intake. A survey conducted by the Quaker Oats© and the American

Dietetic Association regarding influences on calcium, found that many women are

45

confused or uneducated about the recommended daily amount of calcium to consume.
43 % of women surveyed said, “It’s too confusing to figure out how much calcium is
in a serving of a particular food and then add everything up.” Nearly the same
number, 42% of women surveyed agreed that, “I don’t know how much calcium I
need.” (ADA, 2003). This lack of understanding in adults may have a negative
impact on children’s knowledge and intake. In a study of 1117 adolescents, only 19%
knew how many dairy foods that they should consume and only 10% knew the
calcium content of various dairy foods, (N eumark-Sztainer et al., 1997; Harel et al.,
1998; Harel Z, 1998). Given that nutritional education is a central component of
intervention strategies, lack of knowledge translating recommendations into calcium-
rich food servings may be a critical area to target during educational intervention.
2. 4. 7 Parental Influence through Health Benefit Beliefs

Increased understanding of importance of the dietary behavior may help
consumers make behavior changes decisions that promote better health (Carslon &
Gould, 1994; Wardle et al., 2000). However, findings from studies exploring the
impact of diet—health awareness on dietary behavior are not externally consistent.
Some studies have found a positive effect of diet-health awareness (Jensen & ’
Kesavan, 1993; Carslon & Gould, 1994; Variyam et al., 1996; Variyam et al., 2001),
while some have found no significant effect of diet-health awareness on consumer
eating decisions (Jensen et al., 1992; Doutlritt & Gould, 1995). The research
regarding the relationship between parent diet-health awareness and its effects on
children’s calcium intake is limited. One study documented that mother’s awareness

of the diet-health relationship helped to increase children’s under consumed nutrients

46

such as fiber and calcium but was not useful in reducing children’s unhealthy
nutrients (Lin et al., 1996). Another study using data from the CSFII 1994-1996 was
completed to examine the effects of mother’s diet-health awareness on their
children’s dairy product consumption (Kim & Douthitt, 2003). Mothers’ awareness
of diet and health relationships had a significant effect on adolescents’ dairy food
consumption. More research is needed to understand the impact of parental diet-
health awareness on child calcium intake.
2.4.8 Other Influences

In addition to the influences mentioned, additional parental influences that
have been reported include cost and convenience of dairy foods, rules regarding
eating and meals, the overall parent child relationship, family connectedness and
familial cultural practices (Novotny et al., 1999; Auld et al., 2002). Family meal
patterns have been shown to positively impact children’s’ overall diet quality
including calcium intake (Gilhnan et al., 2000; Neumark-Sztainer et al., 2000;
Videon & Manning, 2003). According to a study examining the nutritional quality of
diets of 16,202 children ages 9-14, eating meals such as dinner with their family
increased calcium intake (N eumark-Sztainer et al., 2003). Compared to children who
rarely or infiequently ate dinner with their family, children who ate dinner with their
family each day had higher calcium intakes and were less likely to consume sodas
(Neumark-Sztainer et al., 2003).
2.4.9 Parental Influences Summary

Parental influences play an important role in the development of children’s

eating patterns, eating behaviors and food preferences, and may play an influential

47

role in impacting the adequacy of calcium nutrition in children. Unfortunately, there
is a not a substantial body of work regarding these influences, including which
influences may be most effective, and how they may differ in effect by gender,
ethnicity/race, and socioeconomic status. Because eating behaviors are initiated in
childhood, and may persist into adulthood, (Fletcher et al., 1997; Lytle et al., 2000),
understanding the role of the parent in affecting calcium intake during childhood
should be carefully examined in order to identify targets for intervention (Nicklas,

2003)

48

Chapter 3

METHODS

3.1 Overview of Study Design
This research is a cross-sectional analysis that uses a subset of data collected

by the W1003 USDA multistate project entitled, “Parent and Household Influences
on Calcium intake in Preadolescents. " Two data sets were analyzed from the W1003:
a) qualitative interviews assessing parental influences on calcium intake in children,
and b) a supplement and calcium-fortified food questionnaire assessing use in parents
and children. This study was conducted in three phases. The first phase was to
transform the qualitative data from the interviews into a quantitative data set that
includes variables on parental influences on calcium intake in children. The second
phase was to transform the supplement and calcium-fortified food questionnaire data
into a data set assessing use versus non-use of calcium-fortified foods and
supplements in children. The third phase was to evaluate the association between the
identified parental influences and supplement and calcium-fortified food use in
children. Human subjects approval was obtained from University Committee on
Research Involving Human Subjects (UCRIHS) (See Appendix A for UCRIHS
informed consent). In October 2003, permission from the multistate project
investigators was obtained for use of their data.
3.2 Data Sources

W1003 is a five-year, three-phase, multistate project designed to gain a greater

understanding of the parental motivators and barriers to calcium-rich foods and their

49

influence on calcium intake in children (National Information Management and
Support System: W1003 Multistate Project Summary,(Accessed 2004). The current
study used selected data sets collected in phase I of W1003.
3. 2.1 W1003 Multistate Subjects

The W1003 study population consisted of a convenience sample of 206 Asian,
Hispanic, and Non-Hispanic white parents/ guardians of 10-13 year old children. The
inclusion criteria, in addition to the race/ethnicity requirements were that the parent or
guardian must be the major food preparer in the household and have lived in the
United States for at least one year. This convenience sample was recruited in the
summer and fall of 2003 through ongoing engagement programs directed to youth,
(e. g. extension youth groups, faith—based groups, scouts, and after-school programs).
An informational recruitment flyer was distributed to engagement program leaders to
help recruit eligible participants. A gift certificate incentive was provided for
participation in the study. The data were collected in twelve states: Arizona,
California, Colorado, Hawaii, Indiana, Kentucky, Michigan, Minnesota, New
Mexico, Oregon, Wyoming, and Washington. Each state was given an equal number
of participants of a designated race/ethnic group to recruit (e. g. Michigan recruited
Hispanic and white participants). Michigan conducted 22 interviews (Schoemer-
Interviewer, 2003). The project was approved by the Institutional Review Board of
each respective university.
3.2.2 W1003 Multistate Measures

The first of two types of data that were collected in phase I of the W1003

multistate project was an open-ended, one-on-one qualitative interview designed to

50

uncover parental influences (knowledge, attitudes, beliefs, behaviors) on calcium
intake in children. Interviews explored topics such as (a) availability of calcium-rich
foods and alternatives to these foods in the home; (b) cost and convenience of
consuming calcium-rich foods; (c) family meal patterns; ((1) modeling of calcium
intake in and outside the home by adult family members; (e) family expectations in
and outside the home; (f) action-related behaviors related to calcium intake, e. g.,
regularly purchasing milk; and (g) attitudes and beliefs towards calcium-rich foods.
From these interviews, the calcium-rich foods that were explored included the
following: dairy (milk, cheese, yogurt), foods made with dairy (pizza, pudding,
cream soup), green leafy vegetables (spinach, broccoli, greens, turnips, kale), and fish
with bones (canned salmon and sardines). Parents were asked to describe if they
purchased and consumed these calcium-rich foods for their home, how often they
were consumed and purchased, along with reasons why they did or did not purchase
and/or consume these foods. They were also asked if their child consumed calcium-
rich foods, how often they consumed them, along with reasons why their child did or
did not consume these foods. Parents were asked about these calcium-rich food
groups as a whole (e. g. dairy, green leafy vegetables), as well as individual food
within the specific food groups (e. g. milk, cheese, broccoli). The interviews were
conducted by one interviewer (graduate research assistants or research professors) per
state with 12 total interviewers. All interviewers were provided with an interview
guide that included a list of questions that must be asked and possible follow-up

probes. This guide was developed by the W1003 investigators to aid the interviewers

51

during interviews and provided a consistent format to follow (See Appendix B for
interview guide).

To achieve standardization in the qualitative interviews among states included
in the project, each interviewer was trained in qualitative interviewer techniques
(Seidman, 1998). Practice interviews were piloted and monitored prior to initiation of
subject testing. To enhance the responses of the participants and the quality of data,
the researchers attempted to match the ethnicity between the interviewer and
interviewee. The interviews were approximately one hour in length, were conducted
in a neutral location, audio-recorded, and later transcribed. The information from
these qualitative interviews has been used in W1003 to guide the design and content
of a questionnaire about parental factors influencing calcium intake in children, which
will be used in the next phase of the W1003 project.

The second data source was a supplement and calcium-fortified food
questionnaire developed by the W1003 researchers to acquire information via a
structured interview about children’s use of supplements and calcium-fortified foods
from their parents (See Appendix C for questionnaire including instructions to
interviewers). The information from this questionnaire will b used in W1003 to
improve quality of a calcium food frequency questionnaire which was developed and
validated in the previous W191 multistate project.

During the supplement section, each parent was asked for the brand name,
dose, and history of each dietary supplement he/she consumed in the previous month.
In the calcium-fortified food section, a list of 9 types of calcium-fortified foods

(orange juice, bread, bagels/English muffms/hot dog buns, cold ready-to-eat cereal,

52

cereal/granola bars, energy/protein bars, meal replacement drinks, soymilk, and tofu)
were identified. Each parent was asked if he/she chose the fortified food to increase
calcium intake, and if so, what was the parent’s amount and frequency of use.
Surrogate information for the children and spouses was also provided by the parents.
Structured prompts, including pictures and follow-up phone calls, were employed
when the participant failed to recall the specific type of a certain supplement or
calcium-fortified food.

In addition to the supplement and calcium-fortified food data, the
questionnaire also included sociodeomographic questions about the parent and his/her
child. Self-reported ethnicity/race, age, gender, and level of education of the parent
along with ethnicity/race, age, grade, and gender of child was collected. The
children’s enrollment in the free or reduced-priced School Lunch Program (SLP) was
also documented as a surrogate marker for socioeconomic status.

Transformation of Data
3.3.1 Transformation of Qualitative Data

206 qualitative interview transcripts were received in April 2004 in
Microsoft© Word format. A content analysis approach was used to transform these
qualitative data into a quantitative data set assessing parental influences on calcium
intake in children. Content analysis is a process of systematically analyzing messages
in any type of communication (Kondracki et al., 2002) and consists of coding raw
messages (i.e. textual, material, visual images, illustrations) according to a
classification scheme (Shepherd & Achterber, 1992). The procedures of the content

analysis for this study are discussed in the following sections.

53

Developing a Coding Procedure

The purpose of the content analysis is to identify various parental influences
in each household that.were expressed to have an effect on child calcium
consumption. A specific set of factors (parental influences) (Table 3.1) were of
particular interest to this research. These factors (parental influences) were chosen
based on concepts prevalent in the literature. To ensure systematic identification of
these factors within the qualitative interviews, a codebook of procedures was
developed. Twenty-four transcripts (2 from each state) were initially sampled by the
primary researcher for use in developing the codebook. The codebook includes
definitions of each factor (parental influence), a rule for how to identify the factor in
the text, as well as an example of text that qualifies to be coded as a positive or
negative parental influence factor.

Codebook development was an iterative process. During the preliminary
stages of coding, the codebook was revised multiple times, to make the definitions of
each of the parental influences clear and the rules more precise to ensure a more
consistent coding process. After the twenty-four sample transcripts were coded,
code-checking was completed by giving four transcripts along with the codebook to
three nutrition professionals (two MS, RDs, and one PhD in nutrition) to check their
coding decisions against that of the primary researcher. This helped to further
strengthen the coding scheme by continuing to improve the clarity of definitions and

rules for consistent identification of the factors.

54

Table 3.1. Variables Representing Parental Influences on Calcium Intake Identified
Through Content Analysis

 

Parental Influences Variables and Definitions

Availability: Concerns whether parents stated that calcium-rich foods of
interest are present in the family home (e. g. “We always have milk at our
house”). Lack of availability concerns whether parents stated that calcium-rich
foods were not present in the family home.

Accessibility: Concerns whether parents stated that calcium-rich foods are
made available in a form and location that is likely to increase its consumption
(e. g. “Cheese is cut up into slices and is served at snack times”). Lack of
accessibility concerns whether parents stated that calcium-rich foods were not
accessible for their children.

Convenience: Concerns whether parents stated that calcium-rich foods are
quick, easy to use when preparing meals and/or providing for their child to
consume at meal and/or snack times (e. g. “Yogurt is a quick, easy food that I
always put in her lunches”). Inconvenience concerns whether parents stated
that calcium-rich foods were inconvenient for them to prepare or inconvenient
for their child to consume at meal and/or snack times.

Cost: Concerns whether parents stated that the cost of calcium-rich foods was
a positive or negative factor involved in providing calcium-rich foods for their
children (e. g. “We hardly ever buy yogurt because it is too expensive”, e. g.
“We always have cheese because we get the cheese blocks on sale so it is
cheap”).

Health benefit beliefs: Concerns whether parents stated that calcium-rich
foods were provided to their children because of their importance for their
child’s health (e. g. we always have milk at dinner because the kids need to get
enough calcium). Negative health benefit beliefs concerns whether parents
stated that calcium-rich foods were not provided to their children because of
their harmful health benefits (.e. g. “We hardly ever serve cheese for family
meals or snacks because it is too fattening”).

Child Preference: Concerns whether parents stated that they were purchasing
calcium-rich foods as well as making these foods a part of their meals and/or
snacks because their child liked them (e. g. “We always have yogurt as a snack
option because the kids love it”). Lack of child preference or child dislike
concerns whether parents stated that they did not purchase or make these foods
part of meals and/or snacks because their child does not like them (e. g. “We
don’t serve milk for meals because Jenny can’t stand it”).

Parental modeling: Concerns whether parents stated drinking milk at meal
and/or snack times (e. g. “I always drink milk at dinner,”) when asked about
their milk drinking habits in the interview. Lack of parental modeling concerns
whether parents verbalized not drinking milk at meal and/or snack times.
Parental expectation: Concerns whether parents stated that milk was the
beverage that was expected to be consumed by their children at meal and/or
snack times when asked about rrrilk expectation in the interview. (e. g. “I make
sure that they always have milk for dinner”). Lack of parental expectation

 

 

 

 

 

 

 

 

 

 

 

55

 

concerns whether parents stated that they let their children choose whatever
they want to consume at meal and/or snack times (e. g. “She just gets what she
wants out of the fridge to drink for supper”).

Knowledge of calcium and health: Concerns whether parents stated that they
knew that calcium was important for bone health when asked about calcium
and health during the interview.

Knowledge # dairy servings: Concerns whether parents stated the correct
number of dairy servings needed to meet child calcium recommendations when
asked during the interview.

 

 

 

 

 

After the code-checking was completed, all transcripts were re-coded by the
primary researcher using the revised codes. After the initial coding, further revisions
were made to the codebook to make the definitions and rules for the parental
influence factors more precise. Also finther revisions were made because certain
calcium-rich food groups (green leafy vegetables, and fish with bones) that were
initially evaluated in the codebook were not widely consumed across all participants
and therefore yielded insufficient data for analysis. These factors were dropped from
the codebook. After revisions the transcripts were then coded for a second time by
the primary researcher.

To improve the reliability of the coded data an additional coder was trained to
strengthen the consistency of the coding scheme. Six training sessions (1 hour each)
were completed on codebook instructions with the second coder. Codebook revisions
were made to tighten the definitions and translation rules based on discussions during
training sessions. The second coder then proceeded to code a sample of 24 transcripts
(2 from each state). Six sessions (1 hour each) were completed after the sample
coding to code-check the additional coder’s results against the primary researcher’s.
After additional revisions, the codebook and coding form were finalized and ready for

independent coding by the primary investigator and additional coder. Detailed

56

instructions on the coding procedure are found within the project codebook (See
Appendix D for codebook).
Coding

The purpose of the coding procedure was to identify the positive and negative
factors ( or “parental influences”) on calcium intake in children from the qualitative
interviews. The factors were coded as a +1 if they were identified as a positive factor
and a -1 if they were identified as a negative factor. If a factor was probed for but not
mentioned within the interview then it was coded as 0 and considered a neutral factor.
If specific questions within the interview content outline were skipped by the
interviewer that would elicit information about a particular factor, the factor was
considered missing and was coded with a period (0). The codebook corresponded to
the coding form (See Appendix E for coding form), which provided spaces
appropriate for recording the codes for all factors measured. The primary researcher
coded all the transcripts for the final time. The second coder coded a subset of the
total independently. 20% (40 transcripts) of the sample (n=179) that the coder had
not practiced on previously were randomly selected from a random number table.
The second coder was a blind coder in that they did not know the purpose, research
questions, or hypotheses of the study. The final factors that were coded for which are
the independent variables are listed in Table 3.2.
Cleaning the Data

After the coders coded the data on the coding forms, they proofread their data
entries on the coding forms against the interview text that was highlighted and labeled

and then entered the data into a Microsofi© Excel file. When data entry was

57

complete, an undergraduate assistant also checked for errors in data entry. Data was
subsequently checked the quantitative data set of parental influence factors was
finalized and ready for analysis.
Reliability

After the data was cleaned, a graduate student not involved in the study
calculated the percentage agreement between the two coders for the interviews they
both completed to provide an assessment of interrater reliability. Percentage
agreement scores were calculated as the number of times of observation or coding in
which the two coders agreed divided by the number of possible observations of
coding.
3.3.2 Transformation of Supplement and Calcium-Fortified Food Questionnaire

The second phase of the research was to transform the supplement and
calcium-fortified food questionnaire data into variables that record use versus non-use
of calcium-fortified foods and calcium supplements in children and parents. The
following criteria were applied to the questionnaire data: calcium supplement use
was defined as use of a multivitamin with calcium or a calcium supplement three or
more times per week. If use was less than this, the parent and/or child were not
considered to be a supplement user. Calcium-fortified food use was defined by
average daily consumption of at least one calcium-fortified food. If average use was
less lx/day then the parent and/or child was not considered to be a calcium-fortified
food user. After the criteria were applied to develop the new data set, it was
proofread for accuracy. The sociodemographic variables that were collected from the

questionnaire were added to the data set without transformation and are listed in

58

Table 3.2. This data set was then merged with the data set derived from the
qualitative interviews to form a complete data set in an SPSS data file. See Table 3.2

for list of supplement and calcium—fortified food and variables.

59

Table 3.2. Parental Influences, Sociodemographic, Supplement and Calcium-
Fortified Food Variables

 

 

 

 

 

 

 

 

Parental Influences Variables Possible Values
Availability (dairy group*, milk, yogurt, positive, negative or neutral
cheese) factor
Accessibility (dairy group*, milk, yogurt, positive, negative or neutral
cheese) factor
Convenience (dairy group*, milk, yogurt, positive, negative or neutral
cheese) factor
Cost (dairy group*, milk, yogurt, cheese) positive, negative, or neutral
factor
Culture (dairy group*, milk, yogurt, cheese) positive, negative, or neutral
factor
Health benefit beliefs (dairy group*, milk, positive, negative, or neutral
yogurt, cheese) factor
Child Preference (dairy group*, milk, positive, negative, or neutral
jogurt, cheese) factor

 

Knowledge of number of milk servings to positive or negative factor
meet calcium recommendations

 

 

 

 

 

 

 

 

 

 

 

 

Knowledge of bone health positive or negative factor

Parental modeling for milk positive or negative factor

Parental expectation for milk positive or negative factor

Sociodemographic Variables Possible Values

Participant in school lunch program (SLP) yes, no

Race/Ethnic group of parent and child Hispanic, Non-Hispanic white,
Asian

Gender of child male, female

Gender of parent male, female

Age ofchild 10,11,12,13

Grade of child 5%“, 7‘“, 8‘“

State AZ,CA,CO,HI,IN,KY,MI,MN,N
M,OR,WA,WH

Education level of parent <high school or high school
graduate, some college, college
graduate

 

Supplement and Calcium-Fortified Food Possible Values
Variables

 

Parent and child supplement use user, non-user

 

 

Parent and child calcium-fortified food use user, non-user

 

* Positive and negative parental influence comments were identified about the dairy group overall,
along with positive and negative comments regarding individual foods within the dairy group (milk,
yogurt, cheese).

60

3.4 Analysis

Statistical Package for the Social Sciences (SPSS) Version 13.0 was used for
statistical analyses (SPSS, 2003). Interrater reliability was assessed between the two
coders using percentage (%) agreement. Relationships between sociodemographic
characteristics and child calcium supplement and calcium-fortified food use were
evaluated using chi-square analyses. The statistical analysis for each specific aim is

discussed below.

Specific Aim 1. To identify positive and negative parental influences related to
calcium intake in preadolescents.

Content analysis procedures described above were used to identify positive
and negative parental influences related to calcium intake in preadolescents.
Descriptive statistics were analyzed to detect fi'equencies and percentages of the
parental influences.

Specific Aim 2. To identify patterns of parental influences within the sample

population.

Cluster analysis procedures were used to identify similar patterns of the
following parental influences: availability (dairy group, milk, yogurt, cheese),
accessibility (dairy group, milk, yogurt, cheese), convenience (dairy group, milk,
yogurt, cheese), cost, (dairy group, milk, yogurt, cheese), culture (dairy group, milk,
yogurt, cheese), health benefit beliefs (dairy group, milk, yogurt, cheese), and child
preference (dairy group, milk, yogurt, cheese). A hierarchical agglomerative

clustering method was performed to determine whether a heterogeneous pool of

61

participants could be classified into a smaller number of homogeneous subject
profiles. Starting with each subject as a cluster, the hierarchical procedure calculates
the squared Euclidean distance between each pair of clusters and continues to
combine clusters that have the smallest distance until one single cluster is left. In
order to determine the number of clusters, a hierarchical dendogram (See Appendix
F for hierarchical dendogram) was used and solutions for 2 to 4 clusters were
investigated. The final number of clusters was determined by a substantive analysis
of the characteristics of the persons grouped into the cluster and the number of

personas in the clusters. The solution of two clusters was most interpretable.

After the two cluster solution was determined, a K-means cluster method was
employed (See Appendix G for K-means cluster method). This method produces ‘K-
means’ or clusters of individuals who score similarly on a set of items. In a two
cluster solution, the K-means procedure starts with one cluster or group and splits it
in two by picking the individual farthest from the center in multidimensional space as
a seed for the second cluster (Afifi, 1996). All individuals are then assigned to one or
the other cluster depending on which center they are closest to in multidimensional
space. The objective of clustering is to identify the smallest number of groups that
both maximize distance between groups and maximize frequency within each cluster.
Chi-square analysis was used to identify the sociodemographic distributions for each

cluster.

Specific Aim 3. To relate patterns of parental influences to preadolescent use of

calcium-fortified foods and supplements.

62

This third phase of analysis was to evaluate the association between the
identified parental influences and supplement and calcium-fortified food use in
children. Associations between cluster membership and preadolescent calcium-
fortified foods and supplement use and other sociodemographic characteristics were
evaluated using chi-square analyses and the Mantel-Haenszel test. The Mantel
Haenszel test was used to control for sociodemographics to see if the overall

association found was different across different sociodemographic groups.

63

Chapter 4

RESULTS

4.1 Demographic Characteristics of Sample

Of the 206 interview transcripts that were completed, 191 were used for analysis.
One interview was not used because the quality of the audio recording did not allow
for adequate transcription. Fourteen were not used because questions from the
interview content outline were not asked or adequate probing was not used in the
interview to ensure completeness of responses. Interviews included for analysis were
equally represented among all states with the exception of proportionately more
completed in Arizona, Michigan and proportionately less in New Mexico. Selected
sociodemographic characteristics for the parent and the child (surrogate information
for child provided by parent) are provided in Table 4.1.1. The majority of parents
were mothers of children 11-12 years old, college educated (57%) and did not
participation in school lunch (measured as a surrogate for income) (66%). There
were more girls (55%) than boys (46%) and proportionately more children were Non-
Hispanic white (39%) followed by Hispanic (32%), and Asians (29%). Within the
Asian and Hispanic groups, 9 participants were mixed Asian-white and 20 were
mixed Hispanic-white and were included in the Asian or Hispanic category.

Table 4.1.2 examines child race/ethnicity differences by state of residence. The
majority of Asians were recruited from Minnesota, Oregon, Kentucky and Hawaii.
The majority of Hispanics were recruited from Arizona, Michigan, California,

Colorado and Oregon. The majority of Non-Hispanic white participants were

64

recruited from Arizona, Washington, Colorado, Michigan and Wyoming.
Associations among sociodemographic characteristics and child race/ethnicity were
examined using chi-square analysis. There were no differences among race/ethnicity
groups in terms of gender, grade or age. A significant association between child
race/ethnicity and participation in the free/reduced meal program was found. Out of
the total sample, 19% of Hispanic, 10% of Asian and 6% of Non-Hispanic white
participants were participating in school lunch while a higher percentage of both
Asians and Non-Hispanic whites and a lower percentage of Hispanics were not
participating (See Table 4.1.3). A significant association was also found between
child race/ethnicity and education level where out of the total sample a higher
frequency of Non-Hispanic white (29%) and Asian (20%) were college graduates
compared to Hispanics (9%), while a higher frequency of Hispanics had less

education when compared to Non-Hispanic whites and Asians (See Table 4.1.4).

65

Table 4.1.1. Sociodemographic Characteristics for Parents and Children

 

 

 

 

 

 

 

 

 

 

(n=191)
Race/Ethnic Group of Child
Asian, % 29
Hispanic, % 32
Non-Hispanic White, % 39
Child Gender
Male, (n, %) 45
Female, (11, %) 55
Parent Gender
Male, %' 6
Female, % 94
Child Age (years)
10,% 16
11, % 32
12, % 33
13, % 19
Child Grade
4‘“, 5th 5, 19
6‘“, 7‘“, 8‘“, % 44, 21, 10
Education Level of Parent
< HS or HS graduate, % 18
Some college, % 25
College graduate, % 57
Child participation in free/reduced price
School Lunch Program (SLP)
Yes, % 35
No, % 66
State of Residence
AZ, CA, CO, H1 18, 4, 8, 8
IN,KY, MI, MN, 8, 8, 11, 8
NM, OR, WA, WY, % 2, 8, 8, 7

 

66

Table 4.1.2. Child Race/Ethnicity Differences by State of Residence

 

 

 

 

 

 

 

 

 

 

 

 

 

State Asian (n=56) Hispanic (n=6l) Non-Hispanic

(%) (%) White (n=74)
(%)

Arizona 0 28 23

California 4 10 0

Colorado 0 13 11

Hawaii 16 5 5

Indiana 9 7 8

Kentucky 14 0 10

Michigan 0 20 12

Minnesota 29 0 0

New Mexico 0 3 3

Oregon 18 10 0

Washington 7 0 16

Wyoming 4 5 12

 

 

 

 

Table 4.1.3. Child Race/Ethnicity Differences in free/reduced price School Lunch

 

 

 

 

Participation
Child Race/Ethnicity Yes (SLP) No (SLP)
p Value
Asian, % 10 19 x2 =28.836
p < 0.001
Hispanic, % 19 13
Non-Hispanic white, % 6 33
Total, % 35 65 100
Total N = 191

Table 4.1.4. Child Race/Ethnicity Differences in Education Level

 

 

 

 

Child < HS or HS Some College x2
Race/Ethnicity graduate College graduate p Value
Asian, % 7 3 20 x2 = 40.715

p < 0.001
Hispanic, % 9 15 9
Non-Hispanic white, 3 7 29
%
Total, % 19 25 58 100

Total N = 191

67

4.2 Presence of Parental Influences

Table 4.2.1 and Table 4.2.2 indicate the most prevalent positive and negative
parental influences that were identified from the qualitative interviews through
content analysis procedures. A percentage of 10% or greater was used as the cutoff
for reporting the most prevalent parental influences. Availability (milk, dairy,
cheese), child preference (dairy, cheese, yogurt, milk), health benefit beliefs (dairy,
milk, cheese, yogurt) convenience (dairy, cheese, yogurt), knowledge of calcium and
bone health and knowledge of the number of servings to meet child calcium
recommendations were the most prevalent positive parental influences. Lack of
parental modeling for milk, lack of parental expectation for milk at meals, lack of
availability of yogurt, and child preference (milk, dairy) were identified as the most
negative parental influences to calcium intake in children. Accessibility, cost, and
culture were parental influences that were also identified in the interviews but to a
lesser extent and are not included in Table 4.2.1 and 4.2.2 (See Appendix H for

percent prevalence of all positive, negative and neutral parental influences).

68

Table 4.2.1. Positive Parental Influences Related to Child Dairy Intake

 

Percent Presence

 

(%)

Availability

Milk 94

Dairy (group)* 87

Cheese 53

Yogurt 38
Knowledge

Calcium and bone health 96

# of servings to meet calcium recommendations 68
Child Preference (Like)

Dairy (group) * 65

Cheese 46

Yogurt 39

Milk 26
Health Benefit Beliefs

Dairy (group) * 55

Milk 38

Yogurt 20

Cheese 10
Convenience

Dairy (group) * 25

Yogurt 1 1

Cheese 1 l

 

* Positive and negative parental influence comments were identified about the dairy group overall,
along with positive and negative comments regarding individual foods within the dairy group (milk,
yogurt, cheese).

69

Table 4.2.2. Negative Parental Influences Related to Child Dairy Intake

 

 

 

Percent Presence
(%)

Lack of Parental Modeling
Milk 67
Lack of Parental Expectation
Milk 68
Child Preference (Dislike)
Milk 18
Dairy (group)* 15
Yogurt 1 5
Lack of Availability
Yogurt 16

 

* Positive and negative parental influence comments were identified about the dairy group overall,
along with positive and negative comments regarding individual foods within the dairy group (milk,
yogurt, cheese).

70

4.3 Patterns of Parental Influences (Specific Aim 2)

From the cluster analysis, it was determined that two dominant patterns of
responses defined the clusters. Cluster 1 (n=128), consisted of positive parental
influences for availability of dairy foods, milk, and cheese, positive health benefit
beliefs for dairy, and child preference for dairy and cheese, whereas Cluster 2 (n=63),
consisted of positive parental influences for only availability of dairy and milk, while
the rest remained neutral (See Table 4.3.1). Cluster 1 was considered to represent a
more positive parental pattern towards child dairy use based on its higher frequency
of positive parental influences mentioned when compared to cluster 2 which was
considered to represent a more neutral pattern. Out of the total sample Cluster 1 had
equal representation of girls and boys and proportionately more Non-Hispanic whites
(28%) and Hispanics (26%) and proportionately less Asians (14%). Cluster 2 had
proportionately more girls than boys and proportionately more Asians (16%),
followed by Non-Hispanic whites(l 1%) and a lower frequency of Hispanics (6%).
Clusters did not differ by education level or school lunch participation (See Table

4.3.2).

71

Table 4.3.1. Cluster Patterns

 

Cluster Membership

 

Cluster 1 (n=128) Cluster 2 (n=63)

 

Availability-dairy*
Availability-milk
Availability-cheese

Health benefit beliefs-dairy*
Child preference-dairy*
Child preference-cheese 1

n—ti—tr-dv—or—I
OOOOHH

 

* Positive and negative parental influences were identified about the dairy as a group along with
individual foods within the dairy group

Table 4.3.2. Child-Parent Sociodemographics by Cluster Pattern

 

 

 

 

 

 

 

 

 

 

 

 

 

Cluster 1 Cluster 2 )6
Positive Neutral p Value
Parental Parental
Influences Influences
Child Gender
Female, % 33 22 x2 =
Male, % 34 12 4.282
p < 0.05
Total, % 67 33 100
Total N = 191
Child Race/Ethnicity
Asian, % 14 16 78:16.33
Hispanic, % 26 6 8
Non-Hispanic white, % 28 11 p <
0.001
Total, % 67 33 100
Total N = 191
Parent Education Level
<HS or HS graduate, % 10 8 {=3.061
Some college, % 19 6 NS
College graduate, % 38 19
Total, % 67 33 100
Total N = 191
F rec/reduced price School Lunch
Participants 24 1 1 x2 =
Yes, % 44 22 0.062
No, % NS
Total, % 67 33 100
Total N = 191

 

72

4.4 Calcium Supplement and Calcium-Fortified Food Use

Child and parent calcium supplement and calcium-fortified food use is presented
in Table 4.4.1. Approximately one-third of children (35%) and one-half (49%) of
parents were regularly taking calcium supplements. Ninety percent of children
supplement users were taking a multivitamin/mineral with added calcium and 10%
were taking a calcium supplement while 68% of parents were taking a
multivitamin/mineral with added calcium and 32% were taking a calcium
supplement. Almost two-thirds of children (60%) and one-half of parents(48%) were
regularly consuming calcium-fortified foods. The majority of children and parent
calcium-fortified food users were regularly consuming calcium-fortified orange juice
followed to a lesser extent by cold and hot cereal, bread, meal replacement drinks,
cereal/granola bars, soymilk, tofii, and energy/protein bars (see Table 4.4.2). A
significant positive association was found between child and parent supplement use
(x2 = 29.573, p < 0.001) and child and parent calcium—fortified food use (12 =97.697,
p < 0.001). There were no differences between child supplement users and non-users
in terms of gender or race/ethnicity. Out of the total sample very few users had lower
education levels (some college 7%, <HS or HS graduate 4%) compared to non-users
(some college 18%, <HS or HS graduate 14%), while a higher frequency of college
graduates were found in both users and non-users. There were no differences
between child calcium-fortified food users and non-users in terms of school lunch
participation. Out of the total sample of child calcium-fortified food users had equal
representation of girls and boys, proportionately more Non-Hispanic whites (27%)

and Hispanics (23%) compared to Asians (10%), and proportionately more parents

73

with higher education levels compared to those with <HS or HS education. There
were proportionately more girls than boys who did not use calcium-fortified foods.
There were also proportionately more college graduates, but proportionately fewer

participants with some college compared to users (See Table 4.4.4).

74

Table 4.4.1. Child and Parent Calcium Supplement and Calcium-Fortified Food Use

 

 

Child Parent
(n=191) (n=l91)
Regular Calcium Supplement Use
-Users, % 35 49
-Non-Users, % 65 51
Regular Calcium-Fortified Food Use
-Users, % 60 48
-Non-Users, % 40 52

 

Table 4.4.2 Child and Parent Calcium-Fortified Food Type

 

 

Child Parent
Calcium-Fortified Food Type (n=114) (n=93)
Orange juice, % 68 65
Cereal, % 16 13
Bread, % 9 10
Meal replacement drinks, % 3 4
Cereanranola bars, % 2 1
Soyrnilk, % l 4
Tofu, % 1 0
Energy/protein bars, % 0 3

 

75

Table 4.4.3. Sociodemographics of Children Who Used Supplements

 

 

 

 

 

 

 

 

 

 

 

 

 

Users Non-Users xzand p
(n=66) (n=125) Value

Child Gender
Female, % 17 37 x2 = 0.805
Male, % 18 28 NS
Total 35 65 100

Total N = 191
Child Race/Ethnicity
Asian, % 8 21 x2 = 2.961
Hispanic, % 10 22 NS
Non-Hispanic white, % 16 23
Total 34 66 100

Total N = 191
Parent Education Level
<HS or HS graduate, % 4 14 x2 = 6.581
Some College, % 7 18 p < 0.05
College Graduate, % 24 33
Total 35 65 100

Total N = 191
Child Free/Reduced Price
School Lunch Participation 9 26 78 = 3.451
Yes, % 26 40 p < 0.05
No, %
Total 35 66 100

Total N = 191

 

76

Table 4.4.4. Sociodemographics of Children Who Used Calcium-Fortified Foods

 

 

 

 

 

 

 

 

 

 

 

 

 

Users Non-Users x2 and p
(n=1 14) (n=7 7) Value
Child Gender
Female, % 29 26 x2=4.389
Male, % 31 14 p < 0.05
Total, % 60 40 100
Total N = 191
Child Race/Ethnicity
Asian, % 10 19 x2 =21.989
Hispanic, % 23 9 p < 0.001
Non-Hispanic white, % 27 12
Total, % 60 40 100
Total N =
191
Parent Education Level
<HS or HS graduate, % 9 9 x2 =7.503
Some College, % 19 6 p < 0.05
College Graduate, % 32 25
Total, % 60 40 100
Total N = 191
Child F rec/Reduced Price
School Lunch Participation 19 15 x2 = 0.451
Yes, % 41 25 NS
No, %
Total, % 60 40 100
Total N = 191

 

77

4.5. Relationship between Parental Influences and Patterns of Parental Influences and
Child Supplement and Calcium-Fortified Food Use (Specific Aim3)

No relationship was found between cluster membership and child calcium
supplement use. No relationship was also found between parental modeling, parental
expectation, knowledge of calcium and bone health, and knowledge of number of
servings to meet calcium recommendations and calcium supplement and calcium-
fortified food use. Use of calcium-fortified foods was more likely to occur in
children represented in Cluster 1 (p < 0.05), while use was equally likely to occur in
Cluster 2 (See Figure 4.5.1). No differences between cluster membership and
calcium-fortified food use by child age, gender, and race/ethnicity. However, among
those with less education and lower income, children were more likely to be non-
users versus users in Cluster 2 (See Figures 4.5.2 and 4.5.3).

Figure 4.5.1. Relationship between Cluster Membership and Child Calcium-
Fortified Food Use (p < 0.05)

 

100 j

 

 

I Non-Users, Calcium-
Fortified Foods

Users, Calcium-
Fortified Foods

 

% within cluster

 

 

 

 

Positive Neutral

Cluster Membership

78

Figure 4.5.2. Relationship between Cluster Membership and Child Calcium-
Fortified Food Use, among Free/Reduced Price School Lunch Program Participants

(p < 0.05)

Free/Reduced Price School Lunch Program
Participants (n=66)

 

 

 

 

1 00
80
I Non-Use rs,
Calcium-Fortified
Foods

Users, Calcium-
Fortified Foods

% within cluster

 

 

 

 

 

 

Positive Neutral
Cluster Membership

Figure 4.5.3 Relationship between Cluster Membership and Child Calcium-
Fortified Food Use, Among Parents with Less Education (p < 0.05)

Less than High School or High School Graduate

 

 

 

 

 

 

 

 

 

(n=35)

1 00 1
t...
g 80
3 I Non-Users,
° Calcium-Fortified
E
'_= Foods
:‘.:.'
B
e V Users, Calcium-
°\ \ \\ Fortified Foods

:\\\ s
Positive Neutral
Cluster Membership

79

Chapter 5
DISCUSSION

A substantial body of literature indicates that parents and other caregivers can
influence the food choices of children through the types of food made available at
home, interactions that take place during meals and eating behaviors they model
(Baranowski et al., 1999; Birch, 1999; Nicklas et al., 2001). Limited research,
however, has been completed to understand parental influences related specifically to
dairy and overall calcium intake in youth. Furthermore, little is known about child
calcium supplement and calcium-fortified food use and how parental influences relate
to their intake. This analysis was therefore the first to explore the relationship
between parental influences related to dairy and their role in child use of supplements
and calcium-fortified foods. It was completed in a group of white, Hispanic and
Asian parents of preadolescents. These race/ethnicity groups have been shown to be
at highest risk for developing osteoporosis later in life (Heaney, 2000a).

Parental Influences

Several parental influences were identified related to dairy foods. The most
prevalent positive parental influences were availability, child preference (likes dairy),
health benefit beliefs, convenience, knowledge of calcium and bone health and
knowledge of the number of dairy servings needed to meet child calcium
recommendations. The most prevalent negative parental influences were lack of
parental modeling, lack of parental expectation for milk at meal and snack times and

child preference (dislikes dairy). Other parental influences such as accessibility, cost,

80

and cultural values regarding food type and preparation have been identified in
previous research, (N eumark-Sztainer et al., 1999; Novotny R, 1999; Auld et al.,
2002) but were rarely mentioned by parents as reasons they did or did not provide
dairy foods to their children. The prevalent parental influences that were identified
are discussed in more detail in the following sections.

Availability. Parents were asked about their attitudes, beliefs, and behaviors
towards dairy as a food group, as well as specific dairy foods within the dairy group.
The dairy food group was mentioned as readily available by almost all parents,
although milk may have been driving the high availability of dairy, which is indicated
by almost all parents mentioning it as available. Other dairy foods such as cheese and
yogurt were mentioned as available by many participants, but less frequently than
milk. Potential reasons why these foods were mentioned less often could be because
they are foods not typically part of the Asian culture (Barr, 1994) and yogurt is not
typically part of the Hispanic culture (Novotny et al., 2003). Also, some parents
reported not purchasing specific dairy foods for health reasons (e.g. “Cheese is
fattening so I don’t buy it.”), thereby limiting availability.

Availability has been positively associated with huh and vegetable
consumption in children and adolescents (Domel et al., 1993; Krebs-Smith et al.,
1995; Baranowski etal., 1997; Gibson et al., 1998; Heam, 1998; Weber Cullen et al.,
2000; Edmonds et al., 2001; Cullen et al., 2003). Limited research, however, has
been completed with availability of dairy foods related to total calcium intake. In a
recent longitudinal study evaluating calcium intake in white girls, 5 to 9 years, it was

found that the mother-daughter similarity in milk intake was mediated by the extent

81

to which mothers made milk available to their daughters (Fisher et al., 2004). Only
the girls whose mothers were in the habit of frequently serving milk at meals and
snacks were still drinking significant amounts of milk, and were getting enough
calcium at age 9 (Fisher et al., 2004). Although availability of milk was a common
parental influence in the current study, due to its qualitative nature, the degree to
which parents reported serving milk and other dairy foods at meal times was not
assessed. This may provide a better measure of availability and will need to be
considered in future research.

Adequate dairy intake in children has been inversely associated with home
availability of soft drinks (Bowman, 2002; Fisher et al., 2004). The degree to which
soft drinks were available in the home was not addressed in the current study,
although many parents reported making soda along with other beverages available at
meal and snack times. Consequently, the extent to which other beverages were
available may have lessened the positive impact of milk availability. Because
displacement is not as likely to occur with other dairy foods such as cheese and
yogurt, availability of these foods may have a positive impact on calcium intake
similar to the beneficial effects seen with fruits and vegetables. Because parents are
responsible for making foods available to their children, making milk and other dairy
foods routinely available along with limiting consumption of other beverages at meal
and snack times, may help to ensure that such foods are consumed in the amounts
needed to achieve adequate calcium.

Child preference. Over half of parents (56%) reported that their child had

positive food preferences towards dairy as a group, but many reported mixed

82

preferences for individual dairy foods (e. g. “she loves the taste of yogurt, but dislikes
the taste of milk”). When asked about the dairy group during the interview, parents
may have included foods like ice cream or frozen yogurt in this category, which are
commonly preferred foods by children (Birch, 1999). This may have led to their
overall positive food preference responses towards dairy and mixed child preferences
towards milk, cheese, and yogurt.

Children’s food preferences are shaped by the quantity and quality of
children’s experience with food and eating (Beauchamp et al., 1994). As a result of
many eating occasions in which foods are associated with the social contexts of
eating and with the physiological consequences of indigestion, children come to
accept some foods and reject others, shaping their dietary intake (Birch, 1999).
Children tend to reject unfamiliar foods (neophobia), but this initial rejection can be
modified through repeated exposure. A minimum of 8-10 exposures to new foods has
been shown to increase preferences of these foods (Beauchamp et al., 1994; Birch,
1998a; Birch, 1999). Parents are central to shaping their child’s eating environment
and provide early food exposure, thus play an important role in the development of
children’s food preferences (Baranowski et al., 1999; Birch, 1999; Birch & Fisher,
2000)

Food preferences are also the primary factor influencing child and adult food
choices (Barr, 1994; Neumark-Sztainer et al., 1999; 2000a; Carruth et al., 2000). In
research with adolescents, taste enjoyment of dairy products has been shown to play
an important role in the adequate intake of calcium (Barr, 1994; Neumark-Sztainer et

al., 1997; Smart et al., 1999; Lee & Reicks, 2003; Novotny et al., 2003). Taste

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enjoyment of dairy foods has also been shown to be significantly lower among Asians
than in Caucasians (Barr, 1994; Novotny et al., 1999; Auld et al., 2002). Compared
to the previous findings, the current study also found that white parents reported that
their children had the most positive comments relative to the taste of dairy, followed
closely by Hispanics, with the least reported by Asians. Children who develop
negative food preferences for dairy foods may come from cultures or individual
families that do not provide repeated exposure to dairy foods during early childhood.
This may have contributed to differences in child preferences that were found in this
study as well as in previous findings. There is also recent research showing that
children play an influential role in driving food availability within the home, often
promoting less-nutrient dense foods (Roberts et al., 2003; Jackson et al., 2004). This
may also play a role in limiting exposure to more nutrient-dense foods including
dairy, possibly negatively influencing the development of food preferences.

In a USDA regional project assessing factors influencing calcium-intake in
adolescents, taste enjoyment of milk was identified a key motivator if served at a
certain temperature and with certain “matching” foods (accompanying food type)
(Novotny et al., 1999; Auld et al., 2002). In the current study most parents did not
report that their child only liked milk or other dairy foods if it was with an
accompanying food or served at a particular temperature. This may illustrate a
difference between parents perception of child preference and actual child preference
for dairy foods. More research is needed to fiirther understand how food preferences

for dairy are developed, how availability and food exposure affect food preferences,

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and how differing perceptions between parents and children in food preferences may
influence adequate calcium intake within the family environment.

Health Benefit Beliefs. Positive health benefit beliefs were mentioned by
approximately one-half of parents related to the dairy group as a whole, while milk,
yogurt, and especially cheese as individual foods were mentioned much less
frequently. Individual dairy foods may have been positively mentioned much less
frequently based on the differing health views parents may hold for individual foods
(e. g. “we buy dairy foods for the calcium, but cheese is fattening so we try to avoid
it”). The most common positive health benefit belief among parents was the
importance of dairy for adequate calcium for their children. Findings from studies
exploring the impact of health benefit beliefs on dietary behavior in adults are not
externally consistent. Some studies have found a positive effect (Jensen & Kesavan,
1993; Carslon & Gould, 1994; Variyam et al., 1996), while some have found no
significant effect on consumer eating decisions (Jensen et al., 1992; Douthitt &
Gould, 1995). Research regarding the relationship between parental health benefit
beliefs and their effect on children’s diet quality is limited. A recent study by Kim
and Douthitt found that mothers’ awareness of diet and health relationships had a
significant effect on adolescents’ dairy food consumption (Kim & Douthitt, 2003). In
the W191 regional project with adolescents, health motivations were identified as key
motivators to consuming calcium-rich foods by adolescents (Novotny et al., 1999;
Auld etal., 2002). Parental positive health benefit beliefs, if encouraged to children,

may help to promote child calcium intake, although more research is needed.

85

Convenience. Convenience has been mentioned as a barrier to dairy foods by
children and adolescents in previous research (Neumark-Sztainer et al., 1999;
Novotny et al., 1999; Auld et al., 2002). In the current study, although mentioned
much less frequently than the other factors, it was mostly mentioned as a positive
versus a negative influence by parents. Parents may not perceive dairy foods as
inconvenient as children because within the household and work environment, there
is usually adequate refiigeration for storing dairy foods, whereas, children do not
have the same accessibility to refiigeration when they are outside the home.
Promotion of convenient calcium-rich foods (e. g. string cheese, cereal bars) may help
to increase calcium intake in children and adolescents.

Knowledge. Similar to earlier findings (Neumark-Sztainer et al., 1997;
Novotny et al., 1999; Auld et al., 2002; Accessed 2004), almost all parents were
knowledgeable of the relationship between calcium and bone health. Previous
research has illustrated lack of knowledge in translating dietary recommendations into
the adequate number of food group servings (Harel et al., 1998; Harel Z, 1998;
Neumark-Sztainer et al., 1999; Wardle et al., 2000). Within this sample, the majority
were knowledgeable of the number of dairy servings needed. Although not
quantified, most parents were not knowledgeable of the number of servings needed
from other calcium-rich foods (e. g. leafy green vegetables, tofu, and fish with bones)
to meet calcium recommendations. This suggests more education may be needed to
translate calcium recommendations into number of food group servings outside of

dairy.

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Parental Expectation and Modeling for Milk. A consistent finding across
race/ethnicity groups was the limited parental expectation and modeling of milk,
which is comparable with earlier findings (Novotny et al., 1999; Novotny R, 1999;
Auld et al., 2002; Lee & Reicks, 2003; Hanson et al., 2005). Although few parents
model dairy food intake, modeling of milk by parents, particularly mothers, has been
shown to be positively associated with calcium intake in children in and adolescents,
(Fisher et al., 2004; Hanson et al., 2005). Social Cognitive Theory notes the
importance of the environment, including having approximate role models and norms
(expectations), in shaping behaviors (Anderson et al., 2000; Bandura, 2001). The
apparent lack of these parental modeling and expectation influences relative to milk
drinking may undermine efforts encouraging children and adolescents to drink more
milk. These are two very important areas that if improved may improve overall
calcium intake in children.

Patterns of Paren tal Influences

Parents fell into two main groupings, those indicating more positive parental
influences (positive cluster) and those indicating fewer parental influences (neutral
cluster) related to dairy foods. The positive grouping consisted of parents making
dairy foods available, indicating the importance of dairy to health, citing the
importance of adequate calcium, and having children with positive food preferences
towards dairy. They mentioned these positive influences for dairy as a group and also
for the specific dairy foods of milk and cheese. The neutral grouping, with the
exception of making dairy available, did not mention positive comments towards the

dairy group or specific dairy foods for their children.

87

There were more white and Hispanic parents in the positive grouping and
more Asians in the neutral grouping. This may help to partially explain the two
groupings that were identified. Cheese is a commonly consumed food in the Hispanic
culture, and dairy foods are a commonly consumed food group among whites, but
much less prevalent in consumption among Asians. There were also more girls than
boys in the neutral grouping, suggesting that parents may have not promoted dairy for
girls as much as for boys. The idea that parents as well as children think that boys
need more calcium than girls has been reported in previous literature (Barr, 1994;
Neumark-Sztainer et al., 1997; Novotny et al., 1999; Auld et al., 2002) and may help
to explain the gender differences reported in the current study. There were no
differences between the groupings by income or education level. This is somewhat
surprising due to other work showing a positive relationship between higher income
and education levels and parental influences (e. g. availability, accessibility, family
meal patterns) (Baranowski et al., 1999; Cullen et al., 2001; Fisher et al., 2002;
Boutelle et al., 2003; Neumark-Sztainer et al., 2003). This study, however, had a
disproportionate number of participants of higher income and education levels, which
may help to explain why no differences were found between groupings. The other
parental influences, knowledge, parental expectation, and parental modeling for milk
were initially included in the grouping analysis but did not contribute to
distinguishing different patterns among participants so were removed from the
groupings.

This is the first study to identify groupings of parental influences related to

dairy. Many studies have investigated individual parental influences (e. g.

88

availability, health benefit beliefs, food preferences), but not in combination. This
research provides new evidence that patterns of parental influences may exist and
should be considered in further research and nutrition education directed towards
families.
Supplement and Calcium-Fortified Food Use

The proportion of reported regular supplement users were 35% in
preadolescents, similar to NHANES III estimates of 34-35% among 6-11 year olds
and 24—28% among 12-19 year olds (Ervin et al., 1999a). The proportion of parent
users was 49%, similar to NHANES 1999-2000 estimates of 43% among 20-39 year
olds and 56% among 40-59 year olds (Radimer et al., 2004). Only 10% of the
preadolescents taking any supplement were taking a calcium supplement, which is
similar to previous findings of preadolescent and adolescent calcium supplement use.
The rest were taking a multivitamin/multimineral containing calcium (Barr, 1995;
Dwyer et al., 2001; Lee et al., 2002; Millen et al., 2004; Radimer et al., 2004). 32%
of parent supplement users, which were primarily mothers, reported taking a calcium
supplement, similar to NHANES 1999-2000 estimates of 30% of adult women taking
calcium supplements (Radimer et al., 2004). Consistent with previous findings,
preadolescent supplement users were more likely to be from families with higher
income and education levels, and had parents who were supplement users (Subar &
Block, 1990; Slesinski et al., 1996; Zive et al., 1996).

Almost two-thirds of preadolescents and one-half of parents reported use of
calcium-fortified foods, with the majority of both parents and preadolescents

reporting use of calcium-fortified orange juice. Preadolescent users differed from

89

 

non-users by gender. Users had equal representation of males and females while non-
users had proportionately more females. There may have been more females non-
users based on research mentioned earlier which suggests that many adolescents and
parents have the perception that boys need more calcium than girls, thus calcium-
fortified foods may be promoted more with boys compared to girls. Additionally,
research has suggested that boys consume more calcium because of their higher
average energy intake compared with girls, so girls lower energy intake may also help
to explain why there were more female non-users. Users also differed from non-users
by race/ethnic group. Whites and Hispanics were more likely to users, and Asians
were more likely to be non-users. Cultural differences in the purchasing of calcium-
fortified foods may have impacted use in that calcium-fortified foods are not typical
foods of the Asian culture. This is the first study to report calcium-fortified food use
and their associated sociodemographic characteristics in preadolescents. There are no
current analyses of characteristics of fortified-food users on a large cross-section of
the US. population and no analyses specifically on calcium-fortified food users, thus
more research is needed in this area.
Parental Influences and Calcium-Fortified Food and Supplement Use

The findings of this research provide new evidence that those with more
positive parental influences related to dairy (positive cluster) were associated with
more calcium-fortified food use in preadolescents. Fewer parental influences (neutral
cluster) had no effect on use except with families with less education and lower
income, where it was associated with less use of calcium-fortified foods. Fewer

parental influences (neutral cluster) may be mediated by other factors we did not

90

measure in families with more education and income, such that fewer influences was
not associated with less use in their children.

No relationship was found between parental influences related to dairy and
preadolescent supplement use. Parents from the positive grouping, (e. g. that make
dairy foods available, provide dairy for calcium, and have children that are receptive
to dairy), may be more likely to purchase calcium-fortified foods because they are
widely available foods, contain high amounts of calcium, and are commonly
consumed foods by children (6. g. orange juice, cereal, granola bars). Supplements,
are generally less available, more expensive, inconvenient, and children have been
shown to have poor compliance and adherence with a supplement-dosing regimen
(Block et al., 1988; Andon et al., 1994; Dwyer et al., 2001; Greger, 2001).
Additionally, most supplement users in the current study were taking a
multivitamin/multimineral, not a calcium supplement. Therefore, the parental intent
for supplement users may have not been to increase intakes of calcium specifically,
but rather to rectify a poor diet or add insurance to their child’s diet quality. Also,
because of the small sample size of calcium supplement users, there was probably not
enough information to find any relationships. Therefore, the similarities between
dairy and calcium-fortified foods and their differences from supplements may help to
partially explain the relationships that were found.

Parental influences related specifically to supplements was not the focus of
this study, however, a positive relationship between child and parent use was found,
suggesting that parents do play an important role in influencing use, likely by making

available and possibly by modeling. Children from families of higher income and

91

 

education levels have been shown to be more likely to be supplement users (Subar &
Bowering, 1988; Slesinski et al., 1996; Yu et al., 1997; Radimer et al., 2004), as was
found in the current study, suggesting that sociodemographic characteristics may also
play an important role in influencing preadolescent supplement use. This also
suggests that supplement use may not be as effective as calcium-fortified foods can
be for reaching those in lower income and lower education families who are most in
need.

Inadequate calcium intake is a prominent health concern in preadolescents. In
addition to increasing risk for developing osteoporosis later in life, inadequate intake
has been associated with the dramatic increase in incidence of fractures during
childhood (Miller et al., 2001; Goulding et al., 2004). There are many factors which
negatively impact adequate calcium intake in this age group, such as increases in food
eaten away from home, displacement of milk for other beverages, lactose intolerance,
peer and school influences and psychosocial developmental changes. With all these
negative factors, encouraging a family environment that promotes other calcium-rich
sources, such as calcium-fortified foods, in addition to dairy, may be more effective
in bridging the gap between actual intake and the higher calcium recommendations
during this time period. Parental influences may be particularly effective for those
with less education and income, who may be most at risk of inadequate intake. Thus,
educational strategies involving parents, particularly of lower socioeconomic status,
will need to be considered in developing effective interventions towards increasing

calcium in youth.

92

Strengths and Limitations

A strength of this research is that it is a secondary data analysis on a relatively
large convenenience sample of qualitative data from three different race/ethnic groups
at risk for osteoporosis. It is also the first to explore the relationship between parental
influences as they relate to dairy foods and supplement and calcium-fortified food use
in an understudied population (preadolescents). This data has not been reported
before due to little research on parental influences related to dairy foods and
preadolescent supplement use, and no research on preadolescent calcium-fortified
food use. Information resulting fiom this study will aid in the development of
intervention strategies and educational resources by focusing on strategies to improve
intake in preadolescents who may not consume enough calcium from naturally
occurring sources.

Some limitations of this study should be acknowledged. Due to the non-
random sampling, cross-sectional design, and disproportionate number of subjects of
higher socioeconomic status, the findings from this research are preliminary and need
validation with firrther research. An assessment of acculturation may have added
more precision to the analyses but was not utilized. Furthermore, the regional nature
of the study prevents concluding that the same influences would be found in ethnic
groups from different parts of the country. Thus the findings differences are strongly
suggestive, but warrant caution in generalizing the results. The accuracy in the level
of assessment may have been lessened by utilizing a secondary data set which
provided limited involvement with the data collection process. The interviews took

place at multiple locations with different interviewers for different states that were

93

involved. The interviewers were given the same outline to follow, however,
inconsistencies arose with the ways the interview were conducted, such as differences
in how the questions were asked, with some questions added or omitted by the
interviewer, and differences in probing accountability. Subsequently, possible
measurement error may have occurred during assessment. Additionally, a level of
bias may have been introduced by the way the data was collected in that surrogate
information for the preadolescent was obtained indirectly through the parent without
further validation. This may have also may impinged on the accuracy of the data set.
Direct interviews with the child would have reflected a more accurate assessment of
actual intake of calcium-fortified foods and supplements. Furthermore, the calcium-
fortified food questionnaire measured intentional use or purchase by the parent.
Unintentional use was not noted because a complete dietary assessment was not
completed (e. g. FF Q, 24-hour recall) so an exact depiction of total use could not be

evaluated.

94

Chapter 6

CONCLUSIONS AND IMPLICATIONS

These findings suggest that a major component of parental influences related
to dairy are due to cultural differences. Educational strategies related to calcium—rich
foods should address different ways to incorporate culturally appropriate messages.
Within some families and/or cultures, where dairy is not likely to be consumed,
educational strategies are needed for parents that discuss other ways of obtaining
sufficient calcium for children through foods that would be more culturally
appropriate for their families.

In families that are receptive to consuming dairy, educational strategies that
target parents in promoting dairy foods, may also promote use of calcium-fortified
foods. Educational strategies that help to promote dairy foods through parental
influence, may also promote use of calcium-fortified foods. This may be particularly
effective in those most at risk for inadequate intake, those with less education and
lower income, thereby possibly helping to improve overall calcium
intake.

Parental influences play an important role in establishing food preferences in
childhood (Birch & Davison, 2001), thus promoting positive parental influences may
be particularly important during childhood and preadolescence to help offset the
additional negative influences arising during adolescence (e. g. peer influences,
psychosocial developmental changes, eating away from home, displacement of milk

with other beverages). Research with young adults , suggests that eating habits are

95

established during childhood (Birch, 1998a), fiuther supporting the need to establish
early, healthy eating habits.

Because children have more non-milk options when eating away from home,
there needs to be a place where calcium—rich foods and beverages are available and
emphasized, including newer calcium-rich options such as calcium-fortified foods. A
family environment that encourages dairy along with other calcium-fortified foods
may help to achieve adequate calcium intake in this vulnerable population.

Little research on parental influences related to calcium-rich foods and no
prior research relating parental influences to calcium supplement and calcium
fortified food use is available. Thus these findings need to be confirmed in larger,
more socioeconomically diverse studies. Also, quantitative assessment tools are
needed to assess the salient parental influences that have been identified. Further
research is also needed to more thoroughly explore the factors that affect the
establishment of calcium eating patterns in preadolescent families to ensure that the
family interventions address relevant concerns and needs. Furthermore, research is
needed directly examine calcium-fortified food use in children and adults, evaluating
their prevalence, contribution to total calcium intake, and influences affecting use.
Research with calcium-fortified foods is also needed to see if characteristics of users
differ by calcium-fortified food type. Improved understanding of parental influences
on calcium intake in children along with a greater understanding of how calcium-
fortified foods may help to improve strategies aimed at improving calcium intake in

preadolescents, a vulnerable population.

96

 

APPENDICES

97

APPENDIX A

UCIHRS Informed Consent

98

RESEARCH PARTICIPANT CONSENT FORM

Parent and Household Influences on Calcium Intake among Preadolescents
Beth H. Olson, Ph.D.
Michigan State University
Department of Food Science and Human Nutrition

Purpose of Research
We are asking you to help in a study that is looking at the factors (knowledge, attitude, behavior, and
environment) associated with food intake of adolescent children (ages 11-12 years).

Specific Procedures to be Used

Your participation in the study will include completing an individual interview that will ask about
information on parental knowledge, attitudes, and behaviors, and environmental factors affecting food
intake. The interview will have two parts: part 1 will gather sociodemographic information, and part 2
will collect information on your food intake and food choices. Then, you will complete a
questionnaire given by the interviewer asking about the use of dietary supplements and fortified foods
by you and your child. The entire process will last about an hour. You have the right to decline any
questions or stop the interview at any time. The interview will take place in a neutral location that is
convenient for you. We will audiotape the interview, but your name will not be attached to your tape.
We will not share your tape with anyone except for the project investigators. Tapes will be transcribed
into a written format. This will allow all (anonymous) comments to be summarized and then analyzed
by a computer program for common answers.

Duration of Participation
The interview will last about one hour.

Benefits to the Individual

The information you provide will help us develop new messages for improving dietary intakes of
adolescents. You will receive compensation for participation.

Risks to the Individual
There are no known risks associated with completing the individual interview.

Compensation
You will be paid $25 when you complete the interview.

Confidentiality

Any information about you that is recorded on the tape or any information that is written down by us for
this study will always be locked up. We have created a secret code system to keep your information
private. Once the code numbers have been checked, any lists with names and codes will be destroyed.
Upon the completion of the study, audio tapes will be destroyed. Your name will not be seen next to any
information or in any written reports. Your privacy will be protected to the maximum extent allowable
by law.

Voluntag Nature of Participation

You do not have to participate in this research project. If you agree to participate you can withdraw your
participation at any time without penalty.

Human Subject Statement:
If you have any questions about this research project, you may contact the principal investigator, Dr.

Beth H. Olson at (517)355-8474, x113. If you have questions or concerns regarding your rights as a
study participant, or are dissatisfied at any time with any aspect of this study, you may contact -
anonymously, if you wish - Ashir Kumar, M.D., Chair of the University Committee on Research

99

Involving Human Subjects (UCRIHS) by phone: (517) 355-2180, fax: (517) 432-4503, e-mail:
ucrihs@msu.edu. or regular mail: 202 Olds Hall, East Lansing, MI 48824.

I voluntarily agree to participate in this study.

 

 

Participant’s Signature Date

 

Participant’s Name

 

 

Researcher’s Signature Date

100

APPENDIX B

W1003 Qualitative Interview Guide

101

W1003 Interview Content Outline

Questions for Qualitative Interview with Parents about Calcium Intake and
calcium rich foods in Parents and Children

Intro: Thank you for taking the time to talk with me today. As part of a
research study being done in 12 states, we are interviewing parents of children
10-13 years old to find out ways to make nutrition information more useful for
families like yours. I want to stress that there are no right or wrong answers in
this interview. We are interested in your thoughts and opinions on factors that
influence you and your child’s eating habits.

We would like to tape this interview so we are sure we capture your thoughts in
your own words. But your name will not be linked to the tapes. This interview
will include mostly talking but also some hands on activities. It will take about

one hour.

Do you have any questions before we get started?
I. Calcium-rich foods:

1. I’m going to show you some pictures of foods or groups of similar foods and ask

you a few questions about each one.
[Show picture(s):] How often do you eat (state name of food or food
grouping)?
a. If they eat this food: Tell me some reasons you choose this food.
(Probe about - cost, cultural/family influences, availability, taste,
convenience, accessibility)
1. Where do you typically eat this (these) food(s)? (i.e. do they eat
it at home and/or when out)

2. If they do not eat the food: Tell me some reasons you don’t eat this (these)
food(s). (Probe about — cost, cultural/family influences, availability, taste,
convenience, accessibility)

a. Would you like to include this food in your diet?
b. If yes: What are the main reasons you don’t include this in your diet?

3. Does (name 11 or 12 year old child) eat this (these) food(s)?
a. If yes: What are the reasons your child eats this food?
b. If no: What are the reasons your child does not eat this food?

Repeat Questions [-3 for each food picture. [Dairy; Foods made with Dairy;

Hispanic/Mexican; Asian (including tofu & Hmong foods); Pastas; Greens; Fish;
Beverages (inc. soda, juice, cofl'ee drinks)]

102

H. General family meal patterns
(transition) Now we’d like to talk a little about your family meal patterns.

4.

Let’s walk through the day and have you describe your family’s eating and
drinking patterns starting from when you first get up. We are primarily
interested in your eating habits and the eating habits of (name 11-12 yo
child), but we also want to talk about the whole family.

Let them go through day with minimal probing, asking questions as needed to
get information about each of the following:

Where each meal usually eaten

What time each meal usually eaten

Who prepares each meal

Whether this meal usually eaten together with children or separately
Usual foods eaten at meals (for self and for 11-12 yo child)

Usual drinks/beverages served at meals (for self and for 11-12 yo child)

rm .o-p 9‘1»

Child’s meal pattern:
How is (name of 11-12 yo child) dietary/meal pattern similar or
different from yours?
Go back through and ask more detail about child’s eating pattern. If
information (relating to questions a-f above) has already been given for the
child, there is not need to repeat all of these questions. Only ask questions
about aspects of child ’s eating patterns that were not included in the previous
discussion about family eating patterns. In talking about the child ’s eating
patterns, include additional questions to find out about child’s snacking, and
include question b below specifically about child ’s snacks & activities after
school.
a. Tell me about the snacks your child eats.
i. What time snack usually eaten
ii. Where snack usually eaten
iii. Usual foods eaten as snacks
iv. Usual drinks taken with snacks
b. What happens once school gets out?
i. Where do your children go after school? What do they usually do
after school?

ii. What do you have around the house for your child to eat after
school? What do you have available for your child to drink after
school?

iii. Do you give your kids money to buy foods away from home?

iv. Do they eat at a friend’s house?

Parental expectations:

Now I’d like to ask you a bit more about your meals together as a family.

a. Do you expect your child to eat certain foods before leaving the table?

b. What happens if your child doesn’t like what you are serving for a meal?

103

i. Do you offer choices to your children or family members at meals?
Can you provide an example?
c. What do you expect your kids to drink with meals?
i. Do you offer different beverages to your children at meals? What
beverage choices? What about milk?
(I. What do you expect your kids to drink with snacks?

Eating out:

How often do you eat out? Or order a meal in?

a. What are some of the reasons you might decide to eat out or order a meal
in?

b. When you go, where do you usually eat out?

c. What do you typically eat when you go out? What do you usually drink?

(I. What would your child typically order when you go out? What would
your child typically drink when you eat out?

How do extra-curricular activities affect your family’s meal patterns? For
example, your child’s participation in sports, school activities, etc. Or your
participation in sports, volunteer work, etc.

This question may be addressed somewhere in the discussion about family
meals, depending on the flow of the conversation. If the question is not
addressed during the flow of conversation in Questions [-5, ask it as a
separate question before moving onto the next section of the interview.

III. Influencing children’s eating
(transition) Now we would like to talk with you a little more about food and health.

9.

10.

What kind of conversations do you have about foods with your kids? Do you
talk about food and health with your kids? What kinds of things do you say?

Tell me about a food you think is healthy for your child. How do you get your
child to eat it?

a. Do you eat this food? How does this influence your child?

b. Do you reward your children for eating certain foods?

c. Do you make healthy foods available in your home?

IV. Knowledge of calcium and health

11.

12.

[ Show the respondent a lifespan picture (without DRI numbers):] Here’s a
picture of people at different ages. At what age do you think calcium
requirements are highest? Any reasons for that choice(s)?

What can you tell me about calcium and health?

a. If they do NOT mention bone health (and most will probably mention this),
ask: What about calcium and bones?

104

l3.

14.

15.

l6.

17.

18.

What are the benefits of getting enough calcium for you? How does eating
enough calcium benefit you?
a. What would happen if you didn’t get enough calcium?

What are the benefits of your child getting enough calcium?
a. What would happen if your child (name 11-12 yo child) didn’t get
enough calcium?

Do you have a history of osteoporosis or bone fracture in your family?
a. If yes: Tell me about it.

How concerned are you that (name 11-12 yo child) gets enough
calcium every day?
a. What are the reasons you are concerned (or not) about your child’s intake
of calcium?

[ Show lifespan picture with DRI answers:] This picture shows the
requirements for calcium at various ages in the lifespan. You can see that
calcium requirements for children ages 9-18 are as high as anytime during the
lifespan. This is to support bone growth and development during adolescence
and to strengthen adult bones?

a. What are your thoughts on this information?

We talked about your concerns about whether (name 11-12 yo
child) gets enough calcium everyday. Does this information change your
thoughts on this?

V. Knowledge of calcium requirements and content in foods
(transition) Let’s talk about calcium in foods a little more.

19.

20.

21.

How confident are you that your child gets enough calcium in their diet each
day?

[Show poster with pictures of various foods with blank lines for estimating
servings:] I have a poster with pictures of different foods. Now I’d like you
to estimate how many servings of each of these foods your child would need
to eat to get 1300 mg of calcium. In other words, if each of these foods were
the only source of calcium in your child’s diet, how many servings would they
need to get the recommended amount? (Allow respondent to guess the
number of servings on the poster)

[Show poster with number of servings required to provide DRI for 10-13 year
olds:] This is the actual number of servings your child would need of each
food to get the recommended 1300 mg of calcium. You can see that dairy
foods are good sources of calcium. You only need a few servings of these
foods to meet calcium needs. Other foods are not as rich in calcium.

105

a. Does any of this information surprise you? Tell me what surprised you.

b. How much calcium would you guess 10-13 year old children typically eat
on average?

c. How much calcium would you guess adults eat on average?

22. [Show poster with number of servings plus average calcium intake of pre-
adolescents and adults:] The goal is for 10-13 year olds to eat 1300 mg
calcium per day. Here’s the calcium an average teenager eats. Here’s the
calcium an average adult eats.

a. The average American pre-adolescent gets about 70% of the calcium
she/he needs. Girls (ages 9-13 years) typically eat about 900 mg calcium
per day. Boys (ages 9-13) usually eat a bit more, about 1,000 mg calcium
each day. The average adult only gets about 80% as much calcium as
she/he needs.

b. What’s your reaction to this information? Does this change your
perspective on whether you/child gets enough calcium?

23. What type of information would help you to encourage your child to eat more
calcium rich foods?

Thank you very much for your time and thoughts. They will be very helpful in
developing education strategies and materials.

106

APPENDIX C

W1003 Supplement and Calcium-Fortified Food Questionnaire Interview
Guide and Questionnaire

107

DIETARY SUPPLEMENTS AND CALCIUM-FORTIFIED FOODS

QUESTIONNAIRE
Pugpose
1. This questionnaire is focused on the consumption of dietary

2.

supplements and calcium-fortified foods over the past month.
Using this questionnaire, we are trying to determine:

1) Consumption of calcium supplements and calcium-fortified foods,
such as frequency and amount, in 11-12 year-old adolescents
through the knowledge of parents. '

2) Frequency and amount of parents” intake of calcium supplements
and calcium-fortified foods.

3) Whether people unintentionally consume calcium-fortified foods.

. This questionnaire will ultimately help us modify the present food

frequency questionnaire to better capture the consumption of calcium
supplements and calcium-fortified foods.

Materials Need_eg

1.

9591:5991"

Interview Guide

Dietary Supplement Table

Dietary Supplement Pictures

Block Food Frequency Questionnaire Pictures (Block FFQ Pictures)
Household glasses of sizes 6 oz, 8 oz, and 10 02.

Response Sheet for each respondent

How to Lise Materials

1.

The interview guide works well in a 3-ring binder. Keep a post-it handy
to mark your place should you have to flip through the pages during
the interview. Although it looks like a lot, if you practice before your
first interview, you’ll discover it flows nicely.

The dietary supplement table works well if put aside within easy reach
of the interviewer. If the supplement has a Mona Lisa label — there is a
picture of that supplement.

The dietary supplement pictures work well in the same 3-ring binder as
the interview guide. Use a divider to mark the pictures. Flipping back

108

and forth between the interview guide and pictures works easily
especially if you mark your place with a post-it or your finger.

4. The Block FFQ Picture works well on its own positioned that the
respondent can easily view it at all times during the food part of the
questionnaire.

5. The household glasses can also be on view at all times.

6. The response sheet needs to be copied for each respondent. Mark
answers cleady as you will do your own data entry.

109

Part I: CHILD’S SUPPLEMENT USE INTERVIEW GUIDE

 

To Sag To Do:

 

I am now going to ask you a series of
questions about child’s name use of
vitamin pills or supplements over the past

 

month.
1. Depending upon the responses received Check the
from the parent concerning supplements, appropriate
use the appropriate question below. response box for
a. You said child’s name took question 1. If yes,
vitamin pills or dietary supplements, go to question 2;
did helshe take any supplements, otherwise, go to
this past month? question 4.

b. Did child’s name take any vitamin
pills or supplements, this past
month?

c. You said that child’s name does
not take supplements. I just want to
confirm that helshe took no
supplements this past month.

 

Record each
supplement under
the “Name” column
2. What were the supplements child’s of question 2 as the

names took this past month? interviewee lists
them. Do not ask
for any clarification
at this time.

 

2. If interviewee
responds with
complete name or
names, find the
product(s) in the
Supplement Table
and write the
number of the
supplement(s)
under the “#”
column on the
response sheet.

 

2. For any supplement
recorded, if the
interviewee is able

 

 

 

 

llO

 

To Say:

To Do:

 

to “remember all” of
the product name
that it can be easily
identified in the
Table, then circle 1
on the response
sheet at question 2.

 

2. (continued) What specific type of
Centrum did child’s name take over
the past month?

If the interviewee
remembers the
manufacturer’s
name but not the
specific “type” (for
example, if the
interviewee says
“Centrum”), then
ask question to the
left. Find the
product(s) in the
Supplement Table
and write the
number of the
supplement(s) on
the response sheet
at question 2.

 

If the interviewee
progresses to the
“type” question,
then on the
response sheet at
question 2, circle 2.

 

2. (continued and continuing with the Centrum
example) Would it be A to Zinc, Kids
Chewable, Kids, Performance, Silver for
adults 50+, or Liquid?

If the interviewee
can not remember
the type, then list
the types from the
Supplement Table
using the “would it
be” question to the
left.

Write the number
of identified
supplement(s) on
the response sheet
at question 2.

 

 

 

If the interviewee

 

lll

 

 

To Say:

To Do:

 

progresses to the
“would it be”
question, then on
the response sheet
at question 2,
circle 3.

 

2. (continued) (I have some pictures of
supplement packages, would viewing
these pictures help you remember?

If the interviewee
draws a complete
blank, then ask if
seeing “pictures"
would help. Show
the interviewee
supplement
pictures if helshe
agrees. Write the
number of
supplement(s) on
the response sheet
at question 2.

 

If the interviewee
progresses to the
“pictures", then on
the response sheet
at question 2, circle
4.

 

2. (continued) How about ifl call you at
home and ask you the type of
supplement? Would you be agreeable
to that? When is a good time to call?

If all of the prompts
fail, then ask the
interviewee to
check at home. On
a separate sheet of
paper, write the
time and method of
contact for the
“phone call”. Fill in
the corresponding
boxes when you
call.

 

 

 

If the interviewee
progresses to the
“phone call”, then
on the response
sheet at question 2,
circle 5.

 

112

 

 

To Say:

To Do:

 

 

If the interviewee
says a product not
listed in Table 1,
record the name on
the response sheet
at question 2. If
necessary, follow
the same prompts
above.

 

I am now interested in how often child’s
name has taken these supplements this
past week and how many helshe takes at
one time.

[Each supplement
identified above is
assigned with a
letter, beginning
from A.) Ask the
following questions
for each
supplement
recorded on the
response sheet at
question 2.

 

3. How often this past month did child’s
name take (fill in name of supplement)?

PROBE: Clan'fy each response. For example,
alter a response, “every other day", ask, Would
you say that is 3 or 4 times per week?

If the interviewee
can recall and state
the response as a
frequency, then
record the
response under the
“how often” column
in question 3. The
answer could be
per day, per week,
or per month, but
not all. Write in
number of times,
e.g., 2, 3.5, 5 under
the correct “/day",
“/week", or “Imonth”
column.

 

 

3. When child’s name took this
supplement how many did helshe take
each time?

 

Record the
response under the
“how many" column
in question 3. Write
in a number or
fraction, e.g., 1, 1.5,

 

113

 

 

 

 

To Say: To Do:
2. If it is a liquid
supplement, record
how many

 

teaspoons the child
takes each time.

 

114

 

Part II: Adults’ Supplement Use

 

To Say:

To Do on
Response Sheet:

 

You may ask questions for both adults
simultaneously (as shown below) or one after
the other.

I am now going to ask you a series of
questions about your use of vitamin pills or
supplements, as well as your spouse’s
over the past month.

Also record the
supplement
intakes of his/her
spouse on the next
page if the
interviewee is
willing and able to
respond to these

 

questions.
4 and/or 7. If the interviewee volunteered Check the
previously that he/she took supplements, appropriate

then use the first question (a) below,

otherwise use the second question (b).
a. You said you took supplements,
did Laptake any supplements, this
past month?
b. Did your husband/wife take any
vitamin pills or supplements, this
past month?

response box for
question 4 and/or
question 7. If yes,
go to question 5
and/or 8.
Otherwise, go to
Part III.

 

5 and/or 8. What were the vitamin pills or
supplements yo_utook this past month?
What vitamin pills or supplements did
your husband/wife take?

Record each
supplement as the
interviewee lists
them. Do not ask
for any clarification
at this time.

 

5 and/or 8

If interviewee
responds with
complete name or
names, find the
product(s) in the
Supplement Table
and write the
number of the
supplement(s)
under the “#”
column on the
response sheet.

 

 

5 and/or 8.

 

Forany

 

115

 

 

To Say:

To Do on
Response Sheet:

 

supplement
recorded, if the
interviewee is able
to “remember all”
of the product
name that it can
be easily identified
in the Supplement
Table, then circle 1
on the response
sheet at question 5
and/or 8.

 

5 and/or 8. (continued) What specific type of
Centrum did ypp take over the past
month, as well as your husband/wife?

If the interviewee
remembers the
manufacturer’s -
name but not the
specific “type” (for
example, if the
interviewee says
“Centrum”), then
ask question to the
left. Find the
product(s) in the
Supplement Table
and write the
number of the
supplement(s) on
the response
sheet at question 5
and/or 8.

 

If the interviewee
progresses to the
“type” question,
then on the
response sheet at
question 5 and/or
8, circle 2.

 

 

5 and/or 8. (continued and continuing with the
Centrum example) Would it be A to Zinc,
Kids Chewable, Kids, Performance,
Silver for adults 50+, or Liquid?

 

If the interviewee
can not remember
the type, then list
the types from the
Supplement Table
using the “would it

 

116

 

 

To Say:

To Do on
Response Sheet:

 

be” question to
the left.

Write the number
of identified
supplement(s) on
the response
sheet at question
5 and/or 8.

 

If the interviewee
progresses to the
“would it be”
question, then on
the response
sheet at question
5 and/or 8, circle
3

 

5 and/or 8. (continued) I have some pictures
of supplement packages, would viewing
these pictures help you remember?

If the interviewee
draws a complete
blank, then ask if
seeing “pictures”
would help. Show
the interviewee
supplement
pictures if helshe
agrees. Write the
number of
supplement(s) on
the response
sheet at question
5 and/or 8.

 

If the interviewee
progresses to the
“pictures”, then on
the response
sheet at question 5
and/or 8, circle 4.

 

 

5 and/or 8. (continued) How about if I call
you at home and ask you the type of
supplement? Would you be agreeable
to that? When is a good time to call?

 

If all of the
prompts fail, then
askthe
interviewee to
check at home.
On a separate
sheetofpapen
write the time and

 

117

 

 

To Say:

To Do on
Response Sheet:

 

method of contact
for the “phone
call”. Fill in the
corresponding
boxes when you
call.

 

If the interviewee
progresses to the
“phone call", then
on the response
sheet at question 5
and/or 8, circle 5.

 

5 and/or 8.

If the interviewee
says a product not
listed in Table 1,
record the name
on the response
sheet at question 5
and/or 8. If
necessary, follow
the same prompts
above.

 

I am now interested in how often these
supplement shave been taken this past
week and how many at one time for you
and your husband/wife.

[Every supplement
identified above is
assigned with a
letter, beginning
from A.) Ask the
following questions
for each
supplement
recorded on the
response sheet at
question 5 and/or
8

 

 

6 and/or 9. How often this past month did
m take (fill in name of supplement)?

PROBE: Clan'fy each response. For example,
after a response, “every other day”, ask, Would
you say that is 3 or 4 times per week?

 

If the interviewee
can recall and
state the response
as a frequency,
then record the
response under
the “how often”
column in question

 

118

 

 

To Say:

To Do on
Response Sheet:

 

6 and/or 9. The
answer could be
per day, per week,
or per month, but
not all. Write in
number of times,
e.g.,"2, 3.5, 5
under the correct
“/day", “/week”, or
“/month” column.

 

6 and/or 9. When you took this
supplement how many did 19p take
each time?

Record the
response under
the “how many"
column in question
6 and/or 9. Write
in a number or
fraction, e.g., 1,
1.5, 2. If it isa
liquid supplement,
record how many
teaspoonsthe
child takes each
time.

 

 

That was the last of the supplement
questions. I am now going to ask you a
series of questions about the use of
calcium fortified foods in your family over
the past month.

 

 

119

 

Part III: CALCIUM FORTIFIED FOODS

 

To Say:

To do on Response Sheet:

 

10.When you purchase juice or juice
drinks, do you purposely select the
brands that are fortified with
calcium?

Mark Yes or No on response
sheet. If yes, go to question 113;
otherwise, go to question 12.

 

11.a. To the best of your knowledge,
how often did child’s name drink
calcium-fortified juice or juice drinks
this past month?

Check appropriate response on
response sheet.

Allow the respondent to
spontaneously state the
frequency. If the frequency
doesn‘t fit one of the standard
responses, clan'fy with
respondent.

 

 

 

 

 

11 b. When helshe drank calcium- Check appropriate response on
fortified juice, how much did response sheet*.
helshe usually drink? Prop=Household glasses

11 c. How often did m drink calcium- Check appropriate response on
fortified juice or juice drinks this response sheet.
past month?

11 d. When m drank calcium-fortified Check appropriate response on
juice, how much did M. usually response sheet*.
drink? Prop=Household glasses

11 e. What are the brands of fortified Check all responses that apply.
juices/juice drinks that child’s
name drank this past month?

11 f. What are the brands of the Check all responses that apply.

fortified juices/juice drinks that
ypg drank this past month?

Go to question 13.

 

 

12.What brands of juice or juice drinks
have you purchased over the past
month?

 

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember.

 

*: Juice boxes are 4 and 6 oz which would be less than 94 cup (6 ounces) and

34 to 1 % cups (6 to 10 ounces), respectively.
Juice pouches are 6 and 11 oz which would be 34 to 1 % cups (6 to 10
ounces) and more than 1 % cups (10 ounces), respectively.

120

 

 

To Sajp

To do on Response Sheet:

 

13.When you purchase breads, do
you purposely choose the brands
that are fortified with calcium?

Mark Yes or No on response
sheet. If yes, go to question 143;
othenNise, go to question 16.

 

14.3. To the best of your knowledge,
how often did child’s name eat
calcium-fortified bread this past
month?

Check appropriate response on
response sheet.

 

14 b. When helshe ate calcium-
fortified bread, how much did
helshe usually eat?

Check appropriate response on
response sheet. No prop.

 

14 c. How often did Lo_u eat calcium-
fortified bread this past month?

Check appropriate response on
response sheet.

 

14. d. When you ate calcium-fortified
bread, how much did ypg
usually eat?

Check appropriate response on
response sheet. No prop.

 

15. Can you tell me the brand name(s)
of the fortified bread you and your
child ate this past month?

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember. Go to
question 17.

If different products are
purchased for child and parent,
place a C by child’s products and
a P by parent’s products. Same
with other calcium-fortified foods.

 

 

16.What brands of bread have you
purchased over the past month?

 

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember.

 

121

 

 

To Sag

To do on Response Sheet:

 

17.When you purchase bagels or
English muffins, or hamburger or
hot dog buns, do you purposely
choose those brands that are
fortified with calcium?

Mark Yes or No on response
sheet. If yes, go to 18a;
otherwise, go to question 20.

 

18.3. To the best of your knowledge,
how often did child’s name eat
calcium-fortified bagels, English
muffins or hamburger or hot dog
buns this past month?

Check appropriate response on
response sheet.

 

18 b. When helshe ate calcium-
fortified bagels or English
muffins, hamburger or hot dog
buns, how many did helshe
usually eat?

Check appropriate response on
response sheet. No prop.

 

18 c. How often did M eat calcium-
fortified bagels, English muffins
or hamburger or hot dog buns

this past month?

Check appropriate response on
response sheet.

 

18 d. When ygg ate calcium-fortified
bagels or English muffins,
hamburger or hot dog buns,

how many did ygg usually eat? ,

Check appropriate response on
response sheet. No prop.

 

19.Can you tell me the brand name(s)
of the fortified bagels or English
muffins, hamburger or hot dog
buns you and your child ate this
past month?

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember. Go to
question 21.

 

 

20.What brands of bagels or English
muffins, hamburger or hot dog
buns have you purchased over the
past month?

 

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember.

 

122

 

 

To Say:

To do on Response Sheet:

 

21 .When you purchase cold (ready-
to-eat) cereals, do you purposely
select those brands that are
fortified with calcium?

Mark Yes or No on response
sheet. If yes, go to question 22a,
otherwise, go to question 24.

 

22. a. To the best of your knowledge,
how often did child’s name eat
calcium-fortified cold cereals this
past month?

Check appropriate response on
response sheet.

 

22 b. When helshe ate calcium-
fortified cold cereals, how much
did helshe usually eat?

Check appropriate response on
response sheet. Prop=Block
FFQ Pictures

 

 

22 c. How often did M eat calcium- Check appropriate response on
fortified cold cereals this past response sheet.
month?

22 d. When 1% ate calcium-fortified Check appropriate response on
cold cereals, how much did M response sheet. Prop=Block
usually eat? FFQ Pictures

 

23.What brands of calcium-fortified
cold cereals did you and your child
eat over the past month?

Record the brand name(s) on the
response sheet or check “don’t
know", if the respondent doesn’t
know or can’t remember. Go to
question 25.

 

 

24.What brands of cold cereals have
you purchased over the past
month?

 

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember.

 

123

 

 

To Say:

To do on Response Sheet:

 

25.When you purchase hot cooked
cereal, such as oatmeal, do you
purposely select those brands
fortified with calcium?

Mark Yes or No on response
sheet. If yes, go to question 263,
otherwise, go to question 28.

 

26. a. To the best of your knowledge,
how often did child’s name eat
calcium-fortified hot cereals this

Jest month?

Check appropriate response on
response sheet.

 

26 b. When helshe ate calcium-
fortified hot cereals, how much
did helshe usually eat?

Check appropriate response on
response sheet. Prop=Block
FFQ Pictures

 

 

26 c. How often did ygp eat calcium- Check appropriate response on
fortified hot cereals this past response sheet.
month?

26 d. When m ate calcium-fortified Check appropriate response on
hot cereals, how much did M response sheet. Prop=Block
usually eat? F FQ Pictures

 

27.Can you tell me the brand names
of the calcium-fortified hot cereals
you and your child ate this past
month?

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember. Go to
question 29.

 

 

28.What brands of hot cereals have
you purchased over the past
month?

 

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember.

 

124

 

 

To Say:

To do on Response Sheet:

 

29.When you purchase granola bars
or cereal bars, do you purposely
select those brands fortified with
calcium?

Mark Yes or No on response
sheet. If yes, go to question 30a,
otherwise, go to question 32.

The next question refers to meal
replacement bars. If those are
mentioned here, let the
respondent know you’ll ask about
those next.

 

30.a. To the best of your knowledge,
how often did child’s name eat
calcium-fortified granola bars or
cereal bars this past month?

Check appropriate response on
response sheet.

 

30 b. When helshe ate calcium-
fortified granola bars or cereal
bars, how much did helshe
usually eat?

Check appropriate response on
response sheet. No prop.

 

30 c. How often did you eat calcium-
fortified granola bars or cereal
bars this past month?

Check appropriate response on
response sheet.

 

30 d. When yo_u ate calcium-fortified
granola bars or cereal bars,
how much did M usually eat?

Check appropriate response on
response sheet. No prop.

 

31.Can you tell me the brand names
of the calcium-fortified granola
bars or cereal bars you and your
child ate this past month?

Record the brand name(s) on the
response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember. Go to
question 333.

 

 

32.What brands of granola bars or
cereal bars have you purchased
over the past month?

 

Record the brand name(s) on the
response sheet or check “don’t
know", if the respondent doesn’t
know or can’t remember.

 

 

125

 

 

To Say: To do on Response Sheet:
Note the format of this question
33 a. To the best of your knowledge, differs from the previous ones.

how often did child’s name eat
meal replacement, enerQY. or
high-protein bars?

Check appropriate response on
response sheet. If never, go to
qgestion 33d.

 

33 b.

When helshe ate meal
replacement, energy, or high-
protein bars, how much did
helshe usually eat?

Check appropriate response on
response sheet. No prop.

 

 

 

 

 

33 c. Can you tell me the brand Record the brand name(s) on the
names of the meal response sheet or check “don’t
replacements, energy, or high- know”, if the respondent doesn’t
protein bars helshe ate over this know or can’t remember. Go to
past month? question 33d.

33 d. How often did M eat meal Check appropriate response on
replacements, energy, or high- response sheet. If never, go to
protein bars? question 34a.

33 e. When ypg ate meal Check appropriate response on
replacements, energy, or high- response sheet. No prop.
protein bars, how much did ygg
usually eat?

33 f. What brands of meal Record the brand name(s) on the

replacements, energy, or high-
protein bars did m eat over the
past month?

 

response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember. Go to
question 34a.

 

126

 

 

To Say:

To do on Response Sheet:

 

34 a.

To the best of your knowledge,
how often did child’s name
drink meal replacements,
energy, or high-protein
beverages such as Instant
Breakfast®, Ensure®,
PediaSure®, Boost®,

Check appropriate response on
response sheet. If never, go to
question 34d.

 

 

Slimfast®?

34 b. When helshe drank meal Check appropriate response on
replacements, energy. or high- response sheet. Prop=household
protein beverages, how much glasses
did helshe usually drink?

34 0. Can you tell me the brand Record the brand name(s) on the

names of the meal
replacements, energy, or high-
protein beverages helshe drank
this past month?

response sheet or check “don’t
know”, if the respondent doesn’t
know or can’t remember. Go to
question 34d.

 

 

 

 

34 d. How often did y_o_u drink meal Check appropriate response on
replacements, energy, or high- response sheet. If never, go to
protein beverages such as question 35.

Instant Breakfast®, Ensure®,
Slimfast®, Boost®?

34 e. When M drank meal Check appropriate response on
replacements, energy, or high- response sheet. Prop=household
protein beverages, how much glasses
did m usually drink?

34 f. What brands of meal Record the brand name(s) on the

replacements, energy, or high-
protein beverages did ypg drink
over the past month?

 

response sheet or check “don’t
know", if the respondent doesn’t
know or can’t remember. Go to
question 35.

 

127

 

 

To Say:

To do on Response Sheet:

 

35.

When you purchase soy milk,
do you purposely select those
brands fortified with calcium?

Mark Yes or No on response
sheet. If yes, go to question 36a,
otherwise, go to question 38.

 

36 a.

To the best of your knowledge,
how often did child's name
drink calcium-fortified soy milk
this past month?

Check appropriate response on
response sheet.

 

36 b.

When helshe drank calcium-
fortified soy milk, how much did
helshe usually eat?

Check appropriate response on
response sheet. Prop=household
glasses

 

 

 

 

 

36 c. How often did you drink Check appropriate response on
calcium-fortified soy milk this response sheet.
past month?

36 d. When my drank calcium- Check appropriate response on
fortified soy milk, how much did response sheet. Prop=household
m usually eat? glasses

37. Can you tell me the brand Record the brand name(s) on the
names of the calcium-fortified response sheet or check “don’t
soy milk you and your child ate know”, if the respondent doesn’t
this past month? know or can’t remember. Go to

question 39.
38. What brands of soy milk have Record the brand name(s) on the

you purchased over the past
month?

 

response sheet or check “don’t
know", if the respondent doesn’t
know or can’t remember.

 

128

 

 

To Say:

To do on Response Sheet:

 

39. When you purchase tofu, do
you purposely select those

brands fortified with calcium?

Mark Yes or No on response
sheet. If yes, go to question 403,
otherwise, go to question 42.

 

40 a.

To the best of your knowledge,

how often did child’s name eat
calcium-fortified tofu this past

month?

Check appropriate response on
response sheet.

 

40 b. When helshe ate calcium-
fortified tofu, how much did

helshe usually eat?

Check appropriate response on
response sheet. Prop=Block
FFQ Pictures

 

 

 

 

 

40 c. How often did you eat calcium- Check appropriate response on
fortified tofu this past month? response sheet.

40 d. When yo_u ate calcium-fortified Check appropriate response on
tofu, how much did m usually response sheet. Prop=Block
eat? FFQ Pictures

41. Can you tell me the brand Record the brand name(s) on the
names of the calcium-fortified response sheet or check “don’t
soy milk you and your child ate know”, if the respondent doesn’t
this past month? know or can’t remember. Go to

question 433.
42. What brands of tofu have you Record the brand name(s) on the

purchased over the past
month?

 

response sheet or check “don’t
know", if the respondent doesn’t
know or can’t remember.

 

129

 

 

To Say:

To do on Response Sheet:

 

43 a.

To the best of your knowledge,
did child’s name eat or drink
any other calcium-fortified
foods we have not asked about
over the past month?

Mark Yes or No on the response
sheet. If yes, go to question
43b, otherwise, go to question
43e.

 

43 b.

What is this food and what is
the brand name?

Record the food name and
brand name on the response
sheet. Check “don’t know” if the
respondent doesn’t know or
can’t remember the brand
name.

Record only one food each
page. If more than one calcium-
fon‘ified food is consumed by the
same person, record others on
the next pagefis).

 

43 c.

How often did helshe eat or
drink it this past month?

Check appropriate response on
response sheet.

 

43 d.

How much did helshe usually
eat or drink each time?

Record the amount on the
response sheet, including
serving unit: e.g. cup. Go to
question 43e. Props as
necessary.

 

43 e.

Did m eat or drink any other

calcium-fortified foods we have not
asked about over the past month?

Mark Yes or No on the response
sheet. If yes, go to question 43f,
otherwise, you are finished with
this questionnaire.

 

43 f.

What is this food and what is
the brand name?

Record the food name and
brand name on the response
sheet. Check “don’t know” if the
respondent doesn’t know or
can’t remember the brand
name.

Record only one food each
page. If more than one calcium-
fortified food is consumed by the
same person, record others on
the next page(s).

 

43 9.

How often did M eat or drink it
this past month?

Check appropriate response on
response sheet.

 

 

43 h.

How much did you usually eat
or drink each time?

 

Record the amount on the
response sheet, including

 

130

 

 

serving unit: e.g. cup, teaspoon.
Props as necessary.

 

 

That was the last question about

calcium-fortified foods. It was also the
last question for today’s talk. Thank
you very much for your time and the

information you shared with us.

 

If any information is not clear
about the food(s) mentioned in
Part III, ask whether you can call
the interviewee at home to
clarify. Write the time and
method of contact on a separate
sheet of paper. Complete the
corresponding spaces when you
call. Thank the interviewee for
participating.

 

131

 

APPENDIX D

Codebook

132

Calcium Factors Codebook

Instructions

This codebook is designed to help you in the process of coding transcripts from an
audio taped recording of an interview with an adult. In this codebook you will be
given a set of definitions, rules, and examples of positive and negative factors that
you are to identify in the transcripts. Each factor is defined based on its use in gig
study. You are to refer to these definitions and only these definitions while coding
your transcripts. You may know of other definitions for these words, but those do not
apply to this study. Your first step is to familiarize yourself with the positive and
negative factors and their definitions, rules and examples. Do this by reading through
the list a few times. Ask questions if you do not understand the definition. After
identifying the positive and negative factors you will code them on the corresponding
coding form. You are to code the transcripts based on the instructions that follow.
When reading through the instructions in the codebook have the coding form out to
refer to as you read along. You may have previous experience in research or coding
but because each study is different you are to code only according to these
instructions.

 

Basic Instructions

1. Read each transcript completely one time through without identifying any positive
and/or negative factors.

2. Read each transcript a second time to identify the factors. Be careful, these factors
may be found in words, phrases or even abbreviations. As you find factors mark
them on the corresponding coding form.

3. On the coding form, mark a -1 if the factor is negative, 0 if the factor is not
mentioned, 1 if the factor is positive, and mark a 0(dot) if the factor is missing.
Missing information can be defined if the interviewer in the transcript does not ask
one of the following questions that would prompt a specific factor to be identified. (a.
what are some reasons why you and your child do/do not consume or purchase dairy
foods; b. what do you drink for meals and snacks; c. what do you expect your child to
drink at meals and/or snack times; d. what does your child eat during the day and how
often; e. what do you know about calcium and health, f. how many servings of milk
are needed to equal 1300 mg calcium that is the recommendation for calcium intake
in 9-18 year olds; g. how often does your family eat out or order a meal in; and h.
how does you feel about your son or daughter taking vitamin/mineral supplements).

4. An example for coding can be described if someone in the interview mentions
COST as a reason why they don’t buy yogurt then you would mark a -1 in the yogurt
column to indicate that cost is a negative factor. Conversely, if someone mentions
COST as a reason why they do buy yogurt, then mark a 1 in the yogurt column. If

133

the interviewee does not mention COST as a reason why they do or do not buy
yogurt then the column for yogurt would be marked as a O.

5. When you have identified a specific factor in the transcript use a highlighter to
highlight and also label the specific factor that you are identifying (e. g. +1 cost for
milk) in the transcript as well as marking it on the coding form.

6. The factors (availability, accessibility, convenience, cost, culture, health benefit
effects and child preference) will be applied only to the dairy foods that are
mentioned in the transcript. For example you will be looking to see if foods in the
dairy group as a whole are available, milk is available, cheese is available and yogurt
is available. Even though other foods are probed for in the interview transcript like
leafy green vegetables, you will not be looking to see if leafy green vegetables are
available. You are only concerned about identifying these factors in relation to dairy
foods specifically. The specific dairy foods that are included and foods that are
excluded for analysis are specified below.

Foods to Include

- Daigy Group: The factors (i. e. availability) are referred to in discussion
when looking at the dairy foods as a whole group, not just one particular dairy
food. (i.e. “Yes, we buy all of these dairy foods and always have them in the
house.)

- M115: Any type of milk including chocolate milk, strawberry, vanilla, skim,
1/2%, 1%, 2% or whole milk.

0 Cheese: All kinds of hard cheese, i.e. string, cheddar, aged cheese,
mozzarella, American, etc. Cottage cheese would also be included in the
cheese group.

0 Yogurt: Regular, reduced fat, light, and fat free yogurt included with all
flavors included.

Foods to Exclude

Asian food group: All Asian foods, i.e. stir-fry, chow mein, chop suey, tofu
Beverage group: Soda, iced tea, coffee, latte, orange juice
Calcium-fortified foods: Calcium-fortified juice ( i.e. orange juice,
cranberry juice) calcium-fortified cereal, calcium-fortified cereal bars,
calcium-fortified soy milk
0 Fish group: Cod, halibut, regular salmon, canned salmon with bones,
sardines
0 Foods made with dairy: Pizza, pudding, cream soups, frozen yogurt, ice
cream, cheese wiz, cheese sauce, cheese sticks, and/or cheese spread
Greens: All vegetables, i.e. broccoli, cabbage, lettuce, spinach
Hispanic food group: All Hispanic foods, i.e. enchilada, burrito, taco,
tortilla
o .M_illg: Soymilk, rice milk, cultured buttermilk

134

0 Pasta food group: All pasta foods, i.e. macaroni and cheese, lasagna,
spaghetti

135

The definitions, rules, and examples for identification of factors 1-11 are given

below:

1a. Availability [Positive Factor, (+)]

lb.

Definition: Dairy food is present in the family home. The interviewee M
make dairy foods and/or beverages [a. dairy group, b. milk, c. cheese, (1.
yogurt] present in their home.

Rule: The interviewee must verbalize that he/she buys, gets, has, keeps,
purchases, or cooks with a particular dairy food for the factor to be marked as
a positive factor.

Example#l: Interviewer: “VWzat are some reasons why you choose these
foods, dairy foods? Interviewee: Ok, well milk, we have that in the house
every day. That’s a must.” Coding Answer: +1 Availability milk
Example#2: Interviewer: “What are some reasons why you choose these
dairy foods?” Interviewee: “OK, so they love yogurt so I always try to keep
the yogurt around as a snack.” Coding Answer: +1 Availability yogurt
Example#3: Interviewer: “Why does she pick these dairy foods? ”
Interviewee: “Because I get them and give them to her.” Coding Answer:
+1 Availability dairy

Lack of Availability [Negative Factor, (-)]

Definition: Dairy food is not present in the family home. The interviewee
does not make dairy foods and/or beverages [a. dairy group, b. milk, c.
cheese, (1. yogurt ] present in their home.

Rule: The interviewee must verbalize that he/she rarely
buys/gets/keeps/cooks with, not often buys/gets/keeps/cooks with or does not
buy/get/keep/cook with a particular dairy food in their home. If the
interviewee states that she does not eat a particular dairy food or states that
their child does not either eat it cannot be automatically marked as a negative
availability factor. If the interviewee states that he/she sometimes
buys/gets/keeps/cooks with a particular dairy food, it would be marked as
neutral factor. If the interviewee does not verbalize availability as a positive
or negative factor then the availability factor category will be coded as a
neutral factor on the coding form.

Example#l: Interviewer: “What are some reasons why you don 't drink milk
or eat yogurt? ” Interviewee: “We just have juice or water. Interviewer:
“But basically, that is it? ” Interviewee: “Yeah, juice or water. We do not
purchase milk because our family is all lactose intolerant. We do not purchase
yogurt because it is too expensive.” Coding Answer: -1 Availability milk,
-1 Availability yogurt

Example #2: Interviewer: “Why does she not eat yogurt? ” Interviewee:
“She’s never been exposed to it cause I don’t’ get it.”

Coding Answer: -1 Availability yogurt

136

Example#3: “Why does she not eat yogurt? ” Interviewee: “Because I hate
to buy something and then it just sit there and no one will eat it, so I don’t buy
it.” Coding Answer: -1 Availability yogurt

2a. Accessibility [Positive Factor, (+)]

Definition: Dairy food that is made available in a form and location that is
likely to increase child consumption in the home. The interviewee gpe_s make
dairy foods and/or beverages [a. dairy group, b. milk, 0. cheese, (1. yogurt ]
available in a form (e. g. cutting up cheese in slices with crackers for a snack)
and/or location (e. g. bottom shelf of refrigerator) that is likely to increase their
child’s consumption.

Rule: The interviewee must verbalize that he/she does make dairy foods and/
or beverages available in a form and/or location likely to increase their child’s
consumption.

Example#l: Interviewer: “Why does your child consume these dairy

foods? ” Interviewee: “Well because I buy Gogurts© brand yogurt, the kind
he likes, and leave them on the bottom shelf of my refrigerator so my son can
always get to it.” Coding Answer: +1 Accessibility yogurt

2b. Lack of Accessibil_ity [Negative Factor, (-)]

Definition: Dairy food that is not made available in a form and location that
is likely to increase child consumption in the home. The interviewee does not
make dairy foods and/or beverages [a. dairy group, b. milk, 0. cheese, (1.
yogurt ] available in a form and/or location that are likely to increase their
child’s consumption.

Rule: The interviewee must verbalize that he/she does not keep dairy foods
and/or beverages available in a form and/or location that is likely to increase
their child’s consumption. If the interviewee does not verbalize accessibility
as a positive or negative factor then the accessibility factor category will be
coded as a neutral factor on the coding form.

Example#l: Interviewer: “Why do you consume these dairy foods? "
Interviewee: “I purchase fat fi'ee yogurt for myself because I am on a diet, but
my child cannot have it so ll keep it in a place where they cannot reach it.”
Coding Answer: -1 Accessibility yogurt

3a. Convenience [Positive Factor, (+)]

Definition: Dairy foods are guick and easy to use or prepare. The
interviewee thinks that dairy foods and/or beverages [a. dairy group, b. milk,
0. cheese, (1. yogurt] are easy to use, easy to transport, quick, convenient
and/or require little preparation.

Rule: The interviewee must verbalize that dairy foods are quick, convenient,
easy, or require little preparation.

137

Example#l: Interviewer: “What are some reasons why you chose these
foods, dairy foods? ” Interviewee: “Well, urn yogurt, I don’t know, it’s just
kinda quick, kinda lunch kinda thing or early in the morning quick kinda
thing.” Coding Answer: +1 Convenience yogurt

Example#Z: “What are some reasons why you choose these dairy foods ?”
Interviewee: “If there are quick snack times that is what we choose. Right
now we’ll grab like a slice of cheese or yogurt from the refrigerator on our
way out.” Coding Answer: +1 Convenience yogurt, +1 Convenience cheese

3b. Lack of Convenience [Negative Factor (-)]

Definition: Dairy foods are not guick and easy to use or prepare. The
interviewee thinks that dairy foods and/or beverages [a. dairy group, b. milk,
0. cheese, d. yogurt] are not easy to cook with, prepare, store, and/or
transport.

Rule: The interviewee must verbalize that dairy foods and/or beverages are
not easy to cook with, prepare, store, and/or transport. If the interviewee does
not verbalize convenience as a positive or negative factor then the
convenience factor category will be coded as a neutral factor on the coding
form.

Example#l: Interviewer: “What are some reasons why you do not choose
these foods, dairy foods? Interviewee: “Because they do not store well for
the kids lunches.” Coding Answer: -1 Convenience dairy

Example#z: “What are some reasons why you do not choose these foods,
dairy foods? Interviewee: Because I don’t know to how to cook with them.”
Coding Answer: -1 Convenience dairy

4a. Cost [Positive Factor, (+)]

Definition: Dairy foods are inexpensive or not costly or cheap. The
interviewee thinks that price of dairy foods and/or beverages [a. dairy group,
b. milk, c. cheese, (1. yogurt ] are inexpensive or cheap.

Rule: The interviewee must verbalize that dairy foods are inexpensive or
cheap.

Example#l: Interviewer: “What are some reasons why you eat these
foods? ” Interviewee: “They’re cheap, and they taste good.” Coding
Answer: +1 Cost dairy

Example #2: Interviewer: “What are some reasons why you eat these foods,
other than just the taste? ” Interviewee: “You can prepare a lot of foods with
cheese and it is not expensive.” Coding Answer: +1 Cost cheese

138

4b. Cost [Negative factor, (-)]

Definition: Dairy foods are expensive or cost a lot of money. The
interviewee thinks that price of dairy foods and/or beverages [a. dairy group,
b. milk, c. cheese, (1. yogurt ] are expensive or cost a lot of money.

Rule: The interviewee must verbalize that dairy foods are expensive. If the
interviewee does not verbalize cost as a positive or negative factor then the
cost factor category will be coded as a neutral factor on the coding form.
Example#l: Interviewer: “What are some reasons why you do not eat these
foods? ” Interviewee: “Yogurt, we can not afford it.” Coding Answer: -1
Cost yogurt

Example#Z: Interviewer: “What are some reasons why you do not eat these
foods? Interviewee: “I eat yogurt too but since I don’t have a lot of money
in a month I may only get to eat it once or twice.” Coding Answer: -1 Cost
yogurt

5a. Culture [Positive factor, (+)]

Definition: Dairy foods are part of the family’s culture and/or what the
family grew up eating. The interviewee thinks dairy foods and/or beverages
[a. dairy group, b. milk, c. cheese, (1. yogurt] are part of their culture and/or
what they grew up eating.

Rule: The interviewee must verbalize that dairy foods are a part of their
culture and/or what they grew up eating.

Example#l: Interviewer: “What are some reasons you eat cheese?”
Interviewee: “I’m Mexican, this is part of my culture.” Coding Answer: +1
Culture cheese

5b. Culture [Negative Factor, (-)]

Definition: Dairy foods are not a part of the family’s culture and/or what the
family grew up eating. The interviewee does not think that dairy foods and/or
beverages [a. dairy group, b. milk, 0. cheese, (1. yogurt ] are part of their
culture and/or a type of food that they grew up eating.

Rule: The interviewee must verbalize that their culture and/or the way they
grew up are reasons why they or their child does not purchase or consume
dairy foods. If the interviewee does not verbalize culture as a positive or
negative factor then the culture factor category will be coded as a neutral
factor on the coding form.

Example#l: Interviewer: “What are some reasons why you do not drink
milk? ” Interviewee “It is not in my culture to drink milk. “It is not the way
I grew up to drink and eat these types of foods.” Coding Answer: -1 Culture
milk

Example#Z: Interviewer: “What are some reasons why you do not drink
milk? ” Interviewee: “You know Asians do not drink much milk because we
grew up this way.” Coding Answer: -1 Culture milk

139

Example #3: Interviewer: “ What are some reasons why you do not eat
cheese? ” Interviewee Response: “My husband don’t do, most Asians do not,
because when we were born we don’t eat it.” Coding Answer: -1 Culture
cheese

6a. Positive Health Benefit Beliefs [Positive Factor, (+)]

Definition: Dairy foods are good for health. The interviewee thinks that
dairy foods and/or beverages [a. dairy group, b. milk, c. cheese, d. yogurt] are
important for their own and/or their child’s health.

Rule: The interviewee must verbalize that" dairy foods are good for health
reasons. The interviewee can state any reason that relates to health (e. g.
stating that it is good for them or good for their child, healthy, high in
calcium, good for bones, has protein, helps to control weight, or is low in fat).
If you read a transcript in which the interviewee gives a positive and a
negative factor to a particular food (e. g. “yogurt is good for you but is
sweet”), then the column for health benefit effects of yogurt would be given a
O.

Example#l: Interviewer: “What are some reasons that you eat these dairy
foods? Interviewee: “They are good for your health.” Coding Answer: +1
Health effects dairy

Example#Z: Interviewer: “What are some reasons that you drink milk? ”
Interviewee: “Well, for the calcium and is an excellent source of protein.”
Coding Answer: +1 Health effects milk

Example#3: Interviewer: “What are some reasons that you eat these dairy
foods? Interviewee: “They are low in fat and calories.” Coding Answer:
+1 Health effects dairy

6b. Negative Health Benefit Beliefs [Negative Factor, (-)]

Definition: Dairy foods are not good for health. The interviewee thinks that
dairy foods and/or beverages [a. dairy group, b. milk, c. cheese, (1. yogurt] are
bad for their or their child’s health.

Rule: The interviewee must verbalize that dairy foods are bad for health in
any type of way. Bad for health reason examples include it is bad for me, bad
for my child, makes me sick, gives me allergies, and is fattening or high in
calories. If the interviewee does not verbalize health effects as a positive or
negative factor then the health effects factor category will be coded as a
neutral factor on the coding form.

Example#l: Interviewer: “What are some reasons that you don ’t choose
the cheese very often? Interviewee: “It’s fattening I think.” Coding
Answer: -1 Health effects cheese

Example#l: Interviewer: “What are some reasons that you don 't choose
yogurt?” Interviewee: “It has too much sugar so I would never buy it or
give it to my child.” Coding Answer: -1 Health effects yogurt

140

7a. Child Preference (Like) [Positive factor, (+)]

Definition: Child enjoys or M the taste, texture or flavor of dairy foods.
The interviewee’s child does like the taste, texture, or flavor of dairy foods
and/or beverages [a. dairy group, b. milk, c. cheese, (1. yogurt] or likes them
with other foods.

Rule: The interviewee must verbalize that her child likes the taste, texture and
or flavor of a dairy food, likes it with other foods, or is a big dairy food
consumer. If the interviewee verbalizes that B like the particular food
instead of saying that their child specifically likes the food, it would still count
as a positive factor for the child. If you read a transcript in which the
interviewee verbalizes that her child likes one type of dairy food (i.e. loves
peach yogurt, but not any other kind of yogurt), then it would still be coded as
a positive factor.

Example#l: Interviewer: “Why does your child eat dairy foods ?”
Interviewee: “Because she likes the taste.” Coding Answer: +1 Child
preference dairy

Example #2: Interviewer: “Does she like milk much?” Interviewee: “She
likes chocolate milk and likes it with cereal.” Coding Answer: +1 Child
preference milk

Example #3: Interviewer: “Does she ever eat yogurt?” Interviewee:
“She loves yogurt for the taste. She doesn’t like yogurt with fruit. There is
one kind that doesn’t have fruit on the bottom.” Coding Answer: +1 Child
preference yogurt

7b. Child Preference (Dislike) [Negative factor, (-)]

Definition: Child does not like or enjoy the taste texture, or flavor of dairy
foods or is allergic to them or has lactose intolerance. The interviewee’s child
does not like the taste, texture, or flavor of dairy foods, is allergic to them or
has lactose intolerance.

Rule: The interviewee must verbalize that their child does not like, is allergic
to, or has lactose intolerance to dairy foods. If the interviewee mentions that
the child will not consume a particular dairy food this would also be coded as
a negative factor. If the interviewee does not verbalize child preference as a
positive or negative factor then the child preference factor category will be
coded as a neutral factor on the coding form.

Example #1: Interviewer: ‘ Why does your child not drink milk? ”
Interviewee: “She refused to drink it because she hates the taste. I have tried
everything to get her to drink it, every flavor, and everything. She just will
not touch it.” Coding Answer: -1 Child preference milk

Example#z: Interviewer: ‘ Why does your child not drink milk? ”
Interviewee: Yes, she’s a big ice cream eater but when it comes down to
milk, I can’t get her to drink that.” Coding Answer: -1 Child preference
milk

141

 

 

 

8a. Knowledge of # of Milk Servings [Positive Factor (+)]

Definition: Understanding of the number of milk servings that are needed to
meet dietary calcium recommendations in children. The interviewee is
knowledgeable of how many servings of milk are needed to meet the calcium
dietary recommendations for children between the ages of 9-1 8 years old.
Rule: The interviewee is able identify the correct amount of servings for milk
accounting for answers that are +/- 1 correct serving (Correct Answer: 3-5
servings). If the interviewee gives a range for the correct servings (i.e. 2-3)
and one of the numbers in the range is correct then the interviewee would get
a +1 correct score. The interview question that you need to look for in the
interview transcript to identify this factor is, “How many servings of milk are
needed to equal 1300 mg calcium that is the recommendation for calcium
intake in 9-18 year olds?”

Example#l: Interviewer: “How many servings of milk equal 1300 mg of
calcium? Interviewee: “Oh, I am not sure; I think 4 servings of milk.”
Coding Answer: +1 Knowledge of # of milk servings

8b. Lack of Knowledge of # of Milk Servings [Negative Factor, (-)]

Definition: No understanding of the number of milk servings that are needed
to meet dietary calcium recommendations in children. The interviewee is not
knowledgeable of how many servings of milk are needed to meet the calcium
dietary recommendations for children between the ages of 9-18 year old.
Rule: The interviewee is not able identify the correct amount of servings for
milk accounting for answers that are +/- 1 correct serving (Correct Answer:
3-5 servings). This question will only have a positive or negative factor
response. There is no neutral factor response. If the question is not asked in
the interview transcript then the column will be marked as missing. The
interview question that you need to look for in the interview transcript to
identify this factor is, “How many servings of milk are needed to equal 1300
mg calcium that is the recommendation for calcium intake in 9-18 year olds?”
Example#l: Interviewer: “How many servings of milk equal 1300 mg of
calcium?” Interviewee: “Probably 8 servings.”

Coding Answer: -1 Knowledge of # of milk servings

9a. Modeling [Positive Factor, (+)]

Definition: Consuming milk at meal and/or snack times. The interviewee
consumes milk at meals and/or snack times.

Rule: The interviewee must verbalize that he/she drinks milk at least once
daily for a meal and/or snack. If the interviewee states that he/she has milk
and another beverage at meal and/or snack time this would also be marked as
a positive factor. The interview question that you need to look for in the
interview transcript to identify this factor is, “What do you drink for meals
and snacks?”

142

 

 

 

Example#l: Interviewer: “What do you usually drink with meals each day?
Interviewee: I drink milk with lunch and dinner daily.” Coding Answer: +1
Modeling

Example#z: Interviewer: “What do you usually drink with meals?
Interviewee: I drink milk with breakfast everyday.” Coding Answer: +1
Modeling

9b. Lack of Modeling [Negative Factor, (-)]

Definition: Not consuming milk at meal and/or snack times. The parent
does not consume milk at meal and/or snack times.

Rule: If the interviewee states that he/she has milk daily in cereal or drinks it
a lot, sometimes, usually, or sometimes daily it would be marked as a negative
factor. Also if the interviewee verbalizes that he/she drinks milk g another
beverage at meal and/or snack time it would also count as a negative factor.
This question will only have a positive or negative factor response. There is
no neutral factor response. If the question is not asked in the interview
transcript then the column will be marked as missing. The interview question
that you need to look for in the interview transcript to identify this factor is,
“What do you drink for meals and snacks?”

Example #1: Interviewer: “What do you drink with meals and/or snacks? ”
Interviewee: “Diet coke and water only.” Coding Answer: -1 Modeling
Example#Z: Interviewer: “What do you drink with meals and/or snacks? "
Interviewee: “Water, coffee, milk, or soda.” Coding Answer: -1 Modeling
Example#3: Interviewer: “What do you drink with meals and/or snacks?
Interviewee: “My husband and I will usually drink water and tea
sometimes.” Coding Answer: -1 Modeling

10a. Parental Expectation [Positive Factor, (+)]

Definition: Encouragement or enforcement of milk to be consumed at meal
and/or snack times. The interviewee encourages and/or enforces that their
child has milk with meals and/or snacks.

Rule: The interviewee must verbalize that he/she encourages, enforces,
expects, makes, forces or tells their child to drink milk with at least one meal
or snack daily. The interviewee must verbalize milk as the only beverage that
is expected. The interview question that you need to look for in the interview
transcript to identify this factor is, “What do you expect you child to drink at
meals or snacks?”

Example#l: Interviewer: "VWrat do you expect your child to drink with
meals? Interviewee: “Milk.” Coding Answer: +1 Parental expectation
Example#Z: Interviewer: “What do you expect your child to drink with
meals? Interviewee: “Yes, I expect him to drink milk.” +1 Parental
expectation

Example #3: Interviewer: “What do you expect your child to drink with
meals? Interviewer: "Why does your child drink milk at meals?”

143

Interviewee: “Because I tell her she has to or I make her drink it.”
Coding Answer: +1 Parental expectation

10b. Lack of Parental Expectation [Negative factor, (-)]

Definition: No encouragement or enforcement of milk to be consumed at
meal and/or snack times. The interviewee does not encourage or enforce their
child to have milk with meals and/or snacks.

Rule: The interviewee must verbalize that he/she does not encourage,
enforce, expect, make, force or tell their child to have milk with meals and/or
snacks. If they mention milk 55 some other beverage is expected at meal
and/or snack time then it would also count as a negative factor. This question
will only have a positive or negative factor response. There is no neutral
factor response. If the question is not asked in the interview transcript then
the column will be marked as missing. The interview question that you need
to look for in the interview transcript to identify this factor is, “What do you
expect your child to drink at meal and/or snack times?”

Example #1: Interviewer: “What do you expect your child to drink with
meals? Interviewee “I don’t know, whatever is in the house, usually juice or
water, whatever they want.” Coding Answer: -1 Parental expectation
Example#2: Interviewer: “What do you expect your child to drink with
meals? Interviewee: “Well, if they don’t drink anything it is ok with me.
They can drink milk, juice, water. All that is better than soda. Soda is the last
choice they have. Soda is for me.” Coding Answer: -1 Parental expectation

11a. Knowledge of Calcium and Bone Health [Positive Factor, (+)]

Definition: The interviewee is aware that calcium is important to My
health.

Rule: The interviewee must verbalize an understanding between the
association of the importance of calcium to healthy bones by stating that
calcium is good for bone health or by stating that calcium is needed to help
prevent osteoporosis. The interview question to look for is, “What do you
know about calcium and health?”

Example#l: Interviewer: “What do you know about calcium and health?
Interviewee: “It is important for your bones.” Coding Answer: +1
Knowledge of calcium and bone health

Example#2: Interviewer: “What do you know about calcium and health?
Interviewee: “It is important to prevent osteoporosis.” Coding Answer: +1
Knowledge of calcium and bone health

1 lb. Lack of Knowledge of Calcium and Bone Health [Negative Factor, (-)]

Definition: The interviewee is not aware that calcium is important to bone
health.

144

0 Rule: The interviewee verbalizes no association of the importance of calcium
to healthy bones. This question will only have a positive or negative factor
response. There is no neutral factor response. If the question is not asked in
the interview transcript then the knowledge of calcium and bone health factor
category will be marked as missing. The interview question to look for in the
interview transcript is, “What do you know about calcium and health.”

0 Example#l: Interviewer: “What do you know about calcium and health?
Interviewee: “I don’t know. Not very much.” Coding Answer: -1
Knowledge of calcium and bone health

145

APPENDIX E

Coding Form

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147

APPENDIX F

Hierarchical Cluster Dendogram

148

* * * * * * H I E R A R C H I C A L C L U S T E R A N A L Y S I S * Dendrogram

using Ward Method

Rescaled Distance Cluster Combine

 

 

 

 

 

 

 

 

 

 

 

 

 

C A S E 0 5 10 15 20 25
Label Num + --------- + --------- + --------- + --------- + --------- +
68 -—
190 -—
122 -
106 —-

9
1.6 1
135 -———
143 —~

69 -—
124 -
55 - F—
126 -—
60 -—
153 .1
4
.2 T
170 ~—
184 -—
76 —<
117 ——
148
3 _.
82 -7
114 -—
133
53 -—
45 -
145
8 ——l
46 -
112 -—
129
166 -—
72 'fi
108 -+
109 -d
70 —~
173 -
51 ——

7 -—
125 -—~—
110 -—
115 '—

50 -‘
189 -4 ~—
144 -1

 

 

149

191
66
162
165
167
116
177
74
84
163
47
73
22
120
32
185
15
27
11
26
33
18

20
29
105
65
91
64
56
94
93
98
97
23
59
21
180
99
102
80
178
44
16
34
17
10
31
118
179
181
188
88
57

111

 

 

 

l

l

 

 

 

 

llJl

l

 

 

 

 

 

L

 

150

 

35
147

156
123
14
58
25
19
62
150
168
128
137
138
24
132
85
107
172
87
101
79
149
160
187
104
176
100
113
78
81

139
141
130
152
134
140
171
154
174
151
136
169

38
103

95

96
183

13

54
119

43

l J

 

 

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1

l

1111

 

 

 

 

 

 

 

 

 

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l

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L111

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151

 

175
131
92
49
52
67
142
63
186
36
89
39
182
61
121
40
42
111
71
155
164
37
75
48
127
30
90
86
158
159
41
83
77
161
157

28

 

l

L

1 1

 

 

 

 

 

 

 

152

APPENDIX G

K-means Cluster Method

153

initial Cluster Centers

 

Cluster

 

 

 

Availability dairy
Availability milk
Availability yogurt
Availability cheese
Accessibility dairy
Accessibility milk
Accessibility yogurt
Accessibility cheese
Convenience dairy
Convenience milk
Convenience yogurt
Convenience cheese
Cost dairy

Cost milk

Cost yogurt

Cost cheese

Culture dairy

Culture milk

Culture yogurt
Culture cheese
Health effects dairy
Health effects milk
Health effects yogurt
Health effects cheese
Personal factors dairy
Personal factors milk
Personal factors yogurt
Personal factors cheese

 

 

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OOOOOOOO

u r
.30...

000000000

 

154

 

 

iteration History

 

 

 

 

Change in Cluster
Centers

iteration 1 2

1 2.292 2.785
2 .084 .402
3 .034 .176
4 .055 .246
5 .150 .414
6 .043 .094
7 .049 .1 1 1
8 .032 .069
9 .017 .036
10 .014 .030

 

 

 

 

a. iterations stopped because the maximum number of
iterations was performed. Iterations failed to
converge. The maximum absolute coordinate change
for any center is .022. The current iteration is 10. The
minimum distance between initial centers is 5.916.

155

Final Cluster Centers

 

Cluster

 

 

 

Availability dairy
Availability milk
Availability yogurt
Availability cheese
Accessibility dairy
Accessibility milk
Accessibility yogurt
Accessibility cheese
Convenience dairy
Convenience milk
Convenience yogurt
Convenience cheese
Cost dairy

Cost milk

Cost yogurt

Cost cheese

Culture dairy

Culture milk

Culture yogurt
Culture cheese
Health effects dairy
Health effects milk
Health effects yogurt
Health effects cheese
Personal factors dairy
Personal factors milk
Personal factors yogurt
Personal factors cheese

 

ADO—hooo—IOOOOOOOOOOOOOOOOAOd-l

 

COCOOOOOOCOOOOOOOOOOOOOOOO-fid

 

Distances between Final Cluster Centers

 

I Cluster I 1

1
2

I 1.851

 

2 i
1.851

 

Number of Cases in each Cluster

 

Cluster

Valid
Missing

1
2

 

128.000
63.000
191 .000
.000

 

 

156

 

APPENDIX H

Percent prevalence of positive, negative and neutral parental
Influences

157

Percent Prevalence of Positive, Neutral and Negative Parental Influences

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Positive Neutral Negative
Availability dairy, % 87 9 4
Availability milk, % 94 3 3
Availability yogurt, % 38 43 16
Availability cheese, % 52 41 7
Accessibility dairy, % 3 97 0
Accessibility milk, % 1 99 0
Accessibility yogurt, % l 99 0
Accessibility cheese, % l 99 0
Convenience dairy, % 25 78 1
Convenience milk, % 3 96 1
Convenience yogurt, % 12 89 1
Convenience cheese, % 13 90 0
Cost dairy, % 2 89 9
Cost milk, % 1 98 1
Cost yogurt, % l 94 5
Cost cheese, % 1 97 2
Culture dairy, % 1 97 3
Culture milk, % O 99 1
Culture yogurt, % O 100 0
Culture cheese, % l 99 0
Health benefit beliefs dairy, % 55 40 6
Health benefit beliefs milk, % 33 66 2
Health benefit beliefs yogurt, % 20 78 3
Health benefit beliefs cheese, % 10 84 6
Child preference dairy, % 65 20 15
Child preference milk, % 26 56 18
Child preference yogurt, % 39 46 15
Child preference cheese, % 46 48 6

Positive Negative
Knowledge of bone health, % 96 4
Knowledge of # of milk svgs to 68 32
meet
child calcium recommendations, %
Parental modeling for milk, % 33 67
Parental expectation for milk, % 33 67

 

158

BIBLIOGRAPHY

(1998) Nutrition and Bone Health with Reference to Calcium and Vitamin D. Dietary
Reference Values for Food Energy and Nutrients for the United Kingdom. In

Report in Health and Social Subjects no. 49 [Do Health, editor. London: HM
Stationary Office.

(2000a) Food Marketing Institute: "Trends in the United States, Consumer Attitudes
& the Supermarket, 2000."

(2000b) Why Calcium? [N10 Health, editor. Bethesda, MD.

(Accessed 2004) National Information Management and Support System: W1003
Multistate Project Summary.

Abrams SA, Copeland KC, Gunn SK, Gundberg CM, Klein KO & Ellis KJ (2000)
Calcium absorption, bone mass accumulation, and kinetics increase during
early pubertal development in girls. J Clin Endocrinol Metab 85, 1805-1809.

Abrams SA, Copeland KC, Gunn SK, Stuff JE, Clarke LL & Ellis KJ (1999) Calcium
absorption and kinetics are similar in 7- and 8-year-old Mexican-American
and Caucasian girls despite hormonal differences. J Nutr 129, 666-671.

Abrams SA, Grusak MA, Stuff J & O'Brien KO (1997) Calcium and magnesium
balance in 9-14-y-old children. Am J Clin Nutr 66, 1172-1177.

Abrams SA, O'Brien KO & Stuff J E (1996) Changes in calcium kinetics associated
with menarche. J Clin Endocrinol Metab 81, 2017-2020.

Abrams SA & Stuff J E (1994) Calcium metabolism in girls: current dietary intakes
lead to low rates of calcium absorption and retention during puberty. Am J
Clin Nutr 60, 739-743.

ADA (2001) ADA Reports: Position of the American Dietetic Association: Food
fortification and dietary supplements. J Am Diet Assoc 101, 115-125.

Afifi AA, Clark, V. (1996) Computer-Aided Multivariate Analysis, 3rd Ed. New
York: Chapman & Hall/CRC.

Alaimo K, McDowell MA, Briefel RR, Bischof AM, Caughrnan CR, Loria CM &
Johnson CL (1994) Dietary intake of vitamins, minerals, and fiber of persons
ages 2 months and over in the United States: Third National Health and
Nutrition Examination Survey, Phase 1, 1988-91. Adv Data, 1-28.

159

 

 

Albertson AM, Tobelmann RC & Marquart L (1997) Estimated dietary calcium
intake and food sources for adolescent females: 1980-92. J Adolesc Health
20, 20-26.

Allender PS, Cutler JA, Follrnann D, Cappuccio FP, Pryer J & Elliott P (1996)
Dietary calcium and blood pressure: a meta-analysis of randomized clinical
trials. Ann Intern Med 124, 825-831.

Ames SK, Gorham BM & Abrams SA (1999) Effects of high compared with low
calcium intake on calcium absorption and incorporation of iron by red blood
cells in small children. Am J Clin Nutr 70, 44-48.

Anderson ES, Winett RA & Wojcik JR (2000) Social-cognitive determinants of
nutrition behavior among supermarket food shoppers: a structural equation
analysis. Health Psychol 19, 479-486.

Andon MB, Lloyd T & Matkovic V (1994) Supplementation trials with calcium
citrate malate: evidence in favor of increasing the calcium RDA during
childhood and adolescence. J Nutr 124, 1412S-1417S.

Appel LJ, Moore TJ, Obarzanek E, Volhner WM, Svetkey LP, Sacks FM, Bray GA,
Vogt TM, Cutler J A, Windhauser MM, Lin PH & Karanja N (1997) A clinical
trial of the effects of dietary patterns on blood pressure. DASH Collaborative
Research Group. N Engl J Med 336, 1117-1124.

Auld G, Boushey CJ, Bock MA, Bruhn C, Gabel K, Gustafson D, Holmes B, Misner
S, Novotny R, Peck L, Pelican S, Pond-Smith D & Read M (2002)
Perspectives on intake of calcium-rich foods among Asian, Hispanic, and
white preadolescent and adolescent females. J Nutr Educ Behav 34, 242-251.

Badenhop-Stevens N & Matkovic V (2004) Calcium needs in children. Orthop Nurs
23, 228-232; quiz 233-224.

Ballew C, Kuester S & Gillespie C (2000) Beverage choices affect adequacy of
children's nutrient intakes. Arch Pediatr Adolesc Med 154, 1148-1152.

Bandura A (2001) Social cognitive theory: an agentic perspective. Annu Rev Psychol
52, 1-26.

Baranowski T (2002) Environmental Influences and What Have We Learned From
Dietary Behavior Change With Children? Nutr Today 37, 171-172.

Baranowski T, Cullen KW & Baranowski J (1999) Psychosocial correlates of dietary
intake: advancing dietary intervention. Annu Rev Nutr 19, 17-40.

160

 

 

Baranowski T, Smith M, Heam MD, Lin LS, Baranowski J, Doyle C, Resnicow K &
Wang DT (1997) Patterns in children's huh and vegetable consumption by
meal and day of the week. J Am Coll Nutr 16, 216-223.

Barger-Lux MJ, Heaney, R.P., Packard, P.T., Lappe, J .M., Recker, RR. (1992)
Nutritional correlates of low calcium intake. Clin Appl Nutr 2, 39-44.

Baron J A, Beach M, Mandel J S, van Stolk RU, Haile RW, Sandler RS, Rothstein R,
Summers RW, Snover DC, Beck GJ, Frankl H, Pearson L, Bond JH &
Greenberg ER (1999) Calcium supplements and colorectal adenomas. Polyp
Prevention Study Group. Ann N Y Acad Sci 889, 138-145.

Baron J A, Cole BF, Sandler RS, Haile RW, Ahnen D, Bresalier R, McKeown—Eyssen
G, Summers RW, Rothstein R, Burke CA, Snover DC, Church TR, Allen J1,
Beach M, Beck GJ, Bond JH, Byers T, Greenberg ER, Mandel J S, Marcon N,
Mott LA, Pearson L, Saibil F & van Stolk RU (2003) A randomized trial of
aspirin to prevent colorectal adenomas. N Engl J Med 348, 891-899.

Barr SI (1994) Associations of social and demographic variables with calcium intakes
of high school students. J Am Diet Assoc 94, 260-266, 269; quiz 267-268.

Barr SI (1995) Dieting attitudes and behavior in urban high school students:
implications for calcium intake. J Adolesc Health 16, 458-464.

Barr SI (2003) Increased dairy product or calcium intake: is body weight or
composition affected in humans? J Nutr 133, 2458-2488.

Beauchamp GK, Cowart BJ, Mennella J A & Marsh RR (1994) Infant salt taste:
developmental, methodological, and contextual factors. Dev Psychobiol 27,
353-365.

Bell NH, Yergey AL, Vieira NE, Oexmann MJ & Shary JR (1993) Demonstration of
a difference in urinary calcium, not calcium absorption, in black and white
adolescents. J Bone Miner Res 8, 1 1 11-1 115.

Berdainer GD (2002) Handbook of Nutrition. London, New York, Washington DC.

Berkey CS, Rockett HR, Willett WC & Colditz GA (2005) Milk, dairy fat, dietary
calcium, and weight gain: a longitudinal study of adolescents. Arch Pediatr
Adolesc Med 159, 543-550.

Bemer LA, Clydesdale F M & Douglass J S (2001) Fortification contributed greatly to
vitamin and mineral intakes in the United States, 1989-1991. J Nutr 131,
21 77-21 83.

Birch L (1999) Development of food preferences. Annual Review of Nutrition 19, 41-
62.

161

Birch L, Fisher, J. (1998a) Development of eating behaviors among chldren and
adolescents. Pediatrics 101, 539-549.

Birch LL (1998b) Psychological influences on the childhood diet. J Nutr 128, 407$-
4108.

Birch LL & Davison KK (2001) Family environmental factors influencing the
developing behavioral controls of food intake and childhood overweight.
Pediatric Clinics of North American 48, 893-907.

Birch LL & Fisher J O (2000) Mothers' child-feeding practices influence daughters'
eating and weight. Am J Clin Nutr 71, 1054-1061.

Block G, Cox C, Madans J, Schreiber GB, Licitra L & Melia N (1988) Vitamin
supplement use, by demographic characteristics. Am J Epidemiol 127, 297-
309.

Boutelle KN, Birnbaum AS, Lytle LA, Murray DM & Story M (2003) Associations
between perceived family meal environment and parent intake of fruit,
vegetables, and fat. J Nutr Educ Behav 35, 24-29.

Bowman SA (2002) Beverage choices of young females changes and impact on
nutrient intakes. J Am Diet Assoc 102, 1234-1239.

Carruth BR SJ (2001) The role of dietary calcium and other nutrients in moderating
body fat in preschool children. Int J Obes Rel Metab Disord 25, 559-566.

Carruth BR SJ, Moran 111 JD, Coletta F (2000) Preschoolers' food product choices at
a simulated point of purchase and mothers' consumer practices. J Nutr Educ
32, 146-15 1.

Carruth BR, Skinner JD, Moran JD & Coletta F (2000) Preschoolers' food product
choices at a simulated point of purchase and mothers' consumer practices. J
Nutr Educ 32, 146-151.

Carslon KA & Gould BW (1994) The role of health knowledge in determining
dietary fat intake. Review of Agricultural Economics 16, 373-386.

Cashman KD (2002) Calcium intake, calcium bioavailability and bone health. British
Journal of Nutrition 87, 8169-177.

Cashman KD & Flynn A (1999) Optimal nutrition: calcium, magnesium and
phosphorus. Proc Nutr Soc 58, 477-487.

Chapmen G, Maclean, H. (1993) "Junk food" and "healthy food": meanings of food
in adolescent women's culture. J Nutr Educ 25, 108-113.

162

Cullen KW, Baranowski T, Owens E, Marsh T, Rittenberry L & de Moor C (2003)
Availability, accessibility, and preferences for fruit, 100% mu juice, and
vegetables influence children's dietary behavior. Health Educ Behav 30, 615-
626.

Cullen KW, Baranowski T, Rittenberry L, Cosart C, Hebert D & de Moor C (2001)
Child-reported family and peer influences on fruit, juice and vegetable

consumption: reliability and validity of measures. Health Educ Res 16, 187-
200.

Cullen KW, Baranowski T, Rittenberry L & Olvera N (2000) Social-enviromnental
influences on children's diets: results from focus groups with African-, Euro-
and Mexican-American children and their parents. Health Educ Res 15, 581-
590.

Cutting TM, Fisher JO, Grimm-Thomas K & Birch LL (1999) Like mother, like
daughter: familial patterns of overweight are mediated by mothers' dietary
disinhibition. Am J Clin Nutr 69, 608-613.

Davies KM, Heaney RP, Recker RR, Lappe JM, Barger-Lux MJ, Rafferty K &
Hinders S (2000) Calcium intake and body weight. J Clin Endocrinol Metab
85, 4635-4638.

Devine A, Prince, RL, Bell, R (1996) Nutritional effect of dairy products on bone and
body composition in pubertal girls. Am J Clin Nutr 64, 737-737.

Domel SB, Baranowski T, Davis H, Leonard SB, Riley P & Baranowski J (1993)
Measuring fruit and vegetable preferences among 4th- and 5th-grade students.
Prev Med 22, 866-879.

Douthitt RA & Gould BW (1995) Consumer perceived risk, nutrition information and
dairy product consumption. Indianapolis: American Agricultural Economics
Association.

Drucker RR, Hammer LD, Agras WS & Bryson S (1999) Can mothers influence their
child's eating behavior? J Dev Behav Pediatr 20, 88-92.

Dwyer JT, Garcea AO, Evans M, Li D, Lytle L, Hoelscher D, Nicklas TA & Zive M
(2001) Do adolescent vitamin-mineral supplement users have better nutrient
intakes than nonusers? Observations from the CATCH tracking study. J Am
Diet Assoc 101, 1340-1346.

Edmonds J, Baranowski T, Baranowski J, Cullen KW & Myres D (2001) Ecological

and socioeconomic correlates of fruit, juice, and vegetable consumption
among African-American boys. Prev Med 32, 476-481.

163

Eliason BC, Kruger J, Mark D & Rasmann DN (1997) Dietary supplement users:
demographics, product use, and medical system interaction. J Am Board F am
Pract 10, 265-271.

Ervin RB, Wang CY, Wright JD & Kennedy-Stephenson J (2004) Dietary intake of
selected minerals for the United States population: 1999-2000. Adv Data, 1-5.

Ervin RB, Wright JD & Kennedy E (1999a) Use of dietary supplements in the United
States, 1988-1994. National Center for Health Statistics. Vital Health Stat 11,
244.

Ervin RB, Wright JD & Kennedy-Stephenson J (1999b) Use of dietary supplements
in the United States, 1988-94. Vital Health Stat 11, i-iii, 1-14.

F airweather-Tait SJ & Teucher B (2002) Iron and calcium bioavailability of fortified
foods and dietary supplements. Nutr Rev 60, 360-367.

F ishbein L (2004) Multiple sources of dietary calcium-some aspects of its
essentiality. Regul T oxicol Pharmacol 39, 67-80.

Fisher, Mitchell DC, Smiciklas-Wright H, Mannino ML & Birch LL (2004) Meeting
calcium recommendations during middle childhood reflects mother-daughter

beverage choices and predicts bone mineral status. Am J Clin Nutr 79, 698-
706.

Fisher J, Mitchell D, Smiciklas-Wright H & Birch L (2001) Maternal milk
consumption predicts the tradeoff between milk and soft drinks in young girls
diets. J Nutr 131, 246-250.

Fisher J O & Birch LL (1999) Restricting access to foods and children's eating.
Appetite 32, 405-419.

Fisher J 0, Mitchell DC, Smiciklas-Wright H & Birch LL (2002) Parental influences
on young girls' fruit and vegetable, micronutrient, and fat intakes. J Am Diet
Assoc 102, 58-64.

Fleming KH & Heinback JT (1994) Consumption of calcium in the US; food
sources and intake levels. J Nutr 124, l426S-1430S.

Fletcher J, Branen LJ & Lawrence A (1997) Late adolescents' perceptions of their
caregiver's feeding styles and practices and those they will use with their own
children. Adolescence 32, 287-298.

Francis A, Hofer SM & Birch LL (2001) Predictors of maternal child-feeding style:
maternal and child characteristics. Appetite 37, 231-243.

164

 

 

Fulgoni VL, Huth PJ, DiRienzo DB & Miller GD (2004) Determination of the
Optimal Number of Dairy Servings to Ensure a Low Prevalence of Inadequate

Calcium Intake in Americans. Journal of the American College of Nutrition
23, 65 l -659.

Gerrior S, Putnam J & Bente L (1998) Milk and milk products: their importance in
the American diet. Food Rev 21, 29-37.

Gibson EL, Wardle J & Watts CJ (1998) Fruit and vegetable consumption, nutritional
knowledge and beliefs in mothers and children. Appetite 31, 205-228.

Gillman MW, Hood MY, Moore LL, Nguyen US, Singer MR & Andon MB (1995)
Effect of calcium supplementation on blood pressure in children. J Pediatr
127, 186-192.

Gillman MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Camargo CA, Jr., Field
AE, Berkey CS & Colditz GA (2000) Family dinner and diet quality among
older children and adolescents. Arch Fam Med 9, 235-240.

Gilsanz V, Roe TF, Mora S, Costin G & Goodman WG (1991) Changes in vertebral
bone density in black girls and white girls during childhood and puberty. N
Engl J Med 325, 1597-1600.

Goulding A, Rockell J E, Black RE, Grant AM, Jones IE & Williams SM (2004)
Children who avoid drinking cow's milk are at increased risk for prepubertal
bone fractures. J Am Diet Assoc 104, 250-253.

Greger J L (2001) Dietary supplement use: consumer characteristics and interests. J
Nutr 131, 1339S-13438.

Gueguen L & Pointillart A (2000) The bioavailability of dietary calcium. J Am Coll
Nutr19, 119S-136S.

Guthrie F, Derby, B.M., Levy, AS (1999) What people know and do not know about
nutrition. In "America's Eating Habits: Changes and Consequences. " pp.
243-250 [ERS US Department of Agriculture, Food and Rural Economics
Division, editor. Washington, DC: USDA.

Hanson NI, Neumark-Sztainer D, Eisenberg ME, Story M & Wall M (2005)
Associations between parental report of the home food environment and
adolescent intakes of fruits, vegetables and dairy foods. Public Health Nutr 8,
77-85.

Hare] Z, Riggs S, Vaz R, White L & Menzies G (1998) Adolescents and calcium:

what they do and do not know and how much they consume. J Adolesc Health
22, 225-228.

165

Harel Z RS, Vaz R, White L, Menzies G (1998) Adolescents and calcium: what they
do and do not know and how much they consume. J Adolesc Health 22, 225-
228.

Hamack L, Stang J & Story M (1999) Soft drink consumption among US children
and adolescents: nutritional consequences. J Am Diet Assoc 99, 436-441.

Heaney RP (2000a) Calcium, dairy products, and osteoporosis. J Am Coll Nutr
19(Suppl), 838-998.

Heaney RP, Abrams S, Dawson-Hughes B, Looker A, Marcus R, Matkovic V &
Weaver C (2000) Peak bone mass. Osteoporos Int 11, 985-1009.

Heaney RP, Dowell, M.S, Rafferty, K, Bierman, J (2000b) Bioavailability of the
calcium in fortified soy imitation milk, with some observations on method.
Am J Clin Nutr 71, 1166-1169.

Heaney RP, McCarron, D.A., Dawson-Hughes, B., Oparil, S. (1999) Dietary changes
favorably affect bone remodeling in older adults. J Am Diet Assoc 99, 1228-
1333.

Heaney RP, Rafferty K, Dowell MS & Bierrnan J (2005) Calcium fortification
systems differ in bioavailability. J Am Diet Assoc 105, 807-809.

Heam M, Baranowski, T, Baranowski J. (1998) Environmental influences on dietary
behavior among children: availability and accessibility of fruits and
vegetables enable consumption. J Adolesc Health 27, 235-239.

Holt PR (1999) Dairy foods and prevention of colon cancer: human studies. J Am
Coll Nutr 18, 379S-391S.

Holt PR, Atillasoy EO, Gilman J, Guss J, Moss SF, Newmark H, Fan K, Yang K &
Lipkin M (1998) Modulation of abnormal colonic epithelial cell proliferation
and differentiation by low-fat dairy foods: a randomized controlled trial. Jama
280, 1074-1079.

Holt PR, Wolper C, Moss SF, Yang K & Lipkin M (2001) Comparison of calcium
supplementation or low-fat dairy foods on epithelial cell proliferation and
differentiation. Nutr Cancer 41, 150-155.

Ilich J Z & Kerstetter J E (2000) Nutrition in bone health revisited: a story beyond
calcium. J Am Coll Nutr 19, 715-737.

Ilich-Ernst J Z, McKenna AA, Badenhop NE, Clairrnont AC, Andon MB, Nahhas

RW, Goel P & Matkovic V (1998) Iron status, menarche, and calcium
supplementation in adolescent girls. Am J Clin Nutr 68, 880-887.

166

 

 

IOM (1997) Dietary Reference Intakes for Calcium, Phosphorous, Magnesium,
Vitamin D, and Fluoride: National Academy Press.

Jackson P, Romo MM, Castillo MA & Castillo-Duran C (2004) [Junk food
consumption and child nutrition in Chile]. Rev Med Chil 132, 1235-1242.

J avaid MK & Cooper C (2002) Prenatal and childhood influences on osteoporosis.
Best Pract Res Clin Endocrinol Metab 16, 349-367.

Jensen JK, Gustafson D, Boushey C.J., Auld G, Bock M.A., Bruhn C.M., Gabel K,
Misner S, Novotny R, Peck L, Read M. (2004) Development of a food
frequency questionnaire to estimate calcium intake of Asian, Hispanic, and
white youth. J Am Diet Assoc 104, 762-769.

Jensen JK & Kesavan T (1993) Sources of information, consumer attitudes on
nutrition, and consumption of dairy products. Journal of Consumer Aflairs 27,
357-376.

Jensen J K, Kesavan T & Johnson SR (1992) Measuring the impact of health awarenss
on food demand. Review of Agricultural Economics 14, 299-312.

Johnson RK, Panely C, Wang MQ (1998) The association between noon beverage

consumption and the diet quality of school-age children. J Child Nutr Manage
22, 95-100.

Johnston CC, J r., Miller JZ, Slemenda CW, Reister TK, Hui S, Christian JC &
Peacock M (1992) Calcium supplementation and increases in bone mineral
density in children. N Engl J Med 327, 82-87.

Kalkwarf HJ, Khoury J C & 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.

Khosla S, Melton LJ, 3rd, Dekutoski MB, Achenbach SJ, Oberg AL & Riggs BL
(2003) Incidence of childhood distal forearm fractures over 30 years: a
population-based study. Jama 290, 1479-1485.

Kim S & Douthitt R (2003) Mothers' Health Awareness and Its Impact on Children's
Dairy Product Intakes. Family and Consumer Sciences Research Journal 31,
273-295.

Kondracki NL, Welhnan NS & Amundson DR (2002) Content analysis: review of

methods and their applications in nutrition education. J Nutr Educ Behav 34,
224-230.

167

 

 

Krebs-Smith SM, Heimendinger J, Patterson BH, Subar AF, Kessler R & Pivonka E
(1995) Psychosocial factors associated with fruit and vegetable consumption.
Am J Health Promot 10, 98-104.

Lappe JM, Rafferty KA, Davies KM & Lypaczewski G (2004) Girls on a high-
calcium diet gain weight at the same rate as girls on a normal diet: a pilot
study. J Am Diet Assoc 104, 1361-1367.

Lee S & Reicks M (2003) Environmental and behavioral factors are associated with
the calcium intake of low-income adolescent girls. J Am Diet Assoc 103,
1 526-1 529.

Lee Y, Mitchell D, Smiciklas-Wright H & Birch L (2002) Maternal Influences on 5- is: .
to7-Year-Old Girls' Intakeof Multivitamin-Mineral Supplements. Pediatrics -
109, 1-7. ;

Leveille GA (1994) Food fortification: opportunities and pitfalls. Food Tech 48, 58-
63.

 

Lin B, Guthrie J & Blaylock J (1996) The diets of America's children: Influence of
dining out, household characteristics, and nutrition knowledge [ER Service,
editor. Washington, DC: USDA.

flu.
J

Lin B-H GJ, Frazao E (1999) Away-from-home foods increasingly important to
quality of American diet. Washington, DC, US. Dept of Agriculture,
Economic Research Service. Agriculture Information Bulletin.

Luckey MM, Meier DE, Mandeli JP, DaCosta MC, Hubbard ML & Goldsmith SJ
(1989) Radial and vertebral bone density in white and black women: evidence
for racial differences in premenopausal bone homeostasis. J Clin Endocrinol

Metab 69, 762-770.

 

Lupton JR (1997) Dairy products and colon cancer: mechanisms of the protective
effect. Am J Clin Nutr 66, 1065-1066.

Lysen VC & Walker R (1997) Osteoporosis risk factors in eighth grade students. J
Sch Health 67, 317-321.

Lytle LA, Seifert S, Greenstein J & McGovern P (2000) How do children's eating
patterns and food choices change over time? Results from a cohort study. Am
J Health Promot 14, 222-228.

Matkovic V (1996) Nutrition, genetics and skeletal development. J Am Coll Nutr 15,
556-569.

168

 

Matkovic V, Goel PK, Badenhop-Stevens NE, Landoll JD, Li B, Ilich JZ, Skugor M,
Nagode LA, Mobley SL, Ha EJ, Hangartner TN & Clainnont A (2005)
Calcium supplementation and bone mineral density in females from childhood
to young adulthood: a randomized controlled trial. Am J Clin Nutr 81, 175-

1 88.

Matkovic V & Heaney RP (1992) Calcium balance during human growth: evidence
for threshold behavior. Am J Clin Nutr 55, 992-996.

Millen AE, Dodd KW & Subar AF (2004) Use of vitamin, mineral, nonvitarnin, and
nonmineral supplements in the United States: The 1987, 1992, and 2000
National Health Interview Survey results. J Am Diet Assoc 104, 942-950.

Miller CK, Russell T & Kissling G (2003) Decision-making patterns for dietary
supplement purchases among women aged 25 to 45 years. J Am Diet Assoc
103, 1523-1526.

Miller GD & Anderson JJ (1999) The role of calcium in prevention of chronic
diseases. J Am Coll Nutr 18, 371S-372S.

Miller GD, DiRienzo DD, Reusser ME & McCarron DA (2000) Benefits of dairy
product consumption on blood pressure in humans: a summary of the
biomedical literature. J Am Coll Nutr 19, 1478-1648.

Miller GD, Jarvis JK & McBean LD (2001) The importance of meeting calcium
needs with foods. J Am Coll Nutr 20, 168S-l 858.

Neumark-Sztainer D, Harman PJ, Story M, Croll J & Perry C (2003) Family meal
patterns: associations with sociodemographic characteristics and improved
dietary intake among adolescents. J Am Diet Assoc 103, 317-322.

Neumark-Sztainer D, Storey M, Dixon, L.B., , Resnick MD & Blum RW (1997)
Correlates of inadequate consumption of dairy products among adolescnts. J
Nutr Educ 29, 12-20.

Neumark-Sztainer D, Storey M, Perry C & Casey MA (1999) Factors influencing
food choices of adolescents: findings from focus-group discussions with
adolescents. J Am Diet Assoc 99, 929-937.

Neumark-Sztainer D, Story M, Ackard D, Moe J & Perry C (2000) Family Meals
Among Adolescents: Findings from a Pilot Study. Journal of Nutrition
Education 32, 335-340.

Nicklas TA (2003) Calcium intake trends and health consequences from childhood
through adulthood. J Am Coll Nutr 22, 340-356.

169

 

 

Nicklas TA, Baranowski T, Baranowski J C, Cullen K, Rittenberry L & Olvera N
(2001) Family and child-care provider influences on preschool children's fruit,
juice, and vegetable consumption. Nutr Rev 59, 224-235.

Nicklas TA, Myers L & Berenson GS (1995) Total nutrient intake and ready-to-eat
cereal consumption of children and young adults in the Bogalusa Heart Study.
Nutr Rev 53, $39-45.

NOF (Accessed 2004) NOF. In National Osteoporosis Foundation.

Novotny R, Boushey C, Bock MA, Peck L, Auld G, Bruhn CM, Gustafson D, Gabel
K, Jensen J K, Misner S & Read M (2003) Calcium intake of Asian, Hispanic
and white youth. J Am Coll Nutr 22, 64-70.

Novotny R, Han J S & Biemacke I (1999) Motivators and barriers to consuming
calcium-rich foods among Asian adolescents in Hawaii. J Nutr Educ 31, 99-
104.

Novotny R HJ-S, Biemacke I (1999) Motivators and barriers to consuming calcium-
rich foods among Asian adolescents in Hawaii. J Nutr Educ 31, 99-104.

Oshiro CE, Novotny R & Titchenal CA (2003) Calcium intake of Asian and
Caucasian adolescents in Hawaii. Hawaii Medical Journal 62, 272-276.

Popkin BM, Siega-Riz AM & Haines PS (1996a) A comparison of dietary trends
among racial and socioeconomic groups in the United States. N Engl J Med
335, 716-720.

Popkin BM, Siega-Riz AM & Haines PS (1996b) The nutritional impact of food
fortification in the United States during the 19705. Fam. Econ. Nutr. Review 9,
20-30.

Radimer K, Bindewald B, Hughes J, Ervin B, Swanson C & Picciano MF (2004)
Dietary supplement use by US adults: data fiom the National Health and
Nutrition Examination Survey, 1999-2000. Am J Epidemiol 160, 339-349.

Raj eshwari R, Nicklas TA, Yang SJ & Berenson GS (2004) Longitudinal changes in
intake and food sources of calcium fiorn childhood to young adulthood: the
bogalusa heart study. J Am Coll Nutr 23, 341-350.

Rajeshwari R, Yang SJ, Nicklas TA & Berenson GS (2005) Secular trends in
children's sweetened-beverage consumption (1973 to 1994): the Bogalusa
Heart Study. J Am Diet Assoc 105, 208-214.

Roberts BP, Blinkhorn AS & Duxbury JT (2003) The power of children over adults
when obtaining sweet snacks. Int J Paediatr Dent 13, 76-84.

170

Schoemer-Interviewer SL (2003) Interviewer, pp. Personal communication. Lansing.

Seidman I (1998) Interviewing as Qualitative Research: A Guide for Researchers in
Education and the Social Sciences. New York: Teachers College Press.

Shepherd SK & Achterber CL (1992) Qualitative research methodology: data
collection, analysis, interpretation, and verification. In Research: Successful
Approaches [ER Monsen, editor]. Chicago: American Dietetic Association.

Siega-Riz AM, Popkin BM & Carson T (2000) Differences in food patterns at
breakfast by sociodemographic characteristics among a nationally
representative sample of adults in the United States. Prev Med 30, 415-424.

Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, Berger
ML, Santora AC & Sherwood LM (2001) Identification and fi'acture outcomes

of undiagnosed low bone mineral density in postmenopausal women: results
from the National Osteoporosis Risk Assessment. Jama 286, 2815-2822.

Slemenda CW, Peacock M, Hui S, Zhou L & Johnston CC (1997) Reduced rates of
skeletal remodeling are associated with increased bone mineral density during
the development of peak skeletal mass. J Bone Miner Res 12, 676-682.

Slesinski MJ, Subar AF & Kahle LL (1996) Dietary intake of fat, fiber and other
nutrients is related to the use of vitamin and mineral supplements in the
United States: the 1992 National Health Interview Survey. J Nutr 126, 3001-
3008.

Sloan A (2000) Fortification fi'enzy: the new wellness mindset. Food T echnol 54, 20.

Smart EJ, Gilchrist NL, Turner JG, Maguire P, March R, Hooke EA & Frampton CM
(1999) Teenage girls dietary intake, attitude toward dairy products, and bone
mineral density one year after ccessation of a dairy product food supplement
study. Diet Health Dialogue 29.

SPSS (2003) Statistical Package for the Social Sciences, Version 13.0. Chicago.

Stang J, Story MT, Hamack L & Neumark-Sztainer D (2000) Relationships between
vitamin and mineral supplement use, dietary intake, and dietary adequacy
among adolescents. J Am Diet Assoc 100, 905-910.

Subar AF & Block G (1990) Use of vitamin and mineral supplements: demographics
and amounts of nutrients consumed. The 1987 Health Interview Survey. Am J

Epidemiol 132, 1091-1101.

Subar AF & Bowering J (1988) The contribution of enrichment and fortification to
nutrient intake of women. J Am Diet Assoc 88, 1237-1242, 1245.

171

Teegarden D, Lyle RM, Proulx WR, Johnston CC & Weaver CM (1999) Previous
milk consumption is associated with greater bone density in young women.
Am J Clin Nutr 69, 1014-1017.

USDA (1998) USDA Nutrient Database for Standard Reference, Relase 12 [ARS US
Department of Agriculture, editor: Nutrient Data Laboratory.

USDA (2000) Continuing Survey of Food Intakes by Individuals (CSFII), 1994,96,
1998. USDA. Agricultural Research Service Food Surveys Research Group.

Variyam JN, Blaylock J & Smallwood JM (1996) Modelling nutrition knowledge,
attitudes, and diet-health awareness: the case of dietary fibre. Stat. Med. 15,
23-25.

Variyam JN, Shim Y & Blaylock J (2001) Consruner misperceptions of diet quality. J
Nutr Educ 33, 314-321.

Videon TM & Manning CK (2003) Influences on adolescent eating patterns: the
importance of family meals. J Adolesc Health 32, 365-373.

Wallace K, Baron J A, Cole BF, Sandler RS, Karagas MR, Beach MA, Haile RW,
Burke CA, Pearson LH, Mandel J S, Rothstein R & Snover DC (2004) Effect

of calcium supplementation on the risk of large bowel polyps. J Natl Cancer
Inst 96, 921-925.

Wardle J, Parmenter K & Waller J (2000) Nutrition knowledge and food intake.
Appetite 34, 269-275.

Weaver CM, Peacock M & Johnston CC, Jr. (1999a) Adolescent nutrition in the
prevention of postmenopausal osteoporosis. J Clin Endocrinol Metab 84,
1 839- l 843.

Weaver CM, Peacock M, Martin BR, Plawecki KL & McCabe GP (1996) Calcium
retention estimated from indicators of skeletal status in adolescent girls and
young women. Am J Clin Nutr 64, 67-70.

Weaver CM, Proulx WR & Heaney R (1999b) Choices for achieving adequate dietary
calcium with a vegetarian diet. Am J Clin Nutr 70, 543-548.

Weber Cullen K, Baranowski T, Rittenberry L, Cosart C, Owens E, Hebert D & de
Moor C (2000) Socioenvironmental influences on children's fruit, juice and
vegetable consumption as reported by parents: reliability and validity of
measures. Public Health Nutr 3, 345-356.

172

Werler MM, Shapiro S & Mitchell AA (1993) Periconceptional folic acid exposure
and risk of occurrent neural tube defects. Jama 269, 1257-1261.

Whiting SJ & Wood RJ (1997) Adverse effects of high-calcium diets in humans. Nutr
Rev 55, 1-9.

Wosje KS & Specker BL (2000) Role of calcium in bone health during childhood.
Nutr Rev 58, 253-268.

Yu SM, Kogan MD & Gergen P (1997) Vitarnin-mineral supplement use among
preschool children in the United States. Pediatrics 100,
http://www.pediatrics.org/_cgi/content/full/l/100/105/e104.

 

Zemel MB (2003) Role of dietary calcium and dairy products in modulating
adiposity. Lipids 38, 139-146.

Zemel MB (2004) Role of calcium and dairy products in energy partitioning and
weight management. Am J Clin Nutr 79, 907S-912S.

Zive MM, Nicklas TA, Busch EC, Myers L & Berenson GS (1996) Marginal vitamin

and mineral intakes of young adults: the Bogalusa Heart Study. J Adolesc
Health 19, 39-47.

173

 

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