Multinational Nutrition Challenges in Toddlerhood
Nutrition needs change throughout the lifespan, and the toddler years represent a time of great transition. Infants used to liquids and soft foods gradually take in more and “normal” foods, and by the time they reach the preschool years they have a diet that closely resembles that of their parents, albeit with more snacks. Toddlers have a high nutrient and energy demand: they need to support a fast growth rate, and their increasing levels of activity. As the first year of toddlerhood falls within the first thousand-day window of opportunity, it is very important that toddlers receive adequate nutrition to support their current and future health. We need to monitor the nutrient intakes and status of toddlers individually and in populations to make sure that they are meeting their nutrient needs. This applies both to developing countries, and ones with higher levels of economic and social development.
Hilger and co-workers recently investigated nutrient intakes in four countries representing different geographical regions and phases of economic development: Russia, Germany, Brazil and the United States of America. They conducted a systematic literature review to identify studies from these four countries that looked at toddler nutrient intakes. The studies should include reported intakes of at least one of the following nutrients: vitamin A, vitamin D, vitamin E, folate, calcium, iron or zinc. The studies should have been published since 2000.
The authors uncovered information from only 5 surveys, two from the US and one each from Germany, Russia and Brazil. Only one study was nationally representative: the others used a non-representative sample. In addition, not all studies provided data that allowed the prevalence of inadequate intakes to be estimated. Even so, the data showed:
· 20-30% of toddlers had intakes below the Estimated Average Requirement (EAR)* for vitamin A in Germany, Russia and the USA.
· Around half of toddlers had intakes below the EAR for vitamin E in Germany and the USA.
· Vitamin D intakes were only reported in the USA, where half to three quarters of toddlers had intakes under the EAR.
· Folate intakes were low in Germany (more than half of toddlers did not meet the EAR) but more-or-less adequate in Brazil and the USA. Germany does not have a folic acid fortification program in place, however Brazil and the USA do.
· Calcium intake inadequacy appears to increase between the ages of 1 and 2 years in Brazil and the USA. Around one quarter of Brazilian toddlers, and one third of American, German and Brazilian toddlers do not meet the EAR.
· Only in Brazil do less than 10% of toddlers not meet the EAR for iron. In the USA, Germany and Russia, 10% to 20% of toddlers have an inadequate intake.
· The same pattern exists for zinc as for iron, however there was no data on Russian toddlers’ zinc intakes.
Taken together, it seems that many toddlers do not meet minimum nutrient intake requirements regardless of whether they live in a developing or high-income country. The paucity of data in this age group is astounding: despite looking for articles published in the past 15 years on the nutrient intakes of some of the most populous countries in the world, only 7 publications representing 5 nutrition studies were found. This review also only covered 7 of the 20+ vitamins and minerals considered most important for health. Toddler nutrition can be a challenge, however we need more data describing nutrient status and the reasons for inadequate intakes if we want to improve the situation.
*The Estimated Average Requirement (EAR) is the intake that should meet the needs of 50% of the population
Jennifer Hilger, Tatiana Goerig, Peter Weber, Birgit Hoeft, Manfred Eggersdorfer, Nina Costa Carvalho, Ursula Goldberger and Kristina Hoffmann. Micronutrient Intake in Healthy Toddlers: A Multinational Perspective. Nutrients 2015, 7(8), 6938-6955; doi:10.3390/nu7085316
Citations from the surveys:
Germany – VELS. Kersting and Heseker. Ernährungsphysiologische Auswertung einer repräsentativen Verzehrsstudie bei Säuglingen und Kleinkindern VELS mit dem Instrumentarium der DONALD Studie http://download.ble.de/02HS007.pdf
Brazil – de Castro MA, Verly E Jr, Fisberg M, Fisberg RM. Children's nutrient intake variability is affected by age and body weight status according to results from a Brazilian multicenter study. Nutr Res. 2014 Jan;34(1):74-84. doi: 10.1016/j.nutres.2013.09.006. Epub 2013 Sep 28.
USA – FITS. Butte NF, Fox MK, Briefel RR, Siega-Riz AM, Dwyer JT, Deming DM, Reidy KC. Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed dietary reference intakes. J Am Diet Assoc. 2010 Dec;110(12 Suppl):S27-37. doi: 10.1016/j.jada.2010.09.004
USA – NHANES. Moshfegh, A.; Goldman, J.; Ahuja, J.; Rhodes, D.; LaComb, R. What We Eat in America, NHANES 2005–2006: Usual Nutrient Intakes from Food and Water Compared to 1997 Dietary Reference Intakes for Vitamin D, Calcium, Phosphorus, and Magnesium; U.S. Department of Agriculture, Agricultural Research Service, 2009. Available online: http://www.ars.usda.gov/SP2UserFiles/Place/80400530/pdf/0506/usual_nutrient_intake_vitD_ca_phos_mg_2005-06.pdf
Berry RJ, Bailey L, Mulinare J, Bower C; Folic Acid Working Group. Fortification of flour with folic acid. Food Nutr Bull. 2010 Mar;31(1 Suppl):S22-35. http://www.ncbi.nlm.nih.gov/pubmed/20629350
Herrmann W, Obeid R. The mandatory fortification of staple foods with folic acid: a current controversy in Germany. Dtsch Arztebl Int. 2011 Apr;108(15):249-54. doi: 10.3238/arztebl.2011.0249. Epub 2011 Apr 15. http://www.ncbi.nlm.nih.gov/pubmed/21556262
Orioli IM, Lima do Nascimento R, López-Camelo JS, Castilla EE. Effects of folic acid fortification on spina bifida prevalence in Brazil. Birth Defects Res A Clin Mol Teratol. 2011 Sep;91(9):831-5. doi: 10.1002/bdra.20830. Epub 2011 May 31. http://www.ncbi.nlm.nih.gov/pubmed/21630426