ARTICLE IN PRESS

Disability and Health Journal

-

(2014)

-

www.disabilityandhealthjnl.com

Research Paper

Nutrient intake and use of dietary supplements among US adults with disabilities Ruopeng An, Ph.D.*, Chung-Yi Chiu, Ph.D., and Flavia Andrade, Ph.D. Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, 1206 S 4th Street, Champaign, IL 61820, USA

Abstract Background: Physical, mental, social, and financial hurdles in adults with disabilities may limit their access to adequate nutrition. Objective: To examine the impact of dietary supplement use on daily total nutrient intake levels among US adults 20 years and older with disabilities. Methods: Study sample came from 2007e2008 and 2009e2010 waves of the National Health and Nutrition Examination Survey, a nationally representative repeated cross-sectional survey. Disability was classified into 5 categories using standardized indices. Nutrient intakes from foods and dietary supplements were calculated from 2 nonconsecutive 24-hour dietary recalls. Two-sample proportion tests and multiple logistic regressions were used to examine the adherence rates to the recommended daily nutrient intake levels between dietary supplement users and nonusers in each disability category. The association between sociodemographic characteristics and dietary supplement use was assessed using multiple logistic regressions, accounting for complex survey design. Results: A substantial proportion of the US adult population with disabilities failed to meet dietary guidelines, with insufficient intakes of multiple nutrients. Over half of the US adults with disabilities used dietary supplements. Dietary supplement use was associated with higher adherence rates for vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, calcium, copper, iron, magnesium, and zinc intake among adults with disabilities. Women, non-Hispanic Whites, older age, higher education, and higher household income were found to predict dietary supplement use. Conclusions: Proper use of dietary supplements under the guidance of health care providers may improve the nutritional status among adults with disabilities. Ó 2014 Elsevier Inc. All rights reserved. Keywords: Dietary supplement; Nutrient intake; Disability; Functional limitation; Dietary recall

Adequate nutrition is the key to maintaining body function, preventing diseases, and aging healthily across human’s life span. Among individuals with disabilities, various physical, mental, social, and financial hurdles potentially limit their access to adequate nutrition.1e4 Specific barriers include difficulties in chewing or swallowing,5 loss of appetite caused by pain or medication,6 intellectual disability or mobility impairments that restrain grocery shopping and food preparation,7 limited family and social support,8,9 and financial strain.10,11 Insufficient nutrient intake could contribute to the progression of functional disabilities, particularly among older adults, and further deteriorate their health condition.12 Modifying dietary practices could be an

Conflicts of interest statement: The authors have no funding or conflicts of interest information to disclose. * Corresponding author. E-mail address: [email protected] or [email protected] (R. An). 1936-6574/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.09.001

important intervention strategy to improve the health status and quality of life for individuals with disabilities. Regulated by the Dietary Supplement Health and Education Act of 1994,13 dietary supplements are commercial products that contain one or more dietary ingredients (e.g., vitamins and minerals) and are intended to supplement the usual diet by providing nutrients that may otherwise not be consumed in adequate quantities.14 As noted in the Dietary Guidelines for Americans 2010, ‘‘A basic premise of the Dietary Guidelines is that nutrient needs should be met primarily through consuming foods. In certain cases, fortified foods and dietary supplements may be useful in providing one or more nutrients that otherwise might be consumed in less than recommended amounts.’’15 Given the multiple barriers to accessing healthier foods, proper intake of dietary supplements could help improve the overall nutritional status and alleviate the adverse effects of nutrient deficiencies among individuals with disabilities.16e18 Despite a few studies that explored the dietary patterns and nutrient intake among individuals with

ARTICLE IN PRESS 2

R. An et al. / Disability and Health Journal 12,19e22

disabilities, to our knowledge, no research has been conducted to investigate the role of dietary supplement use in nutritional status for adults with disabilities at the national level. This study examines the impact of dietary supplement use on daily total nutrient intake levels among US adults aged 20 years and older with disabilities using data from a nationally representative repeated cross-sectional survey.

-

(2014)

-

NHANES respondents’ body weight and height were measured by digital scale and stadiometer in the MEC. Body mass index (BMI) is defined by weight in kilograms divided by height in meters squared. Sociodemographic characteristics including sex, age, race/ethnicity, marital status, education, and household income were collected through in-person interview. Disability status

Methods Participants Individual-level data came from the National Health and Nutrition Examination Survey (NHANES) 2007e2008 and 2009e2010 waves. NHANES is a program of studies designed to assess the health and nutritional status of children and adults and represents a multistage probability sample of the US civilian, noninstitutionalized population. The NHANES program began in the early 1960s and periodically conducted separate surveys focusing on different population groups or health topics. Since 1999, NHANES has been conducted continuously in 2-year cycles and has a changing focus on a variety of health and nutrition measurements. Except for NHANES 1999e2000 wave where all respondents were asked to complete a single 24-hour dietary recall interviews, all subsequent waves incorporated 2 dietary recalls, with the first collected in-person and the second by telephone 3e10 days later. In both interviews, each food item and corresponding quantity consumed by a respondent from midnight to midnight on the day before the interview was recorded. The in-person dietary recall was conducted by trained dietary interviewers in the Mobile Examination Center (MEC) with a standard set of measuring guides. These tools aimed to help the respondent accurately report the volume and dimensions of the food items consumed. Upon completion of the in-person interview, participants were provided measuring cups, spoons, a ruler, and a food model booklet, which contained 2-dimensional drawings of the various measuring guides available in the MEC, to use for reporting dietary intake during the telephone interview. From 1999 to 2006, the dietary interviews only asked about food and beverages consumed, and estimating total nutrient intakes from all sources (foods, beverages, and dietary supplements) had been difficult because of the different data collection methods, referent time frames, and data formats. Beginning in 2007, as part of the dietary interviews, data have been collected on the usage of all vitamins, minerals, herbals, and other dietary supplements. With these data collected using similar methods over the same time frame, nutrients from all sources can be readily combined, which helps researchers improve total nutrient intake estimations and increases their ability to estimate percentages of the population adhering to nutrient intake standards.

In NHANES 2007e2008 and 2009e2010 waves, 19 validated questions were administered to assess 5 categories of disability: activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure and social activities (LSAs), lower extremity mobility (LEM), and general physical activities (GPAs). Each question item evaluated the difficulty an individual had in performing a task without the aid of any equipment, and participants were required to choose from among 4 difficulty levels: ‘‘no difficulty,’’ ‘‘some difficulty,’’ ‘‘much difficulty,’’ and ‘‘unable to do.’’ ADLs consist of 4 activities: dressing oneself; walking between rooms on the same floor; getting in and out of bed; and using a fork, knife and drinking from a cup. IADLs consist of 3 activities: managing money; doing household chores; and preparing meals. LSAs consist of 3 activities: going out to movies and events; attending social events; and performing leisure activities at home. LEM consists of 2 activities: walking a quarter mile and walking up 10 steps. GPAs consist of 7 activities: stooping, crouching and kneeling; lifting and carrying; standing up from an armless chair; standing for long periods; sitting for long periods; reaching up over head; and grasping/holding small objects. Disability is defined as having any difficulty (‘‘some difficulty,’’ ‘‘much difficulty,’’ or ‘‘unable to do’’) in performing at least one of the activities within a given category. A survey participant may qualify for multiple disability categories. Among the 12,153 adults aged 20 years and older that participated in NHANES 2007e2008 and 2009e2010 waves, 4216 who qualified for one or more disability categories and were not pregnant, lactating, or on a special diet to lose weight at the time of interview were included in the analyses. Nutrient intake Daily total intake of fiber, vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, vitamin K, calcium, copper, iron, magnesium, phosphorus, potassium, selenium, and zinc were determined by averaging data from the in-person and telephone interviews, and were separated by daily nutrient intakes from foods only and intakes from both foods and dietary supplements. A dietary supplement user is defined as someone that had positive (great than zero) intake of any nutrient under study from dietary supplements. As shown in Appendix 1, dichotomous

ARTICLE IN PRESS R. An et al. / Disability and Health Journal

(2014)

-

3

Statistical analyses

variables were constructed to denote intake of a nutrient within the recommended level specified by the Institute of Medicine (2011).23

Individual sociodemographic characteristics (sex, age, race/ethnicity, BMI, education level, marital status, household income, and survey wave) of US adults aged 20 years and older by disability status (no disability versus any disability) and disability category (ADLs, IADLs, LSAs, LEM, and GPAs) are reported in descriptive statistics. Two-sample proportion tests were performed to compare the unadjusted adherence rates to the recommended daily nutrient intake levels between dietary supplement users and nonusers in each disability category. For each disability category, multiple logistic regressions were used to estimate the adherence rates to the recommended nutrient intake levels, adjusted for individual sociodemographic characteristics. The association between sociodemographic characteristics and dietary supplement use was assessed using multiple logistic regressions. NHANES 2007e2010 multiyear complex sampling design is accounted for in both descriptive statistics and multivariate analyses. All statistical analyses were conducted using Stata 13.1 SE version (StataCorp, College Station, TX).

Sociodemographic characteristics The following sociodemographic characteristics were controlled in multivariate analyses: a dichotomous variable for female (male in the reference group), a continuous variable for age in years, 3 dichotomous variables for race/ethnicity (Non-Hispanic African American, Non-Hispanic other race or multi-race, and Hispanic, with Non-Hispanic White in the reference group), a continuous variable for BMI, a dichotomous variable for college education (high school or lower education in the reference group), 2 dichotomous variables for marital status (divorced or separated or widowed, and never married, with married in the reference group), 3 dichotomous variables for annual household income ($20,001e$45,000, $45,001e$75,000, and over $75,000, with $20,000 or less in the reference group), and a dichotomous variable for NHANES 2009e2010 wave (2007e2008 wave in the reference group).

Table 1 Sociodemographic characteristics of US adults with disabilities: NHANES 2007e2010 Sociodemographics No disability Any disability ADLs Sex Male (%) Female (%) Age in years Race/ethnicity Non-Hispanic White (%) Non-Hispanic African American (%) Non-Hispanic other race/multi-race (%) Hispanic (%) Education High school or lower (%) College (%) Marital status Married (%) Divorced/separated/widowed (%) Never married (%) Annual household income $0e$20,000 (%) $20,001e$45,000 (%) $45,001e$75,000 (%) $75,001 or higher (%) Body mass index Survey wave 2007e2008 wave (%) 2009e2010 wave (%) Sample size Proportion in population with disability (%)

-

IADLs

LSAs

LEM

GPAs

50.72 6 0.59 49.28 6 0.59 42.10 6 0.33

44.12 6 0.66 55.88 6 0.66 60.04 6 0.40

42.47 6 1.36 57.53 6 1.36 58.78 6 0.74

41.23 6 1.11 58.77 6 1.11 58.80 6 0.51

38.96 6 1.19 61.04 6 1.19 57.83 6 0.71

41.33 6 1.22 58.67 6 1.22 59.98 6 0.69

42.87 6 0.82 57.13 6 0.82 60.74 6 38.14

67.94 6 2.46 11.12 6 1.04

75.08 6 2.53 11.11 6 1.35

67.97 6 3.27 14.68 6 1.64

70.42 6 3.05 12.63 6 1.53

69.65 6 3.41 13.43 6 1.71

72.93 6 3.11 13.46 6 1.73

75.36 6 2.57 11.44 6 1.39

14.05 6 1.75

4.66 6 0.77

5.36 6 1.10

6.19 6 1.12

5.75 6 1.57

4.86 6 0.99

4.15 6 0.71

6.88 6 0.85

9.16 6 1.76

11.99 6 2.60

10.77 6 2.33

11.16 6 2.30

8.76 6 2.05

9.04 6 1.77

39.01 6 1.38 60.99 6 1.38

56.34 6 1.87 43.66 6 1.87

63.91 6 2.25 36.09 6 2.25

61.03 6 2.22 38.97 6 2.22

63.13 6 2.13 36.87 6 2.13

61.72 6 2.64 38.28 6 2.64

56.45 6 2.00 43.55 6 2.00

65.26 6 1.06 14.11 6 0.44 20.61 6 1.12

58.13 6 1.35 31.17 6 1.13 10.70 6 0.66

53.36 6 1.63 36.70 6 1.84 9.94 6 0.98

53.84 6 1.63 33.20 6 1.41 12.96 6 1.14

51.43 6 1.67 35.50 6 1.59 13.07 6 0.82

58.84 6 1.46 31.03 6 1.47 10.13 6 1.05

58.15 6 1.46 32.51 6 1.28 9.34 6 0.61

11.50 24.62 23.83 40.05 28.05

6 6 6 6 6

0.61 0.99 0.99 1.39 0.12

49.53 6 2.08 50.47 6 2.08 8193

27.34 34.49 19.10 19.07 30.14

6 6 6 6 6

1.67 1.23 1.13 1.28 0.14

50.00 6 2.60 50.00 6 2.60 4216 27.58 6 0.93

35.46 34.20 16.85 13.50 31.30

6 6 6 6 6

2.15 1.65 1.61 1.49 0.31

50.95 6 2.54 49.05 6 2.54 1646 9.92 6 0.45

32.84 34.88 17.38 14.89 30.49

6 6 6 6 6

1.93 1.41 1.49 1.36 0.24

51.95 6 2.44 48.05 6 2.44 2266 14.03 6 0.44

36.60 34.43 14.39 14.59 30.99

6 6 6 6 6

2.31 1.68 1.59 1.89 0.27

49.67 6 2.53 50.33 6 2.53 1728 10.46 6 0.40

31.95 36.42 16.21 15.42 30.91

6 6 6 6 6

2.34 1.68 1.87 1.94 0.30

50.06 6 3.62 49.94 6 3.62 1451 9.25 6 0.54

27.69 34.66 19.47 18.18 30.39

6 6 6 6 6

1.70 1.36 1.07 1.34 15.33

49.47 6 2.77 50.53 6 2.77 3854 25.05 6 0.96

NHANES survey design is incorporated in estimating the population means 6 SE and percentages 6 SE. Self-reported measures of disability include activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure and social activities (LSAs), lower extremity mobility (LEM), and general physical activities (GPAs).

4

Table 2 Unadjusted adherence rates (%) to the recommended daily nutrient intake levels in US adults with disabilities by dietary supplement (DS) use status: NHANES 2007e2010 Any disability ADLs IADLs DS user

7.74 38.64 79.55 86.78 66.64 81.83 37.50 7.97 7.63 8.57 35.29 80.99 91.19 27.99 90.87 4.99 92.28 64.47

Sample size Proportion (%)

2183 46.23 6 1.21 LSAs

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.09 1.45 1.20 1.00 1.55 1.29 1.80 0.92 0.89 0.93 1.76 1.41 0.88 1.50 0.76 1.07 0.78 1.66

14.20 53.98 84.95 93.87 73.16 88.25 54.52 10.33 11.81 10.50 37.71 87.72 90.81 38.38 95.02 3.68 93.42 72.11

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.45** 2.08*** 1.02** 0.61*** 1.82** 0.89*** 1.33*** 0.97 1.09* 0.80 1.96 1.24*** 0.67 1.79*** 0.65*** 0.56 0.92 1.66***

Nutrient from DS included 14.59 58.03 93.12 97.31 82.65 96.04 80.78 66.31 34.83 13.33 56.17 93.16 95.42 51.93 96.02 3.85 95.88 87.81

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.43** 2.25*** 0.66*** 0.38*** 0.88*** 0.45*** 1.33*** 1.26*** 1.33*** 0.83** 1.66*** 0.97*** 0.70*** 1.75*** 0.49*** 0.59 0.68*** 1.14***

2033 53.77 6 1.21

DS nonuser 5.44 35.76 76.99 85.67 65.14 81.05 36.40 8.25 6.86 7.14 32.10 80.53 88.85 29.39 89.82 4.08 91.00 64.92

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.34 2.41 1.80 1.34 1.78 2.16 2.60 1.60 1.36 1.28 2.20 1.87 1.70 2.01 1.20 1.32 1.07 2.03

929 51.48 6 1.55 LEM

DS nonuser

Fiber Vitamin A Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K Calcium Copper

5.88 34.88 75.81 84.16 61.76 80.80 35.53 10.12 6.27 7.48 31.59 77.50

6 6 6 6 6 6 6 6 6 6 6 6

1.23 1.66 1.66 1.53 1.95 1.86 2.48 1.66 1.16 1.40 2.16 2.12

6 6 6 6 6 6 6 6 6 6 6 6

2.75* 2.44*** 2.27 1.21** 3.88 1.51 2.73** 1.45 1.76 1.40 2.51 2.40 1.41 3.78 1.59 1.12 2.09 2.38

12.61 54.53 91.21 96.68 81.08 95.05 76.46 60.32 30.23 11.21 54.06 90.02 92.99 47.06 93.74 2.73 93.85 83.74

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

2.77* 2.56*** 1.45*** 0.82*** 1.63*** 0.96*** 2.23*** 2.07*** 2.04*** 1.63 2.92*** 2.05*** 1.55 3.01*** 1.23* 1.13 1.49 1.93***

717 48.52 6 1.55

6.21 37.82 78.80 86.84 66.55 82.77 36.26 8.39 6.54 7.77 33.96 81.14 89.93 28.49 90.63 4.99 91.17 63.74

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.20 1.87 1.16 1.14 1.81 1.43 2.11 1.30 1.04 1.44 2.18 1.57 1.15 2.00 0.84 1.24 1.03 1.89

1243 49.57 6 1.43 GPAs

DS user

Nutrient from DS excluded 10.73 52.71 80.86 93.29 67.23 87.01 50.16 9.41 9.17 8.85 38.04 83.23

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

DS nonuser

2.11 2.11*** 2.39 0.98*** 3.54 1.34* 2.15*** 1.19 1.68 1.19 2.13 2.20*

Nutrient from DS included 11.28 56.31 90.35 97.02 79.54 94.40 78.80 61.21 32.74 9.68 52.09 89.61

6 6 6 6 6 6 6 6 6 6 6 6

2.09 2.51*** 1.51*** 0.66*** 1.72*** 0.95*** 2.19*** 2.06*** 2.14*** 1.28 2.42*** 1.82***

DS nonuser 6.58 33.32 78.95 86.87 63.62 84.48 33.17 5.41 6.84 7.03 32.54 80.22

6 6 6 6 6 6 6 6 6 6 6 6

1.52 2.57 2.00 1.38 2.60 1.56 2.50 0.80 1.69 1.37 2.19 2.06

6 6 6 6 6 6 6 6 6 6 6 6

11.20 52.66 81.21 92.39 68.07 85.81 52.07 10.05 10.01 6.65 37.37 84.03 89.65 34.50 93.42 2.23 91.04 68.57

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.68* 2.10*** 1.90 1.06*** 2.85 1.23 1.61 1.18 1.08* 0.69 2.78 1.79 0.91 2.31* 1.10 0.59* 1.58 2.13*

Nutrient from DS included 11.84 55.40 90.94 96.12 79.71 94.45 78.69 64.82 31.82 8.99 54.13 91.27 94.35 48.46 94.84 2.32 94.38 84.93

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.61** 1.77*** 1.00*** 0.71*** 1.66*** 0.74*** 1.68*** 1.67*** 1.61*** 0.86 2.18*** 1.45*** 1.04** 2.69*** 0.91** 0.60* 1.40* 1.69***

1023 50.43 6 1.43 DS user

Nutrient from DS excluded 11.93 54.25 82.96 92.62 71.10 85.96 49.60 8.83 9.93 8.79 37.50 85.00

Nutrient from DS excluded

1.67 3.06*** 1.61 1.47** 2.11* 1.62 2.41*** 1.74 1.18 1.15 2.76 1.60

Nutrient from DS included 12.46 57.95 91.84 96.79 81.39 94.90 77.03 63.32 32.11 11.55 54.99 90.65

6 6 6 6 6 6 6 6 6 6 6 6

1.69* 3.29*** 1.02*** 0.92*** 1.53*** 1.08*** 1.99*** 2.06*** 1.79*** 1.47* 2.41*** 1.35***

DS nonuser 7.87 39.38 79.72 86.91 66.26 81.59 38.26 7.75 7.98 8.74 35.58 81.50

6 6 6 6 6 6 6 6 6 6 6 6

1.13 1.61 1.34 1.10 1.63 1.45 1.74 0.90 0.91 0.96 1.96 1.44

Nutrient from DS excluded 14.51 53.42 84.24 93.61 72.53 87.92 54.22 10.21 11.64 10.22 36.31 87.40

6 6 6 6 6 6 6 6 6 6 6 6

1.54** 2.10*** 1.12* 0.66*** 1.94** 0.89** 1.45*** 0.97 1.05* 0.92 1.90 1.28***

Nutrient from DS included 14.89 57.65 92.77 97.22 82.23 96.05 80.53 66.06 34.39 12.65 55.35 92.83

6 6 6 6 6 6 6 6 6 6 6 6

1.52** 2.29*** 0.74*** 0.41*** 0.94*** 0.47*** 1.44*** 1.27*** 1.37*** 1.01* 1.81*** 1.02***

-

Nutrient

12.01 50.22 79.71 92.58 68.23 86.14 48.76 9.19 9.62 8.60 37.10 83.50 88.41 33.39 91.38 2.59 89.79 68.18

Nutrient from DS included

(2014)

DS user

Nutrient from DS excluded

ARTICLE IN PRESS

Fiber Vitamin A Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K Calcium Copper Iron Magnesium Phosphorus Potassium Selenium Zinc

Nutrient from DS excluded

-

DS nonuser

DS user

R. An et al. / Disability and Health Journal

Nutrient

DS user

ARTICLE IN PRESS

Self-reported measures of disability include activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure and social activities (LSAs), lower extremity mobility (LEM), and general physical activities (GPAs). NHANES survey design is incorporated in estimating the population proportion (percentage 6 SE) adherent to the recommended nutrient intake levels. Two-sample proportion tests were performed to compare the adherence rates between dietary supplement (DS) users and nonusers. *, **, and *** denote the difference in adherence rates between dietary supplement (DS) users (with nutrient intake from DS either excluded or included) and nonusers to be significant at P ! 0.05, P ! 0.01, and P ! 0.001, respectively.

1879 54.52 6 1.14 1975 45.48 6 1.14 659 51.04 6 1.88 792 48.96 6 1.88 772 50.36 6 1.65 956 49.64 6 1.65 Sample size Proportion (%)

6 6 6 6 6 6 89.37 28.44 89.32 5.00 90.87 63.19 Iron Magnesium Phosphorus Potassium Selenium Zinc

1.08 1.45 1.03 1.35 1.34 2.06

89.35 33.00 93.68 2.50 91.00 69.27

6 6 6 6 6 6

1.54 3.02 1.20* 0.83 2.02 2.78

93.95 46.64 95.05 2.62 94.11 83.66

6 6 6 6 6 6

1.46* 3.23*** 1.02*** 0.82 1.73 2.08***

90.92 23.09 90.73 2.46 93.06 61.39

6 6 6 6 6 6

1.40 2.21 1.47 0.74 1.19 2.39

89.45 34.20 94.82 2.47 91.06 69.26

6 6 6 6 6 6

1.56 1.84*** 1.00* 0.71 1.55 1.91**

93.87 46.79 95.38 2.69 94.58 85.41

6 6 6 6 6 6

1.16 1.95*** 0.90** 0.73 1.32 1.73***

91.61 28.15 91.15 5.12 92.19 64.70

6 6 6 6 6 6

0.99 1.56 0.78 1.09 0.86 1.78

90.50 37.90 94.76 3.63 93.06 71.73

6 6 6 6 6 6

0.73 1.89*** 0.69** 0.56 1.00 1.62**

95.09 51.37 95.89 3.81 95.67 87.57

6 6 6 6 6 6

0.77** 1.77*** 0.53*** 0.60 0.75*** 1.17***

R. An et al. / Disability and Health Journal

-

(2014)

-

5

Results Table 1 reports the sociodemographic characteristics of US adults with disabilities. During 2007e2010, over a quarter (27.6%) of American adults had one or more selfreported disability conditions (any of the 5 disability categories). GPAs were the most prevalent disability (25.1%), followed by IADLs (14.0%) and LSAs (10.5%), whereas ADLs (9.9%) and LEM (9.3%) were the least common. Compared to those without disability, individuals with disabilities were significantly more likely to be female, older, non-Hispanic White, divorced or separated or widowed, of lower education and annual household income, and of higher BMI. Table 2 reports the unadjusted adherence rates to the recommended daily nutrient intake levels in US adults with disabilities by dietary supplement use status. A substantial proportion of the American adult population with disabilities failed to meet those guidelines, with insufficient intake of multiple nutrients. During 2007e2010, adherence rates within their recommended levels (nutrient intakes from dietary supplements excluded) varied widely depending on the nutrient e fiber (14.2%), vitamin A (54.0%), vitamin B1 (85.0%), vitamin B2 (93.9%), vitamin B6 (73.2%), vitamin B12 (88.3%), vitamin C (54.5%), vitamin D (10.3%), vitamin E (11.8%), vitamin K (10.5%), calcium (37.7%), copper (87.7%), iron (90.8%), magnesium (38.4%), phosphorus (95.0%), potassium (3.7%), selenium (93.4%), and zinc (72.1%). Over half (53.8%) of individuals with disabilities took dietary supplements. Use of dietary supplements was most common among individuals with GPAs (54.5%) and least common among adults with ADLs (48.5%). Considering nutrient intake from foods only, adherence rates to the recommended daily nutrient intake levels were higher among adults who used dietary supplements than among nonusers. Use of dietary supplement substantially increased the adherence rates to the recommended daily nutrient intake levels for most (13 out of 18) nutrients under study (vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, calcium, copper, iron, magnesium, and zinc), which further widened the gap in nutrient intakes between dietary supplement users and nonusers. Table 3 reports the estimated adherence rates to the recommended daily nutrient intake levels by dietary supplement use status, adjusted by individual sociodemographic characteristics. Use of dietary supplements was found to increase the adherence rates for vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, calcium, copper, iron, magnesium, and zinc intake by 4.2%, 7.8%, 3.4%, 9.6%, 6.9%, 25.9%, 58.0%, 23.8%, 19.2%, 21.3%, 4.4%, 13.6%, and 15.8% (all P ! 0.05) among dietary supplements users with disabilities, respectively. For all nutrients under study, but potassium, the adjusted adherence rates to the recommended daily nutrient intake levels were considerably higher among dietary supplement users than among nonusers (e.g., 81.5% versus

6

Table 3 Adjusted adherence rates (%) to the recommended daily nutrient intake levels in US adults with disabilities by dietary supplement (DS) use status: NHANES 2007e2010 Any disability ADLs IADLs DS user

7.85 39.29 79.63 87.43 66.50 81.98 36.60 8.15 8.25 9.09 35.54 81.02 91.45 27.80 91.24 5.24 92.45 64.98

Sample size Proportion (%)

2183 46.23 6 1.21 LSAs

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.10 1.57 1.13 0.80 1.65 1.19 1.98 1.01 0.97 1.00 1.20 1.56 0.83 1.64 0.73 1.25 0.80 1.76

14.72 54.25 85.66 94.23 72.85 89.12 55.67 9.80 11.75 10.50 37.69 72.34 91.30 39.07 95.78 3.98 94.24 72.67

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.29*** 1.98*** 0.95*** 0.55*** 1.57*** 0.79*** 1.42*** 1.11 1.07* 0.80 1.72* 1.24*** 0.78 1.58*** 0.52*** 0.62 0.77* 1.63***

Nutrient from DS included 15.16 58.48 93.42 97.63 82.40 96.04 81.54 67.78 35.50 13.83 56.89 93.64 95.67 52.68 96.63 4.16 96.44 88.47

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.29*** 2.11*** 0.64*** 0.31*** 0.90*** 0.50*** 1.47*** 1.48*** 1.39*** 0.71** 1.77*** 0.87*** 0.67*** 1.78*** 0.41*** 0.66 0.60*** 1.07***

2033 53.77 6 1.21

DS nonuser 5.29 34.59 76.41 85.77 63.67 81.24 33.50 8.31 7.54 7.54 32.51 80.51 88.62 28.29 89.50 4.60 91.23 64.96

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.28 2.50 1.83 1.32 1.78 2.17 2.58 1.62 1.32 1.34 2.06 2.21 1.65 2.01 1.35 1.45 1.05 1.92

929 51.48 6 1.55 LEM

DS nonuser

Fiber Vitamin A Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K Calcium Copper

5.41 34.48 75.60 84.72 60.97 80.38 34.12 10.21 6.83 8.57 31.13 77.40

6 6 6 6 6 6 6 6 6 6 6 6

1.16 2.01 1.76 1.60 2.18 1.76 2.61 1.71 1.15 0.93 2.00 2.44

6 6 6 6 6 6 6 6 6 6 6 6

2.52* 2.63*** 2.26 1.13*** 3.47 1.42* 2.94*** 1.33 1.70 1.40 1.99 1.91 1.67 3.40 1.33 1.41 1.90 2.20

12.78 54.55 91.09 96.58 79.91 95.12 75.83 61.99 30.23 11.30 55.44 90.37 93.34 46.89 94.40 3.17 94.80 84.08

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

2.56** 2.76*** 1.55*** 0.94*** 1.65*** 1.20*** 2.58*** 2.69*** 2.42*** 1.56 2.83*** 1.79*** 1.56* 2.85*** 1.16** 1.44 1.39*** 1.96***

717 48.52 6 1.55

6.04 37.78 78.85 87.41 66.10 82.69 35.16 8.46 7.16 7.77 33.87 81.02 89.96 27.81 90.87 5.23 91.31 64.26

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.11 1.95 1.04 1.02 1.92 1.27 2.08 1.25 1.06 1.44 1.85 1.70 1.04 1.82 0.81 1.31 0.99 1.85

1243 49.57 6 1.43 GPAs

DS user

Nutrient from DS excluded 11.45 52.68 80.42 93.24 66.09 87.53 51.13 8.39 8.29 10.50 39.33 82.78

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

DS nonuser

2.34 2.17*** 2.40 0.99*** 3.04 1.41** 2.73*** 1.25 1.58 0.80 1.94** 2.13*

Nutrient from DS included 12.08 56.23 90.20 97.10 78.16 94.31 79.29 62.46 32.75 11.20 53.41 89.75

6 6 6 6 6 6 6 6 6 6 6 6

2.34* 2.37*** 1.59*** 0.72*** 1.85*** 1.07*** 2.33*** 2.23*** 2.15*** 1.25 2.17*** 1.72***

DS nonuser 6.83 33.03 79.25 87.55 63.84 83.92 32.42 5.77 7.39 7.29 33.03 80.67

6 6 6 6 6 6 6 6 6 6 6 6

1.57 2.52 2.08 1.19 2.68 1.64 2.56 0.80 1.57 1.19 2.27 2.21

6 6 6 6 6 6 6 6 6 6 6 6

11.15 52.52 81.85 93.38 67.63 87.02 52.64 9.07 9.31 6.65 37.96 84.22 90.04 35.40 94.78 2.34 92.61 69.60

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.46** 2.03*** 1.73* 0.90*** 2.26 1.13** 1.63*** 1.32 0.94 0.69 2.28 1.57* 1.01 1.89** 1.84** 0.68* 1.37 2.11**

Nutrient from DS included 11.89 55.80 91.28 96.72 78.80 94.33 79.04 66.86 32.16 9.70 55.73 91.98 94.67 49.64 95.97 2.45 95.48 86.08

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

1.42*** 1.75*** 0.88*** 0.63*** 1.52*** 0.81*** 1.87*** 2.02*** 1.55*** 0.83 1.98*** 1.23*** 1.01*** 2.43*** 0.79*** 0.68* 1.34** 1.60***

1023 50.43 6 1.43 DS user

Nutrient from DS excluded 11.85 55.01 83.21 92.64 70.29 87.38 52.05 8.25 9.98 8.79 37.87 85.47

Nutrient from DS excluded

1.66 3.25*** 1.74 1.59*** 2.08* 1.47 2.15*** 1.56 1.26 1.15 2.52 1.51

Nutrient from DS included 12.45 58.48 91.57 96.87 81.11 95.00 79.04 65.55 33.18 12.28 55.86 91.30

6 6 6 6 6 6 6 6 6 6 6 6

1.69 3.55*** 1.26*** 1.01*** 1.77*** 1.24*** 1.81*** 2.45*** 2.03*** 1.50** 2.55*** 1.39***

DS nonuser 8.05 39.96 79.71 87.52 66.18 81.81 37.27 7.82 8.61 9.27 35.79 81.61

6 6 6 6 6 6 6 6 6 6 6 6

1.09 1.62 1.23 0.81 1.71 1.28 1.81 0.98 1.00 1.03 1.86 1.54

Nutrient from DS excluded 15.03 53.78 84.90 94.00 72.06 88.81 55.45 9.69 11.58 10.22 36.26 87.78

6 6 6 6 6 6 6 6 6 6 6 6

1.35*** 1.97*** 1.06** 0.59*** 1.74** 0.78*** 1.58*** 1.09 1.08*** 0.92 1.55 1.06***

Nutrient from DS included 15.45 58.19 93.08 97.56 81.83 96.07 81.29 67.45 35.06 13.16 56.02 93.32

6 6 6 6 6 6 6 6 6 6 6 6

1.35*** 2.15*** 0.72*** 0.34*** 0.95*** 0.52*** 1.60*** 1.44*** 1.47*** 0.84** 1.84*** 0.93***

-

Nutrient

12.06 49.59 79.96 93.14 66.96 87.47 48.47 7.02 8.50 8.60 36.38 83.42 89.23 33.76 92.48 3.00 91.43 68.58

Nutrient from DS included

(2014)

DS user

Nutrient from DS excluded

ARTICLE IN PRESS

Fiber Vitamin A Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K Calcium Copper Iron Magnesium Phosphorus Potassium Selenium Zinc

Nutrient from DS excluded

-

DS nonuser

DS user

R. An et al. / Disability and Health Journal

Nutrient

DS user

ARTICLE IN PRESS

Self-reported measures of disability include activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure and social activities (LSAs), lower extremity mobility (LEM), and general physical activities (GPAs). Logistic regressions were performed to estimate the adjusted adherence rates (percentage 6 SE) to the recommended nutrient intake levels, controlling for sex, age, race/ethnicity, body mass index, education level, marital status, household income, and survey wave, and accounting for NHANES survey design. *, **, and *** denote the difference in adherence rates between dietary supplement (DS) users (with nutrient intake from DS either excluded or included) and nonusers to be significant at P ! 0.05, P ! 0.01, and P ! 0.001, respectively.

1879 54.52 6 1.14 1975 45.48 6 1.14 659 51.04 6 1.88 792 48.96 6 1.88 772 50.36 6 1.65 956 49.64 6 1.65 Sample size Proportion (%)

6 6 6 6 6 6 89.61 27.48 89.30 5.27 91.16 64.00 Iron Magnesium Phosphorus Potassium Selenium Zinc

1.15 1.98 1.14 1.51 1.23 1.79

89.87 34.06 94.01 2.73 91.71 70.03

6 6 6 6 6 6

1.37 2.96 1.04** 0.85 1.84 2.89

93.74 47.82 95.60 2.87 94.79 84.44

6 6 6 6 6 6

1.39* 3.24*** 0.91*** 0.87** 1.62* 2.19***

91.53 23.15 91.10 2.64 92.78 61.43

6 6 6 6 6 6

1.39 2.24 1.37 0.76 1.19 2.36

89.31 34.88 95.42 2.62 91.50 69.46

6 6 6 6 6 6

1.69 1.84*** 1.05* 0.75 1.62 1.98**

93.92 47.40 96.05 2.86 94.35 85.86

6 6 6 6 6 6

1.21*** 1.99*** 0.93** 0.77 1.45 1.57***

91.97 27.96 91.48 5.41 92.43 65.21

6 6 6 6 6 6

0.92 1.59 0.74 1.27 0.88 1.81

91.06 38.55 95.50 3.92 93.85 72.21

6 6 6 6 6 6

0.83 1.72*** 0.57*** 0.60 0.86 1.63**

95.35 52.06 96.47 4.13 96.27 88.20

6 6 6 6 6 6

0.73** 1.86*** 0.45*** 0.64 0.65*** 1.12***

R. An et al. / Disability and Health Journal

-

(2014)

-

7

36.6% for vitamin C, 67.8% versus 8.2% for vitamin D, 35.5% versus 8.3% for vitamin E, 88.5% versus 65.0% for zinc, and 56.9% versus 35.5% for calcium). Nutrient intake appeared to correlate with disability severity, as adjusted adherence rates were in general lower for ADL but higher for GPAs. Table 4 reports the estimated odds ratios of any dietary supplement use among US adults with disabilities. Being female, older, non-Hispanic White, having college education, and higher annual household income were associated with higher odds of any dietary supplement use; whereas marital status and BMI were not found to be related to dietary supplement use.

Discussion During the past few decades, use of dietary supplements has increased noticeably among American adults.24 Recent estimates indicate over half (51%) of the US population uses multivitamin/mineral supplements,25 but less is known about the impact of dietary supplement use in daily total nutrient intake among US adults with disabilities. This study addressed this gap and found that over half (53.8%) of the individuals with disabilities used dietary supplements during 2007e2010. Use of dietary supplements substantially increased the adherence rates to the recommended daily intake levels for most of the nutrients studied. Sociodemographic characteristics including sex, age, race/ ethnicity, education, and income were found to predict dietary supplement use in the population with disabilities. Individuals with disabilities are consistently documented to suffer from poor diet quality and elevated nutritional risk.19,22,26 The issue of malnutrition could be exacerbated in the absence of family and social support.1,2,8,9 Use of dietary supplements could help improve the nutritional status for people with disabilities. Despite the beneficial effect of dietary supplements in preventing nutrient deficiency, vitamin and mineral supplements are not intended to replace the usual diet. Foods contain hundreds of naturally occurring substances that are essential for health.14 A healthy eating pattern should be sufficient in providing most or all nutrient needs, and thus dietary supplements are suggested only for specific population subgroups or in specific situations.15 Substantial heterogeneity in dietary patterns and health conditions appeared present among individuals with disabilities, which prevents general recommendations on the types and quantities of dietary supplements to be consumed. Unlike drugs, diet supplement manufacturers are not required to provide evidence on the safety and effectiveness of their products, and the label claims are exempt from approval by the US Food and Drug Administration.27 Scientific evidence on the benefits of some dietary supplements has been well documented for certain diseases, such as iodine supplementation to treat iodine deficiency and

ARTICLE IN PRESS 8

R. An et al. / Disability and Health Journal

-

(2014)

-

Table 4 Adjusted odds ratios of any dietary supplement use in US adults with disabilities: NHANES 2007e2010 Sociodemographics Any disability ADLs IADLs LSAs Sex Male (reference group) Female Age in years Race/ethnicity Non-Hispanic White (reference group) Non-Hispanic African American Non-Hispanic other race/multi-race Hispanic Education High school or lower (reference group) College Marital status Married (reference group) Divorced/separated/ widowed Never married Annual household income $0e$20,000 (reference group) $20,001e$45,000 $45,001e$75,000 $75,001 or higher Body mass index Survey wave 2007e2008 wave (Reference group) 2009e2010 wave Sample size

LEM

GPAs

1.000 1.768 6 0.174*** 1.035 6 0.004***

1.000 1.823 6 0.325** 1.037 6 0.004***

1.000 1.873 6 0.275*** 1.039 6 0.005***

1.000 1.776 6 0.291** 1.038 6 0.006***

1.000 1.996 6 0.358** 1.035 6 0.006***

1.000 1.815 6 0.169*** 1.035 6 0.004***

1.000

1.000

1.000

1.000

1.000

1.000

0.498 6 0.057***

0.497 6 0.100**

0.561 6 0.092**

0.429 6 0.084***

0.487 6 0.102**

0.515 6 0.061***

0.591 6 0.184

0.709 6 0.306

0.761 6 0.225

0.810 6 0.265

0.464 6 0.185

0.535 6 0.180

0.650 6 0.061***

0.760 6 0.141

0.673 6 0.092**

0.653 6 0.102*

0.610 6 0.120*

0.632 6 0.062***

1.000

1.000

1.000

1.000

1.000

1.000

1.608 6 0.162***

1.722 6 0.249**

1.418 6 0.214*

1.646 6 0.234**

1.511 6 0.229

1.560 6 0.152***

1.000 1.044 6 0.092

1.000 1.342 6 0.212

1.000 0.975 6 0.148

1.000 0.987 6 0.153

1.000 1.009 6 0.181

1.000 1.099 6 0.102

0.932 6 0.163

1.212 6 0.309

1.018 6 0.278

1.088 6 0.267

0.793 6 0.225

0.952 6 0.175

1.000

1.000

1.000

1.000

1.000

1.000

1.204 1.760 1.651 0.997

6 6 6 6

0.146 0.203*** 0.257** 0.005

1.144 1.783 1.267 1.001

6 6 6 6

0.182 0.422* 0.334 0.009

1.247 1.817 1.671 0.996

6 6 6 6

0.170 0.297** 0.444 0.009

1.304 1.571 1.600 1.005

6 6 6 6

0.237 0.426 0.382 0.009

1.275 2.176 1.594 1.019

6 6 6 6

0.304 0.558** 0.393 0.010

1.253 1.755 1.635 0.996

6 6 6 6

0.164 0.225*** 0.229** 0.006

1.000

1.000

1.000

1.000

1.000

1.000

0.902 6 0.106

0.906 6 0.155

0.895 6 0.139

1.035 6 0.167

0.952 6 0.159

0.896 6 0.108

4216

1646

2266

1728

1451

3854

Self-reported measures of disability include activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure and social activities (LSAs), lower extremity mobility (LEM), and general physical activities (GPAs). Odds ratios 6 SE were estimated using multiple logistic regressions, accounting for NHANES survey design. *P ! 0.05; **P ! 0.01; and ***P ! 0.001.

calcium and vitamin D supplementation to manage osteoporosis28,29; whereas some need further study,30e32 and others may even pose adverse health effects.33 Mursu et al (2011) documented increased mortality among older women in relation to use of multivitamins, particularly those with supplemented iron,34 but the relationship appeared less consistent in other studies.35,36 Calcium supplements have been linked to excess mortality among men but not women.37 Despite the accumulating evidence to support the use of oral nutritional supplements in clinical practice,38 dietary supplements may have unintended side effects if taken before surgery or interacting with certain medicines.39,40 As such, consultation with health care provider (doctors, pharmacists, and dietitians) is recommended before use of dietary supplements in order to ensure safety and achieve specific nutritional goals.14 Diet supplement users should be cautious of the adverse effect from nutrient overdose. A tolerable upper intake level (UL) is the highest quantity of daily nutrient intake that is unlikely to pose any health risk to nearly the entire

population.41 Daily nutrient intake above its specific UL might do more harm than good. However, nutrient overdose seems rather rare compared to malnutrition due to the unhealthy eating patterns among people with disabilities. For instance, only 0.2% and 0.3% of US adults with disabilities exceeded ULs for copper (10,000 mcg) and Vitamin D intake (100 mcg) during 2007e2010. Among American adults with disabilities, women appeared more likely to use dietary supplements than men, which coincided with findings from previous studies on the general population in the US.24,25,42 Consumption of dietary supplements increased with age.24,25 American Adults aged 60 years and older were more likely than their younger counterparts to use dietary supplements in improving specific parts of their bodies, such as heart and bones.43 Similar to the US general population, use of dietary supplements was more common among non-Hispanic Whites with disabilities.24,25 A socioeconomic ingredient seemed present in dietary supplement use e individuals with higher socioeconomic status (e.g., education attainment, income, and

ARTICLE IN PRESS R. An et al. / Disability and Health Journal

health insurance status) were more likely to use dietary supplements.25,43 Policy interventions targeting people with disabilities through nutrition education, social support, and financial assistance are needed to improve diet quality and address disparities. A ‘‘twin track’’ framework is proposed whereby nutrition programs include mainstream disability and provide disability-specific services, while disability programs ensure specific nutrition-focused support to be delivered as needed.44 In this framework, use of dietary supplements may play an active role besides healthy eating promotion, particularly targeting those with chronic malnutrition and significant access barriers to balanced diets. Health care providers should guide and closely monitor the use of dietary supplements by people with disabilities in an effort to capitalize their beneficial effects and prevent adverse health outcomes. Several limitations of this study should be noted. Dietary intakes in NHANES were self-reported and subject to measurement error, in particular underreporting, and the discrepancy between self-reported and estimated intake was found to peak among obese respondents.45 The study design is observational and cross-sectional, so that the estimated relationship between disability status and nutrient intake should be interpreted as association rather than causation. NHANES is a probability sample of the US noninstitutionalized population, and the dietary intakes within patients in penal/mental facilities, institutionalized older adults, and/or military personnel on active duty are not represented. This study only considered a subset of dietary supplements with dietary fiber, certain vitamins or minerals as main ingredients, whereas other types of dietary supplements (e.g., herbs) were not included.

Conclusions This study compared adherence rates to recommended daily nutrient intakes between dietary supplement users and nonusers in the US adult population with disabilities. Use of dietary supplements (e.g., vitamins and minerals) was found to be associated with noticeably higher adherence rates for most nutrients studied. Considering the substantial access barriers to healthier diets, proper use of dietary supplements under the guidance of health care providers could be effective in improving the nutritional status and health condition among individuals with disabilities.

References 1. Lee JS, Frongillo EA. Factors associated with food insecurity among U.S. elderly persons: importance of functional impairments. J Gerontol B Psychol Sci Soc Sci. 2001;56(2):S94eS99. 2. Lee JS, Frongillo EA. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr. 2001;131(5):1503e1509.

-

(2014)

-

9

3. Webber CB, Sobal J, Dollahite JS. Physical disabilities and food access among limited resource households. Disabil Stud Q. Available from: http://dsq-sds.org/article/view/20/20; 2007;27(3). 4. Wylie C. Health and social factors affecting the food choice and nutritional intake of elderly people with restricted mobility. J Hum Nutr Diet. 2000;13(5):363e371. 5. Cabre M, Serra-Prat M, Palomera E, Almirall J, Pallares R, Clave P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39(1):39e45. 6. Ross MM, Crook J. Elderly recipients of home nursing services: pain, disability and functional competence. J Adv Nurs. 1998;27(6): 1117e1126. 7. Tsai AC, Hsu HY, Chang TL. The Mini Nutritional Assessment (MNA) is useful for assessing the risk of malnutrition in adults with intellectual disabilities. J Clin Nurs. 2011;20(23e24): 3295e3303. 8. Huang DL, Rosenberg DE, Simonovich SD, Belza B. Food access patterns and barriers among midlife and older adults with mobility disabilities. J Aging Res. Available from: http://dx.doi.org/10.1155/2012/ 231489; 2012;2012:8. 9. Mojtahedi MC, Boblick P, Rimmer JH, Rowland JL, Jones RA, Braunschweig CL. Environmental barriers to and availability of healthy foods for people with mobility disabilities living in urban and suburban neighborhoods. Arch Phys Med Rehabil. 2008;89(11): 2174e2179. 10. Aggarwal A, Monsivais P, Drewnowski A. Nutrient intakes linked to better health outcomes are associated with higher diet costs in the US. PLoS One. 2012;7(5):e37533. 11. Turner JB. Economic context and the health effects of unemployment. J Health Soc Behav. 1995;36(3):213e229. 12. Houston DK, Stevens J, Cai J, Haines PS. Dairy, fruit, and vegetable intakes and functional limitations and disability in a biracial cohort: the Atherosclerosis Risk in Communities Study. Am J Clin Nutr. 2005;81(2):515e522. 13. US Food and Drug Administration. Dietary Supplement Health and Education Act of 1994. Available from: http://www.fda.gov/Regu latoryInformation/Legislation/FederalFoodDrugandCosmeticActFDC Act/SignificantAmendmentstotheFDCAct/ucm148003.htm; 1994. 14. National Institutes of Health, Office of Dietary Supplements. Dietary Supplements: What You Need to Know. Available from: http://ods.od. nih.gov/HealthInformation/DS_WhatYouNeedToKnow.aspx; 2011. 15. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, DC: US Government Printing Office; 2010. 16. Allen VJ, Methven L, Gosney MA. Use of nutritional complete supplements in older adults with dementia: systematic review and metaanalysis of clinical outcomes. Clin Nutr. 2013;32(6):950e957. 17. Manders M. Nutritional Care in Old Age: The Effect of Supplementation on Nutritional Status and Performance. Available from: http:// www.fightmalnutrition.eu/fileadmin/images/nursing_homes/literatuur/ Thesis_Marleen_Manders.pdf; 2006. 18. Tulchinsky TH. Micronutrient deficiency conditions: global health issues. Public Health Rev. 2010;32(1):243e255. 19. An R, Chiu C. Dietary intake among US adults with disability. Rehab Res Policy Educ; 2014. in press. 20. Sharkey JR, Giuliani C, Haines PS, Branch LG, BusbyWhitehead J, Zohoori N. Summary measure of dietary musculoskeletal nutrient (calcium, vitamin D, magnesium, and phosphorus) intakes is associated with lower extremity physical performance in homebound elderly men and women. Am J Clin Nutr. 2003;77(4): 847e856. 21. Tomey KM, Sowers MR, Crandall C, Johnston J, Jannausch M, Yosef M. Dietary intake related to prevalent functional limitations in mid-life women. Am J Epidemiol. 2008;167(8):935e943. 22. Xu B, Houston D, Locher JL, Zizza C. The association between Healthy Eating Index-2005 scores and disability among older. Age Ageing. 2012;41(3):365e371.

ARTICLE IN PRESS 10

R. An et al. / Disability and Health Journal

23. Institute of Medicine. Dietary Reference Intakes. Available from: http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Acti vity%20Files/Nutrition/DRIs/New%20Material/5DRI%20Values%20 SummaryTables%2014.pdf; 2011. 24. Gahche J, Bailey R, Burt V, et al. Dietary Supplement Use Among US Adults Has Increased Since NHANES III (1988e1994). NCHS Data Brief. 2011;61:1e8. 25. Wallace TC, McBurney M, Fulgoni VL 3rd. Multivitamin/mineral supplement contribution to micronutrient intakes in the United States, 2007-2010. J Am Coll Nutr. 2014;33(2):94e102. 26. Bartali B, Salvini S, Turrini A, et al. Age and disability affect dietary intake. J Nutr. 2003;133(9):2868e2873. 27. US Food and Drug Administration. Dietary Supplements. Available from: http://www.fda.gov/Food/Dietarysupplements/default.htm; 2014. 28. Taylor PN, Okosieme OE, Dayan CM, Lazarus JH. Therapy of endocrine disease: impact of iodine supplementation in mild-to-moderate iodine deficiency: systematic review and meta-analysis. Eur J Endocrinol. 2013;170(1):R1eR15. 29. Sunyecz JA. The use of calcium and vitamin D in the management of osteoporosis. Ther Clin Risk Manag. 2008;4(4):827e836. 30. Marik PE, Varon J. Omega-3 dietary supplements and the risk of cardiovascular events: a systematic review. Clin Cardiol. 2009;32(7): 365e372. 31. Pittler MH, Ernst E. Dietary supplements for body-weight reduction: a systematic review. Am J Clin Nutr. 2004;79(4):529e536. 32. Yeh GY, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care. 2003;26(4):1277e1294. 33. Pittler MH, Schmidt K, Ernst E. Adverse events of herbal food supplements for body weight reduction: systematic review. Obes Rev. 2005;6(2):93e111. 34. Mursu J, Robien K, Harnack LJ, Park K, Jacobs DR. Dietary supplements and mortality rate In older women: the Iowa Women’s Health Study. Arch Intern Med. 2011;171(18):1625e1633. 35. Alexander DD, Weed DL, Chang ET, Miller PE, Mohamed MA, Elkayam L. A systematic review of multivitamin-multimineral use

Appendix 1 Recommended daily nutrient intake levels by sex and age groups Female Male Female Nutrient (units) 19e30 19e30 31e50 Fiber (g) Vitamin A (mcg) Vitamin B1 (mg) Vitamin B2 (mg) Vitamin B6 (mg) Vitamin B12 (mcg) Vitamin C (mg) Vitamin D (mcg) Vitamin E (mg) Vitamin K (mcg) Calcium (mg) Copper (mcg) Iron (mg) Magnesium (mg)a Phosphorus (mg) Potassium (mg) Selenium (mcg) Zinc (mg)

>28 500e3000 >0.9 >0.9 1.1e100 >2.0 60e2000 10e100 12e1000 >90 800e2500 700e10,000 8.1e45 >255 580e4000 >4700 45e400 6.8e40

>34 625e3000 >1.0 >1.1 1.1e100 >2.0 75e2000 10e100 12e1000 >120 800e2500 700e10,000 6e45 >330 580e4000 >4700 45e400 9.4e40

>25 500e3000 >0.9 >0.9 1.1e100 >2.0 60e2000 10e100 12e1000 >90 800e2500 700e10,000 8.1e45 >265 580e4000 >4700 45e400 6.8e40

36. 37.

38.

39.

40.

41.

42.

43.

44.

45.

-

(2014)

-

and cardiovascular disease and cancer incidence and total mortality. J Am Coll Nutr. 2013;32(5):339e354. Chang SM. Should meta-analyses trump observational studies? Am J Clin Nutr. 2013;97(2):237e238. Xiao Q, Murphy RA, Houston DK, Harris TB, Chow WH, Park Y. Dietary and supplemental calcium intake and cardiovascular disease mortality: the National Institutes of Health-AARP diet and health study. JAMA Intern Med. 2013;173(8):639e646. Stratton RJ, Elia M. A review of reviews: a new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr Suppl. 2007;2(1):5e23. Kanji S, Seely D, Yazdi F, et al. Interactions of commonly used dietary supplements with cardiovascular drugs: a systematic review. Syst Rev. 2012;1:26. Tsai HH, Lin HW, Simon Pickard A, Tsai HY, Mahady GB. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review. Int J Clin Pract. 2012;66(11):1056e1078. Institute of Medicine. Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels. Available from: http://iom.edu/Activities/Nu trition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/ ULs%20for%20Vitamins%20and%20Elements.pdf. Balluz LS, Kieszak SM, Philen RM, Mulinare J. Vitamin and mineral supplement use in the United States: results from the third National Health and Nutrition Examination Survey. Arch Fam Med. 2000; 9(3):258e262. Bailey RL, Gahche JJ, Miller PE, Thomas PR, Dwyer JT. Why US adults use dietary supplements. JAMA Intern Med. 2013;173(5): 355e361. Groce NE, Kerac M, Farkas A, Schultink W, Bieler RB. Inclusive nutrition for children and adults with disabilities. Lancet Glob Health. 2013;1(4):e180ee181. Archer E, Hand GA, Blair SN. Validity of US nutritional surveillance: National Health and Nutrition Examination Survey caloric energy intake data, 1971e2010. PLoS One. 2013;8(10): e76632.

Male 31e50

Female 51e70

Male 51e70

Female 71þ

Male 71þ

>31 625e3000 >1.0 >1.1 1.1e100 >2.0 75e2000 10e100 12e1000 >120 800e2500 700e10,000 6e45 >350 580e4000 >4700 45e400 9.4e40

>22 500e3000 >0.9 >0.9 1.3e100 >2.0 60e2000 10e100 12e1000 >90 1000e2000 700e10,000 5e45 >265 580e4000 >4700 45e400 6.8e40

>28 625e3000 >1.0 >1.1 1.4e100 >2.0 75e2000 10e100 12e1000 >120 800e2000 700e10,000 6e45 >350 580e4000 >4700 45e400 9.4e40

>22 500e3000 >0.9 >0.9 1.3e100 >2.0 60e2000 10e100 12e1000 >90 1000e2000 700e10,000 5e45 >265 580e4000 >4700 45e400 6.8e40

>28 625e3000 >1.0 >1.1 1.4e100 >2.0 75e2000 10e100 12e1000 >120 1000e2000 700e10,000 6e45 >350 580e4000 >4700 45e400 9.4e40

Source: Dietary Reference Intakes, Estimated Average Requirements, Institute of Medicine, 2011. a Daily tolerable upper intake level for magnesium from a pharmacological agent (e.g., dietary supplement) is 350 mg, which does not include magnesium intake from food and water.

Nutrient intake and use of dietary supplements among US adults with disabilities.

Physical, mental, social, and financial hurdles in adults with disabilities may limit their access to adequate nutrition...
272KB Sizes 0 Downloads 9 Views