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974 Canadian Family Physician Le Médecin de famille canadien VOL 49: AUGUST • AOÛT 2003

clinical challenge

défi clinique

VOL 49: AUGUST • AOÛT 2003 Canadian Family Physician Le Médecin de famille canadien 975

clinical challenge

défi clinique clinical challenge

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D

uring late adolescence and into their early 20s, women risk a multitude of nutritional imbalances as nutrient requirements peak while lifestyle choices can compromise dietary intake. Most focus on this age group tends to be about issues of weight: obesity, dysfunctional eating, and eating disorders. Although these are important, this emphasis does not capture the full spectrum of nutritional health concerns of today’s young women.

Dietary defi ciencies, most notably iron, calcium, and folate, are commonly related to inadequate energy intake or the omission of whole food groups.

This article highlights current knowledge about the nutritional health of young Canadian women, profi les trends in their eating patterns, and suggests how family practitioners can support these patients in achieving and maintaining

good nutrition.

Good nutrition and dietary intake

A recent survey of the food consumption pat- terns of Canadian adults (18 to 65 years) and ado- lescents (13 to 17 years) revealed that women’s nutritional habits were not good.1 While energy and fat intakes were close to current recommenda- tions, a substantial num- ber of young women were

reported to consume inadequate amounts of calcium, folate, and iron, nutrients critically important during their reproductive years.

Mean fat intake was reported to be no more than 30% of total energy as fat for both age groups. When their diets were compared with Canada’s Food Guide to Healthy Eating, however, younger women had mar- ginal or below recommended intake of all four food groups.2 High-energy, nutrient-poor foods accounted for 27% to 29% of total energy and 29% to 32% of total fat intake in the diets of both age groups.

Poor food choices combined with limited physi- cal activity3 contribute to the escalating problem of overweight. The prevalence of overweight among girls aged 7 to 13 years increased from 15% to 23.6%

between 1981 and 1996, while the prevalence of obesity more than dou- bled, from 5% to 11.8%.4 Overweight adolescents are at increased risk not only of obesity-associated chronic diseases but also of the cycle of emotional and socioeconomic prob- lems associated with obe- sity. Focusing on dietary restraint is clearly not the answer to this problem, given its link with the growing prevalence of eat- ing disorders.5

Iron deficiency is the most common nutrient

Just the Berries

Concerns about young women’s nutrition

Doris E. Gillis, MSC, MADED, PDT Patricia L. Williams, PHD, PDT

“Just the Berries” for Family Physicians originated at St Martha’s Regional Hospital in 1991 as a newsletter for members of the Department of Family Medicine. Its pur- pose was to provide useful, practical, and current informa- tion to busy family physicians. It is now distributed by the Medical Society of Nova Scotia to all family physicians in Nova Scotia. Topics discussed are suggested by family physicians and, in many cases, articles are researched and written by family physicians.

Just the Berries has been available on the Internet for sev- eral years. You can fi nd it at www.theberries.ns.ca. Visit the site and browse the Archives and the Berries of the Week.

We are always looking for articles on topics of interest to family physicians. If you are interested in contributing an article, contact us through the site. Articles should be short (350 to 1200 words), must be referenced, and must include levels of evidence and the resources searched for the data.

All articles will be peer reviewed before publication.

Professor Gillis is an Associate Professor in the Department of Human Nutrition at St Francis Xavier University in Antigonish, NS. Dr Williams is a Canadian Institutes of Health Research Postdoctoral Fellow in the Atlantic Health Promotion Research Centre at Dalhousie University and an Assistant Professor in the Department of Applied Human Nutrition at Mount St Vincent University in Halifax, NS.

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974 Canadian Family Physician Le Médecin de famille canadien VOL 49: AUGUST • AOÛT 2003

clinical challenge

défi clinique

VOL 49: AUGUST • AOÛT 2003 Canadian Family Physician Le Médecin de famille canadien 975

clinical challenge

défi clinique

deficiency among older adolescent girls and young women due to iron losses during menses and poor dietary intake. Compared with other age groups, female teens have the highest requirement for iron and the lowest intake.6 Between 29% and 84% of young Canadian women are thought not to consume the recommended amount of iron.7 The subtle but serious consequences of iron deficiency can include negative effects on work performance, inadequate body-temperature regulation, and poor intellectual performance.5,8

Although the prevalence of calcium deficiency among young Canadian women is unknown, con- cern about calcium intake has increased because of its association with bone health. Maximizing peak bone mass during the first 2 to 3 decades of life can prevent or delay onset of osteoporosis. About 60% of girls aged 13 to 17 years are reported to consume less than the recommended amount of milk and milk products, the best source of calcium.2 Vitamin D is needed along with calcium to build strong bones;

excess sodium, protein, caffeine, and phosphorus can compromise bone health. The common practice of choosing soft drinks over milk9 not only displaces the nutrients found in milk, but also impairs calcium absorption due to the high phosphorus content of soft drinks.10,11

Folate intake, yet another concern in this repro- ductively active age group, is associated with con- sumption of fruits and vegetables.12,13 In particular, young women from low socioeconomic backgrounds and disconnected from their families tend to con- sume too little fruit and too few vegetables.12

Trends in eating patterns

Lifestyle trends can influence young women’s diets.

Less structured eating, the shift in food consumption from meals to snacks, is widely accepted.14 Dwyer and colleagues reported that, as the number of eat- ing episodes increased, mean intake of energy, total carbohydrates, and sugars increased.15 Eating away from home is common; American data suggest that the iron content of away-from-home food is substan- tially lower than that of food consumed at home.8 In their study of American adolescents, Dwyer and col- leagues found that overweight students were more likely to omit breakfast, eat fewer than two meals a day, and consequently have lower energy intake than their peers.15 Results of a survey of college and university students in Vancouver, BC, revealed that only 54% of both male and female students reported always eating breakfast, despite acknowledging that eating breakfast helped them work better.16 Family

food-purchasing patterns, food costs, and storage and cooking facilities were the main influences on break- fast choices.

Increasing numbers of young women are shifting to various patterns of vegetarian eating. One in five Canadian teenage girls reported not consuming any meat or alternatives, and a further 35.5% consumed less than the recommended two servings a day.2 The more limited the intake of animal foods, the greater the likelihood of nutrient inadequacy, with protein, iron, calcium, and vitamins D and B12 being of par- ticular concern. To compensate for the less biologi- cally available iron in a plant-based diet, vegetarians need to consume twice as much iron as meat-eaters and combine nonheme sources, such as cereals, with foods rich in vitamin C. Because vitamin B12 is found only in animal foods, vegans must include foods forti- fied with vitamin B12 or take supplements. Evidence suggests that well-informed and motivated vegetar- ians can achieve healthy diets.17

What can family practitioners do?

Health care providers are viewed as valuable sources of information on diet, nutrition, and exercise.18 Practitioners must consider all factors that shape their patient’s health, such as income and social status, education, social support networks, culture, health practices, and personal coping mechanisms.

Family physicians can have an important role in encouraging young women to have good nutritional habits, habits that will be a good investment as they confront the nutrient demands of their childbearing years with a view to preventing diet-related chronic diseases in later life. Family physicians can:

• begin by considering the issues important to young women’s health and lifestyles and seek their input in making recommendations for improving their eating practices;

• promote prevention of obesity through healthy life- style practices including physical activity, healthy eating, and positive self-esteem. Avoid recommend- ing restrictive dieting, a practice that has a dismal success rate and can trigger dysfunctional eating behaviour;

• identify young women who could be especially vulnerable to low intake of calcium, iron, and folate, especially if they routinely limit the quantity or variety of food eaten;

• encourage young women to include daily at least three servings of low-fat milk and milk products as a source of calcium for bone health, at least five servings of fruit and vegetables, two to three servings of meat or alternatives, and five or more

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976 Canadian Family Physician Le Médecin de famille canadien VOL 49: AUGUST • AOÛT 2003

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servings of grain products, depending on energy requirements;

• direct vegetarians to reliable and practical informa- tion on healthy vegetarian eating. Focus special attention on incorporating iron combined with a good source of vitamin C and calcium-rich foods into the plant-based diet. Vegans should include dietary sources of vitamin B12, such as B12-fortified soy or rice beverages and fortified cereals, or vita- min B12 supplements;

• recognize that lifestyles at this age are likely to result in erratic eating patterns. Encourage young women to have nutritious food available for on- the-run meals and snacks, and to make wise food choices when eating away from home; and

• focus on healthy eating practices and recommend appropriate vitamin-mineral supplements to young women who are unable to select foods that provide a nutritionally adequate diet. Supplements, how- ever, can never replace healthy eating.

Acknowledgment

We thank Dr Kelley Cavan, an Assistant Professor in the Department of Human Nutrition at St Francis Xavier University, for reviewing the draft of this article.

References

1. Gray-Donald K, Jacobs-Starkey L, Johnson-Down L. Food habits of Canadians:

reduction in fat intake over a generation. Can J Public Health 2000;91(5):381-5.

2. Jacobs-Starkey L, Johnson-Down L, Gray-Donald K. Food habits of Canadians:

comparison of intakes of adults and adolescents to Canada’s Food Guide to Healthy Eating. Can J Diet Pract Res 2001;62(2):61-9.

3. Health Canada. Exercise and leisure activities. Trends in the health of Canadian youth. Ottawa, Ont: Health Canada; 1998. Available at: www.hc-sc.gc.ca/hpph/

childhood-youth/spsc/e_trends.html. Accessed 2003 June 3.

4. Tremblay MS, Willms JD. Secular trends in the body mass index of Canadian chil- dren. Can Med Assoc J 2000;163:1429-33.

5. Dietitians of Canada and American Dietetic Association. Women’s health and nutrition: position of Dietitians of Canada and the American Dietetic Association.

Toronto, Ont: Dietitians of Canada; 1997.

6. Lin BH, Guthrie J, Frazao E. American children’s diet not making the grade. Food Review 2001;24(2):8-17.

7. Chapman G. Food practices and concerns of teenage girls. Ottawa, Ont: National Institute of Nutrition; 1994. Available at www.nin.ca/Public_html. Accessed 2003 June 3.

8. Halterman JS, Kaczorowski JM, Aligne A, Auinger P, Szilagyi PG. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics 2001;107(60):1381-6.

9. Guenther PM. Beverages in the diets of American teenagers. J Am Diet Assoc 1986;86(4):493-9.

10. Miller EC, Maropis CG. Nutrition and diet-related problems. Adolesc Med 1998;25(1):193-210.

11. Health Canada. Healthy eating, dieting and dental hygiene. Trends in the health of Canadian youth. Ottawa, Ont: Health Canada; 1998. Available at: www.hc-sc.gc.ca/

hpph/childhood-youth/spsc/e_trends.html. Accessed 2003 June 3.

12. Neumark-Sztainer D, Story M, Resnick MD, Blum RW. Correlates of inadequate fruit and vegetable consumption among adolescents. Prev Med 1996;25:497-505.

13. McNulty H. Plenary symposium on “Nutritional issues for women”: folate requirements for health in women. Prof Nutr Soc 1997;56:291-303.

14. Zizza C, Siega-Riz AM, Popkin BM. Significant increase in young adults’ snack- ing between 1977-1978 and 1994-1996 represents a cause for concern. Prev Med 2001;32:303-10.

15. Dwyer JT, Evans M, Stone EJ, Lytle L, Hoelscher D, Johnson C, et al. Adolescents eating patterns influence their nutrient intakes. J Am Diet Assoc 2001;101(7):798-801.

16. Chapman GE, Melton CL, Hammond GK. College and university students’

breakfast consumption patterns: behaviours, beliefs, motivations and personal and environmental influences. Can J Diet Pract Res 1998;59(4):176-82.

17. Jannelle AC, Barr SI. Nutrient intakes and eating behavior scores of vegetarian and non-vegetarian women. J Am Diet Assoc 1995;95(2):180-9.

18. Borzekowski DL, Rickert VI. Adolescent cybersurfing for health information: a new resource that crosses barriers. Arch Pediatr Adolesc Med 2001;155:813-7.

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