L Reaves, LM Steffen, JT Dwyer, LS Webber, LA Lytle, DM Hoelscher, HA Feldman, M Zive, SK Osganian

Vitamin Supplement Intake is Vitamin Supplement Intake is Related to Dietary Intake and Related to Dietary Intake and

Physical Activity:Physical Activity:The Child and Adolescent Trial for The Child and Adolescent Trial for

Cardiovascular Health (CATCH)Cardiovascular Health (CATCH)

L Reaves, LM Steffen, JT Dwyer, LS Webber, LA Lytle, L Reaves, LM Steffen, JT Dwyer, LS Webber, LA Lytle,

DM Hoelscher, HA Feldman, M Zive, SK OsganianDM Hoelscher, HA Feldman, M Zive, SK Osganian

This study was funded by National Institutes of Health grant #RO1-HL66643This study was funded by National Institutes of Health grant #RO1-HL66643

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Reaves, et al. J Am Diet Assoc. Volume 106, Dec. 2006

Study ObjectiveStudy Objective

To explore the relationships of vitamin and mineral To explore the relationships of vitamin and mineral supplement use with dietary intake of selected food supplement use with dietary intake of selected food groups, physical activity and other lifestyle groups, physical activity and other lifestyle behaviors, and weight status in the CATCH study. behaviors, and weight status in the CATCH study.



Vitamin Supplement Intake is Related Vitamin Supplement Intake is Related to Dietary Intake and Physical Activity:to Dietary Intake and Physical Activity:

The Child and Adolescent Trial for Cardiovascular Health (CATCH)The Child and Adolescent Trial for Cardiovascular Health (CATCH)

The CATCH Study, 1991-1994The CATCH Study, 1991-1994

Originally, CATCH was a randomized controlled Originally, CATCH was a randomized controlled trial, multi-center intervention evaluating the trial, multi-center intervention evaluating the effectiveness of an elementary school-based effectiveness of an elementary school-based cardiovascular health promotion programcardiovascular health promotion programEnrolled 5,106 ethnically diverse students grades 3-Enrolled 5,106 ethnically diverse students grades 3-55Fifty six intervention schools, 40 control schools in Fifty six intervention schools, 40 control schools in California, Louisiana, Minnesota, and Texas California, Louisiana, Minnesota, and Texas Follow-up surveys were conducted in years 1996-97 Follow-up surveys were conducted in years 1996-97 and 2000-01and 2000-01





Current Study PopulationCurrent Study PopulationThe 2000-01 survey utilized a cross-sectional The 2000-01 survey utilized a cross-sectional study designstudy designExclusions include:Exclusions include:

41 students with outlying energy intakes41 students with outlying energy intakes 178 with other missing data178 with other missing data 229 students who did not return consent forms229 students who did not return consent forms 177 who dropped out of the study177 who dropped out of the study 1,968 students who moved out of survey area or did not 1,968 students who moved out of survey area or did not

participate in the 2000-01 follow-up survey participate in the 2000-01 follow-up survey

2,761 subjects were included in these analyses, 2,761 subjects were included in these analyses, which was 54% of the original cohort.which was 54% of the original cohort.





Data CollectionData Collection

Height and weight were measured and BMI Height and weight were measured and BMI calculated kg/mcalculated kg/m22

Vitamin supplement use and activity behaviors Vitamin supplement use and activity behaviors were assessed by the Health Behavior Surveywere assessed by the Health Behavior Survey

Dietary intake was assessed by the Rockett Dietary intake was assessed by the Rockett Youth/Adolescent food frequency questionnaire Youth/Adolescent food frequency questionnaire (FFQ)(FFQ)





Health Behavior SurveyHealth Behavior SurveyAssessed vitamin and mineral Assessed vitamin and mineral supplement use.supplement use.

Vitamin supplement users Vitamin supplement users were classified as adolescents were classified as adolescents who reported consuming any who reported consuming any vitamin or mineral supplement vitamin or mineral supplement regularly.regularly.

Yes or NoYes or No

Current SmokingCurrent Smoking Yes or NoYes or No

Assessed physical activities Assessed physical activities and TV watching.and TV watching.

Physical activity:Physical activity: Sedentary: less than 3 days Sedentary: less than 3 days

a week of activity a week of activity Active: 4 or more days per Active: 4 or more days per

week of activityweek of activityTeam sports or other Team sports or other organized sports participationorganized sports participation

Yes or NoYes or NoTV watching categories:TV watching categories:

< 1 hour per day< 1 hour per day > 1 hour per day> 1 hour per day





Youth/Adolescent FFQYouth/Adolescent FFQFood list included 149 itemsFood list included 149 itemsFoods were grouped into 10 food categories:Foods were grouped into 10 food categories: Whole grains-Whole grains- ready-to-eat breakfast cereal containing ready-to-eat breakfast cereal containing at least 25% whole grain or bran by weight, cooked at least 25% whole grain or bran by weight, cooked oatmeal, dark bread, brown rice, bulger, kasha, oatmeal, dark bread, brown rice, bulger, kasha, couscous, bran, wheat germ, and popcorncouscous, bran, wheat germ, and popcornRefined grains-Refined grains- ready to eat breakfast cereals with less ready to eat breakfast cereals with less than 25% whole grain or bran, white bread, bagels, than 25% whole grain or bran, white bread, bagels, muffins, rolls, pasta, white rice, pancakes and waffles, muffins, rolls, pasta, white rice, pancakes and waffles, and doughnutsand doughnutsFruit and fruit juice -Fruit and fruit juice - 10 different fruits and juices 10 different fruits and juices





Youth/Adolescent FFQYouth/Adolescent FFQ

Vegetables- Vegetables- 24 vegetables, legumes, and nuts24 vegetables, legumes, and nutsDairy-Dairy- milk, cheese, yogurt, and ice cream milk, cheese, yogurt, and ice creamMeat- Meat- included red and processed meats and poultryincluded red and processed meats and poultryFish and seafood – Fish and seafood – any type of fish or seafoodany type of fish or seafoodFried foods-Fried foods- fried food eaten away from home and fried food eaten away from home and french friesfrench friesSoft drinks-Soft drinks- included high sugar carbonated soda and included high sugar carbonated soda and fruit drinks fruit drinks Desserts-Desserts- cakes, cookies, bars, and pies cakes, cookies, bars, and pies





Statistical MethodsStatistical MethodsDifferences in characteristics between vitamin users and non-users Differences in characteristics between vitamin users and non-users were tested using:were tested using:

Student’s T-tests for continuous variablesStudent’s T-tests for continuous variablesMantel-Haenszel chiMantel-Haenszel chi22 for categorical variables for categorical variables

Linear regression models calculated average daily intake of Linear regression models calculated average daily intake of nutrients and foods controlling for age, sex, race, site, school, and nutrients and foods controlling for age, sex, race, site, school, and energy intake.energy intake.Quintiles of food intake were created for all food groups.Quintiles of food intake were created for all food groups.A food index was created to reflect intakes of food groups:A food index was created to reflect intakes of food groups:

An individual was assigned the sum of scores of 0-4 that An individual was assigned the sum of scores of 0-4 that corresponded to the quintile of intakes in whole grain, fruit, corresponded to the quintile of intakes in whole grain, fruit, vegetables, dairy and fish (Q1=0, Q2=1, Q3=2, Q4=3, and Q5=4) vegetables, dairy and fish (Q1=0, Q2=1, Q3=2, Q4=3, and Q5=4) and reversed for meat, fried food, soft drinks, and dessert intakes and reversed for meat, fried food, soft drinks, and dessert intakes (Q1=4, Q2=3, Q3=2, Q4=1, and Q5=0)(Q1=4, Q2=3, Q3=2, Q4=1, and Q5=0)





Statistical MethodsStatistical Methods

Logistic regression models evaluated the Logistic regression models evaluated the relationship of vitamin supplement use with weight relationship of vitamin supplement use with weight status, smoking, physical activity behaviors, TV status, smoking, physical activity behaviors, TV watching, and dietary intake controlling for age, sex, watching, and dietary intake controlling for age, sex, race, site, school and energy intake.race, site, school and energy intake.





What are the differences What are the differences between vitamin supplement between vitamin supplement

users and non-users?users and non-users?

ResultsResults





Table 1. Characteristics of adolescent vitamin Table 1. Characteristics of adolescent vitamin supplement users and nonusers: CATCH 2001supplement users and nonusers: CATCH 2001CharacteristicCharacteristic Non-supplement Non-supplement

Users (n=2,073) Users (n=2,073) Supplement UsersSupplement Users

(n=688) (n=688)

p-valuep-value

nn %% nn %%

GenderGender

MaleMale

Female Female

10541054

1018 1018

50.950.9

49.1 49.1

291291

397 397

42.342.3

57.7 57.7

<0.001<0.001

RaceRace

WhiteWhite

BlackBlack

HispanicHispanic

Other Other

15011501

257257

230230

84 84

72.472.4

12.412.4

11.111.1

4.1 4.1

543543

6666

5555

24 24

78.978.9

9.69.6

8.08.0

3.5 3.5

0.009 0.009

SiteSite

CaliforniaCalifornia

LouisianaLouisiana

MinnesotaMinnesota

Texas Texas

491491

623623

561561

398 398

2424

3030

2727

19 19

217217

185185

169169

117 117

3232

2727

2424

17 17

0.001 0.001



Table 2. Characteristics of adolescent vitamin Table 2. Characteristics of adolescent vitamin supplement users and nonusers: CATCH 2001supplement users and nonusers: CATCH 2001

CharacteristicCharacteristic Non-supplement Non-supplement Users (n=2,073) Users (n=2,073)

Supplement UsersSupplement Users

(n=688) (n=688)

p-value p-value

nn %% nn %%

SmokingSmoking

YesYes

NoNo

687687

14861486

3333

67 67

200200

488 488

2929

71 71

0.040.04

Weight StatusWeight Status

Normal weightNormal weight

OverweightOverweight

12981298

769 769

6363

37 37

472472

214 214

6969

31 31

0.004 0.004

Physical activityPhysical activity

SedentarySedentary

ActiveActive

10571057

1015 1015

5151

49 49

309309

378 378

4545

55 55

0.006 0.006



Table 3. Characteristics of adolescent vitamin Table 3. Characteristics of adolescent vitamin supplement users and nonusers: CATCH 2001supplement users and nonusers: CATCH 2001

CharacteristicCharacteristic Non-supplement Non-supplement Users (n=2,073) Users (n=2,073)


(n=688) (n=688)

p-value p-value

nn %% nn %%

Team sport Team sport activityactivity

YesYes

No No 822822

1251 1251

4040

60 60

325325

363 363

4747

53 53

<0.001 <0.001

Other organized Other organized sports activitysports activity

YesYes

No No 660660

1413 1413

3131

69 69

269269

419 419

3939

61 61

<0.001 <0.001

Hours of TV Hours of TV

0-1 hours0-1 hours

>= 1 hour >= 1 hour

632632

1440 1440

3131

69 69

282282

406 406

4141

59 59

<0.001 <0.001



Table 4. Nutrient intake of adolescent vitamin Table 4. Nutrient intake of adolescent vitamin supplement users and nonusers: CATCH 2001supplement users and nonusers: CATCH 2001

Non-supplement Non-supplement Users (n=2,073) Users (n=2,073)

Supplement Supplement Users (n=688) Users (n=688)

Mean Mean SE* SE* Mean Mean SE* SE* p-value p-value

Energy (Kcal) Energy (Kcal) 1935 1935 17 17 2008 2008 29 29 0.03 0.03

Total fat (% of kcal)Total fat (% of kcal) 31.5 31.5 11 11 30.5 30.5 0.19 0.19 <0.001 <0.001

Saturated fat (% of Saturated fat (% of kcal) kcal)

11.0 11.0 0.05 0.05 10.6 10.6 0.09 0.09 <0.001 <0.001

Carbohydrates (% Carbohydrates (% of kcal) of kcal)

54.8 54.8 0.14 0.14 55.5 55.5 0.24 0.24 0.009 0.009

Protein (% of kcal)Protein (% of kcal) 14.5 14.5 0.06 0.06 15.0 15.0 0.10 0.10 <0.001 <0.001

Fiber (g)Fiber (g) 14.0 14.0 0.16 0.16 15.6 15.6 0.26 0.26 <0.001 <0.001

*Linear regression models were adjusted for age, sex, race, site, school, and energy *Linear regression models were adjusted for age, sex, race, site, school, and energy intake, except for energy, which was not adjusted for energy intake.intake, except for energy, which was not adjusted for energy intake.



Table 5. Food intake of adolescent vitamin Table 5. Food intake of adolescent vitamin supplement users and nonusers: CATCH 2001supplement users and nonusers: CATCH 2001

Non-supplement Non-supplement Users (n=2,073)Users (n=2,073)


(n=688) (n=688)


Whole GrainsWhole Grains 0.7 0.7 0.01 0.01 0.8 0.8 0.02 0.02 <0.001 <0.001

Refined grains Refined grains 4.3 4.3 0.03 0.03 4.2 4.2 0.05 0.05 0.12 0.12

Fruit and fruit juice Fruit and fruit juice 1.6 1.6 0.03 0.03 1.9 1.9 0.04 0.04 <0.001 <0.001

Vegetables Vegetables 1.9 1.9 0.02 0.02 2.1 2.1 0.04 0.04 0.003 0.003

Dairy Dairy 2.4 2.4 0.03 0.03 2.5 2.5 0.04 0.04 0.22 0.22

Meat Meat 0.99 0.99 0.01 0.01 0.96 0.96 0.01 0.01 0.09 0.09

* * Linear regression models were adjusted for age, sex, race, site, school, and energy intake, Linear regression models were adjusted for age, sex, race, site, school, and energy intake, except for energy, which was not adjusted for energy intake.except for energy, which was not adjusted for energy intake.



Table 6. Food intake of adolescent vitamin Table 6. Food intake of adolescent vitamin supplement users and nonusers: CATCH 2001supplement users and nonusers: CATCH 2001

Non-supplement Non-supplement Users (n=2,073)Users (n=2,073)


(n=688) (n=688)


Fish and seafood Fish and seafood 0.14 0.14 0.003 0.003 0.16 0.16 0.005 0.005 0.05 0.05

Fried food Fried food 0.47 0.47 0.01 0.01 0.40 0.40 0.01 0.01 <0.001 <0.001

Soft drinks Soft drinks 1.36 1.36 0.02 0.02 1.22 1.22 0.03 0.03 <0.001 <0.001

Desserts Desserts 0.22 0.22 0.005 0.005 0.26 0.26 0.008 0.008 0.04 0.04

Diet Pattern (units)Diet Pattern (units)

Food index scoreFood index score 15.7 15.7 0.10 0.10 16.9 16.9 0.16 0.16 <0.001 <0.001

**Linear regression models were adjusted for age, sex, race, site, school, and energy intake, Linear regression models were adjusted for age, sex, race, site, school, and energy intake, except for energy, which was not adjusted for energy intake.except for energy, which was not adjusted for energy intake.



Table 7. Lifestyle activities associated with use of Table 7. Lifestyle activities associated with use of vitamin supplements among adolescents : CATCH 2001vitamin supplements among adolescents : CATCH 2001

Characteristics Characteristics Odds Ratio Odds Ratio

(95% confidence (95% confidence interval)interval)

Weight StatusWeight Status

Normal weight Normal weight

OverweightOverweight

1.001.00

.81(0.68, 0.99) .81(0.68, 0.99)

SmokingSmoking

NoNo

Yes Yes

1.001.00

0.80 (0.66, 0.97) 0.80 (0.66, 0.97)

Physical ActivityPhysical Activity

Sedentary Sedentary

Active Active

1.001.00

1.30 (1.09, 1.55) 1.30 (1.09, 1.55)

**Logistic regression models adjusted for age, sex, race, site, and school, and energy intakeLogistic regression models adjusted for age, sex, race, site, and school, and energy intake

Characteristics Characteristics Odds Ratio Odds Ratio

(95% confidence (95% confidence interval)interval)

Team Sport ActivityTeam Sport Activity

NoNo

Yes Yes

1.001.00

1.42 (1.19, 1.70) 1.42 (1.19, 1.70)

Other Organized Other Organized Sports ActivitySports Activity

NoNo

Yes Yes

1.001.00

1.32 (1.10,1.59) 1.32 (1.10,1.59)

Hours of TV watchedHours of TV watched

0-1 hour per day 0-1 hour per day

> 1 hours per day > 1 hours per day

1.001.00

0.66 (0.55, 0.77) 0.66 (0.55, 0.77)



Food GroupFood Group Quintiles of Dietary Intake* (Odds Ratio (95% confidence intervals))Quintiles of Dietary Intake* (Odds Ratio (95% confidence intervals))

11 22 33 44 55 P trendP trend

Whole grainWhole grain 11 1.181.18 (0.89, 1.58)(0.89, 1.58)

1.221.22(0.90,1.64)(0.90,1.64)

1.49 1.49 (1.12, 2.00)(1.12, 2.00)

1.86 1.86 (1.37, 2.52)(1.37, 2.52)

<0.001<0.001

Refined grainRefined grain 11 1.111.11 (0.83, 1.48)(0.83, 1.48)

0.94 0.94 (0.69, 1.29)(0.69, 1.29)

1.02 1.02 (0.72, 1.44)(0.72, 1.44)

0.76 0.76 (0.48, 1.19)(0.48, 1.19)

0.220.22

Fruit/JuiceFruit/Juice 11 1.301.30 (0.96, 1.77)(0.96, 1.77)

1.96 1.96 (1.45,2.65)(1.45,2.65)

2.202.20(1.62,2.99)(1.62,2.99)

2.812.81(2.03,3.88)(2.03,3.88)

<0.001<0.001

VegetablesVegetables 11 1.281.28(0.95,1.71)(0.95,1.71)

1.141.14(0.84,1.54)(0.84,1.54)

1.401.40(1.03,1.89)(1.03,1.89)

1.571.57(1.13,2.18)(1.13,2.18)

0.0080.008

DairyDairy 11 1.071.07(0.81,1.43)(0.81,1.43)

1.351.35(1.01,1.82)(1.01,1.82)

1.251.25(0.91,1.72)(0.91,1.72)

1.481.48(1.04,2.11)(1.04,2.11)

0.030.03

MeatMeat 11 0.940.94(0.71,1.24)(0.71,1.24)

0.860.86(0.64,1.15)(0.64,1.15)

0.930.93(0.68,1.26)(0.68,1.26)

0.740.74(0.52,1.07)(0.52,1.07)

0.150.15

**Logistic regression models were adjusted for age, sex, race, site, school, and energy intake.Logistic regression models were adjusted for age, sex, race, site, school, and energy intake.

Table 8. Likelihood of using vitamin supplements across Table 8. Likelihood of using vitamin supplements across quintiles of food intake among adolescents: CATCH 2001quintiles of food intake among adolescents: CATCH 2001



Table 9. Likelihood of using vitamin supplements across Table 9. Likelihood of using vitamin supplements across quintiles of food intake among adolescents: CATCH 2001quintiles of food intake among adolescents: CATCH 2001

Food groupFood group Quintiles of Dietary Intake*Quintiles of Dietary Intake* Odds Ratio (95% confidence intervals)Odds Ratio (95% confidence intervals)

11 22 33 44 55 P trend P trend

Fish/seafoodFish/seafood 1.001.00 1.051.05(0.81,1.36)(0.81,1.36)

1.361.36(1.03,1.79)(1.03,1.79)

1.131.13(0.86,1.50)(0.86,1.50)

1.311.31(0.98,1.75)(0.98,1.75)

0.070.07

Fried foodFried food 1.001.00 0.750.75 (0.52, 1.08)(0.52, 1.08)

0.73 0.73 (0.57, 0.94)(0.57, 0.94)

0.500.50(0.39,0.64)(0.39,0.64)

0.490.49(0.35,0.67)(0.35,0.67)

<0.001<0.001

Soft drinksSoft drinks 1.001.00 0.780.78(0.60,1.02)(0.60,1.02)

0.720.72(0.55,0.94)(0.55,0.94)

0.730.73(0.55,0.96)(0.55,0.96)

0.510.51(0.38,0.69)(0.38,0.69)

<0.001<0.001

DessertsDesserts 1.001.00 1.16 1.16 (0.85, 1.58)(0.85, 1.58)

1.29 1.29 (0.91, 1.83)(0.91, 1.83)

0.960.96(0.67,1.37)(0.67,1.37)

1.341.34(0.94,1.92)(0.94,1.92)

0.330.33

Food Index Food Index ScoreScore

1.001.00 1.201.20 (0.87, 1.65)(0.87, 1.65)

1.521.52 (1.13, 2.05)(1.13, 2.05)

1.901.90(1.35,2.66)(1.35,2.66)

2.51 2.51 (1.85, 3.41)(1.85, 3.41)

<0.001<0.001

*Logistic regression models were adjusted for age, sex, race, site, school, and energy intake.*Logistic regression models were adjusted for age, sex, race, site, school, and energy intake.



ConclusionsConclusions

1 in 4 adolescents reported using vitamin 1 in 4 adolescents reported using vitamin supplements in our study.supplements in our study.

Supplement use among adolescents varied between Supplement use among adolescents varied between race, gender, dietary intake, and health behaviors.race, gender, dietary intake, and health behaviors.

Compared to non-users, vitamin supplement users Compared to non-users, vitamin supplement users consumed healthier diets, watched less TV, were consumed healthier diets, watched less TV, were more physically active, and had a healthier weight more physically active, and had a healthier weight status. status.





RecommendationsRecommendations1.1. Because many adolescents use vitamin supplements, Because many adolescents use vitamin supplements,

registered dietitians should remember that they contribute registered dietitians should remember that they contribute to total nutrient intake and should ask about the frequency to total nutrient intake and should ask about the frequency of use, type of supplements taken, and reasons why they of use, type of supplements taken, and reasons why they are used. are used.

2.2. Healthy adolescents who have more healthy dietary Healthy adolescents who have more healthy dietary patterns are more likely to be vitamin supplement users, patterns are more likely to be vitamin supplement users, therefore these individuals are likely at lower risk of having therefore these individuals are likely at lower risk of having poor nutritional status than non-users.poor nutritional status than non-users.

3.3. Supplements are not substitutes for healthy dietary Supplements are not substitutes for healthy dietary patterns, and adolescents should be encouraged to adopt patterns, and adolescents should be encouraged to adopt such healthy patterns rather than rely on vitamin such healthy patterns rather than rely on vitamin supplementation for adequate nutrient intake.supplementation for adequate nutrient intake.





L Reaves, LM Steffen, JT Dwyer, LS Webber, LA Lytle, DM Hoelscher, HA Feldman, M Zive, SK Osganian

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