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5 Nutritional Considerations for Adults To provide a basis for recommending revisions to the meal require- ments of the Child and Adult Care Food Program (CACFP), this chapter presents the committee’s findings regarding food and nutrient intakes by adults. First it relates the findings regarding food intake for two adult age groups to the current Dietary Guidelines for Americans (DGA) (HHS/ USDA, 2005) and MyPyramid food guide (USDA, 2010). Then it presents nutrient intakes in relation to selected types of Dietary Reference Intakes (DRIs). The chapter includes special nutritional considerations relating to meeting the needs for vitamins B12 and D, chronic disease, texture modifi- cations, and recognizing the influence of ethnic and religious tradition on food choices. The chapter ends with the identification of key foods and nutrients that should be either encouraged or limited. To examine intakes, the committee used the data sets, other source materials, and methods that are described in Chapter 3. FOOD INTAKES Most adult participants in CACFP are over the age of 60 years, but younger adults (19–59 years of age) may participate in CACFP if they have disabilities that require them to be in a supervised setting (see Chapter 2). Thus, the committee considered these two age groups separately when comparing food group intake to the amounts specified by MyPyramid for a 2,000-calorie intake level. Although it is recognized that calorie requirements vary greatly among adult men and women, the committee arrived at a 2,000-calorie level for meal planning purposes. It is the closest 77

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78 CHILD AND ADULT CARE FOOD PROGRAM MyPyramid level to the mean of the total energy expenditure for the four age groups in the National Health and Nutrition Examination Survey (NHANES) 2003–2004: men and women, ages 19–59 years and 60 years or older, when body mass index was imputed at 22.5 for the younger and at 25 for the older group of adults (see Chapter 3). Because of the varia- tion in available facilities in adult day care programs, it was not considered practical to set different calorie levels for subgroups at the meal planning stage. It should be noted, however, that portion sizes may be adjusted within facilities, as appropriate. The data in Table 5-1 show the areas that mean adult intakes of all the food groups and subgroups were below the MyPyramid amounts, with the exception of total grains for the 19–59-year age group. For both age groups, mean fruit intake was only about half of the amount that would be consistent with the MyPyramid pattern. Furthermore, within the vegetables group, the consumption of dark green vegetables, orange vegetables, and dried beans and peas was lower than the MyPyramid amount specified for each of these individual subgroups. Neither age group approached the recommended amount of whole grains. Note that the 2005 DGA (HHS/USDA, 2005) encourages the intake of increased amounts of a variety of vegetables and fruits and recommends that at least half of the grain be whole grain. In addition to providing nutrients, fruits and vegetables provide numerous beneficial phytochemicals, which may be protective of a wide variety of age-related conditions (Carlsen et al., 2010). The 2010 Dietary Guidelines Advisory Committee (USDA/HHS, 2010) placed strong emphasis on a diet that is primarily plant-based—rich in vegetables, fruits, whole grains, nuts, and seeds. Meeting the nutrient needs of older and disabled adults with lower calorie requirements poses great challenges in the context of the typical American diet. As seen in the analyses above, calories from solid fats and added sugars for the general adult population far exceed caloric require- ments. Placing limits on energy-dense foods such as fatty meats, full-fat dairy products, sugar-sweetened drinks, and pastries and other desserts can reduce the intake of solid fat, sugars, and calories. This change makes room for more vegetables, fruits, whole grains, and low-fat or nonfat fluid milk and milk products without providing excess calories. ENERGY AND NUTRIENT INTAKES Energy The committee considered estimated energy intakes by adults as dis- cussed in Chapter 3.

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79 NUTRITIONAL CONSIDERATIONS FOR ADULTS TABLE 5-1 Comparison Between the 2,000-Calorie MyPyramid Food Group Pattern and Mean Daily Amounts of MyPyramid Food Groups Consumed by Adults $ 19 Years of Age Age Group 19–59 Yearsa $ 60 Yearsa $ 19 Years Food Group or Componentb 2,000 kcal Pattern Mean Intake Mean Intake Total fruit (cup eq) 2 0.96 1.13 Total vegetables (cup eq) 2.5 1.77 1.65 0.43c Dark green 0.10 0.11 0.29c Orange 0.07 0.09 0.43c Dry beans/peas 0.13 0.13 0.43c Starchy 0.50 0.47 0.93c Other 0.97 0.85 Total grains (oz eq) 6 7.11 5.83 Whole grains (oz eq) 3 0.61 0.86 Total meat and beans (oz eq)d 5.5 5.19 4.08 Total milk group (8 fl oz eq)e 3 1.67 1.33 Vegetable oils (g)f 27 21 17 804g 570g SoFAS (kcal) 267 NOTES: The MyPyramid food intake pattern used is from the Dietary Guidelines for Ameri- cans (HHS/USDA, 2005). Eq 5 equivalent; fl 5 fluid; g 5 gram; kcal 5 calories; oz 5 ounce; SoFAS 5 solid fats and added sugars. aAverage of male and female intake data. bSee Appendix Table H-1 for a list of foods in the MyPyramid food groups and subgroups. cDaily amounts based on the MyPyramid recommendations expressed as cup-equivalents per week. dThe MyPyramid meat and beans group includes meat, poultry, fish, eggs, dry beans and peas, and nuts and seeds (http://www.mypyramid.gov/pyramid/meat.html). eThe MyPyramid milk group includes fluid milk; hard, soft, and processed cheese; yogurt; and milk-based desserts (http://www.mypyramid.gov/pyramid/milk.html). The intake data represent mean intake of fluid milk, cheese, and yogurt. Dietary Guidelines advises “3 cups per day of fat-free or low-fat milk or equivalent milk products” for adults (see HHS/USDA, 2005, p. viii). f5 g 5 1 teaspoon. gEstimated on the basis of the number of grams of discretionary solid fat and the number of teaspoons (tsp) of added sugars, as follows: (fat g 3 9 calories/g) 1 (tsp 3 4.2 g/tsp 3 4 calories/g). SOURCES: Mean intake data from NHANES 2003–2004; MyPyramid patterns from Britten et al., 2006. Nutrients with an Estimated Average Requirement The committee examined nutrient intakes by adults in relation to se- lected DRIs to identify nutrients for which intake is likely to be inadequate

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80 CHILD AND ADULT CARE FOOD PROGRAM or excessive. To do this, the committee conducted analyses of dietary intake data from the NHANES 2003–2004 survey (CDC, 2010). Table 5-2 shows the estimated prevalence of inadequate usual intakes for nutrients that have an Estimated Average Requirement (EAR), by gender and age group. Consistent with other reports, this analysis of NHANES (2003–2004) data (see Table 5-2) shows that older adults (. 60 years of age) are at greater risk than younger adults for inadequate intakes for several nutri- ents. Very few individuals of any age achieve adequate vitamin E intakes. For both age groups, the prevalence of inadequate intakes of vitamins A and C and magnesium exceeds 40 percent; that of zinc ranges from 8 to 26 percent; and all but younger men show a prevalence of inadequate intakes of vitamin B6, folate, and thiamin that range from 6 to 39 percent. Women in both age groups appear to be more likely than men to have a high prevalence of inadequate intakes of protein, thiamin, vitamin B6, folate, and vitamin B12. Iron is a concern only for adult women of child-bearing age. Low protein intake may be of particular concern for older adults because, compared with younger adults, they have lower efficiency of protein utili- TABLE 5-2 Estimated Prevalence of Inadequacy of Protein and Selected Vitamins and Minerals Among Adults Based on Usual Nutrient Intakes from NHANES 2003–2004a Estimated Prevalence of Inadequate Usual Intakes (%) by Age Group (years) and Gender 19–59 Years $ 60 Years Males Females Males Females 14 12 20 Protein 3.4 54 54 54 43 Vitamin A 44 40 49 40 Vitamin C 89 97 92 98 Vitamin E 9 6 12 Thiamin 1.6 Riboflavin 0.8 3.3 2.8 3.7 Niacin 0.2 2.1 1.8 4.6 21 19 39 Vitamin B6 4.2 17 11 24 Folate 3.2 7 9 Vitamin B12 0.9 2.4 Phosphorus 0.2 2.4 1.2 4.8 57 65 78 73 Magnesium 12 Iron 0.1 1.0 1.5 8 12 26 21 Zinc NOTE: Bold font indicates values with a prevalence of inadequacy greater than 5 percent. aAll nutrients in this table have an Estimated Average Requirement (EAR). SOURCES: Intake data from NHANES 2003–2004. The EARs used in the analysis were from the Dietary Reference Intake reports (IOM, 1997, 1998, 2000, 2001, 2002/2005).

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81 NUTRITIONAL CONSIDERATIONS FOR ADULTS zation, and they tend to lose lean body mass over time (Gaffney-Stomberg et al., 2009). Selected Nutrients with an Adequate Intake Intakes of selected nutrients that have an Adequate Intake (AI) rather than an EAR are shown in Table 5-3, by age group and gender, along with the respective AI. The mean and median NHANES (2003–2004) intakes for calcium, potassium, and fiber are lower than the AI for most of these adult age-gender groups, suggesting that the majority of individuals do not meet this target recommendation. Women have lower intakes than do men, with mean and median potassium intakes less than half the a-linoleic and a-linolenic acid intakes are close to the AI on average. TABLE 5-3 Comparison Between Median Nutrient Intakes from NHANES (2003–2004) and the Adequate Intake (AI), by Age Group (in years) and Gender 19–59 Years $ 60 Years Males Females Males Females Calcium (mg/d) AI 1,044 1,044 1,200 1,200 790 846 702 Mean intake 1,068 1,003 758 798 654 Median intake Potassium (mg/d) AI 4,700 4,700 4,700 4,700 3,182 2,342 2,866 2,327 Mean intake 3,112 2,292 2,787 2,290 Median intake Fiber (g/d) AI 36.2 24.1 30.0 21.0 17.3 13.4 16.4 13.8 Mean intake 16.3 12.7 15.7 13.4 Median intake Linoleic acid (g/d) AI 16.3 11.8 14.0 11.0 Mean intake 18.8 14.2 15.1 12.3 Median intake 17.9 13.4 14.2 11.5 α-linolenic acid (g/d) AI 1.6 1.1 1.6 1.1 1.5 Mean intake 1.9 1.4 1.3 1.4 Median intake 1.8 1.3 1.2 NOTES: AI 5 Adequate Intake; g/d 5 grams per day; mg/d 5 milligrams per day. Bold font indicates mean intake values lower than the AI. SOURCES: Intake data from NHANES 2003–2004. The AIs used in the analysis were from the DRI reports (IOM, 1997, 2002/2005, 2005). AIs shown for the 19–59-year-old age group are weighted averages of two DRI age groups.

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82 CHILD AND ADULT CARE FOOD PROGRAM Data from What We Eat in America, NHANES 2007–2008 (USDA/ ARS, 2010, Table 1), indicate that mean vitamin D intake by adult males ages 20 years or older is at the AI of 5.0 g, but it is below the AI for those ages 60 years or older. For all adult females, mean vitamin D intake is well below the AI. Excessive Intake Levels The Tolerable Upper Intake Level for sodium is 2.3 g per day for adults. Reported mean sodium intake is substantially higher for adult males (4.4 g per day) than for adult females (3.1 g per day) (IOM, 2010). The 2010 Dietary Guidelines Advisory Committee (USDA/HHS, 2010) recommended gradual movement toward an even lower maximum sodium intake—1.5 g per day. On average, data from NHANES show that both male and female adults have intakes of saturated fat that exceed 10 percent of total calories (USDA/ARS, 2010, Table 5)—the maximum proportion of saturated fat calories recommended in the 2005 DGA (HHS/USDA, 2005). The 2010 Dietary Guidelines Advisory Committee (USDA/HHS, 2010) recommended intake of less than 10 percent of total calories from saturated fat as an interim step toward reaching a goal of less than 7 percent of total calories from saturated fat. NHANES data also show that cholesterol intake differs substantially by gender (higher for males than for females) and age (starting to decrease at about age 50). On average, males ages 20–69 years have a mean cholesterol intake that exceeds 300 mg per day, whereas mean intakes are below 300 mg per day for adult women and for men ages 70 years and older (USDA/ ARS, 2010, Table 1). SPECIAL NUTRITIONAL CONSIDERATIONS The nutrient comparisons in Tables 5-2 and 5-3 are based on the noninstitutionalized U.S. adult population. However, the committee rec- ognizes that the nutritional concerns of adults who are receiving day care in group homes or centers are not necessarily typical of free-living adults of the same age who can care for themselves. Inadequate intakes are likely more severe in this population, while the demands of chronic conditions and medications may increase the need for some nutrients. Disability and functional dependence, which are characteristic of adults in day care, often are related to disease. Disability in older men is usually related to heart disease and stroke; disability in older women is usually associated with osteoporosis and related fractures, arthritis, and circulatory diseases (Fried and Guralnik, 1997; La Croix et al., 1997). Some individuals entering adult day care may have compromised nutritional status because they have had

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83 NUTRITIONAL CONSIDERATIONS FOR ADULTS limited access to food. Tooth loss, infection, lesions, and other oral prob- lems are prevalent in older adults and, if present, will contribute to altered dietary intake. Younger adults who participate in CACFP have various dis- abilities that may affect their nutritional status and functionality. Vitamins B12 and D Vitamin B12 Vitamin B12 merits special attention. Even though Table 5-2 shows that the prevalence of vitamin B12 inadequacy is less than 3 percent for males and 7 to 9 percent for females, vitamin B12 deficiency may be more prevalent than this. The discrepancy between the apparent prevalence of inadequacy and actual deficiency relates to the absorption of protein-bound vitamin B12 by individuals over the age of 50 years. Ten to 30 percent of this older population may suffer from some degree of atrophic gastritis, leading to a decrease in stomach acid (IOM, 1998). Lack of gastric acid, in turn, leads to decreased absorption of the vitamin B12 provided by animal foods. For this reason, the Institute of Medicine recommends that older adults ob- tain their Recommended Dietary Allowance (RDA) of vitamin B12 mainly in the crystalline form, as from fortified foods (e.g., fortified breakfast cereals) or supplements (IOM, 1998). Data from What We Eat in America (USDA/ ARS, 2010, Table 1) indicate that the mean daily intake of added (crystal- line) vitamin B12 in fortified foods by adults ages 20 years and older was about 1 µg per day—far less than the RDA of 2.4 µg. Vitamin D and Calcium Elderly adults tend to have poor dairy and vitamin D intake, decreased sun exposure as well as reduced dermal synthesis of 1,25-OH2-D, and sec- ondary hyperparathyroidism, all of which contribute to increased risk for poor bone health and fracture risk in this population. Concentrations of provitamin D3 in the epidermis are inversely related to age (MacLaughlin and Holick, 1985), which results in decreased production of vitamin D from sunlight exposure. Estimates of vitamin D synthesis in elderly adults suggest about a 70 percent decrease in the elderly compared to young adults (Holick et al., 1989). In women, bone loss occurs as a result of low estrogen levels that accompany menopause and the combined effects of other age-related changes on vitamin D and calcium metabolism. Estrogen has a regulatory role in synthesis of 1,25-OH2-D (Caniggia et al., 1987), and the reduction of estrogen as a result of menopause is correlated with a progressive increase in parathyroid hormone, which in turn increases bone

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84 CHILD AND ADULT CARE FOOD PROGRAM turnover and risk for osteoporosis (Khosla et al., 1997). Adequate vitamin D intake in this population is important to reduce secondary hyperparathy- roidism and its attendant effects on bone turnover (Gennari, 2001). Low Level of Physical Activity Because of their disability or for other reasons, adults attending day care may be more sedentary than the general population. An analysis of data from the Behavioral Risk Factor Surveillance System found that noninsti- tutionalized adults with disability do not meet basic recommendations for physical activity according to recommendations from the Centers for Dis- ease Control and Prevention and the American College of Sports Medicine (Boslaugh and Andresen, 2006). Messent et al. (1999) identified several bar- riers to activity encountered by individuals with learning disabilities. These included “unclear policy guidelines in residential and day service provision together with resourcing, transport and staffing constraints; participant in- come and expenditure; and limited options for physically active community leisure” (p. 409). An increase in physical activity may improve appetite and allow the consumption of additional food without leading to weight gain. Impact of Chronic Disease Any chronic disease may affect an individual’s nutrient needs or other- wise have an impact on nutritional status. Dietary modifications, which are described briefly below, may be needed to support health, and medications may affect dietary intake or lead to drug-nutrient interactions. Conditions that may require dietary modifications include obesity, frailty, hypertension, type 2 diabetes, and heart disease. Adequate nutrition and good dietary quality for individuals with these conditions may reduce morbidity and mortality. Obesity is associated with disability among older adults (Houston et al., 2009). Weight gain may contribute to disability by making it more diffi- cult to maintain activity levels and mobility (Rolland et al., 2009; Zamboni et al., 2008). Disability has been associated with a myriad of syndromes including malnutrition, inflammatory disease (especially in persons with multiple chronic conditions), and functional dependency (Becker, 1994; Topinková, 2008). For these reasons, among others, it is especially impor- tant for the meals and snacks provided to adults in day care to support healthy weight while providing adequate levels of nutrients. Modified Diets In many cases, adults with chronic disease may be prescribed a spe- cial diet. Some larger adult day care centers have access to a professional

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85 NUTRITIONAL CONSIDERATIONS FOR ADULTS kitchen and a dietitian and can accommodate these needs as directed by each person’s health care provider. Smaller centers and group homes may need more assistance in meeting these needs. The most commonly pre- scribed modifications include lowering sodium, dietary fat, and total calo- ries. For most of the chronic conditions that may result in a need for day care, these modifications are consistent with the Dietary Guidelines and can be accommodated with a general menu, thereby limiting the need for highly specialized individual meals. It should be noted that the American Dietetic Association has long recommended liberalized diets for older adults (ADA, 2005). Consideration of unique special dietary needs is beyond the scope of the committee’s charge. Therefore, the committee focused on the majority of older adults and adults with disabilities who may or may not have common chronic conditions, all of whom are likely to benefit from a diet that follows the Dietary Guidelines. Functional Limitations Adults of any age who have functional limitations often need assis- tance with eating and drinking. Measures described below may be neces- sary to ensure that adequate food and fluid can be consumed regardless of whether the person can eat independently or is fed by a care provider, relative, or friend. Providing Adequate Fluid Meeting fluid requirements may be challenging for the functionally disabled and for older adults. Regardless of age, some disabled adults are unable to drink fluids without assistance, and some may want to restrict fluid intake to reduce the need to urinate. As individuals age, thirst sensitivity decreases; many older adults do not have the trigger initiated by a normal thirst mechanism to consume fluids. The frequent offering of small amounts of beverages helps such individuals meet their need for fluids. Modifying Textures Textures may be modified to accommodate oral health problems, in- cluding but not limited to loose teeth, oral lesions, and gum and periodontal disease. Modifications in texture also may be necessary to accommodate swallowing difficulties that occur because of chronic disease (e.g., Parkin- son’s disease) or catastrophic illness (e.g., stroke, cancer). Examples of texture modifications include the dicing, mincing, pureeing, and liquefying of foods and the thickening of liquids.

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86 CHILD AND ADULT CARE FOOD PROGRAM Recognizing Ethnic and Religious Traditions Many older people have food consumption habits that are from familial and ethnic traditions, and these food habits may not mirror present-day di- etary recommendations. Recognizing the importance of maintaining ethnic, religious, and other food patterns is very important, however. Redeveloping recipes for ethnic foods that may be more healthful has been a successful strategy. FOODS AND NUTRIENTS TO BE ENCOURAGED OR LIMITED The analyses of food and nutrient intakes by adults make it clear that special effort will be needed to both provide and encourage intake of more fruit, vegetables, low-fat dairy products, and whole grains while limiting exposure to and the consumption of foods high in sugar, solid fats, and sodium and of refined grains. Greater intake of fruit and vegetables will im- prove intake of vitamin C, carotenoids (dark green and orange vegetables), folate (dark green vegetables, oranges, and legumes), vitamin B6 (legumes and bananas), magnesium (legumes), potassium, and dietary fiber (most nonstarchy fruits and vegetables). Higher intakes of low-fat milk or yogurt will improve intakes of magnesium, calcium, potassium, vitamin B12, and, if fortified, vitamin D. Inclusion of fortified breakfast cereals will provide some crystalline vitamin B12. The inclusion of more whole grains will im- prove intakes of vitamin B6, magnesium, and dietary fiber. REFERENCES ADA (American Dietetic Association). 2005. Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long- term care. Journal of the American Dietetic Association 105(12):1955–1965. Becker, G. 1994. The oldest old: Autonomy in the face of frailty. Journal of Aging Studies 8(1):59–76. Boslaugh, S. E., and E. M. Andresen. 2006. Correlates of physical activity for adults with disability. Preventing Chronic Disease 3(3):A78. Britten, P., K. Marcoe, S. Yamini, and C. Davis. 2006. Development of food intake patterns for the MyPyramid Food Guidance System. Journal of Nutrition Education and Behavior 38(6 Suppl):S78–S92. Caniggia, A., F. Lore, G. di Cairano, and R. Nuti. 1987. Main endocrine modulators of vitamin D hydroxylases in human pathophysiology. Journal of Steroid Biochemistry 27(4–6):815–824. Carlsen, M. H., B. L. Halvorsen, K. Holte, S. K. Bøhn, S. Dragland, L. Sampson, C. Willey, H. Senoo, Y. Umezono, C. Sanada, I. Barikmo, N. Berhe, W. C. Willett, K. M. Phillips, D. R. Jacobs, and R. Blomhoff. 2010. The total antioxidant content of more than 3100 foods, beverages, spices, herbs and supplements used worldwide. Nutrition Journal 9(1):Article No. 3.

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87 NUTRITIONAL CONSIDERATIONS FOR ADULTS CDC (Centers for Disease Control and Prevention). 2010. NHANES 2003–2004. http://www. cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm (accessed August 18, 2010) Fried, L. P., and J. M. Guralnik. 1997. Disability in older adults: Evidence regarding signifi- cance, etiology, and risk. Journal of the American Geriatrics Society 45(1):92–100. Gaffney-Stomberg, E., K. L. Insogna, N. R. Rodriguez, and J. E. Kerstetter. 2009. Increas- ing dietary protein requirements in elderly people for optimal muscle and bone health. Journal of the American Geriatrics Society 57(6):1073–1079. Gennari, C. 2001. Calcium and vitamin D nutrition and bone disease of the elderly. Public Health Nutrition 4(2 B):547–559. HHS/USDA (U.S. Department of Health and Human Services/U.S. Department of Agriculture). 2005. Dietary Guidelines for Americans, 6th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/DietaryGuidelines/dga2005/document/ (accessed July 23, 2008). Holick, M. F., L. Y. Matsuoka, and J. Wortsman. 1989. Age, vitamin D, and solar ultraviolet. Lancet 334(8671):1104–1105. Houston, D. K., B. J. Nicklas, and C. A. Zizza. 2009. Weighty concerns: The growing prevalence of obesity among older adults. Journal of the American Dietetic Association 109(11):1886–1895. IOM (Institute of Medicine). 1997. Dietary Reference Intakes for Calcium, Phosphorus, Mag- nesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press. IOM. 1998. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press. IOM. 2000. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press. IOM. 2001. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press. IOM. 2002/2005. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Ac- ids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press. IOM. 2005. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press. IOM. 2010. Strategies to Reduce Sodium Intake in the United States. Washington, DC: The National Academies Press. Khosla, S., E. J. Atkinson, L. J. Melton III, and B. L. Riggs. 1997. Effects of age and estrogen status on serum parathyroid hormone levels and biochemical markers of bone turnover in women: A population-based study. Journal of Clinical Endocrinology and Metabolism 82(5):1522–1527. La Croix, A. Z., K. M. Newton, S. G. Leveille, and J. Wallace. 1997. Healthy aging: A women’s issue. Western Journal of Medicine 167(4):220–232. MacLaughlin, J., and M. F. Holick. 1985. Aging decreases the capacity of human skin to produce vitamin D3. Journal of Clinical Investigation 76(4):1536–1538. Messent, P. R., C. B. Cooke, and J. Long. 1999. Primary and secondary barriers to physically active healthy lifestyles for adults with learning disabilities. Disability and Rehabilitation 21(9):409–419. Rolland, Y., V. Lauwers-Cances, C. Cristini, G. A. Van Kan, I. Janssen, J. E. Morley, and B. Vellas. 2009. Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: The EPIDOS (EPIDemiologie de l’OSteoporose) Study. American Journal of Clinical Nutrition 89(6):1895–1900.

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88 CHILD AND ADULT CARE FOOD PROGRAM Topinková, E. 2008. Aging, disability and frailty. Annals of Nutrition and Metabolism 52(Suppl 1):6–11. USDA (U.S. Department of Agriculture). 2010. MyPyramid. http://www.mypyramid.gov/ (accessed June 29, 2010). USDA/ARS (U.S. Department of Agriculture/Agricultural Research Service). 2010. What We Eat in America, NHANES 2007–2008. http://www.ars.usda.gov/Services/docs. htm?docid518349 (accessed October 5, 2010). USDA/HHS (U.S. Department of Agriculture/U.S. Department of Health and Human Services). 2010. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm (accessed June 29, 2010). Zamboni, M., G. Mazzali, F. Fantin, A. Rossi, and V. Di Francesco. 2008. Sarcopenic obesity: A new category of obesity in the elderly. Nutrition, Metabolism and Cardiovascular Diseases 18(5):388–395.