Calcium Intake Pattern among Postmenopausal Women in Ahwaz, Iran
The aim of this cross-sectional study was to determine the calcium intake pattern among post menopausal women in Ahwaz, Iran. Fifty-three post menopausal women (age 57±9 year) were selected randomly. Calcium intake was estimated with a Food Frequency Questionnaire (FFQ) including fourteen items of the richest food sources of calcium. In order to evaluate calcium intake pattern, the food items divided into three categories, as dairy, grain and vegetable. Mean and standard deviation of total daily dietary calcium intake and from dairy, grain and vegetable groups were 984±354, 629±318, 200±133 and 167±151 mg, respectively. Mean and standard deviation of the daily total calcium contribution of dairy, grain and vegetable groups in calcium intake was 61±19, 22 ±16 and 17±14%, respectively. The results of this study suggested that the dietary calcium intake pattern in Ahwazian postmenopausal women is not suitable with regard to high servings of milk and dairy products; because of the effect of this food group (particularly, high fat items) on cardiovascular diseases.
Calcium intake is necessary for bone mass synthesis and also for protection
against osteoporosis. Osteoporosis is an important public health problem in
post menopausal women (Ettinger and Deluca, 1996; World
Health Organization, 1994). It is estimated that osteoporosis prevalence
will increase until 2050 (Cooper et al., 1992).
The estrogen secretion decreases after post menopause due to higher rate of
bone turnover which is related to more bone loss (Garnero
et al., 1996). Dietary calcium intake has been shown to vary widely
in global nutrition (Food and Agriculture Organization/ World
Health Organization, 2004). Many studies in Asia and Africa have reported
the inadequate intake of dietary calcium in different populations where, milk
and milk products are limited in the usual diet or such food items are not consumed
habitually (Prentice et al., 1993; Administrative
Committee on Coordination/Subcommittee on Nutrition, 1997). According to
the Food and Nutrition Board, the recommended daily allowance of calcium for
female adults in Asia is 400-500 mg day-1, although a number of investigators
believed that this level of intake is extremely low for postmenopausal women
(Hickler and Wayne, 1984; Heaney
et al., 1989). A low level of dietary calcium intake is common in
developing countries where diets are not rich in milk and dairy products (Administrative
Committee on Coordination/ Subcommittee on Nutrition, 1997). The main sources
of calcium in the low-income Bangladeshi women are cereals, vegetables and fish,
whereas calcium sources in the high-income group are fish, milk products and
cereals. Milk and milk products are no longer part of the typical Bangladeshi
diet (Islam et al., 2003). In Chinese postmenopausal
women, possibly due to the effects of education or dietary and health counseling,
dietary calcium intake has significantly increased, with an increase in the
consumption of vegetables, milk and soy foods and notably the proportion of
calcium intake from dairy sources (Ho et al., 2004).
Although, milk and dairy foods are strongly effective in increasing calcium
intake, but the proportion of calcium intake obtained from milk and dairy foods
is positively associated with the proportion of energy derived from fat, while
the proportion of calcium obtained from plant foods is negatively associated
with such energy (Zhang et al., 2007).
In Asia, there are few published studies on calcium intake pattern especially among post menopausal women. In the current study, pattern of dietary calcium intake among Iranian post menopausal women in Ahwaz was investigated.
MATERIALS AND METHODS
Fifty-three healthy postmenopausal women in two large educational hospitals
were recruited. They were not patient, but attended their relatives in the hospitals.
The study was conducted in 2007 in Ahwaz, located in South-West of Iran. All
subjects were nonsmokers. Anthropometric measurements were done between 08:00
to 10:00, according to the World Health Organization's standard protocols
(World Health Organization, 1995). Calcium intake was
estimated by a Food Frequency Questionnaire (FFQ) which included 14 items of
rich dietary calcium sources. The items were classified in three groups: dairy,
grain and vegetable. Participants were also asked about consumption of calcium
supplements. Calcium intake from each group was calculated using food composition
tables (Dorosti and Tabatabai, 2007). The presented results
are only from dietary calcium intake and calcium supplements were not included.
Statistical analysis: The data were analyzed by computer using Statistical Package for Social Science (SPSS for Windows, SPSS Inc. Chicago, IL, Version 11.5). Statistical significance level was p<0.05.
RESULTS AND DISCUSSION
Demographic characteristics of participants are shown in Table 1.
The mean, standard deviation and percentage of calcium intake from various food sources are shown in Table 2. As it is shown in the Table 2, dairy products were the main source of dietary calcium intake. Grains and vegetables sources supplied 22 and 17% of dietary calcium intake in Ahwazian post menopausal women, respectively.
The reported calcium intake from the FFQ was 984±354 mg day-1.
Seventy-eight percent of these women failed to meet the recommended Adequate
Intake (AI) of calcium for this age group (1200 mg day-1).
characteristics of postmenopausal women participated in dietary calcium
pattern study in Ahwaz, Iran (N = 53)|
intake and contribution of food groups in dietary calcium pattern study
in postmenopausal women in Ahwaz, Iran (N = 53)|
Results of this cross sectional study showed that although, mean of dietary
calcium intake is close to the recommended adequate intake, but a large proportion
of the participants did not consume enough amounts. In Rassuli
et al. (2001) study, on 73 post menopausal Tehranian women, it was
reported that calcium intake was 448±178 mg. Daily calcium intake in
post menopausal osteoporotic women in North West of Iran was 510±351.3
(Hejazi et al., 2009). Daily calcium intake in
Ahwazian post menopausal women is higher than their peers in Tehran and North
West of Iran. It may be due to differences in socio-demographic and dietary
habits between these geographic regions of Iran. Tehran is the capital city
of the country located in the center, but Ahwaz located in the south-west. Food
and Agriculture Organizations report in 1990 demonstrated that the mean
calcium intake in the developing world was 344 mg day-1 (Hejazi
et al., 2009), which is less than findings of this study (984 mg
day-1). The reported dietary calcium intake in postmenopausal Malaysian
women was 447±168 mg day-1 (Chee et
al., 2002). This could be due to differences in consumption of dairy
products among participants of these studies, as it is indisputable that milk
and milk products are rich sources of calcium. Dairy products contributed 26%
of the total calcium intake in Malaysian women against 61% in this study and
50% reported in Western diets. Mean per capita daily consumption of calcium
in U.S. population was 737 mg (Fleming and Heimbach, 1994),
which is close to our results. This is possibly due to similar dietary calcium
intake pattern of the U.S. population with post menopausal women in this study.
In this study, main source of dietary calcium in post menopausal women was dairy
products (600 mg day-1) (61%). This is equivalent to intake of two
exchanges of such food group. Unlikely, In Malaysian women's calcium intake
pattern, most of the calcium was from vegetables and bean sources (32%), dairy
products (26%), eggs, meat and seafood (16%) and cereals (12%) (Chee
et al., 2002). Similar to results of this study, in the U.S. population,
about 50% of total dietary calcium is supplied by milk and milk products. Milk
as an ingredient in such foods accounted for about 20% of total dietary calcium
intake. Grains and grain products, supplied 12% of calcium and fruits and vegetables
together supplied 6%. The remaining dietary calcium was contributed by meat,
poultry, fish, eggs, legumes and beverages (Fleming and
Heimbach, 1994). Zhang et al. (2007) investigated
calcium intake pattern among Japanese women and showed that plants and fish
were the top dietary calcium sources in Japanese women. It is an expected fact,
because many factors affect pattern of nutrient intake in different populations.
Although, milk and dairy foods are strongly effective in increasing calcium
intake that is directly associated with the proportion of energy derived from
fat, the proportion of calcium obtained from plants and fish is negatively associated
with such energy source Horwath et al. (1995)
have revealed that increasing intake of milk products results in increased dietary
fat and high cholesterol levels. Therefore, it is important to take into account
the fat content of dairy products especially in the elderly. It is the limitation
of this study that fat content of milk and dairy foods was not determined and
it is suggested that this matter be considered in future studies.
In the present study, grains and vegetables were the second and third sources
of calcium intake, respectively. In the Framingham osteoporosis study, Tucker
et al. (2002) evaluated the association between dietary patterns
and Bone Mineral Density (BMD) in older adults. Six dietary patterns were identified.
Dairy, meat and bread consumers group had the highest dietary calcium intake
(933±20 mg day-1). Fruit, vegetable and grain consumers group
was the second (873±33 mg day-1). These results are similar
to our study findings. In the Framingham study, older women and men, in fruit,
vegetable and grain group had the highest BMD. They suggested that higher fruit
and vegetable intake is associated with higher BMD in men and women. Ebrahimof
et al. (2004) in Tehranian rural postmenopausal women showed that
daily intake of more than 1.5 servings of vegetables is associated with higher
heel BMD in women but there was no significant association for fruits. Therefore,
it is necessary to consider calcium content of vegetables while evaluating dietary
In the present study, calcium intake of seventy-eight percents of participations
was lower than current recommendation. It seems necessary to study the calcium
intake pattern of Iranian postmenopausal women at the national level. Similar
to our results, Fifty-six percent of Malaysian women failed to meet the Malaysian
RDA for calcium (450 mg day-1) (Chee et al.,
2002) and 76% of Australian women have consumed less than the recommended
intake even when supplemental calcium was included (Pasco
et al., 2000). Mean dietary calcium intake in 55-92 years Australian
women was 646 mg day-1. For most groups of U.S. females, calcium
intake was substantially less than the RDA (Fleming and
In present study, dietary calcium intake was determined by using FFQ. Chee
et al. (2002) compared food frequency questionnaire and three days
food recalls, in estimation of dietary calcium intake in Malaysian post menopausal
women. The mean difference between the two methods was 51.3 mg and was not statistically
significant. They concluded that FFQ had estimated Malaysian post menopausal
women's calcium intake correctly. As a result, FFQ is a useful and rapid instrument
for evaluating calcium intake. Takahashi (2003) have
validated the food frequency questionnaire based on food groups and showed it
was a useful instrument.
In conclusion, low dietary consumption of calcium in these postmenopausal women
has important implications for their risk of developing osteoporosis. There
arises a need for nutritionists and dietitians in the country to place emphasis
on adequate calcium intake within the population. findings of this cross sectional
study showed that dietary calcium intake pattern in Ahwazian post menopausal
women is not suitable because of higher consumption of milk and dairy products
and the possible effect of this food group on cardiovascular diseases. A recent
national study in Iran showed that at least 40% of postmenopausal women have
low back pain (Saiedpour et al., 2008) and they
may be recommended to increase dairy products. So, it is necessary to educate
post menopausal women about more consumption of vegetables and grains and also
selection of low fat dairy foods.
Authors are thankful to Mohammad H. Haghighizadeh for statistical advice.
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