This study presents results of analyses from the most-recent, nationally-representative health and nutrition survey of Canadians to estimate usual nutrient intakes of Canadian children and adolescents, and assesses the prevalence of nutrient inadequacy in relation to the DRIs. Results from this study showed that the majority of Canadian children and adolescents are meeting AMDR recommendations for macronutrients; however, many children may not be meeting requirements for vitamin D or calcium, while many adolescents may not be meeting requirements for vitamin A, vitamin C, vitamin D, calcium, magnesium and zinc. For nutrients with an AI, there is a concern that both children and adolescents may not be meeting their needs for potassium and fibre, while consumption of sodium was in excess of international recommendations.
Although the available literature on nutrient intakes of children and adolescents is limited, results from this study are consistent with those published on macronutrient intakes of Canadian children and adolescents using one day of dietary recall from the 2015 CCHS- Nutrition, is consistent with results on Canadian children and adolescents using the 2004 CCHS– Nutrition (17, 45), and is also consistent with results for US children and adolescents using the 2015-2016 National Health and Nutrition Examination Survey (NHANES) (46, 47). For example, inadequate intakes of vitamin A, vitamin D, magnesium and calcium is a concern for adolescents in both countries and within Canada between 2004 to 2015, and both children and adolescents may not be meeting their requirements for potassium and fibre (17, 18, 45). Furthermore, the mean estimated energy intakes of Canadian children and adolescents reported in this study were similar to those found in previously published findings using 2004 CCHS and 2015 CCHS- Nutrition – the only exception being for 1-3y, where we observed a mean energy intake of 1,967 kcal/day in our study compared to 1,585 kcal/day in 2004-CCHS and 1,308kcal/day in 2015-CCHS (48). However, this difference may be largely attributable to the exclusion of 1-year olds from our study (as they do not have a TEE equation), as well as methodological differences between this study and other published studies (48) (further discussed in Strengths and Limitations).
In this study, saturated fat contributed to ~10% of total energy in the diets of children and adolescents. A high-energy, high‐saturated fat diet and low activity lifestyle that contributes to obesity and NCDs in adults may be having the same impact on children and adolescents (8). The Canadian Health Measures Survey found that among Canadian children and adolescents, 7% had either borderline or elevated blood pressure measurements, a risk factor for cardiovascular disease (49). Highly processed foods are a major source of saturated fat in the Canadian diet and can also be high in calories, sodium and free sugars (50). Ultra-processed foods contribute more than 50% of total daily energy in the diets of Canadian children and adolescents (51). Considering the mounting evidence that increased consumption of ultra-processed foods has a negative impact on diet quality and health, continued surveillance on nutrient intakes and interventions (e.g., food policies and regulations addressing the food environment, marketing to kids etc.) to reduce consumption of unhealthy processed foods will remain a priority.
An assessment of Canadian children and adolescents’ fibre intake with the recommendation is not possible given the limited usefulness of the AI in assessing nutrient adequacy of groups. Despite this limitation, the importance of an appropriate fibre intake should still be promoted to young Canadians, as recent reports indicate decreasing intakes of fruits, vegetables and whole grains, which are an important source of fibre and potassium (52).
Given its importance in the development of peak bone mass, low calcium intake is a significant health concern for children and adolescence and may play a role in the risk of fractures and developing osteoporosis later in life (53). Other than factors such as lactose intolerance or cultural/family practices and suboptimal intake of calcium may be linked to replacement of dairy products with sugar-sweetened beverages (46). Research has shown that soft-drink consumption is highest in adolescence while milk intake is lowest (54-56). In addition to calcium, milk is an important source of other shortfall nutrients such as vitamin D, phosphorus, magnesium, potassium, vitamin A, and zinc (8). Adolescent females are likely to drink less milk in order to cut kilocalories, favoring low-kilocalorie soft drinks (57).
Nearly 100% of Canadian children and adolescents had a high prevalence of inadequate intakes for vitamin D, similar to results from 2004-CCHS Nutrition (17, 45). This is a likely a reflection of a significant decrease in fluid milk consumption (58, 59), as all fluid milk in Canada is fortified with Vitamin D, and the change in DRI recommendations from an AI (5ug/day for children and adolescents) to a higher EAR (10ug/day) in 2011 (22). Estimates of the prevalence of inadequate intakes of vitamin D from food must be interpreted with caution as Vitamin D can also be synthesized by the body from sunlight (UV radiation) (60).. Additionally, this study does not consider vitamin D from supplements in the assessment; in 2004, 35% of Canadian children and adolescents reported taking a nutritional supplement over the past month (61). Available clinical measures do not suggest wide-spread vitamin D deficiency in Canadian children/youth (60), however, the status of vitamin D in some sub-populations may warrant further consideration (e.g. adolescent females (14-18 years old) (62, 63). This group is an important focus considering obstetric complications for females later in life, as a result of distorted pelvis, bowing of the legs and dwarfing due to vitamin D and associated calcium deficiency (64, 65). Moreover, Canada’s Food Guide (66) was recently updated, with the “Milk and Alternatives” and “Meat and Alternatives” food groups now replaced with a “Protein Foods” group. Given these changes, it may be important to monitor both calcium and vitamin D intakes of children and adolescents in the coming years.
The largest prevalence of inadequate intakes of essential nutrients, such as vitamin B6, vitamin B12, folate, zinc and iron, were seen for adolescent girls 14-18 years. These nutrients are of particular importance for adolescent females as the commencement of menstruation during this age group demands for increased nutritional needs. Similar results were reported previously for female adolescents in the US population (67). Environmental and social factors (e.g. dieting, body image concern) can lead to disordered eating behaviours (68), possibly increasing the risk of inadequate intakes of essential nutrients within this specific population group. A study of Canadian adolescents found that 4.5% of females met the criteria for an eating disorder (69). Considering these findings, adolescent females may be a particularly vulnerable for malnutrition; highlighting the importance of understanding the intake practices of this group to promote better health and nutrition.
Although sodium intakes were lower in this study compared to 2004 (70), Canadian children and adolescents are still consuming too much sodium in comparison to the CDRR. This is a major concern as recent Canadian data indicates that 7% of Canadian children and adolescents now have either borderline or overt hypertension (49). Additionally, emerging evidence indicates an association between high sodium intake and being obese and risk of developing cardiovascular disease in children and youth (71-73). Moreover, these high intakes of sodium may be a specific cause for concern for certain sub-populations of children and adolescents. For example, research has shown that children born with low birth weight may be at a higher risk for developing hypertension if they consume excess sodium across the lifespan (74). Due to an increased risk of cardiovascular disease associated with high sodium intakes, population-level sodium reduction interventions, such as the reformulation of specific food products, have been recommended (23) and have resulted in effectively decreasing sodium levels across the food supply chain in Canada (75).
The Canadian government has initiated several policies since 2015 to improve the nutritional outcomes of children and adolescents. As part of Health Canada's Healthy Eating Strategy, specific recommendations are being considered for food products specifically designed for children and youth (76). As an example, nutrition labelling regulations have been updated to include the percentage daily value of sodium on the Nutrition Facts table on packaged foods marketed to children aged 1-4 years old (77). A promising policy initiative to restrict marketing of unhealthy foods and beverages via traditional and digital marketing advertising (e.g. television advertising) to children under the age of 13 years is also being considered (77). Introduction of such policies may be particularly impactful in reducing the consumption of processed foods in childhood and to prevent NCDs in adulthood. Findings from the current study may act as a benchmark to monitor progress in the quality of Canadian children and adolescents’ dietary intakes given the government’s proposed policy changes.
Strengths and Limitations
This is the first study to utilize nationally representative data from 2015 CCHS – Nutrition to estimate nutrient intakes and the prevalence of nutrient inadequacy among Canadian children and adolescents, in addition to providing interpretation of the results and implications of these findings. Using both dietary recalls and applying the NCI method strengthen the results of these findings as most research in this field utilize only a single day of dietary recall, which is inappropriate to estimate usual intakes. Additionally, methodological considerations were incorporated in this study to strengthen the results, such as a robust outlier removal method recommended by Health Canada (36), accounting for misreporting bias and correcting for self-reported BMI (the published literature on CCHS 2004 do not account for either) and adjustments for covariates such as age, sex, weekend/weekday and sequence of dietary recall.
The results from the present study estimates nutrient intakes from food and beverage consumption only, i.e., the results do not consider supplement use. Furthermore, clinical measures of deficiency were not investigated as 2015 CCHS – Nutrition does not provide these measures. Finally, this study relies on estimating nutrient intakes from foods and beverages found in the most recent national food composition database (the Canadian Nutrient File; CNF) (78). The CNF may not be updated for all nutrients and/or products (30); therefore, reported nutrient estimates reported herein are only as accurate as CNF 2015. Additionally, caution should be exercised when making comparisons between published results on 2004 and 2015 CCHS-Nutrition due to methodological differences in data collection, data processing and data analysis between the two surveys (28). Some of the methodological differences include differences in sample size and response rates, updates to the nutrient databases, use of usual intake estimation methods (e.g., Software for Intake Distribution Estimation (SIDE) vs. NCI), handling of outliers and adjustment for certain covariates in estimation models. Further details on the differences between the two survey cycles can be found elsewhere (28).