Scholarly article on topic 'Missing Lunch Is Associated with Lower Intakes of Micronutrients from Foods and Beverages among Children and Adolescents in the United States'

Missing Lunch Is Associated with Lower Intakes of Micronutrients from Foods and Beverages among Children and Adolescents in the United States Academic research paper on "Health sciences"

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{"Lunch quality" / "Nutrient inadequacy" / "Meal patterns" / "Discretionary calories" / "Meal skipping"}

Abstract of research paper on Health sciences, author of scientific article — Kevin C. Mathias, Emma Jacquier, Alison L. Eldridge

Abstract Background In the United States, the lunch meal contributes more than 20% of the daily intakes of most micronutrients for children and adolescents consuming lunch. Seven percent to 20% of children and adolescents in the United States do not eat lunch on a given day. Objective To identify differences in total micro- and macronutrient intakes of children consuming and missing lunch on a given day. Design Cross-sectional secondary analysis of the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012. Dietary intake was assessed using the first day 24-hour recall of each respondent. Participants and settings The National Health and Nutrition Examination Survey sample represents the total noninstitutionalized civilian population residing in the United States. The sample used in this study included 4,755 children aged 4 to 18 years with complete data for all analyses. Main outcome measures Total day, lunch, and nonlunch micronutrients, macronutrients, solid fats, and added sugar intakes were examined. Statistical analyses performed Linear regression models controlling for age, sex, race/ethnicity, household poverty status, and weekend were used to compare dietary intakes of lunch consumers and nonconsumers. Intakes from nonlunch sources were examined to determine the extent to which differences between lunch consumers and nonconsumers could be attributed to the lunch meal. Results Missing lunch was associated with lower micronutrient intakes, with the lunch meal primarily responsible for the higher micronutrient intakes of lunch consumers compared with nonconsumers. Missing lunch was also associated with lower energy, fiber, and sodium intakes. Added sugar and solid fat intakes of lunch consumers and nonconsumers were not significantly different. Conclusions This study identifies potential concerns for children missing lunch with respect to micronutrient intakes and shows that the lunches consumed by children in the United States are an important source of essential nutrients, but also less healthful dietary components.

Academic research paper on topic "Missing Lunch Is Associated with Lower Intakes of Micronutrients from Foods and Beverages among Children and Adolescents in the United States"

RESEARCH

Original Research: Brief

Missing Lunch Is Associated with Lower Intakes of Micronutrients from Foods and Beverages among Children and Adolescents in the United States

Kevin C. Mathias, PhD; Emma Jacquier, MMedSci; Alison L. Eldridge, PhD, RD

ARTICLE INFORMATION

Article history:

Submitted 26 June 2015 Accepted 18 December 2015 Available online 16 February 2016

Keywords:

Lunch quality Nutrient inadequacy Meal patterns Discretionary calories Meal skipping

Supplementary materials:

Tables 1, 2, 3, 4, 5, and 8 are available at www.andjrnl.org

2212-2672/Copyright © 2016 by the Academy of Nutrition and Dietetics. This is an open access article under the CC BY-NC-ND license (http:// creativecom mons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/jjand.2015.12.021

ABSTRACT

Background In the United States, the lunch meal contributes more than 20% of the daily intakes of most micronutrients for children and adolescents consuming lunch. Seven percent to 20% of children and adolescents in the United States do not eat lunch on a given day.

Objective To identify differences in total micro- and macronutrient intakes of children consuming and missing lunch on a given day.

Design Cross-sectional secondary analysis of the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012. Dietary intake was assessed using the first day 24-hour recall of each respondent.

Participants and settings The National Health and Nutrition Examination Survey sample represents the total noninstitutionalized civilian population residing in the United States. The sample used in this study included 4,755 children aged 4 to 18 years with complete data for all analyses.

Main outcome measures Total day, lunch, and nonlunch micronutrients, macronu-trients, solid fats, and added sugar intakes were examined.

Statistical analyses performed Linear regression models controlling for age, sex, race/ethnicity, household poverty status, and weekend were used to compare dietary intakes of lunch consumers and nonconsumers. Intakes from nonlunch sources were examined to determine the extent to which differences between lunch consumers and nonconsumers could be attributed to the lunch meal.

Results Missing lunch was associated with lower micronutrient intakes, with the lunch meal primarily responsible for the higher micronutrient intakes of lunch consumers compared with nonconsumers. Missing lunch was also associated with lower energy, fiber, and sodium intakes. Added sugar and solid fat intakes of lunch consumers and nonconsumers were not significantly different.

Conclusions This study identifies potential concerns for children missing lunch with respect to micronutrient intakes and shows that the lunches consumed by children in the United States are an important source of essential nutrients, but also less healthful dietary components.

J Acad Nutr Diet. 2016;116:667-676.

Large percentages of children and adolescents have usual intakes of key micronutrients that fall below estimated average requirements.1,2 Excessive intakes of empty calories (eg, solid fats and added sugars)3-5 and sodium6 have also been identified as

poor dietary habits of public health concern. Currently, dietary behavior studies relating meal patterns to dietary intake have focused on breakfast skipping7-12 and consumption of snacks13,14 with few studies investigating the potential for missing lunch to contribute to less healthful dietary intakes.

An analysis of the National Health and Nutrition Examination Survey (NHANES) 2011-2012, from the US Department of Agriculture (USDA), showed that the lunch meal contributes more than 20% to daily intakes of most micronutrients for US children and adolescents consuming lunch.15 Studies examining the National School Lunch Program (NSLP) have

To take the Continuing Professional Education (CPE) quiz for this article, log in to www.eatrightPRO.org, go to the My Account section of the My Academy Toolbar, click the "Access Quiz" link, click "Journal Article Quiz" on the next page, and then click the "Additional Journal CPE quizzes" button to view a list of available quizzes. CPE quizzes are available for 1 year after the issue date in which the articles are published.

© 2016 by the Academy of Nutrition and Dietetics. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

shown that nonparticipation in the NSLP is associated with higher prevalence of micronutrient inadequacies,16 higher intakes of sugar-sweetened beverages, candy, and salty snacks, but lower intakes of baked goods and french fries.17 A limitation of these analyses is that nonparticipants in the NSLP included both children missing lunch and children who brought lunches from home. According to data from the USDA, 7% to 20% of children and adolescents in the United States do not consume lunch on a given day15; therefore, examining differences in the diets of lunch consumers and nonconsumers is needed to provide insight into the extent to which missing lunch is a less healthful dietary behavior than consuming lunch.

The primary objective for this analysis was to determine whether missing lunch was associated with lower daily intakes of micronutrients among US children and adolescents. Prevalence of micronutrient inadequacies is higher among older children and school-aged girls1,16; therefore, the analysis of micronutrients was stratified by age and sex to identify subpopulations of particular concern for low micronutrient intakes. A secondary objective was to determine whether consuming lunch was associated with higher intakes of solid fats, added sugars, and total energy intake. The dietary intakes of micro- and macronutrients from nonlunch sources were examined to determine the extent to which consuming lunch explained any differences in daily intakes between lunch consumers and nonconsumers.

METHODS

Study Population

The 2009-2010 and 2011-2012 NHANES18-22 were combined for this analysis. The survey design is a multistage, stratified area probability sample of noninstitutionalized individuals that is weighted to provide nationally representative estimates for the US population. The sample included 5,155 individuals aged 4 to 18 years of whom 4,755 had complete data for all covariates included in the regression models. This study used publicly available NHANES de-identified data and was exempt from institutional review board approval.

Dietary Intakes

Dietary intakes were obtained from Day 1 interviewer-administered 24-hour dietary recalls using the Automated Multiple-Pass Method.23,24 Recalls were collected by trained interviewers in English or Spanish. Survey participants aged 12 years and older completed the dietary interview on their own, proxy-assisted interviews were conducted with children aged 6 to 11 years, and proxy respondents reported for children aged 5 years and younger. Intakes of 19 vitamins and minerals, total energy, protein, carbohydrate, fat, total sugar, saturated fat, and fiber were analyzed using the Dietary Interview—Individual Foods, First Day data files.25,26 Added sugar and solid fats intakes were analyzed using the 2009-2010 and 2011-2012 Food Patterns Equivalents Databases, which link to the NHANES dietary intake files.27 Micronutrient intakes of lunch consumers and nonconsumers were separated by source to capture two dietary behaviors: food and beverage intake and dietary supplement use. Dietary supplements included vitamins, minerals, herbals, and other dietary supplements as well as nonprescription antacids. Dietary

supplement use on the day of the first 24-hour recall was identified using the Dietary Supplement Use 24-hour—Total Dietary Supplements, First Day data files.28,29

Lunch Consumption Status

Respondents self-reported names for eating occasions in the 24-hour recall. Those reporting "brunch" or "lunch" (in English) and "comida" or "almuerzo" (in Spanish) were considered to be lunch consumers for the purpose of this analysis. The USDA previously defined lunch consumers in an analysis of the NHANES 2011-2012 dataset15 as those reporting "brunch," "lunch," and "comida." We also included "almuerzo" due to the similarity between the time and size of the meal when compared with other eating occasions reported as "lunch."

Nutrient Adequacy Ratios

Nutrient Adequacy Ratios (NARs)30 were calculated as the percentage of the Recommended Dietary Allowance (RDA).31 The RDA is the average daily intake sufficient to meet the needs of 97% to 98% of the population.31 The NAR values for a given micronutrient were calculated to provide context on the potential biological effect for the mean micronutrient intakes of lunch consumers and nonconsumers reported in this study. Comparisons between an RDA value and group averages from a single 24-hour dietary recall are not appropriate to estimate the percentage of individuals in a population who have inadequate usual intakes of a micronutrient.32 For example, wide variability in the micronutrient intake of a group can result in misinterpreting an NAR value of 100% as indicative of low prevalence of nutrient inadequacy. For this study, NAR values are used as a guide to distinguish between the micronutrients where missing lunch had a minimal biological influence (eg, an NAR value >200%) vs micronutrients where missing lunch could have an effect (eg, an NAR value <50%); with greater caution placed on the interpretation of NAR values as they approach 100%.

Statistical Analysis

Analyses were conducted using survey commands in Stata (version 13.1, 2013, StataCorp), which accounted for the complex survey design of the NHANES datasets. Analytical weights based on probabilities of selection and participation in the first 24-hour recall were used, resulting in estimates representative of the US population. Primary sampling units (geographic area) and strata from the first stage of the sampling design were accounted for in estimation of the standard errors. A criteria of (P<0.05) was used for all tests of statistical significance. Results are presented as means or percentages±standard errors. Analyses were conducted for each of the three age groups (4 to 8 years, 9 to 13 years, and 14 to 18 years) separately. On weekends and weekdays, the percentages of children and adolescents missing lunch were calculated using the following formula: (number of children who missed lunch on a weekday/number of children with a dietary recall on a weekday)x 100. The use of dietary supplements on the day of the recall was compared between lunch consumers and nonconsumers using logistic regression models. Linear regression models were used to determine associations of lunch consumption status (lunch consumer vs nonconsumer) with nutrient intakes (ie, are nutrient intakes of lunch consumers different from non-consumers?). All models were adjusted for age, sex, race/

ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other), household income (<130%, 131% to 185%, and >185% of the federal poverty level), and whether the dietary assessment was conducted on a weekend (Saturday or Sunday) or a weekday (Monday to Friday). Distributions of residuals from the regression models were slightly skewed with a few extreme values. The reported differences in intakes between lunch consumers and nonconsumers were not driven by these deviations from normality. For the micronutrient intake analyses, main effects for both sex and lunch consumption were shown in almost all of the micronutrients across the age groups. To show the association for those who missed lunch and those who were girls, the analyses was stratified by sex to allow the most flexible prediction of micronutrient intakes of lunch consumers and nonconsumers for boys and girls in separate models while controlling for the same set of confounders (minus sex). The analysis of micronutrient intakes from nonlunch sources was originally stratified by sex, but the findings were similar for boys and girls; therefore, the results from the combined sample were reported in the main manuscript. Results for the nonlunch source micronutrient analyses stratified by sex are available in Tables 1 and 2 (available online at www. andjrnl.org). Results for the total and nonlunch source macronutrient analyses stratified by sex are available in Tables 3 through 5 (available online at www.andjrnl.org).

RESULTS

The percentage of children and adolescents missing lunch on a given day was 7%±1%, 16%±2%, and 17%±1% for participants aged 4 to 8 years, 9 to 13 years, and 14 to 18 years, respectively (Table 6). Among participants aged 4 to 8 years and 9 to 13 years, missing lunch was more prevalent on the weekend. On weekdays, higher percentages of female participants missed lunch than male participants among both the 9 to 13 years age group (17%±3% vs 11%±3%) and the 14 to 18 years age group (19%±3% vs 15%±2%). Non-Hispanic black and Hispanic participants aged 14 to 18 years had the highest overall prevalence of missing lunch (23%±3% and 25%±2%, respectively). On weekends, approximately 30% of non-Hispanic black children aged 9 to 13 years and 14 to 18 years missed lunch.

Dietary supplement use differed between lunch consumers and nonconsumers for the total sample of 4- to 18-year-old participants, with 19%±1% supplement use among lunch consumers and 11%±2% among nonconsumers (P=0.001; data not shown). Among children aged 4 to 8 years, 26%±2% of lunch consumers and 20%±3% of nonconsumers used dietary supplements on the day of the recall (P=0.13). Among adolescents aged 9 to 13 years, 18%±1% of lunch consumers and 13%±4% of nonconsumers used dietary supplements (P=0.26). Among adolescents aged 14 to 18 years, 13%±1% of lunch consumers and 4%±1% of nonconsumers used dietary supplements (P<0.001).

Micronutrient intakes presented as NAR values are reported in Table 7. Absolute intakes of micronutrient intakes are reported in Table 8 (available online at www.andjrnl.org). Among boys aged 4 to 8 years, mean intakes of vitamin E, vitamin D, vitamin K, and potassium had NAR values <100%, but significant differences were not observed between lunch consumers and nonconsumers. The mean intakes of calcium were significantly different between 4- to 8-year-old male lunch consumers and nonconsumers with 112% of the NAR

value for lunch consumers and 93% of the NAR value for non-consumers. Among 4- to 8-year-old girls missing lunch, the NAR values for mean intakes of vitamin Kand potassium were below 100%, with nonconsumers having significantly lower intakes compared with lunch consumers for both micro-nutrients. Among participants aged 9 to 13 years, micro-nutrient intakes of nonconsumers were significantly lower than lunch consumers, with NAR values <100% for vitamin K, calcium, magnesium, and potassium for both sexes, and vitamin A, vitamin D and phosphorus only among girls. Among participants aged 14 to 18 years, micronutrient intakes of nonconsumers were significantly lower than lunch consumers with NAR values <100% for vitamin A and potassium for both sexes. Among 14- to 18-year-old male non-consumers, NAR values for mean intakes of vitamin C, vitamin D, calcium, and magnesium were <100% and significantly lower than lunch consumers, whereas, NAR values for intakes of vitamin E, copper, iron, and zinc among female nonconsumers were <100% and significantly lower than female lunch consumers. The NAR values for sodium intakes were higher across all age and sex groups among lunch consumers compared with nonconsumers. Female lunch consumers had significantly higher intakes of sodium compared with female non-consumers, whereas among male participants, the sodium intakes were only significantly higher among 14- to 18-year-old lunch consumers compared with nonconsumers (292%± 10% vs 226%±11% of the NAR value).

To determine the extent to which differences between lunch consumers and nonconsumers could be explained by the remainder of the diet, regression models were used to compare the micronutrient intakes from nonlunch sources between lunch consumers and nonconsumers (Table 9). Across all age groups, almost all of the micronutrient intakes from nonlunch sources were lower among lunch consumers as compared with nonconsumers.

The energy and protein intakes of lunch nonconsumers were significantly lower than lunch consumers among participants aged 9 to 13 years and 14 to 18 years (Table 10). Total fat and saturated fat intakes were significantly lower among lunch nonconsumers compared with lunch consumers among participants aged 14 to 18 years. Lunch consumers had significantly higher intakes of fiber compared with nonconsumers. Intakes of total sugar, added sugar, and solid fats were not significantly different between lunch consumers and nonconsumers.

The results from the lunch and nonlunch intake analyses showed that across all age groups intakes of all macronutri-ents from nonlunch sources were significantly lower among lunch consumers than nonconsumers (Table 10). The average energy of lunches consumed was 522, 586, and 740 kcal for participants aged 4 to 8 years, 9 to 13 years, and 14 to 18 years, respectively. Average intake of added sugar at lunch was 15.2, 18.7, and 25.2 g, and intake of solid fat was 10.0, 10.7, and 13.1 g for participants aged 4 to 8 years, 9 to 13 years, and 14 to 18 years, respectively. Average caloric intakes of solid fats/added sugars at lunch were 150, 171, and 219 kcal.

DISCUSSION

Missing lunch was associated with overall lower micro-nutrient intakes, with the lunch meal primarily responsible for the higher micronutrient intakes of lunch

I— O

Table 6. The percentages of children and adolescents who missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

Subject Charateristic 4-8 9-13 14-18

na All days Weekdays Weekendsb na All days Weekdays Weekendsb na All days Weekdays Weekendsb

Sex ) % missing lunch±standard errorcd! ) % missing lunch±standard erroicd! ) % missing lunch±standard errorcd!

Male 1,008 8±2 5±1 15±3 848 14±2 11 ±3 21 ±3 791 16±2 15±2 19±2

Female 909 7±1 5±1 11 ±2 882 18±2 17±3 22±2 717 19±2 19±3 19±2

Race/ethnicity Non-Hispanic white 530 8±2 5±2 15±3 498 18±3 17±4 20±4 428 14±2 14±3 16±3

Non-Hispanic black 440 8±2 5±2 17±3 423 20±2 15±3 32±6 388 23±3 20±4 30±5

Hispanic 711 6±1 6±2 8±2 612 11 ±1 8±1 20±2 502 25±2 26±3 22±3

Other 236 6±2 3±2 10±2 197 11 ±3 9±3 16±5 190 11 ±3 9±3 17±6

Poverty levele 0%-130% 926 8±1 6±2 13±2 724 13±2 9±2 24±4 583 21 ±2 19±3 25±4

131%-185% 234 7±3 0.1 ±0.1 18±6 212 16±3 13±4 22±5 191 16±6 17±7 13±5

>185% 629 7±2 4±3 12±3 661 17±3 16±4 18±4 595 15±2 14±2 18±3

Total sample 1,917 7±1 5±1 13±2 1,730 16±2 14±2 21 ±2 1,508 17±1 17±2 19±2

aTotalsample sizes for each subject characteristic across the three age groups.

Saturday and Sunday were classified as the weekend.

Percentages were calculated as (number of children who missed lunch on a weekday/number of children with a dietary recallon a weekday)x 100. dNationally representative estimates taking into account the survey design of the NationalHealth and Nutrition Examination Surveys. eHousehold poverty level as a percentage of the federal poverty guidelines.

Table 7. Daily micronutrient intakes from foods and beverages expressed as Nutrient Adequacy Ratios (NARs) for children and adolescents who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

N C T I

A Z O D

№ si

Boys Girls Boys Girls Boys Girls

Lunch Missing Lunch Missing Lunch Missing Lunch Missing Lunch Missing Lunch Missing

Nutrient Consumer Lunch Consumer Lunch Consumer Lunch Consumer Lunch Consumer Lunch Consumer Lunch

mo^n MAD

Thiamin 254±6 234±12 232±5 197±12* 195±6 147±10* 168±7 134±9* 178±6 124±9* 143±5 121 ±7*

Riboflavin 334±6 320±16 306±6 237±20* 245±7 201 ±16* 208±7 165± 11 * 189±6 155±12* 173±6 150±8*

Niacin 246±4 254±18 230±5 188±11* 197±5 186±22 172±6 131 ±13* 194±6 144±9* 148±5 122±6*

Vitamin B-6 267±5 283±14 251 ±5 198± 16* 180±6 186±23 164±7 127± 11 * 184±6 147±13* 132±5 107±8*

Folate (DFE)c 261 ±7 223±19* 237±7 204±21 198±10 140± 12* 172±7 133±5* 175±9 128± 11 * 122±6 104±7*

Vitamin B-12 409±8 412±28 356±8 298±27 310±20 271 ±27 247±9 203±17* 280±11 225±20* 179±13 139±14*

Vitamin C 335±14 290±48 319±14 257±27* 165±9 160±24 156±9 162±28 135±16 94±16* 103±6 90±12

Vitamin A 160±3 145±12 146±4 109±9* 112±6 102±11 96±4 72±10* 77±3 62±6* 71 ±4 63±4*

Vitamin E 87±2 86±16 85±2 73±6 64±2 60±6 58±3 47±6 57±2 51 ±4 46±3 36±2*

Vitamin Kd 97±4 87±12 104±4 74±10* 113±6 83±10* 110±8 76±8* 100±9 93±16 86±8 81 ±9

Vitamin D 46±1 42±3 39±1 30±4 43±2 38±4 35±2 26±4* 46±2 37±4* 30±2 27±3

Calcium 112±2 93±6* 99±3 84±8 89±3 71 ±6* 78±2 62±5* 101 ±3 81 ±6* 75±3 67±6

Phosphorus 255±4 233±15 235±4 198±13* 115±3 98±7 99±2 78±4* 137±4 107±5* 100±3 88±8

Copper 216±5 204±13 205±7 172± 11 * 158±7 132±14 136±4 114±9* 151 ±6 112±7* 114±4 90±5*

Iron 138±3 130±8 128±3 109±9 198±8 162±12* 174±6 141 ±8* 174±4 132±8* 86±2 73±5*

Magnesium 178±3 161 ±11 168±4 145±12 107±3 89±7* 95±2 79±5* 77±2 61 ±3* 65±2 57±4

Zinc 196±3 194±14 178±4 151 ±12* 145±5 112±10* 120±4 103±7* 129±4 104±8* 105±3 86±6*

Potassiumd 59±1 58±4 54±1 44±3* 53±1 45±4* 48±1 38±3* 63±2 48±3* 44±1 37±2*

Sodiumd 239 5 224 16 220 4 193±10* 228 5 209 15 202 5 150±10* 292 10 22^±11* 212±5 183±13*

aNAR was calculated by dividing the average intakes from one 24-hour recallby the population specific Recommended Dietary Allowance or Adequate Intake and multiplying this ratio by 100.

Nationally representative estimates taking into account the survey design of the NationalHealth and Nutrition Examination Surveys. cDFE=dietary folate equivalents. 1 DFE=1 mg food folate=0.6 mg folic acid from fortified food.

dRecommened Dietary Allowances have not been established for these micronutrients; therefore, the NAR % was calculated using Adequate Intakes. indicates a significant difference between the micronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

0> SI KJ

Table 9. Daily micronutrient intakes from lunch and nonlunch sources from foods and beverages for children and adolescents who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

Nutrient 4-8 9-13 14-18

Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch

Luncha Nonlunch Luncha Nonlunch Luncha Nonlunch

<—mean±standard errorb—> <—mean±standard errorb—> <—mean±standard errorb—>

Thiamin (mg) 0.41 1.05±0.02 1.32±0.06* 0.46 1.17±0.03 1.26±0.07 0.60 1.19±0.04 1.35±0.05*

Riboflavin (mg) 0.48 1.44±0.02 1.71 ±0.08* 0.51 1.51 ±0.04 1.62±0.10 0.57 1.50±0.05 1.75±0.07*

Niacin 5.6 13.5±0.3 18.3±0.9* 6.5 15.6±0.4 18.4±1.9 8.8 17.1 ±0.5 20.1 ±0.7*

Vitamin B-6 (mg) 0.38 1.18±0.02 1.49±0.08* 0.42 1.30±0.04 1.51 ±0.16 0.58 1.42±0.05 1.60±0.09

Folate, DFEc (mg) 123 377±10 435±32 136 416±17 408±18 172 424±19 468±21

Vitamin B-12 (mg) 1.14 3.46±0.06 4.39±0.28* 1.28 3.69±0.12 4.16±0.32 1.62 3.88±0.18 4.33±0.27

Vitamin C (mg) 20.3 61.7±2.3 68.5±7.2 19.9 52.1 ±2.2 71.9±7.4* 20.2 64.0±6.0 65.2±6.9

Vitamin A (mg) 151 463±10 512±31 162 457±17 505±53 155 439±20 500±28*

Vitamin E (mg) 1.80 4.21 ±0.10 5.66±0.65* 1.99 4.72±0.16 5.77±0.55 2.45 5.29±0.26 6.48±0.35*

Vitamin K (mg) 18.5 36.6±1.5 45.1 ±4.3 19.4 47.3±3.2 47.2±4.3 24.0 46.1 ±4.1 65.2±7.0*

Vitamin D (mg) 1.69 4.70±0.11 5.42±0.41 1.42 4.41 ±0.18 4.53±0.48 1.50 4.25±0.22 4.71 ±0.37

Calcium (mg) 317 744±17 877±45* 320 759±21 841 ±58 364 784±23 961 ±43*

Phosphorus (mg) 374 853±14 1,089±49* 410 917±17 1,074±59* 499 985±21 1,229±55*

Copper (mg) 276 652±15 840±40* 327 698±13 854±59* 370 811 ±26 897±28*

Iron (mg) 3.3 10.0±0.2 12.3±0.06* 3.8 11.0±0.3 12.0±0.7 4.7 11.3±0.3 12.8±0.5*

Magnesium (mg) 65 160±3 201 ±9* 71 171 ±3 199± 11 * 83 193±4 230±7*

Zinc (mg) 2.57 6.82±0.13 8.86±0.50* 2.98 7.54±0.22 8.57±0.52 3.84 8.03±0.22 9.50±0.43*

Potassium (mg) 658 1,491 ±22 1,971 ±101* 693 1,574±30 1,835±116* 806 1,713±42 1,995±67*

Sodium (mg) 925 1,834±42 2,554±108* 1,097 2,113±39 2,635±180* 1421 2,362±56 3,056±152*

aMicronutrient intakes at lunch were calculated by subtracting the nonlunch intakes shown above from the totalmicronutrient intakes from a nonstratified modelestimating totalmicronutrient intakes from foods and beverages for male and female participants combined.

bNationally representative estimates taking into account the survey design of the NationalHealth and Nutrition Examination Surveys. cDFE=dietary folate equivalents. 1 DFE=1 mg food folate=0.6 mg folic acid from fortified food.

*Significant difference between the nonlunch micronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

Table 10. Daily macronutrient intakes from lunch and nonlunch sources among children and adolescents who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

Nutrient 4-8 9-13 14-18

Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch

Luncha Nonlunch Luncha Nonlunch Luncha Nonlunch

) mean±standard errorb / ) mean±standard erroib / ) mean±standard errorb/

Energy (kcal) 522 1,282±16 1,697±58c 586 1,386±23 1,765±84cd 740 1,522±31 1,936±60cd

Protein (g) 20.3 42.3±0.6 58.6±3.3c 23.2 47.6±0.8 58.7±4.5cd 30.2 53.0±1.3 65.8±2.cd

Total fat (g) 19.2 45.6±0.9 62.4±3.1c 22.4 49.3±1.0 64.3±5.0c 29.2 53.9±1.3 71.9±3.7cd

Saturated fat (g) 7.0 16.4±0.4 21.5 ±1.2c 7.7 17.4±0.4 22.3±1.7c 9.6 18.7±0.5 24.1 ±1.4cd

Carbohydrate (g) 67 180±2 230±8cd 74 192±4 244±11c 90 209±5 260±8cd

Total sugar (g) 30 93±2 114±6c 31 94±2 128±8c 37 105±3 132±6c

Fiber (g) 4.3 9.2±0.1 11.7±0.6cd 4.7 10.0±0.2 11.6±0.6cd 5.1 10.6±0.3 12.0±0.4cd

Added sugar (g) 15.2 55.3±1.3 73.8±5.2c 18.7 61.8±2.3 88.0±5.2c 25.2 71.7±2.9 99.2±6.2c

Solid fat (g) 10.0 25.0±0.6 33.0±2.3c 10.7 26.2±0.7 35.3±3.0c 13.1 27.3±0.9 35.7±2.3c

-n N C T I

A Z O D

aMacronutrient intakes at lunch were calculated by subtracting the nonlunch intakes shown above from totalday micronutrient intakes predicted from models estimating totalmicronutrient intakes from foods and beverages for male and female participants combined.

Nationally representative estimates taking into account the survey design of the NationalHealth and Nutrition Examination Surveys. Significant difference between the nonlunch macronutrient intakes of lunch consumers and children who missed lunch (P<0.05). Significant difference between the totalday macronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

consumers compared with nonconsumers. Previous studies on the lunch meal have examined the nutritional content of the NSLP33,34 and compared dietary intakes between NSLP participants and nonparticipants.16 Participation in the NSLP has been associated with lower prevalence of micronutrient inadequacies, especially among adolescents,16 but nonparticipants included children who missed lunch or brought lunches from home or another source. This study is the first to provide insights on the potential of missing lunch to be a public health concern from a dietary intake perspective.

Reporting micronutrient intakes as NAR values (percentage of the RDA) can be used to help distinguish between the micronutrients where consumption of lunch had a minimal biological effect and micronutrients where missing lunch could have influenced nutrient adequacies among children and adolescents. For instance, the average daily intakes of most B vitamins among both lunch consumers and non-consumers were well above the RDA value, which is the average daily intake sufficient to meet the needs of 97% to 98% of the population.31 These results indicate that missing lunch had minimal influence on meeting required intakes of B vitamins for the majority of children and adolescents, but noteworthy to mention a potential concern for B vitamin intakes among girls aged 14 to 18 years missing lunch, especially for folate intakes (104%±7% of the NAR value). This concern is supported by previous studies among children and adolescents showing that only girls aged 14 to 18 years have prevalence of inadequate intakes of B vitamins >4%,1,16 with prevalence of inadequate intakes of folate ranging from 16% to 24%.1Д6

Average daily intakes of fat-soluble vitamins (ie, A, D, E, and K) fell below the RDA and were significantly lower among lunch nonconsumers in many instances, except for boys aged 4 to 8 years. Among older children and adolescents, average daily intakes of minerals (ie, calcium, phosphorus, copper, iron, magnesium, zinc, and potassium) fell below the RDA and were also significantly lower among lunch nonconsumers in many instances. Previous studies have shown higher prevalence of inadequate intakes for minerals and fat-soluble vitamins among older children and female participants.1,16 The results from this study indicate that missing lunch could partially explain inadequate intakes of fat-soluble vitamins and minerals among subpopulations with higher percentages of missing lunch, particularly among girls aged 9 to 13 years and all participants aged 14 to 18 years.

Total daily energy intakes of lunch consumers were higher than nonconsumers for all age and sex groups and statistically significant among those aged 9 to 13 years and 14 to 18 years. The results from the nonlunch source analysis indicated that the calories consumed at lunch were primarily responsible for the higher micronutrient intakes observed. In addition to previous findings on dieting and unhealthy weight control among adolescents,35 we caution against interpreting the lower caloric intakes among lunch non-consumers as a potential weight-loss strategy based on the findings that lower fiber and micronutrient intakes were observed among nonconsumers.

These results of the empty calorie and sodium intakes raise concern with regard to the quality of lunches consumed by children and adolescents in the United States. The quality of

the NSLP33,34 and lunches brought to school36-38 have previously been questioned and new standards for the NSLP are currently being implemented.39 Competitive foods sold in school cafeterias40 and fast-food intake could also provide explanations for high intakes of less healthful dietary components at lunch. Continual monitoring of the quality of all lunches consumed in and out of school is needed to measure the overall effectiveness of changes in policies, but also to identify new areas to target for improving the quality of lunch meals consumed.

Previous studies have noted that multiple unmeasured factors such as attitudes toward healthful eating or dietary preferences could confound associations between consuming lunch and total dietary intake.16,41 Comparing total nonlunch sources of nutrients between lunch consumers and non-consumers was used to address this issue and provides two benefits: the ability to estimate the extent to which lunch contributed to higher total day nutrient intakes among children that consumed lunch compared with those that missed lunch, and comparing the remainder of the diet (nonlunch sources) allows understanding the extent to which other dietary behaviors differ between these two groups aside from lunch consumption. The results showed that across all age groups, almost all of the micronutrient intakes from nonlunch sources were lower and/or not significantly different among lunch consumers compared with nonconsumers. This demonstrates that lunch was primarily responsible for the higher intakes of micronutrients among lunch consumers compared with nonconsumers. To help explain why micro-nutrient intakes from the remainder of the diet were higher among lunch nonconsumers, future research is needed to examine what, if anything, nonconsumers substitute in the place of a lunch meal, their consumption at other meal occasions, and other dietary behaviors. An interesting finding from this analysis was that lunch nonconsumers were less likely to use dietary supplements. This is particularly concerning given that micronutrient intakes from foods and beverages were lower among children and adolescents missing lunch. Future research is needed to understand why children miss lunch and factors that affect the quality and amount of lunch consumed.42 Additional studies examining food and beverage sources of nutrients can also provide further insight into how the diets of lunch consumers and nonconsumers differ.

A limitation of this analysis was that different definitions of what constitutes a lunch meal between respondents could lead to misclassification errors and attenuated associations. Respondents self-reported meal designation of the lunch meal, and for this research, included "lunch," "brunch," "comida," and "almuerzo." Currently, a clear standard definition of a lunch meal (whether based on name, time of consumption, or food and beverage components) has not been established. A second limitation is that an analysis of a single 24-hour recall prevents understanding whether children who missed lunch on the first recall day made up for lower micronutrient intakes on other days of the week, or how many days a week children usually miss lunch. Using single-day intakes to assess nutrient adequacy should be interpreted with caution,32 and the implications of these finding will depend on the frequency with which children miss lunch (eg, whether some children miss lunch on a regular basis or whether most children miss lunch at least once throughout a

week). Lastly, the dietary intakes of children and adolescents were self- or proxy reported/assisted based on the age of the child. The age of the child was included in the regression models to minimize potential differential misreporting bias when estimating differences between lunch consumers and nonconsumers; however, the point estimates could be affected by over- and/or underreporting within the different

age groups.43'44

CONCLUSIONS

A large percentage of children and adolescents are missing lunch on both weekdays and weekends, and the lunch meal is an important source of both essential nutrients as well as less healthful dietary components. These findings are the first to identify potential concerns for children missing lunch with respect to micronutrient intakes, but also raise concerns over the empty calorie and sodium contents of lunches consumed by children and adolescents in the United States.

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17. Briefel RR Wilson A, Gleason PM. Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants. J Am Diet Assoc. 2009;109(2 suppl):S79-S90.

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29. National Health and Nutrition Examination Survey 2011-2012 dietary data. Dietary supplement use 24-hour - total dietary supplements, first day. http://wwwn.cdc.gov/nchs/nhanes/search/DataPage.aspx? Component=Dietary&CycleBeginYear=2011. Accessed April 15, 2015.

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33. Crepinsek MK, Gordon AR, McKinney PM, Condon EM, Wilson A. Meals offered and served in US public schools: Do they meet nutrient standards? J Am Diet Assoc. 2009;109(suppl):S31-S43.

34. Nutrition standards in the National School Lunch and School Breakfast Programs: Final rule. http://www.gpo.gov/fdsys/pkg/FR-2 012-01-26/pdf/2012-1010.pdf. Accessed April 3, 2015.

35. Neumark-Sztainer D, Wall M, Story M, Standish AR. Dieting and unhealthy weight control behaviors during adolescence: Associations with 10-year changes in body mass index. J Adolesc Health. 2012;50(1):80-86.

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37. Farris AR, Misyak S, Duffey KJ, et al. Nutritional comparison of packed and school lunches in pre-kindergarten and kindergarten

children following the implementation of the 2012-2013 National School Lunch Program standards. J Nutr Educ Behav. 2014;46(6): 621-626.

38. Stallings VA. Is lunch from home better than the school cafeteria? JAMA Pediatr. 2015;169(1):16-17.

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40. Competititve foods in schools. http://www.cdc.gov/healthyyouth/ nutrition/standards.htm. Accessed February 18, 2015.

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among U.S. school children aged 6 to 17 years. J Nutr. 2013;143(5): 714-721.

42. Cohen JFW, Jahn JL, Richardson S, Cluggish SA, Parker E, Rimm EB. Amount of time to eat lunch is associated with children's selection and consumption of school meal entrée, fruits, vegetables, and milk. J Acad Nutr Diet. 2016;116(1):123-128.

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AUTHOR INFORMATION

K. C. Mathias is an associate research specialist and A. L. Eldridge is an expert scientist, Nestlé Research Center, is a scientist, Nestlé Infant Nutrition, Florham Park, NJ. Lausanne, Switzerland. E. Jacquier

Address correspondence to: Alison L. Eldridge, PhD, RD, Nestlé Research Center, Vers-chez-les-Blanc, 1000 alison.eldridge@rdls.nestle.com Lausanne-26, Switzerland. E-mail:

STATEMENT OF POTENTIAL CONFLICT OF INTEREST

All authors are employed by the Nestlé Research Center, Lausanne Switzerland (Nestec Ltd).

FUNDING/SUPPORT

Funding was provided by Nestec Ltd (Vevey, Switzerland).

Table 1. Daily micronutrient intakes from lunch and nonlunch sources from foods and beverages for boys who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

l— O

-n N C T I

A Z O D

№ si

Nutrient 4-8 9-13 14-18

Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch

Luncha Nonlunch Luncha Nonlunch Luncha Nonlunch

<—mean±standard error—> <—mean±standard error—> <—mean±standard error—>

Thiamin (mg) 0.42 1.10±0.03 1.42±0.05* 0.53 1.22±0.05 1.34±0.09 0.69 1.44±0.06 1.49±0.10

Riboflavin (mg) 0.50 1.51 ±0.03 1.92±0.09* 0.59 1.61 ±0.08 1.82±0.14 0.66 1.80±0.07 2.02±0.16

Niacin (mg) 5.7 13.9±0.3 20.7±1.4* 7.5 16.2±0.7 22.6±2.6* 10.5 20.5±0.7 23.2±1.4

Vitamin B-6 (mg) 0.39 1.21 ±0.03 1.72±0.09* 0.46 1.34±0.07 1.87±0.26 0.68 1.71 ±0.08 1.92±0.17

Folate, DFEa (mg) 131 392±13 453±38 154 439±28 422±36 185 517±31 518±45

Vitamin B-12 (mg) 1.19 3.71 ±0.09 4.99±0.34* 1.58 4.00±0.26 4.90±0.47 1.79 4.92±0.27 5.42±0.48

Vitamin C (mg) 21.9 62.0±3.2 72.6±11.9 19.9 54.2±3.3 70.6±10.6 21.7 79.7±12.0 70.5±12.6

Vitamin A (mg) 151 487±12 574±46 189 483±27 608±67 159 530±28 568±53

Vitamin E (mg) 1.89 4.19±0.13 6.04±1.09 2.22 4.81 ±0.21 6.65±0.62* 2.75 5.75±0.31 7.62±0.59*

Vitamin K (mg) 18.9 34.2±1.8 47.4±6.6 22.3 45.5±3.3 49.7±5.8 23.1 52.2±6.5 69.7±11.9

Vitamin D (mg) 1.76 5.14±0.15 6.25±0.49* 1.56 4.88±0.33 5.48±0.57 1.69 5.28±0.31 5.48±0.59

Calcium (mg) 339 785±19 919±57* 351 805±41 900±78 402 914±33 1,053±76

Phosphorus (mg) 386 888±16 1169±75* 459 975±37 1,226±89* 562 1,154±34 1,349±65*

Copper (mg) 288 662±14 901 ±58* 382 727±25 933±100 411 933±34 993±61

Iron (mg) 3.5 10.3±0.3 13.2±0.8* 4.3 11.6±0.6 13.0±1.0 5.4 13.7±0.4 14.6±0.9

Magnesium (mg) 68 164±3 210±14* 78 178±6 212±17 93 224±6 253±13*

Zinc (mg) 2.67 7.15±0.16 9.80±0.71* 3.41 8.17±0.38 9.08±0.77 4.54 9.70±0.33 11.43±0.91

Potassium (mg) 674 1,549±30 2,204±133* 756 1,648±48 1,995±159 922 2,033±72 2,226±139*

Sodium (mg) 966 1,901 ±54 2,721 ±190* 1,220 2,220±60 3,185±227* 1,628 2,751 ±95 3,361 ±164*

DFE=dietary folate equivalents. 1 DFE=1 mg food folate=0.6 mg folic acid from fortified food.

aMicronutrient intakes at lunch were calculated by subtracting the predicted nonlunch intakes shown above from the totalmicronutrient intakes reported in Table 8 (available online at www.andjrnl.org). indicates a significant difference between the nonlunch micronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

01 si 01

Table 2. Daily micronutrient intakes from lunch and nonlunch sources from foods and beverages for girls who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

Nutrient 4-8 9-13 14-18

Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch

Luncha Nonlunch Luncha Nonlunch Luncha Nonlunch

<-mean±standard error-> <-mean±standard error-> <-mean±standard error->

Thiamin (mg) 0.39 1.00±0.03 1.18±0.07* 0.39 1.12±0.06 1.20±0.09 0.49 0.94±0.05 1.20±0.06*

Riboflavin (mg) 0.47 1.36±0.03 1.41 ±0.12 0.45 1.43±0.07 1.47±0.10 0.53 1.20±0.07 1.49±0.07*

Niacin (mg) 5.4 13.0±0.4 15.1 ±0.9* 5.6 15.0±0.6 15.6±1.6 7.2 13.6±0.6 17.0±0.8*

Vitamin B-6 (mg) 0.37 1.14±0.03 1.18±0.10 0.39 1.26±0.07 1.27±0.11 0.47 1.11 ±0.05 1.28±0.09

Folate, DFEa (mg) 114 361±13 408±41 121 397±22 396±18 159 329±25 416±30*

Vitamin B-12 (mg) 1.09 3.18±0.08 3.54±0.32 1.02 3.43±0.19 3.61 ±0.32 1.47 2.81 ±0.13 3.32±0.30

Vitamin C (mg) 18.5 61.3±2.8 63.5±6.9 19.8 50.3±2.6 72.7±12.5 18.7 48.1 ±3.1 58.5±7.7

Vitamin A (mg) 151 434±13 426±38 139 435±25 428±61 153 346±26 436±25*

Vitamin E (mg) 1.70 4.24±0.14 5.12±0.42 1.78 4.65±0.26 5.16±0.69 2.14 4.83±0.43 5.43±0.35

Vitamin K (mg) 18.0 39.3±2.0 41.2±5.7 16.8 48.9±4.3 45.4±5.1 24.9 39.9±4.0 60.8±6.8*

Vitamin D (mg) 1.61 4.20±0.12 4.36±0.56 1.30 4.00±0.28 3.80±0.60 1.32 3.19±0.33 3.97±0.45

Calcium (mg) 291 697±21 824±81 294 719±32 793±70 326 651 ±30 870±76*

Phosphorus (mg) 360 815±20 981 ±63* 368 867±31 965±59 436 812±35 1,103 ±94*

Copper (mg) 262 641 ±28 750±51* 280 675±22 795±65 328 686±35 800±42*

Iron (mg) 3.1 9.7±0.3 10.9±0.9 3.3 10.6±0.5 11.2±0.7 4.03 8.84±0.44 10.93±0.74*

Magnesium (mg) 62 157±4 187±16 64 165±5 189±13 74 161 ±6 205 ±13*

Zinc (mg) 2.46 6.44±0.17 7.54±0.56 2.60 6.99±0.31 8.16±0.58 3.13 6.32±0.33 7.70±0.50*

Potassium (mg) 640 1,425±32 1,658± 111 * 637 1,509±47 1,721 ±129 688 1,384±69 1,734±101*

Sodium (mg) 990 1,758±42 2,333±123* 987 2,038±72 2,254±155 1214 1,968±71 2,733±197*

DFE=dietary folate equivalents. 1 DFE=1 mg food folate=0.6 mg folic acid from fortified food.

aMicronutrient intakes at lunch were calculated by subtracting the predicted nonlunch intakes shown above from the total micronutrient intakes reported in Table 8 (available online at www.andjrnl.org). indicates a significant difference between the nonlunch micronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

Table 3. Daily macronutrient intakes from foods and beverages among children and adolescents who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

c fD 4-8 9-13 14-18

6 Males Females Males Females Males Females

N c 3 u~ CD Nutrient Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch

-mean±standard error-

I— O

Energy (kcal) 1,860±20 1,794±103 1,740±28 1,527±82* 2,114±44 2,016±121 1,849±42 1,581 ±73* 2,611 ±70 2,158±122* 1,908±41 1,710±110

Protein (g) 64.9±0.9 64.8±5.0 60.0±1.1 49.6±3.5* 77.4±1.5 67.3±6.1 65.2±1.6 52.7±4.3* 98.3±3.3 74.1 ±4.5* 67.8±2.0 56.9±2.7*

Total fat (g) 66.9±1.0 65.1 ±5.5 63.9±1.3 56.3±3.2* 77.0±1.7 78.0±6.3 67.3±1.9 54.2±5.1* 93.1 ±2.9 85.0±6.1 73.0±1.7 59.6±3.9*

Saturated fat (g) 24.0±0.5 22.6±2.1 22.7±0.6 19.5±1.3* 26.9±0.6 27.2±2.3 23.5±0.7 18.8±1.7* 31.7±1.2 28.5±2.3 24.8±0.7 20.1 ±1.8*

Carbohydrate (g) 255±4 242±13 237±4 211 ±12* 284±7 267±15 252±6 227±13 349±9 279±18* 248±6 240±19

Total sugar (g) 128±2 122±9 116±2 102±8 134±4 139±9 118±3 120±12 166±6 138±12* 117±4 125±15

Fiber (g) 13.6±0.2 11.8± 1.0 13.4±0.3 11.6±0.9 15.4±0.4 11.5± 1.0* 14.2±0.4 11.8±0.6* 18.3±0.5 13±0.7* 13.2±0.3 10.9±0.5*

Added sugar (g) 74.3±1.8 78.8±7.0 66.1 ±1.8 64.3±6.1 86.2±3.9 98.9±8.1 75.7±2.9 79.1 ±7.0 111 ±5 101 ±9 82.1 ±3.3 96.8±14.4

Solid fat (g) 36.1 ±0.8 34.6±4.3 33.8±1.1 29.6±1.6* 40.1 ±1.2 42.6±4.0 34.3± 1.1 30.0±3.1 45.1 ±2.1 42.8±3.7 35.7±1.4 29.1 ±2.8

indicates a significant difference between the nonlunch macronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

A Z O D

01 si 01

Table 4. Daily macronutrient intakes from lunch and nonlunch sources from foods and beverages for boys who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

Nutrient 4-8 9-13 14-18

Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch

Luncha Nonlunch Luncha Nonlunch Luncha Nonlunch

<—mean±standard error—> <—mean±standard error—> <—mean±standard error—>

Energy (kcal) 542 1,318±18 1,812±101* 660 1,455±39 2,028±119* 828 1,784±49 2,164±116*

Protein (g) 20.7 44.2±0.8 65.3±5.2* 26.5 50.9±1.6 67.7±6.1* 35.3 63.0±2.1 74.5±4.3*

Total fat (g) 20.8 46.2±1.0 65.9±5.5* 25.4 51.6±1.4 78.8±6.1* 31.7 61.4±1.9 84.9±5.9*

Saturated fat (g) 6.2 16.8±0.4 22.7±2.1* 8.6 18.3±0.6 27.4±2.3* 10.4 21.3±0.7 28.5±2.2*

Carbohydrate (g) 70 186±3 244±12* 83 201 ±6 268±14* 101 248±7 280±18

Total sugar (g) 30.9 97.3±2.2 122.9±8.7* 34 100±4 140±9* 41 125±5 139±12

Fiber (g) 4.4 9.2±0.2 11.7±1.0* 5.2 10.1 ±0.3 11.5±1.0 5.9 12.4±0.4 13.1 ±0.7

Added sugar (g) 15.7 58.6±1.9 80.2±7.0* 21.2 65.0±3.2 100.1 ±7.7* 26.5 84.9±4.3 102.6±8.9

Solid fat (g) 10.4 25.7±0.8 34.9±4.2* 12.0 43.0±4.1 28.0±1.1* 13.8 31.4±1.4 42.7±3.4*

aMacronutrient intakes at lunch were calculated by subtracting the predicted nonlunch intakes shown above from the totalday macronutrient intakes reported in Table 3 (available online at www.andjrnl.org). indicates a significant difference between the nonlunch macronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

Table 5. Daily macronutrient intakes from lunch and nonlunch sources from foods and beverages for girls who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

l— O

-n N C T I

A Z O D

№ si

Nutrient 4-8 9-13 14-18

Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch Lunch Consumer Missing Lunch Nonlunch

Luncha Nonlunch Luncha Nonlunch Luncha Nonlunch

<—mean±standard error—> <—mean±standard error—> <—mean±standard error—>

Energy (kcal) 500 1,241 ±24 1,535±82* 523 1,327±51 1,577±78* 654 1,255±38 1,705±106*

Protein (g) 19.8 40.2±0.9 49.5±3.4* 20.5 44.7±1.5 52.3±4.5 25.0 42.8±2.0 56.9±2.7*

Total fat (g) 18.9 44.9±1.2 57.0±3.3* 19.9 47.4±1.9 54.1 ±5.4 26.7 46.3±1.7 59.4±3.8*

Saturated fat (g) 6.6 16.0±0.5 19.7±1.3* 6.9 16.6±0.7 18.6±1.8 8.9 15.9±0.6 20.0±1.8*

Carbohydrate (g) 64 174±4 211 ±12* 67 185±6 227±13* 79 169±5 239±18*

Total sugar (g) 29.2 87.6±1.8 101.4±7.9 28.5 89.8±3.2 119.7±11.4* 33.8 83.4±3.2 124.6±14.1*

Fiber (g) 4.1 9.3±0.3 11.5±0.9* 4.2 9.9±0.3 11.8 ±0.6* 4.4 8.8±0.3 10.8±0.5*

Added sugar (g) 14.5 51.6±1.6 65.2±6.1* 16.6 59.1 ±2.7 79.2±6.6* 24.0 58.1 ±2.9 95.4±13.8*

Solid fat (g) 9.5 24.3±0.8 30.0±1.6* 9.6 24.7±1.1 29.8±3.2 12.4 23.3±0.9 29.1 ±2.7*

aMacronutrient intakes at lunch were calculated by subtracting the predicted nonlunch intakes shown above from the totalday macronutrient intakes reported in Table 3 (available online at www.andjrnl.org). indicates a significant difference between the nonlunch macronutrient intakes of lunch consumers and children who missed lunch (P<0.05).

Ol si Ol

Table 8. Daily micronutrient intakes from foods and beverages among children and adolescents who consumed or missed lunch on the first 24-hour dietary recall in the combined National Health and Nutrition Examination Surveys 2009-2010 and 2011-2012

Age Group (y)

Nutrient

4-8 9-13 14-18

Boys Girls Boys Girls Boys Girls

Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch Lunch Missing Consumer Lunch

-mean±standard error-

Thiamin (mg) 1.52±0.03 1.40±0.07 1.39±0.03 1.18±0.07* 1.75±0.06 1.33±0.09* 1.51 ±0.06 1.21 ±0.06* 2.13±0.08 1.49±0.10* 1.43±0.05 1.21 ±0.07*

Riboflavin (mg) 2.00±0.03 1.92±0.10 1.83±0.03 1.42±0.12* 2.20±0.07 1.81 ±0.15* 1.88±0.06 1.48±0.10* 2.46±0.08 2.02±0.16* 1.73±0.06 1.50±0.08*

Niacin (mg) 19.6±0.4 20.3±1.4 18.4±0.4 15.0±0.8* 23.7±0.6 22.3±2.6 20.7±0.7 15.7±1.5* 31.0±1.0 23.0±1.4* 20.8 ±0.7 17.0±0.8*

Vitamin B-6 (mg) 1.60±0.03 1.70±0.09 1.51 ±0.03 1.19±0.09* 1.80±0.06 1.86±0.26 1.64±0.07 1.27±0.11* 2.40±0.08 1.91 ±0.17* 1.59±0.06 1.29±0.09*

Folate, DFEa (mg) 523±15 447±38* 474±13 408±42 593±30 421 ±35* 517±22* 399±16* 702±34 512±46* 488±25 418±29*

Vitamin B-12 (mg) 4.90±0.09 4.95±0.30 4.27±0.10 3.58±0.32 5.58±0.18 4.88±0.53 4.45±0.16 3.65±0.30* 6.71 ±0.26 5.40±0.48* 4.29±0.31 3.34±0.34*

Vitamin C (mg) 83.9±3.6 72.6±12.1 79.8±3.5 64.2±6.7* 74.2±4.0 72.2±11.0 70.1 ±3.9 72.8±12 101.4±2.1 70.2±12.3* 66.8±4.2 58.5±7.6

Vitamin A (mg) 639±14 578±48 585±14 434±39* 671 ±36 613±68 574±26 431 ±61* 688±29 562±29* 499±26 438±25*

Vitamin E (mg) 6.08±0.15 5.97±1.11 5.94±0.15 5.11 ±0.40 7.03±0.23 6.65±0.64 6.42±0.28 5.14±0.68 8.50±0.35 7.63±0.58 6.97±0.43 5.44±0.36*

Vitamin K (mg) 53.1 ±2.4 47.6±6.7 57.3±1.9 40.9±5.6* 67.8±3.6 49.9±3.6* 65.7±4.6 45.6±4.9* 75.2±6.9 69.7±12.1 64.8±5.8 61.0±6.9

Vitamin D (mg) 6.90±0.18 6.28±0.52 5.81 ±0.15 4.51 ±0.59 6.44±0.33 5.65± 0.57 5.30±0.25 3.89*±0.60 6.97±0.36 5.51 ±0.61* 4.51 ±0.34 3.98±0.46

Calcium (mg) 1,125±21 928±63* 988±24 836±82 1156±37 920±79* 1012±26 801 ±69* 1316±45 1056±75* 978±37 872±76

Phosphorus (mg) 1,274±20 1,167±76 1,175±22 988±63* 1,434±34 1,230±90 1,234±31 972±56* 1,717±50 1,343±66* 1,248±32 1,106±94

Copper (mg) 950±20 898±57 903±30 758±50* 1108±50 927±99 954±25 797±62* 1345±49 995±63* 1014±40 804±45*

Iron (mg) 13.8±0.3 13.0±0.8 12.8±0.3 10.9±0.9 15.9±0.6 13.0±1.0* 13.9±0.5 11.3±0.6* 19.2±0.5 14.5±0.9* 12.9±0.4 11.0±0.8*

Magnesium (mg) 231 ±4 209±14 218±5 188±16 256±6 212±17* 229±5 190± 13* 316±8 252±13* 235±6 206±14

Zinc (mg) 9.82±0.14 9.72±0.70 8.90±0.19 7.55±0.58* 11.59±0.39 8.99±0.77* 9.58±0.30 8.22±0.54* 14.24±0.39 11.41 ±0.92* 9.45±0.31 7.72±0.51*

Potassium (mg) 2,223±37 2,205±137 2,064±41 1,683±107* 2,405±50 2,009±160* 2,146±50 1,728±128* 2,956±93 2,257±142* 2,072±68* 1,736±97*

Sodium (mg) 2,867±65 2,685±191 2,637±49 2,315±119* 3,421 ±71 3,140±226 3,028±78 2,248±154* 4,379±153 3,384±168* 3,181 ±79 2,745±193*

aDFE=dietary folate equivalents. 1 DFE=1 mg food folate=0. indicates a significant difference between the micronutrient

6 mg folic acid from fortified food.

intakes of lunch consumers and children who missed lunch within each sex (P<0.05).