Let's Talk Calcium! Mobilizing Young Adults to Increase Their Intake of Dietary Calcium


I  Introduction
II Bone Health and Calcium Intake in Young Adulthood
III Examining Attitudes and Beliefs Towards Calcium in a Young Adult Population
IV Opportunities to Reach a Young Adult Population
V Conclusion
VI Resources
VII References

Submitted by:

  • Andrea Buchholz, RD, PhD, Associate Professor of Applied Nutrition, Dept Family Relations and Applied Human Nutrition, University of Guelph
  • Janis Randall Simpson, RD, PhD, Professor Emeritus, of Applied Human Nutrition, Dept Family Relations and Applied Nutrition, University of Guelph
  • Susan Whiting, PhD, Professor of Nutrition and Dietetics, College of Pharmacy and Nutrition, University of Saskatchewan
  • Michelle Marcinow, PhD Applied Human Nutrition, Dept Family Relations and Applied Nutrition, University of Guelph

I Introduction

According to Osteoporosis Canada, osteoporosis-related fractures are more common than heart attack, breast cancer, and stroke combined (Osteoporosis Canada, 2016). In 2010, the Canadian annual health care expenditure due to osteoporosis-related fractures in adults over the age of 45 was approximately $1.8 billion (Tarride et al., 2012). Osteoporosis is a disease often associated with older women (Nayak et al., 2010); however, male osteoporosis is expected to rise, with the total number of hip fractures among men predicted to be similar to current estimates among women by 2025 (Tarride et., 2012). Therefore, maximizing bone health has considerable implications for decreasing the economic burden on the Canadian health care system.

II Bone Health and Calcium Intake in Young Adulthood

Building strong bones during childhood and adolescence is important for the prevention of osteoporosis, as well as young adulthood, since there is an opportunity to gain bone mass for some skeletal sites into the fourth decade of life (Berger et al., 2010). Young adulthood is a particularly opportune time to maximize bone mass, as this period can be characterized by broad shifts in lifestyle that have the potential to influence and establish lifelong dietary habits. Adequate dietary calcium intake has been implicated in osteoporosis and osteoporosis attributable fractures (Ross, 2011). Despite the importance of adequate dietary calcium intake, as many as 44%–61% of young Canadian adults are not meeting dietary recommendations for calcium (1000 mg/d) (Vatanparast et al., 2009).

Calcium is found in milk products (e.g., milk, yogurt, cheese), fortified products (e.g., orange juice, plant-based milk alternatives), and other dietary sources such as fish (e.g., sardines, canned salmon with bones), legumes (e.g., lentils), selected green vegetables (e.g., spinach, broccoli) and grains (e.g., whole wheat bread) (Ross, 2010). In the Canadian diet, milk products typically provide the richest source of calcium; however, 46%–65% of young adults (17–30 years) (Canadian Community Health Survey, 2004) are not meeting the Eating well with Canada's Food Guide recommended two servings of milk and alternatives per day.

Potential factors contributing to inadequate dietary calcium intake in young adults may include the following: 1) the decline in dietary calcium and milk product intake during the transition from childhood to young adulthood (Nicklas, 2003); 2) the overall decline in per capita milk consumption in Canada over the last 20 years (Canadian Dairy Information Center, 2013), which may be attributable to the competition from other beverages that have been introduced to the consumer market (e.g., plant-based alternatives, soft drinks, sports drinks, bottled water); and, 3) the continuing societal shift away from milk product consumption, which is a topic that has gained media attention and has placed the dairy industry's marketing campaigns under scrutiny. Therefore, having a better understanding of the factors that may influence young adults’ dietary calcium intake, particularly the underlying motivations to increase consumption of calcium-rich foods, is the first step towards developing key messages to be used for nutrition education.

III Examining Attitudes and Beliefs Towards Calcium in a Young Adult Population

There is a scarcity of research examining the determinants of adequate dietary calcium intake in young adults, and as a result, there is little known about the reasons why young adults may or may not be meeting dietary calcium recommendations. The few studies that have been conducted reported barriers to adequate milk product and calcium intake including weight concerns, gastric distress due to milk consumption, perceived fat intake of milk products, sensory attributes (e.g., dislike taste of milk products), and a lack of knowledge regarding calcium content of foods (Klesges et al., 1999; Lewis & Hollingsworth, 1992; Weiglein, 2000). News articles, magazines, radio, and television were found to be sources of nutrition information for young female college students (Lewis & Hollingsworth, 1992). Although informative, these studies may not be representative of the perceptions of present-day young adults.

The purpose of our research was to examine potential influences on dietary calcium intake in a young adult population (18–34 years). Our quantitative study (n=79) aimed to identify milk product health beliefs in this population. Guided by our quantitative findings and the tenets of Social Cognitive Theory (SCT), our qualitative study (n=53) explored young adults’ knowledge of the health benefits of dietary calcium and their perceptions of the importance of adequate dietary calcium intake. Further, we inquired about young adults’ recommendations for strategies to increase dietary calcium intake and ways to promote adequate dietary calcium intake in this population through calcium-related messaging.

The findings of our research are as follows:

  1. Overall, participants held positive views towards milk products, such as acknowledging that milk product consumption is important for bone health and that they would prefer to obtain calcium from milk products rather than supplements. Despite generally positive viewpoints, participants voiced uncertainty regarding the nutritional value of milk products and their role in overall health and weight management.
  2. Participants were also critical of the dairy industry, raising concerns regarding perceived adulteration of milk products and the questionable treatment of dairy cows. Motivators to increase milk product intake included having an increased confidence that milk products do not contain added antibiotics and/or hormones and that cows are humanely treated.
  3. Participants were unaware of the importance of adequate calcium intake in relation to bone health specifically for their age group, but perceived adequate intake to be important for children and older adults. Participants were also unsure of the age at which bone mass is accrued before bone loss occurs. Participants suggested that calcium-related messaging should increase young adults’ awareness of the importance of adequate dietary calcium intake for their age group.
  4. More females than males believed that increasing milk product intake would contribute to the maintenance of strong bones, and female participants indicated that they would be more motivated than male participants to increase dietary calcium intake if they were informed that bone mass can be accrued into young adulthood for certain skeletal sites.
  5. Participants expressed a desire to be better educated about calcium and its relation to health, and suggested that nutrition education should begin at an earlier age. Participants also expressed that they would like to be provided with unbiased nutrition information, in the form of advice from health professionals and research studies. Participants also recommended planning healthy, well-balanced meals and consuming calcium-rich foods habitually as strategies to ensure adequate dietary calcium intake.

IV Opportunities to Reach a Young Adult Population

A key finding of our research is a need for the dissemination of targeted information to young adults. This information could include increasing young adults’ awareness of the importance of adequate dietary calcium intake in relation to bone and overall health, addressing current misperceptions regarding milk products, and improving consumer knowledge regarding the nutritional benefits of milk products and other calcium-rich and nutrient-dense sources.  These initiatives can be implemented by researchers, public health advocates, and health care professionals to promote the importance of adequate dietary calcium intake in the young adult population. The following are suggestions:

  1. Researchers could pilot calcium-related messaging to determine effective strategies to increase dietary calcium intake in the young adult population, and share findings amongst dietitians and physicians (e.g., hosting "lunch and learns" for health care professionals).
  2. Researchers could work with public health organizations to convey calcium-related messages to young adult consumers. Plain language research summaries (e.g., pamphlets) and infographic posters could be developed. These summaries could highlight key facts about dietary calcium, as well as health-related and dietary benefits that would be relevant to young adults. This information could be made available in health care settings such as patient waiting rooms (e.g., walk-in clinics, student health services), and through nutrition education campaigns developed for various environments (e.g., workplace wellness programs, university/college campuses, local community and athletic centres).
  3. General practitioners in private practice or in student health services could take opportunities to discuss broader dietary patterns and health benefits related to adequate dietary calcium intake with their young adult patients when the opportunity arises. The dietetic community could ensure that individual counselling strategies take into account the factors that may influence young adults' dietary calcium intake. Dietitians can also take opportunities to disseminate unbiased nutrition information during individual counselling sessions, through online resources (e.g., blogs, online articles), and while interacting with young adult consumers as in-store dietitians.

V Conclusion

In summary, inadequate dietary calcium intake in the young adult population is concerning, especially considering the opportunity to accumulate bone mass throughout young adulthood for the prevention of osteoporosis late in life. Understanding the factors that may motivate the young adult population to increase dietary calcium intake is important for future research to determine appropriate calcium-related messages, self-regulatory strategies, and effective ways to disseminate information to young adults. This undertaking will inform future nutrition education interventions and knowledge translation initiatives.

VI Resources

Dietitians of Canada is a national association of registered dietitians that provides resources for consumers and health professionals: http://www.dietitians.ca/.

A copy of Eating well with Canada's Food Guide can be found at the following: http://hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

Osteoporosis Canada is a national organization that works to educate, empower and support individuals and groups who are committed to osteoporosis prevention: http://www.osteoporosis.ca/.

Canadian Community Health Survey data can be found at the following: http://hc-sc.gc.ca/fn-an/surveill/nutrition/commun/cchs_guide_escc-eng.php.

Information regarding milk product consumption trends in Canada can be found at the following: http://www.dairyinfo.gc.ca/index_e.php.

VII References

Berger, C., Goltzman, D., Langsetmo, L., Joseph, L., Jackson, S., Kreiger, N., CaMos Research, G. (2010). Peak bone mass from longitudinal data: implications for the prevalence, pathophysiology, and diagnosis of osteoporosis. Journal of Bone and Mineral Research, 25(9), 1948-1957. doi: 10.1002/jbmr.95.

Klesges, R. C., Harmon-Clayton, K., Ward, K. D., Kaufman, E. M., Haddock, C. K., Talcott, G. W., & Lando, H. A. (1999). Predictors of milk consumption in a population of 17- to 35-year-old military personnel. The Journal of the American Dietetic Association, 99(7), 821-826; quiz 827-828. doi: 10.1016/S0002-8223(99)00195-9.

Lewis, N. M., & Hollingsworth, M. (1992). Food choices of young college women consuming low-or moderate-calcium diets. Nutrition Research, 12, 943-948.

Nayak, S., Roberts, M. S., Chang, C. C., & Greenspan, S. L. (2010). Health Beliefs about Osteoporosis and Osteoporosis Screening in Older Women and Men. Health Education Journal, 69(3), 267-276. doi: 10.1177/0017896910364570.

Nicklas, T. A. (2003). Calcium intake trends and health consequences from childhood through adulthood. The Journal of the American College of Nutrition, 22(5), 340-356.

Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., . . . Shapses, S. A. (2011). The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Journal of Clinical Endocrinology and Metabolism, 96(1), 53-58. doi: 10.1210/jc.2010-2704.

Ross, A. C. (2011). The 2011 report on dietary reference intakes for calcium and vitamin D. Public Health Nutrition, 14(5), 938-939. doi: 10.1017/S1368980011000565.

Tarride, J. E., Guo, N., Hopkins, R., Leslie, W. D., Morin, S., Adachi, J. D., . . . Goeree, R. (2012). The burden of illness of osteoporosis in Canadian men. Journal of Bone and Mineral Research, 27(8), 1830-1838. doi: 10.1002/jbmr.1615.

Vatanparast, H., Dolega-Cieszkowski, J. H., & Whiting, S. J. (2009). Many adult Canadians are not meeting current calcium recommendations from food and supplement intake. Applied Physiology, Nutrition and Metabolism, 34(2), 191-196. doi: 10.1139/H09-005.

Weiglein, C. B., D.; Duncan, S.E. (2000). College-age women's perceptions of dairy foods. The Forum for Family and Consumer, 5(1).