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Nutrient and food group intakes of Manitoba children and youth: a population-based analysis by pulse and soy consumption status.

INTRODUCTION

Poor eating habits have been linked to a multitude of negative health outcomes such as increased risk of childhood obesity, type 2 diabetes, and increased risk of developing adult obesity [1]. The rate of childhood overweight/obesity in Manitoba is 31%, a significantly higher proportion than Canada's national average of 26% [2].

Recent data explored the relationship between pulse consumption (beans, peas, and lentils) and nutrient intakes of North Americans [3, 4]. Pulses are a significant source of many nutrients and epidemiological evidence supports the protective link between pulse consumption and diseases [5]. Among adults, consuming at least 1 pulse product during their dietary recall resulted in improved nutrient intakes [3, 4]. Similarly, there have also been substantial amounts of research devoted to the health benefits of soy consumption. Although by definition soybeans are an oil seed, they are considered a legume and are grown like a pulse, and Manitoba Pulse Growers considers them a part of their "pulse portfolio" [6, 7]. With this in mind, and owing to small sample sizes, pulses and soy foods were combined in this study.

In 2015, Health Canada approved a health claim linking soy consumption to lowered cholesterol, based on evidence that consumption [greater than or equal to] 25 g of soy protein per day helps reduce cholesterol [8]. Soy consumption in the American diet was examined using National Health and Nutrition Examination Survey (NHANES) data in a simulation analysis in which MyPyramid servings of meat were replaced with tofu and milk was replaced with soy beverage. This replacement simulation showed an increase in folate, iron, calcium, and magnesium and lowered intakes of saturated fat, cholesterol, protein, and vitamins [B.sub.6] and [B.sub.12] when soy products replaced dairy and meat [9]. Comparably, results from the Canadian Community Health Survey (CCHS) Cycle 2.2 24-hour dietary recall found that adolescent and adult respondents who had consumed at least 1 soy food during their recall had increased intakes of energy, protein, fibre, vitamin C, vitamin [B.sub.6], folate, thiamin, calcium, potassium, phosphorus, magnesium, and iron and lowered intakes of saturated fat [10].

Although the rate of overweight and obesity in Manitoba exceeds the national level, there is limited data on the nutrient intakes of Manitoba's children and youth. Therefore, the objective of this study was to use pulse/soy consumption as an indicator to evaluate the eating profile of Manitoba's children and youth.

METHODS

Participants

Data from the CCHS 2.2 were used for this study and restricted to respondents aged 2-18 years residing in Manitoba. Children under 2 years of age were excluded due to the changes in food sources during the first 2 years of life [11-13]. Twenty-four hour dietary recalls were collected using the US Department of Agriculture's multiple step approach [14]. Details on the CCHS 2.2 survey methodology and sampling designed can be found elsewhere [14, 15]. Pulse/soy consumers were identified as individuals who had reported eating at least 1 soy or pulse food product during their recall period. Serving sizes were not observed. Respondents who did not report consuming any food, consumed only breast milk, or had unreliable recalls (according to Health Canada) were excluded, resulting in a sample size of 1840. Food and ingredient and recipe files were utilized to obtain all sources of pulse/soy foods. Food sources included dry beans, pea and lentil dishes, soybeans, soy flour, soy protein powders, tofu and other fermented products, soy-based dairy products and beverages, and soy-based meat alternatives (patties or wieners). Soya sauce and soy-based margarines were excluded.

Statistical analysis

Food group intake data were obtained from the Canada's Food Guide File that contained previously calculated data for respondent's food group servings [11, 14]. Data for nutrients were expressed as absolute values and quantity per 1000 kcal. General linear models were used to analyze macronutrient, micronutrient, and food group intakes, and to compare nutrient intakes and other variables between nonconsumers and consumers. Logistic regression was used to determine whether any demographic variables increased the likelihood of being classified as a pulse/soy consumer and odds ratios were calculated. The significance level was set at P < 0.05 for differences and 0.05 < P <0.10 for trends. All analyses were performed using PASW SPSS Statistics, version 22.0 (2013) and SUDAAN Statistical Analysis Software Package 10.0 (2008).

RESULTS

Overall, 8.2% of Manitobans aged 2-18 years (n = 150) reported consumption of pulse/soy on any given day. No demographic differences were shown (Table 1). Wholly, the energy and nutrient intake profiles of nonconsumers and consumers did not differ significantly, except when nutrients were expressed relative to energy intake. Per 1000 kcal, pulse/soy consumers had significantly higher intakes of fibre (17%), protein (14%), magnesium (10%), and zinc (15%), and significantly lower intakes of carbohydrate (5%) and vitamin C (22%). Food group intakes between the 2 groups were not significantly different with the exception of the meat and alternative food group, where pulse/soy consumers ate 1 more daily serving than nonconsumers (Table 2).

Vegetable and fruit intake of Manitobans aged 2-18 years fell below the recommended level (range of 4-8 servings per day) of Canada's Food Guide to Healthy Eating. Servings of milk and alternatives were at the low end of the recommended 2-4 servings per day range. The average intake of sodium in both groups, as well as overall, exceeded the established tolerable upper intake levels (UL), which falls between 1500 and 2300 mg/day, depending on age. Vitamin D intakes were below the recommended estimated average requirement intake of 10 [micro]g. Similarly, overall intake of fibre (13.7 g [+ or -] 0.3), regardless of consumption status, fell below the established adequate intake of 19-38 g/day (Table 2) [16].

DISCUSSION

Our results show that consumption of pulse/soy foods is lower in young Manitobans than previously reported studies using adult populations [3,4, 10]. In comparison with soy consumption patterns among Americans aged 9-18 years in NHANES, only 4.5% of respondents reported consuming soy products [9], whereas 2.8% of Canadians aged 2-18 years reported similar consumption using CCHS data [10]. Pulse/soy consumption in the current study may appear to be higher due to the inclusion of pulses in addition to soy, as well as the wider age ranges used. According to an Alberta survey, factors that limit pulse consumption may include disliking the taste, lack of preparation knowledge, and the presence of gastro-intestinal side effects [17]. Although this survey was based on adult respondents, among children (who can be finicky) [18], the "dislike of the taste or texture" was one of the most frequent top-of-mind reasons for not eating pulses [17] and a recent study on lentil consumption in families with young children found that caregiver's/parent's lack of acceptance of lentils was a major barrier to their use/consumption [19].

Previous data on adult pulse intake patterns observed numerous differences in dietary intakes between pulse consumers and nonconsumers and soy consumers and nonconsumers, attributed mainly to the fact that pulses and soy foods contain high levels of these nutrients [3, 4]. However, carbohydrate, fibre, protein, zinc, and magnesium, which were significantly higher among adult pulse consumers at the highest levels of consumption (when pulse intake was quantified by gram) were only significantly different when calculated per 1000 kcal. These differences may be attributed to the fact that the previous study on Canadian adults expressed nutrient intake on 4 levels of pulse consumption [4], whereas the current study simply placed consumers into 1 group due to small sample sizes. Indeed, the majority of nutrient differences in our previously published study on adult pulse consumers were significant only at the highest 2 levels of pulse consumption (consuming >99 g of pulses during recall) [4]. It is possible that grouping Manitobans by amount of pulse or soy product consumed could provide a different picture, although the small sample size of the current study population precluded further subcategorization. Another potential area that may account for differences in intake is the fact that our study includes soy products. For example, 100 g of dark red kidney beans contains 25 g of fibre and 60 g of carbohydrate, whereas the same amount of soybeans contains 6.3 g of fibre and 10 g of carbohydrate [20]. However, based on previous work, both adult soy and pulse consumers reported similar increases in protein as well as fibre intake with consumption [4, 10].

The excessive intakes of sodium observed in this study are consistent with adult levels, as Canadians consume ~3400 mg per day [21]. Adult pulse consumers consume higher amounts of sodium when compared with nonconsumers [4], likely not because of the composition of the pulses, but perhaps reflecting an increased intake of pulse dishes traditionally high in sodium (Mexican dishes, canned bean soups) [22]. Similarly, soy foods such as miso and certain tofu have high levels of sodium and are a major source of dietary sodium in Asian, American, and British diets [23]. Observing the dietary intakes and patterns of all Manitobans aged 2-18 years (regardless of consumption status), it is evident that the majority of Manitoba's youth are not consuming optimal diets. Levels of sodium intake exceed the recommended intake (1000-1500 mg/d), as well as the UL set by the Institute of Medicine [16]. High sodium intake may lead to development of hypertension and cardiovascular disease (CVD) later in life, as sodium intake has been positively associated with high blood pressure among US children and adolescents [24]. Targeted health goals, such as lowering blood pressure/CVD risk, show greater impact when started early as eating habits are being formed [25].

Low vitamin D intakes in this study were similar to intakes reported by a recent Finnish study, and may lead to compromised bone health later in life [26]. Additionally, cross-sectional and cohort studies have shown that higher intake of dairy, fruits and vegetables, and cereals in children are associated with increased bone mass, when compared with diets high in processed foods [27], and children with low dietary fibre intakes have increased body fat [28]. The low fibre intakes of Manitoban youth may play a role in their unhealthy weight status, particularly since both pulse/soy consumers and nonconsumers had low intakes of vegetables and fruit. It is uncertain why pulse/soy consumers had lower vitamin C intakes, although a marginally lower intake of vegetables and fruit may contribute to this result.

Study limitations

As the CCHS 2.2 is a cross-sectional survey, a limitation of the present study is that this 1 day dietary recall may not be a true representation of individual's habitual eating habits, and there exists potential for over- or underestimation of pulse or soy consumption habits. The CCHS 2.2 is a self-reported survey, and although methods were utilized during the 24-hour dietary recall to enhance accuracy [29], the average underreporting of energy intake in the CCHS 2.2 is estimated at 10% [30]. Additionally, some studies have shown that proxy-assisted interviews, which were used for respondents under 11 years of age, inaccurately reflect actual food portions, types of foods, and nutrients consumed [31-33]. The small sample size of this study and the combination of soy and pulse foods may limit the generalizability of the results, as did the fact that portions were not observed. Similarly, comparing consumption rates should be viewed with caution, as most previous studies have observed pulse or soy consumption and not a combination of the two.

RELEVANCE TO PRACTICE

Although pulse or soy consumption does not appear to relate to the nutrient intake profile of Manitobans aged 2-18 years, results from this study shed light on the poor eating habits of Manitoba's children and youth overall. High intakes of sodium and low intakes of vegetables and fruit, fibre, and vitamin D signal a potential public health issue for their future cardiovascular and bone health. The rate of childhood obesity in Manitoba exceeds the national average, leading to a variety of negative health outcomes and incurring high health care costs. Children who are at an unhealthy weight or practice poor dietary habits are also more likely to continue these habits throughout their life, suggesting that there exist opportunities to specifically target "at-risk" groups. The addition of pulse or soy foods in the diet has shown benefits to the overall diet in both adults (pulse) and adults/children (soy). Therefore, these data are relevant to childhood obesity and dietary intake patterns of children and youth. Efforts targeting the dietary habits of young Canadians should be paired with others aimed at improving the quality of the food supply (e.g., reducing sodium, increasing vitamin D, and vegetable and fruit intake) and nutrition education in children.

Acknowledgements

We would like to extend our thanks to Dr. Ian Clara and Kelly Cranswick at the Manitoba Research Data Centre for their statistical help and support.

Funding: This project was funded by Manitoba Healthy Living, Seniors and Consumer Affairs.

Conflict of interest: All authors declare no conflicts of interest.

References

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ADRIANA N. MUDRYJ, MSc (a); HAROLD M. AUKEMA, PhD (a); PAUL FIELDHOUSE, PhD (a, b); B. NANCY YU, PhD (a, b, c)

(a) Human Nutritional Sciences, University of Manitoba, Winnipeg, MB; (b) Manitoba Healthy Living, Seniors and Consumer Affairs, Winnipeg, MB; (c) Community Health Sciences, University of Manitoba, Winnipeg, MB
Table 1. Demographic characteristics of pulse or soy
consumers in Manitoban youth aged 2-18 years based on
1-day dietary recalls from the Canadian Community Health
Survey, Cycle 2.2.

                       % Pulse/soy
                        consumers      Odds
                       (n = 1840)    ratio (a)     95% CI

Sex

Male                       7.3           1       Reference
Female                     9.0         1.23      0.51-2.41

Age (y)

2-8                        7.4           1       Reference
9-13                       8.6         1.16      0.75-2.56
14-18                      4.4         1.13      0.61-2.56

Residential location
in Manitoba

Burntwood, Norman,         7.9         1.21      0.56-2.64
Churchill

Assiniboine,               9.3         1.45      0.71-2.90
Parkland, Brandon

North Eastman,             9.1         1.42      0.57-1.97
South Eastman,
Interlake, Central

Winnipeg                   6.4           1       Reference

Urban or rural

Urban                      8.0           1       Reference

Rural                      8.3         1.04      0.56-2.00

BMI classification

Normal                     8.4         2.90      0.70-6.90

Overweight                 9.2         3.39      0.78-14.73

Obese                      2.9           1       Reference

(a) Logistic regression was used to determine whether any
demographic variables (sex, age, geographic location, or BMI)
increased the likelihood of being classified as a pulse/soy
consumer and odds ratios were calculated.

Table 2. Macronutrient, micronutrient and energy intakes (a)
per day of Manitoban youth aged 2-18 years based on 1-day dietary
recalls from the Canadian Community Health Survey, Cycle 2.2.

                                                Nonconsumers
                        Overall (n = 1840)       (n = 1690)

Food amount (g)          2332 [+ or -] 59     2335 [+ or -] 49
Energy (kcal)            2123 [+ or -] 71     2136 [+ or -] 93
Carbohydrate (g)         294 [+ or -] 12       296 [+ or -] 16
Carbohydrate per          140 [+ or -] 2        140[+ or -]2
  1000 kcal (g)
Fibre (g)               13.7 [+ or -] 0.3     14.1 [+ or -] 0.3
Fibre per 1000 kcal      6.6 [+ or -] 0.3     6.5 [+ or -] 0.2
  (g)
Sugar (g)               140.0 [+ or -] 9.1   142.1 [+ or -] 12.2
Total fat (g)           74.3 [+ or -] 2.0     75.2 [+ or -] 3.0
Total fat per 1000      34.2 [+ or -] 0.5     34.1 [+ or -] 0.7
  kcal (g)
Saturated fatty acid    29.1 [+ or -] 0.7     26.4 [+ or -] 1.4
 (g)
Saturated fat per       10.8 [+ or -] 0.1     12.1 [+ or -] 0.4
  1000 kcal (g)
Monounsaturated         28.1 [+ or -] 2.6     29.1 [+ or -] 0.9
  fatty acid (g)
Monounsaturated         13.3 [+ or -] 0.3     13.3 [+ or -] 0.4
  fatty acid per 1000
  kcal (g)
Polyunsaturated         11.9 [+ or -] 0.3     12.2 [+ or -] 0.3
  fatty acid (g)
Polyunsaturated          5.5 [+ or -] 0.2     5.5 [+ or -] 0.2
  fatty acid per 1000
  kcal (g)
Linoleic fatty acid      9.3 [+ or -] 1.1     10.0 [+ or -] 0.3
  (g)
Linoleic fatty acid      4.6 [+ or -] 0.2     4.6 [+ or -] 0.2
  per 1000 kcal (g)
Linolenic fatty acid     1.5 [+ or -] 0.1     1.5 [+ or -] 0.1
  (g)
Linolenic fatty acid     0.7 [+ or -] 0.0     0.7 [+ or -] 0.0
  per 1000 kcal (g)
Cholesterol (mg)        239 [+ or -] 19.3      225 [+ or -] 10
Cholesterol per 1000      108 [+ or -] 4       107 [+ or -] 6
  kcal (mg)
Protein (g)             75.6 [+ or -] 2.0     75.1 [+ or -] 2.5
Protein per 1000        36.7 [+ or -] 0.7     36.2 [+ or -] 0.6
  kcal (g)
Vitamin A (retinol       594 [+ or -] 19       597 [+ or -] 20
  activity equivalent)
Vitamin A per 1000        291 [+ or -] 9       291 [+ or -] 9
  kcal (retinol
 activity equivalent)
Vitamin D (mg)           6.5 [+ or -] 0.2     6.5 [+ or -] 0.2
Vitamin D per 1000       3.2 [+ or -] 0.1     3.2 [+ or -] 0.1
  kcal (mg)
Vitamin C (mg)            131 [+ or -] 7       132 [+ or -] 7
Vitamin C per 1000        67 [+ or -] 5         67 [+ or -] 5
  kcal (mg)
Thiamin (mg)             1.7 [+ or -] 0.0     1.7 [+ or -] 0.1
Thiamin per 1000         0.8 [+ or -] 0.0     0.8 [+ or -] 0.0
  kcal (mg)
Riboflavin (mg)          2.2 [+ or -] 0.1     2.2 [+ or -] 0.1
Riboflavin per 1000      1.1 [+ or -] 0.1     1.1 [+ or -] 0.1
  kcal (mg)
Niacin (mg)             33.0 [+ or -] 0.7     33.2 [+ or -] 0.8
Niacin per 1000 kcal    15.9 [+ or -] 0.4     15.8 [+ or -] 0.4
  (mg)
Vitamin [B.sub.6]        1.5 [+ or -] 0.1     1.5 [+ or -] 0.1
  (mg)
Vitamin [B.sub.6]         0.7 [+ or -] 0      0.7 [+ or -] 0.0
  per 1000 kcal (mg)
Vitamin [B.sub.12]       3.8 [+ or -] 0.2     3.8 [+ or -] 0.2
  (mg)
Vitamin [B.sub.12]       1.9 [+ or -] 0.1     1.9 [+ or -] 0.1
  per 1000
 kcal (mg)
Folic acid ([micro]g)    134 [+ or -] 15       136 [+ or -] 16
Folic acid per 1000       66 [+ or -] 6         66 [+ or -] 6
  kcal ([micro]g)
Folate (from food in     426 [+ or -] 21       428 [+ or -] 26
  dietary folate
  equiv.) ([micro]g)
Folate per 1000 kcal      206 [+ or -] 4       205 [+ or -] 5
([micro]g)
Calcium (mg)             1078 [+ or -] 45     1080 [+ or -] 58
Calcium per 1000          518 [+ or -] 7       517 [+ or -] 8
  kcal (mg)
Phosphorus (mg)          1358 [+ or -] 41     1357 [+ or -] 54
Phosphorus per 1000       652 [+ or -] 7       648 [+ or -] 8
  kcal (mg)
Magnesium (mg)            268 [+ or -] 5       267 [+ or -] 6
Magnesium per 1000        130 [+ or -] 3       129 [+ or -] 3
  kcal (mg)
Iron (mg)               13.9 [+ or -] 0.6     14.1 [+ or -] 0.8
Iron per 1000 kcal       6.7 [+ or -] 0.1     6.7 [+ or -] 0.1
  (mg)
Zinc (mg)               10.1 [+ or -] 0.3     10.3 [+ or -] 0.4
Zinc per 1000 kcal       4.9 [+ or -] 0.1     4.8 [+ or -] 0.1
  (mg)
Sodium (mg)              3028 [+ or -] 62     3027 [+ or -] 86
Sodium per 1000 kcal     1445 [+ or -] 48     1436 [+ or -] 48
  (mg)
Potassium (mg)           2669 [+ or -] 56     2669 [+ or -] 54
Potassium per 1000       1303 [+ or -] 44     1297 [+ or -] 45
  kcal (mg)
Grain products           6.1 [+ or -] 0.4     6.1 [+ or -] 0.5
  (servings)
Vegetable and fruit      3.8 [+ or -] 0.1     3.8 [+ or -] 0.1
  products (servings)
Milk and                 2.5 [+ or -] 0.1     2.5 [+ or -] 0.2
  alternatives
  (servings)
Meat and                 2.9 [+ or -] 0.1     2.9 [+ or -] 0.1
  alternatives
  (servings)

                        Pulse/soy consumers
                             (n = 150)

Food amount (g)          2294 [+ or -] 341
Energy (kcal)            1964 [+ or -] 246
Carbohydrate (g)          262 [+ or -] 42
Carbohydrate per         133 [+ or -] 6 *
  1000 kcal (g)
Fibre (g)                14.2 [+ or -] 2.0
Fibre per 1000 kcal     7.6 [+ or -] 0.6 *
  (g)
Sugar (g)               117.3 [+ or -] 35.1
Total fat (g)            69.1 [+ or -] 7.2
Total fat per 1000       35.0 [+ or -] 1.5
  kcal (g)
Saturated fatty acid     24.3 [+ or -] 2.7
  (g)
Saturated fat per        12.0 [+ or -] 0.6
  1000 kcal (g)
Monounsaturated          28.4 [+ or -] 2.6
  fatty acid (g)
Monounsaturated          14.1 [+ or -] 0.7
  fatty acid per 1000
  kcal (g)
Polyunsaturated          11.3 [+ or -] 1.3
  fatty acid (g)
Polyunsaturated          5.7 [+ or -] 0.3
  fatty acid per 1000
  kcal (g)
Linoleic fatty acid      9.1 [+ or -] 1.1
  (g)
Linoleic fatty acid      4.7 [+ or -] 0.2
  per 1000 kcal (g)
Linolenic fatty acid     1.5 [+ or -] 0.3
  (g)
Linolenic fatty acid     0.8 [+ or -] 0.1
  per 1000 kcal (g)
Cholesterol (mg)          240 [+ or -] 19
Cholesterol per 1000      131 [+ or -] 32
  kcal (mg)
Protein (g)              79.2 [+ or -] 8.2
Protein per 1000        41.3 [+ or -] 2.0 *
  kcal (g)
Vitamin A (retinol       558 [+ or -] 101
  activity equivalent)
Vitamin A per 1000        293 [+ or -] 19
  kcal (retinol
 activity equivalent)
Vitamin D (mg)           6.4 [+ or -] 1.7
Vitamin D per 1000       3.5 [+ or -] 0.4
  kcal (mg)
Vitamin C (mg)           110 [+ or -] 30t
Vitamin C per 1000       55 [+ or -] 11 **
  kcal (mg)
Thiamin (mg)             1.7 [+ or -] 0.1
Thiamin per 1000         0.9 [+ or -] 0.1
  kcal (mg)
Riboflavin (mg)          2.0 [+ or -] 0.2
Riboflavin per 1000      1.0 [+ or -] 0.1
  kcal (mg)
Niacin (mg)              34.1 [+ or -] 3.7
Niacin per 1000 kcal     17.5 [+ or -] 1.2
  (mg)
Vitamin [B.sub.6]        1.6 [+ or -] 0.2
  (mg)
Vitamin [B.sub.6]        0.8 [+ or -] 0.1
  per 1000 kcal (mg)
Vitamin [B.sub.12]       3.9 [+ or -] 2.9
  (mg)
Vitamin [B.sub.12]       1.9 [+ or -] 0.1
  per 1000
  kcal (mg)
Folic acid ([micro]g)     127 [+ or -] 11
Folic acid per 1000        67 [+ or -] 9
  kcal ([micro]g)
Folate (from food in      400 [+ or -] 47
  dietary folate
  equiv.) ([micro]g)
Folate per 1000 kcal      207 [+ or -] 12
  ([micro]g)
Calcium (mg)             1062 [+ or -] 155
Calcium per 1000          519 [+ or -] 7
  kcal (mg)
Phosphorus (mg)          1365 [+ or -] 164
Phosphorus per 1000      708 [+ or -] 29f
  kcal (mg)
Magnesium (mg)            273 [+ or -] 38
Magnesium per 1000       142 [+ or -] 7 *
  kcal (mg)
Iron (mg)                14.2 [+ or -] 2.4
Iron per 1000 kcal       6.7 [+ or -] 0.5
  (mg)
Zinc (mg)                11.2 [+ or -] 0.9
Zinc per 1000 kcal      5.5 [+ or -] 0.3 *
  (mg)
Sodium (mg)              3031 [+ or -] 588
Sodium per 1000 kcal     1568 [+ or -] 80
  (mg)
Potassium (mg)           2762 [+ or -] 387
Potassium per 1000       1397 [+ or -] 68
  kcal (mg)
Grain products           5.7 [+ or -] 0.6
  (servings)
Vegetable and fruit      3.3 [+ or -] 0.5
  products (servings)
Milk and                 2.4 [+ or -] 0.4
  alternatives
  (servings)
Meat and                4 [+ or -] 0.4 ***
  alternatives
  (servings)

Note: Compared with nonconsumers * P < 0.05, ** P < 0.01,
*** P < 0.001, ([dagger]) 0.1 < P < 0.05.

(a) Intakes [+ or -] SD.
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Title Annotation:Perspectives in practice/Perspectives pour la pratique
Author:Mudryj, Adriana N.; Aukema, Harold M.; Fieldhouse, Paul; Yu, B. Nancy
Publication:Canadian Journal of Dietetic Practice and Research
Article Type:Survey
Geographic Code:1CANA
Date:Dec 1, 2016
Words:4836
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