THE CONSUMPTION of DAIRY and DAIRY ALTERNATIVES and the PERCEPTION of DAIRY in COLLEGE STUDENTS a Thesis Submitted to the Kent

THE CONSUMPTION OF DAIRY AND DAIRY ALTERNATIVES AND THE PERCEPTION OF DAIRY IN COLLEGE STUDENTS

A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science

Melissa R. Gresser

May 2015

Thesis written by

Melissa R. Gresser

B.S., Bowling Green State University, 2013

M.S. Kent State University, 2015

Approved by

______, Director, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Tanya Falcone

______, Member, Master’s Thesis Committee Eun-Jeong Ha

Accepted by

______, Director, School of Health Sciences Lynne E. Rowan

______, Dean, College of Education, Health and Human Services Daniel F. Mahony

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GRESSER, MELISSA, M.S., May 2015 Health Sciences THE CONSUMPTION OF DAIRY AND DAIRY ALTERNATIVES AND THE PERCEPTION OF DAIRY IN COLLEGE STUDENTS (103 pp.) Director of Thesis: Natalie Caine-Bish, P.H.D., R.D., L.D. The purpose of this study was to determine the consumption of dairy and dairy alternatives and the perceptions of dairy in college students enrolled at a Northeast Ohio state university. It was expected that dairy and dairy alternative consumption would be greater in males, students living off campus, and graduate students. It was also expected that there would be a difference in the perceptions of dairy between groups. An online questionnaire was completed by students enrolled in courses at Kent State University participants (n=247). Descriptive statistics were used to describe demographics, consumption of dairy and dairy alternatives, and perceptions of dairy. T-tests were used to analyze differences in the consumption of dairy and dairy alternatives and the perceptions of dairy between gender, living situation, and academic status groups. A p- value of 0.05 was selected a priori for statistical significance. There were no significant differences in consumption of dairy and dairy alternatives in gender, living situation, and academic status groups. There were some perceptions that were significantly different in gender and living situation groups; however, there were no significant differences in perceptions in academic status groups. This study demonstrated that college students are consuming dairy, but not enough to meet the Dietary Guidelines for Americans 2010.

Dairy alternatives are not replacing dairy in college students as demonstrated by this study. Gender is the most influential factor in the perceptions and misconceptions of dairy, especially in females.

ACKNOWLEDGEMENTS

First, I would like to thank my advisor Dr. Natalie Caine-Bish for spending so much time with me on my research journey. I appreciate all the advice, support, and encouragement that she provided to me throughout my education at Kent State University and throughout my research. I also appreciate her confidence in me; she believed in me when I did not believe in myself during my research.

I would also like to thank my committee members, Tanya Falcone and Dr. Eun-

Jeong Ha, for taking time out of their busy schedules to review my work and provide feedback for the development of a stronger thesis. I appreciate all of the advice and encouragement that they provided to me throughout my research and education while at

Kent State University.

Institutional Research at Kent State University, particularly Valerie Samuel, was integral in helping me obtain a random sample of Kent State University students to complete my research. I appreciate the time that you spent helping me obtain the parameters of subjects that were needed for my research.

I would also like to express my gratitude to Edward Bolden at the Research and

Evaluation Bureau for analyzing my data and helping me interpret the results. I also appreciate your patience as I asked for changes in some of the data.

I would also like to extend my appreciation to the Kent State University students that volunteered their time to complete my survey. I truly appreciate the fact that you helped me out, as a fellow student, on my research journey.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...... iv

LIST OF TABLES ...... viii

CHAPTER I. INTRODUCTION ...... 1 Overview of Literature ...... 1 Statement of the Problem ...... 5 Purpose Statement ...... 6 Hypotheses ...... 6 Operational Definitions ...... 7

II. LITERATURE REVIEW ...... 8 Recommendations for Dairy Consumption ...... 8 Dietary Guidelines for Americans ...... 8 MyPlate Recommendations ...... 9 Nutrients Found in Dairy Products ...... 9 Calcium ...... 10 Vitamin D...... 12 Phosphorus ...... 14 Magnesium ...... 15 Protein ...... 16 Effects of Dairy Consumption on Health...... 17 Osteoporosis ...... 18 Weight Management ...... 21 Hypertension ...... 23 Socio-cultural Practices Related to Dairy Consumption ...... 25 African-Americans ...... 25 Asian-Americans...... 27 Hispanic-Americans ...... 28 Current Consumption Patterns ...... 30 Barriers to Dairy Consumption ...... 31 Lactose Intolerance ...... 31 Cow’s Milk Protein Allergy...... 33 Attitudes and Beliefs ...... 34 Organizations Currently Promoting & Educating on Dairy Consumption ...... 36 National Milk Processor Education Program ...... 37 American Dairy Association and Dairy Council, Inc...... 39 National Dairy Council ...... 41 Dairy Farmers of America ...... 41 Food, Farm, and Jobs Bill 2014 ...... 42 Special milk program ...... 43

Dairy margin protection program ...... 44 Anti-Dairy Movements ...... 45 NotMilk.com ...... 45 People for the Ethical Treatment of Animals ...... 46 College Students ...... 46

III. METHODS ...... 49 Study Design ...... 49 Sample...... 49 Questionnaire Development...... 50 Part I: Dairy and Dairy Alternative Consumption ...... 50 Part II: Perceptions of Dairy ...... 51 Part III: Demographic Information ...... 51 Procedure ...... 51 Statistical Analysis ...... 52

IV. JOURNAL ARTICLE ...... 53 Introduction ...... 53 Methods...... 55 Study Design ...... 55 Sample...... 56 Questionnaire ...... 56 Part I: Dairy and dairy alternative consumption ...... 56 Part II: Perceptions of dairy ...... 57 Part III: Demographic information ...... 57 Procedures ...... 58 Statistical Analysis ...... 58 Results ...... 59 Participant Characteristics ...... 59 Types of Milk Consumed...... 60 Frequency of Dairy and Dairy Alternative Consumption ...... 61 Consumption ...... 63 Gender ...... 63 Living situation ...... 64 Academic status ...... 65 Perceptions ...... 66 Gender ...... 66 Living situation ...... 68 Academic status ...... 70 Discussion ...... 72 Consumption ...... 74 Perception ...... 76 Limitations ...... 79 Applications ...... 79

Conclusions ...... 83

APPENDICES ...... 85 APPENDIX A. DAIRY AND DAIRY ALTERNATIVE AND PERCEPTIONS OF DAIRY QUESTIONNAIRE ...... 86

REFERENCES ...... 94

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LIST OF TABLES

1. Demographic Data of Participants Completing the Dairy and Dairy Alternative Questionnaire (n=247) ...... 59

2. Type of Milk Consumed, Fortification of Dairy Alternatives, and Reason for Consumption of Dairy Alternative...... 61

3. Frequency of Consumption of Dairy or Dairy Alternatives Products and Average Serving Size of Dairy and Dairy Alternative Products ...... 62

4. Gender Differences in the Frequency of Consumption of Dairy and Dairy Alternatives per week ...... 63

5. Living Situation Differences in the Frequency of Consumption of Dairy and Dairy Alternatives per week ...... 64

6. Academic Status Differences in the Frequency of Consumption of Dairy and Dairy Alternatives per week ...... 65

7. Gender Differences in the Perception of Dairy ...... 66

8. Living Situation Differences in the Perception of Dairy ...... 69

9. Academic Status Differences in the Perceptions of Dairy ...... 70

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CHAPTER I

INTRODUCTION

Overview of Literature

The Dietary Guidelines for Americans 2010 recommends milk and milk products, including fortified soy beverages, as part of a healthy eating pattern. Milk and milk products are included in a category of foods and nutrients to increase as per the Dietary

Guidelines for Americans 2010 (United States Department of Agriculture (USDA), 2010;

United States Department of Health and Human Services (USDHHS), 2010). MyPlate encourages the United States to consider building a healthy plate at meal times, including dairy. The recommendation of dairy consumption per day is founded on age (USDA, n.d.).

Milk and dairy foods contribute significant quantities of nutrients of concern as outlined in the Dietary Guidelines for Americans 2010 (Huth, Fulgoni, DiRienzo, &

Miller, 2008). Some of these nutrients of concern provided by milk and dairy foods include calcium, vitamin D, phosphorus, magnesium, and protein. Calcium is a major mineral constitute of milk and dairy products; calcium is essential in skeletal health, muscle contraction, and nerve transmission (Heaney, 2009). When fortified with vitamin

D, milk and dairy products are a good source of vitamin D. Vitamin D’s active form, calcitriol, is an active hormone in the regulation of calcium and phosphorus metabolism in regards to bone mineralization (Schmid & Walther, 2013).

Due to the nutrient composition of milk and dairy products, there are potential health benefits for nutrition related diseases, including osteoporosis, weight management, and hypertension. Observational studies and controlled trials have shown a significantly positive association between milk and dairy products consumption, bone turnover markers, and bone mineral density (Rizzoli, 2014). A meta-analysis study concluded that energy restricted, dairy based diets resulted in improved weight loss, increased fat loss, and an increase in lean body mass (Sanders, 2012). Other researchers have shown a significant inverse relationship between the low-fat dairy intake and elevated blood pressure with no benefit from high-fat dairy (Ralston, Lee, Truby, Palermo, & Walker,

2012).

National survey data from the National Health and Nutrition Examination Survey

(NHANES) 2007-2010 revealed Americans drink an average of 1.77 cups of total dairy per day (USDA Economic Research, 2014b). Specifically children ages two to 19 years consumed an average of 2.16 cups of dairy per day and adults age 20 years and older consumed an average of 1.64 cups of dairy per day (USDA Economic Research, 2014b).

NHANES 2001-2002 indicated that 39% of men and 43% of women between 20 and 29 years of age consume less than one daily serving of milk or dairy foods per day (Larson,

Neumark-Sztainer, Harnack, Wall, Story, & Eisenberg, 2009). Consumption patterns show milk and dairy intake is below the recommended three cups of fat-free or low-fat milk and dairy foods per day for adults and children and adolescents aged nine to 18 years of age (USDA, 2010; USDHHS, 2010).

There are social and cultural aspects in regards to the consumption and perception of milk and dairy products. Lactose intolerance is estimated to occur in approximately

80% of non-Hispanic African-Americans; those whom reported being lactose intolerant were less likely to consume milk and dairy foods (Keith, Nicholls, Reed, Kafer, & Miller,

2011). Asian-Americans have the highest risk for osteoporosis, yet Asian-American dietary practices limit calcium intake from dairy possibly due to the interaction of traditional cultural food practices and food availability; lactose intolerance is also observed in up to 100% of Asians (Jackson & Savaiano, 2001). Lactose intolerance is estimated to occur in approximately 50% of Mexican-Americans; cultural determined food preferences and dietary practices also play a role in the low consumption of dairy among Hispanic Americans (Jarvis & Miller, 2002).

There are several barriers to dairy consumption which prevent some individuals from consuming dairy products. One of them is lactose intolerance, for which the traditional treatment is to avoid milk and milk-containing products (Suchy, Brannon,

Carpenter, Fernandez, Gilsanz, Gould, & Wolf, 2010). Another barrier to dairy consumption is cow’s milk protein allergy; the only treatment is to avoid cow’s milk and cow’s milk products (De Koker, Shah, & Meyer, 2014). Attitudes and beliefs are another barrier of dairy consumption, which includes more appealing food and beverage options than dairy, poor accessibility on campus, and unnecessary calories and fat (Mahon &

Haas, 2013).

Another reason for not consuming dairy include anti-dairy organizations including NotMilk.com and People for the Ethical Treatment of Animals, both of which

promote against dairy consumption (NotMilk.com, n.d.; People for the Ethical Treatment of Animals (PETA), n.d.). There are also organizations that promote and educate on dairy consumption in the diet. A few of these organizations include the National Milk

Processor Education Program, American Dairy Association and Council, Inc., National

Dairy Council, and Dairy Farmers of America. For example, the National Milk Processor

Education Program (MilkPEP) is committed to increasing the fluid milk consumption in the United States (Milk Processor Education Program (MilkPEP),2014b). The Food,

Farm, and Jobs Bill 2014 provides the Special Milk Program and the Dairy Protection

Program, which help in the production and consumption of dairy (USDA Food and

Nutrition Service, 2014; USDA Farm Service Agency, 2014).

College attendance is a period characterized by change whereby students explore new environments and adopt new behaviors; one of these behaviors being dietary choices and habits (Poddar, Hosig, Anderson-Bill, Nickols-Richardson, & Duncan, 2012). Peak bone mass is achieved through the third decade of life, therefore adequate calcium intake along with other essential nutrients found in milk and dairy products are important during young adulthood. National survey data indicate 53% young men and 21% of young women between 19 and 30 years of age consume the recommended calcium in the United

States (Larson, Neumark-Sztainer, Harnack, Wall, Story, & Eisenberg, 2009). Other data indicates 39% of men and 43% of women between the ages of 20 to 29 years consume less than one daily serving of milk or dairy products (Cook & Friday, 2005).

Statement of the Problem

The Dietary Guidelines for Americans 2010 recommends the increased consumption of fat-free or low-fat milk, milk products and fortified soy beverages, in meeting foods and nutrients of concern (USDA, 2010; USDHHS, 2010). Peak bone mass is achieved through the third decade of life, therefore adequate calcium intake and other essential nutrients found in milk and dairy products are essential during young adulthood.

College attendance is typically during young adulthood; this period is characterized by the exploration of new environments and adoption of new behaviors. One of these behaviors is dietary choices and habits. Young adults in college tend to engage in poor dietary habits that may put them at risk for poor nutritional status (Poddar, Hosig,

Anderson-Bill, Nickols-Richardson, & Duncan, 2012).

There are also misconceptions regarding dairy alternatives; one of them being dairy alternatives are an equal substitution of nutrients found in milk and dairy products.

There is also not much known regarding the rate of consumption of dairy alternatives in a college population and whether the dairy alternative is fortified. It is also unknown as to the reason why dairy alternatives are being consumed in place of milk and dairy products in the college population.

One dietary habit of concern for young adults in college is the low intake of milk and dairy products. Data indicates that 39% of men and 43% of women between 20 and

29 years consume less than one daily serving of milk and dairy products (Cook & Friday,

2005). Mahon & Haas (2013) found college females indicated a lack of knowledge about

milk and dairy products in their daily diets, other foods or beverage options are more appealing than milk and dairy products, poor access on campus, limited variety of milk and dairy products on campus, unnecessary calories and fat, and side effects as barriers of the consumption of milk and dairy products. There is little other literature as to the perceptions of milk and dairy products in a representative college population.

Identifying the college population’s perceptions towards milk and dairy products could be effective in the education of making milk and dairy products part of a healthy diet by rectifying any misconceptions. Understanding the rate of dairy alternative consumption in college students can be helpful in the education of choosing fortified dairy alternatives in order to help meet nutrients of concern as outlined in the Dietary

Guidelines for Americans 2010. Ascertaining the consumption patterns of milk and dairy products in the college population will be useful in exploring other food alternatives in helping to meet nutrients of concern as defined in the Dietary Guidelines for Americans.

Purpose Statement

The purpose of this thesis is to determine the consumption of dairy and dairy alternatives and perceptions of dairy in male and female students enrolled at a Northeast

Ohio state university.

Hypotheses

H1 = The consumption of dairy and dairy alternatives is greater in male students than female students.

H2 = The consumption of dairy and dairy alternatives is greater in students living off- campus than students living on-campus.

H3 = The consumption of dairy and dairy alternatives is greater in graduate students than undergraduate students.

H4 = There is a difference in the perceptions of dairy between gender groups, living situation groups, and academic status groups.

Operational Definitions

 Undergraduate Student – an individual enrolled for courses at Kent State

University in the pursuit of obtaining a bachelor’s degree.

 Graduate Student – an individual enrolled for courses at Kent State University in

the pursuit of obtaining a master’s degree or a doctoral degree.

 Dairy Alternative – plant-based beverages and plant-based foods made with soy,

coconut, rice, or almonds and fortified with calcium.

 Perceptions – thoughts and feelings, both positive and negative, regarding dairy.

CHAPTER II

LITERATURE REVIEW

Recommendations for Dairy Consumption

Dietary Guidelines for Americans

The Dietary Guidelines for Americans 2010 are based on the most recent scientific evidence review for providing information and advice for choosing a healthy eating pattern. Milk and milk products fall under the category of foods and nutrients to increase in the Dietary Guidelines for Americans, 2010. The recommended intake amounts of milk and milk products, including fortified soy beverages, is three cups per day of fat-free or low-fat milk and milk products for adults and children and adolescents ages nine to 18 years. Two and half cups per day for children ages four to eight years and two cups per day for children ages two to three years (United States Department of

Agriculture (USDA), 2010; United States Department of Health and Human Services

(USDHHS), 2010).

The Dietary Guidelines for Americans, 2010 recommends choosing fat-free or low-fat milk and milk products, which provide the same nutrients with less solid fat and therefore less calories. Soy beverages fortified with calcium and vitamins A and D are considered as part of the milk and milk products group due to the similarity nutritionally and their use in meals (USDA, 2010; USDHHS, 2010).

MyPlate Recommendations

MyPlate promotes the United States to think about building a healthy plate at meal times. The amount of dairy per day recommendations are based on age.

Individuals 19 years or older are recommended to consume three cups of dairy per day.

Children and adolescents from the ages of nine to 18 years are recommended to consume three cups of dairy per day. Children from the ages of two to three years are recommended to consume two cups of dairy per day while children of ages four to eight years old are recommended to consume two and a half cups of dairy per day (USDA, n.d.).

Foods that are a part of the dairy group include all fluid milk, milk-based desserts, calcium-fortified soymilk, cheese, and yogurt. Fluid milk includes fat-free milk, low-fat or 1% milk, reduced fat or 2% milk, whole milk, flavored milks, lactose-reduced milks, and lactose-free milks. Milk-based desserts include puddings, ice milk, frozen yogurt, and ice cream. Cheeses include cheddar, mozzarella, Swiss, Parmesan, ricotta, cottage cheese, and American cheese. Yogurts include fat-free, low fat, reduced fat, and whole milk yogurts (USDA, n.d.).

Nutrients Found in Dairy Products

Milk and dairy foods contribute significant amounts of the nutrients of concerns for adults and children in the Dietary Guidelines for Americans (Huth, Fulgoni,

DiRienzo, & Miller, 2008). Milk and dairy products provide the macronutrients of carbohydrates, proteins, and lipids, as well as micronutrients, including vitamins and

minerals. Minerals found in milk and dairy products include calcium, magnesium, sodium, potassium, phosphorus, chloride, iron, copper, zinc, and selenium (Gaucheron,

2011; Pereira, 2014). Vitamins found in milk and dairy products include fat soluble vitamins A, D, E, and K and the water soluble vitamins thiamin (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxal (B6), biotin (B8), folate (B9), cobalamine

(B12), and vitamin C (Gaucheron, 2011; Pereira, 2014).

Calcium

Calcium is one of the major minerals present in milk and dairy products. The primary role of calcium in the body is structural, providing the rigidity necessary for the skeleton and teeth to function mechanically; bone contains 99% of the body’s calcium

(Heaney, 2009). Calcium in body fluids also exerts critical metabolic functions, binding to proteins and operating as a signal transmitter and protein activator within cells; muscle contraction and nerve transmission are two of the many functions that rely on calcium for activation (Heaney, 2009). Calcium is also involved in blood clotting (Heaney, 2009).

Milk and dairy products may represent the best dietary sources of calcium because of the high content, high absorptive rate, and relatively low cost (Rizzoli, 2014).

In milk, the concentration of calcium is about 1200 mg/L and 99% of calcium is found in the skim milk, where it is distributed between the micellar and aqueous phase

(Gaucheron, 2011; Pereira, 2014). In the micellar phase, calcium is associated with the phosphoseryl residues of caseins while in the aqueous phase, calcium can bind to whey proteins, citrate, or inorganic forms of phosphate-forming salts (Gaucheron, 2011;

Pereira, 2014). Calcium content of milk and dairy products depends on calcium location and calcium’s form in milk and dairy products (Gaucheron, 2011).

Calcium in milk and dairy products are considered to have a higher bioavailability than that of cereals and vegetables, and is similar to calcium carbonate, which is readily absorbed. The typical fractional absorption of calcium from milk and dairy products is in the region of 30% compared to 5% from spinach. The high bioavailability of calcium from milk and dairy products may be due to the absence of factors that inhibit calcium absorption (e.g. caffeine and alcohol) and a number of constituents of milk and dairy products (e.g. lactose and protein) have been proposed to contribute positively to the high bioavailability (Theobald, 2005). A study found that when milk was fortified with vitamin D2, the absorption of calcium was increased (Kaushik, Sachdeva, Arora, Kapila,

& Wadhwa, 2014). In the same study, the retention of calcium in the control group, milk, was 60.71% while the retention of calcium in the vitamin D2 fortified group was 64.14%

(Kaushik et al., 2014).

The Recommended Dietary Allowance (RDA) for calcium for males and females between the ages of nine and 18 years of age is 1,300 milligrams per day (United States

Department of Agriculture (USDA) National Agriculture Library, 2014). The RDA for males and females between the ages of 19 and 50 is 1,000 milligrams per day (USDA

National Agriculture Library, 2014). Milk and dairy products are important sources of calcium, 600 ml of milk corresponds to 720 mg of calcium and therefore, dairy products contribute approximately 70% of calcium to the human diet (Gaucheron, 2011). Two- hundred fifty mg of calcium may be obtained from a 200-ml glass of milk, a 180 g

serving of yogurt, or 30 grams of hard cheese and the consumption of three to four dairy servings per day would allow one to reach the Daily Recommended Intakes (DRI) of calcium (Rizzoli, 2014). Milk and yogurt, depending on the type, typically provides between 200 and 400 mg of calcium per cup, and cheeses generally provide 100 to 200 mg calcium per ounce (Gropper, Smith, & Groff, 2009). Milk and dairy products may represent up to 52-65% of the DRI of calcium (Rizzoli, 2014). Milk and dairy products provide 83% of the calcium in the diets of young children, 77% in adolescent girls’ diets, and between 65% and 72% in adults’ diets (Fleming & Heimbach, 1994). Gaucheron

(2011) considers milk and dairy products to contribute approximately 70% of calcium to the human diet.

Vitamin D

Milk and dairy products are an important source of vitamin D. Vitamin D refers to ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3) which are synthesized by plants and by animal skin under sunlight influence, respectively (Gaucheron, 2011). 7- dehydrocholesterol is synthesized in sebaceous glands of the skin from cholesterol and is secreted onto the skin’s surface (Gropper, Smith, & Groff, 2009). Ultraviolet light penetrates into the epidermis and dermis, thermally activating 7-dehydrocholesterol to cholecalciferol. Cholecalciferol goes into the blood and is circulated in the body; in the liver, cholecalciferol is hydroxylated to 25-hydroxycholecalciferol. 25- hydroxycholecalciferol is transported in the blood to the kidney, and is hydroxylated to

1,25-dihydroxycalciferol, which is the activated form of vitamin D (Gropper, Smith, &

Groff, 2009). Once activated, vitamin D acts as a hormone in the regulation of calcium

and phosphorus metabolism with the aim of maintaining normal calcium and phosphorus concentrations ensuring a normal mineralization of bone (Schmid & Walther, 2013).

Calcitriol, the active form of vitamin D, synthesis is stimulated in response to blood calcium concentration changes and the release of parathyroid hormone (PTH)

(Gropper, Smith, & Groff, 2009). Low blood calcium, hypocalcemia, stimulates the secretion of PTH from the parathyroid gland. PTH then stimulates 1-hydroxylase in the kidney and converts 25-hydroxycalciferol into calcitriol (Gropper, Smith, & Groff, 2009).

Calcitriol then acts alone or with PTH on its target tissues of the intestine, kidney, and bone to increase serum calcium concentrations (Gropper, Smith & Groff, 2009). Vitamin

D enhances calcium absorption by stimulating active transport in the gut, and is necessary for adequate intestinal calcium absorption (Heaney, 2009). Vitamin D also works with

PTH to enhance renal calcium reabsorption and resorption of calcium from bone

(Heaney, 2009; Gropper, Smith & Groff, 2009).

Vitamin D levels in milk and dairy foods are variable and often insufficient to meet body needs by dietary intake only. Studies have reported vitamin D values of milk to be within 0.1 to 0.9 µg/L, which is in accordance with reference nutritional tables

(Pereira, 2014). The widespread strategy in countries such as Canada and the United

States has been to require vitamin D fortification of dairy products (Bonjour, Kraenzlin,

Levasseur, Warren, & Whiting, 2013). Commercially available whole milk which has been enriched with vitamin D presents within 1 to 1.3 µg/100 g (Pereira, 2014). Vitamin

D is relatively unstable and therefore losses can be observed after exposure to light, oxygen, heat, and acidic environments (Gaucheron, 2011).

The absorption of vitamin D varies between 55% and 99% and that absorption does not decrease significantly with age. In a study of the bioavailability of calcium and vitamin D2 in fortified milk, the digestibility of vitamin D2 was 78.25% in vitamin D2 fortified milk and 81.29% in vitamin D2 and calcium fortified milk groups. The vitamin

D2 retention was 76.96% for vitamin D2 fortified milk and 80.19% for vitamin D2 and calcium fortified milk groups (Kaushik et al., 2014). It was concluded that the digestibility and retention of vitamin D2 were positively affected by calcium. It was also concluded that milk was a suitable vehicle for vitamin D2 fortification, furthermore, when used in combination with calcium fortification, bioavailability of these nutrients was increased, indicating a positive interaction between both nutrients (Kaushik et al., 2014).

The RDA for vitamin D for males and females between the ages of nine and 70 years of age is 15 µg per day (USDA National Agriculture Library, 2014). The contribution of milk and dairy products to the vitamin D supply is low; for this reason, different liquid milks are enriched with vitamin D (Gaucheron, 2011). The vitamin D concentration of enriched milk is approximately 0.3 – 0.4 µg/100 g of milk (Gaucheron,

2011).

Phosphorus

Phosphorus is another important element present in milk and dairy products.

Phosphorus is important in bone and teeth acquisition and maintenance, blood pH, a component of biological molecules including RNA, DNA, phospholipids, and ATP, and in metabolism (Gaucheron, 2011). In milk, phosphorus exists in organic and inorganic

phosphorus and the concentration of total phosphorus is approximately 950 mg/L

(Gaucheron, 2011; Pereira, 2014). Organic phosphate is bound to organic molecules like proteins, phospholipids, organic acids, and nucleotides, which are mainly present in the micellar phase (Pereira, 2014). The inorganic form of phosphorus depends on the pH value and is located in the aqueous phase (Pereira, 2014).

The RDA for phosphorus for males and females between the ages of nine and 18 years of age is 1,250 milligrams per day (USDA National Agriculture Library, 2014).

The RDA for males and females aged 19 years and older is 700 milligrams per day

(USDA National Agriculture Library, 2014). Milk and milk products contribute about

30% of daily phosphorus to the U.S. diet (Huth, Fulgoni, DiRienzo, & Miller, 2008).

Magnesium

Compared to calcium, magnesium is not abundant in milk and dairy products. Its concentration in milk is about 120 mg/L. Magnesium is important as a cofactor of enzymatic systems, phosphorylation, DNA transcription, protein synthesis, neuromuscular transmission, and muscle contraction. Ninety-nine percent of magnesium is located in skim milk and is distributed between the micellular and aqueous phase.

Magnesium is sensitive to physiochemical conditions, especially acid pH (Gaucheron,

2011).

The RDA for magnesium for males and females between the ages of nine and 13 years of age is 240 milligrams per day. The RDA for males and females between the ages of 14 and 18 years of age are 410 milligrams per day and 360 milligrams per day

respectively. The RDA for males and females between the ages of 19 and 30 years of age are 400 milligrams per day and 310 milligrams per day. The RDA for males and females between the ages of 31 and 70 are 420 milligrams per day and 320 milligrams per day respectively (USDA National Agriculture Library, 2014). Milk and dairy products have variable concentrations of magnesium depending on their manufacturing process. Milk and dairy products can be considered sources of magnesium; 600 mL of milk provides 65 mg, which corresponds to about 16% of the recommended daily allowance (Gaucheron,

2011).

Protein

Milk and dairy products are considered an important source of protein. Milk supplies protein and the protein fraction can be divided into soluble and insoluble proteins. Soluble proteins, whey proteins, represent 20% of the milk protein fraction and insoluble proteins, caseins, represent 80%. Both soluble and insoluble proteins are classified as high-quality proteins considering amino acid composition, digestibility, and bioavailability (Pereira, 2014).

Milk proteins are frequently considered the best protein source taking into account the essential amino acid score. Whey protein is rich in branched chain amino acids, including leucine, isoleucine, valine, and lysine and casein is rich in histidine, methionine, and phenylalanine. Milk proteins and several bioactive peptides resulting from their enzymatic hydrolysis have shown multiple biological roles that could have a protective action on human health. The main biological actions include antibacterial,

antiviral, antifungal, antioxidant, antihypertensive, antimicrobial, antithrombotic, opiod, and immunomodulatory roles (Pereira, 2014). Protein plays an important role in the bone matrix and bone growth. Protein in bone is used to provide a framework for the hydroxyapatite crystals can form, which helps provide flexibility and increased resistance to tension (Gropper, Smith, & Groff, 2009).

The requirement for protein in well-nourished adolescents and adults is within the normal range of 0.8 – 1.5 g/kg body weight/day (Rizzoli, 2014). Milk provides approximately 32 g/L of protein (Pereira, 2014). One cup of milk can provide eight to 10 grams of protein, 1.5 ounces of cheese can provide nine to 11 grams of protein, a half cup of cottage cheese can provide 13 grams of protein, six ounces of Greek-style yogurt can provide 14 to 18 grams of protein, and traditional yogurt can provide five to seven grams of protein (Gropper, Smith, & Groff, 2009). The consumption of three to four servings of dairy products may represent up to 20-28% of the protein requirement per day in the U.S. diet (Rizzoli, 2014).

Effects of Dairy Consumption on Health

There is a vast amount of literature regarding the associations between dairy intake and a wide range of health outcomes. Though the literature is mixed, the general consensus is that the consumption of dairy products has many benefits. A few of these health outcomes include osteoporosis, weight management, and hypertension.

Osteoporosis

Osteoporosis is a serious health problem in the United States and causes significant morbidity and mortality. Osteoporosis is a condition characterized by low bone mass and bone microarchitechtual deterioration, leading to skeletal fragility and increased risk of fracture (Heaney, 2009). Osteoporosis is a pediatric disease with a geriatric outcome (Gropper, Smith, & Groff, 2009). In children and adolescents, skeletal turnover occurs such that formation of bone exceeds resorption of bone and up to 90 percent of peak bone mass is acquired by 18 years old. Skeletal turnover continues into adulthood with peak bone mass occurring in early adulthood, around age 30. During the fifth decade, bone mass begins to decline (Gropper, Smith, & Groff, 2009). The nutrients that have the greatest physiological impact on bone and skeletal muscle throughout life are calcium, vitamin D, phosphate, and protein; dairy foods contain these nutrients in appreciable amounts compared to their recommended allowances (Bonjour, Kraenzlin,

Levasseur, Warren, & Whiting, 2013). If failed to have good nutrition of these nutrients during peak bone mass, bone mineral density decreases during next phase of life, which can lead to risk of osteoporosis.

Osteoporosis is a systemic skeletal disease characterized by the deterioration of the microarchitecture of bone tissue and low bone density. Bone turnover occurs throughout life, but after about age 30 to 35 years bone resportion exceeds bone formation (Gropper, Smith, & Groff, 2009). Osteoporosis affects both cortical and trabecular bone, although trabecular bone is affected to a greater extent. Sites containing trabecular bone include the vertebral bodies, the femoral neck in the pelvis, and the

radius, which are the principal sites affected in osteoporosis. The symptoms of osteoporosis include dowager’s hump (kyphosis or hunchback-type curvature of the spine), increased fractures, and loosening of teeth due to the loss of calcium from the mandible (Gropper, Smith, & Groff, 2009).

There are two main types of osteoporosis. Primary or hormonal osteoporosis is characterized by demineralization of mostly trabecular bone and occurs primarily in postmenopausal women about 50 to 65 years of age (Gropper, Smith, & Groff, 2009).

Age-related or senile osteoporosis is characterized by demineralization of both cortical and trabecular bone and occurs in both men and women over approximately 70 to 75 years of age. There are also two categories of risk factors: unmodifiable and modifiable.

Unmodifiable risk factors include being a female, having a small body frame size, being

Caucasian, Asian, or Hispanic, having a family history of osteoporosis, age, and menopause (lose of estrogen, which has positive effects on bone formation). Modifiable risk factors include low calcium and vitamin D intake, low physical activity (weight- bearing exercises have a protective effect on bone), smoking, some medications, diets high in sodium, protein, and caffeine, and excessive alcohol and soda consumption

(Gropper, Smith, & Groff, 2009).

Asian-Americans and Caucasians possess some of the same risk factors associated with increased fracture rates and therefore have the highest risk of osteoporosis.

Approximately 20% of non-Hispanic whites and Asian women ages 50 years and older have osteoporosis, compared with 5% to 10% of non-Hispanic African-American women and 10% to 15% of Hispanic women of the same age (Thomas, 2007). It is estimated that

an additional 50% to 65% of non-Hispanic white and Asian women have osteopenia, compared to 35% to 38% of black women and 49% of Hispanic women (Thomas, 2007).

Observational studies and controlled trials show a significantly positive association between dairy food intake, bone turnover markers, and bone mineral content

(BMC) or bone mineral density (BMD) (Rizzoli, 2014). The application of an intervention approach combining nutrition, education, and consumption of fortified dairy products for 12 months showed more favorable changes in biochemical indexes of bone metabolism than calcium supplementation alone among postmenopausal women

(Manios, Moschonis, Trovas, & Lyritis, 2007). The dairy intervention group had greater improvements in pelvis, total-spine, and total-body BMD than both the calcium supplementation and control groups (Manios et al., 2007). Heaney (2000) reported that of 86 observational studies, 64 reported relationships in favor of increased calcium intakes, with reduced fracture risk, bone loss or improved bone mass and of those studies specifically evaluating dairy sources of calcium, approximately 75% supported the conclusion that increased calcium from dairy foods is protective of the skeleton. The hypothesized mechanism of dairy’s role in osteoporosis relates to calcium; high calcium intakes suppress PTH secretion and reduce elevated bone remodeling, and in this process reduces the bony fragility that is the hallmark of osteoporosis (Heaney, 2000). It is noted that when calcium intake is adequate, consuming additional calcium confers no further benefits. Dairy foods contain calcium, phosphorus, and protein; these three nutrients have a beneficial effect on bone organic matrix formation and mineralization while also exerting an inhibitory effect on bone resorption (Bonjour et al., 2013).

There is evidence that protein and phosphorus at the proper level can enhance calcium absorption and renal tubular reabsorption and can contribute to the positive effect of dairy foods on bone health. Increasing vitamin D intakes in older adults has been shown to reduce the risk of fracture and bone loss (Heaney, 2009). A meta-analysis reported that 700 to 800 IU/day of oral vitamin D reduced non-vertebral fractures by 23% and hip fractures by 26% compared to placebo during a 12 month randomized controlled trial. Studies have reported a positive relationship between protein intake and BMD, reduced incidence of fracture, and reduced rate of bone loss (Willet, Wong, Giova, &

Dietrich, 2006).

Weight Management

It is theorized that milk and dairy products may facilitate a role in weight management. There are two models to suggest how milk and dairy promotes weight loss.

The first model involves intracellular calcium’s role in the metabolism of the adipocyte.

High dietary calcium can suppress the concentrations of serum PTH and 1,25 dihydroxyvitamin D. PTH and 1,25 dihydroxyvitamin D increase concentrations of intracellular calcium in adipocytes, which leads to a decrease in lipolysis and an increase in lipogenesis through increase of fatty acid synthase concentrations in the cell (Tudor,

Havranek, & Serafini, 2009). Gunther et al. (2006) study showed a one year change in

PTH was positively associated with the change in fat mass in healthy, normal-weight young women aged 18 to 31 years. The same study showed an acute increase in milk and dairy calcium does not affect fat oxidation during chronically low calcium intakes, however, a long-term increase in dietary calcium leads to an increase in whole body fat

oxidation independently of taking a low-calcium or high-calcium meal (Gunther et al.,

2006).

The second model involves the inhibition of fat absorption in the intestines through binding fatty acids in the intestines by calcium and thereby increasing the amount of fatty acids in fecal excretion (Tuder, Havrenek, & Serafini, 2009). It has been found that calcium from milk dairy foods has a more profound effect on fat loss than calcium from supplements (Gunther et al., 2006). The mechanism of the additional dairy effect on weight loss is not clear, but it has been suggested that it may be due to other bioactive components in dairy products like conjugated linoleic acid, branched amino acids, whey peptides, and lactose (Tuder, Havrenek, & Serafini, 2009).

Chen, Pan, Malik, and Hu (2012) conducted a meta-analysis of 29 randomized controlled trials of weight management and dairy consumption and concluded that the analysis did not support the beneficial effect of increasing dairy consumption on body weight and fat loss in long term studies (> 1 year) or studies without energy restriction.

Dairy products may have modest benefits in facilitating weight loss in short-term or energy restricted randomized controlled studies (Chen, Pan, Malik, & Hu, 2012). After reviewing nine prospective cohort studies on dairy consumption and overweight and obesity in adults, the results provided evidence of a suggestive, but not consistent protective effect of dairy consumption on risk of overweight and obesity (Chen, Pan,

Malik, & Hu, 2012).

In an analysis of 14 studies investigating the effects of increased dairy consumption in the diet on weight, fat mass, lean mass, and waist circumference, the results provided evidence that increased dairy intake had no discernable effect on any of the variables unless it was combined with energy restriction (Abargouei, Janghorbani,

Salehi-Marzijarani, & Esmaillzadeh, 2012). Another meta-analysis study concluded that energy restricted, dairy based diets resulted in improved weight loss, increased fat loss, and an increase in lean body mass (Sanders, 2012).

Hypertension

There is considerable data of observational trials and randomized controlled trials regarding the effects of milk and dairy food consumption on blood pressure and the risk of hypertension. In the Framingham Children’s study, children consuming two or more servings per day of dairy products during preschool years, regardless of fat level, had smaller yearly gains in systolic blood pressure (SBP) and lower SBP by early adolescence (Moore et al., 2005). Overweight young adults were followed for 10 years in the Coronary Artery Risk Development in Young Adults (CARDIA) study; the consumption of reduced fat and higher fat dairy products were inversely related with the risk of high blood pressure (Pereira et al., 2002).

The Rotterdam Study analyzed the association of dairy food intake and the association with hypertension, results revealed that each serving of dairy per day, identified as 150 mL, was associated with a 7% lower risk of hypertension (Engberink et al., 2009). Upon examination of the association with dairy products stratified by low- or

high-fat content, there was a significant inverse association primarily with low-fat dairy intake (Engberick et al., 2009). Fermented dairy products intake was also inversely related with hypertension, but there was no observed association for cheese products and hypertension (Engberick et al., 2009).

The National Heart, Lung, and Blood Institute Family Heart Study showed a 36% lower occurrence of hypertension in American adults with a high intake of low-fat dairy products, independent of calcium intake (Djoussé et al., 2006). The Seguimiento

Universidad de Navarra (SUN) cohort study in Spanish university graduates prospectively showed that low-fat dairy product intake and not whole-fat dairy intake was associated with a 54% lower risk of hypertension incident in the upper quartile (Alonso,

Beunza, Delgado-Rodríguez, Martínez, & Martínez-González, 2005).

In a meta-analysis of nine observational and clinical studies results showed a slight protective effect of low-fat dairy and milk intake on hypertension (Soedamah-

Muthu, Verberne, Ding, Engberink, & Geleijnse, 2012). Ralston, Lee, Truby, Palermo,

& Walker (2012) analyzed five cohort studies with almost 11,500 cases of elevated blood pressure and the objective of separating the effects of high-fat compared with low-fat dairy, results showed a significant inverse relationship between the low-fat dairy intake and elevated blood pressure with no benefit from high-fat dairy.

The mechanism by which dairy products reduce blood pressure remains to be established. One hypothesized mechanism of antihypertension action of dairy is rich in protein and bioactive peptides, which might exert a beneficial effect on blood pressure

possibly by inhibiting the angiotensin-I-converting enzyme, modulating endothelium function, of affecting body weight (Engberink et al., 2009). Another hypothesized mechanism of antihypertension action of dairy products is centered on its key nutrients including potassium, calcium, and magnesium. Dietary potassium restriction leads to deficiency as the kidneys cannot conserve potassium, which increases renal sodium and chloride ion retention; this potassium deficiency has been shown to increase the sodium- hydrogen exchange system by stimulating the sympathetic nervous system and the renin- angiotension system. An increase in sodium-hydrogen activity in vascular smooth muscle cells may elevate cellular sodium ions, which reduces calcium ions through sodium-calcium ion exchange; this would lead to increased systolic calcium concentrations and vasoconstriction. Low concentrations of potassium has also been shown to limit sodium, potassium-ATPase activity resulting in increased intracellular sodium (Kris-Etherton, Grieger, Hilpert, & West, 2009).

Socio-cultural Practices Related to Dairy Consumption

There are social or cultural aspects in regards to perceptions and consumption of dairy products. African-Americans, Asian-Americans, and Hispanic-Americans are minority groups of the population that have social or cultural aspects in relation to dairy consumption.

African-Americans

Dairy intake among African-Americans is less than recommended; analysis of the

2009-2010 National Health and Nutrition Examination Survey (NHANES) data revealed

that non-Hispanic African-Americans consume 1.2 cup equivalents per day. On average, non-Hispanic African-American children aged two to 18 years consume 1.8 dairy servings per day and 76% drink milk once they reach school age (5 years old). Forty- four percent of non-Hispanic African-Americans drink milk once a day during adolescence (ages 13 to 17 years) (Bailey et al., 2013).

Due to the fact that intake of dairy foods and its nutrients have been linked to reduced risk of several chronic diseases, Non-Hispanic African-Americans, whose dairy intake is suboptimal, may be at a higher risk of obesity and hypertension. Compared to

Caucasians, non-Hispanic African-Americans had a 51% higher obesity rate from 2006-

2008 (Centers for Disease Control (CDC), 2009); Zemel et al. (2005) found that non-

Hispanic African-American adults following a calorie-restricted, dairy-adequate (three servings of dairy per day) diet for 24 weeks lost significantly more weight than those only on a calorie-restricted diet with one or fewer servings of dairy per day. Non-

Hispanic African-Americans suffer from the highest rates of hypertension in the U.S.

(Roger et al., 2012); a meta-analysis of prospective studies assessing dairy food consumption and disease outcomes concluded that higher dairy intake was associated with lower incident ischemic heart disease and stroke (Elwood, Pikering, Givens, &

Gallacher, 2010).

Lactose intolerance is estimated to occur in approximately 80% of non-Hispanic

African-Americans (Jarvis & Miller, 2002). Non-Hispanic African-Americans who reported themselves as being lactose intolerant were less likely to consume dairy foods

(35%) compared to those who did not report lactose intolerance (45%) (Keith, Nicholls,

Reed, Kafer, & Miller, 2011). Lactose intolerance did not account for all the lower dairy intake among non-Hispanic African-Americans compared to the general U.S. population;

26% of non-Hispanic African-Americans reported that they consumed less than one serving per day of dairy foods on average, are not lactose intolerant, and do not experience discomfort most of the time after consuming a dairy food, which indicates other factors may also influence lower dairy food intake among non-Hispanic African-

Americans (Keith et al., 2011).

Asian-Americans

Dairy intake among Asian-Americans is less than normal; analysis of the 1999-

2004 NHANES data indicates Asian-Americans adults 18 years or older consume 1.2 servings of dairy per day (Beydoun, Gary, Caballero, Lawrence, Cheskin, & Wang,

2008). Nine-point-two percent of Asian-Americans consumed greater than or equal to three servings of dairy per day. Fluid milk servings of dairy was 0.7 per day, 0.03 servings of yogurt per day, and 0.46 servings of yogurt per day for Asian-Americans

(Beydoun et al., 2008).

The biggest barrier is lactose intolerance. Lactose intolerance has been observed in approximately 100% of Asians (Jackson & Savaiano, 2001). In a study of 20 Chinese-

American couples interviewed, nine parents reported lactose intolerance and two reported having a child with lactose intolerance; among these some ignored dairy products altogether and others used strategies to reduce symptoms, e.g. eating small portions or eating yogurt and cheese (Lv & Brown, 2010). All of the parents considered milk the

most convenient and cheapest dairy product for home use and many parents liked yogurt for its convenience and nutrition and preferred the fruit flavored to plain (Lv & Brown,

2010). In regards to personal willingness to eat more dairy products, most parents were satisfied with their limited dairy product intake and saw no need to increase consumption

(Lv & Brown, 2010).

While lactose intolerance may be one of the reasons for the low consumption of milk and dairy foods in Asian-Americans, other factors such as culturally determined food preferences and dietary practices learned early in life also play a role (Jarvis &

Miller, 2002). Asian-American dietary practices limit calcium intake from dairy, most likely due to the interaction of traditional cultural food practices and food availability

(Jackson & Savaiano, 2001). There is evidence that acculturation of Asian-Americans positively influences dietary patterns of calcium and milk consumption (Jarvis & Miller,

2002).

Hispanic-Americans

Dairy intake among Hispanic-Americans is less than normal; analysis of the

2009-2010 NHANES indicates Hispanic-Americans consume 1.5 cup equivalents of dairy per day. Hispanic-American children aged two to 18 years consume an average of

1.9 dairy servings per day and 87% drink milk when they reach school age (5 years).

Fifty-three percent of Hispanic-American adolescents (age 13 to 17 years) drink milk

(Bailey et al., 2013).

Intake of dairy foods and its nutrients have been linked to reduced risk of several chronic diseases and adequate intakes (three to four servings/day) are recommended by public health authorities. Hispanic-Americans may be at a higher risk of obesity and osteoporosis. Compared to Caucasians, Hispanic-Americans had a 21% higher obesity rate from 2006-2008 (CDC, 2009). Hispanic-Americans have bone density comparable to Caucasian-Americans, their bone mineral density and fracture risk is affected by both racial and lifestyle variables. Some research indicates that fracture risk is increasing most rapidly among Hispanic-Americans, although its cause is not known (Cooper & Ballard,

2011).

Lactose intolerance may be partly to blame for the low calcium and dairy food consumption in Hispanics as well. Lactose intolerance is estimated to occur in approximately 50% of Mexican Americans (Jarvis & Miller, 2002). A 2009 study determined the self-reported prevalence rates of a nationally representative sample of

Hispanic-Americans adults concluded that after age-adjustments, 10.05% considered themselves lactose intolerant (Nicklas, O’Neil, & Fulgoni III, 2009). Other factors such as cultural determined food preferences and dietary practices learned early in life also play a role in the low consumption of dairy among Hispanic Americans. There is evidence that acculturation of Hispanic-Americans positively influences dietary patterns of calcium and milk consumption (Jarvis & Miller, 2002).

Current Consumption Patterns

National survey data from the 2001-2002 National Health and Nutrition

Examination Survey (NHANES) indicate that 39% of men and 43% of women aged 20 to

29 years consume less than even one daily serving of dairy products (Larson, Neumark-

Sztainer, Harnack, Wall, Story, & Eisenberg, 2009). The mean fluid milk intake for the age groups of two to 11 and 12 to 19 years of age was approximately 1 ¾ cup per day according to NHANES 2005-2006 (USDA Agricultural Research Service, 2010). The mean fluid milk intake for the age groups of 20 to 49 and 50 and older years of age was approximately ¾ cup per day according the NHANES 2005-2006 (USDA Agricultural

Research Service, 2010). In all age groups except adults aged 50 years and older, non-

Hispanic African-Americans consumed significantly less milk than non-Hispanic whites and Mexican-Americans (USDA Agricultural Research Service, 2010). Among adults aged 20 years and older, non-Hispanic whites and Mexican Americans consumed on average about ¾ cup milk whereas non-Hispanic African Americans consumed a little over 1/3 cup (USDA Agricultural Research Service, 2010).

National survey data from 2007 – 2010 NHANES two day averages revealed

Americans drink a total of 1.77 cups of total dairy per day (USDA Economic Research,

2014b). Children aged two to 19 years consumed an average of 2.16 cups of dairy per day and adults age 20 years and older consumed an average of 1.64 cups of dairy per day from the 2007 – 2010 NHANES data (USDA Economic Research, 2014b). The data also looked at income level in relation to dairy consumption; lower and higher income were separated by the 185% income poverty line in income threshold. Americans in the higher

income group consumed 1.83 cups of dairy per day compared to 1.67 cups of dairy per day in the lower income category (USDA Economic Research, 2014b).

The preliminary data for 2013 indicates the product weight of beverage milks, fluid creams, and egg nog was 189 pounds per person consumed (USDA Economic

Research, 2014a). The preliminary data in regards to yogurt consumption in 2013 is 14.9 pounds of yogurt was consumed per person (USDA Economic Research, 2014a). The preliminary consumption data for 2013 for all dairy products including beverage milks, fluid creams and egg nog, yogurt, cheese, evaporated and condensed milk, frozen dairy products, and dry products was 607 pounds per person (USDA Economic Research,

2014a).

Barriers to Dairy Consumption

There are several barriers to dairy consumption that may prevent some individuals from consuming dairy products. Some of these barriers are lactose intolerance, cow’s milk protein allergy, and attitudes and beliefs towards milk and dairy.

Lactose Intolerance

One of the barriers to dairy consumption is lactose intolerance. Lactose, milk sugar, is a disaccharide that must be hydrolyzed into its component simple sugars of glucose and galactose in order to be absorbed across the intestinal mucosa. The hydrolysis of lactose requires the enzyme, lactase, which is produced in the intestinal mucosa. The production of lactase by mucosal cells decreases with age and is prominent in individuals of East Asian and African ethnicity. The absence of adequate hydrolysis of

lactose in the small intestine results in the movement of undigested lactose into the distal bowel, where bacteria ferment the sugar producing gas and symptoms of cramps, bloating, flatulence, and diarrhea (Heaney, 2013).

Diagnosis of lactose intolerance can be accomplished with the lactose-hydrogen breath test. A 50 gram lactose solution in water is ingested, and hydrogen gas levels are measured at varying intervals after ingestion. Lactose is incompletely absorbed once it passes the colon and ferments into various gases, including methane, carbon dioxide, and hydrogen as well as short-chain fatty acids. Some of the hydrogen gas is absorbed into the blood and exhaled during passage through the lungs. The specificity of the hydrogen breath test ranges from 89% to 100%, with a sensitivity ranging from 69% to 100%

(Carter & Attel, 2013).

The traditional management of lactose intolerance relies on reducing lactose exposure by avoiding milk and milk-containing products or by drinking milk in which the lactose has been pre-hydrolyzed with lactase (Suchy, Brannon, Carpenter, Fernandez,

Gilsanz, Gould, & Wolf, 2010). Small amounts of milk, yogurt, hard cheeses, and reduced-lactose foods may be effective management approaches; individuals with lactose malabsorption probably can tolerate 12 grams of lactose without significant symptoms, particularly if ingested with other foods (Suchy et al., 2010). There are factors that affect the activity of lactase in the digestion of lactose including pH and acidity. Another factor in the digestion of lactose includes the efficient utilization of lactose from cultured milk products, such as -galactosidase, which could be attributed from the lactase activity of

the bacteria, stimulation of host’s mucosal lactase activity, or slower intestinal transit of cultured milk product compared to milk (Sarker, 2006).

Galactose activity has also been demonstrated in many lactobacilli and differs greatly in their lactase activity; probiotic cultures (e.g. lactobacillus acidophilus and bifidobacterium) possess lower levels of lactase and being more resistant to bile than yogurt cultures are less efficacious in helping lactose digestion. Factors affecting the lactase activity are growth condition survivability of starter cultures, survivability of starter cultures, product manufacturing, and storage conditions, and post-processing treatments (Sarker, 2006). Therefore, cultured and acidified dairy products may be an effective solution to consuming dairy products in lactose intolerant individuals.

Cow’s Milk Protein Allergy

Cow’s milk protein allergy (CMPA) is generally the first food allergy observed in children (Pereira, 2014). CMPA can be IgE-mediated or non-IgE-mediated, in which

IgE-mediated reactions can be immediate and have adverse consequences while non-IgE- mediated reactions are delayed (Pereira, 2014; De Koker, Shah, & Meyer, 2014). The immediate symptoms include anaphylaxis, cutaneous reactions with urticarial and edema, respiratory episodes, and gastrointestinal distress including vomiting, diarrhea, and bloody stools (Pereira, 2014). Pereira (2014) cites most frequently cow’s milk protein allergies are due to whey proteins, mainly beta-lactoglobulin, but can also be promoted by caseins. Solinas, Corpino, Maccioni, & Pelosi (2010) report alpha-lactalbumin, beta- lactoglobulin, and casein allergens as the most important allergens of cow’s milk.

Estimates of the prevalence of CMPA vary from 2% to 7.5% (Pereira, 2014; Solinas,

Corpino, Maccioni, & Pelosi, 2010).

In suspected IgE-mediated CMPA, skin prick tests and blood tests for specific IgE are currently the only acknowledged diagnostic tests (De Koker, Shah, & Meyer, 2014).

Non-IgE-mediated CMPA reactions are more difficult to diagnose, which is compounded by the lack of diagnostic tests to confirm diagnosis. The method for diagnosing non-IgE- mediated CMPA is an allergy focused history, followed by an elimination diet with resolution of symptoms and recurrence of symptoms on re-introduction of foods (De

Koker, Shah, & Meyer, 2014).

The only treatment for CMPA is the complete avoidance of cow’s milk protein.

This requires a diet free from cow’s milk and cow’s milk-based products (De Koker,

Shah, & Meyer, 2014; Pereira, 2014; Solinas, Corpino, Maccioni, & Pelosi, 2010).

Normally, CMPA tends to remit during childhood and quite uncommon in adults; tolerance develops in 51% of cases within two years after diagnosis and 80% of cases attain tolerance within three to four years (Pereira, 2014; Solinas, Corpino, Maccioni, &

Pelosi, 2010).

Attitudes and Beliefs

Mahon & Haas (2013) conducted a mixed-methods approach to determine whether college students consume the recommended amounts of dairy foods on a daily basis and then targeted college-aged females for focus groups to provide insight into why dairy consumption is low among females. The results showed on average, college

students consumed less than one serving of milk or dairy per day and men consumed significantly more milk or dairy than women. The qualitative part of the study with focus groups indicated that the participants communicated a lack of knowledge about the importance of dairy in their daily diets, what a serving size of milk or dairy was, and the recommended amount of servings per day were some barriers related to the self-efficacy toward consuming milk and dairy. Perceived barriers to consuming milk and dairy identified in the focus groups were other food or beverage options are more appealing than milk and dairy, poor access on campus, limited variety of milk and dairy products on campus, unnecessary calories and fat, and side effects. Benefits of consuming milk and dairy identified were healthier, ease of access, various health-related benefits, and fat-free

(Mahon & Haas, 2013)

Fifty-nine older, low-income women participated in nine focus groups to identify the attitudes, beliefs, and barriers related to milk consumption (Mobley, Jensen, &

Maulding, 2014). Most women liked the taste of milk and milk products with one negative attitude toward non-fat and low-fat milk. The primary belief or reason for milk consumption was “good for bones/osteoporosis prevention/good for you/health” and often physician recommended. Barriers to milk consumption were primarily related to personal factors such as gastrointestinal issues and perceived lack of benefit at an older age. Some behavioral and environmental themes including lack of habitual intake, cost and milk spoilage appeared to have less of an influence on milk consumption. The questionable treatment of cows and hormones in milk were mentioned sometimes but did

not to appear to be a primary barrier for milk consumption (Mobley, Jensen, & Maulding,

2014).

The St. Louis District Dairy Council cited low dairy intake was due to several reasons. Some of the reasons for low dairy intake include promotion of or choice of nondairy drinks, which is a result of a 33% decline in family mealtime in the past 30 years

(St. Louis District Dairy Council, 2013). Other reasons include animal rights activism, vegan food patterns, and ethnic food practices or preferences. Reality of lactose intolerance or milk allergy, perception of dairy intolerance, limited knowledge of dairy for overall diet quality and of managing lactose intolerance among health professionals, and the misinformation about dairy among the public were also cited as reasons for low dairy intake. Consumers are less apt to consume milk with the midday and nighttime meals, which leads to fewer occasions per day to consume milk. Changing tastes and preferences are the most common reasons for consuming less dairy (St. Louis District

Dairy Council, 2013).

Organizations Currently Promoting & Educating on Dairy Consumption

There are a variety of organizations promoting and educating the public on dairy consumption. Some of these organizations include the National Milk Processor

Education Program, American Dairy Association and Council, Inc., National Dairy

Council, and Dairy Farmers of America. The Food, Farm, and Jobs Bill 2014 provides the Special Milk Program and the Dairy Protection Program; these programs help in the

production and consumption of dairy (USDA Food and Nutrition Services, 2014; USDA

Farm Service Agency, 2014).

National Milk Processor Education Program

The Milk Processor Education Program (MilkPEP) is funded by the nation’s milk processors, who are committed to increasing the fluid milk consumption (Milk Processor

Education Program (MilkPEP, 2014b). MilkPEP activities are led by a 20 member board, which is monitored by the United States Department of Agriculture (USDA)

Agricultural Marketing Service (MilkPEP, 2014b). MilkPEP works with the trade (retail, schools, foodservice, and vending) to create new business opportunities for milk through channel expansion (MilkPEP, 2014b). Campaigns and organizations funded and supported by MilkPEP include Milk Life, The Breakfast Project, Projecto Desayuno,

MilkDelivers, Got Milk Sales, and Build It got chocolate milk?.

Milk Life is a $60 million cross-platform campaign that reinforces milk’s many nutrition benefits including high-quality protein (America’s Milk Processors, 2014). The campaign spotlights everyday moments of accomplishment, achievement, and enjoyment with milk can help power the potential of every day. With eight grams of high-quality protein in each 8 oz. glass of milk, including milk at breakfast, can help you make the most of your day (America’s Milk Processors, 2014). The Milk Life website includes recipes, food/nutrition information, breakfast, and videos to show the importance of including milk in the diet.

The Breakfast Project promotes a breakfast that includes milk that includes high- quality protein. The Breakfast Project has partnered with Quaker to promote a breakfast of Quaker oatmeal and milk that includes high-quality protein and delivers health energy for the entire family (MilkPEP, 2014b). The Breakfast Project website provides tips, tools, nutritious recipes, and more to help make milk part of the morning routine in breakfast. Projecto Desayuno is the Spanish language version of this organization to help share the latest health and nutrition news about milk, tips, tools, and recipes that are culturally relevant to the Hispanic customer (MilkPEP, 2014b).

Milk Delivers provides information and resources to schools and foodservice professionals and spotlights how milk plays a vital role in these areas. Milk Delivers explains that, “schools are in a unique position to impact children’s food choices – including their milk intake – because many rely on school meals as their major source of nourishment, with over 32 million meals served daily” (MilkPEP, 2014a). The goal of

Milk Delivers is to ensure students have healthful lunches each day, and milk is a nutritious part of the school meal (MilkPEP, 2014a).

Got Milk Sales provides information, tools, and resources for grocery retailers who want to take advantage of the National got milk? Milk Mustache program to grow store sales. Grocery retailers recognize the importance of meal solutions and have implemented a dinner strategy to drive shopper traffic and increase basket rings, and milk is one of the most important items in the cart (America’s Milk Processors, 2014). This campaign of MilkPEP focuses on two long-term meal-occasion based consumer programs that represent prime occasions for milk and retail sales: Protein at Breakfast

and Post-Workout Recovery for athletes (America’s Milk Processors, 2014). These programs feature milk and are designed to change consumer behavior.

The Refuel got chocolate milk? campaign has been gaining momentum since it was launched in 2012 and research suggested that the campaign could evolve and build on strengths of the 2013 My After campaign (America’s Milk Processors, 2014). Build It got chocolate milk? resonated the strongest and delivered a powerful positioning of chocolate milk as an effective post-workout recovery beverage (America’s Milk

Processors, 2014). The key importance of the Build It got chocolate milk? campaign is to educate athletes about what their bodies need post-exercise and to specifically reinforce why chocolate milk is so beneficial (America’s Milk Processors, 2014).

MilkPEP is also involved in the campaign, The Great American Milk Drive, which brings the dairy industry together with Feeding American regarding the issue of hunger, which impacts one in six Americans (America’s Milk Processors, 2014). The national campaign helps elevate awareness for the need of milk in America’s feeding programs and provide Americans a simple way to help (America’s Milk Processors,

2014). The program is designed to encourage consumers to make a simple donation by purchasing an extra gallon of milk and Feeding America will deliver it to local families who need it the most (America’s Milk Processors, 2014).

American Dairy Association and Dairy Council, Inc.

The American Dairy Association and Dairy Council, Inc. (ADADC) has been serving dairy farmers in the states of New York, New Jersey, and Pennsylvania since

1962 and specialize in the promotion of generic dairy products for the purpose of increasing the sales of milk and dairy products (American Dairy Association and Dairy

Council, Inc.(ADADC), n.d.). ADADC is a non-profit corporation that is funded and directed by dairy farmers’ check-off dollars for the purpose of increasing sales of and demand for dairy products (ADADC, n.d.). The mission is to economically benefit dairy farmers by encouraging the consumption of milk and dairy products through advertising, education and promotion, and to reach consumers with product benefits and advantages

(ADADC, n.d.). The ADADC administers the following programs: Hispanic Advertising

& Promotions, Retail Product Quality Space Allocation, Training Workshops for Dairy

Case Managers & Milk Handlers, School Breakfast & Lunch Programs, Medical &

Nutrition Seminars for Health Professionals, Television & Newspaper Publicity, Industry

Relations, Dairy Princess Program, and Crisis Communication Training (ADADC, n.d.).

Another program supported by the ADADC is the Fuel Up to Play 60 campaign.

The Fuel Up to Play 60 is an in-school nutrition and physical activity program launched by the American Dairy Association and Dairy Council, Inc., the National Dairy Council, and the National Football League in collaboration with the USDA (ADADC, n.d.). The program empowers youth to take actions to improve nutrition and physical activity at their school, by implementing long-term, positive changes (ADADC, n.d.). Youth are encouraged to consume nutrient – rich foods including low-fat and fat-free dairy foods, fruits, vegetables, and whole grains and to achieve at least 60 minutes of physical activity every day (ADADC, n.d.).

National Dairy Council

The National Dairy Council (NDC) is a non-profit organization funded by the national dairy check-off program and is committed to nutrition education and research- based communications (National Dairy Council (NDC), 2014). NDC provides science- based nutrition information in collaboration with a variety of stakeholders committed to fostering a healthier nation, including health professionals. Educators, school nutrition directors, academia, industry, consumers, and media (NDC, 2014). NDC was established in 1915 and compromises a staff of registered dietitians and nutrition research and communications experts across the country (NDC, 2014). NDC has promoted child health and wellness through programs such as Fuel Up to Play 60.

Another promotion of the NDC is the Dairy Report. The Dairy Report is a blog written by health professionals (registered dietitians, PhD nutritionists, and communication experts) at the NDC. The purpose of the Dairy Report is to provide the latest news, analysis and opinion on nutrition and health research and events (NDC,

2014). NDC is committed to providing health professional with updated and timely, credible dairy and nutrition research and educational tools to help serve the health professionals’ patients (2014).

Dairy Farmers of America

Dairy Farmers of America (DFA) was created in 1966 when the Associated Milk

Producers, Inc., Mid-American Dairymen, Inc., Milk Marketing, Inc., and Western

Dairymen Cooperative, Inc. gathered and united their talents, leadership, markets, and

capital into a single, stronger cooperative better able to work for the dairy farmer (Dairy

Farmers of America (DFA), 2014). Since then Independent Cooperative Milk Producers

Association, Valley of Virginia Milk Producers Association, Black Hills Milk Producers, and California Cooperative Creamery have merged into DFA in order to take advantage of a unified voice and other benefits that working together brings to their members (DFA,

2014). In 1999, DFA and Dairylea partnered to create Dairy Marketing Services (DMS), which markets milk for both independent producers and cooperative members; DMS is now a national organization (DFA, 2014). Today, DFA is a leading milk marketing cooperative and dairy food processor and serves nearly 13,000 members (DFA, 2014).

Though DFA is a national milk marketing cooperative, it is divided into seven areas, which ensures the grassroots representation of members. The areas are organized into districts, in which members elect representatives to serve on their governing area council, which monitor the marketing of milk and local issues (DFA, 2014). The DFA mission is DFA is a milk marketing cooperative and dairy foods processor dedicated to delivering value to members through secure markets, competitive pricing, and increasing value throughout the entire dairy chain (DFA, 2014).

Food, Farm, and Jobs Bill 2014

The farm bill is an omnibus, multi-year piece of authorizing legislation that governs an array of agricultural and food programs (Johnson & Monke, 2013). Farm bills have traditionally focused on farm commodity price and income support for a handful of staple commodities (corn, soybeans, wheat, cotton, rice, and dairy) since the

1930s (Johnson & Monke, 2013). Some of the most important additions to the farm bill have included nutrition assistance, conservation, horticulture, and bioenergy programs

(Johnson & Monke, 2013). Two of the major programs of the farm bill in regards to dairy are the Special Milk Program and the Dairy Margin Protection Program.

Special milk program. The Special Milk Program (SMP) provides milk to children in schools, childcare institutions, and eligible camps that do not participate in other Federal child nutrition meal service programs, e.g. National School Lunch Program or School Breakfast Program (United States Department of Agriculture (USDA) Food and Nutrition Service, 2014). Schools in the National School Lunch or School Breakfast program may participate in the SMP to provide milk to children in half-day pre- kindergarten and kindergarten programs where children do not have access to the school meals programs. The SMP works by participating schools and institutions receive reimbursement from the United States Department of Agriculture for each half pint of milk served, they must operate their milk programs on a non-profit basis and agree to use the Federal reimbursement to reduce the selling price of milk to all children (USDA Food and Nutrition Services, 2014).

Any childcare program offering free milk under the SMP to low-income children, any child from a family meeting income guidelines for free meals is eligible (USDA

Food and Nutrition Services, 2014). Each child’s family must apply annually for free milk eligibility. Childcare programs must offer only pasteurized fluid fat-free or low-fat milk meeting all State and local standards and should contain vitamins A and D at levels

specified by the Food and Drug Administration (USDA Food and Nutrition Services,

2014).

Since the expansion of the National School Lunch Program and School Breakfast

Program, which include milk, has led to a substantial reduction in the SMP. The SMP has served nearly three billion half pints of milk in 1969, one point eight billion half pints in 1980, and 181 million half pints in 1990 (USDA Food and Nutrition Service, 2014).

In the fiscal year of 2012, over 61 million half pints of milk were served in the SMP

(USDA Food and Nutrition Service, 2014).

Dairy margin protection program. The Dairy Margin Protection Program replaces the Milk Income Loss Contract Program and was effective no later than

September 1, 2014 through December 31, 2018. The program offers dairy producers catastrophic coverage with an annual $100 administrative fee and various levels of buy- up coverage (USDA Farm Service Agency, 2014). Catastrophic coverage provides payments to participating producers when the national dairy production margin is less than $4.00 per hundredweight (USDA Farm Service Agency, 2014). The dairy production margin is the difference between the all-milk price and average feed costs

(USDA Farm Service Agency, 2014). To participate in buy-up coverage, a producer must pay a premium that varies with the level of protection the producers elects (USDA

Farm Service Agency, 2014).

The 2014 Farm Bill Act also creates the Dairy Product Donation Program. This program is triggered in times of low operating margins for dairy producers and requires

the USDA to purchase dairy products for donations to food banks and other feeding programs (USDA Farm Service Agency, 2014). The Dairy Indemnity Payment Program

(DIPP) is also a part of the 2014 Farm Bill Act. The DIPP provides payments to dairy producers when a public regulatory agency directs them to remove their raw milk from the commercial market because it has been contaminated by pesticides or other residues

(USDA Farm Service Agency, 2014).

Anti-Dairy Movements

There are organizations that promote against the consumption of dairy and dairy products. Some of these organizations are NotMilk.com and People Against the Ethical

Treatment of Animals.

NotMilk.com

The indicated goal of NotMilk.com is to help individuals find the whole truth about cow’s milk and dairy quickly and to provide online resources (NotMilk.com, n.d.). The

Milk Letter: A Message to My Patients from Robert M. Kradjian summarizes his letter by stating, “So don’t drink milk for health. I am convinced on the weight of the scientific evidence that it does not ‘do a body good’. Inclusion of milk will only reduce your diet’s nutritional value and safety” (NotMilk.com, n.d.). Neal Barnard’s thoughts on milk is

“There is no nutritional requirement for dairy products. A substantial body of scientific evidence raises concerns about health risks from cow’s milk. These problems relate to the proteins, sugars, fat, and contaminants in dairy products, and the inadequacy of whole cow’s milk for infant nutrition” (NotMilk.com, n.d.).

People for the Ethical Treatment of Animals

Cows produce milk to nourish their young and in order to force animals to continue to give milk, factory farm operators impregnate them using artificial insemination every year (People for the Ethical Treatment of Animals (PETA), n.d.). PETA (n.d.) states,

“Mother cows are hooked up, several times a day, to milking machines. These cows are genetically manipulated, artificially inseminated, and often drugged to force them to produce about four and a half times as much milk as they naturally would to feed their calves”. PETA (n.d.) states, “The good news is that removing dairy products from your diet is easier than ever. Today there is a multitude of nondairy ‘dairy’ products on the market, such as soy, rice, and almond milk and soy ice cream.”

College Students

College attendance is typically during young adulthood, during which time students gain independence in the transition from high school to college and make most of their decisions sans parental guidance. This is a period characterized by change, where students explore new environments and adopt new behaviors. One of these behaviors is dietary choices and habits. Young adults in college tend to engage in poor dietary habits that may put them at risk for poor nutritional status (Poddar, Hosig, Anderson-Bill,

Nickols-Richardson, & Duncan, 2012).

The campus environment may contribute to poor dietary choices which may lead to the development of poor dietary habits and patterns. Some students have difficulty with the responsibilities of purchasing and preparing their own meals and managing new

eating schedules (Cluskey & Grobe, 2009). Students also express concern about the expense of healthy food and they report preferring processed snacks versus fresh produce, which spoils more rapidly (Strong, Parks, Anderson, Winett, & Davy, 2008).

Social and environmental factors additionally may negatively influence students’ dietary habits (Strong, Parks, Anderson, Winett, & Davy, 2008). College students are confronted with additional stressors related to new academic challenges, in addition to the stress associated with learning to navigate food selection and preparation (American College

Health Association, 2010).

Stress is positively associated with the intake of calorically dense, high-fat food

(Zellner et al., 2006). The increase in overall caloric intake is also attributed to the increase of alcohol consumption, which is also associated with the increased consumption of unhealthy food (Kasparek, Corwin, Valois, Sargent, & Morris, 2008). Due to all the various factors, the typical college student’s diet is high in fat, sugar, and sodium and lacks nutrients. The average college student consumes one serving of fruit, one and a half servings of vegetables, half serving of low-fat dairy, and one-point-four servings of whole grains daily (Strong, Parks, Anderson, Winett, & Davy, 2008).

Peak bone mass is achieved through the third decade of life; therefore, adequate calcium intake and other essential nutrients found in milk and dairy products are important during young adulthood. National survey data indicate about half (53%) of young men and 21% of young women (19 to 30 years) in the United States consume the recommended amount of calcium (Larson, Neumark-Sztainer, Harnack, Wall, Story, &

Eisenberg, 2009). Data also indicates 39% of men and 43% of women (20 to 29 years)

consume less than even one daily serving of dairy products (Cook & Friday, 2005). The recommended milk and dairy intake is associated with overall better nutrient quality of the diet and there are several health benefits conferred by bioactive components and nutrients present in milk and dairy products, college students should be encourage to improve total milk and dairy intake, with emphasis on low-fat milk and dairy (Poddar,

Hosig, Anderson-Bill, Nickols-Richardson, & Duncan, 2012).

CHAPTER III

METHODS

Study Design

This study was a quantitative, non-experimental, post-test only design approved by Kent State University’s Internal Review Board. The purpose of this study was to determine the consumption of dairy and dairy alternatives in male and female students enrolled at a Northeast Ohio state university. The study examined dairy and dairy alternative consumption in regards to gender, living arrangements, and level of college education. The study also examined the perceptions of dairy. The independent variables were gender, living arrangement, and level of college education. The dependent variables were the consumption of dairy and dairy alternatives and perceptions of dairy.

Sample

A convenience sample of students enrolled in courses at Kent State University were utilized. Inclusion criteria for participants included being a Kent State University student enrolled in courses and at least 18 years of age. Exclusion criteria for participants were not being a student enrolled in courses at Kent State University and students younger than 18 years of age.

Convenience sampling was completed by obtaining a random e-mail listserv from

Institutional Research at Kent State University and sending the link of the on-line survey

to the potential participants. The convenience sample included the 1,998 Kent State

University students.

Questionnaire Development

The on-line survey consisted of three sections, (Part I: Dairy and Dairy

Alternative Consumption, Part II: Perceptions of Dairy, and Part III: Demographic

Information) (Appendix A). The questionnaire included a total of 44 questions that were a combination of open- and closed-ended questions.

Part I: Dairy and Dairy Alternative Consumption

Part I of the questionnaire included 21 questions in regards to dairy and dairy alternative consumption. One question was the identification of the major type of milk or dairy alternative consumed, which was from the National Health and Nutrition

Examination Survey (NHANES) and altered to also include lactose free milk, almond milk, and coconut milk. Other questions identified whether the dairy alternative was fortified with calcium and reasons for consuming dairy alternatives. Food frequency questions were utilized in regards to milk, yogurt, cottage cheese, cheese, frozen yogurt, ice cream, and pudding or custard. These closed-ended questions in the format of multiple choice were from NHANES. There were also open-ended questions in regards to the average serving size, in ounces, of milk, yogurt, cottage cheese, cheese, frozen yogurt, ice cream, and pudding or custard. There were open-ended questions in regards to the frequency of consumption of coffee and soda and the average serving size of these items.

Part II: Perceptions of Dairy

Part II of the questionnaire included 16 closed-ended questions regarding the perceptions of dairy. These questions utilized a five-point Likert scale and included options ranging from strongly disagree to strongly agree. The questions were created to determine the level to which participants agreed with statements regarding barriers to dairy consumption that were identified in the literature review.

Part III: Demographic Information

Part III of the questionnaire included seven questions compromised of both open- and closed-ended questions regarding the demographic characteristics of the participants.

These questions identified gender, age, race/ethnicity, living situation, academic status, height, and weight. The height and weight information was used to calculate participants’ body mass index (BMI).

Procedure

The survey material was developed using the Kent State University Qualtrics online-survey creation tool and was available to participants through this website. The questionnaire was composed of three sections including dairy and dairy alternative consumption, perceptions of dairy, and demographic information of the participants.

Totaling 44 questions, the survey typically took 10 to 15 minutes to complete.

Participants were recruited through the utilization of a random email listserv obtained from Institutional Research at Kent State University. Email addresses for 1,998

potential participants were entered into Qualtrics survey program and divided into two panels. The questionnaire was sent to participants in late January 2015 and three email reminders were sent out. Survey responses were collected for four weeks and data was summarized in late February 2015.

Statistical Analysis

Statistical analysis was completed using SPSS software version 21(IBM, New

York). Descriptive statistics were analyzed including frequencies, means, and standard deviations for demographic information, consumption of dairy and dairy alternatives, and perceptions of dairy. T-tests were used to analyze intake and perception differences between the gender groups of male and female, living situation groups of students living on campus and students living off campus, and academic status groups of undergraduate students and graduate students. A p-value of 0.05 was selected a priori for significance.

CHAPTER IV

JOURNAL ARTICLE

Introduction

The recommended amount of milk and milk products, including fortified soy beverages, are three servings per day of fat-free or low-fat milk and milk products for adults and children and adolescents ages nine to 18 years (USDA, 2010; USDHHS,

2010). Moderate evidence reveals that intake of milk and milk products is linked to improved bone health (CDC, 2011). The intake of milk and milk products, including fortified soy beverages, is less than recommended amounts for most adults, adolescents and children; the average intake of milk in 2005-2006 NHANES was slightly more than three-fourths cup for individuals two years of age and older (USDA Agricultural

Research Service, 2010).

College attendance typically occurs during young adulthood; a period characterized by change whereby students explore new environments and adopt new behaviors; one of these behaviors is dietary choices and habits (Poddar, Hosig, Anderson-

Bill, Nickols-Richardson, & Duncan, 2012). One of these behaviors of concern is the low intake of dairy products. Larson, Neumark-Sztainer, Harnack, Wall, Story, &

Eisenberg (2009) observed middle adolescent females consumed approximately 3.08 mean daily servings of dairy and middle adolescent males consumed approximately 3.86 mean daily servings of dairy. Between the baseline of middle adolescence and the

follow-up of young adulthood, the daily mean total intakes of dairy products was reduced by approximately 0.5 servings in both genders (Larson et al., 2009). Peak bone mass is achieved through the third decade of life, therefore adequate calcium intake along with other essential nutrients found in milk and dairy products are important during young adulthood (CDC, 2011). National survey data from NHANES 2001-2002 indicate 39% of young men and 43% of young women between 20 and 29 years of age consume less than one daily serving of milk and dairy products (Cook & Friday, 2005).

Larson et al. (2009) found personal, behavioral, and socioenvironmental factors effected the intake of dairy between middle adolescence and young adulthood. Mahon &

Haas (2013) discovered barriers to consuming milk and dairy products in college females including poor access on campus, unnecessary calories and fat, and side effects. It is important to understand the perceptions and barriers of milk and dairy products in both male and female college students to understand what information needs to be educated to the college population to increase dairy intake.

The Dietary Guidelines for Americans 2010 cites fortified soy beverages as part of the milk and milk products category (USDA, 2010; USDHHS, 2010). Mahon & Haas

(2013), Larson et al. (2006), and Larson et al. (2009) only looked at milk and dairy products in their studies, but did not look at intakes of fortified dairy alternatives, which includes fortified soy beverages, either in adolescents or in young adults. These studies also did not look at reasons for fortified dairy alternatives consumption in either population groups. It is important to understand the reasons for dairy alternative consumption and if these dairy alternatives being consumed are fortified to determine the

education that is needed for the individuals in the college population that are consuming dairy alternatives.

The purpose of this study was to determine the consumption of dairy and dairy alternatives and the perception of dairy in male and female students enrolled at a Midwest state university, a region where milk and dairy is readily available. In the present study, the research hypotheses were males would consume more dairy and dairy alternatives than females, students living off campus would consume more dairy and dairy alternatives than students living on campus, and graduate students would consume more dairy and dairy alternatives than undergraduate students. The study also expected that there would be differences in the perceptions of dairy between the groups.

Methods

Study Design

This study was a quantitative, non-experimental, post-test only design approved by Kent State University’s Internal Review Board. The study examined dairy and dairy alternative consumption in regards to gender, living arrangements, and level of college education. The study also examined the perceptions of dairy. The independent variables were gender, living arrangement, and level of college education. The dependent variables were the consumption of dairy and dairy alternatives and perceptions of dairy.

Sample

A convenience sample of students enrolled in courses at Kent State University were utilized. Inclusion criteria for participants included being a Kent State University student enrolled in courses and at least 18 years of age. Exclusion criteria for participants included not being a student enrolled in courses at Kent State University and students younger than 18 years of age.

Convenience sampling was completed by obtaining a random e-mail listserv from

Institutional Research at Kent State University and sending the link of the on-line survey to the potential participants. The convenience sample included the 1,998 Kent State

University students.

Questionnaire

The on-line survey consisted of three sections, (Part I: Dairy and Dairy

Alternative Consumption, Part II: Perceptions of Dairy, and Part III: Demographic

Information) (Appendix A). The questionnaire included a total of 44 questions that were a combination of open- and closed-ended questions.

Part I: Dairy and dairy alternative consumption. Part I of the questionnaire included 21 questions in regards to dairy and dairy alternative consumption. One question was the identification of the major type of milk or dairy alternative consumed, which was from the National Health and Nutrition Examination Survey (NHANES), which was altered to also include lactose free milk, almond milk, and coconut milk.

Other questions identified whether the dairy alternative was fortified with calcium and

reasons for consuming dairy alternatives. Food frequency questions were utilized in regards to milk, yogurt, cottage cheese, cheese, frozen yogurt, ice cream, and pudding or custard. These closed-ended questions in the format of multiple choice were from

NHANES. There were also open-ended questions in regards to the average serving size, in ounces, of milk, yogurt, cottage cheese, cheese, frozen yogurt, ice cream, and pudding or custard. There were open-ended questions in regards to the frequency of consumption of coffee and soda and the average serving size of these items.

Part II: Perceptions of dairy. Part II of the questionnaire included 16 closed- ended questions regarding the perceptions of dairy. These questions utilized a five-point

Likert scale and included options ranging from strongly disagree to strongly agree. The questions were created to determine the level to which participants agreed with statements regarding barriers to dairy consumption that were identified in the literature review.

Part III: Demographic information. Part III of the questionnaire included seven questions compromised of both open- and closed-ended questions regarding the demographic characteristics of the participants. These questions identified gender, age, race/ethnicity, living situation, academic status, height, and weight. The height and weight information was used to calculate participants’ body mass index

(BMI).

Procedures

Totaling 44 questions, the survey would typically take 10 to 15 minutes to complete.

Participants were recruited through the utilization of a random email listserv obtained from Institutional Research at Kent State University. The email listserv included 1,998 potential participants. Email addresses were entered into Qualtrics survey program and divided into two panels. The questionnaire was sent to participants in late

January 2015 and three email reminders were sent out. Survey responses were collected for four weeks and data was summarized in late February 2015.

Statistical Analysis

SPSS software version 21(IBM, New York) was used for statistical analysis of the data. Descriptive statistics including means, standard deviations, and frequencies were used to analyze demographic information, consumption of dairy and dairy alternatives, and perceptions of dairy. The intake and perception data differences between gender groups of male and female were analyzed using unpaired t-tests. Unpaired t-tests were also used to analyze the intake and perception differences between the living situation groups of students living on campus and students living off campus. Unpaired t-tests were also used to analyze the intake and perception differences between academic status

groups of undergraduate and graduate students. A p-value of 0.05 was selected a priori for significance.

Results

Participant Characteristics The total number of respondents were 247 and the response rate of the sample was 12.4%. The majority of the population was female (n=172, 69.6%), Caucasian

(n=189, 76.5%), living off campus with family or relatives (n=79, 32.0%), obtaining a graduate master’s degree (n=59, 23.9%), and with a normal BMI (n=120, 48.6%). The average age of the participants was 26.1 ± 9.70 and the average BMI for the participants was 25.3 ± 5.80. Those whom specified other in regards to race/ethnicity identified as

Native American, African, biracial, Serbian, and Latvian. Table 1 depicts the demographic distributions for the participants in the study.

The majority frequency of coffee consumption for the participants was one or more times per day (n=90, 38.6%) or never (n=70, 30.0%). The average serving size of coffee as stated by participants was 11.4 ± 7.64 ounces. The majority frequency of soda consumption of the participants was never (n=76, 32.1%) and one to two times per week

(n=45, 18.9%). The average serving size of soda as stated by participants was 11.3 ±

6.97 ounces.

Table 1. Demographic Data of Participants Completing the Dairy and Dairy Alternative Questionnaire (n=247) Demographics % (n) x̅ ± SD Gender Male 21.5(53) Female 69.6(172)

Age 26.1 ± 9.70 Race/Ethnicity African-American 3.6(9) Asian 4.9(12) Caucasian 76.5(189) Hispanic or Latino 1.6(4) Other 4.9(12) Living Situation On-campus without roommates 4.5(11) On-campus with roommate(s) 19.0(47) Off-campus without roommates 11.7(29) Off-campus with roommates 24.3(60) Off-campus with family/relatives 32.0(79) Academic Status Freshman 13.8(34) Sophomore 10.9(27) Junior 13.8(34) Senior 19.8(49) Graduate-Master’s 23.9(59) Graduate-Doctoral 9.3(23) Body Mass Index (BMI) (kg/m2) 25.3 ± 5.80 Underweight 3.2(8) Normal 48.6(120) Overweight 21.9(54) Obese 16.1(40)

Types of Milk Consumed

The major milk and dairy product source in the diets of participants was 2% fat milk, which also known as reduced-fat milk (n=73, 29.6%). For those that choose other and specified some of the cited types of milk consumed included cashew milk, oat milk, chocolate milk, and a combination of the other choices. In regards to the fortification of dairy alternatives, the majority that consumed dairy alternatives consumed fortified versions of the dairy alternative (n=64, 79.0%). For reasons of dairy alternative consumption, of those whom it applied to the most cited response was no response (n=64,

48.1%). The second most common response for choosing dairy alternatives was taste

(n=43, 32.3%). Table 2 depicts the major type of milk consumed, whether dairy alternatives were consumed, and reasons for dairy alternative consumption.

Table 2. Type of Milk Consumed, Fortification of Dairy Alternatives, and Reason for Consumption of Dairy Alternative Dairy or Dairy Alternatives %(n) Type of milk (245) Whole milk 6.1(15) 2% fat milk 29.8(73) 1% fat milk 13.5(33) Skim milk 17.9(44) Lactose free milk 2.9(7) Soy milk 4.9(12) Almond milk 19.6(48) Coconut milk 0.8(2) Other 4.5(11) Fortification of Dairy Alternatives (81) Yes 79.0(64) No 21.0(17) Reason of Dairy Alternative Consumption (133) Cost 3.8(5) Calcium 11.3(15) Taste 32.3(43) Availability 4.5(6) No response 48.1(64)

Frequency of Dairy and Dairy Alternative Consumption

Table 3 depicts the frequency of consumption of various dairy or dairy alternative products and the average serving size of these food items. The major cited frequency for milk was 1-6 times per week (n=104, 42.45) and the average serving size was approximately 11.1 ± 5.31 ounces. The major cited frequency for yogurt was 1-3 times per month (n=67, 27.5%) and the average serving size was approximately 5.3 ± 1.77 ounces. For cottage cheese and cheese the major cited frequency of consumption was never (n=131, 53.5%) and 3-6 times per week (n=105, 42.8%), respectively. The average

serving size for cottage cheese and cheese was approximately, 2.7 ± 2.68 ounces and 2.5

± 1.94 ounces, respectively. The major cited frequencies for frozen yogurt, ice cream, and pudding or custard were 1-11 times per year (n=113, 46.2%), 1-3 times per month

(n=103, 42.0%), and 1-11 times per year (n=116, 47.3%), respectively. The average serving size for frozen yogurt, ice cream, and pudding or custard was approximately 6.2

± 4.00 ounces, 8.1 ± 4.02 ounces, and 3.3 ± 2.27 ounces, respectively.

Table 3. Frequency of Consumption of Dairy or Dairy Alternative Products and Average Serving Size of Dairy and Dairy Alternative Products Dairy or Dairy %(n) Average Serving Size Alternative (oz.) x̅ ± SD Milk 11.1 ± 5.31 Never 4.9(12) 1-3 times per month 22.0(54) 1-6 times per week 42.4(104) 1-3 times per day 30.2(74) 4-6 times per day 0.4(1) Yogurt 5.3 ± 1.77 Never 15.2(37) 1-6 times per year 13.5(33) 1-3 times per month 27.5(67) 1-2 times per week 18.4(45) 3-6 times per week 18.4(45) 1 or more times per day 7.0(17) Cottage cheese 2.7 ± 2.68 Never 53.5(131) 1-11times per year 22.4(55) 1-3 times per month 16.3(40) 1-2 times per week 5.3(13) 3-6 times per week 2.0(5) 1 or more times per day 0.4(1) Cheese 2.5 ± 1.94 Never 4.5(11) 1-11times per year 2.5(6) 1-3 times per month 9.0(22) 1-2 times per week 15.9(39) 3-6 times per week 42.8(105) 1 or more times per day 25.3(62)

Frozen yogurt 6.2 ± 4.00 Never 29.8(73) 1-11 times per year 46.2(113) 1-3 times per month 21.2(52) 1-2 times per week 1.6(4) 3-6 times per week 0.8(2) 1 or more times per day 0.4(1) Ice cream 8.1 ± 4.02 Never 7.8(19) 1-11 times per year 30.6(75) 1-3 times per month 42.0(103) 1-2 times per week 13.5(33) 3-6 times per week 5.7(14) 1 or more times per day 0.4(1) Pudding or custard 3.3 ± 2.27 Never 37.6(92) 1-11 times per year 47.3(116) 1-3 times per month 12.7(31) 1-2 times per week 2.0(5) 3-6 times per week 0.4(1) 1 or more times per day 0.0(0)

Consumption

Gender. There were no significant differences between the gender groups in regards to the frequency of consumption of dairy and dairy alternatives per week. Table

4 depicts the gender differences in the frequency of consumption of dairy and dairy alternatives.

Table 4. Gender Differences in the Frequency of Consumption of Dairy and Dairy Alternatives per week Dairy or Dairy Gender N x̅ ± SD P-value Alternative Product Milk Male 53 5.7 ± 5.89 0.311 Female 172 4.8 ± 5.43

Yogurt Male 53 1.4 ± 1.88 0.253 Female 171 1.8 ± 2.57

Cottage cheese Male 53 0.2 ± 0.60 0.357

Female 172 0.4 ± 1.26

Cheese Male 53 5.4 ± 3.77 0.083 Female 172 4.4 ± 3.66

Frozen yogurt Male 53 0.2 ± 0.49 0.555 Female 172 0.2 ± 0.70

Ice cream Male 53 0.6 ± 0.75 0.327 Female 172 0.8 ± 1.46

Pudding or custard Male 53 0.2 ± 0.50 0.282 Female 172 0.1 ± 0.22

Living situation. There were no significant differences between living situation groups in the frequency of consumption of dairy and dairy alternatives per week. Table 5 depicts the living situation differences in regards to the frequency of consumption of dairy and dairy alternatives.

Table 5. Living Situation Differences in the Frequency of Consumption of Dairy and Dairy Alternatives per week Dairy or Dairy Living N x̅ ± SD P-value Alternative Product Situation Milk On campus 58 5.3 ± 6.03 0.668 Off campus 168 4.9 ± 5.37

Yogurt On campus 58 1.4 ± 1.87 0.211 Off campus 167 1.8 ± 2.58

Cottage cheese On campus 58 0.3 ± 0.89 0.628 Off campus 168 0.4 ± 1.21

Cheese On campus 58 5.3 ± 3.82 0.091 Off campus 168 4.4 ± 3.64

Frozen yogurt On campus 58 0.2 ± 0.22 0.345 Off campus 168 0.3 ± 0.75

Ice cream On campus 58 0.6 ± 0.66 0.211 Off campus 168 0.8 ± 1.49

Pudding or custard On campus 58 0.1 ± 0.28 0.998 Off campus 168 0.1 ± 0.32

Academic status. There were no significant differences in academic status groups in the frequency of consumption of dairy and dairy alternatives per week. Table 6 depicts the academic status differences in regards to the frequency of consumption of dairy and dairy alternatives.

Table 6. Academic Status Differences in the Frequency of Consumption of Dairy and Dairy Alternatives per week Dairy or Dairy Academic N x̅ ± SD P-value Alternative Product Status Milk Undergraduate 144 4.9 ± 5.57 0.799 Graduate 82 5.1 ± 5.50

Yogurt Undergraduate 143 1.5 ± 1.98 0.164 Graduate 82 2.0 ± 3.02

Cottage cheese Undergraduate 144 0.3 ± 0.66 0.270 Graduate 82 0.5 ± 1.68

Cheese Undergraduate 144 4.8 ± 3.87 0.176 Graduate 82 4.2 ± 3.38

Frozen yogurt Undergraduate 144 0.3 ± 0.80 0.275 Graduate 82 0.2 ± 0.29

Ice cream Undergraduate 144 0.7 ± 0.97 0.541 Graduate 82 0.8 ± 1.80

Pudding or custard Undergraduate 144 0.2 ± 0.37 0.176 Graduate 82 0.1 ± 0.16

Perceptions

Gender. There were six significant differences between gender groups in regards to perceptions of dairy. The perceptions that had significant differences between groups were concern with the fat content of milk and dairy products, concern with the sugar content of milk and dairy products, concern with the calorie content of milk and dairy products, concern about the treatment of dairy animals, perception of the milk and dairy products being useful in preventing high blood pressure, and having gastrointestinal issues when consuming milk or dairy products. Data showed that females were significantly more concerned with the fat content of milk and dairy products than males

(p=0.037). Females were significantly more concerned with the sugar content of milk and dairy products than males (p=0.011). Females were significantly more concerned with the calorie content of milk and dairy products than males (p=0.009). Females were significantly more concerned about the treatment of dairy animals than males (p=0.039).

Males had a significantly greater perception of milk and dairy products more useful in preventing high blood pressure than females (p=0.028). Females had significantly greater gastrointestinal issues when consuming milk or dairy products than males

(p<0.001). Table 7 depicts the gender differences in regards to the perception of dairy.

Table 7. Gender Differences in the Perception of Dairy Perception Gender n x̅ ± SD P-value I dislike the taste of milk & Male 53 2.1 ± 1.20 0.835 dairy products Female 172 2.1 ± 1.20

I am concerned with the fat Male 53 2.4 ± 1.25 content of milk & dairy 0.037* Female 172 2.8 ± 1.23 products

I am concerned about the Male 53 2.1 ± 1.16 cholesterol content of milk 0.058 Female 172 2.4 ± 1.14 & dairy products

I am concerned with the Male 53 2.1 ± 1.13 sugar content of milk & 0.011* Female 172 2.6 ± 1.16 dairy products

I am concerned with the Male 53 2.3 ± 1.29 calorie content of milk & 0.009* Female 172 2.9 ± 1.26 dairy products

I am concerned about the Male 53 3.0 ± 1.41 0.039* treatment of dairy animals Female 172 3.5 ± 1.17

I am concerned about Male 53 3.2 ± 1.40 antibiotic residues in milk 0.139 Female 172 3.5 ± 1.19 & dairy products

I am concerned about genetically modified Male 53 3.2 ± 1.45 0.096 organisms being present in Female 172 3.5 ± 1.23 milk & dairy products

I am concerned about the presence of recombinant Male 53 3.2 ± 1.41 0.056 growth hormones in milk Female 172 3.6 ± 1.23

& dairy products

Milk & dairy products are Male 53 3.9 ± 0.82 useful in the prevention of 0.227 Female 172 3.7 ± 1.02 osteoporosis

Milk & dairy products are Male 53 3.2 ± 0.89 useful in weight 0.300 Female 172 3.0 ± 0.94 management

Milk & dairy products are Male 53 3.1 ± 0.68 useful in preventing high 0.028* Female 172 2.8 ± 0.71 blood pressure

Milk is an expensive food Male 53 2.8 ± 1.00 0.929 Female 172 2.8 ± 1.02

Milk spoils easily Male 53 3.3 ± 1.17 0.996 Female 172 3.3 ± 0.98

I have gastrointestinal Male 53 1.8 ± 1.08 issues when I consume <0.001* Female 172 2.5 ± 1.43 milk or dairy products

I will choose other Male 53 4.2 ± 0.98 0.648 beverages first instead of Female 172 4.2 ± 1.05 milk while eating out A 1-5 Likert scale ranging from strongly disagree to strongly agree was used and the mean scores were calculated from the composite scores * Shows t-test statistical significance difference where statistical significance was set at p<0.05

Living situation. There were three significant differences between living situation groups in regards to perceptions of dairy. The perceptions that had significant differences were concern about genetically modified organisms being present in milk and dairy products, concern about the presence of recombinant growth hormones in milk and dairy products, and the usefulness of milk and dairy products in preventing high blood pressure. Participants living off campus were significantly more concerned with genetically modified organisms being present in milk and dairy products compared to participants living on campus (p=0.050). Participants living off campus were significantly more concerned about the presence of recombinant growth hormones in milk and dairy products compared to participants living on campus (p=0.038).

Participants living off campus had a significantly greater perception of milk and dairy products not being useful in the prevention of high blood pressure compared to participants living on campus (p=0.004). Table 8 depicts the living situation differences in regards to the perceptions of dairy.

Table 8. Living Situation Differences in the Perception of Dairy Perception Living n x̅ ± SD P-value Situation I dislike the taste of milk & On campus 58 2.1 ± 1.14 0.710 dairy products Off campus 168 2.1 ± 1.22

I am concerned with the fat On campus 58 2.6 ± 1.20 content of milk & dairy 0.297 Off campus 168 2.8 ± 1.26 products

I am concerned about the On campus 58 2.22 ± 0.97 cholesterol content of milk 0.362 Off campus 168 2.4 ± 1.21 & dairy products

I am concerned with the On campus 58 2.5 ± 1.10 sugar content of milk & 0.761 Off campus 168 2.4 ± 1.19 dairy products

I am concerned with the On campus 58 2.7 ± 1.29 calorie content of milk & 0.587 Off campus 168 2.8 ± 1.29 dairy products

I am concerned about the On campus 58 3.3 ± 1.16 0.599 treatment of dairy animals Off campus 168 3.4 ± 1.27

I am concerned about On campus 58 3.1 ± 1.24 antibiotic residues in milk 0.087 Off campus 168 3.5 ± 1.25 & dairy products

I am concerned about genetically modified On campus 58 3.2 ± 1.30 0.050* organisms being present in Off campus 168 3.5 ± 1.29 milk & dairy products

I am concerned about the presence of recombinant On campus 58 3.2 ± 1.32 0.038* growth hormones in milk Off campus 168 3.6 ± 1.26

& dairy products

Milk & dairy products are On campus 58 3.7 ± .76 useful in the prevention of 0.628 Off campus 168 3.7 ± 1.06 osteoporosis

Milk & dairy products are On campus 58 3.2 ± .78 useful in weight 0.168 Off campus 168 3.0 ± .98 management

Milk & dairy products are On campus 58 3.1 ± .49 useful in preventing high 0.004* Off campus 168 2.8 ± .77 blood pressure

Milk is an expensive food On campus 58 2.9 ± .91 0.578 Off campus 168 2.8 ± 1.06

Milk spoils easily On campus 58 3.5 ± 1.01 0.140 Off campus 168 3.3 ± 1.04

I have gastrointestinal On campus 58 2.3 ± 1.38 issues when I consume 0.815 Off campus 167 2.4 ± 1.40 milk or dairy products

I will choose other On campus 58 4.1 ± 1.02 0.432 beverages first instead of Off campus 168 4.3 ± 1.04 milk while eating out A 1-5 Likert scale ranging from strongly disagree to strongly agree was used and the mean scores were calculated from the composite scores * Shows t-test statistical significant difference where statistical significance was set at p<0.05

Academic status. There were no significant differences between academic status groups in the perceptions of dairy. The undergraduate or graduate academic status did not have an effect on the differences in perceptions of milk and dairy products. Table 9 depicts the academic status differences in regards to the perceptions of dairy.

Table 9. Academic Status Differences in the Perceptions of Dairy Perception Academic n x̅ ± SD P-value Status I dislike the taste of milk Undergraduate 144 2.2 ± 1.24 0.310 & dairy products Graduate 82 2.0 ± 1.11

I am concerned with the Undergraduate 144 2.7 ± 1.22 fat content of milk & dairy 0.605 Graduate 82 2.8 ± 1.30 products

I am concerned about the Undergraduate 144 2.3 ± 1.10 cholesterol content of milk 0.980 Graduate 82 2.3 ± 1.26 & dairy products

I am concerned with the Undergraduate 144 2.5 ± 1.17 sugar content of milk & 0.145 Graduate 82 2.3 ± 1.15 dairy products

I am concerned with the Undergraduate 144 2.7 ± 1.26 calorie content of milk & 0.247 Graduate 82 2.9 ± 1.32 dairy products

I am concerned about the Undergraduate 144 3.4 ± 1.23 0.901 treatment of dairy animals Graduate 82 3.4 ± 1.26

I am concerned about Undergraduate 144 3.4 ± 1.24 antibiotic residues in milk 0.758 Graduate 82 3.4 ± 1.28 & dairy products

I am concerned about genetically modified Undergraduate 144 3.5 ± 1.26 0.891 organisms being present in Graduate 82 3.4 ± 1.36 milk & dairy products

I am concerned about the presence of recombinant Undergraduate 144 3.5 ±1.27 0.572 growth hormones in milk Graduate 82 3.6 ± 1.32

& dairy products

Milk & dairy products are Undergraduate 144 3.6 ± 1.02 useful in the prevention of 0.069 Graduate 82 3.9 ± .93 osteoporosis

Milk & dairy products are Undergraduate 144 3.0 ± .93 useful in weight 0.862 Graduate 82 3.0 ± .94 management

Milk & dairy products are Undergraduate 144 2.9 ± .74 useful in preventing high 0.114 Graduate 82 2.8 ± .67 blood pressure

Milk is an expensive food Undergraduate 144 2.9 ± 1.04 0.130 Graduate 82 2.7 ± .99

Milk spoils easily Undergraduate 144 3.4 ± .99 0.323 Graduate 82 3.2 ± 1.11

I have gastrointestinal Undergraduate 144 2.3 ± 1.35 issues when I consume 0.398 Graduate 81 2.5 ± 1.46 milk or dairy products

I will choose other Undergraduate 144 4.2 ± .98 0.908 beverages first instead of Graduate 82 4.2 ± 1.13 milk while eating out A 1-5 Likert scale ranging from strongly disagree to strongly agree was used and the mean scores were calculated from the composite scores

Discussion

The purpose of this study was to determine the consumption of dairy and dairy alternatives and the perceptions of dairy in students enrolled at a Northeast Ohio state university. The results indicated: 1.) gender, living situation, and academic status did not have significant differences in the consumption of dairy and dairy alternatives; and 2.) there were significant differences in gender and living situation groups in regards to the perception of dairy. Therefore the research hypotheses stating male students, students living off campus, and graduate students having greater consumption of dairy and dairy alternatives when compared to their respective classified groups were rejected. The research hypothesis stating there would be differences in the perceptions of dairy between groups was partially accepted.

The demographic data indicated that most of the participants were Caucasian, female, living off campus, and an undergraduate student. The average age of the participants was 26.1 years. Most of the participants were in the normal body mass index category, and the average body mass index for participants was 25.3. Poddar, Hosig,

Anderson-Bill, Nickols-Richardson, & Duncan (2012) and Poddar, Hosig, Nickols-

Richardson, Anderson, Herbert, & Duncan (2009) had race/ethnicity, gender, and body mass index values also had the similar representative samples; however, these studies looked at undergraduate students and did not look at whether participants lived on campus or off campus. Since this study accounted for graduate students at a university setting, the average age for the participants was greater than these other studies.

The results of the current investigation indicated that 69.7% were consuming dairy while 29.6% were consuming dairy alternatives. The results of the current investigation indicated that the participants, whether consuming dairy or dairy alternatives, are not consuming the recommended three cups of dairy or dairy alternatives to meet nutrients of concern. This is in alignment with Mahon & Haas (2013) whom found that on average the college participants in their study were consuming less than one serving of dairy per day. Strong, Parks, Anderson, Winett, & Davy (2008) concluded that the average college student consumes 0.5 servings of dairy daily.

The current investigation was different from other studies; it looked at dairy alternative consumption to see if dairy alternatives were replacing dairy in the diet of college students. The results of the current investigation indicated that dairy alternatives are not replacing dairy in the diets of college students. Students consuming dairy alternatives are still not getting the recommended three cups of fortified dairy alternatives in order to meet requirements of nutrients of concern, specifically calcium. It is possible that there are more barriers associated with the consumption of dairy alternatives. Some of these barriers might be that dairy alternatives are categorized in the same category of

milk and dairy, the price of dairy alternatives, the decreased accessibility of dairy alternatives, and the unfamiliarity of dairy alternatives if individuals did not grow up with dairy alternatives. Due to the possible barriers of dairy alternatives, dairy alternatives may be less desirable than milk and dairy products.

Consumption

The current investigation indicated that gender, living situation, and academic status did not have significant differences in the consumption of dairy or dairy alternatives between groups. The current investigation found no significant differences in consumption of males and females. The current investigation conflicted with Mahon &

Haas (2013) whom found that college men consumed significantly more dairy than college women. Dietary Guidelines Advisory Committee (2010) found that more than

90% of all women consume less than the recommended amount of milk and milk products, and more than 75% of adult men consume less than the recommended amount of milk and milk products. The current investigation found both males and females are not meeting the recommended three cups of dairy or fortified dairy alternatives to meet nutrients of concern outlined in the Dietary Guidelines for Americans, 2010.

A possible barrier to the consumption of milk and dairy products for males and females in a college environment is the availability of other beverages including energy drinks, sports drinks, soda, and coffee that are associated with positive perceptions with their consumption. Coffee, with its caffeine content, is positively perceived to help with stimulation helping students stay awake in class and during late night study sessions.

Another possible barrier to the consumption of milk and dairy products are the misconceptions and myths associated with consuming milk and dairy products. One misconception is that individuals with lactose intolerance need to avoid all milk and dairy products, when in fact most people with lactose intolerance can still enjoy milk and dairy products by choosing lactose free products or consuming lactase enzymes prior to consuming milk and dairy products.

The literature is mixed in regards to living situation and the consumption of dairy.

Some studies have found higher intakes of dairy among students living or eating on campus while another study found students living on campus reduced their meal frequency and intake of dairy (Pelletier & Laska, 2013). The current investigation found no significant differences in the consumption of students living on campus and students living off campus. A possible barrier to consumption of dairy of students living on campus is the meal plan; the university under investigation has a pay per item type dining instead of an all you care to eat dining. This might be seen as a barrier to the consumption of milk and dairy products since students may perceive it pricey to purchase these products compared to other products. A possible barrier to the consumption of dairy of students living off campus is time; taking the time to go shopping and prepare healthy meals, including milk and dairy products, might be seen as an inefficient use of time to study or socialize. Financial restrictions and the misconceptions of healthy foods, including milk and dairy products, might also be barriers to the consumption of students living off campus.

The current investigation found no significant differences in the consumption of graduate students and undergraduate students. Of the reviewed literature, Mahon & Haas

(2013) included graduate students in the study; however, did not compare consumption of dairy between undergraduate students and graduate students. Possible barriers for undergraduate students and graduate students of milk and dairy product consumption are the lack of knowledge regarding health benefits, myths and misconceptions of milk and dairy products, the competition of other beverages in the diet, and social, cultural, or economic factors that preclude the consumption of milk and dairy products.

Perception

The current investigation found significant differences in regards to gender and the perceptions of dairy. The current investigation showed females were more concerned with the fat content, sugar content, and calorie content of milk, and stated having greater gastrointestinal issues when consuming milk or dairy products. In a focus group with college females, Mahon & Haas (2013) found that perceived barriers to consuming dairy included the fat and calories associated with dairy products, which helps confirm the results of this study. Participants also referenced particular ill effects of consuming dairy, which may deter some females from consuming dairy, which confirms the results of the current investigation (Mahon & Haas, 2013). The current investigation found females were concerned with the sugar content of milk and dairy. The sugar content of milk and dairy products could be a possible barrier to consumption, and may have been a reason for the low consumption of milk and dairy products of females in the current investigation. This shows that females perceive milk as less appealing than other

beverages. The results of the current investigation illustrate the overall myths and misconceptions of beverages and their consumption.

Females had a significantly greater concern for the treatment of dairy animals compared to males. Herzog (2007) found that women, on average, show higher levels of positive behaviors and attitudes towards animals (e.g. attitudes towards their use, involvement in animal protection), whereas men typically have higher levels of negative attitudes and behaviors (e.g. hunting, animal abuse, less favorable attitudes toward animal protection). The current investigation confirms that females had a greater concern for the welfare and treatment of dairy animals compared to the perception of males in regards to concern for the treatment of dairy animals. The concern over the treatment of the dairy animals may be a possible barrier to the consumption of milk and dairy since some individuals choose not to consume dairy to make a statement to the dairy industry regarding the welfare of dairy animals.

The current investigation showed males had a greater perception of milk and dairy products being useful in the prevention of high blood pressure. While this result was statistically significant, this result may not actually in significant in reality. This result of the current investigation can not be explained. The result does help illustrate the myths and misconceptions in regards to consuming milk and dairy products and perceived health benefits and health risks of young adults compared to the consumption of other beverages and their perceived health benefits and risks.

The current investigation showed significant differences in regards to living situation and the perceptions of dairy. Participants living off campus were more concerned with genetically modified organisms and recombinant growth hormones being present in dairy, and perceived milk and dairy products not being useful in the prevention of high blood pressure. Currently there is no published literature that discusses living situation and perceptions of dairy; most of the published literature for perceptions of dairy is related to gender (Mahon & Haas, 2013). The concern of genetically modified organisms and recombinant growth hormones being present in dairy and dairy not being useful in the prevention of high blood pressure may possibly be barriers to the consumption of milk and dairy products of students living off campus in the current investigation.

The results showed that participants are consuming coffee and soda; 38.6% of participants were consuming coffee one or more times per day and 15.6% are consuming soda one or more times per day. Pelletier & Laska (2013) found students living on and off campus are exposed to the campus food environment including dining halls, vending machines, a la carte dining facilities, and nearby stores and restaurants, which compete with fast food restaurants and other retail food outlets for students’ patronage. The study also found that frequently purchasing campus area food or beverages was associated with higher consumption of fat and added sugars and lower consumption of dairy. It is important to know if students are consuming other beverages which potentially could be replacing milk and dairy in the diet. It is also important to be aware that the caffeine in

soda and caffeine inhibits calcium absorption, which calcium is nutrient of concern as outlined in the Dietary Guidelines for Americans, 2010.

Limitations

There are limitations that exist with this study. The validity of the questionnaire is a limitation since some of the questions were developed by the researcher, and therefore the reliability of these questions have not been tested. The perception questions were not totaled to see if the overall perception of dairy was good, fair, or poor. This could not be done due to the fact that the questions were not all stated in neutral way.

Another limitation of this study was the data was self-reported. The validity of the responses, whether open-ended or closed-ended questions, cannot be determined.

The open-ended questions in regards to average serving size should be interpreted cautiously since participants are not familiar with the amount of food or beverage that classifies as a serving size even though similar representations were stated in the question of various serving sizes. The question also specified ounces and some participants listed the serving size in cups, which then was converted and could have lost significance.

Applications

The 2005 Dietary Guidelines Advisory Committee reported that seven out of seven randomized controlled trials and 25 out of 32 observational studies showed a significantly positive association between dairy food intake and bone mineral content or bone mineral density (Heaney, 2000). This study showed that college students are not consuming enough dairy products or fortified dairy alternative products to meet the

Dietary Guidelines for Americans foods and nutrients of concern, specifically dairy and calcium.

Osteoporosis is a growing concern in America that affects 10 million Americans, causes two million fractures per year, and cost the nation roughly $19 billion annually.

By 2020, the number of people afflicted is expected to increase to 14 million cases of osteoporosis and more than 47 million cases of low bone mass (Benjamin, 2010).

Osteoporosis and osteopenia are largely preventable diseases. Calcium, vitamin D, phosphorus, and magnesium are nutrients that are necessary for bone health (Prentice,

2004). Milk and dairy products fortified with vitamin D is one food source that contains all of these nutrients.

One of the largest modifiable determinants for bone health is nutrition, including the consumption of soda and coffee (Benjamin, 2010). The United States was ranked first among the countries with high soft drink consumption; the National Soft Drink

Association reported that during 1998, Americans drank over 14 billion gallons of soft drink, which averaged more than 56 gallons of soft drink per person. Results from the

United States Department of Agriculture’s 1996 Continuing Survey of Food Intakes by

Individuals indicated that 50.3% of Americans consume carbonated soft drinks (Kassem,

Lee, Modeste & Johnston, 2003). The current investigation found that 15.6% of participants indicated consuming soda one or more times per day.

The high level of soda consumption has been associated with some health consequences. Guenther (1986) found that soft drink intake was negatively correlated

with the intake of milk, and the nutrients calcium, magnesium, riboflavin, vitamin A, and ascorbic acid. Mazariegos-Ramos et al. (1995) found a significant association between the intakes of at least 1.5 soft drinks containing phosphoric acid per week and hypocalcemia in children 2.4 to 5.6 years of age.

Coffee is widely consumed in the United States, as well as in Europe. This study found that 38.6% of participants stated consuming coffee one or more times per day.

There have been positive and negative health effects associated with coffee consumption.

One suggested negative effect of coffee consumption is an increased risk of hip fractures

(Hallstrom et al., 2013). High intakes of coffee and caffeine have been associated with increased risk of fractures in some observational studies and recent in vitro studies have suggested that caffeine has direct and indirect deleterious effects on osteoblasts

(Hallstrom et al., 2013).

Older adults, Caucasian and Asian women, post-menopausal women, people with a low body weight, and those with low calcium intakes are most at risk for osteoporosis

(Benjamin, 2010). Gammage, Gasparotto, Mack, & Klentrou (2012) found that women and men university students displayed marginal knowledge of the health risks associated with osteoporosis. Mahon & Haas (2013) found that on average university students consume less than one serving of dairy per day and men consumed significantly more dairy than women. Although, this study showed no significant differences in the consumption of dairy, women are more susceptible to osteoporosis.

College students may be more receptive to new advice compared with older adults; therefore nutrition interventions targeting improved dairy intake may be successful in this population (Poddar et al., 2012). Currently, we are using social marketing campaigns to try to increase dairy consumption and these campaigns are not working based on the results of the current investigation. It is important for nutrition professionals to decrease the fallacies associated with dairy and consuming dairy and start to increase positive perceptions associated with dairy and dairy consumption.

The 2005 Dietary Guidelines for Americans and the MyPlate recommendations include soy beverages fortified with calcium and vitamins A and D as part of the milk and dairy group for individuals with lactose intolerance and milk allergy (USDA, 2010;

USDHHS, 2010; USDA, n.d.). The results of the current investigation indicated that individuals whom choose to consume soy beverages and other dairy alternatives are not consuming the recommended amount and the products are not always fortified. It is important that nutrition professionals educate individuals with lactose intolerance with methods to still consume dairy by choosing lactose free products, consuming lactase enzymes prior to consuming dairy, or developing a threshold level for consuming dairy products. For the individuals whom suffer from milk allergy, it is important for nutrition professionals to educate these individuals on the importance of choosing fortified dairy alternatives and helping them to identify a dairy alternative that have similar nutrition to milk and dairy products.

The purpose of the 2005 Dietary Guidelines for Americans and the MyPlate recommendations for adding fortified soy milk as an option to the milk and dairy group

was to provide an alternative to meeting nutrients that are found in dairy products for individuals with lactose intolerance and milk allergy. Instead, the guidelines and recommendations only added more confusion to dairy consumption. The guidelines are not being met whether individuals are consuming dairy or dairy alternatives and this could be a result of a lack of understanding and knowledge of dairy and dairy alternatives and the perceptions of dairy and dairy alternatives, which are categorized within the same dietary food group. It is important to educate individuals on dairy and dairy alternatives by dispelling the myths and misconceptions and changing the perceptions of these foods.

Dietitians can play a valuable role in helping patients achieve maximal physical function and bone accrual (Office of the Surgeon General, 2004). Childhood is an excellent time to initiate counseling aimed at encouraging appropriate nutrition and physical activities and discouraging the adoption of behaviors that negatively affect bone health. All young and middle-aged adults should be encouraged to adopt lifestyles that help prevent bone loss and promote overall health and the prevention of chronic disease

(Office of the Surgeon General, 2004).

Conclusions

This study demonstrated that university students at a Northeast Ohio state university are consuming dairy and dairy alternatives, but are not consuming enough servings daily to meet the Dietary Guidelines for Americans, 2010. Dairy alternatives are not replacing dairy in the diets of university students. The biggest concerns in regards to perception regards gender and misconceptions of dairy, especially for females. Therefore

it is important to educate university students the importance of having three daily servings of dairy or fortified dairy alternatives, the appropriate serving size of dairy products, and dispelling the misconceptions regarding dairy.

APPENDICES

APPENDIX A

DAIRY AND DAIRY ALTERNATIVE AND PERCEPTIONS OF DAIRY QUESTIONNAIRE

Appendix A

Dairy and Dairy Alternative and Perceptions of Dairy Questionnaire

Part I: Dairy and Dairy Alternative Consumption What is the major kind of milk you usually drink and/or dairy products do you eat? o Whole milk o 2% fat milk o 1% fat milk o Skim, nonfat, or ½% fat milk o Lactose free milk o Soy milk o Rice milk o Almond milk o Coconut milk o Other If you consume soy milk, rice milk, almond milk, coconut milk, or other alternative dairy products, is it fortified with calcium? If you consume whole milk, 2% fat milk, 1% fat milk, skim/non-fat/1/2% fat milk, or lactose free milk, please choose not applicable. o Yes o No o Not Applicable If you consume soy milk, rice milk, almond milk, coconut milk, or other alternative dairy products, why are you choosing them instead of dairy? Mark all that apply. If you consume whole milk, 2% fat milk, 1% fat milk, skim/non-fat/1/2% fat milk, or lactose free milk, please mark not applicable.  Cost  Calcium  Taste  Availability  Other (please specify reason) ______ Not Applicable For the following questions, include whole milk, 2% fat milk, 1% fat milk, skim milk, lactose free milk, soy milk, rice milk, almond milk, coconut milk, or other milk and milk products for the following questions regarding frequency of consumption.

On average how often do you drink milk? o Never o 1 time per month or less o 2-3 times per month o 1-2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2-3 times per day o 4-5 times per day o 6 or more times per day What is the average serving size each time you drink milk? For example if you drink the amount similar to a tall coffee from Starbuck’s it is 12 oz. A grande is 16 oz., a venti is 24 oz., and a trenta is 31 oz. ______oz. On average how often do you eat yogurt (not including frozen yogurt)? o Never o 1-6 times per year o 1 time per month o 2-3 times per month o 1 time per week o 2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2 or more times per day What is the average serving size each time you eat yogurt? For example Yoplait yogurt is 6 oz., Chobani greek yogurt is 5.3 oz. ______oz. On average how often do you eat cottage cheese (including low-fat)? o Never o 1-6 times per year o 7-11 times per year o 1 time per month o 2-3 times per month o 1 time per week

o 2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2 or more times per day What is the average serving size each time you eat cottage cheese? For example ¼ cup equals 2 oz., ½ cup equals 4 oz., and 1 cup equals 8 oz. ______oz. On average how often do you eat cheese (including low-fat; including on cheeseburgers or in sandwiches or subs)? o Never o 1-6 times per year o 7-11 times per year o 1 time per month o 2-3 times per month o 1 time per week o 2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2 or more times per day What is the average serving size each time you eat cheese? For example 1 slice of cheese is 1 oz. and ½ cup shredded cheese is 4 oz. ______oz. On average how often do you eat frozen yogurt (including low-fat or fat-free)? o Never o 1-6 times per year o 7-11 times per year o 1 time per month o 2-3 times per month o 1 time per week o 2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2 or more times per day

What is the average serving size each time you eat frozen yogurt? For example ½ cup is 4 oz., 1 cup is 8 oz., and 1 pint is 16 oz. ______oz. On average how often do you eat ice cream (including low-fat or fat-free)? o Never o 1-6 times per year o 7-11 times per year o 1 time per month o 2-3 times per month o 1 time per week o 2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2 or more times per day What is the average serving size each time you eat ice cream? For example ½ cup is 4 oz., 1 cup is 8 oz., and 1 pint is 16 oz. ______oz. On average how often do you eat pudding or custard? o Never o 1-6 times per year o 7-11 times per year o 1 time per month o 2-3 times per month o 1 time per week o 2 times per week o 3-4 times per week o 5-6 times per week o 1 time per day o 2 or more times per day What is the average serving size each time you eat pudding or custard? For example one Snack Pack pudding is 3.25 oz., ½ cup is 4 oz., 1 cup is 8 oz. ______oz. On average how often do you drink coffee? Specify how often per day if you drink coffee daily. If you drink coffee only weekly or monthly, specify how often.

______What is the average serving size each time you drink coffee? For example if you drink the amount similar to a tall coffee from Starbuck’s it is 12 oz. A grande is 16 oz., a venti is 24 oz., and a trenta is 31 oz. ______oz. On average how often do you drink soda? Specify how often per day if you drink soda daily. If you drink soda only weekly or monthly, specify how often. ______What is the average serving size each time you drink soda? For example a traditional aluminum can is 12 oz., or a 20 ounce bottle. ______oz.

Part II: Perceptions of Dairy Choose your agreement/disagreement with the following statements.

Strongly Disagree Neither Agree Strongly disagree agree nor agree disagree I dislike the taste of milk and dairy products I am concerned with the fat content of milk and dairy products I am concerned about the cholesterol content of milk and dairy products I am concerned with the sugar content of milk and dairy products I am concerned with the calorie content of milk and dairy products I am concerned about the treatment of dairy animals I am concerned about antibiotic residues in milk and dairy products

I am concerned about genetically modified organisms being present in milk and dairy products I am concerned about the presence of recombinant growth hormones in milk and dairy products Milk and dairy products are useful in the prevention of osteoporosis Milk and dairy products are useful in weight management Milk and dairy products are useful in preventing high blood pressure Milk is an expensive food Milk spoils easily I have gastrointestinal issues when I consume milk or dairy products I will choose other beverages first instead of milk while eating out

Part III: Demographic Information What is your gender? o Male o Female What is your age? ______What is your race/ethnicity? o African-American o Asian o Caucasian o Hispanic or Latino

o Other ______What best describes your living situation? o I live on campus without roommate(s) o I live on campus with roommate(s) o I live off campus without roommate(s) o I live off campus with roommate(s) o I live off campus with family/relatives What is your current academic status? o Freshman o Sophomore o Junior o Senior o Graduate student – Master’s o Graduate student – Doctoral What is your height? ______inches. What is your weight? ______pounds.

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