population groups at risk of zinc deficiency in australia and new zealand

REVIEW

Population groups at risk of zinc deficiency inAustralia and New Zealandndi_1516 97..108

Rosalind GIBSON and Anne-Louise HEATHDepartment of Human Nutrition, University of Otago, Dunedin, New Zealand

AbstractAim: Although the adverse health consequences of zinc deficiency are becoming increasingly well known interna-tionally, few studies have investigated zinc status in Australia and New Zealand. The aim of this review was toidentify which population groups, if any, in Australia and New Zealand are likely to be at risk of zinc deficiency.Methods: A literature review was conducted to identify papers on zinc status in Australasia using electronicdatabases (MEDLINE, BIOSIS Previews, CINAHL, EMBASE, Web of Knowledge, ProQuest and Cochrane Library).Government databases and reference lists from peer-reviewed journal articles were also accessed.Results: Thirty-one Australasian studies that measured dietary zinc intake and/or serum zinc were identified. Manywere based on a small number of self-selected subjects, and did not use the recommended procedures for evaluatingthe prevalence of inadequate zinc intakes and low serum zinc concentrations. Existing data suggest that at-riskgroups in Australasia are toddlers, adolescents (especially those of Pacific and Aboriginal ethnicities), institutiona-lised elderly and possibly people with diabetes.Conclusions: Data on the zinc status of selected population groups in Australasia are limited. Randomisedcontrolled zinc supplementation trials that include the recommended indicators and other clinical outcomes areneeded to confirm the existence of zinc-related health outcomes among the at-risk groups identified.

Key words: Australia, New Zealand, prevalence, zinc deficiency.

Introduction

Zinc is required for the activity of over 300 enzymes in manymajor metabolic pathways, and has a critical role in a widerange of biochemical, immunological and clinical functions.Hence, in severe zinc deficiency a wide range of disturbancesoccur, which vary with age and the severity of deficiency.Manifestations in infancy often include diarrhoea, dermatitisand behavioural changes, whereas in children anorexia,impaired taste acuity, growth retardation and recurrent infec-tions are more common. During adolescence, delayed sexualmaturation and abnormalities in skeletal growth and miner-alisation have been described, and among the elderly, chronicnon-healing leg ulcers and recurrent infections occur.1

Marginal zinc deficiency, however, is more difficult toidentify because of the absence of frank clinical signsand reliable sensitive and specific biomarkers of zincstatus. Recently, three indicators—dietary, biochemicaland functional—have been recommended for identifying

population groups at elevated risk of zinc deficiency.2 Thedietary indicator is the prevalence of usual zinc intakesbelow the estimated average requirements (EARs). The bio-chemical indicator is the proportion of the population withserum zinc concentrations below the appropriate lower cut-offs, provided the correct protocols are followed for thecollection, separation and analysis of serum zinc.3 The func-tional indicator is the percentage of children less than fiveyears of age with length- or height-for-age less than -2 SDbelow the age-specific median of the reference population.Linear growth has poor specificity so that where possible,it is preferable to combine it with at least one of the otherrecommended indicators. For each indicator, a trigger levelfor the prevalence considered indicative of public healthconcern has been given, at which level an intervention toimprove population zinc status is warranted.

Currently the extent to which zinc deficiency is ofconcern in Australia and New Zealand (NZ) is unknown.Therefore, the aim of this review was to identify whichpopulation groups, if any, are most likely to be at risk to zincdeficiency in Australia and NZ.

Methods

The following searches were conducted in December 2009to identify papers on the prevalence of zinc deficiency in

R. Gibson, PhD, ProfessorA.-L. Heath, PhD, Senior LecturerCorrespondence: R.S. Gibson, Department of Human Nutrition,University of Otago, PO Box 56, Dunedin 9054, New Zealand. Email:[email protected]

Accepted December 2010

Nutrition & Dietetics 2011; 68: 97–108 DOI: 10.1111/j.1747-0080.2011.01516.x

© 2011 The AuthorsNutrition & Dietetics © 2011 Dietitians Association of Australia

97

Australia and NZ in MEDLINE (1950 to December 2009),BIOSIS Previews (1998 to December 2009), CINAHL (1981on), EMBASE (1947 to December 2009), Web of Knowledge(1995 on), ProQuest (1971 on) and The Cochrane Library(1991 on):1 ‘Zinc/ and Australia/’2 ‘Zinc/ and New Zealand/’.

Searches on:3 ‘Zinc’were conducted in Australian and NZ governmentdatabases http://www.health.gov.au and http://www.moh.govt.nz/moh. Reference lists from peer-reviewed journalarticles were also used.

Studies that included reports of either zinc intake orserum zinc concentration were considered to be reporting onzinc status.2 Very few papers were identified in these searchesso the International Zinc Nutrition Consultative Group(ZiNCG) website: http://www.izincg.org was used to deter-mine risk factors for zinc deficiency of relevance to Austra-lian and NZ populations.

Results and Discussion

Table 1 summarises the dietary and non-dietary factors,which have been associated with zinc deficiency for specificpopulation groups, based on the review by Brown et al.1

Groups known to be at increased risk have inadequate zincintakes that may be exacerbated by a physiological statethat leads to high requirements for zinc (per kilogrambody weight); or a pathological condition resulting in poor

absorption (e.g. malabsorption syndromes) or excessivelosses through urinary excretion (e.g. hyperzincuria in dia-betes), intestinal secretions, or intestinal exudates. Some-times, zinc utilisation may be impaired in the presence ofcertain drugs, or secondary to conditions such as alcohol-ism1. Data on the zinc status of these at-risk groups inAustralia and NZ are limited. Only 31 studies were identifiedand are summarised below. Further details on studies ininfants and young children, adolescent girls, and the elderlyare summarised in Tables 2–4; only those that measureddietary zinc intakes or serum zinc concentrations areincluded.

Infants and preschoolers. During the first six months of life,full-term infants with birth weights appropriate for gesta-tional age appear to meet their high requirements for zincthrough breast milk alone, despite the marked decline inbreast milk zinc concentrations during lactation.1 After sixmonths of age, infants and children require additionalsources of bioavailable zinc to meet their high requirementsfor growth.1

Limited data on the adequacy of zinc intakes fromcomplementary diets in Australia and NZ indicate thatintakes may be below the World Health Organization esti-mated needs for breastfed infants aged 6–11 months butprobably meet the needs for those aged 12–23 months.11,13

Whether the zinc intakes of non-breastfed children areadequate is less certain.4–8,14,16 In Australia, only two of thefive studies with data on zinc intakes for preschoolers4–8,16

have reported data on the prevalence of inadequateintakes8,16 (Table 2). The prevalence of inadequate intakes in

Table 1 Dietary and non-dietary factors associated with aetiology of zinc deficiency, and subgroups of the population who areat increased risk based on data from the earlier literature

Dietary factors Non-dietary factors

Low zinc intakes resulting from: High physiological requirements in:• Low energy intakes, e.g. adolescent girls and the elderly • Infancy, especially for SGA infants• Low intakes of red meat, e.g. vegetarians and vegans • Adolescence

• Pregnancy• Lactation

Poor zinc bioavailability: Poor absorption resulting from:• Diets with a high content of unrefined cereals, nuts and legumes (all high

in phytate) and consumed by some health conscious individuals,vegetarians and vegans

• Malabsorption syndromes such as: cysticfibrosis, coeliac disease, Crohn’s disease,short bowel syndrome

• Diets low in cellular animal protein consumed by meat restrictors,vegetarians and vegans

• Hypochlorhydria in the elderly

• Diets with a high content of calcium in presence of a high phytate contentas consumed by some health conscious individuals and vegetarians

• Geophagia

Excessive losses:• Alcoholism• Diarrhoea• Diabetes• Excessive vomitingGenetic diseases:• Acrodermatitis enteropathica• Sickle cell disease

SGA, small-for-gestational-age.

R. Gibson and A.-L. Heath


98

Tab

le2

Zin

cin

take

san

dse

rum

zinc

conc

entr

atio

nsof

Aus

tral

ian

and

New

Zea

land

infa

nts

and

youn

gch

ildre

n

Cou

ntry

&au

thor

Subj

ects

,age

&se

ttin

gD

esig

n&

met

hods

Die

tary

Zn

inta

kes

Bioc

hem

ical

stat

us

New

Sout

hW

ales

,A

ustr

alia

Land

ers

etal

.412

-60

mon

ths

(n=

60)

atte

ndin

glo

ng-d

ayda

yca

rece

ntre

s(L

DD

CC

s)12

–48

mon

ths

(n=

44)

>48–

60m

onth

s(n

=16

)

Chi

ldre

nfr

omth

ree

self-

sele

cted

LDD

CC

sT

hree

-day

wei

ghed

reco

rds

bypa

rent

sin

hom

esan

dby

adi

etit

ian

for

mea

lsin

the

cent

res

(1m

ain

mea

l+

2sn

acks

)W

eigh

t&

heig

htm

easu

red

Mea

n(�

SD)

Zn

inta

kes:

12–4

8m

onth

s:5.

5�

1.3

mg/

day

>48–

60m

onth

s:6.

6�

2.1

mg/

day

5%<

70%

1991

Aus

tral

ian

RD

I

Not

mea

sure

d

Aus

tral

ia:

Nat

iona

lSu

rvey

McL

enna

n&

Podg

er;5

Bagh

urst

etal

.6

24-3

6m

onth

s(n

=38

3)48

-84

mon

ths

(n=

799)

Res

pond

ents

�2

year

sfr

omur

ban

&ru

ral

area

sFe

brua

ry19

95to

Mar

ch19

96

Cro

ss-s

ecti

onal

,m

ulti

stag

era

ndom

sam

ple

In-h

ome

24-h

our

reca

ll+

som

ere

peat

s:ad

just

edfo

rus

ual

Zn

inta

kes

Seve

nda

ysof

the

wee

ksa

mpl

edFo

odha

bits

and

atti

tude

s,FF

Q;

anth

ropo

met

ry

Med

ian

(1st

,3r

dQ

)Z

nin

take

s:24

-36

mon

ths:

6.9

(5.9

,7.

9)m

g/da

y48

-84

mon

ths:

7.8

(6.9

,8.

9)m

g/da

y24

-36

mon

ths:

10%

Zn

from

tota

lre

dm

eat6

48-8

4m

onth

s:22

%Z

nfr

omto

tal

red

mea

t6

Not

mea

sure

d

Pert

h,W

este

rnA

ustr

alia

Soan

eset

al.7

24an

d36

mon

ths

(n=

33)

atte

ndin

gLD

DC

Cs

for

>3co

nsec

utiv

eda

ys/w

eek

full

tim

e;n

=32

LDD

CC

non-

atte

nder

s

LDD

CC

s:ra

ndom

sam

ple

of30

child

ren

atte

ndin

g10

LDD

CC

sac

ross

Pert

h,W

Aus

tral

iaT

hree

-day

wei

ghed

reco

rds

onco

nsec

utiv

ew

eekd

ays

bydi

etet

icst

uden

tsLD

DC

Cno

n-at

tend

ers:

self-

sele

cted

sam

ple

from

neig

hbou

ring

play

grou

psT

hree

-day

wei

ghed

reco

rds

onco

nsec

utiv

ew

eekd

ays

bypa

rent

sba

sed

onda

yca

rean

dho

me

inta

kes

Ant

hrop

omet

ry

Mea

n(�

SD)

Zn

inta

kes:

LDD

CC

:5.

3�

1.6

mg/

day

LDD

CC

non-

atte

nder

s:5.

0�

1.1

mg/

day

Not

mea

sure

d

2007

Aus

tral

ian

Nat

iona

lC

hild

ren’

sN

utri

tion

and

Phys

ical

Act

ivit

ySu

rvey

24–3

6m

onth

s48

–96

mon

ths

50%

girl

sFe

brua

ryto

Aug

ust

2007

Stra

tifie

dra

ndom

sam

ple

1in

-hom

e24

-hou

rre

call

&1

tele

phon

e24

-hou

rre

call

inte

rvie

w;

adju

sted

for

usua

lZ

nin

take

s48

-hou

rre

call

acti

vity

atfiv

e-m

inut

eti

me

inte

rval

sA

nthr

opom

etry

Mea

nZ

nin

take

s:24

–36

mon

ths:

7.8

mg/

day

48–9

6m

onth

s:9.

0m

g/da

yN

one

wit

hin

take

s<

EA

R(a

)

Not

mea

sure

d

Zinc deficiency in Australia and New Zealand


99

Tab

le2

Con

tinue

d

Cou

ntry

&au

thor

Subj

ects

,age

&se

ttin

gD

esig

n&

met

hods

Die

tary

Zn

inta

kes

Bioc

hem

ical

stat

us

Sydn

ey,

Aus

tral

iaW

ebb

etal

.816

–24

mon

ths

(n=

429)

50%

girl

sC

ross

-sec

tion

alda

tafr

omfiv

e-ye

arR

CT

ofas

thm

a.Pr

egna

ntw

omen

recr

uite

dfr

omsi

xho

spit

als

inW

est

Sydn

eyfr

om19

97to

2000

Inta

kes

ofch

ildre

nat

mea

nag

e18

.9m

onth

s:th

ree-

day

wei

ghed

reco

rds

(2w

eekd

ays;

1w

eeke

ndda

y)by

care

rs

Mea

n(�

SEM

)Z

nin

take

:5.

2(0

.12)

mg/

day

1.9

%w

ith

inta

kes

<E

AR

(a)

Not

mea

sure

d

Sydn

ey,

Aus

tral

iaK

arr

etal

.99–

23m

onth

s(n

=13

2)24

–35

mon

ths

(n=

109)

36–4

7m

onth

s(n

=99

)48

–62

mon

ths

(n=

127)

44%

girl

s

Ran

dom

clus

ter

sam

ple,

stra

tifie

dby

SES

betw

een

1993

and

1994

Veni

punc

ture

bloo

dsa

mpl

es:

node

tails

abou

tfa

stin

gst

atus

orco

llect

ion

met

hod

Bloo

dsp

ecim

ens

refr

iger

ated

afte

rco

llect

ion.

Bloo

dno

tta

ken

ifch

ildsi

ck.

CR

Por

AG

Pno

tm

easu

red

Not

mea

sure

dSe

rum

Zn

(mea

n,95

thC

I):

9–23

mon

ths:

13.8

(13.

4–14

.3)

mmol

/L;

24–3

5m

onth

s:13

.6(1

3.2–

14.1

)mm

ol/L

;36

–47

mon

ths:

13.8

(13.

4–14

.2)

mmol

/L;

48–6

2m

onth

s:14

.2(1

3.7–

14.6

)mm

ol/L

;0%

<8

Zn

mmol

/LN

odi

ffer

ence

sby

age

orse

xA

ustr

alia

,Br

isba

neSa

haet

al.10

24–6

9m

onth

s(n

=19

3)O

ctob

er19

97to

May

1998

Two

stag

ecl

uste

rsa

mpl

ing

(26

child

care

&ki

nder

gart

ens)

Non

-fas

ting

finge

r-pr

ick

bloo

dsa

mpl

esin

trac

eel

emen

t-fr

eepa

edia

tric

tube

sfo

rpl

asm

aZ

nC

-rea

ctiv

epr

otei

nm

easu

red

Ant

hrop

omet

rySc

alp

hair

sam

ples

for

Zn

Not

mea

sure

dM

ean

(�SD

)pl

asm

aZ

n:14

.03

�2.

99mm

ol/L

5%w

ith

plas

ma

Zn

<9.

95mm

ol/L

Mea

n(�

SD)

hair

Zn:

1.56

�0.

98mm

ol/g

27.9

%w

ith

hair

Zn

<1.

68mm

ol/g

67%

wit

hha

irZ

n<

1.07

mmol

/gN

ewZ

eala

nd,

Dun

edin

Hea

thet

al.11

9–24

mon

ths

Cau

casi

an(n

=74

)Fu

ll-te

rm;

Nor

mal

birt

hw

eigh

tO

ctob

er19

95to

May

1996

Opp

ortu

nist

icsa

mpl

e:lo

ngit

udin

alst

udy

Zn

inta

ke:

24-h

our

esti

mat

eddi

etre

cord

atni

nem

onth

s;th

ree-

day

esti

mat

eddi

etre

cord

at12

,18

&24

mon

ths

Med

ian

(1st

,3r

dQ

)Z

nin

take

s:9

mon

ths:

4.0

(3.3

,5.

1)m

g/da

y12

mon

ths:

4.5

(3.9

,5.

3)m

g/da

y18

mon

ths:

5.2

(4.3

,6.

4)m

g/da

y24

mon

ths:

5.0

(4.0

,5.

5)m

g/da

y

Not

mea

sure

d



100

New

Zea

land

Dou

glas

etal

.120–

6m

onth

s(n

=8)

Cro

ss-s

ecti

onal

stud

y:Fa

stin

gm

orni

ngbl

ood

sam

ples

take

nN

ode

tails

ofbl

ood

colle

ctio

nm

etho

dO

nly

seru

mZ

nm

easu

red.

Not

mea

sure

dM

ean

(�SD

)se

rum

Zn:

9.2

�1.

7mm

ol/L

New

Zea

land

;3

Sout

hIs

land

citi

es:

Dun

edin

,C

hris

t-ch

urch

Inve

rcar

gill

Ferg

uson

etal

.13

6–24

mon

ths

Pred

omin

antl

yC

auca

sian

Non

-bre

astf

eedi

ng(n

=23

0)

CS-

stud

y;R

ando

mly

sele

cted

from

3ci

ties

Thr

ee-d

ayw

eigh

edre

cord

son

non-

cons

ecut

ive

days

Non

-fas

ting

veni

punc

ture

usin

gIZ

iNC

Gpr

otoc

olH

air

Zn

Mea

n(�

SD)

Zn

inta

ke:

6–11

mon

ths:

5.0

�1.

0m

g/da

y;12

–24

mon

ths:

4.8

�1.

5m

g/da

y

Mea

n(�

SD)

seru

mZ

n:6–

11m

onth

s:1.

0�

1.4

mmol

/L9%

wit

hlo

wle

vels

(b)

Hai

rZ

n:2.

2�

0.6

mmol

/g15

%w

ith

low

leve

ls(c

)

Mea

n(�

SD)

seru

mZ

n:12

–24

mon

ths:

10.8

�1.

8mm

ol/L

15%

wit

hlo

wle

vels

(b)

Hai

rZ

n:2.

1�

0.9

mmol

/g22

%w

ith

low

leve

ls(c

)

New

Zea

land

Mor

gan

etal

.1412

-24

mon

ths

Mea

n(�

SD):

17.1

�2.

9m

onth

s(n

=22

5)

Base

line

ofra

ndom

ised

cont

rolle

dtr

ial:

Thr

ee-d

ayw

eigh

edre

cord

son

non-

cons

ecut

ive

days

Non

-fas

ting

veni

punc

ture

usin

gIZ

iNC

Gpr

otoc

olH

air

Zn

Ant

hrop

omet

ry

Mea

nZ

nin

take

:5.

0m

g/da

yPr

eval

ence

ofin

adeq

uate

inta

kes:

0.9%

(a)

Mea

nse

rum

Zn:

9.7

mmol

/L39

.8%

wit

hlo

wse

rum

Zn(b

)

Hai

rZ

n:1.

8mm

ol/g

32%

wit

hlo

wha

irZ

n(c)

(a)Ba

sed

onE

AR

cut

poin

tm

etho

d.(b

)Ti

me

ofda

ysp

ecifi

ccu

t-of

fs.1

(c)Se

ason

-spe

cific

cut-

offs

.1

1st,

3rd

Q,

1st,

3rd

quar

tile

;E

AR

,es

tim

ated

aver

age

requ

irem

ent;

FFQ

,fo

odfr

eque

ncy

ques

tion

nair

e;R

CT,

rand

omis

edco

ntro

lled

tria

l;R

DI,

reco

mm

ende

ddi

etar

yin

take

;SE

S,so

cioe

cono

mic

stat

us.



101

Tab

le3

Zin

cin

take

san

dse

rum

zinc

conc

entr

atio

nsof

adol

esce

ntgi

rls

inA

ustr

alia

and

New

Zea

land

Plac

e,co

untr

y&

auth

orSu

bjec

ts,a

ge&

sett

ing

Des

ign

&m

etho

dsD

ieta

ryZ

nin

take

sBi

oche

mic

alst

atus

Ade

laid

e,A

ustr

alia

Mag

arey

&Bo

ulto

n1511

year

sF,

n=

106

13ye

ars

F,n

=11

615

year

sF,

n=

104

Long

itud

inal

stud

y.C

hild

ren

born

in19

75–1

976

Four

-day

wei

ghed

reco

rds

atag

ed11

,13

&15

year

sA

nthr

opom

etry

Mea

n(�

SD)

Zn

inta

ke:

F:11

year

s:7.

9�

2.0

mg/

day

F:13

year

s:7.

9�

2.0

mg/

day

F:15

year

s:7.

7�

2.0

mg/

day

%<

0.7

RD

I(a)

11ye

ars:

F:20

%;

13ye

ars:

F:63

%;

15ye

ars:

F:56

%

Not

mea

sure

d

1995

Aus

tral

ian

Nat

iona

lN

utri

tion

Surv

eyM

cLen

nan

&Po

dger

5

12–1

5ye

ars

(n=

653)

16–1

8ye

ars

(n=

433)

Febr

uary

1995

toM

arch

1996

Cro

ss-s

ecti

onal

;m

ulti

stag

era

ndom

sam

ple

In-h

ome

24-h

our

reca

ll+

som

ere

peat

s:ad

just

edfo

rus

ual

zinc

inta

kes

Seve

nda

ysof

the

wee

ksa

mpl

edin

the

surv

eyFo

odha

bits

and

atti

tude

s;FF

Q;

anth

ropo

met

ry

Med

ian

(1st

,3r

dQ

)Z

nin

take

s:F:

12–1

5ye

ars:

8.6

(7.1

,10.

8)m

g/da

yF:

16–1

8ye

ars:

8.7

(7.5

,11

.4)

mg/

day

Not

mea

sure

d

2007

Aus

tral

ian

Nat

iona

lC

hild

ren’

sN

utri

tion

and

Phys

ical

Act

ivit

ySu

rvey

16

9–13

year

s14

–16

year

s20

07

Cro

ss-s

ecti

onal

;st

rati

fied

rand

omsa

mpl

e.1

in-h

ome

24-h

our

reca

ll&

1te

leph

one

24-h

our

reca

ll:ad

just

edfo

rus

ual

inta

kes.

48-h

our

reca

llac

tivi

tyat

five-

min

ute

tim

ein

terv

als

Ant

hrop

omet

ry

Mea

nZ

nin

take

s:9–

13ye

ars:

9.9

mg/

day

Non

ew

ith

inta

kes

<E

AR

(b)

14–1

6ye

ars:

10.0

mg/

day

2%w

ith

inta

kes

<E

AR

(a)

Not

mea

sure

d

1997

New

Zea

land

,N

atio

nal

Nut

riti

onSu

rvey

17M

:15

–18

year

s(n

=10

9)F:

15–1

8ye

ars

(n=

137)

Cro

ss-s

ecti

onal

;st

rati

fied

rand

omsa

mpl

eIn

-hom

e24

-hou

rre

calls

+re

peat

s:us

ual

Zn

inta

kes

calc

ulat

edA

nthr

opom

etry

Mea

n(�

SEM

)Z

nin

take

F:10

.2�

0.69

mg/

day

%<

EA

RU

K(1

990)

:F:

5.5

mg

F:2.

4%

Not

mea

sure

d

2002

New

Zea

land

Chi

ldre

n’s

Nut

riti

onSu

rvey

1811

–14

year

s(n

=57

6)F

=58

2U

rban

&ru

ral

scho

olch

ildre

n

Cro

ss-s

ecti

onal

;st

rati

fied

rand

omsa

mpl

e24

-hou

rre

call

+so

me

repe

ats:

adju

sted

for

usua

lin

take

sA

nthr

opom

etry

Non

-fas

ting

bloo

dsa

mpl

eta

ken

usin

gIZ

iNC

Gpr

otoc

ol

Mea

n(�

SEM

)Z

nin

take

F:9.

4�

0.30

mg/

day

%<

EA

RU

K(1

990)

:F:

5.5

mg

F:2.

4%

Mea

nse

rum

Zn:

12.7

mmol

/L8%

<lo

wse

rum

Zn(c

)

New

Zea

land

Dou

glas

etal

.1213

-17

year

s(n

=31

8)N

umbe

rof

boys

vers

usgi

rls

not

spec

ified

Fast

ing

veni

punc

ture

wit

hpl

asti

csy

ring

esN

om

easu

reof

infla

mm

atio

nre

port

edN

otde

term

ined

Mea

n(�

SD)

seru

mZ

n:F:

9.9

�1.

3mm

ol/L

Dun

edin

,N

ewZ

eala

ndM

cKen

zie-

Parn

ell

&T

hom

son19

11ye

ars

(n=

453)

F=

207

Febr

uary

toM

arch

1984

Long

itud

inal

stud

y:C

onve

nien

cesa

mpl

eN

on-f

asti

ngve

nipu

nctu

rebl

ood

sam

ples

Bloo

dco

llect

edus

ing

IZiN

CG

prot

ocol

sN

om

easu

reof

infla

mm

atio

nre

port

edA

nthr

opom

etry

Not

repo

rted

Mea

n(�

SD)

seru

mZ

n:F:

13.9

�2.

8mm

ol/L

6%<

9.9

mmol

/LN

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gnifi

cant

diff

eren

ces

betw

een

boys

&gi

rls

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sed

onA

ustr

alia

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90R

DI.

(b)Ba

sed

onE

AR

cut

poin

tm

etho

d.(c

)Ba

sed

onti

me

ofda

y-sp

ecifi

ccu

t-of

fs.1

1st,

3rd

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3rd

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tile

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AR

,es

tim

ated

aver

age

requ

irem

ent;

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CG

,In

tern

atio

nal

Zin

cN

utri

tion

Con

sult

ativ

eG

roup

;R

DI,

reco

mm

ende

ddi

etar

yin

take

.



102

Tab

le4

Zin

cin

take

san

dse

rum

zinc

conc

entr

atio

nsof

free

-liv

ing

and

inst

itut

iona

lised

elde

rly

inA

ustr

alia

and

New

Zea

land

Aut

hors

&co

untr

ySu

bjec

ts,a

ge&

sett

ing

Des

ign

&m

etho

dsD

ieta

ryZ

nin

take

sBi

oche

mic

alst

atus

Gee

long

,A

ustr

alia

Flin

tet

al.20

24co

mm

unit

y-ba

sed

elde

rly

free

from

acut

eill

ness

(14

F;10

M)

Two-

stag

ecl

uste

rsa

mpl

ing

for

recr

uitm

ent

Age

d76

.2�

0.8

year

s66

inst

itut

iona

lised

(53

F;13

M):

rand

omsa

mpl

eof

thos

ein

stit

utio

nalis

edfo

r�

3m

onth

sA

ged

82.2

�1.

1ye

ars

Cro

ss-s

ecti

onal

;di

etar

yhi

stor

yfo

rco

mm

unit

ysa

mpl

eT

hree

-day

wei

ghed

inta

kes

for

inst

itut

iona

lised

Wei

ght

mea

sure

dFa

stin

gbl

ood

sam

ples

usin

gIZ

iNC

Gpr

otoc

ol

Mea

n(�

SD)

Zn

inta

kes:

Com

mun

ity:

11.0

�0.

5m

g/da

y21

%(n

=5)

<2/

3rd

Zn

RD

A(1

5m

g/da

y)In

stit

utio

n:7.

6�

1.1

mg/

day

85%

(n=

56)

<2/

3rd

Zn

RD

A(1

5m

g/da

y)

Mea

n(�

SD)

plas

ma

Zn

Com

mun

ity:

13.6

�0.

4mm

ol/L

20%

(n=

5)<

12.2

mmol

/LIn

stit

utio

n:14

.0�

0.3

mmol

/L29

%(n

=19

)<

12.2

mmol

/LN

osi

gnifi

cant

diff

eren

cein

mea

npl

asm

aZ

nbe

twee

ntw

ogr

oups

Ade

laid

e,A

ustr

alia

Bagh

urst

&R

ecor

d2165

–75

year

s(1

95M

;13

6F)

Free

-liv

ing

from

met

ropo

litan

Ade

laid

e

Cro

ss-s

ecti

onal

surv

eyR

ando

msa

mpl

e82

%re

spon

sera

teSe

lf-ad

min

iste

red

FFQ

over

past

year

com

plet

edin

the

hom

e

Med

ian

(5th

,95

thpe

rcen

tile

)Z

nin

take

:M

:12

.0(6

.7–1

9.8)

mg/

day

F:10

.9(5

.7–1

6.0)

mg/

day

M:

45%

<R

DI

(i.e

.12

mg)

F:66

%<

RD

I(i

.e.

12m

g)

Not

mea

sure

d

1995

Aus

tral

ian

Nat

iona

lN

utri

tion

Surv

eyM

cLen

nan

&Po

dger

5

�65

year

s(n

=19

60)

(902

M;

1058

F)Fe

brua

ry19

95to

Mar

ch19

96

Cro

ss-s

ecti

onal

;m

ulti

stag

era

ndom

sam

ple

In-h

ome

24-h

our

reca

ll+

som

ere

peat

s:ad

just

edfo

rus

ual

zinc

inta

kes

All

seve

nda

ysof

the

wee

ksa

mpl

edFo

odha

bits

and

atti

tude

s,FF

Q;

phys

ical

mea

sure

men

ts

Med

ian

(1st

,3r

dQ

)Z

nin

take

s:M

:11

.0(9

.9,

12.3

)m

g/da

yF:

8.6

(7.9

,9.5

)m

g/da

y

Not

mea

sure

d

Vic

tori

a,A

ustr

alia

Now

son

etal

.;22G

rieg

eret

al.23

Age

d80

.2�

10.6

year

s11

5(7

8F;

47M

)R

esid

ents

inhi

gh-l

evel

(H-L

)an

dlo

w-l

evel

(L-L

)ca

reho

stel

s

CS-

stud

yof

subj

ects

ina.

resi

dent

ial

care

faci

lity

Die

tary

inta

kes

via

24-h

our

visu

alpl

ate

was

tesu

rvey

Ant

hrop

omet

ryFa

stin

gbl

ood

sam

ple

No

deta

ilsof

colle

ctio

nm

etho

dsTi

med

-up-

and-

go(T

UG

)te

stH

and

grip

stre

ngth

Mea

n(�

SD)

Zn

inta

ke:

8.0

�3.

0m

g/da

yN

odi

ffer

ence

betw

een

H-L

vers

usL-

Lca

resu

bjec

tsZ

nin

take

ssa

idto

belo

win

~50%

Mea

n(�

SD)

seru

mZ

n:11

.2�

2.8

mmol

/L46

%<

10.7

mmol

/LT

hose

wit

hse

rum

Zn

�10

.7mm

olha

dsl

ower

TU

Gti

me

vers

usth

ose

>10.

7mm

ol,

P=

0.02

Neg

ativ

eas

soci

atio

nbe

twee

nse

rum

Zn

and

TU

Gsc

ore

(r=-

0.44

9,P

=0.

001)

Mel

bour

ne,

Aus

tral

iaLu

kito

etal

.24A

ged

67–1

00ye

ars

115

(78

F;37

M)

Cro

ss-s

ecti

onal

;ob

serv

atio

nal

Rec

ruit

edfr

omge

riat

ric

inst

itut

ion

Fast

ing

bloo

dsa

mpl

eN

ode

tails

ofco

llect

ion

met

hods

Tota

lly

mph

ocyt

eco

unt

&ly

mph

ocyt

esu

bset

anal

ysis

Ant

hrop

omet

ry

Not

mea

sure

dM

ean

(�SD

)se

rum

Zn

M:

12.0

�0.

3mm

ol/L

F:11

.8�

0.2

mmol

/LSe

rum

Zn:

posi

tive

corr

elat

ion

wit

hC

D3

coun

ts(t

otal

T-ce

lls),

CD

4(T

-hel

per

cell)

&C

D19

(tot

alB-

cell)



103

Tab

le4

Con

tinue

d

Aut

hors

&co

untr

ySu

bjec

ts,a

ge&

sett

ing

Des

ign

&m

etho

dsD

ieta

ryZ

nin

take

sBi

oche

mic

alst

atus

Mel

bour

ne,

Aus

tral

iaW

oods

etal

.2510

6(7

2F;

23M

)A

ged

86�

6.6

year

sA

mbu

lato

ryw

hoco

uld

self-

feed

Con

veni

ence

sam

ple

from

14L-

Lca

refa

cilit

ies

Part

icip

ants

ofcl

uste

rR

CT

wit

h20

L-L

care

host

els

Thr

ee-d

ayw

eigh

edre

cord

sfo

ral

lse

tm

eals

serv

edby

diet

itia

nsR

ecal

lof

food

sse

rved

outs

ide

set

mea

lti

mes

Wei

ght;

heig

ht;

DX

Ata

ken

Biom

arke

rsm

easu

red

but

not

Zn

Mea

n(�

SD)

Zn

inta

ke:

F:6.

6�

1.3

mg/

day

46%

<E

AR

(6.5

mg)

M:

8.7

�2.

291

%<

EA

R(i

.e.

12m

g)

Not

mea

sure

d

Mos

giel

,N

ewZ

eala

ndH

orw

ath

etal

.2671

2co

mm

unit

y-ba

sed

elde

rly

(457

F;25

5M

)A

ged

�70

year

sSt

udy

done

inA

ugus

t19

88

Stud

ypo

pula

tion

wer

eth

ose

aged

�70

year

sw

how

ere

regi

ster

edw

ith

Mos

giel

Hea

lth

Cen

tre

85%

ofpo

pula

tion

com

plet

edse

lf-ad

min

iste

red

sem

i-qu

anti

tati

veFF

Q

Mea

n(�

SD)

Zn

inta

ke:

M:

9.3

�2.

4m

g/da

y26

%<

2/3r

dA

ustr

alia

nR

DI

(199

0)(1

2m

g)F:

8.0

�2.

0m

g/da

y53

%<

2/3r

dR

DI

(12

mg)

Not

mea

sure

d

1997

New

Zea

land

Nat

iona

lN

utri

tion

Surv

ey17

817

aged

�65

year

s65

–74:

n=

211

75+

n=

115

Thr

ee-s

tage

stra

tifie

dde

sign

In-h

ome

24-h

our

reca

ll:so

me

repe

ats:

adju

sted

for

usua

lin

take

s

Mea

n(�

SEM

)Z

nin

take

:M

:12

.1�

0.40

4.8%

<U

KE

AR

(199

0)(7

.3m

g)F:

9.2

�0.

311.

3%<

UK

EA

R(1

990)

(5.5

mg)

Not

mea

sure

d

Dun

edin

,N

ewZ

eala

ndde

Jong

etal

.2710

3el

derl

yw

omen

70-8

0ye

ars;

free

-liv

ing

June

toA

ugus

t20

00

Ran

dom

lyse

lect

edfr

omel

ecto

ral

roll;

CS-

stud

yFF

Qov

erpa

stye

ar;

anth

ropo

met

ry;

phys

ical

func

tion

ing

mea

sure

men

tsFa

stin

gve

nipu

nctu

rebl

ood

sam

ple

usin

gIZ

iNC

Gpr

otoc

ol

Med

ian

(1st

,3r

dQ

)Z

nin

take

:8.

5(7

.5,1

0.0)

mg/

day

42%

<2/

3rd

Aus

tral

ian

1990

RD

I(1

2m

g)

Mea

n�

SDse

rum

Zn:

12.4

�1.

4mm

ol/L

12%

<10

.7mm

ol/L

Subj

ects

wit

hhi

ghes

tte

rcile

offu

ncti

onal

capa

city

had

high

erse

rum

Zn

than

thos

ein

low

est

terc

ile(1

3.0

vs12

.0mm

ol/L

;P

<0.

05)

DX

A,

dual

ener

gyX

-ray

abso

rpti

omet

ry;

EA

R,

esti

mat

edav

erag

ere

quir

emen

t;FF

Q,

food

freq

uenc

yqu

esti

onna

ire;

IZiN

CG

,In

tern

atio

nal

Zin

cN

utri

tion

Con

sult

ativ

eG

roup

;R

CT,

rand

omis

edco

ntro

lled

tria

l;R

DA

,re

com

men

ded

diet

ary

allo

wan

ce;

RD

I,re

com

men

ded

diet

ary

inta

ke.



104

these studies was extremely low. In a NZ study, the preva-lence of inadequate zinc intakes for non-breastfed childrenaged 6–24 months was 16%,13 although <1% in anotherstudy for a similar group aged 12–20 months.14

There is also a paucity of data on serum zinc concentrationsfor Australian and NZ infants and toddlers9,10,12–14 (Table 2).Prevalence estimates for low serum zinc concentrations mea-sured using the IZiNCG recommended procedures1 rangefrom 16%13 to 40%14 for NZ toddlers aged 12–20 months,compared with 5% for children aged 24–72 months fromBrisbane, Australia.10

Some relationships between zinc biomarkers and zinc-related functional outcomes have been noted in Australasiantoddlers, suggesting that suboptimal zinc nutriture mayexist. Among Australian preschoolers, a significant inverserelationship between plasma zinc and symptoms of respira-tory disease and sore throat, and a significant positive rela-tionship between hair zinc and height-for-age Z-scores havebeen reported.10 A significant positive relationship has beenreported between hair zinc and weight-for-age Z-scores inNZ infants and toddlers.13

There is a large discrepancy between estimates of therisk of zinc deficiency in young children based on dietaryand biochemical evidence.13,14 The risk of zinc deficiency ismarkedly higher when based on low serum zinc concentra-tions compared with dietary evidence (i.e. usual zinc intakesbelow the 2006 EARs for Australia and NZ).28 Such incon-sistencies may arise in part because the cut-offs applied tothe dietary and biochemical indices of zinc status are basedon data extrapolated from older children29,30 and need to bebetter defined.

Adolescent girls. Dietary requirements for zinc (perkilogram body weight) of adolescents are more thandouble those estimated for toddlers28 and peak at the time ofthe pubertal growth spurt, which in girls generally occursbetween 10 and 15 years. Several other physiological pro-cesses that accompany puberty, including sexual matura-tion, onset of menarche and increased erythropoiesis, alsohave a major impact on the zinc requirements of adoles-cent girls.1,28 Many adolescent girls fail to meet these highzinc requirements. They often have erratic eating patterns,restrict their energy intakes because of concerns about bodyweight and have low intakes of meat, poultry and fish.31,32

Suboptimal zinc status during adolescence could slowskeletal growth and bone maturation, and reduce bone min-eralisation, leading to permanent deficits in bone mineraldensity and thus increased risk of osteoporosis in lateradulthood.31

Australasian data on the zinc status of adolescent girlsbased on dietary intakes and serum zinc concentrations arelimited5,15–19,33–35 (Table 3). In national surveys in Australia5

and NZ17, adolescent girls had the lowest median zinc intakeof the age groups of women studied, except those �65 years.Indeed, the 10th percentile for the zinc intake (6.2 mg/day)for Australian adolescents aged 16–18 years was just abovethe EAR (i.e. 6 mg/day),5 suggesting that up to 10% mayhave had inadequate intakes (Table 3). In the later NZ Chil-dren’s Nutrition Survey (CNS02) conducted in 2002,18 the

prevalence of inadequate zinc intakes was very low overall,although Pacific girls aged 9–13 years had the highest preva-lence (~8%).35 Only the NZ CNS02 survey measured serumzinc. Of the adolescent girls aged 11–14 years, 8% had lowserum zinc concentrations,35 which is reasonably congruentwith results of earlier, smaller NZ studies of adolescents.19,33

Again, in CNS02, Pacific girls aged 9–13 years had thehighest prevalence of low serum zinc concentrations(18%).35

Pregnant women. The estimated total additional zincneeded over the course of gestation is ~100 mg,36 whichappears to be partly met during pregnancy by increasingabsorption and decreasing exogenous excretion of zinc. Nev-ertheless, the ability of these homeostatic mechanisms tocompensate when diets are low in total or bioavailable zincappears limited. Inadequate zinc intakes in some pregnantwomen may lead to an increased risk of preterm births.36

There are no national surveys on pregnant women inAustralia or NZ. Three small studies in NZ suggest that zincintakes for some women during pregnancy may be low,37–39

but the prevalence of inadequate intakes was not reported.In a study of pregnant women (n = 430) from Adelaide,40

when serum zinc concentrations were measured at delivery,59% were reportedly low, but by six months post-partum,the prevalence had decreased to 7–10%. However, the cut-off used here at delivery (i.e. 9.18 mmol/L) is now consideredtoo high.1,29

Women are often advised to take high doses of ironsupplements during pregnancy. Iron supplements may inter-fere with the absorption and metabolism of zinc, especially ifhigh doses are taken without food.1 Some studies, includingone in NZ37, have reported significantly lower mean serumzinc concentrations in pregnant women receiving high-doseprenatal iron supplements compared with controls, althoughthis trend was not evident with a low-dose (20 mg/day)iron supplement taken by the Adelaide pregnant women.40 Arecent review concluded that iron supplementation does notnegatively impact on biochemical zinc status, but urged thatmore data are needed to draw a definitive conclusion onclinical health outcomes.41

The elderly. Zinc intakes in the elderly are often inadequate(Table 4), attributed to reductions in food intake due todecreased energy needs, poor appetite and low intakes ofmeat, often arising from poverty and sometimes physicaldisabilities (e.g. swallowing and dental problems).1,28

Of the adults studied in the national nutrition surveys inAustralia5 and NZ,17 the elderly (>65 years) had the lowestmedian daily zinc intakes, and in Australia, the lowest intakeof red meat,6 trends consistent with other smaller studies inAustralia20,21 and NZ.26,27 Such low dietary zinc intakes maybe especially serious for older adults because zinc absorptionmay decline linearly with age,42 and be compromised byhypochlorhydria and malabsorption syndromes.1 Certainly,in other national surveys in Canada43 and the USA,44 serumzinc concentrations declined with age, a trend also notedamong South Australian adult men.45

No data on serum zinc concentrations were collected onthe elderly (or any other age group) in the Australian5 or



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NZ17 national surveys. However, in a small study of NZnon-institutionalised older women, 12% had low serum zinclevels.27 Institutionalised elderly may be especially vulner-able to low zinc status (Table 4).22–25 In a residential caresetting in Australia, low zinc intakes and a high prevalence(46%) of low serum zinc concentrations23 were reportedamong the elderly residents, although whether inflammationplayed a role in the low serum zinc concentrations is uncer-tain. Suboptimal zinc status in Australasian elderly might beresponsible for impairments in physical functioning23,27 andimmunocompetence.24 Other possible zinc-related degen-erative changes that warrant further study in the elderlyinclude hypogeusia, delayed wound healing, anorexia, dete-rioration of glucose tolerance and depression.46–49 Cautionmust be used when interpreting low serum zinc levels in theelderly because they can be affected by several factors unre-lated to tissue zinc levels, including medication, laxatives,diuretics and inflammation.1,29

Vegetarians. Vegetarians, especially vegans, are vulnerableto zinc deficiency because they have low intakes of poorlybioavailable zinc. Stable isotope studies have confirmed thatabsorption of zinc is lower from a vegetarian comparedwith an omnivorous diet,50 and as a result, vegetarians mayrequire as much as 50% more zinc in their diets thannon-vegetarians.28

Young women often follow a vegetarian dietary patternbecause of ethical, ecological, economic and health con-cerns. In recent national surveys, Australian women aged19–24 years,5 and adolescent women aged 15–18 years inNZ17, were those most likely to report consuming a vegetar-ian diet, or avoiding red meat. Several small studies in Aus-tralasia indicate that both vegetarians and young womenwho exclude red meat from their diets often have lowerzinc intakes,51,52 and higher phytate intakes and dietaryphytate : zinc molar ratios than omnivores.53 In one of theseNZ studies,53 a higher prevalence of low serum zinc concen-trations was noted in the young women who excluded redmeat compared with those who included red meat. Similarfindings have been reported in Canada.32

Nonetheless, serum zinc concentrations are notalways lower among vegetarians compared with non-vegetarians.51,54 Several factors may contribute to theseinconsistent results, including differences in baseline tissuezinc levels, or the use of inappropriate procedures for thecollection or analysis of the blood samples for serum zinc.Other contributing factors may include failure to accountfor confounding factors such as inflammation or use oforal contraceptive agents, small sample sizes, coexistence ofother micronutrient deficiencies and possibly, consumptionof high-dose iron supplements.1,29,37

Interestingly, vegetarianism per se is not necessarily a sig-nificant predictor of suboptimal zinc status. In Canadianadolescents, semi-vegetarians who excluded red meat hadlower plasma zinc levels than either vegetarians or omni-vores,32 suggesting that a poorly planned diet rather thanvegetarianism itself may increase risk of zinc deficiency.

Australian indigenous children. Early studies among Austra-lian indigenous children confirmed the existence of subop-

timal zinc status based on low biochemical zinc status (inserum, hair, and red and white blood cells) in associationwith impaired growth and sexual maturation.55 These find-ings prompted an 11-month randomised controlled trialof zinc supplementation in 1984 with growth-retardedAboriginal children aged 5–15 years.56 Despite a significantbut modest increase in serum zinc in the zinc-supplementedgroup, no positive growth response to zinc supplementationwas observed. These early findings are difficult to interpret.The modest increase in serum zinc despite the high dosesof supplemental zinc was unexpected, and attributed toimpaired zinc absorption as a result of parasitic infections, alink confirmed by more recent studies.57 It is also likely thatsome of the children were undergoing their adolescentgrowth spurt, which could have confounded the abilityto detect a measurable effect on linear growth, despite therandom allocation of treatment, given the wide variation inthe timing of the pubertal growth spurt, and the relativelysmall sample size of the study (n = 204).

A second randomised placebo-controlled trial of zincsupplementation (with and without vitamin A) in Australianindigenous children (n = 392) aged <11 years and hospital-ised with acute diarrhoea also yielded negative results,58

although for the stunted children receiving zinc plus vitaminA supplements, hospital stay and diarrhoea duration tendedto be shorter than for their non-stunted counterparts.Absence of a positive response overall was speculated to arisebecause the children were not zinc deficient at baseline, asuggestion difficult to confirm based on the serum zinc datapresented. Clearly, a larger randomised controlled trial ofzinc supplementation among stunted Australian indigenouschildren with acute diarrhoea, which includes an assessmentof intestinal permeability and infection, and uses the IZiNCGprocedures for serum analyses1,29 is needed to confirm thesefindings.

New Zealand Pacific children. In NZ, Pacific childrenappear to be at highest risk of zinc deficiency. In the CNS02survey, Pacific children aged 5–15 years had the highestprevalence of low serum zinc concentrations (21%),followed by Maori (16%), and NZ European and Other(NZEO) ethnicities. Furthermore, the prevalence of inad-equate zinc intakes although low, was highest in the Pacificchildren (i.e. 8%), who also had the lowest zinc intake perkilogram body weight.35 Interestingly, Pacific boys but notgirls with low serum zinc had a significantly lower meanheight-for-age Z-score than those with normal serum zincconcentrations. Suboptimal zinc status among the NZ Pacificchildren may have been exacerbated by their greater statureand lean body mass, and thus higher requirements for zinccompared with NZEO children.

People with diabetes. A number of clinical conditions areknown to increase the risk of zinc deficiency (Table 1),although very few have been investigated in Australasia. Therising prevalence of diabetes in Australasia,59,60 however, hasprompted interest in the role of zinc in insulin signalling andthe pathogenesis of diabetes in Australia.61 Diabetes mellitusis associated with hyperzincuria, low plasma zinc concen-trations and increased oxidative stress.46,61 Zinc has a protec-



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tive role against oxidation by acting against free radicalattack,62 so that when oxidative stress is experienced bydiabetics with coexisting marginal zinc deficiency, irrevers-ible cell damage may occur, which could produce or exac-erbate some of the classic complications of diabetes. In suchcircumstances, zinc supplementation might protect againstoxidant stress, and thus prevent some of the degenerativecomplications of diabetes.63 More studies are needed toinvestigate the potential role of zinc as an antioxidant micro-nutrient in people with diabetes.

Conclusion

Data on the zinc status of population groups potentially atrisk of zinc deficiency in Australia and NZ are limited. Manyof the published studies are based on a relatively smallnumber of self-selected subjects, and have used proceduresfor evaluating the prevalence of inadequate zinc intakes andlow serum zinc concentrations now considered inappropri-ate. Consequently, it is difficult to apply the recommendedtrigger levels to identify those population groups in Australa-sia at elevated risk of zinc deficiency and of public healthconcern. Existing data suggest that vulnerable groups war-ranting further study are toddlers, adolescents (especiallythose of Pacific and Aboriginal ethnicities), institutionalisedelderly and possibly people with diabetes. Rigorouslydesigned randomised controlled trials of zinc supplementa-tion that include an assessment of dietary zinc intakes andserum zinc concentrations, as well as selected zinc-relatedfunctional outcomes are needed to confirm the existence ofzinc deficiency, and determine whether its clinical conse-quences exist in these potentially high-risk groups in Aus-tralia and NZ.

Acknowledgements

The compilation of this review was funded by Meat & Live-stock Australia.

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population groups at risk of zinc deficiency in australia and new zealand

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