Vidyya Medical News Servicesm
Vidyya, from the Sanskrit "vaidya," a practitioner who has come to understand the science of life.

Volume 1 Published - 14:00 UTC    08:00 EST    20-September-2000      
Issue 160 Next Update - 14:00 UTC 08:00 EST    21-September-2000      

Vidyya Home  Vidyya

Home Of Our Sponsor, Vidyya.  Vidyya. Home

Vidyya Archives  Vidyya Archives

Search Vidyya  Search Vidyya

Visit Our Library  Ex Libris

Subscribe To Our News Service  Subscriptions

All About Us  About Vidyya



















Back To Vidyya Guideline: Counseling To Promote A Healthy Diet

From The US Preventive Services Task Force

RECOMMENDATION

Counseling adults and children over age 2 to limit dietary intake of fat (especially saturated fat) and cholesterol, maintain caloric balance in their diet, and emphasize foods containing fiber (i.e., fruits, vegetables, grain products) is recommended. There is insufficient evidence to recommend for or against counseling the general population to reduce dietary sodium intake or increase dietary intake of iron, beta-carotene, or other antioxidants to improve health outcomes, but recommendations to reduce sodium intake may be made on other grounds. Women should be encouraged to consume recommended quantities of calcium (see Clinical Intervention ). Parents should be encouraged to breastfeed their infants. Providing pregnant women with specific nutritional guidelines to enhance fetal and maternal health is recommended. Although there is insufficient evidence to recommended for or against special assessment of the dietary needs and habits of older adults, recommendations to do so can be made on other grounds. There is insufficient evidence that nutritional counseling by physicians has an advantage over counseling by dietitians or community interventions in changing the dietary habits of patients. See Chapter 22 regarding the role of iron during pregnancy and in the diets of newborns and young children, and Chapter 42 regarding the use of folic acid by women of childbearing age. See Chapter 61 regarding intake of refined sugars and adherent carbohydrates that may affect dental health. Counseling regarding alcohol consumption is discussed in Chapter 52.

Burden of Suffering

Diseases associated with dietary excess and imbalance rank among the leading causes of illness and death in the U.S. Major diseases in which diet plays a role include coronary heart disease, some types of cancer, stroke, hypertension, obesity, and non-insulin-dependent diabetes mellitus.[1] Heart disease is the leading cause of death in the U.S.,[2] with coronary heart disease accounting for up to 1.5 million myocardial infarctions and nearly 500,000 deaths each year.[2] ,[3] Cancer of the colon, breast, and prostate, the three forms of cancer most closely associated epidemiologically with nutritional risk factors, together, cause over 140,000 deaths annually.[4] Cerebrovascular disease, the third leading cause of death, accounted for about 150,000 deaths in 1993.[2] Hypertension, another disease with nutritional risk factors, occurs in about 43 million Americans.[5] Caloric intake, when it exceeds energy expenditure, can also lead to overweight and obesity, which affects about 58 million American adults aged 20 and older.[6] Obesity is a risk factor for a number of serious disorders (see Chapter 21), including both hypertension and adult-onset diabetes mellitus. An estimated 14 million persons in the U.S. have diabetes mellitus, which accounts for over 55,000 deaths each year and is a leading cause of neuropathy, peripheral vascular disease, renal failure, and blindness.[2] ,[7]

Nutritional factors have also been linked to osteoporosis, constipation, diverticular disease, iron deficiency anemia (see Chapter 22), oral disease, and malnutrition. An estimated 40% of women in the U.S. will suffer from osteoporosis-related fractures by the time they reach age 70.[8] Hip fractures in particular are associated with significant pain and disability, decreased functional independence, and high mortality; there is a 15-20% reduction in expected survival in the first year following a hip fracture.[9] Constipation is a complaint of over 4.5 million Americans,[10] and intestinal diverticular disease is reported by nearly 1.5 million persons.[11] The average schoolchild has at least one cavity in permanent teeth by age 9, three cavities by age 12, and eight by age 17.[12] The average adult in the U.S. has 10-17 decayed, missing, or filled permanent teeth and one untreated decayed permanent tooth.[13] Disorders of both overeating and undereating are common among older adults, up to 40% of whom have inadequate dietary intake of three or more nutrients.[14] Many older adults suffer from protein-calorie malnutrition -- up to 50% of nursing home residents in the U.S. may be malnourished,[15] and an additional number suffer from marginal malnutrition that is less clinically evident.

Efficacy of Risk Reduction

Eating habits over a lifetime can have a significant impact on the incidence and severity of many health disorders. The complete body of literature regarding the health effects of foods is beyond the scope of this report and has been the subject of extensive reviews.[1] ,[16] In summary, it is clear that a direct relationship exists between nutritional risk factors and certain key diseases. It is well established, for example, that caloric imbalance (intake exceeding expenditure) can lead to overweight and obesity. Persons who are overweight are at increased risk of glucose intolerance, hypertension, high blood cholesterol, and other disorders (see Chapter 21); reduction of body weight has been shown to reduce these risks.[17] [18] [19] [20] The average person is likely to benefit from dietary practices and physical activity (see Chapter 55) that keep caloric intake commensurate with daily energy expenditures. In addition to the overall objective of caloric balance, modified intake of specific dietary factors may also help prevent certain diseases.

Reduced intake of dietary fat, especially saturated fats (and, possibly, partially hydrogenated vegetable fats), appears to reduce the risk of developing coronary heart disease. A large body of epidemiologic evidence links serum cholesterol levels to the development of coronary atherosclerosis.[21] [22] [23] Serum cholesterol levels can in turn be modified by dietary measures. Clinical trials incorporating reduced total or saturated fat intake, either as a sole intervention or as part of a multifactorial intervention, have reported mixed results in reducing serum cholesterol levels and in decreasing the incidence of cardiac events, such as myocardial infarction and sudden death.[24] [25] [26] [27] [28] [29] [30] [31] [32] Intake of saturated fat correlates more closely with serum cholesterol levels than does total fat intake. Clinical trials have also found that serum cholesterol-lowering drugs can reduce the incidence of coronary heart disease in asymptomatic middle-aged men with hyperlipidemia.[33] [34] [35] [36] [37] [38] These studies found that the incidence of cardiac events in such men is decreased by an average of 2% for every 1% reduction in serum cholesterol (see Chapter 2). (Evidence regarding benefits in persons with preexisting coronary heart disease is reviewed in Chapter 2.)

Modeling studies based on these data suggest that coronary heart disease mortality rates in the U.S. could be lowered by 5-20% if all Americans restricted their fat intake to less than 30% of total calories but that increases in life expectancy among low-risk persons might be modest.[39] [40] [41] Two randomized controlled trials reported that a low-fat diet does not increase high-density lipoprotein (HDL) cholesterol levels unless coupled with physical activity,[42] ,[43] and one meta-analysis of 27 trials suggested that substantial reductions in dietary fat intake might lower HDL cholesterol levels.[44] Some observational studies also suggest a possible association between intake of trans-isomers of fatty acids (formed in the partial hydrogenation of vegetable oils) and unfavorable changes in low-density lipoprotein (LDL) and HDL cholesterol[45] ,[46] and in the risk of coronary heart disease;[47] [48] [49] others suggest an association between fatty acids found primarily in fish oils and reduced risk of cardiovascular disease.[50] [51] [52] Dietary cholesterol intake may also influence serum cholesterol levels, especially LDL cholesterol levels, but the association appears to be weaker and more variable than that of dietary saturated fat intake.[1] Finally, prospective cohort data suggest that a diet with increased intake of fruits and vegetables is associated with decreased risk of stroke, but further study is needed.[53]

The association between foods high in dietary fat and certain forms of cancer is currently under investigation. An effect of dietary fat on carcinogenesis has been demonstrated in animal research. Furthermore, international comparisons of cancer incidence and most case-control studies have revealed an epidemiologic correlation between dietary fat consumption and the incidence of cancer of the breast, colon, prostate, and lung.[54] [55] [56] [57] [58] [59] [60] [61] [62] [63] Within more homogenous populations, however, cohort studies to date have been unable to provide consistent evidence of a causal relationship between increased dietary fat consumption and the incidence of breast, prostate, colon, or other cancers.[64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] Similarly, inconsistent results have been reported in epidemiologic studies of the link between low blood cholesterol and cancer.[75] ,[76] Clinical trials are now in progress to examine further the relationship between dietary fat and cancer.[77] These and other studies may help elucidate whether low-fat diets reduce cancer risk because of decreased fat intake or because of increased intake of fruits, vegetables, or fiber (see below).

A diet emphasizing the consumption of foods high in complex carbohydrates and fiber (e.g., whole grain foods and cereal products, vegetables [including dried beans and peas], and fruits) is an important means of lowering dietary fat consumption by replacing caloric intake from fat. Foods high in complex carbohydrates and fiber and low in fat content also have lower average caloric density, and they are therefore preferred for maintaining caloric balance and healthful body weight.[1] ,[78] ,[79] There are other health benefits associated with the replacement of foods high in simple carbohydrates (e.g., table sugar, honey, corn sweeteners) with those containing starch and fiber. In addition to improving caloric balance, reduced intake and less frequent consumption of refined sugars may lower the risk of developing dental caries (see also Chapter 61),[80] [81] [82] [83] [84] [85] and the avoidance of highly refined grain products reduces the contribution of "empty calories" to the diet.[86]

Increased intake of dietary fiber improves gastrointestinal function.[87] Certain types of dietary fiber may also be helpful in the treatment of glucose intolerance, weight reduction, and the control of lipid disorders.[87] ,[88] The consumption of foods containing large amounts of soluble fiber (e.g., dried beans, oat products) appears to lower levels of LDL cholesterol (independent of their replacement of foods high in saturated fat and cholesterol).[89] ,[90] An insoluble high-fiber diet (most plant foods) may be effective in reducing intracolonic pressure and preventing diverticular disease.[91] The risk of developing colorectal cancer may also be influenced by dietary fiber intake. At least 15 cross-cultural studies have shown an inverse relationship between dietary fiber consumption and the incidence of colon cancer.[92] ,[93] Such studies do not, however, provide direct evidence that high dietary fiber intake, rather than other population dietary characteristics (e.g., low fat intake), is directly responsible for the lower cancer incidence rate. Case-control studies have produced inconsistent results regarding the association between dietary fiber and colon cancer.[94] [95] [96] [97] Meta-analyses of these studies, however, suggest an overall benefit from dietary fiber.[98] ,[99] Observational studies also suggest an association between intake of vegetables and fruits and lower risk of cancer.[86] Cohort studies to date that have examined the relationship between dietary fiber and cancer have produced inconsistent results and suffer from methodologic limitations, including the difficulty of determining whether observed benefits were due to fiber itself or to its substitution of foods high in saturated fats.[73] ,[100] [101] [102] [103]

Reduced intake of dietary sodium may be of clinical benefit to persons who either have sodium-dependent hypertension or are likely to develop it in the future.[104] A number of clinical trials and recent meta-analyses have demonstrated the ability of dietary sodium restriction to lower blood pressure by at least several millimeters of mercury in some hypertensive and normotensive individuals.[105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] In addition, cross-cultural studies have shown a correlation between the sodium intake of different populations and the incidence of hypertension.[119] [120] [121] A multinational study involving 52 sites also demonstrated an association between sodium excretion and the rate of change of blood pressure with age.[122] However, controlled prospective studies will ultimately be necessary to provide definitive evidence that normotensive persons who practice dietary sodium restriction are at lower risk of developing hypertension over time than are those with more typical sodium consumption.

Many American women and adolescent girls consume less dietary calcium than is recommended by major groups (men: 1,000 mg/day; adolescents and young adults, 1,200-1,500 mg/day; women 25-50 years of age, 1,000 mg/day; postmenopausal women, 1,000-1,500 mg/day; pregnant and nursing women, 1,200-1,500 mg/day).[123] Population and cross-sectional studies suggest that reduced calcium intake among women, especially young women, may be an important risk factor for bone mineral loss and postmenopausal osteoporosis,[124] ,[125] and studies suggest that calcium supplementation in adolescence and early adulthood may increase bone mineral density.[126] ,[127] Prospective studies of asymptomatic postmenopausal women have produced inconsistent results about the efficacy of increasing dietary calcium intake as a means of slowing bone loss. Although some studies have reported that a daily intake of 750-1,700 mg/day can reduce significantly the rate of bone loss in asymptomatic postmenopausal women,[128] [129] [130] other controlled studies have shown either no effect or an effect only on compact bone with doses as high as 1,800-2,000 mg/day.[131] [132] [133] [134] A meta-analysis of intervention and observational studies concluded that 1,000 mg of calcium daily would prevent about 1% of bone loss per year.[135] Clinical trials suggest that calcium supplementation may reduce the risk of fractures in postmenopausal women.[135A] ,[135B] In such women, however, estrogen replacement therapy may be a more effective form of chemoprophylaxis than calcium supplementation (see Chapter 68). (See also the discussion of the relationship between exercise and bone density in Chapter 55.) There appears to be little significant risk for women who moderately increase their consumption of dietary calcium. Gross and prolonged use of calcium supplements may, under unusual circumstances, result in milk alkali syndrome or an increased occurrence of kidney stones, although direct evidence of the latter is lacking.[136]

Adequate dietary iron intake may be important for menstruating women and for young children to maintain iron stores and prevent iron deficiency anemia. This topic is discussed in detail in Chapter 22. Although infants and young children may benefit from iron supplementation (see below), there is little evidence from prospective studies of older children and menstruating women that mild anemia in the absence of symptoms is a direct cause of increased morbidity or mortality. It may be clinically prudent, however, to recommend diets including iron-rich foods (e.g., lean meats, certain beans, iron-enriched and whole grain products) for persons at increased risk of iron deficiency.

Current research is exploring the potential health benefits of other minerals and vitamins. For example, evidence suggests that women of childbearing age who take folic acid supplements may be less likely to give birth to children with neural tube defects (see Chapter 42).[137] The role of beta-carotene, vitamins (e.g., vitamin A, vitamin C, vitamin E), and other antioxidants in reducing the risk of cancer, atherosclerosis, and other chronic disease is currently being studied.[138] [139] [140] [141] [142] [143]

Special Populations
Infants and Children.

Infants require breast milk or appropriate alternatives (e.g., infant formulas) to provide adequate nutrition. Nutritional status remains important throughout childhood to facilitate normal growth and development.[144] Epidemiologic evidence and randomized prospective studies suggest that infant consumption of breast milk for at least 6 months may reduce the risk of otitis media, lower respiratory tract illness, meningitis, allergic illness, diarrhea, hospital admissions, and abnormal cognitive development in the child.[145] [146] [147] Breast-fed infants often have higher blood cholesterol levels than formula-fed infants, but current evidence, with the exception of one cohort study,[148] suggests that these elevations resolve with weaning[149] and are not linked to adult blood cholesterol levels or increased risk of heart disease. Iron deficiency anemia during infancy may also be associated with impaired infant neurologic and cognitive development,[150] and infants may therefore benefit from iron-fortified formula and foods to replace depleted iron stores.

The benefits of reduced dietary fat intake during childhood are uncertain. There is some epidemiologic evidence of tracking (persistence of childhood elevations of blood cholesterol into adulthood) and autopsy evidence of atherosclerotic disease among children and young adults with elevated cholesterol levels,[151] ,[152] but evidence of improved health outcomes from lowering blood cholesterol during childhood is lacking. Observational studies provide evidence that children can achieve statistically significant reductions in total and LDL cholesterol levels through dietary fat reduction.[153] ,[154] A potential risk of such interventions is that excessive low-fat diets may not provide children with sufficient nutrients for healthy growth and development,[155] but direct evidence of this adverse effect is limited to extreme cases of dietary restriction. A cross-sectional study found that 10-year-old children with low fat intake had no significant differences in anthropometric measurements, but they were more likely to be deficient in the Recommended Dietary Allowances for calcium, phosphorus, magnesium, iron, and certain vitamins.[156] A recent randomized controlled trial involving children aged 8-10 reported that a diet providing 28% of energy from total fat achieved statistically significant reductions in LDL cholesterol levels with no significant effects on height, ferritin levels, or selected psychometric indices.[157]

Pregnant Women.

Nutritional status is especially important during pregnancy. Studies have shown that low birth weight and neonatal mortality are more common in pregnant women with very poor nutritional status[158] ,[159] and in those who fail to gain adequate weight during pregnancy,[160] [161] [162] [163] although factors other than nutrient intake may account for these outcomes. Prenatal programs providing nutritional support for pregnant women have been associated with improved perinatal outcomes.[164] Pregnancy brings increased requirements for energy and specific nutrients, such as protein, calcium, folic acid, and iron.[162] ,[165] ,[166] Oral iron supplements may be beneficial in preventing iron deficiency anemia in pregnancy, and they are often prescribed routinely as part of prenatal health care. Although an association between moderate to severe iron deficiency anemia and adverse obstetric outcomes has been demonstrated in some observational studies, there is little direct evidence that routine iron supplementation during pregnancy (in the absence of documented anemia or iron deficiency) results in improved clinical outcome for the mother or fetus.[167]

Older Adults.

The elderly can also have special nutritional requirements. Depending on the patient's nutritional status, underlying medical disorders, functional status, dentition, and therapeutic drug regimens, it can be important to modify recommended daily intake levels of calories, sodium, calcium, water, dietary fat, fiber, protein, and other nutrients to reduce the risk of complications.[168] Observational data suggest that older adults benefit to some extent by reducing elevated blood cholesterol levels.[169] It is unclear from current evidence whether women who have already developed clinical evidence of postmenopausal osteoporosis benefit from calcium supplementation.[170] [171] [172] [173] Clinical recognition of protein-calorie malnutrition, especially when manifested by clinically subtle findings, is often delayed among older adults. This has prompted the introduction of nutritional screening initiatives in this population,[174] but direct evidence of clinical benefit from screening is currently lacking.

Effectiveness of Counseling

The effectiveness of nutritional counseling in changing the dietary habits of patients has been demonstrated in a number of clinical trials.[175] For example, randomized controlled trials have shown that dietary counseling of patients with high blood cholesterol can lower serum lipids in both patients and their families[176] and that regular reinforcement can enhance compliance with dietary recommendations.[177] Tailored printed materials distributed in primary care settings have also been effective in lowering dietary fat consumption.[178] Other measures that may enhance compliance with low-fat diets include setting strict limits on fat intake, frequent (e.g., monthly) monitoring, involvement of family in nutritional counseling sessions, and group sessions.[179] Studies have confirmed the effectiveness of nutritional counseling among pregnant women[180] and the important role of parental guidance in modifying the diets of children.[181]

In most studies of nutritional counseling, however, the counselor was not a physician, but rather a nurse, nutritionist, registered dietitian, health educator, or psychologist. Many of the interventions tested in these studies were part of highly specialized or community-wide programs. Such interventions are not easily reproduced in the typical physician-patient clinical encounter. Although physicians can often provide general guidelines on proper nutrition, many lack the time and skills to obtain a thorough dietary history, to address potential barriers to changes in eating habits, and to offer specific guidance on food selection.[182] Patients may also have difficulty with long-term compliance,[183] especially if food selection and preparation for recommended diets are perceived as unappealing or inconvenient. Fat-containing foods, in particular, are a popular component of the American diet.[184] It is possible, however, that physicians can overcome many of these limitations by expanding the content of the nutritional information they provide to patients, by emphasizing to the patient the health benefits of good nutrition, and by referring those requiring help with dietary changes to qualified registered dietitians, nutritionists, health educators, nurses, or other providers with greater nutrition expertise.

Recommendations of Other Groups

Dietary guidelines for the general population have been issued by the Department of Agriculture and the Department of Health and Human Services[185] and reaffirmed by the Surgeon General,[1] in the Year 2000 Objectives for the Nation,[186] and in the "Food Guide Pyramid" released in 1992 by the Department of Agriculture.[187] The Food and Nutrition Board of the National Research Council has published Recommended Dietary Allowances (RDAs) for specific nutrients,[165] and it has released an extensive report on diet and chronic disease risk.[16] Recommendations for nutritional counseling of patients have been issued by the American Medical Association,[188] the American College of Physicians,[189] the Canadian Task Force,[203] and the American Heart Association.[144] ,[190] Guidelines for dietary practices to reduce the risk of cancer have been issued by the National Research Council,[191] the American Cancer Society,[192] and the National Cancer Institute.[193] Recommendations on nutritional counseling to reduce cardiac risk factors have been issued by panels convened by the National Heart, Lung, and Blood Institute[194] and by the National High Blood Pressure Education Program[195] and National Cholesterol Education Program,[196] ,[197] which are endorsed by over 40 organizations and government agencies. Dietary recommendations for children have been issued by the American Academy of Pediatrics[198] ,[199] and National Cholesterol Education Program.[200] Dietary guidelines for pregnant women have been issued by the American College of Obstetricians and Gynecologists[201] and the Institute of Medicine.[162] Recommendations on the use of folic acid supplementation by women have been issued by the U.S. Public Health Service.[202] Dietary guidelines for Americans were updated in 1995.[204]

CLINICAL INTERVENTION

Adults and children over age 2 should limit dietary intake of fat (especially saturated fat) ("A" recommendation) and cholesterol ("B" recommendation), maintain caloric balance in their diet ("B" recommendation), and emphasize fruits, vegetables, and grain products containing fiber ("B" recommendation). Both diet and exercise should be designed to achieve and maintain a desirable weight by keeping caloric intake balanced with energy expenditures. Adolescents and adults, in particular, should reduce total fat intake to less than 30% of total calories and dietary cholesterol to less than 300 mg/day. Saturated fat consumption should be reduced to less than 10% of total calories. To achieve these goals, patients should emphasize consumption of fish, poultry prepared without skin, lean meats, and low-fat dairy products. They should be encouraged to eat a variety of foods, with emphasis on the consumption of whole grain products and cereals, legumes, vegetables, and fruits. Current recommendations from the U.S. Department of Health and Human Services are for at least five servings of fruits and vegetables and at least six servings of breads, cereals, or legumes each day. Detailed food selection guidelines for healthy eating are published elsewhere.[185]

There is insufficient evidence that, for the general population, reducing dietary sodium intake or increasing dietary intake of iron, beta-carotene, or other antioxidants results in improved health outcomes ("C" recommendation); recommendations to reduce sodium intake may be made on other grounds, including the potential beneficial effects on blood pressure in salt-sensitive persons. See Chapter 61 for information regarding intake of refined sugars and dental health. Women should be encouraged to consume recommended quantities of calcium (adolescents and young adults, 1,200-1,500 mg/day; adults aged 25-50, 1,000 mg/day; postmenopausal women, 1,000-1,500 mg/day; pregnant and nursing women, 1,200-1,500 mg/day[123] ) ("B" recommendation). Parents should be encouraged to offer breastfeeding to their infants ("A" recommendation). Pregnant women should receive specific nutritional guidelines to enhance fetal and maternal health. See Chapter 22 regarding the role of iron during pregnancy and in the diets of newborns and young children, and see Chapter 42 regarding the use of folic acid by women of childbearing age. There is insufficient evidence to recommend for or against the special assessment of dietary needs and habits of older adults ("C" recommendation), but recommendations to do so can be made on other grounds, such as the increased prevalence of nutrition-related disorders in this age group. Counseling regarding alcohol consumption is discussed in Chapter 52.

There is insufficient evidence that nutritional counseling by physicians, as opposed to counseling by dietitians or community interventions, is effective in changing the dietary habits of patients ("C" recommendation). Clinicians who lack the time or skills to perform a complete dietary history, to address potential barriers to changes in eating habits, and to offer specific guidance on meal planning and food selection and preparation, should either have patients seen by other trained providers in the office or clinic or should refer patients to a registered dietitian or qualified nutritionist for further counseling.

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Steven H. Woolf, MD, MPH.

REFERENCES

1. Department of Health and Human Services.
The Surgeon General's report on nutrition and health.Washington, DC: Government Printing Office, 1988.(Publication no. DHHS (PHS) 88-50210.)


2. National Center for Health Statistics.
Annual summary of births, marriages, divorces, and deaths: United States, 1993. Monthly vital statistics report;vol 42, no 13. Hyattsville, MD: Public Health Service, 1994.


3. American Heart Association.
Heart and stroke facts: 1995 statistical supplement. Dallas, TX: American Heart Association, 1995.


4. Wingo PA, Tong T, Bolden S.
Cancer statistics, 1995.CA Cancer J Clin 1995;45:8-30.


5. Burt VL, Whelton P, Roccella EJ, et al.
Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995;25:305-313.


6. Kuczmarski RJ, Flegal KM, Campbell SM, et al.
Increasing prevalence of overweight among US adults.JAMA 1994;272:205-211.


7. Geiss LS, Herman WH, Goldschmid MG, et al.
Surveillance for diabetes mellitus: United States, 1980-1989.MMWR CDC Surv Summ 1993;42:1-20.


8. Audran MJ.
Epidemiology, etiology, and diagnosis of osteoporosis.Curr Opin Rheum 1992;4:394-401.


9. Jensen GF, Christiansen C, Boesen J, et al.
Epidemiology of postmenopausal spinal and long bone fractures: a unifying approach to postmenopausal osteoporosis.Clin Orthop 1982;166:75-81.


10. Johanson JF, Sonnenberg A, Koch TR.
Clinical epidemiology of chronic constipation.J Clin Gastroenterol 1989;11:525-536.


11. National Center for Health Statistics.
Prevalence of selected chronic conditions, United States, 1979-81. Vital and health statistics; series 10, no 155.Washington, DC: Government Printing Office, 1986.(Publication no. DHHS (PHS) 86-1583.)


12. Public Health Service.
Oral health of United States children: the national survey of dental caries in U.S.school children: 1986-1987. National and regional findings. Bethesda:National Institutes of Health, 1989. (NIH Publication no. 89-2247.)


13. National Institute of Dental Research.
Oral health of United States adults, the national survey of oral health in U.S.employed adults and seniors: 1985-86. Bethesda: National Institute of Dental Research, 1987. (Publication no. DHHS (NIH) 87-2868.)


14. Posner BM, Jette AM, Smith KW, et al.
Nutrition and health risks in the elderly: the Nutrition Screening Initiative.Am J Public Health 1993;83:972-978.


15. Goodwin JS.
Social, psychological, and physical factors affecting the nutritional status of elderly subjects: separating cause and effect.Am J Clin Nutr 1989;50:1201-1209.


16. Food and Nutrition Board, National Research Council.
Diet and health; implications for reducing chronic disease.Washington, DC: National Academy Press, 1989.


17. Henry RR, Schaeffer L, Olefsky, JM.
Glycemic effects of intensive caloric restriction and isocaloric refeeding in noninsulin-dependent diabetes mellitus.J Clin Endocrinol Metab 1985;61:917-925.


18. Henry RR, Wiest-Kent TA, Schaeffer L, et al.
Metabolic consequences of very-low-calorie diet therapy in obese noninsulin-dependent diabetic and nondiabetic subjects.Diabetes 1986;35:155-164.


19. MacMahon S, Cutler J, Brittain E, et al.
Obesity and hypertension: epidemiological and clinical issues.Eur Heart J [Suppl B] 1987;8:57-70.


20. Rifkind BM, Goor R, Schucker B.
Compliance and cholesterol-lowering in clinical trials: efficacy of diet.In: Schettler FG, Gotto AM, Middelhoff G, et al, eds. Atherosclerosis VI.Proceedings of the Sixth International Symposium. New York:Springer-Verlag, 1983:306-310.


21. Grundy SM.
Cholesterol and coronary heart disease: a new era.JAMA 1986;256:2849-2858.


22. Posner BM, Cobb JL, Belanger AJ, et al.
Dietary lipid predictors of coronary heart disease in men: the Framingham Study.Arch Intern Med 1991;151:1181-1187.


23. Menotti A, Keys A, Kromhout D, et al.
Twenty-five-year mortality from coronary heart disease and its prediction in five cohorts of middle-aged men in Finland, the Netherlands, and Italy.Prev Med 1990;19:270-278.


24. Dayton S, Pearce ML, Hashimoto S, et al.
A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis.Circulation 1969;40(Suppl 2):1-63.


25. Hjermann I, Holme I, Velve Byre K, et al.
Effect of diet and smoking intervention on the incidence of coronary heart disease. Report from the Oslo Study Group of a randomized trial in healthy men.Lancet 1981;2:1303-1310.


26. Multiple Risk Factor Intervention Trial Research Group.
Multiple Risk Factor Intervention Trial: risk factor changes and mortality results.JAMA 1982;248:1465-1477.


27. World Health Organization European Collaborative Group.
European collaborative trial of multifactorial prevention of coronary heart disease: final report on the 6-year results.Lancet 1986;1:869-872.


28. Rinzler S.
Primary prevention of coronary heart disease by diet.Bull NY Acad Med 1968;44:936-949.


29. Turpeinen O, Karvonen MJ, Pekkarinen M, et al.
Dietary prevention of coronary heart disease: the Finnish Mental Hospital Study.Int J Epidemiol 1979;8:99-118.


30. Miettinen M, Turpeinen O, Karvonen MJ, et al.
Effect of cholesterol-lowering diet on mortality from coronary heart disease and other causes: a twelve-year clinical trial in men and women.Lancet 1972;2:835-838.


31. Stamler J.
Acute myocardial infarction, progress in primary prevention.Br Heart J 1971;33:145-164.


32. Frantz ID Jr, Dawson EA, Ashman PL, et al.
Test of effect of lipid lowering by diet on cardiovascular risk: the Minnesota Coronary Survey.Arteriosclerosis 1989;9:129-135.


33. Report from the Committee of Principal Investigators.
A cooperative trial in the primary prevention of ischaemic heart disease using clofibrate.Br Heart J 1978;40:1069-1118.


34. Report of the Committee of Principal Investigators.
W.H.O. cooperative trial on primary prevention of ischaemic heart disease using clofibrate to lower serum cholesterol: mortality follow-up.Lancet 1980;2:379-385.


35. Report of the Committee of Principal Investigators.
W.H.O. cooperative trial on primary prevention of ischaemic heart disease with clofibrate to lower serum cholesterol: final mortality follow-up.Lancet 1984;2:600-604.


36. The Lipid Research Clinics Coronary Primary Prevention Trial Results.
I. Reduction in incidence of coronary heart disease.JAMA 1984;251:351-364.


37. The Lipid Research Clinics Coronary Primary Prevention Trial Results.
II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering.JAMA 1984;251:365-374.


38. Frick MH, Elo O, Haapa K, et al.
Helsinki Heart Study: primary prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease.N Engl J Med 1987;317:1237-1245.


39. Browner WS, Westenhouse J, Tice JA.
What if Americans ate less fat? A quantitative estimate of the effect on mortality.JAMA 1991;265:3285-3291.


40. Taylor W, Pass T, Shepard D, et al.
Cholesterol reduction and life expectancy: a model incorporating multiple risk factors.Ann Intern Med 1987;106:605-614.


41. Grover SA, Abrahamowicz M, Joseph L, et al.
The benefits of treating hyperlipidemia to prevent coronary heart disease: estimating changes in life expectancy and morbidity.JAMA 1992;267:816-822.


42. Wood PD, Stefanick ML, Williams PT, et al.
The effects on plasma lipoproteins of a prudent weight-reducing diet, with or without exercise, in overweight men and women.N Engl J Med 1991;325:461-466.


43. Singh RB, Sircar AR, Singh RG, et al.
Dietary modulators of lipid metabolism in the Indian Diet-Heart Study.Int J Vitam Nutr Res 1992;62:73-82.


44. Mensink RP, Katan MB.
Effect of dietary fatty acids on serum lipids and lipoproteins: a meta-analysis of 27 trials.Arterioscler Thromb 1992;12:911-919.


45. Mensink RP, Katan MB.
Effect of dietary trans fatty acids on high-density and low-density lipoprotein cholesterol levels in healthy subjects.N Engl J Med 1990;323:439-445.


46. Judd JT, Clevidence BA, Muesing RA, et al.
Dietary trans fatty acids: effects on plasma lipids and lipoproteins of healthy men and women.Am J Clin Nutr 1994;59:861-868.


47. Siguel EN, Lerman RH.
Trans-fatty acid patterns in patients with angiographically documented coronary artery disease.Am J Cardiol 1993;71:916-920.


48. Willett WC, Stampfer MJ, Manson JE, et al.
Intake of trans fatty acids and risk of coronary heart disease among women.Lancet 1993;341:581-585.


49. Ascherio A, Hennekens CH, Buring JE, et al.
Trans-fatty acids intake and risk of myocardial infarction.Circulation 1994;89:94-101.


50. Dolecek TA.
Epidemiological evidence of relationships between dietary polyunsaturated fatty acids and mortality in the Multiple Risk Factor Intervention Trial.Proc Soc Exp Biol Med 1992;200:177-182.


51. Kromhout D, Bosschieter EB, deLezenne-Coulander C.
The inverse relation between fish consumption and 20-year mortality from coronary heart disease.N Engl J Med 1985;312:1205-1209.


52. Shekelle RB, Paul O, Shryock AM, et al.
Fish consumption and mortality from coronary heart disease.N Engl J Med 1985;313:820.


53. Gillman MW, Cupples LA, Gagnon D, et al.
Protective effect of fruits and vegetables on development of stroke in men.JAMA 1995;273:1113-1117.


54. Rose DP, Boyar AP, Wynder EL.
International comparisons of mortality rates for cancer of the breast, ovary, prostate, and colon, and per capita food consumption.Cancer 1986;58:2363-2371.


55. Kakar F, Henderson M.
Diet and breast cancer.Clin Nutr 1985;4:119-130.


56. Kolonel LN, Hankin JH, Nomura AM.
Multiethnic studies of diet, nutrition, and cancer in Hawaii.In: Hayashi Y, ed. Diet, nutrition, and cancer. Tokyo:Japan Science Society Press, 1986:29-40.


57. Toniolo P, Riboli E, Protta F, et al.
Calorie-providing nutrients and risk of breast cancer.J Natl Cancer Inst 1989;81:278-286.


58. Kesteloot H, Lesaffre E, Joossens JV.
Dairy fat, saturated animal fat, and cancer risk.Prev Med 1991;20:226-236.


59. Mettlin CJ, Schoenfeld ER, Natarajan N.
Patterns of milk consumption and risk of cancer.Nutr Cancer 1990;13:89-99.


60. West DW, Slattery MLI, Robison LM, et al.
Adult dietary intake and prostate cancer risk in Utah: a case-control study with special emphasis on aggressive tumors.Cancer Causes Control 1991;2:85-94.


61. Hursting SD, Thornquist M, Henderson MM.
Types of dietary fat and the incidence of cancer at five sites.Prev Med 1990;19:242-253.


62. Whittemore AS, Wu-Williams AH, Lee M, et al.
Diet, physical activity, and colorectal cancer among Chinese in North America and China.J Natl Cancer Inst 1990;82:915-926.


63. Howe GR, Hirohata T, Hislop TG, et al.
Dietary factors and risk of breast cancer: combined analysis of 12 case-control studies.J Natl Cancer Inst 1990;82:561-569.


64. Hirayama T.
Epidemiology of breast cancer with special reference to the role of diet.Prev Med 1978;7:173-195.


65. Snowden DA, Phillips RL, Choi W.
Diet, obesity, and risk of fatal prostate cancer.Am J Epidemiol 1984;120:244-250.


66. Willett WC, Stampfer MJ, Colditz GA, et al.
Dietary fat and the risk of breast cancer.N Engl J Med 1987;316:22-28.


67. Jones DY, Schatzkin A, Green SB, et al.
Dietary fat and breast cancer in the National Health and Nutrition Examination Survey. I. Epidemiological follow-up study.J Natl Cancer Inst 1987;79:465-471.


68. Giovannucci E, Rimm EB, Colditz GA, et al.
A prospective study of dietary fat and risk of prostate cancer.J Natl Cancer Inst 1993;85:1571-1579.


69. Hsing AW, McLaughlin JK, Schuman LM, et al.
Diet, tobacco use, and fatal prostate cancer: results from the Lutheran Brotherhood Cohort Study.Cancer Res 1990;50:6836-6840.


70. Severson RK, Nomura AMY, Grove JS, et al.
A prospective study of demographics, diet, and prostate cancer among men of Japanese ancestry in Hawaii.Cancer Res 1989;49:1857-1860.


71. Mills PK, Beeson WL, Phillips RL, Cohort study of diet, lifestyle, and prostate cancer in Adventist men.
Cancer 1989;64:598-604.


72. Hunter DJ, Willett WC.
Diet, body size, and breast cancer.Epidemiol Rev 1993;15:110-132.


73. Willett WC, Hunter DJ, Stampfer MJ, et al.
Dietary fat and fiber in relation to risk of breast cancer: an 8-year follow-up.JAMA 1992;268:2037-2044.


74. Willett WC, Stampfer MJ, Colditz GA, et al.
Relation of meat, fat, and fiber intake to the risk of colon cancer in a prospective study among women.N Engl J Med 1990;323:1664-1672.


75. Kritchevsky SB.
Dietary lipids and the low blood cholesterol-cancer association.Am J Epidemiol 1992;135:509-520.


76. Jacobs D, Blackburn H, Higgins M, et al.
Report of the conference on low blood cholesterol: mortality associations.Circulation 1992;86:1046-1060.


77. Chlebowski RT, Grosvenor M.
The scope of nutrition intervention trials with cancer-related endpoints.Cancer 1994;74(9 Suppl):2734-2738.


78. Miller WC, Lindeman AK, Wallace J, et al.
Diet composition, energy intake, and exercise in relation to body fat in men and women.Am J Clin Nutr 1990;52:426-430.


79. Alford BB, Blankenship AC, Hagen RD.
The effects of variations in carbohydrate, protein, and fat content of the diet upon weight loss, blood values, and nutrient intake of adult obese women.J Am Diet Assoc 1990;90:534-540.


80. Gustafsson BE, Quensel CE, Lanke LS, et al.
The Vipeholm dental caries study: the effect of different levels of carbohydrate intake on caries activity in 436 individuals observed for 5 years.Acta Odontol Scand 1954;11:232-364.


81. Harris R.
Biology of the children of Hopewood House, Bowral, Australia. IV. Observations of dental caries experience extending over five years (1957-1961).J Dent Res 1963;42:1387-1398.


82. Sundin B.
Caries and consumption of sweets in 15- and 18-year-olds interviewed with visualization.Scand J Dent Res 1990;98:96-101.


83. Akpata ES, Al-Shammery AR, Saeed HI.
Dental caries, sugar consumption and restorative dental care in 12-13-year-old children in Riyadh, Saudi Arabia.Community Dent Oral Epidemiol 1992;20:343-346.


84. Frostell G, Birkhed D, Edwardsson S, et al.
Effect of partial substitution of invert sugar for sucrose in combination with Duraphat treatment on caries development in preschool children: the Malmo study.Caries Res 1991;25:304-310.


85. Holt RD.
Foods and drinks at four daily time intervals in a group of young children.Br Dent J 1991;170:137-143.


86. Willett WC.
Diet and health: what should we eat?Science 1994;264:532-537.


87. Federation of American Societies for Experimental Biology.
Physiological effects and health consequences of dietary fiber. Report to the Food and Drug Administration.Bethesda: Federation of American Societies for Experimental Biology, 1987.


88. Bolton-Smith C, Woodward M, Smith WCS, et al.
Dietary and non-dietary predictors of serum total and HDL-cholesterol in men and women: results from the Scottish Heart Health Study.Int J Epidemiol 1991;20:95-104.


89. Glore SR, Van Treeck D, Knehans AW, et al.
Soluble fiber and serum lipids: a literature review.J Am Diet Assoc 1994;94:425-436.


90. Jenkins DJA, Wolever TMS, Rao AV, et al.
Effect on blood lipids of very high intakes of fiber in diets low in saturated fat and cholesterol.N Engl J Med 1993;329:21-26.


91. Painter N.
Diverticular disease of the colon.In: Trowell H, Burkitt D, Heaton K, eds. Dietary fibre, fibre-depleted foods and disease.New York:Academic Press, 1985:145-160.


92. Irving D, Drasar BS.
Fibre and cancer of the colon.Br J Cancer 1973;28:462-463.


93. McKeown-Eyssen GE, Bright-See E.
Dietary factors in colon cancer: international relationships.Nutr Cancer 1984;6:160-170.


94. Modan B, Barrell V, Lubin F, et al.
Low-fiber intake as an etiologic factor in cancer of the colon.J Natl Cancer Inst 1975;55:15-18.


95. Jain M, Cook GM, Davis FG, et al.
A case-control study of diet and colorectal cancer.Int J Cancer 1980;26:757-768.


96. Potter JD, McMichael AJ.
Diet and cancer of the colon and rectum: a case-control study.J Natl Cancer Inst 1986;76:557-569.


97. Sandler RS, Lyles CM, Peipins LA, et al.
Diet and risk of colorectal adenomas: macronutrients, cholesterol, and fiber.J Natl Cancer Inst 1993;85:884-891.


98. Trock B, Lanza E, Greenwald P.
Dietary fiber, vegetables, and colon cancer: critical review and meta-analyses of the epidemiologic evidence.J Natl Cancer Inst 1990;82:650-661.


99. Howe GR, Benito E, Castelleto R, et al.
Dietary intake of fiber and decreased risk of cancers of the colon and rectum: evidence from the combined analysis of 13 case-control studies.J Natl Cancer Inst 1992;84:1887-1896.


100. Hirayama T.
A large-scale cohort study on the relationship between diet and selected cancers of the digestive organs.In: Bruce WR, Correa P, Lipkin M, et al, eds. Banbury Report 7.Gastrointestinal cancer:endogenous factors. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory,1981:409-429.


101. Kromhout D, Bosschieter EB, de Lezenne Coulander C.
Dietary fibre and 10-year mortality from coronary heart disease, cancer, and all causes: the Zutphen Study.Lancet 1982;2:518-522.


102. Phillips RL, Snowden DA.
Dietary relationships with fatal colorectal cancer among Seventh-Day Adventists.J Natl Cancer Inst 1985;74:307-317.


103. Graham S, Zielezny M, Marshall J, et al.
Diet in the epidemiology of postmenopausal breast cancer in the New York State Cohort.Am J Epidemiol 1992;136:1327-1337.


104. Stamler J.
Dietary salt and blood pressure.Ann NY Acad Sci 1993;676:122-156.


105. Grobbee DE, Hofman A.
Does sodium restriction lower blood pressure?BMJ 1986;293:27-29.


106. Parijs J, Joosens JV, Van der Linden L, et al.
Moderate sodium restriction and diuretics in the treatment of hypertension.Am Heart J 1973;85:22-34.


107. MacGregor GA, Markandu N, Best F, et al.
Double-blind, randomized, crossover trial of moderate sodium restriction in essential hypertension.Lancet 1982;1:351-355.


108. Langford HG, Blaufox MD, Oberman A, et al.
Dietary therapy slows the return of hypertension after stopping prolonged medication.JAMA 1985;253:657-664.


109. Morgan T, Adams W, Gillies A, et al.
Hypertension treated by salt restriction.Lancet 1978;1:227-230.


110. Beard TC, Cooke HM, Gray WR, et al.
Randomized, controlled trial of a no-added-sodium diet for mild hypertension.Lancet 1982;2:455-458.


111. Weinberger MH, Cohen SJ, Miller JZ, et al.
Dietary sodium restriction as adjunctive treatment of hypertension.JAMA 1988;259:2561-2565.


112. Miller JZ, Daugherty SA, Weinberger MH, et al.
Blood pressure response to dietary sodium restriction in normotensive adults.Hypertension 1983;5:790-795.


113. Forte JG, Miguel JM, Miguel MJ, et al.
Salt and blood pressure: a community trial.J Hum Hypertens 1989;3:179-184.


114. Elliott P.
Sodium and blood pressure: a review of the evidence from controlled trials of sodium reduction and epidemiological studies.Klin Wochenschr 1991;69:3-10.


115. Cutler J, Follman D, Elliott P, et al.
An overview of randomised trials of sodium reduction and blood pressure.Hypertension 1991;17(Suppl I):I27-I33.


116. Law MR, Frost CD, Wald NJ.
By how much does salt restriction lower blood pressure? I. Analysis of observational data among populations. II. Analysis of data from trials of salt reduction.BMJ 1991;302:811-824.


117. The Trials of Hypertension Prevention Collaborative Research Group.
The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension, Phase I.JAMA 1992;267:1213-1220.


118. Mascioli S, Grimm R Jr, Launer C, et al.
Sodium chloride raises blood pressure in normotensive subjects: the study of sodium and blood pressure.Hypertension 1991;17(Suppl I)-126.


119. Page LB, Damon A, Moellering RC Jr.
Antecedents of cardiovascular disease in six Solomon Island societies.Circulation 1974;49:1132-1146.


120. Kaminer B, Lutz WPW.
Blood pressure in bushmen of the Kalahari Desert.Circulation 1960;22:289-295.


121. Saunders GM, Bancroft H.
Blood pressure studies on negro and white men and women living in the Virgin Islands of the United States.Am Heart J 1942;23:410-423.


122. Intersalt Cooperative Research Group.
Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion.BMJ 1988;297:319-328.


123. National Institutes of Health Consensus Development Panel on Optimal Calcium Intake. Optimal calcium intake.JAMA 1994;272:1942-1948.

124. Turner JG, Gilchrist NL, Ayling EM, et al.
Factors affecting bone mineral density in high school girls.NZ Med J 1992;105:95-96.


125. Murphy S, Khaw KT, May H, et al.
Milk consumption and bone mineral density in middle-aged and elderly women.BMJ 1994;308:939-941.


126. Johnston CC Jr, Miller JZ, Slemenda CW, et al.
Calcium supplementation and increases in bone mineral density in children.N Engl J Med 1992;327:82-87.


127. Lloyd T, Andon MB, Rollings N, et al.
Calcium supplementation and bone mineral density in adolescent girls.JAMA 1992;270:841-844.


128. Horsman A, Gallagher JC, Simpson M, et al.
Prospective trial of oestrogen and calcium in postmenopausal women.BMJ 1977;2:789-792.


129. Recker RR, Saville PD, Heaney RP.
Effect of estrogens and calcium carbonate on bone loss in postmenopausal women.Ann Intern Med 1977;87:649-655.


130. Aloia JF, Vaswani A, Yeh JK, et al.
Calcium supplementation with and without hormone replacement therapy to prevent postmenopausal bone loss.Ann Intern Med 1994;120:97-103.


131. Ettinger B, Genant HK, Cann CE.
Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium.Ann Intern Med 1987;106:40-45.


132. Riis B, Thomsen K, Christiansen C.
Does calcium supplementation prevent postmenopausal bone loss? A double-blind, controlled clinical study.N Engl J Med 1987;316:173-177.


133. Nilas L, Christiansen C, Rodbro P.
Calcium supplementation and postmenopausal bone loss.BMJ 1984;289:1103-1106.


134. Stevenson JC, Whitehead MI, Padwick M, et al.
Dietary intake of calcium and postmenopausal bone loss.BMJ 1988;297:15-17.


135. Cumming RG.
Calcium intake and bone mass: a quantitative review of the evidence.Calcif Tissue Int 1990;47:194-201.


135A. Chapuy MC, Arlot ME, Delmas PD, et al.
Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women.BMJ 1994;308:1081-1082.


135B. Reid IR, Ames RW, Evans MC, et al.
Long-term effects of calcium supplementation on bone loss and fractures in postmenopausal women: a randomized controlled trial.Am J Med 1995;98:331-335.


136. Curhan GC, Willett WC, Rimm EB, et al.
A prospective study of dietary calcium and other nutrients and the risk of symptomatic kidney stones.N Engl J Med 1993;328:833-838.


137. Czeizel AE, Dudas I.
Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation.N Engl J Med 1992;327:1832-1835.


138. Comstock GW, Bush TL, Helzlsouer K.
Serum retinol, beta-carotene, vitamin E, and selenium as related to subsequent cancer of specific sites.Am J Epidemiol 1992;135:115-121.


139. Manson JE, Buring JE, Satterfield S, et al.
Baseline characteristics of participants in the Physicians' Health Study: a randomized trial of aspirin and beta-carotene in U.S. physicians.Am J Prev Med 1991;7:150-154.


140. Stahelin HB, Gey KF, Eichholzer M, et al.
Plasma antioxidant vitamins and subsequent cancer mortality in the 12-year follow-up of the prospective Basel study.Am J Epidemiol 1991;133:766-775.


141. Ziegler RG, Subar AF, Craft NE, et al.
Does beta-carotene explain why reduced cancer risk is associated with vegetable and fruit intake?Cancer Res 1992;52(7 Suppl):2060S-2066S.


142. Stampfer MJ, Hennekens CH, Manson JE, et al.
Vitamin E consumption and the risk of coronary disease in women.N Engl J Med 1993;328:1444-1449.


143. Hodis HN, Mack WJ, LaBree L, et al.
Serial coronary angiographic evidence that antioxidant vitamin intake reduces progression of coronary artery atherosclerosis.JAMA 1995;273:1849-1854.


144. American Heart Association.
Diet in the healthy child: Task Force Committee of the Nutrition Committee and the Cardiovascular Disease in the Young Council.Circulation 1983;67:1411A-1414A.


145. Cunningham AS, Jelliffe DB, Jelliffe EFP.
Breastfeeding and health in the 1980s: a global epidemiologic review.J Pediatr 1991;118:659-665.


146. Lucas A, Brooke OG, Morley R, et al.
Early diet of preterm infants and development of allergic or atopic disease: randomized prospective study.BMJ 1990;300:837-840.


147. Lucas A, Morley R, Cole TJ, et al.
Breast milk and subsequent intelligence quotient in children born pre-term.Lancet 1992;339:199-248.


148. Fall CHD, Barker DJP, Osmond C, et al.
Relation of infant feeding to adult serum cholesterol concentration and death from ischaemic heart disease.BMJ 1992;304:801-805.


149. Jooste PL, Rossouw LJ, Steenkamp HJ, et al.
Effect of breast feeding on the plasma cholesterol and growth of infants.J Pediatr Gastroenterol Nutr 1991;13:139-142.


150. Lozoff B, Jimenez E, Wolf AW.
Long-term developmental outcome of infants with iron deficiency.N Engl J Med 1991;325:687-694.


151. Webber LS, Srinivasan SR, Wattigney WA, et al.
Tracking of serum lipids and lipoproteins from childhood to adulthood: the Bogalusa heart study.Am J Epidemiol 1991;133:884-899.


152. Berenson GS, Wattigney WA, Tracy RE, et al.
Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (the Bogalusa heart study).Am J Cardiol 1992;70:851-858.


153. Quivers ES, Driscoll DJ, Garvey CD, et al.
Variability in response to a low-fat, low-cholesterol diet in children with elevated low-density lipoprotein cholesterol levels.Pediatrics 1992;89:925-929.


154. Viikari J, Akerblom HK, Rasanen L, et al.
Cardiovascular risk in young Finns.Acta Paediatr Scand Suppl 1990;365:13-19.


155. Hardy SC, Kleinman RE.
Fat and cholesterol in the diet of infants and young children: implications for growth, development, and long-term health.J Pediatr 1994;125:S69-S77.


156. Nicklas TA, Webber LS, Koschak ML, et al.
Nutrient adequacy of low fat intakes for children: the Bogalusa heart study.Pediatrics 1992;89:221-228.


157. The Writing Group for the DISC Collaborative Research Group.
Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol: the Dietary Intervention Study in Children (DISC).JAMA 1995;273:1429-1435.


158. Antonov AN.
Children born during the siege of Leningrad in 1942. J Pediatr 1947;30:250-295.


159. Stein A, Susser M, Saenger G, et al.
Famine and human development: the Dutch hunger winter of 1944/45. New York: Oxford University Press, 1974.


160. Singer JE, Westphal M, Niswander K.
Relationship of weight gain during pregnancy to birthweight and infant growth and development in the first year of life: a report from the collaborative study of cerebral palsy.Obstet Gynecol 1968;31:417.


161. Abrams BF, Laros RD.
Prepregnancy weight, weight gain, and birthweight.Am J Obstet Gynecol 1986;154:503.


162. Institute of Medicine, Subcommittee on Nutritional Status and Weight Gain During Pregnancy. Nutrition during pregnancy.Washington, DC: National Academy Press, 1990.

163. Worthington-Roberts BS.
Nutrition, fertility, and family planning.In: Worthington-Roberts BS, Williams SR, eds. Nutrition in pregnancy and lactation.5th ed. St. Louis:CV Mosby, 1993:34-63.


164. Rush D, Leighton J, Sloan NL, et al.
The National WIC evaluation: evaluation of the Special Supplemental Food Program for Women, Infants, and Children. II. Review of past studies of WIC.Am J Clin Nutr 1988;48:394-411.


165. National Research Council, Food and Nutrition Board.
Recommended dietary allowances. 10th ed. Committee on Dietary Allowances.Washington, DC: National Academy Press, 1989.


166. Institute of Medicine.
Preventing low birthweight.Washington, DC: National Academy Press, 1985.


167. U.S. Preventive Services Task Force.
Routine iron supplementation during pregnancy: review article.JAMA 1993;270:2848-2854.


168. Ahmed FE.
Effect of nutrition on the health of the elderly.J Am Diet Assoc 1992;92:1102-1108.


169. Kronmal RA, Cain KC, Ye Z, et al.
Total serum cholesterol levels and mortality risk as a function of age: a report based on the Framingham data.Arch Intern Med 1993;153:1065-1073.


170. Nordin BEC, Horsman A, Crilly RG, et al.
Treatment of spinal osteoporosis in postmenopausal women.BMJ 1980;280:451-454.


171. Riggs BL, Seeman E, Hodgson SF, et al.
Effect of the fluoride/calcium regimen on vertebral fracture occurrence in postmenopausal women: comparison with conventional therapy.N Engl J Med 1982;306:446-450.


172. Resnick NM, Greenspan SL.
Senile osteoporosis reconsidered.JAMA 1989;261:1025-1029.


173. Fujita T, Fukase M, Miyamoto H, et al.
Increase of bone mineral density by calcium supplement with oyster shell electrolysate.Bone Mineral 1990;11:85-91.


174. Dwyer JT.
Screening older Americans' nutritional health: current practices and future possibilities.Washington, DC: Nutrition Screening Initiative, 1991.


175. Glanz K.
Nutrition education for risk factor reduction and patient education: a review.Prev Med 1985;14:721-752.


176. Knutsen SF, Knutsen R.
The Tromso Survey: The Family Intervention Study -- the effect of intervention on some coronary risk factors and dietary habits, a 6-year follow-up.Prev Med 1991;20:197-212.


177. Milkereit J, Graves JS.
Follow-up dietary counseling benefits attainment of intake goals for total fat, saturated fat, and fiber.J Am Diet Assoc 1992;92:603-605.


178. Campbell MK, DeVellis BM, Strecher VJ, et al.
Improving dietary behavior: the effectiveness of tailored messages in primary care settings.Am J Public Health 1994;84:783-787.


179. Barnard ND, Akhtar A, Nicholson A.
Factors that facilitate compliance to lower fat intake.Arch Fam Med 1995;4:153-158.


180. Kafatos AG, Vlachonikolis IG, Codrington CA.
Nutrition during pregnancy: the effects of an educational intervention program in Greece.Am J Clin Nutr 1989;50:970-979.


181. Klesges RC, Stein RJ, Eck LH, et al.
Parental influence on food selection in young children and its relationships to childhood obesity.Am J Clin Nutr 1991;53:859-864.


182. Wechsler H, Levine S, Idelson RK, et al.
The physician's role in health promotion: a survey of primary-care practitioners.N Engl J Med 1983;308:97-100.


183. Randall DE, Marshall JR, Brasure J, et al.
Patterns in food use and compliance with NCI dietary guidelines.Nutr Cancer 1991;15:141-158.


184. Drewnowski A.
Dietary fats: perceptions and preferences.J Am Coll Nutr 1990;9:431-435.


185. Department of Agriculture, Department of Health and Human Services.
Dietary guidelines for Americans. 3rd ed. Bulletin no. 232.Washington, DC: Department of Agriculture, 1990.


186. Department of Health and Human Services.
Healthy People 2000: national health promotion and disease prevention objectives. Washington, DC: Department of Health and Human Services. (DHHS Publication no. 91-50212.)


187. Food Guide Pyramid: A Guide to Daily Food Choices.
Home and Garden Bulletin no. 232.Washington, DC: Department of Agriculture, 1992.


188. Council on Scientific Affairs.
Medical evaluation of healthy persons.Chicago: American Medical Association, 1983.


189. American College of Physicians.
Nutrition: position paper.Washington, DC: American College of Physicians, 1985.


190. American Heart Association.
Dietary guidelines for healthy American adults: a statement for physicians and health professionals by the Nutrition Committee, American Heart Association.Circulation 1988;77:721A-724A.


191. National Research Council, Committee on Diet, Nutrition, and Cancer.
Diet, nutrition, and cancer.Washington, DC: National Academy Press, 1982.


192. Nixon DW.
Nutrition and cancer: American Cancer Society guidelines, programs, and initiatives.CA Cancer J Clin 1990;40:71-75.


193. National Cancer Institute.
Diet, nutrition, and cancer prevention: the good news.Washington, DC: Government Printing Office, 1986.(Publication no. DHHS (NIH) 87-2878.)


194. National Heart, Lung, and Blood Institute.
Heart to heart: a manual on nutritional counseling for the reduction of cardiovascular disease risk factors.Bethesda: National Heart, Lung, and Blood Institute, 1983.(Publication no. DHHS (NIH) 85-1528.)


195. National High Blood Pressure Education Program.
Working Group Report on primary prevention of hypertension.Bethesda: National Institutes of Health, 1993 (Publication no. 93-2669.)


196. National Cholesterol Education Program.
Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction: executive summary.Arch Intern Med 1991;151:1071-1084.


197. Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II).
JAMA 1993;269:3015-3023.


198. American Academy of Pediatrics Committee on Nutrition.
Statement on cholesterol.Pediatrics 1992;90:469-473.


199. American Academy of Pediatrics.
Pediatric nutrition handbook. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics, 1993.


200. National Cholesterol Education Program.
Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents.Bethesda: National Institutes of Health, 1991.(Publication no. 91-2732.)


201. American College of Obstetricians and Gynecologists.
Nutrition in pregnancy. Technical Bulletin no. 179.Washington, DC: American College of Obstetricians and Gynecologists, 1993.


202. Centers for Disease Control and Prevention.
Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects.MMWR 1992;41:RR-14.


203. Canadian Task Force on the Periodic Health Examination.
Canadian guide to clinical preventive health care.Ottawa: Canada Communication Group, 1994:586-599.


204. U.S. Department of Health and Human Services and U.S. Department of Agriculture.
Nutrition and your health: dietary guidelines for Americans. 4th ed.Washington, DC: Government Printing Office, 1995.



Vidyya. Home |  Ex Libris |  Vidyya  | 
Subscription Information |  About Vidyya |  Vidyya Archives | 

Editor: Susan K. Boyer, RN
© Vidyya. All rights reserved.