# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 19 {#section-1 .Chapter-#}

# Nutrition and Overweight

Co-Lead Agencies: Food and Drug Administration\
National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 19-3](#goal)

[Overview Page 19-3](#overview)

[Issues and Trends Page 19-3](#issues-and-trends)

[Disparities Page 19-5](#disparities)

[Opportunities Page 19-5](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
19-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
19-9](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
19-10](#healthy-people-2010-objectives)

[Weight Status and Growth Page 19-10](#weight-status-and-growth)

[Food and Nutrient Consumption Page
19-18](#food-and-nutrient-consumption)

[Iron Deficiency and Anemia Page 19-36](#iron-deficiency-and-anemia)

[Schools, Worksites, and Nutrition Counseling Page
19-40](#schools-worksites-and-nutrition-counseling)

[Food Security Page 19-44](#food-security)

[Related Objectives From Other Focus Areas Page
19-46](#related-objectives-from-other-focus-areas)

[Terminology Page 19-47](#terminology)

[References Page 19-49](#references)

## Goal

Promote health and reduce chronic disease associated\
with diet and weight.

## Overview

### Issues and Trends

Nutrition is essential for growth and development, health, and
well-being. Behaviors to promote health should start early in life with
breastfeeding[^1] and continue through life with the development of
healthful eating habits. Nutritional, or dietary, factors contribute
substantially to the burden of preventable illnesses and premature
deaths in the United States.[^2] Indeed, dietary factors are associated
with 4 of the 10 leading causes of death: coronary heart disease (CHD),
some types of cancer, stroke, and type 2 diabetes.[^3] These health
conditions are estimated to cost society over \$200 billion each year in
medical expenses and lost productivity.[^4] Dietary factors also are
associated with osteoporosis, which affects more than 25 million persons
in the United States and is the major underlying cause of bone fractures
in postmenopausal women and elderly persons.[^5]

Many dietary components are involved in the relationship between
nutrition and health. A primary concern is consuming too much saturated
fat and too few vegetables, fruits, and grain products that are high in
vitamins and minerals, carbohydrates (starch and dietary fiber), and
other substances that are important to good health. The 2000 *Dietary
Guidelines for Americans* recommend that, to stay healthy, persons aged
2 years and older should follow these ABCs for good health: **A**im for
fitness, **B**uild a healthy base, and **C**hoose sensibly. To aim for
fitness, aim for a healthy weight and be physically active each day. To
build a healthy base, let the Pyramid guide food choices; choose a
variety of grains daily, especially whole grains; choose a variety of
fruits and vegetables daily; and keep food safe to eat. To choose
sensibly, choose a diet that is low in saturated fat and cholesterol and
moderate in total fat; choose beverages and foods to moderate intake of
sugars; choose and prepare foods with less salt; and if consuming
alcoholic beverages, do so in moderation.[^6] The Food Guide Pyramid,
introduced in 1992, is an educational tool that conveys recommendations
about the number of servings from different food groups each day and
other principles of the *Dietary Guidelines for Americans.*[^7] \[Note:
In text that follows in this chapter, *Dietary Guidelines for Americans*
will refer to the 2000 *Dietary Guidelines for Americans* unless
otherwise noted.\]

The *Dietary Guidelines for Americans* also emphasize the need for
adequate consumption of iron-rich and calcium-rich foods.Error:
Reference source not found Although some progress has been made since
the 1970s in reducing the prevalence of iron deficiency among low-income
children,[^8] much more is needed to improve the health of children of
all ages and of women who are pregnant or are of childbearing age. Since
the start of this decade, consumption of calcium-rich foods, such as
milk products, has generally decreased and is especially low among
teenaged girls and young women.[^9] Because important sources of calcium
also can include other foods with calcium---occurring naturally or
through fortification---as well as dietary supplements, the current
emphasis is on tracking total calcium intake from all sources, as
demonstrated by an objective in this focus area. In addition, in recent
years there has been a concerted effort to increase the folic acid
intake of females of childbearing age through fortification and other
means to reduce the risk of neural tube defects.[^10]**^,^** [^11] (See
Focus Area 16. Maternal, Infant, and Child Health.)

In general, however, excesses and imbalances of some food components in
the diet have replaced once commonplace nutrient deficiencies.
Unfortunately, there has been an alarming increase in the number of
overweight and obese persons.[^12]**^,^** [^13] Overweight results when
a person eats more calories from food (energy) than he or she expends,
for example, through physical activity. This balance between energy
intake and output is influenced by metabolic and genetic factors as well
as behaviors affecting dietary intake and physical activity;
environmental, cultural, and socioeconomic components also play a
role.![](media/image2.wmf){width="4.497916666666667in"
height="5.031944444444444in"}

When a body mass index (BMI) cut-point of 25 is used, nearly 55 percent
of the U.S. adult population was defined as overweight or obese in
1988--94, compared to 46 percent in 1976--80.Error: Reference source not
found**^,^** [^14]**^,^** [^15] In particular, the proportion of adults
defined as obese by a BMI of 30 or greater has increased from 14.5
percent to 22.5 percent.Error: Reference source not found A similar
increase in overweight and obesity also has been observed in children
above age 6 years in both genders and in all population groups.[^16]

Many diseases are associated with overweight and obesity. Persons who
are overweight or obese are at increased risk for high blood pressure,
type 2 diabetes, coronary heart disease, stroke, gallbladder disease,
osteoarthritis, sleep apnea, respiratory problems, and some types of
cancer. The health outcomes related to these diseases, however, often
can be improved through weight loss or, at a minimum, no further weight
gain. Total costs (medical costs and lost productivity) attributable to
obesity alone amounted to an estimated \$99 billion in 1995.[^17]

### Disparities

Disparities in health status indicators and risk factors for
diet-related disease are evident in many segments of the population
based on gender, age, race and ethnicity, and income. For example,
overweight and obesity are observed in all population groups, but
obesity is particularly common among Hispanic, African American, Native
American, and Pacific Islander women. Furthermore, despite concerns
about the increase in overweight and certain excesses in U.S. diets,
segments of the population also suffer from undernutrition, including
persons who are socially isolated and poor. Over the years, the
recognition of the consequences of food insecurity (limited access to
safe, nutritious food) has led to the development of national measures
and surveys to evaluate food insecurity and hunger and to the ability to
assess disparities among different population groups. With food security
and other measures of undernutrition, such as growth retardation and
iron deficiency, disparities are evident based not only on income but
also on race and ethnicity.

In addition, there are concerns about the nutritional status of persons
in hospitals, nursing homes, convalescent centers, and institutions;
persons with disabilities, including physically, mentally, and
developmentally disabled persons in community settings; children in
child care facilities; persons living on reservations; persons in
correctional facilities; and persons who are homeless. National data
about these population groups are currently unavailable or limited. Data
also are insufficient to target the fastest growing segment of the
population, old and very old persons who live independently.

### Opportunities

Establishing healthful dietary and physical activity behaviors needs to
begin in childhood. Educating school-aged children about nutrition is
important to help establish healthful eating habits early in
life.[^18]**^,^** [^19] Research suggests that parents who understand
proper nutrition can help children in preschool choose healthful foods,
but they have less influence on the choices of school-aged
children.[^20] Thus, the impact of nutrition education on health may be
more effective if targeted directly at school-aged children.
Unfortunately, a survey done in 1994 showed that only 69 percent of
States and 80 percent of school districts required nutrition education
for students in at least some grades from kindergarten through 12th
grade.[^21]

A well-designed curriculum that effectively addresses essential
nutrition education topics can increase students' knowledge about
nutrition, help shape appropriate attitudes, and help develop the
behavioral skills students need to plan, prepare, and select healthful
meals and snacks.Error: Reference source not found**^,^** [^22]**^,^**
[^23] Curricula that encourage specific, healthful eating behaviors and
provide students with the skills needed to adopt and maintain those
behaviors have led to favorable changes in student dietary behaviors and
cardiovascular disease risk factors.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
In order to enhance the effectiveness of these lessons, however,
nutrition course work should be part of the core curriculum for the
professional preparation of teachers of all grades and should be
emphasized in continuing education activities for teachers.

Topics considered to be essential at the elementary, middle, junior
high, and senior high school levels include using the Food Guide
Pyramid; learning the benefits of healthful eating; making healthful
food choices for meals and snacks; preparing healthy meals and snacks;
using food labels; eating a variety of foods; eating more fruits,
vegetables, and grains; eating foods low in saturated fat and total fat
more often; eating more calcium-rich foods; balancing food intake and
physical activity; accepting body size differences; and following food
safety practices.Error: Reference source not found**^,^** [^24] In
addition, the following topics are considered to be essential at the
middle, junior high, and senior high school levels: the *Dietary
Guidelines for Americans;* eating disorders; healthy weight maintenance;
influences on food choices such as families, culture, and media; and
goals for dietary improvement.Error: Reference source not found

Nutrition education should be taught as part of a comprehensive school
health education program, and essential nutrition education topics
should be integrated into science and other curricula to reinforce
principles and messages learned in the health units. Nutrition education
is addressed within a school health education objective. (See Focus Area
7. Educational and Community-Based Programs.) In addition, students must
have access to healthful food choices to enhance further the likelihood
of adopting healthful dietary practices. For these reasons, monitoring
students' eating practices at school is important.

Although health promotion efforts should begin in childhood, they need
to continue throughout adulthood. In particular, public education about
the long-term health consequences and risks associated with overweight
and how to achieve and maintain a healthy weight is necessary. While
many persons attempt to lose weight, studies show that within 5 years a
majority regain the weight.[^25] To maintain weight loss, healthful
dietary habits must be coupled with decreased sedentary behavior and
increased physical activity and become permanent lifestyle changes. (See
Focus Area 22. Physical Activity and Fitness.) Additionally, changes in
the physical and social environment may help persons maintain the
necessary long-term lifestyle changes for both diet and physical
activity.

Policymakers and program planners at the national, State, and community
levels can and should provide important leadership in fostering
healthful diets and physical activity patterns among people in the
United States. The family and others, such as health care practitioners,
schools, worksites, institutional food services, and the media, can play
a key role in this process. For example, registered dietitians and other
qualified health care practitioners can improve health outcomes through
efforts focused on nutrition screening, assessment, and primary and
secondary prevention.

Food-related businesses also can help consumers achieve healthful diets
by providing nutrition information for foods purchased in supermarkets,
fast-food outlets, restaurants, and carryout operations. For example,
the introduction of a new food label in 1993 has resulted in nutrition
information on most processed packaged foods, along with credible health
and nutrient content claims and standardized serving sizes.[^26] While
efforts were made in the 1990s to increase the availability of nutrition
information, reduced-fat foods, and other healthful food choices in
supermarkets, significant challenges remain on these fronts for
away-from-home foods purchased at food service outlets. The importance
of addressing these challenges is suggested by recent data indicating
that nearly 40 percent of a family's food budget is spent on
away-from-home food, including food from restaurants and fast-food
outlets.[^27] One analysis found that away-from-home foods are generally
higher in saturated fat, total fat, cholesterol, and sodium and lower in
dietary fiber, iron, and calcium than at-home foods.Error: Reference
source not found Away-from-home sites include restaurants, fast-food
outlets, school cafeterias, vending machines, and other food service
outlets. This study also suggested that persons either eat larger
amounts when they eat out, eat higher calorie foods, or both.

Many of the Healthy People 2010 objectives that address nutrition and
overweight in the United States measure in some way the Nation's
progress toward implementing the recommendations of the *Dietary
Guidelines for Americans.* The recommendations for food and nutrient
intake are not intended to be met every day but rather on average over a
span of time. Although the Healthy People 2010 dietary intake objectives
address the proportion of the population that consumes a specified level
of certain foods or nutrients, it is also important to track and report
the average amount eaten by different population groups to help
interpret progress on these objectives. Other objectives target aspects
of undernutrition, including iron deficiency, growth retardation, and
food security.

In summary, several actions are recognized as fundamental in achieving
this focus area's objectives:

-   Improving accessibility of nutrition information, nutrition
    education, nutrition counseling and related services, and healthful
    foods in a variety of settings and for all population groups.

-   Focusing on preventing chronic disease associated with diet and
    weight, beginning in youth.

-   Strengthening the link between nutrition and physical activity in
    health promotion.

-   Maintaining a strong national program for basic and applied
    nutrition research to provide a sound science base for dietary
    recommendations and effective interventions.

-   Maintaining a strong national nutrition monitoring program to
    provide accurate, reliable, timely, and comparable data to assess
    status and progress and to be responsive to unmet data needs and
    emerging issues.

-   Strengthening State and community data systems to be responsive to
    the data users at these levels.

-   Building and sustaining broad-based initiatives and commitment to
    these objectives by public and private sector partners at the
    national, State, and local levels.

## Interim Progress Toward Year 2000 Objectives

Of the 27 nutrition objectives, targets for 5 have been met, including 2
related to the availability of reduced-fat foods and prevalence of
growth retardation.[^28] The majority of the objectives have shown some
progress, including those related to total fruit, vegetable, and grain
product intake and total fat and saturated fat intake; availability of
nutrition labeling on foods; breastfeeding; nutrition education in
schools; and availability of worksite nutrition and weight management
programs. For certain other objectives, such as consumer actions to
reduce salt intake and home-delivered meals to elderly persons, there
has been little or no progress. And for others, such as intake of
calcium-rich food and overweight and obesity, movement has been away
from the targets. In particular, the proportion of adults and children
who are overweight or obese has increased substantially, and this
represents one of the biggest challenges for Healthy People 2010.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Nutrition and Overweight {#nutrition-and-overweight-1 .Heading-Special-Sub}

**Goal:** Promote health and reduce chronic disease associated with diet
and weight.

  --------------- -------------------------------------------------------------
  **Number**      **Objective Short Title**

  **Weight Status 
  and Growth**    

  19-1            Healthy weight in adults

  19-2            Obesity in adults

  19-3            Overweight or obesity in children and adolescents

  19-4            Growth retardation in children

  **Food and      
  Nutrient        
  Consumption**   

  19-5            Fruit intake

  19-6            Vegetable intake

  19-7            Grain product intake

  19-8            Saturated fat intake

  19-9            Total fat intake

  19-10           Sodium intake

  19-11           Calcium intake

  **Iron          
  Deficiency and  
  Anemia**        

  19-12           Iron deficiency in young children and in females of\
                  childbearing age

  19-13           Anemia in low-income pregnant females

  19-14           Iron deficiency in pregnant females

  **Schools,      
  Worksites, and  
  Nutrition       
  Counseling**    

  19-15           Meals and snacks at school

  19-16           Worksite promotion of nutrition education and weight
                  management

  19-17           Nutrition counseling for medical conditions

  **Food          
  Security**      

  19-18           Food security
  --------------- -------------------------------------------------------------

## Healthy People 2010 Objectives

### Weight Status and Growth

19-1. Increase the proportion of adults who are at a healthy weight.

**Target:** 60 percent.

**Baseline:** 42 percent of adults aged 20 years and older were at a
healthy weight (defined as a body mass index \[BMI\] equal to or greater
than 18.5 and less than 25) in 1988--94 (age adjusted to the year 2000
standard population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS**.**

Note: The table below may continue to the following page.

+------------------------------+------------+-------------+------------+
| **Adults Aged 20 Years and   | **Healthy  |             |            |
| Older, 1988--94 (unless      | Weight**   |             |            |
| noted)**                     |            |             |            |
+==============================+============+=============+============+
|                              | **19-1.\   | **          | *          |
|                              | Both\      | Females\*** | *Males\*** |
|                              | Genders**  |             |            |
+------------------------------+------------+-------------+------------+
|                              | Percent    |             |            |
+------------------------------+------------+-------------+------------+
| > **TOTAL**                  | 42         | 45          | 38         |
+------------------------------+------------+-------------+------------+
| **Race and ethnicity**       |            |             |            |
+------------------------------+------------+-------------+------------+
| > American Indian or Alaska  | DSU        | DSU         | DSU        |
| > Native                     |            |             |            |
+------------------------------+------------+-------------+------------+
| > Asian or Pacific Islander  | DSU        | DSU         | DSU        |
+------------------------------+------------+-------------+------------+
| > Asian                      | DNC        | DNC         | DNC        |
+------------------------------+------------+-------------+------------+
| > Native Hawaiian and other\ | DNC        | DNC         | DNC        |
| > Pacific Islander           |            |             |            |
+------------------------------+------------+-------------+------------+
| > Black or African American  | 34         | 29          | 40         |
+------------------------------+------------+-------------+------------+
| > White                      | 42         | 47          | 37         |
+------------------------------+------------+-------------+------------+
|                              |            |             |            |
+------------------------------+------------+-------------+------------+
| > Hispanic or Latino         | DSU        | DSU         | DSU        |
+------------------------------+------------+-------------+------------+
| > Mexican American           | 30         | 31          | 30         |
+------------------------------+------------+-------------+------------+
| > Not Hispanic or Latino     | 43         | 47          | 39         |
+------------------------------+------------+-------------+------------+
| > Black or African American  | 34         | 29          | 40         |
+------------------------------+------------+-------------+------------+
| > White                      | 43         | 49          | 38         |
+------------------------------+------------+-------------+------------+
| **Age**                      |            |             |            |
+------------------------------+------------+-------------+------------+
| > 20 to 39 years             | 51         | 55          | 48         |
+------------------------------+------------+-------------+------------+
| > 40 to 59 years             | 36         | 40          | 31         |
+------------------------------+------------+-------------+------------+
| > 60 years and older         | 36         | 37          | 33         |
+------------------------------+------------+-------------+------------+
| **Family income level^†^**   |            |             |            |
+------------------------------+------------+-------------+------------+
| > Lower income               | 38         | 33          | 44         |
| > ([\<]{.underline}130       |            |             |            |
| > percent of poverty         |            |             |            |
| > threshold)                 |            |             |            |
+------------------------------+------------+-------------+------------+
| > Higher income (\>130       | 43         | 48          | 37         |
| > percent of poverty         |            |             |            |
| > threshold)                 |            |             |            |
+------------------------------+------------+-------------+------------+
| **Disability status**        |            |             |            |
+------------------------------+------------+-------------+------------+
| > Persons with disabilities  | 32         | 35          | 30         |
|                              | (1991--94) | (1991--94)  | (1991--94) |
+------------------------------+------------+-------------+------------+
| > Persons without            | 41         | 45          | 36         |
| > disabilities               | (1991--94) | (1991--94)  | (1991--94) |
+------------------------------+------------+-------------+------------+
| **Select populations**       |            |             |            |
+------------------------------+------------+-------------+------------+
| > Persons with arthritis     | 36         | 37          | 34         |
|                              | (1991--94) | (1991--94)  | (1991--94) |
+------------------------------+------------+-------------+------------+
| > Persons without arthritis  | 43         | 47          | 40         |
|                              | (1991--94) | (1991--94)  | (1991--94) |
+------------------------------+------------+-------------+------------+
| > Persons with diabetes      | 26         | DNA         | DNA        |
+------------------------------+------------+-------------+------------+
| > Persons without diabetes   | 43         | DNA         | DNA        |
+------------------------------+------------+-------------+------------+
| > Persons with high blood    | 27         | 29          | 26         |
| > pressure                   |            |             |            |
+------------------------------+------------+-------------+------------+
| > Persons without high       | 46         | 50          | 42         |
| > blood\                     |            |             |            |
| > pressure                   |            |             |            |
+------------------------------+------------+-------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data for females and males are displayed to further characterize the
issue.

^†^A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

19-2. Reduce the proportion of adults who are obese.

**Target:** 15 percent.

**Baseline:** 23 percent of adults aged 20 years and older were
identified as obese (defined as a BMI of 30 or more) in 1988--94 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+-------------------------------+------------+------------+------------+
| **Adults Aged 20 Years and    | *          |            |            |
| Older, 1988--94 (unless       | *Obesity** |            |            |
| noted)**                      |            |            |            |
+===============================+============+============+============+
|                               | **19-2.\   | **F        | *          |
|                               | Both\      | emales\*** | *Males\*** |
|                               | Genders**  |            |            |
+-------------------------------+------------+------------+------------+
|                               | Percent    |            |            |
+-------------------------------+------------+------------+------------+
| > **TOTAL**                   | 23         | 25         | 20         |
+-------------------------------+------------+------------+------------+
| **Race and ethnicity**        |            |            |            |
+-------------------------------+------------+------------+------------+
| > American Indian or Alaska   | DSU        | DSU        | DSU        |
| > Native                      |            |            |            |
+-------------------------------+------------+------------+------------+
| > Asian or Pacific Islander   | DSU        | DSU        | DSU        |
+-------------------------------+------------+------------+------------+
| > Asian                       | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Native Hawaiian and other\  | DNC        | DNC        | DNC        |
| > Pacific Islander            |            |            |            |
+-------------------------------+------------+------------+------------+
| > Black or African American   | 30         | 38         | 21         |
+-------------------------------+------------+------------+------------+
| > White                       | 22         | 24         | 21         |
+-------------------------------+------------+------------+------------+
|                               |            |            |            |
+-------------------------------+------------+------------+------------+
| > Hispanic or Latino          | DSU        | DSU        | DSU        |
+-------------------------------+------------+------------+------------+
| > Mexican American            | 29         | 35         | 24         |
+-------------------------------+------------+------------+------------+
| > Not Hispanic or Latino      | 22         | 25         | 20         |
+-------------------------------+------------+------------+------------+
| > Black or African American   | 30         | 38         | 21         |
+-------------------------------+------------+------------+------------+
| > White                       | 22         | 23         | 20         |
+-------------------------------+------------+------------+------------+
| **Age** (not age adjusted)    |            |            |            |
+-------------------------------+------------+------------+------------+
| > 20 to 39 years              | 18         | 21         | 15         |
+-------------------------------+------------+------------+------------+
| > 40 to 59 years              | 28         | 30         | 25         |
+-------------------------------+------------+------------+------------+
| > 60 years and older          | 24         | 26         | 21         |
+-------------------------------+------------+------------+------------+
| **Family income level^†^**    |            |            |            |
+-------------------------------+------------+------------+------------+
| > Lower income                | 29         | 35         | 21         |
| > ([\<]{.underline}130        |            |            |            |
| > percent of poverty          |            |            |            |
| > threshold)                  |            |            |            |
+-------------------------------+------------+------------+------------+
| > Higher income (\>130        | 22         | 23         | 20         |
| > percent of poverty          |            |            |            |
| > threshold)                  |            |            |            |
+-------------------------------+------------+------------+------------+
| **Disability status**         |            |            |            |
+-------------------------------+------------+------------+------------+
| > Persons with disabilities   | 30         | 38         | 21         |
|                               | (1991--94) | (1991--94) | (1991--94) |
+-------------------------------+------------+------------+------------+
| > Persons without             | 23         | 25         | 22         |
| > disabilities                | (1991--94) | (1991--94) | (1991--94) |
+-------------------------------+------------+------------+------------+
| ######## Select populations   |            |            |            |
+-------------------------------+------------+------------+------------+
| > Persons with arthritis      | 30         | 33         | 27         |
+-------------------------------+------------+------------+------------+
| > Persons without arthritis   | 21         | 23         | 19         |
+-------------------------------+------------+------------+------------+
| Persons with diabetes         | 41         | DNA        | DNA        |
+-------------------------------+------------+------------+------------+
| > Persons without diabetes    | 22         | DNA        | DNA        |
+-------------------------------+------------+------------+------------+
| > Persons with high blood     | 38         | 47         | 33         |
| > pressure                    |            |            |            |
+-------------------------------+------------+------------+------------+
| > Persons without high blood\ | 18         | 20         | 16         |
| > pressure                    |            |            |            |
+-------------------------------+------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data for females and males are displayed to further characterize the
issue.

^†^A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

19-3. Reduce the proportion of children and adolescents who are
overweight or obese.

Target and baseline:

+---------+-----------------------------+-------------+---------------+
| Ob      | Reduction in Overweight or  | 1988--94\   | 2010\         |
| jective | Obese Children and          | Baseline    | Target        |
|         | Adolescents\*               |             |               |
+---------+-----------------------------+-------------+---------------+
|         |                             | ######      |               |
|         |                             | ### Percent |               |
+---------+-----------------------------+-------------+---------------+
| **1     | Children aged 6 to 11 years | 11          | 5             |
| 9-3a.** |                             |             |               |
+---------+-----------------------------+-------------+---------------+
| **1     | Adolescents aged 12 to 19   | 11          | 5             |
| 9-3b.** | years                       |             |               |
+---------+-----------------------------+-------------+---------------+
| **1     | Children and adolescents    | ####### 11  | ####### 5     |
| 9-3c.** | aged 6 to 19 years          |             |               |
+---------+-----------------------------+-------------+---------------+

\*Defined as at or above the gender- and age-specific 95th percentile of
BMI based on the revised CDC Growth Charts for the United States.

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

+------------------------------+------------+------------+------------+
| **Children and Adolescents   | **         |            |            |
| Aged 6 to 19 Years, 1988--94 | Overweight |            |            |
| (unless noted)**             | or Obese** |            |            |
+==============================+============+============+============+
|                              | **19-3a.\  | **19-3b.\  | **19-3c.\  |
|                              | Children   | A          | Children   |
|                              | Aged\      | dolescents | and        |
|                              | 6 to 11    | Aged 12 to | A          |
|                              | Years**    | 19 Years** | dolescents |
|                              |            |            | Aged\      |
|                              |            |            | 6 to 19    |
|                              |            |            | Years**    |
+------------------------------+------------+------------+------------+
|                              | Percent    |            |            |
+------------------------------+------------+------------+------------+
| **TOTAL**                    | 11         | 11         | 11         |
+------------------------------+------------+------------+------------+
| **Race and ethnicity**       |            |            |            |
+------------------------------+------------+------------+------------+
| > American Indian or Alaska  | DSU        | DSU        | DNA        |
| > Native                     |            |            |            |
+------------------------------+------------+------------+------------+
| > Asian or Pacific Islander  | DSU        | DSU        | DNA        |
+------------------------------+------------+------------+------------+
| > Asian                      | DNC        | DNC        | DNC        |
+------------------------------+------------+------------+------------+
| > Native Hawaiian and other\ | DNC        | DNC        | DNC        |
| > Pacific Islander           |            |            |            |
+------------------------------+------------+------------+------------+
| > Black or African American  | 15         | 13         | 14         |
+------------------------------+------------+------------+------------+
| > White                      | 11         | 11         | 11         |
+------------------------------+------------+------------+------------+
|                              |            |            |            |
+------------------------------+------------+------------+------------+
| > Hispanic or Latino         | DSU        | DSU        | DSU        |
+------------------------------+------------+------------+------------+
| > Mexican American           | 17         | 14         | 15         |
+------------------------------+------------+------------+------------+
| > Not Hispanic or Latino     | 11         | 10         | 11         |
+------------------------------+------------+------------+------------+
| > Black or African American  | 15         | 13         | 14         |
+------------------------------+------------+------------+------------+
| > White                      | 10         | 10         | 10         |
+------------------------------+------------+------------+------------+
| **Gender**                   |            |            |            |
+------------------------------+------------+------------+------------+
| > Female                     | 11         | 10         | 10         |
+------------------------------+------------+------------+------------+
| > Male                       | 12         | 11         | 12         |
+------------------------------+------------+------------+------------+
| **Family income level**\*    |            |            |            |
+------------------------------+------------+------------+------------+
| > Lower income               | 11         | 16         | 13         |
| > ([\<]{.underline}130       |            |            |            |
| > percent of poverty         |            |            |            |
| > threshold)                 |            |            |            |
+------------------------------+------------+------------+------------+
| > Higher income (\>130       | 11         | 8          | 10         |
| > percent of poverty         |            |            |            |
| > threshold)                 |            |            |            |
+------------------------------+------------+------------+------------+
| **Disability status**        |            |            |            |
+------------------------------+------------+------------+------------+
| > Persons with disabilities  | DSU\       | DSU\       | DSU\       |
|                              | (1991--94) | (1991--94) | (1991--94) |
+------------------------------+------------+------------+------------+
| > Persons without            | 13         | 11         | 12         |
| > disabilities               | (1991--94) | (1991--94) | (1991--94) |
+------------------------------+------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Maintenance of a healthy weight is a major goal in the effort to reduce
the burden of illness and its consequent reduction in quality of life
and life expectancy. The selection of a BMI cut-point to establish the
upper limit of the healthy weight range is based on the relationship of
overweight or obesity to risk factors for chronic disease or premature
death. A BMI of less than 25 has been accepted by numerous groups as the
upper limit of the healthy weight range, since chronic disease risk
increases in most populations at or above this cut-point.Error:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^29] The lower
cut-point for the healthy weight range (BMI of 18.5) was selected to be
consistent with national and international recommendations.Error:
Reference source not found**^,\ Error:\ Reference\ source\ not\ found^**
Problems associated with excessive thinness (BMI less than 18.5) include
menstrual irregularity, infertility, and osteoporosis. There is some
concern that the increased focus on overweight may result in more eating
disorders, such as bulimia and anorexia nervosa. (See Focus Area 18.
Mental Health and Mental Disorders.) However, no evidence currently
exists that suggests the increased focus on overweight has resulted in
additional cases of eating disorders.

Overweight and obesity are caused by many factors. These factors reflect
the contributions of inherited, metabolic, behavioral, environmental,
cultural, and socioeconomic components. As weight increases, so does the
prevalence of health risks. Simple, health-oriented definitions of
overweight and obesity should be based on the amount of excess body fat
at which health risks to individuals begin to increase. No such
definitions currently exist. Most current clinical studies assessing the
health effects of overweight rely on a measurement of body weight
adjusted for height. BMI is the choice for many researchers and health
professionals. While the relation of BMI to body fat differs by age and
gender, it provides valid comparisons across racial and ethnic
groups.[^30] However, BMI does not provide information concerning body
fat distribution, which has been identified as an independent predictor
of health risk.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Thus, until a better
surrogate for body fat is developed, BMI often will be used to screen
for overweight and obese individuals. Health risks also increase as
waist measurement increases, and thus waist measurement also can be a
useful indicator.Error: Reference source not found

Interpretations of data about overweight and obesity have differed
because criteria for these terms have varied over time, from study to
study, and from one part of the world to another. National and
international organizations now support the use of a BMI of 30 or
greater to identify obesity.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** These BMI cut-points
are only a guide to the identification and treatment of overweight and
obese individuals and allow for the comparison across populations and
over time. However, the health risks associated with overweight and
obesity are part of a continuum and do not conform to rigid cut-points.

Overweight and obesity affect a large proportion of the U.S.
population---55 percent of adults. Between 1976 and 1994, the number of
cases of obesity alone increased more than 50 percent---from 14.5
percent of the adult population to 22.5 percent. Approximately 25
percent of U.S. adult females and 20 percent of U.S. adult males are
obese.Error: Reference source not found Because weight management is
difficult for most persons, the Healthy People 2010 target of no more
than 15 percent of adults aged 20 years and older having a BMI of 30 or
more is ambitious. Nonetheless, the potential benefits from reduction in
overweight and obesity are of considerable public health importance and
deserve particular emphasis and attention. A concerted public effort
will be needed to prevent further increases of overweight and obesity.
Health care providers, health plans, and managed care organizations need
to be alert to the development of overweight and obesity in their
clients and should provide information concerning the associated risks.
These groups need to provide guidance to help consumers address this
health problem. To lose weight and keep it off, overweight persons will
need long-term lifestyle changes in dietary and physical activity
patterns that they can easily incorporate into their lives.

Patterns of healthful eating behavior need to begin in childhood and be
maintained throughout adulthood. These patterns can be encouraged
through nutrition education at schools and worksites that takes into
account cultural and other factors influencing diet. Persons should be
aware of the impact that away-from-home eating can have on weight
management. In order to address physical activity needs, changes in the
physical environment---such as access to walkways and bicycle
paths---and the social environment---through social support and safe
communities---will be needed to achieve long-term success.

There is much concern about the increasing prevalence of obesity in
children and adolescents. Overweight and obesity acquired during
childhood or adolescence may persist into adulthood and increase the
risk for some chronic diseases later in life. Teenaged boys lose some
fat accumulated before puberty during adolescence, but fat deposition
continues in girls. Thus, without measures of sexual maturity, measures
of body fat and body weight are difficult to interpret in children and
adolescents. Therefore, the objective to reduce the prevalence of
overweight and obesity among children and adolescents has a target set
at no more than 5 percent and uses the gender- and age-specific 95th
percentile of BMI from the revised Centers for Disease Control and
Prevention (CDC) Growth Charts for the United States. Interventions need
to recognize that obese children also may experience psychological
stress. The reduction of BMI in children and adolescents should be
achieved by emphasizing physical activity and a properly balanced diet
so that healthy growth is maintained. Additional research is needed to
better define the prevalence and health consequences of overweight and
obesity in children and adolescents and the implications of such
findings for these persons as they become the next generation of adults.

19-4. Reduce growth retardation among low-income children under age 5
years.

**Target:** 5 percent.

**Baseline:** 8 percent of low-income children under age 5 years were
growth\
retarded in 1997 (defined as height for age below the fifth percentile
in the\
age-gender appropriate population using the 1977 NCHS/CDC growth
charts;[^31]\
preliminary data; not age adjusted).

**Target setting method:** Better than the best.

**Data source:** Pediatric Nutrition Surveillance System, CDC, NCCDPHP.

+-----------------------------+----------+---------+--------+--------+
| **Low-Income Children Under | **Growth |         |        |        |
| Age 5 Years, 1997**         | Retar    |         |        |        |
|                             | dation** |         |        |        |
+=============================+==========+=========+========+========+
|                             | **19-4.\ | **Under | *      | *      |
|                             | Under    | Age\    | *Aged\ | *Aged\ |
|                             | Age\     | 1       | 1      | 2 to 4 |
|                             | 5        | Y       | Ye     | Yea    |
|                             | Years**  | ear\*** | ar\*** | rs\*** |
+-----------------------------+----------+---------+--------+--------+
|                             | Percent  |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > **TOTAL**                 | 8        | 10      | 9      | 6      |
+-----------------------------+----------+---------+--------+--------+
| **Race and ethnicity**      |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > American Indian or        | 8        | 9       | 7      | 9      |
| > Alaska\                   |          |         |        |        |
| > Native                    |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > Asian or Pacific Islander | 9        | 9       | 11     | 8      |
+-----------------------------+----------+---------+--------+--------+
| > Asian                     | DNC      | DNC     | DNC    | DNC    |
+-----------------------------+----------+---------+--------+--------+
| > Native Hawaiian and other | DNC      | DNC     | DNC    | DNC    |
| > Pacific Islander          |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > Black or African American | DNC      | DNC     | DNC    | DNC    |
+-----------------------------+----------+---------+--------+--------+
| > White                     | DNC      | DNC     | DNC    | DNC    |
+-----------------------------+----------+---------+--------+--------+
|                             |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > Hispanic or Latino        | 7        | 7       | 8      | 5      |
+-----------------------------+----------+---------+--------+--------+
| > Not Hispanic or Latino    | DNC      | DNC     | DNC    | DNC    |
+-----------------------------+----------+---------+--------+--------+
| > Black or African American | 9        | 15      | 10     | 5      |
+-----------------------------+----------+---------+--------+--------+
| > White                     | 8        | 10      | 9      | 6      |
+-----------------------------+----------+---------+--------+--------+
| **Gender**                  |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > Female                    | 8        | 10      | 8      | 6      |
+-----------------------------+----------+---------+--------+--------+
| > Male                      | 8        | 10      | 10     | 6      |
+-----------------------------+----------+---------+--------+--------+
| **Disability status**       |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > Children with             | DNC      | DNC     | DNC    | DNC    |
| > disabilities              |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+
| > Children without          | DNC      | DNC     | DNC    | DNC    |
| > disabilities              |          |         |        |        |
+-----------------------------+----------+---------+--------+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Preliminary data; not age adjusted.

\*Data for specific age groups under 5 years are displayed to further
characterize the issue.

Retardation in linear growth in preschool children serves as an
indicator of overall health and development and also may reflect the
adequacy of a child's diet. Full growth potential may not be reached
because of less than optimal nutrition, infectious diseases, chronic
diseases, or poor health care. Inadequate maternal weight gain during
pregnancy and other prenatal factors that influence birth weight also
affect the prevalence of growth retardation among infants and young
children.

Growth retardation is not a problem for the majority of young children
in the United States. By definition, approximately 5 percent of healthy
children are expected to be below the fifth percentile of height for age
due to normal biologic variation. If more than 5 percent of a population
group is below the fifth percentile, this suggests that full growth
potential is not being reached by some children in that group. Among
some age and ethnic groups of low-income children under age 5 years in
the United States, up to 15 percent are below the fifth percentile.
While progress has been made in reducing the prevalence of growth
retardation among low-income Hispanic and Asian or Pacific Islander
children, it remains especially high for African American children in
the first year of life.

Interventions to improve children's linear growth potential include
better nutrition; improvements in the prevention, diagnosis, and
treatment of infectious and chronic diseases; and provision and use of
adequate health services. Although the response of a population to
interventions for growth retardation may not be as rapid as for iron
deficiency or underweight, achievement of the objective by the year 2010
in all racial and ethnic, socioeconomic, and age groups should be
possible. Special attention should be given to homeless children and
those with special health care needs.

### Food and Nutrient Consumption

19-5. Increase the proportion of persons aged 2 years and older who
consume at least two daily servings of fruit.

**Target:** 75 percent.

**Baseline:** 28 percent of persons aged 2 years and older consumed at
least\
two daily servings of fruit in 1994--96 (age adjusted to the year 2000
standard\
population).

**Target setting method:** Better than the best.

**Data source:** Continuing Survey of Food Intakes by Individuals
(CSFII) (2-day average), USDA.

Note: The table below may continue to the following page.

+----------------------------------------------+-----------------------+
| **Persons Aged 2 Years and Older, 1994--96** | **Two or More Daily\  |
|                                              | Servings of Fruit**   |
+==============================================+=======================+
|                                              | Percent               |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 28                    |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | DNA                   |
+----------------------------------------------+-----------------------+
| > White                                      | DNA                   |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | 32                    |
+----------------------------------------------+-----------------------+
| > Mexican American                           | 29                    |
+----------------------------------------------+-----------------------+
| > Other Hispanic                             | 30                    |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     |                       |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 24                    |
+----------------------------------------------+-----------------------+
| > White                                      | 27                    |
+----------------------------------------------+-----------------------+
| **Gender and age**                           |                       |
+----------------------------------------------+-----------------------+
| > Female                                     |                       |
+----------------------------------------------+-----------------------+
| > 2 years and older                          | 26                    |
+----------------------------------------------+-----------------------+
| > 2 to 5 years (not age adjusted)            | 43                    |
+----------------------------------------------+-----------------------+
| > 6 to 11 years (not age adjusted)           | 26                    |
+----------------------------------------------+-----------------------+
| > 12 to 19 years (not age adjusted)          | 23                    |
+----------------------------------------------+-----------------------+
| > 20 to 39 years (not age adjusted)          | 20                    |
+----------------------------------------------+-----------------------+
| > 40 to 59 years (not age adjusted)          | 26                    |
+----------------------------------------------+-----------------------+
| > 60 years and older (not age adjusted)      | 35                    |
+----------------------------------------------+-----------------------+
| > Male                                       |                       |
+----------------------------------------------+-----------------------+
| > 2 years and older                          | 29                    |
+----------------------------------------------+-----------------------+
| > 2 to 5 years (not age adjusted)            | 46                    |
+----------------------------------------------+-----------------------+
| > 6 to 11 years (not age adjusted)           | 27                    |
+----------------------------------------------+-----------------------+
| > 12 to 19 years (not age adjusted)          | 22                    |
+----------------------------------------------+-----------------------+
| > 20 to 39 years (not age adjusted)          | 23                    |
+----------------------------------------------+-----------------------+
| > 40 to 59 years (not age adjusted)          | 28                    |
+----------------------------------------------+-----------------------+
| > 60 years and older (not age adjusted)      | 39                    |
+----------------------------------------------+-----------------------+
| **Household income level**\*                 |                       |
+----------------------------------------------+-----------------------+
| > Lower income ([\<]{.underline}130 percent  | 23                    |
| > of poverty\                                |                       |
| > threshold)                                 |                       |
+----------------------------------------------+-----------------------+
| > Higher income (\>130 percent of poverty\   | 29                    |
| > threshold)                                 |                       |
+----------------------------------------------+-----------------------+
| **Disability status**                        |                       |
+----------------------------------------------+-----------------------+
| > Persons with disabilities                  | DNC                   |
+----------------------------------------------+-----------------------+
| > Persons without disabilities               | DNC                   |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

19-6. Increase the proportion of persons aged 2 years and older who
consume at least three daily servings of vegetables, with at least
one-third being dark green or orange\
vegetables.

**Target:** 50 percent.

**Baseline:** 3 percent of persons aged 2 years and older consumed at
least three daily servings of vegetables, with at least one-third of
these servings being dark green or orange vegetables in 1994--96 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** Continuing Survey of Food Intakes by Individuals
(CSFII) (2-day average), USDA.

Note: The table below may continue to the following page.

+-------------------------------+------------+------------+------------+
| **Persons Aged 2 Years and    | **Servings |            |            |
| Older, 1994--96**             | of         |            |            |
|                               | Ve         |            |            |
|                               | getables** |            |            |
+===============================+============+============+============+
|                               | **19-6.\   | **3 or     | *          |
|                               | Meet Both  | More       | *One-Third |
|                               | Recommen   | Daily\     | or More    |
|                               | -dations** | Se         | Servings   |
|                               |            | rvings\*** | From Dark  |
|                               |            |            | Green or\  |
|                               |            |            | Orange\    |
|                               |            |            | Vege       |
|                               |            |            | tables\*** |
+-------------------------------+------------+------------+------------+
|                               | Percent    |            |            |
+-------------------------------+------------+------------+------------+
| > **TOTAL**                   | 3          | 49         | 8          |
+-------------------------------+------------+------------+------------+
| **Race and ethnicity**        |            |            |            |
+-------------------------------+------------+------------+------------+
| > American Indian or Alaska   | DSU        | DSU        | DSU        |
| > Native                      |            |            |            |
+-------------------------------+------------+------------+------------+
| > Asian or Pacific Islander   | DSU        | DSU        | DSU        |
+-------------------------------+------------+------------+------------+
| > Asian                       | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Native Hawaiian and other\  | DNC        | DNC        | DNC        |
| > Pacific Islander            |            |            |            |
+-------------------------------+------------+------------+------------+
| > Black or African American   | DNA        | DNA        | DNA        |
+-------------------------------+------------+------------+------------+
| > White                       | DNA        | DNA        | DNA        |
+-------------------------------+------------+------------+------------+
|                               |            |            |            |
+-------------------------------+------------+------------+------------+
| > Hispanic or Latino          | 2          | 47         | 6          |
+-------------------------------+------------+------------+------------+
| > Mexican American            | 2          | 50         | 5          |
+-------------------------------+------------+------------+------------+
| > Other Hispanic              | DSU        | 44         | 6          |
+-------------------------------+------------+------------+------------+
| > Not Hispanic or Latino      | DNA        | DNA        | DNA        |
+-------------------------------+------------+------------+------------+
| > Black or African American   | DNA        | 43         | 14         |
+-------------------------------+------------+------------+------------+
| > White                       | DNA        | 50         | 8          |
+-------------------------------+------------+------------+------------+
| **Gender and age**            |            |            |            |
+-------------------------------+------------+------------+------------+
| > Female                      |            |            |            |
+-------------------------------+------------+------------+------------+
| > 2 years and older           | 4          | 41         | 10         |
+-------------------------------+------------+------------+------------+
| > 2 to 5 years (not age       | DSU        | 23         | 9          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 6 to 11 years (not age\     | DSU        | 24         | 7          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 12 to 19 years (not age\    | 2          | 38         | 7          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 20 to 39 years (not age\    | 4          | 43         | 10         |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 40 to 59 years (not age\    | 4          | 49         | 11         |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 60 years and older (not     | 6          | 43         | 13         |
| > age\                        |            |            |            |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > Male                        |            |            |            |
+-------------------------------+------------+------------+------------+
| > 2 years and older           | 3          | 57         | 7          |
+-------------------------------+------------+------------+------------+
| > 2 to 5 years (not age       | DSU        | 23         | 8          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 6 to 11 years (not age\     | DSU        | 27         | 6          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 12 to 19 years (not age\    | DSU        | 55         | 4          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 20 to 39 years (not age\    | 3          | 68         | 4          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 40 to 59 years (not age\    | 4          | 64         | 9          |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| > 60 years and older (not     | 6          | 57         | 11         |
| > age\                        |            |            |            |
| > adjusted)                   |            |            |            |
+-------------------------------+------------+------------+------------+
| **Household income level^†^** |            |            |            |
+-------------------------------+------------+------------+------------+
| > Lower income                | 3          | 42         | 8          |
| > ([\<]{.underline}130        |            |            |            |
| > percent of poverty          |            |            |            |
| > threshold)                  |            |            |            |
+-------------------------------+------------+------------+------------+
| > Higher income (\>130        | 4          | 50         | 8          |
| > percent of poverty          |            |            |            |
| > threshold)                  |            |            |            |
+-------------------------------+------------+------------+------------+
| ###### Disability status      |            |            |            |
+-------------------------------+------------+------------+------------+
| > Persons with disabilities   | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Persons without             | DNC        | DNC        | DNC        |
| > disabilities                |            |            |            |
+-------------------------------+------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Aged adjusted to the year 2000 standard population.

\*Data for number and type of daily servings are displayed to further
characterize the issue.

^†^A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

19-7. Increase the proportion of persons aged 2 years and older who
consume at least six daily servings of grain products, with at least
three being whole grains.

**Target:** 50 percent.

**Baseline:** 7 percent of persons aged 2 years and older consumed at
least six daily servings of grain products, with at least three being
whole grains in 1994--96 (age adjusted to the year 2000 standard
population).

**Target setting method:** Better than the best.

**Data source:** Continuing Survey of Food Intakes by Individuals
(CSFII) (2-day average), USDA.

Note: The table below may continue to the following page.

+------------------------------+------------+---+------------+------------+
| **Persons Aged 2 Years and   | **Servings |   |            |            |
| Older, 1994--96**            | of         |   |            |            |
|                              | Grains**   |   |            |            |
+==============================+============+===+============+============+
|                              | **19-7.\   |   | **6 or     | **3 or     |
|                              | Meet Both  |   | More       | More       |
|                              | Recommen   |   | Daily\     | Servings   |
|                              | -dations** |   | Se         | From Whole |
|                              |            |   | rvings\*** | Grain\***  |
+------------------------------+------------+---+------------+------------+
|                              | Percent    |   |            |            |
+------------------------------+------------+---+------------+------------+
| > **TOTAL**                  | 7          |   | 51         | 7          |
+------------------------------+------------+---+------------+------------+
| **Race and ethnicity**       |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > American Indian or Alaska  | DSU        | D |            | DSU        |
| > Native                     |            | S |            |            |
|                              |            | U |            |            |
+------------------------------+------------+---+------------+------------+
| > Asian or Pacific Islander  | DSU        | D |            | DSU        |
|                              |            | S |            |            |
|                              |            | U |            |            |
+------------------------------+------------+---+------------+------------+
| > Asian                      | DNC        | D |            | DNC        |
|                              |            | N |            |            |
|                              |            | C |            |            |
+------------------------------+------------+---+------------+------------+
| > Native Hawaiian and other  | DNC        | D |            | DNC        |
| > Pacific Islander           |            | N |            |            |
|                              |            | C |            |            |
+------------------------------+------------+---+------------+------------+
| > Black or African American  | DNA        | D |            | DNA        |
|                              |            | N |            |            |
|                              |            | A |            |            |
+------------------------------+------------+---+------------+------------+
| > White                      | DNA        | D |            | DNA        |
|                              |            | N |            |            |
|                              |            | A |            |            |
+------------------------------+------------+---+------------+------------+
|                              |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > Hispanic or Latino         | 4          | 4 |            | 4          |
|                              |            | 6 |            |            |
+------------------------------+------------+---+------------+------------+
| > Mexican American           | 3          | 4 |            | 4          |
|                              |            | 6 |            |            |
+------------------------------+------------+---+------------+------------+
| > Other Hispanic             | 4          | 4 |            | 4          |
|                              |            | 6 |            |            |
+------------------------------+------------+---+------------+------------+
| > Not Hispanic or Latino     | DNA        | D |            | DNA        |
|                              |            | N |            |            |
|                              |            | A |            |            |
+------------------------------+------------+---+------------+------------+
| > Black or African American  | 3          | 4 |            | 4          |
|                              |            | 0 |            |            |
+------------------------------+------------+---+------------+------------+
| > White                      | 7          | 5 |            | 8          |
|                              |            | 4 |            |            |
+------------------------------+------------+---+------------+------------+
| **Gender and age**           |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > Female                     |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > 2 years and older          | 4          | 3 |            | 5          |
|                              |            | 9 |            |            |
+------------------------------+------------+---+------------+------------+
| > 2 to 5 years (not age\     | 4          | 4 |            | 5          |
| > adjusted)                  |            | 0 |            |            |
+------------------------------+------------+---+------------+------------+
| > 6 to 11 years (not age\    | 2          | 4 |            | 2          |
| > adjusted)                  |            | 6 |            |            |
+------------------------------+------------+---+------------+------------+
| > 12 to 19 years (not age\   | 6          | 4 |            | 6          |
| > adjusted)                  |            | 9 |            |            |
+------------------------------+------------+---+------------+------------+
| > 20 to 39 years (not age\   | 4          | 4 |            | 5          |
| > adjusted)                  |            | 0 |            |            |
+------------------------------+------------+---+------------+------------+
| > 40 to 59 years (not age\   | 4          | 3 |            | 5          |
| > adjusted)                  |            | 8 |            |            |
+------------------------------+------------+---+------------+------------+
| > 60 years and older (not\   | 4          | 2 |            | 6          |
| > age adjusted)              |            | 8 |            |            |
+------------------------------+------------+---+------------+------------+
| > Male                       |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > 2 years and older          | 9          | 6 |            | 10         |
|                              |            | 4 |            |            |
+------------------------------+------------+---+------------+------------+
| > 2 to 5 years (not age\     | 5          | 5 |            | 6          |
| > adjusted)                  |            | 0 |            |            |
+------------------------------+------------+---+------------+------------+
| > 6 to 11 years (not age\    | 5          | 6 |            | 5          |
| > adjusted)                  |            | 0 |            |            |
+------------------------------+------------+---+------------+------------+
| > 12 to 19 years (not age\   | 9          | 7 |            | 9          |
| > adjusted)                  |            | 7 |            |            |
+------------------------------+------------+---+------------+------------+
| > 20 to 39 years (not age\   | 10         | 7 |            | 11         |
| > adjusted)                  |            | 0 |            |            |
+------------------------------+------------+---+------------+------------+
| > 40 to 59 years (not age\   | 10         | 6 |            | 11         |
| > adjusted)                  |            | 4 |            |            |
+------------------------------+------------+---+------------+------------+
| > 60 years and older (not    | 11         | 5 |            | 12         |
| > age adjusted)              |            | 4 |            |            |
+------------------------------+------------+---+------------+------------+
| **Household income           |            |   |            |            |
| level^†^**                   |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > Lower income               | 4          | 4 |            | 5          |
| > ([\<]{.underline}130       |            | 4 |            |            |
| > percent of poverty         |            |   |            |            |
| > threshold)                 |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > Higher income (\>130       | 7          | 5 |            | 8          |
| > percent of poverty         |            | 3 |            |            |
| > threshold)                 |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| **Disability status**        |            |   |            |            |
+------------------------------+------------+---+------------+------------+
| > Persons with disabilities  | DNC        | D |            | DNC        |
|                              |            | N |            |            |
|                              |            | C |            |            |
+------------------------------+------------+---+------------+------------+
| > Persons without            | DNC        | D |            | DNC        |
| > disabilities               |            | N |            |            |
|                              |            | C |            |            |
+------------------------------+------------+---+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data for number and type of daily servings are displayed to further
characterize the issue.

^†^A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

The *Dietary Guidelines for Americans* recommend that Americans choose a
variety of grains daily, especially whole grains, and a variety of
fruits and vegetables daily.Error: Reference source not found In the
United States, persons of all ages eat fewer than the recommended number
of servings of grain products, vegetables, and fruits.Error: Reference
source not found Vegetables (including legumes, such as beans and peas),
fruits, and grains are good sources of vitamins and minerals,
carbohydrates (starch and dietary fiber), and other substances that are
important for good health. Some evidence from clinical studies suggests
that water-soluble fibers from foods such as oat bran, beans, and
certain fruits are associated with lower blood glucose and blood lipid
levels.[^32] Dietary patterns with higher intakes of vegetables
(including legumes), fruits, and grains are associated with a variety of
health benefits, including a decreased risk for some types of
cancer.Error: Reference source not found**^,^** [^33]**^,^**
[^34]**^,^** [^35]**^,^** [^36]**^,^** [^37]

The *Dietary Guidelines for Americans* recommend three to five servings
from various vegetables and vegetable juices and two to four servings
from various fruits and fruit juices, depending on calorie needs.
Consumers can select from a plentiful supply of fresh, frozen, dried,
and canned products throughout the year to obtain five or more servings
of fruits and vegetables daily. The *Dietary Guidelines for Americans*
recommend that persons choose dark green leafy vegetables, orange
vegetables and fruits, and dry beans and peas often. In 1994--96, the
average daily intake of fruits and vegetables was five servings, but
only about 7 to 10 percent of vegetable servings were dark green or deep
yellow (orange), and only about 5 to 6 percent were legumes.[^38] In
contrast, fried potatoes accounted for about one-third (32 percent) of
vegetable servings consumed by youth aged 2 to 19 years. Consumption of
fruits and vegetables also is tracked at the State level and is
discussed in *Tracking Healthy People 2010.*

The *Dietary Guidelines for Americans* recommend 6 to 11 daily servings
of grain products, depending on calorie needs, with several of these
from whole-grain foods. Although grain product consumption increased
during the 1990s, consumption of whole-grain products remains very low.
In 1994--96, for the population aged 2 years and older, the average
daily intake of grain products was nearly seven servings, but only about
14 to 15 percent of grain servings were whole grain.Error: Reference
source not found The guidelines also recommend that grain products be
prepared with little added saturated fat and moderate or low amounts of
added sugars; however, considerable amounts of fats and sugars are
contributed to U.S. diets by baked products such as cookies, cakes, and
doughnuts.[^39]**^,^** [^40] No State-level data on grain intakes are
available for adults, adolescents, and children.

19-8. Increase the proportion of persons aged 2 years and\
older who consume less than 10 percent of calories\
from saturated fat.

**Target:** 75 percent.

**Baseline:** 36 percent of persons aged 2 years and older consumed less
than 10 percent of daily calories from saturated fat in 1994--96 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** Continuing Survey of Food Intakes by Individuals
(CSFII) (2-day average), USDA.

Note: The table below may continue to the following page.

+----------------------------------------------+-----------------------+
| **Persons Aged 2 Years and Older, 1994--96** | **Less than 10        |
|                                              | Percent of Calories   |
|                                              | From Saturated Fat**  |
+==============================================+=======================+
|                                              | Percent               |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 36                    |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | DNA                   |
+----------------------------------------------+-----------------------+
| > White                                      | DNA                   |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | 39                    |
+----------------------------------------------+-----------------------+
| > Mexican American                           | 37                    |
+----------------------------------------------+-----------------------+
| > Other Hispanic                             | 40                    |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     | DNA                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 31                    |
+----------------------------------------------+-----------------------+
| > White                                      | 35                    |
+----------------------------------------------+-----------------------+
| **Gender and age**                           |                       |
+----------------------------------------------+-----------------------+
| > Female                                     |                       |
+----------------------------------------------+-----------------------+
| > 2 years and older                          | 39                    |
+----------------------------------------------+-----------------------+
| > 2 to 5 years (not age adjusted)            | 23                    |
+----------------------------------------------+-----------------------+
| > 6 to 11 years (not age adjusted)           | 23                    |
+----------------------------------------------+-----------------------+
| > 12 to 19 years (not age adjusted)          | 34                    |
+----------------------------------------------+-----------------------+
| > 20 to 39 years (not age adjusted)          | 41                    |
+----------------------------------------------+-----------------------+
| > 40 to 59 years (not age adjusted)          | 42                    |
+----------------------------------------------+-----------------------+
| > 60 years and older (not age adjusted)      | 47                    |
+----------------------------------------------+-----------------------+
| > Male                                       |                       |
+----------------------------------------------+-----------------------+
| > 2 years and older                          | 32                    |
+----------------------------------------------+-----------------------+
| > 2 to 5 years (not age adjusted)            | 23                    |
+----------------------------------------------+-----------------------+
| > 6 to 11 years (not age adjusted)           | 25                    |
+----------------------------------------------+-----------------------+
| > 12 to 19 years (not age adjusted)          | 27                    |
+----------------------------------------------+-----------------------+
| > 20 to 39 years (not age adjusted)          | 32                    |
+----------------------------------------------+-----------------------+
| > 40 to 59 years (not age adjusted)          | 33                    |
+----------------------------------------------+-----------------------+
| > 60 years and older (not age adjusted)      | 42                    |
+----------------------------------------------+-----------------------+
| ###### Household income level\*              |                       |
+----------------------------------------------+-----------------------+
| > Lower income ([\<]{.underline}130 percent  | 33                    |
| > of poverty\                                |                       |
| > threshold)                                 |                       |
+----------------------------------------------+-----------------------+
| > Higher income (\>130 percent of poverty\   | 36                    |
| > threshold)                                 |                       |
+----------------------------------------------+-----------------------+
| **Disability status**                        |                       |
+----------------------------------------------+-----------------------+
| > Persons with disabilities                  | DNC                   |
+----------------------------------------------+-----------------------+
| > Persons without disabilities               | DNC                   |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

19-9. Increase the proportion of persons aged 2 years and older who
consume no more than 30 percent of calories from\
total fat.

**Target:** 75 percent.

**Baseline:** 33 percent of persons aged 2 years and older consumed no
more than 30 percent of daily calories from total fat in 1994--96 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** Continuing Survey of Food Intakes by Individuals
(CSFII) (2-day average), USDA.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Persons Aged 2 Years and Older, 1994--96**   | **No More Than 30   |
|                                                | Percent of\         |
|                                                | Calories From\      |
|                                                | Total Fat**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 33                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 36                  |
+------------------------------------------------+---------------------+
| > Mexican American                             | 33                  |
+------------------------------------------------+---------------------+
| > Other Hispanic                               | 38                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 26                  |
+------------------------------------------------+---------------------+
| > White                                        | 33                  |
+------------------------------------------------+---------------------+
| **Gender and age**                             |                     |
+------------------------------------------------+---------------------+
| > Female                                       |                     |
+------------------------------------------------+---------------------+
| > 2 years and older                            | 36                  |
+------------------------------------------------+---------------------+
| > 2 to 5 years (not age adjusted)              | 35                  |
+------------------------------------------------+---------------------+
| > 6 to 11 years (not age adjusted)             | 34                  |
+------------------------------------------------+---------------------+
| > 12 to 19 years (not age adjusted)            | 36                  |
+------------------------------------------------+---------------------+
| > 20 to 39 years (not age adjusted)            | 38                  |
+------------------------------------------------+---------------------+
| > 40 to 59 years (not age adjusted)            | 33                  |
+------------------------------------------------+---------------------+
| > 60 years and older (not age adjusted)        | 40                  |
+------------------------------------------------+---------------------+
| > Male                                         |                     |
+------------------------------------------------+---------------------+
| > 2 years and older                            | 30                  |
+------------------------------------------------+---------------------+
| > 2 to 5 years (not age adjusted)              | 33                  |
+------------------------------------------------+---------------------+
| > 6 to 11 years (not age adjusted)             | 30                  |
+------------------------------------------------+---------------------+
| > 12 to 19 years (not age adjusted)            | 30                  |
+------------------------------------------------+---------------------+
| > 20 to 39 years (not age adjusted)            | 29                  |
+------------------------------------------------+---------------------+
| > 40 to 59 years (not age adjusted)            | 28                  |
+------------------------------------------------+---------------------+
| > 60 years and older (not age adjusted)        | 34                  |
+------------------------------------------------+---------------------+
| **Household income level\***                   |                     |
+------------------------------------------------+---------------------+
| > Lower income ([\<]{.underline}130 percent of | 30                  |
| > poverty\                                     |                     |
| > threshold)                                   |                     |
+------------------------------------------------+---------------------+
| > Higher income (\>130 percent of poverty\     | 34                  |
| > threshold)                                   |                     |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

Both the *Dietary Guidelines for Americans* and the National Cholesterol
Education and Prevention Program recommend a diet that contains less
than 10 percent of calories from saturated fat and no more than 30
percent of calories from total fat.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^41] This can be
achieved by obtaining most calories from plant foods (grains, fruits,
vegetables) that have little added fat. Such a healthful diet also can
include low-fat and lean foods from the milk group and the meat group.
The increase of overweight and obesity in the United States indicates
that more attention needs to be paid to serving size and total calorie
content because a low-fat content does not, automatically, signify a
lower calorie content.

The role of fat in the diet is complicated because different types of
fatty acids have different effects on health. Evidence to date is
complicated, but certain messages appear clear: persons in the United
States consume too much dietary fat in general, and too much of the fat
consumed is from saturated fatty acids---the type associated with an
increased risk for heart disease. (See Focus Area 12. Heart Disease and
Stroke.)

Strong evidence from human and animal studies shows that diets low in
saturated fatty acids and cholesterol are associated with low risks and
rates of coronary heart disease. Saturated fatty acids are the major
dietary factors that raise blood low-density lipoprotein (LDL)
cholesterol levels, increasing the risk for heart disease. Increasing
evidence suggests that *trans*-fatty acids also can increase
LDL-cholesterol levels.[^42] Monounsaturated and polyunsaturated fatty
acids do not raise blood cholesterol. Omega-3 polyunsaturated fatty
acids, which are found in some fish such as salmon, tuna, and mackerel,
are being studied to determine whether they offer protection against
heart disease.Error: Reference source not found

A 1989 National Research Council reportError: Reference source not found
indicated that diets high in total fat were associated with a higher
risk of several cancers, especially cancer of the colon, prostate, and
breast, but noted that findings were inconsistent. (See Focus Area 3.
Cancer.) A 1996 review of the evidence showed that the relationship
between the amount and type of fat and the risk of cancer continues to
be uncertain.[^43] To help clarify the relationship between total
dietary fat and the risk of cancer, a randomized clinical trial called
the Women's Health Initiative has been started. Set to conclude in 2003,
it is a multicenter trial designed to test several risk factors for
chronic disease in U.S. females.[^44] A major emphasis is to reduce fat
to 25 percent of dietary calories to determine whether a low-fat diet
has any effect on breast cancer risk.

The proportion of calories in the U.S. diet provided by total fat is
about 33 percent, saturated fat is about 11 percent, and *trans*-fat is
about 2.6 percent.[^45] The primary sources of saturated fat are meats
and dairy products that contain fat. Thus, nonfat and low-fat dairy
products and lean meats are choices that can help reduce saturated fat
intake. *Trans*-fatty acids are formed when vegetable oil is
hydrogenated to solidify the oils and increase the shelf life and flavor
stability of the fats and the foods that contain them. Margarines that
have been formulated to contain no *trans*-fats are available in most
U.S. grocery stores. Other dietary sources of *trans*-fat are restaurant
and fast-food fats (including frying fats), baked products, and some
snack foods, such as chips.

The major vegetable sources of monounsaturated fatty acids include nuts,
avocados, olive oil, canola oil, and high-oleic forms of safflower and
sunflower seed oil. The major sources of polyunsaturated fatty acids are
vegetable oils, including soybean oil, corn oil, and high-linoleic forms
of safflower and sunflower seed oil and a few nuts, such as walnuts.
Substituting monounsaturated and polyunsaturated fatty acids for
saturated fatty acids can help lower health risks.

The proportion of all meals and snacks from away-from-home sources
increased by more than two-thirds between 1977--78 and 1995, from 16
percent of all meals and snacks in 1977--78 to 27 percent of all meals
and snacks in 1995.Error: Reference source not found Away-from-home food
tends to have a higher saturated fat content, and persons tend to
consume more calories when eating away from home than at home.Error:
Reference source not found In 1995, the average total fat and saturated
fat content of away-from-home foods, expressed as a percentage of
calories, was 38 percent and 13 percent, respectively, compared with 32
percent and 11 percent for at-home foods.**^27^** Meals and snacks eaten
by children at school had the highest saturated fat density of all food
outlets. Thus, to help assess fat and saturated fat intake, as well as
develop strategies to help children reduce the amount of fat they
consume, additional tracking of saturated fat and total fat intake from
foods eaten away from home as well as at home is important.

19-10. Increase the proportion of persons aged 2 years and\
older who consume 2,400 mg or less of sodium daily.

**Target:** 65 percent.

**Baseline:** 21 percent of persons aged 2 years and older consumed
2,400 mg or less of sodium daily (from foods, dietary supplements, tap
water, and salt use at the table) in 1988--94 (age adjusted to the year
2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------------------------+----------------------+
| **Persons Aged 2 Years and Older, 1988--94    | **Consume 2,400 mg   |
| (unless noted)**                              | of Sodium or Less**  |
+===============================================+======================+
|                                               | Percent              |
+-----------------------------------------------+----------------------+
| > **TOTAL**                                   | 21                   |
+-----------------------------------------------+----------------------+
| **Race and ethnicity**                        |                      |
+-----------------------------------------------+----------------------+
| > American Indian or Alaska Native            | DSU                  |
+-----------------------------------------------+----------------------+
| > Asian or Pacific Islander                   | DSU                  |
+-----------------------------------------------+----------------------+
| > Asian                                       | DNC                  |
+-----------------------------------------------+----------------------+
| > Native Hawaiian and other Pacific Islander  | DNC                  |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 25                   |
+-----------------------------------------------+----------------------+
| > White                                       | 20                   |
+-----------------------------------------------+----------------------+
|                                               |                      |
+-----------------------------------------------+----------------------+
| > Hispanic or Latino                          | DSU                  |
+-----------------------------------------------+----------------------+
| > Mexican American                            | 25                   |
+-----------------------------------------------+----------------------+
| > Not Hispanic or Latino                      | 21                   |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 25                   |
+-----------------------------------------------+----------------------+
| > White                                       | 20                   |
+-----------------------------------------------+----------------------+
| **Gender and age**                            |                      |
+-----------------------------------------------+----------------------+
| Female                                        |                      |
+-----------------------------------------------+----------------------+
| > 2 years and older                           | 32                   |
+-----------------------------------------------+----------------------+
| > 2 to 5 years (not age adjusted)             | 64                   |
+-----------------------------------------------+----------------------+
| > 6 to 11 years (not age adjusted)            | 26                   |
+-----------------------------------------------+----------------------+
| > 12 to 19 years (not age adjusted)           | 29                   |
+-----------------------------------------------+----------------------+
| > 20 years and older                          | 30                   |
+-----------------------------------------------+----------------------+
| Male                                          |                      |
+-----------------------------------------------+----------------------+
| > 2 years and older                           | 9                    |
+-----------------------------------------------+----------------------+
| > 2 to 5 years (not age adjusted)             | 50                   |
+-----------------------------------------------+----------------------+
| > 6 to 11 years (not age adjusted)            | 16                   |
+-----------------------------------------------+----------------------+
| > 12 to 19 years (not age adjusted)           | 4                    |
+-----------------------------------------------+----------------------+
| > 20 years and older                          | 6                    |
+-----------------------------------------------+----------------------+
| **Family income level**\*                     |                      |
+-----------------------------------------------+----------------------+
| > Lower income ([\<]{.underline}130 percent   | 25                   |
| > of poverty\                                 |                      |
| > threshold)                                  |                      |
+-----------------------------------------------+----------------------+
| > Higher income (\>130 percent of poverty\    | 20                   |
| > threshold)                                  |                      |
+-----------------------------------------------+----------------------+
| **Disability status** (aged 20 years and      |                      |
| older)                                        |                      |
+-----------------------------------------------+----------------------+
| > Persons with disabilities                   | 18 (1991--94)        |
+-----------------------------------------------+----------------------+
| > Persons without disabilities                | 16 (1991--94)        |
+-----------------------------------------------+----------------------+
| **Select populations**                        |                      |
+-----------------------------------------------+----------------------+
| > Females with high blood pressure            | 32                   |
+-----------------------------------------------+----------------------+
| > Females without high blood pressure         | 29                   |
+-----------------------------------------------+----------------------+
| > Males with high blood pressure              | 7                    |
+-----------------------------------------------+----------------------+
| > Males without high blood pressure           | 5                    |
+-----------------------------------------------+----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

The *Dietary Guidelines for Americans* recommend choosing and preparing
foods with less salt (salt consists of both sodium and chloride). Most
studies in diverse populations have shown that salt intake is linked to
increasing levels of blood pressure.Error: Reference source not
found**^,^** [^46]**^,^** [^47]**^,^** [^48] (See Focus Area 12. Heart
Disease and Stroke.) Persons who consume less salt or sodium have a
lower risk of developing high blood pressure.Error: Reference source not
found Data also show that high sodium intake may increase the amount of
calcium excreted in the urine and therefore increase the body's need for
calcium.[^49] Eating less salt may decrease the loss of calcium from
bone.Error: Reference source not found

Most persons in the United States consume more sodium than is needed,
and reduction of sodium or salt or both to no more than 2,400 mg sodium
or 6 g salt per day is recommended by some authorities.Error: Reference
source not found**^,\ Error:\ Reference\ source\ not\ found^** Data from
the Continuing Survey of Food Intakes by Individuals show that, even
without including salt added at the table, both home foods and
away-from-home foods provide excessive amounts of sodium.Error:
Reference source not found Higher sodium intakes also tend to be
associated with higher calorie intakes; for example, males, who consume
more calories than females, also consume more sodium.Error: Reference
source not found

Sodium occurs naturally in foods. However, most dietary salt or sodium
is added to foods during processing or preparation, with smaller amounts
added at the discretion of the consumer in the form of table salt or use
of condiments such as soy sauce.[^50]**^,^** [^51] Thus, both the sodium
content of foods and estimates of the amount of salt added have been
used to assess dietary sodium consumption. Other contributing sources of
sodium are water, dietary supplements, and medications such as antacids.

19-11. Increase the proportion of persons aged 2 years and\
older who meet dietary recommendations for calcium.

**Target:** 75 percent.

**Baseline:** 46 percent of persons aged 2 years and older were at or
above\
approximated mean calcium requirements (based on consideration of
calcium from foods, dietary supplements, and antacids) in 1988--94 (age
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+----------------------------------------------+-----------------------+
| **Persons Aged 2 Years and Older, 1988--94   | **Met Calcium\        |
| (unless noted)**                             | Recommendations**     |
+==============================================+=======================+
|                                              | Percent               |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 46                    |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 30                    |
+----------------------------------------------+-----------------------+
| > White                                      | 49                    |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | DSU                   |
+----------------------------------------------+-----------------------+
| > Mexican American                           | 44                    |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     | 46                    |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 30                    |
+----------------------------------------------+-----------------------+
| > White                                      | 50                    |
+----------------------------------------------+-----------------------+
| **Gender and age**                           |                       |
+----------------------------------------------+-----------------------+
| Female                                       |                       |
+----------------------------------------------+-----------------------+
| > 2 years and older                          | 36                    |
+----------------------------------------------+-----------------------+
| > 2 to 8 years (not age adjusted)            | 79                    |
+----------------------------------------------+-----------------------+
| > 9 to 19 years (not age adjusted)           | 19                    |
+----------------------------------------------+-----------------------+
| > 20 to 49 years (not age adjusted)          | 40                    |
+----------------------------------------------+-----------------------+
| > 50 years and older (not age adjusted)      | 27                    |
+----------------------------------------------+-----------------------+
| Male                                         |                       |
+----------------------------------------------+-----------------------+
| > 2 years and older                          | 56                    |
+----------------------------------------------+-----------------------+
| > 2 to 8 years (not age adjusted)            | 89                    |
+----------------------------------------------+-----------------------+
| > 9 to 19 years (not age adjusted)           | 52                    |
+----------------------------------------------+-----------------------+
| > 20 to 49 years (not age adjusted)          | 64                    |
+----------------------------------------------+-----------------------+
| > 50 years and older (not age adjusted)      | 35                    |
+----------------------------------------------+-----------------------+
| **Family income level**\*                    |                       |
+----------------------------------------------+-----------------------+
| > Lower income ([\<]{.underline}130 percent  | 39                    |
| > of poverty\                                |                       |
| > threshold)                                 |                       |
+----------------------------------------------+-----------------------+
| > Higher income (\>130 percent of poverty\   | 48                    |
| > threshold)                                 |                       |
+----------------------------------------------+-----------------------+
| **Disability status** (aged 20 years and     |                       |
| older)                                       |                       |
+----------------------------------------------+-----------------------+
| > Persons with disabilities                  | 44 (1991--94)         |
+----------------------------------------------+-----------------------+
| > Persons without disabilities               | 44 (1991--94)         |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

Calcium is essential for the formation and maintenance of bones and
teeth.Error: Reference source not found The recommendations for adequate
daily intakes of calcium are 500 mg for children aged 1 to 3 years, 800
mg for children aged 4 to 8 years, 1,300 mg for adolescents aged 9 to 18
years, 1,000 mg for adults aged 19 to 50 years, and 1,200 mg for adults
aged 51 years and older.[^52] Approximated mean calcium requirements are
defined as 77 percent of the recommendations by the Institute of
Medicine for adequate intakes of calcium.Error: Reference source not
found**^,^** [^53] The bone mass achieved at full growth (peak bone
mass) appears to be related to intake of calcium during childhood and
adolescence.Error: Reference source not found Opinion is divided as to
the age at which peak bone mass is achieved, although most of the
accumulation of bone mineral occurs in humans by about age 20 years.
After persons reach their adult height, a period of consolidation of
bone density continues until approximately age 30 to 35 years. A high
peak bone mass is thought to be protective against fractures in later
life.

Osteoporosis is a complex disorder caused by many contributing factors.
(See Focus Area 2. Arthritis, Osteoporosis, and Chronic Back
Conditions.) Regular exercise and a diet with enough calcium help
maintain good bone health and reduce the risk of osteoporosis later in
life. However, the ideal level of calcium intake for development of peak
bone mass is unknown. For the most part, young children appear to meet
the approximate calcium requirements. In contrast, the majority of
adolescent and adult females do not meet the average requirements. This
is in part because of their lower food consumption, as well as the lower
consumption of milk products relative to soft drinks in U.S. diets.[^54]
For example, in the period 1994--96, the amount of soft drinks consumed
was about twice that consumed in the late 1970s and surpassed
consumption of fluid milk. Thus, an increase in consumption of various
sources of calcium is recommended for nearly all groups and especially
for teenaged girls and women. In postmenopausal females---the group at
highest risk for osteoporosis---estrogen replacement therapy under
medical supervision is the most effective means to reduce the rate of
bone loss and risk of fractures.Error: Reference source not found

The relationship between dietary calcium and blood pressure is
uncertain. Results from studies that have used calcium supplements show
a small reduction in systolic blood pressure in hypertensive
individuals, with no significant reduction in diastolic blood
pressure.[^55] Among persons with normal blood pressure, there is no
significant difference in blood pressure with calcium supplements.[^56]

Dietary sources of calcium include milk and milk products such as cheese
and yogurt, canned fish with soft bones such as sardines, dark green
leafy vegetables such as kale and mustard or turnip greens, tofu made
with calcium, tortillas made from lime-processed corn, calcium-enriched
grain products, and other calcium-fortified foods and beverages.Error:
Reference source not found In some locations, water is a source of
calcium, but in amounts that cannot readily be determined. With current
food selection practices, use of dairy products may constitute the
difference between getting enough calcium in one's diet or not. Nonfat
and low-fat dairy products are choices that help reduce the intake of
saturated fat while still providing calcium, vitamin D, and other
nutrients important for bone health. For those who have lactose
intolerance, a range of lactose-reduced dairy products can provide
calcium. Persons who do not (or cannot) consume and absorb adequate
levels of calcium from dairy food sources may consider use of
calcium-fortified foods, while persons with clinical evidence of
inadequate intake should receive professional advice on the proper type
and dosage of calcium supplements. Calcium supplements come in different
forms, including calcium-containing antacids.

Fluid milk (but not yogurt or cheese) is an excellent source of vitamin
D, which is essential for calcium utilization. Vitamin D also is
synthesized in the skin upon exposure to sunlight.

### Iron Deficiency and Anemia

19-12. Reduce iron deficiency among young children and\
females of childbearing age.

Target and Baseline:

+----------+------------------------------------+----------+----------+
| O        | Reduction in Iron Deficiency\*     | 1988--94 | 2010\    |
| bjective |                                    | Baseline | Target   |
+----------+------------------------------------+----------+----------+
|          |                                    | #        |          |
|          |                                    | ######## |          |
|          |                                    |  Percent |          |
+----------+------------------------------------+----------+----------+
| **1      | Children aged 1 to 2 years         | 9        | 5        |
| 9-12a.** |                                    |          |          |
+----------+------------------------------------+----------+----------+
| **1      | Children aged 3 to 4 years         | 4        | 1        |
| 9-12b.** |                                    |          |          |
+----------+------------------------------------+----------+----------+
| **1      | Nonpregnant females aged 12 to 49  | 11       | 7        |
| 9-12c.** | years                              |          |          |
+----------+------------------------------------+----------+----------+

\*Iron deficiency is defined as having abnormal results for two or more
of the following tests: serum ferritin concentration, erythrocyte
protoporphyrin, or transferrin saturation. Refer to *Tracking Healthy
People 2010* for threshold values.

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------+------------+------------+------------+
| **Select Populations,       | **Iron     |            |            |
| 1988--94 (unless noted)**   | De         |            |            |
|                             | ficiency** |            |            |
+=============================+============+============+============+
|                             | **19-12a.\ | **19-12b.\ | **19-12c.\ |
|                             | Aged\      | Aged\      | Females of |
|                             | 1 to 2     | 3 to 4     | Ch         |
|                             | Years**    | Years**    | ildbearing |
|                             |            |            | Age**      |
+-----------------------------+------------+------------+------------+
|                             | Percent    |            |            |
+-----------------------------+------------+------------+------------+
| > **TOTAL**                 | 9          | 4          | 11         |
+-----------------------------+------------+------------+------------+
| **Race and ethnicity**      |            |            |            |
+-----------------------------+------------+------------+------------+
| > American Indian or        | DSU        | DSU        | DSU        |
| > Alaska\                   |            |            |            |
| > Native                    |            |            |            |
+-----------------------------+------------+------------+------------+
| > Asian or Pacific Islander | DSU        | DSU        | DSU        |
+-----------------------------+------------+------------+------------+
| > Asian                     | DNC        | DNC        | DNC        |
+-----------------------------+------------+------------+------------+
| > Native Hawaiian and other | DNC        | DNC        | DNC        |
| > Pacific Islander          |            |            |            |
+-----------------------------+------------+------------+------------+
| > Black or African American | 10         | 2          | 15         |
+-----------------------------+------------+------------+------------+
| > White                     | 8          | 3          | 10         |
+-----------------------------+------------+------------+------------+
|                             |            |            |            |
+-----------------------------+------------+------------+------------+
| > Hispanic or Latino        | DSU        | DSU        | DSU        |
+-----------------------------+------------+------------+------------+
| Mexican American            | 17         | 6          | 19         |
+-----------------------------+------------+------------+------------+
| > Not Hispanic or Latino    | DNA        | DNA        | DNA        |
+-----------------------------+------------+------------+------------+
| > Black or African American | 10         | 2          | 15         |
+-----------------------------+------------+------------+------------+
| > White                     | 6          | 1          | 8          |
+-----------------------------+------------+------------+------------+
| **Family income level**\*   |            |            |            |
+-----------------------------+------------+------------+------------+
| > Lower income              | 12         | 5          | 16         |
| > ([\<]{.underline}130      |            |            |            |
| > percent of poverty        |            |            |            |
| > threshold)                |            |            |            |
+-----------------------------+------------+------------+------------+
| > Higher income (\>130      | 7          | 3          | 9          |
| > percent of poverty        |            |            |            |
| > threshold)                |            |            |            |
+-----------------------------+------------+------------+------------+
| **Disability status** (aged |            |            |            |
| 20 to 49 years)             |            |            |            |
+-----------------------------+------------+------------+------------+
| > Persons with disabilities | DNC        | DNC        | 4          |
|                             |            |            | (1991--94) |
+-----------------------------+------------+------------+------------+
| > Persons without           | DNC        | DNC        | 12         |
| > disabilities              |            |            | (1991--94) |
+-----------------------------+------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

19-13. Reduce anemia among low-income pregnant females\
in their third trimester.

**Target:** 20 percent.

**Baseline:** 29 percent of low-income pregnant females in their third
trimester were anemic (defined as hemoglobin \<11.0 g/dL) in 1996.

**Target setting method:** Better than the best.

**Data source:** Pregnancy Nutrition Surveillance System, CDC, NCCDPHP.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Low-Income Pregnant Females, Third\          | **Anemia**          |
| Trimester, 1996**                              |                     |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 29                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 31                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 26                  |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNC                 |
+------------------------------------------------+---------------------+
| > White                                        | DNC                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 25                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 44                  |
+------------------------------------------------+---------------------+
| > White                                        | 24                  |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Females with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Females without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

19-14. (Developmental) Reduce iron deficiency among\
pregnant females.

**Potential data source:** National Health and Nutrition Examination
Survey (NHANES), CDC, NCHS.

The terms anemia, iron deficiency, and iron deficiency anemia often are
used interchangeably but are not equivalent. Iron deficiency ranges from
depleted iron stores without functional or health impairment to iron
deficiency with anemia, which affects the functioning of several organ
systems. Iron deficiency anemia is more likely than iron deficiency
without anemia to cause preterm births, low birth weight, and delays in
infant and child development.[^57]**^,^** [^58]**^,^** [^59] Iron
deficiency (with and without anemia) in adolescent females has been
associated with decreased verbal learning and memory.[^60] The
prevalence of iron deficiency anemia among children aged 1 to 2 years
and 3 to 4 years and females aged 12 to 49 years in 1988 to 1994 was 3
percent, less than 1 percent, and 4 percent, respectively.

Anemia can be caused by many factors other than iron deficiency,
including other nutrient deficiencies, infection, inflammation, and
hereditary anemias. Anemia is used for monitoring risk of iron
deficiency at the State and local levels because of the low cost and
feasibility of measuring hemoglobin or hematocrit in the clinic
setting.[^61] Anemia is a good predictor of iron deficiency when the
prevalence of iron deficiency is high, such as during the third
trimester of pregnancy. It is not a good predictor of iron deficiency
when the prevalence of iron deficiency is expected to be low, such as
among white, non-Hispanic children aged 3 to 4 years in the United
States. In that case, the majority of anemia is due to other
causes.Error: Reference source not found However, changes in the
prevalence of anemia over time at State and local levels can be used to
evaluate the effectiveness of programs to decrease the prevalence of
iron deficiency.

Iron deficiency and anemia among young children declined during the
1970s in association with increased iron intake.Error: Reference source
not found Although the prevalence of iron deficiency among low-income
children continued to decline from 1976--80 to 1988--94, the prevalence
of iron deficiency among all young children remained the same, and the
prevalence of iron deficiency among females of childbearing age actually
increased.Error: Reference source not found From 1979 to 1996, the
prevalence of third trimester anemia among low-income pregnant females
did not change.[^62]**^,^** [^63]

Iron deficiency is highest among toddlers and among certain racial,
ethnic, and low-income children.[^64] Iron deficiency can be prevented
among young children by teaching families about child nutrition,
including promoting breastfeeding of infants, with exclusive
breastfeeding for 4 to 6 months; the use of iron-fortified formulas when
formulas are used; delayed introduction of cow's milk until age 12
months; and age-appropriate introduction of iron-rich solid foods, such
as iron-fortified infant cereals and pureed meats, and foods that
enhance iron absorption such as vitamin C-rich fruits, vegetables, or
juices.**^Error:\ Reference\ source\ not\ found^**

Nonpregnant females of childbearing age are at increased risk for iron
deficiency because of iron loss during menstruation coupled with
inadequate intake of iron.Error: Reference source not found Pregnant
females are also at increased risk because of the increased iron
requirements of pregnancy.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Consequently, a
Healthy People 2010 objective has been established to reduce the
prevalence of anemia among low-income pregnant females in their third
trimester. Although groups other than low-income females are considered
at risk for iron deficiency during pregnancy, no nationally
representative data exist on the prevalence of iron deficiency or iron
deficiency anemia among pregnant females.

National data indicate that only one-fourth of all females of
childbearing age (12 to 49 years) meet the U.S. recommended dietary
allowance for iron (15 mg) through their diets.[^65] Iron deficiency
among females of childbearing age may be prevented by periodic anemia
screening and appropriate treatment and by counseling them about better
eating practices, such as selecting iron-rich foods, taking iron
supplements during pregnancy, increasing consumption of foods that
enhance iron absorption (for example, orange juice and other citrus
products), and discouraging consumption of iron inhibitors (for example,
coffee and tea) with iron-rich foods.Error: Reference source not found
Some good sources of iron include ready-to-eat cereals with added iron;
enriched and whole grain breads; lean meats; turkey dark meat;
shellfish; spinach; and cooked dry beans, peas, and lentils.

### Schools, Worksites, and Nutrition Counseling

19-15. (Developmental) Increase the proportion of children and
adolescents aged 6 to 19 years whose intake of meals and snacks at
school contributes to good overall dietary\
quality.

**Potential data sources:** Continuing Survey of Food Intakes by
Individuals (CSFII), USDA; National Food and Nutrition Survey, USDA and
CDC; National Health and Nutrition Examination Survey (NHANES), CDC,
NCHS.

Students today have increased food options at school. Although students
may understand that good nutrition and good health are connected, that
understanding may not be reflected in their food choices and meal
patterns. The U.S. Department of Agriculture (USDA) has established
standards requiring schools to plan menus that meet the 1995 *Dietary
Guidelines for Americans*, but these standards do not apply to à la
carte foods; to foods sold in snack bars, school stores, and vending
machines; or to foods students bring from home. Students' food choices
are influenced by the total eating environment created by schools. This
includes the types of foods available throughout the school,
point-of-choice nutrition information in the cafeteria and around the
school, nutrition education provided in the classroom, and nutrition
promotions that reach families and affect the choices of foods brought
to school.

Improving the quality of students' dietary intake in the school setting
is important because, for many children, meals and snacks consumed at
school make a major contribution to their total daily consumption of
food and nutrients. National food consumption data collected in 1994 and
1995 show that school foods had the highest saturated fat density of all
food outlets.Error: Reference source not found School foods also had
higher than recommended levels of sodium---as did other away-from-home
foods and at-home foods. Nonetheless, these analyses also showed
positive aspects of foods obtained from school. School foods had the
highest calcium density of all sources and the highest dietary fiber
density of all away-from-home sources. The establishment of an
environment that supports a good overall diet would enable school
nutrition and food services, in conjunction with students, their
families, and other school employees, to make an important contribution
to short- and long-term disease prevention and health promotion. In
addition, such an environment would foster learning readiness (for
example, by encouraging students to consume substantial
breakfasts).[^66]**^,^** [^67]**^,^** [^68]

19-16. Increase the proportion of worksites that offer nutrition\
or weight management classes or counseling.

**Target:** 85 percent.

**Baseline:** 55 percent of worksites with 50 or more employees offered
nutrition or weight management classes or counseling at the worksite or
through their health plans in 1998--99.

**Target setting method:** 55 percent improvement.

**Data source:** National Worksite Health Promotion Survey, Association
for\
Worksite Health Promotion (AWHP).

  ------------------------------------------------------------------------
  Worksites, 1998--99            Offer                       
                                 Nutrition or                
                                 Weight                      
                                 Management\                 
                                 Classes or                  
                                 Counseling                  
  ------------------------------ ------------- ------------- -------------
  Worksite Size                  Worksite or   Worksite      Health Plan
                                 Health Plan                 

                                 *Percent*                   

  Total (50 or more employees)   55            28            39

  50 to 99 employees             48            21            39

  100 to 249 employees           51            29            37

  250 to 749 employees           59            44            42

  750 or more employees          83            70            50
  ------------------------------------------------------------------------

Worksite programs can reach large numbers of employees with information,
activities, and services that encourage the adoption of healthy dietary
and physical activity behaviors.[^69] (See Focus Area 7. Educational and
Community-Based Programs and Focus Area 22. Physical Activity and
Fitness.) Employer-sponsored programs can be offered onsite or in
partnership with community organizations. Examples of such programs
include weight management classes, physical activity programs, lunchtime
seminars, self-help programs, cooking demonstrations and classes,
healthy food service and vending machine selections, point-of-purchase
nutrition information, and flexible health benefits that include
nutrition-related services.

A recent study of worksite health promotion programs found that specific
interventions at the worksite resulted in employees choosing to reduce
the amount of fat calories they consumed and eating more fruits,
vegetables, and dietary fiber.[^70] Worksite health promotion programs
may reduce health care costs, including employer costs for insurance
programs, disability benefits, and medical expenses.[^71]**^,^** [^72]

If possible, nutrition education and weight management programs at the
worksite should be part of a comprehensive health promotion program. In
addition, employers could reimburse health promotion activities and
provide company time for employees to participate in the programs.[^73]

Worksite programs should be made available to the family members of
employees and company retirees as well as current employees. Also, these
programs should be offered in a culturally and linguistically competent
manner and any educational materials provided should be culturally and
linguistically appropriate.

19-17. Increase the proportion of physician office visits made\
by patients with a diagnosis of cardiovascular disease, diabetes, or
hyperlipidemia that include counseling or education related to diet and
nutrition.

**Target:** 75 percent.

**Baseline:** 42 percent of physician office visits made by patients
with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia
included ordering or providing counseling or education on diet and
nutrition in 1997 (age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Ambulatory Medical Care Survey (NAMCS), CDC,
NCHS.

Note: The table below may continue to the following page.

+------------------------------+---------+--------+--------+--------+
| **Persons With Specific\     | **Ph    |        |        |        |
| Conditions, 1997**           | ysician |        |        |        |
|                              | Office  |        |        |        |
|                              | Visits  |        |        |        |
|                              | That    |        |        |        |
|                              | I       |        |        |        |
|                              | nclude\ |        |        |        |
|                              | O       |        |        |        |
|                              | rdering |        |        |        |
|                              | or      |        |        |        |
|                              | Pr      |        |        |        |
|                              | oviding |        |        |        |
|                              | Diet    |        |        |        |
|                              | and     |        |        |        |
|                              | Nu      |        |        |        |
|                              | trition |        |        |        |
|                              | Cou     |        |        |        |
|                              | nseling |        |        |        |
|                              | or      |        |        |        |
|                              | Educ    |        |        |        |
|                              | ation** |        |        |        |
+------------------------------+---------+--------+--------+--------+
|                              | **      | **     | **Car  | **     |
|                              | 19-17.\ | Hyperl | diovas | Diabet |
|                              | Any of  | ipidem | cular\ | es\*** |
|                              | the     | ia\*** | Disea  |        |
|                              | Three\  |        | se\*** |        |
|                              | Condi   |        |        |        |
|                              | tions** |        |        |        |
+------------------------------+---------+--------+--------+--------+
|                              | Percent |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > **TOTAL**                  | 42      | 65     | 36     | 48     |
+------------------------------+---------+--------+--------+--------+
| **Race and ethnicity**       |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > American Indian or Alaska  | DSU     | DSU    | DSU    | DSU    |
| > Native                     |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > Asian or Pacific Islander  | DSU     | DSU    | DSU    | DSU    |
+------------------------------+---------+--------+--------+--------+
| > Asian                      | DNC     | DNC    | DNC    | DNC    |
+------------------------------+---------+--------+--------+--------+
| > Native Hawaiian and other\ | DNC     | DNC    | DNC    | DNC    |
| > Pacific Islander           |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > Black or African American  | 46      | DSU    | 40     | 54     |
+------------------------------+---------+--------+--------+--------+
| > White                      | 41      | 64     | 35     | 47     |
+------------------------------+---------+--------+--------+--------+
|                              |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > Hispanic or Latino         | DSU     | DSU    | DSU    | DSU    |
+------------------------------+---------+--------+--------+--------+
| > Not Hispanic or Latino     | DSU     | DSU    | DSU    | DSU    |
+------------------------------+---------+--------+--------+--------+
| > Black or African American  | DSU     | DSU    | DSU    | DSU    |
+------------------------------+---------+--------+--------+--------+
| > White                      | DSU     | DSU    | DSU    | DSU    |
+------------------------------+---------+--------+--------+--------+
| **Gender**                   |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > Female                     | 39      | 55     | 34     | 46     |
+------------------------------+---------+--------+--------+--------+
| > Male                       | 44      | 73     | 38     | 49     |
+------------------------------+---------+--------+--------+--------+
| **Age**                      |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > 20 to 44 years             | 45      | 75     | 37     | 49     |
+------------------------------+---------+--------+--------+--------+
| > 45 to 64 years             | 41      | 62     | 36     | 47     |
+------------------------------+---------+--------+--------+--------+
| > 65 years and older         | 33      | 44     | 32     | 45     |
+------------------------------+---------+--------+--------+--------+
| **Family income level**^†^   |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > Lower income               | DNC     | DNC    | DNC    | DNC    |
| > ([\<]{.underline}130       |         |        |        |        |
| > percent of poverty         |         |        |        |        |
| > threshold)                 |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| > Higher income (\>130       | DNC     | DNC    | DNC    | DNC    |
| > percent of poverty         |         |        |        |        |
| > threshold)                 |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| **Disability status**        |         |        |        |        |
+------------------------------+---------+--------+--------+--------+
| Persons with disabilities    | DNC     | DNC    | DNC    | DNC    |
+------------------------------+---------+--------+--------+--------+
| Persons without disabilities | DNC     | DNC    | DNC    | DNC    |
+------------------------------+---------+--------+--------+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data for separate conditions are displayed to further characterize the
issue.

^†^A household income below 130 percent of poverty threshold is used by
the Food Stamp Program.

Note: The table above may have continued from the previous page.

Primary care providers are well positioned in the health care system to
provide preventive services, including nutrition screening and
assessment, referral, and counseling. For example, they can screen for
age-specific and diagnosis-related nutrition risk factors as a part of
routine patient contact. The public views physicians---and registered
dietitians in particular---as credible sources of nutrition
information.[^74] Dietary assessment, counseling, and followup by
physicians and qualified nutrition professionals are effective in
reducing patient dietary fat intake and serum cholesterol.[^75]**^,^**
[^76]**^,^** [^77]**^,^** [^78] For many physicians, referring patients
to qualified nutrition professionals for nutrition assessment,
education, counseling on behavioral change, diet modification, and
specialized nutrition therapies represents appropriate clinical
practice.

Nutrition counseling by registered dietitians and other qualified
nutrition professionals has been found to be cost effective for patients
with hyperlipidemia[^79]**^,^** [^80] and type 2 diabetes mellitus.[^81]
Nutrition services also are a critical component of improved health
outcomes for many other diseases and conditions, including obesity,
gastrointestinal and hepatic disease, renal disease, cancer, HIV/AIDS,
pressure ulcers, burns and trauma, eating disorders, and prenatal care.
A 1997 study that evaluated the cost of covering medical nutrition
therapy under Medicare part B projected savings to the program of \$11
million in 2001 and \$65 million in 2004.[^82]**^,^** [^83] (See Focus
Area 3. Cancer, Focus Area 4. Chronic Kidney Disease, Focus Area 13.
HIV, and Focus Area 16. Maternal, Infant, and Child Health.)

### Food Security

19-18. Increase food security among U.S. households and\
in so doing reduce hunger.

**Target:** 94 percent.

**Baseline:** 88 percent of all U.S. households were food secure in
1995.

**Target setting method:** 6 percentage point improvement (50 percent
decrease in food insecurity; consistent with the U.S. pledge to the 1996
World Food\
Summit).

**Data sources:** Food Security Supplement to the Current Population
Survey, U.S. Department of Commerce, Bureau of the Census; National Food
and Nutrition Survey (beginning in 2001), HHS and USDA.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **U.S. Households, 1995**                      | **Food Secure**     |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 88                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 78                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 91                  |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 76                  |
+------------------------------------------------+---------------------+
| > White                                        | 90                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 75                  |
+------------------------------------------------+---------------------+
| > Mexican American                             | 73                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 89                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 76                  |
+------------------------------------------------+---------------------+
| > White                                        | 91                  |
+------------------------------------------------+---------------------+
| **Lower income level** ([\<]{.underline}130    |                     |
| percent of poverty threshold)\*                |                     |
+------------------------------------------------+---------------------+
| > All                                          | 69                  |
+------------------------------------------------+---------------------+
| > With children (under age 18 years)           | 59                  |
+------------------------------------------------+---------------------+
| > With elderly persons (aged 65 years and      | 85                  |
| > over)                                        |                     |
+------------------------------------------------+---------------------+
| **Higher income level** (\>130 percent of      |                     |
| poverty threshold)\*                           |                     |
+------------------------------------------------+---------------------+
| > All                                          | 94                  |
+------------------------------------------------+---------------------+
| > With children (under age 18 years)           | 91                  |
+------------------------------------------------+---------------------+
| > With elderly persons (aged 65 years and      | 98                  |
| > over)                                        |                     |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| Household characteristics                      |                     |
+------------------------------------------------+---------------------+
| > With children                                | 83                  |
+------------------------------------------------+---------------------+
| > With elderly persons                         | 94                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*A household income below 130 percent poverty threshold is used by the
Food Stamp Program.

Note: The table above may have continued from the previous page.

Food security means that people have access at all times to enough food
for an active, healthy life. It implies that people have nutritionally
adequate and safe foods and sufficient household resources to ensure
their ability to acquire adequate, acceptable foods in socially
acceptable ways---that is, through regular marketplace sources and not
through severe coping strategies like emergency food sources,
scavenging, and stealing. Hunger in this context refers to the uneasy or
painful sensation caused by a lack of food.

While the vast majority of persons in the United States are food secure
and have not experienced resource-constrained hunger, both food
insecurity and hunger have remained a painful fact of life for too many
people.[^84]**^,^** [^85] The specific concern is with food insecurity
and hunger resulting from inadequate household resources. Other sources
of food insecurity (such as illness, child abuse and neglect, or loss of
function or mobility) are not included in this definition. Food
insecurity and hunger may coexist with malnutrition, but they are not
the same thing or even necessarily closely associated. Food insecurity
and hunger, however, are believed to have harmful health and behavioral
impacts in their own right.[^86] These are of particular concern for
pregnant women, children, elderly persons, and other nutritionally
vulnerable groups.[^87]

The United States is committed to increasing food security by working
with local leaders as outlined in the U.S. Action Plan on Food Security,
through USDA's Community Food Security Initiative, and the Maternal and
Child Health Bureau's Healthy Start.[^88]**^,^** [^89]

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-3. Counseling about health behaviors

2\. Arthritis, Osteoporosis, and Chronic Back Conditions

2-9. Cases of osteoporosis

3\. Cancer

3-1. Overall cancer deaths

3-3. Breast cancer deaths

3-5. Colorectal cancer deaths

3-10. Provider counseling about cancer prevention

4\. Chronic Kidney Disease

4-3. Counseling for chronic kidney failure care

5\. Diabetes

5-1. Diabetes education

5-2. New cases of diabetes

5-6. Diabetes-related deaths

7\. Educational and Community-Based Programs

7-2. School health education

7-5. Worksite health promotion programs

7-6. Participation in employer-sponsored health promotion activities

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

10\. Food Safety

10-4. Food allergy deaths

10-5. Consumer food safety practices

11\. Health Communication

11-4. Quality of Internet health information sources

12\. Heart Disease and Stroke

12-1. Coronary heart disease (CHD) deaths

12-7. Stroke deaths

12-9. High blood pressure

12-11. Action to help control blood pressure

12-13. Mean total blood cholesterol levels

12-14. High blood cholesterol levels

16\. Maternal, Infant, and Child Health

16-10. Low birth weight and very low birth weight

16-12. Weight gain during pregnancy

16-15. Spina bifida and other neural tube defects

16-16. Optimum folic acid levels

16-17. Prenatal substance exposure

16-18. Fetal alcohol syndrome

16-19. Breastfeeding

18\. Mental Health and Mental Disorders

18-5. Eating disorder relapses

22\. Physical Activity and Fitness

22-1. No leisure-time physical activity

22-2. Moderate physical activity

22-3. Vigorous physical activity

22-6. Moderate physical activity in adolescents

22-7. Vigorous physical activity in adolescents

22-9. Daily physical education in schools

22-13. Worksite physical activity and fitness

26\. Substance Abuse

26-12. Average annual alcohol consumption

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Anemia:** A condition in which the hemoglobin in red blood cells falls
below normal. Anemia most often results from iron deficiency but also
may result from deficiencies of folic acid, vitamin B12, or copper, or
from chronic disease, certain conditions, or chronic blood loss.

**Body mass index (BMI):** Weight (in kilograms) divided by the square
of height (in meters), or weight (in pounds) divided by the square of
height (in inches) times 704.5. Because it is readily calculated, BMI is
the measurement of choice as an indicator of healthy weight, overweight,
and obesity.

**Calorie:** Unit used for measuring the energy produced by food when
metabolized in the body.

**Cholesterol:** A waxy substance that circulates in the bloodstream.
When the level of cholesterol in the blood is too high, some of the
cholesterol is deposited in the walls of the blood vessels. Over time,
these deposits can build up until they narrow the blood vessels, causing
atherosclerosis, which reduces the blood flow. The higher the blood
cholesterol level, the greater is the risk of getting heart disease.
Blood cholesterol levels of less than 200 mg/dL are considered
desirable. Levels of 240 mg/dL or above are considered high and require
further testing and possible intervention. Levels of 200-239 mg/dL are
considered borderline. Lowering blood cholesterol reduces the risk of
heart disease.

> **HDL (high-density lipoprotein) cholesterol:** The so-called good
> cholesterol. Cholesterol travels in the blood combined with protein in
> packages called lipoproteins. HDL is thought to carry cholesterol away
> from other parts of the body back to the liver for removal from the
> body. A low level of HDL increases the risk for CHD, whereas a high
> HDL level is protective.
>
> **LDL (low-density lipoprotein) cholesterol:** The so-called bad
> cholesterol. LDL contains most of the cholesterol in the blood and
> carries it to the tissues and organs of the body, including the
> arteries. Cholesterol from LDL is the main source of damaging buildup
> and blockage in the arteries. The higher the level of LDL in the
> blood, the greater is the risk for CHD.

**Complex carbohydrate:** Starch and dietary fiber.

**Coronary heart disease (CHD):** The type of heart disease due to
narrowing of the coronary arteries.

**Dietary fiber:** Plant food components, including plant cell walls,
pectins, gums, and brans that cannot be digested.

***Dietary Guidelines for Americans*:** A report published by the U.S.
Department of Agriculture and U.S. Department of Health and Human
Services that explains how to eat to maintain health. The guidelines
form the basis of national nutrition policy and are revised every 5
years. This chapter refers mostly to the 2000 guidelines.

**Fats/fatty acids:** Fats and fatty acids are hydrocarbon chains ending
in a carboxyl group at one end that bond to glycerol to form fat. Fatty
acids are characterized as saturated, monounsaturated, or
polyunsaturated depending on how many double bonds are between the
carbon atoms. Fatty acids supply energy and promote absorption of
fat-soluble vitamins. Some fatty acids are "essential," because they
cannot be made by the body.

> **Saturated fatty acids:** Fatty acids with no double bonds between
> carbon atoms. Levels of saturated fatty acids are especially high in
> meat and dairy products that contain fat. Saturated fatty acids are
> linked to increased blood cholesterol levels and a greater risk for
> heart disease.
>
> ***Trans*-fatty acids:** Alternate forms of naturally occurring
> unsaturated fatty acids produced in fats as a result of hydrogenation,
> such as when vegetable oil becomes margarine or shortening.
> *Trans*-fatty acids also occur in milk fat, beef fat, and lamb fat.
> These fatty acids have been associated with increased blood
> cholesterol levels.
>
> **Unsaturated fatty acids:** Fatty acids with one or more double bonds
> between carbon atoms. These fatty acids do not raise blood cholesterol
> levels.
>
> **Polyunsaturated:** Fatty acids with more than one double bond
> between carbon atoms.
>
> **Monounsaturated:** Fatty acids with one double bond between carbon
> atoms.

**Food Guide Pyramid:** A graphic depiction of U.S. Department of
Agriculture's current food guide that includes five major food groups in
its "base" (grains, vegetables, fruits, milk products, and meats, and
meat substitutes) and a "tip" depicting the relatively small
contribution that discretionary fat and added sugars should make in U.S.
diets. The Food Guide Pyramid provides information on the choices within
each group and the recommended number of servings.

**Food security:** Access by all people at all times to enough food for
an active, healthy life. It includes at a minimum (1) the ready
availability of nutritionally adequate and safe foods, and (2) an
assured ability to acquire acceptable foods in socially acceptable ways.

**Food insecurity:** Limited or uncertain availability of nutritionally
adequate and safe foods or limited and uncertain ability to acquire
acceptable foods in socially acceptable ways.

**HDL-cholesterol:** See cholesterol.

**Hunger:** The uneasy or painful sensation caused by a lack of food.

**Hypertension:** High blood pressure.

**Hypertriglyceridemia:** Elevated levels of triglycerides in the blood.

**Iron deficiency:** Lack of adequate iron in the body to support and
maintain functioning. It can lead to iron deficiency anemia, a reduction
in the concentration of hemoglobin in the red blood cells due to a lack
of iron supply to the bone marrow.

**LDL-cholesterol:** See cholesterol.

**Linear growth:** Increase in length or height.

**Medical nutrition therapy:** Use of specific nutrition counseling and
interventions, based on an assessment of nutritional status, to manage a
condition or treat an illness or injury.

**Metabolism:** The sum total of all the chemical reactions that go on
in living cells.

**Nutrition:** The set of processes by which nutrients and other food
components are taken in by the body and used.

**Obesity:** A condition characterized by excessive body fat.

**Osteoporosis:** A bone disease characterized by a reduction in bone
mass and a deterioration of the bone structure leading to bone
fragility.

**Overweight:** Excess body weight.

**Physical activity:** Bodily movement that substantially increases
energy expenditure.

**Registered dietitian:** A food and nutrition expert who has met the
minimum academic and professional requirements to receive the credential
"RD." Many States and Commonwealths also have licensing laws for
dietitians and nutrition practitioners.

**Sedentary behavior:** A pattern of behavior that is relatively
inactive, such as a lifestyle characterized by a lot of sitting.

**Type 2 diabetes:** The most common form of diabetes, which results
from insulin resistance and abnormal insulin action. Type 2 diabetes was
previously referred to as noninsulin-dependent diabetes mellitus (NIDDM)
and adult-onset diabetes.

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