56.  Counseling to Promote a Healthy Diet



RECOMMENDATION



Counseling adults and children over age 2 to limit dietary intake of fat (especially saturated fat)

and cholesterol, maintain caloric balance in their diet, and emphasize foods containing fiber (i.e.,

fruits, vegetables, grain products) is recommended. There is insufficient evidence to recommend

for or against counseling the general population to reduce dietary sodium intake or increase

dietary intake of iron, beta-carotene, or other antioxidants to improve health outcomes, but

recommendations to reduce sodium intake may be made on other grounds. Women should be

encouraged to consume recommended quantities of calcium (see Clinical Intervention). Parents

should be encouraged to breastfeed their infants. Providing pregnant women with specific

nutritional guidelines to enhance fetal and maternal health is recommended. Although there is

insufficient evidence to recommend for or against special assessment of the dietary needs and

habits of older adults, recommendations to do so can be made on other grounds. There is

insufficient evidence that nutritional counseling by physicians has an advantage over counseling by

dietitians or community interventions in changing the dietary habits of patients. See Chapter 22

regarding the role of iron during pregnancy and in the diets of newborns and young children, and

Chapter 42 regarding the use of folic acid by women of childbearing age. See Chapter 61 regarding

intake of refined sugars and adherent carbohydrates that may affect dental health. Counseling

regarding alcohol consumption is discussed in Chapter 52.



Burden of Suffering



Diseases associated with dietary excess and imbalance rank among the leading causes of illness and

death in the U.S. Major diseases in which diet plays a role include coronary heart disease, some

types of cancer, stroke, hypertension, obesity, and non-insulin-dependent diabetes mellitus.1

Heart disease is the leading cause of death in the U.S.,2 with coronary heart disease accounting for

up to 1.5 million myocardial infarctions and nearly 500,000 deaths each year.2,3 Cancer of the

colon, breast, and prostate, the three forms of cancer most closely associated epidemiologically

with nutritional risk factors, together, cause over 140,000 deaths annually.4 Cerebrovascular

disease, the third leading cause of death, accounted for about 150,000 deaths in 1993.2

Hypertension, another disease with nutritional risk factors, occurs in about 43 million

Americans.5 Caloric intake, when it exceeds energy expenditure, can also lead to overweight and

obesity, which affects about 58 million American adults aged 20 and older.6 Obesity is a risk

factor for a number of serious disorders (see Chapter 21), including both hypertension and

adult-onset diabetes mellitus. An estimated 14 million persons in the U.S. have diabetes mellitus,

which accounts for over 55,000 deaths each year and is a leading cause of neuropathy, peripheral

vascular disease, renal failure, and blindness.2,7



Nutritional factors have also been linked to osteoporosis, constipation, diverticular disease, iron

deficiency anemia (see Chapter 22), oral disease, and malnutrition. An estimated 40% of women

in the U.S. will suffer from osteoporosis-related fractures by the time they reach age 70.8 Hip

fractures in particular are associated with significant pain and disability, decreased functional

independence, and high mortality; there is a 15-20% reduction in expected survival in the first

year following a hip fracture.9 Constipation is a complaint of over 4.5 million Americans,10 and

intestinal diverticular disease is reported by nearly 1.5 million persons.11 The average

schoolchild has at least one cavity in permanent teeth by age 9, three cavities by age 12, and eight

by age 17.12 The average adult in the U.S. has 10-17 decayed, missing, or filled permanent teeth

and one untreated decayed permanent tooth.13 Disorders of both overeating and undereating are

common among older adults, up to 40% of whom have inadequate dietary intake of three or more

nutrients.14 Many older adults suffer from protein-calorie malnutrition_up to 50% of nursing

home residents in the U.S. may be malnourished,15 and an additional number suffer from

marginal malnutrition that is less clinically evident.



Efficacy of Risk Reduction



Eating habits over a lifetime can have a significant impact on the incidence and severity of many

health disorders. The complete body of literature regarding the health effects of foods is beyond the

scope of this report and has been the subject of extensive reviews.1,16 In summary, it is clear

that a direct relationship exists between nutritional risk factors and certain key diseases. It is

well established, for example, that caloric imbalance (intake exceeding expenditure) can lead to

overweight and obesity. Persons who are overweight are at increased risk of glucose intolerance,

hypertension, high blood cholesterol, and other disorders (see Chapter 21); reduction of body

weight has been shown to reduce these risks.17-20 The average person is likely to benefit from

dietary practices and physical activity (see Chapter 55) that keep caloric intake commensurate

with daily energy expenditures. In addition to the overall objective of caloric balance, modified

intake of specific dietary factors may also help prevent certain diseases.



Reduced intake of dietary fat, especially saturated fats (and, possibly, partially hydrogenated

vegetable fats), appears to reduce the risk of developing coronary heart disease. A large body of

epidemiologic evidence links serum cholesterol levels to the development of coronary

atherosclerosis.21-23 Serum cholesterol levels can in turn be modified by dietary measures.

Clinical trials incorporating reduced total or saturated fat intake, either as a sole intervention or

as part of a multifactorial intervention, have reported mixed results in reducing serum

cholesterol levels and in decreasing the incidence of cardiac events, such as myocardial infarction

and sudden death.24-32 Intake of saturated fat correlates more closely with serum cholesterol

levels than does total fat intake. Clinical trials have also found that serum cholesterol-lowering

drugs can reduce the incidence of coronary heart disease in asymptomatic middle-aged men with

hyperlipidemia.33-38 These studies found that the incidence of cardiac events in such men is

decreased by an average of 2% for every 1% reduction in serum cholesterol (see Chapter 2).

(Evidence regarding benefits in persons with preexisting coronary heart disease is reviewed in

Chapter 2.)



Modeling studies based on these data suggest that coronary heart disease mortality rates in the U.S.

could be lowered by 5-20% if all Americans restricted their fat intake to less than 30% of total

calories but that increases in life expectancy among low-risk persons might be modest.39-41

Two randomized controlled trials reported that a low-fat diet does not increase high-density

lipoprotein (HDL) cholesterol levels unless coupled with physical activity,42,43 and one

meta-analysis of 27 trials suggested that substantial reductions in dietary fat intake might lower

HDL cholesterol levels.44 Some observational studies also suggest a possible association between

intake of trans-isomers of fatty acids (formed in the partial hydrogenation of vegetable oils) and

unfavorable changes in low-density lipoprotein (LDL) and HDL cholesterol45,46 and in the risk

of coronary heart disease;47-49 others suggest an association between fatty acids found primarily

in fish oils and reduced risk of cardiovascular disease.50-52 Dietary cholesterol intake may also

influence serum cholesterol levels, especially LDL cholesterol levels, but the association appears

to be weaker and more variable than that of dietary saturated fat intake.1 Finally, prospective

cohort data suggest that a diet with increased intake of fruits and vegetables is associated with

decreased risk of stroke, but further study is needed.53



The association between foods high in dietary fat and certain forms of cancer is currently under

investigation. An effect of dietary fat on carcinogenesis has been demonstrated in animal research.

Furthermore, international comparisons of cancer incidence and most case-control studies have

revealed an epidemiologic correlation between dietary fat consumption and the incidence of cancer

of the breast, colon, prostate, and lung.54-63 Within more homogenous populations, however,

cohort studies to date have been unable to provide consistent evidence of a causal relationship

between increased dietary fat consumption and the incidence of breast, prostate, colon, or other

cancers.64-74 Similarly, inconsistent results have been reported in epidemiologic studies of the

link between low blood cholesterol and cancer.75,76 Clinical trials are now in progress to

examine further the relationship between dietary fat and cancer.77 These and other studies may

help elucidate whether low-fat diets reduce cancer risk because of decreased fat intake or because

of increased intake of fruits, vegetables, or fiber (see below).



A diet emphasizing the consumption of foods high in complex carbohydrates and fiber (e.g., whole

grain foods and cereal products, vegetables [including dried beans and peas], and fruits) is an

important means of lowering dietary fat consumption by replacing caloric intake from fat. Foods

high in complex carbohydrates and fiber and low in fat content also have lower average caloric

density, and they are therefore preferred for maintaining caloric balance and healthful body

weight.1,78,79 There are other health benefits associated with the replacement of foods high in

simple carbohydrates (e.g., table sugar, honey, corn sweeteners) with those containing starch and

fiber. In addition to improving caloric balance, reduced intake and less frequent consumption of

refined sugars may lower the risk of developing dental caries (see also Chapter 61),80-85 and

the avoidance of highly refined grain products reduces the contribution of "empty calories" to the

diet.86



Increased intake of dietary fiber improves gastrointestinal function.87 Certain types of dietary

fiber may also be helpful in the treatment of glucose intolerance, weight reduction, and the control

of lipid disorders.87,88 The consumption of foods containing large amounts of soluble fiber (e.g.,

dried beans, oat products) appears to lower levels of LDL cholesterol (independent of their

replacement of foods high in saturated fat and cholesterol).89,90 An insoluble high-fiber diet

(most plant foods) may be effective in reducing intracolonic pressure and preventing diverticular

disease.91 The risk of developing colorectal cancer may also be influenced by dietary fiber intake.

At least 15 cross-cultural studies have shown an inverse relationship between dietary fiber

consumption and the incidence of colon cancer.92,93 Such studies do not, however, provide direct

evidence that high dietary fiber intake, rather than other population dietary characteristics (e.g.,

low fat intake), is directly responsible for the lower cancer incidence rate. Case-control studies

have produced inconsistent results regarding the association between dietary fiber and colon

cancer.94-97 Meta-analyses of these studies, however, suggest an overall benefit from dietary

fiber.98,99 Observational studies also suggest an association between intake of vegetables and

fruits and lower risk of cancer.86 Cohort studies to date that have examined the relationship

between dietary fiber and cancer have produced inconsistent results and suffer from methodologic

limitations, including the difficulty of determining whether observed benefits were due to fiber

itself or to its substitution of foods high in saturated fats.73,100-103



Reduced intake of dietary sodium may be of clinical benefit to persons who either have

sodium-dependent hypertension or are likely to develop it in the future.104 A number of clinical

trials and recent meta-analyses have demonstrated the ability of dietary sodium restriction to

lower blood pressure by at least several millimeters of mercury in some hypertensive and

normotensive individuals.105-118 In addition, cross-cultural studies have shown a correlation

between the sodium intake of different populations and the incidence of hypertension.119-121 A

multinational study involving 52 sites also demonstrated an association between sodium excretion

and the rate of change of blood pressure with age.122 However, controlled prospective studies will

ultimately be necessary to provide definitive evidence that normotensive persons who practice

dietary sodium restriction are at lower risk of developing hypertension over time than are those

with more typical sodium consumption. 



Many American women and adolescent girls consume less dietary calcium than is recommended by

major groups (men: 1,000 mg/day; adolescents and young adults, 1,200-1,500 mg/day; women

25-50 years of age, 1,000 mg/day; postmenopausal women, 1,000-1,500 mg/day; pregnant and

nursing women, 1,200-1,500 mg/day).123 Population and cross-sectional studies suggest that

reduced calcium intake among women, especially young women, may be an important risk factor

for bone mineral loss and postmenopausal osteoporosis,124,125 and studies suggest that calcium

supplementation in adolescence and early adulthood may increase bone mineral density.126,127

Prospective studies of asymptomatic postmenopausal women have produced inconsistent results

about the efficacy of increasing dietary calcium intake as a means of slowing bone loss. Although

some studies have reported that a daily intake of 750-1,700 mg/day can reduce significantly the

rate of bone loss in asymptomatic postmenopausal women,128-130 other controlled studies have

shown either no effect or an effect only on compact bone with doses as high as 1,800-2,000 mg/

day.131-134 A meta-analysis of intervention and observational studies concluded that 1,000 mg

of calcium daily would prevent about 1% of bone loss per year.135 Clinical trials suggest that

calcium supplementation may reduce the risk of fractures in postmenopausal women.135a,135b

In such women, however, estrogen replacement therapy may be a more effective form of

chemoprophylaxis than calcium supplementation (see Chapter 68). (See also the discussion of the

relationship between exercise and bone density in Chapter 55.) There appears to be little

significant risk for women who moderately increase their consumption of dietary calcium. Gross

and prolonged use of calcium supplements may, under unusual circumstances, result in milk

alkali syndrome or an increased occurrence of kidney stones, although direct evidence of the latter

is lacking.136



Adequate dietary iron intake may be important for menstruating women and for young children to

maintain iron stores and prevent iron deficiency anemia. This topic is discussed in detail in

Chapter 22. Although infants and young children may benefit from iron supplementation (see

below), there is little evidence from prospective studies of older children and menstruating

women that mild anemia in the absence of symptoms is a direct cause of increased morbidity or

mortality. It may be clinically prudent, however, to recommend diets including iron-rich foods

(e.g., lean meats, certain beans, iron-enriched and whole grain products) for persons at increased

risk of iron deficiency.



Current research is exploring the potential health benefits of other minerals and vitamins. For

example, evidence suggests that women of childbearing age who take folic acid supplements may be

less likely to give birth to children with neural tube defects (see Chapter 42).137 The role of

beta-carotene, vitamins (e.g., vitamin A, vitamin C, vitamin E), and other antioxidants in

reducing the risk of cancer, atherosclerosis, and other chronic diseases is currently being

studied.138-143 



Special Populations



Infants and Children.  Infants require breast milk or appropriate alternatives (e.g., infant

formulas) to provide adequate nutrition. Nutritional status remains important throughout

childhood to facilitate normal growth and development.144 Epidemiologic evidence and randomized

prospective studies suggest that infant consumption of breast milk for at least 6 months may

reduce the risk of otitis media, lower respiratory tract illness, meningitis, allergic illness,

diarrhea, hospital admissions, and abnormal cognitive development in the child.145-147

Breast-fed infants often have higher blood cholesterol levels than formula-fed infants, but

current evidence, with the exception of one cohort study,148 suggests that these elevations

resolve with weaning149 and are not linked to adult blood cholesterol levels or increased risk of

heart disease. Iron deficiency anemia during infancy may also be associated with impaired infant

neurologic and cognitive development,150 and infants may therefore benefit from iron-fortified

formula and foods to replace depleted iron stores.



The benefits of reduced dietary fat intake during childhood are uncertain. There is some

epidemiologic evidence of tracking (persistence of childhood elevations of blood cholesterol into

adulthood) and autopsy evidence of atherosclerotic disease among children and young adults with

elevated cholesterol levels,151,152 but evidence of improved health outcomes from lowering

blood cholesterol during childhood is lacking. Observational studies provide evidence that children

can achieve statistically significant reductions in total and LDL cholesterol levels through dietary

fat reduction.153,154 A potential risk of such interventions is that excessive low-fat diets may

not provide children with sufficient nutrients for healthy growth and development,155 but direct

evidence of this adverse effect is limited to extreme cases of dietary restriction. A cross-sectional

study found that 10-year-old children with low fat intake had no significant differences in

anthropometric measurements, but they were more likely to be deficient in the Recommended

Dietary Allowances for calcium, phosphorus, magnesium, iron, and certain vitamins.156 A recent

randomized controlled trial involving children aged 8-10 reported that a diet providing 28% of

energy from total fat achieved statistically significant reductions in LDL cholesterol levels with no

significant effects on height, ferritin levels, or selected psychometric indices.157



Pregnant Women.  Nutritional status is especially important during pregnancy. Studies have

shown that low birth weight and neonatal mortality are more common in pregnant women with

very poor nutritional status158,159 and in those who fail to gain adequate weight during

pregnancy,160-163 although factors other than nutrient intake may account for these outcomes.

Prenatal programs providing nutritional support for pregnant women have been associated with

improved perinatal outcomes.164 Pregnancy brings increased requirements for energy and

specific nutrients, such as protein, calcium, folic acid, and iron.162,165,166 Oral iron

supplements may be beneficial in preventing iron deficiency anemia in pregnancy, and they are

often prescribed routinely as part of prenatal health care. Although an association between

moderate to severe iron deficiency anemia and adverse obstetric outcomes has been demonstrated

in some observational studies, there is little direct evidence that routine iron supplementation

during pregnancy (in the absence of documented anemia or iron deficiency) results in improved

clinical outcome for the mother or fetus.167



Older Adults.  The elderly can also have special nutritional requirements. Depending on the

patient's nutritional status, underlying medical disorders, functional status, dentition, and

therapeutic drug regimens, it can be important to modify recommended daily intake levels of

calories, sodium, calcium, water, dietary fat, fiber, protein, and other nutrients to reduce the

risk of complications.168 Observational data suggest that older adults benefit to some extent by

reducing elevated blood cholesterol levels.169 It is unclear from current evidence whether women

who have already developed clinical evidence of postmenopausal osteoporosis benefit from calcium

supplementation.170-173 Clinical recognition of protein-calorie malnutrition, especially when

manifested by clinically subtle findings, is often delayed among older adults. This has prompted the

introduction of nutritional screening initiatives in this population,174 but direct evidence of

clinical benefit from screening is currently lacking.



Effectiveness of Counseling



The effectiveness of nutritional counseling in changing the dietary habits of patients has been

demonstrated in a number of clinical trials.175 For example, randomized controlled trials have

shown that dietary counseling of patients with high blood cholesterol can lower serum lipids in

both patients and their families176 and that regular reinforcement can enhance compliance with

dietary recommendations.177 Tailored printed materials distributed in primary care settings

have also been effective in lowering dietary fat consumption.178 Other measures that may enhance

compliance with low-fat diets include setting strict limits on fat intake, frequent (e.g., monthly)

monitoring, involvement of family in nutritional counseling sessions, and group sessions.179

Studies have confirmed the effectiveness of nutritional counseling among pregnant women180 and

the important role of parental guidance in modifying the diets of children.181



In most studies of nutritional counseling, however, the counselor was not a physician, but rather a

nurse, nutritionist, registered dietitian, health educator, or psychologist. Many of the

interventions tested in these studies were part of highly specialized or community-wide

programs. Such interventions are not easily reproduced in the typical physician-patient clinical

encounter. Although physicians can often provide general guidelines on proper nutrition, many

lack the time and skills to obtain a thorough dietary history, to address potential barriers to

changes in eating habits, and to offer specific guidance on food selection.182 Patients may also

have difficulty with long-term compliance,183 especially if food selection and preparation for

recommended diets are perceived as unappealing or inconvenient. Fat-containing foods, in

particular, are a popular component of the American diet.184 It is possible, however, that

physicians can overcome many of these limitations by expanding the content of the nutritional

information they provide to patients, by emphasizing to the patient the health benefits of good

nutrition, and by referring those requiring help with dietary changes to qualified registered

dietitians, nutritionists, health educators, nurses, or other providers with greater nutrition

expertise.



Recommendations of Other Groups



Dietary guidelines for the general population have been issued by the Department of Agriculture

and the Department of Health and Human Services185 and reaffirmed by the Surgeon General,1 in

the Year 2000 Objectives for the Nation,186 and in the "Food Guide Pyramid" released in 1992

by the Department of Agriculture.187 The Food and Nutrition Board of the National Research

Council has published Recommended Dietary Allowances (RDAs) for specific nutrients,165 and it

has released an extensive report on diet and chronic disease risk.16 Recommendations for

nutritional counseling of patients have been issued by the American Medical Association,188 the

American College of Physicians,189 the Canadian Task Force,203 and the American Heart

Association.144,190 Guidelines for dietary practices to reduce the risk of cancer have been issued

by the National Research Council,191 the American Cancer Society,192 and the National Cancer

Institute.193 Recommendations on nutritional counseling to reduce cardiac risk factors have been

issued by panels convened by the National Heart, Lung, and Blood Institute194 and by the National

High Blood Pressure Education Program195 and National Cholesterol Education Program,196,197

which are endorsed by over 40 organizations and government agencies. Dietary recommendations

for children have been issued by the American Academy of Pediatrics198,199 and National

Cholesterol Education Program.200 Dietary guidelines for pregnant women have been issued by

the American College of Obstetricians and Gynecologists201 and the Institute of Medicine.162

Recommendations on the use of folic acid supplementation by women have been issued by the U.S.

Public Health Service.202 Dietary guidelines for Americans were updated in 1995.204



CLINICAL INTERVENTION



Adults and children over age 2 should limit dietary intake of fat (especially saturated fat) ("A"

recommendation) and cholesterol ("B" recommendation), maintain caloric balance in their diet

("B" recommendation), and emphasize fruits, vegetables, and grain products containing fiber

("B" recommendation). Both diet and exercise should be designed to achieve and maintain a

desirable weight by keeping caloric intake balanced with energy expenditures. Adolescents and

adults, in particular, should reduce total fat intake to less than 30% of total calories and dietary

cholesterol to less than 300 mg/day. Saturated fat consumption should be reduced to less than 10%

of total calories. To achieve these goals, patients should emphasize consumption of fish, poultry

prepared without skin, lean meats, and low-fat dairy products. They should be encouraged to eat a

variety of foods, with emphasis on the consumption of whole grain products and cereals, legumes,

vegetables, and fruits. Current recommendations from the U.S. Department of Health and Human

Services are for at least five servings of fruits and vegetables and at least six servings of breads,

cereals, or legumes each day. Detailed food selection guidelines for healthy eating are published

elsewhere.185



There is insufficient evidence that, for the general population, reducing dietary sodium intake or

increasing dietary intake of iron, beta-carotene, or other antioxidants results in improved health

outcomes ("C" recommendation); recommendations to reduce sodium intake may be made on other

grounds, including the potential beneficial effects on blood pressure in salt-sensitive persons. See

Chapter 61 for information regarding intake of refined sugars and dental health. Women should be

encouraged to consume recommended quantities of calcium (adolescents and young adults, 1,200-

1,500 mg/day; adults aged 25-50, 1,000 mg/day; postmenopausal women, 1,000-1,500

mg/day; pregnant and nursing women, 1,200-1,500 mg/day123) ("B" recommendation).

Parents should be encouraged to offer breastfeeding to their infants ("A" recommendation).

Pregnant women should receive specific nutritional guidelines to enhance fetal and maternal

health. See Chapter 22 regarding the role of iron during pregnancy and in the diets of newborns

and young children, and see Chapter 42 regarding the use of folic acid by women of childbearing

age. There is insufficient evidence to recommend for or against the special assessment of dietary

needs and habits of older adults ("C" recommendation), but recommendations to do so can be made

on other grounds, such as the increased prevalence of nutrition-related disorders in this age

group. Counseling regarding alcohol consumption is discussed in Chapter 52.



There is insufficient evidence that nutritional counseling by physicians, as opposed to counseling

by dietitians or community interventions, is effective in changing the dietary habits of patients

("C" recommendation). Clinicians who lack the time or skills to perform a complete dietary

history, to address potential barriers to changes in eating habits, and to offer specific guidance on

meal planning and food selection and preparation, should either have patients seen by other trained

providers in the office or clinic or should refer patients to a registered dietitian or qualified

nutritionist for further counseling.



The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by

Steven H. Woolf, MD, MPH.



REFERENCES



	1. Department of Health and Human Services. The Surgeon General's report on nutrition

and health. Washington, DC: Government Printing Office, 1988. (Publication no. DHHS (PHS)

88-50210.)



	2. National Center for Health Statistics. Annual summary of births, marriages, divorces,

and deaths: United States, 1993. Monthly vital statistics report; vol 42, no 13. Hyattsville, MD:

Public Health Service, 1994.



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

TX: American Heart Association, 1995.



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



	5. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult

population: results from the Third National Health and Nutrition Examination Survey, 1988-

1991. Hypertension 1995;25:305-313.



	6. Kuczmarski RJ, Flegal KM, Campbell SM, et al. Increasing prevalence of overweight

among US adults. JAMA 1994;272:205-211.



	7. Geiss LS, Herman WH, Goldschmid MG, et al. Surveillance for diabetes mellitus: United

States, 1980-1989. MMWR CDC Surv Summ 1993;42:1-20.



	8. Audran MJ. Epidemiology, etiology, and diagnosis of osteoporosis. Curr Opin Rheum

1992;4: 394-401.



	9. Jensen GF, Christiansen C, Boesen J, et al. Epidemiology of postmenopausal spinal and

long bone fractures: a unifying approach to postmenopausal osteoporosis. Clin Orthop

1982;166:75-81.



	10. Johanson JF, Sonnenberg A, Koch TR. Clinical epidemiology of chronic constipation. J

Clin Gastroenterol 1989;11: 525-536.



	11. National Center for Health Statistics. Prevalence of selected chronic conditions, United

States, 1979-81. Vital and health statistics; series 10, no 155. Washington, DC: Government

Printing Office, 1986. (Publication no. DHHS (PHS) 86-1583.)



	12. Public Health Service. Oral health of United States children: the national survey of

dental caries in U.S. school children: 1986-1987. National and regional findings. Bethesda:

National Institutes of Health, 1989. (NIH Publication no. 89-2247.)



	13. National Institute of Dental Research. Oral health of United States adults, the national

survey of oral health in U.S. employed adults and seniors: 1985-86. Bethesda: National Institute

of Dental Research, 1987. (Publication no. DHHS (NIH) 87-2868.)



	14. Posner BM, Jette AM, Smith KW, et al. Nutrition and health risks in the elderly: the

Nutrition Screening Initiative. Am J Public Health 1993;83:972-978.



	15. Goodwin JS. Social, psychological, and physical factors affecting the nutritional status

of elderly subjects: separating cause and effect. Am J Clin Nutr 1989;50:1201-1209.



	16. Food and Nutrition Board, National Research Council. Diet and health; implications for

reducing chronic disease. Washington, DC: National Academy Press, 1989.



	17. Henry RR, Schaeffer L, Olefsky, JM. Glycemic effects of intensive caloric restriction

and isocaloric refeeding in noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab

1985;61:917-925.



	18. Henry RR, Wiest-Kent TA, Schaeffer L, et al. Metabolic consequences of

very-low-calorie diet therapy in obese noninsulin-dependent diabetic and nondiabetic subjects.

Diabetes 1986;35:155-164.



	19. MacMahon S, Cutler J, Brittain E, et al. Obesity and hypertension: epidemiological and

clinical issues. Eur Heart J [Suppl B] 1987;8:57-70.



	20. Rifkind BM, Goor R, Schucker B. Compliance and cholesterol-lowering in clinical

trials: efficacy of diet. In: Schettler FG, Gotto AM, Middelhoff G, et al, eds. Atherosclerosis VI.

Proceedings of the Sixth International Symposium. New York: Springer-Verlag, 1983:306-310.



	21. Grundy SM. Cholesterol and coronary heart disease: a new era. JAMA

1986;256:2849-2858.



	22. Posner BM, Cobb JL, Belanger AJ, et al. Dietary lipid predictors of coronary heart

disease in men: the Framingham Study. Arch Intern Med 1991;151:1181-1187.



	23. Menotti A, Keys A, Kromhout D, et al. Twenty-five-year mortality from coronary

heart disease and its prediction in five cohorts of middle-aged men in Finland, the Netherlands, and

Italy. Prev Med 1990;19:270-278.



	24. Dayton S, Pearce ML, Hashimoto S, et al. A controlled clinical trial of a diet high in

unsaturated fat in preventing complications of atherosclerosis. Circulation 1969;40(Suppl 2):1-

63.



	25. Hjermann I, Holme I, Velve Byre K, et al. Effect of diet and smoking intervention on the

incidence of coronary heart disease. Report from the Oslo Study Group of a randomized trial in

healthy men. Lancet 1981;2:1303-1310.



	26. Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor

Intervention Trial: risk factor changes and mortality results. JAMA 1982;248:1465-1477.



	27. World Health Organization European Collaborative Group. European collaborative trial

of multifactorial prevention of coronary heart disease: final report on the 6-year results. Lancet

1986;1: 869-872.



	28. Rinzler S. Primary prevention of coronary heart disease by diet. Bull NY Acad Med

1968;44:936-949.



	29. Turpeinen O, Karvonen MJ, Pekkarinen M, et al. Dietary prevention of coronary heart

disease: the Finnish Mental Hospital Study. Int J Epidemiol 1979;8:99-118.



	30. Miettinen M, Turpeinen O, Karvonen MJ, et al. Effect of cholesterol-lowering diet on

mortality from coronary heart disease and other causes: a twelve-year clinical trial in men and

women. Lancet 1972;2:835-838.



	31. Stamler J. Acute myocardial infarction, progress in primary prevention. Br Heart J

1971;33:145-164.



	32. Frantz ID Jr, Dawson EA, Ashman PL, et al. Test of effect of lipid lowering by diet on

cardiovascular risk: the Minnesota Coronary Survey. Arteriosclerosis 1989;9:129-135.



	33. Report from the Committee of Principal Investigators. A cooperative trial in the

primary prevention of ischaemic heart disease using clofibrate. Br Heart J 1978;40:1069-

1118.



	34. Report of the Committee of Principal Investigators. W.H.O. cooperative trial on

primary prevention of ischaemic heart disease using clofibrate to lower serum cholesterol:

mortality follow-up. Lancet 1980;2:379-385.



	35. Report of the Committee of Principal Investigators. W.H.O. cooperative trial on

primary prevention of ischaemic heart disease with clofibrate to lower serum cholesterol: final

mortality follow-up. Lancet 1984;2:600-604.



	36. The Lipid Research Clinics Coronary Primary Prevention Trial Results. I. Reduction in

incidence of coronary heart disease. JAMA 1984;251:351-364.



	37. The Lipid Research Clinics Coronary Primary Prevention Trial Results. II. The

relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA

1984;251:365-374.



	38. Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study: primary prevention trial with

gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors,

and incidence of coronary heart disease. N Engl J Med 1987;317:1237-1245.



	39. Browner WS, Westenhouse J, Tice JA. What if Americans ate less fat? A quantitative

estimate of the effect on mortality. JAMA 1991;265:3285-3291.



	40. Taylor W, Pass T, Shepard D, et al. Cholesterol reduction and life expectancy: a model

incorporating multiple risk factors. Ann Intern Med 1987;106:605-614.



	41. Grover SA, Abrahamowicz M, Joseph L, et al. The benefits of treating hyperlipidemia to

prevent coronary heart disease: estimating changes in life expectancy and morbidity. JAMA

1992;267:816-822.



	42. Wood PD, Stefanick ML, Williams PT, et al. The effects on plasma lipoproteins of a

prudent weight-reducing diet, with or without exercise, in overweight men and women. N Engl J

Med 1991;325:461-466.



	43. Singh RB, Sircar AR, Singh RG, et al. Dietary modulators of lipid metabolism in the

Indian Diet-Heart Study. Int J Vitam Nutr Res 1992;62:73-82.



	44. Mensink RP, Katan MB. Effect of dietary fatty acids on serum lipids and lipoproteins: a

meta-analysis of 27 trials. Arterioscler Thromb 1992;12:911-919.



	45. Mensink RP, Katan MB. Effect of dietary trans fatty acids on high-density and

low-density lipoprotein cholesterol levels in healthy subjects. N Engl J Med 1990;323:439-

445.



	46. Judd JT, Clevidence BA, Muesing RA, et al. Dietary trans fatty acids: effects on plasma

lipids and lipoproteins of healthy men and women. Am J Clin Nutr 1994;59:861-868.



	47. Siguel EN, Lerman RH. Trans-fatty acid patterns in patients with angiographically

documented coronary artery disease. Am J Cardiol 1993;71:916-920.



	48. Willett WC, Stampfer MJ, Manson JE, et al. Intake of trans fatty acids and risk of

coronary heart disease among women. Lancet 1993;341:581-585.



	49. Ascherio A, Hennekens CH, Buring JE, et al. Trans-fatty acids intake and risk of

myocardial infarction. Circulation 1994;89:94-101.



	50. Dolecek TA. Epidemiological evidence of relationships between dietary polyunsaturated

fatty acids and mortality in the Multiple Risk Factor Intervention Trial. Proc Soc Exp Biol Med

1992;200:177-182.



	51. Kromhout D, Bosschieter EB, deLezenne-Coulander C. The inverse relation between

fish consumption and 20-year mortality from coronary heart disease. N Engl J Med

1985;312:1205-1209.



	52. Shekelle RB, Paul O, Shryock AM, et al. Fish consumption and mortality from coronary

heart disease. N Engl J Med 1985;313:820.



	53. Gillman MW, Cupples LA, Gagnon D, et al. Protective effect of fruits and vegetables on

development of stroke in men. JAMA 1995;273:1113-1117.



	54. Rose DP, Boyar AP, Wynder EL. International comparisons of mortality rates for

cancer of the breast, ovary, prostate, and colon, and per capita food consumption. Cancer

1986;58:2363-2371.



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



	56. Kolonel LN, Hankin JH, Nomura AM. Multiethnic studies of diet, nutrition, and cancer

in Hawaii. In: Hayashi Y, ed. Diet, nutrition, and cancer. Tokyo: Japan Science Society Press,

1986:29-40.



	57. Toniolo P, Riboli E, Protta F, et al. Calorie-providing nutrients and risk of breast

cancer. J Natl Cancer Inst 1989;81:278-286.



	58. Kesteloot H, Lesaffre E, Joossens JV. Dairy fat, saturated animal fat, and cancer risk.

Prev Med 1991; 20:226-236.



	59. Mettlin CJ, Schoenfeld ER, Natarajan N. Patterns of milk consumption and risk of

cancer. Nutr Cancer 1990;13: 89-99.



	60. West DW, Slattery MLI, Robison LM, et al. Adult dietary intake and prostate cancer

risk in Utah: a case-control study with special emphasis on aggressive tumors. Cancer Causes

Control 1991;2:85-94.



	61. Hursting SD, Thornquist M, Henderson MM. Types of dietary fat and the incidence of

cancer at five sites. Prev Med 1990;19:242-253.



	62. Whittemore AS, Wu-Williams AH, Lee M, et al. Diet, physical activity, and colorectal

cancer among Chinese in North America and China. J Natl Cancer Inst 1990;82:915-926.



	63. Howe GR, Hirohata T, Hislop TG, et al. Dietary factors and risk of breast cancer:

combined analysis of 12 case-control studies. J Natl Cancer Inst 1990;82:561-569.



	64. Hirayama T. Epidemiology of breast cancer with special reference to the role of diet.

Prev Med 1978;7:173-195.



	65. Snowden DA, Phillips RL, Choi W. Diet, obesity, and risk of fatal prostate cancer. Am J

Epidemiol 1984;120: 244-250.



	66. Willett WC, Stampfer MJ, Colditz GA, et al. Dietary fat and the risk of breast cancer. N

Engl J Med 1987;316:22-28.



	67. Jones DY, Schatzkin A, Green SB, et al. Dietary fat and breast cancer in the National

Health and Nutrition Examination Survey. I. Epidemiological follow-up study. J Natl Cancer Inst

1987;79:465-471.



	68. Giovannucci E, Rimm EB, Colditz GA, et al. A prospective study of dietary fat and risk of

prostate cancer. J Natl Cancer Inst 1993;85:1571-1579.



	69. Hsing AW, McLaughlin JK, Schuman LM, et al. Diet, tobacco use, and fatal prostate

cancer: results from the Lutheran Brotherhood Cohort Study. Cancer Res 1990;50:6836-6840.



	70. Severson RK, Nomura AMY, Grove JS, et al. A prospective study of demographics, diet,

and prostate cancer among men of Japanese ancestry in Hawaii. Cancer Res 1989;49:1857-1860.



	71. Mills PK, Beeson WL, Phillips RL, Cohort study of diet, lifestyle, and prostate cancer

in Adventist men. Cancer 1989;64:598-604.



	72. Hunter DJ, Willett WC. Diet, body size, and breast cancer. Epidemiol Rev

1993;15:110-132.



	73. Willett WC, Hunter DJ, Stampfer MJ, et al. Dietary fat and fiber in relation to risk of

breast cancer: an 8-year follow-up. JAMA 1992;268:2037-2044.



	74. Willett WC, Stampfer MJ, Colditz GA, et al. Relation of meat, fat, and fiber intake to

the risk of colon cancer in a prospective study among women. N Engl J Med 1990;323:1664-

1672.



	75. Kritchevsky SB. Dietary lipids and the low blood cholesterol-cancer association. Am J

Epidemiol 1992;135: 509-520.



	76. Jacobs D, Blackburn H, Higgins M, et al. Report of the conference on low blood

cholesterol: mortality associations. Circulation 1992;86:1046-1060.



	77. Chlebowski RT, Grosvenor M. The scope of nutrition intervention trials with

cancer-related endpoints. Cancer 1994;74(9 Suppl):2734-2738.



	78. Miller WC, Lindeman AK, Wallace J, et al. Diet composition, energy intake, and

exercise in relation to body fat in men and women. Am J Clin Nutr 1990;52:426-430.



	79. Alford BB, Blankenship AC, Hagen RD. The effects of variations in carbohydrate,

protein, and fat content of the diet upon weight loss, blood values, and nutrient intake of adult

obese women. J Am Diet Assoc 1990;90:534-540.



	80. Gustafsson BE, Quensel CE, Lanke LS, et al. The Vipeholm dental caries study: the effect

of different levels of carbohydrate intake on caries activity in 436 individuals observed for 5

years. Acta Odontol Scand 1954;11:232-364.



	81. Harris R. Biology of the children of Hopewood House, Bowral, Australia. IV.

Observations of dental caries experience extending over five years (1957-1961). J Dent Res

1963;42:1387-1398.



	82. Sundin B. Caries and consumption of sweets in 15- and 18-year-olds interviewed with

visualization. Scand J Dent Res 1990;98:96-101.



	83. Akpata ES, Al-Shammery AR, Saeed HI. Dental caries, sugar consumption and

restorative dental care in 12-13-year-old children in Riyadh, Saudi Arabia. Community Dent

Oral Epidemiol 1992;20:343-346.



	84. Frostell G, Birkhed D, Edwardsson S, et al. Effect of partial substitution of invert

sugar for sucrose in combination with Duraphat treatment on caries development in preschool

children: the Malmo study. Caries Res 1991;25: 304-310.



	85. Holt RD. Foods and drinks at four daily time intervals in a group of young children. Br

Dent J 1991;170:137-143.



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



 	87. Federation of American Societies for Experimental Biology. Physiological effects and

health consequences of dietary fiber. Report to the Food and Drug Administration. Bethesda:

Federation of American Societies for Experimental Biology, 1987.



 	88. Bolton-Smith C, Woodward M, Smith WCS, et al. Dietary and non-dietary predictors of

serum total and HDL-cholesterol in men and women: results from the Scottish Heart Health Study.

Int J Epidemiol 1991;20:95-104.



 	89. Glore SR, Van Treeck D, Knehans AW, et al. Soluble fiber and serum lipids: a literature

review. J Am Diet Assoc 1994;94:425-436.



 	90. Jenkins DJA, Wolever TMS, Rao AV, et al. Effect on blood lipids of very high intakes of

fiber in diets low in saturated fat and cholesterol. N Engl J Med 1993;329:21-26.



 	91. Painter N. Diverticular disease of the colon. In: Trowell H, Burkitt D, Heaton K, eds.

Dietary fibre, fibre-depleted foods and disease. New York: Academic Press, 1985:145-160.



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



 	93. McKeown-Eyssen GE, Bright-See E. Dietary factors in colon cancer: international

relationships. Nutr Cancer 1984;6:160-170.



 	94. Modan B, Barrell V, Lubin F, et al. Low-fiber intake as an etiologic factor in cancer of

the colon. J Natl Cancer Inst 1975;55:15-18.



 	95. Jain M, Cook GM, Davis FG, et al. A case-control study of diet and colorectal cancer. Int

J Cancer 1980;26: 757-768.



 	96. Potter JD, McMichael AJ. Diet and cancer of the colon and rectum: a case-control study.

J Natl Cancer Inst 1986; 76:557-569.



 	97. Sandler RS, Lyles CM, Peipins LA, et al. Diet and risk of colorectal adenomas:

macronutrients, cholesterol, and fiber. J Natl Cancer Inst 1993;85:884-891.



 	98. Trock B, Lanza E, Greenwald P. Dietary fiber, vegetables, and colon cancer: critical

review and meta-analyses of the epidemiologic evidence. J Natl Cancer Inst 1990;82:650-661.



 	99. Howe GR, Benito E, Castelleto R, et al. Dietary intake of fiber and decreased risk of

cancers of the colon and rectum: evidence from the combined analysis of 13 case-control studies. J

Natl Cancer Inst 1992;84:1887-1896.



	100. Hirayama T. A large-scale cohort study on the relationship between diet and selected

cancers of the digestive organs. In: Bruce WR, Correa P, Lipkin M, et al, eds. Banbury Report 7.

Gastrointestinal cancer: endogenous factors. Cold Spring Harbor, NY: Cold Spring Harbor

Laboratory, 1981:409-429.



	101. Kromhout D, Bosschieter EB, de Lezenne Coulander C. Dietary fibre and 10-year

mortality from coronary heart disease, cancer, and all causes: the Zutphen Study. Lancet

1982;2:518-522.



	102. Phillips RL, Snowden DA. Dietary relationships with fatal colorectal cancer among

Seventh-Day Adventists. J Natl Cancer Inst 1985;74:307-317.



	103. Graham S, Zielezny M, Marshall J, et al. Diet in the epidemiology of postmenopausal

breast cancer in the New York State Cohort. Am J Epidemiol 1992;136:1327-1337.



	104. Stamler J. Dietary salt and blood pressure. Ann NY Acad Sci1993;676:122-156.



	105. Grobbee DE, Hofman A. Does sodium restriction lower blood pressure? BMJ

1986;293:27-29.



	106. Parijs J, Joosens JV, Van der Linden L, et al. Moderate sodium restriction and

diuretics in the treatment of hypertension. Am Heart J 1973;85:22-34.



	107. MacGregor GA, Markandu N, Best F, et al. Double-blind, randomized, crossover trial

of moderate sodium restriction in essential hypertension. Lancet 1982;1:351-355.



	108. Langford HG, Blaufox MD, Oberman A, et al. Dietary therapy slows the return of

hypertension after stopping prolonged medication. JAMA 1985;253:657-664.



	109. Morgan T, Adams W, Gillies A, et al. Hypertension treated by salt restriction. Lancet

1978;1:227-230.



	110. Beard TC, Cooke HM, Gray WR, et al. Randomized, controlled trial of a

no-added-sodium diet for mild hypertension. Lancet 1982;2:455-458.



	111. Weinberger MH, Cohen SJ, Miller JZ, et al. Dietary sodium restriction as adjunctive

treatment of hypertension. JAMA 1988;259:2561-2565.



	112. Miller JZ, Daugherty SA, Weinberger MH, et al. Blood pressure response to dietary

sodium restriction in normotensive adults. Hypertension 1983;5:790-795.



	113. Forte JG, Miguel JM, Miguel MJ, et al. Salt and blood pressure: a community trial. J

Hum Hypertens 1989;3: 179-184.



	114. Elliott P. Sodium and blood pressure: a review of the evidence from controlled trials

of sodium reduction and epidemiological studies. Klin Wochenschr 1991;69:3-10.



	115. Cutler J, Follman D, Elliott P, et al. An overview of randomised trials of sodium

reduction and blood pressure. Hypertension 1991;17(Suppl I):I27-I33.



	116. Law MR, Frost CD, Wald NJ. By how much does salt restriction lower blood

pressure? I. Analysis of observational data among populations. II. Analysis of data from trials of

salt reduction. BMJ 1991;302:811-824.



	117. The Trials of Hypertension Prevention Collaborative Research Group. The effects of

nonpharmacologic interventions on blood pressure of persons with high normal levels: results of

the Trials of Hypertension, Phase I. JAMA 1992;267:1213-1220.



	118. Mascioli S, Grimm R Jr, Launer C, et al. Sodium chloride raises blood pressure in

normotensive subjects: the study of sodium and blood pressure. Hypertension 1991;17(Suppl

I):I21-I26.



	119. Page LB, Damon A, Moellering RC Jr. Antecedents of cardiovascular disease in six

Solomon Island societies. Circulation 1974;49:1132-1146.



	120. Kaminer B, Lutz WPW. Blood pressure in bushmen of the Kalahari Desert.

Circulation 1960;22:289-295.



	121. Saunders GM, Bancroft H. Blood pressure studies on negro and white men and women

living in the Virgin Islands of the United States. Am Heart J 1942;23:410-423.



	122. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte

excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ

1988;297:319-328.



	123. National Institutes of Health Consensus Development Panel on Optimal Calcium Intake.

Optimal calcium intake. JAMA 1994;272:1942-1948.



	124. Turner JG, Gilchrist NL, Ayling EM, et al. Factors affecting bone mineral density in

high school girls. NZ Med J 1992;105:95-96.



	125. Murphy S, Khaw KT, May H, et al. Milk consumption and bone mineral density in

middle-aged and elderly women. BMJ 1994;308:939-941.



	126. Johnston CC Jr, Miller JZ, Slemenda CW, et al. Calcium supplementation and

increases in bone mineral density in children. N Engl J Med 1992;327:82-87.



	127. Lloyd T, Andon MB, Rollings N, et al. Calcium supplementation and bone mineral

density in adolescent girls. JAMA 1992;270:841-844.



	128. Horsman A, Gallagher JC, Simpson M, et al. Prospective trial of oestrogen and

calcium in postmenopausal women. BMJ 1977;2:789-792.



	129. Recker RR, Saville PD, Heaney RP. Effect of estrogens and calcium carbonate on bone

loss in postmenopausal women. Ann Intern Med 1977;87:649-655.



	130. Aloia JF, Vaswani A, Yeh JK, et al. Calcium supplementation with and without

hormone replacement therapy to prevent postmenopausal bone loss. Ann Intern Med

1994;120:97-103.



	131. Ettinger B, Genant HK, Cann CE. Postmenopausal bone loss is prevented by treatment

with low-dosage estrogen with calcium. Ann Intern Med 1987;106:40-45.



	132. Riis B, Thomsen K, Christiansen C. Does calcium supplementation prevent

postmenopausal bone loss? A double-blind, controlled clinical study. N Engl J Med

1987;316:173-177.



	133. Nilas L, Christiansen C, Rodbro P. Calcium supplementation and postmenopausal bone

loss. BMJ 1984;289: 1103-1106.



	134. Stevenson JC, Whitehead MI, Padwick M, et al. Dietary intake of calcium and

postmenopausal bone loss. BMJ 1988;297:15-17.



	135. Cumming RG. Calcium intake and bone mass: a quantitative review of the evidence.

Calcif Tissue Int 1990;47: 194-201.



	135a. Chapuy MC, Arlot ME, Delmas PD, et al. Effect of calcium and cholecalciferol

treatment for three years on hip fractures in elderly women. BMJ 1994;308:1081-1082.



	135b. Reid IR, Ames RW, Evans MC, et al. Long-term effects of calcium supplementation

on bone loss and fractures in postmenopausal women: a randomized controlled trial. Am J Med

1995;98:331-335.



	136. Curhan GC, Willett WC, Rimm EB, et al. A prospective study of dietary calcium and

other nutrients and the risk of symptomatic kidney stones. N Engl J Med 1993;328:833-838.



	137. Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by

periconceptional vitamin supplementation. N Engl J Med 1992;327:1832-1835.



	138. Comstock GW, Bush TL, Helzlsouer K. Serum retinol, beta-carotene, vitamin E, and

selenium as related to subsequent cancer of specific sites. Am J Epidemiol 1992;135:115-121.



	139. Manson JE, Buring JE, Satterfield S, et al. Baseline characteristics of participants in

the Physicians' Health Study: a randomized trial of aspirin and beta-carotene in U.S. physicians.

Am J Prev Med 1991;7:150-154.



	140. Stahelin HB, Gey KF, Eichholzer M, et al. Plasma antioxidant vitamins and subsequent

cancer mortality in the 12-year follow-up of the prospective Basel study. Am J Epidemiol

1991;133:766-775.



	141. Ziegler RG, Subar AF, Craft NE, et al. Does beta-carotene explain why reduced cancer

risk is associated with vegetable and fruit intake? Cancer Res 1992;52(7 Suppl):2060S-2066S.



	142. Stampfer MJ, Hennekens CH, Manson JE, et al. Vitamin E consumption and the risk of

coronary disease in women. N Engl J Med 1993;328:1444-1449.



	143. Hodis HN, Mack WJ, LaBree L, et al. Serial coronary angiographic evidence that

antioxidant vitamin intake reduces progression of coronary artery atherosclerosis. JAMA

1995;273:1849-1854.



	144. American Heart Association. Diet in the healthy child: Task Force Committee of the

Nutrition Committee and the Cardiovascular Disease in the Young Council. Circulation

1983;67:1411A-1414A.



	145. Cunningham AS, Jelliffe DB, Jelliffe EFP. Breastfeeding and health in the 1980s: a

global epidemiologic review. J Pediatr 1991;118:659-665.



	146. Lucas A, Brooke OG, Morley R, et al. Early diet of preterm infants and development of

allergic or atopic disease: randomized prospective study. BMJ 1990;300:837-840.



	147. Lucas A, Morley R, Cole TJ, et al. Breast milk and subsequent intelligence quotient in

children born pre-term. Lancet 1992;339:199-248.



	148. Fall CHD, Barker DJP, Osmond C, et al. Relation of infant feeding to adult serum

cholesterol concentration and death from ischaemic heart disease. BMJ 1992;304:801-805.



	149. Jooste PL, Rossouw LJ, Steenkamp HJ, et al. Effect of breast feeding on the plasma

cholesterol and growth of infants. J Pediatr Gastroenterol Nutr 1991;13:139-142.



	150. Lozoff B, Jimenez E, Wolf AW. Long-term developmental outcome of infants with iron

deficiency. N Engl J Med 1991;325:687-694.



	151. Webber LS, Srinivasan SR, Wattigney WA, et al. Tracking of serum lipids and

lipoproteins from childhood to adulthood: the Bogalusa heart study. Am J Epidemiol

1991;133:884-899.



	152. Berenson GS, Wattigney WA, Tracy RE, et al. Atherosclerosis of the aorta and

coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at

necropsy (the Bogalusa heart study). Am J Cardiol 1992;70:851-858.



	153. Quivers ES, Driscoll DJ, Garvey CD, et al. Variability in response to a low-fat,

low-cholesterol diet in children with elevated low-density lipoprotein cholesterol levels.

Pediatrics 1992;89:925-929.



	154. Viikari J, Akerblom HK, Rasanen L, et al. Cardiovascular risk in young Finns. Acta

Paediatr Scand Suppl 1990;365:13-19.



	155. Hardy SC, Kleinman RE. Fat and cholesterol in the diet of infants and young children:

implications for growth, development, and long-term health. J Pediatr 1994;125:S69-S77.



	156. Nicklas TA, Webber LS, Koschak ML, et al. Nutrient adequacy of low fat intakes for

children: the Bogalusa heart study. Pediatrics 1992;89:221-228.



	157. The Writing Group for the DISC Collaborative Research Group. Efficacy and safety of

lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein

cholesterol: the Dietary Intervention Study in Children (DISC). JAMA 1995;273:1429-1435.



	158. Antonov AN. Children born during the siege of Leningrad in 1942. J Pediatr

1947;30:250-295.



	159. Stein A, Susser M, Saenger G, et al. Famine and human development: the Dutch hunger

winter of 1944/45. New York: Oxford University Press, 1974.



	160. Singer JE, Westphal M, Niswander K. Relationship of weight gain during pregnancy to

birthweight and infant growth and development in the first year of life: a report from the

collaborative study of cerebral palsy. Obstet Gynecol 1968;31:417.



	161. Abrams BF, Laros RD. Prepregnancy weight, weight gain, and birthweight. Am J

Obstet Gynecol 1986;154:503.



	162. Institute of Medicine, Subcommittee on Nutritional Status and Weight Gain During

Pregnancy. Nutrition during pregnancy. Washington, DC: National Academy Press, 1990.



	163. Worthington-Roberts BS. Nutrition, fertility, and family planning. In:

Worthington-Roberts BS, Williams SR, eds. Nutrition in pregnancy and lactation. 5th ed. St.

Louis: CV Mosby, 1993:34-63.



	164. Rush D, Leighton J, Sloan NL, et al. The National WIC evaluation: evaluation of the

Special Supplemental Food Program for Women, Infants, and Children. II. Review of past studies of

WIC. Am J Clin Nutr 1988;48:394-411.



	165. National Research Council, Food and Nutrition Board. Recommended dietary

allowances. 10th ed. Committee on Dietary Allowances. Washington, DC: National Academy Press,

1989.



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

Press, 1985.



	167. U.S. Preventive Services Task Force. Routine iron supplementation during pregnancy:

review article. JAMA 1993; 270:2848-2854.



	168. Ahmed FE. Effect of nutrition on the health of the elderly. J Am Diet Assoc

1992;92:1102-1108.



	169. Kronmal RA, Cain KC, Ye Z, et al. Total serum cholesterol levels and mortality risk as

a function of age: a report based on the Framingham data. Arch Intern Med 1993;153:1065-

1073.



	170. Nordin BEC, Horsman A, Crilly RG, et al. Treatment of spinal osteoporosis in

postmenopausal women. BMJ 1980; 280:451-454.



	171. Riggs BL, Seeman E, Hodgson SF, et al. Effect of the fluoride/calcium regimen on

vertebral fracture occurrence in postmenopausal women: comparison with conventional therapy.

N Engl J Med 1982;306:446-450.



	172. Resnick NM, Greenspan SL. Senile osteoporosis reconsidered. JAMA

1989;261:1025-1029.



	173. Fujita T, Fukase M, Miyamoto H, et al. Increase of bone mineral density by calcium

supplement with oyster shell electrolysate. Bone Mineral 1990;11:85-91.



	174. Dwyer JT. Screening older Americans' nutritional health: current practices and

future possibilities. Washington, DC: Nutrition Screening Initiative, 1991.



	175. Glanz K. Nutrition education for risk factor reduction and patient education: a review.

Prev Med 1985;14:721-752.



	176. Knutsen SF, Knutsen R. The Tromso Survey: The Family Intervention Study_the

effect of intervention on some coronary risk factors and dietary habits, a 6-year follow-up. Prev

Med 1991;20:197-212.



	177. Milkereit J, Graves JS. Follow-up dietary counseling benefits attainment of intake

goals for total fat, saturated fat, and fiber. J Am Diet Assoc 1992;92:603-605.



	178. Campbell MK, DeVellis BM, Strecher VJ, et al. Improving dietary behavior: the

effectiveness of tailored messages in primary care settings. Am J Public Health 1994;84:783-

787.



	179. Barnard ND, Akhtar A, Nicholson A. Factors that facilitate compliance to lower fat

intake. Arch Fam Med 1995;4: 153-158.



	180. Kafatos AG, Vlachonikolis IG, Codrington CA. Nutrition during pregnancy: the effects of

an educational intervention program in Greece. Am J Clin Nutr 1989;50:970-979.



	181. Klesges RC, Stein RJ, Eck LH, et al. Parental influence on food selection in young

children and its relationships to childhood obesity. Am J Clin Nutr 1991;53:859-864.



	182. Wechsler H, Levine S, Idelson RK, et al. The physician's role in health promotion: a

survey of primary-care practitioners. N Engl J Med 1983;308:97-100.



	183. Randall DE, Marshall JR, Brasure J, et al. Patterns in food use and compliance with

NCI dietary guidelines. Nutr Cancer 1991;15:141-158.



	184. Drewnowski A. Dietary fats: perceptions and preferences. J Am Coll Nutr

1990;9:431-435.



	185. Department of Agriculture, Department of Health and Human Services. Dietary

guidelines for Americans. 3rd ed. Bulletin no. 232. Washington, DC: Department of Agriculture,

1990.



	186. Department of Health and Human Services. Healthy People 2000: national health

promotion and disease prevention objectives. Washington, DC: Department of Health and Human

Services. (DHHS Publication no. 91-50212.)



	187. Food Guide Pyramid: A Guide to Daily Food Choices. Home and Garden Bulletin no. 232.

Washington, DC: Department of Agriculture, 1992.



	188. Council on Scientific Affairs. Medical evaluation of healthy persons. Chicago:

American Medical Association, 1983.



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

College of Physicians, 1985.



	190. American Heart Association. Dietary guidelines for healthy American adults: a

statement for physicians and health professionals by the Nutrition Committee, American Heart

Association. Circulation 1988;77:721A-724A.



	191. National Research Council, Committee on Diet, Nutrition, and Cancer. Diet, nutrition,

and cancer. Washington, DC: National Academy Press, 1982.



	192. Nixon DW. Nutrition and cancer: American Cancer Society guidelines, programs, and

initiatives. CA Cancer J Clin 1990;40:71-75.



	193. National Cancer Institute. Diet, nutrition, and cancer prevention: the good news.

Washington, DC: Government Printing Office, 1986. (Publication no. DHHS (NIH) 87-2878.)



	194. National Heart, Lung, and Blood Institute. Heart to heart: a manual on nutritional

counseling for the reduction of cardiovascular disease risk factors. Bethesda: National Heart, Lung,

and Blood Institute, 1983. (Publication no. DHHS (NIH) 85-1528.)



	195. National High Blood Pressure Education Program. Working Group Report on primary

prevention of hypertension. Bethesda: National Institutes of Health, 1993 (Publication no.

93-2669.)



	196. National Cholesterol Education Program. Report of the Expert Panel on Population

Strategies for Blood Cholesterol Reduction: executive summary. Arch Intern Med

1991;151:1071-1084.



	197. Summary of the Second Report of the National Cholesterol Education Program (NCEP)

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult

Treatment Panel II). JAMA 1993; 269:3015-3023.



	198. American Academy of Pediatrics Committee on Nutrition. Statement on cholesterol.

Pediatrics 1992; 90:469-473.



	199. American Academy of Pediatrics. Pediatric nutrition handbook. 3rd ed. Elk Grove

Village, IL: American Academy of Pediatrics, 1993.



	200. National Cholesterol Education Program. Report of the Expert Panel on Blood

Cholesterol Levels in Children and Adolescents. Bethesda: National Institutes of Health, 1991.

(Publication no. 91-2732.)



	201. American College of Obstetricians and Gynecologists. Nutrition in pregnancy.

Technical Bulletin no. 179. Washington, DC: American College of Obstetricians and Gynecologists,

1993.



	202. Centers for Disease Control and Prevention. Recommendations for the use of folic acid

to reduce the number of cases of spina bifida and other neural tube defects. MMWR

1992;41:RR-14.



	203. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical

preventive health care. Ottawa: Canada Communication Group, 1994:586-599. 



	204. U.S. Department of Health and Human Services and U.S. Department of Agriculture.

Nutrition and your health: dietary guidelines for Americans. 4th ed. Washington, DC: Government

Printing Office, 1995.