| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 1999;100:450-456.)
© 1999 American Heart Association, Inc.
AHA Conference Proceedings |
Summary of a Scientific Conference on Preventive Nutrition: Pediatrics to Geriatrics
Key Words: AHA Conference Proceedings • prevention • diet • nutrition • obesity • atherosclerosis • diabetes mellitus
 |
Introduction |
|---|
 Top Introduction ObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
The Nutrition Committee of the American Heart Association, with cooperation and support from the Council on Cardiovascular Disease in the Young and the Council on Epidemiology and Prevention, convened a scientific conference on "Preventive Nutrition: Pediatrics to Geriatrics" in Salt Lake City, Utah, 1997. Other sponsors in this endeavor were the American Cancer Society, American Dietetic Association, American Academy of Pediatrics, Division of Nutrition Research Coordination of the National Institutes of Health, and American Society for Clinical Nutrition. The participants of the conference were asked to review the dietary recommendations from several health agencies and the scientific evidence in support of the recommendations and to describe how their commonalities make them appropriate as effective preventive health measures against the major chronic diseases (coronary heart disease, cancer, obesity, and diabetes) for particular age and ethnic groups. Dietary recommendations have been published by each of the above-named health agencies. These recommendations deal with primary prevention. The participants were asked to participate because of their expertise in basic and applied nutrition research and education.
To ensure that the goals of the meeting were effectively met, the plenary session consisted of 18 speakers with expertise in their respective fields. They reviewed the science base for nutrient/disease interactions in the causation of cancer, atherosclerosis, obesity, and diabetes. For each of these chronic diseases, nutrition interactions were addressed from both the epidemiological and clinical perspectives and the biochemical and molecular mechanisms by which specific nutrients are linked to disease. Other speakers and experts were selected to participate in 1 of 4 specific population committees that addressed recommendations targeted to the elderly, women, children, and minorities. They reviewed the available information and identified research needs and gaps in existing recommendations directly relevant to the respective subpopulation. The summary reports from each of these groups are presented later in this document. The conference was directed to physicians and other health professionals (dietitians, dietetic technicians, behavioral scientists, health educators, nutritionists, and nurses), city/county and school healthcare administrators, media and communications specialists, food industry personnel, and members of federal, state, and municipal health and educational agencies.
|
Objectives |
|---|
|
TopIntroductionObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
The objectives of the conference were as follows:
- To review the current state of knowledge on the role of nutritional
factors in the pathogenesis of major chronic diseases.
To synthesize comprehensive preventive nutrition strategies applicable to a broad spectrum of chronic diseases.
To define links between common preventive nutrition strategies that decrease risks for specific diseases such as atherosclerosis, cancer, diabetes, and obesity in children, adults, and the elderly.
To summarize common recommendations for the nutrient groups, carbohydrates, proteins, fats, vitamins, antioxidants, minerals, and fiber in the prevention of atherosclerosis, cancer, diabetes, and obesity.
To emphasize specific needs and differences in various socioeconomic, cultural, and genetically susceptible groups and integrate dietary recommendations for specific groups (namely, children, the elderly, women, and minorities) that can be used to decrease the risk of several chronic diseases.
|
Scientific Process |
|---|
|
TopIntroductionObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
The current scientific basis for nutrient/disease interactions was presented, and the capability of nutritional approaches to decrease risk for several chronic diseases was reviewed. A consensus was then reached through discussions that involved a thorough review of existing recommendations. This review process was based on published clinical and epidemiological literature as well as experimental, biochemical, and molecular studies for recommendations concerning cancer, atherosclerosis, obesity, and diabetes. A review of the database for recommendations in each of the specific population groups was included in discussions by the specific population committees.
|
Scientific Overview |
|---|
|
TopIntroductionObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
"For the two out of three adult Americans who do not smoke and do not drink excessively, one personal choice seems to influence long-term health prospects more than any other: what we eat." Evidence in support of this statement from the first Surgeon General's Report on Nutrition and Health was extensively reviewed during the meeting. A substantial body of clinical and epidemiological evidence shows many common links between nutrients and diet in the 4 major disease categories under consideration: cancer, atherosclerosis, obesity, and diabetes (Table 1
). For example, dietary and
diet-related factors are estimated to have contributed to >30% of
cancer cases in North America. Dietary factors, including a high intake
of saturated fat, are related to some types of cancer (eg, colon,
prostate, and lung). Substantial evidence supports the role of high
total and saturated fat intake in increasing the risk of
atherosclerosis, and there is evidence that dietary
factors are related to higher risks of obesity and diabetes. Foods rich
in other dietary components such as fiber and complex carbohydrates
appear to decrease the risk of certain forms of cancer, such as colon
cancer, as well as coronary heart disease (CHD) and
manifestations of diabetes. In another example, data from a number of
sources suggest that certain components of foods (eg, vitamins A, C,
and E) and other antioxidant compounds are not only protective in terms
of carcinogenesis but also decrease the risk of
atherosclerosis and complications of diabetes.
|
The most likely biological basis for the clinical and
epidemiological evidence is that nutrients contained in the diet can
affect a number of cellular metabolic mechanisms that are
common in the pathogenesis of chronic diseases (Table 2). For example, inflammation,
cell-proliferative responses, and cell-signaling pathways, each
potentially important in the pathogenesis of cancer,
atherosclerosis, and diabetes, can all be affected by
different dietary fatty acids.
|
In the course of reviewing the science base for recommendations
for different age groups and for cancer,
atherosclerosis, obesity, and diabetes, it was realized
that there were far more commonalities among different sets of
recommendations than there were differences. Existing literature
provided a scientific basis to support the conclusion that existing
recommendations crossed disease categories rather than separated them.
In addition, although specific population groups did have particular
needs, the available evidence essentially suggests that all the major
recommendations apply across different population groups. Each of these
sets of recommendations developed by different private and government
organizations may help reduce the risk of cancer,
atherosclerosis, obesity, and diabetes (Table 3).
|
Summary Recommendations for Common Nutritional Guidelines
The consensus in nutrient recommendations from different
organizations can be summarized as follows:
- Saturated fat <10% of calories
Total fat
30% of total calories Polyunsaturated fat
10% of total calories Monounsaturated fat
15% of total calories Cholesterol
300 mg/d Carbohydrates
55% of total calories Total calories to achieve and maintain desirable weight
Salt intake limited to <6 g/d
Because it is difficult for many individuals and populations to calculate diets in weights and percentages, these recommendations can best be achieved by following the US Dietary Guidelines and the Food Guide Pyramid of the US Department of Health and Human Services and Department of Agriculture (USDA). Guidelines include the recommendations that follow:
- Eat a variety of foods.
Balance the food you eat with physical activity—maintain or improve your weight
Choose a diet with plenty of grain products, vegetables, and fruits.
Choose a diet low in fat, saturated fat, and cholesterol.
Choose a diet moderate in sugars.
Choose a diet moderate in salt and sodium.
If you drink alcoholic beverages, do so in moderation.
|
Issues in Special Populations |
|---|
|
TopIntroductionObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
It was agreed that the recommendations listed above should apply to the whole population >2 years of age: children ages 2 to 5 should be phased into the diet. In addition, the specific population committees identified needs and points of emphasis for children, women, the elderly, and minorities, which are summarized below.
Children
Additional evidence from the Pathobiological Determinants of
Atherosclerosis in Youth (PDAY) study has shown that in
older children, the risk factors for coronary artery disease
are the same as in adults. These include elevated plasma
cholesterol levels, diabetes, physical inactivity, and
smoking. These risks are associated with the extent of fatty aortic
lesions. Data are accumulating that dietary and lifestyle modifications
begun in childhood are likely to have benefits later in life.
Comparable studies in the cancer field are lacking, but it is presumed
that early adoption of healthy practices will also decrease long-term
cancer risks. A major concern in the pediatric population is the
increasing prevalence of obesity, which also requires intensive
nutritional education.
Over the past 2 decades, dietary saturated fat and
cholesterol intakes have decreased in American children
without causing an increase in nutrient deficiencies. Nevertheless,
data from the 1994 Infant Nutrition Survey and the USDA Nationwide Food
Consumption Survey (1987–1988) indicate that 23% of young children
(<5 years) receive less than two thirds of the Recommended Dietary
Allowance (RDA) for calcium, iron, or zinc. In several studies in
children, the safety and efficacy of diets to reduce plasma lipid
levels have been demonstrated repeatedly, thus indicating that it is
feasible for school-aged children to adopt diets lower in saturated fat
and cholesterol without compromising growth and
development, which is always a special concern in the pediatric age
group.
Research Needs
- Develop informative biomarkers for all nutrients to
distinguish between RDAs that are set too high and true nutritional
deficiencies.
Develop methods to assess long-term physical activity.
Determine desirable fiber intake on the basis of available evidence.
Develop foods that will help meet nutritional goals by contributing to a healthy diet.
Public Policy
- Implement current and future knowledge relevant to children through
the use of improved physical education and lunch programs in
schools.
With the help of healthcare providers, identify families at high risk of developing chronic diseases.
Promulgate dietary and exercise recommendations to parents, schools, government, industry, and health organizations.
Elderly
The risk of developing any of several major chronic diseases that
kill most Americans, such as CHD, cancer, and diabetes, increases in
the elderly. For example, the 10-year probability of developing heart
disease is 10-fold higher in men or women >65 years of age versus
individuals aged 30 to 34 years. For heart disease, risk factors in the
elderly are similar to those in younger age groups. These include
hyperlipidemia, smoking, low HDL
cholesterol, diabetes, and obesity. Obesity can be
difficult to prevent or treat in the elderly because the ability to
regulate energy intake with energy expenditure appears to decline with
age.
Diet-related factors are also thought to either increase or decrease the risk for cancer, the other major cause of death and disability in the elderly. The benefits of weight control and the consumption of diets rich in food from plant sources and low in saturated fat have been shown to be as important in the elderly as in the general population.
The results of epidemiological and intervention studies indicate that the dietary recommendations promulgated by the USDA, the American Heart Association, the American Cancer Society, and others should lead to decreased rates of heart disease and cancer in the elderly. Specific concerns involving factors that interfere with adoption of these recommendations by the elderly include undernourishment (either in calories or specific macronutrients and micronutrients) secondary to various diseases or deficient diets and the effects of medications administered over the long term.
Research Needs
- Determine the role of micronutrients in the prevention of heart
disease and cancer.
Identify specific components of fruits and vegetables that exert beneficial effects.
Identify factors that can maintain muscle mass with increasing age.
Determine methodology to promote optimal diets and maintain physical activity.
Determine role of hormone replacement therapy.
Identify specific genes and genetic variations that affect risk directly and indirectly by the way they interact with nutrients.
Improve methods of objectively assessing dietary intake.
Public Policy
- Coordinate efforts of public and private health organizations to
publicize the major dietary recommendations developed at this
conference to the population at large as well as the elderly.
Facilitate cooperative efforts between health organizations and the food industry, the American Association of Retired Persons, health maintenance organizations, insurance plans, nursing homes, and community groups.
Advocate for improvement in the national nutrition database for the elderly.
Women
The target population was defined as healthy women and women at
risk for chronic diseases and included all postpubertal females
regardless of age. Obesity is a significant problem in women. Similar
to the population as a whole, dietary factors contribute to the
development of several chronic conditions in women. A number of factors
deserve special emphasis in this group.
Obesity increases a woman's risk for 5 of the leading
causes of death (heart disease, stroke, diabetes,
atherosclerosis, and some types of cancer) and is
associated with increased morbidity and mortality overall. Women have
greater overall weight gain and experience more notable weight
fluctuation than men. Approximately 35% or more of all women 20
years of age are overweight. Importantly, the majority of women
consider themselves overweight, and most are usually trying to lose
weight. Thus, women are particularly at risk for development of
psychological or behavioral disorders associated with food intake,
weight/body image, and self-efficacy. Eating disorders occur more
frequently in young women, and dissatisfaction with body weight and
consequent dieting may continue into adulthood, which contributes
further to weight gain, weight fluctuation, and psychological problems.
As women gain weight, body fat distribution increases risk. Upper-body
obesity in particular has been associated with increased risk of
diabetes mellitus.
The risk of cardiovascular disease and breast
cancer increases with age. CHD is the major cause of death in women and
generally occurs 
10 to 12 years later in life for women than for
men. Premature menopause without estrogen replacement therapy is a risk
factor for CHD. When CHD is diagnosed in women, the rate of morbidity
and mortality is greater than in men. The risk of breast cancer also
increases with early menarche and late menopause and occurs more
frequently in countries in which women have a high average intake of
total and saturated fat, animal protein, total energy, and excess
alcohol. In addition, hypertension occurs in 20% of the adult
population, and women may respond better than men to dietary sodium and
salt restriction. Osteoporosis in aging women, iron deficiency in women
of childbearing age, and risk for neural tube defects in the infant
that develop during pregnancy have all been shown to place women at
special risk, with increased needs for calcium, iron, and folic acid,
as well as improved overall dietary adequacy despite overall energy
intake and weight status.
Research Needs
- Determine the independent effects of vitamin supplements, calcium,
folic acid, alcohol, and phytoestrogens on health and disease
prevention, as well as in the context of the total diet.
Determine the effect of contraceptive use and estrogen replacement on nutrient needs.
Determine the interactions of hormone status, diet, and exercise/physical activity.
Determine the effect of maternal intake of dietary fatty acids on infant growth and development as well as the impact of low birth weight and excessive maternal weight gain on the risk for chronic disease.
Use behavioral research to better understand and characterize eating patterns and dietary practices to improve weight management and develop more effective long-term interventions.
Public Policy
- Target the periconceptional population through physicians'
offices (especially obstetrics and gynecology practices) for the
implementation of the dietary recommendations.
Encourage professional organizations, media groups, and industries that target women to publicize the dietary recommendations for women.
Minority Populations
Although it seems reasonable to assume that all ethnic
groups have similar dietary/nutritional needs, there are numerous
observations of ethnic differences in the occurrence of
nutrition-related risk factors and diseases. Still, the database to
support preventive nutrition recommendations is derived primarily from
studies in white populations. Theoretically, genetic differences can
render a particular set of dietary conditions more harmful or
beneficial in one ethnic group than in another. This is one explanation
for why individuals of different ethnic groups who consume similar
diets might have varying disease profiles. However, another important
explanation does not preclude the presence of ethnic differences in the
predisposition to diet-related diseases; that is, populations differ in
the extent to which they have been exposed to social, cultural, and
economic conditions known to be major determinants of diet-related
diseases. More importantly, even in the presence of known genetic
predisposing factors, conditions such as obesity, diabetes, CHD, and
cancer develop only in the context of a certain set of environmental
circumstances. Genetic factors determine individual variations in
disease susceptibility in response to environmental factors, but the
commonality in genetic factors is much greater than the differences
across ethnic groups. The racial/ethnic designations for US minority
populations are very general groupings based as much on sociopolitical
as on biological influences, and there is tremendous diversity in these
categories. Nonetheless, there is ample evidence that certain minority
populations have acquired the adverse lifestyles that are dominant in
the US population and in some cases have a worse profile than the white
population for lifestyle-related diseases such as obesity,
hypertension, diabetes, CHD, and certain types of cancer. However,
similar findings can be noted for persons living in poverty or other
disadvantageous social circumstances. Ethnic and socioeconomic
factors are critical considerations for the prevention of
lifestyle-related diseases. Attention must be directed toward
culturally determined attitudes, beliefs, and practices, both those
that are socioeconomically related as well as those that may be
relatively independent of socioeconomic status. Some cultural factors
that influence lifestyle behaviors in racial/ethnic minority
populations may be advantageous, such as traditional beliefs and
practices that protect against the adoption of adverse behaviors.
Culturally protective behaviors may coexist with behaviors that reflect
the acquisition of risk associated with the earlier stages of
westernization and upward social mobility.
Research Needs
- Emphasize research on national, social, and behavioral variables
to better identify appropriate environmental, family, and individual
intervention paradigms specific to different minority populations.
Identify reasons for the increased prevalence of obesity in certain minority populations.
Identify reasons for less favorable cardiovascular disease and cancer trends in blacks versus whites.
Determine the role of genetic factors in cross-population differences in disease.
Public Policy
- Involve individuals from the ethnic group in the earliest stages of
intervention programs. The paradigm must be compatible with the
cultural perspectives and social circumstances of the program's target
audience.
Encourage local, state, and federal government to characterize food and nutrient intakes of racial/ethnic minority populations.
Encourage federal, state, and local health authorities to seek creative ways, including funding, to overcome obstacles to increased physical activity and availability of healthful foods in populations of low socioeconomic status.
Encourage public and private sources to fund more interdisciplinary research on communities and cultural change to support the development of culturally appropriate paradigms for reaching low-income and minority populations.
Encourage private industry, especially the food industry, to assume a share of responsibility for closing the diet-related health disparities that affect low-income and minority populations.
Encourage all federally sponsored food programs to adhere to the dietary recommendations.
Encourage state and local health departments to work with local, voluntary health organizations to institute environmental changes that reduce the difficulty of adopting dietary changes at individual, household, and institutional levels.
|
Conclusions |
|---|
|
TopIntroductionObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
The dietary recommendations promulgated by diverse US organizations are in remarkable agreement in their major tenets: (1) consumption of a diet containing a variety of foods; (2) decreased intake of fat, particularly saturated fat, and cholesterol; (3) increased consumption of fruits, vegetables, and whole grains; and (4) consumption of the proper amount of calories to maintain a desirable weight, a goal that is facilitated by regular physical activity. Evidence from numerous published studies indicates that adherence to these recommendations will decrease the risk of developing heart disease, cancer, diabetes, and obesity, the major causes of morbidity and mortality in the United States.
There are major gaps in our knowledge about nutritional adequacy, nutrient-disease interactions, and effective strategies to implement the current recommendations, which have the widely recognized potential to decrease the disease burden of the American population. For example, the reasons for the epidemic of obesity in adults and children of both sexes and all ethnic groups must be firmly established if progress in the prevention and treatment of obesity is to be made. Better indexes of biological sufficiency of micronutrients are needed in order that more accurate RDAs can be determined. Continued identification of specific substances in foods with adverse or beneficial effects on diseases is needed. The numerous genes that probably play a critical role in the causation of major diseases or the protection of individuals from such diseases must be isolated, and their interactions with nutrients must be investigated. Similarly, the roles of specific polymorphic forms of genes that influence individual susceptibility to specific dietary factors must be identified.
Because of the special needs of particular subpopulations, namely, children, women, the elderly, and minorities, some specific recommendations require special emphasis or are not included under the more global recommendations. For children, these include adequate intake of macronutrients to maintain normal growth and development. Special concerns that involve the elderly include undernourishment secondary to chronic disease or the effects of medications and obesity caused by lack of physical activity. Special needs for women include the regular consumption of low-fat dairy products and other calcium-rich foods to prevent osteoporosis and the consumption of folate-rich and folic acid–fortified foods, especially during the childbearing years, to prevent birth defects. Because conditions such as hypertension, obesity, diabetes, heart disease, and certain cancers, all known to be influenced by dietary factors, are often more prevalent in certain ethnic groups, it is extremely important to stress implementation of these recommendations. The challenge of preventing or ameliorating diet-related diseases in minority populations is considerable and involves overcoming the adverse effects of poverty and social disadvantage. Finally, despite significant efforts by all the major health organizations, both public and private, widespread adherence to the current recommendations is lacking. Therefore, innovative programs for education and implementation that involve maximum cooperation between diverse disciplines, thereby minimizing duplication and excess costs, are urgently needed.
|
Acknowledgments |
|---|
We thank the following individuals for their participation as speakers and/or committee members: Adrianne Bendich, Claude Bouchard, L. Arthur Campfield, John Erdman, Maureen Harris, Geoffrey R. Howe, Van S. Hubbard, J. Michael McGinnis, Jose M. Ordovas, Jeremiah Stamler, David F. Williamson, Steven H. Zeisel, Connie Bales, Michael Thun, Terry Bazzarre, Robert H. Eckel, John Foreyt, Ronald M. Krauss, Alan R. Kristal, Lori Mosca, Sandra Bartholmey, Marc S. Jacobson, Suzette Middleton, Linda Van Horn, Kathy Wiemer, Alexis M. Williams, Christine L. Williams, Tim Byers, Noel Chavez, Yvonne Jackson, Steven Shea. Also, we thank Wahida Karmally, Dr Sarah Couch, and Cindy MacDonough for their advice and contributions in reviewing this statement. The conference planning committee expresses its appreciation to the following organizations for providing educational grants: The American Heart Association, Campbell Soup Company, Hoffman-LaRoche, Inc, the Proctor and Gamble Company, and the Martin Himmel Health Foundation.
|
Footnotes |
|---|
A single reprint of this article is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71-0168.
|
References |
|---|
|
TopIntroductionObjectivesScientific ProcessScientific OverviewIssues in Special PopulationsConclusionsReferences |
|---|
-
Dept of Health and Human Services (USDHHS): Public
Health Service. The Surgeon General's Report on Nutrition and
Health. Washington, DC: US Government Printing Office; 1988. DHHS
publication (PHS) 88–50210.
-
Doll R, Peto R. The causes of cancer: quantitative
estimates of avoidable risks of cancer in the United States today.
J Natl Cancer Inst. 1981;66:1191–1308.
-
Howe GR, Benito E, Castelleto R, Cornee J, Esteve J,
Gallagher RP, Iscovich JM, Deng-ao J, Kaaks R, Kune GA, 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.
[Abstract/Free Full Text]
-
Willett WC. Who is susceptible to cancers of the breast,
colon, and prostate? Ann N Y Acad Sci. 1995;768:1–11.[Medline]
[Order article via Infotrieve]
-
Leren P. The effect of plasma cholesterol
lowering diet in male survivors of myocardial infarction: a controlled
clinical trial. Acta Med Scand Suppl. 1966;466:1–92.[Medline]
[Order article via Infotrieve]
-
Dayton S, Pearce ML, Hashimoto S, Dixon WJ, Tomiyasu U. A
controlled clinical trial of a diet high in unsaturated fat in
preventing complications of atherosclerosis.
Circulation. 1969;40(suppl 2):II-11–II-63.
-
Golay A, Bobbioni E. The role of dietary fat in obesity.
Int J Obes Relat Metab Disord. 1997;21:S2–S11.
-
Berry EM. Dietary fatty acids in the management of
diabetes mellitus. Am J Clin Nutr. 1997;66:991S-997S.
[Abstract/Free Full Text]
-
Jenkins DJ. Carbohydrate tolerance and food frequency.
Br J Nutr. 1997;77:S71–S81.
-
Position of the American Dietetic Association: health
implications of dietary fiber. J Am Diet Assoc. 1997;97:1157–1159.[Medline]
[Order article via Infotrieve]
-
Health and nutrition news about soy: researchers from around
the world present on wide range of chronic diseases. The Soy
Connection. 1997;5.
-
Mollerup S, Haugen A. Differential effect of polyunsaturated
fatty acids on cell proliferation during human epithelial in vitro
carcinogenesis: involvement of epidermal growth factor receptor
tyrosine kinase. Br J Cancer. 1996;74:613–618.[Medline]
[Order article via Infotrieve]
-
Rotondo D, Earl CR, Liang KJ, Kaimakamis D. Inhibition of
cytokine-stimulated thymic lymphocyte proliferation by fatty
acids: the role of eicosanoids. Biochim Biophys Acta. 1994;1223:185–194.[Medline]
[Order article via Infotrieve]
-
Buring JE, Gaziano JM. Antioxidant vitamins and
cardiovascular disease. In: Bendich A, Deckelbaum RJ,
eds. Preventive Nutrition: The Comprehensive Guide for Health
Professionals. Totowa, NJ: Humana Press; 1997:171–180.
-
Fontham ETH. Prevention of upper gastrointestinal tract
cancers. In: Bendich A, Deckelbaum RJ, eds. Preventive Nutrition:
The Comprehensive Guide for Health Professionals. Totowa, NJ:
Humana Press; 1997:33–55.
-
Weinstein IB, Santella RM, Perera FP. Molecular biology and
molecular epidemiology of cancer. In: Greenwald
P, Kramer BS, Weed DL, eds. Cancer Prevention and Control.
New York, NY: Marcel Dekker Inc; 1995.
-
Baillie GM, Sherer JT, Weart CW. Insulin and coronary
artery disease: is syndrome X the unifying hypothesis? Ann
Pharmacother. 1998;32:233–247.[Abstract]
-
Giovannucci E. Insulin and colon cancer. Cancer Causes
Control. 1995;6:164–179.[Medline]
[Order article via Infotrieve]
-
US Dept of Health and Human Services and US Dept of
Agriculture. Nutrition and Your Health: Dietary Guidelines for
Americans. 4th ed. Washington, DC: US Government Printing Office;
1995;402–519.
-
US Dept of Agriculture, Agricultural Research Service,
Dietary Guidelines Committee, 1995. Report of the Dietary
Guidelines Advisory Committee on the Dietary Guidelines for Americans,
1995, to the Secretary of Health and Human Services and the Secretary
of Agriculture.
-
Strong JP, Malcom GT, Oalmann MC, Wissler RW. The PDAY
Study: natural history, risk factors, and pathobiology: Pathobiological
Determinants of Atherosclerosis in Youth. Ann
N Y Acad Sci.. 1997;811:226–235.
[Free Full Text]
-
Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL.
Overweight prevalence and trends for children and adolescents: the
National Health and Nutrition Examination Surveys, 1963 to 1991.
Arch Pediatr Adolesc Med. 1995;149:1085–1091.[Abstract]
-
Kuczmarski RJ. Trends in body composition for infants and
children in the US. Crit Rev Food Sci Nutr. 1993;33:375–387.[Medline]
[Order article via Infotrieve]
-
Daily dietary fat and total food-energy intakes: Third
National Health and Nutrition Examination Survey, Phase 1, 1988–1991.
MMWR Morb Mortal Wkly Rep. 1994;43:116, 117, 123–125.[Medline]
[Order article via Infotrieve]
-
Peterkin B, Rizek R, Tippett K. Nationwide Food
Consumption Survey, 1987. Nutr Today. 1988;23:18–24.
-
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.[Abstract]
-
McPherson RS, Nichaman MZ, Kohl HW, Reed DB, Labarthe DR.
Intake and food sources of dietary fat among schoolchildren in The
Woodlands, Texas. Pediatrics. 1990;86:520–526.
[Abstract/Free Full Text]
-
1999 Heart and Stroke Statistical Update. Dallas,
Tex: American Heart Association; 1999.
-
Schaefer EJ, Lichtenstein AH, Lamon-Fava S, McNamara JR,
Ordovas JM. Lipoproteins, nutrition, aging, and
atherosclerosis. Am J Clin Nutr.
1995;61(suppl 3):726S-740S.
-
American Cancer Society Advisory Committee on Diet, Nutrition,
and Cancer Prevention. Guidelines on diet, nutrition, and cancer
prevention: reducing the risk of cancer with healthy food choices and
physical activity. CA Cancer J Clin. 1996;46:325–341.[Abstract]
-
St. Jeor ST. The role of weight management in the health
of women. J Am Diet Assoc. 1993;93:1007–1012.[Medline]
[Order article via Infotrieve]
-
Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing
prevalence of overweight among US adults: the National Health and
Nutrition Examination Surveys, 1960 to 1991. JAMA. 1994;272:205–211.[Abstract]
-
Horm J, Anderson K. Who in America is trying to lose weight?
Ann Intern Med. 1993;119:672–676.
[Abstract/Free Full Text]
-
Poston WS, Foreyt JP, Goodrick GK. The eating self-efficacy
scale. In: St. Jeor ST. Obesity Assessment: Tools, Methods,
Interpretations. New York, NY: Chapman & Hall; 1997:317–325.
-
Andersen AE. Gender differences in eating disorders. Paper
presented at the Scientific Symposium on Eating Disorders,
National Institute of Mental Health; May 7–8, 1993; Chicago, Ill.
-
Tinker LF. Diabetes mellitus: a priority health care
issue for women. J Am Diet Assoc. 1994;94:976–985.[Medline]
[Order article via Infotrieve]
-
Kris-Etherton PM, Krummel D. Role of nutrition in the
prevention and treatment of coronary heart disease in women.
J Am Diet Assoc. 1993;93:987–993.[Medline]
[Order article via Infotrieve]
-
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. JAMA. 1993;269:3015–3023.[Medline]
[Order article via Infotrieve]
-
Hankin JH. Role of nutrition in women's health: diet and
breast cancer. J Am Diet Assoc. 1993;93:994–999.[Medline]
[Order article via Infotrieve]
-
Howe G, Rohan T, Decarli A, Iscovich J, Kaldor J,
Katsouyanni K, Marubini E, Miller A, Riboli E, Toniolo P, et al.
The association between alcohol and breast cancer risk: evidence from
the combined analysis of six dietary case-control studies.
Int J Cancer. 1991;47:707–710.[Medline]
[Order article via Infotrieve]
-
Wardlaw GM. Putting osteoporosis in perspective. J
Am Diet Assoc. 1993;93:1000–1006.[Medline]
[Order article via Infotrieve]
-
West CE. Strategies to control nutritional anemia.
Am J Clin Nutr. 1996;64:789–790.
[Free Full Text]
-
Werler MM, Louik C, Shapiro S, Mitchell AA. Prepregnant weight
in relation to risk of neural tube defects. JAMA. 1996;275:1089–1092.[Abstract]
-
Bell RA, Mayer-Davis EJ, Jackson Y, Dresser C. An
epidemiologic review of dietary intake studies among American Indians
and Alaska natives: implications for heart disease and cancer risk.
Ann Epidemiol. 1997;7:229–240.[Medline]
[Order article via Infotrieve]
-
Polednak AP. Racial and Ethnic Differences in
Disease. New York, NY: Oxford University Press; 1989.
-
Kumanyika SK. Special issues regarding obesity in
minority populations. Ann Intern Med. 1993;119:650–654.
[Abstract/Free Full Text]
-
Kumanyika SK. Diet and nutrition as influences on the
morbidity/mortality gap. Ann Epidemiol. 1993;3:154–158.[Medline]
[Order article via Infotrieve]
-
Wild SH, Laws A, Fortmann SP, Varady AN, Byrne CD. Mortality
from coronary heart disease and stroke for six ethnic groups in
California, 1985–1990. Ann Epidemiol. 1995;5:432–439.[Medline]
[Order article via Infotrieve]
-
Kumanyika SK, Golden PM. Cross-sectional differences in
health status in US racial/ethnic minority groups: potential influence
of temporal changes, disease, and life-style transitions. Ethn
Dis. 1991;1:50–59.[Medline]
[Order article via Infotrieve]
-
Smith GD, Wentworth D, Neaton JD, Stamler R, Stamler J.
Socioeconomic differentials in mortality risk among men screened for
the Multiple Risk Factor Interventional Trial, II: black men.
Am J Public Health.. 1996;86:497–504.
[Abstract/Free Full Text]
-
Link BG, Phelan JC. Understanding sociodemographic differences
in health: the role of fundamental social causes. Am J
Public Health. 1996;86:471–472.
[Free Full Text]
-
O'Hare WP. America's minorities: the demographics of
diversity. Popul Bull. Washington, DC: Population Reference
Bureau, Inc; December 1992;47:1–45.
-
Burhanstipanov L, Dresser C. Documentation of the Cancer
Research Needs of American Indians and Alaska Natives. Bethesda,
Md: Cancer Control Science Program, Division of Cancer Prevention and
Control, National Cancer Institute; 1994.
-
Welty TK, Lee ET, Yeh J, Cowan LD, Go O, Fabsitz RR, Le NA,
Oopik AJ, Robbins DC, Howard BV. Cardiovascular disease
risk factors among American Indians: the Strong Heart Study.
Am J Epidemiol. 1995;142:269–287.
[Abstract/Free Full Text]
-
Howard BV, Lee ET, Cowan LD, Fabsitz RR, Howard WJ, Oopik AJ,
Robbins DC, Savage PJ, Yeh JL, Welty TK. Coronary heart disease
prevalence and its relation to risk factors in American Indians: the
Strong Heart Study. Am J Epidemiol. 1995;142:254–268.
[Abstract/Free Full Text]
-
Jackson MY. Diet, culture, and diabetes. In: Joe JR,
Young RS, eds. Diabetes as a Disease of Civilization: the Impact
of Culture Change on Indigenous Peoples. New York, NY: Mouton de
Cruyer; 1994:381–406.
-
Pappas G, Queen S, Hadden W, Fisher G. The increasing
disparity in mortality between socioeconomic groups in the United
States, 1960 and 1986. N Engl J Med. 1993;329:103–109.
[Abstract/Free Full Text]
-
Sobal J, Stunkard AJ. Socioeconomic status and obesity:
a review of the literature. Psychol Bull. 1989;105:260–275.[Medline]
[Order article via Infotrieve]
-
Gillum RF. The epidemiology of
cardiovascular disease in black Americans. N
Engl J Med. 1996;335:1597–1599.
[Free Full Text]
-
Kumanyika SK, Morssink CB. Cultural appropriateness of
weight management programs. In: Dalton S, ed. Overweight and
Weight Management: The Health Professional's Guide to Understanding
and Practice. Gaithersburg, Md: Aspen Publishers Inc;
1997:69–106.
-
Butrum RR, Clifford CK, Lanza E. NCI dietary guidelines:
rationale. Am J Clin Nutr. 1988;48(suppl
3):888–895.
-
Krauss RM, Deckelbaum RJ, Ernst N, Fisher E, Howard BV, Knopp
RH, Kotchen T, Lichtenstein AH, McGill HC, Pearson TA, Prewitt TE,
Stone NJ, Horn LV, Weinberg R. Dietary guidelines for healthy American
adults: a statement for health professionals from the Nutrition
Committee, American Heart Association. Circulation. 1996;94:1795–1800.
[Free Full Text]
-
Nutrition recommendations and principles for people with
diabetes mellitus. Diabetes Care. 1994;17:519–522.[Abstract]
-
American Academy of Pediatrics, Committee on Nutrition.
Statement on "Cholesterol in childhood."
Pediatrics.. 1998;101:141–147.
[Abstract/Free Full Text]
This article has been cited by other articles:
 |
|
 |
|
  S. K. Kumanyika and C. B. Morssink Bridging domains in efforts to reduce disparities in health and health care. Health Educ Behav, August 1, 2006; 33(4): 440 - 458. [Abstract] [PDF]
|
|
|
|
 |
|
 D. M. Mutch, W. Wahli, and G. Williamson Nutrigenomics and nutrigenetics: the emerging faces of nutrition FASEB J, October 1, 2005; 19(12): 1602 - 1616. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. F. Kushner Low-Carbohydrate Diets, Con: The Mythical Phoenix or Credible Science? Nutr Clin Pract, February 1, 2005; 20(1): 13 - 16. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. A. Cooper Carotenoids in Health and Disease: Recent Scientific Evaluations, Research Recommendations and the Consumer J. Nutr., January 1, 2004; 134(1): 221S - 224. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. N. Cheuvront The Zone Diet Phenomenon: A Closer Look at the Science behind the Claims J. Am. Coll. Nutr., February 1, 2003; 22(1): 9 - 17. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. J. Cornelius, P. L. Smith, and G. M. Simpson What Factors Hinder Women of Color From Obtaining Preventive Health Care? Am J Public Health, April 1, 2002; 92(4): 535 - 539. [Abstract] [Full Text]
|
|
|
|
 |
|
 J. M Ordovas, D. Corella, L A. Cupples, S. Demissie, A. Kelleher, O. Coltell, P. W. Wilson, E. J Schaefer, and K. Tucker Polyunsaturated fatty acids modulate the effects of the APOA1 G-A polymorphism on HDL-cholesterol concentrations in a sex-specific manner: the Framingham Study Am. J. Clinical Nutrition, January 1, 2002; 75(1): 38 - 46. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. S. Gidding;, T. B. Newman, and A. M. Garber Cholesterol Guidelines Debate Pediatrics, May 1, 2001; 107(5): 1229 - 1230. [Full Text]
|
|
|
|
 |
|
 J. Stamler, M. L. Daviglus, D. B. Garside, A. R. Dyer, P. Greenland, and J. D. Neaton Relationship of Baseline Serum Cholesterol Levels in 3 Large Cohorts of Younger Men to Long-term Coronary, Cardiovascular, and All-Cause Mortality and to Longevity JAMA, July 19, 2000; 284(3): 311 - 318. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||