The Surgeon General’s
Report on

NUTRITION
AND HEALTH

1988

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
DHHS (PHS) Publication No. 88-50210

 

the Superintendent of Documents, U.S. Government Printing Office
Washington, DC 20402
GPO Stock Number 017-001-00465-1

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DEPARTMENT OF HEALTH & HUMAN SERVICES

 

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The Surgeon General of the
Public Health Service
Washington DC 20201

MESSAGE FROM THE SURGEON GENERAL

I am pleased to transmit to the Secretary of the Department of Health and
Human Services this first Surgeon General's Report on Nutrition and Health.
It was prepared under the auspices of the Department's Nutrition Policy
Board, and its main conclusion is that overconsumption of certain dietary
components is now a major concern for Americans. While many food
factors are involved, chief among them is the disproportionate consumption
of foods high in fats, often at the expense of foods high in complex
carbohydrates and fiber--such as vegetables, fruits, and whole grain
products--that may be more conducive to health.

1 offer this Report in the context of the obligation of the Surgeon General to
inform the American public of developments in the science base that have
widespread implications for human health. Perhaps the classic example of
such reports is the one issued in 1964 during the tenure of one of my
predecessors, Dr. Luther Terry, which summarized the epidemiologic
evidence available at the time on the relationship of tobacco to health. This
report called attention to the inescapable conclusion that cigarettes were a
major source of illness and death for those who smoked--at that time a
majority of adult men.

This Surgeon General's Report on Nutrition and Health follows the tradition
of the original report on smoking and health. It addresses an area of some
controversy and substantial misunderstanding. And the relative magnitude
of the associated health concerns is comparable, with dietary factors playing
a prominent role in five of the ten leading causes of death for Americans. In
addition, the depth of the science base underlying its findings is even more
impressive than that for tobacco and health in 1964, with animal and clinical
evidence adding to the epidemiologic studies.

On the other hand there are some fundamental differences. Most obvious is
the fact that food is necessary for good health. Foods contain nutrients
essential for normal metabolic function, and when problems arise, they
result from imbalance in nutrient intake or from harmful interaction with
other factors. Moreover, we know today much more about individual
variation in response to nutrients than we know about possible variations in
response to tobacco. Some people are clearly more susceptible than others
to problems from diets that are, for example, higher in fat or salt.

Also, unlike the experience for tobacco in 1964, people are already making
dietary changes, as witnessed by the shift to products lower in saturated fats.
Nonetheless, the important effects of the dietary factors underlying
problems like coronary heart disease, high blood pressure, stroke, some
types of cancer, diabetes, obesity--problems that represent the leading health
threats for Americans--indicate the potential for substantial gains to be
accrued by the recommendations contained in this Report

It is important to emphasize that the focus of this Report is primarily on the
relationship of diet to the occurrence of chronic diseases. The Report is not
intended to address the problems of hunger or undernutrition that may
occur in the United States among certain subgroups of the population. All
Americans should have access to an appropriate diet, but they do not. And
even though the size and numbers of problems related to inadequate access to
food are proportionately much smaller than those related to dietary excesses
and imbalances, the problems of access to food are of considerable concern
to me, personally, wherever they may occur.

The apparently sizable numbers of people resorting to the use of soup
kitchens and related food facilities, as well as the possible role of poor diet as
a contributor to the higher infant mortality rates associated with inadequate
income, suggest the need for better monitoring of the nature and extent of
the problem and for sustained efforts to correct the underlying causes of
diminished health due to inadequate or inappropriate diets.

This report was prepared primarily for nutritional policy makers, although
the eventual beneficiaries of better nutritional policy will be the American
people. I am convinced that with a concerted effort on the part of policy
makers throughout the Nation, and eventually by the public, our daily diets
can bring a substantial measure of better health to all Americans. I
commend to them the recommendations of this Report.

fea Dovg-
C. Everett Koop, M.D., Sc.D.

Surgeon General
U.S. Public Health Service
Foreword

This first Surgeon General's Report on Nutrition and Health marks a key
event in the history of public health in the United States. While the Report
has been developed for use by policymakers, it offers lessons that can be
directly applied to the public. It responds to the increasing interest of
scientists, health professionals, and the American people in the role of diet
in health promotion. Within recent years, concerns about nutrition and
health have expanded beyond the need to prevent deficiencies to encom-
pass the effects of typical American dietary patterns on the incidence of
chronic diseases that are leading causes of death and disability in this
country. Although scientific research has provided substantial insight into
the ways specific dietary factors influence specific diseases, there are still
many uncertainties about diet-disease relationships. The Department of
Health and Human Services, through the Public Health Service and the
Surgeon General, welcomes the responsibility to evaluate the current state
of knowledge and to advise the public accordingly.

This Report reviews the scientific evidence that relates dietary excesses
and imbalances to chronic diseases. On the basis of the evidence, it
recommends dietary changes that can improve the health prospects of
many Americans. Of highest priority among these changes is to reduce
intake of foods high in fats and to increase intake of foods high in complex
carbohydrates and fiber.

The evidence presented here indicates the convergence of similar dietary
recommendations that apply to prevention of multiple chronic diseases.
The recommendation to reduce dietary fat, for example, aims to reduce the
risk for coronary heart disease, diabetes, obesity, and some types of
cancer. This advice is not new. But it is now substantiated by a large body of
evidence derived from many different kinds of research—a research base
that is now even more comprehensive than was the case for the pioneering
1964 Surgeon General’s Report on Smoking and Health.

The weight of this evidence and the magnitude of the problems at hand
indicate that it is now time to take action. In the cause of good health for all
our citizens, I urge support for this Report’s recommendations by every
sector of American society.

Otis R. Bowen, M.D.
Secretary
Preface

The Public Health Service of the Department of Health and Human Ser-
vices has long maintained an interest in the relationship between food and
health. In the 1970’s, this interest began to focus on the ways in which
dietary excesses and imbalances increase the risk for chronic diseases.
With the publication in 1979 of Healthy People: The Surgeon General's
Report on Health Promotion and Disease Prevention, attention turned
toward environmental and behavioral changes that Americans might make
to reduce their risks for morbidity and mortality. Nutrition was one such
priority area. The 1980 report Promoting Health/Preventing Disease: Ob-
jectives for the Nation included 17 specific, quantifiable objectives in
nutrition designed to reduce risks and to prevent illness and death. Also in
1980, the Department published, jointly with the U.S. Department of
Agriculture, the first edition of Dietary Guidelines for Americans. This
report, revised in 1985, includes seven recommendations that, taken to-
gether, address the relationship between diet and chronic diseases.

Diseases such as coronary heart disease, stroke, cancer, and diabetes
remain leading causes of death and disability in the United States. Substan-
tial scientific research over the past few decades indicates that diet can play
an important role in prevention of such conditions. The Public Health
Service has now reviewed this research and has produced a comprehensive
analysis of the relationship between dietary factors and chronic disease
risk. This Surgeon General’s Report on Nutrition and Health summarizes
research on the role of diet in health promotion and disease prevention. Its
findings indicate the great importance of diet to health. They demonstrate
that changes in present dietary practices of Americans could produce
substantial gains in the health of the population. The Public Health Service
is committed to improving the health of Americans through its programs in
education, services, and research.

One mechanism for improving the health of Americans is through the 1990
Health Objectives for the Nation. The role of nutrition in health will
continue to be a focus of national health priorities as we develop new
objectives for the year 2000. Federal, State, and local governments, the
American public, the food industry, and scientists and health professionals
can work together to encourage Americans to make healthy food choices
and to achieve national health goals.
I am pleased to commend to the American people this review of the
scientific evidence that links diet to chronic disease, and I urge that the
findings of this important Report be given your careful consideration.

Robert E. Windom, M.D.
Assistant Secretary for Health

Viii
Contents

Foreword... 0. cece cece cece tere eee n reer r ees e reer ee eee ees Vv
Preface ... cece eee c cece e eee eee eee een n renee eee eee eee es vii
Nutrition Policy Board... 2.6... sees cee reer settee rset rss? xiv
Acknowledgments ........---seeeeereecesse ster srs essere XV
Summary and Recommendations .......-----+:eeeeeeetere erste 1
Chapter 1: Introduction and Background ........-.-++-+eerereeee 21
Chapter 2: Coronary Heart Disease .....0-. eee reer eee eters 83
Chapter 3: High Blood Pressure ......-----++2sreeecrerttrseees 139
Chapter 4: Cancer .....-. 002s eeee ree rer een n et tcs esse reser es 177
Chapter 5: Diabetes .......-.-+--seeecre eer re recess trent 249
Chapter 6: Obesity .......--. 5 seer reer eter errr estes rn sees 275
Chapter 7: Skeletal Diseases ........-.+++-sserrrsrrrrrrtrcte 311
Chapter 8: Dental Diseases ....-.-------eeerrrrrrerte ersten 345
Chapter 9: Kidney Diseases ......--.-+-+sseereersrter essen 381
Chapter 10: Gastrointestinal Diseases ...... cece eee tetris 403
Chapter 11: Infections and Immunity ......00. 00 eee e eee eee 427
Chapter 12: Anemia ......--. 5-000 screen rere errr teers estes 465
Chapter 13: Neurologic Disorders .......ccceeee eer etter 491
Chapter 14: Behavior .......+---+-seesee ener errs tstttee 509
Chapter 15: Maternal and Child Nutrition ..........0eee eee eee 539
Chapter 16: Aging .....---.. esse reer ree erree rere er ernst sees 595
Chapter 17: Alcohol .....---.5- +202 secre eer re rer eree essen sss 629
Chapter 18: Drug-Nutrient Interactions .........- cee 671
Chapter 19: Dietary Fads and Frauds .......-..0e eee cece eens 695
INdeX coc cc cece cece et eee cent ent e eee n ener ease esse 713
1-1.

1-2.

1-3.

1-4.
1-5,

1-6.

1-7.

1-9.

2-1.

2-2.

2-3.

Tables

Recommendations ......... 00: c eee ee ee ee eee e ees 3
Estimated Total Deaths and Percent of Total Deaths for the 10
Leading Causes of Death: United States, 1987 ............. 4
Estimated Total Deaths and Percent of Total Deaths for the 10
Leading Causes of Death: United States, 1987 ............. 22
Selected Events in the History of Nutritional Science

tO 1950 oo. ccc ec cee cee tenet eee eee ees 25
Selected Federal Domestic Nutrition Policy Initiatives,

1862-1988 00. ccc ce cee tenet eee eet e teenies 29
National Nutrition Surveillance Activities ................ 38

Federal Dietary Recommendations for the General Public,
1917-1988 ooo ccc ccc eee eee cee eee tee teens eees 43

Food and Nutrition Board, National Academy of Sciences-
National Research Council Recommended Daily Dietary

Allowances, Revised 1980 ......... 0.0 cee cece eee eens 49
Estimated Safe and Adequate Daily Intakes of Selected
Vitamins and Minerals ............-- 2000 e cece eee eee eee 52

. Annual Per Capita Availability of Selected Commodities in

the U.S. Food Supply, 1965-1985 .. 2.2.0.0... 20: e cece ee eee 65

Mean Daily Intake of Food Energy, Nutrients, and Food
Components for Men, Women, and Young Children From the
Continuing Survey of Food Intakes by Individuals (CSFID),

1985 ooo ccc cc ee cee cee nee eee eee cece een eetaes 69
Death Rate for Coronary Heart Disease by Age, Race, and

Sex, United States, 1985 2.0.2... cece cece neces 85
Prevalence of Coronary Heart Disease by Age, Race, and

Sex, United States, 1985 ............. ee 86
National Cholesterol Education Program Adult Treatment

Panel Classification .......... 6. cece ect e eect e nee 94

Estimates of Serum Cholesterol Change From Given Changes
in Dietary Lipids Based on Isocaloric Controlled
Experiments in Humans .........-..0-- +2 sees e eee e eres 97

La
3-1.

3-2.

4-5.
4-6.

4-7.

4-8.

4-9.

4-10.

Classification of Blood Pressure in Adults 18 Years or

Older ...... cece eee eee een e teense nes nnre nares 143

Estimated Prevalence of Cardiovascular Disease in the United

a 143
. Control Mechanisms for Arterial Pressure .....--------+-- 145

. Major Nutrients and Possible Mechanisms for Influencing

Blood Pressure .......---. ee ee cece eee cette renee 147

. Changes in Weight and Blood Pressure (Baseline to Followup)

in Treatment (Rx) and Control Groups of Five Randomized

Controlled Trials ......... 0000s cece teeter eee tees 149

Studies of Cross-Sectional Association of Blood Pressure

With Alcohol Consumption ..........--++-seeer eres 154
. Prospective Observational Studies of the Association of Blood

Pressure With Alcohol Consumption .......----+-e+seees 155
. Proportions of Cancer Deaths Attributed to Various

Factors .. 0... cece cee eee eee eee teen nent enna enees 180
_ International Changes Since 1950 in Death Certification

Rates for Cancers of Stomach and Lung .........----+++-- 181
_ Cancer Incidence Rates in the Philippines and Among

Filipinos and Caucasians in Hawaii .......c cece eens 182

Reported Relationship Between Selected Dietary

Components and Cancer ....-..---. seer sree eres eens 191

National Cancer Institute Dietary Guidelines .........----- 192

Comparison of Dietary Guidelines for the

American Public .......-..0 2c cece eee reece rere eneenes 193

Summary of Epidemiologic Studies Examining Dietary Fat

and Breast Cancer ........--.s cece eter rer rests eecees 196

Retrospective Human Studies Relating Body Weight and

CANCEL... cece cece eee eee e nese een eens recess 200

Summary of Epidemiologic Studies Examining Dietary Fiber

and Colon Cancer ......-.0eceeeee errr este eer eetereses 205

Dietary Vitamin A and Lung Cancer Risk: A Summary of
Previous Studies .......--.0ceeee reece sere creer terres 211

xi
4-12.

5-1.

5-2.

5-3.

6-1.

6-2.

6-3.

7-1.
8-1.

10-1.
10-2.
11-1.
12-1.

12-2.

14-1.

14-2.
15-1.

. NCI-Sponsored Prevention Clinical Trials Related to

Vitamin A .... 0. cc cece ene e ence cece eeeee 215

Summary of Epidemiologic Studies on Selenium and
Cancer Risk .......... 0. cece cece eee eee e eee e een e ences 221

History of Dietary Composition (Relative Proportion of
Carbohydrate and Fat Calories) Used in Management of

Diabetes ........ 0... ccc ccc cece cnn e nner ee ee ee eeenes 251
Clinical Complications of Diabetes ....................04. 255
American Diabetes Association Dietary Recommendations

for Persons With Diabetes ................ 0. cee 263
Comparison of Metropolitan Desirable Weights With Average
Weights From U.S. Cohort Studies ...........--.....0005 282

Body Mass Index (kg/m?) Used to Define Desirable Weight
and Overweight According to Three Different “Ideal”
Reference Populations ............ 0... ec eeeeee reer e eens 285

Mortality Ratios for All Ages Combined in Relation to the
Death Rate of Those 90 to 109 Percent of Average Weight ... 290

Scientific Validity of Risk Factors ................ 0000 eee 314
Supplemental Fluoride Dosage Scheduled (in mg F/day)

According to Fluoride Concentrations of Drinking Water ... 359
Summary of Digestive Processes ................00e eee 407
Gastrointestinal Hormones ..................--00000- 005 410
Causes of Food-Associated Illness ...............-...--.- 448

Estimates for Percent Prevalence of Impaired Iron Status:
Average of Estimates Using Three Methods: NHANES II,

1976-80 20. cee ce eee teeter eee nnees 468
Total Body Iron and Storage Iron .....................04. 471
Behavioral and Psychologic Hypotheses to Explain

Obesity 0.0... cece cece ent ent eneeeeee 515
Diagnostic Criteria for Anorexia Nervosa and Bulimia...... $20

Selected National Objectives to be Achieved by the Year 1990
Related to Maternal and Child Nutrition .................. 545

xii
15-2.

1-1.

2-1.
4-1.
42.
4-3.

6-1.
8-1.

8-4.

Content of Selected Nutrients in Human Milk, Commercial
Formulas, and Other Milks Used for Feeding Normal Full-
Term Infants ...... 0.000 c eee eee erent tener tees 565

Figures

Dependence of Biologic Function or Tissue Concentration on

Intake of a Nutrient ......... 00.02 eee ee eee eee ete ees 47
Diagram of an Atherosclerotic Plaque ........+-++++++e05: 88
Range of Incidence Rates (International Comparisons) ..... 180
Carcinogenesis ......... 0.0.0 e cece e erence teen ee snes 183
Dietary Fat Intake in Relation to Breast Cancer-Related Death
Rate ooo e cece eee erence eee ene eeneeennnee 187
A Nomogram for Determining Body Mass Index (BMI) .... 284
The Distribution of Mean Decayed and Filled Coronal

Surfaces (DFS) by Age .....-... 00 -e eee eee e eee e ee enees 348
The Distribution of Mean Decayed and Filled Root Surfaces
(DFS) by Age ........ ce cee cece eee eee ene entree ene es 349

Percent of Persons by Severe Loss of Periodontal
Attachment (Pocket Depths Measuring 4 mm or More)
and Age Groups .......... 222s eee reer eee r enter enee 351

Comparison of the Percent of Edentulous Persons in the
1985-86 NIDR Survey to That Reported From the NCHS

Survey Of 1960-62 ..... 0... eee eee eee eee eee teens 351
Schematic Cross-Section of a Typical Mandibular Molar
Tooth .... 0c ce cc cece cece cee ne eet een e eee eena ee naaes 352

The Comparative Structures of Amino Acids, Ketoacids, and
Hydroxyacids ........ 00. e cece eee eee e een e rece enes 391

xii
Nutrition Policy Board
U.S. Department of Health and Human Services

J. Michael McGinnis, M.D. (Chairman), Deputy Assistant Secretary for
Health (Disease Prevention and Health Promotion), Public Health Service

Faye G. Abdellah, R.N., Ed.D., Sc.D., Deputy Surgeon General, Public
Health Service

W. Douglas Badger, M.Div., Deputy Assistant Secretary, Office of Human
Development Services

Mary M. Evert, M.B.A., Director, Office of Community Services, Family
Support Administration

Manning Feinleib, M.D., M.P.H., Dr.P.H., Director, National Center for
Health Statistics, Centers for Disease Control, Public Health Service

Allan L. Forbes, M.D., Director, Office of Nutrition and Food Sciences,
Center for Food Safety and Applied Nutrition, Food and Drug Administra-
tion, Public Health Service

William T. Friedewald, M.D., Associate Director for Disease Prevention,
National Institutes of Health, Public Health Service

Bernard I. Grosser, M.D., Director, Office of Science, Alcohol, Drug
Abuse, and Mental Health Administration, Public Health Service

John Porvaznik, M.D., F.A.C.S., Associate Director, Office of Health
Programs, Indian Health Service, Public Health Service

William A. Robinson, M.D., M.P.H., Chief Medical Officer, Health Re-
sources and Services Administration, Public Health Service

xiv
Acknowledgments

The Surgeon General's Report on Nutrition and Health was prepared
under the general editorship of the Department of Health and Human
Services’ Nutrition Policy Board, whose members are listed on the pre-
vious page. Managing Editor was Marion Nestle, Ph.D., M.P.H.., Office of
Disease Prevention and Health Promotion. Special editorial assistance was
contributed by John Bailar III, M.D., Ph.D., Science Advisor, Office of
Disease Prevention and Health Promotion, and by Darla E. Danford,
M.P.H., D.Sc., R.D., National Institutes of Health. Project Officer during
early stages of preparation of the Report was Ann Sorenson, Ph.D., now
with the National Institutes of Health.

In addition to the guidance of the Nutrition Policy Board's Senior Editorial
Advisors and Staff Working Group, important editorial contributions were
made by Karen Donato, M.S., R.D., Nancy D. Ernst, M.S., R.D., Marilyn
E. Farrand, M.S., R.D., and Van S. Hubbard, M.D., Ph.D., of the Nation-
al Institutes of Health’s Nutrition Education Subcommittee; and by Walter
H. Glinsmann, M.D., Marilyn G. Stephenson, M.S., R.D., John E. Van-
derveen, Ph.D., and Elizabeth Yetley, Ph.D., R.D., of the Food and Drug
Administration’s Center for Food Safety and Applied Nutrition.

Senior Editorial Advisors to the Nutrition Policy Board were:

C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George
Washington University Medical Center, Washington, D.C.

‘Johanna T. Dwyer, D.Sc., Director, Frances Stern Nutrition Center, New
England Medical Center Hospitals, and Professor of Medicine, Tufts Uni-
versity Medical School, Boston, Massachusetts

Samuel Fomon, M.D., Professor of Pediatrics, University of Iowa, Iowa
City, lowa

Richard L. Hall, Ph.D., Vice President, Science and Technology, McCor-
mick & Co., Inc., Hunt Valley, Maryland

Robert I. Levy, M.D., President, Sandoz Research Institute, East Hano-
ver, New Jersey

Walter Mertz, M.D., Director, Beltsville Human Nutrition Research Cen-
ter, U.S. Department of Agriculture, Beltsville, Maryland

XV
Malden C. Nesheim, Ph.D., Vice President for Planning and Budget,
Cornell University, Ithaca, New York

Sushma Palmer, D.Sc., Executive Director, Food and Nutrition Board,
National Academy of Sciences, Washington, D.C.

Irwin H. Rosenberg, M.D., Director, USDA Human Nutrition Research
Center on Aging, Tufts University, Boston, Massachusetts

Theodore Van Itallie, M.D., Professor of Medicine, Columbia University
College of Physicians and Surgeons, New York, New York

Nutrition Policy Board Staff Working Group members were:

Elizabeth Brannon, M.S., R.D., Clinical Nutrition Specialist, Bureau of
Maternal and Child Health and Resources Development, Health Resourc-
es and Services Administration, Rockville, Maryland

Darla E. Danford, M.P.H., D.Sc., R.D., Nutritionist, Nutrition Coordinat-
ing Committee, National Institutes of Health, Bethesda, Maryland

Willie M. Etheridge, M.S., Policy Analyst, Policy Planning and Legislation
Division, Office of Human Development Services, Washington, D.C.

James J. Hearn, L.L.B., Chief, Community Food and Nutrition Program,
Office of Community Services, Family Support Administration, Washing-
ton, D.C.

M. Yvonne Jackson, Ph.D., R.D., Chief, Nutrition and Dietetics Section,
Indian Health Service, Rockville, Maryland

Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention
and Health Promotion, Washington, D.C.

Marion Nestle, Ph.D., M.P.H., Director, Nutrition Policy Staff, Office of
Disease Prevention and Health Promotion, Washington, D.C.

Lana Skirboll, Ph.D., Special Assistant to the Director, Office of Science,
Alcohol, Drug Abuse, and Mental Health Administration, Rockville,
Maryland

Frederick Trowbridge, M.D., M.S., Director, Nutrition Division, Center
for Health Promotion and Education, Centers for Disease Control, Atlan-
ta, Georgia

xvi
Catherine E. Woteki, Ph.D., R.D., Deputy Director, Division of Health
Examination Statistics, National Center for Health Statistics, Centers for
Disease Control, Hyattsville, Maryland

Individuals who contributed to the writing of draft chapters or
portions of the Report were:

Margaret J. Albrink, M.D., M.P.H., Professor of Medicine, West Virginia
University Medical Center, Morgantown, West Virginia (Obesity)

William R. Beisel, M.D., Adjunct Professor, Department of Immunology
and Infectious Diseases, School of Hygiene and Public Health, The Johns
Hopkins University, Baltimore, Maryland (Infections and Immunity)

C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George
Washington University Medical Center, Washington, D.C. (Alcohol)

Joseph E. Ciardi, Ph.D., Research Biochemist, Caries and Restoration
Materials Research Branch, Extramural Program, National Institute of
Dental Research, National Institutes of Health, Bethesda, Maryland (Den-
tal Diseases)

Phyllis A. Crapo, R.D., Department of Medicine, University of California
at San Diego, LaJolla, California (Diabetes)

Jeffrey A. Cutler, M.D., Chief, Prevention and Demonstration Research
Branch, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland (High Blood Pressure)

Peter R. Dallman, M.D., Professor, Department of Pediatrics, University
of California, San Francisco, California (Anemia)

Barbara H. Dennis, R.D., Ph.D., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland (Coronary Heart Disease)

John Duguid, M.D., Ph.D., Neurologist, Massachusetts Institute of Tech-
nology, Cambridge, Massachusetts (Neurologic Disorders)

Robert Edelman, M.D., Chief, Clinical and Epidemiological Studies
Branch, Deputy Director, Microbiology and Infectious Diseases Program,
National Institute of Allergy and Infectious Diseases, National Institutes
of Health, Bethesda, Maryland (Infections and Immunity)

xvii
Nancy D. Emst, M.S., R.D., Nutrition Coordinator, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary-
land (High Blood Pressure)

Lloyd J. Filer, Jr., M.D., Ph.D., Department of Pediatrics, University of
Iowa School of Medicine, Iowa City, Iowa (Maternal and Child Nutrition)

Mattie R.S. Fox, Ph.D., Chief, Nutrient Interaction Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C. (Introduction and Background)

Philip J. Garry, Ph.D., Professor, Department of Pathology, University of
New Mexico School of Medicine, Albuquerque, New Mexico (Aging)

James Goodwin, M.D., Professor and Vice Chairman, Department of
Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (Aging)

Sheila Gottschalk, M.D., Associate Professor of Pediatrics, Louisiana
State University School of Medicine, New Orleans, Louisiana (Maternal
and Child Nutrition) .

Gregory E. Gray, M.D., Ph.D., Assistant Professor, Department of Psy-
chiatry and the Behavioral Sciences, Los Angeles County-University of
Southern California Medical Center, Los Angeles, California (Behavior)

Peter Greenwald, M.D., Dr.P.H., Director, Division of Cancer Prevention
and Control, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland (Cancer)

John H. Growdon, M.D., Massachusetts Institute of Technology, Massa-
chusetts General Hospital, and Harvard Medical School, Cambridge, Mas-
sachusetts (Neurologic Disorders)

Margaret A. Hamburg, M.D., Special Assistant to the Director, National
Institute of Allergy and Infectious Diseases, National Institutes of Health,
Bethesda, Maryland (Infections and Immunity)

James P. Harwood, Ph.D., Executive Secretary, Scientific Review Office,
National Institute on Aging,. National Institutes of Health, Bethesda,
Maryland (Introduction and Background)

Michael Horan, M.D., Chief, Hypertension and Kidney Diseases Branch,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland (High Blood Pressure)

Richard D. Hurt, M.D., Mayo Clinic, Rochester, Minnesota (Alcohol)

xviii
Howard Jacobson, M.D., Institute of Nutrition, University of North Car-
olina, Chapel Hill, North Carolina (Maternal and Child Nutrition)

Mamie Y. Jenkins, Ph.D., Research Chemist, Bioavailability Section,
Experimental Nutrition Branch, Division of Nutrition, Food and Drug
Administration, Washington, D.C. (Introduction and Background)

Alexander Jordan, Ph.D., Supervisory Pharmacologist, Food and Drug
Administration, Rockville, Maryland (Drug-Nutrient Interactions)

George M. Kazzi, M.D., Chief, Department of Obstetrics and Gynecolo-
gy, Harper-Grace Hospitals, and Assistant Professor, Maternal-Fetal
Medicine, Wayne State University School of Medicine, Detroit, Michigan
(Maternal and Child Nutrition)

Joel D. Kopple, M.D., Professor of Medicine and Public Health, Univer-
sity of California at Los Angeles, Chief, Division of Nephrology and
Hypertension, Harbor-UCLA Medical Center, Torrance, California (Kid-
ney Diseases)

Markus J.P. Kruesi, M.D., Staff Psychiatrist, National Institute of Mental
Health, Alcohol, Drug Abuse, and Mental Health Administration, Rock-
ville, Maryland (Behavior)

Elaine Lanza, Ph.D., Diet and Cancer Branch, Division of Cancer Preven-
tion and Control, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland (Cancer)

Harris R. Lieberman, Ph.D., Department of Brain and Cognitive Sciences,
Massachusetts Institute of Technology, Cambridge, Massachusetts (Neu-
rologic Disorders; Behavior)

Gardner C. McMillan, M.D., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland (Coronary Heart Disease)

Albert I. Mendeloff, M.D., M.P.H., Department of Medicine, The Johns
Hopkins University School of Medicine, Baltimore, Maryland (Gastroin-
testinal Diseases)

Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention
and Health Promotion, Washington, D.C. (Introduction and Background)

Sanford A. Miller, Ph.D., Director, Center for Food Safety and Applied
Nutrition, Food and Drug Administration, Washington, D.C. (Introduction
and Background)

xix
Geraldine V. Mitchell, Ph.D., Chief, Bioavailability Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C. (Introduction and Background)

Eliot N. Mostow, M.D., M.P.H., Medical Staff Fellow, Division of Cancer
Prevention and Control, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland (Cancer)

Jerrold M. Olefsky, M.D., Department of Medicine, University of Califor-
nia at San Diego, and San Diego Veterans Administration Medical Center,
San Diego, California (Diabetes)

Youngmee K. Park, Ph.D., Nutritionist, Clinical Nutrition Branch, Divi-
sion of Nutrition, Food and Drug Administration, Washington, D.C. (Intro-
duction and Background)

Jean A.T. Pennington, Ph.D., Assistant to the Director, Division of Nutri-
tion, Food and Drug Administration, Washington, D.C. (Introduction and
Background)

L. Ross Pierce, M.D., Group Leader, Food and Drug Administration,
Rockville, Maryland (Drug-Nutrient Interactions)

Peggy L. Pipes, M.P.N., R.D., Child Development Mental Retardation
Center, University of Washington, Seattle, Washington (Maternal and
Child Nutrition)

Ernesto Pollitt, Ph.D., Department of Applied Behavioral Sciences, Uni-
versity of California, Davis, California (Maternal and Child Nutrition)

Leon Prosky, Ph.D., Deputy Chief, Experimental Nutrition Branch, Divi-
sion of Nutrition, Food and Drug Administration, Washington, D.C. (Intro-
duction and Background)

Jeanne I. Rader, Ph.D., Chief, Nutrient Toxicity Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C. (Introduction and Background)

Lawrence G. Raisz, M.D., Professor of Medicine and Chief, Division of
Endocrinology and Metabolism, University of Connecticut School of Med-
icine, Farmington, Connecticut (Skeletal Diseases)

Judith L. Rapoport, M.D., Chief, Child Psychiatry Branch, National Insti-
tute of Mental Health, Alcohol, Drug Abuse, and Mental Health Adminis-
tration, Rockville, Maryland (Behavior)
Merrill S. Read, Ph.D., Professor and Chairman, Human Nutrition and
Food Systems, College of Human Ecology, University of Maryland, Col-
lege Park, Maryland (Maternal and Child Nutrition)

Basil M. Rifkind, M.D., ER.C.P., Division of Heart and Vascular Dis-
eases, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland (Coronary Heart Disease)

Norman E. Rosenthal, M.D., Chief, Unit on Outpatient Studies, Clinical
Psychology Branch, National Institute of Mental Health, Alcohol, Drug
Abuse, and Mental Health Administration, Rockville, Maryland (Behav-
ior)

Neil L. Sass, Ph.D., Senior Scientist, Office of Management, Center for
Food Safety and Applied Nutrition, Food and Drug Administration, Wash-
ington, D.C. (Introduction and Background)

Claudia Schuth, M.D., Associate Professor of Pediatrics, Louisiana State
University School of Medicine, New Orleans, Louisiana (Maternal and
Child Nutrition)

James H. Shaw, Ph.D., Professor of Nutrition Emeritus, Harvard School of
Dental Medicine, Boston, Massachusetts (Dental Diseases)

Alan J. Sheppard, Ph.D., Chief, Experimental Methods Research Section,
Nutrient Surveillance Branch, Division of Nutrition, Food and Drug Ad-
ministration, Washington, D.C. (Introduction and Background)

Solomon Sobel, M.D., Food and Drug Administration, Rockville, Mary-
land (Drug-Nutrient Interactions)

Robert J. Sokol, M.D., Professor and Chairman and Chief, Department of
Obstetrics and Gynecology, Wayne State University, Hutzel Hospital,
Detroit, Michigan (Maternal and Child Nutrition)

Marilyn G. Stephenson, M.S., R.D., Assistant to the Director, Office of
Nutrition and Food Sciences, Center for Food Safety and Applied Nutri-
tion, Food and Drug Administration, Washington, D.C. (Dietary Fads and
Frauds)

Albert Stunkard, M.D., Professor of Psychiatry, University of Pennsylva-
nia School of Medicine, Philadelphia, Pennsylvania (Behavior)

Robert M. Suskind, M.D., Department of Pediatrics, Louisiana State
University School of Medicine, New Orleans, Louisiana (Maternal and
Child Nutrition)
Shyy Hwa Tao, Ph.D., Research Chemist, Nutrient Interaction Section,
Experimental Nutrition Branch, Division of Nutrition, Food and Drug
Administration, Washington, D.C. (Imroduction and Background)

Thomas Thom, Statistician, Epidemiology and Biometry Research Pro-
gram, Division of Epidemiology and Clinical Applications, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary-
land (Coronary Heart Disease)

Gloria Troendle, M.D., Deputy Director, Food and Drug Administration,
Rockville, Maryland (Drug-Nutrient Interactions)

Momtaz Wassef, Ph.D., Division of Heart and Vascular Diseases, National
Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda,
Maryland (Coronary Heart Disease)

Cora E. Weeks, J.D., Ph.D., Consumer Safety Officer, Division of Reg-
ulatory Guidance, Center for Food Safety and Applied Nutrition, Food and
Drug Administration, Washington, D.C. (Introduction and Background)

Robert W. Wissler, M.D., Ph.D., Donald N. Pritzker Distinguished Service
Professor of Pathology Emeritus, University of Chicago, Chicago, IHinois
(Coronary Heart Disease)

Philip A. Wolf, M.D., Professor of Neurology and Associate Research
Professor of Medicine, Preventive Medicine and Epidemiology, Boston
University School of Medicine, Boston, Massachusetts (Neurologic Disor-
ders)

Bonnie S. Worthington-Roberts, Ph.D., Professor, Nutritional Sciences,
University of Washington, Child Development Center, Seattle, Washington
(Maternal and Child Nutrition)

Catherine E. Woteki, Ph.D., R.D., Deputy Director, Division of Health
Examination Statistics, National Center for Health Statistics, Centers for
Disease Control, Hyattsville, Maryland (Introduction and Background)

Richard J. Wurtman. M.D., Professor, Department of Brain and Cognitive
Sciences, Director, Clinical Research Center, Massachusetts Institute of
Technology, Cambridge, Massachusetts (Neurologic Disorders; Behavior)

Elizabeth Yetley, Ph.D., R.D., Chief, Clinical Nutrition, Division of Nutri-
tion, Office of Nutrition and Food Sciences, Center for Food Safety and
Applied Nutrition, Food and Drug Administration, Washington, D.C. (In-
troduction and Background)
During preparation of the Report, chapters were subjected to six stages of
critical review, three by experts within the Public Health Service (internal
reviews) and three by scientists and professionals recommended as experts
by national scientific and nutrition professional organizations in the private
sector (external reviews). In addition, the senior editorial advisors and staff
to the Nutrition Policy Board listed above provided expert technical eval-
uation throughout the review process.

individuals who reviewed chapters or portions of the Report were:

Phyllis B. Acosta, Dr.P.H., R.D., Director of Metabolic Diseases, Ross
Laboratories, Columbus, Ohio

Lawrence Agodoa, M.D., Coordinator, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda,
Maryland

Duane F. Alexander, M.D., Director, National Institute of Child Health
and Human Development, National Institutes of Health, Bethesda, Mary-
land

Aaron M. Altschul, Ph.D., Diet Management and Eating Disorders Pro-
gram, Georgetown University, Washington, D.C.

Ronald A. Arky, M.D., Professor, Department of Medicine, Harvard
Medical School at Mt. Auburn Hospital, Cambridge, Massachusetts

Louis Avioli, M.D., Professor of Medicine and Oral Biology, Washington
University School of Medicine and Dental School, St. Louis, Missouri

David Badman, Ph.D., Hematology Program Director, National Institute
of Diabetes and Digestive and Kidney Diseases, National Institutes of
Health, Bethesda, Maryland

John Bailar III, M.D., Ph.D., Science Advisor, Office of Disease Preven-
tion and Health Promotion, Washington, D.C.

David H. Baker, Ph.D., Professor of Nutrition and Metabolism, Univer-
sity of Illinois, Urbana, Illinois

Susan Blumenthal, M.D., Medical Officer and Chief, Behavioral Medicine
Program, National Institute of Mental Health, Alcohol, Drug Abuse, and
Mental Health Administration, Rockville, Maryland

Ronette Briefel, Dr.P.H., R.D., Nutritional Epidemiologist, Survey Plan-
ning and Development Branch, National Center for Health Statistics,
Centers for Disease Control, Hyattsville, Maryland

Xxill
Benjamin Burton, Ph.D., Associate Director for Disease Prevention and
Technology Transfer, National Institute of Diabetes and Digestive and
Kidney Diseases, National Institutes of Health, Bethesda, Maryland

Ritva Butrum, Ph.D., Diet and Cancer Branch, Division of Cancer Preven-
tion and Control, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland

Charles E: Butterworth, Jr., M.D., Director, Clinical Nutrition Research
Unit, University of Alabama, Birmingham, Alabama

George F. Cahill, Jr., M.D., Howard Hughes Medical Institute, Boston,
Massachusetts

Doris H. Calloway, Ph.D., Provost Professor Schools. and College, Uni-
versity of California, Berkeley, California

Richard Calvert, M.D., Medical Research Nutritionist, Experimental Nu-
trition Branch, Office of Nutrition and Food Sciences, Center for Food
Safety and Applied utrition, Food and Drug Administration, Washing-
ton, D.C.

Mona Calvo, Ph.D., R.D., Nutritionist, Clinical Nutrition, Division of.
Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety
and Applied Nutrition, Food and Drug Administration, Washington, D.C.

James P. Carlos, D.D.S., Chief, Epidemiology Branch, Epidemiology and
Oral Disease Prevention Program, National Institute of Dental Research, ,
National Institutes of Health, Bethesda, Maryland

Kenneth K. Carroll, Ph.D., Professor, Department of Biochemistry, Uni-
versity of Western Ontario, London, Ontario, Canada

Ranjit K. Chandra, M.D., F.R.C.P., Janeway Child Health Center, Immu-
nology Department, St. John’s, Newfoundland, Canada

Lois Chatham, Ph.D., Director, Division of Basic Research, National
Institute on Alcohol Abuse and Alcoholism, Alcohal, Drug Abuse, and
Mental Health Administration, Rockville, Maryland

Aram V. Chobanian, M.D., Director and Professor, Cardiovascular Insti-
tute, Boston University School of Medicine, Boston, Massachusetts

Joginder G. Chopra, M.D., Special Assistant, Medical Affairs, Office of
Nutrition and Food Sciences, Center for Food Safety and Applied Nutri-
tion, Food and Drug Administration, Washington, D.C.

XXiV
Gregory Christenson, Ph.D., Special Population Studies Branch, Division
of Cancer Prevention and Control, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland

Carolyn Clifford, Ph.D., Diet and Cancer Branch, Division of Cancer
Prevention and Control, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland

James D. Cook, M.D., Division of Hematology, University of Kansas
Medical Center, Kansas City, Kansas

Stephen B. Corbin, D.D.S., M.P.H., Senior Prevention Policy Advisor,
Prevention Policy Staff, Office of Disease Prevention and Health Promo-
tion, Washington, D.C.

Ann Coulston, M.S., R.D., Clinical Research Center, Stanford University
Hospital, Stanford, California

Frances Cronin, Ph.D., R.D., Chief, Diet Appraisal Research Branch,
Nutrition Education Division, Human Nutrition Information Service, USS.
Department of Agriculture, Hyattsville, Maryland

Cheryl L. Damberg, M.P.H., Director of Marketing, General Health Inc.,
Washington, D.C.

Michele DeBartolo, M.P.H., R.D., Senior Clinical Research Associate,
Pharmaceutical Products Division, Abbott Laboratories, Abbott Park,
Illinois

Hector F. DeLuca, Ph.D., Department of Biochemistry, College of Agri-
culture and Life Sciences, University of Wisconsin, Madison, Wisconsin

Dominick P. DePaola, D.D.S., Ph.D., Dean, University of Medicine and
Dentistry of New Jersey, New Jersey Dental School, Newark, New Jersey

Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute, Nation-
al Institutes of Health, Bethesda, Maryland

Karen Donato, M.S., R.D., Nutritionist, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland

Allan L. Drash, M.D., Professor of Pediatrics, University of Pittsburgh
School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Penn-
sylvania
Mary Dufour, M.D., Chief, Epidemiology Branch, Division of Biometry
and Epidemiology, National Institute on Alcohol Abuse and Alcoholism,
Alcohol, Drug Abuse, and Mental Health Administration, Rockville,
Maryland

Harriet P. Dustan, M.D., Veterans Administration Distinguished Physi-
cian and University Distinguished Professor Emeritus, Veterans Adminis-
tration Medical Center, University of Alabama at Birmingham, Bir-
mingham, Alabama

Mary Egan, R.D., M.S., M.P.H., National Center for Education in Mater-
nal and Child Health, Georgetown University, Washington, D.C.

Shirley Ekvall, Ph.D., R.D., Professor and Chief of Nutrition Services,
University of Cincinnati and University Affiliated Cincinnati Center for
Developmental Disorders, Children’s Hospital Medical Center, Cincin-
nati, Ohio

Lillian Emmons, Ph.D., R.D., Comprehensive Psychiatric Services, Inc.,
Cleveland, Ohio

Arnold Engel, M.D., Commission Officer, Medical Statistics Branch,
National Center for Health Statistics, Centers for Disease Control, Hyatts-
ville, Maryland

Frank Falkner, M.D., F.R.C.P., School of Public Health, University of
California, Berkeley, California

Marilyn E. Farrand, M.S., R.D., Public Health Nutrition, Prevention and
Demonstration Research Branch, Division of Epidemiology and Clinical
Application, National Heart, Lung, and Blood Institute, National Insti-
tutes of Health, Bethesda, Maryland

Owen Fennema, Ph.D., Department of Food Science, University of Wis-
consin at Madison, Madison, Wisconsin

John D. Fernstrom, Ph.D., Professor of Psychiatry and Behavioral Neuro-
science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsyl-
vania

Willis R. Foster, M.D., Senior Staff Physician, Office of Disease Preven-
tion and Technology Transfer, National Institute of Diabetes and Digestive
and Kidney Diseases, National Institutes of Health, Bethesda, Maryland

Judith Fradkin, M.D., Chief, Endocrine and Metabolic Diseases Programs
Branch, National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health, Bethesda, Maryland

XXxvi
Victor Frattali, Ph.D., Deputy Director, Division of Nutrition, Office of
Nutrition and Food Sciences, Center for Food Safety and Applied Nutri-
tion, Food and Drug Administration, Washington, D.C.

Robert A. Fried, M.D., Associate Professor and Director of Clinical Af-
fairs, Department of Family Medicine, University of Colorado School of
Medicine, Denver, Colorado

Edward D. Frohlich, M.D., Alton Ochsner Distinguished Scientist and
Vice President for Academic Affairs, Alton Ochsner Medical Foundation,
Staff Member, Section on Hypertensive Diseases, Ochsner Clinic, New
Orleans, Louisiana

Peter Frommer, M.D., Deputy Director, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland

Margie Gallagher, Ph.D., R.D., School of Home Economics, Institute for
Coastal and Marine Resources, East Carolina University, Greenville,
North Carolina

Dian Gans, M.S., Research Assistant, Department of Nutritional Sci-
ences, University of Wisconsin at Madison, Madison, Wisconsin

Stanley M. Garn, Ph.D., Center for Human Growth and Development,
University of Michigan, Ann Arbor, Michigan

Peter Gergen, M.D., Commission Officer, Medical Statistics Branch, Na-
tional Center for Health Statistics, Centers for Disease Control, Hyatts-
ville, Maryland

Dorothy W. Gietzen, Ph.D., Assistant Research Neurophysiologist, De-
partment of Physiologic Sciences, School of Veterinary Medicine, Depart-
ment of Psychiatry, School of Medicine, University of California at Davis,
Davis, California

Susan Gilbert, M.P.A., Associate, Prospect Associates, Rockville, Mary-
land

Walter H. Glinsmann, M.D., Associate Director, Clinical Nutrition, Divi-
sion of Nutrition, Food and Drug Administration, Washington, D.C.

Vay Liang W. Go, M.D., Chairman, Nutrition Coordinating Committee,
National Institutes of Health, Bethesda, Maryland

Murray Goldstein, D.O., M.P.H., Director, National Institute of Neu-
rological and Communicative Disorders and Stroke, National Institutes of
Health, Bethesda, Maryland

XXxvii
DeWitt S. Goodman, M.D., Professor of Medicine, Department of Medi-
cine, College of Physicians and Surgeons of Columbia University, New
York, New York

Phillip Gorden, M.D., Director, National Institute of Diabetes and Di-
gestive and Kidney Diseases, National Institutes of Health, Bethesda,
Maryland

Enoch Gordis, M.D., Director, National Institute on Alcohol Abuse and
Alcoholism, Alcohol, Drug Abuse and Mental Health Administration,
Rockville, Maryland

Stephen L. Gordon, Ph.D., Director, Musculoskeletal Diseases Program,
National Institute of Arthritis and Musculoskeletal and Skin Diseases,
National Institutes of Health, Bethesda, Maryland

Gilman D. Grave, M.D., Chief, Endocrinology, Nutrition, and Growth
Branch, National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland

Jesse F. Gregory III, Ph.D., University of Florida, Food Science and
Nutrition Department, Gainesville, Florida

Joan Gussow, Ed.D., Mary Swartz Rose Professor of Nutrition and Edu-
cation, Department of Nutrition and Education, Teachers College, Colum-
bia University, New York

Wilbur Hadden, M.A., Chief, Programming Staff, National Center for
Health Statistics, Centers for Disease Control, Hyattsville, Maryland

Evan Hadley, M.D., Chief, Geriatrics Branch, National Institute on
Aging, National Institutes of Health, Bethesda, Maryland

Carole Haines, M.P.H., Data Analysis Coordinator, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary-
land

Judith G. Hallfrisch, Ph.D., Senior Staff Fellow, Metabolism Section of
the Gerontology Research Center, National Institute on Aging, National
Institutes of Health, Bethesda, Maryland

Charles H. Halsted, M.D., Ph.D., Chief, Division of Clinical Nutrition,
and Professor of Internal Medicine, School of Medicine, University of
California at Davis, Davis, California

Linda Harris, Ph.D., Special Assistant, Office of Disease Prevention and
Health Promotion, Washington, D.C.

XXVviii
Tamara Harris, M.D., Service Fellow, Office of Analysis and Epidemiolo-
gy Program, National Center for Health Statistics, Centers for Disease
Control, Hyattsville, Maryland

John N. Hathcock, Ph.D., Chief, Experimental Nutrition Branch, Division
of Nutrition, Food and Drug Administration, Washington, D.C.

Maureen Henderson, M.D., Cancer Prevention Research Program, Fred
Hutchinson Cancer Research Center, Seattle, Washington

Stephen P. Heyse, M.D., Director, Disease Prevention, Epidemiology and
Clinical Applications, National Institute of Arthritis and Musculoskeletal
and Skin Diseases, National Institutes of Health, Bethesda, Maryland

Jules Hirsch, M.D., Professor and Senior Physician, Rockefeller Univer-
sity, New York, New York

Gladys Hirshman, M.D., Director, Chronic Renal Disease Program, Na-
tional Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health, Bethesda, Maryland

Peter R. Holt, M.D., Chief, Division of Gastroenterology, Professor of
Medicine, College of Physicians and Surgeons, St. Luke’s Hospital, New
York, New York

Steven S. Hotta, M.D., Ph.D., Medical Officer, Clinical Nutrition Branch,
Division of Nutrition, Food and Drug Administration, Washington, D.C.

Anastacio M. Hoyumpa, M.D., Professor of Medicine, Division of Gas-
troenterology and Nutrition, University of Texas Health Science Center,
San Antonio, Texas

Van S. Hubbard, M.D., Ph.D., Director, Nutritional Sciences Branch,
National Institute of Diabetes and Digestive and Kidney Diseases, Nation-
al Institutes of Health, Bethesda, Maryland

Sandra Huckaby, R.N., M.S.N., Special Assistant, Maternal and Infant
Health Branch, Bureau of Maternal and Child Health and Resources
Development, Health Resources and Services Administration, Rockville,
Maryland

James C. Hunt, M.D., Chancellor, University of Tennessee, Memphis,
Tennessee

Vince L. Hutchins, M.D., M.P.H., Deputy Director, Bureau of Maternal
and Child Health and Resources Development, Health Resources and
Services Administration, Rockville, Maryland

XXiX
William T. Jarvis, Ph.D., Professor of Health Education, Department of
Preventive Medicine, School of Medicine, Loma Linda University, Loma
Linda, California

Clifford Johnson, M.S.P.H., Chief, Nutrition Statistics Branch, National
Center for Health Statistics, Centers for Disease Control, Hyattsville,
Maryland

Norman Kaplan, M.D., Professor of Internal Medicine, University of
Texas Health Science Center, Dallas, Texas

Gerald T. Keusch, M.D., Professor of Medicine, Department of Medicine,
New England Medical Center, Boston, Massachusetts

Matthew Kinnard, Ph.D., Health Scientist Administrator, National Insti-
tute of Dental Research, National Institutes of Health, Bethesda, Mary-
land

Samuel Korper, Ph.D., Associate Director, Office of Planning, Analysis,
and Communications, National Institute on Aging, National Institutes of
Health, Bethesda, Maryland

David Kritchevsky, Ph.D., Associate Director of Anatomy and Biology,
Wistar Institute, Philadelphia, Pennsylvania

Robert Kuczmarksi, M.S.P.H., M.P.H., Dr.P.H., R.D., Health Statisti-
cian, Nutrition Statistics Branch, National Center for Health Statistics,
Centers for Disease Control, Hyattsville, Maryland

William Lands, Ph.D., Department of Biochemistry, University of Illinois
at Chicago, Chicago, Illinois

Lynn A. Larsen, Ph.D., Associate Director, Program Development, Divi-
sion of Nutrition, Office of Nutrition and Food Sciences, Center for Food
Safety and Applied Nutrition, Food and Drug Administration, Washington,
D.C.

Reva C. Lawrence, M.P.H., Epidemiologist, Data Systems, Program Of-
ficer, National Institute of Arthritis and Musculoskeletal and Skin Dis-
eases, National Institutes of Health, Bethesda, Maryland

Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Insti-
tute, National Institutes of Health, Bethesda, Maryland

Gilbert A. Leveille, Ph.D., Staff Vice President, NABISCO Brands, Inc.,
East Hanover, New Jersey
Ephraim Y. Levin, M.D., Medical Officer, National Institute of Child
Health and Human Development, National Institutes of Health, Bethesda,
Maryland

Christine J. Lewis, Ph.D., R.D., Chief, Experimental Clinical Research
Section, Division of Nutrition, Office of Nutrition and Food Sciences,
Center for Food Safety and Applied Nutrition, Food and Drug Administra-
tion, Washington, D.C.

Charles S. Lieber, M.D., Director, Alcohol Research and Treatment Cen-
ter, Chief, Section of Liver Disease and Nutrition, Bronx Veterans Admin-
istration Medical Center, Professor of Medicine and Pathology, Mount
Sinai School of Medicine, New York, New York

Jane Lin Fu, M.D., Acting Chief, Genetic Services Branch, Bureau of
Maternal and Child Health and Resources Development, Health Resources
and Services Administration, Rockville, Maryland

Harald Lée, D.D.S., Director, National Institute of Dental Research,
National Institutes of Health, Bethesda, Maryland

Anne Looker, Ph.D., R.D., Health Statistician, Nutrition Statistics
Branch, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland

Susan K. Maloney, M.H.S., Director, Health Communication Staff, Office
of Disease Prevention and Health Promotion, Washington, D.C.

Alvin Mauer, M.D., University of Tennessee, Division of Hematology/
Oncology, Memphis, Tennessee

Donald B. McCormick, Ph.D., Chairman, Department of Biochemistry,
Emory University School of Medicine, Atlanta, Georgia

Gardner C. McMillan, M.D., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, Maryland

Marilyn McMillen, Ph.D., Statistician, Surveillance and Operations Re-
search Section, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland

Laura McNally, R.D., M.P.H., Nutrition Specialist, Child and Adolescent
Primary Care Services Branch, Bureau of Maternal and Child Health and
Resources Development, Health Resources and Services Administration,
Rockville, Maryland

XXX1
Marsel Mesulam, M.D., Professor of Neurology, Harvard Medical School,
Director, Division of Neuroscience and Behavioral Neurology, Beth Israel
Hospital, Boston, Massachusetts

Esteban Mezey, M.D., Professor of Medicine, Johns Hopkins Hospital,
Baltimore, Maryland

Angela D. Mickalide, Ph.D., Staff Coordinator, U.S. Preventive Services
Task Force, Office of Disease Prevention and Health Promotion, Washing-
ton, D.C.

William E. Mitch, M.D., Rena! Division, Emory University School of
Medicine, Atlanta, Georgia

Elaine R. Monsen, Ph.D., R.D., University of Washington, Seattle, Wash-
ington

Steven R. Moore, M.P.H., Associate Chief of Staff, Office of the Surgeon
General, Rockville, Maryland

Hamish N. Munro, M.D., D.Sc., Senior Scientist, USDA Human Nutri-
tion Research Center on Aging, Tufts University, Boston, Massachusetts

Juan M. Navia, Ph.D., Professor and Chairman, Department of Public
Health Sciences, Schools of Public Health and Dentistry, University of
Alabama at Birmingham, Birmingham, Alabama

Buford L. Nichols, Jr., M.D., Children’s Nutrition Research Laboratory,
Baylor School of Medicine, Houston, Texas

Phillip Nieburg, M.D., M.P.H., Medical Epidemiologist, Division of Nutri-
tion, Centers for Disease Control, Atlanta, Georgia

Daniel W. Nixon, M.D., Associate Director, Cancer Prevention Research
Program, National Cancer Institute, National Institutes of Health, Bethes-
da, Maryland

Marie U. Nylen, D.D.S., Dr. Odont. h.c., Director, Extramural Program,
National Institute of Dental Research, National Institutes of Health, Be-
thesda, Maryland

Carole A. Palmer, M.Ed., R.D., Associate Professor and Division Co-
Chairman, Division of Nutrition and Prevention Dentistry, Tufts Univer-
sity School of Medicine, Boston, Massachusetts

XXXii
Eugene Passamani, M.D., Director, Division of Heart and Vascular Dis-
eases, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland

Penelope Pollard, M.S., M.B.A., Senior Research Associate, National
Health Policy Forum, Washington, D.C.

Donna V. Porter, Ph.D., R.D., Specialist in Life Sciences, Science Policy
Research Division, Congressional Research Office, Washington, D.C.

Roger J. Porter, M.D., Deputy Director, National Institute of Neurological
and Communicative Disorders and Stroke, National Institutes of Health,
Bethesda, Maryland

Barbara Posner, D.P.H., R.D., Associate Professor and Director, Graduate
Nutrition Division, Boston University, Boston, Massachusetts

Ann Prendergast, R.D., M.P.H., Chief Nutritionist, Habilitative Services
Branch, Bureau of Maternal and Child Health and Resources Develop-
ment, Health Resources and Services Administration, Rockville, Mary-
land

Jeanne I. Rader, Ph.D., Chief, Nutrient Toxicity Section, Experimental
Nutrition Branch, Division of Nutrition, Food and Drug Administration,
Washington, D.C.

Edward Roccella, Ph.D., M.P.H., Program Coordinator, National High
Blood Pressure Education Program, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland

Daphne A. Roe, M.D., Professor, Division of Nutritional Sciences, Cornell
University, Ithaca, New York

Quinton Rogers, Ph.D., Department of Physiological Sciences, School of
Veterinary Medicine, University of California at Davis, Davis, California

Daniel Rudman, M.D., Associate Chief of Staff, Geriatric Medicine, North
Chicago Veterans Administration Medical Center, North Chicago, Hlinois

Robert Russell, M.D., USDA Human Nutrition Research Center on Aging
at Tufts University, Boston, Massachusetts

Anna A. Sandberg, Dr.P.H., Coordinator, Clinical Trial, Kidney-Urology
Branch, National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health, Bethesda, Maryland

XXXxiii
Harold H. Sandstead, M.D., Department of Preventive Medicine and
Community Health, University of Texas Medical Branch, Galveston,
Texas

Howerde Sauberlich, Ph.D., Department of Nutrition Science, University
of Alabama, University Station, Alabama

Christopher Sempos, Ph.D., Health Statistician, Nutrition Statistics
Branch, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland

Zekin Shakhashiri, M.S., M.D., M.P.H., Senior Medical Advisor, National
Institute of Neurological and Communicative Disorders and Stroke, Na-
tional Institutes of Health, Bethesda, Maryland

Lawrence E. Shulman, M.D., Ph.D., Director, National Institute of Arthri-
tis and Musculoskeletal and Skin Diseases, National Institutes of Health,
Bethesda, Maryland

Robert Silverman, M.D., Ph.D., Chief, Diabetes Programs Branch, Na-
tional Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health, Bethesda, Maryland

Christine Hamilton Smith, Ph.D., R.D., Home Economics Department,
Food Science and Nutrition, California State University at Northridge,
Northridge, California

Dorothy D. Sogn, M.D., Chief, Asthma and Allergy Branch, Immunology,
Allergic and Immunologic Diseases Program, National Institute of Allergy
and Infectious Diseases, National Institutes of Health, Bethesda, Mary-
land

David A.T. Southgate, Ph.D., AFRC Institute of Food Research, Norwich
Laboratory, Norfolk, United Kingdom

Reynold Spector, M.D., Executive Director, Merck Sharp & Dohme Re-
search Laboratories, Rahway, New Jersey

Judith S. Stern, Sc.D., University of California at Davis, Davis, California

Eugene Streicher, Ph.D., Director, Division of Fundamental Neurosci-
ences, National Institute of Neurological and Communicative Disorders
and Stroke, National Institutes of Health, Bethesda, Maryland

Helene Swenerton, Ph.D., Nutritionist, Cooperative Extension, Depart-
ment of Nutrition, University of California at Davis, Davis, California

XXXIV
Jean K. Tews, Ph.D., Department of Biochemistry, University of Wiscon-
sin at Madison, Madison, Wisconsin

Jeanne L. Tillotson, R.D., M.A., Crofton, Maryland

Phillip P. Toskes, M.D., Professor of Medicine and Director, Division of
Gastroenterology, Hepatology and Nutrition, University of Florida Col-
lege of Medicine and Gainesville Veterans Administration Medical Center,
Gainesville, Florida

Pelagia Turyn-Einhorn, M.D., Medical Officer, Clinical Nutrition Branch,
Division of Nutrition, Office of Nutrition and Food Sciences, Center for
Food Safety and Applied Nutrition, Food and Drug Administration, Wash-
ington, D.C.

Ernestine Vanderveen, Ph.D., Associate Director for AIDS, Division of
Clinical Research, National Institute on Drug Abuse, Alcohol, Drug
Abuse, and Mental Health Administration, Rockville, Maryland

John E. Vanderveen, Ph.D., Director, Division of Nutrition, Food and
Drug Administration, Washington, D.C.

John Wallingford, Ph.D., Nutritionist, Clinical Nutrition Branch, Division
of Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety
and Applied Nutrition, Food and Drug Administration, Washington, D.C.

Donald M. Watkin, A.B., M.D., M.P.H., Manager, Occupational Health
Division, Office of Aviation Medicine, Federal Aviation Administration,
U.S. Department of Transportation, and Research Professor, Department
of Medicine, School of Medicine and Health Sciences, The George Wash-
ington University, Washington, D.C.

Richard Weindruch, Ph.D., Health Scientist Administrator, National Insti-
tute on Aging, National Institutes of Health, Bethesda, Maryland

Gerald Wheeler, Commission Officer, Division of Health Examination
Statistics, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland

Philip L. White, Sc.D., Wilmette, Illinois, Director, Division of Applied

Medical Sciences, American Medical Association, Chicago, Illinois (Re-
tired)

T. Franklin Williams, M.D., Director, National Institute on Aging, Nation-
al Institutes of Health, Bethesda, Maryland

XXXV
David F. Williamson, M.S., Ph.D., Analytic Epidemiologist, Centers for
Disease Control, Atlanta, Georgia

Myron Winick, M.D., R.R. Williams Professor of Nutrition and Pediatrics,
Columbia University College of Physicians and Surgeons, New York, New
York

Deborah Winn, Ph.D., Epidemiologist, Survey Planning and Development
Branch, National Center for Health Statistics, Centers for Disease Con-
trol, Hyattsville, Maryland

Maxwell M. Wintrobe, M.D., Ph.D., D.Sc., Distinguished Professor of
Medicine, University of Utah Medical School, Salt Lake City, Utah

Elisabeth P. Wirick, Food, Nutrition, and Dietetics, College of Health and
Human Services, University of Northern Colorado, Greeley, Colorado

Eleanor A. Young, Ph.D., R.D., L.D., Professor, Department of Medicine,
Division of Gastroenterology and Nutrition, University of Texas Health
Science Center at San Antonio, San Antonio, Texas

William J. Zukel, M.D., Deputy Director, Division of Heart and Vascular
Diseases, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland

The editors gratefully acknowledge the contributions of the following
staff members and others who assisted in the preparation of this
Report:

@ Office of Disease Prevention and Health Promotion

Nancy Chapman, R.D., M.P.H., President, N. Chapman Associates,
Washington, D.C.

Mary Jo Deering, Ph.D., Publications Manager
James A. Harrell, M.A., Deputy Director
Susan K. Maloney, M.H.S., Director, Health Communication Staff

David G. Schardt, M.S., Ph.D., Nutrition Consultant, Nutrition
Media Network, Washington, D.C.

Marilyn K. Schulenberg, Staff Assistant
Maureen Sullivan, M.P.H., M.I.A., Program Analyst, U.S. Food
and Drug Administration, New York, New York

XXXVi
Herbert Szeto, Intern, Nutrition Policy Staff

Sara L. White, M.S., Health Promotion Research Associate, Health
Communication Staff

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XXXVii