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2
Introduction
THE CENTRAL CHARGE to the Committee on Dietary Guidelines
Implementation of the Food and Nutrition Board (FNB) was to
determine how to implement most effectively the consensus that has
emerged regarding the dietary advice that will best promote the public's
health.
For almost a century, dietary guidelines for the U.S. population
have been promulgated by the federal government and other bodies
(Haughton et al., 1987; U.S. Congress, Senate, 1909~. Because the
maintenance of human health requires the ingestion of nutrients found
in food, much of the early dietary advice focused on urging people to
eat the kinds and amounts of foods needed to avoid nutrient defi-
ciency diseases. Little attention was given to developing dietary guidance
intended to reduce the risk of chronic degenerative disease because
there was, until recently, little supporting evidence-other than that
linking excess energy intake to obesity to support such guidelines.
Over the past 25 years, however, substantial advances have been
made in understanding the relationships among dietary patterns, food
and nutrient intakes, and the etiology and pathogenesis of many chronic
degenerative diseases. The roles of diet in health promotion and risk
reduction and in the prevention and control of specific diet-related
diseases have now been characterized. Beginning in the early 1960s,
various sets of dietary guidelines intended to help the population
reduce its risk of certain chronic degenerative diseases began to be
widely disseminated. These are described and compared in the FNB's
18
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INTRODUCTION
19
report, Diet and Health: Implications for Reducing Chronic Disease Risk
(NRC, 1989c) (hereinafter referred to as the Diet and Health report).
The federal government in particular has issued several important
sets of dietary guidelines since the late 1970s. Congress, the legisla-
tive branch of government, held hearings on dietary patterns and
health in the late 1960s and early 1970s that led to the promulgation
of Dietary Goals for the United States (U.S. Congress, Senate, 1977a,b),
suggesting an eating pattern very similar to that later recommended
in the Diet and Health report. The impetus then passed to the execu-
tive branch of government. In 1979, for example, the Surgeon General
of the United States published Healthy People: the Surgeon General's Report
on Health Promotion and Disease Prevention (DHEW, 1979), a landmark
document wherein the federal government explicitly recognized the
importance of nutrition as a major influence on the nation's health.
The following year, this recognition was expanded by the inclusion
of 17 specific nutrition objectives in the report Promoting Health/Pre-
venting Disease: Objectives for the Nation (DHHS, 1980~. Interest in
nutrition as a major component of disease prevention and health
maintenance was further emphasized with the publication in 1980 of
Nutrition and Your Health: Dietary Guidelinesfor Americans (USDA/DHHS,
1980) a joint project of the U.S. Departments of Agriculture (USDA)
and Health and Human Services (DHHS) that became the basis for
federal nutrition policies.
Until recently, efforts to act on new understandings about diet and
health were focused primarily on achieving consensus among scientists
on the appropriateness of certain dietary guidelines and on publiciz
ing various, somewhat different sets of guidelines. -~ ~~ ~
These efforts cul-
minated in the issuance of The Surgeon General's Report on Nutrition
and Health in 1988 (DHHS, 1988) and the FNB's Diet and Health report
in 1989 (NRC, 1989c). Together, these authoritative reviews of the
evidence relating dietary factors to health and disease make it clear
that there is now wide-scale consensus in the United States and in
the international nutrition community on the overall nature of the
dietary modifications needed to reduce the risk of diet-related chronic
diseases. Indeed, there is a striking level of agreement at this time
among dietary guidelines in the United States and those in other
industrialized countries around the world (NRC, 1989c).
In this report, the committee promotes the recommendations of
the Diet and Health report because they are well suited for implemen-
tation. These comprehensive recommendations will be reviewed regularly
and revised as needed to incorporate new findings. In addition, they
specify quantitative targets (e.g., limit fat intake to 30% or less of
calories) and are presented in a priority order that reflects their likely
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20
IMPROVING AMERICA'S DIET AND HEALTH
impact on public health. These qualities facilitate their interpretation
and translation into specific strategies and actions for implementa-
tion and facilitate evaluations of the success of these initiatives.
This committee believes that dietary guidelines used as the basis
for nutrition policy in the United States should be as quantitative as
possible. Therefore, the federal government's progress, albeit slow,
in quantifying its dietary guidelines is to be applauded. Examples of
quantitation include the following:
· The report Healthy People 2000: National Health Promotion and Disease
Prevention Objectives issued by DHHS (1990) recommends that average
total fat intake among people age 2 and older be no more than 30% of
calories and that saturated fat intake not exceed 10% of calories. It
also advises the daily consumption of five or more servings of vegetables,
fruits, and legumes and six or more servings of grain products.
· The population panel of the National Cholesterol Education Program
(NCEP, 1990) recommends that "healthy Americans" beginning at
age 2 consume less than 10% of total calories from saturated fatty
acids, an average of 30°/O or less of calories from total fat, and less
than 300 mg of cholesterol per day.
· The text of the recently issued 3rd edition of the USDA/DHHS
booklet, Nutrition and Your Health: Dietary Guidelines for Americans,
recommends that total fat intake in the diets of adults not exceed 30%
of calories and that saturated fat intake be less than 10% of calories
(USDA/DHHS, 1990~. The report notes that this recommendation
does not apply to children below age 2. The report also recommends
that adults eat daily at least three servings of vegetables, two servings
of fruits, and six servings of grain products, and that pregnant women
or women trying to conceive axroid alcoholic beverages.
· The USDA food guide, "A Pattern for Daily Food Choices," sug-
gests 6-11 servings per day of breads, cereals, and other grain products;
2-4 servings of fruits; and 3-5 servings of vegetables (including dry
peas and beans) (USDA, 1989~.
The committee's strategies and actions for implementation are
qualitative and therefore apply equally well to the recommendations
in the Diet and Health report, The Surgeon General's Report on Nutrition
and Health (DHHS, 1988), and Dietary Guidelinesfor Americans (USDA/
DHHS, 1990) (see Appendix A for all three sets of recommendations).
Thus, the term dietary recommendations is used throughout this report
to refer as a group to these three sets of guidelines. The committee's
recommended implementation strategies and actions also apply to
most or all of the disease-specific dietary guidelines issued by expert
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INTRODUCTION
21
groups (e.g., by the American Heart Association and the National
Cancer Institute), because they are similar to those of the FNB, the
Surgeon General, and USDA/DHHS. However, the committee be-
lieves that the United States should move toward adopting a single
set of dietary recommendations to communicate and promote. One
set of recommendations should reduce confusion and provide
implementors with a common focus for their activities.
PLACING DIETARY RECOMMENDATIONS
IN PERSPECTIVE
Although this report focuses on improving dietary patterns, the
committee emphasizes that diet is only one important determinant of
health and well-being. Various personal behaviors (e.g., refraining
from smoking and abuse of drugs, engaging in regular exercise, and
taking care to avoid accidents) and other factors (e.g., family history
of disease, access to health-care services, and the state of the environ-
ment) are also strongly linked to risks of disease and should not be
neglected in health promotion programs by an overemphasis on diet.
Healthful dietary patterns and life-styles will improve the health of
many people but will not guarantee good health or long life for any
person.
The committee hopes that implementation initiatives undertaken
in response to the recommendations in this report will be linked with
other health-promoting practices whenever possible. A long-term
commitment to implementation by promoting incremental changes is
more likely to be successful than are drastic, one-shot efforts. Be-
cause the food system and public responses to new dietary patterns
change slowly, a realistic time frame for implementation will be mea-
sured in years rather than months.
FROM GUIDANCE TO IMPLEMENTATION
Consensus on dietary guidance is an important advance; however,
guidelines cannot be effective until a coordinated effort is made to
teach consumers how to interpret and apply them and to assist people
in overcoming the difficulties in trying to change their eating behav-
iors. But the many questions about what should be done, and by
whom, and where the effort should be focused have not yet been
addressed systematically. This lack is partly a consequence of a com-
mon, though incorrect, assumption that once there is widespread
awareness of dietary guidelines, most people will adopt and imple-
ment them on their own. In this report, the committee addresses
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22
IMPROVING AMERICA'S DIET AND HEALTH
these and other questions and presents the components of a compre-
hensive plan to implement dietary recommendations.
Although most people in the United States do not choose diets
that conform to all the dietary recommendations, some people have
changed their diets in recent years for what they report to be health
reasons (FMI, 1990~. The changes in public attitude and food con-
sumption reported in Chapter 3 are often attributed to public aware-
ness of various sets of dietary guidelines, but it is clear this is not the
entire explanation.
Although smoking, as an addictive habit, is very different from
eating, the long and continuing effort to reduce cigarette smoking
may offer some useful analogies to the task of changing eating habits.
The antismoking effort has involved alterations in the physical envi-
ronment (by restricting areas in which smoking can occur); positive
examples of nonsmoking by highly visible individuals (e.g., physicians
and politicians); promotion of tobacco avoidance in public and private
education; and assistance to smokers who want to quit. The public
and private sectors have devoted effort and money to the cause. Of
equal importance, however, may have been the common purpose shown
at most levels of government (with continued tobacco subsidies a
notable exception) and the vast effort expended by health-oriented
voluntary groups such as the American Cancer Society, the American
Heart Association, the American Lung Association, and Action on
Smoking and Health. Even greater commitments of money, time,
political will, and other resources will likely be needed to improve
the nation's eating patterns.
IMPLEMENTATION AND THE POOR
This report is directed to the majority of the U.S. population, which
enjoys secure access to food. There is another segment of the population,
however, that has tragically little food security and has uncertain or
inconsistent access to a wholesome, nutritious food supply. This
group includes people who are poor or homeless and people who are
disadvantaged and dependent because of disease or other reasons
(Mayer, 1990; Stoto et al., 1990~. Their diets may not supply adequate
calories and may be low in vitamins and minerals but high in total
fat, saturated fat, cholesterol, and sodium. Alcohol abuse may also
affect some people in this group. The nutritional status of the poor
and disadvantaged can be further compounded by inadequately met
medical, housing, sanitation, education, and other basic needs.
Minority and disadvantaged groups lag behind the U.S. popula-
tion on health status indicators (DHHS, 1990~. For example, black
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INTRODUCTION
23
Americans, compared with the general population, have higher rates
of high blood pressure, stroke, diabetes, and diseases associated with
obesity (DHHS, 1988~. Native Americans and Hispanics suffer greater
disease and mortality burdens than whites (DHHS, 1985~. Surveys
indicate that people with the most education and other resources have
made and benefited from dietary changes, whereas the poor and less
educated have not (Heimbach, 1985~. To lessen the burden of chronic
disease and premature death for all its citizens, the nation will need to
do more than implement recommendations on diet.) It also needs to be
more accommodating to the diverse cultures of its people and focus its
health promotion and outreach efforts on segments of the population
that are least likely to eat well or practice other healthful behaviors.
BARRIERS AND INCENTIVES TO DIETARY CHANGE
Attempts to change dietary behavior are confronted with a par-
ticular set of problems. First, eating is often social and fun. Thus,
many of the food choices that health-care professionals tend to view
as undesirable are seen by the public as sources of pleasure. The
committee does not wish to have people focus on health alone in
deciding what to eat but, rather, to encourage them to modify their
eating behaviors in ways that are both healthful and perceived as
pleasurable. This is a challenging task.
Promotion of dietary change among healthy people may be an
especially formidable problem for another reason: modifying eating
behaviors, unlike quitting smoking, for example, usually produces few
immediate physical or psychological benefits. Moreover, as Carmody
and colleagues pointed out, people are being asked to move away
{~ YArh - l ,/1ATOO O~ in ohm - mr~1 Aimi
v I
11 tell L vv 1 LCI ~ vv "O "1 Led 1~ to Lo 1 two 11 L"1 ~ ~ ~ ~ . . . for the U.S. population
rather than to abandon a recognizably pathogenic behavior (Carmody
et al., 1986, p. 21~.
Events that draw the public's attention to competing risks can be
another barrier to dietary change. For example, at the time of release
of the Diet and Health report, with its recommendations to consume
fruits, vegetables, and poultry, the National Resources Defense Council
warned that children were excessively exposed to agricultural chemicals,
especially to Alar on apples (NRDC, 1989~. Two weeks later, all fruit
imported from Chile was temporarily barred from sale while the U.S.
government sought to learn whether the cyanide discovered in two
seedless grapes was widely dispersed among fruit distributed throughout
the United States (Food Chemical News, 1989a). At about the same
time, 400,000 chickens were destroyed in Arkansas because they were
found to be contaminated with heptachlor, a cancer-causing pesticide
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24
IMPROVING AMERICA'S DIET AND HEALTH
that had been barred from agricultural use 11 years earlier (Food
Chemical News, 1989b; Schneider, 1989~.
Many health-care professionals see such alarms as a diversion of
the public's attention away from more serious food-related issues.
They argue that the hazard, if any, from chemical residues is much
smaller than the known hazard of excessive fat consumption (NRC,
1989c). However, the evidence shows that the public is generally
more concerned about a risk it cannot personally control (like pesti-
cide residues) than one it can (like eating less fat) (NRC, 1989d). If
health-care professionals want people to accept and follow their advice
regarding health-promoting behaviors, they cannot afford to discount-
or to view as distractions the risks that most concern the public at
any given moment.
Given the right incentives, people can surmount barriers to imple-
menting dietary recommendations. For the individual, incentives to eat
well include the likelihood that healthy dietary patterns especially when
combined with other behaviors- will enhance health and reduce the
risk of many diseases. Furthermore, there are increasing opportunities today
for consumers to select and prepare health-promoting and appealing
meals that fit into their ways of life.2 For the private sector, there are
financial incentives to address the public's interest in better nutrition
by developing more appealing food products with reduced levels of
fat, sodium, and sugar. Because dietary improvements can be expected
to improve the nation's health, governments and health-care professionals
have a powerful reason to serve as role models and agenda setters
for efforts to encourage more healthful food consumption practices
and to coordinate, study, and monitor implementation efforts. These
and other incentives to implement dietary recommendations are dis-
cussed in later chapters.
THE TASK OF IMPLEMENTATION: GOALS,
TACTICS, AND POLICIES
Implementation begins with getting information about dietary rec-
ommendations to consumers in languages and formats that are relevant
and comprehensible to them, given their diversities. The information
provided must identify the components of a healthful diet and link
such a diet to a life relatively freer of disease and disability.
The next and more difficult step is helping people to alter their
food consumption practices in more healthful directions. This involves
both individual and public responsibility. Society should not ignore
the needs of people who have decided to move toward more health-
ful food consumption practices but find it difficult to do so. All
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INTRODUCTION
25
sectors of society-including industry, government, and health-care
professionals have a responsibility to help individuals make and
implement choices that result in the consumption of nutritionally
desirable foods. To encourage better eating, health-promoting food
choices must be accessible, easy to identify and prepare, economical,
enjoyable, and adaptable to various life-styles. The committee's strategies
and actions for implementation are designed to make it easier for
people to eat healthful diets without sacrificing convenience or de-
sired life-styles.
Implementation efforts must also take into account the so-called
hidden choices that consumers rarely recognize and over which they
have little or no control. These choices, which are made by others for
consumers, include, for example, the ingredients used by restaurants
(e.g., the types of fats and oils in which foods are cooked). Society
has an obligation to ensure that such hidden choices are, whenever
possible, made in a way that fosters healthful eating.
The goal of implementation efforts is to help people whose diets
are less than ideal to reduce their intake of certain food components
and increase their intake of others, i.e., to increase the prevalence of
eating patterns that conform to dietary recommendations. This goal
will be met in the following ways:
· enhancing awareness, understanding, and acceptance of dietary
recommendations;
· creating legislative, regulatory, commercial, and educational en-
vironments supportive of the recommendations; and
· improving the availability of foods and meals that facilitate
implementation of the recommendations.
The general tactics for increasing the prevalence of healthful eating
patterns can be divided into three classes:
1. Altering the food supply by subtraction (e.g., reducing the fat in
meat and cheese), addition (e.g., appropriate fortification of foods with
nutrients), and substitution (e.g., replacing some of the fat in margarine
with water).
2. Altering the food acquisition environment by providing more food
choices that help consumers meet dietary recommendations, better in-
formation (e.g., more complete and interpretable product labeling),
advice at points of purchase (e.g., tags indicating a good nutrition buy
in supermarkets or cafeterias), and more options for selecting health-
ful diets (e.g. better food choices in vending machines and restaurants).
3. Altering nutrition education by changing the message mix (e.g.,
presenting consistent messages in education programs, advertisements
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IMPROVING AMERICA'S DIET AND HEALTH
for products, and public service announcements) and by broadening
exposure to formal and nonformal nutrition education (e.g., mandating
education on dietary recommendations from kindergarten through
grade 12, in health-care facilities, and in medical schools).
Although common sense suggests that desirable dietary changes
will most likely occur when all these components are made to be
mutually reinforcing, there is insufficient research on their individual
effectiveness or how they can best be assembled into a package. The
attitudes and skills involved in carrying out these various kinds of
interventions belong to different academic, institutional, sectoral, and
societal domains; no substantial effort has been made until now to
ask which combination of approaches offers the best promise of suc-
cess in bringing about dietary change on a national level. In Chapter
3, the committee examines the evidence from community-based stud-
ies to learn which components of integrated programs of dietary change
are associated with success.
THE TASK AND THE IMPLEMENTORS
In approaching the task of proposing strategies and actions for the
nationwide implementation of dietary recommendations in the United
States, the committee has taken a somewhat unconventional route.
Rather than providing a simple list of all the steps that might be
taken to modify diets, it has developed a list of interventions that
seem most likely to work given the need to protect free choice and
to operate within resource limits. The committee has done this be-
cause it believes that consideration of implementation measures without
regard to strongly held values and existing resource constraints is of
little practical value. At the same time, it recognizes that conclusions
regarding both values and resource constraints are subjective.
The committee began its work by imagining a wide range of strategies
for modifying eating behavior. To the extent possible, each of these
was examined in terms of such criteria as history of effectiveness,
affordability, political feasibility, public acceptability, and legal and
ethical considerations. Together, these criteria served as the basis for
selecting implementation strategies and actions that in the committee's
judgment are likely to be successful.
Much of the committee's work was done by four task forces, each
focusing on specific societal sectors: public, private, health-care pro-
fessions, and public education. These groupings were an effective
mechanism for identifying the main interventions that have been at-
tempted to date and for recommending those that might be under-
taken in the future. The recommendations of these task forces are
presented in Chapters 5 through 8.
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INTRODUCTION
1 1 / ~1- 1- ~
27
It is clear that the four sectors have overlapping responsibilities.
For example, all sectors use the media to inform and educate and to
influence the public's diet-related behaviors. Governments make policies
related to meat grading, to labeling, and to the kinds of foods offered
in the school lunch and other food programs, thereby affecting the
food supply, the shopping environment (private sector), and the
educational environment. Mandates for nutrition education in the
nation's classrooms from Congress or state legislatures obviously have
the potential for changing the demands on health-care professionals
as well.
There is a critical need for substantial government involvement
and support in any comprehensive attempt to implement dietary rec-
ommendations. A key responsibility of governments is to serve as a
role model and agenda setter. Public officials must ensure that all
branches of government at all levels (federal, state, and local) work
toward implementation of dietary recommendations by these steps:
(1) initiate or expand practices that conform to dietary recommenda-
tions in dining facilities in government buildings; (2) reconcile legis-
lation, regulations, policies, and practices so that they foster the effort;
(3) use government's convening, educational, and technical assistance
functions to urge private and voluntary groups to improve food se-
lection and consumption patterns; and (4) capitalize on government's
role in setting the diet and health agenda and its leadership in rally-
ing and coordinating support.
Actions taken by the private sector are also cross-cutting. The producers,
processors, and purveyors of food affect the food supply in many
ways. For example, processors and marketers influence the food
acquisition and educational environments through the information
they provide on their packages and in their advertising messages and
by the development and introduction of new food items that vary in
their nutritional desirability. (An average of 34 new varieties of food
and beverage products were introduced each day in the United States
in 1989 iShapiro, 19903.) Producer and processor groups directly
influence classroom education through the creation and distribution
of educational materials designed for use in schools. It is less appar-
ent how much educators can affect the food supply or food acquisition
environment, although they could hope to alter consumer demand
and thus affect the actions of both the food industry and govern-
ments. These interrelationships speak to the need for collaboration
and joint planning of implementation efforts.
All implementation efforts are constrained by the reality that no
government or private or voluntary organization has the power to
command the public to adopt a more healthful diet. Thus, the com-
mittee has also examined the issue of free choice as it relates to mak
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28
IMPROVING AMERICA'S DIET AND HEALTH
ing informed food product choices while the number of choices con-
tinues to increase (see Chapter 8~. Governments, industry, and vol-
untary health organizations lack financial resources, the ability to
coordinate activities among them, and adequate staff and expertise
to give technical assistance. At present, implementation is further
constrained by insufficient knowledge-not so much of detailed rela-
tionships between diet and disease as of the environment in which
change is being implemented. Too little is known about people's
nutritional health because of the lack of comprehensive nutritional
surveillance, and too little is known about the composition of the
food supply and how that changes because of inadequate monitoring of
these variables. Throughout its deliberations, the committee con-
tinually reminded itself of both resource and knowledge limitations
and of the inevitable constraints on government effectiveness.
Chapter 9 contains the committee's directions for research. These
are aimed at generating the knowledge that will improve the ability
to design successful implementation strategies and actions.
BENEFITS AND COSTS OF DIETARY CHANGE
Public health programs are continually starved for resources. Thus,
it is important that the resources available be used efficiently and
that cost-effective projects, i.e., those that accomplish the goals at the
lowest cost, receive first priority.
Devoting resources to implementing dietary recommendations is a
public health project that must compete with other public health projects
for resources. How much should be spent on media campaigns, im-
proved labeling, or developing a manual to advise consumers on
how to meet dietary recommendations? A careful assessment of the
benefits and costs of each action and of the distribution of these ben-
efits and costs is needed to make informed decisions about the allocation
of resources.
Full implementation of dietary recommendations promises consid-
erable benefits in improved health and well-being and fewer costs for
work absence and disability. Unfortunately, implemention of dietary
recommendations will sometimes be difficult and costly. The costs in-
clude (1) the monetary costs of establishing and maintaining the programs
and structures that educate consumers about dietary recommenda-
tions and how to implement them; (2) the costs incurred by the pri-
vate sector in changing production, manufacturing, and processing
practices to emphasize foods that help people to meet dietary recom-
mendations; and (3) the psychological costs that some people will
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INTRODUCTION
29
bear by taking up a new diet that is perceived to be less satisfying
and more troublesome to buy and prepare at least in the short run.
Because implementation of almost any of the recommendations in
this report will have effects that go well beyond nutritional ones, it is
important that hidden costs and benefits be identified beforehand, to
the extent possible. For example, committee recommendations to
modify the formulation of certain foods might raise the price of these
products, at least in the short term a hidden cost.
Given the time and resource constraints for this study, the benefits
and costs of the proposed actions could not be estimated with confi-
dence. The primary difficulty is the lack of quantification of the
effects of past programs to modify dietary practices or observe the
health effects of dietary modifications. The committee recommends
strongly that the plan for every action undertaken to modify dietary
habits include adequate evaluation, which will require adequate re-
sources. Such evaluations would indicate which programs should be
expanded, which ones should be modified (and when the modifica-
tion is successful), and which ones should be discontinued as unsuc-
cessful.
NOTES
Several reports from the National Research Council and Institute of Medicine
address the medical, social, and public welfare needs of the poor in the United
States. These reports include: Risking the Future: Adolescent Sexuality, Pregnancy,
and Childbearing (NRC, 1987), Prenatal Care: Reaching Mothers, Reaching Infants
(IOM, 1988b), Homelessness, Health, and Human Needs (IOM, 1988a), Who Cares for
America's Children? (NRC, 1990), A Common Destiny: Blacks and American Society
(NRC, 1989b), AIDS, Sexual Behavior, and Intravenous Drug Use (NRC, 1989a),
Confronting AIDS: Update 1988 (IOM, 1989), Broadening the Base of Treatmentfor
Alcohol Problems (IOM, 1990), and Alcohol in America: Taking Action to Prevent
Abuse (NRC, 1985). A recent report by the Life Sciences Research Office addresses
nutrition problems among disadvantaged, difficult-to-sample populations (LSRO,
1990).
2. Health-care professionals are in general agreement that all foods that contribute
to healthful diets are, by definition, health promoting and that any food that
supplies energy and nutrients can be nutritionally desirable. There is also gen-
eral agreement that dietary recommendations should not prohibit the consumption
of any food product and that the nutritional composition of the total diet is of
more importance than is that of a single food or meal. However, for practical
purposes, the committee uses the terms health promoting and nutritionally desirable
to describe foods whose consumption is encouraged to meet dietary recommendations.
Examples include fruits, vegetables, and breads. In addition, the committee
describes a healthful diet as one that meets dietary recommendations most of the
time (and is thereby composed largely of health-promoting foods) and that meets
nutrient needs.
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IMPROVING AMERICA'S DIET AND HEALTH
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Representative terms from entire chapter:
dietary guidelines
