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~ 2. Nutrition Nutrition plays a key role in the cause and prevention of many health conditions. As a result, topics covered by the 69 witnesses who concentrated on this area were many and varied. A significant amount of atten- tion was given to the role nutrition plays in two physiological risk factors, hypertension and high serum cholesterol, which contribute to chronic diseases such as cancer, cardiovascular disease, diabetes, and others. Also of major interest were several nutrition-centered areas that are both risk factors for other diseases and health problems in and of themselves-obesity, anorex- ia and bulimia, and anemia. Taking a somewhat different approach to the problems of nutrition, a number of testifiers focused on the basic problem of hunger, rather than on the need for a balanced diet. Special mention was made of hunger as it applies to the homeless and to mig- rant workers. Still others discussed the need for an overall balanced diet and the dietary needs of specific population groups such as pregnant women, infants and children, and hospitalized patients. The relation- ship of good nutrition to birth outcome, mental health, work performance, and the ability to recover from illness also was noted. (~057J Witnesses generally supported continuation and strengthening of the 1990 Objectives concerning nutrition, and pointed to the Surgeon Generals Report; on Nutrition and Health t and the National Research Council's Diet and Health2 as examples of consensus-building documents that had contributed to progress toward the 1990 nutrition objectives. The links between diet and health suggest clear opportunities for reducing disease. Also, as witnesses commented, history shows that given the opportunity, information, and time, Americans will change their eating habits. (~063; #462) However, they also em- phasized that consumers must have the necessary tools. The Society for Nutrition Education comments: Dietary change is not easy, so that even though a food may be better for one's health, it may not be competitive in other factors of choice such as taste, history, ease of preparation, etc. Other strategies are needed to bring the public to actually choose foods that are most nutritious. (#462) 110 Healthy People 2000: Citizens Chart the Course According to dietitian Marilyn Guthrie of the Virginia Mason Clinic in Seattle, if improvements in the nutritional and health status of Americans are to occur, We need to do a better job at going beyond making people aware of relationships between food and health toward giving them the tools and skills to make changes in eating behavior." (i077) Testifiers also discussed strategies for surveillance and interven- tion to change diets. HUNGER The feelings of many testifiers about the problem of hunger in our country are best summed up by Eleanor Young of the University of Texas Health Science Center, San Antonio. Identification of health objectives for the nation relating to nutrition cannot possibly exclude the serious concern of increased hunger in the United States. In the 1960s and 1970s, iden- tification of extensive hunger shocked the American people. In response, development of programs virtually eliminated this problem. Now, during the 1980s, hunger in the U.S. has returned. A fact that has now been well docu- mented by some 20 studies conducted between 1982 and 1986 in major cities, including Boston, Dallas, and Chicago. (#496) The Society for Nutrition Education notes that although the numbers may wax and wane, there al- ways are hungry people in America. (#462) A 1987 report cited by Young estimated that 9 percent of the population is hungry, including 12 million children and 8 million adults. (~496) Several witnesses cited local increases in the number of hungry people, as indicated by a growth in the number of emergency food sites, waiting lists for food services, and the number of people seIved. (~057; #4623 In some states, residency and citizenship requirements block otherwise eligible migrant farm workers and unnatu- ralized immigrants from receiving food benefits. Similar requirements for a permanent domain within the state bar the homeless from participating in public assistance programs. (~462)

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Several objectives were proposed to reduce or eliminate hunger. Dorothy Conway, representing the California Conference of Local Health Department Nutritionists, for instance, proposes that by the year 2000 no one in the United States will go without food for more than 48 hours. (#043J Jean Egan, representing the Michigan Dietetic Association, addresses the importance of locating surplus food and getting it to needy populations. She says that national objectives relating to access to food should be strengthened substantially in the Year 2000 Health Objectives. Witnesses underscored the impor- tance of maintaining government and private sector food programs, emphasizing the need for strong outreach and easy access. (#043; #057J The Society for Nutrition Education calls for congregate facilities, such as school lunch rooms, to be used for feeding homeless people. (#462J School breakfast and lunch programs also can help to reduce hunger and are discussed in the section on special populations. SPECIFIC NUTRITIONAL RISK FACTORS Many nutrition goals are related to risk factors associated with specific diseases or disorders such as heart disease, stroke, cancer, diabetes, osteoporosis, and others. 1NNO of these risk factors-high blood pressure (hypertension) and high serum choles- terol~re central nutrition goals, but they are the focus of Chapter 24 and therefore are discussed brief- ly here. Obesity, anorexia and bulimia, and anemia are directly related to food consumption; they are problems in themselves, as well as causes of other conditions. Food-borne diseases, foods that might cause dental cavities, and calcium intake as a factor in osteoporosis prevention also are nutritional issues; they are discussed in Chapters 18, 26, and 27, respec- tively. Hypertension Individuals with high blood pressure are at increased risk for cardiovascular disease. Much of the testimony on nutrition and hypertension focused on the role of sodium, and there was disagreement among the testifiers. The 1990 Objectives call for reductions in the average daily sodium intake to 3-6 grams and seek increases in the percentage of food that is labeled for sodium content. The American Heart Association (AMA) and other witnesses want to continue to target sodium intake, perhaps with quantitative changes; the AHA suggests that an adult's daily intake of sodium not exceed 3 grams. (#636) However, other witnesses, including the Salt Institute, say that recent research argues for eliminating sodium reduction goals for the general population. Only about one-third of the population is salt-sensitive, and for another third of the population, salt reduction may be harmful, it says. (#053; #082J Chapter 24 continues this discussion in greater length. Cholesterol An elevated blood cholesterol level is one major risk factor for cardiovascular disease. The testimony on nutrition as a way of reducing serum cholesterol levels focused on food labeling; public education; and reduction in the fat, saturated fat, and cholesterol content of manufactured food. Several witnesses favor adding cholesterol content to the objective dealing with food labeling; the 1990 objectives on food labeling included only sodium and caloric values. Other testimony calls for the food industry's coopera- tion in reducing the fat and cholesterol content of foods. One proposal, for example, says that by the year 2000, the saturated fat content (specifically coconut and palm oils) in processed and convenience foods should be reduced 50 percent from present levels. (~178J Several witnesses suggested incorporating the AMA's dietary guidelines for reducing these risk factors into the Year 2000 Health Objectives. These guidelines call for an average daily consumption of cholesterol of 300 milligrams or less per day; the percentage of calories from fat should be less than 30 percent; the percentage of calories from saturated and polyunsaturated fat should each be less than 10 percent. f#627; #636J A primary consideration in changing the public's consumption of fats and other substances must be education, according to Jennifer Anderson of Colorado State University. I would like us to think that as we translate the nutrition information, we also must think of practical messages, telling people how you eat to reduce the risk of chronic disease. I would like us to fly and encourage people to think about how they decrease fat; how they can increase fiber; and how they, therefore, apply the dietary guidelines developed from the U.S. Department of Health and Human SeIvices and the U.S.D.N (~739) Nutrition 111

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Obesity Obesity is an important risk factor for hypertension as well as for diabetes, cancer, and cardiovascular dis- ease. Young describes it as the single most prevalent nutrition problem in the United States. According to the latest National Health and Nutrition Examination Survey (NHANES) study cited in her testimony, 34 million adults in the United States are overweight, which is defined as at least 20 percent above their desirable weight, and 13 million of them are severely overweight, or 40 percent over their desired weight.4 (~496) lithe 1990 Objectives include targets for reducing the proportion of the population that is overweight, and witnesses favored continued efforts in this area. One specific objective recommended for the year 2000 calls for reducing the prevalence of obesity in men by 20 percent and in women by 25 percent. Strategies to achieve these reductions include education, research into causes and interventions, and physicians' npre- scribing~weight reduction. (#496J Another objective proposed is that pilot weight loss programs in which weight loss is rewarded be established for federal and state health workers. (#052) George Bray of the University of Southern California reported that three European and two U.S. studies have now shown that fat distribution is a greater risk factor than total body fat, and that sufficient data exist to add maldistribution of fat to the objectives. Bray proposes that by the year 2000, the prevalence of individuals with waist-hip measure- ments above the tenth percentile for age, as defined by recent epidemiologic data from North America, should be reduced by 10 percent for both males and females, regardless of initial body mass index. (~238) A number of witnesses note that pediatric obesity is a growing problem that should be included in the Year 2000 Health Objectives. (~228; #462J Accord- ing to Nancy Wooldridge, representing the Alabama Dietetic Association, many overweight children remain overweight as adults. (~228) Physical activity is de- creasing among youth while dietary intake remains high, according to testimony. Dodds proposed an ob- jective for the year 2000 calling for the prevalence of obesity among children age 6-11 and girls age 12-17 to be reduced by 10 percent. (#462) Anorexia and Bulimia Some witnesses recommended that targets relating to eating disorders such as anorexia and bulimia be 112 Healthy People 2000: Citizens Chart the Course included in the Year 2000 Health Objectives. A survey of 300 middle- and upper-class shoppers in Boston found that 10 percent of them had a bulimic history.5 (#216) Another study at a large, Eastern university found that only 1 percent of the women had bulimia. Part of the difficulty in determining the prevalence of this disorder, according to the authors of this latter study, is the definition of bulimiac Whether there is an epidemic of bulimia on the college campus or not depends on the definition of bulimia. If bulimia is defined as self-reported overeating in combination with occasional purging, then the answer is an emphatic "yes. If, however, the term bulimia is restricted to the diagnosis of a clinically significant disorder, the answer is "no." Its prevalence rate did not ex- ceed 1.3 percent in a sample of university wo- men, those presumed to be at highest risk.6 The incidence of anorexia is steadily increasing, -with nearly 1 percent of women now affected, accord- ing to the Utah Nutrition Council. A proposed goal for the year 2000 is to prevent and reduce the incidence of eating disorders. The strategies recom- mended to achieve this include media campaigns, outpatient clinics, and a hotline to prevent relapse. (#216) Anemia Conway notes that the use of iron-fortified infant formulas is declining and suggests that this could result in an increase in infant and child iron deficiency anemia. Education and iron supplementa- tion are required to prevent the condition. Conway proposes that the year 2000 objectives on anemia target all age groups. (#043) Sharon Hoerr of Mi- chigan State University echoes Conway's point by cal- ling for the identification of Additional population subgroups at risk for impaired iron status. Specifi- cally she states that "the prevalence of impaired iron status as defined by low iron stores in children aged one to two years, in males aged 11 to 14, and in females aged 15 to 44 years, should be reduced to at least 50 percent of those levels estimated for these groups in NHANES II." (~100) SPECIAL TARGET GROUPS In addition to identifying objectives for several mltri- tion-related conditions, testimony produced recom

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mendations for targeting populations with special nutritional needs. Pregnant women, infants and chil- dren, and hospitalized patients received special atten- tion in the testimony. Others suggested that this list be expanded to include the elderly and some sub- groups within the minority population. Pregnant Women For pregnant women, nutrition counseling was seen as a critical part of prenatal care. The Michigan Die- tetic Association recommended that objectives relating to access to comprehensive prenatal care specifically mention nutritional services. f#O57J The federal Special Supplemental Food Program for Women, In- fants, and Children (WIC) was hailed as an important way to improve the nutritional status of pregnant women. (~057; #063) According to the Grocery Manufacturers of America: 'rhe WIC program is a vivid example of how health objectives can be achieved through cooperation with government, the food industry, the banking industry, local communities, and health professionals. This program has now developed into a food assistance program remar- kable both in its degree of personal nutrition services, as well as its ability to produce measurable improvements in the nutritional status of its clients, and has had an economic impact that is continuing to be viable. (~063J However, several witnesses pointed to the lack of adequate resources as a real obstacle to the potential impact of WIC. The March of Dimes Birth Defects Foundation states, "There is no state in the country that services all of its WIC-eligible women and children. In 42 states, fewer than 50 percent of those eligible are sensed." (#203J The Society for Nutri- tion Education adds that "high volume WIC programs are seldom able to consistently provide individual attention." (#462) Several states are attempting to supplement the WIC program. A study by the Michigan Food and Nutrition Advisory Commission looked at admissions between 1978 and 1982 to a Flint hospital in which children, age two or less, failed to thrive. Shirley Powell, who represents the group, reports that even though these children were in the WIC caseload, their results were poor. Growth failure had nearly doubled [1978-1982] and the increases closely paralleled rising unemployment and deepening recession. The doctor continues to see serious problems, and she is involved in piloting an intervention in which close counseling on infant care and feeding is provided, in addition to WIC's food supplementation. f#390J The Massachusetts Department of Public Health also has tried to go beyond WIC, according to its Commissioner Deborah Prothrow-Stith, but it is still not enough. We are one of the states that significantly supplements our WIC funding, and we do that not only in the monetary reward, but also in looking at foods and agriculture. We have made an alliance with our Department of Food and Agriculture, and women are eligible to receive fruits and fresh vegetables. But even with those initiatives, we have an infant mortality rate that concerns us. (#735J Among the suggested objectives aimed at improv- ing nutrition for pregnant women is one from the Utah Nutrition Council supportive of "goals and objectives that would improve the quality and quantity of sound nutrition education programs, including those targeting pregnant teen girls delivering low- birth-weight infants, who "increasingly need nutritional help and guidance." (~216J Infants and Children Many witnesses emphasized the nutritional benefits of breast-feeding for infants; Chapter 22 provides more detail. Testifiers in this area called for maintaining or increasing the 1990 targets for the percentage of mothers that breast-feed. Many testifiers emphasized the importance of school meal programs for preschoolers and school- age children. According to Carol Neill of the Califor- nia School Food Services Association, school children who are hungry or malnourished suffer a range of effects from permanent necrologic defects to behavior problems, inability to concentrate, and other learning problems. (#161) lithe National School Breakfast Program serves about 4 million children, 89 percent of them at no Nutrition 113

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charge or at a reduced price.7 In addition, ap- pro~mately 24 million children receive a school lunch each school day, many of them free or at a reduced price.8 Food assistance programs are directly related to improvements in dietary habits and nutritional status of children, according to testimony. (#161) Witnesses supported maintaining and extending these programs. Specifically, according to Jacqueline Frederick of the New Jersey Department of Educa- tion: The National School Lunch Program should have guidelines for feeding special populations. In essence, the school lunch program must consider the nutrition requirements of the pregnant teen, the problems of refugee children with marginal nutritional status, and children with various physical and mental handicaps. Nutritious, well-balanced meals should not only be available to each student, but should be tailored to meet their specific nutritional needs. (#618J Witnesses also feel that dietary guidelines are needed for preschoolers and school-age children. They say that adult guidelines sometimes are used to determine appropriate levels for children, but this is not the best approach. (#161; #590) For example, Egan points out that "the progress of the USDA/ DHHS Dietary Guidelines promotion in school lun- ches has been greatly hampered by the lack of ava~la- bility of the revised school lunch recipes that have been adapted to comply with the Dietary Guidelines. (~057J In an attempt to get dietary guidelines designed for children, Neill requests that Congress require a study on "how to apply the USDA/DHHS Dietary Guidelines to children, including, in particular, sodi- um, fat, and sugar recommendations." The group asks that all food companies that supply the school lunch programs review their specifications to ma~- mize compliance with the guidelines. (~161) The Nutrition Education and Training Program (NET), designed to teach children the value of a nutritionally balanced diet through positive daily lunchroom experiences and appropriate classroom reinforcement, also drew support. Carol Philipps of the Midwest Region NET Program Coordinators praises NET not only for contributing to the improve- ment in nutrition topic areas of the objectives, but also for helping in the related areas of dental caries, periodontal disease, obesity and overweight, eating 114 Healthy People 2000: Citizens Chart the Course disorders, and intervention against certain chronic diseases. (#590) In addition to its role in training teachers and school food service personnel, Ann Butler of the Texas Department of Human Services sees the NET network as having the potential to "conduct school food service research, develop workshops and training materials, and provide techni- cal training," in order to offer "an educational framework that would ultimately improve children's nutritional status. (~606) HospRaIized Patients A number of testifiers suggested that malnutntion is a serious problem among hospital patients, even those in general hospitals. Estimates vary according to the criteria used, but they agreed that about half of all patients suffer from malnutrition, and longer-stay patients are more likely to be malnourished than shorter-stay patients.9 Also, according to Joel Kopple of the Harbor-UCLA Medical Center, poor nutritional status is associated with increased morbidity and mor- tality. (~681) Testifiers suggested as objectives that the prevalence of hospital malnutrition be reduced by 25 to 50 percent. (#23S, #496) To reduce hospital malnutrition, Kopple called for an increase in the number of hospital personnel who can assess the nu- tritional status of patients and for training medical students and other health care providers to be more sensitive to nutritional disorders. f#681) EDUCATION AND OTHER PREVENTIVE STRATEGIES Educating both the public and health professionals about the role of nutrition in disease prevention Is an important part of the effort to achieve nutrition objectives. However, witnesses also emphasized the need to go beyond merely informing consumers about good nutrition; they also must have the ability and the will to change their dietary habits. (~007; #077) Nutrition education can come from a varietr of sources: schools, health providers, mass media, com- munity organizations, professional and trade associ- ations, and health professionals. Powell suggests that by the year 2000, every state should have a broad- based, interdisciplinary commission to provide advice, advocacy, and networking on health-related food and nutrition issues for consumers. (#390) Making nutrition counseling a part of school meal programs, the WIC program, or elderly meal programs is very effective, according to the Society for Nutrition

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Education, which reported findings that when WIC clients were counseled about nutrition, the birth weight of their babies increased by 15 to 60 grams.~ (~462) Several witnesses called for the inclusion of nutrition education in the school health curriculum; this is discussed more fully in Chapter 9. Education also must be targeted toward health pro- fessionals. Young pointed out that a 1985 National Academy of Sciences report found nutrition education in medical schools inadequate. She says that not even one-third of medical schools have a required full course in nutrition and suggested, along with other witnesses, that the objectives be expanded to include nutrition education for health professionals. (~496) According to the Grocery Manufacturers' Association, the 1990 objective that virtually all contacts with health professionals include a nutritional component is unrealistic. Instead, efforts should begin with the education of health professionals and then address their contacts with high-risk patients or those with a disorder in which nutrition plays a role. (#063) Once consumers are aware of good nutritional habits, food labels can help them make dietary changes. The importance of dear labeling of fat (saturated and unsaturated), calories, cholesterol, and sodium content was mentioned repeatedly. Health claims permitted on labels should be worded so they do not confuse consumers, and efforts should be made to eliminate health fraud. Kathy Duffy of Harborview Medical Center in Seattle noted that with a large fraction of the population unable to read English, nutrition information should be presented with pictures, signs, colors, or logos. `~0s2~ Restaurant menus and fast-food outlets could also provide information on nutritional content. (~462) Other testifiers said that nutrition education and counseling should be part of general fitness programs; these should include the availability of healthy foods, especially in the workplace where exercise programs are sometimes offered and where cafeteria or vending machine food is available. f#l00; #736J IMPLEMENTATION The goal-setting process must take into account some fundamental issues critical to progress in preventing nutrition-related problems. According to witnesses, these include funding, data needs, adequate staffing with nutritional specialists, and involvement of a variety of players. Many witnesses spoke of an urgent need for a national system to monitor progress toward the nutri- tion objectives. According to Conway, a data system should be integrated at the federal, state, and local levels including, perhaps, a tie-in between local sys- tems and NHANES. (~043) Such a system should have a core set of commonly Identified data items, says the Society for Nutrition Education. (#462) Hoerr notes, as an example, the current use of dif- ferent definitions of obesity and ways to measure it. `#1009 In addition to surveillance objectives, several types of research were proposed. Examples include studies of the cost and benefits of dietary changes (#0774; research into food-borne disease and individual susceptibility (#7334; exploration of food processing techniques that do not require harmful additives (#2284; and general nutrition research, especially by the federal government. (#733) Testimony involved discussion of the roles of many different types of organizations in improving nutrition- al status. These include the federal government through the National Institutes of Health, the Food and Drug Administration, and the Department of Agriculture; the Institute of Medicine's Food and Nutrition Board; state and local health departments; professional associations of dietitians and other health providers; community and social service groups; schools; employers; and the food industry. Represen- tatives of many of these groups testified about their involvement in preventing nutrition-related health problems. Dietitians, for example, emphasized the role they can play in education and counseling. The National Daily Council, in particular, emphasized its public education efforts. f*S71' The American Dietetic Association noted that 33 state health agencies have established dietary recom- mendations but that barriers to implementation, such as inadequate funding, personnel, and administrative structure, interfere with progress in meeting objec- tives. (#007) Others made clear that meeting nutri- tional objectives will require putting in place the resources upon which effective strategies can be built. Nutrition 115

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REFERENCES 1. U.S. Department of Health and Human Services: Surgeon General's Report on Nutrition and Health (DHHS Publication No. [PHS] 88-50210), 1988 2. National Research Council, Committee on Diet and Health: Diet and Health. Washington, D.C.: National Academy Press, 1989 3. Brown, JL: Hunger in the U.S. Sci Am 256~2~:37-41, 1987 4. Najjar MF: Anthropometric reference data and prevalence of overweight, United States, 1976-1980. Vital and Health Statistics Series 11, No. 238 (DHHS Publication No. [PHS] 87-1688), 1987 5. Pope HG, Hudson JI, Yurgelun-Todd D: Anorexia nervosa and bulimia among 300 suburban women shoppers. Am J PsychiatIy 141~2~:292-294, 1984 6. Schotte DE, Stunkard AJ: Bulimia vs. bulimic behaviors on a college campus. J Am Med Assoc 258~9~:1213-1215, 1987 7. Radzikowski J. Gale S.: The national evaluation of school nutrition programs: Conclusions. Am J Clin Nutr 40~2~(suppl.~:454-461, 1984 8. Radzikowski J. Gale S: Requirement for the national evaluation of school nutrition programs. Am J Clin Nuer 40~2~(suppl.~:365-367, 1984 9. Roubenoff R. Roubenoff RA, Preto J. et al.: Malnutrition among hospitalized patients: A problem of physician awareness. Arch Intern Med 147~8~:1462-1465, 1987 10. Rush D (Principal Investigator): Evaluation of the Special Supplemental Food Program for Women, Infants and Children (WIC), voL 1: Summa~y. Research Triangle Institute, New York State Research Foundation for Mental Hygiene, 1987 11. Comm~ttee on Nutrition in Medical Education: Nutrition Education in U.S. Medical Schools. Washington, D.C.: National Academy Press, 1985 TESTIFIERS CITED IN CHAPTER 12 007 Lechowich, Karen, et al.; The American Dietetic Association 043 Conway, Dorothy; California Conference of Local Health Department Nutrition~sts 052 Duf~, Kathy; Harborview Medical Center and Wilkins, Jennifer; Pullman, Washington 053 McCarron, David et al.; The Oregon Health Sciences University 057 Egan, M. Jean; Michigan Dietetic Association 063 Fletcher, Carol; Groce~y Manufacturers of America 077 Guthrie, Marilyn; Virginia Mason Clinic (Seattle) 082 Hanneman, Richard; Salt Institute 100 Hoerr, Sharon; Michigan State Universitr 161 Neill, Carol; Alum Rock Union Elementary School District (California) 178 Reid, Elaine; Sacred Heart Medical Center (Spokane, Washington) 203 Smith, Richard; Hen~y Ford Hospital (Detroit) 216 Utah Nutrition Council 228 Wooldridge, Nangy; Alabama D~etetic Association 238 Bray, George; University of Southern California 116 Healthy People 2000: Citizens Chart the Course

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390 Powell, Shirley; Southeastern Michigan Food Coalition 462 Dodds, Janice; Society for Nutrition Education 496 Young, Eleanor; University of Texas Health Science Center at San Antonio 571 Speckmann, Elwood; National Dairy Council 590 Philipps, Carol; Wisconsin Department of Public Instruction 606 Butler, Ann; Texas Department of Human Services 618 Frederick, Jacqueline; New Jersey Department of Education 627 Stokes, III, Joseph; Boston University 636 Ballin, Scott; American Heart Association 681 Kopple, Joel; University of California, Los Angeles 733 Morse, Roy; Institute of Food Technologists 735 Prothrow-Stith, Deborah; Massachusetts Department of Public Health 736 Wood, Lonng; NYNEX Corporation 739 Anderson, Jennifer; Colorado State University Nutrition 117