Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 29
3
Rationale for Including
Nutrition Instruction
in Medical Education
During the last 20 years, an enormous body of scientif-
ic data has emerged linking diet and food selection pat-
terns to the maintenance of health and the prevention of
some chronic diseases. Evidence supporting this associa-
tion, its individual and public health implications, and
the scientific rationale for requiring medical students
to learn basic nutrition principles and their application
to patient care is presented in the following discussion.
It is not the purpose of this chapter to summarize or
evaluate all data associating nutrition with the major
causes of morbidity and mortality in the United States.
Rather, the committee has selected some examples and
discussed them in light of their relationship to pre-
ventive and therapeutic medical care.
Major developments in medical research and technology
in recent decades have led to the conquest of many
diseases with nutritional or infectious origin. For ex-
ample, the isolation and identification of many essential
nutrients and the elucidation of their roles, together
with the enrichment and fortification of selected foods
and the availability of nutrient supplements, have result-
ed in the virtual elimination of vitamin and mineral
deficiency disease in the United States. In addition, as
general sanitation conditions improved and the use of
antibiotics and other drugs became more widespread, con-
cern about infectious diseases has diminished. As a
result of these developments and new data linking environ-
mental factors and lifestyle to health and illness, medi-
cal attention is shifting to the prevention and treatment
of chronic and degenerative diseases, most of which have a
29
OCR for page 30
30
complex etiology. Diet is not only a factor in the
etiology of these diseases but also is important in their
treatment.
Nutritional factors are implicated in the etiology of
6 of the 10 leading causes of death in the United States:
heart disease, cerebrovascular disease, cancer, adult-
onset (type II) diabetes, arteriosclerosis, and alcohol-
i-nduced cirrhosis (DREW, 1979; DHHS, 1983~. The role of
diet in both the prevention and treatment of many condi-
tions, such as obesity, osteoporosis, gastrointestinal
disorders, low birth weight, dental caries, iron-
deficiency anemia, and certain vitamin and mineral
deficiencies, is clearly documented (DREW, 1979; DHHS,
1983~.
Advances in basic nutrition knowledge and medical
technology have also dramatically affected health care in
the United States. The development of nutritionally sound
intervention techniques, such as parenteral and enteral
nutrition, have prompted new approaches to the management
of patients with a variety of needs, ranging from pre-
mature infants to patients undergoing surgery and those
suffering from burns, trauma, infection, metabolic
disorders, or certain forms of cancer (Fischer, 1975;
Wilmore _ al., 1977~.
Nutrition and its association with health have
attracted much attention in the news media. For example,
newspapers, such as The New York Times, The Washington
Post, and he Wall Street Journal, regularly carry columns
and lead articles concerning diet and nutrition as do
Time, Newsweek and The U.S. News and World Report. Many
popular magazines, such as Ladies Home Journal, Good
Housekeeping, and Runner's World, also feature articles
on nutrition, and a vast assortment of nutrition-related
books has been published. Clearly, the U.S. public is
concerned about nutrition, and many Americans are better
informed than in the past on matters of diet and health.
There are growing expectations that physicians should be
able to provide accurate, current nutrition information
and guidance.
Ample evidence, some of it presented below, supports
the association of nutrition with disease prevention'
health maintenance, acute care delivery, and other
aspects of medical Practice. Therefore, if the
OCR for page 31
31
objectives of medical education are to prepare future
physicians to deliver health care effectively and to keep
pace with the changing needs of their patients and new
scientific discoveries, then nutrition must be considered
a part of the formal training of all medical students.
EVIDENCE ASSOCIATING NUTRITION WITH DISEASE PREVENTION
AND HEALTH PROMOTION AND MAINTENANCE
-
Cardiovascular Disease
The presence of a nutritional component in the etiology
of some diseases points to the need for adequate nutri-
tional knowledge among physicians. The most striking ex-
ample is cardiovascular disease, currently the leading
cause of death in the U.S. adult population, as it has
been for more than 40 years (DHHS, 1984a,b).
ly 43 million Americans are affected by one _ - _
of heart, blood vessel, or cerebrovascular disease, in-
cluding hypertension, coronary heart disease, and stroke
(AMA, 1984) . It is pro jected that as many as 1.5 million
Americans will have a heart attack in 1985, and more than
0.5 million of them will die during this year (DHHS,
1984a). The social and economic consequences of cardio-
v~.~rul~r disease are equally immense.
Approximate
nr mc~re ~ orms
- The American Heart
~ , ~
Association (AMA) estimated that the cost of cardio-
vascular disorders exceeds $7 2 billion annually: $59
billion in direct health expenditures and $13 billion in
productivity lost through illness and disability (AMA,
1985).
These staggering economic and social consequences still
exist despite the steady decline in death rates due to
coronary heart disease in the United States since the late
1960s (NHLBI, 1981a; Stamler, 198 5b; Walker, 1983~. This
decline has been attributed, in part, to improvements in
lifestyle and related risk factors, including changes in
diet (Pell and Fayerweather, 1985; Stamler, 1985a,b).
Surveys show that by the late 1970s, two-thirds of Ameri-
cans had changed their eating patterns because of health
concerns (Jones, 1977; NHLBI, 1981b; Stamler, 1983~.
Correspondingly, since the early 1960s there has been a
reduction in the per capita consumption of foods high in
cholesterol and saturated fat--beef, fat-containing dairy
OCR for page 32
32
products, eggs, and lard--and an increase in the consump-
tion of fish and vegetable fats and oils (Welsh and
Marston, 1982~.
Among those risk factors strongly associated with
coronary heart disease, high blood cholesterol is one of
the most clearly established. The National Institutes of
Health (NIH) Consensus Development Conference on Lowering
Blood Cholesterol to Prevent Heart Disease concluded that
the blood cholesterol level of most Americans is undesir-
ably high (NHLBI, 1985~. The conferees agreed that these
Leigh levels are due, in large part, to Americans' still
higher-than-recommended dietary intake of saturated fat
and cholesterol and that appropriate dietary changes would
reduce blood cholesterol level in many persons. The AHA
Committee on Nutrition has issued similar guidelines (AMA,
1982~. Prevention, including nutritional counselling by
informed primary care physicians, will be a critical com-
ponent to the success of the national effort to reduce the
incidence of cardiovascular disease (Harlan and Stross,
1985; Rahimtoola, 1985~.
High blood pressure affects approximately 38 million
adults in the United States. Many of these people are
aware of their conditions but do not receive treatment or
their blood pressure is inadequately controlled (AMA,
1985~. Lifestyle factors, especially diet, have been
cited as some of the many contributors to the continued
prevalence of high blood pressure in the United States
(Harlan et al., 1983; Levy and Moskowitz, 1982~. For
example, obesity, dietary sodium, and alcohol have been
associated with hypertension in some individuals, and
there is evidence that other dietary factors, including
potassium, calcium, magnesium, chloride, and perhaps even
carbohydrates, may affect blood pressure regulation in
some susceptible persons (Harlan et al., ~q96. MrC~rron
and Kotchen, 1983; McCarron et al., 1984~.
_, ~ A, ~
Public response to education programs designed to
lower high blood pressure and to ensure the maintenance
of normal levels has been striking, according to the
Hypertension Detection and Follow-up Program Cooperative
Group (1982) and the Veterans Administration Cooperative
Study Group on Antihypertensive Agents (1967~. A stronger
emphasis on preventive care during medical education Donald
assist students in developing the skills and attitudes
for effective intervention.
OCR for page 33
33
Malnutrition
Malnutrition is one of the leading factors in the
disability and death of children in developing nations.
The World Bank (Alderman, 1980) and the Food and Agricul-
ture Organization (FAO, 1981) of the United Nations esti-
mate that as many as 800 million persons may suffer from
caloric deficiency and that at least 450 million are
children. Malnutrition is frequently not mentioned on
death certificates as the cause of death. Consequently,
mortality due to malnutrition among infants and young
children is often underestimated (WHO, 1981~.
Malnutrition is not confined to developing countries.
Recent data from studies in the United States (DHES, 1983)
indicate that from 10% to 15% of the infants and children
of migratory workers and some poor rural populations suf-
fer growth retardation because of dietary inadequacies.
In addition, iron and folic acid deficiencies are common
among pregnant and lactating women in the United States
(DHHS, 1983~.
Malnutrition can lead to illness or death, but more
commonly results in generalized functional impairment. In
children living under conditions of poverty and depriva-
tion, malnutrition retards growth and contributes to poor
motor and intellectual development (Winick' 1976~. In
adults, it reduces performance in the workplace. Results
of animal studies and clinical data indicate that some
specific nutritional deficiencies as well as general mal-
nutrition may alter immune function' thereby affecting
response to infection and disease in both children and
adults (Beach _ al., 1982; Gershwin et al., 1985;_ _
Suskind' 1977~.
Public health professionals must diagnose nutritional
problems at the community and national levels as well as
internationally. Medical students in the United States
need to be aware of the magnitude and severity of mal-
nutrition and associated health problems and of their
social consequences both in the United States and through-
out the world. Only with this awareness can appropriate
public health programs and other intervention strategies
be planned.
OCR for page 34
34
Several investigators have reported severe malnutrition
among hospitalized patients in the United States (Bistrian
_ al., 1976; Ballet and Owens, 1983; Butterworth, 1974;
Parsons _ al., 1980; Thompson et al., 19841. Mullen and_ _
coworkers (1979, 1980) reported that the lower the nutri-
tional status of hospitalized patients, the worse the
prognosis for recovery from the primary disease. There is
evidence that a patient's nutritional status may influence
the outcome of cancer therapy (Donaldson and Lenon, 1979~.
Obesit_
Obesity (overnutritiGn) is the most prevalent form of
malnutrition in the United States. The National Center
for Health Statistics reported that Americans on the aver-
age weigh more now than they did 10 years ago (Abraham et
al., 1983, and in press). Thirty-two percent of the men
and 63% of the women in this country are 10% or more
above "ideal weight," and 18% of the men and 24% of the
women weigh 20% or more (Abraham et al., 1983~. Obesity
is associated with elevated blood pressure, blood lipid
levels, and blood glucose (Garrison et al., 1980; Kannel
et al.. 1979: Nooca et al.. 1978). Castelli (1984)
reported that weight is a powerful predictor of virtually
all cardiovascular end points in men and women. Obesity
is a risk factor for, or is associated in some way with,
diabetes, complications of pregnancy, osteoarthritis, some
cancers and infections, and impaired psychosocial function
(Stewart and Brook, 1983~.
Although the definition of ideal weight is controver-
sial (Knapp, 1983), and appropriate body weight standards
and methods of measurement continue to prompt debate
(Abraham et al., 1983; Simopoulos and Van Itallie. 1984),
there is general consensus among researchers that mortal-
ity increases with increasing amounts of excess weight
(Hubert et al., 1983; Lew and Garfinkel, 1979; McCue,
1981; Society of Actuaries and Association of Life Insur-
ance Medical Directors of America, 1980; Vandenbroucke et
al., 1984~. Severely overweight persons, especially those
who are overweight at younger ages, have markedly higher
mortality rates than do people of average weight (Drenick
_al., 1980~.
If physicians are to assume a more active role in
caring for overweight persons 3 assisting patients in
OCR for page 35
35
weight reduction, or encouraging them to maintain a
weight that is closer to ideal, they will require the
appropriate knowledge, skill, and attitude.
Cancer
The role of nutrition in the etiology and the preven-
tion of some cancers is becoming more apparent. For
example, several cancers, especially cancer of the breast
and colon, have been associated with a high fat diet (NRC,
1982), and interim dietary guidelines to lower cancer risk
have been proposed (ACS, 1984; NCI, 1984; NRC, 1982~. Nu-
tritional rehabilitation and support are integral parts of
the treatment regimen for cancer patients (van Eys et al. ,
1979; Wollard, 1979~. The metabolic stress of cancer,
interactions between nutrients and drugs, and the host-
tumor relationship are subjects of active research. It is
important that medical education emphasize the relevance
of nutrition principles to cancer prevention and treatment
and that students are prepared to assess new findings
regarding the relationships between diet, nutrition, and
cancer and their implications for patient care.
Osteoporosis
Osteoporosis is a major cause of bone fractures in
postmenopausal women and the cause of significant morbid-
ity among elderly persons (Avioli, 1984~. Inadequate cal-
cium, vitamin D, estrogens, and fluoride are among the
many factors that have been implicated in the etiology of
this disease (Armbrecht, 1984; Avioli, 1984~. Studies are
under way (DHHS, 1984c,d) to examine the influence of nu-
tritional factors on calcium absorption and excretion, the
metabolic factors contributing to alterations in bone
structure and Practical means for preventing and treat
ins osteoporosis. Because osteoporosis affects the
elderly and because the median age of the U.S. population
continues to increase (Inane and Kane, 1980), new research
findings and their applications to the clinical management
of this disease are becoming increasingly important.
NUTRITIONAL NEEDS OF SELECTED POPULATION SUBGROUPS AND
THE GENERAL PUBLIC
Both physicians and patients need to be aware of how
nutritional needs change throughout the life cycle and the
OCR for page 36
36
consequences of poor nutrition during infancy, childhood,
adolescence, adulthood (including pregnancy, lactation,
and menopause), and old age. The following paragraphs
contain discussions of some specific needs of certain
populations at different life stages and the integral
role of nutrition in primary care medicine and various
medical specialties.
Nutrition and the Outcome of Pregnancy
Managing normal and high-risk pregnancies to ensure
optimal fetal growth and development and neonatal health
requires close attention to nutrition by both mother and
physician. Physicians now widely accept the importance
of adequate weight gain and maintenance of optimal nutri
tional status (i.e., intake of adequate amounts of both
micro- and macronutrients) during pregnancy (Hurley,
1980).
For a woman who begins her pregnancy at normal weight,
the optimum weight gain is at least 12 kg. An underweight
woman should gain even more (Rosso, 1985~. Evidence from
laboratory studies in rats suggests that poor weight gain
is associated with inadequate expansion of maternal blood
volume, which in turn reduces the expected increase in
cardiac output and blood flow to the uterus and placenta
(Rosso and lava' 1980~. Thus, poor nutritional status
before pregnancy and inadequate weight gain and nutrient
intake during gestation may negatively affect fetal weight
gain, thereby increasing the risk of low birth weight and
neonatal mortality (Dobbing, 1981; NRC' 1970; Worthington
_ al. 1977~. The United States ranks 18th among nations
for infant mortality, a major cause of which is low birth
weight. The U.S. Public Health Service has specified that
proper nutrition should be encouraged as one of the
strategies to prevent the occurrence of low birth weight
infants (Brandt, 1984~.
Obesity during pregnancy poses other nutritional and
medical concerns. For example, the efficacy of recommend
ing low calorie diets to this group of women is seriously
questioned. There is evidence suggesting that very low-
calorie diets consumed during pregnancy may induce changes
in metabolism that may result in undesirable sequels in
the fetus, including low birth weight (Rosso' 1985~.
1 _
OCR for page 37
37
The management of normal pregnancies to promote optimal
fetal growth also requires a knowledge of nutrition and
the ability to prescribe a diet that supplies adequate
amounts of all essential nutrients while restricting in-
take of deleterious substances. Among the dietary con-
stituents that may adversely affect the fetus are alcohol
(Marbury et al., 1983; Mills et al., 1984) and caffeine
(Nightingale and Flamm, 1983~.
Infancy and Childhood
The importance of nutrition in the health care of
infants and children is widely recognized. Adequate nu-
tritional intake is a fundamental requirement for optimal
growth and development, and there is concern that child-
hood obesity may be a precursor of such adult diseases as
arteriosclerosis and hypertension. Competent counselling
regarding the merits of breast-feeding, the selection of
appropriate formulas, proper timing for introducing solid
food, and the need for vitamin-mineral supplementation are
all areas in which the pediatrician can provide profes-
sional support. In addition, the pediatrician should be
able to guide parents in the selection of diets adequate
in energy, protein, iron, and other essential nutrients to
promote optimal growth throughout infancy and childhood.
Increasing numbers of children with genetic disorders
and other disabilities are now kept alive and often re-
quire complex nutritional care. The consequences of
various inborn errors, such as disorders of amino acid,
carbohydrate, or lipid metabolism, can be moderated by
dietary intervention (Palmer and Zeman, 1983~. The role
that the pediatrician can play in providing early diag-
nosis and treatment can be exceedingly important to the
survival and well-being of these children.
Nutrition and the Elderlv
J
The growing number of elderly persons in the United
States (Kane and Kane, 1980), especially those who are
institutionalized, are at high risk for certain nutri-
tional deficiencies (Prendergast, 1984~. Several physio-
logical factors may affect the nutritional status of the
elderly, for example, poor dental health, diminished sen-
sitivity to taste and smell, increased need for some
nutrients, high nutrient losses or malabsorption related
to changes in gastrointestinal function, or moderately
OCR for page 38
38
reduced efficiency of digestion (Armbrecht et al., 1984;
Roe, 1983~. Such complicating circumstances as isolation,
bereavement, physical disabilities, and inappropriate
diets contribute to inadequate nutrient intake (Coe and
Miller, 1984~. Primary care physicians and specialists
who are responsible for medical care of the aged must
therefore be aware of their unique health problems and
nutritional needs.
Selected Nutritional Concerns of the General Public
. _ .
Many people are modifying their lifestyle by, for
example, increasing their activity, altering their diets,
and in general, accepting greater responsibility for their
own well-being (Jones and Weimer, 1981; Louis Harris and
Associates Inc., 1979; Stamler, 1978~. For example, the
relationsip of diet and exercise to the maintenance of
health has become a concern of many persons. Although
there is limited evidence that certain diets optimize ath-
letic performance, other evidence indicates that proper
exercise combined with dietary modification may improve
cardiovascular fitness, induce weight loss, and reduce the
risk of osteoporosis (Zohman et al., 1979~. Thus, exer-
cise combined with dietary modification is rapidly becom-
ing a major tool in both preventive and therapeutic
medicine.
Some segments of the general population are adopting
such nontraditional dietary patterns as vegetarianism.
Although some vegetarian diets may be consistent with
good health, others, if not supplemented, may increase
the risk of specific nutritional deficiencies (Goldsmith,
1983; Herbert, 1983~. Still other self-restricted diets,
such as many of the popularly promoted weight reduction
diets (Dwyer, 1980), are often nutritionally inadequate
and should be supplemented or revised. Many physicians
may not have sufficient experience or training in the area
of nutrition to guide patients appropriately in the selec-
tion of foods that may ensure their nutritional well-being
(Cooper-Stephenson and Theologides, 1981; Krause and Fox,
1977; Modrow et al., 1980)e
Physicians as well as patients may be susceptible to
the many inaccurate and sometimes dangerous claims and
inducements offered by the rapidly expanding food
supplement industry. Advertisements do not warn
OCR for page 39
39
consumers about potential toxic effects from excessive
intake of micronutrients at more than 100% of the RDAs
(NRC 9 1980).
Food supplement industry sales were reported to be $1.7
billion for 1981, with an estimated annual growth between
11% and 15% (Alter, 1981; Raven' 1981~. The sales of so-
called natural vitamins grew by 20% in 1980, new vitamin
formulations continue to appear' and promotion of the
products continues to be vigorous (Raven, 1981~. The
data accumulated thus far, although not complete, suggest
that approximately 40% to 50% of the adult U.S.
population daily ingests some kind of micronutrient
supplement (Stewart et al.' n.d.~. Physicians must be
aware of potentially deleterious effects and long-term
consequences of oversupplementation so that they can
guide their patients accordingly.
NUTRITION AND ACUTE CARE
Nutrition has been implicated as a causative factor in
many diseases but may also be efficacious in treatment.
Following are a few examples of the many ways diet can be
used as a management tool.
Diabetes
Nutrition may be involved in the etiology of diabetes,
and, certainly' knowledge of nutrition is necessary for
its management. In some type II diabetics, weight loss
may be the only necessary treatment (Turner and Thomas,
1981~. A low-fat' high complex carbohydrate diet
providing frequent meals and controlled intake of refined
sugar helps to stabilize the level of blood sugar' mini-
mize the danger of cardiovascular complications, and is a
fundamental part of the treatment of diabetes (Bierman,
1985; Zeman and Hansen, 1983~.
Gastrointestinal Disorders
-
Dietary fiber may play a role in both preventing and
managing gastrointestinal disorders (Inglett and Falkehag,
1979~. Data indicate that dietary fiber protects the
intestinal tract against potential carcinogens, influences
bacterial metabolism' and affects the absorption rates of
several nutrients, including glucose (Anderson' 1985;
OCR for page 46
46
DHHS (U.S. Department of Health and Human Services).
1984a. Advance Report of Final Mortality Statistics,
1981. Monthly Vital Statistics Report 33~3) Suppl.,
National Center for Health Statistics, Public Health
Service, U.S. Department of Health and Human Services,
Washington, D.C.
DHHS (U.S. Department of Health and Human Services).
198 4b. Anne Summary of Births, Deaths, Marriages,
and Divorces: United States, 1983. Monthly Vital
Statistics Report 32~13), National Center for Health
Statistics, Public Health Service, U.S. Department of
Health and Human Services, Washington, D.C.
DHHS (U.S. Department of Health and Human Services).
1984c. Osteoporosis. Pp. 1-6 in National Institutes
of Health Consensus Development Conference Statement,
Vol. 5. National Institutes of Health, Public Health
Service, U.S. Department of Health and Human Services,
Washington, D e C ~
DHHS (U.S. Department of Health and Human Services).
1984d. Program in Biomedical and Behavioral Nutrition
Research and Training Fiscal Year 1983. Annual Report
of the National Institutes of Health. NIH Publ. No.
84-2633. Prepared by NIH Nutrition Coordinating Commit-
tee, National Institutes of Health, Public Health Ser-
vice, U.S. Department of Health and Human Services,
Washington, D.C.
Dobbing, J., ed. 1981. Maternal Nutrition in Pregnancy--
Eating for Two? Based on a workshop sponsored by Nestle
Nutrition, held at the Chateau de Rochegude, Vaucluse,
France, June 1-4, 1980. Academic Press, New York.
Donaldson, S. S., and R. A. Lenon. 1979. Alterations of
nutritional status: Impact of chemotherapy and radia-
tion therapy. Cancer 43:2036-2052.
Drenick, E. J., G. S. Bale, I. Seltzer, and D. G. Johnson.
1980. Excessive mortality and causes of death in
morbidly obese men. J. Am. Med. Assoc. 243:443-445.
Dwyer, J. 1980. Sixteen popular diets: Brief nutritional
analyses. Pp. 276-291 in A. J. Stunkard, ed. Obesity.
W. B. Saunders, Philadelphia
, .
OCR for page 47
47
FAO (Food and Agriculture Organization). 1981. Agricul-
ture Towards 2000. Food and Agriculture Organization,
Rome.
Fischer, J. F., ed. 1976. Total Parenteral Nutrition.
Little, Brown, Boston, Massachusetts.
Garrison, R. J., P. W. Wilson, W. P. Castelli, M. Feinleib,
W. B. Kannel, and P. M. McNamara. 1980. Obesity and
lipoprotein cholesterol in the Framingham offspring
study. Metabolism 29:1053-1060.
Gershwin, M. E., R. S. Beach, and L. S. Hurley. 1985.
Nutrition and Immunity. Academic Press, New York.
Goldsmith, G. A. 1983. Curative nutrition--vitamins. Pp.
160-183 in H. A. Schneider, C. E. Anderson, and D. B.
Coursin, eds. Nutritional Support of Medical Practice,
2nd ed. Harper & Row, Philadelphia.
&ryboski, J., C. Hillemeier, S. Kocoshis, W. Anyan, and
J. S. Seashore. 1980. Refeeding pancreatitis in mal-
nourished children.
J. Pediatr. 97:441-443.
Hallberg, L. 1984. Iron. Pp. 459-478 in Present
Knowledge in Nutrition, 5th ed. Part VI. Microminerals.
Nutrition Foundation, Washington, D.~.
Halmi, K. A., J. R. Falk, and E. Schwartz. 1981. Binge-
eating and vomiting: A survey of a college population.
Psycholog . Med. 11: 697-7 06 .
Harlan, W. R., and J. K. Stross. 1985. An educational
view of a national initiative to lower plasma lipid
levels. J. Am. Med. Assoc . 253: 2087-2090 .
Harlan, W. R., A. L. Hull, R. P. Schmouder, F. E. Thompson,
F. A. Larkin, and J. R. Landis. 1983. Dietary Intake
and Cardiovascular Risk Factors, Part I. Blood Pressure
Correlates: United States, 1971-75. Vital and Heal th
Statistics Series, 11. Data from the National Health
Survey, Series 11, [lo. 226. DHHS Publ. No. (PHS) 83-
1676. National Center for Health Statistics, Public
Health Service, U.S. Department of Health and Human
Services, Hyattsville, Maryland.
OCR for page 48
48
Harlan, W. R., A. L. Hull, R. L. Schmouder, J. R. Landis,
F. E. Thompson, and F. A. Larkin. 1984. Blood pressure
and nutrition in adults: The National Health and Nutri-
tion Examination Survey. Am. J. Epidemiol. 120:17-28.
Harris, R. T. 1983. Bulimarexia and related serious
eating disorders with medical complications. Ann. Int.
Med. 99:800-807.
Hathcock, J. N., and J. Coon, eds. 1978. Nutrition and
Drug Interactions. Academic Press, New York.
Herbert, V. 1983. Hematology and the anemias. Pp.
386-409 in H. A. Schneider, C. E. Anderson, and D. B.
Coursin, eds. Nutritional Support of Medical Practice,
2nd ed. Harper & Row, Philadelphia.
Heymsfield, S. B., R. A. Bethel, J. D. Ansley, D. M. Gibbs,
J. M. Felner, and D. O. Nutter. 1978. Cardiac ab-
normalities in cachetic patients before and during
nutritional repletion. Am. Heart J. 95:584-594.
Hubert, H. B., M. Feinleib, P. M. McNamara, and W. P.
Castelli. 1983. Obesity as an independent risk factor
for cardiovascular disease: A 26-year follow-up of
participants in the Framingham Heart Study.
Circulation 67:968-977.
Hurley, L. S. 1980. Developmental Nutrition. Prentice-
Hall, Englewood Cliffs, New Jersey.
Hypertension Detection and Follow-up Program Cooperative
Group. 1982. The effect of treatment on mortality in
"mild" hypertension: Results of the hypertension
detection and follow-up program. N. Engl. J. Med.
307:976-980.
Inglett, G. E., and S. I. Falkehag, eds. 1979. Dietary
fibers: Chemistry and Nutrition. Academic Press, New
York.
Jones, J. L. 1977. Are Health Concerns Changing the
American Diet? NFS-159. National Economics Division
Economic Research Service, U.S. Department of
Agriculture, Washington, D.C.
OCR for page 49
49
Jones, J. L., and J. Weiner. 1981. Health-related food
choices. Pp. 16-19 in Family Economics Reviews, Summer
1981. Agricultural Research Service, U.S. Department
of Agriculture, Washington, D.C.
Kane, R. L., and R. A. Kane. 1980. Long term care: Can
our society meet the needs of its elderly. Ann. Rev.
Publ. Health 1:227-253.
Panel, W. B., T. Gordon, and W. P. Castelli. 1979.
Obesity, lipids, and glucose intolerance. The
Framingham Study. Am. J. Clin. Nutr. 32:1238-1245.
Knapp, T. R. 1983. A methodological critique of the
' ideal weight ' concept. J. Am. Med. Assoc . 250:506-510.
Krause, T. O. , and H. M. Fox. 1977. Nutritional knowledge
and attitudes of physicians. J. Am. Diet. Assoc.
70:607-609.
Kritchevsky, D. 1981. Dietary fiber and disease. Pp.
35-51 in L. Ellenbogen, ed. Controversies in Nutrition.
Contemporary Issues in Clinical Nutrition, Volume 2.
Churchill Livingstone, New York.
Levy, R. I., and J. Moskowitz. 1982. Cardiovascular
research: Decades of progress, a decade of promise.
Science 217:121-129.
Lew, E. A., and L. Garfinkel. 1979. Variations in
mortality by weight among 750,000 men and women.
Chron. Dis. 32:563-576.
J.
Louis Harris and Associates, Inc.
Study: Fitness in America. Great Waters of France,
Inc., New York.
1979. The Perrier
Marbury, M. C., S. Linn, R. Monson, S. Schoenbaum, A. G.
Stubblef ield, and K. J. Ryan. 1983. The association of
alcohol consumption with outcome of pregnancy. Am. J.
Publ. Health 73:1165-1168.
McCarron, D. A., and T. A. Kotchen, eds. 1983. Nutrition
and blood pressure control: Current status of dietary
factors and hypertension. A symposium held September
13-15, 1982, Arlington, Virginia. Ann. Intern. Med.
98 697-890 e
OCR for page 50
50
McCarron, D. A., C. D. Morris' H. J. Henry, and J. L.
Stantob. 1984. Blood pressure and nutrient intake in
the United States. Science 224:1392-1398.
McCue, H., Jr. 1981. The 1969 Build and Blood Pressure
Study. Pp. 182-198 in H. Bostrom and N. L jungstedt'
eds. Medical Aspects of Mortality Statistics. Proceed-
ings of the Thirteenth Skandia International Symposium
held September 23-25, 1980, Stockholm. Almquist &
Wiksell, Stockholm, Sweden.
Mills' J. L.' B. I. Graubard, E. E. Harley' G. S. Rhoads,
and H. W. Berendes. 1984. Maternal alcohol consumption
and birth weight: How much drinking during pregnancy is
safe? J. An. Med. Assoc. 252:1875-1879.
Mitchell, J. E., R. L. Pyle, and R. A. Miner. 1982.
Gastric dilatation as a complication of bulimia.
Psychosomatics 23:96-97.
Modrow,, C. L., C. W. Miles, S. Koerin, J. Dobek, P. Book,
and L. Honaker. 1980. Survey of physician and patient
nutrition education needs. J. Am. Diet. Assoc.
77:686-688.
Mullen, J. L., M. H. Gertner, G. P. Buzby, G. L. Goodhart,
and E. F. Rosato. 1979. Implications of malnutrition
in the surgical patient. Paper presented at the 2nd
Annual Meeting of the Association of Veterans Adminis-
tration Surgeons, St. Louis,, May 1, 1978. Arch. Surg.
114:121-125.
Mullen, J. L., G. P. Buzby, D. C. Matthews, B. F. Smale,
and E. F. Rosato. 1980. Reduction of operative morbid-
ity and mortality by combined preoperative and post-
operative nutritional support. Ann. Surg. 192:604-613.
NCI (National Cancer Institute). 1984. Cancer Prevention.
Public Health Service' National Institutes of Health,
U.S. Department of Health and Human Services, Bethesda,
Maryland.
.
OCR for page 51
51
NHLBI (National Heart, Lung, and Blood Institute). 1981a.
Decline in coronary heart disease mortality' 1968-78.
Pp. 157-258 in Arteriosclerosis, 1981, Volume 2. Report
of the Working Group on Arteriosclerosis. NIH Publ. No.
82-2035. National Heart, Lung, and Blood Institute,
National Institutes of Health, Public Health Service.
U.S. Department of Health and Human Services, Bethesda,
Maryland.
NHLBI (National Heart, Lung, and Blood Institute). 1981b.
Prevention. Pp. 265-426 in Arteriosclerosis, 1981,
Volume 2. Report of the Working Group on Arteriosclero-
sis. NIH Publ. No. 82-2035. National Heart, Lung, and
Blood Institute, National Institutes of Health, Public
Health Service. U.S. Department of Health and Human
Services, Bethesda, Maryland.
NHLBI (National Heart, Lung, and Blood Institute). 1984.
The lipid research clinics coronary primary prevention
trial results. II. The relationship of reduction in
incidence of coronary heart disease to cholesterol
lowering. J. Am. Med. Assoc. 251:365-374.
NHLBI (National Heart, Lung, and Blood Institute). 1985.
Lowering blood cholesterol to prevent heart disease. J.
Am. Med. Assoc. 253:2080-2086.
Nightingale, S. L., and W. G. Flamm. 1983. Caffeine and
health: Current status. Pp. 3-19 in J. Weininger and
G. M. Briggs, eds. Nutrition Update, Vol. 1. John
Wiley & Sons, New York.
Noppa, H. , C. Ben$tsson' P. B jorntorp, U. Smith, and
E. Tibbiin. 1978. Overweight in women--metabolic
aspects. The population study of women in Goteborg
1968-1969. Acta Med. Scand. 203:135-141.
.
NEtC (National Research Council). 1970. Maternal Nutrition
and the Course of Pregnancy. A report of the Committee
on Maternal Nutrition, Food and Nutrition Board,
National Research Council. National Academy of
Sciences, Washington, D.C.
OCR for page 52
52
NRC (National Research Council).
Dietary Allowances, Ninth Revi
1980. Recommended
Bed Edition. A report of
the Committee on Dietary Allowances, Food and Nutrition
Board, Division of Biological Sciences, Assembly of
Life Sciences. National Academy Press, Washington, D.C.
NRC (National Research Council). 1982. Diet Nutrition and
Cancer. A report of the Committee on Diet, Nutrition,
and Cancer, Food and Nutrition Board, Assembly of Life
Sciences. National Academy Press, Washington, D.C.
ARC (National Research Council). In press. Recommended
Dietary Allowances, 10th ed. A report of the Committee
on Dietary Allowances, Food and Nutrition Board,
Commission on Life Sciences. National Academy Press,
Washington, D.C.
Inborn errors of
Palmer, S., and F. J. Zeman. 1983.
metabolism. Pp. 383-440 in F. J. Zeman, ed. Clinical
Nutrition and Dietetics. Collamore Press, Lexington,
Massachusetts.
Parsons, H. G., T. E. Francoeur, P. Howland, R. F.
Spengler, and P. B. Pencharz. 1980. The nutritional
status of hospitalized children. Am. J. Clin. Nutr.
33:1140-1146.
Pell, S., and W. E. Fayerweather. 1985. Trends in the
incidence of myocardial infarction and in associated
mortality and morbidity in a large employed population,
1957-1983. N. Engl. J. Med. 312:1005-1011.
Prendergast, J. M. 1984. Nutritional evaluation of the
institutionalized elderly. Pp. 269-292 in H. J.
Armbrecht, J. M. Prendergast, and R. M. Coe, eds.
Nutritional Intervention in the Aging Process.
Springer-Verlag, New York.
Rahietoola, S. H. 1985. Cholesterol and coronary heart
disease: A perspective.
2095.
Raven, M. 1981. Vitamins:
competitive marketplace.
J. Am. Med. Assoc. 253:2094
The A, B. Cs of today's
Drug Topics 125:45-48.
OCR for page 53
53
Roe, D. A. 1983. Drug and nutrient interactions.
Pp. 320-327 in H. A. Schneider, C. E. Anderson, and
D. B. Coursin, eds. Nutritional Support of Medical
Practice, 2nd ed. Harper & Row, Philadelphia.
Rosso, P. 1985. A new chart to monitor weight gain
during pregnancy. Am. J. Clin. Nutr. 41:644-652.
Rosso, P., and R. Kava. 1980. Effects of food restriction
on cardiac output and blood flow to the uterus and
placenta in the pregnant rat. J. Nutr. 110:2350-2354.
Rudman, D., and P. J. Williams. 1985. Nutrient deficien-
cies during total parent eral nutrition. Nutr. Rev.
43:1-13.
Schuette, S. A., and H. M. Linksweiler. 1984. Calcium.
Pp. 400-412 in Present Knowledge in Nutrition, 5th ed.
Part V. Macrominerals. The Nutrition Foundation,
Washington, D.C.
Schwabe, A. D., B. M. Lippe, J. Chang, M. A. Pops, and
J. Yager. 1981. Anorexia nervosa. Ann. Intern. Med.
94:371-381.
Shils, M. E. 1984. Historical aspects of minerals and
vitamins in parent eral nutrition. Fed. Proc., Fed. Am.
Soc. Exp. Biol. 43:1412-1416.
Shils, M. E., A. W. Burke, H. L. Greene, K. N. Jeejeebhoy3
A. S. Prasad, and H. H. Sandstead. 1979. Guidelines
for essential trace element preparation for parenteral
use: A statement by the Nutrition Advisory Group. J.
Parent. Ent. Nutr. 3:263-267.
Simopoulos, A. P., and T. B. Van Itallie. 1984. Body
weight , health, and longevity. Ann. Int. Med. 100: 285-
295.
Society of Actuaries and Association of Life Insurance
Medical Directors of America. 1980. Build Study 1979.
Society of Actuaries and Associ~tion of Life Insurance
Medical Directors of America, Chicago, Illinois.
Stamler, J. 1978. Lifestyles, major risk factors, proof
and public policy. ~irculation 58:3-19.
OCR for page 54
54
Stamler, J. 1983. Nutrition-related risk factors for the
arteriosclerotic diseases--Present status. Prog
Biochem. Pharmacol. 19:245-308.
Stamler, J. 1985a. Coronary heart disease: Doing the
right things.' N. Engl. J. Med. 312:1053-1055.
Stamler, J. 1985b. The marked decline in coronary heart
disease mortality rates in the United States, 1968-1981;
Summary of findings and possible explanations. Cardi-
ology 72:11-22.
Stewart, A. L., and R. H. Brook. 1983. Effects of being
overweight. Am. J. Publ. Health 73 :171-178.
Stewart , M. L., J . T. McDonald, R. E. Schllcker, and D . P .
Henderson. n.d. Vitamin/Mineral Supplement Use: A
Telephone Survey of U.S. Adults. Unpublished report of
the Bureau of Foods, Food and Drug Administration,
Wa shington, D . C .
Sullivan, A. C., and L. Cheng. 1978. Appetite regulation
and its modulation by drugs. Pp. 21-82 in J. N.
Hathcock and J. Coon, eds. Nutrition and Drug Inter-
relations. Section I. Drug Effects on Nutrient Intake,
Function, and Requirement. Academic Press, New York.
Suskind, R. M., ed. 1977. Malnutrition and the Immune
Response, Kroc Foundation Series, Yol. 7. Raven
Press, New York.
Thompson, J. S., C. A. Burrough, J. L. Green, and G. L.
Brown. 1984. Nutritional screening in surgical
patients. J. Am. Diet. Assoc. 84:337-338.
Turner, M., and B. Thomas, eds. 1981. Nutrition and
Diabetes. Proceedings of a scientific meeting jointly
sponsored by the British Nutrition Foundation and the
British Diabetic Association. University of Kent,
Canterbury. July 7-8, 1981. John Libbey, London.
Vandenbroucke, J. P., B. J. Mauritz, A. de Bruin, J. H. H.
Verhees en, C. van der Heide-Wessel, and R. M. van der
Heide. 1984. Weight, smoking, and mortality. J. Ame
Med. Assoc. 252:2859-2860.
OCR for page 55
55
van Eys, J., M. S. Seelig, and B. L. Nichols, eds. 1979.
Nutrition and Cancer. SP Medical & Scientific Books,
New York.
Veterans Administration Cooperative Study Group on Anti-
hypertensive Agents. 1967. Effects of treatment on
morbidity in hypertension: Results in patients with
diastolic blood pressures averaging 115 through 129
mm Hg. J. Am. Med. Assoc. 202:1028-1034.
Walker, W. J. 1983. Changing U.S. lifestyle and declining
vascular mortality--A retrospective. N. Engl. J. Med.
508:629-631.
Welsh, S. O., and R. M. Marston. 1982. Review of trends
in food use in the United States, 1909 to 1980. J. ~m.
Diet. Assoc. 81:120-125.
WHO (World Health Organization). 1981. The Role of the
Health Sector in Food and Nutrition. Report of a WHO
Expert Committee. World Health Organization Technical
Report Series No. 667. World Health Organization,
Geneva.
\]ilmore, D. W., W. S. McDougal, and J. P. Peterson. 1977.
Newer products and formulas for alimentation. Am. J.
Clin. Nutr. 30:1498-1505.
Wilson, F. A., and A. M. Hoyumpa, Jr.
small intestinal transport. &astroenterology 6:388.
1979. Ethanol and
Winick, M. 1976. Malnutrition and Brain Development.
Oxford University Press, New York.
Wollard, J. J., ed.
Cancer Patient.
1979. Nutritional Management of the
Raven Press, New York.
Worthington, B. S., J. Vermeersch, and S. R. Williams.
1977. Nutrition in Pregnancy and Lactation. C. Y.
Mo shy, Saint Louis .
Zeman, F. J. , and R. J. Hansen. 1983. Diabetes mellitus,
hypoglycemia and other endocrine disorders. Pi. 325-382
in F. J. Ze man, ed. Clinical Nutrition and Dietetics.
Collamore Press, Lexington, Massachusetts.
OCR for page 56
56
Zohman, L. R., A. A. Kattus, and D. G. Softness. 1979.
The Cardiologists ' Guide to Fitness and Health Through
Exercise. Simon and Schuster, New York.
Representative terms from entire chapter:
nutritional status
