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Target Levels and Current Dietary Patterns CALORIES Target: Caloric intake matched to indi- vidual needs anc] appropriate to achieve anc! maintain clesirable body weight. All the national organizations issuing di- etary guidelines include recommendations regarding caloric intake and belly weight. The American Cancer Society (1984~; the National Research Council's Committee on Diet, Nutrition, and Cancer (National Re- search Council, 1982~; and the U.S. Senate Select Committee on Nutrition and Human Needs (1977) all advise a caloric intake that would avoid obesity. The American Heart Association (1986), the National Institutes of Health (19&4b) consensus development conference statement, and the U. S. De- partment of Agriculture (U5DA)/U.S. De- partment of Health and Human Services (DHHS) (1985) recommend caloric intake to maintain desirable body weight, while the National Research Council's Committee on Recommended Dietary Allowances (Na- tional Research Council, 1980) suggests a caloric intake adequate to meet individual needs based on sex, age, and level of phys 45 ical activity. This committee accepts as a target level a caloric intake matched to individual needs and appropriate to achieve and maintain desirable body weight. Dietary Survey Data Estimates of caloric intake from dietary survey data can be unreliable because re- spondents tend to underreport this variable (U. S. Department of Agriculture/U. S. De- partment of Health and Human Services, 19864. The loins Nutrition Monitoring Eval- uation Committee of the U S DA and D H H S stated that `'if reported diets represent usual food energy intakes and such a large pro- portion of the population is overweight, it must be concluded that many Americans are underactive" (U. S. Department of Ag- riculture/U.S. Department of Health and Human Services, 1986~. The report Pro- moting HeatthlPreventing Disease: Objec- tives for the Nation (U.S. Public Health Service, 1980) recommended that by 1990, at least 60 percent of American adults ages 18 to 65 should participate in regular phys- ical exercise; at present, this figure is only about 10 to 20 percent (Powell et al., 1985~.

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46 Summary Data from the 197~1980 National Health and Nutrition Survey (NHANES) indicate that approximately 34 million U.S. adults are obese (body mass index 285th percen- tile), of which 12.4 million are severely obese (body mass index-95th percentile). The incidence of obesity varies widely ac- cording to age and sex, with black adults ages 4~54 having the highest incidence (61.2 percent for females and 41.4 percent for males) (Table 3-1~. Childhood obesity is more difficult to estimate but may range from 4 to 14 percent among low-income populations (Table 3-2~. DESIGNING FOODS TABLE 3-2 Percentage of Low-Income Children Screened with Weight-for- Height Above the 95th Percentile, 31 States, United States, 1984 Age and Group 0-11 months White Black Hispanic American Indian Asianb 12-23 months White Black Hispanic American Indian Asianb Number Exami- neda Weight-for-Height >9Sth Percentile 2-5 years 134,866 68,502 30,595 5,853 3,310 38,260 26,087 5,435 1,259 973 6.0 8.8 7.0 10.3 8.5 9.6 11.3 12.4 13.7 7.4 White82,597 4.1 TABLE 3-l Obese In(livi:luals, Black i53,675 5.3 97 980 in percen American Indian2,455 8.2 Group and Age White Black Asianb 1,791 3.9 Females 6-9 years 25 34 17.9 33.5 White 10,108 7.6 35 - 24.8 40.8 Black 7,836 5.6 45 54 29.9 61.2 Hispanic 417 12.2 55 64 34.8 59.4 American Indian 96 Insufficient data 65-74 36.5 60.8 Asianb 60 Insufficient data Males 25 34 35 44 45 54 55 64 65-74 Both sexes (Age adjusted) 25 74 20.9 28.2 30.5 28.5 25.8 17.5 40.9 41.4 26.0 26.4 27.2 41.1 NOTE: Obese is defined for men as a body mass index of 227.8 k/m2, and for women as a body mass index of 227.3 k/m2. These definitions are used because they represent the sex-specific 85th percentiles for persons 20 to 29 years of age in the 197~1980 National Health and Nutrition Examination Survey. SOURCE: Adapted from U. S. Department of Health and Human Services. 1985. P. 79 in Health United States, 1985. National Center for Health Statistics, DHHS Publication (PHS) 86-1232. Washington D C. U.S. Government Printing Office. NOTE: The Pediatric Nutrition Surveillance System, Centers for Disease Control, uses nutrition-related data collected by local health departments as part of the routine delivery of child health services. These data are the result of examinations of 610,439 new patients at 2,464 clinics in 31 states, the District of Columbia, and Puerto Rico. Anthropometric data on height, weight, and age are converted to percentiles of weight-for-height. These percentages represent the minimal number of children with obesity; these figures would be higher if moderate obesity were also included. aThe total does not equal 610,439 because of unknown or missing data for some variables and the exclusion of states with data errors. bData for Asians include data from an unknown number of recent Southeast Asian refugees. SOURCE: Adapted from Centers for Disease Con- trol. 1986. Annual summary 1984: reported morbidity and mortality in the United States. Morbidity Mortality Weekly Report, 32~54):105. ~7

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TARGET LEVELS AND C URRENT DIETARY PATTERNS TOTAL FAT AS PE RCE NTAGE OF CALORIES Target: Thirty percent or less of calories from fat for adults. Excesses of the first four nutrients iden- tified by the foint Nutrition Monitc~ring Evaluation Committee (INMEC) (bakeries, total fat, saturated fatty acids, and choles- terol) have all been implicated, either di- rectly or inclirectly, in the etiology of car- diovascular disease. Despite ~ 2 percent annual clecline in its prevalence since 1968, cardiovascular disease remains the leading cause of death in the Unitecl States (Centers for Disease Control, 1986a). Influence of Dietary Fats on Serum Lipid Levels The type and amount of fat in the diet have become increasingly ret ognized as factors influencing nutritional status and overall health, as evidenced by numerous clinical studies (Grundy, 1986; O'Brien and Reiser, 1980; Reiser et al., 1985~. It should be remembered that fat contributes about 9 calories/gram, more than twice as many as protein or carbohydrate (about 4 calories/ gram each). In addition, different fatty acids of dietary fats can significantly alter serum lipid levels. In general, saturated fatty acids raise the serum cholesterol level (certain exceptions were discussed in Chapter 2~. Furthermore, monounsaturated fatty acids have been shown to lower cholesterol levels relative to saturated fatty acids. The mon- ounsaturated fatty acids produce reductions similar to those induced by polyunsaturated fatty acids (Becker et al., 1983; Mattson and Grundy, 1985~. Recently, eicosopentaenoic and docosohexaenoic acids (found mainly in fish) have generated considerable scientific and public interest. Studies have shown that they may reduce platelet aggregation and lower serum triglyceride levels (lIerold and Kinsella, 1986~. 47 Dietary Fat and Cancer Some estimates indicate that nearly three- fLurths of all cancers in the United States may be influenced by diet (l)oll ancl Plato, 1981~. Both animal experiments and epi- demi`'logical studies have Shown an associ- ation between dietary fat and the inciclence of cancer, particularly of the l~reast, pros- tate, and large bowel (L)oll and Peto, 19814. The National Research Council ~ Comlnit- tee on Diet, Nutrition, arid Cancer citecl that of all the dietary eolupol~ellts it stlldiecl, "the combined epidemiological and expel- imental evidence is most suggestive for a causal relationship between fat intake and the occurrence of cancel-" (National Re- search Council, 19824. It further concluded that epidemiok~gical studies arid animal ex- periments provide convincing evidence that increasing the intake of total At inCIedSCS the incidence of cancer at c'Cltain sites, particularly the breast and colon, awl, con- versely, that the risk is 1OW0I with lower intakes of fat" (National Research Council, 1982~. Dietary Guidelines for Total Fat Intake All national health organizations agree that total dietary fat intake should be re- duced by some or all members of the U.S. population (depending on how much fat they currently consume) to maintain health and optimal body weight and to reduce the risk of certain diseases, particularly cardio- vascular disease and perhaps cancer. Several groups have qualified their recommenda- tions, directing their advice to modify die- tary fat intake to particular segments of the population. Other groups have focused their recommendations more generally. The Na- tional Research Council's Committee on Diet, Nutrition, and Cancer (National Re- search Council, 1982), a Nationa] Institutes of Ilealth (1984b) consensus development conference statement, and the American Cancer Society (1984) have all recom

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48 mantled that fat intake not contribute more than 30 percent of total calories. Since 1968, the American Heart Association (1968, 1982, 1986) has recommender] that 30 to 35 per- cent of total calories come from fat ant! has recently revised this recommendation to be less than 30 percent. Likewise, the National Research Council's Committee on Dietary Allowances (National Research Council, 1980) suggests a fat intake not to exceed 35 percent of calories, especially in cliets of less than 2,000 total calories. The Committee on Nutrition of the American Academy of Pe- diatrics (1981) suggests that dietary fat not be restricted for children under 1 year of age; after this age, a decrease in the con- sumption of saturated fatty acids, choles- terol, and salt and an increased intake of polyunsaturated fatty acids should be fol- lowec3 with moderation. For the purposes of this report, the committee has accepted, for adults, the target level of 30 percent or less of calories from fat. Dietary Survey Data The average percentage of calories from fat for the entire 1977-1978 National Food Consumption Survey (NFCS) population was 41 percent (U.S. Department of Agri- culture/U. S. Department of Health and Hu- man Services, 1986~. This percentage is recognizes] as a high estimate for 1987 because of dietary changes that have oc- curred and the neglect by many respondents in the survey to report that fat on meat was not eaten. The 1977-1978 data imply an average need! across the general population for an 11 percent reduction in the percent- age of calories from fat, from the present 41 percent to the target level of 30 percent. While it is useful to note this as a general target level, it is important to focus on individual population subgroups, for which the 1977-1978 NFCS provides data. Some subgroups are at or near this 30 percent target level; others exceed it by a wide margin. Recommender] alterations in eating DESIGNING FOODS habits vary greatly, depending on how large a reduction is necessary. A summary of the distribution of individuals from the 1977- 1978 NFCS by population subgroups and by percentage of calories from fat in the diet and the reductions needed to meet the target level are given in Table 3-3; compa- rable data from the 1985 Continuing Survey of Food Intake by Individuals (CSFII) are given in Table 3-4. The percentage of calories from fat in 1985 was below the 41 percent level re- ported in the 1977-1978 survey, as evi- denced by data from the 1985 CSFII. Among children ages 1 to 5, the percentage of calories from fat was 34 percent (U.S. De- partment of Agriculture, 1985~. For women ages 19 to 50, the percentage of calories from fat was 37 percent; for men ages 19 to 50, the percentage of calories from fat was 36 percent (U.S. Department of Agricul- ture, 1985, 1986~. The Nutrition Monitoring Division of the Human Nutrition Informa- tion Service within the USDA (U.S. De- partment of Agriculture, 1985) has sug- gested that some of the differences between 1977 and 1985 may have been due to changes in food selections, such as the shift from whole milk to low-fat milk, as well as to changes in the way (lata were collected (for example, more probing questions were asked about the intake of fat on meat and skin on poultry and the use of fat on vegetables). Summary Data from the 1985 CSFII indicate that the average percentage of calories from fat for adults ages 19 to 50 was 36 to 37 percent, 6 to 7 percentage points above the 30 percent target level. For children ages 1 to 5, the percentage of calories from fat was 34 percent. Data from the 1985 CSFII indicate that 15 percent of children ages 1 to 5 and 12 percent of women ages 19 to 50 had diets meeting the target level (Table 3- 4~.

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TARGET LEVELS AND CURRENT DIETARY PATTERNS TABLE 3-3 Distribution (Percent) of Individuals by Percentage of Calories from Fat and Reductions Needed to Meet Target Level 49 Calories from Fat (%) Roget ::~Dev~l; :: ::::: :: :::: : Dietary Level: ~ ~ ~ ~>30 >40 ::: ::: i: ::: : :: ~c~ ~ ~c40 '50 >50 : ~ Reduction Needed (Percentage Points) Group and Age to Meet Target Level: ::: : ::: :: None : :~: ~ : : 0-10 10-20 >20 Children 1-2 3-5 Females 19-22 23-34 35-50 Males 19-22 23-34 35-50 All (mean)a NOTE: The shaded column represents the target level and the percentage of individuals who met it. :: :::: ::: :::: : ::::: :: ::: : : :: ~ ~:: ~ ~ : :~ ~ 1 ~ ^:^ ::~:: ::::: :: :: - : I: ~ I:: C7: I: :: ~:~ ~ : : :::::::::::: :::::::: : : ::: : 54 57 32 3 32 2 40 38 34 30 u ~ ~ ~: 41 43 46 48 47 52 45 10 10 13 9 14 / 8 aMean for entire survey population (37,785 individuals). SOURCE: 1977-1978 level of intake of percentage of calories from fat based on data from the 1977-1978 Nationwide Food Consumption Survey. Adapted from E. M. Pao and S. J. Mickle. 1981. Problem nutrients in the United States. Food Technol. 35:58-79. TABLE 3-4 Distribution (Percent) of Women and Children by Percentage of Calories from Fat and Reductions Needed to Meet Target Level Calories from Fat (%) Dietary Level: Reduction Needed (Percentage Points) Group and Age to Meet Target Level: ~ - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .~ ~ Ta~e thy Led :: ::: ~:~ ~ :: ~:~ ~ ::: :::: ~::~::~: :: I::: I: :~: ~ ~::~ :::: :: ~ ::::: Aft:: :: :~ it: ~ i:: ~ ~ ~ ~ I: :~: ~ ~ ~ :::::: ~ ~ ~ ::~::~ i:::: ~ :: ~ : .,,~,~ '~ i~ : ~ ~ ~ ~ ~ ~ ~ :: : :: :~: ~ ~ : :~: ~ :: ~ All: ~ ~ :: :~: : :~::~:: ::: ::: :: :::::::: ::~: ::: All. .~ ~ ~ ~.~ ~ ~ ~ ~ ~.~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~;~ ~.~.~ ~ ~ ~ ~ :::::::::::: i:: i: ~ :~ :: ~ :: :::: ::: :: ~:::~: :; ~ ~:~:~ ~;~:~:~;~ Inane ~ ~ ~: :: ::~:: ::::::: ~: ::~:: :: ~::::~ ::~::::~ At: :: :: ~ : : : ~::~ ~ :::~:: ~ :: ::~::~ ~ : ::~ : :~:: : : :~ ~ ~:~ : ~ ~ ~ : : : ~ :~::: ~ ~ ~ ~ ::: : : :: ::~: ~:~:~ :~ ~ ~ ~:~:~ :::: ~ :~: ::: : :~:~13~ ~:~ ~:~;~;~ ~ ~ ~ ~ ~ ~ ~ .~ ~ ~.~ ~ ~ ~i~7~;~ ~ ~ ~ ~ : ~ :~ :~ ~ ::: :: ~ i: A: ~ ~ : :~:: ::: ~1~:~ ~ . ~ ~ ~ ~ :~1~ :~:: :~:~::~:~:::~::~::: I:: ::~:: ~:::~ :: :::: :: ::~ ::::: i::: ::~::: ::::::: ~ i: :::::: ~ :~: :: I::: ::: :~::: ~ ::::: ~ ~ ~ i: At: ::: :: :::::: ~ Ail: :: ::: ~ ~:~:~:~::~:~: :: : i:: :~: :~ ::~: ~ ~ :::::::: : ~ ::: i: ~ ~ :~: :: i: i: ~ ~::::~: ~ ::::: :::: ::::: ::: :~ ::~::: :::: ::::: ::: :::::::: ::: :::: ::: :~ i: : ~:~1::~-~:~::::~:~:~::-~:~:~ : my:: ~ ~::~::~ ~: ~ I: :::: :: ~:::~ ~:~ ~ ~ ~ ~ ~ :~ ~ ~ ~ ~ ~ ~::~: ::: i: :: :: : :::: :~: :::::::: :::::::: ::: i:::: ::::::::: :::::::::: 2~-~-;~ :~:~:~ . ~ em ~ ~ ~ ~ ~ ~ ~ ~: ~ ~ ~: >30 >40 50 0-10 10-20 >20 Children 1-3 4-5 All (age 1-5) Females 19-34 35-50 All (age 19-50) 70 67 69 52 52 52 11 6 6 o o o 34 34 2 34 NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from Human Nutrition Information Service, U.S. Department of Agriculture, unpublished data on 4-day dietary intake, 1987.

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50 SATURATED, MONOUNSATURATED, AND POLYUNSATURATED FATTY ACIDS AS PERCENTAGE OF CALORIES Target: Ten percent or less of calories from saturated fatty acids, 10 percent or less of calories from polyunsaturated fatty acids, and 15 percent or less of calories from monounsaturated fatty acicis for aduZts. "Eating extra saturated fat, high levels of cholesterol, and excess calories will increase blood cholesterol in many people. Ofthese, saturated fat has the greatest influence," states the USDA/DHHS (1985) Dietary Guidelines for Americans. Elevated serum cholesterol levels, a major cause of cardio- vascular disease, have been strongly cor- related to several dietary factors, including a high intake of calories, certain saturates] fatty acids, and cholesterol. Genetics and environmental factors may also play an im- portant role in the development of high serum cholesterol. The 1979 Surgeon Gen- eral's report on health promotion and dis- ease prevention, Healthy People, stated that "premature heart disease is unequivocally associated with elevated blood cholesterol . . . heart attacks are five times as frequent in men and women aged 35 to 44 who have cholesterol levels above 265 (ma per d1) as among those with levels below 220 (ma per c31~. In general, the lower one's blood cho- lesterol level the less the likelihood of heart disease; the higher the cholesterol level the greater the risk" (Office of the Assistant Secretary for Health and the Surgeon Gen- eral, 1979~. Saturated Fatty Acids: Influence on Serum Lipid Levels Saturated fatty acids are estimated to currently contribute about 13 percent of the total caloric intake of the average adult in the United States. These fatty acids, as a group, have been positively correlated with the prevalence of cardiovascular disease in many epiclemiological studies (Hegsted et DESIGNING FOODS al., 1965; Keys, 1970; Stamler, 1979). Sev- eral specific saturated fatty acids have been shown to raise plasma levels of cholesterol and low-(lensity lipoproteins, both of which are correlated with an increased risk of cardiovascular disease (Ahrens et al., 1957; Hegsted et al., 1965; Keys et al., 1965~; lowering the level of saturated fatty acids in the diet will reduce the plasma cholesterol level (Hegstec! et al., 1965; Keys et al., 1965~. Saturated fatty acids occur in both animal and plant fats. Particularly rich sources of saturated fatty acids from plants are coconut ant] palm oils. Animal fats contain saturated fatty acids of a wide range of chain lengths. Specific saturated fatty acids are believed to differ in their ejects on plasma choles- terol. Three saturates palmitic (Cur), myristic (Ci40), and lauric (Cur) acids- have been shown to raise the plasma cho- lesterol level, while stearic acid (Cur), which is high in beef, lamb, and pork fat, appar- ently does not raise the plasma cholesterol level (Hegstec! et al., 1965; Keys et al., 1965~. The actions of the medium-chain fatty acids (C80, C~00) on cholesterol levels are not well stucliec3. As research confirms and refines the effects of stearic acid on the plasma cholesterol level, dietary recom- mendations may change to exclude this saturated fatty acid from the 10 percent caloric recommendation (Bonanome and Grundy, 1987). Dietary Guidelines for Fatty Acid Intake A "reduction" in saturated fatty acid in- take or "avoidance" of excessive intakes, without citing specific levels, has been rec- ommended by the USDA and DHHS (U.S. Department of Agriculture/U. S. Depart- ment of Health and Human Services, 1985), the National Research Council's Committee on Recommended Dietary Allowances (Na- tional Research Council, 1980), and the Surgeon General (Office of the Assistant

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TARGET LEVELS AND C URRENT DIETARY PATTERNS Secretary for Health and the Surgeon Gen- eral, 1979~. Recommendations that intakes be reduced to less than 10 percent of total caloric intake have been made by the A~ner- ican Heart Association (1982) and a National Institutes of Health (1984b) consensus de- velopment conference statement; the U.S. Senate Select Committee on Nutrition and Human Needs (1977) suggested a range of 8 to 12 percent. This committee accepts, for adults, a target level of 10 percent or less of calories from saturated fatty acicis. Due to the unknown potential adverse eEects of prolonged intakes of high levels of polyunsaturated fatty acids, the American Heart Association (1968) the National Insti- tutes of Health (1984b), and the National Research Council's Committee on Dietary Allowances (National Research Council, 1980) have all cautioned against exceeding 10 percent of total calories from polyunsatur- ated fatty acids. This committee accepts, for adults, a target level of 10 percent or less of calories from polyunsaturated fatty acids. The remainder of dietary fatty acids (15 percent of calories or less) should come from monounsaturated fatty acids, which are found in both animal and plant fats. The monoun 51 saturated fatty acids have been shown in some studies to cause a lowering of serum cholesterol when exchanged for saturated fatty acids. They reduce low-density lipo- protein levels to about the same extent as do polyunsaturated fatty acids. There is no evidence that monounsaturates uniquely increase the risk for cancer. The committee accepts, for adults, a target level of 15 per- cent of calories or less from monounsatur- ated fatty acids. Dietary Survey Data Data from the 1985 CSFII indicate that saturated fatty acids, as percentage of cal- ories, average about 13.2 percent in the diets of adults ages 19 to 50 and 13.9 percent for children ages 1 to 5 (Table 3-5~. Data on 4-day intakes for women and children indicate that 10 percent of women (ages 19 to 50) and 4 percent of children (ages 1 t<' 5) had diets that met the target level for percentage of calories from saturated fatty acids (Table 3-6~. Comparable data are not available for men, but the trend is thought to be similar. Data from the 1985 CSFII indicate that 1Al3LL 3-5 (calories from Fat and Fatty Acids, 1985 (in percent) Children at Age Fat or Fatty Acid 1-3 4-5 Females at Age: All (1-5) 1~34 35-50 All (1~50) Males at Age: . 1~34 35-50 All (1~50) 37.6 36.4 Total fat a Saturated fatty acidsb Monounsaturated fatty acids 12.3 12.6 Polyunsaturated fatty acids 5.4 5.5 34.3 34.4 34.3 14.0 13.8 13.9 12.4 5.5 36.2 13.1 37.2 13.4 13.7 7.5 36.6 13.2 13.5 7.3 35.3 12.7 13.5 6.7 13.& 7.0 13.2 13.8 6.8 aThe value for the percentage of calories from total fat exeeds the value for the sum of the total saturated, monounsaturated, and polyunsaturated fatty acids by an amount equal to the value for glycerol and all other non fatty lipid components. bThis category includes all types of saturated fatty acids, with carbon chain lengths front 6 to 18. SOURCES: Adapted from U.S. Department of Agriculture. 1985. P. 49 in Women 1~50 Years and Their Children 1-5 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-1, Human Nutrition Information Service. Hyattsville, Md.: U. S. Department of Agriculture. U. S. Department of Agriculture. 1986. P. 47 in Men 1~50 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-3, Human Nutrition Information Service. Hyattsville, Md.: U. S. Department of Agriculture.

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52 DESIGNING FOODS TABLE 3-6 Distribution (Percent) of Women and Children by Percentage of Calories from Saturated Fatty Acids and Reductions Needed to Meet Target Level Calories from Saturated Fatty Acids (%) Dietary Level: >10'14 '15'19 -20 Group and Age Reduction Needed (Percentage Points) to Meet Target Level: 0-5 5-9 210 Children 1-3 ~5 All (age 1-5) Females 1~34 3~50 All (age 1~50) 59 65 61 55 55 55 35 32 34 35 31 2 33 2 1 NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from Human Nutrition Information Service, U.S. Department of Agriculture, unpublished data on 4-day dietary intake, 1987. monounsaturatec] fatty acids accounted for 13.5 to 13.8 percent of calories in the diets of adults ages 19 to 50 ant! 12.6 percent in the diets of children ages 1 to 5 (Table 3- 5~. Data on 4-clay intakes indicate that 74 to 80 percent of children ages 1 to 5 and 64 to 66 percent of women ages 19 to 50 had diets that met the target level of 15 percent or less of calories from monounsaturated fatty acids (Table 3-7~. Comparable data for men are not available, but the trend is thought to be similar. Data from the 1985 CSFII indicate that polyunsaturated fatty acids accounted for ~ ~ . ~ ~. (% 1 and 4 percent of children ages 1 to 5 years had diets that met the target level for saturated fatty acids. Between 64 to 66 percent of women and 74 to 80 percent of children hail diets that met the target level for monounsaturated fatty acids. About 98 to 99 percent of children and 86 percent of women met the target level for polyunsa- turated fatty acids (Tables ~6 through 8~. CHOLESTEROL . ~at. . r Target: Three hundred milligrams or less o.o to `.~ percent or calories In the cllets ot 1 1 ~ r of cholesterol per day for adults. acquits ages 19 to 50 anct 5.5 percent or calories in the diets of children ages 1 to 5 (Table 3-5~. Four-ciay intake data indicate that 98 to 99 percent of children ages 1 to 5 ant] 85 to 87 percent of women ages 19 to 50 had diets that met the target level for 10 percent or less of calories from polyun- saturatec3 fatty acids (Table 3-8~. Summary Data from the 1985 CSFII indicate that about 10 percent of women ages 19 to 50 In some epidemiological studies, the risk of cardiovascular heart disease has been positively correlated to intakes of dietary cholesterol (Kanne! et al., 1971; Shekelle et al., 1981~. In one study, with intakes of up to about 400 mgll,OOO kcal, the plasma cholesterol response to dietary intakes of cholesterol was approximately linear: Each 1 mg/1,000 keel resulted in a plasma cho- lesterol increase of about 0.1 mg/(11 (Hegstecl, 1986~. Based on the results of that study, with a 2,500-kcal diet, an increase in dietary

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TARGET LEVELS AND CURRENT DIETARY PATTERNS TABLE 3-7 Distribution (Percent) of Women and Children by Percentage of Calories from Monounsaturated Fatty Acids and Reductions Needed to Meet Target Level Calories from Monounsat~rated Fatty Acids (Jo) 53 Dietary Level: _ ~ ~ ~ ~ ~ ~ ~.~ ~ ~ ~.~.~ ~ A - ~ ~ Levels ~ tic ill ~ ~ ~ ~ ~ ~ ~ -aft ~ ~ ~ ~ ~ ~ ~ ~ ~ , ::: -~1~ J~ ~ All. :: ~ ~ . ~.:~.'~:::~ . ~ ~ . :: . .. . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ :~ ~: i: ~ ~ ..: ~. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~.~.~ ::: :~ : :: ~ :~ ~:~:~:~ ~ ~: ~ ~ ~.~ ~.~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .~ ~ ~ ~ ~ . ~ ~ . ~ ~ ~: ~ ~ ~- ~ One ~ ~ ~ ~-~ ~ ~ ~ ~ ~ ~ ~ ~-~ -- ~ ~ I- ~ ~ ~ . : it: ~ : ~:~ :: .vv~ ~ at: :~ ~ ~.~ ~ ~ ~ it. ~ ~ i 4~ ~ ~ ~ ~ ~ ~.~ ~ ~ ~ ~ ~ ~ : ::: :::::::::: ~ ::: :::: :::::::: ::: ::::::::: ::::::: M7^ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ at. : :~1 A: i: ~ ~ ~ -. ~ ~ ~ ~ : ~ ~ ~,~ :~ :::: i:: :: :::: i: :::: :~:: :: i:: :::: ::::::: ::: :~ ~::~:::::~:: :::: ~ i: ~ ~ ~ ~ ~ ~ ~ ~ A: 66~ :~: ~ ~ ~ : :~ : :::: ~ ~::~ :: :::: at:: ::: :~:::~:~:::~:~:::~: : `: At ~ ~ ~ ~ ~ ~ i:: ~ ~ ~ ~ ~ ~ i: :: ~ ~ ~ :~: : : Em:: ~ a: ~:~::~::~ ::~ :: :::::::::::: : ::::::::::::: :::::::: :::::::::::: i::::: :::::: ::::: :: :: :~ ~ ~:~:~,~,~:~ ~:~,~ ail: : ~ ~ ~,~:~ ~:~ .: :~ ~ ~:~ ~ > 15' 19 220 Group and Age Reduction Needed (Percentage Points) to Meet Target Level: 0-5 2~10 Children 1-3 ~5 All (age 1-5) Females 1~34 3~50 All (age 1~50) 20 26 23 33 34 o o o 1 2 1 NOTE:: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from Human Nutrition Information Service, U.S. Department of Agriculture, unpublished data on 4-day dietary intake, 1987. cholesterol of 100 mg/day would be expected to increase the plasma levels by about 4 mg/dl. Likewise, a decrease in dietary cholesterol of 100 mg/day would decrease plasma levels by about 4 mg/dl. Dietary Guidelines for Cholesterol Intake Reports from the USDA/DHHS (1985) and the Surgeon General (Office of the Assistant Secretary for Health and the Sur- geon General, 1979) recommend a "reduc- tion" in dietary intakes of cholesterol but do not cite precise levels. Organizations suggesting specific intakes include the U. S. Senate Select Committee on Nutrition and Human Needs (1977) (250 to 350 midday), the National Institutes of Health (1984b) consensus development conference state- ment (250 to 300 mg/day), and the American Heart Association (1986) ('300 mg/day or 100 mg/1,000 kcal). Restriction of dietary cholesterol in children remains controver- sial, although a lowering of total dietary fat and an avoidance of obesity among this age group have been recognized as good pre- ventive measures (Barness, 1986~. This com mittee accepts, for adults, a target level for cholesterol of less than 300 mg/day. Dietary Survey Data Data from the 1977-1978 NFCS indicate that the average cholesterol intake for the survey population was 385 mg/day, or 214 mg/1,000 kcal (U.S. Department of Agri- culture/U. S. Department of Health and Hu- man Services, 1986~. Fifty-eight percent of the survey population had intakes greater than 300 mg of dietary cholesterol per day. The highest intakes were among 19- to 64- year-olds, with 78 percent of the males and 52 percent of the females consuming more than 300 mg/day. These data are summa- rized in Table 3-9. Data on cholesterol intakes from the 1985 CSFII are presented in Tables W10 and ~11. About 77 percent of children ages 1 to 5 and 62 percent of women ages 19 to 50 had diets that met the target level of '300 mg/day. Summary Data from the 1977-1978 NFCS indicate that about 52 percent of the survey popu

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54 DESIGNING FOODS TABLE 3-8 Distribution (Percent) of Women and Children by Percentage of Calories from Polyunsaturated Fatty Acids and Reductions Needed to Meet Target Level Calories from Polyunsaturated Fatty Acids (%) Group and Age Children 1-3 4-5 All (age 1-5) Females 19-34 35-50 All (age 19-50) :~t L - ells i ~ .... if - ~ A. ~ ~ ~ . ~ ~ ~ -. ~ ~ ~ -G10 ~ - - ~.~:.:.:,~::.~.,.:.:::::~:~.~:~...:~:~.~.:::::~.~:::~: ..: :.::: :: :,:,:,:. :: . ,.;,,.,,,~,., ~,,,,,~,,~,.~, .. -.2-.~-~.' ~ , , - ,:, ~ ~ jot ~ . ~.~.~,, ~-- ~-.-~. ~'--,',~.'.'--,'.',''~,''.~.~.~. ; 's,.o,.-. ~,.; ; I'.'"-"-''". i.... -, -,,....-,: ~...~ i.,- ~.-.~ ~ ~ . it- ~ ~ ~ . ~ ~ ~.~.-~ ~ ,~ ~ ~ - -.. ~ ~ ~ ~ -~.~.~.~.~..-,..~.~.~. ~,~,~,.~,. .-~,- -.~.. ~.~..~ .-~ .,,,, . ~ ~ ~ ~ ~ - - ~ . :. -~...~ ~ i: ~ ~ i. -A . A. ~ ~ i, ~ . ~ i. . in: ~:-~ ~ ~ ~.-..~.,~..~:.~. ..:,.,.-, ..-.., .,, ,.-,-. it'. ~ ~ ~ ~ em- "A ..'.'. ~ .~..'.',~',~.~,~.-~-~.~ ~ , ~ i'. ~ ~-~ '.' . . ~ ~ . ,~. -.. --,.,- ,~ .,, ,, ~ ,. ~ i.- i. ~ ~ i, ~ ~ . .~ .~ ~- ...~.-.~.,~ .:..,.-:.-,.., ~,,~ ... i.. :-- ,-,~,~,~...,~,~.-~-~-~ ~.~,~,~,.,~..~.~.~. 'if ~'2.2~2."~"~'~ ~'~.,~'~'~2S~.~ ~-,~,~-',-,.~'~2 ~2~2 ~'.~,-~''~'.-,~.~-~,~.~, ~ ~ ~,~ ~ ~: ~ ~ ~,~,~,~ ~ ,-~ ~ ~ i: ~ . in: ~ :: :::: ~ ~ ~ ~ ~ : ~ ~ ~:~ ~ ~:~ ~ ~.~.~ ~ ~ ~ ~: ~ ~ ~ ~ i: ::: ~ :: ~ ~ i:: ~:~:~ ~ ~ ~:~ .~ ~ ~.~ ~ ~.~ :~ ~ ~ :~ ~ ::: ~::~:~::~ ~ ~: - .~. ~ i.: ..: ~ hi: ~ ~ i: ~:~. `:s' ~ ~ ~ ~ ~ ~ ~ ~ ~ ~:~;;'~ :~ hi: ~ ~:~ ~: ~ ~ i:: ~:~:~ :~::::::~::::::::~.~. ~:~ :::: ~:~:~ ~:~ JO ~ ~: ~:~ oo~: i. ~ :~ ~.~ ~ in: ~ ~ ~ :::::::: ~ :~. i: ~ :~ ~::~ ::: ::: :.:: Dietary Level: > 105 14 2 15' 19 220 Reduction Needed (Percentage Points) to Meet Target Level 0-5 5-9 2 10 2 2 o o o 12 1 15 0 14 o o o o NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from Human Nutrition Information Service, U. S. Department of Agriculture, unpublished data on 4-day dietary intake, 1987. ration had mean daily cholesterol intakes above 300 ma. This group included 78 percent of males ages 19 to 64 and 52 percent of females ages 19 to 64 years (Table ~9~. Dietary cholesterol intakes from the 1985 CSFII averaged 254 mg/clay for children ages 1 to 5, 304 mg!ciay for women ages 19 to 50, and 439 mg/day for men ages 19 to 50 (Table ~10~. Nearly 77 percent of chil- clren ages 1 to 5 and 62 percent of women ages 19 to 50 from the 1985 CSFII consumed '300 mg of cholesterol per day (Table 11~. CALCIUM TABLE 3-9 Mean Daily Cholesterol Intakes in Relation to Target Level % of Population with the Following Mean Intakes per Day (mg): Group and Age Children 1~ Mean Intake (mg) >300 ~18 19 64 65+ Males ~18 Target: Calcium intake of the Recom- 19~4 mended Dietary Allowance (RDAJ for age 65+ and sex. Dietary Guidelines The National Institutes of Health consen sus development conference statement on osteoporosis recommended adequate nutri tion that included an elemental calcium intake of 1,000 to 1,500 mg/day for post 289 All 328 345 316 442 511 461 385 39 49 52 47 70 78 71 58 NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from U.S. Department of Agri- culture/U. S. Department of Health and Human Serv- ices. 1986. P. 255 in Nutrition Monitoring in the United States: A Progress Report from the Joint Nu- trition Monitoring Committee. DHHS Publication (PHS) 86-1255. Washington, D.C.: U.S. Government Print- ing Office.

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TARGET LEVELS AND CURRENT DIETARY PATTERNS TABLE 3-10 Mean Daily Cholesterol and Calorie Intakes, 1985 55 Children at Age: All (1-5) N utrient 1-3 4-5 Females at Age: Males at Age: All 19-3435-50 (1~50) 1,7071,602 1,661 306302 304 443 427 435 1~34 3.~5() All (1~50) 2 560 Calories (kcal) Cholesterol (nag) 1,3721,564 1,446 247266 254 2 ? 667 2,428 SOURCES: Adapted from the U.S. Department of Agriculture. 1985. Pp. 22 Slid 74 III W<'lnel1 1~5() Years and Their Children 1-5 Years, 1 Day. Nationwide Food Consumption S~lrv~v, Col~tin~lillg S~lrv~v of Food Intakes by Individuals. Report 85-1, Human Nutrition Information Service. Hvattsville? Md.: U. S. Department of Agriculture. U. S. Department of Agriculture. 1986. Pp. 20 and 22 in Men 1~50 Y~;~rs' 1 Rev. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Rep`'rt 85-3, Hulllall Nutrition Information Service. Hyattsville, Md.: U.S. Department of Agriculture. menopausal women, as well as a program of modest weight-bearing exercise and es- trogen replacement (National Institutes of Health, 1984a). The National Research Council's Committee on Dietary Allowances recommended calcium intakes of 800 ma/ day for children ages 1 to 10 and adults ages 19 and older (National Research Council, 1980~. For males and females ages 11 to 18, the recommended daily intake is 1,200 ma. For infants under 6 months, the RDA is 360 ma; for children ages 6 months to 1 year, the RDA is 540 ma. During pregnancy and lactation, an increase of 400 mg/day is recommended for women. This committee accepts as the target level the RDA for calcium for the various age and sex groups. Dietary Survey Data Data from the 1977-1978 NECS indicate that about 42 percent of the survey popu- lation had calcium intakes below 70 percent of the RDA, and 26 percent had intakes between 70 and 100 percent of the RDA. These data are presented in Table ~12. Table ~13 compares Calvin intakes from the 1977-1978 NFCS and the 1985 CSFII TABLE 3-11 Distribution (Percent) of Women and Children by Cholesterol Intakes and Reduction Needed to Meet Target Level Cholesterol (mg) Ret Clever ::~ Dietary Level: c3~ ;~;~ ~ ~ ;~; >30()~ 400 >400~ 500 >500 Group and Age Reduction Needed (Percentage Points) to Meet Target Level: ::: :: :: :::: : Iron ~ ~ ~ ::: ::: :: : ::: ::: 0^ : of :: :~ ::: ~ ~ ~ ~ ~ ~ ::: :7q:: :: , ~: <100 100-200 >200 Children 1-3 4-5 All (age 1-5) Females 19--34 35-50 All (age 19-50) :: Aid:: :: :::: A, :: : ::: :: ::: :~6~.~;~;~:~ ~ ~ Do:::: ``, ~ ,~ I: 11 20 15 20 22 21 7 7 7 11 7 9 - 8 8 NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from Human Nutrition Information Service, U.S. Department of Agriculture, unpublished data on 4-day dietary intake, 1987.

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56 DESIGNING FOODS TABLE 3-12 Distribution (Percent) of Individuals by Calcium Intakes and Increases (as a percentage of RDA) Needed to Meet Target Level Calcium (% RDA) Dietary Level: Shell ~ ;~:': ... . .. . ... ,, ;; .; . ; .. it' -70< 100 <70 Group and Age Children ~1 1-8 Females 9-18 19-64 65+ Males 9-18 19-64 65+ Increase Needed (Percentage Points) to Meet Target Level: 0-30 >30 All (mean) 14 27 28 23 26 29 27 28 26 25 49 58 56 29 32 39 42 NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from U.S. Department of Agriculture/U.S. Department of Health and Human Services. 1986. P. 272 in Nutrition Monitoring in the United States: A Progress Report from the Joint Nutrition Monitoring Evaluation Committee. DHHS Publication (PHS) 86-1255. Washington, D.C.: U.S. Government Printing Office. TABLE 3-13 Mean Daily Dietary Calcium Intakes for Individuals Group and Age Target Level, RDA (mg) Total Intake (mg) 1977 1985 mg/1,000 keel 1977 1985 Children 1~ 4-5 All (age 1-5) Females 19-34 35-50 All (age 19-50) Males 19-34 35-50 All (age 1~50) 800 800 800 800 800 800 800 800 800 717 728 722 611 515 570 871 736 815 824 864 840 685 606 651 975 849 919 602 498 555 389 352 374 364 315 343 622 564 600 402 392 398 366 353 360 SOURCES: Adapted from the U.S. Department of Agriculture. 1985. Pp. 23 and 46 in Women 19-50 Years and Their Children 1-5 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-1, Human Nutrition Information Service. Hyattsville, Md.: U. S. Department of Agriculture. U. S. Department of Agriculture. 1986. Pp. 21 and 44 in Men 1~50 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-3, Human Nutrition Information Service. Hyattsville, Md.: U.S. Department of Agriculture.

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TARGET LEVELS AND CURRENT DIETARY PATTERNS for men, women, and children. Average intakes as well as intakes per 1,000 kcal have increased for all three of these popu- lation groups. CSFII dietary levels of cal- cium averaged above the RDA for men and children and were about half the RDA for adult women. Of interest in the 1977-1978 NFCS and the 1985 CSFII data are the percentage of individuals using vitamin and mineral sup- plements and how this figure has changed recently (Table ~144. The percentage of children ages 1 to 3 using supplements has increased by about 20 percent and for chil- dren ages 4 to 5, by about 35 percent, with an overall increase for children ages 1 to 5 of about 26 percent. For women ages 19 to 34, there has been a 37 percent increase and for women ages 35 to 50, a 66 percent increase, for an overall increase among LABILE 3-14 Use of Vitamin and Mineral Supplements Individuals Using (%) Group and Age 1977 1985 Increase from 1977 to 1985 (%) Children 1-3 ~5 All (age 1-5) Females 1~34 3~50 All (age 1~50) Males 1~34 3~50 All (age 1~50) 50.8 60.7 43.2 58.5 47.4 59.8 40.8 56.0 36.1 59.8 38.9 57.6 19.5 35.4 26.2 37.3 65.7 48.1 42.5 70.0 47.9 66.9 44.9 69.4 SOURCES: Adapted from the U.S. Department of Agriculture. 1985. P. 58 in Women 1~50 Years and Their Children 1-5 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-1, Human Nutrition Information Service. Hyattsville, Md.: U. S. Depart- ment of Agriculture. U. S. Department of Agriculture. 1986. P. 56 in Men 1~50 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-3, Human Nutrition Information Service. Hyattsville, Md.: U.S. Depart- ment of Agriculture. 57 women ages 19 to 50 of about 48 percent. For men ages 19 to 34, there has been a 70 percent increase, and for men ages 35 to 50, a 67 percent increase, for an overall increase among men ages 19 to 50 of about 69 percent. Summary Data from the 1977-1978 NFCS indicate that 42 percent of the survey population have diets containing less than 70 percent of the RDA for calcium, including more than 50 percent of females age 19 and older. Another 26 percent of the survey population have diets containing from 70 to 100 percent of the RDA for calcium, including 31 percent of adolescents ages 9 to 18 (Table W12~. Slean calcium intakes increased from the 1977-1978 N FCS to the 1985 CSFII for men, women, and children; but women's mean intakes still fell short of the RDA (Table ~13~. About three-fourths of the women did not meet 100 percent of the RDA; of this group, half did not achieve 70 percent of the RDA. IRON Target: Iron Intake of the RDA for age and sex. Definition and Prevalence of Iron- Deficiency Anemia Iron deficiency is frequently cited as the most common single nutritional deficiency in the world and the cause of the most common form of childhood anemia in the United States (Dallman et al., 1984~. Nu- tritional iron deficiency is caused by inad- equate amounts of iron in the diet and can adversely affect health status, including a reduction in maximal work capacity, altered immune response, and, in children, behav- ioral abnormalities and a reduction in in- tellectual performance (Federation of Amer- ican Societies for Experimental Biology, Life Sciences Research Office, 19844.

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58 The NHANES II (1976-1980) data on iron status were analyzed by an expert scientific working group of the Life Sciences Research Office, Federation of American Societies for Experimental Biology (1984~. The group's findings on the prevalence of impaired iron status are summarized in Table ~15. It concluded that several population segments had relatively high prevalences of impaired iron status ant! warranted further consid- eration, including children ages 1 to 2, males ages 11 to 14, ant! females ages 15 to 44. It also concluded that the prevalence of im- pairecT iron status was higher for blacks than for whites, was higher for persons below the defined poverty level than for those above it, and was associated with lower education level and, for women, higher parity. A recent report from the Pediatric Nu TABLE 3-15 Prevalence of Impaired Iron Status, 1976-1980 Group and Age Estimated Range of Prevalence (%) Children 1-2 3 - ~10 Females 11-14 1~19 20~4 45 64 6~74 Males 11-14 1~19 20~4 45 64 6~74 9.~9.4 3.6 5.5 3.2 4.5 2.7~.1 ~ 2. ~14. 2 r 4.~9.6 3.8~.8 2.7~.7 3.~12. 1 0.1~.9 0.6 0.S 1.~2.0 1.8 3.6 SOURCE: Federation of American Societies for Ex- perimental Biology, Life Sciences Research Office. 1984. P. v in Assessment of the Iron Nutritional Status of the U. S. Population based on Data Collected in the Second National Health and Nutrition Examination Survey, 197~1980, S. M. Pitch and F. R. Senti, eds. Bethesda, Md.: Life Sciences Research Office, Fed- eration of American Societies for Experimental Biology. DESIGNING FOODS trition Surveillance System of the Centers for Disease Control (1986b) indicated a clecline in the prevalence of anemia among children enrolled in public nutrition and health programs cluring 1975 to 1985. The prevalence of anemia dropped from 7.8 percent in 1975 to 2.9 percent in 1985, with greater declines among children examined at follow-up visits as compared to those of the same age at initial visits. Vasquez- Seoane et al. (1985) have suggested that the decline was probably related to improve- ments in iron nutrition during infancy and childhood, due partly to participation in public nutrition and health programs. Data on children from public health pro- grams with hematocrit values below the 5th percentile are presenter! in Table ~16. As with other indicators of poor nutritional status, the incidence of low hematocrits differs widely among age and ethnic groups. Dietary Guidelines for Iron Intake The National Research Council's Com- mittee on Dietary Allowances (National Re- search Council, 1980) recommends an iron intake of 10 mg/`lay for infants up to age 6 months, children ages 4 to 10, males 19 and older, and females 51 and older. It recom- mends an intake of 15 mglday for children ages 6 months to 3 years, and an intake of i~ mg/day for males ages 11 to 18 and females ages 11 to 50. During pregnancy and lactation, it suggests a daily supplement of 30 to 60 mg of iron. This committee accepts as a target level the RDA for iron for the various age en cl sex groups. Dietary Survey Data The data from the 1977-1978 NFCS in- icate that approximately 33 percent of the survey population had iron intakes of less than 70 percent of the RDA, 23 percent had intakes between 70 and 100 percent of the RDA, and about 44 percent had intakes that met or exceeded the RDA (U.S. De

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TARGET LEVELS AND CURRENT DIETARY PATTERNS TABLE 3-16 Percentage of Low-Income Children Screened with Hematocrit Values Below the 5th Percentile, 31 States, United States, 1984 Hen~tocrit Age and Group Number Examineda <5th Percentile ~11 months White21,278 7.0 Black13,883 6.9 Hispanic4,365 8.0 American Indian967 7.9 Asianl'467 8.1 12-23 months White31,960 6.3 Black24,202 7.7 Hispanic4,516 8.3 American Indian1,153 5.8 Asian ~'660 6.2 2-5 years White66,485 7.6 Black49,985 11.6 Hispanic8,324 10.8 American Indian2,234 6.S Asian 1'1,222 8.6 ~9 years White10,355 3.8 Black8, 277 6.5 Hispanic366 3.6 American Indian103 2.9 Asianb12 Insufficient data NOTE: The Pediatric Nutrition Surveillance System, Centers for Disease Control, uses nutrition-related data collected by local health departments as part of the routine delivery of child health services. These data are the result of examinations of 610,439 new patients at 2,464 clinics in 31 states, the District of Columbia, and Puerto Rico. Hematocrit is the volume of red blood cells in whole blood. aTotal does not equal 610,439 because of unknown or missing data for some variables and the exclusion of states with data errors. bData for Asians include data from an unknown number of recent Southeast Asian refugees. SOURCE: Adapted from Centers for Disease Control. 1986. Annual Summary 1984: reported morbidity and mortality in the United States. Morbidity Mortality Weekly Report 32 (54):107. partment of Agriculture/U.S. Department of Health and Human Services, 1986~. These data are summarized in Table ~17. Groups with the lowest intakes are those previously described as having the highest prevalences of impaired iron status, including children to age 5, males ages 11 to 14, and females their reproductive years, ages 15 to 50. In 59 The most current dietary intake data on men, women, and children are presented and compared to data from the 1977-1978 NFCS in Table ~18. Mean intakes for all three groups have increased somewhat from 1977 to 1985. For children, intakes per 1,000 kcal have also risen, but for men and women the figure has fallen.

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Group and Age Children <1 1-8 Females 9-18 19-64 65+ Males 9-18 19-64 65+ All Increase Needed (Percentage Points) to Meet Target Level: 60 DESIGNING FOODS TABLE 3-17 Distribution (Percent) of Individuals by Iron Intakes and Increases (as a pecentage of RDA) Needed to Meet Target Level Iron (% RDA) Dietary Level: -70 < 10~0 <70 ::~: :~::::::: :~:: :~:.:.:~:: :~: :.:~:~:::~:.:.:~::::.::. ~:~.~:~.~ ~:~4~: ~ 0~30 >30 12 18 27 26 34 38 10 14 23 30 44 55 56 13 26 2 4 33 NOTE: The shaded column represents the target level and the percentage of individuals who met it. SOURCE: Adapted from U.S. Department of Agriculture/U.S. Department of Health and Human Services. 1986. P. 228 in Nutrition Monitoring in the United States: A Progress Report from the Joint Nutrition Monitoring Evaluation Committee. DHHS Publication (PHS) 86-1255. Washington, D.G.: U.S. Government Printing Office. TABLE 3-18 Mean Daily Iron Intakes for Individuals Target Level, Total Intake (mg) mg/1,000 kcal Group and Age RDA (mg) 1977 1985 1977 1985 Children 1-3 15 8.4 10.5 7.1 7.8 4-5 10 9.7 11.6 6.7 7.5 All (age 1-5) 9.0 10.9 6.9 7.7 Females 19-34 18 10.7 11.3 6.9 6.7 35-50 18 10.8 10.8 7.6 7.1 All (age 19-50) 10.7 11.1 7.2 6.9 Males 19-34 10 15.7 16.0 6.7 6.2 35-50 10 16.6 15.8 7.3 6.7 All (age 19-50) 16.1 15.9 7.0 6.4 SOURCES: Adapted from the U.S. Department of Agriculture. 1985. Pp. 23 and 46 in Women 19-50 Years and Their Children 1-5 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-1, Human Nutrition Information Service. Hyattsville, Md.: U.S. Department of Agriculture. U.S. Department of Agriculture. 1986. Pp. 21 and 44 in Men 19-50 Years, 1 Day. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals. Report 85-3, Human Nutrition Information Service. Hyattsville, Md.: U. S. Department of Agriculture.

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TARGET LEVELS AND CURRENT DIETARY PATTERNS Summary Data from the 1977-1978 NFCS indicate that 33 percent of the survey population have diets containing less than 70 percent of the RDA, including more than 50 percent of females ages 9 to 64. Another 23 percent of the population have diets containing only 70 to 100 percent of the RDA for iron, including 38 percent of males and 27 percent of females ages 9 to 18 (Table ~174. A1- though the mean dietary intakes of iron increased from 1977-1978 to 1985 for men, women, and children, they still averaged below the RDA for women (Table .~181. About 95 percent of the women did not meet 100 percent of the RDA; of this group, three-fourths did not achieve 70 percent of the RDA. REFERENCES 61 cular disease. Morbid. Mortal. Weekly Rep. 35(42):65~654. Centers for Disease Control. 1986b. Current trends: Declining anemia prevalence among children en rolled in public nutrition and health programs, selected states, 1975 to 1985. Morbid. Mortal. Weekly Rep. 35(36~:565-566. Dallman, P. R., R. Yip, and C. Johnson. 1984. Prev alence and causes of anemia in the United States, 1976 to 1980. Am. J. Clin. Nutr. 39:437. Doll, R., and R. Peto. 1981. The causes of cancer. Quantitative estimates of avoidable risks of cancer in the United States today. J. Natl. Cancer Inst. 66:1191. Federation of American Societies for Experimental Biology, Life Sciences Research Office. 1984. As sessment of the Nutritional Status of the U.S. Pop ulation Based on Data Collected in the Second National Health and Nutrition Examination Survey, 1976-1980. Washington, D. C.: Federation of Amer ican Societies for Experimental Biology. Grundv, S. M . 1986. Comparison of monounsaturated fatty acids and carbohydrates for lowering plasma cholesterol. N. Engl. J. Med. 314:745. Hegsted, D. M. 1986. Serun~ cholesterol response to dietary cholesterol: A re-evaluation. Am. J. Clin. Ahrens, E. H., Jr., W. Insull, Jr., R. Blomstrand, J. Nor. 44:299. Hirsch, T. T. Tsaltas, and M. L. Peterson. 1957. Hegsted, D. M., R. B. McGandy, M. L. Myer, and The influence of dietary fats on serum-lipid levels in man. Lancet 1:943. American Academy of Pediatrics, Committee on Nu trition. 1981. Nutritional aspects of obesity in infancy and childhood. Pediatrics 68:880. American Cancer Society. 1984. Nutrition and cancer, cause and prevention. An American Cancer Society special report. Ca A Cancer Journal for Clinicians 34(2): 121-126. American Heart Association. 1968. Diet and Heart Disease. Dallas, Tex.: American Heart Association. American Heart Association. 1982. Rationale of the diet-heart statement of the American Heart Associ ation. Report of the Nutrition Committee. Circula tion 65:839A. American Heart Association. 1986. Dietary guidelines for healthy adult Americans. Circulation 74:1465A. Barness, L. A. 1986. Cholesterol and children. J. Am. Med. Assoc. 256:2871. Becker, N., D. R. Illingworth, P. Alaupovic, W. E. Connor, and W. E. Sundberg. 1983. Effects of saturated, monounsaturated, and omega-6 polyun saturated fatty acids on plasma lipids, lipoproteins, and apoproteins in humans. Am. J. Clin. Nutr. 37:355. Bonanome, A., and S. Grundy. 1987. Stearic acid does not raise plasma cholesterol. Clin. Res. 35:365A. Centers for Disease Control. 1986a. Epidemiologic notes and reports: Years of life lost from cardiovas F. J. Stare. 1965. Quantitative effects of dietary fat on serum cholesterol in man. Am. J. Clin. Nutr. 17:281. Herold, P. M., and J. E. Kinsella. 1986. Fish oil consumption and decreased risk of cardiovascular disease: A comparison of findings from animal and human feeding trials. Am. J. Clin. Nutr. 43:566. Kannel, W. B., W. P. Castelli, T. Gordon, and P. M. McNamara. 1971. Serum cholesterol lipoproteins and the risk of coronary heart disease. The Fra- mingham Study. Ann. Intern. Med. 74:1. Keys, A. 1970. Coronary heart disease in seven coun- tries. Circulation 41(Suppl. l):I-1-211. Keys, A., J. T. Anderson, and F. Grande. 1965. Serum cholesterol response to changes in the diet. IV. Particular saturated fatty acids in the diet. Metab- olism 14:776. Mattson, F. H., and S. M. Grundy. 1985. Comparison of effects of dietary saturated, monounsaturated, and polyunsaturated fatty acids on plasma lipids and lipoproteins in man. J. Lipid Res. 26:194. National Institutes of Health. 1984a. NIH Consensus Development Conference Statement on Osteopo- rosis. Vol. S. No. 3. Washington, D. C.: National Institutes of Health. National Institutes of Health. 1984b. NIH Consensus Development Statement on Lowering Blood Cho- lesterol to Prevent Heart Disease. Vol. 5, No. 7. Washington, D.C.: National Institutes of Health.

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