DIET
AND
HEALTH

Implications for Reducing Chronic Disease Risk

Committee on Diet and Health
Food and Nutrition Board
Commission on Life Sciences
National Research Council

NATIONAL ACADEMY PRESS
Washington, D.C. 1989



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DIET AND HEALTH Implications for Reducing Chronic Disease Risk Committee on Diet and Health Food and Nutrition Board Commission on Life Sciences National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1989

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Page ii NATIONAL ACADEMY PRESS · 2101 CONSTITUTION AVENUE, NW ·WASHINGTON, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Frank Press is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Robert M. White is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Samuel O. Thier is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Frank Press and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council. The study summarized in this publication was supported by funds from the National Research Council Fund, a pool of private, discretionary, nonfederal funds that is used to support a program of Academy-initiated studies of national issues in which science and technology figure significantly. The NRC Fund consists of contributions from a consortium of private foundations including Carnegie Corporation of New York, Charles E. Culpeper Foundation, William and Flora Hewlett Foundation, John D. and Catherine T. MacArthur Foundation, Andrew W. Mellon Foundation, Rockefeller Foundation, and Alfred P. Sloan Foundation; the Academy Industry Program, which seeks annual contributions from companies that are concerned with the health of U.S. science and technology and with public policy issues with technological content; and the National Academy of Sciences and National Academy of Engineering endowments. The study was also supported by W.K. Kellogg Foundation, The Henry J. Kaiser Family Foundation, Pew Charitable Trusts, Fannie E. Rippel Foundation, and Occidental Petroleum Corporation. Library of Congress Cataloging-in-Publication Data National Research Council (U.S.). Committee on Diet and Health. Diet and health: implications for reducing chronic disease risk /          First Printing, July 1989 Committee on Diet and Health. Food and Nutrition Board, Commission      Second Printing, May 1990 on Life Sciences. National Research Council.                    Third Printing, May 1991 p. cm.                                                  Fourth Printing, July 1992 Includes bibliographies and index.                               Fifth Printing, March 1993 ISBN 0-309-03994-0 1. Chronic diseases—Nutritional aspects. I. Title. [DNLM: 1. Chronic Disease. 2. Diet. 3. Health. 4. Risk Factors. QU 145 N2761d] RC108.N38 1989 613. 2—dc20 DNLM/DLC for Library of Congress                                             89.3261                                                             CIP Copyright © 1989 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purposes of official use by the U.S. government. Printed in the United States of America Cover photographs: Paul Robert Perry/UNIPHOTO (black-eyed peas); Peter Beck/UNIPHOTO (fish); Hanley and Savage/UNIPHOTO (milk); Peter Beck/UNIPHOTO (fruits; vegetables); Gordon E. Smith/UNIPHOTO (bread); Renee Comet/UNIPHOTO (basket).

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Page iii Dedication The Committee on Diet and Health dedicates this report to the late Lucille Hurley, a diligent and enthusiastic member of the committee who made an invaluable contribution to this study, and to the American people, whose demonstrated interest and concerns about how diet affects their health inspired us to undertake this effort. We hope that this detailed assessment of the data will facilitate an understanding of the complex interrelationship between diet, chronic diseases, and health, and enhance the potential for reducing the risk of chronic diseases.

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Page v COMMITTEE ON DIET AND HEALTH ARNO G. MOTULSKY (Chairman), Center for Inherited Diseases, University of Washington, Seattle, Washington EDWIN L. BIERMAN (Vice Chairman), Division of Metabolism, Endocrinology, and Nutrition, University of Washington School of Medicine, Seattle, Washington DeWITT S. GOODMAN (Vice Chairman), Institute of Human Nutrition, Columbia University, New York, New York DONALD B. McCORMICK (Vice Chairman), Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia CLAUDE D. ARNAUD, JR., Endocrine Section, University of California, San Francisco, and Veterans Administration Medical Center, San Francisco, California JOHN C. BAILAR III, Department of Epidemiology and Biostatistics, McGill University School of Medicine, Montreal, Quebec, Canada HENRY BLACKBURN, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota GEORGE A. BRAY, Section of Diabetes and Clinical Nutrition, University of Southern California, Los Angeles, California KENNETH K. CARROLL, Biochemistry Department, University of Western Ontario, London, Ontario, Canada GEOFFREY R. HOWE, National Cancer Institute of Canada Epidemiology Unit, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada LUCILLE S. HURLEY (deceased), Department of Nutrition, University of California, Davis, California LAURENCE N. KOLONEL, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, Hawaii HENRY C. McGILL, JR., Southwest Foundation for Biomedical Research, University of Texas Health Science Center, San Antonio, Texas ANTHONY B. MILLER, Department of Preventive Medicine and Biostatistics, University of Toronto, Toronto, Ontario, Canada LOT B. PAGE, National Institute on Aging, Bethesda, Maryland RICHARD M. SCHIEKEN, Division of Pediatric Cardiology, Medical College of Virginia East Hospital, Richmond, Virginia RICHARD B. SHEKELLE, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas LOUIS TOBIAN, JR, Hypertension Section, University of Minnesota Hospital School of Medicine, Minneapolis, Minnesota ELEANOR R. WILLIAMS, Department of Human Nutrition and Food Systems, University of Maryland, College Park, Maryland Adviser PAUL D. STOLLEY, University of Pennsylvania, Department of Medicine, Philadelphia, Pennsylvania Food and Nutrition Board Liaison WILLIAM E. CONNOR, Department of Medicine, Oregon Health Sciences University, Portland, Oregon M.R.C. GREENWOOD, Department of Biology, Vassar College, Poughkeepsie, New York Food and Nutrition Board Staff SUSHMA PALMER, Director FRANCES M. PETER, Deputy Director and Editor CHRISTOPHER P. HOWSON, Project Director FARID E. AHMED, Project Coordinator SUSAN E. BERKOW, Program Officer ALDON GRIFFIS, Research Assistant MARIAN F. MILLSTONE, Research Assistant AVIS I. HARRIS, Senior Secretary DOROTHY R. MAJEWSKI, Senior Secretary (until October 1988) MICHELLE E. SMITH, Senior Secretary (from November 1988) ELSIE C. STURGIS, Senior Secretary

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Page vi FOOD AND NUTRITION BOARD RICHARD J. HAVEL (Chairman), Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California HAMISH N. MUNRO (Vice Chairman), U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts EDWARD J. CALABRESE, Environmental Health Program, Division of Public Health, University of Massachusetts, Amherst, Massachusetts DORIS H. CALLOWAY, Department of Nutritional Sciences, University of California, Berkeley, California WILLIAM E. CONNOR, Department of Medicine, Oregon Health Sciences University, Portland, Oregon DeWITT S. GOODMAN, Institute of Human Nutrition, Columbia University, New York, New York M.R.C. GREENWOOD, Department of Biology, Vassar College, Poughkeepsie, New York JOAN D. GUSSOW, Department of Nutrition Education, Teachers College, Columbia University, New York, New York JOHN E. KINSELLA, Institute of Food Science, Cornell University, Ithaca, New York LAURENCE N. KOLONEL, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, Hawaii BERNARD J. LISKA, Department of Food Science, Purdue University, West Lafayette, Indiana REYNALDO MARTORELL, Food Research Institute, Stanford University, Stanford, California DONALD B. McCORMICK, Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia J. MICHAEL McGINNIS (Ex Officio), Office of Disease Prevention and Health Promotion, Department of Health and Human Services, Washington, D.C. WALTER MERTZ, Human Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, Beltsville, Maryland ARNO G. MOTULSKY (Ex Officio), Center for Inherited Diseases, University of Washington, Seattle, Washington MALDEN C. NESHEIM, Office of the Vice Provost, Cornell University, Ithaca, New York Food and Nutrition Board Staff SUSHMA PALMER, Director FRANCES M. PETER, Deputy Director LUCIANA FROST, Administrative Associate UTE S. HAYMAN, Administrative Assistant

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Page vii COMMISSION ON LIFE SCIENCES BRUCE M. ALBERTS (Chairman), Department of Biochemistry and Biophysics, University of California, San Francisco, California PERRY L. ADKISSON, Office of the Chancellor, The Texas A&M University System, College Station, Texas FRANCISCO J. AYALA, Department of Ecology and Evolutionary Biology, University of California, Irvine, California J. MICHAEL BISHOP, The G.W. Hooper Research Foundation, University of California Medical Center, San Francisco, California FREEMAN J. DYSON, School of Natural Sciences, The Institute for Advanced Study, Princeton, New Jersey NINA V. FEDOROFF, Department of Embryology, Carnegie Institution of Washington, Baltimore, Maryland RALPH W.F. HARDY, Office of the President, Boyce Thompson Institute for Plant Research, Ithaca, New York RICHARD J. HAVEL, Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California LEROY E. HOOD, Division of Biology, California Institute of Technology, Pasadena, California DONALD F. HORNIG, Interdisciplinary Programs in Health, Harvard School of Public Health, Boston, Massachusetts ERNEST G. JAWORSKI, Biological Sciences, Monsanto Company, St. Louis, Missouri SIMON A. LEVIN, Ecosystems Research Center, Cornell University, Ithaca, New York HAROLD A. MOONEY, Department of Biological Sciences, Stanford University, Stanford, California STEVEN P. PAKES, Division of Comparative Medicine, Southwestern Medical School, University of Texas, Dallas, Texas JOSEPH E. RALL, National Institutes of Health, Bethesda, Maryland RICHARD D. REMINGTON, University of Iowa, Iowa City, Iowa PAUL G. RISSER, Office of the Vice President, University of New Mexico, Albuquerque, New Mexico RICHARD B. SETLOW, Biology Department, Brookhaven National Laboratory, Upton, New York TORSTEN N. WIESEL, Laboratory of Neurobiology, Rockefeller University, New York, New York Commission on Life Sciences Staff JOHN E. BURRIS, Executive Director

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Page ix Preface In the first half of the twentieth century, research in human nutrition was concerned primarily with the role of essential nutrients, particularly vitamins, in human deficiency diseases. It was not until the end of World War II that nutrition research in human populations in the United States focused on the role of diet in chronic diseases, such as coronary heart disease and cancer. The link forged by these later epidemiologic studies was strengthened by complementary evidence from laboratory studies. In the last decade, the wealth of information provided by these studies has been used by U.S. government agencies and other expert groups to propose dietary guidelines aimed at reducing the risk of one or more chronic diseases among North Americans. Although there has been increasing consensus among various groups on many of the dietary guidelines, there remains a lack of agreement on several specific points. Our incomplete knowledge about the multiple environmental and genetic factors that determine chronic disease risk, specifically dietary and nutritional risk factors, the imprecision in methods for assessing nutrient and dietary status, and the differences among target groups and the objectives of recommendations proposed by many expert groups have all contributed to the variability in dietary guidelines. Furthermore, there has been insufficient documentation of the scientific bases underlying the conclusions and recommendations and the criteria used to derive them. In recent years, the public has-been confronted with a plethora of information on diet and its association with chronic diseases without guidance on how to separate fact from fallacy. The National Research Council's Food and Nutrition Board in the Commission on Life Sciences recognized this dilemma and the need to address the important issue of the role of diet in the etiology and prevention of the major causes of morbidity and mortality in the United States. In 1984, the Board established the Committee on Diet and Health to undertake a comprehensive analysis of the scientific literature on diet and the spectrum of major chronic diseases and to evaluate the criteria used to assess the strength of the evidence on associations of diet with health. This report is the result of this critical and detailed analysis and is the first of a systematic series of reports to be issued in a pattern similar to the Board's Recommended Dietary Allowances (RDAs)—a periodic review that provides guidelines on the desirable amounts of essential nutrients in the diet. The three major objectives of this study were: · to develop criteria for systematically evaluating the scientific evidence relating dietary components, foods, food groups, and dietary patterns to the maintenance of health and to the reduction of risk of chronic disease;

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Page x · to use these criteria to assess the scientific evidence relating these same factors (dietary components, foods, food groups, and dietary patterns) to health and to the reduction of chronic disease risk; and · on the basis of this assessment, to propose dietary guidelines for maintaining health and reducing chronic disease risk, to suggest directions for future research, and to provide the basis for periodic updates of the literature and guidelines as new information on diet and health is acquired. The 19-member interdisciplinary committee appointed to conduct the study was assisted by one adviser and two Food and Nutrition Board liaison members. Collectively, the Committee on Diet and Health included expertise in such disciplines as biochemistry, biostatistics, clinical medicine, epidemiology, foods and food consumption patterns, human genetics, metabolism, various aspects of nutrition, public health, and toxicology. During the course of the study, the committee examined data on the association between diet, health, and chronic disease, focusing on coronary heart disease, peripheral arterial disease, stroke, hypertension, cancer, obesity, osteoporosis, diabetes mellitus, hepatobiliary disease, and dental caries. Whenever possible, the committee looked directly at primary sources of data contained in the literature. Works of other evaluative bodies, for example, the Surgeon General's Report on Nutrition and Health published in 1988 and Dietary Guidelines for Americans published in 1985 by the Departments of Agriculture and Health and Human Services, were important secondary sources of information. By drawing from the vast and diverse epidemiologic and laboratory data base, the committee has attempted to ensure a comprehensive and critical review. Thus, the conclusions and recommendations throughout this report are supported by a detailed discussion of the basis underlying them. The committee held 13 meetings during which it evaluated the literature and prepared its general review and summary. A public meeting convened at the outset of the study served as a forum for open discussion and presentation of views and information by the public and by representatives of the food industry, consumer groups, and scientists. In the early stages of the study, the committee conducted five workshops during which it interacted with and shared the expertise and research findings of a larger community of scientists. These workshops provided committee members an opportunity to consider new or controversial data and all valid scientific points of view and to identify gaps in knowledge. The subjects considered in the workshops included the role of vitamins, minerals, and trace elements in chronic disease risk; the importance of genetic factors in selected diet-related chronic diseases; the association of energy, fiber, and carbohydrates with chronic disease; pediatric diet and the risk of adult chronic disease; and criteria for formulating dietary guidelines. The committee's report is presented in four parts. Part I (Introduction, Definitions, and Methodology) offers four introductory chapters in addition  to the Executive Summary (Chapter 1). These chapters highlight the methods and criteria used by the committee as well as the major conclusions and dietary recommendations, their bases, and their implications. Chapter 2 presents the criteria for evaluating the evidence linking diet and chronic disease. The strengths and weaknesses of methodologies for assessing dietary intake as well as those of specific kinds of studies (both human and animal) designed to assess diet-health relationships are reviewed. Trends in, and assessment of, food consumption patterns and the nutritional status of the U.S. population are discussed in Chapter 3. In Chapter 4, the committee discusses the role of genetics in nutrition and how genetic and environmental factors interact to influence diet-associated risks of chronic disease. Chapter 5 presents the rationale for selecting the major diet-related chronic diseases addressed in this report and provides an overview of the extent and distribution of those diseases in the United States. In Part II of this report (Evidence on Dietary Components and Chronic Diseases), the criteria described in Chapter 2 provide the basis of a review of the evidence by nutrients. The 13 chapters in that section (6 through 18) summarize the epidemiologic, clinical, and laboratory data pertaining to each nutrient or dietary factor and the chronic diseases identified by the committee. Nutrient interactions and mechanisms of action are discussed where applicable. Part III (Impact of Dietary Patterns on Chronic Diseases) briefly reassembles the evidence relating nutrients to specific chronic diseases or conditions and comments on the importance of diet relative to nondietary risk factors in the etiology of those diseases. Part IV (Overall Assessment, Conclusions, and Recommendations) contains two chapters. Chapter 27 presents the committee's conclusions, along with a summary of the process, criteria, and scientific bases underlying them. Chapter 28 presents the

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Page xi committee's dietary recommendations and the rationales for each, as well as a detailed discussion of how the recommendations compare to those issued in the past by other expert groups and the bases for similarities and dissimilarities among these. Also contained in this section is an in-depth discussion of the potential risks and public health benefits of the committee's dietary recommendations. The committee hopes this report will be a useful resource document for scientists in academia and industry, for the general public, and for policymakers. Furthermore, it believes that the nine dietary recommendations presented in Chapter 28 and in the Executive Summary (Chapter 1) can be implemented within the framework of the current U.S. lifestyle. Collaboration among government agencies, the food industry, health professionals (physicians, nutritionists, dietitians, and public health personnel), educational institutions, leaders in mass media, and the general public is encouraged to attain this goal. The committee greatly appreciates the hard work and organization provided by the Food and Nutrition Board staff headed by Dr. Sushma Palmer and consisting of Drs. Christopher Howson, Farid Ahmed, and Susan Berkow, Mrs. Frances Peter, Mr. Aldon Griffis, Ms. Marian Millstone, Ms. Dorothy Majewski, Ms. Avis Harris, Ms. Michelle Smith, and Mrs. Elsie Sturgis. The committee is also greatly indebted to Dr. Charles Lieber of the Bronx Veterans Administration Medical Center for his major contribution to the chapter on alcohol and to the many people who served as consultants, as advisers, and in other resource capacities. Many of these people drafted manuscripts for consideration by the committee, presented their views at the public meeting, or upon request, commented on drafts, presented data, or engaged in discussions during committee meetings, conferences, or workshops. Specifically, the committee expresses its thanks to Dr. Norman Bell, Veterans Administration Medical Center, Charleston; Dr. Peter Bennett, National Institutes of Health; Dr. Gerald Berenson, Louisiana State University Medical School; Dr. Jan Breslow, Rockefeller University; Dr. Raymond Burk, University of Texas Health Sciences Center; Dr. Ritva Butrum, National Institutes of Health; Dr. Tim Byers, State University of New York; Dr. T. Colin Campbell, Cornell University; Dr. James Carlos, National Institute of Dental Research; Dr. Marie Cassidy, George Washington  University; Dr. George Christakis, University of Miami School of Medicine; Dr. Charles Davidson, Massachusetts Institute of Technology; Dr. William Dietz, New England Medical Center; Dr. Jean Durlach, Hospital Cochin; Dr. Johanna Dwyer, Francis Stem Nutrition Center; Dr. S. Boyd Eaton, Emory University; Dr. R. Curtis Ellison, University of Massachusetts Medical Center; Dr. Gail Eyssen, University of Toronto; Dr. L. Jack Filer, Jr., Executive Director of the International Life Sciences Institute-Nutrition Foundation; Dr. Michael Goldblatt, McDonald's Corporation; Dr. Clifford Grobstein, University of California, San Diego; Dr. Scott Grundy, University of Texas Health Sciences Center; Dr. Suzanne Harris, Deputy Assistant Secretary for Food and Consumer Services; Dr. Robert Heaney, Creighton University; Dr. Dwight Heath, Brown University; Dr. D. Mark Hegsted, Harvard University; Dr. Richard Hillman, Washington University Medical School; Dr. Paul Hochstein, University of California; Dr. Michael Holick, Tufts Human Nutrition Research Center; Dr. Paul Hopper, General Foods Corporation; Dr. Edward Horton, University of Vermont; Dr. Thomas Hostetter, University of Minnesota; Dr. Michael Jacobson, Center for Science in the Public Interest; Dr. Norman Kaplan, University of Texas; Dr. Carl Keen, University of California, Davis; Dr. Ahmed Kissebah, University of Wisconsin; Dr. Leslie Klevay, USDA-Human Nutrition Research Center; Dr. David Klurfeld, Wistar Institute; Dr. William Knowler, National Institutes of Health; Dr. Stephen Krane, Harvard University Medical School; Dr. Peter Kwiterovich, Johns Hopkins University; Dr. Orville Levander, USDA-Human Nutrition Research Center; Dr. A. Harold Lubin, American Medical Association; Dr. Lawrence Machlin, Hoffman-LaRoche, Inc.; Dr. Aaron Marcus, New York Veterans Administration Medical Center; Dr. Alvin Mauer, University of Tennessee; Dr. Paul McCay, Oklahoma Medical Research Foundation; Dr. Janet McDonald, Food and Drug Administration; Dr. J. Michael McGinnis, Department of Health and Human Services; Dr. Donald McNamara, University of Arizona; Dr. Judy Miller, Indiana University School of Medicine; Dr. John Milner, University of Illinois; Dr. William Mitch, Emory University School of Medicine; Dr. Curtis Morris, University of California, San Francisco; Dr. Janice Neville, Case Western Reserve University; Dr. Ralph Paffenberger, Stanford University; Mr. Richard Peto, University of Oxford; Dr. Ernesto Pollitt, University of California, Davis; Dr. Gerry Reaven, Stanford University; Dr. Floyd Rector, University of California, San Francisco; Dr.

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Page xii Lawrence Resnick, New York Hospital-Cornell Medical Center; Dr. Irwin Rosenberg, Tufts University; Dr. Paul Saltman, University of California, San Diego; Dr. Raymond Schucker, Food and Drug Administration; Dr. William Schull, University of Texas; Dr. Noel Solomons, Institute of Nutrition of Central America and Panama; Dr. Charles Sing, University of Michigan Medical School; Dr. Michael Stem, University of Texas Health Science Center; Dr. Ira Tabas, Columbia University; Dr. Paul R. Thomas, Institute of Medicine; Dr. Michael Tuck, University of California, Los Angeles; Dr. Myron Weinberger, Indiana University; Dr. Sidney Weinhouse, Temple University School of Medicine; Ms. Clair Wilson, Council for Research Planning in Biological Sciences and the Vegetarian Society of D.C.; Dr. Richard Wurtman, Massachusetts Institute of Technology; and Dr. Catherine Woteki, National Center for Health Statistics. Finally, the committee would like to thank the staff of the library of the National Academy of Sciences for their invaluable assistance in preparing this report and the staff of the National Academy Press, especially Chief Manuscript Editor Richard Morris, who herded this volume through production. Special acknowledgment is due to Dr. Richard J. Havel, Chairman of the Food and Nutrition Board, and other board members for their expert advice, oversight, and constant encouragement over the course of this 3.5-year study. ARNO G. MOTULSKY CHAIRMAN COMMITTEE ON DIET AND HEALTH

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Page xiii Contents Part I: Introduction, Definitions, and Methodology 1 Executive Summary 3 2 Methodological Considerations In Evaluating The Evidence 23 3 Dietary Intake And Nutritional Status: Trends And Assessment 41 4 Genetics And Nutrition 85 5 Extent And Distribution Of Chronic Disease: An Overview 99 Part II: Evidence on Dietary Components and Chronic Diseases 6 Calories: Total Macronutrient Intake, Energy Expenditure, And Net Energy Stores 139 7 Fats And Other Lipids 159 8 Protein 259 9 Carbohydrates 273 10 Dietary Fiber 291 11 Fat-Soluble Vitamins 311 12 Water-Soluble Vitamins 329 13 Minerals 347

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Page xiv 14 Trace Elements 367 15 Electrolytes 413 16 Alcohol 431 17 Coffee, Tea, And Other Nonnutritive Dietary Components. 465 18 Dietary Supplements 509 Part III: Impact of Dietary Patterns on Chronic Diseases 19 Atherosclerotic Cardiovascular Diseases 529 20 Hypertension 549 21 Obesity And Eating Disorders 563 22 Cancer 593 23 Osteoporosis 615 24 Diabetes Mellitus 627 25 Hepatobiliary Disease 633 26 Dental Caries 637 Part IV: Overall Assessment, Conclusions, and Recommendations 27 Overall Assessment And Major Conclusions 651 28 Recommendations On Diet, Chronic Diseases, And Health 665 Index 711

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