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NUTRITION AND PUBLIC HEALTH--NEW DIMENSIONS J. Michael McGinnis Changes are occurring at a rapid pace in the nutrition sciences. This paper discusses various ways in which these changes will shape future public policy and practice related to nutrition. Those who watch the literature and who attend the numerous scientific symposia held annually around the country receive the more than $200 million a year the National Institutes of Health pours into nutrition-related research. Indeed, those who merely read the daily newspapers can sense a biological revolution that will have a vast impact on the way nutrition affects the health of Americans. Yet, for society, scientific accomplishment is only as praiseworthy as its successful application for the betterment of the human condition. It is therefore important to emphasize several of the challenges to be faced in making changes in public health policy, irrespective of the pace of change in the biomedical knowledge base. The following may help to put things into perspective: By many indications, this country's major needs in nutrition today are as follows: 1) control of obesity, 2) elucidation of the role of nutri tion in the chronic diseases, 3) assessment of nutritional status as a step toward control of borderline deficiencies, 4) means of complete intravenous alimentation, and 5) additional knowledge regarding nutrition in the aged, those under stress, and in the convalescent (Sebrell, l953~. 117

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This comment was made 35 years ago this month by the then director of the National Institutes of Health, W. Henry Sebrell, on the occasion of his receipt of the Joseph Goldberger Award in Clinical Nutrition. Advances in the science base, such as those described in papers by R.W. Hanson et al., A. Motulsky, and J.E. Kinsella in this volume, have provided the technical means of addressing many of these needs; but the persistent timeliness of Sebrell's observations of another generation is a poignant reminder of the difficulties of moving progress out of the laboratories and into the community. This is a fact that we should keep firmly in mind as we seek to explore future prospects for harnessing scientific insights more effectively for public health progress. The issues that will shape the public health nutrition agenda of the future can be explored from three perspectives: 1. a summary of some of the major factors influencing the substance of the U.S. nutrition policy agenda, 2. a review of how those factors play on elements of the agenda, and 3. a brief look to the future. FACTORS INFLUENCING NUTRITION POLICY The factors most likely to influence our nutrition policy agenda include the national disease profile, the development of scientific insights, the advent of new technologies, the U.S. demographic profile, economics, changing meal source patterns, and public and professional awareness. Disease Profile Fundamentally, any public health agenda is driven to a substantial extent by the population's profile of disease and disability, the nature of the problems at hand, and the rate at which they are changing. Table 1 illustrates the selected causes of death for which diet may offer important contributions. The list includes 5 of the 10 118

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TABLE 1 Selected Causes of Death, 1985 Rate/100,000 Cause of Death PopulationNumber Heart disease 323.0771,169 Cancersa 193.3461,563 Infant immaturity- 86.6C3,257 Stroked 64.1153,050 Diabetes mellitus 15.536,969 Chronic liver disease 11.226,767 and cirrhosis Atherosclerosis 10.023,926 Undernutritione 0.1134 aCancers are malignant neoplasms, including neoplasms of lymphatic and hematopoietic tissues. bInfant immaturity is disorders relating to short gestation and unspecified low birthweight. CPer 100,000 live births. Stroke includes cerebrovascular diseases. Undernutrition is combined total for 1985 deaths from the lack of food and Kwashiorkor. SOURCE: National Center for Health Statistics (1987) and unpublished data from the Division of Vital Statistics, National Center for Health Statistics (1988~. leading causes of death, 3 of which--heart disease, stroke, and cancer--account for more than 70% of all deaths in the United States (NCHS, 1987~. For some of these, solid nutrition-related factors have been identified (Consensus Conference Statement, 1985; U.S. Department of Health and Human Services, 1988; Levy et al., 1979~. We have begun to see impressive progress in their control, although it is far short of what ought to 119

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be possible. Some of the most intractable causes of death, like cancers and infant mortality associated with prematurity or low birthweight, have nutrition components that are less clear (DHHS, 1988; TOM, 1985; NRC, 1982~. Of course, some must be on the list not because of their size, but--as in the case of undernutrition--because of their nature, because of their very presence in our society. This list represents only a sampling of our health challenges. It does not include problems like acquired immune deficiency syndrome (AIDS), Alzheimer's disease, and arthritis, which are growing rapidly but have no clearly defined nutritional components, or nonfatal sources of disability with dietary elements, like osteoporosis. : ~ ~ the picture a generation or even a decade hence. If a new or newly recognized disease with nutritional correlates should break onto the scene, things could change dramatically. For the present, however, the list in Table 1 is reasonably reflective of how disease profiles contribute to the public health nutrition agenda. Nor as ants necessarily representative of Scientific Insights New scientific insights can change the role of nutrition in public policy. A good example is what is happening in the National Cholesterol Education Program (Cleeman, 1986; Lenfant, 1986, 1987), based on more than half a century of research about the relationship between blood lipids and cardiovascular disease. The future may hold much more as the nutritional sciences embrace the tools of molecular biology and genetics (A. Motulsky and R.W. Hanson et al., this volume). Some of these are discussed below. Table 2 illustrates the research areas identified as being of particular importance by the federal Interagency Committee on Human Nutrition Research. They include the following: Nutrient requirements throughout the life cycle, because of the importance of identifying how age-related metabolic changes have an impact on nutrient needs; 120

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TABLE 2 Interagency Committee on Human Nutrition Research Priorities Nutrient requirements throughout the life cycle Nutrient interactions and bioavailability Nutrition and chronic diseases Energy regulation, obesity, and other related eating disorders Nutrition surveillance and monitoring methodology Nutrition education techniques SOURCE: ICHNR (1986) e Nutrient interactions and bioavailability, in recognition of the integrative nature of human diets and the need to be cognizant of the broader systemic effects of secular trends related to fiber and supplement consumption Nutrition and chronic diseases, because of growing appreciation of the central importance of nutritional factors to chronic disease occurrence, but residual uncertainty as to the nature of the mechanisms; Energy regulation, obesity, and other related eating disorders, because of the disproportionate prevalence of obesity in the United States and its likely association with various health problems; 0 Nutrition surveillance and monitoring methodology. in recognition of the substantial deficiencies in the ability of the United States to reliably assess the population's nutritional status; and 121

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Nutrition education techniques, because of the fact that progress in nutrition is essentially dependent on motivating informed choices conducive to health prospects. Major breakthroughs, or even accumulation of a number of more subtle changes, in any of these areas, could have a substantial impact on public health nutrition policy. Technologies Closely related to and, indeed, derived from the world of new scientific insights is the dazzling array of technologies that present both instruments and challenges for public health nutrition. Table 3 lists several technologies that can be predicted to have a considerable influence on the future course of nutrition policy. TABLE 3 Nutrition-Related Technologies Gene characterization Genetic engineering Food and ingredient synthesis Food composition assays Body composition techniques Microicomputerized bioassays Automated personal diet profiles Automated analysis of food usage Gene Characterization. Mapping of the human genome has yielded the identification of the region of the DNA pathology responsible for sickle cell anemia, 122

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p-thalassemia, Tay Sachs disease, galactosemia, and more than 30 other inherited diseases (Stanbury et al., 1983~. Of the approximately 200 inborn errors of metabolism, almost one-third affect the digestion, absorption, transport, metabolism, or excretion of nutrients and therefore can be at least potentially responsive to diet therapy (Nestle, 1985~. Inborn variations in metabolism with a potentially much broader public health impact are also being characterized (Motulsky, 1987; this volume). Brown and Goldstein's work on familial hypercholesterolemia is a now classic example (Brown and Goldstein, 1984, 1986; Sudhof et al., 1985~. Genetic Engineering. As a logical outgrowth of gene characterization these insights can be applied in efforts to change the offending DNA structure. This may ultimately hold promise for correcting those inborn errors of metabolism mentioned above. But already the technique of engineering genetic change is being put to work in the development of new types of food products. Examples range from manipulation of sperm, ova, and embryos to produce genetically improved animals (Polge, 1985; Van Raden and Freeman, 1985~; to the use of gene transfer systems to develop herbicide-tolerant, insect-resistant, and viral disease-resistant plants (Goodman et al., 1987~; to development of new probes to identify contaminated food. Food and Ingredient Synthesis. As new technologies increase the possibility of modifying traditional foods and developing new foods, an accompanying set of unique problems of food safety, quality, and labeling has emerged (Miller and Stephenson, 1987~. For example, the U.S. Food and Drug Administration (FDA) is increasingly faced with new issues presented by new products like the protein-based fat substitute Simplesse (Anonymous, 1988) or a nonabsorbable, chemically synthesized sucrose polyester fat substitute that may have cholesterol-lowering properties (Glueck et al., 1983; Grundy et al., 1986), or by modified products like the higher oleic acid-, less saturated fatty acid-containing canola oil and the olive oil-enriched Sunola oil (Anonymous, 1987~. The food industry is currently pouring substantial sums of money into the development of new and reformulated food products--more than 7,000 products were projected for 1986 alone (Albrecht, 1986~--that are targeted to a public apparently 123

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fascinated by them. This shows that the old industry axiom, "You can't sell nutrition, n is no longer true. Food composition assays. Despite the fact that food composition analysis is the oldest of the food-related technologies, we still are relatively ignorant about the precise makeup of a sizable share of our food supply, particularly with respect to the various ways in which foods are prepared and served. A leap in our ability to conduct such assays could well have a considerable influence on the conduct of our public health programs. Body composition techniques. The ultimate physiologic effect of the nutrients we consume is a central issue in nutrition. New techniques to make such assessments, like total body electrical conductivity, neutron activation analysis, and magnetic resonance imaging (described in Lukaski, 1987), may help usher in important capabilities in this regard. Microcomputerized bioassays. A related technology with substantial potential to enhance our understanding of the physiologic effects of dietary patterns, as well as the individual variation in the nature of those effects, is the development of automated techniques with widespread applicability to the conduct of our national health and nutrition surveys. For example, the Centers for Disease Control has developed methods for the analysis of vitamins A and E and iron in serum using very small samples (DHHS and U.S. Department of Agriculture [USDA], 1987). Automated personal diet profiles. The cornerstone of the current approach to dietary guidelines is balance. The questions are "what constitutes balance" and "when are we accomplishing it?" Current methodologies for assessing personal diet profiles have considerable weaknesses, but with the increased availability of microcomputers and with advances in the quality of available software for assessing daily diets, we should anticipate an improvement on this dimension. The third National Health and Nutrition Examination survey (begun in 1988), for example, uses an automated 24-hour recall instrument for data collection. 124

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A vulnerable component in the National Nutrition Monitoring System is its inability to track food usage patterns reliably. We simply do not know how much of any given product produced by American agriculture or imported from abroad is actually consumed in any given year or over time (DHHS, manuscript in review). Knowing the form in which it is presented is yet another challenge altogether. Nonetheless, automation may well yield substantially enhanced capabilities for monitoring patterns for food usage. Automated analysis of food usage. Demographic Profile Public policy is generally more responsive to groups whose numbers are growing than those whose numbers are shrinking. Here the dominant theme is "older", as shown in Table 4. Over the course of the twentieth century, TABLE 4 U.S. Population Age Profile Age Group 1900 1980 2010 2040 Under 25 (%) 54.0 41.3 32.7 29.6 65 and over (~) 4.0 11.3 13.8 21.7 85 and over (~) 0.2 1.0 2.3 4.2 Median age (yr) 22.9 30.0 38.5 41.6 SOURCE: U.S. Bureau of the Census (1955, 1975, 1984, 1987~; U.S. Senate, Special Committee on Aging, et al., (1988~. the median age of the U.S. population increased by nearly 16 years, from 23 to 39, with a 1,200% increase in the share of people over age 85 and a 40% decrease in the 125

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share of people under age 25. Indeed, if a projection is made to the year 2040, the population over age 85 will have nearly doubled again relative to that in 2010 and will represent about 4.5% of the total U.S. population (U.S. Bureau of the Census, 1984~. The nutrition concerns of older people are going to move quickly up the public health agenda. Economics One cannot forget the role of economics as a major determinant of public policy. In fact, it is not uncommon for advocacy organizations to define policy simply as a six-letter word spelled "b-u-d-g-e-t." With the food sector accounting for about 10% of the domestic economy (U.S. Bureau of the Census, 1986), it is clear that food is big business. As shown in Table 5, the TABLE 5 Economics of Food, 1985 Expenditure $ (billions) . Sales of farm products USDA farm programs a USDA food programs Processed food industry Food and eating out Nutrition research 142.1 7.7 18.4 83.0 461.0 0.292 aDirect payments to farmers for farm-related activities. SOURCE: U.S. Bureau of the Census (1986) and ICHNR (1988~. 126

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United States spent, for example, 0461 billion for food (groceries) and eating out in 1985 (U.S. Bureau of the Census, 1986~. The processed food industry accounted for $83 billion of the national economy in 1985, farm product sales accounted for $142 billion, and farm and food program expenditures in the USDA alone accounted for over $26 billion. With amounts of this magnitude, economic forces will do much to shape the ways in which nutritional issues are presented in public health. Meal Source Patterns A very practical consideration for public health programs in nutrition is the places people eat. Both as a determinant of nutrient intake profiles and as a possible locus for education and intervention on those profiles, the ways in which meals are taken present special opportunities. These days the watchword for meal taking is "convenience." For example, in 1985 more than half (57%) of American households had microwave ovens (Hotelmen, 1986), which were being used to prepare a new generation of prepackaged meals. And increasingly, people are eating out or purchasing prepared food for consumption off the premises. This is reflected in eating place sales,* which make up two-thirds of total food service industry sales (National Restaurant Association, 1987) and which increased from $104.5 billion in 1984 to $128.6 billion in 1987--a 23% increase in just 3 years. Sales are forecast to reach $138.2 billion in 1988--another 7.5% increase (National Restaurant Association, 1987~. As Table 6 indicates, limited-menu restaurants, the so-called fast-food restaurants, continue to be one of the fastest growing segments of the industry, with forecasted sales of $60.4 billion in 1988. Children under age 18 and adults aged 25 to 34 are frequent patrons, accounting for half the share of takeout restaurant meals in 1987 (National Restaurant Association, 1987~. *Eating places include restaurants, lunchrooms, social caterers, commercial cafeterias, and limited-menu restaurants, as well as ice cream and frozen custard stands. 127

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TABLE 9 Cholesterol Awareness, in Percent Positive Response. - 1983 1986 Public 64 72 Physicians 39 64 aResponse to query on preventive effect of reducing high blood cholesterol. The percentage of the public and physicians responding that lowering of a high blood cholesterol level will have a large effect on coronary heart disease. In 1983, the total number surveyed was 4,007 members of the public and 1,610 physicians. In 1986, the total was 4,004 members of the public and 1,277 physicians. SOURCE: Schucker et al. (1987 a,b). Data from Cholesterol Awareness Survey. adults in their prime (DHHS, unpublished). In 1983, nearly twice as many of the general public as physicians believed in a salutary effect of reducing high blood cholesterol. By 1986, the gap had narrowed, but the public was still in the lead. Data on the nature of physician gains over that period indicate that 25% more physicians surveyed in 1986 believed that lowering high blood cholesterol would have a large effect on heart disease, 12% more believed that low-fat diets will affect blood cholesterol, and 36% more initiated diet therapy at the levels approximating the recommendations of a National Institutes of Health (NIH) Consensus Conference (Consensus Conference Statement, 1985) on the subject (Schucker et al., 1987a). So physician attitudes are changing, but they have a way to go. In sum, myriad factors are converging from various perspectives to affect the U.S. agenda for nutrition policy. In many cases, like those of technologic change, economics, and public demand, they are pressing hard for rapid changes. 132

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PUBLIC HEALTH NUTRITION INTERVENTIONS The kinds of interventions important for any public health activity, whether it be occupational health, AIDS control, or nutrition policy, include agenda setting , (identifying the priorities); public education and information (getting the word out to people); direct services delivery (making sure that people are provided with the tools to make the change); reimbursement policies (payments to health care providers with special capabilities to deliver the services); tax policies (to establish economic incentives for change); health protection regulation (using the regulatory system to safeguard the public against abuses); strengthening multisectoral capacities (enlisting participation at state and local levels as well as from other sectors); training health professionals (and keeping them current in new techniques); research; and finally, monitoring and surveillance. Various factors influence the activities in these intervention categories. Agenda Setting Certain issues, such as caloric balance and dietary fat, cholesterol, sodium, fiber, and calcium, have emerged prominently as a result of the interaction of several of the factors described earlier in this paper Attention is also beginning to be refocused on micronutrients and protein. In each case the closer scrutiny is producing a deeper appreciation of the physiologic and metabolic complexities. Inevitably, the resulting insights influence the agenda by requiring a stratification of the goals and guidelines beneath the population level to accommodate group and individual variations. It is important for the society, however, to ensure that no single factor, whether it be economics, technology, public demand, or a quest for some undefinable standard of scientific purity, be allowed to overwhelm the process of crafting the U.S. national nutrition policy agenda. c, O 133

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Public Education and Information Several things are clear about how information and education efforts are being affected. becoming more innovative. . . . ~. First, they are No longer are posters and pamphlets the only communication vehicle. They still have their place for health care professionals, but Madison Avenue and the news media are the first to capture the public's attention--they have become the front lines of the new public health. Second, and relatedly. many more sectors are involved in the ~ , educational process. professionals are finding new opportunities (and challenges) not just through the media but with employers, teachers, public personalities, and of course the food industry. Third, as the impact of both science and demographics is felt, greater and more specific attention will be directed to subgroups in the population (e.g., the elderly, pregnant women, and minorities). Health care and nutrition Direct Services Delivery At a minimum, each of these factors will compel more attention to the kind of food that is provided to people in public programs like congregate and home-delivered meals for the elderly, supplemental food and food vouchers for the poor, and school cafeterias. The commercial sector also plays a role, however. The major services are financed by people themselves in supermarkets, employee cafeterias, restaurants, and fast-food restaurants, and internal and external pressure is building for a greater involvement of these commercial providers in the promotion of nutrition principles. Public demand provides the greatest impetus, but guidance from the nutrition community is needed. Reimbursement Policies Reimbursement for a service through an insurance mechanism, whether public or private, can be a major stimulus to any public health intervention. Except for isolated examples related to therapeutic interventions in cases like diabetes, cardiac rehabilitation, and end-stage renal disease, nutrition services are largely uncovered. One of the reasons for this is that 134

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reimbursement policies largely focus on physicians, and in a procedure-oriented payment system like the one in the United States, physicians have shown no great interest in providing nutrition services. This may change (for some of the wrong reasons) with the advent of the technologies discussed earlier: body composition techniques, microcomputer bioassays, and automated dietary profiles. Regardless of whether it is driven by technology, the science base, or public demand, it is not unreasonable to expect some sort of nutrition services ultimately to be provided as part of a reimbursable preventive services package. Tax Policies Taxes can be used in a variety of ways to provide incentives to public objectives. Whether to encourage implementation by industry of safety procedures, to encourage development of employee health promotion programs, or to discourage consumption of tobacco, tax policies have proven to be potentially powerful influences. Currently, the applications of taxation to nutrition are largely limited to the provision of incentives for nutrition services at work sites, although some other Western countries have begun experimenting with the use of preferential excise taxes as a means of influencing choices of more healthful food products. Health Protection Regulation Some of the greatest challenges in the field of public health are now in the regulatory arena and will remain there in the future. Issues related to how products are graded and labeled, to the safety and efficacy of new food products, to ways of assessing risk, to whether health claims are allowed in the entrepreneurial efforts to reach the hard-to-reach populations are all critical questions whose complexities are-growing on a daily basis. Strengthening Multisectoral Capacities When contemplating interventions to change individual behavior, it is clear that federalization of the effort 135

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is neither effective nor appropriate. Leadership and support for these efforts must derive from a point as close as possible to that at which the individual can make his or her own personal decision. A major public health challenge will therefore be the need to strengthen the capacities of other sectors--state and local, business and labor, and education and media--to carry forward these efforts. Implications and actions in training health professionals, research, and monitoring and surveillance should be obvious. As intervention approaches become more sophisticated, the training of health professionals in their use will be important. And research and monitoring are fundamental to charting, tracking, and refining the course of progress. FUTURE DEVELOPMENTS IN NUTRITION AND HEALTH Predicting the future is always hazardous in any event, because we tend to view it through essentially linear lenses, yet it inevitably unfolds exponentially to our great confusion. This review has touched some of the major elements of future developments. It is helpful, however, to focus on a few that suggest what we might be facing in the year 2000. We can take as an example what might be in store in the categories of the ICHNR research priorities given in Table 3. Instead of general patterns of nutrient requirements throughout the life cycle, we should focus more definitively on individual variations in those requirements. Instead of undertaking assays of nutrient interactions and bioavailability, we will be titrating ways to use those phenomena to affect disease outcomes Our understanding of the relationships between nutrition and chronic diseases will begin to allow us to move more confidently in using diet as an intervention tool against those diseases, from approaches that are now oligodimensional in character to those of a more - polydimensional nature--in effect, to begin to deploy a kind of matrix management to the use of dietary tools in chronic disease control. 136

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~ Our progress in this respect should be enhanced by a deeper understanding of the relationships between patterns of inheritance and patterns of behavior in predisposing individuals to disease outcomes. We should anticipate a time when nutrition education will not derive just from global homilies but rather from sophisticated and dynamic automated analyses of predispositions and preferences. The results of these advances in the research base will have major implications for the kinds of objectives we will be setting in the twenty-first century. It is possible that after the year 2000 we will develop targets not for aggregate serum cholesterol levels but for some more precise index, perhaps a target ratio of nutrient intake: cellular receptor sites. It is possible that rather than deal crudely with the balance between caloric intake and exercise levels, we will target individual metabolic setpoints. It is even conceivable-that we will target dietary accomplishment of central nervous system levels of certain neural peptides as measured by some over-the-counter metabolic probe. In the agricultural sciences, presumably we will be able to target even more powerfully the use of genetic engineering to enhance changes in crops and livestock. In some version, all these are at least imaginable. And the present offers our About 1,400 people die each Some are already unfolding. most compelling challenges. day as a result of coronary heart disease; death rates from heart disease among blacks are about one-third higher than those among whites, and death rates from stroke are nearly double those among whites (NCHS, 1987~; and twice as many black babies as white babies die (NCHS, 1987~. While we do not have all the answers to these problems, we do have some answers and important hints about others. Nutrition plays a role, and it is possibly quite a large role. It may be that the biggest gap we face today is not a knowledge gap but an application gap, at 137

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least application in an equitable fashion, for all members of society. The dictum primum non nocere, first do no hare, applies to inaction as well as to action. If W. Henry Sebrell were asked today to comment on the state of nutrition sciences, he might marvel at the scientific accomplishments but be more than a little chagrined at the sluggishness--relative to the potential--of society's ability to capture the clues available 35 years ago. He might suggest that as we ponder these new dimensions for nutrition and public health, we not ponder too long before we act. ACKNOWLEDGMENTS The author gives special thanks to Linda D. Meyers and Mary Jo Deering for their assistance in the preparation and editing of this paper. REFERENCES Adelman, S. 1986. Restaurant traffic, sales withstand popularity of microwaves, VCRs. Restaurants USA, September:38-41. Albrecht, J.J. 1986. Business and technology issues in U.S. food science and technology. Food Technol. 40:122-127. Anonymous. 1987. New products and packages: Enriched with 5% extra olive oil. Food Proc. 48~1~:164. Anonymous. 1988. NutraSweet announces protein-based fat substitute. Food Chem. News 29~48~:48-52. Brown, S., and J.L. Goldstein. 1984. How LDL receptors influence cholesterol and atherosclerosis. Sci. Am. 251~5~:58-66. Brown, S., and J.L. Goldstein. 1986. A receptor mediated pathway for cholesterol homeostasis. Science 232:34-47. Cleeman, J.I. 1986. The new National Cholesterol Education Program. Md. Med. J. 35:339-341. Consensus Conference Statement. 1985. Lowering blood cholesterol to prevent heart disease. J. Am. Med. Assoc. 253:2080-2086. 138

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