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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~.
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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
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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
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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;
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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
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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,
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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
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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.
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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
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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~.
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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.
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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.
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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
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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
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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
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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.
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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
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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.
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142
Representative terms from entire chapter:
blood cholesterol
