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3 Rationale for Including Nutrition Instruction in Medical Education During the last 20 years, an enormous body of scientif- ic data has emerged linking diet and food selection pat- terns to the maintenance of health and the prevention of some chronic diseases. Evidence supporting this associa- tion, its individual and public health implications, and the scientific rationale for requiring medical students to learn basic nutrition principles and their application to patient care is presented in the following discussion. It is not the purpose of this chapter to summarize or evaluate all data associating nutrition with the major causes of morbidity and mortality in the United States. Rather, the committee has selected some examples and discussed them in light of their relationship to pre- ventive and therapeutic medical care. Major developments in medical research and technology in recent decades have led to the conquest of many diseases with nutritional or infectious origin. For ex- ample, the isolation and identification of many essential nutrients and the elucidation of their roles, together with the enrichment and fortification of selected foods and the availability of nutrient supplements, have result- ed in the virtual elimination of vitamin and mineral deficiency disease in the United States. In addition, as general sanitation conditions improved and the use of antibiotics and other drugs became more widespread, con- cern about infectious diseases has diminished. As a result of these developments and new data linking environ- mental factors and lifestyle to health and illness, medi- cal attention is shifting to the prevention and treatment of chronic and degenerative diseases, most of which have a 29

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30 complex etiology. Diet is not only a factor in the etiology of these diseases but also is important in their treatment. Nutritional factors are implicated in the etiology of 6 of the 10 leading causes of death in the United States: heart disease, cerebrovascular disease, cancer, adult- onset (type II) diabetes, arteriosclerosis, and alcohol- i-nduced cirrhosis (DREW, 1979; DHHS, 1983~. The role of diet in both the prevention and treatment of many condi- tions, such as obesity, osteoporosis, gastrointestinal disorders, low birth weight, dental caries, iron- deficiency anemia, and certain vitamin and mineral deficiencies, is clearly documented (DREW, 1979; DHHS, 1983~. Advances in basic nutrition knowledge and medical technology have also dramatically affected health care in the United States. The development of nutritionally sound intervention techniques, such as parenteral and enteral nutrition, have prompted new approaches to the management of patients with a variety of needs, ranging from pre- mature infants to patients undergoing surgery and those suffering from burns, trauma, infection, metabolic disorders, or certain forms of cancer (Fischer, 1975; Wilmore _ al., 1977~. Nutrition and its association with health have attracted much attention in the news media. For example, newspapers, such as The New York Times, The Washington Post, and he Wall Street Journal, regularly carry columns and lead articles concerning diet and nutrition as do Time, Newsweek and The U.S. News and World Report. Many popular magazines, such as Ladies Home Journal, Good Housekeeping, and Runner's World, also feature articles on nutrition, and a vast assortment of nutrition-related books has been published. Clearly, the U.S. public is concerned about nutrition, and many Americans are better informed than in the past on matters of diet and health. There are growing expectations that physicians should be able to provide accurate, current nutrition information and guidance. Ample evidence, some of it presented below, supports the association of nutrition with disease prevention' health maintenance, acute care delivery, and other aspects of medical Practice. Therefore, if the

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31 objectives of medical education are to prepare future physicians to deliver health care effectively and to keep pace with the changing needs of their patients and new scientific discoveries, then nutrition must be considered a part of the formal training of all medical students. EVIDENCE ASSOCIATING NUTRITION WITH DISEASE PREVENTION AND HEALTH PROMOTION AND MAINTENANCE - Cardiovascular Disease The presence of a nutritional component in the etiology of some diseases points to the need for adequate nutri- tional knowledge among physicians. The most striking ex- ample is cardiovascular disease, currently the leading cause of death in the U.S. adult population, as it has been for more than 40 years (DHHS, 1984a,b). ly 43 million Americans are affected by one _ - _ of heart, blood vessel, or cerebrovascular disease, in- cluding hypertension, coronary heart disease, and stroke (AMA, 1984) . It is pro jected that as many as 1.5 million Americans will have a heart attack in 1985, and more than 0.5 million of them will die during this year (DHHS, 1984a). The social and economic consequences of cardio- v~.~rul~r disease are equally immense. Approximate nr mc~re ~ orms - The American Heart ~ , ~ Association (AMA) estimated that the cost of cardio- vascular disorders exceeds $7 2 billion annually: $59 billion in direct health expenditures and $13 billion in productivity lost through illness and disability (AMA, 1985). These staggering economic and social consequences still exist despite the steady decline in death rates due to coronary heart disease in the United States since the late 1960s (NHLBI, 1981a; Stamler, 198 5b; Walker, 1983~. This decline has been attributed, in part, to improvements in lifestyle and related risk factors, including changes in diet (Pell and Fayerweather, 1985; Stamler, 1985a,b). Surveys show that by the late 1970s, two-thirds of Ameri- cans had changed their eating patterns because of health concerns (Jones, 1977; NHLBI, 1981b; Stamler, 1983~. Correspondingly, since the early 1960s there has been a reduction in the per capita consumption of foods high in cholesterol and saturated fat--beef, fat-containing dairy

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32 products, eggs, and lard--and an increase in the consump- tion of fish and vegetable fats and oils (Welsh and Marston, 1982~. Among those risk factors strongly associated with coronary heart disease, high blood cholesterol is one of the most clearly established. The National Institutes of Health (NIH) Consensus Development Conference on Lowering Blood Cholesterol to Prevent Heart Disease concluded that the blood cholesterol level of most Americans is undesir- ably high (NHLBI, 1985~. The conferees agreed that these Leigh levels are due, in large part, to Americans' still higher-than-recommended dietary intake of saturated fat and cholesterol and that appropriate dietary changes would reduce blood cholesterol level in many persons. The AHA Committee on Nutrition has issued similar guidelines (AMA, 1982~. Prevention, including nutritional counselling by informed primary care physicians, will be a critical com- ponent to the success of the national effort to reduce the incidence of cardiovascular disease (Harlan and Stross, 1985; Rahimtoola, 1985~. High blood pressure affects approximately 38 million adults in the United States. Many of these people are aware of their conditions but do not receive treatment or their blood pressure is inadequately controlled (AMA, 1985~. Lifestyle factors, especially diet, have been cited as some of the many contributors to the continued prevalence of high blood pressure in the United States (Harlan et al., 1983; Levy and Moskowitz, 1982~. For example, obesity, dietary sodium, and alcohol have been associated with hypertension in some individuals, and there is evidence that other dietary factors, including potassium, calcium, magnesium, chloride, and perhaps even carbohydrates, may affect blood pressure regulation in some susceptible persons (Harlan et al., ~q96. MrC~rron and Kotchen, 1983; McCarron et al., 1984~. _, ~ A, ~ Public response to education programs designed to lower high blood pressure and to ensure the maintenance of normal levels has been striking, according to the Hypertension Detection and Follow-up Program Cooperative Group (1982) and the Veterans Administration Cooperative Study Group on Antihypertensive Agents (1967~. A stronger emphasis on preventive care during medical education Donald assist students in developing the skills and attitudes for effective intervention.

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33 Malnutrition Malnutrition is one of the leading factors in the disability and death of children in developing nations. The World Bank (Alderman, 1980) and the Food and Agricul- ture Organization (FAO, 1981) of the United Nations esti- mate that as many as 800 million persons may suffer from caloric deficiency and that at least 450 million are children. Malnutrition is frequently not mentioned on death certificates as the cause of death. Consequently, mortality due to malnutrition among infants and young children is often underestimated (WHO, 1981~. Malnutrition is not confined to developing countries. Recent data from studies in the United States (DHES, 1983) indicate that from 10% to 15% of the infants and children of migratory workers and some poor rural populations suf- fer growth retardation because of dietary inadequacies. In addition, iron and folic acid deficiencies are common among pregnant and lactating women in the United States (DHHS, 1983~. Malnutrition can lead to illness or death, but more commonly results in generalized functional impairment. In children living under conditions of poverty and depriva- tion, malnutrition retards growth and contributes to poor motor and intellectual development (Winick' 1976~. In adults, it reduces performance in the workplace. Results of animal studies and clinical data indicate that some specific nutritional deficiencies as well as general mal- nutrition may alter immune function' thereby affecting response to infection and disease in both children and adults (Beach _ al., 1982; Gershwin et al., 1985;_ _ Suskind' 1977~. Public health professionals must diagnose nutritional problems at the community and national levels as well as internationally. Medical students in the United States need to be aware of the magnitude and severity of mal- nutrition and associated health problems and of their social consequences both in the United States and through- out the world. Only with this awareness can appropriate public health programs and other intervention strategies be planned.

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34 Several investigators have reported severe malnutrition among hospitalized patients in the United States (Bistrian _ al., 1976; Ballet and Owens, 1983; Butterworth, 1974; Parsons _ al., 1980; Thompson et al., 19841. Mullen and_ _ coworkers (1979, 1980) reported that the lower the nutri- tional status of hospitalized patients, the worse the prognosis for recovery from the primary disease. There is evidence that a patient's nutritional status may influence the outcome of cancer therapy (Donaldson and Lenon, 1979~. Obesit_ Obesity (overnutritiGn) is the most prevalent form of malnutrition in the United States. The National Center for Health Statistics reported that Americans on the aver- age weigh more now than they did 10 years ago (Abraham et al., 1983, and in press). Thirty-two percent of the men and 63% of the women in this country are 10% or more above "ideal weight," and 18% of the men and 24% of the women weigh 20% or more (Abraham et al., 1983~. Obesity is associated with elevated blood pressure, blood lipid levels, and blood glucose (Garrison et al., 1980; Kannel et al.. 1979: Nooca et al.. 1978). Castelli (1984) reported that weight is a powerful predictor of virtually all cardiovascular end points in men and women. Obesity is a risk factor for, or is associated in some way with, diabetes, complications of pregnancy, osteoarthritis, some cancers and infections, and impaired psychosocial function (Stewart and Brook, 1983~. Although the definition of ideal weight is controver- sial (Knapp, 1983), and appropriate body weight standards and methods of measurement continue to prompt debate (Abraham et al., 1983; Simopoulos and Van Itallie. 1984), there is general consensus among researchers that mortal- ity increases with increasing amounts of excess weight (Hubert et al., 1983; Lew and Garfinkel, 1979; McCue, 1981; Society of Actuaries and Association of Life Insur- ance Medical Directors of America, 1980; Vandenbroucke et al., 1984~. Severely overweight persons, especially those who are overweight at younger ages, have markedly higher mortality rates than do people of average weight (Drenick _al., 1980~. If physicians are to assume a more active role in caring for overweight persons 3 assisting patients in

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35 weight reduction, or encouraging them to maintain a weight that is closer to ideal, they will require the appropriate knowledge, skill, and attitude. Cancer The role of nutrition in the etiology and the preven- tion of some cancers is becoming more apparent. For example, several cancers, especially cancer of the breast and colon, have been associated with a high fat diet (NRC, 1982), and interim dietary guidelines to lower cancer risk have been proposed (ACS, 1984; NCI, 1984; NRC, 1982~. Nu- tritional rehabilitation and support are integral parts of the treatment regimen for cancer patients (van Eys et al. , 1979; Wollard, 1979~. The metabolic stress of cancer, interactions between nutrients and drugs, and the host- tumor relationship are subjects of active research. It is important that medical education emphasize the relevance of nutrition principles to cancer prevention and treatment and that students are prepared to assess new findings regarding the relationships between diet, nutrition, and cancer and their implications for patient care. Osteoporosis Osteoporosis is a major cause of bone fractures in postmenopausal women and the cause of significant morbid- ity among elderly persons (Avioli, 1984~. Inadequate cal- cium, vitamin D, estrogens, and fluoride are among the many factors that have been implicated in the etiology of this disease (Armbrecht, 1984; Avioli, 1984~. Studies are under way (DHHS, 1984c,d) to examine the influence of nu- tritional factors on calcium absorption and excretion, the metabolic factors contributing to alterations in bone structure and Practical means for preventing and treat ins osteoporosis. Because osteoporosis affects the elderly and because the median age of the U.S. population continues to increase (Inane and Kane, 1980), new research findings and their applications to the clinical management of this disease are becoming increasingly important. NUTRITIONAL NEEDS OF SELECTED POPULATION SUBGROUPS AND THE GENERAL PUBLIC Both physicians and patients need to be aware of how nutritional needs change throughout the life cycle and the

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36 consequences of poor nutrition during infancy, childhood, adolescence, adulthood (including pregnancy, lactation, and menopause), and old age. The following paragraphs contain discussions of some specific needs of certain populations at different life stages and the integral role of nutrition in primary care medicine and various medical specialties. Nutrition and the Outcome of Pregnancy Managing normal and high-risk pregnancies to ensure optimal fetal growth and development and neonatal health requires close attention to nutrition by both mother and physician. Physicians now widely accept the importance of adequate weight gain and maintenance of optimal nutri tional status (i.e., intake of adequate amounts of both micro- and macronutrients) during pregnancy (Hurley, 1980). For a woman who begins her pregnancy at normal weight, the optimum weight gain is at least 12 kg. An underweight woman should gain even more (Rosso, 1985~. Evidence from laboratory studies in rats suggests that poor weight gain is associated with inadequate expansion of maternal blood volume, which in turn reduces the expected increase in cardiac output and blood flow to the uterus and placenta (Rosso and lava' 1980~. Thus, poor nutritional status before pregnancy and inadequate weight gain and nutrient intake during gestation may negatively affect fetal weight gain, thereby increasing the risk of low birth weight and neonatal mortality (Dobbing, 1981; NRC' 1970; Worthington _ al. 1977~. The United States ranks 18th among nations for infant mortality, a major cause of which is low birth weight. The U.S. Public Health Service has specified that proper nutrition should be encouraged as one of the strategies to prevent the occurrence of low birth weight infants (Brandt, 1984~. Obesity during pregnancy poses other nutritional and medical concerns. For example, the efficacy of recommend ing low calorie diets to this group of women is seriously questioned. There is evidence suggesting that very low- calorie diets consumed during pregnancy may induce changes in metabolism that may result in undesirable sequels in the fetus, including low birth weight (Rosso' 1985~. 1 _

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37 The management of normal pregnancies to promote optimal fetal growth also requires a knowledge of nutrition and the ability to prescribe a diet that supplies adequate amounts of all essential nutrients while restricting in- take of deleterious substances. Among the dietary con- stituents that may adversely affect the fetus are alcohol (Marbury et al., 1983; Mills et al., 1984) and caffeine (Nightingale and Flamm, 1983~. Infancy and Childhood The importance of nutrition in the health care of infants and children is widely recognized. Adequate nu- tritional intake is a fundamental requirement for optimal growth and development, and there is concern that child- hood obesity may be a precursor of such adult diseases as arteriosclerosis and hypertension. Competent counselling regarding the merits of breast-feeding, the selection of appropriate formulas, proper timing for introducing solid food, and the need for vitamin-mineral supplementation are all areas in which the pediatrician can provide profes- sional support. In addition, the pediatrician should be able to guide parents in the selection of diets adequate in energy, protein, iron, and other essential nutrients to promote optimal growth throughout infancy and childhood. Increasing numbers of children with genetic disorders and other disabilities are now kept alive and often re- quire complex nutritional care. The consequences of various inborn errors, such as disorders of amino acid, carbohydrate, or lipid metabolism, can be moderated by dietary intervention (Palmer and Zeman, 1983~. The role that the pediatrician can play in providing early diag- nosis and treatment can be exceedingly important to the survival and well-being of these children. Nutrition and the Elderlv J The growing number of elderly persons in the United States (Kane and Kane, 1980), especially those who are institutionalized, are at high risk for certain nutri- tional deficiencies (Prendergast, 1984~. Several physio- logical factors may affect the nutritional status of the elderly, for example, poor dental health, diminished sen- sitivity to taste and smell, increased need for some nutrients, high nutrient losses or malabsorption related to changes in gastrointestinal function, or moderately

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38 reduced efficiency of digestion (Armbrecht et al., 1984; Roe, 1983~. Such complicating circumstances as isolation, bereavement, physical disabilities, and inappropriate diets contribute to inadequate nutrient intake (Coe and Miller, 1984~. Primary care physicians and specialists who are responsible for medical care of the aged must therefore be aware of their unique health problems and nutritional needs. Selected Nutritional Concerns of the General Public . _ . Many people are modifying their lifestyle by, for example, increasing their activity, altering their diets, and in general, accepting greater responsibility for their own well-being (Jones and Weimer, 1981; Louis Harris and Associates Inc., 1979; Stamler, 1978~. For example, the relationsip of diet and exercise to the maintenance of health has become a concern of many persons. Although there is limited evidence that certain diets optimize ath- letic performance, other evidence indicates that proper exercise combined with dietary modification may improve cardiovascular fitness, induce weight loss, and reduce the risk of osteoporosis (Zohman et al., 1979~. Thus, exer- cise combined with dietary modification is rapidly becom- ing a major tool in both preventive and therapeutic medicine. Some segments of the general population are adopting such nontraditional dietary patterns as vegetarianism. Although some vegetarian diets may be consistent with good health, others, if not supplemented, may increase the risk of specific nutritional deficiencies (Goldsmith, 1983; Herbert, 1983~. Still other self-restricted diets, such as many of the popularly promoted weight reduction diets (Dwyer, 1980), are often nutritionally inadequate and should be supplemented or revised. Many physicians may not have sufficient experience or training in the area of nutrition to guide patients appropriately in the selec- tion of foods that may ensure their nutritional well-being (Cooper-Stephenson and Theologides, 1981; Krause and Fox, 1977; Modrow et al., 1980)e Physicians as well as patients may be susceptible to the many inaccurate and sometimes dangerous claims and inducements offered by the rapidly expanding food supplement industry. Advertisements do not warn

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39 consumers about potential toxic effects from excessive intake of micronutrients at more than 100% of the RDAs (NRC 9 1980). Food supplement industry sales were reported to be $1.7 billion for 1981, with an estimated annual growth between 11% and 15% (Alter, 1981; Raven' 1981~. The sales of so- called natural vitamins grew by 20% in 1980, new vitamin formulations continue to appear' and promotion of the products continues to be vigorous (Raven, 1981~. The data accumulated thus far, although not complete, suggest that approximately 40% to 50% of the adult U.S. population daily ingests some kind of micronutrient supplement (Stewart et al.' n.d.~. Physicians must be aware of potentially deleterious effects and long-term consequences of oversupplementation so that they can guide their patients accordingly. NUTRITION AND ACUTE CARE Nutrition has been implicated as a causative factor in many diseases but may also be efficacious in treatment. Following are a few examples of the many ways diet can be used as a management tool. Diabetes Nutrition may be involved in the etiology of diabetes, and, certainly' knowledge of nutrition is necessary for its management. In some type II diabetics, weight loss may be the only necessary treatment (Turner and Thomas, 1981~. A low-fat' high complex carbohydrate diet providing frequent meals and controlled intake of refined sugar helps to stabilize the level of blood sugar' mini- mize the danger of cardiovascular complications, and is a fundamental part of the treatment of diabetes (Bierman, 1985; Zeman and Hansen, 1983~. Gastrointestinal Disorders - Dietary fiber may play a role in both preventing and managing gastrointestinal disorders (Inglett and Falkehag, 1979~. Data indicate that dietary fiber protects the intestinal tract against potential carcinogens, influences bacterial metabolism' and affects the absorption rates of several nutrients, including glucose (Anderson' 1985;

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46 DHHS (U.S. Department of Health and Human Services). 1984a. Advance Report of Final Mortality Statistics, 1981. Monthly Vital Statistics Report 33~3) Suppl., National Center for Health Statistics, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 198 4b. Anne Summary of Births, Deaths, Marriages, and Divorces: United States, 1983. Monthly Vital Statistics Report 32~13), National Center for Health Statistics, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 1984c. Osteoporosis. Pp. 1-6 in National Institutes of Health Consensus Development Conference Statement, Vol. 5. National Institutes of Health, Public Health Service, U.S. Department of Health and Human Services, Washington, D e C ~ DHHS (U.S. Department of Health and Human Services). 1984d. Program in Biomedical and Behavioral Nutrition Research and Training Fiscal Year 1983. Annual Report of the National Institutes of Health. NIH Publ. No. 84-2633. Prepared by NIH Nutrition Coordinating Commit- tee, National Institutes of Health, Public Health Ser- vice, U.S. Department of Health and Human Services, Washington, D.C. Dobbing, J., ed. 1981. Maternal Nutrition in Pregnancy-- Eating for Two? Based on a workshop sponsored by Nestle Nutrition, held at the Chateau de Rochegude, Vaucluse, France, June 1-4, 1980. Academic Press, New York. Donaldson, S. S., and R. A. Lenon. 1979. Alterations of nutritional status: Impact of chemotherapy and radia- tion therapy. Cancer 43:2036-2052. Drenick, E. J., G. S. Bale, I. Seltzer, and D. G. Johnson. 1980. Excessive mortality and causes of death in morbidly obese men. J. Am. Med. Assoc. 243:443-445. Dwyer, J. 1980. Sixteen popular diets: Brief nutritional analyses. Pp. 276-291 in A. J. Stunkard, ed. Obesity. W. B. Saunders, Philadelphia , .

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47 FAO (Food and Agriculture Organization). 1981. Agricul- ture Towards 2000. Food and Agriculture Organization, Rome. Fischer, J. F., ed. 1976. Total Parenteral Nutrition. Little, Brown, Boston, Massachusetts. Garrison, R. J., P. W. Wilson, W. P. Castelli, M. Feinleib, W. B. Kannel, and P. M. McNamara. 1980. Obesity and lipoprotein cholesterol in the Framingham offspring study. Metabolism 29:1053-1060. Gershwin, M. E., R. S. Beach, and L. S. Hurley. 1985. Nutrition and Immunity. Academic Press, New York. Goldsmith, G. A. 1983. Curative nutrition--vitamins. Pp. 160-183 in H. A. Schneider, C. E. Anderson, and D. B. Coursin, eds. Nutritional Support of Medical Practice, 2nd ed. Harper & Row, Philadelphia. &ryboski, J., C. Hillemeier, S. Kocoshis, W. Anyan, and J. S. Seashore. 1980. Refeeding pancreatitis in mal- nourished children. J. Pediatr. 97:441-443. Hallberg, L. 1984. Iron. Pp. 459-478 in Present Knowledge in Nutrition, 5th ed. Part VI. Microminerals. Nutrition Foundation, Washington, D.~. Halmi, K. A., J. R. Falk, and E. Schwartz. 1981. Binge- eating and vomiting: A survey of a college population. Psycholog . Med. 11: 697-7 06 . Harlan, W. R., and J. K. Stross. 1985. An educational view of a national initiative to lower plasma lipid levels. J. Am. Med. Assoc . 253: 2087-2090 . Harlan, W. R., A. L. Hull, R. P. Schmouder, F. E. Thompson, F. A. Larkin, and J. R. Landis. 1983. Dietary Intake and Cardiovascular Risk Factors, Part I. Blood Pressure Correlates: United States, 1971-75. Vital and Heal th Statistics Series, 11. Data from the National Health Survey, Series 11, [lo. 226. DHHS Publ. No. (PHS) 83- 1676. National Center for Health Statistics, Public Health Service, U.S. Department of Health and Human Services, Hyattsville, Maryland.

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48 Harlan, W. R., A. L. Hull, R. L. Schmouder, J. R. Landis, F. E. Thompson, and F. A. Larkin. 1984. Blood pressure and nutrition in adults: The National Health and Nutri- tion Examination Survey. Am. J. Epidemiol. 120:17-28. Harris, R. T. 1983. Bulimarexia and related serious eating disorders with medical complications. Ann. Int. Med. 99:800-807. Hathcock, J. N., and J. Coon, eds. 1978. Nutrition and Drug Interactions. Academic Press, New York. Herbert, V. 1983. Hematology and the anemias. Pp. 386-409 in H. A. Schneider, C. E. Anderson, and D. B. Coursin, eds. Nutritional Support of Medical Practice, 2nd ed. Harper & Row, Philadelphia. Heymsfield, S. B., R. A. Bethel, J. D. Ansley, D. M. Gibbs, J. M. Felner, and D. O. Nutter. 1978. Cardiac ab- normalities in cachetic patients before and during nutritional repletion. Am. Heart J. 95:584-594. Hubert, H. B., M. Feinleib, P. M. McNamara, and W. P. Castelli. 1983. Obesity as an independent risk factor for cardiovascular disease: A 26-year follow-up of participants in the Framingham Heart Study. Circulation 67:968-977. Hurley, L. S. 1980. Developmental Nutrition. Prentice- Hall, Englewood Cliffs, New Jersey. Hypertension Detection and Follow-up Program Cooperative Group. 1982. The effect of treatment on mortality in "mild" hypertension: Results of the hypertension detection and follow-up program. N. Engl. J. Med. 307:976-980. Inglett, G. E., and S. I. Falkehag, eds. 1979. Dietary fibers: Chemistry and Nutrition. Academic Press, New York. Jones, J. L. 1977. Are Health Concerns Changing the American Diet? NFS-159. National Economics Division Economic Research Service, U.S. Department of Agriculture, Washington, D.C.

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49 Jones, J. L., and J. Weiner. 1981. Health-related food choices. Pp. 16-19 in Family Economics Reviews, Summer 1981. Agricultural Research Service, U.S. Department of Agriculture, Washington, D.C. Kane, R. L., and R. A. Kane. 1980. Long term care: Can our society meet the needs of its elderly. Ann. Rev. Publ. Health 1:227-253. Panel, W. B., T. Gordon, and W. P. Castelli. 1979. Obesity, lipids, and glucose intolerance. The Framingham Study. Am. J. Clin. Nutr. 32:1238-1245. Knapp, T. R. 1983. A methodological critique of the ' ideal weight ' concept. J. Am. Med. Assoc . 250:506-510. Krause, T. O. , and H. M. Fox. 1977. Nutritional knowledge and attitudes of physicians. J. Am. Diet. Assoc. 70:607-609. Kritchevsky, D. 1981. Dietary fiber and disease. Pp. 35-51 in L. Ellenbogen, ed. Controversies in Nutrition. Contemporary Issues in Clinical Nutrition, Volume 2. Churchill Livingstone, New York. Levy, R. I., and J. Moskowitz. 1982. Cardiovascular research: Decades of progress, a decade of promise. Science 217:121-129. Lew, E. A., and L. Garfinkel. 1979. Variations in mortality by weight among 750,000 men and women. Chron. Dis. 32:563-576. J. Louis Harris and Associates, Inc. Study: Fitness in America. Great Waters of France, Inc., New York. 1979. The Perrier Marbury, M. C., S. Linn, R. Monson, S. Schoenbaum, A. G. Stubblef ield, and K. J. Ryan. 1983. The association of alcohol consumption with outcome of pregnancy. Am. J. Publ. Health 73:1165-1168. McCarron, D. A., and T. A. Kotchen, eds. 1983. Nutrition and blood pressure control: Current status of dietary factors and hypertension. A symposium held September 13-15, 1982, Arlington, Virginia. Ann. Intern. Med. 98 697-890 e

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50 McCarron, D. A., C. D. Morris' H. J. Henry, and J. L. Stantob. 1984. Blood pressure and nutrient intake in the United States. Science 224:1392-1398. McCue, H., Jr. 1981. The 1969 Build and Blood Pressure Study. Pp. 182-198 in H. Bostrom and N. L jungstedt' eds. Medical Aspects of Mortality Statistics. Proceed- ings of the Thirteenth Skandia International Symposium held September 23-25, 1980, Stockholm. Almquist & Wiksell, Stockholm, Sweden. Mills' J. L.' B. I. Graubard, E. E. Harley' G. S. Rhoads, and H. W. Berendes. 1984. Maternal alcohol consumption and birth weight: How much drinking during pregnancy is safe? J. An. Med. Assoc. 252:1875-1879. Mitchell, J. E., R. L. Pyle, and R. A. Miner. 1982. Gastric dilatation as a complication of bulimia. Psychosomatics 23:96-97. Modrow,, C. L., C. W. Miles, S. Koerin, J. Dobek, P. Book, and L. Honaker. 1980. Survey of physician and patient nutrition education needs. J. Am. Diet. Assoc. 77:686-688. Mullen, J. L., M. H. Gertner, G. P. Buzby, G. L. Goodhart, and E. F. Rosato. 1979. Implications of malnutrition in the surgical patient. Paper presented at the 2nd Annual Meeting of the Association of Veterans Adminis- tration Surgeons, St. Louis,, May 1, 1978. Arch. Surg. 114:121-125. Mullen, J. L., G. P. Buzby, D. C. Matthews, B. F. Smale, and E. F. Rosato. 1980. Reduction of operative morbid- ity and mortality by combined preoperative and post- operative nutritional support. Ann. Surg. 192:604-613. NCI (National Cancer Institute). 1984. Cancer Prevention. Public Health Service' National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland. .

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