UNIVERSITY OF CALIFORNIA
COOPERATIVE EXTENSION

NUTRITION PERSPECTIVES

Volume 27, No. 4
July/Aug 2002

TABLE OF CONTENTS

Understanding Human Studies
NIH Funds Botanical Center in Iowa to Study Health: Effects of Echinacea and St. John’s Wort
Functional Foods: Service or Disservice?
Flaxseed Can Help Lower LDL Levels
Drinking Tea: Potential Heart Benefits
Plasma Homocysteine in Primary Prevention of Coronary Events?
Palm Oil Adds Nutritional Value
The American Heart Association Advises on Fat Substitutes
Ghrelin Hormone Is an Important Appetite Stimulant
Antioxidant Intake and Risk of Alzheimer Disease
Fatty Acids in Infant Formula Approved
The FDA Scales Back Proposal for Trans-Fat Label on Food
The Obesity-Hunger Paradox
The Consequences of Hunger
Snack Bars Reduce Fruit and Vegetable consumption By School Children
The US Department of Agriculture Report Card On School Meals
The FDA Approves New Sugar Substitute
The US Department of Agriculture Expanding Its Role In The 5 A Day Program
Mexican-American College Students Report Low Fruit, Juice, and Vegetable Intake
Consumer Federation of American Conference Highlights the Next Generation of Foods from Biotechnology

Resources:
Educating Youth About Calcium
New Lunch Handouts for Preschool Children
Detailed Food Images on CD-Rom
Nutritionist’s Note
Children’s Heart Health Guide
Subscription for NUTRITION PERSPECTIVES

UNDERSTANDING HUMAN STUDIES
To learn how diet influences cancer risk, scientists must analyze a variety of research studies. By design, each study type has its own advantages, disadvantages and distinct purposes. This article explains the kinds of studies used to examine the diet-cancer connection in humans.

The most basic question that scientists studying diet and cancer ask themselves is: Which particular foods influence cancer risk in humans? To find the answers, they conduct epidemiological studies. The studies investigate disease risk within specific (and often very large) groups of people.

The largest kind of epidemiological study is the correlation (or ecological) study, which compares diets and cancer rates among entire national or regional populations. Over 25 years ago, a large correlation study examined incidence rates for 27 cancers and 23 countries and compared them with per capita intake of various foods. One of the study’s most famous findings was the startling degree to which meat intake was associated with colon cancer.

But because diets that are high in meat tend also to be high in fat and calories and low in fiber, vegetables and fruits, researchers at the time could only note the close association, they could not conclude that meat was the culprit. For that, they would need to employ smaller, more detailed epidemiological studies that compare sets of individuals, not entire populations.

Comparing Groups of People
In case-control studies, patients with a specific type of cancer (the cases) are statistically matched with a similar group of people without cancer (the controls). Cases and controls are interviewed about their diets, and the differences are compared and analyzed.

By 1995, 26 separate case-control studies had investigated possible associations between colon cancer and different kinds of processed and unprocessed meat, prepared in various ways. The overwhelming majority (81 out if 86) confirmed that high meat intake was lined to increased colon cancer risk in groups of people.

Case-control studies are limited, however, because they generally depend on how well the cases and controls recall the diets they consumed over a particular period. If cases and controls differ in how accurately they remember, significant biases can arise.

Conducting Long-Term Observations
Scientist who conduct cohort studies attempt to avoid such a “recall bias” by closely tracking the diets and cancer rates of a large group of healthy individuals over time. But cohort studies are usually dependent upon the subject’s self-reported diets, and this kind of dietary measurement has been shown to affect the accuracy of data. A group of subjects that is insufficiently large or varied will also limit the validity of the results.

The importance of variability is illustrated by a landmark cohort study that tracked the diets and cancer rates in over 25,000 Seventh-day Adventists for two decades. The results found no association between meat intake and colon cancer.
While epidemiological studies can point to which foods or food substances influence cancer risk, they cannot offer insights into how or why a given food might produce these effects.

It has been theorized that because Adventists as a group are vegetarian, this particular cohort study was ill-equipped to pinpoint a meat-cancer link. (On the other hand, because the subjects ate so many vegetables and fruits, this same study could and did reveal a strong association between diets high in plant foods and lower cancer risk.)

Steering the Course
The epidemiological investigation method that allows researchers to exert the tightest control is the intervention study (or controlled study). This kind of study involves an “intervention group” who are given a food or substance that may be protective against cancer and a “control group” who are given a neutral substance.

The preferred method is the “randomized, double-blind, controlled trial,” meaning that neither the subjects nor the researchers know which subjects have been randomly assigned to the control group, and which to the intervention group.
But it’s difficult to disguise changes to the diet, which is why most of the diet-related controlled studies conducted to date have involved pills of vitamins, minerals or phytochemicals found in various foods.

By reviewing the results of all the different types of studies, and taking into account their specific strengths and weaknesses, American Institute of Cancer Research’s expert report, Food, Nutrition and the Prevention of Cancer: a global perspective, determined that there is a strong relationship between meat consumption and increased colorectal cancer risk.
Source: AICR Newsletter; 76; Summer 2002; p.5.

THE NIH FUNDS BOTANICAL CENTER IN IOWA TO STUDY HEALTH EFFECTS OF ECHINACEA AND ST. JOHN'S WORT
The National Institute of Environmental Health Sciences (NIEHS) and the Office of Dietary Supplements (ODS), components of the National Institutes of Health (NIH), recently announced a 5-year, $6 million grant for the establishment of a research center based in Ames, Iowa to study two botanical dietary supplement ingredients, Echinacea and Hypericum (St. John's wort). Echinacea is reputed to ward off colds and other infections, while St. John's wort is purported to combat mild depression.
The new Center for Dietary Supplement Research brings together two traditionally strong research institutions, Iowa State University in Ames and the University of Iowa in Iowa City. The Center Director, Diane F. Birt, PhD, chairs the Department of Food Science and Human Nutrition at Iowa State University and is an expert in nutrition and its relation to disease. Other Center scientists have expertise in toxicology, medicinal pharmacology, clinical medicine, epidemiology, nutrition, chemistry, biochemistry, molecular biology, botany, horticulture, and statistics.

"The new center joins five other centers to move the NIH into exciting scientific areas relating to dietary supplements used by millions of people in the US and around the world," said Paul Coates, PhD, ODS Director. The new Center for Dietary Supplement Research joins established NIH Centers located at the University of California, Los Angeles; University of Illinois at Chicago; University of Missouri; Purdue University along with the University of Alabama at Birmingham; and the University of Arizona.

The various centers are being funded by the NIH Office of Dietary Supplements, the National Center for Complementary and Alternative Medicine, and other organizations within the National Institutes of Health. The Centers are expected to greatly advance the scientific base of knowledge on botanicals, including issues of their effectiveness, safety, and biological action. The NIEHS Director Kenneth Olden, PhD, who also directs the National Toxicology Program, said, "The herbs and supplements we take into our bodies are important parts of our personal environments. We want to know about their potential effects, good or bad, which is why our National Toxicology Program is conducting herbal safety studies and why we are excited about the Iowa Center's look at potential benefits and identification of biologically active constituents of botanicals."

The National Institute of Environmental Health Sciences, (one of the National Institutes of Health), is the principal federal agency for research and training on the effects of environmental agents on human health. It is the only one of the institutes not headquartered in Bethesda, Maryland, and is in Research Triangle Park, North Carolina. The mission of NIEHS is to develop knowledge that will permit the better management of risks associated with body exposures to or processing of environmental factors or agents. Within this mission, the NIEHS supports research, including relevant nutrition and dietary supplement research, investigating the effects of chemical, physical, and biological environmental agents on human health and well-being. For more information, please visit NIEHS on the Internet, at http://www.niehs.nih.gov/ .

The Office of Dietary Supplements was established at NIH in November 1995 as a result of the Dietary Supplement Health and Education Act passed by Congress in 1994. The mission of ODS is to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, stimulating and supporting research, disseminating research results, and educating the public to foster and enhance the quality of life and health for the US population. The ODS expects to continue to fund investigator-initiated awards as a means to expand research opportunities in the area of dietary supplements. For additional information about ODS and the NIH-funded botanical centers, please visit our website at http://dietary-supplements.info.nih.gov.
Source: NIH Press Release; July 25, 2002.

FUNCTIONAL FOODS: SERVICE OR DISSERVICE?
Some call them “nutraceuticals.” Others say “functional foods” or “designer foods.” But whatever they are called, the question is whether these products provide a service or disservice to consumers.

That’s the question Edzard Ernst, of the School of Sport and Health Sciences, department of complementary medicine at the University of Exeter, United Kingdom, set out to answer in a recent commentary (1). Although Ernst maintains that no clear definition exists for these foods, in his article he defined functional food (FFs) as: “products marketed as foods enriched with (herbal) substances known or assumed to be associated with health benefits.” Functional foods can include everything from Ginkgo biloba breakfast cereals to Kava candy bars and St. John’s wort tortilla chips to Echinacea fruit drinks, he says.
Ernst finds little basis to recommend these types of FFs, objecting to the following factors:

· Invariably the doses of pharmacologically active ingredients in these foods are too low to provide the benefit promised. For example, one study found it would be necessary to consume 27 liters of certain herbal beverage with St. John’s wort to get therapeutic dose of the herb.
· The raw materials are expensive, so in many cases only minimal amounts are used in FFs.
· The manufacturing process is likely to destroy the active ingredient.
· It is nearly impossible to analyze the specific herbal content in FFs.

Most important, FFs may put consumers at risk, Ernst argues. Medicinal herbs do carry some negative side effects and can cause allergic reactions, but there is no post-marketing oversight system for FFs. For example, St. John’s wort can interact with certain prescription drugs, and negative interactions are not necessarily dose-related, he writes. Moreover, FFs can contain non-herbal and unhealthful ingredients, such as high saturated-fat content in tortilla chips. “Thus, an unhealthy food product could be marketed with the implication of a healthy benefit. These risks may appear to be small, but they still outweigh the benefits of FFs which are close to zero,” according to Ernst.

Quality control is another issue. While conventionally registered herbal medicinal products receive quality control in some countries, FFs are regulated by food laws that are not as exacting as are standards for botanical drugs, Ernst argues. Contamination or adulteration can result, leading to serious consequences.

Ernst also worries that consumers may use FFs instead of other, more effective preventive health methods, and their lack of efficacy eventually could keep consumers from using medicinal herbal products. “As consumers will not perceive any benefit from an under-dosed FF,…they are likely to conclude that the specific herb contained in that FF is not effective. This experience, in turn, will discourage them from using this or other effective herbal remedies in situations where they could conceivably benefit from them,” he writes.

Despite all his arguments against FFs, Ernst does not favor a ban on all such products. Indeed, he says, there are products, such as green tea, that can be used regularly without risk of harm, and there are other products, such as garlic-flavored potato chips, that can be enhanced safely with medicinal herbs. “It is therefore crucial to distinguish between FFs where medicinal herbs have been added to imply a health benefit (e.g., St. John’s wort tortilla chips) and botanical products that have been in traditional use and can be shown to be useful in one way or another,” he concludes.

The bottom line for Ernst: FFs currently benefit the manufacturer, not the consumer, and use of the products should be discouraged.
Reference:
1. E. Ernst. Functional foods, neutraceuticals, designer foods: innocent fad or counterproductive marketing ploy? Eur J Clin Pharmacol; 2001; 57: 353-355.
Source: Nutrition & the MD; 28(6); June 2002; p. 4.

FLAXSEED CAN HELP LOWER LDL LEVELS
Another functional food of interest is flaxseed, and research shows that ingesting foods with partially defatted flaxseed can help lower LDL cholesterol levels (1).

Jenkens and colleagues looked at 29 hyperlipidemic adults who participated in two three-week treatment periods in a randomized crossover trial. Treatment group participants got muffins with about 20 g fiber per day from flaxseed (about 50 g partially defatted flaxseed per day); control group participants got muffins with the same amount of fiber, about 20 g per day, but from wheat bran. Both groups consumed self-selected National Cholesterol Education Program Step II diets. Blood pressure and weight were measured at baseline and at the end of each phase, and seven-day diet records were kept the last week of each phase to determine compliance. Daily supplements included four test or control muffins, and participants were told to cut their cereal and bread consumption.

The group eating the flaxseed muffins experienced significant reductions in total cholesterol of 4.6 ± 1.2 percent, in LDL cholesterol of 7.6 ± 1.8 percent, apolipoprotein B of 5.4 ± 1.4 percent, and apolipoprotein A-I of 5.8 ± 1.9 percent. There were no significant effects after either treatment period on serum lipoprotein ratios or HDL cholesterol. The researchers were surprised to find a significant reduction at week 3 among the treatment group for serum protein thio groups, an indicator of protein oxidation, a finding they suggested could be interpreted as an undesirable effect.

The researchers indicated heightened interest in possible health benefits from flaxseed and other oil seeds, particularly in the areas of cardiovascular disease and cancer. The interest comes from the oil seeds’ high content of polyunsaturated fatty acids, vegetable protein, soluble fiber, and flavonoids and related compounds.

According to Jenkins and colleagues, the data confirm that adding partially defatted flaxseed to the diet will reduce serum LDL-cholesterol in the same manner as full-fat flaxseed. “The flaxseed gum is likely the major active ingredient in flaxseed responsible for the lipid-lowering action, but the isolated gum requires testing, as do the vegetable protein and phenolic lignan components.”
Reference:
1. Jenkins DJ, Kendall CW, Vidgen E, et al. Health aspects of partially defatted flaxseed, including effects on serum lipids, oxidative measures, and ex vivo androgen and progestin activity: a controlled crossover trial. Am J Clin Nutr; 1999; 69:395.
Source: Nutrition & the MD; 28(5); May 2002; p. 7.

DRINKING TEA: POTENTIAL HEART BENEFITS
Flavonoids may reduce cardiovascular risk because they have antioxidant, antithrombotic, and anti-inflammatory properties, and they may even reverse endothelial dysfunction (1,2). In 2 studies, researchers assessed the relation between drinking tea, which contains flavonoids, and myocardial infarction-related risk.

In the first study, researchers analyzed data from 4807 participants (mean age, 67) in the longitudinal, population-based Rotterdam Study; none had histories of myocardial infarction (MI). Diet was assessed at baseline with a validated, interview-administered questionnaire. During follow-up (mean, 5.6 years), 116 nonfatal and 30 fatal MIs occurred. In a multivariate analysis, participants who reported drinking more than 375 mL of tea daily were significantly less likely to suffer any MI (relative risk, 0.57) or fatal MI (RR, 0.30) than were participants who reported drinking no tea. Overall dietary intake of flavonoids was not significantly associated with total MI incidence but was significantly associated with lower incidence of fatal MI.

In a multi-center, prospective, observational US study of 1900 patients (mean age, 61) who were hospitalized with MI from 1989 to 1994, tea consumption was associated with a significant all-cause-mortality risk reduction during a median follow-up of 3.8 years. Compared with drinking no tea, drinking more than 0 but less than 14 cups weekly was associated with a 28 percent lower risk and drinking 14 or more cups weekly was associated with a 44 percent lower risk, according to a multivariate analysis.
References:
1. Geleijnse JM, Launer LJ, van der Kuip DAM, Hofman A, and Witteman JCM. Inverse association of tea and flavonoid intakes with incident myocardial infarction: The Rotterdam Study. Am J Clin Nutr; 2002 May; 75:880-6.
2. Mukamal KJ, MD, MPH, MA, Maclure, M, ScD, Muller JE, MD, Sherwood JB, RN, Mittleman MA, MD, DrPH. Tea consumption and mortality after acute myocardial infarction. Circulation; 2002 May 28; 105:2476-81.
Source: JoAnne M. Foody, MD; Journal Watch; June 18, 2002.

PLASMA HOMOCYSTEINE IN PRIMARY PREVENTION OF CORONARY EVENTS?
Elevated serum homocysteine levels correlate with increased cardiovascular risk, but can homocysteine levels be used to identify high-risk patients who might benefit from primary prevention with statin therapy? Investigators analyzed homocysteine levels in more than 5000 adults who were enrolled in a randomized study of lovastatin for primary prevention of cardiovascular events; at baseline, median LDL cholesterol level among participants was 149 mg/dL.

The median baseline homocysteine level was significantly higher among participants who suffered subsequent sudden cardiac death, fatal or nonfatal myocardial infarction, or unstable angina than among those who did not suffer such events (12.1 vs.10.9 µmol/L). In addition, risk for such events increased in stepwise fashion with each quartile of homocysteine level. Among patients whose LDL and homocysteine levels were higher than study medians, lovastatin recipients had a marked reduction in risk compared with placebo recipients (relative risk, 0.46). However, among patients with low LDL levels, homocysteine tests did not distinguish subgroups in whom lovastatin was particularly helpful.

These data suggest that homocysteine is another independent predictor of cardiovascular risk, and patients with both high LDL and high homocysteine levels likely benefit from primary prevention with statins. However, homocysteine was disappointing as a marker for targeting patients with lower LDL levels in whom statin therapy would be beneficial. These findings contrast with recent findings for C-reactive protein: CRP levels helped distinguish patients with significant response to statin therapy, even in the lower LDL groups.

Adapted from: Journal Watch; 22(12); June 2002; p.92.

PALM OIL ADDS NUTRITIONAL VALUE
Palm oil can impart nutritional value to foods, reducing blood cholesterol, LDL cholesterol, research shows (1). Other benefits recorded from adding palm oil to a balanced diet include improved lipoprotein A and apoprotein A1 levels and lowering of blood triglycerides. In addition, virgin palm oil provides carotenes that are strong antioxidants and can be antithrombotic. And red palm oil provides b-carotene and a-tocopherol and tocotrienols.

Palm oil, with soybean oil, sunflower seed oil, and rapeseed oil, provide 60 to 70 percent of the world production of oils and fats. Palm oil is considered highly structured, with the 2-positional fatty acids mainly unsaturated, and the 1- and 3-fatty acids mainly saturated.

Palm oil has various economic and consumer factors to recommend it:

· it is not genetically modified (at this time);
· it comes from the oil palm, which is a perennial crop; and
· the crop has a high oil yield, eight to 10 times higher than that of any other oil crop.

There are various health benefits for dietary palm oil, according to Ong and Goh. Because it behaves as an unsaturated fat, even though it contains almost identical shares of saturated and unsaturated fatty acids, dietary palm oil is helpful in fighting cardiovascular disease. Studies conducted before 1990 found that palm-oil diets reduced blood cholesterol values anywhere from 7 to 38 percent, and later studies found positive effects from palm oil on blood cholesterol and lipoprotein profiles. Evidence from numerous studies confirms that palm oil acts more like a monounsaturated than a saturated oil as far as its effect on blood lipids, so that palm oil mimics olive oil in this regard.

In addition to the positive effects just cited, dietary palm oil does not promote plaque formation in the arteries, with animal trials showing palm oil and sunflower oil diets causing the least atherosclerosis compared with fish oil, linseed oil, and olive oil. Refined palm oil used in foods provides vitamin E and related compounds such as tocotrienol, a natural antioxidant, and mildly refined palm oil also provides carotenoids.

These researchers conclude that palm oil should be the oil preferred by both consumers and food manufacturers, given that it provides oxidative stability, texture, and flavor. “Palm oil is as good as if not better than olive oil, especially with regard to the reduced tendency of blood to clot and the lower [intestinal] uptake of fatty acids. The lower uptake of palm fatty acids in comparison to those from polyunsaturated oils allows for the reduction of blood triacylglycerols and adipose deposits,” they state.
Reference:
1. Ong ASH and Goh SH. Palm oil: a healthful and cost-effective dietary component. Food Nutr Bull. 2002 Mar;23(1):11-22. Food and Nutr Bull; 2002; 23:11.
Source: Nutrition & the MD; 28(5); May 2002; p. 7.

THE AMERICAN HEART ASSOCIATION ADVISES ON FAT SUBSTITUTES
Fat substitutes neither benefit nor detract from overall health, says an American Heart Association (AHA) report published in the June 11 issue of Circulation. Long-term studies are needed to determine whether fat substitutes change obesity prevalence and treatment and how they interact with medications and food ingredients. Data from the Continuing Survey of Food Intake of Individuals food survey in 1989-1991 and 1994-1995 show that children who choose low-fat products can lower their total fat and saturated fat, but may also lower their total energy and vitamin E intake. Use of modified fat products without changes in portion control and physical activity may not lower body weight, said the report. Go to http://circ.ahajournals.org/cgi/content/full/105/23/2800 for the full report.
Source: Nutrition Week; XXXII:12; June 12, 2002; p. 7.

GHRELIN HORMONE IS AN IMPORTANT APPETITE STIMULANT
The hormone ghrelin, (pronounced GRAY-lin), discovered in 1999, is produced by endocrine cells in the stomach. It is a potent appetite stimulant, and it decreases metabolic rate and fat catabolism. Results from a new study indicate that ghrelin has an important role in human appetite and obesity.

Plasma levels of ghrelin were measured (every 30 to 60 minutes for 24 hours) in 13 obese subjects, before and after a 6-month dietary program that produced a mean 17 percent weight loss. At baseline, ghrelin levels rose before each meal and fell promptly after eating. After weight loss, ghrelin levels cycled similarly but were higher both before and after meals than they had been at baseline. In contrast, in 5 additional patients with large weight losses (mean, 36 percent) following gastric bypass surgery, ghrelin levels were very low and did not fluctuate with meals; appetite was reduced permanently and weight regain rarely occurred.
Ghrelin plays an important role in hunger before, and in satiety after, each meal. Moreover, ghrelin levels also may explain the inability of most patients to sustain weight loss after dieting: They experience increased appetite secondary to levels of ghrelin that are chronically higher after weight loss. Finally, many patients may be able to maintain large weight losses following gastric bypass surgery (in contrast to dieting) because gastric bypass inhibits ghrelin production by endocrine cells in the stomach. Add ghrelin to the list of “obesity molecules” that will become targets for drug development as we seek safe treatments to deal with the epidemic of obesity.
Source: Journal Watch; 22(13); July 2002; p.104.

ANTIOXIDANT INTAKE AND RISK OF ALZHEIMER DISEASE
Evidence suggests that oxidative stress may be important in the pathogenesis of Alzheimer disease (AD). Two prospective studies in a recent issue of the Journal of the American Medical Association investigated whether dietary intake of antioxidants is associated with risk of AD (1,2). In the Rotterdam Study, a population-based study of individuals aged 55 years or older at baseline, Engelhart and colleagues found that a high intake of vitamin C and vitamin E from food was associated with lower risk of incident AD after a mean follow-up of 6 years, although statistical significance of the association was borderline. Morris and colleagues, in the Chicago Health and Aging Project study of individuals aged 65 years or older, found that a high intake of vitamin E from food was associated with reduced risk for AD after a mean follow-up of 3.9 years, but only among individuals without the APOE Î4 allele. Intake of vitamin E, vitamin C, and beta carotene from supplements, however, was not significantly associated with risk of AD. In an editorial, Foley and White discuss several methological issues that must be considered in observational studies evaluating whether antioxidant vitamin intake reduces the risk of AD.
References:
1. Engelhart MJ, Geerlings MI, Ruitenberg A, et al. Dietary intake of antioxidants and risk of Alzheimer disease. JAMA. 2002 Jun 26;287(24):3223-9.
2. Morris MC, Evans DA, Bienias JL, et al. Dietary intake of antioxidant nutrients and the risk of incident Alzheimer disease in a biracial community study. JAMA. 2002 Jun 26;287(24):3230-7.
3. Foley DJ, White LR Dietary intake of antioxidants and risk of Alzheimer disease: food for thought. JAMA. 2002 Jun 26;287(24):3261-3.
Source: JAMA; 287(24); June 26, 2002; p.3173.

FATTY ACIDS IN INFANT FORMULA APPROVED
The FDA has approved two controversial fatty acids in a preterm infant formula. Found naturally in breast milk and added to full-term infant formulas, docosahexanoic acid (DHA) and arachidonic acid (ARA) may improve infants’ brain and vision development. The newly approved Enfamil Premature LIPIL, which contains DHA and ARA, will be available later this month, said Mead Johnson, makers of the formula. The fatty acids are controversial because studies have found various results in their effectiveness. The latest study in July’s Pediatrics found no significant benefits on developmental outcomes in preterm infants fed formula supplemented with DHA and ARA as compared to those without the additional ingredients (1). At 18 months, the infants who received the DHA- and ARA-rich formula were shorter in height than control formula-fed infants as well as breast-fed infants. The researchers call for further investigation to include developmental tests and growth measurements beyond the parameter of 18 months of age. Go to www.pediatrics.org/current.shtml for the abstract.
Reference:
1. Fewtrell MS, Morley R, Abbott RA, et al. Double-blind, randomized trial of long-chain polyunsaturated fatty acid supplementation in formula fed to preterm infants. Pediatrics. 2002 July; 110(1 Pt 1):73-82
Source: Nutrition Week; XXXII:14; July 22, 2002; p. 6.

THE FDA SCALES BACK PROPOSAL FOR TRANS-FAT LABEL ON FOOD
The FDA’s continued efforts to require trans-fatty acids to be listed on food labels, will not help consumers very much, according to the Center for Science in the Public Interest (CSPI).

A recent Institute of Medicine (IOM) report found an increased heart disease risk associated with trans-fatty acids and recommended people limit their intake as much as possible.

But the report didn’t provide a daily reference intake value, a recommended amount to eat per day, so the FDA can’t mandate that food labels include a percent daily value for trans-fatty acids, said an FDA spokesperson. Instead, it will require that food labels list the absolute grams of trans-fatty acids in a food.

Listing a percent daily value is essential for helping people understand how their intake of trans fat fits into their overall daily diet, said Margo Wootan, director of nutrition policy at CSPI. “You have to give consumers some idea of how much is too much,” she said. “Without a daily value, they’ll have no way to tell.”

Daily value is key
When the FDA proposed its rule on labeling trans-fatty acids in foods in November 1999, it originally wanted to list trans-fat under saturated fat. The nutrient content label would give the combined total of trans and saturated fat with an asterisk explaining how many grams of trans-fat a product contained. In this format, the percent daily value would cover both types of fat.
But since the IOM didn’t provide a basis to develop a percent daily value, the FDA “will scale back from the original proposal and take a more incremental approach to trans-fat labeling,” said the spokesperson.

This isn’t good enough, said Wootan. “we wouldn’t want trans-fat labeled without a percent daily value, because it would be counterproductive and misleading.”

The FDA won’t be finalizing its rule on trans-fat labeling any faster because of the IOM report. It still plans on completing the rule early in fiscal year 2003, which begins in October, the FDA spokesperson said. Go to www.iom.edu/iom/iomhome.nsf/Pages/Recently+Released+Reports to read the IOM report.
Reference:
1. Wylie-Rosett J. Fat substitutes and health: an advisory from the Nutrition Committee of the American Heart Association. Circulation. 105(23); June 11, 2002; pp. 2800-4.
Source: Nutrition Week; XXXII:14; July 22, 2002; p. 7.

THE OBESITY-HUNGER PARADOX
Increasing obesity rates have hit every group in this country and abroad, even groups that are food insecure and hungry, a paradox that’s not well understood, said researchers at two conferences late last month. Obesity rates are about equal among men and children whatever their socioeconomic status, but low-income women are about 50 percent more likely to be obese than those with higher incomes, found the Surgeon General’s 2001 Call to Action to Prevent and Decrease Overweight and Obesity.

There is also some evidence that non-Hispanic white adolescents from lower-income families may also be more overweight than higher-income adolescents. A 1998 study published in the journal Pediatrics found about 19 percent of adolescent boys and 20 percent of adolescent girls were overweight compared to the national average of 14 percent (1).

No one knows for certain why low-income women are more likely to be overweight or obese than others, but there are several theories, including reliance on nonperishable high-calorie food rather than fresh fruits and vegetables, said Lynn Parker, director of child nutrition programs at the Food Research and Acton Center (FRAC). Parker spoke on the subject at FRAC’s National Policy Conference and the National Food Policy Conference in April 2002. No matter what the reason, more obesity and less physical activity “should be a great concern,” said Parker.

A mother’s sacrifice
Part of Parker’s concern is the impact that chronic diseases associated with obesity have on these women. “Chronic disease is an even heavier cross to bear for low-income people because of their inadequate health care,” she said. They typically go longer before diagnosis, get inadequate care, and are likely to die sooner than higher-income people. Several theories abound on the obesity-hunger paradox in low-income women. One theory is that these women, many of whom are mothers, go through periods of feast or famine.

“When people are faced with food insecurity, they tend to overeat as an assurance against hunger” when food is available, said Peter Basiotis, PhD, economist and director of nutrition policy and analysis at the USDA’s Center for Nutrition Policy and Promotion, who researched the diet quality of low-income women. He spoke at the National Food Policy Conference.

What’s driving what?
Another theory says it’s not the food insecurity driving the overweight, but the overweight driving people to be food insecure, said Basiotis. “Those who are poor and overweight tend to want more food to keep body weight constant. Because they have a larger body size, they need more food.”

That theory is questionable based on other research and surveys showing that overweight and obese people eat fewer calories than normal-weight people, said Christine Olson, PhD, RD, professor at Cornell University, who also spoke at the National Food Policy Conference.

The role of physical activity hasn’t been well studied in the hunger-obesity paradox, said Olson.

“One of the things that happens when people don’t have enough to eat is that they get more lethargic.” Some neighborhoods also present barriers to physical activity because of unsafe streets and lack of exercise facilities, she said.

Choosing the right foods
Low-income women may also turn to cheap, calorie-dense foods, when money is tight. Potato chips and soda have more calories per dollar than vegetables and can lead to weight gain. But Basiotis doesn’t really subscribe to this theory. “If they’re eating more calories than what they need to maintain weight, it doesn’t matter whether those calories are from potato chips or green vegetables.”

The way out
One of the keys to reducing obesity among the poor is to ensure food security, said Olson and Parker. “If people are constantly worrying about where their food is coming from, that isn’t a basis for good eating habits,” Parker said.

The federal food safety net can be part of the solution, she said. The Child Nutrition Program, which includes the school lunch and breakfast programs, has helped improve children’s diet because it requires fruits and vegetables to be served and its meal portion sizes are appropriate for children.

For more information on obesity and food insecurity, go to www.surgeongeneral.gov/topics/obesity to read the Surgeon General’s report.
Reference:
1. Barlow SE and Dietz WH. Obesity evaluation and treatment: Expert committee recommendations. Pediatrics 1998 Sep; 102 (3): e29.
Adapted from: Nutrition Week; XXXII:9; May 6, 2002; p. 3.

THE CONSEQUENCES OF HUNGER
Being hungry makes kids sick, with more ear infections, iron deficiency anemia, and hospitalizations than children who don’t go hungry, found a recent report from the Center on Hunger and Poverty at Brandeis University in Massachusetts. The report, The Consequences of Hunger and Food Insecurity for Children, said food-insecure children under age 3 are 33 percent more likely to be hospitalized than food-secure children. Higher rates of illness means hungry kids miss more school days and are less prepared to learn when in school. Hungry children are also more likely to have poor mental health, be socially withdrawn, and have more behavior disorders. The report is a review of existing studies and was commissioned by ConAgra Foods.
Go to www.centeronhunger.org/pdf/ConsequencesofHunger.pdf to read the report.
Source: Nutrition Week; XXXII:13; July 8, 2002; p. 7.

SNACK BARS REDUCE FRUIT AND VEGETABLE CONSUMPTION BY SCHOOL CHILDREN
With children’s fruit, juice, and vegetable (FJV) consumption nowhere near the recommended five servings a day, various studies have examined factors that affect their intake. One such study, conducted at a south Texas school district, found that fourth-grade students with access only to National School Lunch Program (NSLP) meals consumed significantly more FJV than did fifth-graders who had access to a school snack bar in addition to the NSLP meals (1). The fifth-graders reported a more than 50 percent lower mean lunch intake of juice, total vegetables, and total FJVs. A difference was found for family education, with students whose parents had a high school education or less, consuming significantly less juice but more vegetables and total FJVs than did students whose parents had some higher education.

Fifth-graders who ate solely from the snack bar took far fewer regular total vegetable servings and total FJVs and more high-fat vegetables than did those who ate the NSLP meal. Among students in both grades, girls ate more vegetables than boys did, and African-American girls consumed the most total vegetables. Fourth-graders consumed more fruits than did fifth-graders; still, 0.33 servings/day was the highest reported.

Fifth-graders who selected just the NSLP lunch reported eating a much greater amount of FJVs, by a factor of two, than did fifth-graders who ate snack bar meals or brought lunch from home. Their 0.82 FJV serving was close to the 0.80 FJV serving reported by fourth-graders.

“Consumption will likely increase only when highly preferred fruits, juices, and vegetables are made available and accessible in both snack bars and NSLP meals. Preferences did not account for the differences in FJV consumption between the NSLP and snack bar meals, which suggests that the environment (ie, the lack of FJV choices in the snack bar or the presence of completing snacks and high-fat- and high-sugar dessert foods) may be responsible for the differences,” Cullen and colleagues write.
About 95 percent of US children have access to NSLP meals, and those meals have at least one serving of fruits or vegetables. In the school district studied, a mean of 2.5 FJV servings was offered daily in the NSLP meal.

Behavioral Strategies
A study that looked at behavioral strategies for increasing fruit and vegetable intake among fourth- through sixth-grade students found that children who eat more fruit and vegetables tend to start the day with juice or fruit and eat a vegetable at dinner (2). These children also tend to take extra helpings of fruits and vegetables, drink juice rather than soda, and ask their parents to buy vegetables for snacks and meals.

In this study, a survey tool was used to determine behavioral practices that influenced fruit and vegetable intake. Data were based on children’s self-reports for a 24-hour period, which showed 1.5 servings each of fruits and vegetables per day. The data were collected from children at five elementary schools in a metropolitan area of Minnesota.
References:
1. Cullen KW, Eagan J, Baranowski T, Owens E, de Moor CEffect of a la carte and snack bar foods at school on children's lunchtime intake of fruits and vegetables. J Am Diet Assoc. 2000 Dec;100(12):1482-6.
2. Sandeno C, Wolf G, Drake T, Reicks MBehavioral strategies to increase fruit and vegetable intake by fourth- through sixth-grade students. J Am Diet Assoc. 2000 July;100(7):828-30.
Source: Nutrition & the MD; 28(4); April 2002; p. 5.

US DEPARTMENT OF AGRICULTURE REPORT CARD ON SCHOOL MEALS
The US Department of Agriculture (USDA) last year issued a scathing report on competitive food sales in the nation’s schools, saying these sales undermine the federal school meals programs, send the wrong nutrition messages to students, and pose health risks to the nation’s children (1). In a second report last hear, the USDA delivered news eagerly awaited by school dietitians, finding that school meals are lower in fat and offer more fruits and vegetables than in the past (2).

School Meals Compared
The School Nutrition Dietary Assessment-II (SNDA-II) report compares school meals from the 1998-99 school year to those served in 1991-92, at time periods for which the landmark SNDA-II report found school meals did not meet standards for total-fat and saturated-fat intake. That report, issued before school meals were required to meet the Dietary Guidelines for Americans standards, became a touchstone for complaints about the nutritional quality of school meals.

The SNDA-II report says the percentage of schools offering lunches meeting nutritional guidelines for total fat rose from 34 percent in 1992 to 82 percent in 1999 for elementary schools and from 71 percent to 91 percent for secondary schools. Schools reduced total fat levels from 31 percent to 26 percent of total calories in school breakfasts and from 38 percent to 34 percent in school lunches; the goal for school meals is 30 percent. Saturated fat in school lunches fell from 15 percent to 12 percent and in school breakfasts from 14 percent to 9.8 percent; the goal is less than 10 percent.

Whereas just 1 percent of school lunches met the total-fat standard, and no lunches met the saturated-fat standard, in 1992, in 1999 18 percent of elementary schools and 22 percent of secondary schools met national standards for total fat in lunches, and 15 percent of elementary schools and 17 percent of secondary schools met national standards for saturated fats in lunches. School meals both offered and selected in 1999 exceeded the recommended daily allowances (RDA) for key nutrients, even though lunches served in secondary schools did not provide one-third of the daily recommended calories, and breakfasts in both elementary and secondary schools fell short of the one-fourth of daily allowance for calories.

Competitive Foods
The competitive foods report, meanwhile, suggests that schools are trying to make up for budgetary shortfalls by selling more a la carte foods, offering more fast food options, and signing exclusive beverage contracts. These competitive foods often are low in nutrient density and high in fat, added sugar, and calories, the USDA says. “When children replace school meals with these less nutritious foods and beverages, there is the risk that their daily dietary intake will be inadequate in key nutrients necessary for growth and learning. And when competitive foods are purchased in addition to school meals or in large quantities, there is the likelihood of over-consumption and the risk of unhealthy weight gain,” the report says.

Moreover, the report suggests that schools are sending mixed messages when they teach nutrition lessons in the classroom and then turn around and sell unhealthy foods in the cafeteria. Finally, the USDA reports that offering competitive foods could affect the very viability of school meals programs by leading to lower participation in the school breakfast and lunch program, thereby cutting down on federal meals reimbursement and commodity support.
Reference:
1. [Online source]: School Nutrition Dietary Assessment-II (SNDA-II), at www.fns.usda.gov/cnd.
2. [Online source]: The School Nutrition Dietary Assessment-II (SNDA-II), at www.fns.usda.gov/oane.
Adapted from: Nutrition & the MD; 28(4); April 2002; p. 5.

THE FDA APPROVES NEW SUGAR SUBSTITUTE
The FDA has approved Neotame, the newest calorie-free sweetener that is about 7,000 to 13,000 times sweeter than sugar. The FDA approved the sweetener after reviewing more than 100 human and animal studies aimed at identifying possible cancer, neurological, or reproductive effects. While its amino acid base is the same as aspartame (also known as NutraSweet and Equal), it is heat-stable and can be used in baking, as well as added directly to foods. Neotame may be added to such foods as baked goods, frozen desserts, soft drinks, fruit juices, chewing gum, and syrup. Go to: www.cfsan.fda.gov/~lrd/tpneotam.html for the FDA Talk Paper.
Source: Nutrition Week; XXXII:14; July 22, 2002; p. 6.

US DEPARTMENT OF AGRICULTURE EXPANDING ITS ROLE IN THE 5 A DAY PROGRAM
About 70 percent of US adults and children don’t eat the recommended five servings of fruits and vegetables, but the United States Department of Agriculture (USDA) wants to help boost this number and will begin efforts to further promote the 5 A Day Program.

The USDA Secretary Ann Veneman announced that the USDA will partner with the Department of Health and Human Services, which oversees the National Cancer Institute (NCI), and the National 5 A Day Program at the National 5 A Day Partnership meeting last month.

The USDA wants to provide more information to consumers so they can make better choices on diet and physical activity. It will increase consumer education related to the 5 A Day Program, conduct research related to nutrient values in fruits and vegetables, and help strengthen collaboration among federal, state, and industry organizations to promote fruit and vegetable consumption.

Although this is a great idea, more funding is needed to increase fruit and vegetable consumption, said Margo Wootan, DSc, director of nutrition policy at the Center for Science in the Public Interest. The NCI spends about $1 million a year on communications to promote the 5 A Day Program, compared to the $68 million spent on advertising for M&Ms, she said. “One million dollars isn’t enough to get your message out there and to change the behavior to the degree it needs to be changed.”

A time for greater effort
The lack of additional USDA funding isn’t a downside of the agreement, said Lorelei DiSogra, EdD, RD, 5 A Day Program director. The program will still benefit from the USDA’s involvement, which will provide “lots of opportunities” to the 5 A Day campaign.

The 5 A Day Program is a partnership between the food industry and government to promote eating at least five servings total of fruits and vegetables a day. Go to www.usda.gov/news/releaes/2002/04/hhs5aday.htm.
Source: Nutrition Week; XXXII:9; May 6, 2002; p. 2.

MEXICAN-AMERICAN COLLEGE STUDENTS REPORT LOW FRUIT, JUICE, AND VEGETABLE INTAKE
Mean intake of fruit, juice, and vegetables (FJV) stands at just 2.2 servings a day among Mexican-American college students filling out a self-report questionnaire (1). The majority of those surveyed, 59 percent, consumed just 2.5 or fewer servings a day, and only 7.4 percent consumed the recommended five or more fruit and vegetable servings a day.

Juice was the most popular fruit choice among the 107 Mexican-American college students surveyed, with 23 percent reporting drinking orange or grapefruit juice more than five times a week, and 21 percent drinking grape juice, apple juice, and fruit nectars more than 5 times a week. Some 18.4 percent of participants reported eating fruits such as apples, bananas, pears, berries, and strawberries more than five times a week.

The students ate vegetables less often than fruits, with white potatoes, including baked, mashed, boiled, and French fries, the most prevalent, consumed by 28.8 percent of participants more than five times a week. Only 17.8 percent of participants ate other vegetables, such as green beans, corn, peas, and zucchini, more than five times a week.

Evans and colleagues say the data add to the knowledge of eating habits of Mexican-Americans, the fastest growing minority group in the country, and this knowledge will help target future health promotion efforts to this population. “Among this group of students, attitudes toward eating healthfully were favorable, and knowledge about the recommended number of servings was relatively high. However, to increase fruit, juice, and vegetable consumption among this population, the belief that eating fruits and vegetables is healthful needs to be emphasized.”
Reference:
1. Evans AE, Sawyer-Morse MK, Betsinger. A Fruit and vegetable consumption among Mexican-American college students. J Am Diet Assoc. 2000 Nov;100(11):1399-402.
Source: Nutrition & the MD; 28(4); April 2002; p. 5.

CONSUMER FEDERATION OF AMERICA CONFERENCE HIGHLIGHTS THE NEXT GENERATION OF FOODS FROM BIOTECHNOLOGY
The Consumer Federation of America held its National Food Policy conference on April 22 and 23 in Washington, D.C. The topics discussed included bioterrorism and food, food allergies, nutrition labels, irradiation, and functional foods. In addition, one of the sessions focused on the next generation of biotech crops and foods.

During the panel discussion, Leonard Gianessi, program director and senior research associate of the National Center for Food and Agricultural Policy (NCFAP), highlighted research his organization collected on biotech food crops that he believes will be in farmers’ hands in the coming years.

These crops include alfalfa and wheat enhanced to tolerate the application of broad-spectrum herbicides that can result in fewer applications of chemicals as well as less topsoil erosion. Soybeans, broccoli, peanuts, and eggplant are being developed to fight insects on their own. Research is also being conducted on raspberries, barley, grapes, apples, grapefruit, sunflowers, peaches, and tomatoes enhanced to be protected from diseases that can kill an entire season’s crop.

Although all these crops and foods may not be available tomorrow, they are anticipated in the near future. Researchers around the country are growing many of these crops in field trials which signals that they have begun the Food and Drug Administration review process. Note: The NCFAP report, Plant Biotechnology: Current and Potential Impact for Improving Pest Management in US Agriculture, was released on June 10, 2002, and is available ON-LINE AT http://www.ncfap.org.
Source: Food Insight; May/June 2002; p. 6.

RESOURCES:

EDUCATING YOUTH ABOUT CALCIUM
Evidence continues to mount that US youth have inadequate calcium intakes. If this continues, they may face many undesirable health consequences such as osteoporosis, high blood pressure, and other costly diseases. In response to the need for increased education on calcium for youth, faculty at the Texas Cooperative Extension have developed a website located at http://calcium.tamu.edu. The website is called “Clueless in the Mall” and includes a scavenger hunt format with video and audio clips featuring a former President of the American Medical Association, Dr. Nancy Dickey. The website was developed using extensive input and testing with youth. A teacher’s guide is also available to extend the web experience into other school and community activities. The website has received a favorable review from the Tufts Nutrition Navigator. Please contact Dr. Debra Reed EFNEP Coordinator, Texas Cooperative Extension, College Station, TX at (979) 845-2798 or email dreed@tamu.edu if you would like additional information.
Source: SNE; Nutrition Education for Children Division; Summer 2002.

NEW LUNCH HANDOUTS FOR PRESCHOOL CHILDREN
You are invited to visit the San Luis Obispo Cooperative Extension website to view and print the new handouts for The Lunch Box program. The handouts are designed to assist parents who prepare healthy take along lunches for their young children attending preschool.

There are 5 handouts in the series and they are available in both English and Spanish. The topics included are:

· Healthy Lunches for Preschool Children,
· Learning from Labels,
· Safe Lunches for Preschool Children,
· Appealing Lunches for Preschool Children, and
· 15 Take Along Lunches for Preschool Children.

If you have not seen the handouts, please take a look at them. They have been recently redesigned to be in full color. The link to the handouts is http://cesanluisobispo.ucdavis.edu/. When the page opens, click on Programs then click on the Nutrition, Family and Consumer Science Programs icon, and then open Lunch Box Handouts.

A Prop 10 grant provided the funding for the project. Should you find the information useful in your local programming, please send comment at the website above as to how you have used the handouts. Cooperative Extension would like to share your efforts with the Children and Families Commission of San Luis Obispo County.
[Online Source]: http://cesanluisobispo.ucdavis.edu/; ANR; UC Davis Cooperative Extension, San Luis Obispo.

DETAILED FOOD IMAGES ON CD-ROM
FoodShapes, a company specializing in illustration and design for the food business, is offering a special sale price on each of its 3 CD-ROMs of high-quality digital food images

The 3 collections of food art include FOODSHAPES ORIGINAL FULL COLOR COLLECTION of a variety of American foods; the FOODSHAPES HISPANIC COMPUTER ART collection of foods from Mexico and Hispanic countries of Latin America and the Caribbean; and FOODSHAPES ASIAN FOODS 1 CD-ROM, with illustrations of foods from China and Southeast Asia.

These uniquely detailed, realistic illustrations make food subjects look palatable and appetizing and will enhance your menus, fliers, brochures, presentations, and web pages. Each CD-ROM, if purchased individually, is currently being offered at a special price of $99.99, $60 off the regular price of $159.99. (Shipping and handling is $7.) If all 3 CD-ROMs are purchased together, the price for 3 CDs is lowered to $249.99 ($10 shipping and handling.)

The original full color collection of more than 150 images depicts many kinds of foods. Most major food categories are represented on the CD, including breakfast foods, dairy, meat/fish/high protein, desserts, snacks, beverages, children's foods, Italian foods, side dishes, fruits and vegetables (cooked and uncooked), as well as "new popular foods" such as the smoothie and wrap sandwich; several food borders are also included. Examples of FoodShapes Computer Art can be seen at: http://www.foodshapes.com/fsca/fsca.html

The 167 images in the HISPANIC COMPUTER ART collection portray key ingredients in Mexican/Latin cooking, fruits and vegetables, spices and herbs, everyday dishes, and festival foods. Food categories include rice and bean dishes, meat/fish/poultry main dishes, beverages, snacks, salads, soups, stews and desserts. View sample images at: http://www.foodshapes.com/fsca/hispanic.html

Among the food categories on the ASIAN FOODS 1 CD-ROM are Asian fruits and vegetables, basic ingredients, sauces and condiments, rice and noodle dishes, soups, beverages, sweets, meat and seafood entrees, vegetarian entrees, and basic utensils. Many images are included of healthy stir-fries and steamed dishes. You can view some of the 159 images in this collection at: http://www.foodshapes.com/fsca/asian1.html

The CDs may be directly ordered from FoodShapes by credit card at (phone/fax) 617-666-1846 or (email) info@foodshapes.com. Institutional purchase orders are also accepted.

The food images are provided in several popular formats for both IBM and Macintosh computers for both print and internet uses. Use of the images is royalty free.
[Online source]: FoodShapes at: http://www.foodshapes.com/fsca/fsca.html

NUTRITIONIST’S NOTE
Don’t have time for healthy eating? No problem!

The most common excuse for not eating more healthfully is not having enough time. Yet eating more vegetables and fruits each day, the most important lifestyle change we can make for better health, aside from avoiding tobacco, takes little, if any, time out of a busy day.

· Most fresh fruit (and some vegetables) need no preparation. Grab two pieces before leaving the house for your morning and afternoon snacks: apples, apricots, bananas, berries, cherries, cherry tomatoes, grapes, green beans, nectarines, oranges, peaches, pears, plums, snow peas, star fruit, tangerines, and dried fruits of all kinds.
· Supermarket salad bars offer a variety of already prepared fruits and vegetables. No cutting, no mess. Also try the prepackaged salads, greens and slaws; some salads even include dressings and croutons.
· Containers of cut-up fruit (pineapple rings, sliced strawberries, melon balls, kiwi slices, mango and papaya chunks) can be eaten as is or mixed into cereal or frozen yogurt.
· Bags or boxes of frozen veggies can be added to already prepared soups, stews and casseroles.
· Fresh fruit is offered at most sandwich shops, airports, mall food courts and outdoor refreshment stands.
· Many take-out counters in specialty food stores and supermarkets offer lightly stir-fried or roasted vegetables. This healthy indulgence costs about the same price as a high-calorie dessert.

Remember: Fruits and vegetables offer big health benefits with minimal time investment.
Source: AIRC Newsletter; 76; Summer 2002; p.9.

CHILDREN'S HEART HEALTH GUIDE
Initiating healthful lifestyle "training" in childhood to reduce risk of coronary heart disease later in life is a key principle behind new guidelines published in the July 1 issue of Circulation: Journal of the American Heart Association (AHA).

Helping children visualize a "healthy plate" of food (one half-filled with salad and vegetables, one-fourth with a starch, and one-fourth with a protein), be physically active, and remain smoke-free are fundamental parts of establishing lifelong heart health, said the AHA in announcing its new childhood guidelines.

For physicians, they suggest a variety of tests and interventions, such as cholesterol screening for 2- to 5-year-old children of parents with high cholesterol, educating families about the medical complications of obesity, and teaching young children that smoking is a harmful and addictive behavior.
Source: Mike Mitka; JAMA; 288:4; July 24/31; 2001; p. 441.

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