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FOURTH EDITION
NUTRITION
IN PUBLIC HEALTH
Edited by
Sari Edelstein, PhD, RDN
Professor, Retired
Department of Nutrition
School of Health Sciences
Simmons College
Boston, Massachusetts
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Library of Congress Cataloging-in-Publication Data

Names: Edelstein, Sari, editor.
Title: Nutrition in public health / [edited by] Sari Edelstein.
Other titles: Nutrition in public health (Edelstein)
Description: Fourth edition. | Burlington, MA : Jones & Bartlett Learning,
[2018] | Includes bibliographical references and index.
Identifiers: LCCN 2016048923 | ISBN 9781284104691 (pbk. : alk. paper)
Subjects: | MESH: Nutritional Physiological Phenomena | Needs Assessment |
Nutrition Policy | Public Health Practice | Risk Factors | United States
Classification: LCC RA601 | NLM QU 145 | DDC 362.17/6–dc23 LC record available at https://lccn.loc.gov/2016048923
6048
Printed in the United States of America

21 20 19 18 17 10 9 8 7 6 5 4 3 2 1
© Bocos Benedict/ShutterStock, Inc.
Dedication
To Late Mildred Kaufman

To all our wonderful students,
who will make a positive change worldwide for generations to come.
Contents
Preface viii Guidelines for Causality 44

Acknowledgments xi General Considerations in Nutritional Epidemiologic Studies 47
Contributors xii The Role of Nutritional Epidemiology in Public Health 48
Conclusion 48
Case Study Contibutors xiii
Issues for Discussion 49
Reviewers xiv
Practical Activities 49
Online Resources 49
Part I Applying Nutrition in Part II Shaping the Policies
Public Health 1 that Affect the Public’s
1 Applying Nutrition Science to the Public’s Health 3 Health 53
Carol E. O’Neil, PhD, MPH, RD, LDN
Theresa A. Nicklas, DrPH 3 Creating Public Policy and Advocating for
Nutrition Policies 55
Introduction 4 Jody L. Vogelzang, PhD, RDN, FAND, CHES
Public Health Nutrition and Public Health Nutritionists 5
Introduction 56
Peer-Reviewed Literature and Evidence-Based Practice 5
Characteristics of Public Policy 56
Nutrition Monitoring 10
U.S. Public Health Policy 57
Epidemiologic Studies 16
Policy Formulation 59
Metabolic Diet Studies 19
Policy Creation at the Federal Level 61
Clinical Trials 20
Policy Development at All Levels of Government: Federal, State,
Animal Studies 20 and Local 62
Healthy People 2020 20 Advocating and Influencing Health and Nutrition Policies 67
Nutrient Requirements 21 Importance of Building an Infrastructure of Support 70
Center for Nutrition Policy and Promotion 23 Advocacy Activities and Skills for Individuals 70
Dietary Guidelines for Americans 23 The Future of Public Health 71
MyPlate, MyWins 24 Conclusion 71
Healthy Eating Index 26 Issues for Discussion 71
The Food Label 27 Practical Activities 71
Conclusion 29 Online Resources 72
Online Resources 30
4 Role of the Federal Agencies in Public Health
Nutrition 74
Sari Edelstein, PhD, RDN
2 Nutritional Epidemiology: An Introduction 38
Lisa S. Brown, PhD, RD, LDN Introduction 75
Elisabeth Offenberger, MS, RD Overview of Food, Nutrition, and Consumer Services 75
Introduction 39 Overview of the Food Safety and Inspection Service 77
Overview of Epidemiology 39 Overview of Research, Education, and Economics 77
Overview of Nutritional Epidemiology 39 History of Nutrition Education at the USDA 83
Types of Study Designs Used in Nutritional Epidemiology 41 Food and Drug Administration 87
Contents v
Centers for Disease Control and Prevention 87 8 Intervening to Change the Public’s Eating
Environmental Protection Agency 88 Behavior 150
Brandy-Joe Milliron, PhD
Conclusion 89
Margaret-Claire Chenault, MS
Dana Dychtwald, MS
Introduction 151
Online Resources 91
The Obesity Epidemic 151
Part III Assessing and Intervening Current Eating Trends 153
in the Community’s Changing Eating Behavior 156
Nutrition Needs 93 Conclusion 174
5 Community Needs Assessment 95
Elizabeth Metallinos-Katsaras, PhD, RDN
Katherine Deren, MS Online Resources 175
Introduction 96 Part IV Promoting the Public’s

Community Needs Assessment: Definition and Overview 96 Nutritional Health 183
Steps to Conduct a Community Needs Assessment 97 9 Growing a Healthier Nation: Maternal, Infant, Child, and
Conclusion 111 Adolescent Nutrition with an Emphasis on Childhood
Issues for Discussion 112 Overweight 185
Practical Activities 112 Shortie McKinney, PhD, RDN, LDN, FADA
Online Resources 113 Introduction 186

Healthy People 2020 Objectives 186
6 Planning and Evaluating Nutrition Services for the
Maternal Health 186
Community 115
Julie M. Moreschi, MS, RDN, LDN Preconceptional Period 188
Infancy 192
Introduction 116
Childhood and Adolescence 195
Project Models 117
Overweight in Children from a Public Health Perspective 209
Intervention Mapping 123
Environmental Influences on Children Who Are Overweight 211
Community Health Assessment and Group Evaluation (CHANGE) 124
Public Health Initiatives 212
Program Implementation 125
Opportunities for Public Health Nutritionists to Intervene and Prevent
Determining Team Membership 125
Overweight in Children 214
Health Program Evaluation 127
Conclusion 216
Conclusion 129
Online Resources 218
Online Resources 130 10 Importance of Public Health Nutrition Programs in
Preventing Disease and Promoting Adult Health 225
7 Serving Those at Highest Nutritional Risk 133 Marianella Herrera-Cuenca, DSc, MD
Rachel Colchamiro, MPH, RD, LDN Introduction 226
Jan Kallio, MS, RD, LDN
Chronic Diseases: The Leading Causes of Death and Disability 226
Introduction 134 Prevention Strategies 227
Defining High-Risk Factors 134 Dietary Guidelines for Disease Prevention 230
Improving Services to At-Risk Families 144 Diet and Health: Nutrition Strategies Health Determinants and Risk
Conclusion 144 Factors 232
Issues for Discussion 147 Policies and Programs 244
Practical Activities 147 Conclusion 245
Online Resources 148 Issues for Discussion 245
vi Contents
Practical Activities 245 Food Security in the United States 300

Online Resources 246 Impact of Food Insecurity on the Public 304
Strategies to Assist the Public in Securing Adequate Food 305
11 Promoting Older Adult Nutrition 252
Andrea T.K. Roche, MS, RDN, LDN Conclusion 305
Introduction 253 Issues for Discussion 306
Unique Features of Baby Boomers 254 Practical Activities 306
State of Health of the Older Adult Population 255 Online Resources 306
Health Insurance and Screening 256
Aging-in-Place 257 14 Safeguarding and Securing the Food Supply 310
Rebecca Kahn, MA
Wellness Screening and Interventions 257
Introduction 311
Nutrition Support Services for Older Adults 258
Food Safety Defined 311
Other Public Health Nutrition Interventions 263
Protecting the Food Supply 312
The Future 264
Food Safety Laws 314
Conclusion 265
Hazards to Food Safety 318
Food Safety in the 21st Century 329
Food as a Target 330
Public Health Preparedness for Food Biosecurity 332
12 Providing Nutrition Services in Public Health Primary Food Biosecurity Triad: Food Systems Security, Public Health Vanguard,
Care 269 and Consumer Engagement 337
Lauren Melnick, MS, RDN, LDN
From Awareness to Security 344
Introduction 270 Conclusion 345
Room for Nutrition in Primary Care 270 Issues for Discussion 346
Agency for Healthcare Research and Quality 272 Practical Activities 346
Barriers to Providing Nutrition Services in Primary Care and Strategies Online Resources 347
for Increasing Services 274
Systemwide Change Strategies for Reducing the Cost of Medical
Care 276 Part VI
Managing Programs 361
Chronic Disease Management and Self-Management 276
15 Grant Writing in Public Health Nutrition 363
Summary of Health Insurance Plans 278 Kathleen Cullinen, PhD, RDN
Representative Programs That Deliver Nutrition Services in Primary Introduction 364
Care Settings 280
General Revenue 365
Health Resources and Services Administration, Bureau of Primary
Third-Party Reimbursement 367
Health Care 283
Public Health Department Accreditation 367
Conclusion 287
Developing Skills in Grant Writing 367
Preparing Your Grant Application 368
Data in Grant Writing for Program Planning and Evaluation 370
Analysis of Quantitative Data 375
Part V Protecting the Public’s Data in Program Management and Evaluation 376
Nutritional Health 293 Nutrition Monitoring and Surveillance 377
13 Food Security and Adequate Food Access for the Protection of Human Subjects 377
Public 295 Data Compilation 378
David H. Holben, PhD, RDN, LD, FAND Prior to Submitting Your Grant Proposal 379
Introduction 296 Conclusion 380
Measuring the Food Security Status of the Public 296 Issues for Discussion 380
Contents vii
Practical Activities 380 Synergizing with the Strategic Plan 428

Title of Proposed Project: Farm to Family 381 Partnering to Achieve Shared Goals 429
Online Resources 383 Relations with the Policy Board 429
Communications with the Media 429
16 Staffing, Managing, and Leading Public Health Nutrition
Conclusion 431
Personnel 385
Esther Okeiyi, PhD, RDN, LDN Issues for Discussion 431
Introduction 386
The Role of a Public Health Nutrition Director/Manager 386
Conclusion 402
19 Marketing Nutrition Programs and Services 433
Issues for Discussion 402 Debra A. Silverman, MS, RDN
Introduction 434
Business Marketing Versus Social Marketing 434
Marketing Research 435
17 Leveraging Nutrition Education Through the Public Health
Primary Data 436
Team 405
Deepa Arora, PhD Market Segmentation 437
Introduction 406 The Social Marketing Mix 438
Modifying Nutrition-Related Behavior 406 Evaluation 443
Definition of Nutrition Education 406 Marketing Ethics 443
Impact of Nutrition Education 406 Conclusion 444
The Nutrition Education Team 409 Issues for Discussion 444
Education Programs 412 Practical Activities 445
National Initiatives to Promote Nutrition Education 413 Online Resources 445
Teamwork 414
20 Striving for Excellence and Envisioning the
Conclusion 416
Future 448
Issues for Discussion 416 Jennifer Hughes, MS
Introduction 449
Importance of Professional Development 451
Future Challenges in Public Health Nutrition 453
Part VII Surviving in a Competitive Conclusion 454
World 419 Issues for Discussion 454
18 Networking for Nutrition and Earning Administrative Online Resources 455
Support 421
Sharon Gallagher, MEd, RD, LDN References 455
Introduction 422
Appendix A Helpful Nutrition Web Sites 456
Networks, Alliances, Coalitions, and Consortiums 422
Appendix B State Health Department Web Sites 458
Collaborating with Others for Nutrition Networks 423
Developing a Community-Based Nutrition Network 425 Appendix C Comprehensive Case Study 459
Professional Networking 425 Appendix D List of Abbreviations 461
Earning Administrative Support 427 Glossary 462
The Administration’s Perspective 427 Index 469
Understanding the Agency Vision and Strategic Plan 428
Preface
WHAT IS PUBLIC HEALTH 10. Research for new insights and innovative solutions
to health problems.
NUTRITION?
When these 10 elements are expanded to full
explanations, we create a compendium of information that
Public health nutrition is a complex, multifaceted set
mirrors the table of contents in this book. The organization
of programs dedicated to improving the health of the
of Nutrition in Public Health, Fourth Edition, embraces the
population through improved nutrition. In more detail,
Essential Public Health Service Functions.
public health nutrition primarily exists to:
• Improve the health of the whole population and
teach high-risk subgroups within the population
improved nutrition;
ORGANIZATION OF THIS TEXT
• Emphasize health promotion and disease prevention
through improved nutrition; and The structure of Nutrition in Public Health has been
• Provide integrated community efforts for improved completely reorganized in an effort to better match the way
nutrition with leadership demonstrated by government courses are taught.
offices.1 Part I, “Applying Nutrition in Public Health,” creates
the necessary foundation for readers to understand public
To accomplish these three primary elements of public health nutrition. These chapters include:
health nutrition, the U.S. Public Health Service has
delineated 10 Essential Public Health Service Functions.2 • An explanation that public health goals are built
Each of these 10 elements will assist the reader in on a foundation of sound research, wherein peer-
understanding the steps that must be taken by public health reviewed studies provide the groundwork.
professionals to bring about definitive qualitative and • A journey through studying populations utilizing
quantitative results. epidemiology, and how problems and solutions are
questioned and acted upon.
1. Monitor health status to identify and solve
community health problems. Chapters 3 through 8 comprise Part II, “Shaping the
2. Identify and investigate the causes of health problems Policies That Affect the Public’s Health,” and Part III,
and health hazards in the community. “Assessing and Intervening in the Community’s Nutrition
3. Mobilize community partnerships and action to Needs.” These chapters illustrate the landscape of public
identify and solve health problems. health, including:
4. Develop policies and plans that support individual • The role of the federal government in supporting
and community health. public health nutrition.
5. Enforce laws and regulations that protect health and • How researchers and others determine the need
ensure safety. for public health nutrition in areas of the United
6. Link people to needed personal health services and States.
assure the provision of health care when otherwise • How researchers determine the needs of each
unavailable. community and focus on its nutritional problems.
7. Inform, educate, and empower people about health • An explanation of how nutritional services are
issues. planned and evaluated for a community.
8. Evaluate effectiveness, accessibility, and quality of • Changing the public’s eating behavior as a whole.
personal and population-based health services.
9. Assure a competent public health and personal In Part IV, “Promoting the Public’s Nutritional
healthcare workforce. Health,” Chapters 9 through 12, we strive to educate the
Preface ix
reader about federal programs that provide public health • Issues for Discussion encourage readers to discuss
nutrition for those at risk. These include: topics relevant to the chapter with their peers.
• Practical Activities suggest activities that allow
• Promoting maternal, infant, child, and adolescent
readers to apply what has been learned in the chapter,
nutrition.
either individually or as part of a group.
• Assessing and providing for adult nutrition.
• Online Resources direct readers to websites
• Caring for older adults and their nutritional
relevant to the chapter content.
problems.
• Explaining nutritional programs in public health. These pedagogical features assist in bringing the chapter
material to life as students will need to use critical thinking to
Part V, “Protecting the Public’s Nutritional Health,”
solve public health nutrition problems through application.
delineates 21st century issues in providing safe and secure
food supplies for the public. These include:
• Providing food security and adequate food access for NEW TO THIS EDITION
the public.
• Safeguarding and securing the food supply. Nutrition in Public Health, Fourth Edition, has maintained the
Part VI, “Managing Programs,” and Part VII, “Surviving cutting edge relevance of previous editions, while adding
in a Competitive World,” address the administrative and several enhancements:
managerial portion of public health nutrition and programs. • Reorganized Table of Contents. The Table of
These include: Contents has been completely reorganized for this
• Grant writing for funding of public health nutrition edition in an effort to streamline the content and to
programs. better reflect the way many instructors teach public
• Staffing, managing, and leading public health health nutrition. This has involved rearranging,
nutrition personnel. combining, and separating chapters as necessary. A
• Leveraging nutrition education through a public Transition Guide comparing the Tables of Contents
health team. for the Third Edition and Fourth Edition is available
• Networking for nutrition by earning administrative online.
support. • Thoroughly revised and in-depth content.
• Marketing nutrition programs and services. Each chapter has been updated and enhanced to give
• Striving for excellence and envisioning the future. the reader a vast supply of background information
and a full understanding of public health nutrition.
In addition, new and expanded topics have been
added to the Fourth Edition to reflect current public
FEATURES OF THIS TEXT health issues. These include:
• Updated Dietary Guidelines for Americans,
MyPlate, Healthy People 2020, and other nutrition
An effort has been made to ensure that pedagogical features
indexes
are consistent from chapter to chapter. At the beginning of
• Updated federal nutrition policies and services
each chapter, the reader will find the following:
• Updated approaches to disease prevention and
• Learning Objectives present the chapter’s desired new disease statistics, including current U.S.
outcomes to readers. statistics and census information
• Key Terms help the reader quickly identify critical • Newly added grant writing procedures
new terms, with definitions included in the end-of- • New, comprehensive end-of-text Glossary
text Glossary. • Added Case Studies. Case Studies are now found
at the end of each chapter, reinforcing key concepts
At the end of each chapter, the reader will find the
by presenting real-life examples. Comprehensive
following:
Case Studies that utilize concepts found across the
• Case Studies provide a real-world dimension to span of the text are also found in Appendix C. An
chapter content, illustrating how public health Answer Key for all Case Study questions is available
nutrition issues and programs can affect real people. for qualified instructors.
x Preface
INSTRUCTOR RESOURCES References
Qualified instructors can receive access to the full suite of 1. Division of Epidemiology. School of Public Health,
instructor resources, including the following: University of Minnesota. The LET Program, 1999.
2. U.S. Public Health Service Essential Public Health
• Slides in PowerPoint format, featuring more than Services. Work Group of the Core Public Health
300 slides Function Steering Committee, 1994.
• Test Bank, containing 600 questions
• Answer Key, including answers for Case Studies
found within the text
Acknowledgments
The editor and contributing authors of Nutrition in Public School of Public Health. It is Mildred’s pioneering spirit
Health, Fourth Edition, would like to recognize the editor and fine efforts on the First Edition of this book that have
of the First Edition, Mildred Kaufman, MS, RD. Mildred made the subsequent editions possible. We are grateful to
is an alumnus of Simmons College, which the majority Mildred for this and for her contribution to the field of
of contributing authors call home, and a past Department nutrition, dietetics, and public health.
Head of the University of North Carolina Chapel Hill’s
Contributors
Deepa Arora, PhD Shortie McKinney, PhD, RDN, LDN, FADA

Middle Georgia College University of Massachusetts, Lowell
Lisa S. Brown, PhD, RD, LDN Lauren Melnick, MS, RDN, LDN
Simmons College Cleveland Clinic
Margaret-Claire Chenault, MS Elizabeth Metallinos-Katsaras, PhD, RDN

Drexel University Simmons College
Rachel Colchamiro, MPH, RD, LDN Brandy-Jo Milliron, PhD

Massachusetts Department of Public Health Drexel University
Kathleen Cullinen, PhD, RDN Julie M. Moreschi, MS, RDN, LDN

Michigan Fitness Foundation Benedictine University
Katherine Deren, MS Theresa A. Nicklas, DrPH

Simmons College Baylor College of Medicine
Dana Dychtwald, MS Elisabeth Offenberger, MS, RD

Drexel University Simmons College
Sharon Gallagher, MEd, RDN, LDN Esther Okeiyi, PhD, RDN, LDN
Simmons College North Carolina Central University
Marianella Hervera-Cuenca, DSc, MD Carol E. O’Neil, PhD, MPH, LDN, RD

Universidad Central de Venezuela Louisiana State University
David H. Holben, PhD, RDN, LD, FAND Andrea Teresa K. Roche, MS, RDN, LDN
Ohio University Simmons College
Jennifer Hughes, MS Debra A. Silverman, MS, RDN

Simmons College Mayo Clinic
Jan Kallio, MS, RD, LDN Jody Vogelzang, PhD, RDN, FAND, CHES
Altarum Institute Grand Valley State University
Rebecca Kahn, MA
Simmons College
Case Study Contibutors
Amy Sheeley, PhD, RDN Stephanie Cook, RDN
Shirley Chao, MS, RDN, LDN Louisa Paine, BS
Bridgitte A. Carroll, MS
Reviewers
Susan E. Adams, MS, RD, LDN, FAND June Kloubec, PhD

La Salle University Bastyr University
Jamie Benedict, PhD Angela Kong, PhD, MPH, RD

University of Nevada, Reno University of Illinois at Chicago
Shiva Mehran Davanloo, PhD Diane Longstreet, PhD, MPH, RD, LDN
Collin College Keiser University
Kristen Davidson, MS, PhD Deborah Myers, EdD, RDN, LD

Harvard T. H. Chan School of Public Health Bluffton University
Jeri R. Finn, MS, RDN Payal Patel-Dovlatabadi, DrPH, MPH, MBA

Oregon Health & Science University University of Evansville
Sheila Fleischhacker, PhD, JD Dennis Wissing, PhD, FAARC

National Institutes of Health Louisiana State University, Shreveport
Laura Horn, MEd, RD, LD Lauri Wright, PhD, RDN

Cincinnati State Technical and Community College University of South Florida
Rafida Idris, PhD, MPH

South Carolina State University
© Clive Tooth/ShutterStock, Inc.
Public Health
Applying Nutrition in
PART
1
CHAPTER
© Elnur/ShutterStock, Inc.
1
Applying Nutrition Science to
the Public’s Health
CAROL E. O’NEIL, PHD, MPH, RD, LDN
THERESA A. NICKLAS, DRPH
If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found
the safest way to health.—Hippocrates 460–377 BCE
LEARNING OBJECTIVES
After studying this chapter and reflecting on the contents, you should be able to:
1. Explain how and why nutrition policies, programs, and practice must be evidence based.
2. Evaluate the peer-reviewed literature and assess bodies of evidence used to form nutrition policies
and recommendations.
3. Compare and contrast different types of research studies and explain how they are used to form
policies, programs, and consumer information.
4. Explain how and why nutrition policies, recommendations, and programs are changed at regular
intervals.
5. Use the same resources as public health nutritionists to keep pace with current research or available
programs that are grounded in research.
KEY TERMS
Center for Nutrition Policy and Evidence-based practice National Nutrition Monitoring
Promotion Healthy Eating Index (HEI) and Related Research Pro-
Cohort study Healthy People 2020 gram (NNMRRP)
Cross-sectional study Hierarchy of evidence Nutrition monitoring
Dietary Guidelines for Ameri- National Health and Nutri- Peer-reviewed literature
cans (DGA) tion Examination Survey PubMed
Dietary Reference Intakes (NHANES) Public health nutritionist
(DRI) MyPlate, MyWins Randomized controlled trials
4 Chapter 1: Applying Nutrition Science to the Public’s Health
INTRODUCTION or had a body mass index (BMI) >30.7 The prevalence of

obesity among U.S. children 2–19 years of age was 17.0%
Hippocrates was right, but for the rest of us, appreciation in 2011–2014. The prevalence of obesity among children
of this relationship was a long time in coming. Prior to 2–5 years of age (8.9%) was lower than among children
the 1970s, public health nutrition was focused primarily 6–11 years (17.5%) and adolescents 12–19 years (20.5%).
on feeding programs and preventing nutrient deficiency The same pattern was seen in males and females.6 Obesity
diseases. Early in the 20th century, there was a general is calculated differently in children than in adults because
lack of understanding of the relationship between diet the relationship between BMI and body fat in children
and disease, and diseases such as pellagra and rickets were varies with age and pubertal maturation; thus, a single
common. As food availability improved and the prevalence cutoff cannot be used for all ages. For children, a percentile
of deficiency diseases decreased, there was a growing range on the Centers for Disease Control and Prevention
awareness that dietary excess and imbalance increased the (CDC) growth charts is used: less than the 5th percentile is
risk of developing chronic disease, such as coronary heart underweight, the 5th to <85th percentile is normal weight,
disease (CHD), hypertension, type 2 diabetes mellitus, 85th to <95th percentile is considered obese, and >95th
and cancer.1 percentile is considered obese.8
In 1977, the U.S. Senate Select Committee on A significant increase in obesity in adults and children
Nutrition and Human Needs, under the leadership of was seen from 1999–2000 through 2013–2014; however,
Senator George McGovern, issued Dietary Goals for the no change was seen in children between 2003–2004 and
U.S.2 The goals engendered controversy among health 2013–2014. No significant change in obesity prevalence
professionals and the food industry because of the way they among adults or children was seen between 2011–2012 and
were conceived and presented. At that time, there was also a 2013–2014.6 In the United States, the current estimated
lack of consensus on the impact of food/nutrients on chronic healthcare costs of obesity range from $147 billion to nearly
disease risk. In retrospect, the authors of these dietary goals $210 billion. This does not include the nearly $4.3 billion
were remarkably perspicuous. The statement by Dr. C. associated with job absenteeism and lower productivity
Edith Weir, Assistant Director of the Human Nutrition at work.9,10 Obesity has surpassed tobacco, alcohol, and
Research Division, U.S. Department of Agriculture poverty as a public health risk.11,12 Thus, it is crucial to
(USDA), that “Most all of the health problems underlying work toward reducing disease risk and promoting healthy
the leading causes of death in the U.S. could be modified by behaviors in all individuals.
improvements in diet”2 remains the cornerstone of public These health problems are not unique to the United
health nutrition and nutrition policy in the United States. States. Globally, largely preventable chronic diseases
Today, the preponderance of epidemiologic, clinical, account for 60% of all deaths (35 million people), 80% of
and laboratory data have clearly linked both diet and physical whom live in low- or middle-income countries.13 Over
inactivity with chronic disease. Four of the leading causes the next decade, it is estimated that more than 75% of
of death—heart disease, cancer, cerebrovascular disease, deaths worldwide will result from these diseases, with 60%
and diabetes mellitus—are related directly to poor diet, occurring in developing countries that are experiencing
physical inactivity, and other lifestyle factors.3 The cost of rapid health transitions. The World Health Organization
these diseases to the United States, both in terms of direct (WHO)14 has compared the spread of chronic diseases to
patient care and lost productivity, is staggering; for example, that of communicable diseases; however, chronic diseases
in 2010 heart disease and stroke cost approximately $315.4 appear to be “spread” by the Westernization of diets and
billion with $193.4 billion in direct patient care.4 Cancer the decline in physical activity associated with increasing
care in 2010 cost $157 billion and, in 2012 undiagnosed industrialization rather than by infectious or parasitic
diabetes mellitus cost $245 billion with $176 billion going agents. The WHO finalized a global strategy to improve
to direct medical costs.4 More information about the cost of diet and increase physical activity to reduce the risk of
chronic diseases at the state level can be found through the chronic noncommunicable diseases while continuing
chronic disease cost calculator.5 to carry forward the long-term WHO goals on other
Not included among the four major causes of death, nutrition-related areas, including undernutrition.
but a major contributor to these and other health problems, Relatively few modifiable risk factors—for example, a
is obesity. Obesity has reached epidemic proportions. lack of fruit and vegetables in the diet, obesity, smoking,
National Health and Nutrition Examination Survey inappropriate use of alcohol, and physical inactivity—cause
(NHANES) data from 2011 to 20146 showed that among the majority of the chronic disease burden. Changes in
adults 34.3% of males and 38.3% of females were obese diet and physical activity patterns can significantly reduce
disease risk, often in a surprisingly short time period. It are not able to plan interventions and design policies and
has been estimated that a 1% reduction in intake of fat recommendations that change behavior that will lead to a
and saturated fatty acids and a 0.1% reduction in intake healthier lifestyle.
of cholesterol would, over 20 years, prevent more than Public health nutritionists need to have a broad grasp
56,000 cases of Coronary Heart Disease (CHD)15 and of the sciences, including the pathophysiology of disease,
more than 18,000 deaths; these changes would also save genetics, and biotechnology and its impact on sustainable
more than 117,000 life-years. Improved dietary patterns agriculture, nutrition biochemistry and molecular biology,
could save more than $43 billion in medical care costs nutrigenomics, informatics, biostatistics, epidemiology,
and lost productivity resulting from CHD, cancer, stroke, and, of course, nutrition sciences. Finally, public health
and diabetes and prevent more than 119,900 premature nutritionists need to know what information and resources
deaths among individuals 55 to 74 years of age. As the are available to them to help plan and assess programs at the
average life expectancy in the United States continues to national, state, local, or individual levels.
rise, and if current dietary and physical activity patterns Today, for consumers and health professionals alike,
remain unchanged, the incidence and prevalence of chronic there is a bewildering array of diet and physical promotion
diseases will continue to increase. information available on the Internet and through other
media channels.31,32 A 2009 survey of more than 1,000 adults
conducted by the American Dietetic Association (now the
PUBLIC HEALTH NUTRITION Academy of Nutrition and Dietetics) showed that nearly
AND PUBLIC HEALTH 80% were interested in finding nutrition information on
the Internet, and 70% visited two or three websites when
NUTRITIONISTS using the Internet to find food and nutrition information.
Virtually all participants believed the information they
The Institute of Medicine’s (now known as the Health and found online was reliable and trustworthy.33 It is vital that
Medicine Division of the National Academies of Sciences, health professionals, including registered dietitians, provide
Engineering, and Medicine) The Future of the Public’s Health timely, accurate on line information,34 help consumers
in the 21st Century states that the mission of public health understand that not all information available is accurate, and
is “to assure conditions where people can be healthy.”16 help them understand how to distinguish sound science. To
This report extends the Future of Public Health report, which do this, we as health professionals need to understand how
asserted that public health is “what we as a society do to evaluate information.
collectively to assure the conditions in which people can In this chapter, we look at examples of how to interpret
be healthy.”17 Public health nutritionists or registered and evaluate the professional literature to (1) make
dietitians working in public health settings can play decisive evidence-based practice decisions in public health; (2) learn
roles in improving our nation’s health.16,17 Challenges for the science behind nutrition recommendations, policy, and
health professionals in the 21st century include shifting legislation; and (3) find ways for nutritional science to be
demographics, changes in eating and physical activity translated into messages for consumers.
patterns, disparities in health care, and global economic
pressures.
Public health nutritionists need to be able to understand PEER-REVIEWED LITERATURE
what drives food and physical activity choices by the public. AND EVIDENCE-BASED
Food choices are driven by taste; convenience; accessibility,
availability, and affordability of foods; ethnic or religious PRACTICE
preferences; socioeconomic status; health and nutrition
knowledge; shopping practices; and time.18–26 The decision Peer-reviewed literature is the gold standard for scientific
not to engage in regular physical activity may be driven information provided to the public as well as the information
by lack of knowledge and attitudes about physical activity used for setting recommendations and policies, designing
recommendations, lack of a safe place to exercise or of social and evaluating nutrition programs, and conducting
support, lack of access to programs, and time.27–30 ethical evidence-based nutrition and dietetics practice.
Without knowing why different populations choose Unfortunately, the literature can be difficult to understand,
healthy foods or choose not to exercise, it is difficult to and results from different studies can be contradictory.
understand why people eat what they do, why they do Use of different study designs, populations, or methods—
or do not engage in physical activity, or why they are or including statistical analyses—contribute to the confusion.
Assessing the science behind the policies, programs, conducting the search. The descriptors and the search limits
practice, and consumer information begins with asking a depend on the question(s) you are asking. For example, if
question and finding, reading, and evaluating the articles your question is, “What is the effect of 100% fruit juice
needed to answer it. PubMed is the premiere database for consumption on weight in children?” your descriptors
articles on nutrition topics. This database contains more could be “fruit juice” OR “fruit” AND “weight” OR
than 19 million citations for biomedical articles from “BMI” AND “children” OR “adolescents.” The search
MEDLINE and life science journals. Many citations in might be easier if your search limit is “All Children,” then
PubMed include links to full-text articles from PubMed the last two descriptors could be eliminated.
Central or publisher websites. Important databases for Scanning the titles and abstracts will allow you to
nutrition-related research are shown in Table 1–1. determine which articles are appropriate for answering
After asking a question and determining the appropriate your question. Obtaining the full-text articles, either by
database to use, the next stage is selecting the descriptors and downloading them or visiting the library, and assessing
Table 1–1 Databases Important for Nutritional Sciences Literature Searches

Database Purpose
AGRICOLA Provides citations in agriculture and related fields.

AGRIS International information system for the agricultural sciences and technology; created by the
Food and Agriculture Organization of the United Nations (FAO).
BRFSS Includes eight databases on specific illnesses or aspects of chronic disease prevention
Behavioral Risk Factor and health promotion; designed to help public health professionals and educators locate
Surveillance System: Survey Data program information.
CARIS Created by FAO to identify and to facilitate the exchange of information about current
Current Agricultural Research agricultural research projects being carried out by or on behalf of developing countries.
Information System
The Cochrane Library Contains reliable evidence from Cochrane and other systematic reviews, clinical trials, and
more. Cochrane reviews bring you the combined results of the world’s best medical research
studies and are recognized as the gold standard in evidence-based health care.
Directory of Open Access Journals This database increases the visibility and ease of use of open access journals and promotes
their increased usage and impact.
EMBASE The most comprehensive course for answers on biomedical answers.
ERIC Includes educational research and resources; early childhood education, junior colleges
Educational Resources and higher education; reading and communications skills; languages and linguistics;
Information Center education management; counseling and personnel services; library and information science;
information resources.
Food Safety Research Database The Food Safety Research Information Office is located at the National Agricultural Library.
This office provides information on publicly funded, and to the extent possible, privately
funded food safety research initiatives to prevent unintended duplication of food safety
research and to assist the executive and legislative branches of the government and private
research entities in assessing food safety research needs and priorities.
FSTA The largest collection of food science, food technology, and food-related human nutrition
Food Science and Technology abstracts. It contains more than 580,000 records with approximately 2,000 new records
Abstracts added every month. FSTA covers journal articles (~80%) plus patents, theses, standards,
legislation, books, reviews, and conference proceedings.
Health Source: Nursing/Academic Provides approximately 600 scholarly full-text journals, including nearly 450 peer-reviewed
Edition journals focusing on many medical disciplines. Also features abstracts and indexing for nearly
850 journals.
Table 1–1 Databases Important for Nutritional Sciences Literature Searches (continued)
Database Purpose
Index to Scientific and Technical Indexes the published literature of the most significant conferences, symposia, seminars,
Proceedings colloquia, workshops, and conventions in a wide range of disciplines in science and
technology over the last 5 years.
LILACS Includes bibliographic control and dissemination of health scientific-technique literature from
Latin American and Caribbean Latin American and Caribbean countries, absent from other the international databases.
of Health Sciences Information
System
MEDLINE Sponsored by the National Library of Medicine, contains citations and abstracts to
international biomedical literature from more than 3,700 journals on topics including
research, clinical practice, administration, policy issues, and healthcare services.
Merck Index Online A one-volume encyclopedia of chemicals, drugs, and biologicals that contains more than
10,000 monographs, 32 supplemental tables, and 450 Organic Name Reactions. Entries
cover drugs and pharmaceuticals, describe common organic chemicals and laboratory
reagents, cover naturally occurring substances and plants, the elements and on inorganic
chemicals, and compounds of agricultural significance.
Nursing and Allied Health Source Provides reliable healthcare information covering nursing, allied health, alternative and
complementary medicine, and related topics.
Science Citation Index This database covers the journal literature of the sciences.
Science Direct A Web information source for scientific, technical, and medical research. It offers access to
more than 1,100 journals in 16 fields of science, including the social sciences.
Scopus™ The largest abstract and citation base of peer-reviewed literature.
Web of Science Indexes more than 5,800 major journals across 164 scientific disciplines.
If your library does not have access to these databases, just ask the librarian at your university to help you.
them are the next steps (Table 1–2). This is not a casual quality of the studies—including the extent to which bias
reading to prepare a summary of the article but a critical was minimized, (2) the quantity of the studies—including
evaluation of the published study—try it out with a subject the magnitude of effect, the number of studies conducted,
of interested to you. However, a single peer-reviewed article and the sample size or power of the studies, and (3) the
is not sufficient for making ethical evidence-based practice consistency of results—whether similar studies produce
decisions; setting public health goals (e.g., Healthy People similar results.
2020); developing dietary recommendations (e.g., Dietary Another critical consideration when assessing the body
Reference Intakes [DRI]); mandating nutrition policy (e.g., of evidence is the study design: what type of study was used
Dietary Guidelines for Americans [DGA]); or designing to produce the test results, and what was the relevance to
nutrition programs for health professionals and the public the disease/condition/program under study? Some study
(e.g., the Produce for Better Health Foundation’s Fruits designs are more powerful than others in providing evidence
and Veggies More Matters”). To do this, the strength of a on a topic; this has given rise to the concept of a hierarchy
body of scientific studies must be assessed.35, 36 of evidence38 about the effectiveness of interventions,
The Agency for Healthcare Research and Quality, treatments, practice protocols, or policies. From bottom
through its Evidence-Based Practice Centers, sponsors (least convincing) to top (best evidence) the hierarchy is
the development of evidence reports and technology generally presented as expert opinion, case reports, case
assessments to assist public and private sector organizations series, case-control studies; cross-sectional studies;
in their efforts to improve the quality of health care in cohort studies (prospective or retrospective); randomized
the United States.37 Three important domains should be controlled trials (RCT); and systematic reviews of RCT
addressed to grade the strength of the evidence: (1) the with or without meta-analysis. It should be kept in mind,
Table 1–2 How to Assess an Article from the Peer-Reviewed Literature

Title
1. Did the title reflect what was actually done in the study? The purpose, the populations used, the findings, and conclusions can
be reflected in the title. A positive statement about the contents, rather than a title that is a question, is preferred.
Abstract
1. Did the abstract clearly outline all aspects of the manuscript?
a. The purpose of the study
b. The methods
c. The results
d. The conclusions
2. Was enough information provided to understand what was done and what was found?
Introduction
1. Did the authors provide enough background information to understand why the study was done?
2. Did the authors provide enough background information to let you know what others have done on this topic and where there
might be gaps in the literature?*
3. Were important studies omitted from the introduction? This might suggest bias.
4. Did the authors clearly state the purpose of the study? A hypothesis or research question should have been stated. Not all
study designs are appropriate for testing hypotheses; for example, cross-sectional studies are hypothesis generating.
Materials and Methods (could be phrased Subjects and Methods)
1.
Was the type of study clearly defined?
2.
Did the experimental design allow the research question or hypotheses to be tested?
3.
If appropriate, was a control group included? Was it comparable to the test group?
4.
Was the population appropriate for the study?
5.
Was the population suitable to generalize results?
6.
Was the population well defined?
a. Number/adequate sample size for appropriate statistical power.
b. Gender, age, race/ethnicity, income, etc.
c. Inclusion/exclusion criteria for the study.
d. If the study population was a subset of a larger population, was it clear how the study population differed from the larger
population? This could indicate bias.
e. Was a convenience sample used or were the participants randomized?
7. Were there ethical concerns if human subjects or vertebrate animals were used? Was there a clear statement that the
research had been approved by the appropriate committee?
8. Were the methods presented in enough detail so that the research could be repeated (or built upon) by another research team?
9. Were the methods used reliable and valid?
10. Statistical methods:
a. Were they appropriate?
b. Were outcome variables clearly defined?
c. Did the authors control for potential confounding variables?
d. Was a statistical probability level clearly stated?
11. Was it clearly stated how the data will be presented in the results (e.g., data are presented as mean ± standard error [SE])?
12. Were all terms defined?
Results
This section should present study results only. No methodology should be presented unless it is a combined Results and
Discussion section; there should be no interpretation of the information.
1. Were results organized in a logical sequence?
a. Did the results follow the same order as the methods?
2. Were demographics presented?
3. Were the graphics appropriate?
a. Were they needed? Should more/less be included?
b. Was the information clearly presented in labeled tables and figures? Can the tables and figures stand alone?
c. From a biological standpoint were the data reasonable?
Table 1–2 How to Assess an Article from the Peer-Reviewed Literature (continued)
Discussion
1. Were the study objectives met?
2. Did the authors adequately interpret their results?
3. Did the authors discuss their results and compare them with the current literature?
4. Was the discussion related directly to the results or was it overly speculative?
5. If nonstandard methods were used, were they adequately discussed?
6. Were limitations of the study clearly stated?
7. Were conclusions drawn? Were they supported by the results?
References
1. Were appropriate citations listed? Were they accurate? Were they timely?
2. Were enough references presented so that a cogent whole presentation was in the manuscript?
Acknowledgments
1. Were the funding sources clearly identified?
2. Were there real or apparent conflicts of interest, which could suggest bias?
*
This is difficult for those unfamiliar with the literature but becomes easier with practice and familiarity with the topic.
however, that this hierarchy assumes that all studies were the American Diabetes Association, have grading scales.
well designed and executed. A poor RCT may not provide The NHLBI uses a four-point scale to grade the scientific
the same level of evidence as a very well-designed cross- evidence from different study types (Table 1–3). The
sectional study. Evidence Analysis Library (EAL) of the Academy uses
To assess a body of evidence, many organizations, a five-step process, the fourth of which is to summarize
including the National Heart, Lung, and Blood Institute evidence and the last is to develop a conclusion statement
(NHLBI), the Academy of Nutrition and Dietetics, and and assign a grade.
Table 1–3 National Heart, Lung, and Blood Institute’s Evidence Categories
Category Sources of Definition
Evidence
Category A Randomized Well-designed, randomized clinical trials that provide a consistent pattern of findings in
controlled trials the population for which the recommendation is made. Category A requires substantial
(rich body of data) numbers of studies involving substantial numbers of participants.
Category B Randomized Limited randomized trials or interventions, post-hoc subgroup analyses, or meta-
controlled trials analyses of randomized clinical trials. These are used when there are a limited number
(limited body of of existing trials, study populations are small or provide inconsistent results, or when
data) the trials were undertaken in a population that differs from the target population of
recommendation.
Category C Observational or Evidence is from outcomes of uncontrolled or nonrandomized trials or from
nonrandomized observational studies.
studies
Category D Panel Consensus Expert judgment is based on the panel’s synthesis of evidence from experimental
Judgment research described in the literature or derived from the consensus of panel members
based on clinical experience or knowledge that does not meet the above criteria. This
category is used only where the provision of some guidance was deemed valuable
but an adequately compelling clinical literature addressing the subject of the
recommendation was deemed insufficient to place it in one of the other categories.
Reproduced from: U.S. Department of Health and Human Services, The Obesity Education Initiative. (1998). Clinical Guidelines on the Identification, Evaluation, and Treatment
of Overweight and Obesity in Adults, The Evidence Report (NIH Pub. No. 98-4083), table ES-1. http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf.
For the academy’s EAL, the scoring system is limited to, those designed to determine malnutrition,42
somewhat different. “The Academy uses Grades I, II, III, diabetes risk,43 and food security.44
IV, and V for strong, fair, weak, expert opinion only, and no Nutrition assessment measures indicators of dietary status,
evidence, respectively.” Examples of evidence statements using methods such as 24-hour diet recalls, food frequency
for a wide variety of nutrition-related topics are found on questionnaires (FFQ), food diaries, or newer dietary
the EAL’s website, including, but not limited to Adult assessment methods including digital photography45–49
Weight Management, Bariatric Surgery, Fruit Juice, Heart or use of mobile phones to keep food records.50 Principal
Failure, Hypertension, and Sodium. Caveats that should be strengths of 24-hour diet recalls are that they provide
considered for all types of evidence reviews are that they detailed information about the types and amounts of food
are time-consuming and new studies are continually being consumed on a given day, have a low response burden,
published. Be sure you use the most recent information and are cost-effective.45 The principal limitations are that
available in your evidence review and in your practice. they are memory-dependent, respondents may under- or
In addition to the EAL, the USDA’s Nutrition overreport consumption, and 24-hour diet recalls should
Evidence Library (NEL) conducts systematic reviews to not be used to assess individual diets. Collection of group
inform nutrition policy and programs, including the Dietary data from 24-hour diet recalls with mean reporting, for
Guidelines for Americans. The process that the EAL and example, as used by What We Eat in America, the dietary
NEL use to evaluate a body of literature on a given topic is component of the NHANES, is an appropriate use of
similar. The process used by the NEL is to “recruit expert 24-hour diet recalls45; however, it has long been recognized
workgroup, formulate evidence analysis questions, conduct that 24-hour diet recalls may not reflect usual intake.51,52
literature review for each question, extract evidence and In 2003, staff members of NHANES began collecting
critically appraise each study, synthesize the evidence, and two recalls, the first in person in the Mobile Examination
develop and grade a conclusion statement.” Center and the second 3 to 10 days later by telephone.
The National Cancer Institute, coupled with the Center
for Nutrition Policy and Promotion (CNPP), developed
NUTRITION MONITORING a statistical method to calculate usual intake using both
recalls.53–56 Multiple 24-hour dietary recalls using the
Collecting nutrition and health-related information from multiple pass method45 is the standard for assessing intake
a population is critical for designing and evaluating policies (Table 1–4). Because intake may change on weekend days,
and programs that improve health status and decrease risk it is important to include both weekday and weekend days
factors. Scientists analyze data from nutrition monitoring in the recalls.
programs and use these analyses to contribute to the It should be noted that NHANES also collects
literature. To be useful, information must be collected information on supplement and prescription medication
in a timely manner and presented to scientists, policy intake, food security, some consumer behaviors, and
makers, and the public in a readily understandable form. anthropometrics. These data can be used with the data
Without current monitoring, decisions may be made collected from the recalls not only to further the nutrition
using insufficient information or incorrect assumptions. assessment but also to look for associations among variables.
Nutrition and health-related information can be obtained Food frequency questionnaires vary in the number of
using several methods, notably through nutrition screening, food items, food groups, and food portion assessments—all
assessment, and surveillance; these are often collectively of which affect nutrient intake.57,58 Similar to 24-hour diet
referred to as nutrition monitoring. recalls, FFQs often underestimate intake of total energy,59,60
Nutrition screening is a systematic approach to quickly and energy adjustment can be used to reduce the effects
identify nutrition problems or individuals at nutritional risk of measurement error, that is, regression dilution.61,62 It
who are in need of further assessment or an intervention. is also important that appropriate racial and ethnic foods
Screening can be done in free-living and hospitalized consumed by the population of interest be included when
individuals; however, it is important to use validated designing FFQs. Although a wide variety of FFQs are in
instruments to maximize the chance of correctly identifying use, some have not been validated against 24-hour recalls or
at risk individuals.39,40 The Mini Nutritional Assessment, direct observation. Using meta-analyses, FFQs with longer
used in screening elderly populations,41 is a widely used food lists (200 items) were shown to have 0.01 to 0.17
valid screening instrument. Many other screening tools higher correlation coefficients than FFQs with shorter food
are available for nutrition professionals, including, but not lists (100 items) for most nutrients.63 An advantage of FFQs
Table 1–4 Information Collected During National Health and Nutrition Examination Survey Diet Interviews
5-Step Multiple-Pass Approach For each food Detailed description

and beverage
Step Purpose Additions to the food
consumed during
Collect a list of foods and previous 24-hour Amount consumed
Quick List beverages consumed the period
What foods were eaten in combination
previous day.
Time eating occasion began
➡
Name of eating occasion
Probe for foods forgotten Food source (where obtained)

Forgotten
during the Quick List. Whether food was eaten at home
Foods
Amounts of food energy and 60+ nutrients/food
➡
components provided by the amount of food

(calculated)
Collect time and eating For each Day of the week
Time &
occasion for each food. respondent on
Occasion Amount and type of water consumed, including
each day
total plain water, tap water, and plain carbonated
➡
water
Source of tap water
For each food, collect detailed Daily intake usual, much more or much less than
Detail Cycle description, amount, and usual
additions. Review 24-hour day.
Use and type of salt at table and in preparation
➡
Whether on a special diet and type of diet

Final probe for anything else
Final Probe Frequency of fish and shellfish consumption (past
consumed.
30 days)
Daily total intakes of food energy and 60+
nutrients/food components (calculated)
Reproduced from: NHANES Dietary Web: Dietary Data Overview. Task 2: Key Concepts About NHANES Dietary Data Collection. Tutorial. http://www.cdc.gov/nchs/tutorials/
dietary/surveyorientation/dietarydataoverview/info2.htm.
is that they can be self-administered and thus are suitable Equivalents Database,65 which may be more appropriate
for large epidemiologic studies. for health professionals. Nutrient intake can be assessed
Digital photography to determine food intake,47–49 using the USDA National Nutrient Database for
including by individuals with their own cell phones,50 is Standard Reference,66 the Food and Nutrient Database
also used. These technology methods are appealing, but for Dietary Studies,67 and commercially available diet
accuracy is dependent on training staff, study participants, analysis programs. These databases may not all yield the
or clients to take consistent photographs. Other methods same nutrient analyses, and it is best to be consistent when
used to determine intake include direct observation, plate using them to analyze data. Whenever possible, dietary
waste, and food records with or without the weighing of intake should be confirmed using appropriate biomarkers;
foods. for example, folate intake should be confirmed with
Accurate determination of intake is critical. Intake serum folate levels.68,69 Intake of nutrients or food groups
of food groups can be determined using instruments can be compared with recommended values for specific
as conventional as the MyPlateSuperTracker,64 which populations and, in turn, with the prevalence or incidence
is appropriate for the public, and the Food Patterns of chronic disease.
Surveillance comes from the French verb surveiller, “to nutritional status in the United States. Monitoring efforts
watch over.” In 1968, the World Health Assembly described are divided into five overarching areas: nutrition and related
surveillance as “the systematic collection and use of health measurements; food and nutrient consumption;
epidemiologic information for planning, implementation, knowledge, attitude, and behavior assessments; food
and assessment of disease control.”70 Surveillance, in composition and nutrient databases; and food supply
contrast to surveys, is continuous, and data that are collected determinants. Important monitoring programs are
can be used to provide the framework for public health summarized in Table 1–5. Most of the data sets generated
policies and the rationale for intervention. Surveillance through this program are available to the public. Some
also provides a way to monitor the effectiveness of specific are restricted, due to confidentially or disclosure rules/
interventions. This completes the loop–surveillance studies regulations, but can be accessed by researchers through
that can be used to determine nutritional problems or application to the Research Data Center in the National
nutritional needs. After the intervention, they can be Center for Health Statistics (NCHS) headquarters in
used to determine whether the problems remain or the Hyattsville, Maryland.
intervention was effective.
Most governments track the health and nutrition status Goals of NHANES
of their population. For example, the U.S. government has
• Estimate the number and percent of persons in the
tracked information on food and the food supply for more
U.S. population, and designated subgroups, with
than 100 years, starting with the USDA’s Food Supply Series
selected diseases and risk factors.
in 1909. The first USDA Household Food Consumption
• Monitor trends in the prevalence, awareness,
Survey (known as the Nationwide Food Consumption
treatment, and control of selected diseases.
Survey after 1965) was begun in the 1930s. In 1960,
• Monitor trends in risk behaviors and environmental
the National Health Examination Survey was initiated;
exposures.
however, it did not include information on nutrition and
• Analyze risk factors for selected diseases.
its link with diet. Thus, federal officials could not provide
• Study the relationship between diet, nutrition, and
information on diet and disease or undernutrition to
health.
Congress. The nation’s first comprehensive nutrition
• Explore emerging public health issues and new
survey was the Ten-State Nutrition Survey conducted
technologies.
between 1968 and 1970 in 10 states: California, Kentucky,
• Establish a national probability sample of genetic
Louisiana, Massachusetts, Michigan, New York, South
material for future genetic research.
Carolina, Texas, Washington, and West Virginia. The
• Establish and maintain a national probability sample
NHANES I and II and the Pediatric Nutrition Surveillance
of baseline information on health and nutritional
Systems were initiated in the 1970s.
status.
In 1990, the National Nutrition Monitoring and
Related Research Program (NNMRRP) (PL 101-445) In 2002, the Department of HHS and the USDA
established a comprehensive, coordinated program for integrated NHANES and the Continuing Survey of Food
nutrition monitoring and related research to improve Intakes by Individuals (CSFII), the two major diet and health
health and nutrition assessment in U.S. populations. The surveys, into a continuous data collection system. Now diet
NNMRRP required a program to coordinate federal and nutrition information can be linked directly to health
nutrition monitoring efforts and to assisted state and local status information. The integrated dietary component of
governments in participating in a nutrition monitoring the NHANES is titled, “What We Eat in America.”71
network; an interagency board to develop and implement The NHANES is a program of studies designed to assess
the program; and a nine-member advisory council to the health and nutritional status of the U.S. population.
provide scientific and technical advice and to evaluate The survey combines health interviews and physical
program effectiveness. The NNMRRP also required that examinations with dietary information (Table 1–6).
the Dietary Guidelines for Americans (DGA) be issued Beginning in 1999, the NHANES survey became a
every 5 years, and that any dietary guidance issued by the continuous surveillance program with data released to the
federal government for the general public be reviewed public biannually. Rather than using a random sample, the
by the secretaries of Agriculture and Health and Human NHANES uses a complex, multistage, probability sampling
Services (HHS). design to select participants representative of the civilian,
The NNMRRP encompasses more than 50 noninstitutionalized U.S. population. Oversampling of
surveillance activities that monitor and assess health and population subgroups at different times (e.g., Hispanic
Table 1–5 National Nutrition-Related Health Assessmentsa

Survey Name Date Target Data Collected Dept/Agency
Nutritional and Related Health Measurements

NHANESb 1999–present Civilian, noninstitutionalized Survey elements are similar NCHS, CDC (HHS)
persons 2 months or older; to NHANES III and NHIS.c This
oversampling of adolescents, is a continuous monitoring
African Americans, Mexican system
Americans, and adults >60 years
NHANES III 1988–1994 Civilian, noninstitutionalized Demographics, dietary NCHS, CDC (HHS)
persons 2 months or older; intake (24-hour recall and
oversampling of adolescents, food frequency), biochemical
non-Hispanic blacks, Mexican analysis of blood and urine,
Americans, children 6 years and physical examination,
adults >60 years anthropometry, blood
pressure, bone densitometry,
diet and health behaviors,
health conditions
NHANES III 1988–1994 Representative U.S. elderly See above NCHS, NIH/NIA
Supplemental population
Nutrition Survey
of Older Persons
HHANES 1982–1984 Civilian, noninstitutionalized Demographics, dietary NCHS (HHS)
Mexican Americans in five intake (24-hour recall
southwestern states, Cuban and food frequency),
Americans in Dade Co., FL, and biochemical analysis of
Puerto Ricans in New York, blood and urine, physical
New Jersey, and Connecticut, 6 exam, anthropometry, blood
months to 74 years pressure, diet and health
behaviors, health conditions
NHANES II 1976–1980 Civilian, noninstitutionalized Demographics, dietary NCHS (HHS)
persons 6 months to 74 years intake, biochemical analysis
of blood and urine, physical
exam, anthropometry
NHANES I 1971–1974 Civilian, noninstitutionalized Demographics, dietary NCHS (HHS)
population of the conterminous information, biochemical
states 1 to 74 years analysis of blood and
urine, physical exam,
anthropometry
PedNSS 1973, continuous Low-income, high-risk children, Demographics, NCCDPHP, CDC
birth to 17 years, emphasis on anthropometry, birth weight, (HHS)
birth to 5 years hematology
PNSS 1973, continuous Convenience sample of low- Demographics, pregravid NCCDPHP, CDC
income, high-risk pregnant weight and maternal weight (HHS)
women gain, anemia, behavioral risk
factors, birth weight, and
formula-feeding data
(continues)
Table 1–5 National Nutrition-Related Health Assessmentsa (continued)

Food and Nutrient Consumption

CSFIId 1994–1996; 1989– Individuals of all ages with One- and 3-day food intakes, ARS, HNIS
1991; 1985–1986 oversampling in low-income times of eating events,
households sources of food eaten away
from home
TDS 1961, annual Specific age and gender groups Determines levels of FDA (HHS)
nutrients and contaminants
in the food supply; analyses
are performed on foods that
are “table-ready”
Consumer 1980, continuous Noninstitutionalized Demographics, food stamp U.S. Bureau of Labor
Expenditure population and a portion of the use, average annual food Statistics
Survey institutionalized population in expenditures
the United States
NFCS 1987; 1977–1978 Households in the conterminous Households: quantity HNIS (USDA); ARS
states; all income and low (pounds), money value (USDA)
income (dollars), and nutritive value
of food eaten
Individuals: food intake,
times of eating events, and
sources of foods eaten away
from home
SNDA II 1998 Public schools in the 48 School and food service FNS/USDA
contiguous states and the characteristics, nutrients by
District of Columbia that food group and relationship
participate in the National to the RDA and DGA by
School Lunch Program meals, source of meals, and
nutrient content of USDA
meals
WIC Feeding 1994–1995 Pre- and postnatal women and Demographics, rates of FNS/USDA
Practices Study their children who participate in breast and formula feeding,
Women, Infants, and Children factors associated with
(WIC) program breast feeding
5-A-Day for Better 1991 Adults 18 years and older Demographics, fruit and NCI (HHS)
Health Baseline vegetable intake, and
Survey knowledge, attitudes, and
practices regarding intake
Knowledge, Attitude, and Behavior Assessments
YRBBS Biennial Civilian, noninstitutionalized Demographics, diet and CDC; (HHS)/
adolescents 12–18 years weight; drug, alcohol and NCCDPHP
tobacco use; seat belt and
bicycle helmet use; behaviors
that contribute to violence;
suicidal tendenciese

BRFSS 1984, continuous Adults 18 years and older in Demographics, questions CDC; (HHS)/
households with telephones that assess risk factors NCCDPHP
located in participating states associated with leading
causes of death: alcohol and
tobacco use, weight, seat
belt and helmet use; use of
preventative medical caref
DHKS 1994–1996 Adults 20 years and older who Demographics, self- ARS/USDA
participated in CSFII 1994–1996 perceptions of relative
intake, awareness
of diet and health
relationships, food label
use, perceived importance
of following diet and health
recommendations, beliefs
about food safety, and
knowledge of sources of
nutrients; data can be
linked with intake through
CSFII data
Infant Feeding 1993–1994 New mothers and healthy Demographics, prior FDA
Practices Survey infants to 1 year of age infant feeding practices,
baby’s social situation,
characteristics associated
with breast feeding,
development of allergies
Consumer 1998; 1992–1993 Civilian, noninstitutionalized Demographics, prevalence FDA
Food Handling over 18 years with telephones of unsafe food handling
Practices practices, knowledge of
food safety principles, use of
sources of information about
safe food handling, incidence
of food borne illnesses
Food Composition and Nutrient Data Bases
National Nutrient – – This is the repository for ARS (USDA)
Data Bank values of approximately
7,100 foods and up to 80
components. Essentially all
food composition databases
are derived from this data
bank
Food Label and 1977–1996, All brands of processed foods Prevalence of nutrition FDA (HHS)
Package Survey biennially regulated by the FDA labeling, declaration of
select nutrients, prevalence
of label claims and other
descriptors
(continues)

Food Supply Determinations

AC Nielsen 1985, monthly ~3,000 U.S. supermarkets Sales and physical volume of ERS/USDA
SCANTRACK specific market items, selling
price, percent of stores
selling the product
U.S. Food and 1909, annually U.S. population ERS = Amount of food ERS/CNPP/USDA
Nutrient Supply commodities that disappear
Series into the food distribution
system; CNPP = nutrient
levels of food supply. Results
are totaled for each nutrient
and converted to per day
basis
a
A complete guide to nutrition monitoring in the United States can be found at http://www.cdc.gov/nchs/data/misc/nutri98.pdf.
b
Abbreviations: ARS = Agricultural Research Service; BRFSS = Behavioral Risk Factor Surveillance System; CDC = Centers for Disease Control and Prevention; CNPP
= Center for Nutrition Policy and Promotion; CSFII = Continuing Survey of Food Intakes by Individuals; DHKS = Diet and Health Knowledge Survey; ERS = Economic
Research Service; FDA = Food and Drug Administration; HHANES = Hispanic Health and Nutrition Examination Survey; HHS = Health and Human Services; HNIS
= Human Nutrition Information Service; NFCS = Nationwide Food Consumption Survey; NCCDPHP = National Center for Chronic Disease Prevention and Health
Promotion; NCHS = National Center for Health Statistics; NCI = National Cancer Institute; NHANES = National Health and Nutrition Examination Survey; NHIS =
National Health Interview Survey; NIA = National Institute on Aging; NIH = National Institutes of Health; PedNSS = Pediatric Nutrition Surveillance System; PNSS
= Pregnancy Nutrition Surveillance System; SNDA = School Nutrition Dietary Assessment Study; TDS = Total Diet Study; USDA = United States Department of
Agriculture; WIC = Women, Infants, and Children; YRBSS = Youth Risk Behavioral Surveillance System.
c
See http://www.cdc.gov/nchs/data/nhanes/survey_content_99_16.pdf for complete survey content of NHANES 1999–2016.
d
CSFII and NHANES were combined into a single survey.
e
See http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf = YBRSS report 2004; MMWR summary reports available through CDC website.
See http://www.cdc.gov/brfss/#about_BRFSS = Behavioral Risk Factor Surveillance System for full information.
f
Americans) increases the reliability and precision of health the term “NHANES” produced 35,089 publications on
status indicator estimates for these subgroups. Data collection topics as diverse as national trends in self-reported physical
by the NHANES occurs at three levels: a brief household activity/sedentary behavior in pregnant women; trends in
screener interview, an in-depth household survey interview, cardiovascular risk and trends in obesity; BMI in children
and a medical examination. Because detailed interviews and adolescents; and the association of consumption of
and clinical, laboratory, and radiological examinations 100% fruit juice and nutrient intake in children. NHANES
are conducted, the response burden to participants is data have also shown that there are ethnic/racial and
significant. Interviews and medical examinations take place income differences in dietary intake, including food sources
in a mobile examination center. Because of this sampling for nutrients;73–75 that cardiovascular risk factors cluster
design, using appropriate statistical analyses of NHANES according to socioeconomic status;76 and that hypertension
data are critical. To ensure that NHANES analyses reflect varies according to geographical region.77 These findings
a nationally representative sample, it is important to use the have important implications for intervention strategies.
described weighting system and specialty software (e.g.,
SUDAAN).
It is difficult to quantify the tremendous impact that EPIDEMIOLOGIC STUDIES
NHANES and related programs have had on health policy
and health research in the United States.72 One way to In addition to the NCHS data, a number of long-term,
look at this is the number of publications generated using primarily government funded epidemiologic studies on
NHANES data. A PubMed search in April 2016 using adults and children/adolescents have provided critical
Epidemiologic Studies 17
Table 1–6 Data Available Through NHANES

Health Exam Tests
Health Measurements by Participant Age and Gender
• Physician’s exam: all ages
• Blood pressure: ages ≥8 years
• Bone density: ages ≥8 years
• Condition of teeth: ages ≥5 years
• Vision test: ages ≥12 years
• Hearing test: ages 12–19 and ≥70 years
• Height, weight, and other body measures: all ages
• Ophthalmology exam for eye diseases: ages ≥40 years
• Breathing tests: ages 6–79 years
Lab Tests on Urine (≥6 years)
• Kidney function tests: ages ≥6 years
• Sexually transmitted disease (STD), chlamydia and gonorrhea: ages 14–39 years
• Exposure to environmental chemicals: selected persons ages ≥6 years
• Pregnancy test: girls and women ages ≥12 years, and girls ages 8–11 years who have periods
Lab Tests on Blood: (≥1 year and older)
• Anemia: all ages
• Total cholesterol and high density lipoprotein (HDL): ages ≥6 years
• Glucose measures: ages ≥12 years
• Infectious diseases: ages ≥2 years
• Kidney function tests: ages ≥12 years
• Lead: ages ≥1 years
• Cadmium: ages ≥1 year
• Mercury: ages ≥1 year
• Liver function tests: ages ≥12 years
• Nutrition status: ages ≥1 years
• Thyroid function test: ages ≥12 years
• Prostate specific antigen (PSA): men ages ≥40 years
• Sexually transmitted diseases (STD)
—Genital herpes: ages 14–49 years
—Human immunodeficiency virus (HIV): ages 18–49 years
—Human papillomavirus (HPV) antibody: ages 14–59 years
• Exposure to environmental chemicals: selected persons ages ≥6 years
Lab Tests on Water
• Environmental chemicals: ages ≥12 years in half of households
Other Lab Tests
• Vaginal swabs (self-administered): girls and women ages 14–59 years
• Human papillomavirus (HPV): ages 14–59 years
Private Health Interviews
• Health status: ages ≥12 years
• Questions about drug and alcohol use: ages ≥12 years (no drug testing will be done)
• Reproductive health: girls and women ages ≥12 years
• Questions about sexual experience: ages 14–69 years
• Tobacco use: ages ≥12 years
Anthropometry from the Mobile Examination Center
• Body mass index for children ages 2–19 years; BMI z-score is also determined
• Waist circumference
• Skinfold measurements and body fat measures through DXA
Dietary Information from the Mobile Examination Center
• 24-hour dietary recalls; parents or guardians report for children 0–5 years of age; children 6–11 years are assisted by an
adult; children ≥12 years self-report
• Food frequency questionnaire
(continues)
Table 1–6 Data Available Through NHANES (continued)

After the Visit to the NHANES Examination Center
• Persons asked about the foods they eat will receive a phone call 3–10 days after their exam for a similar interview, all ages.
• Then participants, or an adult for participants 1–15 years old, are asked about food shopping habits.
• Persons who test positive for hepatitis C will be asked to participate in a brief telephone interview 6 months after the exam.
Parents will respond for children.
information used to guide the nation’s health policies and Data from the BHS have contributed significantly to
federal programs. The Bogalusa Heart Study (BHS), the our knowledge and understanding of cardiovascular risk
Framingham Heart Study (FHS), and the Coronary Artery factors in children as well as the history of CVD in early
Risk Development in Young Adults (CARDIA) are leading life. For example, information on children, adolescents,
examples. Other important U.S. epidemiologic studies that and young adults from birth to 31 years of age has provided
have contributed to our knowledge of risk reduction and the framework to establish desirable cholesterol levels in
disease prevention include the Nurses’ Health Study (NHS; children and has led investigators to recommend screening
N = 170,000 women registered nurses between the ages of of cardiovascular risk factors for all children, not only those
30 and 55 years at the beginning of the study) and the NHS with a parental history of heart disease or dyslipidemia,
II (NHS II established in 1989, N = ~117,000 women nurses beginning at elementary school age.
aged between 25 and 42 years); and the all-men Health Data have also suggested that risk factors for CVD
Professional Follow-up Study (initiated in 1986 with 2-year “track”; that is, they remain in a rank relative to peers
scheduled follow-ups), which was designed to complement over time. For example, children with elevated serum total
the NHS, relating nutritional factors to the incidence of cholesterol or low density lipoprotein cholesterol (LDL-
serious illnesses, such as cancer, heart disease, and other C) levels are likely to become adults with dyslipidemia.
vascular diseases in 51,529 male health professionals. Also Bogalusa Heart Study data have been used to characterize
of import is the Iowa Women’s Health Study with a cohort diets of children and secular trends in children’s diets for more
of 41,837 postmenopausal women who have been followed than 30 years.81 BHS data were used as the rationale by the
since 1985. These studies combined have produced more American Academy of Pediatrics for their recommendation
than 2,000 scientific publications and have helped shape that the DGA could apply to healthy children 2 years of age
medical care, risk reduction and health promotion, and and older, and to develop the Academy’s original position
public policy. paper on dietary guidance for healthy children 2 to 11 years
of age.82
One of the major accomplishments of the BHS did
The Bogalusa Heart Study not come from epidemiologic data per se, but from autopsy
The BHS78–80 was designed initially to examine the early studies of participants,83 usually those killed in accidents.
natural history of coronary heart disease and essential Data from the BHS confirmed and extended earlier
hypertension in a biracial (black/white) pediatric studies84 that showed fatty streaks in the aorta were evident
population. The BHS population consists of approximately in the first decade of life and that the extensiveness of these
5,000 individuals who have been studied at various growth lesions was highly associated with serum total cholesterol
phases and have been followed for as long as 15 years. The and LDL-C levels. These findings provided the rationale for
mixed epidemiologic design of the study has included cross- interventions that focused on healthy lifestyles for children.
sectional and longitudinal surveys to provide information
on three questions: (1) what are the distribution and
prevalence of cardiovascular disease (CVD) risk factors Framingham Heart Study
in a defined pediatric population and how are abnormal The FHS has been described as “one of the most impressive
serum lipid levels, blood pressure, and other risk factors medical works in the 20th century.”85 The Framingham
defined in children; (2) do cardiovascular risk factors track study has provided information critical to the recognition
and change over time; and (3) what is the interrelationship and management of atherosclerosis, and its causes and
among these risk factors? Other questions, notably what is complications. Initiated under the auspices of the National
the interaction of genetics and the environment in CVD, Heart Institute (now the NHLBI) in 1948, 1,980 males
were also posed. and 2,421 females were enrolled originally in a 3-year
Metabolic Diet Studies 19
observational study in Framingham, Massachusetts, which sizes of menu items reflected in each 24-hour diet recall;
at the time was a novel idea. Published in 1961, the first follow-up telephone calls to parents to obtain information
report, “Factors of risk in the development of coronary heart on brand names, recipes, and preparation methods of meals
disease—six-year follow-up experience; the Framingham served at home; products researched in the field to obtain
Study,” identified high blood pressure, smoking, and updated information on ingredients and preparation, and
high cholesterol levels as major factors in heart disease their weights (primarily snack foods and fast foods).90 All
and conceptualized them as risk factors. Continued study interviewers participated in rigorous training sessions and
of the population has provided health professionals with pilot studies before the field surveys to minimize interviewer
multifactorial risk profiles for cardiovascular disease that effects. One 24-hour diet recall was collected on each study
have assisted in identifying individuals at high risk as well participant, and duplicate recalls were collected from a 10%
as providing the basis for preventative measures. During random subsample to assess interviewer variability.88,89
its more than 50 year history, the FHS has introduced the
concept of biologic, environmental, and behavioral risk
factors; identified major risk factors associated with heart METABOLIC DIET STUDIES
disease, stroke, and other diseases; revolutionized preventive
medicine; and changed how the medical community Metabolic diet studies are conducted in clinical research
and general population regard disease pathogenesis. centers where study participants are randomized into test or
The National Cholesterol Education Program15 uses the control groups and are fed an experimental diet or “regular”
Framingham risk scoring system to determine the 10-year diet, respectively. Different designs are available for
risk of CHD in adults. Studies like the Framingham metabolic diet studies,91 but the one that provides the most
study have also supplied valuable information to the valid results is a double-blind, placebo-controlled study. In
Eighth Report of the Joint National Committee on the these studies, neither the investigator nor the participant
Prevention, Detection, Evaluation, and Treatment of High knows whether the test or control diet is offered. Because
Blood Pressure.86 it is difficult and expensive to do these studies, they are
In 1971, the Framingham Heart Offspring Study usually short term and have a small sample size; compliance
began,87 consisting of 5,124 males and females, 5 to 70 years and dropout rates are problems.
of age, who were offspring and spouses of the offspring of The Dietary Approaches to Stop Hypertension
the original Framingham cohort. The objectives of that (DASH)92 and DASH sodium93 trials are classic examples
study were to determine the incidence and prevalence of of metabolic diet studies. Epidemiologic, clinical trials,
CVD and its risk factors, trends in CVD incidence and its and studies using experimental animals showed that intake
risk factors over time, and family patterns of CVD and risk of some nutrients, notably low levels of sodium and high
factors. The Offspring Study provided the opportunity to levels of potassium and calcium, lowered blood pressure;
evaluate a second generation of participants, assess new or however, people eat food—not isolated nutrients. To test
emerging risk factors and outcomes, and provide a resource the impact that combination diets incorporating foods
for future genetic analyses. high in these nutrients had on blood pressure, the DASH
The quality of data from surveys and epidemiologic study was conducted. DASH was a randomized controlled
studies depends on the training of personnel and adherence to trial conducted at four academic medical centers with 459
rigid protocols. It also depends on the validity and reliability adult participants. Inclusion criteria were untreated systolic
of the test instruments used as well as on the responses of blood pressure less than 160 mm Hg and diastolic blood
the participants. Instruments may need to be modified for pressure 80 to 95 mm Hg. For 3 weeks, participants ate
specific populations. For example, in the BHS the 24-hour a control diet. They were then randomized to 8 weeks
diet recall method had to be adapted for use in children.88,89 of a control diet; a diet rich in fruits and vegetables; or a
To improve the reliability and validity of the 24-hour diet combination diet rich in fruits, vegetables, and low-fat
recall, quality controls included the use of a standardized dairy foods, and low in saturated fatty acids, total fat, and
protocol that specified exact techniques for interviewing, cholesterol. Salt intake and weight were held constant, and
recording, and calculating results; standardized graduated diets were isoenergic. All food was prepared in a metabolic
food models to quantify foods and beverages consumed; kitchen and was provided to participants. The combination
a product identification notebook for probing of snack diet (or “DASH diet”) was shown too quickly (within 2
consumption, and foods and beverages most commonly weeks) and substantially lower blood pressure. In DASH
forgotten; school lunch assessment to identify all school sodium, a subsequent study, 412 participants were assigned
lunch recipes, preparation methods, and average portion to a control diet or a DASH diet; within the assigned diet,
participants ate meals with high (3,450 mg/2,100 kcals), of nutrients; thus, the number of variables studied is
intermediate (2,300 mg/2,100 kcals) and low (1,150 limited. Special treatments, such as ovariectomies to
mg/2,100 kcals) levels of sodium for 30 consecutive days mimic the physiologic state of postmenopausal women,102
each, in random order. Reduction of sodium intake to levels can be performed on animals. Because the life span of
below the current recommendation of 100 mmol/day and most laboratory animals is short, the effects of dietary
the DASH diet substantially lowered blood pressure, with manipulation can be followed over several generations.
the most significant effect seen in lowering blood pressure Animals can be sacrificed at the end of the experiment and
with the lowest sodium concentration coupled with the the effect of the treatment can be examined closely at the
DASH diet. The DASH diet has been widely embraced organ, tissue, or cellular level. Animal studies can explore
for the treatment of hypertension, and nutrition education molecular mechanisms behind a given observation in
materials are readily available. As elegant and persuasive as humans. For example, ferrets were used to determine that
the DASH studies were, one drawback to feeding studies high doses of beta-carotene caused keratinized squamous
is that participants receive all foods. Therefore, the studies metaplasia in lung tissues that was exacerbated by exposure
cannot assess how compliant people are after the study to cigarette smoke.103 This explains the paradoxical
ends. The PREMIER study94 demonstrated that free- relationship between beta-carotene and smoking seen
living individuals were able to make the lifestyle changes in the clinical trials previously mentioned. It points out
associated with decreased blood pressure. another use of animal studies: that the metabolism of natural
products should be investigated using animal models before
beginning intervention trials, particularly if nutrient doses
CLINICAL TRIALS exceed recommended levels.104
Animals most commonly used in nutrition research are
Clinical trials are commonly used to determine the efficacy rats, mice, rabbits, guinea pigs, dogs, sheep, and monkeys.
of drugs or other pharmacologic agents; however, they can The species selected for a given experiment should be
also be used to assess diet or dietary interventions. They that which is the most similar to human metabolism for a
have many of the same advantages and disadvantages of particular nutrient. The importance of this is illustrated in
metabolic studies. Because clinical trials of diet may involve the classic studies of vitamin C metabolism. Guinea pigs
pharmacologic intervention, they carry a risk that is not are the only laboratory animal that, like humans, have an
usually seen with metabolic diet studies. The classical obligatory requirement for this nutrient; thus, a review of
example of this was seen in the Alpha-Tocopherol, Beta- the literature shows only guinea pigs were used for vitamin
Carotene Cancer Prevention Study (ATBC Study)95 and C research.
the Beta-Carotene and Retinol Efficacy Trial (CARET).96 Many of the elements that make animal studies so
Based on epidemiologic data that showed a relationship appealing in nutrition research are also drawbacks. With the
between dietary intake of fruits and vegetables97,98 or, exception of monozygotic twins, humans are not genetically
specifically, of beta carotene99 and a reduced risk of identical; thus, no matter how carefully a human experiment
developing lung cancer, especially in smokers,100 the ATBC is controlled, responses to dietary manipulations may be
and CARET studies used high doses of beta-carotene in different due to individual genetic backgrounds. Interactions
major cancer chemopreventive trials. Investigators expected between genetics and the environment are easy to study in
to see reductions in lung cancer by as much as 49% in animals, but results are difficult to translate to humans.
some high-risk groups. In actuality, the opposite was seen;
beta-carotene increased the risk of lung cancer, forcing the
CARET study to be stopped early.101 These studies clearly HEALTHY PEOPLE 2020
point to the necessity of additional research, and they have
important public health implications. Individual health is closely linked to community health—
the health of the community and the environment in
which individuals live, work, and play. Community
ANIMAL STUDIES health, in turn, is profoundly affected by the collective
beliefs, attitudes, and behaviors of everyone who lives in
Animal studies are important in nutrition research for many that community. Healthy People 2020, published by the
reasons. Laboratory animals that are genetically identical Department of Health and Human Services (HHS),105 is the
and exposed to the same environmental conditions can be comprehensive health promotion and disease prevention
fed carefully characterized diets with different combinations agenda for the nation; the goals for HP 2020 will remain in
Nutrient Requirements 21
place until superseded by HP 2030. The HP program grew ethnic groups, and develop solutions that are economically
out of health initiatives pursued over the last 30 years. In feasible for state budgets. States and territories have a
1979, Healthy People: The Surgeon General’s Report on Health Healthy People Coordinator who serves as a liaison with
Promotion and Disease Prevention106 provided nutritional goals the Office of Disease Prevention and Health Promotion.
for reducing premature deaths and preserving independence Check out the Office of Public Health in your own state
for older adults. In 1980, Promoting Health/Preventing Disease: and see what the problems relating to public health are and
Objectives for the Nation targeted 226 health objectives for what’s being done about them. For example, I just found
the nation to achieve over the next 10-year period.107 These out about the Partners for Healthy Babies program in my
were followed by HP 2000, 2010, and, now 2020 goals. home state of Louisiana.112
The overarching goals for HP 2020 are:105
• Attain high-quality, longer lives free of preventable NUTRIENT REQUIREMENTS
disease, disability, injury, and premature death;
• Achieve health equity, eliminate disparities, and The first Recommended Daily Allowances (RDAs) were
improve the health of all groups; published in 1941 “as a guide for advising on nutrition
• Create social and physical environments that problems in connection with national defense.”113 The first
promote good health for all; and edition included recommendations for only nine nutrients:
• Promote quality of life, healthy development, and protein, thiamine, riboflavin, niacin, ascorbic acid, vitamins
healthy behaviors across all life stages. A and D, calcium, and iron. In the seventh edition (1968),
Healthy People 2020 has 42 topic areas and tracks additional nutrients were included: folate; vitamins E, B6,
approximately 1,200 objectives. Healthy People 2020 also and B12; phosphorous; magnesium; and iodine. The last
has 12 Leading Health Indicators (Table 1–7); Table 1–8 edition of the RDAs (1989) added vitamin K, zinc, and
shows the principal objectives associated with HP 2020’s selenium. The RDAs should be geared to groups of healthy
Nutrition and Weight Topics. Many of the nutrition people, such as the military or school feeding programs,
objectives are similar to those of the DGA. rather than to individuals. The RDAs are, however, often
The NCHS is responsible for coordinating efforts used to assess the adequacy of an individual’s diet and were
to monitor progress toward the HP objectives. Data are later called the Recommended Dietary Allowances.
gathered from approximately 200 sources, including the In 1993, the question of whether the RDAs should be
NCHS data systems108 and other federal government data changed was posed by the National Academies of Sciences,
systems. State data are also provided for selected indicators, Engineering, and Medicine’s Health and Medicine Division
and additional resources are found in the Health Indicators (HMD) (formerly the Institute of Medicine’s [IOM]
Warehouse.109 Data from HP 2020 can be explored using Food and Nutrition Board [FNB]). Support for change
the DATA2020 section of the HP 2020 website.110 included that (1) sufficient new scientific information
Many states have developed their own HP plans.111 had accumulated to substantiate (reassessment of these
Development of state-specific plans allows states to recommendations; (2) sufficient data for efficacy and safety
prioritize health problems, address needs of specific racial or existed, and reduction in the risk of chronic diet-related
diseases needed to be considered—previously, the RDA
had focused on preventing deficiency diseases; (3) upper
Table 1–7 Leading Health Indicators of Healthy People
levels of intake should be established where there were data
2020
concerning risk of adverse effects; and (4) components of
Access to health services food not meeting the traditional concept of a nutrient—
Clinical preventive services such as phytochemicals—that gave possible health benefits
Environmental quality should be reviewed, and if adequate data existed, reference
Injury and violence intakes should be established.
Maternal, infant, and child health Between 1994 and 2004, the Food and Nutrition Board
Mental health DRI (Dietary Reference Intake) extended and replaced the
Nutrition, physical activity, and obesity
former RDAs and the Canadian Recommended Nutrient
Oral health
Intakes.114 The DRIs are available on the website of the
Reproductive and sexual health
Social determinants Food and Nutrition Information Center of the National
Substance abuse Agricultural Library.114 The DRIs are specified on age,
Tobacco gender, and life stage (e.g., pregnancy or lactation), and
Table 1–8 Principal Objectives Associated with Healthy People 2020’s Nutrition and Weight Topics
Healthier food access NWS-1 Increase the number of states with nutrition standards for foods and beverages provided to
preschool-aged children in child care
NWS-2 Increase the proportion of schools that offer nutritious foods and beverages outside of school
meals
NWS-3 Increase the number of states that have state-level policies that incentivize food retail outlets to
provide foods that are encouraged by the Dietary Guidelines for Americans
NWS-4 (Developmental) Increase the proportion of Americans who have access to a food retail outlet
that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans
Health care and NWS-5 Increase the proportion of primary care physicians who regularly measure the body mass index
worksite settings of their patients
NWS-6 Increase the proportion of physician office visits that include counseling or education related to
nutrition or weight
NWS-7 (Developmental) Increase the proportion of worksites that offer nutrition or weight management
classes or counseling
Weight status NWS-8 Increase the proportion of adults who are at a healthy weight
NWS-9 Reduce the proportion of adults who are obese
NWS-10 Reduce the proportion of children and adolescents who are considered obese
NSW-11 (Developmental) Prevent inappropriate weight gain in youth and adults
Food insecurity NSW-12 Eliminate very low food security among children
NSW-13 Reduce household food insecurity and in doing so reduce hunger
Food and nutrient NSW-14 Increase the contribution of fruits to the diets of the population aged 2 years and older
consumption NSW-15 Increase the variety and contribution of vegetables to the diets of the population aged 2 years
and older
NSW-16 Increase the contribution of whole grains to the diets of the population aged 2 years and older
NSW-17 Reduce consumption of calories from solid fats and added sugars in the population aged 2 years
and older
NWS-18 Reduce consumption of saturated fat in the population aged 2 years and older
NWS-19 Reduce consumption of sodium in the population aged 2 years and older
NWS-20 Increase consumption of calcium in the population aged 2 years and older
Iron deficiency NWS-21 Reduce iron deficiency among children and females of childbearing age
NWS-22 Reduce iron deficiency among pregant females
Reproduced from: Office of Disease Prevention and Health Promotion. Healthy People 2020: Nutrition and Weight Status. https://www.healthypeople.gov/2020/topics-
objectives/topic/nutrition-and-weight-status/objectives. Accessed April 11, 2016.
cover more than 40 nutrient substances. Conceptually, the values. Briefly, the four reference values are the estimated
DRIs are the same as the RDAs in that their formulation average requirement (EAR), RDA, tolerable upper
relies on the best scientific evidence available at the time intake level (UL), and adequate intake (AI). The EAR
of issuance, are designed for healthy individuals over time, is the median usual intake value estimated to meet the
and can vary depending on life cycle stage or gender. The requirements of half of the healthy individuals; it is based
reference values for heights and weights of adults and on specific criteria of adequacy and on careful review of the
children used in the DRIs are from NHANES III. The scientific evidence. Not all nutrients have an EAR because
DRIs differ from the original RDAs in that they incorporate there may not be an acceptable science base upon which to
the concepts of disease prevention, upper levels of intake define one. The EAR is used to calculate the RDA (RDA
and potential toxicity, and nontraditional nutrients. The = EAR + 2 standard deviation of the requirement), which is
latter establishes a precedent; as scientists learn more about the average daily dietary intake level sufficient to meet the
the relationship of phytochemicals, herbals, or botanicals nutrient requirement of approximately 98% of individuals.
and health, these too can be incorporated into the If there is no EAR for a nutrient, there can be no RDA. If
recommendations. Where scientific evidence is available, this is the case, an AI for the nutrient is provided. This value
the DRIs are a set of at least four nutrient-based reference is deemed by experts to meet or to exceed the needs of a
Dietary Guidelines for Americans 23
healthy population. The AI can be used as a guide for intake, the nutrition needs of consumers.”131 The CNPP carries
but it cannot be used for all the applications for which the out its mission to improve the health of Americans by (1)
EAR is used; it is also an indication that additional research advancing and promoting food and nutrition guidance for
is required for a nutrient. The assumption is that when all Americans; (2) assessing diet quality; and (3) advancing
this research is completed and evaluated, the AI can be consumer, nutrition, and food economic knowledge.
replaced by an EAR and RDA. The UL is the highest level The major projects of the CNPP are shown in
of continued daily nutrient intake that is unlikely to pose Table 1–9. The CNPP considers MyPlate/MiPlato and
an adverse health effect. (It is important to note that the SuperTracker as tools; other tools include Food-a-Pedia,
word “tolerable” was chosen to avoid implying a possible What’s Cooking? USDA Mixing Bowl, and the Cost of
beneficial effect.) Raising a Child Calculator.
The HMD has published DRIs and related information
for electrolytes and water;115 energy, carbohydrate, fiber, fat,
fatty acids, cholesterol, protein, and amino acids;116 vitamins DIETARY GUIDELINES FOR
A and K, arsenic, boron, chromium, copper, iodine, iron, AMERICANS
manganese, molybdenum, nickel, silicon, vanadium, and
zinc;117 dietary antioxidants and other related compounds;118 The DGA132 are the foundation of federal nutrition policy,
folate and other B vitamins;119 calcium, phosphorus, nutrition education programs, and information activities.
magnesium, vitamin D, and fluoride;120 and an updated The DGA are evidence-based recommendations for food
volume on vitamin D and calcium.121 A complete set of the (and some nutrient intake) designed to promote health and
DRI books is available online or can be ordered in book reduce the risk of chronic disease for healthy Americans
form or read online. 2 years of age and older. By law (Public Law [PL] 101-
Important uses of the DRIs include individual diet 445), the DGA are developed and published jointly by
planning, dietary guidance, institutional food planning, the departments of HHS and USDA every 5 years. This
military food and meal planning, planning for food assistance relatively quick turnaround time is a result of the changing
programs, food labeling and fortification, developing new science as new studies are added to the evidence base.
or modified food products, and guaranteeing food safety. The eighth edition of the DGA (2015–2020) was released
In planning menus/diets for individuals or groups, it is in January 2016 (earlier editions were published in 1980,
important to meet the RDA or AI without exceeding the 1985, 1990, 1995, 2000, 2005, and 2010). The 2015–2020
UL. The HMD has incorporated the DRIs and other data DGA will remain in effect until the 2020–2025 DGA
into a series of reports, including School Meals: Building are released. Changes in the DGA must reflect current
Blocks for Healthy Children,122 Local Government Actions scientific and medical knowledge available at the time of
to Prevent Childhood Obesity,123 the Public Effects of Food publication. Two important documents demonstrate the
Deserts124 (Workshop Summary), Nutrition Standards necessity of relying on a science base: the 1988 Surgeon
and Meal Requirements for National School Lunch and General’s Report on Nutrition and Health133 and 1989 National
Breakfast Programs: Phase I. Proposed Approach for
Recommending Revisions,125 and the Use of Dietary
Supplements by Military Personnel.126 Summaries of the
Table 1–9 Projects of the Center for Nutrition Policy
development of the DRI127 as well as the uses of the DRI in
and Promotion
dietary assessment128, 129 and to plan menus130 can be found
in the literature. Dietary Guidelines for Know Your Farmer, Know
Americans Your Food
MyPlate, MyWins/MiPlato Nutrient Content of the U.S.
CENTER FOR NUTRITION SuperTracker Food Supply
Healthy Eating Index Birth to 24 Months and
POLICY AND PROMOTION USDA Food Patterns Pregnant Women
USDA Food Plans: Cost of Nutrition Insights
The Center for Nutrition Policy and Promotion (CNPP), Food Internship Program
created in December 1994, is an office of the USDA’s Expenditures on Children by Health and Medicine Division
Food, Nutrition, and Consumer Services. Its mission is Families Study
“to improve the health of Americans by developing and USDA’s Nutrition Evidence Archived Projects
promoting dietary guidance that links scientific research to Library
Research Council’s Report, Diet and Health: Implications for graphics about the 2015–2020 Dietary Guidelines.
Reducing Chronic Disease Risk.1 Download the PowerPoint slide deck to customize
The DGA appear as succinct statements of nutrition the presentation or the PDF to use it as is.
recommendations for the general public, as seen in Table • 2015–2020 DGA: Questions and Answers about the
1–10 and Table 1–11. However, the discussion of the DGA and how it was developed.
evidence and the initial recommendations are made by the
MyPlate, MyWins is the “translation” of the DGA
Dietary Guidelines Advisory Committee. Take a moment
for the public,135 although it too has information available
and learn about the process of how the DGA are developed.
for nutrition professionals.136 This information includes
The website132 for the DGA provides a considerable number
Nutrition Communicators Network, Communicator’s
of tools that can be used by health professionals, including
Guide, Teachers, Health Professionals, and MyPlate
registered dietitians:
Graphic Resources.
• Talk to Your Patients & Clients About Healthy The DGA dictates U.S. federal nutrition policies
Eating Patterns [PDF, 1.6 MB] includes nutrition and programs, which directly affect nearly 45 million
tips and conversation starters for dietitians, nurses, Americans receiving electronic benefits from the
and other providers working with the public. Supplemental Nutrition Assistance Program (SNAP);137
• Shift to Healthier Food & Beverage Choices 30.5 million children participating in the National School
(Handout for Patients or Clients) [PDF, 1.5 MB] Lunch Program;138 nearly 10 million women, infants, and
offers a closer look at a central DGA concept. children receiving benefits under the Special Supplemental
• Cut Down on Added Sugars (Handout for Patients Nutrition Program for Women, Infants, and Children
or Clients) [PDF, 1.9 MB] offers a how-to guide for (WIC) program;139 and more than 3 million adults over
reducing added sugars. 60 years of age through the Elderly Nutrition Program.140
• DGA Presentation for Professionals [PPTX, The DGA also affects information policy, as evidenced
28.3 MB] [PDF, 3.8 MB] has information and in MyPlate, food labels, and federal nutrition education
programs, such as the SNAP-education program. This
program includes toolkits such as the SNAP-Ed Strategies
& Interventions: An Obesity Prevention Toolkit for States, which
Table 1–10 The 2015–2020 Dietary Guidelines for provides evidence-based policy, systems, and environmental
Americans132 changes that support direct educational social marketing
Follow a healthy eating pattern across the life span. All
and ways to evaluate them across various settings. The
food and beverage choices matter. Choose a healthy eating reliance on and the consistency of following the DGA
pattern at an appropriate calorie level to help achieve and ensure that nutrition information promulgated by the
maintain a healthy body weight, support nutrient adequacy, government is the same for all federal programs. Although
and reduce the risk of chronic disease. not mandated, the DGA also provide the foundation for
Focus on variety, nutrient density, and amount. To meet nutrition recommendations and programs from nonfederal
nutrient needs within calorie limits, choose a variety of agencies such as the American Heart Association and the
nutrient-dense foods across and within all food groups in American Cancer Society.
recommended amounts.
Limit calories from added sugars and saturated fats and
reduce sodium intake. Consume an eating pattern low in MYPLATE, MYWINS
added sugars, saturated fats, and sodium. Cut back on foods
and beverages higher in these components to amounts that
fit within healthy eating patterns.
In the United States, food group plans have provided
Shift to healthier food and beverage choices. Choose dietary guidance based on current scientific knowledge
nutrient-dense foods and beverages across and within all for almost 100 years. The USDA published its first
food groups in place of less healthy choices. Consider cultural recommendations in 1916. Between 1916 and the 1940s,
and personal preferences to make these shifts easier to plans had between 5 and 16 separate food groups and were
accomplish and maintain. published by various government agencies. In 1943, as part
Support healthy eating patterns for all. Everyone has a role of the wartime effort, the USDA published the National
in helping to create and support healthy eating patterns in Wartime Nutrition Guide. The Basic Seven Food Guide, derived
multiple settings nationwide, from home to school to work to from the Wartime Guide, was issued and was used until 1955
communities. when the Department of Nutrition at the Harvard School
MyPlate, MyWins 25
Table 1–11 Key Recommendations that Support the Five Dietary Guidelines132
Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level.
A healthy eating pattern includes:
• A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other
• Fruits, especially whole fruits
• Grains, at least half of which are whole grains
• Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and
soy products
• Oils
A healthy eating pattern limits:
• Saturated fats and transfats, added sugars, and sodium
Key recommendations that are quantitative are provided for several components of the diet that should be limited. These
components are of particular public health concern in the United States, and the specified limits can help individuals achieve
health eating patterns within calorie limits:
• Consume less than 10% of calories per day from added sugars
• Consume less than 10% of calories per day from saturated fats
• Consume less than 2,300 milligrams (mg) per day of sodium
• If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and up to two drinks per
day for men—and only by adults of legal drinking age
In tandem with these recommendations, Americans of all ages—children, adolescents, adults, and older adults—should meet the
Physical Activity Guidelines for Americans to help promote health and reduce the risk of chronic disease. Americans should aim
to achieve and maintain a healthy body weight. The relationship between diet and physical activity contributes to calorie balance
and managing body weight. As such, the Dietary Guidelines includes a key recommendation to
• Meet the Physical Activity Guidelines for Americans134†
For substantial health benefits, do one of the following:
• 150 minutes (2 hours and 30 minutes) each week of moderate-intensity aerobic physical activity (such as brisk walking or
tennis)
• 75 minutes (1 hour and 15 minutes) each week of vigorous-intensity aerobic physical activity (such as jogging or swimming
laps)
• An equivalent combination of moderate- and vigorous-intensity aerobic physical activity
For adults 65 years of age and older, do aerobic activity.
For substantial health benefits, do one of the following:
• 150 minutes (2 hours and 30 minutes) each week of moderate-intensity aerobic physical activity (such as brisk walking or
gardening)
• 75 minutes (1 hour and 15 minutes) each week of vigorous-intensity aerobic physical activity (such as jogging or swimming
laps)
• An equivalent combination of moderate- and vigorous-intensity aerobic physical activity
The guidelines recommend that children and adolescents ages 6–17 do 60 minutes (1 hour) or more of physical activity each day. For adults, do aerobic activity.
†
of Public Health recommended collapsing the groups These efforts culminated with the Food Guide
to four. This format was accepted by the USDA in 1956 Pyramid released in 1992, MyPyramid in 2005, MyPlate in
and in 1979 a fifth group—fats, sweets, and alcohol—was 2011, and MyPlate, MyWins in 2015. The introduction of
added. These plans had two things in common: they were MyPlate coincided with the release of the 2010 DGA.141 The
designed to meet nutrient requirements and to prevent MyPlate icon (Figure 1–1) depicts the five food groups:
nutritional deficiencies. With the recognition of the fruit, vegetables, grains, protein foods, and dairy foods,
relationship between diet and chronic disease risk and the but it provides a new, simpler reminder to choose healthy
development of the DGA, it was important to develop a foods at mealtimes than either the Food Guide Pyramid or
food guidance system that included recommendations to MyPyramid did. The seven key consumer messages chosen
prevent the excesses or poor food choices associated with for MyPlate, MyWins is shown in Table 1–12.142,143 The
chronic disease. website also has a variety of information about healthy food
Table 1–12 The Seven Key Consumer Messages

Chosen for MyPlate, MyWins
Balancing Calories
Enjoy your food, but eat less
Avoid oversized portions
Foods to Increase
Make half your plate fruits and vegetables
Make at least half your grains whole grains
Switch to fat free or low-fat (1%) milk
Foods to Reduce
Compare sodium in foods such as soup, bread, and frozen
meals—and choose the foods with lower numbers
Drink water instead of sugary foods
Reproduced from USDA. Dietary Guidelines 2020: Selected Messages for
Consumers. Available at: http://www.choosemyplate.gov/sites/default/files/
printablematerials/SelectedMessages.pdf.
by Individuals (CSFII) data, it is updated every 5 years as

new DGA are released using NHANES data. The updates
FIGURE 1–1 My Plate Icon.
Courtesy of USDA. Choose My Plate. http://www.choosemyplate.gov
reflect collaboration between the CNPP and the National
Cancer Center. Plans to update the HEI to align with the
choices and videos to provide a visual for individuals. The 2015–2020 DGA are under way. Figure 1–2 is the fact sheet
icon, the new website, and the seven key selected messages from the HEI-2010.148 The scoring metric for the HEI is
were pretested for understanding and general appeal.144 composed of 12 subcomponents that are summed for a total
MyPlate, MyWins is more than a simple icon; it is “part possible score of 100. Of the subcomponents, nine—total
of a multimodal communication strategy that includes the fruit, whole fruit, total vegetables, greens and beans, whole
MyPlate, MyWins Web site with the SuperTracker tool grains, dairy, total protein foods, seafood and plant proteins,
to personalize food plans, consumer educational materials and fatty acid ratios—receive “adequacy scores.” These
and e-tools, social media engagement, and a partnership are foods to encourage and a higher score indicates higher
initiative to help coordinate and disseminate consistent consumption. The three remaining subcomponents—
messages of the DGA.”145 The website provides easy to refined grains, sodium, and empty calories (solid fats, added
understand information on healthy food choices for all ages sugars, and alcohol if it exceeds 13 grams/1,000 kcals)—
for both consumers and health professionals. Toolkits for are foods/nutrients to be consumed in “moderation,” and
professionals include the “MyPlate Community Toolkit,” a higher score indicates lower consumption. Recently it
which incorporates First Lady Michelle Obama’s Let’s was shown, using NHANES 2011–2012 data, that the
Move! initiative and is designed to help communities total population (>2 years of age; N = 7,933) had a total
reverse the trend of childhood obesity; and the “Eat Healthy score of 59.0±0.95 (standard error); children (2–17 years
Be Active Community Workshop Series,” which builds on of age; N = 2,857) had a total score of 55.07±0.72; and
the concepts of the DGA by providing detailed tips on how older adults (>65 years of age; N = 1,032) had a total score
to put recommended behaviors into practice. of 68.29±1.76.148 In addition to age being associated with
better diet quality, HEI scores also are higher in individuals
with higher incomes and more education.149 Overall, diet
HEALTHY EATING INDEX quality appears to be improving slowly in the United States;
it is not clear, however, whether improvement will be rapid
The Healthy Eating Index (HEI) was developed to provide enough to meet the all the HP 2020 nutrition goals. Only
a single measure to assess diet quality through adherence improvements in whole fruit intake and empty calories
to the DGA for the U.S. population and the low-income appear to be on track to meet these goals.150
subpopulation.146–148 Originally developed by the CNPP in Tools for researchers, include basic steps to calculate
1995 using 1989–1990 Continuing Survey of Food Intakes HEI scores at different levels: national food supply, food
The Food Label 27
HEI-20101 component Maximum Standard for maximum score Standard for minimum score of zero
Adequacy (higher score indicates higher consumption)
Total Fruit2 5 >0.8 cup equiv./1,000 kcal10 No fruit
Whole Fruit3 5 >0.4 cup equiv./1,000 kcal No whole fruit
Total Vegetables4 5 >1.1 cup equiv./1,000 kcal No vegetables
Greens and Beans4 5 >0.2 cup equiv./1,000 kcal No dark-green vegetables, beans, or peas
Whole Grains 10 >1.5 ounce equiv./1,000 kcal No whole grains

5
Dairy 10 >1.3 cup equiv./1,000 kcal No dairy
Total Protein Foods6 5 >2.5 ounce equiv./1,000 kcal No proteing foods
Seafood and Plant Proteins6,7 5 >0.8 ounce equiv./1,000 kcal No seafood or plant proteins
Fatty Acids8 10 (PUFAs + MUFAs)/SFAs > 2.5 (PUFAs + MUFAs)/SFAs < 1.2
Moderation (higher score indicates lower consumption)
Refined Grains 10 ≤1.8 ounce equiv./1,000 kcal ≥4.3 ounce equiv./1,000 kcal
Sodium 10 ≤1.1 gram/1,000 kcal ≥2.0 grams/1,000 kcal
Empty Calories9 10 ≤19% of energy ≥50% of energy
1 Intakes between the minimum and maximum standards are scored proportionately.
2 Includes 100% fruit juice.
3 Includes all forms except juice.
4 Includes any beans and peas not counted as Total Protein Foods.
5 Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages.
6 Beans and peas are included here (and not with vegetables) when the Total Protein Foods standard is otherwise not met.
7 Includes seafood, nuts, seeds, soy products (other than beverages) as well as beans and peas counted as Total Protein Foods.
8 Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs).
9 Calories from solid fats, alcohol, and added sugars; threshold for counting alcohol is > 13 grams/1,000 kcal.
10 Equiv. = equivalent, kcal = kilocalories.
FIGURE 1–2 Fact Sheet for the Healthy Eating Index, 2010.
Reproduced from USDA. The Healthy Eating Index. http://www.cnpp.usda.gov/sites/default/files/healthy_eating_index/CNPPFactSheetNo2.pdf.
processing, community food environment, and individual In response to these provisions, in the Federal Register of
food intake. Statistical Analysis System (SAS) macros are November 27, 1991, the FDA published a proposed rule
available for calculating the HEI-2005 and the HEI-2010.151 titled “Food Labeling; Reference Daily Intakes and Daily Reference
Values; Mandatory Status of Nutrition Labeling and Nutrient
THE FOOD LABEL Content Revision.” In that document, the agency proposed
to require that foods bear nutrition labeling listing certain
The Nutrition Labeling and Education Act (NLEA) of nutrients and the amount of those nutrients in a serving of
1990 (PL 101-535) amended the Federal Food, Drug, and the food.
Cosmetic Act to provide, among other things, that certain Under the NLEA, some foods are exempt from food
nutrients and food components be included on the label. The labeling laws: food served for immediate consumption
regulatory authority for the food label rests with the FDA (e.g., served in hospital cafeterias and airplanes) and sold by
and the Federal Trade Commission. The Secretary of HHS food service vendors, (e.g., mall cookie counters, sidewalk
(and by delegation, the FDA) can add or delete nutrients vendors, and vending machines); ready-to-eat food that is
included in the food label or labeling if this action is necessary not for immediate consumption but is prepared primarily on
to assist consumers in maintaining healthy dietary practices. site (e.g., bakery, deli, and candy store items); food shipped
in bulk as long as it is not for sale in that form to consumers; Health claims on foods and dietary supplements are
medical foods (e.g., those used to address the nutritional more complicated but can be made after such statements have
needs of patients with certain diseases); plain coffee and tea, been reviewed and authorized by the FDA. Before industry
some spices; and other foods with no significant amounts of can place such a claim on a label, stringent requirements
any nutrients. must be met;159 and all foods allowed to bear such health
Placement of information on the label, type size, claims must fulfill specific criteria. The FDA has provided
manufacturer name and contact information, and other industry guidance on the evidence-based review system the FDA
information related to content are also mandated. To uses to evaluate the publicly available scientific evidence for
accommodate foods sold in small packages, there are significant scientific agreement on health claims or QHCs
special requirements. Further, the USDA regulates poultry and the relationship between a substance and a disease or
in accordance with the Poultry Products Inspection Act health-related condition.159 Approved claims must be clearly
and meat under the Federal Meat Inspection Act. Daily stated along with the requirements for the food, the claim
values (DV) are one of the key elements of the food requirements, and the model claim; statements are available
label; these are the daily dietary intake standards used for on the FDA’s website.159 The FDA has acknowledged that
nutrition labeling. The first daily intake standards for the consumers benefit from more information on food labels
nutrition label, referred to as the U.S. Recommended about diet and health. The FDA thus established interim
Daily Allowances, were established in 1973 and were based procedures whereby QHCs can be made for conventional
on the RDAs.152–154 foods and for dietary supplements. Past court decisions
Food label criteria continue to change to meet current
scientific research and public demand. Another example is Table 1–13a Health Claims Subject to Enforcement
the Food Allergen Labeling and Consumer Protection Act Discretion159
of 2004 (PL 108-282, Title II), which mandated that as of
January 1, 2006, foods containing or potentially containing Calcium, and osteoporosis; calcium, vitamin D, and
any of the eight most common food allergens—milk, eggs, osteoporosis
fish, Crustacean shellfish, tree nuts, peanuts, wheat, and Dietary fat, and cancer
soybeans—include the food name on the label in “plain Sodium, and hypertension
Dietary saturated fat and cholesterol, and the risk of
English” (e.g., this product contains EGGS). These foods
coronary heart disease
account for 90% of food allergic reactions in children and Fruits, vegetables, and grain products containing fiber,
adults. The FDA also provides guidance for industry from a particularly soluble fiber, and risk of coronary heart disease
standpoint of allergens and potential allergens in the food.155 Fruits and vegetables, and cancer
Although gluten is not an allergen, in 2013 the FDA set Folate, and neural tube defects
a threshold for gluten of less than 20 parts per million in Dietary noncariogenic carbohydrate sweeteners, and dental
foods that are labeled “gluten-free,” “no gluten,” “free of caries; carbohydrate sweeteners, and dental caries
gluten,” and “without gluten.”156,157 Soluble fiber from certain foods, and risk of coronary heart
As mandated by the NLEA of 1990, the FDA issued disease
the final food labeling rules for health claims. Updated Soy protein, and risk of coronary heart disease
in 2008, information on the FDA website qualifies and Plant sterol/stanol esters, and risk of coronary heart disease
explains claims that can be made for conventional food and
dietary supplements. The claims fall into four categories: Table 1–13b FDA Modernization Act Health Claims
(1) nutrient content claims; (2) health claims; (3) qualified (Health Claims Authorized Based on an Authoritative
health claims (QHC); and (4) structure/function claims.158 Statement by Federal Scientific Bodies)159
Nutrient content claims are fairly straightforward, for
Whole grain foods, and risk of heart disease and certain
example, calorie free: <5 kcal per reference amount cancers
customarily consumed (RACC) per labeled serving, or low Whole grain foods with moderate fat content, and risk of
calorie: <40 kcal per RACC. Further, “when levels exceed heart disease
13 g Total Fat, 4 g Saturated Fat, 60 mg Cholesterol, and Potassium, and the risk of high blood pressure and stroke
480 mg Sodium per RACC, per labeled serving or, for Fluoridated water, and reduced risk of dental carries
foods with small RACC, per 50 g, a disclosure statement is Saturated fat, cholesterol, and transfat, and reduced risk of
required as part of claim (e.g., “See nutrition information heart disease
for ___ content” with the blank filled in with nutrient(s) Substitution of saturated fat in the diet with unsaturated
that exceed the prescribed levels).158 fatty acids, and reduced risk of heart disease
Conclusion 29
have clarified the need to provide for health claims based sugars and include a footnote that would help consumers
on less scientific evidence rather than just on the standard of better understand the concept of daily values.161 Figure 1–3
significant scientific agreement (SSA) as long as the claims shows a comparison of the current with the proposed label.
do not mislead consumers. The FDA began considering Helping clients understand food labels—including (1) how to
QHCs under its interim procedures on September 1, use them to make careful food selections, which may reduce
2003. Tables 1–13a-b shows the health claims and QHCs or even prevent chronic disease; (2) how the information is
allowed on food labels.159–160 Finally, structure/function especially important to individuals in certain disease states;
claims are allowed on labels. These differ from health and (3) how the food in question integrates into a total
claims in that structure/function claims describe the role of food plan—is clearly within your purview as a nutrition
a substance intended to maintain the structure or function professional. Information on how to read the food label and
of the body. Structure/function claims do not require consumer information is available online.162
preapproval by the FDA. Products with structure/function
claims must include this disclaimer: “This statement has
not been evaluated by the Food and Drug Administration. CONCLUSION
This product is not intended to diagnose, treat, cure, or
prevent any disease.” Examples are “calcium builds strong Complaints that nutrition recommendations are conflicting
bones” and “antioxidants maintain cell integrity.” and confusing are common; however, these recommendations
The FDA has proposed new rules that would update are remarkably similar across agencies, including the
the Nutrition Facts labels. This would help consumers make Dietary Guidelines for Americans, the American Heart
more informed choices. In March 2014, the FDA proposed Association, the American Cancer Institute, and therapeutic
two rules to update the Nutrition Facts labels, and in July diets such as Dietary Approaches to Stop Hypertension.
2015 the FDA issued a supplemental rule that would, among Why? Because the recommendations are based on what the
other things, require the percent daily value (% DV) for added evidence behind the programs dictates. The challenge for all
Nutrition Facts Nutrition Facts

Serving Size 2/3 cup (55g)
servings Per Container About 8 8 servings per container
Serving size 2/3 cup (55g)
Amount per serving
Calories 230 Calories from Fat 72 Amount per serving
Total Fat 8g
% Daily Value*
12%
Calories 230
% Daily Value*
Saturated Fat 1g 5%
Trans Fat 0g Total Fat 8g 10%
Cholesterol 0mg 0% Saturated Fat 1g 5%
Sodium 160mg 7% Trans Fat 0g
Total Carbohydrate 37g 12% Cholesterol 0mg 0%
Dietary Fiber 4g 16% Sodium 160mg 7%
Sugars 1g
Total Carbohydrate 37g 13%
Protein 3g
Dietary Fiber 4g 14%
Vitamin A 10% Total Sugars 12g
Vitamin C 8% Includes 10g Added Sugars 20%
Calcium 20% Protein 3g
Iron 45%
* Percent Daily Values are based on a 2,000 calorie diet. Vitamin D 2mcg 10%
Your daily value may be higher or lower depending on
your calorie needs. Calcium 260mg 20%
Calories: 2,000 2,500
Iron 8mg 45%
Total Fat Less than 65g 80g
Sat. Fat Less than 20g 25g Potassium 235mg 6%
Cholesterol Less than 300mg 300mg
Sodium Less than 2,400mg 2,400mg * The % Daily Value (DV) tells you how much a nutrient in
Total Carbohydrate 300g 375g a serving of food contributes to a daily diet. 2,000 calories
Dietary Fiber 25g 30g a day is used for general nutrition advice.
FIGURE 1–3 Comparison of Current and Proposed Food Labels.

Reproduced from: U.S. Food and Drug Administration. Changes to the Nutrition Facts Label. http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocu-
mentsRegulatoryInformation/LabelingNutrition/ucm385663.htm. Accessed April 12, 2016
nutritionist professionals is to critically evaluate the scientific the most accurate and comprehensive information available,
evidence before it is translated into public health practice. which allows them to make positive lifestyle changes. This
Nutrition professionals need to use this information to chapter reviewed the science behind public health policies,
design, execute, and evaluate programs and policies so that programs, nutrition education materials, and legislation.
positive recommendations are communicated to the public
in a unified way. Doing so assures that consumers are getting
ISSUES FOR DISCUSSION

1. Dietary recommendations for the public change as 3. The Dietary Guidelines for Americans and MyPlate,
scientific studies discover new information. How can My Wins promulgate prudent diets, but Americans
these changes be brought to the public in a way that clearly have difficulty following these recommenda-
does not confuse them or make them feel resentful? tions. Why? If people cannot follow them, should
2. What ethical responsibility, if any, does industry or we continue to make these recommendations?
the media have in assuring the public’s health?
CASE STUDY: EVIDENCE-BASED APPROACH

A number of questions in the nutrition literature have 1. Working in teams, pick either of these questions
not really been answered using an evidence-based or a question you develop with your instructor.
approach; for example: Does fast food intake increase 2. See if you can come to a definitive answer using an
weight in children, and why did the recommendation evidence-based approach.
for intake of added sugars fall from 25% of energy intake 3. Present your results.
in the 2010 Dietary Guidelines for Americans to 10% of
energy intake in the 2015–2020 Dietary Guidelines for
Americans?
ONLINE RESOURCES
1. The World Health Organization’s report on the Com- 6. PubMed online tutorials:
mission on Ending Childhood Obesity: https://www.nlm.nih.gov/bsd/disted/pubmed.html
http://apps.who.int/iris/ 7. Evidence Analysis Library:
bitstream/10665/204176/1/978924151- 0066_eng. https://www.andeal.org
pdf?ua=1 8. Morbidity and Mortality Weekly Report:
2. CDC information on obesity and obesity trends in http://www.cdc.gov/mmwr/mmwrsubscribe.html
the United States: 9. Mobile examination center guided tour:
http://www.cdc.gov/obesity/data/prevalence-maps. http://www.cdc.gov/mmwr/mmwrsubscribe.html
html 10. Young Finns study (duplication of Bogalusa Heart
3. Department of Health and Human Services detailed Study):
recommendations for physical activity: http://youngfinnsstudy.utu.fi
http://health.gov/paguidelines/guidelines 11. NHANES online tutorial:
4. Public Health Genomics Knowledge Base: http://www.cdc.gov/nchs/tutorials/nhanes/index_
https://phgkb.cdc.gov/GAPPKB/phgHome. current.htm
do?action=home 12. Phytonutrients:
5. Internet research tips: https://fnic.nal.usda.gov/food-
http://www.library.cornell.edu/olinuris/ref/research/ composition/phytonutrients
webeval.html
Another random document with
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Flagellants, the formation of their processions, 345, & seq.
The success they met with in different Countries, 350.
Description of one of their itinerant processions in Germany, 351, & seq.
Their establishment and first success in France, 355, 372, & seq.
are there discountenanced at last, 373.
Their fraternities must be distinguished from the sect of Hereticks, called
Flagellants, 368.
Account of these Hereticks, 369.
Account of these fraternities, 370, & seq.
Are, as it were, naturalised in Italy and Spain, 374.
Manner in which they perform these processions in Spain, 374, & seq.
In Italy, 382, & seq.
Real cruelty of these Flagellants upon themselves, 384, 385.
Flagellating fanaticism, a kind of, seems to have taken place in England about the
time of the Rebellion, 340.
Proofs of it, ibid.
Flagellations, are either of a voluntary, or a corrective, or a recommendatory kind.
Voluntary flagellations were in use among most Nations of Antiquity, 79, & seq.
Were unknown, it seems, to the first Christians, 102.
Were not prescribed to religious persons by the first Founders of Monastic
Orders, 118.
Conjectures about the times in which they grew into use among Christians,
192, & seq.
The time at which they certainly became universally used among them, 201, &
seq.
Cruelty with which they are performed, 203, & seq. 384, & seq.
Incredible and superstitious stories contrived to recommend them, 299, & seq.
Flagellations (corrective) their use is known from the earliest times, 51.
Are used as a means of procuring victory in war, 52;
by Masters over their Slaves; great power of Masters in Rome in that
respect, 57, & seq.
Both in antient and modern times by Schoolmasters, 71, & seq.
by Judges, 55;
by Ladies to correct misbehaviour, 319, & seq.
Are useful to defeat captious arguments, 177.
To reward satires or bon-mots, 177, 178, 268, & seq.
To check those who betray the secrets of others, 268, & seq.
To repress competitors, 277.
To confute heresy, 258.
Are, in modern times, used in Seraglios, 172;
in the palaces of the western Sovereigns, 173, & seq.
in Monasteries and the rites with which they are performed there, 131, &
seq. 180.
Flagellations (jocular) performed as a pastime, 96, 97, 39, 240, 241.
Flagellations (recommendatory) 162, & seq.
Flagellations (in general) are undergone by Sovereigns and Great Men, 265.
Are served by Emperors with their own hands, ibid.
Are useful to make one’s fortune, 267.
To acquire reputation, ibid.
Are very proper to enliven and embellish public festivals, 395.
Are capable of being performed with much gracefulness, 375, 376.
The most comfortable manner to receive them, 253.
Their glory completed, 258.
Francis (St.) his stigmats, a contrivance of his, 109.
Is flagellated by the Devil the very first night after his arrival at Rome, 126.
Friars, miracle effected by one, 128, & seq.
Contrivance of certain Friars in Catalonia, 247.
See Monks.
Fulk Grisegonelle, an account of the penance he performs, 391.
G.
Gay quoted, 77.
Gelasius (Pope), puts an end to the festival of the Lupercalia, 94.
Improvements that had been made in it in his time, ibid.
Gerald (Sylvester) his Itinerarium Cambriæ, quoted, 317.
Gil Blas, quoted, 78.
Girard (Father), inflicts Cornelian disciplines on Miss Cadiere, 237.
Gerund de Campazas, a Spanish Novel, quoted, 293, 379.
Goddesses, weapons with which the Antients supplied them, 60, 319.
Gretzer (Father), a strenuous promoter of flagellations, 44, 45.
His consultation of a Physician recited, 402, 403.
Gymnosophists, or naked Sages, 391.
H.
Heloisa. The friendship of Abelard to her, 236, 243.
Henry II. of England, receives a correction from the Church, 251, 252.
Henry III. of France, inlists as a Brother in a fraternity of Disciplinants, 356, & seq.
372.
Henry IV. of France, receives likewise a correction from the Church, 253.
The great indulgence with which he is treated on that occasion, 254, 255.
Hermits, what kind of men they are, 115.
No better than common Friars; story of one, ibid.
Hérodote (Apologie pour), an account of the Book, 128.
Again quoted, 247, 315.
Herodotus, quoted, 85.
Hooëden (the Rector of), accident that happened to his Concubine, 317.
Hope (Cape of Good), in what manner fires are prevented there, 292.
Horace, quoted, 24, 55, 56, 65, 71, 283.
Hudibras, quoted, 327, 339, 376.
Hume (Mr.) quoted, 259.
Husbands corrected by their Wives, 339.
The subject is extensive and deep, and requires a Treatise apart, 340.
I.
James I. flagellated by his Preceptor, 160.
James II. dazzled by Miss Arabella Churchill’s posteriors, 286.
Jerom (St.) his observations on the epitaph of the widow Marcella, quoted, 94.
His exhortation to Sabinus, 109.
Does not seem to have practised any beatings upon himself, otherwise than
with his fists, 110.
Fired with an ardent desire of acquiring the style of Cicero, 111.
Fustigated for that reason by the Angels before the Tribunal of God, ibid.
Jesuit, a Reverend Father Jesuit acts as an agent from Philip II. of Spain, to
persuade a Princess of the Austrian House to marry him, 176.
The eloquence of the Father, ibid.
He only draws in the issue a flagellation upon himself, 177.
Is served with it in the kitchen, 177, 187.
Jesuits, their regularity in inflicting flagellations, 161.
Excellent Latin distich made at the expence of the society by one of their
School-boys, 162.
Jews (the antient) made not self-flagellations part of their religious worship, 27, &
seq.
The impartiality shewn to both sexes among them, 30.
The modern Jews adopt the practice of voluntary flagellations, 35.
A description of their manner of performing them, 35, & seq.
Coercive flagellations were known among them, 27, 28.
The number of the blows was fixed by the Law of Moses at forty, 30.
Innocents (the day of the), a day of great retribution and justice, 328, & seq.
Giving the innocents is an antient as well as ingenious custom, 330, 331.
Italy. Processions of Disciplinants are much in vogue in that Country, 381.
The pageantry and festivity by which they are accompanied, 381, & seq.
Juliet of Gonzaga, abominable act of ingratitude and vanity of that woman, 271.
Juniperus (Brother), a great partisan of nakedness, 393.
His public entrance into the town of Viterbo, and noble carriage as well as
sanctity on that occasion, Ibid.
Justin, quoted, 51.
Justina (the Monk of St.) his Chronicle quoted, 346, & seq.
Juvenal, his singular expression with respect to Augustus, 60.
His account of the cruel wantonness of Roman Mistresses with their slaves,
67, & seq.
The festival of the Lupercalia alluded to by him, 91.
K.
Kennet (Bishop), his Chronicle, quoted, 237.
Kitchen (the), is the appropriated place for flagellations in the Palaces of the
Western Kings and great Men, 185.
Advantages of the place, ibid.
The great share the people of the kitchen bore in former times in supporting
the dignity of Kings, 186.
Farther remark on the importance of the people of the kitchen, 191.
Their laudable zeal in assisting their Masters, 190, 191.
Kolben, his description of the Cape of Good Hope, quoted, 292.
L.
Labat (Father), his travels into Spain and Italy quoted, 382.
Lacedæmon Flagellating solemnities that took place there, 79, & seq.
Are described, or alluded to, by Cicero, Plutarch, Lucian, Seneca, &c. ibid.
Are still in use in the times of Tertullian, 83.
It is difficult to say whether there was more inhumanity or stupidity in these
processions, 395.
Ladies have an abhorrence to cruelty, even in their acts of revenge, 320.
Neither do they intirely overlook offences; remarkable instances of both their
spirited resentment and mercifulness, 321, & seq.
Aim at elegance in all their actions, 320, & seq.
The singular power of the graces to engage their attention, 376.
Have a right to flagellate their Husbands, 339, 340.
Lady (a great), mentioned by Brantôme; the remarkable entertainments and
festivity that took place in her house, 239, & seq.
Lancelot du Lac, the Knight, his History quoted, 218, 228.
Lafontaine, the Poet, quoted, 116, 196, 243, 322, 409.
Law (the study of the), what is necessary to succeed in it, 282.
Lazare (the Fathers of), their seminary; the excellent institution it was, 162.
The extensiveness of their operations, 163, 164.
Their scrupulous exactness in performing their engagements, ibid.
The occasion of their seminary being abolished, 165, 166.
Lazarillo de Tormes, the notorious Spanish Cheat; how punished by his four
Wives, 327.
Legend (Golden), a farrago of Monkish stories compiled by Jacobus de Voragine,
115.
Again quoted, 151.
Lewis XI. of France; the rascally turn of his devotion, 207.
Liancourt (the Lady of), account of this Lady; her competition with the Marchioness
of Tresnel, 278.
Is worsted in the issue, 280.
Libanius, the Sophist, quoted, 288.
Limeuil (Mademoiselle de), a Maid of Honour to the Queen of France, 173, 174.
The misfortune that befalls her, ibid.
Lower discipline defined, 21.
Is adopted by Capuchin Friars and the whole Tribe of Nuns, 21, 404.
Were not unknown to the Greeks and Romans, 287.
Are known in France, 288.
In Italy, ibid.
Among the Persians, 289.
The Turks, ibid.
The Chinese, ibid.
The Arabs, 290.
In Denmark, 291.
Among the Dutch, 292.
In Poland, 179, 292.
In England, ibid.
In Spain, 293.
A few remarks on their propriety, 400, & seq.
Loyola (Ignatius of), gets himself whipt at School, 98.
Lucian, quoted, 24, 81, 82, 96, 319.
Lupercalia, account of that festival, 90, & seq.
It is continued to very late times, 93.
Is greatly improved, 94.
An attempt to revive it, 241.
A farther description of it, 396, & seq.
Had vastly the advantage of all the festivals of the like kind, contrived by other
nations, ibid.
M.
Margaret, Queen of Navarre, attempts to make herself Mistress of the Town of
Agen, 269.
Is forced to fly on horseback with the utmost hurry and expedition, ibid.
The consequences of it, ibid.
Masters in Rome; the great power they possessed over their slaves, 57.
To what degree they abused it, 57, & seq.
Instances of this abuse, 61, 66, & seq.
Provisions made by the Emperors to restrain them, 69, 70;
and by the Church, 61, 70.
Marlborough (the great Duke of), to what he owed his first advancement, 286.
Mathew (Brother), the godly personage he was, 262.
The lecture he bestows upon a young Lady who pays a visit to him in his bed,
263.
Ought not to be imitated, except by persons who possess as much sanctity as
him, 294, 297.
Menagiana quoted, 233.
Menas, a Spanish Friar, does not keep his word to his female penitents, 246.
Middleton, his Letter from Rome quoted, 87, 318, 381.
Milo, how serves Sallust the Historian, who had meddled with his Wife, 65.
Milton quoted, 338.
Mind (the human), how variable and fantastick in her opinions, 281.
Singular instance of it, 281, & seq. 287, & seq.
Miserere, or 51st Psalm, the singing of it particularly used to enliven as well as
regulate the time of religious flagellation among Christians, 32, 371.
Mistresses in Rome; the abuse they made of their power over their female slaves.
See Masters.
Molesworth (Lord), his description of a hunting-match at the Court of Denmark,
291.
Molly Mog, the song made to her honour by Gay, 77.
Molière quoted, 20, 99, 206.
Monastic Orders; by whom first instituted, 118.
Monasteries: voluntary disciplines were not in use in them, in the times of their first
foundation, 118, & seq.
Monks, receive frequent disciplines from their Abbots, 135, & seq.
Cases in which such disciplines ought to be inflicted on them, ibid.
Do not much respect their Abbot, notwithstanding his power of flagellation,
154, & seq.
An explanation of this singularity, ibid.
Great lovers of entertainments, 142.
Account of a treat given by one to some others, 143, 144;
after reckoning for the same, 145, 146.
The remarkable zeal of one against adultery, 138.
The great zeal of another in vindicating the honour of the Virgin, 310, 311.
The wager made by a certain Monk, 314;
comes off winner, 315.
See Friars.
More (Chancellor), adopts the opinion of the usefulness of flagellations for
converting Hereticks, 259.
Munson (Lord), chastised by his Lady, 339.
Farther account of him, 340.
N.
Nakedness is thought by some to possess, of itself, a degree of sanctity, 391, &
seq.
Account of several of its practitioners, ibid.
The strong arguments of Cardinal Damian in its favour, 389.
Is after all but an incomplete act of penance, 395.
Navarre (the Tales of the Queen of), quoted, 188, 330, 331.
Nuns, their confinement and amorous visions, 107, 108.
Settled days on which they are to inflict disciplines upon themselves, 120,
121.
Power of the Abbess to inflict disciplines upon them, 167, & seq.
Cases in which she is directed to use that power, ibid.
The spirited manner in which certain Nuns assert the honour of their Convent,
322, & seq.
O.
Orbilius (the flogging), 71, 160.
Ovid, his advice to Lovers, 341.
Again quoted, 407.
P.
Pardulph (St.) affords an instance of voluntary discipline, in early times, 198.
Pavillon, his verses to the praise of Iris’s Bum, 286.
Penance, or Penitence, is a Sacrament among Catholicks, 22;
its essentials, ibid.
The hundred years penance, what it is, 203, & seq.
Is sometimes performed in twenty days, ibid.
Was but a trifle for Rodolph of Eugubio, and Dominic the Cuirassed, ibid.
The Widow Cechald likewise performs it, 221.
Penitents, processions of Penitents.
See Flagellants.
Blue Penitents in the City of Bourges; their fraternity abolished, 360, 373.
Peregrinus (the Philosopher), flagellatory pastimes of his, 96.
Persians, the use of flagellations is known among them, 53.
Are used at Court, ibid.
Peter I. (the Czar), inflicts flagellations with his own hands, 266.
Petrarch recommends flagellations, 76.
Petronius, his Satyricon quoted, 88, 89.
Philip II. of Spain, sends proposals of marriage to a Princess of the House of
Austria, widow to the late King of France, 176.
Employs in this affair the agency of a Father Jesuit, ibid.
His success and that of the Jesuit, 177.
Philosophers, particular Sects of them among the Greeks practise self-
flagellations, 83.
The greater number of them ridicule practices of this kind, 84.
Physician (a), consulted by Gretzer on the ill consequences of the upper discipline,
403.
His learned decision, ibid.
Picards, a Sect in Germany, declare for a state of complete nakedness, 392.
Carry their notions farther than the Adamites had done, ibid.
Pictures in Churches, are the Libraries of ignorant Christians, 25.
Their too great licence, ibid.
Many wicked thoughts propagated by them, 26;
as well as errors, ibid.
Plautus had been the servant of a Baker, 62;
quoted, 63, & seq.
His allusion to a singular practice of the vulgar in Rome, 95.
Plutarch quoted, 53.
Had been an eye-witness of the flagellating solemnities in Lacedæmon, 79,
80.
Poland; lower disciplines used in that Kingdom for mending the manners of
Servants, 179.
For punishing Fornicators, 292.
Pont Euxine (the Hermit of the), his contrivance to rescue a young Woman from
the hands of a military Man, 196.
Poggio, a tale of his quoted, 116.
Presbyter, whence the word is derived, 143.
Priors or Superiors of Monasteries, are the substitutes of the Abbots, 135.
Are invested with the same power of flagellation, ibid.
Great passion of one and remarkable use made by him of his power, 148.
Are apt to carry the joke too far in their use of flagellations, 153.
Are cautioned against it, ibid.
See Abbots.
Q.
Quintilian quoted, 72.
Quixote (Don), his excellent and polite speech to the fair Maritornes, 295.
Is rather too inquisitive in his conversation with the Senora Rodriguez, 326,
327;
experiences the resentment of the Dutchess and the fair Altisidora, on
that occasion, ibid.
R.
Rabelais quoted, 160, 284.
Rakes, how served in Rome by the Husbands of the Wives whom they courted,
64, & seq.
Raymond, Count of Toulouse, how absolved of his excommunication, 252.
Rodolph of Eugubio, his great feats in the career of flagellation, 202, 203.
Romans, the great power of Masters among them over their Slaves, 57.
See Masters.
Consider a whip as a characteristic mark of dominion, 59, 60.
Flagellations were performed among them with religious views, 88, & seq.
Singular practices of this kind among the vulgar, 94, & seq.
Romuald (St.) a great flagellator, 153.
In one instance flagellates even his own father, 260, 261.
His Monks retaliate his flagellations upon him, 154.
His lucky escape, 157.
Rousseau the Poet quoted, 138, 284.
Russian Baths and Stoves described, 409.
Russian Ladies; how properly they punish a boasting Coxcomb who had affronted
them, 334, & seq.
See Ladies.
S.
Sadragesillus, preceptor to Dagobert, heir to the Crown of France, 74.
How used by his Pupil, 75.
St. Loe (Captain) gets the Boston Magistrates and Select-men served with a
flagellation, 273, & seq.
Saints, the frequent tricks the Devil puts upon them, 125, & seq.
How they have received the advances of the Fair Sex, 261, & seq.
The expedient of a certain Eastern Saint to make himself cry, 364.
Sallust (the Historian), makes free with Milo’s Wife; how served by the Husband,
65.
Sancho, his manner of discipline, 195, 226.
Sanlec, a French Poet; his Satire on Confessors quoted, 234.
Scarron quoted, 285.
Scaligerana quoted, 36, 270.
Schoolmasters of modern times are as fond of using their discipline as ancient
ones, 71, & seq.
Are not worth mentioning in so interesting a book as this, 160, 175.
Scot, a good Story of his, in his Mensa Philosophica, 232.
Scythians, their expedient to conquer their revolted Slaves, 51;
and success, 52.
Seneca quoted, 82.
Slaves, the wanton usage of them in Rome, 61, & seq. 66, & seq.
See Masters.
Solomon (King), recommends flagellations, 76.
His opinion confirmed afterwards by that of Chrysippus, ibid.
Sorbona, whence the word is derived, 143.
Sovereigns; instances of Sovereigns upon whom disciplines have been publicly
inflicted, 250, & seq.
Spain. An account of the processions of Penitents established there, 374, & seq.
Gallantry and nicety of honour that prevail in them, ibid.
The art of performing flagellations with gracefulness is taught there by
Masters for that purpose, 376.
Spirit of Laws quoted, 173.
Stephen (Cardinal), dies suddenly for his having neglected the use of flagellations,
214, 302.
Stylites (St. Simeon), an Anchorite who had fixed his habitation on the top of a
column, 114.
Suetonius quoted, 59, 97.
Superanus, a Greek Philosopher; laudable flagellations he inflicts upon himself,
98.
Surgeon, great favour and confidence shewn to him by a great Princess, 270.
His ungrateful conduit, ibid.
The greatness of his guilt displayed, 271, 272;
his punishment, ibid.
extreme justice of the same, ibid.
Syrians, flagellations of a religious kind used among them, 86, 87.
T.
Tales, Arabian Tales quoted, 290.
Of the Queen of Navarre, 188, 330, 331.
Thracians, flagellations of a voluntary kind used among them, 84.
Tresnel (the Marchioness of), is incensed at the arrogant competition of the Lady
of Liancourt, a woman of inferior birth, 278.
Gets her served with a flagellation, 279.
More serious consequences of the affair, 280.
Triumpher among the Romans, the companion he had in his Car, 59.
V.
Venus, the strange weapon with which the Antients supplied her, 60, 319.
The Temple which the Greeks erected to her, 283.
Vestals, how punished, 167, & seq.
Villemartin (Miss de), is co-spectatress of a flagellation, 280;
is admonished never to do so anymore, 281.
Virgil quoted, 90.
Virgin Mary rescues an Usurer from the hands of the Devils, 304.
The assistance she gives to a person who used to pay devotion to her, 308.
The remarkable zeal of a Monk to assert her honour, 310, & seq.
Visitation (Nuns of the), discipline themselves when they please, 121.
Voltaire (M. de), quoted, 32, 207, 288.
Upper discipline defined, 21.
See Discipline.
W.
Walpole (Sir Robert), his Excise Scheme, preferable, upon the whole to the
schemes that took place in the times of the Roman Emperors, 124.
Whipcord, the great expence made about it by Government, 344.
At what time it began to be used, ibid.
Wife, Roman Wives not much better than modern ones, 64.
Instance of conjugal love of one whose husband offered himself to be
disciplined in her stead, 232.
Inflict castigations upon their husbands, 339, 340.
Witasky, the Buffoon to Peter I. is a good hand at flagellating and cudgelling, 266.
Wurtzbourg, a Sovereign Bishoprick in Germany; a flagellation is an indispensable
step to procure the installation to that See, 256.
C O N T E N T S .
The Introduction, 1
Chap. I. The substance of the account given by the Abbé Boileau of his
design in writing his Book: he seems upon the whole to have been of
opinion that voluntary flagellations were no very antient practice, 17
Chap. II. No persons, under the old Law, inflicted flagellations on

themselves, with their own hands, or received the same from other
persons, 27
Chap. III. Voluntary flagellations were unknown to the first Christians, 39
Chap. IV. The use of flagellations was known among the antient Heathens, 51
Chap. V. The subject continued, 71
Chap. VI. Flagellations of a religious and voluntary kind were practised

among the antient Heathens, 79
Chap. VII. Containing the most ingenious arguments of the Abbé Boileau.
The practise of scourging one’s-self was unknown to the first Fathers
of the Church; and also to the first Anchorites or Hermits, 102
Chap. VIII. A few more of the Abbé Boileau’s arguments are introduced.
Self-flagellations did not make a part of the duties prescribed in the
first Monasteries. The only positive instances of flagellations suffered
by Saints, or the Candidates for that title in the days we speak of, are
those which the Devil has inflicted upon them, 118
Chap. IX. Corrections of a flagellatory kind, inflicted by force, were however,

though in very early times, the common method of correcting offences
of a religious nature; and the power of inflicting them was possessed
alike by Bishops, and the Heads of Monasteries, 131
Chap. X. Strictness of certain Superiors of Convents, in exerting their power 147
of flagellation. The same is abused by several of them,
Chap. XI. Disciplines of the same wholesome kind have been prescribed for
Novices and such persons as are intended to embrace the
ecclesiastical Life, 158
Chap. XII. The same discretionary powers of flagellation have been

established in the Convents of Nuns, and lodged in the hands of the
Abbesses, or Prioresses, 167
Chap. XIII. The subject of voluntary flagellations among Christians, is at last

introduced. That method of self-mortification appears to have been
practised in very early times; but it does not seem to have been
universally admitted before the years 1044 and 1056; which was the
time Cardinal Damian wrote, 192
Chap. XIV. The practice of self-flagellation meets with some opposition; but
this is soon over-ruled by the fondness of the Public, 211
Chap. XV. Another difficulty. Which is the best plight to be in, for receiving a
discipline? 223
Chap. XVI. Confessors at length assume a kind of flagellatory power over

their Penitents. The abuses that arise from it, 227
Chap. XVII. The Church at large also claims a power of publicly inflicting the
discipline of flagellation. Instances of Kings and Princes who have
submitted to it, 249
Chap. XVIII. The glory of flagellations completed: they are made use of for
curing Heresy, 258
Chap. XIX. The subject of the merit of flagellations continued. Holy persons,
though without any public authority, have used them occasionally to
give weight to their admonitions, 260
Chap. XX. The fondness of people for flagellations, gives rise to a number of
incredible stories on that subject, 299
Chap. XXI. A remarkable instance of a flagellation performed in honour of

the Virgin Mary, 310
Chap. XXII. Another story of a female Saint appeased by a flagellation, 317
Chap. XXIII. Formation of the public procession of Flagellants. Different

success they meet with in different Countries, 345
Chap. XXIV. The last Chapter, in which the Abbé Boileau is personally
introduced: he is of opinion that the lower discipline is contrary to
decency, and the upper discipline is liable to bring defluxions on the
eyes, 400
TRANSCRIBER’S NOTE
The character ſ (long-form s) has been replaced by the normal s.
The Greek ϛ (stigma) has been replaced by στ.
Obvious typographical errors and punctuation errors have been corrected after
careful comparison with other occurrences within the text and consultation of
external sources.
Some hyphens in words have been silently removed, some added, when a
predominant preference was found in the original book.
Except for those changes noted below, all misspellings in the text, and
inconsistent or archaic usage, have been retained.
Pg 4: ‘I hvae not the’ replaced by ‘I have not the’.
Pg 9: ‘Sarbonne, and a dean’ replaced by ‘Sorbonne, and a dean’.
Pg 22: ‘I potively aver’ replaced by ‘I positively aver’.
Pg 56: ‘of the Trumvirs’ replaced by ‘of the Triumvirs’.
Pg 61: ‘at last so such’ replaced by ‘at last to such’.
Pg 62: ‘such a mnner that’ replaced by ‘such a manner that’.
Pg 66 Fn [23]: ‘uncontroubled power’ replaced by ‘uncontrouled power’.
Pg 71: missing anchor [24] placed after ‘chastisement.’.
Pg 93 Fn [36]: ‘of Chritianity; and persons of noble familities’ replaced by
‘of Christianity; and persons of noble families’.
Pg 99 Fn [41]: ‘see their appartments’ replaced by ‘see their apartments’.
Pg 110: ‘made it altother’ replaced by ‘made it altogether’.
Pg 134: ‘moveover recommended’ replaced by ‘moreover recommended’.
Pg 139: ‘or solliciting the’ replaced by ‘or soliciting the’.
Pg 162 Fn [64]: ‘the distieh made’ replaced by ‘the distich made’.
Pg 167: ‘inflicting disciciplines’ replaced by ‘inflicting disciplines’.
Pg 177 Fn [67]: ‘his sollicitations’ replaced by ‘his solicitations’.
Pg 179 Fn [68]: ‘new-papers, with’ replaced by ‘news-papers, with’.
Pg 184 Fn [67]: ‘receive an hearsay’ replaced by ‘receive on hearsay’.
Pg 206 Fn [80]: ‘Play of Mollere’ replaced by ‘Play of Molière’.
Pg 210 Fn [82]: ‘Smollet, Franklin’ replaced by ‘Smollett, Franklin’.
Pg 223: ‘from one anther’ replaced by ‘from one another’.
Pg 224: ‘over their growns’ replaced by ‘over their gowns’.
Pg 245 Fn [94]: ‘Charles Borommee’ replaced by ‘Charles Borrommee’.
Pg 249: ‘an indispensible act’ replaced by ‘an indispensable act’.
Pg 250: ‘forgiven his his sin’ replaced by ‘forgiven his sin’.
Pg 284 Fn [102]: ‘a flat noise’ replaced by ‘a flat nose’.
Pg 287 Fn [102]: ‘and expresly chosen’ replaced by ‘and expressly chosen’.
Pg 289 Fn [102]: ‘come expresly to’ replaced by ‘come expressly to’.
Pg 298 Fn [102]: ‘is no unpleassing’ replaced by ‘is no unpleasing’.
Pg 301: ‘he comfessed the’ replaced by ‘he confessed the’.
Pg 318 Fn [111]: ‘the fifth chapter’ replaced by ‘the sixth chapter’.
Pg 319 Fn [111]: ‘See p. 71’ replaced by ‘See p. 79’.
Pg 319 Fn [111]: ‘See p. 76, 77’ replaced by ‘See p. 85, 86’.
Pg 325 Fn [111]: ‘beardless strippling’ replaced by ‘beardless stripling’.
Pg 333 Fn [111]: ‘porper instruments’ replaced by ‘proper instruments’.
Pg 337 Fn [111]: ‘the falshood of’ replaced by ‘the falsehood of’.
Pg 357: ‘same manner it it was’ replaced by ‘same manner it was’.
Pg 381 Fn [115]: ‘bad him go home’ replaced by ‘bade him go home’.
Pg 384 Fn [115]: ‘them, Iay these’ replaced by ‘them, lay these’.
Pg 402: ‘at the learned’ replaced by ‘as the learned’.
Index:
Pg 413: ‘runs the grantlope’ replaced by ‘runs the gantelope’.
Pg 414: ‘Charles Borromeo’ replaced by ‘Charles Borromee’.
Pg 422: ‘Quixotte’ replaced by ‘Quixote’.
Pg 424: ‘indispensible step’ replaced by ‘indispensable step’.
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Nutrition in Public Health 4th Edition

Sari Edelstein (Editor)

Essentials of Public Health 4th Edition Birkhead

Kotch's Maternal and Child Health: Problems, Programs,

Nutrition in Clinical Practice 4th Edition David Katz

Nutrition for Health and Health Care 8th Edition Linda

Foundations for Population Health in Community/Public

Nutrition and Oral Health 1st Edition Gerry Mckenna

The Vitamins: Fundamental Aspects in Nutrition and

Nutrition Therapy and Pathophysiology 4th Edition

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America

To Late Mildred Kaufman

Preface viii Guidelines for Causality 44

Introduction 96 Part IV Promoting the Public’s

Online Resources 113 Introduction 186

Practical Activities 245 Food Security in the United States 300

Practical Activities 380 Synergizing with the Strategic Plan 428

INSTRUCTOR RESOURCES References

Deepa Arora, PhD Shortie McKinney, PhD, RDN, LDN, FADA

Margaret-Claire Chenault, MS Elizabeth Metallinos-Katsaras, PhD, RDN

Rachel Colchamiro, MPH, RD, LDN Brandy-Jo Milliron, PhD

Kathleen Cullinen, PhD, RDN Julie M. Moreschi, MS, RDN, LDN

Katherine Deren, MS Theresa A. Nicklas, DrPH

Dana Dychtwald, MS Elisabeth Offenberger, MS, RD

Marianella Hervera-Cuenca, DSc, MD Carol E. O’Neil, PhD, MPH, LDN, RD

Jennifer Hughes, MS Debra A. Silverman, MS, RDN

Case Study Contibutors

Amy Sheeley, PhD, RDN Stephanie Cook, RDN

Shirley Chao, MS, RDN, LDN Louisa Paine, BS

Susan E. Adams, MS, RD, LDN, FAND June Kloubec, PhD

Jamie Benedict, PhD Angela Kong, PhD, MPH, RD

Kristen Davidson, MS, PhD Deborah Myers, EdD, RDN, LD

Jeri R. Finn, MS, RDN Payal Patel-Dovlatabadi, DrPH, MPH, MBA

Sheila Fleischhacker, PhD, JD Dennis Wissing, PhD, FAARC

Laura Horn, MEd, RD, LD Lauri Wright, PhD, RDN

Rafida Idris, PhD, MPH

INTRODUCTION or had a body mass index (BMI) >30.7 The prevalence of

Table 1–1 Databases Important for Nutritional Sciences Literature Searches

AGRICOLA Provides citations in agriculture and related fields.

Table 1–2 How to Assess an Article from the Peer-Reviewed Literature

5-Step Multiple-Pass Approach For each food Detailed description

Name of eating occasion

Probe for foods forgotten Food source (where obtained)

components provided by the amount of food

Whether on a special diet and type of diet

Table 1–5 National Nutrition-Related Health Assessmentsa

Nutritional and Related Health Measurements

Table 1–5 National Nutrition-Related Health Assessmentsa (continued)

Food and Nutrient Consumption

Table 1–5 National Nutrition-Related Health Assessmentsa (continued)

Table 1–5 National Nutrition-Related Health Assessmentsa (continued)

Food Supply Determinations

Table 1–6 Data Available Through NHANES

Table 1–6 Data Available Through NHANES (continued)

Table 1–12 The Seven Key Consumer Messages

by Individuals (CSFII) data, it is updated every 5 years as

Adequacy (higher score indicates higher consumption)

Total Fruit2 5 >0.8 cup equiv./1,000 kcal10 No fruit

Introduction 96 Part IV Promoting the Public’s