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Risk Factor Monitoring and Methods Branch, National Cancer Institute, Bethesda, MD 20892-7344
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODS OF ASSESSMENTSURVEILLANCESTRATEGIES FOR IMPROVEMENTREFERENCES |
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KEY WORDS: • sugars • diet surveys • dietary behaviors • dietary assessment.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODS OF ASSESSMENTSURVEILLANCESTRATEGIES FOR IMPROVEMENTREFERENCES |
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2
3
4
5)
, with the following
progression: Avoid Too Much Sugar (1
,2)
; Use Sugars Only
in Moderation (3)
; Choose a Diet Moderate in Sugars
(4)
; Choose Beverages and Foods To Moderate Your Intake of
Sugars (5)
From 1980 through 1995, the Dietary Guidelines evolved from
admonishing us to "Avoid too much sugar" to encouraging us to
"Choose a diet moderate in sugars." An intermediate version, "Use
sugars only in moderation," was altered, because the word "only"
was considered unnecessarily negative (6)
. Nonetheless,
the 1995 Guidelines did acknowledge that "sugars should be used in
moderation by most healthy people and sparingly by people with low
calorie needs," implying that there was the potential for excessive
sugars in the diet, although what constituted moderation vs. excess was
never quantified. Also as part of the evolution, the term "sugars"
replaced "sugar" to make it clear that caloric sweetening agents of
all kinds, not just sucrose, were included.
The most recent Dietary Guidelines Advisory Committee (7)
,
citing the rising intakes of sugars concurrent with an increasing
prevalence of obesity, tried to make the statement more stringent by
recommending the phrase, "Choose Beverages and Foods That
Limit Your Intake of Sugars." However, this wording was
changed by the Departments of Agriculture and Health and Human Services
as the brochure went through governmental clearance (5)
.
The text of the current guideline explains that all dietary
carbohydrates are converted to sugar upon digestion, and that all
sugars and starches can promote tooth decay (5)
. However,
foods that contain naturally occurring sugar or starch (milk, fruits,
some vegetables and grain products) can be nutritious. Therefore, the
suggestion is not made to limit all carbohydrates, but rather to brush
one’s teeth after consuming them. The text then goes on to make a
distinction between "added sugars" (those added to foods in
processing or preparation, as opposed to the naturally occurring sugars
in foods such as fruit and milk) and other dietary carbohydrates, and
claims that high intakes are "of concern." It provides a list of
major sources of added sugars and cautions consumers to "limit"
their use of such beverages and foods, implying that the issue being
addressed is one of "empty calories" rather than a physiologic
concern with the biochemical class of nutrients known as true sugars
(i.e., monosaccharides and disaccharides).
This guideline proved to be the most controversial, as evidenced by the
storm of public comments, some suggesting it should be tougher and
others proffering that no guideline on sugars was even necessary
(8)
. Even a bipartisan group of senators joined the fray,
writing a letter to Agriculture Secretary Dan Glickman urging him not
to limit sugars, inferring that doing so would not "adhere to sound
science" (9)
. During the clearance deliberations,
consideration was given to quantifying the recommendation so that,
regardless of which term was used, "limit" or "moderate,"
consumers could know how much was appropriate. This is, after all, the
only one of the guidelines that includes no quantified recommendations.
However, this idea was dropped, ostensibly because there was no
precedent in current guidance on which to base the recommendation.
The Food Guide Pyramid is the federal nutrition education tool designed
to translate the Dietary Guidelines into the kinds and
amounts of food to eat each day, based on Americans’ usual food
consumption patterns (10)
. It has been heralded as a
departure from the Basic Four’s "foundation diet" approach, in
which only minimum recommendations were given, to a "total diet"
approach, designed to balance the competing needs of achieving
nutritional adequacy and avoiding excesses (11
12
13)
. This
total diet approach, in effect, requires an accounting of all energy
sources in the diet. Nevertheless, although the Pyramid graphic
recommends specific quantities for each of the major food groups, i.e.,
grains, vegetables, fruits, meat and milk, it is vague regarding
recommended quantities for foods included in the tip, suggesting only
that they be used "sparingly" (Fig. 1
). Consequently, this total diet concept, the distinguishing feature of
the Food Guide Pyramid, may well be lost on its audience.
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; at that time, when activities of daily living
necessitated that energy intakes be higher than they are today, that
was the equivalent of 30 tsp (150 mL).
The background materials detailing the Pyramid’s development
(11
12
13)
explain that the ranges of recommended intakes
for the major food groups, added sugars and fat were designed to cover
the range of energy needs in the population, i.e., 1300–3000 kcal
(5.44–12.55 MJ), and the concomitant range of the then-current
recommended dietary allowances
(RDA)2
for different gender-age groups (Fig. 2
). If choices were restricted to foods in their lowest fat forms with no
added sugars, the major food groups alone would provide 
1200–2000
kcal (5.02–8.37 MJ). The difference between these minimal energy
levels and an individual’s energy needs formed the basis for
determining the amounts of fats and sugars that could be added to the
diet, with the level of fat held constant at 30% of energy. Because it
is relatively more difficult to achieve nutritional adequacy with a
limited energy allowance, and because the amount of fat was
constrained, lower energy levels necessitated proportionately lower
levels for added sugars.
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shows a sample of foods and the quantity of added sugars in each.
Values were taken from a similar table in the Pyramid brochure and from
the USDA’s Pyramid Servings Database (15)
. Obviously, the
quantity of sugars in a processed food such as cookies and muffins will
vary according to the recipe used. Nonetheless, a review of this table
makes it clear how readily 6, 12 or even 18 tsp (30, 60 or 90 mL) of
added sugars could be obtained. Even someone with an energy allowance
as high as 2800 kcal (11.72 MJ) would exceed his/her suggested level
(18 tsp, or 90 mL) with a large nondiet soft drink from a fast-food
restaurant, leaving no margin for candy, cake, cookies and so on.
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METHODS OF ASSESSMENT |
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TOPABSTRACTINTRODUCTIONMETHODS OF ASSESSMENTSURVEILLANCESTRATEGIES FOR IMPROVEMENTREFERENCES |
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and the Continuing Survey of Food Intakes by
Individuals (CSFII) (15)
, both products of the USDA. The
Food Supply Series tracks the quantities of foods that flow through the
food marketing system. Because this is done at the commodity level, the
various contributors to added sugar intake, cane and beet sugar and the
various corn sweeteners, as well as their disposition, whether added to
beverages or baked goods, for example, can be noted. Although
quantities have traditionally been reported on a lb/(person · y)
basis, with the caveat that much of these added sugars may be lost
through waste or used in processed foods that are eventually exported,
recent analyses have adjusted these estimates by accounting for waste
at various levels, and provided them on a tsp/(person · d) basis to
be consistent with guidance in the Pyramid (10
,16)
.
Further details regarding the assessment of consumption of added sugars
using Food Supply Data can be obtained from Kantor (16)
.
Advances have also been made in the use of survey data to assess food
intakes in relation to Pyramid recommendations (17)
. The
CSFII included, as part of its 1994–96 data release, a Pyramid
Servings Database (PSDB), which converts food intakes to the number of
servings from each group in the Pyramid, as well as the quantities of
added sugars and discretionary fat. In the PSDB, the measure of added
sugars is actually added caloric sweeteners (not strictly sugars in the
biochemical sense); it excludes sugars that occur naturally in foods,
such as fructose in fruit and lactose in milk, and it includes all
sugars used as ingredients in processed and prepared foods as well as
all sugars eaten separately or added to foods upon eating. In short, it
is an ideal metric for the concept of added sugars in both the
Dietary Guidelines and the Food Guide Pyramid. Guthrie and
Morton (18)
provide a thorough review of how this
definition of added sugars differs from previous analyses. Although
there are as yet no other databases that are directly comparable in
assessing this aspect of diets, any survey that uses the CSFII
food-coding scheme can be linked to the PSDB. A system for linking
the codes from the Third National Health and Nutrition Examination
Survey (NHANES III) to the PSDB has been developed and is available on
the National Cancer Institute’s Applied Research Program Website
(http://www-dccps.ims.nci.nih.gov/ARP/NHANES/index.html).
The PSDB has opened the possibility of evaluating the added sugar content of diets relative to quantities suggested in the Pyramid, identifying food sources of added sugars, and examining the relationships between added sugar intake and the nutrient content of diets. The next section reviews these data, along with Food Supply Data, to assess how well Americans are moderating their intake of added sugars.
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SURVEILLANCE |
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TOPABSTRACTINTRODUCTIONMETHODS OF ASSESSMENTSURVEILLANCESTRATEGIES FOR IMPROVEMENTREFERENCES |
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Kantor (16)
has provided estimates of added sugars
from the U.S. Food Supply Data, accounting for the myriad losses
throughout the marketing system and the home. These estimates, on a
dry-weight basis and reported in terms of tsp/(person · d),
represent the amount of sugars and other caloric sweeteners used in
processed products, as well as the amount of table sugar, honey and
syrup applied when food is being prepared and consumed. Figure 3
, taken from the Kantor report, shows the per capita consumption of
these added sugars from 1970 to 1996 and the relative contributions of
the various sources. Although consumption of honey and edible syrups
has remained relatively constant over that time, that of cane and beet
sugar has declined, and that of corn sweeteners has risen dramatically,
resulting in an overall increase in consumption of added sugars of 23%
(26–32 tsp, or 130–160 mL). The 1996 estimate of 32 tsp (160 mL) was
based on an assumption that an additional 20 tsp/(person · d) [100
mL/(person · d)] were lost to waste or export.
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makes the point that, "sugar is the number one food additive,"
because it is so ubiquitous and so unseen. Currently, over three
fourths of the refined sugars in the food supply are used by the food
and beverage industry, with the remainder going directly to the home,
in contrast to the 1950s, when most of the sugar in the food supply
went directly into the home, giving the consumer more control
(19)
. Food Consumption Survey Data
Estimates of added sugar intakes in terms of number of teaspoons
and percentage of energy have been derived from the 1994–1996 CSFII
using its associated PSDB (15)
, and from the 1989–1991
CSFII, using a prototype of the PSDB (17)
. These reports
vary in the number of days of data used to derive the estimates (2- and
3-d estimates, respectively), and the subgroups of the population being
examined. To compare intakes over time, this paper provides estimates
for both periods (Table 2), using intake data from d 1 of each survey and comparable subgroups
for each. Data are provided on the mean number of teaspoons of added
sugar, the mean percentage of energy from added sugars and the
difference between actual and suggested intakes of added sugars
(discussed later). Mean grams of added sugars, dry weight, can be
obtained by multiplying the number of teaspoons by four. The data are
weighted to account for nonresponse; further details regarding the
collection of data in the CSFII can be obtained in the survey
documentation (20
,21)
.
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2
y old in 1994–1996. This level is less than that estimated by the Food
Supply Data (noted above), even after those data were adjusted by an
assumption that nearly 40% of the available caloric sweeteners were
lost to waste or export. Survey data obtained from 24-h recalls are
known to contain a bias in the direction of underreporting, and
although measures were taken to address this problem in the 1994–1996
CSFII with the multiple-pass method, 15% of respondents are
estimated to be low energy reporters (LER), reporting a level of energy
intake that was <80% of estimated basal metabolic rate.
Krebs-Smith et al. (22)
found that LER were less
likely to report sweetened beverages, sweetened grain products, sweet
spreads and syrups, and candy, among other foods, and to report them in
smaller portions than non-LER. It is reasonable to assume that the
true average intake is somewhere between the 20 tsp (100 mL) estimated
by the survey data and the 32 tsp (160 mL) estimated by the Food Supply
Data, in either case, well above average recommended levels. Mean absolute intakes of added sugars are greater for males than for females at every age, although as a percentage of energy, this is not the case. Both measures rise with age to the teen years, then decline with age, for both genders. Asian/Pacific Islanders are the only racial/ethnic group to approach the recommended levels, and African-American non-Hispanics are the farthest from meeting them.
Whether looking at number of teaspoons or percentage of energy from added sugars, the amounts seem to have gone up between 1989–1991 and 1994–1996 for the general population and for every sociodemographic group examined. Some of the change, especially in the absolute level (tsp), could be explained by the improvements in methodology (e.g., the multiple-pass method) between these two surveys, which were designed to minimize problems of underreporting. Nonetheless, even if the magnitude of the real increase is not that great, the increased percentage of energy from added sugars is of concern, because it suggests that Americans are acquiring an even greater proportion of their energy from the tip of the Pyramid than previously believed.
As noted in the introduction, the Pyramid recommends a range of intake
of added sugars, to correspond to the range in energy levels in the
population. Therefore, because body size, metabolic rate and energy
expenditure vary, even within a single gender-age group, not every
person has the same recommended number of teaspoons, grams or even
percentage of energy from added sugars. The last column of data
relating to each time period in Table 2
adjusts for this somewhat by
providing the average difference between actual and suggested intakes
of added sugars. Each person’s suggested intake was based on their
reported energy intake and determined by following a pattern noted in
the Pyramid recommendations: 1 tsp (5 mL) of sugar for every 100 kcal
(0.42 MJ) above 1000 kcal (4.18 MJ). This formula provides a way to
extend the few examples of suggested intakes given in the Pyramid (6
tsp for 1600 kcal, 12 for 2200 kcal and 18 for 2800 kcal) to the range
of energy intakes in the population, in effect calibrating the full
extent of this range to the limited examples.
How much more energy is provided by added sugars than was factored into
the Pyramid’s total diet concept? In 1994–1996, this difference
amounted to 164 kcal (0.69 MJ), or 10 tsp (50 mL) for the average
person, although this varied widely among the many sociodemographic
groups. Among males and females, this difference increased with
increasing age, up to the teen years, then declined with age; it was at
least 100 kcal (0.42 MJ) for nearly all gender-age groups, and
250 kcal (1.05 MJ) for teenage boys and girls. Among racial/ethnic
groups, it was lowest for Asian/Pacific Islanders (73 kcal, or 0.31 MJ)
and greatest for African-American non-Hispanics (196 kcal, or 0.82
MJ), and it decreased with increasing income and education. Individuals
living in the Midwest and South had greater levels of excessive added
sugars than those from other regions. These values represent an amount
of energy that, if intakes are excessive, could be eliminated from the
diet without any nutritional detriment; alternatively, if energy
intakes are not excessive, they represent the amount of energy that
could be provided by other food groups lacking in the diet.
Food sources of added sugars.
Given the high levels of intake, it is instructive to examine the
sources of added sugars in the American diet. Table 3
shows data, also from the 1994–1996 CSFII, on the sources of added
sugars for all persons 2 y old. In producing these data, the
components of food mixtures were not disaggregated, as has been done in
previous analyses of food sources of nutrients (23
,24)
because added sugars are really ingredients in foods rather than
nutrients, and the point is to see which foods and mixtures supply
these ingredients. The full list of foods examined is shown, even
though some amounts are trivial, so that the reader can ascertain the
influence of the food-grouping scheme on the results.
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. The top nine foods shown,
i.e., carbonated soft drinks; fruit drinks; candy; cakes; ice cream,
ice milk; ready-to-eat cereal; sugar, honey; cookies, brownies; and
syrups and toppings together supply nearly three fourths of the added
sugars in the American diet.
Guthrie and Morton (18)
provided a thorough analysis of
food sources of added sugars in the diets of Americans, also using the
CSFII 1994–1996, but grouping the foods somewhat differently than
shown here. They provided food sources by numerous gender-age
groups, in terms of the percentage contribution as well as mean gram
equivalent. Their analysis concurred that soft drinks provided 33% of
added sugars across the whole population, but also found that this
percentage varied widely across gender-age groups, from 13% for
elderly females to 48% for young adult males. Male and female
adolescents, who had the highest intakes of added sugars (averaging
20% of total energy), obtained 40% of their intake of added sugars
from soft drinks. These same authors (25)
found that
children’s soft drink intakes rose between 1989–1991 and 1994–1995,
and that these increases contributed substantially to rising
carbohydrate intakes. Similarly, Chanmugam et al. (26)
found that greater consumption of soft drinks by adults accounted for a
large portion of their greater energy intakes during the same period.
Troiano et al. (27)
, using data from the NHANES III, found
that soft drinks contributed 8% of energy to the intakes of
adolescents; among overweight adolescents, the percentage was even
greater, i.e., 10.3% for males and 8.6% for females. Nonetheless, it
is very difficult to demonstrate a link between added sugar intake and
obesity using self-reported dietary intake data. Overweight people
are more likely to be restricting their intakes on any given day
(28)
and/or to underreport their energy intake
(22)
, and may selectively underreport high sugar foods and
beverages (22)
.
Nutrient intakes associated with added sugars.
Bowman (29)
analyzed the 1994–1996 CSFII data to
determine the relationship between the intake of added sugars (as a
percentage of energy) and that of the major food groups in the Pyramid.
She found that persons with the highest level of added sugars in the
diet, i.e., >18% of energy, had lower intakes of grains, vegetables,
fruits, milk and meat than other persons, resulting in the lowest
intakes of all micronutrients studied. Guthrie (30)
found
that women whose diets met the recommended level of calcium had
significantly lower intakes of nondiet soft drinks and significantly
greater intakes of milk than those of other women. These publications,
and those related to food sources of added sugars, proved to be useful
resources to the Dietary Guidelines Advisory Committee
(7
,31)
and were undoubtedly influential in their decisions
both to recommend the term "limit" over "moderate" and to
mention beverages before foods.
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STRATEGIES FOR IMPROVEMENT |
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TOPABSTRACTINTRODUCTIONMETHODS OF ASSESSMENTSURVEILLANCESTRATEGIES FOR IMPROVEMENTREFERENCES |
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and Harnack et al
(32)
. To use an analogy, if someone had only enough money
for basic necessities such as food and shelter, but they spent their
money instead on some nonessential item, the point would not be whether
that item itself causes harm, but whether it could be justified in view
of budgetary limitations. Adding to the confusion has been the discourse surrounding the definition of sugars, which has served only to obfuscate the issues surrounding this aspect of the diet. Clearly, although the guideline statement addresses sugars rather than "added sugars" per se, monosaccharides and disaccharides and their physiologic properties are not the concern; rather, the excessive use of caloric sweeteners is at issue.
The 2000 Dietary Guidelines Advisory Committee, in their review of the data, concluded that the intake of added sugars was rising; the Departments of Agriculture and of Health and Human Services felt this could not be proven. The data reviewed here seem to suggest that intakes indeed are on the rise; however, even if consensus on that point cannot be achieved, there is the strong evidence that levels are greater than recommended.
Furthermore, there are some genuine dietary concerns that relate to the
abundance of added sugars, i.e., imbalance among the food groups,
especially fruits and milk, and the increasing problem of obesity.
Figure 4
shows the population average intakes of each of the major food groups
in the Pyramid, compared with recommendations, again using CSFII
1994–1996 data. Because the average energy intake was 2000 kcal
(8.37 MJ), the recommended levels were interpolated on the basis of the
levels suggested in the Pyramid publication for 1600, 2200 and 2800
kcal (6.69, 9.20 and 11.72 MJ). Actual intakes fell short of the
recommended level for every food group, especially fruits and milk.
That is, the U.S. population, on average, is taking in fewer servings
of each of these groups than is suggested by the Pyramid for the energy
levels they are consuming, and more of their energy is coming from
added sugars and fat than recommended. Although fat intakes, as a
percentage of energy, are just slightly above what is recommended,
intakes of added sugars exceed recommendations by nearly 10 percentage
points (Fig. 5
). This is consistent with the fact that nutrition education efforts
have focused the public’s attention more on fat than added sugars.
This excessive energy coming from fat and added sugars, i.e., that
which is over and above the recommendations, is the amount of energy in
the additional servings from each of the major food groups required to
meet recommendations—exactly the amount, in fact. This is not because
of some statistical quirk, but because it was planned that way; that is
the total diet concept.
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reviewed the evidence
for an increase in the prevalence of overweight and obesity over the
last several decades; over half of the adult population now falls in
these categories. Clearly, added sugars are not the sole cause of
obesity; both energy intakes and expenditures are suspect. Indeed,
physical activity seems to be declining, although data that capture all
aspects are limited (34)
, and there are reasons to
encourage its increase, as the 2000 Dietary Guidelines Advisory
Committee has done (7)
. But given that large
segments of the population are experiencing an energy surplus, it is
difficult to justify their consuming these sources of "empty
calories." Harnack et al. (32)
examined intakes of
children and adolescents using the 1994 CSFII and found that energy
intakes rose with nondiet soft drink consumption. As noted in an earlier section, the extra energy coming from added sugars, over and above suggested levels, is in the range of 100–250 kcal/d (0.42–1.0 MJ/d), depending on the gender-age group. Using the simplistic assumption that an energy restriction of 3500 kcal (14.64 MJ) results in the loss of 1 lb, then a deficit of 100 kcal/d (0.42 MJ/d) would result in a 10-lb (4.54 kg) weight loss in a year. In actuality, weight loss would be somewhat less than that because a new steady state would be achieved, but the point remains that 100–250 kcal/d (0.42–1.0 MJ/d) is not insignificant. The question is not whether the energy from sugar is the sole cause of obesity but rather, if energy intakes should decrease and intakes of the major food groups are below recommended levels, whether intakes of added sugars should be curtailed to facilitate correction of these imbalances.
Adherence to this guideline may be dependent on many factors, some operating at the macro (or food system) level, others at the micro (or individual) level. Macro-level strategies for improvement might include the following:
assessed the
gap between current food intakes and the recommendations in the
Pyramid, projected that gap to the year 2020, on the basis of Census
projections for population shifts and growth and estimated the changes
in agriculture practices required to meet such a hypothetical demand.
Even with the population increasing by 24%, it was estimated that the
production of caloric sweeteners should be reduced by 17 billion lb
(7.7 billion kg) for the food supply to be in accordance with the
Pyramid recommendations.
. From these alone, total
revenues amount to $1 billion annually. Although the effect of these
taxes on consumption is not clear, the potential for even greater funds
that could be used to support health programs is great.
documented the limited
nutritional value of foods sold in middle-school student stores,
and the widespread practice of using vending machines as a revenue
generator (38)
for schools could prove detrimental to
children’s nutritional well-being.
. These authors found high
sugar cereals were the most frequently advertised food product during
997 commercials and 68 public service announcements on 5 major
networks. At the micro-level, consumers could be aided in their decision making by the following:
. The 1 tsp (5 mL) of sugar for every 100 kcal (0.42
MJ) above 1000 kcal (4.18 MJ) rule, interpolated from the Pyramid
guidance and used in this paper, could be a simple algorithm for
consumers to determine their appropriate level.
that recommends
increased consumption of fruits and vegetables, the emphasis should be
on substituting such foods for the sources of "empty calories" in
the diet. Too often, undue emphasis is put on keeping dietary guidance
messages positive (6)
, which may result in a lack of
clarity—or worse, an energy surplus.
, and this would be beneficial. The values in Table 1
provide a general guide, but labels could provide such data specific to
the particular item and brand. The amounts on the labels could be
listed as grams to be consistent with other items listed; the teaspoon
unit is merely a simple way to relate different quantities of added
sugars to a common household measure of table sugar. The conversion is
a direct one, i.e., 1 tsp = 4 g. Currently, the
Nutrition Facts panel is in agreement with the guideline statement, in
that it includes all sugars, naturally occurring and added. However,
because it encompasses the lactose in milk and the fructose in fruit,
it may cause confusion concerning whether sugars are something that
should be curtailed. For example, if a consumer wanted to compare the
amounts of added sugars in various breakfast cereals, but some of them
contained raisins and others did not, the sugars data on the label
would provide a misleading impression. Equally misleading, however,
would be the use of stripped, concentrated fruit juices for sweetening
while labeling a product as having no added sugars. The definition of
added sugars for the purposes of labeling would have to be considered
carefully, taking into account consistency with current guidance and
enforcement issues. Finally, a related issue is that of label
accuracy. Young and Nestle (43)
found that weights listed
on the label of single-serving baked products underestimated true
weights consistently, by as much as 20–25%. Obviously, to be
effective, labels must be reliable in their descriptions. The 2000 guideline statement is "Choose Beverages and Foods To Moderate Your Intake of Sugars, " although the text encourages consumers to limit their intakes. Despite all the controversy, these semantic differences are trivial. What would truly benefit consumers is a quantified standard against which to gauge their intakes and assistance in determining the amount of added sugars in various products. The methodological tools are now available to conduct surveillance of this dietary aspect.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Abbreviations used: CSFII, Continuing Survey of
Food Intakes by Individuals; LER, low energy reporters; NHANES,
National Health and Nutrition Examination Survey; PSDB, Pyramid
Servings Database; RDA, recommended dietary allowances.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODS OF ASSESSMENTSURVEILLANCESTRATEGIES FOR IMPROVEMENTREFERENCES |
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1. U.S. Department of Agriculture, U.S. Department of Health and Human Services (1980) Nutrition and your health: dietary guidelines for Americans, 1st ed., Home and Garden Bulletin 232. U.S. Government Printing Office, Washington, DC.
2. U.S. Department of Agriculture, U.S. Department of Health and Human Services (1985) Nutrition and your health: dietary guidelines for Americans, 2nd ed., Home and Garden Bulletin 232. U.S. Government Printing Office, Washington, DC.
3. U.S. Department of Agriculture, U.S. Department of Health and Human Services (1990) Nutrition and your health: dietary guidelines for Americans, 3rd ed., Home and Garden Bulletin 232. U.S. Government Printing Office, Washington, DC.
4. U.S. Department of Agriculture, U.S. Department of Health and Human Services (1995) Nutrition and your health: dietary guidelines for Americans, 4th ed., Home and Garden Bulletin 232. U.S. Government Printing Office, Washington, DC.
5. U.S. Department of Agriculture, U.S. Department of Health and Human Services (2000) Nutrition and your health: dietary guidelines for Americans, 5th ed., Home and Garden Bulletin 232. U.S. Government Printing Office, Washington, DC.
6. U.S. Department of Agriculture, Agricultural Research Service, Dietary Guidelines Advisory Committee (1995) Report of the dietary guidelines advisory committee on the dietary guidelines for Americans, 1995, to the Secretary of Health and Human Services and the Secretary of Agriculture.
7. U.S. Department of Agriculture, Agricultural Research Service, Dietary Guidelines Advisory Committee (2000) Report of the dietary guidelines advisory committee on the dietary guidelines for Americans, 2000, to the Secretary of Health and Human Services and the Secretary of Agriculture.
8. Complete Transcript of the Second Meeting of the Dietary Guidelines 2000 Advisory Committee. Http://www.usda.gov/cnpp/dietary guidelines.htm (accessed 9/29/2000).
9. Squires S. Flora and Fauna: The Department of Agriculture: Agency Tackles Obesity, Dietary Guidelines 2000 Washington Post May 5, 2000 A25.
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