American Cancer Society Nutrition Research Articles

Diet quality and cardiometabolic risk factors among breast cancer survivors in the Pathways Study.

11039 Background: Women with breast cancer (BC) have higher risk of developing cardiometabolic conditions compared to women without BC. However, the relationship between healthy eating and onset of cardiometabolic conditions in BC survivors remains unknown. We set out to determine if diet quality at BC diagnosis was related to subsequent development of hypertension, diabetes, and dyslipidemia. Methods: This analysis included 3,415 participants from the Pathways Study, a prospective cohort of women diagnosed with invasive BC (stages I-IV) at Kaiser Permanente Northern California (KPNC) between 2005 and 2013. Food frequency questionnaires were administered at or around the time of BC diagnosis and five diet quality indices (DQI) aligned with healthy eating were evaluated: Dietary Approaches to Stop Hypertension (DASH), a healthy plant-based dietary index (hPDI), 2020 Healthy Eating Index (HEI), American Cancer Society nutrition guidelines (ACS), and the alternate Mediterranean Diet (aMED). Incident hypertension, diabetes, and dyslipidemia were ascertained through electronic health records and participants were followed through first indication of these conditions, disenrollment from KPNC, death, or December 31, 2021. Scores were categorized into ascending quartiles of concordance for each DQI, and multivariable adjusted hazard ratios (HR) and 95% confidence intervals (CI) were estimated. Results: There were 554 (16.2%) incident cases of hypertension, 362 (10.6%) of diabetes, and 652 (19.1%) of dyslipidemia over 39,263 person-years of follow-up. Participants in the highest compared to lowest HEI quartile had lower risks of hypertension (HR=0.70, 95% CI 0.53-0.92, Ptrend<0.01), diabetes (HR=0.56, 95% CI 0.40-0.77, Ptrend<0.001), and dyslipidemia (HR=0.76, 95% CI 0.59-0.99, Ptrend=0.03). Participants in the highest vs lowest hPDI quartile had lower risks of hypertension (HR=0.74, 95% CI 0.55-0.98, Ptrend<0.05) and diabetes (HR=0.65, 95% CI 0.46-0.93, Ptrend=0.02), but not dyslipidemia. Women in the highest vs lowest DASH and ACS quartiles had lower risks of diabetes (DASH:HR=0.56, 95% CI 0.39-0.79, Ptrend<0.001; ACS:HR=0.57, 95% CI 0.40-0.79, Ptrend<0.001), but not hypertension or dyslipidemia. No statistically significant differences for aMED were observed between those in the highest vs lowest quartiles. Overall, HRs were similar across DQIs for hypertension and diabetes, except for aMED, which slightly attenuated for diabetes. Conclusions: Diets concordant with HEI may provide the most overall benefit for preventing cardiometabolic conditions after a BC diagnosis. The benefit of diets aligned with hPDI, DASH, ACS, and aMED appear to vary by cardiometabolic condition. Future analyses will examine how these benefits may be modified by BC treatments. Consuming a healthful diet should be recommended to BC survivors for long-term cardiovascular health.

Abstract PO1-11-05: Diet quality and cardiovascular disease risk among breast cancer survivors in the Pathways Study

Abstract Background: While studies have shown that breast cancer survivors with healthier diets have a lower risk of non-breast cancer-specific and all-cause mortality after a breast cancer diagnosis, the relationship between diet quality and cardiovascular disease (CVD) among breast cancer survivors is not well characterized. We examined the association between diet quality at the time of breast cancer diagnosis and CVD-related outcomes in the Pathways Study, a prospective cohort of 3,415 women diagnosed with invasive breast cancer. Methods: This analysis included four diet quality indices (DQIs) consistent with healthy eating: 1. Dietary Approaches to Stop Hypertension (DASH), 2. healthy plant-based dietary index (hPDI), 3. 2015 Healthy Eating Index (HEI), 4. American Cancer Society nutrition guidelines (ACS). Each DQI was calculated from food frequency questionnaires (FFQ) at or around the time of breast cancer diagnosis, between 2005 and 2013, with a higher score representing a more healthful dietary pattern. DQI scores were categorized into quartiles with the most concordant diets in the highest quartile and the least concordant diets in the lowest quartile, for each DQI. CVD outcomes were ascertained through December 31, 2021 and included ischemic heart disease, heart failure, cardiomyopathy, stroke/transient ischemic attack, arrhythmia, cardiac arrest, valvular disease, venous thromboembolic disease and CVD-related death. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated from proportional hazards regression accounting for clinical and demographic factors. Results: FFQs were completed an average 2.2 (range=0.3-7.6) months after a breast cancer diagnosis, and a total 623 (18.2%) incident CVD events and 340 (10.0%) CVD-related deaths were ascertained over 39,263 person-years of follow-up. Participants in the highest quartile of the DASH DQI had substantially reduced risks of heart failure (HR=0.50, 95% CI 0.31-0.81), arrhythmia (HR=0.76, 95% CI 0.62-0.93), cardiac arrest (HR=0.75, 95% CI 0.60-0.93), valvular disease (HR=0.77, 95% CI 0.62-0.96), venous thromboembolic disease (HR=0.74, 95% CI 0.59-0.92), and a 33% reduced risk of CVD-related death (HR=0.67, 95% CI 0.48-0.95) relative to those in the lowest quartile. Tests for trend across quartiles of the DASH DQI were also statistically significant at a p-value < 0.03. The only notable association found in the other three DQIs was between hPDI and lower risk of heart failure (HR=0.61, 95% CI 0.39-0.95) in women in the highest quartile compared to the lowest quartile (Table 1). Summary: These findings suggest that diets concordant with DASH and hPDI dietary patterns, may be beneficial for preventing CVD and CVD-related death after a breast cancer diagnosis. Table 1. Cox proportional hazard ratios and 95% confidence intervals for quartiles of diet quality indices and CVD events and CVD-related death Citation Format: Isaac Ergas, Janise Roh, Lawrence Kushi, Carlos Iribarren, Mai Nguyen-Huynh, Jamal Rana, Eileen Rillamas-Sun, Cecile Laurant, Valerie Lee, Richard Cheng, Heather Greenlee, Marilyn Kwan. Diet quality and cardiovascular disease risk among breast cancer survivors in the Pathways Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-11-05.

Association between adherence to the American Cancer Society Nutrition and Physical Activity Guidelines and stool frequency among colon cancer survivors: a cohort study

PurposeWe sought to determine whether adherence to the American Cancer Society (ACS) Nutrition and Physical Activity Guidelines was associated with better bowel function among colon cancer survivors.MethodsThis prospective cohort study included patients surgically treated for stage I–IV colon cancer enrolled in the Lifestyle and Outcomes after Gastrointestinal Cancer (LOGIC) study between February 2017 and May 2021. Participants were assigned an ACS score (0–6 points) at enrollment. Stool frequency (SF) was assessed every 6 months using the EORTC QLQ-CR29. Higher SF is an indication of bowel function impairment. ACS score at enrollment was examined in relation to SF at enrollment and over a 3-year period. Secondarily, we examined associations between the ACS score components (body mass index, dietary factors, and physical activity) and SF. Multivariable models were adjusted for demographic and surgical characteristics.ResultsA total of 112 people with colon cancer (59% women, mean age 59.5 years) were included. Cross-sectionally, for every point increase in ACS score at enrollment, the odds of having frequent stools at enrollment decreased by 43% (CI 0.42–0.79; p < 0.01). Findings were similar when we examined SF as an ordinal variable and change in SF over a 3-year period. Lower consumption of red/processed meats and consuming a higher number of unique fruits and vegetables were associated with lower SF (better bowel function) at enrollment.ConclusionsColon cancer survivors who more closely followed the ACS nutrition and physical activity guidelines had lower SF, an indication of better bowel function.Implications for Cancer SurvivorsOur findings highlight the value of interventions that support health behavior modification as part of survivorship care for long-term colon cancer survivors.

American Cancer Society nutrition and physical activity guideline for cancer survivors

The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

Every Day Counts: a randomized pilot lifestyle intervention for women with metastatic breast cancer

To explore the feasibility, adherence, safety and potential efficacy of Every Day Counts; a randomized pilot trial designed for women with metastatic breast cancer (MBC) framed by the American Cancer Society nutrition and physical activity (PA) guidelines METHODS: Women with clinically stable MBC were recruited to complete an interview, dual energy X-ray absorptiometry imaging and phlebotomy at baseline and post-intervention. Multidimensional quality of life, symptom burden, lifestyle behaviors (nutrition and PA) and biomarkers of prognosis were procured and quantified. Women were randomized to the immediate intervention or a waitlist control arm. The 12-week intervention included a curriculum binder, lifestyle coaching (in-person and telephone-based sessions) and intervention support (activity monitor, text messaging, cooking classes.) Women in the waitlist control were provided monthly text messaging. Forty women were recruited within 9months (feasibility). Women in the immediate intervention attended 86% of all 12 weekly coaching sessions (adherence) and showed significant improvements in general QOL (p = 0.001), and QOL related to breast cancer (p = 0.001), endocrine symptoms (p = 0.002) and fatigue (p = 0.037), whereas the waitlist control did not (all p values ≥ 0.05) (efficacy). PA significantly increased for women in the intervention compared to control (p < 0.0001), while dietary changes were less evident across groups due to high baseline adherence. No significant changes in biomarkers or lean mass were noted, yet visceral adipose tissue declined (p = 0.001). No intervention-related injuries were reported (safety). Qualitative feedback strongly supports the desire for a longer intervention with additional support. Lifestyle interventions are of interest, safe and potentially beneficial for women with MBC. A larger trial is warranted.

Associations of Pre- and Postdiagnosis Diet Quality With Risk of Mortality Among Men and Women With Colorectal Cancer.

Dietary patterns, indicators of overall diet quality, are associated with colorectal cancer (CRC) incidence but less consistently with mortality among CRC survivors. We prospectively evaluated associations of diet quality pre- and postdiagnosis with risk of mortality among men and women with CRC. In the Cancer Prevention Study-II Nutrition Cohort, 2,801 participants were cancer free at baseline in 1992/1993 and subsequently diagnosed with invasive, nonmetastatic CRC during follow-up through June 2013. Pre- and postdiagnosis diet data were available for 2,671 and 1,321 participants, respectively, among whom 1,414 and 722 died. Concordance with the Dietary Approaches to Stop Hypertension (DASH), American Cancer Society nutrition guidelines (ACS-score), prudent, and Western dietary patterns was used to evaluate diet quality. Extreme scoring group comparisons showed that prediagnosis ACS-score was inversely associated with all-cause (hazard ratio high v low [HRHigh vLow], 0.78; 95% CI, 0.65 to 0.95) and CRC-specific (HRHigh vLow, 0.74; 95% CI, 0.54 to 1.03) mortality, whereas the Western diet score was associated with higher all-cause mortality (HRHigh vLow, 1.30; 95% CI, 1.03 to 1.64). For postdiagnosis diet, the ACS-score was associated with lower risk of all-cause (HRHigh vLow, 0.62; 95% CI, 0.47 to 0.83) and CRC-specific (HRHigh vLow, 0.35; 95% CI, 0.17 to 0.73) mortality, the DASH score was inversely associated with all-cause (HRHigh vLow, 0.79; 95% CI, 0.62 to 0.99) and CRC-specific (HRHigh vLow, 0.56; 95% CI, 0.35 to 0.89) mortality, and the prudent score was inversely associated with all-cause mortality (HRHigh vLow, 0.72; 95% CI, 0.56 to 0.93). Among participants with a low diet quality before diagnosis, improved DASH (HR, 0.54; 95% CI, 0.31 to 0.92) and prudent (HR, 0.53; 95% CI, 0.29 to 0.95) scores from pre- to postdiagnosis were inversely associated with CRC-specific mortality. Dietary patterns reflective of high intakes of plant foods and low intakes of animal products before and after CRC diagnosis are associated with longer survival.

Association of Survival With Adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis

The American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors (ACS guidelines) include maintaining (1) a healthy body weight; (2) physical activity; and (3) a diet that includes vegetables, fruits, and whole grains. It is not known whether patients with colon cancer who follow these guidelines have improved survival. To examine whether a lifestyle consistent with the ACS guidelines is associated with improved survival rates after colon cancer. This prospective cohort study included 992 patients with stage III colon cancer who were enrolled in the CALGB 89803 randomized adjuvant chemotherapy trial from 1999 through 2001. Data for the present study were analyzed between November 2016 and December 2017. We assigned an ACS guidelines score for each included patient based on body mass index; physical activity; and intake of vegetables, fruits, whole grains, and red/processed meats (score range, 0-6, with higher score indicating healthier behaviors). Secondarily, we examined a score that also included alcohol intake in addition to the other factors (range, 0-8). Lifestyle was assessed during and 6 months after chemotherapy. Hazard ratios (HRs) and 95% confidence intervals (CIs) for disease-free, recurrence-free, and overall survival. Of the 992 patients enrolled in the study, 430 (43%) were women, and the mean (SD) age was 59.6 (11.2) years (range, 21-85 years). Over a 7-year median follow-up, we observed 335 recurrences and 299 deaths (43 deaths without recurrence). Compared with patients with a 0 to 1 ACS guidelines score (n = 262; 26%), patients with a 5 to 6 score (n = 91; 9%) had a 42% lower risk of death during the study period (HR, 0.58; 95% CI, 0.34-0.99; P = .01 for trend) and improved disease-free survival (HR, 0.69; 95% CI, 0.45-1.06; P = .03 for trend). When alcohol consumption was included in the score, the adjusted HRs comparing patients with scores of 6 to 8 (n = 162; 16%) vs those with scores of 0 to 2 (187; 91%) were 0.49 for overall survival (95% CI, 0.32-0.76; P = .002 for trend), 0.58 for disease-free survival (95% CI, 0.40, 0.84; P = .01 for trend), and 0.64 for recurrence-free survival (95% CI, 0.44-0.94; P = .05 for trend). Having a healthy body weight, being physically active, and eating a diet rich in vegetables, fruits, and whole grains after diagnosis of stage III colon cancer was associated with a longer survival. clinicaltrials.gov Identifier: NCT00003835.

American Cancer Society (ACS) Nutrition and Physical Activity Guidelines after colon cancer diagnosis and disease-free (DFS), recurrence-free (RFS), and overall survival (OS) in CALGB 89803 (Alliance).

10006 Background: The ACS Nutrition and Physical Activity Guidelines for Cancer Survivors include: 1) healthy body weight; 2) physical activity; and 3) a diet high in vegetables, fruits, and whole grains. It is not known whether colon cancer patients who follow these guidelines have improved DFS, RFS, or OS. Methods: We conducted a prospective study among 992 stage III colon cancer patients enrolled in an adjuvant chemotherapy trial in 1999-2001. Lifestyle was assessed twice. We applied a score developed by McCullough ML et al. to quantify adherence to the ACS guidelines based on BMI; physical activity; and intake of vegetables, fruits, whole grains, and red/processed meats (range: 0-6; higher = more healthy behaviors). Alcohol is included in the ACS guidelines for cancer prevention, but not cancer survivors; we tested the score without and with alcohol using McCullough et al.’s cut points: 0 pts = &gt;1/d for women, &gt;2/d for men; 1 pt = no alcohol; 2 pts = &gt;0-1/d for women, &gt;0-2/d for men. We estimated hazard ratios (HR) and 95% confidence intervals (CI) for DFS, RFS, and OS adjusting for clinical, demographic, and lifestyle factors. Results: Over 7 y median follow-up, we observed 335 recurrences and 299 deaths (43 without recurrence). Compared to patients with 0-1 pt (262, 26%), patients with 5-6 pts (91, 9%) had 42% lower risk of death (HR: 0.58; 95% CI: 0.34, 0.99; p-trend: 0.01) and a trend toward improved DFS (HR: 0.69; 95% CI: 0.45, 1.06; p-trend: 0.03). When including alcohol in the score, the adjusted HR’s comparing patients with 6-8 pts (162; 16%) to 0-2 pts (187; 91%) were: 0.49 for OS (95% CI: 0.32, 0.76; p-trend: 0.002), 0.58 for DFS (95% CI: 0.40, 0.84; p-trend: 0.01), and 0.64 for RFS (95% CI: 0.44, 0.94; p-trend: 0.05). Conclusions: Colon cancer patients with a healthy body weight who engaged in physical activity, ate a diet high in whole grains, vegetables, and fruits and low in red/processed meats, and drank moderate alcohol had longer DFS and OS than patients who did not engage in these behaviors. Support: U10CA180821, U10CA180882, U10CA180820, K07CA197077, R01CA118553, P50CA127003, R35CA197735. ClinicalTrials.gov:NCT00003835.

Lifestyle Risk Factors Among People Who Have Had Cancer Genetic Testing.

Hereditary cancer genetic counseling often focuses on medically intensive risk-reduction strategies, like imaging and risk-reducing surgeries. Lifestyle factors also influence cancer risk, but health behavior counseling is not common in genetic counseling. Information about typical lifestyle risk factors among patients seeking hereditary cancer risk is sparse. The current study describes cancer risk-relevant lifestyle factors for people who have had cancer genetic testing. Data came from the Health Information National Trends Survey (HINTS 4) collected in 2013. Analytic variables represented American Cancer Society nutrition and physical activity guidelines. Lifestyle factors were assessed for people who had undergone testing for BRCA1, BRCA2, or Lynch Syndrome genes. Among 3016 HINTS respondents, 135 had cancer genetic testing. Of these, 58% were overweight or obese. Eighteen percent reported no moderate-intensity physical activity. Average sedentary screen-time was 3.4h (SE=0.472) daily. Sixty-three percent drank non-diet soda, and 23% of these people drank soda every day. Between 18 and 36% consumed less than 2 ½ cups fruits/vegetables daily. Twenty-four percent were current smokers. Lifestyle risk factors were not different between people who had genetic testing and those who had not. In conclusion, most people who had genetic testing for cancer susceptibility have at least one modifiable risk factor. Genetic counselors have opportunities to impact a counselee's cancer risk not only through risk-tailored medical procedures, but also through lifestyle modification recommendations. Results of the current study may foster a broader discussion of genetic counselors' roles in healthy lifestyle education.

P4-11-06: Uptake of Selective Estrogen Receptor Modulators and Other Breast Cancer Prevention Strategies among High-Risk Women Seen in a Breast Center.

Abstract Background: Selective estrogen receptor modulators (SERMs), tamoxifen and raloxifene, are FDA-approved for breast cancer (BC) risk reduction. However, uptake has been poor in the prevention setting, partly due to a lack of knowledge in the medical community about BC prevention and public misconceptions about the risks of SERMs. We assessed demographic and clinical factors that influence SERM uptake among high-risk women seen in an academic breast center, where specialized risk counseling is provided by a breast surgeon or medical oncologist. Methods: Potential subjects included high-risk women seen for an initial consultation by Breast Surgery or Medical Oncology. Eligibility for SERM use included a 5-year Gail risk ≥1.67%, lobular carcinoma in situ (LCIS), BRCA mutation carrier, or estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive ductal carcinoma in situ (DCIS). Demographic and BC risk factor data was collected from self-administered questionnaires. Clinical data, including prior/current SERM use, was abstracted from medical chart review. Differences in distribution of risk factors, between women who ever took a SERM and those who did not, were examined using chi-square statistics or Fisher's exact test. Multivariable logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals using SERM use as the dependent variable. Results: Among 247 high-risk women enrolled between March 2007 and January 2011, median age 51 (17-82); White/Hispanic/Black/Asian (%): 55/32/7/6. 85% of women were undergoing annual mammography, 94% had a breast biopsy, 19% genetic testing, and 71% Medical Oncology referral. Among 181 (73%) women eligible for a SERM, Gail risk ≥1.67%/LCIS/DCIS/BRCA mutation (%): 35/22/39/3; 83 (46%) ever took a SERM, including 62 on tamoxifen and 21 on raloxifene. Early SERM discontinuation was only 7%. In multivariable analysis, significant predictors of SERM uptake included risk category (DCIS vs. Gail risk ≥1.67%/LCIS/BRCA mutation), higher income, higher body mass index (BMI), and referral to Medical Oncology. In terms of this high-risk population meeting American Cancer Society (ACS) behavioral guidelines for cancer prevention, 53% had a BMI &amp;lt;25 kg/m2, 44% consumed ≤1 alcoholic beverage per day, and 10% engaged in ≥4 hours of moderate physical activity per week; only 3.5% met all 3 recommendations. Conclusions: Among high-risk women seen at a specialized breast center, application of clinical recommendations such as screening mammography, genetic testing, and SERM uptake were relatively high, suggesting that a comprehensive approach to the management of high-risk women is feasible. However, meeting ACS nutrition and physical activity guidelines for cancer prevention was limited, perhaps due to a lack of reimbursable staff to implement these guidelines. Breast cancer risk assessment and available interventions for prevention among high-risk women are underutilized in the U.S. Future studies should focus on the development and delivery of breast cancer prevention strategies. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-06.

Dial up Better Health the American Cancer Society's Nutrition and Physical Activity Research Study

Dial up Better Health the American Cancer Society's Nutrition and Physical Activity Research Study

Nutritional Factors in Ovarian Cancer Prevention: What Have We Learned in the Past 5 Years?

The recommendation of the American Cancer Society Nutrition and Physical Activity 2001 Guidelines regarding ovarian cancer prevention was that “there are no firmly established nutritional risk factors for ovarian cancer, though vegetable and fruit consumption may lower risk.” Since then, a number of studies have been published including several large cohort studies. The main objective of this review was to evaluate the literature from the past 5 yr and determine whether any more firm recommendations could be made at this point. Searches were conducted from 2000 to July 2006, and relevant citations were reviewed. Although population-based case-control studies have fairly consistently shown an increased risk with increase body mass, cohort data are inconclusive. The role of physical activity is also unclear. The current epidemiologic evidence for dietary factors is generally inconsistent to warrant public health recommendations regarding any of these factors.

Individual- and area-level socioeconomic status variables as predictors of mortality in a cohort of 179,383 persons.

The authors have studied whether area-level socioeconomic status predicts mortality independently of individual-level socioeconomic status in 179,383 persons in the American Cancer Society Nutrition Cohort, followed for mortality from 1992 to 2000 (17,383 deaths). They used an area-level variable based on census blocks that was an average of home value, income, education, and occupation. Education was the individual-level socioeconomic status variable. The authors studied socioeconomic status-mortality trends with each socioeconomic status variable adjusted for the other. For all causes, an individual's education was strongly and inversely associated with mortality; a weak but significant inverse trend was also present for area-level socioeconomic status. A similar pattern was seen for all-vascular disease. For all cancers, there was again a significant inverse trend with education but no trend with area-level socioeconomic status. Adjustment for conventional (non-socioeconomic status) individual-level risk factors diminished the effect of both socioeconomic status variables, although significant trends remained for men between education and all-cause, all-cancer, and all-vascular disease mortality. Study data indicate that the predictive value of area-level socioeconomic status variables varies by cause of death but is less important than individual-level socioeconomic status variables. Multivariate models that consider socioeconomic status as a potential confounder may not need to consider area-level socioeconomic status if data are available on individual-level education.

Low prevalence of healthful dietary behavior in a California agricultural county: Emphasis on white and Mexican-American adults

In 1989, the National Academy of Sciences recommended that to lower the risk of chronic diseases, Americans should reduce dietary fat intake to 30% or less of energy, and should consume a daily diet that includes five or more servings of fruits and vegetables and six or more servings of breads, cereals, and legumes ( 1. Committee on Diet and Health, Food and Nutrition Board Diet and Health: Implications for Reducing Chronic Disease Risk. National Academy Press, Washington, DC1989 Google Scholar ). Other national health authorities have recommended similar guidelines ( 2. Diet, Nutrition and Cancer Prevention: A Guide to Food Choices. 4th ed. DHHS (NIH) publication 87-2878. National Cancer Institute, US Dept of Health and Human Services, Washington, DC1987 Google Scholar , 3. The Surgeon General's Report on Nutrition and Health. 4th ed. DHHS (PHS) publication 88-50210. US Dept of Health and Human Services, Public Health Service, Washington, DC1988 Google Scholar , 4. American Cancer Society Nutrition and cancer: cause and prevention. Cancer. 1984; 34: 121-126 Google Scholar ). Nevertheless, results from two national surveys indicate a large discrepancy between scientific recommendations and public behavior ( 5. Patterson B Block G Rosenberger W Pee D Kahle L Fruit and vegetables in the American diet: data from the NHANES II survey. Am J Public Health. 1990; 80: 1443-1449 Google Scholar , 6. Food and Nutrient Intakes of Individuals in 1 Day in the United States, Spring 1977: Nationwide Food Consumption Survey 1977–1978. 4th ed. Preliminary report 2. Consumer Nutrition Center, US Dept of Agriculture, Hyattsville, Md1980 Google Scholar , 7. Kant A Block G Schatzkin A Ziegler R Nestle M Dietary diversity in the US population, NHANES II, 1976–1980. J Am Diet Assoc. 1991; 91: 1526-1531 Google Scholar ). In an attempt to address this situation, the Institute of Medicine reviewed barriers to implementing these guidelines and emphasized the need to put the recommendations into practice ( 8. Committee on Dietary Guidelines Implementation, Food and Nutrition Board, Institute of Medicine Improving America's Diet and Health—From Recommendations to Action. National Academy Press, Washington, DC1991 Google Scholar ).

Self‐reported dietary changes with respect to American cancer society nutrition guidelines (1982–1986)

A follow-up study was conducted by the Illinois Division of the American Cancer Society (ACS) in conjunction with the ongoing National Cancer Prevention Study II (CPSII) to determine whether self-report dietary changes are occurring in accordance with the ACS nutrition guidelines and to identify demographic subgroups that may be targeted for future prevention and education programs. A total of 42,300 CPSII respondents completed a 1986 questionnaire and were matched to 1982 baseline data. Dietary items were recorded as "on the average, how many days per week do you eat the following foods?" Individuals with known chronic conditions, body mass index outside a moderate range, and fewer than four completed food items were excluded. The remaining study population (n = 18,062) included men and women who were apparently healthy and primarily over the age of 50. The distribution of foods reported in 1982 and changes in foods consumed (1982-1986) among selected food groups varied modestly by sex, age, and educational level. Modest changes in the direction of decreasing intake of high-fat foods and increasing intake of high-fiber foods and cruciferous vegetables were reported. Dietary changes consistent with the ACS nutrition guidelines appear to have taken place in this population, particularly for the use of fried foods in males and intake of high-fiber foods and cruciferous vegetables in females.