66--nutricao e saude da mulher

8/2/2019 66--Nutricao e saude da mulher

1/18

from the associationADA REPORTS

Position of the American Dietetic Association and

Dietitians of Canada: Nutrition and Womens Health

ABSTRACTIt is the position of the American Di-etetic Association (ADA) and Dieti-tians of Canada (DC) that womenhave specic nutritional needs and vulnerabilities and, as such, are atunique risk for various nutrition-re-lated diseases and conditions. There-fore, the ADA and the DC strongly

support research, health promotionactivities, health services, and advo-cacy efforts that will enable women toadopt desirable nutrition practices foroptimal health. Women are at risk fornumerous chronic diseases and condi-tions that affect the duration andquality of their lives. Although wom-ens health-related issues are multi-faceted, nutrition has been shown toinuence signicantly the risk of chronic disease and to assist in main-taining optimal health status. Dietet-ics professionals strongly support re-search, health promotion activities,health services, and advocacy effortsthat will enable women to adopt de-sirable nutrition practices for optimalhealth. J Am Diet Assoc. 2004;104:984-1001.

POSITION STATEMENT It is the position of the American Die-tetic Association (ADA) and Dietitiansof Canada (DC) that women have spe-cic nutritional needs and vulnerabil-

ities and, as such, are at unique risk for various nutrition-related diseasesand conditions. Therefore, ADA and DC strongly support research, health promotion activities, health services,and advocacy efforts that will enablewomen to adopt desirable nutrition practices for optimal health.

Women account for approxi-mately half of the populationin the United States (1) andCanada (2). Early denitions of wom-ens health were limited to reproduc-tive health (3). However, more recentdenitions consider the diverse issuesthat affect women today (4) and thecomplex interactions among womensphysical, mental, social, and emo-

tional health (5,6). Womens health-related behaviors are inuenced bymany factors. In particular, gender-based health determinants such asculture and traditions, ethnicity, edu-cation, socioeconomic status, workingconditions, and coping skills need tobe factored into health care policiesand practices that are specically de-signed for women (6-8). The popula-tion of women in the United Statesand Canada currently numbers over150 million, a population that is ex-ceptionally diverse in terms of both

age distribution and ethnic and/or ra-cial status. Thirty-three percent to40% of North American women are of reproductive age, 50% to 54% are be-tween the ages of 45 and 64 years,and 14% to 20% are age 65 years orolder (1,9). In the United States, ap-proximately 40 million women belongto racial or ethnic minority groups (1);13% of the total population are Afri-can American, 11% are Hispanic, 4%are Asian American/Pacic Islander,and almost 1% are American Indian/ Alaska Native women (9). In Canada,

2.5 million women belong to a racialor ethnic minority group; 8% are of Asian origin, more than 3% belong tothe Aboriginal population, and 2% areblack (2). Disparities in health existin the United States as well as inCanada for minority women based ondisparities in socioeconomic statusand access to medical care and healthresources, as well as geographic loca-tion, social, and cultural issues(10,11). Barriers to health care services may inuence morbidity and

mortality from chronic diseases suchas cancer, cardiovascular disease(CVD), diabetes mellitus, obesity, andosteoporosis. In light of this, the Of-ce of Research on Womens Health(ORWH) (12) has recently developeda focused research plan to identifyand address gaps in womens healthrelated to ethnicity and racial dispar-ity (13). Centers of Excellence for

Womens Health exist in both theUnited States (14) and Canada (15)that purport a multidisciplinary re-search agenda on womens health is-sues and an integrated model for thedelivery of clinical health care services to women and provide coordina-tion between clinical services inacademic centers and surroundingcommunities.

Women are at risk for numerouschronic diseases and conditions thataffect the duration and quality of their lives. Dietetics professionals canenhance womens health by helpingwomen recognize the means of main-taining healthful eating habits andhealth-promoting practices. Dieti-tians also can advocate for public pol-icy, legislation, and nancial alloca-tion to optimize the nutritional statusof women and allow for continuedgender-specic research in this area(13).

CURRENT FOOD INTAKE, NUTRITION, ANLIFESTYLE FACTORS A high proportion of young United

States women (20 to 50 years of age)are under consuming a variety of nu-trients as seen in the latest results of the Third National Health Examina-tion Survey (16). Irrespective of eth-nic origin, 75% of women do not meetcurrent Adequate Intakes for cal-cium, and 90% of women have inade-quate intakes of folate and vitamin Efrom food sources alone. Overall,United States women are not meetingtheir nutritional needs through theirtypical diets (16). In Canada, a major-

0002-8223/04/10406-0018$30.00/0doi: 10.1016/j.jada.2004.04.010

984 Journal of THE AMERICAN DIETETIC ASSOCIATION 2004 by the American Dietetic Association


2/18

ity of women (57%) do not meet therecommended requirement of ve ormore servings of fruits and vegetablesa day (17). Although in both countriesthe percentage of energy from fat hasdecreased over time, there has beenan increased consumption of the total

amount of fat, total energy, and re-ned carbohydrates (18). These pat-terns of intake are associated withthe increased prevalence of obesity(19) and insulin insensitivity, as wellas growth factors that may promotethe development of cancer (20).Chronic over consumption of foodshigh in energy and low in nutrientsmay result in marginal nutrient in-takes if substituted for nutrient densefoods or in obesity, if consumed in ad-dition to the basal diet (21). In theUnited States, more than 31% of daily

energy is composed of foods that areenergy dense and nutrient poor (22).This pattern of eating may contributeto excessive intakes of sugar, salt,and fat (22).

Women s increased total paid andunpaid employment may have nega-tively in uenced their dietary prac-tices (23). Seventy percent of womenin the United States and Canada areemployed (2). Although time for foodprepared at home has signi cantlydecreased (24), women are still cook-ing meals more than twice as fre-quently as men (25). Meals eaten out-side of the home account for 27% of allfoods consumed, which represents atwo-third increase over the last 2 de-cades (26). Frequent dining at fast-food establishments may not be con-ducive to a healthy weight; suchmeals contain more energy, fat, cho-lesterol, and sodium while providingreduced amounts of ber and vita-mins (27). Although healthier foodsare becoming more readily available,they are not always chosen. More-over, the portion size of foods sold hasincreased in recent years, especially

at fast-food restaurants (28-30). Por-tion sizes of snack foods and bever-ages consumed within the home alsohave increased, leading to excess en-ergy intakes (31). Although women sdiets may contain excess energy,studies show marginal intakes of cal-cium, iron, vitamin D, and folic acid.For example, in the Nurse s HealthStudy, data indicate that women whoconsume more than 12.5 g of vita-min D daily from foods and supple-ments had a 37% lower risk of hip

fracture, yet only 41% of women metthese levels (32). The prevalence of vitamin D de ciency is 42% among African-American women of child-bearing age and 4.2% among whites,based on serum 25(OH) D concentra-tions (33,34).

Dieteticsprofessionals canenhance womenshealth by helpingwomen recognize

the means ofmaintaining

healthful eating

habits and health-promoting practices.

The generalized lack of folic acid inwomen s diets, as well as the link be-tween its de ciency and neural tubedefects (NTD) (35), have prompted amajor forti cation program of ourand other cereal products in both theUnited States and Canada (36,37). A recent study conducted among336,963 women who underwent ma-ternal serum screening for folic acidshowed a relative decline of 58% inspina bi da and a 43% reduction inanencephaly (38).

Although food sources of nutrientsshould be encouraged, diet alone maynot besuf cient to achieve nutritionaladequacy during all times in a wom-an s life. Currently, 64% of UnitedStates women of childbearing age re-port taking some form of vitamin sup-plement, with cost considered to bethe major barrier to nonuse (39). InCanada, 42% of women report supple-ment use, which contributes to higheroverall intakes of thiamin; ribo avin;

niacin; folate; and vitamins B-6, B-12,C, and D. Among women of childbear-ing ages using multivitamins, 80% at-tain RDA level intakes comparedwith only 19% of nonusers. Accordingto Troppmann and colleagues (40),multivitamin supplements help over-come low intakes of folate, iron, and vitamin D, and calcium supplementswere effective in achieving adequatecalcium intakes. However, a conun-drum exists in that individuals whoare the most likely to use supple-

ments are also those who consumebetter diets, whereas those who con-sume poorer diets and are most likelyto bene t from supplements are lesslikely to use them (16). Readers arereferred to the ADA Position on Nu-trition and Lifestyle for a Healthy

Pregnancy Outcome (41), the Nutri-tion for a Healthy Pregnancy, Na-tional Guidelines for the Childbear-ing Years (42), and PreconceptionHealth-Folic Acid for the PrimaryPrevention of Neural Tube Defects(43) for a more complete review of folic acid supplementation duringpregnancy.

Sedentary lifestyles and reducedphysical activity adversely in uenceweight status (44,45). Women whowork long unpaid hours at home aftertheir occupational employment may

have little time or energy for exercise(46). The majority of North Americanwomen (36% non-Hispanic White,55% African American, and 57% His-panic White) report no leisure timephysical activity. Similarly, most Ca-nadian women (59%) are sedentarywith inactivity increasing with age(47). To promote physical activity inwomen, tness programs should beenjoyable and convenient to a wom-an s daily life (48).

Cigarette smoking often is per-ceived as a means to control weight(49) and is associated with poorer di-ets for many young women (16). Cig-arette smoking is a strong risk factorfor several major chronic diseases, in-cluding lung cancer, hypertension,osteoporosis, heart disease, and cere-brovascular accidents (50,51). Smok-ing cessation should be a priority forimproving women s health and nutri-tion (52). Currently, 22% of women inthe United States (50) and 20% inCanada (2) smoke cigarettes; amonghigh school girls, the prevalence iseven higher (27.7%). Recent researchin Canada suggests that there has

been a 24% decrease in the percent-age of women smokers between 1994and 2000 (2); unfortunately, theUnited States cannot boast the samesuccess (50).

In summary, changes in employ-ment and total workload may nega-tively affect women s energy balanceand nutritional adequacy. Workingconditions, socioeconomic status,availability of health care and otherdeterminants of health are seldomtaken into consideration in nutrition

ADA REPORTS

Journal of THE AMERICAN DIETETIC ASSOCIATION985


3/18

surveys but need to be consideredwhen developing programs for high-risk groups. The overall quality of women s diets is likely to improve byreplacing nutrient-poor foods withfoods rich in nutrients and lower inenergy (16). Means of simplifying

preparation of healthy food at homeneeds to be encouraged, along withestablishing appropriate portion con-trol. Current lifestyle habits shouldinclude opportunities for increasedphysical activity and the incorpora-tion of enjoyable tness programsinto a women s daily life (48). Effortstoward smoking cessation also shouldbe supported.

OPTIMAL FOOD INTAKE, NUTRITION, ANDLIFESTYLE FACTORS

Although an optimal diet is thoughtto contribute to improved health andwell-being, to date, there are no datafrom randomized controlled trialsthat verify the combined effects of multiple dietary recommendations onthe overall health and chronic diseaserisk in women. However, results fromepidemiologic investigations suggestthat diets composed primarily of fruits, vegetables, whole grains, low-fat dairy, and lean meats are associ-ated with a lower risk of mortality inwomen (53,54). This nutritional pat-tern serves as the basis for many of the guidelines promoted by the majordisease-related organizations, suchas the American Heart Association,Canadian Heart and Stroke Founda-tion, American Diabetes Association,Canadian Diabetes Association, and American and Canadian Cancer Soci-eties. Another framework is providedby the Alternate Healthy Eating In-dex (AHEI), which further identi esmore speci c food choices, such as in-creased fruit and vegetable intake,soy or nuts on a daily basis, a ratio of sh and poultry to red meat of 4-to-1,

and more cereal ber. A study by Mc-Cullough and colleagues (55) suggeststhat this eating pattern is associatedwith an 11% lower risk of majorchronic disease and a 28% reductionin risk of CVD in women.

Eating healthful foods in individualportion sizes de ned by the UnitedStates Department of AgricultureHandbook Number 8 (56) can assistin the maintenance of a healthyweight. Importantly, physical activityalso is part of a healthy lifestyle and

has been shown to assist in weightmanagement and decrease visceraladipose tissue, which are importantrisk factors for diabetes mellitus,CVD, and certain cancers (57). Re-cently, the Institute of Medicine re-leased guidelines for physical activ-

ity, which include 1 hour of exerciseper day. Likewise, Canada s Physical Activity Guide to Healthy Active Liv-ing (58) supports an identical recom-mendation. Physical activity is cumu-lative and includes daily activities,plus moderate to vigorous exercise,such as walking at a rate of 4 milesper hour (58). Nutrition education ef-forts should underscore the need forhealthful food choices, portion con-trol, and regular physical activity topromote overall health.

RECOMMENDATIONS FOR COMMONLYOCCURRING CONDITIONSOverweight and ObesityOverweight and obesity are the lead-ing nutritional concerns in both theUnited States and Canada (7,22,59).Obesity is more prevalent amongwomen than men, 27% vs 21%, re-spectively (59). Among United Stateswomen, ages 20 to 74 years, 62% areoverweight, and 34% are obese (60).Furthermore, non-Hispanic blackwomen have the highest prevalence of obesity and overweight; more thanhalf of African-American women areobese, and approximately 80% areoverweight (61). Moreover, morewomen than men are trying to loseweight, even those who are within anacceptable weight range.

Overweight and obesity are associ-ated with heart disease and cerebrovascular accidents (62); type 2 diabe-tes mellitus (63); and cancers of thegallbladder, breast (postmenopausal),endometrium, and colon (64). In addi-tion, gallstones or gallbladder dis-ease, osteoarthritis, gout, sleep ap-

nea, hypertension, hyperlipidemia,pregnancy complications, and irregu-lar menses are more common in over-weight individuals (65). A healthybody weight for a woman, who is notpregnant or lactating, or who is nothighly muscular, is based on the stan-dard of body mass index (BMI) of 18.5to 25 (65,66). Please refer to the Ex-pert Panel of the National Lung andBlood Institute s clinical guidelinesfor the identi cation, evaluation, andtreatment of overweight and obesity

in adults; The Evidence Report (1998)for weight classi cation scheme (65);and Health Canada (66) for details of reference standards.

Obesity may affect a woman s psy-chosocial status and functioning.Early onset of obesity in women is

associated with body dissatisfactionand impaired self-esteem (67). Conse-quently, many overweight and obesewomen may engage in dietingthroughout their lives and may expe-rience periods of weight cycling.Weight cycling has been associatedwith binge eating and a perception of a poor health status (68). Among nor-mal weight, female college students,frequent dieting (69) and rigid dieting(70) have been shown to be associatedwith eating disorders symptoms, bodydissatisfaction (69), and preoccupa-

tion with body weight and shape (70).However, longitudinal studies are re-quired to ascertain whether chronicdieting is a risk factor for eating dis-orders.

In summary, obesity is associatedwith several chronic diseases and co-morbid conditions, such as severalcancers (20), coronary heart disease(62), diabetes mellitus (63), and themetabolic syndrome (71). Weight lossand increased physical activity canhelp reduce the likelihood of thesediseases and conditions. The bestproven method of achieving andmaintaining weight loss is throughlong-term changes in lifestyle, suchas healthful dietary habits and theinclusion of regular physical activity(72). Dietetics professionals shouldencourage women to balance health-ful eating with regular physical activ-ity (52).

Eating DisordersWomen are at increased risk for thedevelopment of eating disorders. Eat-ing disorders are complex, psychiatric

illnesses that are characterized byatypical eating behaviors, disturbedbody image and preoccupation withbody weight and shape, and food in-take (73). Eating disorders, both clin-ical and subclinical, affect approxi-mately 5 to 10 million females in theUnited States (73). Of particular con-cern is that 85% of eating disordersoccur when girls are still growing, ie,at the onset of adolescence (74). More-over, early adolescent anorexia nervosa and bulimia nervosa may in-

ADA REPORTS

986 June 2004 Volume 104 Number 6


4/18

crease the risk for eating disordersduring young adulthood (75).

Young adult women who have eat-ing disorders face an increased likeli-hood of complications during normallife events such as pregnancy. Eatingdisorders during pregnancy have

been associated with a higher fre-quency of Cesarean section andgreater postpartum depression (76)as well as higher rates of miscarriage,obstetric complications, and lowerbirth weight than women who did notshow symptoms of eating disordersduring pregnancy (77).

A signi cant number of women whoare at risk for eating disorders in-clude athletes who seek to improveperformance. Consequences of eatingdisorders in athletes include the Fe-male Athlete Triad, which is com-

posed of disordered eating, amenor-rhea, and premature osteoporosis(78). Other disturbances may includefatigue; anemia; electrolyte imbal-ance; decrease in strength, endur-ance, reaction time and/or speed; andan inability to concentrate (79).

Eating disorders may persistthroughout a woman s life, whichmay increase both physical and psy-chosocial morbidity (80). Primary prevention is the best approach to helpreduce the prevalence of eating disor-ders. This includes educating preado-lescent girls on the importance of ac-cepting their body and promotinghealthy self-esteem (81). Preventionefforts also include screening thosewho exhibit risk factors or mild symp-tomatology (82). As a member of theinterdisciplinary eating disordershealth care team, registered dieti-tians should seek specialized trainingbeyond the minimum competencies totreat effectively those with eating pa-thology (83). To promote healthy self-esteem and normalize eating habits,dietitians should partner with womento include goals in their weight coun-

seling strategies that support bodysize acceptance and the attainment of a healthful weight (84).

AnemiaIn North America, 3% to 5% of youngwomen (18 to 44 years of age) haveclinically manifest iron-de ciencyanemia, while subclinical iron de -ciency ranges between 11% to 13%(85). Iron de ciency decreases energyand endurance and reduces work ef-

ciency and can induce preterm deliv-ery as well as result in low birthweight (86). Women report fatiguethree times as frequently as men, andthis fatigue can be linked to low fer-ritin levels (87). Indicators of low ironstatus are seen more often amongMexican-American women of child-bearing age as compared with non-Hispanic whites (6.2% vs 2.3%) de-spite similar dietary iron and vitaminC intakes, use of supplements, andcontraceptive use (21). Limited accessto screening and treatment, plus fac-tors related to income are all cited aspossible causes (88). Women with un-explained fatigue and ferritin levelsbelow 50 g/L may bene t from ironsupplementation (87). Importantly,dietetics professionals should provideyoung women with guidance on howto increase the consumption of iron-rich foods, as well as methods to en-hance absorption (ie, simultaneousconsumption of vitamin C rich foods).

Premenstrual SyndromeUp to 40% of women of childbearingage experience suf cient PremenstrualSyndrome (PMS) symptoms to affecttheir daily lives, and 3% to 8% experi-ence severe impairment now calledPremenstrual Dysphoric Disorder(PMDD) (89,90). New evidence sug-gests that PMS may be associated withuctuations in calcium homeostasisand parathyroid hormone dysregula-tion. Calcium supplementation (1,000to 1,300 mg/day) has been tested in afew clinical trials and has been shownto alleviate the majority of symptomsincluding irritability and cramping(91,92). A systematic review on the ef-cacy of vitamin B-6 in the treatmentof PMS suggests that doses up to 100mg/day can be of bene t in alleviatingpremenstrual symptoms and premen-strual depression (93). In contrast,consistent ndings have not beenobserved with supplemental multivita-mins, magnesium, manganese, orgamma linolenic acid (94) nor reduc-tions in alcohol, sodium, or caffeine.PMS and PMDD affect a signi cantnumber of women who may seek nutri-tional advice. A thorough dietary as-sessment may provide a basis for nutri-tional guidance that includes betterfood choices and adequate supplemen-tation when required.

Polycystic Ovary SyndromePolycystic Ovary Syndrome (PCOS) isa common endocrine disorder that af-fects 4% to 10% of women of reproduc-tive age (95,96). PCOS falls under theumbrella of Syndrome X disordersand is characterized by insulinresistance, hyperandrogenism, andchronic anovulation (95-97). The syn-drome generally manifests itself atthe time of puberty, with clinicalsymptoms of hirsutism, amenorrhea,and obesity. If left untreated, womenwith PCOS are likely to encountersigni cant reproductive morbidity, aswell as be at increased risk for type 2diabetes; CVD; and cancers of thebreast, endometrium, and ovary(96,97). Weight loss, via decreased en-ergy intake and increased caloric ex-penditure (exercise), is a rst linetreatment for PCOS, with modestlosses in weight of 5%, frequently re-sulting in improved biochemical pro-les (ie, decreased levels of insulinand androgens [both free and total])as well as clinical symptoms (ie, hir-sutism and infertility) (98). Studiesare currently being conducted to de-termine the additional bene t of lowglycemic index diets that incorporateincreased amounts of dietary ber(95,97).

InfertilityInfertility affects six million couplesin the United States, or 10% of thepopulation of reproductive age. Dis-turbed endometrial function, men-strual disturbance, and anovulationare all etiologic factors for infertility(99). In a retrospective study con-ducted among women (n 3,586) re-ceiving assisted reproductive treat-ment, a body mass index (BMI) thatwas either very high ( 35) or low( 20) was associated with the re-duced probability of achieving preg-

nancy (99). Pernicious anemia alsohas been associated with infertility.Low levels of vitamin B-12 and folatehave been noted in infertile women orwomen with repeated miscarriages;nutrient supplementation has yieldedpositive results in a small group of women, but further research must bepursued (100). Achieving or main-taining a healthful weight along withan adequate dietary intake is recom-mended for women who want to con-ceive.

ADA REPORTS



5/18

Pregnancy and LactationNutrition plays a major role in preg-nancy and lactation. Women s dietsand eating habits may signi cantlyaffect the outcome of critical periodsof increased body demands for nutri-ents. Readers are referred to the ADAPosition on Nutrition and Lifestylefor a Healthy Pregnancy Outcome,2002 (41) and Nutrition for a HealthyPregnancy, National Guidelines forthe Childbearing Years (42) for com-plete reviews.

MenopauseNearly 24 million North Americanwomen are in their menopausalyears. The vast majority of womengain weight during these years(101,102). However, the Women s

Healthy Lifestyle Project has shownthat a lifestyle intervention using alow-fat, low-calorie diet plus regularexercise during perimenopause mayabrogate weight gain (103). Meno-pause also is associated with bonelosses of 3% to 5% per year during thetransition years, as discussed furtherin the section on osteoporosis. Amongother symptoms, 15% of women com-plain of severe hot ashes (104). Toalleviate menopausal symptoms, anestimated one-third of American andCanadian women were using hor-mone replacement therapy (HRT)(105). However, these statistics werecollected prior to the release of theresults of the Women s Health Initia-tive, which showed an increased risk:bene t ratio (106). The Study of Women s Health across the Nation(SWAN), a longitudinal study of over3,300 women of varied ethnic back-grounds aged 40 to 55 years (107),will enable a better understanding of how diet and health is related duringmenopause (108). Initial data fromfood frequency questionnaires revealsigni cant differences by ethnicity for

several nutrients (ie, energy intakesare greater among African-Americanwomen, fat intakes are lowestin Chinese and Japanese women,calcium intakes are higher amongwhite women, and ber intake frombeans are almost four times higheramong Hispanic women). Phytoestro-gen intakes also are signi cantlyhigher among Chinese and Japanesewomen who also report the fewest va-somotor, psychologic, and psychoso-matic symptoms compared with the

three other ethnic groups. Forthcom-ing analysis will relate nutrient in-takes to a range of health outcomes atmenopause (108). Meanwhile, clinicaltrials conducted in several countrieshave used soy in the form of food orisoavone extracts to relieve meno-pausal symptoms. Iso avone extractstaken at doses of 70 to 100 mg/dayshow a 40% to 60% reduction of hotashes compared with a 20% im-provement with the placebo (109);lower doses of iso avones do not provide the same bene ts (110). Otherpopular supplements used to reducemenopausal symptoms include ax-seed (111,112), gingko biloba, andblack cohosh (113). A randomizedcontrolled trial of ginkgo biloba (40mg three times a day) showed no

memory improvement after 6 weeks(114). Although there are new regula-tions on Natural Health Products inCanada (115), the potential bene ts,hazards, and interactions of supple-ments with food and/or medicinesremains uncertain (116). Therefore,at present, nutrition interventionsshould focus on limiting weight gainas well as improving the quality of thediet. This may be helpful in enhanc-ing overall health and well-being.

Postmenopause and Old AgeOlder women are more likely to be atincreased nutritional risk than menbecause of limited dietary intake(117). Low fruit and vegetable intake,food avoidance, and cooking andchewing dif culties are among thekey indicators of nutritional risk(118). Preventing sarcopenia, as wellas minimizing bone loss, can improvethe health of postmenopausal women.Regular physical activity and resis-tance training can attenuate lean tis-sue loss with age (119). A cardiopro-tective diet is recommended for theprevention of CVD. Suboptimal in-takes of calcium and zinc are ob-served among approximately 87%and 40% of women, respectively (120).Elderly women may be at increasedrisk for inadequate intake of micronu-trients because of lower energy intake(121). Nutrient supplementation maybecome important (121), but guidanceon appropriate supplement usage isneeded (122).

Disease PreventionNorth American women are at uniquerisk for certain major nutrition-re-lated diseases and conditions, includ-ing diabetes mellitus (123), CVD(124), several cancers (125), and os-teoporosis (126). Over the past 4 de-cades, obesity has increased amongwomen of all races and ages (127). Forpromoting optimal health and reduc-ing the risk of chronic disease, womenshould be encouraged to achieve andmaintain a healthful body weight, tochoose wisely a wide variety of foods,and to follow other prevention strate-gies as outlined in Figure 1.

COMMON CHRONIC DISEASES AMONGWOMENDiabetes MellitusDiabetes mellitus affects an esti-mated 16 million Americans (123)and more than 2.25 million Canadi-ans (128). Approximately 8.9% of women in the United States have di-abetes mellitus (123). The incidenceand mortality data for diabetes melli-tus vary among women according torace and ethnicity. Diabetes mellitusis the fourth leading cause of death in African-American, Native American,and Hispanic women; the sixth lead-ing cause in Asian-American women;and the seventh cause in whitewomen (123). Furthermore, womenwho are African American, Hispanic American, Native American, Asian American, and Paci c Islander are atincreased risk for type 2 diabetes mel-litus (129). In Canada, women whoare single or from low-income groupshave a greater prevalence of diabetesmellitus compared with women whoare married or from higher incomegroups (130). The Expert Committeeon the Diagnosis and Classi cation of Diabetes (131) and Canadian ClinicalPractice Guidelines on Diabetes (132)

provide an in-depth review of theclassi cation, diagnosis, and etiologyof this disease.

The increased prevalence of diabe-tes mellitus in North America is pos-itively associated with the increasedprevalence of obesity (133). Of partic-ular concern is the increasing preva-lence of obesity in women of child-bearing age because this is associatedwith gestational diabetes mellitus(GDM). The prevalence of GDM in-creases when women have an in-

ADA REPORTS



6/18

creased BMI and increased gesta-tional weight gain before 28 weeks of gestation (134). Hispanic and Afri-can-American women are at in-creased risk for GDM (134). Using the

Carpenter and Coustan cutoffs (135),it has been found that GDM compli-cates approximately 4.8% of all preg-nancies in the United States (136)and 2% to 4% of those among Cana-dian women (128).

Recent prospective epidemiologicstudies point to an association betweendiets with a high glycemic index and agreater risk of type 2 diabetes mellitusin women (137), a nding associatedwith increased insulin resistance. In-creased intake of whole grains and a

diet with a low glycemic index may re-duce the risk of diabetes mellitus andCVD because of enhancement of insu-lin sensitivity and an improvement inblood lipid concentrations, respectively

(138,139). Although these ndings ap-pear promising, more prospective long-term research is required before recom-mendations based on consensus can bemade to prevent diabetes mellitus. Therole of the glycemic index in diabetesmellitus medical nutrition therapy re-mains controversial. Current data donot provide convincing evidence of ben-ets from low vs high glycemic indexdiets in persons with the disease(140,141). According to the AmericanDiabetes Association (140), there is not

suf cient long-term bene t to recom-mend low glycemic diets as a strategyin meal planning. However, the Cana-dian Diabetes Association s nutritionguidelines recommend the inclusion of

low glycemic index foods to optimizecontrol of blood glucose concentrations,especially in persons with type 2 diabe-tes mellitus (132). Future research isneeded among subjects who consumemixed meals.Glycemic and insulin pro-les should be studied daylong to as-sess the bene cial effects of higher -ber, reduced fat, and low glycemicfoods, especially when consumed incombination with other foods (141).Readers are referred to the AmericanDiabetes Association s nutrition prac-

Factorsaffectingenergy and/ornutritionalstatus

Cardiovasculardisease

Diabetesmellitus

Cancer

OsteoporosisBreast LungColon/rectum Endometrium Cervix Ovary

Avoidance ofobesity

a (postmenopausal)b (premenopausal)

?c 0d ?

Physicalactivity

? e

? ?

Dietary fatTotal ? f ( 30%) ? ? ? ? ? ?Saturates ? ? ? ? ?Monounsaturates ? ? ? ? ? ? ?Polyunsaturates ? ? ? ? ? ? ?Trans fatty acids ? ? ? ? ? ?n-3s ? ? ? ? ? ? ?

Meat/protein Preferred protein sources are either plant-based or lean meats, sh, poultry, andlow-fat dairy

? ? forprocessed &red meats

? ? ? ?

Fruits andvegetables

? ?

Renedcarbohydrate

? ? ? ? ? ? ?

Dietary ber ? ? ? ? ? ?Minerals Sodium ( ) Chromium (?) Calcium ( ) Calcium ( )

Calcium ( ) Vanadium salts ( ) Selenium (?) Phosphorus (?)Magnesium ( ) Folate ( ) prevent

birth defectsMagnesium ( )

Potassium ( )Calcium ( ) older

personsVitamins Folate ( ) Ant ioxidant

supplements ( )Folate ( ) D ( )

B-6 ( ) K ( )B-12 ( )

Alcohol ?/ (hypoglycemiaor hyperglycemia)

? ? ? ?

Caffeine ? ? 0 ? ? ? ? ? ?Other Herbal preparations ( ) Breastfeeding ( ) Galactose (?) Isoavones (?)

Soy (?)

a Convincing evidence of benet as supported by systematic reviews and/or meta-analyses.b

Probable/possible evidence of harm (studies showing associations are either not so consistent or the number or type of studies is not extensive enough to make a denitive judgment).c ? Insufcient evidence to conclude benet or risk.d 0 No association.e Probable/possible evidence of benet (studies showing associations are either not so consistent or the number or type of studies is not extensive enough to make a denitive judgment).f Convincing evidence of harm as supported by systematic reviews and/or meta-analyses.

Figure 1. Associations between nutritional factors and prevalent diet-related diseases among North American women.

ADA REPORTS



7/18

tice guidelines for the use of alcoholamong persons with diabetes (140).

Women with diabetes mellitus, es-pecially those who are overweight,are predisposed to CVD and hyper-tension (142). It is well establishedthat physical inactivity contributes to

overweight and obesity (143). Approx-imately 31% of adults with type 2 di-abetes mellitus report no regularphysical activity, and another 38%report less physical activity than rec-ommended levels (144). Structuredweight-loss programs that emphasizelifestyle changes that include reducedfat ( 30% of daily energy) and energyintake, regular physical activity, andregular participant contact can helppromote long-term weight loss of 5%to 7% of starting weight in personswith diabetes mellitus (140).

The long-term complications of dia-betes mellitus are exacerbated by ex-cess weight (145). Longitudinal re-search clearly indicates that tightmetabolic control is associated with areduced risk of long-term microvascu-lar complications of diabetes mellitus(146). Furthermore, long-term stud-ies indicate that a sustained moder-ate weight loss in persons who areobese may assist in the improvementof metabolic control as a result of de-creased insulin resistance (147).

Over the past decade, research hasdocumented the coexistence of eatingdisorders among individuals with di-abetes mellitus (148). Women with di-abetes mellitus may be at risk for eat-ing disorders because of their focus ondiet and the need for control of intakeas related to blood glucose concentra-tions. The prevalence of eating disor-ders among female adolescents andyoung adult women with diabetesmellitus is twofold that of females of similar age without diabetes mellitus(149). Intentional insulin misuse oromission for the purpose of weightcontrol may indicate an eating disor-

der in women with type 1 diabetesmellitus. Both insulin misuse and fullor partial syndrome eating disorders(150) are associated with poor meta-bolic control of diabetes mellitus, aswell as long-term complications, espe-cially in type 1 diabetes mellitus(149). Of central concern is the in-creased risk for mortality in this pop-ulation (151).

In conclusion, medical nutritiontherapy (MNT) is essential to diabe-tes mellitus management of women.

This includes attention to diet, in-crease in physical activity, self-monitoring of blood glucose concen-trations, and metabolic parameters(140). Recommendations include con-sumption of a variety of foods withparticular attention to macronutrient

distribution (131,132,140). For womenwith type 2 diabetes mellitus who areoverweight, lifestyle changes includereduced energy intake, increasedphysical activity, and nutrition edu-cation with the goal of promotingweight loss (152). As educators, die-tetics professionals signi cantly con-tribute to the management of personswith diabetes mellitus (153).

Cardiovascular DiseaseCVD is the leading cause of deathamong women over age 70 years. Inthe United States, heart disease rep-resents 42.5% of all deaths in females,whereas, in Canada, it represents37% (154,155). Of all CVD, 54% aredue to coronary heart disease (CHD),20% to cerebrovascular accidents,16% to other forms of heart disease,and the remaining 10% to vascularproblems such as high blood pressureand atherosclerosis. Under the age of 75 years, more men have CHD andmore women have congestive heartfailure (CHF). The incidence of CHDin women lags behind men by 10

years for total events and by 20 yearsfor more serious clinical events suchas myocardial infarction and suddendeath (154).

Hypertension affects52% of women over45 years of age and

is another risk factor for CVD.

Hormone replacement therapy(HRT) is no longer considered a heart-healthy measure (156) and may evenserve as a risk factor (157-160). De-spite improvement in lipid pro les,HRT is associated with an increasedrisk of CHD among healthy women(161,162), as well as among womenwith heart conditions (163,164). Fol-lowing the results of the Women sHealth Initiative trial, the North American Menopause Society (165)advisory panel as well as the Society

of Obstetricians and Gynecologists of Canada (166) concluded that HRTshould not be used for primary or sec-ondary prevention of coronary heartdisease.

To prevent CVD, the type of dietaryfat has become more important than

the total amount of fat. Based on alarge body of evidence, the optimaldiet to reduce risk of CVD containsless saturated fat and a minimumamount of trans -fatty acids from pro-cessed foods (167). Long-chain n-3fatty acids, from sh and certain nutsand seeds, are to be encouraged be-cause of their favorable effect on se-rum triglycerides, platelet aggrega-bility, and endothelium functions andtheir antiarrhythmic effects (168).Prospective studies that have ex-plored n-3 fatty acids and their effect

on cardiovascular risk in women sug-gest that a high intake of sh is asso-ciated with a reduced risk of totalstroke or thrombotic stroke (169) anda reduction of sudden cardiac death.In a large randomized controlledtrial, n-3 supplements showed a 45%reduction in sudden death among pa-tients surviving a recent MI (170).The 50% to 70% decrease in cardiacmortality seen in the Lyon HeartTrial also provides evidence of thebene ts of a Mediterranean-type dietrich in -linolenic acid (ALA), an n-3fat (171).

Irrespective of fat intake, elevatedtotal plasma homocysteine (tHcy) isassociated with a higher risk of CVDas well as low serum folate levels(172). Increasing folate intake fromfoods, through forti cation or with fo-lic acid supplements, improves folatestatus (173) and can reduce totalplasma homocysteine levels in women(174,175), thus potentially loweringthe risk of CVD (176). Eating morefolate-rich foods increases other nu-trients such as ber, phytochemicals,and several micronutrients, while in-

directly lowering intakes of fat. Caf-feine (177,178) and alcohol (178) mayunfavorably affect tHcy metabolism,whereas vitamins B-6 and B-12 mayhave bene cial effects (178).

Hypertension affects 52% of womenover 45 years of age and is anotherrisk factor for CVD. Hypertension canbe signi cantly decreased with a dietrich in low-fat dairy products andgenerous amounts of fruits and vege-tables, as shown in the Dietary Ap-proaches to Stop Hypertension Diet

ADA REPORTS



8/18

(DASH) (179). Such changes in eatinghabits, along with a reduction of di-etary sodium, can reduce blood pres-sure in normotensive, as well as hy-pertensive individuals (180). Sodiumintakes greater than 2,600 mg/dayare considered a strong independentrisk factor for CHF among overweightindividuals (181). This is especiallyrelevant to overweight women whoare particularly vulnerable to CHF(182).

The revised Dietary Guidelines of the American Heart Association(AHA) (167) represent a major shiftfrom a speci c focus on limiting totaldietary fats to a greater emphasis onprotective foods and on the diet as awhole. Data from the Nurse s HealthStudy, which found a cardioprotectivebene t of a prudent eating pattern

(ample amounts of fruits, vegetables,whole grains, legumes, and sh andless re ned grains, potatoes, and redand processed meats), when com-pared with a Western-type diet, sup-port this new paradigm (183). Amongpending issues, the increased avail-ability of fat substitutes and in-creased use by consumers requireslong-term study to assess the truebene ts because many foods that in-corporate fat substitutes also maycontain high levels of re ned carbohy-drates (184).

In summary, dietetic professionalsneed to be aware of important para-digm shifts related to the preventionand treatment of CVD. New risk fac-tors, which include novel proteins andgenetic polymorphisms, need to beconsidered. MNT should go beyondthe traditional lipid modi cationstrategy. Plant foods (rich in folic acidand soluble ber), sh, nuts and seeds(rich in n-3 fatty acids), greens (richin magnesium and potassium), wholegrains (rich in micronutrients andlow in glycemic load) (185), and soy

and vegetable oils (rich in monoun-saturated fats) all provide strong evi-dence-based bene ts. Low-fat dairyproducts also have been shown usefulto lower blood pressure (179). Thespeci c effect of moderate amounts of wine and speci c recommendationsfor women are pending further re-search (186). The lifestyle approachthat provides the most protection in-cludes a healthful diet, weight con-trol, regular physical activity, and ab-stinence from smoking. The reader is

referred to Figure 1 for a summary of risk and protective factors.

CancerCancer is the second leading cause of mortality in North America and is re-sponsible for one out of four deaths(51,187). Cancer incidence and mor-tality rates among females in theUnited States and Canada closelyparallel one another. The top threecancers among North Americanwomen are as follows: cancer of thebreast (accounting for 31% of inci-dent cases and 15% of cancerdeaths); cancers of the lung and bron-chus (accounting for 12% of incidentcases and 25% of cancer deaths);and cancers of the colon and rectum(accounting for 12% of incident

cases and 11% of cancer deaths)(51,187). Differentials between inci-dence and mortality largely re ectpoorer cure rates for lung cancer ingeneral, as well as later stage at di-agnosis for both lung and colorectalcancers. Because early detection is akey factor in controlling many typesof cancer, North American women areencouraged to follow cancer-screeningguidelines established and periodi-cally updated by the National CancerInstitute (United States or Canada)or the American or Canadian CancerSocieties (188,189). Later stage at di-agnosis tends to be a pervasive prob-lem among underserved populations,ie, Native Americans (Aleuts and American Indians), African Ameri-cans, and Hispanics, and contributesto increased cancer-related mortalityand morbidity, therefore underscor-ing the need for both increased pri-mary and secondary prevention ef-forts in these groups (51,187).Gynecologic cancers of the cervix, en-dometrium (uterine corpus), andovary also are a cancer concernamong North American women but

are less prevalent and, in total, onlycomprise 12% of incident cases and8% of cancer deaths (51,187).Cancer is an umbrella term used to

describe over 100 different conditionscharacterized by uncontrolled cellgrowth (51). Given the disease heter-ogeneity, risk factors differ consider-ably among different cancers, suchthat risk factors identi ed for onecancer are not necessarily the riskfactors for another (190). There aresome commonalities that exist;

namely, cancer tends to be slightlymore prevalent among males than fe-males and also is a disease associatedwith aging (51,187). Roughly 77% of cancers are diagnosed at age 55 orolder (51). Although major singlegene mutations in familial cancer

syndromes are responsible for up to15% of cancers, a recent study sug-gests that the overwhelming cause of cancer is because of external factors,such as tobacco, environmental andoccupational exposures, alcohol use,or diet (51,190-194). It is estimatedthat roughly one-third of cancer-re-lated mortality is attributable to di-etary or nutritional factors, includingthose that mediate energy balance orbody weight status (192,195,196).Given the heterogeneity of the dis-ease, however, this estimate is impre-

cise and ranges from 10% to 70%, de-pending on cancer type, gender, andother factors (195,197). The science inthe area of diet and cancer is not asdeveloped as that between diet andother disease, such as CVD. However,large-scale studies are currently un-derway that will more clearly eluci-date associations between various nu-trients and cancer (197). Discoveries,particularly in areas of diet-gene in-teractions, as well as intermediateend points (eg, a biomarker for cancerthat is the equivalent of cholesterol inCVD) are likely to have a major im-pact in this area (190,193,198,199).Results of this work will temperguidelines that were previously con-structed today and well into the fu-ture.

Evidence-based guidelines from the American Cancer Society and theWorld Cancer Research Fund/Ameri-can Institute for Cancer Research(200,201) form the basis of currentdietary recommendations and en-courage the consumption of plant-based diets that rely on minimallyprocessed food and that promote

healthy weight control along with aphysically active lifestyle. Althoughthe possible bene ts of supplementalfolate, calcium, and selenium are ac-knowledged, these organizations advocate that nutrients be provided by awell-balanced diet, instead of in theform of supplements (192,200,201).See Figure 1 for general risk and di-etary factors associated with cancersof the breast, lung, colorectum, endo-metrium, cervix, and ovary.

In conclusion, the study of diet and

ADA REPORTS



9/18

cancer prevention is fairly new and islikely to evolve quickly with gene dis-covery and the elucidation of interme-diate end points. Dietetics profession-als need to be aware of thesediscoveries to target women who aremost at risk and to provide appropri-

ate guidance (making sure that nutri-tional advice is supported by a con-sensus of well-designed trials). Atpresent, the basis of medical nutritiontherapy should be focused on theguidelines established by the Ameri-can (51) and Canadian Cancer Societ-ies (189) and the World Cancer Re-search Fund (64)/American Institutefor Cancer Research (201), which callfor healthy weight control throughoutthe life cycle via a physically activelifestyle and the consumption of ahealthful diet that includes a variety

of minimally processed foods, with anemphasis on plant sources.

OsteoporosisOsteoporosis is a complex, multifacto-rial condition characterized by re-duced bone mass and architecturaldeterioration, leading to an increasedsusceptibility to fractures. Osteoporo-sis is a silent disease; it occurs with-out overt symptoms. It is the mostcommon bone disease in humans andis developing into a major publichealth problem worldwide. Osteopo-rosis and low bone mass (osteopenia)currently affect over 45 million North American adults aged 50 years andolder (202,203). Eighty percent of those affected by osteoporosis arewomen, and all ethnicities are af-fected (126). Forty percent of non-His-panic black women, 59% of Hispanic,and 72% of non-Hispanic white and Asian women over the age of 50 yearsare estimated to have osteoporosis orosteopenia (202). One in two womenwill suffer an osteoporotic-relatedfracture once in her lifetime (126).

Dual-energy x-ray absorptiometry(DXA) is the technical standard formeasuring bone mineral density(BMD); a low BMD is a strong predic-tor of fracture risk (126).

Osteoporotic-related fractures areparticularly devastating to olderwomen, frequently con ning them tolong-term care with, often times, fataloutcomes. In 2001, the estimated di-rect expenditures (hospitals andnursing homes) for osteoporotic andassociated fractures in the United

States were $17 billion (202). In Can-ada alone, the cost of treating osteo-porosis and the resulting fractures isestimated to be $1.3 billion annually,with expectations that the numberwill grow to $32.5 billion in the year2018 (203).

For most people, osteoporosis islargely preventable. Because there iscurrently no cure for the disease, prevention is crucial. Osteoporosis prevention is best accomplished by max-imizing peak bone mass duringgrowth (childhood and adolescence)(204) and by maintaining a healthylifestyle throughout life to keep bonesstrong. There are four critical factorsin preventing osteoporosis: (a) a bal-anced diet rich in calcium and vita-min D, (b) weight-bearing exerciseand a healthy lifestyle with no smok-

ing or excessive alcohol intake, (c)routine bone density measurementsto monitor and screen for osteoporoticchanges, and (d) the use of medica-tions when appropriate (126).

Osteoporotic-relatedfractures areparticularly

devastating to olderwomen, frequently

con ning them tolong-term care with,often times, fatal

outcomes.Nutrition is an important modi -

able factor in the development andmaintenance of bone as well as theprevention and treatment of osteopo-rosis. Of all the nutrients or food com-ponents that affect bone, calcium and vitamin D are the most important.Ninety-nine percent of the body s cal-

cium is found in bone. Bone is livingtissue that constantly undergoes for-mation and breakdown, otherwiseknown as bone turnover. There is lit-tle doubt that bone turnover is re-sponsive to dietary calcium, regard-less of age. In an exhaustive review of the scienti c literature, Heaney (205)found that, in 70 controlled calciumintervention studies, 68 studiesshowed that dietary calcium resultedin either improved bone balance,greater bone gain during growth, re-

duced bone loss in older individuals,and/or reduced fracture risk. The pos-itive effects of supplemental calciumare most pronounced when the base-line calcium intakes are alreadylow to moderate. Dietary calciumstrengthens bone by suppressing

parathyroid hormone and bone re-sorption (205-208). Actual calcium intakes among

United States women (209) are con-siderably lower than the current Di-etary Reference Intakes (DRIs) (210).Inclusion of low-fat dairy products inthe diet is the most desirable way tomeet calcium goals (211). With therecent increases in requirements, it isdif cult to achieve an adequate in-take when dairy products are elimi-nated from the diet. For individualswho cannot consume enough calcium-

rich foods, calcium supplements areneeded. Vitamin D is a major determinant

of intestinal calcium absorption andis required for normal bone metabo-lism. Subclinical vitamin D de ciencyis fairly common in certain subpopu-lations, such as medical inpatients(212,213) and homebound elderlyadults (214-217), and vitamin D in-suf ciency also is common amongyounger women and adolescents, par-ticularly during the winter months(218-220). The result of poor vitaminD status is poor intestinal calcium ab-sorption, secondary hyperparathy-roidism, accelerated bone loss, miner-alization defects, and increased riskfor fractures (215,216,221). The inci-dence of rickets, once believed to be very rare, is now on the rise (222-226).

Given inadequate vitamin D statusamong a high proportion of older in-dividuals, the most recent DRIs havesubstantially increased vitamin D re-quirements in those over age 50 years(210). There are few foods that arenaturally rich in vitamin D; therefore,

milk in the United States and Canadais forti ed with vitamin D to the levelof 2.5 g (100 IU) per serving. A cur-rent position statement on the man-agement of postmenopausal osteopo-rosis is now available (227). Insummary, osteoporosis is a largelypreventable disease. Although genet-ics play a large role in bone health,our skeleton responds (albeit silently)to the nutrients we consume, thephysical activities we participate in,the lifestyle we lead, and our hor-

ADA REPORTS



10/18

monal status. The dietetics practitio-ner should guide women of all ages onhow to modify these controllable riskfactors to improve the health of theirskeleton throughout life, from child-hood to late adulthood.

APPLICATIONS FOR DIETETICSPROFESSIONALS/CONCLUSIONSWomen are at unique risk for certainnutrition-related diseases and condi-tions. Moreover, women s health-re-lated issues are multifaceted. In addi-tion to racial and ethnic background,determinants such as level of educa-tion, socioeconomic status, health careaccess, employment, family responsi-bilities, household composition, and so-cial support may all affect women shealth care behaviors and beliefs. Fur-thermore, dietitians must consider theevolving in uence of media and tech-nology (228) on health care practices.By being familiar with credible Inter-

net sites, dietetics professionals can ap-propriately guide women in their use of health-related information. Figure 2provides a current listing of recom-mended Internet sites in the area of nutrition and women s health. A wom-an s community infrastructure mayalso affect opportunities for a healthylifestyle. Dietetics professionals canhelp promote healthful eating habits,which include helping women gain ac-cess to a wide variety of foods, as wellas increasing opportunities for in-

creased physical activity in schools, col-leges, places of employment, seniorcenters, and the communities at large.Given that nutrition can favorably in-uence a woman s health and decreasethe risk of chronic diseases, dieteticsprofessionals strongly support re-search, health promotion activities,health services, and advocacy effortsthat will enable women to adopt desir-able nutrition practices for optimalhealth.

References1. US Census Bureau, Current

Population Survey, March 2000. Available at: http://www.census.gov. Accessed March 24, 2004.

2. Statistics Canada. Available at:http://www.statcan.ca. AccessedMarch 24, 2004.

3. National Council on Interna-tional Health (now the GlobalHealth Council). 1099. Over-

view: Womens ReproductiveHealth Initiative. Available at:http://www.globalhealth.org. Ac-cessed March 24, 2004.

4. World Health Organization.1998. Mission statement. Wom-en s Health and DevelopmentProgramme. Available at: http:// www.who.org. Accessed March24, 2004.

5. Weisman CS. Changing de ni-tions of women s health: Impli-cations for health care and pol-

icy. Matern Child Health J .1997;3:179-189.

6. Strobino DM, Grason H, Minko- vitz C. Charting a course for thefuture of women s health in theUnited States: Concepts, nd-ings, and recommendations. Soc Sci Med . 2002;54:839-848.

7. Cowell C. Nutrition and wom-en s health: Challenge for the

21st century. JAMWA . 2001;56:73-74.8. Weitz T, Estes CL. Adding aging

and gender to the women shealth agenda. J Women Aging .2001;13:3-20.

9. US Bureau of the Census. Popu-lation Division (1999). UnitedStates Population Estimates by Age, Sex, Race, and Hispanic Or-igin, 1990 to 1997. Available at:http://www.census.gov/population/ estimates/nation. Accessed March24, 2004.

10. Satcher D. American womenand health disparities. JAMWA .2001;56:131-132.

11. Williams DR. Racial/ethnic varia-tions in women s health: The so-cial embeddedness of health. Am J Public Health . 2002;92:588-597.

12. The Of ce of Research on Wom-en s Health. Available at: http:// orwh.od.nih. Accessed March 23,2004.

13. Kim SK. Dietetics professionals

American Cancer Society: http://www.cancer.org American Diabetes Association: http://www.diabetes.org American Dietetic Association: http://www.eatright.org American Heart Association: http://www.americanheart.org American Institute of Cancer Research: http://www.aicr.org American Obesity Association: http://www.obesity.org

Canadian Diabetes Association: http://www.diabetes.caCanada Health Network: http://www.canadian-health-network.caCanadian Women Health Network: http://www.cwhn.caDietitians of Canada: http://www.dietitians.caInternational Osteoporosis Foundation: http://www.osteofound.orgNational Association of Anorexia Nervosa and Associated Disorders: http://www.anad.orgNational Eating Disorders Organization: http://www.nationaleatingdisorders.orgNational Institutes of Health: http://health.nih.gov/search.asp/29National Institutes of Health, Osteoporosis, and Related Bone Diseases, National Resource

Center: http://www.osteo.orgWomens Health Initiative and Ofce of Research on Womens Health:

http://www.4woman.gov/owhNational Osteoporosis Foundation: http://www.nof.orgOsteoporosis Society of Canada: http://www.osteoporosis.caWeight Control Network: http://www.niddk.nih.gov/health/nutrit/nutrit.htm

Figure 2. Recommended Internet sites in the area of nutrition and womens health.

ADA REPORTS



11/18

and women s health research atthe National Institute of Health. J Am Diet Assoc . 1998;98:133-136.

14. Centers of Excellence for Wom-en s Health. Available at: http:// www.4woman.gov/coe. Accessed

March 23, 2004.15. Centers of excellence for wom-en s health. Available at: http:// www.hc-sc.gc.ca/women. AccessedMarch 23, 2004.

16. Arab L, Carriquiry A, Steck-ScottS, Gaudet MM. Ethnic differencesin the nutrient intake adequacy of premenopausal United Stateswomen: Results from the ThirdNational Health ExaminationSurvey. J Am Diet Assoc . 2003;103:1008-1014.

17. Statistics Canada. Canada Com-

munity Health Survey. 2000/01.18. Chanmugam P, Guthrie JF, Ce-cilio S, Morton JF, Basiotis PP, Anand R. Did fat intake in theUnited States really decline be-tween 1989-1991 and 1994-1996? J Am Diet Assoc . 2003;103:867-872.

19. Flegal KM, Carroll MD, Kucz-marski RJ. Overweight and obe-sity trends in the United States:Prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord . 1998;22:39-47.

20. Byers T, Nestle M, McTiernan A, Doyle C, Currie-Williams A,Gansler T, Thun M. The Ameri-can Cancer Society 2001 Nutri-tion and Physical ActivityGuidelines Advisory Committee.CA Cancer J Clin . 2002;52:92-19.

21. National Health and NutritionExamination Survey. Table 68.In: Kramerow E, Lentzner H,Rooks R, Weeks J, Saydah S,eds. Health United States. 1999.With Health and Aging Chart-book. (PHS) 99-1232. Hyatts-

ville (MD): National Center forHealth Statistics; 1999.22. Kant AK. Consumption of en-

ergy dense, nutrient-poor foodsby adult Americans; nutritionaland health implications: Thethird National Health andNutrition Examination Survey,1988-1994. Am J Clin Nutr .2000;72:929-936.

23. Shields M. Long working hoursand health. Statistics Canada. Health Rep . 1999;11:33-48.

24. Clemens LH, Swanson DL, Kles-ges RC. The effect of eating-outon quality of diet in premeno-pausal women. J Am Diet Assoc .1999;99:442-444.

25. Overview of the time use of Ca-nadians in 1998. Statistics Can-ada. Ottawa; 1999. Catalogue12F0080-X1E.

26. Lin B-H, Frazao E. Away-from-home foods increasingly impor-tant to quality of American Diet.USDA, Agriculture InformationBulletin no. 749; January 1999.

27. Paeratakul S, Ferdinand DP,Champagne CM, Ryan DH,Bray GA. Fast-food consumptionamong US adults and children:Dietary and nutrient intake pro-le. J Am Diet Assoc . 2003;103:1332-1338.

28. Young LR, Nestle M. The contri-bution of expanding portion sizesto the US obesity epidemic. Am J Public Health . 2002;92:246-249.

29. Nestle M. Increasing portionsizes in American diets: Morecalories, more obesity. J Am Diet Assoc . 2003;103:39-40.

30. Nielsen SJ, Popkin BM. Pat-terns and trends in food portionsizes. 1977-1998. JAMA . 2003;289:450-453.

31. Smiciklas-Wright H, MitchellDC, Mickle SJ, Goldman JD,Cook A. Foods commonly eatenin the United States, 1989-1991and 1994-1996: Are portion sizeschanging? J Am Diet Assoc .2003;103:41-42.

32. Feskanich D, Willett WC, ColditzGA. Calcium, vitamin D, milkconsumption and hip fractures: Aprospective study among post-menopausal women. Am J Clin Nutr . 2003;77:504-511.

33. Holick MF. Too little vitamin Din premenopausal women. Whyshould we care? Am J Clin Nutr .2002;76:3-4.

34. Nesby-O Dell S, Scanlon KS, Cog-swell ME, Gillespie C, Hollis BW,Looker AC, Allen C, DoughertlyC, Gunter EW, Bowman BA. Hy-povitaminosis D prevalence anddeterminants among African American and white women of re-productive age: Third NationalHealth and Nutrition Examina-tion Survey 1988-1994. Am J Clin Nutr . 2002;76:187-192.

35. American Academy of Pediat-rics. Committee on Genetics. Fo-

lic acid for the prevention of neu-ral tube defects. Pediatrics .1999;104:325-327.

36. Food and Drug Administration.Food standards: amendments of standards of identity for en-riched grain products to require

addition of folic acid. Federal Register . 1996;61:8781-8797.37. Health Canada. Folic Acid. Pre-

conception Health and Folic Acid. 2002. ISBN 0-662-86854-4.

38. Ray JG, Meier C, VermeulenMJ, Boss S, Wyatt PR, ColeDEC. Association of neural tubedefects and folic acid food forti-cation in Canada. Lancet .2002;360:2047-2048.

39. Center for Disease Control. Useof folic acid-containing supple-ments among women of child-

bearing age United States 1997. MMWR . 1998;47:7.40. Troppmann L, Gray-Donald K,

Johns T. Supplement use: Isthere any nutritional bene t? J Am Diet Assoc . 2002;102:818-825.

41. The American Dietetic Associa-tion. Position of the AmericanDietetic Association: Nutritionand lifestyle for a healthy preg-nancy outcome. J Am Diet Assoc .2002;102:1479-1490.

42. Health Canada. Nutrition for a Healthy Pregnancy; NationalGuidelines for the Childbearing years. Ottawa: Minister of Pub-lic Works and Government Ser- vices Canada; 1999.

43. Preconception Health Folic Acidfor the Primay Prevention of Neu-ral Tube Defects A ResourceDocument for Health Profession-als, 2002(47). Available at: http:// www.hcsc.gc.ca/english/folicacid/ report/index.html. AccessedJanuary 27, 2004.

44. Hill JO, Melanson EL. Overviewof the determinants of adulthood

overweight and obesity: Currentevidence and research issues. Med Sci Sports Exerc . 1999;11(suppl):S547-S542.

45. French SA, Story M, Jeffery RW.Environmental in uences oneating and physical activity. Ann Rev Public Health . 2001;22:309-335.

46. Laberge S, Beaubreault D,Delisle S, Dugal S. Le point surlactivite physique des Que be-coises de 25 a 44 ans. 2000;

ADA REPORTS



12/18

Groupe de travail sur la prob-lematique des femmes et delactivite physique de Kino-Que -bec, Secre tariat au loisir et ausport, gouvernement du Que becISBN: 2-550-36715-4.

47. Canadian Fitness and Lifestyle

Research Institute. 2001 Physical Activity Monitor. Available at:http://www.c ri.ca/c ri/pa/surveys/2001survey. Accessed March24, 2004.

48. Segar M, Jayaratne T, Hanlon J,Richardson CR. Fitting tnessinto women s lives: Effects of agender-tailored physical activityintervention. Women s Health .2002;12:338-347.

49. Lowry R, Galuska DA, FultonJE, Wechsler H, Kann L. Weightmanagement goals and practices

among US high school students: Associations with physical activ-ity, diet, and smoking. J Adolesc Health . 2002;31:133-144.

50. American Lung Association.Women and Smoking Fact Sheet;2002.

51. American Cancer Society. Can-cer Facts and Figures 2004. At-lanta: ACS, 2004. Available at:http://www.cancer.org. AccessedMarch 24, 2004.

52. The American Dietetic Associa-tion. Position of the AmericanDietetic Association: Weightmanagement. J Am Diet Assoc .2002;102:1145-1155.

53. Kant AK. A prospective study of diet quality and mortality inwomen. JAMA . 2000;283:2109-2115.

54. McCullough ML, Feskanich D,Stampfer MJ, Giovannucci EL,Rimm EB, Hu FB, SpiegelmanD, Hunter DJ, Colditz CA, Wil-lett WC. Diet quality and majorchronic disease risk in men andwomen: Moving toward im-proved dietary guidance. Am J

Clin Nutr . 2002;76:1261-1271.55. McCullough ML, Keskanisch D,Stampfer MJ, Rosner BA, HuFB, Hunter DJ, Variyam JN,Colditz GA, Willett WC. Adher-ence to the Dietary Guidelinesfor Americans and risk of majorchronic disease in women. Am J Clin Nutr . 2000;72:1214-1222.

56. US Department of Agriculture, Agricultural Research Service.2003. USDA National NutrientDatabase for Standard Refer-

ence, Release 16. Nutrient DataLaboratory Home Page. Avail-able at: http://www.nal.usda.gov/ fnic/foodcomp. Accessed March24, 2004.

57. Riechman SE, Schoen RE,Weissfeld JL, Thaete FL, Kriska AM. Association of physical ac-tivity and visceral adipose tissuein older women and men. Obes Res . 2002;10:1065-1073.

58. Canada s Physical ActivityGuide to Healthy Active Living. Available at: http://www.hc-sc.gc.ca/hppb/paguide/index.html. Accessed March 24, 2004.

59. Must A, Spadano J, Coakley EH,Field AE, Colditz G, Dietz WH.The disease burden associatedwith overweight and obesity. JAMA . 1999;282:1523-1529.

60. American Obesity Association. Available at: www.obesity.org. Accessed March 24, 2004.

61. Flegal KM, Carroll MD, Kucz-marski RJ, Johnson CL. Preva-lence and trends in obesityamong US adults, 1999-2000. JAMA . 2002;288:1723-1777.

62. Kannel WB, Wilson PW, NamBH, D Agostino RB. Risk strati-cation of obesity as a coronaryrisk factor. Am J Cardiol . 2002;90:697-701.

63. Felber JP, Golay A. Pathways

from obesity to diabetes. Int J Obes Metab Disord . 2002;26(suppl 2):S39-S45.

64. World Cancer Research Fund/ American Institute for CancerResearch. Food, Nutrition andthe Prevention of Cancer: AGlobal Perspective. Washington,DC: American Institute for Can-cer Research; 1997.

65. National Institutes of Health.Clinical guidelines on the iden-ti cation, evaluation, and treat-ment of overweight and obesity

in adults. The Evidence Report.NIH Publication No. 98-4083,1998.

66. Health Canada. Of ce of Nutri-tion Policy and Promotion. Ca-nadian Guidelines for BodyWeight Classi cation in Adults2003. Available at: http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/ cg_bwc_introduction_e.html. Ac-cessed March 15, 2004.

67. Wardle J, Waller J, Fox E. Ageof onset and body dissatisfaction

in obesity. Addict Behav . 2002;27:561-573.

68. National Task Force on the Pre- vention and Treatment of Obe-sity. Dieting and the develop-ment of eating disorders inoverweight and obese adults. Arch Intern Med . 2000;160:2581-2589.

69. Ackard DM, Croll JK, Kearney-Cooke A. Dieting frequencyamong college females: Associa-tion with disordered eating,body image, and related psycho-logical problems. J Psychosom Res . 2002;52:129-136.

70. Stewart TM, Williamson DA,White MA. Rigid vs. exible di-eting: Association with eatingdisorder symptoms in nonobesewomen. Appetite . 2002;38:39-44.

71. Bosello O, Zamboni M. Visceralobesity and metabolic syndrome.Obes Res . 2000;1:47-56.

72. Jakicic JM, Wing RR, Wingers-Hart C. Relationship of physicalactivity to eating behaviorsand weight loss in women. Med Sci Sports Exerc . 2002;34:1653-1659.

73. Patrick L. Eating disorders: Areview of the literature with em-phasis on medical complicationsand clinical nutrition. Altern Med Rev . 2002;7:184-202.

74. American Dietetic Association.Position of the American Die-tetic Association: Nutrition in-tervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders nototherwise speci ed (EDNOS). J Am Diet Assoc . 2001;101:810-819.

75. Kotler LA, Cohen P, Davies M,Pine DS, Walsh BT. Longitudinalrelationships between childhood,adolescent, and adult eating dis-orders. J Am Acad Child Adolesc Psychiatry . 2001;40:1434-1440.

76. Franko DL, Blais MA, Becker AE, Delinsky SS, GreenwoodDN, Flores AT, Ekeblad ER,Eddy KT, Herzog DB. Preg-nancy complications and neona-tal outcomes in women with eat-ing disorders. Am J Psychiatry .2001;158:1461-1466.

77. Franko DL, Spurrell EB. Detec-tion and management of eatingdisorders during pregnancy. Ob-stet Gynecol . 2000;95:942-946.

78. Kazis K, Iglesias E. The female

ADA REPORTS



13/18

athlete triad. Adolesc Med .2003;14:87-95.

79. Beals KA, Manore MM. Disor-ders of the female athlete triadamong collegiate athletes. Int J Sport Nutr Exerc Metab . 2002;12:281-293.

80. Fairburn CG, Harrison PJ. Eat-ing disorders. Lancet . 2003;361:407-416.

81. Steiner-Adair C, Sjostrom L,Franko DL, Pai S, Tucker R,Becker AE, Herzog DB. Primaryprevention of risk factors for eat-ing disorders in adolescent girls:Learning from practice. Int J Eat Disord . 2002;32:401-411.

82. Pearson J, Goldklang D, Strie-gel-Moore RH. Prevention of eating disorders: Challengesand opportunities. Int J Eat Dis-

ord . 2002;31:233-239.83. Whisenant SL, Smith BA. Eat-ing disorders: Current nutritiontherapy and perceived needs indietetics education and re-search. J Am Diet Assoc . 1995;95:1109-1112.

84. Parham ES. Promoting bodysize acceptance in weight man-agement counseling. J Am Diet Assoc . 1999;99:920-925.

85. Looker AC, Dallman PR, CarrollMD, Gunter EW, Johnson CL.Prevalence of iron de ciency inthe United States. JAMA . 1997;277:973-976.

86. Brutsaert TD, Hernandez-Cord-ero S, Rivera J, Viola T, HughesG, Haas JD. Iron supplementa-tion improves progressive fatigueresistance during dynamic kneeextensor exercise in iron depletednonanemic women. Am J Clin Nutr . 2003;77:441-448.

87. Verdon F, Burnand B, FalladStubi C-L, Bonard C, Graff M,Michaud A, Bischoff T, de VeveyM, Studer J-P, Herzig L,Chapuis C, Tissot J, Pecoud A,

Favrat B. Iron supplementationfor unexplained fatigue in non-aneamic women: double blindrandomised placebo controlledtrial. BMJ . 2003;326:1124-1128.

88. Frith-Terhune AL, CogswellME, Khan LK, Will JC, Ra-makrishnan U. Iron de ciencyanemia: Higher prevalence inMexican American than innonhispanic white females inthe third National Health andNutrition Examination Survey

1988-1994. Am J Clin Nutr .2000;72:963-968.

89. Cohen LS, Soares CN, Otto MW,Sweeney BH, Liberman RF, Har-low BL. Prevalence and predic-tors of presbyte ral dysphoricdiscorder (PMDD) in older pre-

menopausal women. The Har- vard study of moods and cycles. J Affect Disord . 2002;70:125-132.

90. Hallbreich U, Borenstein J,Pearlstein T, Khan LS. Theprevalence, impairment, impact,and burden of premenstrualdysphoric disorder (PMS/PMDD). Psychoneuroendocrinology . 2003;28(suppl 3):1-13.

91. Thys-Jacobs S. Micronutrientsand the premenstrual syndrome.The case for calcium. J Am Coll Nutr . 2000;19:220-227.

92. Ward MW, Holimon TD. Cal-cium treatment for premenstrualsyndrome. Ann Pharmacother .1999;33:1356-1358.

93. Wyatt KM, Dimmock PW, JonesPW, Shaughn O Brien PM. Ef -cacy of vitamin B6 in the treat-ment of premenstrual syndrome;systematic review. BMJ . 1999;318:1375-1381.

94. Bendich A. The potential for di-etary supplements to reducepremenstrual syndrome (PMS)symptoms. J Am Coll Nutr .2002;19:3-12.

95. Marshall K. Polycystic ovarysyndrome: Clinical consider-ations. Altern Med Rev . 2001;6:272-292.

96. Norman RJ, Davies MJ, Lord J,Moran LJ. The role of lifestylemodi cation in polycystic ovarysyndrome. Trends Endocrinol Metabol . 2002;13:251-257.

97. Gambineri A, Pelusi C, Vicen-nati V, Pagotto U, Pasquali R.Obesity and polycystic ovarysyndrome. Int J Obes Relat Metab Disord . 2002;26:883-896.

98. Kiddy DS, Hamilton-Fairley D,Bush A. Improvement in endo-crine and ovarian function dur-ing dietary treatment of obesewomen with polycystic ovarysyndrome. Clin Endocrinol . 1992;36:105-111.

99. Wang JX, Davies M, NormanRJ. Body mass and probabilityof pregnancy during assisted re-production treatment: A retro-spective study. BMJ . 2000;321:1320-1321.

100. Bennett M. Vitamin B12 de -ciency, infertility and recurrentfetal loss. J Reprod Med . 2001;46:209-212.

101. Matthews KA, Abrams B, Craw-ford S, Miles T, Neer R, PowellLH, Wesley D. Body mass indexin mid-life women: Relative in-uence of menopause, hormoneuse and ethnicity. Int J Obes Re-lat Metab Disord . 2001;25:863-873.

102. MacDonald HM, New SA,Campbell MK, Reid DM. Longi-tudinal changes in weight inperimenopausal and early post-menopausal women: Effects of dietary energy intake, energyexpectorer, dietary calcium in-take and hormone replacementtherapy. Int J Obes Relat Metab Disord . 2003;27:669-676.103. Kuller LH, Simkin-SilvermanLR, Wing RR, Meilahn EN, IvesDG. Women s Healthy LifestyleProject: A randomized clinicaltrial-results after 54 months.Circulation . 2001;103:32-37.

104. Hlatky MA, Boothroyd D, Vit-tinghoff E, Sharp P, WhooleyMA. Quality of life and depres-sive symptoms in postmeno-pausal women after receivinghormone therapy: Results fromthe Heart and estrogen/proges-

tin replacement study (HERS)trial. JAMA . 2002;287:591-597.105. Nelson HD. Assessing bene ts

and harms of hormone replace-ment therapy. JAMA . 2002;288:882-884.

106. Women s health at Stanford.Writing group for the Women sHealth Initiative Investigators.Risks and bene ts of estrogenplus progestin in healthy post-menopausal women. JAMA . 2002;288:321-333.

107. Gold EB, Sternfeld B, Kelsey

JK, Brown C, Mouton C, ReameN, Salamone L, Stellato R. Rela-tion of demograhic and lifestylefactors to symptoms in a multi-racial/ethnic population of women40-55 years of age. Am J Epide-miol . 2000;152:364-473.

108. Huang MH, Schocken M, BlockG, Sowers MF, Gold E, SternfelB, Seeman T, Greendale G. Variation in nutrient intakes byethnicity: Results from thestudy of Women s Health across

ADA REPORTS



14/18

the Nation (SWAN). Menopause .2002;9:309-319.

109. Faure ED, Chantre P, Mares P.Effects of a standardized soy ex-tract on hot ushes: A multi-center, double-blind random-ized, placebo-controlled study. Menopause . 2003;9:329-334.110. Burke GL, Legault C, AnthonyM, Bland DR, Morgan TM,Naughton MJ, Leggett K, Wash-burn SA, Vitolins MZ. Soy pro-te ine and iso avone effects on vasomotor symptoms in peri-and postmenopausal women:The Soy Estrogen AlternativeStudy. Menopause . 2003;10:147-153.

111. Lucas EA, Wild RD, HammondLJ, Khalil DA, Juma S, DaggyBP, Stoecker BJ, Arjmandi BH.

Flaxseed improves lipid pro lewithout altering biomarkers of bone metabolism in postmeno-pausal women. J Clin Endocri-nol Metab . 2002;87:1527-1532.

112. Lemay A, Dodin S, Kadri N,Jacques H, Forest JC. Flaxseeddietary supplement vs hormonereplacement therapy in hypercho-lesterolemic menopausal women.Obstet Gynecol . 2002;100:495-504.

113. Kam IW, Dennehy CE, Tsourou-nis C. Dietary supplement useamong menopausal women at-tending a San Francisco healthconference. Menopause . 2002;9:72-78.

114. Solomon PR, Adams F, Silver A,Zimmer J, Deveaux R. Ginkgofor memory enhancements: Arandomized controlled trial. JAMA . 2002;288:835-840.

115. Health Canada: Natural HealthProducts Directorate. Regula-tions. Canada Gazette Part II, vol 137, no.13, 2003. Availableat: www.hc-sc.gc.ca/hpfb-dgpsa/ regs-cg2.pdf. Accessed March

15, 2004116. American Dietetic Association.Position of the American Die-tetic Association: Food forti ca-tion and dietary supplements. J Am Diet Assoc . 2001;101:115-125.

117. Shatenstein B, Nadon S, Fer-land G. Diet quality amongolder Quebecers as assessed bysimple indicators. Can J Diet Pract Res . 2003;64:174-180.

118. Keller HH, McKenzie JD. Nutri-

tional Risk in vulnerable com-munity-living seniors. Can J Diet Pract Res . 2003;64:195-201.

119. Hughes VA, Frontera WR,Roubenoff R, Evans WJ, SinghMA. Longitudinal changes inbody composition in older men

and women: Role of body weightchange and physical activity. Am J Clin Nutr . 2002;76:473-481.

120. Ervin B, Kennedy-StephensonJ. Calcium, iron and zinc in-takes of elderly supplementand non supplement users inNHANES III. J Am Diet Assoc.2002;102(suppl):A73

121. Ervin RB, Kennedy-StephensonJ. Mineral intakes of elderlyadult supplement and non-sup-plement uses in the Third Na-tional Health and Nutrition Ex-

amination Survey. J Nutr . 2002;132:3422-3427.122. Vitolins MZ, Quandt SA, Case

LD, Bell RA, Arcury TA, Mc-Donald J. Vitamin and mineralsupplement use by older ruralaldults. J Gerontol A Biol Sci Med Sci . 2000;55:M613-M617.

123. Center for Disease Control (2002).National Diabetes Fact Sheet. Available at: http://www.cdc.gov/diabetes/pubs/factsheets.htm. Accessed March 15, 2004.

124. Murphy SL. Deaths: Final datafor 1998. Natl Vital Stat Rep .2000;48:1-105.

125. National Center for HealthStatistics, US mortality publicuse data tapes, 1960-1997, USmortality volumes, 1930-1959.Hyattsville (MD): US Depart-ment of Health and HumanServices; 2000. In: AmericanCancer Society facts and g-ures 2001. Atlanta: The soci-ety.

126. National Osteoporosis Founda-tion. Osteoporosis, Disease Sta-tistics 2002. Available at: http://

www.nof.org. Accessed May 1,2004.127. Kramerow E, Lentzner H, Rooks

R, Weeks J, Saydah S. NationalHealth and Nutrition Examina-tion Survey. Table 68. In:Health United States. 1999.With Health and Aging Chart-book, (PHS) 99-1232. Hyatts- ville (MD): National Center forHealth Statistics; 1999.

128. Health Canada. Diabetes inCanada: National Statistics and

Opportunities for Improved Sur- veillance, Prevention and Con-trol; 1999.

129. Skyler JS, Oddo C. Diabetestrends in the USA. Diabetes Metab Res Rev . 2002;18(suppl3):S21-S26.

130. Choi BC, Shi F. Risk factor fordiabetes mellitus by age andsex: results of the National Pop-ulation Health Survey. Diabeto-logia . 2001;44:1221-1231.

131. The American Diabetes Associa-tion. Diagnosis and classi ca-tion of diabetes mellitus. Diabe-tes Care . 2004;27(suppl 1):S5-S10.

132. Canadian Diabetes Association.Guidelines for the nutritionalmanagement of diabetes melli-tus in the new millennium. Can

J Diabetes Care . 2003;23:56-69.133. Mokdad AH, Ford ES, BowmanBA, Nelson DE, Engelgau MM, Vinicor F, Mark JS. Diabetestrends in the US: 1990-1998. Di-abetes Care . 2000;23:1278-1283.

134. Kieffer EC,CarmanWJ,GillespieBW, Nolan GH, Worley SE, Guz-man JR. Obesity and gestationaldiabetes among African-Ameri-can women and Latinas in De-troit: Implications for disparitiesin women s health. JAMWA .2001;56:181-187.

135. Carpenter MW, Coustan DR.Criteria for screening tests forgestational diabetes. Am J Ob-stet Gynecol . 1982;144:768-773.

136. Ferrara A, Hedderson MM,Quesenberry CP, Selby JV.Prevalence of gestational diabe-tes mellitus detected by the na-tional diabetes data group or theCarpenter and Coustan plasmaglucose thresholds. Diabetes Care .2002;25:1625-1630.

137. Willett W, Manson J, Liu S. Gly-cemic index, glycemic load, andrisk of type 2 diabetes. Am J

Clin Nutr . 2002;76:274 S-280S.138. Liu S, Manson JE, StampferMJ. A prospective study of whole-grain intake and risk of type 2 diabetes mellitus in USwomen. Am J Public Health .2000;90:1409-1415.

139. McKeown NM, Meigs JB, Liu S,Wilson PW, Jacques PF. Whole-grain intake is favorably associ-ated with metabolic risk factorsfor type 2 diabetes and cardiovas-cular disease in the Framingham

ADA REPORTS



15/18

Offspring Study. Am J Clin Nutr .2002;76:390-398.

140. American Diabetes Association.Nutrition principles and recom-mendations in diabetes. Diabe-tes Care . 2004;27(suppl 1):S36-S46.

141. Brand-Miller JC, Thomas M,Swan V, Ahmad ZI, Petocz P,Colagiuri S. Physiological vali-dation of the concept of glycemicload in lean young adults. J Nutr . 2003;133:2728-2732.

142. Leonetti G, Lonati L, Cuspidi C.Hypertension and diabetes inwomen. J Hypertens . 2002;20(suppl 2):S23-S25.

143. Dubbert PM, Carithers T, Sum-ner AE, Barbour KA, Clark BL,Hall JE, Crook ED. Obesity,physical inactivity, and risk for

cardiovascular disease. Am J Med Sci . 2002;324:116-126.144. Nelson KM, Reiber G, Boyko EJ.

Diet and exercise among adultswith type 2 diabetes: Findingsform the third national healthand nutrition examination survey (NHANES III). DiabetesCare . 2002;25:1722-1728.

145. Adler A. Obesity and target or-gan damage: diabetes. Int J Obes Relat Metab Disord . 2002;26(suppl 4):S11-S14.

146. Liebl A. Challenges in optimalmetabolic control of diabetes. Diabetes Metab Res Rev . 2002;18(suppl 3):S36-S41.

147. Pasanisi F, Contaldo F, de Si-mone G, Mancini M. Bene ts of sustained moderate weight lossin obesity. Nutr Metab Cardio-vasc Dis . 2001;11:401-406.

148. Herpertz S, Albus C, KielmannR, Hagemann-Patt H, LichtblauK, Kohle K, Mann K, Senf W.Comorbidity of diabetes mellitusand eating disorders: A fol-low-up study. J Psychosom Res .2001;51:673-678.

149. Rodin G, Olmsted M, Rydall A,Maharaj S, Colton P, Jones J,Biancucci L, Daneman D. Eat-ing disorders in young womenwith type 1 diabetes mellitus. J Psychosom Res . 2002;53:943-949.

150. Bryden KS, Neil A, Mayou RA,Peveler RC, Fairburn CG,Dunger DB. Eating habits, bodyweight, and insulin misuse. Alongitudinal study of teenagersand young adults with type 1

diabetes. Diabetes Care . 1999;22:1956-1960.

151. Nielsen S, Emborg C, Molbak AG. Mortality in concurrenttype 1 diabetes and anorexianervosa. Diabetes Care . 2002;35:309-312.

152. Diabetes Prevention ProgramResearch Group. Reduction inthe incidence of type 2 diabeteswith lifestyle intervention ormetformin. N Engl J Med . 2002;346:393-403.

153. Benedict M. Making a differencewith MNT and diabetes. Oppor-tunity is knocking. Health Care Food Nutr Focus . 2001;17:10-12.

154. American Heart Association.2002 Heart and Stroke Statisti-cal Update. Dallas, Texas: AHA;2001.

155. Heart and Stroke Foundation of Canada, 2002. Women section. Available at: Heart and StrokeFoundation of Canada. Heart Dis-ease information Incidence of car-diovascular disease 2003. Avail-able at: http://ww2.heartandstroke.com. Accessed March 15, 2004.

156. Solomon CG, Dluhy RG. Re-thinking postmenopausal hor-mone therapy. N Engl J Med .2003;348:579-580.

157. Blakeley JA. The heart and es-trogen/progestin replacementstudy revisited. Hormone re-placement therapy produced netharm consistent with the obser- vational data. Arch Intern Med .2000;160:2897-2900.

158. Lemaitre RN, Heckbert SR,Psaty BM, Smith NL, KaplanRC, Longstreth WT Jr. Hor-mone replacement therapy andassociated risk of stroke in post-menopausal women. Arch Intern Med . 2002;162:1954-1960.

159. Waters DD, Alderman EL, HsiaJ, Howard BV, Cobb FR, RogersWJ, Ouyang P, Thompson P,

Tardif JC, Higginson L, Bittner V, Steffes M, Gordon DJ, Pros-chan M, Younes N, Verter JI.Effects of hormone replacementtherapy and antioxidant vita-min supplements an coronaryatherosclerosis in postmeno-pausal women; a randomizedcontrolled trial. JAMA . 2002;288:2432-2440.

160. Viscoli CM, Brass LM, KernanWN, Sarrel PM, Suissa S, Hor-witz RI. A clinical trial of estro-

gen-replacement therapy afterischemic stroke. N Engl J Med .2001;345:1243-1249.

161. Blake JM, Collins JA, Reid RL,Fedorkow DM, Lalonde AB. TheSOGC statement on the WHI re-port on estrogen and progestin

use in postmenopausal women. J Obstet Gynaecol Can . 2002;24:783-787.

162. Writing group for the Women sHealth Initiative Investigators.Risks and bene ts of estrogenplus progestin in healthy post-menopausal women. Principal re-sults from the Women s HealthInitiative randomized controlledtrial. JAMA . 2002;288:321-333.

163. Hulley S, Grady D, Bush T, Furb-erg C, Herrington D, Riggs B, Vit-tinghoff E. Randomized trial of

oestrogen plus progestin for sec-ondary prevention of coronaryheart disease in postmenopausalwomen. JAMA . 1998;280:605-613.

164. Grady D. Cardiovascular dis-ease outcomes during 6.8 yearsof hormone therapy: Heart andestrogen/progestin replacementstudy follow up (HERS 11). JAMA . 2002;288:49-57.

165. NAMS report. Amended reportfrom the NAMS Advisory Panelon Postmenopausal HormoneTherapy. Menopause. 2003;10:6-12.

166. The SOGC statement of theWHI report on estrogen and pro-gesting use in postmenopausalwomen. J Obstet Gynaecol Can.2002;24:783-787.

167. Kris-Etherton P, Daniels SR,Eckel RH, Engler M, HowardBV, Krauss RM, Lichtenstein AH, Sacks F, St. Jeor S,Stampfer M. Summary of thescienti c conference on dietaryfatty acids and cardiovascularhealth. Conference summary

from the Nutrition committee of the American Heart Associa-tion. Circulation . 2001;103:1034-1039.

168. Kris-Etherton PM, Harris WS, Appel LJ. American Heart Asso-ciation. Nutrition Committee.Fishconsumption, shoil,omega-3 fatty acids, and cardiovasculardisease. Circulation . 2002;106:2747-2757.

169. Hu FB, Bronner L, Willett WC,Stampfer MJ, Rexrode KM, Al-

ADA REPORTS



16/18

bert CM, Hunter D, Manson JE.Fish and omega-3 fatty acids in-take and risk of coronary heartdisease in women. JAMA . 2002;287:1815-1821.

170. GISSI-Prevenzione Investigators.Dietary supplementation with

n-3 polyunsaturated fatty acidsand vitamin E after myocardialinfarction; results of the GISS-Prevenzione trial. Lancet . 2000;354:447-455.

171. de Lorgeril M, Salen P, MartinJL, Monjaud I, Delaye J, Ma-melle N. Mediterranean diet,traditional risk factors and therate of cardiovascular complica-tions after myocardial infarc-tion. Final report of the LyonDiet Heart Study. Circulation .1999;99:779-785.

172. Loria CM, Ingram DD, FeldmanJJ, Wright JD, Madans JH. Se-rum folate and cardiovasculardisease mortality among USmen and women. Arch Intern Med . 2000;160:3258-3262.

173. Appel LJ, Miller ER, Jee SH,Stolzenberg-Solomon R, Lin PH,Erlinger T, Nadeau M, Selhub J.Effect of dietary patterns on se-rum homocysteine. Results of arandomized controlled feedingtrial. Circulation . 2000;102:852.

174. Riddell LJ, Chisholm A, Wil-liams S, Mann JI. Dietary strat-egies for lowering homocysteineconcentrations. Am J Clin Nutr .2000;71:1448-1454.

175. Schnyder G, Rof M, Flammer Y,Pin R, Hess OM. Effect of homo-cysteine-lowering therapy withfolic acid, vitamin B12 and vita-min B6 on clinical outcome afterpercuteneous coronary interven-tion. JAMA . 2002;288:973-979.

176. Venn BJ, Mann JI, WilliamsSM,

66--nutricao e saude da mulher

Documents