Epidemiologic studies provide compelling evidence that the dietary and physical activity choices made on a day-to-day basis have cumulative effects on health.1–4 Therefore, the consistent food and exercise patterns adopted early in young adulthood, critically impact health in later years. Currently, 4 of the 10 leading causes of death in the United States are linked to poor diet and physical inactivity and include cardiovascular disease (CVD), type 2 diabetes, certain cancers, and stroke.5 Energy imbalance (more calories consumed than expended) is the primary factor contributing to the public health priorities of the overweight and obese. Overweight and obese individuals are at increased risk for developing several chronic diseases.1,2,6,7
As part of a national campaign by the U.S. government to provide evidence-based recommendations to promote health and reduce the risk of chronic disease through diet and physical activity, the Dietary Guidelines for Americans was created and published in 1980.5 Since then, updated releases have been generated every 5 years. Dietary Guidelines is based on the analysis of current scientific information by the Dietary Guidelines Advisory Committee appointed by the Secretaries of Health and Human Services and the U.S. Department of Agriculture (USDA).5,8 The Dietary Guidelines condenses knowledge about key nutrients, food components, and physical activity into general recommendations for the public that are clustered under the unified focus areas: adequate nutrients within calorie needs, weight management, physical activity, food groups, fats, carbohydrates, sodium and potassium, alcoholic beverages, and food safety.5 The 2005 Dietary Guidelines document was available for the current study. Two specific eating patterns are promoted within the 2005Dietary Guidelines as exemplars of the general recommendations: the USDA Food Guide (MyPyramid) and the Dietary Approaches to Stop Hypertension (DASH) Eating Plan.9,10 In 2010, the Dietary Guidelines were updated and MyPyramid was replaced by MyPlate. The collective recommendations encourage Americans to consume fewer calories, increase activity levels, and select healthier foods.
Notwithstanding this well-intentioned, nationwide initiative promoting lifestyle changes, studies have reported poor adherence to the recommendations made by the Dietary Guidelines.11 In order for these guidelines to be more effective, they must be communicated in consistent, novel ways that consider the unique needs of subgroups, such as young adults. Therefore, expanding the research base for the Dietary Guidelines to include studies on diet and exercise patterns in the young adult sector is valuable for informing future updates and improving messaging strategies.12 Interestingly, diet and exercise patterns have been studied less in this subgroup than in others.13 Delivering a clear, consistent message concerning health risks associated with poor diet and exercise to young adults may increase the likelihood that habits will be embraced early and improve long-term health. Promoting lifestyle choices that contribute to healthy aging is significant because life expectancy continues to increase for the total U.S. population.14 Nurse practitioners (NPs) in primary care practices, hospitals, community clinics, university and college clinics, and public health departments are in a prime position to disseminate these life-changing messages to young adults wherein chronic disease prevention is paramount.
The purpose of this study was to evaluate the dietary and physical activity choices of a sample of young adults from Ohio State university community using the two exemplar eating patterns contained within the 2005Dietary Guidelines, DASH Eating Plan, and MyPyramid as the standard references. The 2005 edition of the Guidelines was available to the U.S. public when the study participants were recruited.
The current study is a secondary analysis of data derived from two randomized, double-blind, experimental studies conducted at the Clinical Research Center at The Ohio State University. Both studies evaluated the effects of a nutritional supplement on the healing of acute blister wounds, which were created on the forearms of healthy, young adult participants.15,16 Exclusion criteria included vitamin, mineral, or other nutritional supplement use within 3 months of study entry. The parent studies were approved by an Institutional Review Board and conducted in compliance with the ethical rules for human experimentation stated in the 1975 Declaration of Helsinki. The current study analyzed demographic, nutritional, physical activity, and body composition data that were collected when participants entered the studies (see Characteristics of the study sample).
The nutritional data used in the current study were generated from electronic food frequency questionnaires (FFQs) that were completed at baseline by the study participants. The VioFFQ software is designed to elicit information about micro- and macronutrient intake during the 3 months prior to completing the questionnaire.17
Data from the two studies discussed below, collected from 60 healthy adults between the ages of 18 and 45 were used for the analysis in the current study. Complete data from 40 participants (20 men and 20 women) were obtained from the first study that took place during 2005–2006 and from a total of 20 participants (10 men and 10 women) from the second study that occurred from 2008–2009.15,18
Before conducting the study, a power analysis determined that 85 subjects would be necessary to obtain 80% power to detect a correlation of 0.266 at an alpha level of 0.05 among select nutrients, physical activity, and body composition. Since there were data from only 60 subjects, the power to detect a correlation of 0.266 at an alpha level of 0.05 was reduced to 67%.
Height, weight, body mass index (BMI), waist-to-hip ratio (WHR), and sagittal abdominal diameter (SAD) were calculated. Height was measured using the Harpenden Stadiometer (Holtain Limited, Crymych, Dyfed, United Kingdom) to the nearest 0.1 cm. Body weight was measured using the ProPlus Scale to the nearest 0.1 kg. BMI was calculated as body weight (kg) divided by height (m) squared. Waist and hip circumference was measured in a standing position using the Gulick tape measure. SAD was measured using the Holtain-Kahn Abdominal Caliper.
Participants also completed a health and lifestyle questionnaire wherein they self-reported levels of education, income, alcohol consumption, and physical activity.
The VioFFQ software tool17 was used to collect the data on dietary behavior and food-use patterns, and to estimate nutrient intake, which is based on the FFQ used and validated for the Women's Health Initiative.19 The dietary analysis utilized the food and nutrient information from the Nutrition Coordinating Center (NCC) Food and Nutrient Database developed and maintained by the NCC, located at the University of Minnesota Division of Epidemiology and Community Health in Minneapolis.
Descriptive statistics, including mean, standard deviation, and range, were used to characterize demographic, nutrient, body composition, and physical activity data. t-Tests were used to determine differences between males and females in select nutrients, BMI, SAD, WHR, and activity levels. Pearson correlation (Pearson r) and Kendall's Tau B were used to describe the linear relationship between select nutrients, BMI, SAD, WHRs, and activity levels. Statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, IL). Significance levels were set a priori at alpha ≤0.05.
Data regarding nutritional intake, body composition, physical activity, and other health-related behaviors were collected from 60 White, Black, Asian, and Indian male or female adults between 18 and 45 years of age. Fifty percent of the sample were male, 5% were Black, and approximately 12% were Asian. The mean age was 25.52 years (SD = 6.33). Approximately 98% of participants self-reported an education level of greater than 12 years. There were no current smokers, but 13% described themselves as former smokers. Thirty-three percent of the sample reported a mean annual income of less than $10,000, while nearly 30% reported an annual income of more than $45,000.
Americans often consume more calories than necessary for daily metabolic requirements, but the recommended levels of key nutrients are not always present in the food choices that supply those calories.5 In this study sample, the average daily levels of six of the seven nutrients of special concern identified in the Dietary Guidelines (calcium, potassium, fiber, magnesium, vitamin A, C, and E) were lower than recommended by either of the exemplar eating plans at the 2,000-calorie level (see Comparison of select nutrients consumed per day). For example, the mean daily intake of potassium for the group was only 3,102 mg (SD = 1,202.58), which was well below advised levels in the DASH (4,704 mg) plan and the USDA MyPyramid (4,044 mg). There were no significant differences between men and women in regard to the nutrients of special concern.
Twenty percent of the sample's body measurements were classified as being obese (BMI over 30), 28% were considered overweight (BMI of 25 to 29.9), and 50% had a BMI of 18.5 to 24.9. The BMI for men (M = 26.59, SD = 6.60) was slightly higher than for women (M = 24.97, SD = 5.06). Although there were no significant differences in BMI or SAD between genders, the data did show a significant effect for gender and WHR, t(58) = 2.65, p = 0.011, with men (0.89) having higher WHRs than women (0.83).
Pearson's correlation was used to determine if relationships existed between body measurements, physical activity, and select nutrients. The WHR and fat intake variables were strongly correlated, r(58) = 0.32, p = 0.01 as were WHR and cholesterol consumption, r(58) = 0.36, p = 0.004. These linear relationships indicated that rising WHR values were associated with increasing intake levels of fat and cholesterol. The BMI and SAD variables were inversely related to physical activity, r(53) = -0.28, p = 0.04; r(53) = -0.35, p = 0.009, respectively. Rising BMI and SAD measurements were correlated with decreasing physical activity levels.
To reduce the risk of chronic diseases the 2005 Dietary Guidelines recommended moderate intensity physical activity for 30 minutes or more per day on most days of the week.5 Only 45% of the sample reported engaging in this level of activity. NPs should also encourage patients to consider their intake of several specific food groups. Whole-grain products and fat-free or low-fat milk or equivalent milk products are strongly encouraged in the Dietary Guidelines because they are valuable to a healthy diet and excellent sources of the nutrients of special concern.
Fruits and vegetables
The current study sample self-reported consuming, on average, only 1 cup (SD = 1.69) of fruit per day, which is below the 2 to 2 1/2 cups (4 to 5 servings) recommended by the MyPyramid and the DASH Eating Plans (see Sample's intake by food groups). Similarly, the average daily amount of vegetables consumed was only 1 1/2 cups (SD = 2.45), which is also less than the recommended 2 to 2 1/2 cups. Additionally, 1.71 daily servings of whole grains did not meet the intake goal of 3 servings and 1.41 cups/day of low fat dairy products (1.29 cups were from full fat sources) were below the advised 2 to 3 cups.
The study sample's average total fat intake per day of 83.20 g (SD = 43.71) exceeded the recommended 48 g/day (DASH) or 65 g/day (MyPyramid). The mean levels of saturated fat (M = 29.01, SD = 14.70) and cholesterol (M = 299.26, SD = 186.87) were higher than advised (10 or 17 g/day; 136 or 230 g/day, respectively).
Carbohydrate consumption averaged 267.14 g/day (SD = 89.99) for the study sample, which is slightly below recommended levels. However, not all carbohydrates are alike and must be chosen carefully if the goal is to utilize those with greater health benefits. Fruits, vegetables, grains, and milk are good sources of healthy carbohydrates that provide energy and important nutrients, while added sugars are carbohydrates that have scant nutritional value. The young adults included in the sample consumed an average of 15 teaspoons (SD = 8.11, range = 3.22 to 43.70) of added sugars daily, which exceeded limits for discretionary calories (6 to 9 teaspoons) for the 2,000-calorie level as suggested by the Dietary Guidelines. Conversely, the average daily fiber intake of 20.70 g (SD = 9.38) did not achieve intake goals of 31 g/day.
On average, the sample's sodium intake (M = 3,872.74, SD = 1,719.92) surpassed advised levels in the DASH (2,329 mg/day) and the MyPyramid eating plans (1,779 mg/day).
Both men and women in the study sample drank less than 1 alcoholic beverage per day. The Dietary Guidelines advises drinking in moderation, which was defined as up to 1 drink per day for women and up to 2 drinks per day for men.5
Dietary and physical activity choices are modifiable lifestyle factors impacting chronic disease risk.20–22 By analyzing data regarding nutritional intake and physical activity from two parent studies and using the DASH Eating Plan and the USDA MyPyramid contained within the 2005 Dietary Guidelines as reference guides, this study reports that the diets of a sample of young adults in a Midwest university community consisting of primarily White, non-Hispanic, well-educated individuals from lower economic groups, are lacking in certain key nutrients linked to good health. Furthermore, their diets contain higher than advised amounts of saturated fats, cholesterol, added sugars, and sodium, which have been associated with several chronic diseases if consumed in high quantities over time. The data also reveal that nearly 50% of the cohort is overweight or obese and that over half do not engage in regular physical activity.
Collectively, these results suggest that young adults in the Midwest with characteristics similar to the study sample are not considering the general recommendations of the Dietary Guidelines.
The excessive consumption of saturated fat, cholesterol, and sodium increases the risk of developing hyperlipidemia and hypertension which can result in CVD, the leading cause of death in the United States.14 The mean daily intake of total fat (83.2 g), saturated fat (29.0 g), cholesterol (299.3 g), and sodium (3,872.7 mg) by the current study sample are in excess of the recommendations of the DASH and USDA MyPyramid eating plans. These findings are similar to the National Health and Nutrition Examination Survey (NHANES) 2007–2008 report “What We Eat in America,” which showed high intake levels of total fat (85.3 g/day), saturated fat (45.5 g/day), cholesterol (309.7 g/day), and sodium (3,679.8 mg/day) for both males and females ages 20 to 49.23 Additionally, the intake goals for fiber are not met by the current study sample. Fiber contains nondigestible carbohydrates that can lower blood cholesterol levels and aids in weight loss while slowing the absorption of sugar, thereby reducing the risks of developing CVD and type 2 diabetes.5,8
The additional findings that a significant portion of the study sample is not consuming the advised daily quantities of fruits and vegetables or engaging in regular physical activity are especially disconcerning because these two practices have significant negative health consequences. The combined daily intake of only 5 servings is similar to the approximate 4.8 servings reported by the NHANES (1999–2000 [ages 19 to 40 years]).24 Only 10% of the study sample report consuming 8 to 10 daily servings of fruits and vegetables, which is comparable to a recent survey conducted in Ohio, which found that only 20.8% of adults polled responded “yes” when asked whether fruits and vegetables were eaten five or more times per day.25 Interestingly, when the CDC analyzed 2000–2009 data from the Behavioral Risk Factor Surveillance System (BRFSS), an ongoing, state-based surveillance system, the findings indicated that the prevalence of consuming fruit two or more times per day or vegetables three or more times per day varied by characteristic. The greatest prevalence was among persons age 65 and older (41.3% for fruit two or more times per day and 29% for vegetables three or more times per day), college graduates (36.9% and 32.2%), persons with annual household incomes over $50,000 (32.9% and 29.4%), women (36.6% and 30.9%), and persons with a BMI less than 25.0 (36.6% and 28.3%).26
Fruits and vegetables contain the majority of the nutrients of special concern identified by the Dietary Guidelines, which are found to be inadequately consumed by the current study sample. They are low in fat and sodium and contain significant amounts of minerals, antioxidants, and other compounds linked to health.27 Several epidemiologic investigations have reported a significant inverse relationship between fruit and vegetable intake and hypertension, weight loss, and the risk of developing type 2 diabetes.28–30 Furthermore, in a recent metanalysis of cohort studies, He et al.31 found that an increased consumption of fruits and vegetables from less than 3 to more than 5 servings per day was related to a 17% reduction in CVD risk. The collective evidence provides robust support for consuming the recommended 8 to 10 daily servings of fruits and vegetables to reduce the risk of developing several major chronic diseases and adopting this strategy early in life.27–31
Another notable lifestyle choice that promotes long-term health and is more valuable if adopted early in life is regular physical activity.5 Conversely, adults who do not participate in leisure-time physical activity are at a greater risk for developing CVD, hypertension, type 2 diabetes, osteoporosis, and certain cancers.6 The current study data demonstrates that 55% of the young adult sample self-reported not engaging in moderate intensity physical activity for 30 minutes or more most days of the week, which was the recommendation of the 2005 Dietary Guidelines. This figure is slightly lower than the value reported by Reeves and Rafferty (~77% for adults between the ages of 18 and 44 years), who pooled national data from the 2000 BRFSS to estimate the prevalence of engaging in leisure-time physical activity in this age group. Similarly, a study by Pronk et al.32 evaluated the prevalence of multiple healthy lifestyle factors among a random sample of adolescents (n = 616), adults (n = 585), and seniors (n = 685) from a large Midwestern health plan and reported that more than half of the adults in their study (61.2%) did not exercise at the recommended levels. Collectively, the data suggest that many young adults in the Midwest and across the nation are not observing the physical activity advisements promoted in the Dietary Guidelines.
Inactivity is also associated with obesity, which is at epidemic proportions in the United States. It is now estimated that over two-thirds of U.S. adults are overweight or obese.33 In the current study, the BMI data indicate that approximately 28% of the young adult sample are overweight and 20% are obese. Though the mean BMI for men (26.6) and women (25.0) in our study are just slightly lower than the national averages for this same age group (27.5 for men, 27.6 for women), the values are within the overweight category.7 High BMIs are associated with a higher risk for CVD, type 2 diabetes, hypertension, and premature death.5 The rising prevalence of high BMIs is another reason NPs must aggressively promote healthy food consumption and adequate physical activity in the young adult population.
Two other measures that are often used to estimate body fat are WHR and SAD. Both WHR and SAD specifically approximate abdominal fat, which is associated with a higher health risk than peripheral fat.34 Additionally, the WHR is a better indicator of cardiovascular risk factors than BMI.35 WHRs for males (0.89) and females (0.83) in the present study are slightly higher than those reported by others (men: 0.88; females: 0.76) in a similar age group.35 Ratios as high as those in our sample are of concern because WHR 0.90 or greater in men and 0.80 or greater in women have been linked to an increased risk for CVD.35
Findings from the current study which suggest that young adults in the Midwest are not heeding government-issued guidelines for healthy eating and physical activity are corroborated, in part, by several previous studies that have evaluated adherence rates in a similar age group to select modifiable healthy lifestyle practices such as consuming high-quality diet foods, maintaining a healthy weight, not smoking, drinking alcohol responsibly, and being physically active.32,36,37 For example, only 10.8% of adults in a Midwestern health plan met all five behavior-related factors and age significantly affected adherence to the behaviors.32 Adults ages 50 to 64 years were more likely to adhere to multiple healthy lifestyle factors, as compared to young adults ages 18 to 49 years. Furthermore, the BRFSS, which monitors and reports data on health-risk behaviors and preventive practices across states, metropolitan and micropolitan statistical areas, and counties reports that the degree of success that U.S. adults have in adhering to healthy lifestyle practices varies by region. In 2008, the BRFSS reported an estimated prevalence of physical inactivity in adults age 18 years and older that ranged from 18.1% in Minnesota to 47.3% in Puerto Rico, from 12.3% in Boulder, Colorado, to 40.1% in Wichita Falls, Texas, and from 9.8% in Douglas County, Colorado, to 40.3% in Hinds County, Mississippi. Similarly, the prevalence of obesity in this age group ranged from 19.9% in Colorado to 34.0% in Mississippi; from 15.3% in Boulder, Colorado, to 39.9% in Orangeburg, South Carolina; and from 12.9% in Summit County, Utah, to 39.9% in Orangeburg County, South Carolina.36 The data suggest that socioeconomic factors such as income, race, ethnicity, education, and environmental conditions are likely influencing food and exercise patterns.
How then can NPs communicate the important lifestyle messages contained within the Dietary Guidelines more effectively to the young adult sector, which likely has unique barriers to success? The first recommendation is that NPs become familiar with the Key Recommendations contained within the 2010 Dietary Guidelines, which was released in January, 2011.8Although there are no drastic revisions to the updated guidelines, the new edition places an even greater emphasis on the obesity epidemic and overall energy balance than the 2005 guidelines. Americans are encouraged to eat less and exercise more to achieve weight loss. A noteable change is that young adults are also being advised to increase the amount and variety of seafood consumed and to reduce sodium consumption. The 2010 Dietary Guidelines document includes recommendations for reducing sodium consumption to levels that do not exceed 1,500 mg among persons who are 51 and older, and those of any age who are Black or have hypertension, diabetes, or chronic kidney disease.8 This recommendation applies to about half of the U.S. population, including children and most adults.
It is also recommended that NPs lead the discussions about healthy food and exercise choices with young adult patients during annual and episodic visits. Screening could include questions about eating patterns, exercise patterns, alcohol consumption, and smoking. An abundance of printed materials and interactive tools are available on the Dietary Guidelines website to assist the clinician in the evaluation process. For example, the Adult Energy Needs and BMI Calculator computes an individual's daily calorie needs to maintain a healthy weight and the Interactive Dietary Reference Intakes (DRIs) for Health Professionals calculates daily nutritional recommendations based on the DRIs. The subsequent step is for NPs to educate young adult patients about the health risks associated with each lifestyle choice. This process could be facilitated by distributing and discussing “Health Facts” sheets, brochures, and worksheets that are also available from the Dietary Guidelines website. It is important that NPs strategize with patients regarding plans to incorporate the recommendations into their daily lives and evaluate the plans at subsequent visits (see Suggested patient-teaching strategies for NPs).5,9,39,40
The limitations of the current study should be considered when interpreting the findings. This research used a retrospective, explorative design that evaluated nutritional and physical activity data from two previous studies, therefore, causality cannot be established. Additional limitations include: 1) the participants were predominantly White, in a lower income bracket, had more than 12 years of education and were recruited from one Midwest university community, which limits generalizability to other samples; 2) self-report data may be affected by recall bias; and 3) self-report tobacco and alcohol use may be inaccurate .41 For example, self-report of alcohol intake is sometimes considered questionable because denial is a trademark of alcohol dependence.
The current study has significant strengths. The nutritional and physical activity data were collected from a segment of the U.S. population that has been studied less than other segments. Additionally, the findings are aligned with the previous studies and surveillance systems that have focused on this subgroup in other geographic areas. This study supports current scientific evidence that targeting this population with more consistent, personalized messages about healthy lifestyle choices is a critical endeavor.
The findings of this study suggest that many young adults in the Midwest are still not successful in following the Dietary Guidelines for Americans that were designed to optimize health and reduce the risk for chronic disease through diet and physical activity. Further research is needed to explore the dietary habits and exercise patterns in larger samples of individuals who enter into adulthood without having attended college and young adults residing in other geographic locations, while considering the influence of socioeconomic factors. Finally, it is critical that further research include qualitative studies of this population to elucidate the barriers that may be hindering young adults from achieving nutritional and physical activity goals. Consistent, tailored messaging by NPs and other healthcare clinicians may improve the chances that young adults across the United States will adopt dietary and physical activity patterns that will ultimately contribute to healthy aging.
Suggested patient-teaching strategies for NPs8,39,40
- Lead the discussion about healthy food and exercise choices with young adult patients during annual and episodic visits.
- Include specific questions about eating patterns, exercise patterns, alcohol consumption, and smoking.
- Educate young adult patients about health risks associated with each lifestyle choice using open discussion and tools such as “Health Facts” sheets, brochures, and posters from Dietary Guidelines8 website at http://www.health.gov/dietaryguidelines/2010.asp#tools
- Strategize with patients regarding plans to incorporate the recommendations into their daily lives using worksheets and tip sheets that personalize the plans.8
- Emphasize that healthy eating is about balance and that it's not a program, it's a lifestyle.
- Position the Dietary Guidelines as trustworthy and usable. Share websites with patients: http://www.health.gov/dietaryguidelines/faq.asphttp://www.health.gov/dietaryguidelines/2010.asp#resourceshttp://www.choosemyplate.gov/http://www.choosemyplate.gov/print-materials-ordering.htmlhttp://www.cnpp.usda.gov/Resources.htm
- Communicate “choice” to empower the individual.
- Keep messaging simple, but true to science.
- Consider tailored behavioral counseling based on Stage of Change Model.38
- Educate patients and develop a plan to increase fruit and vegetable intakes.40
- Evaluate effectiveness of plans at subsequent visits.
1. Stamler J, Dyer AR, Shekelle RB, Neaton J, Stamler RRelationship of baseline major risk factors to coronary and all-cause mortality, and to longevity: findings from long-term follow-up of Chicago cohorts. Cardiology. 1993;82(2–3):191–222.
2. Stamler J, Stamler R, Neaton JD, et al.Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA. 1999;282(21):2012–2018.
3. Bazzano LA, He J, Ogden LG, et al.Fruit and vegetable intake and risk of cardiovascular disease in US adults: the first national health and nutrition examination survey epidemiologic follow-up study. Am J Clin Nutr. 2002;76(1):93–99.
4. Steffen LM, Jacobs DR Jr, Stevens J, Shahar E, Carithers T, Folsom ARAssociations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic stroke: the atherosclerosis risk in communities (ARIC) study. Am J Clin Nutr. 2003;78(3):383–390.
5. U.S. Department of Health and Human Services, U.S. Department of Agriculture. Dietary Guidelines
for Americans, 2005. Washington DC: U.S. Government Printing Office; 2005.
6. CDC. The link between physical activity and morbidity and mortality: A report from the surgeon general. Washington, DC: The President's Council on Physical Fitness and Sports; 1999.
7. Ogden CL, Fryar CD, Carroll MD, Flegal KMMean body weight, height, and body mass index, United States 1960–2002. Adv Data. 2004; (347):1–17.
8. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines
for Americans, 2010. 7th
edition. Washington, DC: U.S. Government Printing Office; 2010.
9. U.S. Department of Agriculture. MyPyramid.gov. Washington, DC: U.S. Department of Agriculture; 2005:OMB 0584–0535.
10. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. Your guide to lowering your blood pressure with DASH. 2006; NIH Publication No. 06–4082.
11. Reeves MJ, Rafferty APHealthy lifestyle characteristics among adults in the United States, 2000. Arch Intern Med. 2005;165(8):854–857.
12. King JCDietary Guidelines Advisory Committee. An evidence-based approach for establishing dietary guidelines
. J Nutr. 2007;137(2):480–483.
13. Park MJ, Paul Mulye T, Adams SH, Brindis CD, Irwin CE JrThe health status of young adults in the United States. J Adolesc Health. 2006;39(3):305–317. Epub 2006 Jul 10.
14. Xu J, Kochanek KD, Murphy SL, Tejada-Vera BDivision of Vital Statistics; U.S. Department of Health and Human Services; Centers for Disease Control and Prevention. Deaths: final data for 2007. Natl Vital Stat Rep. 2010;58(19):1–135.
15. McDaniel JC, Belury M, Ahijevych K, Blakely WOmega-3 fatty acids effect on wound healing. Wound Repair Regen. 2008;16(3):337–345.
16. McDaniel JC, Ahijevych K, Belury MEffect of n-3 oral supplements on the n-6/n-3 ratio in young adults. West J Nurs Res. 2010;32(1):64–80. Epub 2009 Nov 14.
17. Viocare Technologies I. Electronic food frequency questionnaire. 145 Witherspoon Street, Princeton, NJ. 08542.
18. McDaniel J, Massey K, Nicolaou AFish oil supplementation alters levels of lipid mediators of inflammation in microenvironment of acute human wounds. Wound Repair Regen. 2011;19(2):189–200.
19. Patterson RE, Kristal AR, Tinker LF, Carter RA, Bolton MP, Agurs-Collins TMeasurement characteristics of the women's health initiative food frequency questionnaire. Ann Epidemiol. 1999;9(3):178–187.
20. McGinnis JM, Foege WHActual causes of death in the United States. JAMA. 1993;270(18):2207–2212.
21. Murray CJ, Lopez ADMortality by cause for eight regions of the world: global burden of disease study. Lancet. 1997;349(9061):1269–1276.
22. Mokdad AH, Marks JS, Stroup DF, Gerberding JLActual causes of death in the United States, 2000. JAMA. 2004;291(10):1238–1245.
23. U.S. Department of Agriculture, Agricultural Research Service. Nutrient intake from food: mean amounts consumed per individual, by gender and age, what we eat in America, NHANES 2007–2008. 2010.
24. Guenther PM, Dodd KW, Reedy J, Krebs-Smith SMMost Americans eat much less than recommended amounts of fruits and vegetables. J Am Diet Assoc. 2006;106(9):1371–1379.
25. Centers for Disease Control and Prevention. Ohio: burden of chronic disease. 2008
26. Grimm KA, Blanck HM, Scanion KS, Moore LV, Grummer-Strawn LM, Foltz JLCenters for Disease Control and Prevention. State specific trends in fruit and vegetable consumption among adults—United States, 2000–2009. MMWR Morb Mortal Wkly Rep. 2010;59(35):1125–1130.
27. Holt EM, Steffen LM, Moran A, et al.Fruit and vegetable consumption and its relation to markers of inflammation and oxidative stress in adolescents. J Am Diet Assoc. 2009;109(3):414–421.
28. Alonso A, de la Fuente C, Martin-Arnau AM, de Irala J, Martinez JA, Martinez-Gonzalez MAFruit and vegetable consumption is inversely associated with blood pressure in a mediterranean population with a high vegetable-fat intake: the seguimiento universidad de navarra (SUN) study. Br J Nutr. 2004;92(2):311–319.
29. He K, Hu FB, Colditz GA, Manson JE, Willett WC, Liu SChanges in intake of fruits and vegetables in relation to risk of obesity
and weight gain among middle-aged women. Int J Obes Relat Metab Disord. 2004;28(12):1569–1574.
30. Ford ES, Mokdad AHFruit and vegetable consumption and diabetes mellitus incidence among U.S. adults. Prev Med. 2001;32(1):33–39.
31. He FJ, Nowson CA, Lucas M, MacGregor GAIncreased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta-analysis of cohort studies. J Hum Hypertens. 2007;21(9):717–728.
32. Pronk NP, Anderson LH, Crain AL, et al.Meeting recommendations for multiple healthy lifestyle factors: prevalence, clustering, and predictors among adolescent, adult, and senior health plan members. Am J Prev Med. 2004;27(suppl 2):25–33.
33. Flegal KM, Carroll MD, Ogden CL, Curtin LRPrevalence and trends in obesity
among US adults, 1999–2008. JAMA. 2010;303(3):235–241.
34. U.S. Department of Health and Human Services, National Institute of Health, National Heart, Lung, and Blood Institute. The practical guide: Identification, evaluation and treatment of overweight and obesity
in adults. October 2000;NIH Publication Number 00–4084.
35. Dobbelsteyn CJ, Joffres MR, MacLean DR, Flowerdew GA comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. the canadian heart health surveys. Int J Obes Relat Metab Disord. 2001;25(5):652–661.
36. Berrigan D, Dodd K, Troiano RP, Krebs-Smith SM, Barbash RBPatterns of health behavior in U.S. adults. Prev Med. 2003;36(5):615–623.
37. Ford ES, Ford MA, Will JC, Galuska DA, Ballew CAchieving a healthy lifestyle among United States adults: a long way to go. Ethn Dis. 20 01;11(2):224–231.
38. Hughes E, Kilmer G, Li Y, et al.Surveillance for certain health behaviors among states and selected local areas—United States, 2008. MMWR Surveill Summ. 2010;59(10):1–221.
39. Perkins-Porras L, Cappuccio FP, Rink E, Hilton S, McKay C, Steptoe ADoes the effect of behavioral counseling on fruit and vegetable intake vary with stage of readiness to change. Prev Med. 2005;40(3):314–320.
40. Kearney M, Bradbury C, Ellahi B, Hodgson M, Thurston MMainstreaming prevention: prescribing fruit and vegetables as a brief intervention in primary care. Public Health. 2005;119(11):981–986. Epub 2005 Sep 26.
41. Dufour MCIf you drink alcoholic beverages do so in moderation: what does this mean. J Nutr. 2001;131(2S-1):552S-561S.