Dietary Intakes

(1)

SUPPLEMENT

797 Dietary

Intakes

Theresa

A. Nicklas,

DrPH,

Rosanne

P. Fams,

MS Hyg,

Carolyn

Major,

RD, Gail C. Frank,

DrPH,

Larry

S. Webber,

PhD,

James

L Cresanta,

MD, and

Gerald

S. Berenson,

MD

From the Departments of Medicine, Public Health and Preventive Medicine, Biometry, and

Pediatrics, Louisiana State University Medical Center, and Department of Health and

Human Resources, Office of PreventWe and Public Health Services, New Orleans

ABSTRACT. Dietary patterns and racial differences in

nutrient intake were observed in children 6 months to 4

years of age in the Bogalusa Heart Study. Even in this

sample of young children, the composition of the intakes

of the majority of children was not compatible with

prudent recommendations of less than 35% and 10% of

energy from total and saturated fat, respectively. Mean cholesterol intake of the 4-year-old children (390 mg) was approximately one half of the average daily adult levels. The polyunsaturated to saturated fatty acid ratio ranged from 0.41 to 0.53 and sucrose to starch ratio from 1.32 to 1.57, reflecting a high saturated fat and sucrose

intake. White children had greater intakes of sucrose

than black children; however, total fat and cholesterol intakes were greater in black children. Gender differences were noted among the 2, 3, and 4-year-old children: energy, sugar, and starch intakee were greater in boys, and cholesterol intake per 1,000 kcal was greater in girls. Mean intakes per 1,000 kcal in Bogalusa were higher for fat and carbohydrate and lower for protein than reported in the Second Health and Nutrition Examination Survey.

However, when the National Research Council

recom-mended dietary allowances for protein and energy are used for comparison, a more than adequate intake was noted in these children. The data found in this newborn-infant cohort contribute information regarding the early development of dietary habits that likely influence eating behavior in later childhood and adolescence. Pediatrics

1987;80(suppl):797-806; cardiovascular risk factor,

ather-ogenic diet, nutrition.

ABBREVIATIONS. HANES II, Second Health and Nutrition Examination Survey; RDA, recommended dietary allowances.

In the United States, the transition during

in-fancy to a varied intake during childhood is a crucial

period in the nutritional history of children. Foods

offered to children and the supportive environment

in which children learn to select foods establish a

foundation for development of food habits.’3 Food

patterns and eating behaviors established during

the early years influence the development of

car-diovascular &sease.

Development of atherosclerotic fatty streaks and

fibrous plaques begins in childhood.7 The severity of atherosclerosis in the aorta and coronary arteries of children is related to elevated concentrations of serum low-density lipoprotein cholesterol8 and total

cholesterol9 which are influenced by diet in both

infants and children.5 Diet has been recognized

as an important environmental determinant of

car-diovascular disease risk. Consequently, alteration

of eating habits in early childhood may delay or

prevent cardiovascular disease development.’0

Food patterns during infancy and adolescence

have been evaluated, and age- and gender-specific

differences in nutrient and energy intakes

ex-ist.’6 Socioeconomic factors and cultural dietary patterns also affect intake variations.’7”8 However, there is a paucity of information on racial compar-isons of dietary patterns of infants and preschool

children. Data from the Second Health and

Nutni-tion Examination Survey (HANES II)’ describe

dietary intake ofyoung children by race and gender.

Description of dietary intake in the HANES II

study is limited to macronutrients, vitamins, and

minerals Of interest to professionals in cardiovas-cular health is the racial and gender differences in

intakes of cholesterol and specific types of fat and

carbohydrate. Of additional interest is the

contri-bution of meals and snacks to energy intake in this

age group, thus targeting possible areas to make

positive changes in eating habits. Furthermore,

urn-ited data are available on the development of

die-tary intakes for longitudinal cohorts of infants. Five

repeated measures of dietary intake have been

ob-tamed and are presented in this study.

The present study has a three-fold purpose: (1)

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(2)

Race/Gender No. (%) of Children

Gmo lyr 2yr 3yr 4yr

White boys 41 (33) 33 (33) 42 (31) 35 (33) 59 (27)

White girls 40 (32) 27 (27) 39 (29) 29 (27) 60 (27)

Black boys 21 (17) 17 (18) 30 (22) 24 (23) 49 (22)

Black girls 23 (18) 22 (22) 24 (18) 18 (17) 51 (24)

to

describe the dietary intake of a cohort of infants from 6 months to 4 years of age; (2) to evaluate age, race, and gender differences in intakes; (3) to

com-pare the observations with the National Academy

of Sciences’ Recommended Dietary Allowances

(RDA)2#{176}and recommendations of the American

Heart Association.2’

MATERIALS AND METHODS

Population

Written informed consent was obtained from

each child’s parent or guardian prior to

participa-tion in each examination. A detailed description of

the study design, participation, and protocols is

reported elsewhere.22’23 Briefly, all children born between Jan 1, 1974, and June 30, 1975, to mothers

who resided in ward 4 (Bogalusa) of Washington

Parish, Louisiana, were eligible to participate. The

study population by race, gender, and age for the

dietary surveys is shown in Table 1. A random

sample of 125 mothers (81 white, 44 black)

attend-ing the 6-month screening responded to a 24-hour

dietary recall interview to quantitate their infants’

usual day’s total dietary intake. At the 1-year

screening, 99 (79%) ofthese same mothers reported dietary recalls for their infants.6 Subsequently, at the 2-, 3-, and 4-year screenings, 135, 106, and 219 mothers (54% white, 46% black), respectively,

corn-pleted 24-hour dietary recalls. Twenty-four hour

recalls were not collected at the 7-year screening.

Fifty mothers responded to the dietary interview

all five times.

Dietary

Method

Trained interviewers collected all of the 24-hour

recalls.24 Interviewers participated in rigorous

training sessions and pilot surveys prior to the

study. The respondent was usually the mother or

other care giver such as the child’s grandmother.

When mothers were not present for the recall

in-terview, follow-up phone calls or home visits

yen-fled the care giver’s responses. A standardized pro-tocol,24 graduated infant food models for quanti-tation, a product identification notebook for snack probing, and family recipe collection24 were used to ensure the collection of reliable and complete

infor-TABLE 1. Dietary Interview Population Bogalusa Heart Study

mation. Nutrient analyses of commercially

pre-pared infant foods (Gerber Products Co), coupled

with the extended table of nutrient values, a

de-tailed and extensive data base, provided data for

nutrient composition.2 Quality control checks

for fat, carbohydrate, and vitamins have been

re-ported in detail.3032 Duplicate recalls were obtained

from a 10% random subsample of the 6-month-old

study population to test reproducibility of the

method.33

Statistical

Analyses

All analyses were performed with the Statistical

Analysis System. Descriptive statistics (means,

standard deviations, ranges, percentiles)

summa-nize the data. Analysis of variance techniques were used to test for race and gender differences for each

nutrient. Logarithmic transformation was applied

to approach Gaussian distributions, but

untrans-formed means are reported here. Raw data and data

adjusted per 1,000 kcal and per kilogram of body

weight were examined.

Analysis includes a nutritional breakdown of the

total 24-hour period and each ingestion period, eg,

meals and snacks. In development of the 24-hour

recall method, a meal was defined as a mixture of

foods or a food that approximately yields the

nutri-tive value of milk. The food contact period that is

of the greater nutritive value and/or the greater

quantity and/on is eaten at home was coded as

supper. The other is coded as afternoon on evening snack. Nutrient intake of snacks is an accumulation of all snacks consumed in a 24-hour period.

Each child’s intake of energy and protein was

classified into one of four categories for comparison with the RDA2#{176}as follows: <#{189}RDA; between #{189}

RDA and % RDA; between % RDA and RDA;

greaten than RDA. Intakes of dietary cholesterol,

carbohydrate, and fat were compared with the

American Heart Association recommendations for

a prudent diet.21’35

RESULTS

Composition of Dietary Intakes

The mean intakes of selected dietary components

are shown in Table 2. Mean total energy increased

(3)

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(4)

TABLE

3.

Macronutrient Intakes as Percentages of Energy for Infants and Children 6 Months to 4 Years of Age by

Race, Newborn Cohort-Bogalusa Heart Study*

Dietary Component 6 mo 1 yr 2 yr 3 yr 4 yr

White Black White Black White Black White Black White Black

Energy (kcal) Carbohydrates (%) Fat (%) Protein (%) 937 58b 33 13 970 51 38’ 12 1,365 51 37 14 1,342 48 40 13 1,813 49 39 12 2,089 48 40 13 2,007 53” 36 12 2,399 48 40 13 2,128 51 38 13 2,413 50 39 12 *Race comparisons: a p < .05; bj < .01; C <

with age, from 949 calories at 6 months of age to

2,258 calories at 4 years of age. Protein,

canbohy-drate, and fat intakes were lowest at 6 months, had doubled by 3 years, and almost tripled by 4 years of

age. More than 75% of the protein intake came

from animal sources, yielding an animal to vegeta-ble protein ratio of 3:1. The sucrose to stanch ratio

was 1.3 at 6 months, 1.7 at 3 years, and 1.6 at 4

years of age. The percentage of carbohydrate

de-nived from sucrose sources was 25% at 6 months

but approximately 40% at older ages. Total fat

intake also increased with age. Saturated fat was

consistently high, resulting in a polyunsaturated to

saturated ratio of 0.5 or less. Mean cholesterol

intakes were 110, 246, 376, 347, and 390 mg/d from

youngest to oldest ages, respectively.

Racial Contrasts

in Dietary

Intake

Racial differences of dietary intakes were noted

(Table 2). Total energy intake of black children

was significantly higher (P

.05)

than white

chil-then at 2, 3, and 4 years of age. No consistent racial differences were detected in total protein and total carbohydrate intake. Starch intake varied

signifi-cantly between racial groups and was higher for

black children at 3 and 4 years of age (P

s

.01).

However, sucrose intakes were slightly higher for

white than black children at 6 months and 1 and 3

years of age. Total fat intake was significantly

higher for black children at 6 months and 3 and 4

years (P

.05),

averaging 5 to 17 g higher than for

white children.

The percentage of energy from protein,

canbo-hydrate, and fat are given in Table 3. Protein

provided 12% to 14% ofthe kilocalonies for children

in both races and at all ages. For both white and

black children, more than 30% of energy came from

fat sources. Percentage of energy from

canbohy-drates ranged from 47% to 57% across ages and was

higher among white than black children. The

per-centage of energy from fat was slightly higher

among the black children in all age groups.

Dietary components were expressed pen 1,000

kcal to evaluate nutrient density (Table 4). All

6-month-old infants had higher intakes of

carbohy-drate pen 1,000 kcal than fat and protein pen 1,000

kcal. Mean carbohydrate intake per 1,000 kcal

de-creased slightly from 6 months to 4 years of age.

Carbohydrate intakes pen 1,000 kcal were

consis-tently higher in white children at all ages, whereas total fat intake pen 1,000 kcal was higher in black

children. For all children, total sugar intake

de-creased from 95 g at 6 months to 74 g at 4 years of

age. The percentage of carbohydrate from sucrose

increased almost twofold with age: 25% at 6 months

to 42% by 4 years. White children had greaten

sucrose intakes than black children at all ages (Fig

1). Total fat intake pen 1,000 kcal exceeded 30 g for

all ages. Black children consistently had higher

intakes than white children (Fig. 2). Saturated fat

made up 37% to 47% of total fat intake in all

children.

Both races exhibited a marked increase in mean

cholesterol intake from 6 months to 4 years of age

(Fig. 3). Cholesterol intake in black children ranged

from 146 mg at 6 months to 428 mg at 4 years of

age (threefold increase) and in white children from 91 mg to 359 mg (fourfold increase). Cholesterol

pen 1,000 kcal was higher in black than white

chil-dren at each time period. The difference in choles-tenol intakes varied greatly between black and white children at 6 months: 92 and 130 mg, respectively. At 1 year of age, the difference remained for white and black children: 159 and 221 mg, respectively.

However, by 4 years of age, no difference was

ob-served: 171 and 173 mg, respectively.

Gender

Differences

Gender differences in intakes were noted mostly

among the 2- to 4-year-old children in energy, total

sugar, and stanch intakes (boys more than girls, P

<

.05).

When intake was evaluated per 1,000 kcal,

polyunsaturated fatty acid at 2 years and

choles-tenol and protein at 3 years of age were significantly greaten for girls (P s .05).

The percentage of energy from protein,

carbo-hydrate, and fat was similar for both boys and girls.

From 6 months to 4 years of age, percentage of

energy from fat increased slightly and the

percent-age of energy derived from carbohydrate sources

(5)

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- S.- -4 Fig 1. Total sucrose intake by race in young children 6

months to 4 years of age. White children had higher

=

N 0 0 C) C) C) c CO N ‘ C) intakes than black children at all ages studied

, VI

a CO Ci Ci CO N ci CO 4 ‘t ‘“ Ci ‘ “‘

constant, ranging between 11.7% and 13.7% of

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‘ . e r- ad t- c#{243}c a c r- at t c i’ co ‘‘ o ci Both boys and girls showed a threefold increase

CO ‘ r Ci CO ‘-4 O - C’) ‘-4 ‘‘ ‘‘ ‘-4 Ci

- - 5-.. ...S #{149}5S -., . in dietary cholesterol intake from 6 months to 4

‘I

c4 a, SS 5S #S E years of age (Fig 3). Boys’ intakes ranged from 113

N 0 S at) ‘ ;‘ 0) cc & a & c

8

mg at 6 months to 431 mg at 4 years of age, and

. : ginlsingestedfromlO7mgat6monthsto357mg

, : CO Ci C’) C’) - N Ci CO -t ‘ ‘‘ Ci

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at 4 years of age. Cholesterol intakes per 1,000 kcal

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0 CLt .

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- 0_t- , Howeven,at4yearsofage,virtuallynodiffenence

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a

a, a, 174 mg, boys 170 mg).

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Comparison

With RDA

Ca 4,

z

:

The daily intakes of energy and protein were

. compared with the RDA.#{176}Approximately 60% of

I,

:

-

:

- the 6-month to 1-year-old children exceeded the

Ca

2

.E

‘.4 Ca energy RDA, and about 90% to 95% of the children

i

:

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:

- less than 2 years of age ingested more than two

Ca ‘

a. Cl) thirds of the energy RDA. For the 2-, 3-, and

4-4 0 1/) CI’) Cl) r year-old children, 80%, 91%, and 78%, respectively,

SUPPLEMENT 801

(6)

Total gm

OS-0 WHITES 100

90

8O

70

60

50

40

30

20-

10-.-. BLACKS

I,, 55- Per 1000 kcal

0/”

d

3 4

AGE (years)

Fig 2. Total fat intake by race in young children 6 months to children had higher intakes than white children at all ages studied.

4 years of age. Black

I 1O

U,

E

U,

LA.

:-. :-j-:--:-::-T Per kg

, J

0.5 1 2

exceeded the energy RDA, and 97% to 100% of the

2- to 4-year-old children ingested more than two

thirds of the energy RDA. The protein RDA was

met or exceeded by 87% ofthe 6-month-old children and 99% of the 1-year old children. Approximately

97% to 100% of the 2- to 4-year-old children had

intakes greater than the protein RDA.

Distribution of Dietary

Intake

by Meal Pattern

For the total sample of young children 6 months

to 4 years of age, 97% to 100% ate breakfast, 95%

to 100% ate lunch, 88% to 98% ate dinner, and 98%

to 100% ate snacks.

The contribution of energy intake by eating

pe-nod for children 6 months to 4 years of age is shown in Fig. 4. Snacks provided the most energy, mainly

from carbohydrates; breakfast, lunch, and dinner

each provided approximately 15% to 25% of the

energy intake. A closer examination of the

contni-bution of snacks to total energy intake shows that

at 6 months, snacks contributed 50%; whereas at 4

years, snacks declined to 31% of the energy intake.

(The high percentage of total energy from snacks

at 6 months may be related to the small, frequent bottle feedings occurring at this age.) Snacks among older children were high in sucrose and fat, a

pat-tern similar to that seen among 10-year-old

Boga-lusa children.37

DISCUSSION

Because dietary intake is one of the most impor-tant environmental factors related to

cardiovascu-lan disease risk, determining the development of

(7)

p., i000 acci

C

150-100#{149}

.J

)

at

I, L#{224} -I

3

p., ioo kcei

p., kg

05 1 2 3 4

0-s ; 4

AGE (years)

Fig 3. Total cholesterol intake by race or gender in young children 6 months to 4 years

of age. Black children had higher intakes than white children at all ages studied. Choles-terol intakes per 1,000 kcal were higher among girls than boys at all ages.

100

80

60

P E R

C E

N T

6 MO

= BREAKFAST

- SNACKS

3 4 AGE

‘/1//I, LUNCH S\\\\\’ DPINER

410 - Blacks .-. Whites -- Boys --- Girls .-.

SUPPLEMENT 803

400

380

-300

250

200

so

30#{149}

25

-

20-

Is-

10-0J

Total mg

p., a9

Fig 4. Percentage of energy intake by meal period for

young children 6 months to 4 years of age. Snacks

pro-vided most calories, mainly from carbohydrate; breakfast,

lunch, and dinner each provided approximately same

amount of calories (15% to 25%).

and gender differences in intake in this total

corn-munity study are compared with national surveys’9

and other selected samples.’3’6

The dietary intakes of Bogalusa children are

comparable with national survey data.’9 Intakes of

protein, fat, and carbohydrate by gender and age

for preschool children studied from 1976 to 1980

were reported by HANES II.’ A comparison of

mean intakes in Bogalusa and HANES II is

pre-sented in Table 5 with the caveats that (1) the age

groups reported are not identical in the two studies

Toiil mg

and (2) the variability of intakes is large in such

surveys.

For 6-month-old infants, Bogalusa children had

slightly higher mean fat and carbohydrate and

somewhat lower protein intakes per 1,000 kcal than

did 6- to 11-month old infants in the HANES II.

Bogalusa children 1 to 4 years of age showed higher

fat intakes and lower protein intakes than did 1- to

5-year-old children in the HANES II, but

carbo-hydrate intakes were similar across the ages. Mean

macronutnient data expressed per 1,000 kcal for

Bogalusa preschool children are consistent with

national data.

Nutrition of preschool children in the United

States has been investigated by several

research-ers.”’8 Energy intakes of Bogalusa children are

higher than earlier reports,”’3 particularly for

boys. Comparison of energy intakes in Bogalusa to

children from the north central region ofthe United

States show Bogalusa intakes to be 3% and 8%

higher for boys and girls, respectively, at 6 months,

but 26% and 42% higher at 4 years of age. The

difference could reflect a more recent tendency to

overfeed infants and young children. Four-year-old

Bogalusa children are consuming more energy than

6- to 9-year-old schoolchildren in Iowa,’6

Cincin-nati, Ohio and Columbia, MD,38 and the same

amount as Bogalusa 10-year-old children.37’39’4#{176}

Gender differences in energy intakes begin at

(8)

TABLE 5. Mean Intakes of Selected Diet Components of Preschool Children by Gender and Age in Bogalusa and the Second Health and Nutrition Examination

Sun-vey (HANES II)

Study Age, Gender, Protein Fat Carbohydrate

and Study Group (g/1,000 (g/1,000 (g/1,000

kcal) kcal) kcal)

6-il mo

Boys

Bogalusa 30 38 142

HANES II 41 35 131

Girls

Bogalusa 33 39 134

HANES II 39 37 128

1 yr

Boys, Bogalusa 34 43 122

Girls, Bogalusa 33 42 126

2 yr

1-2 yr

Boys, HANES II 37 39 128

Girls, HANES II 38 39 126

3yr

Boys, Bogalu8a 30 42 129

4 yr

3-5 yr

Boys, HANES II 36 39 129

Girls, HANES II 36 39 128

birth, with differences more pronounced after 6

months of age. This suggests that differences in

size for boys and girls41’42 need to be considered

when recommending dietary allowances for energy

intakes of children younger than 10 years.

Filer and Martinez reported the results of a

nationwide study of the diets of 4,000

repnesenta-tive 6-month-old infants in 1964. The mean energy

intake was 822 kcal, slightly less than in Bogalusa.

Protein intake of the total infant population was

38 g (slightly higher than in Bogalusa), total fat

intake was 37 g, and carbohydrate intake was 86 g

(about 40% less than in Bogalusa). A different

eating pattern is seen among 6-month-old Bogalusa

children. The lower mean protein intake (30 g) and

higher energy (949 kcal) and carbohydrate intake

(130 g) reflect a change in eating behavior that has developed during the past 20 years. Total fat intake

has not changed with time. However, the mean fat

intakes (37 g) are higher than the prudent

recorn-mendations of American Heart Association.2’ The

saturated fatty acid intakes at 16% to 14% of energy

found in this study are also similar to reported

values for older Bogalusa children39”#{176}and adults.”

More than 55% of the children exceeded the RDA2#{176}

for protein and energy.

Mean cholesterol intakes of our samples range

from 110 to 390 mg/d. By 2 years of age, mean

cholesterol intake exceeded the 300-mg/d

recom-mendation. In fact, at 2 years of age, only 38% of

white and 24% of black children met the prudent

diet recommendation of 100 mg/1,000 kcal. At 3

years of age, 38% of white and 17% of black

chil-dren, and at 4 years of age 45% of white and 32%

of black children, had cholesterol intakes that met the American Heart Association recommendation. The basis of the racial difference in cholesterol intake may be due to the type of milk introduced

during infancy. Fans et al6 found that white

chil-dren drank more cow’s milk than black children,

who consumed a milk-based formula at 6 months

and 1 year of age. It is possible that this difference

diminishes as consumption of milk decreases and

solid foods increase. Fat, saturated fat, and

choles-terol intakes of newborns and infants with lower

than recommended polyunsaturated to saturated

ratios reflect patterns that may contribute to the

risk of cardiovascular disease in the adult popula-tion.4’45’

A moderate total carbohydrate eating pattern can

be misleading, unless the proportions of complex

and simple carbohydrates are examined. Total

sugar intake increased from 89.7 g at 6 months to

164.0 g at 4 years of age in Bogalusa children.

Morgan and Zabik46 reported an average daily total

sugar consumption of 134 g in a cross-sectional

sample of children ages 5 to 12 years. In fact,

Bogalusa children at 2 years of age are consuming more total sugar than 9- to 10-year-old children.3’

Milk, followed by sweetened carbonated

bever-ages, contributed the greatest amount of dietary

total sugar.47 Milk consumption peaks at 6 months

of age and slowly declines with age thereafter. This explains why infants have a noticeably higher total sugar intake (95.2 g) at 6 months of age, primarily

the sugar lactose, which decreases to 74.4 g at age

4 years. This decrease is counterbalanced with an

increasingly high sucrose intake. The percentage of

carbohydrates derived from sucrose increases with

age almost twofold in Bogalusa children, with white children having higher intakes than black children.

Snacks represent approximately one third of the

daily energy intake and two fifths of the total

carbohydrate (primarily sucrose) intake in the diets

of 1- to 4-year-old children. These findings have

obvious implications for early prevention of obesity, dental caries, and cardiovascular disease.

IMPLICATIONS

In this report of a newborn-infant cohort in

Bo-galusa we described the development of dietary

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behav-SUPPLEMENT 805

ions in late childhood and adolescence. These

ob-servations indicate that racial differences in dietary intake exist as early as 6 months of age and persist

for some children until 4 years of age. To

under-stand the history of cardiovascular disease, food

patterns established during infancy and early child-hood for both races need continuous documentation and evaluation. These patterns should be described for different races and at various stages of growth

and development. Only with vigilant monitoring of

eating patterns in children can we identify intake,

explore the relationship between diet and

cardio-vascular risk factors, and develop a rationale for

dietary change to promote cardiovascular health.

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Pediatrics

James L. Cresanta and Gerald S. Berenson

Theresa A. Nicklas, Rosanne P. Farris, Carolyn Major, Gail C. Frank, Larry S. Webber,

Dietary Intakes

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