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ADA REPORTS
Position of The American Dietetic Association and
The Canadian Dietetic Association: Women’s health and nutrition
s we approach the year 2000, women’s health has emerged
A as both a powerful political platform and a dynamic public
health issue. It has long been recognized that women have
worse health than men, despite the fact that women live longer.
Overall, women have more acute symptoms, chronic conditions,
and short- and long-term disabilities resulting from health prob-
lems. Some diseases are unique to women — ovarian or uterine
cancers, for example — whereas other diseases and conditions,
such as osteoporosis, affect women disproportionately (1).
Minority women carry a disproportionate burden of health
problems. They suffer shorter life expectancy, experience higher
maternal and infant mortality, and have a higher incidence of
chronic diseases such as diabetes and hypertension. Women’s
overall health status is further diminished by higher rates of
poverty, lack of education, and limited or nonexistent access to
medical care. To explore more fully the impact of socioeconomic
disadvantages on women’s health, readers should review the
statements of ADA and CDA on this issue (2,3). In addition, with
longer life spans, women face greater susceptibility to disease and
disability as they age (1,4).
The 1990 revelation that women were less likely to have been
included in clinical trials, that diseases disproportionately affect-
ing women were less likely to be studied, and that women were
less likely to be senior investigators in health trials sparked a
firestorm of criticism. Women’s health exploded in North America
as a volatile issue with the realization that good health for women
means good health for society as a whole. As a result, over the past
4 years, science and medicine have begun to change the way they
look at the health needs of women. US government–sponsored
research programs such as the National Institutes of Health’s
Women’s Health Initiative promise to position women’s issues at
the top of the North American health research agenda.
Although health care reform initiatives in both the United
States and Canada focus on disease prevention, there has been
little research in women’s health to aid in developing sound
prevention strategies. Both ADA and CDA have launched cam-
paigns to advance such research and to educate professionals and
consumers about women’s health and nutrition interventions.
This newly empowered women’s health movement provides an
excellent vehicle for ADA and CDA’s urgent message about the
central role of nutrition in women’s health. ADA’s Nutrition &
Health Campaign for Women (5) represents a major national
effort to provide scientifically supported nutrition information to
help adult women understand ways to prevent disease and
maintain a healthy body weight. As caregivers and food and
nutrition gatekeepers, adult women can have a multigenerational
influence on family health and eating habits.
Results of an ADA survey (6) of more than 1,000 women
revealed a wide gap between respondents’ knowledge and behav-
ior regarding health and nutrition. Although women say they are
aware of the relationship between diet and health, fewer than one
third implement dietary interventions to lower their risk of heart
disease, cancer, or osteoporosis. And although women recognize
obesity as a major concern, motivation to lose weight is driven by
conformity to societal standards of the “ideal body” rather than by
concerns about health promotion or disease prevention (6).
362 / MARCH 1995 VOLUME 95 NUMBER 3
Dietetics professionals are committed to cutting through the
confusion of potentially conflicting and often confusing health
messages to translate scientific information into action steps that
can be incorporated into women’s everyday lives. In this way,
dietetics professionals seek to close the gap between women’s
awareness about nutrition and their ability to attain good health.
POSITION
It is the position of The American Dietetic Association (ADA)
and The Canadian Dietetic Association (CDA) that because of
biological, social, and political factors, women are at unique
risk for major nutrition-related diseases and conditions in-
cluding cardiovascular disease, certain cancers, osteoporo-
sis, diabetes, and weight-related problems. ADA and CDA
strongly encourage health promotion activities, health ser-
vices, research, and advocacy efforts that will enable women
to adopt desirable nutrition practices for optimal health.
SUPPORT PAPER
This support paper focuses on five of the leading causes of
morbidity and mortality in North American adult women: cardio-
vascular disease, cancer, osteoporosis, weight, and diabetes. Di-
etetics professionals are positioned to provide essential nutrition
services (medical nutrition therapy) to women concerning these
diseases and to advocate at the local and national levels for
continued research on women’s health and nutrition issues.
Cardiovascular Disease
Women, society, and health professionals have been slow to
recognize the importance of cardiovascular disease to the health
of women. Yet cardiovascular disease, including coronary heart
disease and stroke, is the number one cause of illness and death
in North American women (7-9). One of every two women will die
of some cardiovascular event. Deaths from cardiovascular disease
outnumber deaths from all cancers prevalent in women (10).
Although women are generally a decade older than men when
cardiovascular disease first strikes, in the end, it kills as many
women as it does men (7,9). Furthermore, women do not fare as
well as men in the course of the disease (7,9). Women are much
more likely than men to die within a year of having a heart attack
and their mortality from bypass surgery is twice that of men (10).
Women are vulnerable to many of the same risk factors for
cardiovascular disease as men, although the significance of the
risk may vary between the sexes. Certain nutrition-related risk
factors stand out as powerful predictors for cardiovascular disease
in women. For example, women with a body mass index (BMI)
equal to or greater than 29 are three times more likely to suffer
from both nonfatal and fatal coronary heart disease (9). Women
with a BMI between 25 and 28.9 are estimated to have an 80%
higher risk of coronary heart disease than lean women with a BMI
of less than 20 (9).
Excess body weight also predisposes women to other risk
factors, including hypertension, diabetes mellitus, and increased
levels of low-density lipoprotein cholesterol (LDL-C) and triglyc-
erides. Recent evidence suggests that the distribution of adipose
tissue in the abdominal region, as measured by waist-to-hip ratio
...................................................................................................................................................
(WHR), is more predictive of cardiovascular disease risk than
overall obesity (9,10).
Consistent with studies on men, a high level of LDL-C in women
is a major risk factor for cardiovascular disease. In women,
however, low levels of high-density lipoprotein cholesterol (HDL-
C) are more predictive of cardiovascular disease than are high
levels of LDL-C, especially if levels of plasma triglycerides are also
high. Contrary to results in men, a high level of plasma triglycer-
ides is an independent risk factor for women (7,10,11).
Hypertension is also more problematic for women than men,
particularly women of color (7). Benefits of treating hypertension
in women, however, are unclear; some studies show no benefit or
increased risk of mortality, particularly in white women (10).
Menopause presents a unique risk factor for cardiovascular
disease, with implications for both nutritional and pharmacologic
intervention.Increasedriskforcardiovasculardiseaseaftermeno-
pause is largely attributable to dropping estrogen levels, which in
turn alter a woman’s lipid profile. Total cholesterol, LDL-C, and
triglyceride levels increase, whereas protective HDL-C levels
remain unchanged or decrease. The ratio of total cholesterol to
HDL-C increases, a risk factor positively linked to cardiovascular
disease in women (10).
Women who take oral estrogen replacement therapy (ERT) at
the time of menopause can expect a 30% to 50% reduction in risk
for both nonfatal and fatal myocardial infarctions (7,10,12). It is
not entirely clear whether hormone replacement therapy (HRT),
an estrogen-progestin combination, brings about a similar reduc-
tion in cardiovascular disease risk, although reports suggest that
effects similar to those of ERT can be expected (12).
Lastly, diabetes mellitus, which is discussed elsewhere in this
position paper, predisposes women more than men to cardiovas-
cular disease.
Clearly, nutrition plays a major role in relation to risk factors for
cardiovascular disease in women. Dietetics professionals can lead
the way in creating an awareness of the disease and promoting
programs designed to reduce its nutrition-related risk factors.
CANCER
Cancer is the second leading cause of death in the United States
and Canada. Diet may play a role in preventing 30% to 70% of
cancers, depending on type.
Breast cancer — a major concern among women — will affect
one of nine women in North America. A complex array of genetic,
environmental, and hormonal factors place women at risk; only
5% to 10% of all women with breast cancer have a strong family
history of the disease. As with many other malignancies, breast
cancer is likely the result of a lifetime of insults and complex
interactions. Diet may make the difference between progression
or prevention of the disease (13).
The role of dietary fat in the development of breast cancer is
controversial, and study results are inconclusive. Laboratory
studies have shown that animals on high-fat diets develop breast
tumors at a higher rate than those on low-fat regimens. One theory
proposes that dietary fat raises levels of estrogen and prostaglan-
dins, hormones that are thought to promote breast cancer risk
(14,15). Another theory is that dietary fat suppresses the immune
system, thus affecting the body’s natural defense system (14,15).
Epidemiologic studies have shown that breast cancer rates in
different countries are associated with national per capita fat
intakes. Breast cancer rates are notably greater among northern
Europeans and North Americans, who consume 30% to 45% of
their total energy from fat, compared with the Japanese, who
consume less than 25% of their total energy from fat (16).
Results from case-control and cohort studies are less clear and
consistent. The Nurses Health Study (17) of 89,000 nurses failed
to reveal any association between breast cancer rates and fat
intake ranging from 30% to 40% of total energy. Researchers
(15,17,18) have suggested that fat intake must be below 25% of
total energy to affect breast cancer rates.
Eating more fruits, vegetables, and whole grains is an effective
way to lower fat intake and a positive step that may decrease the
risk of breast cancer. The literature suggests an inverse relation-
ship between fiber intake and cancer based on observations of
Japanese and American women. Studies of antioxidants found in
fruits and vegetables — vitamins A, C, E; beta carotene; and
phytochemicals—are inconclusive in linking antioxidants to can-
cer prevention (19). A role for antioxidants in cancer prevention
has not been proven and needs further study, specifically the role
in breast cancer prevention (19).
Excess body weight is believed to increase a woman’s chance
of breast cancer, but data here are also inconsistent (20). Al-
though some studies show that a gain of 10 to 20 lb around the age
of 30 years substantially increases breast cancer risk later in life,
other studies show that thin premenopausal women and over-
weight postmenopausal women are at greatest risk (20). Further-
more, although the level of intake and mechanism of action is
unknown, alcohol intake is also reported to increase breast cancer
risk (21).
Colorectal cancer, the third most common cancer in women, is
responsible for more than 10% of all cancer deaths in Canada and
the United States. Family history clearly plays a role in this
disease. As with breast cancer, epidemiologic studies show an
association between colorectal cancer rates and levels of fat
consumption.
The Nurses Health Study (17) showed a positive relationship
between dietary fat intake and colon cancer. A Western diet —
high in animal fat and low in fiber — has been linked to colon
cancer. One explanation is that bacteria in the colon act on bile
acids to produce potential carcinogens. A high-fiber diet removes
bile and cholesterol byproducts and often decreases food’s transit
time through the digestive system, thus reducing disease risk.
Slattery et al (22) suggest that high calcium intake may also exert
a protective role in colon cancer because calcium binds with fat
and enhances excretion of potentially harmful metabolites (22).
Diets high in phytoestrogens, such as found in soybeans, are also
reported to block the development of cancer-promoting sub-
stances (14).
Much less is known about the relationship of diet to other types
of cancer. Overweight women produce a higher level of estrogen
and exhibit greater incidence of endometrial cancer. High dietary
fat and lower consumption of antioxidants have been associated
with ovarian cancer (23).
Research on cancer and the relationship between dietary fat,
antioxidants, and body weight is ongoing. In the meantime,
dietetics professionals should advise women to reduce fat in their
diets while increasing intake of fruits, vegetables, and whole
grains — the sources of potentially protective antioxidants and
fiber. In addition, maintaining a healthy body weight seems to
have a positive effect in preventing cancer and other diseases that
afflict women of all ages.
OSTEOPOROSIS
Osteoporosis is characterized by loss of mineral from the skeleton,
resulting in thin bones that are susceptible to fracture. In the
United States and Canada, osteoporosis affects more than 25
million women over the age of 45 years (24,25). Only a quarter to
half of the patients with hip fractures ever regain previous levels
of functioning; 20% need extensive medical attention (24). In the
United States, annual costs associated with osteoporosis care and
rehabilitation are conservatively estimated at $10 billion (24,25).
Osteoporosis cannot be cured — it can only be prevented or its
progression delayed. The best way to prevent the disease is to
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 363
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ADA REPORTS
build strong bones early in life primarily by consuming a well-
balanced, calcium-rich diet and by making exercise a part of daily
routine. In postmenopausal women, HRT is an effective preven-
tion tool, especially early in menopause when calcium loss is
greatest (26). Although HRT helps reduce risks of coronary heart
disease and osteoporosis, it must be noted that HRT is not
advisable for everyone because of its links to breast cancer, nor is
it without risks if used long term.
Many nutrients influence bone formation, thus underscoring
the importance of a balanced diet. Consumption of adequate
dietary calcium from preadolescence through young adulthood is
critical for building bone mass. Bone continues to be laid down
until about age 30 years, which is longer than originally thought
(27). Nevertheless, preliminary reports of survey data from the
third National Health and Nutrition Examination Survey (28)
suggest that a large percentage of women still may not be
obtaining the Recommended Dietary Allowance (29) for calcium,
especially African-American women, middle-aged white women,
and Hispanic women (30).
Mean bone mass remains essentially unchanged between age
30 and the onset of menopause, after which women lose 2% to 5%
each year until about 5 years after menopause, at which time bone
loss becomes more gradual (27). Experts agree that it is important
to try to prevent osteoporosis. Women should make every attempt
to build up bone mass while they are young by consuming
adequate amounts of calcium and by exercising regularly.
Other dietary factors can also affect bone health. High intakes
of caffeine, alcohol, sodium, and protein increase the amount of
calcium lost in urine. Women consuming a typical Western diet
high in protein and sodium excrete more calcium than do women
consuming lower levels of protein and sodium. Persons on a vegan
diet can maintain calcium balance on a lower intake because their
diets often contain less sodium and protein (31).
Although most investigators agree that the rapid bone loss that
follows early menopause cannot be prevented by calcium supple-
mentation, total calcium intake in the range of 1,500 mg daily can
reduce bone loss in later years (24). Calcium-rich foods or
calcium-fortified foods are the preferred choice, but for those
women who cannot achieve a high calcium intake through diet,
supplementation— ideally, in the form of readily absorbed cal-
cium citrate and calcium carbonate — is recommended (24).
Vitamin D is important to bone health because its active form —
1,25-dihydroxycholecalciferol— stimulates intestinal absorption
of calcium. Older women are especially at risk for vitamin D
deficiency because of a lack of sunlight, poor diet, and decreased
synthesis and absorption. Evidence suggests that women at high
risk for osteoporosis benefit from taking moderate amounts of
supplemental vitamin D (32).
Exercise is also essential for bone health. People who are
immobilized because of illness lose massive amounts of skeletal
mineral, particularly over the first 6 months after immobilization.
Studies determining optimal exercise levels are difficult to con-
duct, but researchers do know that weight-bearing activities such
as walking, gentle jogging, and aerobics are most effective. Studies
indicate that women who walk at least 7 miles per week have
higher bone density than women who walk less than a mile per
week (33).
Smoking adversely affects bone density. Smoking causes estro-
gen to be metabolized more quickly, reduces production of
estrogen, causes earlier menopause, and negatively affects cal-
cium absorption (34). It is well-documented that bone loss is
accelerated in smokers and that ERT is less effective in preventing
fractures in women who smoke (32).
Prevention is the best approach to decreasing osteoporosis
because, once established, the disease generally cannot be re-
versed. Sufficient calcium and exercise are important for women
364 / MARCH 1995 VOLUME 95 NUMBER 3
of all ages. HRT will help prevent rapid bone loss after menopause
and should be used if medically appropriate; HRT is often recom-
mended for women entering menopause with low bone density.
High levels of calcium intake can decrease calcium loss in older
women, especially those more than 5 years past menopause and
those engaging in weight-bearing exercise (24).
WEIGHT
Throughout the course of their lives, women are vulnerable to
several weight-related health risks associated with being over-
weight, losing weight, and being underweight by choice.
Healthy body weight refers to a body size that falls within a BMI
range of 20 to 25. BMI values below and above this range are
associated with increased health risks. Increasingly, WHR is used
in conjunction with BMI to assess weight-related health risk (35).
The WHR is a better indicator of abdominal or truncal adiposity,
a measurement more closely linked to a greater risk of diabetes
mellitus, cardiovascular disease, and some cancers (36,37). A
WHR greater than 0.85 puts women at higher risk of weight-
related health problems (36).
Between one quarter to one third of North American adult
women are overweight. In certain native and ethnic populations,
this figure may be substantially higher (35). Evidence indicates
that there is a weight-gaining trend among adults, despite a
preoccupation with body weight and despite the massive effort
and billions of dollars spent in Canada and the United States trying
to control weight (9,36,38).
Overweight confers a variety of risks on women, particularly
when fat stores are centered in the abdominal or truncal areas of
the body. These risks include coronary heart disease; hyperten-
sion; dyslipidemias, including elevated levels of very low-density
lipoprotein cholesterol and LDL-C; diabetes; gallstone formation;
and cancers of the reproductive organs. Excess body weight has
also been linked to increased risk for osteoarthritis of the knee,
stress incontinence, infertility, and increased risk of infection
after surgery (9,35,36,39,40).
In addition to the known medical risks of being overweight,
women are vulnerable to a variety of social, economic, and
emotional stigmas associated with being fat. Overweight women
may find it difficult to feel good about themselves in a society that
admires, accepts, and rewards thinness and disdains, rejects, and
discriminates against persons who are overweight. Under the
influence of this strong cultural bias for thinness, many women are
unhappy with their body size and shape, believing they are never
thin enough. This fear of fatness drives large numbers of women
to diet almost continuously and to strive to be underweight, which
is associated with medical risks (41-43).
Efforts to lose weight and maintain weight loss are largely
unsuccessful, a fact that predisposes women to a pattern of weight
cycling in which weight is gained and lost repeatedly over the
years. For many women, the constant struggle to control weight
encourages them to engage in a variety of disordered eating
patterns such as compulsive eating, binge eating, purging, severe
energy restriction, and fasting. Although the theory is still very
controversial, some researchers have proposed that the medical
risks associated with a lifetime of dieting and weight cycling may
in fact be independent of actual weight (42-44).
In addition to the potential medical risks these eating behaviors
impose, they also perpetuate ongoing feelings of failure and poor
self-esteem. For some women, these destructive eating patterns
are the early stages of more serious health problems such as
bulimia nervosa and anorexia nervosa (42). Approximately 95%
of those suffering from bulimia nervosa and anorexia nervosa are
women (45).
For women who achieve an unrealistically low body weight
through disordered eating behaviors and starvation diets, the
...................................................................................................................................................
risks of morbidity and mortality increase (45). Some potential
health problems associated with starvation states include brady-
cardia; hypotension; bloating; constipation; amenorrhea;
hypoglycemia; hypokalemia; hypothermia; stunting of growth;
fractures secondary to osteoporosis; and pyschological distur-
bances such as depression, irritability, diminished libido, and
broken sleep (46).
The weight-related issues facing women are complex. Al-
though the solutions remain largely elusive and more research on
the causes and treatments is needed, dietetics professionals can
continue to make a positive contribution.
Poor success rate in the treatment of overweight points to the
need for prevention and early intervention programs for the whole
family. For those already overweight, the known health risks
remain a strong argument for attempted weight loss. At the same
time, it may be necessary to redefine goals for weight loss. Where
practitioners traditionally saw a healthy body weight as the goal,
there is evidence that more modest weight loss of 10% of body
weight may improve heart-related and diabetes health risks (47).
For people who have been repeatedly unsuccessful in weight-
loss attempts, the potential health risks of weight cycling may
support the decision to abandon weight loss as a goal altogether.
Instead of dieting, the focus would be on normalizing eating
behaviors, eating more healthfully, becoming more physically
active, and building positive self-esteem.
Lastly, there is a need to educate society as a whole about
healthy weights and realistic body images. Dietetics professionals
can help young women resist the pressure to conform to unreal-
istic and unattainable standards of appearance, learn to eat more
healthfully, and develop a sense of self-esteem and self-worth
unrelated to body size and shape.
DIABETES MELLITUS
Diabetes mellitus is a major health problem for women, particu-
larly as they age and especially for women of color. It is estimated
that women account for more than half of the incidence of
diabetes (48).
Diabetes plays an important role in women’s health. In the
United States, for example, the percentage of women with diabe-
tes mellitus who die from the disease each year is similar to the
percentage of women with breast cancer who die from that
disease annually (48). In both men and women, diabetes mellitus
is the leading cause of visual impairment and nontraumatic
amputation (48).
In the presence of diabetes mellitus, women face a variety of
increased health risks, many of which are responsive to nutrition-
related interventions. Diabetes mellitus is a powerful and inde-
pendent risk factor for cardiovascular disease. The protective
effects of premenopausal estrogen are mostly eliminated in the
presence of diabetes mellitus (7,11). Women with diabetes have
twice the risk of heart disease than men with diabetes (10). In the
Framingham study (10), diabetes mellitus was associated with a
fivefold risk of cardiovascular disease among women.
Results from the Minnesota Heart survey (49) found that
diabetes mellitus is linked to an overall increased risk of death
from myocardial infarction; in particular, women with diabetes
are 1.4 times more likely to die in the hospital after a myocardial
infarction than are men with diabetes. The higher risk of cardio-
vascular disease in the presence of diabetes mellitus is primarily
linked to a diabetes-related, high-risk lipid profile that includes
the presence of small LDL-C particle size, high levels of plasma
triglycerides, and/or low levels of HDL-C (48,50).
Diabetes mellitus and overweight are interrelated health risks
for women. Excess body weight is a known risk factor for non–
insulin-dependent diabetes mellitus (48). Together, diabetes and
overweight are major risk factors for the development of cardio-
vascular disease. In addition, excess weight negatively affects
blood glucose control primarily through its effects on insulin
sensitivity (48). Hypertension, a major factor in renal disease and
a complication of diabetes mellitus, is more prevalent in women
with diabetes than in men with diabetes (48).
Insulin-dependent diabetes mellitus has been identified as a
risk for the eating disorders bulimia nervosa and anorexia nervosa.
Studies have found that young women with insulin-dependent
diabetes mellitus may manipulate insulin dosage to induce weight
loss through glucosuria (48). In addition, diabetes predisposes
women to an increased risk of endometrial cancer and to maternal
and fetal complications during pregnancy. Infants born to moth-
ers with diabetes mellitus are predisposed to increased risk of
congenital malformation (48).
As with cardiovascular disease, the impact of diabetes mellitus
on women’s health is not widely recognized. Dietetics profession-
als can contribute to the overall health of women by mounting
awareness campaigns and health promotion programs designed
to identify the warning signs of diabetes and create awareness of
additional nutrition-related health risks associated with the dis-
ease. Those working in existing treatment programs need to take
extra care in the management of all nutrition-related risk factors
associated with the disease.
CONCLUSION
Because of unique biological, sociological, and political influ-
ences, women are at particular risk for cardiovascular disease,
breast cancer, osteoporosis, obesity, and diabetes. It is the posi-
tion of The American Dietetic Association and The Canadian
Dietetic Association that nutrition, a critical component of both
risk reduction and treatment, must be included in clinical and
preventive services for women.
Central to this position is the concept of total health. Although
women’s individual risk profiles vary widely, available evidence
indicates that the role of nutrition is remarkably similar from
disease to disease. Consequently, it is important for women’s
overall health that dietetics professionals promote consistent
healthful eating messages as outlined in the US Food Guide
Pyramid (51) and Canada’s Food Guide to Healthy Eating (52).
Medical nutrition therapy, provided by a qualified dietetics pro-
fessional, is essential for women who are at risk for or who already
have one or more of the conditions discussed here.
From a societal perspective, dietetics professionals must work
to increase public knowledge about women’s health by participat-
ing in health promotion and education programs and by advocat-
ing for innovative intervention strategies. In addition, policy
makers and other health professionals must be made aware of the
unique health needs of women and encouraged to support further
research into the role of nutrition in women’s health.
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■ ADA Position adopted by the House of Delegates on October 16,
1994. This position is in effect until December 1998. This position
was developed collaboratively between The American Dietetic
Association and The Canadian Dietetic Association.
■ The American Dietetic Association authorizes republication of
this position, in its entirety, provided full and proper credit is
given. Requests to use portions of the position must be directed
to ADA Headquarters at 800/877-1600, ext 4896.
■ Recognition is given to the following for their contributions:
Authors:
Denise Beatty, MHSc, RD, The Canadian Dietetic Association, and
Susan Calvert Finn, PhD, RD, The American Dietetic Association
Reviewers:
The American Dietetic Association: Dietitians in General Clinical
Practice dietetic practice group; John Foreyt, PhD; Jean Hankin,
PhD, RD; Robert Heaney, MD; Penny M. Kris-Etherton, PhD, RD;
Elaine Monsen, PhD, RD; Walter Willett, MD.
The Canadian Dietetic Association: Susan I. Barr, PhD, RDN,
FCDA; Anne Carlson, RD; Louise Lambert-Lagace, PDt; Heather
Anne Pentz, RDt; Kim Travers, PhD, PDt; Cary Greenberg, RD;
Rosanne E. Maluk, PDt; Andrea Miller, RD; Lora Montebruno, RD;
Gail Marchessault, RD; Sherry Thaxter-Smith, RD; and represen-
tatives from the provincial dietetic associations.