the Stanford Three Community Study1-3 Stephen P. Fortmann, M .D., Paul T. W illiams, M .S., Stephen B. Hulley, M .D., M .P.H., W illiam L. Haskell, Ph.D., and John W . Farquhar, M .D. ABSTRACT A 2-yr mass media cardiovascular health education program in two communities was followed by a 3rd, maintenance yr of reduced effort. In each community, a representative cohort reported its dietary behavior annually to an interviewer using a questionnaire which estimated daily consumption of cholesterol and fat. Relative weight and plasma cholesterol were also measured annually. Both men and women in the treatment towns reported reductions in dietary cholesterol (23 to 34% ) and saturated fat (25 to 30% ) which were significantly larger than those reported in a 3rd, control community. Relative weight was increased in the control community when compared to the treatment towns, perhaps as a result of the aging of the cohorts. Similar patterns were observed for plasma cholesterol changes. The 2-yr changes were maintained or increased during the 3rd, maintenance yr. The changes in individual values for plasma cholesterol showed low level correlations with dietary cholesterol and saturated fat, but the association with weight change was more important. These results suggest that mass media health education can achieve lasting changes in diet, obesity, and plasma cholesterol on a community level. Am. J. Clin. Nutr. 34: 2030-2038, 1981. KEY W ORDS Coronary heart disease, nutrition, health education, preventive medicine The Stanford Three Community Study in- cluded extensive dietary information during an experiment to determine if a community health education program could reduce the risk of cardiovascular disease (CVD). The hypothesis was that behavioral changes re- sulting in reduced CVD risk would occur if the residents of a community were educated about CVD and subsequently trained in spe- cific skills to reduce CVD risk factors. The design, educational strategy, and early results have been reported earlier (1-7). There was a reduction in overall risk of about 20% when population cohorts from treated and un- treated communities were compared after 2 yr. The Three Community Study used a mu!- tifactor risk reduction approach, but because of the importance of dietary factors, Stern et a!. (3) reported separately the dietary changes observed after 2 yr. In this paper we again concentrate on dietary change, reporting the results after a 3rd, maintenance yr of the campaign. M ore importantly, we extend Sterns analysis by examining the dietary change data in relation to changes in plasma cholesterol and relative weight, by examining changes in alcohol intake, and by using an analysis technique which recognizes the com- munity as the unit of intervention. M ethods The Stanford Three Community Study Three northern California communities-W atson- ville, Gilroy, and Tracy-were selected for study. These towns were semirural with mainly agricultural economies and populations in 1970 between 13,000 and 15,000. In each community, a multistage random sample of men and women between 35 and 59 yr of age was invited to participate in the base-line survey during the fall of 1972, and in subsequent annual surveys through 1975. Each survey included interviews about CVD-related k.nowl- From the Stanford Heart Disease Prevention Pro- gram and the Department of M edicine, Stanford Uni- versity, Stanford, CA. 2 Supported by Grants HL 14174 and HL 21906 of the National Heart, Lung, and Blood Institute. S. P. F. was supported in part by NIH Training GrantS T32 HL 07034 and the Robert W ood Johnson Clinical Scholars Program. 3Address reprint requests to: Stephen P. Fortmann, M .D., Stanford Heart Disease Prevention Program, Stan- ford University, 730 W elch Road, Stanford, CA 94305. The American Journal of Clinical Nutrition 34: OCTOBER 1981, pp. 2030-2038. Printed in U.S.A. 1981 American Society for Clinical Nutrition
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EFFECT OF HEALTH EDUCATION ON DIET 2031 edge. attitudes, and behavior and measurements of CVD risk factors. Plasma cholesterol was measured using the Lipid Research Clinics methods as described elsewhere (8). Relative weight was defined as actual weight divided by ideal weight determined according to the mean of the weight-for-height ranges given in the M etropolitan Life Insurance Company Ideal W eight Table (9). W atsonville and Gilroy are separated by a range of low hills, but they share a television station and so were selected to receive the educational program. This pro- gram began in January 1973 and continued through the summer of 1975. During the fall of each year, when the annual surveys were conducted, the educational effort was suspended. During the last year of the campaign ( 1975) the intensity of the media effort was reduced to about half of its former level. The campaign was bilingual (English and Spanish) and delivered through various media, including televi- sion, radio, newspapers, and billboards. Pamphlets, cookbooks, and other informational items were distrib- uted by direct mail to the base-line survey participants. In addition to the mass media and direct mail campaigns, some of the base-line survey participants in W atsonville received personal, small group intensive instruction on risk factor reduction (7). This group consisted of a ran- dom two-thirds of those base-line participants who fell into the upper quartile of risk after stratification for age, and their spouses. The W atsonville reconstituted group to be reported on here excludes these individuals and compensates for their removal by appropriately weighting the remaining one-third of the high risk indi- viduals (1). D ie ta ry q u e s tio n n a ire The dietary questionnaire was a shortened dietary history designed to characterize the usual dietary behav- ior of participants concerning certain foods, rather than their total food intake over some brief, specified time period. There were 47 preceded questions that concen- trated on cholesterol, saturated and unsaturated fat, re- fined sugar, and alcohol intake; no reliable estimate of total caloric intake was possible. The trained interviewers used food models to assist in estimating portion sizes. A computer program later converted questionnaire data into estimates of the daily consumption of cholesterol, saturated and polyunsaturated fat, and alcohol using the food composition data published by Fetcher et al. (10). Stern et al. (3) previously reported on the reproduci- bility of this dietary questionnaire. In brief, Pearson correlation coefficients on between-survey estimates of cholesterol and saturated fat intake of subjects in the control community ranged between 0.48 and 0.SS. T abl e I shows the results of a comparison between the Stanford questionnaire and a 3-day food record in a group of 79 volunteers who received both assessments within a month of each other. The two dietary assessment meth- ods are reasonably comparable in their mean estimates of saturated fat and cholesterol intake but there is a considerable difference in their estimates of caloric and polyunsaturated fat intake. W hile there is no basis for choosing one of these sets of results over the other as the more valid estimate of the usual habits of the community, we have chosen the most conservative course and do not report here the results for calories or polyunsaturated T A BL E 1 Comparison of Stanford short form diet q with 3-day food record in 79 subjects uestionnaire M ean daily intake Nutrient Questionnaire Food record Correlation across individ. ual.st Calories (kcal) 1,676.6 2,075.6 Cholesterol (mg) 450.9 406.9 Saturated fat 0.58 (g) 32.5 33.5 Polyunsatu- rated fat (g) 8.2 18.1 0.S7 0.35 * Subjects were volunteers from the control commu- nity who completed 3-day food records within 2 to 4 wk of completing the questionnaire. t Pearson correlation coefficients. fat. The correlations across individuals are high given the limitations on reproducibility of both techniques. This limitation will also attenuate correlations between dietary variables and physiological variables, thus tend- ing to obscure some important relationships. Such atten- uation must be considered when interpreting the corre- lations presented below. A n a ly s is Except where noted, we use logarithmic transforma- tions of the variables in these analyses ( 1 1). For these data, this transformation appears to result in more nor- mally distributed variables, stabilizes the variance, and aids in achieving additivity in linear models. W e also use schematic plots ( 1 1) since they better represent the data then do plots of the mean and SD. In these schematic plots, the central 50% of the distribution (the interquar- tile range) is represented by a box which contains a horizontal bar to indicate the location of the median. Dashed lines above and below the box show the range of the remaining observations, excluding points which lie more than 1.5 times the interquartile range beyond the end of the box. These extreme poi nt s are shown as dots. All analyses are limited to those members of the initial sample who also completed the final survey. Seventy- eight percent of the people eligible for the initial survey agreed to attend; the subsequent dropout rate was 34% of the base-line sample. Base-line differences between towns are tested by analysis of variance after adjusting for age and sex differences (12). The longitudinal results are analyzed by two ap- proaches. First we ignore the nonrandom assignment of individuals to towns, and treat the observed changes from base-line in a classical experimental framework using as the error term the standard pooled variances for estimating the precision of between-group comparisons. Second, we use a regression analysis that is much less powerful than the first approach for detecting true re- ductions in risk factors, but which recognizes the town as the appropriate unit of intervention (6). In this ap- proach we assume that the changes in dietary factors are linear over the duration of the study and fit separate slopes and intercepts to each town based on the means
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2032 FORT M ANN ET AL . 199. t Test of statistical significance o mi t t e d because of skewed distribution. of each of the four annual surveys. The significance of the difference between the average rate of change in the two treatment towns versus the rate of change in the control town is therefore based in the t distribution with only 6 df. W e used packaged computer programs for much of the analysis. One way analysis of variance and covari- ance, t tests, and frequency distributions were obtained through the Statistical Package for the Social Sciences and regression analysis was performed using the BM DP Statistical Package. Since the educational program was attempting to achieve unidirectional changes in the fac- tors discussed in this paper (i.e., reductions), we use one- tailed t tests throughout when testing the significance of these changes. Two-tailed tests are used to describe cross- sectional patterns at baseline and other fmdings where the direction of the difference was not predicted. Signif- icance levels above 0.1 are indicated as not significant. Results Table 2 shows the distribution of reported dietary variables, relative weight, and plasma cholesterol by sex for each community at base-line. There are considerable differences for all the variables among the three communities. Table 2 shows that this variance among towns is statistically significant for dietary choles- terol and saturated fat even after adjusting for sex and age effects. However, the variance within towns for these variables (not shown) is two orders of magnitude larger than the between-town variance. Table 2 also shows the distribution of alcohol intake by town. The highly skewed nature of this distribution is evident; in all communities and in both sexes a high proportion of respondents re- ported no alcohol intake. Longitudinal analysis, 1972 to 1975 Figures 1 and 2 show the percent change in dietary cholesterol, dietary fatty acids, re!- ative weight, and plasma cholesterol after 3 yr in each community. The declines in re- ported dietary cholesterol and saturated fat intake are uniformly larger in the two edu- cation communities than in the control com- munity. The differences in relative weight are less striking. Plasma cholesterol increased in all communities, but the increase appears larger in the control town. T ABL E 2 Base-line distributions by sex and community for reported dietary variables, relative weight, and plasma cholesterol* Percentile M en women Significance of the variation among towns 25 50 75 25 50 75 Dietary cholesterol (mg/day) W atsonville 413 516 717 336 429 527 Gilroy 443 580 855 313 418 567 p<O.O2 Tracy 437 570 750 284 374 516 Dietary saturated fat (g/day) W atsonville 28 36 49 23 29 39 Gilroy 32 43 56 21 30 38 p <0.001 Tracy 30 40 49 20 25 33 Dietary alcohol (oz/day) W atsonville 0 0.35 0.91 0 0 0.27 Gilroy 0.06 0.45 1.10 0 0.06 0.40 t Tracy 0 0.27 0.93 0 0 0.26 Relative weight W atsonville 1.10 1.17 1.29 1.05 1.15 1.33 Gilroy 1.10 1.21 1.31 1.08 1.19 1.34 p<O.l Tracy 1.10 1.21 1.33 1.07 1.19 1.39 Plasma cholesterol (mg/dl) W atsonville 187 212 240 181 210 237 Gilroy 186 208 240 184 206 232 p <0.08 Tracy 182 * Sample sizes: W atsonville-men 207 167, women 2 236 179 18; Gilroy-men 160, w 198 omen 203; 231 Tracy-men 166, women
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E F F E C T O F H E AL T H E DUC AT I O N O N DI E T 2033 -J > -J 2 U) 4 0 LU Q 4 z LU C.) LU 10 io I i o i- 1 a $. ..4 i a 9 - - - .: 4 io5 io ia9 io FI G. 1. Change i n reported di etary chol esterol and saturated f at f rom 1972 to 1975 i n each of the three towns f or men and women. The one-tai l ed p val ues f or tests of si gni f i cant di f f erences between the control communi ty and each treatment communi ty are shown at the bottom of the f i gure. .J > z .J LU U) 4 0 4 z C.) 182 150 122 100 82 67 55 MAL ES FEMAL ES i P. CHOL ESTER0 L i REL ATI VE L SP. CHOL ESTEROL d REL ATI VE WEI GHT WEI GHT L .H
WATSONVI L L E (treatment) GI L ROY (treatment) D TRACY (control ) D WATSONVI L L E (treatment) GI L ROY (treatment) TRACY (control ) FI G. 2. Change i n pl asma chol esterol and rel ati ve wei ght f rom 1972 to 1975 i n each of the three towns f or men and women. The one-tai l ed p val ues f or tests of si gni f i cant di f f erences between the control communi ty and each treatment communi ty are shown at the bottom of the f i gure. I f we i gnore the vari ance at basel i ne among towns, we may use a t test of the si gni f i cance of these di f f erences. Both men and women i n the educati on towns showed a si gni f i cantl y greater decl i ne i n di etary chol esterol and sat- urated f at when compared to the control town. A l so, whi l e the combi ned sampl e of mal es and f emal es i n Tracy experi enced an average i ncrease of 1% i n rel ati ve wei ght, W atsonvi l l e and Gi l roy showed essenti al l y no change i n rel ati ve wei ght. Si mi l arl y, Tracy experi enced a si gni f i cantl y l arger i ncrease i n pl asma chol estero! . The regressi on anal ysi s of these data i s
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550 450 0 . E 240 A 200 160 250 1.28 1.24 1.20 1.16 1 1 ) E E 0 0 E 0 1 2 3 RELATI VE WEI GHT (p = 0.04) _ ____ 0 A. A A 0 1 2 3 PLAS MA CHOLES TEROL (p = 0.02) 225 215 205 195 - 1 2 3 YEARS 0 1 2 3 YEARS 2034 FORT M A NN ET A L . shown in Figure 3 and the rates of change in each community are given in Table 3. This conservative analytic approach supports the above conclusions both graphically and sta- tistically (the p values shown in the figure are based on one-tailed t tests with 6 df). Dietary cholesterol and saturated fat show almost identical declines in the two educated com- munities and little change in the control town. Relative weight increased in Tracy but was DI ETARY CHOLES TEROL (p = 0 . 0 1 ) A 350 . stable in the two treated towns. Plasma cho- lesterol increased in all communities, but sig- nificantly less in Gilroy and W atsonville than in Tracy. Alcohol consumption (not shown) tended to decrease in all three communities during the study, but the pattern of change for the treatment towns was not substantially differ- ent from the contro!. W e e!ected not to dis- play these data due to the highly skewed DIETARY SATURATED FAT (p = 0.03) REGRESSION LINE MEAN 0 A 0 W ATSONVI LLE (treatment) GILROY (treatment) TRACY (control) FI G. 3. Change in the four risk factors analyzed by the regression method (see text). The one-tailed p value for testing whether the average of the slopes for the two treatment communities is significantly different from the slope in the control community is given at the top of each regression plot. T A BL E 3 Re g r e s s i o n a n a l y s i s wh i c h r e c o g n i z e s t o wn s a s t h e e x p e r i me n t a l u n i t Variable Average annual percentage change in mean the geometric Significance test p values for the difference in the rate of change in the treatment communities vs the rate of change in the control community Community W atsonville vs Average of W atson Gilroy vs Tracy vile and Gilory vs Tracy Tracy W atsonville Gilroy Tracy Dietary cholesterol -11.2 -11.0 -2.8 0.01 0.05 0.01 (mg/day) Dietary saturated fat (g/day) -9.4 -10.3 -0.9 0.05 0.04 0.03 Plasma cholesterol (mg/100 ml) 1.0 0.5 1.7 0.08 0.02 0.02 Relative weight 0.0 0.0 0.3 0.07 0.06 0.04 * One tailed test.
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Log dietary -0.07 saturated fat NS 0.04 -0.07 NS -0.03 0.07 0.03 -0.02 0.06 0.06 T ABL E 5 M ultiple regression associating changes in log plasma 0.16 cholesterol with changes in relative weight and dietary 0.001 variables after 3 yr * Pearson correlation coefficients and their one-sided significance levels are reported. t NS is specified if p > 0.1. Significance levels are not provided for alcohol because of its skewed distribution. EFFECT OF H EAL T H EDUCAT I ON ON DI ET 2035 distribution of alcohol intake and the number of potentially confounding variables. Reported diet and plasma cholesterol Table 4 shows correlations between re- ported nutrient intake, relative weight, and plasma cholesterol level by community. The top half of Table 4 represents the cross-sec- tional analysis at base-line and shows signifi- cant correlations between plasma cholesterol and dietary factors in only one of the three communities. In contrast, relative weight was significantly correlated with plasma choles- terol in all three communities. The lower portion of Table 4 presents the longitudinal analysis correlating change in plasma cholesterol with change in dietary nutrients and relative weight. Changes in di- etary cholesterol and saturated fat are signifi- cantly correlated with changes in plasma cho- lesterol and the longitudinal correlations for T ABL E 4 Correlations between reported nutrient intake, relative weight, and plasma cholesterol level by community* Community Nutrient W atsonville Gilroy Tracy Base-line nutrient intake correlated with base-line log plasma cholesterol level (cross-sectional) Log dietary -0.02 0.08 -0.03 cholesterol NSt 0.03 NS Log dietary alcohol Log relative 0.18 weight 0.001 3-yr changes in nutrient intake correlated with 3-yr changes in log plasma cholesterol (longitudinal) SLog dietary 0.08 0.10 0.10 cholesterol 0.03 0.02 0.01 i Log dietary saturated fat 0.12 0.003 0.13 0.004 0.07 0.03 SLog dietary -0.05 0.14 -0.04 alcohol* SLog relative 0.30 0.22 0.16 weight 0.001 0.001 0.001 relative weight are general!y larger than the cross-sectional correlations. The correlations for dietary cholesterol and saturated fat are low, but consistently present in all towns. The correlations in the treatment towns tend to be larger. Table 4 presents Pearsons correlation coefficients; similar results were obtained us- ing Spearmans p and Kendalls T. Adjustment of the change in plasma cho- lesterol for change in relative weight does not eliminate the association with change in di- etary cholesterol (p < 0.005) or change in dietary saturated fat (p < 0 . 0 3 ) in the treat- ment communities. However, as shown in Table 5, in a multiple regression model con- taining all of these elements relative weight achieves the greatest significance. In this model, changes in dietary cholesterol make no significant contribution once all other fac- tors are known, though change in dietary saturated fat still remains marginally signifi- cant. The model explains 8% of the variance in plasma cholesterol reduction. Discussion Techniques for changing the eating habits of populations are important for implement- ing public health approaches to heart disease prevention (13-17). This paper presents evi- dence that such large-scale dietary changes are possible in the context of a community- wide mass media hea!th education program. Significant reductions in cholesterol and sat- Independent variables Standard regression Coefficients Significance Change log relative 0.4724 p = 10_b weight Change log dietary -0.0139 NSt cholesterol Change log dietary 0.0328 p = 0.02 saturated fat Change log dietary 0.0029 NS polyunsaturated fat Change log dietary 0.0012 NS alcohol R2 = 0.08 * one-tailed significance levels. t p>0.1.
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2036 FORT M ANN ET AL . urated fat intake were reported during both the 2 yr of major effort and during the 3rd, maintenance year. Obesity is also a major health problem in this country. Obesity tends to increase with age, which may explain the significant in- crease in relative weight over just 3 yr in the control community. The fact that this in- crease was not observed in the treatment communities suggests that the mass media can be effective in controlling this public health problem as well. Future efforts should perhaps concentrate on preventing the weight gain which accompanies aging for many in- dividuals. Since our dietary history cannot estimate total caloric intake, we cannot deter- mine whether the effect on weight gain was due to change in caloric intake or physical activity. W hen analyzing the results of studies such as this one, it is tempting to use a standard approach, comparing each member of the sample cohort to himself at base-line. Such an approach can be mis!eading, however, since it ignores variation among towns at base-line. In fact, we did fmd significant vari- ation among towns (about two orders of mag- nitude smaller than the within-town vari- ance). W e therefore used the regression ana!- yses presented in this paper which support the conclusion that real differences between treatment and control communities were pre- sent. Cross-cultural associations between dietary and blood cholesterol have been strong (18). However, several large studies in the United States have found zero (19, 20) or low order (21, 22) correlations between dietary and blood cholesterol. Jacobs et a!. (17) argue persuasively that the well-established rela- tionship between diet and blood cholesterol in metabolic ward studies can be obscured by the low precision of dietary measurements. In this study, we also fmd few significant correlations between diet and blood choles- terol at base-line, but the longitudinal data demonstrate small but significant correlations between changes in plasma cholesterol and both dietary cholesterol and dietary saturated fatty acid change. This study provides further evidence that weight change is an independent and impor- tant determinant of blood cho!esterol (23). W e find highly significant correlations be- tween relative weight and plasma cholesterol both at base-line and longitudinally. In ad- dition, relative weight is the strongest factor in a multiple regression model associating the reduction in plasma cholseterol with changes in relative weight and dietary factors. It re- mains possible that dietary composition was as strong a determinant of plasma cholesterol as weight, but that this was masked in the regression by the lower precision of the di- etary assessment. Although there is evidence that plasma cholesterol levels are slowly faffing in this country (24), the cross-sectional association between plasma cholesterol and age suggests that the former should rise in a population followed longitudinally. In fact, we did ob- serve a smal! rise in plasma cholesterol in all three communities over time, but the rise was significantly less in the two treatment towns (about 2% compared to about 5% ). The other results presented here suggest that this differ- ence in plasma cholesterol change was due to differences in dietary intake and weight gain. One would predict a fall in cholesterol from the dietary changes. In addition to the possi- ble effects of aging, we may have observed a rise because of subtle laboratory drift (despite standardization) or some other time effect. For example, plasma cholesterol did decrease between the 1st and 3rd surveys (1). Interest- ingly, the difference between treatment and control is constant at all surveys. The most prominent threat to the validity of these conclusions is the possibility of bias in self-reported dietary behavior. It is reason- able to suggest that the members of the treat- ment community cohort were especially likely to bias their response to the dietary questionnaire in the direction that the exper- imenters desired. W hile this possibility can- not be dismissed, the existence of real differ- ences between towns is implied by the sig- nificant differences in weight change, an ob- jective measure. The questionnaire data are also partly validated by our observation that changes in reported diet were correlated with changes in plasma cholesterol. The dietary history used in this study ap- pears to estimate adequate!y group dietary cholesterol and saturated fat. Furthermore, the imprecision of this history would tend to obscure the fmdings reported. Nevertheless, the conclusions of future similar studies
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E F F E C T O F H E AL T H E DUC AT I O N O N DI E T 2037 would be strengthened by unobtrusive dietary measures (such as food sales) and a more precise diet measure. I t is also important to note that the changes which occurred in the two treatment towns may have occurred by chance. W hile the regression analysis strengthens the conclusion that real differences between treatment and control towns existed, it does not eliminate the possibility that the changes in the two treatment towns were independent of the in- tervention. I f two of the three towns were destined to display the observed changes, there is one chance in three that the two would both be treatment communities, that is p = 0.33. Only random allocation of at least eight study communities would solve this problem (2 5 ), a strategy that is both financially and practically infeasible. The co- hort analyzed here does not accurately rep- resent the three communities because of drop- outs from the cohort during the 3 yr of the study and because it was surveyed. However, we have repeated these analyses using various assumptions about the behavior of the drop- outs without altering the results (unpublished analysis), and the results from Tracy make it clear that surveying itself has at most a tran- sient effect. Nevertheless, future replications of this study would be strengthened by the addition of repeated independent samples of the community. I t is likely that several of the chronic dis- eases that currently plague the developed world-hypertension, coronary heart disease, diabetes, cancer-are related to diet and obe- sity. The results presented here offer encour- agement that large groups of people are able to apply information on health and behavior obtained from mass media to make changes in dietary practices and obesity. Thus com- munity health education may become a pow- erful, cost-effective tool for improving the public health. The authors thank Professor Byron W . Brown for reviewing this manuscript and M s. Patti M athis, M s. Susan M ellen, and M s. Ann V arady for technical assist- ance. References 1. Farquhar JW , M accoby N, W ood P D, et al. Com- munity education for cardiovascular health. Lancet l977;l:l 192-5. 2. M accoby N, Farquhar JW , W ood P D, Alexander J K . Reducing the risk of cardiovascular disease: effects of a community-based campaign on knowl- edge and behavior. J Comm Health 1976;3: 100-14. 3. Stern M P, Farquhar J W , M accoby N, Russel SH . Results of a two year health education campaign on dietary behavior: Stanford Three Community Study. Circulation l976;54:826-33. 4. Stern M P, Brown BW , Haskell W L, Farquhar JW , W ood P D. Cardiovascular risk and the use of estro- gens or estrogen-progestogen combinations: Stan- ford Three Community Study. JAM A l976;235:81 1- 5. 5. Stern M P, Haskell W L, W ood P D, Osonn K E , K in g AB, Farquhar JW . Affluence and cardiovascular risk factors in M exican-Americans and other whites in three northern California communities. J Chron Dis 1975; 28:623-36. 6. W illiams PT, Fortmann SP, Farquhar JW , V arady A, M ellen S. A comparison of statistical methods for evaluating risk factor changes in community-based studies: an example from the Stanford Three Com- munity Study. J Chron Dis (in press). 7. M eyer AJ, Nash JD, M cAlister AL, M accoby N, Farquhar JW . Skills training in a cardiovascular health education campaign. J Consult Clin Psych 1980;48: 129-42. 8. United States Department of Health, Education and W elfare. Lipid research clinics manual of laboratory operations, vol 1. Lipid and lipoprotein analysis. (DH E W Pub. no. (NI H) 75-6281. W ashington, DC : Government Printing Office, 1974. 9. M etropolitan Life I nsurance Company. New weight standards for men and women. Stat Bull M etropol Life I ns Co l959;40:1. 10. Fetcher ES, Foster N, Anderson iT , Grande F, Keys A. Quantitative estimation of diets to control serum cholesterol. Am i Chin Nutr 1967;20:475-84. 11. Tukey JW . Exploratory data analysis. New Y ork: Addision-W esley, 1977. 12. Snedecor GE, Cochran W G. Statistical methods. 6th ed. Ames, I A: I owa State University Press, 1967:291- 4. 13. Glueck Ci, Connor W E. Diet-coronary heart disease relationships reconnoitered. Am J Clin Nutr 1978;31: 727-37. 14. Primary prevention of the atherosclerotic diseases: report of the I ntersociety Commission for Heart Disease Resources. Circulation l970;42:A55-95. 15. Glueck CJ, M attson F, Bierman EL. Diet and cor- onary heart disease: another view. N Engl J M ed l978;298: 1471-4. 16. Stamler i. Lifestyles, major risk factors, proof, and public policy. Circulation 1978;58:3-19. 17. iacobs ir DR. Anderson iT , Bla ck b u r n H . Diet and serum cholesterol: do zero correlations negate the relationship? Am J Epidemiol 1979;hlO:77-86. 18. Keys A. Seven countries. A multivariate analysis of death and coronary heart disease. Cambridge, M A: Harvard University Press, 1980. 19. Kannel W B, Gordon T (eds). The Framingham Study-an epidemiological investigation of cardio- vascular disease. Section 24: The Framingham Diet Study: Diet and the regulation serum ch olest er oL W ashington, DC : US Dep a r t m en t of H ea lt h , Edu- cation and W elfare, 1970. 20. Nichols AB, Ravenscroft C, Lamphiear DE. Daily
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2038 FORT M ANN ET AL . nutritional intake and serum lipid levels. The Tec- umseh Study. Am i Chin Nutr 1976;29: 1384-92. 21. Kato H, Tillotson i, Nichaman M Z, Rhoads GG, Hamilton HB. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: serum lipids and diet. Am J Epidemiol l973;97:372-85. 22. Garcia-Palmieri M R, Tillotson J, Cordero E, et al. Nutrient intake and serum lipids in urban and rural Puerto Rican men. Am J Cliii Nutr l977;30:2092- 100. 23. M RFIT Research Group. W eight loss and choles- terol lowering. Circulation 1977;56(suppl 3):III-45. 24. Stern M P. The recent decline in ischemic heart disease mo r t a l i t y . An n Intern M ed 1979; 91:630-40. 25. Sherwin R. Controlled trials in the diet-heart hy- pothesis: some comments on the experimental unit. Am i Ep i d e mi o l 1 9 7 8 ; l 0 8 : 9 2 - 9 .
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Vegetarian Pescatarian and Flexitarian Diets Sociodemographic Determinants and Association With Cardiovascular Risk Factors in A Swiss Urban Population
Is Dieting Good For You?: Prevalence, Duration and Associated Weight and Behaviour Changes For Speci®c Weight Loss Strategies Over Four Years in US Adults
Demographic and Psychosocial Correlates of Measurement Error and Reactivity Bias in A Four Day Image Based Mobile Food Record Among Adults With Overweight and Obesity
In The United States Bankruptcy Court For The District of Delaware in Re:) ) Mervyn'S Holdings, LLC, Et Al.) Case No. 08-11586 (KG) ) ) Debtors.) Affidavit of Service