The Surgeon General's Report on NUTRITION AND HEALTH 1988 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service DHHS (PHS) Publication No. 8840210 For sale by the Superintendent of Documents, U.S. Government Printing Of&e Washington. DC 20402 GPO Stock Nuniber 017M)14O465-1 DEPARTMENT OF HEALTH & HUMAN SERVICES The Surgeon General of the Public Health Service Waehington DC 20201 MESSAGE FROM THE SURGEON GENERAL I am pleased to transmit to the Secretary of the Department of Health and Human Services this first Surgeon General's Report on Nutrition and Health. It was prepared under the auspices of the Department's Nutrition Policy Board, and its main conclusion is that overconsumption of certain dietary components is now a major concern for Americans. While many food factors are involved, chief among them is the disproportionate consumption of foods high in fats, often at the expense of foods high in complex carbohydrates and fiber--such as vegetables, fruits, and whole grain products--that may be more conducive to health. I offer this Report in the context of the obligation of the Surgeon General to inform the American public of developments in the science base that have widespread implications for human health. Perhaps the classic example of such reports is the one issued in 1964 during the tenure of one of my predecessors, Dr. Luther Terry, which summarized the epidemiologic evidence available at the time on the relationship of tobacco to health. This report called attention to the inescapable conclusion that cigarettes were a major source of illness and death for those who smoked--at that time a majority of adult men. This Surgeon General's Report on Nutrition and Health follows the tradition of the original report on smoking and health. It addresses an area of some controversy and substantial misunderstanding. And the relative magnitude of the associated health concerns is comparable, with dietary factors playing a prominent role in five of the ten leading causes of death for Americans. In addition, the depth of the science base underlying its findings is even more impressive than that for tobacco and health in 1964, with animal and clinical evidence adding to the epidemiologic studies. On the other hand there are some fundamental differences. Most obvious is the fact that food is necessary for good health. Foods contain nutrients essential for normal metabolic function, and when problems arise, they result from imbalance in nutrient intake or from harmful interaction with other factors. Moreover, we know today much more about individual variation in response to nutrients than we know about possible variations in response to tobacco. Some people are clearly more susceptible than others to problems from diets that are, for example, higher in fat or salt. Also, unlike the experience for tobacco in 1964, people are already making dietary changes, as witnessed by the shift to products lower in saturated fats. Nonetheless, the important effects of the dietary factors underlying problems like coronary heart disease, high blood pressure, stroke, some types of cancer, diabetes, obesity--problems that represent the leading health threats for Americans--indicate the potential for substantial gains to be accrued by the recommendations contained in this Report It is important to emphasize that the focus of this Report is primarily on the relationship of diet to the occurrence of chronic diseases. The Report is not intended to address the problems of hunger or undernutrition that may occur in the United States among certain subgroups uf the population. All Americans should have access to an appropriate diet, but they do not. And even though the size and numbers of problems related to inadequate access to food are proportionately much smaller than those related to dietary excesses and imbalances, the problems of access to food are of considerable concern to me, personally, wherever they may occur. The apparently sizable numbers of people resorting to the use of soup kitchens and related food facilities, as well as the possible role of poor diet as a contributor to the higher infant mortality rates associated with inadequate income, suggest the need for better monitoring of the nature and extent of the problem and for sustained efforts to correct the underlying causes of diminished health due to inadequate or inappropriate diets. This report was prepared primarily for nutritional policy makers, although the eventual beneficiaries of better nutritional policy will be the American people. I am convinced that with a concerted effort on the part of policy makers throughout the Nation, and eventually by the public, our daily diets can bring a substantial measure of better health to all Americans. I commend to them the recommendations of this Report. C. Everett Koop, M.D., Sc.D. Surgeon General U.S. Public Health Service This first Surgeon General's Report on Nutrition and Health marks a key event in the history of public health in the United States. While the Report has been developed for use by policymakers, it offers lessons that can be directly applied to the public. It responds to the increasing interest of scientists, health professionals, and the American people in the role of diet in health promotion. Within recent years, concerns about nutrition and health have expanded beyond the need to prevent deficiencies to encom- pass the effects of typical American dietary patterns on the incidence of chronic diseases that are leading causes of death and disability in this country. Although scientific research has provided substantial insight into the ways specific dietary factors influence specific diseases, there are still many uncertainties about diet-disease relationships. The Department of Health and Human Services, through the Public Health Service and the Surgeon General, welcomes the responsibility to evaluate the current state of knowledge and to advise the public accordingly. This Report reviews the scientific evidence that relates dietary excesses and imbalances to chronic diseases. On the basis of the evidence, it recommends dietary changes that can improve the health prospects of many Americans. Of highest priority among these changes is to reduce intake of foods high in fats and to increase intake of foods high in complex carbohydrates and fiber. The evidence presented here indicates the convergence of similar dietary recommendations that apply to prevention of multiple chronic diseases. The recommendation to reduce dietary fat, for example, aims to reduce the risk for coronary heart disease, diabetes, obesity, and some types of cancer. This advice is not new, But it is now substantiated by a large body of evidence derived from many different kinds of research-a research base that is now even more comprehensive than was the case for the pioneering 1964 Surgeon General's Report on Smoking and Health. The weight of this evidence and the magnitude of the problems at hand indicate that it is now time to take action. In the cause of good health for all our citizens, I urge support for this Report's recommendations by every sector of American society. Otis R. Bowen, M.D. Secretary V Preface The Public Health Service of the Department of Health and Human Ser- vices has long maintained an interest in the relationship between food and health. In the 1970's, this interest began to focus on the ways in which dietary excesses and imbalances increase the risk for chronic diseases. With the publication in 1979 of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, attention turned toward environmental and behavioral changes that Americans might make to reduce their risks for morbidity and mortality. Nutrition was one such priority area. The 1980 report Promoting HealthlPreventing Disease: Ob- jectives for the Nation included 17 specific, quantifiable objectives in nutrition designed to reduce risks and to prevent illness and death. Also in 1980, the Department published, jointly with the U.S. Department of Agriculture, the first edition of Dietary Guidelines for Americans. This report, revised in 1985, includes seven recommendations that, taken to- gether, address the relationship between diet and chronic diseases. Diseases such as coronary heart disease, stroke, cancer, and diabetes remain leading causes of death and disability in the United States. Substan- tial scientific research over the past few decades indicates that diet can play an important role in prevention of such conditions. The Public Health Service has now reviewed this research and has produced a comprehensive analysis of the relationship between dietary factors and chronic disease risk. This Surgeon GeneralS Report on Nutrition and Health summarizes research on the role of diet in health promotion and disease prevention. Its findings indicate the great importance of diet to health. They demonstrate that changes in present dietary practices of Americans could produce substantial gains in the health of the population. The Public Health Service is committed to improving the health of Americans through its programs in education, services, and research. One mechanism for improving the health of Americans is through the 1990 Health Objectives for the Nation. The role of nutrition in health will continue to be a focus of national health priorities as we develop new objectives for the year 2000. Federal, State, and local governments, the American public, the food industry, and scientists and health professionals can work together to encourage Americans to make healthy food choices and to achieve national health goals. vii 1 am pleased to commend to the American people this review of the scientific evidence that links diet to chronic disease, and I urge that the findings of this important Report be given your careful consideration. Robert E. Windom, M.D. Assistant Secretary for Health . . . vu1 Contents Foreword .................................................... v Preface ..................................................... vii Nutrition Policy Board ....................................... xiv Acknowledgments ............................................ xv Summary and Recommendations ................................ 1 Chapter 1: Introduction and Background ........................ 2 1 Chapter 2: Coronary Heart Disease ............................. 83 Chapter 3: High Blood Pressure ............................... 139 Chapter4:Cancer ........................................... 177 Chapter 5: Diabetes .......................................... 249 Chapter6:Obesity.. ......................................... 275 Chapter 7: Skeletal Diseases .................................. 3 11 Chapter 8: Dental Diseases ................................... 345 Chapter9:KidneyDiseases ................................... 381 Chapter 10: Gastrointestinal Diseases .......................... 403 Chapter 11: Infections and Immunity .......................... 427 Chapter 12: Anemia .......................................... 465 Chapter 13: Neurologic Disorders ............................. 491 Chapter 14: Behavior ........................................ 509 , Chapter 15: Maternal and Child Nutrition ...................... 539 Chapter16:Aging ........................................... 595 Chapter 17: Alcohol .......................................... 629 Chapter 18: Drug-Nutrient Interactions ......................... 67 1 Chapter 19: Dietary Fads and Frauds .......................... 695 Index ...................................................... 713 ix Tables 1. 2. l-l. l-2. l-3. l-4. l-5. l-6. l-7. 1-8. l-9. 2-l. 2-2. 2-3. 2-4. Recommendations..................................... 3 Estimated Total Deaths and Percent of Total Deaths for the 10 Leading Causes of Death: United States, 1987 . . . . . . . . . . . . . 4 Estimated Total Deaths and Percent of Total Deaths for the 10 + Leading Causes of Death: United States, 1987 . . . . . . . . . . . . . 22 Selected Events in the History of Nutritional Science to1950............................................... 25 Selected Federal Domestic Nutrition Policy Initiatives, 1862-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 National Nutrition Surveillance Activities . . . . . . . . . . . . . . . . 38 Federal Dietary Recommendations for the General Public, 1917-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Food and Nutrition Board, National Academy of Sciences- National Research Council Recommended Daily Dietary Allowances, Revised 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Estimated Safe and Adequate Daily Intakes of Selected VitaminsandMinerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Annual Per Capita Availability of Selected Commodities in the U.S. Food Supply, 1%5-1985 . . . . . . . . . . . . . . . . . . . . . . . . 65 Mean Daily Intake of Food Energy, Nutrients, and Food Components for Men, Women, and Young Children From the Continuing Survey of Food Intakes by Individuals (CSFII), 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Death Rate for Coronary Heart Disease by Age, Race, and Sex, United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Prevalence of Coronary Heart Disease by Age, Race, and Sex, United States, 1985 . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . 86 National Cholesterol Education Program Adult Treatment Panel Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Estimates of Serum Cholesterol Change From Given Changes in Dietary Lipids Based on Isocaloric Controlled Experiments in Humans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 X 3-1. 3-2. 3-3. 3-4. 3-5. 3-6. 3-7. 4-l. 4-2. 4-3. 4-4. 4-5. 4-6. 4-7. 4-8. , 4-9. 4-10. Classification of Blood Pressure in Adults 18 Years or Older ................................................ 143 Estimated Prevalence of Cardiovascular Disease in the United States ................................................ 143 Control Mechanisms for Arterial Pressure ................ 145 Major Nutrients and Possible Mechanisms for Influencing BloodPressure.. ...................................... 147 Changes in Weight and Blood Pressure (Baseline to Followup) in Treatment (Rx) and Control Groups of Five Randomized ControlledTrials ...................................... 149 Studies of Cross-Sectional Association of Blood Pressure With Alcohol Consumption ............................. 154 Prospective Observational Studies of the Association of Blood Pressure With Alcohol Consumption ..................... 155 Proportions of Cancer Deaths Attributed to Various Factors ............................................... 180 International Changes Since 1950 in Death Certification Rates for Cancers of Stomach and Lung .................. 181 Cancer Incidence Rates in the Philippines and Among Filipinos and Caucasians in Hawaii ...................... 182 Reported Relationship Between Selected Dietary ComponentsandCancer ............................... 191 National Cancer Institute Dietary Guidelines .............. 192 Comparison of Dietary Guidelines for the American Public ...................................... 193 Summary of Epidemiologic Studies Examining Dietary Fat andBreastCancer ..................................... 196 Retrospective Human Studies Relating Body Weight and Cancer ............................................... 200 Summary of Epidemiologic Studies Examining Dietary Fiber and Colon Cancer ..................................... 205 Dietary Vitamin A and Lung Cancer Risk: A Summary of PreviousStudies ...................................... 211 xi 4-l 1. NCI-Sponsored Prevention Clinical Trials Related to VitaminA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 4-12. 5-l. 5-2. 5-3. 6-l. 6-2. 6-3. 7-l. 8-l. Summary of Epidemiologic Studies on Selenium and CancerRisk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 History of Dietary Composition (Relative Proportion of Carbohydrate and Fat Calories) Used in Management of , Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Clinical Complications of Diabetes . . . . . . . . . . . . . . . . . . . . . . . 255 American Diabetes Association Dietary Recommendations for Persons With Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Comparison of Metropolitan Desirable Weights With Average Weights From U.S. Cohort Studies . . . . . . . . . . . . . . . . . . . . . . 282 Body Mass Index (kg/m*) Used to Define Desirable Weight and Overweight According to Three Different "Ideal" Reference Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Mortality Ratios for All Ages Combined in Relation to the Death Rate of Those 90 to 109 Percent of Average Weight . . . 290 Scientific Validity of Risk Factors . . . . . . . . . . . . . . . . . . . . , . . . 314 Supplemental Fluoride Dosage Scheduled (in mg F/day) According to Fluoride Concentrations of Drinking Water . . . 359 10-I. Summary of Digestive Processes . . . . . . . . . . . . . . . . . . . . . . . . 407 10-2. Gastrointestinal Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410 1 l-l. Causes of Food-Associated Illness . . . . . . . . . . . . . . . . . . . . . . . 448 12-I. Estimates for Percent Prevalence of Impaired Iron Status: Average of Estimates Using Three Methods: NHANES II, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468 12-2. Total Body Iron and Storage Iron . . . . . . . . . . . . . . . . . . . . . . . . 471 14-1. Behavioral and Psychologic Hypotheses to Explain Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515 14-2. Diagnostic Criteria for Anorexia Nervosa and Bulimia . . . . . . 520 15-1. Selected National Objectives to be Achieved by the Year 1990 Related to Maternal and Child Nutrition . . . . . . . . . . . . . . . . . . 545 xii 15-2. Content of Selected Nutrients in Human Milk, Commercial Formulas, and Other Milks Used for Feeding Normal Full- TermInfants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565 Figures l-l. Dependence of Biologic Function or Tissue Concentration on Intake of a Nutrient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2-l. Diagram of an Atherosclerotic Plaque . . . . . . , . . . . . . . . . . . . . 88 4-l. Range of Incidence Rates (International Comparisons) . . . . . 180 4-2. Carcinogenesis........................................ 183 4-3. Dietary Fat Intake in Relation to Breast Cancer-Related Death Rate................................................. 187 6-l. A Nomogram for Determining Body Mass Index (BMI) . . . . 284 8-l. The Distribution of Mean Decayed and Filled Coronal Surfaces (DFS) by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 8-2. The Distribution of Mean Decayed and Filled Root Surfaces (DFS) by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 8-3. Percent of Persons by Severe Loss of Periodontal Attachment (Pocket Depths Measuring 4 mm or More) andAgeGroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 8-4. Comparison of the Percent of Edentulous Persons in the 1985-86 NIDR Survey to That Reported From the NCHS Surveyof1960-62 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 8-5. Schematic Cross-Section of a Typical Mandibular Molar Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352 9-l. The Comparative Structures of Amino Acids, Ketoacids, and Hydroxyacids......................................... 391 . . . Xl11 Nutrition Policy Board U.S. Department of Health and Human Services J. Michael McGinnis, M.D. (Chairman), Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion), Public Health Service - Faye G. Abdellah, R.N., Ed.D., Sc.D., Deputy Surgeon General, Public Health Service W. Douglas Badger, M.Div., Deputy Assistant Secretary, Office of Human Development Services Mary M. Ever& M.B.A., Director, Office of Community Services, Family Support Administration Manning Feinleib, M.D., M.P.H., Dr.P.H., Director, National Center for Health Statistics, Centers for Disease Control, Public Health Service Allan L. Forbes, M.D., Director, Office of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administra- tion, Public Health Service William T. Friedewald, M.D., Associate Director for Disease Prevention, National Institutes of Health, Public Health Service Bernard I. Grosser, M.D., Director, Office of Science, Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service John Porvaznik, M.D., F.A.C.S., Associate Director, Office of Health Programs, Indian Health Service, Public Health Service William A. Robinson, M.D., M.P.H., Chief Medical OBicer, Health Re- sources and Services Administration, Public Health Service xiv Acknowledgments The Surgeon General's Report on Nutrition and Health was prepared under the general editorship of the Department of Health and Human Services' Nutrition Policy Board, whose members are listed on the pre- vious page. Managing Editor was Marion Nestle, Ph.D., M.P.H., Office of Disease Prevention and Health Promotion. Special editorial assistance was contributed by John Bailar III, M.D., Ph.D., Science Advisor, Office of Disease Prevention and Health Promotion, and by Darla E. Danford, M.P.H., D.Sc., R.D., National Institutes of Health. Project Officer during early stages of preparation of the Report was Ann Sorenson, Ph.D., now with the National Institutes of Health. In addition to the guidance of the Nutrition Policy Board's Senior Editorial Advisors and Staff Working Group, important editorial contributions were made by Karen Donato, M.S., R.D., Nancy D. Ernst, M.S., R.D., Marilyn E. Farrand,M.S.,R.D.,andVanS. Hubbard,M.D.,Ph.D.,oftheNation- al Institutes of Health's Nutrition Education Subcommittee; and by Walter H. Glinsmann, M.D., Marilyn G. Stephenson, M.S., R.D., John E. Van- derveen, Ph.D., and Elizabeth Yetley, Ph.D., R.D., of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. Senior Editorial Advisors to the Nutrition Policy Board were: C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George Washington University Medical Center, Washington, D.C. `Johanna T. Dwyer, D.Sc., Director, Frances Stem Nutrition Center, New England Medical Center Hospitals, and Professor of Medicine, Tufts Uni- versity Medical School, Boston, Massachusetts Samuel Fomon, M.D., Professor of Pediatrics, University of Iowa, Iowa City, Iowa Richard L. Hall, Ph.D., Vice President, Science and Technology, McCor- mick & Co., Inc., Hunt Valley, Maryland Robert I. Levy, M.D., President, Sandoz Research Institute, East Hano- ver, New Jersey Walter Mertz, M.D., Director, Beltsville Human Nutrition Research Cen- ter, U.S. Department of Agriculture, Beltsville, Maryland xv Malden C. Nesheim, Ph.D., Vice President for Planning and Budget, Cornell University, Ithaca, New York Sushma Palmer, D.Sc., Executive Director, Food and Nutrition Board, National Academy of Sciences, Washington, D.C. Irwin H. Rosenberg, M.D., Director, USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts Theodore Van Itallie, M.D., Professor of Medicine, Columbia University College of Physicians and Surgeons, New York, New York Nutrition Policy Board Staff Working Group members were: Elizabeth Brannon, M.S., R.D., Clinical Nutrition Specialist, Bureau of Maternal and Child Health and Resources Development, Health Resourc- es and Services Administration, Rockville, Maryland Darla E. Danford, M.P.H., D.Sc., R.D., Nutritionist, Nutrition Coordinat- ing Committee, National Institutes of Health, Bethesda, Maryland Willie M. Etheridge, M.S., Policy Analyst, Policy Planning and Legislation Division, Office of Human Development Services, Washington, D.C. James J. Heam, L.L.B., Chief, Community Food and Nutrition Program, Office of Community Services, Family Support Administration, Washing- ton, D.C. M. Yvonne Jackson, Ph.D., R.D., Chief, Nutrition and Dietetics Section, Indian Health Service, Rockville, Maryland Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention and Health Promotion, Washington, D.C. Marion Nestle, Ph.D., M.P.H., Director, Nutrition Policy Staff, Office of Disease Prevention and Health Promotion, Washington, D.C. Lana Skirboll, Ph.D., Special Assistant to the Director, Offtce of Science, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland Frederick Trowbridge, M.D., M.S., Director, Nutrition Division, Center for Health Promotion and Education, Centers for Disease Control, Atlan- ta, Georgia xvi Catherine E. Woteki, Ph.D., R.D., Deputy Director, Division of Health Examination Statistics, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland Individuals who contributed to the writing of draft chapters or portions of the Report were: Margaret J. Albrink, M.D., M.P.H., Professor of Medicine, West Virginia University Medical Center, Morgantown, West Virginia (Obesity) William R. Beisel, M.D., Adjunct Professor, Department of Immunology and Infectious Diseases, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland (Infections and Immunity) C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George Washington University Medical Center, Washington, D.C. (Alcohol) Joseph E. Ciardi, Ph.D., Research Biochemist, Caries and Restoration Materials Research Branch, Extramural Program, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland (Den- tal Diseases) Phyllis A. Crapo, R.D., Department of Medicine, University of California at San Diego, LaJolla, California (Diabetes) Jeffrey A. Cutler, M.D., Chief, Prevention and Demonstration Research Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (High Blood Pressure) Peter R. Dallman, M.D., Professor, Department of Pediatrics, University of California, San Francisco, California (Anemia) Barbara H. Dennis, R.D., Ph.D., Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (Coronary Heart Disease) John Duguid, M.D., Ph.D., Neurologist, Massachusetts Institute of Tech- nology, Cambridge, Massachusetts (Neurologic Disorders) Robert Edelman, M.D., Chief, Clinical and Epidemiological Studies Branch, Deputy Director, Microbiology and Infectious Diseases Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (Infections and Immunity) xvii Nancy D. Ernst, MS., R.D., Nutrition Coordinator, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary- land (High Blood Pressure) Lloyd J. Filer, Jr., M.D., Ph.D., Department of Pediatrics, University of Iowa School of Medicine, Iowa City, Iowa (Maternal and Child Nutrition) Mattie R.S. Fox, Ph.D., Chief, Nutrient Interaction Section, Experimental Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. (Introduction and Background) Philip J. Garry, Ph.D., Professor, Department of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico (Aging) James Goodwin, M.D., Professor and Vice Chairman, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (Aging) Sheila Gottschalk, M.D., Associate Professor of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana (Maternal and Child Nutrition) , Gregory E. Gray, M.D., Ph.D., Assistant Professor, Department of Psy- chiatry and the Behavioral Sciences, Los Angeles County-University of Southern California Medical Center, Los Angeles, California (Behavior) Peter Greenwald, M.D., lX.P.H., Director, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (Cancer) John H. Growdon, M.D., Massachusetts Institute of Technology, Massa- chusetts General Hospital, and Harvard Medical School, Cambridge, Mas- sachusetts (Neurologic Disorders) Margaret A. Hamburg, M.D., Special Assisiant to the Director, National Institute of Allergy and Infectious Diseases-, National Institutes of Health, Bethesda, Maryland (Infections and Immunity) James P. Hat-wood, Ph.D., Executive Secretary, Scientific Review Office, National Institute on Aging,-National Institutes of Health, Bethesda, Maryland (Introduction and Background) Michael Horan, M.D., Chief, Hypertension and Kidney Diseases Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (High Blood Pressure) Richard D. Hurt, M.D., Mayo Clinic, Rochester, Minnesota (Alcohol) . . XVlll Howard Jacobson, M.D., Institute of Nutrition, University of North Car- olina, Chapel Hill, North Carolina (Maternal and Child Nutrition) Mamie Y. Jenkins, Ph.D., Research Chemist, Bioavailability Section, Experimental Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. (Introduction and Background) Alexander Jordan, Ph.D., Supervisory Pharmacologist, Food and Drug Administration, Rockville, Maryland (Drug-Nutrient Interactions) George M. Kazzi, M.D., Chief, Department of Obstetrics and Gynecolo- gy, Harper-Grace Hospitals, and Assistant Professor, Maternal-Fetal Medicine, Wayne State University School of Medicine, Detroit, Michigan (Maternal and Child Nutrition) Joel D. Kopple, M.D., Professor of Medicine and Public Health, Univer- sity of California at Los Angeles, Chief, Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, California (Kid- ney Diseases) Markus J.P. Kruesi, M.D., Staff Psychiatrist, National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Rock- ville, Maryland (Behavior) Elaine Lanza, Ph.D., Diet and Cancer Branch, Division of Cancer Preven- tion and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (Cancer) Harris R. Lieberman, Ph.D., Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts (Neu- , rologic Disorders; Behavior) Gardner C. McMillan, M.D., Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (Coronary Heart Disease) Albert I. Mendeloff, M.D., M.P.H., Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland (Gastroin- testinal Diseases) Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention and Health Promotion, Washington, D.C. (Introduction and Background) Sanford A. Miller, Ph.D., Director, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. (Introduction and Background) xix Geraldine V. Mitchell, Ph.D., Chief, Bioavailability Section. Experimental Nutrition Branch, Division of Nutrition. Food and Drug Administration, Washington, D.C. (Introduction and Background) Eliot N. Mostow, M.D., M.P.H., Medical Staff Fellow, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (Cancer) Jerrold M. Olefsky, M.D., Department of Medicine, University of Califor- nia at San Diego, and San Diego Veterans Administration Medical Center, San Diego, California (Diabetes) Youngmee K. Park, Ph.D., Nutritionist, Clinical Nutrition Branch, Divi- sion of Nutrition, Food and Drug Administration, Washington, D.C. (Intro- duction and Background) Jean A.T. Pennington, Ph.D., Assistant to the Director, Division of Nutri- tion, Food and Drug Administration, Washington, D.C. (Introduction and Background) L. Ross Pierce, M.D., Group Leader, Food and Drug Administration, Rockville, Maryland (Drug-Nutrient Interactions) Peggy L. Pipes, M.P.N., R.D., Child Development Mental Retardation Center, University of Washington, Seattle, Washington (Maternal and Child Nutrition) Ernest0 Pollitt, Ph.D., Department of Applied Behavioral Sciences, Uni- versity of California, Davis, California (Maternal and Child Nutrition) Leon Prosky, Ph.D., Deputy Chief, Experimental Nutrition Branch, Divi- sion of Nutrition, Food and Drug Administration, Washington, D.C. (Intro- duction and Background) Jeanne I. Rader, Ph.D., Chief, Nutrient Toxicity Section, Experimental Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. (Introduction and Background) Lawrence G. Raisz, M.D., Professor of Medicine and Chief, Division of Endocrinology and Metabolism, University of Connecticut School of Med- icine, Farmington, Connecticut (Skeletal Diseases) Judith L. Rapoport, M.D., Chief, Child Psychiatry Branch, National Insti- tute of Mental Health, Alcohol, Drug Abuse, and Mental Health Adminis- tration, Rockville, Maryland (Behavior) xx Merrill S. Read, Ph.D., Professor and Chairman, Human Nutrition and Food Systems, College of Human Ecology, University of Maryland, Col- lege Park, Maryland (Maternal and Child Nutrition) Basil M. Rifkind, M.D., F.R.C.P., Division of Heart and Vascular Dis- eases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (Coronary Heart Disease) Norman E. Rosenthal, M.D., Chief, Unit on Outpatient Studies, Clinical Psychology Branch, National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland (Behav- ior) Neil L. Sass, Ph.D., Senior Scientist, ORice of Management, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Wash- ington, D.C. (Introduction and Background) Claudia Schuth, M.D., Associate Professor of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana (Maternal and Child Nutrition) James H. Shaw, Ph.D., Professor of Nutrition Emeritus, Harvard School of Dental Medicine, Boston, Massachusetts (Dental Diseases) Alan J. Sheppard, Ph.D., Chief, Experimental Methods Research Section, Nutrient Surveillance Branch, Division of Nutrition, Food and Drug Ad- ministration, Washington, D.C. (Introduction and Background) Solomon Sobel, M.D., Food and Drug Administration, Rockville, Mary- land (Drug-Nutrient Interactions) Robert J. Sokol, M.D., Professor and Chairman and Chief, Department of Obstetrics and Gynecology, Wayne State University, Hutzel Hospital, Detroit, Michigan (Maternal and Child Nutrition) Marilyn G. Stephenson, M.S., R.D., Assistant to the Director, OfIice of Nutrition and Food Sciences, Center for Food Safety and Applied Nutri- tion, Food and Drug Administration, Washington, DC. (Dietary Fads and Frauds) Albert Stunkard, M.D., Professor of Psychiatry, University of Pennsylva- nia School of Medicine, Philadelphia, Pennsylvania (Behavior) Robert M. Suskind, M.D., Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana (Maternal and Child Nutrition) xxi Shyy Hwa Tao, Ph.D., Research Chemist, Nutrient Interaction Section, Experimental Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. (Imroduction and Background) Thomas Thorn, Statistician, Epidemiology and Biometry Research Pro- gram, Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary- land (Coronary Heart Disease) Gloria Troendle, M.D., Deputy Director, Food and Drug Administration, Rockville, Maryland (Drug-Nutrient Interactions) Momtaz Wassef, Ph.D., Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (Coronary Heart Disease) Cora E. Weeks, J.D., Ph.D., Consumer Safety Officer, Division of Reg- ulatory Guidance, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. (Introduction and Background) Robert W. Wissler, M.D., Ph.D., Donald N. Pritzker Distinguished Service Professor of Pathology Emeritus, University of Chicago, Chicago, Illinois (Coronary Heart Disease) Philip A. Wolf, M.D., Professor of Neurology and Associate Research Professor of Medicine, Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, Massachusetts (Neurologic Disor- ders) Bonnie S. Worthington-Roberts, Ph.D., Professor, Nutritional Sciences, University of Washington, Child Development Center, Seattle, Washington (Maternal and Child Nutrition) Catherine E. Woteki, Ph.D., R.D., Deputy Director, Division of Health Examination Statistics, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland (Introduction and Background) Richard J. Wurtman. M.D., Professor, Department of Brain and Cognitive Sciences, Director, Clinical Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts (Neurologic Disorders; Behavior) Elizabeth Yetley, Ph.D., R.D., Chief, Clinical Nutrition, Division of Nutri- tion, Office of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. (In- troduction and Background) xxii During preparation of the Report, chapters were subjected to six stages of critical review, three by experts within the Public Health Service (internal reviews) and three by scientists and professionals recommended as experts by national scientific and nutrition professional organizations in the private sector (external reviews). In addition, the senior editorial advisors and staff to the Nutrition Policy Board listed above provided expert technical eval- uation throughout the review process. Individuals who reviewed chapters or potions of the Report were: Phyllis B. Acosta, Dr.P.H., R.D., Director of Metabolic Diseases, Ross Laboratories, Columbus, Ohio Lawrence Agodoa, M.D., Coordinator, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Duane F. Alexander, M.D., Director, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Mary- land Aaron M. Altschul, Ph.D., Diet Management and Eating Disorders Pro- gram, Georgetown University, Washington, D.C. Ronald A. Arky, M.D., Professor, Department of Medicine, Harvard Medical School at Mt. Auburn Hospital, Cambridge, Massachusetts Louis Avioli, M.D., Professor of Medicine and Oral Biology, Washington University School of Medicine and Dental School, St. Louis, Missouri David Badman, Ph.D., Hematology Program Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland John Bailar III, M.D., Ph.D., Science Advisor, Office of Disease Preven- tion and Health Promotion, Washington, D.C. David H. Baker, Ph.D., Professor of Nutrition and Metabolism, Univer- sity of Illinois, Urbana, Illinois Susan Blumenthal, M.D., Medical Oflicer and Chief, Behavioral Medicine Program, National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, RockvilIe, Maryland Ronette Briefel, Dr.P.H., R.D., Nutritional Epidemiologist, Survey Plan- ning and Development Branch, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland . . . xx111 Benjamin Burton, Ph.D., Associate Director for Disease Prevention and Technology Transfer, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Ritva Butrum, Ph.D., Diet and Cancer Branch, Division of Cancer Preven- tion and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Charles E. Butterworth, Jr., M.D., Director, Clinical Nutrition Research Unit, University of Alabama, Birmingham, Alabama George F. Cahill, Jr., M.D., Howard Hughes Medical Institute, Boston, Massachusetts Doris H. Calloway, Ph.D., Provost Professor Schools and College, Uni- versity of California, Berkeley, California Richard Calve& M.D., Medical Research Nutritionist, Experimental Nu- trition Branch, O&e of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washing- ton, D.C. Mona Calvo, Ph.D., R.D., Nutritionist, Clinical Nutrition, Division of Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. James P. Carlos, D.D.S., Chief, Epidemiology Branch, Epidemiology and Oral Disease Prevention Program, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland Kenneth K. Carroll, Ph.D., Professor, Department of Biochemistry, Uni- versity of Western Ontario, London, Ontario, Canada Ranjit K. Chandra, M.D., F.R.C.P., Janeway Child Health Center, Immu- nology Department, St. John's, Newfoundland, Canada Lois Chatham, Ph.D., Director, Division of Basic Research, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, Rockville; Maryland Aram V. Chobanian, M.D., Director and Professor, Cardiovascular Insti- tute, Boston University School of Medicine, Boston, Massachusetts Joginder G. Chopra, M.D., Special Assistant, Medical Affairs, Office of Nutrition and Food Sciences, Center.for Food Safety and Applied Nutri- tion, Food and Drug Administration, Washington, D.C. Gregory Christenson, Ph.D., Special Population Studies Branch, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Carolyn Clifford, Ph.D., Diet and Cancer Branch, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland James D. Cook, M.D., Division of Hematology, University of Kansas Medical Center, Kansas City, Kansas Stephen B. Corbin, D.D.S., M.P.H., Senior Prevention Policy Advisor, Prevention Policy Staff, OfIice of Disease Prevention and Health Promo- tion, Washington, D.C. Ann Coulston, M.S., R.D., Clinical Research Center, Stanford University Hospital, Stanford, California Frances Cronin, Ph.D., R.D., Chief, Diet Appraisal Research Branch, Nutrition Education Division, Human Nutrition Information Service, U.S. Department of Agriculture, Hyattsville, Maryland Cheryl L. Damberg, M.P.H., Director of Marketing, General Health Inc., Washington, D.C. Michele DeBartolo, M.P.H., R.D., Senior Clinical Research Associate, Pharmaceutical Products Division, Abbott Laboratories, Abbott Park, Illinois Hector F. DeLuca, Ph.D., Department of Biochemistry, College of Agri- culture and Life Sciences, University of Wisconsin, Madison, Wisconsin Dominick P. DePaola, D.D.S., Ph.D., Dean, University of Medicine and Dentistry of New Jersey, New Jersey Dental School, Newark, New Jersey Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute, Nation- al Institutes of Health, Bethesda, Maryland Karen Donato, M.S., R.D., Nutritionist, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Allan L. Drash, M.D., Professor of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Penn- sylvania XXV Mary Dufour, M.D., Chief, Epidemiology Branch, Division of Biometry and Epidemiology, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland Harriet P. Dustan, M.D., Veterans Administration Distinguished Physi- cian and University Distinguished Professor Emeritus, Veterans Adminis- tration Medical Center, University of Alabama at Birmingham, Bir- mingham, Alabama Mary Egan, R.D., M.S., M.P.H., National Center for Education in Mater- nal and Child Health, Georgetown University, Washington, D.C. Shirley Ekvall, Ph.D., R.D., Professor and Chief of Nutrition Services, University of Cincinnati and University Affiliated Cincinnati Center for Developmental Disorders, Children's Hospital Medical Center, Cincin- nati, Ohio Lillian Emmons, Ph.D., R.D., Comprehensive Psychiatric Services, Inc., Cleveland, Ohio Arnold Engel, M.D., Commission Officer, Medical Statistics Branch, National Center for Health Statistics, Centers for Disease Control, Hyatts- ville , Maryland Frank Falkner, M.D., F.R.C.P., School of Public Health, University of California, Berkeley, California Marilyn E. Farrand, M.S., R.D., Public Health Nutrition, Prevention and Demonstration Research Branch, Division of Epidemiology and Clinical Application, National Heart, Lung, and Blood Institute, National Insti- tutes of Health, Bethesda, Maryland Owen Fennema, Ph.D., Department of Food Science, University of Wis- consin at Madison, Madison, Wisconsin John D. Femstrom, Ph.D., Professor of Psychiatry and Behavioral Neuro- science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsyl- vania Willis R. Foster, M.D., Senior Staff Physician, Office of Disease Preven- tion and Technology Transfer, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Judith Fradkin, M.D., Chief, Endocrine and Metabolic Diseases Programs Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland xxvi Victor Frattali, Ph.D., Deputy Director, Division of Nutrition, Offtce of Nutrition and Food Sciences, Center for Food Safety and Applied Nutri- tion, Food and Drug Administration, Washington, D.C. Robert A. Fried, M.D., Associate Professor and Director of Clinical Af- fairs, Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado Edward D. Frohlich, M.D., Alton Ochsner Distinguished Scientist and Vice President for Academic Affairs, Alton Ochsner Medical Foundation, Staff Member, Section on Hypertensive Diseases, Ochsner Clinic, New Orleans, Louisiana Peter Frommer, M.D., Deputy Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Margie Gallagher, Ph.D., R.D., School of Home Economics, Institute for Coastal and Marine Resources, East Carolina University, Greenville, North Carolina Dian Gans, M.S., Research Assistant, Department of Nutritional Sci- ences, University of Wisconsin at Madison, Madison, Wisconsin Stanley M. Gam, Ph.D., Center for Human Growth and Development, University of Michigan, Ann Arbor, Michigan Peter Gergen, M.D., Commission Officer, Medical Statistics Branch, Na- tional Center for Health Statistics, Centers for Disease Control, Hyatts- ville , Maryland Dorothy W. Gietzen, Ph.D., Assistant Research Neurophysiologist, De- partment of Physiologic Sciences, School of Veterinary Medicine, Depart- ment of Psychiatry, School of Medicine, University of California at Davis, Davis, California Susan Gilbert, M.P.A., Associate, Prospect Associates, Rockville, Mary- land Walter H. Glinsmann, M.D., Associate Director, Clinical Nutrition, Divi- sion of Nutrition, Food and Drug Administration, Washington, D.C. Vay Liang W. Go, M.D., Chairman, Nutrition Coordinating Committee, National Institutes of Health, Bethesda, Maryland Murray Goldstein, D.O., M.P.H., Director, National Institute of Neu- rological and Communicative Disorders and Stroke, National Institutes of Health, Bethesda, Maryland xxvii Dewitt S. Goodman, M.D., Professor of Medicine, Department of Medi- cine, College of Physicians and Surgeons of Columbia University, New York, New York PhiUip Gorden, M.D., Director, National Institute of Diabetes and Di- gestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Enoch Gordis, M.D., Director, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse and Mental Health Administration, Rockville , Maryland Stephen L. Gordon, Ph.D., Director, Musculoskeletal Diseases Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland Gilman D. Grave, M.D., Chief, Endocrinology, Nutrition, and Growth Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland Jesse F. Gregory III, Ph.D., University of Florida, Food Science and Nutrition Department, Gainesville, Florida Joan Gussow, Ed.D., Mary Swartz Rose Professor of Nutrition and Edu- cation, Department of Nutrition and Education, Teachers College, Colum- bia University, New York Wilbur Hadden, M.A., Chief, Programming Staff, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland Evan Hadley, M.D., Chief, Geriatrics Branch, National Institute on Aging, National Institutes of Health, Bethesda, Maryland Carole Haines, M.P.H., Data Analysis Coordinator, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Mary- land Judith G. Hallfrisch, Ph.D., Senior Staff Fellow, Metabolism Section of the Gerontology Research Center, National Institute on Aging, National Institutes of Health, Bethesda, Maryland Charles H. Halsted, M.D., Ph.D., Chief, Division of Clinical Nutrition, and Professor of Internal Medicine, School of Medicine, University of California at Davis, Davis, California Linda Harris, Ph.D., Special Assistant, Gflice of Disease Prevention and Health Promotion, Washington, D.C. . . . XXVlll Tamara Harris, M.D., Service Fellow, Office of Analysis and Epidemiolo- gy Program, National Center for Health Statistics, Centers for Disease Control, HyattsviUe, Maryland John N. Hathcock, Ph.D., Chief, Experimental Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. Maureen Henderson, M.D., Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center, Seattle, Washington Stephen P. Heyse, M.D., Director, Disease Prevention, Epidemiology and Clinical Applications, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland Jules Hirsch, M.D., Professor and Senior Physician, Rockefeller Univer- sity, New York, New York Gladys Hirshman, M.D., Director, Chronic Renal Disease Program, Na- tional Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Peter R. Holt, M.D., Chief, Division of Gastroenterology, Professor of Medicine, College of Physicians and Surgeons, St. Luke's Hospital, New York, New York Steven S. Hotta, M.D., Ph.D., Medical Gflicer, Clinical Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. Anastacio M. Hoyumpa, M.D., Professor of Medicine, Division of Gas- troenterology and Nutrition, University of Texas Health Science Center, San Antonio, Texas Van S. Hubbard, M.D., Ph.D., Director, Nutritional Sciences Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Nation- al Institutes of Health, Bethesda, Maryland Sandra Huckaby, R.N., M.S.N., Special Assistant, Maternal and Infant Health Branch, Bureau of Maternal and Child Health and Resources Development, Health Resources and Services Administration, RockviUe, Maryland James C. Hunt, M.D., Chancellor, University of Tennessee, Memphis, Tennessee Vince L. Hutchins, M.D., M.P.H., Deputy Director, Bureau of Maternal and Child Health and Resources Development, Health Resources and Services Administration, Rockville, Maryland xxix William T. Jan+, Ph.D., Professor of Health Education, Department of Preventive Medicine, School of Medicine, Loma Linda University, Loma Linda, California Clifford Johnson, M.S.P.H., Chief, Nutrition Statistics Branch, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland Norman Kaplan, M.D., Professor of Internal Medicine, University of Texas Health Science Center, Dallas, Texas Gerald T. Keusch, M.D., Professor of Medicine, Department of Medicine, New England Medical Center, Boston, Massachusetts Matthew Kinnard, Ph.D., Health Scientist Administrator, National Insti- tute of Dental Research, National Institutes of Health, Bethesda, Mary- land Samuel Korper, Ph.D., Associate Director, Offtce of Planning, Analysis, and Communications, National Institute on Aging, National Institutes of Health, Bethesda, Maryland David Kritchevsky, Ph.D., Associate Director of Anatomy and Biology, Wistar Institute, Philadelphia, Pennsylvania Robert Kuczmarksi, M.S.P.H., M.P.H., Dr.P.H., R.D., Health Statisti- cian, Nutrition Statistics Branch, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland William Lands, Ph.D., Department of Biochemistry, University of Illinois at Chicago, Chicago, Illinois Lynn A. Larsen, Ph.D., Associate Director, Program Development, Divi- sion of Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. Reva C. Lawrence, M.P.H., Epidemiologist, Data Systems, Program Of- ficer, National Institute of Arthritis and Musculoskeletal and Skin Dis- eases, National Institutes of Health, Bethesda, Maryland Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Insti- tute, National Institutes of Health, Bethesda, Maryland Gilbert A. Leveille, Ph.D., Staff Vice President, NABISCO Brands, Inc., East Hanover, New Jersey xxx Ephraim Y. Levin, M.D., Medical Officer, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland Christine J. Lewis, Ph.D., R.D., Chief, Experimental Clinical Research Section, Division of Nutrition, Oflice of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administra- tion, Washington, D.C. Charles S. Lieber, M.D., Director, Alcohol Research and Treatment Cen- ter, Chief, Section of Liver Disease and Nutrition, Bronx Veterans Admin- istration Medical Center, Professor of Medicine and Pathology, Mount Sinai School of Medicine, New York, New York Jane Lin Fu, M.D., Acting Chief, Genetic Services Branch, Bureau of Maternal and Child Health and Resources Development, Health Resources and Services Administration, Rockville, Maryland Harald Lee, D.D.S., Director, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland Anne Looker, Ph.D., R.D., Health Statistician, Nutrition Statistics Branch, National Center for Health Statistics, Centers for Disease Con- trol, Hyattsville, Maryland Susan K. Maloney, M.H .S., Director, Health Communication Staff, Office of Disease Prevention and Health Promotion, Washington, D.C. Alvin Mauer, M.D., University of Tennessee, Division of Hematology/ Oncology, Memphis, Tennessee Donald B. McCormick, Ph.D., Chairman, Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia Gardner C. McMillan, M.D., Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Marilyn McMillen, Ph.D., Statistician, Surveillance and Operations Re- search Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Laura McNally, R.D., M.P.H., Nutrition Specialist, Child and Adolescent Primary Care Services Branch, Bureau of Maternal and Child Health and Resources Development, Health Resources and Services Administration, Rockville, Maryland xxxi Marsel Mesulam, M.D., Professor of Neurology, Harvard Medical School, Director, Division of Neuroscience and Behavioral Neurology, Beth Israel Hospital, Boston, Massachusetts Esteban Mezey, M.D., Professor of Medicine, Johns Hopkins Hospital, Baltimore, Maryland Angela D. Mickalide, Ph.D., Staff Coordinator, U.S. Preventive Services Task Force, Office of Disease Prevention and Health Promotion, Washing- ton, D.C. William E. Mitch, M.D., Renal Division, Emory University School of Medicine, Atlanta, Georgia Elaine R. Monsen, Ph.D., R.D., University of Washington, Seattle, Wash- ington Steven R. Moore, M.P.H., Associate Chief of Staff, Office of the Surgeon General, Rockville, Maryland Hamish N. Munro, M.D., D.Sc., Senior Scientist, USDA Human Nutri- tion Research Center on Aging, Tufts University, Boston, Massachusetts Juan M. Navia, Ph.D., Professor and Chairman, Department of Public Health Sciences, Schools of Public Health and Dentistry, University of Alabama at Birmingham, Birmingham, Alabama Buford L. Nichols, Jr., M.D., Children's Nutrition Research Laboratory, Baylor School of Medicine, Houston, Texas Phillip Nieburg, M.D., M.P.H., Medical Epidemiologist, Division of Nutri- tion, Centers for Disease Control, Atlanta, Georgia Daniel W. Nixon, M.D., Associate Director, Cancer Prevention Research Program, National Cancer Institute, National Institutes of Health, Bethes- da, Maryland Marie U. Nylen, D.D.S., Dr. Odont. h.c., Director, Extramural Program, National Institute of Dental Research, National Institutes of Health, Be- thesda, Maryland Carole A. Palmer, M.Ed., R.D., Associate Professor and Division Co- Chairman, Division of Nutrition and Prevention Dentistry, Tufts Univer- sity School of Medicine, Boston, Massachusetts xxxii Eugene Passamani, M.D., Director, Division of Heart and Vascular Dis- eases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Penelope Pollard, M.S., M.B.A., Senior Research Associate, National Health Policy Forum, Washington, D.C. Donna V. Porter, Ph.D., R.D., Specialist in Life Sciences, Science Policy Research Division, Congressional Research QIXce, Washington, D.C. Roger J. Porter, M.D., Deputy Director, National institute of Neurological and Communicative Disorders and Stroke, National Institutes of Health, Bethesda, Maryland Barbara Posner, D.P.H., R-D., Associate Professor and Director, Graduate Nutrition Division, Boston University, Boston, Massachusetts Ann Prendergast, R.D., M.P.H., Chief Nutritionist, Habilitative Services Branch, Bureau of Maternal and Child Health and Resources Develop- ment, Health Resources and Services Administration, Rockville, Mary- land Jeanne I. Rader, Ph.D., Chief, Nutrient Toxicity Section, Experimental Nutrition Branch, Division of Nutrition, Food and Drug Administration, Washington, D.C. Edward Roccella, Ph.D., M.P.H., Program Coordinator, National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Daphne A. Roe, M.D., Professor, Division of Nutritional Sciences, Cornell University, Ithaca, New York Quinton Rogers, Ph.D., Department of Physiological Sciences, School of Veterinary Medicine, University of California at Davis, Davis, California Daniel Rudman, M.D., Associate Chief of Staff, Geriatric Medicine, North Chicago Veterans Administration Medical Center, North Chicago, Illinois Robert Russell, M.D., USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts Anna A. Sandberg, Dr.P.H., Coordinator, Clinical Trial, Kidney-Urology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland . . . xxx111 Harold H. Sandstead, M.D., Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas Howerde Sauberlich, Ph.D., Department of Nutrition Science, University of Alabama, University Station, Alabama Christopher Sempos, Ph.D., Health Statistician, Nutrition Statistics Branch, National Center for Health Statistics, Centers for Disease Con- trol, Hyattsville, Maryland Zekin Shakhashiri, M.S., M.D., M.P.H., Senior Medical Advisor, National Institute of Neurological and Communicative Disorders and Stroke, Na- tional Institutes of Health, Bethesda, Maryland Lawrence E. Shulman, M.D., Ph.D., Director, National Institute of Arthri- tis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland Robert Silverman, M.D., Ph.D., Chief, Diabetes Programs Branch, Na- tional Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Christine Hamilton Smith, Ph.D., R.D., Home Economics Department, Food Science and Nutrition, California State University at Northridge, Northridge, California Dorothy D. Sogn, M.D., Chief, Asthma and Allergy Branch, Immunology, Allergic and Immunologic Diseases Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Mary- land David A.T. Southgate, Ph.D., AFRC Institute of Food Research, Norwich Laboratory, Norfolk, United Kingdom Reynold Spector, M.D., Executive Director, Merck Sharp & Dohme Re- search Laboratories, Rahway, New Jersey Judith S. Stem, Sc.D., University of California at Davis, Davis, California Eugene Streicher, Ph.D., Director, Division of Fundamental Neurosci- ences, National Institute of Neurological and Communicative Disorders and Stroke, National Institutes of Health, Bethesda, Maryland Helene Swenerton, Ph.D., Nutritionist, Cooperative Extension, Depart- ment of Nutrition, University of California at Davis, Davis, California xxxiv Jean K. Tews, Ph.D., Department of Biochemistry, University of Wiscon- sin at Madison, Madison, Wisconsin Jeanne L. Tillotson, R.D., M.A., Crofton, Maryland Phillip P. Toskes, M.D., Professor of Medicine and Director, Division of Gastroenterology, Hepatology and Nutrition, University of Florida Col- lege of Medicine and Gainesville Veterans Administration Medical Center, Gainesville, Florida Pelagia Turyn-Einhom, M.D., Medical OfIicer, Clinical Nutrition Branch, Division of Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Wash- ington, D.C. Emestine Vanderveen, Ph.D., Associate Director for AIDS, Division of Clinical Research, National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland John E. Vanderveen, Ph.D., Director, Division of Nutrition, Food and Drug Administration, Washington, D.C. John Wallingford, Ph.D., Nutritionist, Clinical Nutrition Branch, Division of Nutrition, Office of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. Donald M. Watkin, A.B., M.D., M.P.H., Manager, Occupational Health Division, Office of Aviation Medicine, Federal Aviation Administration, U.S. Department of Transportation, and Research Professor, Department of Medicine, School of Medicine and Health Sciences, The George Wash- ington University, Washington, D.C. Richard Weindruch, Ph.D., Health Scientist Administrator, National Insti- tute on Aging, National Institutes of Health, Bethesda, Maryland Gerald Wheeler, Commission Officer, Division of Health Examination Statistics, National Center for Health Statistics, Centers for Disease Con- trol, Hyattsville, Maryland Philip L. White, Sc.D., Wilmette, Illinois, Director, Division of Applied Medical Sciences, American Medical Association, Chicago, Illinois (Re- tired) T. Franklin Williams, M.D., Director, National Institute on Aging, Nation- al Institutes of Health, Bethesda, Maryland XXXV David E Williamson, M.S., Ph.D., Analytic Epidemiologist, Centers for Disease Control, Atlanta, Georgia Myron Winick, M.D., R.R. Williams Professor of Nutrition and Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York Deborah Winn, Ph.D., Epidemiologist, Survey Planning and Development Branch, National Center for Health Statistics, Centers for Disease Con- trol, Hyattsville, Maryland Maxwell M. Wintrobe, M.D., Ph.D., D.Sc., Distinguished Professor of Medicine, University of Utah Medical School, Salt Lake City, Utah Elisabeth I? Wirick, Food, Nutrition, and Dietetics, College of Health and Human Services, University of Northern Colorado, Greeley, Colorado Eleanor A. Young, Ph.D., R.D., L.D., Professor, Department of Medicine, Division of Gastroenterology and Nutrition, University of Texas Health Science Center at San Antonio, San Antonio, Texas William J. Zukel, M.D., Deputy Director, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland The editors gratefully acknowledge the contributions of the following staff members and others who assisted in the preparation of this Report: o Office of Disease Prevention and Health Promotion Nancy Chapman, R.D., M.P.H., President, N. Chapman Associates, Washington, D.C. Mary Jo Deering, Ph.D., Publications Manager James A. Harrell, M.A., Deputy Director Susan K. Maloney, M.H.S., Director, Health Communication Staff David G. Schardt, M.S., Ph.D., Nutrition Consultant, Nutrition Media Network, Washington, D.C. Marilyn K. Schulenberg, Staff Assistant Maureen Sullivan, M.P.H., M.I.A., Program Analyst, U.S. Food and Drug Administration, New York, New York xxxvi Herbert Szeto, Intern, Nutrition Policy Staff Sara L. White, M.S., Health Promotion Research Associate, Health Communication Staff o Technical Resources, Inc. Joanna Fringer, M.A., Program Manager Jeffrey Baughman, Graphic Artist Colleen Bolton, Graphic Artist Diane Cannon, Graphic Artist James Dofflemyer, Graphic Artist Dana Donofrio, Word Processor Robin Fagan, Graphic Artist Margaret Leahy, Editor Cathy Merritt, Word Processor Laura Pancoast, Word Processing Supervisor Cherie Phillips, Graphic Artist Theodora Radcliffe, Proofreader William Rhodes, Graphic Artist Joan Saunders, Writer/Editor Channah Springer, M . F. A., Proofreader David Tran, Information Specialist o TRITON, Inc. Clarence Johnson, Communications Manager John Borstel, Senior Graphics Editor Sharon Greenspan, Graphics Assistant xxxvii Summary and Recommendations This Report addresses the substantial impact of daily dietary patterns on the health of Americans. Good health does not always come easily. It is the product of complex interactions among environmental. behavioral, social, and genetic factors. Some of these are, for practical purposes, beyond persona1 control. But there are many ways in which each of us can influence our chances for good health through the daily choices we make. In recent years, scientific investigations have produced abundant informa- tion on the ways persona1 behavior affects health. This information can help us decide whether to smoke, when and how much to drink, how far to walk or climb stairs, whether to wear seat belts, and how or whether to engage in any other activity that might alter the risk of incurring disease or disability. For the two out of three adult Americans who do not smoke and do not drink excessively, one personal choice seems to influence long-term health prospects more than any other: what we eat. Food sustains us, it can be a source of considerable pleasure, it is a reflection of our rich social fabric and cultural heritage, it adds valued dimensions to our lives. Yet what we eat may affect our risk for several of the leading causes of death for Americans, notably, coronary heart dis- ease, stroke, atherosclerosis, diabetes, and some types of cancer. These disorders together now account for more than two-thirds of all deaths in the United States. Undernutrition remains a problem in several parts of the world, as well as for certain Americans. But for most of us the more likely problem has become one of overeating-too many calories for our activity levels and an imbalance in the nutrients consumed along with them. Although much is still uncertain about how dietary patterns protect or injure human health, enough has been learned about the overall health impact of the dietary patterns now prevalent in our society to recommend significant changes in those patterns. This first Surgeon General's Report on Nutrition and Health offers com- prehensive documentation of the scientific basis for the recommended dietary changes. Through the extensive review contained in its chapters, the Report examines in detail current knowledge about the relationships among specific dietary practices and specific disease conditions and sum- 1 O Nutrition and Health marizes the implications of this information for individual food choices, public health policy initiatives, and further research. The Report's main conclusion is that overconsumption of certain dietary components is now a major concern for Americans. While many food factors are involved, chief among them is the disproportionate consumption of foods high in fats, often at the expense of foods high in complex carbohydrates and fiber that may be more conducive to health. A list of the key recommendations based on the evidence presented in the Report is provided in Table 1. Magnitude of the Problem Diet has always had a vital influence on health. Until as recently as the 1940's, diseases such as rickets, pellagra, scurvy, beriberi, xerophthalmia, andgoiter (caused by lack of adequate dietary vitamin D, niacin, vitamin C, thiamin, vitamin A, and iodine, respectively).were prevalent in this coun- try and throughout the world. Today, thanks to an abundant food supply, fortification of some foods with critical trace nutrients, and better methods for determining and improving.the nutrient content of foods, such "deti- ciency" diseases have been virtually eliminated in developed countries. For example, the introduction of iodized salt in the 1920's contributed greatly to eliminating iodine-deficiency goiter as a public health problem in the United States. Similarly, pellagra disappeared subsequent to the dis- covery of the dietary causes of this disease. Nutrient deficiencies are reported rarely in the United States, and the few cases of protein-energy malnutrition that are listed annually as causes of death generally occur as a secondary result of severe illness or injury, child neglect, the problems of the house-bound aged, premature birth, alcoholism, or some combination of these factors. As the diseases of nutritional deficiency have diminished; they have been replaced by diseases'of dietary excess and imbalance-problems that now rank among the leading causes of illness and death in the United States, touch the lives of most Americans, and generate substantial health care costs. Table 2, for example, lists the 10 leading causes of death in the United States in 1987. In addition to the five of these causes that scientific studies have associated with diet (coronary heart disease, some-types of cancer, stroke, diabetes mellitus, and atherosclerosis), another three-cirrhosis of the liver, acci- dents, and suicides-have been associated With excessive alcohol intake. 2 Summary and Recommendations O Table 1 Recommendations Issues for Most People: o Furs and cholesterol: Reduce consumption of fat (especially saturated fat) and cholesterol. Choose foods relatively low in these substances, such as vegeta- bles, fruits, whole gram foods, fish, poultry, lean meats. and low-fat dairy products. Use food preparation methods that add little or no fat. o Energy and weight control: Achieve and maintain a desirable body weight. To do so, choose a dietary pattern in which energy (caloric) intake is consistent with energy expenditure. To reduce energy intake, limit consumption of foods relatively high in calories, fats, and sugars, and minimize alcohol consump- tion. Increase energy expenditure through regular and sustained physical ac- tivity. o Complex carbohydrates andfiber: Increase consumption of whole grain foods and cereal products, vegetables (including dried beans and peas), and fruits. o Sodium: Reduce intake of sodium by choosing foods relatively low in sodium and limiting the amount of salt added in food preparation and at the table. o Alcohol: To reduce the risk for chronic disease, take alcohol only in modera- tion (no more than two drinks a day), if at all. Avoid drinking any alcohol be- fore or while driving, operating machinery, taking medications, or engaging in any other activity requiring judgment. Avoid drinking alcohol while pregnant. Other Issues for Some People: o Fluoride: Community water systems should contain fluoride at optimal levels for prevention of tooth decay. If such water is not available, use other appro- priate sources of fluoride. o Sugars: Those who are particularly vulnerable to dental caries (cavities). espe- cially children, should limit their consumption and frequency of use of foods high in sugars. o Calcium: Adolescent girls and adult women should increase consumption of foods high in calcium, including low-fat dairy products. o Iron: Children, adolescents, and women of childbearing age should be sure to consume foods that are good sources of iron, such as lean meats, fish, certain beans, and iron-enriched cereals and whole grain products. This issue is of special concern for low-income families. 0 Nutrition and Health Table 2 Estimated Total Deaths and Percent of Total Deaths for the 10 Leading Causes of Death: United States, 1987 Percent of Total Rank Cause of Death Number Deaths la Heart diseases 759,400 35.7 (Coronary heart disease) (511,700) (24.1) (Other heart disease) (247,700) (11.6) 2a Cancers 476,700 22.4 3a Strokes 148,700 7.0 4b Unintentional injuries 92,500 (Motor vehicle) W8O'J (E, (All others) (45,700) 5 Chronic obstructive lung diseases 78,000 %' 6 Pneumonia and influenza 68,600 3:2 78 Diabetes mellitus 37,800 1.8 8b Suicide 29,600 1.4 9b Chronic liver disease and cirrhosis 26,000 1.2 10s Atherosclerosis 23,100 1.1 . . . AU causes 2,125,100 causes of death in which diet plays a part. Wauses of death in which excessive alcohol consumption plays a part. 100.0 Source: National Center for Health Statistics, Monthly Vital Statistics Report, vol. 37, no. 1 ,April25,sticsReport,vol.37, no. 1, April 25,1989. Although the precise proportion attributable to diet is uncertain, these eight conditions accounted for nearly 1.5 million of the 2.1 million total deaths in 1987. Dietary excesses or imbalances also contribute to other problems such as high blood pressure, obesity, dental diseases, os- teoporosis, and gastrointestinal diseases. Together, these diet-related con- ditions inflict a substantial burden of illness on Americans. For example: o Coronary Heart Disease. Despite the recent sharp decline in the death rate from this condition, coronary heart disease still accounts for the largest number of deaths in the United States. More than 1.25 million heart attacks occur each year (two-thirds of them in men), and more than 500,000 people die as a result. In 1985, illness and deaths from coronary heart disease cost Americans an estimated $49 billion in direct health care expenditures and lost productivity. o Stroke. Strokes occur in about 500,000 persons per year in the United States, resulting in nearly 150,000 deaths in 1987 and long-term dis- ability for many individuals. Approximately 2 million living Americans suffer from stroke-related disabilities, at an estimated annual cost of more than $11 billion. 4 Summary and Recommendations 0 o High Blood Pressure. High blood pressure (hypertension) is a major risk factor for both heart disease and stroke. Almost 58 million people in the United States have hypertension, including 39 million who are under age 65. The occurrence of hypertension increases with age and is higher for black Americans (of which 38 percent are hypertensive) than for white Americans (29 percent). o Cancer. More than 475,000 persons died of cancer in the United States in 1987, making it the second leading cause of death in this country. During the same period, more than 900,000 new cases of cancer occurred. The costs of cancer for 1985 have been estimated to be $22 billion for direct health care, $9 billion in lost productivity due to treatment or disability, and $41 billion in lost productivity due to premature mortality, for a total cost of $72 billion. o Diabetes Meflitus. Approximately 11 million Americans have diabe- tes, but almost half of them have not been diagnosed. In addition to the nearly 38,000 deaths in 1987 attributed directly to this condition, diabetes also contributes to an estimated 95,000 deaths per year from associated cardiovascular and kidney complications. In 1985, diabetes was estimated to cost $13.8 billion per year, or about 3.6 percent of total health care expenses. o Obesity. Obesity affects approximately 34 million adults ages 20 to 74 years in the United States, with the highest rates observed among the poor and minority groups. Obesity is a risk factor for coronary heart disease, high blood pressure, diabetes, and possibly some types of cancer as well as other chronic diseases. o Osteoporosis. Approximately 15 to 20 million Americans are affected by osteoporosis, which contributes to some 1.3 million bone fractures per year in persons 45 years and older. One-third of women 65 years and older have vertebral fractures. On the basis of x-ray evidence, by age 90 one-third of women and one-sixth of men will have suffered hip fractures, leading to death in 12 to 20 percent of those cases and to long-term nursing care for many who survive. The total costs of osteoporosis to the U.S. economy were estimated to be $7 to $10 billion in 1983. o Dental Diseases. Dental caries and periodontal disease continue to affect a large proportion of Americans and cause substantial pain, restriction of activity, and work loss. Although dental caries among children, as well as some forms of adult periodontal disease, appear to be declining, the overall prevalence of these conditions imposes a substantial burden on Americans. The costs of dental care were esti- mated at $21.3 billion in 1985. 5 O Nutrition and Health o Diverticular Disease. Because most persons with diverticular disease do not have symptoms, the true prevalence of this condition is un- known. Frequency increases with age, and up to 70 percent of people between the ages of 40 and 70 may be affected. In 1980, diverticulosis was accountable for some 200,000 hospitalizations. In assessing the role that diet might play in prevention of these conditions, it must be understood that they are caused by a combination (and interac- tion) of multiple environmental, behavioral, social, and genetic factors. The exact proportion that can be attributed directly to diet is uncertain. Although some experts have suggested that dietary factors overall are responsible for perhaps a third or more of all cases of cancer, and similar estimates have been made for coronary heart disease, such suggestions are based on interpretations of research studies that cannot completely dis- tinguish dietary from genetic, behavioral, or environmental causes. We know, for example, that cigarette smoking exerts a powerful influence on the occurrence of both coronary heart disease and some types of cancer. We also know that some people are genetically predisposed to coronary heart disease, stroke, and diabetes and that the interaction of genetic predisposition with dietary patterns is an important determinant of individ- ual risk. For these reasons, it is not yet possible to determine the propor- tion of chronic diseases that could be reduced by dietary changes. None- theless, it is now clear that diet contributes in substantial ways to the development of these diseases and that modification of diet can contribute to their prevention. The magnitude of the health and economic cost of diet- related disease suggests the importance of the dietary changes suggested. This Report reviews these issues in detail. Nature of the Evidence Whereas centuries of clinical observations and decades of basic and clinical research prove that dietary deficiencies of single, identifiable nu- trients can cause disease, research on the relationship of dietary excesses and imbalances to chronic disease yields results that rarely provide such direct proof of causality. Instead, investigators must piece together various kinds of information from several kinds of sources. Nevertheless, the quantity of current animal, laboratory, clinical, and epidemiologic evi- dence that associates dietary excesses and imbalances with chronic dis- ease is substantial and, when evaluated according to established princi- ples, compelling. Scientists must often draw inferences about the relationships between dietary factors and disease from laboratory animal studies or human meta- 6 Summary and Recommendations O bolic and population studies that approach the issues indirectly. Data sources for such human studies include clinical and laboratory measure- ments of physiologic indicators of nutritional status or risk factors, as well as dietary intake data estimated for populations or individuals. Epi- demiologic studies using these data compare dietary intake and disease rates in different countries or in defined groups within the same country. Interpretations of animal studies are limited by uncertainties about their applicability to people. Clinical, laboratory, and dietary intake studies can provide useful information, but each has limitations. Currently available clinical and laboratory measurements reveal only a small part of the complex physiological responses to diet, and they may reflect past rather than current nutritional status. Dietary surveys depend on accurate recall of the types and portion sizes of consumed foods as well as on the assump- tion that the food intake during any one period represents typical intake. Reported intake, however, is not always accurate, and intake reported for a given period may differ significantly from that typical of longer time periods. Dietary intake data provide useful indicators for populations, but even when an association or correlation between a dietary factor and a disease is observed, it is often ditllcult to prove that the dietary factor is an actual or sole cause of that disease. This difference between association and causation is basic to understand- ing the scientific evidence that links diet to chronic disease. Uncertainties in the ability to determine causation have sometimes made it difficult to achieve consensus on appropriate public health nutrition policies. Estab- lished principles require evaluation of the supporting evidence for a given association between a dietary factor and a disease on the basis of its consistency, strength, specificity, and biological plausibility. The evidence showing that dietary intake of saturated fat raises blood cholesterol, which in turn increases the chance of coronary heart disease, illustrates this point. The similarity in results from laboratory, clinical, and epidemiologic research, the apparent relationship between dose and effect in these stud- ies, the observations that the increase in blood cholesterol level is ~p~ifk to saturated fatty acids but not to other types, and the biological plausibility of explanations for the observations, when taken together, provide consid- erable support for concluding that the association is causal, at least for some individuals. For some of the other diseases reviewed in this Report, the available evidence is less complete and less consistent. Nevertheless, much evi- dence supports credible associations between a dietary pattern of excesses u Nutrition and Health and imbalances and several important chronic diseases. These associa- tions, in turn, suggest that the overall health of Americans could be improved by a few specific but fundamental dietary changes. Key Findings and Recommendations Even though the results of various individual studies may be inconclusive, the preponderance of the evidence presented in the Report's comprehen- sive scientific review substantiates an association between dietary factors and rates of chronic diseases. In particular, the evidence suggests strongly that a dietary pattern that contains excessive intake of foods high in calories, fat (especially saturated fat), cholesterol, and sodium, but that is low in complex carbohydrates and fiber, is one that contributes signifi- cantly to the high rates of major chronic diseases among Americans. It also suggests that reversing such dietary patterns should lead to a reduced incidence of these chronic diseases. This Surgeon General's Report on Nutrition and Health provides a com- prehensive review of the most important scientific evidence in support of current Federal nutrition policy as stated in the Dietary Guidelines for Americans. These Guidelines, issued jointly by the Department of Agri- culture and the Department of Health and Human Services, recommend: o Eat a variety of foods. o Maintain desirable weight. o Avoid too much fat, saturated fat, and cholesterol. o Eat foods with adequate starch and fiber. o Avoid too much sugar. o Avoid too much sodium. o If you drink alcoholic beverages, do so in moderation. Evidence presented in this Report expands the focus of these seven guide- lines and provides considerable insight into priorities. Clearly emerging as the primary priority for dietary change is the recommendation to reduce intake of total fats, especially saturated fat, because of their relationship to development of several important chronic disease conditions. Because excess body weight is a risk factor for several chronic diseases, mainte- nance of desirable weight is also an important public health priority. Evidence further supports the recommendation to consume a dietary pattern that contains a variety of foods, provided that these foods are generally low in calories, fat, saturated fat, cholesterol, and sodium. 8 Summary and Recommendations O Taken together, the recommendations in this Report promote a dietary pattern that emphasizes consumption of vegetables, fruits, and whole grain products-foods that are rich in complex carbohydrates and fiber and relatively low in calories-and of fish, poultry prepared without skin, lean meats, and low-fat dairy products selected to minimize consumption of total fat, saturated fat, and cholesterol. The evidence presented in this Report suggests that such overall dietary changes will lead to substantial improvements in the nutritional quality of the American diet. Consuming a higher proportion of calories from fruits, vegetables, and grains may lead to a modest reduction in protein intake for some people, but this reduction is unlikely to impair nutritional status. Average levels of protein consumption in the United States, 60 grams per day for women and 90 grams per day for men, are well above the National Research Council's recommendations of 44 and 56 grams per day, respec- tively . The evidence also suggests that most Americans generally need not con- sume nutrient supplements. An estimated 40 percent of Americans con- sume supplemental vitamins, minerals, or other dietary components at an annual cost of more than $2.7 billion. Although nutrient supplements are usually safe in amounts corresponding to the Recommended Dietary Al- lowances (and such Allowances are set to ensure that the nutrient needs of practically all the population are met), there are no known advantages to healthy people consuming excess amounts of any nutrient, and amounts greatly exceeding recommended levels can be harmful. For example, some nutrients such as selenium have a narrow range of safe level of intake. Toxicity has been reported for most minerals and trace elements, as well as some vitamins, indicating that excessive supplementation with these sub- stances can be hazardous. Finally, some recommendations for dietary change apply broadly to the general public whereas others apply only to specific population groups. These major findings and recommendations of The Surgeon General's Report on Nutrition and Health are noted below. Issues for Most People 0 Fats andcholesterol: Reduce consumption of fat (especially saturated fat) and cholesterol. Choose foods relatively low in these substances, such as vegetables, fruits, whole grain foods, bh, poultry, lean meats, and low- fat dairy products. Use food preparation methods that add little or no fat. 9 0 Nutrition and Health High intake of total dietary fat is associated with increased risk for obesity, some types of cancer, and possibly gallbladder disease. Epidemiologic, clinical, and animal studies provide strong and consistent evidence for the relationship between saturated fat intake, high blood cholesterol, and increased risk for coronary heart disease. Conversely, reducing blood cholesterol levels reduces the risk for death from coronary heart disease. Excessive saturated fat consumption is the major dietary contributor to total blood cholesterol levels. Dietary cholesterol raises blood cholesterol levels, but the effect is less pronounced than that of saturated fat. While polyunsaturated fatty acid consumption, and probably monounsaturated fatty acid consumption, lowers total blood cholesterol, the precise effects of specific fatty acids are not well defined. Dietary fat contributes more than twice as many calories as equal quanti- ties (by weight) of either protein or carbohydrate, and some studies indi- cate that diets high in total fat are associated with higher obesity rates. In addition, there is substantial, although not yet conclusive, epidemiologic and animal evidence in support of an association between dietary fat intake and increased risk for cancer, especially breast and colon cancer. Similar- ly, epidemiologic studies suggest an association between gallbladder dis- ease, excess caloric intake, high dietary fat, and obesity. More precise conclusions about the role of dietary fat await the development of im- proved methods to distinguish among the contributions of the high-calorie, high-fat, and low-fiber components of current American dietary patterns. At present, dietary fat accounts for about 37 percent of the total energy intake of Americans-well above the upper limit of 30 percent recom- mended by the American Heart Association and the American Cancer Society, and above the percent consumed by many societies, such as Mediterranean countries, Japan, and China, for example, where coronary heart disease rates are much lower than those observed in the United States. Consumption of saturated fat and cholesterol is also substantially higher among many Americans than levels recommended by several expert groups. The major dietary sources of fat in the American diet are meat, poultry, fish, dairy products, and fats and oils. Animal products tend to be higher in both total and saturated fats than most plant sources. Although some plant fats such as coconut and palm kernel oils also contain high proportions of saturated fatty acids, these make minor contributions to total intake of saturated fats in the United States. Dietary cholesterol is found only in foods of animal origin, such as eggs, meat, poultry, fish, and dairy prod- 10 Summary and Recommendations tl ucts. To help reduce consumption of total fat, especially saturated fat and cholesterol, food choices should emphasize intake of fruits, vegetables, and whole grain products and cereals. They should also emphasize con- sumption of fish, poultry prepared without skin, lean meats, and low-fat dairy products. Among vegetable fats, those that are more unsaturated are better choices. 0 Energy and weight control: Achieve and maintain a desirable body weight. To .do so, choose a dietary pattern in which energy (caloric) intake is consistent with energy expenditure. To reduce energy intake, limit consumption of foods relatively high in calories, fats, and sugars and minimize alcohol consumption. Increase energy expenditure through regular and sustained physical activity. People are considered overweight if their body mass index, or BMI (a ratio of weight to height described in the Report), exceeds the 85th percentile for young American adults (approximately 120 percent of desirable body weight); they are considered severely overweight if their BMI exceeds the 95th percentile (approximately 140 percent of desirable body weight). Overweight individuals are at increased risk for diabetes mellitus, high blood pressure and stroke, coronary heart disease, some types of cancer, and gallbladder disease. Epidemiologic and animal studies have shown consistently that overall risk for death is increased with excess weight, with risk increasing as severity of obesity increases. Type II (noninsulin-dependent) diabetes mellitus accounts for approxi- mately 90 percent of all cases of diabetes and is strongly associated with obesity. Clinical studies indicate that weight loss can improve control of Type II diabetes. Obesity increases the risk for high blood pressure, and consequently for stroke; it also increases blood cholesterol levels associated with coronary heart disease. In addition, it appears to be an independent risk factor for coronary heart disease. Weight reduction has been shown to reduce high blood pressure and high blood cholesterol. Most obese individuals who achieve a more desirable body weight improve their cholesterol profile, achieving a decrease in both total blood cholesterol and LDL (low density lipoprotein) cholesterol. Some studies have found an association between overweight and increased risk for several cancers, especially cancer of the uterus and breast. In addition, overweight increases the risk for gallbladder disease. 11 0 Nutrition and Health More than a quarter of American adults are overweight. Black women age 45 and above have the highest prevalence, about 60 percent. Although evidence suggests a genetic component to the tendency of many people to become overweight, patterns of dietary caloric intake and energy expendi- ture play a key role. Sustained and long- term efforts to reduce body weight can best be achieved as a result of improving energy balance by reducing energy consumption and raising energy expenditure through physical ac- tivity and exercise. Maintenance of desirable body weight throughout the lifespan requires a balance between energy (calorie) intake and expenditure. Weight control may be facilitated by decreasing energy intake, especially by choosing foods relatively low in calories, fats, and sugars, and by minimizing alcohol consumption. Energy expenditure can be enhanced through regular phys- ical activities such as daily walks or by jogging, bicycling, or swimming at least three times a week for at least 20 minutes. 0 Compk carbohydrates andfiber Increase consumption of whole grain foods and cereal products, vegetables (includiug dried beaus and peas), and fruits. Dietary patterns emphasizing foods high in complex carbohydrates and fiber are associated with lower rates of diverticulosis and some types of cancer. The association shown in epidemiologic and animal studies be- tween diets high in complex carbohydrates and reduced risk for coronary heart disease and diabetes mellitus is, however, difficult to interpret. The fact that such diets tend also to be lower in energy and fats, especially saturated fat and cholesterol, clearly contributes to this difficulty. Some evidence from clinical studies also suggests that water-soluble fibers from foods such as oat bran, beans, or certain fruits are associated with lower blood glucose and blood lipid levels. Consuming foods with dietary fiber is usually beneficial in the management of constipation and diverticular disease. While inconclusive, some evidence also suggests that an overall increase in intake of foods high in fiber might decrease the risk for colon cancer. Among several unresolved issues is the role of the various types of fiber, which differ in their effects on water-holding capacity, viscosity, bacterial fermentation, and intestinal transit time. Other food components associated with decreased cancer risk are com- monly found in diets high in whole grain cereal products containing com- plex carbohydrates and fiber. In addition, some epidemiologic evidence Summary and Recommendations 0 suggests that frequent consumption of vegetables and fruits, particularly dark green and deep yellow vegetables and cruciferous vegetables (such as cabbage and broccoli), may lower risk for cancers of the lung and bladder as well as some cancers of the alimentary tract. However, the specific components in these foods that may have protective effects have not yet been established. Current evidence suggests the prudence of increasing consumption of whole grain foods and cereals, vegetables (including dried beans and peas), and fruits. o Sodium: Reduce intake of sodium by choosing foods relatively low in sodium and limiting tbe amount of salt added in food preparation and at the table. Studies indicate a relationship between a high sodium intake and the occurrence of high blood pressure and stroke. Salt contains about 40 percent sodium by weight and is used widely in the preservation, process- ing, and preparation of foods. Although sodium is necessary for normal metabolic function, it is consumed in the United States at levels far beyond the 1.1 to 3.3 grams per day found to be as safe and adequate for adults by the National Research Council. Average current sodium intake for adults in the United States is in the range of 4 to 6 grams per day. Blacks and persons with a family history of high blood pressure are at greater risk for this condition. While some people maintain normal blood pressure levels over a wide range of sodium intake, others appear to be "salt sensitive" and display increased blood pressure in response to high sodium intakes. Although not all individuals are equally susceptible to the effects of so- dium, several observations suggest that it would be prudent for most Americans to reduce sodium intake. These include the lack of a practical biological marker for individual sodium sensitivity, the benefit to persons whose blood pressures do rise with sodium intake, and the lack of harm from moderate sodium restriction. Processed foods provide about a third or more of dietary sodium. Because about another third of the sodium consumed by Americans is added by the consumer, much can be done to reduce sodium consumption by using less salt at the table and substituting alternative flavoring such as herbs, spices, and lemon juice in the preparation of foods. In addition, choices can be made of foods modiied to lower sodium content and less frequent choices could be made of foods to which sodium is added in processing and preservation. 13 O Nutrition and Health o Alcohol: To reduce the risk for chronic disease, take alcohol only in moderation (no more than two drinks a day), ifat all. Avoid drinking any alcohol before or while driving, operating machinery, taking medica- tions, or engaging in any other activity requiring judgment. Avoid tkhking alcohol while pregnant. Alcohol is a drug that can produce addiction in susceptible individuals, birth defects in some children born to mothers who drink alcohol during pregnancy, impaired judgment, impaired ability to drive automobiles or operate machinery, and adverse reactions in people taking certain medica- tions. In addition, alcohol abuse has been associated with disrupted family functioning, suicides, and homicides. Excessive use of alcohol is also associated with liver disease, some types of cancer, high blood pressure, stroke, and disorders of the heart muscle. Extensive epidemiologic and clinical evidence has identified alcohol con- sumption as the principal cause of liver cirrhosis in the United States, at least in part as a result of the direct toxic effects of alcohol on the liver. Smoking and alcohol appear to act synergistically to increase the risk for cancers of the mouth, larynx, and esophagus. Less conclusive and some- what conflicting evidence suggests a role of alcohol in other types of cancers such as those of the liver, rectum, breast, and pancreas. Studies indicate a direct association between increased blood pressure and the consumption of alcohol at levels beyond about two drinks" daily. Extremely excessive alcohol consumption is associated with cardiomyop- athy. Alcohol consumption by the mother during pregnancy has also been associated with fetal malformations. Although consumption of up to two drinks per day has not been associated with disease among healthy men and nonpregnant women, surveys suggest that at least 9 percent of the total population consumes two or more drinks per day and those in this group need to reduce their alcohol consumption. A threshold level of safety for alcohol intake during pregnancy has not been established. Thus, pregnant women and women who may become preg- nant should avoid drinking alcohol. lone drink is defined as a 12 ounce beer, a 5 ounce glass of wine, or 1% fluid ounces (one jigger) of distilled spirits, each of which contains about 1 ounce of alcohol. 14 Summary and Recommendations O Other Issues for Some People 0 Fluoride: Community water systems should contain fluoride at optimal levels for prevention of tooth decay. If such water is not available, use other appropriate sources of fluoride. The most efficient means of making fluoride available to the general public to reduce dental disease is through drinking water. Numerous epidemio- logic and clinical studies have attested to the efficacy, safety and cost- effectiveness of systemic fluoride in the prevention of tooth decay. Life- time use of water containing an optimal fluoride concentration of approxi- mately 1 part per million has been shown to reduce the prevalence of dental caries by more than 50 percent. Water fluoridation is considered one of the most successful public health efforts introduced in the United States. For children living in areas with inadequate concentrations of fluoride in the water, supplementary fluoride sources should be used at dosages that depend on the fluoride content of the local water supply and the age of the child. The effectiveness of prenatal fluoride administration, however, is uncertain because clinical studies of its effects on subsequent caries inci- dence have been equivocal. Excessive fluoride should be avoided because it may cause mottling of developing teeth. 0 Sugurs: Those who are particularly vulnerable to dental caries (cavities), especially children, should limit their consumption and frequency of use of foods high in sugars. Although genetic, behavioral, and other dietary factors also influence dental health, the major role of sugars in promotion of tooth decay is well established from animal, epidemiologic, clinical, and biochemical studies. Newly erupting teeth are generally more vulnerable to decay than mature teeth. Research has shown that three conditions must exist for the formation of dental caries: the presence of fermentable carbohydrate, acid-producing bacteria, and a susceptible tooth. Caries-producing bacteria metabolize a range of sugars (glucose, fructose, maltose, lactose, and sucrose) to acids that demineralize teeth. The unique role of sucrose (common table sugar) in dental caries is related to its special ability to be converted by these bacteria into long, complex molecules that adhere firmly to teeth and form plaque. 0 Nutrition and Health The most important diet-related interventions are fluoridation of drinking water, or the use of other means of fluoride administration, and control of intake of sugars. While fluoride is the most important factor overall in dental caries prevention, reduction in the frequency of consumption and in the quantity of sugar-rich foods in the diet will also help reduce decay. Sticky sweet foods that adhere to the teeth are more cariogenic than those that wash off quickly. The longer cariogenic foods remain in the mouth, the more they are likely to increase the initiation and progression of tooth decay. 0 Calcium: Adolescent girls and adult women should increase consumption of foods high in calcium, including low-fat dairy products. Inadequate dietary calcium consumption in the first three to four decades of life may be associated with increased risk for osteoporosis in later life. Osteoporosis, a chronic disease characterized by progressive loss of bone mass with aging, occurs in both women and men, although postmenopausal women are twice as likely as men to have severe osteoporosis with conse- quent bone fractures. Evidence shows that chronically low calcium intake, especially during adolescence and early adulthood, may compromise de- velopment of peak bone mass. In postmenopausal women, the group at highest risk for osteoporosis, estrogen replacement therapy under medical supervision is the most effective means to reduce the rate of bone loss and risk for fractures. Maintenance of adequate levels of physical activity and cessation of cigarette smoking have also been associated with reduced osteoporosis risk. Although the precise relationship of dietary calcium to osteoporosis has not been elucidated, it appears that higher intakes of dietary calcium could increase peak bone mass during adolescence and delay the onset of bone fractures later in life. Thus, increased consumption of foods rich in calcium may be especially beneficial for adolescents and young women. Food sources of calcium consistent with other dietary recommendations in this Report include low-fat dairy products, some canned fish, certain vegeta- bles, and some calcium-enriched grain products. o Iron: Children, adolescents, and women of childbearing age should be sure to consume foods that are good sources of iron, such as lean meats, fish, certain beans, and iron-enriched cereals and whole grain products. This issue is of special concern for low-income families. Dietary iron deficiency is responsible for the most prevalent form of anemia in the United States. Iron deficiency hampers the body's ability to produce hemoglobin, a substance needed to carry oxygen in the blood. A 16 Summary and Recommendations O principal consequence of iron deficiency is reduced work capacity, al- though depressed immune function, changes in behavior, and impaired intellectual performance may also result. Because of the serious conse- quences of iron deficiency, continual monitoring of the iron status of individuals at high risk-particularly children from low-income families, adolescents, and women of childbearing age-is vital, as is treatment of those identified to be iron deficient. Proper infant feeding-preferably breastfeeding, otherwise use of iron- fortified formula-is the most important safeguard against iron deficiency in infants. Among adolescents and adults, iron intake can be improved by increasing consumption of iron-rich foods such as lean meats, fish, certain kinds of beans, and iron-enriched cereals and whole grain products. Also, consuming foods that contain vitamin C increases the likelihood that iron will be absorbed efficiently. Policy Implications Dietary Guidance General Public Educating the public about the dietary choices most conducive to preven- tion and control of certain chronic diseases is essential. Educational efforts should begin in primary school and continue throughout the secondary grades, and should focus on the dietary principles outlined in this Report- the potential health benefits of eating a diet that is lower in fat (especially saturated fat) and rich in complex carbohydrates and fiber. The importance of adequate physical activity should also be stressed. Efforts should con- tinue throughout each stage of life to promote the principles outlined in the Dietary Guidelines for Americans. Special Populations A disproportionate burden of diet-related disease is borne by subgroups in our population. Black Americans, for example, have higher rates of high blood pressure, strokes, diabetes, and other diseases associated with obesity (but lower rates of osteoporosis) than the general population. Some groups of Native Americans exhibit the highest rates of diabetes in the world. Pregnant and lactating women also have special nutritional needs. Particular effort should be made to identify and remove the barriers to optimal health and nutritional status in such high-risk groups, using meth- ods that take into consideration their diverse cultural backgrounds. 17 O Nutrition and Health Many older persons suffer from chronic diseases that can reduce functional independence; many take multiple medications that may adversely interact with nutrients. Sound public education directed toward this group-and professional education directed toward individuals who care for older Americans-should focus on dietary means to reduce risk factors for chronic disease, to promote functional independence, and to prevent ad- verse consequences of use of medications. Health Professionals Improved nutrition training of physicians and other health professionals is needed. Training should emphasize basic principles of nutrition, the role of diet in health promotion and disease prevention, nutrition assessment methodologies and their interpretation, therapeutic aspects of dietary in- tervention, behavioral aspects of dietary counseling, and the role of dieti- tians and nutritionists in dietary counseling of patients. Programs and Services Food Labels Food labeling offers opportunities to inform people about the nutrient content of foods so as to facilitate dietary choices most conducive to health. Food manufacturers should be encouraged to make full use of nutrition labels. Labels of processed foods should state the content of calories, protein, carbohydrate, fats, cholesterol, sodium, and vitamins and minerals. To the extent permitted by analytical methods, manufactur- ers should disclose information where appropriate on the content of satu- rated and unsaturated fatty acids and total fiber in foods that normally contain them. Descriptive terms such as "low calorie" and "sodium re- duced" in compliance with the Food and Drug Administration's regula- tions for food labeling may also be helpful, and the expanded use of these terms should be encouraged. Nutrition Services Health care programs for individuals of all ages should include nutrition services such as, when appropriate, nutrition counseling for individuals or groups, interpretation and implementation of prescribed therapeutic diets tailored to individual food preferences and lifestyle, referral to appropriate community services and food assistance programs, monitoring of prog- ress, and appropriate followup. These services should routinely incorpo- rate assessment of nutritional status and needs based on established crite- 18 Summary and Recommendations O ria to identify individuals with nutritional risk factors who would profit from preventive measures and those with nutritional disorders who need remedial care. Food Services Lack of access to an appropriate diet should not be a health problem for any American. Wherever food is served to people or provided through food assistance programs, it should reflect the principles of good nutrition stated in this Report. Whether served in hospitals, schools, military installations, soup kitchens, day care centers, or nursing homes, or whether delivered to homes, food service programs offer important opportunities for improving health and providing dietary education. Such programs should pay special attention to the nutritional needs of older people, pregnant women, and children, especially those of low income or other special dietary needs. Because a large proportion of the population takes meals in restaurants and convenience food facilities, improvements in the overall nutritional bal- ance of the meals served in such places can be expected to contribute to health benefits. Food service programs should also take particular care to ensure that special diets lower in fat, especially saturated fat, are provided to people with elevated blood cholesterol, heart disease, or diabetes; that diets low in sodium are provided to individuals with high blood pressure; and that protein-restricted diets are made available to people with end-stage kidney disease. Food Products The public would benefit from increased availability of foods and food products low in calories, total fat, saturated fat, cholesterol, sodium, and sugars, but high in a variety of natural forms of fiber and, perhaps, certain minerals and vitamins. Food manufacturers can contribute to improving the quality of the American diet by increasing the availability of palatable, easily prepared food products that will help people to follow the dietary principles outlined here. Because the public is becoming increasingly conscious of the role of nutrition in health, development of such products should also benefit the food industry. Research and Surveillance Impressive evidence already links nutrition to chronic disease. However, much more information is needed to continue to identify changes in the 19 O Nutrition and Health national diet that will lead to better health for the Nation. Gaps in our knowledge of nutrition suggest future research and surveillance needs. Examples are: o The role of specific dietary factors in the etiology and prevention of chronic diseases. o The childhood dietary pattern that will best prevent later development of chronic diseases. o The effects of maternal nutrition on the health of the developing fetus. o The nutrient and energy requirements of older adults. o How nutrient requirements translate into healthful dietary patterns. o The development of biodhemical markers of dietary intake to monitor better the effects of dietary intervention. o The identification of effective educational methods to translate dietary recommendations into appropriate food choices. o The establishment of a nutrition surveillance system that will enhance the monitoring of population-specific and State-specific trends in the occurrence of nutrition-related risk factors and conditions. 20 Chapter 1 Introduction and Background Power of nutriment reaches to bone and to all the parts of bone, to sinew, to vein, to artery, to muscle, to membrane, to flesh, fat, blood, phlegm, marrow, brain, spinal marrow, the intestines, and all their parts: it reaches also to heat, breath, and moisture. Hippocrates (-377 B.C.) Introduction It has long been understood that optimal health depends on adequate nutrition, yet knowledge of the ways in which specific dietary factors affect the risk for disease is incomplete. Dietary deficiencies can be manifested in various ways. A deficient intake of energy or nutrients can lead to protein- energy malnutrition or to classic deficiency diseases such as rickets, pel- lagra, or iron deficiency anemia. Protein-energy malnutrition and diseases due to deficiencies of various nutrients are prominent causes of premature death and disability in developing countries but, with a few exceptions, appear to have been eliminated in the United States. When nutrient deficiencies are reported in this country, they are most often observed to be associated with poverty, the additional nutrient require- ments of pregnancy or infancy (IOM 1985), the abuse or neglect of children or older persons, or some combination of these factors. They also are observed to result from the restricted food intake that sometimes accom- panies aging, alcohol or drug abuse, unusually severe and prolonged injury or illness (including prolonged hospitalization), excessive dieting, or re- strictive dietary practices. Thus, pregnant women, young infants, chil- dren, older persons, alcohol and drug abusers, and chronically ill and disabled individuals are at greatest risk for malnutrition due to dietary deficiencies, especially if their income is low. Whatever its root cause, inadequate nutrition retards normal growth, lowers resistance to infectious disease, impairs maternal and child health, and may adversely affect the ability to function at peak physical and mental capacity. These issues are discussed in detail in the relevant chapters of this Report. 21 O Nutrition and Health As problems of nutritional deficiency have diminished in the United States, they have been replaced by problems of dietary imbalance and excess. These imbalances and excesses have contributed to the increased preva- lence and severity of chronic diseases that are major causes of death and disability among Americans. Table l-1 lists the 10 leading causes of death in this country. Among them, five-coronary heart disease and generalized atherosclerosis, stroke, some types of cancer, and diabetes-have been associated with dietary excesses or imbalances, and another three-cir- rhosis of the liver, accidents, and suicides-are often the result of exces- sive alcohol intake. Together, these conditions account for as much as 70 percent of annual deaths among Americans (Collins 1986; NCHS 1986). Dietary excesses or imbalances also have been associated with high blood pressure, obesity, dental diseases, osteoporosis, and, perhaps, kidney and gastrointestinal diseases. Such conditions also contribute to much illness, disability, and death in the United States, and thus to substantial human and economic costs to society. Table l-l Estimated Total Deaths and Percent of Total Deaths for the 10 Leading Causes of Death: United States, 1987 Rank Cause of Death Number Percent of Total Deaths la 2a 3a 4b 5 6 7a 8b 9b IO= Heart diseases 759,400 (Coronary heart disease) (511,700) (Other heart disease) (247,700) Cancers 476,700 Strokes 148,700 Unintentional injuries 92,500 (Motor vehicle) W5,800) (All others) (45,700) Chronic obstructive hmg diseases 78,ooO Pneumonia and influenza w600 Diabetes mellitus 37,800 Suicide 29,600 Chronic liver disease and cirrhosis 26,000 Atherosclerosis 23,100 35.7 (24.1) (11.6) 22.4 7.0 (i::, (2.2) 3.7 3.2 1.8 1.4 1.2 1.1 . . . All causes 2,125,loo BCauses of death in which diet plays a part. Wauses of death in which excessive alcohol consumption plays a part. 100.0 Source: National Center for Health Statistics 1988. 22 Introduction and Background cl Much about the ways in which excessive intake of energy and nutrients might affect health remain to be elucidated. Yet despite uncertainties, much has been learned about diet-disease relationships. This first Surgeon General's Report on Nutrition and Health examines the current state of knowledge of associations among dietary patterns, nutrients, and certain disease conditions. Its purpose is to review the available research evidence that relates diet to health to establish a basis for policies that promote dietary means to improve health. Development and Organization of the Report This Surgeon General's Report on Nutrition and Health has been devel- oped in response to the increasing interest of the public, health profession- als, and policy leaders in the role of diet in health promotion and prevention of chronic disease. In preparing the Report, the Public Health Service (PHS) reviewed past and current research related to diet and disease as a basis for examination of the implications for public policies on nutrition education, services, and research. The Report reviews current knowledge of the influence of dietary factors on specific aspects of health. This first chapter introduces the major themes of the Report in their historical context; it also reviews and synthe- sizes basic information about essential nutrients in the human diet, the levels of intake required for human health, and American dietary patterns, and it explains the criteria used to examine the various kinds of research studies that are reviewed throughout the Report. Chapters 2 through 14 describe the scientific research that has examined associations between specific dietary factors and selected disease conditions in the United States (Coronary Heart Disease, High Blood Pressure, Cancer, Diabetes, Obesity, Skeletal Diseases, Dental Diseases, Kidney Diseases, Gastroin- testinal Diseases, Infections and Immunity, Anemia, Neurologic Disor- ders, and Behavior). Chapters 15 (Maternal and Child Nutrition) and 16 (Aging) review the special nutritional challenges at especially vulnerable stages of the human life cycle. The interactions between nutrients and alcohol and between nutrients and drugs, and the effects of these sub- stances on human nutritional status, are reviewed in chapters 17 and 18, respectively. The Report closes with a final chapter on dietary fads and frauds. Most of the chapters follow a common format. Each begins with a brief introduction and a section entitled Historical Perspective that is designed to establish a historical context for the area under review. A section on 23 O Nutrition and Health Significancefor Public Health contains information currently available on the incidence, prevalence, and cost to the Nation of each of the conditions under review. Many of the chapters contain a further introductory Scien- tific Background section that summarizes technical information needed to understand the research issues reviewed in the Report. The major part of the chapters is devoted to a review of Key Scientific Issues that summarizes current knowledge about possible associations between dietary factors and disease that are most relevant to public policy. Each chapter closes with a section entitled Implications for Public Health Policy that summarizes the signiftcance of the research evidence for di- etary guidance and education, nutrition programs and services, and nutri- tion research and surveillance. Finally, Literature Cited provides an exten- sive list of references to support the scientific findings in each chapter. Historical Perspective Throughout history, human societies have observed relationships between the consumption of certain foods and the preservation of good health or the prevention or treatment of diseases. Although the word "diet" occurs frequently in writings attributed to Hippocrates and to Galen, the term "nutrition" did not appear as an English word until the mid-1400's and was used infrequently until the second half of the 19th century (Todhunter 1973). The modem concept of nutrition-that human life depends on a steady intake of a variety of specific dietary substances in defined amounts-is less than 200 years old. Development of Nutritional Science Conditions related to nutritional deficiency, such as beriberi, rickets, or scurvy, were described in very early writings, but the identification of the specific dietary factors required to prevent or treat these conditions began to occur only in the late 18th century and did not approach completion for another 150 years. Some of the major events in this gradual development of nutrition as a science from the earliest records to 1950 are listed in Table l-2. The chapters of this Report review the great expansion of nutrition research and knowledge that has occurred since then. The earliest efforts to establish the scientific basis of nutrition are usually attributed to the French chemist Lavoisier, who demonstrated in 1789 that the oxygen breathed in air was consumed in the body to produce carbon dioxide and water, and that this central metabolic process was measurable, variable, and related to both the level of physical activity and the amount of 24 Introduction and Background 0 Table 1-2 Selected Events in the History of Nutritional Science to 1950 c. 1500 B.C. c. 400 B.C. c. 300 B.C. c. 200 A.D. 1250 1614 1650 1730 1747 1752 1780 1789 17% 1807 1810-23 1810 1816 1827 1833 1838 1839 1840 Papyrus Ebers contains prescription believed to refer to diabetes. Hippocrates wrote of relationship of diet to health. Beriberi described in ancient Chinese texts. Arataeus gave the name diabetes to the condition of "too much passing of urine." Joinville described scurvy among troops of Louis IX at the siege of Cairo. Sanctorius published studies relating body weight to food intake. Glisson described rickets in De Rachitide. Casal described pellagra, calling it "ma1 de la rosa." Lind proved that citrus fruits cure scurvy in first controlled human dietary experiment. Menghini established presence of iron in blood. Reaumur published experiments on digestion in birds. Spallanzani produced evidence that digestion was the chemical action of gastric juices. Lavoisier and Seguin make first measurements relating oxygen consumption to human energy metabolism. Cod liver oil used as treatment for rickets. Lemon juice offtcially introduced in British Navy to prevent SCUNY. Davy isolated sodium, potassium, calcium, magnesium, sulphur, and boron. Chevreul studied chemistry of animal fats. WolIaston isolated cystic oxide (later named cystine) from urine--first amino acid discovered. Magendie identified dietary nitrogen requirements in dogs. Prout classified food constituents as saccharine, oily, and albuminous (sugar, fat, and protein). Beaumont reported observations and experiments on digestion in his patient St. Martin. Mulder introduced the term "protein." Boussingault conducts first nitrogen balance studies in animals. Liebig published Animal Chemistry, stating basic principles of metabolism. 25 O Nutrition and Health Table l-2 (continued) 1843 1848 1849-57 1850 1850-52 186641 1867 1877 1885 18% 1897 1902 1909-28 1912 1914 1916 1918 1919-22 1921-24 1922 1928 1929 1931-37 1932 1933 Chossat studied the effect of starvation on the body using pigeons. Addison described pernicious anemia. Bernard elucidated digestive action of pan