Dietary Guidelines Advisory Committee Meeting

(8:40 a.m.)

Dietary Guidelines Advisory Committee: Dr. Janet C. King (Chair), Dr. Lawrence J. Appel, Dr. Yvonne L. Bronner, Dr. Benjamin Caballero, Dr. Carlos A. Camargo Jr., Dr. Fergus M. Clydesdale, Dr. Vay Liang W. Go, Dr. Penny M. Kris-Etherton, Dr. Joanne R. Lupton, Dr. Theresa A. Nicklas, Dr. Russell R. Pate, Dr. F. Xavier Pi-Sunyer, Dr. Connie M. Weaver

Executive Secretaries: Ms. Carole Davis, Ms. Kathryn McMurry, Dr. Pamela Pehrsson, Dr. Karyl Thomas Rattay

Others: Dr. Cristina Beato, Dr. Eric Hentges

Dr. Cristina Beato, Acting Assistant Secretary for Health, HHS, welcomed participants to the second meeting of the 2005 Dietary Guidelines Advisory Committee (DGAC).  She noted that since the last meeting in September 2003 the Committee has reviewed recent scientific literature pertaining to the key areas of the Dietary Guidelines.

Dr. Beato thanked the members of Committee for volunteering their valuable time and services to assist HHS and USDA.  She acknowledged the importance of public input to this process and noted that the Committee had received a wide range of comments prior to this meeting.  Dr. Beato invited additional written comments from the public and reviewed the procedures for submitting such comments.  She noted that respondents should be clear and concise and provide the scientific justification for their views.  All comments from the public must be sent to the full committee, using the address in the Federal Register.

Dr. Beato concluded by again thanking the members and the staff for their hard work and gave them her best wishes for a productive meeting.  She then turned the floor over to Dr. King.

Dr. Janet C. King, Chair, Dietary Guidelines Advisory Committee, noted that the Committee has undertaken a challenging task in the short time since the first meeting.  The goal of this meeting is for the full Committee to review the work of the various subcommittees and identify priority issues.  At the next DGAC meeting (March 2004), the Subcommittees will present their draft recommendations, with scientific rationale.  The Committee will work toward consensus on which recommendations to include in the report.  The full Committee will review the draft DGAC report to the Secretaries at the fourth and final DGAC meeting (May 2004).  The final report will be submitted to the HHS and USDA Secretaries in June 2004.

Dr. King introduced Dr. Carol Suitor, a scientific writer formerly with the Institute of Medicine (IOM), who will prepare the draft report. Dr. Suitor was also involved in the last DGAC report.

Dr. King summarized the work of the Committee to date.  Since the last meeting (September 2003), the DGAC Subcommittees and staff have been working to identify priority research questions, conduct literature reviews, identify key scientific findings, and identify outside experts to address important issues.  The Subcommittees also identified overarching topics for consideration by the full Committee.  Dr. King noted that the Subcommittees would present their findings on the second day of the meeting.

Dr. King then reviewed the agenda for the day.  In the morning session, the Committee would hear an update on the Food Guide Pyramid reassessment process, followed by three expert presentations on components of a healthy American diet.  The afternoon session would include an expert presentation on nutritional needs of the elderly, public oral testimony, and a general discussion of overarching issues.

Dr. Eric Hentges, Director, Center for Nutrition Policy and Promotion, USDA, provided an update on the reassessment of the Food Guide Pyramid.  He noted that food guidance at USDA dates back to 1916 and has taken a number of forms over the years.  The Food Guide Pyramid, which was introduced in 1992, is the current food guidance at the USDA and is widely recognized.  A reassessment of the Food Guide Pyramid is currently underway to ensure that it reflects the latest standards in nutrition and to increase consumer use of the Pyramid.

Dr. Hentges noted that his presentation would focus on comments received in response to a notice of proposed changes to the Pyramid that appeared in the Federal Register last September.  The notice included proposed food intake patterns, the background data from which the patterns were developed, and key issues for public comment. 

Dr. Hentges thanked respondents for taking the time to review the extensive data in the Federal Register notice and providing their input.  USDA received 255 letters in response to the notice, containing 1101 separate comments.  Respondents included health and nutrition professionals, health associations, the food industry and trade associations, government agencies, and the general public.

USDA asked for specific input in five areas. The first was the appropriateness of using sedentary, reference-sized individuals in assigning target energy levels for the proposed food intake patterns.  The proposed energy level used the estimated energy requirement equation in the Dietary Reference Intake (DRI) Macronutrient Report.  The proposal to use sedentary energy levels was based on the fact that 64 percent of the U.S. population is overweight or obese.  This issue elicited numerous comments.  Most respondents supported the proposed position, although some suggested using an energy level that reflects a physically active lifestyle.  Quite a few respondents stressed the need to promote physical activity and to include food patterns for active individuals.

The second topic for public comment was the appropriateness of the nutritional goals for the daily food intake patterns and the standards used to set those goals.  The adequacy goal for most nutrients was based on the DRI, the Recommended Daily Allowance (RDA), where one was available, and the Adequate Intake level (AI) or Acceptable Macronutrient Distribution Range (AMDR) from the IOM Macronutrient Report, along with the moderation goals from the 4^th and 5^th editions of the Dietary Guidelines, or Daily Values set by the Food and Drug Administration (FDA) for the Nutrition Facts Labels.

Many respondents supported the use of these standards, although some questioned why Estimated Adequate Requirements (EARs) were not used.  Some comments received were in regards to specific nutrients relative to a nutritional standard, including the following concerns:

• Vitamin E: Respondents noted that the proposed food patterns do not meet the new standard for vitamin E.  They also asked whether the standard is appropriate and whether the current nutritional database was up to date regarding vitamin E.
   
• Iodine and Vitamin D: Respondents asked why these nutrients were not included in the proposed food patterns.  (Dr. Hentges noted that there is an RDA for these nutrients, but information is lacking in the nutrient database.)
   
• Sodium and Potassium: Respondents asked what standards were used, or should be used, for these nutrients.  (Dr. Hentges stated that USDA is awaiting the findings of the IOM Water and Electrolytes panel.)
   
• Trans fats: Respondents asked why there was no goal for trans fats. (Dr. Hentges noted the DRI states they should be "as low as possible" but does not set a quantitative goal on which to base a recommendation.)
   
• Fats: Respondents questioned whether there was good reason to limit fats to 30 or 35 percent of calories, once you have taken care of saturated fat.
   
• Carbohydrates: Respondents suggested using the lowest percentage within the AMDR range as opposed to a median or other goal for carbohydrates.
   
• Fiber: Some thought the proposed goal was too high; others thought it was too low. (USDA is seeking the Committee's input to set the appropriate standard.)
   
• Added sugars: Respondents thought the proposed level was too high and that the term "goal"implied that added sugars are needed.  (Dr. Hentges noted that the DRI level was a limit, not a goal.)

The third issue for public comment was the appropriateness of the proposed food intake patterns.  This issue elicited more comments than any other topic.  Dr. Hentges noted that the proposed food groups and patterns were based on nutrient adequacy and typical food choices.  Respondents questioned whether the proposed patterns were appropriate for educating Americans about healthful eating.  The most common recommendations were that whole grains should be emphasized; types of fats should be differentiated; and foods in the Meat and Beans group should be differentiated.  There was broad support for the proposed changes in the food patterns that emphasized unsaturated fats and oils and greater consumption of whole grains, legumes, and dark green vegetables.  Additional suggestions included:

• Emphasize nutrient-dense choices for fruits and vegetables and other groups that are typically under-consumed

• Greater encouragement of legume consumption

• Include fortified soy products in the milk group

• Decrease grain servings

• Keep meat servings as is because meats are leaner now

• Move potatoes to another food group

• Increase the amounts recommended in the milk group

• Include fortified foods or supplements in the food patterns.

The fourth issue for public comment was whether the amounts to be eaten should be expressed in household measures, such as cups and ounces, or whether it should continue to be expressed in terms of number of servings per day.  There was widespread support for replacing servings with household measures in consumer materials.  Some respondents suggested keeping the term "serving," but clarifying or changing serving sizes.  Many respondents noted that the USDA's food guidance should be in harmony with the Nutrition Facts label.  Dr. Hentges stated that USDA would be meeting with FDA to ensure this happens.

The fifth issue for public comment was the selection of appropriate subsets of the food patterns for use in consumer materials.  Most respondents supported the idea of selecting subsets of the proposed patterns to target various audiences, but the recommendations varied widely as to what these subsets should be.  Dr. Hentges noted that this issue would be addressed in ongoing consumer testing.

Respondents to the Federal Register notice raised a number of additional issues, such as comments on water, recommendations to include physical activity in the food guidance, suggestions for including supplements in the food patterns, and requests to include food patterns for vegetarians.  Although the Federal Register notice specifically requested comments on updating the scientific basis, many people suggested changes in the graphic design.

Dr. Hentges stated that USDA was pleased with the large number of responses, the diversity of audiences, and the range of viewpoints that were expressed.  Areas of widespread agreement included the importance of energy levels and nutritional goals; support for greater emphasis on whole grains, unsaturated fats, and nutrient-dense choices, especially from groups that are currently under-consumed; and the use of standard household measures.

A number of issues will require further discussion, including whether the vitamin E standard is appropriate; whether nuts should be placed in a separate food group; whether legumes should be left in both the Meat and Bean group and the Vegetable group; whether soft margarines should be classified as oils or moved to solid fats, in light of trans fat; whether calcium-fortified soy products should continue to be classified as legumes; and the question of water and whether it should be included in the pyramid revision.  CNPP will seek the Committee's input and guidance in these areas.

Dr. Hentges noted that the revision of the food guidance is still a work in progress.  The comments provided some clear directions, but CNPP staff will continue to analyze and revise the technical basis.  Nothing will be finalized until the Committee has completed its deliberations. CNPP will incorporate new standards the Committee may set and input it may provide relative to any of the issues discussed.  Dr. Hentges stressed that the implementation of the Dietary Guidelines and the Food Guide Pyramid must be coordinated between all agencies and with many other partners.  CNPP looks forward to discussions on strategies for that implementation.

Dr. Hentges presented two tables of data that showed the proposed recommendations versus the current average consumption.  While the proposed recommendations are not that different from current consumption when looking at the major food groups, there are major differences within the vegetables, grains, and fats subgroups.  The proposed patterns would require a three- to four-fold increase in consumption of dark green vegetables.  They would also require consumers to double their consumption of orange vegetables and legumes and triple their consumption of whole grains.  Additionally, the proposed patterns would require a 30 to 60 percent decrease in consumption of starchy vegetables, and a 50 to 60 percent decrease in solid fats.

Dr. Hentges stated that the food patterns would be finalized as soon as the Committee completes its technical report.  Design aspects will continue until just prior to the release of the revised food guide, next year (2005).  Consumer research has been underway for approximately two years and will continue through the implementation of the new guidance.  Public comments will be solicited throughout the process.  CNPP will publish a Federal Register notice in late spring or early summer to solicit input regarding consumer messaging and graphic issues.  The revised food guide will be released in 2005, following the release of the official Dietary Guidelines.

Dr. Hentges acknowledged that the proposed guidance expects Americans to make significant behavioral changes.  He assured the Committee that USDA is committed to providing the public with guidance to help meet this challenge.  He stressed that addressing current issues of overweight and obesity will require partnerships between the federal agencies, between nutrition educators, dieticians, and extension educators, and between federal agencies and industry.

Dr. King asked whether the current Food Guide Pyramid includes specific recommendations for intake of whole grains.  Dr. Hentges replied that the Pyramid gives a range of 6-11 servings of grains per day and recommends at least 3 servings of whole grains.  While this is half of the total grains servings at the lower end of the range, the proportion decreases as the number of servings increases.

Dr. Caballero noted that there seems to be a general consensus that a certain level of activity is an essential component of energy balance.  He expressed concern that it would be confusing to base the food guidance on sedentary people while recommending that people be more active and asked whether it might not be better to base the energy level on certain minimal level of physical activity that most people should try to achieve.

Dr. Hentges noted that most of the health groups that responded felt that the energy level should reflect the reality that most of the population is sedentary and overweight.  He thought it would be important to promote more active levels and stated that the Physical Activity Coefficients could be used to adjust the recommended food patterns for more active groups.  Dr. Hentges emphasized that CNPP is looking to the Committee for guidance in this area.

Dr. Appel asked for details regarding proposed alternatives to the Pyramid.  Dr. Hentges stated that most of the respondents suggested rearranging elements within the current shape to emphasize different issues.

Dr. Clydesdale asked if USDA would be conducting consumer research regarding the issue of aligning the recommended serving size with the Nutrition Facts label.  Dr. Hentges stated that CNPP recognized the need for these to be in harmony and is setting up a meeting with FDA.  He noted that "serving" and "portion" mean the same thing to consumers and that "value sizing" is an economic phenomenon.  That issue will be addressed in message testing.

Dr. Weaver noted that some comments suggested that nutrient density should be shown more clearly on food labels, and she stated that the Committee would pursue that as an overarching issue.  Dr. Hentges noted that many nutrient-dense foods in the proposed patterns are currently under-consumed.  It will be important to identify strategies to get the desired behavior change.

Referring to the question of soft margarines, Dr. Kris-Etherton noted that the food industry is making an effort to get rid of trans fat.  In light of that, she wondered if it would be possible to rethink that category.  Dr. Hentges replied that the previous food pattern was 60% solid fat and 40% oils.  The new recommendation shifts that to 60% oils and 40% solid fat. USDA is looking to the Committee for guidance in this area.  They are also awaiting recommendations from the IOM as to how trans fat and saturated fats will be handled in nutrition labeling.

Dr. Nicklas asked if the comments regarding fiber specified certain age groups.  Dr. Hentges and his staff believed the comments were more generalized, but they would look into it. 

Dr. Lupton noted that those at the low end of the energy scale need to be very careful about the nutrient density of their foods and may not have many discretionary calories available. She wondered if a decreased intake of added fat or added sugars could be recommended for these groups.  Dr. Hentges stated that CNPP recognizes the need for flexibility.  The revised Pyramid will reflect the Committee's guidance on total fat consumption and added sugars.

Dr. Camargo asked if it would be possible to develop two graphics  —  one for sedentary individuals, and a second for those who meet the recommended physical activity goal.  Dr. Hentges replied that the challenge is to come out with appropriate food guidance and to make it relevant to individuals.  The greatest challenge in implementing the revised Pyramid will be connecting with individuals once they are motivated, which may take a number of targeted tools.  Partnerships will also be critical to implementation.

Dr. Camargo also asked where alcohol fits into the Pyramid.  Dr. Hentges stated that USDA awaits the Committee's input with regard to the question of alcohol.

Dr. Pate noted that the last DGAC began to address the issue of integrating dietary and physical activity recommendations.  He stated that this Committee might need to decide how to bring together the two sets of recommendations.

Dr. Bronner asked whether the new Food Guide Pyramid will state clearly that people need to make the best choices within each food group in order to meet the nutrient requirements.  Dr. Hentges replied that it will take a targeted education effort to get consumers to make the behavior changes that will result in more nutrient dense choices in food groups that are currently under-consumed.  The food industry can make some changes independent of changes in consumer behavior, but partnerships will be important.

Dr. Weaver commented that it would be relatively easy to develop a computerized program that would translate the twelve proposed food patterns into a customized Pyramid.  Dr. Hentges agreed that interactive tools present an important opportunity for implementing the revised Pyramid and noted that USDA has already begun to explore this option.

Dr. Caballero expressed concern that consumers may not understand that the Pyramid recommendations are based on the lowest fat and healthiest type of food in each category and that choosing other foods could affect the energy balance.  Dr. Hentges agreed that it would be important to focus education and consumer testing on communicating the energy issue.  He stated that previous communications dealt more with the nutrient adequacy of food choices.  This time around, it will be essential to emphasize calorie content.

Dr. Nicklas noted that physical activity is indirectly reflected in the current Food Guide Pyramid in the range of servings for various caloric levels.  She noted that the Nutrient Adequacy Subcommittee would be looking into whether nutrient density can be quantified in a way that is meaningful to consumers.

Dr. Kris-Etherton asked whether it would be feasible to suggest more nuts in the diet to increase vitamin E intake.  Dr. Hentges noted that it would require a ten- to twenty-fold increase in the current consumption of nuts in order to obtain a meaningful level of vitamin E.  However, USDA will continue to look at the nutrient databases, the DRI recommendation, and the feasibility of recommending increased intake of nuts.  (Dr. Weaver noted that the Nutrient Adequacy Subcommittee would address that issue in its report.)

Dr. Clydesdale asked whether fortification and/or the addition of vitamin E to foods as an anti-oxidant had been taken into consideration as part of the consumption.  Dr. Hentges stated that USDA is reviewing the database to see if it accurately reflects all of the current foods as purchased and available.

Dr. Appel asked whether the title of the document and the Committee could be changed to the "Dietary and Physical Activity Guidelines."  Dr. Rattay stated that the Congressional mandate refers to the document as the Dietary Guidelines and that the name would have to be changed through Congress.  Dr. Appel noted that perhaps the name change could be one of the Committee's recommendations.

Dr. Pate agreed that it seems appropriate to look for ways to draw together the physical activity and dietary guidance, because it is difficult to make energy intake recommendations without considering activity level.  However, he recognized that the physical activity guidelines could be as detailed and extensive as the Dietary Guidelines being considered by this Committee, and that it might be difficult to combine all of that information.

Dr. Kris-Etherton noted that the American Heart Association and others have recommended increased fish consumption and asked if the revised food guide would do so.  Dr. Hentges said there would need to be a strong reason to emphasize an individual food within a group.

Dr. King asked what percent of Americans currently selects a diet that adheres to the Food Guide Pyramid and wondered how to motivate those Americans who do  not to make the necessary changes.  Dr. Hentges acknowledged this would be a challenge.  Most consumers recognize the Pyramid and have a good understanding of the messages, yet implementation is very low.  On the other hand, the increased selection of herbal products on grocery shelves and the popularity of diet books indicate that people want to make a change.  The new Dietary Guidelines, followed by the new food guide and changes in the food labels, present a huge opportunity to connect with consumers.  It will be important not to miss that opportunity.

Dr. Clydesdale suggested that the recommendations could be promoted on the basis of the scientific evidence behind them.  Dr. King noted that there is a lot of competition when it comes to guidance on health and nutrition.

Dr. King thanked Dr. Hentges for an excellent presentation that showed that the work of this Committee is also going to be important to the development of the Food Guide Pyramid.

(Break: 9:50-10:05)

Dr. King welcomed the three panelists who were invited to share their expertise with the Committee.  She noted that the panelists would give their presentations, and would be followed with a discussion between the panel and the full Committee.

Dr. King then introduced the panelists. Dr. Frank Hu is Associate Professor of Nutrition and Epidemiology in the Department of Nutrition at Harvard School of Public Health.  His research is primarily focused on the role of diet and lifestyle determinates in the development of type 2 diabetes and cardiovascular disease.  Most, though not all, of his research is based on two large ongoing cohort studies at Harvard:  the Nurses Health Study and the Health Professionals Follow-Up Study.

Dr. Ronald Krauss is Director of Atherosclerosis Research at Children's Hospital Oakland Research Institute.  He is a Guest Senior Scientist in the Genome Sciences Division of Lawrence Berkeley National Laboratory, and Adjunct Professor in the Department of Nutritional Sciences at the University of California at Berkeley.  Dr. Krauss has been Senior Advisor to the National Cholesterol Education Program and is actively involved in the American Heart Association, having served as Chairman of the Nutrition Committee.  He is founder and Chair of the American Heart Association's Council on Nutrition, Physical Activity and Metabolism.  His research focuses on genetics, dietary and hormonal effects on plasma lipoproteins and coronary disease risk.

Dr. Joanne Slavin is Professor of Nutrition at the University of Minnesota.  She is an expert in the areas of nutrition across the lifestyle, human nutrition, sports nutrition, dietary fiber, and the role of diet in disease prevention.  Her research interests are dietary fiber, phytoestrogens from flax and soy, and whole grains, with a focus on conducting human feeding studies that measure relevant biomarkers for chronic disease prevention.

Dr. Frank Hu, Harvard School of Public Health, noted that he was asked to speak on four very complicated topics: Alternate Healthy Eating Index; the balance of n-6 and n-3 polyunsaturated fatty acids in the diet; fat and obesity; and the foundation of a healthy diet.

Dr. Hu began with a discussion of the Healthy Eating Index (HEI), which was developed by Eileen Kennedy at USDA in 1995 to assess the degree of adherence to the Dietary Guidelines for Americans and the Food Guide Pyramid.  The index includes 10 different components: grains, vegetables, fruits, milk, meat, total fat, saturated fat, cholesterol, sodium, and variety in the diet.  It has been widely used to monitor dietary quality over time in the U.S. and to assess dietary quality in different populations.  However, it has not been evaluated in terms of whether it can predict disease risk, especially cardiovascular disease and cancer.

A study conducted in 2000 examined the relationship between the HEI and the risk of major chronic disease (cardiovascular disease and cancer), using the large cohorts in two ongoing studies at Harvard (nurses and health professionals).  Subjects in the two cohorts were classified according to HEI quintile (multivariate-adjusted) to determine if there was any association between diet and relative risk of major chronic disease.  The data showed a modest inverse association between diet and relative risk in men, but no significant association between diet and risk in women.  In light of these findings, the researchers thought the index should be improved because it did not predict major chronic disease in the two cohorts.

The researchers proposed an Alternate Healthy Eating Index (AHEI) to reflect different types of fats; the level of cereal fiber (to represent whole grain intake); the ratio of white meat to red meat in the diet; consumption of nuts, legumes, and soy; and moderate alcohol consumption.  They predicted that this index would be a stronger predictor of major chronic disease than the original HEI.  In fact, they found a strong universal association between HEI, the AHEI, and major chronic disease in men, as well as a significant universal association between the AHEI and major chronic disease in women.

Dr. Hu presented a table summarizing percent risk reduction associated with the highest quintiles of the HEI and the AHEI.  For men, the HEI was associated with 11 percent decrease in incidence of major chronic disease, and about 28 percent decrease in incidence of cardiovascular disease.  The AHEI was associated with a 20 percent decrease in major chronic disease and a 39 percent decrease in cardiovascular disease.  These findings were significant.

The results for women were especially dramatic.  The HEI predicted no significant risk reduction for women (3 percent reduced risk for major chronic disease, 14 percent for cardiovascular disease).  The AHEI, however, predicted an 11 percent decrease in risk of major chronic disease and a 28 percent decrease in risk of cardiovascular disease.  These results were significant.  This research suggests that the AHEI is a better predictor of major chronic disease than using HEI.  Further research is needed to identify dietary patterns associated with different types of cancer risk, because neither the HEI nor the AHEI predict this risk.  Dr. Hu recommended that the Dietary Guidelines should continue to be evaluated for their ability to reduce risk of chronic diseases that are of major public health concern.

Dr. Hu then turned to a discussion of the relationship between n-6 polyunsaturated fat (n-6 PUFA) and cardiovascular disease, diabetes, and cancer.  He briefly reviewed four randomized clinical trials with coronary endpoints.  The fat intake for subjects in these studies was 34 to 46 percent of energy.  n-6 PUFA was much higher (10 to 20 percent of energy) than the average American diet.  The results of these clinical trials consistently showed a significant reduction of serum LDL cholesterol levels and incidence of cardiovascular events. 

The findings of observational studies of the relationship between n-6 PUFAs and coronary heart disease have also been studied.  A review of 90,000 women in the Nurses' Health Study showed a strong inverse association between median intake of n-6 PUFAs and relative risk of both fatal and non-fatal coronary heart disease.

Dr. Hu noted that there have been several studies, which have examined the effects of n-6 PUFAs on type 2 diabetes.  Several controlled metabolic trials support the benefits of substituting linoleic acid for saturated fat in improving insulin sensitivity.  The Nurses' Health Study also showed a significant inverse association between median intake of n-6 PUFAs and relative risk of type 2 diabetes.

Dr. Hu stated that one concern with n-6 PUFA is its potential effect on cancer, because high polyunsaturated fat has been found to promote tumor growth in animal studies.  However, analysis of twelve major prospective cohort studies found no evidence that high polyunsaturated fat intake is associated with tumor growth. Based on the epidemiological studies, there is no suggestion of increased breast cancer risk with high n-6 PUFA consumption.

Dr. Hu noted that some people are concerned that a high level of n-6 PUFAs may mitigate the benefits of n-3 PUFAs.  They suggest reducing n-6 PUFAs to maximize the benefits of n-3 PUFAs, and some have proposed that the ratio is more important than the absolute amount of n-6 and n-3.  Dr. Hu stated that the evidence suggests that both n-6 and n-3 are important, that high intake of n-6 does not mitigate the benefits of n-3, and that the benefits may be additive.

Alpha-Linolenic acid (ALA) is the main source of n-3 PUFAs in the diet, primarily from plant-based foods.  A review of the Nurses' Health Study found that both ALA and linoleic acid (LA) were associated with significant decreased risk of fatal coronary heart disease and that the ratio was not associated with risk.  A higher amount of n-6 PUFAs does not appear to mitigate the benefits of ALA or fish n-3 fatty acids.  Therefore, Dr. Hu recommended that rather than decreasing n-6 PUFA intake, nutritional strategies should maximize the benefits of both types of fatty acids through a modest increase in n-6 and a more dramatic increase in n-3.

Dr. Hu noted that in 1989, the Diet and Health Committee of the National Academy of Sciences concluded that, "Intake of total fat per se, independent of the relative content of different types of fatty acids, is not associated with high blood cholesterol levels and coronary heart disease." Subsequent studies have shown that the type of fat is in fact more important than the total amount of fat in the diet.

Guidelines issued in 2001 by the National Cholesterol Education Program allow 25 to 35 percent of energy from total fat.  The 2002 IOM Macronutrient Report recommended 20 to 35 percent of energy as an acceptable range but did not set an upper limit for total fat.  The 2000 Dietary Guidelines recommend an upper limit of 30 percent of energy from fat.

A major concern today is the high incidence of obesity.  A low-fat diet has been promoted for weight loss and prevention of obesity, and conventional wisdom holds that the more fat you eat, the more likely you are to become obese.  However, the evidence does not support the conventional wisdom.

Short-term studies show that all types of diet will lead to weight loss if calories are reduced.  Long-term studies provide more valuable information because they show whether a diet can be followed over the long run and whether it can be used to maintain weight loss.  Sixteen long-term studies (six to eighteen months in duration) found no evidence that a low-fat diet is more beneficial than a control diet.  Reducing the percent of dietary energy from fat causes a small short-term reduction in weight, but there appears to be little, if any, relation between dietary fat composition over the range of 18 to 40 percent of energy and body fat. 

Dr. Hu stated that studies conducted in the past three years have found a moderately high-fat diet that includes nuts and olive oil to be more beneficial in terms of adherence, weight loss, and weight maintenance, while also reducing cardiovascular risk factors.

Dr. Hu stated that the exclusive focus on dietary fat has been a distraction in efforts to control obesity and that the proliferation of low-fat products has led to increased consumption of refined carbohydrates.  While it is difficult to draw a correlation between the decrease in fat intake and the increase in obesity, there is reason to be concerned about this dietary trend. 

Dr. Hu suggested that the foundation of a healthy diet should be food-based, not nutrient-based.  There is evidence supporting the benefits of plant-based foods.  He proposed revising the base of the Food Guide Pyramid to include three food groups  —  fruits and vegetables, whole grains, and nuts and legumes  —  in light of the strong evidence that these foods have benefits for cardiovascular disease and cancer.  He recommended placing the entire Pyramid on a base of physical activity.

Dr. Ronald Krauss, Children's Hospital Oakland Research Institute, discussed the role of the carbohydrate to fat ratio and disease risk, the interaction of this ratio with the effects of individual fatty acids on disease risk, and the relationship of the carbohydrate to fat ratio to body weight, including maintenance and weight loss.

He began with several caveats.  First, most of the evidence regarding the disease effects of carbohydrate to fat ratio is derived from epidemiological and observational studies because it is difficult to address disease endpoints through clinical trials.  Intermediate cardiovascular disease and diabetes risk biomarkers are imperfect predictors of clinical disease.  Second, the effects of specific types of carbohydrates and the food sources of those carbohydrates can vary as much as the effects of individual fatty acids.  Finally, the impact of this ratio on disease and disease markers is strongly influenced by energy balance.

Dr. Krauss presented a table showing fat to carbohydrate ratios at various levels of protein intake (15 to 30 percent of calories, in five percent intervals).  For each protein level, he calculated fat and carbohydrate ratios compatible with the IOM AMDRs.  He then looked at published information through 2002 that related these ratios to disease and disease risk markers with particular focus on lipids and lipoproteins since they have a strong predictive value for cardiovascular outcomes.

Two relationships with lipids were very clear in the studies he reviewed:  an increase in HDL cholesterol as fat is increased, and a reduction in triglyceride as fat is increased.  These findings were highly consistent in many short-term observational and clinical trials.

The most predictive measure for cardiovascular outcomes is the ratio of total to HDL cholesterol.  The studies that Dr. Krauss reviewed showed a significant reduction in this ratio as fat level increased in the diet.  This raises interesting issues for dietary recommendations regarding fat.

A meta-analysis conducted last year of more than 100 studies found a strong positive effect of saturated fat on both HDL and LDL cholesterol, such that the total to HDL cholesterol ratio is minimally affected by saturated fat.  Both mono- and poly-unsaturated fats were associated with reductions in LDL.  Monounsaturated fat appears to be driving the inverse relationship between fat and lipid levels, since it is the primary unsaturated fat in the diet.

Dr. Krauss examined disease outcome data from observational studies of omega-3 fatty acids and lipid levels.  These studies found a strong inverse relation between intake of omega-3 fatty acid in the form of ALA and triglyceride levels.  Another metabolic feature of these fatty acids is their effect on insulin sensitivity.  Dr. Krauss reviewed a study that compared a diet high in saturated fats, a high carbohydrate diet, and a Mediterranean Diet.  The study found improved insulin sensitivity on the Mediterranean Diet that was comparable to that achieved with a higher carbohydrate diet.

Summarizing the effects of carbohydrate and fat on metabolic risk, Dr. Krauss noted that:

• Higher ratios lower HDL cholesterol and increase triglyceride and total to HDL cholesterol

• Saturated fatty acids increase LDL and HDL cholesterol and reduce insulin sensitivity, with no significant change in the total to HDL cholesterol ratio, as compared to cis-monounsaturated fats and polyunsaturated fats; these effects are greater for myristic and palmitic acids than for stearic acids
• Cis- monounsaturated and n-6 polyunsaturated fatty acids reduce total/HDL cholesterol ratio

• N-3 polyunsaturated fatty acids reduce triglycerides.

With regard to the question of whether the ratio of carbohydrate to fat modifies the metabolic response to individual fatty acids, Dr. Krauss stated that higher-fat, lower-carbohydrate diets should be considered in the context of moderate to higher protein levels, including more extreme diets that are relatively low in carbohydrate and high in fat and protein.

To assist the Committee in understanding the impact of these more extreme ratios on responsiveness to dietary fatty acids, Dr. Krauss presented data from an unpublished study that he presented last year to the American Heart Association.  This three-year study looked at the effects of saturated versus unsaturated fat on weight loss.  All subjects followed a baseline diet for one week after which they were randomly assigned to four groups:

• Basal (Control Diet):  54% carbohydrate, 30% fat (7% saturated, 13% monounsaturated), 16% protein

• Moderate Carbohydrate Diet: 39% carbohydrate, 31% fat (6% saturated, 13% monounsaturated), 29% protein

• Lower Carbohydrate/Higher Saturated Fat: 26% carbohydrate, 45% fat (15% saturated, 20% monounsaturated), 29% protein

• Lower Carbohydrate/Lower Saturated Fat: 26% carbohydrate, 46% fat (9% saturated, 27% monounsaturated), 29% protein

This study presented an opportunity to examine the interaction of fatty acid composition at the same level of carbohydrate and total fat.  To allow researchers to examine the effect of weight loss on metabolic responses, the study was conducted in three phases:  a one-week pre-weight loss phase, with all subjects on the control diet; a five-week weight loss phase, and a four-week post-weight loss phase to stabilize weight.

At the end of the study, the lower carbohydrate/lower saturated fat diet showed the most significant levels of LDL reduction both pre- and post-weight loss.  There was no significant change in LDL cholesterol on the moderate carbohydrate diet or the lower carbohydrate/higher saturated fat diet.  Although the basal diet was associated with only moderate reduction in LDL cholesterol in the pre-weight loss phase, individuals on this diet actually achieved significant reduction of LDL cholesterol in the post-weight loss phase.  The weight loss had virtually no effect on the LDL levels for individuals on the other diets.

Dr. Krauss noted that the published studies he reviewed would have predicted an insignificant reduction of LDL on the lower saturated fat diet, yet this study found a substantial reduction.  There appears to be some interaction between carbohydrate intake and the magnitude of saturated and unsaturated fatty acids on LDL cholesterol.

Dr. Krauss offered a potential explanation for these findings.  Studies conducted in his and others labs indicate that carbohydrate intake and weight both affect metabolic pathways that give rise to different forms of LDL.  Under conditions where triglyceride levels are low, such as in lean or active individuals or those with low carbohydrate intake, the particular pathway that comes from the liver results in a form of large or medium-sized LDL particles that are cleared effectively by the LDL receptor.  When triglyceride levels are higher due to higher carbohydrate intake, increased adiposity, or sedentary lifestyle, the pathway shifts to allow the liver to deliver more triglycerides.  This gives rise to a distinct, small LDL particle that is cleared less avidly by LDL receptors.

This latter pathway is a critical element of the metabolic syndrome, type 2 diabetes and obesity.  Low HDL, insulin resistance, and many other metabolic disturbances that increase the risk for heart disease accompany the small LDL response.  The low-carbohydrate, high-fat diet was associated with a substantial reduction in small LDL when compared with the control diet, independent of the saturated fat content of the diet.  This is a major benefit of weight loss and needs to be considered in the overall equation.

Dr. Krauss noted that the triglyceride change associated with low-carbohydrate, high-fat intakes appears to be a more significant determinant of the small LDL response than saturated or unsaturated fat content.  However, saturated fat increases the concentrations of the larger LDL particles, which are more cholesterol enriched.

Dr. Krauss stated that the best way to integrate this biochemistry is to look at the ratio of total to HDL cholesterol.  Both of the low-carbohydrate, higher-protein, higher-fat diets in this study led to a reduction in this ratio that was significantly different from the control diet and more than would be predicted from previous studies.  However, the incremental benefits of weight loss on the atherogenic indices are much less pronounced at low carbohydrate to fat ratios.  Dr. Krauss noted that there are no significant differences when combining the effects of diet and weight loss.  This suggests that the carbohydrate to fat ratio and adiposity contribute to the same net pathways.

Dr. Krauss noted that the experimental diets in this study used a higher protein intake to allow lower carbohydrate levels.  The possible effects of increased protein intake are relatively under studied.

Dr. Krauss concluded his presentation by addressing the relationship of carbohydrate and fat intake to weight maintenance and weight loss.  He reviewed studies of at least one year in duration that related change in percent fat intake to loss of body weight, with fat intake ranging from about 12 percent to about 32 percent.  As Dr. Hu mentioned earlier, these studies suggest that lower-fat diets do not seem to offer particular advantages for weight loss, although they may be acceptable for weight maintenance.  Ultimately, it is total energy and total calories that matter. It is clear from all the data that the macronutrient distribution is not a factor influencing weight loss when calories are controlled.

Two studies conducted in the past year sought to provide patients with dietary recommendations based on literature from the Atkins program versus conventional dietary recommendations.  These studies involved diets that were very low in carbohydrate and higher in fat and protein (following the recommendations of the Atkins program) compared with lower fat diets (following the conventional dietary recommendations).  Data from these studies showed that a low-carbohydrate diet performed better than the low-fat diet over a six- month period.  However, a third study  —  the only one carried out for a period longer than six months  —  found that these two diets converged over time, presumably due to lack of compliance.  The lipid and lipoprotein changes in the last study are similar to those found in the study conducted by Dr. Krauss.  With lower carbohydrate intake, the influence of fat content composition on insulin sensitivity appears to be blunted.

In conclusion, Dr. Krauss stated that reduction in total fat leads to modest reductions in weight.  Reduction in dietary carbohydrate to less than 30 percent of calories leads to large early reductions in body weight.  In both cases, reductions in body weight are clearly related to changes in energy intake.  However, these changes may not be sustainable for most individuals.  Trials of low-carbohydrate diets for long-term prevention of weight gain are lacking.

Dr. Joanne Slavin, University of Minnesota, discussed dietary approaches to weight control, with an emphasis on the role of carbohydrates and fiber.  She noted that the primary mechanism of weight control is to eat fewer calories and exercise more.

Eating less carbohydrate can lead to significant change, because carbohydrates are the major source of calories.  Eating less fat has a positive impact on calorie density, but palatability can be an issue.  Eating more protein will also lead to lower calorie intake.  But, Dr. Slavin stressed that there is little data that any of these strategies are very effective in the long run.

The eating and exercise targets from the IOM Report propose 45 to 65 percent of calories from carbohydrates, 20 to 35 percent of calories from fat, and 10 to 35 percent of calories from protein, combined with a total of at least one hour each day in moderately intense physical activity, which is double the daily goal set by the 1996 Surgeon General's report.  Dr. Slavin stressed that nutritional advice is wasted without physical activity.  She expressed concern that consumers do not understand the concept of energy balance.

Dr. Slavin reported that case-control studies of dietary composition find a pattern of Low- carbohydrate intake in obese subjects.  These studies also found a positive association between the percentage of dietary fat and Body Mass Index (BMI).  Dr. Slavin noted that the form of carbohydrate is important, but there is a shortage of good data in this area.

Studies have found that low-fat diets are the optimal choice for the prevention of weight gain and obesity.  Low-carbohydrate diets are more effective at 3 and 6 months for weight loss, but there is no difference between the two types of diets at 12 months.  Overweight subjects who consume low-fat, high-carbohydrate diets tend to eat fewer calories, lose weight, and lose body fat.

Dr. Slavin noted that the National Weight Control Registry is a useful source of information on weight management because it tracks people who have lost at least 30 pounds and maintained that loss for at least one year.  On average, the individuals in the Registry get 24 percent of their calories from fat, 56 percent from carbohydrate, and 19 percent from protein.  Many people stated that eating breakfast was an important factor in their weight loss.  Most reported that they regularly monitor their food intake and body weight.  All reported high levels of physical activity.  This information underscores the fact that weight control is a lifelong process that does not end when the desired weight is achieved.

Dr. Slavin noted that nutritionists typically look at things that can be measured, whether it is calories, macronutrients, or micronutrients.  She suggests that broader things  —  such as dietary patterns, intake of whole foods, timing and frequency of meals  —  are actually more important than we have given them credit for.

Another problem in nutrition is that elements of the diet are interdependent.  Only in a controlled feeding study is it possible to hold fat intake constant and vary fiber intake. In the real world, changing one aspect of the diet can result in many other associated changes in nutrition.  Reducing the amount of fat in the diet will affect the intake of fat-soluble vitamins, while eliminating high-carbohydrate foods can affect intake of other nutrients.

In determining the appropriate balance of macronutrients for an individual, Dr. Slavin sets the base with proteins.  The DRI recommends a range of 10 to 35 percent of calories from protein, 20 to 35 percent of calories from fat, and 45 to 65 percent of calories from carbohydrates.  There needs to be enough fat to get essential fatty acids, fat-soluble vitamins, minerals, and other fat-soluble phytochemicals that are just starting to be studied. 

Carbohydrates are also an important source of vitamins, minerals, and phytochemicals.  The carbohydrate allowance also needs to include adequate dietary fiber, which is 25 to 38 grams per day, depending on age.  The individual's calorie budget and activity level are important factors in determining the overall macronutrient balance.

Dr. Slavin emphasized that the various types of carbohydrates are not equal.  They differ in terms of their chemical structure (mono-, di-, and polysaccharides).  They differ in terms of digestibility  —  starches and sugars get digested, but fiber does not.  They differ in terms of speed of digestion and absorption.  She noted that this variable, often quantified as glycemic index, is important for diabetics.  Carbohydrates differ in terms of fermentability  —  some fibers are more likely than others to ferment in the large intestine, and some ferment more quickly. Finally, the physical structure of carbohydrates  —  including particle size  —  is important, though it is hard to measure.

Dr. Slavin stated that there is general agreement that whole grains contain many valuable components.  However, many of these important nutrients are lost in the milling that is required to produce the refined grain products that many consumers prefer because of their taste, texture, and longer shelf life.

Dr. Slavin illustrated the evolution of dietary advice regarding whole grains over the past two decades.  Prior to 1980, whole grains were promoted as a source of fiber.  In 1989, the National Academy of Sciences report, Diet and Health, linked whole grains with reduced risk for heart disease and some cancers.  In 1999, the FDA permitted whole grain health claims on food packaging.  The fifth edition of the Dietary Guidelines, issued in 2000, emphasized whole grains.  Increased whole grain consumption is one of the objectives of Healthy People 2010.

The 2000 Dietary Guidelines recommended "several servings" of whole grains but did not set a quantitative goal.  The Healthy People 2010 objectives aim for three servings per day, a goal that is also promoted by the USDA and the American Dietetic Association.  However, a 1995 study found that fewer than 10 percent of Americans were only eating one serving a day of whole grains.  A study published last year found that the average whole grain intake was 0.8 servings a day for pre-school children and one serving for adolescents.

Dr. Slavin stressed that before the Committee considers increasing the goal, it is important to consider why people are not meeting the current recommendations.  USDA data show that whole grains represent only 15 percent of U.S. grain consumption and 85 percent of grains consumed is non-whole grain.  If only whole grains are recommended, consumers who are currently consuming 85 percent non-whole grains will need to find acceptable ways to replace 85 percent of the grains in their diet. USDA data also show that consumers get whole grains from many different products, including breads, breakfast cereal, and grain snacks.  The food industry will need to come up with more choices within those categories for consumers to meet whole grain recommendations. 

Dr. Slavin summarized a review of whole grains and human health that is currently in press.  This review provides strong evidence that whole grains are protective against cardiovascular disease, cancer, diabetes, obesity, and all-cause mortality.  Epidemiological studies suggest that an intake of three servings of whole grains per day is associated with significant risk reduction of type 2 diabetes.  Another recent study found that whole grain consumption was significantly associated with insulin sensitivity.  A clinical study in which overweight subjects were fed whole and refined grain diets for six weeks found that fasting insulin was 10 percent lower and insulin sensitivity improved with the whole grain diet.  Subjects on the whole grain diet also tended to lose weight.

Dr. Slavin reviewed epidemiological studies relating to whole grains and obesity.  In the Framingham offspring study, whole grain intake was inversely associated with BMI.  In the Nurses' Health Study published in 2003, women who consumed more whole grains consistently weighed less than women who consumed less whole grains and also had a significantly lower risk of major weight gain.  Another study found that whole grain foods improve markers of bowel health in overweight men.

Although Dr. Slavin does work in the field of dietary fiber, her laboratory also works with lignans and phytoestrogens that are associated with dietary fiber in plant foods. High levels of serum enterolactone, a mammalian lignan, have been associated with decreased cardiovascular disease.  People who eat more whole grains have higher levels of serum enterolactone.  Other valuable components in whole grains that are known to have protective effects against chronic diseases include sterols, resistant starch, antioxidants, and phytate.

Dr. Slavin stressed that it is important to help consumers understand what whole grains are and where they can be found.  The best way to find whole grain products is to read the ingredients label.  A whole grains seal or a whole grain health claim on the package can be helpful, but different companies use them in different ways.  Many products that appear to be whole grain foods  —  such as multi-grain bread  —  are not.  Processed foods, such as cereal and crackers, can be whole grains.

She stated that whole grains typically are our best source of dietary fiber.  The IOM recommends 25 grams per day for women and 38 grams per day for men under 50, and 21 grams per day for women and 30 grams per day for men over 50.  These recommendations are based on protection from cardiovascular disease.  There is insufficient evidence to set an upper intake level for fiber.  Current fiber intake is only 12 to 15 grams per day, so most people get less than half of what they need.

Dr. Slavin pointed out that fiber is not a nutrient in the usual sense.  Dietary fiber consists of non-digestible carbohydrates and lignan that are intrinsic and intact in plants.  Functional fiber consists of isolated, non-digestible carbohydrates that have beneficial physiological effects in humans.  Total fiber is the combination of dietary and functional fiber.

Dr. Slavin emphasized that fiber that is intact and naturally occurring in food is preferable to isolated fiber, which is the form found in supplements.  The original hypothesis regarding the benefits of dietary fiber was based on populations consuming unrefined diets that were high in dietary fiber and slowly digested carbohydrates.  Fiber-rich foods contain many biologically active compounds that are integrated into the plant cellular structure.  These compounds are handled differently in the body than isolated fiber.

Dr. Slavin was pleased that Dr. Hu had mentioned the benefits of cereal fiber.  She referenced a recent study that looked at cereal, fruit, and vegetable fiber intake and the risk of cardiovascular disease in elderly individuals.  This study found that, even late in life, cereal fiber consumption is associated with lower risk of cardiovascular disease.

With regard to fiber and weight loss, Dr. Slavin noted that fiber has many effects on the digestive tract.  It takes longer to digest, it slows down absorption, it slows down stomach emptying, and there is more loss of fecal fat.  Studies that compared the effects of high-fiber versus low-fiber diets found about a 10 percent decrease in voluntary energy intake.  People tend to eat less on high-fiber diets.  These effects were more pronounced in obese subjects.  There is some data that fiber supplements taken post-weight loss aid in weight maintenance.

A recent study published in The Journal of Nutrition compared the effects of fermentable and non-fermentable fiber supplements (27 grams per day).  The researchers saw no effect on food intake or body weight.  This pilot study does not support the use of fiber supplements for weight loss.  However, Dr. Slavin noted that this was only a three-week study.

Dr. Slavin shifted the focus to the issue of fiber and satiety.  She presented a recent study that measured glycemic response and satiety response in subjects who ate several types of breads.  While there was very little difference in the glycemic index for the various types of breads, there were fairly significant differences in satiety that were not totally related to fiber.  Of the breads that were tested, the low-fat, high moisture bread had the biggest change in the feeling of fullness.  This suggests that although fiber is one element of satiety, the volume of the food affects how full people feel.  Another study on satiety found that a more viscous beverage produced greater and more prolonged reductions of hunger.  These studies underscore that how foods look and taste is as important as their nutritional value.

Dr. Slavin noted that there are fairly consistent findings that higher fiber intakes tend to be linked with lower body mass indexes.  The Seven Country Study found that physical activity and dietary fiber, but not dietary fat, were related to skin-fold thickness.  Another study, the Coronary Artery Disease Risk Development in Young Adults (CARDIA) study, found that fiber intake predicted weight gain in young adults.  Dr. Slavin expressed concern that low-carbohydrate diets are also low-fiber diets.  Data published in 2000 found that the Atkins diet provided only 4 grams of fiber per day, the Zone diet provided 18 grams per day, while the plant-based Pritikin and Ornish diets provided 40 and 49 grams, respectively.

Dr. Slavin turned to a discussion of eating patterns.  A recent study found that children who eat breakfast cereal had a low BMI.  Another study found that intake of whole grain breakfast cereals was inversely associated with total mortality.  Data from the National Weight Control Registry also suggested that eating breakfast is important.  Dr. Slavin stressed that it will be important to emphasize to consumers that when you eat is as important as what you eat. 

Dr. Slavin noted that most Americans are meeting less than 70 percent of the DRI for fiber.  On average, men need an additional 20 grams per day, and women need an additional 12 grams per day.  Those on a low-carbohydrate diet have an even greater deficit.  Dr. Slavin stressed that the Committee needs to consider how it will help consumers get the fiber they need.  Assuming an average of 3 grams of fiber per serving, men would need 12 servings of a fiber-containing food per day, and women would need 8 servings.  Another option would be to increase the fiber content of popular foods such as high-fiber cereals, or increase consumption of legumes, dried fruits, fortified foods, or supplements.

Dr. Slavin concluded her presentation with several recommendations for the Committee.  First and foremost, she emphasized that people eat food, not nutrients.  The guidelines need to include foods that people like and also provide essential nutrients.  Taste, convenience, and familiarity are important.

Second, she noted that whole grains are an important vehicle for dietary fiber and other nutrients.  The change would be significant if we can get Americans to increase their consumption of this valuable food group.

Finally, she recommended that strategies are needed to get nutrients, including fiber, into the low-calorie diets that are required for typically inactive Americans, and energy levels must be appropriate for sedentary individuals.  The base of the Food Guide Pyramid should stress the importance of fruits, vegetables, grains, and legumes.

Discussion

Dr. King thanked the panelists for their presentations and opened the floor for discussion.

Dr. Nicklas directed her question to Dr. Krauss and Dr. Hu.  She referenced the literature showing that less than five percent of dietary ALA is available for conversion to EPA and DHA, which is controversial.  She noted that Dr. Krauss very nicely showed that ALA decreases triglycerides.  She asked if there was any evidence with regard to outcomes for cardiovascular disease between the different types of omega-3.

Dr. Krauss replied that it is well established that the longer chain omega-3s are potent triglyceride lowering agents.  On a gram-for-gram basis, he was not sure how different they are from ALA.  The dose that is typically used to show triglyceride lowering is far higher than we could expect to achieve in the diet.  He deferred to Dr. Hu with regard to the disease outcomes.

Dr. Hu agreed with Dr. Krauss that there is no question that fish oils substantially lower triglycerides.  There have been many studies examining the effects of ALA and canola or soybean oil on triglycerides, but the results are not consistent.

The data for fish oil omega-3 is more convincing. Three or four randomized clinical trials  —  including the Diet and Reinfarction Trial (DART) Study, the GISSI Prevention Trial, and DART-2  —  have looked at heart disease and fish oil.  The GISSI Trial and DART have shown conclusively that increasing fish intake can lower coronary heart disease (CHD) mortality rate.  Fish oil is probably beneficial in reducing sudden deaths and fatal CHD among people with established heart disease.  There have been no trials to determine whether fish oil can reduce heart disease in the general population.

No randomized trials have been conducted for ALA and CHD in either the general population or the high-risk population.  Dr. Hu mentioned the Lyon Diet Heart Study, which showed that a diet high in ALA and with a high amount of fruits and vegetables substantially reduced the risk of sudden deaths, total mortality, and even cancer mortality.

Dr. Kris-Etherton asked Dr. Hu if he would distinguish between the longer chain omega-3s and ALA in his recommendations that nutritional strategies should maximize the benefits of both n-6 and n-3 fatty acids.

Dr. Hu replied that ALA is an essential fatty acid, while fish oil, per se, is not.  If you have adequate ALA, you don't need fish oil.  The amount of ALA in the diet is at least 10 to 20 times higher than fish oil.  Dr. Hu agreed that it is probably important to have separate recommendations for ALA and fish oil.

Dr. Pi-Sunyer asked Dr. Krauss whether, given the fact that monounsaturates drive the change in total HDL cholesterol, the Committee should recommend increasing monounsaturated fat.

Dr. Krauss replied that he would not necessarily distinguish mono- and polyunsaturates with respect to their impact on risk for heart disease.  In terms of the data, most of the effect is due to monounsaturates because they are a larger percentage of the variation in fat intake that has been studied.

Dr. Lupton asked whether there is sufficient evidence to make specific recommendations on glycemic versus non-glycemic carbohydrates.  Dr. Slavin stated that the glycemic index is an interesting concept, but it is not useful as a general guideline.  Dr. Krauss noted that the glycemic index poses three problems: it is difficult to quantify and define complex carbohydrates; glucose is not the only issue with carbohydrates; and it is not clear whether there is any benefit regarding satiety and other issues with weight loss.  Dr. Hu noted that the glycemic index has been misused to classify specific foods as "good" or "bad" and should not be used as the sole criteria for choosing foods.  However, it could be a useful research tool and could serve as the basis of recommendations that address eating patterns, such as guidelines to reduce the overall glycemic index of the diet.  This may be more useful for diabetics than for general audiences.

Dr. Pi-Sunyer noted that it is important to consider the overall glycemic index of a mixed meal.  For example, whole grains lower the glycemic index of bananas.

Returning to the issue of dietary pattern and cancer risk, Dr. Go asked the panel whether it is the type of fat or total fat intake that is important.  Dr. Hu responded that there is no relation between total fat intake and cancer risk.  The evidence is fairly strong that higher levels of animal fat result in greater risk for colon cancer, but it is not clear whether that is due to the fat or other compounds in meat.  There is no such correlation with breast cancer.  The link between fiber and cancer risk is still undetermined.  Dr. Slavin noted that colon studies are fairly clear that higher fiber intake is protective for colon and breast cancer, although these findings overlap with phytoestrogen data.  It will be important to find dietary patterns that are protective.

Dr. King asked whether the DRIs for fiber are reasonable if no one can follow them.  Dr. Slavin responded that the recommendations are not impossible on a plant-based diet, though she acknowledged that they are difficult to meet with the typical diet in this country.  The DRIs may be too high for children, but they are a good goal for adults.  The real cause for concern is diets that have no fiber.

Dr. Nicklas noted that most studies on fiber and satiety have focused on adults.  She asked how the lack of fiber affects satiety and intake of other foods in children.  Dr. Slavin responded that a child's initial diet  —  breast milk  —  contains no fiber.  There is a gradual transition in the diet to foods that contain fiber.  In Dr. Slavin's opinion, the DRI levels for fiber in children are too high.

Dr. Lupton asked whether types or amounts of carbohydrates should be the driving force behind recommendations and whether there should be a recommendation on dietary fiber.  Dr. Slavin reiterated her concern that recommendations on dietary fiber lead to the use of supplements rather than real foods, with a corresponding loss of other nutrients in plant-based foods.  Dr. Hu stated that for maximum benefits, whole grains should be the driving force behind carbohydrate recommendations.  It is important to stress that refined carbohydrates should be reduced to balance the increased intake of whole grains.  He noted that it is difficult for the general public to count grams of fiber.  Dr. Slavin stated that she had been surprised to find that there was no link in the scientific data between carbohydrate intake and obesity.  Dr. Hu noted that it is very difficult to study the relation between carbohydrates and body weight because the metabolic process is complex.

Dr. Kris-Etherton asked if the speakers could recommend a fat to carbohydrate ratio for weight loss and maintenance.  Dr. Krauss did not think that any macronutrient ratio is better for weight loss, though a low-fat diet appears to be better for maintenance.  He noted that the distribution between fats and carbohydrates and the types of carbohydrates in the diet become minimal as physical activity increases.  It would be important to promote a variety of ways to achieve weight loss.  While the level of carbohydrate consumption in this country may be excessive, reduced carbohydrate intake needs to be balanced with the need for fiber.

Dr. Slavin stated that there is no real solution without exercise.  High carbohydrate diets are useful for higher activity levels.  There need to be better choices within that category.

Dr. Hu agreed that there is no definitive answer or optimal diet because activity levels and metabolic profiles vary.  It is important to balance science with what people will do.  The Atkins and Ornish diets represent two extremes; few people can stick with them.  Although weight loss studies are inconclusive, they seem to suggest holding fat constant and increasing protein versus carbohydrate, for levels of about 25 percent protein, 35 percent fat, and 40 to 45 percent carbohydrate.  Studies are needed in this area.

Dr. Pate noted that the current Dietary Guidelines say to aim for total fat intake of no more than 30 percent of calories as fat.  He asked if the panelists would recommend changing that. Dr. Hu said yes; Dr. Slavin said no, except for extremely active individuals.

Dr. Clydesdale asked if it would help to change food labeling to reflect fiber content.  Dr. Slavin said this would be helpful, because consumers do want to do better.

Dr. Appel asked whether the Committee should make a distinction between types of carbohydrates, given the confusion regarding this issue.  Dr. Hu stated that there is strong evidence for the benefits of substituting whole grains for refined grains.  Dr. Krauss said the distinction should be made, but it could be hard to translate this into recommendations that are actionable.  He suggested focusing on sugars and fiber.  Dr. Slavin stated that the Committee should make no such distinction because there is little evidence that carbohydrates are bad. The current information of total carbohydrates on the Nutrition Facts Label, with the sub-listing of dietary fiber and sugars should be retained.  She recommended including a fiber guideline due to its protective factors against chronic disease.

(Lunch: 12:40-1:45)

Dr. Janet C. King welcomed Committee members back to the meeting and introduced Dr. Mary Ann Johnson, who was invited to speak on nutritional needs of the elderly.  Dr. Johnson is a Professor of Foods and Nutrition at the University of Georgia.  Her interests and areas of expertise include nutrient bioavailability and interactions involving vitamins and minerals.  Dr. Johnson's research targets human populations, particularly older individuals.  She has studied older individuals in personal care homes, those who are receiving home delivered meals or meals at congregate feeding centers, community-dwelling elderly, as well as the elderly in general.  Dr. Johnson works with state and local agencies through the Georgia Division of Aging Services.

Presentation and Discussion: Nutritional Needs of the Elderly
M. Johnson

Dr. Mary Ann Johnson, University of Georgia, began her presentation by providing some context for the issues she was asked to address. Currently, 35 million people in the U.S. are over age 65 (more than 12 percent of the population).  By 2020, there will be about 54 million older adults. By 2050, there will be 70 million older adults in the country  —  one out of every five people. Older adults vary tremendously in their functional level.  While some are training for competitive athletic events, others at the same age are institutionalized with nutrition related disorders, such as diabetes or heart disease, or other disorders, such as dementia.

Dr. Johnson pointed out that while dietary recommendations are generally developed with community-dwelling, healthy individuals in mind, many federal and state regulations mandate that these and other diet-related guidelines be used for meal planning for congregate and home delivered meals and for meals at long-term care and assisted living facilities and geriatric hospitals.

Dr. Johnson stated that many older people have a tremendous stake in what the Committee deems as a healthy diet because they are at high risk for nutrition-related chronic diseases.  She questioned the endpoints for determining nutritional adequacy, noting that poor vitamin or mineral status have not been ruled out as risk factors for age-related disorders that greatly impair the quality of life for many older people, including sarcopenia, impaired muscle strength, falls, dementia, delirium, depression, hearing and visual disorders, and impaired immune function.

Dr. Johnson presented a table summarizing how and why certain nutritional requirements change with age and how these changes are related to food intake:

• Energy:  Energy needs decrease with age because older adults have less muscle tissue and hence less energy expenditure. As a result, they need to eat less to maintain weight.
   
• Iron:  Iron needs in women over age 50 decrease by more than 50 percent due to cessation of menstruation. In theory, women over age 50 could eat less iron-dense foods.
   
• Vitamin B-6:  Requirements for this nutrient increase with age. Several studies have shown a relationship between oral intake of vitamin B-6 and certain biochemical processes.  There are many sources for this nutrient, including typical foods, fortified foods, and supplements.
   
• Vitamin B-12:  This nutrient, along with calcium and vitamin D, is widely recognized as a nutrition and health problem in older people. The RDA specifies that above age 50, the majority of vitamin B-12 should be from a crystalline form.  This is due to impaired absorption that seems to be linked to the helicobacter pylori (H. Pylori) microorganism.  Vitamin B-12 can be obtained in some fortified foods and through supplements.  Federal regulations do not require adding vitamin B-12 to fortified foods, and it is not naturally present in whole grains.
   
• Calcium:  The need for calcium increases with age to promote bone health in both men and women.  The change appears to be related to a decrease in absorption. Calcium is present in typical foods, especially in dairy products.  The recommendations are two to three servings of dairy foods for adults and older people, but the typical intake of milk is only about one serving.  The current Dietary Guidelines emphasize that people who consume few dairy foods should take a calcium supplement. Dr. Johnson encouraged the Committee to retain that language.
   
• Vitamin D:  There is a three-fold increase in the need for this nutrient among older adults.  The current recommendation is five micrograms a day for adults under age 50, 10 micrograms from age 50 to 70, and 15 micrograms for those over age 70.  This increasing need appears to be linked with decreasing ability of the skin to synthesize vitamin D from the sun.  The most common source of vitamin D is fortified milk, because few typical foods contain this nutrient.  However, it would take six cups of milk per day to meet the vitamin D recommendation for those over age 70.  Also, most other dairy foods are not made with vitamin D-fortified milk.  Dr. Johnson encouraged the committee to keep the current recommendation, but to add that older adults may need a supplement of vitamin D.
   
• Vitamin E:  There is some evidence that high intake might prevent some age-related disorders, though the issue is controversial and the evidence inconsistent.  There is currently no change in the RDA for older adults.  Vitamin E is low in typical foods and it is difficult to design a diet that meets the current RDA.  Vitamin E is present in many supplements.  There are many chemical forms of vitamin E in foods; the chemical forms in supplements would be much more limited.

Dr. Johnson noted that she was less enthusiastic about plant-based diets than previous speakers because even the most well designed plant-based diets are deficient in some nutrients, particularly vitamins D and B-12 which are not naturally present in plant-based diets.

Dr. Johnson stated that, in her opinion, indexing beyond age and gender would be extremely impractical for the general public.  It would be especially difficult for those using the Dietary Guidelines for meal planning in long-term care facilities, assisted living, home delivered, and congregate meals.  Fiber would be one exception, as discussed earlier in the day, but micronutrient requirements need to be independent of energy.

Dr. Johnson stated that nutrition problems in older people are not related to energy density problems.  They have more to do with problems in food choices, nutrition knowledge, availability of healthy food, and access to food.  Food security is also an issue for older adults, many of whom have to choose between buying food and buying medicine or paying rent or utilities.  A recent study suggests that the issue of food security is different among older people because they are more  knowledgeable about what foods are healthy.

Dr. Johnson stated that while the nutritional problems of the elderly could be overcome in part by consuming more nutrient-dense diets, the requirements for some nutrients are so high that they are beyond what typical, or even fortified foods, can provide.  It would be difficult to redesign the food supply to meet nutrient requirements across the lifecycle when younger adults need five micrograms of vitamin D a day and older people may need 15 or more.

Dr. Johnson then presented new evidence that illustrate potential health benefits of vitamin  B-12, vitamin D, and vitamin E. She stressed that it is important to include a message about vitamin B-12 and vitamin D in the Dietary Guidelines and that the Committee should consider the potential benefits of vitamin E.

Vitamin B-12 status has been linked to depression in some studies, though not all. Depression is a widespread disorder in older people, and it has also been linked to other nutrients. Poor B-12 status has been linked in some studies to poor cognition, dementia, and neurophysiological disorders, which are also common problems in older people.  In Dr. Johnson's opinion, the 1998 RDA for B-12 may be too low.  Since the DRIs were published for the B vitamins, at least four studies have suggested that older people may need nearly three times the recommended amount of the crystalline B-12.  Given the importance of B-12, Dr. Johnson stressed that it is vital to ensure that people get at least what is currently officially recommended.  Crystalline intake should be tracked at the national level and included in the USDA databases.

Vitamin D is another important nutrient for older people.  In addition to the role of vitamin D in bone health, there is an emerging literature showing that poor vitamin D status is linked to falls. Other studies are examining the role of vitamin D in muscle function, the link between vitamin D deficiency and chronic pain, and the link between low vitamin D status and multiple sclerosis.  Several researchers are concerned that the 1997 adequate intake for vitamin D may be too low because the level that is associated with optimal health is not well defined.  While this issue is being clarified, it is important to ensure that older people are getting the vitamin D that they need. Dr. Johnson encouraged the Committee to keep the recommendation that older people may need a vitamin D supplement.  It will be difficult to fortify the food supply to ensure adequacy across all age groups.

Vitamin E is controversial but quite interesting.  Poor vitamin E status has been linked in some studies to cardiovascular disease and dementia and other cognitive disorders.  Some studies have shown that vitamin E supplements may offer some benefit for various cardiovascular disease outcomes, dementia and cognitive disorders, and immune function.  Dr. Johnson urged the Committee to consider how the potential benefits of high doses of vitamin E might be included in nutritional recommendations for older people.

In conclusion, Dr. Johnson noted that older people can make beneficial changes in their nutrition and physical activity patterns.  Well-designed, community-based educational programs can help them make these changes.  She emphasized that older people need practical, reliable, and scientifically valid advice about healthy eating to ensure nutritional adequacy, decrease their risk of chronic disease, and improve their quality of life.

Discussion

Dr. King thanked Dr. Johnson for her comprehensive overview of the nutritional needs of the elderly.  She asked if she was correct in understanding that Dr. Johnson suggested that the Committee recommend supplements of vitamin D, calcium (if they don't consume dairy products), and supplements of vitamin E.  Dr. Johnson stated that she would encourage the Committee to retain the language in the 2000 Dietary Guidelines for vitamin D and calcium.  The question of vitamin E supplementation requires further review.

Dr. Weaver stressed that vitamin D requires more attention.  She hoped the NIH conference on vitamin D held last October would help raise awareness that the vitamin D requirements may be too low.  In the meantime, UV-B lights may be the most practical approach.  Dr. Johnson noted that UV-B light exposure can raise the risk of skin cancer and that UV-B light exposure is not that well quantified for older people.

Dr. Weaver asked if Dr. Johnson was recommending crystalline form of vitamin B-12 and how she would handle the recommendations.  Dr. Johnson responded that the RDA for B-12 says that the majority should come from crystalline, whether through supplements or fortified foods.  The problem is that few fortified foods contain B-12 besides fortified breakfast cereals.  Dr. Johnson noted that vitamin B-12 is very common in multi-vitamins.

Referring to Dr. Johnson's statement suggesting that the dietary recommendations for older people should not be indexed for energy, Dr. Pate asked if she would argue against making adjustments for physical activity level.  He also asked if her reasoning was based on potential complications for institutions that are required to follow the Dietary Guidelines, or if it was based on other factors.  Dr. Johnson clarified that she was speaking mainly of the micronutrients, not fat and fiber.  There is no good reason to index most micronutrients to energy. However, Dr. Johnson agreed that physical activity is as important for older people as for people of any other age.

Dr. Clydesdale asked what treatments exist for vitamin B-12 deficiency.  Dr. Johnson stated that B-12 deficiency in older people results from a variety of factors, one of which is the loss of the intrinsic factor, which is a protein that binds to B-12 to deliver it effectively to the intestinal tract.  This results in a much more profound inability to absorb B-12 over time.  Oral intakes of at least 500 micrograms per day appear to overcome the loss of instrinsic factor as well as restore B-12 stores resulting from other causes of B-12 deficiency (e.g., atrophic gastritis).  The more common cause of B-12 deficiency is atrophic gastritis, which involves a decrease in the production of acid and pepsinogen in the stomach and subsequent decrease in cleavage of B-12 from animal foods.  It is currently believed that atrophic gastritis does not markedly diminish the ability to absorb crystalline B-12 found in some dietary supplements and fortified foods, which is why crystalline B-12 is recommended for adults over age 50 as a preventive measure.

Dr. Nicklas asked if some macronutrients were more difficult to digest than others with increased aging.  Dr. Johnson replied that most research suggests that general processes of absorption are not that different with older people.  Changes with absorption are usually thought to be disease related.

Dr. King asked if Dr. Johnson would recommend any changes in the food patterns for elderly individuals in comparison to younger adults, since her comment about plant-based diets seemed to imply that older adults might need higher levels of animal protein.  Dr. Johnson noted that the key issue is to identify strategies to get older people to follow the existing recommendations, rather than developing new food patterns.  She clarified that she did not mean to imply that one type of protein was better for older people.  Her point was that a plant-based diet does not provide vitamin D and vitamin B-12.  Supplements are the best way for older people to get some nutrients unless we radically change our food fortification practices.

Dr. Kris-Etherton asked whether Dr. Johnson would recommend that supplements be at a level to achieve a DRI recommendation, or if there would be any reason to go higher, such as with vitamin E.  Dr. Johnson said that it is premature to make specific recommendations for vitamin E at this time.

Dr. Weaver noted that Dr. Johnson had not recommended any specific differences in fiber intake for the elderly and asked her to comment on whether age would make any difference in our understanding of the relationship between alcohol intake and chronic disease.  Dr. Johnson stated that the current fiber recommendations are based on studies that include many older people.  She would recommend the current DRIs.

Dr. Johnson referred the question of alcohol and age to the Committee because she was not familiar with the literature.  However, she noted that since older people consume fewer calories, they need to be mindful of the fact that alcohol does not provide micronutrients.  In addition, alcohol-induced impairments such as falling and visual and cognitive problems could be exaggerated in older people.

Dr. King referred to Dr. Johnson's statement that the capacity to absorb calcium diminishes with aging and noted that some literature suggests the same is true for iron and possibly zinc.  She asked whether the capacity of older adults to absorb these minerals would be impaired if the fiber recommendation for the elderly was the same as for younger adults.  Dr. Johnson stated that the impact of fiber on mineral absorption is not significant.  Dr. King noted that the phytate that is found in the fiber is usually the problem.  Dr. Johnson agreed that could be an issue if consumption of unleavened whole grains increased, but, in general, fiber is not a cause for concern.

Dr. King thanked Dr. Johnson for her presentation.

(Break: 2:30-2:45)

Public Oral Testimony

Dr. King introduced the public oral testimony section of the meeting.  She noted that over thirty individuals and groups would be sharing their research perspectives and expertise with the Committee.  She reiterated Dr. Beato's statement regarding the important role of public comments in developing the Dietary Guidelines and emphasized that the Committee would welcome written comments throughout the process.  After summarizing the procedures for submitting written comments that were outlined in the Federal Register notice, she laid out the ground rules for the public oral testimony.  She noted that presenters would have three minutes to present their testimony and should stop speaking when the red light came on at the podium.  She then introduced the first presenter.

Mr. Richard Hanneman, Salt Institute, stated that his organization is the trade association of salt companies and is funded from membership dues.  He acknowledged that salt in the diet is related to blood pressure and that federal policy since 1980 has encouraged a reduction in dietary sodium intakes.  He called the Committee's attention to three important developments in the past decade: the emerging consensus that evidenced-based medicine should direct policy; the emerging consensus that evidence-based medicine should focus on health outcomes; and the Data Quality Act, which requires that data, used as the basis for recommendations, should be replicable, and should meet certain quality standards.

Mr. Hanneman noted that the recommendations of the HHS Preventive Services Task Force, the Cochrane Collaboration cited by Dr. Hu, and the Canadian guidelines have all concluded that there is insufficient evidence to support the reduction of dietary sodium.  He stated that the Committee should focus its efforts on improving overall diet quality.  The Salt Institute endorses the Dietary Approaches to Stop Hypertension (DASH) Diet, which is also endorsed by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7).  The DASH-Sodium study shows that sodium reduction is ineffective for normotensives  and not very important for hypertensives.  The Salt Institute also is concerned about the declining amount of iodine in the American diet  —  a nutrient that is provided through iodized salt.

The Salt Institute recommends that the Committee make evidence-based recommendations ensuring compliance with the Data Quality Act and eliminate the dietary guideline on salt.

Mr. Robert Earl, National Food Processors Association, stated that the guidelines must be easily understood, easily implemented, and must trigger behavioral change if they are to contribute to public health.  The goals of the Dietary Guidelines should be to motivate and stimulate action on diet and lifestyle by consumers.

Mr. Earl urged the Committee to place substantial emphasis on "calories count" messages in addressing the balance between food intake and physical activity.  The National Food Processors Association believes that it is critical to increase guidance on physical activity, combined with positive, "how to eat" messages, as opposed to negative, "what to eat" messages.

Mr. Earl stressed that there must be a commitment to assessing consumer understanding of the Dietary Guidelines and the effectiveness of the Dietary Guidelines in promoting behavior change.  Consumer education should then follow.

Mr. Earl urged the committee approach any consideration of changing the focus of the guidelines from healthy Americans to America's overweight and obese populations with consideration to scientific evidence and effective change.

Mr. Earl urged that the Committee clearly articulate the critical need for synergy among the Dietary Guidelines, the Food Guide Pyramid, and food labeling.  Metrics such as energy requirements, physical activity, serving sizes, and nutrient standards should be consistent across the Dietary Guidelines and other communications tools.  The DRI values are scientifically sound and should be used for the Dietary Guidelines, the Food Guide Pyramid, and for future food nutrition labeling changes.

Dr. Elizabeth Pivonka, Produce for Better Health Foundation (PBH), informed the Committee that PBH is the founding partner, along with the National Cancer Institute, of the National Five-A-Day for Better Health Program that encourages all Americans to eat at least five to nine servings of fruits and vegetables each day.  PBH is a not-for-profit 501(c)(3) educational foundation, with financial support from grants and volunteer contributions from the fruit and vegetable industry, the public health community, and concerned citizens.

Dr. Pivonka stated that science supports the important role that fruits and vegetables play in reducing the risks of chronic diseases.  She highlighted three recommendations during her testimony for strengthening the guidelines with regard to fruits and vegetables:

• The Committee should strengthen the fruit and vegetable guideline to state, "Eat at least five to ten servings of fruits and vegetables every day," with greater emphasis on eating fruits and vegetables in a way that maintains their integrity as healthful foods.  Dr. Pivonka noted that replacing low-nutrient, energy-dense foods with fruits and vegetables will help fight the obesity epidemic, and that fruits and vegetables are an excellent source of fiber.
   
• The Committee should include the concept of color as a way for consumers to put into practice the otherwise vague concept of variety and to expand their intake of traditional nutrients, as well as phytochemicals.  Dr.Pivonka mentioned the PBH's The Color Way campaign as a platform for increasing consumption.
   
• The guideline for fruits and vegetables should be strengthened to stress the importance of introducing fruits and vegetables in the early years, in light of recent evidence that 25 percent of infants and toddlers do not consume any fruits or vegetables.

Ms. Alison Kretser, Grocery Manufacturers of America (GMA), stated that GMA recognizes that it has a role to play in combating obesity and continues to seek opportunities to provide solutions.  GMA and its members believe it is important for Americans to understand that to be healthy they must eat a nutritionally balanced diet, be physically active, and moderate their food intake to match their level of physical activity.  GMA recommends that the Committee change the name of the Dietary Guidelines to the "Dietary and Physical Activity Guidelines."

Ms. Amy Myrdal, Dole Food Company, stated that Dole is a long-time supporter of the National Five-A-Day Partnership, which consists of government agencies, non-profit organizations, and industry working collaboratively to increase consumption of fruits and vegetables for better health.  Ms. Myrdal stated that Dole is concerned about the gap between recommended and actual fruit and vegetable intake especially among children.  She noted that research demonstrates that children who eat the most fruits are least likely to be overweight and that consumers generally understand the importance of fruits and vegetables in a healthful diet, though they fall far short of meeting the recommended number of servings.  Ms. Myrdal stated that  consumers need to be provided with the messages, tools, and support in order to meetthese recommendations.

Ms. Myrdal presented four recommendations to the Committee:

·        Provide a clear actionable guideline for fruits and vegetables, such as "Consider eating at least five to nine, or five to ten servings of colorful fruits and vegetables each day." Include specific examples and simple tips for preparing and serving fruits and vegetables.

·        Acknowledge consumer preferences and tastes in the variety of product options available to consumers.

·        Include specific information on the role of fruits and vegetables in weight management, providing essential nutrients without excessive calories.

·        Encourage increased public/private collaboration to maximize resources to conduct the scientific and consumer research required to develop effective educational and promotional programs.

Dr. Joyce Nettleton, Alaska Seafood Marketing Institute, stated that the Institute believes the scientific evidence supporting a range of health benefits from the regular consumption of fish is sufficiently abundant and convincing to warrant a recommendation to the public to consume fish, particularly fatty fish, twice a week.

Dr. Nettleton cited three reasons for expanding dietary advice to include regular fish consumption in the Dietary Guidelines.  First, the current Dietary Guidelines fall short of ensuring adequate and desirable intakes of long-chain omega-3 polyunsaturated fatty acids, or PUFAs, because they are barely mentioned in the Dietary Guidelines. Second, the proposed revision would make the Dietary Guidelines more effective for women of childbearing age and most adults.  Seafood is the major dietary source of an essential fatty acid for fetal and infant development, and the omega-3 long-chain PUFAs found in fish are associated with significant reductions in the risk of cardiovascular disease and mortality.  Third, regular consumption of fish would help offset the potentially excessive intake of omega-6 PUFAs, whose high levels compete with omega-3 PUFAs for the same metabolic pathways and have been shown to be pro-atherogenic in large amounts.

Dr. Nettleton stated that, in contrast to the recent DRI report, the Institute believes the evidence indicates that current intakes of omega-3 PUFAs are inadequate.  The need for omega-3 long-chain PUFAs is best fulfilled by the consumption of long-chain PUFAs; that is, those with 20 carbons or more.  These are the most biologically active forms of omega-3s in cardiovascular health and, in some cases, the only active forms.

The allotted time ran out before Dr. Nettleton completed her testimony.

Dr. Margo Wootan, Center for Science in the Public Interest, focused her remarks on six main points.  First, the Center believes that it is critical to provide clear advice about energy balance throughout the Dietary Guidelines, including clear advice about why and how to choose sensible portions.

Second, the Dietary Guidelines should place greater emphasis on saturated fat and should expand and strengthen the Dietary Guidelines' advice about trans fat.  That advice should be motivational as well as scientifically accurate.  The fat guideline should encourage people to consume no more than 20 grams of saturated and trans fat, combined. The advice about limiting dietary cholesterol intake should be maintained.