APPENDIX II: PUBLIC COMMENTS

Received During the 1990 Dietary Guidelines Review and Revision Process (N=284)

The following is a summary of comments received by the committee during its review and revision of the 1990 Dietary Guidelines. The comments were received from individuals, interest groups, associations, and organizations between September 1994 and February 1995. Each set of comments received, whether from an individual or an organization, is counted here as 1. Note that various groups commented on multiple topics.

General

Many commented that the Dietary Guidelines should be based on a sound scientific base. In addition, many pointed out that the Guidelines should be consistent with other public policy

initiatives. Most people indicated that they support and, through work or personal initiative, communicate the recommendations espoused in the current (1990 edition) Dietary Guidelines.

Eat a variety of foods (N=37)

Eight recommended that this guideline be population based, food centered, and based on a total diet, rather than specific foods. One comment supported advice to consume a variety of foods from among the five major food groups, based on results of a study that concluded variety within the major food groups has a negligible effect on nutritional adequacy over and above variety among the major food groups. Five comments supported changing the guideline to "enjoy a variety of foods." One recommended that the concepts of variety, moderation, and balance be discussed within the text. Two indicated the Guidelines should harmonize varying FDA and USDA serving sizes. One recommended a reverse in the current consumption ratio of animal to plant foods. Seventeen focused on the position of beans within the Food Guide Pyramid and recommended the consumption of beans and other legumes as high-protein meat alternatives and also as low-fat, high-fiber vegetable or cereal servings.

Two supported the use of dietary supplements in the total diet as a way to improve health outcomes for Americans. One requested removal of the statement that supplements are "rarely needed if you eat a variety of foods." One requested strengthening the statement about the association between folate and neural tube defects and calcium and osteoporosis. Three suggested including a calcium guideline or at least emphasizing calcium recommendations. One suggested recommending supplements when appropriate rather than a blanket condemnation of them. One recommended supplement intake by special populations like the elderly, pregnant women, and people on food assistance. One indicated little benefit should be expected from carotenoid supplementation of healthy individuals eating a typical American diet. Two suggested that the contributions of fortified/enriched foods must be acknowledged, particularly if the Recommended Dietary Allowance values shift upward to support goals of chronic disease prevention. One suggested that increased intakes of foods high in copper should be recommended by the Dietary Guidelines because our diets are low in this nutrient, which affects blood cholesterol, blood pressure, promotes thrombosis, and impairs glucose tolerance. One indicated that nuts should be promoted because as plant foods, they lack cholesterol, are high

in beneficial fats, and are a significant source of plant protein, vitamins, minerals, and fiber.

Healthy Weight (N=10)

Two comments recommended continuing to use the word healthy rather than desirable in the guideline, since desirable is ambiguous to the public. Seven recommended a more extensive

discussion of physical activity benefits for weight loss and maintenance and overall health. One suggested that regular aerobic exercise at least 3-4 times a week for 20 minutes should be encouraged. One stated that a healthy weight guideline, with a physical activity focus, should be the key guideline in the document, followed by the importance of vegetable, fruit, and grains consumption and focusing on decreased saturated and trans fatty acid intakes. One suggested accounting for sex, body build, and age in the weight table. One cited studies that point to a relationship between Body Mass Index and risk of coronary heart disease and diabetes, and coronary heart disease and total mortality; the studies concluded that women and men will be healthiest if they begin adulthood with a BMI below 21 and do not increase their weight appreciably as they grow older.

One stated that waist-hip recommendations are not necessary because they are complicated and appear to add little to the prediction of risk beyond weight and weight gain. Two indicated the weight guideline should be used to target obesity prevention, since optimal weights may be unrealistic for people who are seriously overweight, and modest reductions should be encouraged for them. One comment supported weight gain with age, citing the Baltimore longitudinal study that indicates weight gained with age is characteristic of those with the greatest longevity. One comment suggested it is appropriate and realistic to allow for a small amount of weight gain with age for women, but not for men due to "biological realities." One recommended using a BMI of 25 as the cutoff for healthy weight range, after which a rise in total mortality is seen. One suggested that the focus of the guideline should be on defining healthy weight and how to maintain it. One declared that weight loss is a clinical intervention and not within the purview of the Dietary Guidelines.

Vegetables, Fruits, and Grain Products (N=7)

Three suggested a stronger recommendation to increase grain consumption and more practical examples to help achieve this. One suggested outlining the role of complex carbohydrates in

weight control and maintenance. One requested listing the term complex carbohydrates in a uniform manner for consistency and providing clear dietary guidance. One suggested including information on seasonal options, cooking tips, and health benefits. Two asked that fruit and vegetable juices be mentioned as contributing to intakes that meet this guideline, since they are available year around and are economical. One requested that a special recommendation be included on the importance of daily vegetable consumption.

Two believed the committee should recommend obtaining half of grain consumption from whole grain products, since there are many nonnutrient but physiologically active components in whole foods that may be beneficial. One recommended the word phytochemicals not be included in the guideline, since it will serve as a buzzword for the media and supplement industry. One believed antioxidant supplements should not be recommended. One suggested recommending that fiber intakes be obtained from whole foods rather than supplements. One suggested that fiber and antioxidant health claims be consistent with FDA regulations.

Fat, Saturated Fat, and Cholesterol (N=15)

Three suggested focusing on total diet and not specifying foods for this guideline in particular. One recommended tying this guideline to the Food Guide Pyramid and the Nutrition Facts Label. One requested that specific advice for children and older adults be included. Two recommended stressing the importance of lowering saturated and trans fatty acid intakes. One supported a recommendation to consume 10 percent or less of calories from saturated fat. Two recommended emphasizing the importance of lowering saturated fat in the diet, rather than cholesterol, because saturated fat is a greater contributor to blood cholesterol levels. One suggested that individual foods not be evaluated to determine fat content, since the 30- percent level is for the total diet.

Three requested that stearic acid not be grouped with other saturated fatty acids because it does not affectserum lipids. Two requested that trans fatty acids not be discussed, since data on the subject are inconclusive. One supported targeting advice to reduce dietary cholesterol intake to a subpopulation of "at risk" individuals with high blood cholesterol and removing the word cholesterol from the title of the guideline. One did not support quantification of the cholesterol recommendation.

Two supported incorporating wording into the Dietary Guidelines on the benefit (ability to lower blood cholesterol levels) of polyunsaturated fat (PUFA) as part of a lower fat diet. Both stated that low PUFA intake has been directly implicated as a risk factor in coronary heart disease and that there are no known adverse effects of PUFA in the diet. One encouraged recommending consumption of soybean oil, which is high in PUFA and lowers blood cholesterol and may protect against certain types of cancer. One cautioned against low-fat diets, pointing to possible linoleic acid and vitamin E deficiency. One recommended advising consumption of nutrient-dense foods and decreased total fat and suggested presenting dietary guidance in a broader framework of physical activity and appropriate body weight. One suggested that recommended levels of fat intakes be listed in grams rather than percentage of calories, for simplicity.

Sugar (N=11)

Three indicated that sugar's contributions to the diet be highlighted, that is, taste, function in food formulation, and as a fat replacer. One encouraged integrating issues related to dental health, diet and behavior, and nutrient density within a carbohydrate guideline. Four encouraged inclusion of a dental caries guideline focused on all fermentable carbohydrates rather than sugars per se. One pointed to the need for a better definition of moderation. Two suggested the Dietary Guidelines should stress that sugar is of little food value and contributes to tooth decay. Three stated there is no evidence to suggest that added sugars have a different role in human metabolism than those which occur naturally. One suggested a separate guideline for fluoride since dental caries is not just related to sugar consumption. Three would like to eliminate the sugar guideline, while three recommended advising people to consume nutrient-dense foods, which will have the effect of reducing sugar intake.

Two encouraged the intake of artificial sweeteners because they believe consumers maybetter adhere to the first two guidelines (variety and healthy weight) if encouraged to reduce their caloric intake by using these sweeteners. One encouraged use of the term low-calorie sweetener to refer to acesulfame K, aspartame, and saccharin (rather than nutritive or nonnutritive) because the term is familiar to the public and used by industry. Two suggested changing this guideline to "Use sugars in moderation." Five suggested the guideline explain that there is no correlation between sugar and hyperactivity or any other behavioral disorders; three stated there is no connection between sugar intakes and diabetes. One suggested including a caveat if the Food Guide Pyramid is incorporated into the Dietary Guidelines, that some sweets are good sources of some nutrients. Three requested that the sugar recommendation not be quantified. One discouraged use of the sugar guideline because it may discourage consumption of juices, which have to declare the natural sugars content.

Salt (N=18)

One wanted to see a better definition of moderation and an explanation of the risks and benefits of moderating sodium intakes relative to hypertension. One stated there are great dangers to salt overconsumption and cited a reference supporting a 200-mg level (enough to regulate vital functions); one recommended making this guideline a higher priority because food processors are now concentrating more on fat and less on sodium and sugars.

Five applauded the 1990 recommendation pointing to ample data on hypertension and cardiovascular and renal disease to form a basis for recommendations; these comments additionally suggest that recommendations be quantified at 2.4 grams of sodium or less, consistent with National Research Council, NHLBI recommendations. One emphasized that the recommendation does not imply a low-sodium diet but, rather, promotes lowering the average dietary sodium intake from the current 4,000 mg per day to the desirable population mean of 2,300 mg per day. One requested that guidance continue to stress the need to reduce the amount of salt added to foods, as well as encourage industry to add less salt to processed foods. One stated that even if only a certain fraction of the population is salt sensitive, we are not able to identify who these people are, and therefore the recommendations should be population wide.

One urged that the guideline not be eliminated. One indicated that while weight, potassium, and alcohol may influence high blood pressure, sodium alone is a "crucial part of the preventive approach by itself." Three believed there is no scientific basis for a dietary guideline urging normotensive Americans to consume a sodium-restricted diet. They stated that the relationship between sodium restriction and blood pressure in the normotensive population is weak; body weight and alcohol are more strongly related to blood pressure than is sodium; the relationship between diet and blood pressure is complex (multiple electrolytes factor in); the feasibility of achieving substantial reductions in sodium intake on a population basis is remote; and implementation of this guideline could adversely affect implementation of guidelines with greater public health significance. Four stated that the guideline should be omitted or assigned a distinctly low priority. One requested that a quantitative recommendation not be made. One indicated that the data do not support the conclusion that lowering population sodium intakes will prevent a rise in blood pressure with age.

One comment asked that snack foods not be singled out as having high salt content, the rationale being that they vary in content and provide less salt to the diet than many of the more recommended foods (like grains and meats). One indicated that meats, primarily processed meats and grain foods, are the greatest contributors of sodium to the American diet. However, it was pointed out that grain foods are large contributors because of the frequency of intake and that people should not be discouraged from eating grains, which are low-fat and high-complex-carbohydrate foods. One suggested that people should know that most salt in the diet comes from processed foods.

Alcohol (N=152)

Seventy-one comments supported the present guideline, which identifies high-risk drinkers and drinking, while acknowledging the acceptability of moderate consumption (wine was usually specified) as part of a well-balanced diet. One believed moderation relative to alcohol intake should be better explained. Twenty were not in favor of expanding the guideline to promote moderate drinking as potentially beneficial to health and believed that a dietary guideline which reports the health benefits of moderate alcohol consumption would be misrepresented to promote increased drinking. The Guidelines, these 20 stated, should promote regular exercise, smoking cessation, dietary changes, and avoidance of stress to obtain the health benefits associated with moderate alcohol consumption.

Fourteen specifically supported the one drink for women and two drinks for men definition of moderation, without caveat. While 24 others supported the current language, they pointed to a Harvard study that suggests even one or two drinks may not constitute moderation. One encouraged expanding the categories of high-risk individuals to include, among others, people with genetic predisposition to alcohol abuse (or alcoholism) and those who are stressed. One recommended that the guideline discuss the caloric contribution of alcoholic beverages. Eighty-eight supported including a more positive statement about moderate wine consumption and health benefits. Most of these commenters suggested they feel there is documented support of the relationship between moderate wine consumption and a decrease in morbidity and mortality from coronary heart disease, and some indicated there may be mental health benefits as well.

Five pointed to a possible antioxidant role of phenolinic compounds in wine and possible psychological and social benefits of alcohol. One suggested a public health document such as the Dietary Guidelines should not be seen as advocating alcohol consumption. One recommended retaining the guideline, because consumers often place alcohol into a "noncaloric" category and do not factor it into considerations for a total diet. One pointed to the need to help consumers understand what is meant by moderation. Thirteen requested deleting the statement that alcohol consumption is not recommended and stated that this should be an individual choice. One suggested the statement on consumption should be retained. Six recommended that the statement 'drinking has no net health benefit' be deleted.

Seven suggested recommending levels of drinking slightly higher than one per day for women and two per day for men, for potential health benefits. Ten were supportive of promoting wine consumption, preferably with meals. Fourteen supported retaining the 1990recommendations in their entirety. Five indicated that size and weight need to be taken into account when deciding maximum recommended alcohol intakes. Three recommended making the distinction between use and abuse of alcoholic beverages. One indicated that the language on children is too strong; many are introduced to alcoholic beverages without resulting health and behavioral problems. One believed there is no conclusive evidence that an occasional drink during pregnancy is harmful and felt this should be reflected in the Guidelines.

Infants and Children (N=13)

Two comments strongly encouraged incorporating information on infant feeding, including recommendations for breast-feeding through the first year of life. One stated that special dietary needs of infants and children should be addressed, especially with regard to dietary fat intake. One suggested fat should not be restricted until after growth in adolescence is complete; one stated that children should consume 30 percent of calories from fat but not less. One recommended an average of 30 percent calories from fat, including 10 percent from saturated fat. Three recommended a transition from age 2 through the end of linear growth, from the high-fat diet of infancy to a diet that includes no more than 30 percent of calories from fat and 10 percent from saturated fat, consistent with the 1990 nutrition recommendations for Canadians. One believed children's diets should emphasize consumption of omega-3 and monounsaturated fatty acids.

One recommended that calcium sources for adolescent girls and for those who are lactose intolerant should be stressed. Four stressed that recommendations made for adults cannot be applied to all Americans ages 2 and older, while one recommended using the same guidelines for children and adults in order to establish eating patterns from age 2, that is, people should receive consistent messages throughout life. Two suggested avoiding negative language, especially in providing guidance for children. One encouraged greater emphasis on fluoride and fluoride supplements and obesity prevention with an emphasis on physical activity and a sensible diet. One encouraged maintaining 1990 language on alcohol, with added emphasis on potential harmful effects such as fetal alcohol syndrome, abuse by children, and the number of motor vehicle injuries to young adults.

Older Americans (N=5)

Three stated that older Americans should not be treated as a homogeneous group, because doing this ignores special dietary needs of the old and the very old. Specifically, dietary needs of those 65-80 should be viewed separately from those of people 80 and over. Two recommended establishing separate recommendations for older people because they have higher protein needs and lower calorie needs. One stated that the potential benefits of cholesterol reduction have not been established in older populations.

Format/Communicating (N=15)

One comment suggested reordering the guidelines, such that the "eat less . . ." guidelines should be listed first, followed by the "eat more . . ." guidelines. One requested that the positive tone of the guidelines be maintained. One suggested stating messages in a positive, action-oriented tone to provide practical guidance to consumers. Three favored a two-tiered approach, including the first four guidelines in the first tier, and the last three (salt, sugars, and alcohol) in the second tier, stating that the science base for some guidelines is stronger than for others and also implying that prioritization and ranking are important. Eight favored a two-tiered approach, claiming that no particular guideline ought to be emphasized; adherence to all of them is needed to stay healthy. Two stressed the need to translate the Dietary Guidelines into the most "user-friendly terms" possible, with the inclusion of more practical advice.

One recommended providing information in both a graphic and text format with the fewest possible words to enhance consumer communication and improve decision making and comprehension. One suggested identifying consumer attitudes, concerns, and behaviors about food, nutrition, and health, translating guidance into practical dietary recommendations, and prioritizing this information for the consumer. Four cautioned that the Dietary Guidelines serve dual purposes -- (1) public policy and (2) nutrition education of the public -- and recommended that two separate documents be written, possibly by two separate advisory groups. These four also commented that additional consumer-oriented research must take place to capture consumers' perceptions, values, and beliefs, as well as their understanding of the Dietary Guidelines.

Quantification of Recommendations (N=39)

Thirty-one suggested quantifying sodium, cholesterol, fiber, and refined sugar recommendations as follows: less than 2,400 mg sodium and 300 mg cholesterol, at least 25-30 grams of fiber. One recommended changing the sugar and salt guidelines to read: "Use a minimum of sugars," and "Use salt in minimum amounts." One recommended quantification of trans fatty acids, omega-3 fatty acids, folic acid, and vitamin E levels. One requested qualitative rather than quantitative recommendations, because the guidelines are not meant to be standards.

Renaming the Guidelines (N=1)

One suggested changing the name of the guidelines to Nutrition and Fitness Guidelines for Americans and indicated that the word dietary has a negative connotation and that physical activity should be more heavily stressed.


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