In the Matter of:
DIETARY GUIDELINES ADVISORY COMMITTEE
Monday,
September 28, 1998
Economic Research Service
1800 M Street, N.W.
Third Floor, Auditorium
Washington, D.C.
The meeting in the above-entitled matter was
convened, pursuant to Notice, at 9:13 a.m.
DIETARY GUIDELINES ADVISORY COMMITTEE MEMBERS:
CUTBERTO GARZA, M.D., Ph.D.
Chair
Division of Nutritional Sciences
Cornell University
Ithaca, New York
RICHARD J. DECKELBAUM, M.D.
Institute of Human Nutrition
Columbia University
New York, New York
JOHANNA DWYER, D.Sc., R.D.
Tufts University
School of Medicine and Nutrition
Frances Stern Nutrition Center
Boston, Massachusetts
SCOTT M. GRUNDY, M.D., Ph.D.
The University of Texas Southwestern
Medical Center at Dallas
Center for Human Nutrition
Dallas, Texas
RACHEL K. JOHNSON, Ph.D.
Department of Nutrition and Food Sciences
The University of Vermont
Burlington, Vermont
SHIRIKI K. KUMANYIKA, Ph.D.
Department of Human Nutrition & Dietetics
University of Illinois at Chicago
Chicago, Illinois
ALICE H. LICHTENSTEIN, D.Sc.
Jean Mayer USDA HNRC on Aging at
Tufts University
Boston, Massachusetts
SUZANNE P. MURPHY, Ph.D., R.D.
Department of Nutrition
University of California
Davis, California
MEIR STAMPFER, M.D., Dr.P.H.
Channing Laboratory
Boston, Massachusetts
ROLAND L. WEINSIER, M.D., Dr. P.H.
Department of Nutrition Sciences
University of Alabama at Birmingham
Birmingham, Alabama
PARTICIPANTS:
EILEEN KENNEDY
USDA, Deputy Under Secretary
Research, Education and Economics
SHIRLEY WATKINS
USDA, Under Secretary
Food, Nutrition and Consumer Service
LINDA MEYERS
Acting Director, Office of Disease Prevention
and Health Promotion
Senior Nutritional Advisor
to the Assistant Secretary
for Health and Surgeon General
J. MICHAEL McGINNIS
Scholar-in-Residence
National Academy of Sciences
SHANTHY BOWMAN, Ph.D.
USDA, Agricultural Research Service
CAROLE DAVIS, M.S., R.D.
USDA, Center for Nutrition Policy and Promotion
PROCEEDINGS
9:13 a.m.
DR. KENNEDY: Good morning. My name is Eileen Kennedy. I am Deputy Under Secretary for Research, Education and Economics in the Department of Agriculture. I am delighted to be here this morning. And on behalf of Secretary Dan Glickman, Secretary of Agriculture, as well as friends and colleagues at both the Department of Agriculture and Department of Health and Human Services, I am delighted to welcome you to the first meeting of the Dietary Guidelines Advisory Committee.
The Department of Agriculture and Health and Human Services jointly sponsor this activity every five years. It is once again time to look at the scientific evidence and decide whether, based on that scientific evidence, the Dietary Guidelines need to be revised.
I thank all the members of this prestigious committee. I realize how busy everyone is. And it reminds of what we always say in the Department: When you want something done, who do you ask? You ask busy people. So thank you.
Fortunate for me, this is my second time through directly involved with dietary guidelines. And one of the things we took very seriously, we in USDA and HHS, was the recommendations of the prior committee.
And one compelling plea from that committee was that they needed more time. And I think as a testimony to the -- how serious we took those recommendations, we are in fact starting this process earlier, giving us the opportunity, if we need to, to have more meetings. And we think the slow, deliberative process attests to the seriousness of what we are about to do. And I think it's a sign that you USDA and HHS are committed to this process.
I am happy to see so many friends and colleagues in the audience. We have representation from academia, industry, trade associations, consumer groups. In response to the Federal Register notice which was put out, we also have received a surprising number of very thoughtful comments which have been shared with the Committee on issues that we -- we need to consider. And, again, I think this reflects the interest in the whole process.
Again, I think, reflecting the commitment of this Committee, we are fortunate today to have ten of our members present at this meeting. And Dr. Tinker will not be able to joint us today and indicated that at the point when she accepted to be on the Committee and also indicated that if that was a particular constraint from the Committee, she would step aside. So we knew from the beginning she wouldn't be here today.
But let me just say a few words about Dr. Tinker. Dr. Lesley Fels Tinker manages the Nutrition Intervention and Dietary Assessment Unit of the Women's Health Initiative Clinical Coordinating Center of the Fred Hutchinson Cancer Research Center. She has a variety of other hats she wears. She serves as a member of the Cancer Prevention Research Program within the division of Public Health Sciences. Dr. Tinker also serves as an affiliate assistant professor with the Department of Health Sciences at the University of Washington.
Her specific areas of research have focused on fiber and nutritional requirements of diabetes, and she has worked as a nutrition consultant and clinical dietician. Dr. Tinker is a member both of the American Dietetic Association and the American Diabetes Association.
Now I would like to ask the members of the Dietary Guidelines Committee to introduce themselves, indicating their institutional affiliation and a sentence or two about their area of specialty. For those in the audience who are interested, I think it's Tab A has short bios on each of the Committee members.
And with that, Dr. Garza, would you please lead off.
DR. GARZA: Thank you, Dr. Kennedy. And I was asked to ask each of the Committee members to please speak into the microphone because our comments are being recorded, both by a sound system, but also with a transcriber. You can tell that both departments are quite interested in saving all of your comments for posterity. And so we want to make sure that we don't lose any of the nuances. So we will have both a written and an oral transcript of -- of your comments.
My name, as Dr. Kennedy said, is Cutberto Garza. I am at Cornell University where I am on the faculty of Nutritional Sciences. I chaired that department for about ten years and have recently been named Vice Provost for the University as my present post. I have had a longstanding interest in maternal-child health, on nutrient recommendations not only for that age group, but more generally.
And in that capacity, I also chair the Food and Nutrition Board. And I know we have at least two other members of the board, and it's always -- I can tell you it will be fun working with them and with the other members of the Committee that I have had an opportunity to work with in the past. So why don't we move to Suzanne Murphy.
DR. MURPHY: I am Suzanne Murphy at the University of California at Davis, although I have joint appointments also at Berkeley and San Francisco. And I direct the EFNEP Program for the state of California. I am also a researcher, very interested in diet and health generally, and I do a lot of work with dietary assessment methodology and food composition data.
DR. WEINSIER: Roland Weinsier, Chairman, Department of Nutrition Sciences at the University of Alabama at Birmingham. My research interest is primarily in the area of obesity, energy metabolism in this field; serving on various advisory committees such as to the NIDDK, Federal Trade Commission and several other groups.
DR. JOHNSON: I am Rachel Johnson. I am from the University of Vermont in Burlington, Vermont. And my research interests are primarily in the area of pediatric nutrition, energy metabolism and the use of national nutrition survey data. Thank you.
DR. STAMPFER: Meir Stampfer, Professor of Epidemiology and Nutrition, Harvard School of Public Health. My main interests are chronic disease epidemiology, nutrition in adults. We follow in our research group about 250,000 men and women with dietary data to look at their outcomes.
DR. KUMANYIKA: I am Shiriki Kumanyika from the University of Illinois at Chicago. There I head the Department of Human Nutrition and Dietetics, and I am a professor of nutrition and also a professor of epidemiology in the School of Public Health. I was a member of the 1995 Dietary Guidelines Committee, so I am a return visitor to this process.
I have been a member of the American Cancer Society and American Heart Association Dietary Guidelines consensus panels. Also, I chair the National Nutrition Monitoring Advisory Council and do research on diet and chronic diseases, particularly on obesity and with particular interest in obesity in older -- in African Americans and older adults.
DR. DECKELBAUM: I am Richard Deckelbaum, head of the Institute of Human Nutrition at Columbia University. And my own research interests relate to cell biology of lipids and lipoproteins. And as well, being a pediatrician, also I am involved in research programs relating to risk factors leading to chronic diseases in the pediatric age group. And I have been in guideline committees of the American Heart and other organizations; and most recently, guidelines which try to bridge guidelines -- unify guidelines from the pediatric to the geriatric age groups.
DR. DWYER: I am Johanna Dwyer. And my interest is in lifestyle -- or, I'm sorry, life cycle-related nutrition and also lifestyle to some extent. My work right now involves chronic disease, particularly renal disease and quality of life issues, both in that and in aging.
I'm a professor at Tufts University Schools of Medicine and Nutrition, and also a senior scientist at the USDA Human Nutrition Research Center on Aging. And I have served under Dr. Garza on the Food and Nutrition Board for a couple of terms. And I am serving under Dr. Murphy on the uses of the Dietary Reference Intake Committee. And that's been a wonderful experience.
DR. GRUNDY: I'm Scott Grundy from the University of Texas Southwestern Medical School in Dallas. I am the director of the Center for Human Nutrition there. My research interests have been in the fields of effects of different kinds of dietary fats on metabolism as well as obesity and its metabolic complications.
I am particularly interested in the field of cholesterol and have worked with the American Heart Association and the National Cholesterol Education Program, and then more recently I have also been on the Food Nutrition Board and the DRI Committee for developing new RDAs and DRIs.
DR. LICHTENSTEIN: My name is Alice Lichtenstein. I am at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University and also in the School of Nutrition and the Medical School. My area of research is in lipids, fat, dietary fats and lipoprotein metabolism, and more recently isoflavones. I serve on the Nutrition Committee of the American Heart Association and share the industry Heart Association Nutrition Committee panel of the American Heart Association.
DR. KENNEDY: Thank you. Clearly, we have a rich diversity of expertise reflected. And for Dr. Kumanyika and Dr. Garza, I don't know whether you think you are being rewarded or punished, but we appreciate your doing a second tour of duty on this. It is a lot of work.
Before I move on to the next section, I would like to acknowledge our four co-Executive Secretaries who already have done a tremendous amount of work. And without them, this meeting today wouldn't have happened: Dr. Linda Meyers from HHS, Kathryn McMurry, Carole Davis from Center for Nutritional Policy Promotion and Dr. Shanthy Bowman.
It is now my pleasure to introduce somebody that I was fortunate enough early on in our tenures at the Department of Agriculture to work with closely with. And lest we think that all the wisdom regarding nutrition comes from on high, i.e., federal government, Shirley Watkins is one of these individuals who not only has had a federal perspective, but well beyond that has had the opportunity to put dietary guidelines into practice.
And I learned an enormous amount from her work in Tennessee in looking at from the particular point of view of the school meals program in Tennessee, how you use administration regulation policy to really move forward an agenda to the benefits of the public health of children. We're fortunate that she moved from Tennessee to Washington. Their loss; our gain. It is that -- with that I would like to now introduce Shirley Watkins, Under Secretary for Food, Nutrition and Consumer Service who will administer the oath of office to the Committee.
MS. WATKINS: Thank you, Dr. Kennedy, and good morning to all of you. Good morning. Well, I can understand that it is a Monday morning and I know that you are all excited about being here. I can tell by the smiles on your faces that you are just so excited about the week ahead and all of the accomplishments that you are going to make this week.
Like Eileen, I would like to just give you a big welcome from Dan Glickman, the Secretary of Agriculture. Eileen and I both have mentioned this meeting to him. And he is also very excited that you are here.
This is a very distinguished panel. And I am delighted that you are going to be working with us and you accepted this opportunity so graciously. I know for many of you, it is going to take a lot out of your week being here with us.
But we sincerely appreciate the efforts that you are going to put forward as you help us think through the changes, if any, that need to be made in the dietary guidelines. You are all recognized experts in nutrition and health. And we deeply, deeply appreciate your commitment and your mission and your commitment to our mission for both HHS and USDA.
We also want to stress that both USDA and HHS work as partners in this effort. Because of our strong commitment for both families' and children's health, this is a combined effort. It's a concerted effort on our parts for both government and the community organizations to put forth a successful attempt at looking at the Dietary Guidelines. And we look forward to the stimulating and effective working relationship that's going to take place.
I also would like to thank Carole, Shanthy, Kathryn and Linda for the support that you have given prior to this meeting and the support that you will give during the meeting and all of that that will go on after the meeting. There is a lot of work that will go on and we deeply appreciate your efforts.
The Dietary Guidelines is actually the cornerstone for all of the federal nutrition policies that we have to implement. Regardless to where you are, at the local, state or federal level. We see this as the cornerstone of what we are going to be doing. And it is awfully, awfully difficult for us to do our work without having that cornerstone there to help us put all of our efforts into place.
One of the roles that I have to play this morning is to administer the oath of office. And what I would like for you to do is all of the Dietary Guidelines Advisory Committee members to please stand and take your oath of office.
Whereupon,
THE DIETARY GUIDELINES ADVISORY COMMITTEE MEMBERS
having been first duly sworn, assumed the oath of office of the Dietary Guidelines Advisory Committee.
MS. WATKINS: Thank you very much. Would you all give them a round of applause for that.
(Applause.)
MS. WATKINS: They really did not realize they were going to have to do all of that.
This morning, one of the opportunities that I would have would be to introduce Dr. David Satcher, the Assistant Secretary for Health and Human Service and the Surgeon General. Unfortunately, Dr. Satcher is on his way to eastern African. But here is our one and only faithful servant, Linda Meyers.
Dr. Meyers, would you come on behalf of HHS.
DR. MEYERS: Thank you. Good morning. I am Linda Meyers. I am the Acting Director of the Office of Disease Prevention and Health Promotion, and the Senior Nutrition Advisor to the Assistant Secretary for Health and Surgeon General. And I am pleased to join my colleagues at USDA, Ms. Watkins and Dr. Kennedy, in welcoming you.
As Dr. Kennedy indicated and Ms. Watkins reenforced, today's meeting continues a longstanding commitment to a collaboration on nutrition policy between HHS and USDA. We appreciate USDA's taking responsibility for administrative management of this round of the Dietary Guidelines and we are pleased to be a partner with them in this activity.
Now, on -- I have been asked to welcome you on behalf of the Department. And so on behalf of the Department and the Secretary and the Assistant Secretary for Health and Surgeon General, welcome. Thank you for accepting the call to serve on this Committee and best wishes for your task ahead.
Actually, I am sure you, and I know Assistant Secretary for Health and Surgeon General, David Satcher, and certainly I wish that he could be here today in person. As Ms. Watkins indicated, he has been asked on very short notice to -- by the Secretary to represent the Department on a team that is going to Kenya and Tanzania in follow-up to the recent bombing. And so he is on his way there now.
He asked that I ask you, Mr. Chairman, if it is permissible for him to come and talk with the Committee at one of your future meetings.
DR. GARZA: Not only would it be permissible, but we would welcome it obviously. That would be great.
DR. MEYERS: Thank you. I will relay that. The Surgeon General, who is actually going to be the federal official I think most intimately involved with the Dietary Guidelines in HHS, has identified six priority areas for his office and his work on behalf of the American people. Two are related to his trip to Africa: Increasing attention to global health concerns and their effects on the American people, and leading the national response to health consequences of bioterrorism.
You may have heard him talk about the others: Enhancing mental health; eliminating disparities in health among racial and ethnic groups; assuring a healthy start for every child; and helping the American people take personal responsibility for their health. Your task is an important contributor to several of these goals, which are actually departmental goals as well, especially the last one.
As you know, the Dietary Guidelines Bulletin is an easily understood statement of policy, at least we hope it is easily understood. And it forms the basis of the nutrition programs for both departments. That means that these statements and the accompanying text are a framework for all the dietary guidance and nutrition education material prepared by the Department of Agriculture and the Department of Health and Human Services. It is also used as a consumer education tool, one of many, and provides practical advice for dietary patterns of Americans.
You are about to play a crucial role in the development of these guidelines. Your charge is three-fold: First, to review the 1995 edition of the Dietary Guidelines in relation to current scientific and medical knowledge on the relationship between diet and health; second, to determine whether compelling evidence exists that warrants revision of the seven statements or the accompanying text which we refer to collectively as the Dietary Guidelines; and third, to recommend in a report to the Secretaries of Health and Human Services and the Department of Agriculture any specific revisions you recommend along with the rationale for those recommendations.
If Dr. Satcher were talking with you, I'm not sure exactly how he would say it. But based on seven months working for him, I am sure he would eloquently include the requests that you be driven by the science; that you address the most important public health priorities; and that make sure that what you say resonates with the American people. So as you deliberate, I encourage you to put a high priority on ensuring that the proposed statements are scientifically sound in light of a broad base of evidence including consumer research.
Because you are continuing the tradition of a scientifically credible document, the gold standard, to use Secretary Shalala's words, it's critical that changes be based solidly on new evidence or on compelling reinterpretation of existing evidence with the burden of proof on any proposed revisions.
As you deliberate, I encourage you to stay focused on determining what should be the few most significant, science-based dietary guidelines for the nation, those that will have the greatest impact on the health of all Americans. This will clearly be a challenge because the field of nutrition, as evidenced by -- by your membership here, is very broad and encompasses many perspectives.
As you delve into the scientific literature and craft your revisions and recommendations, I also encourage you to remember that the resulting guidance must be easily understood and translated into action by the American public.
Once you've submitted your report to the Secretaries of Health and Human Services and Agriculture, the departments will very closely consider your proposed revisions and jointly issue the Year 2000 Dietary Guidelines for Americans. Now, having said all that about change, I do remind you that you also have the option to recommend no changes if you deem existing guidelines to be still appropriate and consistent with the current evidence.
You are appointed to this Committee because you are highly respected by your peers for your depth and breadth of scientific knowledge. You are recognized for your abilities to communicate clearly and to achieve consensus. And you are recognized for your commitment to promoting public health.
You have an ambitious task before you. I think I speak for my colleagues when I say we think there is no better qualified team of scientists to advise the departments on these guidelines, and we look forward to listening to your deliberations and receiving your recommendations.
And I am now delighted to hand the meeting over to the Chair, Dr. Garza.
DR. GARZA: Thank you, Dr. Meyers. Well, I -- thank you, Dr. Kennedy. It is indeed a privilege to be part of the Dietary Guidelines for the year 2000. Somehow, it has -- it has quite a ring when one -- when one phrases it in terms of the new millennium. And I am certain that all of the other members of this group share that sentiment. We are proud to take up the charge given to us by the Secretaries, and are fully committed to carry it out.
The important -- it's difficult for me -- and I know I can't be too objective -- but it's difficult for me to overstate the important role which nutrition will play in assuring the next generation of healthy people, as I think the Surgeon General has -- has often stated in terms of health goals for the country.
It is my personal view that we have correctly left behind a medical system that had enormous incentives to over-treat. But there is a growing proportion of the American public that is becoming concerned because we seem to be constructing a system that has enormous incentives not to treat.
And there are some of us that would like to see a health system built using the momentum for change which we are now witnessing, that has enormous incentives to minimize the need to treat. And it is this minimizing the need to treat where I think nutrition will be terribly important in terms of health promotion and disease prevention.
I am very pleased to be able to work on this important mission with the co-Executive Secretaries, the staff, and look forward to the preparation of a new report should we deem it necessary to bring about any changes.
At this time, I also want to thank the Agriculture Research Service for taking up the administrative responsibility for this round, and thank the Economic Research Service in whose facilities we are for hosting this meeting.
Now, I am also very pleased, as I look out at the audience, there are many, many friends, some I recognize. I want to welcome each of you. It is encouraging for all of us to see such wide interest in the Dietary Guidelines.
We certainly look forward to working with you throughout this process, whether it is two days long because at the end of this session we decide we can all go home, or whether in fact it is -- it is longer than that. In either case, we will -- there will be future opportunities for you to comment. At this present meeting, however, we will not be taking any oral comments from the audience.
Okay. There will be an announcement before the next meeting in the Federal Register that will include, I hope, an announcement that in fact we will be taking oral comments.
You have the option, however, throughout the process, obviously, to send in written comments. These should be sent to Dr. Shanthy Bowman. We ask that you please not send them directly to committee members because assignments may be shifting and she will be in a much better position to be able to direct your written comments to the appropriate individual.
I want to review very quickly the agenda for the meeting. For those of you in the audience, there are extra copies of this agenda on the table outside if you would like to pick one up, assuming you may not have one.
Now, the first -- the first two presentations on the agenda are intended to provide a context for the task that we are going to undertake. I am very pleased that Dr. Michael McGinnis will be joining us -- or has joined us today and will be providing a historic overview of the Dietary Guidelines.
Dr. Kennedy will then discuss the uses of these guidelines with us to help us understand the important role they play, not only in federal policy, but throughout the entire food sector. The remainder of the day, we are going to focus on updates and discussion of the individual dietary guidelines with presentations by various committee members and some follow-up discussion. We will also discuss the issues of interest that may not be included in the guidelines that perhaps we have to -- we have to also consider.
On the basis of this, we may be able to determine if there is sufficient new information that warrants further revision and review of the guidelines or, as was pointed out by Dr. Meyers, we may all decide to go home because, in fact, we feel that the Dietary Guidelines as presently constituted, are adequate to the task for which they were formulated.
We are going to adjourn today about 5:00 p.m. and then start tomorrow at 9:00 when we will continue with our presentations of these issues. And we plan to adjourn by approximately 12:15 tomorrow afternoon. Are there any comments on the agenda? Now, that's a very brief overview. We will be taking up a matter of time tables and procedures, as well. Okay.
Then let's continue then with -- with Dr. McGinnis' presentation. I believe all -- all of you are familiar with him. He was Deputy Assistant Secretary for Health -- or Disease Prevention and Health Promotion and Chair of the Health and Human Services Nutrition Policy Board.
What many of you may not fully appreciate though is that Dr. McGinnis was instrumental in initiating the Dietary Guidelines for Americans and oversaw the preparation of many of the subsequent, if not all the additions. I don't know. Maybe it was all, Michael. Somehow that makes him seem much more elderly than he is.
DR. McGINNIS: A lot of light-years here.
DR. GARZA: That's right. During his tenure, he was also responsible for the Healthy People initiative, the Surgeon General's report on nutrition and health, and the much cited McGinnis and Foege article on the actual causes of disease.
As I think of public health figures in this country -- and I don't mean to be patronizing or to embarrass Michael -- but it is difficult to think of another person that has had more of an impact on the way we approach issues of this type. And so that we are very fortunate that he has come today.
He is presently a scholar-in-residence at the National Academy of Sciences. And that obviously I think will increase his wisdom, at least that's what I'm told as I walk through those hallowed halls. Michael.
DR. McGINNIS: Well, thank you very much, Bert. That was a very, and far too gracious introduction.
Mr. Chairman, distinguished colleagues, it really is a treat for me to be here with many -- so many young friends of such longstanding duration. You see, as I get more grey hair, I have to go to great lengths to avoid using the word, "old". But I do see as I look around the room some very close colleagues from whom I have learned a great deal over the -- over the years.
And I was impressed with the match between the experience of those of you who are on this Committee, the tremendous talent that is being brought to bear on this task and the magnitude of the challenge that you have. Your chairman brought that home all the more acutely in -- in a rather intimidating fashion when he indicated in effect that you are about to set out the Dietary Guidelines for the next thousand years with the turning of the millennium.
It's, of course, a very special treat for me to talk about the historical context of the guidelines. And as a good historian, I undertook a little archeological dig and pulled out a few relics that I will display from time-to-time in the course of my few minutes here. And I will keep it relatively few because you've got to get to the real work of the agenda which is looking to the future and not the past.
But let me begin by simply underscoring what you've already heard from Shirley Watkins and Linda Meyers in very nice introductions to -- to the nature of the charge before you. Yours is quite simply a vital task for the health of the American people.
As the 1988 Surgeon General's report on nutrition and health, the first and at this point the only Surgeon General's report on nutrition and health said, "Ten years ago, for the two out of three adult Americans who did not smoke and did not smoke excessively, one personal choice seems to influence long-term health prospects more than any other: what we eat." And the Dietary Guidelines serve as the vehicle to inform and direct those choices; hence they are central in every possible fashion to the health prospects of the American people.
The notion of developing dietary guidance is certainly not novel. We could go back to the Greeks, but I won't. I won't even go back as far as 1894 when USDA's W.O. Atwater suggested as a personal observation -- I should emphasize the personal observation component; not official policy at that point -- officials in those days were a little more free to express their opinions in an unfettered fashion.
And his opinion was that a healthy diet would have to be about 15 percent calories from protein, 33 percent calories from fat, and 52 percent calories from carbohydrate. I also won't belabor the mid-1950s developments when USDA recommended the four food groups.
Rather what I will do is start with 1977 and the dietary goals of the Senate Select Committee on Nutrition and Human Needs, the McGovern committee. I do that not only because that committee's reports provided a strategically important transition from one approach to nutrition to another, from an approach to nutrition that focused on reducing nutritional deficiencies to one focused on reducing the burden of chronic disease among the American people; but also because it's -- when I first entered the nutrition scene from a policy perspective and, therefore, have more first-hand knowledge about the developments in the intervening period.
The McGovern committee report was issued in January of 1977. This is it in its Congressional record format. And it recommended that the American diet be increased in carbohydrates to 55 to 60 percent of calories; that dietary fat decrease to no more than 30 percent with a reduction in the intake of saturated fat and, indeed, recommended approximately equivalent distributions among unsaturated -- monounsaturated fats and saturated fats for that 30 percent target; that cholesterol intake decrease to 300 mg per day, sugar intake to 15 percent of calories, and decreasing salt intake to three grams per day.
The McGovern committee goals were met with a great deal of controversy, as you all know, both from industries that were affected, either pro or con, as a result of the issuance of the goals, and also from the scientific community, in particular with respect to questions of the supportability of the specificity, that is, the numerical targets that had been included in the McGovern committee report.
In part, in response to the challenge of that report, in part, in response to the challenge of the controversy, in part, in response to some fundamental obligation of the scientific community, Dr. Julius Richmond, who was Dr. Satcher's predecessor -- in fact, the only previous combined Assistant Secretary for Health and Surgeon General -- asked his friend, Jules Hirsch, who was then in the leadership of the American Society for Clinical Nutrition, if he could pull together a group representing the scientific community from the ASCN membership and look across the board at the literature and develop a way of characterizing that literature in a systematic fashion.
The results of that effort were published in December of 1979 in the Journal of Clinical Nutrition, and I think represented a very major contribution in the following sense: Not only did they cast their net widely to look at the influence of a variety of factors, nutritional factors on health outcomes, that is, to do it in an integrative fashion as opposed to an isolation, but also in their -- in their attempt to quantify the strength of scientific opinion; not to quantify targets, but to quantify the strengths of convergence of opinion in the scientific community about the ties between various candidate nutritional patterns and health outcomes.
As that process was underway, its progress was drawn upon by the development of the 1979 Surgeon General's report on health promotion and disease prevention, Healthy People. This is the first Healthy People report. As you have heard, we are -- we have now passed Healthy People 2000 and are in the process of developing Healthy People 2010.
But in this first Healthy People report, the Surgeon General's report on health promotion and disease prevention, there were some general directions, not quantified goals, but general dietary guidelines included to draw the attention of the American people to some of the possibilities that might be obtained by faithfulness to certain guidelines across a whole population.
With the fact that there had then been issued within a relatively short period of time a statement of Congress, a summary by the scientific community as represented by one scientific organization, and a general statement of one departmental agency, the Department of Health, Education and Welfare at that time, then arose naturally the question, "What about an administration-wide policy?"
There are two agencies within the federal government with vital mandates, historic mandates in the area of food and nutrition policy. And they are the Department of Agriculture and the Department of Health and Human -- Health, Education and Welfare, and now Health and Human Services, and isn't there an obligation, again, to provide a contribution that speaks with one voice.
That obligation in the growing interest among all parties concerned to develop a response, if you will to the quantified targets of the McGovern committee stimulated a meeting in which I participated in 1979 in the offices of Carol Tucker Foreman, then the Assistant Secretary for Food and Consumer Services, the Department of Agriculture -- a meeting that included Carol Foreman and her research counterpart, Rupert Cutler, and her nutrition advisor, Mark Hegsted, from the USDA side; and from our side, Dr. Richmond, Assistant Secretary for Health, me as Deputy Assistant Secretary for Health, Don Fredrickson, the Director of NIH at that time, and Don Kennedy, the Commissioner of the Food and Drug Administration.
And we talked for about an hour or so about ways in which we could fashion a joint approach to this challenge. And I believe it was Don Fredrickson who said, "What we need at this point in time is not dietary goals in a quantified sense, but dietary guidelines for the American people." Mark Hegsted and I were then given the charge of carrying forward an effort, drawing from the best of the scientific resources in both departments.
And to make a rather long story rather short, with a fair amount of -- of furious activity, but activity undertaken in an informal fashion and with considerable input in particular from NIH and FDA, a draft set of dietary guidelines was developed by the two departments and issued in this brochure very attractively designed by USDA graphic specialists. This is the original version of the Dietary Guidelines.
In fact, I noticed as I was digging these out of the -- the archives of my library, that it was issued by Patricia Roberts Harris and Bob Bergland who were the two Secretaries of the Department at that time. And somehow, I got them to sign it. I didn't -- I don't even remember them doing that.
But they were the two Secretaries who issued it. And the curious thing to me at least, and although probably not to those who are much more steeped in the nutrition wars of the day, was the furor that was unleashed with the release of these relatively innocuous statements.
We were attacked from all sides, from the commodity groups, the industries whose economic vitality were being -- vitalities were being threatened, from the scientific community who -- some of who were claiming that the scientific basis for the development of dietary guidelines had not yet reached the point of maturity.
And in fact, on that count, the National Research Council, my -- the organization with which I currently associated, issued in very short order this little publication toward healthful diets which basically said we don't have the scientific basis for dietary guidelines. Go figure.
In any event, the -- the furor that was created with the release of the guidelines was soon followed by an election which -- in 1980 which yielded a change in administrations and assaults of a little different sort, of a political variety, on the guidelines when the administration actually changed. I won't go into the various political discussions in that respect.
I will only say that within that relatively short period of time, the guidelines had become so well entrenched that even rather strong political interest in killing them were unsuccessful and very shortly laid to rest.
And from that point on, the two departments have maintained a very important leadership position in working with you and the scientific community around the country to try to ensure that the Dietary Guidelines meet their full potential in education, in food labeling, in research and in monitoring, and they do shape our perspectives on each of those dimensions.
The only sustained political endeavor that has shaped the course of the Dietary Guidelines since then was found initially in some wording in the appropriations language in the early 1980s that required the two departments -- or directed; required may not be quite the right word if it's appropriation language as opposed to a statute -- that -- that directed the two departments to convene a dietary guidelines advisory committee to ensure that the capture of outside advice was formal and structured, and not just informal. Hence, the Dietary Guidelines Advisory Committee.
The first one was established and was very helpful in the development of the 1985 Dietary Guidelines in which relatively few changes were made, but which were issued with -- with much less controversy, either from industry or from the scientific community, indeed, with formal expressions of support from those groups.
The Dietary Guidelines Advisory Committee -- the second Dietary Guidelines Advisory Committee was also established to assist in the preparation of the 1990 version of the Dietary Guidelines and held similarly to the basic principles that had been set out in the guidelines, introducing a couple of changes which were I think notable. One was the introduction of a quantitative element with a recommendation of 30 percent of calories for fat and the other was a change in the suggested weight tables that were used. And that change resulted in a fair amount of discussion and was a focus also of discussion in the 1995 Committee.
In 1990, the -- Congress' interest in this enterprise became formalized with the passage of Public Law 101445, with the formal direction of the two departments to issue these guidelines every five years, a pattern that had been followed informally up to that point.
And as a result, the Dietary Guidelines for Americans have moved with only minor changes from a contentious document that provided -- to one that provided the statutory basis for federal initiatives in education, research, monitoring and -- and food labeling.
Because the process had worked well in 1990, the two departments used essentially the same process beginning in 1994. And the 1995 edition was released by Secretary Shalala and Secretary Glickman on January 2nd, 1996 during the partial government furlough. Once again, the basic principles of the previous editions were reaffirmed. There were a number of changed based on the current science. I'm not going to go over them because you will be doing so in your discussions.
You have the benefit of two members of the current committee who served on that one -- the last one, your chairman and Dr. Kumanyika -- nice to see you Shiriki -- except to note that I thought the biggest difference from the previous edition was the renewed focus on the health benefits of decreasing sedentary activity by increasing moderate physical activity.
That's an important issue that we'll have to continue to emphasize as we reach out to enhancing the health of the American public. It's very difficult to separate out physical activity patterns from nutritional intake, that is, is part of the formula is the basic laws of thermodynamics.
There is no question that as you grapple with your task in the coming months, you will be confronting many thorny issues. I am not going to go through them all. I will just highlight three that will certainly come up in the course of your discussions.
One is how you deal with weight, both with respect to the appropriate ranges that you signal for the American people, and with respect to the various weight reduction claims that are made on a seemingly daily basis and certainly fill our bookshelves around the country.
There is in some sense some obligation to at least consider those issues that are confronting the American people. You will also have to surely be contending with how you deal with the different types of fats and the scientific evidence that is arising in that respect. And clearly, you will be contending with issues of how you deal with supplements.
It, frankly, is no longer sufficient to use the throw-away line that we get enough from the variety of foods that we eat. We need to probably state a little more directly what the science tells us in that respect. At least it is clearly on the minds of the American people.
But I am slipping beyond the boundary from the past into the future. And so I'll stop at that point. Merely thank you for the opportunity to be with you as you begin your effort to craft Dietary Guidelines for the year 2000 and wish you God speed in that effort. Thank you.
(Applause.)
DR. GARZA: Does anyone have any questions of Dr. McGinnis?
As you were speaking, I was reminded of -- of a list of five "Cs" that I always -- that come to mind when -- when we do things like this. And it seems to me that whether we choose to change or not to change, that you can -- not changing will in itself represent changes of this Committee and that regardless of what we do, it will be somewhat controversial. I don't think that these have ever escaped controversy.
And those are my first -- that because of this, eventually there will be some confusion. No matter how much effort we put in to being clear, there is always an element which is the third one largely because it is complex. I mean, we have to be able to dispel an enormous amount of information and make it understandable and applicable to every day life. And that is an enormous task.
But the saving grace of change, controversy, confusion and complexity is that it is always challenging. And that is what I think keeps us at the helm. Thank you very much for that background.
Now we're going to turn to a very important piece which is, well, why do we do this. Hopefully, not because people will put them on the shelf, but because they are used. And Dr. Kennedy will review those uses for us.
DR. KENNEDY: Thank you. I always enjoy hearing Dr. McGinnis talk about the historical perspective. And one message I took away just then is one can look at history in a variety of different ways. But in my mind, one way of looking at forces which have changed history is the theory of charismatic personalities.
And if you have people who want to do the right thing, it gets done. I think that's a clear example with enormous forces which would have said Dietary Guidelines would have never happened. We have people like Dr. McGinnis, Carole Foreman and Dr. Hegsted in government. So it -- it made it happen.
Both Dr. Meyers and Shirley Watkins have talked about the Dietary Guidelines forming the basis of federal nutrition policy. And I would like to -- to talk a little bit about what the means to us. Let me just kick off with a recent event before I go through the cadre of ways in which it is actually used.
I -- again, I was taken, Michael, with your comment about some of the toing-and-froing between USDA and HHS, HEW in the early years of the Dietary Guidelines. I was delighted on June 23rd in a White House ceremony when President Clinton signed into law our new Agriculture research bill passed by -- we are the Department of Agriculture -- signed by the President, but passed by the Congress, the House of Representatives Ag Committee as well as the Senate Ag Committee. And I keep underscoring ag.
In this new bill, there are six emphasis areas for research in which we aggressively need to charge ahead. And lo and behold, one of those six emphasis areas is nutrition. So I think if people are in this for the long haul, we begin to see progress.
If you look at the progress in some of our nutrition programs, I take as the -- again, one -- one key benchmark, the 1969 White House Conference on Food, Nutrition and Health, another charismatic personality, Jean Mayer, who not only had an agenda of bringing people together; but you look at the enormous pay-offs as a result of that conference, pay-offs for the American public because it was a -- in addition to talking about the science, there was a very action-oriented agenda.
So after that '69 conference, we had nationwide expansion of the Food Stamp Program, nationwide expansion of the school lunch program, creation of the school breakfast program, WIC emerged. We had the Nutrition, Education and Training Program, EFNEP. A whole variety of programs came forward which were serving an identified need in the American population which was defined, measured problems of under-consumption and nutrient inadequacies.
As we have had those cadre of programs being successful, we now realize that the nutritional needs of the at-risk groups, which I'm going to talk about in a moment, really have shifted from on average being ones that are exclusively ones of under-consumption and nutrient inadequacies, and they really have shifted into issues of diet quality, diet chronic disease issues. And so a part of that shift is having us in government look at what should we be doing in the context of programs that serve the public.
So in thinking about Dietary Guidelines being our guiding nutrition policy, we look at the variety of ways that Dietary Guidelines really are a living document. And let me start with within the USDA programs, the cadre of nutrition programs which have emerged over the past 30 to 50 years.
The Food Stamp Program at the moment serves about 21.4 million people monthly. We have the school lunch program which on average on any given day serves more than 26 million meals to students. We have the school breakfast program which is serving about seven million breakfasts daily.
There is the WIC Program where the high point thus far has been about 7.5 million individuals participating in a given month. And the latest statistics indicate that about 45 percent of infants born in the United States at some point during the first year of life are on WIC and approximately one out of four pregnant women in the United States are on the WIC Program.
We also have other USDA Programs: the Commodities Supplemental Feeding Program, the Food Distribution Program on Indian reservations, Child and Adult Care Food Program, the Summer Food Service Program, the Emergency Food Assistance Program. And if you take -- each of those are important, but albeit smaller programs -- that adds an additional six million people who are served by those programs.
So when you look at these programs and then begin to think about, well, the HHS component, clearly a very important program -- nutrition program out of HHS that serves the elderly, the Congregate Nutrition Program as well as Meals on Wheels, both rely on Dietary Guidelines.
The collective of these nutrition programs I used to say serves one out of ten Americans, then I started saying one out of nine. My notes say one out of six. I think we're heading towards one out of five served by one -- one out of five Americans served by one or more of these programs. And so clearly, the reach of the Dietary Guidelines are enormous.
As we've moved through the various additions of the Dietary Guidelines, we in government have been looking at ways of taking the essence of the Dietary Guidelines and incorporating them into the operation of the different programs. And there are a variety of ways this is done. This is done via legislation, via regulation and via some administrative changes that go on in the program.
Shirley mentioned the school programs. In 1994, the Department published the School Meals Initiative for Healthy Children which required the Department to ensure that all school meals met the Dietary Guidelines for fat and saturated fat.
And I think the controversy with these Dietary Guidelines never quite goes away because I was participating in a hearing up on the Hill the day before these regulations guiding the School Meals Initiative were to go final. And I was not the witness of record. I was there with the Under Secretary from the Department. And some questions began to emerge about the appropriateness -- this is 1994; not 1969 -- the appropriateness of the Dietary Guidelines to basically guide the content of school meals.
And one after another of the questions were ala do we really know enough, do we really know enough to think about improving the nutritional quality of school meals based on Dietary Guidelines. I've actually used a tape of this in some graduate courses that I've done.
But this happened to be picked up on C-Span. And I had it at home once. And my what have must then been a six or seven year old, my son was looking at this tape which was pretty boring to a kid. But of course I came on and it was a little bit, marginally more interesting. And he's looking at this tape and then he turns to me and he says, "Mom, why is that congressman yelling at you?".
So I think -- you know, I think it's -- again, I think it's an example of where we not only have to be guided by the science, but we have to make darn sure that we are as a community clear on what we do with the information in operationalizing it. I think we in the Department are proud of that initiative and we want to have the school meals as responsive to the nutritional needs of American children.
We also, in addition to in schools, the direct service kinds of activities, are very engaged in thinking about the companion piece which is the nutrition education/nutrition communications piece. So the Dietary Guidelines are the underpinning of all our nutrition education activities. But in schools, programs like the Nutrition Education and Training Program and Team Nutrition, both of which are geared to motivating children to make healthful food choices.
Let me talk a little bit about the -- the Food Stamp Program because it is the largest of our nutrition programs and is the key program which addresses household food security, household nutrition security.
The nutritional basis of benefits of the Food Stamp Program is something called the Thrifty Food Plan. The Thrifty Food Plan is a market basket of foods that, on the one hand, makes up a nutritious diet, but does so in a way that can be purchased at a relatively low cost. The market basket includes foods from all food groups.
The Thrifty Food Plan is a critical component of our food guidance system. And research that is in the final stages at the Center for Nutrition Policy and Promotion is updating the Thrifty Food Plan to: 1) meet the nutritional needs of the target population, relying of course on the now DRIs.
It is looking at the actual consumption patterns so that you're deviating to the smallest extents possible from typical consumption patterns. But it is also looking at the Dietary Guidelines as the third underpinning in revising the Thrifty Food Plan.
We are glad to see in the Department that in addition to looking at the emphasis of the Food Stamp Program on increasing purchasing power thereby increasing food security in the household, for the first time, nutrition messages based on the Dietary Guidelines will also be printed on Food Stamp coupons.
And these messages are tailored to help Food Stamp recipients choose a healthful diet. Is that all we're doing on nutrition education for Food Stamp households? No, but it is one component. And we're looking at how we bring all of these components together.
We have a variety of other nutrition education, nutrition community -- nutrition communications activities within the Department, hopefully to have multiple reenforcing messages. The Community Nutrition Action Program is one of many of USDA's nutrition education promotion projects.
This program provides information that allows communities to look at ways of improving the nutrition experiences for children. And, again, here the main messages in this community nutrition education program derive from the Dietary Guidelines -- they are built on three of them -- a message which emphasizes variety in the diet; add more fruits, vegetables and grains to the diet; and construct a diet lower in fat.
There are many more nutrition education programs in the Department and all of them are -- all of them in government, not simply USDA -- rely on the Dietary Guidelines as their guiding force in thinking about message development.
Eating for health is one of the seven priority areas identified for improving nutrition in the United States. And this, in fact, is one of the nutrition action themes for the United States that came out in our post-International Conference of Nutrition documents. So we again are looking at ways of very aggressively looking at the variety of programs we have to carry out nutrition education, nutrition promotion.
I think it clicked a while ago that with the resources we have in government, we clearly need to think about partnering. And no longer are we in the days where public sector can do even the lion's share necessarily of nutrition promotion. So we are involved in a series of public/private partnerships which we see as very positive, again, using the Dietary Guidelines as the basis for crafting messages, crafting the intervention.
One that I think has been quite successful that emerged a few years ago is the Dietary Guidelines Alliance where USDA and HHS are liaisons to the activity, but you have private sector industry groups, consumer groups, professional organizations looking at speaking with one voice in promoting the Dietary Guidelines in very creative ways. And the two particular aspects of the guidelines that underpin the messages in the Alliance are variety and physical activity. We would like to see more of that.
Finally, and by no means least since this is probably one of the better known activities out of government, the Dietary Guidelines very specifically influence our food guide pyramid. And the food guide pyramid is a very thoughtful, rigorous activity, again, looking at what are the, at any given point in time, consumption patterns in the U.S. population; what are the nutrient needs of the population; but also, how does one incorporate the Dietary Guidelines into the food guide pyramid.
And my statistics are probably out of date, but I used to say 68 percent of Americans are aware of the food guide pyramid. That number is probably much higher. And lest the committee that is sitting here this morning think their activities are limited to the United States, I was delighted about two years ago when the Minister of Health from the government of Chile invited me down to Santiago, Chile to launch the Chilean version of the food guide pyramid.
And the government was very gracious in acknowledging the amount of work and the amount they drew upon the U.S. activities, the U.S. work that went into our USDA, U.S. food guide pyramid, although they did say they've improved upon ours. I think that's the test of sort of when you become the grandfather of the product. It always gets improved upon in the next generations.
But they relied heavily on the work that went into ours and, again, very aggressively promoting that Chilean food guide pyramid to do the same kinds of things we do in the U.S. which is using that as one jewel in the crown for nutrition promotion.
That was a very quick run-through on some of the very diverse and important ways that we use the Dietary Guidelines. And as we charge ahead in other nutrition-related activities in government, we will continue to use the Dietary Guidelines as the nutritional basis of how we proceed.
I look forward to these meetings because it gives me an opportunity to sit back and really hear people who are experts in their particular area of research talk about the emerging science and how we -- we need to incorporate this into a very action-oriented agenda.
So for me, this isn't work; this really is pleasure. And with that, I want to welcome you all again, both on behalf of the Department of Agriculture and the Department of Health and Human Services. I am delighted to be there and I look forward to a lively deliberation. Thank you.
(Applause.)
DR. GARZA: Are there any questions of Dr. Kennedy? Shiriki?
DR. KUMANYIKA: You mentioned the Chilean guidelines and it reminds me to -- to wonder if our charge includes any global responsibility as we go forward because the issues are -- everything is globalized and certainly food is. And we have recently aligned, at least from the NIH point of view, aligned the weight standard more closely with the standard being used by WHO rather than having different cut-offs for BMI.
So I'm wondering as we go forward with this if we are to think about how what we come up with match evidence from all over the world in what's happening to other populations.
DR. KENNEDY: Well, I think what comes out of this Committee clearly has many unanticipated uses. I had no idea in the last Dietary Guidelines Committee that we in fact would have such a -- an interaction with our sister country and South America. I am taken by the question which the bulletin starts off with, "What should Americans eat to stay healthy?".
Well, I mean, in many respects, that question could be, "What should people eat to stay healthy?". So to the extent that a lot of the work that comes out of this Committee really has ramifications for broad guidelines in other countries, I would think countries would avail themselves of the very deliberative process which comes out of this Committee.
I know there has been some discussion, and I think Dr. Garza has been involved a bit in this, on the -- from an international perspective, UN agencies in trying to look at global dietary guidelines. That's limped along a bit. I don't think they've moved as fast as they would have liked. But I think the science that the Committee will be looking at is not simply restricted to scientific information coming out of the U.S., but really is the well-done research, the well-done science out of a variety of countries. And I think there are lessons to be learned there.
I think the difference, Shiriki, will be as you look at translating it to specific dietary patterns in Country X, there may be some tweaking that's needed. But, again, I think the broad information that gets reflected in the technical report that will come to the two Secretaries and even what we do without bulletin has ramifications for other countries.
DR. GARZA: Any other questions? I just had one comment that while Eileen went over the various federal uses, I want to remind the Committee that, in fact, the Dietary Guidelines serve as a document for a much broader base.
I am always amazed when I look at figures by the Economic -- from the Economic Research Service which shows that if you look at food from the farm to the fork, so to speak, that in fact that food represents anywhere from 20 to 25 percent of our GNP. That is almost twice the size of all of medicine. And so it's not surprising that whatever we do is to some degree controversial because, in fact, it has a potential of impacting an enormous sector of the economic activities in this country.
So then on that note, let's break. We will come back in about ten or 15 minutes and start with some of the presentations from each of the Committee members. Thank you.
(Whereupon, a brief recess was taken.)
DR. GARZA: Okay. As we outlined very briefly at the -- in this earlier section, we're going to begin reviewing issues that require evaluations. We're going to try to focus over the next -- the remainder of this morning's session on those salient changes that we feel we ought to consider.
It isn't the purpose of this discussion that we're going to enter in to reach consensus on any of these issues. I want to make that very clear. What we would like to do is to review the salient science that argues for either keeping the guidelines where they are or, indeed, suggesting potential changes.
After we catalogue the science, then we will be in a better position tomorrow to take a formal vote as to whether or not the Committee will continue or whether we would disband because we feel that, in fact, the present guidelines are adequate.
Now, towards the end of today's meeting and certainly tomorrow, we will also be taking up additional issues that we feel we need to be able to look at. Based on all of this, if -- if we decide to continue, then we will try to -- to think about working groups that we would divide ourselves into. So as you hear these discussions move forward, then I would urge you to start thinking about that group in which you would be most interested in working.
Now, this doesn't mean that if you become part of a group, call them A or B, whether it be for an existing guideline or a new issue the group wants to consider, that you would not have any input into the other guidelines.
All of the discussion, recommendations, deliberations of each of these groups would have to be brought before the full Advisory Committee because, indeed, the report will be the Committee's report. It will not be a series of working group reports. And so then in that sense, all of us will have a very strong input I hope into each of the deliberations of all groups.
Now, over the past few weeks, I have talked to some of you. I haven't had an opportunity to sit down with all of you. We are going to try to hold approximately three meetings over the next year. As you hear the various guidelines and issues discussed, try to keep that -- that framework in mind with the idea that, in fact, by the -- about 12 months, about October of '99, we would have held three meetings, drafted our recommendations, and these would have moved forward to the Department.
Now, in -- in this -- in trying to meet that 12-month framework, we don't have to do that alone. We're going to have lots of help. I've been assured of that by both -- by both of our co-Executive Secretaries. The staff is going to provide support because the working groups may decide they want to work together, either coming together physically or arranging conference calls.
Whatever mode of operation the various groups want -- want to adopt, you will have staff available to each of the groups to help with the organizational task of getting those groups together. The staff will also assist each of the working groups in putting literature searches together, in compiling data, and in helping write the reports.
Now, I would like for you to keep the following framework also in mind. Carol Suitor who is in the back of the room is also going to be part of the staff. Carol has a lot of experience in working in these sorts of reports as do members of the staff that you met earlier today.
And there is -- there are two options. One is each of the groups can choose to write their reports and write -- write the pros and put all that together, or to develop detailed outlines of the reports and then have those outlines fleshed out by staff. They can come back to you; you can then edit them in a way that you feel is most appropriate. The same would hold true for the actual recommendations of changes to the guidelines itself in terms of the booklet of the guidelines.
Now, the reason for my asking you to consider having the staff do a lot of that type of writing is that in -- in the past what we've had is individuals within the Committee become so engrossed in the semantics that we've spent more time discussing semantics than the substantive changes that need to go into the report and the science that compels it. And I would much rather have your attention given to the science that compels keeping a guideline or changing it than arguing about the nuances of words that -- and the perceptions that consumers may have of one word or another.
Now, that doesn't mean that your input will not be important to that. Obviously, it will be. But I want us to focus on the science. That's -- that's your advisory role. That also is a key -- a key word that I think will be very difficult for us to keep in perspective. We do have an advisory role.
I wish I could tell you that the Secretaries will march to the beat of the drums we decide to sound. But we -- they can theoretically take our recommendations and thank us and go their own way. I would hope not and certainly it is the experience of this Committee that that has not been the case. They have always listened very carefully. But we do have an advisory role versus a direct on-line authority to the rewriting of the document. Okay.
That means we need to do two things. One is provide guidance for the actual booklet that will go out to the consumers. But provide a detailed rationale for recommendations for change that we've made for it. Generally, the onus on us are much greater if we want to change something than if we want to keep it. At least that's been my experience. Keeping something unchanged doesn't seem to require the same degree of discussion and documentation.
In discussions with several of you, you have asked me for how we are going to go about documenting though changes that we may want to suggest. That I hope we will get to discuss also perhaps tomorrow; definitely before we leave, because there are two extremes. One extreme is that we can use an evidence-based approach and document literally every article that may show up on a search as to the reasons why we decide to keep it or reject it with some very clear criteria.
Given the breadth of the Dietary Guidelines, trying to do that in its most rigorous fashion probably would be very, very -- well, it not probably -- it would be extremely difficult for us to achieve. On the other hand, we just can't say, "Well, we recommend this change because we got up on Wednesday morning and thought it would be great." That's not going to be acceptable either.
And so somewhere between those two extremes, you're going to have to identify that happy medium of making sure that we present people with a very clear target. What I mean by that, it's a target that they can very readily embrace because they agree, or a target that will lead them to disagree but not because they just disagree, but understanding clearly what the basis for the decision that we've taken may have been and that they can then either do research or marshall argument against it. But the clearness of the target, the transparency of it is terribly important.
We're thinking of also possibly within our next meeting being around January or February. And it would be at that time that we would invite oral comments from the public so we can have the benefit not only of written comments, but also some oral ones as well. We probably as I say would meet then twice after that with subcommittees or working groups meeting throughout that period with the final documentation being available for final review and adoption by October.
That's the framework that I would like you to think about as we begin to lay out the issues because at the end of this, you may decide there is just so much work, there is no way we can get it done by October unless we get resources A, B or C in place, or you may say, "Gee, you know, we could probably do this by March." And I guarantee that both Linda and Eileen would probably be very pleased to hear that. Or you may say, "Look, we've looked at the science and we can really conclude this by the end of tomorrow", which I think would be very surprising to a number of people.
But in terms of framework that is very general, and we can get to the specifics tomorrow after we -- after we go through each of the guidelines and additional issues, do you have any questions just in terms of just general process and framework? Richard?
DR. DECKELBAUM: Two questions. One in seeking help in doing our parts or different sections presuming it will be continued past tomorrow, you might use, you know, available resources within the departments. But as well, we would call upon -- we could call upon individuals that work with us. And I -- are they acknowledged at any point if people outside the Committee contribute towards providing some of the data or helping formulate -- is there an acknowledgement for this contribution?
DR. GARZA: It would be acknowledged in the report.
DR. DECKELBAUM: Right.
DR. GARZA: And to that degree, staff would be -- would be keeping records of anyone that would be contacted. Now, if you contact someone and don't let staff know, then obviously it is very difficult to make that acknowledgement. So that we urge you to make sure that if you reach out to someone and they provide you with either information or advice, that you let the staff know so we can make sure that they are acknowledged.
Also, if at the end of today's session or tomorrow's session or during the times that the working groups meet it is clear that we would benefit as a group by inviting a scientist to come before the group and make a presentation on a -- on an issue that is particularly complex and you want to have that individual provide a summary or perhaps even a point of view, then that would also -- that also is possible.
DR. DECKELBAUM: The second question is, is it within the charge of this Committee to identify areas where there are major gaps that exist in terms of scientific basis for certain areas of recommendations and to identify research needs?
DR. GARZA: Yes. And that can be -- take various -- various forms, Richard. One is in terms of the science itself or perhaps even in terms of the application or in terms of the way we formulate the Dietary Guidelines. There was a strong recommendation made at the last time the Committee met to make sure that as each of these guidelines was being developed, that the USDA or -- and the HHS, but I think it was primarily USDA -- bring together focus groups of consumers to make sure that what we were intending to communicate was actually being communicated because to scientists, something may be terribly clear and transparent. But you test it with a consumer group and oftentimes we are surprised because their understanding of what we were trying to say is very different from the intent.
So there are all types of research we can recommend, either research of that type or the more traditional laboratory-based because we need information.
Shiriki?
DR. KUMANYIKA: My question is how -- is there anything we can do or how can we increase the likelihood that the recommendations, even if they are not changed, will be more acceptable to the scientific community. I am concerned that there are some recommendations that probably I don't think should change and maybe the Committee would decide wouldn't change, but they are hotly debated nevertheless.
And I am wondering if it is either in the format of the report or in the way that we go through our deliberations to reaffirm recommendations if we don't think they should be changed to strengthen the base so that we can reduce the sort of free-for-all that might take place, you know, because of different vested interests and so forth.
DR. GARZA: That's a very important point and I would ask each of the different groups that as you think about the guidelines that are being formulated, if there is a need, either at the end or in an information-gathering stage, to take advantage of one of the scientific meetings, I mean, APHA, ASNS, ASCN, to either at the end of the process explain why in fact we took the positions that we did, or in fact have either workshops or symposia at those
-- at those different scientific forums, that that would be possible. Certainly, that is a very important avenue we have available to us.
Other times if -- if in fact Committee members at the end of the process would like to put together a summary document expressing at least your view of it and writing it up in your respective journals, then certainly you have that -- that -- that opportunity as an individual scientist. I mean, it wouldn't come out of this group, but that's another avenue that is always open to Committee members.
Are there other -- Johanna?
DR. DWYER: -- heard of that's -- if the Committee decides to go ahead, it would strike me that it would be useful to present at scientific meetings. The first one that I can think of is probably ADA and then APHA follows very closely on its tail.
The -- the other thing that might be useful is to have a very brief presentation that was a summary of what was said today with overheads or something so that everybody is singing from the same hymnal. And it would seem to me that if that is the will of the group, that we need to return to that at the end of the day tomorrow.
DR. GARZA: Let's bring that up again because certainly having the scientific community come along with this group is very important. I urge you as you think about that to not forget that this process is aimed primarily at providing consumer support in making dietary decisions and having -- so that the documentation in the Committee report is obviously a scientific one.
The booklet is not intended for an audience of scientists. So keep that in mind. And at times, we tend to confuse the two and that's important that we not. But we'll bring it up tomorrow because it's -- there are important meetings coming up as Johanna says.
DR. LICHTENSTEIN: How much flexibility is there to change some -- the format? I mean, it seems that it's been very consistent that there are ten guidelines. And I don't know if there were -- sort of ten was the magic number. But in some cases, one -- oops, seven, seven guidelines.
DR. GARZA: We could increase it to ten. there is some historical experience with that.
DR. LICHTENSTEIN: Yes, I guess. But it seems to be relatively consistent throughout the various iterations of it. And in some cases, one could think of different ways of grouping various things. So are we going to get any idea of, let's say, what the impact would be of making a more radical change as opposed to fine tweaking?
DR. GARZA: We could advise any of the above. I think it was Kuhn who once said that consistency was a hob-gobbling of little minds or something. So we don't have to be consistent about that. We do have to be right. And so I -- if by being consistent we'll be wrong, then let's not be consistent. But we do need to be right.
And if we need to go down to five guidelines, that's what we would advise the departments to do. If we need to go up, you know, then we just increase the number. But keep in mind that, you know, it has to be something that the public will be able to deal with effectively. But we have all of those avenues ahead of us.
Any other -- okay, then if not, we'll start with Suzanne Murphy who is going to take us through the first guideline. The format will be, we'll have ten to 15 minutes of presentation with about ten or 15 minutes of discussion. Remember, it is -- it is to catalogue issues; not to reach consensus.
DR. MURPHY: Well, thank you for the opportunity to talk about what actually has been a topic I've been interested in for a long time, dietary variety. And I was very pleased to be given this one of the seven guidelines because I thought, hey, for once, I got the easy job. I didn't take the very hardest one. And this should be very noncontroversial and very straight forward. I don't even need 15 minutes.
Well, so I pulled out what I thought were my best references on dietary variety for five of them and read them over, and quickly changed my mind. I said, oops, things got a lot more complicated since I last looked at this topic.
And then Dr. Bowman did a literature search for me and I noticed even after narrowing down all the key words as best she could, there were 1,300 references. Now, I'm not going to stand here and tell you I've read those 1,300 references. Most of what I'll say is based on a much smaller number. But obviously it's a topic that has some complexity.
And I thought in the few minutes that I have today, I'll sort of bring some of these issues to the group and then we can discuss them some more afterwards. I have a few transparencies, mostly to make sure I don't miss any key points.
(Overhead.)
Just to remind you, a variety guideline is the one that's sort of in the center of all the circles. In other words, it's presumably the one that sort of holds the seven circles together. It is the key component. And in the way the book is -- has been organized, it is the opportunity to present the food guide pyramid.
Now, I know initially the food guide pyramid was an outgrowth of the Dietary Guidelines. And Dr. Kennedy mentioned the statistic that 68 percent of consumers at least know what the pyramid is. I would suggest to you a far smaller number know what the Dietary Guidelines are.
And in the classes I teach and the groups I work with, the pyramid is really the graphic and the concept that consumers remember. I teach a lecture occasionally on an introductory nutrition class where there are typically 500 or 600 students.
And when I ask them if they are familiar with the food guide pyramid, usually about 80 percent of them raise their hands. When I ask them if they've seen the Dietary Guidelines, I get blank stares. So clearly the food guide pyramid has been a very useful tool for consumers.
And I think that now we see that the variety guideline is an opportunity to present that in the context of the Dietary Guidelines. But it's not clear to me which is the tail and which is the dog anymore because I don't -- I think we have to remember that the food guide pyramid has been an enormously successful tool. And that my indeed be one of the issues we want to consider in talking about how this guideline is presented.
The third thing that I just want to mention at the beginning is that the simplicity is very appealing. Eat a variety of foods is sort of something no one could argue against, right? I mean, it's -- it's really very simple. And indeed I believe I'm correct in saying it is the only one of the seven guidelines that has not changed by a single word in the four previous editions.
So obviously there has been a lot of consensus about this guideline. And perhaps that is because it is so simple and so easily grasped.
But then we have to ask ourselves, "How is variety defined?". Maybe we'll put it --
(Overhead.)
And again, when I first started thinking about this, I said, well, gee, everybody knows what variety is. But as a matter of fact, it is not easy to operationalize variety. By nutritionists, we really have two different definitions that we use of variety.
Perhaps the most common one is to use it interchangeably with the concept of consuming servings of food that in effect correspond to those recommended by the food guide pyramid. And in some ways, that's more of a dietary score or a food group score. But it's used interchangeably with variety. And, indeed, the concept of variety that has been presented in the past is the concept of food group variety.
But there is a second and perhaps more comprehensive definition of variety. And that's food item variety. In other words, within the food groups, are you consistently consuming the same food. So within the fruit group, do you always eat apples or do you change off among different fruits within the fruit group.
The second concept has been more difficult to quantify. But as many of you know, there has been what I think is an important effort on the part of USDA to develop a healthy eating index. And I was pleased to be involved with Dr. Kennedy in the initiation of that project several years ago now.
And the group that developed that came up with a scheme for defining food item variety. It was basically based on food commodities. And in my opinion, for the first time, we had the opportunity to look at national survey data and try to look at least at perhaps epidemiologic sort of data on what the relationship was between variety and various health outcomes.
So the book as it stands now talks about both kinds of variety. But the first kind is really the focus. And the concept of consuming different foods within a food group is addressed rather briefly in the current booklet.
Now, the question I would have is does the concept that we nutritionists have of variety match how consumers see variety. And I'm not aware of much work that has been done to answer that question. And I would certainly be very interested in hearing more about a consumer perception.
And it is my understanding that there have been or will be some focus groups conducted. But that might, indeed, be a helpful piece of information to guide us on whether we're actually getting a useful concept across to consumers.
(Overhead.)
When we were asked to give these short presentations, the letter from Bert I assume said, "What is the change in the science base? Is there any new evidence that the Committee should begin to consider as in regard to this guideline on variety?".
And so I went through some of the references and I've summarized sort of four points, none of which really is new, although there is additional information available now that confirms what was known from some of the earlier studies.
The first is that I see a clear link between diets which conform to the food guide pyramid and improved nutrient intake. You can certainly show that people whose diets follow the recommendations from the food guide pyramid for the number of servings have higher nutrient intakes than those whose diets do not.
There has been a variety of information published. But just to mention one that was done by Cox, et al. recently looking at children. And I thought that was nice that there is now some more information on children's diets. But toddler diets that followed the food guide pyramid recommendations, this group found the correlation between the -- an index of nutrient intake and food group servings was 0.74. Now, that's a correlation that I would be very pleased to find in a lot of what I do. So it looks like there is a fairly clear link between the food guide pyramid and improved nutrient intake.
The link between variety, however, within the food groups and nutrient intake is less clear. And I actually did not find very much information. And I would perhaps put it forth as a research need to ask the question, "If you control for diets which conform to the food guide pyramid, what is the additional increment of variety within food groups in contributing to nutritional adequacy?". And I found very little to indicate that there was an additional contribution, if you will, from this second type of variety; that is, within group variety.
And given our charge to rely on science, I would say we may have some difficulty in justifying simply because there is not a lot of information available on this second type of variety. Intuitively, it ought to be there. Actually, I have found very little published that shows it is there.
The third point is that variety of either type, in other words, within groups and between groups, doesn't seem too closely linked to fat intake. In other words, people who eat a variety of foods do not necessarily have lower fat diets or lower cholesterol diets or lower saturated fat diets. There is some scattered information on an inverse link, but it's fairly weak in my opinion and fairly sparse. And the fourth point which is really the important one I think is what is the evidence of an association between variety and chronic disease because that's really what the Dietary Guidelines are for, to reduce the risk of chronic disease.
And, again, there has not been a lot of really solid research. And what is available, of course, is epidemiologic. But Ashima Kant in her group, which I think has done a lot of interesting work on dietary diversity as she calls it, and in this case diversity is food group variety -- her group does find a decreased risk of heart disease, for example, with an increase in food group diversity. So there is some evidence that variety at least of the type of following the food guide pyramid does result in a decrease in certain types of chronic disease.
(Overhead.)
The last thing we were asked to address was potential changes in the guideline. And I have three that I think we might wish to discuss. One is to clarify perhaps what we mean by variety. And although the last committee decided not to quantify things very much, it's a possibility at least to come up with a more concise definition of variety. And I think it is something we should at least consider.
For example, the Healthy Eating Index gives maximum number of points if a consumer reports 16 different foods across three days. Now, these are like food commodities. So if you had mashed potatoes and french fries, those aren't two different foods. But if you have apples and oranges, those are indeed two different foods.
I tried to find my reference from -- on the Japanese guidelines. Maybe someone else will remember what it is. But in Japan, they have a specific number that they recommend. And I remember being impressed by how high it is. I believe it is 30 different foods every day, 30 different foods every day which is interesting and, if you will, a -- something we could all think about.
The second possibility is to consider whether we would like to look at a guideline that more specifically says something about the food guide pyramid. If by variety we mean follow the food guide pyramid, should we just say that? And I think, again, that's something that should be considered.
And finally, if indeed we are going to focus on the food guide pyramid, does that mean that the variety of foods guideline could perhaps be combined with the grain, vegetable, fruit guideline in some way?
So I will leave you with those three possibilities and open it for discussion.
DR. GARZA: Any questions for Suzanne?
DR. DWYER: Suzanne, I'm not sure I understand the third point. Could you say that -- could you elaborate a little?
DR. MURPHY: It sort of follows I guess from the second point. If we -- if we decided that eat a variety of foods should be changed to follow the food guide pyramid, would that not subsume the current guideline on eat plenty of grains, fruits and vegetables because, after all, that's the base of the food guide pyramid.
DR. KUMANYIKA: When you looked into Ashima Kant's work, I'm wondering if you came to the conclusion, as I did with one of the papers, that the variety is a proxy for getting fruits and vegetables; it's not -- I mean, in other words, the people with the lowest variety were also the people who didn't consumer fruits and vegetables essentially. And it was poverty-related in part.
And so when you're saying combine with the grain, vegetable and fruit guideline, but I wonder if it is actually a marker for quality and the fruits and vegetables are the last frontier, if you encountered that and thought about it.
DR. MURPHY: As I recall, her varieties or diversity score was just whether people had at least one serving from each of the five pyramid groups. So I think it was a fairly simple score that went from zero to five. And I had not seen the correlation of her score with fruit and vegetable intake. I would assume that because that's only two out of five, that it would be associated with it, but not necessarily the same as.
But, yes, that's certainly a possibility. And of course, any time you're looking at epidemiologic data which is what she was doing, there is the whole issue of whether you've adjusted appropriately for all the confounding variables. And I think that's -- although she did indeed adjust for a wide variety.
I think although her papers were very interesting, that it would be important to have additional research in that area that would confirm or at least support her findings.
DR. KUMANYIKA: I have another question if --
DR. GARZA: Go ahead.
DR. KUMANYIKA: A related question, I'm thinking about the analysis. I don't remember it too well. But where when looking at who are the people who actually have like one -- you know, was it all -- was it one of any foods or were there certain foods that were likely to be the ones omitted in people who had a low number of servings.
But the other issue is mortality because some of their epidemiologic analyses look at mortality as the outcome.
DR. MURPHY: Right.
DR. KUMANYIKA: And there was kind of a brouhaha at one point in the Public Health Association about whether we knew enough to tell people it was good to eat fruits and vegetables; whether, in fact, mortality is the right outcome for Dietary Guidelines. So we might throw that into the hopper of questions to --
DR. MURPHY: Okay.
DR. KUMANYIKA: -- to ask about them. I mean, several things affect mortality besides whether you eat your variety. But --
DR. MURPHY: Right.
DR. KUMANYIKA: -- is it chronic disease or is it mortality and how are we going to weight that evidence?
DR. MURPHY: She does have a paper on heart disease as an outcome. But you're right, it is mortality from heart disease. So I don't think she looked at just morbidity.
DR. DECKELBAUM: In terms of increasing the variety, let's say, even in a single food group, right now things are defined in terms of servings. So even if we followed the guidelines, if you got towards the Japanese model and we provided all these as servings, we would be in trouble in terms of its caloric intake.
So if there is a goal towards increasing variety, there might be some thought placed on, you know, combining variety to within a single serving, mixing two or three vegetables together as a serving, approaches like that because to get up to 30 servings --
DR. MURPHY: And -- and of course, I don't think the Japanese guideline is 30 servings. It just says eat 30 --
DR. DECKELBAUM: Thirty foods.
DR. MURPHY: -- foods. But -- but you raise an interesting point and one that occurred to me also, that are we encouraging over-consumption in some subtle way with this guideline. And, again, I think consumer perception would -- would be interesting to know. Yes.
DR. JOHNSON: I think Richard has raised a really important point though that we should think about which is portion size and the American public's perception of a normal portion size. After spending a year in Europe, I mean, there is just no comparison with what an American considers a portion size of a muffin or a soda or -- with what many other countries in the world I think consider portion size. I do think that is an area of concern that we need to think about.
DR. STAMPFER: Could you just give your opinion as to whether you think the -- there is any value in promoting variety beyond just promoting more fruits and vegetables? Sort of pursuant to your third point, is -- is there a value in variety beyond that for the American diet?
DR. MURPHY: I think the fruit and vegetable concept is a key one because the food guide pyramid is somewhat vague on promoting specific fruits and vegetables. And I think previous committees believed that the variety sort of encompassed the idea that when we say, "Eat five a day of fruits and vegetables", we really don't want people to eat five servings of potatoes and apples every day, day after day after day.
And so if we want people to eat dark green vegetables and yellow and orange vegetables and so forth, maybe the variety concept will push people in that direction.
So, yes, it is important for fruits and vegetables. I would argue that it's probably important for grains, as well, because that is the driving force toward whole grains at this point. As the Dietary Guidelines stand, we don't really have a big focus on whole grains. And so variety you would hope at least includes for most people a mix of refined and less refined grains.
Those are probably in my opinion the two major things that variety addresses.
DR. GARZA: We should ask the staff to look at or researchable topics that could be accomplished -- tasks rather that could be accomplished within the framework that I outlined that would help us evaluate various questions that have come up and questions that you have raised.
DR. MURPHY: Yes. I think there are -- and thank you for giving me an opportunity to state my opinion on this. Because the Healthy Eating Index has been developed for the national surveys, particularly the CSFII, we do indeed have a variety score, if you will, that's now associated with each person that participated in the CSFII.
And Shanthy and I talked a little bit about the possibility, because she was very involved in some of the analyses with the HEI, of looking at how variety per se, that component of the Healthy Eating Index is related, for example, to nutrient intake. And I think that might get at some of the other questions that have come up.
If you control for fruit and vegetable intake, is there an additional effect of variety? If you control for eating the number of servings specified by the food guide pyramid, does that component of the Healthy Eating Index actually contribute any more?
To my knowledge, that has not been done. And I would be very interested in seeing it done.
DR. GARZA: Do you think it is doable within the framework that we're now --
DR. MURPHY: I do. I do.
DR. LICHTENSTEIN: I think with respect to variety, it should even -- the consideration should even be extended beyond the grains and the fruits and vegetables because you can even think within the meat and legume group that you've got, fish with the omega-3 fatty acids as opposed to somebody that's consuming beef all the time.
And if you go into the dairy group, then you've got milk that's contributing D whereas the other dairy products are contributing other good things, but not that. So I think it probably needs to be considered for each group.
And I also think there is some work from out of the Netherlands suggesting that individuals that consume -- and this goes back to the energy issue that individuals that consume a wide -- a very wide variety and a lot of foods versus few foods do end up with a higher energy intake which, again, goes back to defining what variety means with respect to serving sizes versus just numbers of foods; you know, the arbitrary thirty.
DR. MURPHY: Yes. I think that's a good point; that the analyses one would do should control for energy intake because obviously people that eat more food generally tend to eat a greater variety of foods. Good point.
DR. GARZA: Thank you very much. Well, we're going to move on then to the second guideline. And I don't think there are -- there is a public health concern that is greater -- there are certainly others -- than -- than the one of an increase in the obese population within the U.S. And to help us through this guideline is Dr. Weinsier.
DR. WEINSIER: (Slide.) The issues that I've tried to raise for this brief period of discussion are the following. There has been a lot of information that has come out of the past several years in the area of energy metabolism and obesity. So I can't cover it all.
But some that I think we need to look at as background, the weight gain trend, body weight mortality rates. These are fairly well given. But then the roles of metabolism are genes, diet and physical activity on the weight gain trend is a very, very important area.
And that -- regarding that issue, I refer back to the current dietary guidelines, the statement that as people lose weight, the body becomes more efficient at using energy. I don't know exactly what was intended there, but the implication that metabolism plays a role in the rising prevalence of obesity needs to be considered carefully: Are we in fact more efficient after we lose weight such that post-obese, normal weight people are predisposed to obesity?
The second category, designation of overweight and obesity. Should we consider use of the BMI, the Body Mass Index? Should we consider use of the weight circumference? Currently, the guidelines refer to waist/hip ratio and in a nonobjective or non-quantitative way state, "Look at this waist/hip ratio to see if your abdomen is larger than your hip circumference."
And finally, weight loss approach and goals, what weight loss approach should be taken and what should be our goals. Currently, there is a statement in our guidelines under Dietary Guidelines to "reduce caloric intake, eat less fat and control portion sizes." I think we need to consider this as an issue to reconsider whether we want to focus primarily on fat and portion size.
And finally, exercise goal. As Dr. McGinnis said, exercise is inherent in this whole issue and can't really be separated. So back up real quick.
(Slide.)
Under "Background: Weight Gain Trend", this goes pretty much without saying that if we look in the red category -- I don't have a pointer here. But this is -- in the early 1990s, we see that there has been a marked rise in both men on the left, women on the right and the prevalence of overweight and obesity as defined by Body Mass Index.
(Slide.)
So it's pretty well established that something has been happening since the late '70s to the early '90s, that there has been a fairly dramatic, approximately a 31 percent increase in the prevalence of obesity in men and women.
(Slide.)
Is it associated with increased risk? I think most people would agree that there is increased risk of all causes of mortality related to Body Mass Index as shown here in studies by Joanne Manson, reported in New England Journal of Medicine, '95, that if we look at relative risk, it is a fairly steady rise throughout the spectrum, low BMI down to 19, although we have the BMI as being greater than 32.
(Slide.)
But perhaps a more controversial issue is that third category I put: "What is the role of metabolism, genetics and the etiology of the weight gain over time?" This study gives us a chance to look at post-obese individuals. These are individuals who are studied when their Body Mass Index was high and studied again after they were reduced to a normal Body Mass Index and normal body weight, and then pair-matched with never obese control subjects.
Those in red have a positive family history as well as a personal history of obesity. Those in yellow had no family history of obesity and no personal history of obesity.
And then we tracked them over four years with no guidelines in terms of diet exercise. And as you could have predicted yourself, the predisposed or obesity-prone individuals have pretty much as a group put back all of their weight whereas the never obese controls after four years stayed never obese.
None of these individuals in the yellow category rose to the obese category. A few in the post-obese, obesity prone category stayed normal weight. But on average, the weight difference was approximately nine to ten kilograms in between these two groups at the end of four years.
Metabolically, what's going on here that might predispose them to this weight gain? As suggested in the Dietary Guidelines as I read them and at some scientific presentations, people have suggested that there is something in our genes or inherent abnormalities in our metabolism that predispose this group.
And in fact, if we go back and look at the metabolic rates of these two groups which we see here, resting energy expenditure numerically is identical between the groups. Even adjusting for slight differences in body composition, fat and fat-free mass, they are still essentially the same. Thermal cofactor food as a percent of caloric intake, 8.8, 9.8, these are not significantly different between the two groups nor is fuel utilization, is fat oxidation or carbohydrate oxidation notably different between the two groups.
In addition, if we look a correlation between metabolic predictors of the four-year weight gain, there is no significant correlation in any of these categories of energy expenditure at rest, after eating a meal or fuel utilization in terms of prediction of the amount of weight gain.
(Slide.)
There have been six studies to my knowledge in reviewing the literature that have looked at alterations in energy metabolism as predictors of weight gain prospectively. Two of those were in children and four in adults. Basically, what I want to point out here because I can't review all this literature is that they looked at resting energy expenditure in five of those studies. And four of the five found no predictive relationship between resting energy expenditure and weight gain over time.
One, the Ravussin study and Pima Indians was suggested, but only accounted for -- low resting energy expenditure only accounted for about a third of the 13 kilogram weight gain over a period of about two years of follow-up. So this is questionable.
None of the studies looked at activity-related energy expenditure. Thermic effect of food was looked at in two. Neither was found to be predictive.
Total energy expenditure -- total 24-hour energy expenditure was predictive in two cases and not in two other cases. The fact that two were predictive in terms of total energy expenditure whereas resting does not tend to be predictive suggests that maybe there is something in the activity category that may be predisposing, i.e., less activity-related energy expenditure may predispose to weight gain. So let's just keep that in the back of our minds.
Now, in terms of diet, this solid line shows the increasing prevalence of overweight and obesity since the late '70s to the early '90s. I have shown in the dashed line the increased frequency of use of low calorie products. These are low sugar, low fat, but overall low calorie products as a percentage of the population.
So we've risen about four-fold -- slightly over four-fold increased frequency within the U.S. of use of these low calorie products. So we're using more of the products that we're trying to encourage people to use, but frequency of obesity is still rising.
(Slide.)
If we looked at the prevalence of overweight -- I already showed this -- it's increased about 32 percent in both women and men. Average Body Mass Index has increased about five and three percent in those groups respectively.
But if we look at data that are useful for reference, population-wide, survey trends state in terms of fat intake -- this is slightly out of focus, but I can't adjust it here -- average fat intake as percent of total calories, it seems to have fallen if we use USDA nationwide consumption -- food consumption survey data.
So if, in fact, fat intake has gone down and, in fact, as the data suggests, total calorie intake has gone down but certainly not up, then how do we explain the rising prevalence of obesity? Now, my first reaction is don't believe the data -- don't believe these data.
But in fact, if we look at data in Great Britain, they show the same thing: Average energy intake has gone down; prevalence of obesity has gone up. If we look at prospective studies in children in France, same picture: Average energy intake has not gone up; prevalence of obesity has gone up. If we look at data in children in the Bogaloosa study in Louisiana, same picture: Energy intake prospectively, ten year period of time, is going down; prevalence of obesity is going up.
All of the major prospective studies seem to give the same picture. We seem to be doing the right thing from a dietary standpoint, yet we're getting fatter. What are we missing here?
(Slide.)
And that brings me to the other point, the possibility that physical activity may play a role. And in fact, if we look at weight rebound, individuals -- remember, we saw the post-obese normal weight individuals compared to the never obese controls. And we followed them four years. What predicts weight gain? Regular physical activity by self-report suggests a much lower rate of weight gain compared to those who are physically inactive.
A very large study of 12,000 individuals in Finland shows the same picture, that people who are more physically active gain less weight over time. It's more predictive and more consistently predictive of weight gain than energy intake.
(Slide.)
So in concluding on those four points, the role of genetics, recent trend toward increase in obesity prevalence cannot be due to changes in our genetic makeup. Mostly likely, it reflects the influence in environmental changes on our gene expression. Simply put, our genes permit; but the environment determines if we become overweight or obese.
(Slide.)
Regarding abnormalities in energy metabolism, normal variations in energy requirements may influence our tendency toward weight gain. It is unlikely, however, in my view on reviewing the literature that significant variations exist in energy metabolism which by themselves explain the onset of obesity and the rising prevalence over the past few decades.
(Slide.)
Third, with regard to diet, the trend toward decreasing fat and calorie intake in Westernized countries has not prevented the rise in obesity prevalence. It is unlikely that diet is the sole or primary factor accounting for the rising prevalence of obesity if these data are correct.
That's not to say that diet is not important and I'm not trying to say that. We could argue that if we were not as adherent to some of these dietary changes, the prevalence of obesity would have risen much faster.
(Slide.)
With regard to physical activity, reduced total daily -- not just exercise and recreation -- but reduced total daily physical activity may well be the most important current factor contributing to weight gain in Western populations. We don't have the direct data to confirm this. This is more by deduction.
(Slide.)
Then we skip to the second category of things I wanted to mention briefly. BMI as an index of obesity, should we consider it for the guidelines? These data are taken from the NHLBI Clinical Guidelines Report that just came out a few months ago. And they classified normal weight as 18.5 to 24.9 Body Mass Index. Overweight is 25 to 29.9. And obesity is 30 or above.
(Slide.)
The use of BMI makes sense. Body Mass Index correlates very well with adipose tissue. There is some variation for any one individual, sure. But population-wide, there is a nice correlation, 0.96.
(Slide.)
In addition, should we consider weight circumference? According to the NHLBI guidelines and a substantial body of evidence, weight circumference separate of the waist/hip ratio, waist circumference is independently predictive of disease risk such as diabetes, dyslipidemia, even cancer. The guidelines recommended men 40 inches, women 35 inches.
(Slide.)
And then if we take those same set of guidelines, the NHLBI guidelines and look at disease risk, what they've shown -- and the only point I want to make here is you see the relative number of arrows pointing up in terms of disease risk of diabetes, hypertension, cardiovascular disease -- that it rises not only as body mass index rises -- my pointer is slowly dying -- but also at least in the moderate degrees of overweight and obese category, there is a separate effect of weight circumference.
So if you have moderate degrees of overweight obesity plus you have increased weight circumference, you have increased your risk. We may want to consider guidelines such as these.
In terms of treatment -- now I'll bring us down to the bottom category of my initial overview. The treatment algorithm recommended by the NHLBI: 1) Assess risk factors if the person is overweight or if they have increased waist circumference. Then initiate treatment if: 1) they are overweight and have two risks; overweight defined as BMI of 18.5 to 20 -- to 25. Increased waist circumference and two risk factors, consider treatment. Or if they fall in the obese category; i.e., a BMI of greater than 30.
Consider pharmacotherapy as an adjunct only if the BMI is greater or equal to 30 without risk factors or disease. Consider if the BMI is great or equal to 27 with risk factors or disease.
(Slide.)
Now, one other aspect of treatment, certainly as it relates to diet, that I think is an important issue and to consider, and I relate it here, the comment in our current guidelines to reduce caloric intake, eat less fat and control portion sizes.
This particular study has in my mind resolved a major issue that has raised -- that was raised about 20 years ago in terms of what is the major content or aspect of the diet that predisposes certain individuals to overeat in calories.
The objective of this study that was just reported this year was to examine the effect of energy density of meals, i.e., the caloric content of meals, independent of fat content on an ad lib caloric intake. these women, 18 normal weight women, were encouraged and allowed to eat as much food as they wanted over the course of two days, a very short-term study. They were given free access to diets that were either high, medium or low in energy -- energy density, but similar in fat content over the two-day period.
Graphically what we see in terms of the weight that they consumed, i.e., how much food did they consume over the two days, the cumulative intake and food intake into three categories of low, medium and high energy density was essentially identical.
In other words, they ate to a feeling of fullness not knowing what the calorie content of the food was, whether it was fat, sugar or otherwise. But look at the same graph in terms of energy intake and replace weight of food consumed with the number of calories consumed.
So now we have energy consumed over the two days. Now you start to see the differentiation where at the highest intake, the dashed line is high energy dense meals. The dotted line are the low energy dense meals.
Individuals were equally content in terms of their degree of fullness and palatability ratings of all three categories of foods. They could not tell which were high and low fat foods, but they ate considerably different caloric intakes such that the conclusion from this study and supports a number of other previous studies is that subjects consumed similar amounts of food, but more calories on high, medium versus low energy dense meals.
And look at the difference: 1,800 on the high energy dense versus 1,376 kilocalories per day. So what's that a difference of, 424 calories per day difference without even trying. Without even thinking about the calorie content of the food or trying to restrict intake, they had comparable feelings of fullness.
The implications: Energy intake is determined by weight of food consumed rather than palatability of fat content; hence, excessive energy intake and weight gain is more likely with high energy dense, i.e., high calorie meals.
(Slide.)
And the last two slides which should be our weight loss goals. I'm not prepared to say. I'm going to step in some soft sand here and maybe even quicksand because I don't really think there is solid data to tell us what we should say. We need to think about it.
The current concept, and as reported in our guidelines here, is to aim for a loss of five to ten percent of your initial body weight. So if we're overweight or obese, aim for a five to ten percent loss. I don't know if there is solid foundation for this recommendation. I'm not convinced there is.
The weight control registry which looked at 784 individuals who maintained at least a 30-pound weight loss for one year has recently reported -- this just came out last year -- that their average loss was 30 percent of initial body weight. I don't know what their goal was, but it raised the question in my mind, people who do well, this registry, are all people who did well and survived at a consistently low body weight after losing weight, they probably set their weight loss goals much higher.
Some recent data from Tom Wadden suggests that most individuals entering weight loss programs will not be satisfied with a goal of five to ten percent. It's probably closer to three times the ten percent.
(Slide.)
With regard to physical activity goal -- this is my last slide -- current concept, American College of Sports Medicine recommends exercise goal of at least 1,000 kilocalories per week. This is a modest increase in physical activity-related energy expenditure.
The Weight Control Registry, their average -- their average activity expenditure was 2,825 kilocalories per week. This is in contrast to a goal of at least 1,000. So there are 2.8 times that. Seventy-two percent of the 784 individuals exceeded the above goal. It raised the question in my mind, are we being aggressive enough or are we simply setting guidelines that we hope will be more appealing to people who have not been successful.
(Slide.)
So those are my concluding -- my concluding points would be three: 1) In terms of predisposing factors, inherent metabolic and genetic factors are probably not in my view major contributors to weight gain, certainly the recent trend. Diet obviously plays a role, but I think physical inactivity is especially important and needs close examination.
Secondly, appropriate indices of the relationship of weight and health. We might want to consider the body mass index and instead of waist/hip ratio, consider waist circumference.
Third and last, in terms of the approach to prevention and treatment over overweight and obesity, let's consider the caloric content of food. Rather than focusing on a calorie level, think in terms of focusing if the diet is basically composed of low energy dense foods, fruits, vegetables, whole grains, it is probably going to be a lower caloric intake.
Finally, consider and reconsider our goals of five to ten percent weight loss and the level of physical activity. Thanks.
DR. GARZA: Questions?
DR. JOHNSON: I would like to address the issue of when you were talking about I think it was national survey data, looking at reductions in energy and fat. And there are certainly people in the audience that more intimately know the recent USDA CSFII survey than myself.
But my understanding from that survey -- and some of it may be due to improved interviewing techniques which are hopefully helping to alleviate our nagging problem of under reporting. But they do show increased energy intakes in most age and gender groups, and slightly increased total fat intake.
But it -- the outcome of that is a reduction in percent calories from total fat. So the sort of broadly publicized idea that Americans have lowered their fat content is not really true. As a percentage of total calories, yes. But it is because total energy intake has increased. Am I correct about that more or less?
DR. LICHTENSTEIN: Yes.
DR. JOHNSON: Okay.
DR. WEINSIER: Yes, there are a number of data sets. And I think we need to -- if we want to deal with this issue at all, we need to consider it very carefully. And there are others who are more expert in this than I.
However, the national -- the nationwide food consumption survey data have had the advantage, as you are aware, of the bridging study, 1988, allowing for a -- some level of continuity and consistency in the method of comparing which the NHANES, for example, did not have. So that we can look at the 1978 data versus the patterns in the late '80s and the early '90s.
So we have to look very carefully and be aware that all of these are by self-report. All of these have shortcomings. But there does appear to be consistency across population groups, i.e., some within the country, France and Great Britain. So I think we have to keep our level of suspicion high, although I don't know what the bottom line answer really is.
DR. DWYER: Thank you, Roland. I really enjoyed that presentation. I'm all for the BMI and waist circumference. I think those are both useful.
On the caloric density study of Pell, that is certainly interesting, too. The great question, of course, is in the conclusion whether on a two-day experiment, one can -- can say that the regulation of food intake is going to be regulated on bulk. I mean, that's a really old idea as you well know.
But the idea that there may be misses in -- in judgement, particularly -- or in sort of the regulation depending on caloric density I think is valid. And of course, alcohol would be another one that might go into that next because it's a high caloric density thing. And they are just difficult to regulate.
The weight loss, I thought -- at least some other materials I've read suggest not that five to ten percent be the final goal, but that five to ten percent be a -- an actionable beginning goal in a process that might, in fact, lead to much lower losses.
DR. WEINSIER: Well, you've made a lot of statements. And I have to agree with everything you've said, particularly about the energy density studies. Two days, this is clearly short-term. They are in support of longer term studies, but none of them go for very -- very long.
I would argue, without having the data, that if you kept a person on the lower caloric intake such as that they -- such that they were losing weight with a high bulk of food, low energy content -- low energy density, with time they would increase the volume of food and try to overcome that. There are probably other mechanisms that are going to kick in over the long term.
DR. DWYER: Yes.
DR. WEINSIER: But the reason I'm in support of these data of Barbara Rolls and Pell is that most of us eat on a short-term basis. In other words, we're eating from one meal to another. And our degree of satiety is based upon the nutrient content of that meal, the caloric content, the volume of food, all of the factors at that one meal, and partly predisposed by the meal that was shortly before that rather than weeks ago. In other words, most of us don't remain hypocaloric for extended periods of time.
So it is short-term data. But these are the best we've got. I think all the data, however, have been consistent in suggesting energy density probably plays an important role in short-term nutrient -- caloric intake. So I think that's as far as we can go.
Lastly, in terms of the five to ten percent, yes, you are absolutely right. The general idea was -- I'm trying to find the wording here -- that this be the initial step. And I think perspective has been lost on what this five to ten percent goal really means.
"The way it is stated here is weight loss of only five to ten percent of body weight may improve many of the problems associated with overweight." That's the way it's intended. Unfortunately, I think a lot of people think that -- the patients think in my experience that losing five to ten percent will take care of the problem.
DR. GARZA: Let me bring you some perspective, at least from the -- Shiriki can help me. One of the livelier discussions at the last Committee meeting was around this issue.
And what was driving it was the idea that the recidivism rate was so high in terms of weight -- permanent weight loss that it was going to be much important for us to focus on maintaining your weight than trying to get people to lose weight because it was such a losing proposition. Would you care to comment on that?
UNIDENTIFIED VOICE: No pun intended.
DR. WEINSIER: No, that's right. No, that's -- that I think is the underlying philosophy between this five to ten percent and more recently, now, the suggestion that just maintain your weight; don't put weight back on. That makes sense. If you have a choice of gaining weight versus keeping where you are, fine. What is the weight loss goal, however? Is it to maintain the overweight?
So I think we just need to be clear in the wording and to set realistic, but at the same, goals that are important from a health standpoint. That's why I said I think we are in quicksand here. I don't feel so strongly about this, but I feel -- in terms of what the absolute number is. But I think we have to make sure that we're sending a clear message from a health standpoint.
DR. GARZA: But you feel there are new data that would suggest that, in fact, encouraging weight loss as opposed to marshalling most of our efforts towards the prevention of weight gain or the -- just not worrying about weight loss because, in fact, it's just not going to be healthy people who will go into a yo-yo period of weight loss and weight gain, and that, in fact, our efforts have just been misdirected.
So over the long term, it is best if we can get people to control their present weight; just keep it there without gaining is the point I was getting at --
DR. WEINSIER: Well --
DR. GARZA: -- or is it -- is the database essentially the same as it was five years ago on that issue?
DR. WEINSIER: Well, we're not going to be able to resolve this in the next one minute that we have left for this. But --
DR. GARZA: Well, is there -- is there data at all? I'm not asking for it to be resolved.
DR. WEINSIER: Not solid data. There are not going to be solid data. But I think this weight control registry is going to make us think because these are individuals who -- and approximately 50 percent initiated a weight loss program that was on their own. The other 50 percent roughly went through some sort of professional program. They set their sights high and achieved a very significant amount of weight loss and maintained it.
You are talking about a very small proportion of the overall population. The point is if the goals are not out there, if people are not challenged, we may not even get the tip of the iceberg in terms of some people who would be successful whether in professional programs or in self-imposed programs. And we may have to accept the fact that