UNITED STATES
DEPARTMENT OF AGRICULTURE

 

 

 

IN RE:
DIETARY GUIDELINES
ADVISORY COMMITTEE MEETING

 

Pages: 517 through 649
Place: Washington, DC
Date: March 10, 1999.

 

HERITAGE REPORTING CORPORATION
Official Reporters

1220 L Street N.W., Suite 600
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IN THE MATTER OF:
DIETARY GUIDELINES
ADVISORY COMMITTEE MEETING
Wednesday, March 10, 1999
Waugh Auditorium
1800 M Street N.W.
Washington, DC


The proceeding in the above-entitled matter was reconvened, pursuant to Notice, at 9:06 a.m.

BEFORE: CUTBERTO GARZA
Chairman



P R O C E E D I N G S

(9:06 a.m.)

CHAIRMAN GARZA: We want to congratulate all the committee members on getting in here. With no cabs, that's a real testament to everyone's commitment, to say nothing of all of you who have come to join the committee. That's a real testament of your commitment as well, although I understand from Shanthy that the roads in Washington, D.C. are deserted. Another way one can stop government. Two inches of snow. Unfortunately, it serves to reconfirm the prejudices that many of us have about government.

All right, we're going to try and work today through lunch again because there are several that would like to be able to make 2:00, or get to the airport around 2:00, so that if we can do this officially, we'll try to do it. Probably make a decision somewhere around 10, so we don't get quite a frantic about trying to get lunch brought in and perhaps we could arrange for our conference room to have lunch quickly, so that we are not always in the same room throughout the whole period. People got cabin fever yesterday, I think, with a marathon. But that's the general schedule.

What I'd like to be able to accomplish before getting to the working group reports is have a general discussion for about 15 - 20 minutes, leading with how you feel based on the exchanges we had in the last two days, we ought to be configuring the guidelines, regardless of the number we come up with, whether you feel there are major changes to the general configuration. We've had several groups that testified on Monday suggests that in fact we ought to consider some type of tier system to make it easier for consumers to be able to assimilate the information that we give them.

Others, however, I think the American Dietetic Association in particularly, testified that in fact they feel that all the guidelines should be given equivalent weight, and that a tier system, if I'm remembering comments correctly, is not something that they would recommend or that organization would recommend.

We talked -- the various working groups discussed other alternatives, somewhat perhaps with tongue in cheek, should we separate do's from the don'ts, and how some sort of balanced approach, a balanced picture that says this is what you're supposed to do, this is what you're not supposed to do as a way of organizing them in a system that would make them easier to assimilate.

So let's begin there because I think it may help then with the remainder of the discussions, and I don't think we need to necessarily come up with a way, but if we can narrow it down to two or three, certainly no more than three, approaches, then as we begin writing and Carol Suitor begins to put this information together, then she can take -- we can prioritized them, begin to look at some alternate ways of piecing the various working group outputs in a way that is consistent with that prioritization that we come up with.

So are there -- is there any comments about keeping them the way they are, some sort of tier group?

One suggestion, for example, in keeping -- in the tier group is that we ought to put -- I forget who suggested this to me -- salt, sugar, alcohol, and there is a fourth one. Sugar, salt, alcohol.

DR. JOHNSON: Weight. 

CHAIRMAN GARZA: No, it wasn't the weight one. Sodium, in a second. 

VOICES: Sodium is salt.

(Laughter.)

CHAIRMAN GARZA: I thought there were four. Well, maybe there are three. Anyway, put those three in a -- no, no, fat people wanted -- is the people that I spoke with, thought that it would be best to try to put it in the top tier because you could integrate it much more easily with a high fruit, vegetable, grain diet. But that was one approach that was discussed. 

DR. JOHNSON: I also like the idea of having the concept of adequacy, variety or whatever we settle on, and safety as sort of the over-arching theme. You know, that your diet has to be adequate and safe is sort of the first priority, and then we had talked about that. 

CHAIRMAN GARZA: So something along the lines that Suzanne presented, Rachel. In her initial presentation, she had a pyramid, for example, linking the other six guidelines, having two icons linking the other whatever number we come up with -- 

DR. JOHNSON: Um-hmm. 

CHAIRMAN GARZA: -- safety and adequacy, then bringing it all together? Okay.

Johanna and them Meir.

DR. DWYER: I think that the adequacy goes well with something in the text about food security, but that the two concepts are different and that they should be separated into separate guidelines. 

CHAIRMAN GARZA: Adequacy? 

DR. DWYER: Adequacy. 

CHAIRMAN GARZA: Food security? Are you suggesting then another guideline on food security? 

DR. DWYER: No, I'm suggesting one on adequacy that mentions food security. 

CHAIRMAN GARZA: Food security, okay. 

DR. DWYER: And then another one that's on food safety -- 

CHAIRMAN GARZA: Yeah. 

DR. DWYER: -- because they are separate concepts. 

CHAIRMAN GARZA: No, I didn't know whether you meant security, adequacy and safety. That's why I wanted to clarify that.

Meir.

DR. STAMPFER: I think that tier, if we call it that, tiered approach is a good one or somehow some kind of grouping because clearly the health effects of these guidelines differ, and, in particular, the sodium guideline is pretty much geared toward more on risk factor, blood pressure. The sugar guidelines is geared mainly as the displacement of nutrient, other nutrients issue. And the alcohol guideline is more just information rather than recommendation of any sort, except the recommendation not to drink for those who fit into that category. So I think those could be grouped as a secondary kind of other, and maybe not even have their own headlines. 

CHAIRMAN GARZA: You know, that's interesting because we're moving now to a more of a Meso-American pyramid than an Egyptian one. I think they were tiered in Meso-America rather than straight. 

DR. WEINSIER: John, I want to endorse the concept of the tiered approach because I think that the guidelines are all important, but not initially equally important. I think we've identified several guidelines, the ones that relate to plenty of grains, plenty of fruits and vegetables, in the context of a reduced saturated fat, cholesterol intake, and diets appropriate for weight control as more important, highly important, and then we've got other guidelines, as Meir is pointing out, that are still, you know, worthy of note but without giving some feeling to the person who's glancing at this, you know, what do I need to look at, what do I need to take from here. If I forget something, I don't want to forget this. So I like the tiered approach. 

CHAIRMAN GARZA: Okay, I'm getting a consensus that you'd like Carol, as she begins to put this together, to see how we could work with that tier approach, and we will then be able to look at the outcome of that when we meet again in June.

Is that -- so we're not asking you to make a final decision, but at least as a first priority in organizing the information we'll try to do it along these lines. And as she interacts with the various working groups, then we may have various guidelines moving in that tier, among tiers, but that, I think, we can -- we can withstand that sort of wobble for the moment as feedback comes in.

All right, then, let's move on then to the second item before we get into the working group reports, and that is having a sense from each of you when you are definitely going to be unavailable between now and June because Carol will be beginning to write from the information that you've presented her, and begin to put pen to paper, identifying those parts of our report where the information we've supplied is sufficient and one can work those headings out pretty well, identifying other places where there are definite gaps, but begin to focus each of our attention, obviously, on where those gaps are as quickly as possible, and giving you something that you can react to as the final author of this report.

Meir?

DR. STAMPFER: Can you be a little bit more specific about how you see that process going? Are we supposed to come up with something for Carol -- 

CHAIRMAN GARZA: No, no. 

DR. STAMPFER: -- from the subgroups, or she initiates it? What's the process? 

CHAIRMAN GARZA: She will initiate it. For some of the subgroups, we'll need more information. For example, on the sodium one, it's definitely there that we need some additional information to be able to get to that stage. On the other hand, if we decide to go with a guideline on food safety, there is enough information there that in fact all Carol has to do is rearrange it in the format that the green report presently is in, identify where there may be gaps, get back to that group, or if she has questions in organizing the information, getting that group to answer those questions.

Perhaps, Carol, can you --

DR. SUITOR: I think that summarizes it quite well. The food safety is probably the easiest one to start with if it's decided that that's going to be one. And there are others that are -- where your background information has really laid things out pretty much the way you want them, and I can work more efficiently if I initiate as opposed to waiting for you to get me something additional, and I think you'll be able to see better where you really want to change things and I haven't been able to catch the idea you're trying to get across and where you've been expressing yourselves very clearly. 

CHAIRMAN GARZA: Then we'll have the transcripts of the meeting in about two weeks, and so Carol will be able to refer to those transcripts of various presentations. And if it's clear that issues came up which have not been dealt with in the write-ups you've provided, then that gives her then another source of being able to get back to you to answer questions that remain unclear.

So with that in mind then, that you'll be sent information that you'll be expected to respond to quickly, and that's the operative word is quickly, because otherwise we become such bottle necks in the process that it makes Carol getting information back to us for the June meeting impossible.

And so I'd like to ask each of you to send your written schedule to Carol and Shanthy so that we'll know those blocks of time where it's going to be impossible to reach, assuming that the remainder of the time, given the way we've structured this and having Carol do a lot of the yeoman's work of putting this together for the group, that in fact you'll be able to respond within 48 hours to questions she might have, realizing that when you get a draft to look at, you know, we may be able to go 96 hours, is that fair, in getting back to you, you know, but not three weeks because then it really -- it really makes the process impossible because she will be trying to coordinate comments that she will be getting first from the specific working groups, but then also from perhaps more than one working group if it's clear that there is some overlap between information that she's dealing with.

DR. SUITOR: Or contradictions. 

CHAIRMAN GARZA: Or contradictions, that's right. 

DR. SUITOR: If people have their schedules with them and want to tell us before you leave today. 

CHAIRMAN GARZA: Well, that was the other thing -- 

DR. SUITOR: I've got a sheet. 

CHAIRMAN GARZA: We're going to pass this sheet, but I still would like -- you know, in addition to what you tell us today, that's the compulsive part of my nature, when you get back, you know, look at your schedules, compare what you've told us, and get back to Carol so that we will have at least two sources of information from you to extract cooperation that you told us you were going to be -- Dr. Stampfer is laughing.

All right, as each of you are looking at your schedules, and assuming that you're multi-task individuals, the third thing is that in discussions with the weight maintenance group, and they'll be reporting a little later today, there is some serious consideration begin given within that group to asking the committee to consider splitting the guideline on weight maintenance and physical activity.

The rational for that being, as I understand it, is because physical activity is so much more important than just weight maintenance, issues like being able to meet your micro nutrient needs because you have a sufficiently high calorie level is an important dietary issue. But then so are issues that we're dealing with in terms of cardiovascular disease and diet and physical activity, and then physical activity and cancer, et cetera.

DR. DWYER: I was just going to say cancer -- 

CHAIRMAN GARZA: So there are a number of things that speak to considering at least having that as a separate guideline. If we do that, then we need to expand that working group so that they can work on both guidelines since we do expect for them to be some relationship between the two and they can be a maximally compatible, if we decide to go in that direction, at least this first go-around.

So before that gourd gets to make its report, begin to think you feel we ought to be contacting as consultants so that after the report you would have given us some thought rather than asking everybody to respond with a 30 second or a minute warning.

Now, those are the three, so let's -- I don't know whether there is any reason why we'd want to have a public discussion of availability other than to try to work out real conflicts of schedules. And if we can do it quickly, it might be helpful just to see if there are blocks of time when people will be unavailable for a two-week period; I mean, where it's going to be impossible for us to get to you because you either have a grant that's due, your secretary is going to be on vacation, your significant other is leaving you with all the kids. Having gone to that experience, that is not trivial, a trivial happening. I have great respect for single parents having gone through that for only short periods of my life.

Okay, so why don't we begin with Richard. Any periods that you're just not going to be around before our June meeting, and the June dates are 14, 15, and 16.

VOICES; No, 16, 17 and 18.

CHAIRMAN GARZA: That's right. 

MS. BOWMAN: Wednesday, Thursday, Friday. 

CHAIRMAN GARZA: Wednesday, Thursday, Friday, the 16th, 17th and 18th. Okay.

Richard.

DR. DECKELBAUM: Do you want dates when I'll be away one week or more? 

CHAIRMAN GARZA: For one week or more? 

DR. DECKELBAUM: March 23rd to April 9th, I'll be in the Far East. 

CHAIRMAN GARZA: Now, with the -- are others in Richard's work groups going to be away the same time? 

VOICE: Away meaning on e-mail? 

CHAIRMAN GARZA: No e-mail, that's right. That's the definition of "away" these days.

All right, so there is no real conflicts then with working groups.

DR. DECKELBAUM: I'll definitely not be there. 

CHAIRMAN GARZA: Exactly, but others in your working group will be available, so that's good.

Okay, Rachel?

DR. JOHNSON: I'm always on e-mail. 

CHAIRMAN GARZA: Wow. 

DR. JOHNSON: While I'm away. 

CHAIRMAN GARZA: All right, go ahead. 

DR. JOHNSON: But not for large chunks. 

CHAIRMAN GARZA: Roland? 

DR. WEINSIER: Well, again with e-mail, it's not a real concern. In terms of availability through April 8th, with NIDD case section reviews, it's going to be very difficult, and then we have the ASCN meeting and I have a large part in the planning this year, and that's around also April 17 through Tuesday the 20th. That's a major constraint. 

CHAIRMAN GARZA: Are there dates then from the working groups that Roland is in, other members of those working groups those dates are going to be a problem where all of you are going to be unavailable?

Okay, good.

Shiriki?

DR. KUMANYIKA: I don't see any major extended periods when I'll be unavailable. 

CHAIRMAN GARZA: Okay. Now, I should also say that as we go through this I'm assuming that everyone has agreed to sort of the response time that we've outlined.

Dr. Dwyer.

DR. DWYER: Yes. 

CHAIRMAN GARZA: Okay, good. 

DR. STAMPFER: Just a few days at a time, not for a whole week or so. So I can obviously agree to a four-day deadline, I think, written down. 

DR. LICHTENSTEIN: Same situation. 

DR. GRUNDY: Just the end of this month and from the end of May for about an eight week time. 

CHAIRMAN GARZA: Okay, so the end of March the end of May. Are there working groups that Scott shares where those dates are going to be a problem?

I've not heard any because the only other real extended time would be Richard, and I don't think those dates coincide with when you're going to be away.

DR. DECKELBAUM: One of them does, the last week in March. 

CHAIRMAN GARZA: Okay. All right, maybe that would be the only -- the only time we'd have two people away.

Okay, great. Then why don't we begin then with the working group, and I've got to get my agenda.

Eat a variety of foods, you could do it from your places or using the lectern, whatever you feel is most appropriate.

DR. MURPHY: All right, our working group has been looking at the variety guideline and trying to reincarnate it as an adequacy guideline, and after some discussion among yourselves and with some of our colleagues, it looks like we'd still like to try to link the adequacy to the food guide pyramid because that is indeed the primary federal vehicle for offering guidance to the public.

But that, of course, raises some issues of circularity because the pyramid is based on the guidelines and the guidelines won't be set until this committee has completed its work. And then if we want the pyramid to be part of the guidelines, how mechanically or logistically can that be worked out.

So what we have are several issues that need to be explored over the next few weeks with a variety of people and resources that we'd like to take advantage of.

For example, what would be the possibility of integrating the current food guide pyramid into the dietary guidelines as they come out initially, and then at a later time change the food guide pyramid, if it is changed, if USDA finds a need to change it based on the new DRIs or the new guideline? What would be the mechanical process that would need to be followed to update the pyramid which now would be already be in the dietary guidelines booklet?

So the federal people have agreed to work with us to try to come up with some approach that would be feasible, and I think one option being discussed, for example, is perhaps, if necessary, the booklet would be reprinted if there was a change, a significant change in the pyramid itself.

So we're trying to work through some of these issues so that there is an integrated approach to nutritional adequacy that is communicated to policy people as well as the public that integrates both the guidelines and the pyramid, and I personally am a big believer in trying to make our guidance look like it all came from the same intellectual body of knowledge, so it would be nice if we could do that, and we certainly intend to pursue it.

A couple of other things we also would like to investigate further. We'd like to have the guideline offer more flexibility to consumers on how to design an adequate diet. The pyramid gives perhaps a basic structure, but we'd like to clarify that the pyramid can be used by a variety of groups and by a variety of -- for a variety of purposes.

So, for example, we would like to keep certainly the section in there that talks about vegetarian diets and maybe even slightly expand some of the options, for example, for people who are lactose intolerant or people who don't consume animal products at all, what would be options for getting enough calcium.

We might consider adding more on cultural preferences for people of different backgrounds or different culinary interests that want to adapt the pyramid for their purposes. All this information, of course, is available, but we think that perhaps more of it should be pulled into the dietary guidelines booklet so that people see the pyramid as one of -- as a guideline to many ways of implementing a nutritionally adequate diet.

And another thing that we would like to do is to incorporate an expanded text on fortified foods and supplements that reflects more a scientific consensus that these foods do have a place in a nutritious diet, and, of course, there is a whole group working on how that text might be in there, but I think we're all in agreement that it needs to come under the umbrella of this particular adequacy guideline.

So those are the main issues within the guideline itself. We're also interested in trying to work out what goes into the introduction and what goes into the adequacy guideline itself, and it's my understanding, Dr. Garza, that this group will be trying to make those decisions with your help.

CHAIRMAN GARZA: Yes. 

DR. MURPHY: So we've recruited another member to our working group, Roland, it's not just us now. 

DR. WEINSIER: One more won't hurt. 

DR. MURPHY: Because it may be we want the separation between the two parts of the booklet to change somewhat based on the new concept of adequacy.

And, of course, variety is not going to go away. We still believe that variety should be a cornerstone of a nutritionally adequate diet, and so text on variety we would like to keep and would actually like to continue it as a theme and we'll be looking into ways to continue to focus on variety, even though at this point it probably will not be in the wording of the guideline itself. And that's it.

CHAIRMAN GARZA: Okay, thank you.

In response to that I've asked the group -- I'll ask the group to think about the -- how the pyramid is in fact constructed, so we'll be asking -- Shanthy, if you'll remind me to make sure that we have somebody at this next meeting that will review with the group what actually goes into the construction of the food pyramid, remembering that it is not only the dietary guidelines but DRIs and consumption patterns.

One of the attractive aspects of what the group proposes is as DRIs, for example, change and the pyramid is reconstructed based on those recommendations, then it does provide us a mechanism to remain the currency of this between meetings of this advisory -- of the advisory group for the dietary guidelines, because as DRIs are done, that in fact the pyramid can be examined.

It also is clear, however, in our discussions that it will be increasingly important that this group consider making or calling -- asking the secretary's attention to be focused on the need to have much better across-departmental collaboration and cooperation in the construction of the pyramid, so that, in fact, it reflects health as broadly as possible from both the USDA and the HHS perspective. Because if we're going to make it as central a part of the guidelines as the working group has suggested, then just as it is important to make sure that the pyramid remains current in terms of DRI consumption patterns and the latest dietary guidelines, then assuring ourselves that it meets the broad concerns of both departments is very important, so that the group should try to see whether or not we could have language to that effect and speak to both departments in terms of the strength and weaknesses they see in the current process.

Okay, are there any other comments or questions to any of the working group?

Meir.

DR. STAMPFER: I'm -- I have serious doubts as to whether the aim of achieving the guidance that you talked about -- you had a very elegant phrase for it, but giving people alternatives and that sort of thing -- can actually square well with the food guide pyramid. I think the way that the food guide pyramid is constructed it is set forth in a very prescriptive way. Choose two to three servings of dairy, choose two to three servings of the quote "meat group," and I don't know if the -- I certainly agree with your goal about relaxing the prescriptive nature, but the way it's set up now it's -- I don't know if it really can, if we can use that as the guide if we really want to change that tone.

And, in particular, what's wrong with the pyramid? I think there are several things wrong with it. it advocates a high carbohydrate, low fat diet with the carbohydrate at the base without attention to the quality of the carbohydrate. We know that this kind of pattern can lead to metabolic disorders and increased clinical outcomes. it advocates meat and animal products, and it puts meat together with fish, beans and nuts in one group without regard to the different health effects of those -- of those foods. It advocates restriction of polyunsaturated and monounsaturated fats. It includes potatoes as a major vegetable. I think there are some serious flaws in the pyramid, and I think we should be cautious about using that as a basis for our recommendation.

CHAIRMAN GARZA: Remember that the pyramid is based on the dietary guidelines in part. To the extent that the guidelines change, the pyramid will have to change, and that Suzanne also said that in fact they would be giving alternatives within the text so that if, for example, someone wants to meet their calcium needs with other than lactose-containing foods, then that would be included.

I don't know whether any icon would be able to satisfy the broad needs of every single eating pattern in the country. If I go to my own region, I'd like to see a tortilla there instead of perhaps a glass of milk. There is just as much calcium, but not everybody enjoys them as much as I do.

DR. GRUNDY: Do they have tortillas up in New York? 

CHAIRMAN GARZA: Actually, they do; very good ones.

(Laughter.)

CHAIRMAN GARZA: I think they import them from Texas. They are good. We get them flown in actually, but that's another story.

(Laughter.)

CHAIRMAN GARZA: So I think that's -- i didn't see anything incompatible with what you were saying in terms of trying to recognize some of the shortcoming and the options that Suzanne was offering us.

Did I misunderstand what you were saying?

DR. MURPHY: No, and I'm certainly in agreement with Meir's concern about the food guide pyramid appearing prescriptive. I mean, I would like it to be interpreted by consumers as a guide, but not a prescription. And if there is a way we can address that in the text, I would appreciate help from anyone that can offer it; you, in particular. 

CHAIRMAN GARZA: Johanna and then Roland. 

DR. DWYER: I wanted to urge that somehow the concept of food security get in the first part. The reason for that is because I know that elsewhere in the U.S. Department of Agriculture, with the support of a number of voluntary and professional associations, and they developed a measure of food security, and I think it's very important to try to tie that in.

And just as you just urged, Dr. Garza, that there be extensive consultation across departments with respect to this pyramid, also there should be consultation perhaps across departments on that.

In terms of the ethic diversity and different culinary traditions idea, I heartily endorse that too, and in reference to Dr. Stampfer's questions and comments about his concerns about some aspects of the pyramid, I think I heard a presentation by someone who may be here this morning some years ago. It was by Dr. Susan Welch, who showed how the pyramid could be interpreted even to fulfill the old ways Harvard pyramid. It isn't as prescriptive as that it seems to some observers.

CHAIRMAN GARZA: Roland. 

DR. DECKELBAUM: Yeah, I appreciate and basically agree with Dr. Stempfer's comments. I'm not sure that what Dr. Murphy is presenting is substantially different. The risk is not knowing what the pyramid will look like.

Do we have the option to approach this -- we being the subcommittee and the whole committee -- to propose this guideline on the basis of the emphasis within other guidelines?

For example, if we're talking about the grains group, if we're talking about whole grains, if the pyramid doesn't reflect that, or if we're talking about the dairy group and make some verbal descriptions. If the pyramid doesn't reflect that, do we have the option to not include the pyramid and perhaps change the title at that time, instead of, you know, "Let the pyramid be your food guide," I mean -- yeah, then perhaps revert to something like "Choose from the five basic food groups" or something like that? Do we have the option --

CHAIRMAN GARZA: Dr. Roland, the problem with that is the following. It's very difficult to construct total dietary advice based on the guidelines because it doesn't address nutrient adequacy very broadly, and that's why I think it's important not to lose sight that the departments, and I would have put an "s," not the department, but I hope the departments, have the challenge of bringing together the dietary advice this group has with all of the DRIs, and then to try to make it compatible with as many consumption patterns in the country as possible.

Now, if this gourd wants to take it upon itself to also develop the DRIs, make sure they get incorporated --

DR. MURPHY: I resign. 

CHAIRMAN GARZA: I would resign. We both have been involved with that.

It's just not practical. I mean, for us to then say --

DR. DECKELBAUM: I'm not sure that -- 

CHAIRMAN GARZA: -- we're not going to approve our pyramid until we get to see it. I think it would be very helpful if all of us had an opportunity to hear what goes into it because it doesn't represent the work of only this group. It represents the work of an entirely different process, plus the work of this group. And so I don't think that it's going to be feasible to give advice, it says. You know, we're not going to even mention this unless we get pre-approval, and I'm being very frank with the group. I just don't think that's going to happen, but I think it's reasonable.

I mean, I understand the reasons why it can't happen. I don't think it's an agency that's being difficult to work with. I think it --

DR. DECKELBAUM: I wasn't suggesting that we ge pre-approval. I mean, we discussed that at length yesterday. 

CHAIRMAN GARZA: Well, how would you then -- 

DR. DECKELBAUM: No, I was asking if there is the option, because as Suzanne was suggesting, you know, even if a new book needs to be reprinted, I mean, that's a major change at, you know, the last minute. I was asking if the pyramid does not reflect what the consensus of this group was, do we have the option -- I'm asking -- do we have the option to not include the pyramid within the guidelines? 

CHAIRMAN GARZA: What I'm asking is how do we get to nutrient adequacy though without something that has as much work as presumably the pyramid has with both departments? Because if we say "just choose from the five food groups," I mean, yo have to have a lot more detail than just "choose from the five food groups" to make sure that you get iron and you get protein and you get calcium and you get zinc and you get all the other nutrients other than just fat, carbohydrates, and fito chemicals in the diet. That's the challenge.

Shiriki.

DR. KUMANYIKA: I think that for this subcommittee the issue to consider is that no guidance we give means anything unless we tie it to choices from the foods that are available. I mean, that's what we're actually trying to do with the pyramid. It's the current form of food guidance that's based on food groups. And so to that extent it sounds like you're telling people to choose from food groups because you are, because that's where you're going to get your nutrients from.

So the alternative would be to then propose another listing of commodity food groups as an alternative to the pyramid, and I don't think we want to get into that because that has implications that we're going to -- as Bert says -- to go beyond the pyramid.

So I think if think of the text as reminding consumers that any kind of dietary guidance has to be filtered through food choices and that this is a pattern for it, maybe with the language about different preferences and more explanation of what those foods represent, foods that provide calcium and so forth, foods that provide protein, it may take a little bit of the onus off of naming the group only by its commodity category, but also talk about the underlying nutrient base of those foods.

CHAIRMAN GARZA: Yeah, yeah.

Scott and then Alice.

DR. GRUNDY: I have a technical question about the structure of this committee and how it might relate to this, nd I'm not ever quite sure about that.

As I understand it, this committee is a -- it's an advisory group to the departments, but it's not linked to the departments directly. I mean, I think that what we say then is made available to the public, and they could build any kind of pyramid they want to out of what we say, couldn't they?

I mean, we're not just giving -- in other words, these guides are not government guides, are they? The government is not telling the public what to eat, I don't think?

CHAIRMAN GARZA: Our green report is not this. The government produces this based on the green report. 

DR. GRUNDY: That's right. And I have some concern about linking us so closely to the government that would be done here; that, in essence, we are in cahoots with the government in the sense of telling the people what to eat. You know, I'm just raising that from a technical point of view. 

CHAIRMAN GARZA: Well, I mean, the problem that I see, and I -- is that we can't have it both ways. We can't provide guidelines that are unintelligible to the public. 

DR. GRUNDY: No. 

CHAIRMAN GARZA: And we can't -- so that we have to provide some mechanism to have the public be able to implement them.

Now, we can decide, as has been -- as we're discussing, that the pyramid is not the appropriate way of doing that, and we'd like to disassociate any advice we have from the pyramid, or we can say, you know, we recognize this as part of the process. There is an element of trust that in fact government will do its work well in incorporating all three: the dietary guidelines, nutrient requirements and make them achievable by paying attention to consumption patterns, and the example that we used was kale, because it came up in our discussion; that we might be able to say, you know, "America, forget milk, you know; take kale." It's not going to happen.

I mean, what we can do is in the text say, you know, that there are alternate forms for calcium and include kale with many others, and that may be appropriate.

Let me go to Alice, Meir, Richard, and then Rachel and then Suzanne, and Linda. Okay.

DR. DWYER: Forget about the 2:00 planes. 

CHAIRMAN GARZA: I hope you all remember that order because I probably will not. 

DR. LICHTENSTEIN: I came into this meeting actually quite skeptical about including the food pyramid and tying the guidelines to the pyramid for a lot of the reasons that were articulated and also because of my focusing on supplements and that you've got certain foods that somehow now don't fall into any category if they're going to be linked to nutrients.

After hearing all the discussion, I have actually gotten to the point where I am in favor of including the pyramid because of understanding exactly what goes into it, but also realizing that these guidelines alone are really not actionable, and that a lot of the concerns that have been raised are already addressed in this book, and maybe what we need to do is strengthen it. Because if you look at page 10 and 11, Box 3 and 4, good sources of calcium cuts across at least three or four food categories, and good sources of iron is cutting across a lot of those boxes actually within the pyramid, and I think there are examples of that throughout the text.

But the food pyramid as we were informed is what people recognize. It's what people see, and certainly it's been picked up in a lot of ways that perhaps would not have been predicted because it's not just perpetuated by the government, but you see it on the back of cereal boxes, you see it in lots of educational materials that are in the school systems right now.

I think what we need to do is work within it, round it, and message it maybe a little bit.

DR. STAMPFER: I just wanted to echo and follow on what Scott was saying.

This is not our product. This is the product of the government. Our product is the green report, and to that end, I think we can give our best advice according to the guidelines that we feel are appropriate, and the government, in its wisdom if they wish to choose to add in the food pyramid when they create this document, is perfectly free to do so. But I don't think that we're necessary bound. I think it's good to have that degree of separation.

CHAIRMAN GARZA: But let me press you a little bit. 

DR. STAMPFER: Sure. 

CHAIRMAN GARZA: How would you then suggest that we recommend or advise the government that it make these actionable? I mean, one can say, look, you know, construct a pyramid with the guidelines that puts together and then hope that in fact that's carried out, because I -- the alternative of saying, well, you know, don't follow our advice, or don't pay attention to other nutrient requirements, or don't pay attention to prevailing consumption patterns might be the implicit message we'd be giving by saying we don't think that we have to worry about making them actionable.

Now, am I -- so I don't see how we can ignore it is giving some advice to say either we think the pyramid as an actionable item should be discarded and we want to go back to the five food groups, but sort of burying our heads in the sand and saying this is not our concern, I think, would be a dereliction of some of our responsibility.

So if we feel strongly about it, we ought to tackle it in our advice to say that we think whatever icon is used should meet certain characteristics, or endorse it. I hope --

DR. GRUNDY: There is two different things. Saying that it meets certain characteristics is one thing, and I'm not opposed to that; I think that's good. To endorse that -- 

CHAIRMAN GARZA: No, but that's -- 

DR. GRUNDY: -- ahead of time, that's where I have some -- 

CHAIRMAN GARZA: Well, what I heard Suzanne saying was that whatever pyramid was constructed would meet the characteristics we've been told it's based on. 

DR. GRUNDY: We certainly hope so. 

CHAIRMAN GARZA: Did I misunderstand that? 

DR. MURPHY: Right. 

CHAIRMAN GARZA: So it's not, you know, we would recommend any pyramid regardless of how closely it adheres to the guidelines or not, that it should adhere to the guidelines, the DRIs, and pay attention to consumption patterns because that's what makes it actionable. DR. 

WEINSIER: That was my question, so you did answer it by saying yes then, that it will reflect these guidelines because I thought that's what I was asking. 

CHAIRMAN GARZA: Yeah, but that's what we've been told repeatedly is what it's based on. Now, what I can't guarantee is that we would be given approval to say, now, does it meet those three requirements. I can't -- I can't give you that assurance.

But, I mean, so I'd like you to elaborate a bit more. I mean --

DR. STAMPFER: Okay, yeah, I'll try to do that.

I think even the advocates of linking the food guide pyramid with the guidelines have expressed some reservation with some of the aspects of it in terms of say, at least the prescriptive nature or, in my view, a more fundamental issues. So that I think there -- there is at least in a subgroup of this committee a sentiment that we would not accept absolutely as written in its present form the food pyramid as our guide.

So if the question is do we endorse this fully or we reject it, and there is nothing in between, you know, then, you know, maybe we should consider that. But I think the in between approach would be to give our best advice regarding the dietary guidelines and then the government and the departments can decide how they're going to construct the food pyramid, which is beyond our purview anyway.

CHAIRMAN GARZA: Let me pursue that. I am being dense and I apologize. We can't ask -- we can't ask the group to endorse something that doesn't meet the guidelines we're going to come up with. I mean, that's sort of a -- I mean, it's so self-apparent that I hope that that was never being considered by anyone. So that when we say -- when Suzanne is saying "follow the pyramid," it's the pyramid that coincides with the guidelines we're going to be coming up with, and that's the dilemma she presented, to make sure that, well, how do we -- how do we do this. I mean, it was recognized as an issue.

It isn't, "We will endorse any pyramid whether it meets these guidelines or not." So I'm -- that's where my confusion is coming; that I keep coming back to the idea that the pyramid has to meet three criteria. The dietary guidelines is one. Now, when we make recommendations, you know, those guidelines will presumably change. The second is the DRIs, and the third is the consumption patterns, and that's what we are asking, you know, can we approve things that meet those three, and that would then meet with what the committee wants -- the subgroup wants to do.

Am I the only one that's confused?

DR. GRUNDY: Let me comment on that.

I think it's -- I agree with what Meir says as a conceptual thing. I think there is also the problem is that the pyramid are not the guidelines.

CHAIRMAN GARZA: That's right. 

DR. GRUNDY: They are not -- but yet there is a danger that they can be taken so literally as to be the guidelines if we endorse it and say "eat that," then they superseded almost what we've done, and in the minds of the public they become the guidelines as what -- 

CHAIRMAN GARZA: The dilemma is this, Scott, that the public doesn't -- right now doesn't -- is not aware of the guidelines to the same degree that they are aware of the pyramid because it's a simple teaching tool. And so what we can do is say, "Government, forget the pyramid as a way of teaching the guidelines." 

DR. GRUNDY: That might not be a bad idea. 

CHAIRMAN GARZA: Well, that what -- 

DR. GRUNDY: I mean, I think that -- 

CHAIRMAN GARZA: -- I'm trying to get at. We can't have our cake and eat it too is what I'm saying. 

DR. GRUNDY: I do. I think this is better than this. I mean, that's -- because I think that the concepts and the flexibility does exceed that. 

CHAIRMAN GARZA: Okay, well -- 

DR. GRUNDY: And I don't think the public knows that. 

CHAIRMAN GARZA: Suzanne and then -- 

DR. MURPHY: May I go out of order -- 

CHAIRMAN GARZA: Yes. 

DR. MURPHY: -- as chairman of the subgroup, please? And I'd just like to respond to Scott's comment about we seem to be endorsing or getting too close to government process here.

I'd like to suggest that the development of the pyramid is a process that anyone can follow. It happens to be a process that's assigned to USDA. But USDA doesn't do this in a vacuum. They are supposed to be doing it in consultation with this committee, with the DRI committee, with the other agencies of the federal government.

I think it is a good process and if we don't like the process, then I think we should be giving feedback to them that the process is not working, but I don't think we need to look at the pyramid as a government product. It's a product of a consensus of the whole scientific community, of which the Dietary Guidelines Committee is part.

Let's have a speaker at our next meeting. Let's understand better how they get generated. And if we disagree with that process, if we don't think it's working right, then let's say so. But let's not reject the end product of a process because we haven't given enough feedback on the process itself.

CHAIRMAN GARZA: Okay. Let me finish on this side and then we'll come to this. Anybody?

Johanna, did you have your hand up or not?

DR. DWYER: I just -- I think I basically still feel that it's important to have the pyramid in there, but the fundamental thing is that this is not 1940 and the Ministry of Food in Great Britain where what we're doing is prescribing or dictating a national diet. The First Amendment allows anybody to make an alternative pyramid; in fact, many have made many pyramid that are alternative. So this is not dictating what people will eat the way we would be under food rationing or something. This is a set of actionable recommendations that people can take or throw away, and usually, unfortunately, they take the latter course. 

CHAIRMAN GARZA: Richard, and then we'll go down this and that. 

DR. DECKELBAUM: Just two points. One is, you know, what's the mission of this committee. We're part of a broad initiative to improve health in the United States and the American people through a key lifestyle which is nutrition and also exercise. And our job is to provide the science base or the evidence base for that. But the only way this is going to happen is if this is done in partnership with the government and in partnership with industry,

So that if our science suggests that for reason QY that every home needs a minus 70 freezer so that we can implement this and that in that subgroup, we know that that's going to be totally impractical. And even if the science is there, you know, it's not a good thing to come out as a major recommendation of this committee.

If we look in this current thing, this pamphlet, it's not a thing, the food guide pyramid serves as an educational tool, okay. Now, a number of us have been in different organizations that make educational tools, and when you make an educational tool like the slide set, the slide sets are designed so that they can be used by multiple users in different ways, so that you can get multiple messages across for that tool.

So I'm going to take a specific example of the current pyramid. So that, for example, if someone wanted to give a talk and say that potatoes are not the optimum or preferred vegetable, they could point to the current pyramid and say, "Look, compared to the other vegetables that are depicted, potatoes actually occupy a very small amount of space." It's there, but -- no, but you can do that.

Notice that we have two to three servings of dairy products a day. There are other ways to get your calcium and other nutrients that are -- so basically it depends on how you use the slide, if you will, and I think that's what we're talking about. There are multiple ways that this slide or this pyramid can be used as long as you give the verbal message, either in oral presentations or as long as you do it in the text in a decent way.

But at the moment this so far, and the feedback that we get from other groups is that this is a decent educational took and it's been effective. So how we modify it, it could be better, and slides, you know, slide sets are revised every few years. But I think that we've got to realize that the major effect of developing there, to sort of destroy it one shot would be, I think -- would be harmful to steps that have been made in a positive ways towards improving nutrition in the United States, and we have to be very careful, but it is an educational tool. It's not the guidelines and we've all agreed upon that.

So I think we have to take that into consideration, and I would urge those of us who want to use it in different ways, that you can use it. I use it in different ways when I teach, and it's very -- you can use it for all -- as I said to a small group yesterday, you can use the current pyramid basically in most of the discussions that we've been talking about. You can talk about the base in whole grains. You know, it's hard to tell if this loaf is from a whole grain or refined grains, but you can make the point when you are going through that.

And I think that also in thinking of the link of this educational too with what we're going to be writing is that in some of the areas there are controversy, so that it's not universally accepted that this type of nutrient predisposes to this kind of disease versus that kind, so that there are controversies still in the field, and we have to have a tool which allows controversy to be discussed even when the tool is up there.

I mean, I would say that people who might not agree, for example, on the type of sugar or carbohydrate, could effectively use the pyramid for, you know, that kind of argument on either side. It's just a tool.

CHAIRMAN GARZA: Rachel. I'm sorry. 

DR. DECKELBAUM: So I think we've got to be very careful in total disassociation of something that's so recognized by a large segment of the population. What we have to do is explain it better. 

CHAIRMAN GARZA: Thank you. Rachel. 

DR. JOHNSON: I'll be brief.

I'd just like us to -- I'd like to urge us to remember what Dr. Kennedy said several times when she was here, which is we need to think about adequacy of the guidelines as well as current consumption patterns in the population.

For example, we know that 75 percent of the calcium in American's diets is obtained from dairy products. We know from our research that children who do not include a source of milk in their diet do not come close to meeting by the calcium recommendations. They are not substituting, by and large, on average, other high calcium products.

So I am just urging us to try to get away from this good food/bad food approach that I'm very concerned that we're taking. Think about good diets versus bad diets. And think about what is practical and achievable for the U.S. population given current consumption patterns, because the quickest way to have the guidelines totally discounted is to come up with something that is so far removed from current consumption patterns that it won't be acceptable.

CHAIRMAN GARZA: Roland. 

DR. WEINSIER: I didn't have my hand up. 

CHAIRMAN GARZA: Shiriki. 

DR. KUMANYIKA: I have three comments.

One is that we might make the point that people should have a dietary pattern, and by that I mean, similar to what Rachel just said, that ad hoc exchanges might not work for people. I mean, that that -- you know, there is a dominant consumption pattern, and people who have a different pattern should make sure that that pattern is adequate. If we could get that concept in there so that we avoid the idea that people really will do ad hoc substitutions and not have an adequate diet.

The second comment is that I'd like to see us include three of the graphics for the different calorie levels, or I have something I can send to you or to Carol that I did for a clinical publication, and that could be used to make the point that there are different calorie levels for different types. It's in the text but it's not graphically shown.

And the third suggestion is that we include the pyramid annotated. This picks up on Richard's comment. We can show how the dietary guidelines relate to the pyramid, if we can do it without being too busy, by pointing out that within the grain group we will be suggesting a certain type of grain product to be emphasized within that. I'm thinking of some sort of arrows or call-outs around a pyramid that show how this basic eating pattern relates to the dietary guidelines.

CHAIRMAN GARZA: I think what the gourd is saying is come up with some alternative ways, one of which is a way that one might be able to use the pyramid, but think of at least one alternative way. The food groups has been suggested as one alternate way. Another one is not to necessarily tie it to the icon, but to say whatever teaching tool is used see if it can meet these sorts of criteria. Or alternatively, is it possible that in fact one could include multiple pyramids to look at not only various calorie levels, but perhaps different eating styles; one that would really minimize dairy and meats to a greater degree because a growing proportion of the population is choosing that dietary pattern, and how would you do that in a way that also meets dietary, dietary or nutrient needs, and perhaps we could have more than one pattern depicted so that we don't appear quite as prescriptive.

Did that capture all of the various ways that have been suggestions that might be actionable?

Okay, then let's move on then to the next guideline which hopefully will, you know, as planes disappear in the horizon. All right, we're going to be going then to choose a diet with plenty of grain products, vegetables and fruits.

DR. WEINSIER: No, you skipped one. 

CHAIRMAN GARZA: I sure did. Balance the food you eat with physical activity. 

DR. WEINSIER: Basically, these are points that came out of our discussion yesterday and would like to pose to the committee for consideration.

Under the weight guideline, tentative going to weight guideline, I think we discussed and a number of people presented yesterday to remind us that one of the few year 2000, HHS year 2000 goals was to not increase the prevalence of obesity, and this is one of the few such goals which was only not achieved, but was going in the wrong direction. We've heard that approximately 25 percent of the pediatric population and 50 percent of the adult population are now in the overweight or obese categories. And we've heard that genetic factors cannot account for the rise in prevalence in obesity, but rather, are responsive to a changing environment.

So with that as a very brief background, the changes that we've considered and I'd like to suggest to the committee in this guideline are, first, regarding the title or the focus, and the previous title, as everyone probably recalls, is "Balance the food you eat with physical activity: maintain or improve your weight." And we discussed some of the limitations or concerns from focus group analyses about that guideline, particularly the definition of "improve," and also some concern about the word "balance" and the understanding of the word "balance."

A suggestion that our subcommittee would like to make for the full committee would be to consider a title that's perhaps shorter, more actionable, "Achieve a healthy weight." This is just one that we're posing for consideration and to try on to see if it fits. The justification for this recommendation is to maintain a current weigh may be a goal for the population as a whole, but for the individual, in other words, if we're looking at the year 2010 goals, sure, to maintain current body weight may help us meet that goals, but getting to an individual level that the guideline is to help guide toward maximum health benefit, which is expected to be achieved by reaching an ideal body weight or a quote "healthy" weight.

The reason for considering omitting the second half of the recommendation or one-half of the recommendation, which is "Balance the food you eat with physical activity," is that the subcommittee has recommended to the full committee developing a separate section, as Dr. Garza alluded to earlier, that focused on physical activity. If that were taken out of this guideline and put in as a separate guideline, then we probably don't need it in the title. In other words, we could say, "Achieve a healthy weight" and take out the part about "Balance the food you eat with physical activity."

The reason for suggesting take the physical activity out are for the reasons Dr. Garza enumerated earlier, but they include the fact that physical activity is a very, very important lifestyle. It impacts on various ares of health, not just weight, but they include risk of cancer such as colorectal cancer, cardiovascular disease health, increase total energy intake or enable total energy intake to increase, which can improve options for overall health.

Now, with regard to the second issue, the definition, the definition of a healthy weight, we'd suggest a -- probably a fairly small but, I think, important change, and that is to use the BMI, or Body Mass Index, to emphasize that in this guideline, reinforcing, one, the public's recognition of this term "the Body Mass Index," which is being used more and more often, and allowing ease of comparison across guidelines, because now we have other published documents, such WHO and the NIH guidelines and the AOA guidelines that are incorporating the Body Mass Index. So using that term, I think, will make it a little more friendly -- user friendly and perhaps a more appropriate guideline.

The current reference, as you may recall on page 18, is to Figure 3, which shows is color form a graded relationship between weight and height. It is based upon BMI so that's not a divergence I'm suggesting from the past guideline, but we could consider still using this perhaps with introduction into some of the shaded areas the BMI range, so that way we reenforce the BMI, but not necessarily giving up the past figure that was used.

The thing that I do like about this figure is it showed a graded approach. There is nothing new in this area. We will want to emphasize to the public that going from one category of BMI to another doesn't meant you're healthy, you're not healthy, you're normal, you're abnormal. It's a graded approach and we'd like to try to work, if Carol and others can help us, come across with that point that it's a graded thing. Coming closer within the healthy range of BMI is probably better but there is no absolute cutoff.

A disadvantage of using this current description is one, the titles would have to be changed because they don't match up. The words "moderate, overweight, severe overweight" really don't match with the going terms, but I don't see that has a major hurtle. A disadvantage, in addition to that, is that it does not include reference to waist circumference as an independent marker of health risk related to body weight and body fat distribution.

That point being made, we may want to still consider going to an alternative approach which would actually refer to the various BMIs and the categories, but then brings in the impact of waist circumference, this being normal waist circumference, this being higher waist circumference, and then demonstrating relative risk of disease, hoping perhaps that with something like arrows or terms, Carol again may have to help us, trying to imply that this is a graded sort of change, that as your weight gets higher and if your waist circumference is higher, then your risk gradually increases as a population. So we need your input and thoughts, but those are options that we would like the whole committee to consider in terms of definition of a healthy weight.

The next thing was weight goals. We would like to reemphasize, not change, but reemphasize what is in the 1995 guideline, the importance of prevention in increasing the current average body weight, the prevention of a BMI greater than 25, and avoidance of further weight gain. So I don't want to distract from the importance of, regardless of your weight, try not to increase your weight. I think that needs to be reemphasized primarily for the individual who's not currently overweight to emphasize the importance of prevention.

Secondly, to provide guidance on who should lose weight and who may not need to lose weight. This is, again, reenforcement of what was in the 1995 guideline, perhaps just fine tuning it according to recommendations of the WHO and the NIH reports.

Thirdly, to reenforce the 1995 recommendation of a five to 10 percent weight loss, improving overall co-morbid conditions, I think that needs to be emphasized, but in the context of not stopping there, but to add, and I'm asking for the committee to consider that we add to that recommendation of the benefits, health benefits of a five to 10 percent weight reduction if you're overweight, to emphasize the point that medical risk may be maximumly improved by achieving a healthy weight. The justification for this is that they do show a graded approach.

It's not as if you lose five or 10 percent and now you're completely health and removed all of your risk. It may or may not. Generally if the population data hold for the individual, that achieving an ideal body weight or healthy weight would maximally improve the health. This would go along with the current report of Clem, et all, from the Weight Loss Registry, and with the NHLBI guideline of last year.

Fourth, with regard to the weight loss approach, reenforcing, not necessarily changing the emphasis of the 1995 guideline on a healthy lifestyle versus diet, implying that we're trying to establish patterns for good health which include behavioral modification, practices, sound dietary practices compatible with the other guidelines within this whole dietary guidelines booklet. So we don't want to have anything that comes across that this is different guidance in terms of fat intake, or the whole grains or fruits and vegetables, that it should be compatible, that we're giving consistent advice, and I think there are data to support the appropriateness of that general recommendation.

Also including information of portion control, considering possibly, however, moving specific focus and emphasis, removing specific focus and emphasis on the importance of fat restriction per se. That received a fair amount of attention in the 1995 guideline. There are some data that suggests that that may be not only an unwarranted focus, but that it may actually be somewhat misleading, so we have to restructure the wording or simply put the emphasis on what we need to be doing in terms of building a strong dietary foundation which includes good health and weight control rather than specifically providing advice to simply remove fat from the diet, restrict fat.

Finally in this regard, increase physical activity, especially recognizing its role in weight loss maintenance, and we'd like to greatly emphasize that, and I think this will be done in two ways.

One, by enforcing it in the context of this guideline; and, two, have a separate guideline which will then cross reference and reenforce.

Finally, under special considerations, we've talked about the importance of weight control in children and older adults. This is probably not going to be a major change or divergence from the 1995 guidelines, but with kids we'd like to reenforce the message regarding the importance of prevention of obesity beginning in childhood by way of improving eating patterns compatible with the guidelines as a whole, increasing time spent in physical activity, and decreasing time spend in sedentary activities, such as watching television.

Somewhat similar to the 1995 guidelines regarding older adults, the recommendation that guidance of a health care provider may be appropriate with regard to overweight or obese older adults, giving special consideration to the role of physical activity in this older population to maintain muscle mass, strength, reduce risk of falls and fractures, as well as reducing risk of co-morbid conditions of the obese person.

Finally, under special considerations, one of the members of the committee raised a question: Should we further consider describing this guideline, the potential role of drug therapy, anarchic agents, for example? And concern was expressed by some members of the subcommittee that this may be too prescriptive, perhaps too clinically oriented for the dietary guidelines and for the general readership of this guideline, but we will certainly consider that in further deliberations.

So, Rachel or Shiriki, did I miss anything or say something that you think --

DR. JOHNSON: I would just like to -- I know I've said this before. I would just like to emphasize that I think some kind of graphic or box about portion size is really critical. And as I look at the booklet, I think there is a lot of misperceptions in the pyramid, for example, in the grain group when it says six to 11 servings, and when you look at this you know a serving is one slice of bread, a half a cup of rice. And I think if you look at current consumption patterns, that's not typically, if you consider the amount that you have on your plate for meal, that would be less than we might consider a serving.

So I just think if we can link the serving sizes that are given with the pyramid in with the "achieve a healthy weight," really stressing portion size and what is considered a portion size when you flip back to this. I think that would be useful.

DR. WEINSIER: Shiriki. 

DR. KUMANYIKA: What I would add is more advice on eating behavior. As I look through the booklet there really is a lot of -- the subhead anyway -- about weight, and there is one about calorie intake, but I'm thinking about, you know, how to tell if you're overeating. You can't measure your energy balance, but you can get some clues to overeating, and I don't know if the literature will support any tips for people, but portion size and meal pattern or snacking behaviors that might tell people that they're actually eating more than they intend to or want to as the behavioral bridge between the recommendations and actually being able to do something about it. 

DR. JOHNSON: I did fax Roland, I know, a few weeks ago some behavioral weight control tips that are commonly used in behavior weight control programs. And I think the literature supports that behavior weight control as along with physical activity is effective for weight loss. Weight recidivism is another issue. But I think we could pull that in, and I think we could pull some of the pediatric things in there very nicely when we talk about helping children to recognize internal cues of hunger, which is kind of, I think, what you're thinking about when you're talking about how do you know when you're overeating. So I have some things on that that I think I shared with you, Roland, and I can get to you, Carol, as well. C

HAIRMAN GARZA: Any other comments or questions?

Scott.

DR. GRUNDY: Yes. I think the waist circumference is very important to put in. You know, that was developed in the NHLBI and our DDK guidelines, but I think that really it's time as come, and it might be a significant addition to this guideline if we emphasize that. You know, it has several advantages. It's metabolically more liked to risk factors than total body weight, and it might get a little bit around the problem of whether a BMI of 25 in some people is overweight or not, because if you can add in the waist circumference, you can find out whether there is a problem. So maybe adding this on as a major new contribution of this group would be very good.

I think that slide you showed where you tried to combine the two together was a little problematic. You know, we might talk about that. The way circumference is most telling in people who are in the overweight range rather than the obesity range is trying to say that they're above a level of about 30, I think we've learned that, you know, the waist circumference is not much of a factor then, you know, than obesity as a whole take over. But certainly in that range it's extremely important, in the moderate range, and I would advocate that you really push that idea.

CHAIRMAN GARZA: Meir? 

DR. JOHNSON: I wanted to add one thing about pediatrics. I'm sorry. I know there are BMI charts for children, and I've seen some things that have been included in the team nutrition materials for USDA. And I think if we're going to do a BMI thing, if we have room, it might be nice to include some things for children as well. 

CHAIRMAN GARZA: Meir? Johanna? 

DR. DWYER: The BMI simply has to be different for children. It's wrong to have adult BMIs. 

DR. JOHNSON: Right. That's why I'm saying there is a new chart that's based on the soon to be hopefully released growth charts for children. They are a little hung up, but they are due out soon and they've created some BMI charts. 

CHAIRMAN GARZA: Meir. 

DR. STAMPFER: I was just going to talk about the other end of the age spectrum, the elderly, where BMI is actually not a very good predictor of adverse health outcome compared to middle aged and younger old people, and I think part of the reason is -- getting back to what Scott was saying -- there is a loss of lean body mass and you can have the same BMI but be fatter in old age, and the waist can pick that up. 

CHAIRMAN GARZA: Shiriki. 

DR. KUMANYIKA: I'm just wondering if, without setting a precedent that goes through all the guidelines, we should have some sort of special issues box in the weight group, because the Asian descent populations don't have average BMIs that get to 25, that have very high risks associated with waist circumference. If you don't say anything about it might not pick that up, and it's -- so I think it's important to have a place to mention that, and that would also be a place to mention older adults and perhaps some other groups for whom there are special weight considerations. 

CHAIRMAN GARZA: Given this sort of discussion, how practical is it going to be -- again, I'm trying to think of how lengthy this is going to get if we try to make prescriptions for all age groups and physiological states. To think about limiting perhaps some of the charts, then giving -- referring people to other sources, so that rather than putting in a chart that could be misleading because either of ethic issues or age issues, to say, you know, if you're interested in losing weight and want to check whether your weight is adequate, then go to this other resource, because if we try to put it all in one book, then what age group are you going to use. And I'm not saying that that's the way we have to go, but we may want to give Carol enough leeway to say, well, if it can be done, obviously the ideal is to put everything in one text.

If it can't be done, how would you prefer erring? Leaving out a specific age group, and therefore should we make young adults the focus and refer everybody else to other sources, or just refer everybody to other sources? Let me ask Roland as the chair to address that.

DR. WEINSIER: No, I'm very comfortable with that. I like that idea as long as there are precedents for this and we're not getting into issues about it's inappropriate to be referring to other documents that perhaps are not either produced by the government or if they are specific, you know, non-federal documents. Are there any technical issues related to that?

I'm not uncomfortable with the general concept.

CHAIRMAN GARZA: No, I think that it's -- obviously we can go to a surgeon general's report to or an NIH document, that those would be the preferable ones because of the process that most of those documents are put through.

If we went to a specific commercial source for advice, then I think we'd have some problems if we were recommending a specific weight control program, for example, as the origin for information.

DR. LICHTENSTEIN: I would just like to urge that we've said numerous times that prevention is our key target here because treatment has a pretty dismal failure rate. So I think if we're going to emphasize prevention, we have to say something about the pediatric population. 

CHAIRMAN GARZA: No, no, I'm not -- 

DR. LICHTENSTEIN: Yeah. 

CHAIRMAN GARZA: -- saying that we don't mention them, but that, in fact, if we're going to focus on prevention to do that, but if people are concerned about their weight and want to look at weight loss or other things, to send them then to other sources for treatment as a way of trying to contain the size. So I mean, it's just a suggestion. 

DR. JOHNSON: I think it would be nice if we had at least something to help people recognize whether -- I mean they say -- 

CHAIRMAN GARZA: So what age group would you -- 

DR. JOHNSON: -- look in the mirror. I mean, that's probably the best test, but -- 

CHAIRMAN GARZA: What age group then would you ask we prioritized? I think trying to get them all in might be difficult but, you know. 

DR. JOHNSON: Well, I think children needs to be in there. 

CHAIRMAN GARZA: Well, some of us think children are the point, the rest of us are lost causes.

Scott?

DR. WEINSIER: I'd rather look for -- oh excuse me. I'd rather look for some generic type recommendations that are applicable through the -- you know, over two age population, and there may be some caveats that would be specific for, you know, younger and older groups. But to try to, for the sake of this document, which is for the general population, I mean, I suspect there are probably some general -- if we phrase it correctly, that we could, you know, hit some major points that would be applicable throughout the age, and a number of subgroup spectrums. 

CHAIRMAN GARZA: All right. So then Carol's guidance is prioritized the generic statements, give them the most importance, and then look at, if we add charts for all age groups, what that does to lengthen, and then we can decide at a later point whether we're going to eliminate them or not.

Okay, Johanna, you had your hand up?

DR. DWYER: I remember Shiriki said something yesterday, if you do one, then you have to do them all. And I don't know how to deal with it, but I think one way is to certainly reference other sources like you would on an internet web site, and prioritized the generic ones, and then we can decide. I don't want to try to write a book in our heads today. 

CHAIRMAN GARZA: No, we can't. 

DR. DWYER: We still haven't decided what the major things are. 

CHAIRMAN GARZA: Now, on guidelines -- I'm sorry -- on physical activity, please either, you know, if you're not prepared today to suggest who we might want to add as consultants to this group, then send your recommendations or suggestions to either Shanthy or to me because we need to get those individuals working with this group as soon as we can if we're going to evolving a guideline.

I didn't hear anyone objecting in the comments to at least drafting something separate for a physical activity guideline, that we would then take up at our next meeting as an option.

DR. DWYER: I would like to see an expert on physical activity who recognizes the importance of diet as well. Sometimes the physical activity people go off on their own tangents, and we're a Dietary Guidelines Committee, and I think what we're talking about is be holistic and inclusive, but it really does have to relate back to what people eat. 

CHAIRMAN GARZA: Okay. Scott, then Suzanne. 

DR. GRUNDY: You said something about this prevention versus treatment idea. It seems to be kind of a dichotomy. I think, from my view, obesity is a risk factor. It's not a disease, but it's a risk factor for future disease. So the whole idea is prevention. So you're preventing excess weight gain once. If you got weight gain, you're preventing further weight gain. You're preventing the consequences of obesity, so it all is prevention, and somehow it shouldn't be built in that we're just trying to prevent obesity, because even after you're overweight, there is varying degrees of overweight, so it's a continuum and the risk is a continuum, so the concept of prevention should be in there throughout. CHAIRMAN GARZA: That's a good point, yeah.

Okay, Suzanne.

DR. MURPHY: I guess I want to be sure that somewhere as the guideline is worded we keep in mind the real back lash in America against the government, and, I'm sorry, we will be seen somewhat as the government, telling Americans they are all too fat and they're all unhealthy, and a disconnect with the guidance that's coming from us all about obesity. Let's be sure we're not to use the term used before, overly prescriptive in saying what is healthy and what is unhealthy.

I know we have very good scientific evidence on the risk factor that is obesity, but if the tone of the guideline can at least recognize the frustration being faced by a huge number of Americans who has suddenly with the new guidelines found out they were fat and never knew they were fat before. Let's not further perpetuate the problems that have been caused by some of the changing definitions would just be my plea.

CHAIRMAN GARZA: The goal will be then to tell Americans the truth but not make them feel terribly guilty. Okay. 

DR. STAMPFER: Share the pain. 

CHAIRMAN GARZA: Share the plain, that's right.

All right, then, before taking on the next guideline let's take a break and try to be back in 10 minutes so that we can all make -- Kathryn?

MS. MCMURRY: During the break I'll be passing around a list, a lunch order list, if you could please fill it out, we'll get it. 

CHAIRMAN GARZA: Now, I'm sorry. Before the group breaks up, one minute, we need to get -- I still have hopes that we can get some focus groups, although they are not great, the hope I mean, but we will continue to hope. So that if there are specific items that you want tested, and I forgot to ask the variety folks to think about that, and then if the weight or physical activity, there are things we need, then I'd like to get a list to Carole over today, and maybe we want to add to that list before the end of the week, to Carole Davis, so we can give them some specific things to prioritized on, that we would like to have information on as soon as we can.

Okay.

(Whereupon, a recess was taken.)

CHAIRMAN GARZA: Will each of you -- If we'll take our seats, we'll move on then to the third working group, and I don't know whether Dr. Deckelbaum will be doing this from the podium or from his place. He's there, good. So it's choose a diet with plenty of grain products, vegetables and fruit working group. 

DR. DECKELBAUM: Just getting my audio visuals ready here.

Well, this is -- this is essentially what I showed yesterday in terms of the different options that our working group had considered prior to coming here. And then in our later discussions, I'd just like to inform you of where we've come in terms of considerations for the next edition of the guidelines. And it's not necessarily in the same order, but they're interrelated strongly. And basically everything that's on the "options reviewed" has come out with some more focused considerations that we plan to pursue and bring up to the entire committee.

So let's go to the bottom of this overhead which would be "A clearer implementation guidance for grain, vegetables and fruits." And we believe that we should have very serious consideration now for separating grains from fruits and vegetables in a separate guideline group, so there would be a grain group and there would be a fruits and vegetable group.

The rationale for this consideration is based both on the science and evidence that's accumulated in the last five years, plus we believe that it will make great strides towards more efficient and wider implementation of healthier guidelines.

So in terms of the science, I think that in the last five years, as I showed yesterday, there has been a clear proliferation of a number of good studies showing or increasing the concept that whole grains have health benefits and are able to reduce risk of more than one chronic disease group, and we referred to specifically cancer, heart disease and to insulin resistance-related diabetes, so that the data is coming there. It was there before to some extent, but it's been markedly strengthened in the last five-year period. So from the science base it makes sense.

As well, the science base is showing that the benefits of grains, whole grains in particular, are distinct, although they may be related, to benefits of dietary fiber. So that there are -- when you do adjustments for fiber versus -- in whole grain you can see that the benefits of whole grain are not, certainly not totally dependent on fiber intake and there are independent benefits likely -- not likely that are associated with whole grain intake that justify its standing up there on its own; grain standing up there on their own.

As well, we think that because plant foods in a way should form the basis of the diet, it makes sense to have them in two separate groups so that you can better emphasize each group without trying to give -- you know, mix them together.

And this brings us to the top line here, which was an increased emphasis on whole grains in the guideline itself and in the text. So if you look at Box 9 -- this is the one I had a slide of yesterday -- over here, so this -- I know it's difficult for some of you to read the exact wording. But of the -- of the 11 points here, three of them relate to grains, and -- so therefore we think that the message on grains will get across better if it had its own box, and you could amplify.

Now, the concept of whole grains being important is not entirely new because in this box these top three bullet points refer to grains, and two of the three bullet points actually refer to whole grain intake, so it's not new. It's there. And what we'd like to do is enhance it by putting it in a guideline itself and emphasizing it further in the text.

But I think an important point in our considerations is that conclusion of whole grains does not necessarily mean exclusion of other grains, and in coming to what our final sort of recommendations are going to be, we're asking for more analysis to be given to us on the potential of increased whole grain intake, diminishing intake of other potential nutrients that could be contained in enriched or fortified foods. So we think this is an important point that we need data on. Our early review of this did not seem to show any disadvantage, at least in terms of foliate, but there is other micro nutrients that we have to examine, and we'll be working on this over the next few weeks to try to get balances of what happens if all this happens versus another situation, different kinds of potential scenarios.

Now, one that we handled relatively easily was the increased emphasis on nut ingestion, and we believe this should be better emphasized in the new general guidelines, but we've taken care of it very easily by passing it on to another group, and among discussions, we thought that it might fit better under the fat guidelines, but this is still to be determined.

And, finally, we've discussed the clear definition of different types of carbohydrates, and more emphasis on quality versus quantity of grains and of fruits and vegetables; I guess in separate categories now. So that we do agree that, with the recent scientific evidence, that there is justification for emphasizing certain kinds of carbohydrates and the foods that contain them in terms of priority relative to other kinds of carbohydrates and that's foods that are less -- less micro nutrient and macro nutrient enriched, and that compared to foods that might contain -- well, basically what I'm trying to say is empty calories versus enriched food sources which provide more than calories and other kind of health benefits at the same time.

And I think that basically sums up the discussions that we had yesterday and where we plan to go.

CHAIRMAN GARZA: Okay. Are there other comments from other members of the group? 

DR. WEINSIER: This is probably a question to Carol. When we talk about whole grains, I bet if we went around the table we'd probably have a pretty good feel for what we're talking about, but I don't know what the consumer's perception is of whole grain, what meaning it has. And it doesn't need to be answered now; it's just a matter of is this a consumer focus group, user friendly term. 

CHAIRMAN GARZA: I would add that to the list. Remember I asked that right at the break that we start thinking about specific issues we'd like some information on in terms of consumer perceptions. So whole grains would be one.

Alice and then Shiriki.

DR. LICHTENSTEIN: Along those same lines now, the nuts going from one group to another, but still I'd be interested in getting some information on exactly what the pattern is on nut consumption, whether -- you know, what proportion is coming from candy bars versus other kinds of things, so that we might be able to target the recommendations. 

CHAIRMAN GARZA: Okay. So Shanthy, that would be, you heard the -- okay.

Shiriki, did you have something?

DR. KUMANYIKA: Just because sometimes when something is recommended people go overboard with it. Are there any cautions needed in the nut recommendations related to children or the allergenic properties? 

CHAIRMAN GARZA: I'm concerned about the allergy issue, and that's something we need to think about more carefully, especially with peanuts.

Suzanne?

DR. MURPHY: And also along the nut line, I'd be interested in what consumers will say if we call it a fat because I think that gives nuts a very negative image. And since I like it -- yeah, yeah, just another issue to be investigated a little bit more. 

CHAIRMAN GARZA: Okay. Then we'll -- Johanna, are we ready to move on to the next -- 

DR. DWYER: Well, I think we have to mention a whole bunch of different foods. If we mention nuts and we don't mention anything else, milk, legumes, all the others, I think that would be unbalanced, but I'm sure we can do it in an even-handed way. 

CHAIRMAN GARZA: Okay. Richard? 

DR. DECKELBAUM: Thinking about nuts, we've got also concerns of the children. Once again, you know, it's a major -- it's a major cause of aspiration and even death in young kids, so that's got to be built in that, you know, kids probably should be allowed to get it. There is the allergy component, but the major message, I think, should be somewhere and maybe it isn't, because it's really a positive message that there are health benefits that are associated with nuts. And, you know, we had some discussion yesterday about the "do" guidelines versus the nut guidelines, and if we want to increase nuts as part of health, it should be more in the positive "do" guideline. 

CHAIRMAN GARZA: Okay, we'll take one last question on this. Looking at the clock, that's the end. 

DR. LICHTENSTEIN: I guess I'm still not convinced that nuts per se are good just as a stand-alone. I think that the fatty acid patterns associated with the fat in nuts may be compatible with we're currently recommending, but singling out one food and saying, "Well, this food is good as this. This food is associated with health benefits," as opposed to saying, "Well, dietary patterns that include this whole variety of foods are associated with better health outcomes," this seems more reasonable to me at this point.

I'd also be interested focus group-wise as to what the perception would be if a message saying "increase nut intake." Does that mean that if I sprinkle walnuts over my hot fudge sundae, it's going to negate all the saturated fat that's in the whipped cream.

CHAIRMAN GARZA: It makes it taste much better.

(Laughter.)

DR. LICHTENSTEIN: But really, how is it going to be perceived by the consumer. 

CHAIRMAN GARZA: All right, then, let's -- and I'm assuming that the group is going to work on both a grain and a food and vegetable -- 

DR. DECKELBAUM: We may bring you in -- 

CHAIRMAN GARZA: guidelines? 

DR. DECKELBAUM: -- as well, so we can have two and two. 

CHAIRMAN GARZA: Okay. All right, then, let's move on then to choose a diet low in fat, saturated fat and cholesterol.

Dr. Grundy.

DR. GRUNDY: If you don't mind, I'll sit here -- 

CHAIRMAN GARZA: No, you can do that. 

DR. GRUNDY: -- because I think we can dispose of this pretty soon, I hope.

Well, the current recommendation if we look at the overriding recommendation is to chose a diet low in fat, saturated fat and cholesterol. And our group proposed that the rank ordering or the priority be changed in this list to read -- the overriding recommendation would be "choose a diet low in saturated fat, cholesterol and fat," so that the emphasis will shift more to saturated fat and away from total fat.

And the reason for that is that we think the scientific evidence is strongest for the link between saturated fat, cholesterol, coronary heart disease, and it could be estimated that about 25 - 30 percent of coronary heart disease could be attributed to the high intake of saturated fat and cholesterol, and there is a lot of strong scientific support for that.

The low in total fat is a little bit more contentious, and that's why we wanted to move it down on the priority list. This has a long history, the concept of low fat diets, goes back for many years. There is a lot of belief systems built in around that. Some people believe that low fat diets reduce the risk for heart disease independently of saturated fat. Other people believe that diets in a low percentage of fat reduce the risk for obesity, and others believe that it reduces the risk for cancer.

So there are lines of evidence to support all those beliefs. A lot of it is epidemiologic, some of it's studies in animals, not enough clinical trial evidence. But there is a body of data to reenforce that view.

We also feel that strengthen those data are not nearly as strong as they are for the saturated fat, blood LDL cholesterol link, and, in fact, I think if there has been a change in that view, it's towards less of a connection. We heard a talk yesterday about the connection between dietary fat and cancer, and it seems like it's not as strong as it was previously if you look at the observational studies and epidemiologic studies that are out there.

So I think it's also being questioned whether a low percentage of fat in the diet actually will prevent obesity. We've had a low fat guideline for a long time and yet obesity is increasing, percentage of fat actually has gone down, although not absolute amounts, but absolute amount of carbohydrate intake, we think, may have gone up, so to some extent our message may have backfired on us.

So I think we want to soft pedal the low fat a little bit compared to what we used to, and integrate it more into a general comment on total caloric intake.

So that's sort of the basis for our shift in emphasis. In addition, we may leave some of the language as we recommended before pretty much the same. As we discuss each topic, we want to make a strong care for the scientific base of saturated fat. We want to review the evidence for cholesterol and reenforce that. There's an ongoing question about the importance of dietary cholesterol. We have to be objective and careful. I think I tried to present the case yesterday why we believe that it should be in the guidelines and not eliminated.

And then we had come up with some language suggesting that the low fat be closely linked more towards low total fat in absolute terms than percentage fat; shift the emphasis there somewhat in the direction of integrating it in with a total nutrient, macro nutrient intake.

So I think that represents a view of our committee. I don't know that it's a total view of everyone in the room, but it's where we came down after further discussion after yesterday's meeting.

CHAIRMAN GARZA: Okay. Any comments, Richard? 

DR. DECKELBAUM: I would just like to add that we did discuss children, and within the group we felt that the recent evidence from the DISK study, the CAP study and the STRIP study in Finland, that we recommended amounts of fat, 10 percent saturated and 30 percent total, are safe for children; and that we thought that this could be implemented or try to reach that goal beginning with the age of two. 

DR. GRUNDY: Yeah, that reminds me. Another reason I think is that for, you know, keeping the language the same, although we changed around a little bit, and its priority was we're really not coming down with a different recommendation in quantitative terms. I don't know whether that's our goal to do that, but there were quantitative numbers put on the last time, and we're going to try to keep those pretty much the same. 

CHAIRMAN GARZA: Scott, at the risk of initiating a long debate, but I'll try to gavel it if the risk proves to be real, I've heard the working group's concern about trying to really focus the public's attention on saturated fat.

Would we achieve that goal if we chose as a pithy statement "Choose a diet very low in saturated fat and cholesterol and low in fat"? Or would that -- is so subtle that people would never catch it, be confusing in trying to capture the concern that you have that we really need to get people to focus more on the type of fat than the total amount of fat?

And then we'll take this up for about five minutes and then we'll move on to the next one.

DR. GRUNDY: Okay. Well, I think that that -- you know, what you just said would square with what we believe. Whether, you know, that's too -- you know, a little bit radical, any time you use the word "very low" in there, you know, it implies some kind of a radical change, I think, so I think we have to be a little bit careful about that, and I guess that would be my only concern although that's certainly -- we want to go in that direction.

Now, we thought changing the emphasis might take us there. Our current intakes of saturated fat are around 11 - 12 percent, and we also believe that trans fat is at least equivalent to saturated fat, so if there is another two or three percent, that would leave us around 15 percent of cholesterol-raising fat in the diet, which is a lot. And, you know, I think a lot of us would like to see that cut in half; get down around seven percent or something, and I don't know whether that's very low or low. I'm not quite sure.

CHAIRMAN GARZA: So we could decide if it is or not. 

DR. GRUNDY: But, you know, I guess -- I think that a change in the emphasis already is going in a certain, is going in that direction. I don't know whether adding "very low" is a good idea or not. 

CHAIRMAN GARZA: All right. Anyone -- Alice. 

DR. LICHTENSTEIN: I would be a little bit concerned with that approach although it's consistent with the intent. I think by putting "very low in saturated fat" would imply that we're changing the targets, and right now I don't think it has come up that we want to change that 10 percent or less, at least for this guideline and this issue, and especially given that the school lunch program and some other programs are based on those numbers, so that might lead to confusion. 

CHAIRMAN GARZA: No, I mean, the numbers don't change -- 

DR. LICHTENSTEIN: Right. 

CHAIRMAN GARZA: -- I mean, based on what we've said. It's just a matter -- I'm trying to deal with a concern I heard the working group was wresting with, and some of us came down pretty hard when we were having that discussion on total fat issues. I went home saying, well, all right, how else could we achieve the same aim. But Meir, and then we'll -- I don't know whether Suzanne would like to say something. 

DR. STAMPFER: Well, I don't think we have any reasonable basis for restricting intake of polyunsaturated and monounsaturated fats. In discussing this, the reasons for maintaining that restriction, we've done it before, and one committee member characterized it as the sins of the father, that we've kind of stuck with this mantra that fat is bad and that we can't dig ourselves out of the hole. Well, I think that's against the spirit of every five year review.

Another position was we should wait for the Women's Health Initiative because as a component of that trial there's a low fat part. The data for that will not even be available for preparation of the 2005 guidelines let alone this year's guidelines. We're always waiting for new data, so don't regard that as good evidence.

One of the fears was cancer, and that's really been allayed by emerging data. So we're left with the weight gain, which is controversial, and I think some people believe that fat is particularly causative for weight gain, other people don't. My own take is that the evidence is not that strong.

And you could say, well, what's the harm in limiting mono and polyunsaturated. Well, I think there is harm because we know that polyunsaturated fats are beneficial, and this isn't projections or pie in the sky; this is randomized trials with clinical outcomes that have shown that if you substitute polyunsaturated fat for saturated fat, you've reduced coronary heart disease and you don't increase any other adverse health outcome. So I think we should consider that.

CHAIRMAN GARZA: So, Meir, are you suggesting that we go above 30 percent fat? 

DR. STAMPFER: No, no. I don't think we should make a -- 

CHAIRMAN GARZA: We're not changing the number -- 

DR. STAMPFER: No. 

CHAIRMAN GARZA: -- is what I am hearing. 

DR. STAMPFER: No, my suggestion -- my suggestion is to drop the restriction on total fat, nd just restrict the fats that we consider harmful; namely, saturated fat, cholesterol and trans. 

CHAIRMAN GARZA: Well, maybe what we should do is go to a focus group because the concern that I heard expressed was by dropping total fat, that the public then would interpret that to mean that we were going above 30 percent. 

DR. STAMPFER: Well -- 

CHAIRMAN GARZA: And since the group isn't recommending that we should fall below 30, that's still consistent with a low fat diet as a way it's been defined. So that we could always go to a focus group and says, "Now,

if we don't say that, is that permissive in going above 30?"

Now, if you're arguing for going above 30, we need to be more explicit.

DR. STAMPFER: Can I just respond quickly? 

CHAIRMAN GARZA: Yes. 

DR. STAMPFER: I'm not arguing going above 30. I'm arguing against any particular target. I think 30 is reasonable, but I don't think we should say you're eating an unhealthy diet if you go above 30. I think we shouldn't have a prescriptive number except to say maybe the 30 is reasonable, because I think what Suzanne pointed out really quite on target; namely, that if we put nuts with fat, it will have a bad imagine. Well, that's because we've promoted this mantra of fat is bad, and I think we've got to face the emerging data that suggests that certain kinds of fats we need to be avoided, but certain kinds of fat are actually essential for our well being. 

CHAIRMAN GARZA: And you feel that is now sufficiently accepted by the scientific community that no one will argue with Dr. Stampfer's view -- 

DR. STAMPFER: No one will argue? Of course, everybody is going to argue. That's why I'm arguing.

(Laughter.)

CHAIRMAN GARZA: And what I'm saying is that

it's -- one of the hardest things for committees to do is to understand that we're not here to -- the end result very seldom is personally satisfying, and that's why I was pushing. It has to -- it has to reflect what we think is the best consensus of the nation's scientists. Now, if you feel very strongly that in fact we need to reforge a new consensus, then we need to be explicit in that, or there is data that is pushing us in that direction to be more explicit. But I need to have a sense from you as to whether or not the views you've just expressed are pretty common. Now, I mean, in fact --

DR. STAMPFER: One quick thing and then I'll shut up. 

CHAIRMAN GARZA: Yeah. 

DR. STAMPFER: I think our recommendations have to be based on evidence. 

CHAIRMAN GARZA: That's right. 

DR. STAMPFER: And if -- I'm awaiting to hear some credible evidence that's strong enough to support a limitation of polyunsaturated fats and monos given the proven benefits of polies in randomized clinical trials. 

CHAIRMAN GARZA: Okay. 

DR. JOHNSON: I would just like to reinforce what we had talked about yesterday, which is bringing in an expert at our next meeting on the role of fat and obesity, and I've drafted a list of names because I think there is still some issues about the metabolic efficiency of the different macro nutrients, and there are some metabolic clinical data that could support that. So I'd like to hear from someone about those. 

CHAIRMAN GARZA: Okay, Roland and then Shiriki. 

DR. WEINSIER: Yeah, I think I understand what Meir is trying to say, but the way I'm looking at it if wise men disagree, then there is probably more information we need to resolve this issue. I mean, we had a -- 

CHAIRMAN GARZA: Include wise women now as well. We'll get into trouble. 

DR. WEINSIER: Yeah, wise individuals. I mean, we had a very hot and interesting debate that was, you know, presented in the New England Journal, I thin, a year or so ago in terms of what foods to substitute. It's clear, as Meir is saying, we don't have the answer in terms of what's the idea diet for weight control.

I'm just not convinced that the data in to allow us -- see, I'm looking at reverse direction. It's not just a matter of restricting fat, it's the reverse, and that is that we're not recommending a higher carbohydrate intake, or if we don't restrict the fat, then we're recommending a lower carbohydrate intake. There are only so many calories, and those are the two calorie providing groups.

So I think we have to keep that in mind in terms of the major illness in this country, one of which is weight control. The answer is really not in, in my opinion, and that means that we have got to be sensitive to this.

CHAIRMAN GARZA: Shiriki. 

DR. KUMANYIKA: Two unrelated comments. One has to do with the wording. In the spirit of compromise wording where you said "choose a moderate fat diet that's low in saturated fat and cholesterol," would that help to get around the problem of targeting the fat intake?

Just to consider as we go forward trying to do that, that we get "low" and "fat" disassociated from each other, and put "moderate" in there.

The other comment is I'm not sure I agree with Rachel about getting in people to talk about metabolic differences in fat, and this is having been a part of the NHLBI guidelines where we tried to look at -- on obesity treatment we tried to look at the behavioral effects of fat, not the metabolic effects.

In other words, when people were in studies where they lowered their fat, was that more conducive to weight loss? Not necessarily for metabolic reasons, but because it was easy for them to find the foods that they wanted. And so I think if we look at the metabolism but we don't look at how these things play out in the whole person, the lifestyle situation, we might end up with the wrong conclusion, and so that's -- we may need experts to talk about the role of fat in weight management, but it may not be from a metabolic point of view.

CHAIRMAN GARZA: Okay. Johanna? 

DR. DWYER: I fully endorse the revision in terms of the saturated fat, the cholesterol, and I'm the person who feels very strongly that the consensus is not reached about total fat, and that this would not reflect the current view of the science.

But the bigger problem is that I think we may need to give more attention to foods and diets rather than focusing on single nutrients, and that it will be impossible, I don't know, maybe the consumers can tell you in a focus group what they mean by "low," but I think it may be a mis -- you're listening from cardiovascular ears to what low and high are, and it's not at all the same as what the average consumer things. So I think we need to focus on foods and actionable advice to the extent that this is a consumer document and clear advice to policymakers for the part of this document that really is not for consumers but rather for government and voluntary and other organizations.

CHAIRMAN GARZA: I think we've had enough -- well, we've had a number of suggestions, Carol, for the focus group on fat, and you've gotten them all down. 

DR. SUITOR: I hope. 

CHAIRMAN GARZA: Well, then, perhaps you could then e-mail to the group and then we'll add or subtract to them.

Roland.

DR. WEINSIER: Just very quickly another consumer issue. Is the word "saturated" readily understood? I mean, it's in -- when you look at a package of food and you look at the content, the word "saturated" is there. So if we were to say, you know, "Choose a diet low in saturated fat," if this wasn't looked at last time, and I have to guess it was, are we clear that people understand and are going to choose a food that's -- 

CHAIRMAN GARZA: Well, let's go to Dr. Geiger and see they -- was that term tested at all when you looked at your focus groups? 

DR. GEIGER: We didn't look specifically at saturated fats. Some of the people who had relatives or friends of coronary heart disease knew saturated fat was something they needed to eliminate, but they certainly couldn't define it. And others just thought fat was fat. and cholesterol, they really call it fat. 

CHAIRMAN GARZA: I've had students in organic chemistry classes that don't understand the term "saturated," so it's not surprising.

All right, then Scott?

DR. GRUNDY: You know, one other thing that I think is important is how are we going to get at this problem of the low fat food, proliferation of very low or fat free foods that are high in calories that are, you know, out there in the market and to some extent were in response to our low fat recommendation? Are guidelines going to deal with that in any way that will help to reduce that?

Now, the moderate in sugars, I think, is one step in that direction although that was not the primary purpose of that. But is there anything that we can say and include that will get across the concept that there are bad fats and bad carbohydrates both?

CHAIRMAN GARZA: We talked and different groups have talked about trying to incorporate some of that language in the weight maintenance category, perhaps in the introduction, whatever way we decide to try to unify everything to make people aware of the fact that just because it is low fat doesn't mean that it doesn't have calories. 

DR. JOHNSON: One suggestion might be even a comparison of labels which is something I do all the time. When you compare a regular food product with the low fat version, often there is very small difference in calories, and even by circling that and highlighting that, maybe it would be a way of pointing out that just because it's low fat it isn't necessarily low calorie. 

CHAIRMAN GARZA: The other thing we might want to do is consider asking the secretaries, I think the common phrase is that they focus some attention on current labeling. I mean, we think that the labeling is misleading because by saying "low fat" the implicit understanding of consumers is that it's low calorie, that perhaps we ought to ask them to reinvestigate that to make sure that consumers are not misinterpreting it as easily as perhaps they are. So there are various ways we can go beyond the guidelines in terms of getting the secretaries to look at issues.

The last comment now.

DR. LICHTENSTEIN: Just one other thing to consider in line with that is a lot of those foods that are now labeled low fat, maybe some are calorie-wise, the fat that was taken out was unsaturated and not saturated, so we miss the mark on what we really intended to do. 

CHAIRMAN GARZA: Okay. Rachel. Moving on then to choose a diet moderate in sugar is the current guideline.

(Pause.)

DR. JOHNSON: Maybe. I will just have to use my notes.

Okay, we had talked about the sugar guidelines, and what I wanted to present was a potential outline. You know, my notes are all on my slide so I'm going to have to at least pull that up so I can do it. So why don't we move ahead and I'll just --

CHAIRMAN GARZA: Well, why don't we go to the next one and -- 

DR. JOHNSON: -- do it from my desk. 

CHAIRMAN GARZA: From your computer, and that's with the computer. Okay, that would be fine.

Then, Shiriki, can you move on --

DR. KUMANYIKA: Yeah, 

CHAIRMAN GARZA: -- and then we'll come back to.

Do sodium and then we'll come back and do sugars.

DR. KUMANYIKA: I decided to go low tech and to write -- 

CHAIRMAN GARZA: Shiriki, can you get the microphone on, or it should be right there, the label?

(Pause.)

DR. KUMANYIKA: I tried to outline on these transparencies the -- you pulled the plug on it -- what I think are the key points that we need to go over and resolve for salt and sodium. The first two pertain to the overall guideline and consider changing the wording of the guideline, so maybe we could -- should we discuss these now or should I just go through and present -- 

CHAIRMAN GARZA: However you wish. 

DR. KUMANYIKA: I think we -- so to retain the guidelines, we agreed yesterday, but to consider the wording and drop sodium, and the other one I was wondering as I went through making the notes was whether -- yeah, we have that word "choose a diet" in a lot of these guidelines and, you know, what seemed to make sense five years ago may not make sense this time. if we say "choose foods" for -- "choose foods that are low in sodium," it would pick up the -- "or low in salt," it would pick up the fact that a lot of the salt is already in foods. But because there are seasonings that people are substituting, you would miss that, so maybe you do have to keep the "choose diet."

But does anyone have reactions to the idea of trying to drop the word "sodium," or will we take that back to focus groups?

CHAIRMAN GARZA: I don't think we would have to decide right today, but we could certainly ask Carol to add that to her list. 

DR. KUMANYIKA: Okay. You're going to be busy.

I mean, sodium does have partly the medicinal feeling, people -- patients will recognize low sodium diets, but it may not be helpful in the bullet of the guideline if it's mentioned someplace else in the definition.

What about the word "diet," should we add that, the use of the term "diet," which sounds like "dieting," because it's in several of the guidelines now; should we add that to the focus groups? Was that covered?

CHAIRMAN GARZA: That was -- I don't know whether that was covered in the past, whether diet means a reduced caloric.

Connie, has that --

AUDIENCE: (Not on microphone.) 

CHAIRMAN GARZA: Choose an eating pattern. 

DR. KUMANYIKA: I mean I avoid "diet". I can't even use it in questionnaires because a lot of consumers take "diet" to mean a prescribed diet, so I just mention that in relation to the sodium.

Meir?

DR. STAMPFER: One possibility is if we go along with kind of major and minor guidelines, then we could have a different format and maybe just have it, you know, limit your intake of salt or something like that. 

DR. KUMANYIKA: Yeah, that raises different issues though, and I mention later on sort of where to put the importance. But if you start saying "limit," we're back to the avoid and limit type of guidelines. And if I remember correctly from the earliest focus groups, the word "avoid" is not one that's understood by people with limited literacy skills. So. I think it's Dok and Dok who do this presentation.

They said when the tested that in focus groups what people actually saw was "sodium" because they didn't understand the "avoid," so they totally missed the message, you know, associated with limiting it, so leave that to the experts in terms of how to convey, you know, if you could get away with that, but we might consider whether "diet" is the right word.

DR. DWYER: Shiriki, can I ask you one thing on that though?

It seems to me there are others who are far better qualified at least than I to do this sort of communication stuff, but on the scientific issue, are we of one mind that the sodium is the problem rather than the sodium chloride? We talked a little about that, didn't we?

DR. KUMANYIKA: Yeah. I mean, the chloride evidence has never gotten to the point where it becomes the issue partly because most of the sodium in foods is associated with sodium chloride, so it becomes a moot issue.

We did have a presentation last year on the form of potassium that's in foods as an issue related to the potassium data, but I don't know that anybody has thought about whether the other forms of sodium in food are contributing enough quantitatively to be targeted, so I don't think they are considered to be less harmful than sodium chloride. It's just that they're not there in larger quantities.

Alice?

DR. LICHTENSTEIN: Also from a consumer perspective when you think about discretionary sodium that could be added, it's really sodium chloride, whether it be in cooking or at the table. 

CHAIRMAN GARZA: I'd like to try to make sure that we don't deal so much with trying to word-smith this at this point because we need -- we need to go ahead and have the document, the full documents in front of us. 

DR. KUMANYIKA: Okay. 

CHAIRMAN GARZA: Because if we try to deal with it at this level of specificity, some of you will miss your planes. 

DR. KUMANYIKA: Yeah. Well, let's -- 

CHAIRMAN GARZA: And I don't think it's doable anyway. 

DR. KUMANYIKA: -- for these as conceptual issues about how to describe what we're trying to accomplish and leave it to the consumer research to help us decide that in the final analysis.

Okay, the key points in the guideline that are there now are that it's appropriate at this juncture just to get some kind of confirmation that these are things that should be continue to be addressed or added to the text: the definition -- yeah, just to make sure people know what it is we're talking about. Intake is too high. It's higher than physiological needs. Do we want to add something about that eating out may increase sodium intake, which has appeared other places, but most recently in this USDA analysis? That it's mainly in processed and prepared foods, which is there now. Can be lowered safety and "role of iodized salt" would be new points to be added, so maybe we could discuss whether there is support for adding -- that "intake may be increasing associated with eating out, that it can be lowered safely," which we really don't cover in the current text, and the "role of iodized salt."

CHAIRMAN GARZA: Any comments or questions?

Roland.

DR. WEINSIER: Yeah. Was there another section you were going to go to? 

DR. KUMANYIKA: Um-hmm. Well, I just wanted, because some of these will require us to summarize evidence that we've collected, and I think the committee can do that if we think that these topics belong, at least in the next draft. 

DR. WEINSIER: Yeah. I didn't know if you were going to get to our not, I was just going to come back to the issue that some of these made me a little uncomfortable, not what you said, but in the past guideline that the effect of sodium is basically related to one disease; that's hypertension. 

DR. KUMANYIKA: Um-hmm. 

DR. WEINSIER: Whereas hidden somewhere under hypertension is the effect of sodium on calcium. 

DR. KUMANYIKA: I have that on the next one. 

DR. WEINSIER: Okay, that's what I was -- 

DR. KUMANYIKA: Any other? Um-hmm? 

DR. DWYER: I think that something does need to be said about iodized salt, well iodide, that some people are getting too much and some are getting too little. 

DR. KUMANYIKA: So if it's worth the committee -- subcommittee doing the work to try to draft some supporting evidence on those points, we can seek and always come out later. 

DR. DECKELBAUM: What do you plan to address relative to iodized sat? Is it what Johanna is saying? You know, what moderate intake might do or low intake to iodine sufficiency or? 

DR. DWYER: I think, at the risk of being -- making a mistake, the issue is there are clearly some people who are not getting enough. There are also some people probably suffer from iodide toxicity. It happens to be the only connection with salt is that the vehicle for fortification with iodine in the United States is salt. So

it comes in under there, but it's basically something that comes in in the part that we talked about very early this morning that Dr. Lichtenstein presented on the whole issue of fortified foods.

DR. DECKELBAUM: I just want to mention one point on that. When you deliberate in iodized salt, because this report is read outside the United States, that iodized salt has been a major step towards eliminating iodide deficiency. In fact, it's a major step worldwide and it's still -- so one has to be very careful, I would say, specifically on this point on how it could be interpreted outside the United States in areas where iodide sufficiency is common. 

DR. DWYER: Richard, I don't think the point we were making the subcommittee was that we were talking about eliminating that vehicle for fortification. That wasn't -- 

DR. DECKELBAUM: I'm just saying that -- 

CHAIRMAN GARZA: Let me ask if we can let Shiriki go ahead and complete her presentation and then we will go to questions. Otherwise, it may take -- 

DR. KUMANYIKA: Yeah, okay. 

CHAIRMAN GARZA: -- too long. 

DR. KUMANYIKA: But I think we agree that we need to consider what to say because people are aware that this is a fortification vehicle and if we don't say anything, they don't know how to think about it, and what to say about it is the more complicated.

In the guidance -- oh, this is the second over here. We didn't talk about this one yet. And then the next major point is why do sodium intake or salt intake, and there's the blood pressure evidence that can be updated and strengthened based on studies that have come out since 1995, and the other reasons that are or might be listed are shown here: the gastric cancer, asthma, calcium retention. And whether we want to say anything about water intake or water retention here is something I think we should consider.

So we have collected references, updated reference on gastric cancer to see if anything is warranted. We've tried for asthma, but literature is very thin. We've fairly good evidence on calcium retention, although the effect size has been questioned by some people, and we might need to translate that into an affect size that's meaningful or otherwise people could get the wrong idea.

In the community, water retention is something that people associate with sodium intake and a benefit of reducing their sodium intake is water retention. We never mention water anywhere in the guidelines probably, so we should consider the sodium as a logical place to mention water.

In the guidance, we can consider covering whether sodium intake is for everyone. There seems to be a strong sentiment to talk somewhere about salt sensitivity, and we mention that the current guideline it's saying there was no way to tell who is salt sensitive, but we could talk about sodium intake for everyone and maybe pick up some other concerns about adverse effects.

Should we try to come up with a practical target range? I think we should try. Whether it will end up in the final booklet, I don't know, but we're going to -- the subcommittee will make some recommendation about whether to include numbers and what they would be, and I'm thinking a range to have a bottom and a top.

And then a relationship to overall dietary pattern, possible topics: flavor, convenience and I mention the iodine there, but it might have come up earlier. That's the first part of the relationship to overall dietary pattern, to acknowledge reasons why people might be consuming salt or why it's in foods.

And the second part of the relationship to the overall dietary pattern is compatibility with other dietary guidelines and the relative importance in relation of other dietary guidelines if could do that in a way that's constructive.

Targeting would be an issue. Are there people who should be particularly interested in sodium reduction; you know, risk of high blood pressure, whatever?

So the text in there now about other factors also affect blood pressure will have to come into one of these topics, but it shouldn't necessarily be a main heading.

And then finally, how to lower salt or sodium intake or maintain a lower salt intake? There are two categories, and one is discretionary, and flavor issues is where we might talk about substitutions for flavoring; and the other is the obligatory of the salt that's not really in food for flavor, recognizes flavor, but you pick it up as you go along of foods formulated with sodium.

The final point that's come up in discussion is whether we should move the potassium box to the fruit and vegetable section. And the more I look at it the harder it is to understand the placement of that big box. As it is now, it really does jump out at you, so fruit and vegetable people, please try to give the potassium box a home in case we want to move it.

(Laughter.)

DR. DECKELBAUM: Together with nuts. 

DR. KUMANYIKA: Well, potassium issues, you know, fruits and vegetables are a good sources of potassium. 

DR. LICHTENSTEIN: I would just like to ask for some data on the magnitude of iodine deficiency and iodine excess in the United States since that's where these guidelines are at least initially intended for, so we have some idea of what the magnitude of the problem, potential problem is. 

DR. DWYER: The papers in Morbidity and Mortality Reports for -- no, I'm sorry. It's in the Journal of Clinical Investigation. I'll give you the reference. 

DR. KUMANYIKA: Well, we have a CDC report, but I don't know if the whole committee got it, but certainly we could -- it's the proceedings of the whole conference. It could certainly go to everybody. 

CHAIRMAN GARZA: Any other questions or comments?

Roland?

DR. WEINSIER: Yes, just real quick.

I think Shiriki probably has a better suggestion, I mean, her suggestion is probably better in terms of perhaps moving the potassium to the fruit and vegetable guideline. But did you consider the possibility of maybe letting this one focus on choosing diet low in sodium and high in potassium, and go ahead and address both in this context because many of the disease you're dealing with look at sodium/potassium in inverse relationship, so you could justify doing it. But either approach, you know, should handle the problem.

DR. KUMANYIKA: I think that we can consider it. The caution that I've always been aware of is that people are afraid that people will take potassium supplements in other forms, and that there is some people for whom that could be problematic, that they won't take it from the fruits and vegetables. They'll go out and get a potassium supplement and get into trouble. So there has always been a reluctance to recommend potassium increase directly, especially as the evidence doesn't support an independent role in blood pressure. This is very tricky as an advice to consumer issue.

Other people have different ideas, but that's where my concern is.

CHAIRMAN GARZA: I'm going to allow sort of two or three picky questions now. 

DR. JOHNSON: Well, I'm just -- the thought crossed my mind that given the results from the DASH diet that this might be a good place also to just continue to pull together the other guidelines, reenforcing fruits and vegetables, low fat dairy products and the food pattern that was useful in DASH, if this is more or less a hypertension guideline. 

DR. KUMANYIKA: Well, is it? 

DR. JOHNSON: I don't know. Is it? 

CHAIRMAN GARZA: All right, Richard. 

DR. DECKELBAUM: I was just wondering, except for the hypertensive population, which is a significant number of the population, how much of the general population really realize that this is an important -- you know, the importance of potassium, whether that's been covered in any of the focus groups to date. 

CHAIRMAN GARZA: Probably very little would be my guess. 

DR. LICHTENSTEIN: Just to reenforce that, I question whether the general population knows what potassium is and whether they would be better served by just putting more emphasis on fruits and vegetables, and that would take care of it. 

CHAIRMAN GARZA: Scott. 

DR. GRUNDY: I think that all of this is not exactly a hypertension topic. It certainly is an opportunity to get into hypertension. And if you had a -- I know that it's mentioned in the text about the other factors that affect blood pressure, but a table of those factors might be more valuable than a table of potassium sources, so that you could see in one place a list of all the factors that contribute to hypertension, and that could get into your DASH diet and exercise and other things like that. 

DR. DECKELBAUM: Factors contributing to a healthy blood pressure or something like that. 

DR. KUMANYIKA: Yeah. 

DR. JOHNSON: Yeah, that's good. Can't wait. 

DR. WEINSIER: But don't leave out the osteoporosis here. I mean, it's the same sort of inverse relationship between sodium and potassium, I think. I would build on that. I mean, this has potential, you know, powerful effects on two major diseases and perhaps others. 

CHAIRMAN GARZA: The other point that Shiriki reminded me of in the presentation, and this applies to many of the guidelines, and I mention it only so that we all can keep it in mind to Carol in the specific prose is the new data that up to 40 percent or perhaps even more of the total food that is consumed is consumed outside the home, and so that in providing guidance for implementation, it's helping people understand how to implement the guidelines, recognizing that close to half the time they are not eating within the household, and that relates to weight maintenance and to fat control and to a number of other issues.

And we recognized it in the previous guidelines, but perhaps not as explicitly as we should in this one.

So with that, let's turn on then to carbohydrates.

DR. JOHNSON: Okay. You'll see where I had Power Point because I am left-handed and don't do overheads particularly well, but I'm sure you will see them.

Okay, I'm just going to present a proposed outline for the sugar guideline, followed by proposed changes with some rationale and then further information that we feel we need for this sugar outline.

This is just a proposed outline more or less for the technical report, and then we'll pull out for the consumer booklet. I think we probably want to define sugar and I think we need to think about whether or not we want to use or bring in that USDA definition of added sugar, which is sugar that's not naturally occurring in the food product. And it's been very clearly defined by USDA, primarily for use in analyzing their nationwide food consumption data, but we do have that definition.

We have put in some information about current added sugar intake in the U.S. by age, various age and gender groups; the primary sources of added sugar, which I covered yesterday. The number one source is carbonated beverages, followed by sweetened grain products and various others, but I believe there were four sources that are the primary sources of about 75 percent of all added sugars. Then some information on the effect of added sugar on diet quality or this nutrient displacement effect that we've been able to demonstrate with our new ability to look at added sugar in large group consumption databases.

Some information on the changing beverage patterns in the U.S. and their effect on -- particularly on calcium intakes. I think we need to think about how much we want top ut in there about sugar and disease patterns. I think the data are fairly weak on sugar and weight diabetes and cancer, although that world cancer book did recommend reducing sugar, particularly sucrose, for reduced cancer risk, although Dr. Byers yesterday in his presentation did emphasize that he felt the data were weak there.

I'd like to see us reenforce what was in the '95 booklet, that sugar does not appear to be related to children's behavior pattern and continue to try and put to rest the myth that sugar causes hyperactivity or other types of deviate behaviors in children, and some information on dental carries sugar and carry genecity.

In the '95 booklet, there is information on artificial sweeteners. It's fairly brief. I'd like some feedback on whether or not you'd like to continue artificial sweeteners and mention of them. I found one study that related use of artificial sweeteners to enhancing long-term weight maintenance, but I think, again, the data are sparse in that area.

Some of the things the subcommittee has talked about on proposed changes, and I'm not saying, you know, this is the final wording. It's just trying to put the thoughts together that everyone had, that we'd say something like "Choose a diet moderate in food and beverages with added sugars," and these changes were proposed primarily with the intent being to try and emphasize those foods and beverages high in added sugars with low nutrient density, and I heard several times over and over to give special emphasis on beverages since clearly they are the primary source of added sugars in the -- in American's diets.

One big problem that was very clearly brought to my attention yesterday by Kathryn, which I really appreciated, is that the food labels don't currently distinguish added sugars. And if you look in your dietary guideline booklet on page 13 and 13, you'll see a sample food label. And what Kathryn showed me yesterday, she put a can of 100 percent orange juice next to a can of carbonated beverage, and the total sugar content was very similar. So if a consumer looks at the food label and looks at sugar, it's not distinguished, and you'd really have to go into the ingredients to try and distinguish those added sugars. So I think that could be problematic if a consumer is trying to identify added sugars, although I think we could provide a lot of information about that in the booklet.

Some of the information that I think we still need are the consumer information that we've been talking about getting, the understanding of the term "added sugars" versus just "sugars." I'm not really convinced that when we say "sugars" to consumers, do they think of fructose in fruit. According to Dr. Geiger's report, there is some confusion on the part of consumers when we tell them to eat a lot of fruits and then we tell them to moderate their sugar intake, but I'm not really clear how we could best deal with that in a guideline.

Do consumers understand that things like corn syrup and high fructose corn syrup, which are used as sweeteners, would be included in that category of added sugars? And yesterday one of the committee members asked for some strengthening of the information in the data that we have on the carcinogenicity of various sugars.

Okay, that's --

CHAIRMAN GARZA: Any questions or comments from either other members of that working group or the whole committee if none of the working group wants to add?

Meir.

DR. STAMPFER: Just real quick.

I think we should be cautious about the sugar substitutes. I think the current booklet has it right. Unless you reduce total calories, use of sugar substitutes will not cause you to lose weight, and I wouldn't put much emphasis on that new study because it was part of a whole program of weight loss. It wasn't just specifically testing sugar substitutes.

In the Nurses' Health Study, who have gained more than a million pounds, the number one dietary predictor of weight gain was saccharin.

CHAIRMAN GARZA: Well, that may be a totality, but this does raise the point that Scott has made often; that we may want to strengthen our attention of strategy that people might use to limit their total intake, and so the addition of a sugar substitute may give people license to then have twice as much of something else and not understand that it is a caloric balance issue, so maybe we could move some of that to the weight gain to deal with that issue. 

DR. DWYER: Just two points, the first is the last.

In addition to what you mentioned, Rachel, it's also important to consider the carcinogenicity of various fermentable carbohydrates. The point is that it is not limited to sugars; it is also other carbohydrates that are fermentable, so it's a mistake to just link it one way. You'll get a negative when it might be positive.

The other is, it seems to me that it's sensible biologically to consider -- also presenting, presenting total intakes of carbohydrates and then various breakouts under there in the first part where you're talking about defining sugars, and I think that way --

DR. JOHNSON: I don't understand that. Can you clarify? 

DR. DWYER: What I mean is you said on your outline first was the definition. 

DR. JOHNSON: Um-hmm. 

DR. DWYER: And then current use of added sugars. What I am saying is it would make more sense to me to do total, total carbohydrate and total whatever it is, sugars, and then within that do the added, so you get a whole idea of that category.

Does that make sense?

DR. JOHNSON: Yes, I see what you're saying. 

DR. DWYER: Because that will link it back to where the label is now. 

CHAIRMAN GARZA: Okay, any other -- Scott. 

DR. GRUNDY: The way this is -- the way you have written on page 33 of this about the link of sugar to overweight, it's very ambiguous and I think that it does contribute to overweight, and that has to be made clear. Every calorie you take in excess contributes, and this is one way to help to limit calories, so there is multiple reasons for limiting sugar, but I don't think it's written in a very good way here. 

DR. JOHNSON: If you have any citations that link sugar intake with weight, I would very much appreciate them because I know what you're saying about total calories, but the data is very sparse when you compare people with high sugar intakes to people with lower sugar intakes, and look at weight as an outcome. The data is sparse. 

DR. GRUNDY: I think here is my -- I'll tell you the problem, I think, is that you can't relate any one single thing in studies to the overall weight of a population. It's the total caloric intake from multiple sources, so people that would look at fat, and you can't find a relation to fat to weight, you can't find a relation to sugar to weight or any particular thing. But there is no question that the sum of all of those is what makes the total caloric intake, so the studies can't be done in that way. 

DR. JOHNSON: Well, you can't even relate total energy intake to weight because of the problem of underreporting, so we can't even prove that total energy is related to weight very effectively. 

CHAIRMAN GARZA: But we do know something about physics. 

DR. GRUNDY: Yeah, that's right. We are fortunate in that regard is we do know certain things about physics and chemistry. We know your students -- 

CHAIRMAN GARZA: I said "some," not all.

(Laughter.)

CHAIRMAN GARZA: Shiriki. 

DR. KUMANYIKA: In looking for data, there may be data relating behaviors, like intake of certain type of foods rather than the total calorie intake, and I'm thinking of just one study. So if you ask about food patterns, you may be able to pick something up which is suggestive without knowing the mechanism that these behaviors are associated with weight. 

DR. KUMANYIKA: Right. We do have the data that say that -- that associate particular foods with increased energy intake over the last five-year period, so that could be helpful because there is some data that soda is a large part of that component of the increased energy intake. 

CHAIRMAN GARZA: Okay. The only other thing that I would add in terms of your data needs is to look more explicitly at other age and physiological groups in relation to the whole displacement issue. I'm thinking not only of the elderly, but of pregnant women, lactating women, in addition to adolescents. If there are specific groups that we need to be concerned about, we need to identify them and see whether there are any data that would help support. 

DR. KUMANYIKA: Right. As I said, we did that analyses controlling on age and gender, but Shanthy and I, I think, can break it down to see -- 

CHAIRMAN GARZA: Yeah, so I think it's an easy thing to do. 

DR. KUMANYIKA: -- and we can do that. 

CHAIRMAN GARZA: All right. Okay, then -- 

DR. LICHTENSTEIN: One last thing.

I think we talked a little bit yesterday, Rachel, about the diseases. Like you were saying obesity, in your view, doesn't link to added sugars, but some others do. Maybe it would be helpful if we could just consider a grid next time that starts with total calories and goes all the way down to this added sugars category, but that also includes carbohydrate fermentable, non-fermentable, total sugars and then added sugars, so we can see how those things work out. They are not all the same. Some of the issues are only affected by one of those and some perhaps by others, like total calories. Certainly everybody would agree is associated --

DR. KUMANYIKA: I see what you're saying. A gird of disease and then the effects of carbohydrates -- 

DR. LICHTENSTEIN: Correct, yeah. 

DR. JOHNSON: Just for our own use really to think about -- 

DR. LICHTENSTEIN: Yes, for our own use. 

CHAIRMAN GARZA: Okay, we will be moving on to alcohol. 

DR. STAMPFER: This is the same overhead I showed yesterday, and this was supposed to be a controversial guideline but actually there doesn't seem to be a lot of sentiment for major changes in this guideline, and I think most of the changes are in the category of word-smithing, which I don't want to go into now, and we can do that as we refine the document.

Just to briefly mention some of the word-smithy type things, without getting into the words themselves: a greater emphasis on adverse effects coming up front. I think that was a good suggestion; clarification on alcohol use in pregnancy and medications.

This is a nonword-smith issue which we could discuss is whether we should specifically target different age groups because the risk and benefits vary by age and also gender. Should we specifically target or mention breast cancer risk? Right now it says "certain cancers." It's vague. My own view is that we should.

There is one word-smithy thing which I would like to get some feedback on, which is this sentence that several people have mentioned. It's the third sentence in the booklet. "Alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history." And I'd like some guidance here because our charge was to only make changes where there is very clear, good scientific evidence that the guideline is wrong or somehow faulty. And this sentence is obviously true, and I don't think anybody can come up with scientific evidence to the contrary. So if we want to change this sentence, then we need to apply some other principle, and I don't know what the sentiment of the committee is for doing that.

The reason that sentence was put in, as I mentioned earlier, was to emphasize alcohol as part of the diet as opposed to alcohol as a drug. And to that end, I think that the intent was correct, to promote moderation and alcohol is part of the diet, but it's an issue that maybe we ought to have a few words about.

So that's all I had to say about alcohol.

DR. LICHTENSTEIN: I have a problem with that sentence because I think it's inconsistent with the way the other guidelines and other types of foods and components of foods are presented. 

CHAIRMAN GARZA: Roland. 

DR. DECKELBAUM: I support that. This is encompassed on page 1 of the introductory section where "Food choices depend on history, culture and environment, as well as on energy and nutrient needs. People also eat foods for enjoyment." I think it's encompassed in the general guidelines. I think it's out of place, specifically. 

CHAIRMAN GARZA: And, unfortunately, it's being misconstrued. I mean, that, I think, is the other principle; that as an endorsement or a recommendation or an encouragement people should adopt drinking for pleasurable reasons and that, I think, we also take into account. 

DR. DWYER: I think the problem is that it isn't false. The issue is singling out any one thing and saying something special about that. For instance, if we instead of nuts, Meir, if you consider avocados, for example, if you start singling out any one specific thing and saying it is good, I'm not sure that's our purpose here. And so I guess we'd have to say that maybe it should be taken out. 

CHAIRMAN GARZA: I don't know who it was, but somebody commented, I found it convincing that to be consistent we'd have to say, well, you know, fat adds to enjoyment and salt adds to the enjoyment and sugar, and so the -- I mean, yeah, we've singled that one out, and if it's encompassed in the introduction, then perhaps that's sufficient, but I would take that principle. But once we adopt that, to be careful that in fact we're being consistent in other ways throughout the guidelines as well, so I don't want to single this inconsistency alone. I think we need to look for others and make sure that we're not doing this in relationship to other of the guidelines.

Is that helpful?

DR. STAMPFER: Yeah. Yeah, I think that's very helpful, and also if people have other ideas about a message that would enforce the moderation and dietary aspect without being in the same tone as this sentence that a lot of people seem not to like, then, you know, that would be good to work into the wording. 

CHAIRMAN GARZA: Okay. Any other comments related to the alcohol guideline? 

DR. STAMPFER: Can I get a sense of the sentiment of the group on whether to specifically mention breast cancer and also whether to specifically mention age groups and the difference in the risk and benefits? 

CHAIRMAN GARZA: Richard. 

DR. DECKELBAUM: I'd agree just to reenforce -- I don't think you need a replacement sentence of that sentence were used -- 

DR. STAMPFER: Oh, no. 

DR. DECKELBAUM: -- you know, you go on right to the next paragraph about, you know, the benefits of, you know, moderate intake, and leaving that sentence in actually is something that's -- you know, women are only allowed or should only have half the amount of a man does in terms of this accompanying enjoyment with meals. It's discriminatory.

(Laughter.)

CHAIRMAN GARZA: No, I do think that to the degree, Meir, that the group can give the American public the very best guidance in terms of what the risks are as well as what some of the punitive benefits of moderate drinking may be so that in fact people can make their own choices will be important, but it's giving the public .the beset information we can of both sides of that coin. And as we heard from Dr. Gordis and your presentation and the presentation from Tim Byers, it's not a simple story, and it's not going to be an easy statement to craft because of that, but I think we need to be inclusive of the data, of all the data, both risk and benefits in as objective a manner as we possibly can. 

DR. WEINSIER: For consumer purposes, we use the word "moderate" and "moderation" frequently in here and specifically with regard to three guidelines, and I'd just like to be ceratin that that is interpreted appropriately as we intended by the consumer. 

CHAIRMAN GARZA: I'm sure Carol has added that to her list. 

DR. JOHNSON: I'd just like to answer your question about breast cancer, and I say yes, I think we need to say something about the risk, because now it just says "some cancers" or "certain cancers," and I think from a female perspective we really would like to point that out because it's a major concern to a lot of women.

CHAIRMAN GARZA: No, that's fine. I think wherever we can be more specific. I think it's going to be difficult in adhering to our guidance of trying to keep it concise and yet give people the holistic picture with specificity.

All right, I've talked to the two heads of the two working groups that we still have to listen in terms of whether we should break for lunch before or after, and they have both assured me they will need about five minutes, so we're going to do the next two, break for lunch, and then come back and adjourn. And so we should be done, I hope, by about 1:30.

DR. LICHTENSTEIN: Okay, there were no further formal deliberations on the -- or informal deliberations on the issue of supplements. Right now most of the information on supplements is in the first guideline, whatever that first guidelines ends up being. I haven't heard any suggestions that it should actually be moved to another guideline.

There was a little bit about it on grains, fruits and vegetables, but we'll just have to reassess what's going on there.

One option is no further change, but that's probably not a good idea because at the very least we need to update the text consistent with what the new changes have been with respect to foliate and as Dr. Dwyer has just pointed out, iodine and salt just never got in there to begin with.

I think we also have to do a better job, or it seems to be the consensus that we need to do a better job as far as distinguishing between trans that are added due to government policy versus those that are discretionary, and perhaps include a glossary or some definition of what the current terminology is, especially with respect to what the consumer sees and hears as far as enriched, fortified, or other kinds of things.

In addition, between the 1995 and the current guidelines now, there are health claims as far as structure, function claims, and I think we need to give some guidance, and that's missing with respect to what's currently in the guideline.

There also maybe need to put some text in regarding what health claims are, what they mean, how do I use them, how do I react to them, acknowledging that these things or these claims now are on food labels and food packages, and we do have a text now entitled "Where do vitamin, mineral and fiber supplements fit in," and perhaps that needs some modification, again, consistent with what current definitions are and current usage.

One potential is to actually take this whole supplement and the supplement subcommittee and actually merge it with the previously called variety subcommittee. And least this be interpreted as a hostile takeover, I assure you it's not.

(Laughter.)

I happily concede my chairmanship, and perhaps can pick up fruits and vegetables or something, but I think -- right now I think that would be the most efficient and appropriate way of handling this whole topic after having explored other options.

CHAIRMAN GARZA: Any questions or comments?

Shiriki.

DR. KUMANYIKA: I'm listening to this based on my experience of being on the Commission on Dietary Supplement Labels, and thinking that so far your subcommittee is enjoying the luxury of thinking only about certain types of supplements. So I would suggest that what is a dietary supplement that helps a consumer understand there are many types of things called dietary supplements, and that this guidance has to do with the ones that have -- you know, there are vitamins and minerals, or whatever we decide, but that we really help the consumer to figure that out in addition to structure, function, claims and health claims. It's going to be hard to craft something short, but we should integrate the deche and dietary supplements fully into the dietary guidelines, I think, and I'll volunteer to add myself to your subcommittee, which I think should remain separate for that purpose. 

DR. LICHTENSTEIN: I'll let the Chair handle that one. 

CHAIRMAN GARZA: The only other point that we should probably think about, and that's this whole working group, including Shiriki, is the difficulties that the working group faced in terms of the database, trying to determine the role of supplements in the American diet because often the consumption surveys and both done by DHHS and USDA are very -- present us with difficulty in trying to answer or understand the role that supplements are presently playing in the American diet.

And if we're going to craft any information, at least in the future, that is very informed, then making some recommendations as to how that data collection could be done may be useful.

Is that a fair statement, Suzanne?

DR. MURPHY: Sure. I mean, the more data you have to make informed decision the better off. 

CHAIRMAN GARZA: Is the data as poor as I perceive it to be or is it -- could we have other analysis that we haven't done to date that could inform what we're doing? 

DR. MURPHY: Well, to my knowledge, the only released -- there are not any released information from NHANES III on the contribution of supplements to diets, but I believe that's fairly imminent, and I don't know if anyone wants to make a statement to that effect, but that information would indeed be useful for us, and I think, hopefully we'll have it before we finalize the guidelines.

But as an ongoing request from this committee and many others, it's very helpful when the national survey data give us information on supplement use.

CHAIRMAN GARZA: Okay. Well, maybe we could sit down with Shanthy and see what we can do through interdepartmental cooperation, getting some of that information.

Scott.

DR. GRUNDY: Just one point.

In expanding this area a little bit, the public is increasingly bombarded with new types of foods out there and also food additives like fat substitutes added to food, which the FDA called food additives, and now we're going to see more and more enriched foods like catsup enriched, all kinds of things. And, you know, having some interest in what the industry is doing, we're going to see a tremendous amount of this.

Now, we can't cover these points, but I think in this definition of the different categories of supplements, food additives, enriched foods, it would be helpful to the public to have all that in one place. I think Shiriki alluded to that, but we haven't talked about food additives. That came up once previously in our discussion talking about fat substitutes, where do they fit in and so forth, so I don't know.

CHAIRMAN GARZA: No, I was laughing because -- 

DR. GRUNDY: At least a table. 

CHAIRMAN GARZA: -- we may have solved your potato problems. 

DR. GRUNDY: Yeah. 

CHAIRMAN GARZA: We have like a peanut enriched catsup. 

VOICE: Put on our french fries. 

CHAIRMAN GARZA: French fries, that's funny.

Johanna.

DR. JOHNSON: Does it count as a vegetable in the school lunch program? 

CHAIRMAN GARZA: Why not?

Johanna?

DR. LICHTENSTEIN: I think the combined survey that USDA and HHS are now deliberating, getting started, might have better information than prior surveys, and so perhaps it would be a useful statement to include, that this is important. 

CHAIRMAN GARZA: All right, then, if we're ready, we'll move on to food safety. 

DR. DWYER: I will try to make this very quick.

We talked about it last so people were tired and I suppose because of that they agreed. There was one thing that has come up between now -- between yesterday and today that needs attention, and that is that we need to get, in terms of the data, the scientific evidence, we need better data on deaths.

Yesterday we received -- those of us on the committee received a little bulletin. Since then I inquired. The NCHS -- I think it was the NCHS model that the use for estimating deaths from foodborne illness probably was not a very good, or the extrapolation that they made from illnesses to deaths was probably not appropriate, so we need help from CDC or FSIS or somebody to do a better estimate there in the rationale.

We deliberated briefly on the various possibilities for something to say and came up with the "Handle food safety from market to table," one, is probably the most actionable for consumers. We haven't discussed very much the issue of exactly what shall go in it, and let me just mention a few things that might be the core of a separate guideline on food safety.

First, the greatest degree of consensus among the experts consulted was on bacterial foodborne disease because it's the most common problem and easiest for consumers to prevent by their actions.

Next slide.

It's not that there aren't other issues. It's that these are issues that the experts all agree are there. These guidelines that Dr. Woteki talked about -- the ones about clean, separate, cook, chill, follow the label, serve safely, if in doubt, throw it out -- seemed, again, to be well justified, things that people can do that really do help.

Next slide, please.

Also, there seemed to be a good deal of consensus about who the groups are who need special help: pregnant women, very young children, older adults, and then people who are immunosuppressed for a variety of reasons.

Next slide, please.

This, in the questions that Dr. Suitor posed, came under some scrutiny because it's very long and the question is: Do you really need something that says temperature? Do you need a chart if you make text? And I would suggest that if it's used at all, it should be something that's a better graphic than this, but not text; just throw in an illustration.

Next slide, please.

I think that's it. Basically suggest that this be a separate guideline because it fits better, I think, by itself than it would under nutrients or something, some other rubric.

CHAIRMAN GARZA: Any questions or comments?

Either the troops are hungry or it was right on target, and I hope it was the latter.

All right, then, we will adjourn. We will be back at 1:15 and we'll wrap up in 15 to 20 minutes, and we should be out of here by 1:30.

(Whereupon, at 12:30 p.m., the hearing was recessed, to reconvene at 1:15 p.m. this same day, Wednesday, March 10, 1999.)

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AFTERNOON SESSION

(1:21 p.m.)

CHAIRMAN GARZA: Okay, we are reconvening. I want to thank the group for taking such an efficient lunch and being back on time.

The first order is to make sure that everybody has the meeting that's scheduled for June on your calendars, and we have the final dates on that, and we are aware that there is one of us with a conflict on the last day, and so I apologize, because we couldn't find a date that was suitable for everyone. And then we've got some dates -- tentative dates for September.

DR. STAMPFER: What is the date? 

DR. BOWMAN: The June date, it's a Wednesday, Thursday and Friday, that's all I know. 

DR. SALTOS: Sixteenth to the 18th, I think. 

DR. BOWMAN: Sixteen, 17 and 18. 

DR. SALTOS: You're telling me the June one? 

DR. BOWMAN: That's correct. 

CHAIRMAN GARZA: And for September, we had originally planned what? 

DR. BOWMAN: September was 7th, 8th and 9th, something like that. 

CHAIRMAN GARZA: Yes, that's right. I've got them right here. Seventh, 8th and 9th, and what we've been asked is to see if we can possibly do it the preceding week. 

DR. BOWMAN: No, the week following. 

CHAIRMAN GARZA: The week following. 

DR. BOWMAN: Because for these three dates this auditorium is not available. We will have to do it at a different place and then we won't have all this service. 

CHAIRMAN GARZA: And I'm tied up the week of the 13th, but the week of the 20th -- you can't come the week of the 20th? 

DR. BOWMAN: I think we can have the meeting in the Jefferson Auditorium. 

DR. GRUNDY: Since most of us are locked into that, why don't we just have it at another place? 

CHAIRMAN GARZA: Yes, I think that may be the -- 

DR. DWYER: What is the date? 

CHAIRMAN GARZA: The date is the 7th, 8th and 9th. 

DR. DWYER: That's not Labor Day, is it? 

CHAIRMAN GARZA: No, Labor Day is on the 6th.

Would the 8th, 9th and 10th work better? That's a Wednesday, Thursday and Friday, as opposed to Tuesday, Wednesday and Thursday.

DR. DECKELBAUM: That's just right at the beginning of our term, so those of us who have student bodies that we have to handle, like provosts and things -- 

CHAIRMAN GARZA: Well, for us it actually works out well because we start before Labor Day, but I recognize that's just Cornell schedule, that's not your schedule. 

DR. DWYER: I agree that it can't be the following week, but what about the week after that? 

CHAIRMAN GARZA: Well, the problem is that the week of the 20th, there are a number of people who can't do it. The week of the 13th, there are a number of people that can't, so we're locked into either the preceding week -- I don't know whether we explored that. 

DR. JOHNSON: I can't. I can't. 

CHAIRMAN GARZA: All right, so that's the week. So it's the 8th, 9th and 10th, though.

Shiriki?

DR. KUMANYIKA: Do we need a three-day meeting or do we know -- 

CHAIRMAN GARZA: Well, my preference is for us -- to ask you to hold the three days,, and then in June, if it's clear that we're going to have a fairly efficient meeting in September, then we might be able to reduce it to one and a half days, but we'll have a better sense. Liberating a day and a half for you will be much easier than asking you to find a day and a half that late into the season.

All right, so people have those dates?

DR. DECKELBAUM: The 8th, 9th and 10th? 

CHAIRMAN GARZA: That's right. Wednesday, Thursday and Friday.

Now, I have to say that that Rosh Hashanah starts on the 10th at sundown.

DR. LICHTENSTEIN: You know, we ran into that at the last meeting. 

CHAIRMAN GARZA: But if we end at 12, would that be suitable or would that present real problems? Well, then can we go back to 7th, 8th, and 9th? I wanted to make sure that people were aware of that. 

DR. KUMANYIKA: That's why I mentioned the two days because I saw Rosh Hashanah on my calendar and I thought, well, some people will not want to -- 

CHAIRMAN GARZA: So we'll go back to the 7th, 8th and 9th?

And then in June, we've got the 16th, 17th and 18th. I'm going to be real optimistic and not plan any for November.

Okay, the only other thing is whether there is anything that -- any other business that has -- we've transacted today the changes, any of the plans we made with Carol earlier in terms of everybody understands what we're going to be needing in terms of response times. I think Carol has a pretty good sense of beginning with the information she's been given. We need information that's comparable for the physical activity. We're going to start working on that. Then we've got -- if we're going to split or consider splitting the grains from fruits and vegetables, then the group needs to provide some guidance as to how to best do that from the current guideline, and so Richard will start working on that with his group; the adequacy/variety guideline and introduction supplements, we'll start working together so we can provide some guidance for Carol there, and everything else, I think you've got pretty --

DR. SUITOR: Or I'll ask for it. 

CHAIRMAN GARZA: And we all will respond, right? 

DR. SUITOR: Promptly. 

DR. KUMANYIKA: One comment before you leave. Is it possible for the feasibility of standardizing the format across guidelines as you go through them to say the same types of things about each issue in a similar order. I mean, not rigidly, but to give some uniformity and see if that's -- and advise us on whether that's feasible. 

DR. SUITOR: We'll have to do that anyway. 

CHAIRMAN GARZA: That's going to be a goal. 

DR. KUMANYIKA: Okay. 

DR. DECKELBAUM: Actually, if I could just comment on that.

Carol, it might be helpful if -- that might be actually the first thing that you did. If you gave each of the groups a format of how you would like us to give you the material, then it would be easier for you to cut and paste later. So we can prepare our material along the suggested guideline, you know, outline order.

DR. SUITOR: I'll e-mail you what I would suggest. 

CHAIRMAN GARZA: And then what we'll do, as each of the groups feels that they're coming pretty close to a draft they want to discuss with the group in June, then we'll make sure everybody gets that. And as those begin accumulating, it will be clear as to what the format will be because I'm sure it will have evolved to a certain degree. 

DR. GRUNDY: I have worked very nicely with Kathryn. Is that going to shift now? 

CHAIRMAN GARZA: No. 

DR. GRUNDY: We will still -- 

CHAIRMAN GARZA: No, as far as I know, you'll -- the working groups will keep the same -- the same contact person, but in terms of actual drafts, then those will be coming from Carol. If you're not responsive, then the individual we will hold accountable for you not being responsive will be the federal presence you've been assigned, so Kathryn may be at your doorstep. 

MS. MCMURRY: Thank you, thank you for that responsibility. But we will be available to -- you know, everybody has a resource. 

CHAIRMAN GARZA: That's right. 

MS. LYON: If anybody has a problem getting publications, whether they are government or non-government, arranging conference calls, and I would suggest that because of your busy schedules that we try to schedule the conference calls early, earlier than later. 

CHAIRMAN GARZA: That's right. And then Johanna, did you have -- I'm sorry. And I was looking at the wrong person. 

DR. DWYER: I just wanted to say that I think from all of us that we really thank you for all this detail. It's been stressful. You deserve a lot of things. 

DR. GRUNDY: I second that. 

CHAIRMAN GARZA: Well, on that note before we adjourn, and I actually want to thank not only the staff, but each of you. I mean, it's really been a very efficiently working group from conference calling to e-mailing, and it's that sort of commitment and presence that makes this whole process possible. So the staff, believe it or not, has not complained about any of you.

(Laughter.)

And I generally get lots of complaints in other committees about, gee, you know, somebody is not being responsive. So congratulations. That's not an invitation to slacken off. That's to set the bar so that we expect that you will continue being as cooperative and committed to this whole process.

So unless there is any other housekeeping to be done, the meeting is adjourned.

(Whereupon, at 1:33 p.m., the meeting was adjourned.)

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CERTIFICATE OF REPORTER, TRANSCRIBER AND PROOFREADER





In Re: Dietary Guidelines Advisory Committee

Name of Hearing or Event





N/A

Docket No.





Washington, DC

Place of Hearing





March 10, 1999

Date of Hearing



We, the undersigned, do hereby certify that the foregoing pages, numbers 517 through 648 , inclusive, constitute the true, accurate and complete transcript prepared from the tapes and notes prepared and reported by Sharon Bellamy , who was in attendance at the above identified hearing, in accordance with the applicable provisions of the current USDA contract, and have verified the accuracy of the transcript (1) by preparing the typewritten transcript from the reporting or recording accomplished at the hearing and (2) by comparing the final proofed typewritten transcript against the recording tapes and/or notes accomplished at the hearing.







Joyce Boe

Date

Name and Signature of Transcriber

Heritage Reporting Corporation





Lorenzo Jones

Date

Name and Signature of Proofreader

Heritage Reporting Corporation





Sharon Bellamy

Date

Name and Signature of Reporter

Heritage Reporting Corporation