Dr. C. Everett Koop
Surgeon General's Report
Extracts of
The Surgeon General's Report on
NUTRITION AND HEALTH
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
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The Surgeon General of the
Public Health
Service
Washington DC 20201
MESSAGE FROM THE SURGEON GENERAL
I am pleased to transmit to the Secretary of the Department of Health and
Human Services this first Surgeon General's Report on Nutrition and Health. It
was prepared under the auspices of the Department's Nutrition Policy Board, and
its main conclusion is that overconsumption of certain dietary components is now
a major concern for Americans. While many food factors are involved, chief among
them is the disproportionate consumption of foods high in fats, often at the
expense of foods high in complex carbohydrates and fiber--such as vegetables,
fruits, and whole grain products--that may be more conducive to health.
I offer this Report in the context of the obligation of the Surgeon General
to inform the American public of developments in the science base that have
widespread implications for human health.
One of such reports is the one
issued in 1964 during the tenure of one of my predecessors, Dr. Luther Terry,
which summarized the epidemiologic evidence available at the time on the
relationship of tobacco to health. This report called attention to the
inescapable conclusion that cigarettes were a major source of illness and death
for those who smoked-at that time a majority of adult men.
This Surgeon General's Report on Nutrition and Health follows the tradition
of the original report on smoking and health. It addresses an area of some
controversy and substantial misunderstanding. And the relative magnitude of the
associated health concerns is comparable, with dietary factors playing a
prominent role in five of the ten leading causes of death for Americans. In
addition, the depth of the science base underlying its findings is even more
impressive than that for tobacco and health in 1964, with animal and clinical
evidence adding to the epidemiologic studies.
On the other hand here are some fundamental differences. Most obvious is the
fact that food is necessary for good health. Foods contain nutrients essential
for normal metabolic function, and when problems arise, they result from
imbalance in nutrient intake or from harmful interaction with other factors.
Moreover, we know today much more about individual variation in response to
nutrients than we know about possible variations in response to tobacco. Some
people are clearly more susceptible than others to problems from diets that are,
for example, higher in fat or salt.
Also, unlike the experience for tobacco in 1964, people are already making
dietary changes, as witnessed by the shift to products lower in saturated fats.
Nonetheless, the important effects of the dietary factors underlying problems
like coronary heart disease, high blood pressure, stroke, some types of cancer,
diabetes, obesity--problems that represent the leading health threats for
Americans--indicate the potential for substantial gains to be accrued by the
recommendations contained in this Report
It is important to emphasize that the focus of this Report is primarily on
the relationship of diet to the occurrence of chronic diseases. The Report is
not intended to address the problems of hunger or undernutrition that may occur
in the United States among certain subgroups of the population. All Americans
should have access to an appropriate diet, but they do not. And even though the
size and numbers of problems related to inadequate access to food are
proportionately much smaller than those related to dietary excesses and
imbalances, the problems of access to food are of considerable concern to me,
personally, wherever they may occur.
The apparently sizable numbers of people resorting to the use of soup
kitchens and related food facilities, as well as the possible role of poor diet
as a contributor to the higher infant mortality rates associated with inadequate
income, suggest the need for better monitoring of the nature and extent of the
problem and for sustained efforts to correct the underlying causes of diminished
health due to inadequate or inappropriate diets.
This report was prepared primarily for nutritional policy makers, although
the eventual beneficiaries of better nutritional policy will be the American
people. I am convinced that with a concerted effort on the part of policy makers
throughout the Nation, and eventually by the public, our daily diets can bring a
substantial measure of better health to all Americans. I commend to them the
recommendations of this Report.
C. Everett Koop, M.D., Sc.D.
Surgeon General
U.S. Public Health Service
-
This Report addresses the substantial impact
of daily dietary patterns on the health of Americans. Good health does not
always come easily. It is the product of complex interactions among
environmental, behavioral, social, and genetic factors. Some of these are, for
practical purposes, beyond personal control. But there are many ways in which
each of us can influence our chances for good health through the daily choices
we make.
In recent years, scientific investigations have produced abundant information
on the ways personal behavior affects health. This information can help us
decide whether to smoke, when and how much to drink, how far to walk or climb
stairs, whether to wear seat belts, and how or whether to engage in any other
activity that might alter the risk of incurring disease or disability. For the
two out of three adult Americans who do not smoke and do not drink excessively,
one personal choice seems to influence long-term health prospects more than any
other: what we eat.
Food sustains us, it can be a source of considerable pleasure, it is a
refelection of our rich social fabric and cultural heritage, it adds valued
dimensions to our lives. Yet what we eat may affect our risk for several of the
leading causes of death for Americans, notably, coronary heart disease, stroke,
atherosclerosis, diabetes, and some types of cancer. These disorders together
now account for more than two-thirds of all deaths in the United States.
Undernutrition remains a problem in several parts of the world, as well as
for certain Americans. But for most of us the more likely problem has become one
of overeating--too many calories for our activity levels and an imbalance in the
nutrients consumed along with them. Although much is still uncertain about how
dietary patterns protect or injure human health, enough has been learned about
the overall health impact of the dietary patterns now prevalent in our society
to recommend significant changes in those patterns.
This first Surgeon General's Report on Nutrition and Health offers
comprehensive documentation of the scientific basis for the recommended dietary
changes. Through the extensive review contained in its chapters, the Report
examines in detail current knowledge about the relationships among specific
dietary practices and specific disease conditions and summarizes the
implications of this information for individual food choices, public health
policy initiatives, and further research. The Report's main conclusion is that
overconsumption of certain dietary components is now a major concern for
Americans. While many food factors are involved, chief among them is the
disproportionate consumption of foods high in fats, often at the expense of
foods high in complex carbohydrates and fiber that may be more conducive to
health. A list of the key recommendations based on the evidence presented in the
Report is provided in Table 1.
Diet has always had a vital influence on
health. Until as recently as the 1940's, diseases such as rickets, pellagra,
scurvy, beriberi, xerophthalmia, and goiter (caused by lack of adequate dietary
vitamin D, niacin, vitamin C, thiarnin, vitamin A, and iodine, respectively)
were prevalent in this country and throughout the world. Today, thanks to an
abundant food supply, fortification of some foods with critical trace nutrients,
and better methods for determining and improving the nutrient content of foods,
such "deficiency" diseases have been virtually eliminated in developed
countries. For example, the introduction of iodized salt in the 1920's
contributed greatly to eliminating iodine-deficiency goiter as a public health
problem in the United States. Similarly, pellagra disappeared subsequent to the
discovery of the dietary causes of this disease. Nutrient deficiencies are
reported rarely in the United States, and the few cases of protein-energy
malnutrition that are listed annually as causes of death generally occur as a
secondary result of severe illness or injury, child neglect, the problems of the
house-bound aged, premature birth, alcoholism, or some combination of these
factors.
As the diseseases of nutritional deficiency have diminished, they have been
replaced by diseases of dietary excess and imbalance-problems that now rank
among the leading causes of illness and death in the United States, touch the
lives of most Americans, and generate substantial health care costs. Table 2,
for example, lists the 10 leading causes of death in the United Stasates in
1987.
In addition to the five of these causes that scientific studies have
associated with diet (coronary heart disease, some types of cancer, stroke,
diabetes mellitus, and atherosclerosis), another three-cirrhosis of the liver,
accidents, and od suicides--have been associated with excessive alcohol intake.
Table 1
Recommendations
Issues for Most People:
- Fats and cholesterol: Reduce consumption of fat (especially saturated fat)
and cholesterol. Choose foods relatively low in these substances, such as
vegetables, fruits, whole grain foods, fish, poultry, lean meats, and low-fat
dairy products. Use food preparation methods that add little or no fat.
- Energy and weight control: Achieve and maintain a desirable body weight. To
do so, choose a dietary pattern in which energy (caloric) intake is consistent
with energy expenditure. To reduce energy intake, limit consumption of foods
relatively high in calories, fats, and sugars, and minimize alcohol consumption.
Increase energy expenditure through regular and sustained physical activity.
- Complex carbohydrates and fiber: Increase consumption of whole grain foods
and cereal products, vegetables (including dried beans and peas), and fruits.
- Sodium: Reduce intake of sodium by choosing foods relatively low in sodium
and limiting the amount of salt added in food preparation and at the table.
- Alcohol: To reduce the risk for chronic disease, take alcohol only in
moderation (no more than two drinks a day), if at all. Avoid drinking any
alcohol be fore or while driving, operating machinery, taking medications, or
engaging in any other activity requiring judgment. Avoid drinking alcohol while
pregnant.
Other Issues for Some People:
- Fluoride: Community water systems should contain fluoride at optimal levels
for prevention of tooth decay. If such water is not available, use other
appropriate sources of fluoride.
- Sugars: Those who are particularly vulnerable to dental caries (cavities),
especially children, should limit their consumption and frequency of use of
foods high in sugars.
- Calcium: Adolescent girls and adult women should increase consumption of
foods high in calciuam, including low-fat dairy products.
- Iron: Children, adolescents, and women of childbearing age should be sure to
consume foods that are good sources of iron, such as lean meats, fish, certain
beans, and iron-enriched cereals and whole grain products. This issue is of
special concern for low-income families.
Table 2
Estimated Total Deaths and Percent of Total Deaths for
the
10 Leading Causes of Death: United States, 1987
|
Percent of Total |
| Rank |
Cause of Death |
Number of Deaths |
| la |
Heart diseases |
759,400 |
35.7 |
|
(Coronary heart disease) |
(511,700) |
(24.1) |
|
(Other heart disease) |
(247,700) |
(11.6) |
| 2a |
Cancers |
476,700 |
22.4 |
| 3a |
Strokes |
148,700 |
7.0 |
| 4b |
Unintentional injuries |
92,500 |
4.4 |
|
(Motor vehicle) |
(46,800) |
(2.2) |
|
(All others) |
(45,700) |
(2.2) |
| 5 |
Chronic obstructive lung diseases |
78,000 |
3.7 |
| 6 |
Pneumonia and influenza |
68,600 |
3.2 |
| 7a |
Diabetes mellitus |
37,800 |
1.8
|
| 8b |
Suicide |
29,600 |
1.4 |
| 9b |
Chronic liver disease and cirrhosis |
26,000 |
1.2 |
| 10a |
Atherosclerosis |
23,100 |
1.1 |
| All causes |
125,100 |
100.0 |
aCauses of death in which diet plays a part.
bCauses of death in which
excessive alcohol consumption plays a part.
Source: National Center for Health Statistics, Monthly Vital Statistics
Report. vol. 37, no.
1, April 25, stics Report,vol. 37, no.
1, April 25,
1988.
Although the precise proportion attributable to diet is uncertain, these
eight conditions accounted for nearly 1.5 million of the 2.1 million total
deaths in 1987. Dietary excesses or imbalances also contribute to other problems
such as high blood pressure, obesity, dental diseases, osteoporosis, and
gastrointestinal diseases. Together, these diet-related conditions inflict a
substantial burden of illness on Americans. For example:
- Coronary Heart Disease. Despite the recent sharp decline in the death rate
from this condition, coronary heart disease still accounts for the largest
number of deaths in the United States. More than 1.25 million heart attacks
occur each year (two-thirds of them in men), and more than 500,000 people die as
a result. In 1985, illness and deaths from coronary heart disease cost Americans
an estimated $49 billion in direct health care expenditures and lost
productivity.
- Stroke. Strokes occur in about 500,000 persons per year in the United
States, resulting in nearly 150,000 deaths in 1987 and long-term dis- ability
for many individuals. Approximately 2 million living Americans suffer from
stroke-related disabilities, at an estimated annual cost of more than $11
billion.
- High Blood Pressure High blood pressure (hypertension) is a major risk
factor for both heart disease and stroke. Almost 58 million people in the United
Stales have hypertension, including 39 million who are under age 65. The
occurrence of hypertension increases with age and is higher for black Americans
(of which 38 percent are hypertensive) than for white Americans (29 percent).
- Cancer. More than 475,000 persons died of cancer in the United States in
1987, making it the second leading cause of death in this country. During the
same period, more than 900,000 new cases of cancer Occurred. The costs of cancer
for 1985 have been estimated to be $22 billion for direct health care, $9
billion in lost productivity due to treatment., disability, and $41 billion in
lost productivity due to premature mortality, for a total cost of $72 billion
- Diabetes Mellitus. Approximately 11 million Americans have diabetes, but
almost half of them have not been diagnosed. In addition to the nearly 38,000
deaths in 1987 attributed directly to this condition, diabetes also contributes
to an estimated 95,000 deaths per year from associated cardiovascular and kidney
complications. In 1985, diabetes was estimated to cost $13.8 billion per year,
or about 36 percent of total health care expenses.
- Obesity. Obesity affects approximately 34 million adults ages 20 to 74 years
in the United States, with the highest rates observed among the poor and
minority groups. Obesity is a risk factor for coronary heart disease, high blood
pressure, diabetes, and possibly some types of cancer as well as other chronic
diseases.
- Osteoporosis Appoximately 15 to 20 million Americans are affected by
osteoporosis, which contributes to some 1.3 million bone fractures per year in
persons 45 years and older. One-third of women 65 years and older have vertebral
fractures. On the basis of x-ray evidence, by age 90 one-third of women and
one-sixth of men will have suffered hip fractures, leading to death in 12 to 20
percent of those cases and to long-term nursing care for many who survive. The
total costs of osteoporosis to the U.S. economy were estimated to be $7 to $10
billion in 1983.
- Dental Diseases Dental caries and periodontal disease continue to affect a
large proportion of Americans and cause substantial pain, restriction of
activity, and work loss. Although dental caries among children, as well as some
forms of adult periodontal disease, appear to be declining, the overall
prevalence of these conditions imposes a substantial burden on Americans. The
costs of dental care were estimated at $21.3 billion in 1985.
- Diverticular Disease. Because most persons with diverticular disease do not
have symptoms, the true prevalence of this condition is unknown. Frequency
increases with age, and up to 70 percent of people between the ages of 40 and 70
may be affected. In 1980, diverticulosis was accountable for some 200,000
hospitalizations.
In assessing the role that diet might play in
prevention of these conditions, it must be understood that they are caused by a
combination (and interaction) of multiple environmental, behavioral, social, and
genetic factors. The exact proportion that can be attributed directly to diet is
uncertain. Although some experts have suggested that dietary factors overall are
responsible for perhaps a third or more of all cases of cancer, and similar
estimates have been made for coronary heart disease, such suggestions are based
on interpretations of research studies that cannot completely distinguish
dietary from genetic, behavioral, or environmental causes.
We know, for example, that cigarette smoking exerts a powerful influence on
the occurrence of both coronary heart disease and some types of cancer. We also
know that some people are genetically predisposed to coronary heart disease,
stroke, and diabetes and that the interaction of genetic predisposition with
dietary patterns is an important determinant of individual risk. For these
reasons, it is not yet possible to determine the propertion of chronic diseases
that could be reduced by dietary changes. Nonetheless, it is now clear that diet
contributes in substantial ways to the development of these diseases and that
modification of diet can contribute to their prevention. The magnitude of the
health and economic cost of diet-related disease suggests the importance of the
dietary changes suggested. This Report reviews these issues in detail.
Whereas centuries of clinical observations and
decades of basic and clinical research prove that dietary deficiencies of
single, identifiable nutrients can cause disease, research on the relationship
of dietary excesses and imbalances to chronic disease yields results that rarely
provide such direct proof of causality. Instead, investigators must piece
together various kinds of information from several kinds of sources.
Nevertheless, the quantity of current animal, laboratory, clinical, and
epidemiologic evidence that associates dietary excesses and imbalances with
chronic disease is substantial and, when evaluated according to established
principles, compelling.
Scientists must often draw inferences about the relationships between dietary
factors and disease from laboratory animal studies or human metabolic and
population studies that approach the issues indirectly. Data sources for such
human studies include clinical and laboratory measurements of physiologic
indicators of nutritional status or risk factors, as well as dietary intake data
estimated for populations or individuals. Epidemiologic studies using these data
compare dietary intake and disease rates in different countries or in defined
groups within the same country.
Interpretations of animal studies are limited by uncertainties about their
applicability to people. Clinical, laboratory, and dietary intake studies can
provide useful information, but each has limitations. Currently available
clinical and laboratay measurements reveal only a small part of the complex
physiological responses to diet, and they may reflect past rather than current
nutritional status. Dietary surveys depend on accurate recall of the types and
portion sizes of consumed foods as well as on the assumption that the food
intake during any one period represents typical intake.
Reported intake, however, is not always accurate, and intake reported for a
given period may differ significantly from that typical of longer time periods.
Dietary intake data provide useful indicators for populations, but even when an
association or correlation between a dietary factor and a disease is observed,
it is often difficult to prove that the dietary factor is an actual or sole
causeof that disease.
This difference between association and causation is basic to understanding
the scientific evidence that links diet to chronic disease. Uncertainties in the
ability to determine causation have sometimes made it difficult to achieve
consensus on appropriate public health nutrition policies. Established
principles require evaluation of the supporting evidence for a given association
between a dietary factor and a disease on the basis of its consistency,
strength, specificity, and biological plausibility. The evidence showing that
dietary intake of saturated fat raises blood cholesterol, which in turn
increases the chance of coronary heart disease, illustrates this point. The
similarity in results from laboratory, clinical, and epidemiologic research, the
apparent relationship between dose and effect in these studies, the observations
that the increase in blood cholesterol level is specific to saturated fatty
acids but not to other types, and the biological plausibility of explanations
for the observations, when taken together, provide considerable support for
concluding that the association is causal, at least for some individuals.
For some of the other diseases reviewed in this Report, the available
evidence is less complete and less consistent. Nevertheless, much evidence
supports credible associations between a dietary pattern of excesses and
imbalances and several important chronic diseases. These associations, in turn,
suggest that the overall health of Americans could be improved by a few specific
but fundamental dietary changes.
Even though the results of various
individual studies may be inconclusive, the preponderance of the evidence
presented in the Report's comprehensive scientific review substantiates an
association between dietary factors and rates of chronic diseases. In
particular, the evidence suggests strongly that a dietary pattern that contains
excessive intake of foods high in calories, fat (especially saturated fat),
cholesterol, and sodium, but that is low in complex carbohydrates and fiber, is
one that contributes significantly to the high rates of major chronic diseases
among Americans. It also suggests that reversing such dietary patterns should
lead to a reduced incidence of these chronic diseases.
This Surgeon General's Report on Nutrition and Health provides a
comprehensive review of the most important scientific evidence in support of
current Federal nutrition policy as stated in the Dietary Guidelines for
Americans. These Guidelines, issued jointly by the Department of Agri- culture
and the Department of Health and Human Services, recommend:
Evidence
presented in this Report expands the focus of these seven guidelines and
provides considerable insight into priorities. Clearly emerging as the primary
priority for dietary change is the recommendation to reduce intake of total
fats, especially saturated fat, because of their relationship to development of
several important chronic disease conditions. Because excess body weight is a
risk factor for several chronic diseases, maintenance of desirable weight is
also an important public health priority. Evidence further supports the
recommendation to consume a dietary pattern that contains a variety of foods,
provided that these foods are generally low in calories, fat, saturated fat,
cholesterol, and sodium.
Taken together, the recommendations in this Report promote a dietary pattern
that emphasizes consumption of vegetables, fruits, and whole grain
products--foods that are rich in complex carbohydrates and fiber and relatively
low in calories-- and of fish, poultry prepared without skin, lean meats, and
low-fat dairy products selected to minimize consumption of total fat, saturated
fat, and cholesterol.
The evidence presented in this Report suggests that such overall dietary
changes will lead to substantial improvements in the nutritional quality of the
American diet. Consuming a higher proportion of calories from fruits,
vegetables, and grains may lead to a modest reduction in protein intake for some
people, but this reduction is unlikely to impair nutritional status. Average
levels of protein consumption in the United States, 60 grams per day for women
and 90 grams per day for men, are well above the National Research Council's
recommendations of 44 and 56 grams per day, respectively.
The evidence also suggests that most Americans generally need not consume
nutrient supplements. An estimated 40 percent of Americans consume supplemental
vitamins, minerals, or other dietary components at an annual cost of more than
$2.7 billion. Although nutrient supplements are usually safe in amounts
correspending to the Recommended Dietary Allowances (and such Allowances are set
to ensure that the nutrient needs of practically all the population are met),
there are no known advantages to healthy people consuming excess amounts of any
nutrient, and amounts greatly exceeding recommended levels can be harmful. For
example, some nutrients such as selenium have a narrow range of safe level of
intake. Toxicity has been reported for most minerals and trace elements, as well
as some vitamins, indicating that excessive supplementation with these
substances can be hazardous.
Finally, some recommendations for dietary change apply broadly to the general
public whereas others apply only to specific population groups. These major
findings and recommendations of The Surgeon General's Report on Nutrition find
Health are noted below.
- Fats and cholesterol: Reduce consumption of fat (especially saturated fat)
and cholesterol. Choose foods relatively low in these substances, such as
vegetables, fruits, whole grain foods, fish, poultry, lean meats, and low fat
dairy products. Use food preparation methods that add little or no fat.
[This next section is quoted in
Chapter Five of the Book, Life Flow One, The Solution For Heart Disease.]
High intake of total dietary fat is associated with increased risk for
obesity, some types of cancer, and possibly gallbladder disease. Epidemiologic,
clinical, and animal studies provide strong and consistent evidence for the
relationship between saturated fat intake, high blood cholesterol, and increased
risk for coronary heart disease. Conversely, reducing blood cholesterol levels
reduces the risk for death from coronary heart disease. Excessive saturated fat
consumption is the major dietary contributor to total blood cholesterol levels.
Dietary cholesterol raises blood cholesterol levels, but the effect is less
pronounced than that of saturated fat. While polyunsaturated fatty acid
consumption, and probably monounsaturated fatty acid consumption, lowers total
blood cholesterol, the precise effects of specific fatty acids are not well
defined.
Dietary fat contributes more than twice as many calories as equal quantities
(by weight) of either protein or carbohydrate, and some studies indicate that
diets high in total fat are associated with higher obesity rates. In addition,
there is substantial, although not yet conclusive, epidemiologic and animal
evidence in support of an association between dietary fat intake and increased
risk for cancer, especially breast and colon cancer. Similarly, epidemiologic
studies suggest an association between gallbladder disease, excess caloric
intake, high dietary fat, and obesity. More precise conclusions about the role
of dietary fat await the development of improved methods to distinguish among
the contributions of the high-calorie, high-fat, and low-fiber components of
current American dietary patterns.
At present, dietary fat accounts for about 37 percent of the total energy
intake of Americans well above the upper limit of 30 percent recommended by the
American Heart Association and the American Cancer Society, and above the
percent consumed by many societies, such as Mediterranean countries, Japan, and
China, for example, where coronary heart disease rates are much lower than those
observed in the United States. Consumption of saturated fat and cholesterol is
also substantially higher among many Americans than levels recommended by
several expert groups.
The major dietary sources of fat in the American diet are meat, poultry,
fish, dairy products, and fats and oils. Animal products tend to be higher in
both total and saturated fats than most plant sources. Although some plant fats
such as coconut and palm kernel oils also contain high proportions of saturated
fatty acids, these make minor contributions to total intake of saturated fats in
the United States. Dietary cholesterol is found only in foods of animal origin,
such as eggs, meat, poultry, fish, and dairy products. To help reduce
consumption of total fat, especially saturated fat and cholesterol, food choices
should emphasize intake of fruits, vegetables, and whole grain products and
cereals. They should also emphasize consumption of fish, poultry prepared
without skin, lean meats, and low-fat dairy products. Among vegetable fats,
those that are more unsaturated are better choices.
- Energy and weight control: Achieve and maintain a desirable body weight. To
do so, choose a dietary pattern in which energy (caloric) intake is consistent
with energy expenditure. To reduce energy intake, limit consumption of foods
relatively high in calories, fats, and sugars and minimize alcohol consumption.
Increase energy expenditure through regularand sustained physical activity.
People are considered overweight if their body mass index, or BMI (a ratio of
weight to height described in the Report), exceeds the 85th percentile for young
American adults (approximately 120 percent of desirable body weight); they are
considered severely overweight if their BMI exceeds the 95th percentile
(approximately 140 percent of desirable body weight). Overweight individuals are
at increased risk for diabetes mellitus, high blood pressure and stroke,
coronary heart disease, some types of cancer, and gallbladder disease.
Epidemiologic and animal studies have shown consistently that overall risk for
death is increased with excess weight, with risk increasing as severity of
obesity increases.
Type II (noninsulin-dependent) diabetes mellitus accounts for approximately
90 percent of all cases of diabetes and is strongly associated with obesity.
Clinical studies indicate that weight loss can improve control of Type II
diabetes.
Obesity increases the risk for high blood pressure, and consequently for
stroke; it also increases blood cholesterol levels associated with coronary
heart disease. In addition, it appears to be an independent risk factor for
coronary heart disease. Weight reduction has been shown to reduce high blood
pressure and high blood cholesterol. Most obese individuals who achieve a more
desirable body weight improve their cholesterol profile, achieving a decrease in
both total blood cholesterol and LDL (low density lipoprotein) cholesterol.
Some studies have found an association between overweight and increased risk
for several cancers, especially cancer of the uterus and breast. In addition,
overweight increases the risk for gallbladder disease.
More than a quarter of American adults are overweight. Black women age 45 and
above have the highest prevalence, about 60 percent. Although evidence suggests
a genetic component to the tendency of many people to become overweight,
patterns of dietary caloric intake and energy expenditure play a key role.
Sustained and long- term efforts to reduce body weight can best be achieved as a
result of improving energy balance by reducing energy consumption and raising
energy expenditure through physical activity and exercise.
Maintenance of desirable body weight throughout the lifespan requires a
balance between energy (calorie) intake and expenditure. Weight control may be
facilitated by decreasing energy intake, especially by choosing foods relatively
low in calories, fats, and sugars, and by minimizing alcohol consumption. Energy
expenditure can be enhanced through regular physical activities such as daily
walks or by jogging, bicycling, or swimming at least three times a week for at
least 20 minutes.
- Complex carbohydrates and fiber: Increase consumption of whole grain foods
and cereal products, vegetables (including dried beans and peas), and fruits.
Dietary patterns emphasizing foods high in complex carbohydrates and fiber
are associated with lower rates of diverticulosis and some types of cancer.The
association shown in epidemiologic and animal studies be fiber are associated
with lower rates of diverticulosis and some types of cancer. The association
shown in epidemiologic and animal studies be- tween diets high in complex
carbohydrates and reduced risk for coronary heart disease and diabetes mellitus
is, however, difficult to interpret. The fact that such diets tend also to be
lower in energy and fats, especially saturated fat and cholesterol, clearly
contributes to this difficulty. Some evidence from clinical studies also
suggests that water-soluble fibers from foods such as oat bran, beans, or
certain fruits are associated with lower blood glucose and blood lipid levels.
Consuming foods with dietary fiber is usually beneficial in the management of
constipation and diverticular disease.
While inconclusive, some evidence also suggests that an overall increase in
intake of foods high in fiber might decrease the risk for colon cancer. Among
several unresolved issues is the role of the various types of fiber, which
differ in their effects on water-holding capacity, viscosity, bacterial
fermentation, and intestinal transit time.
Other food components associated with decreased cancer risk are commonly
found in diets high in whole grain cereal products containing complex
carbohydrates and fiber. In addition, some epidemiologic evidence suggests that
frequent consumption of vegetables and fruits, particularly dark green and deep
yellow vegetables and cruciferous vegetables (such as cabbage and broccoli), may
lower risk for cancers of the lung and bladder as well as some cancers of the
alimentary tract. However, the specific components in these foods that may have
protective effects have not yet been established. Current evidence suggests the
prudence of increasing consumption of whole grain foods and cereals, vegetables
(including dried beans and peas), and fruits.
- Sodium: Reduce intake of sodiurn by choosing foods relatively low in Sodium
and limiting the amount of Salt added in food preparation and at the table.
Studies indicate a relationship between a high sodium intake and the
occurrence of high blood pressure and stroke. Salt contains about 40 percent
sodium by weight and is used widely in the preservation, processing, and
preparation of foods. Although sodium is necessary for normal metabolic
function, it is consumed in the United States at levels far beyond the 1.1 to
3.3 grams per day found to be as safe and adequate for adults by the National
Research Council. Average current sodium intake for adults in the United States
is in the range of 4 to 6 grams per day.
Blacks and persons with a family history of high blood pressure are at
greater risk for this condition. While some people maintain normal blood
pressure levels over a wide range of sodium intake, others appear to be
"salt sensitive" and display increased blood pressure in response to
high sodium intakes.
Although not all individuals are equally susceptible to the effects of
sodium, several observations suggest that it would be prudent for most Americans
to reduce sodium intake. These include the lack of a practical biological marker
for individual sodium sensitivity, the benefit to persons whose blood pressures
do rise with sodium intake, and the lack of harm from moderate sodiurn
restriction.
Processed foods provide about a third or more of dietary sodium. Because
about another third of the sodium consumed by Americans is added by the
consumer, much can be done to reduce sodium consumption by using less salt at
the table and substituting alternative flavoring such as herbs, spices, and
lemon juice in the preparation of foods. In addition, choices can be made
offoods modified to lower sodium content and less frequent choices could be made
of foods to which sodium is added in processing and preservation.
- Alcohol: To reduce the risk for chronic disease, take alcohol only in
moderation (no more than two drinks a day), if at all. Avoid drinking any
alcohol before or while driving, operating machinery, taking medications, or
engaging in any other activity requiring judgment. Avoid drinking alcohol while
pregnant.
Alcohol is a drug that can produce addiction in susceptible individuals,
birth defects in some children born to mothers who drink alcohol during
pregnancy, impaired judgment, impaired ability to drive automobiles or operate
machinery, and adverse reactions in people taking certain medications. In
addition, alcohol abuse has been associated with disrupted family functioning,
suicides, and homicides.
Excessive use of alcohol is also associated with liver disease, some types of
cancer, high blood pressure, stroke, and disorders of the heart muscle.
Extensive epidemiologic and clinical evidence has identified alcohol consumption
as the principal cause of liver cirrhosis in the United States, at least in part
as a result of the direct toxic effects of alcohol on the liver. Smoking and
alcohol appear to act synergistically to increase the risk for cancers of the
mouth, larynx, and esophagus. Less conclusive and somewhat conflicting evidence
suggests a role of alcohol in other types cancers such as those of the liver,
rectum, breast, and pancreas. Studies Indicate a direct association between
increased blood pressure and the consumption of alcohol at levels beyond about
two drinks(a) daily.
Extremely excessive alcohol consumption is associated with cardiomyopathy.
Alcohol consumption by the mother during pregnancy has also been associated with
fetal malformations.
Although consumption of up to two drinks per day has not been associated with
disease among healthy men and nonpregnant women, surveys suggest that at least 9
percent of the total population consumes two or more drinks per day and those in
this group need to reduce their alcohol consumption. A threshold level of safety
for alcohol intake during pregnancy has not been established. Thus, pregnant
women and women who may become pregnant should avoid drinking alcohol.
(a)One drink is defined as a 12 ounce beer, a 5 ounce glass of wine, or 1.5
fluid ounces (one jigger) of distilled spirits, each of which contains about 1
ounce of alcohol.
- Fluoride: Community water systems should contain fluoride at optimal levels
for prevention of tooth decay. If such water is not available, use other
appropriate sources of fluoride.
The most efficient means of making fluoride available to the general public
to reduce dental disease is through drinking water. Numerous epidemiologic and
clinical studies have attested to the efficacy, safety and cost effectiveness of
systemic fluoride in the prevention of tooth decay. Lifetime use of water
containing an optimal fluoride concentration of approximately 1 part per million
has been shown to reduce the prevalence of dental caries by more than 50
percent. Water fluoridation is considered one of the most successful public
health efforts introduced in the United States.
For children living in areas with inadequate concentrations of fluoride in
the water, supplementary fluoride sources should be used at dosages that depend
on the fluoride content of the local water supply and the age of the child. The
effectiveness of prenatal fluoride administration, however, is uncertain because
clinical studies of its effects on subsequent caries incidence have been
equivocal. Excessive fluoride should be avoided because
For children living in areas with Inadequate concentrations of fluoride in
the water, supplementary fluoride sources should be used at dosages that depend
on the fluoride content of the local water supply and the age of the child. The
effectiveness of prenatal fluoride administration, however, is uncertain because
clinical studies of its effects on subsequent caries incidence have been
equivocal. Excessive fluoride should be avoided because it may cause mottling of
developing teeth.
- Sugars: Those who are particularly Vulnerable to dental caries (cavities),
especially children, should limit their consumption and frequency of use of
foods high in sugars.
Although genetic, behavioral, and other dietary factors also influence dental
health, the major role of sugars in promotion of tooth decay is well established
from animal, epidemiologic, clinical, and biochemical studies. Newly erupting
teeth are generally more vulnerable to decay than mature teeth.
Research has shown that three conditions must exist for the formation of
dental caries: the presence of fermentable carbohydrate, acid-producing
bacteria, and a susceptible tooth. Caries-producing bacteria metabolize a range
of sugars (glucose, fructose, maltose, lactose, and sucrose) to acids that
demineralize teeth. The unique role of sucrose (common table sugar) in dental
caries is related to its special ability to be converted by these bacteria into
long, complex molecules that adhere firmly to teeth and form plaque.
The most important diet-related interventions are fluoridation of drinking
water, or the use of other means of fluoride administration, and control of
intake of sugars. While fluoride is the most important factor overall in dental
caries prevention, reduction in the frequency of consumption and in the quantity
of sugar-rich foods in the diet will also help reduce decay. Sticky sweet foods
that adhere to th e teeth are more cariogenic than those that wash off quickly.
The longer cariogenic foods remain in the mouth, the more they are likely to
increase the initiation and progression of tooth decay.
- Calcium: Adolescent girls and adult women should increase consumption of
foods high in calcium, including low-fat dairy products.
Inadequate dietary calcium consumption in the first three to four decades of
life may be associated with increased risk for osteoporosis in later life.
Osteoporosis, a chronic disease characterized by progressive loss of bone mass
with aging, occurs inboth women and men, although postmenopausal women are twice
as likely as men to have severe osteoporosis with consequent bone fractures.
Evidence shows that chronically low calcium intake, especially during
adolescence and early adulthood, may compromise development of peak bone mass.
In postmenopausal women, the group at highest risk for osteoporosis, estrogen
replacement therapy under medical supervision is the most effective means to
reduce the rate of bone loss and risk for fractures. Maintenance of adequate
levels of physical activity and cessation of cigarette smoking have also been
associated with reduced osteoporosis risk.
Although the precise relationship of dietary calcium to osteoporosis has not
been elucidated, it appears that higher intakes of dietary calcium could
increase peak bone mass during adolescence and delay the onset of bone fractures
later in life. Thus, increased consumption of foods rich in calcium may be
especially beneficial for adolescents and young women. Food sources of calcium
consistent with other dietary recommendations in this Report include 1ow-fat
dairy products, some canned fish, certain vegetables, and some calcium-enriched
grain products.
- Iron: Children, adolescents, and women of childbearing age should be sure to
consume foods that are good sources of iron, such as lean meats, fish, certain
beans, and iron-enriched cereals and whole grain products. This issue is of
special concern for low-income families.
Dietary iron deficiency is responsible for the most prevalent form of anemia
in the United States. Iron deficiency hampers the body's ability to produce
hemoglobin, a substance needed to carry oxygen in the blood. A principal
consequence of iron deficiency is reduced work capacity, although depressed
immune function, changes in behavior, and impaired intellectual performance may
also result. Because of the serious consequences of iron deficiency, continual
monitoring of the iron status of individuals at high risk--particularly children
from low-income families, adolescents, and women of childbearing age--is vital,
as is treatment of those identified to be iron deficient.
Proper infant feeding--preferably breastfeeding, otherwise use of
iron-fortified formula--is the most important safeguard against iron deficiency
in infants. Among adolescents and adults, iron intake can be improved by
increasing consumption of iron-rich foods such as lean meats, fish, certain
kinds of beans, and iron-enriched cereals and whole grain products. Also,
consuming foods that contain vitamin C increases the likelihood that iron will
be absorbed efficiently.
Dietary Guidance
General Public
Educating the public about the dietary choices most
conducive to prevention and control of certain chronic diseases is essential.
Educational efforts should begin in primary school and continue throughout the
secondary grades, and should focus on the dietary principles outlined in this
Report-- the potential health benefits of eating a diet that is lower in fat
(especially saturated fat) and richin complex carbohydrates and fiber. The
importance of adequate physical activity should also be stressed. Efforts should
continue throughout each stage oflife to promote the principles outlined in the
Dietary Guidelines for Americans.
Special Populations
A disproportionate burden of diet-related disease is
borne by subgroups in our population. Black Americans, for example, have higher
rates of high blood pressure, strokes, diabetes, and other diseases associated
with obesity (but lower rates of osteoporosis) than the general population. Some
groups of Native Americans exhibit the highest rates of diabetes in the world.
Pregnant and lactating women also have special nutritional needs. Particular
effort should be made to identify and remove the barriers to optimal health and
nutritional status in such high-risk groups, using methods that take into
consideration their diverse cultural backgrounds.
Many older persons suffer from chronic diseases that can reduce functional
independence; many take multiple medications that may adversely interact with
nutrients. Sound public education directed toward this group-and professional
education directed toward individuals who care for older Americans--should focus
on dietary means to reduce risk factors for chronic disease, to promote
functional independence, and to prevent adverse consequences of use of
medications.
Health Professionals
Improved nutrition training of physicians and other
health professionals is needed. Training should emphasize basic principles of
nutrition, the role of diet in health promotion and disease prevention,
nutrition assessment methodologies and their interpretation, therapeutic aspects
of dietary in- tervention, behavioral aspects of dietary counseling, and the
role of dieti- tians and nutritionists in dietary counseling of patients.
Food Labels
Food labeling offers opportunities to inform people about the
nutrient content of foods so as to facilitate dietary choices most conducive
health. Food manufacturers should be encouraged to make full use of nutrition
labels. Labels of processed foods should state the content of calories, protein,
carbohydrate, fats, cholesterol, sodium, and vitamins health. Food manufacturers
should be encouraged to make full use of nutrition labels. Labels of processed
foods should state the content of calories, protein, carbohydrate, fats,
cholesterol, sodium, and vitamins and minerals. To the extent permitted by
analytical methods, manufacturers should disclose information where appropriate
on the content of saturated and unsaturated fatty acids and total fiber in foods
that normally contain them. Descriptive terms such as "low calorie"
and "sodium reduced" in compliance with the Food and Drug
Administration's regulations for food labeling may also be helpful, and the
expanded use of these terms should be encouraged.
Nutrition Services
Health care programs for individuals of all ages should
include nutrition services such as, when appropriate, nutrition counseling for
individuals or groups, interpretation and implementation ofprescribed
therapeutic diets tailored to individualfood preferences and lifestyle, referral
to appropriate community services and food assistance programs, monitoring of
progress, and appropriate followup. These services should routinely incorporate
assessment of nutritional status and needs based on established criteria to
identify individuals with nutritional risk factors who would profit from
preventive measures and those with nutritional disorders who need remedial care.
Food Services
Lack of access to an appropriate diet should not be a health
problem for any American. Wherever food is served to people or provided through
food assistance programs, it should reflect the principles of good nutrition
stated in this Report. Whether served in hospitals, schools, military
installations, soup kitchens, day care centers, or nursing homes, or whether
delivered to homes, food service programs offer important oppertunities for
improving health and providing dietary education. Such Programs should pay
special attention to the nutritional needs of older people, pregnant women, and
children, especially those of low income or other special dietary needs. Because
a large proportion of the population takes meals in restaurants and convenience
food facilities, improvements in the overall nutritional balance of the meals
served in such places can be expected to contribute to health benefits.
Food service programs should also take particular care to ensure that special
diets lower in fat, especially saturated fat, are provided to people with
elevated blood cholesterol, heart disease, or diabetes; that diets low in sodium
are provided to individuals with high blood pressure; and that
protein-restricted diets are made available to people with end-stage kidney
disease.
Food Products
The public would benefit from increased availability of
foods and food products low in calories, total fat, saturated fat, cholesterol,
sodium, and sugars, but high in a variety of natural forms of fiber and,
perhaps, certain minerals and vitamins. Food manufacturers can contribute to
improving the quality of the American diet by increasing the availability of
palatable, easily prepared food products that will help people to follow the
dietary principles outlined here. Because the public is becoming increasingly
conscious of the role of nutrition in health, development of such products
should also benefit the food industry.
Impressive evidence already links nutrition to
chronic disease. However, much more information is needed to continue to
identify changes in the national diet that will lead to better health for the
Nation. Gaps in our knowledge of nutrition suggest future research and
surveillance needs. Examples are:
-
-
Nature of the Evidence
-
Key Findings and Recommendations
-
Issues for Most People
-
Other Issues for Some People
-
Dietary Guidance
-
Programs and Services
-
Research and Surveillance
Summary and Recommendations
This Report addresses the substantial impact
of daily dietary patterns on the health of Americans. Good health does not
always come easily. It is the product of complex interactions among
environmental, behavioral, social, and genetic factors. Some of these are, for
practical purposes, beyond personal control. But there are many ways in which
each of us can influence our chances for good health through the daily choices
we make.
In recent years, scientific investigations have produced abundant information
on the ways personal behavior affects health. This information can help us
decide whether to smoke, when and how much to drink, how far to walk or climb
stairs, whether to wear seat belts, and how or whether to engage in any other
activity that might alter the risk of incurring disease or disability. For the
two out of three adult Americans who do not smoke and do not drink excessively,
one personal choice seems to influence long-term health prospects more than any
other: what we eat.
Food sustains us, it can be a source of considerable pleasure, it is a
refelection of our rich social fabric and cultural heritage, it adds valued
dimensions to our lives. Yet what we eat may affect our risk for several of the
leading causes of death for Americans, notably, coronary heart disease, stroke,
atherosclerosis, diabetes, and some types of cancer. These disorders together
now account for more than two-thirds of all deaths in the United States.
Undernutrition remains a problem in several parts of the world, as well as
for certain Americans. But for most of us the more likely problem has become one
of overeating--too many calories for our activity levels and an imbalance in the
nutrients consumed along with them. Although much is still uncertain about how
dietary patterns protect or injure human health, enough has been learned about
the overall health impact of the dietary patterns now prevalent in our society
to recommend significant changes in those patterns.
This first Surgeon General's Report on Nutrition and Health offers
comprehensive documentation of the scientific basis for the recommended dietary
changes. Through the extensive review contained in its chapters, the Report
examines in detail current knowledge about the relationships among specific
dietary practices and specific disease conditions and summarizes the
implications of this information for individual food choices, public health
policy initiatives, and further research. The Report's main conclusion is that
overconsumption of certain dietary components is now a major concern for
Americans. While many food factors are involved, chief among them is the
disproportionate consumption of foods high in fats, often at the expense of
foods high in complex carbohydrates and fiber that may be more conducive to
health. A list of the key recommendations based on the evidence presented in the
Report is provided in Table 1.
Magnitude of the Problem
Diet has always had a vital influence on
health. Until as recently as the 1940's, diseases such as rickets, pellagra,
scurvy, beriberi, xerophthalmia, and goiter (caused by lack of adequate dietary
vitamin D, niacin, vitamin C, thiarnin, vitamin A, and iodine, respectively)
were prevalent in this country and throughout the world. Today, thanks to an
abundant food supply, fortification of some foods with critical trace nutrients,
and better methods for determining and improving the nutrient content of foods,
such "deficiency" diseases have been virtually eliminated in developed
countries. For example, the introduction of iodized salt in the 1920's
contributed greatly to eliminating iodine-deficiency goiter as a public health
problem in the United States. Similarly, pellagra disappeared subsequent to the
discovery of the dietary causes of this disease. Nutrient deficiencies are
reported rarely in the United States, and the few cases of protein-energy
malnutrition that are listed annually as causes of death generally occur as a
secondary result of severe illness or injury, child neglect, the problems of the
house-bound aged, premature birth, alcoholism, or some combination of these
factors.
As the diseseases of nutritional deficiency have diminished, they have been
replaced by diseases of dietary excess and imbalance-problems that now rank
among the leading causes of illness and death in the United States, touch the
lives of most Americans, and generate substantial health care costs. Table 2,
for example, lists the 10 leading causes of death in the United Stasates in
1987.
In addition to the five of these causes that scientific studies have
associated with diet (coronary heart disease, some types of cancer, stroke,
diabetes mellitus, and atherosclerosis), another three-cirrhosis of the liver,
accidents, and od suicides--have been associated with excessive alcohol intake.
Table 1
Recommendations
Issues for Most People:
- Fats and cholesterol: Reduce consumption of fat (especially saturated fat)
and cholesterol. Choose foods relatively low in these substances, such as
vegetables, fruits, whole grain foods, fish, poultry, lean meats, and low-fat
dairy products. Use food preparation methods that add little or no fat.
- Energy and weight control: Achieve and maintain a desirable body weight. To
do so, choose a dietary pattern in which energy (caloric) intake is consistent
with energy expenditure. To reduce energy intake, limit consumption of foods
relatively high in calories, fats, and sugars, and minimize alcohol consumption.
Increase energy expenditure through regular and sustained physical activity.
- Complex carbohydrates and fiber: Increase consumption of whole grain foods
and cereal products, vegetables (including dried beans and peas), and fruits.
- Sodium: Reduce intake of sodium by choosing foods relatively low in sodium
and limiting the amount of salt added in food preparation and at the table.
- Alcohol: To reduce the risk for chronic disease, take alcohol only in
moderation (no more than two drinks a day), if at all. Avoid drinking any
alcohol be fore or while driving, operating machinery, taking medications, or
engaging in any other activity requiring judgment. Avoid drinking alcohol while
pregnant.
Other Issues for Some People:
- Fluoride: Community water systems should contain fluoride at optimal levels
for prevention of tooth decay. If such water is not available, use other
appropriate sources of fluoride.
- Sugars: Those who are particularly vulnerable to dental caries (cavities),
especially children, should limit their consumption and frequency of use of
foods high in sugars.
- Calcium: Adolescent girls and adult women should increase consumption of
foods high in calciuam, including low-fat dairy products.
- Iron: Children, adolescents, and women of childbearing age should be sure to
consume foods that are good sources of iron, such as lean meats, fish, certain
beans, and iron-enriched cereals and whole grain products. This issue is of
special concern for low-income families.
Table 2
Estimated Total Deaths and Percent of Total Deaths for
the
10 Leading Causes of Death: United States, 1987
|
Percent of Total |
| Rank |
Cause of Death |
Number of Deaths |
| la |
Heart diseases |
759,400 |
35.7 |
|
(Coronary heart disease) |
(511,700) |
(24.1) |
|
(Other heart disease) |
(247,700) |
(11.6) |
| 2a |
Cancers |
476,700 |
22.4 |
| 3a |
Strokes |
148,700 |
7.0 |
| 4b |
Unintentional injuries |
92,500 |
4.4 |
|
(Motor vehicle) |
(46,800) |
(2.2) |
|
(All others) |
(45,700) |
(2.2) |
| 5 |
Chronic obstructive lung diseases |
78,000 |
3.7 |
| 6 |
Pneumonia and influenza |
68,600 |
3.2 |
| 7a |
Diabetes mellitus |
37,800 |
1.8
|
| 8b |
Suicide |
29,600 |
1.4 |
| 9b |
Chronic liver disease and cirrhosis |
26,000 |
1.2 |
| 10a |
Atherosclerosis |
23,100 |
1.1 |
| All causes |
125,100 |
100.0 |
aCauses of death in which diet plays a part.
bCauses of death in which
excessive alcohol consumption plays a part.
Source: National Center for Health Statistics, Monthly Vital Statistics
Report. vol. 37, no.
1, April 25, stics Report,vol. 37, no.
1, April 25,
1988.
Although the precise proportion attributable to diet is uncertain, these
eight conditions accounted for nearly 1.5 million of the 2.1 million total
deaths in 1987. Dietary excesses or imbalances also contribute to other problems
such as high blood pressure, obesity, dental diseases, osteoporosis, and
gastrointestinal diseases. Together, these diet-related conditions inflict a
substantial burden of illness on Americans. For example:
- Coronary Heart Disease. Despite the recent sharp decline in the death rate
from this condition, coronary heart disease still accounts for the largest
number of deaths in the United States. More than 1.25 million heart attacks
occur each year (two-thirds of them in men), and more than 500,000 people die as
a result. In 1985, illness and deaths from coronary heart disease cost Americans
an estimated $49 billion in direct health care expenditures and lost
productivity.
- Stroke. Strokes occur in about 500,000 persons per year in the United
States, resulting in nearly 150,000 deaths in 1987 and long-term dis- ability
for many individuals. Approximately 2 million living Americans suffer from
stroke-related disabilities, at an estimated annual cost of more than $11
billion.
- High Blood Pressure High blood pressure (hypertension) is a major risk
factor for both heart disease and stroke. Almost 58 million people in the United
Stales have hypertension, including 39 million who are under age 65. The
occurrence of hypertension increases with age and is higher for black Americans
(of which 38 percent are hypertensive) than for white Americans (29 percent).
- Cancer. More than 475,000 persons died of cancer in the United States in
1987, making it the second leading cause of death in this country. During the
same period, more than 900,000 new cases of cancer Occurred. The costs of cancer
for 1985 have been estimated to be $22 billion for direct health care, $9
billion in lost productivity due to treatment., disability, and $41 billion in
lost productivity due to premature mortality, for a total cost of $72 billion
- Diabetes Mellitus. Approximately 11 million Americans have diabetes, but
almost half of them have not been diagnosed. In addition to the nearly 38,000
deaths in 1987 attributed directly to this condition, diabetes also contributes
to an estimated 95,000 deaths per year from associated cardiovascular and kidney
complications. In 1985, diabetes was estimated to cost $13.8 billion per year,
or about 36 percent of total health care expenses.
- Obesity. Obesity affects approximately 34 million adults ages 20 to 74 years
in the United States, with the highest rates observed among the poor and
minority groups. Obesity is a risk factor for coronary heart disease, high blood
pressure, diabetes, and possibly some types of cancer as well as other chronic
diseases.
- Osteoporosis Appoximately 15 to 20 million Americans are affected by
osteoporosis, which contributes to some 1.3 million bone fractures per year in
persons 45 years and older. One-third of women 65 years and older have vertebral
fractures. On the basis of x-ray evidence, by age 90 one-third of women and
one-sixth of men will have suffered hip fractures, leading to death in 12 to 20
percent of those cases and to long-term nursing care for many who survive. The
total costs of osteoporosis to the U.S. economy were estimated to be $7 to $10
billion in 1983.
- Dental Diseases Dental caries and periodontal disease continue to affect a
large proportion of Americans and cause substantial pain, restriction of
activity, and work loss. Although dental caries among children, as well as some
forms of adult periodontal disease, appear to be declining, the overall
prevalence of these conditions imposes a substantial burden on Americans. The
costs of dental care were estimated at $21.3 billion in 1985.
- Diverticular Disease. Because most persons with diverticular disease do not
have symptoms, the true prevalence of this condition is unknown. Frequency
increases with age, and up to 70 percent of people between the ages of 40 and 70
may be affected. In 1980, diverticulosis was accountable for some 200,000
hospitalizations.
In assessing the role that diet might play in
prevention of these conditions, it must be understood that they are caused by a
combination (and interaction) of multiple environmental, behavioral, social, and
genetic factors. The exact proportion that can be attributed directly to diet is
uncertain. Although some experts have suggested that dietary factors overall are
responsible for perhaps a third or more of all cases of cancer, and similar
estimates have been made for coronary heart disease, such suggestions are based
on interpretations of research studies that cannot completely distinguish
dietary from genetic, behavioral, or environmental causes.
We know, for example, that cigarette smoking exerts a powerful influence on
the occurrence of both coronary heart disease and some types of cancer. We also
know that some people are genetically predisposed to coronary heart disease,
stroke, and diabetes and that the interaction of genetic predisposition with
dietary patterns is an important determinant of individual risk. For these
reasons, it is not yet possible to determine the propertion of chronic diseases
that could be reduced by dietary changes. Nonetheless, it is now clear that diet
contributes in substantial ways to the development of these diseases and that
modification of diet can contribute to their prevention. The magnitude of the
health and economic cost of diet-related disease suggests the importance of the
dietary changes suggested. This Report reviews these issues in detail.
Nature of the Evidence
Whereas centuries of clinical observations and
decades of basic and clinical research prove that dietary deficiencies of
single, identifiable nutrients can cause disease, research on the relationship
of dietary excesses and imbalances to chronic disease yields results that rarely
provide such direct proof of causality. Instead, investigators must piece
together various kinds of information from several kinds of sources.
Nevertheless, the quantity of current animal, laboratory, clinical, and
epidemiologic evidence that associates dietary excesses and imbalances with
chronic disease is substantial and, when evaluated according to established
principles, compelling.
Scientists must often draw inferences about the relationships between dietary
factors and disease from laboratory animal studies or human metabolic and
population studies that approach the issues indirectly. Data sources for such
human studies include clinical and laboratory measurements of physiologic
indicators of nutritional status or risk factors, as well as dietary intake data
estimated for populations or individuals. Epidemiologic studies using these data
compare dietary intake and disease rates in different countries or in defined
groups within the same country.
Interpretations of animal studies are limited by uncertainties about their
applicability to people. Clinical, laboratory, and dietary intake studies can
provide useful information, but each has limitations. Currently available
clinical and laboratay measurements reveal only a small part of the complex
physiological responses to diet, and they may reflect past rather than current
nutritional status. Dietary surveys depend on accurate recall of the types and
portion sizes of consumed foods as well as on the assumption that the food
intake during any one period represents typical intake.
Reported intake, hoaever, is not always accurate, and intake reported for a
given period may differ significantly from that typical of longer time periods.
Dietary intake data provide useful indicators for populations, but even when an
association or correlation between a dietary factor and a disease is observed,
it is often difficult to prove that the dietary factor is an actual or sole
causeof that disease.
This difference between association and causation is basic to understanding
the scientific evidence that links diet to chronic disease. Uncertainties in the
ability to determine causation have sometimes made it difficult to achieve
consensus on appropriate public health nutrition policies. Established
principles require evaluation of the supporting evidence for a given association
between a dietary factor and a disease on the basis of its consistency,
strength, specificity, and biological plausibility. The evidence showing that
dietary intake of saturated fat raises blood cholesterol, which in turn
increases the chance of coronary heart disease, illustrates this point. The
similarity in results from laboratory, clinical, and epidemiologic research, the
apparent relationship between dose and effect in these studies, the observations
that the increase in blood cholesterol level is specific to saturated fatty
acids but not to other types, and the biological plausibility of explanations
for the observations, when taken together, provide considerable support for
concluding that the association is causal, at least for some individuals.
For some of the other diseases reviewed in this Report, the available
evidence is less complete and less consistent. Nevertheless, much evidence
supports credible associations between a dietary pattern of excesses and
imbalances and several important chronic diseases. These associations, in turn,
suggest that the overall health of Americans could be improved by a few specific
but fundamental dietary changes.
Key Findings and Recommendations
Even though the results of various
individual studies may be inconclusive, the preponderance of the evidence
presented in the Report's comprehensive scientific review substantiates an
association between dietary factors and rates of chronic diseases. In
particular, the evidence suggests strongly that a dietary pattern that contains
excessive intake of foods high in calories, fat (especially saturated fat),
cholesterol, and sodium, but that is low in complex carbohydrates and fiber, is
one that contributes significantly to the high rates of major chronic diseases
among Americans. It also suggests that reversing such dietary patterns should
lead to a reduced incidence of these chronic diseases.
This Surgeon General's Report on Nutrition and Health provides a
comprehensive review of the most important scientific evidence in support of
current Federal nutrition policy as stated in the Dietary Guidelines for
Americans. These Guidelines, issued jointly by the Department of Agri- culture
and the Department of Health and Human Services, recommend:
- Eat a variety of foods.
- Maintain desirable weight.
- Avoid too much fat, saturated fat, and cholesterol.
- Eat foods with adequate starch and fiber.
- Avoid too much sugar.
- Avoid too much sodium.
- If you drink alcoholic beverages, do so in moderation.
Evidence
presented in this Report expands the focus of these seven guidelines and
provides considerable insight into priorities. Clearly emerging as the primary
priority for dietary change is the recommendation to reduce intake of total
fats, especially saturated fat, because of their relationship to development of
several important chronic disease conditions. Because excess body weight is a
risk factor for several chronic diseases, maintenance of desirable weight is
also an important public health priority. Evidence further supports the
recommendation to consume a dietary pattern that contains a variety of foods,
provided that these foods are generally low in calories, fat, saturated fat,
cholesterol, and sodium.
Taken together, the recommendations in this Report promote a dietary pattern
that emphasizes consumption of vegetables, fruits, and whole grain
products--foods that are rich in complex carbohydrates and fiber and relatively
low in calories-- and of fish, poultry prepared without skin, lean meats, and
low-fat dairy products selected to minimize consumption of total fat, saturated
fat, and cholesterol.
The evidence presented in this Report suggests that such overall dietary
changes will lead to substantial improvements in the nutritional quality of the
American diet. Consuming a higher proportion of calories from fruits,
vegetables, and grains may lead to a modest reduction in protein intake for some
people, but this reduction is unlikely to impair nutritional status. Average
levels of protein consumption in the United States, 60 grams per day for women
and 90 grams per day for men, are well above the National Research Council's
recommendations of 44 and 56 grams per day, respectively.
The evidence also suggests that most Americans generally need not consume
nutrient supplements. An estimated 40 percent of Americans consume supplemental
vitamins, minerals, or other dietary components at an annual cost of more than
$2.7 billion. Although nutrient supplements are usually safe in amounts
correspending to the Recommended Dietary Allowances (and such Allowances are set
to ensure that the nutrient needs of practically all the population are met),
there are no known advantages to healthy people consuming excess amounts of any
nutrient, and amounts greatly exceeding recommended levels can be harmful. For
example, some nutrients such as selenium have a narrow range of safe level of
intake. Toxicity has been reported for most minerals and trace elements, as well
as some vitamins, indicating that excessive supplementation with these
substances can be hazardous.
Finally, some recommend,tions for dietary change apply broadly to the general
public whereas others apply only to specific population groups. These major
findings and recommendations of The Surgeon General's Report on Nutrition find
Health are noted below.
Issues for Most People
- Fats and cholesterol: Reduce consumption of fat (especially saturated fat)
and cholesterol. Choose foods relatively low in these substances, such as
vegetables, fruits, whole grain foods, fish, poultry, lean meats, and low fat
dairy products. Use food preparation methods that add little or no fat.
High intake of total dietary fat is associated with increased risk for
obesity, some types of cancer, and possibly gallbladder disease. Epidemiologic,
clinical, and animal studies provide strong and consistent evidence for the
relationship between saturated fat intake, high blood cholesterol, and increased
risk for coronary heart disease. Conversely, reducing blood cholesterol levels
reduces the risk for death from coronary heart disease. Excessive saturated fat
consumption is the major dietary contributor to total blood cholesterol levels.
Dietary cholesterol raises blood cholesterol levels, but the effect is less
pronounced than that of saturated fat. While polyunsaturated fatty acid
consumption, and probably monounsaturated fatty acid consumption, lowers total
blood cholesterol, the precise effects of specific fatty acids are not well
defined.
Dietary fat contributes more than twice as many calories as equal quantities
(by weight) of either protein or carbohydrate, and some studies indicate that
diets high in total fat are associated with higher obesity rates. In addition,
there is substantial, although not yet conclusive, epidemiologic and animal
evidence in support of an association between dietary fat intake and increased
risk for cancer, especially breast and colon cancer. Similarly, epidemiologic
studies suggest an association between gallbladder disease, excess caloric
intake, high dietary fat, and obesity. More precise conclusions about the role
of dietary fat await the development of improved methods to distinguish among
the contributions of the high-calorie, high-fat, and low-fiber components of
current American dietary patterns.
At present, dietary fat accounts for about 37 percent of the total energy
intake of Americans well above the upper limit of 30 percent recommended by the
American Heart Association and the American Cancer Society, and above the
percent consumed by many societies, such as Mediterranean countries, Japan, and
China, for example, where coronary heart disease rates are much lower than those
observed in the United States. Consumption of saturated fat and cholesterol is
also substantially higher among many Americans than levels recommended by
several expert groups.
The major dietary sources of fat in the American diet are meat, poultry,
fish, dairy products, and fats and oils. Animal products tend to be higher in
both total and saturated fats than most plant sources. Although some plant fats
such as coconut and palm kernel oils also contain high proportions of saturated
fatty acids, these make minor contributions to total intake of saturated fats in
the United States. Dietary cholesterol is found only in foods of animal origin,
such as eggs, meat, poultry, fish, and dairy products. To help reduce
consumption of total fat, especially saturated fat and cholesterol, food choices
should emphasize intake of fruits, vegetables, and whole grain products and
cereals. They should also emphasize consumption of fish, poultry prepared
without skin, lean meats, and low-fat dairy products. Among vegetable fats,
those that are more unsaturated are better choices.
- Energy and weight control: Achieve and maintain a desirable body weight. To
do so, choose a dietary pattern in which energy (caloric) intake is consistent
with energy expenditure. To reduce energy intake, limit consumption of foods
relatively high in calories, fats, and sugars and minimize alcohol consumption.
Increase energy expenditure through regular and sustained physical activity.
People are considered overweight if their body mass index, or BMI (a ratio of
weight to height described in the Report), exceeds the 85th percentile for young
American adults (approximately 120 percent of desirable body weight); they are
considered severely overweight if their BMI exceeds the 95th percentile
(approximately 140 percent of desirable body weight). Overweight individuals are
at increased risk for diabetes mellitus, high blood pressure and stroke,
coronary heart disease, some types of cancer, and gallbladder disease.
Epidemiologic and animal studies have shown consistently that overall risk for
death is increased with excess weight, with risk increasing as severity of
obesity increases.
Type II (noninsulin-dependent) diabetes mellitus accounts for approximately
90 percent of all cases of diabetes and is strongly associated with obesity.
Clinical studies indicate that weight loss can improve control of Type II
diabetes.
Obesity increases the risk for high blood pressure, and consequently for
stroke; it also increases blood cholesterol levels associated with coronary
heart disease. In addition, it appears to be an independent risk factor for
coronary heart disease. Weight reduction has been shown to reduce high blood
pressure and high blood cholesterol. Most obese individuals who achieve a more
desirable body weight improve their cholesterol profile, achieving a decrease in
both total blood cholesterol and LDL (low density lipoprotein) cholesterol.
Some studies have found an association between overweight and increased risk
for several cancers, especially cancer of the uterus and breast. In addition,
overweight increases the risk for gallbladder disease.
More than a quarter of American adults are overweight. Black women age 45 and
above have the highest prevalence, about 60 percent. Although evidence suggests
a genetic component to the tendency of many people to become overweight,
patterns of dietary caloric intake and energy expenditure play a key role.
Sustained and long- term efforts to reduce body weight can best be achieved as a
result of improving energy balance by reducing energy consumption and raising
energy expenditure through physical activity and exercise.
Maintenance of desirable body weight throughout the lifespan requires a
balance between energy (calorie) intake and expenditure. Weight control may be
facilitated by decreasing energy intake, especially by choosing foods relatively
low in calories, fats, and sugars, and by minimizing alcohol consumption. Energy
expenditure can be enhanced through regular physical activities such as daily
walks or by jogging, bicycling, or swimming at least three times a week for at
least 20 minutes.
- Complex carbohydrates and fiber: Increase consumption of whole grain foods
and cereal products, vegetables (including dried beans and peas), and fruits.
Dietary patterns emphasizing foods high in complex carbohydrates and fiber
are associated with lower rates of diverticulosis and some types of cancer.The
association shown in epidemiologic and animal studies be fiber are associated
with lower rates of diverticulosis and some types of cancer. The association
shown in epidemiologic and animal studies be- tween diets high in complex
carbohydrates and reduced risk for coronary heart disease and diabetes mellitus
is, however, difficult to interpret. The fact that such diets tend also to be
lower in energy and fats, especially saturated fat and cholesterol, clearly
contributes to this difficulty. Some evidence from clinical studies also
suggests that water-soluble fibers from foods such as oat bran, beans, or
certain fruits are associated with lower blood glucose and blood lipid levels.
Consuming foods with dietary fiber is usually beneficial in the management of
constipation and diverticular disease.
While inconclusive, some evidence also suggests that an overall increase in
intake of foods high in fiber might decrease the risk for colon cancer. Among
several unresolved issues is the role of the various types of fiber, which
differ in their effects on water-holding capacity, viscosity, bacterial
fermentation, and intestinal transit time.
Other food components associated with decreased cancer risk are commonly
found in diets high in whole grain cereal products containing complex
carbohydrates and fiber. In addition, some epidemiologic evidence suggests that
frequent consumption of vegetables and fruits, particularly dark green and deep
yellow vegetables and cruciferous vegetables (such as cabbage and broccoli), may
lower risk for cancers of the lung and bladder as well as some cancers of the
alimentary tract. However, the specific components in these foods that may have
protective effects have not yet been established. Current evidence suggests the
prudence of increasing consumption of whole grain foods and cereals, vegetables
(including dried beans and peas), and fruits.
- Sodium: Reduce intake of sodiurn by choosing foods relatively low in Sodium
and limiting the amount of Salt added in food preparation and at the table.
Studies indicate a relationship between a high sodium intake and the
occurrence of high blood pressure and stroke. Salt contains about 40 percent
sodium by weight and is used widely in the preservation, processing, and
preparation of foods. Although sodium is necessary for normal metabolic
function, it is consumed in the United States at levels far beyond the 1.1 to
3.3 grams per day found to be as safe and adequate for adults by the National
Research Council. Average current sodium intake for adults in the United States
is in the range of 4 to 6 grams per day.
Blacks and persons with a family history of high blood pressure are at
greater risk for this condition. While some people maintain normal blood
pressure levels over a wide range of sodium intake, others appear to be
"salt sensitive" and display increased blood pressure in response to
high sodium intakes.
Although not all individuals are equally susceptible to the effects of
sodium, several observations suggest that it would be prudent for most Americans
to reduce sodium intake. These include the lack of a practical biological marker
for individual sodium sensitivity, the benefit to persons whose blood pressures
do rise with sodium intake, and the lack of harm from moderate sodiurn
restriction.
Processed foods provide about a third or more of dietary sodium. Because
about another third of the sodium consumed by Americans is added by the
consumer, much can be done to reduce sodium consumption by using less salt at
the table and substituting alternative flavoring such as herbs, spices, and
lemon juice in the preparation of foods. In addition, choices can be made of foods modified to lower sodium content and less frequent choices could be made
of foods to which sodium is added in processing and preservation.
- Alcohol: To reduce the risk for chronic disease, take alcohol only in
moderation (no more than two drinks a day), if at all. Avoid drinking any
alcohol before or while driving, operating machinery, taking medications, or
engaging in any other activity requiring judgment. Avoid drinking alcohol while
pregnant.
Alcohol is a drug that can produce addiction in susceptible individuals,
birth defects in some children born to mothers who drink alcohol during
pregnancy, impaired judgment, impaired ability to drive automobiles or operate
machinery, and adverse reactions in people taking certain medications. In
addition, alcohol abuse has been associated with disrupted family functioning,
suicides, and homicides.
Excessive use of alcohol is also associated with liver disease, some types of
cancer, high blood pressure, stroke, and disorders of the heart muscle.
Extensive epidemiologic and clinical evidence has identified alcohol consumption
as the principal cause of liver cirrhosis in the United States, at least in part
as a result of the direct toxic effects of alcohol on the liver. Smoking and
alcohol appear to act synergistically to increase the risk for cancers of the
mouth, larynx, and esophagus. Less conclusive and somewhat conflicting evidence
suggests a role of alcohol in other types cancers such as those of the liver,
rectum, breast, and pancreas. Studies Indicate a direct association between
increased blood pressure and the consumption of alcohol at levels beyond about
two drinks(a) daily.
Extremely excessive alcohol consumption is associated with cardiomyopathy.
Alcohol consumption by the mother during pregnancy has also been associated with
fetal malformations.
Although consumption of up to two drinks per day has not been associated with
disease among healthy men and nonpregnant women, surveys suggest that at least 9
percent of the total population consumes two or more drinks per day and those in
this group need to reduce their alcohol consumption. A threshold level of safety
for alcohol intake during pregnancy has not been established. Thus, pregnant
women and women who may become pregnant should avoid drinking alcohol.
(a)One drink is defined as a 12 ounce beer, a 5 ounce glass of wine, or 1.5
fluid ounces (one jigger) of distilled spirits, each of which contains about 1
ounce of alcohol.
Other Issues for Some People
- Fluoride: Community water systems should contain fluoride at optimal levels
for prevention of tooth decay. If such water is not available, use other
appropriate sources of fluoride.
The most efficient means of making fluoride available to the general public
to reduce dental disease is through drinking water. Numerous epidemiologic and
clinical studies have attested to the efficacy, safety and cost effectiveness of
systemic fluoride in the prevention of tooth decay. Lifetime use of water
containing an optimal fluoride concentration of approximately 1 part per million
has been shown to reduce the prevalence of dental caries by more than 50
percent. Water fluoridation is considered one of the most successful public
health efforts introduced in the United States.
For children living in areas with inadequate concentrations of fluoride in
the water, supplementary fluoride sources should be used at dosages that depend
on the fluoride content of the local water supply and the age of the child. The
effectiveness of prenatal fluoride administration, however, is uncertain because
clinical studies of its effects on subsequent caries incidence have been
equivocal. Excessive fluoride should be avoided because
For children living in areas with Inadequate concentrations of fluoride in
the water, supplementary fluoride sources should be used at dosages that depend
on the fluoride content of the local water supply and the age of the child. The
effectiveness of prenatal fluoride administration, however, is uncertain because
clinical studies of its effects on subsequent caries incidence have been
equivocal. Excessive fluoride should be avoided because it may cause mottling of
developing teeth.
- Sugars: Those who are particularly Vulnerable to dental caries (cavities),
especially children, should limit their consumption and frequency of use of
foods high in sugars.
Although genetic, behavioral, and other dietary factors also influence dental
health, the major role of sugars in promotion of tooth decay is well established
from animal, epidemiologic, clinical, and biochemical studies. Newly erupting
teeth are generally more vulnerable to decay than mature teeth.
Research has shown that three conditions must exist for the formation of
dental caries: the presence of fermentable carbohydrate, acid-producing
bacteria, and a susceptible tooth. Caries-producing bacteria metabolize a range
of sugars (glucose, fructose, maltose, lactose, and sucrose) to acids that
demineralize teeth. The unique role of sucrose (common table sugar) in dental
caries is related to its special ability to be converted by these bacteria into
long, complex molecules that adhere firmly to teeth and form plaque.
The most important diet-related interventions are fluoridation of drinking
water, or the use of other means of fluoride administration, and control of
intake of sugars. While fluoride is the most important factor overall in dental
caries prevention, reduction in the frequency of consumption and in the quantity
of sugar-rich foods in the diet will also help reduce decay. Sticky sweet foods
that adhere to th e teeth are more cariogenic than those that wash off quickly.
The longer cariogenic foods remain in the mouth, the more they are likely to
increase the initiation and progression of tooth decay.
- Calcium: Adolescent girls and adult women should increase consumption of
foods high in calcium, including low-fat dairy products.
Inadequate dietary calcium consumption in the first three to four decades of
life may be associated with increased risk for osteoporosis in later life.
Osteoporosis, a chronic disease characterized by progressive loss of bone mass
with aging, occurs inboth women and men, although postmenopausal women are twice
as likely as men to have severe osteoporosis with consequent bone fractures.
Evidence shows that chronically low calcium intake, especially during
adolescence and early adulthood, may compromise development of peak bone mass.
In postmenopausal women, the group at highest risk for osteoporosis, estrogen
replacement therapy under medical supervision is the most effective means to
reduce the rate of bone loss and risk for fractures. Maintenance of adequate
levels of physical activity and cessation of cigarette smoking have also been
associated with reduced osteoporosis risk.
Although the precise relationship of dietary calcium to osteoporosis has not
been elucidated, it appears that higher intakes of dietary calcium could
increase peak bone mass during adolescence and delay the onset of bone fractures
later in life. Thus, increased consumption of foods rich in calcium may be
especially beneficial for adolescents and young women. Food sources of calcium
consistent with other dietary recommendations in this Report include 1ow-fat
dairy products, some canned fish, certain vegetables, and some calcium-enriched
grain products.
- Iron: Children, adolescents, and women of childbearing age should be sure to
consume foods that are good sources of iron, such as lean meats, fish, certain
beans, and iron-enriched cereals and whole grain products. This issue is of
special concern for low-income families.
Dietary iron deficiency is responsible for the most prevalent form of anemia
in the United States. Iron deficiency hampers the body's ability to produce
hemoglobin, a substance needed to carry oxygen in the blood. A principal
consequence of iron deficiency is reduced work capacity, although depressed
immune function, changes in behavior, and impaired intellectual performance may
also result. Because of the serious consequences of iron deficiency, continual
monitoring of the iron status of individuals at high risk--particularly children
from low-income families, adolescents, and women of childbearing age--is vital,
as is treatment of those identified to be iron deficient.
Proper infant feeding--preferably breastfeeding, otherwise use of
iron-fortified formula--is the most important safeguard against iron deficiency
in infants. Among adolescents and adults, iron intake can be improved by
increasing consumption of iron-rich foods such as lean meats, fish, certain
kinds of beans, and iron-enriched cereals and whole grain products. Also,
consuming foods that contain vitamin C increases the likelihood that iron will
be absorbed efficiently.
Dietary Guidance
General Public
Educating the public about the dietary choices most
conducive to prevention and control of certain chronic diseases is essential.
Educational efforts should begin in primary school and continue throughout the
secondary grades, and should focus on the dietary principles outlined in this
Report-- the potential health benefits of eating a diet that is lower in fat
(especially saturated fat) and richin complex carbohydrates and fiber. The
importance of adequate physical activity should also be stressed. Efforts should
continue throughout each stage oflife to promote the principles outlined in the
Dietary Guidelines for Americans.
Special Populations
A disproportionate burden of diet-related disease is
borne by subgroups in our population. Black Americans, for example, have higher
rates of high blood pressure, strokes, diabetes, and other diseases associated
with obesity (but lower rates of osteoporosis) than the general population. Some
groups of Native Americans exhibit the highest rates of diabetes in the world.
Pregnant and lactating women also have special nutritional needs. Particular
effort should be made to identify and remove the barriers to optimal health and
nutritional status in such high-risk groups, using methods that take into
consideration their diverse cultural backgrounds.
Many older persons suffer from chronic diseases that can reduce functional
independence; many take multiple medications that may adversely interact with
nutrients. Sound public education directed toward this group-and professional
education directed toward individuals who care for older Americans--should focus
on dietary means to reduce risk factors for chronic disease, to promote
functional independence, and to prevent adverse consequences of use of
medications.
Health Professionals
Improved nutrition training of physicians and other
health professionals is needed. Training should emphasize basic principles of
nutrition, the role of diet in health promotion and disease prevention,
nutrition assessment methodologies and their interpretation, therapeutic aspects
of dietary in- tervention, behavioral aspects of dietary counseling, and the
role of dieti- tians and nutritionists in dietary counseling of patients.
Programs and Services
Food Labels
Food labeling offers opportunities to inform people about the
nutrient content of foods so as to facilitate dietary choices most conducive
health. Food manufacturers should be encouraged to make full use of nutrition
labels. Labels of processed foods should state the content of calories, protein,
carbohydrate, fats, cholesterol, sodium, and vitamins health. Food manufacturers
should be encouraged to make full use of nutrition labels. Labels of processed
foods should state the content of calories, protein, carbohydrate, fats,
cholesterol, sodium, and vitamins and minerals. To the extent permitted by
analytical methods, manufacturers should disclose information where appropriate
on the content of saturated and unsaturated fatty acids and total fiber in foods
that normally contain them. Descriptive terms such as "low calorie"
and "sodium reduced" in compliance with the Food and Drug
Administration's regulations for food labeling may also be helpful, and the
expanded use of these terms should be encouraged.
Nutrition Services
Health care programs for individuals of all ages should
include nutrition services such as, when appropriate, nutrition counseling for
individuals or groups, interpretation and implementation ofprescribed
therapeutic diets tailored to individualfood preferences and lifestyle, referral
to appropriate community services and food assistance programs, monitoring of
progress, and appropriate followup. These services should routinely incorporate
assessment of nutritional status and needs based on established criteria to
identify individuals with nutritional risk factors who would profit from
preventive measures and those with nutritional disorders who need remedial care.
Food Services
Lack of access to an appropriate diet should not be a health
problem for any American. Wherever food is served to people or provided through
food assistance programs, it should reflect the principles of good nutrition
stated in this Report. Whether served in hospitals, schools, military
installations, soup kitchens, day care centers, or nursing homes, or whether
delivered to homes, food service programs offer important oppertunities for
improving health and providing dietary education. Such Programs should pay
special attention to the nutritional needs of older people, pregnant women, and
children, especially those of low income or other special dietary needs. Because
a large proportion of the population takes meals in restaurants and convenience
food facilities, improvements in the overall nutritional balance of the meals
served in such places can be expected to contribute to health benefits.
Food service programs should also take particular care to ensure that special
diets lower in fat, especially saturated fat, are provided to people with
elevated blood cholesterol, heart disease, or diabetes; that diets low in sodium
are provided to individuals with high blood pressure; and that
protein-restricted diets are made available to people with end-stage kidney
disease.
Food Products
The public would benefit from increased availability of
foods and food products low in calories, total fat, saturated fat, cholesterol,
sodium, and sugars, but high in a variety of natural forms of fiber and,
perhaps, certain minerals and vitamins. Food manufacturers can contribute to
improving the quality of the American diet by increasing the availability of
palatable, easily prepared food products that will help people to follow the
dietary principles outlined here. Because the public is becoming increasingly
conscious of the role of nutrition in health, development of such products
should also benefit the food industry.
Research and Surveillance
Impressive evidence already links nutrition to
chronic disease. However, much more information is needed to continue to
identify changes in the national diet that will lead to better health for the
Nation. Gaps in our knowledge of nutrition suggest future research and
surveillance needs. Examples are:
- The role of specific dietary factors in the etiology and prevention of
chronic diseases.
- The childhood dietary pattern that will best prevent later development of
chronic diseases.
- The effects of maternal nutrition on the health of the developing fetus.
- The nutrient and energy requirements of older adults.
- How nutrient requirements translate into healthful dietary patterns.
- The development of biochemical markers of dietary intake to monitor better
the effects of dietary intervention.
- The identification of effective educational methods to translate dietary
recommendations into appropriate food choices.
- The establishment of a nutrition surveillance system that will enhance the
monitoring of population-specific and State-specific trends in the occurrence of
nutrition-related risk factors and conditions.
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