The Surgeon General's Report on NUTRITION AND HEALTH The Surgeon General's Report on NUTRITION AND HEALTH Summary and Recommendations 1988 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service DHHS (PHS) Publication No. 88-50211 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC 20402 DEPARTMENT OF HEALTH & HUMAN SERVICES 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 heahh. 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. Perhaps the classic example 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 Ear 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 there 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, uniike 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 Rep&t 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 kventual 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 Foreword This first Surgeon General's Report on Nutrition and Health marks a key event in the history of public health in the United States; While the Report has been developed for use by policymakers, it offers lessons that can be directly -applied to the public. It responds to the increasing interest of scientists, health professionals, and the American people in the role of diet in health promotion. Within recent years, concerns about nutrition and health have expanded beyond the need to prevent deficiencies to encom- pass the effects of typical American dietary patterns on the incidence of chronic diseases that are leading causes of death and disability in this country. Although scientific research has provided substantial insight into the ways specific dietary factors influence specific diseases, there are still many uncertainties about diet-disease relationships. The Department of Health and Human Services, through the Public Health Service and the Surgeon General, welcomes the responsibility to evaluate the current state of knowledge and to advise the public accordingly. This Report reviews the scientific evidence that relates dietary excesses and imbalances to chronic diseases. On the basis of the evidence, it recommends dietary changes that can improve the health prospects of many Americans. Of highest priority among these changes is to reduce intake of foods high in fats and to increase intake of foods high in complex carbohydrates and fiber. The evidence presented here indicates the convergence of similar dietary recommendations that apply to prevention of multiple chronic diseases. The recommendation to reduce dietary fat, for example, aims to reduce the risk for coronary heart disease, diabetes, obesity, and some types of cancer. This advice is not new. But it is now substantiated by a large body of evidence derived from many different kinds of research-a research base that is now even more comprehensive than was the case for the pioneering 1964 Surgeon General's Report on Smoking and Health. The weight of this evidence and the magnitude of the problems at hand indicate that it is now time to take action. In the cause of good health for ail our citizens, I urge support for this Report's recommendations by every sector of American society. Otis R. Bowen, M.D. Secretary V Preface The Public Health Service of the Department of Health and Human Ser- vices has long maintained an interest in the relationship between food and health. In the 1970's, this interest began to focus on the ways in which dietary excesses and imbalances increase the risk for chronic diseases. With the publication in 1979 of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, attention turned toward environmental and behavioral changes that Americans might make to reduce their risks for morbidity and mortality. Nutrition was one such priority area. The 1980 report Promoting Health/Preventing Disease: Ob- jectives for the Nation included 17 specific. quantifiable objectives in nutrition designed to reduce risks and to prevent illness and death. Also in 1980, the Department published, jointly with the U.S. Department of Agriculture, the first edition of Dietary Guidelines for Americans. This report, revised in 1985, includes seven recommendations that, taken to- gether, address the relationship between diet and chronic diseases. Diseases such as coronary heart disease, stroke, cancer, and diabetes remain leading causes of death and disability in the United States. Substan- tial scientific research over the past few decades indicates that diet can play an important role in prevention of such conditions. The Public Health Service has now reviewed this research and has produced a comprehensive analysis of the relationship between dietary factors and chronic disease risk. This Surgeon General's Report on Nutrition and Health summarizes research on the role of diet in health promotion and disease prevention. Its findings indicate the great importance of diet to health. They demonstrate that changes in present dietary practices of Americans could produce substantial gains in the health of the population. The Public Health Service is committed to improving the health of Americans through its programs in education, services, and research. One mechanism for improving the health of Americans is through the 1990 Health Objectives for the Nation. The role of nutrition in health will continue to be a focus of national health priorities as we develop new objectives for the year 2000. Federal, State, and local governments, the American public, the food industry, and scientists and health professionals can work together to encourage Americans to make healthy food choices and to achieve national health goals. vii I am pleased to commend to the American people this review of the scientific evidence that links diet to chronic disease. and I urge that the findings of this important Report be given your careful consideration. Robert E. Windom, M.D. Assistant Secretary for Health . . . Vlll Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Nutrition Policy Board ........................................ x Acknowledgments ............................................ xi Summary and Recommen.dations ............................... 1 Appendix A: Selected Events in the History of Nutritional Science to 1950 ....... ;. ................ 21 Appendix B: Selected Federal Domestic Nutrition Policy Mjlestones. 1862-1988 . . . . . _ . . . . . . . . _ . . . . . . . . . . . . . . 25 Appendix C: Federal Dietary Recommendations for the General Public, 1917-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Appendix D: Implications for Public Health Policy . . . . . . . . . . . . . . . 33 Full Report Contents 1. Introduction and Background 11. Infections and Immunity 2. Coronary Heart Disease 12. Anemia 3. High Blood Pressure l3. Neurologic Disorders 4. Cancer 14. Behavior 5.' Diabetes 15. Maternal and Child Nutrition 6. Obesity 7. Skeletal Diseases 8. Dental Diseases 9. Kidney Diseases 10. Gastrointestinal Diseases 16. Aging 17. Alcohol 18. Drug-Nutrient Interactions 19. Dietary Fads and Frauds iX Nutrition Policy Board U.S. Department of Health and Human Services J. Michael McGinnis, M.D. (Chairman), Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion), Public Health Service Faye G. Abdellah, R.N., Ed.D., Sc.D., Deputy Surgeon General, Public Health Service W. Douglas Badger, M.Div., Deputy Assistant Secretary, Office of Human Development Services Mary M. Evert, M.B.A., Director, Office of Community Services, Family Support Administration Manning Feinleib, M.D., M.P.H., Dr.P.H., Director, National Center for Health Statistics, Centers for Disease Control, Public Health Service Allan L. Forbes, M.D., Director, OfIice of Nutrition and Food Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administra- tion, Public Health Service William T. Friedewald, M.D., Associate Director for Disease Prevention, National Institutes of Health, Public Health Service Bernard I. Grosser, M.D., Director, Office of Science, Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service John Porvaznik, M.D., F.A.C.S., Associate Director, Of&e of Health Programs, Indian Health Service, Public Health Service William A. Robinson, M.D., M.P.H., Chief Medical Officer, Health Re- sources and Services Administration, Public Health Service X Acknowledgments The Surgeon General's Report on Nutrition and Health was prepared under the general editorship of the Department of Health and Human Services' Nutrition Policy Board, whose members are listed on the pre- vious page. Managing Editor was Marion Nestle, Ph.D., M.P.H., Office of Disease Prevention and Health Promotion. Special editorial assistance was contributed by John Bailar III, M.D., Ph.D., Science Advisor, OtTice of Disease Prevention and Health Promotion, and by Darla E. Danford, M.P.H., D.Sc., R.D.,. National Institutes of Health. Project Officer during early stages of preparation of the Report was Ann Sorenson, Ph.D., now with the National Institutes of Health. In addition to the guidance of the Nutrition Policy Board's Senior Editorial Advisors and Staff Working Group, important editorial contributions were made by Karen Donato, MS., R.D., Nancy D. Ernst, M.S., R-D., Marilyn E. Farrand, M.S., R.D., and Van S. Hubbard. M.D., Ph.D., of the National Institutes of Health's Nutrition Education Subcommittee; and by Walter H. Glinsmann, M.D., Marilyn G. Stephenson, M.S., R.D., John E. Vander- veen, Ph.D., and Elizabeth Yetley, Ph.D., R-D., of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. Senior Editorial Advisors to the Nutrition Policy Board were: C. Wayne Callaway, M.D., Director, Center for Clinical Nutrition, George Washington University Medical Center, Washington, D.C. Johanna T. Dwyer, D.Sc., Director, Frances Stem Nutrition Center, New England Medical Center Hospitals, and Professor of Medicine, Tufts Uni- versity Medical School, Boston, Massachusetts Samuel Fomon, M.D., Professor of Pediatrics, University of Iowa, Iowa City, Iowa Richard L. Hall, Ph.D., Vice President, Science and Technology, McCor- mick & Co., Inc., Hunt Valley, Maryland Robert I. Levy, M.D., President, Sandoz Research Institute, East Hano- ver, New Jersey Walter Mertz, M.D., Director, Beltsville Human Nutrition Research Cen- ter, U.S. Department of Agriculture, Beltsville, Maryland Xi Malden C. Nesheim, Ph.D., Vice President for Planning and Budget, Cornell University, Ithaca, New York `Sushma Palmer, D.Sc., Executive Director, Food and Nutrition Board, National Academy of Sciences, Washington, D.C. Irwin H. Rosenberg, M.D., Director, USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts Theodore Van Itallie, M.D., Professor of Medicine, Columbia University. College of Physicians and Surgeons, New York, New York Nutrition Policy Board Staff Working Group members were: Elizabeth Brannon, M.S., R.D., Clinical Nutrition Specialist, Bureau of Maternal and Child Health and Resources Development, Health Resources and Services Administration, Rockville, Maryland Darla E. Danford, M.P.H., D.Sc., R.D., Nutritionist, Nutrition Coordinat- ing Committee, National Institutes of Health, Bethesda, Maryland Willie M. Etheridge, M.S., Policy Analyst, Policy Planning and Legislation Division, Office of Human Development Services, Washington, D.C. James J. Heam, L.L.B., Chief, Community Food and Nutrition Program, Office of Community Services, Family Support Administration, Washing- ton, D.C. M. Yvonne Jackson, Ph.D., R.D., Chief, Nutrition and Dietetics Section, Indian Health Service, Rockville, Maryland Linda D. Meyers, Ph.D., Nutrition Advisor, Office of Disease Prevention and Health Promotion, Washington, D.C. Marion Nestle, Ph.D., M.P.H., Director, Nutrition Policy Staff, Gflice of Disease Prevention and Health Promotion, Washington, D.C. Lana Skirboll, Ph.D., Special Assistant to the Director, Office of Science, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland Frederick Trowbridge, M.D., M.S., Director, Nutrition Division, Center for Health Promotion and Education, Centers for Disease Control, Atlanta, Georgia xii Catherine E.. Woteki, Ph.D., R.D., Deputy Director, Division of Health Examinatiqn Statistics, National Center for Health Statistics, Centers for D,isease Control, Hyattsville, Maryland During preparation of the Report, chapters were subjected to six stages of critical review, three by experts within the Public Health Service (internal reviews) and three by scientists and professionals recommended as experts by national scientific and nutrition professional organizations in the private sector (external reviews). In addition, the senior editorial advisors and staff to the Nutrition Policy Board listed above provided expert technical eval- uation throughout the review process. A full list of the many individuals who contributed to the writing or to the review of chapters or sections of the Report can be found in the Acknowledgments section of the complete Surgeon General's Report on Nutrition and Health. The editors gratefully acknowledge the contributions of Joanna Fringer. Program Manager, and Margaret Leahy, Editor, Technical Resources Inc., Rockville, Maryland, David Schardt, Nutrition Consultant, Washington. D.C., and Nancy Chapman. N. Chapman Associates, Washington, D.C.. to the preparation of this Report. A complete list of staff members and others who contributed to the Report's preparation is also given in its Acknowledgments. . . . xl11