Extracts of
The Surgeon General's Report on


Public Health Service

The Surgeon General of the
Public Health Service
Washington DC 20201


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 Ameriam 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 considerahle 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


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
Issues for Most People:
Other Issues for Some People:
Table 2
Estimated Total Deaths and Percent of Total Deaths for the
10 Leading Causes of Death: United States, 1987

Percent of Total
RankCause of DeathNumber of Deaths
laHeart 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
3aStrokes148,700 7.0
4b Unintentional injuries92,500 4.4
(Motor vehicle)(46,800) (2.2)
(All others) (45,700) (2.2)
5 Chronic obstructive lung diseases 78,0003.7
6Pneumonia and influenza68,6003.2
7aDiabetes mellitus37,800 1.8
8bSuicide 29,600 1.4
9bChronic liver disease and cirrhosis26,000 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:

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:

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

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:
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