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.
U.S. Public Health Service
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.
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.
|Percent of Total|
|Rank||Cause of Death||Number of Deaths|
|(Coronary heart disease)||(511,700)||(24.1)|
|(Other heart disease)||(247,700)||(11.6)|
|5||Chronic obstructive lung diseases||78,000||3.7|
|6||Pneumonia and influenza||68,600||3.2|
|9b||Chronic liver disease and cirrhosis||26,000||1.2|
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:
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.
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.
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:
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.