BY MARGARET EASTMAN
ashington has a new kickball game. It's called nutrition. The rules of the game are fuzzy; the players are government administrators, Congressmen, consumers, public interest groups, and health professionals. The object of the game is lofty: to provide better nutrition guidelines so Americans will know what to put in their stomachs. It's unclear, however, how the players are going to score. The problem with the kickball game is that it is really a battle over turf, primarily between two federal agencies: the Department of Health, Education, and Welfare (HEW) and the Department of Agriculture (USDA). The United States has no national nutrition policy, and no agency is responsible for its design. Instead, in the words of a recent General Accounting Office (GAO) study, the country has" ... a de facto policy which is, in effect, 12
a piecemeal series of programs instituted over the years, often because of a sense of emergency and with little thought given to its interaction or relationship with existing programs." Without a referee or chalk lines to limit play, many federal agencies have entered the kickball game, particularly in the area of nutrition research. According to the GAO, these include: • National Institutes of Health (HEW); . • Agricultural Research Service (USDA); • Food and Drug Administration (HEW); • Center for Disease Control (HEW); • Health Services Administration (HEW); • Alcohol, Drug Abuse, and Mental Health Administration (HEW); • Department of Defense; • Agency for International Development; • National Science Foundation; American Pharmacy VoI.NS18, No.4, April 1978 / 172
• Cooperative State Research Service (USDA); • National Aeronautics and Space Administration; and • Veterans Administration. Enthusiasm for the kickball sport has been particularly strong in the last decade, with the accumulation of more and more statistical evidence linking inadequate nutrition with the nation's leading causes of death, including cardiovascular disease and cancer. One Capitol Hill player, former presidential candidate Sen. George McGovern (D-SD) stole the federal agencies' thunder when he ran away with the ball by releasing his Senate committee's national dietary guidelines-not once, but twice (see below).
Burke, who believes in a multi-disciplinary team approach to nutritional support and nutrition education. Such a cross-disciplinary approach is advocated by the American Society for Parenteral and Enteral Nutrition (ASPEN), a rapidly growing international group of eminent scientists, researchers and health professionals from the many fields involved in the nutritional support of the critically ill patient. Burke is active in ASPEN, which publishes its own journal.
Lack of Nutrition Education Among Health Professionals Nutrition's fragmented national status is far from startling, considering that some health professionals are "nutritional morons," in the words of one government administra tor. The American Medical Association (AMA), in reporting on a survey of 114 medical schools' nutrition curricula (July 1976), said that only 63 percent of the responding schools offered nutrition courses, and that only 23 percent of these required a separate course in nutrition (although 75 percent said nutrition was incorporated in other courses). Senator McGovern's nine-year-old "temporary" Senate Select Committee on Nutrition and Human Needs (defunct as of January 1978) introduced legislation in 1973 that would have provided grants of $10 million each year for five years to help put some muscle into medical and dental school nutrition education programs. But this bill and similar bills are stalled in Congress, notes the GAO report. "I think there is no question that there is a remarkable need for nutrition education in the medical community and in institutions," said W. Arthur Burke, PharmD, who directs the department of parenteral nutrition at Wilmington Medical Center in Wilmington, Delaware. "Schools are not teaching nutrition," added American Pharmacy VoI.NS18, No.4 , April 1978 / 173
Ph o tos by Michae l Do la n
"Congress is looking at the tip of the iceberg," said Burke, who also believes that nutrition education should start at home-within the institution. Institutional Default That some institutions are not doing their nutritional homework, indeed" are totally remiss in recognizing their responsibility in how they provide this crucially important, yet seemingly simple human need," in Burke's words, is amply illustrated by the following brief patient history. A 63-year-old man with a history of hypertension was admitted to the coronary care unit of a major urban hospital with severe chest pains. The diagnosis was myocardial infarction.
During his recovery period, the man was given a hospital menu card with a choice of breakfasts. The patient chose eggs (high in cholesterol) and bacon (high in sodium and saturated animal fat). Whether eating such food really made or will make any difference in the MI pa tien t' s recovery is a moot po in t. But, noted Burke, the incident is one example of blatant "institutional lack of awareness" of the connection between diet and disease. Burke, who in his capacity as a pharmacist-clinician has been granted staff privileges in the departments of surgery and/or medicine in several local institutions, can both prescribe for and admit patients to the hospital. He and his specially-trained staff see patients requiring metabolicnutritional repletion on physician referral. "Over the past few years I have been averaging approximately 350 consultations each year for patients needing aggressive parenteral or enteral nutritional support," Burke said . "It is estimated that 10-15 percent of hospitalized patients require such therapy. "These patients typically present with severe protein-calorie deficiency as a result of their disease and/or poor nutritional history, premature births or congenital defects, trauma, extensive surgery, or their drug therapy. "Too often in our nation's hospitals," Burke continued, "the death of a patient is conveniently attributed to his 'weakened condition,' yet rarely is the actual cause-starvation -cited ." There is no excuse for that starvation, Burke feels. ~'With the many modalities and special techniques of nutritional support given to the medical world by such brilliant innovators as Drs. Jonathan Rhoads, Stanley Dudrick, George Blackburn and others-and the educational efforts of organizations like ASPEN-it is no longer necessary or acceptable for a patient to endure prolonged morbidity-or death-because of severe metabolic depletion resulting from starvation." Burke believes that pharmacists should become more active in nutri13
tion education, which he describes as "A new, vital and viable role" for the profession . "There is a desperate need for pharmacists to counsel in the community," he said . Burke also believes that more pharmacy schools should offer, at least on an elective basis, didactic courses in intravenous fluid and electrolyte therapy, and principles and practice of nutritional support in institutions.
Diet and Disease Evidence that diet and disease are related is not new. Yet, strangely, few but the authors of fad-diet books have attempted to tell Americans what to eat and why. Positive correlations have been found between high fat consumption and cancers of the breast and colon; there is also some evidence of a connection between lack of fiber in the diet and cancer of the lower intestinal tract. Epidemiological studies in man have shown that diet is such an important factor in cancer incidence that it can reverse a country's disease pattern, said Gio Gori, PhD, who directs the National Cancer Institute's diet, nutrition and cancer program. For example, said Gori, when Japanese migrate to the U.S., their patterns of low colon and breast cancer and high stomach cancer incidences shift dramatically within two to three generations until they pattern those of this country, which are exactly the reverse. The Framingham (Massachusetts) Heart Study, which began in 1950 with 5,127 men and women free of coronary heart disease, showed that elevated blood cholesterol (above 240) in the 30-39 age group was a factor in developing premature heart disease. Even high school diet affects the risk of heart attack, said John A . Scharffenberg, MD, MPH, at the annual meeting of the American Association for the Advancement of Science (AAAS) in Washington, DC, in February 1978. Scharffenberg, who in 1971 designed a coronary risk evaluation program called "Heartbeat" at Loma Linda University, California, recently compared the dietary habits and blood cholesterol levels of high 14
school youth at a Seventh-day Adventist school and a Ca tholic school in Bakersfield, California. Scharffenberg, a vegetarian, found only 21 percent of Adventist boys had cholesterol levels above 180, compared to 61 percen tat the Catholic high school. T riglycerides were lower in the Adventist group, which consumed less sugar. The Advent{st boys also ate less meat. To what extent a "prudent" diet can alleviate or prevent high blood cholesterol is still unknown, but diet is thought to be one factor in prevention of heart disease.
McGovern's Controversial Goals While scientists were asking themselves whether Americans' increased . intake of fats and sugar and overconsumption of salts, cholesterol and alcohol meant anything, South Dakota Senator George McGovern was proceeding nonstop on Capitol Hill to show that they did. " Dietary Goals for the United States," first released in February 1977 by McGovern's Senate Select Committee on Nutrition and Human Needs, and revised last December, is an un preceden ted effort to change American eating habits. McGovern minces no words : "The simple fact is that our diets have changed radically within the last 50 years, with great and often very harmful effects on our health .... In all, six of the ten leading causes of death in the United States have been linked to our diet." Basically, the goals call for: • Increasing the consumption of complex carbohydrates and naturally occurring sugars by eating more fruits, vegetables and grain products; • Reducing the consumption of refined sugars by about 45 percent; • Reducing overall fat consumption from about 40 percent to about 30 percent of energy intake; • Reducing saturated fat con-
sumption to account for about 10 percen t of total energy in take; • Reducing cholesterol intake to about 300 mg a day; and • Reducing the intake of salt to about five grams a day. Some consumer groups feel McGovern's committee capitulated to the meat and egg industries in the second edition of "Dietary Goals," because in revising the gqals the commi ttee modified its original recommendations to reduce the consumption of meat and eggs. "I t (the revision) represen ts a serious setback for the leadership role and legislative independence of the U.S. Senate, (and) the health and welfare of the American people," charged Alex Hershaft, PhD, president of the Washington-based VegAmerican Pharmacy VoI.NS18. No.4. April 1978 / 174
etarian Information Service, Inc., at the February AAAS meeting. Reactions to the goals generally in the scientific arena have ranged from an endorsement by David M. Hegsted, PhD (professor of nutrition at Harvard University's School of Public Health) to a condemnation by Robert Olson, MD, PhD.
Olson, based at St. Louis University School of Medicine in St. Louis, Missouri, recently charged that the bases of the dietary goals are " ... intuition, epidemiologic data interpreted in the most liberal way, and political goals associated with a hoped-for reduction in the cost of health care." He said the goals are not based on scientific evidence and represent a "series of fallacies." McGovern responded to Hershaft's and Olson's charges through a staff aide, saying: "The feeling was that the recommendations represented our best judgment as to prudent dietary guidelines based on all the testimony received, including that of Dr. Olson and Dr. Hershaft, as to how to minimize the health risk of our current dietary practices." McGovern had no comment on former staff member Nick Mottern's charges that the senator, in modifying recommendations on meat, capitulated to the cattle industry in his home state of South Dakota. But a McGovern aide said the report addressed itself to the fat content in meat, not meat protein. Consumers and Nutrition Regardless of the eventual impact American Pharmacy VoI.NS18. No.4. April 1978 / 175
of the McGovern dietary guidelines, public interest and consumer groups have been working to change American diets in their own ways. Michae1 Jacobson, PhD, who directs the Center for Science in the Public Interest (CPSI), believes there should be a special agency charged with "nutrition advocacy." "We need an independent Office of Nutrition Advocacy to help make available to society the benefits that could be had by applying the knowledge gained from nutrition research," said Jacobson. Nutritionist Bonnie Liebman of CSPI told those attending the January 1978 Consumer Assembly, sponsored by the Consumer Federation of America, that social pressures exerted by advertising and business influences must be broken if Americans are going to start eating better. She cited a Finnish county-North Karelia-as an example of a community that successfully reduced its high rate of heart disease. The North Karelia project-undertaken with government help-took aim at three factors: high blood cholesterol, hypertension and smoking. The increase in the number of heart attacks recorded in the Finnish county since 1972 has leveled off, said Liebman, and the stroke rate has already decreased 30 to 40 percent. Asked if she thinks the U.S. needs a more centralized federal thrust on nutrition, Liebman said competition between USDA and HEW "could be good because we could get more action." Richmond's Industry Survey "There's a limit to how much you can expect from supermarkets because they're in business to make money," said CPSI's Bonnie Liebman. Yet, because supermarkets are the "point of purchase," what they do and don't do in terms of nutrition education can be as vital to consumers as any federal effort. Frederick W. Richmond (D-NY), who chairs the nutrition subcommittee of the House Committee on Agriculture, set out to find out how industry does educate consumers on what they eat. Of 53 leading food companies sur-
veyed by Richmond's subcommittee, on1y 13 were able to provide information on nutrition education expenditures. Of 10 food trade organizations surveyed, only two provided such information. Only 15 companies said they had a formal nutrition policy statement. In spite of consumer complaints that the nutritiona1 labeling established by FDA in 1973 isn't working, survey respondents said they saw no reason to improve such labeling. In hearings on January 31, 1978, before the Richmond subcommittee, Joseph Danzansky, Giant Food Inc.'s chairman of the board, said that food companies will voluntarily provide nutrition education materials to their customers to better compete with each other, but that if forced by government to provide more information, they will do the least possible. Esther Peterson, former consumer adviser to Giant Food and now special assistant to the President for consumer affairs, told listeners at Consumer Assembly '78 that "Several enlightened companies have realized that consumerism is also good business and have instituted a variety of voluntary consumer programs designed to give consumers more useful information and more input into corporate policy making." Danzansky described Giant's new nutrition education program with the National Heart, Lung, and Blood Institute (see the nutrition department of American Pharmacy, January 1978). The year-long program, begun last month, will include nutritional displays in high-traffic aisles, signs in the store and consumer radio spots. "I can honestly say we are trying," Danzansky told the House subcommittee. The Richmond subcommittee concluded that the National Dairy Council tries harder than any other industry group, and urged others to follow suit. The NDC, together with its state and local affiliates, spent $12.7 million in 1977 for nutrition education, Richmond found-more than any single agency of the U.S. government except a program of the U.S. Extension Service. At hearings before the National Commission on Digestive Diseases 15
on March 2, 1978, Richmond said he would introduce the National Consumer Nutrition Information Act later that month. The six-part bill would include a USDA media program, a mechanism for reviewing privately produced nutrition education materials, and an outreach program for community nutrition workers.
Lack of a Cohesive Nutrition Policy But what industry may do voluntarily does not solve the problem of giving Americans a more coord ina ted program in nutrition education. Such an effort must be based on scientific research in human nutrition, and on coordinating findings among all the federal agencies responsible for such research. According to a recent Presidential report on nutrition and the GAO report, there have been only tentative efforts to coordinate the multitude of federal programs in nutrition. In 1969, a USDA official initiated the 16
Federal Interagency Communication in Nutrition (FICIN) committee. But the committee, which includes a dozen separate governmental entities identified in the GAO study, does not have official status and is not required to publish notices of its meetings in advance in the Federal Register, according to GAO . Thus the committee's impact-if any-has been difficult to measure. In the area of human nutrition research, there has been a specific effort by one federal agency to "coordinate itself." In June 1975, the National Institutes of Health (NIH) formed the NIH Nutrition Coordinating Committee to strengthen cooperation in nutrition research among
the 11 institutes and pull their efforts together. NIH director Donald Fredrickson said it is difficult to centralize nutrition research within NIH, since such research cuts across disciplinary boundaries in five institutes, including the National Cancer Institute, the National Heart, Lung, and Blood Institute and the National Institute of Arthritis, Metabolism, and Digestive Diseases. Fredrickson said NIH spent about $80 million on nutrition research in FY 1977, and expects to spend about $85 million in FY 1978. Bu t NIH, an agency of HEW, is just one of the 12 federal agencies charged with conducting, overseeing or funding human nutrition research. The other federal agency primarily sharing the charge is USDA's Agricultural Research Service. It would be foolhardy to attempt to tell Americans what to eat with any certainty without basing ' those guidelines on solid nutritional research. Yet, as the GAO study pointed out, there are numerous obstacles-beyond mere fragmentation-to getting solidly grounded research findings on nutrition. Nutrition research inherently poses the following problems: • It is extremely difficult, in terms of methodology, to do either proAmerican Pharmacy VoI.NS18 , No.4, April 1978 / 176
spective or retrospective clinical trials in nutrition with human subjects; • Nutrition research is a multi-disciplinary field, not a well-defined discipline; • There is a shortage of nutrition scientists, especially in the area of clinical nutrition research; • There is a shortage of nutrition educators. The GAO study found that "There are presently far more openings for academic nutritionists than candidates to fill them ... ;" • The number of graduate students enrolled in nutrition education is low compared to the need; • Nutrition per se is often spread among many departments within one university, and "Only during the past 10 or 15 years have universities consolidated nutrition-related areas in comprehensive departments and programs," says the GAO; and • The instability of federally funded biomedical research. The President's Biomedical Research Panel, which was established by legislation in 1974 and made its report in April 1976, found that among the 160 witnesses it queried, the absolute necessity of achieving some kind of funding stability was a recurring litany. This kind of monetary stability is especially important to investigators involved in longterm nutritional research that depends on broadly based epidemiological studies and/or clinical trials.
developed, through a contract with the University of North Carolina, 35 self-instructional programs and a curriculum guide in applied nutrition for health professionals. The programs, which are offered for a fee by Health Sciences Consortium, Inc., in Chapel Hill, North Carolina, are specifically geared to physicians, pharmacists, nutritionists and other health professionals. • Supermarket chains must become more involved with nutrition education on a voluntary basis. Giant Food's joint nutrition education program with the National Heart, Lung, and Blood Institute is one example of industry's effort to educate consumers on what to buy. • Restaurants and fast food chains must do more "nutrition educating" on a voluntary basis. According to Howard R. Roberts, PhD, acting director of FDA's Bureau of Foods, 38 percent of food dollars are spent on meals purchased and/or consumed away from home. A survey done by the A.C. Nielsen Company showed that in 1976 consumers
spent $57 billion in restaurants, a sum which the company notes nearly equals total U.S. grocery sales in 1964.
• A government initiative stemming from the White House should pull together all the federal efforts in nutrition. The President has already taken the first steps toward that initiative, by calling for an inter-agency working group-headed by the assistant secretary for health-to evaluate the McGovern committee's dietary recommendations. • There must be, as the American Dietetic Association (ADA) points out in its journal on March I, 1978, a "kindergarten-through-high school plan that introduces nutrition concepts as part of basic education." In schools, recommends ADA, lunch facilities should double as "laboratories for teaching nutrition." The words of Harvard nutritionist David Hegsted seem to best sum up the whole nutrition issue: "The question to be asked ... is not why should we change our diet but, why not?"O
Toward Bridging Nutritional Gaps While changing American eating patterns cannot be done overnight, next month, or next year, Senator McGovern's idea of a "prudent" diet based on correlative-not necessarily causative-data, seems to be a sane approach. To raise "nutritional awareness" in the U.S., the following steps seem warranted: • Instituting or expanding nutrition curricula in medical, pharmacy, nursing, dental and public health schools. Nutrition education, as Arthur Burke of Wilmington Medical Center suggests, must begin with health professionals. • Continuing education in nutrition must become a priority for health professionals. The FDA has
Michael Jacobson, PhD (above), wants a "nutrition advocacy" office to spread the knowledge gained from nutrition research. Esther Peterson (left) believes businesses are recognizing that "consumerism is also good business. "
American Pharmacy VoI.NS18, No.4, April 1978 / 177
17
ashington has a new kickball game. It's called nutrition. The rules of the game are fuzzy; the players are government administrators, Congressmen, consumers, public interest groups, and health professionals. The object of the game is lofty: to provide better nutrition guidelines so Americans will know what to put in their stomachs. It's unclear, however, how the players are going to score. The problem with the kickball game is that it is really a battle over turf, primarily between two federal agencies: the Department of Health, Education, and Welfare (HEW) and the Department of Agriculture (USDA). The United States has no national nutrition policy, and no agency is responsible for its design. Instead, in the words of a recent General Accounting Office (GAO) study, the country has" ... a de facto policy which is, in effect, 12
a piecemeal series of programs instituted over the years, often because of a sense of emergency and with little thought given to its interaction or relationship with existing programs." Without a referee or chalk lines to limit play, many federal agencies have entered the kickball game, particularly in the area of nutrition research. According to the GAO, these include: • National Institutes of Health (HEW); . • Agricultural Research Service (USDA); • Food and Drug Administration (HEW); • Center for Disease Control (HEW); • Health Services Administration (HEW); • Alcohol, Drug Abuse, and Mental Health Administration (HEW); • Department of Defense; • Agency for International Development; • National Science Foundation; American Pharmacy VoI.NS18, No.4, April 1978 / 172
• Cooperative State Research Service (USDA); • National Aeronautics and Space Administration; and • Veterans Administration. Enthusiasm for the kickball sport has been particularly strong in the last decade, with the accumulation of more and more statistical evidence linking inadequate nutrition with the nation's leading causes of death, including cardiovascular disease and cancer. One Capitol Hill player, former presidential candidate Sen. George McGovern (D-SD) stole the federal agencies' thunder when he ran away with the ball by releasing his Senate committee's national dietary guidelines-not once, but twice (see below).
Burke, who believes in a multi-disciplinary team approach to nutritional support and nutrition education. Such a cross-disciplinary approach is advocated by the American Society for Parenteral and Enteral Nutrition (ASPEN), a rapidly growing international group of eminent scientists, researchers and health professionals from the many fields involved in the nutritional support of the critically ill patient. Burke is active in ASPEN, which publishes its own journal.
Lack of Nutrition Education Among Health Professionals Nutrition's fragmented national status is far from startling, considering that some health professionals are "nutritional morons," in the words of one government administra tor. The American Medical Association (AMA), in reporting on a survey of 114 medical schools' nutrition curricula (July 1976), said that only 63 percent of the responding schools offered nutrition courses, and that only 23 percent of these required a separate course in nutrition (although 75 percent said nutrition was incorporated in other courses). Senator McGovern's nine-year-old "temporary" Senate Select Committee on Nutrition and Human Needs (defunct as of January 1978) introduced legislation in 1973 that would have provided grants of $10 million each year for five years to help put some muscle into medical and dental school nutrition education programs. But this bill and similar bills are stalled in Congress, notes the GAO report. "I think there is no question that there is a remarkable need for nutrition education in the medical community and in institutions," said W. Arthur Burke, PharmD, who directs the department of parenteral nutrition at Wilmington Medical Center in Wilmington, Delaware. "Schools are not teaching nutrition," added American Pharmacy VoI.NS18, No.4 , April 1978 / 173
Ph o tos by Michae l Do la n
"Congress is looking at the tip of the iceberg," said Burke, who also believes that nutrition education should start at home-within the institution. Institutional Default That some institutions are not doing their nutritional homework, indeed" are totally remiss in recognizing their responsibility in how they provide this crucially important, yet seemingly simple human need," in Burke's words, is amply illustrated by the following brief patient history. A 63-year-old man with a history of hypertension was admitted to the coronary care unit of a major urban hospital with severe chest pains. The diagnosis was myocardial infarction.
During his recovery period, the man was given a hospital menu card with a choice of breakfasts. The patient chose eggs (high in cholesterol) and bacon (high in sodium and saturated animal fat). Whether eating such food really made or will make any difference in the MI pa tien t' s recovery is a moot po in t. But, noted Burke, the incident is one example of blatant "institutional lack of awareness" of the connection between diet and disease. Burke, who in his capacity as a pharmacist-clinician has been granted staff privileges in the departments of surgery and/or medicine in several local institutions, can both prescribe for and admit patients to the hospital. He and his specially-trained staff see patients requiring metabolicnutritional repletion on physician referral. "Over the past few years I have been averaging approximately 350 consultations each year for patients needing aggressive parenteral or enteral nutritional support," Burke said . "It is estimated that 10-15 percent of hospitalized patients require such therapy. "These patients typically present with severe protein-calorie deficiency as a result of their disease and/or poor nutritional history, premature births or congenital defects, trauma, extensive surgery, or their drug therapy. "Too often in our nation's hospitals," Burke continued, "the death of a patient is conveniently attributed to his 'weakened condition,' yet rarely is the actual cause-starvation -cited ." There is no excuse for that starvation, Burke feels. ~'With the many modalities and special techniques of nutritional support given to the medical world by such brilliant innovators as Drs. Jonathan Rhoads, Stanley Dudrick, George Blackburn and others-and the educational efforts of organizations like ASPEN-it is no longer necessary or acceptable for a patient to endure prolonged morbidity-or death-because of severe metabolic depletion resulting from starvation." Burke believes that pharmacists should become more active in nutri13
tion education, which he describes as "A new, vital and viable role" for the profession . "There is a desperate need for pharmacists to counsel in the community," he said . Burke also believes that more pharmacy schools should offer, at least on an elective basis, didactic courses in intravenous fluid and electrolyte therapy, and principles and practice of nutritional support in institutions.
Diet and Disease Evidence that diet and disease are related is not new. Yet, strangely, few but the authors of fad-diet books have attempted to tell Americans what to eat and why. Positive correlations have been found between high fat consumption and cancers of the breast and colon; there is also some evidence of a connection between lack of fiber in the diet and cancer of the lower intestinal tract. Epidemiological studies in man have shown that diet is such an important factor in cancer incidence that it can reverse a country's disease pattern, said Gio Gori, PhD, who directs the National Cancer Institute's diet, nutrition and cancer program. For example, said Gori, when Japanese migrate to the U.S., their patterns of low colon and breast cancer and high stomach cancer incidences shift dramatically within two to three generations until they pattern those of this country, which are exactly the reverse. The Framingham (Massachusetts) Heart Study, which began in 1950 with 5,127 men and women free of coronary heart disease, showed that elevated blood cholesterol (above 240) in the 30-39 age group was a factor in developing premature heart disease. Even high school diet affects the risk of heart attack, said John A . Scharffenberg, MD, MPH, at the annual meeting of the American Association for the Advancement of Science (AAAS) in Washington, DC, in February 1978. Scharffenberg, who in 1971 designed a coronary risk evaluation program called "Heartbeat" at Loma Linda University, California, recently compared the dietary habits and blood cholesterol levels of high 14
school youth at a Seventh-day Adventist school and a Ca tholic school in Bakersfield, California. Scharffenberg, a vegetarian, found only 21 percent of Adventist boys had cholesterol levels above 180, compared to 61 percen tat the Catholic high school. T riglycerides were lower in the Adventist group, which consumed less sugar. The Advent{st boys also ate less meat. To what extent a "prudent" diet can alleviate or prevent high blood cholesterol is still unknown, but diet is thought to be one factor in prevention of heart disease.
McGovern's Controversial Goals While scientists were asking themselves whether Americans' increased . intake of fats and sugar and overconsumption of salts, cholesterol and alcohol meant anything, South Dakota Senator George McGovern was proceeding nonstop on Capitol Hill to show that they did. " Dietary Goals for the United States," first released in February 1977 by McGovern's Senate Select Committee on Nutrition and Human Needs, and revised last December, is an un preceden ted effort to change American eating habits. McGovern minces no words : "The simple fact is that our diets have changed radically within the last 50 years, with great and often very harmful effects on our health .... In all, six of the ten leading causes of death in the United States have been linked to our diet." Basically, the goals call for: • Increasing the consumption of complex carbohydrates and naturally occurring sugars by eating more fruits, vegetables and grain products; • Reducing the consumption of refined sugars by about 45 percent; • Reducing overall fat consumption from about 40 percent to about 30 percent of energy intake; • Reducing saturated fat con-
sumption to account for about 10 percen t of total energy in take; • Reducing cholesterol intake to about 300 mg a day; and • Reducing the intake of salt to about five grams a day. Some consumer groups feel McGovern's committee capitulated to the meat and egg industries in the second edition of "Dietary Goals," because in revising the gqals the commi ttee modified its original recommendations to reduce the consumption of meat and eggs. "I t (the revision) represen ts a serious setback for the leadership role and legislative independence of the U.S. Senate, (and) the health and welfare of the American people," charged Alex Hershaft, PhD, president of the Washington-based VegAmerican Pharmacy VoI.NS18. No.4. April 1978 / 174
etarian Information Service, Inc., at the February AAAS meeting. Reactions to the goals generally in the scientific arena have ranged from an endorsement by David M. Hegsted, PhD (professor of nutrition at Harvard University's School of Public Health) to a condemnation by Robert Olson, MD, PhD.
Olson, based at St. Louis University School of Medicine in St. Louis, Missouri, recently charged that the bases of the dietary goals are " ... intuition, epidemiologic data interpreted in the most liberal way, and political goals associated with a hoped-for reduction in the cost of health care." He said the goals are not based on scientific evidence and represent a "series of fallacies." McGovern responded to Hershaft's and Olson's charges through a staff aide, saying: "The feeling was that the recommendations represented our best judgment as to prudent dietary guidelines based on all the testimony received, including that of Dr. Olson and Dr. Hershaft, as to how to minimize the health risk of our current dietary practices." McGovern had no comment on former staff member Nick Mottern's charges that the senator, in modifying recommendations on meat, capitulated to the cattle industry in his home state of South Dakota. But a McGovern aide said the report addressed itself to the fat content in meat, not meat protein. Consumers and Nutrition Regardless of the eventual impact American Pharmacy VoI.NS18. No.4. April 1978 / 175
of the McGovern dietary guidelines, public interest and consumer groups have been working to change American diets in their own ways. Michae1 Jacobson, PhD, who directs the Center for Science in the Public Interest (CPSI), believes there should be a special agency charged with "nutrition advocacy." "We need an independent Office of Nutrition Advocacy to help make available to society the benefits that could be had by applying the knowledge gained from nutrition research," said Jacobson. Nutritionist Bonnie Liebman of CSPI told those attending the January 1978 Consumer Assembly, sponsored by the Consumer Federation of America, that social pressures exerted by advertising and business influences must be broken if Americans are going to start eating better. She cited a Finnish county-North Karelia-as an example of a community that successfully reduced its high rate of heart disease. The North Karelia project-undertaken with government help-took aim at three factors: high blood cholesterol, hypertension and smoking. The increase in the number of heart attacks recorded in the Finnish county since 1972 has leveled off, said Liebman, and the stroke rate has already decreased 30 to 40 percent. Asked if she thinks the U.S. needs a more centralized federal thrust on nutrition, Liebman said competition between USDA and HEW "could be good because we could get more action." Richmond's Industry Survey "There's a limit to how much you can expect from supermarkets because they're in business to make money," said CPSI's Bonnie Liebman. Yet, because supermarkets are the "point of purchase," what they do and don't do in terms of nutrition education can be as vital to consumers as any federal effort. Frederick W. Richmond (D-NY), who chairs the nutrition subcommittee of the House Committee on Agriculture, set out to find out how industry does educate consumers on what they eat. Of 53 leading food companies sur-
veyed by Richmond's subcommittee, on1y 13 were able to provide information on nutrition education expenditures. Of 10 food trade organizations surveyed, only two provided such information. Only 15 companies said they had a formal nutrition policy statement. In spite of consumer complaints that the nutritiona1 labeling established by FDA in 1973 isn't working, survey respondents said they saw no reason to improve such labeling. In hearings on January 31, 1978, before the Richmond subcommittee, Joseph Danzansky, Giant Food Inc.'s chairman of the board, said that food companies will voluntarily provide nutrition education materials to their customers to better compete with each other, but that if forced by government to provide more information, they will do the least possible. Esther Peterson, former consumer adviser to Giant Food and now special assistant to the President for consumer affairs, told listeners at Consumer Assembly '78 that "Several enlightened companies have realized that consumerism is also good business and have instituted a variety of voluntary consumer programs designed to give consumers more useful information and more input into corporate policy making." Danzansky described Giant's new nutrition education program with the National Heart, Lung, and Blood Institute (see the nutrition department of American Pharmacy, January 1978). The year-long program, begun last month, will include nutritional displays in high-traffic aisles, signs in the store and consumer radio spots. "I can honestly say we are trying," Danzansky told the House subcommittee. The Richmond subcommittee concluded that the National Dairy Council tries harder than any other industry group, and urged others to follow suit. The NDC, together with its state and local affiliates, spent $12.7 million in 1977 for nutrition education, Richmond found-more than any single agency of the U.S. government except a program of the U.S. Extension Service. At hearings before the National Commission on Digestive Diseases 15
on March 2, 1978, Richmond said he would introduce the National Consumer Nutrition Information Act later that month. The six-part bill would include a USDA media program, a mechanism for reviewing privately produced nutrition education materials, and an outreach program for community nutrition workers.
Lack of a Cohesive Nutrition Policy But what industry may do voluntarily does not solve the problem of giving Americans a more coord ina ted program in nutrition education. Such an effort must be based on scientific research in human nutrition, and on coordinating findings among all the federal agencies responsible for such research. According to a recent Presidential report on nutrition and the GAO report, there have been only tentative efforts to coordinate the multitude of federal programs in nutrition. In 1969, a USDA official initiated the 16
Federal Interagency Communication in Nutrition (FICIN) committee. But the committee, which includes a dozen separate governmental entities identified in the GAO study, does not have official status and is not required to publish notices of its meetings in advance in the Federal Register, according to GAO . Thus the committee's impact-if any-has been difficult to measure. In the area of human nutrition research, there has been a specific effort by one federal agency to "coordinate itself." In June 1975, the National Institutes of Health (NIH) formed the NIH Nutrition Coordinating Committee to strengthen cooperation in nutrition research among
the 11 institutes and pull their efforts together. NIH director Donald Fredrickson said it is difficult to centralize nutrition research within NIH, since such research cuts across disciplinary boundaries in five institutes, including the National Cancer Institute, the National Heart, Lung, and Blood Institute and the National Institute of Arthritis, Metabolism, and Digestive Diseases. Fredrickson said NIH spent about $80 million on nutrition research in FY 1977, and expects to spend about $85 million in FY 1978. Bu t NIH, an agency of HEW, is just one of the 12 federal agencies charged with conducting, overseeing or funding human nutrition research. The other federal agency primarily sharing the charge is USDA's Agricultural Research Service. It would be foolhardy to attempt to tell Americans what to eat with any certainty without basing ' those guidelines on solid nutritional research. Yet, as the GAO study pointed out, there are numerous obstacles-beyond mere fragmentation-to getting solidly grounded research findings on nutrition. Nutrition research inherently poses the following problems: • It is extremely difficult, in terms of methodology, to do either proAmerican Pharmacy VoI.NS18 , No.4, April 1978 / 176
spective or retrospective clinical trials in nutrition with human subjects; • Nutrition research is a multi-disciplinary field, not a well-defined discipline; • There is a shortage of nutrition scientists, especially in the area of clinical nutrition research; • There is a shortage of nutrition educators. The GAO study found that "There are presently far more openings for academic nutritionists than candidates to fill them ... ;" • The number of graduate students enrolled in nutrition education is low compared to the need; • Nutrition per se is often spread among many departments within one university, and "Only during the past 10 or 15 years have universities consolidated nutrition-related areas in comprehensive departments and programs," says the GAO; and • The instability of federally funded biomedical research. The President's Biomedical Research Panel, which was established by legislation in 1974 and made its report in April 1976, found that among the 160 witnesses it queried, the absolute necessity of achieving some kind of funding stability was a recurring litany. This kind of monetary stability is especially important to investigators involved in longterm nutritional research that depends on broadly based epidemiological studies and/or clinical trials.
developed, through a contract with the University of North Carolina, 35 self-instructional programs and a curriculum guide in applied nutrition for health professionals. The programs, which are offered for a fee by Health Sciences Consortium, Inc., in Chapel Hill, North Carolina, are specifically geared to physicians, pharmacists, nutritionists and other health professionals. • Supermarket chains must become more involved with nutrition education on a voluntary basis. Giant Food's joint nutrition education program with the National Heart, Lung, and Blood Institute is one example of industry's effort to educate consumers on what to buy. • Restaurants and fast food chains must do more "nutrition educating" on a voluntary basis. According to Howard R. Roberts, PhD, acting director of FDA's Bureau of Foods, 38 percent of food dollars are spent on meals purchased and/or consumed away from home. A survey done by the A.C. Nielsen Company showed that in 1976 consumers
spent $57 billion in restaurants, a sum which the company notes nearly equals total U.S. grocery sales in 1964.
• A government initiative stemming from the White House should pull together all the federal efforts in nutrition. The President has already taken the first steps toward that initiative, by calling for an inter-agency working group-headed by the assistant secretary for health-to evaluate the McGovern committee's dietary recommendations. • There must be, as the American Dietetic Association (ADA) points out in its journal on March I, 1978, a "kindergarten-through-high school plan that introduces nutrition concepts as part of basic education." In schools, recommends ADA, lunch facilities should double as "laboratories for teaching nutrition." The words of Harvard nutritionist David Hegsted seem to best sum up the whole nutrition issue: "The question to be asked ... is not why should we change our diet but, why not?"O
Toward Bridging Nutritional Gaps While changing American eating patterns cannot be done overnight, next month, or next year, Senator McGovern's idea of a "prudent" diet based on correlative-not necessarily causative-data, seems to be a sane approach. To raise "nutritional awareness" in the U.S., the following steps seem warranted: • Instituting or expanding nutrition curricula in medical, pharmacy, nursing, dental and public health schools. Nutrition education, as Arthur Burke of Wilmington Medical Center suggests, must begin with health professionals. • Continuing education in nutrition must become a priority for health professionals. The FDA has
Michael Jacobson, PhD (above), wants a "nutrition advocacy" office to spread the knowledge gained from nutrition research. Esther Peterson (left) believes businesses are recognizing that "consumerism is also good business. "
American Pharmacy VoI.NS18, No.4, April 1978 / 177
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