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DIET AND CORONARY HEART DISEASE In This Issue: Payes Coronary Heart Disease Today ................................ 3 AHF's Position Statement ........................................ 4 Ouestions on Diet-Hea t Factors... 6 The Case for Dietary Mo Yication ..,, _.......... g ChofRVroi- ood_and- . .. ........ .. 12 L- ~ i [_ ~-~ Vol. 3/No. 3• Published for fhe Advancemen AHF Officials Present Diet-Heart White Paper At Congressional Ilearings; Comments Invited With health maintenance programs now in the fore- front of Administration and Congressional priorities, The American Health Foundation has intensified its long-term efforts to bring about extensive modifica- tions of the "average American diet"-and thus help reduce coronary heart disease. In particular, the Foundation has been acting as the catalyst for a coordinated effort by government agen- cies, the food industry, communications media, and health care organizations to formulate dietary :ecom mendations which will be considered "national policy" and provide the "essential first step to optimum health" for all Americans. Position Statement: Much of the results to date can be credited to the position statement completed last summer by AHF's Food & Nutrition Committee. After several months of review and revisions, this "white paper" was approved by our Board of Scientific Con- sultants and presented (11/15/71) at Congressional hearings being held by-the House Subcommittee on Public Health and Environment. Appearing before the House subcommittee were Emest L. Wynder, M.D., president of AHF; Guy E. Living- ston, Ph.D., professor and director, Institute of Hu- man Nutrition, Columbia University; and George J. Christakis, M.D., director of nutrition division and professor of community medicine, The Mount Sinai School of Medicine. Dr. Livingston is chairman of AHF's Food & tiutrition Committee, and Dr. Christakis is chairman of its Subcommittee for Public Information. After the hearings ended, chairman Paul G. Rogers (D-Fla.) announced that he would submit AHF's pro- posals to the National Academy of Science and ask for their recommendations. Another indication that AHF is already making a national impact on dietary think- ing was the tremendous number of articles in daily newspapers and consumer magazines when the position- statement was first announced in mid-November. Clear- ly, there is a growing mandate for more information about the benefits of dietary modification. Comments Invited: Because of its far-reaching conse- quences and the opposition it may provoke, comments about the position statement are invited, and will be The American Health - - Foundation Nesletter - considered for publication in future issues of this news letter. For this purpose, and so that AHF's objectives will be fully understood, we are publishing below a letter that was recently sent to key government offi- cials to enlist their support.... -. Dear Sir: The American Health Foundation, a voluntary organi- zation dedicated to the improvement of the health of the people of the United States through the applica- tion of preventive medicine, has become increasingly concerned with the high incidence of cardiovascular disease as a major cause of morbidity and of mortality in our nation. - Recognizing the relationship between diet factors and cardiovascular disease, the Food and Nutrition Com- mittee of the Foundation has undertaken to serve as a catalyst in prom.oting effective action on the part of all forces which must be brought to bear on this prob- lem if use are to be successful in combatting this deadly disease. - Obviausly involving as it does the food industrx the medical profession, and the communications media, such a complex effort requires the coordinated par- ticipation of the Executive and Legislative branches of the government as well as the regulatory agencies under their jurisdiction. Among the key factors of con- cern to our Food and Yutrition Committee are: 1) The role of the regulatory agencies in establishing food product standards and labeling requirements con- sistent with our current knowledge of the qualitative and quantitative aspects of food fats in relation - to blood lipids. 2) The efforts of the U.S. food industry in developing food products for the consumer consistent with this knowledge. 3) The role of the food service industry in reflecting current knoudedge, with regard to fats and the dietary constituents in foods served to the public away fror.i home. 9/ The problem of communication to the public, through all appropriate media, the knowledge and motivation required to achieve an optimum diet for prevention of coronary heart disease. continued P 2

The American Health Foundation Newsletter The American - Health FOundation, Inc. EDITORIAL BOARD 2 East End Avenue -G,1Dert Cant. Cheuman New York. N.Y. 10021 - Deloen Jones_ Ee,tor (212) 628-6300 OFFICERS AND BOARD OF TRUSTEES. Preawertt - Ernast L yVynaer. M 0 Secretary - Thomaa J Rons. Jr Vice PtesWentNew York Amerr.an A/r,mea. Inc EFecutlve Vice Pres<OerH Devla L Davles T.easurer Warner G CosQrove.Jr Manaq,n9 Partner $hlllCS & Company Honorary Chairman Dev,C J Mahoney Preaipertt. NOIIor1 S-, Ilic. / TRUSTEES kV Cna,rman I NhIl,am J Levrtt cha,rman. Boara ot Ovecton L.evm and Sons.Inc Lol,n V Puonam. II Prevtlenl Ronaon Corporat- Juhus Cahn Presbenl Fam,ty Health Commun,cat- Mra Charlee A Dana Huqo J Gelard.n V- Pr-dent Loeo Rhoaoes d Co Georqe Jarnes. M D, M P H Dean Mount S-l School of MeO,ane Dr Ralph LanAau Pres,oent Halcon INwnai,onal. IIIC . Eawara H Meyer Pri-aent & ChIet Esec Olllcer Grey Aevertlsm9 Inc John H Mitchell Pres aent Screen Genn G William Moore Pres,aent Felocrest Mllls. Inc Joseph M Murthd Pres,oent Santl9,en d Murtha. Inc Robert R Pauley Marwell M RaDE Partner StroOCM & Stroock 6 Ldven BOARD OF SCIENTIFIC CONSULTANTS Cnairman GeorqeJames MO,MPH Dean Mount S,na, School of Med,une . Sol R Baker M D r 13oCiate ChnKal Protessor of Rao~aoqY Uroversity of Cal,fornul et Los Anqeles Lawrence Bergner M D - Ass' stant Commssioner N.Y C,ty Dept of Health t.sater Breslow M D M P H Cnalrr.'an. Dept of P.evennve and Sot,al Meeic,ne School od Mea,c~n! Unversrty of Cal,tornla at Los Anpeles Gloert Cant Mea,cal Eanor 8 Consultant Time.Inc - John Casset. M D M P H. Professor and Head Department of Ep,aem,oloqy Umversrty ot North Carol- Jerome Cornfiela B S Research Professor in Biostahstics Grbuare Sa+od of PuObc Healtb Umvers,ty of PittsOUrqn - Rene J Duboe. Ph D P.oWessor The Rockefeller UnlverLty Alv7n Freiman. M D Chlef Orv or Meo.cal Systeme Mer.qnal HoSp~tal /or Cancer and All.eo D-ases Takesni Hlrayarna M 0 Chief of Eppae-ogy Dlvislon NanonalCancer Center(Japdn) Marvrn Kuschnet M D Protessor and Cnarman Department of Pathology State Universrly of New York at Story Brook G E L-QSton Ph D Protessorana Duector Inent~te ol Human Nutnnon Caumda umversty Freoe-k C RooOns M D Den ScnWl ol Meo,une Ce western Reserve Umver6dy Gofthard Scnetrier M D Profe550r of MeO~Gne Unlver9ly of He,oelberp (Germany) Morton K Scnwartx Ph D cha,rman. Dept ot B-ne-try Memonal HoSp,tal tor CanCer and A/l~eo Dlseaaes FretlenckJ Stare. M D. Ph.D. Protessor and Cnanman Da~ara Un,vers,rynnon School of PuWic Health YNlham L Evan. Ph D Theodore B Van Italue. M D Consultsnt - Dlrector of Mea""e fGr Univ9r4y Resources - St Luke S Hospaal Center PuDl,inea by The Amencan Health Foundatwn. Inc . a nor.Grofitt tP, e-ertpf corpOrat,on E4neC tor inCustnal educatonal Co hons_ povernment and meolcal leaoers concerned w,tn 11o¢2at n¢2atn care Meo,a are ~nv~teo to repr,nt from tna newvetler freely. wrth cremt b tn9 Fountlation Pease lorwaro aoores3 changes to The Amencan Health Founaahon. 2 East End Avenue New York. N Y 10021 As a first step, our Food and Nutrition Committee un- dertook to define its position on the role of diet in cor- onary heart disease, based on a comprehensive survey of the available medical literature. In so doing, it has reviewed the clinical and epidemio!ogical evidence re- (ating to the causes of coronary heart disease, its rela- tionship to diet, and the possibilities for reducing the incidence of the disease through dietary interventic.n. On the basis of this review, this Committee has pre- pared recommendations for an action program uhich has been approved by the Board of Scientific Consul- tants of The A merican Health Founda tion A copy of this position statement is formally being sub- mitted to you hzreuith. We respectfully call your atten- tion to these recommendations. One of the key recom- mendations made is that the Food and Nutrition Board of the National Aca_demy of Science -National Research CouncLlshould: . A) Set masimum as well as minimum recommended al- lowances for all essential nutrients. B) Establish nutritional guidelines for processed foods, including level and composition of fat as well as other nutrients. - - - CI Aid in the evolution of meaningful, informatire means of labeling foods with respect to nutritive values. Although our position is fully supported by our Board of Scientific Consultants, which include some of the leading investigators in the field of nutrition and car diooascular disease, and even though our proposals are in general agreement with those advanced by the Inter -Society Commission of Heart Disease Resources, we appreciate there may be other medical experts and in- dustrial forces who will take issue with our conclusions and our recommendations. They may demand further proof, proof that cannot be produced in the foresee- able future. Meanwhile, the onslaught of arteriosclerosis continues. Wecannot wait any longer to apply existing knoudedge. We are dealing with a disease that once symptomatic is unlikely to be cured, even in the future, more effectively than at present. The high price of inaction can be avoided, particularly since our recommendations are of a practical nature. _ The majority of our experts agree that the American food industry is now in a position to implement the rerommendations made here in a practical fashion. Knowing of your long standing interest in health care and particularly disease prevention, we hope that you will give this problem your careful attention and will urge the Food and Nutrition Board of the National Academy of Science to take a firm stand on th.is issue. s/Ernest L. K'yoder, M.D., President The American Health Foundation s/George James. M.D., Chairman Board of Scientific Consultants J

Coronary Heart Disease Toda~-: A New Epidemic (Adapted from the Introduction to AHF's "Position Statement on Diet and Coronary Heart Disease.') Improvements in techniques have permitted ph-y sicians to more accurately diagnose coronary heart disease and myocardial infarction. Improved techniques cannot, however, explain the truly meteoric rise in the preval- ence and incidence of coronary heart disease which has occurred in the past 40 years. The rarely observed disease of 1918 now accounts for more than 50% of the deaths of males over the age of 40 in the United States, and it appears to be affecting a progressively greater number of young people. In a recent report of the Inter-Society Commission on Heart Disease Resources, the Atherosclerosis and Epi- demiology Study Groups noted: "The National Health Examination Survey of 1960-62 estimated that 3.1 million American adults age 18 to 79 had definite coronary heart disease ICHDI and 2.4 mil- lion had suspect CHD, together representing about 5% of the population.... It was further estimated that of Americans under age 65, almost 1.8 million had definite CHD and 1.6 million had suspect CHD. "Every year about a million persons in the United States experience either a myocardial infarction or-sud- den CHD death. There are over 600,000 deaths each year due 'to CHD.... Over 200,000 more succumb to atherothrombotic disease of major arterial vessels in other parts of the body. Approximately 165,000 of the coronary deaths occur in persons under 65 years of age, with a greater toll (3 to 7I among men than women. For middle-aged men, the United States has one of the high- est CHD death rates in the world.... Analysis of mortal- ity trends gives no sign that these high death rates ere decreasing. "A North American man has about one-chance in five of developing clinical CHD before age 60, mostly in the form of myocardial infarction.... About 2S°k of those experiencing a first premature heart attack die within three hours of onset of symptoms, often prior to-hospi- talization and before medical care can be obtained.... Arr other 10% die within the first weeks after their attack. "For those middle-aged persons fortunate enough to re- cover, prognosis for longevity is markedly impaired. They are approximately five times as likely to die within the next five years as those without a history of pre- vious coronary disease. In most cases death is due to re current acute coronary episodes. Clinical atheroscler otic disease in the arteries of other organs is similarly associated with a reduced life expectancy." In truth, an epidemic has struck. With sudden death as a major characteristic, prevention rather than treatment of coronary heart disease must be the goal. MORTALITY FROM DISEASES OF HEART BY ETIOLOGIC TYPE Annual Death Rate per 100,000 Durlny 1966-117 and Percent Change Since 19t1041 United Statea Whlte Male Populatlon - . All fonr Cw~entW MewNte Nry.rlanalw Anerr-orr.ao (4clr•w Gnnarr) ' MiM yun> .N-a hrtant Caanee Sina 1N4i1 fq-ea h-t Clunre tina ttMFet fM-ff lvsaat LIUnN finn ee.-et s11e-p hKM CAanea f.r_ Iri.-n - wa-n hrtrt queM fFa. 1111114,41 All Aga f 3721 - 2 4.2 - 22 6.2 - 34 15.5 - 29 310.7 + 2 Onder S 39.4 - 22 36.8 - 24 # j• f 5-24 3.3 -2A 1J - 29 .4 -S6 f .3 f 25-34_._ 15.2 - 19 1.4 1 2.4 -44 .4 -20 tJ -14 35-44 __ 103.8 - 4 - 1.2 -! 5.8 = 42 2.4 -14 16.1 ~ 45-54 - 394.4 - 4 1.2 + 9 12.0 - 39 11.3 - 21 343.5 - 2 55-64 045.1 1 S_ 1.3 + 18 21.1 - 27 38.1 - 25 90A.2 + 2 65-74 -- , 2,308.3 + 1 1.0 - 9 26.2 - 1! 101.9 - 2a 1,979.6 + 4 75 and oru__ 5,418.5 - 3 J + 17 241 - 30 21118.7 - 33 4,360.6 + 3 •ConQenRal maMormat.ons of thec,rculatory system. More than 90 percent of the deaths in th,s cla5s,ficat,on are oue to congenital defects of the heart tAajusted on tsas.s ot age tlislrDUtion of the Un,ted States total populahon. 1940 - Z Less than 20 deaths or death rate less than 0 05 in e,ther pe-o Percent change not computed § Less than 0 5 Note Oata for other dhseases of the heart are not shown, they cons,st largely of syph,llit,c or degeneratrvs heart Msease of heart diseases unsoecit,ed as to type source Metropolitan LAe StaLsbcal Bulletin, March 1971. - a .~..:~rl.~.

f- A Precis of the Diet-Heart Position Statement Prepared by AHF's Food & Nutrition Committee After careful and extensive studies of current dietary habits in relation to coronary heart disease, much of which shows that the present nutritional environment predisposes to coronary heart disease, The American Health Foundation is recommending that a series of changes in our national diet pattern should now be initiated by the appropriate public and private agencies. Informed and forcefulleadership will be needed to im- plement these changes, leadership which AHF is pre- pared to furnish. The Foundation accordingly recom- mends that immediate and appropriate steps be taken to alter the American diet pattern by: 1) Adjusting total caloric intake to avoid obesity. 2) Decreasing the total dietary fat to about 35% of daily calories. 3) Changing the dietary fat from predominantly satu- rated to approximately iso-caloric amounts of sat- ESTIAIATED DEATH RATES PER 100,000 POPULATION FOR THE 10 LEADING CAUSES OF DEATH: USA, 1970 ~:. ~; ~lank y. Cawe of death (E1gh th Revl.lon, Internstlaul CLssifizatioo of Dis- easea. Adapted, 1963) Death rate Percent, of total deat6a A11 uuses-------- 940.4 100.0 Dlseases of heart---=-- 360.3 38.3 ~`.. tta11pant neoplasas, including neopLs.a of 17.phatic and he.a- , " tepoletic tLsaes----- 162,0 17.2 Carebrovascular - dlseaaea-------------- 101.7 10.6 4 ~ Accidents-------------- 54.2 5.6 3 lofluenu and Y pnetaonta------------- 30.3 3.2 y ! A ~. : Certafn causes of .ortalit7 in early lnfanc7--------------- 20.9 i - 2.2 [ 7 Dlabetes .ellitua------ 18.5 2.0 ~ a Arterioscleroals------- 13.9 1.7 f 9 Cirrhosls of llver----- 13.6 1.7 ~ lo )ronchitis, eetph7s.oa, and asthee------------ 14.9 1,6 A11 other eausea------- 145.8 13.3 L Source Nat,onal Center tor Health Staustics. 9/21/71. 4 urated, mono-unsaturated, and poly-unsaturated (linoleic). 4) Decreasing dietary cholesterol to about 300 milli- grams daily. It is also suggested that the intake of complex carbo- hydrates be favored, and that the intake of salt IKaClI be reduced to about 5 grams per day (adjusted to cli- matic and working conditions). As should be apparent, the intent of these recommenda- tions is to help correct "over nutrition," balance caloric input with caloric output, and establish reasonable in- takes of saturated and poly-unsaturated fats, choles terol, sugars, and salt. In addition, The American Health Foundation is pre- pared to carry out its leadership role in implementing these recommendations by: A) Publicizing- the alarming degree of coronary risks associated with our present national diet pattern. B) Advancing the principles of the fat-controlled diet. C) Encouraging nutrition education at all levels of the curriculum with special emphasis on medical schools. D) Working with groups of experts, the regulatory agencies, agriculture, and industry for these rational improvements in the nutritional qualities of the average American diet. E) Inviting others with related capabilities to join us in making a similar commitment. In dedicating itself to this course of action, The Ameri- can Health Foundation fully recognizes that the ratnifi cations produced by diet-heart relationships have devel. oped into one of the most active and controversial areas of clinical nutrition research in the past few years. Also, while in some areas our conclusions are unequivocal, in others they point to the need for continued inquiry and research to reach the unequivocal status. Despite these considerations, AHF is convinced that there is much more to be gained by taking advantage of what is presently known, and pursuing its recommended course of action, than could possibly be lost from any future negative conclusions. In this regard, the recom- mendations arrived at by AHF are in broad agreement with similar ones recently prepared by the Inter-Society Commission for Heart Disease Resources and by the American Heart Association. - A Long-Term Process: The mass entrance into a-dietary change of such broad proportions must of necessity be evolutionary, held back as it will be by I11 initial lack of education on the part of the public, and 12i the current inability of industry and agriculture to universally im- plement these recommended dietary changes. Both of these obvious problems may take years to overcome, and both will require public demand to eventually be implemented. Such a slowly-developing program will afford the opportunity to obtain partial readings, either

/ positive or negative as the program unfolds, and to compensate accordingly, if need be. One group that can logically be charged with responsi- bility for the direction and magnitude of modifications in the diet pattern of our society is the Food and Nutri- tion Board of the National Academy of Sciences/Na- tional Research Council. The Food and Nutrition Board has the stature and authority to formulate recommenda- tions which will be considered as "national policy-'-and to modify possible resistance from those segments of industry and agriculture which sense a threat to their current established products.,A ccordingly, AHF is pro- posing that the Food and Nutrition Board should. 11 Establish at once nutritional guidelines for all proc- essed and/or fabricated foods relative to the level and composition of fat and/or oils. 2) Aid in the establishment of meaningful and informa- tive ways of labelling these foods from the stand- points of fat and/or oil quantity and quality, so that labels may be of optimum service to the consumer in pointing out the pertinent-nutritional values con- tained therein. 3/ Continue with or even accelerate their efforts to set maximum as well as minimum recommended allow- ances for all other essential nutrients. In order to place the role of diet in its proper setting of being only one of several factors, albeit a very important one, in controlling the risk of coronary heart disease, The American Health Foundation also plans to develop educational programs for the general public. These pro- grams will point out the importance and ways of avoid- ing obesity, minimizing smoking, reducing blood pres- aure, increasing physical activity, and preventing destructive psychic stress. All such programs, including those concerned with the recommended dietary changes, should begin well below the high school age level. Summary of Investigations: In preparing this position statement, we have considered evidence from biochem- ical, epidemiological, and clinical research bearing on the hypothesis that diet (specifically dietary fat), ath- erosderosis, and coronary heart disease are metabolic- ally and epidemiologically related. These investigations include lal four decades of animal experimental studies linking high intakes of saturated fat and cholesterol with atherosclerosis and serum lipid elevation; (b) various types of clinical and epidemiolog- ical studies in man associating elevated serum lipid lev- els with increased risk of coronary heart disease; and /c) 13 diet intervention studies testing the hypothesis that modification of diet so as to lower serum lipid levels will prevent or delay the development of atherosclerosis and coronary heart disease- There are many design and operational defects in most of these studies, and the results are neither uniform nor conclusive. Nonetheless, the data strongly suggest that the "average American diet" which is relatively high in calories, saturated fat, cholesterol, simple sugars, and >4 + .. DISTRIBUTION Oi SERUM CHOLESTEROL LEVELS T T _T Age Group - 35-44 ~ - 45-54 ....... 55-64 I MEN Q f/ ~ I 1 ~ t • i -4A~nm ,ly~ 150 190 230 •270 310 350 390 20 c 15 a 10 5 Dietary modifications, similar in principle to those used in the intervention studies, are capable of ameliorating, reversing or preventing the risk factors of hyperlipid- emia, obesity, and possibly hypertension. The programs used in these studies have resulted in an appreciable reduction in incidence of coronary heart disease. As a result of these investigations, we believe the time has come when public and private agencies alike should take forceful action. Let us begin by bringing to the attention of the Food and Nutrition Board, the Depart- ment of Health, Education and Welfare, the regulatory agencies, the food industry, and the public, the timeli- ness of fully evaluating our national diet pattern. And let this be done with intensified regard to (1) its nutri- tional value and potential for preventing coronary heart disease, and (2) with specific recommendations for mod- ification to a diet pattern more nearly optimal for -con- temporary Americans. ;. IN 1815 MEN AND 2256 WOMEN BY AGE ` r`A

(r Some Helevant Questions on Diet-Health Factors, With the Answers from AHF's Position Statement Question: What groups of experts can provide the rec- ommendations and-guidelines for the food industry and the public? - The burden of proof would appear to be on those who would not alter the present diet pattern. We have dis- cussed how the present nutritional environment may predispose to coronary heart disease. Obviously all fav- orable features of our present diet should be retained, but there is no escaping the concept that our present diet is not-completely right for the way we live. The average American is-ell advised to moderate his intake of calories, saturated fats, cholesterol, and possibly simple sugars. By himself, and with his limited knowl- edge of food values, he cannot make the necessary ad- justments in his meal plans without running the risk of inadvertently omitting essential nutrients. Agriculture and the food industry can make desirable changes in the availability and composition of foods, but need guide- lines from expert groups. PER CAPITA CONSUMPTION OF ENERGY FOODS PROTEIN, FAT AND CARBOHYDRATES (UNITED STATES,1910-1970) ~ , 125 ~ 100 0 ~ 75 u a" 50 1910 1920 1930 1940 1950 1960 1970 Proten Fat • Food Carbonydrate energy U S D A (47) \11 0 Orily a nationally recognized panel of nutrition scien- tists such as the Food and Nutrition Board has the stature and authority to formulate official recommenda- tions, which will be considered as national policy. The Board can work with the Food and Drug Administration and other regulatory agencies in the development of new policies with respect to food standards, labelling. etc., with all segments of the food industry, and with the various medical and public health associations: includ- ing, for example, the National Institutes of Health, American Medical Association, American Heart Asso oation, and the American Public Health Association in establishing guidelines. Question:Are the proposed changes in diet pattern-safe and sound? - The diet intervention studies so far reported have re- vealed no nutritional hazards associated with fat con- trolled diets. Statistical analysis of incidence and mor tality from cancer in five of the diet trials reveal that- eholesterol-lowering diets to not influence the risk of cancers. Accordingly it can be concluded that risks attendant with diet modification are minimal in compar ison to those known to be associated with the average American high calorie, high saturated fat diet. Question: What dietary changes are desirable and feasible? - In terms of specific foods, the modifications recom- mended mean a possible decrease in consumption of all classes of foods as a means of calorie control. Particular- ly affected would be high calorie foods rich in saturated fat. Use of lean meat, fish, poultry, and low-fat dairy products would be increased, and that of fat-rich meats and dairy products and eggs decreased. Consumption of fruits, vegetabies, cereals, low fat baked goods, and vegetable oils would remain the same or might be in- creased somewhat. That such dietary changes are both possible and acceptable has been well demonstrated in 40 c 0 30 a r 20 0 ~ ~ 10 a PER CAPITA FDOD CONSUMPTION MAJOR SOURCES OF PROTEIN ;UNITED STATES,1910- 1970) '••..... _ .............. 0 T TT1 1910 1920 1930 1940 1950 1960 1970 - Meat - Da,y -- Eggs ....,•,•„ Flour & .~.~. Poultry Cereals U S 0 A (47) & F,sn ` ~Y!

the Feasibility 'Itial of the National Diet-Heart Study and in various research projects. Question: What nutritional attributes of the present diet should be retained? Any proposed diet modification must not violate or negate the gratifying gains in public health nutrition resulting from advances in the nutrition sciences al- ready incorporated in the American diet pattem. It must be recognized that in the last four decades, the public health problems of scurvy, pellagra, beri-beri, goiter, severe protein-calorie_malnutrition, rickets and vitamin A deficiency have been greatly reduced and some have been completely gradicated from the Ameri- can scene. However, the virtues of our present diet patterns should not be extolled so vociferously that they are considered inviolable and not susceptible to improvement. - Ideally, the general diet will continue to be varied and include ample amounts of all essential nutrients. The modifications must be in the direction of correcting the excesses and nutritional imbalances that are manifest by obesity, hyperlipoproteinemia, and hypertension. Question: Is a large enough segment of the population affected to justify a redesign of the American diet pattern? A conservative estimate is that at least one-third of the adult male population has hyperlipidemia induced by the nutritional environment. This is surely a high enough proportion to warrant consideration of planned diet modification as a preventive measure. Question: Are the-data implicating nutritional factors in the pathogenesis of coronary heart disease sufficient to indict the contemporary dietpattern? Is the diet pattern of contemporary man nutritionally optimal? - PER CAPITA FOOD CONSUMPTION-MEATS (UNITED STATES, 1910-1970) 300 ~ 200 0 u ~ 100 a 0 I F-1 -T-r--f_-T - 7-T i--F-T-T-7 1910 1920 1930 1940 1950 1960 1970 + I I .~,~ Poultry ~ Beet & Pork , Veal U 5 D A (47) The epidemiological studies of the past two decades strongly suggest that the customary diets of such di- vergent populations as Scandinavians, Cretans, Yemen- ites, Bantu, Yugoslavians, Polynesians, Japanese, and other ethnic groups play an important role in determin- ing serum lipid patterns and, in turn, the relative inci- dence of coronary heart disease. Populations having diets relatively low in saturated fat exhibit comparatively low serum cholesterol levels. With the notable exception of the Masai and rural Swiss, populations with saturated fat-rich diets have the dubious distinction of having the highest coronary heart incidence rates. Although epidemiological data of this type can be used in forming hypotheses, they cannot be construed as demonstrating a cause-and- effect relationship between diet pattern, serum lipids and coronary heart disease. Nonetheless, they strongly suggest it. . Significantly, diets rich in the more saturated fats are likely to be high in calories, in animal protein, and in sugar. and are likely associated with economic_prosper- ity and relatively limited physical activity It is evident that diet pattern is a determinant of the pattern and level of serum lipids, and that these in turn are a deter minant of coronary heart disease incidence. Our national diet favors the serum lipid levels associ- ated with a high risk of coronary attack In this regard, -the "average American diet" cannot be considered optimal. Question: Hou, susceptible is the nutritional determi- nant to modification? - - Given a process in which environmental factors-are major determinants, the logical hypothesis is that cer- tain of these are under an individual's control and, hence, his personal choices and actions may increase or decrease his chances of having a manifestation of coro- continued P 11 PER CAPITA FOOD CONSUMPTION- FATS AND OILS (UNITED STATES, 1910-1970) 400 VeQetaDle ....,..,, Total Fats - Ammal Fats oils & 0,1s U S D A (47) 7 J

The Case for A Modification of American Diets !The following statements were abstracted from among many of equal im- portance and interest which were made during a recent meeting of AHF's Food and Nutrition Committee. We have selected, rather arbitrarily, those comments that seem most likely to indicate the full range of considerations investigated by those responsible for drafting the "Position Statement on Diet and Coronary Heart Disease. "/ Guy E. Livingston, Ph.D.: From the beginning days of this Committee on Food and Nutrition of the Ameri- can Health Foundation, it has been apparent that if a viable program were to emerge from our deliberations the following requirements had to be met.... • Data relating to the role of diet and coronary heart disease had to be reviewed and a determination made if the time would not come when prudence alone dic- tated that recommendations for alteration of the Amer- ican diet were justifiable to reduce the continuing growth of coronary heart disease. • Specific recommendations based upon the interpre- tation of these data had to be made for prudent changes which might be recommended in the diet. • Rational means for carrying out the recommendations had to be identified and correctly positioned with re- spect to the four spheres of action we have identified in our committee assignments -which, of course, are food industry, food service industry, government ac- tion, and public information. • An action program had to be developed for the im- plementation of the recommendations in these four major areas. Two Special Statements: As I read what we call our White Paper or Position Statement-which was pre- pared by the Public Information Subcommittee under Dr. George Christakis - there are two very brief state- ments which really stand out. I would like to refer to them at this point: "The burden of proof would appear to be on those who would not alter the present diet pattern. " 8 I think this is a very, very relevant statement, and I certainly hope that from our deliberations today we will see that there is general agreement about it. Finally, in setting the tone for what we plan to do here, there is the recommendation that "The American Health Foundation should play a leadership role in setting the stage for rational improvements in the nutritional quali- ties of the average diet. " This, I think, says it beauti- fully and concisely, and that is exactly what we want to start doing today. We know the problems, we know some things can be done ahead of others, and we want to identify them. If we can do that - and I am confident that we will -- this will have been a most significant day in advancing the health of the American public. George J. Christakis. M.D.: Before getting into the details of our White Paper, and relating it to the whole diet-heart question, I would like to have the luxury of making a few personal comments. I have been to a few places around the world, and have seen some evidence of disease, illness, disability, and death; but I must say that I have never seen a disease such as coronary heart disease, as we call it. If certain trends continue, then maybe the chipping away has paid off. But this is hardly the way to run a store when you-have a problem that is causing some 700,000 deaths a year. You don't just chip away at a problem like that -not when it is as catastrophic as it is, clinically and epidemiologically, in terms of mortality and disability. It is time now to stop and think, to take hold, to say, "Where are we? Where do we go from here?" 'Ttl6villim.rf

PERCENTAGE OF DEATHS DUE TO CARDIDWSCULAR DISEASES INCLUDING CDNGENITAL MALFORMATIONS OF THE CIRCULATORY SYSTEM BY AGE GROUP 'YX~ O 30 C K 20 : tMdv sl4 IsT. 2134 ]SM 4154 SS64 6'rr. 75 • s _ Age Group in Years ' - Stamier~(43) A Scientific Stalemate: Perhaps I have no right to say this, because so many have worked so hard over the course of the last two decades, but the scientific community has spent itself by combatting itself in this area of diet and heart. There is a stalemate, an inability of society to recognize what can be done now, largely because we in the scientific community have not made ourselves clear, we have not come to a con- sensus, we have not guided-the whole lay community. In fact, if the hyperlipoproteinemias hadn't come up, we would be beating if not a dead horse at least an unconscious horse by now. What I am saying is that, fortunately, we did come up with conclusions about the hyperlipoproteinemias, and this lends a great deal of impetus to further investigation of the diet-heart field. I feel we are very lucky that, first of all, we have the science we now do in the lipid field; and, secondly, per- haps equally important, we have people in the food in- dustry who are really interested in this problem. Food for Thought: From time to-time, I have had the good pleasure of working with members of the food in- dustry, and they want to know the truth. They want guidelines, and they want to act. As a matter of fact, if anything constructive has been done, I think they have done it. They have helped feed the country, feed the world, and they feel it this way - sometimes from the top down. They also feel, sometimes, a sense of disparagement when someone points out that not all food is nutritious, or does the thing that it should for health, as if food and health were synonymous. They don't always under- stand this, of course. Everyone has his axe, and every- one wants to sell Product X over Product Y. But they are always w lling to listen, always willing to learn. Well, enough of the bouquets, except that it is real and I think we should all recognize that. John C. Cassel. N1.D.: In all of history, disease has been prevented by social action more frequently than by any advances in medical science per se. It is also important to recognize that we are the first society ever to have available a diet in which the choice is not constrained by famine or scarcity. - The first approaches to making decisions about types of diets, and the absence of famine or scarcity, were made on the basis of preventing malnutrition syn- dromes. Those recommendations, if you look back on them, have led to marked changes in both the national awareness of what is good food, the types of enrichment of food, and the types of products that are produced. What we are hearing today, I think, is that we are now ready for a second look at this problem: that we no longer have to combat the malnutrition syndromes anything like two or three decades ago. But now there is reasonably good evidence to suggest that we have failed to take into account the other deleterious aspects of diet.... And I would think that the solution is going to have to come through mass action rather than through individual action. Dilemma for Decision-Makers: If you think back, I can't recall any major decision in the public health field ever being made with 100% proof - even the in- troduction of penicillin. So when one asks, "How do de- cisions get made?" I suppose the answer is: The time is ripe for a decision to be made when we have few other alternatives, when we have enough conviction that what we are proposing is not going to do harm, and when we have at least a series of findings that converge on each other and tend to support each other from a number of different scientific disciplines. Today, the evidence coming from molecular biology, clinical medicine, and epidemiologic studies all converge to the same point. There are discrepancies which have not been resolved, and this is something to wrestle with. But the combination of opinions, recent findings, history -and the fact that we have precious little in the way of alternatives-all this comes together as a rather convincing argument for dietary modifications. 9

coronary heart disease unacceptable. If it is really un- acceptable, and if from that we go to certain risk factors and start making them unacceptable, then the pressures will build up. ._ George James. M.D.: One of the things you learn in , the public health field is an enormous respect for public health history. And one of the things that the American people seem to-have the most contempt for today is any reference to public health history. There are some lessons of great value in history, however, and it might be well to spend just one moment to look backwards. In 1906, in New York City, 75% of the dairy herds sup- plying the city with milk had cows in them which were positive for tuberculosis by the tuberculin test. At that time, tuberculosis was the leading cause of death in the country, not only in New York City. The Health Depart- ment said, "This is terrible." There was a new technique known as pasteurization whichhad come into the field, and they said, "It is so easy to pasteurize milk, let's do it." Reasons for Resistance: The dairy industry in New York immediately got up in arms and said, "This is im- possible. Number one, we don't have the equipment; it's going to take us years to do it. Number two, it is going to be enormously expensive. It is going to raise the price of milk to such a degree that milk will be priced - out of the market and babies will starve." They also said, "The farmers of New York State would be com- pletely ruined financially. We would have starvation rampant, depression rampant, and everything else would go to pieces." . The interesting thing is that pasteurization became the law in New York State, because the Health Depart- ment maintained its pressure. But it took 30 years, to about 1936, before it was required-with the excep- tion of highly selected types of certified milk-to have pasteurized milk, at least in the large population cen- ters. The Job for AHF: Geoffrey Vickers was here from Great Britain a couple of years ago, and he made the state- ment that "public health progress occurs by redefining the unacceptable." Of course,_ what he meant is that when people in this nation declare something unaccept- able, they finally do something about it. Our job at The American Health Foundation, since we do deal with the general public and we do deal with scientists and practitioners in medicine, is to make Adapting to Change: Abel Waldman, who for many years was Director of Environmental Sanitation at Johns Hopkins School of Public Health,_would often make this statement: 'Yndustry adapts to changes even while fighting them." That is exactly what happened with pasteurized milk, and what is happening today with air pollution control and cigarette smoking We are dealing with the food industry, however, and it's a very interesting group, because they are not fight- ing change. They are asking for authoritative state- ments, and they are willing to do things. The technology is pretty well worked out. But we haven't yet persuaded the general population to accept these things....People who are in a profit-making industry need the help of the voluntary agency groups, because these are the groups that have to educate the public to make it profitable_ for industry to produce foods of a low-risk factor. Progress by Choice: If the general public at least de- manded a choice, then there would be progress. Why can you not go to a restaurant and ask for margarine, or a specific kind of P-S ratio of margarine? Why is it that in many hotels you can't even get skimmed milk with your cereal in the morning? Why is it that when you go to a restaurant and order fish you often get a heavy cream sauce on top, and it is difficult to stop them from putting it on, and you-don't know what is in the menu, and you don't know if your fried food is made with fats which have become heavily saturated from being in the same vat for three months? These are the kinds of things that we have to make somewhat unacceptable to the general public. We have to do that-not by being arrogant, but by being factual; not by pretending to know more than we know, but by telling what we know. We have got to get people to realize there is an epidemic of coronary heart disease. We have got to get them to realize that risk factors are, to the best of our current knowledge, andesirable- and unacceptable. The First Step: We can argue that the fine points of proof remain to occur. If we take the advice of some people, we will do a 30-year prospective study, with double-blind control groups. A couple of generations would go by before we would have the results. But if we can develop a group of intelligent citizens that de- mand that something be done, and who view this situa- tion with concern and alarm, that is the first step. We don't believe that diet is the sole cause of coronary heart disease. We never want to be accused of that. But a White Paper can only cover a certain number of items, and we would like to have this one on diet be as good as it can be. Hopefully, it will make it possible _ to shorten the time delay which has so often plagued all of us in preventive medicine between the time when we find something we think is useful and the time when it is generally applied.