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Sten.ographic Transcript Of HEARINGS Before The s -s ~a~.--r't. ~. -~~-. v- .., .; ~•.- .re ~_1 ..:U'!.....1_ ~...~ti ~ E tJ~ ='t.:. ~rI .._~:ra :~ ~OTED STATES SENATE Volume No. SJ's Ei R; ~_.:_4JTED TO Z:ELLE : D IS I-'s`'.SES Ue&-lcsday, 28 July 1976 Washington, D. C. ACE-FEDERAL REPORTERS, INC. Official Reporters 415 Second Street, N.E. Washington, D. C. 20002 Telephoha: (Code 202) 547-6222 NATIONWIDE COVERAGE TIMN 210997

l;R-9?..'. U Q. GIBSON ngl 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 24 R.poden. Inc. ~ 25 C O N T T. N T S 1/L Statement of: Page Dr. Gio Gori, ) 175 National Institute of Cancer ) . ) Dr.-Frnst Wynder ) 206 American Health Foundation ) . ) Dr. Mark Fiegsted ) 218 Harvard University ) ) Dr. Dave-Y.ritchevsky ) .224 Wistar Institute, ) Philadelphia, Pennsylvania ) ) Dr. Jerry Woc7an ) 229 Massachusetts Institute of ) Technology ) TIMN 210998

173 DIET RELATED TO KILLER DISEIISES f ; , 2 3 5 6 7 8 9 10 11 ~ 12 t 13 ; f 14 15 16 17 18 19 20 21 22 23 24 ~~ P^' ~. Inc. ~ 25 Wednesday, July 28, 1976 U. S. Senate Select Committee on Nutrition and Human Needs Washington, D. C. The Select Committee met at 10:00 a.m., pursuant to call, in room 224 of the Russell Senate Office Building; the Honorable George McGovern, chairman of the committee, presiding. Present: Senators McGovern, Humphrey, Dole, Bellmon,• Percy and Taft. Senator McGovern. I'd like to welcome to the second day of these hearings on nutrition as it relates to disease and health Dr. Gori, of the National Institute of Cancer; Dr. Ernst Wynder, American Health Foundation; Dr. Mark fiegsted, Harvard University Dr. Jerry Wogan, Massachusetts Institute o•f Technology; and Dr. Dave Kritchevsky, Wistar Institute, Philadelphia, Pennsylvan Cigarette smoking is related we are told to 30 percent of the cases of cancer in the United States and there's now stron, preliminary evidence bad diets contribute to at least another , 30 percent of the cancer cases. This morning we will narrow our investigation into the relationship between diet and cancer.. Yesterday we ranged over the whole field of diet as it rela~ to a number of health problems. Today's hearing we hope will a. es TIMN 210999

174 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 15 16 17 18 ~ 19 20 21 22 ~ 23 L 24 I ~ nc. 25 elucidate the need for a more comprehensive examination of the links between diet and cancer and the role diet can play in pre- venting the occurrence of this lethal disease that now destroys the lives of so many Americans. The horrors of cancer are known to everyone. It is the second biggest killer in the United Stat and perhaps our most dreaded disease. Therapy still proves to be an ineffective solution in most cases of cancer. Even early detection and intensive chemotherapy or radiation treatment rarely improve the survival from many cancers. However, cancer is not totally unavoidable. It is not an inevitable consequence of life. Many striking correlations have been found between diet and cancer. Positive correlations have been found between high fat consumption and breast cancer and colon cancer; betwe'en a lack of fiber and cancer of the lower intestinal tract. These findin s alone illustrate the potential of a prudent diet for controlling the growth of cancer at its ethiologic root. Correlation, of course, is not causation, but causation nee not be proven before action is very strongly warranted. The United States is preeminent in its scientific and medical exper- tise. We must avail ourselves of this valuable resource in the total commitment of reducing the incidence of cancer in this country and it is to that goal that this morning's hearing is designated. In view of our experience yesterday, which took us up until TIMN 211000

1.75 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. ; 25 about 20 minutes to 2:00, I think if we are going to stay on schedule in the time that the Senate is following a heavy schedu on the Senate floor that if there's no objection by the members of the committee or the witnesses;,what I'd like to do is to ask each of the five-witnesses ta open with a statement. We will use your entire prepared statement but if you could hold your opening testimony to about ten minutes and then if the members of the committee would do the same thing -- I'll ask the staff to time us so that after we have had ten minutes of questioning from a member of the committee we will be asked to defer further questions until the next time around. . On that basis, I'd like to call our first witness, Dr. Gori of the National Institute of Cancer. STATEMENT OF DR. GIO GORI, NATIONAL INSTITUTE OF CANCER Dr. Gori. Thank you, Mr. Chairman. I believe that if I have . to summarize, and I have a few slides to show, I may have to impose you with some lecturing this morning. Senator McGovern. You can if you wish, Dr. Gori, read your statement as far as time permits. I don't want us to feel this is a hard and fast rule. Dr. Gori. I think I will try to stick to your demands this morning and, of course, I will have to be sketchy by definition so if you have any questions I will be more than glad to answer them at any time during my presentation. e TIMN 211001

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 ~ RK+o.ters, ~ 25 Senator McGovern. Members of the committee should feel free to break in from time to time. Dr. Gori. I'd like to frame the program of cancer a little bit within the other diseases that plague our society today and you don't see well the bottom of the slide here, but the bottom line goes from 1900 to 1970, so it's a 70-year span off time and you can see that during that time most of the infectious disease have been conquered. Today tuberculosis, influenza, pneumonia and smallpox and a number of other'diseases have been conquered greatly due to improved prevention -- vaccines, better sanitatio of water, food., etc. People live longer and by living longer they expose them- selves to develop those diseases of a chronic nature such as heart disease and cancer that we have seen raising dramatically in the last 30 years. Nutrition is coming of age and only a few years ago it would have raised some eyebrows to have said that nutrition it- self may be responsible for cancer or cardiovascular diseases. The evidence we have today makes,this statement not only a possi bility but a certainty. I'd like to get into the details of this a bit now. Most of the information we get is from epidemiologic studies, namely studying the experience of different cancers in different populations. If we take, for example, Japanese migrants to the United States to Hawaii in particular, you can see that they E; n TIMN 211002

177 1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 i ~ s t ~..... change their original experience for colon and stomach cancer to the experience in the United States. For instance, stomach cancer is very high in Japan and low in the United States. Colon cancer is low in Japan and high in the United States. Within two generations the experience of these immigrants to the United States changes from the experience in Japan to the experience in the United States.. This is true for a number of other migrant populations. It' true by and large for other cancers. Breast cancers follow a similar pattern for the Japanese migrants and we have similar data for Polish migrants to the United States, for migrants in different countries like migrant groups in Colombia, all indi- cating that a change in dietary habits is followed with a change in experience in cancer incidence. Senator Bellmon. Are you sayi::g that the incidence of other forms of cancer goes up when immigrants come to this country? You mentioned stomach cancer going down•. Dr. Gori. Yes, some go up and some go down, meaning that they are doing something good in their dietary habits and some- thing bad. i•7e'll give you some details on that later on perhaps -There are differences between geographic locations in the world for certain types of cancer. For instance, breast cancer is very high in the United States as you can see and if you go down to Miyagi, which is a locality in Japan,•it's very low. • TIMN 211003 S

I 1/ft 1 The same thing is true for prostate cancer. 2 Senator McGovern. Later on, Dr. Gori, are you going to 3 tell us what the ingredients in the diet are which explain this 4 Dr. Gori. Yes. I•will touch on that briefly. The stomach 5 cancer you can see the dramatic differences'we observe between 6 Japan -- very high, and the experience in the United States. B1 7 and large, stomach cancer today is a disease of the poor 8 connected with probably a low intake of vitamin C and protein, 9 a high intake of carbohydrates, starch in particular, that is 10 typical of the diet of the poor in many countries. 11 Now somebody could say that there are other things that 12 change when*migrant populations go from one place to another; 13 for instance, the environment. -I'd like to show some data. Th 14 environment is not likely to be responsible for this measure of 15 chandes. Indeed, the pollution levels in Japan are very 16 similar to the pollution that we have in this country, if not 17 worse, and another strong element of evidence is what we have 18 observed in smokers. Smokers are known to inqest, to introduce 19 in their bodies, large quantities-of carcinogens: Carcinogenic 20 substances are very similar to what is present in the environme tr 21 and if this carcinogenic substance was responsible for producin 22 certain forms of cancers, like colon cancer and breast cancer, 23 we should observe an excess of these cancers in smokers because 24 again they take in so much of these carcinogens. Indeed, we 25 don't observe this, indicating therefore that these types of TIMN 211004

1,19 i 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 carcinogens are not likely to affect certain forms of cancer like colon cancer, stomach cancer, breast cancer., Here, for instance, you see the difference in benzoapyren ingestion of benzoapyrene between smokers and non-smokers in the LosxAngeles area. It's a 24 time'and again for certain forms of cancer that we believe are dietary dependent we don't see any excess in cancer in smokers in spite of the fact that all this enormous amount of carcinogens. We have alsc indication that people that are exposed to .DD.T 30 years ago -- crop dusters and factory workers -- do not have an experience of increased cancer incidence, indicating that probably'DDT at the levels used and experienced by these people was not a risk factor for cancer in the human populati Also, we have studies with users of sweeteners like saccharin and cyclamates and they also, as you can see from th data here, do not show an increased experience of cancer over the non-users. Now the stomach cancer experience in Japan is changing dramatically over the last 20 years. There's been a continuin decrease of stomach cancer and an increase of colon and breast cancer. This follows the change in dietary-patterns that 22 23 24 i 25 have been introduced in Japan after the war. As you can see, they have decreased their intake of s*tarches, have increased dramatically their intake of milk, milk products, eggs and. TIMN 211005

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 0 ?2k i 23' 40'. ", " i f meat. Now all this indicates that their diet is becoming more westernized and indicates therefore that they can be expected to change their old patterns of cancer incidence -- low colon cancer, high stomach cancer -- to the reverse, which is true in' the westernized societies-- low stomach cancer and high colon cancer and high breast cancer, and this apparently is happening in Japan right now. There is also a strong correlation between dietary fat intake and experience of breast cancer. A similar correlation can be made for colon cancer but in the interest of brevity I won't show that. And you can see here that as the dietary intak of fat, the bottom line, increases, you have an almost linear increase in the incidence of breast cancer. Now I want to emphasize that this is a very strong corre- lation, but that correlation does not mean causation. I don't think anybody can go out today,and say that food causes cancer. , We•all have to eat food and what we say is not that food causes cancer, but.that certain imbalances in the diet may be predis- posing or may form certain metabolic imbalances that eventually lead to the development of these forms of cancer that we are talking about. ?4'! ;1differentiate Senator Belimon. You use the term dietary fat. Do you j4have a strong correlation to saturated fats similar to the IS i{ between animal and vegetable fats? Dr. Gori. We could differentiate that, too. You would s ~ TIMN 211006 v..~,.....,.. . .

; 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 weaker correlation with the unsaturated fats. Now here you can see for the United States the numbers of cases a year that appear to be related to diet. We have 40.9 percent of the total incidence for males and about 60.1 percent of the total incidence for females and these are in general the forms of cancer that tends to be dependent on nutrition because of epidemiologic studies that correlate with nutritional factors Stomach, liver, breast, prostate. There are a few other forms of cancer for which evidence is being collected,,but we don't have yet as strong evidence as we have,for these•forms of cance here. Again, I want to emphasize we are not saying that there is a strict close relationship between diet and these particular fo of cancer. The only thing we have are strong clues that dietary factors play a preponderant role in the development of these tumors. If this is true, then it would seem desirable that we try to put some priority on our research and action to see what it is that causes these imbalances and eventually leads to the rms formation of cancers. In other terms, we all hear about excesser ?1;in the deficiencies of nutrients. What we need to define in 11 1?!ithe first place is what'is normal nutrition. What should people i ?3f!eat in the first place? ~ ?;1 In order to define this, we need to develop elements of ?S.evidence that may be valid in a general term at the statistical TIMN 211007

182 I 1 2 levels for the average American,'but we must develop information that can be useful for the individual citizen that presents 3 4 5 6 7 8 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 himself to a doctor and wants to have a tailor-made recipe for what it is that he should eat. It should be emphasized that we don't need any new breakthrough in basic research. Nutrition science has developed essentially all the basic knowledge that is necessary to achieve this goal; namely, trying to find out what people should eat. What we.need to do is to engage in detailed and extensive biometric studies that may be able to pinpoint what the individu differences are among the various people that make up our popu- lation, the various conditions that they have. For instance, we are different in terms of body size, sex, age, metabolic conditions, and all this influences our nutritional requirements We are different in terms of behavioral types. Some of us are very active. Some of us are a little slower.. And this would require, of course, a different nutritional input. One element is the environment. Some of us live•in condi- tions that require more'calories, for instance, than others. People that live in Alaska during the winter obviously have different requirements than people that may live in Florida. A1 these elements need to be put together in some coordinated form requiring some massive approach to the study of the population iihich then could be translated into what we have heard yesterday so that we may come up with some useful, practical suggestions " TIMN 211008

183 1 2 3 4 5 6 7 8 9 10 11 12 13 16 ~I is the need of educating our people. Education is important, but it's also important to have . the right things to educate with, the right information,to dis- tribute. Besides trying to define what people should eat, what normal nutrition is, it is very important that we develop methods to assess the nutritional status of individuals. Today these methods by and large exist only and can be operated only in very sophisticated settings of some sophisticated hospital center. Again here, the basic information needed to develop these tests is available. We don't need any major breakthrough. It is important, though; to develop these tests for assessi nutritional status-so,that they can be performed in the field without too much technical difficulties and, therefore, it could ~ 1 14 be applied i; i 15 :! population to the analysis of the nutritional conditions of the in general. obviously has significance not only to the indi- A11 this so 18. wi 11 have .i 1Q ' instance. 17 ;: vidual i ~ that we may better approach his nutritional needs, but significance in terms of defining food policy, for We all say we have heard that people are hungry, but ?o;'we have not defined very well yet what they are hungry for. If 21'we can define the nutritional conditions better, then we may be :2 able to have a more enlightened•and more rational approach to a 23 foad policy that may restore good nutritional conditions in r F }•>these populations. ~4...~... .» ! 251 The third element is that we should know what the nutrition ng 61 TIMN 211009

184 1 2 3 4 5 6 7 9 10 11 12 13 14 • 15 16 17 18 19 20 21 22 23 value of foods is. The Department of Agriculture has been doing and is still doing a valient effort in this area, but they woulI need some additional major support to now develop this informa- tion to a greater•detail. In summary then, we don't want to indicate that the eviden~ we have gives a clear causative link between nutrition and cancer. As•I said before, nutrition is not like smoking. We can all do without cigarettes, but eat we must. The evidence that we have rather indicates that imbalances in our diet, either increases or deficiencies, cause such metabolic distur- bances over a period of many years that eventually they favor the appearance of certain cancers. Therefore, it appears obvious that more research and niore knowledge has to be applied in this direction to find out whether we can reverse this particular chain of events. Many factors may be involved in the causation of cancer. Nutrition is one of them and it appears that if we could modify just this particular factor we may be able to influence by and large the frightful cancer incidence that we experience in this country. This does not mean that we should not do research on other carcinogens that may be present in the diet, like food additive or colorants and other intentional or unintentional carcinogens. 24 ;I i( It simply means that the evidence we have today of the link 25;~ ~1between nutrition and cancer does not point to particular e TIMN 211010

1 2 3 4 5 6 7 8 9 10 11 12 13 carcinogens, but rather to the influence of diet itself. This is the evidence that we have. Therefore, I feel personally that greater emphasis should be put to study those nutritional dietary elements that may be causative off cancer or may be conducive to cancer. Besides the aspects of nutrition in the ethiology of cance4, obviously nutrition is important to the cancer patient. The cancer patient by and large loses his appetite. Food tastes bal to the cancer-patient and this in turn becomes a vicious cycle. He loses weight, becomes nauseous and loses his capacity to cope with his disease or with the•aggressive forms of therapy that are used today -- surgery, chemotherapy, radiotherapy. Therefore, we need and we have initiated research to see whethe we can reverse this process and persuade the cancer patient to ingest more food. As we.said before, the cancer patient loses taste for foodj . .l ~ We can possibly modify his perception so that food tastes good again or we can change the taste of the food itself so that food again can be ingested. We can also try behavioral approac es persuading the patient to ingest more. For patients that cannot inqest food and cannot digest it, like patients with cancer in the head and neck, cancer of the gastrointestinal tract, then i we have other techniques developed like gastric feeding or intravenous feeding,parenteral nutrition as it is known. Again, in this field, we don't need any basic information to be TIMN 211011

1 developed. All the basic information is available. All we need 2 l i d is to conduct extensive clinical trials that prove w l an 3 reinforce what we already know so that these techniques of the 4 elimination of the cancer patient could come- out of the very 5 specialized cancer centers where they are pra cticed today. Ther 6 may be four or five in the country that can d o this and become 7 available to the small hospital any place in the United States, 8 hi h i i ome. ent s n or perhaps even to the ambulatory pat 9 This is a particularly cruel program with children. Childre 10 are finicky by nature even when they are well and when they are 11 sick, particularly with cancer, it is a real problem and a cruel 12 problem and a heartbreaking-problem to try to feed.them properlyl. 13 We are therefore addressing specific and particular attention 14 h h di i ere. c program e pe atr to t 15 In summary then, we have in our program at the Cancer 16iInstitute six major goals. We're trying to assess better what l~;iis the role of nutrition in the causation of cancer and therefor 18.!if we know this, in the prevention of cancer. In order to do 19 this we will have to do some studies that may help define what '~ we should eat in the first place; what is normal for us to eat; 11 •' uhat is desirable, according to our body build, to our behaviora rharacteristics, to our environmental characteristics. We need, ~ `1`to define the nutritive value of foods and to develop methods 6 1 4r..„,,, ylt'"ssess the individual status, individual nutritional status. :t have to study the potential of nutrition in helping the TIMN 211012

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 patient to survive the aggressive therapies we are using today and, lastly, to develop educational methods that could put forward all this knowledge at the different levels at which it has to be used --.for the physician. And we all heard yesterdAy how little physicians today know of nutrition, but this is not surprising. It's not their fault. The physician needs to have something to-go by. Today, by and large, we cannot provide the physician with a body of information that is useful to him in confronting a cancer patient. I don't mean that we have to provide a cookbook here that the physician has to look in, but.at least we should provide him with a textbook from which he can get useful infor- mation that he can apply to the•individual that presents to his office. The same is true for the nurses, the dietitians, the school that may have to impose or foster a nutritional educationton the population at large, on the children, and we believe that the problem cannot be solved -- the educational problem cannot be ~ solved very rapidly. After all, our practices today are the nutritional practice which are the heritage of 2,000 years or more of food tradition. We have a tradition to break and to modify in our families in terms of traditional foods, traditional preparation, traditional tastes. Perhaps we need to modify feeding habits since the beginning. TIMN 211013

We heard yesterday of the problems that the unborn child has if the mother does not have the proper nutrition. There ar other problems in terms of setting feeding habits since the ~ 4 beginning. The way we feed children today with our formulas may not be the right one. After all, we just try to be conveni t 6 or the mother today so that she can feed a big bottl e three or 7 four times a day to this child, and we feel that he' s happy whe ' he's full like a keg and'burps. Perhaps this is not what he should do. Under natural conditions a child is likely to be 10 attached to his mother's breast for a long time and eats rather 11 small amounts of food very'frequently, which perhaps may deter- 12 mine the size of his stom ach and the reflexes to which he's 13 used in order to consider himself satiated. 14 TheiA, of course, all the other problems with children, 15 with teenagers, the problem of advertising, the problems of 16 industry. We have again a tradition that we ha ve to face with 17 industry itself, with agricultural practices. We'have to face 18 the realities. It is cheaper:to grow a pound o f fat than to. 19 raise a pound of meat or protein and it's cheap er to produce 20 starches than it is to produce protein again.. It's cheaper to 211)roduce sugar than it is to produce starch in many instances. 22.. All these economic patterns somehow will clash with some 13nf the suggestions that turn out from the experimental°evidence q1that we have and will have to be faced. This, of course, again 0 A..+.1.rr %.. ! .ri11 require some time, some good will from a variety of people. TIMN 21101

189 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 It cannot be solved overnight. We need to impose on our- selves some long-range goals before all these things can be achi but I believe personally that the proper information developed at the right time presented in the proper way, not necessarily legislative position, could persuade our society to'turn to mor healthy food habits. Thank you very much. Senator McGovern. Thank you, Dr. Gori. All right. If you could just take your place at the table, Dr. Gori, there's one statement in your prepared testimony that I found very striking and I think-it summarizes a major point that needs to be called to the attention of the committee and needs to be underscored in our hearing record. I want to make sure that'I understand the full implications of it. You say at the top of page 3 of your statement that diet is an important factor in the caiusation of various forms f cancer; that it is correlated to more than half of all cancers 18., in women and 19 1 at least one-third of all cancers in men. I think that's an incredible statement. '0 ~ Are you not telling us, in effect, that bad eating habits ,1 is a more important cause of cancers, based on the present JJ evidence, than cigarette smoking? Dr. Gori. For males, they are probably equivalent. For w;f'*'•lies, you're really right, sir. The dietary component in concentration is far more important than anything else. The vec TIMN 211015

190 1 2 3 4 5 6 7 8 9 10 11 12 1 13 ~ 14; ~ fact is'that females smoke less than males. That's the only thing that allows us to make that statement. Senator McGovern. Well, Dr. Gori, before we go on to the next witnesses -- and I want to advise Senator Percy that we have suggested that each witness try to limit himself to ten minutes in their opening statement. I wanted to just make some preliminary observations about what I think we have already learned and then perhaps•you other gentlemen can comment on it, but I have been very impressed in listening to the testimony both yesterday and in reading through the testimony today -- we have seen that eating more is not necessarily eating better. This committee has looked at the problem of hunger in the United States and underconsumption and I think Dr. Lee was right~' yesterday when he 15 i have played 16 ~I that there 17 ;I get enough a are said that our investigations and our hearings central role millions of to eat, but Dr. 18"official in the government, in alerting the nation to the fact Americans who are hungry who don't Cooper, the nation's leading health confirmed yesterday that six out of 19 ten of the leading causes of death in the United States are 20 related to bad eating habits; not necessarily too little to eat; 11yin some cases top much; in other cases the wrong kinds of food. ?? I think it's time for a major initiative in the United :3 States to eliminate bad eating habits and to make this the JS highest possible national priority. I have been impressed in watching'these Olympic games the last few days with the way the TIMN 211016

1 2 3 4 5 6 7 8 9 10 11 12 13 14 fact is'that females smoke less than males. That's the only thing that allows us to make that statement. Senator McGovern. Well, Dr. Gori, before we go on to the next witnesses -- and I want to advise Senator Percy that we have suggested that each witness try to limit himself to ten minutes in their opening statement. I wanted to just make some preliminary observations about what I-think we have already learned and then perhaps-you other gentlemen can comment on it, but I have been very impressed in listening to the testimony both yesterday and in reading through the testimony today -- we have seen that eating more is not necessarily eating better. I This committee has looked at the problem of hunger in the United States and underconsumption and I think Dr. Lee was right I yesterday when he said that our investigations and our hearings' 15s'have played a central role in alerting the nation to the fact 16,{that there are millions of ,Americans who are hungry who don't i; 17iget enough to eat, but Dr. Cooper, the nation's leading health 18 official in the government, confirmed yesterday that six out of 19 ten of the leading causes of death in the United States are :0 related to bad eating habits; not necessarily too little to eat; =~ in some cases too much; in other cases the wrong kinds of food. - I think it's time for a major initiative in the United :1 States to eliminate bad eating habits and to make this the N 'hi h t g es possible national priority I have been impressed in i.eW. a......... .., r vntchina'these Olympic games the last few days with the way the TIMN 211017

1 countries have been able to improve the whole physical tone o.f'. 2 theirr populace by a sustained physical training.. There's no 3 reason why the same thing couldn't be done in terms of improving 4 ur eating habits, but I'd like to suggest in a couple minutes 5 five or six possible steps that we might take to improve our 6 eating habits.and then get the reaction of you gentlemen. 8 Senator Percy. Mr. Chairman, are we going into the questi n ,period now with Dr. Gori~ 9 Senator McGovern. No. 10 Senator Percy. I would like my colleagues also to have a 11 chance to make any comments. 12 Senator McGovern. I don't intend to dominate the hearings, 13 Senator Percy. Let me put your mind at rest. 14 Senator Percy. I just wanted to know what the procedure 15 of the chair would-be. 16 Senator McGovern. The procedure is that each member of th 17 committee is going to have ten minutes to question the witnesse 18 on the first time around. 19 Senator Percy.. And you're taking yours now? 20 21 Senator McGovern. There's no discrimination at all here. This is not so much a question as it is a series of observation~ 22 that I would like to make to the doctors for any comment that 23 any of them would care to make in their testimony. First of all, a comprehensive nutrition surveillance syste I think we have been so negligent in this area that we really TIMN 211018

1 don't even know the eating habits of large numbers of Americans 2 Secondly, a nutrition education program from the first grade 3 through medical school. Thirdly, increased emphasis by the 4 medical community and the government on preventive health care 5 and the creation of a nutritional profile or examination so that 6 an individual will know.what is best for him or for her to eat. 7 Fourth, greater coordination by the different governmental 8 agencies in the area of nutrition and health with a centralized 9 office and greater emphasis on health in our food and agricul- 10 tural policy. Fifth, greater research in the area of human 11 nutrition from the effects of additives. And finally, preventid n 12 made an integral part of any health insurance program we under- 13 ~i take. 14 ~~ ~ 15 I' Dr. care to just comment on those general those are all the questions I'd like to direct at Gori, if you'd 'observations, 0 161 this time and 17 if other members of the panel have additional comments we would be glad to take those now before we proceed 18 . with the other witnesses. 19 Dr. Gori. I believe the first point you made was sur- vefllance, Senator. Senator McGovern. Yes. .: ~ Dr. Gori. Yes, this is an important issue that we should ~ rxl'dnd and continue. Personally, I believe that some of the :t i .,} e!torts done so far have been by necessity imperfect, mostly .' ~ tlecausa we do not know precisely what individuals should eat TIMN 211019

1J.3 I 2 3 4 5 6 7 8 9 10 11 12 13 14, 15 I ~ 16' 19 Zt , .y :• !t! a,,,,, '.... a, as I indicated before, and we do not have good methods to assess nutritional status with individuals in the field. Just by asking people what they eat will not provide us with very reliable information. This is a well known fact in many of these studies that have been•conducted. I think, though, that the development of these methods will not require a great deal of time. We could have them developed in one or two years. These methods when available and applicabl to the field should allow us to conduct more meaningful sur- veillance. In the matter of education, I believe that was your second point, Senator -- Senator McGovern. From the"first grade on through medical school. Dr. Gori. Again there, it's very important. We have heard iupon yesterday -- and I would not go into details that were touched ,,yesterday I7 I would just like to suggest that in order to 18 educate we need something to give,•some education to give. By nnd large, today, the information that we have is preliminary And we need to develop better information that would allow us 'O to make precise nutritional prescriptions for the individual presents himself to us rather than coming up with general rocortznendations as we can do today. In other terms, it does little help to the physician to ~'tiov that the average American should eat"60 grams of protein a TIM.N 211020

194 16 +.". ~„.. 1 2 3 4 5 6 7 8 9 10 11 12 13 ~ ; 14 day. The average American does not exist. We have individual Americans and they all vary from newborns to old people, vdry active, very slow, different sexes, different metabolic patterns different environments where they live. All this can be put together in a meaningful way just by analyzing the population. This will require again some substantial effort in field studies to see what individuals and how individuals respond to needs to nutrition. This comes to the third point that you were making, namely the definition of what we should eat. This also will have to ta into account individual requirements, as I just said. What we have today is some statements at large that we can make about a nutrition and food policy for the general population, but it's going to be much more difficult with the information that we V is;1have to individualize this himself• to a physician. apply Senator McGovern. I take it under that point, Dr. Gori, information and to be able to 16;it to every man that presents ,I 19 that you have no question at all there°s'a'need for much greater t•; emphasis on preventive medicine, regardless of how we eventually ;~ +rrive at this system. There needs to be a shift in the k ;aAireetion of more concern on the part of the whole medical cc)-usunity and the government in the amount of resources that arc j investing in preventive medicine. . 'It or, Gori. ny opinion. we There's no question. Medicine has two prioritie One is to maintain health. The other is to cure , Ke s TIMN 211021

195 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 181 i disease. And people that are sick.today obviously need to be taken care of and I wouldn!t like to sound like I'm advocating that we should spend less to find cures, to find ways of managi 'the patient. However, if we look toward our children and the future of this country, it is obvious that we have to pay atten-+~ tion to prevention without thinking of all the economic impli- cations that health care will have if we let it go unchecked as we have done so far. In those terms, then, we should address those elements that from the evidence in man seem to be correlated with the development of disease. Diet and nutrition we heard about yesterday and we hope to hear today has two major elements in this correlation. The second would be smoking, in my opinio~ and a few other life style connected habits that are engrained in our society like drinking, for instance. So all this should be viewed as an investment in the futuro and we should not expect out of our investment in prevention very rapid results. All the diseases that seem to be dependent 19~ion nutrition and other factors need several years to develop, 70'several decades, and only after several decades can we expect ?1`to see a decline in these diseases if we-start today with pre- a ~ ventive measures. Senatpr McGovern. . Senator Percy. Senator Percy. I have one question I' d like to put to the 1lane1, but I'd like to defer to Senator Taft first and Senator 8e11mon, TIMN 211022

196 i' Senator Taft. Thank you very much, Senator. I ?i The only thing it seems to me that hasn't been covered is 3Othe areas of cancer which are not affected by nutritional ~ 41aspects. I assume there are quite a few. Iiow about leukemia 5 and cancer of the bone and muscular tissues? Is there any evidence'that they are affected by nutritional factors? 7 Dr. Gori. We would like obviously to have an answer for 8 all of them, Senator, but we have to admit for sorme we don't Q know what the actual situation would be. Certainly for lung '7 cancer there's uncontrovertible evidence that smokinq is a '~ factor. For a number of other cancers smoking also is an impor- tant tant factor, particularly when coupled with alcohol consumption. ~ This is particularly true of the cancers of the upper alimentary ° tract, cancer of the kidney and of the bladder. 1 Besides smoking, I believe that the evidence points to ' nutrition as the single most important factor. Again, with b°oking we can incriminate smoking and we have one element to t 1nok at. With nutrition -- again we*don't need to smoke, but I Senator Taft. What about leukemia? Is there any connectio a r r ,1ting we must. Therefore, the situation is somewhat different •+tahlishedt hr. Gori. Leukemia, there are several theories linking it '="netic disorders, some'linking it to exposure to x-rays $I``• rndiation in general, some linking it to exposure to TIMN 211023

Ia/ 1 2 3 4 5 6 7 8 9 10 il 12 131 ~ 14' t8 chemicals. There is some evidence that there may be a dietary component in the development of leukemias, too. I would hesi- tate, though, to put all these theories now in a'hard frame. I would consider them still very soft at this particular time and I would prefer to say we don't know what causes leukemia in man. We have a lot of evidence of what causes it in animals, but in man it's a different story. Senator Taft. Thank you. Senator Bellmon. Ir. Gori, I'm a little confused now. Are you telling us that the state of the art or that the medical. profession now has available knowledge adequate to advise an individual as to how to eat or how to live and in this way cut down on the incidence of cancer, or are you asking us for support so that you can conduct the research and gather this 15 i1 ~kind of information? .~ ° 16' Dr. Gori. The evidence that is available to the physician SI today is not very_specific. We can develop very rapidly more specific information that every physician could use in con- fronting fronting an individual patient. Today the physican can make .,, ;Anme prudent recommendations, but there's little that we know r'M)out micronutrient requirements'and those vitamin reauirements ., '~anrt those fine-tuned elements of nutrition that appear so ~7 i""Censary in the maintenance of health- or in the lack or excess the nhpearance of disease: Therefore, if any support is forthcoming, this is something TIMN 211024

of what it will buy: better information for•the physician so that he can apply it to the individual patient that comes to his office. 1 2 3 Senator Bellmon. Well, if you were to advise say a 50 year old male blue collar worker today as to his•diet, what would you tell him? Dr. Gori. Well, Senator Humphrey yesterday was expressing 4 5 6 7 a question like that about himself going to the cafeteria down 8 in the Senate, and the answer was a little vague I'believe. 9 The answer essentially was that I would have to know a little 10 11fi more about this man, first of all his history. I would like to lknow what he likes to eat so that we don't have to hit him with lw~ °t,~ W 13 a prescription that he's not going to like. In general, the 14 type that you are talking about is probably overweight and so 15 you would like to recommend him to eat less calories. If he h.is to eat less calories, the first thing he has to cut down is 10, fats because pound for pound fats are twice as caloric as any i 1 other food we eat. Then you will have to tell him to cut down I on his sugar and his starches and things of this sort which t t 0'yviously will cut down the bulk of food that he has to eat and "+•t will not please him because he's used to be filled up in -1'*11= to feel satisfied. So the-next prescription is that he "'111uld eat more bulky foods like vegetables and fruits so he ,..~ :s. "II ti11 his needs and feel satisfied. Perhaps he willhave to eat two hours later because that TIMN 211025

199 1 passes rapidly, but if he keeps eating this kind of food he can 2 eat four meals a day and very likely he will not p ut on very 3 much weight. Of course , I'll tell him not to smok e, not to 4 ' drink immoderately. I ll tell him also not to wor ry because I 5 think that that may be part of•the problem many of us have.today 6 Senator Bellmon. So the state of.the art is that you could 7 i ce. get some very definite adv 8 Dr. Gori. It.'s true, but I would have to know as a physici n 9 would have to know better about his nutritional status in terms 10 of his vitamin balance, his calcium, potassium balance, his 11 phosphate balance, his nitrate balance, his zinc balance -- a 1 ?~~ ;,number of things that as we develop more knowledge in this area 13lappears so much important in maintaining his individual health. 14 'S In all aspects -- his eyes, his teeth, his hair, his skin, his lungs -- all these elements of health need to be developed more in depth and, as I said before, we have the information, the b.isic information that is necessary. We just need to conduct ~ c.:ose extensive biometric field studies that would allow us•the t '•-)tion of how to apply them to individual Americans rather than =~ the average American. ::enator IIellmon. Well, this sounds like quite a different 0 ""- t"•ch than some kind of a national nutrition education progra ~'rr talking more on the basis of a one-on-one relationship the physician and an individual patient. Or• Cori, Well, you have that relationship, of course, as TIMN 211026

200 1 2 as well as you have a global relationship to the nation. two obviously need different information and a different •The approac n 3 4 Globally I think we can make recommendations today far easier than we could make them at the individual level. As we said 5 before, I can make the same prescription for the general popu- 6 lation that we would make for your hypothetical blue collar I 81 worker 50 years old. These would in general hold today. Str Bllmon I see Dr Wynder there apparently enaoe.-. - dis I I~agreeinq. Did you have a different opinion? 9 Dr. Wynder. No. I always agree with my colleague, but if '°i ~ 11 ;~ !I have any differences I'would like to say them in my formal 12 , comments. 1) Senator Bellmon:. I have no more questions. Thank you. Senator Percy. Mr. Chairman, I felt your summary of yes- 'S terday was a very. helpful thing and I put yesterday's hearings `1 down as six sentences that were rather interesting to me and I'd like to ask just one question. ~ The first observation I felt was important was the nation's hi17;iest ranking health officer confirmed without any equivocatio I thAt six of the ten killer diseases are connected to diet. The 'rrnt four would include heart disease, stroke, cancer and ~ t A!~f!tQA. Secondly, that nutrition is one of the most important, if the most important component of preventive health care today Third, nutritional deficiency diseases are a minorr problem I . TIMN 211027

201 t 2 3 4 5 10 tt in this country. Primarily nutritional problems are those associated witPi•overconsumption. I think that came as a rather shock and surprise to me and if anyone has any observations on and sugar consumption. 'genera ru e, ericans s ou a , , m 6; Fourth, the American people know very little about nutritio 7! The average American diet is not inducive to good health. As a h ld e 4- 1ess reduce fat cholestero]' 8` I 1 A that during the course of your comments today we would apprecia Fifth, the medical profession knows very little about nutrition and doesn't emphasize it certainly in its medical ' schools. Today's medical school graduates know more about heart ~ transplants than basic nutrition. Finally, nutrition education is needed to help every citiz~ I understand what is good nutrition in order to take greater , t•ersonal responsibility for health. Now that doesn't do full justice to yesterday's hearing, bu, t think supplemented by the comments of our chairman, they give *fair insight to those with us today that were not here n t f !vaterday With respect to our hearing today on cancer, I'd like to ~ ~ °''' o«u (luestion or to make a couple of observations to see or not in the judgment of our panel they are accurate. Aa much as 90 percent of cancer is said authoritatively to `" •«=ibuted to environmental causes, many of them manmade. TIMN 211028

202 i 2 3 4 Diet is linked to more than a half of all cancers in women and at least one-third of all cancers in men. Diets with too many fatty refined foods lacking in high fiber ingredients are impli- cated in colon cancer., A diet built around starch is linked to 5~gastric cancers. There's a correlation between heavy alcohol 61 1 consumption combined with cigarette smoking and cancer of the 7 ~ esophagus. A high fat diet is connected to breast cancer. 8`Smoking is linked to lung cancer. i 9~' My question, Dr. Gori and any of the other panel members 10' that would care to comment, is simply this: How much cancer tI ti t r can be prevented by changes in bad smoking, drinking and eating habits? Fiow should the American people change their dietary habits to minimize the risk of cancer? What would be the 4 hest low cancer risk diet? Either answer that now or in the 1 c-nurse of your testimony which we are interested to hear. Dr. Gori. Well, first, there's a point of modification i'dlike to point out that in our interac tions with the environ- *rnt we have really three portals of communication. We have •`•r q3strointestinal tract. We have the lungs. We breath our 'kr. And we have our skin. Those, by and large, are our "r'tceR or interfaces through which we communicate with the ..~ r : ( nl1Ct(`n t . the chances of getting in contact with the environment, celculate the surface of these three portals of the '"sstnAl tract, of the lung and of the skin, and the number of TIMN 211029

203 1 2 3 5 6 71 1 81 i molecules that over a lifetime come in contact with the surfaces the chances of interaction is approximately one for-the skin, 1,000 for the lung, 1,000,000 for the gastrointestinal tract. In other terms, we have thousand times more chances to interact with the environment through our lungs than we have with the skin and a million times more to our gastrointestinal tract than we have with the skin. Now these are rough estimates, but please keep in mind so 9 f, ilthat you're not surprised when you say or when somebody says the 10 i idiet plays a preponderant role in the condition of the disease, it is the major way that we have to get in contact with the 12 environment, with the outside of us, so to speak. I 1 .4 S As far as opportunities for prevention, smoking of course is well known to cause lung cancer. If people stop smoking today, if everybody stopped smoking today, we would not conquer ~ . ' lung cancer immediately. It would take about ten years, but in crn years we could expect to reduce lung cancer 90 percent at I r lrast of what it is today. Approximately 90,000 cases'a year y"uld be saved by these ten years. As far as the dietary related cancers, we have said that we . one third of all' cancers in male and about 50 percent of eAncers in females and this would amount -- I'll have to '41 out the figures here -- of course,•the precise amount would '`•4 "tR from year to year because the cases would change,'but it i Z 110 (ln the order of 60 to 80 thousand cases for males and TIMN 211030

204 1 about 120,000 perhaps for females. I have all the figures here. I showed this slide before. This is incidence. I was talking of mortality. If we speak of incidence, cancer of the stomach, 2 3 4 colon, rectum, kidney, breast and prostate, we have 138,000 cases in~males and 201,000 cases for females. Now this is the ultimate potential for prevention. Whether we can achieve that and how much time will be required, this is an open question 5 6 obviously; but any modification that we would make of our diet in the right direction as we have suggested before should be ab~ t0, to show or to provoke a decline in these figures five or ten 11 years after the measures are adopted. Senator Percy. Dr. Wynder, do you want to comment? I Dr. Wynder. I can comment on it in my general presentatio~ + Senator McGovern. I'd like to urge my colleagues, if we can, to go back to the format we agreed on here at the beginning s I'm sorry I interrupted it myself just briefly, but we really '•nneed to hear from the other doctors. It was my hope that t r1a3t of the-questions could be reserved'as far as the answers ~ srr concerned until all of the doctors have had a chance to "•"" a brief opening statement. ."•enator Humphrey, do you have anything you want to say at cir,e? V -enator Humphrey. No. I think I would like to hear the and then we'll have a good deal of evidence on which our questions and I'd like to withhold until then. e a ~~~ TIMN 211031

is 1 2 3 4 5 6 7 8 9 10 !1 1? 0 I I a Senator McGovern. Is that agreeable with you, Senator Percy? Senator Percy. Yes, sir. (Complete statement of Dr. Gori follows) TIMN 211032

i 2 3 4 5 Senator McGovern. All right. Dr. wyncder, let's proceed to you then and we will go right through the panel and then after each doctor has had a chance for an opening statement we will have questions. STATEMENT OF DR. ERNST WYNDER, AMERICAN HEALTH FOUNDATION. Dr. Wynder. Mr. Chairman, first of all, I would like to „throughout the world, I}:now there's no other country ~ 10' give my appreciation for the American Congress to research possible in this country what it is. Fiaving make cancer traveled I tl that's l i d spent so much of its funds for research, basi.c and appe, as this country, and this gives us as scientists the opportunity 12 that we have in these areas. ,] .~ .~ I am President of the American Health Foundation, a foundation that has as its basic model that medicine should help I)r.ople die young as late in life as possible. In other words, ~ ue should die free,of disease'later in life. My training is in internal medicine but my love is for preventive medicine and t '«r epidemiology. t What I would like to do is pinpoint some of the specific '~lnts that Dr. Gori made to tell you how we arrived at the lusion that we have in terms of the role of environmental ~'''nra in cancer. ~',or+Q Years ago when I was privileged to serve on a national «+'~ fOrCe on arteriosclerosis we ended up with the same state- *N a~ t'fc'u qaver that arteriosclerosis is not an inevitable

207 1 consequence of age. Today we believe the same thing holds true 2 for cancer. Most cancers are manmade. Let me give you one 3 example in terms of tobacco. We have known the evidence for 4 many years. How has society reacted? How can we react? 5 We can react through what we call individual preventive medicin 6 and a great number of people have given up smoking and their• 7 lung cancer rates have decreased. But all of us suffer from i ,? I , , : what we call the illusion of immortality. We can educate peoplo but we all believe it will not happen to us. Therefore, I would like to make the strong point for what I call managerial preventive medicine, namely, to change the product and all you have to do is look at your newspapers and you recognize how the nicotine yield of the cigarette has been reduced. American industry has shown what it can do and we hav4 :~'Kkm that the lung cancer rate among those who smoke low-tar cigarettes has decreased. What we need is individual preventiv ~-dicine and managerial preventive medicine. Now using nutrition and what we learned in epidemiology, 'n mY formal text I have given you my view of contaminants. We'I •_°,- read in the newspapers a great deal of all kinds of materia~s "•''- We think relate to disease -- EDT, cyclamates, red dye. ~" •<•lieve these agents have had so far not any effects on• 'R c•zncer incident in man and i urge my colleagues in these to consider the cost-benefit ratio of any material that " t`"in from our food. TIMN 211034

208 1 2 3 4 5 6 7 91fascinating studies have been done to determine how this defi- 8 In terms of deficiencies, the specific example that I give relates to alcoholism. 111coholics -- maybe I should be more careful -- our data show that only those that consume seven shot of whiskey a day or more, if they also smoke, have an increased risk of cancer of the mouth, larynx and esophagus. Some 50 percent of these cancers relate to heavy alcohol intake, not in our view because alcohol is carcinogenic but in our view alcoholfism jis involved with nutritional deficiencies, and some very i 10 ! ! ,,ciency on a cellular level relates to carcinogenesis. ttf,i When we talk about nutrition, specifically we do not mean 1?,.obesity. IIow many times does a patient say to me, "How come I 13 qot a coronary attack, because I'm very slim?" We can be slim 1{ znd yet have hyperlipidemia. in cancer, we found only two types 15 of cancer, cancer of the uterus and cancer of the female kidney, 6 relate to obesity. The rest of them relate to overnutrition. r? What do we mean by overnutrition? Our data suggests that fivernutrition in fat and fat-related variables, possibly cholest rol would like to give two examples -- cancer of the colon which i~ vrry common in our society. It is rare in Japan and increases . E"the Japanese when they migrate to our country. It has a sex °'tio of about one to one, which roughly indicates that whatever must be equally done by men and women. incidentally, the of lung cancer is not one to one. UQw how do we go about in epidemiology to establish the TIMN 211035

6VJ . t t evidence? First, we use logic. Well, logic means that if I 2 look for a cause of lung-cancer I look for something that I inhale through my lungs. If I look for a cause of colon cancer- 3 4 and you really don't have to go to medical school to learn this, 5 excepting you've got to learn logic -- you look in the feces. 6 Somewhere in the feces there's got to be a carcinogen. So having started with the logic, you next go to correlatio s, 7 Bland the first correlation is the slides that Dr. Gori did not show you but he showed one for breast which I will also show, b 9 1a'this one applies to.cancer of the colon and you see that the larige ~~ fat.content in a given population in both men and women, the .? higher the rate of colon cancer. As the chairman said and Dr. ~ c•ori said, correlation obviously does not mean causation, but i i the absence of correlation causation is highly unlikely. . Now Japan represents one of the gold mines for the ,";dciemiologist because their rate of disease is totally differe t 0 t`:•,in our country and their vital statistics is excellent and '^rir medical facilities just as good as ours. So recently'Dr. Yama and I -- Dr. Yama is my counterpart tlational Cancer Institute, chief of epidemiology -- we "^ "=eharing a monograph comparing cancer in Japan and the States. . "!nl OE the things we are finding is that whereas we consume ~` "1'alories, the major difference is in terms of total fat The Japanese until recently consumed only ten percent TIMN 211036

210 I 2 3 I of total calories in fat and we are consuming more than 40 percq I come back to this to ask ourselves whether sedentary man is capable to metabolize that much fat in our diet. The next slide shows you the same data for cholesterol. In 511 1 J d 1 166 ll' f m o ~ s 1960 tie average apanese consume on y mi ~gra ~ b;cholesterol a day and in 1911 we consumed 509. So our choleste ~ r consumption is very high compared to the Japanese, but let me 9 again stress these are correlations and these are not necessaril, q causations. So now you go to epidemiology. You do case control studie~ 4 I You take several hundred colon cancer patients and several hundred control patients and you ask questions. What did we :-arn? There were in America practically no differences in ,orr.,s of any factor that we studied. Particularly noteworthy -ofound no relation to constipation, which means that transit '~"c• is not important. Specifically we asked dietary questions, you know if I asked you what you ate yesterday'and measured f : "s• you ate yesterday I would find out nothing. I want to v what you ate 10, 20 or 30 years ago. We have a limitation ' ct•tclemiology, namely getting a dietary history. tn Japan, where so many people ate rice, we found people """illon cancer had a more westernized diet. Haenszel, s'" ~~Q trntional Cancer Institute, said colon cancer patients ~^c~Xt, so meat might contain a carcinogen. I do not conclusion, but meat is an important-contributor to nt. ol y TIMN 211037

211 1 the total fat consumption. 2 Now in metabolic epidemiology we take the human being and' 3 study his feces in the laboratory. The next slide we selected ,. •.z 7 4 I fecal material from various populations, high and low, and you i ~-~ 5 find that those populations that have low rate of colon cancer i 6. 1 have a low output of bile acids and neutral steroids and we 7 have a high input. Again, it doesn't mean causation, but it is . J4 8 an interesting association, and Dr. Hill in England found the ~ same thing in studies that he did around the world. ~ Now next we show in the next slide -- and I think this is ~ very important -- that patients with colon cancer put out more K:~~ , 'hile acid metabolytes and neutral steroids. a Senator Humphrey. What does that all mean? ~ Dr. Wynder. Bile acid is a material in our stool. It's 9 t :-rived from chloresterol and these bile acides we have subse- *•.wnt1y shown in an experimental study are tumor promoting to rat. So we have a suspicion borne out by experimental lies that bile acids are tumor promoting to man and to '"O'•el and we know where bile acids come from and we have shown t`'L the stool of patients with colon cancer can metabolize za}' a C-40 colic acid more rapidly than controls. ~""'°rru+re, we have compared the Japanese and American and 'n J 4• 'I nothing genetic on this. It is just an effect that t^t4tes to the amount of bile acids that we put out. 1"n4tor McGovern. Dr. Wynder, just to clarify, you're TIMN 211038

1 2 to , it 4 , i talking really about high fat foods and you re•late that to the incidence off colon cancer? Dr. Wynder. That's correct, andswhat I have done is I hav shown the interrelationship of metabolic epidemiology and experimental studies and I will come at the end to show what I think we ought to do about it. Senator Bellmon. Are you talking now about animal fats or vegetable fats,? Dr. Wynder. Well, in our study we have shown for the experimental animal the effect of saturated and unsaturated fats was identical. This is contrary to the-experience in the arteriosclerosis where the effect of saturated and unsaturated fats rated is different. Let me give you an example of breast cancer. Everybody talks about breast cancer. What can we do about it to treat it. But what do we know about prevention? Breast cancer, nctain, is very uncommon in Japan, statistically eight times 1e';s common. When they move to this country, second generatio 34;>anese, breast cancer rate goes up. So now what does logic 3ay? Logic says that dietary fat influences hormones and 1~"t^rY fat influences the constituents of the breast flow. Now the next slide shows what I have just indicated. You at° !'o,+ much less breast cancer is in Japan, and if these wer rates in our-country, then we would'be much better off. 11-rOi'ie m,-,Y say, well, but the Japanese women have obvious~y I TIMN 211039

213 1 2 3 4 smaller breasts. May I say we studied breast size and we found no correlation of breast size to the rate of cancer. Now again we studied hundreds of cases of breast cancer. We found some relationship in terms of late pregnancy, late menopause and 5'family history; no relation to obesity; but we could not explain I bithe major differences between our two populations. So next agai I 7 11we went to metabolic epidemiology. 8; Just the other day we presented in a scientific meeting in 9 Germany for the first time that the diet has a profound influenc 10 on the production of prolactic. These are the same data to the it The next slide shows that if I take a group of women and I f I r.tudy their prolactic level at night -- I , i association that I have indicated before. Senator McGovern. Prolactic means what? Dr. Wynder. Prolactic is a pituitary hormone that in anima "tuclies relate to breast cancer•. You have to study this at •:t,;ht because when you study it during the day the prolactic '~+ a half-life of ten minutes in the blood. It happens to have +::•11f-life of 50 hours in the breast. If you look at it in the 'r "aYbe you don't find it. So we took these women and studied ;,rolactic level and then we put them on a vegetarian diet. four weeks on the vegetarian diet, the prolactin level wen ,~. 4 ti t0 60 percent. I don't say causation, but a very interest next slide you see in the experimental animal where we n a L t • ~ng TIMN 211040

2 4 5 6 7 8 9 10 initiated breast cancer with this high fat diet, both saturated and unsaturated. In the rat model, this effect related princi- pally to the ratio of prolactin over estrogen, the former increasing with ahigh fat diet. I In our current studies of the effect diet exerts on breast fluid, we find a significant amount of lipids, cholesterol and cholesterol metabolites in women on the standard American diet. We are now concerned with the question of whether the amount of lipids and cholesterol can be influenced by dietary manipulationi and whether, as we expect, the breast fluid composition in 111~,IJapanese women differs from that of American women. Our presen~ 12 ~f „hypothesis is that specific hormones are tumor-promoting and r r ,a! ,; 'S : . that specific tumorigenic agents are yet to be identi.fi.ed, possibly within the breast fluid. However, it is important stress that both factors are controlled by nutrition. The reason I'm emphasizing this is to show the inter- to relation of animal studies metabolic epidemiology and classical, epidemiology. Next you ask the question, obviously, what shoul~ u4 do about it as prudent men? I Now the interagency for cardiovascular diseases has t^corunended some time ago that for the prevention of arterio- =~terosis we should have a prudent diet. The next slide shows "'at this prudent diet ought to be. It should have fewer ,'`°ries. It should be low in fat and should be lower in 'yZorusterol, What we are suggesting is that this type of TIMN 211041 ,

1 2 3 prudent diet it would be prudent to adopt it also for the long- term reduction of the incidence of cancer. Now it may well be that even this prudent diet is not good ajenough for sedentary men because let•us recognize that we not i 5' only overeat but we underexercize. It®s very interesting that ~ 6lyou and I produce all the chloresterol we need and I ask myself 7`what does it mean. One of my great heros in medicine is Charles i 8 Darwin because he sat down and looked at evolution. So we look 9 at the evolution of nutrition. It's my view that primitive 11.) man'ate no chloresterol, ate very little fat, and on top of this 1 he always ran after something or ran away from something, so ' essentially he expended a lot of calories. So we today in our society that overeat, underexercise, and does not have the i t s ^-taholic capacity to deal with these excesses. Now what we are looking for here in carcinogenesis is not ,lomuch specific carcinogens as promoting, but carcinogenic• '.lctors that'relate to these specific cancers and others Dr. mentioned. Finally, what is the answer. In the last slide I will sho .`-i what I think is very important, what we need to do in nutri- we must have an interdisciplinary approach to nutritional 'T•'Inogenesis that needs to be coordinated, Mr. Chairman, by I "'-ono within the NIH or the HEXq to coordinate the various '"''',oters of nutrition efforts that now go on. in classical epidemiology through demography, case/control TIMN 211042

1 2 3 4 5 6 7 8 9 10 studies and metabolic studies, and relate these to chemistry and biology and public health. Now Pasteur, to paraphrase him, said the great scientist not only discovers but he also works very hard on the applicati of his or her discovery. Iiow are we going to apply it? We need to apply it in part through education, and you very correct put your finger on that the nutritional education needs to be given in our children. Now the question is how? Having just done under an NCI grant a study of health behavior in children, we recognize that 11~ ( these children don't listen to us' adults. I remember I had a I 12ijlittle six year old boy in my car and he said to me, Uncle Erns ,i . 1 3~how old is your car? I said it's six years old, just as old 14 ~5 "What do you think is old?" Fie said, "Twelve." We need to recognize that•children only listen to peers. 4 as you are. The kid says, "That isn't very old." And I said, So we in the American Iiealth Foundation came up with a new program, and I would like to mention this now because I would like to see it mandated to be part of all school systems in our ,country where at the present time we do practically nothing on ;hoa1th maintenance education. The children called it a "Know your Body" program where ,r not only tell them about our body but we actually take the "•toresterol and we take their blood pressure and we take their "*I,tht and we get histories on smoking and drinking habits. e ly 11 ,~~NiN 211~43

Z 1 / 1 2 3 4 5 6 7 8 9 10 11 13 14 Mind you, the hypertension in blacks doesn't begin with the stroke when the people are 40, but we see it in the six and seven and eight and ten year olds. We found 16 percent of children in New York had chioresterol levels over 180 milligram~ percent. If you take the chloresterol level of children in Mexico and Wisconsin, those two curves do not overlap. Then we.give these children a health passport. We call it a health passport and it•says "Know your Body. Nobody takes better care of you than yourself." And if children get the passport, we then send this passport to the children and we hop by getting this information directly to the children, getting them directly involved in knowing these risk factors, we think we can reduce these risk factors in children. We have malnutrition of the poor and malnutrition of the affluent. If we are going to overcome this, we have to do it i 11 161through research, more funding for research, but applying wiiat IS!I l1 ` we already know. '8 . f 9 . _ E Senator McGovern. Thank you very much, Dr. Wynder for that excellent testimony. We really appreciate it. (Complete statement follows) t TIMN 211044

218 1 2 3 A Senator.McGovern. Our next witness is Dr. Mark Iiegsted of Harvard University. STATEMENT OF DR. MARK HEGSTED, HARVARD UNIVERSITY. ~ Dr. Hegsted. That's kind of -a hard act to follow. I I . 5~appreciate the opportunity, and as a member of the older group b 11that testified before, I would like to express the appreciation ~ 7';of the nutritional community for the activity of this committee 8lover the last many years. t0 t 4 : , 4 I think I'm correct, Senator McGovern, stated the original aim of the committee was that poverty and undernutrition be overcome and obviously a lot has happened in that area and I think one of the things we haven't yet done is develop a sur- vr_illance system to tell'us what we have accomplished and where vefailed. I think that's.on,e of the things that we need in our nutrition program and we need to have them expanded to include kinds of problems we're talking about today. So.that we're not misunderstood, I want to emphasize that ~-ti1l think undernutrition is a worse problem than over- I think people have a right to an adequate diet and •':tcik it's shameful and not to be tolerated if there are any '` ='antial number of people in the United States that don't ~., t•1 qood diet. So I trust this committee will maintain its in the problem of undernutrition until it's solved. '.Onator McGovern. Dr. Iiegsted, on that point, I want to You,and I know I speak for every member of the committee, TIMN 211045

219 t 2 3 4 5 6 7 81 that we are not in any way turning away from our concern for the hungry and the undernourished in this country. One of the very important functions of this committee is to maintain an oversigh on our various supplemental feeding programs -- the school lunch program, the WIC program, the food stamp program --- to see that those programs that are primarily for the poor -- not so much th school lunch program,,but the others,-- that they continue to 'function and that we improve them, but this.is simply a new . emphasis that the.committee is getting into and should not be interpreted as a turning away from our concern with our original objective. Dr. flegsted. I was sure that was true, Senator, but I also tp 1t !1 4 wanted to indicate that in view of what I'm going to say next that I want to be sure everybody didn't misunderstand me and nssume that I didn't feel there were any problems of undernutrit Senator McGovern. I think it's well that the point was I r V Dr. IIegsted. But I think now we turn to really a problem the majority of the United States. These are the problems most of us in this room are going•to die of and someone '1,0oint out -- I guess•it was Ernst -- it's not the fact that ''a 're qoing to die of these diseases that's so important, but we die. our objective is to push back that time so that we die youn nY primary function or primary purpose here today is simply s lion . 91 TIMN 211046

1 2 3 4 5 6 7 8 9 10 11 12 13 ,? to point out, as has already been pointed out, that we include ~ in these diseases coronary artery disease which kills about half the people, many important forms of cancer, diabetes, hyper- tension, obesity, and various other things, all of which have a strong nutrition component, and these diseases will obviously become more important as we develop more efficient and effectiv ways of cont.rolling the infectious disease as has already been emphasized. The primary evidence is epidemiologic but, as Dr. Wynder has pointed out, it's not limited to that and everywhere in the world and indeed in affluent groups within the developing countries who assume the western type diet they develop the sam disease patterns. Although the evidence is epidemiologic for most of these, I think the exception is coronary artery disease where we have clear evidence that coronary artery diseases is not a primary problem in populations with a low chloresterol level and it's clear that diet controls chioresterol levels, We have a clear linkage between plasma serum lipids athero- so sclerosis and coronary arteries and I think one of our main aim t • . " in the next few years is to develop exactly this kind of a { . '!knowledge so that we can identify high risk individuals with r"qard to these other diseases. This we do not yet have. I wanted to spend a little time to talk about the genetic factor because it seems to me this is aponfusing factor in man~~ ""^le'3 minds. When we say it's genetic, many people assume. TIMN 211047

111 that because it's genetic nothing can be done about it. Obviousty 2 nothing could be further from the truth. Approximately 10 percent of American men can eat the average American diet with impugnity as far as heart disease is concerned, but the rest of us are all hyperchlorestoral'limited and our benefits to be derived from an appropriate diet are directly related to our 7 genetic susceptibility. 8 It's the most susceptible individuals that have the most 9 to gain. So the statements that we hear quite often that these 10 are genetic diseases and therefore we can't do anything about 11 i j ~ them are exactly misleading. 12 ~ As I say, we need in our research effort to aim to try to identify things we can measure so we can identify these high ,4 S . I r risk individuals. I think it's clear that these problems are associated -- that the problem associated with excess consumpti are going to be more difficult to deal with than those of under consumption. It's not so difficult to convince people who wantl :^ore food to eat it and it basically is not very difficult to :1,ld nutrients to foods if we can convince ourselves or the 4°owers that be tNat this is required. We have the technology tO improve diets as far as essential nutrients, but the problem ') ' convincing people to eat less of the kinds of things they A, tikO to eat is going to be a more diff.icult problem and we don' + ',^1r very well how to deal with that. As I think everyone has emphasized and maybe not enough, bn t TIMN 211048

We should eat less sugar. We should eat more unsaturated fat, i 2 3 4 9,1 :0 tt ? of diet that is not associated with these things. The benefits t 4 , c all of these diseases, heart disease, cancer, diabetes, have a complex etiology. Diet is not the sole cause, but diet is one of the causal factors and this can be modified. I'd like to suggest that the prudent diet for Americans is that we should eat less food. We should eat less meat. We should eat less fat, particularly saturated fat. We should eat less chlorestero . more fruits, and vegetables and cereal, particularly whole grain cereal. All of the diseases we are talking about are correlated wit the kind of diet we have now. We should move towards the kind we are going to derive from these can't be really calculated, :)ut I believe that people in the United States deserve the best !.ind of knowledge that we ha-e available and the important ;uestion it seems to me is what are the risks and benefits from J':At we do now and what we*might do based on this kind of know- : r i~e Ile know what the risks are now and they are high and I I t " slt} submit that there are no identifiable nutritional risks •+:'jciated with shifting our diet in the direction that I have and if that's true, then that ought to be the directio •~. "nu1d be going. t think recommendations of this kind will be difficult for ple, primarily because many of them will feel that these h n TIMN 211049

21.3 1 2 3 4 5 6 7 8 9 10 tt 12 are exactly contrary to what their idea of a good diet is. We have failed to identify the moderate diet that many Americans should consume in our concern over undernutrition. I want to emphasize, as have others, that these associations do not repre- sent or mean that the same causal factors are involved. Cer- tainly we should have much increased effort to identify those causal factors. We know what they are. We may be able to have our cake and eat it, too, so to speak; but at the moment I think we are a long way from.identifying the causal factors, but certainly there seems to be no alternative except to support more research to identify the actual causal factors. Meanwhile, it seems to me Americans deserve the best advice ~ that we have available and I think modification of the diet'in t .j i I I tlirection I have indicated is what they should be told. Thank you. Senator McGovern. Thank you very much, Dr. Hegsted, for 'our testimony. (Complete statement follows) ne TIMN 211050

6G4 1 2 Senator McGovern. And now we will hear from Dr. Dave Kritchevsky from the Wistar Institute, Philadelphia, Pennsylvani~. 3I STATEMENT OF DR DAVE KRITCHEVSKY WISTIIR INSTITUTE I ~ , , . k 4 PHILADELPHIA, PENNSYLVANIA. ~ 5 Dr. Kritchevsky. Well, I'd like to add my thanks to those ~ b~!of the other members of this panel for the.opportunity to presen ~ 7'iYou with some of our views, and I would'.like to address a little ~ g°-bit of time to some of the work that has given us some of the s I r ~ 9 leads that we are now following. ~ '0 While most of the data from man are epidemiological in I I -.1 nature, animal studies can provide relatively rapid answers to '2 complex questions. Now it's not easy to translate animal result I to the human situation but these results provide important f t di - h ~ es are essen t s u cly. ypes o ues to further inquir So bot tial for a broad-based assault on the problem of cancer. i s t : One of the first of the dietary components that has been s t Is :tucidied for its relation to cancer has been fat, which has been •"cussed to some extent already, and it was found that the leve ~: fat was very important so that going from 2 to 8 percent fat v:11 cause a great augmentation in tumor growth but going from ' tn 26 percent does not cause a greater increase. The plateau '' r-irs to be at 16 percent fat. ;sow most of these studies have been done on skin cancer I '-'i POs of breast cancer. Fat in experimental animals is have no effect onleukemia. Dr. Wynder has already TIMN 211051

1 2 3 4 5 6 7 8 0 commented on the fact that the type of fat may affect the metabolism of chlorestorol, but it may affect other things such as the enzymes which in turn metabolize those substances which cause cancer. So it may be a secondary effect but a very impor- tant one. Now the current knowledge is that the type of products of chloresterol which are excreted may yield clues to the productiob of colon cancer and I think we need a lot more information as to~ IIhow those changes come about, but I think fat is only one com- 'I~ _ 10;iponent of the diet. It's the one that's been mentioned most , ~~;lbecause it's the most visible as far as total calories are con- , 1?1 cerned. ,3 There are some suggestions that protein in the diet may 1 have an effect, but in contrast to the effect on heart disease 5 where there's some suggestions that animal protein may be worse I I than vegetable protein in cancer experiments it seems that.the anount of protein is more important. Another dietary component which is receiving a lot of 4ttention now is fiber. Fiber is that•non-nutrient portion of `-'t(` diet which used to be called roughage and the epidemiologica ='utics, mostly from Africa, would suggest that a lot of the -i=e.ises that are prevalent in'the western world and not preva- •'"lin black Africans are due to their consumption of a high I think this is an understatement or overstatement fact because actually a lot of -their diet is different 1 TIMN 211052

226 1 from ours as well as their life style. 2 Data that Hill in England and others have got together sho 3 that the highest correlation, the highest positive correlation 4 with colon cancer is the amount of fat in the diet and that the 5 correlation with the lack of fiber.in the diet, while still 6 positive, is quite low. Of course, in general, populations that 7 eat a high fat diet don't eat a high fiber diet, so it's a 8 question of which does what. However, there's another very 9 important aspect of fiber in the diet and that is fiber is an a 1- 10 inclusive term and we are now finding out that substances that il 12{ are not absorbed by us may be different in chemical composition and there's a lot of work to be done. There's a lot going on 13 already to discern which particular component of which particula, r +1 fiber does the job we're interested in. oS Bran, for instance, has gotten an awful lot of exposure 1 t because of popular books on the subject, but there are a lot of • studies that show as far as human chloresterol levels are con- i cerned it has no effect whatsoever. It doesn't increase stool , hulk or transit time. So it may have an effect in one direction~ : 'at not in another. Another very important thing is just now beginning to get '"^ntion which is the total diet and the interaction of the `IlTvnents. Both Drs. Ilegsted and Wynder have commented on '"hiqh levels of chloresterol in the diet and to most people Rt~O he3ns high fat, high chloresterol, leading to high levels 1 TIMN 211053

227 1 2 3 4 5 6 of chloresterol in the blood. Other factors in the diet can affect how much chloresterol gets into the blood and I think this is a relatively unexplored area of nutrition. It's very complex because the interaction of a number of components requires attention to be paid to more metabolic processes than the studies of.any single component, but I think this will yiel to expanded research and will permit us to get a much better picture of what the total diet does. So that I would say that coordinated studies on diet which assess the effects of protein, fat, carbohydrates, vitariins, fiber,, trace elements -- not one single thing, but interaction, '2 is something that has to be done. l In the 30 or so years since research on diet and cancer i t have been done, we have learned a lot more about the compositio of the diet and a lot more about the mechanisms of tumor formation and growth and this knowledge, along with the genetic ancl cancer chemistry of nutrition gives us a more solid base fo~ I r r.t?wer research and I think, all of this can only help those '''ople interested in the aspects such as genetics and growth of '°.•nors and the people working in diet. I think that, as everybody has said, the important factor •1tre addressing ourselves to here is what we need is a well °-,led diet, but one.that is eaten in moderation. Moderation `` Oort of a cop-out word, but it's about the best advice that qiven and easily understood. I think that more precise TIMN 211054

228 i 2 3 4 5 6 7 ,2 t t t I data which can be gathered only through more research will give us a more accurate picture of what we can prescribe and what would be both nutritious and acceptable. I think this is another thing, that in a free living society the diet'not only has to be good for them, but it has'to be good. Senator McGovern. Thank you very much for your testimony. (Complete statement follows) TIMN 211055

I 2 3 4 5 6 7 Senator McGovern. Our final witness is Dr. Jerry Wogan, of the Massachusetts Institute of Technology. STATEP4ENT OF DR. JERRY WOGAN, P411SS11CIiUSETTS INSTITUTE OF TECEiNOLOGY. Dr. Wogan. Thank you very much, Senator. I'd like to add my thanks to those of my predecessors for the opportunity to present my views. I have my remarks outlined on a couple slides which I'm suffering from the disadvantage of being the last man on the program and therefore many of the points that I'wish to make have already been made. Nonetheless, I would like to focus on a point which has been raised in several contexts but I think which deserves very considerable-attention in connection with the formulation of prevention strategies because I feel very strongly, as the other witnesses have indicated, that cancer is •1 preventable disease and we should do everyt ling that we can t : :o to formulate a prevention strategy. However, I would like to introduce •'w,discussion dealing with the necessity of distinguishing '4'tueen association and causation. This is a pdint which was "'oin the chairman's introductory remarks and has been made a cautionary tone to '"°,'ral times since. Y think in the formulation of a really effective preventivq "'''^gY this distinction has to be kept i"i 11 Point out in my remarks. I kould like to begin by expressing in mind for reasons th4 a view which is very t TIMN 211056

230 1 2 3 4 5 6 7 8 9 10 11 12 widely held now by investigators seeking to find the causation of cancer, and that is that the view that most cancers are in fact induced, that is initiated, by exposure to chemicals and this view arises from basically three lines of reasoning. One of these we have heard described in considerable detai this morning; that is, the epidemiological evidence in human populations, the geographic localization of high incidence regions, time trends within a given region and migrant studies. All of these point to the existence of environmental factors which affect cancer incidence. However, there's a huge amount of laboratory evidence which•indicates that hundreds of compounds, hundreds of known 13 ~ chemicals, are able to induce cancer in animals. Some of these 5 I , find their way into the environment albeit usually at very low levels, at levels far below those which are affected in inducin cancer in animals. Nonetheless, they are there and the pre- liminary indication is that -- or the question really is, to what extent do these contribute to the causation of cancers in Man? I will return to that point in just a moment. Finally, there is the kind of negative evidence in relatio i .~ to the causation of various forms of cancer and that is that t'1e other two known causes of cancer -- namely, virus and ~ ~ latiii 4don -- can be assocated epidemologically only with a YOry restricted set of cancer types. In the case of ionizing t+;liation, cancer of the bone, and lettkemias in the case of ""A'ionizing radiation there's ultraviolet light, the inductioz~~ TIMN 211057

231 1 2 3 4 5 6 7 of skin cancer, and in the case of viruses the best evidence, although it's not conclusive, is an involvement in the etiolog of lymphomas and leukemias. Well, the question is, then, what chemicals are associate with what forms of cancer, and on the next slide I have reviewed this. There are basically only three instances in which a specific chemical insult has been associated with a 81 specific form of cancer•. One that's been mentioned over and I qi over again this morning is cigarette smoking and lung cancer l0, and cancer of other organ sites. The specific chemicals that 11t are involved in this case have yet to be identified., but the '2 association is very strong. This represents, as I indicate 3 here, probably the highest exposure rate of any known chemical 4 carcinogen inducing the greatest effect in populations exposed I t to them. As also has been mentioned on many occasions before, this cigarette smoking could account for as much as 30 or 35 percen of the incidence of total cancers. Occupational exposures represent historically the best established linkage between "xPosure to specific chemical agents and specific cancer forms ~''%e recent occurrence of vinyl chloride induced liver cancer' _4E,erhaps the most dramatic example of this association. However, it's thought that occupational exposures per se "'aunt for no more than one to three percent of total cancers Pinally, as several previous speakers have indicated, wit TIMN 211058

232 1 2 3 4 5 6 7 8 9 101 ~ ~~;iincidence of liver cancer in the U.S. population are both very , i low, so this represents numerically a minor fraction '3 total cancer risk. ,4 all that's been said and written about the importance of food- borne contaminants and food-borne carcinogens and the risk that they pose for inducing human cancers, there's only one known example of the association between a food-borne carcinogen and the occurrence.of a specific form of cancer, and that is the association between the ingestion of the mold produced compounds called aflatoxins which are very powerful carcinogens in the occurrence of liver cancer. This has been established in Africa in several countries in Africa, and in Asia. However, the level at which these compounds occur in the U.S. diet and also the of the Well, what about the remaining cancers? Is there evidence which would link chemical exposure to the'remaining fraction of cancers for which we don't know the etiology? At the moment, we haven't a specific answer for this, so I I 'Jould like to call attention to the fact that there are still , 10ne things about carcinogens in the environment that we don't t ,^, Ow . i First of all, we don't know that we'can identify all of. chemically, but more important than that, among the ones we can identify are the possibilities of synergisms -- is• of low levels of multiple agents acting in a more than additive form in the initiation of cancer. . TIMN 211059

233 Second, the possibility of the changing patterns of carcinogen exposure which might in fact be related to the findin s question here today and that is, where in fact is the best evi- dence or where in this kind of model in which cancer is initiatei by an exposure to a chemical and then promoted, as has been said earlier by various environmental factors like diet -- where ~. does diet fit into this picture? Well, there are several ways in which this could take place although these are very poorly characterized except in•a few ani lappear in the environment, but once they are ingested or once models. One is in the case of altered metabolism of carcinogens It's very well established now that most and probably all car- cinogens are not in themselves active in the form in which.they exposure takes place, either in animals or in man, they are metabolically converted to another form which becomes much more As Dr. Kritchevsky just pointed out, the diet has a very Sramatic effect on the enzyme capabilities, enzymatic capa- t ,lilities for doing that kind of'conversion, and the interactions '•in take place in either direction, in sensitization or in pro- •"ction, so that in the formulation of control strategies•this 0 'ctor has to be taken into consideration. Second, there are examples from the animal model systems `t Vhich the organ site which is affected by a given carcinogen d na 1 TIMN 211060

234 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 )8 tQ . can be completely changed by dietary manipulation. For example,' I mentioned aflatoxins earlier which in animals with a very hig degree of specificity induce cancer of the liver, only cancer of the liver; but when those same animals are fed a diet which ' marginally deficient in vitamin A, not overtly deficient but simply marginally deficient, the target site changes from the liver to the colon. Senator Percy. Doctor, could I ask if the key to the puzzle you put up here, for those of us who are laymen, if we could use the word interaction for synergism? Is that correct? Dr. Wogan. Yes. Synergism, as I'm using it here, refers to a combined effect which is much greater than simply the additive effects of the end number of individual components. Senater Percy. And carcinogen is a cancer causing agent? Dr. Wogan. Yes. These are agents which induce cancer. Senator Percy. I just wanted to be sure you understood we are not medical students. We are struggling with this chartl Dr. Wogan. Let me just put the main point of the whole thing in a nutshell. In the formulation of a control strategy, the point that I'm ma}:ing here is that if we make specific dietary recommendations without knowing the•initiating factors, if these remain unknown and if we don't identify them, then there is a risk of formulating preventive strategy on the basis t I 1wl'ich would include both factors, but what's even more risky in ,s af di.et which in fact may either not be nearly as effective as +. ., , s ne TIMN 211061

1 my judgment than that is that we may make recommendations which 2 would switch the risk by modify ing the sensitivity.of specific 3 organs to the act ion of chemic als which ca n in fact induce 4 cancer an d which are prEsent. 5 This is basically the mes sage that I would like to leave 6 from this slide. I don't mean to overemph asize this, but I 7 think we shouldn't lose sight in theformul ation of preventive 8 strategy of the importance of identifying the causal factors an 9 not equating associations, epidemiological or otherwise, with 10 u ti Th k . causa on. yo an Senator McGovern. Thank you, Dr. Wogan, for your presen- tation. tation. ~ (Complete statement follows) 4 , : t I i , TIMN 211062

236 1 2 3 4 5 6 7 8 9 10 11 !I l i 2 Senator McGovern. Dr. Wynder, as you know, there's been a growing anxiety in this country about the impact on food additives and food contaminants as a factor in cancer. My own wi e has been very much concerned about that and not buying things that have nitrates in them and avoiding things that look like they are painted red and so on. But I was surprised in your statement that you say there's no really measurable evidence tha food contaminants and food additives are significant factors in cancer. Would you elaborate on that a little? Dr. Wynder. Well, as you know, Senator McGovern, the ,4decisions were-essentially made on the basis of the Delaney 13'amendment which states that any food additive ingested into an t4 animal at any concentration producing any kind of tumor needs t S be banned, and it's really on that basis that we have banned ~ DDT and cyclamates without, I believe, proper epidemiological evidence. In other words, what I was saying is that the evidenc I in epdemiology has shown no relationship that these i particular , let's say cyclamates or saccharine -- and there was just recentl sf'aher from Dr. Kessler of Johns Hopkins that the longterm intake of these sweeteners did not increase the risk for bladder :ncer. I recognize we'can get involved in the concept of professio al L '°`" lg of carcinogenesis and in my view this is a theoretical" "'eii8Rion that probably won't get us anywhere. Therefore, I TIMN 211063

1 2 3 4 5 6 7 8 9 10 il 12 13 stress the point that we have got to look at each material that we ban from the point of view of cost-benefit. Iff we want to eliminate DDT, then we've got to say, okay, this is the kind of cost•-it will have to the society and these are the potential benefits we have, and then we've got to bring in the industrial component. We've got to bring into the crop of agriculture and we've got to bring in the epidemiologists. It is my view that the National Cancer Institute has recently dealt effectively with this general problem by esta- blishing a national clearinghouse for environmental carcinogenes simply because it felt that there was a lot of -- a great deal of decisions were made which I believed did-not really regard ki s the whole link of cost-benefit effects that are related to banni g 14 a substance, and I wonder whether perhaps Dr. Gori may want to ~5 comment as to where this national clearinghouse for environmenta ~ carcinogens now stands because,I think that's a new effort by 7 f j the NCI to bring greater order into this very difficult area. Senator McGovern. What I was getting at is whether -- ind Dr. Gori maybe you wish to comment -- whether you think we -1ve created exaggerated fears of the impact of food additives Ird what Dr. Wynder described as contaminants. Dr. Wynder. I certainly believe that. Senator McGovern. You think we have exaggerated'them? Dr, Wynder. The problem, Senator, is that -- I love the Media and they are ver y, very important, but when I talk TIMN 211064

238 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 to them about let's say the food additives that were just banne they say that makes news, that makes headlines, but preventive medicine is dull. It never makes any news. Somebody once defined preventive medicine as applying to the faceless and the nameles,s and the unidentifiable, to themselves and others. So this really doesn't get anybody. But it is very attractive to the news media and I believe we ought to be very, very careful before the American public believes we're living in a sea of carcinogens that really everything we do is carcinogenic and cannot distinguish the important from the unimportant. Senator r7cGovern. Well, my impression from these hearings is that it's been comparatively recently that medical science and medical research has started to look systematically at the relationship of diet to cancer and perhaps to some of these other major killers. Is that true? Is this comparatively a new concern and new emphasis on the part of the medical professi, instead of looking for exotic chemicals and various things in the air that may be causing cancer, that we are now beginning to look at less dramatic things but maybe more.fundamental things, and that's what we eat? Is that impression correct? 2211 Dr. Wynder. In fact, Senator, Dr. Al Tannenbaum deserves 23,1a great deal of credit with some early studies on nutrition r N~carcinogens in the early '50s where he already showed that ftw f :Sicaloric excesses in experimental animals lead to tumor formatior~ t . on; TIMN 211065

239 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 but it was subsequently that we and others have shown in epidemiology and really demonstrated this applies not only to animals but also to man, and finally we have come to the fore- front and I would like to give a great deal of credit to the National Cancer Institute that had the kind of vision and leadership to pick up these epidemiological data and say to the scientific community, "here's a great lead that you need to pur- sue," and it is my view that the NIII and the HEW must not only wait until people in the scientific community have an idea, but must, in my view, get them to coordinate efforts in a new direction and the National Cancer Institute deserve a great deal of credit for bringing nutritional carcinogens into the forefron Senator McGovern. I'd like to direct a question to L1r. ^ Iiegsted and I know, Doctor, you have cautioned and all the docto have against trying to make any definitive analysis about what a 1a!person ought to eat until you know something about the person, b would it generally be right to say that most Americans would be 4 better off if we ate less fat, less sugar, less salt, less ' liquor, and ate more fiber, cereal, roughage type foods? Dr. Hegsted. I certainly agree, only I'd expand your :ist a little. I think we ought to eat less meat, less a >>turated fat, less chioresterol, less sugar, less salt, and 1~11rease our consumption of fruits, vegetables and cereals, grain cereals. I think, as I said, I see no possible risk in suggesting t. rs Lit TIMN 211066

1 2 3 4 5 6 7 8 9 10 11 t? kind of diet, no health risk, and the probability of benefits are all these to be seen in correlation as well as some of the. more definitive studies. Senator McGovern. Are there a number of cereals on the market that are readily available to the pepole in the stores that you could endorse, that you can recommend? I don't want a commercial endorsement, but I don't want you to give out any particular name. In other words, can you go up to the super- market and pull off the shelf cereals that provide the kind of roughage and nutritional content that you think is desirable? Dr. FFegsted. I'd like to comment a little more on that, ,because as far as I know, fiber is essentially not measurable a 3 the moment. It's something that increases transit time through .A the intestinal tract and increases people's bulk and what we I measure in the laboratory ordinarily and call food fiber is simply not what we are talking about. It's unfortunate, but thalt is the state of the art.and it's a wasteland right at the moment, I •Lz Dr. Kritchevsky pointed out, wheat bran has fiber in it by :,~finition. We.. know that. Whole grain cereals have fiber in "^m because they.practice what we talk about. But by analysis, " 3 really cannot tell. So that I think the best advice at the ' `11'nt would be whole grain cereals or.high bran cereals, '~'•'•vugh even there, I'm hesitating a little because I understa '`` "'fe now evidence that methods of processing may determine < "I rR'Ictivity of some of these so-called fibrous materials. TIMN 211067

241 1 Senator PZcGove.rn. That's really what I was getting at, whether these highly processed cereals that we eat -- and you know all the popular brands -- whether as a general rule you think those are good foods. Dr. Fiegsted. I'd hate to comment on individual foods as 2 3 4 5 6 good foods. Most foods are good foods in moderation. 7 Senator•'McGovern. That was another point that Dr. 8 Kritchevsky made. 9 Senator Belimon. I thought when the Doctor mentioned 10 cereals you were talking about cereal grains. You weren't 11 talking about Post Toasties. 12 Dr. Fiegsted. All cereal, anything that's made out of 13 cereal, not specifically breakfast cereals. 14 I Senator McGovern. The closer you can come to the -- the 15; ~ ib less processing and refining and so on that goes into this, ~ ordinarily the better; is that not true? t ) ~ .9 Dr. Hegsted. I think I'd have'a general feeling in that direction, but I couldn't produce any particular evidence. I think usually when we think of processing of cereals, we are ,talking about removal of bran to produce the white flour and uhite rice.. That, by definition, would have less fiber in it than the unmilled material. But the kinds of processing that 'T0 into breakfast cereals, I'm not really sure whether'they are "^rY important and, of course, on a nutritional basis, most of . t~~m are fortified. TIMN 211068

242 I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Senator McGovern. Senator Humphrey, you haven't had a chance to do any questioning yet. I'll defer to you. Senator Humphrey. Again, I want to express my thanks to our witnesses for the informative session we have had here. It's quite evident that we are more or less feeling our way as legislators in this field. The purpose of this committee is to focus attention upon the matters that have been discussed and hopefully to explore further areas. This morning I was listening to the Today Show -- maybe some of you noted it -- there was a psychiatrist that was on the show and he was relating diet to mental health and mental disturbance or psychic disorders, and he was using -- he actually had some tests and he was demonstrating by film on the Today Show of where a particular-patient reacted very sharply to fish and showing the effect of the diet upon attitude, upon one's beha vior. Without going into that, I suppose that is an area that's now being explored. Am I correct? Is this an area of some major exploration? Dr. Gori. I don't know how major, Senator Humphrey, but certainly it's an area that is being explored. Dr. Ilegsted. Certainly some aspects of it are. Senator Ilumphrey. We know about certain foods in terms 2< i «. : of allergies to skin and feelings of digestive disorder and so on, but this was in terms of the attitudinal reactions. We TIMN 211069

1 have information now, don't we, insofar as smoking, to cut it 2 out -- cigarette smoking in particular -- has reduced -- or at 3 least we have signs of reduction of the incidence of lung cance 4 Dr. Gori. In som e of the younger ones,'yes. 5 Senator Humphrey. We also have evidence that by reducing 6 the tars that you redu ce the danger of lung c ancer. Now we 7 passed legislation her e in Congress that says that you have to 8 have certain,types of mechanical equipment on automobiles. We 9 have what we call the safety legislation, so if you're going to IO get into a car you have legislative mandates. As a matter of It fact, we have gone so far now as to tell the automobile producerj -? how much mileage he has to get out of his car and we're on the environmental aspects of it in terms of pollution. t Maybe I'm not properly informed and I hesitate to even ` bring it up because I may show my ignorance of it, but have we , Passed legislation that says you will reduce the tar in the ciclarette to so many milligrams? t Dr. Gori. There have been severall bills proposed, but to ~ "7 knowledge none has passed. Senator Humphrey. Isn't it a good idea? Dr. Gori. I think it is a good idea. Senator IIumphrey. I mean, after all, there is demon- '•al."le evidence that cigarette smoking is a health hazard; is m 'It correct? Dr. Gori. Yes. TIMN 211070

244 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Senator Humphrey. I just thought I'd bring this up as a matter of whether we ought to have some legislative intent here on this matter. After all, you can't go around throwing out colic acid around, can you? You can't take certain chemicals that we know are poisonous and just pass them around. I recollect when I was a pharmacist we had to register all of those poisons. Dr. Gori. Could I comment briefly on this subject, Senato Senator Humphrey. Yes. Dr. Gori. I happen to be heavily involved in smoking and health with the Cancer Institute and of course this problem has been with us for a long time because as many of us --,and Dr. Wynder has indicated -- this is the single most clear cause of cancer in humans today, smoking, and the single most preventabl cause. Of course, how do you approach such a problem? You try to 7 educate people not to smoke and this we have done. After 15 effort, we still have, by years or so of intensive educational the latest counts, some 50 to 60 million Americans who smoke. Smoking has been with us for 500 years. It's not likely that ~ ue are going to cancel it in ten years. It's likely it will <<ike a few more decades before smoking disappears from our •ociety. As you have indicated, legislation has been lagging perhap t"this issue for a variety of reasons that I don't want to tou h i ~ TIMN 111071

I 2 upon, mostly economics of this particular problem, but also the 3 fact that people want to smoke continue to smoke inspite of 4 all warnings. 5 Therefore, we felt that something had to be done for peopl 6 who continue to smoke and it is well known that the more you 7 smoke the higher your risk. Therefore, we tried to see whether 8 we could produce cigarettes that eventually could reduce the 9 risk to a minimum level, the less hazardous cigarette. I'm 10 sure you have heard about it before. 11 The program was started in 1968 and I'm happy to say that 12 we have reached a very definitive goal at this particular time. 13 We can produce cigarettes that essentially are made of hot air. 14 Senator Humphrey. That's strong political competition. 15 Dr. Gori. It's difficult to make them less hazardous than 16 that, but people won't smoke them. So we have tried to introdu~ e some flavor into these cigarettes so they would become palatabl4 ~ 17 18 to the smoker without increasing the carcinogenicity. The ` evidence is that this can be-done. The industry has come out 19 i with new types of-cigarettes which, in my opinion, with smoking 20.1 ~~ moderation, would not increase the risk of the smoker over that of the non-smoker appreciably. 22, There is not such thing as a safe cigarette. All cigarett will always have a degree of hazard. However, we have enough evidence to say that certain cigarettes if smoked in moderation Qven thqugh we know they,are going to produce some risk, are no s TIMN 211072

246 1 2 3 4 5 6 7 8 9 10 11 15 I going to produce such a risk that it's going to be shown demonstrably in the general population. Senator Humphrey. In other words, they are safer than others? Dr. Gori. Well, they are much less hazardous than others. Senator Humphrey. Now the cigarette industry has done a great deal about this itself. I mean, they run full page ads day after day about amounts of tar in this cigarette and they have a new kind coming out every week. They've evengot one e called "More" coming out which indicates there's more to come. What I'm pointing out here is that the cigarette industry, because of this pressure from the surgeon general and from the ,research, has tried to get to the public with what is a less hazardous cigarette. What about the food industry. Do you think this will have `S the same effect?' As there's exposure of certain types of !7 chemicals, certain types of foods that are less conducive to j health and more conducive to health hazard, that you will be ' finding the food industry advertising, for example, that this " product contains less sugar? I noticed Pillsbury just put out ~ a drink product and they've cut in half the sugar and instead of talking about or ignoring the sugar content today it's half , . ~ the sugar that they're talking about. Could we expect more of this? Dr. Gori. Yes. I don't believe there is any industry in I TIMN 211073

247 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 the United States that would like to kill its customers. All of them have an interest in keeping them alive and well. This is true for the cigarette industry as well. I'm sure that given th opportunity they would prefer to sell cigarettes that don't harm the public rather than vice versa. It's very true of the food industry I'm sure. There would be a different approach with the food industry than we-have with cigarettes. Cigarettes have something we can do without eventually and for which you can become even missionary or zealous. Food is a different story. Food is a must. Senator Humphrey. Now getting back to what I talked about yesterday, which is the thing that disturbs me, we can educate our,people to better nutritional standards. [Je can put it into a theoretical framework for a moment. Theoretically, we can train men and women to prepare food properly. We can produce the proper kinds of food providing they are home to produce it, providing they eat at home, providing there are a lot of other I 17 181 rthings. But many of the people, most everybody you're going to 1911 !see on Capital Hill doesn't get home for lunch and I watch them coming in here in the Senate and they pick up a cardboard box 11 and some coffee in a carton and a couple of rolls that would ., sicken a dreadnought, and that's their breakfast. I protest tha :1. !in my office. I tell them they ought to eat at home. I don't t~ . s 4,113nt them to eat on my time. I believe people ought to eat '11 bofore they get to work. t TIMN 211074

248 What do we do about this? Here you are, men of the medical 2 3 4 5 6 7 8 9 10 11 12 13 14 15 161 profession. We obviously know you're deeply concerned and interested.and you're doing marvelous research. Let's presume that if we had a life style where you could sort of like they used to have 50 or 70 years ago, where you were close to home a where mother was fixing the bread and you sort of had your own smoke house out there and all that kind of stuff. I don't know whether it was all that healthy or not, but it sounds good. Heretoday, people are on the run. It's cafes. It's,cafeterias. It's take-out food, and particularly more and more it's, the frozen food items that theyy go into anysupermarket and purchase. Now what can we do to improve those standards? What can we do not only to see whether or not there's rodents in the kitchen. I noticed one of the largest hotels in Washington, this morning was served notice that their kitchen was contamina by vermin and rats and mice. We have survived those problems 17~Ifor a long time. What do you do to see to it that the meal tha 'B'you buy or the prepared food that you purchase has some nutri- tional tional standards to it? We're dealing with the practical probl :'' of people and their food'habits. Jlr. Gori. You have to consider the problem in its global . terms. Senator HUmphrey. Let's kind of consider it at home for ' " wtiile, in the United States. Dr. Gori. At home you willl have to address the people tha r TIMN 211075 '

249 1 are not at home, the children on one side, and you mentioned 2 how sensitive children are to good advice and even to the 3 political implications in getting mothers and fathers to the 4 corner of -- I don't remember what street it was yesterday that 5 you mentioned in Minneapolis -- 6 Senator Humphrey. 7th and Nicholas. 7 Dr. Gori. So you want to have to consider the children 8 and Dr. Wynder had an approach this morning that he had indicatq d . 9 this health passport, and this kind of personal involvement the 10 children would have. Of course, they become the adult generati4 n 11 of 50 years from now and something has to be done for the 12 adults alive today, so you have to educate adults as well, whic 13 is the most difficult thing. ~ 14 i I believe yesterday you said some of us are lost; there's z i ~ 15 S 16 othing that can be done about it. Something can b"e done about it either by direct education or by indirectly providing them 17 ~ with some management aspects -- management situations whereby 18 ~ their choices are modified. Again, I say I realize we have 4 ,.i not tamper with the freedom of choice of the individuals and give them some opportunities available. On the other hand, one may consider that the choices we think we make often are deter- nined'by what we see on television and what we get through the school. So the free system may not be as,free as it looks on the surfact at least. Therefore, we need here to persuade those that make up i TIMN 211076 °

250 1 public opinion to accept a particular policy rather than anothe r. 2 I don't know that home food is all that good necessarily versus 3 4 institutional food. I believe that strides can be made on the 5 home front, but probably we could even make better strides in 6 terms of changing the food and nutritional habits of institu- 7 tionalized food, cafeterias, etc., s.tarting with the Senate 8 perhaps. 9 I'd like to leave some time for other comments by my 10 colleagues. 11 Dr. Wynder. I think preventive medicine, Senator, like 12 politics, is the art of the possible and we need to recognize 13 that we have certain restraints in this country that even 14 though we may well be right, we will'not succeed. In 1950 15 when I first went with our cancer data to Dr. Green as a 16 medical student, he said, now that you have found the truth, 17 you have taken the first step; and I didn't realize how long 18 it would be until we convinced this country that smoking is 19 injurious to our health. 20 Interestingly enough, the tobacco industry, because of 21 public pressure and because of laws that were passed on tar anq 22 nicotine levels, then took up the ball to produce products 23 which are significantly less harmful than they were 25 years 24 ago. When it began there was an average of 40 milligrams of Inc. tar and 2.2 milligrams of nicotine and nobody then would have 25 predicted 25 years later we would have cigarettes on t.he markeq TIMN 21107'I

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 with between 5 and 10 milligrams of tar and between .6 and .8 milligrams of nicotine. So it can be done with the proper kind of incentives. In my view, having testified a number of times before congressional committees, it cannot be done with legislation against the industry, be it the tobacco or food industry. So,I think we ought to suggest the proper incentives for the food industry in this area of managerial preventive medicine because the greatest progress has not been made with what we,can do for the individual because we all believe it's not going to happen to me. So managerial preventive medicine means to prepare the kid of foods that are proper for our sedentary way of living. The meat, industry oug It to consider whether grass feeding does not have a nutrition and an important economic influence over corn feeding, with all the corn we save there we could feed a lot of people, and I don't have to tell you and all of you know Ithat grass fed beef is significantly lower in fat content than 1$1 corn fed beef. f 19 ~~ In the case of milk, you ought to ask yourselves at what 70 ,I certain levels the fat content of milk ought to be. There are ? t = some that say the upper level should be 2.5 percent. This is I .y e . "+ay well accept. Milk is very nutritious but not with fat in ;~. w f it. the type of legislative proposal that I think the milk industry :I Now we come to the eggs. Eggs have a problem and perhaps TIMN 211078

252 1 2 3 4 5 6 7 . 8 9 10 11 12 13 14 15 16 17 18 ,9 as our good friend, Jerry Stamler, says, eggs are really only used.to lay chickens; but eggs are a very important part of our breakfast and only recently I have given up eggs and you get up in the morning and want to eat eggs and you want to eat baco and you wonder what you can eat. My suggestion to the egg industry is the egg industry ough to see if they can reduce the chioresterol content. These are some of the suggestions that we have and I think the 1lmerica industry is the most ingenuous industry of all and if you give tem the right kind of incentives they can produce the kind of fodd that is both nutritionally good tasting and commensurate with the way we can metabolize it. Senator Humphrey,. My time is up. Dr. Hegsted. I'd just comment that we have one example of modified margarine which is aimed specifically at the kind of problem we're talking about, and I think also we should be sure that the thing we are trying to do is correct. We really don't have very good evidence that eating these kinds of food is nutritionally bad. Obviously, I think before you came in, :~ Senator, we were talking about the need for some kind of a :' surveillance program, what our problems are. I think the tough ': Part'in all this, as I see it, is the food demand in the United I Ratates is essentially fixed by the population. If you eat more i something you're going to eat less of something else, and I "4think under those conditions somebody.wins and somebbaylYoses, ~ n TIMN 211079

L`JJ I 2 I but the health of the population has to be the primary directive of what does happen. 3 Senator McGovern. Senator Percy. 4 Senator Percy. Mr. Chairman, I'd like to ask Dr. Kritchevs Ky 5 and Dr. u7o.gan if they could comment on whether or not it is 6 possible to get any hard figures or facts as to what would be 7 the percentage of cancer,that could be prevented by dietary 8 changes. We haven't had those figures this morning. 9 Let me just ask, if you could respond to the figures given 10 by Dr. Marvin Schinderman of the National Cancer Institute. He 11 said that 30 percent of cancer deaths cold be prevented; that 12 30 percent of -- that diet changes alone could save about 15,000 13 lives a year. He mentioned as an example, 5,000 breast cancer 14 deaths, one out of every six could be prevented if American 15 women ate less animal fats, increased consumption of roughage 16 could cut the cancer death total by one-third, from 30,000 to 17 1) 20,000. Would you care to comment whether those figures he's given are in the ballpark? Dr. Wogan. Well, in my opinion, they are in fact minimum figures. They represent the two incidences in w.hich the corre- I 't:lations are best established with breast cancer and fat, so my , ,.. ~ ,~. be that substantially more would in fact be pre- ~!ventable by diet if ':own guess would { we knew what specific recommendations to mak Dr. Kritchevsky. I'd like to say that Dr. Wogan's la,st words really put the hook on it, if we knew which recommenda la . Itior. TIMN 211080

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 to make. The suggestions that are being made are based on epi- demiological studies that we know the diet doesn't cause the cancer; it seems to promote them. Hopefully, removal of that promoting cause will then prevent cancer totally, but we really have no data on that. On the basis of what we know, we have to follow the prudent diet. We can't wait until all the returns are in because then the electorate may be dead. Senator Percy. I'd like to say I struggle(? with the same moral issue. What is our moral obligation as legislators? Wha do we have as a body of fact? I tend to think it's going to be fcrer\ hard to legislate in this area. I'm not a smoker but a person can look at all of•the various factors that cause cancer and sa well, now I'm willing to suppress five of these factors and observe them rigidly and carefully, but over'here in the cigarettes I just -- a fairly strong cigarette is what they wan and they are not harming anyone else. If we start to legislat 17 for everythigg that everybody can do to injure themselves, it-'9 18 ~just be unbelievable the areas we'd get into, but I think edu- 19'~ ,cation and knowledge and understanding, so at least if we injure I : ourselves we know we're injuring ourselves, and take it into 2t account -- and we've got information available as to how we can reduce the incidence by other means. That is our best hope I :1 i ithink and I just don't think,we're wise enough to know'how to .~ - „~Iegislate in this field. But together with industry and the .; 1?eJical profession, I hope legislators can provide the public TIMN 211081

0 k 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 forum that we are in, by the very questions that you havc-- Dr. Wynder. I would just like to take you up on this thin_ that if we would all die free of disease we would certainly hel the economy of our country. If we would prevent disease we would certainly reduce the health care costs to our nation. We are now up to $118 billion a year, a fair portion of all of our salaries. It seems to me that legislators have to be concerned about the economics of prevention because we do not live in an island to ourselves. If I'm sick due to my own hands, I injure my family, I injure my co-workers. In fact, unnecessary ilines injures my countrymen. So you have to consider the economics of health insurance and some day we are going to have national health insurance -- we'd better take stock with these elements. Now I'm not for prohibiting anything, but I am a great believer in informing the people. I'm a great believer in providing the proper incentives to individuals to have a good health habit and I am,a great believer in providing politically doable incentives to industry to provide us an environment and provide us.products that are as healthy as possible. Senator Percy. This is one area that I think we can legis 2? late. Certainly we can prevent the dumping into Lake Superior ,e- and Lake Michigan of chemicals, certainly if it's a known poiso' rnd it's going to be found in fish, but the environment is anot area that I tend to think we can really go to work on because t ..~.,._~,_._..~.,.~ 0 er ese TIMN 211082

256 are factors that simply everybody is exposed to. 1 2 3 4 5 6 7 8 9 10 !1 12 13 Senator Humphrey. I'd like to ask a question. On the basis of legislation, which I tend to agree with you on, you do 't want to apply that; however, to other products? Some products' that only injure the individual at least directly -- heroine and cocaine -- we do legislate against products like that. The are primarily injurious at first to the individual and subse- quently to society. Senator Percy. That's true, but I would simply say that I m not about to co-sponsor any bill somebody puts in legislating h w much sugar can go into a product. I think there are other area of higher priority than that and we have a lot better chance at and one that Dr. Wogan mentioned*was that the exposure to industrial chemical accounts for not more than five percent of all cancers. I'd like to have that clarified because the Council on ~ Environmental Quality concluded in its sixth annual report that I exposure to cancer causing substances on the job was the bigges : environmental threat•to Americans. Dr. Samuel Epstein of Case S~estern University told the Environmental Council this January ~ that the majority of 365,000 cancer cases reported last year uere traceable to environmental sources and could be prevented if federal regulatory agencies such as EPA would crack down on inclustrial polluters. Now would you care to reconcile the two conflicting pieces TIMN 211083

1 2 3 4 5 6 7 8 9 10 11 12 13 14 of testimony we have there? Dr. Wogan. I don't think I can reconcile them. I•think the clearly established relationships between occupational exposure and proportion of total cancers in the working popula- tion is in the range that I mentioned. The highest estimate that I have heard or seen is on the order of 8 percent. This does not mean, however, that this hazard should be minimized by any means. It is in fact one which is perhaps more amenable to control than any other single type of exposure. The other factor -- and I would like to emphasize this -- this refers only to those cancers which are initiated by exposur~ to the workplace. This does not, however, include whatever othe cancers may result from wider dissemination of the carcinogens into the general environment and there are in fact several lines ~ 15 ~ 1 16 ~ 17 ~ , of evidence that suggest that in some instances, at least the occupationally related cancer,gives a clue as to what carcinogeno may in fact be getting distributed to, for example, the families ' Senator Percy. I have just one last question and then ~ '13 A :Senator Bellmon can ask his questions. 19, 18 ~I of workers. fl For the average person when they face this dilemma now, 0 ., " uhat do we do about it? Taking into account Dr. Cooper's testi- ); : '" +At,out heart transplants than basic nutrition, where does the ~ . t1 :41 4verc1ge person go? Do they go to their physician for nutrition !"Any Yesterday that medical school graduates today know more TIMN 211084

25 £i I 2 3 4 5 6 7 10 il 12 13 counseling or should they go to a dietitian or a nutritionist or do you recommend a book or just reread all the testimony given today? What does the average person do about this problem? D..Rritchevsky. Right now it would appear that the best source would be the evidence given today because there is no central place. Nutrition is something that everybody considers himself an expert on. People who write books with particularly 8 9 appealing titles get a lot of readership when the book may not always contain everything that has to be known. I think the best approach -- and it's going to be a long one -- is the one Dr. Wynder has started. I agree with you. I don't think you ca legislate the amount of anything you can put into the food, but if you educate people into reading the labels on the food and 14 flthey don't buy the food which they figure is bad, the industry 15; ;Iwakes up to what they should be making. F 16iI li Senator McGovern asked about cereals. If you went to ; . 17 v t .I f 9 says, if you read the side panel, a lot of these high fiber breakfast cereals, regardless of what the front of the package cereals -- the first ingredient is the sugar, because the idea is that you can't get the taste people want without the sugar. Dr. Wynder. Currently we are involved in a study of coronary disease. We are learning from that that a very importa :component in health behavior modification is so-called allied ~'~~alth professionals. I believe we, as physicians, are trained 1 to do largely therapeutic medicine and economic incentives can n it TIMN 211085

259 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 w only be given in the area of therapeutic medicine. If I had my way, I would like to divide medical care into therapeutic care and the preventive care. Starting in early childhood, we have plenty of nutritionists, sociologists and educationists and peo~ with general education who are modestly trained to deal with young people, older people in the area of nutrition and other health related problems. And so I recommend that we provide some kind of new health school of allied health professionals that are regulated by national regulations rather than by state regulations, and that will take charge of these preventive care programs. Hypertension could significantly be reduced by such allied health professionals working in all states and under physician regulations they could conduct even the monitoring of the therapy. So I think if we want to do better in preventive care, we've got to have the proper incentives and I think it's best done by allied health professionals rather than the current medical establishment. Senator Percy. Thank you very much. And, Mr. Chairman, I'd like to thanYk our panel very much today for 'an extraordinar' 'I interesting and informative morning. .2 Dr. Hegsted. I'd like to comment on what Ernst said. I 'l,think we misunderstand when we blame the physician for his lack ~;af knowledge in nutrition. The main problem is that the physic~ ~I MI '7~hds had no way to apply nutrition and because he doesn't have le ly an TIMN 211086

L0 U 1 any way to apply it he doesn't learn it. 2 I believe, like Dr. Wynder has r., ici, the PhyS ici.*1n ouqht ,3 to be able to make a diagno ,is and a prescri pt ic~n in dietary 4 terms, but you need some group to fill that proscription in 5 terms of telling the person how to chan(le his diet, specif.icall 6 in terms of cooking products and so o n. 7 That will never come from the ph ysician. I thi nk in terms 8 of getting nutrition into medical edu cation, it's go ing to take 9 some special legislat ion. The mecIica l schools can b e bought, 10 but they can't do it any other way. 11 Senator McGovern . Senator }3ellmon. 12 Senator Bellmon. I'll try to be very brief, Mr . Chairman. 13 We have had some talk this morning about additives in 14 foods. I'm a grain farmer, wheat grower, and something trouble 15 me and that's the subtractive processes that our manufacturers 16 go throuah. It seems like everything that the millers or baker 17 do to my grain makes it cost more and make s it worth less as 18 far as it s nutritional value is concerned. They take out the 19 germ Whic h has the protein and vitamins an d some of the 20 minerals in it and they take out the bran which is where the 21 fiber is, and all it leaves is the starch and then they put in 22,1 1 preservatives which are sort of low-level poisons and mak e it ?3 I i ~ the bacteria and insects won't eat it and feed it to the people and raise the price by a factor of about ten. My question is, is there any way we can legislate in this . TIMN 211087

261 1 area? Do we need some law that manufacturers cannot diminish 2 the natural nutritive value of food? 3 Dr. Kritchevsky. You'd have to have a set of data on 4 what the nutrient value is. I think Dr. Gori already touched 5 on that. We need a much better evaluation of that. 6 You know, the reverse is true in Italy. It's illegal to 7 make whole wheat products. 8 Senator Bellmon. I didn't know that. Is there some 9 sound basis? ~ 10 Dr. Kritchevsky. The basis goes back four or five hundre t 11 years, that a lot of the insects were in the outer husk and 12 the way to make sure nobody put it in the bread was to make it 13 illegal. There are concerns in Italy trying to make•whole 14 wheat bread and it's being confiscated. 15 Senator Bellmon. But is your conclusion, then, that 16 there's no legislative remedy-for`this problem? I believe Dr. 17 Hegsted just mentioned that we might need legislation requirin 18 nutritional education in our educational system. 19 Dr. Hegsted. I don't think one can do more than establis: ~ food standards for specific products. Senator Bellmon. We could establish a food standard by legislation... :I Dr. Hegsted. You couldn't do that. Well, yes. That's what Food and Drug Administration does. You will never get away with it if you want to prohibit white flour products. I'm TIMN 211088 *

LVL I t 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 sure of that. I don't see any -- if the desirability or lack of desirability depends on what they are eaten with, it makes it very difficult to deal with specific foods individually because you can't blame anything particularly on a specific food. We have to deal with the diet. That's what makes this whole problem so difficult and why we can hardly respond to your question of what's the significance of white flour versus whole wheat flour in the diet. Senator Bellmon. Well, I realize the difficulty of legislating in the area, but it seems that if the information you have given us this morning -- I believe it was Dr. Wynder who pointed out there are 90,000 cancer cases a year due to ~ cigarettes, 138,000 cancer cases in males and 230,000 cases in females due to diet, and this would seem, even though Senator Percy feels perhaps these people don't hurt anybody else, they do cause a tremendous cost to the Treasury just through Medicare and Medicaid in treating these kind of diseases. It seems we have a legitimate reason to be concerned and I don't like to . ~ think that we are helpless. ~ 201, 1tr. Gori. I believe that many of the things we have said 111 , this morning would require some changes. Nobody likes to change .~ 21%particularly when we come to food. We have engrained traditions 13iI said that this morning. That may be difficult to change. 14`Industry is'no different than anybody else. They don't like to ~. ~. :SCchange either, and one may expect some difficulties in trying 11 f TIMN 211089

263 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 to impose a new food policy on the public. You'd have again, say, the economics of fats which I mentioned this morning. It's easier to produce a pound of fat than it is to produce a pound of meat or protein. Also, the business of milk,-milk is very nutritious; however, it is very probable that the content of fat in milk today is excessive. For years we have bred cows to produce the highest fat content because that seemed to be the thing to do. Senator Bellmon. That's not the case any longer. I1olstein's are the most popular breed and they are low fat producers. Dr. Gori. That might be the right direction then. We hav this problem here we would face to try to.reduce the fat conten and the chloresterol in the eggs. Perhaps we can breed hens th may produce low chloresterol eggs or we could process the eggs in such a way that we could remove the chloresterol. This is conceivable. There are possible ways to do this today. Then•you have the problem of calories, the starch, the sugar in particular. The sugar is going to be a major problem 191 I due to the amountof sugar in the world today. There, one may 20 1' ~ think of a number of incentives that can be given, not the' I fuel, and they can find an outlet for this particular industry. Then, of course, the economics, aesthetics and the economicis 11 1 'least, the possibility of transferring sugar into fuel. It's very feasible that this could be done and it could be used for }, of taste, which are the economics of the advertising industry TIMN 211090

264 + t 1 2 3 4 5 ' 6 7 8 9 10 11 12 13 14 15 16 all these would need to l,r t$••., ! c! t lc~ul t tn come u with the specifics here, c,.~rt.ic-ui.,r 1: i• f,~;• t.lir0 spccifi for some' legislation, but in T; t•, pos,ible th~ a cooperative effort hern whr.rv!r•; c,r nn;-;r% rtroup collec the information availahlo anri mat ,••: c t •,•:a: i nforms -- the education process with tlci!c ir,:circ .,r zr n, 1 s~• :~ cit.:. this info mation to the industry anc3 to the, crm•:ur•f•r an•l inVo1voS them -- I think this is conducive to thosr• nc,<1 i f i i -sis thrl t we have advocated today. Senator Belimon. well, now, I have a rlnrtrcre in aqricultur and during the•years I was in school I wa, rocluired to take many courses in nutrition. I'm arivi ,eci th~it at the University of Oklahoma Medical School that the only nutrition courses that are offered are elective. Is this cqenr.r.31 lv tre ue tnroughout medical training? Do doctors not qet training in nutrition as a part of their formal education? 17 Dr. Wynder. That's more or less true. Even in the great 18 school of my colleague on my left, who has an excellent depart- 19i ment of nutrition, but to what extent they have-an impact on th ?fl1 students is another question. i i ?1 ,; Senator Bellmon. Well, are those courses elective? Are ~2 students not required to take courses in nutrition? Dr. llegsted. I suspect certainlyy in 95 or 98 percent of ~s ttie medical schools the nutrition courses will be elective. :s ~ i Senator Bellmon. Now here's an area, it would seem to me, s t 5 TIMN 211091

265 ! I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 like we could legitimately legislate in. most medical schools get a pretty good slice of federal funds and most of them want more. Dr. liegsted. I cannot really recommend that, but I'd like some encouragement. Dr. Wynder. Senator, you need to recognize the weakness of man himself. Senator Bellmon. You don't have to specialize in nutritio but at least you ought to have a speaking acquaintance with it. Dr. Wynder. Then you need to apply it to be a surgeon, and there's no question if our great heart transplant surgeons speak here they get a great deal of attention, and preventive medicine always has a problem. •I once testified before a committee and the congressman said, "Look, Doctor, where you sit last week some people were sitting with kidney disease and they pleaded for some more money for kidney dialysis disease and they had 250 letters. flow many letters do you have?" I didn't have any letter because preventive medicine will always be not as attractive as curative medicine. We need to recog- nize that. Therefore, what I said before, to try to train and have very expensive training in medicine toward health education is probably not the way we should go, but to take allied health professionals that feel challenged by nutrition, that feel challenged by health behavior modification -- I think that's I TIMN 211092

I 1 2 3 4 5 6 7 8 9 10 11 12 13 14' 15 16 17 18 19 20 21 22 23 where we ought to legislate. Dr. Kritchevsky. I think it should he noted where these elective courses in nutrition are offered, they are becoming increasinly popular. I think the administration of a lot of medical schools is behind the interest of the students. More an more -- at. Cornell, for instance, a few years ago they had an open elective nutrition course which had to be given at night because they didn't have a room big enough to seat all of the students. Senator Bellmon. I was very much impressed bytlr. Wynder' health passport for children. Is this a one-time program? Do you prepare a health passport once and is that the end of it? Dr. Wynder. No. My hope is that within this decade the Congress will legislate this type of health maintenance strategy for all the children in our country. We were funded to do a specific study to determine whether the use of the health passpo concept could indeed reduce risk factors in children. Currently there are 3,000 children in this program in Westchester County, New York, and what we hope, over a three-year period, is to show whether by'this type of effort we reduce the risk factors in our children. And if we do, and I think we shall -- if we do it, then we hope to come back and say to you that this ought to be a national program. Senator Bellmon. As I understood from your testimony, you simply analyze the current condition of the child or diagnose it ; TIMN 211093

I 2 3 4 5 '6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Do you do further and recommend dietary cl<an(lor.? Dr. Wynder. Absolutely. To tho 5e chil(iron that Il,zve elevated chloresterol -- we deal with the children. tro obviousl deal with the parents also because there's a hirTh correltion between the chloresterol level of children and parnnts because after all we tend to eat together. Then we have a very excellen rapport with the teachers. So we built into tlie school curri-it - culum how nutrition can affect each child's health. Then we havr peer committees within these children and in one school these children formed a peer group and marched on the cafeteria -- what Senator Humphrey said applies to the Senate cafeteria -- they said we don't like this kind of food and we want different kind of food. So we have a total commitment from the children and the parents and the teachers to affect risk factors in our study schools. Senator Bellmon. I haven't heard any one of the doctors on the panel this morning mention junk foods. Maybe that's not a specific term, but potato chips and popcorn and so on, carbonated beverages. We spend a lot of money for food stamp programs and school lunch programs and a lot of times it seems that the coke machines get more attention than the school cafeterias at lunch time. Dr. fiegsted. I think with regard to the food stamp progra we need some information -- I commented on that before -- we ~. „ C ?s1:need information on what has ha ppened. What do they eat? liave ~ . TIMN 211094 ..UQ

268 t I 2 4 5 6 7 8 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 I think the junk foods have taken, I woulcl n.ly, an exeessile we changed the food habits and nutritional s;t~ltu . with tlie food stamp program?• beating relative to their nutritional value or lack of it. Senator Bellmon. Most of them are hiqh in oil anci starche Dr. Hegsted. Many of them are, but it clenrncls on how much you eat and we tend to think that that's a bad way to cat. Ptost of us who are older think that is not the way people should eat but that's the way they do eat and I think we have to be open- minded about,it and look at it in terms of what we know and what we don't know. Senator Bellmon.. So you wouldn't, as a panel, condemn these'~kind of foods? Dr. Hegsted. I'm old enough to condemn them somewhat, but I think.much of the information does not have a good nutritiona basis. Dr. Kritchevsky. It's a matter also of total calories. Again, you can educate people to take their calories from what we consider a more acceptable form and it might be easier, but , for a lot of people these are all the calories•they get or most of the calories.they get. There's been a study done recently on fast-food hamburgers and they find one of those meals provides a respectable amount of the daily requirements o both the necessary nutrients and vital nutrients. Senator Bellmon. That's'all I have. TIMN 211095