[Senate Hearing 108-989]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 108-989
 

                             OBESITY WAR:
                   ARE OUR DIETARY GUIDELINES LOSING

=======================================================================

                                HEARING

                               before the

                         COMMITTEE ON COMMERCE,
                      SCIENCE, AND TRANSPORTATION
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 30, 2003

                               __________

    Printed for the use of the Committee on Commerce, Science, and
                             Transportation

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        SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                     JOHN McCAIN, Arizona, Chairman
TED STEVENS, Alaska                  ERNEST F. HOLLINGS, South
CONRAD BURNS, Montana                    Carolina, Ranking
TRENT LOTT, Mississippi              DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas          JOHN D. ROCKEFELLER IV, West
OLYMPIA J. SNOWE, Maine                  Virginia
SAM BROWNBACK, Kansas                JOHN F. KERRY, Massachusetts
GORDON H. SMITH, Oregon              JOHN B. BREAUX, Louisiana
PETER G. FITZGERALD, Illinois        BYRON L. DORGAN, North Dakota
JOHN ENSIGN, Nevada                  RON WYDEN, Oregon
GEORGE ALLEN, Virginia               BARBARA BOXER, California
JOHN E. SUNUNU, New Hampshire        BILL NELSON, Florida
                                     MARIA CANTWELL, Washington
                                     FRANK R. LAUTENBERG, New Jersey
      Jeanne Bumpus, Republican Staff Director and General Counsel
             Robert W. Chamberlin, Republican Chief Counsel
      Kevin D. Kayes, Democratic Staff Director and Chief Counsel
                Gregg Elias, Democratic General Counsel
                                 ------

          SUBCOMMITTEE ON CONSUMER AFFAIRS AND PRODUCT SAFETY

                PETER G. FITZGERALD, Illinois, Chairman
CONRAD BURNS, Montana                RON WYDEN, Oregon, Ranking
GORDON H. SMITH, Oregon              BYRON L. DORGAN, North Dakota


                            C O N T E N T S

                              ----------
                                                                   Page
Hearing held on September 30, 2003...............................     1
Statement of Senator Fitzgerald..................................     1

                               Witnesses

Graham, Ph.D., John D., Administrator, Office of Information and
  Regulatory Affairs, Office of Management and Budget, Executive
  Office of the President of the United States...................    14
    Prepared statement...........................................    16
Hentges, Dr. Eric, Executive Director, Center for Nutrition
  Policy and Promotion, Food, Nutrition, and Consumer Services,
  U.S. Department of Agriculture.................................     4
    Prepared statement...........................................     5
Jacobson, Ph.D., Michael F., Executive Director, Center for
  Science in the Public Interest.................................    23
    Prepared statement...........................................    25
Lawrence, Ph.D., Arthur, Acting Principal Deputy Assistant
  Secretary for Health, U.S. Department of Health and Human
  Services.......................................................     8
    Prepared statement...........................................    11
Ornish, M.D., Dean, Founder and President, Preventive Medicine
  Research Institute, Clinical Professor of Medicine, University
  of California, San Francisco...................................    27
    Prepared statement...........................................    31
Specter, Hon. Arlen, U.S. Senator from Pennsylvania..............    26
Trager, MD, Stuart, Atkins Nutritionals, Inc.....................    42
    Prepared statement...........................................    44
Willett, MD, Dr.P.H., Walter C., Fredrick John Stare Professor of
  Epidemiology and Nutrition, Departments of Nutrition and
  Epidemiology, Harvard School of Public Health..................    39
    Prepared statement...........................................    41

                                Appendix

Letter dated September 30, 2003 to Hon. Peter Fitzgerald from
  Marianne SMith edge, MS, RD, LD, FADA, President, American
  Dietetic Association...........................................    61
State of Connecticut Department of Social Services, prepared
  statement......................................................    62

 
                             OBESITY WAR:
                   ARE OUR DIETARY GUIDELINES LOSING

                              ----------


                      TUESDAY, SEPTEMBER 30, 2003

                               U.S. Senate,
      Subcommittee on Consumer Affairs and Product
                                            Safety,
        Committee on Commerce, Science, and Transportation,
                                                    Washington, DC.
    The Subcommitte met, pursuant to notice, at 2:30 p.m. in
room 253 of the Russell Senate Office Building, Hon. Peter G.
Fitzgerald, Chairman of the Subcommitte, presiding.

        OPENING STATEMENT OF HON. PETER G. FITZGERALD,
                   U.S. SENATOR FROM ILLINOIS

    Senator Fitzgerald. Good afternoon. I'd like to call this
meeting to order. And I'd like to thank our witnesses and our
guests for being here at this hearing on the Federal
Government's Dietary Guidelines for Americans.
    In the last two decades, there has been a dramatic surge in
the incidence of diabetes and obesity in the United States.
According to the Center for Disease Control, the number of
persons per million persons with diagnosed diabetes has gone
from 5.76 in 1980 to 12.01 in the year 2000.
    Similarly, in 1985, according to the CDC, in no state in
the union were more than 14 percent of the citizens obese, with
obesity being defined as a body mass index greater than or
equal to 30 or about 30 pounds overweight for a five foot four
inch person.
    But by 2001, in all states but Colorado, more than 15
percent of the citizens were obese. And in some of the states
now, the population is approaching over 25 percent obesity. In
fact, it's getting close to a third of the people in this
country being clinically obese.
    My own state of Illinois dramatically demonstrates this
disturbing trend. According to the CDC, in 1985, less than 10
percent of Illinois residents were obese. By 2001, between 20
and 24 percent of Illinois residents were obese.
    In all, close to one-third of Americans are now clinically
obese. And nearly 64 percent of all adults are overweight.
Moreover, twice as many children and three times as many
adolescents are overweight as was the case in 1980 which,
incidentally, was the year the Government first published the
Dietary Guidelines for Americans.
    The toll diabetes and obesity are taking on America is
enormous. Obesity is now responsible for over 300,000 deaths a
year. Diabetes causes serious life-threatening conditions and
painful lifestyle adjustments for those who suffer from it and
for their families.
    We spend tens of billions a year treating complications
from diabetes and obesity, and billions more on research. And
yet the trends are all going in the wrong direction. We are
losing the battle of the bulge.
    In 1992, the USDA first promulgated its now famous Food
Guide Pyramid. The pyramid strongly encouraged Americans to
load up on foods which are high in carbohydrates and high on
the glycemic index, foods such as breads, cereals, rice and
pasta.
    At the same time, the food pyramid discouraged Americans
from consuming high protein foods that are low in carbohydrates
and low on the glycemic index, foods such as meats, fish, nuts
and dairy products.
    The purported rationale at the time was to try to get
Americans to cut down on their consumption of dietary fats in
order to lessen the incidence of heart disease and obesity.
Since that time, and taking their cue from the USDA's dietary
advice that carbs are good and fats are bad, millions of
Americans have gone on low-fat diets. And grocery manufacturers
have responded by introducing numerous varieties of fat-free or
low-fat foods.
    In order to make the foods taste good, many of the
processors have added starches and sugars to their low-fat or
no-fat products. The result has been that Americans are now
eating less fat but more carbohydrates and starches. And as
indicated at the outset, Americans are now getting fatter,
faster, and at younger ages than ever before.
    In recent months, reams of new evidence have begun to pour
in that Americans are facing a glycemic overload, and that
excessive carbohydrate intake is to blame. In May of this year,
the New England Journal of Medicine published two studies that
suggested that high protein, low carbohydrate diets lead to
more and quicker weight loss than low fat, high carbohydrate
diets.
    Although more research needs to be completed, there is no
evidence that the people in the studies who undertook the low
carbohydrate diets increased their risk factors for heart
disease.
    The witnesses we have called today will present a variety
of viewpoints. One is an advocate of a low carbohydrate diet.
Another is an advocate of a low fat diet. Another will argue
sort of a middle ground and suggest that some fats are healthy
and others are not, and that some carbohydrates are healthy,
and others are not.
    To a certain extent, all will agree that the current food
pyramid could be made much better. There seems to be general
agreement that the food pyramid's simplistic message that carbs
are good and fats are bad is troublesome and misleading.
    The Federal Government revises its Dietary Guidelines for
Americans every 5 years. Now, as an Advisory Committee is
meeting to make recommendations for the 2005 revisions, we have
an obligation to ask a painful but obvious question. Is there a
link between our ever expanding waistlines and the Government's
own Dietary Guidelines.
    My own view is that there is such a link. The USDA food
pyramid probably has more to do with diabetes and obesity than
Krispy Kremes. In fact, the pyramid's advice to load up with
six to eleven helpings of high carbohydrate foods a day does
more to promote the interest of grain and sugar producers than
to promote the good health of ordinary Americans.
    Moreover, while I respect the many hardworking public
servants in the USDA, I think it's the wrong agency to be
giving us dietary advice. The primary mission of the USDA is,
after all, to promote the sale of agricultural products. So
putting the USDA in charge of dietary advice is in some
respects like putting the fox in charge of the hen house.
    Under current practice, both the USDA and the Health and
Human Services Department have a role in developing the Dietary
Guidelines. The lead agency role in rewriting the Guidelines
now rotates between the two agencies.
    For example, USDA was the lead agency in rewriting the 2000
dietary guidelines. And currently HHS is serving as the lead
agency for the 2005 guidelines.
    As recommended by one of the witnesses on the second panel,
Dr. Willett, I believe that instead of the USDA and HHS jointly
writing the guidelines, the HHS should alone write them. In my
judgment, the HHS is less likely to be cozy with farm groups
and the food companies. And it has access to one of the world's
best sources of health research, the National Institutes of
Health.
    Accordingly, after this hearing, I plan to introduce
legislation that would remove the USDA as the General in our
war on obesity, and replace it with the HHS. While it's true
that special interests influence virtually all policies coming
out of Washington, in most cases the American public is cheated
only in economic terms.
    In the case of the Dietary Guidelines for Americans,
however, there is the potential that citizens could be cheated
out of advice that would protect their health and their lives.
In revising the Dietary Guidelines, therefore, we need to make
a special effort to ensure that unbiased science, not politics,
triumphs; and that consumers' interests prevail over private
economic interests.
    Nothing less than the health and well-being of all
Americans, young and old, is at stake. And with that, I'd like
to invite our first panel to come up to the witness table. And
I would like to introduce the witnesses from my left to my
right.
    First, we have Dr. Eric Hentges, Executive Director of the
Center for Nutrition Policy and Promotion, Food, Nutrition, and
Consumer Services at the U.S. Department of Agriculture; Dr.
Arthur Lawrence, Assistant Surgeon General and Acting Principal
Deputy Assistant for Health and Human Services; and Dr. John D.
Graham, Administrator, Executive Office of the President,
Office of Management and Budget.
    And I'd like to thank all of you for being here. We have
copies of all of your written statements, I believe. And we
would encourage you to the best you are able to, rather than
reading your opening statements, if you could summarize them in
a brief 5-minute or so opening remarks, and we will be happy to
include your full statements in the record. Dr. Hentges,
welcome.
    Dr. Hentges. Thank you. Thank you, Mr. Chairman.
    Senator Fitzgerald. If you could pull that microphone
closer to you. They are not very sensitive, so you have got to
have them right up to your mouth. Thank you.

 STATEMENT OF DR. ERIC HENTGES, EXECUTIVE DIRECTOR, CENTER FOR
 NUTRITION POLICY AND PROMOTION, FOOD, NUTRITION, AND CONSUMER
            SERVICES, U.S. DEPARTMENT OF AGRICULTURE

    Dr. Hentges. Thank you, Mr. Chairman. I am Eric Hentges.
And I am the Executive Director of the U.S. Department of
Agriculture's Center for Nutrition, Policy and Promotion. I'm
pleased to be here to describe the status of the process that
USDA and the Department of Health and Human Services have
jointly undertaken to review and publish the Dietary Guidelines
for Americans.
    It is of great importance to this administration to provide
current, accurate and consistent messages to the American
public on diet and nutrition. We are committed to improving the
health of Americans in fighting the growing obesity epidemic.
    The challenge of obesity did not occur overnight, and it
will not go away overnight. And we cannot solve it alone. To
this end, the President has launched his Healthier U.S.
initiative, which consists of four key strategies. Two of these
strategies are directly addressed by the Dietary Guidelines,
and that is eat a nutritious diet and be physically active
every day.
    The Dietary Guidelines serve multiple purposes. First and
foremost, though, they do form the basis for Federal nutrition
policy. They set standards for nutrition and food assistance
programs. They guide nutrition education programs. They provide
dietary advice to consumers. And also they serve as the vehicle
whereby Federal agencies speak with one voice on nutrition
issues for the health of Americans.
    The mandate to the Guidelines, as you've noted, is in the
National Nutrition Policy and Related Research Act of 1990. The
Act requires the Secretaries to jointly publish the Dietary
Guidelines for Americans at least every 5 years.
    The departments are modeling the 2005 Dietary Guidelines
development process after those used to prepare the previous
editions. The Secretaries chose to use the Federal Advisory
Committee Act process to establish the advisory panel.
    Regarding the Committee's selection, as in previous years,
the USDA and HHS announced its intention to establish the panel
through a Federal Register notice. This was on May 15 of this
year.
    The solicitations of nominees is an open, public process. A
13-member committee has been appointed to review the 2000
edition of the Guidelines and determine if revisions are
warranted. Members of the Committee are recognized experts in
their field, and collectively represent the scientific
knowledge, the current scientific knowledge, of nutrition and
health.
    Members reflect race, gender and geographic diversity. The
Committee's duties are solely advisory and time limited.
According to the charter that established the committees, their
duties are as follows: If the Committee decides that no changes
are necessary, the Committee will inform the Secretaries, and
this will terminate the Committee.
    If the Committee decides that changes are warranted based
on the preponderance of scientific and medical knowledge, the
Committee will determine what issues for change need to be
addressed.
    The focus of the Committee should be on the review of new
scientific evidence. The Committee shall make and submit its
technical recommendations and the rationale for these
recommendations in a report to the Secretaries. The Committee's
focus should be on these recommendations and the supporting
science rather than translating the recommendations into a
communications document.
    Upon the submittal of the Committee's recommendations, the
Dietary Guidelines Advisory Committee will be terminated. The
first meeting of this committee occurred on September 23 and 24
of this year. At the conclusion of that meeting, the members
unanimously decided to proceed with the comprehensive review of
the science in order to develop the recommendations.
    The Advisory Committee's expected to hold four public
meetings. All the meetings will be announced in the Federal
Register. And it will be open to the public. There will be
opportunity for both oral and written testimony to the
Committee, and the minutes of each meeting will be posted on
the internet.
    Once the Committee has completed its deliberations, the
Advisory Committee will submit its report to the Secretaries by
June 2004. The departments will independently review the
Committee's recommendation. Subsequent to that review, the two
departments will collaborate to publish the official 2005
Nutrition and Your Health: Dietary Guidelines for Americans.
    In conclusion, Mr. Chairman, I appreciate the Committee's
interest, your interest, in nutrition and its critical role in
an overall healthy lifestyle for Americans. This concludes my
comments. Thank you, sir.
    Senator Fitzgerald. Thank you. Dr. Lawrence.
    [The prepared statement of Dr. Hentges follows:]

  Prepared Statement of Eric Hentges, Executive Director, Center for
Nutrition Policy and Promotion, Food, Nutrition, and Consumer Services,
                     U.S. Department of Agriculture
    Thank you, Mr. Chairman. I am Eric Hentges, Executive Director of
the Center for Nutrition Policy and Promotion (CNPP) at the U.S.
Department of Agriculture (USDA). I am pleased to be here today to
describe the status of the process that USDA and the Department of
Health and Human Services (HHS) have jointly undertaken to review and
publish the Dietary Guidelines for Americans.
    Providing current, accurate, and consistent messages to the
American people on diet and nutrition is of great importance to this
Administration. We are committed to improving the health of Americans
and fighting the growing obesity epidemic. The challenge of obesity did
not appear overnight; it will not be solved overnight, and we cannot
solve it alone. But our responsibilities to promote the Nation's health
demand action now. To that end, the President launched his HealthierUS
initiative, which consists of four key strategies. The Dietary
Guidelines directly support two of them, specifically, eat a nutritious
diet and be physically active each day.
    The Dietary Guidelines provide the basis for Federal nutrition
policy. Specifically, the Guidelines provide advice for healthy
Americans, over the age of two, about food choices that promote health
and quality of life, as well as prevent disease. The Dietary Guidelines
serve multiple purposes: they form Federal nutrition policy; set
standards for food and nutrition assistance programs; guide nutrition
education programs; and provide dietary advice to consumers. They also
serve as the vehicle for the Federal government to speak with ``one
voice'' on nutrition issues for the health of the American public.
    The mandate for the Dietary Guidelines is the National Nutrition
Monitoring and Related Research Act of 1990 (7 U.S.C. 5341), which
requires the Secretaries of Agriculture and Health and Human Services
to jointly publish the Dietary Guidelines for Americans at least every
five years. The Guidelines must: (1) contain nutritional and dietary
information and guidelines for the general public; (2) be based on the
preponderance of current scientific and medical knowledge; and (3) be
promoted by each Federal agency in carrying out any Federal food,
nutrition, or health program. USDA and HHS issued the Dietary
Guidelines voluntarily in 1980, 1985, and 1990. The 1995 edition was
the first statutorily mandated report.
    The Departments are modeling the 2005 Dietary Guidelines
development process after those used to prepare the previous editions.
Following this precedent, the Secretaries chose to use the Federal
Advisory Committee Act (FACA) process to establish an advisory panel. A
13-member Dietary Guidelines Advisory Committee (DGAC) has been
appointed to review the 2000 edition of the Guidelines and recommend
if, on the basis of current scientific and medical knowledge, revisions
are warranted.
    Also as in previous years, USDA and HHS announced their intention
to establish the Advisory Committee in the Federal Register on May 15,
2003. This notice requested nominations from the public for Committee
membership. The solicitation of nominees was an open, public process.
The Advisory Committee members are recognized experts in their fields
and collectively represent the current scientific knowledge in
nutrition and health with expertise across a broad spectrum of
specialty areas. The membership reflects race, gender and geographic
diversity. The Secretaries of USDA and HHS jointly appointed the DGAC
members and chairperson. (Committee member list attached)
    The Committee's duties are solely advisory and time-limited.
According to the Charter that established this Committee, its duties
are as follows:

   If the Committee decides that no changes are necessary, the
        Committee will so inform the Secretaries of USDA and HHS. This
        action will terminate the DGAC.

   If the Committee advises that changes are warranted, based
        on the preponderance of the scientific and medical knowledge,
        the Committee will specify which issues for change need to be
        addressed.

   The focus of the Committee should be on the review of the
        new scientific evidence.

   The Committee shall make and submit its technical
        recommendations and the rationale for these recommendations in
        a report to the Secretaries. The Committee's focus should be
        its recommendations and the supporting science rather than
        translating the recommendations into a communication document.

   Upon the submittal of the Committee's recommendations, the
        DGAC will be terminated.

    The first meeting of the 2005 DGAC occurred on September 23-24,
2003. At the conclusion of the meeting, the members unanimously decided
to proceed with a comprehensive review of the science in order to
develop their recommendations.
    The 2005 DGAC is expected to hold three additional public meetings.
All meetings will be announced in the Federal Register and will be open
to the public. There will be an opportunity for oral and written
testimony to be provided to the Committee. Meeting minutes will be
posted on the Internet. Once it has completed its deliberations, the
Advisory Committee will submit its report to the Secretaries by June
2004. At that time the Departments will independently review the
Committee's recommendations for changes to the guidelines. Subsequent
to that review, the two Departments will collaborate to publish the
official 2005 Nutrition and Your Health: Dietary Guidelines for
Americans.
Conclusion
    Mr. Chairman, I appreciate this Committee's interest in nutrition
and its critical role in an overall healthy lifestyle for all
Americans. As we prepare to revise the Dietary Guidelines, we are
mindful of the critical contribution they make to life-long eating
habits and good health. But, the Federal government cannot do this job
alone. Meeting this challenge requires input from all of the
Guidelines' many stakeholders.
    This concludes my prepared remarks. I would be happy to answer any
questions you might have at this time.
                                 ______

                               Attachment
                 Dietary Guidelines Advisory Committee
    Lawrence J. Appel, M.D., M.P.H., Professor of Medicine, Johns
Hopkins University School of Medicine, Baltimore, MD. Dr. Appel is a
physician and clinical researcher who has conducted several studies on
the impact of nutrition and lifestyle modification on blood pressure
and cardiovascular risk. Currently, he serves on the Nutrition
Committee of the American Heart Association, and is currently serving
as Chair to the Institute of Medicine's study on electrolytes and
water.

    Yvonne Bronner, Sc.D., R.D., L.D., Professor and Director of MPH/
DrPH Program, Morgan State University, Baltimore, MD. Dr. Bronner has
more than 20 years of experience in research, training, and program
development in the areas of nutrition and maternal and child health.
She serves on numerous advisory committees such as the Institute of
Medicine's Food and Nutrition Board and the Department of Health and
Human Services Maternal and Child Health Review Panel.

    Benjamin Caballero, M.D., Ph.D., Director and Professor of the
Center for Human Nutrition and Division of Human Nutrition, Department
of International Health, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD. Dr. Caballero is an internationally recognized
expert in pediatric nutrition whose focus includes childhood obesity
and amino acid and protein metabolism. He has served on a number of
expert advisory panels, including the recent Institute of Medicine's
Panel on Dietary Reference Intakes on Macronutrients.

    Carlos Arturo Camargo, Jr., M.D., Dr.P.H., Assistant Professor of
Medicine, Harvard Medical School; Assistant Professor of Epidemiology,
Harvard School of Public Health, Boston, Massachusetts. For the past 17
years, Dr. Camargo has conducted research on the health effects of
moderate alcohol consumption, primarily the ``protective'' association
between moderate drinking and the risk of cardiovascular diseases. His
recent work has been based on several large epidemiologic cohorts,
including the Physicians' Health Study, the Nurses' Health Study, and
the Health Professionals' Follow-up Study.

    Fergus M. Clydesdale, Ph.D., Distinguished Professor of Food
Science and Head of the Department of Food Science, University of
Massachusetts, Amherst, Mass. Dr. Clydesdale's research interests
include physical-chemical changes in food during processing, mineral-
fiber interactions in foods, and technological optimization of
physiological and functional properties and color-sensory interactions
in foods. He has served on numerous committees, including the FDA Food
Advisory Committee and the Institute of Medicine's Food and Nutrition
Board.

    Vay Liang W. Go, M.D., Professor of Medicine, University of
California at Los Angeles (UCLA) School of Medicine. Dr. Go is an
international authority on the brain-gut connection in nutrition,
especially with regard to gut hormones. He is currently editor of the
journal Pancreas. He is the former director of Nutrition at the NIH's
National Institute of Diabetes, Digestive and Kidney Diseases, the
former Executive Chair of Medicine at UCLA, and a consultant to the
Food and Drug Administration in nutrition. Dr. Go has served as Core
Director at the UCLA Center for Dietary Supplements Research:
Botanicals, and as Associate Director of the UCLA Center for Human
Nutrition. Dr. Go continues to be the Associate Director of the NCI-
funded Clinical Nutrition Research Unit, located at the UCLA Center for
Human Nutrition.

    Janet C. King, Ph.D., R.D., Senior Scientist, Children's Hospital
Oakland Research Institute, Oakland, Calif., Professor Emerita,
Department of Nutritional Sciences and Toxicology, University of
California at Berkeley, Calif.; Adjunct Professor, Department of
Nutrition and the Department of Internal Medicine; University of
California at Davis, Calif. Dr. King has published extensively and is
internationally recognized for her research on energy and zinc
metabolism in healthy adults and pregnant women. Dr. King was chair of
the Food and Nutrition Board in 1994 when the paradigm for the new
Dietary Reference Intakes was established. She served as director of
the USDA Western Human Nutrition Research Center for eight years.

    Penny M. Kris-Etherton, Ph.D., R.D., Distinguished Professor of
Nutrition, Pennsylvania State University, University Park, Penn. Dr.
Kris-Etherton has expertise in the area of diet and coronary heart
disease risk factors, as well as nutritional regulation of lipoprotein
and cholesterol metabolism. She is a member of the Institute of
Medicine's Panel on Dietary Reference Intakes for Macronutrients.

    Joanne R. Lupton, Ph.D., Regents Professor, University Faculty
Fellow and William.W. Allen Endowed Chair in Human Nutrition, Texas A&M
University, College Station, Texas. Dr. Lupton has conducted research
on the effect of diet, primarily the consumption of fats and fiber, on
the development of colon cancer. Dr. Lupton has served as chair of the
recently released Macronutrient Report from the Dietary Reference
Intakes Committee of the National Academy of Sciences and is the chair
for the National Academy of Science panel to determine the definition
of dietary fiber.

    Joanne R. Lupton, Ph.D., Professor of Animal Science, of Food
Science and Technology, of Nutritional Sciences, and of Veterinary
Anatomy and Public Health, Texas A&M University, College Station,
Texas. Dr. Lupton has conducted research on the effect of diet,
primarily the consumption of fats and fiber, on the development of
colon cancer. Dr. Lupton has served as chair of the recently released
Macronutrient Report from the Dietary Reference Intakes Committee of
the National Academy of Sciences and is the chair for the National
Academy of Science panel to determine the definition of dietary fiber.

    Theresa A. Nicklas, Dr.P.H., M.P.H., L.N., Professor of Pediatrics,
Department of Pediatrics, Children's Nutrition Research Center, Baylor
College of Medicine, Houston, Texas. Dr. Nicklas' expertise pertains to
cardiovascular health and nutritional epidemiology, child nutrition,
and health promotion and chronic disease prevention. Her current work
examines eating patterns of children as predictive factors for obesity
in young adulthood. She was a member of the Dietary Patterns Advisory
Panel of the National Heart, Lung, and Blood Institute's National
Growth and Health Study.

    Russell R. Pate, Ph.D., Associate Dean for Research, School of
Public Health, and Professor, Department of Exercise Science,
University of South Carolina, Columbia, S.C. Dr. Pate is widely
recognized for his expertise in physical activity and physical fitness
in children, and the overall health implications of physical activity.
He coordinated the effort that led to the development of the
recommendation on Physical Activity and Public Health by the Centers
for Disease Control and Prevention and the American College of Sports
Medicine. He currently serves on an Institute of Medicine panel that is
developing guidelines on prevention of childhood obesity.

    F. Xavier Pi-Sunyer, M.D., M.P.H., Director, Obesity Research
Center, Professor of Medicine, Columbia University College of
Physicians and Surgeons; Chief, Division of Endocrinology, Diabetes,
and Nutrition, St.Luke's-Roosevelt Hospital, New York, N.Y. Dr. Pi-
Sunyer is an international expert in obesity and diabetes, focusing on
the role of nutrition in the prevention and treatment of these
increasingly prevalent diseases. He was invited to give a presentation
to the 2000 Dietary Guidelines Advisory Committee on the topic of
glycemic index and has served on expert panels and advisory panels to
several NIH Workshops and to the National Academy of Sciences Food and
Nutrition Board.

    Connie M. Weaver, Ph.D., Head and Distinguished Professor,
Department of Foods and Nutrition, Purdue University, West Lafayette,
Ind. Dr. Weaver is a leader in the nutrition community, having served
as President of the American Society for Nutritional Sciences and in a
number of leadership roles for the Institute of Food Technologists. She
has also served on the National Academy of Sciences' Food and Nutrition
Board as a panel member for the Dietary Reference Intakes for Calcium
and Related Nutrients and as a committee member to the National Academy
of Sciences for Food Chemical Codex.

          STATEMENT OF ARTHUR LAWRENCE, Ph.D., ACTING

        PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR HEALTH,

          U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Lawrence. Thank you, Mr. Chairman. Good afternoon.
Pleased to be here.
    My name is Arthur Lawrence, and I serve as Assistant
Surgeon General and the Acting Principal Deputy Assistant
Secretary for Health at the Department of Health and Human
Services. And I appreciate the opportunity to speak with you
today.
    Most Americans make choices about what to eat throughout
the day, every day. Making healthy food choices for themselves
and their families is key to Americans' overall health and
well-being. That's why the Dietary Guidelines for Americans
were developed in 1980 and remain so important today.
    The Dietary Guidelines form the scientific and the medical
basis for healthy food recommendations. Because many diseases
and conditions are preventable when Americans adopt and
maintain healthy lifestyles, HHS Secretary Tommy Thompson is
passionate about making sure that Americans have access to
science-based information about diet and nutrition in
understandable formats.
    Today I will highlight nutrition habits of Americans,
provide a brief history of the Dietary Guidelines, and
illustrate the importance of scientific consensus in the
ongoing effectiveness of health and nutrition programs.
    Let me start with dietary trends. Based upon scientific
evidence, we know that a diet that, first, includes a variety
of fruits, vegetables and grains; second, that is moderate in
sugars, salt and total fat; and, third, that is low in
saturated fat and cholesterol, constitute a diet that promotes
health and helps prevent disease.
    Unfortunately, few Americans are meeting the National
objectives for fruit, vegetable and grain intake. And most
Americans' diets exceed saturated fat recommendations. In
addition, more than half of all Americans are not meeting
objectives for physical activity.
    Over the past two decades, the prevalence of overweight and
obesity, as you have said, sir, has increased. This is a
serious problem when you consider that four of our country's
leading killers, heart disease, cancer, diabetes and stroke,
are all linked to poor diet and inadequate physical activity.
Over 60 percent of American adults are overweight or obese, and
15 percent of our children and adolescents are overweight.
    According to the results of a recent survey conducted by
the CDC, more than two-thirds of American adults are trying to
lose weight or keep from gaining weight. But many do not follow
guidelines recommending a combination of fewer calories plus
more physical activities.
    Let me say a few words about the history of the Dietary
Guidelines. Clearly, we must continue evaluating current
science and make sure that we are translating it into messages
that Americans can understand and apply to how they shop for
food and how they eat. It is a very dynamic process.
    Some very positive progress has been made. For example,
more people are reading food labels. And consumption of fruits
and vegetables has significantly increased over the past
decade.
    The Dietary Guidelines for Americans are a reflection of
the current scientific and medical knowledge and are therefore
continuously and vigorously reviewed. The Guidelines are
jointly developed by the Department of Health and Human
Services, and the United States Department of Agriculture. They
have been issued every 5 years since 1980.
    It was in 1977, after years of discussion and scientific
review, that the Senate Select Committee on Nutrition and Human
Needs recommended dietary goals for the American people. The
dietary goals were met with a great deal of controversy from
industry groups as well as the scientific community.
    To support the credibility of the science utilized by the
Committee, the Department of Agriculture and the Department of
Health, Education and Welfare, the predecessor agency to our
current HHS, assembled scientists from the two departments and
from throughout the Nation.
    From these efforts, the first Dietary Guidelines for
Americans were issued in 1980. Congress then directed the two
departments to convene a Dietary Guidelines Advisory Committee
to assure that a broad-based perspective was formally
solicited.
    The Advisory Committee assisted in preparing the 1990, the
1995, and the 2000 versions of the Guidelines. A new committee
has been jointly appointed by HHS and USDA for each edition.
    HHS and USDA have begun the process of developing the 2005
edition for which HHS has the lead for chartering the Advisory
Committee. The HHS USDA Dietary Guidelines Advisory Committee
that will assist our departments in preparing the 2005 edition
held its first meeting last week.
    The Committee members are recognized experts in human
nutrition and physical activity, and have demonstrated their
commitment to the public's health and well-being. After
preliminary discussions of key recent developments in nutrition
and physical activity, they concluded that further review of
the scientific literature is necessary.
    They began to chart the course of their deliberations, and
are committed to the transparent evidence-based review that
will guide their recommendations to the Secretaries of the
respective departments.
    All federally-issued dietary guidance is required to be
consistent with the Guidelines. For example, the Guidelines
serve as the basis of numerous physical activity and nutrition
campaigns throughout HHS. Highlights include the National
Cancer Institute's 5-9 A Day for Better Health; the National
Heart, Lung and Blood Institute's Cooking the Heart Healthy Way
Recipes and Interactive Menu Planner; the National Institute of
Diabetes and Digestive and Kidney Diseases' Take Charge of Your
Health: A Teenager's Guide to Better Health, which encourages
teenagers to take charge of their health by eating better and
by being more physically active; and finally, the CDC's
National Bone Health Campaign, called Powerful Bones, Powerful
Girls, which promotes optimal bone health among girls aged 9 to
12 years in an effort to reduce their risk of osteoporosis in
later life.
    The Guidelines are also used to develop nutrition policies
and guidelines. The Food and Drug Administration uses the
guidelines to address food labeling policies. And the
Guidelines serve as the basis for national health objectives
for nutrition and physical activity as outlined in Healthy
People 2010.
    Mr. Chairman, in closing, I will add that at HHS we are
working closely with other departments and agencies as well as
with partners in academia, communities, foundations and
business groups throughout the Nation to educate Americans
about healthy choices and physical activity.
    As you know, the epidemic of overweight and obesity led
President Bush to launch the Healthier U.S. initiative.
Healthier U.S. identifies four key pillars to improve and
maintain health. First, be physically active each day. Second,
eat a nutritious diet. Third, get preventive screenings.
Fourth, make healthy choices.
    As part of Healthier U.S., the President announced two new
Executive Orders that direct key Federal departments and
agencies to develop plans to promote fitness and health. In
response, Secretary Thompson created steps to a Healthier U.S.,
and directed HHS agencies to make prevention of chronic
illnesses and diseases a top priority.
    Secretary Thompson is committed to advancing the goals of
Healthier U.S. by giving the public and policymakers clear,
scientifically proven information. The Steps grants program is
the centerpiece of this initiative.
    Last week, Secretary Thompson announced the four states,
seven cities and one tribal council that were awarded the Steps
grant based on their exemplary application. The messages in the
Dietary Guidelines will be used to promote healthy eating,
physical activity in these communities.
    Additionally, the Surgeon General's Call to Action to
Prevent and Decrease Overweight and Obesity concludes that a
healthy diet and regular physical activity are consistent with
the Dietary Guidelines and should be the cornerstone of any
prevention or treatment effort. These are examples of how the
Dietary Guidelines serve as the framework for many Federal
nutrition programs, policies and initiatives.
    Mr. Chairman, distinguished guests, thank you very much for
the opportunity to speak with you today about the Dietary
Guidelines for Americans. And I will be happy to answer any
questions you may have, sir.
    Senator Fitzgerald. Thank you, Dr. Lawrence. Dr. Graham.
    [The prepared statement of Dr. Lawrence follows:]

 Prepared Statement of Arthur Lawrence, Ph.D., Acting Principal Deputy
  Assistant Secretary for Health, U.S. Department of Health and Human
                                Services
    Good afternoon, Mr. Chairman and distinguished members of the
Subcommittee. My name is Dr. Arthur Lawrence, and I serve as Assistant
Surgeon General and Acting Principal Deputy Assistant Secretary for
Health. My professional background is clinical pharmacy and
pharmacology. Thank you for the opportunity to speak with you today.
    Most Americans make choices about what to eat throughout the day,
every day. Making healthy food choices for themselves and their
families is key to Americans' overall health and well-being, and
essential to reducing risk of long-term diseases and conditions. That
is why the Dietary Guidelines for Americans were developed in 1980 and
are so important today.
    The Dietary Guidelines for Americans form the scientific and
medical basis of what Americans need to understand to make healthy
eating choices. So many diseases and conditions are preventable when
Americans adopt and maintain healthy lifestyles. That is why HHS
Secretary Tommy G. Thompson is passionate about making sure that
Americans have access to science-based information about diet and
nutrition in understandable formats.
    Today I will highlight dieting patterns and nutrition habits of
Americans, provide a brief history of the Dietary Guidelines, and
illustrate the importance of scientific consensus in the ongoing
effectiveness of HHS health and nutrition programs.
Dietary Trends
    A healthy diet is balanced and includes all major food groups.
Based upon the best scientific evidence available, we know that a diet
that includes a variety of fruits, vegetables, and grains, especially
whole grains; is moderate in sugars, salt, and total fat; and is low in
saturated fat and cholesterol is a diet that promotes health and helps
prevent disease. Total calories consumed must be balanced with physical
activity to maintain a healthy weight. And, food must be kept safe to
eat in order to provide nourishment and avoid food-borne illness.
    Unfortunately, few Americans are meeting the national consensus
objectives presented in Healthy People 2010 for fruit, vegetable, and
grain intake, and most Americans' diets exceed saturated fat
recommendations. Yet, according to a National Cancer Institute Survey,
these problems are not primarily due to a lack of ``awareness''--as
awareness of the need to eat five or more servings of fruits and
vegetables per day has nearly tripled since 1991.
    More than half of all Americans are not meeting objectives for
physical activity. The prevalence of overweight and obesity has
increased. Over 60 percent of American adults are overweight or obese
and 15 percent of our children and adolescents are overweight. Four of
our country's leading killers--heart disease, some cancers, diabetes,
and stroke--are linked to poor diet and inadequate physical activity.
More than 300,000 deaths each year are linked to poor diet and
inadequate activity patterns.
    Americans spend $33 billion a year on weight-loss products and
services. According to a 1999 survey conducted by the Centers for
Disease Control and Prevention, more than two-thirds of American adults
are trying to lose weight or keep from gaining weight, but many do not
follow guidelines recommending a combination of fewer calories and more
physical activity. Only 15 percent of Americans have received advice
from a doctor or health professional about their weight.
    Although these statistics are of great concern, progress has been
made. More people are reading food labels. Over the past decade,
consumption of fruits and vegetables has increased and saturated fat
consumption has decreased. Although reversing the trends in overweight
and obesity will require change at the societal and environmental
levels, as well as at the individual level, efforts to educate and to
promote behavioral change at the individual level must continue.
History of the Dietary Guidelines
    Assuring a continuing evaluation of the current science and
translating that science into messages that Americans can understand
and apply is essential, and it's a dynamic process. The Guidelines are
a reflection of the current preponderance of the scientific and medical
knowledge, and therefore must be continuously and vigorously reviewed.
    The Dietary Guidelines for Americans are jointly developed by the
Department of Health and Human Services (HHS) and the United States
Department of Agriculture (USDA). The Guidelines have been issued every
five years since 1980. The current edition focuses on three principles:
Aim for fitness, Build a healthy base, and Choose sensibly.
    HHS and USDA have begun the process of developing the sixth
edition, which will be published in 2005. For the 2005 edition, HHS has
the lead for chartering the advisory committee. The goals of this
edition of Dietary Guidelines are the same--to promote health and
reduce disease risk for Americans based upon state-of-the-art
scientific evidence.
    Early nutrition policy in the United States focused on preventing
nutritional deficiencies such as iron deficiency anemia and hunger.
Throughout the 1970s, as deficiency diseases became less common, there
was growing recognition of the role of excesses and imbalances of
certain dietary components related to disease risk and the occurrence
of chronic diseases.
    In 1977, after years of discussion, scientific review, and debate,
the Senate Select Committee on Nutrition and Human Needs recommended
what they viewed as Dietary Goals for the American people. The issuance
of the Dietary Goals by Congress was met with a great deal of debate
and controversy--both from industry groups and from the scientific
community. These groups questioned the scientific support for the
specificity of the quantitative aspects of the Dietary Goals.
    To support the credibility of the science utilized by the
Committee, the U.S. Department of Agriculture and the Department of
Health, Education and Welfare assembled scientists from the two
departments and from throughout the Nation. In February of 1980 the
Dietary Guidelines for Americans were issued. They represented the best
scientific perspective at that point in time. However, the debate
continued about the scientific evidence used to support the Dietary
Guidelines. This led to Congressional report language directing the two
departments to convene a Dietary Guidelines Advisory Committee to
assure that a broad based perspective across the continuum was formally
solicited.
    Since 1985, external science advisory committees composed of food
and nutrition experts from outside of government have been relied upon
to provide expert and objective scientific assessment of the need to
revise the Dietary Guidelines for Americans and to propose suggested
changes for departmental consideration based upon new scientific
findings. Since the issuance of the 1985 Dietary Guidelines, much less
debate over the scientific basis for the guidelines has ensued either
from industry or the scientific community.
    In recognition of the fact that nutritional science evolves, in
1990 Congress formally directed HHS and USDA to issue these guidelines
every five years (Public Law 101-445).
    The Dietary Guidelines Advisory Committee was established to assist
in the preparations of the 1990, 1995, 2000, and now 2005 versions of
the Dietary Guidelines. A new Committee has been jointly appointed by
HHS and USDA for each edition.
Dietary Guidelines Framework for HHS Programs
    The information contained in the Dietary Guidelines for Americans
report is based on the current preponderance of the scientific and
medical knowledge. Thus, in two decades, the Dietary Guidelines for
Americans have moved with only minor changes from a contentious
document to one that represents broad scientific consensus and provides
the statutory basis of Federal nutrition programs, policies, and
education efforts. These changes reflect the growing emphasis on health
promotion and reducing disease risk.
    The Dietary Guidelines serve as a framework for many Federal
initiatives. Amidst multiple messages that are confusing to the public,
the Dietary Guidelines for Americans provide a vehicle for the
government to speak with one clear voice. All Federally issued dietary
guidance for the general public is required to be consistent with the
Guidelines. For example, the Dietary Guidelines for Americans serve as
the basis of numerous physical activity and nutrition campaigns
throughout HHS. Highlights include:

   NIH's National Cancer Institute's 5-9 A Day for Better
        Health, a campaign to increase the average consumption of
        fruits and vegetables to at least 5 daily servings;

   NIH's National Heart, Lung, and Blood Institute's Cooking
        the Heart Healthy Way Recipes and Interactive Menu Planner,
        which are tools for consumers to meet the nutrition goals of
        the guidelines;

   NIH's National Heart, Lung, and Blood Institute's Red Dress
        Project, designed to raise awareness that heart disease is the
        #1 killer of women and provide tools for women to reduce their
        risk of heart disease;

   NIH's National Institute of Child Health and Human
        Development's Milk Matters, a nationwide campaign dedicated to
        increasing calcium consumption among America's children and
        teens;

   NIH's National Institute of Diabetes and Digestive and
        Kidney Diseases' Take Charge of Your Health: A Teenager's Guide
        to Better Health that encourages teenagers to take charge of
        their health by eating better and being more physically active;
        and

   The Centers for Disease Control and Prevention's National
        Bone Health Campaign, Powerful Bones, Powerful Girls, which
        promotes optimal bone health among girls aged 9-12 years in an
        effort to reduce their risk of osteoporosis later in life.

    The Dietary Guidelines are also used to develop nutrition policies
and guidelines. The Food and Drug Administration uses the Dietary
Guidelines to address food-labeling policies. The Dietary Guidelines
for Americans serve as the basis for the national health objectives, as
outlined in Healthy People 2010, for nutrition and physical activity.
The Dietary Guidelines for Americans influence dietary and physical
activity variables measured in the National Health and Nutrition
Examination Survey (NHANES), a survey conducted by the National Center
for Health Statistics of the Centers for Disease Control and
Prevention. This survey collects information about the health and diet
of people in the United States.
Conclusion
    The HHS-USDA Dietary Guidelines Advisory Committee that will assist
our Departments to prepare the 2005 edition of the Dietary Guidelines
held its first meeting last week. The members of this committee are
recognized experts in human nutrition and physical activity and have
demonstrated their commitment to the public's health and well-being.
After preliminary discussions of key recent developments in nutrition
and physical activity they concluded that further review of the
scientific literature is needed. They began to chart the course of
their deliberations for the next several months. We know that
scientific results may vary, sometimes seem counter-intuitive and are
rarely clear enough to speak for themselves. That is why the experts we
have enlisted are focused on a transparent, evidence-based review that
will guide their recommendations to the Secretaries of the Departments.
    The epidemic of overweight and obesity led President Bush to launch
a HealthierUS initiative in June 2002, based on the premise that
increasing personal fitness leads to the improved health of our Nation.
HealthierUS has identified four key dimensions: be physically active
each day; eat a nutritious diet; get preventive screenings; and make
healthy choices. As part of HealthierUS, the President announced two
new Executive Orders that direct key Federal departments and agencies
to develop plans to better promote fitness and health for all
Americans.
    In response to that directive, HHS created Steps to a HealthierUS,
directing all agencies within HHS to make prevention of chronic disease
a top priority. Secretary Thompson is committed to advancing the goals
of HealthierUS by giving the public and policy makers clear,
scientifically proven steps to embrace prevention. While the primary
goal of the Steps to a HealthierUS initiative is to help Americans
realize that even small steps can make a dramatic difference in good
health, HHS is committed to specific goals to prevent diabetes,
obesity, and asthma through this Department-wide initiative. Steps to a
HealthierUS will achieve these outcomes by improving nutrition,
increasing physical activity, and preventing tobacco use and exposure.
The Steps grants program is the centerpiece of this initiative. Last
week, Secretary Thompson announced the four states, seven cities, and
one tribal council that were awarded these grants. The messages in the
Dietary Guidelines for Americans will be used to promote healthy eating
and physical activity in these communities.
    Additionally, the Surgeon General's Call to Action to Prevent and
Decrease Overweight and Obesity concludes that a healthy diet and
regular physical activity, consistent with the Dietary Guidelines for
Americans, should be promoted as the cornerstone of any prevention or
treatment effort.
    These are all examples of how the Dietary Guidelines serve as the
framework for many Federal nutrition programs, policies, and
initiatives.
    Mr. Chairman and distinguished members of the subcommittee, thank
you for the opportunity to discuss the importance of the Dietary
Guidelines for Americans.

       STATEMENT OF JOHN D. GRAHAM, Ph.D., ADMINISTRATOR,

         OFFICE OF INFORMATION AND REGULATORY AFFAIRS,

       OFFICE OF MANAGEMENT AND BUDGET, EXECUTIVE OFFICE

             OF THE PRESIDENT OF THE UNITED STATES

    Dr. Graham. Thank you very much, Senator, for the
opportunity to be here. It's a little unusual for an OMB
official to be testifying before this particular committee, and
we appreciate the outreach and the opportunity.
    This area of Dietary Guidelines and the Food Guide Pyramid
has long been of interest to me personally. Prior to joining
the Administration, I served on the faculty of the Harvard
School of Public Health for 17 years, where I founded the
Harvard Center for Risk Analysis. And in that capacity, I
learned about the powerful role that dietary choices play in
determining how long people live and how healthy their lives
are.
    In this capacity, I also learned from one of my faculty
colleagues, Professor Walt Willett, who I'm very proud is here
today; and you are going to hear from a real expert later in
this hearing. And I want to recognize not only Professor
Willett, but the tremendous cadre of postdoctoral fellows,
junior faculty members, doctoral students who have worked with
him over the last decade, and more, producing a lot of the
science that's going to be deliberated on in the process you
have heard about from the last two witnesses.
    When I came to OMB, I saw the area of information to
consumers about food as one of the key areas for the
administration to make progress on, helping market forces drive
toward healthier offerings of food to the American people. One
of my first actions at OMB was to issue a prompt letter to the
Food and Drug Administration encouraging the Agency to finalize
a regulation begun under the previous administration that
requires that the trans fat content of food be placed on the
food label.
    I'm pleased that finally and most recently this regulation
has been finalized. This is an important regulation because it
actually provides consumers an opportunity to demand foods with
lower trans fat content, and also encourages companies to lower
the trans fat content of their foods.
    FDA estimates, and my staff thinks it's reasonable, that
this is going to result in a lower rate of both non-fatal and
fatal heart attacks with a multi-billion dollar benefit impact
on our society.
    Although the overall health of Americans continues to
improve, and I think it's important that we remember that on
all the depressing discussion of obesity and diabetes, we are
indeed overall getting healthier; but we do have these serious
and disturbing problems, Senator, that you mentioned at the
beginning of the hearing. And they are significant risk factors
for our biggest killers in the United States.
    Accordingly, in May of this year, I issued another prompt
letter to both the Departments of Agriculture and the
Department of Health and Human Services requesting that as they
considered changes in these important and influential policy
documents, they take into account the wide body of new
scientific knowledge, much that you referred to in your opening
statement surrounding the links of food consumption and health
outcomes.
    The current Dietary Guidelines, while going a long way
toward encouraging healthy behaviors, are not adequately
designed to most effectively promote beneficial health
outcomes. Recent studies suggest that adherence to the Dietary
Guidelines has only a modest impact on the risk of
cardiovascular disease, and no significant impact on other
chronic diseases such as cancer.
    Given the wide-ranging impact of the Guidelines, we believe
that revisions to them, based on sound science, can have more
meaningful impact on overall public health.
    One of my principal concerns with the current Dietary
Guidelines is that, with respect to fat intake, they focused
almost exclusively on the reduction of intake of saturated fats
and cholesterol. They do not adequately account for other types
of bad fats, if you will, such as trans fatty acids; and good
fats such as omegas-3 fatty acids.
    There is a growing body of evidence that suggests that
consumptions of trans fatty acids in addition to consumption of
saturated fats and cholesterol increase the risk of coronary
heart disease; and the consumption of omegas-3 fatty acids
reduces the incidence of coronary heart disease.
    The recent revision to the American Heart Association's
Dietary Guidelines recognizes this evidence regarding omega-3
fatty acids by recommending consumption of certain fish, those
highest in omega-3 fatty acids, at least twice a week, and
inclusion of oils and other food sources high in omega-3 fatty
acids.
    The Food Guide Pyramid, introduced first in 1992, is also a
critically important source of consumer information about a
healthy diet. As noted in the Report of the Dietary Guidelines
Advisory Committee, consumers find the pyramid to be the most
useful part of the Dietary Guidelines. In fact, they themselves
suggest that readers, quote, ``let the pyramid guide your food
choices.''
    Given the emphasis on the easy-to-understand pyramid,
revisions should better differentiate the health benefits and
risks for different types of foods to encourage healthier
eating habits. The current pyramid, for example, combines meat,
poultry, fish, dry beans, eggs, and nuts into a single, quote,
``meat and beans group,'' unquote.
    Research suggests, however, that these foods may not be
equivalent in terms of their health impacts. Consideration
should therefore be given to grouping foods that have similar
health effects, so that consumers can make more informed
dietary choice.
    OMB will be collaborating with USDA and HHS as they
implement this ambitious program that they have already told
you about.
    We have a responsibility at OMB, mandated by Congress, to
oversee the quality of information that all Federal agencies
disseminate to the American people. Under the Information
Quality Law, OMB has developed governmentwide guidelines on the
quality of information. And they govern the activity that you
are hearing about today.
    OIRA, my office at OMB, has a stronger ability to
participate in these activities because we've recently added
public health science staff to our office in the fields of
toxicology, epidemiology, as well as health policy.
    In conclusion, we at OMB support ongoing efforts to revise
and update the Dietary Guidelines and the Food Guide Pyramid. I
look forward to comments and questions.
    [The prepared statement of Dr. Graham follows:]

 Prepared Statement of John D. Graham, Ph.D., Administrator, Office of
 Information and Regulatory Affairs, Office of Management and Budget,
         Executive Office of the President of the United States
    Good afternoon, Mr. Chairman, and Members of this Subcommittee. I
am John D. Graham, Ph.D., Administrator, Office of Information and
Regulatory Affairs (OIRA), Office of Management and Budget. I
appreciate this opportunity to testify before you today on the review
and revision of the Dietary Guidelines for Americans and the Food Guide
Pyramid. This has long been an area of strong interest for me. Prior to
joining OMB, I served for 17 years on the faculty of the Harvard School
of Public Health, where I founded the Harvard Center for Risk Analysis.
In this capacity, I learned about the powerful impact of dietary
choices on public health.
    One of my first actions at OMB was to issue a ``prompt'' letter to
the Food and Drug Administration (FDA), encouraging the agency to
finalize its rulemaking to require that amounts of trans fat be listed
in the nutrition labels on all food. FDA issued the final rule in July.
Given the strong scientific link between the consumption of trans fat
and coronary heart disease (CHD), it is hoped that consumers will
factor information about trans fat content into their food purchasing
decisions. The increased attention on trans fat content should
encourage food manufacturers to reduce the amount of trans fat in their
products. The rule is expected to have a multibillion dollar effect in
health benefits through the reduction of fatal and non-fatal heart
attacks.
    Although the overall health of Americans continues to improve, we
have serious health problems in this country related to people being
overweight and obese. These conditions are significant risk factors for
heart disease and other chronic illnesses. Accordingly, on May 27,
2003, I issued another prompt letter to the Departments of Agriculture
and Health and Human Services requesting that, as they consider changes
to these very important and influential policy documents, they take
into account the wide body of new scientific knowledge surrounding the
links between food consumption and health outcomes.
    The current dietary guidelines, while going a long way toward
encouraging healthy eating behaviors, are not adequately designed to
most effectively promote positive public health outcomes. Recent
studies suggest that adherence to the Dietary Guidelines has only a
modest impact on the risk of cardiovascular disease, and no significant
impact on other chronic diseases, such as cancer. Given the wide-
ranging impact that the Dietary Guidelines have on American dietary
intake patterns, we believe that revisions to these guidelines, based
on sound science, can have a meaningful impact on overall public
health. For instance, CHD is our Nation's largest cause of premature
death for both men and women, killing over 500,000 Americans each year.
It has been shown that even a modest improvement in dietary habits may
lead to significant reductions in morbidity and mortality due to CHD.
    One of my principal concerns with the current Dietary Guidelines is
that, with respect to fat intake, they focus almost exclusively on the
reduction of intake of saturated fats and cholesterol. They do not
adequately account for other types of ``bad'' fats, such as trans fatty
acids, and ``good'' fats, such as omega-3 fatty acids. There is a
growing body of evidence that suggests that consumption of trans fatty
acids, in addition to consumption of saturated fats and cholesterol,
increases the risk of CHD, and that consumption of omega-3 fatty acids
reduces the incidence of death due to CHD. The recent revision to the
American Heart Association's dietary guidelines recognizes this
evidence regarding omega-3 fatty acids by recommending consumption of
certain fish (those highest in omega-3 fatty acids) at least twice a
week and inclusion of oils and other food sources high in omega-3 fatty
acids.
    The Food Guide Pyramid, which was first introduced in 1992, is also
a critically important source of consumer information about healthy
dietary patterns. As noted in the Report of the Dietary Guidelines
Advisory Committee on the Dietary Guidelines for Americans (2000),
consumers find the Pyramid to be the most useful part of the Dietary
Guidelines. In fact, the Dietary Guidelines themselves suggest that
readers ``let the pyramid guide your food choices.''
    Given the emphasis on the easy-to-understand Pyramid, revisions
should better differentiate the health benefits and risks from
different types of foods to encourage healthier eating habits. The
current Pyramid, for example, combines meat, poultry, fish, dry beans,
eggs, and nuts into a single ``Meat and Beans Group.'' Research
suggests, however, that these foods may not be equivalent in terms of
their health effects. Consideration should therefore be given to
grouping foods that have similar health effects so that consumers can
make more informed dietary choices.
    Section 301 of the National Nutrition Monitoring and Related
Research Act of 1990 (7 U.S.C. 5341) requires the Secretaries of USDA
and HHS to jointly publish a report entitled Dietary Guidelines for
Americans at least every 5 years. The last report was published in
2000. OMB plans to work closely with the Departments of Agriculture and
Health and Human Services as they consider revisions to the Dietary
Guidelines for Americans. USDA and HHS have appointed members to a
Dietary Guidelines Advisory Committee, which is composed of 13
nationally recognized experts in the field of nutrition. This Committee
has been established to review the available science and provide expert
advice as the revision process goes forward. USDA has just published a
request for comment on the proposed daily food intake patterns and the
supporting technical data for the Pyramid. These proposed patterns and
data, along with the comments received through the notice, will be
shared with the 2005 Dietary Guidelines Advisory Committee. The
Advisory Committee will issue a report to the Secretaries of
Agriculture and Health and Human Services, with suggested text for the
Dietary Guidelines and rationale for any changes made from the 2000
edition. The report should be made public by the fall of 2004. The
revisions to the Dietary Guidelines and the Pyramid--which are
scheduled to be published by USDA and HHS in the winter of 2005--will
work in concert, and the Advisory Committee will inform both processes
    OMB's collaborative efforts with USDA and HHS will complement our
oversight responsibilities in a related area: information quality.
Under the Information Quality Law,\1\ OMB has developed government-wide
guidelines to ensure and maximize the quality of information
disseminated by agencies, information such as that contained in the
Dietary Guidelines and the Pyramid. OIRA's ability to play a stronger
role in these issues in the years ahead will be enhanced with the
recent addition to OIRA's staff of analysts with expertise in the
fields of toxicology, epidemiology, decision science, and health
policy.
---------------------------------------------------------------------------
    \1\ Section 515 of the Treasury and General Government
Appropriations Act for Fiscal Year 2001 (Public Law 106-554; H.R.
5658).
---------------------------------------------------------------------------
    In conclusion, we support ongoing efforts to revise and update to
the Dietary Guidelines and the Food Guide Pyramid. In particular, we
recommend that they emphasize the benefits of reducing the consumption
of foods that are high in trans fatty acids and increasing the
consumption of foods that are rich in omega-3 fatty acid. That
concludes my prepared testimony. If you have any questions, I would be
happy to answer them.

    Senator Fitzgerald. Well, thank you very much, Dr. Graham.
And I want to compliment you for getting involved in this whole
discussion. As you said at the start of your testimony, it's
unusual for the OMB to be involved in a hearing like this. But
when you think about it, it's your office in the White House
that has to deal with our budgetary problems.
    And you, having served at the School of Public Health at
Harvard, certainly would know the costs to our society and to
our economy by problems that come from diabetes and obesity. So
I applaud you for inserting yourself into this debate.
    I want to ask at the start whether the panelists think that
the Dietary Guidelines that are being revised, whether they
should be directed at healthy Americans or should there be some
guidelines directed at overweight Americans. The reason I ask
this question is because a majority of Americans, it would now
appear a majority of American adults, about 64 percent, are
overweight.
    So wouldn't it make sense to address the Guidelines to that
majority that is overweight. Dr. Lawrence, would you have any
thoughts on that?
    Dr. Lawrence. The Guidelines, Mr. Chairman, are designed to
lay out a nutritional blueprint. Overweight and obesity is a
balance between calories in and calories out.
    And it is extremely difficult to set up basically two
completely different sets of nutritional standards for that
kind of grouping. Good nutrition is good nutrition, whether or
not one is overweight and obese or not.
    The issue becomes one of calories in, calories out. The
equation is always based on what one eats versus what one
expends. So as we move forward, I think that the strategy that
probably would be more profitable would be to translate the
information that is garnered from the scientific review itself
about what constitutes good nutrition in clear, concise
messages for all Americans.
    One of the ways that I think that we can approach the issue
is to have people understand that physical activity is a key
aspect of moderating weight. Personally, I had a difficult time
my entire life moderating my weight. And the way that I deal
with it is by changing the equation. Reduce the intake,
increase the activity, and weight is moderated.
    I watched the Guidelines carefully because they give me a
standard for nutrition that I should be observing and
attempting to maintain.
    Senator Fitzgerald. Dr. Hentges.
    Dr. Hentges. Senator, your question is a very interesting
one, and one that the Dietary Guidelines Advisory Committee did
start to address and look at as they set up working groups to
move forward. One of those working groups is specifically
looking at weight maintenance, physical activity together.
    And they did actually go through some of the thoughts that
you have had here. Is it an issue of maintaining weight. Is it
losing weight and maintaining it after it has been lost. And so
those debates are ongoing. And the Committee does recognize the
question that you put forth.
    Senator Fitzgerald. Well, it will be interesting to see how
you come out on that. Now, Dr. Hentges, I was pretty tough in
my opening statement on the USDA. I have great regard for the
Department and for the good work that it does for our
agricultural community. And I come from a big agricultural
state and have done a lot myself to promote the interests of
corn and soybean producers.
    But do you not agree that it's a difficult task that you
are called upon on one hand, being there as kind of a
department to advocate for the interests of our American
farmers; and on the other hand, now being called upon to set
nutritional standards for Americans.
    If the interests of the grain farmers or American farmers
aren't aligned with the interests of consumers of food, how do
you deal with that? And aren't you likely to be buffeted from
side to side by all the ag interest groups that will descend
upon the Department to try and influence the guidelines you put
out?
    Dr. Hentges. As you know, USDA's overall mission is a safe,
affordable, nutritious food supply. And in our partnership with
the Department of Health and Human Services, on looking at diet
and health issues, what the agriculture brings forth in that
partnership is that knowledge of everything from production to
processing to the entire food chain programs where you have
food and supply economics as well as education programs through
the extension service, and nutrition research as noted in the
six human nutrition research centers that USDA have.
    So the entire food chain knowledge works in partnership
with Health and Human Services on their public health knowledge
to provide this overall logical recommendations.
    And I have, I would say that that partnership advances us
on what needs to be done, what kinds of foods need to be
provided.
    The Department has a food consumption survey. It also has,
maintains the nutrient database for foods. And these programs
work in concert with Health and Human Services as well in the
national health, in Hanes Consumption Survey Program.
    Senator Fitzgerald. Now, there are several published
reports that describe how the Guidelines were put together in
the year 2000, the last time the Guidelines were revised. And
there are a lot of stories that were written about how your
panel recommended to the Department that the Guidelines
recommend, I think they wanted to use the word ``limit'' on
limit the intake of sugar; and at the behest of sugar growers,
the Department appeared to change that wording to instead of
limit, said moderate.
    Now, isn't that a pretty clear example of where the
Department can get pressured by agricultural interests?
    Dr. Hentges. I was not there at that time, so I do not know
the specifics of what actually happened. But I know that the
issue over the years for all editions has been that there be a
consistency of language. And we have seen language changes over
the five editions.
    I believe in 1985, and Dr. Lawrence can correct me if this
isn't right, in 1985, the language consistently talked about
avoidance. And then in 1990, the language consistently changed
to choose a diet, with the idea that negative language wasn't
helping, and more positive was.
    So as I understand the issue that you referred to, that
again was a consistency across Guidelines language choice.
    Senator Fitzgerald. Now, these Guidelines first started
coming out in 1980. But as I said in my opening statement, I
indicated there has been a dramatic increase in obesity, weight
gain, and diabetes during the time that we've had the
Guidelines in effect.
    Isn't that troubling to the USDA and the HHS? I mean,
clearly something's gone wrong. We can't just say that it's not
Americans aren't exercising enough. Maybe they aren't. Then we
have to revise the Guidelines with the expectation that they
are not going to exercise as much as we'd like them to.
    Would you care to comment, Dr. Hentges?
    Dr. Hentges. We currently have a Federal Register notice
that was published on September 11 for the technical revisions
of the Food Guide Pyramid. One of the questions that we are
addressing in that technical notice is what is the appropriate
energy level.
    National Academy of Sciences in its deliberations on the
dietary recommended intakes, the DRI panels, put together
estimated energy requirement equations. And one of the factors
in those equations is a coefficient that takes into account
your activity.
    And so as to Dr. Lawrence's point earlier, the balance of
energy, what is the appropriate energy level. So, yes, it is
troubling that we have great recognition of the pyramid, but we
do have what seems to be a low implementation and lack of
knowledge that you first must select an appropriate energy
level as you select the rest of your food pattern.
    Senator Fitzgerald. Dr. Lawrence, do you care to comment on
that, just the fact that obesity and diabetes have increased
dramatically since the Dietary Guidelines first came out?
    Dr. Lawrence. Epidemiologically, we have seen an increase
in diabetes. We have seen an increase in overweight and
obesity. I am unaware of any science that directly links those
two.
    I think that it all comes down to an issue again, Mr.
Chairman, of establishing what constitutes good nutrition, and
then communicating that in a way that the Nation and
individuals can understand about how one maintains good
nutrition and balances calories in with calories out.
    The phrase that I use for what my trainer has taught me is
that I need to earn my calories every day, which is a very
simple one-liner; but also is difficult to tailor messages to
meet each and every category of individual. So the question
becomes one of how do we, in a public health way, express to
the individuals who are at risk that this constitutes good
nutrition; and here is how you maintain your most optimal
health status.
    Senator Fitzgerald. Now, in the next panel, I think all of
the witnesses are going to at least argue, or will at least
agree that there are two problems with the food pyramid: One,
that it really doesn't distinguish types of carbohydrates,
healthy and unhealthy carbohydrates, and also doesn't really
distinguish between some healthy fats and fats that are less
likely to be healthy.
    And that gets to the question I'd like to ask Dr. Graham.
You wrote the letter encouraging USDA and HHS to include
information on omegas-3 fatty acids and trans fats in the
Dietary Guidelines. Is that a concern of yours that the food
guidelines don't really differentiate between types of fats and
perhaps types of carbohydrates, although you didn't really
mention that in your letter as I recall.
    Dr. Graham. No. And certainly our letter was not intended
to be a comprehensive critique of either the Guidelines or the
Pyramid. But, yes, we do feel there needs to be some more
attention to the differences between, think of it as good fats
and bad fats.
    And I think that if you look at the history and the
evolution, you already see evidence of the Guidelines gradually
incorporating some of that evidence. But as you said earlier in
the hearing, there has been quite a substantial body of
evidence since 5 years ago. And I think there's room for more
progress in that direction.
    Senator Fitzgerald. Well, my final question, and this may
be unfair to get Dr. Graham involved in this debate, but from
your perspective at the OMB, you want to be concerned, as you
said in your statement, that science determines the Guidelines,
and not politics; that this is far too important to play
politics with.
    Do you have any preference on the agencies or the agency
that should be in charge of drafting the Dietary Guidelines, or
are you comfortable with the USDA and HHS jointly doing the
Guidelines?
    Dr. Graham. Well, Senator, I listened very carefully to
your opening statement on that question, and that's the only
thing I can react to because I haven't seen any specifics
behind the idea you have. But I think one thing to keep in mind
is there are a large number of well-trained, well-motivated and
very health-oriented professionals at the U.S. Department of
Agriculture.
    And in your advocacy of trying to make progress in this
area, I hope you'll continue to think through the question of
whether there's a way to harness that expertise without trying
to in some sense create an artificial separation between
different units who are inevitably, quite frankly, going to
participate in a process like this.
    The other comment I would add is you have an understandable
motivation to try to take the commercial interests out of this
process and try to let the science speak. But it's even more
complicated than that. Because if you look closely at the
various segments of the food industry, there's tremendous
scientific and technical expertise in the food industry.
    And they have organizations like the International Life
Sciences Institute who make a very constructive contribution to
the discussion of food, nutrition and public health. So I would
encourage you to think of ways to sort of broaden the
participation, but in a disciplined way that will allow the
science to speak.
    Senator Fitzgerald. Well, thank you. One final question,
Dr. Graham. Do you have any, Dr. Graham or the others, do you
have any thoughts on the composition of the current panel?
    I know it's been criticized by the Center for Science and
the Public Interest I think it was. They thought that some of
the scientists on the 13-member advisory panel were already too
tied to industry. And they were pointing out that some of those
scientists, although good scientists, had been paid by various
agricultural or food industry interests to produce research on
their behalf previously.
    Do any of you have any concerns about ties that members of
that panel may have to people with too big of an economic stake
in this debate?
    Dr. Graham. Well, one point I would make, Senator, is that
if the participating scientists, and I haven't reviewed the
individuals, but if they didn't have any ties to any of these
segments of the diverse food industry or to the agencies who
have an interest in this issue too, I would wonder whether they
were genuinely experts in the subject area. And I hope we are
going to make sure that we go get the most knowledgeable people
and use that as our most important guideposts.
    Dr. Hentges. I can tell you, Senator, that the four major
professional nutrition societies took it upon themselves for
the first time, this would be the American Society of
Nutritional Sciences, American Society of Clinical Nutrition,
the Institute of Food Technologists and American Dietetics
Association, all independently wrote letters to the Secretaries
supporting and in fact endorsing the selection of this
committee.
    Dr. Lawrence. I would add one thing, sir. And that's to
keep in mind that this is an open scientific process. The
thirteen members will be working through seven subcommittees
that are under the Federal Advisory Committee Act, which means
that the procedures will be transparent.
    The Committee broke itself into a subgroup on energy
balance and weight maintenance, one on nutritional adequacy,
one in hydration, one on fatty acid metabolism, one on
carbohydrate metabolism, one on ethanol metabolism and one on
food safety.
    These will all be open scientific processes. And the public
gets to weigh in. Advocacy groups get to weigh in. Certainly
Members of Congress get to weigh in, should they so choose.
    And I would say that I agree with Dr. Graham's observation
that it's very difficult to find someone who is truly an expert
who has not worked in one of these areas.
    Senator Fitzgerald. Well, that's a good point. And I
suppose if you get a broad enough spectrum of viewpoints,
they'll all cancel each other out so that no one viewpoint
would take unilateral control of the panel.
    Well, thank you all very much. I appreciate you coming up
here to testify. And I'd like to invite the second panel to
come up to the witness table.
    On the second panel, we have Dr. Dean Ornish, Clinical
Professor of Medicine at the University of California in San
Francisco; Dr. Walter Willett, the Fredrick John Stare
Professor of Epidemiology and Nutrition at the Department of
Nutrition and Epidemiology, Harvard School of Public Health;
Dr. Stuart Lawrence Trager, Clinical Assistant Professor of
Orthopedic Surgery with the Atkins Center for Complimentary
Medicine; Mr. Michael F. Jacobson, Director of the Center for
Science in the Public Interest.
    And I do believe Senator Specter wanted to come to
introduce Dr. Ornish. So, Doctor, I'll maybe wait for you to
begin until the end. And why don't we start with Mr. Jacobson.
    And Dr. Willett and Dr. Trager, could you move your name
tags in front of you, thanks.

 STATEMENT OF MICHAEL F. JACOBSON, Ph.D., EXECUTIVE DIRECTOR,
           CENTER FOR SCIENCE IN THE PUBLIC INTEREST

    Mr. Jacobson. Thank you very much, Senator. Thank you very
much, Senator. I appreciate the opportunity to testify at this
very interesting hearing. And I applaud you for holding the
hearing.
    I'd like to emphasize three major points. The first two
concern the Federal Government's dietary advice to the public.
The third concerns the utter failure of the Government to adopt
policies and programs to translate its dietary advice into
improved diets.
    The basic problem with the Food Guide Pyramid is that it
fails to distinguish between better and worse foods within a
food group, thus the dairy group mixes fat free milk with high
fat cheese. The protein group mixes fatty meat with wholesome
beans and fish. The grains group mixes white bread with whole
wheat broad.
    One could follow the pyramid's advice and have either a
terrific diet or an awful diet. The pyramid needs to be revised
so as to encourage people to eat more of the most healthful
foods and less of the least healthful ones.
    Several years ago, my organization took a stab at that by
developing not a triangle, but a real pyramid, four sides, that
divided foods into the good, the medium and the seldom foods.
And there are various other graphic ways to distinguish between
the better or worse foods within a category.
    The Dietary Guidelines for Americans, a very different
document, provides more valid advice than the pyramid, and
serves as a useful reference for nutritionists and journalists.
It should be updated, and it's timely to have a review.
    I think many people will have views on whether to include
omegas-3 fatty acids or whatever. However, no matter what it
says, the public never sees anything beyond the headlines.
    Several of those headlines need to use clearer, stronger
language and highlight specific foods to avoid. For instance,
one guideline admonishes people to choose a diet low in
saturated fat and cholesterol and moderate in total fat. To be
more useful to the average person, it should say something
like, ``Eat less meat, cheese and egg yolks.''
    Senator Fitzgerald. Doctor, can I interrupt you for a
second to give special dispensation to Senator Specter to
introduce his friend, Dr. Ornish. And I apologize for this
interruption, and I hope you'll forgive me, but I need to be
mindful of Senator Specter's time. And I will go right back to
you right after that.
    Mr. Jacobson. Of course.
    Well, thank you. I only wish I had as generous an
introduction from the Senator from Washington, D.C.
    [Laughter.]
    That will have to wait. As I was saying----
    Senator Specter. I can stay and reintroduce you.
    [Laughter.]
    Mr. Jacobson. As I was saying, for Dietary Guidelines for
Americans, most people don't see beyond the actual ten, there
are ten now, Guidelines. Several of the Guidelines need to use
clearer, stronger language.
    Instead of saying, ``Choose a diet that is low in saturated
fat and cholesterol and moderate in total fat,'' which doesn't
connect very well with my Aunt Esther, we need to use
something, language more like, ``Eat less meat, cheese and egg
yolks to reduce saturated fat and cholesterol.''
    Similarly, the guideline concerning sugars now reads,
``Choose beverages and foods to moderate your intake of
sugars.'' As you noted in your questioning, the food industry
forced the Government to replace the more candid word ``limit''
with the muddy ``moderate.''
    The Guideline could state, ``Consume less soda pop, candy
and other sweets to reduce your intake of sugars,'' and
similarly with other guidelines.
    Unfortunately, as you pointed out, when the Center for
Science and the Public Interest reviewed the members of this
committee, we found that there are numerous people with very
close ties to the food industry and were unlikely to get the
most useful guidelines possible.
    Just as you mentioned, having USDA co-oversee the
development of the Guidelines is like having the fox oversee
the chicken coop. We are putting the fox right in with the
chickens, in with this kind of committee, where a couple of
members of the Committee serve on boards of trustees of
industry trade associations.
    And there are plenty of distinguished people, distinguished
researchers who don't have those kinds of close corporate ties.
I've suggested to the Secretaries that they replace several
members of the Committee with people who don't have those kinds
of industrial biases.
    Most importantly, though, the Government does virtually
nothing to implement its dietary advice in terms of education
programs and food and agricultural policies. We live in a
society which automobiles, television, urban design, marketing
practices and the wealth to eat anything, at any time, conspire
to promote obesity, heart disease and other health problems.
    The Federal Government needs to lead a major effort to
promote better diets and more physical activity. However, the
Division of Nutrition and Physical Activity at the Centers for
Disease Control has an annual budget of only $35 million. That
compares to McDonald's one billion dollars plus marketing
budget, over a billion dollars just for that one company.
    A serious effort to promote health would include such
measures as requiring chain restaurants to list the calorie
content next to each item on menu boards and menus. We have got
nutrition information on packaged foods. It's high time that
people who went to restaurants got a modicum of nutrition
information.
    Several states in the District of Columbia are considering
legislation that would require calories on menu boards and in
menus. The Federal Government should consider similar
legislation.
    We need to protect children's health by getting soft drinks
and other unhealthful foods out of schools, and getting
commercials for junky foods off of TV shows watched by young
children. The CDC needs to mount well-funded media campaigns to
encourage people to eat healthier diets, to switch from white
bread to whole wheat bread, to replace soda pop with water or
fruit juice and the like, skim milk.
    We should be eating more fruits and vegetables. We need an
investment of several hundred million dollars a year.
    The Food and Drug Administration should help make shopping
easier by developing a healthy food symbol that companies could
use on labels to highlight the best choices. The Swedish
government did that several years ago.
    The Government needs to use its own facilities, from
Congressional cafeterias to upgrade that vegetable platter that
Senator Specter talked about, to Federal prisons, to Defense
Departments to the Defense Department commissaries and mess
halls. Government has a lot of reach. And state and local
governments could do the same.
    And Congress should explore pricing mechanisms, taxes,
subsidies and other means that would reduce the costs of the
most healthful foods, such as fruits and vegetables, and
increase the costs of the least healthful foods such as meat
and cheese. One simple option would be to give food stamp
recipients bonus coupons for fruits and vegetables.
    Well, I appreciate your attention. Thank you very much,
sir.
    Senator Fitzgerald. Thank you, Mr. Jacobson. With the
consent of the Committee, I would like the Committee record to
show no interruption in your testimony, and to show Senator
Specter's introduction of Dr. Ornish immediately following.
    [The prepared statement of Mr. Jacobson follows:]

 Prepared Statement of Michael F. Jacobson, Ph.D., Executive Director,
               Center for Science in the Public Interest
    Thank you very much for holding this hearing and inviting me to
testify. I would like to emphasize three major points. The first two
concern the Federal government's dietary advice to the public through
the Food Guide Pyramid and Dietary Guidelines for Americans. The third
concerns the utter failure--or inability--of the government to
translate its dietary advice into improved diets.
    The basic problem with the Food Guide Pyramid is its failure to
distinguish between better and worse foods within a food group. Thus,
the dairy group mixes fat-free milk with high-fat cheese. The protein
group mixes fatty meat with wholesome beans and fish. The grains group
mixes white bread with whole wheat bread. Thus, one could follow the
pyramid's advice and have either a terrific diet or an awful diet. The
pyramid needs to be revised so as to encourage people to eat more of
the most healthful foods and less of the least healthful. My
organization did that several years ago by creating a real pyramid that
separates each category of food into ``anytime,'' ``in moderation,''
and ``seldom'' foods.
    Turning now to the Dietary Guidelines for Americans, it provides
more valid dietary advice and serves as a useful reference for
nutritionists and journalists. However, the general public never sees
anything beyond the 10 headlines. For starters, 10 items is far too
many to keep in mind. That number should be reduced.
    More importantly, several headlines need to use clearer, stronger
language and highlight specific foods to avoid. For instance, one
guideline admonishes people to ``Choose a diet that is low in saturated
fat and cholesterol and moderate in total fat.'' To be more useful to
the average person, it should say something like: ``Eat less meat,
cheese, and egg yolks to reduce saturated fat and cholesterol.''
Similarly, the guideline concerning sugars now reads ``Choose beverages
and foods to moderate your intake of sugars.'' The food industry forced
the government to replace the more candid word ``limit'' with the muddy
``moderate.'' The guideline should state: ``Consume less soda pop,
candy, and other sweets to reduce your intake of sugars.'' The
guideline stating ``Choose and prepare foods with less salt'' could be
strengthened by stating ``Cut your salt intake by eating fewer salty
processed foods and restaurant meals.'' Unfortunately, the Committee
recently chosen to revise the Dietary Guidelines includes numerous
people with such close ties to the food industry that we are unlikely
to get the most useful guidelines.
    Most importantly, though, the government does virtually nothing to
implement its dietary advice in terms of education programs and food
and agriculture policies. We live in a society in which automobiles,
television, urban design, marketing practices, and the wealth to eat
anything at any time conspire to promote obesity, heart disease, and
other health problems. The Federal Government needs to lead a major
effort to promote better diets and more physical activity. However, the
division of nutrition and physical activity at the Centers for Disease
Control has an annual budget of only about $35 million. That compares
to McDonald's $1 billion-plus marketing budget. A serious effort to
promote health would include such measures as:

   requiring chain restaurants to list the calorie content next
        to each item on menu boards and menus;

   banning soft drinks and other junk foods from schools;

   getting commercials for junky foods off of television shows
        watched by young children;

   mounting mass-media campaigns to encourage people to improve
        their diets, such as by replacing white bread with whole wheat
        bread; soft drinks with water, fat-free milk, or fruit juice;
        and eating more fruits and vegetables. To be effective, such
        programs need to be funded at a level of several hundred
        million dollars per year.

    In addition, the government should:

   devise a ``healthy food'' symbol that companies could use on
        food labels to highlight the best choices in grocery stores.
        The Swedish government has done that.

   Also, the government needs to use its own facilities, from
        congressional cafeterias to Federal prisons to Defense
        Department commissaries and mess halls, to improve diets, and

   it needs to develop pricing mechanisms that would reduce the
        costs of the most healthful foods--such as fruits and
        vegetables--and increase the costs of the least healthful
        foods--such as meat and cheese.

    Thank you very much.

    Senator Fitzgerald. So, Senator Specter from Pennsylvania,
welcome.

               STATEMENT OF HON. ARLEN SPECTER,
                 U.S. SENATOR FROM PENNSYLVANIA

    Senator Specter. Thank you very much, Mr. Chairman. I was
told to arrive at 3:30, and I got here at 3:29.
    [Laughter.]
    Senator Specter. But I can see with your customary
efficiency, Senator Fitzgerald, you are ahead of the curve as
usual. And I appreciate being in your hearing room.
    I might say publicly that you are an outstanding Senator.
And there are 99 of your colleagues who are very regretful that
you have decided to return to the private sector and your
family. We are going to miss you here.
    Senator Fitzgerald. Thank you.
    Senator Specter. And thank you for presiding at this
hearing. It is my pleasure to introduce a very distinguished
American doctor, Dean Ornish, who is the originator and
principal behind the Preventive Medicine Institute at
Sausalito.
    Dr. Ornish has an outstanding academic career, a summa cum
laude from the University of Texas, Baylor Medical School,
Harvard Medical School, Massachusetts General Hospital, and has
written five books; identified as one of the most interesting
men in America, people in America, pardon me, ladies, in 1996;
and perhaps most significantly has been a leader in a very
unusual approach to illness in working on retrogression of
heart ailments.
    Dr. Ornish has developed a technique and a procedure for
reducing the calcification in blood vessels, not just stopping
it, but reducing it. He talks about a variety of text-made
stress control and yoga and diet and exercise. And now he's
working on, and I think is in the latter stages, of
establishing the scientific proof of retrogression of prostate
cancer, so that he is an outstanding leader, a young man, but
has made really remarkable progress in quite a number of
fields.
    He has been a witness on two occasions before the
Subcommittee which I chair on Labor, Health, Human Services,
and Education. And having gotten a last copy of his testimony,
I can tell you it is substantive, substantial and very much
worthwhile.
    When he talks about obesity, he has special expertise. All
you have to do is look at him and know that he has special
expertise in obesity, because he is not.
    His forte is of special interest to me for another reason.
My son has a Ph.D. in nutrition, and been a professor--an
assistant professor at Penn State for 3 years and done
extensive research and has worked--has crossed paths with Dr.
Ornish.
    And our son, Steve, is now a medical student at the
University of Vermont. Take his background in obesity, in the
clinical work, and it is a very, very important field. And the
Senate and the Congress and our Subcommittee, my Subcommittee
has done extensive work on it so that it is a very big item.
    Just on one personal note, we had a hearing with a
distinguished panel as you have today, a different panel on
stress reduction. And afterward we went to the Senate dining
room for lunch. And everyone had fish, except for Dr. Ornish
who had a vegetable platter.
    And the Senate is not known for its vegetable platters. It
was not haute cuisine, but Dr. Ornish truly was disciplined,
was practicing non-obesity at the time.
    Thank you very much, Mr. Chairman. And I thank the panelist
in the middle of his presentation for letting me interrupt. As
Senator Fitzgerald knows, this is a job at 100 miles an hour on
roller skates, and we are always supposed to be someplace else
10 minutes ago. So thank you.
    Senator Fitzgerald. Well, Senator Specter, thank you very
much for that wonderful and very heartfelt introduction of Dr.
Ornish. We appreciate you coming by.
    And, Dr. Ornish, having had that great introduction by
Senator Specter, why don't you go ahead. Thank you.

            STATEMENT OF DEAN ORNISH, M.D., FOUNDER

          AND PRESIDENT, PREVENTIVE MEDICINE RESEARCH

           INSTITUTE, CLINICAL PROFESSOR OF MEDICINE,

            UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

    Dr. Ornish. Thank you, Senator Fitzgerald. I'm honored to
be here along with my distinguished colleagues and the visitors
here.
    I'm going to try to cover a lot of information fairly
quickly. I also want to assume your leadership in this area,
which I particularly appreciate.
    I first want to talk about some of the things that Specter
alluded to, to demonstrate how powerful changes in diet and
lifestyle can be. Because people often think it has to be a new
drug or new laser or something really high-tech to be powerful.
    And as he indicated, we are able to demonstrate that even
severe heart disease often can reverse when people make much
bigger changes in diet and lifestyle than had heretofore been
recommended. And if you looked at these patients, which we
published in the Lancet and the Journal of the American Medical
Association and other peer review medical journals, if you took
the average amount of blockage in the coronary arteries, it got
worse after 1 year, the green line, and even worse after 5
years.
    This is the so-called natural history of heart disease. And
these people were following the conventional 30 percent
American Heart National Cholesterol Education Program Diet.
It's not enough to keep heart diseases even from getting worse.
But when people made bigger changes, they saw some reversal
after 1 year, and even more reversal after 5 years.
    There was a 90 percent reduction in the frequency of chest
pain. And 99 percent of the patients blood flow to the heart is
measured by cardiac PET scans, either to stop, to reverse the
progression of their heart disease. We all publish this in JAMA
as well.
    We are about to publish findings to see whether this can
affect the progression of prostate cancer in collaboration with
Dr. Peter Carroll at UCSF, and the late Dr. William Fair from
Sloan-Kettering. And we took men with biopsy-proven prostate
cancer and randomly divided them into two groups. Half of them
made these intensive changes in diet and lifestyle.
    Their PSA levels, which as you know is a marker for
prostate cancer, declined or improved in the experimental
group; rose or got worse in the control group. And when we
looked at the effect on the prostate tumors themselves grown in
a tissue culture, we found a sevenfold difference between the
groups that made these intensive changes compared to those who
didn't.
    We also have worked with Blue Cross/Blue Shield nationally
and through Highmark in Pennsylvania. They found that it
reduced their health care costs by half, both in those with and
those without coronary disease, whereas with the mass control
group, the patients didn't show those similar cost savings.
    So it's not only medically effective, but also cost
effective. And Medicare is now in the midst of conducting a
demonstration project in hospitals around the country that
we've trained through our nonprofit institute.
    Now, as you indicated, there is an obesity epidemic. Two-
thirds of American adults and 50 percent of children are
overweight.
    And just to illustrate that, these are not election
returns, but these are the incidence of obesity beginning in
1985. And as it gets darker blue, it's bad, 1986, 1987, 1988,
1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, a new category
in 1997 with 20 percent in red, 1998, 1999, 2000; and then in
2001, Mississippi, more than 25 percent of the people are
overweight or obese in that state.
    Now, why is that. There's a myth that you allude to in your
opening statement which is that there's a Dietary Guidelines
that said Americans should eat less fat. The percent of
calories in fat is lower. Americans are fatter than ever.
Therefore, the fat is not the culprit.
    But in fact the reality is that Americans are eating more
fat than ever but they are eating even more simple
carboydrates. So the percentage of calories from fat is lower,
but the actual amount of fat is higher than ever. So the goal
is to try to decrease both.
    Now, this is one way to lose weight that's very effective.
    [Laughter.]
    Dr. Ornish. But like most weight loss approaches, doesn't
last very long.
    There's no mystery in how you lose weight. You burn more
calories by exercising or you eat fewer calories, which is why
if you eat less food, you can lose weight on any diet. The
problem is people get hungry and they tend to get off the diet
and gain the weight back.
    The other way to eat fewer calories is to change not only
the amount of food but also the type of food. And if you eat
less fat, you are eating fewer calories, because fat has nine
calories per gram, whereas protein and carbohydrates have only
four.
    So when you eat less fat, you consume fewer calories
without having to eat less food. So you don't have the daily
battle of hunger deprivation if you reduce the fat, because fat
is so dense in calories.
    The other reason that people eat too many simple carbs, and
this is something that I think all of us here would agree on,
if they eat too many calories, if they eat too many simple
carbohydrates, these are things like sugar, white flour, white
rice, alcohol, with a high glycemic index.
    These get absorbed quickly, and so they make your blood
sugar spike. Your pancreas makes insulin to bring it back down,
which is good, but insulin also accelerates the conversion of
calories into fat, which is not good.
    And you can consume large amounts without getting full. You
can consume virtually unlimited amounts of sugar without
getting full.
    Where we differ, and certainly where Dr. Trager and Dr.
Atkins and I would differ, is where you go from there. And the
goal is not to go from simple carbs to bacon and pork rinds and
sausage, which are not health foods, but to complex
carbohydrates, things like fruits, vegetables, whole wheat
flour, brown rice, soy beans and so on in their natural forms.
    These are rich in fiber, which both slow the absorption of
the food so you don't get that rapid rise in blood sugar; you
don't get the insulin response. And the fiber fills you up
before you get too many calories. You can only eat so many
apples. You are going to get full before you get too many
calories.
    So whole foods are more dense in nutrients. They are less
dense in calories. And they are high in fiber. And they have a
low glycemic index.
    Again, all fats are not bad. Some are good. And the first
panel made reference to the omega-3 fatty acids which can in
small amounts reduce sudden cardiac death by 50 to 80 percent
or more. They can reduce the risk of prostate, breast and colon
cancer. And only three grams a day provide you these protective
benefits.
    So an optimal diet is both low in total fat and
particularly in saturated fat. It contains the necessary
amounts of omega-3 fatty acids, which is really only about
three grams a day; low in simple carbs and high in complex
carbs.
    And it's a specter. To the degree you move in that
direction, you are going to lose weight and gain health. So
it's not just what you exclude from a diet but also what you
include that's protective.
    And when you go from a typical American diet that's high in
animal protein, high in fat, high in saturated fat, high in
oxidants, to a low-fat, whole foods, plant-based diet, you are
not only reducing your intake of disease-promoting substances,
but you are getting a thousand others that are protective.
    Now, what about the Atkins diet. Because there has been a
lot of interest in that lately. And what makes it so seductive,
besides telling people what they want to hear, is that it's
based on a half truth. The half truth is that Americans do eat
too many simple carbs, and you do lose weight by eating fewer
of them.
    But the problem is that if you go to a high animal protein
diet, you are getting the exact opposite of what you want. You
are getting more disease-promoting substances and lower the
ones that are protective.
    Because protective ones, with few exceptions, are found in
fruits and vegetables and grains and beans. One study of the
Atkins diet funded by the Atkins Center in the American Journal
of Medicine, found that 70 percent were constipated, 65 percent
had bad breath, 54 percent had headaches.
    This is not a healthy way to eat. And you might lose weight
and start attracting people to you, but when they get too
close, then they are going to have a problem.
    [Laughter.]
    Dr. Ornish. More seriously, in a peer review journal last
year, was a case reported of a 16-year-old girl who died after
2 weeks on a high protein diet, and found that the potassium
and calcium were very low, which can predispose to that, which
we know often happens on high protein diets. The calcium and
potassium excretion is great.
    Also, osteoporosis, excuse me, renal function, may decline
in women in high animal protein diets. And osteoporosis is
higher as well.
    Now, you made reference in your opening statement, Senator,
about the two articles in the New England Journal of Medicine
about high protein diets. And the problem with these articles
is that they are not measuring disease. They are just measuring
risk factors, like triglycerides and weight.
    They also are not comparing to what I consider a healthy
diet. They are really comparing two diets, neither of which I
think is particularly helpful. They compare it to American
Heart Association, National Cholesterol Education Program Diet
which is not very low in fat and is very high in simple
carbohydrates. And they are not looking at long-term outcomes.
    What they found in those two studies was that the LDL
cholesterol, which is the most strongly linked with heart
disease, rose a little on the American Heart Association Diet,
and rose a little on the Atkins-type diet. So neither diet
really did very well.
    The triglycerides fell because, again, they were comparing
it to a high, simple carbohydrate diet. In contrast, in our
studies, we found a 40 percent reduction in healthy LDL
cholesterol. And none of those patients were taking
medications.
    Worse, the one study that's actually looked at what happens
to your heart when you go on a high protein diet, from Dr.
Richard Fleming, this was also published in a peer review
journal, Angiology, found if you look at the top two scans, the
upper left is the beginning, and the upper right is after a
year.
    Red is good in these scans. It means there's more blood to
the heart. And the blood flow improved on the low-fat diet. But
on the lower two, these are representative of a patient on a
high protein diet, the blood flow actually worsened.
    And so you can lose weight on an Atkins type diet, but you
may be harming your health in the process. We found the average
person in our study lost 25 pounds and was able to keep off
half that weight 5 years later. So we have long-term data.
    Fewer than 1 percent of people in the National Weight Loss
Registry have been able to lose weight and keep it off. And
keeping it off is the key. You can lose weight, but you can't
keep it off on these kinds of diets.
    The last thing I want to talk about are the Mediterranean
diets which are clearly a better diet, but it's not an optimal
diet. If you look at the incidence of heart disease, it's lower
in Mediterranean countries than the United States and England,
but still lower in rural China. And you find the same pattern
with breast cancer and prostate and colon cancer as well.
    So, in summary, when you switch from a diet that's high in
animal fat, animal protein and simple carbs, a typical American
diet in other words, to what I would consider a more optimal
diet, a low fat, whole foods diet; when you eat less fat, you
are getting fewer calories without having to eat less food.
    The high fiber content of the fruits, vegetables, grains
and beans reduces your insulin level. So you lose weight. You
don't get the rise in triglycerides and such. The fiber fills
you up before you get too many calories. You avoid the disease-
promoting substances and you get thousands of others that are
actually protective.
    So, therefore, an optimal diet is low in total fat, low in
saturated fat, has adequate omega-3 fatty acids, low in simple
carbs, high in complex carbs. It's not all or nothing. To the
degree you move in that direction, you are going to lose weight
and gain health. Thank you.
    [The prepared statement of Dr. Ornish follows:]

    Prepared Statement of Dean Ornish, M.D., Founder and President,
Preventive Medicine Research Institute, Clinical Professor of Medicine,

                University of California, San Francisco
    Mr. Chairman, distinguished colleagues, thank you very much for the
privilege of being here today. My name is Dean Ornish, M.D., founder
and president of the non-profit Preventive Medicine Research Institute
and Clinical Professor of Medicine at the School of Medicine,
University of California, San Francisco (UCSF). I appreciate the
opportunity to appear before this Committee.
    In Woody Allen's movie ``Sleeper,'' a man wakes up 200 years in the
future to find that science has proved deep-fried foods to be healthy.
Is the future here already?
    By now, many Americans are thoroughly exasperated by the seemingly
contradictory information in the press about what a sound diet is. I
often hear some people say, ``If the doctors can't make up their minds,
I'll eat whatever I want and quit worrying about it.''
    That would be unfortunate. Science can help people resolve
conflicting claims and to distinguish what sounds good from what is
proven to be true. Nowhere are the claims more conflicting than in the
area of diet and nutrition. Unfortunately, this is an area where
misinformation can make a huge difference to an individual's health and
well-being. Science requires rigorous evidence to support and defend
claims.
    For the past 25 years, my colleagues and I at the Preventive
Medicine Research Institute have conducted a series of scientific
studies and randomized clinical trials demonstrating, for the first
time, that the progression of even severe coronary heart disease often
can be reversed by making comprehensive changes in diet and lifestyle,
without coronary bypass surgery, angioplasty, or a lifetime of
cholesterol-lowering drugs. These findings were published in leading
peer-reviewed journals.1, 2, 3, 41, 46 Our recent research
indicates that a similar program may affect the progression of prostate
cancer as well.\4\ Along the way, we learned what is an optimal diet
for losing weight and keeping it off as well as how to motivate people
to make and maintain changes in diet and lifestyle.
    There is an epidemic of obesity facing America as well as in much
of the industrialized world. Some 300,000 Americans a year die from
illnesses caused or worsened by obesity, a toll that may soon overtake
tobacco as the chief cause of preventable deaths. Approximately 65
percent of adults and 15 percent of children are overweight or obese,
and that number is increasing.
    Why? Weight is a function of energy balance. There is no mystery in
how to lose weight: consume fewer calories and burn more calories.
However, many Americans are eating too many calories and burning too
few calories.
    Americans burn too few calories because they exercise less.
Cutbacks in physical education classes, the rise in labor-saving
devices, and the prevalence of television, video games, and computers
has reduced the amount of time that most Americans spend exercising
each day. For example, just 6 percent of schools require physical
education for high-school seniors. ``It's time to get children, ladies,
and gentlemen off the couch and onto the playground,'' said Health and
Human Services Secretary Tommy Thompson.
    Americans eat too many calories primarily because they eat too much
fat and too many simple carbohydrates. Also, portion sizes have
increased.
    One way to eat fewer calories is by consuming less food, which is
why people can lose weight on any diet that restricts portion sizes
sufficiently. However, it is hard to sustain weight loss because they
often feel hungry and deprived when they eat less. A panel of weight-
loss experts convened by the National Institutes of Health Nutrition
Coordinating Committee concluded that ``there is a strong tendency to
regain weight, with as much as two-thirds of the weight lost regained
within one year of completing the program and almost all by five
years.''
    An easier way to consume fewer calories is to be mindful of the
type of food as well as the amount of food.
    Any type of fat (saturated, monosaturated, or unsaturated) has nine
calories per gram whereas protein and carbohydrates have only four.
Thus, when you eat less fat, you consume fewer calories without eating
less food, thereby increasing satiety without adding calories. In
short, you can eat more and weigh less.\5\
    The other reason that Americans consume excessive calories is that
they often eat too many simple carbohydrates. These include sugar, high
fructose corn syrup, white flour, white rice, and alcohol. Because
these are low in fiber, large quantities of calories can be consumed
without feeling full.
    Also, the lack of fiber may cause these foods to be absorbed
quickly, causing blood glucose levels to spike too high. Your body
responds by making more insulin, but too much insulin accelerates the
conversion of calories into triglycerides, which increases body fat and
raises triglycerides levels. In addition, these insulin surges may
cause a reactive hypoglycemia (low blood sugar), increasing hunger and
a desire to eat more simple carbohydrates in a vicious cycle, sometimes
called ``carbohydrate cravings.''
    Insulin enhances the growth and proliferation of arterial smooth
muscle cells, which may worsen coronary artery blockages
(atherosclerosis).\6\ Over time, insulin surges may lead to insulin
resistance, causing further weight gain and may contribute to diabetes.
Insulin also increases the secretion of lipoprotein lipase, increasing
the uptake of fat into cells, leading to weight gain.\7\
    The message of some recent articles has been, ``Americans have been
told to eat less fat, the percentage of calories from fat is lower yet
Americans are more overweight than ever. Thus, dietary fat is not
responsible for obesity.'' 8, 9 Actually, per capita
consumption of fat has risen by 10 pounds/year since 1975 whereas per
capita consumption of simple carbohydrates has increased even more, by
20 pounds/year. In other words, Americans are eating more fat than
ever, but they are consuming even more simple carbohydrates, so while
the percentage of calories from fat may be lower, the amount of dietary
fat is higher than ever.
    I agree with high-protein advocates such as the late Dr. Robert
Atkins that many Americans eat excessive amounts of simple
carbohydrates. The diagnosis is correct, but the prescription is wrong.
The solution is not to go from simple carbohydrates to pork rinds,
bacon, and brie, because these are high in fat (and thus dense in
calories) as well as high in disease-promoting substances such as
cholesterol, saturated fat, and oxidants.
    A better approach is to reduce the intake of simple carbohydrates
and increase the consumption of complex carbohydrates (also called
``whole foods''). These include fruits, vegetables, legumes, and whole
grains such as brown rice and whole wheat flour in their natural forms.
    These foods are naturally high in fiber, which slows their
absorption, preventing a rapid rise in blood sugar. Fiber also fills
you up before you eat too many calories, whereas you can eat large
amounts of sugar without feeling full. In summary, whole foods are more
dense in nutrients, less dense in calories, and high in fiber.
    In the Coronary Artery Risk Development in Young Adults (CARDIA)
Study, for example, 2,909 healthy black and white adults, 18 to 30
years of age, were followed over 10 years. Body weight was inversely
associated with dietary fiber and carbohydrate and positively
associated with protein intake.\10\ Meat has virtually no dietary
fiber.
    In addition, complex carbohydrates are low in disease-promoting
substances such as cholesterol, saturated fat, and oxidants and have at
least a thousand substances that are protective. There is growing
interest in what are known as ``functional foods,'' i.e., foods
containing substances that are disease-preventing and health promoting
beyond the traditional nutrients such as the amount of fat, protein,
and carbohydrates that they contain. These include phytochemicals,
bioflavinoids, carotenoids such as lycopene, retinols, sulforaphanes,
isoflavones, lignans, geninstein, polyphenols, and other nutrients that
have anti-cancer, anti-heart disease and anti-aging properties and may
reduce the risk of many chronic diseases.\11\ In other words, what we
include in our diets is as important as what we exclude.
What is the evidence that complex carbohydrates are beneficial?
    Increased whole-grain intake was associated with decreased risk of
coronary heart disease in 75,521 women followed for 10 years.\12\ A
diet high in whole grains was associated with a reduced risk of type 2
diabetes in 42,898 men followed for 12 years. The relative risk of
developing type 2 diabetes was 58 percent lower when comparing the
highest with the lowest quintile of whole-grain intake.\13\
    Whole-grain consumption improves insulin sensitivity in overweight
and obese adults.\14\ 11,040 postmenopausal women who enrolled were
matched on total grain fiber intake, but differing in the proportion of
fiber consumed from whole vs. refined grain, were followed for 11
years. Fiber from whole grains, but not refined grains, was inversely
associated with all-cause mortality.\15\ Total fat and animal fat
intake were higher and carbohydrate intake was lower in those with
recently-diagnosed diabetes or previously-undiagnosed diabetes in the
multinational, multicenter study of the Mediterranean Group for the
Study of Diabetes.\16\
    In the Iowa Women's Health Study, fiber from whole grains (complex
carbohydrates), but not refined grains (simple carbohydrates), was
inversely associated with all-cause mortality in 11,040 postmenopausal
women followed for 11 years.\17\ In other words, the women who consumed
more complex carbohydrates lived longer than those who consumed more
simple carbohydrates.
What is the evidence that high protein diets may be harmful?
    There has been a resurgence of interest in low-carbohydrate, high-
fat diets such as the Atkins diet, so it may be useful to spend a few
minutes discussing it. Just about everyone knows someone who has lost
weight on this kind of diet. Given the American epidemic of obesity,
isn't that good?
    Not necessarily. The goal is not just to lose weight, but to lose
weight in a way that enhances your health rather than potentially
harming it and allows you to lose weight safely and to keep it off.
Losing weight is important, but the history of medicine is replete with
examples of weight-loss approaches that were harmful to health (e.g.,
amphetamines, fen-phen). When you go on a high-protein, high-fat diet,
you may temporarily lose weight (because you are eating fewer simple
carbohydrates), but you may also harm your health in the process. Also,
fewer than 1 percent of people in the National Weight Loss Registry
maintain their lower weight using a high protein diet. Most successful
people use a low-fat diet to lose weight and maintain lost weight.\18\
    A wide body of scientific evidence links the consumption of animal
protein, saturated fat, and cholesterol with cardiovascular disease,
cancer, and other chronic illnesses.19, 20, 21, 22, 23 High
protein diets may cause loss of calcium and decreased levels of urinary
citrate, leading to osteoporosis and kidney stones.\24\ Urinary
excretions of calcium and acids are higher after intake of animal
protein but are lower after plant-protein intake.\25\ Ketone bodies
formed on a high protein diet result in the loss of calcium, magnesium,
and potassium.26, 27
    Recently, a case report in a peer-reviewed journal described the
fatal ventricular fibrillation cardiac arrest of a sixteen-year-old
girl who had started a high protein/low carbohydrate diet two weeks
earlier and presented with profound hypokalemia (low potassium levels)
during resuscitation attempts.\28\ A high protein diet may increase
postprandial lipemia and increases in free fatty acids which may have
harmful effects on platelet aggregation (blood clots) and may promote
ventricular arrhythmias (dangerous irregular
heartbeats).29, 30
    In one of the few peer-reviewed journal articles that studied an
Atkins diet, 70 percent of patients were constipated, 65 percent had
halitosis, 54 percent reported headaches, and 10 percent had hair loss
during six months on a high protein/low carbohydrate diet.\31\ These
findings may be due to the fact that your body excretes toxic
substances through your breath, bowels, and perspiration.
    High total protein intake, particularly high intake of nondairy
animal protein, may accelerate renal (kidney) function decline.\32\ In
a randomized controlled trial, ketogenic diets impaired cognitive
performance in higher order mental processing after only one week.\33\
Why are some studies claiming that a high protein diet is better than a
        ``low-fat'' diet?
    Three recent studies suggested that a high protein diet is better
than a ``low-fat diet'' with respect to short-term changes in weight,
triglycerides, and HDL-cholesterol (HDL-C).31, 34, 35
However, the high protein diet was compared to a conventional 30
percent-fat American Heart Association/National Cholesterol Education
Program diet which was not very low in fat and was high in simple
carbohydrates.
    Neither a high protein diet nor a 30 percent-fat diet is very
effective in lowering the harmful LDL-cholesterol (LDL-C) or in
maintaining long-term weight loss.\36\ Thus, these studies showed that
both diets were comparably ineffective.
    A high protein diet will lower triglyceride levels in someone who
is eating a typical American diet or an AHA/NCEP diet that is high in
simple carbohydrates. As described earlier, a diet high in simple
carbohydrates causes insulin surges, and insulin stimulates the liver
to make more cholesterol (by stimulating an enzyme called HMG-CoA
reductase, which cholesterol-lowering drugs such as statins inhibit).
This explains why high protein diets do not always exacerbate
hypercholesterolemia.\37\ To some, the fact that a high protein diet
does not raise LDL-C very much is surprising given the amount of
saturated fat and cholesterol in the diet. This is somewhat akin to the
story of Dr. Johnson's dog walking on its hind legs: it doesn't do it
very well, but it's amazing it can do it at all.
    A 30 percent-fat diet reduces LDL-C by only about 5-7 percent in
most patients.38, 39, 40 Also, since a 30 percent diet is
usually high in simple carbohydrates (which increase triglycerides), a
high protein diet often shows a greater reduction in triglycerides than
a 30 percent-fat diet.
    However, in our studies we found that a diet much lower in fat (10
percent of calories), low in simple carbohydrates and high in complex
carbohydrates decreased LDL-C much more than a 30 percent fat diet: by
40 percent rather than only 5-7 percent after one year in ambulatory
patients not taking lipid-lowering drugs.\41\ This is comparable to
what can be achieved by taking cholesterol-lowering drugs but at a
fraction of the cost, and without potentially harmful side-effects.
    In another study, 100 people were randomly assigned to one of four
diets for one year: a high protein diet; a 30 percent-fat diet; a 15
percent fat calorie-controlled diet; or a 10 percent-fat whole foods
diet with an emphasis on complex carbohydrates. Weight loss was one
pound/week on the 10 percent-fat diet and 0.6 pound/week on the high
protein diet. Reductions in total cholesterol (TC), LDL-C,
triglycerides, and TC/HDL ratios were significant only in patients
either following a 10 percent-fat diet or a 15 percent fat calorie-
controlled diet. Only patients following the high protein diet showed a
worsening of each cardiovascular disease risk factor (LDL-C,
triglycerides, TC, HDL-C, TC/HDL ratio, homocysteine, Lp(a), and
fibrinogen), despite achieving statistically significant weight loss.
After one year, there was a 52 percent decrease in LDL-C on the 10
percent-fat diet whereas there was a 6 percent increase in LDL-C on the
high protein diet.\42\
Need to distinguish between risk factors and actual measures of disease
    Dr. Atkins claimed that his diet can reverse coronary heart disease
but never published any peer-reviewed data to support this assertion,
nor has anyone else.\43\ Unfortunately, most studies of a high protein
diet measured only risk factors such as weight and lipids rather than
examining the underlying disease processes.
    The only study to do so found that blood flow to the heart improved
on a very low-fat whole foods diet but actually worsened on a high
protein diet.\44\ Serial coronary arteriography in coronary heart
disease patients consuming a conventional 30 percent-fat AHA/NCEP diet
revealed that the majority showed progression (worsening) of coronary
atherosclerosis.38, 45 However, coronary heart disease
patients who followed a 10 percent-fat diet demonstrated significant
regression of coronary atherosclerosis after one year as measured by
quantitative coronary arteriography and even more regression after five
years (the amount of exercise was not significantly different between
groups).\45\ There was a direct correlation between the intake of
dietary cholesterol and fat and changes in coronary atherosclerosis.
They also had 2.5 times fewer cardiac events than the control group. In
contrast, control group patients following a 30 percent-fat AHA/NCEP
diet showed even more progression of atherosclerosis after five years
than after one year. Also, 99 percent of experimental group patients
were able to stop or reverse the progression of coronary heart disease
as measured by cardiac PET scans.\46\
    HDL-C decreased 9 percent, yet they showed clear improvement in
coronary atherosclerosis (blockages), myocardial perfusion (blood flow
to the heart), and cardiac events. Thus, we need to move beyond
simplistic notions that anything which raises HDL-C is beneficial and
anything that lowers HDL-C is harmful. There are no data showing that
the physiologic reduction of HDL-C levels with a low-fat diet is
detrimental.\47\
    In countries such as Asia where a low-fat diet has been the norm,
HDL-C levels are low yet the incidence of cardiovascular disease is
among the lowest in the world. HDL returns cholesterol to the liver, a
pathway known as reverse cholesterol transport. Most Americans consume
a diet high in saturated fat and cholesterol, so those who are able to
increase HDL-C are at lower risk than those who cannot, since they will
be more efficient at metabolizing excessive dietary fat and
cholesterol. However, reducing dietary fat and cholesterol may cause a
decrease in HDL-C because there is less need for it. This does not
confer the same risk of atherosclerosis as in Americans with low HDL
levels who are consuming a high-fat diet.\48\
    In simple terms, when you have less garbage (saturated fat and
cholesterol), you need fewer garbage trucks (HDL-C) to remove it.
Eating a stick of butter will raise HDL-C in those who are able to do
so, but that does not mean that butter is good for the heart. Decreases
in HDL-C due to a low-fat diet have a very different prognostic
significance than someone who cannot raise HDL-C on a high-fat diet.
Are some fats good for you?
    Yes. Just as complex carbohydrates are beneficial but simple
carbohydrates can be harmful, some fats are beneficial and others are
harmful. Trans fatty acids are generally considered to be harmful.
Because of this, the FDA is now requiring the labeling of trans fatty
acid content on food items.
    Trans fatty acids are found in many of the fast, baked, and
processed foods that Americans love to eat. Food manufacturers often
put oils through a process called ``hydrogenation'' which extends the
shelf life of products. Unfortunately, it may decrease the ``shelf
life'' of those who eat them. For example, one study found that just a
2 percent increase in trans fatty acid intake caused a 25 percent jump
in the risk of heart disease.\49\
    On the other hand, the omega-3 fatty acids can substantially reduce
the incidence of sudden cardiac death and may help prevent some forms
of cancer. Only three grams per day of fish oil may reduce sudden
cardiac death by up to 50 percent. More than this amount provides no
significant additional benefits.\50\
    Saturated fats, which are rich in butter and red meat, for example,
raise the harmful LDL-cholesterol and are associated with both heart
disease and many of the most common forms of cancer, including prostate
cancer, breast cancer, and colon cancer. Monosaturated fats are more
neutral. Polyunsaturated fats may help prevent against heart disease
but may increase the risk of some forms of cancer; this is
controversial and is actively being studied.
    I have been working with senior management of PepsiCo during the
past two years in helping them to develop a variety of more healthful
products at their companies, including Tropicana, Quaker Oats,
Gatorade, Aquafina, Frito-Lay, and Lipton. We began with the commitment
to substantially reduce or eliminate trans fatty acids from most of
their products, which was announced earlier this year. I hope they
inspire other food companies to follow their lead.
    We are also developing nutrition and exercise education materials
for schools and for the general public. When companies like PepsiCo use
their marketing resources and expertise to educate people about the
benefits of healthy lifestyles and to provide more healthful products
that are convenient and tasty, then the health of our country may
improve. Also, they can help change attitudes to make it fun and
exciting to exercise and eat right rather than having it seem about
boredom and deprivation.
Do we need a new food pyramid?
    I agree with Dr. Walter Willett who has proposed a pioneering
restructuring of the USDA food pyramid to reflect the latest research
findings described in this testimony.\51\ The only point of difference,
which is relatively minor, is the emphasis on increasing the intake of
olive oil for most Americans.
    Olive oil is clearly a better choice than oils that are high in
saturated fat. However, olive oil lowers LDL-cholesterol only when it
is consumed instead of oils that are higher in saturated fat. Since
olive oil is 14 percent saturated fat, increasing the consumption of
olive oil may increase the consumption of saturated fat unless it is
done as a substitute for foods that are higher in saturated fat. In one
study, olive oil reduced blood flow by 34 percent within hours and
impaired the function of cells lining the arteries (endothelium).\52\
    In addition, a balanced intake of omega-3 fatty acids and omega-6
fatty acids may be desirable, but the ratio of omega-6 fatty acids to
omega-3 fatty acids in the typical American diet is 20:1. The ratio of
omega-6 fatty acids to omega-3 fatty acids in olive oil is 10:1, so
consuming a lot of olive oil may worsen this ratio. And olive oil has
almost none of the beneficial omega-3 fatty acids.
    Also, since all oils are 100 percent fat, and fat has nine
calories/gram (as described earlier), increasing the intake of olive
oil is likely to increase the consumption of calories, causing weight
gain.
    The Mediterranean diet is clearly a better diet than a typical
American diet,\53\ but an Asian diet may be even better. Beneficial
components of the Mediterranean diet include antioxidant-rich foods
such as vegetables, fruits, and omega-3-rich fish and canola oils.
Heart disease, breast cancer, prostate cancer, and colon cancer are
even lower in those consuming an Asian diet than a Mediterranean diet.
What are effective strategies in motivating people to make and maintain
        beneficial changes in diet and lifestyle?
    In general, my colleagues and I have found two basic approaches are
effective. The first is to make small, incremental changes such as
walking 2,000 steps more per day and to consume 100 calories less per
day. Over time, these small changes add up and make a meaningful
difference. This is the approach popularized by Dr. James Hill in his
program, ``America on the Move.''
    A second approach is to motivate people to make more intensive
changes in diet and lifestyle. Paradoxically, some people find it
easier to make big changes than small ones because when they make
comprehensive changes in diet and lifestyle, they often feel so much
better, so quickly, that it reframes the reason for making these
changes from fear of dying to joy of living.
    Alterations in diet, for example, may affect blood flow within
hours, for better and for worse.\54\ After a whole foods, low-fat meal,
blood flow to the brain may improve, so people often describe feeling
more alert and aware. Blood flow to the heart often improves; in our
studies, most patients reported dramatic reductions in the frequency of
angina within a few weeks. Erectile dysfunction may improve as blood
flow increases to sexual organs.55, 56 Most patients are
able to lose weight and keep it off.
    One of the most effective anti-smoking campaigns was organized by
the California Department of Health Services. Billboards featured a
``Marlboro Man'' character with a limp cigarette hanging out of his
mouth with the headline, ``Smoking causes impotence.'' For many men,
this is more motivating than ``smoking causes heart attacks and
emphysema,'' which are too frightening to contemplate.
    Many patients say that there is no point in giving up something
that they enjoy unless they get something back that's even better--not
years later, but weeks later. Then the choices become clearer and, for
many patients, worth making. They experience that something beneficial
and meaningful is quickly happening.
    The benefit of feeling better quickly is a powerful motivator and
reframes therapeutic goals from prevention or risk factor modification
to improvement in the quality of life. To these patients, concepts such
as ``risk factor modification'' and ``prevention'' are considered
boring and they do not initiate or sustain the levels of motivation
needed to make intensive lifestyle changes. ``Am I going to live
longer, or is it just going to seem longer?''
    In our experience, it is not enough to focus only on patient
behaviors such as diet; we often need to work at a deeper level.
Depression, loneliness, and lack of social support are epidemic in our
culture. These affect not only quality of life but also survival.
Several studies has shown that people who are lonely, depressed, and
isolated are many times more likely to get sick and die prematurely
than those who are not.\57\ In part, this is mediated by the fact that
they are more likely to engage in self-destructive behaviors when they
feel this way, but also via mechanisms that are not well-understood.
For example, many people overeat when they are stressed, lonely, or
depressed. They sometimes say, ``I use food to fill the void,'' or,
``Fat coats my nerves and numbs the emotional pain.''
    In summary, an optimal diet for most people is low in both fat and
in simple carbohydrates and high in complex carbohydrates, based
predominantly on fruits, vegetables, whole grains, and legumes in their
natural forms, with moderate amounts of fish or fish oil to provide
protective omega-3 fatty acids.
    Changing from a diet high in fat, animal protein, and simple
carbohydrates to a low-fat, whole foods diet provides many benefits:

   When you eat less fat, you eat fewer calories without eating
        less food;

   The high fiber content of fruits, vegetables, grains, and
        beans reduces insulin levels, so you lose weight and lower
        cholesterol levels;

   Fiber fills you up before you get too many calories;

   You avoid the foods rich in substances that promote
        illnesses; and

   You get thousands of other substances that are protective.

    It's not all or nothing; you have a spectrum of choices. To the
degree you reduce your intake of simple carbohydrates and excessive
fat, then you may lose weight and gain health.
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on weight loss and cardiovascular disease risk factors. Preventive
Cardiology. 2002; 5(3):110-8.
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of Cardiology 50th Annual Scientific Sessions, Orlando, Florida, March
20, 2001.
    \44\ Fleming R, Boyd LB. The effect of high-protein diets on
coronary blood flow. Angiology. 2000; 51:817-826.
    \45\ Ornish D, Hart J. Intensive Risk Factor Modification. In:
Hennekens C, Manson J, eds. Clinical Trials in Cardiovascular Disease.
Boston: W.B. Saunders, 1998.
    \46\ Gould KL, Ornish D, Scherwitz L, et al., Changes in myocardial
perfusion abnormalities by positron emission tomography after long-
term, intense risk factor modification. JAMA. 1995; 274:894-901.
    \47\ Connor WE, Connor SL. The case for a low-fat, high-
carbohydrate diet. N Engl J Med. 1997; 337(8):562-563.
    \48\ Bonow RO, Eckel RH. Diet, obesity, and cardiovascular risk. N
Engl J Med. 2003; 348:2057.
    \49\ Oomen CM, Ocke MC, Feskens EJ, et al., Association between
trans fatty acid intake and 10-year risk of coronary heart disease in
the Zutphen Elderly Study: a prospective population-based study.
Lancet. 2001; 357(9258):746-51.
    \50\ Leaf A, Weber PC. Cardiovascular effects of n-3 fatty acids. N
Engl J Med. 1998; 318(9):549-57.
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Scientific American, December 17, 2002.
    \52\ Vogel RA, Corretti MC, Plotnick GD. The postprandial effect of
components of the Mediterranean diet on endothelial function. Journal
of the American College of Cardiology. 2000; 36(5):1455-60.
    \53\ de Lorgeril M. Salen P. Martin JL. Monjaud I. Delaye J.
Mamelle N. Mediterranean diet, traditional risk factors, and the rate
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report of the Lyon Diet Heart Study. Circulation. 1999; 16;99(6):733-5.
    \54\ Vogel RA, Corretti MC, Plotnick GD. A single high-fat meal
transiently impairs endothelial function and blood flow. Am J Cardiol.
1997; 79:350-354.
    \55\ Butler RN, et al., Geriatrics. 1994; 49(10):27-32.
    \56\ Kim JH, et al., Journal of Urology. 1994; 151(1):198-205.
    \57\ Ornish D. Love & Survival: The Scientific Basis for the
Healing Power of Intimacy. New York: HarperCollins, 1998.

    Senator Fitzgerald. Dr. Ornish, thank you very much. Dr.
Willett.

          STATEMENT OF WALTER C. WILLETT, MD, Dr.P.H.,

         FREDRICK JOHN STARE PROFESSOR OF EPIDEMIOLOGY

          AND NUTRITION, DEPARTMENTS OF NUTRITION AND

         EPIDEMIOLOGY, HARVARD SCHOOL OF PUBLIC HEALTH

    Dr. Willett. Thanks very much. I really appreciate the fact
that you are holding this hearing and looking seriously at
these tremendous problems that we face. I will skip most of
what I was going to give for background.
    Senator Fitzgerald. Would you pull that microphone over?
    Dr. Willett. Sure. I'll skip what I was going to talk about
in terms of background because you very well I think indicated
and described the health crisis that we are facing here. I just
might add that the full price in terms of this epidemic of
overweight and obesity is yet to be paid, both in human cost
and in health costs, because it probably will lag at least 30
years or so before you really see all of the diabetes, the so-
called renal failure and complications of that. So we haven't
really seen the full price at all up until this point in time.
    We have had this growing problem of overweight and
diabetes. I might also add that we had made, until the mid-
1980s, great progress in reducing the incidence in mortality
from coronary heart disease and stroke. And beginning in about
1980, our progress totally stalled in terms of further reducing
the incidence of coronary heart disease and mortality from
stroke. We made a little progress in----
    Senator Fitzgerald. Doctor, I'd ask you to pull the
microphone even closer. Thanks.
    Dr. Willett. Sure. We have had very little progress in
these really important health indicators. But on the other
hand, our long-term studies indicate that together with not
smoking and regular exercise, by making the right dietary
choices, we can reduce rates of heart disease by more than 80
percent, stroke by more than 70 percent, diabetes by more than
90 percent, and some cancers by more than 70 percent. So
there's huge potential for health improvements that we are not
taking advantage of now.
    Unfortunately, the current USDA Food Guide Pyramid fails to
provide useful guidance to the public, and has almost certainly
led many people to make food choices that have resulted in
premature death, because they avoided healthy fats in the diet
that prevent cardiac arrhythmias and sudden death.
    I think you have alluded to the core message of the pyramid
is to eat large amounts of starch and avoid all fats.
Randomized trials that have gone on for a year or more do not
show that reducing the percentage of calories from fat reduces
weight. And as you pointed out, that it does indicate for some
people that high carbohydrate diets actually makes it more
difficult to control weight.
    And without going into all of the details of this debate,
it's surprising how few good studies there have been of diet
and weight control in the long run. Just recently we are
starting to get a few studies. But given the importance of this
topic, the data are actually very limited. And we clearly need
to do more studies.
    In our long-term follow-up of over 100,000 men and women
funded by the National Institutes of Health, we saw no overall
benefit for those who most closely followed the dietary pyramid
and that really indicates a tremendous loss of opportunity that
we've had with the current pyramid.
    And, again, we also saw fatal increases in fatal heart
attacks among those consuming lower amounts of unsaturated fats
such as salad dressing, which is discouraged by the pyramid. As
Mr. Jacobson mentioned, there are really some very fundamental
flaws in the pyramid, mainly because the pyramid fails to
distinguish the types of fats that--trans fats and saturated
fats are something we want to limit, but unsaturated fats, and
it's not just omegas-3 fatty acids. Omega-6 fatty acids also
improve blood lipipds and reduce cardiac mortality.
    The pyramid promotes high intake of starches, and really
doesn't distinguish between whole grain and refined grain
adequately. And, in fact, refined grain really belongs with
sugar among the things that we should be using sparingly.
    Also, as pointed out earlier, the pyramid doesn't
distinguish among protein sources which have very different
implications for health. And the issue of high dairy
consumption, which I hesitate to talk about since I grew up in
Wisconsin, but this inevitably is going to introduce large
amounts of saturated fat into the food supply. And somebody
always eats it. And moreover, there's actually not good data
that the very high levels of dairy consumption are safe in the
long run.
    In view of these serious shortcomings, a major redrawing of
the pyramid is needed. The underlying principle should be that
the pyramid is based upon the best available scientific
evidence, and for this reason it should be more closely linked
to the U.S. Dietary Guidelines.
    They were not close together back in 1992 when the pyramid
was created, and the Guidelines as mentioned earlier have been
refined and moved farther and farther away from what the
pyramid is today. And I think we saw with wisdom that Congress
required that the Guidelines be reviewed every 5 years. Because
science does move forward. And we do continually need to make
refinements to bring it up to date and consistent with the best
available knowledge.
    And I do agree that responsibility for review and updating
of the Guidelines and pyramid should not be the primary
responsibility of the Department of Agriculture because of
conflicts of interest with agro-economic sectors that are
almost inevitable.
    A better arrangement would be to have the pyramid be the
primary responsibility of the Department of Health and Human
Services in consultation of course with USDA and other groups
of nutritionists within the Government, because the basic issue
is human health.
    Finally, the pyramid should undergo continuous evaluation
just as the Guidelines do. For example, we have done this using
our large prospective data bases, and we are prepared to work
with the Department of Agriculture on Health and Human Services
to, while their Guidelines are being revised, to evaluate in
our large populations where we can essentially look at how
people ate all the way from 1990, 1980 up until now, and see
how various choices influence the outcome.
    So we can simulate different combinations of dietary
choices as might be suggested by different guidelines and
actually assess what the estimated outcome would be. And we are
prepared to work with the national committees doing that job.
    Americans do deserve the very best guidance about dietary
choices because their health is at stake. And with a better
process for developing and refining our dietary advice, we can
make an important difference in the health and well-being of
our Nation. Thanks.
    [The prepared statement of Dr. Willett follows:]

  Prepared Statement of Walter C. Willett, MD, Dr.P.H., Fredrick John
Stare Professor of Epidemiology and Nutrition, Departments of Nutrition
           and Epidemiology, Harvard School of Public Health
The USDA Food Guide Pyramid: Lost Opportunity for Better Health
    The state of health and health care in the U.S. is alarming. Over
\2/3\ of the U.S. adult population is overweight or obese, and this
rate is growing rapidly. The long-term health consequences of this
epidemic are dire. Medical care costs are increasing at over 10 percent
per year, and the full costs of overweight and obesity have yet to be
experienced as they have a 10-30 year lag.
    On the other hand, our long-term studies indicate that, together
with not smoking and regular exercise, making the right dietary choices
can reduce rates of heart disease by more than 80 percent, stroke by
more than 70 percent, diabetes by over 90 percent and some cancers by
more than 70 percent.
    Unfortunately, the current USDA Food Guide Pyramid fails to provide
useful guidance to the public, and has almost certainly led many
persons to make food choices that have resulted in premature death. The
core message of the Pyramid is to eat large amounts of starch and avoid
all fats; randomized trials of one year or longer document that this
does not lead to better weight loss, and recent evidence suggests that
this may actually make weight control more difficult for many people.
In our long-term follow-up of over 100,000 men and women funded by the
NIH, we found no overall benefit for those who most closely followed
the Food Guide Pyramid. Also, we saw increases in fatal heart attacks
among those consuming lower amounts of unsaturated fats, such as in
salad dressing, which are discouraged by the Pyramid.
    Major flaws in the present Pyramid include:

    1.  Failure to distinguish types of fat, some of which are
        undesirable, such as trans and saturated fat, but unsaturated
        fats have a positive role in maintaining health.

    2.  Promotion of high intake of starches, whether refined or whole
        grain, which contribute to excessive calories and risks of
        diabetes and heart disease.

    3.  Failure to distinguish among protein sources, which have very
        different implications for health.

    4.  Promotion of high dairy consumption, which inevitably
        introduces large amounts of saturated fat into the food supply.

    In view of these serious shortcomings, a major redrawing of the
Pyramid is needed. The underlying principle should be that the Pyramid
is based on the best available scientific evidence. For this reason it
should be more closely linked with the U.S. Dietary Guidelines, which
are appropriately updated every five years at the request of Congress.
Responsibility for review and updating of the Pyramid should not be the
primary responsibility of USDA because conflicts of interest with agro-
economic sectors are almost inevitable. A better arrangement would be
to have the Pyramid be the primary responsibility of HHS in
consultation with USDA because the issue is human health.
    Finally, the Pyramid should undergo continuous evaluation. For
example, as we have done using large prospective databases, whether
adherence to the content of the Pyramid is associated with better long-
term health should be assessed. In addition, the ability of the Pyramid
to convey its content to various segments of the population needs to be
carefully evaluated.
    Americans deserve the very best guidance about dietary choices
because their health is at stake. With a better process for developing
and refining our dietary advice, we can make an important difference in
the health and wellbeing of our Nation.
References
    (1) Rebuilding the Food Pyramid. Walter C. Willett and Meir J.
Stampfer. Scientific American. Vol 288, No. 1, pages 52-59, January
2003.
    (2) Primary Prevention of Coronary Heart Disease in Women through
Diet and Lifestyle. Meir J. Stampfer, Frank B. Hu, JoAnn E. Manson,
Eric B. Rimm and Walter C. Willett. New England Journal of Medicine,
Vol 343, No. 1, pages 16-22; July 6, 2000.
    (3) Eat, Drink, and Be Healthy: The Harvard Medical School Guide to
Healthy Eating. Walter C. Willett, P. J. Skerrett and Edward L.
Giovannucci. Simon & Schuster, 2001
    (4) Dietary Reference Intakes for Energy, Carbohydrates, Fiber,
Fat, Protein and Amino Acids (Macronutrients). Food and Nutrition
Board, Institute of Medicine, National Academy of Sciences. National
Academies Press, 2002.

    Senator Fitzgerald. Dr. Willett, thank you very much. And
last but not least, Dr. Trager. Thank you for waiting
patiently.

                STATEMENT OF STUART TRAGER, MD,
                   ATKINS NUTRITIONALS, INC.

    Dr. Trager. Mr. Chairman, thank you for asking me to appear
before your Committee. I commend your leadership in trying to
tackle the serious national crisis in obesity.
    After following Dr. Ornish, it would be easy to think it's
a beauty pagent between diets. What is more important is that
we all remember the common enemy today is fighting obesity. It
is disheartening that as we fight to manage the rising costs of
health care and to improve the quality of life for our
population, research suggests that less than 20 percent of
individuals trying to lose or maintain their weight actually
follow recommendations to increase physical activity and reduce
their caloric consumption.
    As a physician and an orthopedic surgeon, I have seen the
difficulty my patients have eating less. And as a six-time Iron
Man triathlon finisher, I know a great deal about exercising
more.
    This is not about mortgaging your health, bad breath or
body odor. It is about recognizing that four-fifths of those
who want to take an active role in managing their weight have
abandoned recommendations to eat less and exercise more.
    With the incidence of obesity and overweight doubling in
our adult population, and tripling amongst our adolescents,
there's no longer time for continued repetition of a message
that has proven ineffective. We must look for new strategies
that in addition to being supported by medical science are more
likely to alter the course of this public health epidemic.
    To this end, I would like to review with you today some of
the emerging science supporting controlled carbohydrate
nutrition, a strategy that has worked for me and can help many
in their fight against obesity.
    Most notable of the recent prospective trials comparing
this approach with standard dietary intervention are studies
from Duke, University of Cincinnati, and a multicenter NIH-
funded pilot program conducted at the Universities of
Pennsylvania, Colorado and Washington that has been published
in the New England Journal of Medicine.
    In sharp contrast to many of the previous attempts to
discredit this nutritional strategy by simply comparing low and
high fat intake, investigators in these studies demonstrated
that by limiting carbohydrates, the principle that serves as
the cornerstone of this approach, individuals achieve equal or
greter weight loss than that seen with traditional
recommendations.
    Of equal importance, these results were achieved in
conjunction with consistently lowered triglyceride levels as
well as an increase in HDL cholesterol without significant
elevation of either LDL, bad cholesterol or total cholesterol.
In addition to showing efficacy, it is vital to recognize that
in none of these studies was there indication of any health
risk with this strategy. And in fact significant reduction in
established coronary risk factors was noted, as in the trial
completed at Duke University by Dr. Eric Westman, where
triglyceride to HDL ratio demonstrated an eightfold improvement
when carbohydrates were restricted.
    Furthermore, work by Dr. Jeffrey Volek from the University
of Connecticut has shed light on claims suggesting a controlled
carbohydrate program will lead to an unhealthy rise in post-
meal circulating fat levels within the bloodstream, showing
when carbohydrates are restricted, post-meal lipemia actually
decreased.
    Controlled carbohydrate nutrition is not only supported by
but also founded in science. At the center of this foundation
is the metabolic shift from carbohydrate-based energy
production to a physiologic state where energy for fuel is
derived from the oxidation or breakdown of stored fat.
    In addition to the weight loss that occurs from this
transition, Dr. Westman's work at Duke lends credence to the
anecdotal reports of people actually feeling better while
following this strategy, with 85 percent reporting improved
energy, 51 percent improved mood, and over one quarter of
subjects reporting lessened heartburn and pre-menstrual
symptoms.
    The Atkins Approach is a four-phase strategy addressing
initial obstacles like carbohydrate cravings as well as the far
more important goal of instilling life-long dietary and
physical activity modifications that we know yield lasting net
health benefits.
    Inherent to the success of this approach is the
identification and reintroduction of healthy carbohydrates into
the diet in an amount that does not promote weight gain, and an
understanding that when it comes to impacting blood sugar, not
all carbohydrates produce the same result. Through examination
of glycemic index, we can measure a carbohydrate's impact on
blood sugar and the resulting production of insulin.
    The modulation of insulin, as we've earlier heard, through
dietary choices is extremely important. By educating consumers
about nutrient dense whole foods rather than highly processed
and refined simple carbohydrates, controlled carbohydrate
nutrition offers a notable alternative to caloric restriction
and fat reduction; a message that has been too difficult for
many to follow.
    With increasing public interest in this nutritional
strategy resulting in renewed enthusiasm for fighting obesity,
and medical science demonstrating actual health benefits rather
than risks, we are truly in a unique position. Counting
carbohydrates is quite simply easier for many than eating
smaller amounts of less satiating foods.
    As the science in support of controlled carbohydrate diets
continues to mount, and the National Guidelines are revisited,
much can be gained from decisions made to enhance, rather than
stand in the way of this very encouraging development in
fighting obesity.
    To this end, we would hope that revisions to the Guidelines
include recommendations that recognize the benefits of adequate
protein consumption, incorporate a balance of untreated fats,
and finally, teach carbohydrate awareness so that Americans can
learn to respect and understand how this group of
macronutrients impacts not only their weight but also their
health.
    Additionally, incorporating the concept of glycemic index
is of great importance, offering a mechanism to counter the
increasing consumption of highly refined carbohydrates, and aid
in refocusing attention toward those that are nutrient dense
and should be part of a healthy diet.
    If more research is needed, let's fund it. Providing
unrealistic goals has led to apathy. And non-specific
recommendations have led to misinterpretation. The time is
right to rely on evidence-based science to develop strategies
to effectively impact this crisis.
    Thank you for your time, and again your interest, in this
very important subject.
    [The prepared statement of Dr. Trager follows:]

   Prepared Statement of Stuart Trager, MD, Atkins Nutritionals, Inc.
    Chairman Fitzgerald, members of the Committee, I am Dr. Stuart
Trager representing Atkins Nutritionals, Inc., the company founded by
Dr. Robert Atkins to provide adherents to the Atkins low carbohydrate
lifestyle with educational materials and products to help them achieve
success on the Atkins plan. I thank you for asking me to appear before
your Committee. I commend you for tackling the serious national crisis
in obesity, diabetes and other ills by looking into ways the government
can improve its recommendations to Americans on their diets.
Magnitude of Current Problem
    With over 300,000 deaths annually in the United States attributed
to obesity, the current epidemic has reached a state of true emergency,
referred to as one of the top threats to the health of our Nation by
the Centers for Disease Control (CDC). This crisis has steadily
increased in over the past 30 years, with current estimates suggesting
that 64.5 percent of American adults are overweight or obese and that
approximately \1/3\ of the population is in the category of clinical
obesity, defined as a body mass index of more than 30 Kg/M \2\. This
alone represents a two-fold rise since 1980.
    These statistics, combined with reports suggesting that our
adolescents and teens are currently becoming increasingly sedentary--
one study showing that by the age of 18 or 19, up to 56 percent of
surveyed girls reported no regular physical activity--raise additional
cause for concern. In our adolescent population, the prevalence of
overweight and obesity has nearly tripled in the past 20 years, as
compared to the doubling in the adult population. Even in a study
looking at individuals trying to lose weight or not gain weight, fewer
than 20 percent of these people are following recommendations to
increase physical activity and reduce calories.
    In addition to the tremendous human cost associated with lost lives
due to obesity, we are gaining increased awareness of the relationship
between this condition and numerous other significant diseases,
including diabetes, coronary artery disease, hypertension, asthma,
gout, gall bladder disease, stroke and certain cancers, including
prostate, liver, kidney, colon and breast. Estimates of the number of
years of life lost as a result of overweight and obesity range as high
as 20.
    With regard to quality of life, the effects are even more dramatic,
resulting in the equivalent of aging 30 years. With current estimates
placing a number of individuals considered overweight or obese at more
than 120 million, we are speaking of a problem of great magnitude.
    Including direct and indirect costs, obesity has become a major
contributor to the rising financial burden of caring for our
population, with current estimates ranging up to $117 billion. We are
on pace to exceed the price of tobacco-related medical care in the next
few years. This is also approximately 50 percent of the cost of
treating all cancers (direct and indirect).
    In 1995 alone, 5.7 percent of the U.S. health expenditure was for
individuals with body mass index over 29. From 1996 to 1998, overweight
resulted in a 15 percent increase in annual per capita Medicare
spending, with a 37 percent increase being associated with obesity. The
direct costs of coronary heart disease, non-insulin dependent diabetes
mellitus and hypertension attributed to obesity were estimated at
$42.62 billion.
    Within the workplace, estimates suggest that $20-30 billion per
year are lost in productivity to lost time due to the increased medical
problems linked to obesity. Employees lost 39.3 million workdays in
1994 due to obesity-related medical conditions, representing a 50
percent increase since 1988.
Urgency of Current Problem
    At the same time we are fighting to manage the rising costs of
healthcare, and to improve the quality of life for our population, we
have seen little progress in combating obesity through the national
dietary guidelines initially presented nearly 30 years ago. Total
caloric intake has risen. Despite relentless admonishment regarding the
evils of fat consumption, we have seen only limited success in lowering
the percentage of total fat intake, with overall consumption actually
increasing.
    It is interesting to note that during this period of increased
attention to fat reduction, carbohydrate intake has risen sharply. Just
as an anecdotal example, Krispy Kreme is currently selling 5 million
doughnuts per day, and 2 billion per year. A single store can make and
sell anywhere from 3,000 to 12,000 doughnuts per hour, and every two
minutes enough doughnuts are made to stack the height of the Empire
State Building, and every week enough to reach from New York to Los
Angeles.
    This increased carbohydrate consumption occurs at a time when
scientific studies are showing a clear relationship between
carbohydrates and serum triglyceride levels. Elevated triglycerides and
its concomitant suppressed HDL represent an independent risk factor for
coronary artery disease. Additionally, the identification of what we
call ``Metabolic Syndrome'' further establishes the relationship
between obesity and elevated triglycerides. This syndrome is considered
an independent cardiac risk factor, equal in importance to and in some
cases a precursor for other well established risks, such as diabetes,
hypertension, and previous myocardial infarction. The syndrome is
present in up to 47 million Americans. Its components include:

   Waist circumference greater than 40 inches (35 inches in
        women)

   Serum triglyceride level > 150 mg/dL

   HDL < 40 mg/dL in men and 50 mg/dL in women.

   Blood pressure of 130/85 mm Hg or higher

   Fasting glucose level of 110 mg/dL or higher

    When looking specifically at cardiac risk factors, despite
tremendous gains in understanding the etiology, treatment and
prevention of coronary heart disease, we have made only modest gains in
preventive risk reduction. Only 3-10 percent of individuals in the
United States and Europe currently fall within the guidelines of having
low risk profiles, even though reaching these goals would result in a
80-90 percent reduction in coronary events, coronary vascular disease
mortality and could increase life span by an estimated six to ten
years.
    Looking beyond coronary disease, the failure to provide a viable
solution to the obesity epidemic has spawned a current level in
obesity-related surgical treatment that is currently being performed on
approximately 80,000 people per year.
    Clearly the challenge to all of us involves:

   Recognizing obesity as a public health issue;

   Realizing that the solution must be safe, effective and
        practical and may not come in ``one size fits all''; and
        finally

   Remaining open to new approaches supported by emerging
        research.
A Different Solution
    The traditional dietary establishment has recommended nutritional
guidelines that have failed to curb the growing epidemic of obesity.
Although this is likely the result of a combination of external factors
related to lifestyle that impact energy consumption and expenditure,
the message of caloric control and fat reduction has not produced the
anticipated reduction in the rising rate of obesity that was expected.
    Experts agree that the solution is NOT to be found in a particular
diet, but rather a modification of lifestyle risk factors for obesity.
These would include dietary modifications combined with exercise to
reach long-term net health gains.
    Atkins represents just this type of intervention, focusing on
educating individuals to make intelligent food choices favoring
nutrient dense whole foods in a way that includes adequate protein and
fat which provides satiety and satisfaction and improves compliance. By
shifting attention from calorie counting, portion control, and fat
reduction, Atkins teaches individuals how to make better selections
while at the same time address other significant health risks through
exercise.
    Atkins is a personalized approach to identifying a level of
carbohydrate consumption that is consistent with achieving ideal body
weight that can then be maintained for a lifetime of improved health.
Simple, straightforward and safe, controlled carbohydrate nutrition
offers a different solution to the challenge of weight reduction and
maintenance, and one that can help many people meet their weight
management goals.
    The scientific evidence supporting controlled carbohydrate
nutrition dates back many years, with reports from as early as 1972
(Young et al., J. Clinical Nutrition) demonstrating that lowering
carbohydrate consumption significantly reduces body fat even when
calories are maintained equal (1,800).
    Even in adolescents fed more calories (1,100 vs. 1,830), work by
Sondike has demonstrated that more weight is lost with low carbohydrate
intake as compared with low calorie/low fat approaches. More recently
studies completed at Duke University under the direction of Dr. Eric
Westman confirmed greater weight loss at six months with a low
carbohydrate program, approximately twice that seen with a traditional
low fat approach (30 versus 18 lbs). Work supported by the American
Heart Association and performed by Bonnie Brehm, MD, looking at 53
obese women showed that more weight (8.5  1.0 vs. 3.9
 1.0 kg; p<0.01) and more body fat (4.8  0.67
vs. 2.0  0.75 kg; p<0.01) were lost on a low carbohydrate
diet than on a low fat/low calorie program. Insulin and glucose levels
also improved on Atkins, diminishing the risks of developing diabetes.
    There have recently been several articles published in the New
England Journal of Medicine (Foster et al.) as well as the Journal of
the American Medical Association (Stern et al.) that have examined the
safety and efficacy of the controlled carbohydrate nutritional
approach. These studies have shown that by limiting carbohydrates,
individuals demonstrate equal or greater weight loss (statistically
significant through the first six months) than that seen with
traditional recommendations, without any clinical evidence of increased
cardiovascular or metabolic risk identified. These studies contain
follow-up through 12 months, and in at least one case, in a multi-
center study funded by the NIH, individuals are being followed
prospectively for a total of two years.
    Within these studies, laboratory analysis of established serum risk
factors for coronary artery disease demonstrate consistent reduction of
triglyceride levels, as well as improvement in the HDL (good
cholesterol) without significant increase observed of either total or
LDL cholesterol. In Dr. Westman's work at Duke University, an eight-
fold improvement in the TG/HDL ratio was recorded. A separate study
completed by Dr. Jeff Volek has demonstrated that for individuals
followed on a controlled carbohydrate nutritional program, post-
prandial lipemia, as measured as circulating TAG, is actually seen to
decrease, as well as fasting TAG. These are both important measures of
coronary heart disease. Studies have also demonstrated a reduction in
measures of inflammation recently hypothesized to play an important
role in the development of coronary artery disease--as measurement by
levels of C-reactive protein (O'Brien et al. and Volek et al.).
Mechanism of Action
    The principals of this approach involve modifying the metabolic
pathways in which energy is used to encourage the oxidation of stored
fat for fuel, while at the same time minimize the storage of excess
calories within the body as fat. These goals are achieved with the
Atkins Nutritional Approach by limiting carbohydrate intake, through a
four phase program. This program is designed to help individuals
effectively manage carbohydrate cravings initially and to maximize long
term success through the transition to a lifetime strategy that
involves reintroducing nutrient dense whole foods with complex
carbohydrates to identify a personalized carbohydrate threshold.
    From a physiologic perspective, controlled carbohydrate nutrition
relies on the lipolysis or breakdown of stored fat for fuel. Although
this pathway is ordinarily a secondary method of providing energy, by
limiting the availability of carbohydrates it can readily become the
primary mechanism and in doing this, has been shown to result in
improved energy levels, elevated mood, as well as lessened cravings,
heartburn, and premenstrual symptoms (Westman). This is all while
allowing people to consume satisfying good tasting food in ample
portions and lose weight.
    Inherent in the conversion and support of this metabolic pathway
for long term maintenance, and the reintroduction of healthy
carbohydrates into the diet is an understanding of recent science that
has demonstrated that when it comes to impacting blood sugar (glucose)
levels, not all carbohydrates are created equally. Specifically, it is
the amount and rate of rise in blood sugar levels that is important
here, concepts referred to glycemic index (GI) and glycemic load
(product of GI X total grams).
    Because not all carbohydrates are digested, (i.e., fiber), their
impact on blood sugar levels is lessened. Similarly there are certain
other carbohydrates, like sugar alcohols that do not raise blood sugar
levels and therefore provide taste and flavor to foods. These do not
result in the insulin spikes that occur when other blood sugar raising
carbohydrates are consumed. Since insulin interferes with the breakdown
of fat, and also is involved with the storage of excess calories as
body fat, the minimization of the modulation of this hormone through
dietary choices plays a key role in controlled carbohydrate nutrition.
    Several investigators have suggested that the apparent metabolic
advantage that has been demonstrated in studies, (i.e., Sondike et al.)
that show individuals can lose more weight while consuming a greater
total amount of calories when carbohydrates are limited have suggested
this may be related to the increased metabolic demands associated with
the macronutrient breakdown and resynthesis of glucose through the
process of gluconeogenesis (formation of new glucose) that takes place
when carbohydrates are limited. Others have suggested that the presence
of ketones, or components of the diet itself may increase satiety and
help reduce total caloric consumption. Regardless of the mechanism,
there has been sufficient evidence to demonstrate the weight loss, and
predominantly body fat loss does occur while following a controlled
carbohydrate program, even without caloric restriction.
The Popularity of Controlled Carbohydrate Nutrition
    It is difficult to determine if the current popularity of
controlled carbohydrate nutrition stems from the realization, that as
explained by Walter Willett of the Harvard School of Public Health
``mainstream nutritional science has demonized dietary fat, yet 50
years and hundreds of millions of dollars of research have failed to
prove that eating a low fat diet will help you live longer.'' It could
be that three decades of a national campaign to reduce fat intake has
done nothing to combat the rise of obesity in this country (CDC/NCHS).
    Clearly there is no sound nutritional reason for U.S. sweetener
consumption to have increased to 22 million tons in 1999 from only 12.2
million in 1980, and high fructose corn syrup consumption to have
quadrupled to 9.2 million tons from 1980 to 1999. Looking at this
another way, moving toward a nutritional strategy that focuses on
reducing simple sugars--estimated by Michael Waldholz from the Wall
Street Journal to have (on a per capita basis) increased by 28 lbs or
22 percent from 1970 to 1995--clearly has much to offer. Regardless of
the cause, an approach must be outlined and implemented to address the
finding by Waldholz that sugar and sweeteners represented 36 percent to
40 percent of the U.S. consumption of carbohydrates.
    In light of the emerging science that supports the safety and
efficacy of controlled carbohydrate nutrition, recognizing the reasons
why, by some estimates, 35 million Americans are currently following
this strategy is extremely important. It may also offer a significant
clue in solving this country's obesity problems. With enthusiasm for
weight loss and improved health through nutrition rekindled, it is time
to work together to build rather than destroy. At the very least, we
need to recognize that our population is not satisfied with the dietary
recommendations they have been given.
    Counting carbohydrates is quite simply easier for many people than
eating smaller amounts of less satiating foods. This empowerment serves
as a cornerstone of controlled carbohydrate nutrition, and fosters a
renewed interest in making educated food choices that many find
extremely gratifying. This is especially true for the many who have
been unsuccessfully managing their weight through standard
recommendations, who now feel able to take control, and to improve
their health by managing their carbohydrates . . . in contrast to
struggling with portion control and unsatisfying cuisine.
    We are in a unique situation, having learned much from well
controlled research studies that have identified actual health benefits
rather than risks associated with following the controlled carbohydrate
nutritional strategy. We have also seen a growing number of people show
renewed interest in how what they eat impacts their health. If
providing unrealistic goals has led to apathy, and non-specific
recommendations have led to misinterpretation, the time is right to
rely on evidence based in science to develop strategies to effectively
have an impact on this crisis.
The Role of the Government
    As the science in support of controlled carbohydrate diets
continues to mount, it is important for the all the policymakers
involved in revisiting the national dietary guidelines not to ignore
this evidence
    Any revision of the guidelines should incorporate some of the
Atkins Nutritional Principles such as:

   Consuming adequate protein (at least 30 to 35 percent of
        total calories) to provide satiety and increased thermogenesis

   Incorporating a balance of untreated fats in adequate
        amounts to provide satiety and meet nutritional needs

   Teaching carbohydrate awareness so that Americans learn to
        respect and understand which carbs are the most nutrient dense
        and which are high or low glycemic index.

    If more research is needed, let's fund it. It's hard for me to
imagine any other public health crisis more important than those I've
outlined for you today.

    Senator Fitzgerald. Thank you. Those were all very good
introductory statements. And as best I can, I want to stay away
from the battle between the diets here. I know we have some
prominent dietitians here, but I do think there are some areas
of agreement.
    Although I guess I would charactize Atkins as trying to
limit total carbs, whether complex or simple, you would want to
limit carbs. And you wouldn't discourage the consumption of
fats to the extent that the low fat diets would certainly. You
don't discourage beef consumption.
    Dr. Ornish would be more likely to examine what kind of
carbs you are looking at. You'd want to promote what you call
complex carbohydrates and eliminate the simple carbohydrates.
And you would distinguish as well between the fats, between the
good and bad fats.
    And I think, Dr. Willett, you are along those same lines.
Notwithstanding those differences, I would think that all of
you would be concerned about the level of carbohydrates that
are recommended by that food chart. Clearly, it's a problem
that they don't distinguish between highly refined
carbohydrates and whole-grain carbohydrates.
    Assume that some American citizen is following that, and
this citizen just happens to like white bread. And they have
six to eleven servings of white bread, six to eleven servings
of white bread, cereal, white pasta, white rice. What kind of
effect on one's blood sugar is that likely to have, any of you?
    Dr. Ornish. Let me respond to that. First of all, you are
right that there is a big difference between simple and complex
carbs. And I think all of us agree on that. It's probably worth
just highlighting what we all agree on.
    I think we all agree that Americans eat way too many simple
carbs. And I think we all agree that the food pyramid needs to
be revised. And I want to salute Dr. Willett for his primary
advocacy in that area. I think it's fantastic.
    And I think we agree pretty much with just some minor
differences on how that should be. But I do think that complex
carbohydrates should remain the mainstay of most Americans
diet. Because in fact studies that Dr. Willett and his
colleagues have done have shown that if you divide people into
quintiles from the high complex carbohydrate and comparing the
lowest simple carb, that people live longer, that they do
better, and so, as opposed to going to high animal protein
foods which really do create problems.
    We found, you know, we have long-term randomized control
trial data showing that people lose more weight, and it only
makes sense if you are, if we all agree that simple carbs cause
people to gain weight, and if fat has nine calories per gram
versus four for protein and carbs, the goal is to limit the
intake of both.
    Because the simple carbs we've already talked about. And by
eating less fat, you are eating fewer calories without having
to eat less food. So you don't have the hunger.
    And we did find out that the LDL cholesterol went down by
40 percent, far more than occurs on either an Atkins diet or
the American Heart Association. So the studies that have been
coming out are really comparing two diets that I think are
fairly ineffective, as opposed to comparing--and the problem is
that the headline reads, ``Low fat diets are not effective,''
when the diet they are comparing it to is not really very low
in fat and tends to be high in simple carbs.
    Senator Fitzgerald. Dr. Willett?
    Dr. Willett. Thanks. I think there is a lot in common here.
And the amount of carbohydrate there is very high. But I think
there is a problem in terminology.
    First of all, it's simple carbohydrates, or complex
carbohydrates really include all starches. So Wonder Bread and
white pasta and white rice really are complex carbohydrates.
And we need better clarification. What we are really talking
about is whole wheat----
    Senator Fitzgerald. So what are you encouraging? What type
of carbohydrates are you encouraging the consumption of?
    Dr. Willett. Whole grain, minimally refined carbohydrates,
particularly----
    Dr. Ornish. This we agree on.
    Senator Fitzgerald. So you would call them whole grain,
minimally refined carbohydrates. Those are okay. But do those
carbohydrates get converted into sugar just like simple sugar
but maybe at a slower rate?
    Dr. Willett. They do, at a slower rate. But I think the
point has been made earlier that they do come along with other
micronutrients, minerals and vitamins that do seem to have
positive health benefits. So from what we are seeing is that
there is a positive health benefit of having some whole grain,
high fiber carbohydrates in the diet.
    But in fact, what we have looked at is up to three or four
servings a day, and servings roughly quantified, we see
benefit. I think if you really tried to consume 50 or 60 grams
of carbohydrates as really whole grains, in fact most people
can't tolerate that. Because there would be so much fiber,
abdominal pains and things like that.
    So, in reality I think a moderate carbohydrate diet, I
think it is appropriate----
    Senator Fitzgerald. But you really suggested that the
refined carbohydrates in the white bread should almost be
classified up with the----
    Dr. Willett. Sugar.
    Senator Fitzgerald. Sugars----
    Dr. Willett. Absolutely.
    Dr. Ornish. I agree with that.
    Senator Fitzgerald.--should be used very sparingly, so that
they have the refined carbohydrates on the wrong end of the
food pyramid.
    Dr. Willett. Exactly. They have really negative health
effects in terms of what they do to risk of diabetes and heart
disease. In fact, there are pretty strong predictors of
diabetes----
    Senator Fitzgerald. Some of them are like eating table
sugar, is that correct, according to your article in Scientific
America?
    Dr. Willett. That's right. And metabolically, that's what
they do too in terms of the changes in triglycerides reductions
and HDL and high insulin levels.
    Senator Fitzgerald. Let's be blunt then. If the food chart
is encouraging the consumption of the equivalent of table
sugars at the bottom, that's a problem; isn't it?
    Dr. Willett. That's a severe problem. I see this when I
look out in the real world at what people are actually given
within the weight program. It's large amounts of very high
glycemic carbohydrates. And many healthy foods are not allowed
because they are too high in fat according to their guidelines.
    I also almost had to cry, I was at the Indian community in
Oklahoma a few weeks ago and looked at what the Department of
Agriculture was feeding those people. It was large amounts of
refined starches. In fact, the USDA guidelines said because
these Native Americans have high rates of diabetes and heart
disease, we provided them with high carbohydrate diets.
    And it was almost entirely high-refined starches. Indians
of course developed----
    Senator Fitzgerald. Can you give an example of those highly
refined starches?
    Dr. Willett. Well, the one that really makes you want to
cry is that of course Indians developed corn. And that was one
of their staples. And it was a corn that was before hybrid
corn, small kernels, more oils, more minerals. And that's what
they ate.
    What they had, the Department of Agriculture commodity
warehouse there was it was degerminated maize flour, which
means it's pure powdered starch. And that is exactly what
causes diabetes, one strong contributing factor to diabetes.
    Senator Fitzgerald. It's just like eating table sugar.
Isn't that it?
    Dr. Willett. It's worse, actually.
    Senator Fitzgerald. It's worse.
    Dr. Willett. It's worse.
    Senator Fitzgerald. It's higher on the glycemic index, I
think you said, than table sugar.
    Dr. Willett. That's right. It's worse than table sugar.
    Senator Fitzgerald. Now, what about potatoes? You talked
about potatoes in your article too. And I think you said that
white bread is 100 on a glycemic index. And as I recall, you
said a boiled potato was 123.
    Dr. Willett. Right. It's really in the same ballpark. And
it's basically because the carbohydrate is very rapidly broken
down into sugar and absorbed as glucose. So potatoes, and
interestingly, my grandparents survived the depression on
potatoes; and there's a lot of cultural attachment to potatoes.
    They were better tolerated when we were a society that was
highly physically active and we worked on farms for 8, 10 hours
a day. But none of us, even those of us who run three miles a
day, are anywhere near that physically active.
    Therefore, we have higher insulin resistance and less well
tolerate that high glycemic load. So it is a real problem that
the Department of Agriculture puts potatoes there as a
vegetable. And so----
    Senator Fitzgerald. Right. And that's the next rung up,
right? They are encouraging three to five servings of that a
day.
    Dr. Willett. Right. So it's not just the 11 servings a day
of starch. It's up to 13 or so.
    Senator Fitzgerald. And let's get this straight. Eating a
boiled potato is worse than eating table sugar, right?
    Dr. Willett. It's basically in the same category.
Metabolically, it will be worse.
    Senator Fitzgerald. So that really could have a relation to
all the diabetes that's out there.
    Dr. Willett. Yes.
    Senator Fitzgerald. And the insulin resistance and the
obesity. Dr. Ornish?
    Dr. Ornish. I agree with what Dr. Willett is saying, but I
think it's worth pointing out that instead of only looking at
foods in isolation, if you are eating a potato along with some
broccoli and vegetables and other high fiber, whole wheat bread
and so on, it's really the glycemic index of a meal that you
are eating, rather than just a specific food that you need to
look at.
    Senator Fitzgerald. So that the absorption rate of the
potatoes will be slowed.
    Dr. Ornish. It will be influenced by the other foods that
you are eating. So it's not that you should never eat potatoes,
I don't think, because, you know, the people in our studies
were eating potatoes.
    Senator Fitzgerald. But its absorption will be slowed, but
will it not eventually be made into fat if you are not active
enough to burn up that energy?
    Dr. Ornish. Well, that's true of any food. If you are
eating more calories than you are burning up, you will gain
weight, but not limited to potatoes per se.
    Senator Fitzgerald. Well, this raises a question about the
whole grains that all of you agree are good. You may absorb
them more slowly into your blood, and they may be lower on a
glycemic basis, but aren't they eventually, if you are not
doing enough exercise, aren't they eventually going to be
converted into fats even if they are from carbohydrates from
whole grains?
    Dr. Ornish. Well, that's true of any foods. If you eat more
than you are burning up, you are going to convert it to fat.
The nice thing about whole grains is not only do you absorb
them more slowly so you don't get the insulin surges which do
accelerate the conversion of calories, particularly of
triglycerides, but they fill you up before you get too many
calories.
    You can consume virtually unlimited amounts of sugar
without getting full. A can of soft drink has 12 to 14
teaspoons of sugar. But you can only eat so many apples or so
many pieces of whole wheat bread. You are going to get full
before you get too many calories.
    So you really get a double benefit. You get full before you
get too many calories, and you absorb those foods more slowly
so you don't get the insulin surge. And the other thing that
happens is a little like a pendulum. When your blood sugar goes
way up, it doesn't come down to where it stops. It goes down
below where it started. So you get the low blood sugar which
creates these cravings for more carbohydrates.
    I want to emphasize also, just to clarify, that in our
studies showing reversal of heart disease or equivalents of
prostate cancer, it is a very extremely low fat, 10 percent fat
diet. Because that's what it takes when you are trying to
reverse disease. The more moderate recommendations don't go far
enough even to keep it from progressing.
    But if we are just talking about losing weight or feeling
better or preventing disease, we have a spectrum of choices.
It's not all or nothing. But to the degree that you eat fewer
simple carbs and more complex, maybe I think your term probably
is a better one, more less unrefined foods, you are going to
lose weight; you are going to feel better; you are going to
gain health.
    Senator Fitzgerald. Dr. Trager, do you want to stick up for
the Atkins Institute?
    Dr. Trager. Sure. There's actually no reason to stick up.
What you have described is the maintenance phase of the Atkins
nutritional approach for people who are not opposed to eating
animal protein.
    Basically people can follow the Atkins approach as lifetime
maintenance. And one of the biggest misconceptions about what
Atkins is all about, what Atkins is about is controlling
carbohydrates. Choosing that level where your weight is
maintained once you get to the maintenance level, the lifetime
strategy.
    It's about just what you described, choosing the nutrient
dense, whole foods, the complex carbohydrates, vegetables and
protein in an amount that makes you full, that takes away
hunger and allows you to go on and live your life in a way
that's not about fighting portion control; in a way that has
not led people to run away from our dietary recommendations.
    Senator Fitzgerald. You kind of reverse this food pyramid,
don't you?
    Dr. Trager. I think it's putting the emphasis, taking the
emphasis away from carbohydrates as the main source of energy
and realizing that protein and fats have health benefits as
well.
    And when you take away the simple carbohydrates we've been
talking about, you have to use something in exchange. Some of
it can be complex carbohydrates, but it can be also be protein
and some fats, as we've seen from these studies where risk
factors have not in any way worsened.
    So we have to remember that the largest study that's been
done is the 30-year-trial we've seen the American public go
through where they've seen----
    Senator Fitzgerald. What study is that?
    Dr. Trager. I'm talking the study of the American people,
where we've given them recommendations and they haven't
followed them. And obesity has risen. And diabetes has risen.
    And people don't want to or are unable to follow even the
recommendations to limit fat as seen in that pyramid. So this
reduction of fat that we've talked about that's very useful in
some individuals with this heart disease, is so difficult for
many people to follow, that what happens is what we are seeing
right now.
    People are eating more calories, and they are eating more
fat as part of that. They are not getting filled up with the
food. And this emphasis on eating low fat food that's not
filling, has led to replacement with more and more
carbohydrates.
    So if we do nothing and if we tell people to lower their
fat, we see what's happening. People are struggling with that
dietary advice. And making it more stringent and telling them
even more specifically, is going to leave some people out.
    There's no one-size-fits-all solution to weight management
for our country.
    Senator Fitzgerald. Let Mr. Jacobson have a crack at it
here.
    Mr. Jacobson. I would like to put this issue aside.
    Senator Fitzgerald. Can I ask a question. Is the NIH doing
a study now of which diet is the best? Dr. Willett, did you
mention an NIH study?
    Dr. Willett. Well, there are several studies that are being
funded. And of course it's not--there are so many different
comparisons you can make, so many different levels of fat and
combinations with carbohydrate, and of course combinations with
physical activity.
    But several large studies have been started or are about to
be started, which is really good. These are things we should
have done about 20 years ago. But there is clearly reason for--
--
    Senator Fitzgerald. When did they start them, very
recently?
    Dr. Willett. Well, the big ones that I know are just about
to receive funding. They actually haven't started yet. And,
interestingly, these studies are not hugely expensive compared
to the long-term trials of heart disease prevention which
require tens of thousands of people for many years.
    For, you know, one or two hundred people followed for 2
years, you can actually derive a huge amount of information. So
these are only modestly expensive studies. And we need to do
more, because a lot of the debate has been just simply because
we haven't had good data.
    These are resolvable questions. Also, I think the point was
made that one size does not fit all. That someone who's lean
and active can tolerate a diet, a different kind of diet than
someone who is more sedentary or perhaps has some genetic
insulin resistance.
    So a number of studies need to be done. Some are started,
but we need to do more studies in this area.
    Senator Fitzgerald. Mr. Jacobson?
    Mr. Jacobson. Well, I think the nutrition arguments are
going to be fought out at the Dietary Guidelines Committee
meeting over the next year or so. I think what your Committee
can focus on is the process and then the implementation of
whatever these wise people recommend to the American public.
    In terms of process, you are suggesting having HHS take
over this issue of--largely from USDA. And I'm not sure that's
the best fit. At times, USDA has been better than HHS.
    USDA came up with recommended limits on sugar intake,
refined sugar intake 10 years ago, saying the average person
should consume no more than ten teaspoons a day. HHS has never
come to that point.
    In the battle over trans fat, people at NIH were resisting
putting trans fat on food labels for years. The bias or the
conflict of interest at HHS is there's never enough science.
    An alternative to either agency would be to have the
National Academy of Sciences take over the Dietary Guidelines
and come up with a recommendation every 5 years, the way it
comes up with other recommendations. It may be a way to
insulate the Committee from these industrial pressures at USDA
and from some of the intellectual biases at HHS.
    So the process is one thing to consider. And of course
conflicts of interest of committee members. The second thing is
implementation. You know, it probably wouldn't matter if these
guidelines said we should all eat Limburger cheese on white
bread with anchovies. People are not going to follow it. They
never hear of these things.
    The government programs to implement these are negligible.
Meanwhile, industry is spending billions of dollars encouraging
kids to eat candy, sugary candies for breakfast, and McDonald's
french fries.
    Senator Fitzgerald. But after the Food Guidelines, the
pyramid was promulgated in 1992. Didn't we then see a sudden
surge in the food companies taking their cue from the food
pyramid, offering low fat foods; and in some cases they
stripped the fat out, but to maintain the taste they added a
lot of sugar.
    Mr. Jacobson. Well, no, no, no. The food nutrition labeling
came in in 1993. And that was the big driver for the lower fat
foods. The FDA came up with definitions for low fat, reduced
calories, and so on.
    The pyramid didn't have anything to do with it at all. And
actually, and when the lower fat foods came out----
    Senator Fitzgerald. But on some foods you'll see at the
store they'll have the food pyramid printed right on the label.
    Mr. Jacobson. And it says, Registered U.S. Department of
Agriculture also. I mean, Pennsylvania Department of
Agriculture. I don't think anybody reads it. It's----
    Senator Fitzgerald. Well, the food industry, those who feel
they benefit by the food pyramid, will spend a lot of money
advertising their place on the food pyramid. That's my
perception.
    Mr. Jacobson. They spend very little money advertising
anything along those lines. They put, some of the companies put
the triangle on their packages. But if you think it has an
effect, I think otherwise.
    I think this committee should think about the ways that the
pyramid or the Dietary Guidelines can be implemented. You know,
calories, everybody thinks, I think everybody thinks calories
are important. Is there calorie information when you go to a
restaurant, when you buy meat, when you buy a bottle of--can of
beer? No.
    Government could require calorie information in those
places. You turn on television. Are your kids going to see ads
to eat carrots or french fries. The answer is obvious.
    The junk food served in schools, 98 percent of high schools
have junk food vending machines according to Centers for
Disease Control. Government could intervene in an area like
that.
    That's what I think this committee ought to think about.
And I hope you and others will think about the legislation that
could move us forward based on the current Dietary Guidelines
for Americans or the next version. But there's a lot of room
for some action.
    But it seems like people in Washington wring their hands
over this obesity problem, and then they find out they are
going to have to step on some toes or spend some money, and all
of a sudden, they have disappeared.
    Senator Fitzgerald. Dr. Ornish or Dr. Willett?
    Dr. Ornish. I think one of the reasons that Dr. Willett has
put so much energy into the food pyramid and has played such an
important leadership role is that it does matter. And I think
it matters for a number of reasons.
    I used to think if we just did good research, that would
change medical practice and how people eat. And I think
research is important, but it's also important to work with the
food companies because they are in the behavioral modification
business as well. But, at least until recently, they haven't
always used that to the advantage of the American people.
    I've consulted directly with McDonald's, with ConAgra, and
most recently with Pepsico. and I've been particularly
impressed with what Pepsico has been doing. Pepsico as you know
includes Tropicana, Quaker Oats, Aquafina, as well as Frito Lay
and some of the other products.
    And I think a combination, a lot of these food companies
are concerned both about not becoming the next big tobacco.
They are concerned about litigation. And here again the kinds
of guidelines the Federal Government sets help influence what
they do, in part because of their concerns about litigation,
but also because they see there's a great market opportunity.
    If you look at the areas of the growth in the food
industry, they have been in organic foods, they have been in
the kinds of unrefined foods that Dr. Willett mentioned. And so
I think that the combination of the concern about litigation
and the opportunity to do something beneficial, many of these
companies are rather than taking, say, the vending machines out
of school, are stocking them with healthy products.
    And I think those kinds of private partnerships should be
encouraged. And then, if that doesn't work, then consider a
regulation. But I think that the environment and the atmosphere
is very different now than it was even 5 years ago.
    Senator Fitzgerald. Dr. Willett.
    Dr. Willett. I agree with both Dr. Jacobson and Dr. Ornish
because, I think as you said in your introduction, the Food
Guidelines and the food pyramid are really very important, both
because of educational impact, and we have seen a major change
in the U.S.----
    Senator Fitzgerald. In how it affects the WIC Program and
the school lunch program.
    Dr. Willett. Right.
    Senator Fitzgerald. All of those are influenced by the food
pyramid.
    Dr. Willett. Absolutely. And I'm very saddened that I see
what those kids and mothers are being fed, because they are
very high glycemic diets in general. So this is important to
get right.
    And, also, Americans have made changes in their diet. And
unfortunately they have not been such good ones, but they were
sort of what they were being told.
    They did increase the intake of carbohydrates, and the
percentage of calories and fat went down. So these do have an
impact. It's just that they have been off target.
    And I think it's an indication of people want this
information and they will act upon it, not everybody, not right
away. But I also do agree with Dr. Jacobson that this is of
course only part of the answer. And there are lots of other
things that can be done as well.
    I think everyone here would agree that we can't continue to
subject our kids to this barrage of very carefully crafted,
aggressive advertising to eat junk food, that that's one
example where we can put some limits on. And from surveys our
school have done, very high percentage of the public supports
that.
    They don't support limitations on advertising for adults,
but protecting children is something that is very much
supported politically. And second, I think everything that has
a label or comes in a container can have calories on it.
There's actually no additional costs of doing that.
    But there's no reason that everything you get at McDonald's
or Burger King, or maybe Pepsico will do it voluntarily.
There's no reason that that shouldn't contain caloric content.
    Senator Fitzgerald. Dr. Jacobson pointed out that the USDA
has been ahead of the HHS in some respects. But I have
questions about the USDA being our general in the war on
obesity.
    We've been in this war for about 30 years, and we are
getting more obese. We are not winning the war. And I think
after a certain point, you have got to make the kind of
decision Lincoln made in the Civil War, that he was going to
bring in General Grant.
    I think we need a new general in this war. And I think that
it certainly, industry pressure groups can influence any part
of the Federal Government. Certainly they can influence the HHS
almost as readily as they could the USDA.
    But you'd start out at least with more of an orientation
toward pure science, I think. And less coziness with the farm
groups and the food companies at the HHS. And they have the
National Institute of Health.
    And while defenses could be launched for the USDA, I do see
it primarily as a department that is there to promote sales on
behalf of American farmers. And they do a pretty good job at
that.
    And so I want to ask Dr. Trager, Dr. Willett and Dr. Ornish
about their thoughts of moving the responsibility for the Food
Guidelines to the HHS or to a different agency.
    Dr. Trager. I think the biggest and most important goal is
that we recognize evidence based science and we leave some of
the preconceived ideas about nutrition behind, and start
looking at what we are learning now; recognizing as those we
heard in the first panel, nutrition is a science and is moving
rapidly forward, our knowledge, the research that's coming out.
    And I think the biggest and most important goal is to have
the recommendations reflect what we are seeing as different
options for people. If the recommendation is to not rule out or
limit the large number of people who can be helped from a
policy that's different from that which we've seen.
    Dr. Willett. There's no solution that's perfect, of course,
simply because our institutions are made of humans and we are
all not perfect and subjected to our biases and external
pressures.
    But I do think HHS taking the lead would be an advantage. I
think it's also worth seriously considering Dr. Jacobson's idea
of perhaps the National Academy of Science Institute of
Medicine as an alternative as well.
    There may be a bit more insulation there. And certainly the
Food Nutrition Board is heavily involved in these issues and
essentially creates the RDAs. I think that same mechanism could
be used here. So it would be a better move, I think.
    Senator Fitzgerald. The food groups would probably never
allow that bill to pass. That's if you want my--because then
you would really take it out of the government. Dr. Ornish, do
you have any thoughts?
    Dr. Ornish. No. I agree with Dr. Willett.
    Senator Fitzgerald. OK. This, actually, and I'm really
getting close to wrapping up. But when I first came to the
Senate, I was surprised to realize Illinois, my state, is one
of the only states in the country that has a mandatory physical
education requirement for students in high school.
    And there was discussion, at the time of the Colombine
shooting in Colombine, Colorado, there was some discussion of
mandating physical education for all kids in our public high
schools across the country. I don't think any state besides
Illinois has a mandatory PE requirement for their kids in their
high school.
    And I know Secretary Thompson at HHS has said that it's
time to get children, ladies and gentlemen, off the couch and
onto the playground. He noted that just 6 percent of schools
require physical education for high school seniors, and that he
was concerned that cutbacks in physical education classes, the
rise in labor saving devices, and the prevalence of television,
video games and computers has reduced the amount of time that
most Americans spend exercising each day.
    I assume all of you agree with that, that we have to have
more exercise. We have to burn more calories. And we are
getting to the stage where we are burning up fewer and fewer
calories with our more and more sedentary lifestyle. Dr.
Ornish?
    Dr. Ornish. Yes, I actually put that in my written
testimony, because I think it's terribly important. Of all the
things to cut back on, that seems to be the most shortsighted.
    And studies are showing that not only does physical
exercise in high school help people reduce obesity, just as one
statistic, diabetes in teenagers has gone up 70 percent in the
last 10 years. And with all the ravages of diabetes that Dr.
Willett alluded to earlier, the eye and nerve, kidney, heart
disease damage, this may be one of the first generation that
lives a shorter lifespan than our parents.
    But also studies have shown that when students exercise,
their academic performance improves. It actually improves in
direct proportion to how much they exercise. So we've talked a
lot about diet, but let's not lose sight of the exercise part
as well. And that's something that I think we would all agree
on.
    Dr. Willett. I completely agree with that. And the point
here is that this is going to cost money. And this whole idea
that we have to have programs that are cost neutral when we do
not have a cost neutral health care system, where costs are
going up astronomically for treatment, and we are not willing
to put money into the basic prevention that would have enormous
health benefits, is very, very shortsighted.
    It is interesting that essentially in the northeast all the
elite private schools have an hour a day of physical activity.
I think that's what all kids really deserve. And we are just
going to have to say this is something that, yes, we have to
add an hour to the day. We can't shortchange academics, but
this is a basic value.
    And somehow the fact that we are the richest country in the
world and we say we can't afford it, is really hard to
understand what's happened to our priorities.
    Senator Fitzgerald. That's why your food pyramid that you
published in Scientific American had exercise at the base of
the pyramid, I suppose.
    Dr. Willett. Absolutely.
    Senator Fitzgerald. And Dr. Trager, I guess you run
marathons.
    Dr. Trager. I clearly am a big proponent of exercise. I
think that teaching children early instills this value, clearly
realize that any weight loss or weight management program in
which exercise is a part has a greater chance of long-term
success.
    I think it's also important, though, to disconnect exercise
from weight loss, and to realize that exercise has other health
benefits; cardiovascular wellness for one, independent of any
weight loss, so that people don't just exercise to lose weight;
they exercise for good health.
    Senator Fitzgerald. Dr. Willett, one final question. I know
that some of your research articles urge caution on consuming
red meat because of the saturated fat content. But I'm told
that you advocate the consumption of poultry. And isn't it true
that some types of poultry such as the thigh on a chicken can
contain more saturated fat than a lean cut of beef?
    Dr. Willett. Well, you could make some comparisons, but
actually the fat in poultry is much more unsaturated than the
fat in beef fat, so that----
    Senator Fitzgerald. So the fat in poultry is much more
saturated?
    Dr. Willett. Much more unsaturated.
    Senator Fitzgerald. Much more unsaturated.
    Dr. Willett. Yes. So the fat is less saturated. It's
actually not a terribly bad balance of fat in poultry fat. So,
in moderation, that is going to be better than fat in beef fat.
    So it's, again, there is--the issue is more than of course
just blood lipids here, that there's quite a bit of evidence,
many studies showing increased risk of colon cancer and
prostate cancer in high red meat consumption. And it's not
clear that it's just the fat per se, so that's part of the
rationale.
    Senator Fitzgerald. Dr. Trager, would you have any----
    Dr. Trager. I'd argue that some of that research is still
unclear, whether or not it's the way the food is prepared, the
charring of the meat for instance with the red meat is one
issue.
    It's also very important to realize that one of the
greatest risks for cancer, be it colon or prostate, is obesity.
And in managing obesity and giving a people a tool they can use
that works for them in the real world to fight obesity, again,
the enemy from the beginning here, lowers the risk of cancer
and many of these other health problems.
    It's also important to recognize that when carbohydrates
are limited or restricted, the effects of saturated fat and
not--the negative effects have not been demonstrated. These are
all in studies, including the one from Dr. Ornish showed, from
Dr. Fleming, looking at the heart, where they looked at a high-
fat versus a low-fat diet, not a controlled carbohydrate diet.
    Senator Fitzgerald. Dr. Ornish?
    Dr. Ornish. Well, I think that, I agree with Dr. Trager
that we should take an evidence-based approach. But Dr. Willett
has conducted some pioneering studies, as have many, many
others, showing that red meat is associated with breast,
prostate, colon, cancer, heart disease, and any of a number of
illnesses.
    And so I think it's important to highlight where we agree
in terms of reducing the intake of refined carbohydrates in
particular. But to me they should be--or if you are not going
to eat a plant-based diet, eat fish, because fish gives you the
protein. It also gives you the protective omegas-3 fatty acids,
but it doesn't have the disease enhancing substances that are
found in----
    Senator Fitzgerald. But a lot of fish apparently contain
mercury.
    Dr. Ornish. Well, that's a problem. I agree with that. So
that's why I think eating a plant-based diet is even better.
And take three grams a day of fish oil but without the mercury
and the PVCs; that I think is an optimal diet. But recognizing
what's practical, I think you are better off eating the fish.
    Senator Fitzgerald. OK. Well, you guys have been wonderful
witnesses. We appreciate you all being here and thank you very
much for your patience.
    And we'll leave the record open to close of business for
now, for any other statements to be put in the record. Thank
you very much. This meeting is adjourned.
    [The meeting was adjourned at 4:43 p.m.]
                            A P P E N D I X

                              American Dietetic Association
                                    Chicago, IL, September 30, 2003
Hon. Peter Fitzgerald,
Chairman,
Committee on Commerce, Science, and Transportation,
Consumer Affairs and Product Safety Subcommittee,
United States Senate,
Washington, DC.

Dear Chairman Fitzgerald:

    The American Dietetic Association (ADA) commends the Committee for
recognizing the importance of nutrition as a national health concern.
We ask that our letter be made a part of the official record for the
hearing on obesity and how it can be addressed through the Dietary
Guidelines and Food Guide Pyramid revisions.
    The ADA is the world's largest food and nutrition professional
association. Now 85 years old, ADA is dedicated to serving the public
through the promotion of optimal nutritional health and well-being. The
work of this Chicago based association and the services of its nearly
70,000 members are based on rigorous academic instruction, supervised
practice and continuing education relying on peer-reviewed nutrition
research and resources representing significant scientific consensus.
    The purpose of the Dietary Guidelines for Americans is to provide
up-to-date scientific information and advice on how to choose healthful
dietary and exercise patterns. It is also to promote healthy food and
activity choices among all Americans. These guidelines form the basis
for sound decisionmaking by policymakers at all levels of government in
the administration of food, nutrition, and health programs. The Dietary
Guidelines for Americans, however, are also significant for their
impact on the American consumer. In today's increasingly complex and
confusing food environment people want basic, useable information
derived from rigorous science and broad, objective analysis.
    Because nutrition is a complex and dynamic field that requires
constant vigilance in order to stay up to date with the best science
available, the Dietary Guidelines Advisory Committee has a huge
assignment. We are confident that this diverse and experienced panel of
experts qualified to review emerging science, will evaluate the
strength of the evidence, and advise on guideline revisions
accordingly. We have no doubt that they will make recommendations for
change in the guidelines as appropriate.
    As a tool for the work ahead, ADA has recommended the evidence
should be systematically analyzed and graded to bring the best
information to the forefront for review. Adopting a transparent
evidence grading process may remove some of the concerns that have been
expressed by those who monitor the work of the Dietary Guidelines
Advisory Committee. ADA recommends the integration of their work in a
graphic that consumers may use to make healthful choices in diet and
exercise.
    The ADA strives to communicate healthful eating messages to the
public that emphasize the total diet, or overall pattern of foods
eaten, rather than any one food or meal. If consumed in moderation with
appropriate portion sizes and combined with regular physical activity,
all foods can fit into a healthful diet.
    The Dietary Guidelines for Americans and the UDSA Food Guide
Pyramid along with other policies such as Reference Dietary Intakes,
Nutrition Labeling, and Healthy People 2010 are all supportive of the
total diet approach. The Dietary Guidelines for Americans recommend
moderation for certain dietary components such as total fat and sugars
while emphasizing nutrient adequacy. Unfortunately, most Americans do
not follow the Dietary Guidelines for Americans. Most U.S. children
exceed total and saturated fat guidelines while getting fewer than
recommended servings of vegetables, fruit, and dairy foods.
    We suggest a more targeted focus to address the epidemic of
overweight and obesity. ADA has identified strategies to address these
complex issues, and urge special focus should fall on children to
promote healthy weights through healthful eating practices and daily
physical activity.
    In addition, we recommend that Federal agencies and insurers
designate obesity as a disease. This designation would lead to system
changes for reimbursement and include sanctioned insurance coverage of
obesity treatment. It would mean that 211 categories of obesity defined
under the ICD-9 codes would be covered, not just surgical intervention
for the morbidly obese. And critical to the issue of obesity is the
allocation of adequate resources. Unless the U.S. Government and
private sector entities find ways to pay for research, education,
intervention and health care related to overweight and obesity, the
outcomes will be predictable--we will not make the necessary progress
to have a healthy population in the coming years. Obesity-related
conditions will continue to consume a large proportion of dollars spent
on health care.
    As the work on the Dietary Guidelines for Americans continues this
year, ADA will continue to:

   Urge that the process associated identify and rely upon
        formal evidence based review of the strongest science
        available.

   Focus on how consumers will perceive and use the guidelines
        themselves. The final document should reinforce the importance
        of the total diet or overall eating pattern and not single out
        specific foods.

   Stress the need for consistent information to help consumers
        understand portions and serving sizes.

   Recommend that this version of the Dietary Guidelines for
        Americans be consumer tested with consumer groups.

    ADA believes that Federal agencies relying on the work of the
Dietary Guidelines Advisory Committee can present the best science
available and deliver a message that is clear and practical for
consumers. The differing perspectives of USDA and OHHS should not
matter. These two agencies will come together in one voice to deliver a
clear message on nutrition priorities in the form of the Dietary
Guidelines For Americans.
            Sincerely,
                     Marianne Smith Edge, MS, RD, LD, FADA,
                                                         President.
                                 ______

        State of Connecticut--Department of Social Services
                                     Hartford, CT, November 3, 2003

Consumer Affairs and Product Safety Subcommittee,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.

Dear Honorable Senators:

    Below are my comments with respect to revising the U.S. Dietary
Guidelines and Food Guide Pyramid. The existing Guidelines and Pyramid
are very good from a public health perspective and should not be
scrapped. They need only a few modifications:

   1.  A section should be added to the Dietary Guidelines on food
        preparation including how to preserve flavor and nutritional
        value. Another section could discuss how to enjoy a meal. See
        the 10 Guidelines of the German Nutrition Society (DGE) for a
        Wholesome Diet. They are very good.

   2.  The whole grain recommendation should be strengthened: 3 or more
        servings of whole grains should be stated in the Food Guide
        Pyramid's Bread, Cereal, Rice, and Pasta group. Whole grains
        promote health, whereas refined breads and cereals generally
        have a neutral effect except to replace high-fat-food calories.

   3.  Cooked dry beans and peas, and nuts should be placed entirely in
        the Pyramid's Meat and Beans group. This will reduce confusion
        and enable the recommendations to be more useful to
        vegetarians.

   4.  At least one ounce or equivalent of cooked dry beans, peas or
        nuts should be eaten daily. This will discourage the
        consumption of high-saturated fat foods. Cooked dry beans,
        peas, and nuts are also good sources of protein, dietary fiber
        and minerals.

   5.  The breads and cereals recommendation should be eased slightly.
        Reducing the Pyramid's Bread, Cereal Rice and Pasta group
        servings by one, to 5-10, will keep it more in line with actual
        consumption and because more carbohydrate will now be provided
        in the Meat and Beans group due to the greater emphasis on
        beans, peas and nuts.

   6.  Calcium fortified soy products should be included with the Milk
        group.

   7.  Fruits but not vegetables should be limited because of their
        high sugar content.

   8.  The many benefits of breads and cereals are often offset by
        their high saturated fat, trans fat or sodium content. The
        Guidelines should help consumers to choose brands with lower
        fat and sodium so that they can eat their required servings of
        breads and cereals without overdosing.

   9.  The sodium standard of 2,400 milligrams per day or 1 milligram
        per kilocalorie should be stated more forcefully.
        Epidemiological studies fail to show a relationship between
        sodium and hypertension precisely because education works:
        Hypertensives know to consume less sodium. Clinical trials have
        clearly demonstrated a causal relationship between sodium and
        hypertension.

  10.  The sugar standard should not be weakened; it should be
        strengthened. Although sugar restriction may not be as
        important in preventing diabetes as once thought, there is
        growing evidence that hyperglycemia leads to tissue necrosis.
        Eating empty calories also replaces needed nutrients.

    I have attached a revised Food Guide Pyramid showing the changes.
It works nicely. I thank you for this opportunity to comment.
            Yours truly,
                                    Douglas R. Buck, Ph.D.,
                                        Public Health Nutritionist.
                              Attachments

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