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REVIEW OF NUTRITION RESEARCH
AND EDUCATION ACTIVITIES

Y 4. AG 8/1: 103-28 ^^=^— =

Revleu of Kutrltion Research and Ed.

HEARING

BEFORE THE

SUBCOMMITTEE ON DEPAKTMENT OPERATIONS

AND NUTRITION

OF THE

COMMITTEE ON AGRICULTURE
HOUSE OF REPRESENTATIVES

ONE HUNDRED THIRD CONGRESS

FIRST SESSION

JULY 15, 1993

Serial No. 103-28

zomn

DEC23»93

ofthec^;;l»te^^

Printed for the use „ _„ .

U.S. GOVERNMENT PRINTING OFFICE
72-928 WASHINGTON : 1993

For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
ISBN 0-16-0A17A1-4

REVIEW OF NUTRITION RESEARCH
AND EDUCATION ACTIVITIES

Y 4. AG 8/1: 103-28

Revieu of Nutrition Research and Ed...

HEARING

BEFORE THE

SUBCOMMITTEE ON DEPARTMENT OPERATIONS

AND NUTRITION

OF THE

COMMITTEE ON AGRICULTURE
HOUSE OF REPRESENTATIVES

ONE HUNDRED THIRD CONGRESS

FIRST SESSION

JULY 15, 1993

Serial No. 103-28

DEC 23 893

I Oifii^

Printed for the use of the CommSi'l'EK'*AKlfWiitepi»^^^^^

U.S. GOVERNMENT PRINTING OFFICE
72-928 WASHINGTON : 1993

For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
ISBN 0-16-041741-4

COMMITTEE ON AGRICULTURE

E (KIKA) DE

GEORGE, E. BROWN, Jr., California,

Vice Chairman
CHARLIE ROSE, North Carolina
GLENN ENGLISH, Oklahoma
DAN GLICKMAN, Kansas
CHARLES W. STENHOLM, Texas
HAROLD L. VOLKMER, Missouri
TIMOTHY J. PENNY, Minnesota
TIM JOHNSON, South Dakota
BILL SARPALIUS, Texas
JILL L. LONG, Indiana
GARY A CONDIT, California
COLLIN C. PETERSON, Minnesota
CALVIN M. DOOLEY, California
EVA M. CLAYTON, North CaroUna
DAVID MINGE, Minnesota
EARL F. HILLLMiD, Alabama
JAY INSLEE, Washington
THOMAS J. BARLOW III, Kentuclqr
EARL POMEROY, North Dakota
TIM HOLDEN, Pennsylvania
CYNTHL^ A McKINNEY, Georgia
SCOTTY BAESLER, Kentucky
KAREN L. THURMAN, Florida
SANFORD D. BISHOP, Jr., Georgia
BENNIE G. THOMPSON, Mississippi
SAM FARR, California
PAT WILLIAMS, Montana
BLANCHE M. LAMBERT, Arkansas

LA GARZA Texas, Chairman

PAT ROBERTS, Kansas,

Ranking Minority Member
BILL EMERSON, Missouri
STEVE GUNDERSON, Wisconsin
TOM LEWIS, Florida
ROBERT F. (BOB) SMITH, Oregon
LARRY COMBEST, Texas
WAYNE ALLARD, Colorado
BILL BARRETT, Nebraska
JIM NUSSLE, Iowa
JOHN A BOEHNER, Ohio
THOMAS W. EWING, lUinois
JOHN T. DOOLITTLE, California
JACK KINGSTON, Georgia
BOB GOODLATTE, Virginia
JAY DICKEY, Arkansas
RICHARD W. POMBO, CaUfomia
CHARLES T. CANADY, Florida
NICK SMITH, Michigan
TERRY EVERETT, Alabama

Professional Staff

DiANNE Powell, Staff Director

Vernie Hubert, Chief Counsel and Legislative Director

Gary R. Mitchell, Minority Staff Director

James A Davis, Press Secretary

Subcommittee on Department Operations and Nutrition

CHARLES w.

GEORGE E. BROWN, Jr., California,

Vice Chairman
BILL SARPALIUS, Texas •
CALVIN M. DOOLEY, California
JAY INSLEE, Washington
GLENN ENGLISH, Oklahoma
DAN GLICKMAN, Kansas -
CYNTHIA A. McKINNEY, Georgia
SANFORD D. BISHOP, Jr., Georgia
HAROLD L. VOLKMER, Missouri
EVA M. CLAYTON, North Carolina
TIM HOLDEN, Pennsylvania
CHARLIE ROSE, North Carolina
SAM FARR, California
TIM JOHNSON, South Dakota
EARL POMEROY, North Dakota
BLANCHE M. LAMBERT, Arkansas

STENHOLM, Texas, Chairman

ROBERT F. (BOB) SMITH, Oregon
BILL EMERSON, Missouri
STEVE GUNDERSON, Wisconsin
WAYNE ALLARD, Colorado
BILL BARRETT, Nebraska
JOHN A BOEHNER, Ohio
THOMAS W. EWING, lUinois
JACK KINGSTON, Georgia
CHARLES T. CANADY, Florida

(H)

CONTENTS

Page

Clayton, Hon. Eva M., a Representative in Congress from the State of North
Carolina, prepared statement 4

Smith, Hon. Robert F. (Bob), a Representative in Congress from the State
of Oregon, prepared statement 6

Stenholm, Hon. Charles W., a Representative in Congress from the State
of Texas, prepared statement 1

WrmESSES

Anderson, Jennifer, president, Society for Nutrition Education, and associate
professor and extension specialist, department of food science and human

nutrition, Colorado State University 47

Prepared statement 161

Brittain, Jere A., coordinator, integrated pest management and agromedicine,

Clemson University 57

Prep£U"ed statement 175

Haas, Ellen, Assistant Secretary, Food and Consumer Services, U.S. Depart-
ment of Agriculture 8

Prepared statement 72

Response to written questions 23

Johnsrud, Myron D., Acting Assistant Secretary, Science and Education, U.S.

Department of Agriculture 12

Prepared statement 92

McCarron, David A., M.D. professor of medicine, Oregon Health Sciences

University 59

Prepared statement 185

Nichols, Buford L., Jr., M.D. Director Emeritus, Children's Nutrition Re-

se£u*ch. Agricultural Research Service, U.S. Department of Agriculture 38

Prepared statement 105

Response to written questions 121

RivUn, Richard, M.D., president, American Society for Clinical Nutrition,

Inc. 43

Prep£u-ed statement 147

Response to written questions 152

Rosenberg, Irwin H., M.D., professor, medicine and nutrition, eind Director,
Human Nutrition Research Center on Aging, U.S. Department of Agri-
culture, Tufts University, Boston, MA 40

Prepared statement 127

Schuman, Stanley H., M.D., South Carolina agromedicine program, depart-
ment of family medicine. University of South CaroUna 56

Prepared statement 172

Schuster, Ellen, State coordinator, expanded food and nutrition education

program, Minnesota Extension Service, University of Minnesota 45

Prepared statement 155

Woteki, Catherine E., director, food and nutrition board, Institute of Medi-
cine, National Academy of Sciences 42

Prepared statement 137

Young, Eleanor A., professor, department of medicine, division of gastro-
enterology and human nutrition. University of Texas Health Science Center

at San Antonio 61

Prepared statement 194

Response to written questions 212

(III)

Page

Submitted Material

Branstool, C. Eugene, Assistant Secretary, Marketing and Inspection Serv-
ices, U.S. Department of Agriculture, statement 220

Dupont, Jacqueline, National Program Leader for Human Nutrition, Agricul-
tural Research Service, U.S. Department of Agriculture, statement 228

Mathias, Melvin M., Human Nutrition Scientist, Cooperative State Research
Service, U.S. Department of Agriculture, statement 235

REVIEW OF NUTRITION RESEARCH AND
EDUCATION ACTIVITIES

THURSDAY, JULY 15, 1993

House of Representatives,
Subcommittee on Department

Operations and Nutrition,
Committee on Agriculture,

Washington, DC.

The subcommittee met, pursuant to call, at 10:30 a.m., in room
1300, Longworth House Office Building, Hon. Charles W. Stenholm
(chairman of the subcommittee) presiding.

Present: Representatives Dooley, English, Volkmer, Rose, Lam-
bert, Smith, Gunderson, and Allard.

Also present: Representative Minge, member of the committee.

Staff present: Julia M. Paradis, assistant counsel; Glenda L.
Temple, clerk; James A. Davis, Merv Yetley, Pete Thomson, and
L5nin Gallagher.

OPENING STATEMENT OF HON. CHARLES W. STENHOLM, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. Stenholm. This public hearing of the Subcommittee on De-
partment Operations and Nutrition will now come to order.

Today, we continue a series of hearings looking at our Nation's
agricultural research capacity. Specifically, we will address the
subject of nutrition research and education.

TTie U.S. Department of Agriculture supports approximately 20
percent of the human nutrition research conducted by the Federal
Government. This is accomplished by our federally supported 1862
and 1890 land-grant colleges and by agency research performed at
regional laboratories by the Agricultural Research Service. This re-
search not only examines basic mechanisms of nutrition and
growth but seeks to extend these results to the public as well.

The food pyramid and recommended dietary allowance guidelines
have both received major input from nutrition researchers at
USDA. Through the Extension Service, results of nutrition research
are communicated to the public. The Expanded Food and Nutrition
Education Program, EFNEP, is an effective agency program which
seeks to educate consumers, particularly those in at-risk population
groups, about nutrition.

In addition, feeding programs administered by the Department
ensures a low-cost, available food supply for those segments of our
population most in need. The WIC Program, the Food Stamp Pro-
gram, and childhood nutrition programs are all effective examples.

(1)

Our food supply is increasingly challenged for vsirious reasons.
High levels of fat, chemical residue contamination, and microbial
contamination are just a few examples of recent criticism directed
at our food supply. When taken out of context, these criticisms may
influence consumers by making them more susceptible and sjonpa-
thetic to emotional appeals and misinformation which may appear
in the media.

For American consumers to make informed food choices, they
must be well informed not only about the risks but also about the
benefits of our food supply.

It is becoming more clear that many of the debilitating diseases
fi'om which we in America suffer today are related to diet. Whether
to prevent low birth weight babies through adequate prenatal nu-
trition, osteoporosis in the elderly through adequate calcium nutri-
tion, or niunerous other medical conditions, it is essential for Amer-
icans to be educated about the importance of a well-balanced and
nutritious diet.

Teaching oxir population the essentials of a well-balanced diet
may have more influence upon public health thgin possibly any-
thing else we could do. If we can better educate consumers about
healthful nutrition habits, we will not only prevent debilitating dis-
eases later in life, we will also be investing in America. Every dol-
lar we save in preventative medicine is a dollar to be invested in
our children's future.

The assumption upon which this hearing is based is that strong
linkages between nutrition research and nutrition education will
lead to a better educated and therefore healthier consumer.

The U.S. Department of Agriculture is involved in various re-
search and education activities involving nutrition. This hearing
will review these activities and the linkages among them and elicit
recommendations on how to strengthen the chain leading from pro-
duction agriculture to nutrition research to the consumer.

Witnesses have been asked to address the issue of nutrition re-
search and education. First, what are some examples of ongoing
nutrition research and the extension of these results to consumers?

Second, what nutrition research is currently being done in at-risk
population groups £ind how are these results being expressed? How
effective are ongoing extension education programs such as
EFNEP — Expanded Food and Nutrition Education Program? Are
there any contemporary examples of nutiition research and edu-
cation programs seeking to link the agricultural and health com-
munities? How effective is interagency research coordination and
how can this be made more effective? How to improve the level of
nutrition expertise that physicians receive? What should be the top
priorities for nutrition research and education today?

One of the major issues facing us today is hunger, not just world
hunger but hunger in our own Nation as well. This hearing will
seek to link our food production, nutrition, and health sectors in a
new way.

If we are to properly address the challenging issues we will face
in the future, it is essential to begin this dialog today. With your
assistance, we are excited about moving forward with confidence.

Included in the record today will be a written statement from As-
sistant Secretary Eugene Branstool of the Agricultural Marketing
Service at USDA.

Also statements from Dr. Dupont and Dr. Mathias.

[The prepared statements of Mr. Branstool, Dr. Jacqueline Du-
pont, and Dr. Melvin M. Mathias appear at the conclusion of the
hearing.]

Mr. Stenholm. Mr. Smith.

Mr. Smith of Oregon. Thank you, Mr. Chairman.

I w£int to welcome the witnesses this morning. I have a prepared
statement for the record.

Mr. Stenholm. Mr. Dooley.

Mr. DoOLEY. Thank you, Mr. Chairman. I have no formal state-
ment to make.

Mr. Stenholm. Before I call the first panel, any prepared state-
ments received from members will appear at this point in the
record.

[The prepared statements of Mrs. Clayton and Mr. Smith of Or-
egon follow:]

EVA M. CLAYTON HOUSE OFFICE SUILOING

llTOntmcT NoamCuou-u WASHINGTON OC 20515-3301

12021 225-3101

ConsreclfS of tf)e tBniteb States;

^ousfe of 3^epregentattbeK

8Ba8l)tngton. IBC 20515-3301

STATEMENT FOR REP. EVA M. CLAYTON

SUBCOMMITTEE ON DEPT. OPERATIONS AND NUTRITION

HEARING ON EDUCATION AND NUTRITION

15 JULY 1993

Thank you, Mr. Chairman. I am pleased that you
are contmuing to focus the Subcommittee's attention on
issues related to nutrition, and the relationship it has to
the research of which the Department is so intricately
involved. In an overall note, I am pleased to see that
recent Subcommittee hearings have sought to tie together
major areas of concern which confront our nation's
capacity to produce a safe and reliable food supply.

I am familiar with programs conducted by the
Agriculture Extension service such as the Expanded Food
and Nutrition Program (EFNEP) which effectively
communicates to consumers the findings of our nation's

nutritional research. This educational process is
particularly helpful to those "at-risk-groups" who are
vulnerable to bad nutritional practices.

Despite recent findings relating to contamination and
pesticide residues, the overall problem facing our
American consumers remains the high levels of fat that
make-up the bulk of our nation's diet. If we are to
undertake real health care reform, we must also
concentrate on "preventative care." I believe that the
Department of Agriculture can and should play an
important role in the future health of our nation.

Again, thank you Mr. Chairman for holding this
hearing, and I welcome the distinguished participants
from the Department of Agriculture and the academic
world. Your comments are meaningful and crucial to the
future of American nutrition.
Thank you.

STATEMENT OF THE HONORABLE BOB SMITH
SUBCOMMTITEE ON DEPARTMENT OPERATIONS AND NUTRITION
REVIEW OF NUTRITION RESEARCH AND EDUCATION ACI'IVITIES

JULY 15, 1993

Thank you Mr. Chairman. I wish to welcome all of our witnesses, especially Ellen
Haas, the Assistant Secretary for Food and Consumer Services. Ms. Haas has testified
many times before the Agriculture Committee in her previous capacity as Director of
Public Voice. I look forwsird to hearing her recommendations concerning the programs
of the Department of Agriculture fi-om an insider's view.

Consumers in the United States have a wide variety of healthy food choices for
their diets and, according to USD A, spend 11.4% of disposable income on food, a record
low. Our food production system is the best and the most efficient in the world, thanks
to United States farmers and ranchers. Consumers reap the benefits of this food
production and processing system.

And yet consumers are constantly told by the media of new reports outlining the
dangers of a specific food or a method of production. At times there are so many of
these reports that consumers will tend to disregard sill advice — throwing out the wheat
with the chaff.

The purpose of our hearing today to hear from USDA and other expert witnesses
on what is being done to improve the nutritional well-being of people in the United
States — through research and education activities. The basic advice issued by USDA is
the Dietary Guidelines for Americans. I will be interested to hear from out witnesses
how this basic, common sense advice is conveyed, whether the message is received, and
how USDA measures the results of its efforts. Are Americans improving their nutritional
well-being? Are we healthier today than ten or twenty years ago?

I look forward to this hearing and welcome all of our witnesses. Thank you Mr.
Chairman.

Mr, Stenholm. We will call our first panel, Ellen Haas, Assist-
ant Secretary, Food and Consumer Services, and Myron Jolmsrud.

STATEMENT OF ELLEN HAAS, ASSISTANT SECRETARY, FOOD
AND CONSUMER SERVICES, U.S. DEPARTMENT OF AGRI-
CULTURE

Ms. Haas. Good morning, Mr. Chairman and members of the
subcommittee.

I am very pleased, as you would imagine, to be here today along
with Myron Johnsrud, who is representing the Acting Assistant
Secretary for Science and Education, to discuss nutrition research
and education activities of the U.S. Department of Agriculture.

I would hke to say, with your permission, Mr. Chairman, I would
like to include my full remarks, but I would like to summarize
what I have in front of me.

Mr. Stenholm. Without objection.

Ms. Haas. Let me begin by saying I think we share with you
very much the intent of this hearing that nutrition must become
a priority mission of the Department of Agriculture, and we thank
you very much for holding this hearing which recognizes that im-
perative.

As you know, I have appeared before this important committee
many times in my career. This is my first time as the Department
of Agriculture's Assistant Secretary for Food and Consumer Serv-
ices. My appearance here underscores Secretary Espy's commit-
ment to nutrition, and today's hearing acknowledges the impor-
tance of the three missions of the Department of Agriculture: Agri-
culture, rural development, and nutrition.

Secretary Espy has pledged to make nutrition education a prior-
ity and to work to integrate nutrition into the agriculture, health,
and welfare policies of the Clinton administration. I am committed
to doing just that. Secretary Espy and I want to commend you, Mr.
Chairman, and members of the subcommittee for focusing on our
national nutrition responsibiUties.

With the clear evidence of the relationship between nutrition and
health, enabling Americans to adopt eating habits that follow the
U.S. dietary guidelines is essential. It is not enough for us to help
produce food or even to distribute it better. We need to go beyond
and estabhsh nutrition programs that promote healthfiil eating
habits and, most importantly, empower consumers with enough in-
formation to make healthful choices for themselves and their fami-
lies.

There is no question that diet is related to chronic disease. The
1988, Surgeon General's report on "Nutrition and Health," foimd
that for the two out of three Americans who neither smoke nor
drink, eating patterns may shape their long-term health prospects
more than any other personal choice. With the cost of health care
spiraling, these are choices that no American can afford to ignore.
Other research supports these findings.

Our nutrition education programs at Food and Consumer Serv-
ices in the Department of Agriculture are firmly grounded in re-
search to find out why diets are not as good as they shoiild be and
what we can do to help people improve them.

Over the past year, the Human Nutrition Information Service's
research on the factors influencing diet has focused on the diets of
single parents, the characteristics of food label users, the character-
istics of those concerned about food safety, trends in the use of
fruits and vegetables and, most importantly, the diets of children.

A Food and Nutrition Service study examined the nutrient con-
tent of the school lunch program, and we are currently developing
vaUdated food frequency questionnaires to assess the diets of WIG
chents and to provide a basis for nutrition education.

High-quaUty scientific research, relevant to the areas of policy
development, is absolutely essential. We need to continue to assxire
the professional community and the public that the Department of
Agriculture is a credible source of scientifically accurate and imbi-
ased dietary guidance. If it is perceived to be influenced by political
or special interest concerns it will not, and probably shoiUd not, be
accepted.

While we have done much reseeirch and produced many edu-
cational materials, USDA's effort has been fragmented over eight
USDA agencies and has lacked in overall strategy. We need to
build our capacity to improve our coordination so that we are offer-
ing a unified, effective message to the American people.

All of the nutrition research and education efforts we undertake
depend on working partnerships within USDA, with other Federal,
State, and local governments, and with the private sector.

As you know, I am a firm believer in the importance of making
linkages and biiilding coahtions to achieve shared pohcy gosds. All
of us who are part of the food system-farmers, consumers, indus-
try and Government — have a stake in this vital agenda.

I am extremely interested in developing a nutrition education
initiative to pull together all of the leading organizations and indi-
viduals in the area of nutrition education for information sharing,
networking, and collaborative outreach. Goordinating mechanisms
such as the Dietary Guidance Working Group and the Human Nu-
trition Goordinating Gommittee have been developed at the staff
level with representation from every agency with responsibility for
some aspect of nutrition education, research, monitoring, or food
assistance programs.

But at the same time that we work on coordinating our message,
we must also work on communicating it more effectively by har-
nessing USDA's extensive electronic resources to provide more re-
sponsive, persuasive, and far-reaching communications.

For example, we are using print brochures to compete with the
billions of dollars spent to produce the light and sound shows that
are part of today's food advertising. We need to stretch our reach
by using new commxmications technology. If the teenagers watch-
ing MTV are the ones we need to reach, and our research tells us
they are, then our messages should be on MTV.

We need to use the results of all our research more effectively.
Our nutrition monitoring research tells us that food consvunption
patterns differ by income level, by age, and ethnic group. We must
develop communications strategies that empower these high-risk
groups as well as the average consumer to make healthful choices.

There already exists a scientific consensus on what msikes a
healthful diet. USDA's Human Nutrition Information Service, in

cooperation with the Department of Health and Human Services,
has provided dietary guidelines for Americans since 1980. The two
Departments will soon review and revise the guidelines to ensure
that they represent the best and most up-to-date advice we can
give.

Also, our food guide pyramid, which visually illustrates the die-
tary guidelines, is the best known product of HNIS's nutrition edu-
cation research. This pyramid, known to himdreds of millions of
Americans across the country, has become a powerful tool for con-
veying the nutrition message — not only in USDA's nutrition efforts,
but also appearing on box tops and packages of the food industry
and other private sector initiatives.

But still we have to find out how we can best build the pyramid
into education programs, and we need to do more of that.

Also, the new food labeling law promises to provide consumers
with Imowledge about exactly what they are eating. But the new
food label is only beneficial to consumers if they understand what
they are reading. With proper education, the new label will em-
power consumers to make healthful choices.

We not only need to broaden our education effort, we must make
sure we are providing all segments of the population, particularly
the most vulnerable, with nutrition information.

USD A will spend more than $300 million this year on nutrition
research, monitoring, and education activities. Nearly half of that
goes to support our nutrition education activities in the WIC pro-
gram while very Uttle of it is used for nutrition education in the
Food Stamp Program. Nutrition education must be an integral part
of all of the 14 food assistance programs managed by FNS to en-
sure that participants — and now we have one of six Americans who
are recipients of one of our 14 food assistance programs — to make
informed decisions about the food they select.

I will summarize the specific nutrition initiatives that we have
underway.

The Food Stamp Program, as you know, is the largest single food
assistance program, but it has the smallest nutrition education
component. Less than one-tenth of 1 percent of the food stamp
budget goes for nutrition education. Clearly, we must do more to
provide nutrition education for the 27 million Americans who rely
on food stamps to supplement their food purchasing resources.

However, for the first time, FNS will award $500,000 for food
stamp nutrition education demonstration grants this summer.
These grants will support development, implementation, and eval-
uation of innovative community nutrition interventions that focus
on improved knowledge and skills for meal planning, budgeting,
and food preparation.

I have set as a priority making nutrition education an integral
part of the Food Stamp Program and moving from that one-tenth
of 1 percent to a meaningful program that helps consumers who
are needy.

Unlike the Food Stamp Program, the WIC program provides nu-
trition education as part of its mission, along with packages of nu-
tritious foods and referrals to help in social services. It is designed
to focus on the relationship between proper nutrition and good

health and to assist participants at nutritional risk to make posi-
tive changes in their diets.

Of the approximately $140 million we spend on WIC nutrition
education, about $60 million is used to promote and support
breastfeeding.

Other current initiatives include the WIC nutrition education as-
sessment project, which will investigate the effect of nutrition edu-
cation provided to participants and, the second national WIC nutri-
tional services conference that is being held this August.

Also, the nutrition education and training program is the only
national school based nutrition education program. It seeks to build
healthy food habits by teaching the fundamentals of nutrition to
children, parents, educators, and food service personnel.

Although the program is authorized to $25 million, appropriated
funds are less than half of that. Together, Congress and tiie admin-
istration need to place a priority on rebuilding the capacity and
funding for this program which was cut back so severely in the
early 1980's.

A recent collaborative effort produced the strategic plan for nutri-
tion education in the child nutrition program. The plan provides a
structure that identifies 10 national goals. It was developed by rep-
resentatives from industry, professional organizations, ^d Feder^
and State agencies.

Other NET activities promote interagency coordination of child
nutrition activities and provide technical assistance to other Fed-
eral agencies.

A good example of the partnerships we should continue to en-
courage is the NET technical assistance that is ongoing in the de-
velopment of national nutrition education guidelines for the Cen-
ters For Disease Control Prevention.

Nutrition education is a vitally important component of school
health and education, and I want to do more in this area.

In order to respond to the need for greater and more effective nu-
trition services for participants in the food distribution program on
Indian Reservations, USDA has recently formed an interagency
task force for Native American nutrition education. Nine Federal
agencies that have responsibilities for providing nutrition education
are members of the task force as weU as two Native American or-
ganizations engaged in food assistance.

The task force is committed to supporting nutrition education
which is especially geared to Native Americ£ins cultures and needs.

In 1993, we requested and received $135,000 in iunds appro-
priated to the FDPIR nutrition education program. These nmds
were made available for purchasing nutrition education publica-
tions and materials.

Mr. Chairman, while all of these food program initiatives are ex-
cellent examples of nutrition education activities within our pro-
grams, they are not enough. We need to reach beyond what is to-
day's status quo. We need to reach more Americans with this criti-
cal information.

President Clinton has charged his Cabinet to reexamine the way
the Federal Government is doing business and to find new and bet-
ter ways to provide services for the American taxpayer. Secretary
Espy is committed to meet this objective and has asked the new

members of his subcabinet to help the President reinvent Govern-
ment.

In that vein, we are undertaking a review that includes the man-
ner in which the Department is organized to meet our national re-
sponsibilities for nutrition research, monitoring, and education.
This is the first such review since the food and nutrition study of
the 1979 President's Reorganization Project.

I believe that it is fundamentally important that the Department
of Agriculture refocus on its nutritional mission. Oxir programs
touch the lives of every American every day, and their health and
their future depend on it.

Mr. Chairman and members of the subcommittee, for many years
I have worked on behalf of consumers to promote access to a safe,
nutritious, and affordable food supply. I greatly value the oppor-
tunity that Secretary Espy and President Clinton have given me to
improve the nutritional and health status of American consumers.
I look forward to working very closely with the subcommittee to
meet that goal.

Thank you.

[The prepared statement of Ms. Haas appears at the conclusion
of the hearing.]

Mr. Stenholm. Thank you.

Next we will hear from Dr. Myron Johnsrud, Acting Assistant
Secretary, Science and Education.

STATEMENT OF MYRON D. JOHNSRUD, ACTING ASSISTANT
SECRETARY, SCIENCE AND EDUCATION, U.S. DEPARTMENT
OF AGRICULTURE

Mr. Johnsrud. Mr. Chairman, members of the subcommittee,
good morning. I am pleased to be with you, as Ellen indicated, to
discuss the Science and Education nutrition research and education
activities of the USDA.

Again, my complete statement has been submitted for the record,
Mr. Chairman, and I will touch on most of that in my comments.

Dr. Plowman would like to have been here and sends his regrets
that he had previous commitments long-standing outside the city
and could not be here for the hearing.

My statement includes discussion on research and educational
activities of the Agricultural Research Service, Cooperative State
Research Service, and the Extension Service. Much more could be
said about nutrition research programs than the time allows this
morning, Mr. Chairman, and with permission I woxild like to file
more detailed testimony from ARS and CSRS.

Mr. Stenholm. Without objection.

Mr. Johnsrud. Food and nutrition programs are part of a larger
context and relate to issues of economics, health, and environment.
I echo what Ellen Haas stated relative to the fact that Secretary
Mike Espy has pledged to work to integrate nutritio(n into the ad-
ministration's agricultural health and welfare policies and the
USDA Science and Education agencies stand ready to support him
in this endeavor.

Poor nutrition is expensive and increases oversdl health care
costs to individuals and society. It compromises a child's potential
to grow into a strong healthy adult. Along the way, it affects a

child's ability to concentrate and to learn in school. The saying is
that "everyone eats; unfortunately, everyone doesn't eat well."
Some do not eat well because they don't have the economic re-
sources to do so and others do not eat well because they don't know
what or how much food is good for them to eat.

USDA science and education agencies are developing and com-
municating the information that helps produce more nutritious
foods, what constitutes an optimum cUet, and helps maintain our
human health.

The 1977 farm bill designated USDA as the lead agency for nu-
trition research and education, but our commitment in this area
began long before 1977. In fact, this year marks the centennial of
USDA's involvement in nutrition research.

USDA's mandate, from the very beginning, has been to ensure
that people of this country have a safe and adequate food supply.
From the farm to the kitchen table, many decisions are made that
affect the quality and wholesomeness of our Nation's food supply.
Those decisions are made based on the current knowledge and in-
formation drawn from the nutrition research and education.

This is why the USDA's Science and Education agencies are di-
rectly involved in both nutrition research and nutrition education.
Neither of these components, research nor education, can stand
alone. One gathers necessary information for food producers, proc-
essors, and consumers, while the other aids in disseminating that
information in soiind practical ways that empower individuals and
families to make wise, economical, and healthy food choices.

A safe and wholesome food supply begins back at the seed.
Breeding more nutritious varieties of crops and developing nutri-
tious ways to produce, harvest, and process foods. One of the first
big projects in the ARS Plant, Soil and Nutrition Research Lab in
Ithica, New York was to study fertilizers' effect on the carotene
content of tomatoes.

Carotene is precursor to vitamin A and both vitamin A and caro-
tene have been linked to a reduced risk for some types of cancer.
Today, an ARS scientist is busy breeding a new tomato variety that
could easily have as much vitamin A as a sweet potato wluch is
one of the highest dietary sources of vitsunin A.

We are learning precisely what levels of nutrients the body needs
for health. For example, at the ARS Nutrition Research Center on
Aging, many new findings suggest that even modest dietary
changes may improve health status of the elderly. Researchers
have found that vitamin E and X)ther antioxidants may enhance the
immune system, improving the ability of the body to combat dis-
ease. Next time you watch a commercial for vitamins, notice which
vitamin group is currently highhghted.

ARS scientists are working with the medical scientists at George-
town University, Johns Hopkins University, and the University of
Maryland, and other institutions to further study vitamin and min-
eral bioavailabihty from foods as well as interactions with other
different carbohydrates in the diet. The results of these studies are
important in defining ways to improve food consumption by genet-
ics and processing to best meet people's needs.

The Human Nutrition Research Center in Grand Forks, North
Dakota focuses on mineral needs and they have done pioneering
work on mineral needs to nevirological and behavioral functions.

The Children's Nutrition Research Center in Houston, Texas, as-
sociated with Baylor College of Mediciue, conducts studies of nutri-
ent needs for normal and preterm infants. The center has equip-
ment not available anj^where else to monitor growth of organs,
muscle, bones, and fat during pregnancy and of infants and nurs-
ing mothers. Recently, the center has begun a totally vmprece-
dented study of nutrient needs and growth processes of teenage
mothers.

This research, carried out by our Nation's land-grant imiver-
sities, emphasizes nutrient requirements, interrelationship of nu-
trients, effects of nutrients on the immune system, and food
consumer behavior.

One of the very important research studies currently underway
looks at the food behavior of adolescent and young adults. There
is virtually no information about the effect of nutrition and health
concerns on the food intake by this group of 18 to 24 year olds. Re-
search findings on what motivates the food choices of this age
group will be used by extension and health professionals to develop
appropriate and effective programs.

Research, however, is only half the job. The other half is edu-
cation.

Information is only useful when it has been communicated to
those that put information to work. And the information must be
commiuiicated in practical and relevant terms for the appropriate
audience including consumers, farmers, food processors, plant and
animal breeders, dieticians, health professionals, and all those who
make decisions about food and nutrition.

For example, several years ago, ARS scientists developed a natu-
ral fat substitute called oatrim, made fi*om oats, rich in soluble
fiber and can replace sill or parts of the fats in many foods. Today,
just a few of the commercial products that contain oatrim are bolo-
gna, hotdogs, Peachtree brand cookies, low-cal cheese, and even
many of the prepared dinners marked imder the trade mark
Healthy Choice.

The Cooperative Extension System which links the USDA Exten-
sion Service, the 74 land-grant universities, and the 3,000-plus
county administrative imits provides nutrition, diet, and health
education to a wide variety of audiences. The programs are de-
signed to provide people of all ages with the knowledge to make in-
formed decisions about what to eat. Objectives include helping peo-
ple reduce the risk of chronic disease, give birth to healthy babies,
practice responsible and healthy self-care, help children attain opti-
mum long-term health, minimize nutritional inadequacies, and im-
prove consumers' abihty to make informed choices related to food
safety, quahty, and composition.

One of the most well-known nutrition education programs con-
ducted by the Cooperative Extension System is the expanded food
and nutrition education program. This intensive education program
is designed to help low-income famihes not only gain knowledge,
but gain the skills and adopt the behaviors that lead to a healthier
diet.

These low-income families often are at increased risk for develop-
ing nutrition and health-related problems. We have found that
families who complete the 6-month program are able to make sig-
nificant improvement in their diets, while spending less money on
food.

As food dollars stretch further and diets improve, health risks for
these low-income families are reduced. To improve evaluation of
this program, EFNEP, we have developed a new evaluation/report-
ing system. The new system has the capability to identify how
many pregnant and nursing women are participating in EFNEP
and what types of public assistance they are receiving.

It also allows us to analyze people's diets before and after the
program for their adherence to the USDA food pyramid, for key nu-
trients like protein, calcium, and fiber, and for the percent of cal-
ories coming fi"om protein, fat, and carbohydrates. Training in the
new system is underway and implementation will take place this
fall.

The Extension Service and Food and Nutrition Sei-vice are col-
laborating to develop nutrition education programs that meet the
needs of WIC clientele, pregnant women, nursing mothers, and
children fi*om birth to 5 years of age. The goals of this initiative
are to improve knowledge and behavior in those £ireas such as food
selection, purchasing, storage, safety, and preparation and to im-
prove breast-feeding and dietary behaviors.

Another example of Extension's education programs is one tar-
geted specifically toward addressing the problems of the needs of
Native Americans. Health and nutrition education programs on
many reservations target Native American youth and focus on the
broader concept of wellness by combining health and nutrition
learning activities with physical exercise including tribal dancing.

The Extension agents work with youth along with elders, to pro-
mote healthy lifestyles and reduce chronic diseases. One of the
most important needs for nutrition education centers on maternal
and infant health. Even within the broad category of women and
infants, we see a group of people about whom we are particularly
concerned, namely, pregnant teens. There are a host of reasons for
this concern.

Teens themselves are still growing and learning to make inde-
pendent decisions about the food they eat. Their own needs are in-
creased by the critical needs of their pregnancy. Thus, it is no won-
der that teens are at high risk of giving birth to babies below the
healthy birth weight of 5.5 pounds. In general, low birth weight is
one of the greatest determinants of infant death and disabilities,
and poor nutrition is one of the major risk factors associated with
low birth weight.

Low birth weight occurs in approximately 7 percent of all births.
Medicaid pays almost $19,000 per deUvery of a low birth weight in-
fant versus $3,500 of a normal weight infant. Thus, low birth
weight costs the Nation somewhere in the range of $5 billion each
year.

Mr. Chairman, I believe that you and the members of the sub-
committee may have heard of the '*have a healthy baby*' program
in the State of Indiana. Of the over 2,000 teens and adults enrolled

in this program, we have been able to collect data on about two-
thirds or about 1,200 babies.

The data reveals that over a 3-year period, 97.9 percent of the
babies were bom normal weight and only 30 babies — 2.4 percent,
compared to Indiana's average of 6.6 percent — ^were bom at below
normal birth weight. As a result, the Extension Service program in
Indiana prevented 52 low birth weight babies at a savings of $3.12
million in neonatal intensive care.

To put this in perspective, the total dollars spent on the program
in the last 3 years has been $156,000, in other words, for each dol-
lar spent on the program, $20 were saved. That is a tremendous
return on investment in prenatal education. This program is cur-
rently being replicated in over one-half dozen other States.

"Have a healthy baby" is only one of a number of educational ef-
forts we have for pregnant and parenting teens. For the past 8
years the **becoming a mother" program of North Carolina has
demonstrated its impact on babies and mothers. Beginning as a
home visitor program, teens are taught good eating patterns to en-
sure appropriate weight gain leading to a healthy birth.

Following the delivery, the young mothers become involved in a
peer support group. Successful parenting is one of the focuses. An-
other is encouraging the teens to remain in school. We feel that
parenting education is of importance equal to nutrition during
pregnancy because our goal is to prevent overall child abuse and
neglect.

Because maternal and infant health is of such vital importance
to CES, and because educational programs rely on a strong re-
search base, we have entered into a new and exciting collaborative
relationship with the Agricultural Research Service's Children Nu-
trition Research Center.

The Extension food and nutrition specialists with Purdue Univer-
sity, who developed the **have a healthy baby" program, have been
assigned to and working with the Cluldren's Nutrition Research
Center since April of this year. The purpose is to link the scientific
findings of the CNRC with Extension faculty and staff throughout
the country.

A request has been sent out to each State Extension Service ask-
ing them about their priorities, needs related to research in the
areas of maternal and child health and the kinds of material which
are needed, at what levels in terms of language and cultural con-
tent and so on, and what the staff development training needs are.

Our plan is to conduct teleconference smd satellite conferences to
address these needs. We have already begun to share the knowl-
edge of the CNRC and, for example, researchers recently discovered
that smoking alters the nutrient content in milk of lactating moth-
ers. Information on the health consequence of smoking by lactating
mothers has been communicated to local Extension educators who,
in turn, are incorporating this information into news articles,
broadcast items, and teaching materials.

I will now take a moment to discuss the education for people who
have low education levels or who may not be proficient in EngUsh.
We believe there is more to enabUng people to understand informa-
tion than to simplify the written word.

Of course, we recognize the importance of written materials and
use these regularly, but we use research information of different
educational methodologies to guide our decisions about program-
ming. Our EFNEP participants are building skills as they apply
principles of nutrition, food safety, and money management in
hands-on experience.

One of these issues deal with the cultural differences. In Cahfor-
nia, for example, Extension has hired faculty who are bilingual and
bicultural to work with the Hispanic population. In this way, we
can develop materials that conform to cultural values and food hab-
its of this important population.

In other instances, paraprofessionals are hired to work in the
neighborhoods. The best example of that is the EFNEP program
that used the system for 25 years of emplo5dng a program assistant
from the community. This lends credibility to the system, and helps
present a program that is meaningful and increases the access of
the people to the xiniversity.

We also use volunteers in the Extension system. And the use of
volxinteers as teachers is also a great community development ef-
fort because the people own and share the knowledge and it is not
something that belongs to the outside experts.

Hunger and undernutrition have been identified through our
community-based needs assessment in several States. Florida and
Montana have worked on this issue through public poUcy edu-
cation. In both States, Extension has formed cosilitions of public
and private organizations in order to strengthen the safety net for
the people in need.

Chronic disease prevention is another area where Extension col-
laborates with a host of agencies, public and private-nonprofit. For
example, the States of Pennsylvania, New York, and Maryland and
the States of South Carolina, Georgia, and North Carolina have
formed two coalitions funded by NIH and NCI for development of
cancer control coaHtions.

CES sees nutritional education as a hoUstic, comprehensive ef-
fort. We work to understand the needs of people and create pro-
grams that will be effective in a particular situation. This edu-
cational effort is coupled with many of the other nutrition and nu-
trition education activities available from USDA and other health
serving agencies and organizations.

Additionally, USDA agencies which provide resegu-ch and edu-
cation work collaboratively for greater program effectiveness and
early impact. ARS, CSRS, ES, the Food and Nutrition Service, and
the Human and Nutrition Information Service all participate in
interagency groups. These include the Dietary Guidsince Working
Group, Human Nutrition Coordinating Committee, Food Safety
Task Force; all which help ensure better coordination to try to
avoid duplication.

Also, ES depends on the HNIS consulting group which provides
feedback on what HNIS has found relative to education materials
and they work back and forth to assure that all educational mate-
rials have the best input from both agencies in terms of which au-
dience is targeted.

Also, I think it is important to mention, as we close, that Science
and Education agencies cooperate closely with other Federal De-

partments. The Interagency Committee on Human Nutrition Re-
search is chaired jointly by the Assistant Secretary for Science and
Education of the USDA and the Assistant Secretary for Health at
the Department of Health and Humsin Services o This committee
also includes representation from National Aeronautics and Space
Administration, AID, Department of Commerce, Department of De-
fense, Veterans Affairs, and Office of Science and Technology Pol-
icy.

There is a great deal of collaboration with private industries. I
mentioned oatrim earlier which has been licensed by ARS to three
companies, and sales top $1 bilUon in just over 1 year since their
introduction.

I would cite the Extension Service's involvement with a coalition
of Government industries, trade associations, and private compa-
nies to put together food labeling kits to help people better under-
stand and read food labels.

Mr. Chairman, this concludes my statement and I would be
pleased to attempt to respond to any questions.

[The prepared statement of Mr. Johnsrud appears at the conclu-
sion of the hearing.]

Mr. Stenholm. We thank both of you for your testimony. This
very intriguing but also extremely important dialog that needs to
continue because we need to start looking at some ultimate solu-
tions.

The first question I would like to ask of you both, and Ellen, I
will start with you, this is one area in which we have cross-jurisdic-
tional interests as far as the Congress is concerned. We have mul-
tiple agencies of the Federal Government involved to one degree or
another with nutrition education and feeding programs.

How can existing food and nutrition programs be made to work
better when we look at some of the competing interests? I don't
want to use the word "competing"; a lot of people have a lot of good
intentions. The results are out there, but at the same time the
criticisms are there. I mean the fact that we still have hunger in
America, for example, is a valid criticism which indicates that we
still have some problems.

Ms. Haas. I think for too long, Congressman Stenholm, the prob-
lem of nutrition has been dealt with in isolation. There is not an
effort to integrate and to reaUze that hunger can't be isolated from
health, it can't be isolated from food, from agricultural policies,
from welfare poUcies. And I think that nutrition is a bridge be-
tween how you grow the food, and the actual health outcome of the
individual. We in the Department of Agricultiu-e are that bridge in
providing nutrition education and research.

What has been missing for the past decade is leadership that can
bring all of those groups together to come out with ways of educat-
ing consumers in a more effective manner. We have a great deal
of research and scientific consensus over the past decade — ^the U.S.
dietary guidelines, the Surgeon General's report, the "Healthy Peo-
ple 2000" report.

But we have not been able to translate to the consumer, to dis-
tribute that information and educate. I am hopeful that this hear-
ing is the beginning of that process to find a way to bring those

messages in a more coherent manner. So I applaud you for bring-
ing us all together today.

Mr. Stenholm. Dr. Johnsrud, would you have any specific sug-
gestions on the educational side of how we might accomplish that
goal, the goal of better education, better information, better trans-
fer of education. Ellen, I take a little exception, not for purposes
of debate today, but for purposes of suggesting that perhaps you
and I both need to take a look at the scientific consensus. As I have
read through some of the other testimony that we will hear later
today, there is ample reason to beUeve that there are some exciting
things now happening in the field of science that £ire beginning to
challenge some of the consensus of the last 5 or 10 years. I don't
say this for argumentive purposes today, but just to preface my
question to Dr. Johnsrud, as to how we take new science and new
development of nutrition research and make it apply in a more con-
structive manner as far as the educational side of it is concerned.

Mr. Johnsrud. Mr. Chairman, I would respond with several
comments. One, as I said in my testimony, we have continued to
work hard from the production of food to the utilization; so as you
breed new crops you develop the nutrition quaUty of those crops.
Second, we have also begun and really have been working hard to
focus more sharply on the needs of a specific group of cUentele, spe-
cifically, there are particularly pressing needs with the young, and
the elderly. So we need to tailor our education program to focus
that way.

Oftentimes, as I said earher in my testimony, for information to
be meaningful you have to get down to what the people can under-
stand, how it relates to their culture and so forth, so we have had
to address our resources that way.

Third, £ui area that as we have had discussions before, the ex-
panded Food and Nutrition Program used to be heavily one-on-one.
We have started to change our ways on how we can reach more
with the same amount of resources. That is through more group ef-
fort as people become more comfortable working that environment.

We have strengthened our ties to research. We are feeling good,
now ARS and Extension Service have tied together at the Baylor
Medical College and already we see benefits from that. There are
many things I could mention of how we have tried to look more
sharply, focus more sharply and use our resources more crisply; but
it is not easy. We are finding, for example, the language matter.
We have to put additional resources into getting materials so the
information is meaningful to whatever the group may be. There £u*e
a lot of things we comd talk about, but these are some examples.

Ms. Haas. Mr. Chairman, if I can just add, I agree with you that
knowledge about nutrition is not static. Or knowledge about the re-
lationship of diet and health. I mentioned in my testimony that we
are now preparing for the revision of the dietary guidelines that
will take place again in 1995. The last time we did it was in 1990,
I believe.

So this continuing effort by the Depsirtment of Agriculture and
HHS will review what we have learned in that time since the last
time we had that scientific consensus. But again we have the gen-
eral trends and that is where we see the need to reduce fat in the
diet £ind sodium and to increase vegetable smd fruit and fiber in-

takes. We have to take into account all we are learning in this dec-
ade to see if what we are providing as dietary guidance is the most
current and the most up to date. So I would agree with you, but
what we are basing it on today does provide a consensus, if not
unanimous but true consensus.

Mr. Stenholm. Mr. Gunderson.

Mr. Gunderson. Thank you, Mr. Chairman. I thank both of you
for your testimony.

I guess we should start out by welcoming Secretary Haas to the
establishment. But I have to tell you that in the eyes of the pubUc,
you are now part of the problem rather than the solution, so get
ready.

Ms. Haas. That is the establishment? I join you, Congressman
Gunderson in that honor.

Mr. Gunderson, I thought I would tell you what I think is part
of the problem, and perhaps it is pertinent that we have this hear-
ing today as we begin the Budget ReconciUation Conference. If
Ross Perot were here, he would simply lift up the statements I
have in my hand and say this is part of the problem. This is the
testimony we are going to get today from the Government. We are
going to start out with Ellen Haas, Assistant Secretary for Food
and Consumer Services, then we are going to get something from
Dr. Johnsrud, Acting Assistant Secretary for Science and Edu-
cation, then we are going to get a statement from Dr. DuPont from
the National Program for Human Nutrition at Agriculture Re-
search Service, then Dr. Mathias from Cooperative State Research
Service, and then Mr. Rosenberg, who is Director, USDA Human
Nutrition Research Center on Aging, and then from Mr. Branstool,
who is an Assistant Secretary for Marketing and Inspection Serv-
ices, and then Dr. Nichols, who is the Director Emeritus for Chil-
dren's Nutrition Research Center, and then a statement from Cath-
erine Woteki, Director of Food and Nutrition, Institute of Medicine,
National Academy of Sciences, and that doesn't coimt any State
people.

Ms. Haas. I agree with you 100 percent, Congressman Gunder-
son. The Department of Agriculture is the new USDA and you see
before you two of us speaMng for the Depsutment, not the 10 who
have written the testimonies that you have here.

Mr. Gunderson. These 10 people are all doing the same thing.

Ms. Haas. But they are showing you aspects of the issue. I also
mentioned in my testimony that one of our greatest challenges in
the nutrition area, as it has grown in importance, as we see health
care costs spiraling, we realize that preventive health means better
nutrition, that we need to have a more cohesive policy within the
Department of Agriculture. We have programs fragmented across
the agency and we are looking at ways that we can bring together
nutrition and nutrition policy in a way that is not spending the
tEixpayer's dollar unwisely in a duplicative manner.

So I referenced a report back in 1979, which was the last time
the Government looked at food and nutrition in its disparate ways
across the Government. I hope now in 1993 we take another look
at how we can better perform the function of enhancing nutritional
status of consumers rather than having so many messages, but

really bring it together in a more coordinated fashion than it has
been in the past.

Mr. GuNDERSON. I hope we can get a major consohdation and re-
organization of all this. This is only at USDA for the most part.
Tlus doesn't count all the other branches of Government doing the
same thing.

All we succeeded in doing in this country in my opinion is we
convinced the American people that all food is bad for them. We
have convinced them vegetables and fruits are full of pesticides and
that 99 percent fat free milk has too much fat in it. So they decide
to have a Snickers bar and a can of coke because, if they are going
to die from food anyway, they might as well have the food that
tastes best.

Ms. Haas. I would agree with you that how the USDA is orga-
nized to fulfill its nutrition mission is vitally important. I know it
is vitally important to the Secretary. I know this is something, as
I stated in my testimony, that we are addressing and I would like
to hope that in the next 6 months when we come back again to con-
tinue this discussion on nutrition, that you will see changes that
will bring about better messages and more informed consumers
and better research and education efforts.

Mr. GuNDERSON. Well, I hope so, too.

One final question, when you talk about dietary guidelines, are
we going to differentiate between the dietary needs of adults and
children or do we anticipate a single set of dietary guidelines?

Ms. Haas. At the present time, I can only say they are for all
Americans, but I beUeve that we have to take a very careful look
at the special needs of children. We serve 25 million children in our
national School Lunch Program. Children's education on nutrition
is very small and meeiger. I think we have to take very pgirticular
care that the research that is the underpinning of that educational
effort is really research that pertains to children specifically. At the
present time we have this one set for all Americans.

At some later time maybe the subcommittee, the Department of
Health and Human Services, and USDA may determine there is a
need for children. The American Academy of Pediatrics provided
guidelines for children, the American Heart Association has pro-
vided guidelines for children. We need to look at the special needs
of kids because they are the hope of the future.

Mr. GUNDERSON. I look forward to that.

Thank you, Mr. Chairman.

Mr. Stenholm. One other statement I have here is the question,
do you think that food and nutrition should become a part of a new
health promotion curriculum in nursing schools? Certainly nutri-
tion and health are directly related; there is a consensus on that.
And therefore that is one of the goals that we are all looking at.

I was disturbed as I was holdmg townhall meetings last week
that in two separate occasions I had volunteers involved in the
WIC program complaining, botii pubhcly and privately, about the
bureaucracy that is now taking over in the WIC program as a re-
sult of trying to tie together health and nutrition. And in one case
it was almost fatal afready, in which an individual volunteering
their time is just sa5dng thai we have managed to turn a good pro-

gram into a bureaucratic mess. That bothers me and I know it
would bother you.

Ms. Haas. It bothers me greatly. I will in 2 weeks be speaking
at the Nutrition Services Conference of WIC, in August, in Denver.
Again, the program is one where it is a Federal-State cooperative
effort, so federally we provide the funds and we provide the guid-
ance and the rules but it is also carried out at the State level. I
will have to look into that and get back to you.

That you have a barrier to effectiveness is something that gives
us concern and if the bureaucracy is standing in the way, we want
to change that.

Mr. Stenholm. These two individuals I referred to have tremen-
dous amounts of credibility so I bring that up for purposes of point-
ing out that that is an area of concern.

Ms. Haas. I appreciate that,

Mr. Stenholm. I would t\im the subcommittee over to Ms. Lam-
bert for any questions she may have or for any other members. And
if you will, you would call the next panel. We will submit addi-
tional questions to you in writing for purposes of the record on
where we want to go.

[The information follows:!

DEPARTMENT OF AGRICULTURE

OFFICE OF THE SECRETARY
WASHINGTON, D.C. 20250

AUG 1 2 1993

Honorable Robert F. Smith
Ranking Minority Member
Committee on Agriculture
United States House of Representatives
1301 Longworth House Office Building
Washington, D.C. 20515

Dear Congressman Smith:

Enclosed are the responses to questions submitted following the Committee'^
hearing on nutrition research and education.

If the committee needs additional information, I will be pleased to provide it.

Sincerely,

Ellen Haas
Assistant Secretary for
Food and Consumer Services

AN EQUAL OPPORTUNITY EMPLOYER

You recently joined with the National Food Processors Association
promoting a new program "Label Facts for Healthy Eating." The
goal of your project is to develop educational materials that can
be used to inform consvimers on the new food IcQsel and how this
information can be used to ensure healthy diets. Please tell us
how consumers can benefit from this program.

We believe the new food label will be an effective tool that
consumers can use to help them choose a healthful diet. To be
most effective, consumers need to know what a healthful diet
means. The Food Guide Pyramid, based on the principles of the
Dietary Guidelines for Americans, defines a healthy diet. If
consumers know at least the relative amounts of the major food
groups to include in their diet, then the label can help them
decide which foods within each group to select.

The Human Nutrition Information Service (HNIS) has been involved
in a number of activities related to the new food label :

o HNIS participated in the development of the National Food

Processors Association Educator's Resource Kit, "Label Facts
for Healthy Eating." Staff presented a speech at the
kickoff conference for this project in November 1990; served
on the steering committee for the project; and reviewed all
drafts of the educator's kit.

o Since 1991, HNIS has participated in an internal work group
established by the Food Safety and Inspection Service (FSIS)
and the Food and Drug Administration (FDA) . This lead to
the establishment of the National Exchange for Food Labeling
Education (NEFLE) . The exchange allows public and private-
sector groups to pool their ideas and, in some cases, their
funds, to ensure that consumers learn what they need to know
to make the most of the new food label . HNIS also
participates in another work group established to foster
discussion and coordination of label-related research.

o HNIS research is ongoing to make label education efforts as
effective as they can be. To better target educational
efforts, research is being conducted to identify
characteristics that distinguish label users from nonusers .
So far, the data indicate that label users are knowledgeable
about nutrition, care about the quality of the food they
eat, and believe that the Dietary Guidelines are important.
Actual differences in nutrient intake have been related to
label use. For example, label users have diets higher in
vitamin C and lower in cholesterol than nonusers. Results
of this research have been presented at two national NEFLE
conferences and at the Society for Nutrition Education's
annual conference, July 19-21, 1993. USDA plans to expand
the data being gathered on consumers' use and understanding
of food labels. New food labeling questions are being added
to the 1994-1996 Diet and Health Knowledge Survey (DHKS) .

Two publications are being developed on the new food label.
One is for consumers to use in conjunction with the Food
Guide Pyramid to choose a healthful diet, a companion to a
piece FDA and FSIS are developing to help consumers
understand the basic content of the new label . The other
publication is a desk reference for professionals- -
particularly those who will be developing materials for
their own audiences. Both HNIS publications are expected
to be available by the end of 1993 .

Recently^ there was an article in Prevention magazine concerning
nutrition. In a survey, in its 10th year. Prevention Magazine
found that 49% of all American adults do not adhere to good
nutritional practices. Do you have any theories on why this is
so? Is there euiy thing the federal government Ceui do to change
this figure?

While Americans eat better today than they did a decade ago,
current dietary habits need considerable improvement. There was
a shift to a lower-fat, higher- carbohydrate diet between 1977-78
and 1989-90, according to consumption surveys conducted by the
Human Nutrition Information Service (HNIS) , but the average
American still eats more fat and fewer fruits, vegetables, and
grain products than recommended by the Dietary Guidelines. The
need for more and better nutrition education is clear.

To find effective ways to help consumers improve their diet, we
conduct research on the potential barriers to dietary change.
According to USDA's Diet and Health Knowledge Survey (DHKS) which
started in 1989, some of the major barriers may be lack of
awareness about the relationship between diet and health, lack of
motivation, inaccurate perceptions about the quality of one's own
diet, and lack of knowledge and skill to implement healthy eating
practices .

o Lack of Awareness: While meal planners seemed to know that
what they eat can affect their health, they don't really
know why. Almost ninety percent of meal planners
interviewed in our surveys agreed with the statement: "What
you eat can make a big difference in your chance of getting
a disease, like heart disease or cancer." But fewer knew
how health problems are related to specific nutrients. More
than 8 0 percent of respondents knew about health problems
related to sodium and cholesterol, only 75 percent knew
about health problems related to how much fat a person eats.
Fewer still --65 percent or less- -were aware of health
problems related to saturated fat, calcium, fiber, and iron.

o Lack of Motivation: In our surveys, meal planners were

asked how important it was to them personally to follow each
of the Dietary Guidelines. Although many considered it
important to "avoid too much fat," about one in eight meal
planners rated this Guideline of low importance.

o Meal planners were also asked to rate the importance of
"eating a variety of foods," of "eating at least five
servings a day of fruits and vegetables," and eating at
least six servings a day of breads, cereals and other grain
products." (These servings of fruits, vegetables, and
grains are the minimum amounts suggested in the Food Guide
Pyramid.) Meal planners placed a lot of importance on
"variety" but less importance on or little understanding of
what variety really means. About one-fourth of survey

participants said that it was of low importance to them
personally to eat at least five servings a day of fruits and
vegetables .

o Inaccurate Perceptions: People's perceptions c±)out their
diets don't always match reality. For example, about 40
percent of main meal planners responding to the knowledge
survey thought their diets were "about right" in terms of
fat. But only about one -fourth had fat intakes that met the
Dietary Guideline to limit fat to 30 percent of calories or
less. Similarly, for saturated fat, about 50 percent of
meal planners thought their diets were "about right." But,
fewer than 35 percent reported intakes that met the
Guideline to limit saturated fat intake to less than 10
percent of calories.

o Lack of Knowledge: The last barrier to dietary change is
lack of knowledge about how to put the Guidelines into
action. In recent research, consumers expressed an interest
in nutrition and some understanding of the health benefits
of following the Dietary Guidelines, but said they found it
difficult to "put it all together." They need "how-to"
information that shows practical ways to eat healthy.
Knowledge about nutrients in foods and about how to plan for
variety in the diet may help.

There is also confusion about which of the many different
sources of nutrition information consumers should trust.
They say they get conflicting advice emd don't know who to

believe.

There is much that the Federal government can do better to help
Americans improve their diet . The need for a widespread
nutrition education effort is essential. We must be sure we not
only help produce and distribute food but give consumers the
knowledge they need to develop healthful eating habits.

We need to continue our research and reviews to ensure that our
standards for a healthful diet are sound and up-to-date.

Do you believe that American consiimers are confused as to what
nutritional advice to follow since there are frequent euid
sometimes conflicting studies coming out on this topic?

Yes, our data indicate that many consumers are confused about
what diet advice to follow. About three-quarters of the main
meal preparers interviewed in USDA's Diet and Health Knowledge
Surveys agreed with the statement: "There are so many
recommendations about healthy ways to eat, it's hard to know what
to believe." Women from low-income households were more likely
than those from higher income households to agree with this
statement. In addition, results from focus groups conducted
during development of educational materials suggest that
consumers are confused and frustrated by diet advice they
perceive as conflicting or difficult to understand. They want
specific "how to" advice on choosing a healthful diet in terms
they can understand and which they can easily put into action.

While much has been done to reduce conflicting advice about diet
and health, obviously more needs to be done. The issuance of
Dietary Goals by the Senate Select Committee on Nutrition in 1977
and the Dietary Guidelines in 198 0 by USDA and the Department of
Health and Human Services (HHS) were milestones in translating
nutrition research into principles for a healthful diet that
consumers can understand and trust. While new research will
continually expand and refine what we know about the relationship
of diet to health, the Dietary Guidelines represent a consensus
of nutrition experts on the meaning of a healthful diet. These
Guidelines have been widely accepted by the professional
community and consumers, and serve as the basis of Federal
dietary guidance policy. A study of the impact of the Dietary
Guidelines conducted in 1988 concluded that the simple
presentation of high priority dietary guidelines is an effective
way of communicating nutrition information, and emphasized the
importance of experts in health and nutrition speaking with one
voice in identifying important dietary practices.

USDA's nutrition education materials and programs as well as
those of other Federal agencies and the private sector have
focused on helping consumers understand and implement the Dietary
Guidelines. Beginning in the early 1980s, the Human Nutrition
Information Service (HNIS) conducted research to develop a new
food guide to help consumers apply the Dietary Guidelines to
their daily food choices. Unlike earlier food guides, this
guide addresses both concerns about nutritional adequacy and
excesses. Recently illustrated as the Food Guide Pyramid, this
guide has been well received by professionals, the media, food
industry, educators, and consumers as a practical tool for
selecting a healthy diet. Widespread use of this tool in Federal
nutrition education materials and programs as well as those of
the private sector, promises to reduce consumer confusion and
empower them to choose a healthy diet. HNIS plans to actively
promote and facilitate understanding and use of the Food Guide
Pyramid.

The Agriculture Appropriations bill passed by the House o£
Representatives proposes to transfer the functions of the Human
Nutrition Information Service back to the Agriculture Research
Service (ARS) . Please comment on this treuisf er from Food euid
Consumer Services to ARS.

The Human Nutrition Information Service (HNIS) was created
precisely because the organization arrangements in place at that
time were unable to provide the appropriate data in a timely
manner. I do not believe that reassigning these key functions to
ARS will solve the problem. The solution lies in making HNIS
perform its responsibilities correctly and that is exactly what
the agency's new senior managers are committed to doing.

ARS is primarily engaged in basic research while HNIS conducts
applied research more directly linked to the policy and
programmatic needs of the Department. For example, HNIS work in
food composition is very different from the ARS work. The food
composition and analysis work done in HNIS is aimed at compiling
as much information as is available from industry, from private
or government laboratories, or other sources on the nutrients in
foods. Such information is then aggregated and becomes part of a
complex system of computer programs which store all available
nutrient data and other descriptive information such as growing
area, methodology, processing, and season. Such information is
used in food intake surveys, for nutrition education programs, to
facilitate the labeling of foods, and to develop guidelines for
food assistance programs. In contrast, the Nutrient Composition
Laboratory (NCL) of the Agricultural Research Service focuses on
the development and improvement of the methods for the chemical
analysis of foods. They supply very little actual nutrient data
to us. HNIS has had to get its nutrient data from extramural
contracts with universities and independent laboratories. Also,
conducting food surveys requires expertise of many types of
professionals in addition to research scientists. For example,
HNIS employs numerous nutritionists, home economists, economists,
food technologists, and chemists to staff the various technical
systems required by the survey, to develop and improve the
methodology on dietary intake, and to manage the survey. In
summary, moving the HNIS work to ARS would require a complete
redefining of the ARS mission from basic to applied research.

72-928 0-93-2

One of the surveys sponsored by the Human Nutrition Information
Service is the Continuing Survey of Food Intakes by Individuals .
Some have expressed concern zUsout the cost of this survey ($14
million covering 15,000 individuals). Please explain the uses of
this survey and whether the costs are in line with similar
surveys .

Data obtained from the Continuing Survey of Food Intakes by
Individuals (CSFII) are unique in several ways. The CSFII
provides the only nationwide information on:

o Multiple days of dietary intake for all age and sex groups
used in determining proportions of individuals at risk for
poor nutrition and in addressing food safety concerns.

o Multiple food program participation (Food Stamp, Women,
Infants, and Children Supplemental Food Program (WIC) ,
School Breakfast and Lunch) within households and links
between program participation and food and nutrient intakes.

o Links among attitudes and knowledge about diet and foods

with actual behaviors of individuals for use in the planning
and targeting of nutrition education programs.

o Household and individual water sources and the quantities of
water consumed by individuals as requested by the
Environmental Protection Agency (EPA) and the Food and Drug
Administration (FDA) .

o Water sources of fresh fish eaten by individuals as
requested by the EPA and the FDA.

o Whether foods eaten were home grown as requested by EPA.

o Food usage by age and sex group and the nutrient

contributions from those foods for use by the Federal Trade
Commission (FTC) in evaluating advertising claims and to
predict demand for agricultural and other food products.

o Where foods are obtained and eaten by age and sex group for
economic analysis of food consumption, for tracking away
from home eating, and for targeting nutrition education
strategies.

o Nutrient contribution of foods eaten away from home by age
and sex group, for example, the nutrient contribution of
foods eaten at "fast food" restaurants for teens.

o Portion sizes and frequency of foods eaten by individuals --
"per user" food information. This information has been used
in developing effective nutrition education materials, such
as the Food Guide Pyramid. A publication providing this
information has been cited as the legal source of data for

meeting regulations issued in California's Proposition 65.

o Food consumption patterns of the population and population
subgroups .

o Food and nutrient intakes that reflect seasonal differences.

For the current CSFII, the budget proposes to spend $13.5 million
over a four-year period surveying approximately 15,000
individuals or approximately $900 per person. HNIS has carefully
reviewed its options in obtaining this cost estimate, and
believes it to be reasonable. The costs of the CSFII were
developed with the Census Bureau and are in line with costs of
surveys conducted by the Census Bureau. Included in this
estimate are costs associated with developing the survey and
conducting a pilot study, development of five questionnaires,
training manuals for in-house and field staff, publicity
materials, and data collection and processing for a full-scale
pilot study. Additional costs .are associated with administering
the survey, conducting the extensive field interviews, collecting
the data, and coding, editing and "weighting" the data into
useable form. Conducting the survey itself will consist of one
in-person household interview, two in-person dietary interviews
per individual, and one telephone follow-up interview per
household (for a total of 42,000 interviews). Although the data
collection procedures for two surveys are very different, the
cost per person of the CSFII is substantially lower than the per
person cost of the National Health and Nutrition Examination
Survey (NHANES) conducted by the Department of Health and Human
Services .

HNIS is exercising strong management control over the CSFII. The
CSFII contract is a fixed price contract designed to produce
quality data in a timely manner.

Some Members of Congress euid others have raised concerns as to
whether USDA suffers from an inherent conflict of interest in
dealing with nutritional issues. How do you regard this
perception of a conflict of interest? Does it have any effect on
HNIS in the development of the dietary guidelines?

I am aware of criticism that the Department of Agriculture has
received in the past regarding the appearance, whether real or
perceived, of a conflict of interest in dealing with nutritional
issues. Nutrition policy based on high-quality scientific
research is a long-held principle at this Department.

Because the Department of Agriculture oversees the food
production of this country, administers food assistance programs
for the poor, and provides leadership in nutrition research and
education, it has a special role to play in establishing
nutrition policy. This role must center on ensuring that a
balance exists between the producer and consumer interests within
USDA. The Department's position is clear in demonstrating that
for nutrition policy, producer needs are best served by serving
the needs of the consumer first based on the best scientific
research. What the Department of Agriculture says about
healthful eating must be and is scientifically accurate and
unbiased. If it were to be perceived as being influenced by
political concerns or the concerns of any special interest
groups, it would not and should not be accepted.

A conflict of interest, whether real or perceived, has not and
will not have any effect on the Human Nutrition Information
Service in their leadership role in developing the Dietary
Guidelines. Beginning with the 1980 revision and again with the
1985 revision, USDA and the Department of Health and Human
Services (HHS) have established a Dietary Guidelines Advisory
Committee made up of nine prominent experts in nutrition and
health to review the Guidelines in light of new scientific
evidence. The Committees have conducted their work at open
meetings to the public allowing for public input. Each Committee
has recommended revisions to the Dietary Guidelines in a report
to the Secretaries of both Departments. The recommendations of
each Committee have been totally accepted with minor changes for
grammatical clarification and from the text of the Dietary
Guidelines. We are going to be using that same process for the
review and possible revision of the Dietary Guidelines due to be
completed in 1995. We at USDA and our colleagues at HHS believe
this process provides for broad professional and public input.

Looking at the historical record, the 1980, 1985, and 1990
Dietary Guidelines for Americans were widely accepted and widely
used. The professional community has raised no conflict-of-
interest concerns about these earlier efforts. USDA and HHS can
assure this Committee that we will continue in that tradition in
the updating of the Dietary Guidelines that will be released in
1995.

will nutrition education (or "dietary therapy" a term used by the
Center for Science in the Public Interest) be a part of the
Clinton health care reform package? Should it be?

According to the Department of Health and Human Services (HHS) ,
the President's health care reform package has not been finalized
yet and discussing its content would be premature. However, HHS
is interested in the area of nutrition education in schools.
Attached is a copy of a letter from Secretary Shalala on the
subject .

At USDA, we are committed to making nutrition education an
integral part of all food assistance programs. Secretary Espy
has pledged to make nutrition education a priority and to work to
integrate nutrition into the agriculture, health and welfare
policies of the Clinton Administration. While nutrition
education is one of the primary missions of the Women, Infants,
and Children Supplemental Food Program (WIC) , it is the smallest
component in the Food Stamp Program that serves more than 27
million people. The Nutrition Education and Training Program is
the only national school -based nutrition education program which
has received only half of the authorized funds over the past
several years .

Ms. Haas. Thank you, Mr. Chairman.

Ms. Lambert [assuming chair]. Tliank you. Welcome. As the
chairman jumps out the door, I would like to thank him for bring-
ing up these important issues for us.

I always appreciate the efforts of this subcommittee on bringing
the important issues before us.

Being the product of a home economist and farmer, I have a tre-
mendous amount of interest in this issue, as well as representing
an extremely leirge agricultural rural area with an enormous
amount of poverty in it. I am a believer in preventive medicine,
and nutrition plays a tremendous role in that. The only way to
make that positive is to educate people and get that word out.

I am especially interested in todays topic of nutrition research
and education and especially USDA's role in that area. We learned
in yesterday's hearing, leadership in this area is not only needed
to help inform the public of healthy dietary practices, but to edu-
cate the pubUc on the benefits of the safe and an abundant food
supply that we have in this Nation.

While I am sure that we will focus on distribution of dietary in-
formation, there is another area that I hope we will also explore.
I have held a long-standing belief the public should be well aware
of the benefits that consumers accrue nrom production agriculture;
coming from an agricvdtural area you can imagine why.

The critical link we all enjoy with the Nation's farmers is impor-
tant. However, the relationship is one that seems largely over-
looked. One could cite the onslaught of negative news articles re-
garding certain pohcies. Rarely do we take the time to pull back
and see the critical role our agriculture plays in our Nations well-
being.

I know the Extension Service does an excellent job, especially in
my district, as well as my State, in providing information to our
farmers and communities. I am anxious to learn what efforts could
be undertaken to educate the pubUc further on a variety of other
issues involving nutrition. Before I start on my questions, I would
like to welcome Madame Secretary and let you know we look for-
ward to working with you.

Ms. Haas. Thank you.

Ms. Lambert. And Dr. Johnsrud.

Mr. Johnsrud. Thank you.

Ms. Lambert, As I said, coming fi'om a predominantly agricul-
tural area and a product of a farmer and a home economist, who
is very dedicated to that, I have referred to the need to clarify the
agriciiltural or the beneficial role of agriculture in the Nation's
economy. Is there an effort within the nutrition education sector to
include information regarding agricultural benefits, on the com-
plementary role of agriculture in this Nation as to what it does?

Ms. Haas. Up to this point, Congresswoman Lambert, in the ma-
terial that I have reviewed, it di(hi't tend to do that. I think that
is an omission.

If we are really going to educate about food and its relationship
to health, we need to elso have an understanding of how that food
is grown, and children in particular have a wonderful opportunity
to learn that food doesnt just come from the supermarket; it
doesn't grow in a can, but really grows in the fields.

I think that as we face the chsdlenge of making nutrition a prior-
ity mission for the Department of Agriculture and really reinvigo-
rating our nutrition education effori;s, it is my hope we can inte-
grate agriculture and nutrition into our messages.

We are dedicated to doing that. Nutrition education is one of my
priorities and I hope by the end of this term that we will see great
differences and that it is win-win for the farmer and the consumer.

Mr. JOHNSRUD. We have had specied efforts over the yeeirs in the
Department of Agriculture in e-idition to those that Ellen men-
tioned. I will cite some to illustrate: "Agriculture in the classroom"
focuses on helping children in the classroom to imderstand that
food just doesn't come from the cooler in the grocery store, and that
reaches a whole array of kids in the school system.

Another is the urban gardening program which functions in the
city, helps to educate how food grows and how to raise food. That
is a useful program.

As part of our program with the integrated pest management, we
help and work directly with the producers to produce food that has
a land of production practices that helps assure a healthful food
supply with good use of pesticides so they are not a critical issue.

We do give special attention to helping, from the producer sector
all the way through to the consimier, to imderstand the elements
of raising a safe and nutritious food supply within the spectrum of
youth and adults. We could cite others, but I cite those to say at-
tention has been given. This doesn't mean that more attention
doesn't need to be given, but there is attention being given to it.

Ms. Lambert. It is a critical role we can play. We see the dove-
tailing of USD A as well as other agencies. My history in biology,
I don't see enough youngsters coming home with a Dixie-cup of
whatever the latest bean that needs to be grown in kindergarten
or first grade or whatever. It is critical that we have a marriage
there, have an understanding of what agriculture does in providing
a safe and an abundant food supply, and how critical that is to
your individual health as well as what you can learn from that in
preventive medicine.

I was very disturbed when we talked about the nutrition edu-
cation and the Food Stamp Program. Being the largest single food
assistance program and recognizing that it has the smallest
amount of nutrition education, is in my opinion unacceptable. I
think one of the areas that is difficult for us in an area where we
have a large sector of poverty, and we also have a large sector of
farmers, is that you often see a clash because of the media and the
perception from the general public of conflicts, specifically that
these programs take away from the farming community and the
farming community doesn't want to see that happen.

There is a tremendous opportimity to educate both sides of that
and to begin to work on that as far as nutritional studies that we
could allow in these programs. I guess most importantly, do we see
that happening or do we see that in the future of nutritional edu-
cation?

Ms. Haas. I can't be emphatic enough to say that that will hap-
pen. When we held the national hunger forum, which was the first
forum of the Secretar/s issue forums to set an agenda for the fu-
ture, we did not only have a panel on "access to food," but we called

it "access to a healthy diet." It really is imperative that we provide
and make nutrition an integral part of our Food Stamp Progrsim
and the fact that we have not provided that kind of nutrition edu-
cation, I think, is a very sad commentary, because the 27 milUon
people who are part of the Food Stamp Program are tremendously
vulnerable and each of their food purchases means so much. It is
very short-sighted if we are just providing assistance for food with-
out imderstanding the health consequences of tomorrow.

So we will — I won't even say redouble — ^but multiply by many
times our efforts to bring that kind of nutrition communication in
our 1994, 1995 budget. You will see that we will have this kind of
preventive health measure and nutrition education as an integral
part of our Food Stamp Program.

Ms. Lambert. I am glad to hear that. I think it will reap rewards
not only in health benefits, but in the relationship between those
that may be in conflict.

Ms. Haas. If I could say again that during the national hunger
forum we had more than 65 speakers. We had many farm organiza-
tions represented at the table, and I remember the senior vice
president for the National Pork Producers took his time to speak
about nutrition and the need for additional nutrition education and
other farm group representatives, as well, did the same.

What we heard fi*om the many people who were there as well as
nutritionists is that this is a direction we do have to go. We intend
to do that and I think that it will reap all kinds of benefits, as you
have just said.

Mr. JOHNSRUD. May I comment in response to your question rel-
ative to the education for food stamp recipients?

Ms. Lambert. Yes.

Mr. JoHNSRUD. About 60 percent of the EFNEP participants who
participate each year are currently food stamp recipients, approxi-
mately 40 percent are WIC participants.

Ms. Lambert. And that is quite important to not just Umit it to
one assistance program, but to make sure that you have all of them
incorporated into it. I have a particular county in my district that
reaped tremendous benefits fi-om the dovetailing of all of the dif-
ferent assistance programs and how they can work to accentuate
and accelerate all of the different programs to work together.

One last question, how is the Extension Service utiUzed in dis-
bursing nutrition information?

Mr. JoHNSRUD. I gave several indications in the testimony. We
do it through intensive programs like the one-on-one, almost one-
on-one, or small group settings with families and youth in the
EFNEP program. For example, the program has a definitive agen-
da, 6-month program, and families graduate fi-om the program
when they have developed certain skills in dietary management in
their family, in food purchasing using the Food Stamp Program, et
cetera. That is one approach.

Another approach, it may well be in larger group settings with
the elderly, for example, that are in either retirement homes or el-
derly communities.

Another example is the youth program. By youth, I include ages
that include pregnant teenager-s. I have seen programs, for exsun-
ple, where the Extension Service goes into the high school.

Ms. Lambert. That was my next question.

Mr. JoHNSRUD. Programs for pregnant teenagers, on how they
maintain their health so they will do everything they can to avoid
a low birth weight baby. That is a very costly venture for society
when you get a low birth weight baby.

We have a youth development program, and this penetrates into
many programs. In addition, we edso use the mass media £uid it is
done through everything from the pubUc mass media to also using
satellites extensively now. We are using the sateUite system to
offer programs that will penetrate communities with sateUite
downlink where staff are present with a group of people to help
them understand and interact with the teachers of those courses.

What you do with the Hispanic population in Los Angeles, for ex-
ample, may be different than how you approach the Native Amer-
ican popidation in South Dakota or what you do with a group of
youth in Lincoln, Nebraska.

Ms, Lambert. So there is an active movement as far as the infil-
tration of the Extension Service into the school systems as well as
working with other programs, the WIC programs and the other
county programs.

Mr. JoHNSRUD. Yes. At the local level, the program assistant in
EFNEP will work and get referrals directly from the local food and
nutrition office and that is where they identify, and in fact do pro-
grams at the office where the families come,

Ms. Lambert. Are there areas where you feel there could be
more involvement from the Extension Service?

Mr. JOHNSRUD. There is always room for more. There are people
not being touched yet so there is a constant effort to see how we
can improve that process and there are studies being done. In fact,
the current fiinding of the $3.5 million that Ms. Haas mentioned
is a joint effort with her office and our agencies to see if there are
better ways to more effectively reach the group you are targeting
on. So the first year effort is designed specifically to see if there
are more effective ways to really make a difference with these fam-
iUes,

Ms. Lambert. My personal opinion is there is a lot that can be
done and that two heads are better than one, and if you can get
the groups together, that would be great.

Mr, JOHNSRUD, I would add, most of our nutrition is in concert
with other agencies. When you get on the ground, you see coordina-
tion with other local agencies that tie back oftentimes to the USDA
or HHS.

Ms. Lambert. Yes.

Ms. Haas. I was just going to add, the issue of reach is really
a very important one to recognize. Again, when we talked about
the 27 million people who participate in the Food Stamp Program,
the EFNEP program, which is such a good program, reaches less
than 400,000 of our food stamp recipients. So we have to find dif-
ferent models so that we can reach that large niunber who are
making food choices every day that may really compromise their
health.

Ms. Lambert, Thank you.

Mr. Stenholm [resuming chair]. We thank you both for your at-
tendance. We look forward to working with you in the days, weeks,
and months ahead.

Ms. Haas. Thank you very much.

Mr. JoHNSRUD. Thank you.

Mr. Stenholm. We will call panel 2.

Diverting a bit from the regular order, I would like to on behalf
of Chairman de la Garza extend to you, Dr. Nichols, his regrets at
not being here and being able to introduce you personally today. He
is tied up in a meeting at the White House, and he was sure you
would imderstand why he wouldn't be here. Dr. Nichols, I extend
a Texas greeting to you also and would now jdeld to our good friend
from Minnesota, David Minge, for an introduction that he would
like to make before he has to get on to some other pressing busi-
ness today. David.

Mr. Menge. Thank you, Mr. Chairman. I am honored to be able
to introduce Ellen Schuster who is with the Minnesota Extension
Service. She is a registered dietitian and a certified home econo-
mist. She has coordinated the Expanded Food and Nutrition Edu-
cation Program in Minnesota for the past 8 years. As a professor
at the University of Minnesota, the focus of her work is on low lit-
eracy nutrition educational materials. Her published works include
a pamphlet on nutrition for low Uteracy audiences and a brochiu*e
for educators and others who need assistance in developing read-
able written material. These pieces are being used by consumers
and educators in many States, and I am honored to introduce Prof.
Ellen Schuster to the Subcommittee on Department Operations
and Nutrition. Thank you, Mr. Chairman.

Mr. Stenholm. Thank you. I hope everybody else doesn't feel
sHghted. If you do, we will think up a pretty good introduction for
the rest of you on down the line.

Mr. Minge. She is special.

Mr. Stenholm. That is obvious. We will first hear from Dr.
Buford Nichols, director emeritus, Agricultural Research Service,
Children's Nutrition Research Center in Houston. Dr. Nichols.

STATEMENT OF BUFORD L. NICHOLS, JR., M.D., DIRECTOR
EMERITUS, CHILDREN'S NUTRITION RESEARCH CENTER,
AGRICULTURAL RESEARCH SERVICE, U.S. DEPARTMENT OF
AGRICULTURE, ACCOMPANIED BY DENNIS BIER, DIRECTOR

Dr. Nichols. Thank you, Mr. Chairmsin, members of the sub-
committee, it is a privilege to appear before you.

Mr. Stenholm. Excuse me, Dr. Nichols, I vmderstand each of you
have been briefed as to the necessity of stajdng within the 5-
minute rule. We will run the clock, and we would deeply appreciate
each of you staying within that 5 minutes as close as you possibly
can. Your entire statements will be made a part of the record.

Dr. Nichols. Thank you. I am Dr. Buford Nichols, and I served
as Director of the Children's Nutrition Research Center, the CNRC
from its founding in 1978 until this month. I am now the director
emeritus, as you indicated, and I am proud to announce that the
new CNRC Director, Dr. Dennis Bier, to my left is joining us today.

Dr. Bier is a very distinguished nutrition scientist who comes to
Baylor College of Medicine and to the ARS from Washington Uni-

versity in St. Louis. Mr, Chairman, I compliment you on the timely
interest that you have in the topic of nutrition research and edu-
cation. As Dr. Johnsrud pointed out, this year we celebrate the cen-
tennial of the USDA's involvement in himian nutrition research. As
I see it, nutrition is the study of how food is related to health, and
prevention of disease is one of its most fundamental objectives.

The Department's leadership is quite appropriate since its long-
term mission is our food supply, its production, processing, dis-
tribution, and consumption. The research work that we do at the
Children's Nutrition Research Center has the potential to impact
all of these aspects concerning the American food supply. As Ms.
Haas stated, 5 of the 10 leading causes of death in this country
have a nutritional basis. To us at the CNRC it is clear that these
nutritional antecedents begin in infancy and early childhood.
Learning the sequence of events and preventing them with ade-
quate nutritional education could represent a very substantial sav-
ings in health costs in the future of this Nation.

Ms. Haas commented about the important linkage between food,
agriculture, and health. I point out that the CNRC at Baylor Col-
lege of Medicine is located in the Texas Medical Center. It is not
just a Texas brag, this is the largest medical complex in the world,
and we are very pleased to have a food and nutrition component
in that environment. In response to Congressman Gunderson, the
CNRC is the only Federal center providing the foundation of basic
research for applied programs such as the WIC and school lunch
programs, as well as for the general education efforts in nutrition
conducted by Extension and other agencies.

We link agricultural production and food processing with medi-
cine to make babies and their mothers healthier. As Dr. Johnsrud
indicated, we are studying the relationships between adolescent
nutrition and the outcome of teenage pregnancy. The relationship
between intake of milk, particidarly, and bone growth during the
adolescent growth spurt is an issue in which we have pioneered
and are leading the world. The primary function of the CNRC is
research. However, we also want our research to be used. To broad-
ly apply our research results we must keep sight of the fact that
people produce and eat foods, not nutrients. We must be able to ac-
curately translate research findings about nutrient needs into prac-
tical recommendations about food needs, and Secretary Haas and
Dr. Johnsrud both talked about the dietary guidelines.

Secretary Haas also indicated that the dietary guidelines are xm-
certain as to how they apply to the yoimg child. To do the outreach
of the CNRC, we have for many years actively collaborated with
the extension, WIC, child nutrition, and other USDA programs,
and as Dr. Johnsrud said, this year the extension service placed
their national program leader for infant and maternal health at the
CNRC to help distribute our research findings. The relationship be-
tween food and health has historically been a key part of the mis-
sion of U.S. agriculture. In this the centennial year of the USDA
human nutrition research, I believe that it is time to rededicate oxir
efforts to that effect. We at the CNRC are proud to take our place
in that line of USDA researchers stretching back a century to the
pioneering work of Dr. Atwater and we are ready to move forward
to a better and healthier future for all of our people.

We thank you, Mr. Chairman, for the opportunity to participate
in this hearing and we look forward to further demonstration of the
linkages between food, diet, and health.

[The prepared statement of Dr. Nichols appears at the conclusion
of the hearing.]

Mr. STE^fHOLM. Thank you, Dr. Nichols.

Next, Dr. Rosenberg.

STATEMENT OF IRWIN H. ROSENBERG, M.D., PROFESSOR,
MEDICINE AND NUTRITION, AND DIRECTOR, HUMAN NUTRI-
TION RESEARCH CENTER ON AGING, U.S. DEPARTMENT OF
AGRICULTURE, TUFTS UNIVERSITY

Dr. Rosenberg. Mr. Chairman, and subcommittee members, my
name is Dr. Irwin Rosenberg, and I am professor of medicine and
nutrition and Director of the USDA Human Nutrition Research
Center on Aging at Tufts University in Boston. I want to thank you
for this opportunity to testify on this very important issue.

In the 15 years since Congress first appropriated funds to the
Department of Agriculture to establish our center, the only such
center dedicated to research on nutrition and aging in the world,
we have been studying the nutritional needs of the elderly and the
dietary requirements for maintaining health and preventing dis-
ability and disease of our aging population. At the beginning of this
century 1 in 25 Americans was over the age of 65, and early in the
next century 1 in 5 will be over the age of 65, and older Americans
are the fastest growing segment of our population, and they are the
ones who are at the highest risk of degenerative conditions that
can lead to loss of function, to disability, and to the loss of inde-
pendence and quaUty of Uves which makes our older years oo im-
portant.

We continue to seek ways of assessing the nutritional and health
status of older Americans who, Uke infants and children at the
other end of the spectnun of life, are at increased risk of
undernutrition and malnutrition, but in this case because of the
changing physiologic status of elders and for social factors as well.
I will mention just a few of our research findings which are being
translated into programs to help the health and well-being of the
elderly, and I would like to add a few more details to the written
record if I may, Mr. Chairman.

Mr. Stenholm. Without objection.

Dr. Rosenberg. Our research focuses not only on the needs of
older Americans, but on older Americans themselves. Thousands
have participated in our studies over the past decade, and they
have been some of the best agents for educating their peers about
the importance of proper nutrition and the maintenance of health
in the older years. Some examples of our work are to be listed in
the following: Osteoporosis, as was mentioned earlier, seriously af-
fects more than 1.3 miUion American women at an expense of $10
bilhon in health care costs. Equally important to research on cal-
cium needs that has been mentioned is research that shows that
we must meet our requirements for vitamin D in that same popu-
lation if we are to prevent bone loss, since this popiilation has spe-
cial requirements imposed upon it by their special physiologic
changes.

Our investigators have also documented the importance of phys-
ical activity to stimulate the skeleton for maintenance of body cal-
cium and also to maintain the strength and function of our mus-
cles. We have worked to define the healthiest mix of dietary fats
which influence blood cholesterol and related lipids, and the risk of
degenerative conditions of the cardiovascular system. Our scientists
have been instrumental in the setting of national guidelines for the
prevention of heart disease under the national cholesterol edu-
cation program. We have emphasized studies of the interaction of
nutrition and specific forms of exercise and developed programs
that are effective in helping older adults maintain their lean mus-
cle and associated physical strength and mobihty. Our investiga-
tors have focused research on the relationship between the vitamin
intake in our diets and our immune systems, which tend to decline
with age and the importance of nutrition and preventing that de-
cline.

Similarly, we have studied the relationship between nutrients,
especigdly antioxident nutrients in the development of cataracts.
Cataract extraction is the most common operation in the elderly at
a cost of at least $4 biUion annually in this coimtry, and here we
have a nutritional means of lessening the risk and lessening the
progression. No condition is more devastating to the quaUty of life
of older Americans and that of his or her own family than the loss
of cognitive function, mental alertness, and memory. While many
conditions contribute to the loss of cognitive function in some of our
older population, our research causes us to emphasize the impor-
tance of nutritional factors, including dietary vitamins for the
maintenance of heeilthy central nervous system functions. These
and related research findings showing that healthy choices fi*om
the abundance of food grown on our farms can contribute to the

Prevention of disability and special forms of undernutrition have
een communicated to the public in many ways.

The work described above is published in scientific journals and
books, and has been widely quoted in the public press, and also dis-
seminated through the publication and education efforts directly
through the Department of Agriculture. Hundreds of newspaper
and magazine articles in the past year alone have described these
research accomplishments and have been commented upon by our
elderly consumers. We have used our pubUcations and networking
through our own research volunteers and their organizations for
the distribution of information about the benefits of proper nutri-
tion and physical activity.

In conclusion, the research at the USDA Human Nutrition Re-
search Center on Aging can be looked upon as an example of a very
productive and fi-uitful association between Government and the
Drivate sector, since our research and its dissemination to the pub-
ic depend critically on the utilization of resources and expertise
3oth in the Government and at the university and private level. I
believe that it is possible over the next decade that our investment
in proper nutrition and physical exercise among the aging popu-
lation will fundamentally alter our concepts and costs of health and
health care.

We need to examine our techniques for introducing this informa-
tion into medical practice so that diet and nutrition become an in-

tegral part of health care and health maintenance. Thank you, Mr.
Chairman.

[The prepared statement of Dr. Rosenberg appears at the conclu-
sion of the hearing.]

Mr. Stenholm. Next Dr. Woteki.

STATEMENT OF CATHERINE E. WOTEKI, DIRECTOR, FOOD AND
NUTRITION BOARD, INSTITUTE OF MEDICINE/NATIONAL
ACADEMY OF SCIENCES

Ms. Woteki. Thank you, Mr. Chairman, and good morning. I am
Catherine Woteki, Director of the Food and Nutrition Board. I
would like to request that my written testimony be entered into the
record and I will summarize orally some of the points in that testi-
mony.

Mr. Stenholm. Without objection.

Ms. Woteki. Also for the record I would like to correct a
misimpression that arose during the questioning of the earHer
panel. The Food and Nutrition Board is part of the National Acad-
emy of Sciences, and although our name carries national as part
of it, we are not a Government agency. The academy is a private
institution chartered by the Congress during the Lincoln adminis-
tration in 1863, specifically for the purposes of providing advice to
the Government when the Government asks for that advice.

Mr. Stenholm. I don't blame you for clearing that up.

Ms. Woteki. What I would uke to do is to point out that my
written testimony addresses aspects of four of the questions that
you have posed to us that relate to communicating research results
to the pubUc, research needed in at-risk populations, nutrition ex-
pertise among medical personnel, suid priorities in nutrition re-
search, and that written testimony is based on studies that have
been performed by the Food and Nutrition Board. I can make cop-
ies available to you and to the members if you would like to have
copies of those studies that are referred to.

In my oral testimony I would like to really concentrate on two
of the areas, communicating research results to the public and pri-
orities in nutrition research. The Federal Government has made
recommendations for improving American people's diet for almost
a century, and those activities were really initiated by the Depart-
ment of Agriculture in 1917. Early dietary guidance was directed
mainly at the avoidance of deficiency diseases. We have made sub-
stantial advances, though, in the last 25 years in understanding
how diet affects health, particularly in the role that diet plays in
the cause and the prevention of chronic diseases. So in our view
the main challenge is no longer to determine what eating patterns
should be recommended to the public, although admittedly there is
more to be learned and a substantial amount more to be learned.

The main question facing us is how to inform and encourage the
population to eat to improve its chance for a healthier life. Now,
there are really a very limited number of tactics that we can use
to increase the prevalence of healthful eating patterns. There are
three of them. We can alter the food supply, we can take things out
of it that may be harmful to health, we can add things to it that
may be beneficial to health, and we can make substitutions. The
second tactic is we can alter what we call the food acqviisition envi-

ronment by providing people with more choices. We can provide
them with better information to help them make those choices. We
can provide them with advice at the points that they make those
purchases, in cafeterias and in the grocery stores, and we can es-
sentially provide them with a better menu of selections when they
go to vending machines and restaurants.

The third tactic we can use is to alter the nutrition education
message that we provide, and if I could leave you with one idea
from my testimony, it is that in order to improve America's diet
and health it is going to require more research on basic aspects of
nutrition as well as on education, but that is not going to be suffi-
cient in order to improve Americans' health. We are going to have
to involve all three of these tactics. The second topic that I wanted
to discuss with you briefly today relates to priority needs in nutri-
tion research. The Food and Nutrition Board is currently conduct-
ing a study of resesirch opportunities in the nutrition and food
sciences. The study is jointly supported by the Department of Agri-
culture, the Department of Health and Hiunan Services, and the
Pew Charitable Trusts. Its objectives are to identiiy the most prom-
ising research opportunities in the nutrition and food sciences and
to examine the structure and the quahty of education and training
of researchers in all of the different tjrpes of settings in which that
training occurs, and to make recommendations to facilitate the ap-
plications of our research in clinical and pubUc health policies and
programs.

Some of the people that are testifying today are actually mem-
bers of that committee. Dr. Rosenberg is, for example. We plan to
release the report on December 15, of this year, during a s3rmpo-
sium to be held in Washington, DC. Because the committee is still
working to complete its manuscript and recommendations, I am
limited in what I can tell you about its conclusions and rec-
ommendations. But what I can do is to tell you that the report will
provide in-depth discussions of research needs and opportunities in
four areas; basic understanding of the genetic, molecular, cellular,
and physiological processes of how diet affects health, techniques
for enhancing the food supply, understanding food behavior and
how it relates to how diets are selected, people's health £ind ulti-
mately the diseases that they suffer, and last, ways to improve the
diet and health of individuals and populations.

I will plan to send copies of the report to this subcommittee upon
its release. I appreciate the opportunity to appear before the sub-
committee and to provide you^ with the findings of the Food and
Nutrition Board about nutrition research and education.

[The prepared statement of Ms. Woteki appears at the conclusion
of the hearing.]

Mr. Stenholm. Dr. Rivlin.

STATEMENT OF RICHARD RIVLIN, M.D., PRESIDENT,
AMERICAN SOCIETY FOR CLINICAL NUTRITION, INC.

Dr. RrvLlN. Thank you, Mr, Chairman, I am very appreciative of
the honor and the opportunity of speaking before you. I would like
to make a few key points and ask that my entire written testimony
be entered into the record.

Mr. Stenholm. Without objection.

Dr. RrvLlN. I come to you today as the program director of the
Clinical Nutrition Research Unit at Memorial Sloan-Kettering and
Cornell. I would like to point out this is a program that is fimded
by the National Institutes of Health. I would like to begin by say-
ing that it is important in our understanding of the health care
Erocess to realize that NIH and USDA both have important roles
ut that they are different. The role of NIH is to be disease-ori-
ented and of USDA to be food-oriented, and I think it is the smooth
interrelations of these two agencies that are very important to oiu*
mission. But also and perhaps of increased relevance to today's de-
Uberations I am coming to you as the president of the American So-
ciety for Clinical Nutrition, which is the leading U.S. society and
perhaps in the world of physicians and basic science investigators
who are working on nutrition in disease prevention and treatment,
and our society and its members are resilly leaders in the field. I
think the important thing we have to realize is that nutrition is an
important aspect of prevention.

We are all concerned with keeping the health care system stable
financially, instituting health care reform, and in any issue that in-
volves prevention, nutrition has a very key role. This key role goes
all the way fi-om the manufacture of food to its handling by the in-
dividual, the processing and the production of waste. Increasingly
we are learning that while there are, as you Mr. Chairman pointed
out earlier, broad areas of consensus, there are other ways in
which this consensus needs to be modified, and the role of our soci-
ety— Americgin Society for Clinical Nutrition — £ind the role of our
lives as investigators is to emphasize these areas of consensus and
also look for the ways to improve this.

I would like to give you several examples of how the role of nutri-
tion and prevention is really so crucial. We have heard fi-om others
about low birth weight individuals who represent 7 percent of all
births, and we believe that adequate prenatal nutrition and nutri-
tional counseling could reduce the $3 bilUon to $7 billion that we
spend in this area.

Iron deficiency. Iron deficiency has a long-term effect on intellec-
tual development. We cannot allow our young children to be iron
deficient. On the other hand, we have a disease in the United
States, a disease of excess. In fact, the leading type of malnutrition
or bad nutrition in the United States is not so much nutritional de-
ficiency as it is nutritional excess, and we recognize the crucial role
of obesity, particularly in childhood. It is astonishing that at least
one-quarter of all American children are overweight and of these
one-third already have an elevated serum cholesterol, and as you
know, the child is father of the man, and the overweight children,
the overweight adolescents, and those with the high cholesterol,
they will be the overweight and high cholesterol adults of the fii-
ture.

In addition, we have heard fi-om others about the importance of
nutrition in older Americans, and we estimate now that 85 percent
of older Americans have chronic diseases that could be assisted by
nutritional intervention. So nutrition is important in the sense that
we can prevent disease and once an individual is iU, he or she can
recover more quickly, so nutrition is involved in every stage of ill-
ness, fi-om the initiation — fi*om the prevention of the illness, fi*om

the prevention of the complications of the ilhiess, and even the pre-
vention of the side effects of the treatment of the disease.

We also know that calcium is very crucial in the formation of
bones and teeth, that we need to build bone mass when we are
young, and we need to prevent it from being lost when we are
older, and our studies on osteoporosis certainly show how impor-
tant it is to prevent disease. I would like to say that in this era
when there is an increased emphasis upon diseases and health of
women and rightly so, certain areas of male health have been ne-
glected with respect to prevention. Of these osteoporosis in msdes
we feel is an area that has been neglected, and our group has just
completed a major review of this area.

Not only do we need research, we need education. We need to
translate the effects of the results of research into a plan of action.
We need to have more research. We need to have more training.
We need to support training, and we all need to work together to
accomplish these areas. So I would like to summarize by saying
that it is a great privilege to appear before you, but I think the
thing that you have to keep in mind at all times is that no system
of hesdth care reform which intends to reduce the cost of disease
can be complete without a crucial component of nutrition: Nutrition
in research, nutrition in training, nutrition in prevention of dis-
ease, nutrition at every stage of the process.

I hope that the subcommittee wiU realize that the support of nu-
trition by the USDA is a very crucial aspect of this process. Thank
you.

[The prepared statement of Dr. Rivlin appears at the conclusion
of the hearing.]

Mr. Stenholm. Thank you.

Ms. Schuster.

STATEMENT OF ELLEN SCHUSTER, STATE COORDINATOR, EX-
PANDED FOOD AND NUTRITION EDUCATION PROGRAM, MIN-
NESOTA EXTENSION SERVICE, UNIVERSITY OF MINNESOTA

Ms. Schuster. Mr. Chairman and members of the subcommittee,
I am pleased to be here today to discuss nutrition education, re-
search, and EFNEP, the Expanded Food Nutrition Education Pro-
gram. I thank Representative Minge for that special introduction.
I also ask that my full statement be included in the record, and I
will summarize that statement.

I will be focusing on two areas, some specific examples of how
nutrition research reaches consumers through the Extension sys-
tem and the effectiveness of EFNEP. One example of nutrition re-
search ciurently underway in Minnesota is a project to study the
effectiveness of a low fat nutrition education intervention program
aimed at adults with low reading skills. Communities of color and
those with a lower socioeconomic status and educational attain-
ment are more likely to be at risk for cardiovascular disease.

EFNEP families are serving as the study population for this 3-
year National Heart Lung Blood Institute grant received by the
school of public health at the University of Minnesota. To date we
have been able to assess the reading abiHty of EFNEP families in
three Minnesotan counties. Nine percent read at less than a fourth
grade reading level, 30 percent read between a fourth and eighth

grade reading level. However, printed nutrition education materials
focusing on low fat eating are written at a tenth grade reading
level or higher. Thus the results of this project will have implica-
tions far beyond Minnesota.

In addition, the above literacy statistics prompted me to develop
and pilot a brochure on the new USDA food pyramid last year, and
about 26 States are using this piece.

EFNEP and Extension effectively collaborate with other agencies
to reach at-risk populations to bring university research to them.
Families take charge is a Dakota County project that links Exten-
sion and the EPSDT program. EPSDT is the early periodic screen-
ing diagnosis and treatment program that provides physical, men-
tal, and emotional screening for children and teens whose families
are eligible for medical assistance. A colleague of mine at the Min-
nesota Department of Human Services who knew the EFNEP pro-
gram thought that the use of paraprofessionals or peer educators
was an effective and cost saving strategy to bring health and nutri-
tion education to famihes in EPSDT. Using the EFNEP model, this
project has hired and trained a health educator/outreach worker
and a family mentor. Using one to one home visits, families in cri-
sis are empowered to take responsibility for their Uves and the
Uves of their children. Crisis affects these families in many ways.
Family mealtimes are forgotten, which may lead to hungry and ill-
nourished children; food may not be handled safely, which may
lead to food poisoning, causing illness and more crisis; parents may
not focus on prevention of disease, thus accelerating poor nutri-
tional habits.

Based on anecdotal information, the outreach worker has ob-
served that famihes of color have increased their enrollment in this
program.

Extension is bringing the most current research to youth through
two different projects, jump in Minnesota and chances and choices
with food. We have waiting lists of neighborhood agencies that are
interested in implementing our jump in Minnesota program that
teaches inner-city youth nutrition, fitness, and leadership skills.
Chances and choices with food, a program that trains teen teachers
to teach younger children about food safety, is being taught in
about half of the counties in Minnesota.

As you know, we are approaching the 25th anniversary of
EFNEP. EFNEP's model of training and hiring community or peer
educators is effective. EFNEP staff work with families in extreme
crisis, but the focus is on what the family is doing right. This is
a powerful strategy when working with families who have been
told for so long what they are doing wrong or not doing at all.
EFNEP staff also link families to community resources they are
unaware of or may not ordinarily access. Here are some statements
from actual EFNEP participants that speak to the effectiveness of
the program.

A single mom states, "I am a single parent who at 21 moved out
of my mother's house and didn't know how to cook well enough to
feed my family and definitely not knowing how I was supposed to
try on my limited budget. The EFNEP program came into my life
and not only gave me the confidence to prepare meals but showed

me how to budget and plan my diet as well. This program was in-
formative and in my situation it was a necessity."

An EFNEP youth participant states, "I am going to start eating
more healthy foods because of what I learned. This class helped me
to see what food can do to you."

A mom states, "This class has been very valuable to me in many
ways. Though I have three children under school age and find it
is difficult to get out, I did not want to miss a single class. This
class has really made me think about wise purchasing of groceries,
meal planning, and proper nutrition. In my opinion mis class
should be required for anyone receiving food type funding fi*om our
Government."

Mr. Chairman, this concludes my remarks, I will be happy to re-
spond to any questions which you or other members of the sub-
committee may have.

[The prepared statement of Ms. Schuster appears at the conclu-
sion of tiie hearing.]

Mr. Stenholm. I yield to Dr. Allard for an introduction.

Mr. Allard. Thank you, Mr. Chairman. I thank the chairman for
giving me an opportunity to introduce to the committee Dr. Jen-
nifer Anderson from Colorado State University. She is associate
professor in food and nutrition at the extension specialist depart-
ment of food science and human nutrition, and. Dr. Anderson, I
would like to welcome you to this subcommittee and look forwsird
to hearing your testimony. Thank you, Mr. Ch£drman.

STATEMENT OF JENNIFER ANDERSON, PRESIDENT, SOCIETY
FOR NUTRITION EDUCATION, AND ASSOCIATE PROFESSOR
AND EXTENSION SPECIALIST, DEPARTMENT OF FOOD
SCIENCE AND HUMAN NUTRITION, COLORADO STATE UNI-
VERSITY

Ms. Anderson. Thank you. Congressman Allard, for that intro-
duction. The Society for Nutrition Education, SNE, commends you,
Mr. Chairman, and members of this subcommittee for recognizing
the importance of reviewing nutrition research and nutrition edu-
cation, and most specifically for addressing the linkages that are
needed between these activities. We have reached a point in the
hesdth of our Nation that requires a stronger and a more perma-
nent link between food production, nutrition, and public health.

As Congressman Allard has said, I am an extension specialist as
well as associate professor at Colorado State University, so Mr.
Chairman, I, too, come from a very rural State, a very large State
where many of the challenges I face in nutrition education and re-
search are much like your own in Texas. Many members of SNE,
including myself, are always involved and very actively involved in
trying to link agricultural production to the health of our commu-
nities by providing effective nutrition education programs.

We are constantly striving to see how we can use research find-
ings and how to communicate those findings to target clientele
groups, especially the high risk and needy audiences. But we also
want to try to make the messages effective and try to help people
understand what they can do to help their own health and long-
term outeomes. We recognize that USDA is indeed a leader and we
hope that USDA will maintain their leadership role in translating

the research into public information that is really usable. For the
sake of the future of effective nutrition education, we have identi-
fied three priorities.

What I wish to do, Mr. Chairman, is summarize my written testi-
mony into three main points, and I have tried throughout the writ-
ten testimony to address each of the eight questions that you posed
to us.

Our first point is that research and nutrition education have
been and must remain linked. We have heard that today fi*om
other members of this panel, and Dr. Johnsrud earlier very well ex-
pressed the role of cooperative Extension as an exemplary program
which is linking nutrition research and nutrition education. These
programs are research based and they are unbiased. The key to the
effectiveness is the positioning of cooperative Extension service
within the land-grant university. The Society for Nutrition Edu-
cation has many of our members working within cooperative Exten-
sion as well as with the expanded food and nutrition education pro-
gram.

Let me further give an example of how we link this research to
apphcation and education. Looking at the role of antioxidants in
chronic disease, we have a national campaign to encourage the
public to eat five servings of fi^t and vegetables a day. Working
in the rural isolated areas of northeast Colorado, I am investigat-
ing ways that we can try to integrate that information into the
classroom. Including methods to help the children through teacher
education, through the school lunch, as well as through the commu-
nity efforts to understand what does that message mean as I go
along the school cafeteria, or to the grocery store.

Our second priority is to see an increase in the visibility of nutri-
tion in USDA through improved coordination of nutrition at the na-
tional. State, as well as the local levels. We strongly urge USDA
to coordinate and raise the visibility of all nutrition activities, the
education, the research, and food assistance. This would provide a
strong lin^ between agriculture and health. A further suggestion
fi-om the Society of Nutrition Education would be to integrate all
food assistance programs to assure they are delivering a consistent
message and capitalize on each other's success. Standards for per-
sonalizing nutrition education components should be enhanced in
the food assistance programs we heard described today — ^WIC,
EFNEP, school lunch, cMld care feeding programs. We must link
the food, nutrition, £ind health consistently with agencies at the na-
tional, State, and local level. We need to work together and not in
isolation.

Another example is the work within USDA and the new nutri-
tion education initiative moneys, allowing 17 States to explore new
strategies in which cooperative Extension will work with WIC ch-
entele. Colorado is fortunate to be one of those States, and I look
forward to investigating new strategies and avenues to bring better
nutrition education material that really helps the individual know
what to do when they are trying to feed their family on a very lim-
ited budget. This has tremendous opportunities for success.

Finally, SNE asks for your support to look at research priorities
in nutrition education. Three types of research, we believe, are
needed for effective nutrition education. Basic research on the nu-

trition-related behaviors so we understand why people behave the
way they do, why they eat those foods, why they buy those particu-
lar foods at the supermarket. Second, we need research to help us
develop better strategies for implementation in order to change
knowledge and behavior. We know nutrition education c£in change
knowledge. We have some data to say it changes some attitudes,
some data to say it works on some behavior, but we need more
money to really show what is the best way that we should ap-
proach this to get the information to where it is needed. The third
research priority is for pohcy research, as an example: What effect
will changes in the new food label make on consumer food choices.

For effective dietary guidance there are four dimensions, we be-
lieve, in the process. Obviously, there is diet and health, but re-
search beyond just nutrient requirements, and dietary guidelines.
I applaud the efforts that we heard this morning of looking at revi-
sions and updates to keep it abreast of the current research. For
dietary guidance, the tools and the systems, as well as looking at
the research for consumer food choices is needed. We need research
at each stage.

The Society for Nutrition Education certainly appreciates the
leadership this subcommittee has given to nutrition over the years.
With your continued support, the health of Americans can be im-
proved. We must strengthen the link between nutrition research
and nutrition education, increase the visibiUty of nutrition in
USDA and support research which helps all Americans choose food
that promotes health.

Thank you, Mr. Chgdrman, for the opportunity of being here
today and addressing you.

[Tlie prepared statement of Ms. Anderson appears at the conclu-
sion of the hearing.]

Mr. Stenholm. Thank you, and thank each of the psuieUsts
today. Have any of you in your work had any experience with some
of our producer check-off programs and some of the research fund-
ing that is now being made available through check-off programs?

Ms. Anderson. I personally, Mr. Chairman, have been able to
work with the Colorado Beef Council and have received, through
grants, some of the money directly from the food check-off program.
It has allowed us, for example, to develop nutrition education mate-
rials and posters for food service operators and also for work sites
where people gather and congregate to eat. That program and four
of the 24 posters we developed are now being used by the National
Livestock and Meat Board nationally to see how we can provide nu-
trition education without always having a direct educator to reach
the chentele. We have to look at creative ways so, yes, I personally
have been involved and many other members of SNE have also
benefited from that check-off program.

Mr. Stenholm. Dr. Rosenberg.

Dr. Rosenberg. We have at the Hvunan Nutrition Research Cen-
ter on Aging, we have interacted with some of the National Dairy
Council activities with respect to research on the effects of dairy
products as sources of calciiun and vitamin D for medntenance of
bone health and strength.

Mr. Stenholm. Dr. Nichols.

Dr. Nichols. We have a major program funded by the Soybean
Coimcil. There are some anomalies concerning cholesterol metabo-
hsm in populations that are fed soy compared to those that are fed
milk protein, and this major effort is to understand how cholesterol
is synthesized and how it is handled in a population fed soy as a
protein source versus other protein sources.

Mr. Stenholm. Dr. Anderson, you made the comment that the
Society of Nutritional Education strongly urges USDA to coordinate
and raise the visibility of all nutrition programs and further inte-
grate, see that we are not working in isolation. Also you made a
comment along the same lines that Dr. Nichols included on page
14 of his written statement, which is the basis of the question that
I just asked during the follow up, and that is where you say farm-
ers and ranchers now more than ever know that they must produce
food that will meet the consumers needs. They have seen their
markets buffeted by the winds of public opinion, often fanned by
musings of people who are heavy on opinions and light on facts.

The mission of USDA is to find facts and to use them to help
both producers and consimiers of food. If I need a one-paragraph
reason for why this hearing is being held today, that is it. From
the producing side we are just constantly buffeted by opinions, not
necessarily based on consensus of fact, but based on fact as some-
one perceives it at a point in time. I have felt very strongly in the
necessity of increased coordination between producers and consum-
ers and have not been willing to cede the consumer representation
to self-appointed experts, that I consider those of you at this table
experts in the field of nutrition or you would not be here. You
wouldn't be in the job that you are in. You understand the com-
plexities of the subject before you. You understand that all the an-
swers are not in, that research is necessary and continuing to find
new areas, you also understand the importance of education.

You hear this gener^ theme, but somehow, some way we are los-
ing, and I use that term loosely, we are losing the pubhc opinion
battle to the tabloid TV, to the instantaneous sensationalism of
whatever issue happens to be fi*ont page at the time, whether it is
somebody finding a hypodermic needle in a Pepsi Cola c£in or what-
ever it is that happens to come, and then all of a sudden we find,
as Paul Harvey says, the rest of the story usually comes later after
the damage is done. But in the case of nutrition, it has to be based
on the best science available. Each of you on your own in the writ-
ten statements have indicated the absolute necessity of coordina-
tion of effort and of continuing to try to improve our educational
effort, and that, too, is an ongoing science. That is why I asked the
question. There is a lot of excitement among the producing seg-
ments of our society today of finally coming to recognize that the
consumer is always right, but if the consumer's opinion is not
based on the best scientific fact available, that being right may also
be wrong, and that is the challenge that we have.

Dr. Rivlin.

Dr. Rivlin. I would like to comment. I think you have made a
number of very telling points, and perhaps one mistake that the
nutrition community has made as a whole is that we tend to tell
people what not to do rather than what to do, and more and more
we should emphasize the positive aspects of our message. It is not

"don't do this; don't do that," but "take more fruits and vegetables,
take a diet that is better" to show them that they can eat and also
enjoy the food.

Mr. Stenholm. I will yield to Dr. Allard, then I want to have an-
other round of questioning myself with the panel. Dr. Allard.

Mr. Allard. Thank you, Mr. Chairman. I would like to talk a Ut-
tle bit about how you get this message to people. I am a veterinar-
ian so I try to learn how to keep instructions simple and straight-
forward and so sometimes we write a prescription for a dog cedled
Fifi and say give one tablet three times a day at 8-hour intervals
and it never gets taken at 8-hour intervals, and sometimes they are
so careless with the labeling of their medication that the owner
themselves end up taking the medication. They get it confused with
their own, and so — I see this problem with labels on meats or foods
in general.

Are we better off to kind of take the food group approach where
you teach people an education process, basically the five food
groups and the general concepts in balancing your diet or do we get
involved with labels where we have a lot of technical jargon, choles-
terol, and fats and protein and we have digestible and undigestible
protein and get into all that? I would like to have you comment on
that a little bit if you would, please.

Ms. Anderson. If I may comment first, I would say that I think
we have made great efiForts recently to try to communicate the te-
nets of the dietary guidelines which are telling the pubUc eat less
fat, eat more finiite and vegetables, look at the sodium you are con-
suming. With the food guide pjrramid we are now trying to put into
action those dietary guideline recommendations. As a nutrition ed-
ucator, that is the sort of effort we applaud. We never want the
{)ubUc to think of food as good and bad. As the chairman has right-
y identified, there is paranoia which I encounter daily. People will
call me fi*om physicians to profession£ds to the consumer, asking
what do I do, and what will I get if I eat a particular food.

I think the food guide pjrramid and the new labeling regulations
will fit in very well. The pubUc have heard us say 30 percent of
calories fi"om fat. Well, that doesn't mean anjrthing. What does it
mean when I go into the supermarket and put foods in my cart?
What it means is to balance out each day. See, you get foods that
look hke the pjn-amid, it is not avoiding fat, it is not avoiding your
favorite foods, but it is making selections and choices that allow
you to put foods together. I think we are doing a much better job,
but what we need is to enhance our efforts to see how well we are
doing at communicating that information, and then evaluating it.

I think it is better than it has been. We need to keep this liiied
together and integrate information and put it into meaningful edu-
cational messages. It is not black and white. Nutrition science is
not black and white. We do have distinct recommendations, and I
think that is what makes our field exciting because next year I
may be talking about something very different in terms of nutrition
science and what does it mean to me as an educator.

Mr. Allard. Where is the best place to get that message out, to
go to our schools or do we target food stamp recipients?

Ms. Anderson, I think we need to investigate all channels, fi*om
schools to worksites to community channels, using the media, using

anytiiing we can as long as the message is consistent. The people
who are self-professed nutritionists, if you will, who wish to go out
and either sensationalize an issue, look at something as discreetly
black and white, good or bad, they are the ones that put out bad
messages or ineffective messages. What I do personally and what
many members of the society urge, is to work with media. We have
been working, as you know, in partnerships, to try to get out mes-
sages through a medium that people relate to.

We have recently used Saturday morning TV as a way of trying
to get accurate nutrition information within the Saturday morning
cartoons so children are not just bombarded with only food adver-
tising but rather nutrition education information.

Mr. Allard. At least in the State of Colorado a lot of the school
board curriculums are set up by local school boards, and I see that
they have taken out courses and teach yoxmg students how to cook
and sew and everything like that, and I think both men and
women need to have that training in today's world, and how do you
get that message to those policymaking groups at the local level?

Ms. Anderson. We need to recognize that nutrition is a science.
It is not something that goes into just home economics, it fits into
science curriculum, it can go into math, it can go into reading. I
also would encourage at the Federal level that there is greater co-
operation between the U.S. Department of Agriculture and the U.S.
Department of Education. NET dollars provide such an opportunity
to impact the curriculum nationally, State, and then at the local
level. You are absolutely right, Congressman, that we do have a di-
lemma as we are looking at a reduction in some of the curricular
activities, but nutrition has to be recognized at all levels to make
sure that the message is consistent and available,

Mr. Allard. ThaiOt you, Mr. Chairman.

Mr. Stenholm. Is there a problem between the educational insti-
tutions of America and the coordination of nutrition education in-
formation? Can any of you cite specific examples of where, I think
what I heard Dr. Anderson say, there is need for better coordina-
tion; several of you used that in your written testimony. Can you
give me an example of where perhaps right now we have a cross
purpose happening? Dr. Woteki.

Ms. Woteki. I might respond to that by emphasizing one of the
points that I made in my testimony. I think that there are exam-
ples where we are perhaps working at cross purposes. One would
be the educational message that we deliver in the classroom in ele-
mentary and secondary schools £ind the food that we are actually
offering to students in the school lunch program. The point that I
had tried to make is that nutrition education is extremely impor-
tant, and a research base that will help us to actually understand
what types of education will actually affect behavior is something
that we absolutely need to do, but even if we had that information
and we put people in the situation where they can't then act on
that information, whether it is the cafeteria food in a factory or a
vending machine, it does not supply individuals with the healthful
choices that we are going to be ineffective in improving ultimately
the American people's health.

Mr. Stenholm. Do any of you really believe anything short of ge-
netic engineering that we are ever going to have children bom that

are going to like spinach, vegetables, carrots, and broccoli? No mat-
ter how much we educate them? Don't answer that. I was just a
Httle facetious there, but we all know that if you have been around
kids or raised them or been in schools you know that that is always
going to be a practical problem, but not a reason for not pursuing
what we are talking about here. I think one of the most exciting
aspects of today's hearing and the testimony and the suggestions
that you make is the relationship with pubUc health, nutrition and
public health, and as we begin the debate in September on the
health system reform necessary in this country — over and over and
over ag£dn you see preventive health makes sense.

The problem is the up-front costs. Whatever you do up front
tends to cost and therefore becomes a budget problem. The long-
term investment that turns out to pay dividends is a constant polit-
ical problem for us, but I don't think there would be any disagree-
ment. In fact, I see in most of your statements you emphasize the
importance of better nutrition, of targeting scientific research to
find some of the answers in a better way, to seek a better balance
in what a balanced diet should look like, it has been fascinating to
me to see some of the research. We talk about the fat content. We
will hear from a witness later in the next panel that has done some
interesting work regarding fat content of milk and a completely dif-
ferent conclusion in some aspects than some other research that
has occurred. Constantly changing. One of the fi:nstrating things
for the political system is where we have scientific information
leading to separate but coequal solutions. But are there any sug-
gestions on how we could improve the level of nutrition expertise
that physicians receive? Dr. Rivlin.

Dr. RrVLlN. Well, that is music to oiu* ears. I think we absolutely
have to support nutrition education. Dr. Eleanor Young, whom you
will hear later, has been a pioneer in nutrition education — she her-
self leads one of the Nation's most successful nutrition education
programs, has received awards and has really emphasized taking
a leadership role in this. The future of our Nation is going to de-
pend upon the education of physicians in the field of nutrition. It
is sad to say that only about a quarter of the Nation's medical
schools have required courses in nutrition, and I think that is a
tragedy.

Mr. Stenholm. Twenty-five percent?

Dr. RrvLlN. Only 25 percent of our Nation's schools have nutri-
tion as a required component of the curriculum. Even though we
all eat — some wisely, some not too well — ^we do not educate our
physicians in the field of nutrition. At our own medical school we
ourselves have introduced the first required nutrition courses, and
we are only one of 25 percent. I think one very important role that
the USDA could have would be to support nutrition education in
medical schools, and also fellowship training in nutrition as a spe-
cialty so that a young physician would choose the field of nutrition
as against gastroenterology, endocrinology, cardiology. I think
these are very important areas in which the USDA could make a
very major significant and permanent impact.

Mr. Stenholm. Dr. Rosenberg.

Dr. Rosenberg. I would also add that the concentration on the
importance of nutrition and health in which the USDA and this

subcommittee are taking leadership are going to cause us, I be-
lieve, to incorporate that kind of challenge in the health care re-
form process that you described is going to begin in earnest in Sep-
tember. Although I have been involved in three medical schools in
trying to enhance the quality of nutrition education for medical
students and physicians-to-be, I believe there has to be a very im-
portant element of change in guidelines of practice. We need to es-
tablish guidelines by which our physicians are actually practicing
medicine and practicing preventive care, and nutrition is going to
be an extremely critical aspect of that.

Nutrition is not at the present time adequately involved in even
our concepts of preventive care in health care practice. I believe we
need to do both. We need to educate our students, but we need to
have them graduate into careers in which nutrition is used actively
in preventive medicine and health care. We need both, and I think
that this kind of emphasis on the importance of nutrition and
health with this kind of leadership needs to become an integral
part of that discussion.

Ms. Anderson. May I just add, Mr. Chairman, one other point.
I don't think it should stop there. I think we need to educate physi-
cians to recognize when nutrition educators and qualified nutrition
personnel should be brought into the health care team. I think that
is a key element here, not only educating a physician in medical
school, but allowing them to understand when nutrition education
and qualified nutrition personnel should be working with them as
a viable health care team member.

Dr. Bier. As a former member of the faculty of one of the 25 per-
cent of medical schools that have a required nutrition course, I
have to say that it required an extraordinary effort to extract a few
hours of educational time fi'om the surgeons and other specialists
who all claim that they don't have enough time to teach their own
disciplines. If we are going to link nutrition health with health care
policy, I think it is absolutely crucial there has to be some message
which comes down that says we must educate physicians in nutri-
tion, to educate them at the pregraduate level and to educate them
through their postgraduate training programs and to have the
boards incorporate nutritional information within the material that
they are required to learn.

Mr. Stenholm. I can't help but observe, having been involved in
this health system reform effort for the past 2 years, there is a very
visible reason why we have this today. We have evolved into a na-
tion of specialists and you just used the word, specialists, where ev-
eryone tells us, almost everyone, tells us, the Congress, that we
really need to have three general practitioners for every one spe-
cialist. We have almost the opposite.

It shouldn't surprise anyone that if we have a nation of teaching
hospitals, teaching institutions that are turning out specialists be-
cause that is where the demand is, that you are going to have that
kind of a situation.

It shouldn't surprise einyone why, in a world of specialists, that
a subject as mundane as nutrition would not find itself with very
much popularity. That is part of the change of our health care sys-
tem that is going to have to occur. It is going to be very difficult,

going to be very slow, but if we are going to achieve what is nec-
essary in cost containment, we are going to have to look at that.

We have gone so far as to suggest that any institution that wants
to continue in the current pattern is absolutely free to do so, but
do it with your own money, that Federal-subsidized dollars might
need to be going to those that recognize a more balanced curricu-
lum. It tends to make people nervous and upset for a brief period
of time.

Dr. Rivlin.

Dr. RrvLiN. You have touched on a nimiber of important points,
and I just wanted to say briefly that I think we need two things:
First, we need to have more nutrition for every physician; ques-
tions about food and nutrition are among the most frequently
asked of physicians regardless of specialty. Everyone needs some
nutrition.

Second, there also needs to be a recognition that there are cer-
teiin special areas where expertise in the field of nutrition is needed
and for this reason nutrition also needs a specialty designation.

In addition to that, I would like to reinforce what we heard ear-
her that physicians also have to know the proper place of dieticians
who are certified and are experts in that area. So we need to know
how to use them most effectively.

Mr. Stenholm. So very true.

All of us can be guilty of overspeak and oversimplification and
I just was. But it is in that spirit that these hearings are trying
to give us a little bit of a foundation on which way the Agriculture
Committee can go to be of help in this area.

I couldn't agree more with Dr. Anderson, your statement. USDA
should face up to a credibiUty issue by changing from production
orientation to one which gives equed emphasis to consumer and
public health concerns.

It has been very difficult for those of us on the producing side
to come aroimd to agreeing to that, but I think most do. There is
still a lot of nervousness about it out there because of the gen-
ersdizations by so many. Dr. Nichols, you pointed out the public
polls. But that is why I asked the first question regarding producer
fiinding. I happen to beUeve, as a producer, we are going to need
to fimd higher priority research areas in nutrition, at least provide
the seed money as producers, to challenge the State £ind Federal
entities to put the dollars where the higher priorities are.

I hope we can continue the dialog between those of you assem-
bled and others as we try to build these support groups, or what-
ever you might want to call it, of credibility teams or whatever it
is that can challenge some of these pubUc opinion experts that put
their finger in the wind and decide, "This is a popular issue, and
we can raise a couple million bucks," which is not helpful to any-
thing that anybody here has talked about.

But it is the real world we have to deal with. They are not going
to go away. It is a free country. But by the same token if we are
going to be successful in maintaining the food production system
we have, we are going to have to do a better job in areas of re-
search, education, than what we are doing today.

Dr. Bier.

Dr. Bier. Just for the record, even though we were discussing
physician education, I would like to just say that I think all of us
at this table would support the fact that we mean health profes-
sional education, nursing schools, physical therapists, rehab, physi-
cian assistants, and all those programs as well, not just medical
students.

Mr. Stenholm. Let the record show that the heads of everyone
at the table were shaking affirmatively.

Thank you very much. We appreciate your attendance. We thank
you for the future input that you will have working with this sub-
committee as we try to make some sense out of this and move us
in a more positive direction.

We thaiik you for your time and attendance today.

We will call the next panel and I prefer you call the first witness,
Mr. Allard, since we are under time constraints. I will go vote and
be right back.

Mr. Allard [assuming the chair] . Panel 3, if you would come to
the table, please. We will go ahead and proceed. I would like to call
first on Dr. Stanley Schuman.

STATEMENT OF STANLEY H. SCHUMAN, M.D., SOUTH CARO-
LINA AGROMEDICINE PROGRAM, DEPARTMENT OF FAMH^Y
MEDICINE, MEDICAL UNIVERSITY OF SOUTH CAROLINA

Dr. Schuman. Yes, sir. Thank you for inviting me. I request that
my written comments be put in the record.

Mr. Allard. Without objection, so ordered.

Dr. Schuman. I hesitate to read them knowing that you people
are so literate and articulate that I feel almost iUiterate in this dis-
tinguished group.

What I would like to say is that I am fi*om a program in family
medicine from South Carolina, a State which was poor before it
was fashionable for other States to be poor.

We have had to manage with very limited resources. In our State
we have managed since 1984 to develop a linkage between
Clemson, the land grant college and the Medical University in
Charleston, South Carolina.

We did this with a very small line item funding of I think less
than $200,000 the first year in 1984. We have survived fi-om year-
to-year based on a constituency largely of primary care physicians,
farmers, consumers, and Farm Bureau, Women in Agriculture, and
support groups like that have kept this ahve as a clinical consulta-
tion service and pubUc service orientation.

We have found that this teamwork can operate effectively not
only in food quality and food safety, but in other areas broad based
in prevention of occupational hazards on the farm, including skin
cancer and premature hearing loss, and family farm stress.

So we operate as a preventive medicine arm linked to the 46
counties. Our main focus has been the busy overworked primary
care physician, and as I heard the testimony today, I heard about
12 different agencies all trying to reach target groups through spe-
cially designed programs.

In our 46 counties and Uttle communities in South Carolina,
there is generally only one person or with one group of practition-
ers whose services encompass the teenage pregnancy, the poor peo-

pie, the elderly, the infants, and school children, the overfed rich
people, the bulimia patients — they should have been mentioned to
this subcommittee — the nationwide epidemic of bulimia has not
been mentioned and it should be. This is a major problem as well
as obesity.

The person who sees all these subgroups in our community is the
primary care family physician, the pediatrician, and internist. If
you want cost-effectiveness as an agent of change in the commu-
nity, if you must raise the level of awareness of nutrition's latest
advances to the primary care physician. Then you would reach all
these 12 or 15 groups.

So my concluding statement is that if the busy physicians can be
updated in these areas, it is just as vital as patient's access to the
physician. I agree with Dr. Rosenberg, by that we mean, the physi-
cian and his extended team including the nurse, access to nutri-
tionists, to the hospital, and to the home economics adviser and to
whoever else is a resource in the community.

I would like to conclude by saying that if we have one rec-
ommendation, it would be for more family primary care physicians
of the type who want to go to rural areas and want to be involved
in caring and preventive services, not only to farmers and farm
families, but to consumers.

[The prepared statement of Dr. Schuman appears at the conclu-
sion of the hearing.]

Mr. Allard. Thank you for your testimony, Dr. Schuman.

I might add, before I call the next witness, that in my district
there is a yoimg — small town actually started to sponsor a few
promising young members of this community to get into family
practice and they just started, so we will wait and see the results
of that program but we have to look at those approaches.

Next we have Dr. Brittain.

STATEMENT OF JERE A. BRITTAIN, COORDINATOR, INTE-
GRATED PEST MANAGEMENT AND AGROMEDICINE,
CLEMSON UNIVERSITY

Mr. Brittain. Thank you, Mr. Chairman. I represent the agricul-
tural part of the agromedicine initiative in South CaroUna and
have been closely associated with Dr. Schuman in this initiative for
7 or 8 years now.

I would like to mention in an anecdotal way, a young physician
named Oscar Lovelace, in family practice in a smsdl rursd commu-
nity of Prosperity, South Carolina. Oscar grew up in Columbia, our
State capital, but when he was a youngster, he frequently visited
his grandfather's farm at Prosperity and eventually had the oppor-
tunity to show a dairy calf and the calf became a cow, and eventu-
ally Oscar showed the State champion Guernsey cow. He was very
Eroud of this cow and her picture hangs in a conspicuous place in
is ofBce.

He says that experience induced him to establish what is now a
thriving family practice in Prosperity; that 4-H project and that
cow.

Dr. Lovelace incidentally is a protege of Dr. Schuman; Dr.
Schuman was his preceptor at MUSC.

About 3 years ago as part of a Kellogg funded phase of the
agromedicine project in South Carolina, Dr. Lovelace provided
space in his office at Prosperity for nutrition specialists from
Clemson and Winthrop Universities to offer nutrition information
and counseling to his patients. I think Oscar is an excellent exam-
ple of a new model of primary care physician who is approaching
the health of his patients in a preventive £ind hoUstic way.

Oscar is one of the agromedicine advisory physicians who have
been identified in all 46 counties of South Carolina who are avail-
able to consult with the county Extension office on health issues.

I would like to comment a bit now on the value, from a coopera-
tive extension standpoint in agriculture and economics and 4-H, of
having access to the medical community. During the Alar con-
troversy a few years ago, we, as cooperative extension people, were
besieged with phone calls from concerned parents, physicians, and
school people asking, is it safe to eat apples?

I think it is impossible to estimate the value of having access to
Dr. Stanley Schuman, an epidemiologist and nutritionist to reply
to these concerns in a calm and science-based manner.

Dr. Schuman has developed a unique agenda for physicians as
well as farmers in our State. He probably has more name recogni-
tion across our State than anybody in Extension.

The core of his message is that our safe, abundant, and afford-
able food supply should be recognized as a cornerstone of health
promotion. He collaborates with a wide array of faculty, ranging
from agricultural production people to nutrition to youth faculty.

I think our academic programs at Clemson and MUSC have been
influenced by the agromedicine program. A rotation in
agromedicine is available to medical students at MUSC and we
have attempted to integrate this model at Clemson in some of our
graduate degree programs. The faculties share a strong interest in
teaching interdisciplinary and preventive approaches to pest and
disease management. This involves using pharmaceuticals or pes-
ticides in a minimal way, and in the context of the general health
of the family or community.

I think the cooperative Extension system and the entire land-
grant system are in the midst of reexamining and redefining its
role at the national. State, and local levels. Consumers and envi-
ronmental organizations have established themselves as stakehold-
ers in the food production system as has been mentioned before.

Agriciiltural production and processing groups have begun to ac-
knowledge that consumers have a legitimate interest in how food
is produced and in land and water stewardship.

I think this process of consensus seeking will be well served by
close collaboration between the land grant and medical univer-
sities.

As we travel together to every comer of the State, Dr. Schuman
and I have often shared the thought that agriculture and medicine
is in the same business, namely himian health. I have attached as
exhibits 1 and 2 to my prepared statement, comments by two of my
colleagues regarding the EFNEP program and the nutrition edu-
cation program in South Carolina, and would like for these to be
recorded as part of my testimony.

Thank you for this opportunity.

[The prepared statement of Mr. Brittsdn appears at the conclu-
sion of tiie hearing.]

Mr. Stenholm. Without objection, they will be placed in the
record. Thank you.

Next, Dr. McCarron.

STATEMENT OF DAVID A. McCARRON, M.D., PROFESSOR OF
MEDICINE, OREGON HEALTH SCIENCES UNIVERSITY

Dr. McCarron. Mr. Chairman, members of the subcommittee, I
want to emress my appreciation for the invitation to testify today.
I am a professor of medicine at the Oregon Health Sciences Univer-
sity, and while I am not formally trained in the nutritional
sciences, my comments reflect the research experience from my di-
rectorship of one of the national institutes of digestive, diabetes
and kidney diseases' clinical nutrition research units, suid as the
chairman of the National Kidney Foundation, council on hyper-
tension.

At a time when we look toward sophisticated molecular biology
to provide the next medical breakthrough, I refer to nutrition re-
search as exploration of the low-tech solution we can all "live with."

I would pose to the committee the thesis that after communicable
diseases, nutrition holds the greater potential to increase life ex-
pectancy by reducing the incidence of common medical disorders. A
decade ago at a time when various Federal and volimtary health
service organizations were saying that salt restriction was the only
viable nutritional intervention to prevent hypertension, I and my
colleagues at Oregon initiated a series of studies that suggested
that that was too simplistic a public health approach. Today the
high blood pressure research community knows that was the case.

Our earlier work now backed by extensive but still incomplete
experience has led to the concept that a lack of several minerals
in the diet is the primary nutritional issue for individuals at risk
of high blood pressure. The minerals sire calcium, potassium, and
magnesium which are underconsumed by populations who are at
risk of high blood pressure in this country. Those include the elder-
ly, African-Americans, the obese, heavy consumers of alcohol, and
yoimg pregnant subjects.

The dietary source that has been identified for these minerals
that is lacking in the diet is not surprisingly dairy products which
do provide 70 to 75 percent of our daily exposure to calcium, 30 to
35 percent of the potassium, and 20 to 25 percent of the magne-
sium.

Furthermore the association of linking salt and blood pressure
with dietary intake of these minerals is sufficient.

How could we have so badly missed the mark on what seems to
be such a simple issue as a saltshaker?

I would contend that we pulled the trigger on setting pubUc pol-
icy and nutrition education goals before we executed the proper nu-
tritional studies. Nutrition education is an appropriate critical pub-
lic health measure, but it is only as good as the science that sup-
ports it.

Think about the information paradox we have developed here.
Dairy products, for decades often labeled as unhealthy because of
perceived adverse effects of their fat content on cardiovascular risk.

They turn out to be the food source whose consumption has been
most consistently linked to a reduced risk of hypertension — ^hyper-
tension, after cigarette smoking, the most important risk factor for
heart disease in this country.

There are now a variety of national health institute initiatives
xinderway which are extending these observations, they include the
young pregnancy subject where reduction in blood pressure has
been linked to a 40 to 50 percent reduction in low birth weight
prenates, African-Americans whose incidence is three times that of
other groups, salt sensitive subjects who do not have to restrict so-
dium as long as these minerals are included in their diet, hyper-
tensive subjects already on medications, 40 to 50 percent of whom
may be able to come off of expensive drugs.

Just the findings fi'om the pregnancy trial alone could 3deld sev-
eral billions of dollars a year savings if prematurity drops as dra-
matically as postulated by the leaders of that trial.

An important factor that stimulated the advances in this area of
nutrition research was the funding fi*om the dairy industry which
provided much of the initial resources. Without that commitment,
the evolution of the data base and the recruitment of other inves-
tigators and funding supports fi'om NIH and USDA would not have
occurred.

That experience speaks cogently to the role of the agricultural
commodity groups must play in underwriting future nutrition re-
search in this country if we are to experience similar nutritional
breakthroughs for other common medical disorders.

Supporting the research without conveying the findings to the
consumer, however, means no pubUc health benefits. In this era of
minerals and blood pressure control that is unfortunately the case,
as the dairy industry has not fully informed either consumers nor
health care professionals about these advantages in nutrition re-
search.

The first step in that direction was actually taken last year when
the National Heart Lung and Blood Institute issued its fifl;h report
on the "Joint National Commission of the Detection, Evaluation
and Treatment of High Blood Pressure in America." That document
added to its preventive recommendations the need to maintain life-
long dietary potassium, calcium, and magnesiiun intake as protec-
tion against high blood pressure.

Based on our experience in Oregon, if there is one message I
would like to leave with you today it is this coimtry must get seri-
ous and acknowledge the impact that nutrition has on the health
of all of us. I believe the process in improving nutrition education
Euid research and linking it to other organizations is an important
task that the Department of Agriculture needs to foster.

I would suggest five simple recommendations, first and foremost,
expansion of the USDA's efforts in the area of health needs to be
a priority.

Second, means a commitment to the fiscal support of coordinated
research and education.

Third, there is no way to avoid the most costly and challenging
type of human research that is the study of humans who also hap-
pen to be the most difficult experimental animal to deal with.

Fourth, the Department must focus on foods and not single nutri-
ents in supporting research and integrating the results and com-
municating the results to all segments of society.

Finely, the marketing efforts of various commodity groups that
USDA has oversight must be tied to targeted scientific research. I
would argue that advertisement about an agricultural commodity
that does not inform the consumer about the nutritional benefits
only serves to employ copy editors and does httle to sustain the ag-
ricultural foundations of our society.

Again, I wish to thank you, Mr. Chairman, for the opportunity
to testify and I will be pleased to answer questions.

[The prepared statement of Dr. McCarron appears at the conclu-
sion of the hearing.]

Mr. Stenholm. Thank you.

Dr. Young, let this Red Raider be the one to welcome you here
fi*om the University of Texas.

STATEMENT OF ELEANOR A. YOUNG, PROFESSOR, DEPART-
MENT OF MEDICINE, DIVISION OF GASTROENTEROLOGY
AND HUMAN NUTRITION, UNIVERSITY OF TEXAS HEALTH
SCIENCE CENTER AT SAN ANTONIO

Ms. Young. Thank you very much, Mr. Stenholm, and other
members of the subcommittee. I thank you for the opportimity to
testify before this subcommittee on the linkage of nutrition as re-
lated to research and education.

I am Dr. Eleanor Young, from the University of Texas Health
Science Center at San Antonio. I am not a physician, I do hold a
doctorsd degree in nutrition fi*om the University of Wisconsin, but
for the past 25 years I have been involved in the clinical depart-
ment of medicine at our university.

I would like to ask that my statement be placed in the record
and I would briefly summarize the key points in that statement.

I would like to focus specifically on the linkage between nutri-
tional research and medical education and practice because physi-
cians are essential in that linkage and because, up to the present
time, this linkage has not been as strong as it should be.

On the panel just before us we heard a few comments relative
to this. The first question I would like to raise is what is the evi-
dence for the role of physicians as related to nutrition, health, and
disease? The evidence is overwhelming. Certainly it is documented
in terms of the application nutrition, treatment of disease, preven-
tion of disease, and promotion of health.

In my estimation, it is no longer an option, it is essential for all
physicians. Today, nutrition is an essential consideration of the
overall medical care of every patient, and thereby is a responsibil-
ity of their physician. Thus, it is incumbent that basic nutrition
principles be integrated in medical education. Every physician is
held responsible for the appropriate application of nutrition support
in the care of patients, as well as in the prevention of disease, and
promotion of health, not just the treatment of disease, but also pro-
motion of health.

This strong stance is based on several sources of evidence briefly
summarized here.

72-928 0-93-3

For example, the Surgeon General's report, "Nutrition and
Health," which has been mentioned severed times today and the
Food and Nutrition report "Diet and Help: Imphcations for Reduc-
ing Chronic Disease," these two documents alone include several
thousands of pubhshed research foundations providing evidence for
the central role of nutrition in health and disease.

We can no longer ignore the fact that of the 10 leading causes
of morbidity and mortality in the United States, our diet plays a
direct or indirect role in at least eight of these.

Other overriding emphasis includes "Healthy People 2000: Na-
tional Hesdth Promotion and Disease Prevention": One of the objec-
tives was "to increase to at least 75 percent the promotion of pri-
manr care providers who provide nutrition assessment and counsel-
ing, and that definitely is important.

llie evidence fi:om several studies suggests that only about 25 to
40 percent of physicians currently provide such support for their
patients. Additioncd evidence is supported by Public Law 101-445
passed in 1990 that gives a mandate that "students enrolled in
U.S. medical schools and physicians practicing in the United States
have adequate training nutrition."

This law also provides a clear mandate that all phvsicians are re-
sponsible to see that nutrition care is an essential component of
overall mediccd care of every patient, thus enforcing my comment
earlier that this is no longer an option.

A final point of evidence I think is not only that appropriate nu-
trition support may lessen but also in some cases prevent the pain,
sickness, disease, or trauma associated with disease, but may also
be cost-effective, lessening significantly the economic burden on pa-
tients and thus on the total healtli care of the United States which
right now is a very prime consideration for all of us, given the over-
whelming evidence as briefly outlined here that physicians do in-
deed have a professional mandate to provide nutrition education
and support for their patients.

The question now at this moment in time is why has the aca-
demic community generally failed to accept this challenge?

According to the most recent documentation that I have, mainly
fi*om the Ajmerican Medical Association, it suggests that only 24 to
25 percent of all U.S. medical schools have any required nutrition
course, a comment that we heard earlier. About twice this number
of schools do have an elective in nutrition but evidence also shows
that most students do not select these electives.

So consequently today at most about 60 to 70 percent of students
graduating fi"om U.S. medical schools wiU graduate without knowl-
edge, even basic knowledge and understanding of nutrition assess-
ment and support for patients. They will not recognize the signifi-
cant impact this has on both individual patients and on the health
care of people in the United States in general.

The barriers to this situation are many, numerous, and signifi-
cant. I think most of you have already received a copy of the excel-
lent document Nutrition Education for Physicians which was just
pubhshed this year, and at the request of Health and Hum£ui Serv-
ices, and was circulated to HHS.

I sissiune the members of this subcommittee have reviewed that
document. Some of the key barriers on the top of my Ust are, first

of all, we have a vacuiim in creative leadership, leadership at the
academic medical school level and also at the Federal level.

Second, competition within the medical curriculum. An over-
whelming knowledge base has continued to expand and must be
continually whittled down to fit into the 4-year timefi*ame of medi-
cal education and is expected to be learned within the same time-
fi-ame as we had 30 years ago, but now with an increasing amount
of information.

Another barrier of course is failure of medical schools to recog-
nize the essential role of nutrition, a fact we all recognize now.
Also, the competition within the medical schools, not just for cur-
riculum time, but for funding of nutrition is a significant barrier.

There is a lack of viable reimbursement for nutntion care in the
system. Currently nutrition counseling, treatment, and manage-
ment of disease, as well as prevention of disease and promotion of
wellness, is generally not reimbursable even though prevention of
disease is cost-effective compared to the expenditure of trying to re-
verse disease after it is weU established. The practice of medicine
has not thus far turned this around.

There are a lot of possible alternative initiatives that could be
taken in terms of trying to enhance nutrition education by physi-
cians.

I have seen the red Ught go on, so it is time for me to stop.

Basically there are many steps that should be taken. We need a
stronger recommendation for a central coordinating board. Govern-
ment coordinating board. Right now this doesn't fall within the di-
rect realm of any one of the Federal Government agencies, so some-
body needs to try to coordinate the efforts in this regard.

I think we may need to generate financial support fi-om industry,
perhaps maybe a tax break to industry to provide a lot of support.
We need adjustments in the mechanisms of reimbursement so
wellness and promotion of health is included, which now it is not.

We need to increase the number of nutrition questions on the na-
tional medical boards because that obviously would be a way to en-
courage medical schools to support nutrition more.

Also there needs to be a greater abihty of physicians who can re-
spond to the public. A lot could be said about that.

We need to have a more exploratory and relevant questionnaire
for monitoring nutrition in the medical schools. We need a whole
new approach, not just the hours that are taught in nutrition edu-
cation, but we need to know more of the concepts and achievements
of nutrition education for physicians. We need to provide perhaps
funding to establish a chair, perhaps matched by medical schools
to help, contributed to by Government or by business, that could
help to fund this.

In conclusion let me just try to summarize briefly that there is
overwhelming scientific evidence that supports the essential role of
nutrition education and practice by every physician.

Second, the application of nutrition support for patients by physi-
cians definitely is no longer an option.

Third, unfortunately, most physicians — approximately 60 percent
of all our students who graduate fi-om U.S. medical scnool today —
have not been adequate^ trained in nutrition to support patients
in the treatment and prevention of diet-related diseases.

Foiirth, therefore, to date most physicians have not been success-
ful in providing that kind of nutntion care because they have not
really been educated to this essential aspect of medical care and
they don't recognize or appreciate its impact on decreasing disease
and promoting health.

Finally, now in 1993, the appUcation of the nutritional research
linked to patient care is definitely no longer an option and the time
is right now.

Thgmk you.

[The prepared statement of Ms. Young appears at the conclusion
of the hearing.]

Mr. Stenholm. I thank each of you. I always like to ask the last
paneUst in a hearing like this the first question, have you heard
anything stated by somebody today where you wished you could
have answered the question, or has somebody made a statement
that irritated you so much that you would like to correct the
record?

Ms. Young. I could have added to the last discussion in the last
panel about nutrition education which I think I just have. So that
IS sufficient, I think.

Mr. Stenholm. Thank you.

Dr. McCarron, I would ask you this question and want each of
you to comment: How can we avoid the stigma that often goes with
industry-sponsored research? Dr. Yoimg, you recommended it. If in-
dustry pays for it, it is immediately suspect, it seems. How do we
avoid that?

Dr. McCarron. First of all, I think that is an excellent question,
Mr. Stenholm. I would say also yesterday in a casual conversation
at the USDA, the first statement fi*om the individual was, but your
research was largely supported by the dairy industry. So that prob-
lem rests even witmn the agency I think.

My answer to that 9 years ago when interviewed Uve on CBS
Morning News after a paper was pubUshed in Science about our
work, the impUcation was, c£ui we beUeve you?

My answer then remains as it was and is today, the data is the
data. The scientific process allows for wa3rs to check on the outcome
of research. The source of fiinding makes no difference whatsoever.

Mr. Stenholm. Dr. Brittain.

Mr. Brittain. Mr. Chairman, I think part of the answer in re-
sponding to the notion that if something is industry-supported, it
is therefore biased, would be for the industry to support research
and education activities through foundations that are independent
of the industries.

A lot of large corporations do that, such as the Kellogg Founda-
tion, and I believe tnat that would be one way to buffer or put dis-
tance between the industry and the recipients that receive research
supports.

Ms. Young. I think, also, that the responsibility for health care,
especially for ph3rsician8, is not just to he funded by the Federal
Government but everybody in the United States; all industry and
business also can profit by that. So why shouldn't they contribute
to it?

So there may be ways that industry and business perhaps could
give funding to support nutrition education in medical schools,

without necessarily it being acknowledged as being supported by so
and so, or whatever particular industry or business.

In other words, tiiey give a donation to a nutrition foundation or
scholarship fund, and (uspersed with no names attached, i.e. with-
out mention of the specific source of funding — ^but could still be rec-
ognized for their contribution to support nutrition education. What
about a tax break or some way to recognize their contribution with-
out name recognition.

Mr. Stenholm. Dr. McCarron.

Dr. McCarron. If I could reflect on a comment that was made,
foundations are a good source of pulling money, but it doesn't
change the scientific process tiiat requires that when you report
data, that your colleagues verify it. That is the safest and the most
time tested way of assuring l^at data is gathered in unbiased fash-
ion.

The other issue I would like to raise is that there are a lot of
parallels between what we are talking about today and the orphan
drug issue that FDA has had to address in other committees of the
Congress, Senate and House, in the past. By that I mean the
health issues we are talking about have the very generic quahty to
them.

It is hard to get your arms around who benefits and if we are

foing to be successful in recruiting otiier sources of funding, which
do Delieve is criticsd and I do believe the pubhc sector should join
in partnership with the private sector, not just the agricultural
commodity groups, but the food corporations of this country, there
has to be some incentive for them to join in this effort. I am not
sure it is there right now.

We need to think about ways in which we can stimulate that in-
terest.

Mr. Stenholm. How did the South Carolina agromedicine project
get started?

Dr. SCHUMAN. It started as a response I think to the peach farm-
ers— ^isn't that right. Dr. Brittain — ^who were being harassed by the
health department in terms of using a nematicide.

Mr. Brittain. That happened to be the crisis that was underway
at that time. I think Dr. Schuman's group was actually already ex-
isting at MUSC and they had been grant funded, and we had some
leaders in the Clemson organization and I think at MUSC who rec-
ognized that agriculture needed to have a more human face. We
were getting pretty well bombarded by consumer groups and the
Green movement, and suggestions were being made then and now
that somehow farmers were not very good environmental stewards
of tiie food supply and were in some sort of negative collaboration
with the agribusiness industry.

I think the reason our State offered to fund it during that period
of time was in response to the pubhc perception that we were more
interested in profit than we were in the human side of agriculture,
the food side.

Dr. Schuman. It was started with a line item of less than
$200,000 between the two institutions. It was a noru*enewable
thing so we had to defend oxirselves every year as a line item. Over
the course of 8 or 9 years we have developed constituencies in all
46 counties. Farm Bureau, Women In Agriculture, nutritionists.

and primary care ph3rsicians who see us as a continuing education
outreach from both campuses.

I feel the more I hear these issues that are so complex and can-
not be solved that, including environmental medicine and occupa-
tional medicine and wellness programs and — ^they are getting more
out of the health dollar, that the primeuy c£u*e physician must be
kept in the loop, that this person is overworked and is busy but can
exercise quite a bit of leadership in networking with resources.

So that in the current sc£u*e, for example, NAS promoted by Dr.
Landrigan and his pediatric lobby took over 3 years and $1,300,000
to tell us that children are not Uttle adults, was not a whole lot
of yield from the national study. I couldn't resist putting that in.

You mentioned what £u*e some of the polarizations that have
been going on in the American Academy of Pediatrics has not
served their patients well in that effort.

They have linked pesticide residues, parts per biUion with lead,
and the chemistry is just not the same.

So I got off the subject there but in these areas of concern, in
our State and the recent concern, and you mentioned ambiguous
messages. On the one hand, NAS says children are not Uttle adults
and we have to do better than measuring the parts per billion, on
Hie other hand, keep eating your fruits and veggies. Not a very
clear message to the public.

In our State we waited by the phone all week and we didn't get
a single phone call frt>m a concerned school, or day care center —
it was like day and night with the Alar controversy. We got one
call from one TV station and they didn't even want to use it on the
air. But we feel the primary care physician has enormous potential,
and in response to your eloquent plea for better education, I know
what it is to fight curriculum committees. I have not done t^at.

We have taken a different tack which is — ^medicine is a lifelong
learning process and I believe I can reach more physicians in pri-
mary care 5 years after they are out of medical school than when
they are in medical school. I will give a food quality and safety lec-
ture to the entire freshman class, one hit for 1 hour. I have done
that 3 years in a row. That is kind of fiin. But then the students
become Uttle surgeons and Uttle OB's and Uttle gastroenterologists
and Uttle cardiologists doing their thing. They are so deUg^ted to
be speciaUst doctors at that stage.

But after thev ^et out, they become community-oriented and they
are highly reacncu>le, if you package it right, and if you reach them
in the context of their practice. I think t^ey are a vastly neglected
resource for preventive medicine. Practitioners don't relate espe-
ciaUy to the health departments' buUetins or relate to llealthy
People: 2000," and all these high-powered conferences which are
ver^ important at the national level.

They do relate to what is going on in AUendale County, or what
is going on in SummerviUe. That is what they want from
agromedicine — if you can respond to their patient-need, then you
have their full attention. If you are available at the end of the
phone line, if Jere Brittain is available at the end of his phone line
for the truth about atrazine in ground water, Jere can inform me.
Togetiier we can talk about parts per bilUon and the health of the
farm family using that weU for the doctor.

So it is this teamwork that we found that has been very reward-
ing and very cost-effective. I am not full-time agromedicine, I am
half-time family medicine, and half-time agromedicine.

So I don't plan to devote my entire time to agromedicine. That
would take me out of the clinical setting. That would be wrong. But
we work with all the agencies. We do work with the State health
department, with the poison control center, and it has been a good
program. Trying to get it started in other States, the major obstacle
is territoriality between the campuses. You have problems with Re-
publicans and Democrats.

You try to get a program started and you have problems, for ex-
ample, in Alabama, you get the medical school in Alabama to meet
with Auburn, but you have the football rivalry and all of a sudden
sdl they want to talk about is their two football teams instead of
agromedicine.

We often say a State has too many medical schools, or too many
football and basketball teams. When we talk about how we got
started in South Carolina, if s because MUSC does not have a foot-
ball team and Clemson does, so we are no threat to Clemson.

Mr. Stenholm. Your red light went on.

Dr. SCHUMAN. Thank you very much.

Mr. Stenholm. Thank you.

Mr. Allard.

Mr. Allard. Thank you, Mr. Chairman.

I agree, so much of this is a matter of perspective. In our State,
UNC means the University of North Colorado, but you mean Uni-
versity of North Carolina.

Listening to your testimony, the thought crossed my mind, how
much interest do ph3rsicians have in nutrition? I would suspect that
it is the students that Dr. Schuman was talking about, how they
all want to be surgeons and speciahsts in one particular area or an-
other, and probably tiiey are not focusing on nutrition at that time.

Would any of you like to address that?

Ms. Young. I will.

Mr. Allard. Dr. Young.

Ms. Young. There is a great deal of interest among physicians
in general. At our school in San Antonio, in my written testimony,
I have a brief description of what we do there in terms of nutrition
and you may want to note, if you read it, we have quite a number
of physicians that are in all the different areas of medicine who
participate in what we try to do in terms of nutrition education.

So in the program we have — ^we have a course, the first, second,
third, and fourth year, and also in our residency training program,
that tries to build on each year in medical school education — ^we
collaborate with many of the physicians in our school. We have
physicians from surgery, ob/gyn, pediatrics, internal medicine that
work with us. I find them a^ very collaborative and very support-
ive.

Not only do they contribute some nutrition in teaching the medi-
cal students, but also in turn the very fact that they do that, makes
them more aware of the fact that nutrition is very much related to
what they do in practice of whether it is oh/gyn or pediatrics or
whatever.

So I find, at least in the setting that I work in, a very strong sup-
port fi'om physicians in almost every one of the disciplines.

Mr. Allard. You were sharing statistics with this subcommittee,
and correct me if I am wrong, you said 25 percent of medical
schools have nutrition as a requirement?

Ms. Young. Yes, that is correct.

Mr. Allard. And 60 percent have nutrition as an elective.

So less than 60 percent of the physicians who graduate probably
have not had any nutritional training.

Ms. Young. That is correct. Especially because most students do
not select to take the electives.

Mr. Allard. Including premed?

Ms. Young. That's right. I am only sharing my experience in my
school, but basically what you say is correct, most students will
graduate fi'om medical school without having had any exposure
even to the principles of nutrition assessment and the support they
should be able to provide their patients, no matter what area of
practice they go into.

Mr. Allard. I suppose the family doctor is the fi*ont-line person
out there and probably the one that would be best to talk about nu-
trition. Do most family doctors, family practice programs, have a
nutrition requirement?

Ms. Young. I don't think most do, but I know they are most
ofi;en in the field of primary care. This group, on a national level,
has sponsored several conferences specifically to help train family
practitioners in the area of nutrition. So this particular area of
physicians has been much more in tune with it and has been tak-
ing positive steps in that direction.

Mr. Allard. Dr. McCarron, would you like to make a comment
on that question?

Dr. McCarron. Yes, I think that first of all on our situation in
Oregon, we have a solution for the conflict £ind that is you only
build one medicsd school and you don't have as much problems. We
just have to deal with Seattle.

The interest of physicians I think varies greatly. As part of our
clinical nutrition research unit with the sponsorship of the Na-
tional Kidney Foundation, we are entering the si^h year of a
nonpharmocological treatment of high blood pressure, basically how
you treat hypertension by diets.

We have been to 23 cities and we have touched 5,000 health care
professionals, less than 5 percent of the attendees are physicians
even though that is what it is labeled. That is who the mailings
go out to.

So while I £un optimistic once you are in practice, it comes down
to the time, can they get away and attend these meetings, et
cetera.

I think one of the things this committee can do besides giving di-
rectives to the Department is to also take the message back to your
constituency fi-om the agricultural community. The agricultural
sector of this committee has to understand that they are as big a
player, if not a bigger player, in the evolution of health care in this
country as the pharmaceutical industry is.

Mr. Allard. Do the physicians think of nutritionists as part of
their team or have they identified someone in their community who

would help them if they had nutritional questions, or do they think
about the extension service and the nutritional program there?

I want you to show for the record that everybody nodded no.

Ms. Young. I would comment that the answer is, no, they don't.
Most physicians, as we have said, 60 to 70 percent of all physicians
in the United States have not had nutrition experience in their
medical training. Therefore, they are not in tune with thinking
about that or asking/seeking nutritionist referrals.

Mr. Allard. Maybe this ought to be more of a focus to the Ex-
tension Service to work on primary care physicians.

Dr. SCHUMAN. I would like to say, as I am hstening to my col-
leagues, I think that — on the optimistic side — if you are willmg to
allow nutrition to become part of wellness, there is a growing
movement for sports medicine and wellness, and health in the
workplace. I think that will become part of the curriculum, if it is
part of that package.

In other words, there is a httle tension between nutrition as part
of diabetes, kidney disease, and so forth and nutrition as part of
a positive proactive health promotion and wellness. In our little
group we have just added a family physician, certified in family
medicine and in sports medicine.

Peter Carek is going to be a first-rate leader in this area because
he sees nutrition as part or wellness. I think that is important.

Second, I wanted to mention, before I forget, the food industry,
the commodities, dairy, and so forth, the industry as a group has
to realize the entire American food supply is constantly under at-
tack by people first hitting apples with Alar, and then hitting this
group and that group, and cranberries Euid fat in the beef and so
forth.

The industry as a group has to realize that this is a generalized
attack on confidence, trust, and appreciation of the U.S. food sup-
ply which again is the best in the world.

Mr. Allard. Well said.

Thank you, Mr. Chairman.

Dr. SCHUMAN. When I go before the farmers, the Pork Board
wants me to talk about pork and the Poultry Board wants me to
talk about poultry, but generally this attack is against all of the
producers and the quality of the supply.

Ms. Young. I would like to urge this committee, urge you very
strongly to consider what you might be able to do to be effective
in coming up or trjdng to support some overgdl Federal agency that
would specifically look at medical education.

As you read the report that has been done by Health and Human
Services this past year, there is no Federal agency that really is
responsible more or less for overseeing that area and I think if
there was such a group, that a lot of things could be collaborated
much better and more effectively and be much more profitable I be-
Ueve.

Mr. Stenholm. I am curious, how much emphasis goes into nu-
trition in training veterinarians, for example?

Mr. Allard. There is a lot of nutrition in veterinary schools.

Ms. Young. More than in human medical schools.

Mr. Allard. We are hit over and over again in the 4 years, but
it is so much an important part of the animals we treat. I was

thinking of comments that Dr. McCarron made on potassium, cal-
cium, and magnesium, I think you just upset the physiology of tiie
kidneys.

I may have to go back to see about sodium, but we do spend an
awful lot of time on that, yes.

Dr. McCarron. I must say that I am a nephrologist by training
so hopefully I have not gotten too twisted.

There is another general thought, as this coimtry in the health
care priorities and research priorities explores insertion of genetic
material into animals as a way to eliminate common problems, how
far ofT the mark have we gotten that we stiU just don't understand
so much that is basic from the food supply and its contribution to
health?

There is something awry here, and I think that leadership is
going to have to come out of the agricultural communitvr. In this
town, it has to come out of those Members of Congress who are in-
terested in the long-term support of the agricultural community.

Mr. Stenholm. I have been a reluctent convert to tiie basic
statement that there is nothing new to be discovered in poUtics, po-
Utical science, or in ideas. I thought as we got into toda/s hearmg
that we had really thought about something new, trying to involve

fh3rsicians and the pubhc health sector wim agriculture, and then
mid out South Carolina beat us to it by 9 years.

It is tough for a Texan to admit privately or pubUcly that that
happened.

Dr. Young, are you familiar with the efforts of Andy Vistell, the
county agent in San Antonio, trying to put together a resource
group for purposes of answering questions on foodssifety when they
arise? Are you famiUar with his efforts?

Ms. Young. What is the name?

Mr. Stenholm. Andy Vistell, the county agent in Bexar County.

Ms. Young. I am not familiar with that partic\ilar person, but
I am famiUsu* with what they do and so forth.

Mr. Stenholm. He has an interesting concept going on, and I
would suggest to him to get in touch with you, because there are
some physicians that have gotten involved with him and his pro-
gram. Basically what it is, in my simple terms, is an effort on a
local basis to build resource groups to answer questions whenever
there is an assertion made about the food safety question.

Ms. Young. That would be good.

Mr. Stenholm. There is a place that can be hooked onto that
will have credibility. What he is seeking is nonagricultural-types,
which goes back to agromedicine, as I come to understand what
you are doing in South Carolina.

I totally agree to that as far as building credibility. I really can't
think of a better entity than a physician to deal with credibility re-
garding food safety, tliere are probably others just as good, but I
can't think of too many better. That is the concept. That is why we
appreciate. Dr. Brittain, and Dr. Schimian, you snaring what South
Carolina is doing.

Dr. SCHUMAN. You said you were scooped, but in 1825 — this is
an editorial from the new Journal of Agromedicine, but first, the
pubhsher will be delighted that I brought the first issue of the jour-
nal, but in 1825 Joseph Johnson, M.D., wrote to the ag society of

South Carolina his views on improving the health of the low coun-
try plantations. That is 75 years before the discovery in the 1900's
of mosquitos and yellow fever. Dr. Johnson observed an increase in
the fevers and jaundice of rice fieldworkers who were exposed to
inadequately maintained drainage ditches.

He sJso urged farmers to take summer retreats to higher
grounds to avoid bad air„ Hence the name of the village near
Charleston called Summerville. This advice he offered in humility.
"It would be presumptuous for a physician to offer an5rthing to your
society on agricultural science," he said.

This was in a quarterly published at $4 per year subscription
called the Carolina Journal of Medicine, Science and Agriculture.

What have we learned about agromedicine? Nothing new. These
people in 1825 really understood it. We eat three times a day, we
go to the doctor once a year.

Mr. Stenholm. Lest the other panelists feel now the compulsion
to confess along the same lines, let the record show that there have
been no original ideas expressed by anybody at this hearing today.
All right, that is fascinating. I think that is a good place to end this
hearing because it shows where we have some real fertile ground
that needs to be cultivated. Yesterday's hearing on pesticides and
the National Academy of Sciences study was an extremely good
one, also for purposes of delineating the record as to what we are
talking about with the safety of our food supply, nutrition. It has
to be where it begins, and we have a lot of thoughts now to go into
this.

We appreciate each of you taking your valuable time to come and
share with us and say to you as we have to the others, we look for-
ward to working with you as we try to come up with some — I hesi-
tate to say better answers, try to utiUze the educational processes
that this country has experienced over 217 years in a better way
to meet the 1990's problems, I guess, is the best way that we talk
about it. Science and education, they go together. Thank you for
being here.

[VHtiereupon, at 1:45 p.m., the subcommittee was adjourned, to
reconvene, subject to the call of the Chair.]

[Material submitted for inclusion in the record follows:]

TESTIMONY OF ELLEN HAAS

ASSISTANT SECRETARY, FOOD AND CONSUMER SERVICES

U.S. DEPARTMENT OF AGRICULTURE

BEFORE THE

HOUSE SUBCOMMITTEE ON DEPARTMENT OPERATIONS

AND NUTRITION

HOUSE COMMITTEE ON AGRICULTURE

JULY 15, 1993

Good Doming Mr. Chaiman. I 2un pleased to be here today,
along with Myron Johnsrud who is representing the Acting
Assistant Secretary for Science and Education, to talk about
nutrition research and nutrition education activities at the
United States Depcurtment of Agriculture (USDA) . Nutrition must
become a primary mission of USDA. This hearing recognizes that
imperative.

As you know, I've appeared before this important committee
many times, but this is my first as USDA's Assistant Secretary
for Food and Consumer Services. My appearance here underscores
Secretary Espy's commitment to nutrition and today's hearing
acknowledges that there are three parts of USDA — agriculture,
rural development and nutrition.

Secretary Espy has pledged to meike nutrition education a
priority and to work to integrate nutrition into the agriculture,
health and welfare policies of the Clinton Administration. And I
aa cosmitted to doing just that. Secretary Espy and I want to
coomend you, Mr. Chainan, and Menbers of the conaittee for
focusing on our national nutrition responsibilities.

VutritioB eduestioB is sssential

With the clear evidence of the relationship between
nutrition and health, enabling Aaericans to adopt eating habits
that follow accepted dietary guidelines is essential.

It is not enough for us to help produce food, or even
distribute it better. We need to go beyond and establish
nutrition education progress that promote healthful eating habits
and empower consumers with enough information to make healthful
choices for themselves and their families.

There is no question that diet is related to chronic
disease. The 1988 Surgeon General's Report on Nutrition and
Health found that for the two out of three Americans who neither
smoke nor drink, eating patterns may shape their long-term health
prospects more than any other personal choice. With the cost of
health care spiraling, these are choices no American can ignore.

The 1989 report Diet and Health by the Food and Nutrition
Board of the National Research Council found that diet is a
factor in several najor chronic diseases including cardiovascular
disease, hypertension and certain cancers. Healthy People 2000,
the Department of Healtli and Human Services national health
objectives, relied on this research in identifying the 21
National Health Objectives for Nutrition.

Healthy People 2000 cites four "cornerstones" that are
ftindamental for the achievement of these objectives. USDA has
responsibilities for these cornerstones, two of which are
addressed at this hearing:

1. Narked Improvement in accessibility of nutrition
Information and education for the general public, and

2. The maintenance and Improvement of a strong national
program of basic and applied nutrition research.

Researeh amd edmoatiea

Our nutrition education programs are firmly grounded In
research conducted not only at USDA but also by Cooperative
Extension Partners at State and Land Grant Universities across
the country. Finding out trhy diets are not as good as they
should be and irtiat we can do to help people li^rove them Is the

purpose of our nutrition education research. Over the past year,
the Human Nutrition Information Service's (HNIS) research on the
factors influencing diet has focused on the diets of single
parents, the characteristics of food label users, the
characteristics of those who are concerned about food safety,
trends in the use of fruits and vegetables, and the diets of
children.

A major study. The School Mutrltion Dietary Assessment
Study, will be out later this year. This study examined the
nutrient content of the school lunch program through the menus
planned and offered to students, the foods chosen by
participants, the amount of foods consumed and the effect on the
nutrient intake of participants.

FNS is currently developing validated food frequency
questionnaires to assess the diets of WIC clients and to provide
a basis for nutrition education.

High quality scientific research, relevant to the areas of
policy development, is absolutely essential. We need to continue
to assure the professional cooaxinity and the public that USDA is
a credible sotirce of dietary guidance. Nhat we say about
healthful eating must be scientifically accurate and unbiased.
If it is perceived to be influenced by political concerns or the

concerns of any special interest groups, it will not, and
probably should not, be accepted.

While we have done much research and produced many
educational materials, the effort has been fragmented and lacking
an overall strategy. At least eight USDA agencies are involved
in nutrition education and research activities. And within each
agency, the efforts are further scattered. We need to improve our
coordination so that we are offering a unified, effective message
to the American people.

coordlBation

All of the nutrition research and nutrition education
efforts we undertedce depend on working partnerships within USDA,
with other Federal, State and local governments, and with the
private sector. I am a firm believer in the importance of making
linkages and building coalitions to achieve shared policy goals.
All who are part of the food system — consumers, farmers,
industry, and government — have a stake in this agenda.

There has been cooperation and collaboration eunong various
public and private groups. But we must do much more. We not
only need to work together, we need to coordinate more
effectively the work we do. I am extremely interested in
developing a nutrition education initiative to pull together, for

information-sharing and networking, all the leading organizations
and individuals in the area of nutrition education.

Some efforts have been made to address this problem. Within
USDA, many agencies have responsibility for some aspect of
nutrition — education, research, monitoring or the direct
provision of food assistance. Coordinating mechanisms have been
developed at the staff level including the Dietary Guidance
Working Group, and the Human Nutrition Coordinating Committee
with membership and representation from every agency with
nutrition activities.

HNIS works closely with the Family Economics Research Group
that studies the economic factors which may affect dietary
status. They also work closely with HHS agencies such as the
Food and Drug Administration on food labeling education, the
Office of Disease Prevention and Health Promotion on general
dietary guidance issues, and with the various National Institutes
of Health agencies such as the National Institute on Aging in
developing education materials. HNIS collaborates with
Cooperative Extension Partners at Land Grant Universities to
review and distribute nutrition education materials for
consumers .

FNS and the Extension Service have joined together to
provide intensive nutrition education to WIC program recipients.

FNS also coordinates with HHS agencies such as the Maternal and
Child Health Bureau, Medicaid, Office for Substance Abuse
Prevention, Centers for Disease Control, Head Start, Healthy
Start, and the Indian Health Service. FNS is also involved in
the Department of Education's Even Start and the Office of
Migrant Education.

Exaaples of multiple Federal agency and private sector
coordination include HIC and the Surgeon General's Healthy
Children Ready to Learn Initiative; Operation Weed and Seed; and
the National Breastfeeding Promotion Efforts — USDA's
Breastfeeding Consortium is made up of over 25 organizations,
including the Academy of Pediatrics, the American Nurses
Association, the Healthy Mothers, Healthy Babies Coalition, and
the Agricultural Research Service Children's Nutrition Research
Center at Baylor College of Medicine.

CemmuaioatloBs Strategy

At the same time ve work on coordinating oxir message, we
must work on communicating it more effectively.

We live in a technologically sophisticated world yet we
continue to disseminate information mostly by brochure and
pamphlet. The Department has extensive electronic resovirces which

we need to harness for nore persuasive and far-reaching
coBBunicat ions .

For example, we are using print brochures to conpete with
the billions spent to produce the light and sound shows that are
today's TV food ads. Americans watch television so that's %rhere
we have to be. We need to fight fire with fire and stretch our
reach by using new coaaunications technology. If the teenagers
who are watching MTV are the ones we need to reach — and our
research tells us they are — then our messages should be on MTV.

We need to use the results of all our research more
effectively. We have conducted national food consua^tion surveys
and do food coqposition research that tells us that food
consumption patterns differ by income level and, often, ethnic
group. HNIS has determined the informational needs of pregnant
teens, elderly consumers, and adults with low literacy skills.
Healthy People 2000 cites the special needs of high-risk
populations, such as lev- income and minority vomen. We must
develop materials that empower these high-risk groups as well as
the average consumer to make healthful food Voices.

Hiere already exists a scientific consensus on what makes a
healthful diet. USOA's Human Nutrition Information Service in
cooperation with the Department of Health and Human Services has
provided Dietary Guidelines for Americans since 1980. The two

departaents will soon review and revise the guidelines to ensure
that they represent the best advice we can give the public.

The Food Guide Pyrasid, irtiich visually translates the
dietary guidelines, is the best known product of HMIS' nutrition
education efforts. This pyramid has becoae a powerful tool for
conveying the nutrition message — not only in USDA's nutrition
education efforts, but in the food industry and other private
sector initiatives. For example, the Food Pyramid is on the back
of Cheerio' s boxes on breakfast tables across America and other
food companies are finding ways to use it. But there is still
confusion about how best to build the pyramid into education
programs anJi we must do more to help consumers.

The new food labeling law promises to be another useful tool
in nutrition education efforts. The label enables us to provide
consumers with knowledge about exactly irtiat they're eating. But
the new food label is only beneficial if consumers understand
trtiat they're reading. We can't just glue the new label to
packages and irailk away. We have to explain irtiat It means and how
to use it. With proper education, the new label will empower
consumers to make healthful choices.

Food-assiatane* prograna need a nutrition aducation eomponant

We not only need to broaden our education effort, we need to
broaden our base. He must make sure we are providing all segments
of the population — particuleurly the most vulnerable — with
nutrition information.

USDA will spend more than $300 million this year on
nutrition research, monitoring and education activities. Nearly
half that money goes to support nutrition education in the WIC
program while very little of it is used for nutrition education
in the Food Stamp progriun, relative to the size of the program.
Nutrition education must be an integral part of ail food
assistance progrzuns.

We estimate that one of every six Americans is served
through the 14 food assistance progreuns managed by the Food and
Nutrition Service of USDA. Without education, program
participants may receive food but not the information they need
for a healthful diat.

Our rola in providing nutrition education in the food
assistance programs is to ensure that our participants make
informed decisions about the food they select and eat. Several
of our programs have specific nutrition education initiatives
underway, and they are as follows:

Food Stamp Program

The Food Stamp Program is the largest, single food
assistance program, serving more than 27 million people. But, it
has the smallest nutrition education component. Less than l/io
of 1 percent of the Food Stamp budget goes for nutrition
education. We need to do more and enlist the aid of the Committee
and other interested groups to be creative in reaching this
diverse population.

Cvirrently, through the Food Staunp Progreun (FSP) ,
administrative matching funds are provided for State initiated
nutrition education plans that are conducted exclusively for the
benefit of Food Steunp applicants and participants, and do not
duplicate USDA's Expanded Food and Nutrition Education Progreun's
efforts in the States. However, only nine states meOce use of
this 50/50 plan. Clearly, we must do more to provide nutrition
education for the 27 million Americans who rely on food stamps to
supplement their food p\irchasing resovirces.

For the first time, FNS will award $500,000 in Fiscal Year
1993 for Food Stamp Nutrition Education Demonstration Grants.
These grants, which do not require matching funds, will support
the development, implementation and evaluation of innovative
community nutrition interventions directed to Food Stamp

participants. Educational objectives will focus on improved
knowledge, abilities and skills for meal planning, budgeting and
food preparation. These grants will be awarded in September
1993.

Secretary Espy has set as a priority making nutrition
education an integral part of the Food Steunp Program. In
response, the FNS staff is working on a long-range plan for
nutrtion education.

This plan could include providing nutrition education videos
in food stamp %raiting rooms, updating the food stamp poster and
brochure to reflect the food guide pyramid (these materials are
12 years old) , and making these publications relevant to the
lives of the recipients %rho are getting the food benefits.

Tha Spacial SupnlMiental Program for Women. Infants, and Children

Unlike in the Food Stamp Program, nutrition education is one
of the primary missions of the HIC program. As I stated earlier,
almost half of the program dollars we spend on nutrition
education is for the HIC Program.

This Committee is well aware of the effectiveness of the WIC
progr«ua. He know that nutrition education, as a major HIC

activity, contributes to those positive benefits and the overall
effectiveness of the program even though we can't attach a
precise dollar figvire to it. Nutrition education is fundamental
to the mission of WIC and HIC staff take their responsibility
seriously.

WIC provides nutrition education along with nutritious food
packages and referrals to health and social services. Many of
the neediest WIC clients are young mothers with low reading
skills. The nutrition education we provide — the foods and
dietary habits we recommend — were developed using research data
on what people are eating and what they should be eating for
proper nutrition. It is our task to translate this information
into practical dietary advice for low-income women during
pregnancy and lactation, and for parents on how to feed their
families.

By regulation, at least two nutrition education contacts
must be offered during the participant's certification period.
The first contact is usually provided as part of the
certification process. Additional nutrition education contacts
are offered to participants during food voucher pickup, health
clinic visits or at other scheduled times.

WIC nutrition education is designed to focus on the
relationship between proper nutrition and good health and to

assist participants at nutritional risk to mzJce positive changes
in their diet. In Fiscal Year 1992 approximately $140 million
was spent on nutrition education in the WIC program.
Approximately $16 million of these funds are used to promote and
support breastfeeding. Examples of other current WIC nutrition
education activities include:

The HIC Nutrition Education Assessment Project. This study
will investigate the effect of WIC nutrition education on
participants' nutrition-related knowledge, attitudes,
behavior and satisfaction with services.

The second National WIC Nutrition Services Meeting. The
theme of this year's conference will be the provision of
quality nutrition services to WIC participants in a manner
which accommodates their cultural, ethnic, and educational
differences.

The Department's FY 1993 appropriation included $3.53
million for the Extension Service to collaborate with WIC on
a special nutrition education initiative. This will provide
additional nutrition education to the neediest of WIC
participants .

FNS is developing a handbook. Nutrition and Feediny During
Infangy; a Handbook for Use in the WIC and CSF Prooraas for

14 -

use as a reference guide for nutritionists and other health
professionals who provide nutrition education to caretakers
of infants in the WIC and Commodity Supplemental Food
Programs.

FNS awarded Breastfeeding Promotion Grants in Fiscal Year
1991 and 1992 to explore the effectiveness of using
incentives donated from the private sector for Improving
breastfeeding rates. The promotion of breastfeeding is an
important part of nutrition education for new mothers and
babies.

USDA hosts ongoing semi-annual meetings of the Breastfeeding
Promotion Consortium to exchange information on how
government and private health Interests, Including major
health professional organizations, can work together to
promote breastfeeding and to explore and li^>lement joint
efforts.

Nutrition Education and Training Program fWET^

NET alms to help build good food habits by teaching the
fundamentals of nutrition to children, parents, educators, and
food service personnel. It is the only national school-based
nutrition education program. It should be noted that the NET
program is authorized at $25 million but that appropriated f\inds

ar« lass than half of that. Together, the Congress and the
Adainistration must place a priority over the next several years
on rebuilding the capacity for this progreun that was cut bade so
severely in the early 1980s.

The nutrition education activities are coordinated with the
National School Lunch and School Bre«dcfast Prograas, the Child
and Adult Care Food Prograa and the Sunner Food Service Prograa.
KET reaches children by coordinating learning experiences in the
schools, child care centers, and the conninity.

Curriculum and audiovisual program Materials are developed
and purchasad with NET funds to provide nutrition inf oraation
that appeals to, and addresses the needs of, children.

Recently, through a collaborative effort, a Strategic Plan
for Nutrition Education in the Child Nutrition Prograas has been
developed. The Plan provides a structure that Identifies ten
national goals for nutrition education and training, nutritious
aeal service, and nutrition education leadership. The Plan vaa
developed through a strategic planning process that included
nutrition partners from Industry, professional organisations, and
Federal and State agencies.

In early March, a National NET Conference, entitled
Proaotino Healthy gating Habits For Our Children was conducted.

16 -

The Strategic Plan for Nutrition Education was the centerpiece of
the conference. Other NET activities promote Interagency
coordination of child nutrition activities. Examples include:

— contracting with the National Food Service Management
Institute (NFSMI) to develop guidelines for conducting a
nutrition education needs assessment in schools.

Providing technical assistance to the revision of HHS'
Handboolc of Head Start Nutritionists.

— > Providing major technical assistance to the Head Start

Bxireau (HSB) , Adainistratioh For Children and Families, for
Padres Hispanos EnAcclon (PHA) , a nutrition education
project funded by HSB/Kraft General Foods for parents of
Hispanic Head Start children.

— Providing technical assistance in the development of
national guidelines for nutrition education being developed
by the Centers for Disease Control and Prevention, Division
of Adolescent and School Health. This is another good
example of the kinds of partnerships we should continue to
develop.

Nutrition education is an important component of school
health and education and USDA wants to do more in this area. The

Centers for Disease Control (CDC) has launched a significant
initiative to expand health education in the nation's schools and
we have been actively coordinating with CDC on this initiative.

Food Distribution Program on Indian Reservations fFDPIR^ .

In order to respond to the need for greater and more
effective nutrition services for participants in the FDPIR
program, USDA recently formed an Interagency Working Group for
Native American Nutrition Education. Nine federal agencies that
have responsibilities for providing nutrition education, or
health care services to Native Americans, are members of the
Working Grojp, as are two Native American organizations engaged
in food assistance. The goal of the Working Group is to provide
increased and improved nutrition education services to Native
American groups through collaboration and coordination to avoid
overlap and more efficiently use resources. The Working Group is
committed to supporting nutrition education which is specifically
geared to the needs and cultures of Native Americans. .

The Working Group is not our only initiative in support of
nutrition education for participants in the FDPIR program.
Nutrition education fact sheets were developed that address a
variety of diet-related health conditions common among Native
Americans, such as diabetes, hypertension, and obesity, and more

general issues, such as nutrition during pregnancy and nutrition
requirements for the elderly.

In 1993, we requested and received, $135,000 in funds
appropriated for FDPIR nutrition education. These funds were
made available to purchase nutrition education publications and
materials for Indian Tribal Organizations and State agencies.

Mr. Chairman, while all these food program initiatives are
excellent examples of nutrition education activities within our
programs, it's not enough, and we need to do more.

President Clinton has charged his Cabinet to reexamine the
way the federal government is doing business and to find new and
better ways to provide services for the American taxpayer.
Secretary Espy is tiOcing this charge seriously and has directed
his appointees to help the President reinvent government. The
Department is undertaking a sweeping review, and the manner in
which we are organized to meet our national responsibilities for
nutrition research, monitoring and education is, of course, part
of that review — the first such review since the Food and
Nutrition Study of the 1979 President's Reorganization Project.

I believe it is fundamentally important that the Department
refocus on its nutritional mission. Our progrzuns touch the lives

of every Anerican every day. The Department's structure oust,
then, reflect this significant national responsibility.

Mr. Chairman and Members of the Committee, for many years I
have worked on behalf of consumers to promote access to a safe,
nutritious and affordable food supply. I value the opportunity
that Secretary Espy and President Clinton have given me to help
improve the nutritional and health status of American consumers.

This concludes my statement. I would be happy to answer any
questions that you or the Committee members might have.

STATEMENT OF

DR. MYRON D. JOHNSRUD

ACTING ASSISTANT SECRETARY

SCIENCE AND EDUCATION

U. S. DEPARTMENT OF AGRICULTURE

BEFORE THE

SUBCOMMITTEE ON DEPARTMENT OPERATIONS AND NUTRITION

COMMITTEE ON AGRICULTURE

U. S. HOUSE OF REPRESENTATIVES

July 15, 1993

Mr. Chairman and Members of the Subcommittee, I'm pleased to be with you
today to discuss the Science and Education nutrition research and education activities
of the U.S. Department of Agriculture (USDA). Dr. Plowman sends his apologies for
not being here; he had a long-standing commitment out of the city. My statement
includes a discussion of some of the research and education activities of the
Agricultural Research Service (ARS), the Cooperative State Research Service (GSRS),
and the Extension Service (ES). Much more could be said about our nutrition
research programs than time allows this morning, Mr. Chairman, and with the
permission of the Subcommittee, I would like to file for the record more detailed
testimony from ARS and CSRS.

Food and nutrition programs are part of a larger context and relate to issues of
poverty, economics, health and the environment. Secretary Mike Espy has pledged to
work to integrate nutrition into the agriculture, health and welfare policies of the Clinton
Administration, and the USDA Science and Education agencies stand ready to support
him in this endeavor.

Poor nutrition is expensive-it increases overall health costs to individuals and to
society. It compromises a child's potential to grow into a strong, healthy adult. Along
the way, it affects a child's ability to concentrate and to learn in school. The saying is
"Everyone eats; unfortunately, everyone does not eat well." Some do not eat well
because they do not have the economic resources to do so. Others do not eat well
because they do not know what or how much is good for them to eat.

USDA's Science and Education agencies are developing and communicating
the information that helps produce more nutritious foods, that helps us understand
what constitutes an optimum diet, and that helps maintain our health.

The 1977 Farm Bill designated USDA as the lead agency for nutrition research
and education, but our commitment began long before 1977; this year marks the
centennial of USDA's involvement in nutrition research. USDA's mandate, from the
very beginning, has been to ensure that the people of this country have a safe and
adequate food supply. From the farm to the kitchen table, many decisions are made
that affect the quality and wholesomeness of our nation's food supply. And those
decisions are made based on the current knowledge and information drawn from
nutrition research and education. This is why the USDA Science and Education
agencies are directly involved in both nutrition research and nutrition education.
Neither of these components-research nor education-can stand alone. One gathers
necessary information for food producers, processors and consumers, while the other
aids in disseminating that information in sound, practical ways that empower
individuals and families to make wise, economical and healthy food choices.

-2

72-928 0-93-4

A safe and wholesome food supply begins back at the seed ~ breeding more
nutritious varieties of crops and developing more nutritious ways to produce, harvest
and process food. One of the first big projects at the ARS Plant, Soil and Nutrition
Research Lab in Ithaca, New York, was to study fertilizer's effect on the carotene
content of tomatoes. Carotene is a precursor to vitamin A, and tx)th carotene and
vitamin A have been linked to a reduced risk for some types of cancer. Today, an
ARS scientist is busy breeding a new tomato variety that coukJ easily have as much
vitamin A as a sweet potato, one of the highest dietary sources of vitamin A.

We are also learning predseiy what levels of what nutrients the body needs for
health. For example, at the ARS Human Nutrition Research Center on Aging, many
new findings suggest that even modest dietary changes may greatly improve the
health status of the eklerly. Researchers have found that vitamin E and other
antioxidants may enhance the immune system, improving the body's ability to combat
disease. Next time you watch a commercial for vitamins, notice just which vitamin
group currently is being highlighted.

ARS scientists also are working with medical scientists at Georgetown
University, Johns Hopkins University, the University of Maryland, and other institutions
to further study vitamin and mineral bioavailability from foods as well as their
interactions with different kinds of carisohydrate in the diet. The results of these
studies are important in defining ways to improve food composition by genetics and
processing to best meet peoples' needs.

The Human Nutrition Research Center in Grand Forks, North Dakota, is

particularly focused on mineral needs and they have done pioneering work on the
relationship of mineral needs to neurological and behavioral functions.

The Children's Nutrition Research Center (CNRC) in Houston, Texas,
associated with the Baylor College of Medicine, conducts studies of nutrient needs for
growth of normal and pre-term infants. The Center has equipment not available
anywhere else to monitor growth of organs, muscle, bones and fat during pregnancy
and of the infants and nursing mothers. Recently, the Center has begun a totally
unprecedented study of nutrient needs and growth processes of teenage mothers.

CSRS, through the nutrition, food quality and health program of the National
Research Initiative, is conducting a number of research projects with the objective of
developing a better understanding of nutrients and consumer behavior related to
nutrition. This research, carried out by the Nation's land-grant universities,
emphasizes: (1) bioavailability of nutrients; (2) the interrelationship of nutrients; (3)
nutrient requirements of healthy individuals across all age groups; (4) mechanisms
underlying the relationship between diet and health maintenance, such as the effect of
nutrients on the immune system; (5) the cellular and molecular mechanisms underlying
nutrient requirements, including the modulation of gene expression by nutrients; and
(6) food consumer behavior, including identifying and developing methods to
overcome obstacles to adopting healthy food habits, to convey knowledge to target
audiences, and to ascertain factors that affect food choices.

One very important research study currently underway looks at food behavior of
adolescents and young adults. Researchers working with adolescents showed that

while the teens were developing very strong opinions about food, nutrition, body
image and health, their parents still had a great deal of control over their food intake.
They then addressed what happens to teens when they enter the transitional years of
young adulthood (18-24 years). There is virtually no information about the effect of
nutrition and health concerns on food intake by this consumer group. Focus panel
research has shown that 18-24 year-olds feel quite pressed for time and are very
concerned about food costs. Fast food is their staple because it is fast, cheap,
familiar, and safe. At the same time, they worry about nutrition-mainly dietary fat,
cholesterol, salt and sugar, but also pesticides, additives, and other chemicals. The
next step in the project will be to determine the factors most influencing consumption
of specific food items, such as beef, cheese, and various fruits and vegetables. The
enhanced understanding of what motivates tine food choices of this age group will be
used by Extension and health professionals to develop appropriate and effective
programs.

Research, however, is only half the job; the other half is education. Information
is only useful when it has been communicated to those who put the information to
work. And the information must be communicated in practical and relevant terms for
the appropriate audience, including consumers, farmers, food processors, plant and
animal breeders, dieticians, health professionals, and all those who make decisions
about food and nutiition.

For example, several years ago, ARS scientists developed a natural fat
substitute called oabim, made from oats, that is rich in soluble fiber and can replace all

or part of the fats in many foods. Today just a few of the commercial products that
contain oatrim are bologna, hot dogs, Peachtree brand cookies, low-cal cheese, and
even many of the prepared dinners marketed under the trade name "Healthy Choice."

The Cooperative Extension System (CES), which links the USDA Extension
Service, 74 Land-Grant Universities, and 3,150 county administrative units, provides
nutrition, diet, and health education to a wide variety of audiences. The programs are
designed to provide people of all ages with the knowledge to make informed decisions
about what they eat. Objectives include helping people reduce the risk of chronic
disease, give birth to healthy babies, practice responsible and healthy self-care, help
children attain optimum long-term health, minimize nutritional inadequacies, and
improve consumers' ability to make informed choices related to food safety, quality
and composition.

One well known nutrition education program conducted by CES is the
Expanded Food and Nutrition Education Program (EFNEP). This intensive education
program is designed to help low-income families not only gain knowledge, but also
gain the skills and adopt the behaviors that lead to a healthier diet. These low-income
families often are at increased risk for developing nutrition and health-related
problems. We have found that families who complete this six-month program are able
to make significant improvements in their diets, while spending less money on food.
As food dollars stretch farther and diets improve, health risks for these low-income
families are reduced.

To improve the evaluation of EFNEP, ES has recently developed a new

evaluation/reporting system. The new system has the capability to identify how many
pregnant and nursing women are participating in EFNEP and what types of public
assistance they are receiving. It also allows us to analyze people's diets before and
after the program for their adherence to the USDA Food Guide Pyramid, for key
nutrients like protein, calcium and fiber, and for the percent of the calories in the diet
coming from protein, fat, and cartxihydrates. Training on the new system is
underway, and implementation will take place this fall.

ES and the Food and Nutrition Service (FNS) are collat^orating to develop
nutrition education programs that meet the special needs of WIC clientele-pregnant
women, nursing mothers, and children from birth to five years of age. The goals of
this initiative are to improve knowledge and tjehavior in areas such as food selection,
purchasing, storage, safety, and preparation and to improve breastfeeding and dietary
behaviors.

Another example of Extension's nutrition education progranis is one whk^h is
targeted specifically toward addressing the problems and needs of Native Americans.
Health arKl nutrition education programs on many reservations target Native American
youth and focus on a broader concept of wellness by combining health and nutritkxi
learning activities with physical exercise, including trit^al dance. Extension agents work
with youth, atong with their ekJers, to promote healthy lifestyles and to reduce chronic
diseases.

Perhaps one of the most important needs for nutrition education centers on
maternal and infant health. Even within the broad category of women and infants, we

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see one group of people about whom we are particularly concerned -- pregnant teens.
There are a host of reasons for this concern. Teens themselves are still growing and
learning to make independent decisions about the food they eat. Their own needs are
increased by the critical needs of their pregnancy. It is no wonder that teens are at a
very high risk of giving birth to babies below the healthy birthweight of 5.5 pounds.

In general, low birthweight is the greatest determinant of infant death and
disability, and poor nutrition is one of the major risk factors associated with low
birthweight. Low birthweight occurs in approximately 7% of all births. Medicaid pays
almost $19,000 per delivery of a low birthweight infant versus just $3,500 per delivery
of a normal weight infant. Thus, low birthweight costs the nation somewhere in the
range of $5 billion each year.

Mr. Chairman, I believe that you and Members of the Subcommittee may have
heard of the "Have a Healthy Baby" program in Indiana. Of the over 2,000 teens and
adults enrolled in this program, we have been able to collect data on about two-thirds,
or over 1 ,200 babies. The data revealed that, over a three-year period, 97.9% of the
babies were born normal weight and only 30 babies (2.4% compared to Indiana's
average of 6.6%) were born low birthweight. As a result, this Extension Service
program in Indiana prevented 52 low birthweight babies at a savings of $3.12 million in
neonatal intensive care. (That is 52 low birthweight babies x $2,000 per day x the
average stay of 30 days in a neonatal intensive care unit = $3.12 million.) To put this
in perspective, the total dollars spent on the program in the last three years has been
$156,000. In other words, for each dollar spent on the program, we save $20. That's

-8

100

a tremendous return on the investment in prenatal education. This program is
currently being replicated in over a half dozen other States.

"Have a Healthy Baby," however, is only one of a number of educational efforts
we have with pregnant and parenting teens. For the past eight years, the "Becoming
a Mother" program of North Carolina has demonstrated its impact on both babies and
mothers. Beginning as a home visitor program, teens are taught good eating patterns
to ensure appropriate weight gain leading to a healthy birth. Following delivery, the
young mothers become involved in a peer support group. Successful parenting is one
focus; another is encouraging the teens to remain in school. We feel that parenting
education is of importance equal to nutrition during pregnancy because our goal is to
prevent overall child abuse and neglect.

I would like to make special reference to working with these young mothers to
remain in school. High school graduation and post secondary education is one of the
most important indicators of future self-sufficiency. One of the concerns with teens
having babies is that they tend to not complete their education. By enrolling these
young women in this and similar programs that include support to remain in school,
we can turn this situation around so that they are not only able to be good, nurturing
parents, but they have a future for themselves, their new families, and the communities
in which they live.

Because maternal and infant health is of such vital interest to CES and because
educational programs rely on a strong research base, we have entered into a
collaboration with the ARS Children's Nutrition Research Center. The Extension Food

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101

and Nutrition Specialist with Purdue University, who developed the "Have a Healthy
Baby" program, has been wort<ing at CNRC since April of this year. Her purpose is to
link the scientific findings of CNRC with Extension faculty and staff throughout the
country. A request has been sent out electronically to each State Extension Service
asking them about their priority needs related to research in maternal and child health,
the kinds of materials which are needed and at what levels (e.g., specific language
and cultural content), and staff development and training needs. We plan to conduct
teleconferences and satellite conferences to address these needs. However, we
already have begun to share the knowledge of CNRC. For example, researchers
recently discovered that smoking alters the nutrient content in the milk of lactating
mothers. Information on the health consequences of smoking by lactating mothers
has been communicated to local Extension educators who, in turn, are incorporating
this information in news articles, broadcast items and teaching materials.

I will now to take a moment to discuss education for people who have low
educational levels or who may not be proficient in English. Extension believes that
there is more to enabling people to understand information than simplifying the written
word. Of course, we recognize the importance of written materials and use these
regularly, but we also use research information of different educational methodologies
to guide our decisions about programming. For instance, we operationalize the old
adage, "Give a man a fish and he'll eat for a day; teach him to fish and he'll eat
forever." Our EFNEP participants, for example, are building skills as they apply
principles of nutrition, food safety and money management in hands-on experience.

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102

We also are sensitive to cultural differences among people. In California, for
example, Extension has hired faculty who are both bilingual and bicultural to work with
the Hispanic population. In this way, we can develop materials that conform with the
cultural values and food habits of this important population.

In other instances, paraprofessionals are hired from the community to work with
people in their neighborhood. The best example of this is the EFNEP program. For
over 25 years, EFNEP program assistants have worked one-on-one and in small
groups to teach their neighbors. This methodology lends credibility to the information
being presented and increases the access of the people to the university.

Additionally, Extension uses community volunteers as teachers. The use of
volunteers as teachers is a great community development effort. The people own and
share the knowledge; it is not something that belongs to the 'experts.*

Hunger and undernutrition have been identified through our community-based
needs assessments in several States around the country. Ftorida and Montana have
worked on this issue through public policy education. In both States, Extension has
formed coalitions of public and private organizations in order to strengthen the safety
net for people in need.

Chronic disease prevention is another area where CES collatxirates with a host
of agencies, public and private-nonprofit. For example, Pennsylvania, New York and
Maryland and the States of South Carolina, Georgia and North Carolina have formed
two coalitions that have been funded by the National Institutes of Health (NIH) National
Cancer Institute for the development of cancer control coalitions.

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103

CES sees nutrition education as a holistic, comprehensive effort. We work to
understand the needs of people and create programs that will be effective in the
particular situation. This educational effort is coupled with many of the other nutrition
and nutrition education services available from USDA and other health serving
agencies and organizations. Additionally, USDA agencies which provide nutrition
research and education work collaboratively for greater program effectiveness and
impact. ARS, CSRS, ES, Food and Nutrition Service (FNS), and the Human and
Nutrition Information Service (HNIS) all participate in interagency groups. These
groups include the Dietary Guidance Working Group, the Human Nutrition
Coordinating Committee, and the Food Safety Task Force, which help ensure that
programs within USDA are coordinated and complementary and not duplicative.

The ES/HNIS Consulting Group provides feedback to ES and HNIS as nutrition
education materials are developed and through critiques of material as these are used
with various target audiences.

The Science and Education agencies also cooperate closely with other Federal
Departments. The Interagency Committee on Human Nutrition Research is chaired
jointly by USDA Assistant Secretary for Science and Education and the Assistant
Secretary for Health at the Department of Health and Human Services. This
Committee also includes the National Aeronautics and Space Administration, the
Agency for International Development, the Department of Commerce, the Defense
Department, Veterans Affairs and the Office of Science and Technology Policy.

There is also a great deal of collaboration with private industry. I mentioned

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104

oatrim earlier, which has already been licensed by ARS to three companies. Sales of
products containing this healthy substitute already top $1 billion in just over a year
since their introduction. Another example is Extension Service's involvement in a
coalition of government agencies, trade associations and private companies to put
together food labelling kits to help educate the public on how to read and understand
food labels.

Mr. Chairman, this concludes my statement. I would be pleased to answer any
questions which you and other Members of the Subcommittee may have.

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105

Testimony by

Dr. Buford L. Nichols, Jr., M.D.

Director Emeritus

Children's Nutrition Research Center

Submitted to the
Subcommittee on Department Operations and Nutrition

Committee on Agriculture

U.S. House of Representatives

The Honorable Charles W. Stenholm, Chairman

July 15, 1993

106

Dr. Buford L. Nichols, Jr., M.D.
IttJOR POIMTa

o The relationship between food and health is clear. Of
the ten leading causes of death in the United States, five —
heart disease, cancer, strokes, dietbetes, and atherosclerosis —
are attributeOsle at least in part to diet. These five diseases
accounted for 71% of all deaths in 1987.

o USDA's long-time mission is our food supply — its
production, processing, distribution, and consumption. This year
we celebrate the centennial of the USDA's involvement in human
nutrition research.

o The Children's Nutrition Research Center is providing the
foundation of basic research for applied prograuns such as WIC and
School Lunch as well as for general education efforts on
nutrition.

o He at the CNRC link agricultural production and food
processing together with medicine to make mothers and their
babies healthier. The CNRC's mission is to find ways in which
better food can produce healthier children today and healthier
adults tomorrow. These studies will also help the nation's
agricultural industry in producing and processing food products.

o The quality of our federal, state, and local assistance
prograuas could be vastly iiqproved by better coordinating the work
of the various agencies involved.

o The quality of the aid becomes paramount once the
quantity is there, and research is going to be the key factor in
determining what constitutes a quality package of food
assistance.

o The ARS human nutrition research centers are uniquely
well-suited to address these research problems. We must be able
to accurately translate research findings about nutrient needs
into practical recommendations about food needs for health.

o The production and consuiQ>tion of food and its
relationship to health has historically been a key part of the
mission of the Department of Agriculture. In this, the
centennial year of USDA human nutrition research, I believe that
it is time to reded icate ourselves to that effort.

107

Testimony by

Dr. Buford L, Nichols, Jr., M.D.

Director Emeritus

Children's Nutrition Research Center

Mr. Chairman and members of the Subcommittee, it is a
privilege to be asked to appear before you today. I am Dr.
Buford Nichols, and I have been Director Emeritus of the
Children's Nutrition Research Center (CNRC) for about two weeks
now. I served as Director of the CNRC from its founding in 1978
until this month, when I passed on my administrative duties so
that I can have more time to ^pend on research and giving advice
on nutrition issues.

I am proud to announce that my successor. Dr. Dennis Bier,
is here today. Dr. Bier is a very distinguished nutrition
researcher, a past president of the American Society for Clinical
Research, a member of the Institute of Medicine's Food and
Nutrition Board, and he chaired the expert panel for the National
Institute of Child Health and Development's Five- Year Plan on
nutrition research. He comes to us from Washington University in
St. Louis, where he was co-director of the Pediatric
Endocrinology and Metabolism Division and director of Mass
Spectrometry Resource and the Pediatric Clinical Research Center.

I compliment you, Mr. Chairman, for your most timely
interest in the topic of nutrition research and education.
Nutrition is the study of how food is related to health. I
believe that the relationship between food and health will
continue to grow in importance for at least two major reasons.

First, new scientific information is showing in more detail
the linkages between diet and diseases. Of the 10 leading causes
of death in the United States, five — heart disease, cancer,
strokes, diabetes, and atherosclerosis — are attributable to
diet. These five diseases accounted for 71% of all deaths in
1987.

Second, I believe that increasingly tight budgets will force
a reassessment of priorities and will cause an increased emphasis
on programs with a high rate of return. In the health arena
prevention programs, especially including nutrition programs,
have a very high rate of return on investment. The WIC program.

108

for example, has been estimated by the General Accounting Office
to save $3.50 for every dollar invested in providing WIC benefits
to pregnant women. Prevention is almost always cheaper than
treatment, and prevention of disease is the basic objective of
the study of nutrition.

08DA Leads in Human Nutrition

The U.S. Department of Agriculture has long been a leader in
the field of human nutrition. In fact, this year we celebrate
the centennial of the USDA's involvement in human nutrition
research. The fact that USDA has played the lead role in human
nutrition research is quite appropriate. USDA is concerned with
our food supply — its production, processing, distribution, and
consumption. The research work that we do at the Children's
Nutrition Research Center has the potential to impact all of
these. Research at the molecular level is opening up new vistas
of understanding in nutrition as in many other fields, but the
application of those research results for the benefit of people
requires that we keep sight of the fact that we produce and eat
food, not nutrients. We must be ahle to accurately translate
research findings about nutrient needs into practical
recommendations about food needs for healthy growth.

AR8 - Children's Nutrition Research Center

The Children's Nutrition Research Center is providing the
foundation of basic research for applied progreuns such as WIC and
School Lunch as well as for general education efforts on
nutrition. CNRC is the only USDA nutrition research center
dedicated to work on the food needs of mothers and of children
from pregnancy through adolescence. We link agricultural
production emd food processing with medicine to make mothers and
their beUaies healthier.

The CNRC is an Agricultural Research Service lab which is
operated by Baylor College of Medicine in cooperation with Texas
Children's Hospital. The CNRC is located in the Texas Medical
Center, which is the largest medical complex in the world.
Baylor College of Medicine has the largest pediatrics department
in the country, and Texas Children's Hospital is the largest

109

children's hospital in North America. The scope and depth of
expertise availetble within the Texas Medical Center is a singular
resource that allows very productive col leUaorat ions to be brought
to bear on complex research problems.

The CNRC is also unique in that, in addition to M.D. 's and
Ph.D. human nutrition specialists, we also have on staff several
swine nutrition scientists and a plant physiologist, who runs
what is probably the only greenhouse located in a major medical
center. We are also one of the world leaders in the technology
of stable (non-radioactive) isotopes, which with our other unique
facilities gives us the ability to do research that cannot be
done anywhere else.

Nutrition Education

Promoting a healthy lifestyle for children and their
feunilies is a natural outgrowth of our roles as advocates of good
nutrition. The primary function of the CNRC is research.
However, we also want our research to be used. That requires
making the step from information eQ>out nutrients to information
about foods, and then helping in the effective delivery of that
information to the target population.

Since its founding CNRC personnel have taught a course on
nutrition to medical students at Baylor College of Medicine, and
we also have people on staff who have long been active in
breastfeeding education work. In addition to working with other
research centers, both in and out of USOA, we have for many years
actively worked with Extension, WIC, Child Nutrition, and other
USDA progreuns to speed the application of the fruits of our work.
The CNRC played a major role in developing the information on
breastfeeding that the WIC progreun uses, and we have reviewed and
edited most of the other materials on food emd nutrition which
are used in the WIC program.

The Center has formed a Nutrition Information Committee to
increase awareness of scientific research conducted at the CNRC
by serving as sources for news releases, responding to media
calls and fielding questions from concerned parents across the
nation. This committee also serves as a scientific review board

for dietary information prepared for educators and the general
public by government and non-government agencies.

One of the best examples of research in infant nutrition
that has been appropriately and well communicated to consumers
concerns the benefits of breastfeeding. The effective
communication of research findings in this area is largely
responsible for the fact that at least 60-75% of infants (versus
a much smaller percentage two decades ago) are now breastfed for
at least a short period of time. Much of the research in this
area conducted at the Children's Nutrition Research Center has
been reported in Center newsletters that reach not only parents
in the local area but also Extension Specialists around the
country who, in turn, transmit these research findings directly
to consumers. In fact, the Extension Service has just placed a
National Program Leader for Infant and Maternal Health at the
CNRC in order to enhance the flow of information from CNRC
researchers to the people who most need that information. A more
recent research binding, which we are just transmitting through
this network, is the fact that both the quantity and quality of
milk production suffers significantly when nursing mothers smoke.

ARS Nutrition Research Results

The Agricultural Research Service, through the CNRC and the
other human nutrition research centers, is having a major impact
on human nutrition research. For example, in a recent book on
nutrition during lactation by the National Academy of Sciences,
about a third of the articles cited were by CNRC scientists. Let
me speak a little bit about the work that the CNRC is doing in
order to illustrate some of the fascinating and important things
that are going on in the field of nutrition research.

Stable Isotop* Researeb Links Agriculturs, Nutrition, and
Medicina

Radioactive isotopes have long been used in many types of
studies, but they cannot be used in studies of healthy infants.
We now have the ability to use natural substances labeled with
non-radioactive, or stable, isotopes. Stable isotopes can safely
be given to healthy infants. By taking breath, saliva, stool.

Ill

and other seunples we can measure very precisely what is going on
inside the body. The CMRC is a world leader in this technology.

In our Plant Physiology Unit we produce foods, not just
nutrients, which are uniformly leibeled with stable isotopes. We
can then feed these and follow them through the body, almost like
having a little video camera attached to each food molecule. We
can trace processes that no one had any idea were occurring, and
we can study a wide variety of nutrients and processes
simultaneously.

For exaunple, we grew spirulina algae in a chaunber with
carbon dioxide containing leUaeled carbon. All the carbon in the
resulting algae was thus labeled. Then we fed the algae to a
hen, which produced eggs containing labeled carbon. In the
process we discovered that all of one tutino acid, proline, in the
hen contained only laibeled carbon atoms, meaning that all the
proline came from the diet and none was made in the body. Thus,
we showed that proline is an essential nutrient for hens, meaning
that it is entirely absorbed from the diet. Despite the
intensity with irtiich poultry nutrition has been studied, that
fact was unlcnotni.

The fault was with the method, not the earlier poultry
researchers. Our knowledge of essential and non-essential
nutrients in all animals, including man, comes from deprivation
studies. However, body chemistry changes under starvation
conditions. It seems that hens can make proline if they have to,
but do not under normal conditions.

This same technology now allom us to study normal human
metabolic requirements without starving infants. For example, we
have grown soybeans «rtiich are labeled with stable isotopes and
are making them into infant formula for feeding studies.

How many other nutrients, in both humans and animals, have
we been leaving out of the dietary requirements because we
thought that they were normally produced in the body instead of
being absorbed from the diet? The CNRC now has the technology to
find out very precisely what the body does with the foods that we

112

eat, and the answers we are getting are often different from
established assumptions.

This is an excellent example of a nutrition research program
that is linking the agriculture and health communities. By
uniformly labelling foods rather than just specific nutrient
components, CNRC research has the potential to identify, in a
variety of foods, which nutrients influence human health, whether
favorably or unfavorably, and identify the cunounts of those
nutrients that are actually digestible. This information, in
turn, could result in marketable improvements in the nutritional
characteristics of these foods, either through agricultural
research or through the application of known technology to a
previously-unknown problem. The potential importance of our work
to production agriculture is indicated by the fact that we are
now receiving research support from the American Soybean
Association.

Caleluai R«quir«iiiants for Children

For example, we have fovind that current dietary
recommendations for calcium intake for girls from infancy through
puberty are inadequate for proper growth. In studies which have
major implications for osteoporosis prevention, CNRC has
discovered that calcium absorption and bone growth in girls is
significant at age 5-8, reaches a maximum at ages 8-13, and drops
off substantially at age 15-16, or two years after menarche
(first menstrual period). Current recommendations for age 1-10
are 800 milligrams per day of calcium (about 3 servings/day of
dairy products), increasing to 1200 mg/day for ages 11-24.

CNRC scientists believe that the recommended milk needs
should be Increased to reflect the fact that children need much
more calcium at much younger ages than previously thought. We
have also found that more than 85% of all girls over age 11 are
not getting even the currently-recommended amounts of calcium.

Dairy products supply about 2/3 of all dietary calcium, so
this research has obvious implications for USDA commodity
programs as well as for USDA feeding programs such as school

113

lunch, WIC, and Food Stamps. It also could have a major health
impact in reducing osteoporosis later in life.

Protain Requirements for Nursing Mothers

Our new technology is also playing a pivotal role in
changing the protein recommendations for nursing mothers. Our
work has shovm that nursing mothers need 33% more protein than
the current recommended amount. These results have been sent by
the Food and Nutrition Service to state nutritionists and may
well result in an increase in the amount of protein provided to
women in WIC progreuns.

We also have indications that recommendations for other
nutrients for nursing mothers may be too low as well.

Preaatur* Infants

The CNRC has made a major impact in improving the feeding of
premature infants. It costs edsout $1,000 per day to care for
premature beUaies — $2,000 if they are in intensive care. We are
getting many of these preemies out of the hospital up to 10 days
sooner by using new formulas and feeding strategies. CNRC has
shown that preemies do not zUssorb carbohydrate energy as well as
full-term infants, and we are also doing studies on differences
involving fats and other nutrients. We have also identified two
growth factors in human milk, and one of these has been licensed
for studies that may lead to its addition to baby formula. We
have shown that feeding colostrum to newborn piglets gives a 700%
increase in protein synthesis compared to those fed mature milk,
and this has helped lead to more efforts to use mother's milk in
the feeding of premature infants.

t—nm.qm Mothers

Our work on the nutrient needs of nursing mothers leads to a
very obvious and profound question: What about the nutrient
needs of teenage mothers? We know that teenage mothers tend to
have smaller babies. Low birthweight and poor gro%rth are
associated with increased blood pressure, chronic lung disease,
coronary disease, and diabetes later in life.

114

Teenage mothers are actually "children who are having
children." But we know very little about their nutritional
needs, about whether and how competition for food may occur
between the needs of a growing girl and the needs of a growing
fetus. We as a society have far too many teenage mothers, and we
have a particularly large concentration of them, divided among
many racial groups, in Houston. Although unfortunate for
society, it provides us with an excellent pool of research
subjects.

The pregnant teenager is very good example of a high-risk
population in which nutrition research is badly needed and in
which an effective education effort based on sound research could
pay a handsome dividend to society. It costs much less to have
healthy babies than it does to hospitalize premature infants. If
better nutrition can reduce the number of low birthweight babies,
then the health care savings from this research investment could
be enormous. CNRC is also working with the Extension Service to
address this national priority.

Metabolic Research Unit

Whether working with pregnant teenagers, adult women, or
children, much of our research relies on bringing in volunteers
into our Metabolic Research Unit, or MRU. In the MRU we can
closely monitor the amount and type of food they eat and the uses
to which those foods are put. However, we do not have the funds
to fully staff the MRU. We are the only USDA nutrition center
that does not have a fully functional MRU, and we badly need
that. The facilities are there, but we need additional staff to
fully operate them. Currently our hours of operation are limited
by the lack of staff to care for volunteers who have committed
themselves to these various studies.

Plant Physiology Unit

We also need to get our Plant Physiology Unit fully
operational. This unit is in essence a very high-tech
greenhouse. We have grown labeled rice, soybeans, and peas
hydroponically in small batches to prove our methods. We could
grow other food crops as well. However, we need additional funds

115

to grow larger quantities and to process them into formula and
food for our studies.

By using this unit to produce foods that are leUseled with
stable isotopes, we will be able to determine how a baby actually
uses real foods and how that bioavailability is impacted by
processing methods. Most nutrition studies focus on nutrients,
but farmers, food processors, and consumers are concerned with
food, not just nutrients. Bridging that gap between food and
nutrients is an important part of our work.

We are working closely with scientists, both with ARS and
universities, at other locations on a number of projects of
mutual interest. For example, stzUsle isotope technology allows
us to gather, as a byproduct of our need to grow food plants with
l2a>eled nutrients, some intriguing information on how and when
food plants grow and use nutrients. Because of the need to use
st2ible isotopes efficiently, we measure when fertilizer is used
to make leaves and when it is used to make soybeans, for example.
This has obvious implications for production agriculture.

Also, ARS rice researchers now have new information to
explore based on the CNRC's ability to grow rice hydroponically
at about twice the yield gotten in the field. Rice is one of
many crops where researchers have not established a theoretical
maximum yield. As with the MRU, the basic Plant Physiology Unit
facility is already in place but additional funds are needed to
fully staff and operate it.

Cholesterol

The CNRC cadre of multi-disciplinary efforts includes USDA
scientists who are working with specially-bred pigs. Among other
things, they are coming up with some intriguing findings on
cholesterol .

Cholesterol is absent from current infant formulas, but is
present in very high levels in mothers' milk. Now we have shown
that cholesterol is vital for brain development. Piglets from
low-cholesterol bloodlines become retarded on low-cholesterol
diets — you can actually pick them up without any fuss. As many

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of you know from experience, handling a normal piglet is more
like grabbing a live electrical wire.

While both human babies and piglets can apparently make
their own cholesterol, the pig results indicate that the genetic
potential may be present for problems among some humans. We also
think that dietary cholesterol in infancy may improve the body's
ability to handle cholesterol in adulthood. This work could lead
to major changes in infant formulas and recommendations for
dietary cholesterol early in life.

These pig experiments provide an important example of
nutrient-gene interrelationships because they demonstrate a
genetic increase in needs for dietary cholesterol. This
genetically-based individuality of food needs sets a priority for
future investigations on human and animal nutrient-gene
relationships. It raises a new question — will there be a time
in which we can target genetically-susceptible children for
specific dietary intervention?

Breastfeeding

The CNRC has been a leader in promoting breastfeeding for
many years. CNRC scientists have shown that the eunino acid
pattern in mother's milk is carefully tailored to the needs of
the infant at any given age, and that this is true in many
species besides humans. Infant formulas now in use seek to avoid
shortages of any amino acid by providing about twice as much
total protein as mother's milk. The baby must bum off the
excess amino acids, which is one reason why formula fed babies
have higher temperatures and heart rates, sweat more, etc. This
line of research could lead to foirmulas that are better tailored
to the age of the infant.

CNRC work has also proven that breast fed babies digest milk
sugars more efficiently than do formula fed infants, A baby
takes in about three times as much energy for its size as an
adult does. A baby's colon acts like the rumen of a cow in
fermenting and absorbing the extra sugar. This has implications
in diarrhea treatment, for example, since diarrhea prevents the
fermentation and sharply reduces the baby's energy intake.

117
11

Infant Fomulas

We are also working to improve infant formulas. Among other
things, we are exploring differences in energy metabolism between
breast- and formula-fed infants. Formula fed babies work harder,
have higher temperatures and heart rates, and have different
sleep patterns. We have already identified two growth factors in
human milk, and one of these has already been licensed for
studies that may lead to its addition to baby formula.

We are now working with Texas A&M University to make infant
formula from labeled soybeans grown at the CNRC. We are also
working with scientists at Cornell to put labeled nutrients into
the artery leading to a cow's udder. This should not only tell
us more about the cow's metabolism, but should also produce
labeled milk which we can then make into formula. These labeled
formulas can then be used in feeding studies to determine more
precisely how babies use these foods to grow.

Nutrition and Health

The CNRC's mission is to find ways to produce healthier
children today and healthier adults tomorrow. These studies will
also help the nation's agricultural industry to produce foods
more efficiently, to document the nutritional value of those
foods, and to tailor those foods as necessary to better meet the
needs of future generations. A natural outgrowth of successful
research is a move towards food and nutrition education, to share
that information with the public, and part of our effort at the
CNRC is dedicated to that purpose, although research is our
primary mission.

We are but a part of the food and nutrition progreuns within
the USDA. We believe that those programs are working. GAO has
estimated that WIC progrzun benefits provided to pregnant women
reduce the incidence of low birthweight beJsies by 25%, and that
they reduce by 44% the incidence of very low birthweight bzUaies
(3.3 pounds or less).

However, we can do a better job. Karen Konzelmann, who is
noted for her work with the "Have a Healthy Baby" program while

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with the Indiana Extension Service, tells of an farmer and county
commissioner who explains that preventing 5 low birthweight
infants will pay for his country extension budget for the entire
year. Ms. Konzelmann is now National Program Leader for Infant
and Maternal Health and has been placed at the CNRC by the
Extension Service to serve as a link between CNRC and extension
workers throughout the country. Programs like this illustrate
the fact that as penetration, or the ability of extension and
other programs to reach target populations, improves, then the
quality of the information and its delivery becomes relatively
more important.

Coordination and Quality in Government Programs

I believe that the effectiveness of our federal, state, and
local assistance programs could be vastly improved by better
coordinating the work of the various agencies involved. If ve
had a more client-oriented system where programs like WIC, EFNEP,
and Maternal Child Health Services and other federal, state, and
local assistance programs worked together closely and where
eligibility procedures were simplified and standardized then I
think that our results would be much improved. Feeding programs,
for example, can be conduits for needed information about food
and health and can also serve to reach more children with needed
immunizations. Both basic and c>pplied nutrition research should
be an integral part of that system, as seen be the fact that
research results just from the CNRC alone could well have a major
impact on basic food packages provided through programs such as
WIC. As I said before, the quality of the aid becomes paramount
once the quantity is there, and research is going to be the key
factor in determining what constitutes a quality package of food
assistance.

Human Nutrition Research Meeds

I believe that there is also a need for improvement in the
support of human nutrition work within the ARS. We are gaining
new knowledge and rapidly opening new areas for study, but the
research budgets for the ARS human nutrition centers have been
stagnant even though our costs are going up. The House again

119

provided only level funding for the ARS nutrition centers in the
FY 1994 agricultural appropriations bill.

As I mentioned earlier, there is a vast void in our
knowledge concerning the food needs of pregnant adolescents.
More research is also needed concerning the nutritional needs of
the fetus during development. The effects of what we eat on
brain and nervous system development and the development of the
gastrointestinal tract are virtually unexplored- Research also
is needed to identify the pediatric antecedents of adult
disease — e.g., do obesity, heart disease, and cancer have their
origins in childhood and should dietary interventions to reduce
the incidence of these deadly diseases start early in life?

Another pressing research need across all areas of nutrition
concerns the consequences of inadequate, inappropriate, or
excessive food intake. One of the drawbacks in effectively
educating people on what they need to eat is the inzibility to
answer obvious and logical questions concerning the consequences
of adapting or not adapting particular recommendations concerning
%rhat foods should be eaten and in what amounts.

The ARS human nutrition research centers are uniquely well-
suited to address these research problems. He are the only place
where such research is being conducted under a long-term
strategic plan. CNRC research is peer- reviewed, and thus is held
to the highest standards. He coiq>ete successfully for research
funds through peer-reviewed coiqwtitive processes such as at the
Mational Institutes of Health, and all CNRC research is also
overseen by an outside advisory board composed of top nutrition
researchers from around the world.

Ceaolvsiom

The production and consui^>tion of food and its relationship
to health has historically been a key part of the mission of the
Department of Agriculture. In this, the centennial year of USDA
human nutrition research, I believe that it is time to rededicate
ourselves to that effort.

120

Farmers and ranchers now more than ever know that they must
produce food that will meet the customer's needs. They have seen
their markets buffeted by the winds of public opinion, often
fanned by the musings of people who are heavy on opinions and
light on facts. The mission of USDA is to find facts and to use
them to help both producers and consumers of food.

Marketing is already recognized as an important part of that
mission, and I believe that the linkage between food and health
should and will play an even larger role in USDA's mission in the
years to come. The federal budget is not just a zero-sum game,
it is now a shrinking-sum game. If we place a higher priority on
USDA programs dealing with food and nutrition research and
delivery, then I believe that we will see substantial savings in
the medical portion of the federal budget. That will help both
our budget and our people.

We at the CNRC link agricultural production and food
processing together with medicine to make mothers and their
babies healthier. These healthy children will, in turn, have an
opportunity to contribute to the future of this country rather
than draining our medical and fiscal resources. We are proud to
take our place in that line of USDA researchers stretching back a
century, to the pioneering work of Attwater, and moving forward
into a better and healthier future for all our people.

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Dr. Buford L. Nichols, Jr., M.D.

Response to Written Questions

July 15, 1993

1. How inportant is nutrition in preventative health care today?

The recognition of the importance of nutrition to good
health is firmly established. Further, new scientific
information is showing in more detail the linkages between diet
and diseases. Of the 10 leading causes of death in the United
States, five — heart disease, cancer, strokes, diabetes, and
atherosclerosis — are attributable to diet. These five diseases
accounted for 71% of all deaths in 1987.

Prevention of disease is the basic objective of the study of
nutrition. Prevention is almost always cheaper than treatment.
Increasingly tight budgets and the debate over the cost of our
health care system may force an increased emphasis on prevention
programs instead of our current heavy reliance on acute care
programs. In the health arena prevention programs, especially
including nutrition programs, have a very high rate of return on
investment. The WIC program, for example, has been estimated by
the General Accounting Office to save $3.50 for every dollar
invested in providing WIC benefits to pregnant women.

2. Many individuals claim that aore applied research is needed
and less inquiries into fundamental science. Please describe how
some of the basic Betabolie research conducted at the CHRC
relates to consumers.

Basic research provides the foundation of information on
which applied research is conducted, as well as many of the tools
with which that applied research is conducted. The thesis behind
the question is that, somehow, going directly to applied research
will provide faster, cheaper answers. The truth is often quite
the opposite. Basic research provides the direction, i.e. shows
the way, that applied research should go. Without this
direction, applied research is often inefficient, incomplete, and
ineffective.

Many of our most significant gains from research have flowed
from breakthroughs in basic research. History has shown that
both basic and applied scientific research are needed, along with
education programs in order to make new discoveries and translate
them into a form that will benefit society. Basic research gives
us the tools with which to answer questions that are important to
the health of people throughout the world. Basic research done
at CNRC has produced a number of payoffs, such as the newly-
developed ability to accurately measure cholesterol synthesis,
and promises even more in the future.

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Cholesterol

Cholesterol synthesis in the body can now be accurately
measured using stable (non-radioactive) isotope technology which
was developed by CNRC scientists. This allows studies which were
impossible just a few years ago. For example, it has long been
known that people who consume soy protein instead of meat protein
have lower blood cholesterol levels, but we do not know why. The
American Soybean Association is helping to fund a study using
this new technology to find out whether this effect is from the
cholesterol in the diet or from some factor in soybeans that
changes the rate at which cholesterol is either synthesized or
broken down in the body.

In proving the effectiveness of the new methods to be used
in the study of soy and meat cholesterol, we have already found
that formula-fed babies manufacture over 3 times as much
cholesterol as do breast-fed babies, and that blood cholesterol
levels are significantly higher for breast-fed babies.
Cholesterol is absent from current infant formulas, but is
present in very high levels in mothers' milk.

We think that dietary cholesterol in infancy may improve the
body's ability to handle dietary cholesterol in adulthood, which
in turn impacts on diseases such as atherosclerosis. It may be
that a lack of dietary cholesterol causes formula-fed babies to
emphasize making cholesterol instead of controlling it, and that
this may lead to higher blood cholesterol later in life. This
theory has been developed from animal models, but could not be
tested in humans until CNRC scientists developed these new
methodologies using stable isotopes. We hope to do a study of
cholesterol synthesis in breast- and formula-fed infants over
time using this new technique. This work could lead to major
changes in infant formulas and recommendations for dietary
cholesterol early in life.

In the written testimony reference was made to our research
on pigs, where a lack of dietary cholesterol produced brain
damage in genetically low-cholesterol pigs. Although normal
pigs, like humans, can make cholesterol, these experiments
indicate that the genetic potential may be present for problems
among some humans. This example of genetically-based
individuality of food needs will lead to more such
investigations, and it also raises the possibility of targeting
genetically-susceptible children for specific dietary
inter-vent ion.

Protein Requirements in Sick Children

All over the world common illnesses, such as measles, often
contribute to malnutrition and more serious infections later on.
However, little is known about the nutrient needs of sick
children. CNRC is initiating a study in which the protein needs
of children will be measured before and after a routine measles

123

vaccination (which often causes a mild fever) in order to find
out whether they need nore or less protein when they are ill.
This will be done by feeding labeled protein and measuring the
iUDOunts excreted and exhaled. (Metabolized protein is calculated
by measuring the zunount of ledseled carbon dioxide in the breath) .

Caloiua Requirements for Girls

In the written testimony we summarized CNRC research showing
that girls need much more calcium, and at much yovmger ages, than
previously thought. He have also found that more than 85% of all
girls over age 11 are not getting even the currently-recommended
amounts of calcium. Dairy products supply about 2/3 of all
dietary calcium, so this research has obvious implications for
USDA commodity programs as well as for USDA feeding progr2UBS such
as school lunch, HIC, and Food Steunps. It also could have a
major health impact in reducing osteoporosis later in life.

Protein Requirements for Hurslng Mothers

Our new technology is also playing a pivotal role in
changing the protein recommendations for nursing mothers. Our
work has shown that nursing mothers need 33% more protein than
the current recommended amount. These results have been sent by
the Food and Nutrition Service to state nutritionists and may
well result in an increase in the auBOunt of protein provided to
women in WIC prograuu.

We also have indications that recommendations for other
nutrients for nursing mothers may be too low as well.

Premature Infants

The CNRC has made a major impact in improving the feeding of
premature infants. It costs about $1,000 per day to care for
premature babies — $2,000 if they are in intensive care. He are
getting many of these preemies out of the hospital up to 10 days
sooner by using new formulas and feeding strategies, such as
using mother's milk in the feeding of premature infants. This
subject was also mentioned in the testimony.

Teenage Pregnancies in Different Ethnic Groups

CNRC is conducting a ground-breaking study of adolescent
growth and nutrition in various ethnic groups. He feel that this
study will have major implications for such issues as adolescent
pregnancy. He know that teenaged mothers tend to have smaller
babies, and low birthweight babies are a particularly severe
problem among black teenagers. This study is examining
adolescents from four major ethnic groups to establish baseline
values for gro%fth and energy needs, with the objective of using
those for subsequent studies of adolescent pregnancies.

124

As mentioned in the testimony, we know very little about the
nutritional needs of pregnant adolescents, about whether and how
competition for food may occur between the needs of a growing
girl and the needs of a growing fetus. Low birthweight and poor
growth are associated with increased blood pressure, chronic lung
disease, coronary disease, and diabetes later in life.

Biological Effects of Human Milk Proteins

Stable isotope technology developed at the CNRC allow us to
look at processes which cannot be measured any other way, and
some very fundamental questions are being raised. For example,
some milk proteins in the diet are completely broken down during
digestion and then manufactured again as needed. This may well
indicate that the closely-regulated proteins are so important
that no flexibility can be allowed in the concentrations of those
substances maintained in the body. Only stable isotope
technology can accurately determine what happens to individual
molecules inside the body and so open this unique new window into
human metabolic processes.

We have also found that other proteins in mother's milk are
apparently absorbed and then excreted intact. If they are not
being metabolized, then they must serve some function other than
the basic building of tissue. We believe that some of these
proteins may play a role in triggering growth and development in
the baby's nervous, digestive, immune, and other systems.
Identifying the uses to which these proteins are put would allow
them to be synthesized and added to infant formula.

Infant Fomula

As discussed in the testimony, we have produced labeled
soybeans and as working with scientists at Cornell to produce
labeled milk which we can then make into formula. These labeled
formulas can then be used in feeding studies to determine more
precisely how babies use these foods to grow. Mother's milk, soy
formula, and cow's milk formula all have different compositions,
and understanding how the baby digests and uses each of these
should lead to improvements in feeding recommendations and in the
composition of infant formulas.

Breastfeeding

The CNRC has been a leader in promoting breastfeeding for
many years. As we learn more about breastfeeding, we also may
allow improvements to be made to infant formulas. For example,
we have a pending patent with regard to the use of lactoferrin,
which is a protein found in mothers' milk. Lactoferrin appears
to stimulate development of the infant's digestive system, and
may in part account for the fact that formula-fed babies do not
develop as fast and have more health problems in this area than
do breast-fed babies. This discovery is now being developed by a
commercial company as a possible addition to infant formula.

125

Infant formulas now in use seek to avoid shortages of any
amino acid by providing about twice as much total protein as
mother's milk. CNRC scientists have shown that the amino acid
pattern in mother's milk is carefully tailored to the needs of
the infant at any given age, and that this is true in many
species besides humans. This line of research could lead to
formulas that are better tailored to the age of the infant.

CNRC work has also proven that breast fed babies digest milk
sugars more efficiently than do formula fed infants. A baby
takes in about three times as much energy for its size as an
adult does. A baby's colon acts like the rumen of a cow in
fermenting and absorbing the extra sugar. This has implications
in diarrhea treatment, for exeunple, since diarrhea prevents the
fermentation and sharply reduces the baby's energy intake.

3. Explain how the presence of an Extension specialist at the
CNRC helps extend research results.

The Cooperative Extension Service (CES) is a nationwide
educational network that links research, science, and technology
to the needs of people where they live and work. Extension's
purpose is practical education for dealing with issues critical
to the nation's future. Extension education combines the
expertise and resources of federal, state, and local governments.
CES has the reputation of being a reliable and impartial source
of research-based educational and information programming.

CES has several specific advantages related to disseminating
nutrition research. They are known for communicating in lay
language and presenting nutrition information in the practical
context of "real food," and they have the ability to
electronically distribute information to all 50 states and to
U.S. territories. In other words, they are a key part of the
interface which translates scientific research information into
language that the public can understand and assimilate.

A veteran Extension educator with extensive experience in
reaching and teaching pregnant adolescents and adults was
selected and located at the CNRC in the Texas Hedical Center.
She has begun establishing contacts and relationships with
scientists and educators within the medical and research
communities. Linkage are also being formed with other Federal
agencies, universities, and organizations which focus on issues
related to maternal and child health. An education and research
Needs Assessment is being conducted of all 50 States and
territories with an emphasis on issues involving culturally
diverse and limited resource populations.

Careful study of the results of the Needs Assessment will
provide a specific focus for CES to use in addressing issues
across the country. CES believes that these results could help
them in the development of educational materials to meet

72-928 0-93-5

126

coBBunity needs, as well as the targeting of specific groups.
Other significant outcomes would be identifying staff development
and training needs for those who teach in local comnunities -
both rural and urban. Additionally, feedback from Extension
locations could help CNRC in identifying future research needs.

In summary, we believe that this relationship with the
Extension Sezrvice offers a way to speed the dissemination and use
of CNRC research to improve the health of U.S. mothers and babies
and to provide savings of health care dollars spent on and by
American families.

4. What shovld be the relationship between nutrition research and
extension in a reorganised U80A7

This is a difficult question to answer without knowing the
details of the re-organization plan. We do know, however, that
the CNRC will continue with its fundamental research mission.
We also want our research to be used, so we will also work to
transmit that information to health care professionals, members
of the media, and the public at large. That requires making the
step from information about nutrients to information 2d>out foods,
and then helping in the effective delivery of that information to
the target population through all available means. We will
continue to use the very helpful services of the Baylor College
of Medicine Public Affairs Office in this effort as well as the
Extension Service, other USDA agencies, and other means which may
become available.

Research centers such as the CNRC exist in order to produce
information that c<m be used to help improve the well-being of
our citizens. The Extension Service was created in order to get
needed information to the end user as quickly and effectively as
possible. Since both CNRC and Extension play a role in
nutrition, we would hope that CNRC could work closely with the
Extension Service. Similarly, we at the CNRC want to work
closely with and provide assistance to other nutrition-related
programs within USDA and within other government agencies.

5. What is the single greatest need to improve nutrition
research and education in the futture?

The greatest needs is funding of faculty training and
development in both medical and graduate schools. A long-term
commitment to research funding in the area of nutrition is
necessary in order to attract well-qualified students into
nutrition as a career. An increased emphasis on nutrition
education as part of the basic education of medical
professionals, including but not limited to doctors, is also
needed.

127

TESTIMONY

IRWIN H. ROSENBERG, M.D.

PROFESSOR OF MEDICINE AND NUTRITION

AND
DIRECTOR, USDA HUMAN NUTRITION RESEARCH CENTER ON AGING

TUFTS UNIVERSITY
BOSTON, MA

PRESENTED TO

SUBCOMMITTEE ON DEPARTMENT OPERATIONS & NUTRITION

COMMITTEE ON AGRICULTURE

U.S. HOUSE OF REPRESENTATIVES

JULY 15, 1992

128

Mr. Chalnum:

My naae is Dr. Irwin Rosenberg, and I an a Professor of
Medicine and Nutrition and Director of the U.S.D.A. Hxman
Nutrition Research Center on Aging at Tufts University in Boston.
I want to thank you for this opportunity to testify. In the IS
years since Congress first appropriated funds to the Department
of Agriculture to establish this center, we have been studying
the nutritional needs of the elderly and the dietary requirements
for maintaining health and preventing disability and disease of
our aging population. At the beginning of this century, 1 in 25
Americans was over the age of 65, and early in the next century,
1 in 5 Americans will be 65 or over. Older Americans are the
fastest growing segment of our population, and they are the ones
«^o are at the highest risk for degenerative conditions of the
vascular system, central nervous system, the eyes and pther
sensory organs, the immune system, and the muscular skeletal
systems that can lead to loss of function to disability and to
the loss of independence and quality of life so important to our
older years. On the other hand, the maintenance of these
functions can result in a vigorous, independent and enriching
mature segment of our lives.

The maintenance of vigorous function and activity throughout
the adult years and into the elderly years depends upon many
factors including our genetic heritage, but to a very great
extent on our life-style, especially with respect to nutrition
and related physical activity. Our research in the recent past
has addressed the way in which proper diet and nutritional
practices throughout the adult life span, but particularly in the
middle and older years, will maintain health and prevent disease
and degenerative conditions.

We continue to seek ways of assessing the nutritional and
health status of older Americans, who, like infants and children
at the other end of the spectrum of life, are at increased risk
of under-nutrition and malnutrition, but in this case because of
their changing physiological status of elders and for social
factors as well.

Our research focuses not only on the needs of older
Americans but on older Americans themselves. Thousands have
participated in our studies over the past decade, and they have
been some of the best agents for educating their peers about the
importance of proper nutrition and the maintenance of health in
the elder years.

Dietary ReqaireaMits for Celoiva mad Vitaslm D

We have conducted studies in Aaarican women before and
beyond menopause to study the specific relationships among
dietary factors and physical activity in the maintenance of a
strong skeleton that will be resistant to fracture and
compression. Osteoporosis seriously affects more than 1.3

129

million American women at an expense of $10 billion in health
care costs. Our studies have shown that after those first few
crucial years beyond menopause, meeting dietary needs for calcium
is critical for the prevention of loss of calcium from the
skeleton, particularly in that third of older women who have the
lowest intakes. Equally important is the research that shows
that we must meet our requirements for vitamin D in that same
population if we are to prevent bone loss since this population
has special requirements imposed by declining ability to make
vitamin D in the skin in the presence of sunlight and some loss
of sensitivity to the actions of the vitamin that controls the
absorption and utilization of calcium from our diets. Our
investigators have also documented the importance of physical
activity to stimulate the skeleton for maintenance of body
calcivim and also to maintain the strength and function of our
muscles that are so important for balance in the prevention of
falls that lead to fracture and disability.

Fats and Oils and cardiovascular Health

We have worked to define the healthiest mix of dietary fats
which influence blood cholesterol and related lipids and the risk
of degenerative conditions of the cardiovascular system. Our
scientists have been instrumental in the setting of national
guidelines for the prevention of heart disease under the National
Cholesterol Education Program. Heart disease, as you know, is
our number one cause of death and medical expenses have been
estimated as $65 billion per year.

Physical Activity and Muscle Strength

We have also studied the interaction of nutrition and
specific forms of exercise, and have developed programs that are
effective in helping older adults maintain their lean muscle and
associated physical strength and mobility. These same exercise
programs can greatly diminish the risk of late-life onset of
diabetes as well as cardiovascular disease and at the same time
foster a vigorous lifestyle that maintains independence with less
need for long-term care.

Vitamins and Inmun* Function

We have identified and characterized the role of several
nutrients in our diets, including vitamin B6, vitamin E, and zinc
for maintaining a sturdy immune system in older adults. Dietary
prevention of the declining function of our immune system with
aging could help reduce the risk of infectious disease and even
that of cancer.

130

Vutritieaal Cataraota

W« hava found an association between several dietary
factors, especially the antioxidant nutrients, vitamin C, vitaain
E, and beta carotene, and reduced risk of cataract, a condition
that accounts for more operations in the elderly than any other
at a cost of $4 billion annually as well as a great degree of
loss of function and quality of life.

MutritioB and Mental Fuaetioa

No condition is aore devastating to the quality of life of
the older Anerican and that of his or her own family than the
loss of cognitive function, mental alertness and memory. While
many conditions contribute to the loss of cognitive function in
some of our older population, our research causes us to emphasize
the iiq>ortance of nutritional factors including dietary vitamins
for the maintenance of healthy central nervous system functions,
especially in the elderly. We have found that as many as 25% of
older Americans may be at risk of certain vitamin deficiencies
including vitamin B12, because of changing absorptive and
physiologic functions with age. Vitamin B12, vitamin B6. and
folate in the diet in adequate amounts can prevent, and at times
reverse, some of the cognitive and neurologic i^;>airaent seen in
some older Americans. Even more iiqportantly, maintenance of
dietary adequacy with these and related nutrients could prevent
some disabling conditions affecting mental function.

rn— iin Ins tlag to Oldar Amarieaas

These and related research findings showing that healthy
choices from the abundance of food grown on our farms can
contribute to the prevention of disability and specific forms of
under-nutrition and thereby to the maintananca of vigorous oldar
years, hava bean cwsmunicated to the public in many ways. By
interacting with other federally-sponsored programs that study
and track the behavior of oldar Americans, wa can determine that
soma of these massages are affecting behavior in the direction of
better nutrition and health. The work described above, published
in scientific journals and books, has been widely quoted in the
public press and also disseminated through the publication and
education efforts of the Department of Agriculture. Hundreds of
newspaper and magazine articles in the past year alone have
described these research accomplishments and some of the positive
effects of proper nutrition and exercise have been the focua of
network televiaion programs over a dozen times in the paat year.
We have used the Tufts Diet and Nutrition Letter, with hundreds
of thousands of subscribers, to disseminate the poaitiva results
of nutrition research to the country at large, and we have uaed
our publicationa and networking through our own research
volunteers and their organizations for the distribution of
information about the benef ita of proper nutrition and physical
activity.

131

In conclusion, the research at the USDA Human Nutrition
Research Center on Aging at Tufts University can be looked upon
as an example of a very productive and fruitful association
between government and the private sector since our research and
its dissemination to the public depend critically on the
utilization of resources and expertise at both the government and
university level.

Research and education programs in nutrition need our
highest national priority if we are to prevent disability and
maintain productivity. I believe that it is possible over the
next decade that our investment in proper nutrition and physical
exercise among our aging population will fundamentally altei: our
concepts and costs of health and health care. We must not miss
that opportunity. To invest properly in human nutrition and
health, we need more precise information on what our elders are
eating in different situations and locations. We need to assess
the impact of our feeding programs on health and function. I«e
need to know a great deal more about the relationship between
dietary factors and the maintenance of cognitive function and
prevention of dementia and cerebrovascular disease. We need to
examine our techniques for introducing this information into
medical practice so that diet and nutrition become an integral
part of health care and health maintenance.

(Attachment follows!)

132

U.S. House of Representatives

Committee on Agriculture

Subcommittee on Department Operations and Nutrition

APPENDIX II

Testimony Of:
IRWIN H. ROSENBERG, M.D., DIRECTOR

UNITED STATES DEPARTMENT OF AGRICULTURE

HUMAN NUTRITION RESEARCH CENTER ON AGING

TUFTS UNIVERSITY

Jvdy 13, 1993

FY1993 SELECTED
RESEARCH ACCOMPLISHMENTS

133

• Vitamin E supplements restored impaired acute phase immune responses
and reduced signs of oxidative damage following an intense bout of eccentric
exercise in healthy but sedentary older men.

• Beta-carotene supplementation improved the antioxidant capacity of plasma
in healthy older women and decreased the susceptibility of phospholipids to
oxidative modification.

• Vitamin E supplementation in healthy young and older adults decreased
plasma lipid peroxide concentration and increased cellular immune responses
assessed by delayed-type hypersensitivity skin tests.

• The ratio of carbon to oxygen was determined to be an effective measure of
body fatness that is not sensitive to hydration of lean body mass. This new method
created a valid and precise measure of body composition in aging and illness.

• The immune system was found to directly affect resting energy expenditure
and thus ultimately affect body composition.

• Knee height was demonstrated to be a valid and accurate method and a
practical alternative index to height when comparing the body composition of
individuals and populations.

• In adults with chronic inflammation, progressive resistance exercise was
foimd to lead to an increase in lean body cell mass as well as improvements in
strength and functional status.

• The active metabolite of vitamin D, 1,25-dihydroxy vitamin D, stimulates
calcium absorption and has direct favorable effects on bone whereas parathyroid
hormone (PTH) promotes bone loss.

• Women who walked seven miles or more per week had higher bone density
in the legs, trunk, and whole body than those who walked less than one mile per

134

week. Walking at least one mile per day appears to be an effective means of
reducing bone loss.

• A new approach was defined for establishing vitamin D requirements
through the observed relationship between vitamin D intake and serum
concentrations of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH).
In a double-blind trial in women with adequate calcium intakes, a 400 lU vitaunin D
supplement retarded bone loss in the winter and provided an overall benefit at the
spine.

• Body composition was found to change with season. In the summer/fall,
lean and bone tissue mass increase and fat decreases in the arms, legs, tnmk, and
whole body. In the winter/spring these changes reverse. Overall, there is a loss of
lean tissue mass in the legs and an increase in fat tissue mass in the trunk.

• In healthy postmenopausal women, weight was found to be inversely related
to rate of bone loss from the spine in those up to but not beyond 106% of ideal body
weight. This finding suggests that thinness is a risk factor for osteoporosis, rather
than that obesity protects against bone loss.

• In healthy late postmenopausal women, current smokers were foimd to have
accelerated rates of bone loss from the radius, with similar trends at the spine and
hip. Smokers had a lower mean level of serum calcium and lower mean fractioiud
calcium absorption than nonsmokers. Thus, the adverse effects of smoking on bone
health are not limited to the young adult population.

• Clinical investigations indicate that the current RDA for energy substantially
imderestimates the usual energy needs of healthy elderly as well as young adult
men.

135

• Energy regulation following underfeeding was found to occur primary by
adaptive variations in energy intake rather than expenditure.

• Data from three population samples demonstrated positive correlations
between plasma vitamin C and HDL cholesterol levels independent of other
determinants of HDL cholesterol such as sex, body mass index, and smoking.
Further, blood pressure decreased with increasing plasma vitamin C levels.
Vitamin C levels in the human lens and aqueous humor was dramatically
increased by vitannin C supplementation.

• Excentric cleavage mechanism of beta-carotene was found to exist in the
intestines of humans, monkeys, ferrets and rats. The same enzyme thai primarily
cleaves the central double bond of the beta-carotene molecule also cleaves the
molecule at several other double bonds resulting in the formation of a mixture of
products.

• An increased number of bacteria in the stomach and upper small intestine
was found to cause poor absorption of food-bound vitamin B12. Killing or reducing
the number of bacteria in the stomach and upper intestine normalizes the poor
absorption of food bound vitamin B12.

• The localization of carbohydrate responsiveness of lipogenic gene expression
to periportal hepatocytes using in situ hybridization has been accomplished.

• Hepatocytes damaged by hypoxic injury have been fovmd to be replaced by
cells regenerating from the midlobular region of the liver.

• A system for developing cataracts was established using hyperbaric oxygen or
hyperoxia exposure of guinea pigs. Preliminary data indicate that animals with low
ascorbate status are more subject to cataract formation induced by oxygen exposure.

• A rat was developed and bred which requires ascorbate.

136

• A clear definition of normal ranges of LDL particle sizes has been developed,
and documentation provided that LDL particle size can be altered by changes in
triglyceride levels and that LDL particle size is not an independent coronary heart
disease (CHD) risk factor.

• A clear definition has been developed for familial lipoprotein disorders
associated with premature CHD and documentation of their prevalence in CHD
patients provided. These familial disorders include: [al Lp(a) excess, [b] dyslipidemia
(low HDL cholesterol, high triglycerides), [c] combined hyperlipidemia (elevated
LDL and triglycerides), [d] hypoapobetalipoproteinemia (elevated apoB), [e]
hypoalphalipo-proteinemia (low HDL), and [f] hypercholesterolemia.

• The significance of lowering of LDL cholesterol and raising of HDL
cholesterol in post-menopausal women with estrogen replacement therapy has
been demonstrated.

• Hydrogenation has been found to decrease the hypolipidemic effect of com oil
relative to saturated fat.

• Hypochlorhydria, a frequent condition in the elderly population, has been
found not to lead to an impairment of mineral absorption as previously proposed.

• Long-term (6 months) feeding of diets low in fat and cholesterol and enriched
in (n-3) PUFA decreased production of IL-6, TNF, granulocyte-monocyte colony
stimulating factor, lymphocyte proliferation and the delayed hypersensitivity skin
reaction. These effects were not observed when essentially the same diet [but low in
fish-derived (n-3) PUFA] was fed for 6 months.

• Vitamin E deficiency caused by malabsorption in a patient decreased IL-2
production, lymphocyte proliferation and delayed hypersensitivity skin test All of
these parameters were improved following vitamin E repletion.

137

Statement of

Catherine E. Woteki, Ph.D., R.D.

Director of the Food and Nutrition Board

Institute of Medicine/National Academy of Sciences

Good morning, Mr. Chairman and members of the Committee. I am Director of the
Food and Nutrition Board, a division of the Institute of Medicine of the National
Academy of Sciences. The Food and Nutrition Board (FNB) was established in 1940 to
address issues of national importance that pertain to the safety and adequacy of the
nation's food supply. In its fifty years of existence, the Board has examined the science
and made recommendations to improve food quality and safety, thereby contributing to
improving public health and preventing diet-related diseases. As the country's health
profile and status have changed, the emphasis of the Board's activities has shifted in
recent years fi^om concern primarily about nutritional deficiencies to excesses or
imbalances in food components and their effects on health. The Board has become
increasingly concerned with the translation of available scientific knowledge of food
composition and human nutrition to the improvement of public health.

In my testimony, I will draw upon studies conducted by the Food and Nutrition
Board to focus on four of the questions posed by the committee:

• What are some examples of recent nutrition research that has been
appropriately and well communicated to consumers?

• What nutrition research is currently being done in "at risk" population
groups and how are the results of this research being communicated to the
appropriate populations of consumers?

• What level of nutrition expertise is found among medical personnel and
how can it be improved?

• What are the priority needs in nutrition education and research today?

The twentieth century has witnessed noticeable shifts in the direction of nutrition
programs, policy, and research in industrialized nations-from identification and
prevention of nutrient deficiency diseases in the first three decades of the century to
refinement and application of knowledge of nutrient requirements in the subsequent two
decades. In the second half of the century, emphasis on nutrient deficiency diseases
decreased as the major causes of mortality shifted from infectious to chronic diseases.
Attention then turned to investigating the role of diet in the maintenance of health and
the reduction of the risk of such chronic diseases as heart disease and cancer.
Subsequently, epidemiologic, clinical, and laboratory research demonstrated that diet is
one of the many important factors involved in the etiology of these diseases. During the
past few decades, scientists have been faced with the challenge of identifying dietary
factors that influence specific diseases and defining the mechanisms by which they
contribute to disease. Simultaneously, public health policymakers, the food industry,
consumer groups, and others have been debating how much and what kind of evidence
justifies giving dietary advice to the public and how best to mitigate risk factors on which
there is general agreement among scientists.

138

Communication with the Public

The federal government has made recommendations for improving the American
people's diet for almost a century. Early dietary guidance was directed mainly at the
avoidance of deficiency diseases, with little attention given to reducing the risk of chronic
conditions other than obesity. However, there have been substantial advances in the past
25 years in understanding the relation of diet to health. Consensus has developed about
the role of diet in the cause and prevention of chronic diseases. The Food and Nutrition
Board's report Diet and Health: Implications for Reducing Chronic Disease Risk and the
Surgeon General's Report on Nutrition and Health reached similar conclusions about
dietary modifications needed to reduce the risk of diet-related chronic diseases.

In 1991, a Food and Nutrition Board committee reached the conclusion that the
main challenge no longer is to determine what eating patterns to recommend to the
pubb'c (although, admittedly, there is more to be learned), but how to inform and
encourage the population to eat to improve its chance for a healthier life. The
committee's report Improving America's Diet and Health: From Recommendations to
Action concludes that simply issuing and disseminating reconmiendations is insufficient to
produce change in most people's eating behaviors.

Although federal and state programs exist to implement the government's Dietary
Guidelines, and the private sector produces and publicizes food producu to help people
meet the recommendations, there is a clear need for comprehensive and coordinated
actions to improve America's diet and health. This goal will be met in the following
ways:

• enhancing awareness, understanding, and acceptance of dietary
recommendations;

• creating legislative, regulatory, commercial, and educational environments
supportive of the recommendations; and

• improving the avaflability of foods and meals that £acilitate implementation
of the recommendations.

The genera] tactics for increasing the prevalence of healthful eating patterns are
limited. We can alter the food supply by subtraction (e.g., reducing the fat in meat and
cheese), addition (e.g., appropriate fortification of foods with nutrients), and substitution
(e.g., replacing some of the fax in margarine with water). We can alter the food
acquisition enviroimient by providing more food choices that help consumers meet
dietary recommendations, better information (e.g., more complete and interpretable
product labeling), advice at points of purchase (e.g., tags indicating a good nutrition buy
in supermarkets or cafeterias), and more options for selecting healthful diets (e.g., better
food choices in vending machines and restaurants). Lastly, we can alter nutrition

139

education by changing the message mix (e.g., presenting consistent messages in education
programs, advertisements for products, and public service announcements) and by
broadening exposure to formal and nonformal nutrition education (e.g., mandating
education on dietary recommendations from kindergarten through grade 12, in health-
care facilities, and in medical schools).

Desirable dietary changes will most likely occur when all these tactics are
undertaken in complementary, mutually reinforcing ways. However, there is insufficient
research on their individual effectiveness or how best to employ them. The report makes
recommendations to government, the private sector, health-care professionals, and
educators as to how to implement the dietary recommendations, and on the research
needed to establish a better base for designing cost-effective, efficient, and effective
implementation strategies. I have appended a copy of the report's summary to my
testimony.

Research in At-Risk Populations

In the last four years, the FNB has published three reports that review the
scientific evidence concerning the role of diet in health. They recommend research for
four areas in which subgroups of the population may be at risk of ill health. The four
research areas are:

• gender and ethnic differences in nutritional status,

• gender and ethnic differences in nutrition as related to chronic
disease,

• nutritional needs during pregnancy, and

• nutritional needs during lactation.

In recent decades, scientists have identified many dietary factors that influence the
incidence and course of specific chronic diseases and have attempted to define the
pathophysiological mechanisms. The Committee on Diet and Health, assembled by the
Food and Nutrition Board in 1984, undertook a comprehensive analysis of the scientific
literature on diet and the spectrum of major chronic diseases and assessed the strength of
the evidence on associations of diet with health. In its report. Diet and Heahh. the
Committee concluded that diet influences the risk of several chronic diseases:
C'.therosclerotic cardiovascular diseases, hypertension, certain forms of cancer (especially
cancers of the esophagus, stomach, large bowel, breast, lung, and prostate), dental caries,
chronic liver disease, and a positive energy balance produces obesity and increases the
risk of noninsulin dependent diabetes mellitus.

A key question is to what extent gender and ethnicity interacting with other
genetic traits and environmental factors including diet affect health. Most chronic
diseases whose etiology and pathogenesis are influenced by nutritional factors have

140

genetic determinants. Hypertension, obesity, hyperlipidemia, atherosclerosis, and various
cancers appear to aggregate in families and also occur in greater proportions in males or
females. For example, coronary heart disease (CHD) death rates in men are three times
greater than in women in such high-incidence countries as the United States, the United
Kingdom, northern European countries, New Zealand, and Australia. These sex
differences are small after women pass menopause and in such low-CHD-incidence
countries as France and Japan. In countries where CHD deaths have declined,
proportional declines have generally been steeper among women than among men.

The Committee on Diet and Health identified seven categories of research that,
when taken together, reflect a conceptual framework for interdisciplinary collaborative
research that encompasses diK^erent kinds of investigations. The range includes short-
and long-term experiments in vitro and in vivo, food consumption surveys, food
composition analyses, descriptive and analytical epidemiologic studies, metabolic studies
and clinical trials in humans, and social and behavioral research. The specific research
recommendations are elaborated on in the report. Briefly, the seven categories of
research are:

• Identification of foods and dietary components that alter the risk of chronic
diseases and elucidation of their mechanisms of action

• Improvement of the methodology for collecting and assessing data on the
exposure of humans to foods and dietary constituents that may alter the
risk of chronic diseases

• Identification of markers of exposure and early indicators of the risk of
various chronic diseases

• Quantification of the adverse and beneficial effects of diet and
determination of the optimal ranges of intake of dietary macro- and
microconstituents that affect the risk of chronic diseases

• Through intervention studies, assessment of the potential for chronic
disease risk reduction

• Application of knowledge about diet and chronic diseases to public health
programs

• Expansion of basic research in molecular and cellular nutrition.

In 1987, the FNB established the Committee on Nutritional Status During
Pregnancy and Lactation to conduct a detailed assessment of knowledge of maternal
nutrition and how recent findings should be applied in perinatal care. The Committee's
review of the literature and recommendations are contained in two reports: Nutrition

141

During Pregnancy: Weight Gain and Nutrient Supplements, and Nutrition During
Lactation.

In both reports, the Committee found few well-designed studies and little scientiGc
evidence regarding many important issues. Most of the emphasis in the literature focuses
on the needs of the fetus and infant. Relatively little attention has been given to the
mother and her needs. Virtually none is given to women later in life or women's
nutritional health aside from childbearing functions.

The Committee reviewed the evidence concerning the effects of gestational weight
gain on short-term fetal, infant, and maternal health outcomes, as well as maternal
fectors that could modify those effects. The Committee focused on the links between
gestational weight gain and short-term pregnancy outcomes because data relating weight
gain to long-term outcomes are relatively scanfy, and there is no strong evidence
indicating that weight gain affects long-term outcomes directly without first affecting
shorter-term outcomes. The Committee considered gestational weight gain as an
etiologic determinant, i.e., a cause, of these maternal and child outcomes. The
Committee identified many gaps in our knowledge of how maternal health is affected by
weight gain during pregnancy.

The Committee found that most studies of human lactation have focused on the
qualify and quantify of milk produced or on the effects of human milk on infants. Far
fewer studies have targeted the effects of lactation on short- or long-term maternal
health. The Committee found no studies that evaluated the effects of maternal nutrition
on long-term outcomes related to lactation. From a nutritional standpoint, the stress on
the mother during lactation is substantial relative to the nutritional needs Imposed by
pregnancy (a condition that has attracted much more attention). The breastfed infant
doubles its weight in the first 4 to 6 months after birth and has additional energy
demands beyond the gains in energy stores associated with growth. The metabolic
adjustments that redirect nutrient use from maternal needs to milk synthesis and
secretion involve nearly every maternal organ system. The Conmiittee identified several
high priorities for research.

Nutrition in Medical Education

In 1985, the FNB issued a report entitled Nutrition Education in U.S. Medical
Schools. The report's major conclusion was that nutrition education programs in U.S.
medicfd schools are largely inadequate to meet the present and future demands of the
medical profession. It recommended that medical schools and their accreditation bodies,
federal agencies, private foundations, and the scientific communify make a concerted
effort to upgrade the nutrition curriculum. The committee recognized that extraordinary
demands are placed on the medical education system, but, nevertheless, concluded that
the reconmiended curriculum changes could be accomplished with minimal disruption.

142

Unfortunately, we cannot point to any changes in the teaching of nutrition in
medical schools that can be attributed to the report's recommendations. A recently
conducted survey by the American Society for Clinical Nutrition documents that there
has been an erosion in the number of hours devoted to nutrition topics in medical
schools.

Priority Needs in Nutrition Research

The Food and Nutrition Board is currently conducting a study of research
opportunities in the nutrition and food sciences. The study is jointly supported by the
Department of Agriculture, the Department of Health and Human Services, and the Pew
Charitable Trusts. Its objectives are to identify the most promising research
opportunities in the nutrition and food sciences, to examine the structure and quality of
education and training of researchers, and to make recommendations to facilitate
applications of research in clinical and public health policies and programs. We plan to
release the report on December 15, 1993 during a symposium to be held in Washington,
DC. Because the committee is working to complete its manuscript, I am limited in what
I can tell you about its conclusions and recommendations.

The report describes a wide range of needs and opportunities for research in the
nutrition and food sciences. The areas were selected on the basis that the research
would be likely to enhance the health of individuals and the public, and that it would be
intellectually challenging for researchers. The report provides in-depth discussions of
research opportunities in four areas: understanding genetic, molecular, cellular, and
physiologic processes; enhancing the food supply; understanding food behavior and diet,
health, and disease relationships; and improving the diet and health of individuals and
populations. The report will conclude with recommendations for improving education
and training of researchers. I will plan to send copies of the report to this subcommittee
upon its release.

I appreciate the opportunity to appear before this subcommittee and to provide
you with the findings of the Food and Nutrition Board about nutrition research and
education.

(Attachment follows:)

143

SUMMARY

IMPROVING

AMERICA'S DIET

AND HEALTH

FROM RECOMMENDATIONS TO ACTION

A report of the Committee on
Dietary Guidelines Implementation

Food and Nutrition Board
Institute of Medicine

Paul R. Thomas, Editor

NATIONAL ACADEMY PRESS
Washington, D.C 1991

144

NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, D.C 20418

NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils
of the National Academy of Sciences, the National Academy of Engineering, and the
Institute of Medicine. The members of the committee responsible for the report were
chosen for their special competencies and with regard for appropriate balance. This
report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy
of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was established in 1970 by the National Academy of Sciences
to enlist distinguished members of the appropriate professions in the examination of
policy matters pertaining to the health of the public. In this, the Institute acts under
both the Academy's 1863 congressional charter responsibility to be an adviser to the
federal government and its own initiative in identifying issues of medical care, research,
and education. Dr. Samuel O. Thier is president of the Institute of Medicine.

This study was supported by the Henry J. Kaiser Family Foundation through Grant
No. 87-4338 and by the National Cancer Institute, National Institutes of Health, U.S.
Department of Health and Human Services, through Contract No. NOl-CN-85072.

Library of Congress Cataloging-in-Publication -Data

Institute of Medicine (U.S.). Committee on Dietary Guidelines Implementation.
Improving America's diet and health: from recommendations to action /
a report of the Committee on Dietary Guidelines Implementation, Food and
Nutrition Board, Institute of Medicine; Paul R. Thomas, editor,
p. cm.
Includes bibliographical references.
Includes index.
ISBN 0-309-04139-2

1. Diet — Standards — United States. 2. Nutrition policy — United States.
3. Health. I. Title.

[DNLM: 1. Diet. 2. Health. 3. Nutrition. 4. Risk Factors.
QU 145 I593i]
RA784.I57 1991
363.8'0973— dc20
DNLM/DLC
for Library of Congress

91-7471
CIP

No part of this book may be reproduced by any mechanical, photographic, or electronic
process, or in the form of a phonographic recording, nor may it be stored in a retrieval
system, transmitted, or otherwise copied for public or private use, without written
permission from the publisher, except for the purposes of official use by the U.S.
government.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The image adopted
as a logotype by the Institute of Medicine is based on a relief carving from ancient
Greece, now held by the Staatlichemuseen in Berlin.

145

Preface

146

Viii PREFACE

However, the strategies and actions are sufficiently general to be
applied as well to several sets of dietary recommendations developed
during the 1980s.

The intended audience for this report is the many people who
share some responsibility for implementing dietary recommendations
in the United States. Examples of implementors include public- and
private-sector policymakers, supermarket managers, restaurant owners,
food writers, the entire nutrition community, and deans of schools of
higher education.

(The complete report is held in the committee files.)

147

TESTIMONY OF

RICHARD RIVLIN, M.D.

FOR THE

THE AMERICAN SOCIETY FOR CLINICAL NUTRITION. INC.
Mr. Chairman:

I am Richard Rivlin. M.D. I am the Program Director of the Clinical Nutrition
Research Unit at Memorial Sloan Kettering Cancer Center and Professor of Medicine and Chief
of the Division of Nutrition at New York Hospital-Cornell Medical Center. I am testifying
before you today as President of the American Society of Clinical Nutrition, the major
scientific society of physicians and basic science investigators concerned with research and
education in nutrition and disease prevention and treatment. Our Society and its members are
dedicated to the science of nutrition and to bringing the fruits of that science to the American
public in the form of improved nutritional practices for disease prevention, correct dietary
management of disease and special systems of nutritional support required during disease and
trauma.

Nutrition: A Prevention and Cost Containment Stratepv

It is now abundantly clear that many components of our foods and special combinations
of foodstuffs are not only required for optimal growth and development, but also are strongly
implicated in many of the major causes of disability and death. Healthy people who are well
nourished are less likely to have health problems and when well-nourished people become ill,
they are likely to get better sooner. Correspondingly, individuals who are malnourished are
more likely to become ill, and are less likely to recover.' It is crucial therefore that the
consuming public be made fully aware of the role of nutrition in their growth and development,
health maintenance, and disease prevention and that the scientific community assist in
conveying this message. New technologies are also at hand that can enable our nation to
produce safer and more nutritious food.

A large portion of the health care bill is devoted to diseases that can be prevented.
Nutrition represents a central element in disease prevention. Some members of our population
who are least well-served by current health care practices are also most vulnerable to the
diseases that now can be modified by nutritional means.

'Jules Hirsch, M.D., testimony before the U.S. House of Representatives Subcommittee on
Appropriations for the Department of Labor, Health and Human Services, Education and
Related Agencies, March 1993.

148

Dietan' factors are associated with 5 of the leading 10 causes of death: cancer, stroke,
diabetes, coronary heart disease, and atherosclerosis. About 25% of the adult population is
overweight. Overweight is associated with elevated serum cholesterol levels, elevated blood
pressure, diabetes and is an independent risk factor for coronary heart disease. The relationship
between obesity and chronic disease in minority populations has been acknowledged by the
NIH Report on Minority Health needs.

Obesity, diabetes, hypertension, and osteoporosis, which disproportionately afflict
women and minorities, are special targets for research and intervention. The nutrition of the
elderly and the need for special nutritional practices during childhood, adolescence and
pregnancy require our attention. Carcinoma of the breast, of the prostate and of the colon are
now occurring in epidemic proportions in this country. All three malignancies have been
shown to be affected by nutritional practices. The wasting that accompanies AIDS as well as
many cancers is yet to be understood. Nonetheless, the tools are now at hand to understand
and combat these adverse nutritional states which contribute to increase health care costs.

Nutritional problems affect Americans in all age groups. However, the young, the poor,
and the elderly are particularly vulnerable. Successful prevention of many of the problems that
occur in adults begins in childhood. Although multiple examples illustrate these comments,
we will cite only a few.

o Low birth weight infants represent seven percent of all births. Adequate prenatal

nutrition and nutritional coimseiing will reduce the $3 to $7 billion that the United
States spends armually for the care of low birth weight infants.

o Chronic iron deficiency in infancy and childhood appears to have a long-term impact

on intellectual development. Iron deficiency can be reduced by increasing efforts to
persuade mothers to breast feed, and through the promotion of iron-containing infant
formulas.

o Up to 27% of American children are obese, and one-third suffer from

hypercholesterolemia. Overweight acquired during childhood or adolescence is

149

associated with early mortality and increases the risk for chronic disease.' However,
few children give any thought to the health effects of foods. Feeding programs such
as the school breakfast or school lunch do not address either the fat or sodium content
of the fat composition of the meals they serve. Nonetheless, the participation of
millions of children in these feeding programs suggests the potential for modification
of a significant portion of a child's caloric intake. Obesity and hyperlipidemia add
substantially to the annual $150 billion costs of diabetes, cardiovascular disease, and
stroke in the United States.

o A substantial portion of older Americans have dietary intakes or diseases which place

them at a high risk of malnutrition. Eighty-five percent of older Americans may have
chronic diseases which could be assisted by nutrition interventions. Twenty-five
percent of the aged admitted to hospitals are malnourished and their hospital costs may
be double those of other elderly.''

o Calcium is essential to the formation of bone and teeth and most of the accumulation

of bone mineral occurs by age 20. Deficiency in calcium intake is related to bone
disorders and low calcium intake is clearly an important factor in osteoporosis. Hip
fractures represent a major source of disability among the elderly. Attention to calcium
intake in childhood may significantly improve calcium stores in bone, and reduce the
rate of hip fractures. High blood pressure is associated with sodium intake and low
sodium intake may prevent blood pressure from increasing with age particularly among
high risk populations.

Nutrition is involved in the preservation of health, and implicated as a cause of disease
and disability. It also constitutes a treatment for many diseases and disabling conditions.
Nutrition should therefore be a major element in any health promotion, disease and disability
prevention strategy. A comprehensive nutrition and prevention strategy should involve
education for health professionals and the public, nutrition labeling and related information

-Healthy People 2000. Department of Health and Human Services, Publication Number
(PHS) 91-50213, September 1990.

'Nutrition Screening, A Consensus Conference sponsored by the Nutrition Screening
Initiative, April 8 - 10, 1991, Nutritional Screening Initiative, 2626 Pennsylvania Avenue,
N.W., Washington, D.C. 20037.

150

requirements, health insurance coverage of nutrition assessment and patient education in health
insurance, and support for basic and clinical science through clinical nutrition research and
training centers, and increased numbers of research grants.

The Importance of Translating Research Into Practice and Behavior

We believe that one of the most important activities of the federal government is to
encourage communication to the public about nutrition and its relevance to maintaining good
health. This program should focus on schools and local civic organizations. It should benefit
from the research which is yielding so much significant information about the role of nutrients
in reducing the number of low birth weight children, the role of folic acid in preventing birth
defects of a neurologic nature such as spina bifida, and the role of antioxidants in prevention
of heart disease and cancer. This utilization of scientific information could do much to restrain
spending for health care and control the federal deficit, a large part of which results from poor
health. Communication to the public should emphasize the broad areas of consensus among
health scientists about the role of nutrition in the prevention and treatment of many diseases.

In addition, we believe it is time for our nation to take positive steps to assure that
physicians are adequately trained in nutrition so they may assist patients in dietary management
and similar prevention strategies. Recent surveys have indicated that nutrition was discussed
with only 25% of patients seeing primary care physicians. Another survey found that few
primary care physicians utilize nutrition in their clinical practice; compare that to the use of
pharmaceuticals. This survey also indicated the lack of emphasis on nutrition in medical
education in both undergraduate medicine and residency training." We believe that nutrition
education for health professionals must be a mandated component of the curriculum for
physicians and other health professionals who have primary care responsibilities.

Agriculture Programs

The Agriculture Departments research, education and service programs in nutrition have
had a ver>' positive impact on health and need continued support as part of a general nutrition

"Levine, B.S., Wigren, M.M., Chapman, D.C., Kemer, J.F., Bergman, R.L., Rivlin, R.S.:
A national sur\'ey of attitudes and practices of primary-care physicians relating to nutrition:
strategies for enhancing the use of clinical nutrition in medical practice. American Journal of
Clinical Nutrition 1993;57:115-9.

151

prevention and cost containment strategy. Nutrition research sponsored by the Department of
Agriculture consists of investigations of interactions of foods with the genetic potential of
consumers. B\ understanding the mechanisms of food-genome interactions, the government
is better able to provide critical information for continued improvement of human diets. The
research must also incorporate the broad scope of age and risk factor distributions in the U.S.
population. Improvement in diet is essential to the preservation of health.

Dietary guidelines for the American public are carried forth in publications like
"Nutrition and Your Health: Dietary Guidelines for Americans" published by the U.S.
Department of Agriculture and the Department of Health and Human Services. These
guidelines are based on a thorough evaluation of current scientific evidence which links food
intake and the risk of developing several diseases. There is an urgent need for research to
provide further substantiation for the biological basis of the Dietary Guidelines. This woujd
lead to future refmements of the Guidelines that will improve dietary practices and health
maintenance, and reduce the incidence of obesity, diabetes, hypertension, heart disease, cancer,
and a host of other health-related problems.

Summary and Conclusion

There should be expansion of the science base that supports our knowledge of human
nutrition. This expansion of the science base is needed to improve our dietary guidance to
Americans to achieve better health and to increase our understanding of nutritional
interventions to prevent, treat, or cure diseases such as heart diseases, cancer, diabetes, kidney
diseases, and AIDS.

T^ae is currently a shortage of academic and research facuby in clinical nutrition.
There is an immediate need to expand current training programs to increase the number of
physicians and PhDs selecting research and technology careers in clinical nutrition.

There is a need to improve the training of medical students in nutrition in both their
preclinical and clinical years so that they have a better understanding of the role of nutrition
in clinical nutrition. At this time ^proximately, only 35% of U.S. medical schools have
formal courses in nutrition in their preclinical and clinical years.

There is also a need to improve outreach programs to the public and practicing
physicians since they are necessary to disseminate the latest research fmdings for clinical
application and patient education.

152

The American Society for Clinical Nutrition, Inc.

THE CLINICAL DIVISION OF THE AMERICAN INSTITUTE OF NUTRITION

August 4, 1993

Officers (1993-1994)

President
Richard S. Rivlin

Vice President

Richard L. Atkinson, Jr.

Vice President- Elect
M.R.C. Greenwood

Secretary

Bruce R. Bistrian

Tivasurer
Lynn B. Bailey
TYeasurer-Elect
Janet C. King

Councilors
Steven H. Zeisel
Robert M. Russell
Kenneth H. Brown

AIN Secretary
Roy J. Martin

Editor-in-Chief
Norman Kretchmer

Executive Officer
S. Stephen Schiaffino

The Honorable Charles W. Stenholm, Chairman
Subcommittee on Department Operations and

Nutrition
U.S. Agriculture Committee - 1301 LHOB
U.S. House of Representatives
Washington, D.C. 20515

Dear Congressman Stenholm:

After completing my testimony before the
Subcommittee on Department Operations and Nutrition of
the U.S. House of Representatives Agriculture Committee
on July 15, 1993, I was asked to submit answers to
questions that were handed to me as I left the hearing
room. The answers to the questions are as follows:

la. How can wa iaprove the level of nutrition
expertise that physicians receive?

a. Require that all medical schools in the
United States include formal courses in
basic nutrition and clinical nutrition
(including nutrition assessment and
nutrition support.) in the pre-clinical
and clinical years. These courses should
be taught by qualified professionals in
basic and clinical nutrition.

b. Increase the numbers of post graduate
courses in clinical nutrition for
practicing physicians (i.e. meetings and
home study programs.

c. Increase the number of residency and
fellowship training programs in clinical
nutrition.

d. Provide opportunities for medical school
faculty training programs in basic and
clinical nutrition.

9650 RockviUe Pike, Bethesda. Maryland 20814-3998 • Tilephone (301) 530-7110 • Fax (301) 571-1892

Publisher of Ihc American Journal of Clinical Nulnlion

153

lb. What should b« tha top prioritios for nutrition raaoaroh
and oduoation prograaa today?

a. Increase the number of clinical nutrition research
training programs to provide well trained
professionals to conduct clinical nutrition
research and training programs.

b. Increase funding for research in the following
areas :

1. nutrient -gene interaction.

2. role of nutrition in the prevention and
treatment of chronic diseases (i.e. cancer,
heart, kidney, diseases of children, etc.).

3. role of nutrition in improving the health of
women and minorities.

4. Obesity - relation to chronic diseases,
overweight in childhood and adolescence and
its association with early mortality and
increased risk for chronic diseases.

2. How aff active is intaragancy cooparation and coordination
in satting and achieving nutrition research and education
goals and obj actives?

There have been several attempts by the Departments of Health
and Human Services and the Department of Agriculture to coordinate
efforts 2unong federal agencies in developing nutrition research and
education objectives. We support these efforts. However, there is
need for an effective central planning group to coordinate efforts
to support nutrition research and education, nutrition policy, and
nutrition interventions because of the well defined role of
nutrition in health maintenance and disease prevention. Strong
consideration should be given to the establishment of a central
organization to coordinate the development of nutrition policy,
nutrition education of health professionals and the public, and
nutrition research and training.

3. Plaasa dasoriba tha rola of nutrition in pravantativa
haalth oara.

Many components of our foods and special combinations of
foodstuffs are not only required for optimal groifth and development
but are also strongly implicated in many causes of disability and
death. Healthy people who are well-nourished are less likely to
have health problems and when the well nourished become ill, they
are likely to get better sooner. Correspondingly, individuals who

- 2 -

154

are malnourished are more likely to become ill and are less likely
to recover or may have longer periods of convalescence in a health
facility.

A significant portion of our national health bill is devoted
to diseases that can potentially be prevented. Nutrition
represents a central element in disease prevention. There are some
members of our population who do not have adequate healthcare and
therefore are most vulnerable to the diseases that can now be
modified by nutritional means.

4. What is th« single greatest need to improve nutrition
research and education in the future?

a. Increased funding to expand the science base that
supports our knowledge of human nutrition. Recent
research findings are providing stronger evidence
of the role of nutrition in disease prevention and
health maintenance.

b. Increase the number of academic and research
faculty in clinical nutrition at medical schools.
At the present time there is a shortage of
physicians and other health professionals in
clinical nutrition.

c. Improve the training of medical students in
nutrition in both their preclinical and clinical
years. This can be accomplished by providing funds
for faculty training programs and the support of
faculty positions in clinical nutrition in medical
schools.

d. Improve outreach programs to disseminate the latest
research findings for clinical application and
patient education. Improve consumer education
programs to provide information on how good
nutrition can improve the quality of life.

I hope the answers to these questions are helpful to you and
your committee. If I can be of further assistance, please contact
me.

Sincerely yours,

J 4- dj:

S . Rivlii

RSR/tmc

Richard S. Rivlin, M.D.
President, American Society for
Clinical Nutrition

- 3

155

STATEMENT OF ELLEN SCHUSTER, M.S., R.D. , C.H.E.
MINNESOTA STATE EFNEP COORDINATOR
BEFORE THE SUBCOMMITTEE ON DEPT. OPERATIONS AND NUTRITION
COMMITTEE ON AGRICULTURE, U.S. HOUSE OF REPRESENTATIVES

July 15, 1993

Mr. Chairaan and Meabers of the Subconaittee , I aa pleased to
be here today to discuss nutrition research and EFNEP (the Expanded
Food and Nutrition Education Prograa) . I will be focusing on two
areas: soae specific exaaples of how nutrition research reaches
consuaers through the Extension systea and the effectiveness of
EFNEP.

First, I would like to highlight an exaaple of nutrition
research that is currently underway in Minnesota. It deals with
tiro areas that are critically iaportant to "at risk" populations:
literacy and low-fat eating. The School of Public Health at the
University of Minnesota received a 3 year National Heart, Lung,
Blood Institute grant to study the effectiveness of a low-fat
nutrition education intervention prograa aiaed at adults with low
reading skills. Coaaunities of color and those with a lower
socioeconoaic status and educational attainaent are aore likely to
be at risk for cardiovascular disease. Thus, EFNEP feuiilies serve
as an accessible research population. To date, we have been able
to assess the reading ability of EFNEP faailies in 3 counties in
Minnesota. Nine percent read at less than a fourth grade reading

156

level; thirty percent read between a fourth and eighth grade
reading level. These results have implications for all nutrition
educators who work with "at risk" populations since research
indicates that printed nutrition education materials focusing pn
low-fat eating are written at a tenth grade reading level. As a
result of this research, we are making a concerted effort in
Minnesota to insure that nutrition education, and other materials,
are written at an appropriate reading level so that the information
is accessible to consumers. Towards this effort, I developed and
piloted a brochure on the new USDA Food Pyramid last year and about
26 states are using this piece; over 100,000 copies have been
distributed nationwide .

Another exciting project that we have in Minnesota links
agriculture to nutrition education programming. Project Grow is a
program to encourage self-help on Indian Reservations through
utilization of land resources and in the process, promote health
and nutrition. We are now expanding community agriculture and
education efforts to include health and nutrition on five
reservations using the EFNEP model - hiring and training
paraprofessionals or peer educators to bring University nutrition
research to the reservation population. Health problems such as
Type II diabetes and obesity among Native Americans clearly
indicates a need for intensive nutrition education programming. In
addition, a needs assessment of the five reservations involved in
the project found that in addition to diabetes and obesity, other

157

health and nutrition needs are the development of food preparation
skills, commodity food usage and pregnant teen nutrition. This
project uses a community-based model like EFNEP, thus sensitivity
to the culture and its values will be an important part of this
project.

EFNEP and Extension effectively collaborate with other
agencies to reach "at risk" populations and bring University
research to them. Families Take Charge is a Dakota County project
that links Extension and the EPSDT program. EPSDT is the Early and
Periodic Screening Diagnosis and Treatment program and it provides
physical, mental and emotional screening for children and teens
whose feunilies are eligible for Medical Assistance. A colleague at
the Minnesota Department of Human Services, the agency that
administers this program, came to me when she was aware of the
opportunity to expand health education and prevention in the EPSDT
program. She was aware of EFNEP, was impressed with our training,
program delivery and staff and thought that the use of
paraprofessionals or peer educators was an effective and cost-
saving way to bring health and nutrition education to fajnilies.
From this initial meeting. Families Take Charge was born. Using
the EFNEP model. Extension has hired and trained a health
educator/outreach worker and a family mentor. Extension brings the
most current nutrition research to "at risk" families - especially
information about feeding children and food safety. Using one-to-
one home visits, families in crisis are empowered to take

72-928 0-93-6

158

responsibility for their lives and the lives of their children.
Crisis affects these families in many ways: family mealtimes are
forgotten which may lead to hungry and ill-nourished children; food
may not be handled safely which may lead to food poisoning, causing
illness and more crisis; the parent may not focus on prevention of
disease and promotion, thus accelerating poor nutritional habits.
Based on anecdotal information from this project which has been
operating for a little over a year, the outreach worker has
observed that families of color will enroll in this program if
personally asked to - an increased enrollment in this health
prevention program has been the result. This may mean that fewer
families will have to wind up with health conditions that are
chronic and costly.

Lastly, I want to address the effectiveness of EFNEP. As you
know we are approaching the 25th anniversary of the EFNEP program.
In Minnesota we operate 12 EFNEP projects at this time and many
have waiting lists. This is astounding because we do not give
families health care services, food or money. We give them skills
and education. However, families want this program because they
are concerned about their families' health and nutrition, and they
want to learn how to save money at the grocery store. In our youth
EFNEP program we are training teen teachers to teach younger
children about nutrition, fitness and food safety in two different
projects - Jump In Minnesota and Chances and Choices with Food. We
have waiting lists of neighborhood agencies that are interested in

159

implementing our Jump In Minnesota program that teaches inner-city
youth nutrition, fitness and leadership skills through fun
activities. Chances and Choices with Food is being taught in about
half of the counties in Minnesota. This is an example of
bringing the most current University research about food safety to
the children of our state.

One of EFNEP's goals is the improvement of the diets of
program participants. Our families eat more varied diets as a
result of their EFNEP education. Program participants eat
nutritious foods like milk and fruit and vegetables more often as
a result of the information and skill-building in EFNEP.

The EFNEP model of training and hiring community or peer
educators works. EFNEP staff work with families in crisis but have
the ability to focus on what the family is doing right. This is a
powerful strategy when working with families who have been told for
so long what they are doing wrong or not doing at all. EFNEP staff
also effectively link families to community services and programs
they are unaware of or may not have ordinarily accessed. Here are
some statements from actual EFNEP participants that speak to the
effectiveness of the program:

A single mom states: "I am a single parent who at 21 moved out
of my mother's house and didn't khow how to cook well enough to
feed my family — and definitely not knowing how I was supposed to
try on my limited budget. Barbara and the EFNEP program came into
my life and not only gave me the confidence to prepare meals and

160

experiment with new recipes, but showed me how to budget and plan
my diet as well. This program was informative and in my situation
it was a necessity."

An EFNEP youth participant states: "I'm going to start eating
more healthy foods because of what I learned. This class helped me
see what food can do to you."

A mom states: "This class has been very valuable to me in many
ways. Though I have three children under school age and find it is
difficult to get out, I did not want to miss a single class. This
class has really made me think about wise purchasing of groceries,
meal planning and proper nutrition. In my opinion, this class
should be reguired for anyone receiving food type funding from our
government . "

Mr. Chairman, this concludes my prepared statement. I will be
happy to respond to any questions which you or other members of the
subcommittee may have.

161

TESTIMONY OF
THE SOCIETY FOR NUTRITION EDUCATION

BY
DR. JENNIFER ANDERSON, PRESIDENT

The Society for Nuirition Education (SNE) commends you, Mr. Chairman and member.s of
thi.s .subcommittee, for recognizing the importance of reviewing nutrition research and
nutrition education and the linkages between these two activities. We have reached a point in
the health of our Nation that requires a stronger and more permanent link between food
production, nutrition, and public health.

I am Dr. Jennifer Anderson, President of SNE and Associate Professor and Extension
Specialist in the Department of Food Science and Human Nutrition at Colorado State
University. Today I am representing SNE, a Society of 2,3{X) nutrition professionals working
to link the fields of nuirition, food, and education. I ask that my full testimony be included in
the permanent record of this hearing.

Many members of SNE, including myself, are very involved in linking agriculture production
to the health of our communities by providing effective nutrition education programs. We are
constantly .striving to use the findings of nuirition research and to communicate to target
audiences appropriate nutrition and health messages through the most effective channels.
Historically, USDA has supported basic nutrition research fundamental to growth and
development, protection of the health of Americans, and maintenance of the quality of life of
elderly persons. Dr. Nicholas and Dr. Rosenberg have explained the current commitment to
continuing that type of research. USDA is recognized as a leader and should remain a leader
in translating that research into usable information for the public. For the sake of future
effective nutrition education, we have identified three priorities. First, we ask your
Committee to make a commitment and ensure that this linkage between research and
education remains intact. We also request that you support increased visibility for nutrition at
USDA, and advocate for adequate funding and support for nutrition education/intervention
research.

Our first point is that, research and nutrition education have been, are, and must remain
linked.

Nutrition education works. Research findings prove that nutrition education consistently
changes knowledge, and also can change attitudes and behavior. We need more research to
know how to positively affect both attitude and behavior. An example of recent nutrition
research that was effectively translated to consumers, concerns the role of antioxidants in
chronic disease. This research guided the successful 5-A-Day national campaign. Nutrition
education researchers are now evaluating how to use this 5-A-Day message (eat 5 servings of
fruit and vegetables a day) in a variety of channels. For example, with the assistance of
county extension agents I am investigating how to deliver information to K-6 graders in rural
schools and how to most effectively include the school lunch program, local supermarkets,
and the media in the effort.

Certainly the role of fat and specific fatty acids in chronic diseases such as coronary heart
disease and cancer is well documented. Subsequent messages to eat less fat have been
translated to consumers through the new USDA Food Guide Pyramid. This research has also

162

rcsulicd in a myriad of new low-fal and no-fal foods in the supermarkcL

The new Food Guide Pyramid, which has been based on recent nutrition research, conveys
the tencLs of the Dietary Guidelines, namely variation, moderation, and proportionality. The
Dietary Guidelines themselves, .since their inception 13 years ago, have communicated
nutrition and health recommendations reflecting the most recent nutrition research. Nutrition
education programs communicate these to consumers.

Numerous trade and non-profit a.ssociations (such as IFIC, AHA. NLSMB. and the Dairy
Council) have created nutrition education materials. As an example, the Dairy Council has a
long history of developing nutrition educational materials and curriculums. A unique aspect
of their materials has been the evaluation research component. This exemplifies the process
SNE is supponing, namely the coupling of development with strong evaluation and
implementation of materials and programs.

A more recent example of a nutrition education activity conducted by the private sector
involves collaboration between a professional organization, industry, and the media for mutual
benefit. The Society for Nutrition Education recently entered into a partnership with
Mcdonald's Corporation and CBS Television. The result was, as many of you know, a series
of one minute television programs that aired on CBS Television immediately before a popular
Saturday morning cartoon, Ninja Turtles. SNE developed and provided technical expertise for
the content of those programs. In addition, SNE nutrition education experts were then
involved in the development of print material and brochures that accompanied the media
message. Those printed materials, which are disseminated through pediatricians' offices and
parent magazines, receive wide exposure. Let me publicly state that not every SNE member
was supportive of this partnership. A strength of SNE is our diversity, which has allowed us
to analyze issues from multiple perspectives.

The SNE board viewed the McDonalds partnership as an opportunity to provide an accurate,
high-quality nutrition education message during Saturday morning cartoons. Regardless of
with whom we collaborate with or form partnerships, nutrition educators are committed to
maintaining a consistent, research-based message. The information message must be based on
sound nutritional science research and must be translated for the public in order to help them
with their food choices and nutritional practices. The communication or educational program
itself must also be based on nutrition education/communication research. That is, the
translation and communication strategies must be research-based as well as the message itself.
Relatively more resources have been allocated to research to determine what the message
should be. Equal attention needs to be given to research to find ways of enhancing
translation and communication of the message.

The CD-ROM medium is also being used to deliver nutrition education to school children
through a partnership between the Society for Nutrition Education and another member of the
private sector, the Dole Company. The use of computers to build nutrition into the
curriculum is expanding rapidly. Other opportunities will be exploited in the future as new

163

and crcalive delivery techniques for nutrition education are explored. The private sector
will benefit by collaborative agreements with professional organizations and the govemmeni.

Nutrition education shouldn't be limited to a promotional campaign. When the private sector
collaborates with a professional organization such as SNE, the result is nutrition education
rather than a promotional campaign. For the desired changes in behavior to occur, nutrition
education must be an ongoing, sustainable effort. Nutrition education requires behavior
change models grounded in research, not just information transfer. We need to recognize that
a few seconds on television is not a nuuiiion education program or model. Instead, electronic
media such as TV must be part of an integrated program in which diverse communication
channels support a goal-oriented long term plan for making sustained impact. Curricula,
nutrition education programs, and nutrition materials will constantly need review and
evaluation. In this capacity, the public sector and professional organizations can provide
valuable guidance to the private .sector.

The Cooperative Extension Service is an exemplary program which links nutrition research
and nutrition education. Extension services provide nutrition education programs that are
targeted to local clientele needs and community issues. These programs are research-based
and unbiased. The key to its effectiveness is the positioning of Cooperative Extension within
the land grant university. The Society for Nutrition Education has many of its members
working in Cooperative Extension and in the Expanded Food and Nutrition Education
Program.

Today Cooperative Extension responds to current problems by applying research results
within our fields of expertise and by gathering information from the entire land grant
university system, including the U.S. Department of Agriculture. Cooperative Extension
actually takes the university to the people through off-campus offices located in almost every
county in every state. Through our extension agents, we help apply scientific knowledge on
the job and at home and give all people access to the resources at the land grant university.
The agents also carry research and information needs back to the campus. Dr. Usinger has
addressed the Cooperative Extension Service in her testimony and Ms. Schuster has spoken
on EFNEP.

The Expanded Food and Nutrition Education Program (EFNEP) helps low-income families -
those often most affected by chronic disease and with limited access to health care - make
the most of their scarce resources. The outreach efforts of EFNEP teach program participants
to plan for daily food needs and to prepare nutritious, low-cost meals. In addition, education
helps participants to select and buy food economically and to effectively use other
supplemental programs available to them. Indigenous paraprofessionals employed by EFNEP
adapt nutrition education materials and classes to the target ethnic groups. As more families
and children live in poverty, their risk of nutritional deficiencies grows and the potential
benefits from nutrition education accelerate. Let me illustrate.

164

In the Colorado Springs area in Colorado, 197 EFNEP graduates learned to save an average
of $150.20 on their monthly food bills. As a group, they thus save a monthly total of nearly
$30.(KX). Such .savings prompted the following letter from a program participant.

"... [My hu.sband] definitely enjoys the savings in grocery
buying. I remember .sharing with you how we are in .spending
money, but with the EFNEP program we have cut our grocery
expense and have bought more and belter food products for less
money. I have really surprised my.self. We really recommend
the program to anyone who qualifies for it."

Attached to my testimony is an impact statement from another EFNEP unit in Colorado that
illustrates the effectiveness of this program.

With respect to nutrition expertise among medical personnel. SNE believes strongly that it is
not the level of nutrition experti.se that is the issue, rather the need to recognize when the
physician should call upon the services of a qualified nutrition professional. Registered
dietitians or other qualified nutrition professionals should be vital members of the health care
team. Certainly the value of nutrition services in preventing chronic disease and improving .
health and saving money is already evident

In Massachusetts for example, 29 case studies have illustrated positive health outcomes, and
over $471,000 has already been saved. Nutrition education for women who developed
diabetes during pregnancy saved $5,300 per client in hospital costs and improved their health
outcome. The cost of nutrition services was only $210 per client.

As a member of the Coalition for Nutrition Services in Health Care Reform, SNE strongly
supports the inclusion of nutrition in the basic benefit package as delineated in the position
statement from the Coalition. Nutrition education is not only effective but saves money.

SNE recognizes the need to educate medical personnel and medical students. Nutrition
courses are being required in some medical schools, which we applaud. However, the
emphasis is on nutritional biochemisuy rather than the preventative role of nutrition in
chronic disease. Further, present courses do not address how to provide concrete guidance to
patients regarding food choices. Therefore the services of nutrition educators is required for
these crucial services. My position at Colorado State University, as with many of my
colleagues within SNE, involves training and educating our students to be nuu-ition
professionals and thus be an integral part of health care system comprising preventive,
therapeutic, and rehabilitative services. Nutrition services comprise an essential, though often
under-appreciated, component of health care. That must change, and one way is to better
educate the medical personnel regarding the value of nutrition education as a preventive tool
and the value of nutrition screening to identify those persons in need of nutrition education
and counseling.
Our second priority is to increase the visibility of nutrition in USDA through improved

165

coordination of nutrition at the National, State, and Local levels.

SNE strongly urges USDA to coordinate and raise the visibility of all nutrition activities -
education, research, and food assistance. This would provide a strong link between
agriculture and health. A further suggestion would be to integrate all food assistance
programs to assure that they are delivering a consistent message and capitalizing on each
other's success. Standards for personalizing the nutrition education component should be
enhanced in such food assistance programs as WIC, Food Stamps, EFNEP and School Lunch.
We must link food, nutrition, and health consistently, with agencies at national, state, and
local levels working together and not working in isolation.

USDA should face up to credibility issues by changing from a production orientation to one
which gives equal emphasis to consumer and public health concerns. Effectively, linking
agriculture to health would thus be more likely to occur. One example of a policy change
that would enhance health would be a change in commodity reimbursement policy.

While the links among nutrition, health and agriculture have always existed, some recent
nutrition education research and programs have brought together health and agriculture
interests. An example is the Cooperative Extension program called the Northeast Network,
which is a food, agriculture, and health public policy education program. The Northeast
Network is designed to help citizens in the Northeast consider the consequences of alternative
food policies and make informed decisions about food and agriculture issues that face them as
individuals, as members of their communities, and as representatives of various organizations
with which they may be affiliated. Developers of this program recognized rightly that
problems affecting public health are often inextricably linked to factors affecting agricultural
practices. Consumer interests and concerns about the food supply are increasingly relevant to
growers, processors, marketers, wholesalers, and retailers. The Northeast Network deals very
broadly with the food system and considers as stakeholders those who supply agriculture and
aquaculture inputs, those who produce plants and animals, those who process commodities
into finished items, and those who transport, market, sell, and serve food products. It
assumes that consumers' health is ultimately dependent on the products of the food system.

Another example of coordination between nutrition services are seen in the new USDA
Nutrition Education Initiative monies allowing 17 states to explore new strategies in which
Cooperation Extension works with WIC clientele to provide nutrition education to hard-to-
reach groups. Competitive grants such as this must be recognized as a need so that the
research is conducted and then communicated to the public. Nutrition science must form the
basis of nutrition education programs for populations at risk due to limited resources as well
as other at-risk groups vulnerable to chronic disease.

SNE acknowledges the recent efforts of USDA to work with at-risk populations, but we
recommend an expansion of these efforts to include low literate adults, older Americans,
limited resource families, ethnic sub-groups, non-English speakers, women's health issues,
pregnant teens and the homeless.

166

An example of nulrilion research thai I have been involved with examined blue and while
collar employees wiih high levels of blood cholesterol. Results from ihis study will be used
to provide appropriate nutrition education to this at-risk target population. Between 1990 and
1992, Departments of Health in the .states of Colorado, Minnesota. Mi.s.souri, and Wa.shingion
collaborated with the Centers for Di.sca.se Control and Prevention to conduct a randomized
trial comparing the efficacy of two alternative approaches to dietary education following
cholesterol .screening in worksites. Forty worksites were a.ssigned randomly to one of two
alternate educational interventions for those workers found to have cholesterol levels of 200
mg or higher which is the level the NCEP idenlifies as placing one at risk for heart di.scasc.
Cardiova.scular risk factors including total cholesterol were measured at baseline as well as 6
and 12 months later. There was little difference between the two intervention groups in
cholesterol change at 6 months, but at 12 months those receiving the special intervention
showed a 5.39^ drop in cholesterol while those receiving the usual intervention showed a drop
of only 1.9% (hence a 3.4% reduction attributable to the intervention). We concluded that a
behavioral-oriented dietary educational intervention following cholesterol screening can have a
meaningful impact on long-term cholesterol levels, and hence on the risk of heart di.seasc.
Such research may be published in the Journal of Nutrition Education, which is SNE's vehicle
for dissemination of nutrition education research results.

Nutrition education in the future will undoubtedly involve greater collaboration both within
ihe USDA as well as between the USDA and other agencies. Research efforts will be
enhanced by greater cooperation. There will need to be greater collaboration both within the
federal government and within and between agencies so as to enhance coordination. Using
standard bases of information, such as the standards used to educate consumers (namely the
RDA's, Dietary Guidelines, and education around the food label), would be an example of a
desirable product of a good collaboration. Representatives of the public sector, the
universities, and the researchers conducting evaluation studies of nutrition education materials
and programs should also collaborate with representatives of federal agencies. Such was the
case during the development and evaluation of the USDA Food Guide Pyramid. Increased
collaboration between agencies involved in nutrition monitoring, such as that between USDA
and CDC, is desirable.

In addition, increased collaboration among NET programs on a statewide basis is also highly
desirable. Partnerships, alliances, collaborations, linkages, and cooperation in conducting
nutrition science and nutrition education research as well as in developing and evaluating
programs and materials will be of increasing importance to nutrition education in the future.
University faculty (including professionals in the outreach arms of land grant Universities
such as Cooperative Extension personnel), professionals in public health nutrition, and
professional organizations will all benefit from closer association with government or
industry. Industry and government will seek the expertise of nutrition education researchers
and practitioners as they develop their programs. This kind of close cooperation will help
research to guide practice and will allow practitioners to inform researchers as to what needs
investigation.

167

Federal agencies such as USDA should modify iheir rules to ease barriers and facilitate
collaboration with groups outside of government. SNfE applauds the efforts of FDA and the
NEFLE clearing house as an example of interagency and public/private collaboration.
However, further coordination of research and material development at FDA still needs to
occur. The U.S. Department of Education has never embraced nutrition. Enhancing USDA
and U.S. Department of Education collaboration would be highly desirable in order to make
nutrition an integral part of education efforts.

Perhaps the time has come to establish a Nutrition Education Council. This should be a
clearing house where the public and private sectors can meet to set the agenda for nutrition
education, to generate new ideas, and to coordinate new efforts. The Society for Nutrition
Education has members with the expertise to provide leadership and vision for such a
Council. Along these lines, the current effort to improve nuuiiion labeling and the
coordination of materials at the national level is to be applauded. The Nutrition Labeling
Education Program has included the federal government, professional organizations, and
various private and public sector organizations. There is a definite need to further such
cooperation.

Finally, SNE asks for your support of the following research priorities in nutrition
education research.

Nutrition education is a process by which we assist people in making healthful food choices
by applying knowledge from nutrition science about the relationship between diet and health.
It is a deliberate effort to improve the nutritional well-being of the public. Multiple factors
affect food choice, all of which must be assessed if effective educational approaches and
nutrition messages are to be developed for all segments of the population. Research enhances
practice; however practice must inform research and guide its direction.

Adequate funding and support for nutrition education/intervention research is critical. We
need to better understand those at risk and other audiences, as well as policies and
environments which influence their food choices.

Three types of research are needed for effective nutrition education: 1) basic research on
nutrition-related behaviors so that we understand why people behave the way they do; 2)
research to develop strategies for implementation in order to change knowledge and behavior
practices; and 3) policy research (for example what effect will changes in the food label make
on food choices). For effective dietary guidance, there are four dimensions in the process:
diet and health research beyond nutrient requirements; dietary guidelines; dietary guidance
tools/systems; and consumer food choices. Research is needed at each stage.

168

A lisi of priority needs in nutrition education research would be as follows:

1. Fundamental research to understand food decision-making processes and

policy-making at the individual, family, community, school, corporate, state,
national, and international levels. This should include such areas as:

i. current knowledge, altitudes, decision-making processes, food behaviors,

and influences on them for at-risk groups as well as the general
population.

ii. changes in food behavior.

iii. similarities and differences among diverse sub-population groups (ethnic
and racial groups, income groups, family structure).

iv. policy research to

a. understand impact of policies on food choices.

b. understand decision-making process of policy decision-makers.

2. Study of theory-based interventions through each stage of the food deci.sion-
making process, including areas such as:

i. formative research for program development.

ii. process and outcomes of interventions (formative and summative

evaluation),
iii. differential effects of interventions on diverse population subgroups.
iv. longitudinal research to assess development of food patterns as well as

long term impact of interventions.

3. Determination of the economic benefits of nutrition education. Data on the
economic value of nutrition education and nutrition services are lacking, and
what is published is generally not measuring just the effects of nutrition
education. Assessing patterns of eating and measuring behavior changes over
time, with special note taken of the influence Of family members, will require
future attention. An increase in the dissemination and articulation of the
findings of nutrition education research will provide valuable input for such
research into the next century.

4. Development of improved methods for fundamental food choice research and
for studying interventions. These will include methods for studying the
decision-making process, food behavior, and changes in behavior over time.

5. Establishment of guidelines for standards in nutrition education, especially in
school-based education. These standards should be provided to maximize the
health outcomes and the desired changes in knowledge, attitude, and behavior.

169

The Society for Nutrition Education appreciates the leadership this committee has given to
nutrition over the years. With your continued support, the health of Americans can be
improved. We must strengthen the link between nutrition research and nutrition education,
increase the visibility of nutrition in USDA, and support research which helps all American.s
choose food that promotes health.

(Attachment follows:)

170

Colorado State University Cooperative Extension

Putting Knowledge to Work

«••

Expanded Food and Nutrition Program
Reaches Hard-to-Reach Audiences

Situation

Pueblo County continues to show a large number of
unemployed, also a high percentage of families enrolled in
public assistance and food stamp programs. It is a
continuous challenge for these limited-income families to
provide nutritionally adequate diets and to manage their food
resources from month to month. In looking at the nutrition
program participants, in 1990, 60% were Hispanic, 34%
were white and S % were of black, Indian and Asian descent.
The standard- ethnic foods eaten by many Pueblo residents
are typically high-fat content. A contributor to this is the use
of lard or shortening, plus the convenience and ease of
frying as a food preparation method. This high-fat diet is a
major contributor to obesity, heart disease, diabetes and
other related diseases.

Colorado State University Cooperative Extension's
Expanded Food and Nutrition Education Program enrolls
participants from hard-to-reach, limited income, high-risk
audiences in Pueblo County. The EFNEP program provides
twelve lessons on general nutrition and health, food safety,
budgeting food stamps or food money, reading labels, and
other nutrition helps. Para-professionals present the lessons
in the homes of program participants, or they meet with
small groups in parent centers, churches, or other facilities
in the clients' area. This Is the most successful educational
delivery method for this hard-to-reach audience.

Impacts Achieved

Documented behavior changes at the completion of
the twelve-lesson EFNEP curriculum compared to behavior
at time of program enrollment relating to diet changed and
use of food resources showed the following:

—More than 80% of participants had food for three or
more weeks each month.

-Thirty percent of participants had food lefi over at
the end of the month.

Cooperadw
Extension

171

-Increased by 49% (to 70%) the number who read
labels regularly.

-Increased by 45% (to 89%) the number who
compare cost per serving before buying.

-Increased by 34% (to 74%) the number who use
fortified cereals.

-Increased by 28% (to 74%) the number who use
low-sugar cereals.

-Increased by 34% (to 81%) the number who thaw
food properly to reduce food-borne illness.

-Increased by 48% (to 79%) the number who reduce
fat in recipes regularly.

-Increased by 33% (to 79%) the number who reduce
the amount of fried foods their family eats.

-Increased by 30% (to 94%) the number who use oil
instead of lard shortening.

Participants reported the following comments:

*'/ was really pleased with my nutrition lessons. Because 1
learned how to feed my family in a healthy manner. '

•'/ enjoyed the program and would recommend this program to
anyone who asked. '

*'...was a very informative program. I'm glad I took the classes
and I wish my mom could of taken the class with me. '

*'l enjoy the program and it is educaiionaL I would like this
program to continue. '

*Ijust want to thank you far the excellent program you have and
let you know that I am a smarter person thanks to...leadiings she gave
me. Every mother should enroll if the 're able. Thank you very much
EFNEP and Georgia Hoffman. '

*l would like to tell you how much I have enjoyed my lessons
with Jeania. She kept (helped) me a lot and I learned a lot. I am a foster
mother to a 1 1/2 year old bay who is very much under weight. Her help
with him was good and I am a diabet (diabetic) and she helped me a lot
with my diet. '

-Georgia K. Hoffmann
Pueblo Count; OfTice
Pueblo, (719) 546-«000 Ext 3190
Colorado State Unirersitj
CooperatiTe Extenaon

172

July 15, 1993

U.S. House of Representatives

Committee on Agriculture

Subcommittee on Department Operations and Nutrition

Testimony

Stanley H. Schuman, M.D., Dr. P.H.
South Carolina Agromedicine Program

Department of Family Medicine

Medical University of South Carolina

171 Ashley Avenue, Charleston, SC 29425

803-792-2281/ Fax 803-792-4702

My comments today will focus on two areas: 1 ) the cost effectiveness of the South
Carolina Agromedicine Program as a contemporary example of a program which links
the agricultural and health communities, and 2) improving the level of nutrition
expertise among primary care physicians. My colleague, Or. Jere Brittain, will discuss
the impact of the program on Clemson University and the agricultural community.

Agromedicine is a process which utilizes the resources of the Cooperative Extension
Service and local health professionals in delivering university-based agricultural
medicine to health practitioners, farm families and consumers. The attached figure
depicts our view of agromedicine as interdisciplinary cooperation between the health,
agricultural and environmental sciences.

The South Carolina Agromedicine Program (SCAP) was established in 1984 as an
interuniversity program between the College of Agricultural Sciences of Clemson
University and the College of Medicine of the Medical University of South Carolina.
SCAP faculty and staff serve as a medical resource on agricultural health concerns to
the Cooperative Extension Service as well as to our state's health care professionals
and citizens. Nutrition ancTfood quality is one of many areas of SCAP public service,
education and research. Examples of other areas include pesticide health effects,
insect transmitted diseases, prevention of skin cancer, noise induced hearing loss and
farm family stress.

A great deal of SCAP's educational activities are focused on food and nutrition. Our
lecture, "Quality of the American Food Supply," hasbeen one of our most frequently
requested lectures. I have presented this lecture about 50 times in the past two years
in South Carolina and around the country to a variety of audiences including the
public, agricultural professionals, physicians and medical students. The message is
simple:

Americans enjoy a safe, abundant and affordable food supply which is

173

rigorously monitored by a number of federal and state agencies. A varied
diet rich in fruits and vegetables promotes health and prevents disease.
As consumers, we can rely on an abundance of natural anticarcinogens
in a balanced diet to counteract any man-made chemical residues or
naturally occurring molds and toxins. A balanced diet needs to be
supplemented with regular exercise and medical care.

These facts have been summarized in a videotape for student and public education.
At this time, SCAP is producing two additional videotapes on food quality. One is for
physician education while the other is designed for patient viewing in physicians'
waiting rooms.

In September 1 991 , SCAP in cooperation with the South Carolina Academy of Family
Physicians, was successful in having the American Academy of Family Physicians, at
its annual meeting in Washington, D.C., adopt a resolution endorsing the quality of the
American food supply. The resolution closes with "... Be it resolved, that the
Academy:

Acknowledges the improving quality of the American food supply and the
major contributions of American agriculture to our patients; this
acknowledgement to be communicated to the consuming public through
the media and to farm organizations, and

Will continue to follow the most prudent guidelines to protect our
patients and promote optimal nutrition."

SCAP has just completed a self-study monograph on food quality that has been
distributed to the 92 SCAP consulting physicians in all of the 46 counties of South
Carolina. This monograph has been accredited by the American Medical Association
and the American Academy of Family Physicians.

The above activities are examples of SCAP initiatives in nutrition and food quality
designed to inform the busy practitioner. It is not easy to reach physicians during
their undergraduate and post graduate training or during practice. Should more time
be allotted for nutrition education in the curriculum of medical students and residents?
Definitely, but this is not likely to change in the immediate future. As ongoing medical
research clearly establishes the linkage between diet and optimum health and disease
prevention, more time for nutrition education will be made available in the curriculum
and it will be taught more effectively.

My experience over the past nine years with the South Carolina Agromedicine
Program has convinced me that the medical and agricultural communities must work
together in nutrition education and research. With fewer dollars available, it makes
sense for these two disciplines to work together in nutritional research and education
which have such a major impact on health. The busy physician's "access" to up-to-
date nutritional information is just as vital as patients' "access" to the physician.

Teamwork will expand the success of the Extension mission and the health care
mission.

(Attachment follows:)

174

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175
July 15, 1993

U.S. House of Representatives

Committee on Agriculture

Subcommittee on Department Operations and Nutrition

Testimony of

Jere A. Brittain, Ph.D.

IPM and Agromedicine Coordinator

Office of IPM Programs

266 Poole Agricultiu^ Center

Clemson University

Clemson SC 29634-0375 -

803-656-4460/FAX 803-656-4960

About five years ago, the small, rural community of Prosperity, South Carolina, had no
family physician. (Prosperity has received a bit of unusual attention recentiy because
it is located near a town named Clinton). When a young physician named Oscar
Lovelace was a boy growing up in nearby Columbia, he frcquentiy visited his
grandfather's farm at Prosperity and eventually showed the state champion dairy cow
as a 4-H project. He recentiy said that he returned to Prosperity to establish what is
now a thriving family practice because of that 4-H project and that cow.

Three years ago, as part of a Kellogg Foundation funded Agromedicine project. Dr.
Lovelace provided space in his office for nutrition specialists and graduate students
from Clemson and Winthrop Universities to provide nutrition education and
counseling to his patients. Oscar Lovelace is an excellent example of rural family
practice physicians who are approaching the health of their patients in a preventive,
holistic manner. He recognizes and uses the resources of his County Cooperative
Extension system as an integral part of his practice. As a County Agromwiicine
Advisory Physician, Dr. Lovelace, in tum, is available to the County Extension staff
for consultation on community health issues.

During the Alar controversy a few years ago, our Cooperative Extension agents and
specialists were besieged with phone calls fi-om concerned parents, physicians and
school officials asking, "Is it safe to eat the apples?" It is impossible to estimate the
value of having access to Dr. Stanley Schuman, an epidemiologist and pediatrician, to
respond to these concerns with calm, professional, science-based advice.

Dr. Schuman has developed a unique educational agenda for physicians as well as
farmers in our state and region. The core of his message is that our safe, abundant,
affordable food supply should be recognized as the cornerstone of health promotion.
Dr. Schuman is currentiy collaborating with one of my faculty associates in
Cooperative Extension, Dr. Rose Davis, in a nutrition education initiative aimed at
family practice physicians in our region. He also serves as medical advisor to our
statewide Extension committee on food quality and safety chaired by Professor Libby
Hoyle.

176

Dr. Schuman and his associates at the Medical University of South Carolina have
collaborated with faculty at Clemson, Winthrop and South Carolina State on a wide
range of projects involving rural health. These include farm safety, youth at risk,
health screenings, medication compliance, coping skills and life styles relating to
stress, heat and sunlight-related illness.

Academic programs at both Clemson and MUSC have been influenced by the
Agromedicine program. A rotation in Agromedicine is now available to medical
students at MUSC. At Clemson we have attempted to incorporate some elements of
physician training methods into our graduate degree in plant health (integrated pest
management). Medical and agricultural faculties share a strong interest in teaching
interdisciplinary, preventive approaches to pest and disease management. This
involves the use of pharmaceuticals or pesticides in a minimal way, and in the context
of the general health of the whole-family or whole-farm as well as the community.

The Cooperative Extension system and indeed the entire Landgrant university system
is in the midst of examining and redefming its role at the national, state, and local
levels. Consumers and environmental organizations have established themselves as
active stake holders in the food production system. Agricultural production and
processing groups have begun to acknowledge that consumers have a legitimate
interest in how their food is produced and in land and water stewardship.

This process of consensus seeking will be well served by close collaboration between
Landgrant and medical universities. As we have traveled together to every comer of
South Carolina, Dr. Schuman and I have often shared this thought: fanners and
physicians are actually in the same business. Both occupations are about human
health.

Attached as Exhibits 1 and 2 are comments ft-om two of my colleagues outlining
accomplishments of the EFNEP program in South Carolina and summarizing other
extension initiatives in nutrition.

(Attachments follow:)

177

Exhibit 1
EXPANDED FOOD AND NUTRITION EDUCATION PROGRAM

(EFNEP)
SOUTH CAROLINA

KATHERINE L. SHARMAN, PH. D. , R.D.
STATE EFNEP COORDINATOR

The Expanded Food and Nutrition Education Program (EFNEP) is
a federally funded program administered in South Carolina by the
Clemson University Extension Service. Its primary purpose is to
improve diets of limited resource families, thus enabling them to
enjoy better health, improved stamina, and increased productivity.

EFNEP education is tailored to the needs, interests, financial
resources, age, ethnic backgrounds, and learning capabilities of
participants. EFNEP includes programming for two primary audiences
- young families with children and youth age five to nineteen.

EFNEP 's objectives are:

1) to improve diets and nutritional welfare for the total family.

2) to increase knowledge of the essentials of human nutrition.

3) to increase the ability to select and buy food that
satisfies nutritional needs.

4) to improve practices in food production, storage,
preparation, safety, and sanitation.

5) to increase ability to manage food budgets and related
resources such as food stamps.

During FY 1992, approximately 4,000 homemakers were enrolled
in the Adult Phase of the Expanded Food and Nutrition Education
Program (EFNEP) . Food and nutrition lessons were tailored to the
individual needs of all homemakers and their families through the
use of computerized analysis of Family Records. In group
settings, the most frequently occurring nutritional needs of the
group members were addressed. All homemakers acquired some
knowledge and skills needed to plan, procure and prepare
nutritious foods for the family.

EFNEP county and state staff continued to receive assistance
from other agencies in identifying potential homemakers and in
working with homemakers in groups. Agencies who provided referrals
or cooperated with EFNEP in forming groups were as follows:
Department of Social Services, WIC, Food Stamp Program, County
Mental Health Agencies, Head Start, Interfaith Community
Services, and various anti-hunger agencies.

During FY 1992, over 60% of EFNEP families participated in the
food stamp program, 40 in WIC, and 50% had children who
participated in the National Child Nutrition Program. All
paraprofessionals, EFNEP Supervising home economists and EFNEP Area
Agents participated in training on the services of other agencies
and how to effectively make referrals.

178

All new homemakers were asked if they received food stamps or
WIC, and if not, were given information about these programs.
There were over 5,000 referrals from EFNEP to other programs. All
the major agencies, including the Department of Social Services and
the Department of Health and Environmental Control were visited by
the Supervising Home Economists and the 57 paraprofessionals in 38
counties. Contact was made by the EFNEP Coordinator with the state
level Health and Human Services Finance Commission, Department of
Social Services and the WIC Program to establish or improve
referral systems.

Officials of these agencies were informed about EFNEP and
were urged to make referrals to EFNEP. Various referral and
feedback procedures were discussed. As a result, over 1,500
referrals were made to EFNEP from other agencies.

Cooperation was obtained on referral of potential clients to
EFNEP from the following agencies: Food Stamp Program, WIC
Program, Mental Health Agencies, Soup Kitchens, Food Pantries,
Head Start Program, Salvation Army, and Department of Social
Services, and Interfaith Community Services.

During FY 1992, 4-H EFNEP operated in 32 counties involving 47
paraprofessionals. Approximately 5,000 youth were enrolled. These
youth learned knowledge and skills to enable them to make wise food
selections and to prepare simple meals and snacks.
Approximately 500 volunteers devoted over 6,000 hours to the youth
program. Ninety-five percent of youth were involved in a
comprehensive series of 6 to 16 lessons.

It is estimated that 95% of enrolled youth learned food and
nutrition skills and knowledge that will significantly improve
their food choices. While participating in 4-H EFNEP, all youth
were informed of regular 4-H activities and urged to participate
and to join a 4-H club after graduation from EFNEP. Approximately
90% EFNEP youth participated in at least one regular 4-H activity
during the year or continued as a 4-H member after graduation
from EFNEP.

179

Exhibit 2

Comments of Professor Rose Davis,

Extension Nutrition Specialist,

Clemson University

Question 1. Examples of recent research that has been well communicated to
consumers.

The issue of fat and its relationship to heart disease has been effectively communicated
to consumers. Recent surveys have shown that American adults and youth know that
too much fat is harmful to their health. However, they are having difficulty in
translating this to their food selections.

Question 2. Current research for "at risk" groups and methods of communication to
these groups.

Research continues on the harmful effects of too much fat in our diets. Educators are
finally realizing that you must go where the people are to deliver nutrition information.
This has lead to an increased emphasis on teaching people at the worksite and in
churches. We have two programs which do this: Nutrition Education for the
Congregation with the primary target audience being the African-American churches;
and Nutrition At Work. Both of these programs were developed in cooperation with
the Center for Health Promotion at the SC Department of Health and Environmental
Control.

Question 5. Nutrition Education examples from the private sector.

The American Cancer Society has a series of lessons called "Changing the Course";
this is for School Food Service Programs and educates the employees in better meal
service in the public schools. It also has a component for the classroom that involves
the School Food Service Supervisor working with the classroom teacher and students.

The American Heart Association has several programs. One is "Heart At Work"
which reaches people at the worksite; they also have a supermarket program that
assists consumers with shopping and a restaurant program that evaluates restaurant
menus for fat and sodium.

All of these activities are very successful; they are even more effective when several
groups, i.e.. Extension Service, Health Department, are involved with them in
delivering the information.

Question 6. Expertise in medical profession.

Personal opinion - no "hard data"; I think that the medical profession is severely
lacking in nutrition expertise. However, let me quickly say that I do not believe that it
is the MD's primary responsibility to counsel people on nutrition. S^e is trained to
provide medical expertise and the nutrition counseling should be done by a trained
professional, namely the registered dietitian. More resources should go to training and
educating more registered dietitians to provide these services in hospitals and
physicians offices. Third party payment (insurance) should be available for nutrition
counseling.

180

Question 7. Interagency coordination of nutrition education activities.

We have no problem with this in SC. DHEC, DSS, School Food Services and
Extension all cooperate in many ways to meet the needs of SC citizens. We know that
one agency cannot do it all and in our small, rural, poor state, we must cooperate.

Question 8. Priority needs in nutrition education and research.

Research:

Economic value of preventing disease through improved nutrition; put a $ value on our

educational efforts.

Study methodology for reaching diverse groups, i.e., effective methods for reaching

African-Americans, Hispanics, etc.

Education:

Teaching consumers to evaluate nutrition information received through the media and

other outlets

New nutrition labels

181

EHP7S7
Rep. March 1993

Clemson University
Expanded Food & Nutrition
Education Program

Extension

WHAT IS EFNEP?

The Expanded Food and Nutrition Education Program (EFNEP) is an integral part of the Cooperative Extension
System Home Economics and 4-H Youth Programs. EFNEP teaches limited-resource audiences how to improve their
dietary practices and become more effective managers ot available food resources.

WHOM DOES IT TARGET?

EFNEP includes programming to reach two pnmary audiences: Adult and Youth.
Adult: Limited-resource homemakers/individuals living in either rural or urban areas who are responsible for planning and
preparing the family's food, with emphasis on households with young children.
Youth: Limited-resource 4-H youth (ages 9-19 years) living in rural or urban areas.

The assurance that all eligible persons shall have equal access to the benefits of the program and facilities without regard
to race, color, national origin, sex, religion, age. or handicap is an important objeaive ot the Extension System. This
objective permeates the efforts of the Expanded Food and Nutrition Education Program.

OBJECTIVES OF THE EXPANDED FOOD AND NUTRITION EDUCATION PROGRAM:

To help limited-resource families and youth to acquire the knowledge, skills, attitudes, and changed behavior neces-
sary to improve their diets in normal nutrition

EFNEP can be expected to result In:

1 . Improved diets and health for the total family.

2. Increased knowledge of the essentials of nutrition.

3. Increased ability to select and buy food that satisfies nutritional needs.

4. Increased ability to manage resources that relate to food, including federal assistance programs such as food stamps.

5. Improved practices in food purchase, storage, safety, and sanitation.

182

PERCENT OF IMPROVEMENT IN DIETARY INTAKE AND SELECTED FOOD
BEHAVIOR AFTER PARTICIPATION IN EFNEP

MILK

(Two or more

servings)

ENTRY: E^SE '3°,;
EXIT:

FRUITS/

VEGETABLES

(Four or more servings)

ENTRY: B^SaaS 17%

66%

MINIMUM
ADEQUATE DIET
(One or more servings from
each food group)

ENTRY: 1ISSmi^JJ!?^fl 25%

ADEQUATE DIET

(Two or more servings of milk

and meat and four or more of ' ^^ ~g?"

fruit, vegetables, and breads/cereals)

ENTRY.

EXIT:

03%

55%

Making and Using a Shopping
List (Saves tTKiney, time, and
extra trips)

ENTRY:

EXIT:

20%

I 89%

Planning Meals to Feed
Their Family Better

ENTRY: Bsavwacfa u%

90%

Budgeting Food Money or
Stamps to Last All Month

ENTRY: EE^glg^^ 20°/

95%

183

HOW DOES EFNEP WORK?

ADULT:

Homemakers are taught either individually or in small groups by EFNEP Program Assistants who have received
trarning in nutrition education by an Extension Home Economist. The Program Assistants teach homemakers basic
nutrition, food-buying skills, menu planning, and management of available resources including food stamps.

YOUTH:

Youth of 4-H age (9-19) are taught in small groups by volunteer leaders who have received training from Extension
personnel in nutrition and how to wori< with youth The 4-H EFNEP groups work through a series of lessons focused on
nutrition knowledge, food preparation skills, and food choices. There is opportunity for youth and leaders to participate in
other 4-H opportunities.

WHO IS EFNEP HELPING TODAY? WHO HAS EFNEP HELPED SINCE 1969?

■ 85% have a family Income of less ■ Over 70.000 homemakers

than $8,863 per year have benefited from the program

■ 53% receive Food Stamps ■ Over 87,000 youth have benefited from

• the program

■ 22% of the Program homemakers are

White. 77% are Black, 1% Hispanic, and ■ Over 15.000 volunteers have worked

less than 1% Amencan Indian and Asian with both the adult and 4-H program

■ 72% live in rural areas, 28% in urban
areas

184

WHO TO CONTACT?

If you are interested in finding out more about EFNEP please
contact the county Cooperative Extension office number listed on
ttie right:

Prepared by Katherine L. Sharman, Ph.D., R.D., Extension
Program Coordinator, Expanded Food and Nutrition Education
Program

^ J Printed on recycled paper with soy ink

"Rie ClerTBon Unfversily Cooperairv9 Exienston Semes

oHen Its pfografm to pecp'e of all ages, regardless of race. sei. reigton.

rvaional otigm. or handicap and s an equaJ qspodun^ty errployer.

Ciemeon University Cooperattrtg witti U.S. Depervnenl of AgriculOn, S«utfi CeroUne

Counbcft, Extension Servic*. B.tC Webb. Director. Clermon. S.C. Issued In

Furtherance ot Cooperative Eiienwon Work in Agncullure mni Honw Economic*,

Acu ot Miy 8 and June 30. 1914

County Extension Offices

Abbeville

459-4106

Greenwood

229-6681

Aiken

649-6671

Hampton

943-3621

Allendale

584^207

Horry

248-2267

Anderson

226-1581

Jasper

726-3470

Bamberg

245-2661

Kershaw

432-9071

Barnwell

259-7141

Lancaster

283-3302

Beaufort

525-71 18

Laurens

984-2514

Beriieley

761-8499

Lee

484-5416

Calhoun

874-2354

Lexington

359-4265

Chafleston

722-5940

McCormick

465-2112

Cherokee

489-3141

Marion

423-8285

Chester -

385-6181

Mariboro

479-6851

ChesterfiekJ

623-2134

Newberry

276-1091

Clarendon

435-8429

Oconee

638-5889

Colleton

549-2596

Orangeburg

534-6280

Darlington

393-0484

Pickens

868-2810

Dillon

774-8218

Richland

256-1678

Dorchester

563-3441

Saluda

445-8117

Edgefiekj

637-3161

Spartanburg

582-6779

Faiifiek)

635-4722

Sumter

773-5561

Rofence

661-4800

Union

427-6259

Georgetown

546-4481

Williamsburg

354-6106

Greenville

232-4431

York

684-9919

185

WRITTEN TESTIMONY BEFORE

THE U.S. HOUSE OF REPRESENTATIVES

COMMITTEE ON AGRICULTURE

SUBCOMMITTEE ON DEPARTMENT OPERATIONS AND NUTRITION

PREPARED BY

DAVID A. McCARRON, M.D.

PROFESSOR OF MEDICINE

THE OREGON HEALTH SCIENCES UNIVERSITY

JULY 15, 1993

Members of the House, Staff and Colleagues, I want to express my appreciation for being asked
to testify before the Committee on Agriculture's Subcommittee on Department Operations and
Nutrition, as it considers the linkage between nutrition research and nutrition education in the
United States. I appear here today as a health care professional whose formal training was not
in the nutritional sciences, but whose career path has led to 15 years of exploration of the link
between the food we eat and one of the most common medical disorders in adults in this
coimtry, high blood pressure, or hypertension. I currently direct one of the National Institutes
of Digestive, Diabetes and Kidney Diseases' Clinical Nutrition Research Units (CNRU). The
CNRU at Oregon is the only one of the eight NEH CNRUs which has hypertension as one of its
two primary foci. The other focus is lipid disorders in adults. I also currently chair the Council
on Hypertension for the National Kidney Foundation. The basic question you are considering
today, I consider of utmost importance to this country. At a time in our nation's history when
we are struggling with harnessing the costs of the most successfiil health research and health care
system in the world, it would appear that the critical contribution of our diet to our nation's
health may be discounted as an important factor in the equation that we all wish to see solved.
That is, how to deliver to our citizens optimal health care that is affordable to our society.

In a day and age when the advances of molecular biology and its attendant exploration of the
genetic basis for the diseases, conmion and rare, that afflict humans, have the attention of the
media, it would be easy to overlook the power of proper diet in our lives to deliver the insurance
that we all seek against the ravages of preventable diseases. In contrast to these "sophisticated
scientific endeavors" that dominate much of our interest in the biomedical field today, I often
refer to nutrition research as the exploration of the low-tech solutions we can "live with." If
there is one thought I wish to leave you with today, it is that this country must get serious
in acknowledging the impact that nutrition has on our lives.

There is general agreement that public health strategies that will prevent common diseases that
strike us prematurely and at tremendous costs to human potential and society's resources, must
be the lynch pin of a national effort to reduce the cost of health care. We have reason to be
optimistic that such public health measures could be successftil. We have experience as a society

186

and a species. We live longer today than our forefathers because of public health measures, the
eradication of many communicable diseases. As a society we talk about other reasons for why
we live longer - sophisticated drug development, new life-support technologies, etc, but those
advances have not had the impact that smallpox or tetanus vaccinations have had, or general
hygienic efforts, such as sewage treatment of water purification, have had. We need only look
at those countries where these types of public health advances still have not been reached to
know what their value is in improving life expectancy. Or, we can simply look at what AIDS
is doing to this country, to be reminded of the importance of public health preventive measures
to extending the length and quality of life.

I would like to pose to this Committee the thesis, that the topic of discussion today, nutrition,
is the other factor, after infectious diseases, that holds the greatest potential to reduce suffering
from common chronic diseases. That potential will only be realized if it is made a priority by
society and the individuals that govern us, such as yourselves. If one simply looks at the major
medical causes of premature morbidity and mortality in the United States, they all have a strong
tie to diet. Beginning with pregnancy and low birth-weight infants, moving through
childhood/adolescent eating disorders to adult disorders such as diabetes, cancer and
cardiovascular disease, and fmally, osteoporosis in our elderly, we already have the insights to
know that proper diet could be a prime component in their prevention.

Let me provide some real examples of the potential we are talking about drawn from areas of
clinical medicine I am familiar with from my research. The dietary intake of dairy products
during the last three months of pregnancy predicts an infant's blood pressure at six months and
two years after birth. We know that the lower an infant's blood pressure at birth, the lower her
or his blood pressure will be throughout life, which translates into a lower overall heart disease
risk for life. The impact of milk on an infant's blood has been linked to the mineral rich content
(calcium, potassium and magnesium) of that food source. This effect of milk consumption on
early childhood blood pressure development has also been demonstrated in three- to five-year-old
youngsters, as reported by the Framingham Family study last year. The investigators from
Boston called the beneficial impact of milk on blood pressure the strongest blood pressure
protective factor ever identified in children.

Along this same theme, scientists from a multi-center study in the Southeastern United States
reported that differences in milk and dairy product intake between Caucasian and African-
American teenage girls accounted for all of the racial differences in blood pressure. Again, this
impact was linked to the mineral content of milk. Even though these white teenage girls
reported more milk intake, a perceived source of fat and extra calories, they were thinner than
their African American peers. This association of dairy product intake with leanness in America
had originally been reported by ray laboratory in our analysis of the U.S. Government database
HANES I, which we published in SCIENCE in 1984. It was subsequently documented by other
researchers in Europe. Thus, this series of findings offers a simple, nutritional public health
strategy to keep blood pressure down early in childhood and adolescence, which means setting
up these youngsters for a healthier adult life.

187

Furthermore, this series of findings provides a possible explanation for why racial differences
in blood pressure exist in this country, a factor that we know strongly contributes to the greatly
increased risk of heart disease, stroke, and kidney failure in our African-American peers. In
fact, scientists at Wayne State University have reported that two containers of yogurt per day
for several months will reverse hypertension, improve diabetic control, and regress hypertrophy
(thickness of the heart muscle) in black, diabetic hypertensives. I do not have to calculate what
the economic and quality of life impact is. It equates to billions of dollars saved to our health
care system and greater productivity and contribution to our society of a high risk group that has
suffered throughout the history of this country from premature morbidity and mortality from
these common disorders.

The importance of these fmdings are being further explored by investigators in Southern
California in an NIH-supported study. In our program at Oregon, we have recently been
awarded the Coordinating Center for a multi-center study of the impact of diet on blood pressure
in adult Americans. The study is structured to include at least 50% African- Americans when
it is concluded in 1996-97. Think about the implications, though, of what I have just stated.
The National Institutes of Health in 1993 has set out to test, for the first time ever, the benefits
of a balanced diet on blood pressure control in adult Americans. I am sure most members of
Congress, as most consumers would assume that this theory had been properly tested long ago,
but it has not!

The thread of this clinical nutrition saga extends well beyond the examples presented above.
Studies by our program at Oregon have demonstrated that approximately 40% of individuals with
mild hypertension will achieve good blood pressure control by simply increasing their calciimi
intake by 1000 mg/day. We have recently completed a comparison of using a dietary source of
calciimi and compared it to calcium supplements. Both sources of calcium lowered blood
pressure to about the same degree, but as we will report later this fall in The American Journal
of Clinical Nutrition, the subjects who were treated by diet corrected not only a deficit in their
calcium intake, but also deficits in their potassium and magnesium intake as well. Of greater
significance, even though the subjects who used a dietary rather supplement source, more than
doubled their dairy product consumption, they experienced no adverse effects in terms of weight
gain or blood lipid levels. "Common wisdom," as expressed by the average consumer, would
have predicted just the opposite. The NIH Trial of dietary patterns and blood pressure control,
noted above, will test the benefits of diet in treating hypertension further.

Another high risk population currently being tested for blood pressure benefits of maintaining
an adequate calcium intake, are yoimg, first time pregnant mothers of lower economic status.
These young women are at substantially greater risk of developing hypertension during their first
pregnancy. The hypertension, while frequently of only limited consequences to the mother, is
often associated with premature low birth weight infants. This clinical trial is testing the impact
of 2000 mg of calcium as opposed to the current recommendation of 1200 mg during pregnancy.
Based upon the hflH's estimates and the preliminary studies in this area by investigators from
Johns Hopkins, our program, and investigators from abroad, it is anticipated that this simple
intervention, costing less than 13 cents per day, will cut the incidence of premature, low birth-

188

weight infants by 40-50%. Published data from Quebec, Canada has already reported that
women at risk who maintain a calcium-rich diet from dairy products experience a 40% reduction
in their risk of hypertension and its complications during pregnancy.

With each low birth-weight, premature infant costing an average of $250,000 the first year of
life, according to the March of Dimes, the impact of this potential public health strategy could
mean as much as $4 to $8 billion saved in Federal health care costs alone within the first
eighteen months of initiating it. The savings in terms of human potential can not be estimated.

The implication of this body of research I have touched upon concerning blood pressure
benefitting calcium intake was recently acknowledged by the Joint National Commission on the
Detection, Evaluation and Treatment of Hypertension from the National Heart Lung and Blood
Instimte at NIH. This report added as a preventive and treatment measure the recommendation
that subjects with hypertension, or at risk of developing it (that's all of us), maintain a life-long
intake of dietary potassium, calcium and magnesiimi. This means milk and dairy products,
which supplies 70-75 % of our calcium, 30-35 % of our potassium and 20-25 % of our magnesium
exposure on a daily basis. In fact our work and that of many other laboratories worldwide, over
the past decade, has unequivocally demonstrated that the benefits of dietary calcium are highly
dependent on the simultaneous ingestion of these other two electrolytes, and also salt.

This latter fact, that the intake of these three electrolytes appear to protect against salt's
perceived adverse effects on blood pressure, brings me to issue of the discordance between
nutrition research and nutrition education. If one simply asked consumers on the street, or in
this Congressional Hearing, what was the dietary factor most strongly linked to an increased risk
of hypertension, they would most likely say "salt." And yet, within my peer group of
hypertension researchers, it is well-recognized that the link between high salt and high blood
pressure is very tenuous. In fact the advances of the past ten years have led many of us to
appreciate the importance of dietary deficiencies and not excesses in the genesis of hypertension.

This fact has led many of us to also come to grips with the obvious, but long overlooked
principle, that it is not single nutrients which affect our health to the good or the bad; it is the
food. In this case, dairy products are the foods most frequently identified as being the source
of the calcium responsible for lowering blood pressure. We recognize that it is also the
potassium and magnesium that comes with calcium in the food source that accounts for this
protective effect. Not only does the mineral content of milk appear to be essential, but also the
fats in dairy products have also been reported by our group to contribute to the anti-hypertensive
effect of miUc and dairy products. Think of the confusion for the consumer. Federal public
policy and nutrition education efforts have emphasized the putative adverse cardiovascular
consequences of dairy products because of their fat content and have warned repeatedly about
the risk of dietary salt.

What are they to believe? For now it will be these "wives' tales of the past," and not the facts
which have emerged from nutrition research. What are the barriers to proper education of the
populace? I would argue they are multiple and formidable. I would also argue they are not

189

unique to the area of research I have chosen to highlight, dietary factors influencing blood
pressure control. The barriers include forging public policy before the research to support
is ever executed. There appears to be an uncontrollable urge on the part of iixlividuals involved
in setting public health policy in the area of nutrition to make pronouiKements before the proper
data is available to support them. It is as though the public must have an answer and there must
be good nutrients and bad nutrients.

A corollary to this fvst barrier is the lack of funds to support the nutrition research that needs
to be undertaken to properly document the relationships that exist between our nutritional
patterns and diseases. Setting policy in advance of science, creates perhaps the biggest barrier -
what do you tell the people, if after you have set the policy, the scientific studies indicate that
the policy is misguided or simply wrong? I would propose to the Subcommittee, that we have
such a conflict with the long ago, signed-off on position that reduction of dietary salt was the
nutritional goal for the prevention and treatment of hypertension. That is not to mention the
conflict set in motion, if not only that dairy products do turn out to be an important contributor
to reducing hypertensive heart disease, but also that butterfat actually possesses blood pressure
lowering actions, as the preliminary work already indicates it does. I could envision some very
confused consumers.

Perhaps an equally important barrier is the way in which most consumers receive their nutrition
information. It rarely comes from the health care professional, since most physicians possess
only a rudimentary understanding of the nutritional sciences as they apply to the practice of
medicine. The origins of this deficit in physician education was addressed several years ago by
the National Academy of Sciences in their report on the status of the nutritional sciences in
medical school education. It was not a glowing report!

Unfortunately, much of the nutrition information our consumers are exposed to comes from the
marketing efforts of the food industry. By the very nature of the corporate sector, using
nutrition information as a marketing tool means segmenting foods by their specific nutrient
uniqueness that sets one product apart from another. This does two things: first, its sets people
thinking about single nutrients and not foods; second, it introduces the concept of good foods
and bad foods based upon a single nutrient characteristic of a food product. In essence, there
is little or nothing to be gained by talking about food and the importance of the total diet, as the
maiiceting benefits hinge upon the specific qualities of one product versus another.

That is where the agricultural sector has difficulty competing. For many agricultural producers,
the nutritional qualities their commodities bring to the marketplace are not communicated in
corporate reliance on the benefits of the specific nutritional aspects of the food product
produced. I am aware that one major food corporation has taken steps recently to convey,
eventually, a total diet message for several high risk populations. The impact and success on
consumers' understanding of that unique mariceting approach remains to be determined.

The agricultural sector's response, too frequently in the past, has been to compete with the food
corporations on the same basis, flashy marketing ploys that ignore the overall nutritional benefits

72-928 0-93-7

190

that the commodity actually possesses. More than the private corporations involved in food
production, the various fanning groups are much more dependent on the conununication of the
total diet message. By that, I mean that they have a "generic" product to promote whether it
be com or fluid milk, as examples. There is no specific food product that the consumer can
focus on. As a consequence, the verification of the health benefits of a specific commodit>'
through the scientific process and its communication to the consumer must rest on this "generic"
approach. The commodity groups of the agricultural sector have been reluctant, in my view,
to undertake what is required to educate, effectively, the consumer about how their commodities
contribute to a "healthy diet. "

In supporting that conclusion, I have to rely, once again, on our experience at Oregon.
Obviously, our focus on the health benefits of dietary calcium in the prevention of hypertensive
heart disease has placed us in parallel with the long-term interests of the dairy industry. In the
niid-1980s, several leaders of this commodity group recognized the wisdom of the approach (I
have suggested above) is needed. They consolidated nutrition research funding around' the
nutritional benefits concentrated in their commodity, i.e. calcium and other electrolytes. They
developed a multi-dimensional research strategy centered on the concepts emerging from our
laboratory, but utilizing also the expertise of investigators from a variety of campuses throughout
the country. That targeted approach, without doubt, catalyzed the development of the database
I have alluded to above, regarding the life-long, beneficial impact of milk and dairy product
consumption on a variety of cardiac risk factors for several high risk populations.

The approach initiated in 1984 required the cooperation of both regional and national dair>
organizations including the Wisconsin Milk Marketing Board, the National Dairy Council, the
California Milk Advisory Board, as well as many other regional dairy promotion units. Soon
after its inception in 1985, the National Dairy Board assumed much of the funding and
coordination responsibility for this national research effort. While I am not without bias, there
is little question that this effort, in its structure, financial commitment and outcome was both
time and cost effective. Using an approach similar to that developed by the United States
Department of Agriculture through its highly successful Human Nutrition Research Centers
funded by the Agricultural Research Services, the dairy industry provided a prototype for other
agricultural groups to replicate.

How do I measure the success of that program? It is evident that the multiple NIH trials I have
mentioned would not have been proposed or funded were it not for this targeted effort and the
preliminary data it generated. Personally, the awarding to my research group of one of the
NIH's eight Clinical Nutrition Research Units in 1989 was the peer acknowledgement of our
success in developing a compelling case to further explore the nutritional value of the minerals
in milk. That event linked NIH nutrition funding based upon a "disease model" with industry
resources focusing on a "health promotion and prevention concept."

Precisely, the issues that I suspect underlie this Committee's interest in holding today's hearing
were being addressed by this coordinated research effort. Its funding by the dairy industry,
through the appropriate mechanism established by Congress and the National Dairy Board, was

191

the driving force behind the development of a national nutrition research effort directly tied to
defining the health benefits of their commodity. It had immediate application in terms of
nutrition education for consumers and health professionals. The rather substantial value this
effort delivered to the setting of public health policy are obvious from the examples noted above.

To address the latter two points, through the CNRU at Oregon, a Physician's Education Program
on the Non-Pharmacologic Management of Hypertension was delivered with sponsorship of the
National Kidney Foundation with funding from the National Dairy Board. That one-day
program has visited 23 cities, been attended by over 5,000 health professionals and was cited
several years ago by the WHO's Hypertension League as the best source for practicing
physicians on how to prevent and treat hypertension by dietary means. We also delivered a
quarterly review entitled Nutrition and Blood Pressure Reviews, also sponsored by the NKF.
In terms of affecting public policy, the incorporation of the recommendation to maintain life-long
potassium, calcium, and magnesium intake by the panel from the National Heart, Lung and
Blood Institute is compelling documentation. I have to emphasize that without forwarding
thinking leadership coming out of Wisconsin, California, Washington State, and United Dairy
Industries Association in Chicago, the umbrella group for National Dairy Council in 1983-84,
none of this would have been possible.

As an indication of just how fragile these commitments are, however, within weeks of the NIH
decision to award one of their CNRU's to the National Dairy Board's Institute at Oregon, we
were notified by Dairy Board staff that the substantial and critical funding provided to us by the
Board would be phased out over an 18-month period. Citing data they claimed indicated that
health professionals and consumers would never be interested in nutrition information linking
milk and dairy product consumption with a reduction in heart disease risk, the staff of the Dairy
Board began a process that has largely dismantled a national network of nutrition researchers
centered around, but hardly limited to, our program at Oregon.

However, the responses the Board got from its surveys are not surprising as the one component
of this entire eight-year effort that was never properly developed was an aggressive education
program to alert the consumer and the health care worker as to the evolution of the information
flowing out of this program. It is not surprising that given decades of messages to the
contrary, when the uninformed were asked what their response would be if this data were
true, they gave an uninformed response. It is evident to all of us directly involved, that the
millions of dollars invested by the Board would not yield their full return unless a serious effort
was also made by the Board to tie the outcome of this nutrition research program to the day-to-
day marketing strategy of the dairy industry. Even when the NIH issued their new prevention
recommendations last October regarding the need to maintain the electrolyte intake pattern found
in milk, only a minimal and under-funded effort was made to communicate this to the public.
When alerted about the NIH Calcium Intake and Pregnancy Trial, discussed above, no interest
was expressed to establish a link with the program staff at NIH who were directing the project.

So, without follow through to convey the new nutrition information and further expand the
research effort by leveraging the industry's commitment off of appropriate Federal initiatives.

192

such as the various NIH studies I have cited and the CNRU at Oregon, the outcome is
predictable. Research is successful in dramatically expanding our understanding of the health
benefits of a major food group, but the consumer is left largely uninformed. I can assure this
Committee that if a multi-national pharmaceutical corporation had the permanent patent on a
factor that: 1) could potentially eliminate the need for 40% of their competitors' antihypertensive
drug prescriptions; 2) offers significant protection might be afforded against hypertensive
disorders of pregnancy and the attendant reduction in low birth-weight infants; 3) might be the
answer to preventing salt's adverse effects on blood pressure; 4) had significant benefits for
reducing the excessive risk of heart disease, stroke, and kidney failure that African- Americans
face, I do not have to suggest what the corporate response would be.

In fact, our own experience with another consumer education program we share with Dr.
Rivlin's CNRU at Cornell, suggests that consumers do want access to current nutrition
information. Dr. Rivlin and his colleagues at Cornell developed three years ago a Calcium
Information Center funded by SmithKline Beecham. The 800 # that is the center piece of that
consumer education program, which we administer out of the CNRU in Portland, will be used
by over 35,000 consimiers and health care professionals this year alone. The CIC has also
favorably impacted upon the execution of the NIH pregnancy trial on calcium, by directing
private funding into the NIH program office involved. The quality of the NIH study and the
data generated has been consequently enhanced by the additional financial resources made
available.

The dairy industry made all the right initial moves and then walked away from the opportunity
to derive the social and economic rewards it deserved and society needed. Fortunately,
individuals within the current political leadership of the U.S. dairy industry have provided partial
funding to sustain portions of this nutrition research effort. That continued support provided by
a number of units of the National Dairy Council likely insure that critical components of this
research program are maintained.

I believe the process of improving nutrition research and education in this country and linking
it to the organizations and corporations that have the most to gain is an important task that the
Department of Agriculture needs to sustain. My own professional experience over the past
fifteen years has convinced me of its value to the citizens of this country. The USDA has many
fme programs, not the least of which is the USDA Human Nutrition Research Centers
represented here today. In addition there are the nutrition information programs under Assistant
Secretary Haas' supervision, which will benefit substantively from her lifelong, professional
commitment to consumer education and advocacy.

I would offer these concluding recommendations to the Committee for its consideration.

First, the promotion and expansion of the Department's efforts in this area of health care needs
to be a priority. Why? Because the health of our citizens and the financial viability of the
agricultural sector of our economy are inextricably linked. We win at both ends of the table.

193

Second, priority and commitment means fiscal support of coordinated research and education
projects. While small grant programs of ARS are the life blood of our future successes, the
application of what we already have some understanding of, means financial resources to sustain
critical masses of researchers such as currently exists at the USDA Human Nutrition Research
Centers. I suspect, though, that each of the current directors find themselves severely restrained
in their effectiveness, because even these programs are not fully funded and they need to be.

Third, there is no way to avoid the support of the most costly and challenging type of research
required, the study of humans. The work must be tied to coordinated, multi-disciplinary
research efforts, but funding must be sufficient to insure effective and timely execution. In the
end the smdy of human diseases, their treatment and prevention must be done in himians, the
most difficult of all experimental animals.

Fourth, the Department must focus on foods, and not single nutrient issues, in supporting
nutrition research, interpreting the results and commimicating the findings to all segments of
society.

Fifth, the marketing efforts of the various commodity groups operating imder the guise of the
USDA must be tied to their long-term support of targeted scientific research that applies directly
to their commodity. The support has to be substantial and not token in its nature. Businesses
involved in scientific enterprises know that R&D budgets of 2, 3, or 4% of revenues will not
sustain the corporation. The same applies to the producers of our basic food commodities, 20
to 25% of available promotion dollars need to be expended on a yearly basis in order to generate
the information around which promotion efforts should center. I would argue that an
advertisement about an agricultural commodity that does not inform the consumer about
nutritional benefits of the commodity only serves to employ copy editors, and does little to
sustain the agricultural foundations of our society.

I want to again extend my appreciation to the Committee for offering me the opportunit>' to
share my professional experience in nutrition research and education. I believe the questions
you are considering are vital ones for the health of our citizens, the viability of the farmers of
America, and the fiscal soimdness of the United States budget, as the members of Congress face
the challenge of reducing health care cost while improving the health and productivity of all
members of our society.

194

LINKING NUTRITION RESEARCH TO MEDICAL EDUCATION

AND PRACTICE

TESTIMONY PRESENTED TO

U.S. House of Representatives

Committee on Agriculture

Subcommittee on Department Operations

and Nutrition

Room 1301, Longworth House Office Building

Washington. DC 20515

ON
July 15. 1993

BLBAMOR A. YOUIIO, PH.D., RO, LD

PROFESSOR, DBPARTMBNT OP MBDICIMB

DiyiSIOM OP GASTROEMTBROLOOy AMD HUmil MUTRZTIOM

THB UmVERSITY OP TBIAS HBALTH SCIBlfCB CBMTBR

AT SAM AMTOMZO
SAM AMTOMIO, TBXAS 78284-7878
TBLBPHOHBt 210-567-48C2
TBLBPAZ: 210-567-4654

195

TABLE OF CONTENT
I. Introduction

II. Evidence for the Role of Nutrition
in Health and Disease

III. What are the Barriers?

IV. Possible Alternative Initiatives

to Enhance Nutrition Education and

Nutrition Practice for Physicians 8

V. Initiatives at the University of Texas
Health Science Center at San Antonio,
San Antonio, Texas 13

VI. Selected References 16

196

LINKING NUTRITION RESEARCH TO MEDICAL EDUCATION AND
PRACTICE

Honorable Eddie De La Garza, Chairman, Conunittee on Agriculture

Honorable Charles W. Stenholm, Chairman, Subcommittee on Department
Operations and Nutritiion

and other members of the Subcommittee

I . Introduction

Thank you for the opportunity to testify before this Sub-
Committee on the linkage of nutrition research to the education and
practice of physicians.

I am Dr. Eleanor A. Young, Professor, The University of Texas
Health Science Center at San Antonio, Texas. I am not a physician,
but I do hold a doctoral degree in Nutrition from the University of
Wisconsin. For the past 25 years I have served as a faculty member
in the clinical Department of Medicine, Division of Gastroenter-
ology and Human Nutrition. During this time I have been involved
in: 1) the development of a nutrition education program for our
medical students; 2) providing nutrition consultation to patients
referred by physicians; and 3) active nutrition research.

INTRODUCTION. During this quarter of a century, there has been
increasing evidence to clearly document the necessity for nutrition
in the practice of medicine, including:

1) the application of nutrition in the treatment of disease

2) the provision of nutrition education in the prevention of
disease

3) the promotion of health so as to prevent nutrition-related
disease.

It has become very clear that the application of basic
nutrition knowledge and scientific principles is an absolute
necessity in the medical care of patients today. It is NO LONGER AN
OPTION. We can no longer suggest that perhaps nutritional care of
patients may be important. We can no longer relegate nutrition
support to a level of minor considerations. We can no longer just
ignore nutritional care altogether. Today nutrition is an
essential consideration of the overall medical care of every
patient, and is thereby a responsibility of every physician.
Thus, it is incumbent that basic nutrition principles be integrated
in medical education. Every physician is held responsible for the
appropriate application of nutrition support in the care of
patients, as well as in the prevention of disease, and the
promotion of wellness. This strong stance is based on several
sources of evidence briefly summarized here.

197

II. EVIDENCE FOR THE ROLE 07 NUTRITION IN HEALTH AND DISEASE

1. Documentation in the scientific literature.

The evidence accumulated to document the central role of
nutrition as related directly or indirectly to eight of the ten
most common causes leading to morbidity and mortality in the U. S.
places clinical nutrition in a strategic position in disease
prevention and health promotion (1) .

Estimated Total Oaaths and Percent of Total Deaths for the
10 Leading Causas of Death: United States, 1987

Percent

ofTmal

R;ink

Cauic of Oeaih

Number

Deaths

!•

Heuri diseases

7S9.400

35.7

(Coronary heart diseasel

(SI 1.7001

(24.11

lOiher hean disease)

I247.7UU)

(11.6)

2«

Cancers

476.7UU

22.4

Sirulies

148.700

7.0

Uninieniionai injuries

n.xo

4.4

(Moiur vehicle)

|46.ilUU)

12.21

(All others)

(43.7001

12.21

Chronic obstruciive lung diseases

78.000

3.7

Pneumonu and influenza

68.600

3.2

7»

Diabetes mellilus

17.8UU

1.8

8»

Suicide

29.UIO

1.4

9»

Chronic liver disease and cirrhosis

26.UOO

1.2

I0«

Aiherusclerosis

23.100

I.I

All causes

2.123.100

100.0

•Causas ol oeaui n wtacii dwi plays • pan.

BCausM d deatn n wncn mgomiv* aicanai consumoiion puys a part.

Souca: National Caniar (or H«anh Statistics. UoniniY Vital Siaiisiics A«oa/(. vol. 37. no.
1. April 25. 196a.

The Surgeon General's Report on Nutrition and Health (2)
summarized the significant accumulation of evidence to support the
role of nutrition in the major diseases and disorders.

As a follow up of this Report (2) , the Food and Nutrition
/Board published an extensive documentation of the epidemiological
and clinical data confirming the role of diet related to health and
disease. The title, DIET AND HEALTH: IMPLICATIONS FOR REDUCING
CHRONIC DISEASE RISK (3) , indicates the emphasis placed on reducing
the risk of these diseases via dietary changes. The three major
objectives of this classic study were:

A. To develop criteria for systematically evaluating the
scientific evidence relating dietary components, foods, food
groups, and dietary patterns to the maintenance of health and to

198

the reduction of risk of chronic disease;

B. To use these criteria to assess the scientific evidence
relating these same factors (dietary components, foods, food
groups, and dietary patterns) to health and to the reduction of
chronic disease risk; and

C. On the basis of this assessment, to propose dietary
guidelines for maintaining health and reducing chronic disease
risk, to suggest directions for future research, and to provide the
basis for periodic updates of the literature and guidelines as new
information on diet and health is acquired.

2 . Changing recommendations to actions

In 1989 the Institute of Medicine released the document:
Improving America's Diet and Health from Recommendations to Action,
a report of the Committee on Dietary Guidelines Implications (4) .
This document had two major goals:

A. To propose detailed strategies and options for the
implementation of dietary guidelines by government agencies at all
levels; by educational institutions and those who provide nutrition
information to the public; and by certain segments of the private
sector, including institutions concerned with mass feeding; and

B. To examine the potential benefits and costs of
implementing dietary guidelines.

The role of health care professionals, especially physicians,
in putting into action the dietary guidelines was stressed.
Physicians usually represent the initial contact made by people
seeking health care (estimated in the millions / day) .

Since diet/nutrition is a very significant factor in health
and disease, a primary question posed is HOW do we enhance
awareness, understanding and acceptance of nutrition
recommendations so as to effect change in dietary patterns and
thereby impact positively on health promotion and disease
prevention in the U. S.? Certainly, physicians are the health care
providers who are expected to be foremost in leadership in changing
dietary recommendations to ACTIONS.

3. Objectives for the year 2000

An important objective published in HEALTHY PEOPLE 2000:
NATIONAL HEALTH PROMOTION AND DISEASE PREVENTION OBJECTIVES (5)
was:

"Increase to at least 75 percent the proportion of primary care
providers who provide nutrition assessment and counseling and/or
referral to qualified nutritionists or dietitians."

199

The baseline figure in 1988 estimated that physicians provided
diet counseling for only an estimated 40 to 50 percent of patients
(6) . Approximately only 2 6% of adults reported that "eating proper
foods" was often or sometimes discussed during visits to a doctor
or other health professional for routine care (7) . A meta-analysis
of 9 physicians surveys, 2 chart audit studies, and 1 consumer
survey estimated that physicians provide diet counseling for only
40 to 50 percent of patients (6) .

The question is how can physicians provide nutrition
counseling in a way that will effect positive change?
Specifically, how can physicians realistically do this unless they
are appropriately educated, motivated and convinced that nutrition
is important in overall health care?

4. Congressional Law 101-445

In 1990, Public Law 101-445 was passed by the 101st Congress.
The purpose of this law was: to strengthen national nutrition
monitoring by requiring the Secretary of Agriculture and the
Secretary of Health and Human Services to prepare and implement a
ten-year plan to assess the dietary and nutritional status of the
United States population, to support research on, and development
of nutrition monitoring, to foster national nutrition education, to
establish dietary guidelines, and for other purposes. Section 302,
Nutrition Training Report stated:

"The Secretary of Health and Human Services, in consultation
with the Secretaries of Agriculture, Education, and Defense, and
the Director of the National Science Foundation, shall submit,
within one year after the date of enactment of this Act, a report
describing the appropriate Federal role in assuring that students
enrolled in United States medical schools and physicians practicing
in the United States have access to adequate training in the field
of nutrition and its relationship to human health".

This law is a clear mandate that all physicians are
responsible to see that nutrition care is an essential component of
the overall medical care of every patient, and points out again
that this is NO LONGER AN OPTION.

5. Care effectiveness and cost effectiveness of nutrition support

A final point in evidence of the responsibility of physicians
providing appropriate nutritional support is based on rapidly
accumulating evidence that appropriate nutritional support not only
can prevent or lessen the impact of disease, but may be able to
significantly lessen the economic cost of disease or illness (9-
18) . A key consideration is not only that appropriate nutrition
support may lessen, or even in some cases prevent, the pain,
sickness, disease, or trauma associated with disease or disorder

200

via the application of nutritional support, but may also be cost-
effective, lessening significantly the economic burden on patients,
and thus on total health care (9-18) .

The above five facets of evidence strongly support the
responsibility of physicians to be educated in basic principles of
nutrition, and to apply appropriate nutrition support for every
patient.

III. WHAT ARE THE BARRIERS?

Given the overwhelming evidence as briefly outlined above
that physicians do indeed have a professional mandate to provide
nutrition education and support to their patients, the question at
this time, 1993, is VfHY has academic medicine generally failed to
accept this challenge, this responsibility? Selected barriers
follow.

1. Vacuum in Creative Leadership

Without a clear, strong advancement in clinical nutrition
education leadership, positive changes are not likely to occur (19)
Creative leadership is needed at the academic medical school level,
and at the federal level.

2. Competition within the medical curriculum

An overwhelming knowledge base has continued to expand
significantly, and somehow must continually be whittled down
to''fit" into the 4-year curriculum. Thus, there is much, much more
expected to be learned, but within the seuoe time fraune as 30 years
ago! .

Competition for curriculum time is a major barrier, and there
are no easy ways to get around this. However, some creative
approaches may be taken to effectively deal with this. Medical
schools must find solutions to this barrier.

3. Failure of medical schools to recognize the essential role of
nutrition in medical practice

Currently only a very few medical schools have a Nutrition
Department or Division staffed with funded faculty, a fact that
indicates non-recognition of the essentiality of nutrition in
medical education and practice.

4. Funding competition within the medical school

201

Not only is there competition among departments for curriculum
time, but also for funding. Funding is allocated to each
department depending on a number of factors, including: faculty
support; allocation of space and supportive staff; revenue
generating ability via patient care; research funding/achievement;
teaching/education responsibilities. Thus, a nutrition department
must provide not only nutrition education, but also provide patient
care revenue, gain research grant support, and support faculty and
supportive staff. Lack of institutional resource base may make it
impossible to develop and maintain a nutrition department unless
adequate funding base can be provided and maintained.

5. Nutrition care reimbursement system

Lack of a viable reimbursement system for dietary counseling
creates a significant barrier in practice. Currently, nutritional
counseling in the treatment or management of disease, e. g. ,
diabetic diet, lip id- lowering diet, etc., as well as in the
prevention of disease, or promotion of health/wellness, is
generally NOT REIMBURSABLE. Consequently, since financial
reimbursement drives most of medical practice, and since it appears
that in the future greater emphasis will be placed on prevention of
disease and wellness, the outlook for changing this situation is
not currently optimistically viewed. Even though prevention of
disease is cost effective compared to expenditures to try to
reverse disease after it may be well established, the practice of
medicine has not thus far turned this around.

IV. POSSIBLE ALTEBMATIVB IHITIATIVES TO BHmOfCB MOTRITIOH
EDUCATION AMD HUTRITIOM PRACTICE FOE PHT8ICIAVS

What positive initiatives can be a means to facilitate an
aggressive movement that will ensure nutrition education for all
physicians, the subsequent practice of nutrition support for all
patients, as well as a focus on prevention of disease and promotion
of health?

1. INCREASE NUMBER OF PHYSICIANS CERTIFIED BY THE AMERICAN BOARD
OF NUTRITION IN PREPARATION FOR NUTRITION LEADERSHIP IN U.S.
MEDICAL SCHOOLS (24,25).

We need increased numbers of physicians who have had
appropriate training in clinical nutrition and who have met the
standards of the American Board of Nutrition (ABN) so that there
will be sufficient numbers of such professionally trained
physicians available in practice in the U. S.. These are the
professional physicians who are needed to be the leaders in all U.
S. medical schools to spearhead the appropriate training of all
medical students / housestaff in the application of clinical

202

nutrition in the practice of medicine.

Even if we do have conferences/symposia in order to establish
what nutrition should be covered in medical school education, we
still need MDs trained in nutrition to be those nutritionist
physicians to lead this effort in every medical school.

Without strong MD-nutrition leadership in the medical school
setting, programs are not likely to be successful. We need well-
trained physicians to be leaders in the medical education /
clinical setting of medical schools. The competition for financial
funding to develop this leadership is strong at present, especially
in light of the cost of medical care and medical education at this
time. Financial assistance (or some financial break/reward/
incentive) will be needed. Funding sources are limited for
education. Federal funding will be required to achieve this
important aspect of advancement of nutrition.

Credentialing by the ABN of physicians who have appropriate
background, training and interest in nutrition will be important in
order to provide leadership in clinical nutrition in the medical
school environment. Eventually, this will enhance the "importance"
and"recognization" of MDs in nutrition as are other MDs who hold
"boards" in pediatrics, surgery, internal medicine, or other
specialties. Most funding support and allocations of education and
patient care operate through departments delineated by medical
specialties. At present, most medical schools do not have a
separate department in clinical nutrition. . .even though this has
been a specific strong recommendation by a number of reports on
nutrition in medical education over the past ten years. The
National Academy Press publication: Nutrition Education in U. S.
Medical Schools, NAS, 1985, indicated the following:

"The committee observed a distinct lack of organizational
structure and administrative support for nutrition programs in the
schools they surveyed. This environment was found to be counter-
productive in efforts to foster the long-term survival of a
program. To ensure permanence, the committee recommends that the
responsibility for the nutrition program be vested in a separate
department or a distinct division of the medical school. In
addition, each medical institution should allocate specific funds
for the support of at least one faculty position in nutrition."
(19).

In order to enhance the above recommendations. Federal funding
may make possible or help support:
1) Stipends to help defray the expense of physicians to:

a. Attend conferences designed to offer comprehensive overview

Of scientific nutrition principles as well as clinical
application of nutrition in preparation for taking the ABN
examination.

b. Funding for physicians to participate in one of several
nutrition training programs in the U. S.

203

c. Funding to assist medical school support for continued
development of nutrition training programs.

d. Financial support for the development of available
conferences/symposia specifically designed to prepare those
MDs interested.

e. Stipends for interested physicians to prepare for and take
the ABN examination.

2. DOCUMENT: NUTRITION EDUCATION FOR PHYSICIAN by Bruer, Schmidt
and Chapel, 1993.

Send a copy of this document to the Dean of every U. S. medical
school requesting a response for commitments from them as to what
they believe that they can do to improve nutrition education for
physicians in their respective schools, and what they plan to do.

3. MEDICAL SCHOOL NUTRITION LEADERSHIP CONFERENCE

Host well planned demonstration conference, or consensus
conference for chairpersons of medical school departments to
consider the role of nutrition in each specialty, e.g., OB-GYN,
surgery, pediatrics, etc., and to raise the level of awareness of
need to have nutrition an essential component in practice. This
could include: ways to achieve, ways to collaborate, determination
of cost-effectiveness.

It is no wonder chairpersons of departments in medical schools
do not want to "give up time" in the curriculum for nutrition, as
many do not yet know the role that nutrition could play, much less
want to "go to bat" for the curriculum time and faculty to do it.

4. DEVELOPMENT OF FEDERAL LEADERSHIP

It is strongly recommended that a central Coordinating Board,
or Department, or Task Force, or Office, be established to
coordinate: -development of a cooperative plan of action
with various federal departments/offices.

-all can contribute in some way

-each has unique ways to be effective in increasing
nutrition education / practice by physicians

-some have not contributed ...but could
Example: Office of Education.

The Office of Education, 1991, called a meeting of all
Governors and obtained a consensus on 6 national goals needed in
education to be achieved by the year 2000. The strategy to achieve
these goals called for local groups to pool resources with
private/public sectors and work with schools/parents to achieve
these goals. Panel groups will monitor achievement of these goals.

204

Wouldn't the Office of Education be effective in perhaps
gaining support for nutrition education in medical curriculum using
a similar process? Funding such a process?

Example: Office of Education.

It has been estimated that in the U. S. we are spending
$39 billion on various aspects of obesity. The prevalence of
obesity in the U. S. has NOT decreased. In fact, it has INCREASED,
especially in the adolescent age group. It is well established that
obesity is a major risk factor contributing to several major
"killer diseases" in the U.S.:CVD, hypertension, stroke, diabetes.

What is the medical community really doing about this?

What could be the impact of a NATIONWIDE AWARENESS /
EDUCATION about the prevention of obesity, and the wellness of
desirable body mass index?

What could be the role of the Office of Education?

5. GENERATE FINANCIAL SUPPORT FROM INDUSTRY

Financial support from industry, especially health care and
food industry, may be very open to such support. Perhaps a "tax
break" could be provided if they support nutrition in medical
schools, e.g.: support for faculty development

support a "Chair in Nutrition"

support a training program

support a faculty position

6. REIMBURSEMENT FOR NUTRITION

Adjustment of mechanisms for reimbursement of codes to include
nutrition consul tat ion/ support is needed. Changes in the system to
include prevention of disease would require different approaches
for "reimbursement", and would probably be very influential in
enhancing the nutrition education of and practice of nutrition by
physicians.

Currently billions of dollars are spent on the treatment of the
major killer diseases in the U. S.. Many of these diseases could
be prevented or at least lessened in severity if the principles of
good nutrition had been an active aspect of life style from early
life onward. This is the major "cost-effective" way to signifi-
cantly decrease health care costs for these diseases (1-3, 9-18).

7. INCREASE THE NUMBER OF NUTRITION-RELATED QUESTIONS ON THE
NATIONAL BOARD EXAMS

A careful review of the United States Licensing Examination
booklet published to assist candidates prepare for this examination
provides an outline of the general principles that medical students
are responsible for. It also provides sample questions. For almost
every organ system outline, there are nutrition-related concepts,
principles, and facts indicated. (Ref. United States Medical

205

Licensing Examination. Part I. Examination Guidelines and Sample
Items. National Board of Medical Examiners, 1991);.

Yet, very few question on nutrition are reported to actually be
on the exams. Therefore, a much greater effort should be taken to
assure that a significant number of nutrition questions are
included. This will indeed enhance the awareness of medical
schools to be more cognizant of inclusion of nutrition in the
medical curriculum.

8. PHYSICIAN RESPONSE TO THE U. S. PUBLIC

There is need to create a significantly greater visibility of
physicians who can effectively respond to the public regarding
nutrition. Currently, the public tends to have a poor, negative
attitude/ opinion regarding the nutrition expertise of physicians,
a fact that often encourages the public to seek nutrition
information from unreliable sources (13, 26). This tends to
inhibit the public from seeking reliable medical/nutrition
information. This is often a costly, unproductive, and sometimes
dangerous endeavor for the uninformed consumer. The U. S. public
will welcome a more pro-active stance from physicians in response
to the many questions that they seek to obtain reliable answers to.

9. MONITORING NUTRITION EDUCATION IN MEDICAL SCHOOLS

Funding is needed to support a more exploratory and relevant
questionnaire for monitoring nutrition education in medical schools
by the Association of American Medical Colleges for the Liaison
Committee on Medical Education. Since accreditation is one
important way to enhanced medical education, perhaps the LCME could
place greater specific emphasis on nutrition in medical education.
Some concepts/achievements in nutrition practice would be more
important than the "number of hours" in the curriculum.

10. CHAIRS IN NUTRITION

Funding to establish "Chairs in Nutrition" in selected medical
schools, perhaps funds matched by the medical school, or perhaps
contributed by industry or business, could be very positive in
assisting medical schools to achieve a stronger nutrition program.

11. FELLOWSHIPS

Provide fellowships for medical students during medical school
with requirement to "give back time" served in a Nutrition Support
Service or some other medical nutrition service. (Similar to
Army/Navy programs)

Physicians to take one-two years nutrition training in
preparation for taking the ABN exsunination, and to develop creative

206

faculty leadership in nutrition in a medical school.

12. "CAPITATION" FUNDING

Consider "capitation" type of funding to medical schools for
development of: 1) Department or Division of Nutrition

2) Nutrition curriculum program

3) Faculty position

13. GRANT FUNDING:

1) Evaluation of effectiveness in nutrition education
courses/teaching techniques

2) Computerized nutrition modules, self -interactive programs

3) Computerized student self -assessment of nutrition status

dietary intake

4) Evaluation of application of nutrition assessment by
fourth year medical students / residents

in: hospitalized patients
clinic patients
community setting patients

V. INITIATIVES AT THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT
SAN ANTONIO

The San Antonio experience of development and maintenance of
a viable nutrition program in medical education at the University
of Texas Health Science Center, San Antonio, Texas, can be
characterized as a quarter century of collaboration, persistence
and a conviction that nutrition is an essential aspect of medical
education. Initially this direction was facilitated by the fact
that this was a new medical school with a bit more ease in moving
through the curriculum committee, securing administrative support,
and obtaining funding. This would not have happened without the
initial and continued leadership of Dr. Elliot Weser. We have had
financial assistance from the University of Texas Medical School,
and also from a number of other sources, including: The Nutrition
Foundation and the Metropolitan Life Foundation.

Briefly, our overall curriculum is outlined in below. This
program was designed to be an integrated, longitudinal approach
that would build on nutrition concepts and competencies over the
four years of medical education. Over the years this plan has
fluctuated to some extent, but has remained relatively steible.

207

The University of Texas Health Science Center at San Antonio

San Antonio, Texas 78284
Integrated Approach to Comprehensive Nutrition in the Medical Curriculum

MSI

Topics

In
Nutrition

MS II

Introduction

Clinical

Medicine

MS in

Therapeutic
Nutrition
Luncheon
Conference

Serfos

MS IV

Clinical

Nutrition

Bective

Housestaff

Conferences
Rounds

Interdiscipllnafy Nutrition Task Fore*

Nutrition integratad In Medical Curriculum

Nutrition Uctura Seriea

ff inrmon nvwwn

In Year I an elective. Contemporary Topics in Nutrition, is
designed to cover 16 basic nutrition topics. It is very popular,
is given at the noon time with bring-your-lunch informality. This
year of 1992 we have enrolled 160 of 200 medical students.

Year II incorporates a 6-10 hour section in the Introduction
to Clinical Medicine course required of all 200 students. With
emphasis on nutrition assessment and support, case management
presentations, and a symposium forum are utilized to highlight the
role of specific nutrients in the pathophysiology of selected
diseases.

The clerkship in Year III provides a 10 hour Therapeutic
Nutrition Luncheon Conference Series required of all 200 students.
The 28 to 30 students on the medical clerkship service participate
in a one and one-half hour luncheon once a week for six weeks.
Each meal served is one typical of a diet that could be prescribed
for a patient, such as: sodium restricted; protein restricted;
Step I lipid lowering diet; low-lactose diet. It is a practical
approach to some issues essential for tihe physician in moving
concepts of nutrition into an effective mode needed to enhance
patient compliance to diet prescribed by the physician.

In Year IV a Clinical Nutrition Elective is available for a
two -week (80 hrs) to a four-week (160 hrs) period. The last two
years have seen a curtailment of elective time in the fourth year
of the medical curriculum, but we have had excellent participation
in this elective. Some years up to 90 / 200 students selected this
course. Several years it was the most widely selected elective in
the fourth year. This elective provides considerable independent
study of selected nutrition-related topics with a specific focus on
the area of medicine that the student plams to pursue in the

■ 13

208

future. This course has a student-goal but faculty-assisted
orientation. All students participate in nutrition assessment and
support of patients on nutrition rounds, case management
discussions, and student preparation/presentation of selected
nutrition issues. Students are generally serious in their approach
to utilize their time effectively, and they provide a very positive
feedback in their course evaluations.

Most recently a more intense focus on development of a strong,
integrated nutrition for our housestaff is in process. It is
recognized that this is crucial in developing an effective
nutrition service for patients, and in increasing the visibility of
clinical nutrition in practice. A growing collaboration among
gastroenterology, pediatrics, surgery, and pharmacy faculty is
enhancing our efforts to encourage an environment in which
nutrition concepts are put into practice as a routine aspect of
patient care.

A Nutrition Task Force with representation of all major areas
of medicine was initially formed so as to obtain and secure broad
faculty participation. Many faculty participate in the above four
courses, but also incorporate nutrition concepts in other courses
throughout the medical curriculum. We maintain a listing of time
and nutrition concepts that are incorporated in the curriculum. In
the 1991-92 academic year our analysis indicates that approximately
99 hours directly related to nutrition are covered in the medical
curriculum. This emphasis continues to highlight how nutrition
plays a role, often an essential, pivotal role, in almost every
aspect of medical education. A dual effect of this incorporation
of nutrition has stimulated a greater awareness of nutrition in
specific clinical areas by physicians who then became more
interested in and supportive of nutrition as related to their
clinical expertise and practice.

The Nutrition Lecture Series has been a wonderful way to bring
many physicians who are nationally and internationally recognized
for their contributions to and expertise in nutrition to our
campus. Many members of the American Society for Clinical
Nutrition and the American Institute of Nutrition have enhanced our
efforts to provide a recognition of nutrition on our ceunpus via the
Nutrition Lecture Series.

SUMMARY

Clinical nutrition in medical education has made significant
strides over the recent past. There are still a number of hurdles
to surmount, and goals to achieve. We will do this with critical
insight, and a carefully mapped out plan of action. We will
continue to bring together advancement of the science of nutrition
as reflected primarily in our research as a basis for the
application of nutrition in multi-clinical settings and within the
constraints of medical care of our times. With all of this, we

209

will sail forward with enthusiasm, a positive spirit of progressive
movement, and with a clear sensitivity of the human spirit,
especially in the application of nutrition not only to our
patients, but also to a positive movement toward the prevention of
disease and the promotion of health.

VX. SELECTED REFERENCES

1. National Center for Health Statistics. Advance report of final
mortality statistics, 1987. Monthly Vital Statistics Report, vol
37, no.l, April 25, 1988.

2. Koop CE. The Surgeon General's Report on Nutrition and Health.
U. S. Department of Health and Human Services, Public Health
Service, DHHS (PHS) , Publication No. 88-50210, 1988.

3. Committee on Diet and Health. Diet and Health. Implications
for Reducing Chronic Disease Risk. Washington, D.C.: National
Academy Press, 1989.

4. Committee on Dietary Guidelines Implementation. Improving
America's Diet and Health. From Recommendations to Action.
Washington, D. C. : National Academy Press, 1991.

5. Healthy People 2000. National Health Promotion and Disease
Prevention Objectives. Washington, D. C. : U. S. Department of
Health and Human Services, Public Health Service, DHHS, Publication
No. (PHS) 91-50212, 1990, pp. 128-129.

6. Lewis CE. Disease prevention and health promotion practices of
primary care physicians in the United States. Am J Prev Med, 4
(suppl): 9-16, 1988.

7. Schoenbom CA. National Center for Health Statistics. Health
Promotion and Disease Prevention: United States, 1985. Vital and
Health Statistics. Series 10, No. 163. DHHS Pub. No. (POHS) 88-
1591. Washington, D.C.: U. S. Department of Health and Human
Services, 1988.

8. National Nutrition Monitoring and Related Research Act of 1990.
Pviblic Law 101-445, 101st Congress.

House Reports: No. 101-788 (Committee on Agriculture)
Congressional Record, Vol. 136 (1990) .

9. Regenstein M. Reimbursement for nutrition support. Nutr J
Clin Pract 4:194-202, 1989.

10. Disbrow DD. The costs and benefits of nutrition services: a
literature review. J Am Diet Assoc 89 (4) Suppl. S3 - S66, 1989.

210

11. Splett PL. Effectiveness and cost effectiveness of nutrition
care: a critical analysis with recommendations. J Am Diet Assoc
11 (suppl): SI - S50, 1991.

12. O'Brien DD, RE Hodges, AT Day, KS Waxman, T Rebello.
Recommendations of nutrition support team promote cost containment.
JPEN 10 (3):300-302, 1986.

13. Bennet J. Hidden malnutrition worsens health of elderly. NY
Times, Oct 10, 1992, 14A.

14. Reilly, Jr, JJ, SF Hull, N Albert, A Waller, S Bringardener.
Economic impact of malnutrition: a model system for hospitalized
patients. JPEN 12:371-376, 1988.

15. Campos, .ACL, MM Meguid. A critical appraisal of the
usefulness of perioperative nutritional support. Am J Clin Nutr
55:117-130, 1992.

16. Coldirtz GA. Economic costs of obesity. Am J Clin Nutr
55:503S - 507S, 1992.

17. Coats KG, SL Morgan, AA Bartolucci, RL Weinsier. Hospital-
associated malnutrition: a reevaluation 12 years later. J Am Diet
Assoc 93(l):27-33, 1993.

18. Splett, PL. Position of the American Dietetic Association:
affordable and accessible health care services. J Am Diet Assoc
92(6) :746-749, 1992.

19. Winick M. Committee on Nutrition in Medical Education.
Nutrition Education in U. S. Medical Schools. Washington, D. C. :
National Academy Press, 1985.

20. Young EA. Perspectives on nutrition in medical education. Am
J Clin Nutr 56:745-751, 1992.

21. Young EA. Nutrition - an essential component of health and
health care. J Am Col Nutr 1:227-237, 1982.

22. Feldman EB. Educating physicians in nutrition - a view of the
past, the present, and the future. Am J Clin Nutr 54:618-622,
1991.

23. Kushner RF, FK Thorp, J Edwards, RL Weinsier, CM Brooks.
Implementing nutrition into the medical curriculum. Am J Clin Nutr
52:401-403, 1990.

24. Weinsier RL. Nutrition education in U. S. medical schools.
Nutr. Inter. 1:30 - 36, 1985.

25. Young EA. The American Board of Nutrition: perspectives and

211

directions. Am J Clin Nutr 46:383-386, 1997.

26. Halsted CH. Toward standardized training of physicians in
clinical nutrition. Am J Clin Nutr 56:1-3, 1992.

27. Schollar A. Why med students miss their minimum daily
requirement of nutrition education. New Phys 38:16-21, 1989.

Testify. 793

212

Dr. Eleanor Young

1. How can we Inprove the level of nutrition expertise that
physicians receive?

A. Esteiblish a specific creative leadership linkage between the
Federal Government (USDA ??) and medical education in
nutrition. We need a central coordinating board or agency.
Right now, no one agency "pays attention" to nutritional
expertise/knowledge of physicians. Could there be a possible
linkage with the American Association of Medical Colleges..
..possibly USDA and AAMC??? It is the AAMC that annually
surveys nutrition courses in medical schools. This should
include more than "hours in nutrition".

B. Funding that could support strong MO-nutrition leadership:
-Chair in nutrition at selected schools

-Development of unique nutrition curriculum

-Faculty position

-Fund medical student during medical education with
proviso for "pay back" via extended service time in a
nutrition support service or some other medical nutrition
service

C. Support nutrition training progreun for physicians who qualify
via certification by the American Board of Nutrition. We need
some physicians to be leaders in nutrition in medical schools.
Appropriate training and passing boards in nutrition (American
Board of Nutrition) to increase the number of well-trained
physicians in nutrition to be leaders in medical schools is
greatly needed.

D. Provide research grants to:

-Determine the effectiveness of different aspects of medical
nutrition education prograuns

-Determine the effectiveness of how medical students provide
nutrition assessment/support for patients

-Determine quantity/ quality of nutrition application to patient
care: - MDs in different fields in medicine

- medical students: year 1 vs year 4 medical training

-Conduct nutrition assessment survey of medical students,
male vs female, year 1 vs year 4. Our experience is that when
medical students actually experience nutrition assessment of
themselves, they are much more aware of this for patients.

E. Need a reimbursement system for nutrition: prevention of
disease, and promotion of wellness. This is not now covered
for reimbursement in most cases.

F. Need to create greater visibility of physicians who can
effectively respond to the public. A recent study showed that
in 1990 Americans made an estimated 425 million visits to
providers of unconvent i ona 1 therapy versus 388 million to all
U.S. primary care physicians. NEJM 328:246, 1993.

213

2 . How can we more effectively integrate the food production and
health care sectors in the future?

A. Encourage more healthful foods in:
-school cafeterias

-in medical school cafeterias

-improve food choices in vending machines (esp. in schools)
-enhance nutrition education in grade and high schools
-enhance first hand experience in how foods are grown, cared

for, harvested, transported, nutritional value, costs
-produce some well designed TV programs on food production,
marketing, nutritional values and how modified by various
factors (genetics, fertilizers, climate, water, etc.)
-good documentary programs on food and how related to health

B. Enhance information about food contaminants and safety of foods
and food production

C. Devise some ways that surplus food commodities can be
distributed to the poor. We waste too much food while the
poor and homeless go hungry. We need to do something about
this.

3 . What should be the top priorities for nutrition research and
education today?

A. Several suggestions regarding nutrition research in medical
education are listed in question 1 above.

B. The role of diet: in breast cancer.

in colon cancer

C. Education and research is needed on OBESITY IN THE U.S

how can we make the $39 billion currently estimated to be spent
on obesity more effective through education and research on
methodology to prevent this disease. Development of effective
public televised educational progreuns on various aspects of
prevention could be very effective.

4 . How important is nutrition in preventative health care today?

Preventative health care today is more important today than
ever before. The evidence accumulated to document the central role

72-928 0-93-8

214

of nutrition as related directly or indirectly to eight of the ten
most common causes leading to morbidity and mortality in the U. S.
places clinical nutrition in a strategic position in disease
prevention and health promotion.

The Surgeon General ' s Report on Nutrition and Health summarized
the significant acciunulation of evidence to support the role of
nutrition in the major diseases and disorders. As a follow up on
this Report, the Food and Nutrition Board published an extensive
documentation of the epidemiological and clinical data confirming
the role of diet related to health and disease. The title. Diet
and Health: Implications For Reducing Chronic Disease Risk,
indicates the emphasis placed on reducing the risk of these
diseases via dietary changes.

A key consideration is not only that appropriate nutrition
support may lessen or even prevent diet-related diseases, but may
also be cost-effective, lessening significantly the economic burden
on patients, and thus on total health care.

Reference: Health care reform legislative platform: economic
benefits of nutrition services. J. Amer. Diet. Assoc, 93(6) :686-
690. One copy is enclosed.

Submitted by Dr. Eleanor A. Young, Ph.D., RD, LD, Professor, The
University of Texas Health Science Center at San Antonio, San
Antonio , Texas .

Responses are submitted in answer to supplementary questions
forwarded following the hearings held on July 15, 1993, Washington,
D. C. before the U. S. House of Representatives, Subcommittee on
Department Operations and Nutrition, Washington, D. C. .

Eleanor A. Younq^, / Ph . It/ , RD. LD
DATE : A/^ J3,nn

'■'■^

215

MMRffORTS

Hoalth care pefopm legislative platfonii:
Econemic benefits of nutrition services

If you are among the two out of three Americans who do not
smoke or drink excessively, your choice of diet can influence
your Icmg-term health prospects more than any other action
you might take Eight out of the ten leading causes of death
including heart disease, stroke, some types of cancer, and
diabetes, are related to diet and aicohoL

— The Sxirgeon General's Report on Nutrition and Health (1)

The American Dietetic Association, Association of the Faciil-
ties of Graduate Programs in Pubbc Health Nutrition, Asso-
ciation of State and Territorial Public Health Nutrition Direc-
tors, and The Society for Nutrition Education (The Coalition)
believe quality health care must be available, accessible, and
affordable to all Americans. Quality health care is defined to
include nutrition services that are integral to meeting the preven-
tive, therapeutic, and rehabilitative health care needs of all
segments of the population. Nutrition services of screening,
assessment, education, counseling, and treatment must be in-
cluded in health care reform proposals. Nutrition services must be
covered as a benefit in the basic benefits package currently being
considered by the Admuustration. Coverage for nutrition services
must be provided under Medicare and Medicaid, other public
programs, and private and corporate insurance programs These
services must be provided by an RD or other qualified profession-
als who meet licensing and/or other standards prescribed by the
Secretary in regulations.

Any health care reform proposal must include nutrition ser-
vices. These cost-effective services must be a component of the
basic benefits package currently being considered by the Admin-
istration for the Medicare and Medicaid prograirts, other public
programs, and private and corporate insurance programs. Nutri-
tion services must be maintained in all comprehensive federal,
state, and local programs designed to improve the public's health.
This basic benefits package is fundamental to meeting mini-
mum health care needs of all Americans. Nutrition services
included in the basic benefits package are cost-effective, espe-
cially for persons at risk for acute and/or chroiuc medical condi-
tions. These services prevent the need for more costly medical or
surgical treatments and reduce costly complications associated
with disease progression. Nutrition services are an integral part of
health care for those at nutrition risk in primary care, acute care,
outpatient care, home care, and long-term-care settings; for
mothers and children; for older Americans; and in preventive
care.

This platform was developed by The American Dietetic Association last
year and has undergone numerous revisions. Early this year. ADA asked
other nutrition organizations to review the platfonn. Their suggestions
were included and three organizations signed into this version of the
platform.

ADA members and staff who helped draft or review the platform
include the following.

ADA Members: Ann Coulston, MS, RD (coordinated the platform
development); Ann Gallagher, RD; Pat Splett, PhD, MPH, RD; Mary
Story. PhD. RD; and Rebecca Mullis, PhD, RD

Technical experts: Tina Colaizzo-Anas. MS, RD; Linda Hofmeister, RD;
, Eleanor Young, PhD, RD; BenConnell, PhD, RD; Elizabeth Diemand, MS,
RD; Janet Levihn, RD; Eleanor Schleinker, Betsey Haughton. MS, RD;
Sara Bonam, MS, RD; Leslie Tinker. MS, RD; Unda Newcomb, MS, RD; .
Harriet Cloud, MS, RD; Elizabeth Leif, RD; Deborah Golden, MS, RD;
Patricia McKnight, MS, RD; and Dorothy Marshall, RD.

ADA staff: Michele Mathieu-Harris; PatU Blumer, and Julie Stauss, RD.

Nutrition programs and services that promote health and
prevent disease are fundamental to health care reform. These
programs and services must foster personal and community
responsibibty for healthy behaviors and life-styles and be deliv-
ered In pnmary care, pubbc health, and community settings. To
maximize the benefit, these nutrition programs and services must
be culturally appropriate and meet the needs of the vulnerable
and frequently underserved segments of our population and be
included in preventive care, in maternal and child health care, and
in health care services for older Americans.

ECONOMIC BENEFITS OF NUTRITION SERVICES
IN ACUTE CARE

Nutrition services in acute care play a vital role in the
recovery of the pattern. The Coalition supports coverage and
indirect reirnbursement of nutrition services in the basic
benefits package and under Medicare for inpatients Nutri-
tion services must be identified as separate and distinctfrom
administrative services.

Among hospitalized adults, excess costs for patients with malnu-
trition were $5,575 for surgery patients and $2,477 for medical
patients (2) . Adequate nutrition is essential to reduced morbidity
and mortality from acute and chronic disease Well-nourished
individuals are more resistant to disease and are better able to
tolerate other therapy and to recover from acute illness, surgical
interventions, and trauma.

Inadequate nutritional intake can precipitate disease or in-
crease its severity. Early detection of nutrition-related problems
and appropriate nutrition treatment are effective in preventing
increased morbidity from many diseases. In other words, nutri-
tion treatment can help the patient recover more quickly and
decrease the number of days required in the hospital.

Nutrition services are currently included in the room and board
charge on an inpatient's bill. Medically necessary nutrition ser-
vices in inpatient health care settings must be considered special-
ized care and be reimbursed separately, in a manner similar to
other services (eg, those of occupational and physical therapists) .

This separate coverage is particularly important m light of the
following points:

■ Malnutrition occurs in up to 50% of hospitalized patients (3);

■ The correlation between malnutrition and disease complica-
tions is high;

■ Advances have been made in nutrition administered by vein or
tube;

■ Evidence indicates that nutrition intervention corrects malnu-
trition, prevents disease complications, and speeds rehabilitation;

■ Evidence shows that nutrition is critical to certain patients'
progress (eg, those with diabetes, pressure sores, and cardiovas-
cular disease) after acute care.

RDs control costs by ensuring judicious use of costly high-tech
nutrition therapies, including parenteral nutrition (nutrition by
vein) (4) . When parenteral nutrition is used properly, postopera-
tive complications can be reduced by 38% (5). Parenteral nutri-
tion administration and monitoring may cost as much as $500 per
hospital day. Substantial savings can be realized when enteral
feeding (via tube in the gastrointestinal tract) is substituted for
parenteral nutrition. Because nutrition in medical education is in
its infancy, it is the RD who has the expertise to make this
determination in the acute-care setting. An RD in Philadelphia,
Pa, who works with a managed health care company saved her

686 / JUNE 1993 VOLUME 93 NUMBER 6

216

finii $60,000 by competent discharge planning and transitional
feeding planning for a patient receiving parenteral nutrition.

RDs provide an essential role in ensuring the most cost-
effective provision of nutrition care. For example, there are more
than 200 nutrient products on the market. Cost savings have been
realized when RDs manage hospital nutrient solution formularies.
One dietitian saved a hospital $40,000 aivnually by determining
that a more expensive parenteral formula was not more therapeu-
tically beneficial than the standard formula.

The American Dietetic Association has developed validated
practice guidelines for specific disease states and conditions.
These conditioi\s include kidney disease, liver disease, lung dys-
function, bums, diabetes, AIDS, cancer, short-bowel syndrome,
bone marrow transplantation, solid organ transplantation,
parenteral and enteral nutrition treatment, pediatric nutrition
care, and older adult nutrition care. In developing and using
practice guidelines, dietitians aim to link standardized practice to
positive outcomes, thereby ensuring efficiency and effectiveness
in the deliveiy of care. For example, positive outcomes of nutri-
tion intervention in bum care include increased survival rates,
decreased length of hospital stay, decreased length of stay in
intensive care units, decreased complications, and decreased
negative weight changes (6)

Several factors have contributed to an increase in the demand
for nutrition services: the aging of the population, the AIDS
epidemic, the higher acuity level of hospitalized patients, and the
coexistence of malnutrition with chroiuc diseases.

In sum. The Coalition recommends separate reimbursement
for nutrition services in acute-care settings as a clinically effective
and cost-effective component of health care reform.

ECONOMIC BENEFITS OF NUTRITION SERVICES
IN OUTPATIENT CARE

Appmpnale nutrition services are a cost-effective u>ay to keep
people heaUhy and save scarce health care dollars. The
Coalition supports coverage and reimbursement for nutri-
tion assessment and treatment in the basic benefits package
and in Medicare Part B, Medicaid, and other plans for high-
risk patients. The Coalition supports outpatient nutrition
services provided to patients under the care of a physician
with development of a plan prescribing the type, amount, and
duration of nutrition services.

Because the prospective payment system has decreased the
length of hospital stays, many patients go home requiring further
care. However, nutrition treatment — previously provided to
inpatients who need to follow special diets after discharge — may
not be reimbursed by Medicare as an outpatient service. Because
these critical follow-up costs may not be paid by Medicare or other
sources, many patients do not follow throu^ with the necessary
nutrition treatment.

For example . when patients with diabetes are released fitim the
hospital, maintenance of a diet plan can be critical to the stabili-
zation of the health of the patient and prevention of rehospitaliza-
tion. Diabetes requires daily management — including balancing
of food, exercise, and (in some cases) medication — to control
blood glucose, maintain appropriate weight, and prevent or delay
serious, permanent damage (blindness, amputation, or death).
Appropriate nutrition services are a clinically effective way to
treat people with diabetes. The most cost-effective use of nutri-
tion services is to keep patients healthy by giving them the training
they need to maintain a healthy life-style.

Medically necessary nutrition services in outpatient health care
settings must be considered specialized care and be reimbursed
in a maimer similar to care provided by occupational and physical
therapists.

ECONOMIC BENEFITS OF NUTRITION SERVICES
IN HOME CARE

Costs of home health care can be reduced by early application
ofniuruwnservicesfbrnutritionrrelateddiagnosis. Patients
whose care plan includes nutrition treatment and patients
onenteralandparenteralnutriticmtherapymustbeassessed
and treated in line with the care plan developed with a
physician The Coalition supports coverage and indirect
reimbursement of nutrition assessment and treatment as
part of the basic benefits package and under the Medicare
program.

Because the prospective payment system has decreased the
length of hospital stays, many patients are discharged requiring
further nutrition treatment. Many of these patients, who cannot
be placed in a nursing facility or make periodic trips to the
physician's office or clinic, receive health care at home. Nutrition
treatment that was previously provided to inpatients who have
serious and complex nutrition treatment needs is not currently
provided as a home health care benefit.

Many patients are discharged when they still require nutrition
therapy by vein (parenteral) or tube feeding (enteral) in the
home. Although home enteral and parenteral nutrition can poten-
tially save costs associated with expensive hospitalization, the
home care industry has not been able to respond adequately to the
care needs of home parenteral and enteral nutrition patients
because of lack of reimbursement for nutrition treatment. Exces-
sive costs for these therapies can be reduced by early nutrition
assessment and appropriate nutrition treatment in home care
settings. Home parenteral or enteral nutrition treatment requires
regular foUow-up and monitoring by RDs to prevent hospital
readmission because of complications.

Provision of nutrition services in the home health care setting
is a cost-effective way to treat people with diabetes and other
chronic diseases such as kidney failure and AIDS. For example,
patients with diabetes are a large population group for which
nutrition treatment can be critical to the stabilization of health and
the prevention of rehospitalizadoa Diabetes management re-
quires daily attention to food intake, exercise, and medication to
control blood glucose and prevent or delay disease complications .

Currently, nutrition services are included in administrative
costs and are not separately billable. Home health agencies with
limited administrative funds are often forced to use employees
who are not trained to assess the nutritional status of patients
This often leads to complications for the patient, more costly care,
and increased use of higher cost options for feeding that are
reimbursed by Medicare. Dollars can be saved by using the
appropriate health professional

Medically necessary nutrition services in home health care
must be considered specialized care and be reimbursed in a
manner similar to care provided by occupational and physical
therapists.

ECONOMIC BENEFTTS OF NUTRITION SERVICES
IN LONG-TERM CARE

Nutrition services provided in long-term care improve the
quality of Itfe, slow the rate of physical deterioration, and
preverufwriher costly hospitalization or the need for a higher
level of care. The Coalition supports coverage and indirect
reimbursement of nutritum assessment and treatment in
long-term-care facilities as part of the basic benefits package
and under the Medicare program

It is often assumed that daily provision of three nutritious meals
meets the nutrition needs of nursing home resklents. In reality,
individualized nutrition services are necessary because an in-

JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 1

217

AO/IHffORTS

creasing number of residents require a higher level of acute care.

For a variety of psychosocial, economic, and medical reasons,
the elderly in nursing homes are particularly prone to suffer from
protein-energy malnutrition as well as from certain micronutnent
deficiencies. Appropriate nutrition services can improve quality
of life, slow the rate of physical detenoration, and prevent costly
hospitalization or the need for a higher level of skilled care.

Decubitus ulcers (pressure sores) can be a significant problem
in nursing home residents. It is estimated that the average
.pressure sore costs $15,000 to treat and frequently involves
surgical treatment (T) . Conditions such as anemia, hyperglycemia,
dehydration, food-drug interaction, and vitamin/mineral deficien-
cies also are indicators of patients at risk for development of
pressure sores. Nutrition treatment delivered to residents with
decubitus ulcers can speed the healing process, and optimal
nutrition care can help prevent them from reoccumng. The
development of pressure sores correlates directly *tth the inci-
dence of protem-energy malnutrition.

Many residents are on enteral or parenteral feedings that
require the expertise of an RD to determme the optimum balance
of nutrients and Quid. Consultation by an RD in these situations
can create significant savings for the facility. For example, a
skilled nursing facility saved $3,000 per month on one patient
after an RD conducted a nutntion assessment and evaluation that
resulted in improved patient acceptance of meals and decreased
use of a costly supplement.

Federal requirements mandate that nursing facilities employ a
qualified dietitian on a full-time, part-time, or consultant basis.
Nutrition services are included as a part of the facility's adminis-
trative costs, rather than as aseparate charge. Financial pressures
in the health care delivery system often force facilities to use a
consultant dietitian for a minimum number of hours per month,
and then use less qualified personnel to cover the rest of the time .
The increase in acuity level of the residents combined with the few
hours the dietitian has in the facility make it more likely now that
the nutrition needs of residents are not met. This, in turn, can lead
to increased complications and health care costs.

Therefore. The Coalition recommends coverage and indirect
reimbursement for nutrition assessment and treatment in long-
term-care facilities.

ECONOMIC BENEFITS OF NUTRITION SERVICES
IN PREVENTIVE CARE

Health promotion and disease prevention nutrUion services
and programs are necessary, cost-effective, and humanitar-
ian measures for the prevention of and delay m theprogres-
sicm toward disease. These services and programs must be
universally available and offered in a variety of settings that
are both traditional and innovative and that foster personal
responsibility for health behaviors and life-style. To majri-
mize the benefit, nutntion services must be responsive to an
individual's culture, learning capacity, and life situation
and must ensure access to a nutritious diet The Coalition
supports inclusion of nutrition services and programs in
preventive care.

The goals of preventive care are to keep people healthy in theu-
communities, to reduce the incidence and severity of preventable
diseases, to improve health and quality of life, and to reduce total
medical costs, particularly costs for medication, hospitalization,
and extended care.

A quality health care system must be available, accessible, and
affordable; contain mechanisms for monitoring and evaluating the.^
public's health; ensure that providers of nutrition care programs
and services are qualified and have advanced nutrition training/
education; use clinical and applied research to improve health

care practice; and maintain a comprehensive federal, state, and
local public health infrastructure to protect the community's
health.

A quabty health care system that is available, accessible, and
affordable to all Amencans must mamtain a comprehensive
federal, state, and local infrastructure. The infrastructure must be
accoimtable for momtoring and evaluating the public's health; for
ensuring that providers of health care programs and services are
qualified and have advanced training/education in nutntion; for
ensuring accessibility; for applying research to health care prac-
tice; and for coordinating the private and public debvery systems.

Eating habits can have a significant impact on the incidence and
severity of many health disorders. A direct relationship clearly
exists between nutrition risk factors and certain key diseases.
Consider the following information released in the Surgeon
General's Report (1) in 1988:

■ Coronary heart disease: Despite the recent sharp decline in
the death rate for coronary heart disease, more than 1 .25 million
heart attacks occur each year (two thirds of them in men), and
more than 500,000 people die each year as a result. It still accounts
for the largest number of deaths in the United States. (Today, the
cost of treatment is $136 billion.)

■ Stroke: In 1987, strokes occurred in about 500.000 people,
resulting in nearly 150.000 deaths and long-term disability for
many more individuals. Approximately 2 million Amencans suffer
from stroke-related disabilities, at an estimated annual medical
cost of more than $1 1 billion.

■ High blood pressure: High blood pressure is a major risk factor
for both heart disease and stroke. Almost 58 million people,
including 39 million who are under the age of 65, have high blood
pressure. Occurrence of hypertension increases with age and,
with the aging of the population, will become a more prevalent
risk factor.

■ Cancer: More than 475,000 people died of cancer in the United
States in 1987, making it the second leading cause of death in this
country. During the same period, more than 900,000 new cases of
cancer occurred. In 1 985, the costs of cancer were estimated to be
$22 billion for direct health care, $9 billion in lost productivity
because of treatment or disability, and $4 1 billion in lost produc-
tivity because of premature mortality, for a total cost of $72 billion.

■ Diabetes MeUuus: Approximately 1 1 million Americans have
diabetes, but almost half of them have not been diagnosed. In
addition to the nearly 38.000 deaths in 1 987 attributed directly to
this condition, diabetes also contributes to an estimated 95,000
deaths per year from associated cardiovascular and kidney com-
plications. Diabetes care costs $20 billion per year.

■ Obesity: In the United States, obesity affects approximately 34
million adults aged 20 to 74 years; the highest rates are among the
poor and minority groups. Obesity is a risk factor for coronary
heart disease, high blood pressure, diabetes, and possibly some
types of cancer, as well as for other chronic diseases.

The Surgeon General 's Report ( 1 ) goes on to state that eating
and drinking habits contribute to heart disease, cancers, strokes,
diabetes mellitus, obesity, and other fatal diseases. The link
between dietary fat and coronary heart disease is well established,
and now early studies appear to link fat intake to some cancers,
specifically breast, colon, and prostate cancers.

In an aging population, a higher-fat, higher-calorie diet and less
physical activity results in more obesity. The incidence of diabetes
IS increasing by 6% each year because of the change in the
American life-style. Major risk factors include being over 40 years
old, overweight, and a member of a nunonty population and
having a blood-related family member with diabetes.

Nutrition programs and services, the cornerstone of treatment,
can prevent, postpone, or mitigate the onset or progression of this
disease and thus save scarce health care dollars.

) / JUNE 1993 VOLUME 93 NUMBER 6

218

Other benefits of nutrition services include prevention of obe-
sity, coronary heart disease, some types of cancer, and other
chronic diseases and their complications; improved recovery
from illness; improved physical, social, and mental well-being;
reduction in the need for medical services and recurrent hospital-
izations because of malnutrition and related problems; mainte-
nance of independent living; and costs averted for medical and
institutional care, surgery, and drug therapy.

Healthy People 2000 (8) states profoundly that a nation's
health is measured by more than its death rate . Good health comes
firom reducing unnecessary suffering, illness, and disability. It
comes also from the citizens' improved quality of life and sense of
well-being. Healthy People 2000 acknowledges that this nation
has the means to prevent premature death and disability and
achieve the potential for Americans to live healthy lives in their
own communities. We must now implement what we know about
promoting health and preventing disease. Personal choices have
a powerfiil influence over one's health prospects. The public must
have the information and guidance necessary to make the wisest
health choices, and nutrition plays a daily role in those choices.

Health promotion and disease prevention are our best opportu-
nities to reduce the ever-mcreasing portion of our resources spent
to treat preventable diseases and functional impairment

ECONOMIC BENEFITS OF NUTRITION SERVICES
IN MATERNAL AND CHILD HEALTH

Nutntum services for pregnant vxumen can lead lotheproper
growth and der>elopmetU of the fetus and prevention of low-
birth-weight infants and cosily complications. Nutrition ser-
vices are of critical importance to promote growth and devel-
opment of infants and children, partiadariy those with
developmental disabilities and chronic medical conditions
The Coalition supporlsfamily-centered nutrition services for
all pregnant and breast-feeding women and for infants and
children and supports referral to established programs such
as the Special Supplemental Food Program for Women,
Irtfants. and Children (WIC) and EPSDT Pregnant women
andchildrenidentifiedatrisk, or with other complications or
conditions, should receii'e preventive, therapeutic and reha-
bilitative nutrition services.

No period in life is more important to good health than the months
before birth. The prenatal period may be the starting time for good
health or the beginning of a lifetime of illness and shortened life
expectancy. Early nutrition intervention can substantially change
the course of events to improve pregnancy outcome.

Each year in the United States, nearly 39.000 babies die before
the age of 1 year. Low birth weight, which occurs in 7% of ail births,
is the greatest single hazard to infant health, costing the nation
$3.5 to $7.5 billion each year. Medicaid pays almost $19,000 per
delivery of a low-birth- weight infant vs just $ 3,500 per delivery of
a normal-weight infant (9) . Poor nutrition is one of the m^jor risk
factors associated with low birth weight. Women who gain less
than 21 lb during pregnancy are more than twice as likely to
deliver low-birth-weight in&mts than are those who gain more.
Nutrition is also vital to growth and development (including brain
function development) of in&nts.

Assessment of nutritional status is an integral part of care at the
iieginning of pregnancy and periodically throughout pregnancy
and breast-feeding to provide continuing monitoring and recom-
mend appropriate intervention. Nutrition intervention is cost-
effective. In 1992, the US General Accounting Office estimated
that every $1 spent on the WIC program for pregnant women
yiekis up to $4.21 in Medicaid savings.

Specialized professioiud counseling on feeding should be pro-
vkled to parents of tow-birth-weight infants, other infants at high

risk, and in&nts who require special formulas. Parents of children
with special health care needs should also receive ongoing profes-
sional advice on appropriate diets and feeding methods. These
include children with physical or developmental disabilities or
those with a chronic medical condition caused by or associated
with geneticAnetabolic disorders, birth defects, prematurity,
trauma, infection, or perinatal exposure to drugs. These children
make up 10% to 15% of the pediatric population, but the costs of
their care are disproportionately high (10).

Common nutrition problems among children — obesity, failure
to thrive, undernutrition, iron deficiency, and dental caries — can
have significant short-term and long-term consequences. Be-
cause eating habits are formed at an eariy age, the establishment
of healthful eating patterns by children is particularty important.
Children need good nutrition during diildhood for adequate
growth, development, and maintenance of health to decrease the
cost of health care later in life.

Nutrition problems among adolescents include obesity, chronic
dieting, eating disorders, hyperlipidemia, and dental caries. Of
American children and adolescents. 15% to 27% are obese. The
prevalence of obesity among children in the United States has
increased significantly in the last two decades, and these children
have an increased risk of adult obesity and its complications. The
potential cost of these diseases could be prevented or significantly
reduced with nutrition services for youth m primary care and
other preventive health care settings.

ECONOMIC BENEFITS OF NUTRmON SERVICES
FOR OLDER AMERICANS

Nutntum assessment and treatment are essential to decreas-
ing morbidity, mortalUy, and attendant health care costs for
vulnerable older Americans. The Coalition supports the Nu-
trition Screening Initiative recommendation for the inclu-
sion of nutrition screening for this populatum. For those
identified as being at nutritional nsk, nutrition assessment
and treatment must be covered and reimbursed by Medicare.

Every day 5,000 people turn 65, and by the year 2030, 21% of the
population will be over the age of 65 ( 1 1 ) . Advancing age brings
mcreased dependency' and added health care costs. 'Today, older
.^mencans make up almost 1 2% of the population but account for
36% of health care costs and 30% or more of all hospital stays and
drug prescriptions ( 1 1 )

The impact of chronic health problems increases with age.
Eighty-five percent of the older population has a chrotuc disease
such as diabetes, hypertension, or cancer (12). Many of these
diseases are diet related. Cardiovascular disease affects 50% of
people over age 70 (13). Decline in nutritional status is not an
inevitable part of the aging process; rather it is environmentally
determined and frequently results from inattention to nsk factors
that can be unproved by nutrition screening, assessment, educa-
tion, counseling, and treatment

Nutritional nsk is the most important predictor of the total
number of physician visits, visits to physicians in emergency
rooms, and the occurrence of hospital episodes, according to a
study by Wolinsky (14). Twenty-five percent of the "oW" oW are
admitted to the hospital with moderate to severe malnutrition
( 15) . In a study of older patients admitted to a hospital those who
were malnourished had actual hospital charges double that of
those who were not malnourished, and their average length of stay
was 5.6 days longer than patients without malnutrition (16).
Proper nutrition assessment and treatment for those vulnerable
older persons are essential in decreasing health care costs.

Once older persons have been identified as malnourished,
services through pubbc/private partnerships, such as home-deliv-
ered meals, should be made available to those who need them.

JOURNAL OP THE AMERICAN DIETETIC ASSOCIATION / 1

219

Adequately nourished patients have decreased morbidity and
mortality and fewer secondarj' medical complications and dis-
eases. Their wounds heal faster, they have fewer infections, and
their hospitalizations are shorter. These factors ail reduce Medi-
care, Medicaid, and other third-party payer costs.

Nutrition services are critical because of their direct and
immediate impact on the pauent's health or medical condition.
Provision of nutrition services decreases costs of medical and
institutional care, surgery, and drug therapy. Often elderly pa-
tients do not seek or follow up on recommended nutrition treat-
ment because the cost of such services is not reimbursed to them.

OVERVIEW OF COSTS TO THE AMERICAN PUBUC
FOR CHRONIC DISEASE

Nutnuon is a daily concern for all Americans. For the past 1 5 years
Americans have become mcreasingly health conscious. However,
disturbing statistics still exist as to the ability of Americans to
understand and implement the array of messages they receive on
nutrition and health.

■ One third of all Americans are overweight (17).

■ 1.5 million deaths m 1987 were diet related (I).

■ More than 250.000 (7%) cf US infants have low birth weight,
which contributes to the Limted States being ranked 23rd among
mdustrialized countries in infant mortality (18).

■ Of American children and adolescents, 15% to 27% are obese
(19)

■ The United States spends $2.3 billion daily on health care. In
1 992, diet-related disease consumed a major portion of the $838.5
billion price tag for this nation's health costs (20).

■ More than $200 billion is spent for treatment of diet-related
illness affecting 100 million Americans, including heaat disease,
high blood pressure, cancer, diabetes, and obesity (1).

■ More than $100 billion is spent for coronary heart disease m
direct health care expenditures alone (8).

■ More than $72 billion is spent for cancer, mcluding productivity
losses (1).

■ $39 3 billion is spent on obesity (21).

■ Between $3.5 and $7.5 billion is spent annually on low-birth-
weight infants (8. 18).

■ $302 billion, or 36% of health care costs are spent for older
Amencans, whereas Medicare spent just $102 billion on older
Amencans m fiscal year 1990 (22).

■ $20 billion is spent annually on diabetes treatment, according
to figures from the American Diabetes Association.

■ Another $33 billion is spent annually on illusionary "quick fix"
weight loss solutions by 65 million Americans, according to
Representative Ron Wyden's opening statement before the House
Subcommittee on Regulation, Business Opportumtie.«, and En-
ergy Hearing: Safety and Effectiveness of Weight Loss Programs
(May 7, 1990).

The mam challenge is no longer to determme what eating
patterns to recommend to the public (although there is more to
be learned), but how to inform and encourage an entire popula-
tion to eat so as to improve its chance for a healthier life, thus
driving down the cost of health care. There is a de?.- need for
comprehensive, coordinated action to improve Americans' diet
and health, as documented in the following federal publications;

■ Healthy People 2000: National Health Promotion and Dis-
ease Pre»ention Objectives (8);

■ The Surgeon General 's Report on Nutruton and Health ( 1 ) ;

■ OuidetoClmicalPreventiveServices: An Assessment of the
Effectiveness of 1 69 Iraerventixms, issued by the US Preventive
Semces Task Force. 1989;

■ The Dietary Guidelmesfor Americans, 3rd ed, issued by the
US Departments of Agriculture and Health and Human Services.
1990;

■ Diet and HecUth, issued by the Institute of Medicine. National
Research Council of the National Academy of Sciences, 1989.

In spite of the overwhelming documentation in these reports
linking diet to disease, the United States spends only 3% of its
health care dollars on preventing disease, according to the Cen-
ters for Disease Control.

The nation can no longer afford to ignore its own reports and
must reduce the high cost of disease in this country. Nutrition
programs and services are the cornerstone of cost-effective
prevention and must occur early in life to help drive down the
spiraling cost of health care. More aggressive nutrition interven-
tion early in life can have major impact on disease.

Referencas

1. The Surgeon General's Report cm Nutrition aTid Health- Washing-
ton. DC: US Dept of Health and Human Services;1988 DHHS publicaUon
(PHS) 88-50210.

2. Reilly J. Hull SF, Alert N, Walker A, Bringardener S. Economic impact
of malnutntion: a model system for hospitalized patients JPEN. 1988;
88: 371-376.

3. Coats KG, Morgan SL, Baitolucci AA, Weins;<jr FIL. Hospital-associ-
ated malnutnuon: a reevaluaUon 12 years later J Am Diet Assoc. 1993;
93:27-33.

4. Position of The American Dieteuc Associauon: the role of the regis-
tered dietitian m enteral and parenteral nutnuon support. J Am Diet
Assoc 1991:91:1440-1441.

5. The Veterans Affairs Total Parenteral Nutrition Cooperative Study
Group. Penoperative total parenteral nutnuon m surgical paUents A'
EnglJMed- 1991:325:525-532,

6. Paulsen LM, Splett PL. Summary document of nutnbon mtervention
in acute illness: bums and surgery. In: Splen PL, du-ector. EffecUveness
and Cost EffecUveness of NutriUon Care: A CriQcal Analysis with Recom-
mendations. J Am Diet Assoc. 1991:91 (suppi): S15-S19

7. StudyGuide PrevenlicmandTrealmeraofPressureSores Evans-
viUe, Ind: Bristol Myers Co; 1989,

8. Healthy People 2000: National Health Promotion and Disease
Prevention Objectives Washington, DC: US Dept of Health and Human
Services; 1990, DHHS Puhbcauon (PHS) 91-50213,

9. Schore J, The Savings of Prenatal Costs for Newborns and Their
Mothers From Participation m the WIC Program. Washington, DC:
Food and Nutrition Service, US Department of Agnculture; 1990,

10. Baer M. Faman S, Mauer A. Children with special health care needs.
In: Call to Action: Better Niuraicm for Mothers, Children and
Families Washington, DC: NaUonal Center for Educauon m Maternal
and Child Health; 1990,

11. StatisticalAbstracloftheUnitedSlates: 1991 lllthed. Washing-
ton, DC: US Bureau of the Census; 1991.

12. Roe D, GeruUric Nulntum. Englewood Cliffs. NJ: Prenuce-Hall;
1992,

13. CmgL. Nulntum and Aging Co\\mii\>s,Otao: Ross laboratories;
1991.

14. WolinskyFD.CoeRM.MiUerDK.PrendergastJM. Creel MJ. Chavez
NM. Health service utilization among the non-insUtutionalized elderly.J
HeaUh Soc Behav. 1983,24,325-337.

16. Agarwal, N. American Society for Clinical Nutrition; conference
abstract. May 1986.

16. Robinson G, Goldstein M, Levine G. Impact of nutritional status on
DRG length of stay. JPBW 1987; 11:49-51.

17. Forster JL. Jeffrey RW, Schmid TL, Kramer FM, Preventing weight
gain m adults: a pound of prevention HeaUh Psychol 1988: 7:516-525,

18. Early Intervention: Federal Investments Like WIC Can Produce
Savings. Washington, DC: US General Accounting Office; 1992. Publi-
caUon No. GAO/HRD-92-18.

19. Gortmaker S, Dietz W, Sobol A, Wehler C. Increasing pediatric
obesity in the Umted Stales, AmJDis Child. 1987; 141:535-540,

20. 1 of Every 7 dollars last year was consumed by health care. Wash- >
ington Post. January 4, 1993,

21. Colditz GA, Economic costs of obesity. Am J Clin Nutr. 1992; 55:
503S-507S,

22. Aging America: Trends and Projections. Washington. DC: US
Dept of Health and Human Services; 1991, DHHS PublicaUon 91-28001.

690 / JUNE 1993 VOLUME 93 NUMBER 6

220

^■*2Sfc:*.\ DEPARTMENT OF AGRICULTURE

OFFICE OF THE SECRETARY
WASHINGTON. D.C. 202S0

STATEMENT OF

C. EUGENE BRANSTOOL

ASSISTANT SECRETARY FOR MARKETING AND INSPECTION SERVICES

U.S. DEPARTMENT OF AGRICULTURE

BEFORE THE
HOUSE COMMITTEE ON AGRICULTURE
SUBCOMMITTEE ON DEPARTMENT OPERATIONS AND NUTRITION

JULY 15, 1993

Mr. Chairman and Members of the Subcommittee, I am pleased
to have this opportunity to present this statement on the
nutrition activities of Marketing and Inspection Services
agencies.

The agencies within the Department of Agriculture's (USDA)
Marketing and Inspection Services are responsible for a number of
diverse activities, from strengthening the economic position of
farmers and other rural residents, to controlling animal and
plant pests and diseases, to inspecting grain, meat and poultry.

Marketing and inspection continue to be our major focus.
However, over the past few years, we have assumed new
responsibilities in the nutrition education arena. This is not
too surprising, considering our ongoing role in ensuring a safe
and high quality food supply and our recent nutrition labeling
initiative. In addition, we operate a toll-free Meat and Poultry
Hotline, which provides an effective way to deliver information
to consumers about the food they eat. Clearly, USDA agencies
such as the Human Nutrition Information Service (HNIS) , the Food
and Nutrition Service (FNS) and the Extension Service have a
greater role to play in nutrition education than we do. However,
our role has expanded, and needs to be represented in a
discussion of nutrition education activities within USDA.

Meat and Poultry Hotline

I will begin with our activities related to the Meat and
Poultry Hotline. USDA's Food Safety and Inspection Service
(FSIS) has operated a Meat and Poultry Hotline since 1979; since
1985, the hotline has been toll-free and nationwide to reach a
larger and more geographically dispersed audience. Staffed by
home economists and registered dietitians, the hotline received
almost 138,000 callis last year from consumers eibout the safe
handling of meat and poultry.

AN EQuAi. C=POn' ,%iry smplOyER

221

Several years ago, FSZS noticed an Increasing number of
calls and questions on nutrition issues. Recognizing the need
for interagency cooperation in providing nutrition information to
consumers, we consulted with HNIS, FNS, and the rest of the
nutrition education community within USDA on this issue. In
October 1991, we began responding to basic nutrition questions
regarding meat and poultry on the hotline. Questions that go
beyond this general scope continue to be referred to HNIS, the
Extension Service, the National Agricultural Library, and other
appropriate health care professionals. This year, we have
received 560 calls related to nutrition, approximately 3 percent
of the total calls received.

Nutrition Label Reform

The decision to begin answering nutrition questions related
to meat and poultry products coordinated well with another
initiative that was underway — nutrition label reform. In 1989,
USDA joined the Department of Health and Human Services (HHS) to
sponsor a study by the National Academy of Sciences to provide
options for improving food labeling. In November 1991, FSIS
issued a regulatory proposal for a mandatory nutrition labeling
program for processed meat and poultry products and voluntary
guidelines for single ingredient, raw meat and poultry products.
The Food and Drug Administration (FDA) simultaneously proposed
regulations on nutrition labeling for foods other than meat and
poultry to comply with the Nutrition Labeling and Education Act
of 1990. While FSIS was not required by this legislation to
issue regulations for meat and poultry, the agency proposed such
regulations under the Federal Meat Inspection Act and the Poultry
Products Inspection Act. After soliciting public input through
hearings and comments in response to regulatory proposals, FSIS
and FDA issued final nutrition labeling regulations on January 6,
1993. The new label will appear on meat and poultry products by
July 1994, although some manufacturers may choose to use the new
labeling sooner.

The new nutrition labeling was designed with today's public
health priorities in mind. It reflects the fact that conditions
linked in part to diet, such as heart disease and some forms of
cancer, have become much more prevalent than nutritional
deficiency diseases, such as scurvy, of past generations. The
new label provides more specific information on fat, for
instance, detailing how much saturated fat and cholesterol are in
the product.

Because the new labeling reflects current knowledge
regarding nutrition and health and provides more specific
information on nutrients, it can be a useful nutrition education
tool in combination with other efforts. For that reason, we
spent much effort during the developmental stages ensuring that
the labeling was as useful as possible to consumers. And, we are

222

spending much effort now ensuring that educational progreuns to
help consumers use the new labeling are in place. I must
emphasize at this point that we have undertaken these activities
in full cooperation with the FDA as well as the many USDA
agencies, represented here today, involved in nutrition
education.

Public Education Campaign on the New Label

USDA and FDA initiated their public ceunpaign on the new
labeling in 1991, recognizing that consumers would need
assistance in making accurate, sound dietary choices in
accordance with the Dietary Guidelines for Americans.
Recognizing that a cooperative effort was the most effective way
to accomplish this goal, the agencies coordinated a public and
private sector National Exchange for Food Labeling Education to
include representatives from Government, and health, consumer,
industry, and educational groups. The Exchange allows these
groups to pool their various resources and, in some cases, their
funds, to carry out this massive public education campaign.

A particular goal of the Exchange is to see that the
labeling educational needs of special populations, such as older
Americans, children, people with dietary restrictions and people
with low reading skills, are met.

The Exchange holds periodic public meetings to identify
educational needs, discuss and analyze research, and establish
new programs. Its first meeting, held in February 1992, dealt
with campaign strategy and the education initiatives of public
and private-sector groups. The second meeting, in September
1992, focused on the communication process as it relates to food
labeling. A third meeting, "Educational Challenges of the New
Food Label," was held in June 1993.

Among the food labeling education projects FSIS has
developed or that are in progress include a joint FDA/USDA
consumer brochure, a separate brochure for low literacy adults,
and a special issue of FSIS' consumer magazine. Food News for
Consumers .

Research plays an important part in the campaign to help
ensure that the materials developed are properly targeted, carry
clear and understandable messages, and are properly disseminated.
Currently, FSIS, FDA, and HHS' Public Health Service are
collaborating on a study of consumers' use of food labels.

The education campaign will be a multi-year effort, with the
organizations involved continuing to develop education materials
and programs as the new labeling is phased-in. FDA's and USDA's
intent is to establish a self -perpetuating Ceunpaign that can be
integrated into the routine educational activities of public and

223

private-sector organizations for years to come.

New Products in the Marketplace

In addition to providing a tool for nutrition education,
USDA believes the new food labeling will serve another function —
that is, encouraging companies to manufacture meat and poultry
products with improved nutritional profiles. We have seen that
trend already, with an increase in products with nutritional
claims such as "light" and "low fat." However, the new nutrition
labeling requirements are now mandatory for processed products,
and nutrient content claims more standardized. As a result,
consumers will receive more accurate information on the
nutritional value of various products, which we believe will
encourage companies to improve their products further.

I mention this point because I believe it is important to
recognize that not only is it important to educate consumers
about nutrition, but we must also provide the American public
with foods that meet current nutritional goals. We must ask
ourselves whether we are doing enough to ensure that consumers
are offered such products in the marketplace.

For that reason, I want to emphasize that the Marketing and
Inspection Service agencies, through their regulatory and
marketing activities, are helping make available to consumers
products with improved nutritional profiles. This is a good
example of where regulatory and marketing functions coexist very
well. Through these programs, we can influence the quality and
nutritional benefits of products the industry markets and the
consumer demands.

An example of these nutritional benefits has been changing
grade standards for meat to reflect the growing demand for leaner
cuts. In 1987, for instance, the Agricultural Marketing Service
(AMS) renamed the "Good" grade for beef to "Select," which
resulted in a significant increase in consumer use of the lower
fat grade. While this was not technically a change in a grading
standard, but rather a name change, it made the lower fat grade
more appealing, and certainly more responsive to consumer demand.

In 1989, beef quality and yield grade were separated,
enabling cattle producers who produce cattle with less fat to be
paid more for their animals.

AMS also changed the U.S. grading standards for lamb and
mutton to respond to a consumer demand for leaner lamb. Payment
to producers is more for the lean portion of the carcass than for
the fat portion.

Another way we are promoting the marketing of products with
better nutritional profiles is by reassessing our policies on

224

food standards. FSIS is exploring whether existing standards of
identity and composition for meat and poultry products may
actually impede the development of products that are lower in
fat, cholesterol, and other less desirable food components.

FSIS has roughly 60 regulatory standards for meat and
poultry products such as beef stew and frankfurters. The
standards for the most part set requirements for minimum meat and
poultry content and limits on maximum fat and water. These
standards were originally designed to prevent economic
adulteration and dilution of protein and other beneficial
nutrients. However, due to the shift of scientific and public
health concern from underconsumption to overconsumption of
certain food components, we need to reassess our policies.

That is why we are in the process of developing a generic
standard of identity for substitute meat or poultry products that
resemble the time-tested and recognized traditional versions. We
want to provide another option to manufacturers who want a
product with an improved nutrient profile — and call it by its
traditional name. For instance, under a generic standard for
substitute products, a processor who wants to produce a
frankfurter with a better nutritional profile could add other
ingredients, such as fat replacers, not allowed in the
traditional standard. The processor would have to include a
descriptor such as "lean" or "low fat" next to the product name
to differentiate it from the traditional frankfurter. Both
traditional and substitute products would carry nutrition
labeling.

These three components — better nutrition labeling,
comprehensive nutrition education, and meat and poultry products
with improved nutrient profiles — together provide a sound
strategy toward improving the nutritional status of Americans.

Mr. Chairman, that concludes my statement.
(Attachment follows:)

225

226

FOOD NEWS

Spring-Summer 1993
Vol. 10, No. 1-2

Food News for Consumers is published by
USDA's Food Safety and Inspection
Service, the agency charged with ensuring
the safety, wholesomeness and proper
labeling of the nation's meat and poultry
supply. The magazine reports how FSIS
acts to protect public safety, covering
research findings and regulatory efforts
important in understandings how the
agency works and how coruumers can
protect themselves against foodbome
illness.

Assistant Secretary for Marketing
and Inspection Services

C. Eugene Branstool

FSIS Administrator
H. Russell Cross

Associate Administrator

Donald L. White

Acting Director, Information and
Legislative Affairs
Patncia D. Wagner

Director, Consumer Awareness

Wayne Baggett

Editor

Mary Ann Parmley
(202) 690-0351

News Wires Editor
Herb Gantz

Design Director
Julie Olson

Cover Illustration
Mark Holmes

Production Coordinator
Maxine Grant

Food News for Consumers is mtblished four
times a year. Subscription prux is $5.00
(domestic) or $6.25 (foreign) per year.

To subscribe, fill out order blaiik on back
cover.

Send comments and ir^uiries to:
Editor. Food News for Consumers,
FSIS/ILA, Room 1180 South.
VS. Department of Agriculture,
Washington, DC 20250,
Telephone: (202) 6900351.

Use of commercial and trade names does
not imply approval or constitute
endorsement by USDA or the Food Safety
and [inspection Service.

Now: Accurate Nutrition
Labeling

A Message from FSIS Deputy Administrator
for Regulatory Programs
Margaret O'K. Glavin

It is our mission at USDA's Food
Safety and Inspection Service to
see that the nation's meat and
poultry products are safe,
wholesome and accurately labeled.
That's our responsibility under fed-
eral law.

Now I'm proud to say we're
expanding that mission in a vital
new direction. We are saying meat
emd poultry labels must also give
the product's nutritional profile.

Why? Because we know that what
we eat has an important impact on
our health. There are substances in
food many Americans should
limit — fat, cholesterol, etc. And there
are other nutrients — certain vita-
mins and minerals — that physicians
and dietitians tell us we're not get-
ting enough of. The new labels will
give f>eople the ii\formation they need to make healthier diet choices.

Still, this new information may at first seem confusing. That's why FSIS is work-
ing with FDA, other USDA agencies and the broader food commuiuty to teach
consumers how to use the new labels. This special issue is an important step.
There are stories on how to read the new nutrition panel and interpret every sec-
tion of the new label. There is a story with answers to questions consumers are
asking today about the nutritional aspects of meat and poultry products.

For food writers and educators we've supplied a background piece, "Food
Labeling and the Law," to explain which federal agencies are doing what and
why. And for those trying to "explain" the new labels to the public, see "NEFLE
News" for a list of other label education publications now or soon to be available.

It's been four years since 1989 when we first asked the National Academy of
Sciences to verify how important solid nutrition labeling could be to the American
public. Now, finally, you'll be seeing *he fruits of our efforts. This year and next
the new labels will be making their debut on grocery shelves.

I know it was worth the time and effort it took to get these nutrition labels to
you. Please take the time to learn how to use them to stay healthy and keep your
families healthy.

Ms. Glavin, who joined FSIS in 1982, is respot\sible for the proper labeling of meat
and poultry products including the use of approved additives and packaging
materials. She also heads compliance and program review activities.

• SmiMG-SurUMB) tM9

227

CONTENTS

H's Truel Government Materials
aren't copyrighted so you can use
contents and art!*

Consumer Education

The New Food Label

4 So You Have a Nutrition Question...

Hoiv much is a gram? Wliat is cholesterol? Our Meat and Poultry Hotline answers
current questions on the nutritional aspects of meat and poultry products.

6 Using the New Nutrition Panel — A Pullout Chart

Serving sizes, daily values, vitamin needs, tvatching your daily gram-goals —
this covers it all.

8 Your Food Label — A Good Read

This illustrated guide to the new meat and poultry labels covers the 6 parts of the
USDA label and definitions of our new descriptor terms.

10 Food Labeling & the Law

A 1-page factsheet on USDA/FDA jurisdiction over food products, the impact of the
Nutrition Labeling and Education Act and a timetable on when changes will take
place.

11 Who Needs Help Interpreting the New Labels & Why

Most people will need some lielp with the new labels, but some groups —
those with reading problems, non-English speakers — will need more.

13 NEFLE News

Like to see the publications other education and industry groups have underway to
explain the new nutrition labels? Here's a list courtesy of NEFLE, the National
Exclmngefor Food Labeling Education.

14 Label...What Label?

29% of Americans do not read food labels. Assistant editor Herb Gantz looks
humorously at why they don't, but seriously at why they should.

News Wires

15 TSP — No, it's not a new Oriental seasoning. It's Trisodium Phosphate, a new safe
compound for reducing bacteria onjresh chicken as it's processed at the plant.

15 E. coli IS emerging as a recurring problem. Here are our recommendations for
protecting yourself and your family.

(The complete report is held in the committee files.)

•Exception: Cartoon on p. 14 is copyrighted through
United Feature SjTtdicate.

FOOD NEWS FOR CONSUMERS • SPRING-SUMMgR 1993 • 3

228

STATEMENT OF

DR. JACQUEUNE DUPONT

NATIONAL PROGRAM LEADER FOR HUMAN NUTRITION

AGRICULTURAL RESEARCH SERVICE

U. S. DEPARTMENT OF AGRICULTURE

BEFORE THE

SUBCOMMITTEE ON DEPARTMENT OPERATIONS AND NUTRITION

COMMITTEE ON AGRICULTURE

U. S. HOUSE OF REPRESENTATIVES

JULY 15. 1993

Mr. Chairman and Members of the Subcommittee, I appreciate the opportunity
of submitting this statement discussing briefly the nutrition research activities of the
Department of Agriculture's (USDA) Agricultural Research Service (ARS).

USDA's role has always been to ensure that the nation has a safe, adequate
food supply. It also means producing a variety of foods that, collectively, provide all
the nutrients essential for a balanced diet. To do this, an essential need is for precise
knowledge of what the body requires for optimal growth and health. Recommended
intakes of nutrients have been established for a few dozen constituents. But we are
learning today that there are hundreds-some at very low levels--that are active in the
body.

Recommended intakes of nutrients will become more specific based on the
different needs. We know today that men, women, nursing mothers, infants, and the
elderly have different nutritional needs. We are learning to be much more precise
about what constitutes "nutrition" for different groups of people. Research is
providing a sound scientific basis for nutritional decisions which will contribute to a
more healthy lifestyle for individuals. Preventive measures based on sound nutrition

229

should reduce health care costs for families. The nutritional needs of the elderly,
pregnant and lactating women, and infants and children are receiving more attention.
But we don't have all the tools we need--our knowledge of what nutrients are needed
and how they interact at different life stages in different population groups is not
sufficient. On the opposite side is finding out what foods contain what levels of those
essential nutrients.

A 1 992 study of a group of children on a diet typical of undernourished children
showed convincing evidence that a lack of adequate dietary zinc impairs the ability of
vitamin A to fully carry out its function in the body. Dietary supplementation was
found to increase blood levels of the two nutrients and improve night vision.

What are the dietary needs of adults? Recommendations on dietary energy
requirements form the basis for determining the amount of food aid given to poor
families and for assessing the adequacy of the food supply in different communities.
Research findings indicate that present recommendations substantially underestimate
usual energy needs and that current Recommended Dietary Allowances underestimate
usual energy requirements for physical activity.

Recent studies at USDA Centers indicate that half as many noninstitutionalized
persons who consumed lower levels of vitamin C were found to have increased blood
pressure compared to those whose intake of the vitamin was relatively high. It still
must be determined whether other components of a low vitamin C diet affect blood
pressure.

230

Othei" studies indicate that individuals with cataracts were found to have lower
intakes of folic acid and vitamin Bg than those of connparable age without visual
impairment.

To address these and other issues, the ARS conducts research on human
nutritional requirements at five major nutrition research centers.

The oldest center is located at Beltsvilie, Maryland and conducts research on
all classes of nutrients and their interactions. It is particularly noted for studies of
energy metabolism and body compositions. Controlled feeding studies using 20 to
100 volunteers, men and women with diverse racial and ethnic backgrounds, are
conducted to determine effects of nutrients on indicators of heart disease, cancer,
obesity, and other nutritionally related conditions. The Beltsvilie Center's Nutrient
Composition Laboratory is the historic leader in developing methods for nutrient
analyses of food. Their work is particularly urgent now in relation to needs for
nutrient labeling of processed foods. A recent significant contribution on food
composition, related to the concerns of the National Cancer Institute, is publication
of the carotenoid content of foods. Vitamin and mineral bioavailability from foods as
well as their interactions with different kinds of carbohydrate in the diet are important
in defining ways to improve food composition by genetics and processing to best
meet peoples' needs. ARS scientists work with medical scientists at Georgetown
University, Johns Hopkins University, University of Maryland, and other institutions.

The Human Nutrition Research Center at Grand Forks, North Dakota, is
particularly focused on mineral needs. Recent studies have shown the importance of

231

fatty acids of beef, not just the heme, in facilitating iron absorption from diets that
meet recommended intalces of fiber. The scientists at the Grand Forks Center are
internationally recognized for their discoveries in ultratrace element needs. They are
leaders in research on human copper requirements, a trace mineral prevalent in nuts,
whole grains, and beans. The scientists have done pioneering work on the
relationship of mineral needs to neurological and behavioral functions. The Grand
Forks Center works with faculty of the University of North Dakota Medical School.

The Human Nutrition Research Center on Aging at Tufts University, College of
Medicine, in Boston, Massachusetts, is the world leader in nutritional needs of the
elderly. The Boston Center is operated by contract with Tufts University and has
active interaction with many of the medical faculty at the University. You will be
hearing from Dr. Rosenberg today. Major studies of nutrient requirements to maintain
a healthy immune system, cardiovascular function, resistance to osteoporosis, and
visual function are ongoing. We recently expanded research on neurological function
in relation to nutrition and aging. Our studies of vitamin B^j' ^ol'C acid, and
antioxidant nutrient requirements during aging are leading to better understanding of
needs for delaying some degenerative processes.

The Children's Nutrition Research Center (CNRC) in Houston, Texas, associated
with the Baylor College of Medicine is also internationally unique. Or. Nichols will be
addressing the Subcommittee and I'm sure he would concur the research being
conducted at the Houston Center is unique and exciting. The studies of nutrient
needs for growth of normal and preterm infants have led to better nutritional support

-4

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both in relation to breast feeding and formula supplements. We have recently begun
an unprecedented study of nutrient needs and growth processes of teenage mothers.
The Center has equipment not available anywhere else to monitor growth of organs,
muscle, bones and fat both during pregnancy and of the infants and nursing mothers.
These studies, especially in relation to calcium, will be the first to enable us to identify
predictors of bone maturation and possible later needs for bone maintenance
throughout life.

The Western Human Nutrition Research Center (WHNRC) in San Francisco,
California, is especially dedicated to devising and testing methods to monitor
nutritional status. The scientists work in close cooperation with many scientists in
the University of California system. Joint projects between WHNRC and University
of California, Berkeley, the University of California, Los Angeles, and the University
of California, Davis are active. WHNRC efforts are currently focused on defining an
optimum combination of diet restriction and physical activity to achieve sensible
weight loss, and on exploring the relationship between eating behavior, body
composition, nutritional status and risk factors associated with chronic disease.

Our human nutrition research scientists cooperate with each other in many
working groups. They also work to assist the Food and Nutrition Service, such as
recently in relation to school lunch needs. The CNRC has an Extension Food and
Nutrition Specialist co-located to expedite the incorporation of new knowledge into
education programs. We work with different institutes of the National Institutes of
Health: heart, cancer, alcohol. We have very active cooperation with the Human

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Nutrition Information Service (HNIS) and the National Center for Health Statistics in
their food consumption and nutritional status survey responsibilities. For example,
ARS research was essential to the development of dietary guidelines jointly issued by
HNIS and HHS.

Dr. Johnsrud mentioned some of the existing coordinating mechanisms, I
personally serve as a USDA/ARS representative on seven of those inter- and intra-
agency committees and task forces~the purposes of which are to coordinate nutrition
research activities.

Nutrition research is an iterative, interactive process dealing with the whole
body-fetus to centenarian-within different social contexts. A pressing research need
across all areas of nutrition concerns the consequences of inadequate, inappropriate,
or excessive nutrient intake. Another is a much greater understanding of all the many
facets of nutritional problems associated with poverty. Research to define nutrient-
gene interactions so that the susceptible individual can be identified is badly needed.
All aspects of nutrition in neurodevelopmentand cognitive ability, as well as nutrition
and development of the gastrointestinal tract, are virtually unexplored. Research also
is needed to identify the pediatric antecedents of adult disease-e.g., do obesity, heart
disease, and cancer have their origins in childhood and should dietary intervention
start early in life? These are some of the research issues of vital importance to
national health care costs and the vitality of the nation.

Research is not done for knowledge alone; that knowledge must be available
to those who need it. Research results are disseminated in a variety of ways. They

234

are made available to the Extension Service. They are discussed at scientific
symposia and published in journals. ARS provides information to the popular press,
radio, and television. We recognize that the wealth of facts and information can be
confusing and, at times, conflicting, but we in the research community are constantly
striving to provide updated validated research results for communication to industry
and the consuming public. Good data and good communication will assist us in
making informed choices from a nutritious food supply that promote a healthier
population—from birth to our senior years.

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235

STATEMENT OF

DR. MELVIN M. MATHIAS

HUMAN NUTRITION SCIENTIST

COOPERATIVE STATE RESEARCH SERVICE

U.S. DEPARTMENT OF AGRICULTURE

BEFORE THE

SUBCOMMITTEE ON DEPARTMENT OPERATIONS AND NUTRITION

COMMITTEE ON AGRICULTURE

U.S. HOUSE OF REPRESENTATIVES

JULY 15. 1993

Mr. Chairman and Members of the Subcommittee, I am Dr. Melvin M. Mathias,
Human Nutrition Program Scientist for the Department of Agriculture's (USDA)
Cooperative State Research Service (CSRS). I appreciate the opportunity to submit
this statement on behalf of CSRS to describe the agency's program, working
relationships, and accomplishments in human nutrition.

CSRS supports the equivalent of 175 full-time scientists conducting about 500
research projects at universities and laboratories. Much of this work is carried out by
research, teaching, and extension faculty at the Nation's 74 land-grant universities.
These universities bring together nutritionists, food technologists, economists, and
social and behavioral scientists to address the complex issues of nutritional quality of
foods and consumer food choice. CSRS supports nutritional research through its
partnership programs including Hatch and Evans-Allen funding, as well as special and
competitive grants, and graduate fellowships. On average, these funds are leveraged
at least three-fold by matching funds; each dollar of Federal funding brings with it at
least three dollars from other sources to do this research.

Graduate and post-doctoral students receive nutrition training undergirded by a
understanding of the food system from production through consumption and its
effects on human diet and health. The CSRS uses institutional and agency peer
reviews to evaluate the quality of research and graduate training programs. Programs
sponsored by CSRS tap talented scientists from a diverse array of colleges of
agriculture, human ecology, and medicine at public and private institutions.

236

One important program~the nutrition, food quality and health program of the National
Research Initiative Competitive Grants Program (NRI)-is designed specifically to
stimulate new and innovative research. It has been endorsed broadly by many
professional organizations as well as consumer groups, food industry representatives,
educators, and service providers. Research emphasizes: (1) bioavailability of
nutrients; (2) the interrelationship of nutrients; (3) nutrient requirements of healthy
individuals across all age groups; (4) mechanisms underlying the relationship between
diet and health maintenance, such as the effect of nutrients on the immune system;
(5) the cellular and molecular mechanisms underlying nutrient requirements, including
the modulation of gene expression by nutrients; and (6) food consumer behavior,
including identifying and developing methods to overcome obstacles to adopting
healthful food habits, to convey knowledge to target audiences, and to ascertain
factors that affect food choices.

Through the past several years, CSRS-supported research has led to important
accomplishments in several areas:

o Bioavailability of Vitamins
The degree to which food nutrients are available for absorption and utilization, termed
bioavailability, is a critical issue for estimating nutrient allowances and labeling of
foods. Nutrients are rarely found in foods as a single compound. Most frequently
they are bound to numerous enhancing or inhibitory factors. Folic acid is an excellent
example of a vitamin available in several forms in food, and its bioavailability is
inhibited by several components of food. Research done in land-grant universities
indicates that a 50% bioavailability factor can be assumed for folic acid. This specific
information will be critical as the Public Health Service develops and implements a
practical approach to preventing neural tube defects.

o Food behavior of adolescents and young adults
Researchers working with adolescents showed that while the teens were developing

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very strong opinions about food, nutrition, body image, and health, their parents still
had a great deal of control over their food intake. They then addressed what happens
to teens when they enter the transitional years of young adulthood (18-24 years).
There is virtually no information about the effect of nutrition and health concerns on
food intake by this consumer group. Focus panel research has shown that 18-24 year
olds feel quite pressed for time and are very concerned about food costs. Fast food
is their staple because it is fast, cheap, and familiar. At the same time, they worry
about nutrition-mainly dietary fat, cholesterol, salt, and sugar, but also pesticides,
additives, and other chemicals. The next step in the project will be to determine the
factors most influencing consumption of specific food items, such as beef, cheese,
and various fruits and vegetables. The enhanced understanding of what motivates the
food choices of this age group will be used by Extension and other health
professionals to develop appropriate and effective programs.

o Nutritional status of rural elderly in the South
The overall objective of this regional research project was to determine the quality of
life of elderly persons in the rural South by assessing their actual and perceived
nutrition, clothing, and housing status. A large team of researchers from the
historically Black 1890 land-grant universities made several findings. They showed
that medical costs are the most serious concern, followed by concerns for energy,
housing and food. They confirmed that a high percentage of monthly income was
spent on food; the highest reported was 35% among black females. They found that
participation rates in community service programs, including senior centers andfiome
delivered meals, were very low. The study concluded that community services need
to be more effective in reaching rural elders. How best to do this is the topic of their
current research project.

o Identification and' isolation of Protective Compounds in Foods
More than forty foods have been identified as having cancer-preventive properties

238

over the last decade. Fourteen classes of phytochemicals, the chemical components
of plants, possess cancer-preventive properties. Phytochemicals may also play a role
in preventing other chronic diseases, such as coronary heart disease and osteoporosis.
For example, monoterpenes, tocotrienols, phenols, and saponins in plants have been
shown to have beneficial effects on the cardiovascular system. Quercetin inhibits
antigen-induced human white blood ce'! responses. USDA and university scientists
are part of a major effort with National Cancer Institute to develop a more complete
understanding of how these compounds act and interact with other active agents in
food.

o Low-fat Meat Products
In response to consumer demands, USDA and university meat scientists have been
instrumental in outlining the principles and developing the technologies to formulate
acceptable low-fat meat products. Developing palatable products has been
challenging, but food processors now employ carageenans, soy proteins, modified
food starches, and oat bran to bind fat and water in the formulation of low-fat meat
products while retaining the sensory properties usually associated with high-fat
products. Some of these innovative low-fat products can be found in fast-food
restaurants, grocery shelves, and school lunch programs.

Priority research needs. I want to highlight three pressing, priority needs in
nutrition research:

First, expand the human nutrition component of the National Research Initiative's
Competitive Grants Program. USDA and the Department of Health and Human
Services play key roles in meeting the 21 nutrition goals outlined in the Federal
government's Healthy People 2000 objectives. The list of researchable issues is long.
The President's FY 1994 budget addresses this need by proposing a significant
increase for the National Research Initiative (NRI) and, more specifically, human
nutrition research funded through the NRI.

239

Human nutrition research supported through CSRS competitive and cooperative
programs will make significant contributions to this interagency effort. For example,
we have instituted new research to expand our understanding of food consumer
behavior, including ways to overcome obstacles to consumer adoption of healthful
food habits, convey nutrition information to target audiences, and ascertain factors
which affect food choices. We continue to fund research which applies new
techniques in molecular biology to expand our understanding of nutrient requirements
and the role of nutrition in optima! health.

Second, we need to more thoroughly document the conseouences of nutrition
research and education on the health and well-being of citizens. We don't know
enough yet about the full impact of nutrition research and outreach on human health.
We have data from studies of the Expanded Food and Nutrition Education Program
(EFNEP) and the Special Supplemental Food Program for Women, Infants, and Children
(WIC) which suggest that nutrition education improves child and maternal health and
decreases spending for medical care. A full assessment of the cost-effectiveness of
nutrition efforts will require multidisciplinary analyses.

Third, expand human nutrition training. Training of nutritionists in the continuum
from food systems to molecular biology to public health is critical to accomplishing the
Healthy People 2000 objectives. Land-Grant Universities provide the intellectual
environment through complementary research and extension activities in the range of
disciplines relevant to nutrition. The capacity-building, fellowships, and strengthening
programs are designed to support recruitment, education, and training of nutrition
professionals.

Mr. Chairman, when totalled, the scientists in ARS, CSRS, and the Extension
Service and the university-based system make a powerful team dedicated to improving
the nutritional needs of consumers.

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Full text of "Review of nutrition research and education activities : hearing before the Subcommittee on Department Operations and Nutrition of the Committee on Agriculture, House of Representatives, One Hundred Third Congress, first session, July 15, 1993"

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