F, N 19iiiiiiii
PRPAE BY TH iT OFTH
SEEC COMTE NNTIO
8S1L00T COMMITTEERO NUTRITION AND HUMAN NEEDS
GEORGE MesoymnN, South Daloa, chairman
ERMAN E. TALMADGE, Georgia CHARLES H. PERCY, Illinois PHILIP A. HART, Micligan R OBERT DOLE, Kansas
WALTER F. MONDALE 1Mesota HENRY BELI&ION, Oklahoma
EDWARD M. KENNEDY, Massachusetts RICHARD 8, 80HWEIKER, Pennsylvania GAYLORD NELSQN, Wisconsin ROBERT TAFT, JE., Ohio ALAN CRANSTON, !Qalifornia MARK O. HATFIELD, Oregon
HUBERT H. HUMPHREY, Mitmesota
ALAN J. Broke, Blaff Director
MnArA. L. MArs, Beneral Counsel
first.:"Nutrition and Health" report, published in December 1' examnad the problems of nutritional ignorance in the United
*tesand the -reluctance of the Administration to introduce nutriOo at elh considerations into food And economic policymaking.
Th sc6d edition retains the substance of the first, but Chapter
IIIhasbeen expanded to review the involvement of nutritional health Uc~r bi United States .and world food policy in this century. The Au~yfind, in effect, that we have regressed smece World War II in "r Udertanding of the importance of nutritional health considerat'food and edonomic policy.
Sne1972, the United States has been faced with an unexpected
*ordwie fod shortage that: may be the most protracted since that iofWoldWar II. We are relearning to manage our food system under unfamiliarr circumstances of low stockpiles and uncertain productill..In this new ers we seek guidelies..
I1073, President Nixon appointed a'Committee on Food within i4!Cst of Living Council, his Administration's first mechanism for nd atmfg cosumer food prices and balancing the numerous demands mad. O the limited food stocks. In managing the food system, the
Nlx~handP.Ord Administrations have entered into the marketplace soadlically to control prices. Measures such as the soybean embargo
adte delays in grain sales to the Soviet Union in 1974 and 1975, hv been IME minute steps, treating effects rather than causes. The 'Admtrations have argued that the marketplace should be the Panipslarbiter in the struggle over our. reduced food supply. Alghthis position has a clean, simplistic appeal, the consequences
s ing but clean.
SIURVITAL OF THE FITTEST
Ae Administrations' policy is one of survival of the fittest, leaving .nemmeail interests in a position of unchallenged superiority., As ,pricesr rie the marketplace does not allocate food to thos wtho eannt affggd .t Nor does the marketplace necessary stimulia the consumption of the most nutritious foods, ilvng) theleast amount of resources for production and consumption.
To be ampre specific, we And tato at:the same time a, significant minority at home and perhaps a majority overseas are going hungry, Many Ameri cans are consumingv too many calories. Six. out of the nine diseases among the 10 leading causes: of death in the United States (Accidents are the other cause in the 10) are -believed to have overco1numption of -nutrients and food additives among their .causes. Obesity is a major health problem, and the food industry,-stimulating consumption, produces foods with "empty" calories and atfciall
-dfifferen~tiated foods, relymg for their appeal on salt, fat, sugar And lattificial colorins and flavorngs. In a time of severe food shortage,
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a l o n e.
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that would enable us to use greater foresight in manazine the:: food
dence4orAh6se in Congress fighting to expand food assistance programs. But the Administration apparently saw greater knowledge as a threat rather than a help. The Ten-State Survey was reorganized to includeonly general findings, concealing groups at high risk in broad categories, thus making remedial action more difficult. Dr. Schaefer resigned.'.,
The AdmIliiistration's practice of permitting and even perpetuating nutritional* ignorance apparently extends to the Department of Agriiculture'.s 11ous6hold Food Consumption Survey. Formerly scheduled to start in January 1976, the survey was delayed more than a year by the Office of Management and Budget supposedly for technical reasons. But on6 o1fleial reports that, in fac't, the Administration did not want to be embarrassed in an election:year by.-preliminary findigswhich might very well show a decline in the nutritional quality of the American diet.
Th Household Food Consumption Survey is important not only as a general 'indicator of the content of the American diet, but as the data base for food stamp allotments. Therefore, the delay of a new survey permits continued use of data which may keep allotments lower than'they should be.
In additional the Household Food Consumption Surv as it is resentlY 4kuctured, does not provide the best basis for establishingpood assistanbe allotments because it measures o nutrient intake, not the adVal nutritional health of the respondentsAxperts insist that proper analysis of nutritional health must include physical examination and biochemical testing as well as a measure of nutrient intake. The Household Food Consumption Survey as currently planned has no nutritional he alth component, and therefore, can study what is eaten but not the effects of these consumption patterns.
'President Ford does not have to be bound by the practices of the Nixon Administration. To help start returning nutritional health to its Appropriate place in U.S. food and agriculture policy, I ask the Presi4 ut to appoint the Secretary of H alth, Education, and Welfare to V6 Agricultural Policy Committee.
In addition, I urge the President to actively support the creation of a... truly comprehensive nutrition monitorig system such as that described, in Chapter II and outlined in S. 2867. 1 also urge him to provide the funds and administrative, support that will permit HEW to become an effective voice for nutritional health.
IN CONCERT WITH CONGRESS
Support by the President of activities in nutritional health would be completely in concert with recent Congressional action. In May, the IbUse Agriculture Committee approved a bill that would provide $5 imion for human nutrition research in the Dep'artment of Agriculture, a 60 percent increase over the amouni currently spent.
0 6 mi ee appr
In-June the Senate Appr priations 7om itt' oved a House
provision, that would increase the funding for the Household Food Consumption Survey by $1.6 million over USDA's request. The Sell'aUlAppropriations committee also approved in June $21 million of a $24.2 million request by Senator Humphrey for various nutrition research and education projects within HEW. The Committee also approved my request that the National Cancer Institute be directed to spend up to $15 million for human nutrition research and my request
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COMMENTS BY SENATOR PERCY
It is important that nutritional health become an integral element of U.S. food policy decisions. It is equally important, however, to inject the consideration of the impact of nutrition in our health policy.
As early as 1971, 1 began to feet that the medical profession was illequipped to deal with nutrition as a basic component of health care. That understanding rompted m ntroduction of a nutrition education amendment to t9e Health 74ower Bill of 1971, which opened up Special Projects funding under the Act to training and research
n human nutrition.
pro[Vsni clusions of this re ort indicate that we have not made significant progress since 1971. Bespite the fact that six of the ten leading causes of death in this country have been connected to diet, modem medicine still concentrates on disease and therapy; and aims at death prevention rather than health promotion and maintenance. For all the medical knowledge we accumulate and the technological breakthroughs we achieve, people are still not getting the information, direction, and support they need to keep healthy.
The report attributes much, if not all, of the blame for this unsatisfactory state of affairs on the administration. In my view, blame, if placed, must be shared by all concemed-Congress, the food industry, the medical profession, educators, and the general public. A!thou h Government must do its part, it cannot be all things to all peopf'3. If we have learned one lesson from public policy mistakes of the past, it is that Government must not promise what it cannot deliver.
National food and health policies, however effective, can help only those who help themselves. Increasingly, research findings tell us that we are in large measure responsible for our state of health. It is becoming common knowledge that much cardiovascular disease, most cirrhosis of the liver, obesity and its consequences, and many gastrointestinal disorders are self-induced by overeating, smoking, overdrinking, and eating the wrong foods. Changes in bad eating and drinking habits, therefore, caia make dramatic improvements in the health of the population. Such im rovements, however, depend to a a great extent on the will and capaTility of the people to take personal responsibility for their own health.
How to get people to do what is good for them without violating their personaJ freedoms is a most difficult challenge. Where eating and drinking are concerned, the problem is doubly difficult. The consequences of poor nutritional habits are unfortunately paid much too late to establish cause and effect, let alone provoke action. The significance of this staff report hes in its potential to promote and inculcate good nutritional habits and to increase personal responsibility for health.
CHARLFs H. PERCT.
The Senate Select Committee on Nutrition and Human Needs held hearings in June 1974, to measure the progress that had been made in achieving the goals set at the 1969 White House Conference on Food, Nutrition and Health and to focus attention on the need for a comprehensive national nutrition policy.
This report is the second edition of the fifth in the series of staff studies expanding on recommendations and testimony offered at the hearings and intended to establish specific objectives for United States food and nutrition policy.
This report concerns itself primarily with America's self-knowledge of its nutritional health; more specifically, the availability of nutrition evaluation and counseling to individuals and the adequacy of our national nutrition monitor ing system. The bureaucratic and political problems of applying nutritional health considerations to food policy are also examined. Nutrition education outside the medical setting, the status of nutrition research and the nutritional quality and safety of food are topics left to further inquiry.
The other reports in the staff series are: Nutrition and the International Situation-September 1974; Nutrition and Food Availability (discussing food production and retailing) -January 1975; Nutrition and Special Groups, Part I-Food Stamps-Maxch 1975; Nutrition and 07overnment-Towards a National Nutrition Policy-May 1975. The first edition of Nutrition and Health was published in December, 1975.
Foreword --------------------------------------------------------- III
AMitional comments by Senator Vil
Note ------------------------------------------------------------- Ix
NuTmTxori -AND HEALTH II
introduction ------------------------------------------------------ 3
',Eating in the dark ------------------------------------------------- 3
IU diseases of 4
Under-nutrition ----------------------------------------------- 8
Other f actors affecting nutritional health status- 17
Nutrition knowledge ------------------------------------------- 17
Monitoring national nutritional health --------------------------- 19
Filling the 19
Food production and. nutrition policy ---------------------------- 20
Health, the governing 21
Chapter L-Access to individual nutrition 23
Examination failure -------------------------------------------- 25
The nutrition counseling system --------------------------------- 29
Health maintenance organizations --------------------------- 31
Public health clinics- 32
Nutrition referral 33
The third parties ---------------------------------------------- 33
DTweuwion ---------------------------------------------------- 33
Federal support ------------------------------------------- 35
Chapter II.-National nutrition assessment- 37
Current surveys ----------------------------------------------- 40
1 Small sample ---------------------------------------------- 41
The CDC system ---------------------------------------------- 42
The food consumption survey ----------------------------------- 45
Survey technique ---------------------------------------------- 46
A plan for nutritional 48
Recommendations --------------------------------------------- 49
Chapter III.-The importance of nutritional health considerations in food
The impact of World War I ------------------------------------- 51
New influence for nutrition ------------------------------------- 54
British bread ---------- -------------------------------------- 54
New guide for production --------------------------------------- 55
Problems of plenty ------------------------- ------------------ 56
Relearning food policy coordination ------------------------------ 57
Decline in influence -------------------------------------------- 58
The social factor ---------------------------------------------- 59
The nutrition threat ------------------------------------------- 59
Struggle to be heard ------------------------------------------- 61
Summary Land discussion --------------------------------------- 65
Recommendations --------------------------------------------- 67
Bibliography ------------------------------------------------------ 69
A. Benefits from human nutrition research ------------------------- 75
B. Economic benefits from the elimination of hunger in America------ 79
C. Au "alternative diet" fortepeeto fahrslrtchatPg d ie ea -- - -- - -- - -- - -- - 9
D. What should be the Dprmn' oei urto n itpran
ing to health?-- - - - - - - - - - -- 9
E.New control of famplc decie ------- ------- 13
F. Levels of nutrition a for .
G. Hospital mn-on
H. Outpatient nutri
1. Letter from The Lib -J. Nutrition programs i Stae he~hagnis-------------- 6
-K Funding needs for nurto triig-------------- 7
Su rv ey -- - - - - - - - - - - -
N. Requiremlents for dt rmte17 ainiefo osmto surveys for the speiid rbe ,rasdi ilr ------- 0
P. Providing for teodrytriaii'b eo'ficWifz~~
activities --------- - -- - - -21
illt r c -- - - - - --- - - 2
'. fo tion U.HE noetDrLarneE.Ln Jronntiidliltrd2 29
V.Acn mmrnu rmH Wo bri~ln ~ irfoi a c i i i s - - -- - - - - - - --.- - 3
W. H W mmrndmo oriairiofdprmftlnuaih
a c i i i s - - - - - - - - - - --- -- - 3
If.HE nurto coriaigcm itechrer -----23 Y.Anulporsreotonurto coriaigidtnte..--- 23 Z. Asaeetonurionplc fo th ehrdfi 0
NUTRITION AND HEALTH 11 Nutrition and Health Revised With a
Study of the Impact of
Nutritional Health Considerations
on Food Policy
EATING IN THE DARK
The problem of disease prevention itself has changed radically since
.190Q whenpneumonia, influenza and tuberculosis were the leading killers. Today, heart disease, cancer and stroke claim our attention
there is much greater recognition today that the kinds and amounts of food and liquor we consume and the style of living of our sedentary society are major contributing factors to the development of chronic illness and to change these patterns of behavior rewes the active involvement of the individual.-The Department of ealth, Education,
and Welfare's Forward Plan for Health, fiscal year 1977-81.
One in three men in the United States can be expected to die of heart disease or stroke before age 60 and one in six women. It is estimated that 25 million Americans suffer from high blood pressure and that about 5 million are afflicted by diabetes mellitus. These diseases have been directly related to over-consumption of certain foods.' At the same time, millions of Americans are not receiving the nuWents they need. The Department of Health, Education, and Welfare's Health and Nutrition Examination Survey (HANES) reported in"1974, for example, that significant numbers of children are deficient in iron. The h' hest incidence of this learning inlDeding deficiency was found among ck children, ages 1 to 5, above & poverty line, where 22 percent were affected.
The consequences of malnutrition both through the over- and underconsumption of nutrients is expensive not only in terms of human suffering and wasted potential, the monetary cost is staggefing. Dr. George M. Briggs, rofessor of nutrition at the Univer it f
California at Berkeley tod the Select Committee. at hearings isnl 'yDoecember 1972, that the annual health bill to the United States from" h I ye n 'and improper eating habits might be as much as $30 billion, or at hat time, about one third of the Nation's health costs. HEW reported the health care costs to be $104 billion in 1974. Dr. Briggs' estimate was based on a report issued in 1971 by the Department of Agri6ulture, Benefits of Human Nutrition Research (A dix A).
Dr. John W. Farquhar, of the Stanford University Me ical Center, told: the National Nutrition Policy hearings that the elimination of obesity in the United States might cut in half the $24 billion being spent on treatment of premature cardiovascular disease.
In a paper prepared for the Select Committee in 1969, &onomic Bene ts from the Elimination of- Hunger in America, Barry M. PopStatistics from reports and testimony presented to the Select Committee's Ntt$onal Nutrition Poll hearl4n p Btu 1974,
Tune 1 .7 ,june 1974, appearint In National Nutrition Po"ci 76
Part 6, eart disease, p. 263 ; high blood pressure, p. 2 21); betes,
kin, of the Institute of Research on Poverty at the University consin, made the following estimates of economic benefits tha flow from eliminating malnutrition among the poor (Appendi )
Education.-Improved nutrition improves learnmg, prevent terruption of cognitive development and increases the ability centrate and work ($6.4-10 l 0
Physical Performance.-Improved nutrition increases the c for prolonged physical work, ri11 productivity of work
increases the momiyativ rresistan
ease and lowers the severity of.disea._.1201-502 million).
Mortality.-Improved nutrition decreases fetal, infant, ch certain typesoin maternal mortality (S-68-167 million).
Ia '0661ts. -Improved wintrition naikes .
mothers w& 1 helt y idren, Also, fetter. Aditatekl.pated
ii '!iic' :t i I ''. 1) 1 0 1 'J e adii~ i ,
to better eduated c dren ($1.3-45:141%lon...
It is clearthat poor nutrition is a. major public health problem in' the
United Stlates. Its caus oistooted in ou~r -habits and our econorne s tem, and it isa prh eqiteatly aggravated'by Ignorincel.
THE Disiklas oF Odmi-ABUlDkfVO]
Testifying at the National. Nutrition' -Policy hearings, Er,. Wli E. onnor, co-chaiknan of the Select. Committee's panel on-utrto
and health, reported
the VatE j i f Am ericans suffer from ove .r-abubdance of -fo'T h
changed 'bbologyfd our land . .has led to a whole new Apectrum of disae l which nutritional fal ors either play the primne etiological role or else, arigy contributory to the development of the given disease state, that is coronay." disease, besty, an ,p o. .
'lhe Wall Stret Jouranal, in an rticle on the increased inteet.i preventive care, reported recently:
The idividiual, s ays Dir. John H. Knowles, president of the researeh-osie Rockefelle Foundation, "must realize that a perpetuation of the presets of high-costz, after-the-fact medicine will only result in higher costs andmr frustration. Thiq next major advance in the health of the; Amenican peol.wl result only ftrm what the individual is willing to do for hhnself."
onsider dcrncer and heart'disease. It has become clear that neither is "Cugt like a cold: Instead, both usually arise after decades of abuse to the body. Yaso heavy smoking or
mary or contributing dietary factors in some of the most wide-sra' diseases:
1 Coronary heart disease.-An excessive amount of choletrl
saturated fat and calories in the diet.
2. High blood pressure.-Dietary salt and excessive clre
contributing to obesity.
3. Diabetes mellitus.-Excessive calories with associated b ty
(also high dietary cholesterol and saturated fat intakes a
predispose to the vascular complications of diabetes).
4. Obesity.-Excessive calories and lack of physical actvt
with the result that caloric intake exceeds caloric expenditue
5. Dental caries.-High intake of sugar.
6. Liver disease.-Excessive usage of alcohol.
Ia the report, Nutrition in the Causation of Cancer, published in November 1975 in Cancer Research, journal of the American Association fez eanter--Research-, Dr. Ernest L. Wynder, -of the AmericW Health Foundation, said:
t. epidemiological evidence suggests that nutrition, as used in the broadest se se*,. affects the incidence of a large portion of human cancers, perhaps relating to astnuch as 50 per cent oi all cancers in women and one-third of all cancers in men On the dev*ped nations).
Aud, Dr.. Wynder reported that the most important contributingi factor, seems: to be over-consumption of certain nutrients. Mentioning' fat 94id cholesterol, he said:
I&I must copsider whether the human metabolic process can properly handle the ,e*ormous -' lexcess of foods so prevalent in our developed society. The conseqiietices of such excesses, in view of our increasingly sedentary lifestyle, very
pimsibly could'be drastic, and therefore this area must be further investigated.
Table 1 shows the 10 leading causes of death in the United States,
*th "the diet4elated illnesses noted.
TABLE I.-DEATH RATES FOR THE 10 LEADING CAUSES OF DEATH, UNITED STATES, 1972 7- [Based on 10 percent sample of deaths; rates per 100,000 population]
Death Percent of
.v -,Rank and cause of death rate total deaths
Allcauses ------------------------------------------------------------ 942.2 100.0
171 ses of he(art I ----------------------------------------------------------- 361.3 38.3
2pMafignant neoplasms, including neoplasms of lymphatic and hematopoitic tissues I- __ 166.6 17.7 3r Cerebrovascular Measesl ------- -------------------------------------------- 100.9 10.7
4, Accidentg ------- ----------------------------------------------- 54.6 5.8
5,.. Irffluenza and pneumonia ----------------------------------------------------- 29.4 3.1
6.J)kbetes mellitus _.__ --ii ---------------------------------------- 18.8 2.0
7, Coirtain causes of mortalil In Ii i n ncy ------------------------------------- 16.4 1.7
&, trio clerosis I ------------------------------------------------------------ 15.8 1.7
9 ,uv, osis of liver I ----------------------------------------------------------- 15.7 1.7
10 711mnchitis, emphysema and asthma -------------------------------------------- 13.8 1.5
AJIo her causes ------------------------------------------------------------- 148.9 15.8
r-Ndrition related causes.
ese illnesses, even though most are related to the over-consumptiollof certain foods, are not peculiar to any one income level. Figure 1, from the HEW Health and Nutrition Evaluation Survey (HANES), sho' that obesity, one of the nation's major health problems, is suffero'almost equally at almost all income levels.
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Expeiene in other nations as well as our own indicates that a genwaki~ketio ofdertain foods in thd diet is likely to lead to improved gure2 thws, for example, that there as a greater incidence
O'dtt arfro h disease in the more affuet nations where then
Wkw f oleterlishigher.
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ning its driioelt in to caounies edadt in seese f foatss
sfor t sa tenl in certai r s v
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iiiiiiii'hilren th .............d iiiiiiii Indian 'of isolated.... m ervations,
an~io hs nne wohvn;koldeoftevxosfo si t
rberution o h ncente 9Bhrit isesedrig, rdiWvJ a deteasortion it nrirtion o
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The trendi in nutritional, contenf of A erica's food is similar.iTi
national dcnsute o uvycnutdmi1 yteD
Tht ofArcuefunderciu tha nthe m befAeian eev
a:iiiiii nutritionally adequate diiiiiiethd elne ro 0to5 pre. 10yar.Aswl b otdlte n hs eotter ssoefer1
the~~i~~ii nex cosmtonsreill show the decline continuing.i~i T h S w edill~ii~~liiiiiiiii:~iii: ::::::: :::: ::ii::H isiH::::::::: ::::::~~iiiiiii: i~i~~iii~i~i :!~iiiih r e p o r t g a v e th e fo llow~::: ~~ii::~~iiii!:iii~ii i !i~iiiiiiiii:::: ~iii~ii in g a d v ic e a s r e g a r d9i" a veiiiiriiii:H:ii~iii~iiiii ::i::::i:: ........
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Theiii~ii consumpti iii~iiiio o ve talsfr ip ttedh pout ihi o fat'~ii~: content,~~i~ fiiiiiii sh lean!iii meati~iii pouIi l try bread and.............d
sh ouiiiii: l dllll~i b e p ro p ort io n a tely in crea se...............................................................
Natiiiiiiiiii~ii, i nai ii l It~~iiitut ofi PubicHeath Theit i:~ is veysiia.t.he"ler.iv"detfr..uin~~
and cholesterol consuption recommended by he Select Comr ittke'
stami~ iotoef prgany cleaning biity gothan usepi
STATES, 1971ii72 (Hii PEIIAR.....
Percent ofPercnt b
with ina e e nitkith intks en intake!!i!!!!!!
I~~ tD5yas ohsxs'
18 to44 yers, f1ale
Calcium ---------------------Ii----------i56.39i 110 74.50 8101
Iron ------------ ------------i i---------i 94.245794.66498
Vitam in.................--------------- 73.54 82 64.42 149
Vitamin CiiiiH -------. I -------------- -------72.2610593 7132
60 years and over, both ;exes: ,
...m- - - - - -- -. 121 44.:67 108
Iron -------------- 6 ----------- -------- 62.66 95 67.31 93
INOM ABV OERYLVL
Viai ---- --- 91175.0 199
Vitamin C -------- ------- ------- '42' 82 189 523 1 127
18 t7 44 years, female:
............ .. . . .. ;, 7 4 1 1 4 2!!!!!!!!! !!!!!!!!!
Ironi-----------II...iiii 46.97 114 64 .... 109
Via i iii---- ---- --i5.5 19652. 22
Viai! --- --- &9 7 37 6
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1*4 ignificang atoectn tiht composition of odsan
tismea-4 an Sepembrease.Ts, wepsde inradequated knowlie to raddow on th fod sare, unoabl to eaeis fipac In t
asd~~~ ,n, rcsubfcomit tpe of the ouse ppro sh~~~ppe~74 T.e W.ore tbeuynledmicnterirencoof anuI,An~k ignficat fce isai tha hit theein were erios ae< f#6mfhmi&. between itend on7 the serounes of terolnoe spent!~~~~~ pnma wyfo horse from b. ot Gov erent anies srn reeec tablesd of whihnAricltueeI v, An HW: intenal reortods ntitheaor orte reference.Iht wSol (Appn&D, t, b dicusee tablrdelghwth aminort aid otent of Ig = aters o cosum tio he u mariid o teoe of the moe frand im~roe nd rcine manyifthse, oy uatin ewr hunde Still~iabtha fator to he sevra copthoandfnow s nd thehm
af,460 compeiti~nlogieareual cotol rptos mersr tmpc.I esti 11161y'bfini-eAgriultret alscommte affeth urtonal halth.ri tibnsGommitde, n Apive97,T.W serod pistmayaffecto VitUAmr
.Ri$, udaa. u ntriivevareltn offosnrition to athten fobm Subcomitte~j~har1 Wittn od ithserians havte arolmo kyuting theiroindividualrnutritionalrhealt:
"W getting rea del idpencue fbof h idesrntrent dgficisan
,4*t b4 jt 1.57 T ,onl edicalmexmin ation dores o th oroent
inquire into the nutritional status of the patient.-The rote for, 4*Art attack among men from 3 5 to 44 years is five time& greater wbew Ahe blood cholesterol level is over 260 mg% tha if it ia, u-ndqr 206 jag yet how many men know their cholesterol level? Iron deficiency, ommjo is widespread among children and can affect learning, but how many mothers know the iron status of their children? : I..' ., .. *. ., I
A report on nutrition research prepared by the Nutrition inter l disciplinary Cluster of the President's Biomedical Research Panel of the National Academy of Sciences says:
In general, our approach to good nutrition has been to provide the recompaqn0ed dietary allowance of nutrients for everyone and more recently to restritt. excespi caloric intake to reduce the risk for certain diseases. Even though this approAbh through public health measures and education has been,. extremely beneicWj it is inadequate in providing optimal nutrition for the individual.
-Chapter I of this report will show that the medical profession has been extremely slow to take nutrition seriously. Doctors and nutritionists consulted in the preparation of this report said unifomly ihat nutritional evaluation in most physical examinations is'done in a., eursory fashion, if at all; that no uniform' standaxds are currently:. bab* applied in nutritional assessment; and that doctors generally do Mot follow up on prescribed diet changes even th-bugh experience indlimtes that the importance a physician attaches. to a diet is a ma jor fictor In its success. Possibly the most striking evidence of the medical pro'fe&sion's disdain for nutrition, however, are the findings of MaInutrioba in hospitals.
In addition to those ignorant of their nutritional status, there:-,&e millions of people suffering diet-related chronic illnesses whb .,need proper diet management but who are, not receivm*g it. largely bbcj use of a shortage of qualified nutrition counselors. An article by, Dir.,Lsww rence Power, chief of medicine and chief of endoffmiiology at. De6dit General Hospital, offered in testimony at hearings on natiob:01 health insurance, held in July 1974 by the House and Way's Means CommitLtee, discusses this problem:
the average patient today is disabled by a disease that has been fb five or ten or more years. The leading causes of death in the 'United States. arb now coronary artery disease, obesity, emphysema, hypertension,, diabetes., an# cerebral vascular disease. They are all characterized by progressive (often asymptomatic) stages of development evolving over many years. Yet "the tem" continues to address itself to "the crisis." Its emphasis, for examplej. iK 6ft the heart attack and its management, not the coronary artery disease that leads to it and its prevention.
Most patients presently in need of medical care do not ha* ,6: tradition
ease illnesses . . Most patients have long term, amietly grumbling disabiRtift that are manageable for protracted periods of time. biabetes and arthritis tome readily to mind. Such patients require the kind of supportive services tbo few existing health care centers are able to give. Such patients need a new kind health provider. They need new ways of being instructedin the"irianagementl their disorders . . The average patient is taught little oruothing about his medication and even less about the aims of therapy. As an examp)ip of tbe@e shortcomings in the diabetic section area, many patients recently selected at random from within our own waiting room population could not indicate what a food exchange was, why they were testing their urine for s pr, a.nd the me"g of ketones if they found them.
As will be discussed, the HEW internal report, TVLV $h Oe,
Department'8 Role in Nutrition and Diet Perftining, to: ffelg i p-
muma inicte tatHE as e ewax oqlia"Uli llaf eL shotag ofA
= weip ntriton cunseingat lasdt sine 1971, but it has not
AN o ths rpor dicuses the failure to establish an affatr io mnitrin sytemin the United States and the con&d exoxnle, thatthentition data bem ued to esash
theint~or te Fod Sampprogram, as weH as atandearla for
andpriateuses, inadequate, being drawn solely from Hpiiehol Foo Cosumption Survey, which speasures conumpionpaters bt des measure the impact of consumption P44444,t~rogh hysial xamnation and laboratory testing .of
no l ..,urvy tomeasre>oth consumption and nutritipnal 404*-t:... keTenStte utitin urvey-was conducted from li) 1. Wljo "waspremturly dsmatled when its findings ofpalntri*U'uan o fo.00expasio ofFederal feeding programs. Its suecoor, he ealh ad NtriionExamination Survey, has provided wf W dorsfin, ut ts seflnes is extremely limited because it 4W~~~~~~q ~ nosetf. trikgop ylctien nor axe data provided in
Au~oinr her isa ned oras continuing monitoring system 4W4 RP4* l* 'at rou)s a hih nutritional risk that weald, not
&& h al ichemias saus but measure and report on he robabe mpat o cangs in food prices ad other important
Tha EW rportmenioned above indicates that the Det~kt~t*W81a. dvsed y is ow oficials as early as 1971 of the need
-ji6,v:nt~ton.suveilanebut it has not followed the steps
-t = ini'dualandcllective nutrition knowledge leaves
op n fr 'psiles" det plans and fraudulent reducing Wll*-4i: iso howsthefoo inustry, through advertising, to guide
_ _d' clice toardthemos prfiable foods and toward ever-mecreasWasu, tin Te reortof the: Select Committee's subpanel
Efie pomoionof oodis eleantto obesity, it is important to know the magntudeof xpeniturs fr foduavertising. U11rich and Briggs (J. D. U11rch nd G M.Brigs i "Th Geer1 Public" in U.S. Nutrition Policies in th $weiesstte hatthi amuntis bot four bilon dollars yearly. In contrast, the utrtionFoudatin, n agncyto hich many of food industry groups belong 44bv~shhm. nbisedand oun nurition as one of its aim, has only about
4 avilale t itfor hispurpose. Educational materials prepared Tie i tional Livestock and Meat Board are in
widetoein an cajsroos~arundthenation. 0,6*"& aone isavaiabl foreduation in obesity prevention to a repreOq~swe oansrtizn f co~er an health scientists, free of even indirect
to te fod idusry? ow uch of the public's current attitudes and jo ae deermned y th naure of. the advertising to which they are
U t J
Not only do television networks find great economit. aAlvailtme M food advertising, they would find considerable ecanomm -PeriLia rmfi
Z ads attempting to counter heavy consumption of the foiods.&und, ated to health problems. A television executive said in an interview he was free to run nutrition spots showing the virtues of Vating nut itious foods that would be alternatives for food such as candy but that pressure from advertisers would not permit spot d
consumption of foods containing high levels of cholesterol oi gktvAl recent article in the Wall Street Journal reported that "a h0go s6ftz drink company" had pulled its ads off WBZ in Boston r4i]V'Ath after the station's consumer reporter read a list of 10 terribl6 f&6dt; i produced by the Center for the Study of Science in the Publi 611, tqoi t., Included in the list were: Pringels potato chips', Wondeibrefad' getqil Gerber baby food and'Coca Cola.
Attempts to solve nutrition problems through greatergop
mation, such as nutritional labeling are important,, buV tv0d thid information may be overridden by advertising. The Federtl TAde Commission has attacked various erroneous nutrition clatras alddAig now considering a trade regulation that would require food 'adv' ers to provide nutrition information in any ad making a niftrigonil claim.
The commission rejected, however, a staff proposal foraregulafiow that would require nutrition information to be M*cluded.'in:ev6r ad.
The report supporting the staff position strongly implied., tfiat although certain foods are required to have nutrition labelling .Ahls
does not proVide adequate protection for:the consumer. The existence of nutrient labelling is itself an afrirmative reason in suppdit'or advertising disclosure. Without advertising disclosure, ipassive food adi&.Wtt9 may well undermine or even defeat the intendedpurpose of nj!trienVkLb 1s..,Massive food advertising which avoids the subject. of brand-spec; ift.;Iu tiq4iinfoxmation-and instead attempts to sell food products solely. for suctifaqt taste, appearance and association with social pleasures-has the cApkeAlty, oN tendency to obscure the importance of nutrition and to reduce- the iniPMA RC6 or relevance of nutritional labets to consumers.
The report further noted a study which indicates that. '.'in: the absence of information to the contrary from an auth'orlt4iv 6's dr' ou Q.
consumers believe that.heavily advertised name:, brands' T
products, high in nutrient value.1)
Hearings on the new regulations bezan. in June 1976. Butthere almost no chance that the Commission will reverse itself au'd. a the staff-proposed rule. An official said the foodindus1r "'is fiai I P to fight World War III if necessary" to ptevomt it.
FOOD PRODUCTION ANDNUTRITIO14 POLICT
Until recently it was assumed that traditional patterns oflar cbb tural production and food marketing. could be relied upon tq' ,p izd, 7 1
the majority of Americans with, a niitritiou8 'dlet.
The rise in food andenergy prices, startiag in 197 i '19 c"'hi
viewpoint, however. Conservation of resources i& replacing, oo!Tum& tion as a gudde, and the worldwide trend is- toward fh, t nibst dMWWe use of all re*sources, m6luding food.- W erea:s resou ces *&p ob ox I I 0, i
to be adequate to provide unlimited selections of all food, it is now becoming clear that choices must be made between types of food to be
grown. Whereas the choice of food to be grown has traditionally !) en left to the agricultural community, the reduction of plenty is requiring food producers and manufacturers to share with others in the decisions of how limited resources will be used.
This is the challenge of Frances Moore Lappe in Diet for a Small Planet in which she argues that continued high consumption of grainfed beef in the United States and other nations may be leading not only tohealth problems because grain-fed beef has a high fat content but to the wasting of food resources since it is more efficient to consume am directly than through livestock. Lappe estimates that the UnitegrStates feeds about 90 percent of its oats, corn, barley and sorghum :to animals as well as "considerable" quantities of milk products, fish meal and wheat germ. Quoting an official of the USDA's Economic Research Service, she reports "we in-tie developed countries use Practically as much erain asjeed as those in the poor countries eat directly asfood." (The bigh price of grain recently has brought some reduc tlon in cattle feedlot operations. A USDA economist estimates that about 54 percent of U.S. cattle were grain-fed in 1975 compared to about 70 percent in 1974. He expects, however, that grain-feeding will rise to about 60 percent by the end of 1976.)
In his conclusion to U.S. Nutrition Policies in the Seventie8, a collection of reports by experts, based on the findings of the White House Conference, Dr. Jean Mayer, organizer of the conference and the Select Committee's hearings says:
the complex food supply of a country of over 200 million can no longer be all. r d to evolve solely in response to "the forces of the market.'y
ne, challenge to the traditional formulators of food policy was acknowledeed by the Department of Agriculture's chief economist, Don Paarlberg, m' a speech given in September 1975 to the National Public Policy Conference (Appendix E). He said:
The biggest issue of agricultural policy is this: Who is going to control the farm policy agenda.and what subjects will be on it?
HEALTH, THE GOVERNING FACTOR
In times of shortage, health must be the governing factor in the allocation of resources. The importance of this principle is made clearl. in a speech by Dr. C. E. Butterworth, former head of the American ;Yedical Association's Council on Food and Nutrition and director of the Nutrition Program at the University of Alabama Medical Center, delivered in May 1975 to the American Society for Clinical Nutrition:
Sh&H the farmer plant his crop oblivious to the health needs of the nation? Must the consumer depend on cleverly contrived television commercials to diWose his symptoms and formulate appropriate treatment? May the State Npartment permit overseas shipment of food without first determining the potential effect of such shipment on the health of both the donor and recipient ilatiou?
Under circumstances of reduced resources and increased complexity, it.becomes essential that a nation have the best possible knowledge of its nutritional status so that health considerations can properly guide
%apter III examines the growing influence of nutritional health concerns on food policy which reached a peak during World War II, but then declined, first because of food surpluses, then because of fear of political and commercial consequences.
73--156-76 ------ 3
Th teaearias, basedt oneequestfonnhycairs eceve tesle
la eur, Nbtadefods Eeatin pians .8. iulrl Medical dcaor, S of mcedica chooa c urr foen laslen and wmnta hr r no itaon ap0:7 parent eie burok for medicaleol .< hscas
etd W owedgcae- ththeles study ofnccathpals s.Dr hadrdH.
fro of adeseivrdt the medleal schol sureye provican
Aeia soecuricunm howe, onloe-ifh.
peet o laBmeica scools-caofrdn indepeymdenal tool.I 92 h 6im:iongloded ind descrition of. bioheusr comn heNtiio on
dation.- tly -asnt changed inc the ast survey sonord
b~tf~onT'oundh tahatg the nutrition in etinschostCioe Fahs Mosimprovets nuterit euain inA suvyfutamedical e protencya~ medicall practtiioer in nutition alt counsereenou
eee isudarto eadcatetoe whvo n stu ti medical scols.
adutins asoat nutritional nformain isdeaeed vrenmeia
4-tepot by r.n Marg ae n PhieipsTh e an JhanaT D er-urto duainiU..Medical Students, published in the Jnay17
*aEcatio#, foun that the perfm aons ad liutatinbtte
1967 to second year medical students in four Massachusetts medical schools indicated the majority "were not farniliax with many of the basic concepts and information related to nutrition that the panel of experts considered to be important for them to know." Out of a possible 100 points, School A scored 46; B, 35; C, 37; and D, 39.
The Chicopee Falls conference recommended that each medical school designate a person.or committeeto beresponsiblefor nutrition education and take other steps to raise -consciousness about': kndgroater financial support for, nutrition education.
Ten years later, the same groups held a similar conference in Williamsburg, Virginia, and the summary of the proceedingsreported:
While progress has occurred in some schools since that time (19621, the tedching of nutrition has not generally been integrated into the curriculum of: We fii6dical student, the training of the house staff or the allied health professions.. : I
There were "a few identifiable teaching units in nutrition withl n" A nerican medical schools . with a formally named director, coordinator and staff. Some of these present required courses in nutrition supported by electives. In other schools the nutrition content is interspersed within the curriculum of the usual departmental teaching programs and specifically defined nutrition murses exist only as electives
Rarely does there exist funding specifically assigned to support nutrition ir M#ing of medical students. Federal funding for this:purpose has not beeri alllocated. The existing training grants in nutrition provided by the National lwtifttes bf Health are designated for research training, not for teaching applied n;gtrition to medical students.
Dr. Philip White, head of the AMA's Department of Foods and Nutrition, the successor of the Council on Foods and Nutrition, reports that there hw been "very definite progress since the 1972 conference." A report compiled in 1974 by the AMA's Depaxtment of Foods ond Nutrition said that of the 85 medical schools responding to. a qA69tionnaire (there are about 110 medical schools in the United States):. 57 had identifiable course material in nutrition in their curricula. Twelyt of these had nutrition courses only in the basic science courses; 33had nutrition training in the more important clinical education;. and. 12 had it in both clinical and pre-clinical courses. Thus, 47, schools oat of 85, or better than 50 percent, offered some significant nutrition traiaing, Dr. White said.
The report said: "It is evident that continued efforts are required to obtain adequate infiltration of nutrition into the curricula of,.,. most schools." The AMA sponsors visiting professors to. ass4t medical schools in nutrition training and is planning-to provide -a scholaiAip for nutrition research for medical students.
Senator Richard S. Schweiker, a member of the Select ConirnittA6, introduced legislation, most recently in 1973, that wouldha.,V provided grants of $10 million for each of 5 years to assist medical 4nd dental schools in strengthening nutrition education in their curricula. The bill has not subsequently been resubmitted by Senator Schw6ikeytIts intent has been accomplished under the Special Projects sectioii of the Public Health Service Act. This section has provided gr stimulate training in various areas,: including nutrition. Thip Pttk4 Health Service Act as passed by the House in July 1975, droppedlhe Special Projects section. It continues, however, as a title in S.3239In hearings on nutrition education held by the Select Committee Mi 1973 and chaired by Senator Schweiker, Dr. Stanley Schultz, of the University of Pittsburgh School of Medicine offered some insight into medical schools' reasons for failing to embrace nutrition education.
1?&Ws:tb* most important element of education in nutrition; namely the use V.t nutritional counseling as an instrument of preventive medicine, has been grossly understressed.
Most deficiency states can be readily diagnosed and equally readily treated, but in this country they should never have occured in the fizst place.
The reasons for these occurrences are multiple, and many of them, for example, economic prmures, are beyond the scope of medical education.
Nevertheless, medio4,- education is not entirely without fault. Its focus is largely on diagnosis and treatment and the well-known proverb "an ounce of prevention Is worth a pound of cure" is just beginning to see the light of day; given thei skyrocketing costs of medical care today one might well paraphrase this statement to read "an ounce of prevention is worth a ton of cure." .. In shork few medical school curricula adequately stress the potential preventive accruemen* of proper nutrition in a systematic fashion.
Although every well-trained. physician will question their patients with respect to whether or not they smoke cigarettes and how much alcohol they consume, dietary habits are for the most part ignored unless indications of underzpWtlou. provernutrition are already apparent. One Kof the reasons for the lack of systematic emphasis on nutrition counseling
in medical education is that too little is known with respect to the way in which lang-term. and presumably normal nutritional habits may predispose individuals tar acute w well as chronic diseases.
Faumme research is needed in these areas and it is not unreasonable to expect that Waoking effectiveness will parallel the acquisition of knowledge.
But perhaps equally important, current curricula tend to underplay preventive medicine in general and the role of nutritional counseling as an instrument of preventive medicine in particular.
For the most part, this subject is taught within the context of acquired diseases, so that the inevitable emphasis is one of "crisis medicine" rather than 49.0risis prevention.12
,,One of the most important consequences of this flaw in medical education is the failure of many doctors, if not most, to do a thorough evaluation.of patients' nutritional status, conducting physical examinations with an eye for nutrition-related illnesses and performing tests that will reveal nutritional condition.
Doctors and nutritionists interviewed for this report each offered differing criteria for Jud nutritional status, and there is no commonly agreed upon stan ard checklist for measurin it, but all agreed that nutritional evaluation is too often not done at I in general physical examinations. Atte. ts re being made, however, to develop standards for this evaluation. h' National Academy of Sciences' Food and Nutrition Board is working on a handbook that will provide doctors with guidelines for nutritional assessment. The Depaxtment of Health, Education and Welfare is completiDg nutrition screening guidelines for children for use in community health clinics, tentatively entitled Nuhition Disorders of Ohildren, Screening, Follow-Up, Prevention,
to be published late in 1976.
One of the most complete listings of criteria for both individual and community nutrition assessment is provided in Nutritional Assessmeht in Health Programs, bompiled from the proceedings of a conference sponsored b the American Public Health -Association under contract from HZV and published first in 1973. Table 3, from that report, presents a plan for various levels of nutritional assessment for adults that might be undertaken for an 'individual or for a group survey. Data gathered at each level is used as a basis for the next level of examination.
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SogChristakis, editor of the report, recommnonds that any
pierl'h al examiation irve evaluation at least up o the idj i-V 1 nlcedin the table. He says that most physcians d notsgie thia kind:o attention to nutritional status. Appendix Fprides other e t Ifiolm the nutritional assessment report for the evalradi of WiA4td c children; adolescents and the eldely. It is olear fiom the
1ht ibt 8 of tests for the elderly that they rxe a graoup at special A fd probably the group thdst neglpecied i nutritional assessmet.
SAlhter iset of guidelines for asseessment rppked by Dr. C. E.
Whit4*,th; director of nutrition at the' M persity of Alabamia
W iaf:etr and-Dr. George C. Blaekburn, assistant profeso sofr
sure~yat Harvard Medical School, appear in the March-ApriO.1978 fdi~ "Netrition Today. Thegtuidelmnes wee developed ih response to codleins found in a number of hospitals and discussed by Dr. Butrtt in the March-April 1974 issue of the same magazime.
Tam convinced that introgenic malnutrition lhas become a significatt.factor in determining the outcome of illnessa for many patienta. (8Sice "fitgentc is AM -t eaplemism for "physical iducd ehp it wduld be better461sea forthrightly and refer to the condition as "hysican-induced malnutiion.") I
susecta9s as matter of fact, that one of the lretpockets of unrecognized maliiu ion ierica, and Canada too, exists, not in rural slumis or urban ghettos, Iit'in the rate rooms and wards of -bilg cityliospitals.
Drx, Butterworth, who has trained medical students and house doothrsiy~l t d five case historis of paient malnurtion that pro
Y, and said:: "I hav had the opportny tosvs a nmer
O s*J and to discuss th ituxationt wit many physiciani and nutRion scientists. As a result, I am convinced that the problem-of has ital malnutrition is serious and nationwide."
Theile then lists the following fa ilings affecting the nixtritional 6alth 0 ospital patients:
1, *aiure: to record height and weight.
Rotan of staff at frequentlintprvals.
3.'of responsibility for ptent.
4., rlne use of glucose and saieintravenous feedings.
to observe patient's od intake.
6 ithoding meals because ofrdiagnastic tests.
T:., ieMf tube-feedings in inadlequate exmounts, of uncerti comiposition, n
uder unsanitary conditions.
8. norance of the composition of viamin mixturs and other ntitiona
Faiureto recognize increased nutritional needs*due to injury or ilitness.
.poA~ after surgery.
11 Faftere to appreciate the role of ntritlidn in the preve ottn and reovry 11 akfib infection; the unwarranted religan onantibiotics.n
12. Lack of communication and interaction between physician and detitian.
As staff professionals, dietitians, should be concerned with the nutritional
114-heallh of every hospital patient.
13. Delay of nutrition support until the patient is in an advanced state Of
de U pletion, which is sometimes irreversible.
4.1 imited availability of laboratory tests to assess ziutritional status: failitre to use those that are available.
Iln the more recent article, Butterworth and Blackburn say.
aIt is owr belief that malnutrition has .for too long been identified with the "cldasicial"l vitamin defciency syndromes by physicians,nud other health profeaalonals. -Although these, far-advanced syndromes are occasionally encountered And shouiaont be missed, overt 'vitamrin deficiencies are best regarded as rare
meia uiste. ycnrsnoen-aoi antiinwihhf oVX
iwlbreerdtbyteabeain"C whc eeosi wb1V ha bee found toafc rmoefut o'n-afo eia f' ugf .
paiet w hos lns a eurdhsiaiainfrtoweso dTh tnad sdi crdtto o optl elwt.ntii bu primril inrlto ofo rprtonadted isbdp tas in asuigta "ainshv rprde.A ilb~ie,1S dittasrrl aetm opromaltedte pc d,
acrdtainstna... eA Ahspopsdt h oitC ~~s
so onAceia i ofHs ireidsan rsfo uital car tha wol lc rae epai nntiioa se.wn, Inntoi
MUMeainet that pregnancy and the patient's pregnancy nutritional status or
wy t4tue, what happened to her after she left the acute care delivery system.
e .--TaE NURarrON COUNSmLINe SYSTaM
boctore often defer the job of nutrition evaluation and counseling to 'dietitians and nutritionists. (The distinction between the terms dietitian and nutritionist is not well defined. The AD denies a Autyitionist as a dietitian with advanced trang ustally involved ia stakununity health programs. The Association is trying to phase out than term ntritinmst.) The structure of thea nutrition counseling
a.-nt easily definable, but it is possible to categorize" the thih provide nutrition asistance and the key problems int exandn these services. (The following summary will disuse
to sllngtrgted primarily to mediced servities and does not cover dgistao ofered by agencies such as the Department of Agricultutre's
Ro si b Sr vice.) i
WAATh~ea eno accurate figures on the members of dietitieans andE #10fti~tsemployed in the United States,- the jobs in which they s~r eploedand their degree of trai..n. The ADA's ommissin oiDieetissad in its 1972 report ". . the Commission muist *:phalo te lack of reliable data (on manpoweir). We have made
f whhare little better than informned guesses." An
id he, ak1rea, saddying manpower needs for dieti.ians ad nutri tioist, t apblis health, said in Professional ResM Alaspovse for
6maunty salth Program8, published in 1973:
Al 9ree'Ittime both the government and the scoos lack an adequate
Th~ikq'of ..=. g relevant data to bear on this questin (of manpower needs)l, a** n A 4benceof such data the schools will cenitne to ftione without
00Ae tle surance that their graduates will find approprnate emploympent ar
tu~t thei; nng is maximal relevant to the jobs they are likely to flpd.
Ofici& i HEW's Division of AssociatednHealth Professions are
ftffy.& a of the deficiencies in pesnnel data but sa they do not
hom.Ihfit da to conduct needed studies.
.i..4.Esim *e bas*don data provided by the ADA and the Bureau of aboraan.Lisies indicate that there are between 30,000' and 33.00G dietitian and nutritionists employed in the United States. The ADA es same that between 50 and 60 per cent of the work force is employed unpitaet eare, or 16,000 to 18,000,
do eftmse that about 14,500 of these are emploped in hospitals
sd:banish maintenance organizations; with another 1,500 to 2,000 in~ubithbalth care; and about 1,000 in private practice consultant asdauxteded care facilities or inivolved in referad services to which
&iW~&-ay send patients for cotmeling.
A 10jo survey by the ADA showed approimately 10,500 ietitians employed in hospitals, but this is a conservative estimate vo10 a number of dietitians may not belong to ADA. The Associatoq,.es~titats that only 40 percent of the total is primarily involved
APatient counseling. The majority are either strictly administpators. o~r have responsibility for overseeing food preparation and: cnunsehing patients.
Hospital dietitians generally work under difficult. conditions; usually the dietitian-patient ratio is about 1 to 100. Dr..'Lawrefi4, Power, chief of medicine and endocrinology at Detroit General Hospital, described the circumstance's of many hospital dietitians in an article in the Journal trition Education, October-Decegber
1973, entered as testimony d ng national health misurance -he"g s held iba July 1974 by the House Ways and Means Committee.-*',,
She is routinely called at the last minute to instruct patients who have -been
hospitalized for several weeks and are now dressed for disleharge with waltin relatives double-parked on tke street below.
Even without these routine impediments, the dietitian is expected % d cb ", sultation or two to change the life-long habits of a group of slowly coxnprehend-, ing patients for whom truly effective training would require hours of timeN4 weeks of visits.
An. official of the American Hospital Association said.that many, dietitians would have more time for counseling if they delegated mo" of their non-counseling duties, but she acknowledged that in most h-oll, pitals dietitians would have difficulty meeting the hospital acereditation standards requiring them to make rounds with doctors whoa necessary because these rounds are of ten irregularly schedulea.
Statistics gathered in 1969 by HEW, reported. in Health XanpQV*r, in Hospitals, found 9,400 dietitians employed full-t6ae in hospitals. pf all types, including Government-operated hospitals, with 6 pe, c nt the budgeted positions unfilled. The vacancy rate was. 3,9 percent juFederal hospitals; 7.9 percent in State, and local government hospitols! and 5.8 percent in nongovernmental hospitals..
A preliminary report of a 1973 HEW study of hospital manpower, Survey of Selected Hospital Manpower, February 1973, fouild %#7 full-and art-time dietitians employed in "community hospitals, t"t is hospitX both publicly and privately owned offering general mediial and surgical care rather than specWized care such as for- tuberculosig." The national vacancy rate was 4.9 percent. Vacancy rates by regibn were: Northeast, 4.5 percent; North Central, 4.5 percent; SouthA9 percent; and West, 3 percent. The 1973 survey found 6,986 dietitiand employed in community hospitals full-time. The report cautionR,,hdwever, that there may be considerable error in its figures because. at sample size and sampling error.
A growing number of hospitals and health maintenance Org&MZftetions are offering nutrition counseling for out-patients. An example is: Lutheran General Hospital in Park Ridge, Illinois, where diet c6tinseling is done on both an individual and group basis. (In the case *f group counseling, the patient attends an individual counseling seWon before joining a group.) Appendix H is the out-pa*ient fact sheet.. eiplaining the service to doctors. The hospital has a continui-pg diabetk, counseling clinic, which charges $35 for four ly2hour sessions, and a continuingly obesity clinic is being planned. The hospital also offers individual counseling at the rate of $12 an hour.
Sheila E. Henderson, director of the hospital's nutrition secti6n, says that for every person using the service: There are many more with the same or greater needs who cannot afford 'it are not willing to pay for both health insurance (and the service). There axe more who assume that it really couldn't be very important if it is not = by any insurance programs and are not fortunate enough to have a physician who recognizes and supports the need.
dfw at en i o Ie sh ou h an M rs.H an rson say
OpTs oners abot thierd pyarny peeapeatheleis
MA In ahr statmen rpaedtor Vthe thr annt aein
.ricethssie the i retetiret ato Htarb owMe
ag~~~~ ~ in ounoptauomitanapstinfriapattime itif as r Cm n outp tieint piaes.endti ndoh evceeit n
it G al oiitn repeat otaten dvisitn increaedi11.e
rathot~s 6od eaatin u0npere.bthrese in patiet hisits9. Whee fe aboi 81 ,nthddmn for c ittan outatin nutioenist ermi bt 4
ent ofat ein inta sthe sevice becse eereo saldo.
e irsns Wasngtn andbot othr sates willnt payfrc rehe
af~ve heatcaet W e ae fore toe animit emint
"stNit dieto of the Thirdtpti percs suhaeiat Harinsuredical Ir ve~fJ4Satery heaidat a o rtoi oneig usd h
We~a~estrugging n orptetswowr hospitaltomianapsie for lipatte oetat
V~~~~gand gowr nouuptenta hltcin. Th is isan aort bervt, acosty andwes groing Thhopialfo asoit :reports thet Juainr 1975t Jocreale 1f1t2 perentin197wile Ahospiaioccncy thonetinte ta thlie. exped Ntrition 66Ae~tIdl, nedai he an or.,6 uttientiion iteists, woul waee14,
reimbursIdo WehalMdiareinWsngo and s other tirdno party porayera
biltaiv o pevntoimhathel 6Welt mainenanrced torgitio iat *Wae m~s..btes, this riatn offern buhas medical isrice bxw**&IAaid feWe. Asow waietwhor hospitald hr ealth care pro9U 10 no statistics ont tehnnumbers of, diettiancstl ansur
...... ii i
She on -o ermrver in the optasand asy c ou neli oute
04t,4W.Dte sveyo seveal HMOimaned hEW ofical ixpndictuesof sgw aIW4 ut,-aiento, nutritioniviceslre noteye1well3devel
Oi) syo~l aecstm. Thi isdepiaiyt tenwesoh
',Te AA i, sasrnot ythattraced ale nogh membpatyaerst
epy.411-tim nutritiong its hore ditans. Out of 162e hMO'hsar
eda129 bean i opraiations17 offrn laer. Andca Heroficial
fo-r"fe ,n HMO'dfe.A wuld hprbal have te heath ea 50,00 videa, tvxe rpporstatfultimote nuitio conseo.theren are nlyr
0,000 or m byHMO'suScrier o nly ninHMO's.e oil
'hih anot ubscribr e a~ nog ebrht
rpor an fl-tmentrtinst r ieiias.(utof12i
1 Wd b HE.W,.129.began.perat.on.in.190.or.la.er.).n.HEW.off.cia
........... a H M O, w ou ld..... p rob ab ly, ................................................ a t least. ......
........ u p o t u l -t m n u trii on ...... .N i i H @i co u n elo r T h r re o l
6 JI0'.swit 50,00 r moe suscrbersandonlynineof hesehav
iio~ than.ii 100 iiii subscriiiiiiii.
n profie mot comrehelive nuthio Herltensurone Plan ob eatrNY. r, ~ihWn t,0lr tion s i197ad tare ofein titionceliun 98 Hp 12flienutritioniedutdo and oneig. helhvse r wod'urtai byunselinicalon workh other t adieitia aev 3,0 sbciesoa Hont-aeitin basis. curers anl 15erl rm I oti. fimds unovdegrucoeigfr theo1973iActcand50tothersuha
hreni, 19i4bADAsre fnd 1,80it.ei pgladins ublic hath. Ofath Mtota ce heiz aA i abutto 1,000aeionvolvd coeing eTheusesiceae'ioio mb cinictavrer ostons.a ittano urtins bt i.wsc
-ashigh nrio groeandonel wit the highoe s acnutno diMtary avoienAults tbrtha. Curret1aM'bae.qafo f' erally haver lthaes to7 Aths sn 0 ercs. hv umte1plctda
each ave MternaUandChl HEALTH PLIIC
dre' ProgrADsre fon hich dntiioneimin n~uriins Hisordinalli Titleofthe Ostotal, rthe ADAsoepro anildalth, asitosu atdnurto Moto h oenetefr ndeaycounsehug.sdretilt" Iadpnatome mther, r oinats n hite.yhsismn" migtrn adi Apalchs ohealtha precnts omean ohnk entl ofv He~alEctcs, teesries h6Sae and Welfar4n Mals eac comlee ideral f d the l xentadh Prind m on rvle offredin others clinhic antthen Departmingia ne so reenring procedues o snthen thia eut cwihcvr s]~ appenhidi IhialtLirary spofteCongrtnsvcs rep
a mte ponsod etn adkido nutrition counselin servg o stae. inthesmostirecente ofepatei spring an;ito lceistg o eue osrnte h nutrition posmtoons, prpae m 11e ApdxIis an arilLbfiias of teCntressreort nCmuiyITa lethve o t, r s ribngSate t nutrition c tivicetr.lh .e ingenendroteSats.heHWr
poesitonsoe hch51revcasn Manye ar i Ifo t llin are amnstrtiv positions, hweer so17 y EApe'f
bility for clinical services including counselin.I diin tesi the clinics, doctors and nurses, also provideconeig
;P *ioo, r~ ityanbe cofnt heath aculas poy nuri iqV 4 tis estim ttic te i e diffiut cco urdigton arolHn
-V~~k4CS6A~r4 pt acticie Atin aryland e n nu1968.iShesha yVi mot o thin biocemi ireat theuIsrelg INtittdn
@Ipg-s alo: 'recivte anm M..inmda dietitasadeisifrog
m~st'reen dee.Se hasurii counsel eeras from abol
-t W~oraocics rntyaiing nutrtins referr say othe sk
XA ,urve shwe.abt 7er fedppeti ill aynf nutriitici 4A,~ ~~ r th utanme ADA thes tatreferaltservic ur
MveTp~on a rfera ajor idicante atold ontarib uter 61% wboPfgan p ouseh scievice isyln tirdparty he s
.. Th4BueQrssAsoiaio, h poi
leppo~oo.-inHaia ad eceves on Mt.enn nutritloniserice, fro & Vxitvii -f Deahtfe.ghe ncutr ntselrvic ermals beoveredoin no unde conidraio. Wltr .
I* ~ ~ ~~i rao rbe ofontn nutrition Mdrerl ad Meicaidsu aslu ros m l reatio to nutrition
persoil~sugh by the ADA.i ht"efe~epew
iounso~g.", Cnsounsteln AA hoe h efal service undl
JPrqy, wefidvocosnregeeally unprepartypamets
61ift6 ~ ~ totond appqreciate tht imotanceofntritiyt
"PEW i ~ ~ cihtou nutrition counseling. Onlce shrdpry aboen f~i ut -Stiat cunslicaTelu sch os esiato, the Americy P~uutcon~eligalhohnutrition rainiea miaht be conseredi
11eath areplannowundr cosidraton. altr J Me
iii.iiiiiiiiiiiiiiiiisidientii~~ii ofiii== the A ssociationihasiexpressediconcern iforii ii-i~iiiiiiil~iiii..
t i o ..................... ... ... ... ........... .. ... ......... .......... ... ... ... ................ ......
................................... ..............................ritio. ax a n M i ai d s...
es~aljteam rtri sBueCosin eaint!urto ev
k~s.Nat~ialheath nsurncepropsal vay winter coerae o
H .1 h en e y G r a iiBiii === iii ==Niiii iiii T i& :thiiiiiiiiiiiiiiiiiiiiIeii k in d....................... A D A
Senatr Gerge c~ovrn, hairan ofthe eleciComitteiin
trodceda bll n Ocobe 195, 257, hatwoud auhorze eim
bursentforinutitin cunseingas hom helthservce nde
.........................................................e .m i~ iiiii
aproahn eetsy ori mormae may suee hirom birosem-calo theW has eent po keen nier- telast 10yar.IPi~wq!fi ewytos An hoflivirl m the m D ivising of ei ud h health Manpowuterwobee nd maknlited intgh"U46.;
-itonhl edgetniialnidial asoo ls ndtmeds ]optfb EWe thas rnutriyonakein mote iristy inte iinta go dctrs the Special Proje Diecon of hedbiieoth Br .o Hlt iMangower hs he igiliveri, e oif the deg
nin hsteriiitroduc edio in t medical scol n ediasch~s'v~ Thevimsed tntrainis an iteriorititfo: ritst.e uledi the alos troetal tsfeen of theul: telh .C
trinnd ohasbeingrdu ito titian an duition oke9 ninrte Dareotenuho hesige speal siists l w me m ibt&
in~~~~~~ 1971 th ineaIE ebr b iied ta hre a iu ng
Oeute n the alo totagpufrecnftetak-fntit~ie then followin eine to mattan.ad niinssg
tre aenion inhelh a cancy r in Nutrition positnsrbuinin Stalt ? (Apeel pojeted Need fotre ubli Hat Nuriostsinrtae :U0 i-sIwr O tliiesifro 37 ... Sa sin'glaeeo that
10 re nt.lo wi dc rans e ni vacns inSate, en g.,ritialn poition 00,tditaeadlclhelhaece ctin tof 0,0 beutien (5hd Divisie.n of Alinfoma J166 eudo atrot 4e400 fommPuiHt Nutitionists in ltte ctyandcut ees rlisfo37Saeinicated that mayoems r etas e sunpl wol ed6 f ur b10restmt 20,700 ng natoso dietitians will be needed in hospit* o pxim nSatey 13,0 presenty empl,0oye.n.V~su as~lts~* rto inres 1/000ppten numberiis of utriielt pe uowrcj~
...making nutrition personnel eligible for paymentswi oie oh# cre services and stipulating dietary counseling serviceasn"b.srvc fo third party payment in national health insurance pln.Ti.wudr'ule tat legislation identify nutritional care as, an essential copnn fIr~fv halth care services and stipulate dietary counseling servieasnelgbestvo fo third party payment.
And the report said:
"Nutritional service must be a reimbursable item in elhcr''aiis't come a part of the health care system." I. .
In spite of this 1971 report, HEW has takennoraacinticease nutrition manpower. The Division of soitdHat Pofessions, under the Bureau of Health Manpowrthc e~ b te vehicle for Federal stimulation for nutrition ighsno hd enough staff to study nutrition manDOWe:nes heesn
official ~or iHE hewih nesoss 'frespnewilt "fc esn negisterd mannspowerthr.t
smo~edj alot$2. mdlid fbt niscatitanr 195,oraoul62 ercent~~~ df-h oal$22irco ofpnutritio ti pr pbli ML Cia ,lot dosntr icoded asar of the mlinpoie
ow m ce t ADA rnt prt uchd sa ni:n ri
A estate. lyud offnig ~f ariin oranial qtpedi
vindicates grae supr i e e ach fo, bye n9e0 "verdnt "
gl~wtha preaio weirdM dieinvenryte, winds ya
b atinr the yea ontrnsedp bntos the 4syap ofdei L g.'Thire isalsthe new PubladiciHealth aseitvnce foacvne ainng.A urvyof 0 iilits f Fedtraio ai in tonurtogasial iftli~~~ w r. ell%:o h ouldrycomced one ofr onl thfou tuy
SUOffi 'afirdin oa precsgrnt s ADeoto shchoosofdpu
hegaobl~een the nroeed, fupor raer funigrqurmet for M~niptbwentaiI ofantrin-ine in O s oosoali al hyselthihwudb
Prpoedc age t tene blcHealth Service Act proide a3soli woijKe~pad, te.; obles. ot r o eral aecto nutrition ra'i Dietetics. ~n relamgt nutrition trai.beoe n o nmg, aor tps
proram, *ddvacedtaing, i difcuol, if notie impssilthpe s Aot ~ ~ sppr offered.th. ewbil
-2~~~~~Io chrce ofhpg the, lulcelhSrieAtpoegsao si aiso
pport. ~ b tha nutriintaigitiy on eution andv~hc o tl's urpos. TheAdos inoterall artcs of esponsiersoe nj*4,and te proisals conatinue to betrviewe tasnn ar cattee emopareegenerallyaonfhospital foodrser Quorason fortherather hanaco toelgsana itrltst w~do traningmayre. hani n hoevalutits an
1. That Congress approve a Nutritional Heafth'Service'Act thait would provide support for:
a. Introduction of classroom and clinical nutrition training into aU, mt fical and dental schools, with a target date for completion of 1980; and mid-icareer training of doctors in nutrition.
b. Support for training of dietitians and nutritionists, with emp
vanced training; scholarships for low-income students; and mid-careeir trghiing'
c. Grants to assist in the establishment of nutrition referral servioesand'the expansion of out-patient nutrition services in hospitaJs. These grants -would be discontinued upon institution of coverage of such services by third-party, insurers.
d. Grants to study ways of improving nutrition evaluation and care 6f, ho pital patients.
2. That Congress require HEW, in concert with profes ionml..organizations, to review medical licensing examinations to, dete'rm"14.$ how they might be changed to encourage improved. nutriti6n,.ed'i1c&tion in medical schools.
3. That Congress approve S. 2547 to provide Mediwa- covorage for nutrition counseling as a home health care service and that,,Q 4gress require HEW to consult with third party health insurance payers to develop guidelines for coverage of out-patient nutrition c*64n,9'elin.g4. That Congress require HEW to review regulations law's
governing Federal and State health care delivery services to &temndne changes necessary to ensure that nutrition evaluation and counseling are provided by all these services.
5. ThatCongress require HEW to consult with appropnate pro'fessional organizations and health care providers to determine: a. Current capabilities nationwide for individual nutritional assesswent nd counseling.
b. Projected technical and manpower needs in this area over the next la-y-pairo. Recommendations should be required by January 1, 1977.
6. That HEW consult immediately with the American Hospital Association and professional groups to determine'a means of.'Offeding the adoption of nutrition evaluation and care' standards in hos-pitids'.
7. That Congress require HEW to embark on a continuing kftln paign of public education in nutrition that would concentrate on: foods that may be harmful to health, especially those considered too often eaten in excess; common dietary deficiencies; alternative diets; and standards for measuring the quality of nutritional evaluations that should be given during physical examinations. An annual report would be made to Congress on the progress of this campaign for a period of not less than 5 years.
141...AAnAIOALN 'RITION ASSESSMENT
ii~r of utrtionn te United States cannot be accomplished
'by itio6 srvey whch podee some nice figures but usually do not indiatp hat eedsto b doe. The nutritional problems mn various uhi~owd tei~ontry in aos communities, among cultural groups,
ii*4 1W ort, W ariale n o agreater or ler degree require soluprori~e t th repeciv groups. We must strive for regional
a &'stfti whch illidetiy problems and provide the support T lo ftni&-D Mar Hegtedin an article appearing in the
f al4f he merc "a DidcAbsociatio n, April 1974.
'Theuppotpae ofstudingthe Nation's nutritional health isex Ik,,,d'oiai~l i tetimnybefore 'the Agriculture Subcommitte
p ftprition 1immittee in April 1974, in which T. W Xdi~intbr Afi~tr o th Aricultural Research Service listed th
ou~ehld Fod Casumption Survey.
nf out food co s~m on and dietary levels is essential to develop Mont Of TSDAfoodplans oir budgets. These todd plans are basi
rit ernment police and programs, each as the determination
efty for ax~liesof ifferent sise and composition, determination
putrtionlly deqate diet that can serve as a basis for foo
tw~noo nd venproidethe* data that would be needed in the even OF ay p:oo ontrl o foo raiig programs. The food consumption dataar A dimeopingreliale p>dtttish projections and in making realisi
kowhld ood onsmpto earveys prvde the information on foo
chae lve th~isliely to be use i developing specifications nu 'Ptjren ction TheFoodandDrug Adininistiration plans to use the data t %&Wbri4 Achgrous o indvidals may be taking in foods with any unusua Ojfitht'dfaddtivs o reidus.'he National: Marine Fisheries Service isde p*;ka* *'ths. ropsed atinwie survey to meet their data needs on
6 "kft,~~~~~ Vushaedesmt nneed of improvement, what nutrients inth dW s bebwj~ecomendd lvel, and what specific foods contribute toth
kk fe~rUstmon noes hedata being used now to establishth
-n~~e~ fo th $6bilionfod stamp program and for other dietary
'dtne ,urfoes y USA, nd other agencies are being taken fro 1 h&Xuseh d Fod Cnsu >tion Survey, conducted most recently inrAW. 6. fod cnsuptin survey measures food intake, but iti mat~te~bet mesureof n tonal health. Because it does not gaug the *ca heath o thebod, there-is no Measure of the impact o
The mpotanc ofphy ia and biomedical measurement isex
an rticl intheJuy 1974, Jourmal of the American Diefti
on y D. iltla ichaman, then chief, of the Preventabl Dimalss nd utrtin Ativtyat the Center for, Disease Control
The major objective data utilized for determining nutritional status' are anthropornetric and biochemical. The purpose of data on dietary intake in the assessment of both the individual and population groups is to identify avenues for intervention. Although biochemical data may show that a group of individuals is iron deficient, this information is of limited value in planning a program to correct the situation unless one has considerable knowledge of the dietary habits of the group. Conversely, just because an analysis of dietary intake shows that iron intake is below the recommended allowance, there is no assurance that the population is, in fact, iron deficient.
Given the problems of collection and analysis of food consumption data, nutrient losses during handling and cooking of food, and the vagaries of the human memory, the suggestion gleaned from dietary data that a population group is ingesting suboptimal amounts of a nutrient must be.confirmed by more objeouve data. These include biochemical values, body measur6ments, and th6, 0 eence or absence of clinical signs.
The deficiencies of the HFCS, particularly as a basis f4r setting standards for food assistance programs, will be discussed i'ft grpater detail later. It is apparent from the foregoing why,'althoue-h -MDA had been conducting food consumption surveys since befo ,,1'900, Americans were shocked in 1967 and 1968 by the reports otmakutrition in the United States, of hunger amid pleiXty,
These discoveries prompted Congress to approve, in Decem 41 in the Partnership for Health Amendments, a, charge to the, *pprq of Health, Education, and Welfare to "make a, compreiieJaSI'Ve Wli of the incidence and location of serious hunger and matnutAW U
health problems incident thereto" and "report'his findings' and riecommendations for dealing with these conditions within 6 ijaoqip oT_The mandate from Congress was to devise the first'lsu'ryey W 4J p United States that would measure nutritional health'boti on.the bisis of food consumption and physical and biochemical sta An
those at nutritional risk by specific location -and report enough fashion to guarantee proinpt remedial action.
Dr. Arnold Schaefer, chief of the Nutrition Vmvam;m the:.
Health Service, who had administered U.S. nutrition SLUMeysin eveloping countries,. was placed in charge of w1lat wag to b6, t4 oft ambitious program of nutrition evaluation to be, midertakenw,, country to date. Officials considered conducting a survey of 20 Bi
but narrowed it to 10: California, Kentucky, Louisianal- Mmsuoha-& setts, Michigan, New York (with a special survey M New YorlkwSouth Carolina, Texas, Washington, and West.Virginia. T would interview and physically examine 75,900: people in about g,2-,"o sample households, with the sampling concentrating on- low-micome areas and would cost about $5.4 million.
The survey ran into trouble almost immediately. In Januaty 4-968, $1.4 million was assured to get it started, but in April, the fiscaliyehr 1968 funds were cut back to $750,000. Then in June anadditicinsil $975,000 was approved. The Government Account' Offioe noted. in
a. report on the Ten-State: "Thus, about 7 months after-thw to al of legislation requiring a comprehensive study, contracts CTbe'en awarded for surveys in 5 of the 10 States." I .
Nevertheless, in January 1969, Dr. Schaefer was able to.teU:the Select Committee that:
The preliminary data clearly indicates an alarming prevalence of those Aaineteristics that are associated with under-nourished groups. Even though :these findings come from a small sub-sample of the total National Nutrition Survey, it is unreasonable in an affluent society to discover such signs as those seen to date.
miarecgJ onan'qunefiatil cotainger nthe enlton erd
4"or?'re~kn. Obxnsnnunedinmaent spnecsitate sfra ooe a Tl~~oijr Scmefe advwd"op to epnd theerr int Toerca.
time twas cla mtadbintrto offircietly reiesnt QleAe. aatii pstre f r.Scadieir, ad shatesa weeated fakn that~~~~ ~ rel:pevn h inlrslsotend-Ste fom hvin tanye
dath Inagenin Ohe own note
6 $*-& e..Ntritout itin oateris, whihe oid 19ovid
t6'.Ji'mCaxerprjec diecorMatrlevend Cid poeepltation & 4-Meca M datio goldgesand aareor ainu
.hjsid. Finhily, atac on the Ten-Mat urve thes mnt asNion' sech .h Deptenthel imtrjesthse onSurvey a board. thefNctivconald AcadeyiofoScience iiii( witi he HW bueauca.Can m ento nshNtitiond Council ofthps Firt he utoriy. equstd b Dr Shaileyfd to pndctne Isiurey inutrifour ffiae sate '(hic sttisie~l oGentaer fore Heith Statisticslaneorganizatio tktllk1611ftina~,,sf~Y),wa deAsibdiiyo Deprt. Scurefrn infrmauetdpfn.dhs l~bi to )%Moth utriion roga at eurndotvely t ine prore ta incld itaes W(%Ii~, Tquet tehniany wersane ton benassrigt theow Cntrfi4oti aur- t ~ ~ ~ ~ a ad t sblsre :nthetCommuendabl Dhiseaseudtprvid thowo~l andaurvil~n rterlm natvere i ispempontont
I hlp'o'"blgh oodfothitiory HuiEWi n srtadrys Robrt Haiu Wxti~t9.-'- isi"ues *s lsodeitl ingly h cp of the Ten-State sanimrovey,
was ividd inhalfand hkrd frome the- 10ae tuies ..it to oeintof .4. J;Soi~p1 a~tb odand Nurito mustd mov e beyonl theagoal of Spyiete, '4me~~ckAcemyof'editris'unde n o n utrition exssi hscountry.f The J -A~ocatin, esphiit findonucings'ftesuvyt acftioenurgram
iWAS Awgnd to~h N toniCeteforglth tatilntis onztionus
*Wh im, istp#lly h no eingit takenot asurett inemaither This
"Y~~prompi~y qxa06 n tlheat HANeS wouldi prove popid "n= n dta ad rfiaed i tie nalt ik by specific locmatin Srey
Follow-' de dfga f.ay eeometssofn"a State sureillanor Disese otrolCD thenkn nd xte ofthie'pblems in terms.0
Befoe cotiningithhe asre willatsee, suchs aipracity is faot
F, c wa decribn& he imsdinisf hed TStatmae whitlng awa3v Amt th montorug ys mpar tily eay Feecomxmplte $2 Mio
-4 p4As of ctiviy W nd msove bone healof miliondolar wadueer
iiiiiiiiiiiiiii! ii~ iii~it 4 0i ii
to~iiiii cosrc eiohmsrlaoaoyaCD inAln.Son r.ebfr
w as fi i hi ng ............ retain one-si" '' ii xth ''' of...............................that : he ou
...........f iiiiiiini th uve.B heedo My n tigsemdprfcl:: la 1 h
Ten-State Suve wol riseniiarasniqetosabuii~tom )
theii wa on uner
Durii~ in thenet ear te urvyi mi ne nieaiv bcuiy iihi o
1970,iiiiii~iiii Dr. Scaee ag i aperdbfreteSlc omite etetO t
pii mi nr results of iii~i th....... we..atfaiie.o...rwth..cuft
lessiii thanii $160aya eefv ie slklyt ufrsrosmlurto:a
fiies ean in $660aya nivr nevee yrp~esltrh hr
aei zeidiii Hiiiiiii~ i stnedrlfedniiirmii dm-e nfecie! &
tstimn wathcuforeoigtesrefrmhscnrlInJl t9,
...... copue program ofi~i .... suvywa reedt tana Hv:w
iinvlve trnfern aiii th optrcrsi rcsfrmMrlnt:(0r
a n d t r a n sfe rrin g aill t h e in fo r m a tio n t o n e w c a r d s w h ic h c o u ld b e u s e d o n the = == ==
CDC computer. A ii but on ofte iopue safiMayaniefsdih
opt !iiliiio to trnfr nJnay171 fe h optrmv a ctoei h
ni reiiiiiiiiiii~iiiiiiiiiiiiiii~iiiiiiiii N utr= i ti on,,, Pro ra wa move to,,, Atlanta.ii A g iniiii he -Wh l stffreusdtotrnser n ha sm mnt, r.Shafe rsind ro -h
N u trition P ro g ra m H e w as a ssig n ed to th e P an A m erican H e lt .........i
i n M a r c h 1 9 7 1.
"Thei finaasofteTn-ttiureieeridnwthcnrves.Vc rei dn Age anhdasahn tac nte16 B ouetr
'Hne nAerc'a atofa fesv acsn ugr ihmo x
grating! the.......... iirtnc ........ manuriio in this. conty Alos....laelu
Senat'' o, H ollings...... of.,., South....... C arolina..,,,., ....... back. ,,,, A ccusin .... of .....' t
suprs thei Suvy herlae oeo tesre' idns naSnt peh
C D C ....................................................... d e ie ................... c h r g s c la i m ing....................................................t o
d iffi cu ltie s in co m p ilin g th e d a ta A fter th e fu ro r, th e fi n a l rep o rt o f. the : s u r v ey
was releasedi with almost no fanfareiii in thesummr of 972. In 1973 Senator! Mc''iioverniiii askediiii theii Governmen Azini
A needin" 'Dr Carter's report, surveying begun by the 'TenROW is being continued by HANES, umder the direction of the lbinm of Health Examina tion Statistics of HEW's National Center I 4ith Statisdids. Laboratory work for HANES is done by the Center' for Disease Control. The first HANES began in 1971, and
c~ft thdring in the first half of the sample was completed in October
tfieringP of the full sample was finished in June 1974. The jI&NES cycle started with sample testing in Atlanta in 14OVatthe 197 5, and the full survey began in February -1976 and wilw completed in 2% to 3 years. (A description of the goals and meth ooy of HANES II appears in Appendix L.)
T~k goTen-State HANE gather data on clinical health and food cosuption, butsit differs from the Ten-State in two important respets:, (1): Data gathered from a national 'sample and therefore doeslnot identify special nutrition problems by location, making effeet raradia action difficult if not possible. (2) HANES results are jdlit~vaileable until from 3 to 5 years after data collection beon, again hempering remedisk action.' (Ten-State data was provided an prehimiInary form less than a year after the survey began, and it is probable that the SA.alrepor w ould have heen issued f ar sooner had not administrative changes been ordered.)<
SII wflsl e 20,000 tq 30,000 persons covermn ages 6
rR00t"A?4.years, lo variotswincomqq levels. Since it is a probability sam#ple, pA pan by deiiion be representative without draw from
a4 as0P1 of the count4-y. HANES I .drew samples from 30, States
and .Pistrict of olumbia but did not collect samples in much of the Mi west..'.
A report~a ,entitl e lim'inary Tecknolo!y Assessment of T.S. Food, Nutritage1, and, Agiutr Inforoustion Syegem, prepared for Coagres' Ofli9e 0f Technol Assesnent by -the consultants Sidney MV. Cantor Associates, ad that neither HANES or the Household Peod, josmPtioi' Srvey provided information- needed to permit prompt, prWrective nation. @ said:
IHANES and -HFCS are designed to give overall views of nutrition status and family food consumption, respectively, on a national scale. The nutrition program official needs to be able to identif argeqt grops and populations in specifle geographic areas, to sign prior1ties acc6rtig to specified criteria, and to have a simp. efficient approach to program evaluation as well.
jn Ji tstimony at the .National Nutrition Policy hearings Dr.
PViliog-rsin, diretpr of research at St. Joseph's despital m* Lan;r&W,. Pen~nsylvania, said, like Dr. Schaefer, that highly averaged
00#Means that certain vulnerable groups are missed.
...there is concern that the present survey procedures provide averages that beflnadirdtently conceal the real extent of nutritional problems-particularly iq groups at apecal risk.
For exaniple,c we find that migrant workers are not adequately examined )$iket these circumstances. In addition, populations, such as those on Indian tseirvations, continue to have 'Major problms of inadequate nurtrition.
Trhe, general studY of: a varied- population also leads to a broader A1e6dooia aprah. HANES .is "Painting Tth a broad brush 1516hemicaly," 'said an expert- coilsuilted in the preparation of this report. He and another nutritionist agreed that the surver should be
iidev eliiioiipiiiiiiiia d eep er k n o w iii~i~ii~il e in sp ecii~iii~iiH= i fi c ...................................
Thiisiiiiiiiiiiiiiiiiiiiiiinfr aio ab ui h ttso ihrs o is expressedin tiiiihe recommendations th 1969Whiteiii
......~~~ ~~ -, riiiiii== iiiOii
The i need tserhotnitioniadihelth eedsof secia
grusi ct.W ietee i itiniietkn ntoa rbbiiyUV1.
malnutriti .wrt.aaiailt ...elvryo.srics.adth...tit
We recommend.tha.the.Departmetof elhdctoad aep
tocrr u ntii suvillneadmoiiiiame tslcedt~ 6u
iai n a n d ...................................................... ............
Techniques nee tob ieeoeio@mntrn it n t dniypolm
befoe tey ecoeiciicallyii evident.i
Th ae eomne htpiriyfrti ido td!e
gie o reco ilde;epcatmtes rmr ,col
ch ld e ; n ....................... N iiii ~lwincom iiiiiii i ncl dii I nd asiimi r n
11 toftv-up to the Ten-State Survey promised by Secer
19ftc; at srvelln" capacity to identify the nature and extent
of te (alntrition) problem in terms of families and indfividuals,"
Wqfta -,p. uch less than his promise.
geterfunds from other projects, CDC developed a
am:in which it is assisting nine States in gathering, Comysngheghweight, hematocrit and 'eog n levels
c children involved in EPSDT screening. Te work is
douwb hat s known as the Nutrition Activity of the Bureau of 89MF~~rdication, with a staff of about eight prfessionals, fullAmnrg the sources of funding ha een the veereal$
hgiae cotr1 program. About $250,000 was to be expended for. th~e
et~f~r~i fiscal year 1976.
IaELOngrwtlik obesity and anemia in children, is sent td CDC by
;Kentucky, Louisiana, Tennessee and Washington
0r6 work is' being done with Oregon, Ohio Foia and
t Pt -Thie t~imate goal," said a CDC report in Januai 1975,
('ae a sl imple domputer systern that can be exorte to indfr"d gesor other gographical entities, which wrill theni be able
td v~dp'#'erwn data.
CreDlCid nvleonly children, not only because they
hih-risk group, but because nutritional problem ai re mhore
easlvidntified and treated in children. In addition, exitin maternal :6 64 1 t idktidn 0 irdams insure that a high volume of -mwdinoe
h~~t _* ~ tedf. e CDC system, because it cover a limited
Iqme group, and geographc area mnn way begins to
Ved .:for spediic data on ih risk populations.
Ae.id $0 million for fisea year 1977 to permit expansian
i ain id: all 8 0 States, requiring the hiring of 80aditional
cut thib request to $1.9 million, which wo1ul hae
P ~ e program to operate in 20 States, including the fiv now 1A e Cmplet program. The HEW request was cuit to zer by the
AanagFement and Budget, reportedly because O1MB wras not
",tioAii gnew projectM. Upon the request of Senator McGovern, the L abond Health, Education and Welfare Subcommittee of the
S~h~t ations Committee authorized in Junie 1976, the $1.9
Aire inclusion in the HEW Appropriation bill.
major problem with HANES, mentioned ealr, ithe tim~a in data gathering and reporting. As already notd, data
twno o HANES I took about 2 years and is expected to take 21
.tA II is not likely until 1979. Izi his testimony at the National Nutrition Policy hearings, Dr. 0ouran said:
Ke HANES survey does a masterful job at the present time within its frame qf reference. On the other hand, this is a cyclical evaluation occurring over a 5t4PRMyeAr period and is not flexible enough to provide current information in ordA r Mo pond rapidly to national needs. an tim -nole in at co11ection also make- s 7..1 difcult ifno inipdasible, ~ ~ ~ ~ ~ ~ ~ ~ ii toda n eainhpbtenntiinsau n *
come since the prices of, food are likely ,to. dh weeoneide* *f 2%- to 3-year period. The, justification-
But because of the time lag, it is doubtful whethermake an accurate measure of the effectiveness 'of Feder t grams or provide the data whefiA it is needed or pR 4y
In addition, the long time-span of the. surv-y priits ev avoid northern climes during the winter wit the bile units used in the survey. The result of tis lik$ to beol data to reflect seasonal differences in nutrien cons=upti tional status which could have a significant imact oye possibly indicating better nutriional stats han igt U winter readings were to be taken.
Mr. McDowell realizes that there is i aprobem Wth ti Isays the only cure is more money and pen Oio net olh 4 year is spenton HANES and about half of = isWi us &or tional component. The survey -currently on oys 34 f10d eratinag in two mobile examination units. ith twi'" Mr. McDowell says, the survey could be don i~n b i1 the
More funds are also the answer to the n.robem ofa
of reports and inaccessibility of data. The 0 stfr. rep orof Technology Assessment said: "Little detaile 4 alys "J
undertaken to determine the nature and :etet ofsa that nug'ht exist among different variables" an M4i. that found the HANES reports "very hard to red."
The data gathering for the first phase of &e firstA
pleted in October 1972, but preliminary biochemical84 e mngs were not published until January 1974. Part of 'the del. from insufficient staff to process the data n ie qui idy. Iheesats ticians were employed in assembling the pre nina.y dietary any bo chemical report, and they completed their -- kiq urJl 1.7; and printing occupied the rest of the time, 1 pI It4 -Ao ;
Work on the final dietary, bio-chemical' 1p chMealn reports for HANES I -is expected to be complete in j publication of some or all of the re8ports,*,.9 k v ~ e ol 1gm There are currently three statisticians, two- Auti- as advisors employed in completing these reports 'aod a
reports. In -addition, they must process ne da flw HANES II.
The -small staff size will mean lengthy yt of bei 4 certain HANES data that could provide -i fica& insi impact of diet on health, such as: the, relati bip 9f M W q
Mr. McDowell acknowledgzedjt his group does not have the time to fle.loit the mass of drata collected. Tiere are many inter-rela.18 itmaighb be abudied, he said, but "we catenly scrtcth the W pt14 teo partially remedy this HANES data tapes
NO iv*~Adaletooutside researchers for a small fea.
YJ 128A !dq it,- BANES does perform a setal functio in reportmiVtritional status, but it doesn't fil the inmpotent gap
W Olricowedge about the nutritional status alaras of the come, k ** Wtiedlax.monig hh-risk groups, norddoes it reportbin a tidibly lpmow-V4 it asic. nutrition findings or 4he^ relationships between iuo~w- Ai&health' findings. The CC system does not neet these
THE FOOD CONSUMPTION ST87RVB
reaiu nuito survey, now being planned, is the
,4giqjt rq department's Household Food Consumption Survey.
In Wtrewr ask rspondents detaled questions above QW,1t44ipoording data that not only permits, analzn eating habi u also estimates of quantities of fpeod eaten'.terb pereA~mtes of nutrients consumed.
i $wW toJRous9e Conference recommended that these serves be v~duoed, a 5-ear intervals, but the survy w 11 not even be Ale to
a)-e schedule, partially because ot polities (A sumnary
pf A,,tqbe reported and their expected uses appears as ApI oaiii~i- to original plan, the pilot anrvey for te next HFCS
da t.sart in mid-1974 and then the basec survey was to get under
V*YJjonsoy1975. However, in July 194 the Ofice of, ManageWou 44 udet directed the AgriculturalRsac Service to con(V iudy alternative survey techniques. Th contract for this
fin M~nWstudy was signed in June 1976, and the, consultant's
were received early in- 1976. The surve is expect to begin
*one for wanting a delay in 1974 are reportedly by one
11& budget considerations; doubt about te survey's metho~br; ivd farthat the- survey, might produce discourage data
Itis ofintiest to note here that the Departmeni of Agriecutture
r*"stdin June 1976, that the Agriculture Sbcommnittee of the Se~te A stions Committee cut $1.e million that had been
'd ...te, House Agriculture Appropiatibns Subcominattee to
t~c *'Paitent's $2.85 million budget request for, the HPOS in
supporting the additional appropriation,thHossuom
_11.ttW prt said:
Thie data, provided by a previous survey on food consumption and dietary le el in the United States is now 12 years old. Current data is urgently needed by schools, hospitals, prisons and similar institutions to determine dietary levels
t@ fedin prgram. Sch up-to-date information is also essential for those
we espnsile or determination of poverty guidelines and for the stig an adiiditraionof Iour food stamp, child nutrition and other food so=Mnption programsTh@eAgriculture.Department reqxrested: that the $1.6 million addit4on and sevreral other Home annmnpriations he eliminated "in view of
retained the amount however.
be ~ ~ SRV~ timelyi togte4noiait
wilhe superwior. fampd 1500 oshodsdvlo a 8. coletrigs-dry ao ndivweistada -yhitrfo16kbhl.
Indsifctiono the HOS be smlso ,0:lelY 6^r.0M cutures ofThe Ha apesz il e3,0 ousehod Appropriaties 1975 buy .Jdalash obatnre inoey&xstm wt"O L'i and EnieapeingpServieo ape nec ure f the, Ati Natood conlumptioniand dietfar iosanapesnttve andl oethereda reseach aend dcThesreiilemlycom,1
areii riica ide.tif. in 'toepota
fodnftetters ndriiona qualty.totaou5mlin
AThog theC unFike HANEis ellael wuddtheri i.t and tiney th wathy canfratide regonll o esnllp9M daisnn haleaspeirfoo tecnutiondtreahri
PrA E. pr oued at the b egi nn f t e sti n o # r. Gralylmie fo itk is obviously lwd statustowvi ght ifferne s in nudet -Sbo ibM1 Af deculue of alue touee "poffi ia on ietarywstod'A" Academby of Scinc Fooand NutitinAstat dmntr o, 4Wf' ance (RDA),edoinot indvicaeo the rturlRsac ifr*I several reaonsmto why dtr sdies avaaeanestillmnto 1"-bk andiffherecera eerhadeuainlrgas in nutritionali reqirme fo-callbeted "conitioning fuacitorsc deftsg whc may i anter wha rfint -iebigatbwf tndin, thsorae utliain reuire dt nt riinl tts
-athe iskinl onte hsftor-aepir e andito" theset *K~ therms subject; b h mrcnPblc1dhAs~~t! unadequcntacy ofrsorem studieins t: Finally liite hod betke in mbidsl thepnedb u-ot ttsonale rm lgh ifeentss iradl evingtiinliitko vn .-trei and not nearily aometfcuate, aditay ad o.mnai ,suha h 16, cnfdeny cie c odadNtiinBadsRcmeddDp.Ak, inc(RAdniniae the HFCSnc wil studyiton on1 xv-texfr invve cal ra o r ieabrry t esat erlmttos hs teue measurenctual nutritional stauretu s nn ndvdia be -alueu asonitisoild bcor in e as ocretdsa, eei *e1=
i nly itsol e eti in htpeen nwege fA
iiiiona req ir me tsisrapdl.e ol.n.h.tfod.......e...n'm ol e
an nt eesarlyacuatan tat-ddtinaiabraoyaiilnil P
gion r nodrbfr urtoa eiinycnb eemndAi
ni dene. $i AiV,-f
i nciheiiiiistdiol efypttrsAn.WI4n
............ p r g a s. W
Oww$OW Uite States have an effective system of nutrition moni-UM~kV ,6 amer must be: No.
what-such a system might involve, itis necessary
mak adisincion between different MLdseof nutritional assessment.
AW &a~ib~ tiedie nutritiondl assessmn, such as HANE8 and 'thoRPOSo nuriton aurvays Continuing examination of nutritional -*ttwosuc asthat performed by the few States working with CD0
ii 14~ob~ei a. aiae. An adequai6 system provides both' for
11$rvw*'Rd-he HANES and HFCS are intended to periodically o+W g et el~b ib e data,. REW officials describe the C sstemn
9,hW*1 hepoeti al to meet the need for smurveillane otan
kili 4~ecficmonitoring of nutritional status that would supply
4MasW-Mih t base action programs.
:- 11" )W*Whve seen, the general surveys are seriously deficient, and -theCD~i opeating in less than a dozen States and is only monitortinlindicators in children. There is no surveillance
ulation in this sysAuns
,n841iton eperts have recommended that there be created a
ltioW& ftntnuosly monitoring nuffitiesi status nationally, based
ofeidicators, including food price changes and reports
4M~f-AlEW report, mentioned in previous sections, entitled
W740Ww~jbiha Depatments, Role in Nutriio and Diet PertainW toHealh?,prepared in 1971, advocated a surveillance system that w~tdd. "c ontiuuly collect, analyze and distribute nutritionally4 4M ow being obtained by all Federal nutrition programs
rieprojects, and national surveys.
0*-pMepo to the report, written in May 19172, said:
e in collected by the National Center for Health Statistics and
lea ted dring the course of the Ten-State Nutrition Survey, is exceedingly
eviasding information on the nutritional status of selected s6geents
16 ifljMPg-etion of the T-.S. population.
,,!Tn1 H ASstdy is a specific time study, using a data collection system and ,Adeveloped for only the one purpos~q. It is eastly, but can be valuable
as ajo (ad prhaps sole) means of establishing baseline data. However, Wth 6 BtateNutrition Survey nor the National Center for Be41t
SivY'constitute an operational: servellihee system.
W~ti xeqire is an operational system that makes use of many, other sourdq. p
Jaifrmaionthat caun if properly evalupted, pqd combined with data
I ppcic -nutrition studis provide the needed continuing gulidance for
p&aining and change. if properly, established, most of the basic informan Wlolteted A, part of other health systems.
Suha surveillance system should be engineered so that it is an acceptable '@*mluato remedial Action once the. mechanim hows9 that remedies, should be
hat. -is. neededi a system whhcvs the, populan, particularly ulation groups particular risks, tests for the adequacy or inadequstional stus in relationship to the most critical components of humian identifies and, characterizes the. populations suffering from nutritional
theih have genuipe and signficant,,implications for. the hqalth of
le~~~~makin~~~g'upithe populay, andiefd caeswih sl fo
udtion: of remedial actih
to s iece rerte n iseda syst echaoulo dupe mrelat hly
epeecomande hatn ofoo pcritcaurtoarflswudb trive orsecionitodatnd cangerpt aes.eherpot i or beloe term aveilang u theupane l:... lishmeng of loal 8rdtateo, rena Nutritiota; ~o*4 biesfomcaland dieatr copertmence. Impa roe hMprt.aur cnomhosiafloo and fodeafety ciisas
Basedtion an aoemnalsot adcrrn expe opinn efinde that ood euase attennrer
m g.................... should ilude:...
1ai. NForitonrtm survencthpaecomned tht etstleas videhgeneraflobalin dtata on tregnal rtoy etr it lncl riskoups.ca .n deaycmtn. .mrvdontrn .f nmUi
2.se Coni nusiofpsancurt nutrition antraillease of hig ing should include:
1. Nutritiiio survey .co.d ct.d.t.at.e.st......inter al.......
level and a State capacity, to saanplo its ntire pplto eide1,
3. A continuous national monitoring, based o nyo urto surveys and surveillance but on other indieas o urtoa elh that would provide reports on a monthly or bidmnhy ai.
When 'Arnold Schaefer was director of theHWNtij ,-O gram he suggested that 'USDA and HIEW ji ocsi'uito assessment, with HEW developing a, nutritional elhcopnnzo the HFCS.
Under this plan, the HFCS performs itscurnlasiedtk plus the work being done now by HANES.Ti oldmeEh
aforementioned monitoring requirement for aelndtaoth general population. This arrangement wouldpemthecbnai. of the best aspects of both surveys, the food cnupindto h HFCS, based on 3-day and 7-day estimatesofodinaendh physical and biomedical evaluation of HANE.Iwolmenta the HFCS, which might be renamed, would b bet es i~ only food consumption but also its affect., allown tt e sO ny reliably for setting standards for food assistnepogasad Jr evaluating them.I
In addition, it would permit basic nutrint l elhdaa o gathered in a year's time, rather than over a2J- yeri"'.,d to be reported more promptly. It would not, be eesr o h ei cal component to sample as large a population h osmto component, perhaps 30,000 of the 90,000 planndfrte]zFC.Ti would be a manageable size and approxuinatete-gml ur~l studied by HANES.
With the need for general nutrition assessaetben efom4b the new combined survey, the needs of peisilgop ol:b xm
I i'- iii .... iii( i iii(' 'HH'''' ..........
......... ... III, a r jciht w ud n e u rn ln o
go newyutl1981111st1y1aroig1h soe fHAE
to t e tin g o p m r p c ~ es ig could be used and thereiiiiiiiiiiiiii ..................................
4otai4 A1 tatroporuit frexermntngwthvaiustet
mtoo Crem ehdlgiscnieetocmpcad
mh'*Otie:~ threisa ee fr esarh n hi aea
n &cpcttocninuul mitor inits, c ii linisadsililll
th urtoa ttso iri poplaion, hidre ad aU a
welst~uaiytod ado apin fte nieStt ou
Imiiii : 1.T".bidcalprhp t2-o -ea tra .Ti dt ol
I'........at th S at iiiii ii~iiiiiiiiiiiii l eveiii l an sen t to C D C ...............................al
'I'ii CD, yteioudmaeus f h nwiFiiAE cm
bined.s.r.y..nd.. h -==H ANE spci a groups==H~ iiii survey :::::: studying.......... local...
pouaiosa wl s dpi awtsigeciqsdvlod iiii thiiiiiil su veys
The plan just outliii~iiidesH frgting ofinatioal, baselin
.................................... an con in ou m o it ri giipe ia g rou ps..................... A,, th ird,, co p n,,,, .........................
... ................................................. ....................... ........ ... ..... ............. .. ... .
tionia basis, would gather data from a variety of sources, food proces- i N N N
sots: @@ @ an ealrhsiastidpryisrr nd the Satesur veillance syte an puls n tl or i-moi= i i ntl reors These =iiii
would esiat hnsintepoetalfr h opltinahivn
we ros th ipatyo isiurs p tar Sta m ion feasm nrtalina a a
5.Tat Congress require HEW tod iniAt tudyde~miQ anic nnalr carept to uengess tmonio p tonalythees.iO0 ues aftendeqacy pofuaton fod compig-ikorr~l mnlyfood ai-tivebss idtha recommendationsoetMI Thy anuiatry, 1977, nd actouedd nto bensmteuo:fod daafold thFood-at Consuprs daon Suryof 198e4rvilac~ 6.phtongrst ofquiheHE geto caracy pstusaib t. po
in tchiqesfr yica n iceia utiineaui *
7.Thtionres qireUD o tdiodiosmtpv mv
ii 1 ''
1"g IMPORTANCE OF NUTRITIONAL HEALTH CONN% "I::. ,,-91DERATIONS IN FOOD POLICYMAKING
v 4 government has a responsibility to see that its population is as "....4dequately nourished as possible. The nutritionist is in the best position tb. judge how far this responsibility is being met, and it is only logical that he gheW d also participate in the development of measures to improve the
-Manual on Food and Nutrition Policy, Food, and-Agriculture Organization of the United Nations
anuar 197 President Nixon, confronted by a world food 44146 -, hit,, "Was A 4ving up domestic f d ri es and bringing 9t1aMfioif,,o1"rseas, created a Committee on ood in the Cost of Ilving.409uncil. The role of the Committee, which temporarily reduced the power of the Secretary of Agriculture over food policy, was to '44'4401he interests of consumers with those of producers.
iNm tee on Food and its successors have been composed of key Cabih':A'member's and Presidential counselors who have direct
*Alt -tt t anagemen rply, with one exceptionhe m t of the food su
Tfie Secretary of 'Health, Education, and We f are
Althaugh HEW. administers the Nation's public assistance gogram, which is greatly affected by food prices, matemal and Id
heqjth and general nutrition services in public health clinics, the NafioVs primary nutritional health survey and surveillance system,, andinvests more in human nutrition research then any other Agency, the. Secretary of HEW has not been appointed to the Committee on FQ64, the President's Committee on Food, which superseded it in 1974, or the current food poli coordinating body, the Agricultural PolicT Committee, created in ffarch 1976.
This failure is symbolic of the continuing failure of the Nixon and
4 fti g's t r nation to make the connection between nutritional
aii4166d policy. It is a failure to recognize that nutritional heAlfl&iathe proper goal ofany, food policy and that as such, it must be 66rL4dered ina-ny deliberations on food policy:
Before discussing the reasons for this ornission, it is important to briefly review the expansion of the role of nutritionO h6alth conididerations in U.S. food policy during the first half of this century.
THE IMPX&'OF WORLD WAR I
,..'the first Federal attempt to manage the Nation's f6od emnomy
ftme as the United States entered World War 1. Food shortages1were driving up food prices, and Congress authorized the appointment of a Food Administrator to regulate the food marketplace and expand available food supplies.
A key tool in building up food stocks was a conseriaI patheir which relied heavily on the education of housewives ase se of
alternative menus that would conserve vital food stuffs. 'u t,
wheat, and sugar.
This program flowed naturally from the growth of no oth~f
edg that began in the early 1%007 dd the resulting a6-s of the relationship of diet to hoa th..
In 1911, seioutiats had- dise:6vbbed the iAlM s
to health, and. the6 follovvag yestx,tthdunt-ib ilt VVga W t be
understood. Table 4 from The Role of the Federal Gov as#t 'in
Human Nutrition Research, a report -by the Congressoa Research
Service, shows the breakthroughs in huqian nutrition ti5
began ih the early: 1900's.
TABLE 4.-MILESTONES AND CONCEPTUAL DIVAOPWSETS IN TE NUTRITION RESEARCH I
Milestone Datke Pa ind acceptu
Me ihi ni proved the presence of iron in 147 1700's-. --- Lvelster' ge-el
blood by drying it and emng the "1oelt Mr
iron with a magnet. A pops and. -_~q
James Lind showed .that scurvy (the 1753 fliwarey atft r
vitamin C-deftiency disease) could be
Cured by giving cirut fruits. 1nio lt
Magendie demonstrated for the 1st time 8 1 00s. NUtriMon knomb
that life could not be supported without VMdbs'ain t tHdu
a source of nitrogen in the food. eli ru us,
Mulden introduced the Word "proten":. 1838 .
Eijkman produced, for ;he. 1st time in 19710 s..auaiv t4 -history, a disease of dietary orn m bf arf Mr r= W& o 6I
when he induced beriberi in fowLb W7lip agtiga
rmoving the bran from their rice d t.
Osborne aind Mendel recogivized- that 1#V.dbliai certain aminoaci(150 and tryt phane) were indispensabife;'and some
p rotei ns were i ncom plete because they
lack essential amino acids.
Hopkins, a biochemist who had isolate 191Z a...ill the amino acid tryptophang.,in 1906i
showed that unknown nlutrients in
natural foods were essenrtial to life.
Casimir Funk proposed the term "vita- 1912 -----mines" for cortaini idipensable food
McCollum & Kennedy reported the lind- 1910 --r-- --ing of a water-soluble B vitamin asI J f
the antiberiberi (ator (timin,
vitamin 8-1).1 0;,iI Mellanby presented the 1st data on the .1919 1915-0... .detici
role of a fat-soluble "accdssary factor" adfatt ie
in the prprention of rickets vitaminn cape ift"o'
Mc~ollum isolated the 2d. fait-soluble 192n ---.--- .. 1Mdrtta 4 -t
vitamin from codliver oil (the 1st wasasn vitamin A) and called it vitamin D. 1M Goldberger demonstrated that pal ages 192 4.... ..4.)9
could be cured by a dietary factor ite
nonprotein segmnint'er yeast ilkratt7 P
(later shown to be niacin, vitamint 8-3X.
Isolation and later synthesis of ascorbic 1928"2 J T k>ot i iP
Burr and Burr identified linoleic acid as A1929 .---- .... the essential fatty acid. i i
Kuhn, the chemist responsible for isolat- 1935 ing riboflavin, vitamin B-2, synthe-rr sized this vitamii. -ii ~1T
see footnot1e at end of table. e % It'
.NE iiiNCEPTAL DEVELOPMENTS IN THE lIiSORY OF HUMAN
.N.UTRITION RESEARCH --Contiaued
*(neDate Period Conceptual developments
.....ad1 8 W a- .... ............... -- .... iii1848d thd 1959s.. Orac ngu falehebltor"sr
ilnit alanae to etemin th
1940 ---------- "eians ofation ahtbdycntvitaents ant nomiarates, vitmi (latein, min9, v s..........
'*,, 14nd 19n0ad anairns-e.Rnsitemssbnahmitnednu
a~~~~~ ~toit demonstrate the oftercts ofsmt90he.........
oncans oaf mctital state.insan
Ky~~mieas demeastratedt thatio thbi5o.lo.g.-.,.....
Icll nerou systnenm play anym roleems and inoaediety.blim
rera d isc v tefmnin ofte 19498 ........ n t B-1 was oa tedoenzy E g
190an170s (1) Exactd reltioshi ofinutrietsoinlth
*ys~ ~~ deootlerse thse andct prvnto ofmi disease -----------ow~ of tram mee nutiate
.1 M ply at atl thInuarl vl
..e cho-hysaloica conrf of5 foo--------1960s-190': (1) Exat ravmenhi to n utri nd t n th Nowfrntirs onena an ma ntio n be ome sefdirected at g.
a ~ ~ ~ ~ ~ ~~ 2 lel prf arece bymet Di. MichlueatnrMiugtn(i(WoJnn2,195
Sources: ~ ~ ~ ~ ~ ~ ~~ 3 A)bsllstnsonNurtonrhpti)&Nes odh n Ph.d tlEation of ditr
Thea~disoveres, omin behduingn nt at the weluar, brought
soil .ignficnc toduewa4im exprie chehsooia Eu nroean food
ar4e had in) efcrsleinamsIrvemonto expeurienctint
th ~ ~~ eal mwhol pouatoi sufrdvaynbeeesoe main-drtdIin
1,hI rethy Dfes. fchll em a diastein iwe mW hght of, thefining Sore:'ilnsi utritione," dbrought & Joln.)Ew awaees ofe P"The r volo oNurition
0inctof % Natos, Teur 195.lak"en fnua Ntrition elh gishr ia
$6iti Poieush in befor, saigadate;h arruh
Pe enldat h re, shd e warte dxeneat rhe urope foo dst
-aresensaiv ineffecnutrionlcodo-b in a llssv countrileesiment hid where foduretiotns wufered impoeying thgeepopu alntgreitest. Fl u!fs 4fehis ofwas.rnthme other, anewe inat of risondslms isueird mstcecae theygh ha now possibility of uplemntiote offiial
in pblit h3ercet Ninten agitual Statet of Bavria Mite wasie as muhe 6
Discussi ) The mpatio of mprdtriton onthHealth ofuluen AlnerabeIgoupsy, tulihed pcite expersimetnodnhwn pid geaill dren, tr and wseillh eight resut from cls&adton
-i' sholn'fe meals orevn ofe aclastfyl dweeaily" thei regudlwar ies. f m78--15ii i ng i7i 5iial
'r#iiii iiiiiiihlihers n h ueruoi dahrtefo 91 o11
*A u 8 ecnti h a-iutua tteo aai i as a muchas6 H. in Berlin. In Roubaix and Tourcoing, two industrial towns of occupied Nothr Frne h ae oeb iiiiiiiiiiiiiiii 1 percentiiiiiii and 183 i percent respec ivl i Dicsigteipc f rvdnitiono h elho
vunrbegopterpripdeprmnsi odnso ig
.................. .......................... ei gh resu tin fro adiin i
661!i m g"reeofagasoildily to thir reuaBt.....
iii7iiiiiiiii9== iiiiiiiiiiiiiiiiiiiiiiiiiiii5iiiiiliiiiiiiiii iiii iiiiiiiiiiii7& - 5iiiiillliiiil i i ii !i iliiiii ii iiil
Similar results had been found in Japan, New Zealand- Norway, Scotland, the United States and other nations, the report said. In 1936, the League had published the Report on the Phyeiologiod Baies of Nutrition, which outlined principles of nutrition and specified nutritional requirements for individuals at various: stages., f development.
The effect of new nutrition knowledge and the wartime expeniotWe was to place a new kind of obligation on the food economy and the general economy, the demand for an adequate diet; that is, a diet containing all the nutritional components to support and advance health.
Nutritional health was recognized by the Mixed Committee of the League of Nations as an important aspect of food policy and economic policy as it related to food. The report of the Mixed Committt* recommended:
The advice of nutrition and sociaJ-economic experts should, in our opWon, be sought whenever a question of agricultural or commercial policy arises.
NFw INFLUENCE FORNUTRITION
The Federal Government sponsored domestic food aid programs during the Depression, including the first food stamp program. When the United States entered World War 11, the rapidly expanding body of nutrition knowledge was martialed not only to guide military and civilian food consumption but to guide food production as well. (The larger role for nutrition is outlined in the recommendations of the National Nutrition Conference for Defense, the first national nutrition conference, convened in May 1941 Appendix 0.) In., The Farmer in the Second World War, Walter Wilcox reports:
Dr. Louise Stanley, chief of the Bureau of Home Economics (of the Depaxt ment of Agriculture), in her annual report for 1942, said: "In setting goals for agriculture in the past year, the Department considered nutritional needs aA well as market requirements. Food specialists in the Bureau cooperuted with COM, modity committees in working on these problems." This statement higblighft. another landmark in agricultural activities. Not that the idea of better nutrition, was a new departure. Throughout the Thirties scientific investigators ace-umulAted a large body of evidence indicating widespread malnutrition. Home economists were making progress in educational programs regaxding healthful diets. Agri-, cultural economists and administrators were aware of the 'hidden hunger' problem in the midst of agricultural surpluses. The food stamp program waak.an experiment designed as one method of dealing with this problem. ]gut it was only when production goals were set for the first time in the fall of 1941 that the rel& tive nutritive -value of different products had a distinct influence on the cropAnd livestock goals set for the following year.
The War Food Administration would have probably not undOr-.;taken a controversial program in 1943 to increase mil owro mduction,
requiring payments to producers of about half a billion d a year.
according to Wilcox, "except for the constant prodding by thoseinterested in seeing people get more total milk solids to ninprove. their, diets." And, he said, "The wide movement for 'unproved nutrition W" also a factor in the rapid expansion of milk dehydration f during the war."
Another example of the wartime impact of nutritional health b'di 0cerns on food policy is the change in the manufacture of:bread in
in the4 early 1940's. As Ross Hall reports in Foodfor Nougit
i, ela .tomarily ground al th wheat germ and bran out of
'aizc at flour-.to produce white flour, termed 70 percent extraction Aug' e'gmeant the flour was 70 percent of the dry weight of the
*heat. Whole wheat floutr is 100 percentt extractioni.) Early
ap, .wa', heMinistry of Food proposed adding vitamin B, to white
Sout96restore some of the nutrient cent lost durig grinding'. Soine I 1*Islohist argued, however, that whole wheat flour shotild be reire.Millers fought this, says all, because the "were not the
MSinterested m n gin their ways, prima b ecaueo hi
itiirestments in machinery and marketing mthods."
an eperiment involym*g rats; in which whole wheat floor
VV1PrM5ferable to enrichment, the Ministry suggested millers
W 85 recent extraction, but permitted- them to grind to 70 pdrebt @hd ihen add enough bran t6 restore the flour to the 85 perbftt 19V64.1 Controversy continued until 1942, when the government
-all rered- 85 percent extracting. Hall suggests tis order resatdnot from pressure by nutritionists but because of reduced shippigto England. After the war, 70 percent extraction was again the
Nuw GUIDE FOR PODUCTION
idbrandum prepared by the United States for presentation to*&thnited Nations Conference on Food and Agriculture in 1948,
fiI" ')btenew perspective that nutrition science was bringing to
$,1 4 ofthle pre-war national programs for redirecting farm production were
endmic policies aimed at improving prices of individual commodities,
mler~g'the nation's export position and poviding for national selfarrlslany.uch less atention was given to the nd for Iete dies. 'The specrl wairtime food programs provide actual experience in guiding productlan in the maium contribution to food needs. "Both provide useful experience
adachieving production pograms speciffloally concerned with
,The Soals, or objectives for national food production, should be determined on tite hant both of the nutritional needs to be served and of the capacity at the allyj fpr economical food production.
J tough nutritional health concerne had a new impact in the United Sftk* during the war, nowhere are the basic connections between foodand economic and nutritional health policies more aret t)han usRuglnd A report by A. H. J. Baines and D. F. Holnswrh Di*s lq orking Class Families with Children Before and Afterth aodWorld War, in the Nutrition Abstracts and Reviewd (1963) out41Ies theP fundamenRtal changes in England which led to an actual
u Ipoveent in nutritional health at a time when imported food ,tonowg was cut in half and the economy was under great stress.
-fowere: many reasons for this (improvement of nutritional health): attainanal 40 full employment, reduction of class disparity, and deliberate direction at fo( olicy towards improvement of the diet of the nutritionally vulnerable
gro 5. result of food control was perhaps not wholly foreseen. To' take n'
rauo in full was a legal right which became almost a duty Hence rationing 4rd increased and then maintained the consum stion of severalbasic foode in the
ythe racec pofthewartenational l tr tio ided moreio maeoomcep poliyid vian Apreca taeoe th ar'b IM
IIweeincrass supplies cmr a vetion in the Bfoode cand manyb nrseo the economyte~ thendsood byenteie was ereda 19o7 heood tocut rd h4 suaies.o Ite sgiant gs thoer iport mesrswr 9vsbio c~ takiang office wucas ol restorelcontrcdpiefrepetn mtesa'
Thes,1950'seand 1960'soroughtI there waml ~e wt fhromalevel ofp1.4licaion onutitna alhcnes:tod icnoi pieolic rogh yanrsiton oftebnft1o9hs*p~i andofell, ra chinod stpil irelatied e hewx oerp it in 7,io thefod the essnom ramdcd..Ma~R
eept i oifitecoran Whar pneoridenrmnsfrti ingfltivelf s es ontro l 194 o f food pi to the t
The Ru5sand grai6sals anogh worlntdStesamsueo seuS.y gthdnvrbeoekonrain stocksie down to 2.4 mllio 1948. Stck oe to 32. million tons i4 to 157Q1WA161 With sulrechiood sirples, heeniu aslo 6, the com2,pting deado the foodagai sls oneun domesticnd itheKraina ed consumeropI emilte
(esentia orfin asayes fn orl ooducinsot-s inc.reain useofk con andote gra ilin tn n17,telws pressure Stomaxmze the2. nuiiona eosi 17.
Coing auhfter 20yerlseof treaie pahiied f cnfi o pre oucting n172emaed n eno tie .Teews3mlf ecoomsts and ecnonmicolanners. n r a onedtcne orientedl to deing wit surluss. The foda1 osbe n- eutatt 20cyeasn reltie gooad ghr rin etoedlvsok.Teeai thatur the economz woudhe huroa etvnded of1e od' ---,
Comnentlyarsofrltvpeny thefis shoksal ofw My skrocktin dom etfod pnerie ag iutonfr 'ut experts wer e cughtmithu coaneigerlFodpiayh& 6 wrietewic to copein with p.The iUtdae-a, v4t* supples, heaftively: gogwid outther twsams icr~ial
sofgen ecoomeice foren policlua necnmptc ane Th Ami dtr n exrerve o of general economiiiiii i cte iiiiioiy osdrain itioo oiy an' ~i area ththa ee hepesre fte ereay fAgitib
...llwortmatly.the Administration's food polay weald be guided
abio. solely considerations of price. and domestic and international political advantage. .
RELEARNING FOOD POLICY COORDINATION
,Although domestic food prices begea to riesharplyin 1972, addent.'Nixo withheld acion to expand, feed poution anti .973, not wanting to alienate fankers during an election year. HowV10t,"0niJanuary 1,18whtebeimgof PhaeIII of the ;ogeic Stabilization Program, he aiithd food policy control away
tIin the ,Agriculture Secretary :1thuh the appointmentoth
as on Food of th Cos of Liig ouned. This Gommittee
composed. of: The Secretary of the Trauy(chairmea); SeateAdrycof Agrloultur e; Chairmna of the C ouncil oEconomic Advisors;Ihwrarnof she Office of Management and Budget; and Director af 4hio,4Oof'iving Council.
l. F E Wmaiit, worried -about the impact of rising domestic food
seainflation, were joined in food policy, discussions by the etary-of State as the soyban embargo in 1973 -and the generally reduced stocks available for food aid began to jeopardize relation
nations held important to TJ.S. interests overseas. When the Cost Lif waoucg was. abolished on June 19, 1974 by Executive Order 4*DedixLP., he food.(policy coordinating mechanism was retained
a Presidbnt's Committee on Food, composed of : The Secretaries
Agricultuire, State, Tesr; the Director of OMB,; the chairman the Council of Economic Adisr and the Executive Director of
Th: vjani on International Ecnoi Peoc.
46i the Same time, Kenapth Rush, Counelr to the President on ,=4"nolicy, created a Food Deputies Group (Appendix Q
rXV 0watil meet bi-weekly, acting to handle other than the most otant food policy issues and further strengthening the coordinat+4 'j?1 by developing background information on important
%Cutive Order and the Rush memo created the basic decisionshig structure used in 1974 and 1975 to delay sales of grain to the 'viet taion to guard against radical domestic food p'cmres.
qet frm prices began to decline in early 1976 adgrain farmers
W1 of lst sales because. of government intervention in the President Ford, camnpaigni g in the Illinois primary,. ancAl 'in March the creation ofa Agricultural Policy Commite
ed to take over the work of coordinating food policy and headed oretar Butz (Appendix R). By returning the Department of cture to a predonunant role in food policymaking th Amnsa & AVeasgl that it was no longer fearful Of shortages.
new comnuttee is composed of the Secretaries of Agriculture,
aTreasury and Commerce and various econonuc and other adAlsoincude istheSpeial Asistant for Consumer Aflfairs.
eecetary of Health, Education, and Welfare, as nted befoe
asben excluded from this comnuttee as well as th previous Coardnaing committees.
This is nasrpsixx Gawenal econotm istsE and agiutra:6bo
seach o paythe leadership role that it did duingteli0s''4W and194's n lying a fountdationifer food policy. In the irs hlf of the century, humnan ntritionrsmhhdbe concern puiadly with dietary def iciencis d enifctin th elemntsneeed for good health. This researchal d fao ih, medial pofesiondsince, ire a sense, food becameadrti~:=o whic coud administered to banis visible disess Howevei the 1950's and 1960's, themautithoa rbe f h Natin bganto shift from those of deficihncy t hs feci Mostnutitinal problems, with the exception o bstbem invsibe, ag cumulative effects, not prone t uc ~ass For utriionresearchiers, the cumulative nutrition iesspon the rospct o long, expensive studies that may no avmuhpy off'inknolege or professional status.
The rtileWhat Hlas Hadpened to NuaritionbHoadA Scheidr, irs published in 1050,1 appearing in ies iee providesinsgt mnto this new ea for nutrition reserh on.ta the lst oant it~ain -dlicovery, that of vitai nws ad in~~~a 197 TSheider said:
th da seems t6 be gaining ground that nurtio usbdiea theoetiall clsed science. T1hih is not to say that activity a tpe~nfd as a theendof the nineteenth cemtury, analysts andanlssndi iE busnes wih respectable 'quantitation' have reassumdteani!U Otion Eailydisernible is a preoccupation with 'levels' and'ne-oaanhp. The ist ar clsed; the items are known; the excitingdasoth10'sin earl 100'sareover; nutrition is a 'mature' science (whtevrta ii, A conequece of this period of uncertainty and lc fdcini huma nuriton. research has been a low level o ee~ 6nig ,The mostprehensive, usable report on this spednT oeo theFeera Gvernment in Human Natrtio Resehe 'CogresioalResearch Service, shows that onl$7 dowa spen in isc1 1975: about $60 million went to HW 1"i~o went o USA; $2.6 million to DOD and $400,00t h V'egb Admiistatin., The report also found a generallakocoriton amon theagmcies.
This onditon of neglect may be due not only to h akudii i~ or pre rseach interest. The food industry hasonyrb.eatn concered abut nutrition res earch and then prinaiya trltSt nutrtiolabling. This attitude has been reflected h o' 'rg in utrtio search by the Department of Agricutia I Miu thee re ndcations that not only do the agenciessehtk ~otv poltialgan in human: nutrition research but ta hr~,sm N areensonthat this research might develop ifraiI
reaensthecorruption of some popular food item.
All hes fators contribute then to the inabilityofntion-e's to comand he respect they once did.
Sq@a eater factor in the exclusion of nutritina h aonaerns aq foo licy may be the history of nutrition a~pprt sopportn a ,ariety of programs and activities wich countradics A da litratan
ea.rod uction of nutritional health cnerns ten to1 expand
lconsainpr interest bpeaod issues of price or political rdantage to eas of social or husaanitarian repniblt. These axe areas 4 ay require massive spendnand o prologed governmental
V. ve mm the marketplace cnha of the, consumer.
.e aNihonAdministration's uaderstanding and fear of the had *atof, (nutritional health cosnsiderat ions, to its food and general
onmi policies were developed early.
17a44:1968, malntrition wa discovered in the U.nitd Sate
groups who had never benefited firom the wartim abcom,
le wo had essentially remained i h Depression. The evience, d 6 by the Citizensk Bear of inquiry into Hiunger and qilnunmrlyI.episodnithowevr A noe in t i ,blihc
er:hne in the midst of food surpluses resulted mn Congrss
'onng ofthe 1Departmen t of Health, Education, and Welfare
d6 i Ars comprehensive nutritional health survey in th Naon's
ry 0h Ten-State Survey. The preliminary findings of the Tenidbwy res.ented in Januakry 1969, to the newly created Seleat
steon Nutrition and Humian Needs, showed that nutrition
'widespread and directiyrelated to poverty.
These fidings were politically explosive. They not only called into anlestion the functioning of the food marketplace but the basic tnt if" sh.* economic systenm'in which a siniiant portion ofthe peol 4ould remain in permanent poverty. Ofmore inmediatd short-run political concern, the finding supported demanidsder miasive Federal spending to improve the diets of millions.
-A The- Whxte House Conference on Food, Nutrition and- Health, lbd by President Nixon in 1969 in respddise to the reactiontve ozestic hunger, advocated expansion drThe food stdmp rora
schooll lunch and other direct food assistance programs Th
eoflrence, recommendations ase included support ot a guaranteed Aiiim income at a level higher than that desired by the 1Nixon lminis tration. Nutrition experts, led to an analysis of general food ey l And economic policy by their concern for nutritional health, themselves in direct conflict with the Nixon Administration.
hePolitics of a Guaranteed Income, Daniel P. Moynihan, an
chtct of the Administration's guaranteed income proposal, says:
m~ iiood'of the (White House) conference was hostile to the Administration.
e ,,WRO (National Welfare Rights organization) raised the standard of ,500M or Fight," and found in Senator Eugene J. McCarthy a sympathiser jj&sponsor.
ltg-rn: Admnsrto a s opposed oAi massivre Fedieval snendingr for
nomlfntioni g do nt nowkeitl, e sau-u fpoi
of d asoerieftainsodcnsmto
ttus ofdifferet etosaof the populanc fttilri rti 'S
tin. 1969e Wiear Houase CoeentM Leuto mNiong, madisrptt Manad n e 1 nesodthta puolisheod byethe ot endAgctre whnbsdo(h e~
iTti o nsa in saoys: ..................
Before pCoite aned tha intelligent foruteiinogmt xistin stuation:voilyin folda cnprionblen utji~l~t~ ood and nurtionoth poatrin. In 194, the ntona Nurtion Consenon odadl iut eomjord U.S. pronenal organizaish ntoa urto r aluded in aseiits ecoedationsumto habit andth
survys of rntietion healthhe oaio 'i other cohuntrite soise Coarnfrmc aeomne ,6 nrtin mooing ehsoania Mapneariong FodadNtiino Natinin Wol1973) whiayssd Teoresut ofhe suvy anre se also iorlted ti wnint-nl'eh easn sgiulte, fod y spring iwad foen raes de ntfe n~iia fodan.utrition pr olicyas welleasinealt e
itncme appatsrentmmtodtion AdmiSeet Cmitte N ,j fela trleffcientiinsrelac
oSadrte po antroa intrve noa thecain.t f ,intieon rikilling theaTen-tte Suorepronsr vequlatce Hnehosoai andini Nutrition Examinati Chrevius chptrld(3, c Amnstaionli: Te accutablfte forvy the nutritioal inohelnnmdcatil.fd i l Wnagictrearod t ocesn tn oegntaehey latte point,. during.. ntiiadprice inceaesiy 973 l and 1974 eardtion how abeclie ipant t co Nsupion ofmanitaintatterto topai poct and to ntdecline in fh oodrilfod e-t I'
heldpaccotisechangeton nutritional health.cneucsofi&:oq4
erce n ecrd h6sigh u93nemploym prtent on nutrixeWhe .a b made, ut thne nnitdoSae hast?. Whti 2ip~
y4ift history, it is not surprising that the Department of
ture asked the Agriculture Subcommittee of the Senate
atiGns Committee in June 1976, to drop the $1.6 million Iffo.use, had added to improve the Department's Household
C6wumption Survey. Nor is it sur rising that the Office of eme : nt.,,And Budget delayed the HCS survey to prevent it
141 is during an election year and also declined to approve
e anT the nutrition surveillance program of the Center for
me. Control, L
Alf *ssolution of the Ten-State Survey, a few officials within
confiiiued to attempt to win power for nutritional health conations., But the following history of -their activities shows they
ed:to be viewed as a thireat.
STRUGGLE TO BEHEARD
Naibdm Smith, a professor of pediatrics at the University of
I t who had pafticipated in the Ten-State, was brought to
W'M We summer of 1970 as a special assistant to the Secretary,
Ro 6'rt Finch, then Elliot Richardson, responsible for devising a 'nutrition program. Dr. Smith had no budapt and no control over program. It is possible that he was brouXi in to allow the Del t to claim an interest in nutrition and cover the dismantling I 'the-"Tbn-State Survey, which nearly coincided with Dr. Smith's
ith presented a proposal to Secretary Richardson which inuded an pitialtive in surveillance of high-rise groups. It wa's politely
eived*. ' d li tely rej ected. Dr. Smith lef t af ter 10 mon ths. He b ad ounlOdL *hen he arrived that he would stay only a year, and this I hl&'V ,R, h6ted his effectiveness. An official familiar with the period
t her*'6 wa*:S' "not enough steam up, enough interest."
No trace of Dr. Smith's proposal could be found by HEW officiaL%
10 locate it in the preparation of this report
after the White House Conference, a small group of HEW
an meeting informally to consider what direction the De
eat u1A take in nutrition. In June 1971, the group. headed by
Ogden C., Johnson, then director of the Division of Nutrition in lood and Drug Admini tration, was asked to "undertake a study
e, e of the Depaxtment in nutrition and diet as related to
IjAis was to be used in Department planning for the period
Soptember 1971, the group produced a report, quoted several I.X.e krliw in this report, titled Rhat Shouid be the, Department"s
Wrwon and Diet Pertaining to. Hedth? (Appendix D). The
is the most thorough examination of nutrition problems
solutions produced by HEW since then.
Ahe needs cited in the report were:
Ck Mop: a nutrition surveillance system. ("Most of the alternatives proposed in, this report will prove effective only if a nutrition surveillance system
(q ized.12) "It would be adop a Departinental. policy on nutrition and health. (
us to have a 9tated nutrition health policy that could be used not onlY
the Department. but would also serve to guide other Federal and State es in their consideration of programs that have direct or indirect influence
the nutritional health of individuals and population groups.")
s t a ff s.......r..l.t..d.....io n s ...n....tr.i.......a...........................
taken.iiiiiiiiiii Asntderirm hsrpr, otcniin ecieb
Johnsoniiiii comiteein191 xis tda. hereor
sadapro aiirwt t ok eas hr a o.iniw
the....p.....anks. As ani~ inoml itadou nthesi,.i
be easily ignorediii .....................................
T hei n ex a tte m p t to ..............................................
HE em ohv ensatd ycac.SceayRcm o
readiiiiaii article oniithe Op-Ed page of the Junei 14iii1iii2iNew ..... Tii~ill~~ ims wriiiiite by Her .Hiz2dihimno h . Hw CmayEite Nutrition......literac..y,............
Weiii ar aino ntiinlilieae.Dsit elho sinii lw
edeof uriin tomnyo s ono nw hta aa a&a
iiiiii o f..................................ed.a....h. f o o d s t h............... ...............
haveiii anaudn odsplytoretighbtir eeirtn.AdW
not just th porwhi reafeceihoghlwe-icoefailesu
iiiiiiii ........ .......... .......................
Nutriiiiiiiitioneuainiutbcmeapirtycnenofsaead oa o
met n l col.Te odadbvrg nutre hud 9pr-h
i i i i i i i i i~ i i iiiH i iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~ ~ iiiiiiiiiiii ii~ iiiiiiiiiiiiiiiii ............................................................................ . . . .
40 um ggge fine..... tu in of. th agricultural system, but'
rom sa ............ fu ndi~iiiiJi .... ................................. ch alenge to he t adit ona m an ger
tte coriaigc m itei uy 17,sae u
nu~itina helt inarclurla el seooic po iy.~~ iii
t .....................................................................................im e d :iiiii
................. TJW ZEN SHALL HAVE ACCESS TO N ADEQUAT
OF'SOCIALiiiiiiii~i ," ,, OR ECONOMIC STATUS.i~iiii~iiiiii Mi , ,,,,,,,,,,,,,,,,, ..............
sttepn tengos n o ay n hesetin n oo sppy
and rocssig o fod mst b gien he ighst rio ity byii
No e *i e t as........as ......e......a....s.c.or..Th.ose.a.e...........oi for iHH
!iiiii~i'iiiiiiii ''ii !i ii iiii~iHHi .. ....6 4,
Th rftdd hwvrtk asrngpstinfr cnmi q-iy asi a rrqustitiqalacsstideut desiiirin 1h6ms
.................. an.......e n f n o e ma n e an e an t it a
sect!i oniiii~iii on=iii~ii i nternationa nutrition:::::: problem itvnue ac=ofo picy, sayng
a ienwigtofcrai ran mesth roen ed o ok i ol
thna qiaen egto nia rti.Pr e hsosrvto ]- o
neesrl dcaeamao hf i ietr patie b mriasiotoii~e
grin o h essfiin ainatog hsmgtb opsineat
Bu, f t er de o stae that such a shift would be actually beneiiiiiiii ifiiiiiiiiiiiiiiiiilitoi
ei can~ helh then evaluatio ofiiiii such ai mov woudiii be; woty ..... iiiiiii
Earl in17,th o fdrfiga ttmn frteDeatet
w asi~i ii,,,, take..vr...........nde.......st nt.ecr tar......al
bu nt emes f hecomtte.On f he ws r CaresU
of ChiildHat fara ebro h onsnpnli 91
Th e ttmnHat seti fNtiin(pedxB)
wa dpe nFbury17 steDprmntspsto nnti
iiiion. Th ttmn ssmlri oet h ono rf tt-let
estalisi iiiiin Wtersosiiiyfre i plce .o
o t e D e p a rt m en ts iiiii i iiii iiiii i ii!! i n o a a s th e re a t to n u tr iiiiiiiiiiiiii iiiii!!iii iiiiiiiiiiiiii iiiiiii 111111 iiiiitiiiil h e a lth.
Are Ihe::Advantages and maximum health benefits of cereal grainspxoslucts-as a dominant source of protein and eftlories in the human are 6e; Implications of efforts to gra&s-fed rather than grain-fed cattle 6a*iimptioh? What is the time-frame for shifting to predominantly tle lit; this country; what would be the environmental impact and
4QUsequence of such a change? Is there a potential role f or the
vernment in providing incentives to facilitate a major switch in the
6cate gTMn and raise livestock?
8 te mechanisms for change and by what methods can we suppleaducatiotial activities to produce desired alterations in the diet
itsw of AmIricans? Must we look forward to the kinds of dismal t w7fteave experienced-despite nation-wide educational efforts--in
current anti-smoking campaign?"
hese agd other questions in the memo have not been included in study,,oxcording to an HEW official but they are an indication W" officials in the department have a sense of the role for health
envisioned by the White House Conference and the
0.1s, howevery no organizational mechanism in HEW for realiz
The coordinating committee, plagued by lack of budget,
*nowncr nersonnel. and bureaucratic infighting, did not produce nlP
ry to Dr. Cooper, and he did not renew its charter
it 04;4 in April 1975 (Appendix CC). Currentlv there is no
nutrition coordinating body. One option that had
under wnsideration is an Office. of Nutrition that would provide us,=djull-time activity in coordinating HEW nutrition policy.
w6ul# cost money, but even if the investment were made, it is U wbather nutritional health considerations would have
significantly impact on food policy. For this to happen, the power st begivm by the President. The history of the Ten-State Survey no sh&wsothat unless the President and those concerned with food L the Cabinet axe prepaxed to give: health a predominant
Y:. ia, i
e in food and economic policy it is impossible to effectively
'04,programs that even attempt to examine the state of the
on'sk nutritional health, much less take steps to improve it.
Jj4W: official who struggled with drafting the departmental
Wst tement pointed out: "You can't . build policy from the ttom up You've got to have some decisions on the big pieces."
SUMMARY AND DiscussioN
,#cute 66d shortages during World Wax I resulted in rapidly rising
esiie'food rices and the creation of the Food Administrationp kh effectivery took most control of the food system awaY from 6paitment of Agriculture and better represented the consumer's t, With the Food Administration's food conservation program, deral Government attempted for the first time altering the
iding consumption to maintain health and conserve
of nutrition knowledge during the 1920's and 1930's
er expanded consumer expectations beyond matters of price to tritional content of the diet. This new element of demand was as a factor into food policy decisions during World Wa II
,It, Again 4ecsme necessary to create a food coordinating agency,
ductioi decisions aswell as diki gidb" formuated Reconumended Daily. Alloacs In 1973, President Nixon acted, as.................................
with food shortages, to hold down dmsi odpie, ~1. h
Secretary of Agoiulture to share powrit-he!" obg
and Presidential advisors. This
ticularly the food stamp and womten, nat;cide WC po M
In addition, they have not acted to mdrt rc nrdt'A in-puts- or food processing and retailing.....................
industries for price fixing and/or strutrlpolmshtjl mi consumer overcharge and excess prft.(e urto] o
Availability, December 1974.) In daig'ihitrainl4. samers, the Administrations 'have faoei..sltia n nltr clients in the distribution of food aiinsteoevdcef'rar need in other nations. (See NutritionadteItrainlStain September 1974.) Finally, the Adminsrtoshv oent t
guide the diet choiesof the public i asta ol osreto resources nor have they encouragei h poutono. h ns
nutritious crops requiring the least reorcs
In short, the Nixon and Ford Amnsrtoshv::nttki many of the kinds of steps to fight odpieicessWtjAnutrition deficiencyy taken by preiu diitain ae
serious food shortages.
The normal operation of the maxetlcryignPic S
allocator of resources, may provide gnrleut ntmso l~t
but it is evident that in times of 'ShotghemrepA6 Snt..'
1. Providing the public with thems elhu ait o ddo
the knowledge and incentive to impede slcin
2. Producing, processing and mreigfo namne hti
most conservative of non-renewalersuc.
If the food system is to be manaeinawyttwllmt"u health and conservation -needs itiseenilta h,,p
1. Insist that all decisions relatigt odplc
economic policy as it may relate to ntiinb osdrdiiAteIl,9 of their impact on nutritional healh n ht:~sb r41ft
ensure that food policy has as its prnia]olte mrvmet0 nutritional health.
2. Support this policy with fumd n raiain opoh-1Ah following activities, which have -beenko-fra es 0yist comprise the basis for an effective fodadntito ytm
a. Investigation of the nutritional neeso hepbi.
This would include: improved ntiinsrelac;epne research in nutrient requirementsanthsudofhei R 0
varying levels of nutrient consumptin
k- Imtraming the capacity of the food8upply and the economy to meet
would *include:. expanded research into improving nutrient
bwt... through breeding; evaluation of land and other resources
a irtew, towaxd maximizing the production of nutrients using the
10 resources; elimination of wasteful processing and marketing tiess; encouragement of greater competition in processing and
IcA ting sectors; improvement of food assistance programs.
PuMe e*wation in diet to improve health, prevent dise"e and conf"d.
This would include: improved nutrition training for medical stuOpnt ; vxpanded training of personnel for nutrition evaluation and
*tiwe(irig,;, support for nutrition evaluation and counseling of outV ento;41nproved nutrition education in schools; use of television
b4f d6me4ie food supplies remain relatively plentiful, consumer
s&e willprobably continue to be directed toward matters of price M14 e.,Pressure to maximize the nutritional benefit of the food supply
to gwidefhe public's diet will probably come only with greater ortaps 6r.new evidence of dangers to health in the current diet. However, although no acute food shortages exist now, such shorts could develop quickly given the low level of world stocks and the predictability of food production levels around the world. The low V Iof 'stocks does not permit much lead time in redirecting our food tem.
Under conditions of unexpected, sharp reduction in world food supes, major crop-growing nations like the United States would emgo food. The longer these embargoes could be postponed, the less
ce for turmoil in food deficient nations.
In addition, although the United States does not and may not face
impose by war, new physical and political limits on raw
a. ri : S, particularly non-renewable resources, are now a parent.
..me of these resources, particularly oil and gas, are essentiaFto food
duction. Consequently, it would benefit the United States, to both PAXHme the nutritional benefit of the food supply and conserve it at
6 same time, as we are attempting to do with fuel.
And the evidence indicates that it is to the benefit of our physical
al-th to do so.
Under these circumstances the United States must both: develop comprehensive food and nutrition policy; and ensure that nutritional ealth is one of the principal if not the principal guides for that olicy. ,
(Agpendices DD through NN are excerpts from various reports
document published since World War-1 describing the need for
d/or 'Wrays of implementing a national food and nutrition policy.
p endix 00 is Senator McGovemps bill--S. 2867;.-introduced in an ary 1976, which would establish a Federal Office of Food and U. tion, with statements and press reports related to the bill.)
it 'i's recommended: tiagr nutritional health concerns
1. That, as a first step to iintegra ii
Into United States food and agricultural policyt the President appoint
ii= i= = = i = = =i =68
the....... ........... .... He lh d c ton n efr o eA rc lu a
P o~iiiiiii~li cy C o mmliii@i tteeiiiiii estab lish ed~i iniiiiii M axii 1976.ii~iiiiiiiiii"iiiiiiiii~li"~iiiiiiii i'=iiiiiii ............................... !ii=ii===i='iii iiii= ii "i'
2. Tha Cogrs ebishwti h EeuieOfceo h h
den aiOifi c ofFo n urtorsonil o eeo]gp
fo thei ipoemn of th ainsntrtoa elh n oasi
ote ain nti eset h fiewud ucina ecie
!i!iiiiiiiiii!!iii 2867 i i (A p p endiiiiiiiiiiiiiiiiix 0 0 ), w ith itsiiiiiiiiiiiiiiiiiiiiiii iiiriiiiiiiii d u tiei in l d i g i iiiiiii ==iii p ai........rii iiii=lD
ioniiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii ofiiii annuaiiiiiiliiiiii fo d a d n t ii n paif r p e e t to ih h
S ta t e o f th e U n io n m e ss a g e ; c o o r d in a tioniiiiii o f n u tritio n su r v e illa n ce liiiiiiiiiii~ili iiiilllliiiii liiiiilll iiiii lliiii llii iiiiiilliiiii... ii..
program andi coordiiati o ofntiio..iite.nvaiu e
patet andi Agencies.iii i iii
3. That Co isetbihwti heDprmn fArelu
as prscidin .26,aisisatSceayfo odloi
4. ThtCnresetblsiihniE nOfieo ittoa
Helt Evlaioni chwudbersosblo masrg
rrin oniii th urtoa elhipiaindmsial n
internationallyiof US.ifoodiproductionipocessing andimarketin po~ii~ilicii nd..............omc.........as.....m.....at...........n
5.i ThtCnrs eur h ertx fHatEuain n
Welar topoidearprinulyo h eatet' lm1
Amn~an Association for Cancer Researcn. Cancer Rtesearech, Syns:4 Nk iion in the Causation of Cancer. Baltimore, Maryland. ~~it ovdfer 1975.
Amerian Dietetic Association Special Task Force. Tracer; Nutrition I- ervce Personnel. Chicago. 1975. krfc~OurO: Research Serviee, Department of Agriculture, Dietary
rees of Huseholds in the Unsted States, Sprin g 196. Household
Fo- &W tpiote Survey 1965-66 Report No. 6. July 1969.
Agrculure Subconnnittee of the Committee on Appropriations,
-Hedt of Representatives. Agricutre-Environmental and' Conrurer rotection A popriaions for 1975, hearings, Part 4: AgricuirdlPrkograms. Gverninat Printing Ofce, 1974.
Baies'A4H. J. andHll insorh D. F. Diets of Working Close Flies With Children Befre and After the Second World War.
Ntiion Albstracts and Reviews. Vol. 33, 1963. The University J-:. Pes, Aberdeen, England.
Bodle, M. A.; Mclinton, E. Patricia; Nap, Carole. Survey of Thera4~ uiCounelling &Brvices for the Non-Hospital Patient. The Journal
the Canadian IDietetic Association, Vol. 35, January 1975,
Bureauof the Budget. Coordination of Federal Nutrition Programs.
Wdshinthn, D.C. 1945.
uttrwrth, C. E. Jr The Dimensions of 'Clinical Nutrition. Ameriei 'burnal of Clinial Nutritiotn, 28: September 1975.
'Buttrorth, C. E., Jr. Thei Skeleton in the Hospital Closet. Nutiln Today, March/April 1974..
Butemrorth, C E., Jr.; Blackburn, George C. Malnutrition in Hosif. Nutrition Today. Marh/pril 1975.
Cato, Sidney M. Associates. Prlmnr Terchnology Asseament of j,~ V.' ,od Nutriio and Agricultural Inomto Sytems. Offie ofehologyv Assessment. November 1974.
l~~amtesn!. The Ten-State Nutrition Suervey: An Asialytis. Souithtr egional Council. October 1974.
Cenerfor Disease Control. Nutrition Surveillance. January 1975. ,,Ceterfor Disease Control. Nutrition Surveillance. April 1975. Thapan, Cynthia B. and Quimby, Freeman H. The Role of the Federal
0amient in Human Nutrition Research. Congressional Research Sevce report, published by the Select Committee on Nutrition and V: unan Needs. Government Printing Office, Washington, D.C.
Wn~takis George (Editor) Nutritional Assessment in Health Pro9. American Public Health Association. November 1973.
Tommttee on Ways and Means, House of Representatives. National
Heth Insurance hearings, Volume 8 of 9, July 1, 2, and 9, 197-4.
Govenment. Printinge Offce.
AriAAAg LffAAce. WaMDshAgnLD. 19I73.
Council on Foods and Nutrition, American Medical Association. Conference on Guidelines for Nutritional Education in Medica Sch6ools and Postdoctoral Training rogrms, Jume 5--27, 1972. Amterlean
Medical Association. 1972.
Department of Health, Education, and Welfare. Forward Plan for
Health, FY 1977-81. June 1976.
Department of Health, 'Educention, and Welfare. Health Esewees
Statistics 1974. Health Resources Administration, Nationall Op er
of Health Statistics. 1974.
Department of Health, Education, eand Welfare. Preliminary 4iiga
ofthe First Health and,,Nutr* ion Examination Surey, Uni Sa, 1971-72:'Anthropometric and Clinical Findings.. Health Resources Administration, Nationa Center for Health SiatisticA. 'April
Department of Health, Education, and Welfare. Prelimintag 'i
ange of the First Heat and Nutrition Examinatio Burwyney,
States, 1971-72: Zietary Inakle and Biochemic ,al Findigg Vth Resources Administration, National Center for Health B8tatistm.
Department of Health, Education, and Welfare. Ten-State, Nutrition
Surey,1968-1970, Volume 1-IV. Health Services and Mental
Health Administration, enter for Disease Control. 1972.
Department of Health, Eduicaion, and Welfare. Health Alasgowp*in
Hospitals. Washm' ton, D.C. 19).
Department of Health, Education, and Welfare. Survey q
Hospital Manpower. February 1973. Washington, D.O.C
Destler, I. M. 'Uited States Food Policy; Reconcili o
International Objectives. Draft paper prepared for aelit Y-4, te
17th Annual Convention of the International Studies Ascep
Royal York Hotel, Toronto, Canada, February 25--29, J976.
Dukakis, Michael S. Food-'--Majleor Issue for Decades to oe.
Letter to the Editor, Washington Post. 1976.
Economic Research Service. Food Consumption, Prices sand kieadi.
tures. Department of Agricultur~e. January 1976.
Egan, Mary C. Baelkud Paper on the Recommendations
feresees and Groups Related t National Nutrition Poal* 1917-174
Department of Health, Eduication, and Welfare. May 197 .
Federal Register. Federal Trade Commission-Food'.4adm'tw
Proposed Trade Regulation Rude and Staff Statement. November 11
Finch, Rober H. Toward a Comprehensive Food and Nutiod.Rea
gramn. Public Heat Reprt. 1o. 841, No. 8, Augusit 1960..Departl
that of HealtEuainad Welfare.
Gallesh, iz R. Bso'IShrnKing Becomes 1,cl TV. Sgr: bt
Knocking Produets. Wali 1Street Journal. October 20, -1975.,
General Accounting Office. Valuation of EBgorte to Deteqmine Nuti
tional Health of the U.S. Populaion B-16431(3). Novem~ber.:20
Hall, Ross H. Food for Nought. Harper & Row. HagerstownMaryland
a: Mass Foiaesdr NatrtionalF Policyo Bn tequrement.n
oraothmberia 0D17.ipearting Asoiodfration ystempri s,74
Jareport2.GNttovenen Prlitingcy NOe.Washingto, D.O.14
Dorryotih~y, ofssli, raeNotrmtie 'Or ien a
Enith. Wall Stee Juna.ebury22196
X Wobr.stea rHamilton, Mary Rors, Rn. BaNe. Yiain Wor?.hw ID 1975..
E.n (Ed&Asiat. U.S NatttionalF Polic iRtequ&rents W.nd ,;4QenitPepe fo he ic of Tnaio. TheesRdeniheofNarition held 2Deiclbe r e d 197ic. Geerig Fonv ra. io Aug ste ,197 ',-4nggin repr. Novretio Printin Meical Wsholto, iD.e-oerMc prear of the DepaMeetn of ood AndNeriion,
1 atei Aedcasoia tion. 174
Maw, DnReiewP The Poies Cofm~ ExpeGuraneIncoe. RandBomk
)-jugBepitot. Washmgton, D.. 1975.
Bo Facd Mooelha efre,Swdn Dietfo aSllPne.Bland EBereks.195
)4 Jeln Gomittee onS Nutrition andcie Huin eedtis. Govern Satmg Offce Womashngon D.C9My3174 '~~~Mild(omt fteLau fNtons Z.e Developin af NutritionaSuvilneytta to Hoflth Amluerian etetoic Asociatione. ol.s 65.Jul 1937.
UVQ".tudy G.Nr to neateto elh Education eia c l, &and el1974. Shoulreard be the Department Roe indsn NutritionDe Amcn toMeialth (unpublished repot.Setmr191 Moufew Dntol of Far Policyf Described Milling &Rakdmg
Naraety G. ScThes utrionKled of edticaln Studnts
Sokofn Meia1 EuainVl74,Jnar.91 NatoaNuryio MConsorm B ieites for h ElmNationa ofNurgeio loaical. nstitte o Reseron Povrty Humnves ovscneMaltn H. Huelng a MaNutrition inrvtielUniced Sttes,
t Pane. Daof ialreort No ional Ma em f 1975.s175
iiiiiiii~i !iii7 2
RnasnEdad HAeiasLvHows.NttonR iw,
S p e c i a l S u p p le m e n t.ii~ii~iiiiiiiiiiiiil iiiiiiiiiiiiiiii 'ii~~iiiiiiii~iiiiiiiiiiii~~~~i~iiiiiiiiii iiiii i iiiiiiiii i! !iiii~iiiiiiiii Ii!iii~iii~~iiiiiii~~iiiiiiii/ J u lyiiiH 1 9 7 4
Schneider,,, i~i Ho ar A. What iiiiiiii,,'H as Ha pe e toi~iiiiiiiiiii Nutrition ar .....
i n......f...........s.....e.......i....o.........................6 3 .
Seec Comte.o..rtonadHma..d.NainlNuriin PoiySuy17:Pr -urto n e|h ue2i94
G o e n e t P i t n O ffi ce.....................................................
SeetCmiteo urto n ua ed.Ntoa urto
PoiySuy17:Pat6 -pedxt utiinadHNlh
Sh~:etive ifs pano anstdy hfondexpctdancy ShirinfeA rc 'v:W Lota~ h rom Adis Codg e, S nute tet and fori
a re co pl pA w tagp pti nofeiting knowlta e gutre xe gen'itude ofan these b..epaefnt estiate w Takgedte
rmaty ccr fm alvaing uTritigon-rmeates hee:
creasedr Vriniidtraloperormane and satise faHm c nmcsi effviciy iNbsa food Seve. A ig vas-reervirmn asoit
r halth probhlm are ieta t prelsote rmst all Agiutr 1)u couldboiied bynmis Uimvements oMinet;. TH.an
t oesalt probles and othersio s dgicusrlseac
latrin this eprteth ratue for. man ofithersitn hietr, inhU.tan titin oterc couinAriestua ofcom ar ch
pentI. epaente ofoArihealthurei h US
Betrealth otentia r aimrved ietis pn revetersExisfcinro w fleua foresimating aoteantil e benefits ro irn baie as ~lpoe h et Most nutritiomst Adane cinriians feeled
*Huan Ntitionses artclaDivisiong rchlr Rsarch erin exedn
f r Issued ugustua 1971fyoScince and EuaonSfUitdsatsfDeartin ad ir hmn DutrtC. n
poten tial from improe iti rvnaiei hti a ee or modify the develomnofadsaesaesthtaciclcniin does not develop. h ao eerhtrsntowdhsbe on the role of diet intraighatprbesaerhyhvedel oped. This approach hashaliiesucs.UD sax mpss
their dietary requirements.
Benefits could be shared~ by l.Bnft rmbte urto
made possible by improved dits, woudb vial oteetr
woul bte enited pu oe cnoi n-nnhiepplt ,grop ol bnftmstfo fecieaplcto f.'urn
lo the ntire~ pouaio fro reerhyttoedn.Sm h
a.nd describe. t i ifcl opaeadla iueo h viac of pain or the loss ofa family ebr aifcin rmhaty emotionally adjusted famle;cre civmn;adteopr
Major healt beft alogrne.Peitnsfthexnto which diet may be ivle ntedvlpeto vroshat problems~ have been ae'ncren nweg f eaoi ah ways~ of nutrints, but piaiyo bomlmtblcptwy
human~ body isa compe n eyaatv ehns.Frms essential metblcpoessatraepahaseitwihcnb utilized in responset hsooial it rohrstes rgety
and food habits istuted at a al g ih elaodtene
geeal eonzdadawd nation idetras ilexist
low cmae flect on choi o ntk eeso sm ire
iiiiiiiiiiiii from the igh~iiiii@iii~iiiiiiiiiiiii dieath rateiiiiiii areas alm ostiiiiiiiii alwaysi resultsi in aiiiiii~iii~ii~iiiiii
oedu-ctii intedahrtatog h i rovmnner p
iiiiiii i@ iii i~ iiii iii iiiiii'm iii
iiie h ee ciee ytoewowr br.adcniudt v e m t h e...................l..w.....r.at e..........................................................................................................................o wiii i ir a teiii iii
*rm ~ ~ ~ iiiiiiiiii ............... hi~ r-aeaes ato h d a t .I f h et
.r a t f o r iiiiiiii t h e.....ig h...d..a...h...........................................................,
weeapidt h nieUS oulto,1049mr esn ne
65~ ya wol aede e erdrn h eiod15- .Ih
'dahrt o n f h oe aeaes Nrsa ha eild
-there ~@ would hav bee 13163 fee dets hehget ahrt
-'ze the soil a being depeted for sveral year...........ts
1osb&rltosi ewe umrgnldesadhat fsced
TAL!.MGIUEO EEIT RMNTIINRSAC
iises i n i i96062.
TABLE I.-MAGNITUDE OF BENEFITS FROM N4UTRIION I1ESEACH-Cntned
Health problem Magnitudeo f loss det' ~
Eyg----------- 48.1 purcent, or 86 million pepeover 3Lea%kore2 ecn ee epebido
corrective lenses in 1966; 81DObcme bln ey w it orcielys
year; $103 million in welfare.. Coseti --------------10 perment of women ages 9 or more with vitamin
intakes below recommended daily allowances. Allergies -----------32 million people (9 percent) are alegc------- 20 percent pepe reivd
16 million With hyever astma ------------7-15 million people (3-6 percent) allera~ to milk ---90 pretpoleivd Over 693 thousand persons (I in 3000) allergic to. Do, gluten.
Digestive ----------8,495 thousand work-days lost; 5,013 thousand school- 25pIS ewr aue
days los; About420 million incidents of acute condi- codtns tion annually.
$4.2 billon. annual. cost; 14 million persons with Over bllion in co duodenal ulcers; $5 million annual cost; 4,000 new cases each day. f
Kidney and urinary-------- 55,000 deaths from renal failure; 200,000 with kidney 20 percent reductinnm deaths stones. adct odtos
Muscular disorders-------- 200,000 cases ------------------------------ 10pecn redctio incaes
Cancer ---------------- 600,000 persons developed cancer in 1968; 320,000 20~ percent reduction in ncdec
persons died of cancer in 1968. and deaths.
PART B. INDIVIDUAL SATISFACTIONS INCREASED
Improved work efficiency---------------------------------------------5 percent increase in on the job
Improved growth and de- 113,000 deaths from accident. 324.5 million work-days 25 percent fwrdah n
velopment lost; 51.8 million people needing medical attention work-days ls
and/or restricted activity.
Improved learning ability--- -. Over 6.5 million mentally retarded persons witlh I.Q. Raise I.Q. by 10 points for persons below 70; 12 percent of school age children need with I.QJ. 7M.~ special education.
PART C. INCREASED EFFICIENCY IN FOOD SERVICES
Improved efficiency in food --------------------------Notestimated.
preparation and menu
Reduced losses of nutrients -- - - - - - - -- -- -- -- -- Do.
in food storage, handling, and preparation.
Improved efficiency in food------------------------------------------ Do.
Improved efficiency in food --- -- --- -----1---- -- --- -- Do.
LEADING CAUSES OF DEATH
Rates per 100,000, U.S. 1969
Diseases of Heart 3641
Vascular lesions affecting IC .
central nervous system
Accidents S .
Influevzoa nd PneumoriC 4.
Certain d-iseases of early infancy 2 .9
Diabetes Melitus .
General Arteriosclerosis 16.7
Other Bronchopulmoruic dliseaSsS 15.6
Cirrhosis of Liver 15.0
All other causes 145.3
SW.M OUREA OF r IEW
S.04MCBNFISFO H LM~INION
.... H U N G E R IN A M E R IC A i iiiiI ~,=iiiiiiiiiilili i ................................
[by Ba r M .iiiiiiiipkiiniii
...................... .... ..... .... .... ................TR A Mi i i ii i i !i iI i I + iIii iii iiiiiliii =~i
'T h e r e l t i o s h i .. e w e e t he... . .. .... .................... ... e i n a t ................................................... i o o fi~i) ............................................ .............................nd) iii........................ ............ii...............................
,poe etlaWpyia efrmne n oee otlt n
A.... wil acret hssceyan h oet ouaii ml
nurtin'1 liiaed heebeeit a as b iee a ial I C&AA 6. continue malntrition
Tr inl ua aia r mewr iutlzdodermin h
4t v l e o f........................... th b en ei t .................................... w il accrue................................................. ov e the................................................ lifet..............im of............... th.............................
i6 ent4: manurse povrt population The 4 most ::: siniicn gai is
frmh'hreuainlaheeet nti ra h lmntoo
bali~inaog 3mlinpo hlrnwl rdc 63t
$1. bilo nraei N vrte ieieo hs hlrn h
rate o t~al coomi beefis romtheeliintio ofmalutiioniii wilb" eten$44 n 5. i lion .
INTRODUCTIONHunger and mantiinhv enakyc nce nrn i n this
. ... .. .. ...... ................................ .... iii iiiiiiiiiiiiiiiiii8 0iiiiiiiiiliilii
Theseii catgoie.ax..esntd ..... wth-thircuultiv...nmi
workiii ($6.4419.2iii billi on).i ii
2.iiiilii~i~iiiiiiiiiiii P i cal performaniiiiii-iiiprovedi nu riio increase.iiiiiiii thi -c pa it
iiidiiii e a n d.................e..ty............. (.........................
anier a n y e of..........al......t..li...................il lio )
.I ntrgneaiod fecs.Imrve ntitonmaeihalh
mothers'!!! who........lth.c....rn..Al.o....ter edu.ate..axent
lea to!!~! betreuaelcide $.-$. ilo)
T h e s e c o......................................................................................................
theiiiiiiiiiliiiiiii poverty......... ........... wer eli m ina ed the pr s n au n r a e o
aioil poutcneraivl stmtd, oudb bten 1.
an 503blloasuig htmoiatotriig ii..~~
ahiiieeet an tim hrion wuldreai te ame I so*i
notd tat lthughal theseiiiiii rea iosisbewenth vnoii4e
gories such as physical and mental performance are quite clear Many ii~i i
of th e sp ecificii intierrelatio nsh ips h ave no t b een ex a m in ed foriiiii th eir ii ii !! i iiiiii iiiii~iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii ................................................
efet n ag oultos Teerltinhp aemilibsd o
s m a ll ......u i................e.....e.s...a....f.r...................d
..................................................................ir st, esti m a tio n o f th e n u m b eriii~iiii~i~iiii~i~i
malnouriiiiiii~~~iiiiiiiii~~iiiii shd second determination ofth cooicefetsi
theii a n a ysi s : ::::::::::::::::::::::::: =. .
A on these are small sole studies such'as those done by
4M~ed&,8Art mothers and children. Much at the datqa used is
"zq-,n].ubised reports made by OEO or the Senate ann
04 Ntfain. and Human Needs Table 1 shew thovet
Woo Tale.2, the percent manuished; ad Tble 3, toe
i~~ iii ...... .......... .......... ii
TABLE 1.--POVERTY POPULATION
4 Non South South
Urban Rural Urban Rural
Non* Non- Non- Non*
bhite white White w hite WIp white White whit; Total
10 10 183520 141,120 2,900 5,00 44992 il4,170 64528 76ORD
6 173 1,15 621 519,551 19,654 19 433 281,591 418,824 43839 3,657.86
1, 6 ......10 937.870 1, 166022 64,398 570..02 6,625 1,248,728 1,141,972 7,37 ,327
....00 348,.516 1,.053,.192 42,3 562,522 288,106 1,150,208 602,571 ..........
2j.7, 96 505, 787 896, 074 42.,209 547, 103 313,9000 679, 049 363,15 --.....-.
-.. ---. 299,649 203,265 16 3 144,60 146,55 149,840 10,348 ..........
A fe'w me an woervge 14 to 17 work. Most of this age gromp are inclled ia the age 6 to I7Tgroup.
sjtk~:,W crrentpdlation survey with poverty level based on the USDA' lowdeat pried food plan (econeasy plan).
TABLE 2.-POVERTY POPULATION MAI.NOURISHIED [Percent aaneerishadj
Urban Rural Urban Rural
P, r A White Nonwhite White Nonwlit Wh1i1te Nonwhite White Nonwhite
30 57 38 25 33 S4 30 6
14 o fi.....----- 30 50 22 65 35 GA0
fl t .....----- 35 65 40 63 60 70 70 60
'Soke PopiitBaryM.,'"Economic Benefits from toe Elmton oMalnutrition," siudy prprdfor the UI.S. $*go 6 mt.i Nurto .n Han.... Neds, July 1969.
.. TABLE 3.-MALNGURISHED POPULATION
Urban Rural Urban iteral
'ApWie ht hie wieWhite wht Whie ie Tota
---154,243 104, 606 53,625 740 17, 787 24,296 34 251 38, 717 328, 265
---186-------- 248 517, 779 9,715 3,74 4,671 112, 636 83, 765 121, 152 1: 165,700
..247, 592 375, 148 233,2(L4 22, M3 171, 031 279, 508 212,.284 285 493 1, M2, 9 w--- ling---- 433 200 174,258 231,702 27,845 196,883172,864 M3, 042 241,028 1,707,82
vrw602, 339 252, 894 197, 136 27, 436 191,486 187, 854 135A 1015 201 1,740, 215
19- 769--- 194, 722 81, 306 10, 510 86, 7/8 102, 5804 888 66209 8M6 771I
'v OL1, 719, 391 1, 619,407 89, 688 92 804 705 636 8P9,747 801, 040 8W1 859 7, 605 5W
Suc:Cambination of tables I and 2.
7zNational Nat tion Survey in 10 states, while completed for purpose of data cnamha not
sed hasbeen only partially released. It is generally accpted that HEW doesno want to 3ruls th rmath bause the incidence of mAlnutrition was found to besowdpr.
II.i'i~ CALCULATION OFECNMIiENFTSA
Quantifiiiiiabe econmic eeisfoih liiaino aniA
mayiii~i~ be reaiin th....f etlprorachsc~ efv~
a n ce m o rb id ity m o r ta lity a n d in te rg en era tio n a l eve = ts s A ll 6 f th eE 6;
effectsliiiii canibieiiestiae.Eciapciilbetknuii~iaey A~i~iiii fewiiiiii p int m stb kptinmndiFrsti mlnuiiid ho
hospiiliaizedi~i include iiot onyti atet, los llyugihlde.
hai ngsii~iii u!!iiti illnsse tow imildmdrtoisvrianti tio co trbut d t ales er r rea er eg eealt ou h ei im mediate........................................
wiiiiiiii~iith ter ia cacnm ofi theibronchusiiii of ....ii soldb
cnsi de e as dy in not of ne m i a but...............................
ch=,il wiiiith moert orseeelnurto wh io ato
e n eitiii!!i~~ii s s ih o ul l dn id reia ......................... ................................t
nour~ii~iiishedichid h gatoei tiirbbywudntbieU
fatal~~iii i ii~i or w o liiidiiiii n th v oc u r d a al .......................................
fromi~iiiiiiiiiiiiiiiii ........ i m in at io .......................... m a n t iin iiiliiiiiiil b eiex clu d edifro m ..,iiiiiiilii
ion inis stdy.Te.aorexluin.s..ecsti..re...cnnc
tiiiiiiiiiiiioith the treatment of the malnourished. Described briefly, th is=~~ ~~~~iiiiiiii iiitiii heii co st...... ..... .. ... m iiii ciiiiiiiiiiiii serv icesiiii==== in clu d ing....... the:::::::::::: i ............ to::::::::::::: h o sp ita o f
patiiiiiiien ramn of mant iadrled isss n h c
ou-ptintan halh ener adoterclniiteametpls h
c o s t t o p a r e n t s............................................................................................. b y
p rii = ==i v a te======== .................. th e c o st o f tra n sp or t to a n d fro m tre a t m en t a n d for:::::::::::::::::== === ii ................................. iiiii ..... ................ii= =:===== === ==:==iiii====== = .............
A~ren~ge years.* If the under nutrition occurs after the age of M ushee probably will be no permanent damage.
O d~mzthetmshed children eve it they have aot suffered brain
qw W.vnysuffer retarded as 'tive development. The wpathy of
Aa~ki deprivation (especial anemia and .protein deficiency)
AMAIES& AM odly developed intor-sensory intages ive performance.
laof this apathy and listlessness is -questionable but
fih1WJi~U'W Cariote. sees these aspeats of t*he inifant'a behavior
ito-aguressive withdrawal franm the environment." The
AMOiverybid~de4not deal enough with visual and tactile sensations 4wd hwof ecntacts with other persedal. In total be does not
v~ze te ,siiui -il around him. This leads to either a delay in the
.Oeit ,Przm kleucational skill- earing to write."'
1191Zhrdi ehildaen aged e6-8 cannot ax e flt ully the ptehti al to con ant,&Wand work displayed, bynell-ourished children of the same backr~wd.. Hungry -students are unable to concentrate, have poor
-? .1 0resiritable, moody and unable to sustain mental aplia Uo. Mbatrolled sudies. done in Asia, Afriea, and the United States ,hav shan):hes increased food intake produces chesges in mntal
..ahl significant and suggestive studies within the United
Sakenm .dning moei in rural areas, tether inan uarhan area. Dwi=awyedr study in isolated and stable Kentucky county school
-ctdhidren of the experimental schools with improved nutrition gied 30 months in mental age, compared to 15.5 months gained'by 8558bidto of th6 patrol schobleMa diflerene of14.5 months (a 1 armfjttanc .e I4 peent better than the control grorip).9 In 1944, K meS-4 Pnid and Samuel conducted a Study on nutritional
anance in normal and mentally retarded children in New York
tyL i fty of the children classified as normal mnlnourished and 80 aa n.mal; well-nourished were matahed for clronological age, -I.Q., an& B~v between Kublman-Binet or Stanford-Binet tests. Followmg.a anniod I observation which varied between 1, and 3% years, widand ad group with the nutritional supplements showed an
AvergejQ ncraseof +ul8 point in contrast wit an average of 0.9
Cant and De~icardie qualify their findings by the duration of the untreated malnutrition and the proofinfancy. Also they feel the question of permanent retardation remains open. Also they feel it is d tul t "distinguish the particular contributions of early severe malnutrition, adequate environment,
- a exehetal opportunities to defective cognitive function." ;' -Grtloand E. R. DeLicardie, "The Long-Term Consequences of Protein-Calorie Malntrition," 4V~r~wAq,29,No. 5 (May 1971): 111. Also, Josqnin Cravioto, "Malnutrition and Behavioral Develnt he Preshoo Child," from Pre-School Child Mainstritis, National Academy of Sciences*a* 49erchCouncil, Publication 1282, Washington, D.C. 1966.
i GW17.Graham, "Effect of Infantile Malnautrition on Growth,"1 Feat~ion Proceedins, 26, (Januaryi): 1897
nCravioto "*Malnutrition and Behavioral Development in the Preshool Child," rmPeBho
-tn, Rational A-cademy of Salanes-National Research Council, Publication 122 Wash..196.
-- evito Eias De~icardle and Herbert G. Birch, "Nutrition, Growth mad Neueitgrtve
--: An Experimental and Ecologic Study," Peditre, 38 N. 2, IIr Augus 100W)
of these quotes are taken from Cravioto, et al. "Notriftoa Growt ," 80
Aastin Martin, Nutrition in Actios (NYrk: Holt, Riashard, and lmmo, 1903) 213&
8.aSrimahaw, "Nutrition and Mental Development" -(Pape delivered at the Twenty*Plt
Commemoration of the Nutrition Foundation, Inc,1November 17, 1904: 18, It.
Raltams, Nutrin (as Natakell (New York, and Copny Inc., 1968)
n d Loo..n.ardX M.4we ran w Exmnn mrerima n Westszkar,, *Qlal at the Dtome
2. &onomic Benefits
The pertinent economic benefits from higher mental performance. were calculated by using the lifetime income differential between. ,& h-school drop-outs and high-school graduates." There areAwo.,luic assumptions which justify this: First, gains in yearly achievenim the same implication for future earnings as do gains in knowledp resulting from more years of schooling. Second, short-term gwns.um educational achievement can be maintained over time. Some childroh with better nutrition will attend school for an extra year while. odws, will gain in achievement. The extra year in school and. the.gaawm yearly achievement will be assumed to have the same impact on.. a person's earning potential. Among malnourished children aged 0-5 and 6-181 10-30 percent higher achievement will be gained by eliminating, malnutrition.
The income differential between high-school graduates and drop-outs, is fairly representative of what additional schooling (or an inr ea.9e,:J*=' achievement) is worth in economic terms. ". why the dx6poutgraduate differential is more appropriate is that average educational. attainment for under-privileged children falls within the tenth to twelfth grade range. If more is learned in earlier years and is.:. Inaintained, it would seem most akin to lengthening the average period in high school, moving it closer to the twelfth grade level. . .. 11 12
In Table 4 the results of those calculations of higher performance can be found. The percentage discussed earlier were used here. The total impact of increased educational achievement from. the elimination of malnutrition ranges from $6.3 billion to $18.8 billion. These.lowerand upper bounds give the range of benefits attributed to higher achieveinent.
TABLE 4.-ECONOMIC BENEFITS OF EDUCATION, EDUCATIONAL ACHIEVEMENT-CHILD.REN-(-0-17),.
Urban Rural Urban Rural Total
Lower limit ------------- $922,769,720 $728,909,486 $435,762,503 $624,465,180
---------Upper limit ------------- 2, 768, 3Q9, 159 2,186,728,459 1,307,287,510 1, 873, 395, 540
Lower limit ------------- 1, 885, 935,890 51,070,778 787 321 464 842,001,397 J.Upper limit ------------- 5,657,807,669 153,212,333 2, 361:.964: 392 2,526,004,192 ----------------Total:
Lower limit ------------------------------------------------ $6, 278, 236,A18
Upper limit ------------------------------------------------------------------ 18, 834.70%:254
Note: Numbers may not add due to rounding.
11 Income data was available for each grouping from the Current Population Survey. Present values vwe calculated using standard rates of survival, a 6 percent interest rate and a 2 percent growth rate (4 percent discount rate). An explanation of the present value concept and the tables of present values for various education levels can be obtained from the author.
Is Thomas 1. Ribich, Education and Poverty (Washington, D.C.: The Brookings Institution IMI: 68-70. For a further discussion of this subject gee Aapters I and 4. This income differential was cii from the Current Population Reports. Series P-60, No. 56 which gives the present value of lifetime incomes for a normal population and the present value for the poor. The pqverty population values were not used due to peculiarity of the data for high-school grad-ttates iind above. Much research has indicated the difficulty with education and poverty linkages. Thee values wM then deflated by about2o percent. The reasons for this are straight-forward. Theincome differential beMmn dropouts and graduates for the normal population must overstate this differential since persons Irk -the )verty subgroup would have lower average and lifetime income. It is the ratio of the high school graduke gilfferential for people with less than $3,000 income versus people with iticbme of $3A00-$6,00D.Dus to the fact that education is less Important for poor people, their differential will, peak earlier than tbivormal ,opula n, h ,he he d fla on are o e ilhat on -h -2
rom n u he resea by rofe sor Robins n H lis er, fo mLrly ofThe TTn A, vi rs T e _0 0 el
siti P Is r t r e I e Ity
u r ts f t' w tc
ve ucrimin tim reinforce is tec (Ju
to U h n usio s f ester Thurow
Po rtV ng pro ss a rin n liv
and D a th hru e.
tio T 5 esu' 6 t e s m
v~l Ahen w~i school. T erpentg reduction in th is raeo re >se children whoall no ongnser repeating
rates ~a loh oest 1opyetonTer ecni thuencoeftre 4W ed Ac~ngte ofmbee tfmalnodd he chibetw en 122f880,
yiw'ofag (he chol o WhaitNonw tilighis
failre ate todRtraln th timrit Rurahl enwh
168 oeyaofschool. nrlle andrchPerfrangTe Jtona of thumate Vbple n ialre rte ufrrbosend irlsoae 10for it. ysapr oldsnat s to tS: Sata werenomi eeist avilso a esm16 t1hen the fadurtsn
Nomhweci~e icoe tes eath Soueadthus noea
rlUrban Rural Uban ta
-- - -- -- -- -- -- 8.... ..1 770. 2 .. .2 2,88 1
soure;V1vol.4,.. 2, sring1.6 Th ....ur rat ..usedi..fo.........d,.i........1...... Thi, 6sa prxmaey1 h
meia orheaZ :69 0 o 3 ad 4to15 at wr nt vilbl orth ge 1 o 7 hn hefingerte.tn
nheelntio of Salutriinwlhf rbise working peolean povrty (1t 11oWwmn)wlieprineae:O ec M .-Imr ~ ~Lvity Th resultant------- lifetime18 economic4 be,1,4 1,1,86 ------1hp ~ ~ ~ ~ ti productivity--gain wi156 range,42 from311 396458 ------LOW9~fo workt are---------- one of767 the679 three,21 major5 requi------bolism- retrmnst epu h iep
mt mothers Ther ist ad clos correlation.
:efomacaloreadr productivity. ftew
tca~~mio bee frmat iaon f theacntvition beilfec
taken, two things will happen. First, the body will adapt onwltt this lower food intake by avoiding effort. Second, the bod weight.
Numerous studies done in the United States. and ote etm
industrial countries illustrate the significance of th~is rltn between improved nutrition and physical performiicei best controlled studies was done with aircraft workers inSuhr California. "One group of workers was given large~ doses of4gvo vitamins 5 days a week for 9-13 months; a control grouiprtwas~iv placebo. During the last 6 months the vitamin grou,~sow~.at tically significant superiority over the placebo group 'i bntes (3.90 days compared with 4.79 days), in turnover oflbr4be.8. per 100 as compared with 13.5), and in merit ratings baelnA aeq;
appraisal of efficiency-"1
Table 7 shows the relationship between additional protein intake and an improved capacity for work. These studies had poor cotrl and leave much doubt of the significance of this relationship.
TABLE 7.-PROTEIN INTAKE AND CAPACITY FOR WORK'
Intake of InakYear, occupational groups, and "performance capacity" per day I
1939-41--- Miners (Germany):
Rising- ----------------------------------------------------3 WV12
F ai lin g - - - - - - - - -..-- - - - - - - - - - - - - - - - - - - - - - - - - --..
Unchanged -- - - - - - - - - - - - - - - - p o .1 0
Falling -- - - - - - - - - - - - - - - - - 7
1946-Scientists (United States):
Unchanged -------------------------------------------------------- 3,04W .8
Steep rise after 6 weeks----------------------------------------------------------- 1.6
1951-Students (United States):
Doubling ofmuscle power in 12 %eeks' training perid- ..------------------ 4,00 2. Z0
Slight increase in 12 weeks----------------------------------------------------- tJO
No change in 8weeks---------------------------------------------------------2Keller and Kraut, "Work and Nutrition" p. 73.
2. Economic Benefits
The pertinent economic benefits were calculated only for the malnourished working population between the ages of 14 a--4 h
in crease in worker performance of 10-40 percent depends on the'dere of labor intensity and the previous nutritional status of~h wrkx
The calculation of benefits is based on one assumption: The employment picture of each worker from each rueexz.repin..,rr= 3.
assumed to be constant. Thus, his productivity will incres i i
job and salary will not change so each worker will not Qcp increase in productivity.
Then, the benefits to society for each workers' mpoec pn
,ductivity are the 10-40 percent increase in productivty, t~-s,.b, present value of lifetime earnings for his sex-ra8ce-reingo Benefits of $6.5 to $25.9 billion will necessarily accruetosieIy' a terms of increased productivity. These benefits are i dae %M
12 The Keller and Kraut and the UNFAO articles summarize many of theseues W. D. Keller and H. A. Kraut "'Work and Nutrition,"' Geoffrey H. Boneu, e., WorReiw IW1 and Dietics, V. 3, ow York: hAffner, 1962). W. W. Tttle an~Edward Herbert, 'Work Capact ity bBekatadaUdMrli rW4 Jvwnel Aiuerrn Dietetic Aswdat.ion, 37, (August 190). United Nations Food and Agriculture Organization, 2VutUWes and W~orkingJ~d* e (Rm:UF0 1962). 4 .
C. E. A. Winslow. 2%e Cal of Sickese and the Price of health, World Healt Omahto, 5) 14Wslow, 7e Cot f icknee, p. 35.
r $73, 4,40 477 9317 4 3 2 556,6 04,63,21 ............. .
259........ 10-- 22278,60 percen994.... The..... eicbene
ii is n4es an an infiveagr
~ N................. .................. 51 1 4 60......5 1 50 2 4 -- - -- -
.A ~ ~ ~~ ~t anibd response, alternautrtionfwrokdasilbemsddu
fterial toxins, and$nutritional alterati
in, iro, vtamns oan C re
R. J. Williams samplezof th ese relationship e es.ae ht
"8VerY...*MM~o mAimiea, any yetars, whcontiofte cadth tia~useresitane todisas ich wa no loee bytiue betenous
is thehieettosles tnhnh tht forlth cndtryue ast
im"Ista in disafristc weroes adddtote douiset owe
Pcw #u~tio ca lea posagedator rinfctin wit tubterulial
ricetsi a' prtooa inecisil Size and suped oehnesmgrop thi Ynergism ~~ rs ar nefrnewth ratdep se 100 ternaears of
,T~~~~~~~ 0.16 i ne~ nereec ihnnteii groptecivmg rusteu
of balanc."' P .oinceirn te nms wer an mCall te
.*wtren Thefollwing at atpes thes prneel. Getzpet
Ldt hs caledattnAnd to b oein 28va prstin
,&Ul n ~hch ve2ereico any eatrss, aorinetnive o this sadet
oped tiiiiiiiiiiiiiiiiiaieiwhichiwasinotilowered byibetterihousing
vlnlon, prmnl J.ope F. Brock ed., Reet Adrses counHrmes
): !W fresh mlk, meat and ri).eade oth it.Dwe
-subsequently developing tuberculosis than in over I ooo individuals who did not develop this disease."
b. Keller reviewed some of the experiments done. with vitamin C.' He found that although most of the studies have shown a relationship between vitamin C intake and absences from work, different studies have indicated different doses of this vitamin are needed. Schuevk6rt ('saw effects only on doses of as much as 1,000 mg. ascorbicacid per day, while Baker and Winckler (1955) found a reduction in the number of short absences from work on daily supplements of 100 mg. of vitamin C."-"
c. The International Labor Organization provides an excellent ,example of the influence of a good lunch on accidents. The U-N Food and Agriculture nutrition committee interpreted these resulta as a reflection of the relation between nutrition and morbidity. In this Canadian study the results before and after the opening the lunch
room per million man/hours worked were determined.'
first aid treatment ---------------------------------------------------------- 3,000 2, LV
Lost time accidents ---------------------------------------------------------- 49 42
Note: 3 years average.
2. Exonomic Benefits
As with physical performance, economic benefits were calculated
-only for the working poor although school attendance will-i also. Table 9 gives morbidity rates for males and females in the overall work force for age groupings, rates less than those for the poor popult tion. A reduction in these rates will produce gains to society which mILY accrue to the individual or to the corporation. The increase in produr,tive time will produce gains between $200 and $500 million- These benefits are shown in Table 10.
TABLE 9.--MORBIDITY RATE
[Percentage days lost from work per person per yeaTj
Age Mate Femab
17 to 24 ------------------------------------------------------------------------ 0.0132 & 0164
.25 to 44 ------------------------------------------------------------------------ .0256 on
45 to 64 ------------------------------------------------------------------------ .0532 .0=
Source: U.S. Department of Health. Education, and Welfare. Disability Days: U.S. July 1965 to June 1966. Vft# md Health Statistics, series 10, No. 47, GPO, October 1968.
17 ]bid., p. 376.
18 Keller and Krant "Work and Nutrition," p. 75.
19 UNFAO, P. 26 gon ILO Studies and Reports, New Series, N. 4, Nutrition in indushl, 190,,p. 4L-