in A ‘ 613$ \ceg ‘f39o ‘ FUEL National Cholesterol Education Program Report of the Expert Panel on ' a Population Strategies for t 3;; Blood Cholesterol Reduction if Executive Summary i,“ {6 US. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service . National Institutes of Health National Cholesterol Education Program Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction Executive Summary US. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service 0 National Institutes of Health - National Heart, Lung, and Blood Institute L9 National Cholesterol Education Program NIH Publication No. 90-3047 521.5, DEPOSWQR‘I November 1990 NOV 2 8 c Population Panel Report Executive Summary Dedication To JOSEPH STOKES III, MD. Dr. Joseph Stokes was a member of this panel until his untimely death in June 1989. It was his characteristically clear-sighted vision of the need for population strategies to lower blood cho- lesterol that led to the formation of the panel, and his contribu- tions to the formulation and execution of the panel‘s work were extraordinary. Dr. Stokes played a pivotal role in shaping the de- velopment of the National Cholesterol Education Program (NCEP) as a leading member of the program's Coordinating Committee. His insight, scholarship, and commitment to public health were vitally important in ensuring the early success of the NCEP. Dr. Stokes’ leadership and effective advocacy on behalf of the NCEP mirrored his dedication and monumental contribu- tions to the prevention of cardiovascular disease in the United States. We dedicate this report to the memory of Dr. Joseph Stokes with respect and affection. Population Panel Report Executive Summary National Cholesterol Education Program Expert Panel On Population Strategies For Blood Cholesterol Reduction Richard A. Carleton, M.D., Chairman of the Panel Johanna Dwyer, D.Sc., RD. EX-Officio Members Laurence Finberg, MD. James I. Cleeman, M.D., Executive Director of the Panel June A. Flora, PhD. Nancy Ernst, M.S., RD. DeWitt S. Goodman, MD. William T. Friedewald, MD. Scott M. Grundy, M.D., PhD. Basil Rifkind, MD. Stephen Havas, M.D., M.P.H., M.S. Gertrude T. Hunter, MD. Consultant David Kritchevsky, PhD. Karen A. Donato, M.S., RD. Ronald M. Lauer, MD. Russell V. Luepker, MD. Staff Marguerite A. Evans, M.S., RD. Amelie G. Ramirez, M.P.H. Linda Van Horn, Ph.D., RD. Laurie A. Quint-Adler, M.P.H., RD. William B. Stason, MD. Joseph Stokes III, M.D.* * Deceased ii Population Panel Report Executive Summary Table of Contents I. OVERVIEW AND SUMMARY II. BACKGROUND AND INTRODUCTION A. B. C. Coronary Heart Disease Rationale for Both a Population Approach and a High-Risk Approach to Blood Cholesterol Guidelines From Other Authoritative Sources 1. International 2. United States 111. CONCLUSIONS OF THE POPULATION PANEL IV. RECOMMENDATIONS A. E—i I. K. wnwwcow Nutrient Intake 1. Rationale for Nutrient Intake Recommendations Eating Patterns Healthy Children and Adolescents Special Groups Health Professionals The Food Industry Mass Media Government Educational Systems Measurement of Blood Cholesterol Research and Surveillance V. GLOSSARY VI. BIBLIOGRAPHY 12 15 17 17 18 20 24 24 25 26 27 27 28 29 30 33 35 iii Population Panel Report Executive Summary 2-5. iv List of Figures Relationship Between Serum Cholesterol Level and CHD Death Rate (MRFIT Screenees) Cholesterol Distribution in the US. Population (Males / Females Combined, Ages 20-74, NHANES II 1976-80), and Potential Changes in the Distribution List of Tables Recommendations of the Adult Treatment Panel of the National Cholesterol Education Program for Classification of Patients CHD Risk Factors Other Than LDL-Cholesterol Dietary Recommendations Related to Blood Cholesterol Levels by United States Organizations Since 1983 Guidelines for Referral of People Based on Their Blood Cholesterol Level 10-11 13 30 Population Panel Report Executive Summary I. Overview and Summary Coronary heart disease (CHD) is a major pub- lic health problem in the United States. Despite substantial success in reducing premature deaths from CHD in the past two decades, this disease continues to kill more than 500,000 Americans annually. About 1,250,000 Americans suffer myocardial infarctions each year, and millions more have angina pectoris. In addition, signifi- cant degrees of asymptomatic CHD are very common in our population. In addition to its impact on the Nation’s health, CHD costs the US. economy over $50 billion annually. Coronary heart disease is the result of athero— sclerosis, in which deposits of cholesterol and other lipids, along with cellular reactions, thicken ar- tery walls. This process gradually reduces the caliber of the artery and restricts blood flow. In- adequate blood flow may cause injury to or death of tissue beyond the site of reduced flow; in the coronary arteries, this leads to myocardial infarc- tion or sudden death. Many factors influence not only whether a person will develop CHD but also how rapidly atherosclerosis progresses. Genetic predisposi- tion, gender, and advancing age are recognized factors over which we have little control. High blood cholesterol, cigarette smoking, high blood pressure, excessive body weight, and long—term physical inactivity are also key risk factors over which we have considerable control. Control of each of these factors is important in the preven- tion of CHD. People with diabetes may also be able to avoid or delay vascular disease by control- ling the other risk factors. High blood cholesterol levels clearly play a causal role in CHD. This conclusion is based on experimental laboratory work, extensive clinical and pathological research, and numerous epidemi- ologic studies over the past several decades. The magnitude of the problem posed by elevated blood cholesterol levels is very clear. High CHD rates occur among people with high blood cholesterol levels of 240 mg / dL (6.21 mmol / L) or above. However, an even larger number of cases occurs in Americans with blood cholesterol levels below 240 mg / dL. It is important to note that the aver- age cholesterol level for the adult US. population is about 210 mg / dL. Furthermore, approximately 55 percent of adult Americans have cholesterol levels at or above 200 mg/dL. For these reasons, two kinds of strategies are needed: patient-based strategies, which seek to help those with the highest blood cholesterol lev- els, and population-based strategies, which seek to reach all Americans. The population approach aims both to lower the blood cholesterol level of individuals and to reduce the average cholesterol level throughout the population. When both approaches are used, the effects are synergistic. Two important types of research provide ground for optimism that CHD morbidity can be reduced, and that the trend of reduced CHD death rates will continue or accelerate. First, studies consistently indicate that reducing blood choles- terol can reduce the likelihood of developing or dying from CHD. Dietary factors in individuals and in entire populations have important effects on blood cholesterol levels (although genetic makeup, expressed, in part, as a low level of HDL— cholesterol or as a high level of LDL—cholesterol, also plays a major role). Second, this report clearly indicates that many effective strategies exist for helping Americans develop more healthful eat- ing patterns and lifestyles. The Population Panel of the National Choles- terol Education Program offers a set of recom- mendations designed to help healthy Americans lower their blood cholesterol levels through Population Panel Report Executive Summary changes in eating patterns and thus reduce their likelihood of developing CHD. Recognizing that Americans’ food consumption is influenced by many factors, the panel directs its recommenda- tions to individuals, to special population groups, to health professionals, to the many components of the food industry, to relevant government agen- cies, and to public and private education systems. In addition, the panel’s recommendations address cholesterol screening, and the need for continued research and evaluation as eating patterns change, blood cholesterol levels decrease, and CHD con- tinues to decline. The panel recommends the following nutrient intakes for healthy Americans: 0 Less than 10 percent of total calories from saturated fatty acids. 0 An average of 30 percent of total calories or less from all fat. 0 Dietary energy levels needed to reach or maintain a desirable body weight. 0 Less than 300 mg of cholesterol per day. Each is intended to be achieved by an individ- ual as an average of nutrient intake over sev- eral days. These recommendations concerning nutrient intakes are appropriate for the general popu- lation, including healthy women and individu— als 65 years of age and older. As healthy children join in the eating patterns of others in the family, usually at about 2 years of age or older, they should follow the recommended nutrient intake and eating pat- terns. To achieve more healthful eating patterns, the panel recommends that healthy Americans select, prepare, and consume foods that contain lower amounts of saturated fatty acids, total fat, and cholesterol; choose a variety of foods to ensure recommended intakes of carbohydrates, protein, and other nutrients; and consume only enough calories to maintain desirable weight. The panel also makes recommendations for other groups: Health professionals should both practice and advocate the recommended eating patterns; ensure that education of future health profes- sionals includes appropriate nutrition educa- tion; and work with industry, government, voluntary groups, and health care agencies to facilitate adoption of the recommended eat- ing patterns. The food industry, food and animal scientists, and food technologists should increase efforts to design, modify, prepare, promote, label, and distribute good-tasting, safe foods that are lower in saturated fatty acids, total fat, and cholesterol. Government agencies should provide consistent, coordinated nutrition statements and policies emphasizing low saturated fatty acid, low-fat, and low-cholesterol eating patterns; should expand and standardize food labeling require- ments to identify clearly the content of satu- rated fatty acids, total fat, cholesterol, and to- tal calories; and should take other steps to im- prove the consumer comprehension necessary to achieve the recommended eating patterns. Educational programs at all levels should incor- porate curricula that emphasize the back- ground, benefits, and methods of achieving eating patterns that are lower in saturated fatty acids, total fat, and cholesterol. This rec- ommendation includes elementary through high schools, vocational programs (especially in culinary arts), colleges, universities, and health professional schools. Measurement of blood cholesterol, followed by appropriate education and counseling, is best initiated in the health care setting; but in spe- cific circumstances and especially for selected segments of hard-to-reach population groups, public screening for blood cholesterol, when carried out with high quality standards, is ap- propriate. Research and surveillance must be ongoing to develop new information concerning diet, Population Panel Report Executive Summary blood lipids, and CHD; the development of better data bases concerning food composi- tion, food consumption patterns, illness rates, food product development, and nutrition education and communication is critical. Implementation of these recommendations will promote adoption of eating patterns that will help most Americans lower their levels of blood cholesterol. The result, an approximate reduction of 10 percent or more in the average blood choles- terol level of the US. population, will lead to an approximate reduction of 20 percent or more in coronary heart disease and, in consequence, to significant improvement in the health and quality of life of Americans. Population Panel Report Executive Summary II. Background and Introduction Cholesterol was identified many years ago as a prominent chemical component of the athero- sclerotic lesion in human arteries. Following those early observations, a large base of scientific evi- dence has accumulated linking dietary saturated fatty acid (SFA) and cholesterol intake, blood cho- lesterol, atherosclerosis, and coronary heart dis- ease (CHD). Animal, biochemical, genetic, meta- bolic, clinical, and epidemiologic research have all made important contributions to understand- ing these relationships. Clinical intervention trials have shown reduced CHD rates when cholesterol levels are reduced. While it is apparent that indi- viduals with high blood cholesterol levels are at high risk of CHD, a larger number of individuals with more moderately elevated cholesterol also have increased risk of coronary events; such indi— viduals comprise a substantial proportion of the adult US. population. From these observations, it follows that a two-pronged strategy is appro- priate to address the high prevalence of CHD in Americans. The patient—based approach seeks to identify those at highest risk and to treat them to lower their blood cholesterol level. The popula- tion approach seeks to influence the population at large to alter current eating patterns, and thereby to lower individual and average population lev- els of blood cholesterol. These two approaches are complementary means of achieving lower rates of CHD and better health of the public. This report deals with the population approach. In 1984, the National Institutes of Health (NIH) convened a Consensus Development Conference on Lowering Blood Cholesterol to Prevent Heart Disease. Among the recommendations from this conference were identification and treatment of individuals with high-risk cholesterol levels, changes in eating patterns for members of the general public, and the creation and implementa- tion of a national cholesterol education program, which the National Heart, Lung, and Blood Insti- tute (NHLBI) had begun to plan in early 1984. The National Cholesterol Education Program (NCEP) was launched in November 1985. The goal of the NCEP is to reduce the prevalence of elevated blood cholesterol in the United States, thereby contributing to the reduction of CHD morbidity and mortality. The NCEP is designed to reach and influence both health professionals and the public. This program provides an oppor- tunity for individuals to assume an active role in reducing their risk of CHD. Under the direction of a multidisciplinary coordinating committee rep- resenting a variety of agencies and organizations, the program has accelerated the process of in- creasing public and professional awareness of the importance of reducing elevated blood choles- terol levels. The NCEP has issued reports devel— oped by its Expert Panel on Detection, Evalu- ation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel or ATP) and its Laboratory Standardization Panel (LSP). The pres- ent report has been developed by a third panel, the Population Panel, which has conducted an in- tensive review of the scientific basis for making blood cholesterol-lowering recommendations, especially eating pattern recommendations, to the general public. A fourth panel will report later on blood cholesterol reduction in children and ado- lescents. A. Coronary Heart Disease Atherosclerosis is a complex disorder, the development of which involves the interplay of many factors. Blood cells such as monocytes and platelets, the blood coagulation system, endothe- lial cell damage, and deranged function of arterial Population Panel Report Executive Summary wall macrophages and smooth muscle cells all contribute to the atherosclerotic process. Many other risk factors play important roles. The proc— ess involves the deposition of cholesterol in arte- rial walls and progresses with cellular prolifera- tion, fibrous tissue deposition, and further choles- terol deposition, creating progressively larger atherosclerotic plaques. As atherosclerosis pro- gresses, the opening in the artery through which blood flows is gradually reduced in size. The degree of arterial narrowing may be abruptly in— creased by thrombosis, by plaque disruption, or by smooth muscle spasm. Closure of an artery may cause injury and death of tissue beyond the site of blockage. When a coronary artery closes, myocardial infarction or sudden death is a com- mon outcome. Approximately 1,250,000 Americans each year suffer a myocardial infarction. More than 500,000 die annually from CHD. More than 6,000,000 Americans have symptomatic CHD, while it is estimated that nearly 70 percent of adult Ameri- cans have some degree of atherosclerotic narrow- ing of their coronary arteries. From a public health perspective, CHD is a major health problem. The economic costs have been estimated to be over $50 billion annually for illness care and lost earn- ings and productivity related to CHD. Although the precise causes of atherosclerosis have not been identified fully, clinical, epidemi- ological, animal, and biochemical evidence dem- onstrate that many major factors contribute to the process. Three of these factors—gender, advanc— ing age, and genetic composition—cannot be changed, but their effects can be mitigated. Several other important risk factors for CHD are modifiable and provide opportunities for in- dividuals and populations to reduce their likeli- hood of developing CHD. The most important are high blood cholesterol, high blood pressure, and cigarette smoking. Numerous epidemiologic studies show that the smoking habit increases the chances of developing CHD, as well as the proba- bility of lung cancer or emphysema. The risk of both CHD and lung disease decreases with smok- ing cessation. High blood pressure accelerates the atherosclerotic process; control of high blood pressure reduces the likelihood of stroke and probably decreases the incidence of CHD. Other risk factors have also been identified. Three are of particular note: overweight, diabetes mellitus, and a sedentary lifestyle. Maintaining or achieving a desirable weight is important both by itself (because excess weight is probably an in- dependent risk factor for CHD) and because people who have a desirable body weight are less likely to have high blood cholesterol, a low high density lipoprotein (HDL) cholesterol level, or high blood pressure and are also less likely to de- velop diabetes mellitus than obese people. It may be possible to prevent many cases of non-insulin- dependent diabetes mellitus by avoiding obesity; furthermore, there is hope that control of the three major modifiable CHD risk factors will help dia- betics avoid many vascular complications. Mod- erate, regular aerobic exercise throughout life is also important, in part because it enhances car- diovascular fitness and facilitates control of high blood pressure and excess body weight, and in part because of its generally favorable effect on HDL-cholesterol. As has been reviewed extensively in section V of this report, entitled Scientific Evidence for Rec- ommendations Affecting the General Public, con- sistent evidence from multiple avenues of research implicates high blood cholesterol in the causation of atherosclerosis and CHD. Both genetic and dietary factors influence blood cholesterol levels. Saturated fatty acids (SFA), cholesterol, and ex- cessive calories in the diet tend to elevate the blood cholesterol level. There is now conclusive evidence that lowering elevated blood cholesterol decreases CHD risk; this has special importance for dietary recommendations. The N CEP represents a major effort to reduce CHD rates in the United States by helping to lower elevated blood cholesterol levels, in part through favorable alterations in eating patterns. Together, the National High Blood Pressure Edu- cation Program, federally sponsored smoking education programs, and the NCEP are designed to reduce the three major modifiable risk factors for CHD and improve the health of the American public. Population Panel Report Executive Summary B. Rationale for Both a Population Approach and a High-Risk Approach to Blood Cholesterol Epidemiological, clinical, and experimental evidence clearly demonstrate that the likelihood that a person will develop or die from CHD is directly related to the level of blood cholesterol. This relationship is well illustrated by the 10-year followup experience of men, initially ages 35 to 57 years, screened for the Multiple Risk Factor Inter- vention Trial (MRFIT).1 As shown in figure 1, using data from MRFIT, the relationship is con- tinuous and the risk increases with rising choles- terol levels. The risk of dying from CHD increases slowly between 150 mg/dL (3.88 mmol/ L) and 200 mg/ dL (5.17 mmol / L) and more rapidly when the cholesterol level exceeds about 200 mg/dL (5.17 mmol/ L). For those individuals with cho- lesterol levels between 240 mg / dL (6.21 mmol / L) and 300 mg/dL (7.76 mmol/ L), the likelihood of CHD is increased up to fourfold above that for those with levels below 200 mg/dL (5.17 mmol/ L). Similar relationships between blood choles- terol and CHD have been found in many other studies. In the United States, as in many other nations of the world, a majority of people have a blood cholesterol level high enough to increase signifi- cantly the likelihood of CHD. Thus, data from the National Health and Nutrition Examination Sur- vey, known as NHANES 11 (1976-80) (figure 2, page 10), showed the mean cholesterol level for the adult US. population to be about 210—215 mg/dL (5.43-5.56 mmol/L).2 Approximately 30 percent of adult Americans had cholesterol levels of 200-239 mg/dL (5.17-6.18 mmol / L), and more than 25 percent had levels of 240 mg/dL (6.21 mmol/ L) and above. Figure 1 shows the high CHD death rate of those in this upper 25 percent of the cholesterol distribution. Despite the lower relative risk of the 75 percent of the population with blood cholesterol levels below 240 mg/dL (6.21 mmol/ L), this group experiences about 60 percent of all CHD deaths, reflecting both the larger number of people at risk and the effects of mildly to moderately elevated cholesterol levels as well as the influence of other risk factors. The fact that risk of CHD is by no means restricted to those with high blood cholesterol levels supports the need for a combined population and high-risk approach to CHD prevention. Based on the scientific evidence of increased CHD risk with elevated blood cholesterol, along with the evidence that risk can be reduced by lowering high blood cholesterol levels, the ATP of the NCEP issued a series of recommendations for a strategy of detecting and treating individu- als with a high blood cholesterol level.3 This panel, building on the work of the Consensus Develop- ment Conference on Lowering Blood Cholesterol to Prevent Heart Disease, classified blood choles- terol levels for adults. Levels under 200 mg/dL (5.17 mmol/ L) are termed "desirable." Levels be- tween 200 mg/dL and 239 mg/dL (5.17 and 6.18 mmol/ L) have been classified "borderline-high," while levels of 240 mg/dL (6.21 mmol/ L) and Figure 1 Relationship Between Serum Cholesterol Level and CHD Death Rate (MFlFIT Screenees) N (a) & O O O r u v 10 Year CHD Death Rate (Deaths/1 .000) .A O I iiillliilllilllL u 1' 1 15:0 200 250 300 Serum Cholesterol (mg/dL) 0 From 361,662 Men Screened for MRFIT Program Population Panel Report Executive Summary above have been designated as "high." The ATP has presented a comprehensive set of recommen— dations for intervention in individuals with cho- lesterol levels above the desirable range. These recommendations emphasize that after initial screening for total cholesterol level, therapeutic decisions should be based on the level of low density lipoprotein (LDL) cholesterol (see table 1). Adult Americans with LDL-cholesterol levels that are persistently high-risk (or borderline-high- risk if definite CHD or two or more of the other major CHD risk factors listed in table 2 are pres- ent) should follow the recommendations of the ATP of the NCEP. The ATP set forth detailed recommendations indicating that dietary therapy is the mainstay of treatment. Drug therapy should generally be considered only after 6 months of intensive diet- ary therapy reinforced by the help of a health professional with special nutrition expertise (e.g., a registered dietitian), and then only if the LDL- cholesterol level remains significantly elevated. This conservative approach to drug therapy is wise because drugs can not only bring benefits but can also have deleterious effects. The potential impact of the recommendations of the ATP on the blood (serum) cholesterol dis- tribution of the adult US. population is indicated conceptually by the broken line in figure 3, page 10. These recommendations of the ATP should, over the years to come, reduce the proportion of individuals in the United States with high choles- terol levels (240 mg/ dL [6.21 mmol / L] and above), and should also reduce the proportion of indi- viduals with borderline-high cholesterol levels (200-239 mg / dL [5.17-6.18 mmol/ L]). Even in the event that the high—risk approach recommended by the ATP is largely effective, however, many people will remain at risk of CHD. The recommendations from the Population Panel of the NCEP follow. They are intended to extend the benefits of cholesterol lowering to the population as a whole by promoting adoption of eating patterns that will help lower the blood cholesterol levels of most Americans. In turn, these eating patterns should help to shift the curve representing the population distribution of cho- lesterol to the left, as shown in figure 4, page 11. As the recommended eating patterns become widely adopted, the average blood cholesterol level should decrease by approximately 10 per- cent or greater. Table 1 Recommendations of the Adult Treatment Panel of the National Cholesterol Education Program for Classification of Patients Classification Based on Total Cholesterol Classification Based" on LDL-Cholesterol <200 mg/dL (<5.17 mmol/L) Desirable Blood Cholesterol 200-239 mg/dL (5.17-6.18 mmol/L) Borderline-High Blood Cholesterol 2240 mg/dL (26.21 mmol/L) High Blood Cholesterol Source: NCEP A TP, January 1988.3 <130 mg/dL (<3.36 mmol/L) Desirable LDL-Cholesterol 130-159 mg/dL (3.36-4.11 mmol/L) Borderline-High-Risk LDL-Cholesterol 2160 mg/dL (24.13 mmol/L) High-Risk LDL-Cholesterol Population Panel Report Executive Summary Table 2 CHD Risk Factors Other Than LDL-Cholesterol - Male sex - Cigarette smoking - Hypertension measurement) - Diabetes mellitus disease - Severe obesity (230% overweight) Source: NCEP ATP, January 1988.3 - Family history of premature CHD (definite myocardial infarction or sudden death before age 55 in a parent or sibling) - Low HDL-cholesterol concentration (below 35 mg/dL confirmed by repeat - History of definite cerebrovascular or occlusive peripheral vascular The anticipated combined and compatible ef— fects of the recommendations from the Adult Treat- ment Panel and from the Population Panel of the NCEP are estimated in figure 5, page 11. Most Americans would have a desirable blood choles- terol level. Far fewer Americans would require drug therapy for persistently high blood choles- terol. The anticipated effect would be to reduce the morbidity from CHD and to produce a contin- ued or accelerated decline in the mortality rate from CHD in the United States. C. Guidelines From Other Authoritative Sources 1. International The work of many scientists has shown that atherosclerosis and CHD constitute a major health problem afflicting numerous nations of the world. The linkage of CHD to national eating patterns has been established. There is widespread inter- national consensus, based upon repeated reviews of the scientific evidence, that the average popu- lation intakes of total fat, SFA, dietary cholesterol, and food energy are excessive in many countries and should be reduced. As a result, since 1973 more than 40 groups of scientists and health pol- icy makers from other nations have recommended changes in population eating patterns with the purpose of reducing blood cholesterol. Most have focused on the prevention of CHD. These recom- mendations have been summarized by Truswell (1983),4 and in the report of the National Research Council (NRC), Diet and Health: Implications for Re- ducing Chronic Disease Risk.5 A World Health Or— ganization (WHO) study group in 1989 proposed "population nutrient goals" to control noncom- municable diseases and suggested that these be introduced as part of nutrition policy in all coun- tries.""7 These nutrient goals are remarkably simi- lar to those of the NRC 1989 and NCEP 1990. Population Panel Report Executive Summary Cholesterol Distribution in the U.S. Population (Males/Females Combined, Ages 20-74, NHANES ll 1976-80),2 and Potential Changes in the Distribution Figure 2 ‘0 Population distribution of serum cholesterol values. The borderline- high and high cutoff levels are shown as dotted lines to indicate the proportions of the population above or below 200 or 240 mg/dL (5.17 or 6.21 mmol/L). Percent of Population o o n o . . o . Illllljllllllllllllllllll O 1 00 200 300 400 Serum Cholesterol (mg/dL) Figure 3 ‘0 Expected shift in population distri— bution of serum cholesterol val- ues with widespread application of ATP guidelines. The dotted- dashed line represents an esti- mate of the effect of treating many people with elevated cholesterol levels. Percent of Population E E "\. oAIAllllllllllzlllIl-I‘Illll E 100 200 300 400 Serum Cholesterol Level (mg/dL) 10 Population Panel Report Executive Summary Cholesterol Distribution in the U.S. Population (Males/Females Combined, Ages 20-74, NHANES ll 1976-80),2 and Potential Changes in the Distribution (I) m Percent of Population & 1000 200 300 400 Serum Cholesterol Level (mg/dL) 10 ~ I .5 e- I x E ’ \\ g. I = .1 \ : o 6— I 5 \ : o. '-. \5 *5 ’ \. \‘ E 4* I "\ ‘A w I \ 2 ’ - \ \ m : 0- 2— I . E \ \ - E \ / - : \... \ 0 I I l l l l l l I T l I l i L I l l I..':I‘ — l 1 4L4 100 200 300 400 Serum Cholesterol Level (mg/dL) Figure 4 Expected shift in population dis— tribution of serum cholesterol val- ues if the recommendations of the Population Panel result in a 10% decrease in blood cholesterol of Americans. The dashed line shows the effect of the recom- mendations. Figure 5 Anticipated combined effects of the recommendations of the ATP (dotted-dashed line) and the Population Panel (dashed line). 11 Population Panel Report Executive Summary 2. United States Over the years, many reports linking CHD and diet have appeared in the United States. These have included several diet statements from the American Heart Association (AHA) issued be- tween 1961 and 1988, the 1970 and 1984 reports of the Inter-Society Commission for Heart Disease Resources concerning primary prevention of ath- erosclerotic diseases)"9 the Bethesda Conference on Prevention of Coronary Heart Disease,10 and the recent NRC report on diet and health.5 12 The dietary recommendations issued since 1983 by major health organizations in the United States are summarized in table 3. There are com- mon themes—recommendations for a lower in- take of SFA and total fat, a reduction in dietary cholesterol, an increased intake of complex carbo- hydrates, and the control of obesity. The advice given is similar from all these organizations, al- though some groups are more specific than oth- ers. Several recommend reductions of total fat intake to 30 percent or less of calories, of SFA to less than 10 percent of calories, and of dietary cholesterol to less than 300 mg per day. Population Panel Report Executive Summary Table 3 Dietary Recommendations Related to Blood Cholesterol Levels by United States Organizations Since 1983 Agency/Report Year ‘ Audience Saturated Total Cholesterol Carbohydrate Body Weight Fat Fat USDA/DHHS 1985 Public Avoid too Avoid too Avoid too Avoid too Maintain Dietary Guidelines much much much much sugar; desirable for Americans Increase weight starch & fiber NCEP-ATP 1987 Report of the Expert Panel on. . .High Blood Cholesterol in Adults Step 1 Adult <10% 330% <300mg/day 50-60% Achieve & maintain patients desirable weight Step 2 with high <7% 330% <200mg/day 50-60% blood cholesterol AHA 1988 Dietary Treatment of Hypercholesterolemia Steps 1 & 2 for patients identical to NCEP Steps 1 & 2 AHA 1988 Public <10% <30% 3300 mg/day 50-55% with Maintain best body Dietary Guidelines for emphasis on weight Healthy American Adults complex carbs. AHA 1983 Children 310% Approx. 3300 mg/day Approx. Caloric intake Diet in the Healthy 30% 55% based on growth Child rate & activity level and to maintain de- sirable body weight AAP 1986 Children Decrease 30-40% Decrease with Maintain ideal body Prudent Life—style for with moderation weight Children: Dietary Fat moderation and Cholesterol DHHS 1988 Public Reduce Reduce Reduce Increase Achieve & maintain The Surgeon General's for most complex desirable weight Report on Nutrition carbs.; and Health' Limit sugars NRC 1988 Public 310% 330% 3300 mg/day Achieve & maintain Designing Foods: Animal desirable weight Product Options in the Marketplace" NRC 1989 Public <10% 330% <300 mg/day >55% with 26 Balance food intake Diet and Health: implications for Reducing Chronic Disease Risk * A review supporting USDA/DHHS (1985) recommendations. servings grains & legumes/day, with physical activity to maintain 25 servings fruits body weight & vegetables per day " The report accepted these target levels from other authorities; it also made recommendations on marketing and policy issues and research imperatives. ,3 32,2 $331113 Population Panel Report Executive Summary III. Conclusions of the Population Panel After carefully considering the extensive sci- entific evidence linking blood cholesterol, athero- sclerosis, CHD, and diet, this panel concludes that excessive intakes of saturated fatty acids, to— tal fat, and dietary cholesterol, together with ex- cessive body weight, all contribute importantly to biologically unnecessary and undesirable eleva- tions of blood cholesterol. The panel also reaf- firms the conclusion of previous panels (AHA, ATP, NRC) that elevated levels of blood choles- terol produce a high prevalence of severe athero- sclerosis in coronary arteries, resulting in a high incidence of CHD and premature death. Accord— ingly, the panel concludes that it is important for Americans to change their eating patterns to re- duce the average intakes of saturated fatty acids, total fat, and dietary cholesterol, and to eliminate excess body weight. The panel concludes that changing eating pat- terns will influence blood cholesterol levels and that eating patterns can be changed, while pre- serving the nutritional adequacy, variety, and af- fordability of good-tasting food. The panel re- gards reduction of dietary saturated fatty acid intake from both animal and vegetable sources as being of greatest importance. The work of the National Research Council‘1 concerning the po- tential for reduction of fat in foods of animal ori- gin indicates the feasibility of change in saturated fatty acid content of foods. Furthermore, the panel agrees that observance of the Dietary Guidelines for Americans issued by the US. Department of Agriculture (USDA) and the Department of Health and Human Services (DHHS) can help promote health for individuals beyond the age of 2 years.12 Although there are challenges to implementing some of the recommended changes, the panel be- lieves that the potential benefits outweigh the ex- penditure of resources needed to achieve these changes. The panel believes that eating patterns of most Americans can change through a process of combining education for the public and actions by the many sectors of society that influence the availability, purchase, preparation, and consump- tion of foods. The panel agrees with estimates that the health benefits to be expected for the average American, based upon available evidence, approximate a 2 percent reduction in CHD risk for each 1 percent reduction in blood cholesterol level. It is from these perspectives that the Popula- tion Panel of the NCEP offers recommendations to help individuals in the United States lower their blood cholesterol levels. 15 Population Panel Report Executive Summary IV. Recommendations These recommendations are designed to en- courage and assist each individual to adopt eat- ing patterns to lower his or her blood cholesterol level and to reduce the number of people in the United States who develop or die from CHD. A blood cholesterol level under 200 mg/dL (5.17 mmol/ L) is termed desirable for adults. To help Americans learn whether they have an elevated blood cholesterol level, this panel concurs with the ATP recommendation that all adult Ameri- cans should have their blood cholesterol level measured at least every 5 years. The average level of blood cholesterol in the US. adult popu- lation is approximately 210-215 mg / dL (5.43-5.56 mmol / L). It is anticipated that the recommended changes in eating patterns will result in a reduc- tion of 10 percent or greater in the average person’s blood cholesterol level and shift the population distribution curve for blood (serum) cholesterol values as shown in figure 4, page 11. The nature of the food consumed by Ameri- cans is influenced by many factors. These recom- mendations are intended to provide guidance to many segments of the food production-consump- tion chain. Success will require adoption of these recommendations by all healthy Americans, health professionals, the food industry, educators at all levels, mass media, and many government agen- c1es. Accordingly, the panel makes the following recommendations for the entire population of healthy Americans. This population approach aims to promote healthful food choices and to make good- tasting food, lower in saturated fatty acids and cholesterol, more widely available to all Ameri- cans. Those whose blood Cholesterol levels are higher than desirable can be expected to pay the most attention and to benefit the most from these recommendations. In addition, most individuals with desirable cholesterol levels can participate in the recommended eating patterns, and expect to lower CHD risk. The recommendations in this report are compatible with the Dietary Guide- lines for Americans as set forth by the USDA and the DHHS. A. Nutrient Intake The panel concludes that health and nutrition professionals, the food industry, and the general public need specific guidance concerning intake of certain nutrients. RECOMMENDATION A. 1: The panel recommends the following pattern of nutrient intake for all healthy Americans": 0 Less than 10 percent“ of total calories from saturated fatty acids. 0 An average of 30 percent of total calories or less from all fat.+ 0 Dietary energy (calorie) levels needed to reach or maintain a desirable body weight. 0 Less than 300 mg of cholesterol per day. * Concerning the very young, as healthy children join in the eating patterns of others in the family, usually at about 2 years of age or older, they should follow the recommended nutrient and eating patterns. t Each gram of fat contains 9 Kilocalories (often called calories). A person consuming 1,500 calories daily should consume no more than 450 calories (1,500 calories x 0.30 = 450 calories) derived from all fat. At 9 calories per gram, less than 50 grams of fat (450 calories + 9 calories / gram = 50 grams) should be consumed on the average day, and less than one-third or 17 grams of the 50 gram total should be from saturated fatty acids (1,500 calories x 0.10 : 150 calories; 150 calories + 9 calories / gram 2 <17 grams). l7 Population Panel Report Executive Summary Because food intake varies from day to day, these recommendations are meant to be achieved by each individual as an average of nutrient in— take over several days. The nutrient intakes recommended are criti- cal to health-promoting eating patterns. They are essentially the same as those recommended by the American Heart Association, the National Research Council, and in the Step—One therapeu- tic diet of the ATP of the NCEP. The eating patterns that will be required in order to achieve these nutrient intakes by the public are to be at- tained gradually over time. Ultimately, changes in the food system will facilitate these changes in population-wide eating patterns. By contrast, the Step-One diet is intended to treat individuals who are at high risk of CHD because of substantially elevated blood cholesterol levels, through inten- sive nutritional counseling in a clinical setting, and with the intent of achieving a rapid and cer- tain response. What makes the Step-One diet therapeutic for those at high risk is prescription in a medical setting along with the monitoring and followup offered by health professionals. The same eating pattern is suitable for adoption by the population at large in order to achieve a popu- lation—wide reduction of blood cholesterol. It is the intent of the recommendations of the Popula- tion Panel to foster healthful eating for Ameri- cans, young and old. 1. Rationale for Nutrient Intake Recommendations This recommended pattern of nutrient intake is intended for healthy individuals. Strong scien- tific evidence indicates that attainment of each of the four recommendations will help most indi- viduals lower their blood cholesterol and, in turn, reduce their probability of developing CHD. The specific nutrient intake recommendations are based on the scientific evidence, but the exact numerical values reflect both science and prag- matism. Thus, there is Virtually unanimous agree- ment that SFA intake should be reduced. Most agree that the science base makes less than 10 18 percent of calories from SFA an appropriate level, although there is no precise guidance as to which level under 10 percent is best. For the sake of practicality, consistency, and comprehensibility, the phrase ”less than 10 percent” has been cho- sen. A similar process led to recommendations for total fat and cholesterol intakes. The available knowledge concerning the mechanisms through which these nutrients affect blood cholesterol is summarized in section V, Scientific Evidence for Recommendations Affecting the General Public. The panel’s rationale for each of the recom- mended nutrient intakes follows. a. Fat Intake Most of the US. population should reduce total dietary fat intake—by an amount that varies according to how much fat is currently con- sumed—to help achieve and maintain desirable body weight and to reduce the risk of certain diseases, particularly CHD. (See table 3, page 13, for a summary of recommendations from other authoritative groups.) Different kinds of fatty acids have different effects on blood cholesterol levels. In general, SFA raise blood cholesterol levels. Polyunsaturated fatty acids (PUFA) of the omega-6 series lower blood cholesterol levels, as do monounsaturated fatty acids (MUFA) and omega-3 PUFA, when substituted for SFA. Total Fat. The panel recommends a target for individuals of an average of 30 percent of total calories or less from total fat. The percentage of calories from total fat intake, independent of the relative content of the different types of fatty ac- ids, does not determine the level of blood choles- terol or CHD risk. As stated in the NRC report on Diet and Health: Implications for Reducing Chronic Disease Risk, “Fat intake should be reduced by curtailing the major sources of dietary fats rather than by eliminating whole categories of foods.”5 It is not necessary to resort to very low fat diets (e.g., 10—20 percent of total calories) to achieve a maximal reduction of blood cholesterol levels through dietary means, provided that intakes of saturated fatty acids are kept low. Therefore, the Population Panel Report Executive Summary panel accepts a target for individuals of an aver— age of 30 percent or less of calories from fat. The panel does not recommend severe reduction of total fat intake; however, a limit to total fat intake is a rational part of a program aimed at reducing the risk for CHD because such a limit facilitates reduction of saturated fatty acid intake, and fa- cilitates maintenance of desirable body weight. There is also evidence that suggests that a diet lower in fat may prevent certain types of can- cer.513 Survey data indicate that for children ages 1 to 5 years, the average proportion of calories de- rived from fat was 34 percent; for women ages 19 to 50 years, 37 percent; and for men ages 19 to 50, 36 percent.”17 Thus, to achieve an average intake of 30 percent of calories or less from fat, reduc- tions in calories from fat of at least 4-7 percent of total calories will be required, on average, for most Americans. For many individuals with fat intakes that are higher than average, however, an even greater reduction in fat intake will be neces— sary. Saturated Fatty Acids. The major decrease in total fat should be in calories from SFA. Data from the USDA”17 indicate that SFA, as a propor- tion of calories, average about 13.2 percent in the diets of adults ages 19 to 50 years and 13.9 percent in those of children ages 1 to 5 years. Thus, the average reduction in the percentage of calories from SFA that is required to achieve the recom- mended nutrient intake is at least 3-4 percent. In- dividuals currently deriving higher percentages of calories from SFA will need to make greater re- ductions. The greater the decrease in SFA intake, the greater will be the decline in blood cholesterol levels. Therefore, the reduction in saturated fatty acids in the diet should be as great as possible, consistent with palatability and practicality. This panel recommends a target of less than 10 percent of calories from SFA as both practical and palat- able for Americans. Other fatty acids. The remaining fatty acids, up to 20 percent of total calories, should come from unsaturated fatty acids. PUFA can provide up to, but no more than, 10 percent of total calories. The average intake of omega-6 PUFA in the American diet is about 7 percent of total calories,5'14‘17 which is an acceptable intake. Fish oil supplements gen- erally do not reduce blood cholesterol levels. Omega-3 PUFA, however, reduce blood choles- terol when substituted for SFA. The other major type of unsaturated fatty acids, MUFA, should provide the remaining dietary fat. The current average intake of MUFA for the population is ap- proximately 14—16 percent of calories. A slight re- duction in average MUFA intake can be expected because foods of animal origin containing SFA often also have substantial amounts of MUFA. Other Nutrients. Reducing fat intake will re- duce energy intake unless other nutrients replace fat. Two other major macronutrients, protein and carbohydrates, as well as many micronutrients, are of importance. The panel recommends that the intake of carbohydrates be increased to 50-60 percent of total calories, primarily by increasing the intake of complex carbohydrates. This can be achieved by increasing the intake of vegetables and fruits, and of breads, legumes, and whole grain cereals. These plant products generally contain low levels of fat and are good sources of several vitamins, minerals, and dietary fiber. Protein intake should not be increased to com— pensate for the decrease in calories derived from fat. The recommended intake of protein is be- tween 10 percent and 20 percent of calories. In general, average protein intake by adults in the United States considerably exceeds the recom- mended dietary allowance (RDA), which is 0.8 g / kg of desirable body weight for adults. Overall, the diet consumed should meet the RDA’s for all other nutrients. 19 Population Panel Report Executive Summary b. Body Weight Body weight is influenced by many factors; energy balance between caloric intake and caloric expenditure largely dictates whether excess body fat accumulates. Many health problems are re— lated to obesity. Obese people are more likely to have elevated blood cholesterol and triglyceride levels, a reduced level of HDL-cholesterol, high blood pressure, and adult-onset diabetes melli- tus, and are more likely to develop CHD indepen- dently of these other factors. Loss of excess weight and maintenance of a desirable body weight is an important way of reducing blood cholesterol lev- els. The exact dietary energy (calorie) level needed to attain or maintain desirable body weight must be individually determined from observed changes in body weight. c. Cholesterol Intake Many studies have shown that dietary choles- terol raises the blood cholesterol level. It has been estimated that with a 2,500 calorie diet, for every 100 mg/ day decrease in cholesterol intake, the blood cholesterol will decrease by about 4 mg/ dL.18 This response holds even at low intakes, and thus, the lower the cholesterol intake, the lower will be the blood cholesterol on the aver- age. There appears to be considerable inter-indi- vidual variability in response of blood cholesterol to dietary cholesterol intake. Based on the ob- served effects of dietary cholesterol intake on blood cholesterol levels, the panel concludes, as have many investigators and expert panels, that high dietary cholesterol intake contributes to the de- velopment of atherosclerosis and increased CHD risk in the American population and should be reduced. Data from the USDA”17 indicated that the average daily intake of dietary cholesterol is 304 mg and 435 mg for women and men, respec- tively. The Population Panel recommends an in- take of less than 300 mg of cholesterol per day. 20 B. Eating Patterns The nutrient intakes recommended in this report are consistent with the Dietary Guidelines for Americans as set forth by the USDA and the DHHS.12 These guidelines are suggested for most Americans. They do not apply to people who need special diets because of disease or condi- tions that interfere with normal nutrition. Such people may require special instruction from a health professional with expertise in nutritional counseling, such as a registered dietitian, in con- sultation with their own physicians. These USDA / DHHS guidelines12 are: 0 Eat a variety of foods; 0 Maintain desirable weight; 0 Avoid too much fat, saturated fatty acids, and cholesterol; 0 Eat foods with adequate starch and fiber; 0 Avoid too much sugar; 0 Avoid too much sodium; and 0 If you drink alcoholic beverages, do so in mod- eration. The first two guidelines form the framework of a good diet—eating a variety of foods to ensure getting the essential nutrients, and eating only enough calories to maintain desirable weight. The next five guidelines describe special characteris- tics of a good diet—avoiding too much fat, satu- rated fatty acids, and cholesterol; getting adequate starch and fiber; and avoiding too much sugar, sodium, and alcohol. This report focuses on the two guidelines that are particularly related to blood cholesterol and the prevention of CHD: Avoid too much fat, saturated fatty acids, and cholesterol; and main- tain desirable weight. Population Panel Report Executive Summary The guidelines also set forth the principle that reductions in energy derived from fat should be offset by increased consumption of foods contain- ing complex carbohydrates such as starch and fiber. The Population Panel recommends that between 50 percent and 60 percent of calories come from carbohydrates. Several valuable documents have been devel- oped to assist people to follow the Dietary Guide- lines for Americans. These documents can also be used to follow the recommendations in this re- port. These include four new booklets to help consumers put the Dietary Guidelines into prac- tice,19 and Dietary Guidelines and Your Diet,20 which includes “A Pattern for Daily Food Choices.” The pattern suggests daily servings from the major food groups.21 Valuable information is also con- tained in booklets and brochures available from the National Institutes of Health and the Ameri— can Heart Association. RECOMMENDATION B. 1: The panel recommends that healthy Americans, both adults and children, select, prepare, and con- sume foods that contain lower amounts of saturated fatty acids, total fat, and cholesterol. The following specific practices can help Americans, both adults and children, lower blood cholesterol levels. These food choices and prepa- ration methods form the framework of a good diet. Eating a variety of foods to get essential nutrients and only enough calories to maintain desirable weight is also important. These eating patterns are fully compatible with cultural and ethnic considerations and with personal prefer- ences for good food. 0 Fruits, vegetables, whole grain products, legumes such as beans and peas. These prod- ucts contain complex carbohydrates, fiber, and minimal amounts of saturated fatty acids. Accordingly, it is recommended that healthy Americans: Eat a greater quantity and variety of fruits, vegetables, breads, cereals, and legumes. These choices will help to meet nutritional needs for minerals, vitamins, dietary fiber (including soluble fiber), and complex carbohydrates, and to replace calories from fat. Low-fat dairy products. Dairy products con- stitute a major source of fat and saturated fatty acids in the average American diet. For this reason, it is recommended that healthy Americans: Eat more low-fat dairy products such as skim or low-fat milk and skim or low-fat milk products. Choose them, in place of regular whole milk, cheese, cream, ice cream, butter, or other butterfat-rich products, to help meet nutritional needs for calcium, protein, and vitamin D (skim milk is an excellent source of calcium with minimal accompanying fat). Low-fat meat, poultry, fish. Red meats, both in surface fat and fat within the meat tissue, provide a substantial proportion of fat and saturated fatty acids for the average Ameri- can. Choosing lean cuts of beef, pork, veal, or lamb, removing surface fat, and substituting fish or skinless poultry can significantly re— duce saturated fatty acid intake. Thus, the panel recommends that healthy Americans: Eat moderate amounts (e.g., about 6 ounces per day, cooked) of trimmed, lean red meat, poultry without skin, or fish in place of choices high in saturated fatty acids. These choices will help meet nutritional needs for protein, iron, and zinc. Cholesterol is found only in products from animals. - Organ meats—liver, sweetbreads, kidneys, and brain—are very rich in cholesterol, and consumption should be limited. Eggs. Egg yolk serves as an important source of dietary cholesterol for most Americans. An average large egg yolk contains 213 mg of cholesterol. These facts lead the panel to rec- ommend that healthy Americans: 21 Population Panel Report Executive Summary 22 Eat egg yolks only in moderation. Egg whites do not contain cholesterol and they can be eaten often. Fats and oils. All vegetable products are free of cholesterol. Many oils come from vege- table products. Most contain large propor— tions of monounsaturated and polyunsatu- rated fatty acids and small proportions of satu- rated fatty acids. Tropical oils such as palm kernel oil, coconut oil, and palm oil contain relatively large proportions of saturated fatty acids. Accordingly, the panel recommends that healthy Americans: Use oils, margarines, and shortenings with vegetable oils containing primarily unsatu- rated fatty acids instead of saturated fatty acids. Consumption of tropical oils, especially the most highly saturated palm kernel and coconut oils, should be minimized. Baked goods. Most commercially prepared baked goods contain ingredients composed of saturated oils or fats; many contain egg yolks. For these reasons, the panel recommends that healthy Americans: Choose prepared baked goods that have been made with unsaturated vegetable oils and, at most, small amounts of egg. Breads and most rolls are low in saturated fatty acids and cho- lesterol while other commercial products such as croissants, cakes, biscuits, doughnuts, and muffins are often high in saturated fatty acids. Convenience Foods. Increasingly, Americans are consuming meals, entrees, mixes, and other packaged foods that are conveniently recon— stituted and / or reheated. While many of these products have constituents containing large proportions of saturated fatty acid, many do not. Accordingly, it is recommended that healthy Americans: Choose ”convenience foods” guided by low saturated fatty acid, total fat, and choles- terol content as well as by cost considera- tions. Food labels. Increasingly, valuable informa- tion is presented on food labels concerning amounts and sources of saturated fatty acids, fat, cholesterol, and other nutrients. For this reason, the panel recommends that all healthy Americans: Know your food by reading food labels, in- cluding both ingredient and nutrition infor- mation. Choose more often foods with lower amounts or proportions of saturated fatty ac- ids and / or fat and of cholesterol. Saturated fatty acids and cholesterol are often found together in foods. Saturated fatty acids are provided primarily by animal products such as the fat in meat, butter, whole milk, cream, cheese, and ice cream. These foods are also major sources of cholesterol. Food preparation. Preparation of food can significantly increase the proportion of calo- ries from all fat and from saturated fatty ac- ids. For this reason, it is recommended that healthy Americans: Keep use of fats to a minimum when prepar- ing foods. Use the smallest amount possible of fat and fatty foods as ingredients. Cook foods in ways that minimize or eliminate fat content, such as broiling, boiling, steaming, microwaving, or baking, instead of frying in fats; Use smaller amounts of ingredients high in saturated fatty acids. Where fats are neces- sary, substitute fats high in unsaturated fatty acids for fats high in saturated fatty acids; substitute equal or smaller amounts of un- saturated margarine or oil for butter; Use low-fat alternatives in food preparation. For example, substitute 1%, skim, or reconsti- tuted nonfat dry milk for whole milk or higher fat choices. Use low-fat yogurt, buttermilk, or evaporated skim milk in place of sour cream, cream, or cream cheese. Eating out. Americans, on average, derive a significant portion of their nutrition outside of the home. Thus, the panel recommends that healthy Americans: Population Panel Report Executive Summary In restaurants, select menu items that are low in saturated fatty acids, total fat, and choles- terol as well as cooked foods that are baked, boiled, or broiled without fat. Ask for lean cuts of meat trimmed of excess fat. Request that sauces and salad dressings be served in separate containers if high in fat and use them sparingly. Ask for information on ingredients and preparation of restaurant food. When eating out and on other social occasions, choose foods with less fat—e.g., larger amounts of vegetables, fruits, and grain products, and smaller amounts of foods that are likely to be high in saturated fatty acids. - Fast foods. While increasing numbers of ”fast food” outlets have choices in which low propor- tions of calories are derived from saturated fatty acids, many others contain large amounts of saturated fatty acids and cho- lesterol. For these reasons, the panel rec- ommends that healthy Americans: Ask for information on the fat and satu- rated fatty acid content of ”fast food” se- lections and choose foods that are nutri- tious and low in saturated fatty acids, to- tal fat, and cholesterol. Overly simple solutions. An habitual pat- tern of eating that is consistently low in satu- rated fatty acids, total fat, and cholesterol is recommended. Focusing solely on the elimi- nation of a single food such as egg yolks, however, is not necessary and will not, by itself, achieve sufficient blood cholesterol lowering. As indicated earlier, skim or low- fat dairy products and small portions of trimmed, lean red meat are desirable and nu- tritionally valuable. These foods and eggs in moderation can all be part of a blood choles- terol—lowering eating pattern. The panel there- fore recommends that all healthy Americans: Recognize that no single food or supplement is the answer to achieving a desirable blood cholesterol level. - Fish oil supplementation will not lower blood cholesterol levels in most people. However, consumption of fish, a food low in saturated fatty acids, instead of foods that are higher in saturated fatty acids, is desirable. - Dietary fiber supplements are not a pana- cea for blood cholesterol problems. Foods rich in soluble dietary fiber are, however, a useful addition to a low saturated fatty acid, low-fat, and low-cholesterol eating pattern. - Alcohol is not recommended as a means of preventing CHD because it has not been shown to be effective and because of the potentially harmful effects of excessive al- cohol intake. RECOMMENDATION B. 2: Thefgpanel urges the public to recognizei‘that an elevated blood cholesterol level is one of the important modi- fiable CHD risk factors together with smoke: ' ing, high blood pressure, Eiexcess body weight, and physical inactivity. The recommended eating patterns should be considered part of a personal health program Which also emphasizes the following risk factors for coronary heart disease. Smoking, high blood pressure. Being a non— smoker, and preventing and controlling high blood pressure are both important factors in prevention of CHD. Excess body weight. It is important for all healthy Americans to achieve and maintain desirable body weight by limiting energy (calorie) intake and by engaging in regular moderate exercise. Maintenance of desirable body weight is a useful means of controlling blood cholesterol. Physical inactivity. Apart from beneficial effects on body weight and on blood pressure, regular exercise throughout life is associated with a lower risk of CHD. 23 Population Panel Report Executive Summary C. Healthy Children and Adolescents RECOMMENDATION C. 1: The panel rec- ommends that healthy children follow the recommended eating patterns that are lower in saturated fatty acids, total fat, and choles- terol as they begin to eat with the family, usually at 2 years of age or older. The Population Panel has reviewed evidence concerning benefits and safety for children and adolescents of an eating pattern that is lower in saturated fatty acids, total fat, and cholesterol than the usual American diet. The panel also recog- nizes that the caloric and nutrient needs of chil- dren are critical for supporting growth and de- velopment. Since eating habits developed during childhood can influence lifetime practices, the panel urges prudent movement to the recom- mended eating pattern. Healthy children should be allowed to share in family food choices, reci- pes, and menus. Adolescents are particularly en- couraged to maintain a low saturated fatty acid, low total fat, and low-cholesterol eating pattern. Infants and children under the age of 2 years have dietary requirements different from those of older people. Infants whose diet is primarily mother’s milk or formula often appropriately consume 40 percent or more of calories from fat. The Population Panel recommends that this well- established pattern of infant nutrition be encour- aged. Care must be taken to ensure sufficient energy and nutrient intake to meet the needs of the growing child. A forthcoming report from the Expert Panel on Blood Cholesterol Levels in Chil- dren and Adolescents will deal with strategies for detection, evaluation, and treatment of children and adolescents at high risk of later CHD because of high blood cholesterol levels and will provide additional details about implementation of strate- gies for encouraging desirable eating patterns for healthy children. 24 D. Special Groups RECOMMENDATION D. 1: The panel recommends that particular attention be paid to nutritional concerns of special segments of the population. The eating patterns of specific groups of Americans should be considered. Population groups with special dietary concerns include women, older Americans, cultural and ethnic groups, low-income groups, and individuals with special nutritional needs. 0 Women. Women, like men, can and should adopt the recommended eating patterns that are lower in saturated fatty acids, total fat, and cholesterol as a means of reducing their likelihood of disease. The special needs of women for nutrients such as calcium, iron, and zinc can be met within these eating pat- terns. 0 The elderly. For most individuals 65 years of age and older, the recommended eating pat- terns that are lower in saturated fatty acids, total fat, and cholesterol, that help maintain desirable body weight, and that are nutrition- ally adequate, are appropriate. Special atten- tion, possibly including nutrition guidance from a qualified health professional with spe- cial nutrition expertise, may be needed for some elderly people who have special nutri— tional needs or who are limited in their ability to procure, prepare, or consume food. 0 Cultural groups. Foods and menus should accommodate cultural, regional, and ethnic preferences, while incorporating the recom- mended intakes of saturated fatty acid, total fat, and cholesterol. 0 Low-income groups. Low-cost foods meet- ing the recommended eating patterns are avail- able; individuals of lesser economic means can and should select these to improve their diets and share in better health. Population Panel Report Executive Summary 0 People with special nutritional needs. Health professionals should be attentive to individu- als who have special nutritional needs, such as pregnant or lactating women, patients with food allergies, and many patients with diabe- tes mellitus, or chronic kidney, heart, or liver disease, who often need counseling from a health professional with special nutritional ex- pertise. E. Health Professionals RECOMMENDATION E. 1: The panel rec- ommends that health professionals advise patients and the public to attain the recom- mended eating patterns. Physicians, nurses, registered dietitians, nu- trition and health educators, pharmacists, and other health professionals have the opportunity to be important influences on patients and the public concerning the attainment of the panel’s recommendations. Health professionals should both practice and advocate the recommended eating patterns. Initial and continuing nutrition education for health professionals should empha- size the panel’s recommendations. Health pro- fessionals, as needed, should obtain assistance from others with special nutrition counseling ex- pertise to facilitate achievement by patients and the public of the recommended eating patterns. In particular, health professionals should: 0 Ensure that adult patients have their blood cholesterol measured accurately and that the meaning of the results is clearly explained in keeping with ATP guidelines; 0 Encourage and counsel their patients, as members of the public, to follow eating pat- terns that are low in saturated fatty acids, total fat, and cholesterol but that are nutri- tionally adequate; 0 Support the use of more effective communica- tion approaches for populations such as low- income, low-education, and minority groups, encouraging them to adopt these eating pat- terns; Provide shopping and food preparation guide- lines that include economical food alterna- tives that are lower in saturated fatty acids, total fat, and cholesterol and that incorporate cultural, ethnic, and personal food preferences; Develop simple dietary self-assessment and self-monitoring techniques to help individu- als evaluate and monitor their own eating patterns; Work with industry, government, and volun- tary groups to improve, expand, and simplify consumer—oriented nutrition information, advertising, and labeling; Encourage health departments, hospitals, and clinics to provide nutrition education and serv- ices consistent with the nutrient intakes and eating patterns recommended by this panel through efforts such as printed materials, videotapes, and nutrition information serv- ices; Encourage all medical and other health pro- fessional schools to incorporate educational components consonant With the eating pat- terns and principles recommended by the panel; Work with health care agencies such as the medical centers of the Department of Veter- ans Affairs, the military health care system, private and public hospitals, local neighbor- hood ambulatory health centers, and other health care delivery organizations, to help patients and staff adopt and follow the eating patterns recommended by the Population Panel; Identify individuals with special nutritional needs or eating problems who may benefit from assessment and intervention by a quali- fied health professional with expertise in nu- trition counseling such as a registered dieti- tian; and Serve as role models for the public by adher- ing to the recommended eating patterns. 25 Population Panel Report Executive Summary F. The Food Industry What people eat is influenced by many fac- tors. These include both individual factors and the nutritional environment of the Nation. Indi- vidual factors include the variety of cultural heri- tages, economic factors, the availability of food, the taste of food, and knowledge about food. The environment includes a broad array of influences on the food chain. Recognizing the influence of each of these factors on the food that Americans eat, the panel makes the following recommenda- tions concerning the diverse elements in the US. food chain. RECOMMENDATION F. 1: The panel rec- ommends that food producers, manufacturers, and distributors increase the availability of good-tasting foods that are lower in saturated fatty acids, total fat, and cholesterol. 0 Encourage food industry and agricultural commodity groups to adopt products, poli- cies, and positions consistent with these rec- ommendations while assuring both continued responsiveness to consumer desires and nec- essary profitability; and 0 Provide professional education materials, and consumer brochures, cookbooks, and recipes, as well as other print and nonprint educa- tional materials indicating ways of practicing the recommended eating patterns. RECOMMENDATION F. 2: The panel rec— ommends that the food industry participate actively in helping the public attain desir- able eating patterns through labeling and advertising activities. This can be accomplished through the follow- ing activities. 0 Expand efforts to produce, manufacture, and market animal products lower in saturated fatty acids, total fat, and cholesterol with par— ticular emphasis on leaner cuts of meat and lower fat dairy products; - Continue efforts by the agriculture industry to produce, manufacture, and market proc- essed plant products containing smaller amounts of saturated fatty acids, and larger amounts of complex carbohydrate and die- tary fiber, including soluble fiber; 0 Continue development of safe food preserva- tion techniques suitable for products contain- ing unsaturated fatty acids; 0 Continue development of methods for mass preparation of food containing lower levels of saturated fatty acids, total fat, and cholesterol; 0 Continue development of foods and menus that will help people attain the recommended intakes of saturated fatty acids, total fat, and cholesterol and that will ensure adequate nu- trient intakes; 26 This can be accomplished through the follow- ing activities. 0 Promote foods that are low in saturated fatty acids, total fat, and cholesterol, working with the advertising industry and the media to ensure that accurate messages reach large segments of the public; 0 Provide comprehensible quantitative informa- tion on most food labels concerning saturated fatty acids, total fat, cholesterol, and calories to enable consumers to make informed choices; 0 Avoid misleading the public through adver- tising or product labeling (e.g., refrain from promoting the ”no cholesterol” claim for plant origin products when these products contain relatively large amounts of fat, especially satu— rated fatty acids, and avoid making health claims that are not supported by scientific evi- dence); 0 Publicize the good taste and economy as well as the health-promoting characteristics of an eating pattern low in saturated fatty acids, total fat, and cholesterol; and 0 Encourage hard-to-reach segments of the population such as low-income, low-educa- tion, low-literacy, and minority groups to choose food products that are low in satu- rated fatty acids, total fat, and cholesterol. Population Panel Report Executive Summary RECOMMENDATION F. 3: The panel rec- ommends that food vendors and other food distribution sites participate actively in the national effort. This can be accomplished through the fol— lowing activities. 0 Develop and disseminate point-of-purchase information in individual grocery stores, su- permarket chains, restaurants, and cafeterias to identify foods low in saturated fatty acids, total fat, and cholesterol; 0 Label, promote, and expand the selection of food choices that are lower in saturated fatty acids, total fat, and cholesterol in places pro— viding food to large numbers of people such as institutional food services, restaurants, convenience or ”fast food” outlets, schools, worksites, government agencies, hospitals, transportation services, catering services, and other feeding programs; 0 Expand the availability and encourage the selection of foods that are lower in saturated fatty acids, total fat, and cholesterol in gov- ernment-subsidized or -supervised food pro- grams (e.g., school lunch programs); and 0 Continue to develop ethnically and culturally appropriate food selections that are lower in saturated fatty acids, total fat, and cholesterol. RECOMMENDATION F. 4: The panel rec- ‘ ommends that the food industry, including food and animal scientists, food technolo- gists, and nutritionists, continue to develop and modify foods to help the public meet the recommended eating patterns. This can be accomplished through the follow- ing activities. 0 Intensify research and development of food products that are lower in saturated fatty ac- ids, total fat, and cholesterol; 0 Continue development of economically fea- sible uses of food processing by-products— such as meat trimmings—containing saturated fatty acids, fats, and cholesterol, other than as human food; and 0 Assure that as substitutes for food compo- nents such as fat are developed, there is clear evidence of safety for human consumption. G. Mass Media RECOMMENDATION G. 1: The panel rec- ommends that the mass media provide infor- mation on a lower saturated fatty acid, Iotver total fat, and lower cholesterol eating pattern. Through their news, information, entertain- ment, and advertising policies and programming, the mass media have the ability to influence large numbers of people. As critical channels of com- munication to the public, the mass media are ex- tremely important allies in the effort to reduce blood cholesterol levels throughout the popula- tion. H. Government RECOMMENDATION H. 1: The panel rec- ommends that government facilitate attain- ment of healthful eating patterns by modify- ing policies and approaches. Federal, state, and local governments are re- sponsible for many programs and policies related to nutrition and to health. The following govern- mental activities Will help promote cholesterol- lowering eating patterns. 0 Increase collaboration among government agencies—cg, the USDA, the Federal Trade Commission, the Federal Communications Commission, the US. Department of Veter- ans Affairs, and the DHHS including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the Centers for 27 Population Panel Report Executive Summary Disease Control—to provide consistent, coor— dinated nutrition statements and policies em— phasizing low saturated fatty acid, low-fat, and low—cholesterol eating patterns; 0 Help consumers make informed choices through expansion and standardization of food labeling requirements, especially through collaborative efforts of the FDA and USDA with the food industry, to include on most packaged foods easily comprehensible labels that clearly identify, among other nutritional characteristics, the content of saturated fatty acids, total fat, and cholesterol, as well as total calories; 0 Develop, implement, and educate consumers concerning quantitative definitions for such terms as ”lean,” ”low-fat,” ”low in saturated fatty acids,” and ”lite”; 0 Improve labeling of meat to help consumers select lean cuts; 0 Increase state and federal government efforts to provide consistent nutrition education and food choice guidance for the public empha- sizing the desirability of foods with low-satu- rated fatty acid, low total-fat and low-choles- terol content; and 0 Revise food-related policies to stimulate pro- duction and distribution of foods low in satu- rated fatty acids, total fat, and cholesterol (e. g., the recent encouraging movement toward reduction of saturated fatty acid content of school lunch programs). I. Educational Systems Attainment of lower blood cholesterol levels and reduced risk of CHD will be enhanced if educational programs at all levels—elementary through high school grades, vocational schools, colleges, universities, and medical schools—in- crease nutrition education. Accordingly, the panel recommends a focus on low saturated fatty acid, low-fat, and low-cholesterol eating patterns in the following nutrition education materials and ac- tivities: 0 Curricula in health education, science, and home economics classes as appropriate for kindergarten through 12th grades; 0 Curricula of culinary arts education programs emphasizing purchase, preparation, and pres- entation of foods and menus low in saturated fatty acids, total fat, and cholesterol; 0 Curricula of university food science depart- ments, including consideration of how ad- vances in molecular biology, genetic, and pro- duction techniques can facilitate development of new food products with reduced saturated fatty acid, total fat, and cholesterol content; 0 Curricula of college and university under- graduate programs, especially biological sci- ence, health, nutrition, and physical educa- tion; and 0 Curricula of all pre- and postdoctoral physi- cian and other health professional education programs (e.g., for nurses, dietitians, and pharmacists). RECOMMENDATION 1. 1: The panel recom- mends that all public and private educational systems become active partners by dissemi- nating information about the role of eating patterns in CHD prevention. RECOMMENDATION 1. 2: The panel recom- mends that existing nutrition education programs expand and be compatible with the recommended eating patterns, and that mes- sages from major organizations concerning health-promoting eating patterns be consistent. 28 Many organizations already offer nutrition education programs to help Americans reduce cholesterol levels or meet other dietary goals. Examples are programs offered or supported by voluntary organizations (e.g., American Heart Population Panel Report Executive Summary Association, American Cancer Society) or by fed— eral, state, or local government agencies. Educa— tion programs offered through the network of USDA’s Extension Service can effectively com- municate nutrition information to targeted audi- ences. Divergent messages can confuse the pub- lic; consistent, coherent information is needed. I. Measurement of Blood Cholesterol RECOMMENDATION]. 1: The panel rec- ommends that public screening for blood cholesterol be undertaken only under condi- tions that ensure adherence to high quality standards. Measurement of blood cholesterol serves to augment awareness of elevated blood cholesterol as a personal health problem. Recognizing the vital importance of cholesterol awareness, the N CEP has promoted a broadly based public edu- cation program—"Know Your Cholesterol Num- ber”—to encourage all adult Americans to know their blood cholesterol level. The ATP recommended that all American adults have their blood cholesterol measured at least once every 5 years. Cholesterol measure- ments should meet the accuracy and precision standards of the Laboratory Standardization Panel. The usual approach to detecting high blood cho- lesterol is through the physician’s office. In addi- tion, public screening provides the possibility of detecting large numbers of individuals with high blood cholesterol. However, the reliability of cho- lesterol measurements, the education of partici- pants, and proper referral and followup in public screening programs all need special attention. Only under specific conditions should gen- eral public screening for blood cholesterol be used to supplement screening in the health care set- ting. The NHLBI Workshop Regarding Public Screening for Measuring Blood Cholesterol22 rec- ommended the following criteria for public screening. 0 Use recruitment approaches that attract all adult segments of the community and develop special approaches for harder-to-reach target groups. These include men, younger adults, low-income or low-education groups, and minorities; 0 Evaluate the performance of each cholesterol analyzer before conducting a public choles- terol screening, and document ongoing inter- nal and external quality control procedures, to ensure that cholesterol measurements are precise and accurate, and that they meet the standards of the Laboratory Standardization Panel of the NCEP; 0 Ensure that public screening programs are managed by staff trained and supervised by appropriate health professionals and are sup- ported by a qualified health institution and that the quality of all aspects of screening programs is evaluated; 0 Provide cholesterol screening at a reasonable cost to the participants, with moderation of the cost for certain low-income group partici- pants as necessary; 0 Provide reliable verbal and printed educa- tional information about cholesterol levels from knowledgeable staff, so that individuals understand the meaning and limitations of a single cholesterol measurement, receive in- formation on dietary practices to lower cho- lesterol, and are given clear instructions with respect to their own medical followup; 0 Recommend referrals on the basis of the NCEP guidelines shown in table 4, page 30; and 0 Emphasize that screening is not a substitute for health care and cannot replace medical monitoring of blood cholesterol levels of indi- viduals already under treatment. Recommendations for screening children and adolescents and for managing younger people with elevated cholesterol levels will emerge later from the NCEP’s Expert Panel on Blood Choles— terol Levels in Children and Adolescents. 29 Population Panel Report Executive Summary Table 4 Guidelines for Referral of People Based on Their Blood Cholesterol Level Blood Total Cholesterol Level L‘ Recommended Action Greater than or equal to 240 mg/dL (High) Between 200 and 239 mg/dL (Borderline-High) Less than 200 mg/dL (Desirable) *lndividuals should be seen by their physicians within 2 months. Source: NCEP ATP, January 19883 Refer to physician for followup.* Refer to physician for iollowup* if history of coronary heart disease (CHD) or if two or more other CHD risk factors (excluding HDL-cholesterol) detected on interview (see table 2, page 9). If no reported history of CHD or less than two other risk factors, refer to physician within 1 year for repeat cholesterol measurement. Recommend a repeat blood cholesterol followup in 5 years. K. Research and Surveillance RECOMMENDATION K. 1: The panel recommends that research and evaluation on the relationships between food and health continue and that the panel’s recommenda- tions be reconsidered in a timely manner as ' new scientific information becomes available. The following specific activities should be undertaken: 30 Continue efforts to clarify even further the role and the interactions of dietary compo- nents and nutrients, and blood lipids, athero- sclerosis, and CHD; Improve analytical methods for food compo- sition and continue development and applica- tion of the National Nutrient Databank of commodity and commercial products, includ- ing brand name information as appropriate to provide reliable information about nutrient composition of foods consumed by Ameri- cans; Collect and evaluate data, individual and so- cietal, pertaining to dietary change along with evaluations of effects on CHD and other health status indicators. These data should include information on food production, processing, and consumption patterns and costs; popula- tion levels of blood cholesterol; and trends in cause-specific morbidity and mortality. In— formation concerning the efficacy of reaching all segments of the population should be Population Panel Report Executive Summary collected at the national, state, regional, and local levels. Many of these databases are on- going through the work of government agen- cies—e.g., NHANES surveys; National Cen- ter for Health Statistics (NCHS) mortality sta- tistics; FDA/NHLBI consumer and NHLBI health professional surveys; FDA total diet surveys; USDA nationwide food consump- tion surveys; state-based behavioral risk fac- tor surveys—and should be continued or im- proved, while other data needs will require development of new monitoring systems; Expand research and development related to the reduction or alteration of fat content in foods of animal origin as recommended in the National Research Council report, Designing Foods;11 and Continue to identify, develop, and evaluate effective nutrition education and communica- tion methods. 31 Population Panel Report Executive Summary V. Glossary AHA ATP CHD DHHS FDA HDL LDL LSP MRFIT MUFA N CEP NCHS NHANES NHLBI NIH NRC PUFA RDA SFA USDA American Heart Association Adult Treatment Panel coronary heart disease United States Department of Health and Human Services Food and Drug Administration high density lipoprotein low density lipoprotein Laboratory Standardization Panel Multiple Risk Factor Intervention Trial monounsaturated fatty acids National Cholesterol Education Program National Center for Health Statistics National Health and Nutrition Examination Survey National Heart, Lung, and Blood Institute National Institutes of Health National Research Council polyunsaturated fatty acids recommended dietary allowance saturated fatty acids United States Department of Agriculture 33 Population Panel Report Executive Summary VI. Bibliography 1. MRFIT Research Group, personal communi- cation, 1989. 2. National Center for Health Statistics— National Heart, Lung, and Blood Institute Collaborative Lipid Group. Trends in serum cholesterol level among US. adults aged 20- 74 years. Data from the National Health and Nutrition Examination Survey, 1960 to 1980. journal of the American Medical Association 257:937-42, 1987. 3. National Cholesterol Education Program. Report of the Expert Panel on Detection, Evalu- ation, and Treatment of High Blood Cholesterol in Adults. Bethesda, MD: US. Department of Health and Human Services, Public Health Service, National Institutes of Health, Na- tional Heart, Lung, and Blood Institute, NIH Pub. N 0. 88-2925, January 1988. 4. Truswell AS. The development of dietary guidelines. Food Technology in Australia 35:498-502, 1983. 5. National Research Council. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press, 1989. 6. Gyarfas 1, Stanley K. Diet and chronic dis- eases: A global perspective. Acta Cardiol— ogica XLIV:487-89, 1989. 7. World Health Organization Study Group on Diet, Nutrition, and Prevention of Non- communicable Diseases. Diet and chronic diseases: A global perspective (in press.) 8. Inter-Society Commission for Heart Disease Resources. Primary prevention of the ath- erosclerotic diseases. Circulation 42:A55, 1970. 9. Inter-Society Commission for Heart Disease Resources. Optimal resource for primary prevention of atherosclerotic diseases. Circu- lation 70:155A—96A, 1984. 10. 11. 12. 13. 14. 15. American College of Cardiology. Eleventh Bethesda Conference: Prevention of coro- nary heart disease, September 27—28, 1980, Bethesda, MD. American journal of Cardiol— ogy 472713-76, 1981. National Research Council, Committee on Technological Options to Improve the Nutritional Attributes of Animal Products, Board on Agriculture. Designing Foods: Animal Products Options in the Marketplace. Washington, DC: National Academy Press, 1988. US. Department of Agriculture / Depart- ment of Health and Human Services. Nu- trition and Your Health: Dietary Guidelines for Americans, 2nd ed. Washington, DC: US. Government Printing Office, HG-232, 1985. National Cancer Institute. Cancer Control Objectives for the Nation—1985-2000. NCI Monographs, No.2. Bethesda, MD: US. Department of Health and Human Services, Public Health Service, National Institutes of Health, 1986. Human Nutrition Information Service. Nationwide Food Consumption Survey: Con— tinuing Survey of Food Intakes by Individuals, Women 19—50 Years and Their Children 1-5 Years, 1 Day. Hyattsville, MD: US. Depart- ment of Agriculture, CSFII Report No. 85-1, November 1985. Human Nutrition Information Service. Na- tionwide Food Consumption Survey: Continu- ing Survey of Food Intakes by Individuals, Men 19—50 Years, 1 Day. Hyattsville, MD: US. Department of Agriculture, CSFII Report No. 85-3, 1985. 35 Population Panel Report Executive Summary 16. 17. 18. 36 Human Nutrition Information Service. Nationwide Food Consumption Survey: Con— tinuing Survey of Food Intakes by Individuals, Women 19-50 Years and Their Children 1—5 Years, 4 Days, 1985. Hyattsville, MD: US. Department of Agriculture, CSFII Report No. 85-4, 1985. Human Nutrition Information Service. Nationwide Food Consumption Survey: Con- tinuing Survey of Food Intakes by Individuals, Women 19—50 Years and Their Children 1-5 Years, 4 Days, 1986. Hyattsville, MD: US. Department of Agriculture, CSFII Report No. 86-3, 1986. Grundy SM, Barrett-Connor E, Rudel LL. Workshop on the impact of dietary choles- terol on plasma lipoproteins and atherogenesis. Arteriosclerosis 8:95-101, 1988. 19. 20. 21. 22. Human Nutrition Information Service. Dietary Guidelines and Your Diet: Preparing Foods and Planning Menus; Making Bag Lunches, Snacks and Desserts; Shopping for Food and Making Meals in Minutes; Eating Better When Eating Out. Hyattsville, MD: US. Department of Agriculture, HG-232 #8- 11, 1989. Human Nutrition Information Service. Dietary Guidelines and Your Diet. Hyattsville, MD: US. Department of Agriculture, HG-232 #1-7, 1986. Cronin F], Shaw SM, Krebs-Smith SM, et a1. Developing a food guidance system to implement the dietary guidelines. journal of Nutrition Education 192282-302, 1987. National Heart, Lung, and Blood Institute. Recommendations regarding public screen- ing for measuring blood cholesterol: Sum- mary of a National Heart, Lung, and Blood Institute workshop, October 1988. Archives of Internal Medicine 149:2650-54, 1989. ma 4 123‘ IIflllllllllllllllllllllllllllllllull DISCRIMINATION PROHIBITED: Under provisions of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimina- tion under any program or activity (or, on the basis of sex, with respect to any education program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Therefore, the National Heart, Lung, and Blood Institute must be operated in compliance with these laws and Executive Orders. NIH Publication No. 90-3047 November 1990 Q!