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In the Matter of:
Dietary Guidelines Advisory Committee Meeting Transcript
Friday, June 18, 1999
Economic Research Service
1800 M Street, N.W.
Waugh Auditorium
Washington, D.C.
Pages: 582 through 717
HERITAGE REPORTING CORPORATION
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The meeting in the above-entitled matter was convened, pursuant to Notice, at 9:05 a.m.
IN ATTENDANCE
CUTBERTO GARZA, M.D., Ph.D.
Vice Provost and Professor, Cornell University
Associate Director, Food and Nutrition
Programme, United Nations University
SHIRLEY WATKINS
USDA Under Secretary, Food and Nutrition Services
EILEEN KENNEDY, D.S.C.
SUZANNE P. MURPHY, Ph.D., R.D.
Researcher, Cancer Research Center of Hawaii
University of Hawaii
LINDA MEYERS, Ph.D.
HHS/OPHS
CAROL W. SUITOR
SCOTT M. GRUNDY, M.D., Ph.D.
Chair, Department of Clinical Nutrition
Director, Center for Human Nutrition
University of Texas Southwestern Medical
Center at Dallas
SHIRIKI K. KUMANYIKA, Ph.D., M.P.H., R.D.
Associate Dean for Health Promotion and Disease Prevention
University of Pennsylvania School of Medicine
Center for Clinical Epidemiology and Biostatistics
ROLAND L. WEINSIER, M.D., Dr.P.H.
Chair and Professor, Departments of Nutrition Sciences and Medicine
School of Medicine
University of Alabama at Birmingham
LESLEY FELS TINKER, Ph.D., R.D.
Assistant Member, Fred Hutchinson Cancer Research Center
Affiliate Assistant Professor
Department of Health Sciences
University of Washington
JOAN LYON, M.S., R.D., L.D.
HHS/OPHS
ALYSON ESCOBAR, M.S., R.D.
USDA/CNPP
SHANTHY BOWMAN, Ph.D.
USDA / Agrciltural Research Service
KATHRYN McMURRY, M.S.
HHS/OPHS
RACHEL K. JOHNSON, Ph.D., M.P.H., R.D.
Interim Associate Dean, College of Agriculture and Life Sciences
Associate Professor, Nutrition Food Sciences
University of Vermont
RICHARD J. DECKELBAUM, M.D.
Director, Institute of Human Nutrition
Columbia University College of Physicians and Surgeons
ALICE H. LICHTENSTEIN, D.Sc.
Professor, Tufts University School of Nutrition Science and Policy
Senior Scientist
Jean Mayer USDA Human Nutrition Research Center on Aging
Tufts University
MEIR J. STAMPFER, M.D., Dr.P.H.
Professor of Epidemiology and Nutrition
Harvard School of Public Health
Associate Professor of Medicine
Harvard Medical School
CAROLE DAVIS, M.S., R.D.
USDA/CNPP
DR. GARZA: Good morning. And welcome to the third session of this committee meeting. Before we get started with -- with today's agenda, there are just a few housekeeping issues that I need to take care of. The first is the fourth meeting of the committee will very likely be in this room, but we're still trying to confirm that. So please watch the Federal Register to get the definite location for the next meeting.
Second, I wanted to remind all of the non-committee members who are present that if you have any comments to make on either anything that you have heard or not heard, to urge you to please send your written comments to Shanty and not directly to members of the committee to assure that in fact all of us can have the benefits of those comments because she will then distribute them to all -- all of the committee members. If you don't do that and follow that procedure, then there is no effective mechanism for getting those comments into the public record. So please make sure that you refer those directly to her.
The fifth meeting, which we hope we don't hold -- and I want to -- I want to underline that. Our intention is to finish up in September -- again, will very likely be held here. But please read the Federal Register for the final -- the final location of -- of that meeting.
And then we're going to start off with looking at some -- some specific issues that were left over from yesterday and then move from there to the more general discussion of the guidelines and how they might be most appropriately configured or presented.
But before I turn to Suzanne and giving her a chance to get the overhead ready for reconsidering the first bullet, I want to welcome Under Secretary Shirley Watkins, Under Secretary for Food and Nutrition Services who will be joining us this morning. I'm not sure whether she will be here for all of the session --
UNDER SECRETARY WATKINS: I will be here for all of the session.
DR. GARZA: Very good. Welcome we're very pleased to have you here.
UNDER SECRETARY WATKINS: Thank you.
DR. GARZA: And so I don't think we have anyone else that we should recognize. So, Suzanne, you're next.
(Laughter.)
DR. GARZA: I meant as Shirley, dignitaries I'm going to get in trouble for not noticing. That didn't come out quite the way we intended, I know. That happens from doing e-mail at 5:30 in the morning.
DR. MURPHY: Well, we had interesting working dinner last night. And I have for your consideration some revisions to the first guideline as it is now called. I don't want it to be Suzanne's guideline anymore please. And it's definitely no longer a variety guideline.
One decision that I think we have tentatively taken is that the text of this first guideline will include the current version of the food guide pyramid, although we can certainly open that for discussion again. But the consensus of the members that I've talked with at least is that it is appropriate and indeed almost necessary to include that text -- to include the pyramid itself in the text.
And once we took that decision, that seemed to lead us to some ideas about the actual wording of the guideline. And I have three to show you and to then open for discussion.
There are really just two, the first one and then two variations on the second one. The first one says, "Adapt the pyramid to plan your healthful" -- "or healthy eating pattern." And the thinking behind this was we want to communicate the concept that the pyramid is a structure or a foundation or a shape, if you will. But it can be used for many different healthy eating patterns.
And much of our thinking last night was how to communicate the concept that you don't have to eat just the foods that are pictured on the pyramid, that you can indeed adapt it. And so adapt seemed to be a nice word to get that concept across. But we're not certain that it will be a consumer-friendly word and we are not certain that it will be correctly interpreted. So maybe some feedback on that would be useful.
The second option is to, "Use the pyramid to plan your eating pattern." Possibly its best feature is all the alliteration, lots of Ps. But at any rate, this one seems to maybe be a little more straight-forward, but it doesn't as nicely encompass the idea that you can sort of tailor the pyramid to your own healthful diet.
And the third variation then is the same as the second one but instead of "to plan your eating pattern", "to shape your eating pattern" which gives a little more dynamic nature to it perhaps.
The third thing I would like to mention before we have discussion -- and I assume -- are we going to have discussion following? I had an opportunity last night, and possibly some of the other members did as well, to look through some of the information from the Dietary Guidelines Alliance. And I think as far as consumer-friendly messages, this really has got it down.
And we as committee members would do well to look at some of the communication techniques that are incorporated in here and in the -- in the revision or the new version of the owner's manual in the tool kit. I was very impressed with this approach to communication. And certainly, there are many things in here that we could profit from. So then I would appreciate any thoughts or feedback.
DR. GARZA: Any comments? Meir?
DR. STAMPFER: I would like to put in a plug for the first -- the first one, although I like the shape idea; maybe the first one with shape instead of plan. But that's a detail. But the main point of the -- I think the advantage of the first one is, as you expressed it very well, that it's a guide that you can tailor to in many ways.
And at the end of the last meeting, I think there was some sentiment in the committee to -- to try to have some alternative pyramids that would provide guidance for other healthy patterns. And -- but that did not seem possible to -- to come up with in a timely way.
So I think the adapt mode captures the spirit of that. And in the text, I think it, you know, would be reasonable to discuss the pyramid. But I certainly would not want to see us endorsing the pyramid as the healthy eating pattern. So I think -- I think adapt captures all that. So that would be my vote.
DR. MURPHY: And to expand also, you reminded me of another concept that came up last night which is very early in the text of this guideline, we would like to talk about how you can adapt this for vegetarian diets and, in addition, how you could adapt it for a particular cultural diet like, for example, a Mexican American diet or an Asian diet and feature that more than it has bene in the past perhaps.
DR. GARZA: Carole, would it be possible to -- as part of the focus groups, to look at variations of these things to see what they communicate? Because I think this was the concern that I heard expressed most often, that it's not so much how individual committee members may feel about this. It's how will the consumers react and respond to them because I think all of us want for those concepts that have been expressed by both Suzanne and Meir to be conveyed. And -- but we don't know whether in fact we would succeed with any one of these, or perhaps they all are going to be too nebulous for consumers, regardless of what this group may feel.
MS. DAVIS: I'm happy to say our questionnaire or moderator's guide has just received ONB clearance. And the guide that was --
DR. MURPHY: Oh, very good.
MS. DAVIS: Last night, so -- no, I -- I found that out this morning, that they had received it yesterday. So we can try to get these titles in, you know, to try to make some adjustments in there. And certainly the "adapt", I would be interested to see, you know, what the reaction would be to that.
DR. GARZA: And I would -- I guess the other word would be "shape" versus "plan" to see how people would -- would react to both because, I think as Meir said, we could -- we could shift wording accordingly. I don't think any of us are -- feel particularly wed to any of these as long as they convey the idea of flexibility and adaptability with a healthy eating pattern.
MS. DAVIS: I'll try.
DR. GARZA: Okay. Richard and then Roland?
DR. DECKELBAUM: I would just like to endorse the concept that we include the word, "healthy" or "healthful", in the bullet because it does convey a very specific, strong, positive message.
DR. GARZA: Okay. Roland?
DR. WEINSIER: Just to reiterate a little bit, in the focus groups, I think what we're trying to convey with the word, you know, "adapt", or use the -- the pyramid more or less as a blueprint rather than a prescription is that we are not trying to indicate that every person or population has to have dairy products or has to have meat on a daily basis.
But the foundation of a sound diets builds upon the grains, the fruits, the vegetables, and understanding that there are various calcium-rich foods, protein, iron-rich foods that are important for building a diet. So we're not trying to convey anything less than that, but there is flexibility with the pyramid to build a healthy diet. Does that make sense? Is that --
DR. GARZA: I think -- yes.
DR. WEINSIER: It might just reiterate -- I'm trying to reiterate, but to make sure that we're all saying the same thing.
DR. GARZA: I think so. I think there are just various eating plans. We should recognize, however, that -- and I don't know how to get this into the -- into the guidelines easily. But if one chooses to exclude all animal products, that in fact it does require a level of knowledge given the U.S. food system that is more specialized in terms of meeting iron requirements and zinc requirements and folate and a number of other nutrients.
And so we -- we need to make sure that we convey to do this -- to do this in a knowledgeable way. I keep referring to my -- my niece who feels she is a vegetarian because she consumes potato chips and coca cola as the core of her diet. Well, technically she's correct. But I don't think that -- that any of us would ever endorse that as a healthful diet.
And somehow we need to -- to communicate to people that certainly it's possible, but do it thoughtfully and in the same way that we would like to limit their animal consumption -- their animal food consumption, to limit their intake of saturated fats and other things that can be abused, as well.
And so we put quite a bit of care into that. And I want to make sure we put as much care into alternative eating patterns as we have on -- on the omnivorous patterns we've included in the information we have. Okay. All right.
Then maybe we have put Suzanne's guideline to rest.
DR. MURPHY: And renamed it.
DR. GARZA: And renamed it. All right.
DR. STAMPFER: Bert?
DR. GARZA: Yes?
DR. STAMPFER: Since -- since that discussion went so fast, is it -- I -- I'm just wondering, maybe you could give us some ideas of what the -- what's -- how the text is going to change for that guideline for what -- well, what we're going to -- we're -- sort of what the outline might be.
DR. GARZA: The plan still is to have comments come from you in terms of -- of changes to the text. Those would be sent to Shanty. Shanty will then forward them on to -- to Carole, Suzanne and myself. And we will begin with the working group to shape the text. But I hope it would reflect both issues of flexibility that Roland just brought together, the points that -- that Suzanne made about making sure that we cover the alternatives, and that we carefully think about the information we give people so that they understand that this is to be done in a -- in a thoughtful way.
When we say adapt, it does shift a significant burden to the consumer. And we need to make sure that they avail themselves of information that's appropriate.
DR. STAMPFER: Just so I'm sure that I understand the thrust of that -- of this guideline, it sounds like it's sort of a combination of adequacy and kind of overall diet planning. Is that correct?
DR. GARZA: Well, what we're going to do -- there is still the introduction. And what we've been toying with for the introduction is rather than -- we may -- we may jettison the word, "introduction", or keep it. But what we're going to try to convey in the introduction is that consumers should make the diet a key part of a -- of a healthy lifestyle, and then put into context food safety, physical activity.
And we may in fact want for staff to -- especially DHHS staff -- to get to us the -- the various recommendations that are presently made by the government in terms of healthy lifestyles to see if there is an easy way that -- that we can combine this in a consumer -- consumer-friendly way.
I keep reminding myself that just as it's impossible to tell consumers, "Well, on Mondays you eat this way for a healthy baby and on Tuesdays you eat this other way if you want to avoid heart disease; on Wednesdays you eat this other way if you want to avoid cancer", that consumers have to deal with all of this information in a very integrated fashion.
And so we may want to put in there messages that in fact transcend diets so that people can understand that the diet is a key foundation for a healthy lifestyle, but it's only -- it's only a -- a piece of it; that there are other things they need to pay attention to.
So I hope we can somehow get the flavor of that into the introduction whether we say, you know, "Plan a healthful diet", as the key -- or, "Make the diet a key of a healthy lifestyle or something", and incorporate in text that would expand on that a little bit with two or three paragraphs.
We might be able to shorten the introduction a bit because then we want to be the key message, taking Roland's admonitions to us to heart, that says, you know, be very, very specific about what you want people to go away with, and then move to this other -- these other messages in the first guideline, however it might be worded. So is that -- is that helpful, Meir, before we go to Suzanne?
DR. MURPHY: Well, I was going to actually expand --
DR. GARZA: All right. Go ahead.
DR. MURPHY: -- slightly. It's my assumption that we will start with the text as it is currently worded. In other words, we're not going to start all over again. So I would encourage the committee members to give the working subgroup any feedback you have on the current text because we never really talked at any length --
DR. GARZA: About text, that's right.
DR. MURPHY: -- about the text because we've been so focused on trying to get the headline right. So although there will be a few changes, I'm assuming that we're pretty much going with what we have.
DR. GARZA: And my expectation is there will be a lively exchange over the summer over hyperspace on text, but that the text will be reviewed very carefully. What we'll be doing at the next meeting is hopefully not going over substance because we would have agreed on substance in the first three meetings.
And this -- and the last meeting will be looking more carefully at -- at the wording to make sure that it represents what we intended it as a committee because in the end, we're going to have to endorse all of the guidelines rather than to feel responsible only for the one in which any of us might have worked on directly -- or most directly. So -- yes.
DR. DECKELBAUM: Is there any information available about how people perceive the introduction section of this booklet as compared to the information under the specific guidelines?
DR. GARZA: Carole? I thought we thought the introduction was put in there for the -- for to make the committee feel better.
DR. DECKELBAUM: So in that vein, I would suggest -- because if you're going to have the word, "pyramid", and you're going to have "healthy" or "healthful" in the bullet, if you go through most of the points, perhaps not physical activity in the integration, most of the points in the current introduction will fit very well under the bullet and, therefore, may get better attention.
DR. GARZA: Also I meant that we may want to shorten the introduction and use it to convey the idea of making diet part of a -- of a lifestyle.
DR. DECKELBAUM: I'm just suggesting that "may" is too soft a word here.
DR. GARZA: Oh. Well --
DR. KUMANYIKA: I guess a question along the same lines is whether the -- I guess it would be the Public Health Service has a guideline that says, "Have a healthy lifestyle". I mean, I know we have specific guidelines for a lot of elements of a healthy lifestyle. But is there one that says this is something that people should consciously think about and try to do rather than just sort of roll along until something happens?
DR. GARZA: The sense I have is that we've never really integrated them into one because we have the smoking one, physical activity. I mean, there are lots of pieces, but not a -- a generic document. Is that --
DR. KUMANYIKA: Yes, that's -- that's also my impression. I think the closest we're coming are the Surgeon General's priorities, one of which has a healthy lifestyle with four components in it. But I don't know of any particular paper at this point other than budget documents that -- and in his speeches that have that.
So we might consider if we can use a bullet for the introduction to say something affirmative like, you know, "Have a healthy lifestyle", and then the first piece is, "Adapt a pyramid", and another piece is physical activity and weight because actually when I talk to consumers and even reporters who are health reporters for magazines, there are a lot of people who feel that life takes care of itself, that health takes care of itself. So they -- they're still waiting for a reason to think about the healthy lifestyle. So we might be able to help by putting that introductory thing under a bullet.
MS. DAVIS: That's not 11, is it?
DR. GARZA: No, no. That's not 11. No, no, we're -- we're only dealing with the introduction. In fact, the guidelines have a context. We're going to -- we're going to also have to have a suggestion for the -- for the department. See, we want for this -- for the guidelines. And given Congress' action today, maybe we could even get away with it -- of having two stone tablets or something.
(Laughter.)
DR. DECKELBAUM: We're already planning it.
DR. GARZA: That's right. As the icon for the dietary guidelines. Well, that's already been tested. It's been confirmed that --
DR. KUMANYIKA: It's probably copyrighted.
UNIDENTIFIED VOICE: They said it didn't work.
(Laughter.)
DR. GARZA: That reminds me of why God will never get ten years, you know. All right. Is there -- are there any other discussions on -- on this first guideline and -- or the introduction? Okay. Roland?
DR. WEINSIER: Maybe you were going to come back to this later, but there was a fair amount of discussion about the possibility instead of just having -- as Carole is getting at dot, dot, dot -- a long, long list and a longer -- and a lengthening list of -- of guidelines, to have some sort of over-arching --
DR. GARZA: We will -- we will come back to that, the general format for this, of how we structure them. And I -- I don't know whether the other guidelines will take as long. But I don't have the sense that we will. Of course, I probably damned it right there. But on food safety, do any -- does anyone have any concerns left over that we need to -- to readdress?
The major issue that I recall -- and that may have been because I raised it, so I -- is that we need to make sure that in the -- in the green section of our report, the recommendations to the Secretaries, that we stress the need for research and the system that will support food safety for the consumer and that we not inadvertently convey the message that we expect the consumer will now carry the bulk of the responsibility for assuring the safety of our food supply; that this is still a government and industry responsibility and that we're only dealing with those issues that relate to the consumer.
But, obviously, we can't put that into the guidelines. But we need to make sure that officially we state that very clearly. And that's not in any of our text yet. Are there any other -- okay.
On the grain guideline, I think Richard had a -- some comments.
DR. DECKELBAUM: Just a few comments. I think the discussion we had the other day was quite positive. And in view that we -- I think the -- the working group will consider softening the bullet perhaps to read something like, "Choose a variety of grain products including whole grains". And the reason for that is that we recognize that a lot of the other grains are enriched with folate and importantly other vitamins, as well. So that's one thing that we would definitely consider.
I think we would also increase the emphasis on the benefit of grains of -- containing other vitamins and other -- other nutrients and that could be associated with good health.
I think a general -- a general observation we can make about grains, fruits and vegetables which actually form the base of the food pyramid is that much of the evidence that we have for their benefit does come from observational association studies. There have been very few intervention studies on grains, fruits and vegetables.
There are some, for example, the DASH study which doesn't exactly address our end points -- so that something we could consider recommending in the green book is something that might be needed to strengthen the science base, although the observational studies I think provide a fairly decent science base to allow us to use the word, "may have benefits", in a number of areas.
And I think the final thing that we will consider in the revision of the text is the question or the suggestion that one of the benefits is actually displacement of some of the other nutrients that don't carry as much benefits.
DR. GARZA: Okay. Any questions? Yes?
DR. JOHNSON: I would just like to emphasize to keep the word, "variety", in the guideline. I think this is a guideline where we need to re-emphasize the portion-size theme that we're trying to it sounds like run throughout the document. I'm not sure that we want the message to be, "Eat an unlimited amount of grain every day".
And I'm referring to this paper that Suzanne shared with us on variety. And it is actually the carbohydrate group which is one of the groups when there is variety that's associated with a higher angaria intake.
So I think we just need to have a caution there about -- because I think this is -- in my mind, this is one of the aspects of the pyramid that we see the most misconceptions when we see the six to 11 serving sizes. And I think we need to really emphasize the portions in this area.
DR. GARZA: That's a very good point.
DR. DECKELBAUM: I would agree.
DR. GARZA: Meir?
DR. STAMPFER: I want to make a plea to keep the wording of the bullet the way it was suggested initially, especially whole grains for a couple of reasons. One is that the American diet is basically -- for carbohydrates is -- there is not that much whole grain. So that's the element that needs to be emphasized.
I think we're not saying only whole grains, but I think the emphasis should be in increasing whole grain. And even -- even Dr. Pesunier who was quite vigorous against the -- against the glycemic index supported the notion of increased -- of recommending increased fiber intake. And that's where we get it.
So I think there is good science to back up an emphasis on whole grains and also it meets -- it fits the changes that I think really should be recommended. So I would vote to keep it the way it is.
DR. GARZA: And given the fact that I think there is -- there is a general consensus for keeping it that way, that we make sure that the science portion, the green book reflect the status of the science and why we felt that in fact the evidence was sufficiently compelling for making that change and -- and putting that emphasis.
And right now, I don't think -- I don't think the green section of the -- of the report is quite there yet. I think it assumes that everyone will -- will necessarily buy into that rather than having a -- the type of documentation we discussed yesterday.
DR. DECKELBAUM: But I would like to ask if that really is the consensus, that we leave it the way it is, because from the discussions the other day, I picked some lack of total consensus on this point.
DR. GARZA: All right. Well, that's important because I -- I didn't --
DR. DECKELBAUM: So I would like the committee to address it.
DR. GARZA: Yes. Alice?
DR. LICHTENSTEIN: I'm a little skeptical also now about the especially -- I'm wondering if we can get some information on what percentage of the iron intake is represented by enriched products and what the impact would be of having a shift from enriched to whole grain products on iron intake; and then also now with the addition of the folate.
I think fiber intake is certainly an issue in the United States. We also do get it from fruits and vegetables.
DR. GARZA: So you're concerned that if half of the -- of the grain servings came from whole grains, that that would significantly undermine the intake of key micronutrients in the diet.
DR. LICHTENSTEIN: Or that's what -- that's the information that I would like to see.
DR. STAMPFER: In the enrichment of refined --
DR. GARZA: We are for fortification because it's not enrichment.
DR. STAMPFER: The fortification applies only to folate. The enrichment is just designed to add back the nutrients that are stripped out and --
DR. GARZA: Well, that's enrichment, but --
DR. LICHTENSTEIN: What about --
DR. GARZA: -- so there are iron products that are iron-fortified. Is that -- is that still true, Kathryn? You look --
MS. McMURRY: I think that the iron isn't necessarily adding to restore what was lost.
DR. GARZA: No, that's right. That's why I wanted to correct it, that it's fortification as opposed to enrichment. Okay. Shanty, would it be possible to -- to look at our consumption data and see what the impact would be if given the eating patterns in the U.S., if one were to take 50 percent of the recommended grain servings as whole grains, whether in fact that would have a -- a significantly negative or adverse impact on iron intake.
I -- I mean, there are other issues of bioavailability. But I think those would be more difficult to model in terms of whether phytate which you also would increase -- the -- my sort of very rough approximation that I can't give you a methodology for would suggest that if it were half of the grain products, it probably wouldn't' have that much of an impact. But I -- on bioavailability.
But you probably should recognize that it's not only a fortification issue. It also is a potential bioavailability issue.
DR. JOHNSON: I think if we look at folate, too, if that's a concern. I know there has been some debate about whether the USDA database is updated with current folate enrichment levels. It is? I know I saw some back and forth on a list --
DR. GARZA: And the FDA has done some recent calculations on the -- on folate intake based on new fortification. So I think that if we were to contact either Chris Lewis or Becky Ethly's group, that they could give us that information.
Now, whether or not -- I think it was -- it was Linda who suggested that FDA may be reconsidering the fortification of whole grains with folate, as well. Did I misunderstand that, that FDA was considering that?
DR. MEYERS: As I understand it, there is some staff-level discussions keyed off of your -- some of your observations at an earlier meeting. And so they are -- they are looking into the -- the issue of fortification of -- of whole grains. And I don't think -- and nothing mandatory. But they're looking into at a staff level. And we can get an update for you on where that is, what they're actually doing.
DR. GARZA: And the other thing is could you ask if -- if whole grain breads are iron fortified? No. I didn't think they were, but I wasn't sure. Let me go to Richard and then Suzanne, then we'll come back to --
DR. DECKELBAUM: Following the guidance that we really want to rely on published data, if we get some of this data, can we use it in the green book?
DR. GARZA: Well, only to make changes. If we're going to use that data to keep what we have, then theoretically, I think we would be -- we would be all right. But it's a matter I think of reassuring ourselves that we're not doing anything that will be harmful. I think that was the intent of Alice's question.
DR. LICHTENSTEIN: Yes.
DR. DECKELBAUM: I think that's a very good way of putting it.
DR. MURPHY: We do have the profiles, the nutrient profiles, of both the whole and the enriched grain groups that was handed out. And there is -- there is no reason in my opinion for concern about iron because, indeed, the whole grains are higher in iron than the enriched grains. So I don't think that would be an issue. Indeed, whole grains are higher in zinc. And folate, they came out to be very similar, as well.
I think there are two issues though that we don't -- I don't see any way that we're going to grapple with them in the near future. And that is if you recommend whole grains very strongly in the guideline, people may shift the mix that they choose. And so this is the mix they chose in the past. But will it or will it not be the same mix in the future? And we have no way to know that until we put the guideline out and actually see what consumers do.
But I'm not personally concerned that we're going to really shift the micronutrient content. And I think we will increase the fiber content of the U.S. diet with that.
My concern is if we focus too much on whole grains, consumers will give up and say, "It's impossible for me to get six servings of whole grains. I'm just going to forget grains." And again, I don't see any way to solve that except to try and -- maybe focus groups could help with that. I don't know.
DR. GARZA: Well, that's what I thought was especially was -- was providing an emphasis, but not being as quantitative to be discouraging. Scott and then --
DR. GRUNDY: One question I had was about which one is more likely to lead to caloric over-consumption, enriched or whole grains. I would kind of just superficially think the whole grains might tend to reduce caloric consumption of -- you know, and that maybe some of our concern about pushing a very low fat product as the answer might -- that might include a lot of enriched products. Am I wrong about that or is that --
DR. GARZA: Well, I don't know how we can relate it to low fat. But I would agree that the decreased fiber content probably lends them to -- to over-consumption more easily.
DR. GRUNDY: Maybe that would be a reason to shift the emphasis a little more to whole grains.
DR. GARZA: Alice and then Shiriki.
DR. LICHTENSTEIN: I think that could probably cut both ways because by shifting to whole grains, then you're increasing variety and with the -- within the grain food group variety is related to total caloric intake. So it could really go both ways.
One comment about the micronutrient intake. I think especially for iron and folate, you can't just look at the absolute numbers. And I think somehow we're going to have to also look at bioavailability because the amount of iron may be the same amount. But it may just not get absorbed, and especially if we disproportionately increase the amount of whole grains.
And the only other point was that I think we really need to be very strong in our advice for today about warning against over-consumption, that -- warning against over-consumption because of total calorie intake.
DR. GARZA: Shiriki?
DR. KUMANYIKA: Do we have any information about the cost of whole grains and accessibility to low income consumers?
DR. GARZA: I don't. I don't know whether --
DR. MURPHY: Is there anything over the ERS maybe?
DR. GARZA: -- whether ERS -- is there somebody in the ERS in the audience that can help us?
DR. KUMANYIKA: Yes, Betsy.
DR. GARZA: Where's Betsy?
UNIDENTIFIED VOICE: I don't know that we have -- but I could go ask our price analyst if they have information on that.
DR. GARZA: We don't have to do it today, but maybe you could get back and let us know if there are large price differentials. I have no doubt that there are differences in distribution and availability or accessibility. I would doubt if -- I mean, I -- I often tend to think that these tend to be primary concerns -- have been the primary concern of upper income groups. And so it would certainly be -- if you walk into an upscale type of grocery store, you're more likely to find them than in your neighborhood -- and in inner-cities --
DR. KUMANYIKA: Because I'm worried that if -- if they're not accessible, then what we're doing is creating a situation where people with low income automatically have poorer diets because we're saying that it's more desirable to have the whole grains. It's been hard enough to get low fat milk into inner-city communities.
So if we say that, then that would I think become a mandate for those who are -- are concerned about low income communities to change the distribution of whole grains because I consider them a little bit of a yuppy food. We don't want to have yuppy guidelines.
DR. GARZA: Well, it gets us back to the chicken-and-egg issue. See, I, too am being contaminated because what is -- you know, if we -- if in fact the availability of more science -- rather of foods that then more easily make up a healthful diet have been -- has been increased because of the guidelines and identifying these meal patterns or food patterns and we really feel that whole grain -- increasing the whole grain intake in the country would be a healthful change, then do we make the recommendation so we propel the availability or do -- or are we -- if we don't do that, then will we be saddled with the status quo forever. And I'm -- I'm not sure I have an easy answer for that.
DR. DECKELBAUM: So when we look in the owner's manual on the first pages, "Warning: Proceed slowly but surely when shifting gears towards healthy habits. After all, small steps work better than giant leaps." So I really -- we want to only have a September meeting, right, so -- so we really need -- I would like a consensus. I'm hearing two different views and I don't know how you would like to solve this, Bert. But --
DR. GARZA: Well, I agree.
DR. DECKELBAUM: Because I -- I can see the positive points in both sides here.
DR. GARZA: Well, maybe we need to ask what sort of information would dissuade you from having the -- the phrase, "especially whole grains"? I mean, because I don't think quite honestly that you're going to get the type of specific information that takes into account bioavailability. I mean, that is -- that is a major struggle.
DR. KUMANYIKA: But can't we just get some expert opinion from somebody that works in the field as to whether it's something that we really -- should be a major concern or not be a major concern both from the standpoint of decreasing our intake because whole grain products are no fortified with iron and from the impact of -- of adding extra fiber and phytates to the diet and its impact on the enriched products.
And the same thing with folate. We know that the bioavailability is extremely is -- or is different between the endogenous folate and the microcrystallate folate.
DR. GARZA: Then let me make the following suggestion then. If we can get Dr. Shaw or her group to take the information that they have on the pyramid and calculate what percent of iron, both in source and in quantity, would be the percent shift we would see in source and in quantity if we went to half the -- as much as half the servings in the grain group to whole grains or a quarter of the servings.
And then once we get that information, if Richard would have a conference call with one or two people that might be expert to inform the working group as to whether or not this would be a concern. And if it's iron that is the major issue, then we could certainly -- iron and folate.
DR. KUMANYIKA: Folate.
DR. GARZA: Meir?
DR. STAMPFER: Well, if you're going to go the nutrient adequacy route in order to make this judgement, then -- then you also have to consider what the fiber intake -- what would happen to fiber intake with -- with that kind of shift because we're trying to make a balance here, and try to translate that into -- into human health. And there is a variety of studies that show that people who eat more fiber, particularly from cereal sources, are at lower risk for -- for various diseases.
And even just looking at whole grain products, there is epidemiologic data that supports it. But we have to -- so if you're going to do the nutrient route, let's add fiber to the mix.
DR. GARZA: Okay. That I think we can do.
DR. DECKELBAUM: That's a good point. I have it down but I didn't mention it, is that we have discussed among our working groups different points during this meeting, that splitting grains from fruits and vegetables will let fiber fall a little between the boards. And we thought we need to re-emphasize that stronger in both sections.
DR. GARZA: I would -- I would estimate that we would see reductions of about 15, 20 percent at most. I mean, is that sort of percentage going to unnerve anybody?
DR. DECKELBAUM: Fifteen, 20 percent in --
DR. GARZA: Of iron. Well, if you -- if you're going -- because of the calories, I mean -- if you are going to replace it by that much, it would -- that I would see on a quantity basis given the -- but that doesn't speak to -- that's the least bioavailable form that you would be displacing anyway because it would be -- you would be displacing other grain products, I mean, not -- it wouldn't displace iron from either legumes or iron from -- from meats. I mean, I don't think people would make that trade-off. And I would see them as being more -- more bioavailable from both of those sources than whole grains.
All right. Then that would not -- that would not cause anybody a major concern. All right. Then I -- given that, let's keep "especially grains" for right now. And if we see that we're somewhere beyond those limits, we'll try to e-mail everyone and -- any other issues, concerns?
All right. Fruits and vegetables.
DR. LICHTENSTEIN: This guideline is reasonable straight-forward. And there were -- there were some points that were brought up during the discussion. And for the most part, I'm going to have to rely on looking at the transcript to address those issues. But I don't think any major changes or modifications actually had come up.
I think language with respect to fiber is going to need to be incorporated in there appropriately and strengthening perhaps the value of variety within fruits and vegetables and choosing from a wide variety of different alternatives and back-referencing to I think what's now box two which has to do with serving size, so individuals can get a clearer idea of how well they're doing.
DR. GARZA: Rachel?
DR. JOHNSON: Well, I think, you know, based on my earlier comment, if we, you know, take a careful look at this variety paper, this is probably one area that we really want to emphasize, you know, "Plenty of fruits and vegetables", because in fact here, you know, variety in vegetables was actually associated with lower energy intakes. So I think --
DR. LICHTENSTEIN: Well, do you -- are you suggesting we make a change?
DR. JOHNSON: What's the bullet now? What's our --
DR. LICHTENSTEIN: "Choose a variety of fruits and vegetables daily." And that primarily addressed the different nutrient contributions of the different foods that would fall into that category.
DR. GARZA: Were you suggesting, "Choose a variety of plenty"?
DR. LICHTENSTEIN: No, no. No, I just -- I guess I feel more comfortable with the variety word in the bullet with this guideline maybe than even in the grain guideline.
DR. GARZA: Shiriki?
DR. KUMANYIKA: Is the -- I have two issues. One is whether the concept of choosing a variety really gets to the get enough fruits and vegetables. I mean, some of the population groups that have low fruit intake may not really get the message that it's a certain amount of fruit that everybody should eat. And the "Choose a variety" is less clear, for example, then "Eat five a day", which really pushes people up to that minimum.
The other issue has to do with weight gain.
DR. LICHTENSTEIN: Well, wait. How would you suggest we address that with the first point?
DR. KUMANYIKA: Well, I'm just -- I mean, I'm thinking more to "Make sure you eat enough", you know, "eat enough fruits and vegetables".
DR. LICHTENSTEIN: But we're back to the first guideline essentially.
DR. KUMANYIKA: Or something that talks about the servings because choosing a variety if you're not having them. Just choosing variety sounds like you're fine-tuning something that -- that may not exist. But the other --
DR. GARZA: Are we back to "Choose plenty of a variety"?
DR. KUMANYIKA: Well, it's more of a --
DR. STAMPFER: "Plenty of different fruits and vegetables."
DR. KUMANYIKA: It's enough -- I mean, "Eat enough fruits and vegetables". I mean, if it's adequacy, "Eat enough fruits and vegetables", and the different comes in for getting nutrients from different fruits and vegetables. But I'm not sure we are as worried about the variety as we are about the quantity.
Fruit consumption is really low. I mean, when I looked at the data, it's amazing the number of people in the population who go through that three-day data point without eating any fruits and vegetables at all, much less a variety.
DR. LICHTENSTEIN: No potatoes? No fruits and vegetables?
DR. KUMANYIKA: I mean, no fruits -- no fruits. And there are some who eat no vegetables. But there is more who eat -- in some groups, it's as many as 30 or 40 percent who will eat no fruit in the three-day data point. So --
DR. GARZA: But we may -- we may want to consider a suggestio that Meir made that I'm not sure everybody heard. And that was, "Eat plenty of different fruits and vegetables". Would that convey what you want more -- more readily than "Choose a variety"?
DR. LICHTENSTEIN: Well, the question I have about the plenty has to do with experience in blood pressure studies where we've ended up giving potassium in pill form because people gain weight when they start taking -- when you prescribe the potassium in fruit and vegetable form on top of the rest of the diet.
So I'm actually wondering if anyone has looked into the possibility that unlimited consumption, for example, of orange juice is something that people don't recognize has calories in it. They decide that's a good thing. And those who eat fruit are using that as a beverage and fairly large servings. And it counts.
DR. GARZA: Well, I was relating to the -- to the variety paper that found that in fact they didn't have a --
DR. JOHNSON: This didn't include beverages. You're absolutely right. Fruit juice consumption is continuing to increase.
DR. LICHTENSTEIN: And there is language in there right now to address it suggesting that most of the fruits and vegetables come from the whole -- the plant and not juice.
DR. JOHNSON: Right. In this paper, the juices are in the energy-containing beverage category, not in fruits and vegetables.
DR. GARZA: Well, maybe we could then turn this over to Carole, as well. I mean --
MS. DAVIS: I knew this was going to --
DR. GARZA: Well, I mean, that's exactly -- well, that -- because it -- it comes down to those issues, as how will these be perceived by consumers whether it's "Choose a variety", or, you know, "Eat plenty", and see what -- what impact that would have. It doesn't answer the question though that Shiriki raises. Is by using "plenty", the impact would be over-consumption? I hope an informed guess would be I just can't imagine people eating so many fruits and vegetables, they're going to gain weight.
DR. LICHTENSTEIN: Because there is a displacement issue, that if they're eating a lot of fruits and vegetables, then --
DR. GARZA: Well, that's what I mean, that I just can't -- well, no. Whether you could deal with that in the text -- because if we plan for every abuse, that might be difficult. I mean, we could say, well, you know -- Roland?
DR. WEINSIER: I was just going to reiterate that it is a displacement issue and there are data to indicate that when more low fat fruits, vegetables, starches are given ad libitum, calorie intake does not only not go up, it tends to go down. So I think that we're coming onto fairly safe grounds there. And get back to the real issue, is it eat variety or is it eat more. And as Shiriki is pointing out, I think the issue is to eat more. So however the wording is, whether -- I mean, one of your statements is, "Eat lots of fruits and vegetables". Remember that? That sells volumes to me. And then --
DR. GARZA: I don't know whether we could -- we could look at, again, data to give us any -- any guidance as to how much juice would you have to drink before you end up pushing calories. And if that data does exist, to include in the guideline, you know, make no more than two of your servings juice servings or something.
DR. WEINSIER: And Alice does, you know, emphasize -- it's stated in here, you know, select most of it as whole --
DR. GARZA: No, but we need to get more descriptive by putting a -- and the other way of backing that up would be to look at some data to say, well, are individuals who are over-consuming energy, you know, taking six to eight servings of fruit juices a day as opposed to one or two.
DR. LICHTENSTEIN: Can I just say one thing about the variety? Though -- one of the reasons for variety is what's the major vegetable that's consumed here in the United States, is potatoes, as -- in what form? French fries is high up there if not the highest. And by getting variety in there, then we do send the message that consuming six servings of french fries a day -- which I don't know how many servings of large fries in a fast food establishment -- is it four?
DR. STAMPFER: One large fries is four portions.
DR. LICHTENSTEIN: Four servings. So if you consume one medium and one large fries, you're meeting, you know, the guideline. So for that reason -- and then what we know about food consumption --
DR. GARZA: So it's choose probably a different -- not -- we never -- we never wanted to get rid of the variety. You're right. I mean, they would -- have either different or variety, but --
DR. MURPHY: So it's not either or.
DR. GARZA: No, it's not either or. "It's eat plenty of different fruits and vegetables", or, "Choose a variety."
DR. LICHTENSTEIN: Or "Choose plenty of different fruits and vegetables".
DR. MURPHY: No.
DR. LICHTENSTEIN: No? Okay. All right.
DR. MURPHY: I don't think that's --
DR. GARZA: That's right. That hadn't -- it's "Eat plenty of different fruits and vegetables" or "Choose a variety" are the two that we had discussed.
DR. LICHTENSTEIN: Okay. So where do we go with this?
DR. GARZA: Well, we turn to Carole to say can you help us resolve this.
DR. LICHTENSTEIN: Okay.
DR. GARZA: And we also talked about the possibility of getting more data analysis on the relationship between fruit juice consumption and calories. And I don't know whether that's possible. I mean, I don't know the data sets that well.
DR. KUMANYIKA: There is some. I mean, the -- any -- in the food frequency questionnaires that dump out sources, fruit juices and drinks are separate. And I think even in some of the data we have, the USDA data, it's easy to separate the fruit juices.
I really want to sort of raise a red flag here because I'm convinced, especially with children, that people feel that they are doing a good thing by giving their kid, you know, six boxes of juice or something that says juice on it and that we're not paying enough attention to the fact that that's defined, at least by the Five A Day Program, as a serving of fruit.
And it's more accessible than -- because if you go to a cooler, you might choose a fruit juice as opposed to something else. But the fresh fruit or other servings of fruit are harder to come by. And I'm really worried that if we say that without having, you know, a sugar and beverages guideline, we'll create a problem.
And then people are looking at fruit juice also for calcium, especially people who don't like milk and don't want to use milk. You see calcium really big on the orange juice. And that convinces you to drink more. And it is -- it's calorific, especially with the size containers we have. It adds up.
DR. LICHTENSTEIN: Plus orange juice is relatively cheap.
DR. KUMANYIKA: Yes, relatively, yes.
DR. LICHTENSTEIN: Which is going to --
DR. GARZA: It's more predictable in terms of quality, so --
DR. LICHTENSTEIN: Right. But we're not talking about putting a precautionary note about juice in the guidelines. So the guideline is one issue, testing two different options. And then the other issue is strengthening what we've already said about juice in the text.
DR. KUMANYIKA: I'm talking about putting a cautionary note somewhere about calories from beverages.
DR. LICHTENSTEIN: Right, yes. I agree with you.
DR. KUMANYIKA: Wherever it fits, I think that's where it should go.
DR. GARZA: And that's what I'm saying, that we might -- that if we were going to do that, we would have to have at least reflective on some database. And we would have to find out whether Shiriki's perception is real because it's a perception. I mean, I'm --
DR. KUMANYIKA: No, it's based on data. I just don't have it on me --
DR. LICHTENSTEIN: And there's data on children, data on children.
DR. JOHNSON: And we do have the -- well, we have the data from Barbara Rosen McManus, not in children, that says that energy intake regulation seems to be affected when the carbohydrate calories are in beverage form rather than in food. So I think there is certainly good scientific ground for what Shiriki is saying.
DR. GARZA: Okay. Very good. All right. Then do you have enough --
DR. LICHTENSTEIN: So we're going to tackle that in this guideline.
DR. GARZA: That's right.
DR. LICHTENSTEIN: Yes, I have -- I think so.
DR. GARZA: Okay. Fat, an easy one.
DR. GRUNDY: Okay. I'll give you mine. I think I want to take a little poll here. I guess what I got out of yesterday was that there are -- people are pretty comfortable with the numbers that we have and, secondly, that the evidence has shifted enough in favor of putting emphasis on -- more emphasis on saturated fat and including in that dietary cholesterol.
But there is still a lot of difference of view or opinion on the total fat and how to say it. It's not that we -- I think the idea that we would change the recommendation for total fat and -- and number-wise, there is not much enthusiasm for doing that. But I also think that the wording that people have suggested does reflect actually a different view about that, even though we may not change the numbers.
So I was -- you know, two thoughts came up from yesterday. One was that we would keep the guideline the same wording that we had before, and just change the -- the order and have saturated fat, cholesterol and total fat, and choose a diet low in those, like we have now. And, you know, that would be one way to achieve a change in emphasis without modifying anything. And so the numbers that we had before would fit and so would the words. But we would re-arrange them for a change in emphasis.
The other is to actually introduce this idea of moderate total fat because I think that the -- what the word, "low", is -- means different things to different people. This 30 percent fat, is that low? Well, it's lower than we -- what we take in now and it's low compared to what we used to take in, even more so. So actually for a long time, I thought the word, "low", meant 30 percent fat.
But other people are saying now that, you know, maybe that term in the mind of the general public has shifted more toward what I would call a very low fat diet which would be less than 20 percent fat or something like that.
So I'm not sure where the public is in thinking about that term, "low". So, you know, what I would -- what would help me, I think, is if we would kind of ask everybody here on the committee what they think about that term, "low" and "moderate", and what it means to them and -- and whether they would favor going with a recommendation actually that we put forward, I think which was our subgroup's major number one on our list, was "Choose a diet low in saturated fat and moderate in other fats".
But yesterday that seemed to run into a lot of opposition. So maybe if -- if people are willing to kind of express their opinion and go around the room. And it would help me out.
DR. GARZA: So the two choices are "Choose a diet low in saturated fat, cholesterol and total fat" --
DR. GRUNDY: Right.
DR. GARZA: -- and the other would be "Choose a diet low" --
DR. LICHTENSTEIN: "Choose food", wasn't it?
DR. GARZA: "Choose food", but then "Choose foods" --
DR. LICHTENSTEIN: And then shift to diet.
DR. GARZA: All right.
DR. LICHTENSTEIN: Isn't that it?
DR. GARZA: Well, I thought you were --
DR. LICHTENSTEIN: "Choose foods" --
DR. GRUNDY: Well, what does it say right now? It says, "Choose foods" --
DR. GARZA: All right. So "Choose foods low in saturated fat, cholesterol and total fat". I mean, that's the problem. That's why I went to diet. And then the other one is "Choose foods/diet low in saturated fat and cholesterol and moderate in total fat".
DR. GRUNDY: Yes, or --
DR. STAMPFER: "Other fats".
DR. GRUNDY: "Other fats".
DR. GARZA: Yes, Alice?
DR. LICHTENSTEIN: There could be "Choose a diet" -- excuse me, "Choose foods low in saturated fat and cholesterol and a diet moderate in fat" or "a moderate fat diet".
DR. GRUNDY: Okay. I was -- we could talk about the exact words, too. I mean, but -- but also --
DR. GARZA: But a mixture of low with moderate.
DR. GRUNDY: Yes, the idea of whether we would introduce the word, "moderate", related to fats or not. That's -- I think that's the question that we can talk about.
DR. GARZA: Okay. Meir -- we'll just go around the room -- do you have a preference for either low or moderate?
DR. STAMPFER: Well, I don't like either of them very well. But of the -- if I'm forced to choose, well, I like the -- I like the one that's in the draft. But if I'm forced to choose --
DR. GARZA: Can you read that to make sure that --
DR. STAMPFER: All right. "Choose foods that are low in saturated fat and cholesterol." And I --
DR. GARZA: Period. And then leave the total fat out.
DR. STAMPFER: That would be my preference. But, you know --
DR. GARZA: Okay. Well, assuming that that -- that that's not going to -- going to run into opposition.
DR. STAMPFER: Right, okay. Choosing between the two, I would certainly strongly favor moderate versus low because it gets a point across that I hope we're in agreement on, we should be, that there is a difference in the type of fat and its association with risk of major diseases.
And the emphasis really should be on saturated fat and trans -- trans is important, but not enough to make it into the headline. But the polyunsaturated fats are not just healthful as substitute calories for saturated fat, but they are actually essential. They're beneficial on their own.
Randomized trial data show with clinical end points that if you substitute polyunsaturated fat in place of saturated fat, you have lower actual disease end points. And we -- we have to base this on scientific data. So I think if we just say "low in total fat", we're equating all sorts of fats. And we're just behaving as though science hasn't progressed over the last 40 years.
DR. GARZA: Okay. Alice?
DR. LICHTENSTEIN: I would like to see "low for saturated fat and cholesterol and moderate for total fat". But I would also really like to see us distinguishing between foods and diet. And I think that some of the misinterpretation that we seem to be hearing about with how the message has been received is because we haven't made that distinction before.
DR. GARZA: Let me ask you, I mean, if -- if -- to comment on -- if we've been telling the public low and now we go to moderate, do you think that that's going to then signal that we all ought to increase our fat intakes because we've gone from low to moderate?
DR. LICHTENSTEIN: Actually, I don't. I think what it's going to achieve is being more in sync with what's out in the public domain now -- that now I think -- over the past five years, I think there has been a shift in the definition of a low fat diet. And part of that has come from media coverage. And I think there was -- I forgot where there was a story recently.
But you see a lot about the low fat diet, less than ten percent. You have foods that actually are marketed that way now. So I think we have to acknowledge that there has been a shift is perception -- apparent shift in perception.
It would be nice if we could find out real quickly. But unfortunately, that may not be the case. But if we just do a survey of what's in the public domain, it appears that there has been a paradigm shift.
DR. GARZA: All right. Carole, you might want to start getting prepared for a third one.
DR. DECKELBAUM: I would vote for low and moderate. I think in the text, it will have to spell out very clearly the messages, what low means and what moderate means so that there won't be confusion and that it won't be misused by industry or other groups. And I guess we'll wait to hear from Carole about whether there is going to be potential confusion.
DR. GARZA: Rachel?
DR. JOHNSON: Low and moderate.
DR. GARZA: Low and moderate, good. Lesley?
DR. TINKER: Low and moderate for all the same reasons that have been expressed already.
DR. GARZA: Roland?
DR. WEINSIER: I can't follow the low and moderate. I would go crazy with that myself. And I don't know how a consumer would deal with it. But I think it's "Choose meals low in fat, especially saturated fat and cholesterol". The word, "especially", tells me everything. I tend to forget everything else. Even in the previous one where we're talking about grains, the "especially" jumps out at me. And I think that was one of the suggestions that Scott made yesterday, "Choose foods or meals low in fat, especially saturated fat and cholesterol".
DR. GARZA: Well, that came from someone else. I don't know whether -- whether Scott wants to be associated with that.
DR. GRUNDY: Our group didn't put that forward. I -- I think that was Suzanne's suggestion.
DR. WEINSIER: I wrote it down when -- something.
DR. GARZA: Yes, I think it was Suzanne.
DR. WEINSIER: Oh, okay. Yes, right.
DR. GARZA: So we now have in addition to "Choose foods" -- or "Choose a diet" -- "Choose foods low in fat"?
DR. WEINSIER: "Choose meals low in fat" --
DR. GARZA: "Choose meals low in fat".
DR. WEINSIER: -- "especially saturated fat and cholesterol".
DR. GARZA: Okay.
DR. KUMANYIKA: I'm not going to be easy with this. I think --
DR. GARZA: Why should you be any different, Shiriki?
DR. KUMANYIKA: I think we are agreed that the 30 percent level is right. And it's that our expertise is not in which word is going to be understandable to consumers. I would rather see the guideline say 30 percent or "Eat less than a third of your calories as fat", and let the experts in consumer communication figure out how to do that because we have a lot of comments that say consumers don't know what moderate means for some of the other guidelines.
So I'm not sure that this is where our expertise should be used to try to convey a number which we all agree on by picking a word and guessing how consumers are going to relate to it.
DR. GARZA: Okay. Suzanne, you get the last word.
DR. MURPHY: Well, obviously, I liked the "especially" option because I thought it did convey a tiered approach that "especially saturated fat and cholesterol" -- without getting into the low and moderate words. But I do feel strongly that if we have been telling consumers forever to eat a diet low in fat and now we say eat a diet moderate in fat, that's permission to increase. And I think that's entirely the wrong way to be going given the levels of obesity in the United States.
DR. GARZA: Alice?
DR. LICHTENSTEIN: I'm -- I actually didn't interpret that -- the words after "especially" as two tier. But that really gets me worried because I think the most important aspect is the saturated fat and cholesterol. And if by saying "a diet low in fact, especially saturated fat and cholesterol" continues as the previous one seemed to give more emphasis on total fat than the saturated fat and cholesterol, I think we're going -- we're not going in the right direction.
I'm also concerned -- I understand that we don't want to be, I think the word was zig-zagging that was used yesterday. And we don't want to make major changes all the time. However, I think if we always fall back on, well, we've been saying this for a long time and we -- therefore, we shouldn't change it, I think that's really dangerous because I think over the past five years and especially ten years, there is more and more data showing that changing -- you have to change -- changing total fat does not impact at least on cardiovascular risk factors. It really is saturated fat.
DR. GARZA: Let me ask Carole then to add to her growing list three different concepts, one that says "Choose a diet that is low/moderate in fat, but low/very low in saturated fat" -- "Choose a diet low in fat and very low in saturated fat" or something -- or "Choose a diet moderate" -- well, that would be interpreted to mean, gee, we ought to increase our fat intakes.
And we can -- we can deal with the various wordings that we've -- that have gone around the table. But they seem to center around those issues. And Shiriki makes a lot of sense when she says that I don't think any of us has expertise on how the public will interpret those words.
But the consensus seems to be we would like to continue limiting the fat intake of the American population rather than giving them license to increase it because of obesity. But we would like to call attention to the fact that in -- the major issue related to other diseases are saturated fat and cholesterol. And so that we would like them to make more marked reductions in both of those fats than in their total fat intake.
DR. LICHTENSTEIN: Just to reiterate from yesterday, it's not just obesity with total fat. It also is that in the U.S. diet, total fat and saturated fat track very closely.
DR. GARZA: Yes.
DR. LICHTENSTEIN: So that's the other reason.
DR. GARZA: Yes. Okay. So if you could get our consumer experts to try to get back to us to how we communicate best where we capture the -- the -- the emphasis on saturated fat and cholesterol and not give people the signal that we're trying to say that you can increase your fat intakes from present levels, but that the American public ought to continue trying to get down to 30 percent. Is that -- is that a fair --
DR. GRUNDY: Yes. Well, I think that's fair, what you just said. I think that what I heard going around the room is still a divided view on this. But --
DR. GARZA: Well, I think is it a division on the concept or how we communicate the concept?
DR. GRUNDY: Well, I think it's on how we communicate, yes. That's true. But I think it does reflect some difference in view about the whole issue. I would still come back that the saturated fat ought to be out front.
And that some -- you know, I heard around the room kind of a general view that there should be some distinction or moderation in the total fat compared to the saturated fat. And just how that's stated is not clear.
I still would go back to there is two ways to say that. One is by changing the emphasis, put it at the end rather than at the beginning and with -- and not change the words, just the order. That also -- that does imply a change in emphasis in itself which I think would be acceptable to many of us.
The other would actually take it the next step and -- and moderate the total fat which there is a surprising number of people who favored that. So I think that either way you cut it, there is going to be a change in emphasis and just how we deal with the total fat. Maybe we still have to talk about that some more.
DR. GARZA: I -- I -- I don't see any disagreement between what you said and what I just said which may speak to the -- the communication issue that revolves around this problem because I -- I think that we're all in agreement. I don't -- I don't think there is any disagreement as to concept. It's how do you communicate it effectively. But the emphasis has to be on saturated fat and cholesterol, but not give inadvertent permission to increase the total amount of fat.
DR. LICHTENSTEIN: I'm getting a little nervous now with this consumer research, that we started with the first guideline where essentially it was variations on a theme and to see how it was being communicated. Now, although I -- I agree that it -- with what you just said, that it seems like we're sort of in the same place, but as how best to communicate it.
I think that the kinds of things we're asking Carole to test now are not variations on the same theme. I think substantially the wording itself is very different. And the issue then is the chicken and the egg again. Do we use the guideline to re-educate -- or continue to educate the American public or is the American public going to tell us what they know and then we're going to try to craft the guideline around that?
DR. GARZA: No, I don't think that's what we expect from them, the consumer group. We're going to come -- use the various iterations we've talked about which all are trying to communicate the same thing and find out which comes closer to communicating the message. So it's not "Tell us what you want us to tell you", and then we'll take a poll and -- you know, if we hear from 80 percent of the American public that like, you know, their two servings of french fries a day, it's not -- yes.
MS. DAVIS: We are doing 14 focus groups here. There is a different mix of the types of people that we are dealing with. Some are low income. Some are overweight; you know, older Americans, a few that way. So this is just going to be a representative thing. And as I said, we just got the clearance for the moderator's guide we have in there.
So we'll do what we can to make the changes. But if you really want a lot of this done and we can go back and they are not going to let us do, we have to have more money, we may have to accept donations from somewhere to do it. But we'll -- we'll do the best we can. But we're getting a lot of new ideas that we didn't have in there.
DR. GARZA: Well, I mean, we -- we knew at the beginning we were going to come back to how do we communicate these messages.
MS. DAVIS: And we will have another round of focus groups later on. But I know you were needing this conceptually to -- to go forward. But we will have --
DR. GARZA: Well, maybe -- maybe you can reorder the task because I think this is going to be key, Carole, I mean in terms of getting the committee to a consensus because there seems to be consensus in the substance, not consensus in how to communicate it which goes beyond the expertise that this group has. And so feedback would be useful.
DR. MEYERS: Carole, my understand is that the -- the -- some of these concepts are already included like --
MS. DAVIS: Already there.
DR. MEYERS: -- like the moderate fat is there. So if there is a --
MS. DAVIS: Yes.
DR. MEYERS: -- little bit of tweaking, that makes it easier.
MS. DAVIS: To do -- now you're wanting moderate and fat in the same thing, those kinds of things. I think we can work some of it in, but --
DR. GARZA: I don't -- I don't think it's an impossible task. I mean, but then I don't have to do it. Just --
MS. DAVIS: Get your low fat diets in there, your very, very low.
DR. DECKELBAUM: Since we're an advisory panel, I would just like to ask, in the past -- in the past, do these bullets come out from the advisory panel or have they been changed --
DR. GARZA: Yes.
DR. DECKELBAUM: -- because you just said we're not the experts on communication.
DR. GARZA: No, but in the past, they have come to -- yes. That's why I am very concerned that -- that if we're going to choose one over another one when we all understand why we're choosing it because in the end, that's what's going to be the most visible. Very few people will read the text for each of the bullets. And even fewer will read the scientific rationales.
DR. DECKELBAUM: So it really is important what we decide.
DR. GARZA: That's right. People will -- at least the government will pay attention to you, Richard. So yes.
DR. DECKELBAUM: And do you --
MS. McMURRY: I just want to remind the committee that the ILSE focus groups that were submitted earlier did address the issue of moderate versus low total fat in the guidelines. That may provide some insight, as well.
DR. GARZA: Okay. So I think we have agreement on the -- on the message. It's how we convey it -- how we convey that is -- is at issue. All right. Let's take a coffee break until 10:30 and we'll come back and 10:30 and move on to the weight guideline.
(Whereupon, a brief recess was taken.)
DR. GARZA: Can I ask if everyone would please take their seats, we'll get started. Can I get -- so committee members, we have a date for the meeting. So mark your calendars for November 30th, December 1st and December 2nd. And if you're -- if we -- if we are super efficient, we won't have to return to Washington on November 30th, December 1st and 2nd. So isn't that an attractive thought, especially for those of us from Hawaii.
DR. MURPHY: I was starting to enjoy these meetings.
DR. GARZA: Well, we're -- all right. Let's continue. So we can get to format issues in a timely way, to the weight guideline. In this regard, I want to take time to -- I talked to both Roland and Lesley earlier today. And Lesley will be taking primary responsibility for the physical activity guideline in the future, keeping the same working group that's been working on it. And so Roland will continue to work on physical activity, but will continue -- but not as chair. But will continue as chair on the weight guideline. Okay.
DR. WEINSIER: So on the weight guideline?
DR. GARZA: The weight guideline.
DR. WEINSIER: There were a lot of useful suggestions. I think the key changes that I perceive from your feedback was that the title, "Achieve and maintain a healthy body weight", is probably pretty close to being on target. Of the many suggestions, basically I was getting a feeling that we need to add a lot more, but make it a lot shorter.
But in trying to keep that in mind, these were some of the points that came across most repeatedly or most notably; that the BMI figure, the body mass index figure as a revision of the 1995 guideline is -- is probably the way to go. But we still have the dilemma of how to incorporate a chart or a figure for BMIs for children. And we were still talking about that at the break and -- and we have to get back to you whether that's going to even be feasible within a page limit.
A second page or suggestion --
DR. JOHNSON: Roland, I'm sorry. Could I just interrupt just for a minute to find out, since I wasn't here yesterday, was there general support to include something about BMI in children? It's just a matter of how to best do it in -- in the least amount of space or was there some --
DR. WEINSIER: Well, we really didn't get discussion on that.
DR. GARZA: There wasn't a lot of discussion. Although I know there is some concern about using a single cut-off for all children in terms of BMI.
DR. WEINSIER: Well, and it is pretty evident that we don't have a single cut-off for -- for all children. Plus, you know, it gets into gender differences with children which you don't have for the adults.
So you have the age difference as well as the gender difference as well as we don't have a -- a published reference for BMI yet, although USDA and CDC are working on one that should come out. It requires a fair amount of text to explain how to use that chart.
So the option right now appears to be if we don't use a pediatric BMI chart, make it clear that the one we're including only refers to adults 18 and over, and that guideline -- a reference may be provided where they can look up one for children, or to incorporate some new BMI charts which would the expand the text. Rachel, do you want to comment?
DR. JOHNSON: Well, I would just like to put in a plug that if we can get it in there in a reasonable space allocation, I think we should. A quarter of all U.S.
children are overweight and it's getting worse. And that's where we're targeting our prevention effort. So I think if we can do something for the pediatric population, we should make the effort.
DR. GARZA: We've asked Carole to try to design a one inch-by-one inch square icon from two to 85 with a BMI, to keep it short but include --
DR. WEINSIER: A second important suggestion is to perhaps eliminate the box -- the new box called, "Estimate your risk of disease", remember, the one with all the arrows, the very number of arrows. That we're getting too quantitative, perhaps too clinical and that there may be misinterpretations.
A third useful suggestion was to put further emphasis on preventing further weight gain, particularly people with BMIs greater than 25, not just on the importance of controlling and perhaps losing weight, but to prevent further weight gain. Make sure the emphasis comes across on older adults in terms of the importance or lack thereof of changing BMIs.
A concept which has not been brought in here is one of cycling, weight cycling. And since this is such a common problem or at least concern, that at least it be addressed in terms of are there health risks and is it better to try to lose or not to try to lose at all.
And then a sort of general commentary, perhaps the text is too dense and see if we can get more to bullet form type material. There were a number of other suggestions which are -- are written down, but I think those are the highlights.
DR. GARZA: Any other comments or concerns? The one that seems the most substantive that we didn't resolve deals with children. And I don't know whether any of you have any other suggestions for Roland because I don't think we've given them adequate guidance as to how much are you willing to sacrifice in terms of -- of being succinct and broadening the guideline because I think it would be very difficult to get it -- to cut it down and add another chart with the explanatory text, you know, and --
DR. WEINSIER: It would require two charts and explanatory text. But by saying that, I don't want to minimize the importance. I -- my bias is it's very, very important. I mean, I want to just say that very clearly. So, yes, let's get feedback.
DR. GARZA: But I don't think that -- I think we've had Rachel whose -- who has had a very clear preference. But I haven't heard from anybody else. So --
DR. WEINSIER: No feedback is -- as you said the other day, means that they support --
DR. GARZA: Rachel's position that we ought to -- yes.
DR. JOHNSON: Well, they are guidelines for all Americans. And we pretty much decided we're not going to do separate guidelines for children. So --
DR. WEINSIER: But there is a section -- there is a section on children right now, but it's descriptive. It doesn't get back to how do they assess whether they are at a healthy weight or overweight, perhaps even under weight. There is no reference for them --
DR. GARZA: Suzanne?
DR. MURPHY: Yes, I'm not --
DR. WEINSIER: -- in terms of measurement.
DR. MURPHY: -- a pediatric obesity specialist by any means. But I would ask if parents don't tend to rely on their pediatrician more and whether this is the way to communicate to parents that children might be overweight? Is that a real issue, parents not recognizing that their children are overweight?
DR. GARZA: Well, that raises a very good point because at the present time -- I mean, the recommendation is that you put children on special diets for weight reduction. I mean, that that ought to be done if there is a problem under medical supervision. And are we going to -- are we going to be sending a mixed message? And I think that -- that merits some discussion. Let's go to Alice, Meir, then Richard.
DR. LICHTENSTEIN: I think because these guidelines are intended for all Americans, if that chart did not include data for children, then that's a justification for putting a separate chart in for children. And also the issue, do parents know whether their child has -- is in energy imbalance, part of that is cultural. And again, I think more information to at least give guidance to health care professionals, if not individual parents, on making the determination would probably be helpful.
DR. GARZA: This document though, is it intended for health professionals? So --
DR. LICHTENSTEIN: I understand that.
DR. GARZA: All right.
DR. LICHTENSTEIN: It sometimes is -- it gets used --
DR. GARZA: No, I know, but it's --
DR. LICHTENSTEIN: Okay. All right. But it should at least --
DR. GARZA: We could say, you know, "Consult your health professional".
DR. LICHTENSTEIN: Okay. Okay, but it at least should -- it should cover all the people it's intended to cover.
DR. GARZA: Meir?
DR. STAMPFER: I would support putting it in even though it -- even though it's cumbersome and takes a lot of space because there really is a terrific epidemic of obesity in children. And if our emphasis on the adult side is -- is toward prevention because we all know how difficult it is to treat obesity, that that really has to begin in childhood. So I think that deserves some emphasis.
DR. GARZA: Richard?
DR. DECKELBAUM: This is speaking from my prejudice, but most pediatricians don't know how to carefully define overweight. And I would think that the most common thing that they -- that they use would be weight-for-height charts. That would be the most common. But then they don't know what the definition for overweight is on those weight-for-height charts, 20 percent, 30 percent.
Rachel just handed me the USDA -- a USDA publication which in fact has BMI charts for children and that could be considered. What I would suggest is that for this that Rachel have some -- give some input to you, Roland. And I will also ask Christine Williams who has thought a lot about obesity prevention in children to go over what's in there and to review some of the questions we just brought up.
DR. JOHNSON: Yes, Christine is a well recognized expert in the area of childhood nutrition and obesity.
So --
DR. DECKELBAUM: And she's --
DR. JOHNSON: And she works with Richard. I feel -- is that okay?
DR. GARZA: Well, I mean, I feel that that would be fine. My -- when you consult these outside experts though, I would ask if you please underscore that we are dealing with prevention.
DR. DECKELBAUM: Well, that's what she --
DR. GARZA: And so that -- so that if -- if by putting in the chart in there we're going to be promoting a therapeutic response because my child is overweight, that's the danger that I see. And I would like for people to -- when you talk to them, see whether we're going to be helping or making matters worse.
We can have text that talks about the importance of preventing obesity, but I'm not -- I'm not as convinced that getting them to the next step of say, "Now, diagnose whether in fact your child is overweight", and then -- and then obviously from the diagnosis, we'll follow a treatment of a restriction that may not be appropriate for children. So I -- get us feedback on those issues as to how we could best address that.
DR. WEINSIER: One thing Elaine McLaughlin has indicated to me -- clarify if I'm mistaken -- that this
is -- Richard, this is a proposal that's under development and is soon to be released. But we don't know what soon is defined as. But this is a federal soon. So I don't know that these charts are going to be ready in time for --
MS. McMURRY: Yes, these charts are based on the revised NCHS growth charts which are imminently to be released. But I was told about a year ago, as well.
DR. WEINSIER: Well, I mean, but -- I mean, we're trying to bring this to closure within the next how many months we've got left. So it's one thing if we by consensus around the table say, yes, do it, and it's not available. There is some risk.
DR. JOHNSON: Do you think we could have staff contact Bill Deits at CDC and, I mean, I know we've been hearing for some time and I know there were some problems with the slopes of the curve and some different things. But, Linda, do you think you could get a release date maybe?
DR. GARZA: Okay. Then let's move on to physical activity. And there obviously it's not as well developed. I don't know whether it would help to have any further discussion or whether we could bypass. Do you, Roland or Lesley, need any additional information from the committee or -- I mean, we had -- I think everybody liked the outline and the approach that was being taken.
DR. TINKER: And we do have consensus that we want the extra guideline.
DR. GARZA: Well, for right now, I think that there was sort of the sense that we should proceed. Now, officially, we won't be adopting that until September. I notice the optimism, see. We would be doing that in September as our final meeting. But, all right. Then we'll go to another easy one, salt.
DR. KUMANYIKA: This one is easy. I summarized what I thought were the resolved issues. We still have a lot of wording and content to work out. But the issues that I believe we are in agreement are, one, to keep the guideline; two, to continue the emphasis on blood pressure, retaining mention of other factors that relate to blood pressure; to mention other sodium-related health factors in whatever way the evidence supports. And the one that we have to get some clarity on, maybe with some consultation, is exactly what the literature says in sum on the bone-loss issue.
We have agreed to advise on the sources of sodium including the link to calorie intake, with specific advice on eating out and ways to reduce salt intake when eating out. We've agreed to mention iodine. Again, we don't know exactly what it is we're supposed -- we need to say about iodine. But we've agreed that it's worth mentioning.
Keep 2,400 as the upper limit and be clear that the recommendations apply to children -- or how they apply to children.
The unresolved issues, the wording we're not clear on. The latest version that we were batting around yesterday was, "Choose and prepare foods with less sodium or salt". Some people have said less than what. So we're going to have the -- the word, the moderate, the less, the lower, to struggle with.
The other wording that I wanted to -- that I suggested that we test is the difference between the "Most Americans eat too much salt" and the "You may be eating more sodium than you think". That difference in perception when people see something phrased as most Americans, whether they can exclude themselves from it and would respond more to a direct -- a direct statement.
And the other thing that I mentioned coming from one of the comments that I think we should include in the focus groups if it's -- if it can be fit in with the moderator's guide that we have is salt or sodium on the food label, the point about possibly dropping salt or sodium from the name of the guideline was discussed in the comments as not align with the food label, you know, if we only use the word, "salt", because the food label says sodium and doesn't relate sodium to salt.
And that -- that might actually be a problem if people recognize the term, "salt", more than sodium. Then we're not sure what sodium is actually accomplishing there on the label.
This may already have been tested in the nutrition facts focus groups. But I think we need some information on that point. I may have forgotten something, but those are the issues that I have in my notes.
DR. GARZA: Okay. Any other points people wish to raise? Okay.
DR. KUMANYIKA: See, it was easy.
DR. GARZA: That's right. And now we go to alcohol.
DR. STAMPFER: I don't have much to add beyond the discussion of yesterday. I think the suggestions for changes were mostly in wording and emphasis a bit more on elderly and -- and maybe figuring out a better way to organize the discussion of benefits and -- and risks and the -- adding the suggestion of emphasizing individual differences in reaction.
There was one thing though that I forgot to raise which I probably should raise to the committee for their reaction which is that Dr. Gordis in his letter suggested -- and he actually -- I don't know if you -- how many of you looked at that. But he actually -- or he and his staff have sort of written a whole proposed guideline. So we have one to look at.
But one of the points that -- that he raised was whether we should say, "If you don't drink, don't start", actually recommending against starting drinking. And I had thought about that, also. And I don't think that that's a reasonable suggestion that can be supported by the data.
I think the -- the -- the benefits of moderate alcohol consumption are very strongly supported by the data. And I think we would be doing a disservice to recommend against starting, just as I think we would be doing a disservice recommending starting.
So my reaction to that is to leave it as it is, "If you choose to drink", or, "If you" -- "If you drink alcoholic beverages", leave it to the consumer and basically adopt a neutral stance. But I did want to raise that for discussion if other people had a reaction.
DR. GARZA: Any -- any thoughts on "Just say no" versus "If you drink"? Yes? Roland?
DR. WEINSIER: Well, I don't have the answer, but I think we need to think about it because I have the feeling it's a -- it's a question that a lot of people have. Is it important enough, valuable enough that I should be including it as part of my -- my diet.
And if we don't address it, then we're not giving guidance. So having raised that issue, if we are to address it, do we go to Dr. Gordis' recommendation? I'm leery of not addressing it because I think people are going to be looking for it.
DR. GARZA: No, I don't think the issue is dropping the guideline. It's changing the guideline to read, "If you don't drink, don't start".
DR. WEINSIER: That's what I'm referring to.
DR. GARZA: Yes, but that -- all right. So then -- all right.
DR. WEINSIER: No, if -- did I misunderstand? Because right now you're saying -- and I don't remember sitting here -- "If you don't drink, don't start". It's not in there, right?
DR. GARZA: No. And it's never been in any previous guideline. All the alcohol guidelines have been of this mode, "If you drink, drink in moderation", and none of them have said "Don't start" and none of them have said "Do start".
DR. WEINSIER: But --
DR. GARZA: They just say "If you do". The other major change that is in the guidelines now is it goes one step further than in the past because we're saying these -- the moderation applies only to those individuals over the age of 45; I mean, that in fact --
DR. STAMPFER: Yes, that's probably the biggest change in this guideline, that --
DR. GARZA: So that it's -- it is postponing --
DR. WEINSIER: That's a big protective barrier I guess.
DR. GARZA: But what -- what -- what -- if we -- if we go the route that Dr. Gordis has suggested, that it eliminates the 45 and older age group. And what we're saying is you should never initiate; here it's saying, yes, if you drink, drink so in moderation; but its health benefits are limited to the 45 and after age group. And there was quite a bit of levity yesterday as to -- especially for women, that they have a ten year window. You'll recall that discussion.
DR. STAMPFER: Yes, I mean, actually if you take Dr. Gordis' suggestion, then in a couple of generations, this -- that would imply, you know, no one should ever drink in America. I think we've been down that road already.
DR. GARZA: Linda?
DR. MEYERS: The 1990 committee had some of these same discussions. Their solution -- I'm not suggesting it; I'm just stating what it was -- was to say there are no net health benefits.
DR. MURPHY: And that was in the guideline.
DR. MEYERS: Yes. I mean it was in the text.
DR. GARZA: That was taking into account the potential for abuse, for falls and --
DR. MEYERS: Yes, that's --
DR. GARZA: -- for issues of that -- of that kind. But that -- well -- any comments about that?
DR. GRUNDY: Well, they're not net for the nation, but for individuals. You couldn't say that necessarily. I think that's a little bit problematic. I mean, I agree with the conclusion. Probably the disadvantages may out-weigh the advantages overall. But I'm not sure. Since it's for individuals, you might be a little hard pressed to say that.
The other thing I think you -- Meir's point of view, it's -- I think if we said, "Don't start", that's a little bit of a moral judgement that would go beyond just the scientific recommendation. And I think -- although I think it's a good idea not to start, I'm not sure that this group could say that.
DR. GARZA: My sense from the letter is that that was predicated on the idea that the potential of abuse was present at any age.
DR. GRUNDY: I'm sure it is.
DR. GARZA: And therefore by our inadvertently or intentionally being interpreted to say, gee, you know, there are significant health benefits to be gained after this age, that by giving that, we still are going to have then -- is it ten percent or -- of the -- ten percent of the population that would be initiating drinking at age 45 would -- would be at risk of abuse because of -- of a biological problem.
DR. STAMPFER: But that's unsupported --
DR. GARZA: Not a moral one. I mean, so
it's --
DR. STAMPFER: -- unsupported though by data. That was -- that was a judgement.
DR. GARZA: No, I know. But I mean that's -- I mean, because --
DR. STAMPFER: Very few people initiate alcohol after like their 20s or so.
DR. GARZA: That's right.
DR. STAMPFER: But there are no data one way or the other on what their risk is.
DR. GARZA: But I asked if the biological risk was attenuated with age. And I thought his answer was no.
DR. STAMPFER: Their own data say that it strongly is. And, in fact, the NIA -- the NIA document that was distributed to the committee on age at initiation showed very, very clearly that the early age at initiation was associated with higher risk. And that we've added to the proposed -- and I think it's an important point to stress, that young people should -- should be -- you know, should not drink.
DR. GARZA: Okay. Any other points? So is the consensus still to keep the -- the bullet as it presently is? Do you want to alter the text in any way that talks about net health benefits to either the individual or the public, but giving the working group any further guidance on that?
DR. WEINSIER: I concede on my concerns unless somebody like, you know, Carole Davis were to tell me
that -- that consumers read this. And I doubt -- you know, reading it over again, I doubt this would occur. I'm not suggesting we have another focus group. But --
DR. GARZA: You could just get everybody to read it.
DR. WEINSIER: You know, I just would not want it to not address a major concern. But in re-reading it, I think it does. I honestly do.
DR. GARZA: So you think it does --
DR. WEINSIER: I think it's adequate.
DR. GARZA: -- it in balance gives the message that you would like to see conveyed.
DR. WEINSIER: Yes, or the message that I think should be conveyed, yes.
DR. GARZA: Shiriki?
DR. KUMANYIKA: I think based on our prior experience with the 1995 committee, we have two concerns. And one of them we hadn't -- we haven't mentioned this much. One is how consumers will perceive it. And the other is potential for misuse of the guideline for marketing purposes and so forth.
So that's probably as great a concern with this one as -- that consumers will read the fine print and find something to abuse in there, is that it will give -- be allowed to interpret -- to be interpreted wrongly to consumers. And I have a great concern about that. I don't know how we can test that. But it's certainly worth thinking about.
DR. GARZA: I think how -- you know, trying to limit how people will interpret it is going to be really difficult. But if you read it, does it convey in a balanced way where you think the status of the science now is?
DR. KUMANYIKA: Yes, I like -- I mean, I like it the way it is. I think it's good.
DR. GARZA: Any other comments before we move on to another easy one? The sugar guideline, let's go on then to the sugar.
And I -- before -- before Rachel speaks, I want to stress that this is -- this is an issue of -- of generic interest. I know I've had some communication expressing concern that -- that one specific food or foods are being targeted.
And I certainly want to make sure that when you -- as you read the guideline, that in fact you feel that we're dealing with this generically as dealing with the American diet and the role that added sugars are playing, with added sugars being those for which calories are being added to either enhance flavor of a sweet nature without -- without having any other functional component.
I mean, as a preservative for example, I think like that. I think it would be pretty difficult for us to say that you ought to eliminate added sugar from jams. But assuming that we all agree that the reason they were -- jams were first created was for -- as a way to preserve fruits, in addition to being quite enjoyable. Okay. So let's -- let's move on then. Rachel?
DR. JOHNSON: Okay. Thanks. On my list, I -- the points that I took away were that the committee favors continuing with a separate guideline; that there was support for an emphasis on moderating intake of foods and beverages that are high in added sugars. We need focus group information on what the best wording is for the consensus of the group in terms of what our intent is.
And then Carole and I have talked a bit -- I think we'll talk some more -- about how we'll craft those questions or we can get some input here now.
I had a comment on adding something to the text about using water as a good source of fluids. It seemed like this was a bit of a home that we could emphasize the calcium message because we've agreed that there is somewhat -- some concern about the falling calcium intakes in the U.S. and that without a separate calcium guideline, this might be a place to get some of that stressed in the text.
There was some testimony on including two new sugar substitutes that have been approved by FDA. Is it asasulphane-K -- asasulphane potassium and sucrylose. And we're going to see if we can get some consumption data on those. I think they're really -- pointing out that sugar substitutes don't replace -- or shouldn't -- how is that -- that was your comment, Bert -- not replacing the calories saved from sugar substitutes saved in the diet.
And then some comments in terms of any way we can mesh this guideline better with the weight and the adequacy guideline would be beneficial, hoping to tie it in with those two other guidelines.
DR. GARZA: On the last comment, I want to -- as soon as we finish with the -- with the sugar guideline, I want to come back to Shiriki's suggestion of how we take the matrix she presented and assure that in fact across the guidelines, we're dealing with -- with the cross-cutting issues as part of our format discussion.
So are there other comments on sugar though before we --
DR. STAMPFER: Yes. I support -- I support this guideline. And I'm straying off to the territory that Shiriki pointed out is not our area of expertise. But I'm a little concerned about the added sugars concept. And it seems like the main reason that we're using that instead of sugar is -- is that perhaps the perception that fruit has natural sugar and that people might be confused. But I really question that, whether lots of people think of fruit as -- as having lots of sugar.
And if we -- if we just stick with added sugar, then we're opening the door to an easy loophole of concentrated white grape juice or in my health food store, you can -- you can get products that have evaporated cane juice and so on.
And sugar -- I think we may be putting too much emphasis on this perception that sugar -- that people think of fruit as -- as a high sugar food. And I really don't -- I wonder if that's really true. And if it's not true, then the guideline would be simpler and less prone to loopholes if we just talked about sugar.
DR. GARZA: I thought this came up because of a consumer, that that's where we got into the added business,s that it was through --
DR. STAMPFER: Right, but -- but is that a general perception or is that one comment in one focus group that's now shaping national policy?
DR. GARZA: Well, I -- I don't know.
DR. JOHNSON: I think that's a good point. And I agree totally with Meir. And I think this is something that Carole and I have talked about, is, you know, if consumers in fact don't think of foods like fruit as being high in sugar, then maybe we are, you know, creating more than we need to if -- if the perception of sugar is -- I think we're looking at it with our scientist hat when you -- and the biochemical definition of sugar versus the consumer understanding.
DR. GARZA: Suzanne?
DR. MURPHY: I am still ambivalent on that. But I'm glad we're discussing a little bit more. But one of my concerns is if you really focus on added sugars, it makes it more difficult, as the text points out, to use the nutritional facts label. And I really in the end think that is a tremendous tool for looking at the amount of sugar in any food. Just looking at the ingredient list doesn't always tell you what you want to know.
So if we keep the added sugars, I would like to see us beef up at least some -- some ways that consumers can still use the total sugars number on the label.
DR. GARZA: Richard?
DR. DECKELBAUM: I think if you read the revised text, both -- both points that have come up or actually discussed head on right at the beginning, there is a strong definition of what added sugars means. And then there is some advice in the third paragraph down the page of how to read the label and how to get some indication of what the added sugars are. So I think that's already been addressed.
I think Bert brought up a good point about, you know, what about jams. But, you know, how heavy do people go on jams? You know, jams really go easy and we don't take a huge amount -- I mean, I don't think most people take a huge amount of jam as part of their diet.
DR. GARZA: The reason I raised that is because there is -- I want to make sure that we all read this text --
DR. DECKELBAUM: So I don't want to be discriminatory --
DR. GARZA: -- with -- with the idea because it's quite -- it's quite easy for -- I think for us to mobilize either individuals or groups that feel that we're being -- that they're being targeted. And I want to be as up front as we can. But I don't think it's the intent of any of us to target any -- any single group or food.
I mean, that this is a generic concern. It relates to health. And we would like to be as -- as helpful as we can to the American public in helping them choose a balanced diet that's going to promote health. I mean, that's the issue.
DR. LICHTENSTEIN: I'm sort of ambivalent also, which is unusual, on this point. But one thing, I have heard -- and I'm a little bit concerned with -- is on ways of getting around if the "added" remains. And I think some discussion of things like dried -- I don't know, whatever it was -- beet sugar or concentrated grape juice that are sort of used as a substitute so that one can say, you know, only natural sugars or something like that would be included in the text or somehow addressed.
DR. GARZA: Now, I thought that though the term, "added", now had a specific governmental definition. Is that true?
DR. JOHNSON: Well, I don't know if it's an official governmental definition, but it's the definition that's used in the CSFIA database to define added sugars. And we've put it in here on page -- it's on page 25 under Tab 10 -- or, no, maybe that's not the definition. I'm sorry. It's actually on page 23. Where did we put that? I'm sorry. Oh, right under the introduction.
DR. TINKER: It's is on 23 --
DR. JOHNSON: Yes, right under the introduction.
DR. TINKER: -- "Added sugars are defined by the U.S. Department of Agriculture as all sugars used as ingredients in processed and prepared foods." Is that what you're referring to?
DR. JOHNSON: Yes.
DR. GARZA: Either for a functional purpose or just for taste, I mean, it's -- it's either one. But we need to -- we -- I think the working group is going to need some guidance from you again whether -- how they deal with this issue. Now, in this point, tacit means that you want to go along with the -- silence means you want to go along with the guideline as it presently stands? And the presently stands is "added sugar", I mean -- with the term, "added", stick it in there.
DR. DECKELBAUM: We are the working groups.
DR. GARZA: That's what I'm saying. I'm looking at the rest of the group. Is that the way you want to go?
DR. WEINSIER: I don't hear a compelling reason to change it. I think the text hits it right up front and keeps addressing the distinction between added and natural. And it seems to me that the presentations raise the issue that added sugar, particularly in sodas, is a major concern. And I -- I had the feeling this is getting at it. And yet it's buffered by the text. So I'm going to --
DR. GARZA: And the health -- the health issue is one primarily of the over-consumption of calories? Is that the basis for the --
DR. LICHTENSTEIN: And displacement of other nutrients as foods.
DR. GARZA: And displacement. Because for the first, I think there is very little data, right? I mean, at least when we looked at the epidemiological data to suggest that it's contributing to obesity. And so that it's primarily a displacement issue.
DR. WEINSIER: Well, they also say behavior and tooth decay. They're highlighted.
DR. LICHTENSTEIN: No, no.
DR. WEINSIER: Behavior is not?
DR. LICHTENSTEIN: Behavior is not a problem.
DR. GARZA: Behavior is not a problem. Behavior is not an issue, no.
DR. WEINSIER: Well, it's --
DR. LICHTENSTEIN: We address -- we address it and indicate that there is no evidence to support it.
DR. WEINSIER: Oh, that's right. Does not -- yes.
DR. LICHTENSTEIN: And clarified the issue on tooth decay because it really has to do with texture and how long it's in the mouth.
DR. GARZA: Yes. So it's a displacement issue that drives this. So make sure that in fact the scientific base for that displacement issue is -- is as strong as we all feel. So take a look at the -- at the science for that in -- in the material that we get back from Rachel.
DR. KUMANYIKA: Yes, I mean, I like it with "added sugars". It seems to -- I mean, it's clear to me what's intended, both in the bullet and in the text. When I look at the text, I don't know -- were you still here when I was -- when I showed that little matrix of crossing the guidelines?
Because this would be a good place to address the bottom of the pyramid issue, for example, where the choices within the grains category, if you focus on the foods that are processed with a lot of added sugars, you would de-emphasize those foods and you would take some of the other foods in that category which was the criticism of the pyramid early on, that you could get your six servings from cakes and cookies.
So we were talking about using these guidelines to relate them across the other guidelines and show how you implement this in your other food choices. And I think that would make it even clearer what the implications are for food choices here.
DR. GARZA: Why don't we move on then to that matrix. I don't know if we have an overhead of the -- of the matrix. Did you have an overhead of it yesterday, Shiriki?
DR. KUMANYIKA: I had -- I gave it to Carole. I mean, I could draw it again. It's very easy to draw.
DR. GARZA: But I thought it would be useful if we used it to think about now the integration of the message across the various guidelines. So that as the group begins to refine the text, that you keep this matrix in mind so that we can make sure that it -- it comes out as a consistent whole.
Shiriki, do you want to give us your thinking behind the matrix?
DR. KUMANYIKA: Well, just to say how I'm thinking about it -- and I haven't had a chance to write it out for the sodium guideline. But I see it as most important for the fat, sugar and sodium so they don't appear as separate guidelines from the guidance about across the other categories. But they are described as ways of modifying or, you know, fine-tuning the considerations for adequacy, weight, physical activity, fruits and vegetables, grains and food safety where they're applicable.
And I -- I do have a failing for lacking to fill in cells of matrices like this. And so we wouldn't want to do it ad nauseam until it became a very boring document, but as a guide underneath to make sure that we hit the points, does sodium relate to adequacy of the diet in any way, just to think that through. And if there is something to be said there, to say it. Does sodium relate to weight? Well, if people reduce their calories, they reduce their sodium intake and that might be something to work in.
Issues -- are there any issues related to sodium and physical activity? The fruits and vegetables, a lot of them are low in sodium and are sort of natural ways to get less sodium. Some grain products are prepared with more sodium than others, so read the label. And then the sodium food safety issues about preservatives, if there is any assurance we want to give people about that aspect.
And I think this -- sugar lends itself to several of those, you know, emphasizing the foods that have other nutrients when you get your calories would relate to adequacy. Certainly it relates to weight in terms of sources.
So that's the idea. I'm not sure where it fits. But as a theme underlying the way we describe those fat, sugar and sodium, I was suggesting it.
DR. GARZA: Okay. Try to keep the matrix in mind and as you go through the text then. And the other issue that came up --
DR. DECKELBAUM: I would just -- sorry.
DR. GARZA: Go ahead.
DR. DECKELBAUM: Just well this is on -- you know, this chart is going to have two cities, one on the X axis and one on the Y axis. I think if you put weight at the bottom, too, on the vertical axis, it would be helpful for some of the ones on the --
DR. KUMANYIKA: Weight and physical activity almost want to be on both axis, yes.
DR. DECKELBAUM: Yes.
DR. GARZA: Okay. The main message is for us to really think about how we can integrate them. The other issue that came up, and I'm going to modify the -- Suzanne suggested it a little bit earlier because it -- it may be a -- it's not like some advantages, but some disadvantages.
We talked about the ABCs of the guidelines, the A being for adequacy, B for balance, and C for control. But you used moderation. But I couldn't think of the ABMs.
I mean, that was -- so the ABCs may be a -- but if you can think about a way that we could use in the introduction to have people think about -- you know, so how that might be presented because if we're going to ten, then having some construct around which we could get people to think about the guidelines and grouping them not in a tier saying, gee, this is more important than this other; but that we are talking about adequacy, balance and moderation in some way.
Whether we do that with ABCs or some other clever way, perhaps you could get the communication here to -- at USDA and DHHS to think about a clever way of doing it. Another way that came up yesterday was maybe we could use a mobile or something to bring it about. I think Alice suggested that, of balance and moderation and --
DR. LICHTENSTEIN: With an umbrella over it for the first one.
DR. GARZA: And anyway, so we used our thinking about whether, you know, they're easy for us to convey the message and organize the guidelines in some way that -- that would be effective in communicating what you want. Certainly, the three broad groups that Suzanne mentioned seem -- at least I have not been able to come up with an alternative because we are talking about all three.
There is some overlap among those concepts, but they're basically the three. Okay.
DR. MURPHY: Yes, I changed the topic slightly. Actually, before we leave the matrix, that brought up an issue I wanted to ask about. Certainly in the adequacy guideline, we talk a lot about fat and sugar. And one of the issues that keeps coming up is do we only talk about saturated fat and cholesterol. And I think we have decided that it's okay to talk about total fat, for example.
So when we have a recurring theme on fat, is it -- is everyone comfortable with saying reduce to foods low in fact? Is there a preferred wording? Because Carole and I keep coming up against this. We keep saying things like hydrogenated vegetable oils. And I think that's very clumsy. I would like a kind of recurring theme that's more easily interpreted. Yes, Alice?
DR. LICHTENSTEIN: We really do want people to choose foods that are low in saturated fat and cholesterol because if --
DR. MURPHY: Right.
DR. LICHTENSTEIN: -- the emphasis is just on total fat, people could end up choosing and say, okay, we'll have a certain amount of fat, you know, to -- so that I eat a moderate or low fat diet, and I'm just going to eliminate all of the -- you know, take out salad dressing. All I'll use is fat-free salad dressing. I'll have some fat-free brownies. And I'll include cheese and whole milk because that's where I'm going to get the fat for my diet so that I'm around 30 percent of calories.
And that's just what we don't want people to do, not that there is good and bad foods, but we really want them to focus on the foods that have saturated fat and cholesterol.
DR. GARZA: So does that -- does that help? I think the emphasis has to be on the reduction of saturated fat.
DR. GRUNDY: I'm not sure I understood your question, posing that question.
DR. MURPHY: Well, we have perhaps over-simplistic messages that we've used. For example, throughout the document, we talk about weight control and the importance of reducing -- of increasing nutrient density by decreasing fat and sugar -- added sugars and fats.
But we've sort of gone through. And every time it said decrease fat, we've made it more complicated by saying decrease certain types of fat. And it just makes it a more involved message that recurs repeatedly throughout the document.
DR. GRUNDY: I see. Somehow you have to take the headline that we're going to decide on and then bring that in throughout the document. Right? That has to be done. Right?
DR. MURPHY: Exactly.
DR. GRUNDY: So we have to be very concerned about the wording throughout the whole document once we --
DR. MURPHY: And since we don't know the headline exactly yet --
DR. GARZA: I would be less concerned about bringing in hydrogenated vegetable fats --
DR. GRUNDY: Yes.
DR. GARZA: -- because of the trans issue and Meir than just to say, you know, "Choose foods low in saturated fat and don't worry too much about hydrogenated vegetable oils". I don't know whether most consumers could deal with that anyway.
DR. STAMPFER: Well, can I comment on that? I think the theme when we talk about fat in the other guidelines should be saturated fat -- saturated fat, either that alone or saturated fat and cholesterol, and not total fat. And, you know, yes, it's complicated. But that's the biology and that's where the science is. So we have to deal with -- I mean, part of this is education for the consumers.
Regarding the hydrogenated fat, I think it is an important issue. I don't think it should be part of the recurring theme because of the extra complication. But for that reason -- and this came up earlier yesterday talking about, well, should there be a whole paragraph on trans.
Well, I certainly support that there absolutely should be quite a careful explanation because -- precisely because it's complicated and this is the only place that consumers get it.
It's not on the food label. And this is our opportunity to provide some education. Trans is unique because it -- it raises LDL cholesterol and lowers HDL. There is nothing else that does that. If you want a fat to target, that's a bad one. It's -- but it's two percent of calories approximately.
So quantitatively, it's less important. But gram-for-gram, it's certainly about twice as bad as saturated fat on the LDL/HDL ratio. So I think -- I think it deserves and needs the paragraph in the fat guideline. But I don't think it merits the recurring theme. And I think the recurring theme should be saturated fat.
DR. GARZA: So, all right, Meir agrees then. Okay. Alice?
DR. LICHTENSTEIN: And for the most part, if saturated fat goes down, then cholesterol is going to go down. So I think you -- to simplify it, you could just go with the saturated -- foods that are low in saturated fat.
DR. GARZA: Lesley?
DR. TINKER: I think some of it may be tempered by which of the guidelines across the top line we're talking about. For example, in the weight -- the weight guideline, when the concept is energy density and trying to decrease that, it might be an easier message to understand about total fat than saturated fat, not to exclude saturated fat.
But the question would be like, "How would you bring in the saturated fat and cholesterol in the weight guideline and still get the energy density?". So what I'm suggesting is it may be tempered a bit since we're using it as a guideline, not a -- not a locked in grid, to look at the separate guidelines and see which ones work best.
DR. GARZA: Okay. Roland?
DR. WEINSIER: Yes, I'm not sure this is the place to introduce it because I'm falling back to the comment about the ABCs or the ABMs, the -- you know, the adequacy, balance and moderation. These -- these terms get me back to the science side and away from the consumer side.
They are important for us to consider around this table. But I don't see them as important messages to the consumer which have to be action-oriented and realistic and practical. The theme that I see running through this is choosing plant-rich meals and being physically active. And if there are only little bits of information of sound bites that we can get across, I think we need to be very clear on what those are.
As scientists, we need to make sure that the message involves moderation, adequacy and balance. But I'm not sure that those are the words or the concepts that need to come across in the document. I think the words and the emphasis are on choosing plant-rich meals and increasing physical activity with re-emphasis throughout essentially all the guidelines.
The only one I can't really fit that in is the safety one. But I don't know if I'm going off on a tangent here, but I just don't want to lose sight of what we're trying to do.
DR. GARZA: I think all of us would agree that -- that there is an important message in getting the American public to increase its fruit and vegetable consumption. But neither do we want to say, gee, you don't have to pay attention to any other part of your diet.
And that's -- that's the balance that we have to always struggle with is, yes, if you're just a vegetarian, you have to worry about legumes and other -- and other protein and mineral-rich foods. If you're an omnivore, then you have to go with making sure that you don't have a lot of saturated fat in your diet. So it's -- it's agreeing, but not being too simplistic that we -- we misinform people either. So --
DR. DECKELBAUM: You go to museum of ancient civilizations. You quite often see wheels and circles as something that has formed the structure or belief and of course later implementation. And we will go into this century. I have a modest suggestion that if we -- if we sort of had a wheel or a circle with the different guidelines and here at the base --
(Laughter.)
DR. DECKELBAUM: -- you can have weight and physical activity and perhaps a line for safety which crosses, you know, all the guidelines. That might be a -- sort of a visual approach that one could use. And then the -- of course, the advantage of a wheel is for those who have their favorite guideline, you can rotate it so --
(Laughter.)
DR. GARZA: So much enthusiasm. I don't want to -- but what I would like to do is concentrate on the theme you're going to incorporate in the text and let the --
DR. DECKELBAUM: I think it's --
DR. GARZA: Yes, it does. But use -- use the concepts that are driving it so that as we -- as you look at the text, we deal with the issues of the bottom line messages, much as Roland has been asking us to do.
DR. LICHTENSTEIN: This is our joke about --
DR. GARZA: Yes, I know. But that's -- okay. Now, let me get then to format in the last 35 minutes that we have to make sure that we are all on the same page. I think we have a pretty fair idea as to the format in terms of the guidelines for what we're going to at least be working from. I mean, most of them are -- are in pretty good shape now.
The next issue though is how we then support the recommended changes. And I will throw out the following format. And then we can -- so that we can have something that we can start a discussion on, that we very carefully outline the changes that are being recommended in each of the guidelines. If it's a new guideline, obviously it's all -- it's brand new. And so for that -- in that case to make sure that you identify the key concepts or ideas that will be incorporated in that guideline.
And then under each of those headings, either for change or key idea, as -- for the new guidelines, we will have three sections. One section concentrates on supporting evidence. That briefly, not exhaustively, but briefly gives both the strengths and the weaknesses of the documents you're going to cite in support of the change.
A second section that deals with other evidence that may not be as supportive. And I'm having difficulty trying to come up with a label for that section that -- that was suggested I think by Shiriki. Maybe she could help me with what do we -- what do we call that section. Again --
DR. LICHTENSTEIN: Do you mean peer reviewed versus non-peer reviewed, or is it --
DR. GARZA: No. We -- this all has to be peer reviewed. You do not have any --
DR. LICHTENSTEIN: So no focus groups because that's not peer reviewed.
DR. GARZA: Well, I don't know whether we can use focus group data for the basis of a change. I mean, you can --
DR. LICHTENSTEIN: But to support it, but --
DR. GARZA: I mean, we can talk about a change -- yes.
DR. WEINSIER: I mean, Alice's point is well taken. I mean, a lot of --
DR. GARZA: No, no. I'm -- I'm agreeing. I'm not disagreeing.
DR. SUITOR: Some of the changes are communication changes and others are content.
DR. GARZA: Yes. And I guess I don't feel that we're as compelled to put a scientific justification for the communication changes. I mean, I don't know how you do that. If you -- so that we should really be addressing the more substantive.
DR. LICHTENSTEIN: Then I guess I don't understand the section.
DR. GARZA: Now, some of the changes are substantive. For example, I think "added sugar" I think has both a communication and a substantive piece to that. So we ought to be able to provide the scientific basis for that change.
And I -- it will require judgement on your parts to decide what is just communication and what is more substantive. On the substantive issues though, we'll need supporting evidence, other evidence that in fact isn't supporting, and again briefly going over the strengths and weaknesses of that database, and then a concluding paragraph or paragraphs.
Or as -- as you look at the body of literature, the conclusions that you came to based on those analyses for each of those key points for -- in -- in the case of the new guidelines and the changes for the existing guidelines that are substantive.
DR. LICHTENSTEIN: Oh.
DR. GARZA: So let's have a discussion of either modifying that or if you feel comfortable with that. Rachel?
DR. JOHNSON: I guess I have a question. If we present other evidence, do you -- you know, if that other evidence is in the peer reviewed literature but we feel that the supporting evidence out-weighs that or do you want us to -- I mean, I don't view it as our role to really present a critique of the other evidence if it's -- I mean, you know, do you want us to point out the holes in the other evidence or do you just want us to somehow --
DR. GARZA: Why did you find --
DR. JOHNSON: -- communicate a balance that the supporting evidence out-weighed the other evidence.
DR. GARZA: Either because of strength or quantity, but I -- I want to make sure that we can point out that in fact we looked at as many sides of an issue as -- as we could rather than just to say, well, here is my case and I didn't look at any other part of the literature, only those that supported what I wanted to tell you.
DR. LICHTENSTEIN: Is this then -- it would have to be essentially an exhaustive review of the literature if you're going to go with both sides.
DR. GARZA: Well, exhaustive in the sense that we've got five years, though we would certainly expect you to be able to judge, you know, which are the highest quality papers for both for and against, and that you limit your -- your discussion to those papers.
I don't think we can -- we either have the time or necessarily the support to be able to do it exhaustively. I mean, in some areas, that would mean literally hundreds of papers. It can't be done.
DR. LICHTENSTEIN: That's why I'm bringing it up.
DR. GARZA: Yes, no, you can't do that. And so that, you know, you should be able in your strengths to say, look, you know, here is -- I really like this paper because it's a double-blind control trial; it was designed real strong; it was -- and it trumped these other three that were purely observational.
They are the strongest papers we could find and they have these additional weaknesses that made it very difficult to undermine the control trial that was done. Is that -- does that type of --
DR. DECKELBAUM: When I look at the grain guideline, I actually need guidance on this because I think the science base for whole grains is strong. But I think part of this meeting and even the previous one has -- you know, has brought up questions as to, you know, concerns if we sort of -- if we make whole grains 50 percent or more of the grain -- or 78 percent of the grain input, could that have, you know, adverse effects because of the fortified or enriched grain sector.
And if we're going with the adage, do no harm, so the do no harm evidence that we're going to get is not published data, but it's going to be on data available to government sources because there is not going to be a lot of published data that we can base our conclusion, do no harm. So I'm just -- I --
DR. GARZA: Well, but the basis for the change is not going to be that analysis, but the body of data that you've referred to. So if you don't feel that the data are strong enough on which to place public policy, then we ought to say that and -- when we review that in September.
If you feel that it is, you can always say, gee, we think we ought to increase our intake, give whatever -- whatever guidance you feel the data permits you to give. Does that --
DR. DECKELBAUM: Well, that's why I brought up the possibility of changing the word, "especially", to "including" because including and putting whole grains in puts us a strong emphasis in the bullet on whole grains. But --
DR. GARZA: Maybe "including" is as far as we'll be able to go this time.
DR. DECKELBAUM: So, I mean, this is what the group brought up. And I take that seriously, do no harm. And I think that's a major point.
DR. GARZA: That's right.
DR. DECKELBAUM: And on the do-no-harm side, do we have published scientific literature?
DR. GARZA: That gets to quantity is what you're saying.
DR. STAMPFER: You know, just to -- in terms of the literature review, what are you balancing that fear against? Where is the published data that says it's going to be harmful that you're countering? There is no data. So, you know, I don't think it's an issue here. I mean, you're taking some unpublished data to support a position that's not going -- countering any published data that there is harm. So there is no problem.
DR. GARZA: Well --
DR. DECKELBAUM: No, but the question came up if whether whole grains might displace other types of grains that carry with them some beneficial nutrients. So one example -- the studies have been mainly done on adult populations. But the groups who may be more at risk for nutrient -- for a fall in nutrient intake could be children and adolescents. So they would be getting the same message.
DR. GARZA: Well, there is huge data, Meir on bioavailability and minerals and whole grains. The issue is whether there is any data that says that that's theoretical or -- or a body of literature can influence how much --
DR. STAMPFER: Yes.
DR. GARZA: -- we can recommend. And so that there is some merit for the working group to look at the data carefully and see whether they can defend "especially" or "including" unless -- because in operationalizing that in a guideline will be important that we tell people, gee, three or -- or six of the 11 or three of the six servings should be whole grains.
And if -- if there is any epidemiological data that could help the group bring greater specificity to that guideline, that would be great. If not, all we can say is based on epidemiological data, the inclusion of whole grains in your diet, you know, is healthful.
And we're not quite sure what -- what ingredients there are about whole grains that makes it possible, but -- and therefore, we -- we're recommending the inclusion of the whole food rather than, you know, taking a fiber supplement alone or -- or any nutrient associated with grain foods alone because the science doesn't permit us to identify any single component.
But something that -- that would help us quantify the guideline. So if -- if I volunteer Meir to help you with the epidemiological quantification of that --
DR. DECKELBAUM: He's already agreed.
DR. GARZA: Yes, okay. But does that give you a sense? I mean, it's -- it's going as far as a science base will permit us and giving people good advice. Okay. Does everybody feel they have enough of a -- this is enough guidance for getting this ready?
You know, given the dates of our upcoming meeting in September, then I would suggest that you try and finish both the text for guidelines, because obviously you're going to have to then build from that text the supporting documentation since it will be either changes or key concepts; that we try to do all of this by August the 15th because that will then permit us to circulate the material, ask people to read over it, get back to Shanty by September 1st so she can put down your concerns and comments in the booklets then that you would be getting that would be distributed for our meeting in September.
What is the date? Maybe that's not even more -- that's not enough time for you. I don't -- it's the 7th? No, that doesn't give you enough time. Yes, what date line do you need to get it mailed out and prepared? Two weeks before?
Well, August the 15th -- yes, I wanted to see if we could have an iteration with the whole committee so that the committee's comments could be looked at -- could be included in the notebook you would get, so that in fact you would -- you would know the concerns that Scott had or that Shiriki had.
And then we would come prepared for that September meeting to be able to address some of those concerns rather than to just deal with them here without any -- any ability to think about whether you thought they were valid and, therefore, possible changes.
MS. LYON: How far in advance to want to have them to look at them would be the question. With August 15th, we could probably get them to you for sure by a week ahead.
DR. GARZA: The other thing is whether you want to look at calendars again and sort of look at another date in September or -- yes, I think that's -- that's even more difficult. So it's -- all right, because I just saw people looking at what's moving ahead, or do we not worry about trying to get an -- an iteration and just get things by the 15th; have Shanty mail you the notebooks and just react here?
DR. STAMPFER: We're going to work through Carole?
DR. GARZA: Well, you're going to work through --
DR. STAMPFER: I mean Shanty and Carole.
DR. GARZA: Shanty and Carole, that's right.
DR. GRUNDY: Can I follow up on that question?
DR. GARZA: Sure.
DR. GRUNDY: One thing that I think would be very helpful, if -- if I knew who I relate to specifically and who can give me definitive information to interpret what you just said. Now, you know, I think that it might be -- I kind of have a general view of what you just said. But somehow all of that has to be very clear in the minds of a staff person that I interact with closely because I would do this by many phone calls or e-mails to work out the details of this. So --
DR. GARZA: Well --
DR. GRUNDY: -- how --
DR. GARZA: -- each of the working group has a key staff member that they're working with. And I would like to come back and say, well, do you want to -- you know, is it best to relate to that staff member so that we don't make Carole the funnel of every -- you know --
DR. GRUNDY: Well, that's the question I'm raising.
DR. GARZA: Yes. No, and I -- I --
DR. GRUNDY: Yes. And I would like to know who that person is --
DR. GARZA: And then have those individuals deal with Carole so that --
DR. GRUNDY: Well, that could be --
DR. GARZA: -- could be easier.
DR. GRUNDY: I mean, Kathryn I've worked with very closely. But now that seems to have broken down a little bit this last time because Carole has taken the lead. So, you know, I had a bit of a problem there.
DR. GARZA: I think if there are -- if there are questions that have to do with -- with process, that the staff should be able to handle those pretty well. Once you get to text, then I think we've got to shift to the -- to you and Carole working together because you're now not putting substance to it, but trying to --
DR. GRUNDY: Right.
DR. GARZA: -- to say, gee, you know, we don't -- the references don't seem to match or, you know, there's -- you're not addressing this change. And yet it seems to be a very important one in the guideline. And it's -- it's a hole in the document that needs to be addressed. Is that sort of differentiation going to be confusing? Shiriki?
DR. GRUNDY: Yes, just a bit. But not --
DR. KUMANYIKA: Well, I had the same problem. And I think what -- at least for some of us, what's helpful to me is to have the staff liaison be a coordinator and to make sure all the communications get to the right people and that I'm reminded of what I'm doing when.
But that could be duplicative with communication directly with Carole. I just don't want -- it's not an either or situation because we need both. We need to communicate directly with Carole, but we also need somebody to help make those things happen. And that's -- that's --
DR. GARZA: Yes, but that we've had -- I mean, you've --
DR. KUMANYIKA: Well, then that broke down the last time. The staff was out of the loop and it got --
DR. GARZA: Why did it not -- why did it not -- because it seemed to have worked with some groups and not others then. Is that because a person wasn't available or there was a shift in personnel or --
DR. KUMANYIKA: No. I think there was a misunderstanding --
DR. GRUNDY: Out of the loop is the right word.
DR. KUMANYIKA: -- of whether they were still needed in the loop.
DR. GRUNDY: Right, exactly.
DR. KUMANYIKA: And we figured out too late that, yes, they were needed in the loop.
DR. GARZA: Well, they're still needed in the loop is what I want to stress. I don't think that we've gotten anybody off the loop. Am I --
DR. MURPHY: Well, all communications should go to both people.
DR. GARZA: Exactly yes.
DR. MURPHY: I mean, when I send something to Carole -- this Carole, I always copy this Carol.
DR. GARZA: That's right.
DR. GRUNDY: That would be the case with that. I want to know exactly how I should do it.
DR. GARZA: Do it -- all right. Do it -- do it by e-mailing and copying both.
DR. GRUNDY: Yes, all right.
DR. GARZA: So anything you send to one, send to the other.
DR. GRUNDY: I like to talk on the telephone. And you don't get this straightened exactly what am I supposed to do now, this week, and have instructions. And I would like for that person to know that.
DR. GARZA: Okay. And, Kathryn, I mean, we'll work with Carole. And you should, Scott, then communicate -- e-mail both --
DR. GRUNDY: Right.
DR. GARZA: -- and either Carole or Carol or both will get back to you. But they're your two contacts.
DR. GRUNDY: Okay. That's very helpful to me.
DR. MEYERS: Yes, and we will track -- that -- that will enable the government staff, liaison, to track the process, to make sure that the process is going and nothing is falling through. And it will enable you two to work on substance. And then we will also -- we are also setting up an internal process for weekly conversations with Carole and all the teams, as well. So in theory it should work.
DR. GARZA: So does that help everyone?
MS. DAVIS: Maybe we should go over who are the groups again. There has bene some personnel change. Does that -- yes?
DR. GARZA: All right. Then let me ask each of the chairs if they knew who their -- their contact person is.
DR. GRUNDY: Kathryn is my person, right, Kathryn?
MS. McMURRY: Right.
DR. GRUNDY: You're my person.
MS. McMURRY: Right.
DR. KUMANYIKA: And I'm working with --
DR. GARZA: Shiriki?
DR. KUMANYIKA: -- Joan, with --
DR. GARZA: Joan. And now is going to I know change assignments soon. But not before this process is over?
MS. McMURRY: We may need to a dual cc.
DR. KUMANYIKA: We need to talk about that.
MS. LYON: Today is my last day.
DR. GARZA: Yes, I know.
MS. LYON: Part-time, I get to be part-time.
MS. McMURRY: Yes, we've managed to have a little of her time.
DR. GARZA: All right. So we should -- Shiriki should still continue to talk to Joan until other -- other --
MS. McMURRY: Yes, well, but I think that Kathryn --
DR. KUMANYIKA: I think that Kathryn, too.
DR. GARZA: All right. So Joan and Kathryn.
DR. LYONS: CC me.
DR. GARZA: All right. So it's Joan and Kathryn, Shiriki.
DR. KUMANYIKA: Okay.
DR. WEINSIER: But my understanding is that Joan is the primary person. But I've had tremendous support from Kathryn and, I don't know, Alyson, Carole and Shanty.
DR. GARZA: Okay.
DR. WEINSIER: Am I correct?
DR. GARZA: Btu continue with Joan and Carole as your primary contacts. Bring in whoever else you wish certainly, but they're --
DR. WEINSIER: Yes.
DR. GARZA: -- they're the primary people --
DR. WEINSIER: But it's worked well.
DR. GARZA: Lesley, I think it's Kathryn --
MS. McMURRY: Sometimes e-mail is -- is consistently available outside of the office. So if you could cc me on -- you know, Joan -- cc me and make sure we don't lose anything.
DR. GARZA: So the physical activity guideline, is it you, Kathryn, that is the primary staff person?
MS. McMURRY: It's Joan and --
DR. GARZA: Joan and Kathryn. All right. Rachel?
DR. JOHNSON: I believe mine is Carole Davis and Alyson Escobar. And I always cc Shanthy and Carol Suitor.
DR. GARZA: Okay.
DR. JOHNSON: Is that --
DR. GARZA: That sounds great.
DR. JOHNSON: Am I right? Now, I don't know. Carole or Alyson, is one of you my main contact?
UNIDENTIFIED VOICE: Me.
DR. JOHNSON: Okay.
DR. GARZA: Richard?
DR. DECKELBAUM: Working with -- with Meir and Alice. And we finished most of our work early on. I think we were one of the early ones. And so we were working with Etta Saltos. And I think, Alyson, you were going to replace Etta Saltos.
DR. GARZA: So who is the primary person?
MS. DAVIS: She can be, fruits and vegetables.
DR. GARZA: Well, we're with grains now. So don't -- don't confuse us.
MS. DAVIS: Grains, oh, okay. Grains, too, for her. Grains, too.
DR. KUMANYIKA: Healthy eating pattern.
MS. DAVIS: And cc me. So she would be the main one for grains and fruits and vegetables.
DR. GARZA: All right. So it would be Alyson and you would cc Carole.
MS. DAVIS: CC me.
DR. GARZA: And then Alice?
DR. LICHTENSTEIN: I'm on fruits and vegetables. So it would be --
DR. GARZA: It would be Alyson with a cc to Carole. All right. And alcohol?
DR. STAMPFER: Joan and Kathryn.
DR. GARZA: Joan and Kathryn. So the primary person is --
DR. STAMPFER: Kathryn.
DR. GARZA: Kathryn is the primary person. And the Suzanne's guideline.
DR. MURPHY: Oh, no. The first guideline.
DR. GARZA: Who is responsible for Suzanne's guideline?
DR. MURPHY: Carole, and I don't know who else I cc.
MS. DAVIS: Alyson can be cc'ed, but I'm the main --
DR. GARZA: But Carole is the primary person. Well, is that clear then? Because this -- as we come to the home stretch on this, Scott, is that going to be all right? We have to make sure that each of you understands what the --
DR. GRUNDY: Right. I think that is very helpful. But I think it's also -- all the staff liaisons should know exactly the process that we're -- we've talked about here. Maybe if you could --
DR. GARZA: Well, yes. And the point that Linda has made that they will -- they will be meeting weekly.
DR. GRUNDY: Yes, that's right. That should help a lot.
DR. GARZA: That should keep everybody informed.
DR. GRUNDY: Right.
DR. GARZA: Now, if you find, however -- if any of you find that for whatever reason either staff is not able to get back to you, then don't wait until three weeks have gone by. Get to Shanthy and say, gee, you know, it's been three days and I've not heard. And Shanthy will be the -- the fall-back for if after three days you don't think things are going right.
But don't make the default time more than three days. The worst thing that can happen is for us to come back in September and for one of you to say, "Well, gee, I tried in July and I never got an answer to this e-mail", so that you've been waiting for two months --
DR. KUMANYIKA: Could we be practical --
DR. GARZA: There must be -- the accountability will be with the committee member that if you don't get a response within a three-day period, that either you understand why or that you'll get to Shanthy so she can help you.
DR. STAMPFER: Just sort of to pursue this line of exactly what we're going to do from now until September. It sounds like a pretty big task ahead. Are -- originally there was the suggestion that -- that everyone respond to the details of the current draft. Now, is that still on the table, that everyone respond?
DR. GARZA: Yes.
DR. STAMPFER: To this -- this draft. And then by some --
DR. MURPHY: We need a date for that, I agree.
DR. STAMPFER: I think we -- we talked about some date coming up.
DR. GARZA: Yes, we talked about July the 15th.
DR. STAMPFER: Okay. And then the --
DR. GARZA: So that you should get your comments into the current draft by July the 15th. Now, that doesn't mean that any of you should wait to work on those drafts until July 15th. That you should -- you know some changes that have already been agreed to.
And you should start working on the documentation of those changes. But if -- if you want any more changes other than the ones that have been discussed here, you should get those comments, whether they're of the niggling kind or the more substantive kind, to Shanthy and she will then distribute them.
DR. STAMPFER: Okay. And then the next sort of question --
DR. GARZA: Well, before we leave this one, does everybody understand?
DR. STAMPFER: And so she'll distribute them to everyone.
DR. GARZA: Or at least to the working group because everyone won't be responsive. Now, she can -- if you want to see everything, we can do that. That would be easier I heard someone say.
DR. STAMPFER: Define, see everything. You mean, if Meir sends a copy --
DR. GARZA: If Meir sends something on variety --
DR. STAMPFER: -- to Richard, do I need the copy of his --
DR. GARZA: And then you will see the -- his comments on variety; if -- if Alice sends something on physical activity, you would see the physical activity. If Scott sends something on fruits and vegetables, you would see it on fruits and vegetables.
DR. MURPHY: But could they please be compiled so we don't get two or three e-mails every day on different topics? And then on July 15th, I don't know what I have and what I don't have.
DR. GARZA: So how -- how do you want to do that? Do you want to just have weekly updates so Shanthy just sends all the material once a week?
DR. MURPHY: How about if Shanthy --
DR. STAMPFER: Sorted by guideline?
DR. MURPHY: How about send it all on July 15th?
DR. GARZA: Okay. On July 15th --
DR. MURPHY: Sixteenth.
DR. STAMPFER: But then -- then the -- the main author of the text, Carole, is going to have a lot of work to do, and the chairs. I mean, maybe it's good to get some of the comments earlier if we can.
DR. GARZA: All right. Let me try this. And staff needs to be very, very, very frank. We can talk about a two-tiered process. One is that when Meir sends his comments to Shanthy about the -- to the -- that relate to the various guidelines, you would be the traffic cop and send those comments immediately to the chair. And everybody else, you would wait until the end of July and to Carole.
And so that -- so that Shanthy then can begin accumulating the comments for mailing out to everybody by the 15th. She wouldn't wait until the 15th to send them to the specific working groups. You would get those immediately. So that as comments came in on the -- on the first guideline, they would be sent to Suzanne and to Carole. And in this case, you would send them to me.
DR. STAMPFER: The related thing is it will be very helpful if we're really careful about sort of when the new drafts are presented so that there is no confusion of which version we're commenting on because that's really a drag to be commenting on the draft that has already been tossed out. So if they can be -- you know, we can, you know, date them and be really clear.
DR. GARZA: They'll be dated. I mean, all drafts that you get of the guidelines or of the green book will have a date.
UNIDENTIFIED VOICE: Could I --
DR. GARZA: Well, hold it. Let me get -- let me go just down the -- Alice?
DR. LICHTENSTEIN: I need a little bit more clarification on the comments. We've had a tremendous amount of comments over this three-day period and we've discussed them and whatever. We're talking now about comments over and above what's already been said?
DR. GARZA: That's right.
DR. LICHTENSTEIN: Okay. Because I guess now I'm having a little problem understanding what exactly to do with the comments. The model here is the comments were made. We've discussed it. Occasionally we've polled the committee. Now we can be getting multiple comments on the same sentence or -- you know, or -- or section from different committee members. We won't have the advantage of being able to discuss it and bat around alternatives. So if they're not consistent, what -- how --
DR. GARZA: Then you're going to have to use your own judgement, Alice. This -- this is --
DR. LICHTENSTEIN: Okay. Fine. I have no problem with that. I just wanted to get lessons to do that.
DR. GARZA: No, definitely you can do it.
DR. LICHTENSTEIN: Great. Okay, that's -- that's great. The other --
DR. MURPHY: Can we not poll the group? I mean, if we get two really divergent --
DR. GARZA: Well, that's your judgement.
DR. LICHTENSTEIN: That's a judgement because otherwise it's going to get extremely cumbersome.
DR. GARZA: Yes, if someone is niggling and you just think that, gee, that makes a lot of sense because it just clarifies the sentence, then I don't think you need to send the clarification to everyone. On the other hand, you get two very opposing views that are quite substantive. Then why don't you --
DR. LICHTENSTEIN: Sure.
DR. GARZA: -- call me first and then we'll decide if we're going to go ahead and -- and -- otherwise it can get really confusing very quickly.
DR. LICHTENSTEIN: That's what I'm getting at. And then just from a very practical perspective, this, you know, sort of three days that we should be getting responses back and forth, does this mean Shanthy doesn't take any vacation and -- I mean, I --
DR. GARZA: No, Shanthy gets no fun or frivolity at any time.
DR. LICHTENSTEIN: I mean, what -- you know, if we don't hear in three days -- we don't hear from Shanthy in three days, I mean, I don't understand exactly how that's going to work on a practical basis. And what's feasible?
DR. GARZA: Are there three days -- I used three days as an example.
DR. LICHTENSTEIN: Right.
DR. GARZA: I mean, I don't think that, you know, 72 hours comes to the clock and you have to panic. But it's -- it's -- I wanted to stress that you --
DR. LICHTENSTEIN: The real issue --
DR. GARZA: -- shouldn't wait. That the onus is on the committee to make sure that the process is moving along.
DR. LICHTENSTEIN: Okay.
DR. GARZA: So if you can tolerate five days, it's because you can tolerate it. But you shouldn't come to the committee meeting and say, "Well, you know, I e-mailed X and" --
DR. LICHTENSTEIN: Okay.
DR. GARZA: -- "X never responded so" --
DR. LICHTENSTEIN: So then you just go to Y if you haven't heard from X.
DR. GARZA: Yes. So is it -- is that enough of a guideline to --
DR. GRUNDY: Yes, right. And another question. the green book that we're working on, is there a draft to that now?
DR. GARZA: Yes, it's in here.
DR. GRUNDY: Okay.
DR. LICHTENSTEIN: Tab 10.
DR. GARZA: Tab 10.
DR. GRUNDY: Okay. So it's a draft that we are to modify, that's --
DR. GARZA: Oh, that's -- it needs extensive modification. That is in the least good shape. The best is --
DR. GRUNDY: Right.
DR. GARZA: -- the guidelines are in better shape than Tab 10.
DR. GRUNDY: Okay. Is that on e-mail so that we can -- I mean is that on a disc?
DR. GARZA: It will be. You will --
DR. GRUNDY: It will be on a disc.
DR. GARZA: Okay. Good. Because it doesn't follow the format that we've just discussed for example.
DR. GRUNDY: Right. Okay.
DR. GARZA: But it is a -- a starting document. Now, the difficulty there is though -- and that brings up another -- another logistical issue. Is
whether -- don't work -- don't modify that draft other than your own sections. Otherwise, I don't see how Carole can keep track.
So that as you modify each of the guideline -- each of the components of Tab 10 that relate to your -- to your guideline, then modify only that part. You can send your comments to other people. But Carole will assume that -- that in fact the only person making the modification on Tab 10 will be the chairs of the respective guidelines.
So the chairs will -- will coordinate within their working group. Does that -- would that be the easiest way, Carole, for you to keep track of who is doing what?
DR. SUITOR: Well, there is also the possibility, like Alice has sent faxes of things that she wants to have changed. And that's fine to not go in and work directly in the --
DR. GARZA: Okay.
DR. SUITOR: But --
DR. GRUNDY: Is that better?
DR. SUITOR: It can be --
DR. GRUNDY: Would that be better?
DR. SUITOR: It can be easier. It's easier for me to spot changes in what you want.
DR. GARZA: Well, how would you -- how would you prefer it?
DR. SUITOR: Well, what -- I think that the committee members can choose which they prefer.
DR. GARZA: Let me ask this. Then if you make changes in the electronic version, that you bold the changes that you send to Carole so she'll know that on the version that's dated July 4th, you know, and it has the bolded copy, she will be able to know the changes you made on the July 4th copy. Then when --
DR. SUITOR: Because sometimes the revision marks don't show up, sometimes they do.
DR. GARZA: Well, I was going to say, bolded should -- should --
DR. LICHTENSTEIN: But you can't bold things if you eliminate them. And that's where the confusion comes in when you electronically --
DR. GARZA: Well, that's the problem. All right. Let me ask that you put -- we'll really getting to the nitty-gritty -- things you want to eliminate, put in parentheses. The parentheses always -- always show through. Okay. Or -- Carole, is that going to be all right? If eliminated text will be in parentheses and added text will be in bold. How do you want to do it because people feel that they want very detailed instructions.
DR. SUITOR: It might be useful for me to meet with staff --
DR. LICHTENSTEIN: Yes, we would like to do that.
DR. SUITOR: -- after this and we set out --
DR. GARZA: Okay.
DR. LICHTENSTEIN: And then we'll send it out.
DR. SUITOR: -- some suggestions.
DR. GARZA: All right. That's fine. Is that -- is that all right with the committee?
CHORUS OF VOICES: Yes.
DR. GARZA: And you will be given detailed instructions on how to change text and -- and so we can keep control and come here with a relatively unencumbered and clear draft.
DR. LICHTENSTEIN: And we'll also send out the time line and the procedures.
DR. GARZA: Yes. And when -- when will staff get together to do this?
DR. LICHTENSTEIN: We're asking that they meet right after this meeting. And then we also have a conference call scheduled on Monday morning.
DR. GARZA: So people should get --
DR. LICHTENSTEIN: So you should have it by Tuesday or Wednesday.
DR. GARZA: Tuesday or Wednesday, that's great. All right. So we've got several key deadline dates though. One is -- the most important will be August the 15th whereby you will try to get as many of these documents to the point that they will be considered by -- at the September meeting. So keep that August the 15th date on your -- on your vacation calendars. Okay? All right. Any other format, process, staff? Carol, since you're a key person, do you have any other --
DR. SUITOR: I think if I work things out with staff --
DR. GARZA: There's no other thing that you need the committee for then. Shanthy, any -- any issues? That would be the staff, so that's -- Kathryn?
MS. McMURRY: For clarification, that will be August 15th drafts will be distributed to this committee. The committee will be expected to comment on those in writing?
DR. GARZA: Well, and the other thing I think we could -- we could hope to do by August the 15th is get them to people as early as we can. And if there are substantive issues, I think that trying to get a general iterative process is going to be impossible. That --
MS. McMURRY: Well, if we could suggest that they e-mail --
DR. GARZA: Yes, e-mail or things like that we'll have to work out.
MS. DAVIS: Yes, I need to have some -- Shiriki -- Richard I've already talked to. I need to -- I need to talk to you more.
DR. DECKELBAUM: Yes.
MS. DAVIS: But there are a few things on the focus group. We're having a second round of focus groups and you might be thinking about the kinds of things that sections that should be tested when you get further along with the text -- we could be doing stuff with e-mail --
DR. GARZA: Well, bring those up with your individual working groups, okay?
MS. DAVIS: Well, I mean, it's just a general thing to think about.
DR. GARZA: So there is a -- there is a second round of focus groups that Carole wants you to think about.
MS. DAVIS: Because I'm not on all the work groups. So --
DR. GARZA: Okay. Any other points before we adjourn? Right on time.
DR. WEINSIER: Well, we don't need to address this, but I thought a major issue this morning was going to be to address basically how are we going to deal with ten, 11 separate guidelines versus some sort of paradigm or whatever since this could be --
DR. GARZA: Well, that was the adequacy --
DR. WEINSIER: Yes, I know, but --
DR. GARZA: -- balance, moderation --
DR. WEINSIER: -- I never felt we came to a --
DR. GARZA: No, but I -- I --
DR. WEINSIER: -- resolution. If somebody asked me where do we stand, I would have to say I don't know.
DR. GARZA: Well, I mean -- first of all, that the overall format is not something that we're going to have to --
DR. WEINSIER: We're going to have to worry about that?
DR. GARZA: -- worry about. I think how that's formatted will be a departmental issue. I mean, all we're doing is recommending the guidelines. If you can think of over-arching concepts that you want them to think about as they --
DR. WEINSIER: Well, that's what I thought we were --
DR. GARZA: And we talked about adequacy, moderation and balance. If you have other -- other suggestions, send them in. I mean, I couldn't think of one -- of any -- of any better one. Nobody else said, "Well, I have." So, again, silence I took as agreement.
DR. WEINSIER: Well, I came up with the one other one. But I can send it again.
DR. GARZA: All right. Well, let's -- let's send it out to the group then because it's a bit late to --
DR. WEINSIER: Right. No, I understand.
DR. GARZA: -- to do that. I hear about 12 conversations at least going on in the room and the meeting is not adjourned. So if I can get Joan and Lesley to hold off just a bit, we will adjourn in just a little while.
MS. McMURRY: I just wanted to -- this is sort of a detail that you need not spend too much time with. But it's something staff could work on as you're working on completing the drafts. There are two appendices in the green book --
DR. GARZA: Oh, thank you.
MS. McMURRY: And just, we would like to get some feedback on whether you would like to include those or not. There is one that deals with the history of the dietary guidelines for Americans and one that summarizes public comments.
DR. GARZA: And those would be done by -- by staff. But we want to know whether you want them included as part of the green book. Again, it's a summary of public comments which was included in the last green book and a history of the guidelines which would just be updated. But it was also an appendix to the green book. The silence then says that you want to see both continued and so that Peter will be helping prepare those.
DR. DECKELBAUM: Will we be getting public comments right until the September meeting?
DR. GARZA: I would hope, yes. And then we would -- the September meeting, we would be -- because that would be the first time that drafts would be available. And we would be making -- so I think we would. I mean, that that would be the --
DR. SUITOR: I think that's desirable.
DR. GARZA: Yes, that that would be desirable. Until a week after the September meeting, and then we could either poll people if there were substantive issues that we wanted to change. And then decide whether we have to have the November meeting because issues have been raised that are of such importance that we can only discuss them in a plenary session.
So I would imagine the public comments would come until some date after September. And we can decide that a little bit later into the process. All right. Any other?
And I just want to thank everyone. This has been a terribly productive meeting, at least from my perspective. We are at the home stretch with still an enormous amount of collaboration and cooperation across all the committee. And I -- at least as a Chair, I want to tell you how -- what a pleasure it remains because it could be quite -- quite difficult and it hasn't turned out that way. So thank you very much. And we'll see you in September.
(Whereupon, at 12:06 p.m. on Friday, June 18, 1999, the meeting was concluded.)
Name of Hearing or Event: Dietary Guidelines Advisory Committee
Docket No.: N/A
Place of Hearing: Washington, DC
Date of Hearing: June 18, 1999
We, the undersigned, do hereby certify that the foregoing pages, numbers 582 through 717 , inclusive, constitute the true, accurate and complete transcript prepared from the tapes and notes prepared and reported by Sharon Bellamy , who was in attendance at the above identified hearing, in accordance with the applicable provisions of the current USDA contract, and have verified the accuracy of the transcript (1) by preparing the typewritten transcript from the reporting or recording accomplished at the hearing and (2) by comparing the final proofed typewritten transcript against the recording tapes and/or notes accomplished at the hearing.
Date: 6-23-99
Name and Signature of Transcriber Heritage Reporting Corporation: Bonnie Niemann
Date: 6-25-99
Name and Signature of Proofreader Heritage Reporting Corporation: Lorenzo Jones
Date: 6-18-99
Name and Signature of Reporter Heritage Reporting Corporation: Sharon Bellamy
Last updated July 13, 1999