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Human Foods and Food-Consumption Patterns Food is the major route for human exposure to dioxins and dioxin-like com- pounds (referred to collectively as DLCs). Most DLCs in foods are contained in the lipid component of foods of animal origin. While DLC exposure through fruits, vegetables, and grains also occurs, it is thought to result primarily from the adhesion of soil to plant material. DLCs have relatively long half-lives in the human body, and the rate of elimination of these compounds from the body is inversely related to age and increased adiposity (Kreuzer et al., 1997), presum- ably on the basis of the age-associated increase in adipose tissue depots. Thus, the overall body burden tends to increase over time, even if exposure levels do not change. The ability to estimate dietary exposure and the within-population variability in exposure to DLCs is limited by the availability of appropriate data. The most recent National Health and Nutrition Examination Survey (NHANES) included testing of serum dioxin levels on a subsample of individuals and dietary measures on all participants, which should provide a clearer picture of exposures. (Dioxin measurements were added to this survey in 1999-2000, and the first data were released in January 2003, too late for inclusion in this report.) At this writing, the best available approach to estimating DLC exposure through diet is to combine information from two sources: the U.S. Department of Health and Human Ser- vices, Food and Drug Administration's (FDA) Total Diet Study (IDS), which has been accumulating information on the DLC content of selected commonly consumed food items since 1999, and the national food-consumption monitoring surveys that are conducted repeatedly by the U.S. Department of Agriculture (USDA). The consumption data selected for this report were based on actual 110

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS 111 intakes rather than on disappearance data in order to obtain a more accurate perspective when the data was applied to exposure estimates. The committee commissioned an analysis based on these data; the analysis is discussed later in this chapter and in Appendix B. Aspects of current dietary patterns in the United States with regard to fat intake and to consumption of products that contribute the largest share of exposure to DLCs (i.e., meats, poultry, dairy products, and fish) are reviewed briefly below. DIETARY-INTAKE PATTERNS Overall, American adults derive about 34 percent of their dietary energy from fat and one-fourth to one-third of that is from saturated fat, which is largely animal fat. USDA survey data (1977-1978, 1989-1991, and 1994-1996) show that the average adult intake of fat in total grams increased slightly (from an average of 78.5 g/d to 83.1 g/d) between the 1989-1991 and 1994-1996 surveys (although the percent of dietary energy derived from fat decreased from 34.9 percent to 32.9 percent, a function of an overall increase in dietary energy intake). Saturated fat intake was more stable over the same time period at an average of 27.6 to 28.3 g/d (although again, the percent of dietary energy from saturated fat decreased). Fat intakes were substantially higher for men than for women (Ken- nedy et al., 1999~. The stability of the average absolute intakes, however, masks real changes in the food sources of fat over the same time period. A steady substitution of low-fat and skim milk for whole milk and yogurt occurred between 1970 and 1990, but consumption of cheese and of cream products (including sour cream, half and half, cream-based dips, and light cream) increased (Enns et al., 1997~. A trend toward more poultry and fish consumption and less red-meat con- sumption occurred over the same time period. Based on national food supply data (Putnam and Allshouse, 1993), the U.S. population per capita consumed an aver- age of 18 lb less red meat, 26 lb more poultry, and 3 lb more fish and shellfish in 1992 than in 1970. Adults (both men and women) consume more meat and fish than children, but children are major consumers of dairy products. On average, children con- sume almost twice as much milk and dairy products as do adults. Fish consump- tion is of particular interest for several reasons. One is that fish consumption has been increasing in the population, and this trend is generally a good one from a health standpoint. However, the level of DLCs in fish is variable; fish from contaminated waterways and those that receive feed that contains DLCs have higher DLC levels. Furthermore, there are relatively small subgroups of the popu- lation whose reliance on fish may be more important than that for the general population. These subgroups have the potential to have substantially higher DLC exposures than the general population.

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2 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY American Indian groups in traditional fishing cultures (primarily in the North- east and northern Midwest) and Alaska Native and northern Canadian groups (Northern Dwelling populations) that traditionally consume large amounts of fish and marine mammals, and rural subsistence and sport fishers in various parts of the country, are potentially at risk. A number of rivers and lakes that are impor- tant for fishing, including the Great Lakes, are near or downstream from indus- trial sources of contamination. While data on dietary exposures to DLCs in these groups are limited, a few studies are relevant. Outside of American Indian groups, there is a paucity of data on the intakes of subsistence or sport fishers. Frequent consumption of game fish is of concern because many of these fish are particularly high sources of DLCs (Anderson et al., 1998~. Subsistence fishing is a cultural tradition in many African-American families and in Southeast-Asian immigrants. DLC Analyses of Foods Consumed Due primarily to the high cost per sample to analyze DLCs, there is relatively little information on the DLC content of the U.S. food supply. Recently however, FDA conducted DLC analyses for selected foods collected as market basket samples in the 1999-2000 and 2001 TDS. The TDS survey samples foods pur- chased by FDA personnel from supermarkets or grocery stores four times per year; one sample is collected from each of three cities from each of four geo- graphic regions. Each market basket contains similar foods purchased in the three cities in a given region. The market basket food samples are then prepared as for consumption, and the three samples of a food from a region are composited into a single sample, prepared in duplicate, and analyzed for DLCs. Representative ranges of DLC content in foods from a portion of the 2001 analysis are presented in Table 5-1 (the complete analysis is presented in Appendix B). The ranges on the table reflect the estimates of the absolute DLC levels in foods not exposure levels, which are determined by the amount of food consumed. Furthermore, the analysis was based on whole food or wet weight rather than on a lipid basis in order to maintain consistency with consumption data and to preserve data quality, although inclusion of the lipid content might have been useful in comparisons among reports. Table 5-1 shows that DLCs may be found in all foods, with a range of content within each food group. However, only in animal products, specifically red meat, fish, and dairy products, do concentrations reach more than 0.10 ppt. In general, higher DLC concentrations are associated with higher fat contents, par- ticularly with animal fats. Foods representing the upper levels of these ranges include high-fat cuts of beef, bacon, frankfurters, full-fat cheeses, fatty fish (e.g., salmon), and butter. On the other hand, within each of these categories, foods containing relatively low levels of DLCs can be selected, including lean steak (0.03 ppt), lean ham (0.04 ppt), cottage cheese (0.03 ppt), shrimp (0.06 ppt), and

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS TABLE 5-1 Dioxin and Dioxin-like Compound (DLC) Content Per Gram in Selected Food Groups from the 2001 Total Diet Study 113 Food Group DLC Content (ppt toxicity equivalents) Meat, fish, poultry, eggs Beef, pork, lamb Processed meats Fish, shellfish Poultry Eggs Dairy foods Cheese Cream/ice cream Milk Fats, oils, nuts Butter Vegetable oils Nuts Breads, cereals Breads Crackers Pasta Breakfast cereal Fruits, vegetables Fruit Vegetables 0.005-0.46 0.01-0.21 0.01-0.33 0.004-0.06 0.01-0.05 0.002-0.24 0.0001-0.06 0.0006-0.01 0.22 0.002-0.06 0.003-0.006 0.001-0.05 0.001-0.02 0.0001-0.02 0.0007-0.01 0.0007-0.01 0.0001-0.05 NOTE: Mean toxicity equivalents at nondetects = 0. SOURCE: Douglass and Murphy (2002). margarine (0.03 ppt). Fruit, vegetable, and grain products have considerably lower concentrations of DLCs, but because large volumes are consumed, these foods also contribute to total DLC exposure (Douglass and Murphy, 2002~. USDA's Agricultural Research Service conducts a nationally representative survey, formerly known as the Continuing Survey of Food Intakes by Individuals (CSFII), which has now been merged with NHANES. This survey provides im- portant information about the types of foods Americans are consuming and the quantities consumed (NCHS, 2003~. The 1994-1996 CSFII was conducted between January 1994 and January 1997. In each of the three survey years, data were collected from a nationally representative sample of noninstitutionalized individuals of all ages in the United States. The 1998 CSFII was a survey of children ages O through 9 years. It was conducted using the same sampling and dietary intake methodologies as the 1994-1996 CSFII so that the survey results could be merged to increase the total sample size for children. In both surveys, dietary intakes were collected through

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4 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY in-person interviews using 24-hour recalls on two nonconsecutive days, approxi- mately one week apart. A total of 21,662 individuals provided data for the first day; of those individuals, 20,607 provided data for the second day. Each dietary recall included a record of all foods and beverages consumed in the previous 24 hours, including the gram weight of each food or beverage consumed. Data obtained from the sequential CSFIIs over the past 30 years indicate a trend in food consumption toward a lower total saturated fat intake and a lower total fat intake as a percent of energy consumed, although with a higher total energy intake. A summary of 1994-1996 CSFII intake data for foods that are most likely to contain high amounts of DLCs is presented in Figures 5-1 through 5-3. The figures demonstrate that differing age and sex groups tend to be exposed to DLCs through intakes of foods from different food groups. For example, male adolescents and men consume considerably more beef than women, with little consumed by children under 6 years of age. More fish is consumed by adults than by children, and more by men than by women. On the other hand, the average milk and dairy consumption is highest for young children; adults consume con- siderably less. The committee commissioned an analysis (see Appendix B) to estimate ex- posures to DLCs from the U.S. food supply for venous age and sex groups. The analysis utilized data from the TDS for samples collected in 2001 (which were 45 40 35 In 30 o O 25 3 20 1 5 CD 1 0 5 o 0-5 M/F 6-11 M 6-11 F 12-19M 12-19F 20&Up 20&Up M F Age Range (y) by Gender FIGURE 5-1 Beef consumption by age and sex, 1-day average intake, 1994-1996. Val- ues represent population intake averages of absolute amounts of beef consumed per indi- vidual for 1 day. Error bars are standard errors of the mean. M = male, F = female. SC)IJRCE- Fond Survevs Research Group (1997~.

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS 500 450 is, 400 In o 350 250 A 200 a: 150 100 50 o 115 0-5 M/F 6-11 M 6-11 F 12-19M 12-19F 20&Up 20&Up M F Age Range (y) by Gender FIGURE 5-2 Fish consumption by age and sex, 1-day average intake, 1994-1996. Val- ues represent population intake averages of absolute amounts of fish consumed per indi- vidual for 1 day. Error bars are standard errors of the mean. M = male, F = female. SOURCE: Food Surveys Research Group (1997~. 40 - ~, 35- 30- (n o ~ 20 o 15 10 25 - o 0-5 M/F 6-11 M 6-11 F 12-19 12-19 F 20 & Up 20 & Up M F Age Range (y) by Gender FIGURE 5-3 Dairy consumption by age and sex, 1-day average intake, 1994-1996. Values represent population intake averages of absolute amounts of milk and dairy foods consumed per individual for 1 day. Error bars are standard errors of the mean. M = male, F = female. SOURCE: Food Surveys Research Group (1997~.

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116 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY analyzed for 17 dioxin congeners). The TDS data were linked to intake data from the 1994-1996 and 1998 CSFII to estimate dietary exposure to DLCs, through foods actually consumed. The TDS weighting factors developed for use in esti- mating exposure based on analyte concentrations in TDS foods are based on results of the 1987-1988 USDA Nationwide Food Consumption Survey, and therefore are not likely to reflect current patterns of intake. Therefore, the analy- sis commissioned by the committee used results from the 1994-1996,1998 CSFII. Because relatively few foods were sampled for the TDS relative to the thou- sands of foods in the CSFII database, CSFII foods were grouped to estimate DLC content from the most similar analyzed food. This method generates substantial errors for individual intake estimates, but because FDA sampled the foods it considered most representative of the U.S. diet, the results should provide reason- able average DLC intake estimates. These limitations must, however, be taken into consideration when interpreting the results. The results of this merged analysis (presented in Figures 5-4 through 5-11) allow a view of the relative contnbution, within the limitations of the data, to total DLC intake from venous food groups based on actual U.S. dietary intake. The analysis did not utilize "usual intakes" (commonly used for nutrient intake levels from foods) because of the extensive variability of levels of contaminants (e.g., DLCs) in foods. Other Foods and Mixtures 10% Fats, Oils and Mixtures 1% Fruits, Vegetables and Mixtures 10% Eggs and Mixtures 4% Fish and Mixtures 4% Poultry and Mixtures'' Meat and Mixtures 35% Dairy Foods and Mixtures 30% FIGURE 5-4 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), children ages 1 through S years. Nondetects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight.

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS Other Foods and Mixtures 13% Fats, Oils and Mixtures 1% Fruits, Vegetables and Mixtures 9% Eggs and Mixtures 2% Fish and Mixtures 6% Poultry and Mixtures' 7% 117 Dairy Foods and Mixtures 24% Meat and Mixtures 38% FIGURE 5-5 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), children ages 6 through 11 years. Nondetects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight. Other Foods and Mixtures ~ 4o/^ Fats, Oils and Mixtures Fruits, Vegetables and Mixtures 9% Eggs and Mixtures 2% Fish and Mixtures 5% Poultry and Mixtures " 7% Dairy Foods and Mixtures 16% Meat and Mixtures 46% FIGURE 5-6 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), boys ages 12 through 19 years. Nondetects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight.

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118 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY Other Foods and Mixtures 12% Fats, Oils and Mixtures 2% Fruits, Vegetables and Mixtures 9% Eggs and Mixtures Fish and Mixtures 10% Poultry and Mixtures 7% Dairy Foods and Mixtures 1 1 % Meat and Mixtures 46% FIGURE 5-7 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), men ages 20 years and older. Nondetects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight. Other Foods and Mixtures ~ Ro/O Fats, Oils and Mixtures 1% Fruits, Vegetables and Mixtures 8% Eggs and Mixtures 2% Fish and Mixtures 5% Poultry and Mixtures 7% Dairy Foods and 17% ixtures Meat and Mixtures 45% FIGURE 5-8 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), girls ages 12 through 19 years. Nondetects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight.

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS Other Foods and Mixtures 13% Fats, Oils and Mixtures 2% Fruits, Vegetables and Mixtures 1 1% Eggs and Mixtures 3% Fish and Mixtures 12% Dairy Foods and Mixtures 1 polio Poultry and Mixtures 7% 119 Meat and Mixtures 40% FIGURE 5-9 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), women ages 20 years and older. Nondetects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight. Other Foods and Mixtures 15% Fats, Oils and Mixtures 1% Fruits, Vegetables and Mixtures 12% Eggs and Mixtures 4% Fish and Mixtures 4% Poultry and Mixtures 7% Dairy Foods and Mixtures 20% Meat and Mixtures 37% FIGURE 5-10 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), pregnant and/or lactating females ages 12 years and older. Non- detects = 0. Percentages were calculated based on mean 2-day average DLC intake/kg of body weight.

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120 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY Other Foods and Mixtures 12% Fats, Oils and Mixtures Fruits, Vegetables and Mixtures 10% Eggs and Mixtures 3% Fish and Mixtures 8% Poultry and Mixtures - . 7% Dairy Foods and Mixtures 7o/^ Meat and Mixtures 42% FIGURE 5-11 Estimated percent contribution of foods to intakes of dioxins and dioxin- like compounds (DLCs), males and females ages 1 year and older. Nondetects = 0. Per- centages were calculated based on mean 2-day average DLC intake/kg of body weight. Because it was not possible to more closely define the food categories, the "fruits, vegetables and mixtures" and "other foods and mixtures" categories con- tain an array of items. Foods that fell within the general category of fruits and vegetables included raw and cooked vegetables and fruits, along with vegetable items prepared as mixtures that contained some milk, eggs, cheese, and meat. The others foods and mixtures category included food combinations and mixtures, some of which were made with animal food products. The imputation of foods in these two groups to data from the CSFII also required making generalizations about specific intakes. The data in the figures are relative exposures, with DLC nondetect levels assumed to be zero. The committee chose this reference value because it felt that, under these circumstances, this value gave the most accurate representation of the DLC intake. The common alternative methods (assuming nondetects = I/2 of the limit of detection or nondetects = the limit of detection) are more conservative, but they tend to artifactually indicate a greater contribution of substances known to be low in DLCs (grains, fruits, and vegetables) because of their relative roles in the total diet. The results of the analysis, discounting the other foods and mixtures cat- egory, suggest that DLC exposure levels to the general adult population from animal-food products and based on estimated amounts consumed by population groups, are greatest from meat, followed by dairy foods and fish. The estimates for dairy foods do not take into account the consumption of low-fat and skim milk because only whole milk was analyzed. The dairy foods estimates do, however,

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS 139 free and easy to implement. Selecting low-fat products; trimming and discarding visible fat from meat, fish, and poultry; discarding skin from fish and poultry; avoiding practices that add or retain animal fat; and washing vegetables and peeling root and waxy-coated vegetables are recommended. Food and Nutrition Assistance Programs USDA administers several food assistance programs that provide a variety of benefits to target recipients. The four primary programs are the Food Stamp Program, the National School Lunch Program, the School Breakfast Program, and WIC. The nationwide average monthly participation rate for the Food Stamp Program was just over 19 million in fiscal year 2002 (FNS,2003b). More than 28 million children participated in the National School Lunch Program in fiscal year 2002, and more than 8.1 million participated in the School Breakfast Program (FNS, 2003c, 2003d). Statistics for the WIC program show that in fiscal year 2002 nearly 7.5 million people participated in the program (FNS, 2003e). The target recipients for the National School Lunch and School Breakfast Programs and WIC participants are of particular interest to this report. Although surveys of participants in the National School Lunch Program showed that they had greater intakes of energy, protein, and several vitamins and minerals compared with nonparticipants, they also consumed greater amounts of total fat and saturated fat per day than nonparticipants (Devaney et al., 1993~. Data from the School Nutrition Dietary Assessment Study-II show that in the survey years 1998-1999, at least 70 percent of elementary school lunches served met the program standard for calories (one-third of the Recommended Dietary Allowance), but exceeded the program standards for levels of fat and saturated fat. Results also showed that, on average, elementary school lunches provided 33 percent of calories from total fat and 12 percent of calories from saturated fat. At the same time, calories provided from carbohydrate were below the recommended 55 percent (Fox et al., 2001~. WIC providers encourage pregnant women to breastfeed their babies and the program supplies a greater variety and quantity of foods and offers longer partici- pation to breastfeeding participants (FNS, 2003a). Fifty-six percent of WIC par- ticipants initiate breastfeeding in the hospital; however, only 45 percent are still breastfeeding at discharge, and only 16 percent continue breastfeeding to 5 months of age. WIC participants who breastfeed and are most likely to continue breast- feeding are those who receive the special food package for breastfeeding mothers along with information and advice on breastfeeding (IOM, 2002b). WIC participants receive a food package that includes milk, cheese, and eggs. The recent report, Dietary Risk Assessment in the WIC Program (IOM, 2002b), identified adherence to Food Guide Pyramid recommendations, includ- ing consumption of fat, saturated fat, and cholesterol, as an appropriate criterion for reducing dietary risk, recognizing that essentially low-income women and

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140 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY children will meet this criterion. However, whether WIC participants are at risk for greater exposure to DLCs than the general population has not been determined. DIETARY GUIDANCE The ultimate goal of dietary guidance and consumer education with regard to DLC exposure is to reduce body burdens across the whole population, and par- ticularly for women prior to pregnancy and breastfeeding. Empowering individu- als, through information, to make dietary changes that reduce DLC exposure is theoretically possible but requires a long-term view. The stability of these com- pounds in the body means that reduction in risk through dietary choice is ineffec- tive in the short run, but it is likely very important over years and decades, particularly if begun in childhood. There are several sources of dietary recommendations and associated educa- tional tools for the general population that are consistent with the reduction of DLC exposure through the reduction of animal fat intake. HHS and USDA jointly developed the Dietary Guidelines for Americans (USDA/HHS, 2000), which provide recommendations to the general population, based on current scientific evidence, about the relationship between diet and risk for chronic disease, and which serve as guides for how a healthy diet may improve nutritional status. By statute, these guidelines now form the basis of federal food, nutrition education, and information programs. The Food Guide Pyramid is designed as an educa- tional tool to translate these recommendations for the public (USDA, 1996~. The U.S. Dietary Guidelines recommend that Americans over the age of 2 years "choose a diet that is low in saturated fat and cholesterol and moderate in total fat," and specifically that individuals should keep their "intake of saturated fat at less than 10 percent of total calories" and should "aim for a total fat intake of no more than 30 percent of total calories" (USDA/HHS,2000~. In this context, the U.S. Dietary Guidelines recommend choosing "vegetable oils rather than solid fats (meat, dairy fats, shortening)" and fat-free or low-fat milks, yogurts, and cheeses, and limiting intakes of high-fat processed meats and organ meats (including liver) and sauces made with cream. Similar to the U.S. Dietary Guidelines, the American Heart Association's (AMA) 2000 dietary guidelines "advocates a population-wide saturated fat intake of less than 10 percent energy, which can be achieved by limiting intake of foods rich in saturated fatty acids (e.g., full-fat dairy products and fatty meats)" (Krause et al., 2000~. Another report, Dietary Reference Intakes for Energy, Carbohy- drate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (IOM, 2002a), is consistent with the Dietary Guidelines and the AHA recommendations in that it identifies the association between the excessive intake of saturated fats with the increased incidence of heart disease and the development of certain cancers. Further, the reports cited above all recommend that individuals strive to

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS 141 achieve and maintain a healthy body weight, that is, to avoid gaining excess weight because of the known adverse health consequences of obesity, indepen- dent of the increased body burden of DLCs due to the accumulation of total body fat. The committee did not, however, find evidence to support a reduction in DLC body burden through weight loss. Thus, preventing obesity is preferred as a means of reducing the potential for DLC accumulation. The committee identified two areas in which changes in individual behavior could reduce DLC exposure, but which are not advised because of countervailing risks. These are reductions in fatty-fish consumption below current recommenda- tions of 1 to 2 fish meals per week and in breastfeeding. Each of these are discussed briefly below. Fish A recommendation that emerged very recently and does not appear specifi- cally in the current U.S. Dietary Guidelines recognizes the potential health ben- efits of fish consumption. Unlike the saturated fat in dairy products and meats, the fatty acids in fish have been shown in epidemiological studies to be beneficial to health. The strongest evidence for the importance of omega-3 fatty acids is a reduction in risk of sudden death from cardiac arrest: epidemiological studies show a lower risk with greater fish consumption among both men and women (Daviglus, 1997; Guallar, 1995; Hu et al., 2002~. Two long-chained, highly polyunsaturated fatty acids, docosahexaenoic acid and eicosapentaenoic acid, are thought to be responsible for these health benefits by providing strong antiarrhythmic action on the heart, by serving as precursors to prostaglandins, and by providing anti-inflammatory and anti-thrombotic ac- tions. There is a large body of epidemiological evidence to indicate that con- sumption of omega-3 polyunsaturated fatty acids, which are present in fatty fish, seafood, and certain vegetable oils, is beneficial in preventing heart disease (Conner, 2000; Hu et al., 2002; Siscovick et al., 1995~. Potential adverse effects on immune function and increased clotting time from high intakes of omega-3 fatty acids have also been identified, but there is a need for greater clinical evidence to support the epidemiological findings (IOM, 2002a). Research is un- derway and will help address these issues. Based on current evidence in support of this decrease in risk for heart disease associated with the consumption of omega-3 fatty acids, AHA recommends eat- ing fish two times per week, including fatty fish such as mackerel, lake trout, tuna, and salmon (Krause et al., 2000~. While AHA acknowledges the reported effects of omega-3 fatty-acid supplements in patients with heart disease, it con- cludes that "further studies are needed to establish optimal doses of omega-3 fatty acids...for both primary and secondary prevention of coronary disease..." and that "consumption of 1 fatty fish meal per day (or alternatively, a fish oil supple- ment) could result in an omega-3 fatty acid intake...of approximately 900 ma/

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42 DIOXINS AND DIOXIN-LIKE COMPOUNDS IN THE FOOD SUPPLY day, an amount shown to beneficially affect coronary heart disease mortality rates in patients with coronary disease" (Krause et al., 2000~. In addition to heart disease, some studies suggest that there are benefits of omega-3 fatty acids against a variety of health conditions (Conner, 2000~. These include inflammatory diseases such as rheumatoid arthritis (Carder et al., 2002), epileptic seizure (Schlanger et al., 2002), endometrial cancer (Terry et al., 2002), age-related macular degeneration (Seddon et al., 2001), prostate cancer (Terry et al., 2001), and premature birth (Allen and Harris, 2001~. The increasing evidence of health benefits from the consumption of fish argues that efforts to reduce the DLC content in fish should be promoted, rather than restricting intake in order to reduce DLC exposure. One caution regarding fish consumption exists with regard to women who are pregnant or who may become pregnant: some species of fish, particularly long-lived, larger predatory fish may contain high levels of methylmercury, a developmental neurotoxin that may harm a fetus's developing nervous system if ingested at high levels. FDA has issued guidance to women of childbearing age, advising them to limit their consumption of fish to an average of not more than 12 oz/wk of cooked fish (approximately two to four servings). FDA also recommended that pregnant or potentially pregnant women eat a variety of fish; avoid eating shark, sword- fish, king mackerel, and tilefish; and check with their state or local health depart- ment to see if there are special advisories on fish caught from freshwater lakes and streams in their local area (CFSAN, 2001~. The degree of contamination of farmed and wild-caught fish varies geo- graphically and with changes in aquaculture practices (Gerstenberger et al., 1997; He et al., 2001~. However, as sources of fats used in fish feeds change, so do the levels of DLCs that are introduced through this route. Thus, accurate data on regional sources that contribute to geographic variability are needed. Addition- ally, the committee recognizes that there are comigrating contaminants that will be found with DLCs in many types of fish, but an examination of these other contaminants was beyond the committee's charge and were not considered in this report. In summary, fish are important sources of nutrients and potentially beneficial omega-3 fatty acids, and they also have cultural importance in the traditional diets of many population groups. But, unlike meats and poultry, fish cannot easily be trimmed to reduce their fat content. Therefore, fish consumption should be encouraged at currently recommended levels (1 to 2 fish meals per week), except for fish caught where known DLC contamination has occurred and fish adviso- . . nes are In p ace. Breastfeeding As previously mentioned, AAP recommends exclusive breastfeeding until the age of 6 months and continued breastfeeding with supplementary foods until

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HUMAN FOODS AND FOOD-CONSUMPTION PA'ITERNS 143 at least the age of 1 year. The benefits of breastfeeding have been clearly and positively identified, at the level of the infant, the mother, the family, and society (Work Group on Breastfeeding, 1997), and it would be inappropriate to interfere with the current upward trend in breastfeeding rates in the United States because of as yet only theoretical detrimental effects of the DLC levels currently found in breast milk. It is important to emphasize that changing the mother's diet during pregnancy and lactation will not have an impact on reducing DLC levels in her breast milk, since the accumulated body burden is what determines DLC expo- sure to the fetus in utero and to the nursing infant. Rather, the focus on reducing DLC exposure should begin after weaning and throughout childhood, so that the next generation of women will enter their reproductive years with lower body burdens of DLCs. This is a long-term agenda and emphasizes the value of reduc- ing animal-fat consumption for children, with particular benefits for girls. For children, the general dietary guidance that applies to adults is appropriate for children over the age of 2 years, including the use of low-fat or skim milk rather than whole milk (AAP Committee on Nutrition, 1983; AHA, 1983~. SUMMARY The major sources of DLCs in the food supply are animal fats, although small amounts appear in most foods. Exposure can be reduced through the re- duced intake of animal fat by selecting lean cuts of meat, poultry, and fish; trimming visible fat and removing skin, as appropriate; and by selecting low-fat dairy products. DLCs on fruits and vegetables can be reduced through washing and through peeling root and waxy-coated vegetables. In general, these precautions are consistent with current dietary advice, with two major exceptions. Although breast milk is a relatively concentrated source of DLCs, particularly in first lactations, and contributes significantly to body bur- dens, the evidence of the benefits of human breast milk overall outweighs the potential risks from this source. The focus should be on reducing lifetime body burdens through other means so that future generations of breastfeeding mothers will increasingly transmit lower levels through this important source of infant nutriture. The second exception is the conflict between recommendations to con- sume more fatty fish and the fact that some of the highest concentrations of DLCs in the food supply come from these fish, both farmed and from the sea. Some subsets of the population are likely to be at greater than average risk from this source and should be monitored. The accumulating evidence of health benefit from fatty fish (e.g., mackerel and salmon) suggest that rather than avoiding this food, the focus must again be on reducing the content of DLCs in future stocks.

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