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Nutrition Labeling: Issues and Directions for the 1990s (1990)

Chapter: 6. Nutrition Label Content

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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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Suggested Citation:"6. Nutrition Label Content." Institute of Medicine. 1990. Nutrition Labeling: Issues and Directions for the 1990s. Washington, DC: The National Academies Press. doi: 10.17226/1576.
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6 Nutrition Label Content Beyond the issue of the specific foods to be covered by nutrition labeling requirements is the actual information that should be provided on food labels. The current nutrition information panel contains information on calories, protein, fat, carbohydrate, sodium, and percentage of the U.S. Recommended Daily Allowances (U.S. RDA) for protein and seven vitamins and minerals (21 CFR §101.9; USDA, 1989~. Over information about the nutrient content of foods frequency may be obtained from the ingredient listing and from nutrient descriptors found on the principal display panel of food labels (see Chapter 7~. In light of the findings and recommendations in The Surgeon General's Report on Nutrition and Health (DHHS, 1988) and the National Research Council (NRC) report, Diet awl Health: Implications for Reducing Chronic Disease Risk MARC, 1989a), this information is at once incomplete and excessive. The Committee was directed to consider recommendations for food labeling reform based on the knowledge of nutrition in relation to long-term health contained in these reports. For nutrients and other food components currently included or proposed for inclusion on the nutrition information panel, this chapter describes their health relevance, dietary recommendations, current provision of labeling information, and the Committee's recommendations for nutrition labeling. Comprehensive information on dietary sources of nutrients and dietary intake patterns are provided in Chapter 4. 158

NUTRITION LABEL COSTED 159 CALORIES Health Relevance of Calories Scientists, consumers, and food manufacturers all acknowledge that the information about calories per serving is one of the key elements of the nutrition information panel. Because of this consensus, only the highlights of current scientific evidence are provided in the discussion that follows. There is consensus among health care professionals Hat obesity (defined as excess body fat) is associated with excess morality. Nutrition and Your Health: Dietary Guidelines for Americans (IJSDAIDHHS, 1985), the Surgeon General's report (DHHS, 1988), the NRC Diet and Health report (1989a), and the Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans (USDA, 1990) emphasize the importance of maintaining a healthy or desirable weight to minimize the risk for chronic diseases such as diabetes, coronary heart disease (CHD), stroke, hypertension, and certain Apes of cancer. The causes of obesity include genetic factors, diet, and inactivity. In experimental animals, diets high in fat promote obesity (Schemmel et al., 1970~. It is not clear how caloric density and diet composition influence obesity in humans. An estimated 34 million American adults are obese (based on a standard of greater than 20 percent in excess of desirable body weight), and more than 80 million Americans are trying to control their weight (CCC, 1985~. In order to maintain a stable body weight, caloric intake must be in balance win energy expenditure. Methods used to lose weight emphasize the need to decrease caloric intake and increase energy expenditure (Kayman et al., 19903. Provision of information on the caloric content of food products may be useful not only for obese individuals trying to lose weight but also for those who are trying not to gain excess weight. The number of calories in a food is the one component of the food label that consumers seem to understand. Current Provision of Desired Information Information about calories often is found in two places on the food label: the nutrition information panel and He principal display panel. C)n the nutrition information panel, the Food and Drug Administration (FDA) and the U.S. Department of Agriculture (USDA) require the disclosure of total calories per seeing, expressed as kilocalories (21 CF~ §101.9(c)~3~. The principal display panel may include nutrient descriptors that are regu- lated by FDA and/or USDA, such as low calorie, reduced calorie, diet, sugar free, and no sugar, with some minor differences (21 CF11 §105.66(c), (d), `fl; USDA, 1982a). Some descriptors may be misinterpreted by the consumer to imply that a food is low in calories. There is a need for more uniform use of the terms light and lite with respect to the caloric content of foods to avoid con-

160 Nl~lWTION LABEl1NG sumer confusion (NRC, 1988), since four government agencies (FDA, USDA, the Federal Trade Commission ~Cl, and the Bureau of Alcohol, Tobacco, and Firearms) have jurisdiction over products Hat carry these terms. The noncaloric use of these terms is discussed in Chapter 7. For the purposes of marketing and nutrition education, some manufacturers are currently declaring calories in terms of the food's contribution to the total number of calories to be consumed in a day. One example is the increasing number of packaged foods designed to be eaten as a single meal and the use of various reference standards for total daily calories. The establishment of a single daily standard for calories for any purpose, including labeling, is difficult given the wide range of average caloric intakes for adults. However, if manufacturers are going to refer to the total number of calories to be consumed in a day, Hen a reference standard needs to be established. Committee Recommendations The Committee recommends that: FDA and USDA should continue to require the disclosure of calories expressed as ldlocalories per serving on the nutrition information panel. If the manufacturer chooses to express nutrients as a percentage of total calories, 2,000 calories should be used and stated as the reference point for the average adult who engages in light physical activity. This amount will overestimate the needs for some individuals (e.g., many women) and underestimate the needs for others (e.g., many men). A daily reference standard based on a population average of 2,350 calories has been proposed by FDA (55 ~d. Reg. 29,476-29,533, July, 19, 1990), but a 2,0(X)<alone level would provide a standard that is both an amount closer to the average intakes of women and under the population average intake (which in general seems to consume more calories than are needed) as well as a round number for easier reference and use In calculations. · Descriptors related to caloric content of foods Hat are currently defined by FDA and USDA should be continued. · FDA and USDA should define and standardize the terms light, lite, and diet and other descriptors Hat can be interpreted as caloric claims. FAT AND CHOLESTEROL Health Relevance of Dietary Fat and Cholesterol Current Dietary Recommendations for Fat and Cholesterol Most heals organizations in the United States that have examined the relationship between dietary fat and atherosclerotic disease have recommended

NUTRITION LIBEL CONTENT 161 that dietary saturated fatty acid intakes be reduced in order to reduce plasma cholesterol levels and thereby reduce the incidence of and mortality from CHD and related conditions. The specific recommendation has usually been to reduce total fat intake to 30 percent or less of total calories and saturated fatty acid intake to less than 10 percent of total calories (NRC, 1989a). Although it is widely believed that even lower total fat and saturated fatty acid intakes would be more beneficial, there has been concern about the palatability of foods with lower levels of fat content. Because no human populations that consume large proportions of polyunsaturated fatty acids (more than about 10 percent of total daily calories) have been adequately studied, and because some observations in experimental animals have suggested that polyunsaturated fatty acids might contribute to cancer, recommendations regarding fat intake usually include a limit on polyunsaturated fatty acid intake to about 10 percent of total calories. The American Heart Association (AMA, 1986), the Surgeon General's report (DHHS, 1988), and the NRC Diet and Health report (NRC, 1989a) included recommendations to limit cholesterol intake to 300 mg daily as a means of lowering plasma cholesterol concentrations and thereby preventing atherosclerotic disease. Rods of Fat and Cholesterol in the Body Fats and Oils Fats and oils are complex organic molecules that are formed by combining three fatty acid molecules with one molecule of glycerol. Generally, fatty acids are straight chains of carbon atoms with two hydrogen atoms bound to most carbon atoms, but they vary in chain length and in the number of double bonds between carbon atoms. Generally, fatty acids in animal and plant tissues range from 4 to 24 carbon atoms. Those with no double bonds are called saturated fatty acids, those with one double bond are called monounsaturated fatty acids, and those with more than one double bond are called polyunsaturated fatty acids. Fats containing predominantly saturated fatty acids are solid or viscous at room temperature; those containing predominantly monounsaturated or polyun- saturated fatty acids are liquid at room temperature. One polyunsaturated fatty acid, linoleic acid, which has 18 carbon atoms and two double bonds, is an es- sential nutrient because it is necessary for normal cellular function but the body cannot synthesize it; other fatty acids required by mammals can be synthesized by the body. The principal function of fatty acids consumed in the mammalian diet is energy. Fats stored in adipose tissue provide a long-term reserve source of energy, because they produce about twice as much energy per unit of mass as protein or carbohydrate does. Fats and oils also greatly affect the taste, consistency, stability, and palatability of foods. Humans prefer foods containing

162 NUTRITION LABELING more than 15 percent fat (by weight, about 30 percent of calories), even though 5 percent fat in the diet (by weight, 10 percent of calories) is nutritionally adequate. The U.S. population currently consumes about 36 percent of its calories from fat (LSRO, EASES, 1989). Fats and oils in Americans' diets are derived from plant and animal sources. Generally, saturated fatty acids are derived from meat and daily products, whereas mono- and polyunsaturated fatty acids are derived from plant sources. Three exceptions are palm, palm kernel, and coconut oils, which are quite rich in saturated fatty acids. Cholesterol A quite different material than fats and oils, cholesterol is commonly classified among the lipids. It is a large molecule composed of several six-carbon rings joined together at their sides and with other structures joined to the outside rings. Cholesterol is an essential component of mammalian tissues, but it is synthesized in the body and is not an essential nutrient. Cholesterol is used to produce body hormones and cellular structures, but not for energy. It has no taste and its presence or absence does not affect the palatability of foods. Currently, U.S. intakes by men and women range between 304 and 435 mg/day (NCEP, 1990~. Health Effects of Dietary Fat and Cholesterol Coronary Heart Disease Evidence that dietary fat or cholesterol was involved in causing atherosclerosis and CHD first appeared early in the twentieth century, at about the same time that myocardial infarction was identified as a distinctive clinical syndrome and was found to be related to atherosclerosis and thrombosis of the coronary arteries. Almost no attention was directed toward diet as a possible cause of atherosclerosis or its major clinical sequela, CHD, until after World War II, when it became apparent that this disease had reached epidemic proportions in the industrialized countries. In the Scandinavian countries, heart disease rates declined ~amadcally during World War II, a period when foods rich in fat were in short supply (Keys, 1975). Retrospective case-control studies also revealed that CHD was associated with serum cholesterol concentrations and that the senile cholesterol concentration was controlled, in part, by the amount and type of fat and cholesterol in the diet. International comparisons, studies of migrant populations, and observations of vegetarians showed that saturated fatty acid and cholesterol intakes were associated with CHD rates, but these correlations were often confounded by other differences in life-style. Many controlled experiments in humans and animals have demonstrated that saturated fatty acids and cholesterol in the diet elevate serum cholesterol concentrations, and when saturated fatty acids were replaced with monounsat-

NzrrRlTIoN LABEL conquer 163 u~a~ and polyunsaturated fatty acids, serum cholesterol concentrations were lowered (NRC, 1989a). A massive research project, the National Diet Heart Study, showed that serum cholesterol levels could be lowered in free-living populations by fat-modified diets. On the basis of early observations, AHA rec- ommended reductions in dietary saturated fatty acids in 1957 Cage et al., 1957y, and later it recommended reductions in dietary cholesterol intake (AMA, 1965~. The Surgeon General's report (DHHS, 1988) and the NRC Diet and Health report (NRC, 1989a) reaffirmed these recommendations. The concentration of cholesterol in plasma (or serum) has been considered a major risk factor for CHD. Fat and cholesterol, which are insoluble in an aqueous medium, are carried in the blood within particles stabilized by specialized proteins (apolipoproteins). There are several distinct classes of lipoproteins in plasma, each containing different proportions of cholesterol and other fats. Subsequent epidemiological studies disclosed that the concentration of low- density lipoprotein (LDL) cholesterol was positively associated with the risk of CHD (Medalie et al., 1973) and that the concentration of high-density lipoprotein (HDL3 cholesterol was inversely associated with the risk of CHD (Gordon et al., 1977; Miller et al., 1977~. These associations were confirmed in animal experiments and in postmortem human studies relating plasma lipoprotein cholesterol concentrations to atherosclerotic lesions (Solberg and Strong, 1983~. Thus, it became important to distinguish between the effects of LDL and HDL cholesterol concentrations. Evidence Regarding Saturated Fatty Acids In 1952, two independent groups of investigators- in the United States (Kinsell et al., 1952) and in Europe (Groen et al., 1952) discovered almost simultaneously that the saturation level of dietary fatty acids influenced plasma cholesterol concentrations. A large number of human and animal experiments subsequently confirmed that saturated fatty acids with chain lengths of 12 to 16 carbon atoms (lauric, myristic, and palmitic acids) were the most active in raising serum cholesterol concentrations, whereas fatty acids with chain lengths of 10 or fewer carbon atoms or 18 carbon atoms (stearic acid) had no effect. Investigators developed equations that consistently predicted (on average) the effects of changes in fatty acid intake on the plasma cholesterol concentration. Monounsaturated fatty acids, represented mainly by oleic acid, had little or no effect on plasma cholesterol concentrations compared with the effects of equivalent calories such as those from carbohydrate and, therefore, were omitted from these predictive equations. The predictive power was also increased when stearic acid was omitted from the intake of saturated fatty acids. Recent exper- iments have reconfirmed the observation that, although stearic acid contributes calories, it does not raise plasma LDL or HDL cholesterol levels (Bonanome and Grundy, 1988~. When saturated fatty acids are replaced by polyunsaturated fatty acids,

164 NUTRITION LABELING represented in the diet mainly by linoleic acid, serum cholesterol concentrations are reduced to as low as and possibly lower than the levels produced by equivalent calories such as those from carbohydrate (NRC, 1989a). Recent experiments have also reconfirmed that oleic acid maintains LDL cholesterol concentrations at about the same level that polyunsaturated fatty acids do and showed that it does not lower HDL cholesterol levels (Grundy, 1987~. Thus, monounsaturated fatty acids might be included with polyunsamra~ fate acids in a computation of fatty acids that would be expected to produce more desirable plasma lipoprotein profiles. Several epidemiological comparisons found a strong association between average intakes of saturated fatty acids and mortality from CHD (Keys, 1975~. A low samurai fatty acid intalce (less than 10 percent of total calories) is common to all populations with low CHD rates. The results of correlations based on individual intakes within a population have been less consistent and conclusive. This discrepancy is attributed to the low range of intakes within each population and to the misclassification of dietary intakes and endpoints. The effects of dietary fatty acids on plasma lipoproteins and atherosclerosis have generally been confirmed in animal experiments. Another issue concerns the health effects of stearic acid, a samurai fatty acid. Unlike the other saturated fatty acids, it has been found that stearic acid does not elevate serum cholesterol levels. The results of early studies have been confirmed by recent experiments in humans; however, the controversy continues. Evidence Regarding Omega-3 Farm Acids In early research on the effects of polyunsaturated fatty acids on lipoprotein metabolism, investigators noticed that some of the highly unsaturated oils from marine sources were as effective as vegetable oils in lowering serum cholesterol levels. Years later, it was reported that Eskimos who consumed large quantities of fish had low rates of atherosclerotic heart disease. Renewed investigations showed that the effects on lipoprotein metabolism were due to the high proportions of omega-3 polyunsaturated fatty acids in oils from marine mammals. When these fatty acids are included in the diet, they dramatically reduce plasma triglyceride levels but do not seem to reduce LDL cholesterol levels unless they are substituted for saturated fatty acids (Woodward and Carroll, 1988~. They also affect the hemostatic system by altering platelet function and prostaglandin metabolism In ways that may reduce the risk of thrombosis (Herold and Kinsella, 1986~. The potential beneficial effects of omega-3 fatty acids have led to some recommendations that individuals should increase their consumption of fish oils that contain these substances in order to prevent atherosclerosis and thrombosis. However, many studies have also found some adverse effects for example, an increase in LDL cholesterol levels~nd neither the beneficial effects nor the safety of high intakes of omega-3 fatty acids have been thoroughly documented. The Surgeon General's report (DHHS, 1988) and the NRC Diet and Health

NUTRITION LABEL CONTENT 165 report (NRC, 1989a) did not recommend increased intakes of fish oils as a means of preventing CHD. Fish oils and omega-3 fatty acids must be differentiated from fish as a food. Fish is widely recommended as an excellent source of protein Hat is low in fat, and in some epidemiological studies, fish consumption is inversely associated with cardiovascular disease (Kromhout et al., 1985~. Evidence Regarding Trams Fatty Acids When vegetable oils are hy- drogenated to make them more palatable as substitutes for animal fats, geomet- ric isomers of the unsaturated fatty acids called bans fatty acids are farmed. Because these isomers are not present in natural foods in the proportions Hat occur in hydrogenated fats, their effects on lipid and lipoprotein metabolism, plasma lipid levels, and atherosclerosis have been investigated intensively (NRC, 1989a). Although bans fatty acids lack any activity as essential fate acids, no deleterious effects have been demonstrated in humans, and no deleterious ef- fects have been found in animal experiments with levels of intake comparable to customary human intakes. There remains some possibility of a long-term effect of bans fatty acids on lipid metabolism, and this question should be reconsid- ered periodically as knowledge of lipid metabolism and the changes underlying chronic disease increases, but present knowledge provides no basis for limiting or reducing the current usual intake of bans fatty acids. Evidence Regarding Dietary Cholesterol Although the first evidence linking a dietary lipid with atherosclerosis came from experiments with rabbits in 1913, the discovery of the effects of saturated fatty acids on plasma cholesterol levels in 1952 overshadowed the potential effects of dietary cholesterol. Most animal species, including guinea pigs, swine, and several nonhuman primates (notable exceptions are dogs and rats), have been found to be sus- ceptible to the cholesterolemic effects of dietary cholesterol. Indeed, in animal models of diet-induced atherosclerosis, cholesterol seems to be more important than the type or amount of dietary fat. Epidemiological studies have almost invariably found strong correlations between dietary cholesterol intake, plasma cholesterol concentrations, and CHD (McGill, 1979~. However, there were also strong correlations of saturated fatty acid intakes with CHD, and multivariate analyses of the data usually resulted in nonsignificant correlations of dietary cholesterol intake with CHD rates. Cross-sectional dietary studies, designed to test individuals within a popu- lation for the association between dietary intakes and plasma cholesterol levels, usually found no association between dietary intakes of cholesterol and plasma cholesterol or lipoprotein concentrations. These negative results were considered inconclusive based on the limited range of dietary intakes found within popula- tion groups (in contrast to the wide ranges of mean intakes between population

166 NUTRITION LABELING groups), and also because measurement error seriously degraded correlations based on individual values. The independent effect of dietary cholesterol is an important issue, because one widely produced and consumed food, the egg, is rich in cholesterol but contains only moderate amounts of saturated fatty acids. Beginning in about 1960, a number of carefully controlled experiments in humans measured plasma cholesterol levels (and later, LDL and HDL cholesterol concentrations) in individuals fed diets containing varying amounts of cholesterol. Eventually, a consensus indicated that dietary cholesterol did affect plasma cholesterol levels, particularly LDL cholesterol levels, independent of total fat intake and type of fat. Furthermore, several long-term cohort studies of humans have recently reported that reliable estimates of dietary cholesterol intake, when expressed as milligrams per 1,000 kcal, were positively correlated with the incidence of CHD during subsequent years of follow-up (Shekelle et al., 1981; Stamler and Shekelle, 1988~. The correlations were independent of the plasma cholesterol levels. These results suggest the possibility that dietary cholesterol might influence atherosclerosis or its clinical manifestations by some mechanism other than elevation of LDL cholesterol levels. Cancer There is less evidence linking total dietary fat and saturated fatty acids to cancer than to heart disease, but the accumulated epidemiological evidence does suggest that dietary fat intake is associated win the risk of colon, prostate, and ovarian cancers and, possibly, with breast cancer (NRC, 1982, 1989a). Animals fed high-fat diets are more likely to develop cancers of the breast, intestinal tract, and pancreas than are those fed low-fat diets. In animals, polyunsaturated fatty acids promote cancers more effectively than do saturated fatty acids, but high samurai fatty acid intakes also increase the probability of cancer in animals if the minimum requirement for polyunsaturated fatty acid intake is satisfied. Although dietary cholesterol intake is highly correlated with saturated fatty acid intake in humans, there is no evidence that either high or low cholesterol intakes are associated with cancer at any site. Some reports that low plasma cholesterol levels were associated with a higher risk of cancer led to concern about the potential adverse effects of plasma cholesterol-lowering diets, but these associations were thought to be due, in part, to low plasma cholesterol levels in early cancers that is, a result of the cancer rather than a precursor. Galibladder Disease Most gallstones occurring in the U.S. population are the result of the presence of excess secretion of cholesterol into the bile by the liver. Because

NUTRITION LAME CONTENT 167 both dietary cholesterol and polyunsaturated fatty acids increase secretion of cholesterol by the liver, it has been hypothesized that these dietary components may be responsible for gallstones. Coding of cholesterol to some species of rodents causes gallstones. Obesity predisposes an individual to gallstone formation, presumably be- cause it is associated with increased secretion of cholesterol into the bile. How- ever, no epidemiological or experimental evidence In humans has directly im- plicated either dietary cholesterol or fat as a cause of gallstones. It is likely that some individuals who are genetically predisposed may be susceptible to He lithogenic effects of dietary fat or cholesterol, but these individuals cannot yet be identified (NRC, 1989a). Current Provision of Desired Information There are three locations on food labels that may provide useful information about fat and cholesterol, including the ingredient listing, He nutrition inforrna- tion panel, or descriptors of specific levels or Apes of fats and cholesterol on the principal display panel. Ingredient Listing Ingredients are required to be listed on a majority of packaged foods; this would provide information on food components that are fats and oils, whether derived from animal or plant sources (21 CFR §101.4(b)~14~; USDA, 1989~. The common or usual names of fats and oils would reveal fat sources; however, the current ingredient listing rarely provides information about the salivated fatty acid or cholesterol content for consumers seeWng this information. Ike use of weight as the criterion for listing ingredients may cause the consumer to overlook a more important measure, that is, the relative contribution of fats and oils to available calories in a food. For example, fats and oils provide more than twice the amount of calories per gram compared with protein and carbohydrate, but fats might not be listed first on the ingredient label because of their weight. However, the actual fats and oils present in a product can be difficult to determine. Until 1971, all fats were allowed to be listed generically on ingredient labels as '~vegetable shortening" by FDA and as "shortening" by USDA. When regulations that required listing of specific fats and oils by weight were proposed, a convincing case was made that product sources often change, depending on their availability and price. An individual listing was judged to be costly for manufacturers and, ultimately, for consumers, if labels had to be changed every time the source changed. The resulting compromise allows manufacturers to list fats and oils as they are contained in the product (by weight) or to list all those that might be used from time to time. Under this so-called "andJor" provision, any specific product would likely contain one or two of the oils listed

168 NUTRITION LABELING The great disadvantage of "and/or" labeling of fats and oils is Mat many of the commonly used oils vary widely in fatty acid content. If coconut oil is the only oil used, over 80 percent of the fatty acid content of the product might be saturated; if rapeseed oil were chosen, the same product might have a fatty acid content that was less than 7 percent saturated fatty acids. Although fatty acid content varies among many of the commercial oils, functionality of the oil in many products such as baked goods limits the range of fatty acid content of oil that can be used. Nevertheless, the information that is clearly relevant to the product's composition and that many consumers consider important in planning their diets teas often been unavailable. Nutrition Information Pane] If a manufacturer chooses to or must provide nutrition labeling, the label must declare the amount of fat per serving in grams (21 CFR §101.9(c)~6~. Only if a claim about the fatty acid content is made must the content of saturated and unsaturated fatty acids be declared on the nutrition information panel, using the terms saturated fat and unsaturated fat. In this case, the percentage of total calories contributed by fats is required; however, the cholesterol content is not (21 CFR §101.25(c)~. If a claim regarding cholesterol is made, the amount per serving must be given on the label, but no specific information about the fatty acids need be listed (21 CF~ §101.25(b)~. As a result, foods rich in cholesterol but containing certain vegetable oils may describe their relatively low percentage of saturated fat without revealing the cholesterol content. For foods with a significant amount of vegetable fats, the fatty acid content may not be reported if there is a claim of the absence of cholesterol on the label. For food labels that provide either fatty acid or cholesterol content, FDA requires that the label indicate that such information is given for individuals who, on the advice of a physician, are modifying their dietary intake of fat andfor cholesterol (21 CFR §101.25(d)~. Since the 1986 proposal to regulate cholesterol-related terms, this requirement has not been enforced but is an indication of the specific subpopulation on which the concept of a low-saturated- fat, low-cholesterol eating pattern was originally focused Within the past 5 years, a national consensus on the efficacy of plasma cholesterol reduction in the prevention of CHD in the entire population has been reached that favors dietary modification as the first step in achieving a reduction in the risk of CHD. In July 1990, FDA issued a tentative final rule that included revised quantitative fat declaration and definitions with criteria for their use (55 Fed. Reg. 29,45~29,473, July 19, 1990~. The agency continued to use its existing rules on total fat content When fatty acid or cholesterol content is declared, both are to be declared immediately following the statement of fat content and

NUTRITION LABEL CONTENT 169 require the listing of polyunsaturated and saturated fatty acids and allow the voluntary listing of monounsaturated fatty acids. Cholesterol content is to be stated in milligrams per serving to the nearest S-mg increment, except for a food that contains less than 2 mg/serving. In a food that contains less than 1 g of fat or fatty acids, a statement of "less than 1 g" is allowed in lieu of the specific amount. No information is currently required on the nutrition information panel con- cerning the number of calories from fat in foods. Current dietary recommenda- tions state that the percentage of calories from fat in the total diet should be 30 percent or less, with 10 percent or less each from saturated fatty acids and 10 percent or less each from monounsaturated and polyunsaturated fatty acids. Consumers must be encouraged to apply these guidelines in forming their di- etary patterns over a total meal or in assessing a day's food rather than using them as standards for accepting or rejecting single products. For example, a single high-fat item can be perfectly acceptable as part of a generally low-fat meal. This concept suggests that fat should not ordinarily be expressed as a per- centage of calories on individual food labels. To do so would tend to encourage consumers to apply fat intake recommendations to single foods. With current information on total fat, a consumer needs to have some additional knowledge of the number of calories per gram of fat in order to make the calculation to determine the percentage of calories from fat in foods. No information is currently required concerning the saturated fatty acid content in foods without additional information. It can be assumed that the majority of consumers would be unable to determine the percentage of calories from total fat and saturated fatty acids in foods. At the same time it is important to avoid the apparent labeling of foods as good or bad based on a listing of the percentage of calories from fat on the package, since it is the percentage of calories from fat in the total diet, and not a specific food, that is the concept consumers need to understand. Current regulations define polyunsaturated fatty acids to be cis,cis-methy- lene-inteIrupted polyunsaturated fatty acids, and saturated fatty acids to be the sum of lauric, myristic, palmitic, and stearic acids in foods (21 (~K § 101.25(c)~2~(ii)~. The shorter-leng~ saturated fatty acids (those with chain lengths of 10 or less) are excluded from the definition because decades ago they were determined to have no effect on serum cholesterol concentrations. Stearic acid was included in the definition because, presumably, the evidence did not support its exclusion at that time. Current recommendations concerning dietary fat advise that saturated fatty acid intake be reduced to 10 percent or less of calories, which at least implicitly accepts the existing regulatory definition of saturated fatty acids, which would include a few percentage points of stearic acid. However, the issue of retaining stearic acid in the regulatory definition of saturated fatty acids needs further examination. A definition for monounsaturated

170 NI~TRITION LABELING fatty acids as cis-monounsaturated fatty acids has been proposed in the recent FDA tentative final rule (55 Fed. Reg. 29,456-29,473, July 19, 1990~. Principal Display Pane! Descriptors for Fat and Cholesterol Descriptive words and phrases have been used by manufacturers on the principal display panel to describe the fat and cholesterol contents of their products; however, no specific descriptor definitions have been finalized for fatty acids or cholesterol. Statements that are demonstrably true, such as cholesterol free for products that are totally vegetable in origin, have been allowed. However, products bearing this label could be high in saturated fatty acids. For individuals who are attempting to lower their blood cholesterol levels, the claim could be confusing and is certainly not helpful on such products. Descriptors related to fat content, such as lean, extra lean, low fat, and reduced or lower fat, have been defined by USDA (1987~. At present, FDA has only informal policy guidelines for several of these terms. In 1986, FDA proposed a series of definitions, including those for no cholesterol, low cholesterol, and cholesterol reduced (51 Fed. Reg. 42,588- 42,589, Nov. 25, 1986~. However, these regulations were not finalized, in part because they failed to deal with the issue of fatty acids in conjunction with the cholesterol labeling terms. For labeling purposes, USDA has informally adopted FDA's 1986 proposed definitions. In July 1990, FDA issued a tentative final rule that included revised quan- titative fat declaration and definitions with criteria for their use (55 Fed. Reg. 29,45~29,473, July 19, 1990~. In the tentative final rule, the agency defined the following terms by providing extensive criteria for their use: cholesterol free, free of cholesterol, no cholesterol, low cholesterol, low in cholesterol, choles- terol reduced, reduced cholesterol, cholesterol free food, and low cholesterol food, as well as comparative cholesterol statements. Statements such as "con- tains 100 percent vegetable oil" or "contains no animal fat" are allowed only if the nutrition label includes quantitative information on total fat, fatty acid, and cholesterol contents. Descriptors for cholesterol and saturated fat could be useful if well-founded definitions can be established. Their continued unqualified use on food products that are high in one component and low in another (e.g., high in saturated fat and low in cholesterol) is counterproductive. Considerable discussion has surrounded the potential confusion created for many consumers when manufacturers use statements such as 95 percent fat free on the principal display panel. For the manufacturer, this refers to a percentage of fat by weight. However, consumers normally would not consider the difference between the weight of fat and the calories from fat in a product. As a result, they would often misinterpret this reduction of fat by weight as a reduction of total calories from fat. For example, a frankfurter that is 80 percent fat free

NzrrRlTloN L4BF~ CONTENT 171 (by weight) may contribute over 70 percent of its total calories from fat. For consumers trying to follow current dietary recommendations to choose foods lower in total fat, such statements could create unnecessary confusion, leading to dietary practices Cat may actually increase the levels of fat in Weir diets. USDA Policy Memorandum 046 defines the requirements for such terms on product labels (USDA, 1982b). Percent fat free statements are acceptable on product labels if the label also bears a positive declaration of the product's fat content (e.g., along with the statement 95 percent fat free, the label would have to also bear the declaration contains 5 percent fat). FDA does not have regulations for such statements. Committee Recommendations The Committee recommends that: . FDA and USDA should require the disclosure of total fat, saturated fat, unsaturated fat, and cholesterol contents per serving in grams (milligrams for cholesterol) on the nutrition information panel, with saturated and unsaturated fat either indented or otherwise identified as subcategories of total fat. FDA and USDA should require the listing of calories per seeing from total fat, saturated fat, and unsaturated fat on the nutrition information panel. FDA and USDA should allow, as an option, the disclosure of monounsat- urated and polyunsaturated fatty acid content per serving in '~rams on the nutrition information panel. · FDA and USDA should define descriptors for cholesterol content for use on the principal display panel. · FDA and USDA should define descriptors for total fat and saturated, monounsaturated, polyunsaturated, and unsaturated fatty acid content on the principal display panel. · FDA and USDA should require that when a manufacturer refers to "x percent fat free" (by weight) and other similar terms on a package, it should also be required to state "x percent calories from fat" in close proximity in the same type size and lope face. FDA and USDA regulations should continue to permit `'and/or" labeling of fats and oils in the ingredient listing on the conditions that the food carries full nutrition labeling and that the stated saturated fat content listed is the highest level that would be achieved with any mixture of the listed fats and oils. · FDA and USDA should establish an entity to evaluate the issue of the cholesterolemic effects of stearic and other fatty acids (e.g., bans fatty acids) and related changes that may need to be made in redefining fatty acids for regulatory purposes.

172 N~r~TION LABELING CARBOHYDRATES Health Relevance of Carbohydrates The Dietary Guidelinesfor Americans recommended that Americans modify their intake of carbohydrates by eating foods containing adequate starch and fiber and avoiding too much sugar (USDA/DHHS, 1985~. In the broadest sense, that report promoted a dietary pattern that emphasizes consumption of vegetables, fruits, and whole-grain products- foods that are rich in complex carbohy~es and fiber and relatively low in calories—and fish, poultry prepared without skin, lean meats, and low-fat daily products selected to minimize consumption of total fat, saturated fatty acids, and cholesterol. More recently, the health relevance issues involving consumption of simple and digestible complex carbohydrates and dietary fiber were extensively evaluated in both the Surgeon General's report (DHHS, 1988) and the NRC Diet and Health report (NRC, 1989a). The recommendations from these reports serve as a cornerstone for the discussions presented below. Complex Carbohydrates Complex carbohydrates, or polysaccharides, are made up of long chains of glucose molecules. In typically consumed foods, this category is largely made up of starch. Some glycogen is also consumed, but it is a minor component of meats. Carbohydrates contribute about 45 percent of adult caloric intake (DHHS, 1988), more than half of which comes from complex carbohydrates (NRC, 1989a). Starches from cereals, tubers, beans, and certain legumes thus make up a significant proportion of human caloric intake. Most, but not all, starches in foods are digestible. Foods naturally high in complex digestible carbohydrates are invariably high in fiber as well. Thus, it is particularly difficult to divide the effects of these two component categories. Current dietary recommendations suggest that carbohydrate consumption be increased to more Han 55 percent of calories. The Diet and Health report suggested that this increase from about 45 to 55 percent of calories be accomplished with complex carbohydrates, not sugars; however, the specific proportion of the 55 percent of total calories that should be from complex carbohydrates was not provided (NRC, 1989a). In both the Surgeon General's and the NRC reports, there is a clear consensus on the beneficial health effects of eating foods containing high proportions of complex carbohydrates. Diet and Health recommended Hat the intake of starches and other complex carbohydrates be increased by eating six or more servings of a combination of breads, cereals, and legumes daily (NRC, 1989a). The Surgeon General's report stated, `4The public would benefit from increased availability of foods and food products low in calories, total fat, saturated fat, cholesterol, sodium, and sugars, but high in a variety of natural

NUTRITION LABEL CONTENT 173 forms of fiber and, perhaps, certain minerals and vitamins" (DHHS, 1988, p. 19). Selection of foods naturally high in starch is an excellent way to achieve this recommendation. They are readily available, generally inexpensive, and highly acceptable to the human palate. Although there is no specific linkage between complex carbohydrate con- sumption and lowered chronic disease incidence, diets that exclude or that have low levels of whole-grain products, tubers, legumes, and vegetables are associ- a£ed epidemiologically with a variety of chronic health problems, including obe- sity, cancer, heart disease, and diabetes mellitus. '~Populations consuming high- carbohydrate diets . . . have a comparatively lower prevalence of noninsulin- dependent diabetes mellitus," according to Diet and Health ARC, 1989a, p. 9~. An explanation for this observation may be that diets high in complex carbohydrates result in a lower prevalence of obesity, which is a risk factor for diabetes. Moreover, for individuals with diabetes mellitus, diets containing 50 to 60 percent of total calories as carbohydrates have been recommended by the Task Farce on Nutrition and Exchange Lists of the American Diabetes Association (ADA, 1987~. High-carbohydrate diets not only improve glucose tolerance and insulin sensitivity but are also generally low in fat. The ideal proportion of complex and simple carbohydrates in diets for individuals with diabetes is not yet resolved (DHHS, 1988~. Health professionals generally recommend reliance upon foods containing complex digestible and indigestible carbohydrates and avoidance of simple sugars (especially sucrose) and fats. In summary, foods containing high proportions of complex carbohydrates are highly desirable for overall good heals, not necessarily because of their specific contribution to chronic disease prevention but because these foods are usually low in fat and calories and are high in fiber. Simple Carbohydrates The term sugars is used here generically to describe a group of mono- and disaccharides commonly found in foods. These simple carbohydrates include the monosaccharides glucose and fructose and the disaccharides sucrose, lactose, and maltose. Sucrose, or common table sugar, and two corn-based sweeteners, corn syrup (a cornstarch hydrolysate containing glucose, maltose, and longer- chained polymers of glucose) and high-fructose corn syrup (E317CS, which is made up of mixtures of fructose, glucose, and glucose polymers) are commonly added to processed foods for their sweetening and thickening properties. Consumption patterns of carbohydrates have changed markedly in this cenblly. Although Americans today consume fewer total carbohydrate calories due to a reduced intake of wheat flours, cereals, and potatoes, there have been increased intakes of simple sugars in He past 75 years. It is estimated Hat He per

174 NllTRlTION LABELING capita intake of total carbohydrates fell from 493 g/day during 1909-1913 to 413 g/day in 1985 (NRC, 1989a). During the period 1909-1913, 68 percent of total carbohydrate calories were from starch compared with a little over half today. In 1986, FDA estimated that Americans were obtaining 21 percent of their total calories from simple carbohydrates: 4 percent from fructose, 9 percent from sucrose, 5 percent from corn syrups, and 3 percent from other sugars. The most marked recent change in intake patterns is the displacement of sucrose with fructose. In the mid-1980s, HFCS began to replace sucrose in soft drinks and in a variety of other processed foods. Glinsmann et al. (1986) reported that in 1985, HPCS accounted for 30 percent of the total sugar used in foods. The major shifts in simple carbohydrate intake patterns have led to a number of health concerns. The effects of sucrose, in particular, and simple sugars, in general, on the incidence of dental caries, CHD, diabetes mellitus, and even behavioral aberrations, such as hyperactivity and criminality, have been raised. Except for the unquestionable contribution of sugar to dental canes, nutrient dilution, and as a potential source of excess calories, none of the other concerns has been borne out. Children and others vulnerable to dental caries should limit their consump- tion and frequency of use of foods high in sugars, according to the Surgeon General's report. "Caries-producing bacteria have a rather high need for a range of simple sugars (glucose, fructose, lactose, maltose, and sucrose) that they read- ily metabolize to acids that demineralize teeth" (DHHS, 1988, p. 15~. Genetic, behavioral, and other factors also influence dental health. At one time, there was concern whether sugar intake contributed to mortality from CHD (Yudkin, 1964~. However, in 1986, a Sugars Task Force of FDA concluded that there was no conclusive evidence that dietary sugars are an independent risk factor for coronary artery disease in the general population (Glinsmann et al., 1986~. In individuals with diabetes mellitus, blood glucose and insulin respond differently to different types of simple and complex food carbohydrates (C\apo, 1984~. The rise in blood sugar following ingestion of a food—commonly referred to as the glycemic index (Crapo, 1984 - varies with the Me of sugar and starch, digestibility of He starch, food form, fiber type, and the cooking and preparation procedures (OHMS, 1988~. Diets high in complex carbohydrates but low in sugars are generally recommended for people with diabetes mellitus. However, there is no scientific evidence that high-sugar diets cause or lead to non-insulin-dependent diabetes. The scientific data supporting beliefs that high carbohydrate diets are associated with hypoglycemia, hyperactivity, or criminality are inadequate. Results of controlled clinical studies to test the carbohydrate-hypoglycemia-hyperactivity connection have been negative (NRC, 1989a).

NUTRITION LABEL CONTENT 175 Current Provision of Desired Information Information on total, complex, and simple carbohydrate contents of foods may appear in the ingredient listing, the nutrition information panel, and the principal display panel. The ingredient list may provide useful information on the content of sugars and other carbohydrates in foods, provided that these components are added as ingredients to the food (21 CFR §101.4~. Quantitative information is indicated only by the order of ingredients listed on a food label. However, this format may be misleading if a consumer wants to know the relative amount of total simple sugars in the product. For example, a breakfast cereal may contain total simple sugars as a primary ingredient, but it may contain them at such levels that none of the individual sugars is the largest ingredient by weight in the food. Thus, one or more nonsugar ingredients (such as wheat flour) may be listed first on the ingredient list before any sugar is listed, although total sugars may be the major ingredient (by weight) of that cereal. Another issue is the increasing use of mild-flavored fruit juices or concentrated fruit juices stripped of their flavor to sweeten foods because consumers perceive sugars from fruit juices differently from other sugars (John Vanderveen, Center for Food Safety and Applied Nutrition, FDA, personal communication, 1990~. The nutrition information panel can be most helpful in providing quanti- tative carbohydrate information (21 CF1< § lOl.9(b)~5~. Carbohydrate content is listed in grams per serving, unless a serving contains less than 1 g. In that case, the statement "contains less than 1 g" or "less than 1 g" may be used as an alternative. Some manufacturers voluntarily subdivide total carbohydrate into total complex carbohydrate (containing more than 2 saccharide units) and to- tal simple carbohydrates or sugars (mono- and disaccharides), although present regulations do not require or allow a listing of simple and/or complex carbohy- drates on the nutrition information panel. This practice should be encouraged to aid consumers who desire such information. Terms such as sugar free, sugarless, and no sugar may appear on the principal display panel (21 CFR §101.66(f); USDA, 1982a), and brand names may imply some information regarding sugar content (for example, Sugar Smacks~. However, the principal display panel of most foods generally does not provide information about carbohydrate content. Committee Recommendations The Committee is concerned about the current provision of information about carbohydrates contained in foods, specifically, the fact that sugars con- tained in foods are dispersed throughout the ingredient listing based on the predominance by weight. A preferable approach would be to cluster them under the generic term sugars, and with individual sweeteners listed in descending order (by weight) in parentheses. For example, a wheat- and oat-flour-based ce-

176 NurRlTIoN LABELING real may have the following ingredient label: wheat flour, sugars (sucrose, corn syrup, and fructose), oats, etc. Current FDA regulations allow the use of "andfor" labeling for fats and oils. The Committee believes that consideration should be given to allowing similar "andJor" labeling for sugars. By using the example given above, the ingredient list would read as follows: wheat flour, sugars (sucrose, corn syrup, and/or fructose), oats, etc. "And/or" labeling of sugars would give the manufacturer flexibility in the use of sweeteners and, presumably, could result in reduced costs for consumers. The Committee recommends that: · FDA and USDA should continue to require the disclosure of carbohydrate content per serving in grams on the nutrition information panel. · FDA and USDA should allow, as an option, the listing of the content of com- plex carbohydrates (which are defined as digestible polysacc}~arides such as starch and glycogen) and sugars (which are defined as digestible mono- and disaccharides) per serving in grams on the nutrition information panel. The term total carbohydrate should be used when carbohydrate components are listed on the nutrition information panel, with these subgroups indented · FDA and USDA should allow, as an option, the listing of calories per serving from total carbohydrate, complex carbohydrate, and sugars on the nutrition information panel. · The ingredient listing should group all sugars together under the term sug- ars with mono- and disaccharides (including glucose [dextrose], fn~ctose, lactose, sucrose, invert sugar, and honey, as well as corn syrup, HECS, and mild-flavored and "stepped" concentrated fruit juices) in a parentheti- cal listing, in descending order by weight under this tend. Sugar alcohols, such as mannitol and sorbitol, would be listed separately and would not be grouped with sugars. · I;DA and USDA should consider allowing manufacturers to use"and/or,' labeling for sugars. · I;DA and USDA should define descriptors that apply to terms used for carbohydrate and sugar content on foods labels. DIETARY FIBER Health Relevance of Dietary Fiber The American public has been inundated with advice to increase consump- tion of dietary fiber. The Dietary Gu~delinesfor Americans stated that Americans should eat foods containing adequate starch and fiber (USDAIDHHS, 1985~. The Surgeon General's report and the NRC Diet and Health report advised consumers to increase consumption of whole-gain foods and cereals and veg-

NUTRITION L4BFL CONTENT 177 etables and fruits in order to increase intakes of complex carbohydrate and fiber (DHHS, 1988; NRC, 1989a). Unfortunately, trends in food intake patterns since the turn of the century indicate that Americans have been consuming fewer rather than greater numbers of foods that are rich in fiber. The National Cancer Institute's dietary guidelines suggested that adults consume 20 to 30 g of dietary fiber daily with an upper limit of 35 g (Butrum et al., 1988~. Stanza et al. (1987) estimated from the second National Health and Nutrition Examination Survey (NHANES IN that mean intake of fiber by adults (19 to 74 years) in the United States was 11.1 g/day (with women consuming an average of 9.4 g and men consuming 12.9 g), well below that recommended by the National Cancer Institute. Dietary fiber is a term that refers to a heterogeneous group of plant food components that are resistant to digestion by enzymes produced by the human gastrointestinal tract (LSRO, FASEB, 1989~. These components include cellulose, hemicelluloses, pectins, and lignins from plant cell walls and gums, algal polysaccharides, and mucilages from plant cells (NRC, 1989a). There has been a great deal of interest in the specific effects of dietary fiber on several chronic diseases. The strongest argument for an increase in consumption of dietary fiber is the important contribution it makes to normal bowel function. Clear scientific associations of fiber intake with the incidence of heart disease, certain types of cancer, and diabetes mellitus have not been made. One reason may be the difficulty in designing appropriate experiments to specifically test for the effect of dietary fiber. Foods high in dietary fiber are also generally low in calories and total and saturated fatty acids and devoid of cholesterol; thus, determination of a specific fiber effect in a feeding study is difficult. Moreover, foods have a variety of fiber components, and each may have different actions. Chemically and physiologically, cellulose, lignin, hemicellulose, pectin, and alginates (all relatively purified fiber types) behave differently. Wheat bran, oat bran, and rice bran (all heterogeneous mixtures of fibers) are not similar in composition. It is also very difficult to analyze dietary fiber chemically, and thus it is hard to correlate the role of specific fiber components to health effects (NRC, 1989a). Recently, there has been some effort to subclassify the possible health ef- fects of soluble and insoluble dietary fiber. Soluble fiber includes pectins, gums, mucilages, and some hemicelluloses that are reasonably water soluble. Insolu- ble fiber includes cellulose, lignin, and most hemicelluloses. These subclasses of dietary fiber have physiologically different and potentially important effects on colon function. Wheat bran and other forms of insoluble fiber decrease transit time and increase dry and wet stool weight. Softer stools lead to easier elimina- tion and lessen the chance of hemorrhoids. Higher-fiber diets may also increase satiety and, thus, may be beneficial for weight control (NRC, 1989a). Some clinical studies have suggested that "water-soluble fiber from foods such as oat bran, beans, or certain fruits are associated with lower blood

178 N~rR~rioN LAsELfiNG glucose and blood lipid levels," whereas there is "some evidence . . . that an overall increase in intake of foods high in fiber might decrease the risk of colon cancer" (DHHS, 1988, p. 12~. However, Diet and Health concluded: "In general, the evidence for a protective role of dietary fiber per se in CHD, colon and rectal cancers, stomach cancer, female gynecologic cancers, diabetes, diverticulosis, hypertension, and gallstones is inconclusive. Even where the evidence is strongest, it has not been possible to adequately separate the effects of fiber from those of other components of the diet" (NRC, 1989a, p. 302~. Appropriate studies are sorely needed to clarify the possible effects of fiber on health. For example, intervention studies in human populations could clarify the role of specific fiber components in health (NRC, 1989a). Current Provision of Desired Information Information on the dietary fiber content of a food may be stated in several places on food labels. No information would be readily available from the ingredient listing, unless a consumer was aware of the fiber sources among a product's ingredients. The fiber content is allowed on a food product, although current regulations do not require its listing as part of the nutrition information panel. If the manufacturer chooses to list fiber content, it must follow the approved analytical method of the Association of Official Analytical Chemists Minsky et al., 1985) to determine the total dietary fiber content of He product. The section on analytical considerations in Chapter 4 provides further discussion of difficulties associated with total dietary fiber analysis, and its subcomponents. Descriptors such as high in dietary fiber have become increasingly common on the principal display panel. However, the agencies have not established formal rules or definitions for such terms. In a 1988 policy letter responding to a citizen petition, FDA proposed the following descriptor terms for dietary Sber a source is 2 g, a good source is 5 g, and an excellent source is 8 g in a serving of food (Ronk, 1988~. The term s fair source (10 percent ofU.S. RDA), good source (25 percent), and excellent source (40 percent) were defined in a 1986 FDA policy letter, assuming that a minimum daily intalce of 20 g of fiber daily was used in shelf labeling programs (Ronk, 1986~. USDA does not currently have any official policy on declaring dietary fiber content on food labels. Committee Recommendations The Committee recommends that: · FDA and USDA should require the disclosure of fiber content per serving in grams on the nutrition information panel under the term total dietary dyer.

NUTRITION LABS CONTENT 179 · FDA and USDA should define the scope of foods from anumal origin and other foods that contain little or no dietary fiber which should be exempted from this requirement. PDA and USDA should discourage labeling of soluble or insoluble fiber contents until methodologies approved by the agencies allow for the ad- equate and reproducible quantification of the soluble and insoluble fiber contents of a variety of foods. · FDA and USDA should define descriptive terms allowed to be used for venous source levels of dietary fiber on food labels. PROTEIN Health Relevance of Protein The Dietary Guidelines for Americans stress that Americans should eat a variety of foods to have a healthful diet (USDA/DHHS, 1985~. People need over 40 different nutrients to stay healthy. Although a certain amount of protein is need for good health, the diets of the majontr of Americans contain protein in excess of the Recommended Dietary Allowances (RDA) (NRC, 1989b). USDA surveys have consistently revealed that the average protein intake for all respondents ranging in age from infancy to over 75 years exceeds the RDA and represents approximately 11 to 16 percent of calories (NRC, 1989a). Protein is an essential nutrient. Amino acids obtained from the digestion and absorption of dietary proteins are synthesized into enzymes, a variety of hormones, neurotransmitters, and carrier, structural, and binding proteins. The amino acid hyptophan can be converted to the vitamin niacin. Amino acids can also be used as a source of energy when energy is limiting, most can be made into glucose and stored as glycogen when carbohydrate is limiting, and all can be stored as fat. In mammals, 10 amino acids (histidine, isoleucine, leucine, lysine, me~ionine, phenylalanine, threonine, tryptophan, valine, histidine, and arginine [for premature infants and total parenteral nutrition-fed patients]) cannot be synthesized in sufficient amounts (Heird et al., 1972; NBC, 1989b3. These essential amino acids must be supplied by the diet. The nonessential amino acids can be synthesized from dietary sources of utilizable carbon and nitrogen. Protein intake has been associated with an increased risk for several chronic diseases. The data linking too much protein, specifically too much animal protein, with CHD risk in humans are primarily based on epidemiological evidence. Since animal protein and saturated fatty acid intakes are often highly correlated, it is difficult to establish a specific cause-and-effect relationship in population studies. However, some evidence in humans indicates that in cases where soy protein was substituted for animal protein, serum cholesterol was lowered. In addition, vegetarians tend to have serum cholesterol values lower

180 NUWTION LABELING than Rose of the general population (NRC, 1989a). This difference may also reflect, in part, over lite-style differences. The relationship between the amount and the type of dietary protein and cancer in humans is being actively studied. Epidemiological evidence suggests a possible relationship between high intakes of dietary protein and increased risk for certain cancers (NRC, 1982~. Once again, this may be confounded by the high correlation between intakes of fat and protein in the Western diet (NRC, 1989a). There is also some debate as to whether high intakes of dietary protein promote osteoporosis. A high dietary protein intake in the form of a purified isolated nutrient increases the amount of calcium excreted in the urine. However, Were is little evidence Hat diets traditionally high in protein increase He risk for osteoporosis, especially if the phosphorus intake increases with protein intake, as it does in the United States (NRC, 1989a). Finally, there are data linking high-protein diets win age-relined progression of renal disease in humans and experimental animals (NRC, 1989a). More research is needed to clarify this relationship. In summary, many of the studies linking high-protein diets with increased chronic disease in humans are epidemiological in nature, which does not prove that there is a cause-and-effect relationship. These associations also reflect He high correlations between the intakes of protein and other constituents such as fat and fiber. There is little or no evidence to indicate beneficial heals effects from high protein intakes, as stated in the 1989 RDA report (NRC, 1989b3. Current Provision of Desired Information Information on the protein content of packaged foods may be found in three areas on the food label, including the ingredient listing, the nutrition information panel, and the principal display panel. Although the ingredient listing includes food components in descending order of prominence by weight, it provides little useful information on protein content (21 CF~ § 101.4~. For example, miLlc-based formulated foods may contain various proteins in the form of nonfat dry milk, soy protein isolate, and yeast. The current nutrition panel provides information about protein in two places: the amount of protein in grams per serving listed immediately after calories, and the percentage of the U.S. RDA, where protein is the first listed nutrient (21 CFR § 101.9(c)~4), (7~. Terms such as high protein may appear on He principal display panel, although this term has not been officially defined. When used for shelf labeling, products must contain 18 g of high-quality protein (at 45 g/day) or 26 g of lower-quality protein (at 65 g/day) per serving to use the term excellent source.

NuTRlTIoN user coNrENT 181 Committee Recommendations Although protein is an important nutrient, most Americans consume suffi- cient amounts. The Committee recommends that: FDA and USDA should continue to require the disclosure of protein content per serving in grams on the nutrition information panel. However, protein should be moved to a position of less prominence. The current requirement to list protein content as a percentage of the U.S. RDA should be eliminated. FDA and USDA should allow, as an option, the listing of total calories per serving from protein. · FDA and USDA should define descriptors that apply to terms used for protein content on food labels. SODIUM Health Relevance of Sodium Recent dietary recommendations have advised Americans to reduce their intake of sodium. The Dietary Guidelines for Americans recommended avoiding too much sodium (IJSDA'/DHHS, 1985~. The Surgeon General's report (DHHS, 1988) recommended that consumers reduce their intake of sodium by choosing foods relatively low in sodium and limiting the amount of salt added during food preparation and at the table. Diet and Health ARC, 1989a) recommended that Americans limit their total daily intake of salt (sodium chloride) to 6 g or less by limiting the use of salt during cooking, by avoiding the addition of salt to food at the table, and by greatly limiting the consumption of salty, highly processed salty, salt-preserved, and salt-pickled foods. Sodium is one of the most common, yet most important, minerals. It is found in most plant and animal tissues and fluids and is essential to life. In humans, sodium is the major cation in extracellular fluids (blood, lymph, and interstitial fluid), and its concentration is a major determinant of intra- and extracellular fluid volumes. Along with potassium, the major cation of intracellular fluid, sodium controls the passage of water in and out of the cells. It is a major electrolyte in the body and, along with a few other ions, controls the electrical properties of cells (NRC, 1989a). The sodium concentration in extracellular fluids, and thus extracellular fluid volume, is maintained primarily by the kidneys, interacting with the endocrine and nervous systems. Too little sodium in extracellular fluid (hyponatremia) can result from abnormally high sodium excretion by individuals with certain kidney diseases. ~ normal humans, salt ingested in excess of that needed to maintain normal serum levels is excreted in urine and sweat. If renal function

182 NVTRlTlON LABELING is impaired, the sodium concentration in extracelluLdr fluid can increase and, through its osmotic pressure, draw fluid from cells into the extracellular fluids (including blood), thus causing susceptible individuals to develop edema and heart failure. Beyond its physiological properties, salt has always been prized for its value as a preservative and a flavor in the majority of foods. In recent decades, Americans have developed a strong taste for salt and now consume it in amounts far in excess of normal physiological requirements. Salt, or sodium chloride, is 40 percent sodium by weight. Most sodium is ingested as sodium chloride in solid foods, but other sources of dietary sodium can be important. Most municipal water supplies contain less than 20 mg of sodium per liter, but some contain naturally as much as 1,000 mg/liter. Sources of dietary sodium, in addition to sodium chloride, are other salts (e.g., sodium bicarbonates and sodium-containing preservatives and flavor enhancers that are added during food manufacturing or processing. The majority of dietary salt is added to food during processing. Results of studies vary, but estimates are that 10 to 3S percent of dietary salt occurs naturally in the food, 35 to 75 percent is added during manufacturing and processing, and 15 to 35 percent is added by the consumer at mealtime (NRC, 1989a; Shank et al., 1983). The sodium intake of Americans has increased markedly since World War II, along with the consumption of foods manufactured andJor prepared outside the home. The sodium content of some prepared foods can be quite high. At limited-menu restaurants, sandwiches frequently contain more than 900 mg of sodium; a meal of a hamburger, fries, ketchup, and a milkshake can provide more than 1,000 mg of sodium; a triple cheeseburger can contain over 1,800 mg of sodium (Massachusetts Medical Society, 1989~. Physicians have been concerned about the adverse health effects of sodium ingestion since the early l900s. The principal concerns have been the role of sodium in causing high blood pressure (hypertension), heart failure, and edema. Dietary restriction of sodium can be lifesaving for certain individuals with severe renal or heart failure and for those who retain sodium and/or water, thus building up their extracellular fluid volume. Lowering of sodium intake helps to reduce blood volume and edema; at times, an extremely low sodium intake is mandatory to preserve life. Sodium's role in increasing blood volume and edema is generally well understood. Much less well understood is the role that sodium plays as a causative factor in high blood pressure (hypertension). Hypertension, generally uncommon in populations with low sodium intakes, is a common cause of morbidity and mortality in the United States. It is estimated that as many as 60 million people in the United States are hypertensive, as defined by the National Heart, Lung, and Blood Institute (NIMBI). Hypertension is a major risk factor for some of the most common causes of death in the United States: coronary artery disease, hypertensive heart disease, arteriosclerosis, and

NUTRITION lABEL CONTENT 183 stroke. In addition, hypertension is a major cause of renal failure. It is often familial; individuals can have a genetic predisposition to hypertension, but there is no known genetic marker (NRC, 1989a). Perhaps 10 to 30 percent of the U.S. population is genetically predisposed to hypertension and has a higher risk of developing hypertension as a result of sodium ingestion. The incidence of hypertension increases with age; it has been estimated that 65 percent of Americans will develop hypertension by the time they are age 65 to 74. It is much more common among black Americans than among whites, suggesting a genetic predisposition of blacks to develop the disease. Although the etiology of some types of hypertension is known (e.g., renovascular hypertension), the cause of the most common form—essential hypertension—is not known. Sodium plays an important role in the development of hypertension in at least some populations, along with other factors (age, obesity, alcohol consumption, stress, and other nutrients, such as potassium and chloride). It is clear mat reductions of dietary sodium can achieve a modest amelioration of hypertension in at least some population subgroups. It would therefore seem reasonable, given the high incidence of hypertension in Americans, for the U.S. population to reduce its sodium consumption. The above statements are generally undisputed within the medical and scientific communities. What is disputed is the precise role that sodium plays in the etiology of hypertension. Most authorities agree that sodium is an important factor in the development of hypertension in susceptible individuals and that excess sodium can exacerbate hypertension. The most telling information comes from epidemiological studies, many of which show a relationship between sodium intake and the incidence of hypertension. Although studies of some societies whose populations ingest relatively large amounts of sodium did not find an increased incidence of hypertension, studies of other cultures did, giving credence to the role of genes in causing hypertension (NRC, 1989a). Conversely certain societies with traditionally low levels of dietary sodium have a low incidence of hypertension. It is difficult to control studies of large populations for other factors known to influence blood pressure, such as body weight, exercise, and stress levels. Nevertheless, experts agree that there is a positive correlation between dietary sodium and blood pressure in large populations (DHHS, 1988; NRC, 1989a). Finally, a reduction of sodium intake does not have a significant effect on the blood pressure of all hypertensive individuals, but it does benefit certain individuals. It has been estimated that about half of all hypertensive individuals in the U.S. population are sensitive to salt. At present, the only way to determine whether an individual's blood pressure is related to salt intake is through a lengthy dietary trial during which salt intake is varied. It is hoped that, in the future, some simple test performed early in life could make that determination. The overwhelming consensus of medical experts who have considered the

184 NUTf21TION LABELING health effects of sodium is that Americans should reduce the amount of sodium they consume. The reasons are that the average American diet contains an amount of sodium far in excess of that required for good health, high sodium intake correlates positively with the development of hypertension in a large number of individuals, and hypertension and its sequelae are major health problems in the United States. It can reasonably be expected that a lowering of sodium intakes in the United States will lower both the incidence and the severity of hypertension. Americans are now concerned about the amount of sodium they consume and its role in disease. Through the success of public information campaigns such as those by FDA, NHLBI, and the AHA, the majority of Americans now know that excess salt or sodium ingestion is associated win poor health. Current Provision of Desired Information Information on the sodium content of packaged foods may be found in the ingredient listing, the nutrition information panel, and the principal display panel. The ingredient listing provides information about salt and sodium-containing compounds added to foods (21 CF~ §101.4) FDA's original nutrition labeling regulations did not require that sodium be listed unless a sodium or salt claim was made. If sodium was declared voluntarily, the label had to state the amount of sodium in milligrams per seeing. Sodium content was to be listed when the serving contained more than 10 mg of sodium, and was to appear in 5-mg increments. The voluntary listing of the sodium content of ordinary foods did not trigger full nutrition labeling. If a food's label claimed that it was useful in regulating sodium or salt intake (food for special dietary use), however, the label had to declare the food's sodium content both as sodium per seeing and the amount of sodium per 100 g of food. Because of a growing national concern over the deleterious health effects of excessive dietary sodium, FDA made the quantitative listing of sodium a required part of nutrition labeling effective in 1986. Sodium content was to be listed when the seeing contained more than 5 mg per seeing, and was to appear in 5-mg increments up to 140 mg of sodium per seeing. Above that level, it was to be given in 10-mg increments (21 CF1< §101.9(c)~8~(i)~. The same regulations defined the descriptive terms sodium free, low sodium, very low sodium, and reduced sodium, and provided for the proper use of those terms on the principal display panel. They also defined the terms without added salt, unsalted, and no salt added (21 CFR §101.13~. Thus, only for the past few years has the quantitative labeling of sodium been required as part of nutrition labeling whenever it is used or when a specific claim is made Hat the food is useful in regulating sodium or salt intake. On foods for special dietary use, the previously mandated dual listing of milligrams

NurRlTIoN lABEL CONTENT 185 of sodium per serving and milligrams per 100 g of food is no longer required; sodium is to be listed only in milligrams per serving. USDA requirements for listing the sodium content of foods are essentially identical to those of FDA. Unless a sodium claim is made, the listing of sodium content is voluntary and the listing of sodium content per serving alone does not trigger full nutrition labeling. When provided or required, sodium content must be expressed in milligrams per serving. One difference from FDA's requirements is that in the absence of a sodium claim, sodium content is not a required component of nutrition labeling. USDA's definitions for descriptors of sodium content on the principal display panel are identical to FDA's, but USDA also permits use of the term salt free, following the same criteria for sodium free (USDA, 1984a). Committee Recommendations Current regulations for the provision of information on the sodium content of foods are faulty only in that sodium content is not required to be declared on all foods. Therefore, the following recommendations are similar to current FDA regulations and USDA policy. The Committee recommends that: · FDA and USDA should continue to require the disclosure of sodium content per serving in milligrams, regardless of source (whether natural or added), on the nutrition information panel. Descriptors for sodium content on the principal display panel, as currently defined by FDA and USDA, should be continued. a POTASSIUM Health Relevance of Potassium Potassium was accorded status as a potential public health issue by the recent report on nutrition monitoring (LSRO, FASEB, 1989~. No specific rec- ommendation was made in either the Surgeon General's or the NRC reports. Potassium is closely related to sodium in many ways. It is the major cation in intracellular fluid, and so its concentration is a primary determinant of intracellular fluid volume. Along with sodium, potassium controls the passage of water in and out of cells and the electrical properties of cellular membranes. Because of its importance in maintaining the function of all cellular mem- branes in the body, marked derangements of intracellular potassium concentra- tions, either high or low, can cause serious illness and death. Generally, the body's homeostatic mechanisms are quite efficient in maintaining normal potas- sium levels, and healthy individuals who are not taking diuretics rarely suffer

186 NUTIUTION L4BEllNG from potassium imbalance. Severe alterations are relatively rare, and they are almost always associated with other serious, symptomatic disease. Most severe potassium losses from the body are associated with losses of body fluids. Copious vomiting or diarrhea can cause low serum potassium levels. Relatively large amounts of potassium can be excreted in urine through the prolonged use of diuretics. She development of kidney disease leads to an imbalance of potassium that needs to be controlled by therapeutic means. The importance of potassium to normal body function means Hat serious potassium depletion is associated with marked clinical symptoms of disease. The observation that increased potassium and reduced sodium inters can lower blood pressure was first made decades ago, but the significance of this finding is still being debated ERG, 1990; LSRO, FASEB, 1989; NRC, 1989a). Because of the frequency of use of diuretics for the treatment of heart failure and hypertension, many consumers are aware of the possibility that diuretic agents may lower serum potassium levels in individuals with these diseases. The general public is relatively unaware of the possible role of potassium in lowering blood pressure. Current Provision of Desired Information Under current FDA regulations and USDA policy governing nutrition labeling, the declaration of potassium is voluntary. If potassium is declared, Be amount must immediately follow the sodium content and include the number of milligrams of potassium in a specified serving (portion) of food. As with sodium, the content can be zero when the serving contains less than 5 ma of potassium, and must be given in 5-mg increments up to 140 mg of potassium per serving. Above that level, it must be given in 10-mg increments (21 GFR § lOl.9(c)~8~(ii); USDA, 1984b). Committee Recommendations Neither an excess nor a deficit of dietary potassium is a public health problem for Americans. A relatively small number of individuals who excrete high amounts of potassium (e.g., those on certain diuretics) need potassium-rich diets or potassium supplementation of their diets. Thus, the quantitative listing of this mineral should be permitted for foods that are rich in potassium and required on foods when a claim is made that the food is useful in providing dietary potassium. Existing FDA regulations and USDA policy are satisfactory. Therefore, the Committee recommends that: · Disclosure of potassium content on the nutrition information panel should remain voluntary, unless a potassium claim is made.

NUTRITION L4BFL CONTENT . 187 If disclosed on the label, potassium content per serving should be listed in milligrams. VITAMINS AND 1\IINERALS The following discussion includes a review of the micronutrients currently required on He nutrition panel (vitamins A and C, thiamin, niacin, riboflavin, calcium, and iron) and several additional ones (vitamin B6, fluoride, folate, potassium, and zinc), for which current public heals concerns have been raised (LSRO, FASEB, 1989; NRC, 1989a). Over micronutrients, many of which are currently allowed on an optional basis on the nutrition label, that were discussed in recent reports were not judged in those documents to be current or potential public health problems, nor were specific recommendations made concerning their consumption; therefore, they are not considered for food labeling. Health Relevance of Nutrition Labeling Recommendations Calcium Recent dietary recommendations have advised Americans to increase their intake of calcium. The Surgeon General's report recommended that adolescent girls and adult women should increase their consumption of foods high in calcium, including low-fat dairy products (DHHS, 1988~. The Diet and Health report advised that consumers maintain adequate calcium intake (NRC, 1989a). The 1989 report, Nutrition Monitoring in the United States, advised that calcium merited priority monitoring due to the low dietary intakes by women and the possible association with age-related osteoporosis (LSRO, FASEB, 1989~. In the body, 99 percent of the calcium is stored in the bones and teeth, where it contributes to the formation and maintenance of these tissues. The rest is in fluids and soft tissue, playing a role in nerve conductivity, muscle contraction, and blood clotting. Throughout life, skeletal calcium is continuously turned over through resorption and formation. Calcium absorption is influenced by dietary calcium intake, the interaction of calcium with other dietary substances in He small intestine, and the level of activity of the transport systems that moves calcium into the body. The 1989 RDA subcommittee judged that adequate calcium during the formative years was the way to reduce the risk of osteoporosis (NRC, 1989b). Peak bone mass is determined by a number of factors, including hormonal status, genetics, and various dietary components during the years of bone mineralization. Evidence of the role of dietary calcium in peak bone mass is still unclear, inconsistent, and incomplete. Further research is need to determine the exact mechanism of skeletal formation and other factors Hat

188 Nl~RlTION LABELING influence skeletal health. However, He efficiency of absorption is increased during periods of high physiological requirements, such as during pregnancy and in children during growth periods. Conversely, calcium absorption in elderly individuals and other population subgroups is impaired. The presence of various other dietary factors, notably protein and vitamin D, affect calcium absorption. For women who are in the postmenopausal stage of life, the rate of decline in bone mineral is strongly de- pendent on estrogen status. At present, results of studies of the effect of calcium supplementation on age-related bone loss are inconclusive, but supplementation combined with estrogen treatment has been reported to be as successful as es- ~gen alone in slowing the rate of bone loss. Factors other than calcium intake (genetics, age, sex, body weight, hormonal status, and physical activity) are related to osteoporosis ARC, 1989a). Some studies have suggested Hat a high calcium intake has been associated with lowering blood pressure. The Surgeon General's report indicated that men and children had es~ mean intakes of 105 and 115 percent, respectively, of the RDA for calcium, whereas women had estimated mean intakes that were 78 percent of the RDA (DHHS, 1988~. The 1989 RDA included a higher recommendation for calcium (1,200 ma) for males and females aged 11 to 24 in order to permit full mineral deposition (NRC, 1989b). The same level is set for pregnant and lactating women. For people in older age groups, the 1980 level of 800 mg was retained. A level of 250 mg/day is recommended for newborns. Assessment of calcium status in survey populations has not been done. Iron The Surgeon General's report recommended that because dietary iron deficiency is responsible for the most prevalent form of anemia in the United States, children, adolescents, and women of childbearing age should be sure to consume foods that are good sources of iron (DHHS, 19881. The report indicated that this was of special concern for low-income families. The recent nutrition monitoring report concluded that high monitoring priority should be accorded to iron because it is a current public health issue (LSRO, FASEB, 1989~. An is a constituent of blood, most notably hemoglobin, in tissues such as myoglobin and in a variety of cytochromes and enzymes, all of which make it essential for life. It is also stored in several body organs. The main physiological role of iron is to carry oxygen to the body tissues. The body's iron content is regulated by the amount of iron absorbed by the intestinal mucosa. Absorption is influenced by body stores, the amount and form of dietary intake, and the dietary components with which it is ingested. Inadequate intakes of dietary iron can ultimately lead to anemia. Currently, there is no single biochemical indicator available to assess iron inadequacy in

NUTRITION BABEL CONTENT 189 the general population in a reliable manner; however, operational definitions of anemia have been set by the World Health Organization and proposed by the Centers for Disease Control. The consequences of iron deficiency ascribed to the resulting anemia can occur before reduced hemoglobin levels are apparent. Decreased work capacity, reduced physical performance, and impaired immune function have been reported to be associated with low hemoglobin levels in adults. In children, iron deficiency has been associated with apathy, short attention span, irritability, and a reduced ability to learn (NRC, 1989b3. In He United States, iron deficiency is primarily observed during four specific periods in life (NRC, 1989b). The first is from 6 to 48 months of age and is due to the low iron content of milk, rapid body growth, and limited iron stores in the body. The second period is during adolescence, another dine of rapid body growth and expanding red blood cell mass. The third is the female reproductive period and is due to menstrual iron losses. Finally, the fours period is during the female reproductive process, when the mother's blood volume expands, there are increased demands due to fetus and placenta, and there are blood losses during childbirth. Heme iron, primarily obtained from animal sources, is a highly absorbable form and seems to represent a significant source in many individuals. Absorption of non-heme iron, primarily obtained from plant sources, is believed to be enhanced by consumption with foods containing vitamin C, which is present in high amounts in the diets of most age groups. Other dietary substances can substantially decrease the absorption of nonheme iron. The recent trend of reduced meat intake may decrease iron intake in the population, because red meats are an important source of dietary iron. The Surgeon General's report indicated that the estimated mean intakes by women and children were 61 and 88 percent of the 1980 RDA, respectively, whereas estimated mean intakes by men were 159 percent of the RDA (DHHS, 1988~. The 1989 RDA for iron was set at 15 mg/day for adult women in the United States, a level believed to provide a sufficient margin of safety. This level was a reduction from the 18-mg/day level set in 1980, since the prevalence of iron deficiency anemia in that age group is low. Available data suggest that 10 to 11 mg of iron per day in a typical Amencan's diet is sufficient for most women. The RDA level of 10 mg/day for males aged 19 to 60 remained unchanged. Win little evidence of iron deficiency among the elderly, the RDA for this group is set at 10 mg/day. On average, an additional 15 mg/day is needed throughout pregnancy; however, this is usually obtained through the use of iron supplements. Infants aged 3 months to 3 years need 1 mg/day if they are bottle- fed. For children aged 6 to 36 months, the RDA is set at 10 mg/day. Adolescent males need 12 mg/day, whereas the level for adolescent females is 15 mg/day.

190 Vitamin A NUTRITION LABELING Vitamin A and carotenes were accorded the status of a potential public health issue by the Expert Panel on Nutrition Monitoring (LSRO, FASEB, 1989~. No specific recommendation was made in either the Surgeon General's or NRC reports. Vitamin A represents a group of compounds that are critical for vision, growth, cellular differentiation and proliferation, reproduction, and the immune system. The body's need for vitamin A can be met by dietary intake of preformed retinoids with vitamin A activity, generally from animal products, or by consumption of carotenoid precursors of vitamin A. Carotenoid precursors are found in plants, the best known being beta-carotene. Carotenoid-rich food consumption is inversely associated with lung cancer risk, though such foods are not protective against lung cancer for smokers (NRC, 1989a). Preformed vitamin A, mainly retinyl esters, is efficiently absorbed. Most carotenoids are not well absorbed, unless they are present in oil. Retinol and a portion of the active carotenoids are absorbed and transferred to the liver which contains about 90 percent of the total body stores of the vitamin. Carotenoids that are not otherwise converted are generally deposited in adipose tissue or the adrenal glands. The absorption and utilization of carotenoids and vitamin A are enhanced by dietary fat, protein, and vitamin E. Absorption is depressed by diets that are very low in fat and when either peroxidized fat and other oxidizing agents are present or when deficiencies exist for protein, vitamin E, iron, or zinc. Inadequate dietary intake of vitamin A is found most commonly in children under age 5. Deficiency can also occur in situations of chronic fat malabsorption. Clinical signs range from night blindness to total blindness. Other signs of deficiency include loss of appetite, hyperkeratosis, and increased susceptibility to infections. The estimated mean intakes of vitamin A by men, women, and children are reported to be close to or above the RDA for vitamin A (DHHS, 1988~. The RDA for adults is set at 1,000 retinal equivalents (RE) for men and 800 RE for women (NRC, 1989b3. No increment of vitamin A intake is necessary during pregnancy; however, a daily increment of 400 to 500 RE is needed during lactation. For an infant consuming 3 cups of mink daily, the RDA of 375 mg will be met. Because of the demands of rapid grown, the RDA for vitamin A is set at 400, 500, and 700 RE daily for the age groups 1 to 3, 4 to 6, and 7 to 10, respectively. Beyond age 11, the sexes have separate RDAs that are the same as those for adults.

NUTRITION L4BFL CONTENT 191 vitamin C Ascorbic acid was accorded the status of a potential public health issue by the Expert Panel on Nutrition Monitoring PRO, EASES, 1989~. No specific recommendation was made in either the Surgeon General's or NRC reports. The primary function of vitamin C (ascorbic acid) is its role as a cofactor in hydroxylation reactions requiring molecular oxygen and reactions with other dietary factors. It also affects the function of leukocytes and macrophages, immune response, wound healing, and allergic reactions. Ascorbic acid is well absorbed in the intestines and increases the absorption of inorganic iron when the two nutrients are ingested together. Epidemiological studies suggest some possible protection against cancer by vitamin C-containing foods and Britain C itself, but the effect of vitamin C on cancer in experimental studies in animals is far less clear. Dietary deficiency of vit~nin C can eventually lead to scurvy, characterized by weakening of collagenous structures that result in widespread capillary hemorrhaging. In the United States, scurvy is rare but can occur in infants fed diets consisting exclusively of cow's mild and in elderly individuals on inadequate diets. The calculated amount of vitamin C intake can vary due to destruction during storage and preparation, use of supplements (which are ingested by 35 percent of the population), limitations of food composition tables, and the addition of ascorbic acid to processed foods for its properties as an antioxidant. The average dietary vitamin C intake by adult men is 109 ma; for adult women and children the average intakes were 77 mg and 84 ma, respectively (DHHS, 1988~. The RDA for adults and elderly individuals is set at 60 mgJday, which is usually provided in mixed diets (NRC, 1989b). The recommendation for vitamin C intake by smokers is set at 100 mg/day, due to the increased requirements in this group. The increment for pregnant women is 10 mg/day and for lactating women it is 35 mg/day for the first 6 months of lactation and 30 mg/day for the second 6 months of lactation. The RDA for infants is set at 30 mg/day, which increases gradually for children to the adult levels by age 15. Thiamin In Nutrition Monitoring in the United States DISCO, FASEB, 1989), thiamin was not considered to be a current public health issue. No specific recommen- dation concerning thiamin was given in either the Surgeon General's or NRC reports. Thiamin is used in the body as the coenzyme thiamin pyrophosphate for the oxidative decarboxylation of alpha-keto acids and the activity of transketolase in the pentose phosphate pathway. It is rapidly absorbed in the small intestine. Thiamin deficiency primarily occurs in situations in which the enrichment

192 N~r~TlON LABELING of white rice and white flour has not been implemented or low levels of dietary thiamin are associated with consumption of raw fish, whose intestinal microbes contain thiaminase. In the United States, thiamin deficiency is unlikely in healthy individuals but has been observed in individuals whose heals is otherwise compromised by such conditions as alcoholism, renal disease, chronic febrile infections, chronic intravenous feeding, or inborn errors in metabolism. Deficiency is associated with abnormalities of carbohydrate metabolism related to decreased oxidative deca~oxylations. The clinical condition associated with a prolonged deficient intake is beriberi, which is characterized by mental confusion, anorexia, muscle weakness, ataxia, peripheral paralysis, edema or muscle wasting (depending on the type of beriberi), tachycardia, and enlarged heart. The average thiamin daily intake is reported to be 1.75 mg by adult men, 1.05 mg by adult women, and 1.12 mg by children aged 1 to 5 (NRC, 1989b). A minimum of 1.0 mg/day is the recommended level for all adults (NRC, 1989b). An additional 0.4 mg/day is recommended throughout pregnancy for maternal and fetal growth as well as increased maternal caloric intake. An increment of 0.5 mg/day is recommended throughout lactation. The 1989 RDA allowance for infants is 0.4 mg/1,000 kcal; this increases to 0.5 mg/1,000 kcal for children and adolescents. Riboflavin In Nutrition Monitoring in the United States (LSRO, FASEB, 1989), n- boflavin was not considered to be a current public health issue. No specific recommendation concerning riboflavin was given in either the Surgeon Gen- eral's or NRC reports. This B vitamin functions primarily as a part of two Gavin coenzymes (flavin mononucleotide and Gavin adenine dinucleotide) that catalyze many oxidation- reduction reactions. Riboflavin is essential in the function of vitamin B6 and niacin. Riboflavin is readily absorbed in the small intestine. Deficiency is rare in the United States, but symptoms include oral-buccal cavity lesions, a generalized seborrheic dermatitis, and normocytic anemia Average reported intakes are 2.08 mg/day by men, 1.34 mg/day by women, and 1.57 mg/day by children ages 1 to 5 ARC, 1989b). A minimum intake of 1.2 mg/day is recommended for adults (NRC, 1989b). An additional intake of 0.3 mgiday is recommended during pregnancy; and 0.5 mg and 0.4 mg/day are recommended for the first 6 months and thereafter, respectively, for lactation. Because of the possibility of growth inhibition with inadequate intakes by children, the allowance is set at 0.6 mg/100 kcal for infants and approximately 1 mg/day for children.

NlJTRITION lABF1 CONTENT Niacin 193 In Nutrition Monitoring in the United States (LSRO, FASEB, 1989), niacin was not considered to be a current public health issue. No specific recommen- dation concerning niacin was given in either the Surgeon General's or NRC reports. This nutrient functions in the body as part of two coenzymes—nicotinamide adenine dinucleotide and nicotinamide adenine dinucleotide phosphate. These coenzymes are present in all cells and function as part of the metabolic processes of glycolysis, fatty acid metabolism, and tissue respiration. Pellagra is a deficiency disease characterized by dermatitis, diarrhea, inflammation of the mucous membranes, and ultimately, dementia. Pellagra was once a common nutritional disease in the United States but it is no longer a public health issue. Niacin occurs in the diet in high concentrations in meats. Conversion of tryptophan to niacin contributes to the dietary source pool for niacin. The conversion factor is 60:1 ~yptophan to niacin. As a result, mink and eggs are considerable sources of Iryptophan because it is converted to niacin. Niacin in processed cereal grains is biologically unavailable. However, fully synthetic niacin is added to fortified milled grain products, making them good sources. The calculated daily intakes of total niacin equivalents are 27 mg by women and 41 mg by men (NRC, 1989b3. The RDA for niacin is 15 mg/day for adult women and 19 mg/day for adult men. Dunng pregnancy and lactation, the increments are 2 mg/day and 3 mg/day, respectively. For infants under age 6 months, the RDA for niacin is 5 mg/day and increases to 6 mg/day until age 1. For children the niacin RDA climbs gradually to the adult levels. Vitamin B6 In Nutrition Monitoring in the United States (LSRO, FASEB, 1989), vitamin B6 was considered to be a potential public health issue. No specific recommen- dation concerning vitamin B6 was given in either the Surgeon General's or NRC reports. Vitamin B6 is comprised of various dielary compounds pyridoxine, pyri- doxal, pyridoxamine, their phosphate esters, and glycosylated forms of pyridox- ine. The various dietary forms are all absorbed by intestinal mucosal cells. In the liver, erythrocytes, and other tissues, these forms are conver~d to pyridoxal phosphate and pyridoxamine phosphate, which serve as coenzymes in transam- ination and numerous other reactions. Deficiency rarely occurs alone, but rather is seen in individuals who are deficient in several B-complex vitamins. Charac- teristics of severe deficiency include epileptiform convulsions, dermatitis, and anemia. Infants experience a variety of neurological symptoms and abdominal distress. Biochemically detected marginal vitamin B6 nutriture has been observed in certain subgroups of ~e U.S. population.

194 NurRITIoN LABELING Although present in a number of foods, considerable losses of the vitamin occur during processing. Bioavailability varies widely and is influenced by food composition and certain drug interactions. The requirement for vitamin B6 increases as the intake of protein increases. Average vitamin B6 intake was 1.87 mg/day by adult males, 1.16 mg/day by adult females, and 1.22 mg/day for children aged 1 to 5 (NRC, 1989b). The RDA for vitamin B6 is 2.0 mg/day for men and 1.6 mg/day for women, win an average protein intake of 100 g/day and 60 gm/day, respectively (NRC, 1989b). However, the RDA would not be sufficient for individuals whose habitual protein intake is above the 90th percentile. During pregnancy an increase of 0.6 mg/day is needed, and during lactation an additional allowance of 0.5 mg/day is needed to compensate for additional protein requirements. During Be first 6 months of life, 0.3 mg/day is recommended and 0.6 mg/day is recommended for older infants. The recommendation is 1.0 mg/day for children aged 1 to 3, 1.1 mg/day for children aged 4 to 6, and 1.4 mg/day for children aged 7 to 10. Toxicity of vitamin B6 supplements has been reported at doses greater than 100 mg/day. Folate In Nutrition Monitoring in the Muted States (LSRO, FASEB, 1989), folate was considered to be a potential public health issue. No specific recommendation concerning folate was given in either the Surgeon General's or NRC reports. Folate functions metabolically as a coenzyme in the transport of single- carbon fragments from one compound to another in amino acid metabolism and nucleic acid synthesis. Deficiency of folate leads to impaired cell division and altered protein synthesis. Late consequences lead to overt megaloblastic bone marrow and macrocytic anemia. Folate is widely distributed in the food supply, being particularly rich in liver, yeast, leafy vegetables, legumes, and some fruits. However, up to 50 percent of food folate can be destroyed during food preparation, processing, and storage. Bioavailability is variable, depending on the physical form, and the presence of inhibitors, binders, or other factors in foods. The average daily intake is generally from 280 to 300 ,ug in the United States. The RDA for folate is 200 Mg/day for adult males and 180 ,ug/day for adult females (NRC, 1989b). These levels appear to provide normal tissue stores and other indicators of folate status. Due to the problems of adsorbability, the RDA during pregnancy is set at 400 Mg/day to accommodate increased requirements. During lactation the RDA is set at 280 Mg/day for the first 6 months of pregnancy and 260 Mg/day up to 1 year. For the first 6 months of life, the RDA is set at 25 ,ug/day and at 35 Mg/day up to age 1. For children, the RDA increases incrementally to the adult level.

NurRrTloN labs collard Fluoride 195 The Surgeon General's report (1988) recommended that community water systems should provide fluoride at optimal levels for the prevention of dental canes. Diet and Health ARC, 1989a) advised that it is necessary to maintain an optimal fluoride intake, primarily during the years of tooth formation and growth. In Nutrition Monitoring in the United States (LSRO, FASEB, 1989), fluoride was considered to be a potential public health issue. This mineral is incorporated into bone and tooth enamel in the human body and is believed to be beneficial, if not essential, to dental health. The negative correlation between tooth decay in children and fluoride concentrations in Ming water was demonstrated nearly 50 years ago. Subsequent studies have confirmed that fluoridation of public water supplies is an effective and practical means of reducing dental canes. The protective effect against caries is greatest during ma~cunal tooth formation in the first 8 years of life. Evidence sugggests, however, Rat adults can benefit from continued consumption of fluoridated water. The richest dietary sources of fluoride are tea and marine fish consumed with their bones. Much of the fluoride intake depends on the effects of the water supply on beverages and food preparation where fluoridation is used. Absorption of fluoride is variable, creating difficulties in establishing dietary recommendations. Although no RDA has been established for fluoride, the estimated safe and adequate daily dietary intake ranges from 1.5 to 4 mg/day for adults (NRC, 1989b). For those in younger age groups, the range is set to a maximum level of 2.5 mg/day. Ranges of 0.1 to 1 mg/day are set for birth to 12 months, and 0.5 to 1.5 mg/day for ages 12 to 36 months. Z. In Nutrition Monitoring in the United States (LSRO, FASEB, 1989), zinc was considered to be a potential public health issue. No specific recommendation concerning zinc was given in either the Surgeon General's or NRC reports. Zinc is an essential mineral and is a constituent of several hundred enzymes that are involved in numerous metabolic pathways. Zinc status is subject to strong homeostatic regulation. Although large amounts are deposited in bone and muscle, the body pool of readily available zinc is small and has a rapid turnover rate. As a result, there is evidence that zinc deficiency has a rapid effect on cell growth and repair. The general signs of dietary zinc deficiency include loss of appetite, growth retardation, skin changes, and immunological abnormalities. Pronounced deficiency results in hypogonadism and dwarfism. Signs of marginal deficiency are manifested as slowed wound healing, hair loss, and impaired taste and smell acuity.

196 NUTRITION LABELING The bioavailability of zinc from foods varies widely; animal products are good sources, whereas whole-grain products contain less available forms of the mineral. The interaction of zinc with dietary protein, physic acid, and copper may have practical significance in Americans' diets. The zinc content of typical diets of adults furnishes 10 to 15 mg/day (NRC, 1989b). Dietary intakes are lower than recommended levels in some groups DISCO, EASED, 1989~. Infants and young children consume diets containing about 5.5 to 8.5 mg of zinc per day. Elderly individuals generally consume from 7 to 10 mg of zinc per day. The RDAs for zinc for adult men and women are 15 mg/day and 12 mg/day, respectively (NRC, 1989b). A zinc intake of 15 mg/day is recommended during pregnancy; during lactation, an additional zinc intake of 7 mg/day is recommended for the first 6 months and an additional 4 mg/day is recommended for the second 6 months. A recommendation of 5 mg/day is set for formula-fed babies. For adolescent children, the recommendation is set at 10 mg/day. Current Provision of Desired Information Current food labels provide information on the vitamin and mineral content in the ingredient listing, the nutrition information panel, and the principal display panel. The ingredient listing provides information about any individual vit~nins and minerals that have been added to foods during the manufacturing process (21 CF1( §101.41. No information is available about the micronutrient composition of other ingredients of foods in the ingredient listing. The nutrition information panel lists the micronutrients currently required when nutrition labeling is used in the following order: vitamins A and C, thiamin, riboflavin, niacin, calcium, and iron (21 CFR § 101.9(c)~7~. Other optional vitamins and minerals, when they are added or naturally occurring, must be listed following the required micronutrients. Each micronutrient is listed as a percentage of the U.S. RDA contained in the food. The U.S. RDAs are standards based on the 1968 RDA, and a more extensive discussion is provided in Chapter 7. The percentages are expressed in 2 percent increments up to the 10 percent level, in 5 percent increments up to the 50 percent level, and in 10 percent increments above the 50 percent level. Nutrients present in amounts less Man 2 percent of the U.S. RDA may be indicated by a zero or an asterisk referring to a footnote at the bottom of the table: "contains less than 2 percent of the U.S. RDA of this (these) nutrient (nutrients)" (21 CFR §101.9(c)~7~(i)~. When a product contains less than 2 percent of the U.S. RDA for at least five of the required nutrients, the manufacturer may choose to declare no more than three of those nutrients, with an appropriate accompanying statement. The principal display panel frequently carries terms describing the content of vitamins and minerals that manufacturers wish to highlight in promoting a food. FDA regulations provide that a claim may be made that a food is a significant

NUTRITION lABEL COMET 197 source of a vitamin or mineral if that micronutrient is present in a food at a level equal to or in excess of 10 percent of the U.S. RDA in a serving (21 Con §101.9(c)~7~(v)~. Other examples of micronutrient descriptors include high in vitamin C, iron fortified, or high in calcium. However, currently there are no official definitions for such terms for specific micronutrients. Committee Recommendations On the basis of recent dietary recommendations, current public health is- sues, and the consumption patterns of Americans, the Committee considered the current requirements for and potential changes in He listing of micronutrients on the nutrition information panel and acknowledges that the current selection of micronutrients required to be listed is dated. The Committee's recommendations for change are based on current consumer interest, scientific evidence to support consensus on health benefit, conclusions drawn by reports of expert panels, and knowledge of essential nutrients. Although a more comprehensive listing could be recommended, the limitation of space on labels for nutrition information and He lack of scientific evidence demonstrating general public health problems led the Committee to focus its attention on micronutrients reported to be current public heals issues (see Table 6-1~. The Committee based its decision primarily TABLE ~l Priority Status as a Public Heals Issue of Fbod Components Current Potential Public NoeCurrendy Public Health Health Issue, Public Health Issue Further Study Needed Issue Food energy Fat Saturated fat Cholesterol Alcohol Iron Calcium Sodium Dietary fiber Vitamin A Carotenes Folacin Vitamin B6 Vitamin C Potassium Zinc Pluande Protein Carbohydrates Vitamin E Thiamin Riboflavin Niacin Vitamin B12 Magnesium Copper Phosphorus SOURCE: Adapted from LSRO, FASEB (Life Sciences Re- search Office, Federation of American Societies for Experimental Biology). 1989. Nutrition Monitoring in the United States: An Update Report on Nutrition Monitoring. Prepared for the U.S. Department of Agriculture and U.S. Department of Health and Human Services. Government Printing Office, Washington, D.C. 408 pp.

198 NUTRITION LABELING on the attention given to them by reports from the Surgeon General, the Expert Panel on Nutrition Monitoring, and NBC (DHHS, 1988; LSRO, FASEB, 1989; NBC, 1989a). As indicated several times in this report, the Committee put primary emphasis on the importance of consuming a diet consisting of a variety of foods. The decision to limit the number of micronutrients to be listed engendered concern, and therefore led the Committee to add the following words of caution on important dietary sources of nutrients. Labeling dairy products as particularly good sources of calcium might lead to the consumption of foods also rich in animal protein, which has been shown to enhance urinary calcium excretion, thereby compromising calcium status and perhaps even exacerbating the risk of osteoporosis ARC, 1989b3. Emphasizing iron richness may bring particular attention to foods for which the bioavailability of iron is said to be high, such as meats that contain the heme forms of iron, whereas recent reports (such as the Surgeon General's, Diet and Health, and the Dietary Guidelines) have urged moderation in the consumption of these foods (DHHS, 1988; NRC, 1989; USDA/DHHS, 1985~. On balance, however, the Committee acknowledges the considerable consumer interest generated in these nutrients, in part, by these recent reports and recognizes that there are other sources of calcium and iron that possess considerable nutritional benefit and that need to be identified for the consumer. For vitamins A and C, there is little evidence of a public health problem in the U.S. population. If food sources rich in vitamin A were to be listed, it is unlikely that the nutritional value of provitamin A-Wpe compounds (carotenoids) would be distinguished from preformed vitamin A (retinoids). Not only are there likely to be important biological differences in the ability of these compounds to inhibit chronic degenerative diseases but also carotenoids are found in foods (plants) whose consumption is encouraged, and retinoids are found in foods (animal products such as liver) whose consumption is not encouraged. Listing of vitamin C would provide information on good sources of this nutrient (e.g., fruits and vegetables), but those sources also provide a variety of other important micronutrients. For zinc and folate, there was even less evidence demonstrating the need to emphasize consumption of foods rich in these nutrients. Consumers should likewise assess their intake of vitamins and minerals in terms of total diet rather than the contribution of individual foods. The current listing on the food label of micronutrients as a percentage of the U.S. RDA encourages manufacturers of some food products to fortify each micronutrient to 100 percent. Treatment of vitamins and minerals in qualitative rather than quantitative terms would help to reduce the incentives for overfortification of foods. Furthermore, the current listing implies more precision and accuracy than really exists due to the inaccuracy in measuring at least some of the nutrients in this group.

NUTRITION L4BF1 CONTENT 199 The Committee recommends that: · FDA and USDA should continue to require disclosure of calcium and iron content per serving, but use He source definitions described in Chapter 7 (i.e., very good source of, source of, and contains). · FDA and USDA should allow, as an option, disclosure of Be content of all other micronu~ients for which RDAs exist. · FDA and USDA should establish standardized definitions for the terms used to describe the micronutrient content of foods on Me principal display panel and these definitions should be the same as those used on the nutrition information panel (see Chapter 7~. REFERENCES ADA (American Diabetes Association), Task Force on Nutrition and Exchange Lists. 1987. Nutritional recommendations and principles for individuals with diabetes mellitus. Diabetes Care 10:126-132. AHA (American Heart Association), Committee on Nutrition. 1965. Diet and Heart Disease. American Heart Association, New York. AHA (American Heart Association), Committee on Nutrition. 1986. Dietary guidelines for healthy American adults. Circulation 74:1465A-1468A. Bonanome, A., and S.M. Grundy. 1988. Effect of dietary steanc acid on plasma cholesterol and lipoprotein levels. N. Engl. J. Med. 318:124~1248. Butrum, R.R., C.K. Clifford, and E. Lanza. 1988. NCI dietary guidelines. Rationale. Am. J. Clin. Nutr. 48:Suppl. CCC (Calorie Control Council). 1985. Sweet Choices~uestions and answers about sweeteners in low-calorie foods and beverages. CCC, Atlanta. 6 pp. Crapo, P. A. 1984. Theory vs. fact: The glycemic response to foods. Nutr. Today 19:6-11. DHHS (U.S. Department of Health and Human Services). 1988. The Surgeon General's Report on Nutntion and Health. Gove~ntnent Printing Office, Washington, D.C. 727 PP Glinsmann, W.H., H. Irausquin, and Y.K. Park. 1986. Evaluation of health aspects of sugars contained in carbohydrate sweeteners: Report of Sugars Task Force. J. Nutr. 116:S1-S216. Gordon, T., W}3. Castelli, M.C. Hjortland, W.B. KanneL and T.R. Dawber. 1977. High density lipoprotein as a protective factor against coronary heart disease. The Framingham Study. Am. J. Med. 62:707-714. Groen, J., B.K. Tjiong, C.E. Kamminga, and A.F. Willebrands. 1952. The influence of nutrition, individuality and some other factors, including venous forms of stress, on the serum cholesterol; an experiment of nine months duration in 60 normal human volunteers. Voeding 13:556-587. Grundy, S.M. 1987. Monounsaturated fatty acids, plasma cholesterol and coronary heart disease. Am. J. Clin. Nutr. 45:1168-1175. Heird, W.C., J.F. Nicholson, J.M. DriscolL Jr., NJ. Schullinger, and R.W. Winters.

200 NUTRITION LABELING 1972. Hyperammonemia resulting from intravenous alimentation using a mixture of synthetic 1-amino acids: A preliminary report J. Pediatr. 81:162-165. Herold, P.M., and J.E. Kinsella 1986. Fish oil consumption and decreased risk of cardiovascular disease: A comparison of findings from animal and human feeding trials. Am. J. Clin. Nutr. 43:566-598. HPI`RG (Hypertension Prevention Trial Research Group). 1990. The hypertension pre- vention trial: Three-year effects of dietary changes on blood pressure. Arch. Intern. Med. 150:153-162. Kayman S., W. Bruvold, and J.S. Stem. 1990. Maintenance and relapse after weight loss in women: Behavioral aspects. Am. J. Clin. Nutr. In press. Keys, A. 1975. Coronary heart disease_the global picture. Atherosclerosis 22:149-192. Kinsell, L.W., J. Partridge, L. Baling, S. Margen, and G. Michaels. 1952. Dietary modification of serum cholesterol and phospholipid levels. J. Clin. Endocrinol. 12:909-913. Kromhout, D., E.B. Bosschieter, and C. de Lezenne Coulander. 1985. The inverse relation between fish consumption and 20-year mortality from coronary heart disease. N. Engl. J. Med. 312:i205-1209. Lanza' E., D.Y. Jones, G. Block, and L. Kessler. 1987. Dietary fiber intake in the U.S. population. Am. J. Clin. Nutr. 46:790 797. LSRO, FASEB (Life Sciences Research Office, Federation of American Societies for Experimental Biology). 1989. Nutrition Monitoring in the United States: An Update Report on Nutrition Monitoring. Prepared for the U.S. Department of Agriculture and the U.S. Department of Health and Human Services. Govemment Printing Office, Washington, D.C. 408 pp. Massachusetts Medical Society, Committee on Nutrition. 1989. Fast Food Fare: Consumer Guidelines. Prepared by Connie Roberts. N. Engl. J. Med. 321:752-756. McGill, H.C., Jr. 1979. The relationship of dietary cholesterol to serum cholesterol concentration and to atherosclerosis in man. Am. J. Clin. Nutr. 32:2664-2702. Medalie, J.H., H.A. Kahn, H.N. Neuteld, E. Riss, and U. Goldbourt. 1973. Five- year myocardial infarction incidence. II. Association of single variables to age and birthplace. J. Chronic Dis. 26:32~349. Miller, N.E., D.S. Thelle, O.H. Forde, and O.D. Mjos. 1977. The Tromso Heart Study. High-density lipoprotein and coronary heart-disease: A prospective case-control study. Lancet 1:96~968. NCEP (National Cholesterol Education Program). 1990. Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction, National Institutes of Health. Government Printing Office, Washington, D.C. 140 pp. NRC (National Research Council). 1982. Diet, Nutrition, and Cancer. Committee on Diet, Nutrition and Cancer, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 478 pp. NRC (National Research Council). 1988. Designing Foods: Animal Product Options in the Marketplace. Report of the Committee on Technological Options to Improve the Nutritional Attributes of Animal Products, Board on Agriculture. National Academy Press, Washington, D.C. 367 pp. NRC (National Research Council). 1989a. Diet and Health: Implications for Reducing Chronic Disease Risk. Report of the Committee on Diet and Health, Food and Nu-

NUTRrTlON LABEL CONTENT 2~)1 trition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 749 pp. NRC (National Research Council). 1989b. Recommended Dietary Allowances, 10th ed. Committee on the 10th Edition of the Recommended Dietary Allowances, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 285 pp. Page, I.H., F.J. Stare, A.C. Corcoran, H. Pollack and C.F. Wilkinson. 1957. Atheroscle- rosis and the fat content of the diet. Circulation 16:163-178. Prosky, L., N.G. Asp, I. Furda, J.W. DeVnes, T.F. Schweizer, and B.F. Harland. 1985. Determination of total dietary fiber in foods and food products: Collaborative study. J. Assoc. Off. Anal. Chem. 68:677-679. Rock, RJ. 1986. Policy letter of June 24, 1986, to Giant Food, Inc., Washington, D.C. Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. Rank, RJ. 1988. Policy letter of August 26, 1988, to J.S. Kahan and B.L. Rubin, Hogan and Hartson, Washington, D.C. Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, D.C. Schemmel, R., O. Mickelson, and J.L. Gill. 1970. Dietary obesity in rats: Body weight and body fat accretion in seven strains of rats. J. Nutr. 100:1041-1048. Shank F.R., L. Larsen, F.E. Scarbrough, J.E. Vanderveen, and A.L. Forbes. 1983. FDA perspective on sodium. Food Technol. 37:73-77. Shekelle, R.B., A.M. Shtyock, O. Paul, M. Lepper, J. Stamler, S. Liu, and WJ. Raynor, Jr. 1981. Diet, serum cholesterol, and death from coronary heart disease. The Western Electric Study. N. Engl. J. Med. 304:6~70. Solberg, L.A., and J.P. Strong. 1983. Risk factors and atherosclerotic lesions. A review of autopsy studies. Arteriosclerosis 3:187-198. Stamler, J., and R. Shekelle. 1988. Dietary cholesterol and human coronary heart disease: The epidemiologic evidence. Arch. Pathol. Lab. Med. 112:1032-1040. USDA (U.S. Department of Agriculture3. 1982a. FSIS Policy Memorandum 039. Food Safety and Inspection Service, Washington, D.C. USDA (U.S. Department of Agriculture). 1982b. FSIS Policy Memorandum 046. Food Safety and Inspection Service, Washington, D.C. USDA (U.S. Department of Agriculture). 1984a FSIS Policy Memorandum 049C. Food Safety and Inspection Service, Washington, D.C. USDA (U.S. Department of Agriculture). 1984b. FSIS Policy Memorandum 078. Food Safety and Inspection Service, Washington, D.C. USDA (U.S. Department of Agriculture). 1987. FSIS Policy Memorandum 070B. Food Safety and Inspection Service, Washington, D.C. USDA (U.S. Department of Agriculture). 1989. FSIS Standards and Labeling Policy Book. Food Safety and Inspection Service, Washington, D.C. USDA (U.S. Department of Agriculture). 1990. Report of the Dietary Guidelines Ad- visory Committee on the Dietary Guidelines for Americans, 1990. Government Printing Office, Washington, D.C. 48 pp. USDA/DHHS (U.S. Department of Agriculture and U.S. Department of Health and Hu- man Services). 1985. Nutrition and Your Health: Dietary Guidelines for Americans, 2nd ed. Govemment Printing Office, Washington, D.C. 24 pp.

202 NUTRITION LABELING Woodwind, CJ.H., and K.K. Carroll. 1988. Nutrition and human heals aspects of marine oils and lipids. Pp. 2-28 in Manne Biogenic Fats and Oils, R.G. Ackman, ed. CRC Press, Boca Raton, Fla. Yudkin, J. 1964. Dietary fat and dietary sugar in relation to ischemic heart disease and diabetes. Lancet 2:~5.

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Nutrition Labeling: Issues and Directions for the 1990s Get This Book
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Nutrition Labeling offers a thorough examination of current nutrition labeling practices and recommends ways to make food labeling information consistent with recent dietary recommendations from the U.S. Surgeon General and the National Research Council.

The volume proposes implementing a food labeling reform program, addressing such key issues as requiring mandatory nutrition labeling on most packaged foods, expanding nutrition labeling to foods that do not currently provide this information, making federal requirements uniform between agencies, and updating the nutrient content and format of food labels.

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