recommended only 1) consumption of a nutritionally adequate diet, 2) a reduction in calories from fat to 35% of total calories with an increase in the intake of linoleic acid,

3) consumption of a diet which emphasizes whole grain products, fruits, and vegetables and minimizes alcohol, salt, and refined sugars, and 4) urges the prevention and control of obesity through reducing excess consumption of calories and increased physical activity. It does not make a specific recommendation about dietary cholesterol.

27.

The prescription for a better British diet (21)

recommended:

1) moderate reduction in the intake of fat, sugar, meat and alcohol, 2) increased intakes of cereals, potatoes, vegetables and fruits, and 3) no change in the intake of milk, eggs, fish, pulses and nuts.

28. The first assistant director general of public health division, Commonwealth Department of Health in Canada, W.A. Langford, in writing on a food and nutrition policy for Australia (22) stated that a food and nutrition policy should aim at insuring that all Australians consume a nutritionally adequate diet. The basic five food group plan is seen as the basis for such a diet. He summarized by saying, "The dietary goals for Australia are: 1) increase breast feeding, 2) provide nutrition education on a balanced diet for all Australians, 3) reduce the incidence of obesity, 4) decrease total fat consumption, 5) decrease refined sugar consumption, 6) increase consumption

of complex carbohydrates and dietary fiber by ingesting whole grain cereals, vegetables and fruits, 7) decrease the consumption of alcohol and of salt." No recommendation is madé about regulating the intake of dietary cholesterol.

29.

The Norwegian Nutrition Policy program as stated by the Royal Norwegian Minister of Agriculture in 1975 (23), recommended 1) reduce fat from 42% to 35% of energy intake, 2) increase starchy foods, 3) reduce sugar intake, and 4) substitute polyunsaturated fats for unsaturated fats. Again, no recommendation is made respective to the intake of dietary cholesterol.

30. It is thus seen that many national committees concerned with setting nutrition policy and making recommendations to the public in various countries do not include a specific

recommendation regarding dietary cholesterol.

Spontaneous Changes in Mortality Rates from Coronary
Disease. Why?

31.

Although coronary heart disease (CHD) was first recognized as a clinical entity by Herrick in 1912, the lesions of the disease have been seen by pathologists for centuries. Epidemiologists have been captivated by the spontaneous changes in mortality rates from coronary heart disease. In the United States there was a remarkable increase in mortality rates from coronary disease between 1912 and 1963, which lead to the view that coronary heart disease was an uncontrolled epidemic in this country.

Unexpectedly, however, the mortality rate, from coronary heart
disease in the U.S. has been decreasing at the rate of 1-2%
per year since 1963 for obscure reasons which are being studied
in this country and elsewhere.

32. Several countries are currently experiencing a

decrease in death rate from coronary heart disease. In the

United States, the decrease of 28/100,000 in 4 years is greater than elsewhere, as shown in Table 1 below.

Table 1

Trend in the Death Rate for Coronary Heart Disease
Selected Countries, 1969-73

The Reprint of 1977 Working Group to Review Arteriosclerosis; From U.S.DIEW Publication (NIH) 73-1526. 1971 Report by NHLBI Task Force on Atherosclerosis.

Despite this. large decrease, the United States continues to have one of the highest death rates in the world from these diseases. In addition, deaths from cardiovascular diseases other than coronary heart disease are also decreasing and their rate of decrease exceeds that for noncardiovascular diseases. The recent improvement in mortality from cardiovascular disease is illustrated by the calculation that, if the 1968 rates had persisted to 1977, 191,500 additional coronary heart disease deaths (15 percent more) would have occurred in 1977.

33. An even greater number of countries are experiencing an increase in CHD from 4 to 44/100,000 between 1969 and 1973 in northern European countries and in northern Ireland and Scotland. The reasons for this, even in the Scandinavian countries which have had recommendations from their governments for 8 years which parallel the "Dietary Goals for the U.S.", is far from clear.

34. The U.S. Department of Health, Education and Welfare held a conference in May of 1979, to study this decline in coronary heart disease mortality in the U.S.A. (24). It reached the following conclusions: 1) the decrease in coronary heart disease mortality is real and not the result of artifacts or changes in death certificate coding, 2) both primary prevention through changes in risk factors and fundamental clinical research leading to better care probably have contributed to but do not fully explain the decline, and 3) a precise quantification of the causes requires further study, especially those designed to document whether the frequency of non-fatal coronary events is changing.

35.

Since 1968 the downward trend in CHD mortality has

been seen in men and women, whites and blacks, and for all

adult ages.
The overall rate of decline has been greatest
among black women.

36. As regards improved medical care, specialized hospital procedures for monitoring, prevention and treatment of cardiac arrhythmias has become the standard aspect of the treatment of individuals with acute myocardial infarction. The reported mortality occurring from acute coronary heart disease treated in hospitals fell from 30-20% in the past decade. It must be realized, however, that 70% of coronary heart disease deaths occur out of a hospital. There have been improvements in medical and surgical care of CHD. Coronary bypass surgery has increased exponentially, but its widespread use is recent and could not have affected mortality rates in the 1960's.

37. CHD mortality is falling faster than general mortality, but that is also falling. Since 1900 the crude death rate in the U.S. has fallen from 17 to less than 9/1000. The fall is characteristic of all age groups as shown in Figure 1 (25). Many causes of death (except lung cancer, chronic lung disease and suicide-homicide) are falling at the same rate as CHD, Jones (26) has suggested that this positive force for health is a more vigorous and illness-free childhood.