The 1969 White House Conference on Food, Nutrition and Health: 50 Years Later

ABSTRACT

The 1969 White House Conference on Food, Nutrition and Health (WHC) was a landmark conference that influenced the nutrition agenda for decades. This commentary details events that led to moving the WHC recommendations to implementation and action. The Special Supplemental Nutrition Program for Women, Infants and Children, the National School Lunch Program, and the Dietary Guidelines for Americans are used as examples to illustrate some overarching factors that are critical to unraveling the complex process of science and evidence linked to action.

Introduction

The 1969 White House Conference on Food, Nutrition and Health (WHC) was a seminal event that influenced the nutrition agenda for the next several decades (1). The WHC brought together stakeholders from the policy arena, academia, and civil society. The conference produced ∼1800 recommendations, of which 1650 were implemented within 2 y of the WHC (2). The present commentary summarizes the key events that precipitated the WHC and outlines the process that was used for linking recommendations on paper to the implementation of policies and programs. This commentary uses a political economy lens to evaluate the processes emerging post-WHC. As noted by one researcher, “In designing and implementing food security and nutrition policies and programs, decision makers are motivated by complex and often contradictory forces, especially when they need to work with and often through actors with competing economic, political, and social interests and objectives” (3). The basic premise of this commentary is that technically sound solutions to nutrition problems are vital, but typically they alone are not enough to influence the public agenda; political factors can be more critical in ensuring whether programs thrive or vanish than research alone.

Background

At the beginning of the 1960s it was unlikely that hunger and malnutrition would be considered as significant problems in the United States. The country had emerged from World War II with a sense of optimism, the economy was strong, and the food rationing which occurred during the war was a distant memory for many. This changed in the mid-1960s when the discovery of hunger and malnutrition stunned many Americans.

US government data indicated that underweight in children was a problem (4). However, this evidence evoked only a limited interest from politicians, the mass media, and the general public. In the fall of 1967 Congress directed the Department of Health, Education and Welfare (HEW) to survey and identify the prevalence, magnitude, and distribution of malnutrition and related problems within the United States: an effort that became the Ten State Nutrition Survey of 1968–1970. The bipartisan Senate Select Committee on Nutrition and Human Needs was established in 1968 and became instrumental in championing issues related to hunger and malnutrition under Senator George McGovern (D-SD, 1963–1980). Soon the presence of hunger in one of “the richest countries in the world” captured attention. In 1967, Senators Robert Kennedy (D-MA, 1965–1968) and Joseph D Clark (D-PA, 1957–1969) had visited Cleveland, Mississippi, a small town in the Delta, and uncovered unexpected levels of poverty, hunger, and malnutrition (5). This was followed quickly by a report Hunger USA: A Critical Review (6), developed by the Citizens Board of Inquiry, a Columbia Broadcast System (CBS) documentary, “Hunger in America” (7), and “hunger tours” by politicians to poverty-stricken areas. These closely spaced events created a heightened public and media awareness about the magnitude of hunger in the United States and great controversy about the extent and magnitude of hunger in the country. Congressmen whose states were flagged as having high levels of hunger were embarrassed and angered and were heartened by an assault attacking the findings entitled Hunger USA: A Critical Review (6). It included stinging critiques about the accuracy of the information provided in Hunger USA (8). One issue concerned the representativeness of the population surveyed, implying that it focused on isolated situations and was not a reflection of the typical situation of poor people in the United States. At this point the debate about hunger in America might have gradually vanished, but well placed, highly visible politicians and individuals continued to champion the issues of hunger and malnutrition. Concurrently with the reports, the ongoing survey, and hunger tours, Congressional hearings on hunger and malnutrition continued to be held by the Senate Select Committee on Nutrition and Human Needs until 1977. During this cacophony, the Ten State Nutrition Survey continued its surveys, presented updates to Congress, and published its findings (via the CDC in 1972) (9). Results from Texas and Louisiana confirmed malnutrition in large numbers of the poor sampled in these states and provided further evidence on the critical metrics of hunger and poor nutritional status.

In December of 1969 the WHC was convened by President Richard Nixon, who fervently urged that hunger in America must be eliminated: “I ask this of a Congress that has already splendidly demonstrated its own disposition to act. It is a moment to act with vigor; it is a moment to be recalled with pride” (1). It was chaired by Dr. Jean Mayer, professor at the Harvard School of Public Health. In the 6 mo before the WHC, dozens of committees and individuals representing major federal, state, and local governments, the private sector, and voluntary organizations ranging from professional societies to churches and advocacy groups met to formulate recommendations. The drafts of the recommendations were then debated, modified, and agreed upon at the December 1969 WHC held in the Shoreham Hotel in Washington, DC. This hotel is ∼1 mile away from the White House, and while the conference was in progress, the city was in the midst of marches, tear gas, and demonstrations against the Vietnam War. The landmark conference led eventually to the nationwide expansion of food stamps and the National School Lunch Program (NSLP); creation of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC); permanent authorization of the National School Breakfast Program; and sowed the seeds for food-based dietary guidelines and nutrition labeling.

The Rest of the Story: From Recommendations to Action

The WHC influenced the nation's nutrition agenda for the rest of the century and beyond. What are sometimes overlooked are the tremendous efforts that were needed to translate the WHC recommendations into action. Some specific examples below illustrate some overarching concepts that characterize the strategies linking WHC recommendations to action.

WIC

The WHC report noted that, “Food supplementation of high-risk pregnant women and their infants is warranted” (1). This provided impetus for the ultimate creation of the Special Supplemental Food Program for Women, Infants and Children, later renamed the Special Supplemental Nutrition Program for Women, Infants and Children. In 1972, as a 2-y pilot, the WIC program was authorized with an appropriation of 200 million dollars per year, but administration officials at the USDA argued that WIC was unnecessary because it duplicated an existing program, the Commodity Supplemental Food Program, which provided supplemental foods and targeted similar groups (women, infants, and children). Ultimately, after the department was successfully sued to release the funds appropriated for WIC (10), the first site opened in 1974 in Pineville, KY (11).

The division of opinions on WIC's potential impact on improving diets and nutritional status did not end with the opening of the first sites, and the USDA called for a nationwide evaluation of the program. This was somewhat unusual because the newly minted program had just become operational. Nevertheless, the evaluation carried out by the University of North Carolina (UNC) (12) reported statistically significant improvements in neonatal outcomes among pregnant women who participated in WIC and an increase in intakes of nutrients targeted for improvement among preschool-age children in WIC. However, the report provoked diverse opinions. A major criticism of the UNC evaluation was the research design employed; WIC pregnant women were compared with non-WIC women with different characteristics at the outset, suggesting a potential bias toward WIC results (13). Competing voices in Washington, DC suggesting “WIC works” or “WIC does not work” vibrated throughout the city.

Around the same time that the UNC results were being disputed as inconclusive, Congress faced the dilemma of whether the WIC program had amassed enough positive evidence to justify reauthorization as part of the 1978 Child Nutrition Program. Congressional hearings relied heavily on a 1977/1978 study by one of us (14), which indicated that WIC participation improved birth weight, decreased low birth weight, and improved hematological status. WIC was reauthorized. Yet controversies about its effectiveness continued because of the scarcity of research on WIC. Many additional studies were conducted during the early 1980s that reinforced the findings of positive and both clinically and statistically significant effects of WIC on the diets and nutritional status of women and children (10). However, this portfolio of studies did not convince the entire research community of its effectiveness. Quite to the contrary, both critics and supporters of WIC continued to voice equally strident opinions. In an 11 July, 1981 letter to then Vice President George HW Bush, one commenter noted:

I have been collaborating with the Office of Management and Budget (OMB) on an assessment of the WIC program and a justification for cutting this very popular but wasteful and un-needed program: as Mr. Stockman [R-MI, 1977–1981; OMB, 1981–1985] found out, it is a pet of the Senate. (15)

The opposition of the OMB to the WIC program was complicated. The OMB, reflecting the wishes of the White House, proposed that the child nutrition programs, including WIC, be bundled into a block grant, with the funds allocated directly to states, which would then have the authority to disburse the funds as they saw fit across the range of child nutrition programs. WIC became a source of controversy between the White House and the health community (16). As noted, “When the political cost of attempts to cut WIC became too great, President Reagan (with support from Republican Senators Robert Dole (R-KA, 1961–1996) and Jesse Helms (R-NC, 1973–2003)) conceded the need for WIC but attempted to remove older children from it” (16). Again, the President failed and WIC was left relatively untouched by Congress.

Ten years after WIC was implemented, the second nationwide evaluation of the program was launched, in part to settle the debate about the impact of WIC on women, infants, and children, and results provided further evidence of a range of positive impacts on the diets and nutritional status of women, infants, and children (17, 18). At that time in 1987 political appointees at the USDA still opposed WIC and attempted to dilute the positive results reported by altering the narrative of the final report (19). In response congressional proponents arranged for an unusual joint press conference held between the House of Representatives and the Senate. As reported by the New York Times, “Congressional leaders today accused the USDA of deleting key sectors of an extensive study of a national program for feeding pregnant women and children, in order to obscure the study's favorable findings” (19). This bipartisan Congressional press release muted much of the remaining debate as to the effectiveness of WIC.

Three lessons emerge from WIC's stormy early history. First, this is a vivid example of the utility of translational research and how it can be linked to policy. WIC had a strong research component built into its funding, and policy-relevant studies were conducted and have continued to emerge over the decades since then. Second, although evidence is important, advocacy is king. The collective efforts of researchers, advocacy groups, and the press were critical in advancing the recommendations from the WHC through to legislation, regulations, and oversight and a continuation of support for the WIC program until today. Finally, WIC had bipartisan political support from the program's inception and influential committees such as the Senate Select Committee for Nutrition and Human Needs were major champions for WIC.

NSLP

The NSLP administered by the USDA is the oldest child nutrition program in the United States. It traces its roots to small, local programs in various cities around the country in the early part of the 20th century. It came into national visibility in 1946 during the post–World War II period, when Congress established the program as “a measure of national security,” to safeguard the health and well-being of the nation's children and to encourage the domestic consumption of nutritious agricultural commodities (20). Surprisingly, the program was championed by 2 Southerners, Rep. Allen Ellander of Louisiana, a former protégé of Huey Long, and senator Richard B Russell of Georgia, one of the most conservative members of Congress at the time. The program grew from 1946 onward but the funding was scarce and federal subsidies few. Whereas the program served many middle- and upper-income children who were able to pay for lunch, the benefits to low-income children were very limited, especially in the poorest school districts.

A key recommendation from the WHC was for the expansion of the NSLP to provide a highly nutritious lunch to every American schoolchild (1). Not every area in the United States had a statewide lunch program. In 1973, Legal Services of Rhode Island sued the State of Rhode Island to ensure that the NSLP was available statewide (21). Participating in this lawsuit was Dr. Jean Mayer (Harvard School of Public Health), whose testimony was critical in providing the scientific base to justify this statewide expansion of the lunch program, followed by testimony of Eileen Kennedy of the Providence Health Centers. Legal Services won the case and within 1 y the school lunch program was established statewide in Rhode Island. Similar suits were brought and won in other states as well.

The early post-WHC controversies about the NSLP revolved around access to lunch, particularly for poor children, because historically the programs at the turn of the 20th century on which it was based were designed to feed poor immigrant and other children in cities like New York. Fortunately, this battle was won with the expansion of the NSLP and the later legislation that added the National School Breakfast Program targeted specifically to poor children. Later debates in the 1980s and beyond began to focus on the nutritional content of the meals themselves. Traditionally this was based on a pattern, the type A school lunch, which specified the amounts of meat, milk, bread, fruits, and vegetables to be provided. In 1981 administrators at the USDA considered changing the nutritional standard for school lunches. Although much of the proposal was innocuous, one provision championed by political appointees entailed crediting or counting ketchup as one of the vegetables allowed in the vegetable category rather than leaving it simply as a condiment; the amount of ketchup to be credited was based on a vegetable equivalency standard. A major uproar erupted, fueled by the advocacy community and partisan politics, and headlines ridiculing ketchup as a vegetable appeared in national newspapers. Advocates viewed the proposed changes in school lunch regulations as taking food away from children. The Food Research Action Center, a major antihunger group, developed a cartoon showing a half a hamburger and a dollop of ketchup with the headline, “This will be your child's school lunch” (22). At the same time, a series of cartoons penned under Doonesbury, day after day, mocked the proposed regulation. Ultimately the proposed regulations were withdrawn and several senior officials in the USDA were fired. The “ketchup as a vegetable” example illustrates how inadequate technical research (especially in the absence of common sense about how people regard food), partisan politics, and powerful press-advocacy coalitions can influence policy.

Dietary Guidelines for Americans

The WHC in tandem with the Senate Select Committee on Nutrition and Human Needs sowed the seeds for the development of food-based dietary guidelines. The WHC had called attention to the devastating effects of overweight and obesity on chronic degenerative, noncommunicable diseases and one of the early activities of the Senate Select Committee was the development of Dietary Goals for Americans (23). Dietary goals/guidelines have always been controversial and these were no exception because in addition to 7 goals with broad advice to the American people about healthy diets there were a set of goals for agricultural production. As might be expected, these goals were not without debate. A minority report drafted by the committee members Senators Percy, Schweiker, and Zorinsky noted, “The report clearly reflects extreme diversity of scientific opinion on these questions {dietary goals}. We have become increasingly aware of the lack of consensus” (24). This ambiguity within the scientific community was reflected in an April 1977 statement submitted by the American Medical Association, which noted in part that, “The evidence for assuming that the benefits to be derived from the adoption of such universal goals as set forth in the report is not conclusive … and potential for harmful effects … would occur through the adoption of the proposed national goals” (25). This was a powerful statement from a leading health organization which would much later become one of the main proponents of the Dietary Guidelines for Americans (DGAs) published by the USDA and the HEW. The dietary goals, yet again, raise the question, “How much evidence is needed to develop public policy?” The Select Committee's dietary goals were later subjected to review and debate by a group of scientific experts, further refined, and this document became a proponent for the first official federal set of recommendations from the USDA/HEW, the DGAs, released in 1980 just at the end of the Carter Administration (26). In the next decade, the DGAs continued to be debated and revised, but the advice remained largely the same.

In 1990 the DGAs were mandated by statute as part of the National Nutrition Monitoring and Related Research Act (27). This authorizing legislation dictated that the DGAs be reviewed and revised as necessary on a 5-y cycle. The continued relevance of the DGAs is demonstrated by the attention and heated debates that occur in every 5-y cycle. In every 5-y period since then there has been controversy: the 1995 guidelines provoked an intense debate on the health benefits of alcohol, as might be expected because several religious groups view alcohol very negatively, and the very powerful Senator Thurmond of South Carolina had lost a child who died in a drunken driving accident. Other controversial topics in 2000 were the benefits of vegan diets, sugars, and alcohol. Controversy in the 2015 guidelines, however, took a different turn, with debate about whether sustainability should be included as a justification for recommendations to lower meat consumption. It was included in the Dietary Guidelines Technical Advisory Committee's Report but not in the DGAs as finally issued by the USDA and United States Department of Health and Human Services (USDHHS), largely due to Congressional objections, ongoing debate about larger issues such as climate change, and questions about the expertise of the advisory committee on the sustainability issue (28). The controversy then became much broader, with some members of Congress questioning the entire process involved in the development, as well as the scope, of the DGAs, the procedures for selecting advisory committee members, and the standards of acceptable evidence that should be required in the technical report (29). Some in the research community viewed this as an assault on science, others as legitimate criticisms. The upshot was that Congress mandated that the National Academy of Sciences review the DGA process and make recommendations to improve it (30). Nevertheless, controversy has continued; even a few months ago an article criticized the administration for issuing specific questions that the Dietary Guidelines Advisory Committee (DGAC) was to answer: “How the Trump Administration limited the scope of the USDA's 2020 dietary guidelines” (31). What was lost in this debate is, first, the fact that it is the 2 Cabinet-level departments, the USDA and USDHHS, which ask for advice on specific issues, and it is they who have the ultimate authority to release the DGAs, not the DGAC, an advisory committee. Second, the USDA and USDHHS have taken to heart the many suggestions of the National Academy committee and the process is far more reliant on systematic, evidence-based reviews than ever before. What remains to be seen is if the product of the 2020 DGAC and the resulting DGAs are more policy relevant and evidence-based than some prior editions. Leadership at all levels and with all stakeholder groups will be needed to ensure that, although partisanship and advocacy are inevitable in making public policy, scientific evidence and not ideology remains the bedrock for US nutrition policy.

Summary

One theme that runs through this commentary is that leadership is necessary to make nutrition policy a reality and to make programs a success. The forms of leadership are many, and leadership often has a partisan tinge to begin with, but to survive over time, true leaders must make compromises and be bipartisan. The WHC was a flagship event that coalesced a broad group of stakeholders around critical issues of hunger and malnutrition in a highly political context. Its ultimate impact, however, hinged on the ability to translate the recommendations into action.

A second theme is that science is essential in nutrition policy. However, policy formulation is not a scientific undertaking but a complex and politically fraught process. Scientific evidence on the nature of the nutrition problems and potential solutions themselves are often not enough to influence public policy.

Our third theme is that political economy science is critical: all sorts of actors (advocates, partisans, politicians, bureaucrats), institutions (Congress, the government, industry, the media), attitudes (vested interests, biases, ideologies), contexts, and processes such as legislation and negotiation are involved in the policy process. These elements and their interactions all determine whether, in the end, science will be successfully linked to policy and program implementation.

A fourth theme is that advocacy can trump science when it comes to implementing policy. This illustrates the need for scientists and others to actively engage in program advocacy and actualization. In the case of the WIC, it is unlikely that the program would have succeeded without strong translational research showing positive outcomes on health, but it also needed the active involvement of the advocacy community to ensure the intent of Congress was honored. In contrast to the WIC, the NSLP research portfolio was on weak grounds until the 1980s, but powerful political leaders on both sides of the aisle and program advocacy in the form of lawsuits at local and state levels pulled the program through to become nationwide.

A fifth theme in this commentary is that there is no one-size-fits-all answer to the question about when data are enough to establish, implement, and guide effective policy. An amalgamation of scientific evidence reinforced by significant scientific agreement around effective approaches is the gold standard for policy formulation, but the realities of its translation are often elusive. There is often limited evidence to guide policy formulation, which may lead to misdirected programs, and therefore program oversight and evaluation are critical. As more policy-relevant, translational research and real-world experiences become available, programs must adapt and change in line with the newer evidence to address the changing nutrition profile of the intended beneficiaries. Ongoing research and reformulation will continue to be essential to ensure that programs evolve and continue to be relevant to the realities of the times.

To sum up, necessary ingredients such as policy-relevant science, leadership, advocacy, and the science and art of politics must be blended together to make nutrition policies that truly advance the public's health and well-being.

Notes

The authors reported no funding received for this commentary.

Author disclosures: The authors report no conflicts of interest. JD was a participant and organizer at the White House Conference.

Abbreviations used: DGAC, Dietary Guidelines Advisory Committee; DGAs, Dietary Guidelines for Americans; HEW, Department of Health, Education and Welfare; NSLP, National School Lunch Program; OMB, Office of Management and Budget; UNC, University of North Carolina; USDHHS, United States Department of Health and Human Services; WHC, White House Conference on Food, Nutrition and Health; WIC, Special Supplemental Nutrition Program for Women, Infants and Children.