Food Labeling: Health Claims; Soy Protein and Coronary Heart Disease

I. Background Information

On November 8, 1990, the President signed into law the Nutrition Labeling and Education Act of 1990 (the 1990 amendments) (Public Law 101-535). This new law amended the Federal Food, Drug, and Cosmetic Act (the act) in a number of important ways. One notable aspect of the 1990 amendments was that they provided procedures whereby FDA is to regulate health claims on food labels and in food labeling. In the Federal Register of January 6, 1993 (58 FR 2478), FDA issued a final rule that implemented the health claim provisions of the act (hereinafter referred to as the 1993 health claims final rule). In that final rule, FDA adopted Sec. 101.14 (21 CFR 101.14), which sets out rules for the authorization and use of health claims by regulation. Additionally, Sec. 101.70 (21 CFR 101.70) establishes a process for petitioning the agency to authorize by regulation the use of health claims about a substance-disease relationship (Sec. 101.70(a)) and sets out the types of information that any such petition must include (Sec. 101.70(f)). In response to the 1990 amendments, FDA also conducted an extensive review of the evidence on 10 substance-disease relationships. As a result of its review, FDA has authorized claims for 8 of these 10 relationships, one of which focused on the relationship between dietary saturated fat and cholesterol and reduced risk of CHD. CHD is the most common, most frequently reported, and most serious form of cardiovascular disease (CVD) (58 FR 2739, January 6, 1993). Further, although the agency denied the use on food labeling of health claims relating dietary fiber to reduced risk of CVD (58 FR 2552), it authorized a health claim relating diets low in saturated fat and cholesterol and high in fruits, vegetables, and grain products that contain dietary fiber (particularly soluble fiber) to a reduced risk of CHD. In the proposed rule entitled ``Health Claims and Label Statements; Lipids and Cardiovascular Disease'' (56 FR 60727, November 27, 1991) (hereinafter referred to as the saturated fat/cholesterol proposed rule), FDA set out criteria for evaluating evidence on diet and CVD relationships. The agency focused on those aspects of the dietary lipid and CVD relationship for which the strongest scientific evidence andagreement existed. FDA noted that, because of the public health importance of CHD, identification of ``modifiable'' risk factors for CHD had been the subject of considerable research and public policy attention. The agency also noted that there is general agreement that elevated blood cholesterol levels are one of the major ``modifiable'' risk factors in the development of CHD. FDA cited Federal Government and other reviews that concluded that there is substantial epidemiologic and clinical evidence that high blood levels of total and low density lipoprotein (LDL)-cholesterol are a cause of atherosclerosis and represent major contributors to CHD. Further, factors that decrease total blood cholesterol and LDL-cholesterol will also decrease the risk of CHD. FDA concluded that it is generally accepted that blood total and LDL-cholesterol levels are major risk factors for CHD, and that dietary factors affecting blood cholesterol levels affect the risk of CHD. High intakes of dietary saturated fat and, to a lesser degree, of dietary cholesterol are consistently associated with elevated blood cholesterol levels. FDA tentatively concluded that the publicly available data supported an association between diets low in saturated fat and cholesterol and reduced risk of CHD (56 FR 60727 at 60737), and it confirmed that conclusion in the saturated fat/cholesterol final rule (58 FR 2739 at 2751). Based on its review using the stated criteria, and on its consideration of comments received in response to the proposed rule entitled ``Health Claims; Dietary Fiber and Cardiovascular Disease'' (56 FR 60582), FDA concluded that the publicly available scientific information supported an association between diets low in saturated fat and cholesterol and high in fruits, vegetables, and grain products (i.e., foods that are low in saturated fat and cholesterol and that are good sources of dietary fiber) and reduced risk of heart disease (58 FR 2552 at 2572). In the 1993 dietary fiber and CVD final rule, in response to a comment regarding the apparent hypocholesterolemic properties of specific food fibers, FDA again articulated its criteria for evaluating diet and CHD relationships (58 FR 2552 at 2567). FDA agreed that the effectiveness of naturally occurring fibers in foods in reducing the risk of CHD may be documented for specific food products. Further, the agency indicated that if manufacturers could document, through appropriate studies, that dietary consumption of the soluble fiber in a particular food has a beneficial effect on blood lipids predictive of CHD risk, they should petition for a health claim for that particular product. In response to two petitions that documented such evidence, FDA has authorized health claims for soluble fiber from certain foods and reduced risk of CHD in Sec. 101.81 (21 CFR 101.81) (62 FR 3600, January 23, 1997, and amended at 62 FR 15344, March 31, 1997, and 62 FR 8119, February 18, 1998). In the Federal Register of November 10, 1998 (63 FR 62977), and in response to a petition from Protein Technologies International, Inc. (Ref. 1 and Ref. 2), the agency proposed Sec. 101.82 to provide for health claims on the relationship of soy protein and reduced risk of CHD (hereinafter referred to as the soy protein proposed rule). In the soy protein proposed rule, FDA considered the relevant scientific studies and data presented in the petition as part of its review of the scientific literature on soy protein and CHD. The agency summarized this evidence in the soy protein proposed rule and presented the rationale for a health claim on this food-disease relationship as provided for under the significant scientific

agreement standard in section 403(r)(3)(B)(i) of the act and Sec. 101.14(c) of FDA's regulations. Proposed Sec. 101.82(c)(2)(ii)(A) identified the substance that is the subject of the proposed claim as soy protein from the legume seed Glycine max. The soy protein proposed rule included qualifying criteria for the purpose of identifying soy protein-containing foods eligible to bear the proposed health claim. The proposal also specified mandatory content for health claim statements; identified additional, optional information for such statements; and provided model health claims. In its evaluation of the scientific evidence for a relationship between consumption of soy protein and blood total and LDL-cholesterol levels, the agency found the data suggestive but not sufficient to establish a dose-response for this relationship. However, the agency did find consistent, clinically significant reductions of total and LDL-cholesterol levels in controlled trials that used at least 25 grams (g) of soy protein per day. Thus, the agency proposed to base the qualifying level of soy protein on a total daily intake of 25 g, as suggested by the petitioner. Therefore, in Sec. 101.82(c)(2)(iii)(A), FDA proposed the qualifying criterion for a food to bear the claim as 6.25 g of soy protein per reference amount customarily consumed (RACC) (i.e., 25 g divided by 4 eating occasions per day). In the soy protein proposed rule, FDA had tentatively indicated its intention to use a specific analytical method to measure soy protein for assessing compliance with the qualifying criterion. Comments persuaded the agency that the method would be inadequate for many products. Therefore, in the Federal Register of August 23, 1999 (64 FR 45932), FDA issued a proposed rule to provide for an alternative procedure for assessing compliance (hereinafter referred to as the soy protein reproposal). In the soy protein reproposal, in Sec. 101.82(c)(2)(ii)(B) FDA proposed that it would rely on measurement of total protein and require manufacturers, when soy is not the sole source of protein in foods, to maintain records that document the amount of soy protein in products and to make these records available to appropriate regulatory officials for inspection and copying upon request.

II. Summary of Comments and the Agency's Responses

In response to the soy protein proposed rule, the agency received approximately 130 submissions, each containing one or more comments, from consumers, consumer organizations, professional organizations, government agencies, industry, trade associations, health care professionals, and research scientists. About half of these submissions supported the proposed rule without providing grounds for this support other than those provided by FDA in the preamble to the soy protein proposed rule. The majority of the remaining comments were generally supportive, but requested modification of one or more provisions of the proposed rule. Some comments provided additional data on the relationship between soy protein and CHD, including one submission, originally submitted as a health claim petition and converted to a comment on the soy protein proposed rule (Ref. 3), that included a comprehensive review of available scientific evidence about the relationship. Some of the comments that disagreed with the soy protein proposed rule provided specific support for their positions. Some of the comments were received after the date for submitting comments had passed. Although the agency is not obligated to respond to late comments, in the interest of assessing the totality of the available data, it has considered each of these comments to the extent that it provided complete information for review or references accessible to the agency and addressed issues not raised in earlier comments. The agency has summarized and addressed the relevant issues raised in the comments in the sections of this document that follow. In response to the soy protein reproposal, the Agency received approximately 10 submissions, each containing one or more comments. The agency has summarized and addressed these comments in section II.C.2 of this document.

A. Eligibility of Soy Protein as the Subject of a Health Claim

In the soy protein proposed rule, the agency assessed whether soy protein satisfied the preliminary requirement that a substance that is the subject of a health claim is associated with a disease for which the U.S. population is at risk (63 FR 62977 at 62978). Based on analyses presented in earlier rulemakings and its review of data on the mortality, morbidity, and costs of CHD and prevalence of ``high risk'' and ``borderline high'' total and LDL-cholesterol levels in the United States (Refs. 4 through 8), the agency tentatively concluded that, as required in Sec. 101.14(b)(1), CHD is a disease for which the U.S. population is at risk. One comment reviewed additional sources of information and reached the same conclusion. In the soy protein proposed rule, FDA also tentatively concluded that soy protein from Glycine max satisfied the preliminary requirement of Sec. 101.14(b)(3)(i) that the substance be a food that contributes taste, aroma, or nutritive value (63 FR 62977 at 62978). Sources of soy protein identified in the soy protein proposed rule included foods composed of or derived from whole soybeans and foods that contain processed soy protein ingredients: Isolated soy protein (ISP), soy protein concentrate (SPC), soy flour (SF), texturized soy protein, or texturized vegetable protein (TVP). In addition to protein, these foods and ingredients contain other naturally occurring soy constituents, such as isoflavones, fiber, and saponins. The specific processing steps employed determine the extent of retention of such naturally occurring constituents in the final product. In assessing whether the petitioner had demonstrated that soy protein is safe and lawful at the level necessary to justify the claim, FDA noted that the petitioner stated that soy protein ingredients were in common use in food before January 1, 1958, and that they are generally recognized as safe (GRAS) by self-determination (63 FR 62977 at 62978). Because the fractionation procedures used to convert vegetable flours to vegetable protein isolates and concentrates were commonplace prior to 1958, the petitioner also asserted that ISP and SPC can be defined as soy flour ``subject only to conventional processing as practiced prior to January 1, 1958.'' In addition, FDA reviewed information submitted by the petitioner about potential risks of consuming soy products: allergenicity (Refs. 9 and 10), exposure to trypsin inhibitors (Refs. 11 through 16), reduced bioavailability of minerals (Refs. 13, 17, 18, 19, and 20), and hormonal disturbances due to soy isoflavones (Refs. 21 through 26). Based on the totality of the evidence and, in particular, its common use in food, the agency did not take issue with the petitioner's view that the use of soy protein is safe and lawful as required in Sec. 101.14(b)(3)(ii). Thus, FDA tentatively concluded that the petitioner provided evidence that satisfied the requirement in Sec. 101.14(b)(3)(ii) that use of soy protein at the levels necessary to justify a claim is safe and lawful under the applicable food safety provisions of the act (63 FR 62977 at 62979). Several comments agreed with the agency's conclusion and some provided the rationale for their support. A number of comments disputed the

petitioner's assertion of GRAS status for soy protein and raised questions about the safety of soy protein-containing foods. The specific aspects of disagreement are summarized and discussed in the following sections of this document. 1. Concerns About the Safety of Soy Protein-Based Infant Formulas (Comment 1). Many of the comments that raised concerns about the safety of consuming soy protein-containing foods addressed the safety of soy protein-based infant formulas. The observed or hypothesized detrimental effects of such formulas discussed in these comments included: hormonal disturbances due to estrogenic effects of soy isoflavones; thyroid abnormalities; altered mineral balance, especially for zinc; and diabetogenic effects in infants. FDA is aware of concerns raised about the safety of soy infant formulas, but notes that these are speculative at this time, pending the results of definitive research. FDA also notes that the American Academy of Pediatrics (Ref. 73) and the New Zealand Ministry of Health (Ref. 74) have recently issued guidelines for the safe and suitable use of soy-based infant formulas. Some issues regarding effects of infant formula are unique because infants may be entirely dependent on formula as a sole source of nutrition and the relevance of such issues for soy protein consumed as part of a mixed diet by the general U.S. population is not clear. In any case, concerns about effects of soy protein specific to infant formulas are beyond the scope of the current rule, which authorizes a health claim about the relationship of soy protein and CHD for foods intended for use by the general population. Health claims are not permitted on foods represented or purported for use by infants and toddlers less than 2 years of age unless specifically provided for in the authorizing regulation (21 CFR 101.14(e)(5)). Diets restricted in fat, saturated fat, and cholesterol are not recommended for infants and young children, and the current rule (Sec. 101.82) contains no provisions for use of the health claim about the relationship between soy protein and CHD on foods for infants and toddlers. 2. Comments on Petitioner's Self-Determination of GRAS Status for Soy Protein (Comment 2). One comment specifically agreed with the petitioner's assertion that soy protein-containing food ingredients are generally recognized as safe (GRAS) by self-determination and based on common use in food before January 1, 1958, in conformance with Sec. 201(s) of the act. The comment also noted that, although soy protein is not listed as GRAS or prior sanctioned in Title 21 of the CFR, FDA has noted that these lists ``do not include all substances generally recognized as safe for their intended use'' and, as stated at 21 CFR 182.1, ``[i]t is impracticable [for FDA] to list all substances that are GRAS for their intended use.'' This comment also agreed with the petitioner's conclusion that fractionation procedures used to convert vegetable flours to vegetable protein concentrates and isolates were commonplace in various sectors of the grain industry, such as corn processing, well before 1958. Therefore, SPC and ISP can be defined as soy flour ``subject only to conventional processing as practiced prior to January 1, 1958.'' The comment concluded that SF (including steam-treated SF), SPC, and ISP all fall within the category of ingredients that are GRAS through experience based on their common use. Several comments objected to the petitioner's self-determination of GRAS status, citing a variety of reasons. As stated previously, FDA does not take issue with the petitioner's self-determination of GRAS status, and the comments, discussed below, have not convinced the agency to change that conclusion. (Comment 3). Some comments raised objections on the basis that FDA has not approved the GRAS status of soy protein. Although FDA has not ruled formally on the GRAS status of soy protein ingredients, it has not challenged determinations that soy's use as dietary protein is GRAS. Food ingredients whose use is generally recognized as safe by qualified experts are not required by law to receive FDA approval. Under the health claim petition process, FDA evaluates whether the substance is ``safe and lawful'' under the applicable food safety provisions of the act (Sec. 101.14(b)(3)(ii)). As discussed in greater detail below, FDA did not receive sufficient evidence from comments to challenge the petitioner's assertion that soy protein ingredients are GRAS by self-determination. The petitioner met the showing required by Sec. 101.14(b)(3)(ii) that the substance be ``safe and lawful.'' (Comment 4). One comment claimed that the Center for Food Safety and Applied Nutrition recently returned a petition requesting GRAS recognition for soy protein. The document referred to by the comment was a notification by Archer Daniels Midland Company (GRN 000001), rather than a petition for FDA action, and the subject of the notification was soy isoflavone extract, rather than soy protein. At the company's request, FDA ceased evaluation of the GRAS Notification pending the company's updating of the file (Ref. 75). Thus, this comment was incorrect. (Comment 5). A comment asserted that petitioner's basis for GRAS self-determination of the use of soy protein as a dietary protein ingredient (i.e., common use in food before January 1, 1958) was incorrect. Because the 1979 Select Committee on GRAS Substances (SCOGS) report (Ref. 76) determined that, at the time of the report, likely average dietary exposure to soy protein isolate was only about 150 milligrams (mg) from food items, the comment asserted that soy protein isolates could not have been in common use before 1958. FDA finds that this comment is groundless and inaccurately characterizes the findings of the SCOGS. The 1979 SCOGS report includes the background statement ``Edible soy protein isolates for food uses appeared about 1957 as a major article of commerce.'' The 1979 SCOGS Report also cited a 1972 National Research Council survey of GRAS ingredients that listed 14 food categories in which soy protein isolates were used and calculated an average daily intake of several grams. Soy protein isolates represent only one of several possible sources of soy protein in foods. In addition, for purposes of determining if a substance is GRAS, common use is not restricted to common use in the United States. (Comment 6). A comment supporting the petitioner's self- determination of GRAS status noted that use of soy as a food dates to about the 11th century BC in the eastern half of north China. From about the first century AD to the 15th-16th century, soybeans were introduced in Korea, Japan, Indonesia, the Philippines, Vietnam, Thailand, Malaysia, Burma, Nepal, and northern India. Soybeans first grew in the United States in 1765 and were used then to manufacture soy sauce and vermicelli (soybean paste) (Ref. 77). A comment that disputed the petitioner's self-determination of GRAS status speculated that the species of soybean grown early in its history in Asia may have differed significantly in its content of nutrients and other active components from the modern species that is cultivated in this country. FDA does not find this comment compelling. Although the composition of soybeans has likely changed over time, modern soybean species and

cultivars are, in any case, encompassed within the period of common use of soy and soy protein in food. (Comment 7). One comment questioned whether the Asian experience could provide assurance that soy is safe. Drawing parallels with herbal medicine in terms of attitudes, monitoring deficiencies, and the general difficulty in detecting toxicities with long latency, this comment concluded that the long history of apparent safe use of soy products cannot assure they are without risk (Ref. 78). The comment did not provide evidence to document that soy products, consumed at levels necessary to justify the claim, are not generally recognized as safe. Moreover, considerable research is underway at this time because of the hypothesized benefits of the historical use of soy products by certain population groups. FDA supports the ongoing research to clarify the effects, both potentially beneficial and potentially adverse, of soy and agrees that any effects due to changes in the conditions of use should be monitored. However, the information currently available does not lead FDA to object to the petitioner's self-determination of GRAS status of soy protein. (Comment 8). Several other comments asserted that the proposal did not adequately establish the GRAS status of soy protein food ingredients in that the proposal did not include a thorough evaluation of the safety of potentially harmful components, e.g., lysinoalanine, nitrites and nitrosamines, trypsin inhibitors, phytate, and isoflavones. FDA notes that the 1979 SCOGS report (Ref. 76) discussed several of these components extensively and recommended that it would be prudent to develop food grade specifications for soy protein isolates that would set acceptable limits on the levels of lysinoalanine, nitrites, and nitrosamines. But, the possible presence of these components in soy protein isolates did not lead the SCOGS panel to recommend against GRAS status of soy protein isolates. As noted above, the agency finds the petitioner met the showing required by Sec. 101.14(b)(3)(ii) that soy protein is ``safe and lawful.'' The agency lacks documented evidence of adverse effects in humans and has received no information about actual levels of potentially harmful components or about threshold levels for adverse effects in humans. Accordingly, the agency has no basis to conclude that soy protein is not safe and lawful. The specific comments about potentially harmful components of soy are discussed below. 3. Lysinoalanine: Potential Toxic Effects (Comment 9). A few comments noted concerns about the presence of lysinoalanine in soy protein isolates and cited the SCOGS report (Ref. 76), which indicated that lysinoalanine was implicated as a renal toxic factor in rats. FDA finds that the comments inaccurately reflected the findings of the SCOGS report. The SCOGS report noted that the relatively severe alkali treatment used to modify viscosity and adhesive properties of soy protein isolates used as sizing and coating adhesives in the production of paper and paperboard products can cause formation of lysinoalanine. The report evaluated the risk of lysinoalanine exposure from soy protein adhesives and binders used in paper and paperboard food packaging. The 1979 SCOGS report noted that, ``For edible isolated protein production, extraction is usually carried out at a pH below 9 to avoid hydrolytic or rheological changes'' and concluded that, while relatively low levels of lysinoalanine had been reported in some samples of food grade soy protein isolate, available information indicated that the levels of lysinoalanine in food grade soy protein isolates pose no hazard to the consumer (Ref. 76). FDA notes that the comments that expressed concern about lysinoalanine in soy protein ingredients did not provide any information about lysinoalanine levels in food grade soy protein ingredients nor about use of alkali-processed soy protein as a food ingredient. FDA finds that the potential presence of lysinoalanine in soy protein isolates used for sizing and coating adhesives in paper and paperboard products is not relevant to the safe and lawful use of soy protein in food. FDA also notes that the production of small amounts of lysinoalanine during alkali processing has also been documented with casein and lactalbumin, so it is not unique to soy. Good manufacturing practices are and should be employed to minimize the production of lysinoalanine because of its deleterious effects on protein quality. 4. Nitrites and Nitrosamines: Potential Carcinogenic Effects (Comment 10). Some comments expressed concerns about the potential presence of nitrites in soy protein and the potential their presence poses for the in vivo formation of nitrosamines, which have been shown to be carcinogenic in experimental animals. FDA notes that many natural and processed foods contribute to the total human intake of nitrite. In an appendix titled ``Health Aspects of Nitrites in Soy Protein Isolates,'' the SCOGS report (Ref. 76) presented an estimate of the consumer exposure to nitrite contributed by soy protein in perspective to nitrite from other dietary sources and that formed in the gastrointestinal tract by reduction of salivary and dietary nitrate. The SCOGS report estimated the maximum daily nitrite consumption for a vegetarian eating meat alternatives prepared from soy protein to be 0.04 mg/kilogram (kg) body weight (or 2.8 mg for a 70-kg person). The report estimated daily per capita intake of nitrite from other foods of plant origin and cured meats to be about 2.4 mg and daily exposure to nitrite from saliva to be 15 mg. The report estimated that nitrite formed in the intestine from reduction of ammonia or organic nitrogen compounds contributed about 90 mg/day. Given the relatively minor potential contribution of soy protein to total nitrite exposure, and the fact that no data were submitted to document the current levels of nitrites or nitrosamines in soy protein isolates, FDA is not persuaded of the necessity for establishing specifications for acceptable levels of these compounds. 5. Trypsin Inhibitors: Potential Effects on Pancreatic Function (Comment 11). A number of comments presented evidence that modern heat treatment and other processing do not entirely eliminate the activity of trypsin inhibitors in soy protein-containing products. Additional references provided in comments (Refs. 79, 80, 81, and 82) suggested that the mechanism of feedback regulation of pancreatic enzyme secretion may be responsible for deleterious effects on the pancreas--hyperplasia and formation of nodules--seen in animal studies. Further, Leiner (Ref. 80) demonstrated that infusion of high levels of isolated trypsin inhibitor in humans can evoke this mechanism but noted that further research was needed to assess whether frequent exposures to low levels of trypsin inhibitors consumed in the diet could have the same effect. Other comments cited evidence for potential anticarcinogenic effects of these and other protease inhibitors (Ref. 83). Leiner (Ref. 82) hypothesized that any anticarcinogenic effect of protease inhibitors would likely be manifested at levels too low to evoke their adverse effects on the pancreas. FDA notes that the observed adverse effects have been limited to animal

studies. To date, deleterious effects of consumption of low levels of soybean trypsin inhibitors have not been documented in humans. For example, Mills et al. (Ref. 84) conducted a prospective study of fatal pancreas cancer among 34,000 California Seventh-day Adventists, a group with high soy consumption. Compared to all U.S. whites, Adventists experienced decreased risk from pancreas cancer death, which was not statistically significant. Although there was a suggestive relationship between increasing meat, egg, and coffee consumption and increased pancreatic cancer risk, these variables were not significantly related to risk after controlling for cigarette smoking. However, increasing consumption of vegetarian protein products, beans, lentils, and peas as well as dried fruit was associated with highly significant protective relationships to pancreas cancer risk. Therefore, FDA finds that the information presented in these comments has not documented deleterious effects of dietary intake of trypsin inhibitors from soy in humans and, thus, does not lead the agency to take issue with the petitioner's conclusion that the use of soy protein is safe and lawful as required by Sec. 101.14(b)(3)(iii). 6. Phytate: Effects on Mineral Balance Comments raised concerns about the potential deleterious effect of soy protein and its phytate content on mineral status. Phytate, the salt of phytic acid or inositol hexaphosphate, is a natural plant constituent containing six negatively charged phosphate groups that can form strong complexes with divalent cations such as calcium, magnesium, iron, zinc, and copper. Concerns relative to soy have concentrated mainly on iron and zinc, based primarily on studies of the absorption and bioavailability of these minerals. (Comment 12). One comment cited a study in which a soy protein- based purified diet induced iron deficiency in monkeys (Ref. 85). The same comment also noted two studies in humans--one that found inhibition of the absorption of nonheme iron from both semisynthetic meals and meals comprising conventional foods by various soy protein- containing ingredients (Ref. 86), and one that found increasing inhibition of nonheme iron absorption with increasing amounts of phytate in liquid formula meals that contained soy protein isolates (Ref. 87). In a study cited in another comment, the substitution of some meat in a mixed meal by soy protein caused a decrease in the absorption of nonheme iron and an increase in the absorption of heme iron (Ref. 88), so that overall iron absorption was not compromised. Another comment reported that human feeding studies with soy protein that have examined measures of iron status have not shown detrimental effects (Ref. 89). A comment raised concerns about the effect of soy protein on zinc status based on studies of absorption of zinc from soy infant formula (Ref. 90) and a study that showed decreased serum thymulin in subjects fed a low-zinc, soy protein-based experimental diet designed to produce mild zinc deficiency (Ref. 91). As noted earlier, issues specific to infant formula are outside the scope of this rulemaking and the experimental diet in the latter study (Ref. 91) is of limited relevance to the likely conditions of consumption of soy protein in the population that is the target of the health claim. Another comment cited two studies (Refs. 92 and 93) showing no adverse effects of soy protein on absorption of zinc from meals in subjects with adequate zinc status. One comment provided additional information on the mechanism of phytate interference with zinc homeostasis (Ref. 94) and characterized the problem as more than a matter of decreased bioavailability of the zinc consumed in a meal. The comment noted that phytate can remove from the duodenum zinc that is mainly derived from pancreatic secretions, that is, zinc that may have been consumed 1-2 weeks earlier. Although these data are derived from animal studies, the comment indicated that the physiology of zinc homeostasis is not qualitatively different across species. This comment expressed concern that high consumption of soy protein might exacerbate marginal zinc deficiency, which is difficult to diagnose, and suggested that labeling should include the content of both zinc and phytate so consumers can be educated that a molar ratio of phytate:zinc of less than 10 is needed to avoid detrimental effects on zinc status, as suggested by research in animals (including Ref. 95). The comment acknowledged that education would be needed for the public to utilize such labeling. The agency recognizes that adequacy of iron and zinc status in largely plant-based diets is a legitimate concern. FDA finds that the evidence of potential adverse effects of soy protein on iron and zinc status is equivocal. Interpretation of the evidence is difficult because findings in human studies are often inconsistent with results of animal studies. Moreover, many factors affect the absorption of these minerals, including the amount consumed in a meal, the enhancing and inhibiting effects of other components of the meal, and the nutritional status of the subject. Animal studies suggest that zinc status is a strong determinant of effects of phytate/ soy on zinc absorption: zinc absorption is more impaired with zinc deficiency, in contrast to the effect of low iron status, which enhances iron absorption. However, given the lack of documented evidence for impaired iron and zinc status in humans consuming soy protein as part of a mixed diet, FDA is not persuaded of the necessity for the suggested labeling with respect to the phytate: zinc molar ratio. Nor is it persuaded that many consumers would find the suggested information, which is highly technical, useful at this time. 7. Soy Isoflavones: Estrogenic Effects Many comments addressed concerns about the possible deleterious consequences of phytoestrogen effects of the soy isoflavones, genistein and daidzein. Most of these addressed proliferative (and potentially carcinogenic) effects on estrogen-sensitive tissues, effects on circulating hormone levels and potential deleterious effects on fertility, and potentially adverse effects on sexual development. a. Proliferative effects. (Comment 13). Several comments cited a number of studies of in vitro effects of individual isoflavones on proliferation of estrogen-sensitive cells. For example, Dees et al. (Ref. 96) found that genistein increased a number of indices for proliferative activity in MCF-7 human breast cancer cells. As the authors noted, these findings are consistent with the conclusion that dietary estrogens at low concentrations do not act as antiestrogens, but act like estradiol to stimulate human breast cancer cells to enter the cell cycle. However, many other studies (reviewed in Refs. 97 and 98) have found that the phytoestrogens present in soybeans inhibit breast cancer cell proliferation in vitro (at lower concentrations, closer to physiological levels) and inhibit mammary cancer development in various animal models. FDA concludes that studies in transformed cells cannot predict with certainty whether effects will be beneficial or detrimental in humans consuming soy protein. (Comment 14). Comments argued that two reports showed effects of dietary intake of soy isoflavones on breast tissue in women. Petrakis et al. (Ref. 99) studied 24 normal pre- and postmenopausal white women, ages 30

to 58 years, who underwent monthly nipple aspiration of breast fluid and gave blood and 24-hour urine samples for biochemical studies. The women consumed no soy in months 1-3 and 10-12. During months 4-9 the women ingested daily 38 grams (g) of soy protein isolate containing 38 mg of genistein (daidzein content was not reported). This study's findings indicated that prolonged consumption of soy protein isolate had a stimulatory effect on the breast of premenopausal women, characterized by increased secretion of breast fluid and elevated levels of plasma estradiol. The study also detected evidence of epithelial proliferation (hyperplasia) in 7 of the 24 subjects during consumption of soy. McMichael-Phillips et al. (Ref. 100) examined the effects of dietary soy supplementation on the proliferation rate of premenopausal, histologically normal breast epithelium and the expression of progesterone receptor. Women (n = 48) with benign or malignant breast disease were randomly assigned to receive their normal diet either alone or with a 60-g soy supplement (containing 45 mg isoflavones) taken daily for 14 days. Serum concentrations of the isoflavones genistein and daidzein increased in the soy group at 14 days. The proliferation rate of breast lobular epithelium significantly increased after soy supplementation when both the day of menstrual cycle and the age of patient were accounted for. Progesterone receptor expression increased significantly in the soy group. The authors concluded that further studies are required to determine whether the short-term stimulation of breast proliferation is due to estrogen agonist activity and to examine the long-term effects of soy on both the pituitary gland and breast. FDA finds that the detection of proliferative effects in these two studies suggests the need for additional research. The findings do not, however, establish that the observed effects are detrimental and are not supported by the findings of epidemiologic studies of soy intake and risk of premenopausal breast cancer (Ref. 101). b. Fertility and Hormone Levels. (Comment 15). Some comments referenced a number of studies that reported reduced fertility in animals exposed to phytoestrogens (including Refs. 102, 103, and 104). Some of these studies involved phytoestrogens other than those found in soy or consumption of soy under extreme or unusual conditions. FDA is not convinced of the relevance of these studies to human consumption of soy protein. (Comment 16). Comments cited the study of Cassidy et al. 1994 (Ref. 105) as suggesting the potential for deleterious effects on human fertility. These investigators examined the influence of a diet containing soy protein on the hormonal status and regulation of the menstrual cycle in six premenopausal women. Soy protein (60 g containing 45 mg isoflavones) given daily for 1 month significantly (p1 ---------------------------------------------------------------------------------------------------------------- Annual Total 21 CFR No. of frequency per annual Hours per Total Hours respondents response responses response ---------------------------------------------------------------------------------------------------------------- 101.82(c)(2)(ii)(B)................. 25 1 25 1 25 ---------------------------------------------------------------------------------------------------------------- \1\ There are no capital costs or operating and maintenance costs associated with this collection.

Table 3.--Estimated Annual Reporting Burden \1\ ---------------------------------------------------------------------------------------------------------------- No. of Total 21 CFR Section No. of responses per annual Hours per Total hours respondents respondent responses response ---------------------------------------------------------------------------------------------------------------- 101.82(c)(2)(ii)(B)................. 5 1 5 1 5 ---------------------------------------------------------------------------------------------------------------- \1\ There are no capital costs or operating and maintenance costs associated with this collection.

Manufacturers must determine that their products are qualified to bear any claim used on foods labels or in labeling, including meeting the requirement for a qualifying amount of soy protein to bear the health claim authorized for use by this regulation. In the absence of a validated analytical methodology for soy protein in foods that contain other proteins, manufacturers will need to use records, e.g., the food's formulation or recipe, to determine if such a food contains 6.25 g per RACC. In this rule, FDA is requiring that firms maintain the records they use to determine that a food is qualified to bear the claim, and that those records be submitted to FDA upon written request. Based upon its experience with the use of health claims, FDA estimated that 25 firms would market products bearing a soy protein and CHD health claim and that one of each firm's products would contain a source or sources of protein in addition to soy. FDA received no comments that challenged this estimate. FDA estimates that, annually, it would request records to assess compliance from 20 percent of firms subject to the

recordkeeping requirement. The records that would be required to be retained by Sec. 101.82(c)(ii)(B)(2) are records that, as described above, FDA believes a prudent and responsible manufacturer uses and retains as a normal part of doing business. Thus, the burden to the food manufacturer would be that involved in assembling and providing the records to appropriate regulatory officials upon written request. The requirements contained in this rule would require only a minimal burden, no more than one hour per response, from respondents. The information collection provisions of this final rule have been submitted to OMB for review. FDA will publish a notice in the Federal Register announcing OMB's decision to approve, modify, or disapprove the information collection provisions in this final rule. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

VI. References

The following references have been placed on display in the Dockets Management Branch (address above) and may be seen by interested persons between 9 a.m. and 4 p.m., Monday through Friday.

1. Protein Technologies International, Inc., ``Health Claim Petition,'' May 4, 1998 [CP1, vol. 1-3]. 2. Protein Technologies International, Inc., ``Addendum to Health Claim Petition,'' August 10, 1998 [CP1, vol. 4]. 3. American Soybean Association, ``Health Claim Petition for Soy Protein,'' October 29, 1998 [C1, vol. 8-12]. 4. DHHS, Public Health Service (PHS), ``The Surgeon General's Report on Nutrition and Health,'' U.S. Government Printing Office, Washington, DC, pp. 83-137, 1988. 5. Food and Nutrition Board, National Academy of Sciences, ``Diet and Health: Implications for Reducing Chronic Disease Risk,'' National Academy Press, Washington, DC, pp. 291-309 and 529-547, 1989. 6. DHHS, Public Health Service (PHS) and National Institutes of Health, ``National Cholesterol Education Program: Population Panel Report,'' Bethesda, MD, pp. 1-40, 1990. 7. Sempos, C. T., J. I. Cleeman, M. D. Carroll, C. L. Johnson, P.S. Bachorik, D. J. Gordon, V. L. Burt, R. R. Briefel, C. D. Brown, K. Lippel, and B. M. Rifkind, ``Prevalence of High Blood Cholesterol Among U.S. Adults. An Update Based on Guidelines From the Second Report of the National Cholesterol Education Program Adult Treatment Panel,'' Journal of the American Medical Association, 269:3009-3014, 1993. 8. Ross, R., ``Atherosclerosis,'' in Cecil--Textbook of Medicine, J. B. Wyndaarden, L. H. Smith, and J. C. Bennett, editors. Harcourt Brace Johanevich, Inc. Philadelphia, P. 293-298, 1992. 9. Van Sickle, G. J., G. K. Powell, P. J. McDonald, and R. M. Goldblum, ``Milk- and Soy Protein-induced Enterocolitis: Evidence for Lymphocyte Sensitization to Specific Food Proteins,'' Gastroenterology, 88:1915-1921, 1985. 10. Sampson, H. A. and S. M. Scanlon, ``Natural History of Food Hypersensitivity in Children with Atopic Dermatitis,'' Journal of Pediatrics, 115:23-27, 1989. 11. Roebuck, B. D., ``Trypsin Inhibitors: Potential Concern for Humans?'' Journal of Nutrition, 117:398-400, 1987. 12. Anderson, R. L. and W. J. Wolf, ``Compositional Changes in Trypsin Inhibitors, Phytic acid, Saponins and Isoflavones Related to Soybean Processing,'' Journal of Nutrition, 125:581S-588S, 1995. 13. Erdman, J. W., Jr. and R. M. Forbes, ``Effects of Soya Protein on Mineral Availability,'' Journal of the American Oil Chemists' Society, 58:489-493, 1981. 14. Liener, I. ``Significance for Humans of Biologically Active Factors in Soybeans and Other Food Legumes,'' Journal of the American Oil Chemists' Society, 56:121-129, 1979. 15. Kennedy, A. R., ``The Evidence for Soy Products as Cancer Preventive Agents.'' Journal of Nutrition, 125:733S-743S, 1995. 16. Adlercreutz H. and W. Mazur, ``Phyto-oestrogens and Western Diseases,'' Annals of Medicine, 29:95-120, 1997. 17. Liener, I. E., ``Factors Affecting the Nutritional Quality of Soya Products,'' Journal of the American Oil Chemists' Society, 58:406-415, 1981. 18. Erdman, J. W., Jr. and E. J. Fordyce, ``Soy Products and the Human Diet,'' American Journal of Clinical Nutrition, 49:725-737, 1989. 19. Breslau, N. A., L. Brinkley, K. D. Hill, and C. Y. C. Pak, ``Relationship of Animal Protein-rich Diet to Kidney Stone Formation and Calcium Metabolism,'' Journal of Clinical Endocrinology and Metabolism, 66:140-146, 1988. 20. Portale, A. A., B. P. Halloran, M. M. Murphy, and R. C. Morris, Jr., ``Oral Intake of Phosphorus Can Determine the Serum Concentration of 1,25-dihydroxy-vitamin D by Determining its Production Rate in Humans.'' Journal of Clinical Investigation, 77:46-55, 1986. 21. Moule, G. R., ``Clinical Aspects of Nutritional Infertility of Ewes,'' Australian Veterinary Journal, 46:428-435, 1970. 22. Anthony, M. S., T. B. Clarkson, C. L. Hughes, Jr., T. M. Morgan, and G. L. Burke, ``Soybean Isoflavones Improve Cardiovascular Risk Factors Without Affecting the Reproductive System of Peripubertal Rheusus Monkeys,'' Journal of Nutrition, 126:43-50, 1996. 23. Honore, E. K., J. K. Williams, M. S. Anthony, and T. B. Clarkson, ``Soy Isoflavones Enhance Coronary Vascular Reactivity in Atherosclerotic Female Macaques,'' Fertility and Sterility, 67:148- 154, 1997. 24. Cline, J. M., J. C. Paschold, M. S. Anthony, I. O. Obasanjo, and M. R. Adams, ``Effects of Hormonal Therapies and Dietary Soy Phytoestrogens on Vaginal Cytology in Surgically Postmenopausal Macaques,'' Fertility and Sterility, 65:1031-1035, 1996. 25. Lee, H. P., L. Gourley, S. W. Duffy, J. Esteve, J. Lee, and N. E. Day, ``Dietary Effects on Breast-cancer Risk in Singapore,'' Lancet, 337:1197-1200, 1991. 26. Cassidy, A., S. Bingham, and K. D. R. Setchell, ``Biological Effects of a Diet of Soy Protein Rich in Isoflavones on the Menstrual Cycle of Premenopausal Women,'' American Journal of Clinical Nutrition, 60:333-340, 1994. 27. Bakhit, R. M., B. P. Klein, D. Essex-Sorlie, J. O. Ham, J. W. Erdman, Jr., and S. M. Potter, ``Intake of 25 g of Soybean Protein With or Without Soybean Fiber Alters Plasma Lipids in Men With Elevated Cholesterol Concentrations,'' Journal of Nutrition, 124:213-222, 1994. 28. Baum, J. A., H. Teng, J. W. Erdman, Jr., R. M. Weigel, B. P. Klein, V. W. Persky, S. Freels, P. Surya, R. M. Bakhit, E. Ramos, N. F. Shay, and S. M. Potter, ``Long-term Intake of Soy Protein Improves Blood Lipid Profiles and Increases Mononuclear Cell Low- density-lipoprotein Receptor Messenger RNA in Hypercholesterolemic, Postmenopausal Women,'' American Journal of Clinical Nutrition, 68:545-551, 1998. 29. Bosello, O., L. Cominacini, I. Zocca, U. Garbin, R. Compri, A. Davoli, and L. Brunetti, ``Short-and Long-term Effects of Hypocaloric Diets Containing Proteins of Different Sources on Plasma Lipids and Apoproteins of Obese Subjects,'' Annals of Nutrition Metabolism, 32:206-214, 1988. 30. Carroll, K. K., P. M. Giovannetti, M. W. Huff, O. Moase, D. C. K. Roberts, and B. M. Wolfe, ``Hypocholesterolemic Effect of Substituting Soybean Protein for Animal Protein in the Diet of Healthy Young Women,'' American Journal of Clinical Nutrition, 31:1312-1321, 1978. 31. Crouse, J. R., III, T. Morgan, J. G. Terry, J. Ellis, M. Vitolins, and G. L. Burke, ``A Randomized Trial Comparing the Effect of Casein with That of Soy Protein Containing Varying Amounts of Isoflavones on Plasma Concentrations of Lipids and Lipoproteins,'' Archives of Internal Medicine, 159:2070-2076, 1999. 32. Cruz, M. L. A., W. W. Wong, F. Mimouni, D. L. Hachey, K. D. R. Setchell, P. D. Klein, and R. C. Tsang, ``Effects of Infant Nutrition on Cholesterol Synthesis Rates,'' Pediatric Research, 35:135-140, 1994. 33. Descovich, G. C., C. Ceredi, A. Gaddi, M. S. Benassi, G. Mannino, L. Colombo, L. Cattin, G. Fontana, U. Senin, E. Mannarino, C. Caruzzo, E. Bertelli, C. Fragiacomo, G. Noseda, M. Sirtori, and C. R. Sirtori, ``Multicentre Study of Soybean Protein Diet for Outpatient Hypercholesterolaemic Patients,'' Lancet, 2:709-712, 1980. 34. A. Gaddi, G. C. Descovich, G. Noseda, C. Fragiacomo, A. Nicolini, G. Montanari, G. Vanetti, M. Sirtori, E. Gatti, and C. R. Sirtori, ``Hypercholesterolaemia Treated by Soybean Protein Diet,'' Archives of Disease in Childhood, 62:274-278, 1987. 35. Gaddi, A., A. Ciarrocchi, A. Matteucci, S. Rimondi, G. Ravaglia, G. C. Descovich, and C. R. Sirtori, ``Dietary Treatment for Familial Hypercholesterolemia--Differential Effects of Dietary Soy Protein According to the Apolipoprotein E Phenotypes,'' American Journal of Clinical Nutrition, 53:1191-1196, 1991.

36. Giovannetti, P. M., K. K. Carroll, and B. M. Wolfe, ``Constancy of Fasting Serum Cholesterol of Healthy Young Women Upon Substitution of Soy Protein Isolate for Meat and Dairy Protein in Medium and Low Fat Diets,'' Nutrition Research, 6:609-618, 1986. 37. Goldberg, A. P., A. Lim, J. B. Kolar, J. J. Grundhauser, F. H. Steinke, and G. Schonfeld, ``Soybean Protein Independently Lowers Plasma Cholesterol Levels in Primary Hypercholesterolemia,'' Atherosclerosis, 43:355-368, 1982. 38. Gooderham, M. J., H. Adlercreutz, S. T. Ojala, K. Wahala, and B. J. Holub, ``A Soy Protein Isolate Rich in Genistein and Daidzein and its Effects on Plasma Isoflavone Concentrations, Platelet Aggregation, Blood Lipids and Fatty Acid Composition of Plasma Phospholipid in Normal Men,'' Journal of Nutrition, 126:2000- 2006, 1996. 39. Grundy, S. M. and J. J. Abrams, ``Comparison of Actions of Soy Protein and Casein on Metabolism of Plasma Lipoproteins and Cholesterol in Humans,'' American Journal of Clinical Nutrition, 38:245-252, 1983. 40. Holmes, W. L., G. B. Rubel, and S. S. Hood, ``Comparison of the Effect of Dietary Meat Versus Dietary Soybean Protein on Plasma Lipids of Hyperlipidemic Individuals,'' Atherosclerosis, 36:379-387, 1980. 41. Huff, M. W., P. M. Giovannetti, and B. M. Wolfe, ``Turnover of Very Low-density Lipoprotein-Apoprotein B is Increased by Substitution of Soybean Protein for Meat and Dairy Protein in the Diets of Hypercholsterolemic Men,'' American Journal of Clinical Nutrition, 39:888-897, 1984. 42. Jacques, H., D. Laurin, S. Moorjani, F. H. Steinke, C. Gagne, D. Brun, and P. J. Lupien, ``Influence of Diets Containing Cow's Milk or Soy Protein Beverage on Plasma Lipids in Children with Familial Hypercholesterolemia,'' Journal of the American College of Nutrition, 11 (suppl): 69S-73S, 1992. 43. Jenkins, D. J. A., T. M. S. Wolever, G. Spiller, G. Buckley, Y. Lam, A. L. Jenkins, and R. G. Josse, ``Hypocholesterolemic Effect of Vegetable Protein in a Hypocaloric Diet,'' Atherosclerosis, 78:99-107, 1989. 44. Kurowska, E. M., J. Jordan, J. D. Spence, S. Wetmore, L. A. Piche, M. Radzikowski, P. Dandona, and K. K. Carroll, ``Effects of Substituting Dietary Soybean Protein and Oil for Milk Protein and Fat in Subjects with Hypercholesterolemia, ``Clinical Investigative Medicine, 20:162-170, 1997. 45. Laurin, D., H. Jacques, S. Moorjani, F. H. Steinke, C. Gagne, D. Brun, and P. J. Lupien, ``Effects of a Soy-protein Beverage on Plasma Lipoproteins in Children with Familial Hypercholesterolemia,'' American Journal of Clinical Nutrition, 54:98-103, 1991. 46. Lovati, M. R., C. Manzoni, A. Canavesi, M. Sirtori, V. Vaccarino, M. Marchi, G. Gaddi, and C. R. Sirtori, ``Soybean Protein Diet Increases Low Density Lipoprotein Receptor Activity in Mononuclear Cells from Hypercholesterolemic Patients,'' Journal of Clinical Investigation, 80:1498-1502, 1987. 47. Meinertz, H., O. Faergeman, K. Nilausen, M. J. Chapman, S. Goldstein, and P. M. Laplaud, ``Effects of Soy Protein and Casein in Low Cholesterol Diets on Plasma Lipoproteins in Normolipidemic Subjects,'' Atherosclerosis, 72:63-70, 1988. 48. Meinertz, H., K. Nilausen, and O. Faergeman, ``Soy Protein and Casein in Cholesterol-enriched Diets: Effects on Plasma Lipoproteins in Normolipidemic Subjects,'' American Journal of Clinical Nutrition, 50:786-793, 1989. 49. Mercer, N. J. H., K. K. Carroll, P. M. Giovannetti, F. H. Steinke, and B. M. Wolfe, ``Effects on Human Plasma Lipids of Substituting Soybean Protein Isolate for Milk Protein in the Diet,'' Nutrition Reports International, 35:279-287, 1987. 50. Meredith, L., M. Liebman, and K. Graves, ``Alterations in Plasma Lipid Levels Resulting from Tofu and Cheese Consumption in Adult Women,'' Journal of the American College of Nutrition, 8:573- 579, 1989. 51. Potter, S. M., R. M. Bakhit, D. L. Essex-Sorlie, K. E. Weingartner, K. M. Chapman, R. A. Nelson, M. Prabhudesai, W. D. Savage, A. I. Nelson, L. W. Winter, and J. W. Erdman, Jr., ``Depression of Plasma Cholesterol in Men by Consumption of Baked Products Containing Soy Protein,'' American Journal of Clinical Nutrition, 58:501-506, 1993. 52. Potter, J. M. and P. J. Nestel, ``Greater Bile Acid Excretion with Soy Bean Than with Cow Milk in Infants,'' American Journal of Clinical Nutrition, 29:546-551, 1976. 53. Sacks, F. M., J. L. Breslow, P. G. Wood, and E. H. Kass, ``Lack of an Effect of Dairy Protein (Casein) and Soy Protein on Plasma Cholesterol of Strict Vegetarians. An Experiment and a Critical Review,'' Journal of Lipid Research, 24:1012-1020, 1983. 54. Shorey, R. L., B. Bazan, G. S. Lo, and F. H. Steinke, ``Determinants of Hypercholesterolemic Response to Soy and Animal Protein-based Diets,'' American Journal of Clinical Nutrition, 34:1769-1778, 1981. 55. Sirtori, C. R., E. Agradi, F. Conti, O. Mantero, and E. Gatti, ``Soybean-protein Diet in the Treatment of Type-II Hyperlipoproteinaemia,'' Lancet, 1:275-277, 1977. 56. Sirtori, C. R., C. Zucchi-Dentone, M. Sirtori, E. Gatti, G. C. Descovich, A. Gaddi, L. Cattin, P. G. Da Col, U. Senin, E. Mannarino, G. Avellone, L. Colombo, C. Fragiacomo, G. Noseda, and S. Lenzi, ``Cholesterol-lowering and HDL-raising Properties of Lecithinated Soy Proteins in Type II Hyperlipidemic Patients,'' Annals of Nutrition Metabolism, 29:348-357, 1985. 57. Steele, M. G., ``The Effect on Serum Cholesterol Levels of Substituting Milk with a Soya Beverage,'' Australian Journal of Nutrition and Dietetics, 49:24-28, 1992. 58. van Raaij, J. M. A., M. B. Katan, J. G. A. J. Hautvast, and R. J. J. Hermus, ``Effects of Casein Versus Soy Protein Diets on Serum Cholesterol and Lipoproteins in Young Healthy Volunteers,'' American Journal of Clinical Nutrition, 34:1261-1271, 1981. 59. van Raaij, J. M. A., M. B. Katan, C. E. West, and J. G. A. J. Hautvast, ``Influence of Diets Containing Casein, Soy Isolate, and Soy Concentrate on Serum Cholesterol and Lipoproteins in Middle- aged Volunteers,'' American Journal of Clinical Nutrition, 35:925- 934, 1982. 60. Verrillo, A., A. de Teresa, P. C. Giarrusso, and S. La Rocca, ``Soybean Protein Diets in the Management of Type II Hyperlipoproteinaemia,'' Atherosclerosis, 54:321-331, 1985. 61. Vessby, B., B. Karlstrom, H. Lithell, I. B. Gustafsson, and I. Werner, ``The Effects on Lipid and Carbohydrate Metabolism of Replacing Some Animal Protein by Soy-protein in a Lipid-lowering Diet for Hypercholesterolaemic Patients.'' Human Nutrition: Applied Nutrition, 36A:179-189, 1982. 62. Wang, M. F., S. Yamamoto, H. M. Chung, S. Y. Chung, S. Miyatani, M. Mori, T. Okita, and M. Sugano, ``Antihypercholesterolemic Effect of Undigested Fraction of Soybean Protein in Young Female Volunteers,'' Journal of Nutritional Science and Vitaminology, 41:187-195, 1995. 63. Widhalm, K., G. Brazda, B. Schneider, and S. Kohl, ``Effect of Soy Protein Diet Versus Standard Low Fat, Low Cholesterol Diet on Lipid and Lipoprotein Levels in Children with Familial or Polygenic Hypercholesterolemia,'' Journal of Pediatrics, 123:30-34, 1993. 64. Wolfe, B. M., P. M. Giovannetti, D. C. H. Cheng, D. C. K. Roberts, and K. K. Carroll, ``Hypolipidemic Effect of Substituting Soybean Protein Isolate for All Meat and Dairy Protein in the Diets of Hypercholesterolemic Men,'' Nutrition Reports International, 24:1187-1198, 1981. 65. Nagata, C., N. Takatsuka, Y. Kurisu, and H. Shimizu, ``Decreased Serum Total Cholesterol Concentration is Associated with High Intake of Soy Products in Japanese Men and Women,'' Journal of Nutrition, 128:209-213, 1998. 66. Anderson, J. W., B. M. Johnstone, and M. E. Cook-Newell, ``Meta-analysis of the Effects of Soy Protein Intake on Serum Lipids,'' New England Journal of Medicine, 333:276-282, 1995. 67. DHHS, National Heart, Lung, and Blood Institute, National Cholesterol Education Program, ``Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction (Population Panel Report),'' Chapter II. Background and Introduction, NIH Publication No. 93-3046, Bethesda, MD, 1993. 68. Food and Nutrition Board, National Academy of Sciences, ``Diet and Health: Implications for Reducing Chronic Disease Risk,'' National Academy Press, Washington, DC, pp. 23-40, 1989. 69. Department of Health and Human Services, ``Guide to Clinical Preventive Services: Report of the U.S Preventive Services Task Force,'' 2d edition, Washington, DC: Office of Public Health and Science, U.S. Department of Health and Human Services, April 1989. 70. Anthony, M. S., T. B. Clarkson, B. C. Bullock, and J. D. Wagner, ``Soy Protein Versus Soy Phytoestrogens in the Prevention of Diet-induced Coronary Artery Atherosclerosis of Male Cynomolgus Monkeys,'' Arteriosclerosis, Thrombosis, and Vascular Biology, 17:2524-2531, 1997. 71. Nestle, P. J., T. Yamashita, T. Sashara, S. Pomeroy, A. Dart, P. Komesaroff, A. Owen, and M. Abbey, ``Soy Isoflavones Improve

Systemic Arterial Compliance but Not Plasma Lipids in Menopausal and Perimenopausal Women,'' Arteriosclerosis, Thrombosis, and Vascular Biology, 17:3392-3398, 1997. 72. Sitori, C. R., E. Gianazza, C. Manzoni, M. R. Lovati, and P. A. Murphy, ``Role of Isoflavones in the Cholesterol Reduction of Soy Proteins in the Clinic,'' letter to the editor, American Journal of Clinical Nutrition, 65:166-167, 1997. 73. American Academy of Pediatrics, Committee on Nutrition, ``Policy Statement--Soy Protein-based Formulas: Recommendations for Use in Infant Feeding,'' Pediatrics, 101:148-153, 1998. 74. Ministry of Health, ``Soy-based Infant Formula,'' Wellington, New Zealand. 75. Kahl, L., Office of Premarket Approval, Center for Food Safety and Applied Nutrition, FDA, Letter to M. W. Empie, Archer Daniels Midland Company, November 25, 1998. 76. Select Committee on GRAS Substances, Life Sciences Research Office, ``Evaluation of the Health Aspects of Soy Protein Isolates as Food Ingredients,'' Prepared for the Bureau of Foods, Food and Drug Administration, Contract No. 223-75-2004, Federation of American Societies for Experimental Biology, Bethesda, MD, 1979. 77. Hymowitz, T. and J.R. Harlan, ``Introduction of the Soybean to North America by Samuel Bowen in 1765, Georgia, Gazette, September 17, 1766,'' article from http/www.nsrl.uiuc.edu/ beanhistory/intrnall.html. 78. Sheehan, D.M., ``Herbal Medicines, Phytoestrogens, and Toxicity: Risk:Benefit Considerations,'' Proceedings of the Society for Experimental Biology and Medicine, 217:379-385, 1998. 79. Liener, I.E., ``Trypsin Inhibitors: Concern for Human Nutrition or Not?'' Journal of Nutrition, 116:920-923, 1986. 80. Liener, I.E., R.L. Goodale, A. Deshmukh, T.L. Satterberg, G. Ward, C.M. DiPietro, P.E. Bankey, and J.W. Borner, ``Effect of a Trypsin Inhibitor from Soybeans (Bowman-Birk) on the Secretory Activity of the Human Pancreas,'' Gastroenterology, 94:419-427, 1988. 81. Liener, I.E., ``Possible Adverse Effects of Soybean Anticarcinogens,'' Journal of Nutrition, 125:744S-750S, 1995. 82. Liener, I.E., ``Soybean Protease Inhibitors and Pancreatic Carcinogenesis,'' letter to the editor, Journal of Nutrition, 126:582-583, 1996. 83. Kennedy, A.R., ``The Bowman-Birk Inhibitor from Soybeans as an Anticarcinogenic Agent,'' American Journal of Clinical Nutrition, 68(suppl):1406S-1412S, 1998. 84. Mills, P.K., W.L. Beeson, D.E. Abbey, G.E. Fraser, and R.L. Phillips, ``Dietary Habits and Past Medical History as Related to Fatal Pancreas Cancer Risk Among Adventists,'' Cancer, 61:2578-2585, 1988. 85. Fitch, C.D., W.F. Harville, J.S. Dinning, and F.S. Porter, ``Iron Deficiency in Monkeys Fed Diets Containing Soybean Protein,'' Proceedings of the Society for Experimental Biology and Medicine, 116:130-133, 1964. 86. Cook, J.D., T.A. Morck, and S.R. Lynch, ``The Inhibitory Effect of Soy Products on Nonheme Iron Absorption in Man,'' American Journal of Clinical Nutrition, 34:2622-2629, 1981. 87. Hurrell, R.F., M.A. Juillerat, M.B. Reddy, S.R. Lynch, S.A. Dassenko, and J.D. Cook, ``Soy Protein, Phytate, and Iron Absorption in Humans,'' American Journal of Clinical Nutrition, 56:573-578, 1992. 88. Lynch, S.R., S.A. Dassenko, T.A. Morck, J.L. Beard, and J.D. Cook, ``Soy Protein Products and Heme Iron Absorption in Humans,'' American Journal of Clinical Nutrition, 41:13-20, 1985. 89. Bodwell, C.E., C.W. Miles, E. Morris, E.S. Prather, W. Mertz, and J.J. Canary, ``Long-term Consumption of Beef Extended with Soy Protein by Men, Women, and Children: II. Effects on Iron Status,'' Plant Foods in Human Nutrition, 37:361-376, 1987. 90. Lonnerdal, B., ``Nutritional Aspects of Soy Formula,'' Acta Pediatrica Supplement, 402:105-108, 1994. 91. Prasad, A.S., S. Mefta, J. Abadallah, J. Kaplan, G.J. Brewer, J.F. Bach, and M. Dardenne, ``Serum Thymulin in Human Zinc Deficiency,'' Journal of Clinical Investigation, 82:1202-1210, 1988. 92. Sandstrom, B. and A. Cederblad, ``Zinc Absorption from Composite Meals. II. Influence of the Main Protein Source,'' American Journal of Clinical Nutrition, 33:1778-1783, 1980. 93. Solomons, N.W., M. Janghorbani, B.T. Ting, F.H. Steinke, M. Christensen, R. Bijlani, N. Istfan, and V.R. Young, ``Bioavailability of Zinc from a Diet Based on Isolated Soy Protein: Application in Young Men of the Stable Isotope Tracer, 70Zn,'' Journal of Nutrition, 112:1809-1821, 1982. 94. Oberleas, D., ``Mechanism of Zinc Homeostasis,'' Journal of Inorganic Biochemistry, 64:231-241, 1996. 95. Lo, G.S., S.L. Settle, F.H. Steinke, and D.T. Hopkins, ``Effect of Phytate:Zinc Molar Ratio and Isolated Soybean Protein on Zinc Bioavailability,'' Journal of Nutrition, 111:2223-2235, 1981. 96. Dees, C., J.S. Foster, S. Ahamed, and J. Wimalasena, ``Dietary Estrogens Stimulate Human Breast Cells to Enter the Cell Cycle,'' Environmental Health Perspectives, 105(suppl 3):633-636, 1997. 97. Adlercreutz, C.H.T., B.R. Goldin, S.L. Gorbach, K.A.V. Hockerstedt, S. Watanabe, E.K. Hamalainen, M.H. Markanen, T.H. Makela, K.W. Wahala, T.A. Hase, and T. Fotsis, ``Soybean Phytoestrogen Intake and Cancer Risk,'' Journal of Nutrition, 125(suppl):757S-770S, 1995. 98. Barnes, S., ``Effect of Genistein on In Vitro and In Vivo Models of Cancer,'' Journal of Nutrition, 125(suppl):777S-783S, 1995. 99. Petrakis N.L., S. Barnes, E.B. King; J. Lowenstein, J. Wiencke, M.M. Lee, R. Miike, M. Kirk, and L. Coward, ``Stimulatory Influence of Soy Protein Isolate on Breast Secretion in Pre- and Postmenopausal Women.'' Cancer Epidemiology, Biomarkers, and Prevention, 5:785-794, 1996. 100. McMichael-Phillips, D.F., C. Harding, M. Morton, S.A. Roberts, A. Howell, C.S. Potten, and N.J. Bundred, ``Effects of Soy- protein Supplementation on Epithelial Proliferation in Histologically Normal Human Breast,'' American Journal of Clinical Nutrition, 68(suppl):1431S-1436S, 1998. 101. Wu, A.H., R.G. Ziegler, A.M.Y. Nomura, D.W. West, L.N. Kolonel, P.L. Horn-Ross, R.N. Hoover, and M.C. Pike, ``Soy Intake and Risk of Breast Cancer in Asians and Asian Americans,'' American Journal of Nutrition, 69(suppl):1437S-1443S, 1998. 102. Setchell, K.D.R., S.J. Gossellin, M.B. Welsh, J.O. Johnston, W.F. Balistreri, L.W. Kramer, B.L. Dresser, and M.J. Tarr, ``Dietary Estrogens--A Probable Cause of Infertility and Liver Disease in Captive Cheetahs,'' Gastroenterology, 93:225-233, 1987. 103. Leopold, A.S., M. Erwin, J. Oh, and B. Browning, ``Phytoestrogens: Adverse Effects on Reproduction in California Quail,'' Science 191:98-99, 1976. 104. Drane, H.M., D.S. Patterson, B.A. Roberts, and N. Saba, ``Oestrogenic Activity of Soya-bean Products,'' Food and Cosmetic Toxicolology, 18:425-427, 1980 105. Cassidy, A., S. Bingham, and K.D.R. Setchell, ``Biological Effects of a Diet of Soy Protein Rich in Isoflavones on the Menstrual Cycle of Premenopausal Women,'' American Journal of Clinical Nutrition, 60:333-340, 1994. 106. Duncan, A.M., B.E. Merz, X. Xu, T.C. Nagel, W.R. Phillips, and M.S. Kurzer, ``Soy Isoflavones Exert Modest Hormonal Effects in Premenopausal Women,'' Journal of Clinical Endocrinology and Metabolism, 84:192-197, 1999. 107. Faber, K.A. and C.L. Hughes, Jr., ``Dose-response Characteristics of Neonatal Exposure to Genistein on Pituitary Responsiveness to Gonadotropin Releasing Hormone and Volume of the Sexually Dimorphic Nucleus of the Preoptic Area (SDN-POA) in Postpubertal Castrated Female Rats.'' Reproductive Toxicology, 7:35- 39, 1993. 108. Faber, K.A. and C.L. Hughes, Jr., ``The Effect of Neonatal Exposure to Diethylstibestrol, Genistein, and Zearalenone on Pituitary Responsivesness and Sexually Dimorphic Nucleus Volume in the Castrated Adult Rat,'' Biology of Reproduction, 45:649-653, 1991. 109. Medlock, K.L., W.S. Branham, and D.M. Sheehan, ``Effects of Coumestrol and Equol on the Developing Reproductive Tract of the Rat.'' Proceedings of the Society for Experimental Biology and Medicine, 208:67-71, 1995. 110. Medlock, K.L., W.S. Branham, and D.M. Sheehan, ``The Effects of Phytoestrogens on Neonatal Rat Uterine Growth and Development.'' Proceedings of the Society for Experimental Biology and Medicine, 208:307-313, 1995. 111. Harrison, R. M., P. P. Phillippi, and M. C. Henson, ``Effects of Genistein on Estradiol Production in Pregnant Rhesus Monkeys (Macaca mulatta),'' abstract, American Journal of Primatology, 45:183, 1998. 112. Fritz, W. A., L. Coward, J. Wang, and C. A. Lamartiniere, ``Dietary Genistein: Perinatal Mammary Cancer Prevention, Bioavailability and Toxicity Testing in the Rat.'' Carcinogenesis, 19:2151-2158, 1998. 113. Freni-Titulaer, L. W., J. F. Cordero, L. Haddock, G. Lebron, R. Martinez, and J. L. Mills, ``Premature Thelarche in Puerto Rico. A Search for Environmental Factors.'' American Journal of Diseases of Children, 140:1263-1267, 1986.

114. White, L., H. Petrovitch, G. W. Ross, and K. Masaki, ``Association of Mid-life Consumption of Tofu with Late Life Cognitive Impairment and Dementia: The Honolulu:Asia Aging Study,'' abstract, The Neurobiology of Aging, 17 (suppl 4), S121, 1996. 115. White, L., H. Petrovitch, G. W. Ross, K. H. Masaki, R. D. Abbott, E. L. Teng, B. L. Rodriguez, P. L. Blanchette, R. J. Havlik, G. Wergowske, D. Chiu, D. J. Foley, C. Murdaugh, and J. D. Curb, ``Prevalence of Dementia in Older Japanese-American Men in Hawaii: The Honolulu-Asia Aging Study,'' Journal of the American Medical Association, 276:955-960, 1996. 116. Sheehan, D. M., E. Willingham, D. Gaylor, J. M. Bergeron, and D. Crewes, ``No Threshold Dose for Estradiol-induced Sex Reversal of Turtle Embryos: How Little is Too Much?'' Environmental Health Perspectives, 107:155-159, 1999. 117. Sheehan, D. M., ``Literature Analysis of No-threshold Dose- response Curves for Endocrine Disruptors,'' abstract, Teratology, 57:219, 1998. 117A. Setchell, K. D. R., ``Phytoestrogens: the Biochemistry, Physiology, and Implications for Human Health of Soy Isoflavones,'' American Journal of Clinical Nutrition, 68 (suppl):1333S-1346S, 1998. 118-119. Lu, L. J. and K. E. Anderson, ``Sex and Long-term Soy Diets Affect the Metabolism and Excretion of Soy Isoflavones in Humans,'' American Journal of Clinical Nutrition, 68 (suppl):1500S- 1504S, 1998. 120. Kimura, S., J. Suwa, M. Ito, and H. Sato, ``Development of Malignant Goiter by Defatted Soybean with Iodine-free Diet in Rats,'' Gann, 67:763-765, 1976. 121. Van Wyk, J. J., M. B. Arnold, J. Wynn, and F. Pepper, ``The Effects of a Soybean Product on Thyroid Function in Humans,'' Pediatrics, 24:752-760, 1959. 122. Hydovitz, J. D., ``Occurrence of Goiter in an Infant on a Soy Diet,'' New England Journal of Medicine, 262:351-353, 1960. 123. Shepard, T. H., G. E. Pyne, J. E. Kirschvink, and M. McLean, ``Soybean Goiter: Report of Three Cases,'' New England Journal of Medicine, 262:1099-1103, 1960. 124. Pinchera, A., M. H. MacGillivray, J. D. Crawford, and A. G. Freeman, ``Thyroid Refractoriness in an Athyreotic Cretin Fed Soybean Formula,'' New England Journal of Medicine, 273:83-87, 1965. 125. Chorazy, P. A., S. Himelhoch, N. J. Hopwood, N. G. Greger, and D. C. Postellon, ``Persistent Hypothyroidism in an Infant Receiving a Soy Formula: Case Report and Review of the Literature,'' Pediatrics, 96:148-150, 1995. 126. Ishizuki, Y., Y. Hirooka, Y. Murata, and K. Togashi, ``The Effects on the Thyroid Gland of Soybeans Administered Experimentally in Healthy Subjects,'' Nippon Naibunpi Gakkai Zasshi, 67:622-629, 1991. 127. Divi, R.L., H. C. Chang, and D. R. Doerge, ``Anti-thyroid Isoflavones from Soybean: Isolation, Characterization, and Mechanisms of Action,'' Biochemical Pharmacology, 54:1087-1096, 1997. 128. Divi, R. L. and D. R. Doerge, Inhibition of Thyroid Peroxidase by Dietary Flavonoids.'' Chemical Research and Toxicology, 9:16-23, 1996. 129. Fort, P., R. Lanes, S. Dahlem, B. Recker, M. Wyman-Daum, M. Pugliese, and F. Lifshitz, ``Breast Feeding and Insulin-dependent Diabetes Mellitus in Children,'' Journal of the American College of Nutrition, 5:439-441, 1986. 130. Fort, P., N. Moses, M. Fasano, T. Goldberg, and F. Lifschitz, ``Breast and Soy-formula Feedings in Early Infancy and the Prevalence of Autoimmune Thyroid Disease in Children,'' Journal of the American College of Nutrition, 9:164-167, 1990. 131. Monoz, L. A. and W. H. Yang, ``Kunitz Soybean Inhibitor: A Specific Allergen in Food,'' New England Journal of Medicine, 302:1126-1128, 1980. 132. Livsmedels Verket, National Food Administration, Allergic Reactions to Food, April 10, 1997, report based on Foucard, T., U. Edberg, and I. Malmheden Yman, ``Fatal and Severe Food Hypersensitivity. Peanut and Soya Underestimated Allergens,'' Lakartidningen, 94:2635-2638, 1997. 133. Malmheden Yman, I, Livsmedels Verket, National Food Administration, Letter to Jane McLennan, Ministry of Health, New Zealand, May 30, 1997. 134. Eigenman, P.A., A.W. Burks, G.A. Bannon, and H.A. Sampson, ``Identification of Unique Antigenic Fractions of Soy and Peanut,'' abstract, Journal of Allergey and Clinical Immunology, 97:328, 1996. 135. Gunn, R.A., P.R. Taylor, and E.J. Gangarosa, ``Gastrointestinal Illness Associated with Consumption of a Soy Protein Extender,'' Journal of Food Protection, 43:525-527, 1980. 136. Teixeira, S., S.M. Potter, R. Weigel, S. Hannum, C.M. Hasler, and J.W. Erdman, Jr., ``Effects of Feeding 4 Levels of Soy Protein for 3 and 6 Weeks on Blood Lipids and Apolipoproteins in Moderately Hypercholesterolemic Men,'' submitted. 137. Wong, W.W., E.O.B. Smith, J.E. Stuff, D.L. Hachey, W.C. Heird, and H.J. Pownell, ``Cholesterol-lowering Effect of Soy Protein in Normocholesterolemic and Hypercholesterolemic Men,'' American Journal of Clinical Nutrition, 68 (suppl):1385S-1389S, 1998. 138. Fumagalli, R., L. Soleri, R. Farina, R. Musanti, O. Mantero, G. Noseda, E. Gatti, and C.R. Sirtori, ``Fecal Cholesterol Excretion Studies in Type II Hypercholesterolemic Patients Treated with the Soybean Protein Diet,'' Atherosclerosis, 43:341-353, 1982. 139. Jenkins, D. J. A., C. W. C. Kendall, C. C. Mehling, T. Parker, A. V. Rao, S. Agarwal, R. Novokmet, P. J. H. Jones, M. Raeini, J. A. Story, E. Furumoto, E. Vidgen, L. C. Griffin, S. C. Cunnane, M. A. Ryan, and P. W. Connolly, ``Combined Effect of Vegetable Protein (Soy) and Soluble Fiber Added to a Standard Cholesterol-lowering Diet,'' Metabolism, 48:809-816, 1999. 140. Jenkins, D. J. A., C. W. C. Kendall, E. Vidgen, C. C. Mehling, T. Parker, H. Seyler, D. Faulkner, M. Garsetti, L. C. Griffin, S. Agarwal, A. V. Rao, S. C. Cunnane, M. A. Ryan, P. W. Connolly, L. A. Leiter, V. Vuksan, and R. Josse, ``The Effect on Serum Lipids and Oxidized LDL of Supplementing Self-selected Low-fat Diets with Soluble Fiber, Soy, and Vegetable Protein Foods,'' submitted. 141. Washburn, S., G. L. Burke, T. Morgan, and M. Anthony, ``Effect of Soy Protein Supplementation on Serum Lipoproteins, Blood Pressure, and Menopausal Symptoms in Perimenopausal Women,'' Menopause: The Journal of the American Menopause Society, 6:7-13, 1999. 142. Nilausen, K., and H. Meinertz, ``Variable Lipemic Response to Dietary Soy Protein in Healthy, Normolipidemic Men,'' American Journal of Clinical Nutrition, 68(suppl):1380S-1384S, 1998. 143. Duane, W.C., ``Effects of Soybean Protein and Very Low Dietary Cholesterol on Serum Lipids, Biliary Lipids, and Fecal Sterols in Humans,'' Metabolism, 48:489-494, 1999. 144. Yu-Poth, S., G. Zhao, T. Etherton, M. Naglak, S. Jonnalagadda, and P. M. Kris-Etherton, ``Effects of the National Cholesterol Education Program's Step I and Step II Dietary Intervention Programs on Cardiovascular Disease Risk Factors: A Meta-analysis,'' American Journal of Clinical Nutrition, 69:632-646, 1999. 145. Denke, M. A., ``Revisiting the Effectiveness of the National Cholesterol Education Program's Step I and Step II Diets: Cholesterol-lowering Diets in a Pharmaceutically Driven World,'' American Journal of Clinical Nutrition, 69:581-582, 1999. 146. Denke, M. A., ``Review of Human Studies Evaluating Individual Dietary Responsiveness in Patients with Hypercholesterolemia,'' American Journal of Clinical Nutrition, 62(suppl):471S-477S, 1995. 147. Balmir F., R. Staack, E. Jeffrey, M. D. Jimenez, L. Wang, and S. M. Potter, ``An Extract of Soy Flour Influences Serum Cholesterol and Thyroid Hormones in Rats and Hamsters,'' Journal of Nutrition, 126:3046-3053, 1996. 148. Sugano, M., and K. Koba, ``Dietary Protein and Lipid Metabolism: A Multifunctional Effect,'' Annals of the New York Academy of Sciences, 676:215-222, 1993. 149. Kirk, E. A., P. Sutherland, S. A. Wang, A. Chait, and R. C. Leboeuf, ``Dietary Isoflavones Reduce Plasma Cholesterol and Atherosclerosis in C57BL/6 Mice But Not LDL Receptor-deficient Mice,'' Journal of Nutrition, 128:954-959, 1998. 150. Tovar-Palacio, C., S. M. Potter, J. C. Hafermann, and N. F. Shay, ``Intake of Soy Protein and Soy Protein Extracts Influences Lipid Metabolism and Hepatic Gene Expression in Gerbils,'' Journal of Nutrition, 128:839-842, 1998. 151. Anthony, M. S., G. L. Burk, C. L. Hughes Jr., and T. B. Clarkson, ``Does Soy Supplementation Improve Coronary Heart Disease (CHD) Risk?'' abstract, Circulation, 91:I-925, 1995. 152. Colquhoun, D. M., R. J. Hicks, and G. E. Kelly, ``Lack of Effect of Isoflavones on Human Serum Lipids and Lipoproteins,'' abstract, Arteriosclerosis, 109:75, 1994. 153. Hodgson J. M., I. B. Puddey, L. J. Beilin, T. A. Mori, and K. D. Croft, ``Supplementation with Isoflavonoid Phytoestrogens Does Not Alter Serum Lipid Concentrations: A Randomized Controlled Trial in Humans,'' Journal of Nutrition, 128:728-732, 1998. 154. Cassidy, A., S. Bingham, and K. Setchell, ``Biological Effects of Isoflavones in

Young Women: Importance of the Chemical Composition of Soyabean Products,'' British Journal of Nutrition, 74:587-601, 1995. 155. Sirtori, C. R., E. Gatti, O. Mantero, F. Conti, E. Agradi, E. Tremoli, M. Sirtori, L. Fraterrigo, L. Tavazzi, and D. Kritchevsky, ``Clinical Experience with the Soybean Protein Diet in the Treatment of Hypercholesterolemia,'' American Journal of Clinical Nutrition, 32:1645-1658, 1979. 156. Sirtori, C. R., M. R. Lovati, C. Manzoni, M. Monetti, F. Pazzucconi, and E. Gatti, ``Soy and Cholesterol Reduction: Clinical Experience,'' Journal of Nutrition, 125(suppl):589S-605S, 1995. 157. Sirtori, C. R., Universita Degli Studi di Milano, letter to E. Gugger, Archer Daniels Midland Company, May 25, 1997. 158. USDA Food Composition Laboratory and Nutrition Data Laboratory, Department of Food Science and Human Nutrition of the Iowa State University, ``USDA-Iowa State University Database on the Isoflavone Content of Foods--1999,'' US Department of Agriculture. 159. ``The Keystone National Policy Dialog on Food, Nutrition, and Health: Final Report,'' Keystone, CO, 1996, pp. 57-70. 160. Levy, A., B. Derby, and B. Roe, ``Consumer Impacts of Health Claims: An Experimental Study, FDA Center for Food Safety and Applied Nutrition, Division of Market Studies,'' January 1997. 161. Office of Premarket Approval, Center for Food Safety and Applied Nutrition and Office of Surveillance and Compliance, Center for Veterinary Medicine, Food and Drug Administration, ``Guidance on Consultation Procedures: Foods Derived from New Plant Varieties,'' October, 1997. 162. Rulis, A. M., Office of Premarket Approval, Center for Food Safety and Applied Nutrition, FDA, ``Letter to Diane Re, The Agricultural Group of Monsanto,'' January 27, 1995. 163. Food and Drug Administration, ``Memorandum of Conference,'' Participants: Monsanto and FDA, September 19, 1994. 164. Rulis, A. M., Office of Premarket Approval, Center for Food Safety and Applied Nutrition, FDA, ``Letter to Sally L. Van Wert, AgrEvo USA Company,'' May 12, 1998. 165. Food and Drug Administration, ``Note to the File: BNF0055-- Glufosinate-tolerant Soybean Lines,'' April 21, 1998. 166. Rulis, A. M., Office of Premarket Approval, Center for Food Safety and Applied Nutrition, FDA, ``Letter to Edward W. Raliegh, DuPont Agricultural Products,'' March 14, 1997. 167. Food and Drug Administration, ``Memorandum of Conference,'' Participants: DuPont and FDA, December 5, 1996.

List of Subjects in 21 CFR Part 101

Food labeling, Nutrition, Reporting and recordkeeping requirements.

Therefore, under the Federal Food, Drug, and Cosmetic Act and under authority delegated to the Commissioner of Food and Drugs, 21 CFR part 101 is amended as follows:

PART 101--FOOD LABELING

The authority citation for 21 CFR part 101 continues to read as follows:

1. Authority: 15 U.S.C. 1453, 1454, 1455; 21 U.S.C. 321, 331, 342, 343, 348, 371.

2. Add Sec. 101.82 to subpart E to read as follows:

Sec. 101.82 Health claims: Soy protein and risk of coronary heart disease (CHD).

(a) Relationship between diets that are low in saturated fat and cholesterol and that include soy protein and the risk of CHD. (1) Cardiovascular disease means diseases of the heart and circulatory system. CHD is one of the most common and serious forms of cardiovascular disease and refers to diseases of the heart muscle and supporting blood vessels. High blood total cholesterol and low density lipoprotein (LDL)-cholesterol levels are associated with increased risk of developing CHD. High CHD rates occur among people with high total cholesterol levels of 240 milligrams per deciliter (mg/dL) (6.21 millimole per liter (mmol/L)) or above and LDL-cholesterol levels of 160 mg/dL (4.13 mmol/L) or above. Borderline high risk total cholesterol levels range from 200 to 239 mg/dL (5.17 to 6.18 mmol/L) and 130 to 159 mg/dL (3.36 to 4.11 mmol/L) of LDL-cholesterol. The scientific evidence establishes that diets high in saturated fat and cholesterol are associated with increased levels of blood total and LDL-cholesterol and, thus, with increased risk of CHD. (2) Populations with a low incidence of CHD tend to have relatively low blood total cholesterol and LDL-cholesterol levels. These populations also tend to have dietary patterns that are not only low in total fat, especially saturated fat and cholesterol, but are also relatively high in plant foods that contain dietary fiber and other components. (3) Scientific evidence demonstrates that diets low in saturated fat and cholesterol may reduce the risk of CHD. Other evidence demonstrates that the addition of soy protein to a diet that is low in saturated fat and cholesterol may also help to reduce the risk of CHD. (b) Significance of the relationship between diets that are low in saturated fat and cholesterol and that include soy protein and the risk of CHD. (1) CHD is a major public health concern in the United States. It accounts for more deaths than any other disease or group of diseases. Early management of risk factors for CHD is a major public health goal that can assist in reducing risk of CHD. High blood total and LDL-cholesterol are major modifiable risk factors in the development of CHD. (2) Intakes of saturated fat exceed recommended levels in the diets of many people in the United States. One of the major public health recommendations relative to CHD risk is to consume less than 10 percent of calories from saturated fat and an average of 30 percent or less of total calories from all fat. Recommended daily cholesterol intakes are 300 mg or less per day. Scientific evidence demonstrates that diets low in saturated fat and cholesterol are associated with lower blood total and LDL-cholesterol levels. Soy protein, when included in a low saturated fat and cholesterol diet, also helps to lower blood total and LDL-cholesterol levels. (c) Requirements. (1) All requirements set forth in Sec. 101.14 shall be met. (2) Specific requirements--(i) Nature of the claim. A health claim associating diets that are low in saturated fat and cholesterol and that include soy protein with reduced risk of heart disease may be made on the label or labeling of a food described in paragraph (c)(2)(iii) of this section, provided that: (A) The claim states that diets that are low in saturated fat and cholesterol and that include soy protein ``may'' or ``might'' reduce the risk of heart disease; (B) In specifying the disease, the claim uses the following terms: ``heart disease'' or ``coronary heart disease''; (C) In specifying the substance, the claim uses the term ``soy protein''; (D) In specifying the fat component, the claim uses the terms ``saturated fat'' and ``cholesterol''; (E) The claim does not attribute any degree of risk reduction for CHD to diets that are low in saturated fat and cholesterol and that include soy protein; (F) The claim does not imply that consumption of diets that are low in saturated fat and cholesterol and that include soy protein is the only recognized means of achieving a reduced risk of CHD; and (G) The claim specifies the daily dietary intake of soy protein that is necessary to reduce the risk of coronary heart disease and the contribution one serving of the product makes to the specified daily dietary intake level. The daily dietary intake level of soy protein that has been associated with reduced risk of coronary heart disease is 25 grams (g) or more per day of soy protein. (ii) Nature of the substance. (A) Soy protein from the legume seed Glycine max. (B) FDA will assess qualifying levels of soy protein in the following fashion: FDA will measure total protein content by the appropriate method of analysis given in the ``Official Methods of Analysis of the AOAC International,'' as

described at Sec. 101.9(c)(7). For products that contain no sources of protein other than soy, FDA will consider the amount of soy protein as equivalent to the total protein content. For products that contain a source or sources of protein in addition to soy, FDA will, using the measurement of total protein content, calculate the soy protein content based on the ratio of soy protein ingredients to total protein ingredients in the product. FDA will base its calculation on information identified and supplied by manufacturers, such as nutrient data bases or analyses, recipes or formulations, purchase orders for ingredients, or any other information that reasonably substantiates the ratio of soy protein to total protein. Manufacturers must maintain records sufficient to substantiate the claim for as long as the products are marketed and provide these records, on written request, to appropriate regulatory officials. (iii) Nature of the food eligible to bear the claim. (A) The food product shall contain at least 6.25 g of soy protein per reference amount customarily consumed of the food product; (B) The food shall meet the nutrient content requirements in Sec. 101.62 for a ``low saturated fat'' and ``low cholesterol'' food; and (C) The food shall meet the nutrient content requirement in Sec. 101.62 for a ``low fat'' food, unless it consists of or is derived from whole soybeans and contains no fat in addition to the fat inherently present in the whole soybeans it contains or from which it is derived. (d) Optional information. (1) The claim may state that the development of heart disease depends on many factors and may identify one or more of the following risk factors for heart disease about which there is general scientific agreement: A family history of CHD; elevated blood total and LDL-cholesterol; excess body weight; high blood pressure; cigarette smoking; diabetes; and physical inactivity. The claim may also provide additional information about the benefits of exercise and management of body weight to help lower the risk of heart disease; (2) The claim may state that the relationship between intake of diets that are low in saturated fat and cholesterol and that include soy protein and reduced risk of heart disease is through the intermediate link of ``blood cholesterol'' or ``blood total and LDL- cholesterol''; (3) The claim may include information from paragraphs (a) and (b) of this section, which summarize the relationship between diets that are low in saturated fat and cholesterol and that include soy protein and CHD and the significance of the relationship; (4) The claim may state that a diet low in saturated fat and cholesterol that includes soy protein is consistent with ``Nutrition and Your Health: Dietary Guidelines for Americans,'' U.S. Department of Agriculture (USDA) and Department of Health and Human Services (DHHS), Government Printing Office (GPO); (5) The claim may state that individuals with elevated blood total and LDL-cholesterol should consult their physicians for medical advice and treatment. If the claim defines high or normal blood total and LDL- cholesterol levels, then the claim shall state that individuals with high blood cholesterol should consult their physicians for medical advice and treatment; (6) The claim may include information on the number of people in the United States who have heart disease. The sources of this information shall be identified, and it shall be current information from the National Center for Health Statistics, the National Institutes of Health, or ``Nutrition and Your Health: Dietary Guidelines for Americans,'' USDA and DHHS, GPO; (e) Model health claim. The following model health claims may be used in food labeling to describe the relationship between diets that are low in saturated fat and cholesterol and that include soy protein and reduced risk of heart disease: (1) 25 grams of soy protein a day, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease. A serving of [name of food] supplies ____ grams of soy protein. (2) Diets low in saturated fat and cholesterol that include 25 grams of soy protein a day may reduce the risk of heart disease. One serving of [name of food] provides ____ grams of soy protein.

Dated: October 19, 1999. Margaret M. Dotzel, Acting Associate Commissioner for Policy. [FR Doc. 99-27693 Filed 10-20-99; 10:35 a.m.] BILLING CODE 4160-01-P