In your statement, Dr. Brandt, you indicated on page 2 the scope of your department's nutrition research and I tried to follow that through to see if I could understand the specifics that you actually spent money for. You said 95 percent of the amount, which was $144.3 million, was spent by the National Institutes of Health which basically means that is where most of your money went.

Then on the next page, you said NIH has supported research in areas such as-and you have mentioned three areas: Environmental and host factors that affect nutritional requirement, et cetera; dietary sodium; and the role of national inhibitors in the prevention of cancer.

Is it my assumption that that accounts for $144 million?

Dr. BRANDT. Absolutely not. These are only the areas that we thought the committee would find of special interest.

Dr. Wyngaarden is the Director of the NIH and can discuss that in some detail.

Mr. MACKAY. That's good. I would like to ask Dr. Wyngaarden, if I might, if you would give me and I won't be embarrassed at how basic it is—I am under the impression from what I hear that NIH is in the high-tech business. And if there was a valid criticism, it is that NIH is in the business of artificial hearts and things that expand the life span but that NIH prioritywise is not really working too much in the areas that have to do with the quality of the years that we have now.

I may not even be stating that well, I am so basic. So I want to ask you: It seems to me that one way we could start dealing with our health cost problems in America would be doing research on trying to make people live a more healthy life, which I think has to do with exercise, nutrition, and a lot of things.

What I would like to find out is how much of this $144 million went into that, and what else you do, and what proportion of your total effort is that?

Dr. WYNGAARDEN. Yes, sir, Mr. MacKay, I will try to respond to that. I hope in the few moments that I address this question that I can also answer your concern about the distribution of our efforts because our efforts do span the entire spectrum of basic studies on up into clinical and community application and education.

Of the $144 million in nutrition research, roughly half is in research grants. We have 1,318 regular research grants and about 80 program project grants in addition that are conducted in the extramural community in universities and other institutions around the country.

We have about 150 contracts for specific nutritional inquiries. We also support seven clinical nutrition research units. But in addition, some 60 other centers organized for other topics, also conduct nutrition research.

Of the total $144 million, roughly two-thirds we classify as basic research. This has to deal with the fundamental mechanisms of vitamins and metabolic reactions, for example. And slightly more than one-third is in application-clinical research and clinical trials. We have slightly more than $10 million in clinical trials in which we are actually investigating nutritional problems and their effect on specific disease situations.

In Dr. Brandt's testimony he hit a few high points of our program but we have a booklet here which summarizes fiscal year 1981, which I would be happy to submit for the record, which summarizes all of our programs in biomedial and behavioral nutrition research and training.

Mr. BROWN. Without objection, we will receive that for the record.

[Document is on file with the Science, Research and Technology Subcommittee and is available from NIH; "Annual Report of the National Institutes of Health Program in Biomedical and Behavioral Nutrition Research and Training Fiscal Year 1981," NIH Publication No. 82-2092, June 1982.]

Dr. WYNGAARDEN. We have an update of this for fiscal 1982, too, which is currently in press which we will be glad to forward when it is available. The range of topics addressed by our research grant program and incentive program runs many, many pages.

Mr. MACKAY. I think I speak for a lot of people who are comfortably ignorant in this area and I think it is probably appropriate that I should be representing a number of ignorant people since I consider myself fairly ignorant, but I believe the public perception is very rapidly changing in terms of public priorities. And the public is very much interested in this relation of nutrition and lifestyle or preventive health care. I have the perception that the public may be way ahead of the Government.

The question I want to ask is not how many pages of that is directed to nutrition research but is that increasing, and what percent of that is the total? What is the percentage of that of your total activities, and how is that percentage changing?

In other words, what is your perception of the problem?

Dr. WYNGAARDEN. Yes. At present, 4.1 percent of our entire budget is in the field of nutrition.

Mr. MACKAY. 4.1?

Dr. WYNGAARDEN. 4.1 percent.

Mr. MACKAY. Is that higher now than it used to be, or lower? Dr. WYNGAARDEN. It is increasing. The $144 million of 1982, we estimate will go to $155 million in 1983.

Mr. MACKAY. What percent will the $155 million be?

Dr. WYNGAARDEN. Well, that will increase just slightly because that increase is, in percentage terms, more than the increase of our total budget, so it might go up another tenth of a percent or so. Mr. MACKAY. Now, who in your institution makes that decision about what percentage of your research efforts should go into nutrition, or does your institution function as a contractor for people like the Department of HHS? In other words, do you have a say in the policy or do you simply take their money and do what they say?

Dr. WYNGAARDEN. No; we have▬▬

Mr. BROWN. Dr. Wyngaarden is glad that you asked that question, Mr. MacKay.

Mr. MACKAY. Well, my ignorance is so great that I don't know whether I am a good guy or a bad guy. But I have this feeling that 4.1 percent is a spectacularly inappropriate set of priorities.

Dr. WYNGAARDEN. We have considerable administrative freedom in directing resources toward important problems. There are several mechanisms that are in place at present.

First of all, the power of the scientific mechanism is that of the investigator-initiated research proposal. The best ideas come from the minds of the investigators who are working as new ideas present themselves. So we rely, in the first instance, on the proposals that are submitted to us. They are evaluated alongside of proposals in every other field.

The first question is the technical merit and scientific excellence of the proposal itself. There is a second round of peer review at the level of the councils of the funding institutes and they apply additional consideration such as program relevance and program bal

ance.

We have also for several years had a Clinical Nutrition Coordinating Committee within the NIH and that Committee is made up of representatives of all the Institutes, and they do meet and review the programs.

In areas where it is felt wise to stimulate additional work they have done a number of things, such as convening conferences to bring related investigators together, they have issued reports, they have issued requests for proposals in specific areas, requests for applications in certain areas; they have convened ad hoc task forces to address specific problems. A good example of that recently has been in the nutritional approach to chronic renal failure-end stage renal disease. Such an ad hoc committee met just last month and as a result of that we are now preparing a request for cooperative agreement proposals that we hope will interest about 10 centers in a joint effort to address that problem.

The percentage of the budget in the nutrition field varies substantially from one institute to another, for example, the National Institute of Arthritis, Diabetes, Digestive, and Kidney Diseases has nearly 72 percent of its budget in nutrition work.

The National Institute of Child Health and Human Development has over 8 percent in nutrition work. And the Division of Research Resources, which funds, among other things, our clinical research centers, some 60-plus of those around the country, has almost 9 percent of its resources in nutrition work.

So the Institutes that have a very special interest here are clearly funding a larger proportion of the work.

Mr. BROWN. Would the gentleman yield to me?

Go ahead, Dr. Brandt.

Dr. BRANDT. I just want to make one other point. I think that it is difficult, Mr. MacKay, to look only at dollars. Some forms of research are considerably more expensive than others. Let me give you a specific example: Cancer is still one of the leading killers. A study of radiation and drug treatment of a particularly common cause of cancer may cost a great deal more than studies, for example-as we are getting ready to carry out-on diet and prevention of cancer.

So I don't think that one can get a full picture of the priorities simply by looking at dollars unless one had some common base for doing it, which we, unfortunately, don't have.

Mr. BROWN. While you are discussing this point that MacKay has raised, I noted a recent article in Science magazine describing and agonizing the reappraisal that you are going through with regard to whether you keep your commitment to maintain the 5,000 grants, or whether you reduce that in order to maintain the programs in some other areas.

I gather that other actors such as OMB are having some influence in this and that you may be under great pressure to maintain the 5,000 grants which you will have to take out of the hide of some other programs. That raises some very serious questions about what is going to happen to the nutrition centers, which are already underfunded, and to some of the other programs that I am sure you are worried about.

I have no idea what the current status of that reappraisal is but I wonder if I could ask you to comment on that, and how you see this impacting the nutrition research situation?

Dr. BRANDT. Dr. Wyngaarden can get into specifics, but I would like to give the overall view of this for a moment.

We feel that the two really essential components of the National Institutes of Health and, indeed, the research activities of the Public Health Service generally, Mr. Brown, are the investigatorinitiated research grants. Those are the ones that have paid off remarkably in the past; they allow us to utilize the greatest genius that is available in the United States. And, as you know, after a long, agonizing appraisal involving the Congress and every interested, and even a few uninterested, participants, the number of 5,000 came out as sort of a stabilization figure that would allow universities, research institutions, and others to do some longrange planning.

I think that the second basic component we see in the National Institutes of Health is the intramural program, which, again, has produced great advances in medicine and health, and we think we will continue to do so.

Hence, a reappraisal of the role of the investigator-initiated research grant versus other kinds of mechanisms is one that is not easily undertaken and one that, as you know, took nearly 10 years to arrive at the first time and I am sure that we will be undergoing this for some time. But Dr. Wyngaarden, I think, can talk to the specifics of it.

Dr. WYNGAARDEN. Yes; in the 1984 budget, in order to fund the 5,000 new and competing renewals, we have proposed a transfer of substantial moneys out of the center program, among others, as you indicated. And that does mean that those centers that come up for competitive renewal this year will be against much stiffer competition than they would otherwise be. Two of the seven nutrition centers are up for renewal this year.

Mr. BROWN. All right, I thought that was what was going to happen.

Mr. MacKay.

Mr. MACKAY. You are saying, then, because of budget constraints and a commitment to maintain a level of investigator-initiated research grants, you are actually going to strip money away from nutrition centers?

Dr. WYNGAARDEN. No; I didn't really say that.

Mr. MACKAY. Well, I would like to know.

Dr. WYNGAARDEN. We are proposing the transfer of funds from several other categories into the research grant category. And one of those categories involves specialized centers and a very small fraction of those specialized centers are nutrition centers.

And of the seven CNRU's that we currently fund, two are up for competitive renewal this year. So they would be in this group that will be against very stiff competition.

Mr. MACKAY. I am trying to get at the question of what is driving our setting of priorities in our policies in health research. I agree the biggest repository of innovation and genius is the investigator-initiated research.

However, I would think someone should be saying to the investigators, we think top priority should be in this area or this area. I think a part of the decision they make is whether we are going to investigate in areas of top priority.

I think somebody has said to them nutrition is incidental. Fourand-a-half percent-suppose I am off by a magnitude of 10—I agree the other research is more expensive. The other research is also driven by people who probably have something to do with where the investigators research, like drug companies and others, who have a different vision of how we can achieve better health in this country.

I am suggesting to you that somewhere in this system at the policy level, which I think we are, somebody has got to say that if you keep going this way, there is not enough money in the world to keep people healthy the way we are trying to do it.

I am asking: Is there somewhere in this labyrinth someone who makes that kind of decision? And if so, who did it, and got us at 42 percent?

Dr. BRANDT. I think that the process for setting research priorities in this country is, to say the least, a complex one. It involves, obviously, the Congress-the Congress funds various institutes at the NIH in differing amounts and, therefore, by those kinds of decisions sets priorities.

It comes from the executive branch because we make recommendations to the Congress about how we think those funds ought to be appropriated and into which Institutes and into which kinds of programs. And it comes from the scientific community.

We have, as a policy, set the constraint that we are going to fund only the best research. We would not put more money into nutrition research or any other kind of research that was of poor quality. And I am sure you wouldn't want that to happen. So that one of the things that has happened over the last few years has been that the nutrition research grants are coming in in larger numbers-better research, more research-that is aimed at the very thing that you are talking about. I think, Mr. MacKay, when you read the objectives that we have set for ourselves by 1990 in nutrition, they are aimed at precisely-we have precisely the same goals.

Our concern is to try to get people of this country to take the responsibility for their own health. And to do those things that will lead them to a better quality of life and, in fact, a better health status. That includes, among other things, nutrition, and exercise.

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