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UNITED STATES OF AMERICA
DEPARTMENT OF AGRICULTURE
AND
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIETARY GUIDELINES ADVISORY COMMITTEE
THIRD MEETING
THURSDAY, APRIL 30, 2009
The meeting came to order at 8:30 a.m.,
Dr. Linda Van Horn, Chairperson, presiding.
PRESENT:
LINDA V. VAN HORN, PHD,RD,LD CHAIR
NAOMI K. FUKAGAWA, MD,PHD VICE CHAIR
CHERYL ACHTERBERG, PHD MEMBER
LAWRENCE J. APPEL, MD, MPH MEMBER
ROGER A. CLEMENS, DRPH MEMBER
MIRIAM E. NELSON, PHD MEMBER
SHARON M. NICKOLS-RICHARDSON, PHD MEMBER
THOMAS A. PEARSON, MD,PHD,RD MEMBER
RAFAEL PEREZ-ESCAMILLA, PHD MEMBER
XAVIER PI-SUNYER, MD, MPH MEMBER
ERIC B. RIMM, SCD MEMBER
JOANNE L. SLAVIN, PHD,RD MEMBER
CHRISTINE L. WILLIAMS, MD, MPH MEMBER
ALSO PRESENT:
CAROLE DAVIS, CO-EXECUTIVE SECRETARY AND DFO,
USDA
KATHRYN McMURRY, CO-EXECUTIVE SECRETARY, DHHS
ROBERT POST, ACTING EXECUTIVE DIRECTOR, CNPP,
USDA
CAPT. SARAH LINDE-FEUCHT, DHHS
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TABLE OF CONTENTS
PAGE
Tab 8, Dr. Andrea Carlson and Dr. Mark Lino
The USDA Food Plans, Eating Healthy
for Less Money 6
Discussion 25
Tab 9, Dr. Brian Wansink
Food and Nutrition
Consumer Behavior 39
Discussion 67
Tab 11, Sodium, Potassium, Water
Subcommittee Report, Dr. Appel 86
Discussion 100
(Break) 120
Tab 12, Nutrient Adequacy Subcommittee
Update Report, Dr. Nickols-
Richardson, 120
Discussion 138
Tab 13, Subcommittee Report on Energy
Balance, Dr. Pi-Sunyer 160
Discussion 167
Tab 14, Subcommittee Report on
Carbohydrates and Protein,
Dr. Slavin 184
Discussion 201
Lunch hour 221
TABLE OF CONTENTS (Continued)
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PAGE
Tab 15, Subcommittee Report on Ethanol
Dr. Eric Rimm 222
Discussion 233
Tab 16, Subcommittee Report on Fatty
Acids and Cholesterol, Dr.
Thomas Pearson 247
Discussion 272
Tab 17, Science Review
Discussion 281
Tab 18, Grading of the Evidence
Discussion 298
Adjourn 316
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1 P R O C E E D I N G S
2 (8:28 a.m.)
3 CHAIR VAN HORN: Well, good
4 morning, everyone. And yesterday we heard
5 from four expert presenters and from the Food
6 Safety and Technology subcommittee.
7 This morning we have two more
8 presentations in areas where the Committee
9 felt outside expertise would be valuable.
10 We will also hear updates from the
11 work from the remaining six subcommittees.
12 Oh, okay.
13 (Off the record comments.)
14 CHAIR VAN HORN: All right. Start
15 over. All right. Good morning. Yesterday we
16 heard from our four expert presenters and from
17 the Food Safety and Technology subcommittee.
18 This morning we have two more
19 presentations in areas where the Committee
20 felt outside expertise would be most valuable.
21 We'll also hear updates on the
22 work from the remaining six subcommittees.
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1 Again, I'd like to remind the Committee that
2 this meeting is open to the public to observe,
3 and we should do our best to please announce
4 your name before you speak.
5 We also will do our best to stay
6 on time following the agenda that was just
7 mentioned.
8 Today, we have our first
9 presentation from Andrea Carlson, and Mark
10 Lino. Dr. Andrea Carlson has been an
11 economist at the USDA Center for Nutrition
12 Policy and Promotion, since 2000.
13 She is the team leader for the
14 USDA Food Plans and Food Prices Database
15 Project and works on the cost of raising a
16 child project.
17 Her research focuses on
18 improvements and verifications on the USDA
19 Food Plans, and Cost of a Healthy Diet and the
20 CNPP Food Prices Database.
21 Dr. Mark Lino has been employed as
22 an economist with the US Department of
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1 Agriculture for the past 20 years. He works
2 on research related to food and nutrition,
3 including the USDA Food Plans which are used
4 to set SNAP, formerly Food Stamps, allotments,
5 and the Department of Defense's Basic
6 Allowance for sustenace Rate for Service
7 Members.
8 He also works on the USDA's
9 Expenditures and Children's Project which is
10 used to set state child support and foster
11 care payments.
12 And with that, I'd like to welcome
13 both of you. Thank you.
14 DR. CARLSON: Thank you very much
15 for inviting me to present to you today. The
16 title of my presentation is "The USDA Food
17 Plans, Eating Healthy for Less Money."
18 The question that I'd like to
19 address is: "Can a nutritious diet be
20 inexpensive?" Well, unfortunately, I'm going
21 to give you the typical economist answer. "It
22 depends." It's an economist.
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1 On the one hand, a nutritious diet
2 can be very expensive, depending on what foods
3 you choose. On the other hand, a nutritious
4 diet can be very inexpensive if you choose the
5 right foods.
6 To demonstrate that, we have put
7 together this scatter plot for you. Up in
8 this corner -- okay. There we go. Up in this
9 corner we have the very healthy, inexpensive
10 foods. In this corner over here we have the
11 expensive healthy diets. This a plot of total
12 HEI score with the daily expenditures.
13 Down in this corner, we have --
14 okay. Well, we'll go over here, then. Okay.
15 Down in that corner we have the inexpensive
16 diets that are not very good for you. They
17 are very low HEI scores, and then finally in
18 the lower right-hand corner, we have the
19 expensive diets that are not very good for
20 you, have a very low HEI score.
21 So, the point is, there really
22 isn't a -- with Americans' diets, people can
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1 spend a lot or people spend a little, and we
2 get healthy diets and we get unhealthy diets.
3 Now, how do we get people into
4 that upper right-hand corner, because we
5 certainly would like -- or the upper left-hand
6 corner. We certainly would like people to
7 spend a little bit and get a very healthy
8 diet.
9 The USDA Food Plans are mechanisms
10 to help guide consumers to eat healthy for
11 less. We have four food plans. The thrifty
12 food plan, the low-cost, the moderate cost and
13 the liberal food plan.
14 The thrifty food plan, I'm going
15 to talk more about in a minute, but let me
16 tell you a little bit about the low-cost,
17 moderate cost and liberal food plans.
18 All three of these food plans are
19 used in divorce court to estimate the cost of
20 food for setting alimony payments. They are
21 also used in the cost of raising a child
22 report that CNPP does to allocate the
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1 expenditures that are used for food on -- the
2 household expenditures on food, to allocate
3 those out to children.
4 And the CRC, the cost of raising a
5 child report is used to set foster care
6 payments and it's also used to set child
7 support payments.
8 The low-cost plan is used to --
9 it's used in bankruptcy courts to allocate
10 money for food for bankruptees, and finally,
11 the liberal plan is used to set the food
12 allotment for service members by the
13 Department of Defense.
14 Okay. So, next, we'll talk about
15 what is the thrifty food plan. Well, the
16 thrifty food plan is a minimal cost,
17 nutritious diet. The plan has a set number of
18 market -- as a set of market baskets
19 specifying the type and quantity of foods that
20 should -- that individuals could purchase,
21 could consume at home to obtain a nutritious
22 diet.
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1 The thrifty food plan also then
2 forms the basis for the supplemental nutrition
3 assistance program, the SNAP, formerly the
4 Food Stamp Program. It sets the basis for
5 those -- that program's maximum allotments.
6 So, people ask, well, what is a
7 minimal cost? This can mean a lot of
8 different things to economists, so I'm going
9 to define it here. A minimal cost we have
10 defined, we simply take the cost of the
11 previous months thrifty food plan and inflate
12 it.
13 So what that means for a family of
14 four, which we define as two adults, ages 20
15 to 50, a child, age six to eight, and a child,
16 age nine to eleven, and for in February of
17 2009, this was $137 per week for that family
18 of four. That's what we would consider a
19 minimal cost.
20 This is about 25 percent below
21 what the average family of four spends on
22 food, so it's -- that is considered a minimal
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1 cost.
2 Now, since you're the Dietary
3 Guidelines Advisory Committee, I assume you're
4 actually interested in, well, what do we
5 define as a healthy diet.
6 For the most recent update of the
7 food plans, we used the 1997 to 2004 Dietary
8 Reference Intake. These were used to set the
9 recommendations for Vitamin A, Vitamin C,
10 iron, fiber, all of those things that we have
11 DRI's for.
12 There were some nutrients that
13 didn't have DRI's. There were also some
14 things that we needed to incorporate, and for
15 those we used the 2005 Dietary Guidelines for
16 Americans, particularly, we used the
17 recommendations for intakes of saturated fat,
18 sodium and cholesterol, and we also included
19 the physical activity recommendation.
20 Then, in addition, then, we used
21 the 2005 Food Pyramid, MyPyramid. The
22 MyPyramid recommendations for food group and
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1 subgroup intakes. So, we -- this is how we
2 defined a healthy diet.
3 Well, how did we go about setting
4 this up? How did we go about deriving these
5 baskets? Well, I'm going to start out by
6 saying it's a very data-driven operation, so
7 for the most recent updates which were done in
8 2006 and 2007 -- 2006 was the thrifty and 2007
9 was the other three.
10 We used the 2001 and 2002 National
11 Health and Nutrition Examination Survey or
12 NHANES. From that we drew the food
13 consumption, and the nutrient content of food.
14 And unfortunately NHANES doesn't have prices.
15 We need to have prices in order to do the
16 food baskets.
17 So, what we had to do, what CNPP
18 had to do was, we had to compile this food
19 prices database. We, through a long,
20 complicated process that goes on for a year,
21 we matched the food, the ingredients used to
22 make the foods in Nielsen, NHANES. Remember
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1 NHANES is foods that people report eating, not
2 foods that people report purchasing in the
3 store.
4 So, we then -- we broke those
5 down, got the foods that people actually
6 purchased and then matched those to the
7 Nielsen Homescan Data, and then we were to
8 able to get prices for the foods that people
9 consume.
10 For the thrifty food plan, we
11 created a subset of Nielsen based on just the
12 low-income sample of the Nielsen data. These
13 food baskets are updated every month and for
14 that we use the Consumer Price Index to update
15 that.
16 Our basic methodology is a
17 standard economic optimization model and this
18 selects -- and we used this model to select a
19 nutritious diet. It has to meet certain
20 standards. It has to meet the dietary
21 standards which we have already discussed.
22 It has to fall within the cost
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1 constraint. In other words, it has to be at
2 or below whatever the cost constraint is for
3 the years that we're working with.
4 We need to -- we take into account
5 current consumption by food categories. There
6 are 58 food categories that we work with.
7 I'll be talking more about those in a minute.
8 And the energy levels are set to
9 maintain medium weight at a low-active
10 physical activity level. In other words, 30
11 minutes a day of moderate activity.
12 For those of you that would like
13 to see more of a schematic, we can do it this
14 way. We have the inputs, and I will be
15 describing the inputs in more detail in a
16 minute.
17 We have the average consumption by
18 food category, and again, there are 58 food
19 categories. We have the cost per hundred
20 grams by food category, the nutrient profile
21 per hundred grams, and the MyPyramid Food
22 Group Profile for 100 grams for each of those
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1 food categories.
2 The constraints you've already
3 seen. This would be the nutrient standards,
4 the DRI's, the MyPyramid recommendations, and
5 the cost constraints. These inputs and
6 constraints are put together into a
7 mathematical optimization process.
8 This spits out a solution, not
9 quite as simple as that sounds, but it does
10 give us a solution. This solution is in 58
11 categories of foods as consumed. People can't
12 buy, can't go to the grocery store and buy a
13 plate of spaghetti.
14 They have to go to the grocery
15 store and buy pasta, and tomato sauce or
16 marinara sauce, depending on how they want to
17 make their spaghetti and meat and cheese and
18 all of that.
19 And so, we then go through a
20 conversion process, and we come out with
21 market baskets. There are 15 age-gender
22 groups, and for each of those we have 29
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1 market basket -- 29 food categories for the
2 market baskets. All right.
3 I said I was going to tell you a
4 little bit more about the inputs, because they
5 are sort of interesting, at least for me. The
6 first -- it's a two-step process to create
7 these inputs.
8 The first step is to divide all of
9 those 6,000 foods in NHANES into 58
10 categories. Each food goes into one and only
11 one category, and this would be the
12 predominant food.
13 Some examples of these might
14 include -- we have breakfast cereals we divide
15 up by whether it's a whole-grain or a
16 nonwhole-grain. We notice within the whole-
17 grains we also had to divide it up by low-
18 calorie and high-calorie. It's essentially
19 low SoFAAS and high SoFAAS foods.
20 The vegetables are divided up
21 pyramid subgroup and then also by whether
22 there's added fat or no added fat or a very
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1 limited amount of added fat.
2 The fruits are divided up into
3 four groups, citrus fruits, melons and
4 berries, and then all the other fruits, those
5 are whole fruits, and then we have two 100
6 percent juice categories which mimic the whole
7 fruit categories.
8 Milk and milk-based foods, we
9 divide those up into lower fat and higher fat
10 milk and milk-based foods. We also have milk
11 desserts and we have a separate group for
12 cheese.
13 And then finally, the meats, not
14 only did we have to divide those up by
15 discretion -- by the amount of discretional
16 solid fat in those, we also had to divide
17 those up by cost.
18 And then the fish, we divided up
19 by the amount of fat that's in it. And I'm an
20 economist, so I'll just leave it at that. The
21 good fat.
22 Once we've divided these foods up
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1 into the 58 food groups, and it was
2 nutritionists who did that, we didn't leave
3 that job to the economists, then, we used
4 consumption weights to calculate the cost per
5 100 grams for the cost per each of these 58
6 food categories, the nutrient profile and the
7 MyPyramid -- the number of pyramid equivalents
8 in each of these categories.
9 Okay. So, we've seen the inputs
10 -- you've seen the inputs. You've seen the
11 constraints. We're going to leave the
12 optimization process as a black box for now.
13 I'd be happy to describe it, but you probably
14 don't want to hear it.
15 And so now, I'm going to talk
16 about the results. And on Tab Number 8 you
17 should have a copy of the Thrifty Food Plan
18 market basket towards the back of that tab,
19 and what you're seeing there are the pounds
20 per week that an individual would purchase to
21 create a healthy diet.
22 And these are divided up in the 29
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1 food categories, so we have things like whole-
2 grain breads, rice, pasta and pastries. And
3 this includes the whole-grain flour for people
4 that want to bake.
5 This, again, represents the foods
6 that would be purchased to prepare a diet that
7 would -- that meets the model constraints.
8 So, you can see these foods. They
9 are very heavy in whole grains. They are very
10 heavy in fruits and vegetables. They have
11 some meat. They have milk. They have meats
12 and beans, and they are a little bit low on
13 some of these table fats and other -- and
14 added sugars, as you might expect.
15 So the question is: Is this
16 basket healthy? Well, it met the dietary
17 recommendations in almost all of the
18 nutrients. It met the dietary recommendations
19 for MyPyramid and almost all of the nutrients.
20 The nutrients that were not met,
21 not surprising, were vitamin E, potassium and
22 sodium, but we did actually do much better
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1 than consumption.
2 I'm going to talk a little bit
3 about vitamin E. For children, we actually
4 managed to meet 100 percent of the RDA for the
5 children's baskets. The other market baskets
6 for the adults were 63 to 95 percent of the
7 RDA.
8 For potassium we are at the 15
9 market baskets -- we're somewhere between 70
10 to 98 percent of the Adequate Intake. And
11 again, that is higher than consumption for
12 each market basket.
13 And this was actually true --
14 those -- vitamin E and sodium was -- vitamin E
15 and potassium, I'm sorry, were also true for
16 the low-cost and moderate cost and liberal
17 food plans. We just couldn't meet those --
18 the cost was not the issue, it's just the
19 foods that are out there.
20 The sodium, the TFP actually does
21 better in sodium than the other market
22 baskets, and the TFP market basket met the
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1 sodium recommendation for five groups,
2 children ages one and ages two to three, and
3 females ages 12 to 13, 51 to 70 and 71-plus.
4 The sodium levels in the other
5 baskets ranged from 2,322 milligrams a day for
6 females ages 14 to 18, up to 3,629 milligrams
7 a day for males age 14 to 18. So, we were
8 always below the median consumption for each
9 of these age-gender groups, and significantly
10 below the average.
11 Well, okay, so how did we do this?
12 What changes -- if you were to go out
13 tomorrow and start recommending changes, what
14 would you do? Well, in a nutshell, what we
15 might do is, we need to increase -- this is
16 probably very similar to what your
17 recommendations might look like.
18 We need to increase the grains,
19 particularly whole grains consumption, and
20 this would be in -- this is in pounds per
21 week. We are -- we need to increase the
22 vegetables and the fruits and the milk
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1 products. Meat and beans appear there's no
2 change, but there are some shifts within it.
3 With each of these groups there
4 are shifts within it. The grains, as I
5 mentioned, moved towards whole grains, the
6 vegetables moved towards dark green
7 vegetables, the orange vegetables and the
8 legumes, and the milk -- the fruits move
9 almost all to whole fruits.
10 In fact, the model preferred to do
11 all whole fruits. We had to force a little
12 bit of orange juice in there because people
13 really like orange juice.
14 Milk products is almost all skim
15 milk, as opposed to cheese, which accounts for
16 most of the increase. Within the meat and
17 bean groups there's a shift towards more nuts,
18 again, looking for that vitamin E.
19 And then the other foods, not
20 surprising, have a significant drop and that's
21 where your savings comes in. So, we're not
22 having fats, oils, and we have a limited
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1 amount of fats, oils and sweets in our market
2 basket, but that's probably what you're going
3 to tell us anyway. So, that shouldn't be too
4 surprising.
5 So, I want to return to my scatter
6 plot and talk about the economics of
7 nutrition, and I'll wait for the pointer. So,
8 I'll talk wherever he wants to go. All right.
9 So, we'll start up in the upper
10 left-hand corner. This is where we wanted to
11 end up. We want people to eat healthy for
12 less money, if they don't want to spend a lot
13 of money on food. That's where we wanted to
14 end up, and there are certainly people that
15 are doing that. If you use the thrifty food
16 plan, that's where you'll end up.
17 You also have the option of
18 spending a lot of money and getting healthy
19 diet. If you want to move towards the liberal
20 food plan, you can follow that as well.
21 However, I'm sure as a Committee
22 you probably don't want people down here no
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1 matter how much money they're spending. We
2 really don't people making poor food choices
3 that would -- no matter how much money they're
4 spending, to be on that bottom part of the
5 graph.
6 So, let's return to the economics
7 of nutrition. An unhealthy diet can be
8 inexpensive, but it can also be very
9 expensive.
10 A healthy diet can be expensive,
11 but it can also be inexpensive, and we have
12 forthcoming research from CNPP demonstrating
13 that with that scatter plot, even when you
14 start controlling for the normal things that
15 would protect HEI score, price is really not
16 -- what you spend on food really doesn't
17 account for -- doesn't do much for the --
18 doesn't explain much of the HEI score. For
19 men, the relationship is insignificant. For
20 women the association is very small.
21 USDA has resources available to
22 translate from the food plans to something
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1 that consumers might use. It does require
2 some nutrition educators intervention, and the
3 SNAP-Ed connection has over 4 million hits in
4 -- had over 4 million hits in fiscal year
5 2008, and this has a recipe database which
6 nutrition educators can use to find recipes,
7 and also this is open to every consumer within
8 the United -- this is open to anybody who has
9 access to the Web.
10 There are also the State EFNEP
11 programs, and the SNAP Nutrition Education
12 Programs, which also help.
13 With that, I'd like to thank you
14 for the invitation, and I'm happy to introduce
15 -- to address any questions as well as Dr.
16 Mark Lino as well.
17 MEMBER WILLIAMS: I was thinking
18 of most pediatricians' offices where they
19 don't have access to a nutritionist, and is it
20 possible to translate some of this into
21 educational materials that, for example, show
22 different plates with breakfasts and lunches
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1 and dinners that would fit into the thrifty
2 food plan?
3 DR. CARLSON: It is possible. I'm
4 pretty sure you don't want an economist
5 actually doing that translation. And FNS is
6 working to translate some of that material and
7 their materials are mostly web-based, so
8 pediatricians could certainly print that out
9 and make it available to their patients.
10 And MyPyramid.gov, also -- if you
11 follow the pyramid you can save money. I
12 mean, that's kind of the bottom line. As long
13 as you choose the lower-cost foods.
14 CHAIR VAN HORN: Tom.
15 MEMBER PEARSON: I wanted to
16 follow up on that last comment you just made.
17 We were evaluating a video tape in 16 clinics
18 in Upstate New York, randomized to either the
19 video tape or not, followed with 036 and nine-
20 month, four-day random diet recalls to the
21 Penn State Nutrition Assessment Lab.
22 And then, a Cornell student put on
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1 as her honors thesis, a linking of those foods
2 to an Oregon and Washington cost database at
3 that time. So, they weren't actually local
4 costs, but it didn't matter because it was all
5 relative to the database.
6 And there was really no -- the
7 video tape was looking at lowering --
8 implementing the guidelines of ATP-2, which
9 was a fat and cholesterol target.
10 DR. CARLSON: Okay.
11 MEMBER PEARSON: So, our end point
12 was Hegsted score.
13 And so, if you looked across the
14 quartiles of Hegsted score between the lowest
15 change in -- actually, it was an increase in
16 projected cholesterol, serum cholesterol. The
17 best one, the fourth one, was about $1.75 per
18 person per day savings without any emphasis on
19 cost. I mean, we didn't even put in --
20 DR. CARLSON: Right.
21 MEMBER PEARSON: So, I guess the
22 message for me there, and maybe the question
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1 for you would be -- and Dr. Drewnowski,
2 yesterday, I think, also showed a lot of
3 scatter.
4 So, you can construct any -- any
5 diet you want for any cost you want.
6 DR. CARLSON: Correct.
7 MEMBER PEARSON: You know, the
8 foie gras is not only expensive, but it's
9 probably kind of not so good for you, you
10 know.
11 And so, the point really has to do
12 with the behavior that, within a cost that
13 people can afford going up the ATI.
14 DR. CARLSON: Exactly.
15 MEMBER PEARSON: And so that's the
16 question, is what is our database, our
17 evidence database for interventions that will
18 do that. That seems to be the behavioral
19 economics question that we need, not that
20 we can't construct these diets, but that we
21 can't implement them.
22 DR. CARLSON: Right. And I have
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1 seen other studies in addition to the one you
2 described, although they are a bit smaller,
3 where people may actually do a cost
4 intervention as well as a nutrition
5 intervention, and they find that the families,
6 in trying to have the kids -- the one in
7 particular I'm thinking about had overweight
8 children, and so they were doing an
9 intervention with the whole family, and over
10 the course of a year the grocery bills went
11 down because they changed the behavior of that
12 family.
13 MEMBER PEARSON: But, I mean, that
14 should be the main motivator, for people eat
15 healthy. Right now everybody thinks it's more
16 expensive.
17 DR. CARLSON: Right. Right. And
18 there's a lot of myth out there that it's more
19 expensive. I'm not quite sure where that came
20 from, because certainly people have been
21 eating healthy. I get emails all the time
22 from people saying, "I eat this and this and
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1 this. Is this healthy?"
2 And I look at it and I say, "Well,
3 I'm not a nutritionist. Type it into
4 MyPyramid," and they come back and say, "Oh,
5 well, it is very healthy. I guess I'm good.
6 Why is it -- why do people say it's so
7 expensive?" I don't know.
8 CHAIR VAN HORN: I think the --
9 and I'm going to get to you two in just one
10 minute, but I think this is the key issue, and
11 that's why we're so glad that you're here
12 today.
13 We didn't need you to be a
14 nutritionist. We needed you to be an
15 economist, and what we're trying to do here, I
16 think, is blend the two skills --
17 DR. CARLSON: Right.
18 CHAIR VAN HORN: -- and
19 backgrounds so that we can, in fact, provide a
20 reassurance to the American people that the
21 kinds of recommendations we're making are
22 affordable, and there are ways to pick and
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1 choose.
2 We know what the nutrition is, but
3 we don't know how to get the cost savings
4 across. And I think that's what we're really
5 after here.
6 DR. CARLSON: Right. Right.
7 CHAIR VAN HORN: Save, and then --
8 MEMBER PI-SUNYER: Yes. Pi-
9 Sunyer. I wanted to ask you, you know,
10 yesterday Dr. Drewnowski made a big point, and
11 he keeps making this point, that people are
12 eating nutrient-dense, calorically-dense food
13 because it's cheaper for them per thousand
14 calories.
15 You're saying that they can do
16 perfectly well and eat inexpensively, and
17 don't need to do that. But, I think 4 million
18 hits isn't a whole lot for a country that has
19 300 million people.
20 So, how can you get this across as
21 part of your message and goal?
22 DR. CARLSON: Well, first off,
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1 there are some advertising limitations. I
2 mean, we just don't -- USDA has a very limited
3 budget. We have several million hits on the
4 MyPyramid website.
5 So, one of the issues with
6 Drewnowski's thing -- and, yes, I'm saying you
7 can eat more. And, in fact, the food baskets,
8 if you measure by weight, by pounds of food,
9 you get more in the thrifty food plan than
10 people eat.
11 I understand from volumetrics that
12 pounds are -- pounds or grams or whatever,
13 what make you feel full. Calories don't
14 necessarily make you feel full. So, the cost
15 per calorie, I wonder how important that
16 really is.
17 I really think that the cost per
18 gram is much more important, and perhaps even
19 since we're talking -- if we're going to go
20 with -- with MyPyramid, perhaps even the cost
21 per cup equivalent or ounce equivalent is
22 really the correct metric within economics, to
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1 measure dollars per what are people eating,
2 not dollars per calorie, because dollars per
3 calorie are a convenient measure, but they
4 don't make you feel full.
5 MEMBER PEREZ-ESCAMILLA: Yes.
6 This Rafael Perez-Escamilla, and thank you for
7 a wonderful presentation, and I think
8 consistent with what you are saying and other
9 Committee members are commenting on.
10 I published a paper several years
11 ago with CSFII data showing that the
12 relationship between income and the healthy
13 eating index was modified by food label use.
14 So, no matter how much money you
15 had, if you didn't use the food label to make
16 your food purchases, you were not eating
17 healthy, and you could actually have much less
18 money, but if you used the food label you
19 would eat healthier.
20 DR. CARLSON: Exactly.
21 MEMBER PEREZ-ESCAMILLA: So, I
22 think what we're getting at is that nutrition
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1 education and teaching people in culturally-
2 appropriate ways how to use the Federal
3 nutrition tools, the food labels, MyPyramid
4 and so on is very crucial, and that income
5 matters, but by itself will not make the
6 difference.
7 DR. CARLSON: That is true.
8 MEMBER NELSON: This is Mim
9 Nelson. Thank you also for the presentation.
10 I think it's a nice balance to the
11 presentation we had yesterday, and sort of
12 looking at the whole picture.
13 I wish you'd been here yesterday.
14 It would have been great. But, one thing --
15 I mean, when we think about the way Americans
16 eat these days, versus how they ate in the,
17 you know, 20 years ago, the foods eaten away
18 from home are such a bigger contributor to
19 intake and potentially to expenditures.
20 And I'm not a -- I'm so far away
21 from being an economist, but I just have to
22 think that I wonder how much we've been -- you
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1 know, how the Federal Government, as well as,
2 you know, committees like ourselves have
3 really started to think about the realities of
4 the full income spectrum of foods eaten away
5 from home and how they really enter in,
6 because it's really different now.
7 DR. CARLSON: Right. Well, as it
8 turns out, I just -- I'm co-author on a paper
9 that just got preliminarily accepted in the
10 Journal of Nutrition, that does -- that
11 basically takes the food plan model and brings
12 in food away from home.
13 Now, we were working at just the
14 thrifty level, but you could certainly rerun
15 it with the other plans in -- that may match
16 more what some higher-income Americans are
17 spending.
18 And what we've found is, you can
19 incorporate some food away from home into your
20 diet and make it healthy. It's very difficult
21 to find those foods when you're away from
22 home.
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1 And so -- but the paper outlines
2 what -- what needs to be done, what choices
3 you can make of what's available right now and
4 what people actually reported eating at
5 NHANES.
6 CHAIR VAN HORN: Cheryl, your
7 comment?
8 MEMBER ACHTERBERG: Cheryl
9 Achterberg. Again, your presentation is
10 illuminating in terms of what's
11 hypothetically, theoretically possible, but it
12 -- I believe in your thrifty food plan you're
13 having folks soak their beans overnight and
14 cook them all day?
15 DR. CARLSON: No. No. That's
16 definitely not true. That is actually
17 something that people think. When we did the
18 prices database we were very, very, very
19 careful on this. Part of the reason it takes
20 so long is we go through all of the recipes in
21 NHANES and look for convenience foods.
22 Beans and legumes are assumed to
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1 be purchased canned. If you want to bring
2 them, there's certain recipes that taste a
3 whole lot better if you soak them and cook
4 them yourself.
5 You can certainly do that, because
6 that's certainly cheaper. You have a little
7 money for something else. But, we assume that
8 people are purchasing their beans canned.
9 We assumed that people are
10 purchasing their soup in cans. We assumed
11 that purchasing spaghetti sauce. We assumed
12 the macaroni and cheese comes from a box, if
13 they said it came from a box.
14 We assumed that any foods eaten
15 with high frequency such as pizza and egg
16 rolls were purchased frozen, that they were
17 not made from scratch.
18 MEMBER ACHTERBERG: Thank you.
19 That's important with that time trade-off.
20 DR. CARLSON: Right.
21 MEMBER ACHTERBERG: All right.
22 Thank you.
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1 CHAIR VAN HORN: Is Dr. Lino
2 ready?
3 MS. O'CONNELL: Brian is next.
4 CHAIR VAN HORN: Oh, is Brian --
5 MS. O'CONNELL: Mark was just for
6 questions.
7 CHAIR VAN HORN: Okay. We had
8 some --
9 COURT REPORTER: Your microphone
10 is not on.
11 CHAIR VAN HORN: Sorry. Can you
12 hear me now? All right. This is Linda Van
13 Horn.
14 Our next speaker is Dr. Brian
15 Wansink, and we're delighted to have him back
16 with us. He is the John Dyson Professor of
17 Marketing -- of Nutritional Sciences at
18 Cornell.
19 He also is the Director of the
20 Cornell Food and Brand Lab, which uniquely
21 focuses on the psychology behind what people
22 eat and how often they eat it.
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1 His research focuses on how ads,
2 packaging, personality traits influence the
3 usage and frequency of volumetrics and healthy
4 foods. His research is on consumption volume,
5 and has won national and international awards
6 for its relevance to consumers.
7 And with that, I'd just like to
8 thank you, Brian, for joining us today.
9 DR. WANSINK: It is great to be
10 back here. It's great to be back for a bunch
11 of reasons. You could probably guess, but
12 it's great to be back here for a reason that
13 none of you could ever guess.
14 It was two years ago next month
15 that I gave a talk in this exact same room, at
16 this exact same podium and right after that,
17 during the break, I was approached by Dr. Eric
18 Hentges, the former executive director of
19 CNPP, and he told me I was one of the
20 finalists being considered for the position.
21 So, that meant a lot to me and it
22 means a lot to be back.
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1 MS. DAVIS: Who knows what will
2 happen.
3 DR. WANSINK: I also -- I remember
4 very few things from that conversation, first
5 of all, because it hit me so dramatically, and
6 the second reason was, it was during the
7 break, I just finished buying two diet Dr.
8 Peppers from the pop machine out there. I
9 spent the entire conversation trying to hide
10 them, fearing I would be disqualified.
11 So, here's where we're talking
12 about food, nutrition and consumer behavior.
13 Now, there's a bunch of different schools of
14 thought when it comes to how people change.
15 There's a health belief model, social
16 cognitive model and so on.
17 With only 20 minutes what I want
18 to touch on is the consumer behavior, the
19 psychology view of things and the marketing
20 overview. And this is for two reasons.
21 First of all, I think a consumer
22 behavior perspective and a marketing
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1 perspective provides the most compelling
2 answers to the questions that you posed to me.
3 But second of all, I think it
4 points towards the most promising solutions.
5 And, indeed, this is the approach we've used
6 when I was Executive Director at CNPP to
7 actually try to get this stuff out there.
8 And at the end of every slide
9 there will be some bottom of the page
10 citations, and typically these will be ones
11 that you can look for more information. They
12 are oftentimes mine. And I have them there,
13 because if you're to go to those articles, you
14 could find all the stuff you need.
15 And most part of the stuff, it's
16 not only cited, it comes from my book,
17 Marketing Nutrition.
18 Here's the overview of the
19 questions that you asked me to consider. What
20 are the determinants of intake? What is
21 effective nutrition information? What is
22 segmenting messages and markets? How do you
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1 do that?
2 What are optimal models that kind
3 of relate from transitions to different
4 lifestyles? When does nutrition information
5 fail? And, how do you get people to
6 prioritize nutrition?
7 There's a tremendous amount of
8 overlap in the last five questions here. And
9 so what I've done is, I've broken them in a
10 way that I think I can tackle a lot of these
11 questions in a different sort of format.
12 I'll talk about something called
13 the Web of Science and Drivers of Intake. But
14 for the most part, these last five issues I
15 will be discussing under the heading of
16 segments and markets, messaging and
17 leveraging, and then intervention and change.
18 The first thing is: Where do you
19 find most of the published information on food
20 and nutrition behavior? This is the most
21 important thing I will talk about today. If
22 there's only one take-away you have, it will
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1 be this.
2 You find most published research
3 on food nutrition and behavior, not on PubMed.
4 Okay. That's the tip of the iceberg.
5 There's a lot of correlation-based studies,
6 there's a lot of epi studies, but they don't
7 tell you the psychology about why something's
8 happening.
9 They don't really delve into that
10 because a lot of the data that's used can't do
11 that, but I would say that 93 percent of the
12 things that inform me most about my research
13 end up being from journals in psychology,
14 economics, consumer behavior, sensory studies,
15 marketing, sociology, food technology,
16 education, communication, and most of these
17 aren't indexed in PubMed.
18 Why? Well, it could be because
19 very few articles in these particular journals
20 specifically relate to food. A lot of the
21 ideas in those journals specifically relate to
22 behavior, not -- not a lot of the articles
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1 specifically relate to food.
2 And if there's only one take-away
3 for the NEL people, make sure that you inhabit
4 the NEL index if you're going to look at
5 behavior, the stuff that comes from the
6 journals that really do study behavior.
7 The place to find this, the best
8 place is the Web of Science. It also
9 encompasses all the PubMed sort of stuff, and
10 you do find it in any database. Web of
11 Science, also known as the Social Science
12 Citation Index.
13 Okay. What are the drivers of
14 food intake? Well, let's look at three
15 drivers of accessible food intake. Now, we're
16 going to focus on accessible stuff versus
17 inaccessible foods because I think it's more
18 relevant to looking at consumer behavior in
19 this context.
20 Now, there's three things that
21 influence food intake. It's when or how often
22 you eat it, it's what you decide to eat and
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1 it's how much. These don't happen in a linear
2 way like this.
3 I mean, because you can buy a big
4 thing of chips and have them sit in front of
5 you, and the question is, when are you going
6 to eat the next chip. Typically this is the
7 way that it happens.
8 Let's look at them in sequence
9 here. The when question, the drivers of the
10 when are physiological factors. They can be
11 hunger, they can be deficiencies. There can
12 be a lot of emotional factors, and recent
13 studies showed that emotions end up driving
14 what people eat.
15 Two things can be going on. They
16 can either be going -- they can either be
17 eating to maintain a mood, that is, they're
18 happy, and they want to continue being happy,
19 or they can be -- things can be eaten to
20 regain a mood. Tend to happen when you're in
21 a negative sort of state.
22 Now, a lot of the research that's
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1 looking into it shows that if you're trying to
2 maintain a mood there's a slight tendency that
3 you end up having to eat healthier foods than
4 if you're trying to regain a mood, you end up
5 looking for things that give you that initial
6 hit, and that long-term disappointment.
7 In terms of salience, internal --
8 there's internally and externally-generated
9 salience. Internally generated salience is
10 the type thing where you say, "Geese, I cannot
11 get ice cream off my mind." You're driving
12 home and you're saying "Ice cream. Ice cream.
13 Ice cream."
14 Externally-generated salience
15 sends up, you know, the sort of thing that you
16 don't even think about this until you pass the
17 donut plate at work, and you kind of go, "Yes,
18 I'm hungry for a donut.” When you weren't
19 before.
20 Those influence people in
21 different ways, and because you eat different
22 amounts of stuff.
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1 Now, the internally-generated is
2 often based on scripts and emotions. Scripts
3 would be if you end up coming home regularly
4 and walk into the kitchen, and your script is
5 to open the refrigerator and see what's there.
6 That becomes the natural sort of way to do
7 things.
8 The salience, we did kind of an
9 interesting piece of research a short time ago
10 that showed that people who walk home through
11 the kitchen end up weighing -- and it's self-
12 reported data, on average 17.2 pounds more
13 than people who don't walk home through the
14 kitchen.
15 Externally-generated sensory
16 salience, you see, smell, hear somebody talk
17 about a food. But it ends up being why a
18 fruit bowl is a good idea and a candy jar is a
19 bad idea.
20 In terms of what we eat, some of
21 the same drivers that grade those out are
22 going on for what we eat, and physiological
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1 factors will influence what you want to eat,
2 in terms of your hunger and deficiencies, as
3 will emotion and salience.
4 But what also kicks in when we
5 look at what you eat is specific self-stated
6 drivers of choice. But typically these will
7 vary a little bit. Typically the top four,
8 based on the survey you'll look at, it says
9 "Taste is most important, and convenience and
10 then price, and the last health."
11 What typically isn't broken out is
12 what "health" means. And oftentimes for
13 people, it means different things for
14 different segments. Health doesn't mean, you
15 know, I'm going to be getting all the vitamin
16 B I need for today. Health will be, "I'll
17 lose weight, or I won't gain weight, or fall
18 asleep in the middle of the afternoon."
19 What's very often looked at is the
20 unstated driver, and it's the idea that the
21 person's immediate environment, whether it be
22 their cupboards, table, candy dishes and so
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1 on, end up having an incredible influence on
2 what we choose, but we will not acknowledge it
3 because we don't really think it's happening.
4 You know, you've read about that
5 in my book, "Mindless Eating," and it gives
6 you some more ideas about that. In terms of
7 how much, in terms of how much again,
8 physiological factors and emotional factors,
9 but also it ends up being how closely we
10 monitor what we eat and what we consider the
11 consumption norm to be for that situation.
12 That consumption norm could be,
13 "What we normally do," or it could be what the
14 guy next to us is doing, and -- but it's
15 biased by a lot of things around you and I'll
16 give you a real basic idea of this framework.
17 When we look at all the things
18 that can influence us, when they lead us to
19 overeat, it typically is mediated by two
20 different things, either poor consumption
21 monitoring which ends up being sort of our
22 unawareness of how many food-related decisions
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1 we actually make, or is it being mediated
2 through this idea of consumption norms, that
3 the size of a plate suggests that three and a
4 half ounces looks better than three ounces.
5 The second thing to look at is
6 consumer segments and markets. Who pays
7 attention to nutrition information? Well, I
8 -- an often-cited figure is 70 percent of
9 consumers report paying attention to nutrition
10 information.
11 I don't know where this comes
12 from, but about two and a half years ago, I
13 was doing an interview at 60 Minutes, and the
14 correspondent at one point said, this is when
15 this stuff was going on about the New York
16 labeling of foods, and she asked, she cited
17 this and says, "So won't labeling transform
18 the way people eat in New York City?"
19 And at the break time I said,
20 "Where did you get that 70 percent figure?"
21 You know, I think of this stuff all the time,
22 and I've never heard it. And she goes, "Oh,
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1 everybody knows it."
2 Fair enough. Okay. Well, you
3 hear a figure like this. What's that -- do
4 they report paying attention? Is just like we
5 report doing sit-ups every day when we talk to
6 our physician? Or we report flossing three
7 times a day when we talk to our dentist?
8 And what's, "pay attention?" Does
9 that "pay attention" ignore -- I'm not sure
10 what it means. How often? Is it every time,
11 or that one time I paid attention to nutrition
12 information?
13 The fact is, most controlled
14 studies of behavior, a lot of these are done
15 in supermarkets, which is most relevant for
16 what we're talking about -- most controlled
17 studies that show that only 12 to 22 percent
18 end up reading the labels for this level of
19 detail.
20 And some of these studies also
21 showed that the 12 or 22 percent who do this
22 are the people who need it least. They're the
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1 ones that go, "140 calories. I thought it had
2 138." They're not the ones who need to
3 change.
4 So let's consider three segments
5 of consumers. The nutrition vigilant segment,
6 these are the people who have changed or they
7 are pretty much on target to begin with.
8 The next segment is this nutrition
9 predisposed segment. This is the segment
10 that, they'd like to change, and they'd like
11 to eat better if it was easy to do so.
12 And the last one is the nutrition
13 disinterested segment. The thing about these
14 segments is that they cut across demographics,
15 and in the research that we've done, the
16 segment you're in is a much better
17 determinative of your behavior than your
18 demographic group that you belong to.
19 So where can you get the biggest
20 change for the smallest cost? I think these
21 nutrition predisposed people. Now, the
22 nutrition vigilance, if we talk to the choir
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1 and get them to eat two less calories a day,
2 that's probably good, but I think they're
3 going to find the information nevertheless.
4 So I've got a couple of things
5 here. They are the kind of people who read
6 magazines like this, Men's Health. You know,
7 how to do 200 push-ups by next week. I mean,
8 they don't really need as much of our help as
9 do the second group.
10 Now I've got a magazine that might
11 be appealing to them, too. We have People
12 Magazine here. It's Hollywood's Hottest
13 bodies, 100 Tips From The Stars To Lose
14 Weight.
15 They're looking for an easy
16 answer. They're looking for something that
17 can just nudge their life in the right
18 direction, and eat a little bit better.
19 The last group, the nutrition
20 disinterested, that's going to be a tough row
21 to hoe, and maybe the best bang for the buck
22 would be to make sure the second segment moves
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1 as far as they can, and maybe drags along the
2 disinterested spouses they might have.
3 Messaging and leveraging. Well,
4 I've broken this into four really brief
5 questions that I'm going to answer with some
6 empirical data.
7 First, when is labeling most
8 effective; second, what are best practices
9 from health claims; third, what nutrition
10 knowledge is most correlated with food intake;
11 four, what types of messages are most
12 effective with what types of segments.
13 First, when is labeling most
14 effective? One of the concerns with labeling,
15 these are the two horns of the dilemma when it
16 comes to labeling, is that nutrition
17 information, whether it be a pyramid, or
18 whether it be fat information, or whether it
19 be something else, a little number or a star,
20 is either totally ignored, or when it is
21 attended to, can lead to these unmerited
22 health halos.
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1 These unmerited health halos ended
2 up being the thing that, on one of our studies
3 -- we showed that there are ten grams of
4 protein in something. People ended up
5 inferring that, because it had ten grams of
6 protein -- ten grams of soy protein, that
7 would reduce birth defects and cure cancer.
8 No. One way around this is use
9 front and back label claims. Using both sides
10 of a package. A short blurb in front is a
11 take-away for about 80 percent of the
12 population that's disinterested. The full
13 claim on the back, and you kind of target the
14 15 or 25 percent who really do want more
15 information.
16 What are best practices from
17 effective claims? This is kind of an
18 interesting thing done that looked at the
19 effectiveness of the different health claims
20 that the FDA has put on labels, and if we look
21 at some of them, the ones that are most
22 effective, they targeted a specific segment,
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1 they received significant media attention, and
2 are often introduced with aggressive partnered
3 marketing campaigns.
4 And you think of the oats and the
5 oat recommendation in Cheerios, for instance
6 about 15 years ago, 20 years ago, that
7 highlighted quantitative benefits that
8 provided proof and helped provide vivid,
9 personally relevant health problem.
10 Third, what nutrition knowledge is
11 most correlated with food intake? The key
12 thing to look here is the very last bar. If
13 people knew that a certain food had an
14 attribute, that didn't really influence them
15 that much, and again, this is a -- this is
16 survey data.
17 If they only knew the consequence,
18 you know, that soy is good for heart disease,
19 that had a little bit more of an impact. But
20 when they could pair the reason why the
21 product gave you the consequence, it was that
22 group that was most likely to change their
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1 behavior.
2 What types of messages are most
3 effective with what segments? Let's take a
4 look at two positive messages. I think Dr.
5 Drewnowski mentioned this a little bit
6 yesterday. These are the positive sort of
7 "eat this" messages versus the negative,
8 "don't eat that," messages.
9 Now the research says -- it's all
10 over the map. Okay. But my take on this
11 literature is that, basically, whether a
12 positive message is effective or a negative
13 message is effective depends on the situation
14 and the individuals.
15 So with the positive message, in
16 doing the review, I think what's going on is
17 they will work best with optimistic people,
18 people who eat because it tastes good, and
19 people who don't think too hard about eating,
20 people who eat healthy to feel good, people
21 who see eating as a choice, and people who
22 value food as a way to stay healthy.
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1 The negative message, you know,
2 "don't eat that," seems to be more effective,
3 you know, based on a review of the literature,
4 with pessimistic people, or people who like to
5 think logically about each decision, people
6 who eat healthy because they're afraid of
7 getting sick, people who see eating as an
8 obligation, people who value food as a way to
9 not get sick.
10 Which group do we fall in? I
11 mean, the vast majority of people I hang
12 around with who are in the profession are in
13 the second group. And I think, for a lot of
14 us, negative messages might be better than the
15 --
16 MEMBER NELSON: Scientists.
17 DR. WANSINK: For the scientist,
18 exactly.
19 But for the bulk of people out
20 there, the positive messages work best with
21 most people with most mind sets in most
22 situations.
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1 So in terms of intervention and
2 choice, what are effective intervention
3 strategies for the nonvigilant consumer?
4 Those are the bottom two parts of the pyramid.
5 Well, in one study we did, we
6 found that people make over 200 more decisions
7 than they -- about food a day than they
8 believe they make. Now, they're not making
9 these decisions when they're in front of
10 MyPyramid.gov. They're not making them when
11 they're reading a nutrition brochure, they're
12 making them wherever they work and play,
13 wherever they purchase and prepare food.
14 And the fact is, nutrition
15 information is really not there when most
16 people need it. But I think if we could get
17 -- when people are making these 200 decisions,
18 we could get them to just think twice, to just
19 pause four or five times and make the decision
20 to turn left and the decision to turn right,
21 that's all it would take for the bulk of
22 people to start eating a little bit better
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1 instead of a little bit worse.
2 Now, one way we could do that is
3 if we all had a personal dietitian who, every
4 time you're going to make a decision, to kind
5 of tap us on the shoulder and say, "think
6 again." That might -- that would be one
7 solution. A bad one, but that would be
8 possibly a solution.
9 But I think another solution is to
10 have this 24-7, 360 degrees nutrition
11 information surrounding people so that there
12 is a reminder there, and it doesn't have to be
13 their personal dietitian.
14 One solution, probably -- it can't
15 be a governmental solution, because that would
16 be a huge task.
17 One solution would be to partner
18 with MyPyramid, and that was the intent we had
19 when Rob, and Jackie Haven, and John Webster
20 and myself started the partnering with
21 MyPyramid, getting a hundred companies to
22 promote the Dietary Guidelines in whatever way
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1 they wanted, and wherever -- to whatever
2 public they wanted.
3 What's the role of social
4 marketing and nutrition education motivation?
5 This is one of the questions asked. I think
6 social marketing -- I guess by that question
7 what was meant was like Facebook and Twitter,
8 and things like that, I guess. That's the way
9 I interpreted it.
10 Well, I think there's tremendous
11 potential for good and bad. The danger is
12 that there's a lot of food and nutrition
13 misinformation. Now Dr. Van Horn's journal,
14 the Journal of the American Dietetic
15 Association, has a great article in there
16 about nutrition information. That's one of
17 their ADA, sort of position papers. It goes
18 into that in a lot of detail.
19 But there's also these things -- I
20 have people ask me every other day about
21 something like magic berries, or something
22 like that, and there's a website that's, "What
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1 Your Mother Told You," and people are looking
2 at these as sources of nutrition information
3 in the absence of other things. Well, what
4 circumstances had the most promise? I think
5 the circumstance where these sort of things
6 work best end up being either when it's a
7 movement, or when it's a lifestyle choice,
8 like veganism.
9 I always -- I'm amazed at how
10 radical somebody can change their life once
11 they decide it belongs to a cause bigger than
12 themselves, whether it be to be a vegetarian,
13 or vegan, or whatever the case is.
14 But I think these circumstances
15 also have a lot of promise when it's a cool
16 cause. We've seen some real cool causes over
17 the last few months. These cool causes have
18 to be identity bandwagons. It's one thing
19 they all have in common is that if you're --
20 if this isn't feeding your identity or
21 demonstrating who you are, it doesn't work.
22 And the problem with Dietary Guidelines is can
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1 they ever be cool or movement inspired?
2 And for the 15 blessed months I
3 was with CNPP, this is what we thought about
4 and tried to make happen in different ways.
5 And I don't think it hurts to use this bottom-
6 up approach with the young'uns, you know, with
7 the little kids that are out there, but it's
8 also probably not worth holding our breath at,
9 because what we can also do is use a top-down
10 family strategy, and it ends up being
11 targeting the nutritional gatekeeper.
12 The nutritional gatekeeper is
13 considered to be the person who purchases and
14 prepares most of the food. And in 1943,
15 nutrition education showed that this person
16 has a disproportionate impact on what every
17 person in their family eats.
18 Back then it tended to be a
19 mother. Now it's tending to be relatives,
20 fathers, things like this. But in a study in
21 2004, one finding of 1004 gatekeepers is that
22 they believe they influence 72 percent of the
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1 eating decisions of their family.
2 It's either for the better or for
3 the worse, and it's either directly, or it's
4 indirectly. It's directly to what they bring
5 in the house, or it's indirectly by what they
6 end up eating when they are out at a
7 restaurant with their kid, or what they end up
8 doing when they give their kid five bucks to
9 go to eat lunch at school.
10 And so the idea would be to target
11 the person who makes the decisions, and also
12 at the same time build awareness for their
13 kids with this 360-degree, 24-7 approach, that
14 I think is becoming a lot more common given
15 some of the cool things that companies are
16 doing.
17 So let's bring it on home here to
18 the nutrition predisposed consumer segment.
19 Now if we look at this pyramid, and we look at
20 the entire United States there, we can have
21 two strategies. We can say, there's no person
22 left behind, but that's an impossible starting
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1 point, because it's really hard to change
2 people who want to change, let alone people
3 who don't want to change, or don't think they
4 need to change.
5 Another strategy would be to say,
6 "Why don't we start where we can make the
7 biggest difference right away." Folks in the
8 nutrition predisposed segment, and then
9 focusing on the nutritional gatekeepers as a
10 way to get us there.
11 So in transitioning from this
12 recommendation to lifestyle change, if we look
13 at the nutrition vigilance, hey, we can
14 provide them information and reminders, which
15 we already do. We do an incredible job with
16 that.
17 With the nutritionally
18 predisposed, we can provide tools, whether it
19 be web-based or whether it be iconic on
20 packages, that provide them product solutions,
21 which is typically a company thing to do.
22 But the nutrition disinterested,
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1 this has to be a stealth health approach, in
2 that passive environmental or product-related
3 changes, whether it be reformulations, portion
4 control packaging, or other stealth health
5 will probably be the best way to get them to
6 move if it's not their spouse or family
7 member.
8 So before we move on to questions,
9 I want to just give a special USDA CNPP stand-
10 up recognition to all the people who have been
11 working on the policy and the DGAC, and Dr.
12 Robert Post, the inimitable Carole Davis,
13 Colette Rihane, and then Kellie O'Connell, who
14 so gently gets us to do stuff without us
15 feeling anything more than just slightly
16 nudged.
17 For promoting of Dietary
18 Guidelines, Jackie Haven, John Webster, Dr.
19 Patricia Britten is back there, and Janie
20 Fleming have done amazing things over the last
21 two years.
22 So I think we're open for
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1 questions.
2 CHAIR VAN HORN: Yes. Thank you.
3 Here we go again. Linda Van Horn. Thank
4 you, Brian, very much. That was excellent and
5 certainly raises lots of questions, I think,
6 for this group, as you well know.
7 And I think when we invited you to
8 come, that -- the kinds of topics that you
9 were addressing are, of course, uppermost on
10 our mind, and I think probably the most
11 specific one being this issue of education
12 versus motivation.
13 And I think you're addressing it
14 in terms of issues related to things like
15 labeling and, you know, is labeling education,
16 or does it motivate, and who does it motivate,
17 and how do we address that.
18 And you know, if you could
19 elaborate a little bit on that, and then I'm
20 sure others have questions, as well.
21 DR. WANSINK: I can, yes. That's
22 a good question. In looking at the idea
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1 between motivation versus education, the
2 problem with us as Americans, and I'm not
3 speaking from studies as much as I'm speaking
4 just from what I observe, is that I think we
5 seem to be an all or nothing -- we have an all
6 or nothing mentality.
7 And we tend to be very impatient.
8 And the problem with motivation is that
9 people don't seem to be motivated to make
10 small changes, because they want big results,
11 so they're motivated to make a huge change,
12 and then it doesn't work, and then they become
13 discouraged and they fall into that third
14 segment.
15 And that's why, when it comes to
16 encouraging people to eat nine fruits or
17 vegetables a day, holy cow. When has that
18 ever happened? But getting people in a small
19 distance, that doesn't take much motivation.
20 All it involves them doing is making a
21 slightly smaller decision.
22 And so instead of motivating a
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1 great change like, you know, like giving up
2 pizza, or you know, never eating fried food
3 again in their life, which they're not
4 probably going to do, I think if we can move
5 them in these small directions gradually, it's
6 not going to entail them having to change
7 their life.
8 CHAIR VAN HORN: Rafael.
9 MEMBER PEREZ-ESCAMILLA: Yes.
10 Rafael Perez-Escamilla. Thank you for this
11 very useful presentation. I do think it's
12 very relevant for the work that we are doing.
13 Studies have consistently shown
14 that acculturation of immigrants into the US
15 mainstream culture, however we define that,
16 influences quite a bit food choices and other
17 lifestyle behaviors.
18 And I think it would be incredibly
19 useful if you and your colleagues could
20 include the dimension of acculturation in your
21 research, because it would be very interesting
22 to see how people respond to the cues around
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1 them in terms of their food choices, how they
2 are when they arrive, how they change as they
3 become more acculturated.
4 DR. WANSINK: What's interesting
5 is that 60 years ago, this is just only a meat
6 and potatoes country, but what happened after
7 World War II is, when GI's came back after
8 having experienced these different foods, they
9 kind of brought some of these tastes with
10 them.
11 And now here 60 years later, if
12 you go to any town in America that's over
13 3,000, you're going to find the most popular
14 restaurant on one side of the street, it's
15 going to be a Chinese restaurant that's open
16 'til eleven every night. And on the other
17 side of the street, it's going to be the
18 Mexican restaurant. And unlike a lot of
19 cultures, we end up being, I think, one of the
20 most flexible in terms of being able to adapt
21 different meal patterns.
22 MEMBER PEREZ-ESCAMILLA: Thank
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1 you.
2 MEMBER NELSON: Brian, thanks a
3 lot. This is Mim Nelson. I really enjoyed
4 it, and I think that -- you know, I think one
5 of the neat things with these Dietary
6 Guidelines will be -- it's going to -- we're
7 going to move things forward around behavior
8 and the environment, but one question I have
9 is -- is I don't know that it's a concern, but
10 the sort of -- the partnering with food
11 companies around the social marketing, which I
12 think is good, but I kind of feel like they're
13 orphans out there, the green beans and the
14 sort of lettuces that don't have the
15 stakeholder -- you know, they don't have --
16 the things that we actually want to market
17 mostly - with the exception of maybe whole
18 grains that come in a package with a label -
19 the things that we want to be getting people
20 to eat more of don't have -- you know, there
21 isn't the stakeholder there. There's not the
22 company behind that green bean.
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1 So how do we deal with the whole
2 range of foods that don't have those, you
3 know, large stakeholders, if you will.
4 DR. WANSINK: I like that. I like
5 that. I've got an answer for that. For the
6 first part of your comment, when you said
7 you're going to look at behavior, that does my
8 heart good to look at that, because if you
9 look at what all of you have in common, even
10 though you have different research interests
11 and different specialties, almost every single
12 one of you comes from a behavior-related
13 background.
14 You deal with behavior as it
15 relates to food safety, or with food
16 technology. You deal with behavior as it
17 relates to seeing patients, or behavior as it
18 relates to dietitians.
19 So there's this inherent behavior
20 component that every one of you have that
21 makes me say that you are a legendary
22 Committee.
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1 Second thing about the green
2 beans, about pinto beans, about canned
3 spinach, the biggest determinant of whether
4 that gets eaten is whether it gets purchased
5 and brought in the house, and that's one way
6 of talking to the nutritional gatekeeper --
7 you know, we can say, yes, but you know, they
8 only account for maybe 72 percent of what's
9 eaten in their household.
10 72 percent is a whole lot better
11 than saying, there's nothing we can do about
12 it.
13 And that's why I think trying to
14 convince, you know, little Billy and little
15 Audrey to eat better is going to be a whole
16 lot less effective than trying to convince the
17 person that purchases and prepares food to
18 bring the stuff in and use it.
19 MEMBER NELSON: Yes. I mean - I
20 agree with you. I think that the gatekeeper
21 is big, but -- but if we rely on the food
22 industry and sort of try to get them to market
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1 -- the problem is you have sort of David and
2 Goliath. Even though they may be trying to do
3 their best for the most part, those are the
4 food -- you know, for the most part, those are
5 the foods that we're trying to get people away
6 from.
7 I mean, it is -- it's tricky, I
8 think.
9 DR. WANSINK: I see what you mean.
10 Well, I think one thing going on is they can
11 be our partner. They don't have to be our
12 spokes -- they don't have to be -- they don't
13 have to be our voice. They can just be a
14 partner.
15 But the second thing that's going
16 on is, there are economic interests in beans,
17 whether it be the canned green beans. We
18 don't all have to eat fresh fruits and
19 vegetables as the Guidelines say. We can eat
20 canned and frozen things.
21 MEMBER NELSON: Yes.
22 DR. WANSINK: But second of all,
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1 I'm pleased that we have a lot of retailers
2 that are interested in doing this, too,
3 because it's incredibly in the retailer's
4 interest to get people to buy a lot of
5 produce, because it's got --
6 MEMBER NELSON: Exactly.
7 DR. WANSINK: -- massive margins.
8 MEMBER NELSON: Exactly. Exactly.
9 So maybe it is empowering the retailers more
10 -- yes. Great.
11 MEMBER PEARSON: Tom Pearson.
12 Brian, your segmentation of consumers
13 obviously is kind of a bit of transtheoretical
14 model and a little bit of fusion of innovation
15 kind of rolled into one.
16 The problem with maybe the
17 nutrition disinterested, and it is a pyramid,
18 and they're on the bottom of the pyramid, and
19 by definition, that's a big group.
20 And so, I wonder what we could do
21 to think about really getting them involved.
22 Now from a clinical standpoint, we deal with
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1 the stages of change all the time, and the
2 typical patient that we see is, in fact,
3 precontemplater.
4 He just, you know -- he or she
5 doesn't -- you know, have any idea. And so,
6 what we try to do is not to move them up to
7 somebody who's actively changed, but just up
8 one more step into the next phase.
9 So what would you say about --
10 about strategies to get the nutrition
11 disinterested, like you said, dragged into the
12 nutrition predisposed so that at least we
13 could start to get across the idea of a
14 healthy diet being a social norm in the same
15 way that some of our tobacco efforts have
16 gotten into -- into obviously saying that a
17 smoke-free environment is the normative
18 environment?
19 DR. WANSINK: Well, let me talk
20 about one segment, and it's not how we move
21 them into the next -- move them up the
22 pyramid, so to speak, it's how we grow them up
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1 the pyramid, and these end up being a lot of
2 the younger people that we have out there.
3 I think there's a lot of neat
4 things that are going on now that haven't gone
5 on before. It's cooler now to cook in the
6 kitchen. There's a lot of programs looking at
7 some things like this.
8 We, ourself, are starting
9 something called smarterlunchrooms.org, and we
10 have all the research that goes on about how
11 you can get kids to eat better school lunches
12 without taking away their cookies. And it's -
13 - it's a very effective thing.
14 So I think one thing is, we can
15 keep an eye on these younger -- this younger
16 generation, and try to grow them into people
17 who are kind of at least nutrition
18 predisposed.
19 But a lot of the older -- with a
20 lot of the older people, I think things can
21 happen from family members more than it can
22 help from us, whether it be a child coming
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1 home and saying, "hey, I learned how to cut up
2 an onion today in class," or whether it be a
3 spouse who comes home and is feeling a little
4 bit empowered to maybe add that can of green
5 beans to a casserole that he or she wouldn't
6 have otherwise done.
7 And so I think that might be able
8 to help -- that might be able to happen almost
9 through contagion through other family
10 members, but I still think the best thing we
11 can do in the meantime is try to build in
12 these stealth health approaches that companies
13 might be doing, whether it be through
14 packaging to move them in that direction.
15 CHAIR VAN HORN: Naomi and then --
16 MEMBER NELSON: Can I follow up on
17 -- I'm sorry. This is Mim. Just, Tom --
18 sorry, I just -- I feel compelled to follow up
19 because -- Brian, I don't know, I mean, if you
20 would agree with this, but I would say that
21 the way you get the disinterested to eat
22 better is by choice architecture, basically,
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1 that if we can recreate -- I mean, we've done
2 some research of this where we don't --
3 there's no -- it's not about changing their
4 choices, it's just that you create an
5 environment where cities -- I mean, I've
6 talked about this before, but they just
7 naturally, what they're going to get off the
8 shelves is going to be healthier, so it's not
9 even about them making a decision.
10 So that's the way you get the
11 bottom part of the pyramid is you get
12 collective change within that community.
13 CHAIR VAN HORN: Okay. Naomi and
14 then Larry.
15 VICE CHAIR FUKAGAWA: Naomi
16 Fukagawa. Thank you, Brian. I do resonate
17 with your suggestion that the youth of today
18 really are our future and our hope, because I
19 do think that the vast majority of them are in
20 the nutrition predisposed group, much to my
21 surprise.
22 And so therefore, they can
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1 influence, you know, their parents, and the,
2 quotes, "older generations." But one of the
3 big issues, and as alluded to by Dr. Carlson,
4 is the fact that we are still or have had
5 people focus on calories, and that perhaps
6 focusing on the weight of food that they're
7 purchasing or eating could be something that
8 might modify behavior.
9 But then, how do we -- or do you
10 have any suggestions for efforts that we might
11 make with respect to education about portion
12 control, because oftentimes we think of this
13 as a cup, but we know this isn't a cup. I
14 know, I mean, you know, the classic cup and
15 the measures.
16 DR. WANSINK: Yes. Well I think
17 there's two dimensions to nutritional balance,
18 and one of them I had zero appreciation for
19 before about five years ago. One of them ends
20 up being, do we eat the right number of
21 calories, like I said.
22 But the other one ends up being,
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1 do we eat in the right balance. And I think,
2 with some of these kids who are growing up,
3 rather than saying, you can't eat that, you
4 can't eat that, don't eat too much of that,
5 that's really not a very, you know, empowering
6 and encouraging thing to do, but instead,
7 giving them the substitute and saying, "You
8 can't eat this, why don't you try this? Why
9 don't you do something with this?"
10 I think that's where there's a
11 tremendous amount of promise, but it's not
12 what we've ever really done in the past.
13 We've tended to view nutrition as being "don't
14 do that," whether it be don't eat enough
15 calories, or don't eat that food.
16 You know, and I like what you said
17 about children. I gave a series of talks in
18 California maybe last week or the week before,
19 and one of them was at Cal Poly, and there's
20 an interesting woman there named Ann McDermott
21 who's starting these really crazy outreach
22 programs that bizarrely seem to work.
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1 One was called "Food Dudes," where
2 she goes into this junior high kid, Hispanic
3 junior high kids, teaches them how to cook,
4 and sees what happens, sees what happens after
5 that.
6 And they go home, they teach their
7 parents, they think it's cool to cook. And a
8 month ago, you could have never convinced me
9 that you're going to convince any junior high
10 kid, junior high boy to cook.
11 And I think it's because we don't
12 try. We don't try enough ways to find the
13 right way.
14 MEMBER APPEL: This is Larry
15 Appel. A very interesting talk. I wanted to
16 think globally. What do you -- and I think
17 this stealth health approach is really quite
18 important, and yet this Committee really
19 focuses on pretty narrow issues often.
20 You know, like does sodium affect
21 health, something like that. So can you give
22 us some guidance here, because I'm a bit
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1 concerned because the stealth health questions
2 often, you know, don't have as robust a
3 database to support them, and you know, you
4 use a grade of evidence approach, and we're
5 going to be left with, you know, Cs, you know,
6 because we don't have evidence that cutting
7 portions and a quarter actually leads, you
8 know, prevents obesity downstream.
9 We might have data from single
10 meal studies in front of us, so we need some
11 guidance from you on the stealth health and
12 what our role in this Committee could be.
13 DR. WANSINK: Well, yes. I think
14 the charge of the Committee is being not
15 necessarily to talk about communication, I
16 mean, as much as that happens after the --
17 after you've actually delivered the report.
18 But in terms of thinking who and
19 what is going to be the best changes to make,
20 whether it be thinking in terms of what's
21 realistic for a nutritional gatekeeper to
22 think about.
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1 You know, what's the easiest thing
2 to do for the growing nation of people who
3 maybe aren't that adept at knowing how to cook
4 beans. You know, is it realistic to have
5 maybe the major recommendation be to, you
6 know, soak beans and eat them every day?
7 I mean, that's why -- I mean,
8 there's a lot of things to think about, but in
9 keeping in mind who kind of the target markets
10 are, it won't change the science at all, but
11 it might just change the way you think about
12 the science, maybe the way it gets -- where
13 the emphasis lies.
14 MEMBER APPEL: Well, let me just
15 follow up. I mean, we -- I think everybody
16 realizes we have this incredibly -- this
17 incredible trend towards eating food outside
18 of the home with, you know, the gatekeeper may
19 be bringing them to the restaurant.
20 You know, you either choose, you
21 know, --
22 DR. WANSINK: Cheesecake.
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1 MEMBER APPEL: Cheesecake Factory
2 or another place. But you get there and, you
3 know, massive portions. I mean, are, you
4 know, strong statements about the environment
5 and selection.
6 I mean, I'm sort of struggling
7 because I think that we're -- some of these
8 issues are so beyond the narrow research
9 question that we often pose, ourselves. Or
10 this Committee poses.
11 DR. WANSINK: Yes. They are. And
12 you know, being able to stay within those
13 guidelines, and I think Dr. Post and Carole
14 will be able to keep you within the guidelines
15 of what's going on, maybe looking more in
16 terms of maybe how this gets implemented in
17 some ways.
18 CHAIR VAN HORN: Linda Van Horn.
19 Thank you very much, Brian, for all of your
20 words of wisdom and experience. We really
21 appreciate everything that you provided.
22 DR. WANSINK: Thank you.
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1 CHAIR VAN HORN: Thank you.
2 With that, we're ready to move
3 along now for our subcommittee reports, and
4 Dr. Appel, you're on.
5 MEMBER APPEL: Okay. So my duty,
6 I guess, is to go over our subcommittee
7 progress to date, so let me first start off by
8 acknowledging our Committee members, besides
9 myself, the chair, Tom Pearson, Christine
10 Williams, and the person that keeps us on
11 track, Holly McPeak.
12 So in terms of topic areas, we
13 have -- we cover water, sodium and potassium,
14 and we've made this our sort of basic
15 structure in terms of priorities. Finishing
16 up the water chapter, which really doesn't --
17 and I'll point out, doesn't have a huge amount
18 of new data to change the guideline.
19 Sodium in children, which is a
20 fresh start, and Christine's going to bring us
21 up to date on the progress on that. Sodium in
22 adults, and the third is potassium.
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1 So the first research question is
2 water, what amount of fluid is recommended.
3 And we've actually had a lot of progress on
4 this. We saw this as our low-lying fruit. We
5 got an expert, Mike Sawka in January, already
6 reported back that he's -- based on his view
7 of the literature, and he's perhaps the
8 world's -- one of the world's experts on
9 amount of fluid that's required for health,
10 there's been no major studies to change our
11 recommendation.
12 So what we -- what I did was to
13 actually update the 2005 chapter already.
14 This might be sort of like the canary in the
15 cage, the first pass at trying to take what we
16 did in 2005 and update it.
17 So added some additional text on
18 water and the elderly, which came up in the
19 comments to the Committee. A section on
20 hyponatremia, which is low serum sodium. It
21 doesn't occur often in a healthy population,
22 but there's potential for miscommunication if
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1 you don't address it.
2 We do have a need to coordinate
3 with other committees, potentially Xavier's
4 Committee or Joanne's on caloric versus
5 noncaloric beverage and preference for that,
6 and not -- that's sort of an issue on hold.
7 But I'll bring this up too -- I've
8 been on our Science Committee which is, you
9 know, concerned about the grading of evidence
10 approach and how we're going to deal with
11 this.
12 There was, in January, very
13 interesting, we had the subcommittee
14 discussion with Mike Sawka, and he goes, "This
15 is the right conclusion." You know, and it
16 basically is no different from before, but
17 then -- so it's a multipart -- it's a
18 multipart conclusion with three distinct
19 elements.
20 Very informative. I think it's
21 helpful to the public, to the nutrition
22 science community to have it -- have a three(
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1 part statement, but then how do you apply a
2 grade of evidence to that, you know, and I'm
3 not quite sure.
4 So, the other groups may find
5 themselves in the same situation where your
6 best -- your best conclusion is not one that
7 is so narrow as to then put a grade.
8 So the second question is what are
9 the health effects of salt or sodium chloride
10 on health, and so here's the status update.
11 Literature searches have been
12 completed for adults and children. The
13 articles are being abstracted, and there's
14 been great progress spearheaded by Christine
15 on effects of sodium on blood pressure in
16 children.
17 So Christine, do you want to take
18 the lead here?
19 MEMBER WILLIAMS: Well basically,
20 this is the results of the search results for
21 sodium in children, and there was 771 total
22 citations retrieved, 71 reviews and 700
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1 trials. 62 were selected, 14 reviews and 48
2 trials.
3 And of the 14 reviews, eight were
4 included, six excluded, and of the 47 trial
5 citations, 28 included and 19 excluded. And
6 then, reviewing these articles, we excluded an
7 additional ten articles, and then we added 14
8 additional articles and one additional review
9 article, and there may actually be a few more
10 added after this.
11 So the current status is that
12 there are 61 clinical trial citations, 32 were
13 included and 29 excluded, and 15 reviews, nine
14 included and six excluded.
15 In addition to these articles,
16 there are a number of background articles that
17 we'll use too, as far as prevalence of
18 hypertension in children, morbidity, mortality
19 related to left ventricular hypertrophy and
20 other things that are present in hypertensive
21 children, tracking of blood pressure in
22 children and a few other areas, but basically
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1 the review, the search results are almost
2 completed.
3 MEMBER APPEL: Good. I think the
4 one lesson perhaps for other subcommittees
5 from what Christine identified is that the NEL
6 searches can come short. They really depend
7 on whether you have the right inputs, and I
8 think there was an age restriction that led to
9 a few studies not being abstract or
10 identified.
11 So we -- I think -- I think
12 everybody really needs to consider some of
13 these more comprehensive reviews that,
14 together with the NEL search, might give you a
15 more comprehensive view. Otherwise you're
16 going to miss some articles.
17 Okay.
18 MEMBER PI-SUNYER: Can I ask you a
19 question?
20 MEMBER APPEL: Sure.
21 MEMBER PI-SUNYER: You're talking
22 about trials which are interventional, right?
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1 And you only picked 48 out of 700. The rest
2 were excluded just because they were no good?
3 MEMBER WILLIAMS: No. The 700
4 included intervention trials and observational
5 epidemiologic studies.
6 MEMBER PI-SUNYER: Okay.
7 MEMBER APPEL: You know, it's a
8 lot of, you know how the indexing of the
9 literature is. Sometimes it's crisp and
10 sometimes it's not, and this one -- this
11 literature search doesn't go back just three
12 or four -- I mean, to 2003 or 2004, it goes
13 all the way back because it's a fresh start.
14 So the indexing, you know, could
15 be -- you could get trials that are part of
16 review articles, you know, and stuff like
17 that, so --
18 MEMBER APPEL: But they went back
19 to '64 --
20 MEMBER PI-SUNYER: But were most
21 of these --
22 MEMBER WILLIAMS: We went back to
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1 1970.
2 MEMBER PI-SUNYER: But were most
3 of these actual intervention trials or
4 observations --
5 MEMBER WILLIAMS: There were 12
6 intervention trials finally included.
7 CHAIR VAN HORN: But you did look
8 at some observational trials?
9 MEMBER WILLIAMS: Actually, in the
10 bottom there the 32 clinical citations
11 includes the 12 intervention trials, and then
12 the rest were observational.
13 CHAIR VAN HORN: Okay.
14 MEMBER PEREZ-ESCAMILLA: Are these
15 from the US and abroad?
16 MEMBER WILLIAMS: Yes. English
17 language.
18 MEMBER APPEL: Okay. So the
19 subcommittee yesterday discussed three issues
20 that I think are going to be important ones
21 that this -- this -- the Committee as a whole
22 is going to have to decide on.
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1 The first is the target sodium
2 level, and just to refresh your memory, for
3 the general population, the recommendation in
4 the 2005 Dietary Guidelines was 2300
5 milligrams per day.
6 And in those who are most
7 responsive to the effects of sodium, 1500
8 milligrams per day, and that's middle and
9 older age adults, African-Americans and
10 hypertensives.
11 And as Frank pointed out, you get
12 more bang for your buck going, you know, from
13 -- from around a hundred millimoles or 2300
14 milligrams down to the 1500 milligrams, a very
15 steep part of the dose response curve.
16 This 1500 milligrams applies to,
17 you know, almost 70 percent of the population,
18 so the issue that's going to -- that we're,
19 you know, going to have to make a decision on,
20 probably the biggest one of our subcommittee,
21 is whether we should shift to 1500. The
22 reason for doing it, not doing it, you know,
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1 as Frank mentioned yesterday, even if you're
2 not in one of those high-risk groups, you
3 know, if you -- if you live long enough, you
4 will be.
5 So -- which is good. And it's
6 also, from public health, your point's
7 confusing when you have more than one number
8 out there and what category you should jump
9 into.
10 But that's a big issue. So stay
11 tuned. The second one is whether or not to
12 adjust sodium and potassium goals by estimated
13 caloric intake, which actually came up
14 indirectly in the presentation we heard, and
15 you know, it's difficult, and I'll give you a
16 very concrete example why.
17 Approach the joint effects of
18 sodium potassium. The intake of one affects
19 the biologic responsiveness of the other, and
20 typically, if you're consuming a high sodium
21 diet, a high potassium diet mitigates the
22 effects.
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1 It doesn't eliminate them, but
2 mitigates. And the converse, in setting a low
3 potassium diet, low sodium intake is -- has
4 greater benefit.
5 And the fourth issue is data
6 source on sodium. There have been -- there's
7 pretty limited -- we're going to rely on NCI,
8 I think, to provide the summary tables once we
9 have an idea of what types of -- the format of
10 those tables for all the nutrients.
11 So this -- let me just go over
12 this sodium-potassium adjustment issue. Some
13 people might think this is quite mundane, and
14 on the other hand, it is very important in
15 terms of -- because some of our Guidelines are
16 calorie adjusted and others not.
17 Effectively, you know, the
18 cholesterol recommendation of 300 milligrams
19 per day is an absolute recommendation, not a
20 calorie adjusted recommendation, whereas the
21 saturated fat, a recommendation of ten percent
22 effectively is a calorie adjusted
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1 recommendation.
2 So I've outlined, here is the
3 reasons to calorie adjust. And the first is a
4 very basic -- it's -- it's fact. It's not
5 theorem, it's fact. It's -- the absolute
6 intake of sodium potassium is inextricably
7 linked to caloric intake. The higher your
8 caloric intake, the higher your sodium
9 potassium intake.
10 The second thing is, in real life,
11 we adjust by calories. We all ate, you know,
12 lunch together, some of us ate more, some of
13 us ate less, but it was the similar foods, and
14 if you're preparing foods in a household,
15 you're typically eating the same foods, just
16 more or less of them.
17 So we are doing this in real life,
18 you know, and then in clinical trials, like
19 the trials that I -- the feeding studies I do,
20 when you try to keep weight constant, you have
21 to provide people with a certain amount of
22 calories.
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1 And the sodium levels in those
2 calories are -- are adjusted, and I'll show
3 you that in a second.
4 The reason not to adjust is that
5 there's no clear biologic rationale,
6 especially for sodium, where you need next to
7 nothing, so if you need next to nothing, why
8 do you adjust next to nothing, you know. But
9 there's a practical element to this.
10 So this just gives you a handle,
11 and it's from a clinical trial, but this is a
12 clinical trial that, you know, helped us make
13 these recommendations. So just go to that --
14 let's say the column on the right, what we
15 call the intermediate level.
16 Well at 2100 calories per day, the
17 second row, well, that's where our
18 recommendation came from, 100 millimoles,
19 which is, you know, 2300 milligrams per day.
20 But if you were eating a diet with 1600
21 calories, well, that intermediate level --
22 that diet provided 80, but if you were active,
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1 physically active on the bottom row, somebody
2 who consumed 3100 calories per day, that
3 intermediate level was 140.
4 Okay. So that's in part why, you
5 know, we learned, you know, in the -- from the
6 first speaker that -- that it was difficult,
7 in young men, to reach the sodium goal
8 because, you know, young men typically have
9 higher levels of caloric intake, and it's
10 going to be difficult for them to achieve the
11 numbers.
12 So you know, how we approach this
13 is -- is not totally clear to me at this
14 point. But I think, you know, the -- I think
15 this is an important issue.
16 The research question on
17 potassium, what are the health effects of --
18 or what are the effects of potassium on
19 health. This is our third -- third priority
20 -- I guess the third tier. We are on hold. I
21 think the -- we started the literature
22 searches, but I'm not sure the abstraction's
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1 being done.
2 So, I think that's about it. That
3 might be the last slide.
4 CHAIR VAN HORN: Okay. Xavier.
5 MEMBER PI-SUNYER: Pi-Sunyer. Do
6 you think that part of the reason obese people
7 have more hypertension is because they are
8 eating more calories and therefore, getting
9 more sodium?
10 MEMBER APPEL: Yes. I think part
11 of it, and I -- I don't have -- I have a slide
12 from one of our feeding studies where we
13 actually have the 24-hour urine excretion, in
14 non-overweight, overweight and obese
15 individuals, and the number of people that
16 were, you know, who were under 2300 milligrams
17 per day in terms of urinary excretion was
18 almost nothing in the people who were obese
19 because, you know, they're consuming, you
20 know, 3,000 calories per day whereas the
21 nonoverweight person, you know, is -- it's not
22 -- we're talking about averages here, of
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1 course, but you know, their caloric intake is
2 less.
3 So, you see a very graded
4 response. So, that's part of the reason, and
5 then the other reasons that obese people might
6 have more in -- the literature on whether the
7 responsiveness to sodium is more -- whether
8 they are more salt-sensitive, obese are more
9 salt-sensitive than non-obese is a bit mixed.
10 We didn't find it in our feeding
11 studies, but others have, so that's -- I think
12 there are other factors besides salt.
13 CHAIR VAN HORN: Rafael.
14 MEMBER PEREZ-ESCAMILLA: Yes.
15 Larry, we have conducted focus groups in our
16 Latino community in Connecticut and several
17 times the comment about the Food Pyramid has
18 been where is the water, why there isn't a
19 glass of water, why there is no message about
20 water being communicated to us in that
21 pyramid.
22 So, the question is: Do you think
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1 there is scientific justification to display
2 water to the people, water in the Food
3 Pyramid.
4 MEMBER APPEL: Yes. Larry Appel
5 again. We -- in the 2003 IOM report, you
6 know, we explored the need to, you know, the
7 eight glasses per day and whether there's need
8 for what we call purposeful drinking, just to
9 -- and the bottom line was that people,
10 through just their usual activities, without
11 even thinking, you know, are going to meet
12 their normal fluid -- their fluid
13 requirements.
14 What I think we didn't deal well
15 with, and which I think is going to be
16 important, is the caloric issue, where when we
17 talk about beverages, that -- or fluids that
18 people consume, we need to integrate this with
19 the broader theme of controlling calorie
20 intake.
21 And that probably is sort of a
22 back door approach to recommending water as
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1 well as other beverages without calories.
2 MEMBER WILLIAMS: Right. I would
3 like Joanne to comment on this, because this
4 definitely gets at the cross-cutting issue
5 that we discussed yesterday in that group.
6 MEMBER SLAVIN: Actually, I wanted
7 to ask another question, too. Is that okay?
8 Yes, we discussed yesterday
9 because of the interest in water and also
10 weight and obesity. So, I think both of our
11 Committees will be thinking more about water,
12 and how to assess that on different fronts.
13 But my question had to do with the
14 evidence-based review for sodium. I see, like
15 for kids going back to 70's, but for the
16 adults, what kind of data is there, and what's
17 the effort? Is that going to work in that
18 framework at all, or are there --
19 MEMBER APPEL: Well, this is one
20 where, you know, we -- the 2005
21 recommendations were largely based on the IOM
22 report which was completed just about the same
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1 time as the Guidelines.
2 So, you know, my -- the outcome
3 variables that we are going to look at are new
4 studies with blood pressure, cardiovascular
5 disease, kidney disease. We have a broad net
6 stroke.
7 But, you know, I stayed recently
8 on top of this literature. I do get surprised
9 every once in a while, you know, with
10 something I haven't, you know, -- that I
11 haven't -- wasn't aware of.
12 But, I'm not sure there's going to
13 be anything major. I think, though, one area
14 where we -- where I'd like to just spend a bit
15 of that for -- to document, is the cohort
16 studies.
17 The problem, though -- these are
18 cohort studies. They are not clinical trials,
19 necessarily, with clinical cardiovascular
20 outcomes, and it's a very confusing literature
21 with a lot of methodologic pitfalls, but I
22 think it needs to be summarized because people
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1 are misusing that literature in ways that --
2 that, you know, -- but anyway, I think we need
3 to review that literature, and so I will be
4 doing that as well as I think the more
5 relevant outcome variable, which is just blood
6 pressure.
7 CHAIR VAN HORN: Right. And I
8 think if you could just elaborate a bit on
9 that. I think, you know, the issue of sodium
10 and intake being, you know, already higher
11 than what the biologic requirement is by quite
12 a bit.
13 You know, there's no fear about
14 limiting to 1500 milligrams from what I'm
15 hearing you say, what Frank said yesterday.
16 The point is that if, again, if
17 you're not hypertensive, you're possibly
18 prehypertensive, and the data show from the
19 OMNI Heart, as well as the DESCG trials,
20 sodium trials, that even normotensive
21 individuals benefit with blood pressure
22 lowering with a reduced sodium intake.
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1 MEMBER APPEL: Yes. And now we
2 also have the trials hypertension prevention.
3 It shows long-term follow-up with reduced
4 clinical events. But, that's only -- you
5 know, there are only a few of those trials.
6 In contrast, there are many more
7 epidemiologic studies but, you know, it's a
8 mine field in terms of methodologic issues,
9 but I think it needs to get summarized and we
10 need to just present it just for completeness
11 sake.
12 CHAIR VAN HORN: Larry, the other
13 thing, and then Tom. The other thing about
14 this issue in terms of the sodium potassium
15 relationships, it would appear to me that the
16 very recommendation to increase dietary
17 sources of potassium, which would be fruits,
18 vegetables, et cetera, would actually
19 accomplish both an increase in potassium and a
20 lowering of sodium if, in fact, those foods
21 are increased in the diet. Correct?
22 MEMBER APPEL: Correct. But a lot
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1 depends on processing. So, you know, it's how
2 you prepare your fruits and vegetables.
3 MEMBER PEARSON: Since we have a
4 couple of minutes, I wonder if I could raise
5 this issue relative to the evidence, and with
6 the water and electrolyte group, I think this
7 came up and it was kind of one of our
8 decisions, and that is to -- with the NEL
9 search is to really prioritize the randomized
10 trials and then the prospective observational
11 trials, and maybe not spend a lot of time on
12 cross-sectional and case control studies
13 because of the -- particularly with a
14 lifestyle variable like diet, their proneness
15 to really just irretrievable confounding.
16 And so this -- with Larry's --
17 with our group with Larry, we raised this
18 initially, but I think this is what crept into
19 the fatty acid group and many of the other
20 groups, but I think one of the reasons to
21 raise this is that we wouldn't want to have,
22 kind of heterogeneity of evidence, depending
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1 on what nutrient you were talking about.
2 So, I raise that issue now,
3 because it came up, and I think the sodium
4 literature is a good example that there are
5 enough trials to really -- even in pediatrics
6 to get down to a real core of science that are
7 really going to be difficult to trump with,
8 say, cross-sectional data.
9 I don't know if maybe Larry could
10 comment on that.
11 MEMBER APPEL: Yes. I think that,
12 you know, it's -- when you have a mature
13 field, you can basically deal with trials and
14 cohort studies but if, depending -- I think
15 it's not -- I hesitate to be a hundred percent
16 universal on this one, because I think there's
17 going to be some really important research
18 questions where the database isn't as mature,
19 and we're going to just have to deal with
20 cross-sectional data.
21 But be right up front and center
22 that, you know, causality is going to be --
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1 inferences are going to be tenuous, especially
2 if there is, you know, if there already are
3 public health messages so that you get these
4 weird directions, directionality, like it's a
5 -- you know.
6 MEMBER PEARSON: But there is a
7 NEL resource issue as well, in terms of the --
8 where to start, et cetera, so that we use that
9 valuable resource wisely.
10 MEMBER APPEL: Yes. I guess I've
11 already done that to some extent, you know,
12 with the searches that have crossed my desk.
13 You know, if it just says "We evaluated," I
14 mean, maybe we should make this more explicit
15 -- and I know this is not a Science Committee
16 discussion, but if you come across a cross-
17 sectional study, you know, you have to have a
18 good reason to select it as opposed -- because
19 that's going to require NEL
20 time to retrieve and abstract and then
21 catalogue.
22 You know, most of the time I just
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1 -- I did not consider those relevant to the
2 question.
3 CHAIR VAN HORN: Right. And I
4 agree with you. I think we've seen already
5 that where the literature is mature and we
6 have the luxury of selecting among randomized
7 control trials, and that's where we'll go.
8 But obviously the variability
9 across these topics does require a little bit
10 of, you know, selection related to that.
11 Mim.
12 MEMBER NELSON: Yes. A question
13 about understanding that -- this is Mim Nelson
14 -- that probably our pallet has changed around
15 salt, because there's just been so much salt
16 in the diet.
17 But, irrespective of that, is it
18 -- thinking about -- I want to make sure we
19 don't forget about the pleasure of eating and,
20 you know, sort of how wonderful it is.
21 And is it possible to have a
22 palatable good-tasting diet at 1500 milligrams
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1 of sodium?
2 MEMBER APPEL: Yes.
3 MEMBER NELSON: Okay. A good job.
4 Then you answered my question. I just think
5 it -- I want to make sure we don't propose
6 something that's just, you know, tastes
7 terrible.
8 MEMBER APPEL: No. I mean, I
9 think that we've done, you know, studies.
10 Others have, too, of -- you know, there's a
11 lot of -- you know, there are populations in
12 the world that eat next to nothing. You give
13 them sodium and they say this tastes awful.
14 MEMBER NELSON: Yes. Right.
15 MEMBER APPEL: You know, so -- I
16 mean, our pallets are very accustomed to this.
17 So, you know, I guess, you know, we're I
18 guess, you know, setting what the standard is.
19 The reality we are going to never,
20 you know, and in my lifetime, if we get to
21 2300 milligrams I'd be a very happy person,
22 but 1500 probably is not -- you know, meat,
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1 there's going to be a huge period of time for
2 industry to catch up and make our food
3 flavorful.
4 And I think they've done a --
5 they're doing it. Yes. And I think they've
6 been successful.
7 CHAIR VAN HORN: Xavier.
8 MEMBER PI-SUNYER: Pi-Sunyer. If
9 you go to 1500 calories, what percentage of
10 that is added salt versus inherent in foods?
11 MEMBER APPEL: That is a great
12 question. I think most of it still will be
13 inherent in foods.
14 MEMBER RIMM: Should we have it at
15 the table or do we add it --
16 MEMBER APPEL: Add it at the
17 table. Okay.
18 MEMBER PI-SUNYER: I mean, I
19 think that makes an impact on whether you're
20 going to eventually express this per calorie
21 or not.
22 MEMBER APPEL: Well, you know, the
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1 problem with this, we have so little data on
2 actually sources, you know, that's good. You
3 know, there's this pie chart that everybody
4 shows that's -- you know, the study that's
5 based on around 60 people, that 70 percent of
6 sodium comes from processed food.
7 That's -- that really hasn't been
8 updated, there hasn't been good data to
9 reflect the change in our habits, again, the
10 sodium from restaurants.
11 My instincts are that it's still a
12 huge amount from processed and very little
13 added by individuals. But I think this is one
14 of -- I was talking to Robert Post a few
15 months ago, and I said, "Well, that would be a
16 good use of stimulus money."
17 Over two years figure out, you
18 know, currently what our -- you know, what the
19 distribution of sources of sodium is and do it
20 in a rigorous way, because we really -- that
21 data is missing.
22 MS. McMURRY: Am I on? This is
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1 Kathryn McMurry. I just wanted to point out
2 to you and the rest of the Committee that
3 there are some tables of top food sources of
4 nutrients, of certain selective nutrients in
5 the last tab of your notebooks, including
6 energy, sodium, choline, fatty acids.
7 I don't believe it covers
8 specifically processed versus other foods, but
9 -- Table 2 is sodium.
10 CHAIR VAN HORN: Thank you.
11 That's helpful.
12 MEMBER SLAVIN: Am I on?
13 CHAIR VAN HORN: Yes. Joanne.
14 MEMBER SLAVIN: Joanne Slavin. I
15 have two questions. The first is, I think
16 grain products are a big contributor to sodium
17 intake, so as we recommend, some of the
18 recommendations saying more grains, more whole
19 grains, it's hard to make those products
20 really low-sodium, and the other question I
21 have or concern is typically sodium, sugar
22 bounces around.
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1 So you take sodium down in a
2 product and then sugar, a lot of times has to
3 go up just for taste.
4 So, in being really restrictive on
5 sodium, I think we can drive other issues that
6 we might not like the results of.
7 MEMBER APPEL: Yes, again, so far.
8 But I think that even on -- if you go to the
9 supermarket you still see some, you know,
10 whole wheat bread that does have, you know,
11 that also is marketed as, you know, 20 to 25
12 percent less than other products.
13 I think -- I don't remember what
14 line, but you know, part of the problem with
15 this field is that there are -- you know, that
16 our recommendations drive, you know, drive the
17 industry, you know, and so -- you know, so to
18 some extent we need to -- we do need to take
19 into account what's currently available but,
20 you know, there are -- there seems to be
21 incredible creativity among the food
22 manufactures on accomplishing our goals, not
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1 just sodium, but others, too.
2 CHAIR VAN HORN: I have personal
3 experience from research that we did with
4 middle school aged children that, you know,
5 even in as short a time as three to four
6 weeks, reduction of sodium in their natural
7 daily intake results in not only reduced
8 intake, but then the inability to go back to
9 eating as much sodium as was previously being
10 consumed, because it now tastes so salty
11 compared to what it did when it was reduced.
12 So, I wonder, Christine, if you
13 wouldn't mind, you know, you did a fabulous
14 job of reviewing the literature, but in terms
15 of, you know, trying to move forward in terms
16 of the children, especially and trying to
17 change those taste perceptions that work
18 within, you know, what's a normal level of
19 sodium, you know, are there things that you
20 can think of that we should be addressing?
21 MEMBER WILLIAMS: There was a
22 recent article about the sodium in school
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1 lunches, and it's still relatively high, and
2 that's certainly one area that we could work
3 on to gradually reduce in a step-wise manner
4 the amount of sodium, and I think that would
5 help with children to get them used to foods
6 that are less salty.
7 And there are other ways that --
8 venues that we could do the same.
9 CHAIR VAN HORN: Cheryl.
10 MEMBER ACHTERBERG: Given the lack
11 of literature and data sets that I keep
12 hearing, everyone referred to it. It seems
13 like this is another moment where we might
14 want to do some modeling, at least in terms of
15 when we get the set of recommendations we
16 think we want to have, eat more of this, eat
17 less of that, however it turns out, that we
18 should model that to see what impact it has on
19 sodium levels, and then perhaps consider
20 adjustments accordingly.
21 Since we don't have the evidence
22 base, and we do intend to do some modeling in
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1 some other areas, I think we could justify
2 doing this piece as well.
3 CHAIR VAN HORN: Good. Rob.
4 DR. POST: This is Rob Post. I
5 have a question, and it's for Larry.
6 At the IOM Committee meeting on
7 strategies to reduce sodium, has there been
8 information presented? I thought ILSI
9 presented information that updated the rather
10 old data on sources of sodium.
11 MEMBER APPEL: Yes. That's based
12 on an unpublished analysis of NHANES 3. Okay.
13 And I don't really have much more than the
14 presentation.
15 I thought that, you know, for the
16 Committee, you know, if we -- there are a few
17 issues. One is, I think we want to present
18 our data in a certain way. You know, we
19 wanted to look at food intakes by weight by
20 not just gender and age, but by weight status,
21 you know, and to do this in a uniform
22 presentation.
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1 So, I felt that we probably would
2 wait for the format and then use the NCI data
3 to address issues of top ten contributors and
4 other things that would be -- would -- but it
5 would be sort of like in the same sort of
6 cookie-cutter mold as everything else that
7 we're looking at.
8 MS. McMURRY: Just to point out,
9 the data in your notebooks is based on the
10 NHANES 2005-2006 data, using the NCI
11 methodology.
12 MEMBER APPEL: I think it would be
13 -- you know, I don't know who's in charge of
14 this, but it would be useful to actually get
15 those tables, you know, the way we want them,
16 and get into -- because I think that would
17 inform us for, you know, in the process here.
18 CHAIR VAN HORN: Yes, right.
19 Well, with that, actually, that will be a good
20 segue to the next group, which will be the
21 nutrient adequacy group, but we will first
22 take a break, and then Shelly will bring us up
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1 to date on that and talk more about the
2 modeling issues, because I think that's really
3 relevant.
4 So, 15-minute break. Thank you.
5 (Whereupon, the above-entitled
6 matter went off the record at 10:11 a.m. and
7 resumed at 10:29 a.m.)
8 CHAIR VAN HORN: All right.
9 Welcome back. And we're ready to launch into
10 the nutrient adequacy subcommittee.
11 Shelly.
12 MEMBER NICKOLS-RICHARDSON: Okay.
13 This is Shelly Nickols-Richardson, and this
14 is an update for nutrient adequacy.
15 The Committee members are --
16 appear on the screen, and I do want to
17 acknowledge Trish Britten with USDA and Eve
18 Essery at HHS who have been very instrumental
19 in keeping us moving forward with our work on
20 the subcommittee.
21 Are you going to click for me?
22 Okay. So, just a few slides that update what
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1 our questions are and how we've prioritized
2 those questions, so as a refresher, our
3 priority one questions are looking at within a
4 fixed energy intake, what dietary patterns is
5 or are associated with achieving recommended
6 nutrient intakes.
7 As things stood from the last
8 meeting, we also had the question of what
9 dietary patterns is or are associated with
10 positive health outcomes, and I'll provide an
11 update related to that question.
12 What environmental factors related
13 to diet are associated with achieving
14 recommended nutrient and food group intakes,
15 what individual behaviors related to diet are
16 associated with achieving recommended nutrient
17 and food group intakes. So, those are our
18 priority one questions.
19 Okay. And our priority two
20 questions, then, are what nutrients are most
21 likely to be consumed by the general public in
22 amounts low enough to be of concern, what food
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1 groups are most likely to be consumed by the
2 general public in amounts -- I think -- yes,
3 low.
4 Sorry about that. Low enough -- I
5 think we know how we're eating, but low enough
6 to be of concern, and then what nutrients and
7 food groups are most likely to be consumed by
8 the general public in amounts high enough to
9 be of concern.
10 And I'll mention why that was sort
11 of inserted into this Committee's work. Also,
12 for our priority two questions, looking
13 specifically at folic acid, the overall or
14 overarching question is folic acid intake in
15 the US post-fortification era related to any
16 healthy or unhealthy outcomes.
17 And then our subquestions under
18 this include: Is the serum folic acid status
19 of women of childbearing age related to neural
20 tube defects? Is the serum folic acid status
21 of men and women related to cardiovascular
22 disease, strokes, colon cancer and
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1 precancerous polyps?
2 And then how do folic acid intake
3 levels from foods after mandatory
4 fortification and supplementation affect serum
5 folate levels and help outcomes?
6 Another priority two question is
7 related to vitamin D, and is an increase in
8 vitamin D intakes above current consumption
9 levels associated with positive health
10 outcomes?
11 Then we do have some priority
12 three questions. These include our special
13 nutrient recommendations needed for certain
14 subgroups. These are really being updated
15 from the 2005 reports, so, specifically
16 looking at iron in women, B12 in elderly,
17 vegetarians, pregnant women and smokers.
18 And then another question that has
19 come up or an area that it appeared that we
20 needed to address from the Science Review
21 Committees and from presentations from the
22 last overall DGAC meeting was related to
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1 nutrient supplements.
2 This also came up when we had our
3 webinars and our conference calls related to
4 folate as well, and some of the
5 supplementation issues specific to folate.
6 Another priority three question
7 is: Has the nutrient composition of food
8 significantly changed since 2005, in a manner
9 that impacts nutrient adequacy, and then, is
10 there any evidence that nutrient bio-
11 availability has significantly changed due to
12 alterations in the nutrient matrix of foods,
13 including things like food fortification or
14 functional foods.
15 Okay. So, where we exist now with
16 our questions, and just the status update in
17 looking at dietary patterns, nutrient intakes
18 and health outcomes, we had some discussion in
19 our subcommittee on our calls, looking at the
20 process of the NEL searches versus data and
21 modeling of really just the modeling analyses
22 that could be done looking at nutrient
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1 composition within fixed energy intakes.
2 After sort of several rounds of
3 where do pieces fit within this subcommittee
4 related to, say, carbohydrate protein
5 subcommittee, energy balance subcommittee, I
6 think we've finally come to a consensus that
7 what the nutrient adequacy subcommittee will
8 really focus on, is the question of modeling
9 and using that as a procedure for looking at
10 the fixed calories, and can we meet nutrient
11 needs related to the fixed energy intake.
12 So, looking at range of patterns
13 of intake, diet quality, within those patterns
14 and within fixed calories, rather than going
15 through NEL searches specific to some of the
16 intervention trials related to health
17 outcomes, which will now be shifted to the
18 other subcommittees.
19 Our priority for looking at
20 nutrients is within the context of foods, so
21 again, keeping in mind that nutrients come
22 within our food system and really looking at
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1 the patterns of foods that would be able to
2 meet the nutrient recommendations.
3 The question about water, because
4 that came up in the -- I think it was the
5 carbohydrate protein subcommittee, and then
6 under energy balance, I sat in on those
7 sessions yesterday, and it does look like we
8 can model water into the diet as we do the
9 modeling process.
10 This question actually came up in
11 relation to discretionary calories, rather
12 than sort of the water, per se, sort of
13 purposeful drinking kinds of questions.
14 So, I think in terms of linking it
15 to discretionary calories and what do you do
16 when you substitute water for sugar-sweetened
17 beverages and other beverage choices, we can
18 do that in that context, but if it links to
19 sort of the water purposeful drinking context,
20 we can add that or contribute that to the --
21 that particular subcommittee, looking at
22 sodium and fluids.
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1 And again, our role would really
2 be looking at diet quality, so again,
3 depending on what beverage is being
4 substituted, and where water fits into the
5 overall diet, what does that do in terms of
6 nutrient recommendations and meeting those
7 recommendations.
8 The priority of the dietary
9 patterns for nutrient intakes really looking
10 at that link to health, we will focus on maybe
11 just one or two, probably things like
12 breakfast intake because we do know that
13 breakfast intake as a pattern of eating or a
14 way of eating does connect to certain
15 nutrients such as calcium, vitamin D, for
16 example, and certain types of foods such as
17 milk, fluid milk and whole grains, for
18 example.
19 But we're not going to focus on
20 really those health outcomes. Those will be
21 moved over to carbohydrate, protein, and I
22 think energy balance subcommittee will really
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1 address the health-related outcomes looking at
2 dietary patterns.
3 Okay. So, then, with the
4 environment and environmental factors and
5 nutrient food group intakes, again, much of
6 this will be integrated with the carbohydrate
7 protein subcommittee and the energy balance
8 subcommittee.
9 So, really, those systematic
10 reviews will be housed under those two
11 subcommittees, and what we will do within sort
12 of nutrient adequacy, then, is having some
13 supporting or include supportive statements
14 within our section of the report that really
15 link the reader to or the information to those
16 other subcommittees.
17 So, the environmental factors,
18 individual behaviors, so we can go onto the
19 next Committee. Yes.
20 MEMBER SLAVIN: You need to move
21 the slides.
22 MEMBER NICKOLS-RICHARDSON: I'm
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1 sorry. I'm sort of doing it, and he's sort of
2 doing it, so -- okay. Okay. We're on
3 environmental factors, and actually this slide
4 will look very similar to the next slide. So,
5 when we think about environmental factors, and
6 then in individual behaviors -- and let's go
7 back one.
8 There we go. So, the
9 environmental factors, the individual
10 behaviors, this sort of looks very similar, so
11 what our subcommittee will really be doing is
12 just providing supportive statements that then
13 connect readers or connect the science,
14 really, to the energy balancing carbohydrate,
15 protein subcommittee.
16 So, we won't be leading those NEL
17 searches. The other subcommittees will be
18 doing that. Okay. Nutrients of concern.
19 When we move to sort of our second priority,
20 questions or our level two priority questions.
21 Nutrients of concern. There were
22 some questions about what is the definition of
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1 a shortfall nutrient? How do we really
2 identify or establish some criteria for what
3 constitutes a nutrient of concern, and so now
4 we have some information that was collected
5 and provided by Trish and Eve, and so we have
6 more information that will help us define what
7 shortfall means, and then how we would
8 establish these nutrients of concern.
9 So, the criteria that we have
10 right now that we're working with will include
11 usual intake data to look at sort of those
12 shortfall nutrients. We have information from
13 the last overall Committee meeting that were
14 provided about usual intakes of Americans or
15 people residing in the United States.
16 Also connecting that to functional
17 indicators, then, in using the IOM reports as
18 guides for what are some of the functional
19 indicators or serum concentrations or health
20 outcomes that would identify that there's
21 something linked to a shortfall nutrient, and
22 then what are the health outcomes?
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1 So, what are the nutrients that
2 are really of public health significance? So,
3 if there are nutrients that we might not be
4 meeting the recommendations in the diets, but
5 the functional outcome or the health indicator
6 really is not a public health concern or
7 doesn't have a lot of significance, then we
8 won't focus on those nutrients as much as we
9 will on those where there are clearly
10 established public health implications.
11 We've identified this area as a
12 priority for having the first draft of the
13 text ready by the May 29th deadline, so we'll
14 be working on that pretty diligently here in
15 the next month.
16 For food groups of concern, again,
17 trying to define what is the definition of
18 that, what does that actually mean? So, sort
19 of a same process here, looking at usual
20 intakes of shortfall food groups from
21 information that was provided and from the
22 national database is looking at food intake,
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1 trying to link that, then, to the nutrients
2 that are related to those foods or nutrients
3 that might not be met because of the foods
4 that are being consumed or not being consumed
5 and, again, linking this to health outcomes.
6 So, there needs to be some, you
7 know, pretty significant evidence, or some
8 significant implication for what the health
9 outcome is for foods that are not being met.
10 We did add sort of this piece
11 about the SoFAAS, in terms of what the
12 nutrient adequacy subcommittee will do is that
13 we'll really just look at this within the
14 context of nutrient shortfalls and dietary
15 patterns.
16 But then, in terms of how this
17 links to health outcomes, this will be
18 related, then, to the other subcommittees, so
19 the solid fats would be part of the health
20 outcomes would lie or reside within the fat
21 subcommittee, the alcohol within that group,
22 and then the added sugars really within
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1 carbohydrate protein.
2 So, all that we would be doing is
3 just identifying from usual intakes and
4 dietary patterns that there are these issues
5 related to the SoFAAS, and then the health
6 outcomes would come within those other
7 subcommittees.
8 For folic acid in health outcomes,
9 the subcommittee did have a webinar
10 presentation with Joel Mason. His
11 presentation really focused on the question
12 about colon cancer, precancerous polyps and
13 folate intake, post-fortification.
14 We had a conference call then with
15 Lynn Bailey who we asked to focus on the
16 neural tube defect question. In relation to
17 folate, Dr. Bailey also presented some
18 compelling evidence related to folate
19 supplementation, intake and serum folate
20 concentrations and changes that have occurred
21 post-fortification.
22 So, I think the Committee is now
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1 feeling quite comfortable with recommendations
2 that could be made here. We have a search and
3 sort plan that has been completed. The
4 articles have been looked at and so some of
5 those are under review, and we've -- we're
6 anticipating a June deadline for the first
7 draft related to the folate questions.
8 For vitamin D, again, knowing that
9 the AHRQ report will be coming out June, end
10 of June-ish or June sometime, and that there
11 will be a public meeting of the IOM Committee,
12 either late July or early August and hoping to
13 have either subcommittee members attending
14 that public meeting or other staff from HHS
15 and USDA attending that so that we'll have as
16 much information as we can that's in a public
17 format that we could use.
18 Heavily using the AHRQ report when
19 it's available to really come up with our
20 interpretation of what that information is
21 showing us in terms of vitamin D and where we
22 need to be with recommending foods related to
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1 vitamin D intake.
2 The pattern of protein intake was
3 a question that we had been looking at, but
4 we've now decided that this really fits better
5 with the carbohydrate protein subcommittee,
6 and so those questions have really been moved
7 there, and working with Joanne in that
8 subcommittee if there are things that are
9 needed from nutrient adequacy.
10 But, largely the protein sort of
11 patterning and overall macronutrient
12 patterning will fit within that subcommittee.
13 Then, the special populations and
14 the nutrient questions specifically related to
15 iron, B12, nutrient supplements, I think we're
16 maybe a little bit further along with the B12
17 question.
18 We believe that there really is
19 only a minimal review of literature that will
20 be required to update the 2005 report, and in
21 anticipation of having the first draft of that
22 particular piece of our text done by the end
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1 of May.
2 So then, the question about
3 nutrient supplements that has arisen, I think
4 we can fit this into nutrient adequacy, sort
5 of looking at where do we meet recommendations
6 for the overall diet, but then looking at some
7 of the special populations that it might be
8 advisable to recommend supplements for certain
9 populations.
10 So, looking at some of the
11 literature on that, and making recommendations
12 where that seems to be appropriate.
13 In terms of nutrient composition
14 and bioavailability, this is on hold. I
15 believe that where we are with this now is
16 that because we believe that probably our food
17 intake information, usual intake which
18 encompasses much of those foods that have now
19 become functional foods and so on, that with
20 that information we'll be able to address this
21 sort of indirectly, and not really take time
22 to address this directly at this point, and
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1 sort of keeping this piece till the end, and
2 if it's needed, to do some of the nutrient
3 composition questions.
4 If we need to include those, we'll
5 do that at the end, but hopefully through the
6 other work that we have with the subcommittee,
7 some of this will be evident in the modeling
8 and the information there.
9 Okay. So, I think that is
10 everything we wanted to cover. The question
11 of discretionary calories and this term has
12 come up.
13 We do plan to address sort of the
14 definition of that, and introduce that in the
15 introduction to the nutrient adequacy text for
16 our subcommittee, but I think maybe that might
17 be a piece of discussion, how would you like
18 nutrient adequacy to handle discretionary
19 calories if you want us to address that at
20 all, or if that will be something that really
21 comes up in energy balance or some of the
22 other macronutrient-related subcommittees.
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1 CHAIR VAN HORN: Okay. Open for
2 discussion. Thank you Shelly. Xav.
3 MEMBER PI-SUNYER: I think -- this
4 is Pi-Sunyer. I think you should include
5 discretionary calories as an item in your
6 deliberations because I think it is important,
7 and it does -- it does impact on energy
8 balance, but we are not specifically dealing
9 with it because it really deals so much with
10 nutrient adequacy.
11 So, I think it would be very
12 helpful, and it would be complementary if you
13 did that.
14 CHAIR VAN HORN: Yes. I just
15 think -- well, those of us on the Committee
16 are familiar with this, maybe not so subtle
17 issue that Shelly has been raising here, is
18 that this group will be depending much more on
19 the whole modeling concept of how to actually
20 achieve nutrient adequacy working with foods
21 and recommendations for food patterns that
22 will achieve that end.
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1 And so, I think that the idea of
2 discretionary calories and exactly how that
3 should happen makes total sense to fit within
4 that subcommittee as well.
5 And, in fact, I don't know about
6 the rest of you, but I found fascinating --
7 Thank you very much, Kathryn for pointing it
8 out -- the data at the end of our booklets
9 here related to 2005-6 NHANES data, and I did
10 not recognize -- I don't know if you all did,
11 that grain-based desserts are now our number
12 one contribution to calories in this country.
13 Grain-based desserts. What is
14 that? I looked to see what it includes.
15 Cakes, cookies, doughnuts, pies, crisps,
16 cobblers and granola bars. All right. That's
17 the number one contributor to our energy
18 intake.
19 Second is yeast breads, and then
20 third is chicken. And fourth is soda and, you
21 know, the liquid calories that we were talking
22 about.
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1 So, I definitely hear what you're
2 saying as far as the discretionary calories
3 because I think most of us would consider
4 those food groups part of that, and where and
5 how can a person achieve all their nutrient
6 needs, include some of these foods, but not as
7 their number one contributor to caloric
8 intake.
9 Larry.
10 MEMBER APPEL: Okay. I'll just
11 comment -- make one comment about that Table
12 1, because it's important. Dariush
13 Mozaffarian also analyzed NHANES, and it's
14 really important to stratify this by age,
15 because he found that soda is number one
16 source of energy in children, and so we really
17 need to make sure that we display this across
18 the spectrum of age, because it's probably
19 going to be different.
20 My -- I don't see a question that
21 I think really drove some of the
22 decisionmaking in 2005 and I'll just -- it may
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1 not even be a question, but there was this
2 modeling approach that was done and it
3 occurred, and many of us learned about it at
4 the very end, but -- so, in the end they said
5 well, these are the patterns that the US data
6 developed and that meet the Dietary
7 Guidelines.
8 And then they said, okay. Well,
9 what real -- what dietary pattern out there
10 actually meets these goals as well. And then
11 it was actually very -- you know, there
12 actually weren't a lot of patterns, at least
13 at this point we hadn't -- that actually
14 started to display the nutrient intake in
15 sufficient detail that you could say, "Oh,
16 well, here's a diet pattern that actually
17 meets nutrient intake."
18 But, at that point, you know, we
19 -- I made people aware, well, the DASH diet
20 does, you know, so it was a backhanded
21 addition, you know, that occurred at the very
22 end.
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1 And so, what I'm thinking that's
2 actually quite important, that in terms of
3 where we might go, is just -- well, what about
4 the Mediterranean dietary pattern, you know.
5 And I think that one of the things
6 the Committee can do, and I'm not sure it's an
7 exhaustive literature search, is to say, okay,
8 well, once we've defined it, now, what do we
9 know about the nutrient composition and are
10 there shortfall nutrients.
11 Because otherwise -- I mean, one
12 of the big changes we could make, you know,
13 from this Committee is that we say, "Well, the
14 Mediterranean Diet is a good dietary pattern
15 and meets all the nutrient goals, but we need
16 to have data, and I don't know -- better to
17 start soon rather than later on this one, and
18 we can probably identify other patterns, you
19 know, can -- you know, Southeast Asian dietary
20 pattern meet all the goals, too.
21 MEMBER ACHTERBERG: I think that's
22 exactly what the Committee is determined to do
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1 and front-end it instead back-end it, and
2 define which dietary patterns do we want to
3 evaluate at specific calorie levels.
4 So, can we meet it at 1500
5 calories? Can we meet it at 2000? What's it
6 look like at 2500? So, we really are modeling
7 and evaluating these things in a way that will
8 connect back to some of the decisions and
9 information being evaluated in the other
10 subcommittees.
11 MEMBER APPEL: This is Larry
12 again. But is it a modeling exercise, or is
13 it trying to find out in the literature, are
14 there -- are there people that are actually
15 consuming these diets.
16 You know, it sort of -- it seems
17 to be both. You're right, Linda, yes.
18 MEMBER ACHTERBERG: It's a little
19 bit of both, but as we have done some
20 preliminary work, looking at what the
21 literature has, it doesn't answer all the
22 questions that we want to answer.
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1 So we're convinced we have to do
2 modeling, especially if we want to look at a
3 range of different dietary patterns. The
4 literature is spotty, and especially if we're
5 trying to connect back to specific calorie
6 levels, that's where it really has a gap.
7 MEMBER PI-SUNYER: Yes. This is
8 Pi-Sunyer. I think this is one area where
9 maybe, looking at other literature besides
10 English literature might be helpful, certainly
11 in the Mediterranean diet, there's a lot of
12 work in Italy and Greece and France and Spain
13 that have looked at some of this and some of
14 that is not in the English literature, but is
15 pretty good data, particularly, the French.
16 MEMBER NELSON: This is Mim
17 Nelson. Just to add on, I think, you know,
18 hearing Dr. Sacks yesterday looking at the
19 literature more, it's clear -- it's like this
20 wide range that when you're looking at the
21 macronutrients there's a wide range that
22 works.
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1 It's -- the tricky part is all the
2 sort of getting the whole market basket of
3 micronutrients into it. So, I think that it
4 needs to come from both -- we didn't want to
5 limit to any just sort of specific diets, we
6 wanted to -- they might be a starting place,
7 but that there's probably a whole other range
8 that's not named "diet," you know, that
9 Americans may follow.
10 But, one question I have is have
11 we in this Committee -- sorry, I'm on the
12 Committee, so I should know this answer, but
13 we haven't explicitly talked about which fixed
14 calorie levels we wanted to address, and I
15 think that, as a Committee, I think we need to
16 come up with -- are we going to do it for
17 1600, 2000, 25 -- or what's the level we're
18 going to do it at, because I think that will
19 be -- then that's how the modeling then goes
20 from there.
21 MEMBER NICKOLS-RICHARDSON: And
22 this is Shelly Nichols-Richardson. That is a
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1 very good question, and yesterday I spent some
2 time with Trish, and she actually opened up
3 her modeling spread sheets, if you will, and
4 it can run from twelve -- or a thousand, a
5 thousand calories all the way up in 200-
6 calorie increments.
7 So, the modeling can be done for a
8 wide range of calorie levels, and I did ask
9 the question: Where are the odd numbers? And
10 she said that, you know, you can interpolate
11 that, that there's really not a need to do
12 that, but we can look all across the board of
13 energy level.
14 MEMBER ACHTERBERG: Cheryl
15 Achterberg, adding a comment. Being sensitive
16 to the fact that lots of people are on weight
17 loss diets, so we may not want to stay within
18 the specific calorie level recommended by
19 different age groups right now, but also look
20 at some other options, if somebody is on a
21 calorie restricted diet, then what can they
22 accomplish.
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1 MEMBER PI-SUNYER: The fact is
2 that very few people are on calorie-restricted
3 diets. They think they are, but they're not.
4 CHAIR VAN HORN: That is the
5 problem. I think we'll ask Eric first, and
6 then --
7 MEMBER RIMM: Eric Rim. I just
8 had two questions. One is you referred to the
9 SoFAAS in saying that we -- looking at
10 contributors of SoFAAS to health outcomes you
11 would give to the other groups, the fat group
12 and to the alcohol group.
13 But will you be modeling alcohol
14 within your dietary pattern such that they do
15 contribute to 70 percent of people who drink
16 alcohol? I mean, it is part of -- potential
17 part of the pattern. There's a lot of people
18 that drink.
19 So, I sort of had turfed that in
20 my report, I'll say, oh, we gave that to
21 nutrient adequacy, so -- so I want you to say
22 yes so I can actually say that when the time
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1 comes.
2 MEMBER NICKOLS-RICHARDSON: And
3 this is Shelly Nichols-Richardson. I'm
4 looking at Trish. Was alcohol included in the
5 2005 modeling?
6 MEMBER RIMM: I mean, it's the
7 sixth contributor to calories right here on
8 this list that you just pointed out to us.
9 MEMBER NICKOLS-RICHARDSON:
10 Exactly, and what I will say is that we won't
11 let it fall into the gap between our two
12 subcommittees.
13 MEMBER RIMM: Okay.
14 MEMBER NICKOLS-RICHARDSON: So, we
15 won't look at health outcomes related to that.
16 That's you, but in terms of modeling --
17 Trish.
18 DR. BRITTEN: Yes. It's part of
19 what we look at as discretionary calorie
20 allowance. That can be split out a number of
21 ways so we could look at, you know, how many
22 -- how many alcoholic drinks or how much, how
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1 many calories from alcohol could fit within
2 various patterns.
3 MEMBER RIMM: Okay. Yes.
4 DR. BRITTEN: So, yes, it's a
5 choice, really, in the way we model things.
6 It could be from solid fat, it could be from
7 added sugar, it could be from alcohol.
8 MEMBER RIMM: Okay. Good. So
9 then the second thing is -- sort of relates
10 back to Larry's comments before, on sodium. I
11 do -- is sodium being part of the modeling?
12 The only concern I have about
13 modeling the sodium guideline is that assumes
14 that the food supply will stay the way it is,
15 and I think we shouldn't make that assumption.
16 We should model forward and not backwards.
17 Just the way we sort of -- we got
18 rid of trans in a lot of foods by, you know,
19 modeling in such a way that we could say there
20 are foods that you could create that are
21 without trans, and another point is that you
22 can make breads that are going to potentially
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1 be low in sodium and higher in sugar, then,
2 but there's other ways to make food that can
3 have lower sodium.
4 So, I would hate to model
5 backwards.
6 MEMBER NICKOLS-RICHARDSON: Shelly
7 Nichols-Richardson. Again, a really good
8 question, and I think, yes, sodium is included
9 in the modeling process, and so I think what
10 we could do is potentially look at if we can
11 make some assumptions about what we think the
12 food supply might do over the next five to ten
13 years, and then model based on some of those
14 changes.
15 MEMBER RIMM: Yes, I guess it just
16 shouldn't be restricted solely on the fact
17 that some of the foods may be higher in sodium
18 now, because the industry is slowly moving
19 towards a lower sodium.
20 MEMBER NELSON: Back to this sort
21 of usual intake of looking at these grains as
22 being the number one contributor of calories,
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1 grain desserts or -- I'm thinking about the
2 modeling and, you know, I think we think about
3 the SoFAAS are just one piece of this
4 discretionary calories, and I think that we
5 need to make sure that in our modeling and how
6 we come out with our report, that we identify
7 that, you know, Shelly, you have a slide here
8 on shortfall food groups.
9 In a sense, we were looking at the
10 micronutrients and we're looking at shortfall,
11 but also ones that we get too much of. In a
12 sense, I think we have to think about
13 shortfall food groups, and then, you know,
14 exploded food groups where we're getting too
15 much. It's sort of the yin and the yang of
16 both of them.
17 MEMBER SLAVIN: This is Joanne
18 Slavin. One thing we talked about yesterday
19 was organic and suggested that food safety
20 should handle it, and I just want to make sure
21 it doesn't get lost, because it doesn't really
22 fit, you know, particularly well.
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1 I like Eric's hand-off's. I like
2 to do those myself, and I noticed my Committee
3 has had a lot of those, so it seems like
4 organic, sustainable, we need a discussion of
5 that and it may be one of the cross-cutting,
6 rather than nutrient adequacy, because it
7 could potentially fit here, too, but I just
8 don't want to lose sight of those issues.
9 MEMBER CLEMENS: Roger. I agree
10 with you Joanne, and we actually -- thanks for
11 everyone's comments. Yesterday we actually we
12 exchanged some information last night, and so
13 we've included it on our heavy docket already.
14 Thank you very much.
15 We have the right -- we reserve
16 the right, though, to turf it back.
17 MEMBER SLAVIN: Pass the hot
18 potato. Yes. Go ahead.
19 MEMBER PEARSON: This is just a
20 minor comment, but relative to the folic acid
21 questions, I want to make sure that -- again,
22 it is a minor point, but that it doesn't fall
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1 in between the cracks.
2 The -- your first question has to
3 do with related to neural tube effects, and
4 the second one has to do with cardiovascular
5 disease, strokes, et cetera.
6 And, at least from my reading of
7 the literature, you're going to come up with
8 some very different conclusions between those
9 two.
10 One thing fitting in the middle is
11 congenital heart disease, which has to do with
12 the same pathways of pyrimidine and purine
13 metabolism that the neural tubes are, and I
14 think there is a developing literature that
15 they're seeing some declines in that as well.
16 And as one then looks at the
17 supplementation issue in women of childbearing
18 age, that's on the plus side that will balance
19 some of the voices on the negative side.
20 MEMBER NELSON: Can I comment,
21 because actually, I'm feeling better about the
22 folate question than when we started out. I
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1 think, our Committee, we've had two
2 presentations, and what was nice is sort of we
3 had two ends of the spectrum, scientists, you
4 know, presenting.
5 Yet I found that there was
6 incredible harmony in what they were talking
7 about in terms of what they're thinking about
8 folate and recommendations and while this is
9 preliminary, and it's really from the
10 presentations, and then reviewing a number of
11 the papers, that overall, the fortification
12 seems to be a really good thing for overall
13 health, neural tube defects are coming down
14 that, over time it probably will help with
15 some of the other cardiovascular issues that
16 we're not concerned about that.
17 There may have been a slight blip
18 in something going on there, but that it's
19 probably going to come down to something like
20 this, that with women of childbearing years,
21 that they really should be taking extra folate
22 supplementation, that the foods probably may
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1 not be quite enough, but that actually older
2 adults were -- however we decide to define
3 that, that in fact they should not be taking
4 extra folate in supplement form, that it's the
5 people -- it's the skewing to the right with
6 way too much, not with what our food supply is
7 now.
8 That's probably actually
9 beneficial, and so I feel pretty good harmony
10 around it, but it's less confusing than it
11 was, and so I think that that's where we're
12 going to fall out.
13 MEMBER PEARSON: I think that was
14 consistent with what I'm seeing. Ours is
15 purely a congenital --
16 MEMBER NELSON: Yes.
17 MEMBER PEARSON: So that we don't
18 -- when they say there is no effects on
19 cardiovascular disease, that's not --
20 MEMBER NELSON: We're not -- I
21 don't --
22 MEMBER PEARSON: -- exactly --
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1 MEMBER NELSON: Yes. I don't
2 think we're going to say that. I think that
3 -- I think that there is overall benefit for a
4 whole host of things, so --
5 CHAIR VAN HORN: I think the point
6 that came out loud and clear to me as a
7 participant, at least, on some of those
8 discussions is exactly what Mim was just
9 referring to that, you know, at the younger
10 age in childbearing years, you know, extra
11 folate would be beneficial, that the food
12 supply, when people derive their folate from
13 the food supply, even the fortified food
14 supply, that's beneficial.
15 Where we potentially get into
16 trouble is in the elderly taking additional
17 supplements of any kind, but especially folate
18 in excess of nutrient needs could potentially
19 be detrimental.
20 And, you know, that's where I
21 think we've seen, as Mim was pointing out, the
22 extremes, and the caution that we provide over
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1 and over again about preferentially deriving
2 the majority of the nutrient intake from food.
3 MEMBER NELSON: But I think that
4 will be an important message about that
5 actually there may be some harm with older
6 adults taking extra folate by supplement. I
7 think that's an important message, because
8 it's one -- they've been hearing the opposite
9 in the media for a couple decades.
10 MEMBER ACHTERBERG: One last
11 comment on the supplement part. I think
12 that's why this subcommittee is saying we have
13 to speak to supplementation in a variety of
14 different spots.
15 But I have another issue. I just
16 want to clarify a little bit with the whole
17 group relative to food groups, and that's, as
18 we're looking at food groups, we're looking at
19 the food groups as has been, I'll say at this
20 point, traditionally defined by USDA.
21 And I think one of the things we
22 have to keep straight, as we do this work, is
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1 that these food groups make sense in terms of
2 the science we're used to, and the way we're
3 used to manipulating it, but it may not make
4 sense to the general public.
5 And so, as people are talking
6 about what do we need to present to the
7 general public, what's going to motivate
8 people to change their diets, et cetera, that
9 may be a different kind of messaging, and a
10 different way of conceiving some of these
11 groupings than the way we're analyzing it and
12 doing the modeling and drawing some
13 conclusions.
14 So, I know it's beyond the scope
15 of this report, and this particular Committee
16 to recommend exactly how and what needs to be
17 communicated to the public.
18 But we've heard some presentations
19 today, and I did want to make that distinction
20 and get that out on the table, that it's not
21 necessarily one and the same in terms of our
22 thinking, our presentation and what the public
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1 can or should receive later on.
2 CHAIR VAN HORN: Okay. Anything
3 else in regard to nutrient adequacy? Larry?
4 MEMBER APPEL: Just a comment,
5 because I was listening to this discussion on
6 folate and supplements. This is going to be a
7 tough one, because it's really quite
8 integrated in terms of the literature.
9 I mean, there are these cohorts
10 studies that suggest that higher intake is
11 beneficial for cardiovascular disease, and yet
12 you have the trials, you know, which I think
13 sort of provide the trump that high intakes at
14 least of the supplements are bad.
15 And I'm just sort of -- you know,
16 concerned about as the -- there could be a ton
17 of effort to just replicating what I think
18 many of the people in this group already know,
19 which is that these -- that there's
20 observational evidence that tended towards
21 benefit and trials that documented harm.
22 And I just -- it's like all of the
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1 subcommittees are going to be swamped with
2 work, and I'm just -- I don't know how to deal
3 with this, but I sense that, you know, you're
4 going to spend a lot of effort compiling a
5 body of literature that you already know says
6 there's a tendency towards benefit and then
7 the trials came out and showed no benefit, and
8 even harm.
9 I don't know how you're going to
10 resolve this. It's going to be a lot of work
11 for a conclusion you already know, I think.
12 CHAIR VAN HORN: Well, on that
13 bright note, let's move forward.
14 MEMBER APPEL: Yes, I was the
15 pessimist category on Brian's slide --
16 CHAIR VAN HORN: Yes. We're going
17 to give you all the negative messages, Larry.
18 All right. Dr. Pi-Sunyer. Let's
19 see if we can turn this around and talk about
20 energy balance and subcommittee report.
21 MEMBER PI-SUNYER: So the members
22 of our subcommittee are Mim Nelson, Rafael
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1 Perez-Escamilla, Joanne Slavin, Christine
2 Williams and Linda Van Horn, and our staff
3 helper is Eve Essery, who's been terrific in
4 giving us support throughout this. So, I want
5 to thank her.
6 I want to move to the topic areas,
7 that what we've done here is split the topic
8 areas amongst the different subcommittee
9 members and have each one take a lead on one
10 of them. All of them are high-priority, so we
11 haven't divided it into priority one and two.
12 Rafael is going to take the energy
13 density question. Christine will do the
14 childhood overweight and obesity. Mim and
15 Christine are working on the dietary behaviors
16 aspects, and Mim on the environment.
17 I'm taking the macronutrient
18 proportions. With regard to weight management
19 for special population subgroups, Rafael will
20 do gestational weight gain, breast-feeding and
21 lactation.
22 And I'm going to do weight
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1 management for older adults. And then Mim
2 Nelson who was on the other Committee on
3 physical activity will deal with that.
4 If we go to energy density. Could
5 you move that forward, please. The question
6 here is: How is energy density related to
7 body weight and health? To what extent is
8 dietary energy density associated with BMI?
9 To what extent is dietary energy density
10 associated with highly-prevalent chronic
11 diseases?
12 Questions addressed in the
13 discussion: What dietary intake patterns are
14 associated with diets and different energy
15 density? Which nutrient intake patterns are
16 associated with diets with different energy
17 density?
18 This is -- this whole topic is the
19 one that has gone the furthest with regard to
20 NEL research. The NEL librarian has completed
21 the searches, and it will be the first topic
22 that we address.
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1 With regard to childhood
2 overweight and obesity, the question is: What
3 is the role of dietary intake in the
4 maintenance of healthy weight and prevention
5 of childhood overweight and obesity?
6 As I mentioned, Dr. Williams will
7 be handling this. The status is that NEL is
8 updating several searches conducted by the
9 American Dietetic Association’s Evidence
10 Analysis Library on childhood obesity, and
11 they have a very good number of searches.
12 And this will be the second
13 question that is going to be reviewed by the
14 NEL. I might mention that this is one that
15 hasn't been done before, so they're going to
16 go back and do the literature search further
17 back than is the case in most of the other
18 searches.
19 With dietary behaviors, the
20 question is: What is the relationship between
21 behaviors related to food intake and body
22 weight, what dietary behaviors are associated
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1 with the maintenance of healthy weight and
2 prevention of obesity in childhood, what
3 behaviors related to food intake most
4 contribute to achieving and maintaining a
5 healthy weight in adults, what behaviors
6 related to food intake most contribute to an
7 unhealthy body weight in adults?
8 The status is that published
9 systematic reviews are being considered and an
10 additional NEL review will be conducted on
11 individual behaviors that are selected by the
12 subcommittee.
13 With regard to the environment,
14 the question is: What environmental factors,
15 e.g. access, availability, type and quantity
16 of food contribute to an unhealthy body
17 weight?
18 Status, published systematic
19 reviews are currently being considered by the
20 SC.
21 With regard to macronutrient
22 proportion, the question is: What is the
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1 optimal proportion of dietary fat,
2 carbohydrate and protein to maintain a healthy
3 body mass index, to lose weight if overweight
4 or obese, to avoid regain in weight reduced
5 persons?
6 The status is the search and sort
7 plan is currently with the NEL librarian, and
8 initial searches are being conducted right
9 now.
10 With regard to weight management
11 for population subgroups, the question is: How
12 does gestational weight gain impact short,
13 e.g. premature, small for gestational age and
14 large for gestational age, and longer-term,
15 e.g. childhood obesity, pregnancy outcomes?
16 The status is that Rafael is going
17 to review the IOM report on the reexamination
18 of Pregnancy Weight Guidelines. This report
19 is expected out in June of 2009.
20 With regard to breast-feeding and
21 weight change, that question is in
22 development. With regard to energy
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1 requirement during lactation, this is also
2 under development.
3 And for older adults, what is the
4 effect of weight loss versus weight
5 maintenance on health outcomes? This status
6 is the PICO chart and search and sort plans
7 are in development.
8 With regard to physical activity,
9 the question is how is physical activity
10 related to body weight and other nutrition-
11 related aspects of health? How much physical
12 activity is needed to maintain a healthy BMI,
13 to lose weight, if overweight or obese, to
14 avoid regain in weight-reduced persons?
15 Mim, who was on the Advisory
16 Committee for this report is going to review
17 that report, Physical Activity Guidelines and
18 Physical Activity Guidelines Advisory
19 Committee Report.
20 So, we will not need a search for
21 this particular topic, and she will be in
22 charge of writing that up.
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1 So, in summary, these are the --
2 the topics that we're working on, and all of
3 them are moving forward, I think, in a
4 satisfactory fashion.
5 CHAIR VAN HORN: Great. Thank
6 you. Comments from the Committee? Questions?
7 Larry?
8 MEMBER APPEL: Yes. Xavier, I was
9 just curious. What were the -- you said the
10 behaviors, the Committee's going to decide on.
11 Any idea, I mean, which ones you're thinking
12 about? I mean, there's a pretty huge
13 literature.
14 MEMBER PI-SUNYER: Yes. I think
15 I'll let Mim answer that, or --
16 MEMBER NELSON: Yes, you're right.
17 There's a wide range, and at the moment we're
18 trying to be fairly systematic about this, and
19 so what we're doing is, we're looking at a
20 number of reviews at the moment.
21 And from those -- I'll say, I
22 think we're further along in the environment
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1 question than we are in the behavior one, but
2 the plan is to really look at these reviews on
3 behavior and then to try to make a judgment
4 call based on those systematic reviews on the
5 specific -- whether it's going to be three or
6 five, I don't know what the number's going to
7 be, and then do specific searches around --
8 because it's infinite, you know, it's just
9 infinite.
10 Try to pick the ones that seem to
11 have the most evidence, and then do some
12 specific NEL searches on those behaviors.
13 If I can comment just on the
14 environment, the plan is right now is that
15 there are a number of very recent systematic
16 reviews on the influence of the environment,
17 and so we're not going to do an NEL search on
18 specific -- the whole thing about the
19 environment, you can't take -- it's the
20 environment.
21 You can't take one little -- you
22 can't disaggregate it, and so what we're going
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1 to be doing -- NEL is helping us with really
2 making sure we're getting all of the good,
3 systematic reviews, and then we're going to
4 use those to base our -- for the writing and
5 the commenting.
6 CHAIR VAN HORN: You know, Brian
7 has left, but in regard to the presentation we
8 heard this morning and his suggestions to look
9 further than what PubMed has to offer, are you
10 --
11 MEMBER NELSON: Absolutely. I
12 agree with him completely. I do think there's
13 actually a fair amount of literature in the
14 PubMed. I think there's a lot. There is also
15 a whole other area, and I think I want to talk
16 to Eve a little bit further on some of these
17 other sources, but yes, I agree.
18 And I think that we -- the tricky
19 part here is going to be making sure -- this
20 is the first time we've done this question. I
21 think we want to make sure that we focus on
22 those behaviors that have the most evidence,
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1 and so, yes, I think we need to look beyond
2 just the PubMed.
3 CHAIR VAN HORN: Other comments
4 from the Committee? Anything else? Tom?
5 MEMBER PEARSON: I think you kind
6 of put this in terms of behaviors and
7 environment and other factors related to
8 weight and weight gain, and weight loss
9 retention. But are you going to look at
10 specific programs and packages that have been
11 tried in terms of interventions? That
12 obviously gets kind of bleak.
13 MEMBER PI-SUNYER: You mean you're
14 talking like specific diet plans, like Atkins
15 plan and Weight Watchers and things like that?
16 MEMBER PEARSON: Well, I was
17 thinking more about more behaviorally-
18 integrated programs, rather -- that have
19 actually put a lot of those individual factors
20 you're going to find together into an omnibus
21 program.
22 Now, if those include some of
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1 these commercialized diets, maybe, but you
2 know, programs that try to put all this stuff
3 together, rather than the individual
4 behaviors.
5 Weight Watchers or, you know, some
6 of these other programs that try to synthesize
7 some of this stuff.
8 MEMBER PI-SUNYER: Some of that
9 will come in with regard to dietary patterns.
10 Some of that will come. Also the
11 macronutrient proportions will discuss some of
12 that.
13 But if you're talking about a
14 holistic kind of lifestyle change, including
15 exercise, diet and other plans within a
16 specific kind of program, we have that
17 reasonably compartmentalized. We don't have
18 it as saying this is the way you have to do
19 it.
20 MEMBER NELSON: Tom. This is Mim
21 Nelson. If I could just add to what Xavier
22 said.
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1 Hearing Dr. Sacks yesterday speak,
2 if you look at the data, when you're talking
3 about losing weight and keeping it off,
4 especially that population. Support -- you
5 know, it doesn't matter where it comes from,
6 you know, decent support seems to make --
7 keeps coming out over and over again and self-
8 monitoring, and there's a bunch of sort of key
9 things.
10 I actually think that we may be
11 able to address this without sort of saying,
12 you know, Weight Watchers or one of the -- you
13 know, there are a number of great programs out
14 there. There's probably a number of not-so-
15 great programs.
16 But I don't know that we need to
17 go into these specific programs, but that the
18 sort of what makes -- what prepares someone
19 for successful weight maintenance over time?
20 We have some pretty good ideas around that in
21 terms of behavior.
22 But I'm glad you brought that up
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1 because I think that when I think about this
2 section, in a sense I also need to think about
3 weight maintenance of ideal body -- you have
4 to almost think about the three categories,
5 because they're quite different.
6 And so, I appreciate that, because
7 I don't know, Xavier, if you disagree, but I
8 think there are ways to sort of look at that,
9 the importance of support and self-monitoring,
10 in a different way than the ideal body weight
11 person.
12 MEMBER PEARSON: Just one comment
13 is that we're -- the Obesity Guidelines are
14 being, obviously, redone by the National Heart
15 Lung and Blood Institute, and I chair a
16 guideline implementation working group with
17 that, and we are probably going to look at
18 this body of information from this perspective
19 about really what does work, what is the
20 evidence of implementability of a specific
21 guideline.
22 I don't think we're going to have
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1 that done within the time frame that's going
2 to help these Guidelines. But, it is that
3 other part of that, that coin about if you're
4 a health maintenance organization and you have
5 a million dollars to spend on an obesity
6 program, how do you spend it? That is an
7 important question.
8 CHAIR VAN HORN: Chris.
9 MEMBER WILLIAMS: To take the
10 childhood obesity question one step further,
11 there have been some excellent reviews
12 recently on the obesity prevention trials,
13 intervention trials in children.
14 But I think we could try to tease
15 apart these multidimensional interventions and
16 try to identify the strategies that have been
17 most successful as far as food intake and
18 behavioral interventions as well.
19 CHAIR VAN HORN: Right. That was
20 going to be my comment, is you know, that
21 we're not only about weight loss, but we're
22 about prevention of weight gain, and the
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1 strategies and behaviors related to those two
2 different populations, I think really do need
3 to be teased apart, because they're not
4 necessarily the same.
5 I do, however, want to go back, to
6 what you said, Mim, about the need for ongoing
7 support. I think that -- if we see nothing
8 else in the literature that is consistent with
9 every intervention study, it's "out of sight,
10 out of mind."
11 If there is not continuing
12 support, ongoing availability of updating and,
13 you know, somebody to whom the person can be
14 accountable, then the, you know, success drops
15 off precipitously.
16 Joanne.
17 MEMBER SLAVIN: Yes. Joanne
18 Slavin here. I'm a little concerned about the
19 intervention trials, because a lot of this
20 stuff on weight maintenance, it's just, you
21 know, people reporting back. So the people
22 that were successful at losing weight, the
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1 things that they do, exercise, monitor, eat
2 breakfast.
3 You know, a lot of that is just
4 self-report data, and I think we're going to
5 have to go with that because we're not going
6 to -- we're going to have to use that because
7 that's the best data there is.
8 MEMBER APPEL: Yes, this might be
9 a case where you want to have somebody from a
10 trial that I participated in, because we did
11 do a weight maintenance trial and actually
12 Rena Wing did one, too, different strategies,
13 and the problem that I sense is that the
14 primary results paper that just look at the
15 randomized groups that have been published and
16 not sort of like the sort of what were the
17 correlates of sustained weight loss.
18 So, that might be, you know,
19 something to consider for our next meeting.
20 MEMBER PI-SUNYER: You mean to
21 have a speaker?
22 MEMBER APPEL: Yes. I don't know
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1 who the best one is, but I mean, we now have
2 two big trials of weight loss maintenance and
3 randomization of different strategies but
4 they, you know, that was typically the
5 different channels, internet versus in person
6 kind of thing.
7 But they did -- my understanding
8 is -- well, I know about our trial, weight
9 loss maintenance, but I think Rena Wing also
10 has predictor variables and follow-up
11 variables that might help inform this.
12 But, as I said, the problem is
13 that it's relatively early -- you know, these
14 haven't been published as far as I know. I
15 know we've been, you know, they're in analysis
16 right now.
17 MEMBER PI-SUNYER: Well, we have
18 you here, but we could certainly ask Dr. Wing
19 to come, I would think.
20 CHAIR VAN HORN: Cheryl.
21 MEMBER ACHTERBERG: I just want to
22 do a cross check on the scope of what our work
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1 is. So, as we're talking about this, is the
2 intent here to describe elements that seem
3 important in success of a weight loss program
4 or weight maintenance program, or are we
5 trying in the report to really do a critique
6 and analysis of all these various things?
7 I'm just checking. What is our
8 scope in writing this report relative to this
9 topic?
10 MEMBER SLAVIN: Joanne Slavin. I
11 always get concerned about -- actually, when
12 Eric -- or when Brian said if we had a
13 dietitian chasing us around all day, you know,
14 that would work and, you know, the cost of a
15 lot of these interventions is not practical.
16 So, even if it works, you know, if
17 I had a personal chef and a dietitian, maybe
18 I'd do better, too. So, trying to -- you
19 know, this -- I think that cost-effectiveness
20 of a lot of stuff we are going to recommend is
21 really important. If it's not available to
22 people, what good is it?
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1 You know, and I'm sure some of the
2 newer strategies with internet and other types
3 of support make it more possible, but a lot of
4 the things that are out there are really
5 costly.
6 CHAIR VAN HORN: The unfortunate
7 thing is that those innovative strategies
8 using things like internet, and I'm familiar
9 with some of them, and from pilot work that
10 we've been doing are very successful, but
11 you're not going to see them in the literature
12 yet because they are still at some of the
13 preliminary, you know, stages.
14 But they're also, again, drawing
15 from other literature, related to behavior
16 change. You know, some of these kinds of
17 methods have been reported for substance
18 abuse, other things that, you know, we can
19 borrow from, which was, of course, you know,
20 how the motivational intervention literature
21 has been adapted to changing diet.
22 So, you know, I think the same
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1 thing is true in terms of some of these other
2 issues as well.
3 Tom.
4 MEMBER PEARSON: Yes. Just to
5 say, I mean, there is this huge literature of
6 over 6,000 papers on a Canadian database about
7 implementation of guidelines, and so the
8 question is: Do you want to get into that
9 about really what works in terms of -- you've
10 got the biology worked out. You've got the
11 science worked out about what works, and then
12 really then you've got the science about how
13 to make it work.
14 So, that's another version of your
15 question, Cheryl.
16 MEMBER ACHTERBERG: Don't get me
17 wrong, anybody. I love this stuff and, you
18 know, I can dwell in it, but I'm beginning to
19 get the feel that, as a group, we need to draw
20 some parameters about what we're really going
21 for here.
22 We're breaking new ground, but
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1 what are we really going for.
2 CHAIR VAN HORN: I think that, you
3 know, the work Xavier and this group have done
4 already, you know, begins to address some of
5 those things.
6 And while I think the Nutrient
7 Adequacy Committee has, you know, again taken
8 the modeling approach, I think the energy
9 balance group is going to go back to evidence
10 and try to come up with what's available both
11 directly in terms of weight and energy
12 balance, but also approaches that, perhaps,
13 are cutting-edge and leading.
14 So I have to -- I think we have to
15 rely on the expertise assembled in that group
16 to help us determine what is reasonable in
17 terms of some of these boundaries for that
18 particular question.
19 MEMBER ACHTERBERG: Okay. And I'm
20 not questioning the group. Please don't take
21 it that way. But, I'm wondering if this might
22 not, in the end, fall out to a cross-cutting
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1 issue, and maybe there's a section of this
2 report that speaks more directly to what you
3 just mentioned, Tom, what works.
4 What works in terms of
5 interventions or behavior changes that we
6 might speak to, but I'm not sure that's a
7 direct part of the Dietary Guidelines. I
8 guess that's what I'm trying to find my way
9 through.
10 MEMBER SLAVIN: I think one way --
11 this is Joanne Slavin -- to limit scope is to
12 look at preventing weight gain, and not, you
13 know, because the weight loss, there's -- each
14 of these -- and they're huge categories, you
15 know, losing weight, and in -- you know, the
16 nice thing about the people that have
17 successfully lost it and kept it off, they
18 have some strategies.
19 People that have never put it on,
20 what are their strategies? And I do think for
21 Dietary Guidelines -- and, you know, I know
22 we've talked about that there aren't very many
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1 of those people around.
2 We have a lot more people that are
3 overweight now, so we need to do something
4 fairly drastic, rather than just business as
5 usual. So --
6 MEMBER NELSON: Well -- this is
7 Mim Nelson -- I think that there's enough
8 literature, and it's very different between
9 the sort of not gaining weight, ideal body
10 weight, or overweight, let's just say, and
11 sort of not drifting up and looking at that
12 pattern of behaviors that's related to a
13 healthier body weight.
14 And I think that it's a different
15 literature, but there's enough of it, I
16 believe at this point in time, to look at the
17 weight loss and weight maintenance folks.
18 I'm not worried about scope with
19 this. I will say that, you know, this
20 originally, these two questions were
21 originally in both Committees, as Shelly just
22 said, and we made a decision because there's
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1 so much overlap that you still want someone,
2 if they're losing weight or whomever, to have
3 a good quality diet that we've merged them so
4 that there's just two questions.
5 But I agree. I think that --
6 well, I mean, I think this behavior and the
7 environment ones are not just around energy
8 balance, too. It's about wholesome quality of
9 -- we'll see where it ends up. You know, once
10 it's written, we'll see where it goes.
11 CHAIR VAN HORN: All right. Well,
12 thank you for that lively discussion, and I
13 think we now ready to move on for carbohydrate
14 and protein, and this will be the last
15 subcommittee before our lunch break.
16 MEMBER SLAVIN: Thank you, Kellie,
17 and I want to thank all of the USDA and other
18 staff. We've had a wonderful, really great
19 support.
20 So, Jan Adams has taken over as
21 our chair, and Colette kind of kicked us off,
22 and Eve has done a ton of work, so it's been
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1 really nice working with everybody.
2 And I appreciate all you people
3 out there in the hinterland, so hopefully
4 there's some people from my neck of the woods
5 that are linked in here so this new technology
6 has been really fun, too.
7 I want to acknowledge my
8 Committee, Cheryl, Xavier, Linda, and I think
9 we've expanded our approach, and when you see
10 how many questions we have, we're going to
11 have to do some dumping to Eric. Maybe Eric's
12 got some time. So, anybody else want some
13 chores? I might send them over.
14 So, a lot of our work was done
15 before in 2005. There's a whole section on
16 carbohydrates and protein. Kind of by
17 default, there was some discussion within
18 that.
19 There was also some discussion of
20 protein in other sections, and we've renamed
21 this Committee Carbohydrates and Proteins, so
22 that's given us some new direction that we'll
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1 discuss.
2 Okay. These are some of our
3 overall research questions, and then we're
4 going to break them down into some categories,
5 and I want to mention that some of our
6 questions overlap a lot with other Committees,
7 and we discussed that yesterday, and some of
8 them are cross-cutting that we'll talk about
9 later, too.
10 How is carbohydrate consumption
11 related to health, how is protein consumption
12 related to health, how is fiber consumption
13 related to health, and these are very general
14 questions and we'll talk more about some of
15 the health outcomes we want to get after.
16 What is the utility of glycemic
17 index, glycemic load for providing dietary
18 guidance for Americans? And I'll discuss this
19 later, but this is the question that we've
20 made the most progress on. It was done well
21 in 2005, so it's really just an update.
22 And some of our protein questions
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1 that we're working on are going to be more
2 difficult, because there was nothing that we
3 could start with.
4 How are non-caloric sweeteners
5 related to body weight? There's a lot of
6 overlap with our Committee and the Energy
7 Balance, and I'm on both so we're trying to --
8 you know, some of these topics may go one way
9 or the other.
10 So, what is the impact of
11 consumption of liquids versus solid foods on
12 weight gain, this is a topic we'll talk more
13 about today, but also just the water issue has
14 some overlap here.
15 And then a new question we had a
16 lot of interest in is the role of probiotics
17 and prebiotics in the diet.
18 Okay. Number one, carbohydrate
19 consumption related to health. What is the
20 evidence that the types and percentages of
21 carbohydrate in the diet influence health
22 outcomes?
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1 And I want to mention a lot of the
2 health outcomes for body weight are going to
3 move over to the other group. So, some of the
4 reviews, we know there will be some overlap in
5 our reviews, but I think the actual discussion
6 will be in energy balance.
7 Some of the other diseases we want
8 to get at, Type 2 diabetes, cardiovascular
9 disease and cancer.
10 What is the relationship between
11 consumption of carbohydrate containing foods
12 and oral health, and this is an example, when
13 Larry talked about the low-hanging fruit, that
14 there really isn't a lot of new information.
15 It was done well in 2005, and it's essentially
16 just updating what was there.
17 We don't think there's anything
18 earth-shattering that needs to be included
19 into that.
20 You see some of the stars, these
21 are ones that have been added or tweaked since
22 our last meeting, are low-carbohydrate diets,
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1 low-calorie diets, safe and effective for
2 long-term weight loss and maintenance, and
3 this is an example of a topic that would move
4 over into Energy Balance.
5 Does the type of carbohydrate,
6 sugar versus starch, high-fiber alter body
7 weight and/or maintenance. And you can see
8 kind of the overlap here with the carbohydrate
9 -- if the carbohydrate is the question that
10 our Committee -- or the protein, our Committee
11 will take the lead on that.
12 What is the association between
13 added sugar intake, sugar-sweetened beverages
14 and body weight, and I appreciate Adam giving
15 us some insights, both on that and the liquid
16 versus solid.
17 This is a topic we're working on.
18 There's been, you know, 2005, there was a
19 discussion of that, too.
20 What is the role of carbohydrates
21 on satiety? And when we get into kind of the
22 cross-cutting issues, all of the satiety ones
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1 were dumped. I shouldn't say "dumped."
2 Given, honored -- our Committee is honored to
3 take those all on.
4 And part of the reason is that
5 every Committee, seems -- you know, fat --
6 fatty acids had satiety and we thought it
7 would be better for those all to come to our
8 Committee. So, we're going to do a very broad
9 review on the role of -- you'll see this on
10 all of our lists here.
11 What's the relationship between
12 fruits and vegetable intake and health and the
13 relationship between whole-grain intake and
14 health, and these were questions that were
15 asked in 2005, so it's essentially an update
16 of those.
17 Okay. It's haunted. How is
18 protein consumption related to health? Pretty
19 much the same questions, cut and paste, take
20 protein, you know, switch it around with
21 carbohydrate. Type and percentage of protein
22 in the diet influencing health outcomes.
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1 And this was not reviewed at all.
2 So, we've had some discussions, how far we
3 want to go back in our NEL process in this,
4 and this, as I go through here, this is the
5 lit review that we're kind of jumping in and
6 trying to get moving on just to see what the
7 scope of it will be.
8 High-protein diets, safe and
9 effective? A lot of that will go over to
10 Energy Balance, and it was great having Frank
11 here yesterday to discuss that.
12 Role of protein on satiety. I
13 told you that's going to be generalized into a
14 question on satiety. Dried beans, peas and
15 health. Some of the other -- we wanted to
16 expand our carbohydrate, and Cheryl's going to
17 have to help me out here, because there's a
18 lot of food group Nutrient Adequacy, and it's
19 nice being on these three Committees, so I can
20 kind of make sure we're not duplicating
21 effort.
22 But a lot of -- we wanted to
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1 expand out of fruits and vegetables, whole-
2 grains to other high-carbohydrates, and make
3 sure that we give that a look.
4 I suspect there's not a huge
5 database. It's a developing database.
6 Relationships between milk product intake and
7 health, and this is -- if you go back to the
8 old 2005 Dietary Guidelines, it was in Section
9 6. It doesn't really fit with any place.
10 Obviously, milk has carbohydrates, it has
11 proteins. It doesn't fit into a protein-
12 carbohydrate, but we'll make sure we check it
13 out here.
14 Other animal products, meat, fish,
15 eggs and health, and this is where we have
16 overlap with the Fatty Acid group and some of
17 the other groups.
18 How do the health outcomes of a
19 vegan diet compare to that of an animal-based
20 diet? A lot of interest in different eating
21 patterns, and even how do we ask these
22 questions.
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1 So, I really appreciate the
2 support of Trish and some of the modeling
3 people, and I think some of these questions,
4 there will be some literature base, but not a
5 huge amount.
6 So, in trying to model these
7 diets, trying to put together different diets
8 to see can we -- and this overlaps, obviously
9 with Shelly's Committee, Nutrient Adequacy.
10 Do we have questions on that?
11 The last one is one of the
12 questions that has been discussed, how do the
13 health outcomes of a plant-based diet compare
14 to that of an animal-based diet? Where we
15 have some real needs from the Committee to
16 define what that is.
17 So, a lot of people wanting to ask
18 that question. It came to our Committee, but
19 how do we define that? There's no easy ways
20 of getting that, either from the NEL or
21 getting it from the modeling.
22 So, we will have to just make some
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1 decisions in both those as moving that
2 forward.
3 Fiber and health. How is fiber
4 consumption -- yes, Mim.
5 MEMBER NELSON: What's the
6 difference between a vegan diet and animal-
7 based versus a plant-based and animal-based --
8 MEMBER SLAVIN: Well, that's the
9 good--
10 MEMBER NELSON: I mean, aren't
11 they the same? Isn't that the same question?
12 MEMBER SLAVIN: I think the vegan
13 diet compared to an animal-based diet is an
14 easy one to get at because those are really
15 clear.
16 Lots of discussion on plant-based
17 protein, a plant-based diet, health benefits
18 of a plant-based diet, and from what we can
19 see, there's no definition. There's no
20 accepted -- so it's moving more towards a
21 plant-based diet as the total amount of foods.
22 MEMBER NELSON: That seems -- the
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1 plant-based one seems to be more holistic than
2 just the vegan --
3 MEMBER SLAVIN: Absolutely. And
4 it may be a question that will not be -- might
5 be impossible. That's not one that we've
6 actually gotten to yet, for the NEL or even
7 the modeling, trying to come up with how you
8 would model that.
9 MEMBER ACHTERBERG: Peer review --
10 MEMBER SLAVIN: Thank you. How is
11 fiber consumption related to health, the
12 relationship between consumption of fiber-
13 containing foods.
14 This is -- we tried to separate
15 out foods, dietary fiber and functional
16 fibers, what's available on that. And then,
17 you see satiety again with fiber. So, those
18 will all go into a satiety sort.
19 This is the one where we actually
20 made the most progress, and I appreciate it.
21 We talked about this at our meeting yesterday,
22 what's the utility of the glycemic index,
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1 glycemic load for providing dietary guidance
2 for Americans.
3 You see, it's body weight, which
4 is discussed here, just because it seemed to
5 fit here within our group, and also other
6 health measures. Some of the ones we've
7 already listed, Type 2 diabetes,
8 cardiovascular, cancer.
9 2005 it was well-reviewed. There
10 have been about, I don't know, four systematic
11 reviews published recently, a few recent
12 papers, so Eve has given us the results of the
13 NEL, so I think this is the one where we've
14 made the most progress. And it's going to be
15 not as much work, because there was so much
16 done since 2005.
17 And some of these additional
18 questions. This is like our market basket or
19 our basket of "Where do these fit? Why don't
20 you take them?"
21 So, this is -- Eric's not
22 listening right now. I'm going to -- oh, you
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1 are listening. Okay. Never mind.
2 How are noncaloric sweeteners
3 related to body weight? And this is an
4 example of one that -- this question could go
5 lots of different places, but it's in our
6 Committee, just to ask this -- go back and do
7 the NEL search on this and start from scratch,
8 really, because it wasn't addressed in the
9 2005 Guidelines.
10 You can see this one of
11 consumption of liquids versus solid foods on
12 weight gain. This gets into -- if I look at
13 the Venn diagrams of how these things relate
14 to each other, sugar, sugar-sweetened
15 beverages gets into this, but also the water
16 question.
17 You know, like does -- and does
18 our -- even though we got into this discussion
19 yesterday in the subcommittee that most
20 consumers think that you can drink water and
21 lose weight. There's really no data on that,
22 but people typically do eat for calories that
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1 -- you can try to trick them, but if they're
2 not eating calories, they're not full. So,
3 trying to do a broad review on that.
4 And then this last additional
5 question, which there was nothing in 2005,
6 probiotics and prebiotics in the diet.
7 Okay. Where are we at? The PICO
8 Charts and literature search and sort plans
9 have been approved for all the research
10 questions, so that is done.
11 The prebiotics/probiotics is the
12 one we really haven't made any progress on,
13 and I notice everybody else did a much better
14 job than we did on priorities. So -- which --
15 whenever we meet everything's a high-priority,
16 so it's hard to get anything down into
17 category three.
18 I mentioned that the search has
19 already been completed on the glycemic index
20 load, and the dental caries questions. Those
21 are fairly easy, and ones that are not going
22 to take a huge amount of new effort.
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1 We did decide yesterday, and this
2 is why this is probably a little disorganized.
3 The way we're presenting this is that the
4 protein and health question is going to be the
5 first one that we're going to do -- that has
6 moved to the top of our search that we're
7 going to try to get done by end of May.
8 And then the question, obviously,
9 was how far are we going to go back, and we're
10 going to start, I notice, with Christine going
11 back to 1970 for her search. Sometimes it's a
12 little overwhelming.
13 So we're going to start with 2000,
14 go back to that, and if we get 3,000 hits,
15 then we'll -- that may -- you know, that
16 decision really hasn't been made. We're going
17 to start with that.
18 Cross-cutting topics. I think
19 we're the cross-cutting kings. We're always
20 cross-cutting, so we like move to every group,
21 you know, we're like utility infielders. We
22 go anywhere we're needed.
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1 So satiety is one where a lot of
2 other people can come to us. We're going to
3 do a search on that, and we're going to write
4 that section up.
5 Food group questions. We have a
6 lot of overlap with food groups, and I
7 appreciate -- I haven't really acknowledged
8 the people on my Committee that are taking the
9 lead. Dr. Pi-Sunyer is taking the lead on the
10 glycemic index and some of the dietary
11 patterns. Cheryl is taking the lead on that,
12 and I know that there will be a lot of overlap
13 with the -- Shelly's Committee also, with both
14 food groups and dietary patterns.
15 And then the macronutrient
16 proportions in weight and health, we had a lot
17 of discussion about that yesterday. It's
18 mostly in the energy balance, but some of the
19 questions about protein and carbohydrates,
20 some of those topics may get into our section
21 or in our -- you know, a lot of the reviews
22 will be the same type of reviews, the same
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1 literature, not sure exactly which section it
2 will end up with, or if it will be in a bigger
3 cross-cutting section.
4 Any other discussion? Questions?
5 MEMBER NELSON: Thanks, Joanne.
6 This is Mim Nelson. A question about satiety,
7 because you could look at satiety by first
8 looking at the effect of proteins or -- and
9 then looking at carbohydrates and look -- or
10 you could look at what type of dietary pattern
11 influences satiety in the most positive way.
12 And it seems like that may be a
13 better way than sort of reducing down the
14 elements, or maybe you have to do both.
15 That's sort of -- because I think satiety --
16 it's also so linked to situation that, you
17 know, as Brian has so eloquently showed. So I
18 think there's -- satiety is a tricky one.
19 MEMBER SLAVIN: Yes. I appreciate
20 that. Looking at that area, I think you have
21 to do the controlled -- you know, as we've
22 heard today, and I'm a total believer in the
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1 diet food.
2 I love food. You know, I've
3 always loved food, so I think that food has
4 more than the components. No question about
5 it. But to do these studies, when you compare
6 macronutrients, usually you put things in a
7 drink or something and completely control
8 them.
9 And if you don't control
10 macronutrients, your results are meaningless.
11 I mean, like the satiety studies that -- that
12 -- where people don't give the same calories,
13 they don't get their carbohydrates or, you
14 know, things -- when they're comparing groups,
15 it's not very helpful.
16 So when you look at the way those
17 studies are done, typically, too, I think the
18 people's assessments are wrong. Because
19 lipids are actually pretty -- you know, they
20 don't make people full, and as dietitians we
21 always say, oh, the reason people like fat is
22 because they feel fuller.
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1 Look at that literature, it's not
2 true at all. So I think there's that -- just
3 starting with, okay, what about
4 macronutrients, and then typically in fiber
5 studies, you know, you change the types of
6 fibers, the kinds of fibers, that's a huge
7 literature base.
8 And then you can do like energy
9 density studies, or you can do whole-food
10 studies. So it's -- you know, I agree with
11 you that it's not just the macronutrients,
12 other things do affect it.
13 MEMBER NELSON: Can I just add a
14 follow-up question?
15 MEMBER SLAVIN: Sure.
16 MEMBER NELSON: I appreciate that.
17 Back to the -- I know in the energy
18 subcommittee, and I may have misunderstood,
19 but it seems like Xavier is taking over the
20 sort of -- the influence of the range of
21 macronutrients on body weight, and then here,
22 looking at protein, carbohydrate -- like the
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1 individual things, it seems like, isn't that
2 one question?
3 I mean, like that should only be
4 done once. I mean, if you're looking at the
5 range of macronutrients on body weight, then
6 you are looking at the subcategories. You
7 don't have to do it individually and
8 separately. Is that correct?
9 MEMBER SLAVIN: Yes. No, we're
10 definitely --
11 MEMBER NELSON: It's just going to
12 be done once?
13 MEMBER SLAVIN: It's only going to
14 be done once.
15 MEMBER NELSON: Yes. Okay.
16 MEMBER SLAVIN: What we have it --
17 our outline yesterday, cross-cutting issues
18 and questions, low-carbohydrate, high proteins
19 and body weight. You know, it was originally
20 put together with that.
21 MEMBER NELSON: Okay.
22 MEMBER SLAVIN: That was our
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1 question with our group. It does overlap.
2 MEMBER NELSON: Yes.
3 MEMBER SLAVIN: So it can be done-
4 -
5 MEMBER NELSON: It's going to be
6 done once.
7 MEMBER SLAVIN: -- in energy
8 balance.
9 MEMBER NELSON: Yes.
10 MEMBER SLAVIN: Macronutrient for
11 sure in energy balance. The liquid versus
12 solid in body weight.
13 MEMBER NELSON: Is different.
14 MEMBER SLAVIN: Yes. We're going
15 to do it just because we agreed to do it, and
16 also the non-caloric sweeteners and body
17 weight. But they -- I think they are all
18 examples of cross-cutting. They do fit more
19 than one subcommittee.
20 MEMBER RIMM: This is Eric. I was
21 afraid to turn my microphone on, thinking you
22 may give me a few of these responsibilities.
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1 I want to ask an issue that's come
2 up in both the subcommittees that I'm on and
3 that applies here quite clearly. And what
4 you've done is pulled a lot of the questions
5 that were asked in 2005, as well as establish
6 ten new ones, which will give you a lot of
7 work.
8 And I don't know if there can be
9 some discussion across everybody here, is what
10 do we do about those questions where, for
11 instance, for fiber and coronary heart
12 disease, the last technical report had very
13 nice listing of the 15 studies and showed that
14 it was clearly protective. Is it really worth
15 our effort for you to go back and to have --
16 do the NEL searches, find the three more
17 studies that have been done, and try to
18 rewrite all that?
19 At some point we should say, okay,
20 this -- this is an issue that we know, it's
21 done. There may be more data on it but, you
22 know, how much time do you have and how much
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1 work, I would rather you spend more time on
2 things that are on satiety that haven't been
3 done. So --
4 MEMBER SLAVIN: And I think that's
5 like the glycemic index is a good example of
6 that, that there's some systematic reviews.
7 We feel like we can update it pretty quickly.
8 You know, because the 2005 was well-written.
9 It was well-researched.
10 MEMBER RIMM: So are we going to
11 pull the 2005 technical report paragraphs and
12 say, okay, here's -- we're copying them
13 directly and adding a paragraph on the end
14 saying, "Here's the latest?"
15 CHAIR VAN HORN: Right. Well, I
16 think we need to work with NEL on this, and to
17 -- you know, as we've said in other examples
18 for, you know, the AICR report just published
19 from --
20 MEMBER RIMM: Yes.
21 CHAIR VAN HORN: -- the, you know,
22 cancer people, and the 7,000 reviews they did,
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1 you know, that would be foolish to go back
2 over that territory.
3 MEMBER RIMM: Yes.
4 CHAIR VAN HORN: So I totally
5 agree that we should borrow from the existing
6 reviews that have, you know, been --
7 MEMBER RIMM: This is us, I mean--
8 CHAIR VAN HORN: Right.
9 MEMBER RIMM: I mean, this is
10 Larry. Larry wrote this five years ago. Is
11 he going to --
12 CHAIR VAN HORN: You want to go do
13 it again?
14 MEMBER RIMM: -- exactly cut and
15 paste things that he wrote before? And I
16 think that -- I think we should do that.
17 MEMBER SLAVIN: We need him to
18 sign a disclaimer first so they don't sue us.
19 MEMBER RIMM: Yes, right.
20 MEMBER SLAVIN: But otherwise we
21 can steal, right?
22 CHAIR VAN HORN: Right. Let me
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1 add one more thing though, because especially
2 on fiber, in fact, as soon as you were done,
3 Eric, I was going to jump in with this issue
4 because this is one that I'm particularly
5 conscious of. Why? Because of the inadequate
6 intake in our American diet right now.
7 I mean, when we look at what are
8 the nutrients that are shortfall nutrients,
9 Americans eat half -- half as much dietary
10 fiber as they should. And we all know that if
11 we could flip it around and that people would
12 just consume adequate sources of dietary
13 fiber, a lot of the other things we're trying
14 to do would fall into place.
15 So in my mind, you know, I agree
16 with you completely that, rather than spending
17 additional time looking for yet another reason
18 to talk about how wonderful dietary fiber is,
19 we need to borrow from what the Nutrient
20 Adequacy Committee has been advocating, which
21 is let's show people how to add more dietary
22 fiber to their diet in order to achieve those
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1 goals and make that happen.
2 I mean, that's been something on
3 the reports for the last ten years that I'm
4 aware of that we don't get enough dietary
5 fiber. We all know that but nothing's been
6 really done about that in terms of increasing
7 it. So to me that would clearly be a message
8 that needs to be made somehow better and more
9 effective in terms of improving that very
10 important component of the diet.
11 And as I said, the things that
12 keep company with that change could actually
13 help us in terms of achieving other goals.
14 MEMBER SLAVIN: And, you know, I
15 think that's a good example, too, with the ADA
16 evidence-based -- you know, because the
17 dietary fiber position paper we just wrote and
18 published in October of 2008. So there's a
19 ton of work that's already done. You just use
20 that. And that's why whenever we get into, we
21 can only use certain data or, you know,
22 there's got to be a randomized trial or
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1 anything like that.
2 I think each of these questions is
3 going to have to line up fairly differently.
4 Because if there is a systematic review,
5 great, that helps us out a lot. If there's
6 nothing, then, you know, like we'll have to
7 start more from scratch. So each of these
8 searches is going to look real different.
9 MEMBER RIMM: But on a -- this is
10 Eric again. On a related note, you're not
11 going back to all the questions that were
12 there in the 2005 report, so should we assume
13 that the three that you didn't go back to fall
14 off the map and aren't important?
15 I think that's what I'm struggling
16 with. Some of the things that we're doing, I
17 know we would find the same answer if we
18 looked again. Is it worth having them there,
19 or just getting rid of them and saying, okay,
20 we don't have to go through that again, even
21 though --
22 MEMBER SLAVIN: You mean like
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1 dental caries?
2 MEMBER RIMM: You don't want to --
3 yes. Right. Do you need to drive that point
4 home again. I guess so. Can we just have
5 conclusions -- at the end have conclusions
6 we're carrying forward from the last report,
7 as opposed to having to go through and
8 document every one of them?
9 MEMBER PI-SUNYER: Eric, I don't
10 think we've resolved this issue about how to
11 write this up. I mean, I agree with you. I
12 mean, I wrote the glycemic index stuff last
13 time. I could just grab it and put it back in
14 verbatim.
15 But we really haven't resolved
16 that, how we're going to do that, are we going
17 to put it in quotations, or are we going to
18 say "This is what we said," and then add a
19 paragraph or --
20 MEMBER RIMM: I think we all need
21 to do the same thing, whatever it is, across
22 each chapter, and that's why I brought it up
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1 now before I have to give my talk and say
2 that.
3 MEMBER APPEL: Well, I am a little
4 bit out of the -- I did update the water
5 chapter, and my fundamental premise was that
6 like this is a textbook, you know, and this is
7 version two. We did version one, and we
8 really fine-tuned that text, you know,
9 massaged it to, you know, on both the
10 conclusions as you know, we tortured ourselves
11 in the text.
12 Why rewrite everything, you know,
13 and it's just a matter of figuring out how we
14 describe the new text, the new conclusions,
15 the grade of evidence and the additional
16 literature and, you know, maybe -- I have one
17 prototype we could use but, you know, you
18 might want to not look at it and think about
19 how you would do it, and then we'll take the
20 best of both sides and make it --
21 VICE CHAIR FUKAGAWA: Naomi
22 Fukagawa. So I think the question about
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1 satiety and the components of the diet that
2 influence behavior and satiety is extremely
3 important. But the field of the connection
4 between the gut and the brain is also a field
5 that's really, you know, exploding. How do
6 you propose to approach, you know, melding the
7 two areas since it could truly be overwhelming
8 because we don't want to just do protein-
9 carbohydrate, because we want whole foods, et
10 cetera? Just a thought.
11 MEMBER SLAVIN: Joanne here again.
12 Thanks, Naomi. I live in this world, so yes.
13 You know, I think the prebiotics-probiotics
14 will -- that is another kind of new topic to
15 think about where you get into the gut and
16 brain reactions, but also, yes, for sure,
17 satiety and the gut hormones and huge
18 literature base.
19 I think it, you know, when I -- I
20 always don't want to get too far off of
21 dietary guidance because each of these topics
22 can, you know, quickly expand to a huge
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1 literature base and not -- at the end of the
2 day I don't know how much information it will
3 give us to help people eat better.
4 So I guess it could -- you know,
5 for the satiety for sure, that if you look at
6 the literature, lots of things are affecting
7 it besides just the macronutrients, fiber, gut
8 fill, feedback from gut hormones.
9 So I guess that could be explained
10 in the beginning section. You know,
11 summarized just so people understand it's
12 fairly complicated.
13 CHAIR VAN HORN: Right. I think
14 that issue and then, Mim, you'll be next. But
15 I think that the issue that you're just
16 raising is the one that we keep coming back to
17 which is, we have to establish up front in our
18 report what we did and why we did it.
19 And the decision-making process is
20 something that collectively I think that's
21 what we're charged to do. So, you know, I
22 don't think there's any one right way or wrong
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1 way to do this. We are now engaging in a new
2 -- this will be the first time, really, that
3 we're basing everything on an evidence base
4 that was not previously available. So we're
5 breaking new ground even in that.
6 But in addition, as we've said
7 over and over every time we meet, you know,
8 we're presenting this report through the
9 filter of an obesity epidemic and an obese
10 environment that we are taking very seriously
11 as we go forward with these recommendations.
12 And so I think as we begin to make decisions,
13 I think that will be one of the considerations
14 we make over and over again, is how is this
15 going to help us with our obesity problem?
16 How is this going to help us in making changes
17 in that regard.
18 And I think if we kind of keep all
19 those factors together -- and I feel it
20 already. I don't know if you do, but now that
21 we've met this number of times, I feel that we
22 are moving closer to some decisions about some
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1 of these programmatic decisions. And as the
2 expertise comes forth in terms of the
3 components within each question, I think,
4 again, as I said to Cheryl, we have to rely on
5 the body of experts that are dealing with it
6 to help make some of those decisions.
7 And I think -- you know, I agree
8 we have to come up with some standardized
9 approaches. We can't do one thing in one
10 group and another thing in another. But I
11 think that will become abundantly clear. None
12 of us want to review data that has already
13 been really well-reviewed, and we do want to
14 take advantage of new data that might help us
15 go forward in the time ahead.
16 Mim.
17 MEMBER NELSON: Just a follow up
18 on that. This is Mim Nelson. Larry, I think
19 I'm -- and maybe Linda, this is what you're
20 just saying, I think the way to deal with
21 those questions that are basically the same
22 questions, and the evidence is pretty much the
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1 same, but there may be some tweaking, as you
2 said, you just -- you update it, you edit it,
3 but you don't need a whole NEL search.
4 And I'm thinking of fiber in
5 particular. Joanne, I think that, you know,
6 one of the important things that's different
7 in fiber, and you certainly know this area
8 better than I do, but it's fiber in foods not,
9 you know, just sprinkling fiber that makes the
10 difference, you know.
11 And that's actually a difference,
12 and that will be important to sort of
13 highlight. And so I think it's -- I mean, I
14 don't think you just necessarily -- that we --
15 I can't imagine we are just going to lift, you
16 know, three columns and it's exactly the same,
17 put it in italics, and this was from -- it's -
18 - you know, that there is some editing, but
19 understanding that there's not much
20 difference, and that's fine to say.
21 CHAIR VAN HORN: Rafael.
22 MEMBER PEREZ-ESCAMILLA: Yes. One
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1 of the public comments from the American
2 Dietetic Association has been do we need to
3 revise the Guidelines every five years, or
4 should it be done every ten years. So I think
5 that the outcome of this issue, and it's going
6 to help a lot to answer that question because
7 if it ends up being a very similar report to
8 the 2005, it would suggest to me that, you
9 know, maybe five years is not the right amount
10 of time.
11 But given all of the discussions
12 that we've had, I don't think that's going to
13 be the outcome. I think there's going to be
14 quite a bit of new information.
15 CHAIR VAN HORN: Right.
16 MEMBER PEREZ-ESCAMILLA: And
17 approaches.
18 CHAIR VAN HORN: Right. And to
19 that very point, I agree with you completely,
20 Rafael, and in the discussion we had in one of
21 our subcommittees, I don't remember which one,
22 that issue came up as being if related to the
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1 access to the existing data, in terms of what
2 the NHANES data show currently related to
3 actual intake.
4 And our strong suggestion, as we
5 go forward, is that if it's going to continue
6 to be every five years, then the subsequent
7 group needs to be able to look at the progress
8 that was made since the other report and be
9 available -- have available to them the
10 current intake of the American public so that
11 a new guideline can be made on the basis of
12 what people have done since the last report.
13 If that can't be done, then ten
14 years probably is the right time frame. But
15 if it can be done -- and I don't see why it
16 can't be, given the current electronic age,
17 then that would be the strong recommendation.
18 And as I said about dietary fiber,
19 we see it. It's right in front of our eyes.
20 People don't eat enough dietary fiber. That's
21 a huge teachable moment here that, you know,
22 can help us flip this around. And so I think
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1 that is the beauty of gathering together,
2 taking the evidence, but also looking at what
3 the problems are, and how to go about fixing
4 them.
5 Other thoughts, comments about
6 anything that we've said this morning, because
7 we are rapidly approaching the lunch hour?
8 Any other topics, cross-cutting or otherwise?
9 All right. Well, thank you all
10 for a very, very lively discussion. We will
11 adjourn now until 1:30, 1:15. Maybe we can
12 start at 1:15, since we're breaking a little
13 early, and we'll pick it up with Eric and
14 alcohol.
15 So thank you.
16 (Whereupon, the above-entitled
17 matter went off the record at 12:00 p.m. and
18 resumed at 1:27 p.m.)
19 CHAIR VAN HORN: Welcome back. We
20 are delighted to be resuming our discussion
21 today in regard to the updates from the
22 various subcommittees of the Dietary
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1 Guidelines Advisory Committee, and now we will
2 be hearing Dr. Eric Rimm fill us in on
3 ethanol.
4 MEMBER RIMM: Thank you. Before I
5 start, I'd like to thank my colleagues at the
6 USDA and HHS, which have been instrumental in
7 putting this together. Rachel Hayes and
8 Patricia Guenther who -- as well as a few
9 others, but thank you, Rachel, for pushing us
10 along and putting together a lot of the
11 background for the talk today.
12 So, actually, maybe I'll -- I'm
13 going to change a little bit about what I was
14 going to say based on the conversations we've
15 had in the last two or three hours about what
16 to do about guidelines that were made in the
17 past which may or may not change. So I wanted
18 to quickly preface some of what we're doing
19 now and how we're going forward based on what
20 was said in 2005, and one of the first
21 questions they asked was among persons who
22 consumed four or less drinks per day, what is
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1 the dose response between alcohol and health.
2 And this was the answers or the
3 conclusions that were made, that one to two
4 drinks per day lowers total mortality. One to
5 two drinks lowers CHD, and one drink slightly
6 increases breast cancer. And these actually
7 are unlikely to change, and so at our meeting
8 yesterday which was actually incredibly
9 helpful, I mean, I think the decision was that
10 we don't really need to pursue this further.
11 But in light of what Joanne's
12 doing, I think maybe I will pursue this
13 further myself, and just summarize any new
14 evidence that has been published in the last
15 four or five years which I assume will support
16 this. Most of what I've read will continue to
17 support this. So I'll update what was said
18 before, but I don't think we're going to push
19 the NEL database to try to, you know, come up
20 with a new review of these three topic areas.
21 However one thing that is
22 different between the Dietary Guidelines and
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1 between NIAAA's recommendation is that the --
2 I think we should pursue looking at drinking
3 patterns. There has been a fair bit of
4 research I know for a fact in the last five
5 years, but also even previous to that in the
6 last five to ten -- ten to 15 years on
7 drinking patterns influencing alcohol intake
8 and health.
9 So if you go back and look at the
10 2005 Dietary Guidelines I have a quote here
11 from the actual Dietary Guideline which says,
12 "This definition of moderation is not intended
13 as an average over several days, but rather as
14 the amount consumed in any single day."
15 So -- which means that if you --
16 let's use males as an example. If you drink
17 and do so in moderation, that would be two
18 drinks a day or less. But that's meant to be
19 that day.
20 And if you look at NIAAA's
21 recommendation, which I'll -- I don't have it
22 on the slide, but I'll just read from my
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1 computer. It means that a man should drink no
2 more than four drinks in any one day, but no
3 more than 14 in any one week, which means that
4 you are allowed to sort of space out your two
5 drinks per day over the course of the week, as
6 opposed to only having two on any given day.
7 And I know that we all can sort of
8 joke about that and think about our own
9 personal experiences, or we can actually look
10 at what the literature shows us. And I think
11 there are -- everybody knows that we didn't
12 intend for you to have all 14 drinks on Friday
13 night.
14 But as I actually remember back to
15 the first time I talked about this nine months
16 ago, there is now a body of literature to
17 suggest that having it on three or four days
18 per week may give similar benefits.
19 So what I will probably be doing
20 is updating those key areas which I talked
21 about, heart disease, mortality and breast
22 cancer, with respect to drinking patterns and
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1 potentially come up with different -- slightly
2 modified dietary guidance which hopefully will
3 be more in line with NIAAA as well as other --
4 other bodies that have talked about alcohol in
5 moderation.
6 So we sort of reviewed the areas
7 where we thought there would be the lowest-
8 hanging fruit and the most literature on
9 drinking patterns and that would be in
10 cardiovascular disease mortality, blood
11 pressure, diabetes. And because patterns are
12 a little tricky when it comes to accidents and
13 falls and trauma, I thought it was important
14 to include this because even though someone
15 may, a male, may be drinking up to four drinks
16 in any one day, a woman up to three drinks in
17 any one day, that actually could be associated
18 with increased risk of falls and trauma and
19 accidents.
20 So we did our search and sort
21 plan, we went through and I picked 1995 as our
22 arbitrary date to go back to. Joanne picked
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1 2000. Christine picked 1970. I picked 1995
2 mostly out of my sort of knowledge of the
3 data, that it wasn't until the mid-1990's,
4 maybe a little bit before, before people
5 really started doing rigorous long-term
6 studies on drinking patterns in chronic
7 disease.
8 So there were some studies in the
9 Eighties on binge drinking and hemorrhagic
10 stroke, but we'll see what we get here, and if
11 we like, we'll go back further if we feel like
12 we've missed something.
13 What is the relationship between
14 alcohol intake and weight gain? This was the
15 one that we thought we actually could start
16 on. It was something that was relatively
17 well-defined. You could come up with a PICO
18 terms for this and sort of get going, and
19 hopefully have this as our chapter -- or as
20 our summary and conclusion by the end of May
21 or early June.
22 This is something that the
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1 previous guidelines did take on as a question,
2 as one that they got to the end and said
3 there's not enough data. There's no evidence
4 to suggest that drinking in moderation is
5 associated with weight gain.
6 There have been a lot of studies
7 in this area. It's also an area where there
8 haven't been long-term trials, obviously, but
9 we also felt that the 7200 cross-sectional
10 studies that were out there that were probably
11 going to be picked up by the NEL group would
12 not be worth reviewing because there are so
13 many reasons that people start and stop
14 drinking, and if one of them is related to
15 body weight, cross-sectional studies on
16 alcohol and body weight wouldn't be that
17 useful.
18 And since there are a number --
19 actually a lot more prospective studies now on
20 alcohol and weight gain, I thought we would
21 review those. And as Larry pointed out, even
22 those are complicated because of just the many
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1 different ways you can analyze prospective
2 data where you have repeated measures of
3 alcohol and body weight.
4 Nonetheless, we'll take that up as
5 sort of our first charge. And also, we're
6 also going to have some summaries from NHANES,
7 which we'll be looking at, specifically the
8 contribution of alcoholic beverages relative
9 to other major sources of discretionary
10 calories among those who consume alcohol. So
11 that may be part of our chapter, but it will
12 be descriptive in nature.
13 We also wanted to look at how
14 effective -- how effective are predictors of
15 alcohol-related disorders. There are always
16 the sort of the list of disclaimers of who
17 should not drink, and we wanted to see if we
18 could examine that in a little bit more detail
19 to see if there are better predictors of who
20 may go on to drink at an unhealthy -- in an
21 unhealthy range, either in their midlife or in
22 older ages.
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1 And, again, this is probably a
2 pretty long literature. We talked to -- we
3 had a conference call with people from NIAAA
4 who pointed us to some really nice resources
5 that they have now on a new NIAAA website that
6 was launched in February of 2009. So we may
7 lean on that a bit for this, and plus we'll do
8 a search back to 1995.
9 This is the one where I've turfed
10 a bit off to Joanne and others, and since
11 she's not listening, it's perfect. She
12 accused me of not listening, so I wanted to
13 catch her up for that.
14 What is the relationship between
15 consuming alcoholic beverages and macro and
16 micronutrient profiles in overall metabolic
17 consequences? And this one started out as
18 many different questions that we ended up sort
19 of shrinking into one to make it a little less
20 work.
21 There's issues related to alcohol
22 and folate status, issues related to alcohol
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1 and glycemic index of the diet, and there's
2 issues related to alcohol in altering
3 macronutrient profiles.
4 So we put this on hold, and I
5 guess we could take parts of it back or we
6 could help you out, Joanne, or help out the --
7 help out Shelly, if necessary, if it becomes
8 part of it. But we are going to do at least
9 an NHANES analysis to look at how much energy,
10 sugar or other carbohydrate, protein, and fat
11 is provided by alcoholic beverages, among
12 those who consume beer, wine and spirits.
13 We will have sort of, I think, the
14 standard equivalency as part of our Guidelines
15 showing that the ethanol in beer, wine and
16 spirits is about the same. However, there is
17 the point that not everybody drinks beer
18 straight or wine straight or distilled spirits
19 straight, and that there may be other calories
20 that come along with -- well, I guess wine,
21 you almost always have as wine.
22 But I guess if you have wine
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1 coolers, maybe not, if there's added sugar
2 there and distilled spirits. If you have a
3 White Russian, it comes with milk and
4 calories, and I guess beer you usually drink
5 alone.
6 But we -- we actually have the
7 ability to -- we have the ability -- not
8 "alone." I meant it's not mixed. It's not
9 mixed with other calories.
10 So with the NHANES data, we
11 actually have some ability to look at on
12 specific days where it was measured, where the
13 other calories came from. So that will be, I
14 think, more of an informative descriptive
15 analysis than anything that answers any
16 specific question.
17 So this is our action item in
18 order of the questions, what is the
19 relationship between alcohol intake and weight
20 gain, which we'll be starting on. Question
21 one, again, is the drinking patterns.
22 Question three is the how
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1 effective are predictors of alcohol-related
2 disorders, which will be both using NIAAA's
3 website as well as the new search, and finally
4 question four, which will be tabled and passed
5 to energy balance.
6 I think that's it. Yes. So I
7 thought that would be quick, and I'm more than
8 happy to take questions.
9 CHAIR VAN HORN: Thank you, Eric.
10 Just to set the record straight, in
11 Pittsburgh they drink a shot in a beer. I
12 just wanted you to know that.
13 All right. Cheryl.
14 MEMBER ACHTERBERG: This might be
15 for the future, but if some modeling is done,
16 it might be interesting to look at the
17 potential of legalizing alcohol at age 18, and
18 then what impact would that have on the diet
19 for those 18 to 21 year olds, if -- if you
20 made certain assumptions and put that in
21 there.
22 MEMBER RIMM: I'm guessing that is
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1 way beyond the purview of the Dietary
2 Guidelines, but --
3 MEMBER ACHTERBERG: I said for
4 future.
5 MEMBER RIMM: Yes. No, I mean,
6 that's -- and I know that's been kicked
7 around. There's lots of governors and things
8 like that who are trying to change the -- or
9 potentially change the drinking age.
10 Yes. Okay. Well, I mean, I guess
11 it could be something that we have in our sort
12 of recommendations for future study. I know
13 people are studying the impact of alcohol
14 consumption if you change the guideline. I
15 don't think anybody's looked at the impact of
16 what happens if 18-year-olds start to drink
17 and do they eat more pizza and things like
18 that.
19 Oh, sorry. If 18-year-old's
20 legally drink, does that impact their --
21 right, diet and pizza, doughnut and pizza
22 consumption, correct.
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1 CHAIR VAN HORN: The other
2 question that I would just raise, in terms of
3 our ongoing discussions about discretionary
4 calories and, you know, the concept of where
5 those calories might come from, would you
6 think that that topic related to the caloric
7 intake related to alcohol might be something
8 to consider in terms of weighing and
9 balancing, you know, weight control in terms
10 of alcohol intake?
11 MEMBER RIMM: Yes. I mean, I
12 think the -- our biggest challenge will be to
13 see if we can come up with something which we
14 feel comfortable with for a conclusion like
15 the alcohol and weight gain because that
16 obviously will tie in with energy balance.
17 And if -- if we are comfortable enough, it's
18 not like there's suddenly magically going to
19 be 15 cohort studies that all descend upon us
20 that say there's no association.
21 But I know there is a reasonable
22 amount of evidence on moderate consumption and
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1 weight gain, so you know, I hate -- I don't
2 think I want to go beyond the Guidelines where
3 we are right now, in terms of drinking more,
4 although I guess you could make the argument
5 that if we changed the Guidelines or altered
6 the Guidelines to be more in line with
7 patterns of consumption described by NIAAA on
8 those days where people have -- men have four
9 drinks and women have three drinks, that
10 actually could contribute a fair bit to their
11 calories on that day, up to 15 or 20 percent.
12 So I think that's a good point. I
13 think it's probably worth at least having some
14 comment on that or some discussion on that.
15 CHAIR VAN HORN: The data that
16 I've seen observationally suggests that, you
17 know, alcohol keeps company with more
18 saturated fat calories, more sodium calories,
19 et cetera.
20 So it's not only the alcohol, it's
21 the company it keeps, and the fact that, you
22 know, disinhibition, the more alcohol you
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1 drink, often accompanies, you know, selection
2 of foods that you might not otherwise choose,
3 so if indeed weight control is your goal, this
4 whole concept of discretionary use of calories
5 knowing that other calories you eat along with
6 that, you know, could undermine your attempts.
7 MEMBER RIMM: Yes. I mean, that's
8 -- I have seen some of that literature, too,
9 and it's a challenge because, you know,
10 there's a hundred prospective studies saying
11 that alcohol in moderation lowers risk of
12 heart disease.
13 So if it's coming with a lot of
14 saturated fat and sodium, I don't know if
15 that's contributing enough to the overall
16 average intake of the diet to impact heart
17 disease because in those studies you control
18 for diet or you don't control for diet, it
19 doesn't make any difference.
20 So, you know, I think the
21 hypertension research may be a little bit
22 trickier because clearly at the high end there
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1 is an association between alcohol and
2 hypertension, and maybe some of that is
3 disinhibition at four drinks a day and you're
4 eating lots of sodium.
5 But in light consumption, if
6 anything, it lowers blood pressure because of
7 vasodilation and other factors. So, I mean,
8 there is literature. I guess it's probably
9 worth looking into it, though.
10 MEMBER APPEL: This is Larry
11 Appel. I'd like to follow up on what you
12 said, Linda, about sort of the association of
13 other nutrients. I was one of the people that
14 asked Gary to table question four, and I
15 wanted -- I think it's relevant to discussions
16 about other nutrients.
17 I said, you know, we could look
18 at, you know, the nutrient intakes of
19 nondrinkers, people who are one drink a day,
20 two drinks a day, four drinks a day. But, you
21 know, I said, well, that's -- you know, that's
22 interesting but, you know, it's almost like
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1 saying, well, what are the nutrient intake of
2 people with low saturated fat versus middle
3 versus high or, you know, the same thing is
4 like low versus middle versus high, any other
5 nutrient.
6 And is it really that relevant
7 when we're saying, you know, I think most
8 people believe that you can consume one or two
9 drinks and eat a healthy dietary pattern,
10 which is the issue.
11 So I felt that question four
12 really might not just be tabled, but just
13 eliminated or part of it, but I don't want to
14 -- I'd be interested in hearing what other
15 people have to say about this.
16 MEMBER RIMM: I think that, to
17 Linda's point, I think it is a good point,
18 just because if you eat low-saturated fat it
19 doesn't have a biological impact on you that's
20 going to impact diet and your dietary intake
21 of other factors.
22 Alcohol clearly does lead to
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1 disinhibition, so there is -- the issue is
2 while you're drinking the alcohol, does it
3 impact your diet, and there is literature on
4 that. So, I mean, again, I don't know if it's
5 going to necessarily rise to the level of a
6 NEL search unless we really think there's
7 enough out there or unless the -- you know,
8 Shelly or Joanne thinks that we should address
9 it because they can't address it in their
10 sections.
11 MEMBER SLAVIN: This is Joanne
12 Slavin. I just think of all of alcohol as
13 discretionary calories. It's the only one
14 that really meets that. Nobody needs to
15 consume it, so everything else, fat,
16 carbohydrates, protein, are not discretionary.
17 You know, a certain amount of them have to be
18 included.
19 So alcohol's a bit of an out --
20 you know, it hangs out -- you know, it
21 outlies, because you know, it's not necessary,
22 so it's all discretionary. It's the perfect
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1 example of what's discretionary. So and I
2 think tabling it is a good idea. I would
3 agree with that.
4 MEMBER PEARSON: Well, just to --
5 also just -- this is Tom Pearson. The other
6 thing, obviously, just to reemphasize here is,
7 is that all of this is really dealing with the
8 individuals who are drinking four or less
9 drinks per day, and there's just the
10 recognition that all of the health data are
11 bad of that, so we really -- I'm not sure if
12 you said that specifically, Eric, but I just
13 wanted to make sure that that assumption was
14 here, and so the issues of what is likely to
15 change are in that range of consumption rather
16 than heavy alcohol.
17 MEMBER RIMM: Well, there still is
18 data on disinhibition below five drinks a day.
19 I mean, people still -- potentially -- again,
20 I'm not speaking from personal experience.
21 I've heard that there -- I mean, there is --
22 it can impact your diet even when you're not
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1 drinking --
2 MEMBER SLAVIN: Hey, Eric, we all
3 know you're from Wisconsin, so, come on.
4 MEMBER RIMM: So the -- actually,
5 the other point that I didn't bring up, which
6 is what I should have, based on some things
7 that were said earlier is that we -- we
8 probably will lean a bit on the WCRF report
9 for alcohol and cancer.
10 It's not that I've left that out,
11 it's just that they've done the world's best
12 review on alcohol and every possible cancer
13 that was published only six months ago. So
14 rather than, you know, putting more weight on
15 the NEL database to do that over again, that
16 we’ll -- we'll lean on that a fair bit.
17 CHAIR VAN HORN: I just -- just to
18 mention one more time, the caloric issue
19 because, at minimum four drinks would be, at
20 minimum 400 calories, and could be
21 considerably more than that depending on what
22 you're drinking and what you're concocting
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1 within that.
2 And, again, as we were talking
3 about beverages, this is another one of those
4 occasions where calorie consumption could
5 really be significant and by most people's
6 standards, not even recognized as being such a
7 major contributor, not only because of the
8 calories from the alcohol itself but, again,
9 the disinhibition that accompanies it. So I
10 think that's the only point I'm trying to
11 make.
12 Rafael.
13 MEMBER PEREZ-ESCAMILLA: Rafael
14 Perez-Escamilla. Eric, if I understand
15 correctly, the way you are defining alcohol
16 intake patterns is based on the frequency, the
17 number of drinks?
18 MEMBER RIMM: Yes. It's based on
19 average. I mean, before everything was based
20 solely on average and not on frequency, and
21 now we'd like to take frequency into account
22 by looking at alcohol patterns which is
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1 frequency and average.
2 MEMBER PEREZ-ESCAMILLA: Okay.
3 Because when I hear that word "patterns," it
4 also brings to mind the issue of the type of
5 drink, and I know from your previous
6 presentation that the benefit has been found,
7 irrespective of the type of drink as long as--
8 MEMBER RIMM: Correct.
9 MEMBER PEREZ-ESCAMILLA: -- it has
10 ethanol. But I still think that understanding
11 the dietary intake patterns associated with
12 different types of drinks, and even within
13 wine, for example, red versus white. So it's
14 a whole issue of what are people eating with
15 different types of drinks, you know, hard
16 liquor versus beer, versus wine, red versus
17 white wine. I think that descriptive
18 information may be -- may be useful to know.
19 MEMBER RIMM: Yes. And I think we
20 will have some of that from NHANES. I think
21 it's only descriptive in nature, though. It
22 doesn't -- it doesn't lend itself to a
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1 guideline.
2 It's not like I'm saying, "Well,
3 if you drink red wine, then therefore, you
4 should have this type of food." I think it --
5 you know, if this was a research article it
6 would be interesting in that we could describe
7 the different patterns in this country. And
8 people have done that here and in Mexico and
9 in France and other places, and there are
10 distinct differences in how people eat based
11 on what their choice is, their beverage choice
12 is, and it's dependent on culture.
13 So, yes, I mean, it could be part
14 of a description. I just don't think it will
15 change. Well, maybe it will change, you know,
16 our discussion of calories, but I don't think
17 it will necessarily change the Guidelines on
18 alcohol.
19 MEMBER PEARSON: I haven't looked
20 at this for a few years, but I think some of
21 the patterns are more represented with certain
22 beverages than others, so that I think you
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1 probably, as we look at the patterns that Eric
2 -- as he's defining, you're probably going to
3 have to look at the type because there will be
4 more binge drinkers in, you know, the one or
5 two glass of wine day drinker is going to be
6 fundamentally different than a person who
7 binge drinks with wine, who's going to be from
8 fundamentally different than the distilled
9 spirit group. So I think you're going to
10 probably have to get into that anyway with the
11 patterns.
12 MEMBER RIMM: Yes. I mean, that's
13 -- I hate to say it, but that's a bunch of
14 Americans sitting around a table. That's a
15 bit of a stereotype here. But the world's
16 literature, if I'm going to summarize the
17 world's literature on heart disease, diabetes,
18 breast cancer, you know, it turns out there
19 are people that are binge drinkers of red wine
20 that live in France, and there are people that
21 are binge drinkers of spirits in Finland and
22 binge drinkers of beer in Germany.
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1 So the literature on chronic
2 disease is going to be across the board. So,
3 you know, we will have to see what it tells us
4 in terms of patterns.
5 CHAIR VAN HORN: Okay. That is
6 excellent. A really thorough job. Thank you
7 so much. I think we can move along and talk
8 now about fatty acids.
9 Tom.
10 MEMBER PEARSON: This is Tom
11 Pearson on behalf of our subcommittee that
12 we've renamed Fatty acids and Cholesterol. I
13 don't know if she stuck that in there.
14 And I just want to recognize my
15 subcommittee colleagues, Roger Clemens, Eric
16 Rimm and Naomi Fukagawa, and particularly
17 recognize Shirley Blakely who keeps us all
18 sane, or at least heading in the right
19 direction, and certainly the help from her as
20 well as the -- our NEL colleagues, et cetera,
21 we've -- with our working group, I've had a
22 webinar, I think a very useful webinar on
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1 omega-3 and omega-6 fatty acid ratios.
2 At our face-to-face meeting Roger
3 Clemens gave us a very useful update at the
4 Experimental Biology Symposium on some issues
5 relative to types of fats and outcomes. And
6 so I think we've had the opportunity to have
7 considerable input to this issue of fatty
8 acids and cholesterol.
9 So, if I can figure out how to do
10 this, the -- so we have five questions. I
11 think one of them is not a NEL question.
12 We're actually going to show some of those
13 data today.
14 We have -- the next two questions,
15 two and three we would have as our priority
16 one questions, and questions four and five
17 would be our priority two questions. So, kind
18 of did it that way.
19 And so, you see here the first
20 three questions was the evidence for the
21 implementation of the Dietary Guidelines for
22 fats, going back well before 2005, in fact.
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1 The second is what is the
2 influence of dietary fat and cardiovascular
3 disease and other health outcomes, and the
4 third is what dietary components affect plasma
5 LDL, HDL and non-HDL cholesterol.
6 And question two and three have
7 considerable overlap with the 2005 Guidelines.
8 Just a comment at this point, that non-HDL
9 cholesterol was used instead of triglycerides
10 since it does have some target values in the
11 Adult Treatment Panel of three guidelines in
12 terms of therapeutic targets and therefore
13 possible goals for guideline implementation.
14 And so I'm going to be talking
15 about each of these questions. Just in terms
16 of the other two questions, the relationships
17 between consumption of n-6 and n-3 fatty acids
18 and the health outcomes, and then an area of
19 discussion that we'd like to bring before the
20 whole group for certainly some resolution,
21 associations between -- of consumptions of
22 fats from specific foods.
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1 This is a very careful wording, so
2 we're really interested in not just foods with
3 fats, but fats from foods -- there's a
4 distinction. And so there are three
5 particular foods, nuts, fish and chocolate
6 that have enough data to talk about them in
7 terms of specific, in which the fats from
8 those foods may, in fact, have a meaningful
9 health outcome.
10 So, I did want to spend a little
11 bit of time with this first question which is
12 really a question from a number of the
13 databases that we have available, and I want
14 to thank Pat Guenther and others for pulling
15 these together for us.
16 And so what's the evidence for
17 implementing the Dietary Guidelines for fats,
18 and the question is: How did intakes of fat
19 and cholesterol by Americans change between,
20 say, the late 1970's and the latest data we
21 have available, 2005 and six, according to our
22 dietary surveys, how did they change in terms
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1 of the absolute amounts consumed, and how did
2 they change relative to the distributions of
3 macronutrients that is a percent of calories
4 as fats.
5 And I think there's probably a
6 back drop here to talk about. The 2005
7 Guidelines certainly had particularly focused
8 on atherosclerotic cardiovascular disease,
9 coronary heart disease and stroke,
10 particularly as issues related to dietary fats
11 and cholesterol, and that's certainly
12 appropriate.
13 It's probably also appropriate to
14 say that despite mortality reductions in those
15 diseases, the incidence data, in new cases of
16 those data, I think -- and they've been just
17 reviewed as recently as the cardiovascular
18 pulmonology meetings suggest really no change
19 in the incidence of these major killers in the
20 United States since certainly 1990 and
21 possibly even 1980.
22 Certainly we had tremendous
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1 reductions in both incidence and mortality
2 from, say, 1968 to, well, say, 1990, but the
3 mortality reductions since 1990 had to do more
4 with the reductions of case fatality rates
5 than really the decrease in incidents.
6 So, we're doing a better job in
7 keeping people alive and converting these
8 diseases from fatal, acute diseases to chronic
9 debilitating diseases, and the attendant
10 health care costs.
11 I think also is the suggestion of
12 cereal, and some of this is NHANES data as
13 well, is the suggestion that blood cholesterol
14 levels in the United States have not changed
15 since, say, 1990, and some of the changes that
16 have occurred, particularly in men are
17 probably attributable to pharmacologic agents,
18 certainly HMG-CoA reductase inhibitors are the
19 number one class of prescribed drug in the
20 United States, and so there is some non-
21 dietary factors dealing with that as well.
22 So, in that backdrop, then let's
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1 look at the data talking about the intake of
2 fats and cholesterols in the surveys that we
3 would say would be most representative of
4 Americans.
5 And, as you can see the surveys
6 across. So, there's really quite a bit of
7 data. Look at the numbers, as you can see
8 them, and obviously these have been thought to
9 be representative, statistically
10 representative samples in the United States.
11 Having said that, we will
12 recognize the methodological vagaries of
13 dietary assessment going forward, and I think
14 what our conclusion was, is this is the -- the
15 closer you got to the right margin, the more -
16 - the more certainty you had of -- of
17 methodological consistency.
18 In other words, those on the left
19 side, particularly the NFCS had a number of
20 methodologic differences, and I think Eric had
21 pointed out particularly the undercounting of
22 calories in -- in the 1977 surveys, and
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1 perhaps even the 1989 surveys.
2 Having said that, and to be
3 honest, et cetera, I think as you go along,
4 there's relatively little evidence to suggest
5 in terms of absolute amounts that the amount
6 of fat consumption has done much in the United
7 States, possibly even gone up.
8 That's the second line there. The
9 saturated fat, again, in terms of grams --
10 thank you very much. -- also has been I think
11 really quite flat, again, if anything has gone
12 up, the polyunsaturated fats may actually have
13 increased quite a bit, and the monounsaturated
14 fats have perhaps increased somewhat as well.
15 For the dietary cholesterol in
16 terms of milligrams per day, I think what you
17 can see is -- is certainly, since, say 2000,
18 very little changed and perhaps a little bit
19 of an increase since, say, the 1990's, et
20 cetera.
21 And then what you can also do is
22 then look at these in terms of percent of
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1 calories and their -- you can recognize that,
2 and particularly the bottom line there, maybe
3 asking you to go down to the bottom, the
4 energy kilocalories you can see, as we know
5 with our obesity epidemic, there's been this
6 increase in -- in calories over this time
7 which, of course, is part of the denominator
8 for the percent of calories from fat.
9 Having said that, I think these,
10 with the exception of probable decrease from
11 the late 1970's, these have been remarkably
12 stable in terms of percent of calories from
13 total fat since, say, 1990, and also with
14 saturated fat around eleven percent or so over
15 this period of time.
16 Larry.
17 MEMBER APPEL: Yes. Eric has
18 pointed out it's -- this is a pretty broad age
19 range, too.
20 MEMBER PEARSON: Yes. Absolutely.
21 MEMBER APPEL: So we've had
22 changes in the distribution of age over time.
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1 So, these are not age-standardized or
2 adjusted in any way, these are just crude
3 levels of intake?
4 AUDIENCE MEMBER: Not age-
5 adjusted.
6 MEMBER APPEL: Not age-adjusted.
7 So, it might, for -- I mean, it's going to all
8 be difficult because we don't have the data
9 sets and we might have to more finely tune
10 this to a --
11 MEMBER PEARSON: As a statistical
12 sample of the United States over this period
13 of time, I don't think the age pyramid changed
14 that much. It is worth talking about gender
15 differences, which I'll show you in a minute,
16 but I think the point is well-taken.
17 And the evidence suggests again
18 that about eleven -- eleven and a half percent
19 of calories have been from saturated fat over
20 this period of time, suggesting that, oh, say,
21 probably 60 or so percent of Americans are not
22 at our saturated fat guidelines given the
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1 distribution of saturated fat across the
2 population.
3 So, with the exception of the
4 increase in calories, you really don't see
5 very much change in the quality of the fat
6 constituents in the diet.
7 This is the data for men, just to
8 show that there are some differences here.
9 The message is that, essentially the same,
10 possible increases in saturated fat in men,
11 but I think the thing to talk about here
12 really is the dietary cholesterol with most
13 Guidelines, including the 2005, suggestion 300
14 milligrams a day, and a showing that at about
15 350 and up, this would suggest that quite a
16 minority of men in the United States are at
17 the cholesterol targets.
18 Women -- And this is the percent
19 of calories, again, not a whole lot of change
20 over this period of time. A substantial
21 increase in the number of kilocalories per day
22 in terms of energy in men.
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1 In terms of women, perhaps a
2 little bit more positive information.
3 Certainly lower grams of saturated fat.
4 Perhaps also relatively high levels of
5 monounsaturated fat, and here you can see the
6 big male-female difference and that is, is
7 that with an average of say, 230 milligrams
8 per day of cholesterol, a substantial majority
9 of women will be at the Guidelines for dietary
10 cholesterol.
11 So, this is a -- probably the
12 largest gender difference that you would see.
13 And, again, for -- it's percent of
14 energy. I think pretty similar for total
15 unsaturated fat for -- for women as in men.
16 And again, the saturated fat, if
17 anything, possibly rising over this period of
18 time. And the caloric intake actually rising
19 substantially again with the proviso that
20 there's an undercounting of this in the 1970's
21 and Eighties.
22 So, what you're left with is -- is
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1 the Dietary Guidelines, as you see here, from
2 relatively general, nonspecific guidelines of
3 the 1980's in '85 to quite specific targets
4 for total fat and saturated fat and
5 cholesterol.
6 Obviously, not a lot of progress
7 has been made. There's really -- I think it's
8 striking of the lack of change, and again,
9 with some vagaries by -- by gender but
10 essentially when you pair this to the lack of
11 blood cholesterol change and the lack of
12 coronary incidence, I think you basically have
13 essentially this level of fat and cholesterol
14 consumption committing us to the continuation
15 of our cardiovascular disease epidemic.
16 MEMBER SLAVIN: Can I just bring
17 in one thing? It's Joanne Slavin here. If
18 you go back out to the Eighties, you had like
19 40 percent of the calories from fat. There
20 really was some change there. That was
21 obviously --
22 MEMBER PEARSON: Yes. And I think
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1 all of us have seen from the 1960's and
2 Seventies and the very spotty data we had with
3 some substantial changes, this was also the
4 peak of the coronary epidemic was 1968 with
5 some very steep changes in coronary incidence,
6 according to the very few data that we have on
7 this during that time.
8 CHAIR VAN HORN: Mim.
9 MEMBER NELSON: It seems -- this
10 is Mim Nelson -- that a lot of the speakers
11 that we've heard and I'm sure there's been a
12 discussion about that a high-quality diet is
13 looking like there may be a real range in
14 terms of macronutrients in terms of fat, and
15 so I'm wondering, the utility of sort of
16 looking at this when actually what we may be
17 proposing is that a range from, you know, 25
18 to 45 or -- there's a huge range.
19 I mean, saturated fat being in and
20 of itself, it's own entity, but that in a
21 sense, does it matter now, now that we're
22 looking at it from a lens where the range, if
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1 you have fruits and vegetables in the whole --
2 you look at the whole diet, that the range of
3 fat is just fine from a health perspective.
4 So, do you see where I'm coming
5 from?
6 MEMBER PEARSON: No.
7 MEMBER NELSON: Sorry. That we're
8 presuming, or when you present this, I guess
9 I'm hearing from you -- I'm concerned, because
10 we haven't gone down in all of these things,
11 and yet what we're hearing more of, and what
12 the evidence is showing us is, in fact, you
13 don't need to come down.
14 You can be high, you can be low.
15 If saturated fat -- if we worry about
16 saturated fat, and that's there, but -- and
17 that hasn't changed, but I'm concerned and I
18 want to make sure that we don't contradict
19 ourselves.
20 CHAIR VAN HORN: Tom is not done
21 yet.
22 MEMBER NELSON: Okay.
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1 MEMBER PEARSON: Yes. We're just
2 --
3 MEMBER NELSON: Okay.
4 MEMBER PEARSON: Well, just to say
5 is, is that, you know, if you believe in the
6 work of Keyes and Hegsted and the -- all of
7 those trials that really tried to understand
8 the main determinants of group cholesterol
9 levels.
10 It was -- it was the saturated
11 fat, dietary cholesterol, and the
12 polyunsaturated fats, and there have been also
13 some equations with monounsaturated fat and,
14 again, none of those have changed.
15 But I think terms of the things
16 that keep them up, all of these guidelines,
17 obviously say "less than." Okay. There's no
18 suggestion that there's -- except that perhaps
19 extraordinarily low levels that there would be
20 any health issues there, so these are all less
21 than.
22 And so the drivers of maintaining
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1 a high population cholesterol level would be
2 the saturated fats and cholesterol. And
3 those, I think, are the particular data.
4 So, in terms of total fat, I'll
5 agree with you, and that's the liberalization
6 in the 2005 Guidelines, as well as the Adult
7 Treatment Panel 3 Guidelines of being able to
8 go up, and usually having to do with the
9 liberalization of monounsaturated fats, rather
10 than replacing those with carbohydrates.
11 So, I guess that part I am
12 agreeing with you. But it's the saturated fat
13 and the cholesterol, I think is striking in
14 the times that we've had stable high
15 cholesterol levels and stable high coronary
16 disease incidents levels, we have stable high
17 saturated fat and dietary cholesterol levels.
18 I think that's the -- that's point.
19 And so, the real question is the
20 role of the Dietary Guidelines in really
21 getting to a level where we could expect our
22 incidence of coronary disease to fall.
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1 MEMBER RIMM: So, I think -- this
2 is Eric Rimm. I think we are completely on
3 board with what you're saying. Is that, you
4 know -- in some of our discussions is why do
5 we need a -- why do we need a guideline for
6 total fat.
7 We can't base it on necessarily
8 chronic disease, but maybe is able to be able
9 to base it on weight gain, because that's part
10 of his work. And what we've heard yesterday
11 from Frank Sacks and from the trials in
12 Israel, it didn't make any difference for
13 weight gain.
14 MEMBER PEARSON: Right.
15 MEMBER RIMM: So, I think we are
16 somewhat in agreement in there, the
17 subcommittees -- clearly, there's still
18 evidence for saturated fat and trans fat.
19 MEMBER PEARSON: And as you'll
20 see, one of our questions deals with this
21 trying to tease apart that issue to confirm
22 what you supposed.
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1 MEMBER NELSON: You almost wonder
2 -- it's Mim -- if we forget about the total
3 fat recommendation and we only talk about
4 saturated fat and cholesterol, you know, it
5 would be a departure that's on the table.
6 MEMBER RIMM: It's on the table.
7 MEMBER PEARSON: Okay. So,
8 relative to the influence of a variety of
9 dietary fat constituents on cardiovascular
10 disease and other health outcomes, I think we
11 would look at these as a review of the data
12 just to identify any new information on these
13 topics over the next -- over the past five or
14 six years, and probably suggest that there
15 won't be any major changes here.
16 There may be some, relative to the
17 breadth of these -- these questions, probably
18 in cardiovascular disease, these are quite
19 well-established relationships. There may be
20 some other health issues that we would like to
21 pick up with our -- with our NEL searches.
22 So, the PICO Charts, as you see
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1 here, have to do with these dietary
2 constituents and particularly some
3 subquestions about gender differences, genetic
4 susceptibility issues, et cetera.
5 In terms of the NEL search, as you
6 can see, a lot of, again, attention on
7 cardiovascular disease and diabetes. We are
8 probably having to do with the WCRF just
9 having a thorough review of dietary fats and
10 cancer, we should refer to that rather than to
11 do that in NEL.
12 Okay. Another focus in the 2005
13 Guidelines had been relationship to serum
14 lipids, particularly LDL cholesterol. We've
15 expanded this a little bit to HDL cholesterol
16 and to non-HDL cholesterol. Both of those are
17 tertiary or secondary target values in the
18 Adult Treatment Panel III Guidelines.
19 And so, there are some
20 subquestions that we would be also looking at
21 with this particular set, and so we're talking
22 about some genetic polymorphisms affecting the
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1 associations between these dietary components
2 and plasma LDL, particularly apoprotein E, but
3 some other ones as well.
4 What is the effect of total
5 dietary fat on LDL cholesterols at different
6 levels of dietary saturated fat? This gets to
7 the point, Mim, that you were making, is this
8 really -- is this really saturated fat, or is
9 -- and then can you let the total fat kind of
10 run above that, and so that basically is
11 looking at the literature to answer that
12 question you were raising.
13 Similarly effective dietary
14 cholesterol levels of dietary saturated fat,
15 kind of the idea is, is if your dietary
16 saturated fat is, say, very low, is there a
17 good evidence to suggest that you could
18 liberalize your dietary cholesterol.
19 And we are very aware of,
20 obviously, the Keyes and the Hegsted's
21 equations about their independence.
22 There are a couple of questions.
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1 These two questions are ones that we've
2 selected in terms of doing our first NEL
3 searches and to get the evidence tables
4 together as a little pilot of all of this.
5 The first is the association
6 between LDL and dietary stearic acid. This
7 has to do with the effects across the class of
8 -- of saturated fats.
9 The potential for heterogeneity in
10 these and certainly the suggestion in a number
11 of studies that dietary stearic acid has very
12 different effects, or actually very little
13 effect on LDL, compared to the other LDH-
14 raising fatty acids.
15 And then, the next question was
16 the effects of consuming natural versus
17 synthetic trans fatty acids on these lipid
18 endpoints. So, this is -- there was quite a
19 bit of discussion on trans fatty acids in the
20 2005 Guidelines, although there was not a
21 recommendation that came from them.
22 But I think we'd like to firm up
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1 that and then do the specification of those
2 that are -- that are manufactured versus
3 naturally-occurring, in terms of trans -- in
4 terms of the general issue of the trans fatty
5 acids being deleterious, I think we were going
6 to assume that as a pretty well-proven
7 subject.
8 And so this is somewhat of a
9 smaller specification of that -- that larger
10 topic.
11 Can we advance.
12 The third question -- so, this is
13 the -- this is the PICO Chart for that. I
14 think we've talked about this relative to
15 lipid outcomes. Next slide.
16 Okay. The next question we had,
17 looking at these issues of n-6 versus n-3
18 fatty acids and health outcomes. There's
19 obviously been a literature on this and one of
20 our webinars dealt with issues related to the
21 ratio of these two as part of -- of
22 unsaturated fatty acids, polyunsaturated fatty
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1 acids in the diet, and so we're going to look
2 further.
3 I think we were able to resolve
4 with that literature, I think quite well, but
5 there are a couple of other issues related to
6 the sources of the n-3 fatty acids, the marine
7 versus plant, and I think this is a worthwhile
8 effort, as these obviously have very different
9 sources and obviously oftentimes get lumped
10 together.
11 That may be the right thing to do,
12 but it would be nice to see if, in fact, plant
13 versus marine n-3 fatty acids, in fact, showed
14 any difference in health effects.
15 And then looking at the diet
16 higher in n-6 fatty acids, lower the risk of
17 health outcomes relative to other fats in the
18 diet as a next subquestion of this larger
19 question.
20 So, the PICO Chart. Next slide.
21 You can see here now, the outcomes relative to
22 this -- thank you -- is, obviously has some
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1 broader and perhaps more specific set of
2 outcomes, neurological development, cognitive
3 development.
4 Obviously, dementia, perhaps,
5 issues as well. Serum lipids, cardiovascular
6 disease and insulin sensitivity. Again, we'll
7 -- for cancer, I think the WCRF report has
8 dealt with this and finally, macular
9 degeneration.
10 Then finally, and something we'd
11 like some input from you about was the
12 associations from these foods that have some
13 specific fat profiles, so this is fats from
14 foods, from specific foods, again, and related
15 to our willingness to look at specifically the
16 issues relative to nuts, relative to fish with
17 a collaboration with the Food Safety Group and
18 the issues that they've already discussed with
19 you, and relative to chocolate.
20 There was a number of other
21 specific foods discussed, including milk and
22 milk products, red meat, but we thought that
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1 those were really much more over into the
2 protein and other areas whereas these are
3 particularly related to the health effects of
4 their fat constituents.
5 And so the PICO Charts for this
6 looks as -- as we have it here with outcomes
7 for these also looking at the effects of these
8 on obesity and BMI, diabetes, as well as the
9 serum lipids and cardiovascular disease
10 endpoints, and again referring the cancer to
11 the WCRF report.
12 And then finally, turfing the fat
13 intake in society to our carbohydrate and
14 protein friends, and our dietary patterns to
15 particularly some of the very high or very low
16 fat diets. Some of those things that Frank
17 Sacks was talking about, obviously to the
18 nutrient adequacy subcommittee.
19 So, those are our report.
20 CHAIR VAN HORN: Great.
21 Excellent.
22 Joanne Slavin.
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1 MEMBER SLAVIN: I'm wondering
2 about for the nuts and the chocolate, you
3 know, the assumption is that it's related to
4 the fat and isn't it more of a whole foods
5 question, because the chocolate could very
6 well be all phytonutrients and have nothing to
7 do with the fat, or --
8 MEMBER PEARSON: This is the issue
9 -- chocolate obviously is a stearic acid
10 issue, but it clearly has many other
11 compounds, flavonols, theobromines, et cetera,
12 et cetera, and so you may be -- may be right.
13
14 But it was a largely fat product
15 that we were looking at as the fats in those
16 foods being -- having any health effects, with
17 the possibility of identifying any other
18 health effects in the trials that we're
19 looking at the fat issues.
20 But, you know, we're -- if you
21 would like to steal them from us, we could
22 probably be argued out of it.
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1 MEMBER APPEL: Larry Appel. I'm
2 not sure this goes to Tom or to Linda or to
3 the whole group, but your first question
4 dealing with trends, and I think it's sort of
5 stimulated by a lot of discussions we've been
6 having today about like what are the impact of
7 these Guidelines.
8 So, is this something that is just
9 isolated to your chapter, or should we be
10 thinking about sort of a parallel set of
11 tables for some of the recommendations that
12 have been made, you know, whether it's for
13 sodium or fruits and vegetable intake, and
14 then rather than sort of like having a -- this
15 gets to an issue of standardization.
16 I mean, if it's an important
17 enough issue for your chapter, I think you
18 could make the same argument for a few of the
19 repeated recommendations in other chapters.
20 If you looked at the -- I'm sure
21 you have. There were, I think, similar kinds
22 of trends in some of the chapters of the 2005
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1 Guidelines so your point, Larry, is very well-
2 made, that -- that this may be something we'd
3 like to standardize, just, say, in 2005 there
4 were some trends over, say, the last 20 or 30
5 years, and for some issues and not for others.
6 So, I think that really is
7 probably a group decision that we'd want to
8 make.
9 I think they are quite informative
10 relative to the -- the -- what we've been
11 talking about is really developing Guidelines
12 that would really make a difference.
13 MEMBER PI-SUNYER: I would --
14 Xavier here. I would agree with that. I
15 think that -- and it does show the lack of
16 impact in many of these trends over the years.
17 In fact, some of them have gotten worse.
18 So, I think it would be a good
19 thing to have more of them, as indicative of
20 where our problems are.
21 MEMBER RIMM: This is Eric. This
22 wouldn't quite speak to the 2005 Guidelines
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1 yet, because this is NHANES 2005-2006.
2 MEMBER NELSON: Right.
3 MEMBER RIMM: Before the
4 Guidelines had a chance to kick in.
5 MEMBER NELSON: This is Mim. But
6 I guess I -- I'm thinking of the Physical
7 Activity Guidelines that we just did, and one
8 of the things that we did was one of the early
9 chapters that was, you know, a condensed
10 chapter was really looking at the patterns of
11 physical activity over time, and what I would
12 advocate, I think, as opposed to pieces --
13 disaggregating all the pieces in the different
14 chapters is that we might consider that there
15 is a chapter up front that really talks about
16 the trends or the change in diet over time up
17 to as recent data as we have so that you can
18 sort of look at the whole thing as opposed to
19 sort of separating it out.
20 And then it's -- I think it's the
21 alarming piece that we're trying to get to,
22 because it shows that certain things have
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1 really gotten bad. Other things have stayed
2 exactly the same, you know, so -- and the
3 calories have gone up. It paints the whole
4 picture.
5 CHAIR VAN HORN: I would tend to
6 agree that having the, again, current status
7 of the diet of the American people should be
8 an ever-present message in front of them, but
9 I also think that each chapter, in some ways,
10 stands alone for some groups.
11 And so, I would hate to miss out
12 on opportunities to point out, because I see
13 this happening, at least in the circles I
14 keep, that there is sort of a moving away from
15 concern related to saturated fat.
16 You know, basically it's a "let
17 statins take care of it" mentality that
18 suggests that, you know, because we're
19 widening the range of dietary fat intake that
20 it no longer matters.
21 And I don't think that's what
22 we're saying at all. In fact, that's what Tom
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1 was just pointing out.
2 So, I think, rather than risking
3 that, you know, mixed message, we really do
4 need to be fairly deliberate about pointing
5 out what the potential problems are, what the
6 current situation is, and why this Guideline
7 is addressing it.
8 And I think Tom just did a great
9 job of that. Rafael.
10 MEMBER PEREZ-ESCAMILLA: Yes.
11 Rafael Perez-Escamilla. And, Tom, my question
12 is: Did the 2005 report address genetic
13 polymorphisms and their interaction with
14 dietary fats and cholesterol?
15 Because, I think that's a very
16 exciting area. That is going to be a new
17 contribution here. And I know you are not
18 done with the review, but do you predict there
19 will be enough useful information that can be
20 translated into recommendations to the public?
21 MEMBER PEARSON: Well, I think one
22 gets into the issues of so-called personalized
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1 medicine and that is largely a promissory note
2 at this point, so I think -- but we've --
3 those of us who deal with cholesterol
4 disorders, obviously have been impressed by
5 some patients having substantial benefits from
6 the same dietary advice that the experts had
7 who didn't change any at all, and there's
8 obviously a very complicated backdrop to that.
9 But there's certainly a number of
10 known polymorphisms, and so one of the
11 questions is, is how far is that from
12 implementation, and the answer is it may not
13 make a difference for this go-around, but it
14 may set the stage for future -- future
15 Guidelines.
16 MEMBER WILLIAMS: Chris Williams.
17 I just wondered on that question four, with
18 the n-3 and n-6 fatty acids, that you may need
19 to take that down to birth, since there have
20 been so many studies of neonates and up to age
21 one or two, and then follow-up studies that
22 might be worthwhile to look at that.
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1 MEMBER PEARSON: That's
2 interesting because obviously some of the
3 formulas have had substantial amounts of n-3
4 fatty acid variabilities.
5 MEMBER CLEMENS: 2002.
6 MEMBER PEARSON: Yes. So, Chris,
7 that's a very good point. I think you should
8 probably change that, the PICO down to birth,
9 because of particularly the use of these in
10 various formulas.
11 MEMBER CLEMENS: That is a very
12 good question. This is Roger. There's a
13 great question there, Chris. The formulas in
14 the United States have been used since 2002,
15 however, it would be interesting to explore,
16 Tom, perhaps there may be data, longitudinal
17 data as early as the late Nineties, so we get
18 at least maybe ten years worth of data and see
19 if there's anything worth it to look at.
20 MEMBER ACHTERBERG: Not to be
21 picky, but the Guidelines are for age two and
22 up.
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1 MEMBER WILLIAMS: Chris Williams,
2 but some of the studies look at neonates and
3 then follow them to an older age, and then the
4 studies continued in intake after age two.
5 MEMBER PEARSON: Yes. Obviously
6 with the fatty acids, obviously, we have --
7 you assume the breast-fed child is kind of on
8 autopilot relative to the fat, fat intake, but
9 I think in this instance, it's probably an
10 exception to that.
11 I was quite interested in reading
12 about the variability between one formula and
13 the next and some of these things, so --
14 CHAIR VAN HORN: Other topics
15 related to this subcommittee?
16 (No response.)
17 CHAIR VAN HORN: Okay. If not,
18 then I think we're at the point in our --
19 thank you. I don't think I have any slides.
20 I think we're at the point in our
21 discussion now where we are ready to begin
22 some of the discussion of cross-cutting
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1 questions that are identified by Joanne Spahn
2 in Tab 17.
3 These are topics that have been
4 addressed by each of the subcommittees in one
5 way or another, and have come up in ways that
6 we now want to try to address, as far as who
7 really is best suited to maybe address these
8 questions, and also maybe just trying to
9 identify some standard approaches to how we
10 might want to move ahead with those.
11 And I also guess we should
12 probably think about from the NEL's point of
13 view and the writing point of views that this
14 is the time when I think we want to engage our
15 staff, wonderful, capable staff people in
16 terms of providing further input, so it might
17 be not a bad idea to grab a microphone so you
18 can maybe answer some of these questions as we
19 go forward, just to be on the ready.
20 So, starting with the food groups
21 question, that obviously does cut across
22 everything as far as dealing with the
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1 questions like fruits and vegetables, how do
2 they relate to both adequacy of nutrients as
3 well as health outcomes.
4 Same thing with whole grains. We
5 talked a little bit about the dried beans and
6 peas issues related both to questions of
7 vegetable protein, but also fiber and also,
8 you know, calorie control and inexpensive ways
9 to meet those nutrient needs, questions that
10 really do kind of cut across all these various
11 topics.
12 We've said very little about milk
13 and milk product intake, other than Joanne's
14 comment that it has protein, it has
15 carbohydrate and it sort of fits into that
16 category.
17 And then looking at other sources
18 of protein, the animal protein versus
19 vegetable protein questions, and Tom was just
20 talking about nuts, but we also have fish and
21 egg yolks and a variety of different foods
22 that cut across these different topics.
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1 So, I guess the question we might
2 want to raise now, and this is where I'd want
3 input from either Joanne or Joan as to, you
4 know, recommendations for how best we can
5 address this in light of the already pretty
6 heavy workload that each of these
7 subcommittees has.
8 So, if anyone wants to start, and
9 we obviously have other cross-cutting
10 nutrients or issues to talk about, but I think
11 food groups is probably the biggest one, and I
12 would love to open that up for consideration.
13 Tom.
14 MEMBER PEARSON: Well, let me just
15 use fish as an example. I think the American
16 reductionism, obviously thinks that the only
17 thing that's in a fish is fish oil. And the
18 last time I looked there was some protein and,
19 you know, a variety of other things.
20 And so, this is backed up by the
21 literature which, of course, the fish oil
22 supplements, usually with the illness groups,
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1 have been very variable, and to my reading,
2 you know, unimpressive.
3 Whereas, the observational
4 epidemiology for fish consumption has been
5 really quite consistent and strong. And so,
6 one thing is, you could go up and say that
7 there's really -- it's all observational bias
8 and the people that eat fish are just
9 healthier than people who don't eat fish, and
10 the whole thing is confounded, or you can say
11 that there's really something about eating
12 whole fish versus just the lipid parts that
13 you put into a fish oil capsule.
14 So, I think this is an example,
15 kind of a microcosm of this food group thing
16 because, depending on how you look at this,
17 you would make -- make some different
18 conclusions.
19 But I think the -- I would hope
20 that our Dietary Guidelines would talk about
21 eating whole foods, rather than putting it
22 into a pill.
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1 CHAIR VAN HORN: Yes. Linda Van
2 Horn. Once again, looking at the NHANES data,
3 it's kind of fascinating to see, based on the
4 current intake that the number one source of
5 omega-3 fatty acids is salad dressing.
6 You have to be number four to get
7 to other fish and fish-mixed dishes. So, it's
8 interesting that that food product, salad
9 dressing is the number one source of omega-3,
10 alpha linolenic acid and -- and so, you know,
11 it's providing that level of intake.
12 But the benefits of eating fish,
13 as you point out, there are many studies that
14 show there's something that transcends the
15 omega-3 beyond that aspect of it that fish
16 consumption is healthful. So, I do think
17 we're going to want to take that into
18 consideration.
19 Now, I don't know, Joanne. I
20 guess Joanne is --
21 MS. SPAHN: I'm here.
22 CHAIR VAN HORN: Oh, you're here.
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1 Okay. If you would want to address it from
2 the context of the literature searching that
3 the group is already doing.
4 I know one of the questions we're
5 trying to -- or issues we're trying to address
6 is not duplicating effort, and wanting to be
7 sure that whatever group it is that's taking
8 this on, provides the results for the benefit
9 of the overall Committee.
10 So, I don't know if you want to
11 mention anything more about that, or better
12 processes for doing that.
13 MS. SPAHN: I'm Joanne Spahn, and
14 I'm the director of the new USDA Nutrition
15 Evidence Analysis Library, and as I was
16 sitting in on each of the subcommittee
17 meetings that occurred prior to the full group
18 meeting, it does look like each of the
19 subcommittees have selected those food groups
20 in this case that they take ownership of.
21 So I don't -- I think initially
22 the issue was there was more than one
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1 Committee doing milk products or there was
2 more than one Committee doing other food
3 groups, so it looks like it's differentiated
4 and those foods that have been identified to
5 be done have been assigned. So, I think it's
6 not an issue at this moment.
7 CHAIR VAN HORN: Larry.
8 MEMBER APPEL: Larry Appel. Are
9 you envisioning, Linda, that we're delegating
10 the food groups to individual subcommittees,
11 but then in the end the report is going to
12 sort of grab all those food groups and put
13 them into a chapter the way we did last year?
14 I mean, that makes sense to me,
15 but it might be -- I'm not sure we made that
16 decision.
17 MEMBER SLAVIN: Yes. I mean that
18 was my understanding based on our last meeting
19 and the discussion when this had already
20 become an issue. Again, to prevent
21 duplication of effort, the goal was to make
22 sure that each food was addressed in some
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1 subcommittee, but that ultimately the data and
2 knowledge would be synthesized into that
3 direction.
4 How we go forward with that, I
5 guess, we'll be looking to Ann for further
6 help with the writing of that. But, you know,
7 as the groups continue to deliberate about
8 this, you know, if there are key issues that
9 are raised in fatty acids related to fish,
10 that, you know, don't make sense in some other
11 context, you know, then we would want to point
12 that out, I would think.
13 Eric.
14 MEMBER RIMM: So I think that I'm
15 not -- I know that yesterday at our meeting we
16 discussed the fat group not doing milk and not
17 doing meat, even though they are recommended
18 as food groups, because the recommendations
19 currently are for lean or low-fat or lean
20 meat, so we felt like that it was not part of
21 our group, but I'm not sure that was picked up
22 by anybody else, and I don't know if anybody's
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1 specifically doing searches of meat and milk.
2 Okay. Milk. Okay. So then I
3 guess it's because it is a -- I'm looking at
4 the pyramid right here. It is actually one of
5 the -- it is the fourth group listed as -- I
6 don't think we've ever done a search on it
7 before, so I don't know if we will do the same
8 for red meat.
9 MEMBER SLAVIN: Well, we have
10 animal protein within our subgroup, you know,
11 so that would pick it up, but not
12 specifically, and then it overlaps with fish
13 now.
14 So, there will be some issues the
15 way we're doing it that will have to come
16 together at the end and makes sure --
17 MEMBER RIMM: Right.
18 MEMBER SLAVIN: -- it does get
19 covered as food groups because, you know, if
20 you look at some of the stuff that has been
21 presented, the stuff that Andrea presented
22 this morning, you know, there's shortages with
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1 the dairy group. There's shortages with
2 fruits and vegetables, you know, as far as
3 what actually people are consuming and NHANES.
4 So -- and there's nutrients that
5 are shortfall, but also this whole
6 phytochemical and health benefits of eating
7 foods rather than nutrients. So, it's a
8 really broad topic. I think, as it comes
9 together at the end, we may have to think of
10 it in different ways to make sure it doesn't
11 get dropped.
12 MEMBER RIMM: Yes. I think --
13 Linda, if you think back to the 2005 -- this
14 is Eric Rimm again, sorry -- to the 2005
15 Dietary Guidelines, the one thing I think that
16 was -- one of the two things that was taken
17 out between the technical report and the final
18 Dietary Guideline was fish, because I guess
19 there wasn't enough evidence in the terms of
20 primary prevention which we've taken that on
21 because I think there is enough evidence now.
22 But I think we should keep that in
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1 mind when we're looking at milk and meat to
2 make sure that there's -- and I think there
3 was a pretty broad body of evidence out there.
4 MEMBER SLAVIN: Yes. This is
5 Joanne Slavin again. Just think of iron and
6 zinc, too, some of the nutrients that when you
7 put these diets together, if you take the red
8 meat out, it's harder to meet those. So, we
9 forget.
10 MEMBER RIMM: Yes. I guess so. I
11 mean, I know that argument's been used a lot
12 for dairy products saying that without the
13 three servings recommended for milk, that we
14 wouldn't have enough calcium, but to me that
15 seems like a backward recommendation.
16 Why don't we, you know, recommend
17 that people eat more broccoli because it had
18 calcium in, and it would be a good source.
19 Broccoli, we should have four servings a day
20 of -- well, I know, but there's other -- I
21 mean, I don't think we should recommend a food
22 just because it has a micronutrient, as
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1 opposed to keeping it, you know, focused on
2 foods. Just my opinion.
3 MS. SPAHN: Just to make sure we
4 don't lose a food group in a loophole, because
5 I don't feel like I'm confident in saying
6 which group was working with which food group
7 yet. Should we just go through the exercise
8 of saying which group was working on which
9 food group?
10 CHAIR VAN HORN: I think it is
11 stated below --
12 MS. SPAHN: My apologies.
13 CHAIR VAN HORN: -- if you'll look
14 at Tab 17, right.
15 MS. SPAHN: My apologies.
16 CHAIR VAN HORN: Okay.
17 MEMBER RIMM: That was a great
18 question.
19 CHAIR VAN HORN: Yes.
20 MEMBER RIMM: You had the answer.
21 CHAIR VAN HORN: Okay. It's been
22 requested that, for the sake of the public, we
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1 should just reiterate what it states in our
2 book which is that fruits and vegetables and
3 health will be presented by the carbohydrate
4 and protein group, likewise whole-grain intake
5 in health.
6 It -- pretty much all of these
7 relate to, Joanne, that we just -- why have we
8 been talking about this all day, in that the
9 carbohydrate and protein group pretty much
10 wins the prize for accumulating the most foods
11 in the food groups, because they really are
12 attending to beans and peas, milk products and
13 also the animal protein and vegetable protein.
14 The only other group identified,
15 at least in this segment, is the fatty acids
16 group that's addressing the foods that we just
17 talked about, nuts and egg yolks and chocolate
18 and that kind of thing.
19 MEMBER PEARSON: This is Tom
20 Pearson. We had ceded egg yolks, milk and the
21 red meat by the time these were printed, so --
22 MEMBER SLAVIN: Those are the
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1 original questions at the bottom.
2 MEMBER PEARSON: Right.
3 MEMBER SLAVIN: But I think we
4 have ownership of all the food groups by the
5 carbohydrate and protein subcommittee, except
6 for specific foods that are outlined in the
7 fatty acids, many which are fish, chocolate
8 and nuts.
9 CHAIR VAN HORN: Okay. I think
10 that as far as the other cross-cutting topics,
11 we also have pretty much addressed those most
12 of the day. Those relate to macronutrient
13 proportions and weight, as well as health.
14 That was one of the key questions
15 that kind of we've talked about over the last
16 several meetings. I don't know, Xavier, if
17 you want to add anything more to that.
18 MEMBER PI-SUNYER: No. I just
19 wanted to say that, you know, that we will be
20 working on that in the Energy Balance
21 Committee, and also talking to Joanne in the
22 Carbohydrate and Protein Committee, so we'll
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1 take care of it between us.
2 MS. SPAHN: I think that one --
3 Joanne Spahn. We had decided that the NEL
4 would do one sort list to serve both -- the
5 members of both those Committees so that it
6 would be consolidated.
7 CHAIR VAN HORN: Right. Maybe for
8 the benefit of everyone listening and those
9 who have not been regularly attending these
10 meetings, the interesting phenomenon is that
11 since we started we have really blended, as a
12 Committee, and I think because so many of us
13 sit on multiple subcommittees, we kind of
14 don't view ourselves as isolated from each
15 other, but rather more cohesive.
16 And I believe that NEL and Joanne
17 and Joan are very much aware of needing to
18 look at these topics overall and so, to
19 prevent duplication of effort, these kinds of
20 decisions are being made daily as we look at
21 the literature and see which direction it
22 sends us.
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1 So, while I think some of the
2 cross-cutting issues initially seemed like,
3 you know, major differences across the groups,
4 I think they now have become part of the
5 ongoing discussion in every group, and there's
6 a lot of sharing of that information.
7 I don't sense -- and please,
8 Committee members, tell me if I'm wrong, but I
9 don't sense that any of us at this point have
10 any concerns that the cross-cutting issues
11 that we've been dealing with all day aren't
12 being addressed by someone.
13 And then if somebody has a pet
14 topic that feels as though nobody's addressing
15 it, you know, this would be a good time to
16 raise that, but I think in terms of covering
17 the literature and identifying which group has
18 the major responsibility for addressing that
19 topic, I believe we now have that covered from
20 our previous discussions.
21 Is that true? Yes. Okay. Good.
22 All right. Then, if there are no other
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1 cross-cutting issues to discuss, then we're
2 asked to look at Tab 18, which takes us to our
3 recently-approved approach for use in grading
4 the body of evidence.
5 And again, for people who are not
6 here, we actually have a chart that has -- I'm
7 familiar with it. It's been used in several
8 other groups, major groups that are doing
9 these comprehensive reviews of the literature.
10 And essentially it evaluates the
11 data on the basis of elements of quality,
12 consistency, quantity, public health nutrition
13 impact and generalizability on the left and
14 grades of strong, moderate, limited, expert
15 opinion only or grade not assignable across
16 the top.
17 So, essentially, each group and
18 each review of every study will conclude with
19 a designated evaluation of the grade of that
20 particular study, and it's on the basis of
21 those grades that decisions are made in terms
22 of the evidence, the quality of the evidence
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1 and the recommendations that will be made.
2 No? Not true?
3 MEMBER APPEL: Is -- this is Larry
4 Appel. You said "grade each study," or is it
5 "grade each conclusion"?
6 CHAIR VAN HORN: Yes. Sorry. The
7 studies get graded in the process of coming up
8 with the decision on the conclusion, but
9 that's absolutely right. You're correct.
10 That's it.
11 It's the conclusion against the
12 grade, because those are the key messages that
13 then come forth as far as what the
14 recommendations are.
15 MEMBER PI-SUNYER: You can't grade
16 the individual components.
17 CHAIR VAN HORN: Exactly. Tom.
18 MEMBER PEARSON: Unlike some of
19 the other guideline activities, this one, I
20 think is a little bit of a hybrid between a
21 couple of dimensions of guideline development
22 versus guideline implementation, from the
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1 usual guideline development, the strong,
2 moderate and limited has to do with the level
3 of evidence.
4 These Guidelines, however, put in
5 also this public health nutrition impact,
6 which is a little different and across those
7 grades, just to note, the size of the effect
8 is clinically meaningful.
9 The point I'm getting to is that
10 the guideline implementers, the guideline
11 developers basically say A causes B, or -- or
12 this should be -- this, you know, is
13 beneficial to lower.
14 Guideline implementers use the
15 words "must, could, may" -- "must, should, may
16 or not at all." And it has to do with the
17 strength of the evidence, of the impact of it.
18 So, you can have a significant,
19 consistent evidence base of a weak effect.
20 And in that instance, as a public health
21 imperative say, a weak effect -- are you going
22 to say that everyone must do this, even though
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1 the impact -- the public health impact?
2 So, I'm just pointing out that
3 there's a little bit of a hybridization here,
4 compared to say AHA, AHDC Guidelines which are
5 just talking about the scientific evidence,
6 this has an implementation component to it.
7 That's okay with me, but let's
8 just make sure we recognize that.
9 MEMBER NELSON: This is Mim
10 Nelson. I appreciate this. I think it's
11 really, really important to use this, and I
12 think that when we went through the Physical
13 Activity Guidelines, we actually spent an
14 unbelievable amount of time developing -- I
15 know you guys used some of this to develop
16 that.
17 One suggestion might be -- and I
18 tell you, it's more of a piece for the writing
19 is because it's -- it's -- you've got two
20 frames, and both frames are important. The
21 grading and the elements.
22 And we ended up with a physical
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1 activity. We had sort of, you know, one, two,
2 three, four, and then we had A, B, C. So, you
3 could rate them on the two frames without
4 always having to use all the words. I mean,
5 this is more of a very small, little technical
6 thing, but it was very helpful from -- you
7 know, it was a 2-B or a 3-A.
8 I mean, it's just an easy way to
9 refer to it. It's just an idea. But I think
10 this is really, really helpful.
11 CHAIR VAN HORN: Good. Other --
12 other comments about the grading process and
13 rating?
14 I think probably the most
15 important thing is that, as we've discussed,
16 you know, over these last two days now, the
17 next step is for us to move forward and put
18 this into practice over this next month where
19 hopefully the experience of actually doing
20 this will help all of us recognize maybe where
21 some of the pitfalls are that we may not know
22 about right now, but we will once we actually
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1 walk the road.
2 But I know that each subcommittee
3 chair has in mind their number one target that
4 they planned to put forth over this next
5 month, and the goal is, by the end of May, to
6 have one of them completed as far as the whole
7 review and the recommendation.
8 Yes. Eric. Yes, sure.
9 MEMBER RIMM: Sorry, I just wanted
10 to ask a quick question of what Tom said.
11 This is Eric Rimm -- what Tom said did concern
12 me a little bit, so the -- if you use the
13 example of alcohol and breast cancer, where
14 the association is modest, there's a ten
15 percent increase for a drink day.
16 You can argue whether that, in
17 some people's mind is modest or not. It's
18 important. It's been shown in 30 studies.
19 So, there's clear evidence that alcohol
20 increases risk of breast cancer, yet what I --
21 I mean, I would grade that as strong, because
22 there's 30 studies, but it's only a ten
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1 percent increase.
2 So, it's actually only a sort of a
3 moderate effect. You sort of get distracted
4 by the fact that you're grading both the
5 quality and the amount.
6 CHAIR VAN HORN: Right.
7 MEMBER RIMM: And then the
8 significance.
9 MEMBER PEARSON: So that would be
10 an incidence of a randomized trials -- this is
11 Tom Pearson -- that would be a class, probably
12 with 1-A evidence.
13 CHAIR VAN HORN: Right.
14 MEMBER PEARSON: With --
15 MEMBER RIMM: Quality strong.
16 CHAIR VAN HORN: Strong.
17 MEMBER PEARSON: With the high-
18 quality from randomized control trials --
19 MEMBER RIMM: It's not a
20 randomized control trials of alcohol and
21 breast cancer.
22 MEMBER PEARSON: I guess that's
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1 right. So, maybe it would be like a two-way
2 or something.
3 MEMBER RIMM: So, the fact that
4 the --
5 MEMBER PEARSON: But the point is
6 it would be strong.
7 MEMBER NELSON: This is Mim. It
8 doesn't always have to -- I think -- I think
9 Tom's right. I think we have to be a little
10 careful. If the evidence is strong, the
11 evidence is strong regardless of whether
12 they're -- the magnitude of the risk or the
13 change.
14 And so --
15 MEMBER RIMM: Well, under public
16 health nutrition, in fact, it does say the
17 size of the effect is clinically meaningful.
18 Significant difference is large and, you know,
19 it's ten percent.
20 MEMBER NELSON: And I think -- and
21 it might be that we have to take out the
22 "large." I'm not sure. We might have to all
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1 look at that. This is the first time I've
2 seen the chart.
3 MEMBER RIMM: I think there will
4 probably be other examples in nutrition --
5 MEMBER NELSON: Yes.
6 MEMBER RIMM: -- where it's so
7 overwhelmingly strong evidence that the
8 magnitude of the effect is modest.
9 CHAIR VAN HORN: Yes. And please
10 remember -- and again, for those who aren't
11 here, it says "draft."
12 MEMBER NELSON: Yes.
13 MEMBER RIMM: Oh, no. That's why
14 I was just looking. I wasn't hanging like
15 this, saying this is wrong. I was looking for
16 some help on what to do.
17 CHAIR VAN HORN: No, no, no.
18 Exactly. And that's my point about, we're
19 going to walk through this and uncover those
20 kinds of pitfalls.
21 MEMBER RIMM: Okay.
22 MEMBER NELSON: Yes.
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1 MEMBER RIMM: Well, there you go.
2 CHAIR VAN HORN: And say, whoops,
3 we can't do it that way because, of course, we
4 have to let women in America know that a drink
5 a day could be a risk factor for breast
6 cancer, and that's something that we need to
7 point out.
8 Yes.
9 MEMBER PEARSON: But just to give
10 an example, you know, people must reduce the
11 consumption of trans fatty acids as well as
12 possible. I mean, would you be willing to
13 make that relative to the evidence at hand?
14 There are whole cities that have
15 done that. Okay. That's a must.
16 MEMBER NELSON: Yes.
17 MEMBER PEARSON: Okay. Are we
18 going to say that women must avoid alcohol?
19 No. You know, "may" or, you know -- so the
20 point is, on the implementation side, once you
21 take the evidence and then put them into a
22 recommendation, you change this from the
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1 scientific evidence to what you really
2 recommend for the public health of the people.
3 MEMBER NELSON: Right.
4 MEMBER PEARSON: And that's when
5 you use these different verbs.
6 CHAIR VAN HORN: I think that's
7 very important, but I'll take it back yet
8 again to the -- also the concept of
9 discretionary calories. There is no biologic
10 requirement for alcohol, you know, at all.
11 And so, therefore, you know, the
12 concept of consuming alcohol is a personal
13 choice that relates to this use of
14 discretionary calories, if that's your choice,
15 that is fine, but you should know what the
16 risk is of including that beyond the caloric
17 issue to the health issues. And I think
18 that's all we're trying to differentiate.
19 MEMBER PEARSON: But my point is,
20 as the guideline developers in perhaps
21 advising the implementers, it's our choice
22 about what we would recommend in terms of what
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1 those verbs are.
2 CHAIR VAN HORN: Absolutely.
3 Right. Right. I think that's very true. And
4 I think, again, this next month should prove
5 very interesting as we all kind of get in the
6 driver's seat and try to actually go forward
7 with this.
8 I think from what I'm hearing and
9 seeing, we pretty much have covered most of
10 our agenda at this point. Are there any other
11 issues that either staff or Committee members
12 might have in regard to current situation,
13 next immediate steps?
14 I can also say that our next
15 meeting is planned for sometime in the fall.
16 That has yet to be formally designated, but we
17 have our work cut out for us between now and
18 then.
19 Mim.
20 MEMBER NELSON: This is Mim. Just
21 -- and this is "my brain is a sieve piece,"
22 and this relates to carbohydrates. I just
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1 have one follow-up question because there's a
2 lot of new evidence on the effects of glycemic
3 index and load on eye health, macular
4 degeneration and cataracts.
5 And I just don't know if you have
6 considered that, because I think that this is
7 beyond, you know, the phytochemicals, but
8 actual load, and I just think that that's
9 something that should be -- I'm happy to send
10 you a couple of papers. I think it's an
11 important issue. Okay.
12 CHAIR VAN HORN: Oh, Larry.
13 MEMBER APPEL: Yes, two things.
14 Can -- I need to be -- I'm very concrete.
15 What do you want at the end of May? Do you
16 want a full chapter or what is the deliverable
17 at the end of May?
18 CHAIR VAN HORN: My understanding
19 but, again, somebody from --
20 MS. SPAHN: This is Joanne Spahn
21 from the NEL.
22 CHAIR VAN HORN: Go ahead.
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1 MS. SPAHN: I think the goal is to
2 have one NEL-related question complete, which
3 would be the evidence summary and a conclusion
4 statement for at least one of the questions
5 that you have in your portfolio of questions.
6 MEMBER APPEL: So, conclusion
7 statement and grade of evidence?
8 MS. SPAHN: Correct.
9 MEMBER APPEL: Okay.
10 MS. SPAHN: And you may consider
11 when you do the grade of evidence, to comment
12 on risk benefit, because that's one piece
13 that, you know, some of the other libraries do
14 in recommendations, but not always in the
15 conclusion statement of just the body of the
16 literature review.
17 CHAIR VAN HORN: Yes, I agree.
18 MEMBER APPEL: I think we need
19 some discussion about when you can use
20 systematic review instead of NEL, you know,
21 under what circumstances, because I heard a
22 lot of people saying, you know, there are
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1 these reviews, and I want to rely on it, and
2 we need to have some sort of structure to that
3 decision-making.
4 CHAIR VAN HORN: Yes. I agree,
5 Larry. We've kind of raised this and backed
6 away, raised it and backed away several times.
7 I think the understanding that I have right
8 now is that none of us want to unnecessarily
9 replicate a very thorough review that was done
10 by another respected body that, especially
11 recently, that we can point to.
12 We also don't necessarily want to
13 review again accepted literature that we know
14 already in the 2005 Guidelines or elsewhere
15 has already been accepted as is, and there's
16 nothing new since then.
17 So, having said that, I think the
18 more interesting question is when do we decide
19 that it's -- it requires additional
20 investigation?
21 And I think that we have to rely
22 on each subcommittee to make those
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1 determinations, and that's what we're hoping
2 for is that, you know, if somebody really
3 thinks we can't -- we can't make a valid
4 recommendation unless we also go back or
5 continue to review this particular topic.
6 MEMBER APPEL: Yes. Because I
7 think it came up, or at least when I was
8 listening to Mim talk about the -- you know,
9 the behaviors, you know, and I'm not sure this
10 is coming from ADA, it's really -- you know,
11 somebody wrote a good review and, you know, is
12 that good enough for us in terms of --
13 MEMBER NELSON: Well, not
14 behaviors environment, but behaviors we're
15 going to do some NEL searches, yes.
16 MS. SPAHN: My understanding --
17 this is Joanne Spahn. My understanding was
18 that once we have this first round of
19 questions that were NEL-oriented done, that
20 both Larry and Xav were going to look at an
21 old question and a new question, one that
22 looked at literature that had been done in the
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1 past like the glycemic index question, and one
2 that's relevant -- that's brand new, maybe
3 sodium in children, and decide for the report
4 how exactly are we going to grade evidence
5 from the past report knowing that we probably
6 can't answer every question related -- using
7 the NEL system.
8 CHAIR VAN HORN: Is that -- does
9 that satisfy everybody temporarily, at least?
10 MEMBER PI-SUNYER: Yes. I mean,
11 it's going to be difficult because we didn't
12 grade it at all last time around.
13 MEMBER NELSON: Not formally.
14 MEMBER PI-SUNYER: Not formally.
15 MEMBER PEARSON: This is Tom. I
16 think, though, that the state of the art -- I
17 mean, the last -- the last time I did one of
18 these and didn't grade it, I regretted it in
19 about a year.
20 I think it's become the state of
21 the art.
22 CHAIR VAN HORN: Yes. I think
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1 there are many --
2 MEMBER PI-SUNYER: But the
3 question is, how to go back and deal with
4 what, you know, the 16 studies you quoted last
5 time.
6 CHAIR VAN HORN: Right. I think
7 there's no question that this will be a new
8 report for lots of reasons and, you know, with
9 lots of issues that have come up in these, you
10 know, several meetings that we've had, this
11 being one of them.
12 But I believe, you know, that as
13 long as we collective come to decisions about
14 how to go forward and establish that clearly
15 in the report so that readers can understand
16 why and how we made our decisions and how we
17 moved forward, that is likely to be the most
18 important aspect of this whole thing, because
19 again, the collective expertise around the
20 table clearly can make those kinds of choices
21 better than anybody else in terms of, you
22 know, looking at what's already there.
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1 Any other comments, questions?
2 If not, I just want to thank
3 everyone, certainly all the members, the
4 staff, and everyone that attended with us over
5 these last couple of days. We're glad you
6 joined in and we hope you found it interesting
7 and useful, and we look forward to proceeding
8 from here.
9 Thank you.
10 (Whereupon, the above-entitled was
11 adjourned at 3:02 p.m.)