The Need For A Public Health Approach To The Dietary Guidelines For Americans

Transcription

1 March 30, 2018 Dr. Donald Wright Deputy Assistant Secretary for Health Office of Disease Prevention and Health Promotion Office of the Assistant Secretary for Health United States Department of Health and Human Services Wootton Parkway, Suite LL 100 Rockville, MD Mr. Brandon Lipps Administrator Food and Nutrition Service United States Department of Agriculture 3101 Park Center Drive Alexandria, VA Kristin Koegel Food and Nutrition Service Center for Nutrition Policy and Promotion United States Department of Agriculture 3101 Park Center Drive, Suite 1034 Alexandria, VA Re: Topics and comments to be examined in the review of the scientific evidence supporting the development of the Dietary Guidelines for Americans; Docket No. FNS Dear Dr. Wright, Mr. Lipps, and Ms. Koegel: The, Program in Nutrition, Teachers College Columbia University (Tisch Food Center) presents these comments in response to the proposed topics for the Dietary Guidelines for Americans (DGAs). The Tisch Food Center cultivates research about connections between a just, sustainable food system and healthy eating, and translates it into recommendations and resources for educators, policy makers, and community advocates. The Center focuses on schools as critical levers for learning and social change. The Need For A Public Health Approach To The Dietary Guidelines For Americans

2 The national childhood obesity rate among 2 to 19 year-olds is 18.5% (Hales et al., 2017; Hales et al., 2018) and the rate of type 2 diabetes is rapidly increasing in this group (4.8% per year as per a recent estimate) in this group (Mayer-Davis et al., 2017). Adult obesity rates 39.6% (Hales et al., 2017) and another 31% are overweight. This means 7 out of 10 adults overweight or obese (CDC, 2017). Type 2 diabetes is closely linked to obesity and has higher medical costs of any disease, contributing over $100B to health care costs in 2013 (Dieleman et al., 2016). We have known for over six decades that habits track from childhood to adulthood and when highly palatable, particularly high sugar foods, are available people choose these over more nutrient-dense options (Yudkin, 1956). Additionally, there are over three decades of evidence that childhood eating behaviors are linked to lifestyle-related chronic diseases in adulthood (Kemm, 1987) and childhood obesity is associated with increased risk of obesity and metabolic syndrome in adults (Biro et al., 2010; World Health Organization, 2018) and premature mortality in adulthood (Reilly et al., 2011). This public health approach was the framing of the 2010 Report of the Dietary Guidelines Advisory Committee (DGAC), The single most sobering aspect of this Report is the recognition that we are addressing an overweight and obese American population. Across all age, gender and ethnic groups, it is clear that urgent and systems-wide efforts are needed to address America s obesity epidemic as top priority. Everything within this Report is presented through the filter of an obesegenic environment in critical need of change. This is especially true in regard to American children whose incidence of obesity has tripled in the past five years. (DHHS, 2010, letter to the secretaries). This lens also guided the 2015 DGAC Report, The 2015 DGAC s work was guided by two fundamental realities. First, about half of all American adults 117 million individuals have one or more preventable, chronic diseases, and about two-thirds of U.S. adults nearly 155 million individuals are overweight or obese. These conditions have been highly prevalent for more than two decades. Poor dietary patterns, overconsumption of calories, and physical inactivity directly contribute to these disorders. Second, individual nutrition and physical activity behaviors and other health-related lifestyle behaviors are strongly influenced by personal, social, organizational, and environmental contexts and systems. Positive changes in individual diet and physical activity behaviors, and in the environmental contexts and systems that affect them, could substantially improve health outcomes. (USDA, 2015, executive summary). The reality in America is the same today, and the process of creating the DGAs should reflect that. Taking a public health approach is relevant to be able to make food-based recommendations to maintain the health of Americans, important to address a significant public health concern of increased chronic diseases, has potential Federal impact for the development and implementation of our nation s food and nutrition programs, particularly for child nutrition programs, and avoids duplication as the Dietary Guidelines for Americans are the main guidance for eating to achieve and maintain health. The Tisch Food Center is concerned that determining topics and questions before appointing the DGAC has potential pitfalls. Of greatest concern, it is not clear whether the final Dietary Guidelines for Americans report will include only those topics identified by the agencies. As such, we urge USDA and HHS to: Include topics of public health importance that are not reviewed by the 2020 DGAC by carrying over advice from the 2015 DGAs. Describe current dietary patterns, including food groups and nutrients for each stage of life. Conducting this review is mentioned as a planned activity: Note that for each stage of life, current dietary patterns, including intakes of food groups and nutrients, will also be described. This type of review is standards for the Dietary Guidelines Advisory Committee. We recommended that this

3 review is conducted and for the outcomes to be presented in the detailed and comprehensive presentation such that was in the Dietary Guidelines Advisory Committee Report in Revise the topics and questions in each life stage to reflect this public health framing. As an example, we recommend the following revisions to the topics and questions in the children and adolescents section. Proposed Revisions to the questions for children and adolescents Topic 1: Dietary patterns to meet nutrient needs, maintain health, and reduce risks of lifestyle-related chronic diseases in childhood, adolescents, and into adulthood. We recommend that this topic replace the proposed topic of dietary patterns to promote health and normal growth and meet nutrient needs. For this topic, we recommend questions related to food-based recommendations for the basic food group (questions 1 4). Answering these questions provides data for question 5 on potential revisions for the USDA Food Patterns, to ensure that following any of these dietary patterns will meet nutrient needs, maintain health, and reduce chronic diseases in childhood, adolescence, and into adulthood. Question 6 addresses the context that enables the adoption of health eating patterns (based on the USDA Food Patterns) in children and adolescents. Questions 1. Fruits and Vegetables: How many total servings and what types of fruits and vegetables are recommended to ensure children and adolescents meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? How does current consumption of fruits and vegetables in children and adolescents compare to what is recommended? 2. Grains: How many total servings and what types of whole grains are recommended to ensure children and adolescents meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? What is the maximum recommendation for refined grains for children and adolescents to meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? How does whole grain and refined grain consumption in children and adolescents compare to the what is recommended? Recent research on what is known about the types of fruits and vegetables needs to be updated. Additionally, for dietary guidance and for the development of Federal food and nutrition programs, data on how consumption compares to recommendations is necessary. While much has been established about the health benefits of whole grains, and the risks of high consumption of refined grains, the research on what is appropriate for children and adolescents needs to be updated to provide dietary guidance in on grains and to inform Federal food and nutrition programs. 3. Proteins: How many total servings and what types of plant-based legumes, nuts, and seeds are recommended to ensure children and adolescents meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? How many total servings and what types of animal-based protein (meats, poultry, seafood, eggs) are to recommended to ensure children and adolescents meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? There is increasing research on the balance of plant-based and animalbased protein that maintain long-term health. This needs to be updated to make appropriate dietary guidelines and to help inform Federal food and nutrition programs. What is the balance of plant-based and animal-based proteins that

4 helps to maintain health and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? How does the amount and types of plant-based and animal-based protein consumption in children and adolescents compare to the what is recommended? 4. Dairy: How many total servings and what types of dairy products are to recommended to ensure children and adolescents meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? How do the amount and types of dairy consumed in children and adolescents compare to what is recommended? 5 Dietary Patterns: Based on the findings of the above questions, are changes to the USDA Food Patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) needed to ensure that following any one of these dietary patterns during childhood and adolescence meet nutrient needs, maintain health, and have reduced risk of chronic diseases in childhood, adolescence, and into adulthood? 6. Personal, social, organizational, and environmental contexts and systems: What are the policies, systems, environmental factors, and educational programs that facilitate children and adolescents to move closer to the USDA food patterns from current dietary patterns? Recent research on dairy products needs to be reviewed to inform dietary guidelines and Federal food and nutrition programs. Once the above questions have been answered it is prudent to review the USDA Food Patterns to determine what needs to be changed and updated based on the most current science. Social science can help to understand how context facilitates adoption of healthy food patterns. This can help inform dietary guidelines, federal food and nutrition programs, and food

5 Topic 2: Added Sugars We commend the decision to specifically look at added sugars as a component of concern in children and adolescents diets, considering that they contribute over 16% of the calories consumed by US children and youth (Vos et al., 2017)) and that they increase the risk of developing obesity, cardiovascular disease, hypertension, obesity-related cancers, and dental caries (Vos et al., 2017)) and that they increase the risk of developing obesity, cardiovascular disease, hypertension, obesity-related cancers, and dental caries (Vos et al., 2017)) Nevertheless, as indicated above for all food groups and nutrients of concern, the review of the literature should not only look at How much added sugars can be accommodated in a healthy diet during childhood and adolescence while still meeting food group and nutrient needs? but specifically look at the relationship between consumption of added sugars and health outcomes, including: 1) overweight and obesity, 2) type 2 diabetes, 3) cardiovascular disease; in an attempt to provide clear and specific recommendations to limit consumption. In addition, we recommend that the evidence is looked separately for added sugars in solid products and sugar in liquid form (i.e. sugar-sweetened beverages) given that liquid carbohydrates are less filling than the solid forms (Pan et al., 2011). For SSBs in particular, there is robust solid evidence about the association with weight gain/childhood obesity (Ludwig et al., 2001; Malik et al., 2013; Malik et al., 2009), and the association between SSB consumption and type 2 diabetes (Greenwood et al., 2014; Imamura et al., 2015; Malik et al., 2010; Wang et al., 2015), coronary heart disease (Huang et al., 2014), and dental caries. Questions 1. How is the amount of added sugars consumed (from both food products and in beverages) during childhood and adolescents related to: 1) body composition (weight gain, BMI, overweight, obesity), 2) type 2 diabetes, 3) cardiovascular disease in childhood, adolescence, and into adulthood? 2. What is a safe upper limit for total added sugars (from both food products and beverages) in children and adolescents diets to prevent adverse health outcomes (i.e. obesity, diabetes, CVD)? 3. What are the policies, systems, environmental factors, and educational programs that facilitate children and adolescents reducing added sugar consumption? A review of the research on how added sugar intake impacts long-term health consequences is needed to inform dietary guidance and Federal food and nutrition programs. A safe upper limits of total added sugar, based on the scientific evidence, is needed to inform dietary guidance and food Social science can help to understand how context facilitates reducing added sugar consumption in children and adolescents. This can help inform dietary guidelines, federal food and nutrition programs, and food Topic 3: Sodium Sodium consumption remains a concern for Americans with current guidelines (AHA, 2017) classify roughly one out of two adults as hypertensive, and new data from the CDC found average American adult consumes 4,000 mg of sodium per day, well above the 2,300 mg per day recommended by the National Academy of Medicine. (Cogswell, 2018). This makes it critical to review science on appropriate sodium consumption for children and adolescents.

6 Questions 1. How is the amount of sodium consumed during childhood and adolescents related to: 1) body composition (weight gain, BMI, overweight, obesity), 2) hypertension, 3) cardiovascular disease in childhood, adolescence, and into adulthood? 2. What is the safe upper limit of sodium in child and adolescents diets to prevent adverse health outcomes? 3. What are the policies, systems, environmental factors, and educational programs that facilitate children and adolescents reducing sodium consumption? A review of the research on how sodium intake impacts longterm health consequences is needed to inform dietary guidance and Federal food and nutrition programs. A safe upper limit of total sodium, based on the scientific evidence is needed to inform dietary guidance and food Social science can help to understand how context facilitates reducing added sugar consumption in children and adolescents. This can help inform dietary guidelines, federal food and nutrition programs, and food Topic 4: Types of Dietary fat There has been much scientific research on dietary fat over the past few decades, including the past five years. There needs to be a review on the effect of replacing saturated fatty acids with polyunsaturated fatty acids (and monounsaturated fatty acids) in children and adolescents impacts the risk of CVD in children, adolescents and into adulthood. It is not possible to evaluate the effect of saturated fats on the risk of CVD without considering which nutrients would replace it. As a 2017 Presidential Advisory from the American Heart Association explains, studies that did not take the replacement nutrient into account have mistakenly concluded that saturated fat intake had no significant effect on CVD risk. (Sacks et al., 2017, Siri-Tarino et al., 2009, Chowdhury et al., 2014). This could update and build upon the 2015 Guidelines recommends that intake of saturated fats should be limited to less than 10 percent of calories per day by replacing them with unsaturated fats. Questions 1. How does replacing saturated fatty acids with polyunsaturated and monounsaturated fatty acids during childhood and adolescents impact 1) body composition (weight gain, BMI, overweight, obesity), and 2) cardiovascular disease in childhood, adolescence, and into adulthood? 2. What is the safe upper limit of saturated fat in child and adolescents diets to prevent adverse health outcomes? 3. What are the policies, systems, environmental factors, and educational programs that facilitate children and adolescents consuming a healthy amount and ratio of dietary fat? Recent research needs to be reviewed to determine what types of dietary fats should be recommended in dietary guidelines and to inform Federal food and nutrition programs and food Guidance is needed on the total amount of saturated fat that is safe in childhood and adolescents. Social science can help to understand how context facilitates determines which types and how much fat children and adolescents consume. This can help inform dietary guidelines, federal food and nutrition programs, and food

7 Topic 5: Caffeine Caffeinated beverage are mentioned in the proposed beverage topic and warrant specific investigation for children as there has been increasing evidence of excessive intake of caffeine in childhood and adolescence due to caffeine being present in increasing numbers of food and beverages. Questions 1. What is the safe upper limit of daily caffeine for children and adolescents? 2. What are the policies, systems, environmental factors, and educational programs facilitate the reduction of caffeine in children and adolescents? Review of the scientific evidence is needed to determine upper limits for caffeine to inform dietary guidance and food Social science can help to understand how context presents risks and protective factors for children to consume caffeine. This can help inform dietary guidelines, federal food and nutrition programs, and food In conclusion, these comments provide recommendations for revisions of topics and question for one of the lifestyle stages, children and adolescents 2 to 18 years, to have a public health and prevention lens which is necessary to address the most crucial dietary guidance recommendations for our time. We recommend applying this lifestyle approach to each age group, and using a similar lens and similar questions. We also strongly encourage including topics of public health importance that are not reviewed by the 2020 DGAC by carrying over advice from the 2015 DGAs. And finally, we support the plan to describe current dietary patterns, including food groups and nutrients for each stage of life. Once again, there is clear evidence that eating patterns during childhood and adolescence influence adult health status. This connection needs to be acknowledged and address in the Dietary Guidelines for Americans. Additionally, as established in both the 2010 and Dietary Guidelines for Americans, personal, social, organizational, and environmental contexts and systems provide risk and protective factors. This social science evidence needs to be understood and incorporated into the Dietary Guidelines for Americans. Thank you for the opportunity to provide comments on the proposed topics and process for the 2020 DGAC. Respectfully submitted, Pamela Koch, EdD, RD Executive Director, Research Association Professor, Program in Nutrition Department of Health & Behavior Studies, Teachers College, Columbia University pak14@tc.columbia.edu

8 REFERENCES American Heart Association. (2017) High blood pressure redefined for first time in 14 years: 130 is the new high November. Available at Biro, F. M., & Wien, M. (2010). Childhood obesity and adult morbidities. Am J Clin Nutr, 91(5), 1499S-1505S. doi: /ajcn b Chowdhury R, Warnakula S, Kunutsor S, et al. Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis [published correction appears in Arch Intern Med. 2014;160:658]. Ann Intern Med. 2014;160: doi: /M Cogswell ME, Loria CM, Terry AL, et al. (2018) Estimated 24-hour urinary sodium and potassium excretion in U.S. adults. JAMA Mar 7; doi: /jama Dieleman J.L., Baral R., Birger M,, Bui A.L., Bulchis A., et al. (2016) US Spending on Personal Health Care and Public Health, JAMA, 316(24): doi: /jama Greenwood, D. C., Threapleton, D. E., Evans, C. E., Cleghorn, C. L., Nykjaer, C., Woodhead, C., & Burley, V. J. (2014). Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose-response meta-analysis of prospective studies. Br J Nutr, 112(5), doi: /s Hales, C. M., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2017). Prevalence of Obesity Among Adults and Youth: United States, NCHS Data Brief(288), 1-8. Hales, C.M., Fryer C.D., Carroll, M.D., Freedman D.S., Ogden C.L., (2018). Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, to JAMA, doi: /jama Huang, C., Huang, J., Tian, Y., Yang, X., & Gu, D. (2014). Sugar sweetened beverages consumption and risk of coronary heart disease: a meta-analysis of prospective studies. Atherosclerosis, 234(1), doi: /j.atherosclerosis Imamura, F., O'Connor, L., Ye, Z., Mursu, J., Hayashino, Y., Bhupathiraju, S. N., & Forouhi, N. G. (2015). Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. Bmj, 351, h3576. doi: /bmj.h3576 Kemm, J. R. (1987). Eating patterns in childhood and adult health. Nutr Health, 4(4), doi: / Ludwig, D. S., Peterson, K. E., & Gortmaker, S. L. (2001). Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet, 357(9255), doi: /s (00) Malik, V. S., Pan, A., Willett, W. C., & Hu, F. B. (2013). Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr, 98(4), doi: /ajcn Malik, V. S., Popkin, B. M., Bray, G. A., Despres, J. P., Willett, W. C., & Hu, F. B. (2010). Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care, 33(11), doi: /dc Malik, V. S., Willett, W. C., & Hu, F. B. (2009). Sugar sweetened beverages and BMI in children and adolescents: reanalysis of a meta-analysis. Am J Clin Nutr, 89. doi: /ajcn Mayer-Davis, E. J., Dabelea, D., & Lawrence, J. M. (2017). Incidence Trends of Type 1 and Type 2 Diabetes among Youths, N Engl J Med, 377(3), 301. doi: /nejmc

9 National Center for Health Statistics. (2017) Health, United States, 2016: With Chartbook on Long-term Trends in Health. Hyattsville, MD Pan, A., & Hu, F. B. (2011). Effects of carbohydrates on satiety: differences between liquid and solid food. Curr Opin Clin Nutr Metab Care, 14(4), doi: /mco.0b013e328346df36 Reilly, J. J., & Kelly, J. (2011). Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. Int J Obes (Lond), 35(7), doi: /ijo Sacks FM, Lichtenstein AH, Wu JHY, et al; American Heart Association. Dietary Fats and Cardiovascular Disease: A Presidential Advisory from the American Heart Association. Circulation Jul 18;136(3):e1-e23. doi: /CIR Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr. 2010;91: doi: /ajcn Vos, M. B., Kaar, J. L., Welsh, J. A., Van Horn, L. V., Feig, D. I., Anderson, C. A. M.,... Council on, H. (2017). Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association. Circulation, 135(19), e1017-e1034. doi: /cir Wang, M., Yu, M., Fang, L., & Hu, R. Y. (2015). Association between sugar-sweetened beverages and type 2 diabetes: A meta-analysis. J Diabetes Investig, 6(3), doi: /jdi World Health Organization. (2018). Why does childhood overweight and obesity matter? Retrieved from United States Department of Health and Human Services and United States Department of Agriculture. (2015). Scientific Report of the 2015 Dietary Guidelines Advisory Committee. First Print February, 2015 United States Department of Agriculture and United States Department of Health and Human Services. (2010). Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans. Released May 28, 2010 Yudkin J. (1956). Man Choice of Food. Lancet. May 12, 1956