Presented by Marian Neuhouser, PhD, RD Member, 2015 DGAC WHI Nutrition SIG June 5, 2015

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1 An inside look at the Scientific Report of the 2015 Dietary Guidelines Advisory Committee Presented by Marian Neuhouser, PhD, RD Member, 2015 DGAC WHI Nutrition SIG June 5, 2015

2 2015 Dietary Guidelines Advisory Committee Provides science-based recommendations to the Federal government on How food, nutrition, and physical activity Can promote the health of the U.S. population Help reduce the burden from major chronic diseases and other lifestyle-related health problems How best to accomplish these goals at individual and population levels Scientific report informs the 2015 Dietary Guidelines for Americans policy document

3 Areas of Potential Public Policy Impact U.S. Department of Health and Human Services Healthcare Systems Affordable Care Act Medicaid and Medicare National Prevention Strategy Grant Funding for public health research and infrastructure Food and Nutrition Labeling Nutrition Facts Label Restaurant and vending labeling U.S. Department of Agriculture Food, Agriculture and Farm Policies, Resources, and Products Federal Food Assistance Programs: National School Lunch Program Child and Adult Care Food Program Nutrition Supplemental Nutrition Assistance Program (SNAP) Commodity Supplemental Food Program Special Supplemental Nutrition Program for Women, Infants and Children (WIC) DGAC Report: Policy document applications

4 2015 Dietary Guidelines Advisory Committee Chair Barbara Millen, DrPH, RD Millennium Prevention Steven Abrams, MD Baylor College of Medicine Lucile Adams-Campbell, PhD Georgetown University Medical Center Cheryl Anderson, PhD, MPH University of California, San Diego J. Thomas Brenna, PhD Cornell University Members Wayne Campbell, PhD Purdue University Steven Clinton, MD, PhD The Ohio State University Frank Hu, MD, PhD, MPH Harvard School of Public Health Miriam Nelson, PhD Tufts University Vice Chair Alice H. Lichtenstein, DSc Tufts University Marian Neuhouser, PhD, RD Fred Hutchinson Cancer Research Center Rafael Perez-Escamilla, PhD Yale University Anna Maria Siega-Riz, PhD, RD University of North Carolina, Chapel Hill Mary Story, PhD, RD Duke University Timothy Griffin, PhD Tufts University Consultant Subcommittee Members Michael Hamm, PhD Michigan State University Michael Perri, PhD, ABPP University of Florida

5 DGAC Subcommittees 2015 DGAC Subcommittees Science Review Subcommittee SC 1 SC 2 SC 3 SC 4 SC 5 Food and Nutrient Intakes, and Health: Current Status and Trends Dietary Patterns, Foods and Nutrients, and Health Outcomes Diet and Physical Activity Behavior Change Food and Physical Activity Environments Food Sustainability and Safety Nutrients of concern Food group intakes Food sources Eating behaviors Dietary patterns Health concerns Food pattern modeling Dietary patterns and health outcomes Foods and nutrients and health outcomes Self-monitoring Eating out Household food insecurity Food/menu label use Mobile health Acculturation Screen time/sedentary behavior Settings: Schools/afterschool Childcare Post-secondary Worksites Food access Food marketing Food safety: Preventing foodborne illness Caffeine Non-caloric sweeteners Dietary patterns and sustainability Sleep patterns

6 Cross-cutting Topics Examples Sodium Added Sugars Physical Activity Saturated Fat What Works Health impact of and modes/methods/settings for helping Americans meet diet and physical activity recommendations to promote health

7 Examining the Evidence Data analyses (NHANES data) Food pattern modeling analyses (NHANES) NEL systematic reviews (de novo) Existing reports Existing high-quality evidence-based reports Existing systematic reviews Existing meta-analyses Public comments Go to Resources and select Data Analyses

8 SC 1: Food and Nutrient Intakes, and Health: Current Status and Trends 2015 DGAC Subcommittee 1 MEETING DGAC: December 15, 2014 Marian Neuhouser SC 1 Chair Alice H. Lichtenstein DGAC Vice Chair Steve Abrams Cheryl Anderson Mary Story

9 2015 DGAC: MEETING 7 Scope of SC1 Examined food and nutrient intakes shortfall nutrients, overconsumed nutrients and nutrients of public health concern food and eating environment/eating behaviors prevalence of chronic health conditions. Context for actions to facilitate and implement behavior change and adoption of healthy eating practices Taken together, these analyses inform the remaining chapters in the report, which will provide the contextual and scientific foundation for the 2015 Dietary Guidelines for Americans. Food and Nutrient Intakes, and Health: Current Status and Trends

10 2015 DGAC: MEETING 7 Methodology Data analyses (21 questions) National Health and Nutrition Examination Survey (NHANES), including What We Eat in America (WWEIA) Additional data sources: SEER/NCI; SEARCH for Diabetes in Youth Study; CDC population-based birth defects surveillance system; National Health Interview Survey; Alzheimer's Association; other CDC publications Food pattern modeling analyses (7 questions) In addition, brought forward summaries from analyses by previous DGACs for several questions. Food and Nutrient Intakes, and Health: Current Status and Trends

11 Percent of Population Ages 2+ with Usual Intakes below EAR vitamin D vitamin E magnesium calcium vitamin A vitamin C zinc vitamin B6 folate iron thiamin copper phosphorus selenium vitamin B12 niacin riboflavin Percent of population What We Eat in America, NHANES

Ages 1-3 Ages 4-8 Ages 9-13 Ages 14-18 Ages 19-30 Ages 31-50 Ages 51-70 Ages71+ 0

12 Sodium: Percent of age/sex group with usual intakes above the UL Males: Ages 1-3 Ages 4-8 Ages 9-13 Ages Ages Ages Ages Ages71+ Females: Ages 1-3 Ages 4-8 Ages 9-13 Ages Ages Ages Ages Ages DGAC Report Figure D1.3 What We Eat in America, NHANES

13 Nutrients of Concern (shortfall and overconsumed) Vitamin A, vitamin D, vitamin E, folate, vitamin C, calcium, and magnesium are under-consumed relative to the EAR. Iron is under-consumed by adolescent and premenopausal females. Potassium and fiber are under-consumed relative to the AI. Sodium and saturated fat are over-consumed relative to the UL or other maximum standard.

14 Nutrients of Public Health Concern Of the nutrients that are under-consumed or over-consumed, which present a substantial public health concern, including over the UL? Data Analysis Involves nutrient intake, blood measures (if available) and health outcomes

15 Review of the Evidence- Nutrients of Concern What We Eat in America, NHANES dietary survey ( )( ) Second National Report on Biochemical Indices of Diet and Nutrition in the U.S. Population, Centers for Disease Control and Prevention, 2012 Prevalence of health conditions, from the CDC

16 Nutrients of Public Health Concern Nutrient Vitamin D Calcium Potassium Fiber Sodium ( ) Saturated fat ( ) Iron (children, premenopausal females, pregnancy) Indicator/health concern Bone health Bone health Blood pressure Gastrointestinal health Blood pressure CVD Iron deficiency

17 Conclusion Statement Nutrients of Concern Nutrient intake data, together with nutritional biomarker and health outcome data, indicate that vitamin D, calcium, potassium, and fiber are under-consumed and may pose a public health concern. Nutrient intake data, together with nutritional biomarker and health outcome data, indicate that sodium and saturated fat are over-consumed and may pose a public health concern. Note dietary cholesterol did not fit criteria for definition of nutrient of concern

Total Fruits Estimated percentage of persons below, at, or above recommendation M 1

to 13 F 14-18 F 19-30 F 31-50 F 51-70 F 71+ Intake below recommendation Intake

20-20 0 20 40 60 80 100 % below recommendation % at or above recommendation What We

18 Total Fruits Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M M M M M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F F F F F 71+ Intake below recommendation Intake meeting recommendation Intake above recommendation All % below recommendation % at or above recommendation What We Eat in America NHANES SC 1: Food and Nutrient Intakes and Health: Current Status and Trends

Total Vegetables Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M 14-18 M 19-30 M

recommendation Intake above recommendation All 1+ 100-100 80-80 60-60 40-40 20-20 0 20 40 60 80 100 % below recommendation % at or

19 Total Vegetables Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M M M M M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F F F F F 71+ Intake below recommendation Intake meeting recommendation Intake above recommendation All % below recommendation % at or above recommendation What We Eat in America NHANES SC 1: Food and Nutrient Intakes and Health: Current Status and Trends

Whole Grains Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M 14-18 M 19-30 M 31-50 M 51-70 M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F 14-18 F 19-30 F 31-50 F

20 Whole Grains Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M M M M M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F F F F F 71+ Intake below recommendation Intake meeting recommendation Intake above recommendation All % below recommendation % at or above recommendation What We Eat in America NHANES SC 1: Food and Nutrient Intakes and Health: Current Status and Trends

Refined Grains Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M 14-18 M 19-30 M

recommendation Intake above recommendation All 1+ -100 100-8080 -6060-4040 -20 20 0 20 40 60 80 100 % below recommendation % at

21 Refined Grains Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M M M M M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F F F F F 71+ Intake below recommendation Intake meeting recommendation Intake above recommendation All % below recommendation % at or above recommendation What We Eat in America NHANES SC 1: Food and Nutrient Intakes and Health: Current Status and Trends

Total Dairy Estimated percentage of persons below, at, or above recommendation M 1 to

13 F 14-18 F 19-30 F 31-50 F 51-70 F 71+ Intake below recommendation Intake meeting

20 40 60 80 100 % below recommendation % at or above recommendation What We Eat in

22 Total Dairy Estimated percentage of persons below, at, or above recommendation M 1 to 3 M 4 to 8 M 9 to 13 M M M M M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F F F F F 71+ Intake below recommendation Intake meeting recommendation Intake above recommendation All % below recommendation % at or above recommendation What We Eat in America NHANES SC 1: Food and Nutrient Intakes and Health: Current Status and Trends

limit Intake at limit Intake above limit All 1+ -100-80 60-60 40-40 20-20 0 20 40 60 80 100 % below recommendation % at or

23 Calories from Solid Fats and Added Sugars Estimated percentage of persons below, at, or above limits M 1 to 3 M 4 to 8 M 9 to 13 M M M M M 71+ F 1 to 3 F 4 to 8 F 9 to 13 F F F F F 71+ Intake below limit Intake at limit Intake above limit All % below recommendation % at or above recommendation What We Eat in America NHANES SC 1: Food and Nutrient Intakes and Health: Current Status and Trends

24 Vegetables, 8% Fruits and Fruit Juice, 5% Percent of Energy Intake from Major Food Categories Snacks and Sweets, 16% Beverages (not milk or 100% fruit juice), 12% Mixed Dishes Condiments, gravies, spreads,salad dressings, 2% Other, 29% Pizza, 4% Burgers, sandwiches, tacos, 14% Grains, 11% Protein Foods, 11% Dairy, 7% Meat, poultry, seafood dishes, 4% Rice, pasta, grain dishes, 5% Soups, 1% What We Eat in America, NHANES

25 Sources of Sodium Sources of Saturated Fat Condiments 5% Dairy Beverages 3% 5% Beverages 1% Snacks and Sweets 8% Grains 11% Vegetables 11% Protein Foods 14% Mixed Dishes 43% Vegetables 6% Snacks and Sweets 18% Grains 4% Condiments 7% Dairy 13% Mixed Dishes 36% Protein Foods 15% What We Eat in America, NHANES

Food sources of added sugars: Percent from

VEGETABLES 1% CONDIMENTS, GRAVIES, SPREADS,

SOFT DRINKS 25% Sugar Sweetened Beverages 39%

SPORT and ENERGY DRINKS 3% PROTEIN FOODS 0%

26 Food sources of added sugars: Percent from major food categories FRUITS+FRUIT JUICE 1% VEGETABLES 1% CONDIMENTS, GRAVIES, SPREADS, SALAD DRESSINGS 2% ALCOHOLIC BEVERAGES 1% COFFEE and TEA 7% SNACKS AND SWEETS 31% BEVERAGES (NOT MILK or 100% FRUIT JUICE) 47% SOFT DRINKS 25% Sugar Sweetened Beverages 39% GRAINS 8% MIXED DISHES 6% FRUIT DRINKS 11% SPORT and ENERGY DRINKS 3% PROTEIN FOODS 0% DAIRY 4% DGAC Report Figure D1.36 What We Eat in America, NHANES

27 Calories from beverages Nineteen percent of total energy comes from beverages, including milk and 100% fruit juice. Of this 19% of energy, major sources are: Sugar-sweetened beverages (35%) Milk and milk drinks supply (26%) 100% fruit juices (10%). Beverages supply 47% of added sugars intake. Changing sugar sweetened beverage intake could have large population impact But- this is also where policies and food availability comes into play SYSTEMS What is available at your workplace? Local sports stadiums? etc

28 Trends in Location of Meal and Snack Consumption ERS: Nutritional Quality of Food Prepared at Home and Away from Home,

29 Milligrams Sodium Density Milligrams per 1000 kcal by where obtained HEI Limit Store Restaurant Quick serve restaurant School/day care DGAC Report What We Eat in America, NHANES

30 Percent of energy Saturated fat density Percent of total energy by where obtained 16.0 Store 14.0 Restaurant DGA Limit Quick serve restaurant School/day care DGAC Report What We Eat in America, NHANES

31 Empty calories per 1000 total calories 400 Empty calorie* density Calories per 1000 kcal by where obtained HEI Limit Store Restaurant Quick serve restaurant School/day care *Empty calories are calories from solid fats and added sugars DGAC Report What We Eat in America, NHANES

32 2015 DGAC Dietary Patterns, Foods and Nutrients, and Health Outcomes Chapter 2 Anna Maria Siega-Riz SC 2 Chair Alice H. Lichtenstein DGAC Vice Chair Cheryl Anderson Tom Brenna Steven Clinton Frank Hu Rafael Pérez- Escamilla Marian Neuhouser

33 2015 DGAC SC 2 A major goal of the DGAC was to describe the common characteristics of a healthy dietary pattern. Committee focused on research examining dietary patterns because the totality of diet may have synergistic and cumulative effects on health and disease. Dietary Patterns, Foods and Nutrients, and Health Outcomes

34 Dietary Patterns, Food and Nutrients, and Health Outcomes Definition of Dietary patterns: The quantities, proportions, variety or combinations of different foods and beverages in diets, and the frequency with which they are habitually consumed. Health Outcomes Examined in relation to Dietary Patterns: Cardiovascular disease, body weight, type 2 diabetes, cancer, congenital anomalies, neurological and psychological illnesses, and bone health Part D. Chapter 2

35 Dietary Pattern Methodologies Selective Diets People who meet/don t meet criteria Hypothesis Testing Indexes/ Scores Cluster Analysis Factor Analysis Individuals scores on quality and its components Groups of individuals and their diet patterns Factors explaining variation in individuals scores How do dietary patterns relate to health outcome?

36 2015 DGAC: MEETING 5 USDA NEL Process Step 1: Topic identification and systematic review question development Step 2: Literature search, screening, and selection Step 3: Data extraction and risk of bias assessment Step 4: Evidence synthesis Step 5: Conclusion statements and grading the evidence Step 6: Research recommendations and technical abstracts Introduction to SC Reports

37 Elements Risk of bias Quantity Consistency Impact Generalizability NEL Reviews: Grading the Evidence Grade I: Strong Studies of strong design free from design flaws, bias and execution problems Several good quality studies; large number of subjects studied; studies have sufficiently large sample size for adequate statistical power Findings generally consistent in direction and size of effect or degree of association and statistical significance with very minor exceptions Studied outcome relates directly to the question; size of effect is clinically meaningful Studied population, intervention and outcomes are free from serious doubts about generalizability Grade II: Moderate Studies of strong design with minor methodological concerns or only studies of weaker study design for question Several studies by independent investigators; doubts about adequacy of sample size to avoid Type I and Type II error Some inconsistency in results across studies in direction and size of effect, degree of association or statistical significance Some study outcomes relate to the question indirectly; some doubt about the clinical significance of the effect Minor doubts about generalizability Grade III: Limited Studies of weak design for answering the question or inconclusive findings due to design flaws, bias or execution problems Limited number of studies; low number of subjects studied and/or inadequate sample size within studies Unexplained inconsistency among results from different studies Most studied outcomes relate to the question indirectly; size of effect is small or lacks clinical significance Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied Grade IV: Grade Not Assignable Serious design flaws, bias, or execution problems across the body of evidence Available studies do not directly answer the question OR no studies available Independent variables and/or outcomes are too disparate to synthesize or single small study unconfirmed by other studies Studied outcomes relate to the question indirectly; size of effect cannot be determined Highly unlikely that the studied population, intervention and/or outcomes are generalizable to the population of interest

38 Dietary Patterns, Foods and Nutrients, and Health Outcomes 2015 DGAC Major Conclusions Numerous dietary patterns were identified, with the most common ones defined using indices or scores such as the Healthy Eating Index (HEI)-2010, the Alternate HEI-2010, or various Mediterranean-style dietary patterns, the DASH pattern, vegetarian patterns, and data-driven approaches. The Committee s examination of the association between dietary patterns and various health outcomes revealed remarkable consistency in the findings.

39 Dietary Patterns, Foods and Nutrients, and Health Outcomes 2015 DGAC Major Conclusions Strong evidence: CVD; weight loss among overweight and obese adults Moderate evidence: T2D; colorectal cancer; postmenopausal breast cancer; and body weight weight gain or incidence of overweight and obesity (adults) Limited evidence: Premenopausal breast cancer; lung cancer; neural tube defects; depression (adults); age-related cognitive impairment; bone health (adults); and body weight (children) Grade not assignable: Prostate cancer; depression (post-partum women; children); congenital heart defects; cleft lip/palate; and bone health (children)

40 Dietary Patterns, Foods and Nutrients, and Health Outcomes 2015 DGAC Major Conclusions Common characteristics of dietary patterns associated with health benefits include: higher intake of vegetables, fruits, whole grains, lowand non-fat dairy, fish/seafood, legumes, and nuts; moderate intake of alcohol (among adults); lower consumption of red and processed meat, and low intake of sugar-sweetened foods and beverages, and refined grains. The whole may be more than the sum of its parts

41 Special Topic: Added Sugars 2015 DGAC: 2015 MEETING DGAC 7 What is the relationship between the intake of added sugars and cardiovascular disease, body weight/obesity, type 2 diabetes, and dental caries? What is the relationship between the intake of low-calorie sweeteners and body weight/obesity and type 2 diabetes?

42 2015 DGAC: 2015 MEETING DGAC DGAC Food Pattern Modeling Added sugars available in the USDA Food Patterns (Healthy U.S.-Style, Healthy Mediterranean-Style, and Vegetarian Patterns) in calories, teaspoons, and percent of total calories per day CALORIE LEVEL Empty calorie limits available for added sugars (assuming 45% empty calories from added sugars and 55% from solid fat) Healthy U.S.-style Healthy Med-style Vegetarian Average Average (tsp) Healthy U.S.-style 7% 4% 4% 3% 4% 6% 6% 7% 7% 6% 7% 9% Healthy Med-style 6% 4% 4% 5% 4% 6% 6% 6% 6% 6% 6% 8% Vegetarian 8% 6% 6% 5% 5% 7% 6% 7% 6% 6% 6% 7% Average 7% 5% 4% 5% 4% 6% 6% 6% 6% 6% 7% 8%

43 2015 DGAC: 2015 MEETING DGAC 7 Recommendations for Added Sugars The DGAC recommends limiting added sugars to a maximum of 10 percent of total daily caloric intake. This recommendation is supported by: The food pattern modeling analysis conducted by the DGAC The scientific evidence review on added sugar and chronic disease risk conducted by the DGAC showing strong evidence supports reducing added sugars intake to reduce health risks.

44 This was a whirl wind snapshot of the Scientific Report of the 2015 DGAC For more details please go to Thank you Questions?

Scientific Report of the 2015 Dietary Guidelines Advisory Committee

Scientific Report of the 2015 Dietary Guidelines Advisory Committee BEVERAGE RECOMMENDATIONS: Sugar Sweetened Beverages & Water Rafael Pérez-Escamilla, PhD Yale School of Public Health National Academies