GOOD MORNING. GOOD MORNING, EVERYONE. I WOULD LIKE TO GO AHEAD AND START THE MEETING TODAY. WELCOME EVERYONE TO THE THIRD MEETING OF THE DIETARY GUIDELINES ADVISORY COMMITTEE. WE HAVE OVER 880 INDIVIDUALS REGISTERED TO VIEW THE WEBCAST LIVE TODAY. I WOULD LIKE TO WELCOME THE PUBLIC TO THE MEETING. WE HAVE ALL 14 MEMBERS OF THE ADVISORY COMMITTEE HERE TODAY. HAVE THEIR NAMES LISTED UP ON THE SLIDE FOLKS CAN SEE FOR THE PUBLIC, IF YOU'RE NOT FAMILIAR WITH ALL THE ADVISORY COMMITTEE MEMBERS GO TO THE DIETARY WEBSITE AND THERE'S A SHORT BIOSKETCH ON EACH OF THE 14 MEMBERS THE DIETARY GUIDELINES COMMITTEE. IN ADDITION O THE MEMBERS AROUND THE TABLE I WANT TO INTRODUCE A FEW FOLKS UNDERSECRETARY CONCANNON, THE UNDERSECRETARY FOR FOOD AND CONSUMER SERVICES. DON RIGHT WHO IS MY BOSS, THE HHS DEPUTY ASSISTANT SECRETARY FOR HEALTH FOR DISEASE PREVENTION AND HEALTH PROMOTION. IN ADDITION WE HAVE JACKIE HAVEN, DEPUTY DIRECTOR AND ACTING EXECUTIVE DIRECTOR FOR THE CENTER FOR NUTRITION POLICY AND PROMOTION AT USDA, FROM HHS. KELLIE CASAVALE, A CO-EXECUTIVE SECRETARY WORKS WITH ME IN OUR OFFICE. WE HAVE COLLIDE ROHANI, THE LEAD CO-EXECUTIVE SECRETARY FROM THE FDA, FROM CENTER OF NUTRITIONAL POLICY AND SEAN BOLLMAN FROM THE AGRICULTURAL RESEARCH SERVICE THE FOURTH CO-EXECUTIVE SECRETARY. IN ADDITION WE HAVE A DOZEN OR TWO FEDERAL STAFF HERE IN THE ROOM WITH US WHO DIRECTLY SUPPORT THE ADVISORY COMMITTEE AND THEIR WORK. I WOULD BRIEFLY LIKE TO REVIEW THE AGENDA FOR TODAY. WE HAVE FOUR EXPERT SPEAKERS THIS MORNING AND THEN THIS AFTERNOON WE'LL HAVE SUBCOMITTEE REPORTS WITH DISCUSSION REPORTING ON THE WORK THE COMMITTEE HAS DONE SINCE THE LAST MEETING IN JANUARY. SUBCOMITTEES HAVE MET THIS WEEK, ONE OF THE SUBCOMITTEES MET ON LATE ON WEDNESDAY AFTERNOON AND THE OTHERS MET YESTERDAY TO CONTINUE THEIR DISCUSSIONS AND FINALIZE THEIR PRESENTATIONS FOR THE FULL COMMITTEE TODAY. THE COMMITTEE OF COURSE IS EXPLORING A WHOLE LOT OF DIFFERENT TOPICS AND TODAY THEY WILL BEGIN THEIR DISCUSSION OF THE AVAILABLE SCIENTIFIC EVIDENCE FOR FEW OF THEIR QUESTIONS, STRENGTH OF THE EVIDENCE AND IMPLICATIONS OF THIS. THE COMMITTEE OF COURSE IS WORKING FULL SPEED. WE HAVE A TIGHT TIME LINE. WE HOPE TO HAVE THE COMMITTEE REPORT COMPLETED BY END OF CALENDAR YEAR SO END OF 2014. AT THAT TIME WE WILL HAVE A PUBLIC MEETING AFTER THE COMMITTEE DISBANDED TO GIVE ORAL TESTIMONY ON THE COMMITTEE'S REPORT. OUR TWO DEPARTMENTS WILL USE THAT INFORMATION TO DEVELOP THE DIETARY GUIDELINES FOR AMERICANS THE POLICY DOCUMENT DIETARY GUIDELINES FOR AMERICANS WE HOPE TO HAVE OUT BY THE END OF 2015. SO THE COMMITTEE'S WORK WILL BE DONE AT THE END OF 2014 AND THE POLICY DOCUMENT WILL COME OUT IN 2015. THE COMMITTEE PLANS TO HAVE THREE MORE PUBLIC MEETINGS THIS CALENDAR YEAR TO DISCUSS ITS RECOMMENDATIONS AND FINALIZE WHAT IT WANTS TO PUT INTO THE REPORT. WE PLAN TO ANNOUNCE THOSE THREE DATES WITHIN THE NEXT MONTH OR TWO ON OUR WITH WEBSITE DIETARYGUIDELINES.GOV, SO IN A MONTH TO THREE WEEKS WE'LL HAVE ALL THREE FEATURE MEETING DATES OF THE COMMITTEE POSTED ON OUR WEBSITE. WE DO HAVE THE PRESENTATIONS FROM THE JANUARY MEETING NOW POSTED ON OUR WEBSITE. I WANT TO APOLOGIZE IT'S TAKING SO LONG TO GET THE PRESENTATIONS FROM THE JANUARY MEETING UP. WE'RE WORKING HARD TO SHORTEN THAT PROCESS BUT WE'RE REQUIRED TO MEET 508 LAW FOR ANYTHING WE POST ON OUR WEBSITE. AND FOR COMPLEX SLIDE PRESENTATIONS THAT TAKES QUITE SOME TIME. THE LINK TO THE WEBCAST, ARCHIVE WEBCAST TODAY WILL BE ON THE WEBSITE NEXT WEEK AND HOPEFULLY WITHIN THREE WEEKS WE'LL HAVE THE SLIDE PRESENTATIONS BOTH FROM THE FOUR EXPERT SPEAKERS AS WELL AS THE FIVE SUBCOMITTEE REPORTS FROM TODAY AND BARBARA MILLEN'S TALK THIS AFTERNOON. WITHOUT FURTHER ADIEU I WOULD LIKE TO ASK MARY STORY, COMMITTEE MEMBER TO COME FORWARD AND INTRODUCE OUR FIRST SPEAKER. MARY. THANK YOU. I'M PLEASED TO INTRODUCE DR. WILLIAM DIETZ WHO IS ONE OF THE MOST INTERNATIONALLY ESTEEMED OBESITY EXPERT RESEARCHER AND SCHOLARS IN THE FIELD. AND WHO IS A HOUSEHOLD NAME. IN THE OBESITY AREA. HE IS A PEDIATRICIAN AND HAS HIS Ph.D. IN NUTRITIONAL BIOCHEMISTRY FROM ER MIT. SENIOR ADVISER TO THE ROBERT WOOD JOHNSON FOUNDATION AND CONSULTANT TO THE INSTITUTE OF MEDICINE. BEFORE THAT FROM 1997 TO 2012, HE WAS DIRECTOR OF NUTRITION PHYSICAL INACTIVITY, AND OBESITY CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION AT THE CDC. BEFORE HE WENT TO CDC HE WAS A PROFESSOR OF PEDIATRICS, TUFTS UNIVERSITY SCHOOL OF MEDICINE AND DIRECTOR OF CLINICAL NUTRITION AT THE FLOATING HOSPITAL NEW ENGLAND MEDICAL CENTER HOSPITALS. HE ALSO SERVED ON THE 1995 DIETARY GUIDELINES ADVISORY COMMITTEE. HE HAS BEEN ACTIVELY INVOLVED IN MANY PROFESSIONAL ASSOCIATIONS, COUNSELOR AND PAST PRESIDENT OF THE AMERICAN SOCIETY FOR CLINICAL NUTRITION. AND PAST PRESIDENT OF THE NORTH AMERICAN ASSOCIATION FOR THE STUDY OF OBESITY. HE'S RECEIVED FAR TOO MANY AWARDS FOR ME TO EVEN MENTION NOW BUT WE'RE PLEASED TO HAVE HIM COME AND PRESENT HEARSAY THOUGHTS TO THE COMMITTEE, OBESITY AND HEALTH SETTINGS BARRIERS AND OPPORTUNITIES. WELCOME. OKAY. GREAT. THANK YOU. MARY, THANKS FOR THAT INTRODUCTION. I NEED TO AMEND HER OPENING COMMENTS. I'M A HOUSEHOLD NAME ONLY WHERE I LIVE. IN THE HOUSE OF MY CHILDREN. BUT I THINK THAT'S REALLY OVER THE TOP. I'M ALSO REALLY PLEASED TO BE ABLE TO ADDRESS THIS COMMITTEE. THE 1995 COMMITTEE WAS A MUCH LESS REGIMENTED PROCESS. I THINK AS I RECALL WE HAD MAYBE FOUR STAFF. AND NOW I UNDERSTAND THERE WERE ABOUT 50. AND WE HAD TWO FROM HHS AND TWO FROM USDA. WE CERTAINLY WEREN'T ENGAGED IN THE KIND OF SYSTEMATIC REVIEWS THAT YOU HAVE BEEN IMMERSED IN. BUT IT'S ALSO A PLEASURE TO BE HERE AMONG SO MANY FRIEND WHO I HAVE KNOWN SO LONG. NOTICE I'M NOT USING THE TERM OLD FRIENDS BECAUSE THE AMBIGUITY OF THAT SOMETHING TO AVOID. I HAVE BEEN ASKED TO TALK EFFECTIVE PREVENTION HEALTHCARE SETTINGS BARRIERS AND OPPORTUNITIES. I'M GOING TO TRY THE DRAW SOME PARALLELS WITH THE CHALLENGES THAT WE FACE IN OBESITY PREVENTION AND CONTROL CHALLENGES FACE IN TERMS OF DISSEMINATION OF DIETARY GUIDELINES. I THINK THAT AS I HAVE SEEN THE DIETARY GUIDELINES EMERGE OVER THE LAST 20 YEARS, IT REALLY IS CLEAR THAT THE MODIFICATIONS TO THE GUIDELINES ARE PRETTY MINIMAL OR MINOR. THOUGH AS COMMITTEE YOU THINK THEY'RE SO EARTH SHAKING AND THEME CHANGING. BUT THE POINT TO MAKE IS THIS IS NOT SO MUCH ABOUT WHAT, THOSE GUIDELINES ARE, ABOUT -- BUT RATHER HOW WE DISSEMINATE AND IMPLEMENT THEM. THAT'S BEEN A CHALLENGE SINCE THE BEGINNING. I THINK IF WE THINK IN TERMS OF THE SOCIAL ECOLOGICAL MODEL, THE MEDICAL SETTINGS ARE LIKELY TO HAVE THE SMALLEST IMPACT IN TERMS OF OBESITY PREVENTION AND CONTROL AS WELL AS IMPLEMENTATION OF THE GUIDELINES. MOST OF THE WORK TO DATE ON OBESITY IS OUTER LEVELS FEDERAL STATE AND INSTITUTIONAL LEVELS. WE KNOW RELATIVELY LITTLE I THINK OR COMPARED TO WHAT WE KNOW ABOUT POLICY IN THOSE ARENAS, RELATIVELY LITTLE ABOUT THE WAYS TO EFFECTIVELY DELIVER CARE FOR OBESITY. THE OTHER POINT HERE IS THESE CIRCLES NEED TO BE PORE OUTSIDE, TO DATE -- POROUS, TO DATE NOT AS THEY SHOULD BE SO THERE'S A CROSS TRANSLATION OF WHAT'S HAPPENING AT THE COMMUNITY LEVEL BEING REINFORCEED AND -- BY WHAT THE MESSAGES ARE AND STRATEGIES ARE ELSEWHERE. IT'S ALSO IMPORTANT TO MENTION THE DIFFERENCE BETWEEN THE PREVENTION O OBESITY AND THAT FOR TREATMENT OF OBESITY. THERE'S A NICE PAPER THAT MAY OR MAY NOT HAVE BEEN IN THE PAPERS YOU REVIEWED BY CLAIRE WONG IN PUBLISHED IN AMERICAN JOURNAL OF PREVENTIVE MEDICINE IN 2012 WHICH SHE MODELED THE CALORIC DEFICIT NECESSARY TO RETURN THE MEAN BMI OF CHILDREN BACK TO WHERE IT WAS IN THE 1970s BY 2020, SO THIS IS THE DAILY PER CAPITA DEFICIT. FOR 2 TO 5-YEAR-OLD THIS IS'S 30-CALORIES A DAY. FOR 11 -- 6 TO 11, IT'S 150, FOR 12 TO 19, IT'S ABOUT 180. AND IN A PAPER THAT KEVIN HALL PUBLISHED FOR ADULTS, IT'S ABOUT 220-CALORIES. AND THOSE IN MY VIEW ARE CALORIC DEFICITS READILY ACHIEVED BY POLICY AND ENVIRONMENTAL MODIFICATIONS BUT THEY WON'T EFFECT THE SEVERITY OF PEOPLE WITH SEVERE OBESITY FOR WHOM CALORIC DEFICITS TO GET BACK THE HEALTHY WEIGHT ARE SUBSTANTIAL AND BEYOND THE REACH OF ANY OF THE POLICY AND ENVIRONMENTAL CHANGES THAT WE ARE IMPLEMENTING. SO BROADLY ACROSS THE COUNTRY. THE OTHER POINT IS CURRENTLY THE TREATMENT OF OBESITY IS NOT ALIGNED VERY WELL WITH SEVERITY OF OBESITY AND COST. THESE ARE DATA CALCULATED FROM THIS PAPER FROM OTTER BURN, NOTICE ABOUT 8% OF THE POPULATION HAVE B MI ABOVE 35, GRADE 2 OBESITY. THESE ARE SELF-REPORTED DATA RATHER THAN MEASURED DATA SO THEY'RE UNDER ESTIMATES OF OBESITY. NOTICE THAT 8% OF THE POPULATION 40% OF THE COST OF -- GENERATES 40% OF THE COST. AND THESE PATIENTS ARE DESERVEDLY THE FOCUS OF INTENSIVE INTERVENTIONS RECOMMENDED BY THE REPORT RELEASED IN THE FALL FROM THE HEART ASSOCIATION AND THE OBESITY SOCIETY. THESE ARE THE RECOMMENDATIONS FOR THE TREATMENT OF SEVERE OBESITY WITH GOAL OF 56 TO 10% WEIGH LOSS IN SIX MONTHS. THAT'S A WEIGHT LOSS SUFFICIENT TO REDUCE COMORBIDITIES ASSOCIATED WITH OBESITY. AN INTENSIVE LIFESTYLE INTERVENTION IS DEFINED AS AT LEAST 14 VISITS WITHIN A SIX MONTH PERIOD. WITH CALORIC DEFICIT OF 500-CALORIES PER DAY THE LEVELS OF INTAKE FOR WOMEN AND MEN AND RECOMMENDATION OF IMPLEMENTATION OF THE PHYSICAL ACTIVITY GUIDELINES OR 150 MINUTES PER WEEK. THESE GUIDELINES AS YOU KNOW DON'T NECESSARILY MANDATE CONTINUOUS PHYSICAL ACTIVITY BUT AT LEAST TEN MINUTE INCREMENTS. AND THE IMPLEMENTATION OF THE STRATEGIES BY BEHAVIORAL MODIFICATION. ABSENT FROM THIS REPORT, AND ABSENT FROM I THINK IT WAS THE 1998 NHLBI REPORT ARE ANY DATA OR ANY SUGGESTIONS ON HOW THESE STAT INJURIES OUGHT TO BE IMPLEMENTED. THE ISSUE HERE WE KNOW WHAT TO DO. THIS IS A LENGTHY SYSTEMATIC REVIEW THAT RECOMMENDS THESE STRATEGIES FOR WEIGHT LOSS BUT IT DOESN'T TELL US HOW WE SHOULD BEGIN TO IMPLEMENT THE STRATEGIES FORTUNATELY THERE HAVE BEEN -- MAYBE UNFORTUNATELY, THERE HAVE BEEN FIVE STUDIES, ONE IN PEDIATRICS, FOUR IN ADULT POPULATION WHICH POINTS TOWARDS INNOVATIVE WAYS TO DELIVER THIS TYPE OF INTERVENTION. THE SLIDE THAT HAS THESE STUDIES ON IT IS AT THE END OF THE HAND OUT BUT THESE ARE THE CHARACTERISTICS OF THOSE STUDIES. THE ADULT STUDIES WERE LARGE ENOUGH THAT WE COULD CONSIDER THEM EFFECTIVENESS STUDIES, THEY INVOLVED 300 PLUS PATIENTS. BUT CHARACTERISTIC OF ALL FIVE OF THESE STUDIES, FOUR A ADULT, ONE PEDIATRIC TRIAL, IT RELIED ON CARE EXTENDERS RATHER THAN MULTI-DISCIPLINARY TEAMS. THE TRAINING OF THOSE CARE EXTENDERS AN CREDENTIALS OF THOSE CARE EXTENDERS WERE NOT REPORTED IN THESE STUDIES BUT PROBABLY HIGHLY VARIABLE. . INTERESTINGLY ENOUGH, THE DELIVERY OF CARE BY CARE EXTENDERS WAS TRADITIONAL OR MORE INTENSIVE TYPES OF INTERVENTIONS AND THE FEW STUDIES THAT USED ENTERIN THE ACCESS THE RESULTS WERE NOT SIGNIFICANTLY DIFFERENT. I THINK THESE POINT THE WAY TOWARDS HOW WE SHOULD CONCEPTUALIZE CARE FOR A HIGHLY PREVALENT DISEASE WHICH WOULD OVERWHELM THE CARE SYSTEM IF MODE OF CARE WAS TRADITIONALLY DELIVERED. WE ALSO KNOW SOMETHING NOW ABOUT FACTORS RELATED TO LONG TERM WEIGHT MAINTENANCE. IN MANY RESPECTS THE ISSUE HAS BEEN NOT SO MUCH WHETHER PEOPLE WITH LOSE WEIGHT BECAUSE PEOPLE ARE LOSING WEIGH ALL THE TIME USING A VARIETY OF STRATEGIES. BUT THE ISSUE IS HOW TO SUSTAIN THE WEIGHT LOSS AFTER IT OCCURS. THESE ARE THE STRATEGIES THREE DIFFERENT STUDIES HAVE TO WHICH THREE STUDIES HAVE CONTRIBUTED. REALLY EXCELLENT STUDY WAS LONG TERM RESULTS OF LOOK AHEAD TRIAL FOR OBESITY. WHICH SHOW THE GREATER THE INITIAL WEIGHT LOSS THE GREATER THE LONG-TERM SUCCESS AT WEIGHT MAINTENANCE. WEIGHT MAINTENANCE IF YOU LOOK CAREFULLY AT THE CURVES BECOMES EASIER OVER TIME. THERE'S AN INITIAL DECLINE MODEST REGAIN FOR MOST OF THESE AND THEN A PLATEAU. CHARACTERISTICALLY, THESE PATIENTS WHO HAVE LOST WEIGHT AND SUSTAINED IT ARE CONSUMING A LOCALRY LOW FAT DIET, THEY SELF-MONITOR THEIR WEIGHT. INTERESTINGLY THEY ARE USING MEAL REPLACEMENT STRATEGIES. THERE IS A REVIEW STEVE HUMANFELD PUBLISHED YEARS AGO ON NEUTRASYSTEM THAT SHOWED MEAL REPLACEMENT STRATEGIES SUSTAINED WEIGHT LOSS OVER A FIVE YEAR PERIOD. I SUSPECT THAT'S BECAUSE IT'S EASY TO LOSE WEIGH ON A VERY DEFINED DIET AND WHEN PEOPLE WENT BACK ON REGULAR DIET AND REGAINED WEIGHT THEY REINSTITUTED THE MEAL REPLACEMENT STRATEGY. SO IT WAS INTERESTING TO SEE THE REAPPEARANCE OF MEAL REPLACEMENT IN THE LOOK AHEAD TRIAL. THE OTHER POINT TO BE MADE ABOUT LONG TERM WEIGHT MAINTENANCE, THIS IS AN AREA WHERE CHANGES WITHIN COMMUNITY SETTINGS, INSTITUTIONAL SETTINGS REALLY NEED TO REINFORCE WHAT WE'RE EAR TRYING TO ACCOMPLISH MEDICALLY. IF PATIENTS LEAVE A MEDICAL SETTING WHERE THEY HAVE BEEN SUCCESSFUL IN THESE STRATEGIES OR BEHAVIORS ARE NOT REINFORCED IN A SYSTEMATIC WAY BY THE ENVIRONMENT, RELAPSE OCCURS, I THINK THERE IN LIES A CHALLENGE. HOW DO WE PREPARE PROVIDERS TO DELIVER CARE FOR NOT JUST THIS PROBLEM BUT OTHER CHRONIC DISEASES WHICH ARE SO PREVALENT AND REQUIRE A REFORMULATION, IF YOU WILL, OF THE MEDICAL CARE DELIVERY SYSTEM? WELL, I BELIEVE WE HAVE TO START WITH INTERPROFESSIONAL EDUCATION. I MAY DESCRIBE THIS AS MEDICAL BUT APPLIES EQUALLY TO SOCIAL WORKERS, KINESIOLOGISTS AND NUTRITIONISTS. CURRENTLY, THE QUALITIES OR COMPETENCIES OF PROVIDERS ARE SET BY THE CURRICULUM. THE FOCUS AS -- IN MEDICAL SCHOOLS PARTICULARLY, IS ON THE BASIC SCIENCES AND THEN CLINICAL EXPOSURE. AND THE CURRICULUM DEFINES THE EDUCATIONAL OBJECTIVES, PEOPLE ARE TESTED ON THOSE EDUCATIONAL ONTIVES. AND WITHIN THIS CONTEXT THERE IS A CHALLENGE IMPLEMENTING A NUTRITIONAL CURRICULUM. THE ACADEMIC NUTRITION AWARDS NIH AWARDED FOR TEN YEAR PERIOD HAD MODEST DEGREE OF SUCCESS IN SOME INSTITUTIONS BUT DIDN'T PERMEATE THOSE INSTITUTIONS SUFFICIENTLY TO FULLY INTEGRATE NUTRITION EDUCATION IN TO THE CURRICULUM. THIS SILOIZATION THAT EXISTS, AND THE COMPETITION AMONG VARIOUS SCIENCES FOR AIR TIME IN THE CURRICULUM REALLY EXCLUDES A CROSS-CUTTING ISSUE LIKE THE DIETARY GUIDELINES, LIKE OBESITY PREVENTION AND CONTROL. BUT I THINK WE'RE MOVING TOWARDS A DIFFERENTER RA. ONE WHICH THE COMPETENCIES ARE INCREASINGLY DEFINED BY THE NEEDS OF THE HEALTH SYSTEMS. AND ACA MAYBE THE AFFORDABLE CARE ACT MAYBE ONE OF THE DRIVERS OF THIS. IF WE ARE SUCCESSFUL IN MOVING IN THIS DIRECTION, THEN THE NEEDS OF THE HEALTH SYSTEMS ARE GOING TO DEFINE WHAT THE COMPETENCIES ARE OF PROVIDERS WHICH IN TURN IS GOING TO DICTATE WHAT THE CURRICULUM SHOULD BE. IT MAY WELL MOVE FROM A KNOWLEDGE BASE CURRICULUM AROUND THE BASIC SCIENCES TO ONE THAT'S MORE PRACTICAL. AND AIMED AT PREVENTION. WHICH IS CERTAINLY MAYBE LESS COSTLY THAN THE TREATMENT OF THE CHRONIC DISEASES TODAY. THIS PAPER BY FRANK FOR ME HAS BEEN A PIVOTAL PAPER. HE MAKES THREE POINTS ABOUT WHAT THE COMPETENCIES ARE, THE GENERAL COMPETENCIES ARE OF THESE PROVIDERS. ONE, CAPACITY TO WORK IN INTERPROFESSIONAL TEAMS. A SECOND IS RECOGNIZE AND AMPLIFY THE LINKAGES BETWEEN PUBLIC HEALTH OR COMMUNITY LEVEL WORK AND CLINICAL WORK. THE THIRD IS A FAMILIAR -- FAMILIARITY WITH INFORMATION TECHNOLOGY. BECAUSE INCREASINGLY IT'S IMPOSSIBLE TO ABSORB ALL OF THE KNOWLEDGE AROUND ALL THE ISSUES FOR WHICH PROVIDERS ARE CHALLENGED. THE OTHER PIECE OF THIS IS WE NEED TO THINK IN DIFFERENT TERMS HOW WE DELIVER CARE BUT NOT ONLY DO WE TRANSFORM THE MEDICAL SYSTEM TO THE ACCOMMODATE THE HIGH PREVALENCE OF OBESITY BUT EFFORTS HAVE TO BE COMPLIMENTED BY ENVIRONMENTAL CHANGES WHICH REINFORCE WHAT WE'RE TRYING TO ACCOMPLISH CLINICALLY. THIS MODEL IS CURRENTLY REVISED BY SEVERAL OF US WHO ARE WORKING IN AN IOM ROUND TABLE OBESITY SOLUTIONS BECAUSE THE POINT HERE IS THESE SYSTEMS NEED TO BE INTEGRATED. NOT JUST LINKED BUT FULLY INTEGRATED. THAT IS THE PROMISE WHICH THE SAME MESSAGES OR STRATEGIES IMPLEMENTED IN MEDICAL SYSTEMS ARE REINFORCED BY ENVIRONMENTAL SYSTEMS. I WOULD CALL YOUR ATTENTION TO THIS -- THESE RECOMMENDATIONS FROM THE ROBERT WOOD JOHNSON FOUNDATION WHICH ARE GOING TO HAVE ENORMOUS IMPACT ON THEIR FUNDING STREAMS AS WELL AS IT PROVIDES A NICE FRAMEWORK FOR HOW WE SHOULD BE APPROACHING THIS INTEGRATION ISSUE CAREFULLY. THE FIRST TENANT IS INVESTING IN AMERICA'S YOUNG CHILDREN A PRIORITY. I THINK WE SEE THE PROMISE OF THAT BY THE DECLINES THAT WERE REPORTED PREVALENCE OF CHILDHOOD OBESITY IN 20 '02 TO 5-YEAR-OLDS TWO WEEKS AGO IN JAMA. I THINK WHY THOSE CHANGES OCCURRED RELATES TO THE PRETTY MODEST CALORIC DEFICIT NECESSARY TO GET THE CHILDREN BACK TO WHERE THEY WERE IN THE 1970s. WE NEED TO FUNDAMENTALLY CHANGE HOW WE REVITALIZE NEIGHBORHOODS INTEGRATING HEALTH AND COMMUNITY DEVELOPMENT BECOMES A HIGH PRIORITY, PARTICULARLY RELEVANT TO THIS DISCUSSION IS BROADEN INCENTIVES OF HEALTH PROFESSIONALS AND INSTITUTIONS TO MOVE BEYOND THE CLAY IN THIS CASE WALLS OF TREATING PATIENTS TO A STRATEGY TO HELP PEOPLE LIVE HEALTHY LIVES. IN THAT SETTING THE ROLE OF PROVIDERS AND THE ROLE OF HEALTHCARE DELIVERY SYSTEMS HAVE TO REALLY FOCUS ON BOTH OF THESE ELEMENTS. THE PROVIDERS NEED TO BECOME ADVOCATES FOR COMMUNITY LEVEL INTERVENTION AND HEALTH SYSTEMS INCREASINGLY ARE RECOGNIZING THAT UNDER ACA AND WITH OTHER PRESSURES, THAT THEIR INVESTMENT NEEDS TO BE BEYOND PATIENT CARE AND TO COMMUNITY LEVEL INTERVENTIONS. THERE IN LIE IT IS PROMISE FOR DISSEMINATION NOT ONLY OF EFFECTIVE OBESITY PREVENTION AND CARE BUT ALSO THE IMPLEMENTATION OF DIETARY GUIDELINES. SPECIFICALLY WITH RESPECT TO OBESITY THERE ARE A NUMBER OF BARRIERS, PROVIDER STIGMA, AND TALKING ABOUT SUCH A STIGMATIZED CONDITION. IF WE CAN'T TEACH MEDICAL STUDENTS OR NURSING STUDENTS OR NUTRITIONISTS THE RIGHT LANGUAGE TO USE IN ADDRESSING THE PROBLEM, WE WON'T GET FAR. CURRENTLY FEW CURRICULA TEACH MEDICAL STUDENTS HEALTH PROFESSIONALS HOW TO OPEN THIS CONVERSATION THE OTHER REFLECTION OF BIAS AND CONTRIBUTOR TO STIGMATIZATION IS ABSENCE OF PEOPLE FIRST LANGUAGE. WE DON'T TALK CANCER CHILDREN OR ASTHMA CHILDREN, WE TALK ABOUT CHILDREN WITH ASTHMA. WE TALK ABOUT CHILDREN WITH DIABETES. WE SHOULD BE TALKING ABOUT CHILDREN WITH OBESITY. THE TERM OBESE CHILDREN OR OBESE ADULT IS A REFLECTION, IT'S AN IDENTITY, NOT A DISEASE. IF WE TALK ABOUT CHILDREN WITH OBESITY OR ADULTS WITH OBESITY, WE'RE TALKING ABOUT THOSE INDIVIDUALS WITH THE DISEASE. THAT LANGUAGE NEEDS TO CHANGE BUT IT'S NOT BEING TAUGHT. I MENTIONED LACK OF TRAINING RELATED TO OBESITY BUT PARTICULARLY LACK OF TRAINING RELATED TO HOW ONE COUNSELS PATIENTS EFFECTIVELY, ENGAGING THEM IN CARE. TIME IS A FACTOR, IN A BUSY CLINIC, IT'S HARD TO SPEND THE TIME COUNSELING PARTICULARLY THAT PROVIDER IS A PHYSICIAN WHICH LINKS BACK TO THE NEED TO HAVE VARIETY OF HEALTH PROFESSIONALS TRAINED IN THIS TREATMENT. THERE'S ALSO THE PERCEPTION OBESITY IS A -- WHEN PROVIDERS THINK THAT OBESITY IS METABOLIC PROBLEM THEY'RE LESS LIKELY TO COUNCIL ABOUT THE ENVIRONMENTAL CONTRIBUTORS TO THE DISEASE. AND THE PROVIDER CHARACTERISTICS ALONE ARE A DETERMINANT WHETHER THEY COUNCIL. SO JUST LIKE PROVIDERS WHO SMOKE DON'T COUNCIL ABOUT TOBACCO CESSATION, PROVIDERS WHO THEMSELVES ARE OVERWEIGH OR INACTIVE ARE LESS LIKELY TO COUNCIL ABOUT THESE -- ABOUT THOSE BEHAVIORS. INADEQUATE CARE SYSTEMS WE ADDRESSED, LACK OF REIMBURSEMENT IS A SIGNIFICANT DETERRENT WHICH MAY WELL CHANGE. SO THESE ARE COMPETENCIES THAT I THINK ARE RELEVANT NOT ONLY TO THE IMPLEMENTATION OF EFFECTIVE OBESITY STRATEGIES WITH SOME MODIFICATIONS AS INDICATED BUT ALSO THE COMPETENCIES RELEVANT TO THE IMPLEMENTATION OF THE DIETARY GUIDELINES. SO JUST AS BEHAVIOR CHANGE STRATEGIES ARE NECESSARY, TO CHANGE BEHAVIORS AN ENGAGE PATIENTS AROUND OBESITY TREATMENT, SAME IS TRUE AROUND IMPLEMENTATION OF DIETARY GUIDELINES. PART OF THIS ALSO INVOLVES WHETHER PROVIDERS ARE KNOWLEDGEABLE ABOUT THE DIETARY GUIDELINES. THERE ARE FEW KNOWLEDGEABLE AND FEWER FAMILIAR WITH THE GUIDELINES AND RECOMMENDATIONS FOR OBESITY CARE, THOUGH THOSE PATIENTS PERMEATE THEIR PRACTICE. AS I MENTIONED THE ABILITY TO WORK WITH AND WITHIN TEAMS AND THE USE OF INFORMATION TECHNOLOGY BOTH OF THOSE ARE RELATED TO EFFECTIVE DISSEMINATION OF THESE GUIDELINES. AND PARTICULARLY IMPORTANT AS THE ABILITY TO INTEGRATE WORK ACROSS SECTORS SO EVEN IF WE'RE SUCCESSFUL AT CONVINCING AND EDUCATING AND PROMOTING THE IMPLEMENTATION OF COUNSELING STRATEGIES RELATED TO THE DIETARY GUIDELINES, UNLESS THOSE ARE REINFORCED BY MESSAGES OUTSIDE THE COMMUNITY, OUTSIDE THE CLINIC, UNLESS WE HAVE CLINICAL AND COMMUNITY INTEGRATION OPPOSED TO LINKAGES OR COOPERATION I THINK WE'RE NOT GOING TO SUCCEED IN THE WIDE DISSEMINATION AND IMPLEMENTATION OF THESE GUIDELINES. THE -- BUT THE MOST HELPFUL AND HOPEFUL AREA IS THIS EMPHASIS WE SEE INCREASE NOT ONLY MEDICAL SETTINGS BUT REINFORCED BY THE VARIOUS STRATEGIES LIKE THE AFFORDABLE CARE ACT IS A FOCUS ON HEALTH AS WELL AS DISEASE. AND AS YOU WELL KNOW, THE DIETARY GUIDELINES THEIR IMPLEMENTATION IS LIKELY TO HAVE ENORMOUS IMPACT ON PREVENTION OF CHRONIC DISEASES. BUT UNLESS WE'RE SUCCESSFUL AT BOTH CHANGING THE COMPETENCIES OF PROVIDERS AS WELL AS THE INTEGRATION OF THESE STRATEGIES MORE BROADLY WITHIN COMMUNITIES, WE'RE NOT LIKELY TO SUCCEED. IN CLOSING, THESE FROM THE FIVE STUDIES I MENTIOND EARLIER. I LOOK FORWARD TO YOUR QUESTIONS. THANK YOU. [APPLAUSE] MA'AM. THIS IS MIM NELSON TUFTS UNIVERSITY. BILL, THANK YOU. THAT WAS WONDERFUL. QUESTION, DO YOU FEEL LIKE THERE'S GOOD EXAMPLES OUT THERE WE CAN LOOK AT? I CAN BELIEVE THERE PROBABLY ARE THAT INTEGRATE THE MEDICAL SYSTEM WITH THE COMMUNITY ENVIRONMENT? ONE THEME IS VERY MUCH ABOUT WHAT WORKS. YEAH. I'M LOOKING FOR THOSE IN THE OBESITY FIELD. I HAVEN'T FOUND THEM YET. ONE EXAMPLE WHICH BEGINS TO APPROXIMATE THAT IS DELIVERY OF DIABETES PREVENTION PROGRAM AND YMCAs BUT THAT'S NOT RESPONDING TO THE QUESTION YOU'RE ASKING ME BECAUSE THAT'S DELIVERY OF A CLINICAL INTERVENTION AND COMMUNITY SETTING. WHICH IS NOT THE SAME AS AN INTEGRATED APPROACH. BUT THERE ARE GROUPS THAT ARE INTERESTED IN FINDING THESE EXAMPLES THAT ROBERT WOOD JOHNSON PROMPT THAT, THE GROUP WORKING AT THE ROUND TABLE. MAYBE OTHER EXAMPLES IN OTHER AREAS OF MEDICINE WHERE THAT'S THE CASE BUT I'M NOT AWARE OF ANY PLACE DOING IT WELL WITH RESPECT TO NUTRITION FUZZCAL ACTIVITY AND OBESITY. THANK YOU, DR. DIETZ. THIS IS WAYNE CAMPBELL, PURDUE UNIVERSITY. THE THIRD SLIDE YOU PRESENTED ON THE PERCENTAGE OF COSTS ATTRIBUTABLE TO OVERWEIGHT AND OBESITY I WOULD JUST APPRECIATE A RECAP ON THE POINT YOU WERE TRYING TO MAKE WITH THIS SLIDE, CORRECT ME PLEASE, IF I'M WRONG BUT THERE'S AN APPROXIMATE EQUAL PROPORTION OF HEALTHCARE EXPENDITURES AMONG DIFFERENT GRADES FROM OVERWEIGHT TO MORBID OBESITY YET THE PERCENTAGE OF PEOPLE THAT ARE AFFLICTED BY THESE CONDITIONS IS DISPARATE. THAT'S CORRECT. AND OUR CARE SYSTEM IS NOT ALIGNED TO ADDRESS THIS WELL. I THOUGHT I TOOK AWAY FROM YOUR STATEMENT THAT UNDERSTANDABLY OR LEGITIMATELY WE SHOULD BE FOCUSING ON THE GRADE 2 AND GRADE 3 OBESITY BUT I WONDER FROM A PREVENTATIVE PERSPECTIVE WHETHER OR NOT THAT'S THE MOST APPROPRIATE WAY TO APPROACH THIS WHEN ECONOMICALLY YOU ARE ACTUALLY EQUAL BUT YOU HAVE A GREATER CHANCE OF PREVENTING PEOPLE FROM GETTING OVER THERE, IF YOU START IN THE OVER WEIGHT CATEGORY. CORRECT. DEPENDS WHETHER YOU ARE TALKING COST OR NUMBERS. IF FOCUS IS COST WE NEED TO IF CUSS ON THE MOST SEVERELY OVERWEIGHT INDIVIDUALS. IF WE ARE TALKING NUMBERS, YOU'RE RIGHT. THE NUMBERS ARE IN THE OVERWEIGHT AND GRADE CATEGORY. BUT I CONTENT IN THE OVERWEIGHT CATEGORY EFFECTIVE STRATEGY AROUND PREVENTION ARE POLICY BASED AND ANALOGOUS TO THINGS THAT WE HAVE BEEN DOING IN PUBLIC HEALTH. GRADE ONE LEVEL IS PROBABLY ONE WHICH COULD BE EASILY ADDRESSEDDED IN A PRIMARY CARE SETTING IF THOSE PROVIDERS ARE COUNSELING EFFECTIVELY. BUT I DON'T THINK -- I THINK SPECIALIZED CARE WILL BE REQUIRED FOR GRADE 2 AND GRADE 3 LEVEL PATIENTS. BUT FROM A DIETARY GUIDELINES PERSPECTIVE TO HIT THE -- ONE PERSPECTIVE WOULD BE YOU SHOULD BE TRYING TO MEET THE GUIDELINES THAT MEET OR IMPACT THE MOST PEOPLE IS THAT A VIEW YOU WOULD SHARE? ABSOLUTELY. I WAS TALKING -- I WAS ASKED TO TALK ABOUT OBESITY AND SO THAT'S THE FOCUS OF THIS SLIDE AND THIS TALK BUT IN TERMS OF IMPLEMENTATION, YES, I THINK THAT THE TARGET OUGHT TO BE PEEP PEOPLE NOT OVERWEIGHT OR PEOPLE IN THE OVERWEIGHT CATEGORY OR GRADE 1. THAT'S A BIG NUMBER. THE DISTRIBUTION IN THE POPULATION OF PEOPLE WITH OBESITY VERSUS THOSE NOT OR PEOPLE WITH OVERWEIGHT OR OBESITY IS ABOUT 65% OF THE U.S. POPULATION. SO MINORITY FALLS IN THIS HEALTHY WEIGHT CATEGORY. YOU'RE RIGHT. I THINK THIS COUNSELING AND IMPLEMENTATION, GUIDELINES HAVE THE BIGGEST IMPACT ON PEOPLE WHO ARE OVERWEIGHT OR GRADE 1 OBESITY. ALICE (INAUDIBLE) TUFTS UNIVERSITY. VERY HELPFUL SUMMARY WHERE WE ARE NOW. I'M WONDERING LOOKING FORWARD TO FUTURE, WHAT YOU INDICATED WAS THAT A LOT OF PROGRAMS HAD LIMITED SUCCESS. DO YOU HAVE ANY IDEAS ON ALTERNATE APPROACHES THAT MAYBE MORE PARTICULAR IN TERMS OF PREVENTION AND ANY THOUGHTS HOW THE DIETARY GUIDELINES MIGHT SUPPORT SOME OF THOSE? I'M NOT SURE WHETHER THAT'S ONE QUESTION OR TWO. YOU CAN DECIDE. I THINK THE LOOK AHEAD TRIAL IS REALLY A GREAT DEMONSTRATION OF PROFOUNDLY SUCCESSFUL CLINICAL INTERVENTION. THERE'S A SIGNIFICANT PROPORTION OF PATIENTS IN THAT TRIAL WHO DID NOT RESPOND. KNOWING WHO THEY ARE AND HOW WE APPROACH THOSE IS AN IMPORTANT CHALLENGE. BUT THE SECOND PART OF THE QUESTION HAD TO DO MORE WITH PREVENTION AND TARGET OF PREVENTION IF I UNDERSTOOD. COULD YOU CLARIFY THAT PIECE? I DIDN'T FOLLOW THAT. I THINK THAT WE HAVEN'T BEEN PARTICULARLY SUCCESSFUL IN DEVELOPING PREVENTION PROGRAMS. WONDERING IF YOU HAVE ANY IDEAS ON WHERE NEW DIRECTIONS MIGHT BE AND WHETHER THERE'S ANY WAY THE DIETARY GUIDELINES MIGHT HELP IN SHEPHERDING SOME OF THOSE PROGRAMS FORWARD. THAT'S A CHALLENGING QUESTION BECAUSE I THINK THERE IS A LOT OF MOVEMENT IN PLACE AROUND PREVENTION AT THE INSTITUTIONAL LEVEL. KEVIN WORK AT USDA KIDS IN SCHOOLS RECENT ANNOUNCEMENT THOUGH CARRIES SOME RISK UNIVERSAL SCHOOL BREAKFAST AND LUNCH PROGRAMS. THAT'S HAD A PROFOUND EFFECT, CONTINUE TO HAVE A PROFOUND EFFECT ON SCHOOLS. THE WORRY I HAVE KEVIN IS THE DOUBLE BREAKFAST RISK FOR THE -- FOR THE UNIVERSAL SCHOOL BREAKFAST. SO I THINK THAT THAT'S IN PLACE. I THINK WE'RE SEEING THE IMPACT OF THAT. WE'RE ALSO SEEING IMPACT OF THE KIND OF INDIVIDUAL LEVEL BEHAVIOR CHANGE OR PARENTAL CHANGE BECAUSE AT THE NATIONAL LEVEL WE SEE DECREASES IN CONSUMPTION OF SUGAR DRINKS AN DECREASES IN CONSUMPTION OF FAST FOOD. YOU'RE AWARE THE HEALTHY WEIGHT COMMITMENT FOUNDATIONS RESULTS OF REDUCING THE CALORIES IN THE U.S. FOOD SUPPLY BY 6.4 TRILLION-CALORIES RATHER THAN THE ORIGINAL 1.5 OR WHATEVER IT WAS, THAT THEY HAD PROPOSED. SO I THINK THE 2 TO 5-YEAR-OLDS ARE THE BENEFICIARIES OF THOSE NATIONAL TRENDS. AND I SUSPECT THAT WE'LL SOON SEE RESULTS IN 6 TO 11 AGE GROUP AS THEY COME ALONG. ALL THAT TO SAY THE EXTENT TO WHICH THE DIETARY GUIDELINES CAN BE INCORPORATED IN THOSE POLICY INITIATIVES THAT AFFECT EARLY CARE AND EDUCATION IN SCHOOLS IS ALL TO THE GOOD. THAT'S LIKELY TO HAVE THE BIGGEST IMPACT. THE OTHER PLACE, THE ADULT EQUIVALENT TO SCHOOLS ARE WORK SITES. I DON'T THINK THERE'S MUCH EXPERIENCE HOW TO BEGIN TO IMPLEMENT STRATEGIES IN DIETARY GUIDELINES THOUGH THOSE WORK SIGHT AND EMPLOYERS ARE AWARE OF COSTS CHRONIC DISEASES AND HAVE TAKEN STEPS TO IMPLEMENT THEM. THOSE ARE MOST SUCCESSFUL IN LARGE BUSINESSES, THE REAL CHALLENGE IS SMALL TO MEDIUM SIZE BUSINESS WHICH CONSTITUTES 60% OR 70% OR MAYBE MORE OF U.S. BUSINESSES. THERE MAYBE SUCCESS IN THOSE WORK SITES IS GOING TO BE DEPENDENT ON SUCCESS IN IMPLEMENTING THESE STRATEGIES AT THE COMMUNITY LEVEL BECAUSE THEY DON'T HAVE THE CAPACITY NECESSARILY TO DO IT -- WHAT THE LARGE BUSINESSES DO. THANK YOU FOR THIS WONDERFUL TALK. THERE'S STILL A LOT OF DEBATE REGARDING WHETHER IT WOULD BE A CONDITION OR A DISEASE ESPECIALLY FOR CHILDREN. SO SINCE YOU THOUGHT OBESITY DISEASE, THAT CAN HAVE ADVANTAGES IN TERMS OF TREATMENT AND OTHER ISSUES. I BELIEVE OBESITY IS A DISEASE, A DISEASE IS DEFINED AS A STATE OF ILL HEALTH. AND I THINK EVEN THOUGH THERE IS A SUBSET OF PEOPLE WITH OBESITY WHO ARE OTHERWISE METABOLICALLY NORMAL, THERE NOW APPEARS TO BE EARLY MORTALITY EVEN AMONG THAT GROUP. I ALSO THINK THAT THE DESIGNATION OF OBESITY, THE DESIGNATION OF OBESITY ALONE AS DISEASE DOES NOT INCREASE LIKELIHOOD THAT REIMBURSEMENT FOR TREATMENT WILL OCCUR. BECAUSE I THINK THAT DEPENDS MORE ON DEMONSTRATION OF EFFECTIVE TREATMENT STRATEGIES. DOES THAT ANSWER YOUR QUESTION? I THINK THE MAIN -- ESPECIALLY FOR SOME PARENTS IS THEY DON'T WANT THEIR CHILDREN TO BE STIGMATIZED. RIGHT. I THINK THIS COMES TO THE KIND OF TERMS WE USE HEN WE DISCUSS THIS PROBLEM WITH PARENTS. I WOULD NEVER USE OBESITY IN A CONVERSATION WITH A PATIENT. EVEN HEAVIEST ADULT PATIENT DOES NOT DESCRIBE THEMSELVES AS HAVING OBESITY. THEY SAY THEY HAVE A WEIGHT PROBLEM. BECAUSE OBESITY IS SUCH A STIGMATIZING TERM. AND I THINK INCREASINGLY, AT THE COMMUNITY AND INSTITUTIONAL LEVEL, WE'RE SEEING A MOVE AWAY FROM THE USE OF THAT TERM AS FOCUS AND MORE FOCUS ON HEALTH AND WELLNESS, A PLACE WHERE THE DIETARY GUIDELINES WOULD BE QUITE EFFECTIVE. MARY. THEN CHERYL, SOMEBODY ELSE CAN KEEP TRACK OF THESE QUESTIONS, THE ORDER IF YOU WOULD. I'LL COUNT ON YOU BARBARA. MARY STORY. COULD YOU TALK, BILL, ABOUT WHAT YOU SEE AS IDEAL INTEGRATION OF THE HEALTH SYSTEMS INTO THE ENVIRONMENT AND THE COMMUNITY? AND ALSO IF THERE'S ANY LESSONS LEARNED FROM OTHER COUNTRIES THAT HAVE DONE OR ARE DOING THAT WELL? I'M NOT SURE I KNOW OF ANY PLACE DOING IT WELL, THE DEFINITION OF INTEGRATION IS WHEN YOU CAN'T TELL WHERE THE INFORMATION IS COMING FROM. I'M SURE YOU'RE AWARE, IN THE EARLY CARE EDUCATION SETTINGS WHAT IS RECOGNIZED IS PEOPLE TRAINED IN EDUCATION CAN'T SPEAK TO HEALTH ISSUES AND VICE VERSA. THE IDEAL WOULD BE WHEN BOTH GROUPS SPEAK WITH THE SAME VOICE AROUND THE SAME STRATEGIES. THAT'S INTEGRATION. WE'RE BEGINNING TO UNDERSTAND OR EXPLORE HOW THAT SHOULD WORK WITH RESPECT TO PREVENTIVE STRATEGIES AROUND OBESITY. NO, I DON'T HAVE A GOOD EXAMPLE. CHERYL. BILL -- A GOOD EXAMPLE. BILL, YOU MENTIONED IN YOUR TALK THAT THE RECENT TRENDS DATA WE HAVE SEEN IN 2 TO 5-YEAR-OLDS AND DECREASE THAT WE SEE FROM LAST EXAMINATION PERIOD TO NOW MIGHT BE REFLECTIVE OF A SMALL AMOUNT OF KILO CALORIE DEFICIT NEEDED IN THESE INDIVIDUALS TO REFLECT EARLIER INTAKE PATTERNS MIGHT HAVE BEEN LIKE. ARE YOU AWARE OF DATA OR EFFORTS THAT MIGHT SUPPORT THAT CONCLUSION AS YOU KNOW WE'RE LOOKING AT TRENDS IN OBESITY AS A PART OF THE DIETARY GUIDELINES ADVISORY COMMITTEE ACTIVITIES. ANY GUIDANCE TOWARD WHAT WE MIGHT USE TO TRY AND BETTER UNDERSTAND WHERE WE ARE IN THAT AGE GROUP WOULD BE HELPFUL. I THINK THAT THAT'S A REALLY IMPORTANT QUESTION BECAUSE WE CAN ONLY SPECULATE TESTIMONY CHANGES MAY HAVE BEEN AN IMPORTANT CONTRIBUTOR. KEVIN, I'M NOT PAN DOORING TO YOU HERE. THE USDA DESERVES CREDIT FOR THOSE CHANGES. LET ME EXPAND ON THOSE CHANGES IN PREVENIENCE. THE 43% IS EXUBERANT INTERPRETATION OF DECLINES THAT OCCURRED. I THINK -- I BELIEVE THERE'S A SIGNIFICANT DECLINE. IF YOU LOOK AT THE DATA ALL THE WAY FROM THE 1970s THE 13PARENT% IN 2003, 2004 IS AN OUTLIER. WHEREAS 8.5% IS MORE CREDIBLE FIGURE SO THERE HAS BEEN A DECREASE IN THE NEIGHBORHOOD OF 20%. YOU ARE AWARE OF THE PEDIATRIC SURVEILLANCE SYSTEM THAT REPORTED A DECREASE IN IN OBESITY IN 18 STATES. AND PEDIATRIC NUTRITIONAL SURVEILLANCE SYSTEM IS A SURVEY OF LARGELY WIC BASED PATIENTS OR CLIENTS. I CALCULATED THE OTHER DAY THE MAGNITUDE OF THE DECREASE IN THOSE 18 STATES. IT'S ABOUT 5%. IT'S A DIFFERENT POPULATION, 2 TO 4-YEAR-OLDS IN LOWER INCOME CHILDREN. SO YOU MIGHT NOT EXPECT THE SAME RESULTS THAT YOU SEE IN THE N HAYNES DATA. BUT THE SAMPLE IS ENORMOUS. LIKE 1.5 MILLION KIDS OPPOSED TO 800 OR SO IN NCHS, N HAYNES SAMPLE. SO SHORT ANSWER I DON'T THINK WE KNOW WHY THOSE OCCURRED ABSENT THE BROAD ECONOMIC SHIFTS AT THE NATIONAL LEVEL AND PROGRAMS LIKE WIC THAT INFLUENCED THOSE KIDS BUT CHANGES ARE CONSISTENT. I THINK THERE ARE REAL DECLINES BUT WE CERTAINLY DON'T HAVE ENOUGH INFORMATION TO THE EXTENT TO WHICH EARLY CARE AND EDUCATION SETTING WHICH IS AN APPROPRIATE TARGET FOR THE IMPLEMENTATION OF THESE STRATEGIES AND THE CHILD AND ADULT CARE FEEDING PROGRAM STANDARDS WILL BE FORTHCOMING WILL HOPEFULLY INCORPORATE THESE STANDARDS SO THEY CAN BE IMPLEMENTED IN A POLICY RELATED MANNER WITHIN EARLY CARE AN EDUCATION SETTINGS. DR. DIETZ, AS YOU KNOW, -- I'M SORRY, THE CHILDREN UNDER TWO YEARS OF AGE ARE CURRENTLY NOT BEING INCLUDED. BUT COMMITTEE IS FORMED BUT CONSIDER THE POSSIBILITY OF CHANGING THAT. Q. THIS YEAR? SAY THAT AGAIN? IN THIS RELEASE OF DIETARY GRIND? NO. FOR -- PUBLIC INFORMATION IT WOULD BE FOR 2020. THE COMMITTEE MADE FOR THESE RECOMMENDATIONS. ALSO THE DIETARY GUIDELINES TRADITIONALLY HAVE NOT EMPHASIZED, PRECONCEPTION NUTRITION DURING PREGNANCY. SO IN YOUR VIEW HOW IMPORTANT IS IT OR IT'S NOT TO INCLUDE ISSUES AFFECTING EARLY STAGES OF LIFE? CRITICALLY IMPORTANT. WE KNOW A VARIETY OF BEHAVIORS DURING PREGNANCY PRE-DISPOSED CHILDHOOD WEIGHT PROBLEMS TOBACCO USE, EXCESSIVE WEIGHT GAIN PREPREGNANT WEIGH AND DIABETES DURING PREGNANCY. THERE'S ONLY LIMITED INTERVENTIONS COMPREHENSIVE AN DIRECTED AT THOSE RISK FACTORS. WE ALSO KNOW IN THE FIRST YEAR OF LIFE RAPID WEIGH GAIN IS ASSOCIATED WITH SUBSEQUENT LEVELS OF OBESITY. I WAS PART OF THE BIRTH -- WHAT WAS CALLED MARY? B-24. I SHOULD REMEMBER THAT. THE THINKING IN B-24 WAS RIGHT ON TARGET. BECAUSE IT'S LESS ABOUT WHAT NEEDS TO BE DONE BUT HOW WE HELP PARENTS IMPLEMENT THOSE STRATEGIES. SO THAT'S RIPE AND I I'M HOPEFUL THAT THE 2020 GUIDELINES, THERE WILL BE ENOUGH INFORMATION ON MORE SPECIFICITY HOW WHICH COUNCIL PARENT AND DELIVER THOSE STRATEGIES AND MESSAGES THROUGH PEDIATRIC PRACTICES OR PRIMARY CARE THAT WILL HAVE A DENT. BUT THAT IS A TERRIBLY IMPORTANT PERIOD OF LIFE AND THINGS TO BECOME ENTRAINEDDED AT THAT AGE. THIS IS ANNA MARIA SIEGA-RIZ. GIVEN THE FACT OUR COMMITTEE IS INTERESTED IN UNDERSTANDING WHAT WORKS, WHETHER OR NOT WE FAILED IN IMPLEMENTING DIETARY GUIDELINES BECAUSE THE MEAL REPLACEMENT SAYS THAT WE HAVEN'T DONE A GOOD JOB IN TEACHING PEOPLE HOW TO EAT LOCALRY FOODS THAT ARE HEALTHY FOR THEM. SO TALK ABOUT THAT. BECAUSE TO ME, THIS IS MY OWN PERSONAL VIEWPOINT, WHILE MEAL REPLACEMENTS SERVE A PURPOSE TO HAVE THAT BE SUSTAINED AS PART OF HEALTHY LIFESTYLE IS PROBABLY NOT AS DESIRABLE. GOOD POINT. A FORMULAIC DIET LIKE LIQUID SUPPLEMENT IS EASY. THAT'S WHAT YOU HAVE. YOU DON'T HAVE -- EXCUSE ME. YOU DON'T HAVE A LOT OF CHOICES. WHEREAS I THINK THE PROBLEM WITH THE US DIET IS HOW MANY CHOICES WE HAVE. ONE THING I HAVE THOUGHT ABOUT, I HAVEN'T SEEN IMPLEMENTED, IF WE THINK ABOUT THE DIETARY CONSTITUENTS WHICH MEDIATE SAY TIETY, THEY'RE FIBER AND PROTEIN. IF YOU LOOK AT THE MOST SUCCESSFUL DIETINGS SHORT TERM, THEY FOLLOW THAT PATTERN. I LOVE TO SEE A TRIAL WHICH THOSE ARE THE MAIN TARGETS FOR INTERVENTION AND THE IMPACTS THAT HAS BECAUSE LONG TERM THAT MIGHT BE A RELATIVELY EASY DIET TO RETURN TO. ABOUT SEPTEMBER THOSE DIETS ARE CARBOHYDRATES. IF YOU THINK DIETARY CHOICES MOST VARIATION IS IN THE CARBOHYDRATE SIDE OF THE DIET. SO IF WE REDUCE OR RESTRICT, REDUCE CARBOHYDRATES AN FOCUS ON NUTRIENTS LIKE FRUITS AND VEGETABLES LIKE A GOOD SOURCE OF LEAN PROTEIN AND HIGH SOURCE DIETARY FIBER PERHAPS IN WHOLE GRAINS AND THE CARBOHYDRATE SIDE, THAT MIGHT BE A NICE MEAL REPLACEMENT. IT WOULD BE INTERESTING TO LOOK AT WHAT THE PREPACKAGED MEAL HOUSE THOSE COMPARE TO THE RECOMMENDATIONS ON DIETARY GUIDELINES. I DON'T KNOW. BUT SEEMS TO ME THERE'S MARKETING OPPORTUNITY IS THERE FOR COMPANIES THAT ARE INNA BUSINESS. WAYNE. WAYNE CAMPBELL. IN SUMMING UP SOME OF YOUR POINTS, YOU TARGETED THE RECOMMENDATIONS OF THE ROBERT WOOD JOHNSON FOUNDATION SPECIFICALLY ON THE IMPORTANCE I AGREE WITH INVESTING IN AMERICA'S YOUNG AS PRIORITY FOR ESTABLISHING LONG TERM HEALTHY AMERICA, MY QUESTION IS DOES THAT COME WHEN I THINK ABOUT THAT THERE'S THE GREATEST HEALTHCARE SPENDTURES ARE IN OLDER ADULTS AND PRE-LENS OF OBESITY TEND TO BE PEOPLE IN 60s. SO I'M WONDERING WHAT THE MESSAGING IS, FOR SHORTER TERM VERSUS LONGER TERM EMPHASIS ON IMPROVING AMERICA'S HEALTH. WITH RESPECT TO PEOPLE MIDDLE AGED, THOSE THAT ARE THE MOST LIKELY TO BE OVERWEIGHT AND OBESE. I THINK IN FOCUSING ON YOUNG CHILDREN DOESN'T MEAN WE EXCLUDE OTHER PARTS OF THE POPULATION. FROM THE HEALTHCARE EXPENDITURE SIDE, OLDER ADULTS ARE GENERATING COSTS. SOME STRATEGIES PARTICULARLY IN THE SECOND AND THIRD RECOMMENDATION FROM THAT COMMISSION I THINK BEGIN TO GET A CULTURE OF HEALTH WHICH PERMEATES THAT REPORT. IF WE ESTABLISH CULTURE OF HEALTH AND BEGIN EARLY, AND ALSO REACH THE ADULTS WITH CHRONIC DISEASES OR RISK FACTORS FOR THE CHRONIC DISEASE, WE MAY WELL HAVE AN EFFECTIVE PREVENTIVE STRATEGY WHICH REDUCES THOSE COSTS BUT IT'S A FAIR POINT. WHETHER WE NEED TO INTENSIFY AND HOW TO INTENSIFY INTERVENTIONS IN OLDER ADULTS IS AN OPEN QUESTION. JUST TO FOLLOW-UP, ONE DISCUSSION WE HAVE HAD AS A COMMITTEE INCLUDED COMMENTS ABOUTIUS OF DIETARY GUIDELINES IN PROMOTING AN PREVENTING OR PROMOTING HEALTH PREVENTING DISEASE VERSUS TREATMENT OF DISEASE. AND I JUST WONDER WHAT YOUR PERSPECTIVE IS ON BREADTH OF DIETARY GUIDELINES GIVEN WHAT YOU SAID ABOUT THE IMPORTANCE OF A LIFE COURSE APPROACH. I THINK THE DIETARY GUIDELINES ARE CRITICAL TO THE IMPLEMENTATION OF THE HEALTHY LIFESTYLE. BUT IS NOT AS FAR AS EXTENDING DISEASE TREATMENT. THE REASON -- THE REASON I'M PRESSING A BIT IS BECAUSE -- SO YOU GAVE VERY STRIKING STATISTICS THAT WE ALL ARE FAMILIAR WITH ABOUT THE PREVALENCE OF OBESITY NOW AND WHETHER OR NOT IF IT IS INDEED A DISEASE, WHETHER OR NOT GUIDELINES ARE IN FACT TREATING -- IT SHOULD BE ALSO INCLUDING FOCUS ON TREATMENT OF DISEASE AS BODY WEIGH. YEAH. I THINK THAT THE DIETARY GUIDELINES PROVIDE AN IMPORTANT ADJUNCT TO TREATMENT BUT NOT SUFFICIENT. IMPLEMENTATION OF DIETARY GUIDELINES IN A PATIENT WITH SEVERE OBESITY I DON'T THINK IS GOING TO CHANGE THEIR WEIGHT. IS IT GOING TO MAKE THEM HEALTHIER? SURE THAT'S NOT A TRIVIAL CONSIDERATION. BUT IT WILL NOT HELP THEM LOSE WEIGHT AND WILL PROBABLY NOT HELP THEM ELIMINATE RISK FACTOR OR REDUCE CHRONIC DISEASES WHICH THEY'RE SUSCEPTIBLE OR SUFFERING. SUGGESTING WE NEED TO BE ABLE TO ACHIEVE 5 TO 10% WEIGH LOSS YOU STARTED OFF WITH FROM A HEALTH PERSPECTIVE IS OUTSIDE THE REALM OF DIETARY GUIDELINES. IMPLEMENTATION OF DIETARY GUIDELINES ACHIEVES A 500-CALORIE DEFICIT, IT WOULD BE A REASONABLE WAY TO BEGIN TO APPROACH THERAPY. I SUSPECT THAT IMPLEMENTATION OF THE GUIDELINES IN A PATIENT WITH SEVERE OBESITY WON'T ACHIEVE THAT DEFICIT. THANK YOU. THANK YOU SO MUCH FOR THE VERY INTERESTING AN PROVOCATIVE INSIGHTS. MY QUESTION REFERS BACK TO THE ACCHA REPORT THAT YOU POINTED OUT AND IDENTIFIED THE TARGETS FOR WEIGHT LOSS THAT ARE IDENTIFIED. BUT I WONDER YOUR REACTION AS EXPERT IN THIS AREA TO IDENTIFICATION BY THAT GROUP OF 15 DIFFERENT EVIDENCE BASED PROTOCOLS FOR WEIGHT LOSS WITH EFFICACY AND EFFECTIVENESS DEMONSTRATED 24 TO IN SOME CASES 48 MONTHS. WHETHER OR NOT YOU SEE THAT SET OF RECOMMENDATIONS AS ANY BREAK THROUGH IN TERMS OF THE MANAGEMENT OF OVERWEIGH AND PREVENTION OF COMPLICATIONS OF OVER WEIGH AND OBESITY. GOOD QUESTION. I THINK IT SYSTEMATIZES THE APPROACH WE CAN TAKE BUT DOESN'T SPECIFY THEM. WOULD YOU AGREE WITH THAT? IT TO ME REALLY GETS TO IDENTIFICATION OF EVIDENCE BASED OPTIONS. RELATED TO THAT, THE GUIDELINES SUGGEST THAT ALL THESE ARE EFFECTIVE WITH CALORIC RESTRICTION IF GUIDED BY THE QUALIFIED PROFESSIONAL OR PARAPROFESSIONAL WHO AS YOU POINTED OUT BEFORE, ARE MANAGED WELL TRAINED AND MANAGED SUPERVISED BY THE PROFESSIONALS. SO IT'S BEGINNING TO GET AT THE KIND OF INTEGRATION YOU'RE TALKING ABOUT, A WELL TRAINED PARAPROFESSIONAL WORKING WITH A SKILLED CLINICIAN TO PROVIDE OPTIONS, RANGE OF OPTIONS THAT MAY PLAY TO IF iT NEEDS AND PREFERENCES OF THE PATIENT. MAYBE SOME OPPORTUNITIES THERE TO REALLY INCREASE OUR EFFECTIVENESS. YES. A KEY RECOMMENDATION IN HERE WHICH I DIDN'T MENTION IS THAT, THAT THE CHOICE OF THE DIET, IS REALLY MORE AT THE DISCRETION OF THE PATIENT OR NEGOTIATION BETWEEN PROVIDER AND PATIENT. THAT'S SOUND. IN ADDITION, IT DIDN'T SPECIFY MODE OF BEHAVIORAL MODIFICATION WHICH IS ALSO AT THE DISCRETION AND WITHIN THE CAPACITY OF PROVIDER. YES. MARY AN NEUHOUSER, FRED HUTCHINSON CANCER CENTER. A BARRIER YOU MENTIONED THE PASSING WAS REIMBURSEMENT BARRIER. AND HOW DO YOU SEE THAT CHANGING OVER THE NEXT FIVE YEARS WITH AFFORDABLE CARE ACT AS WELL AS OTHER AVENUES? WHAT CAN WE AS PROFESSIONALS DO ABOUT THAT? WELL, I'M NOT GOING TO SUGGEST YOU READ THE 2000 PAGE REPORT ON THE AFFORDABLE CARE ACT. I THINK THERE'S SO MUCH IN THERE THAT I DON'T KNOW ALL THE DETAILS BUT THE PROMISE OF THE AFFORDABLE CARE ACT, IT MOVES US MORE TOWARDS A CAPITATED SYSTEM WHICH THE REIMBURSEMENT LEVELS ARE GOING TO BE ASSOCIATED WITH HOW EFFECTIVE WE ARE AT REDUCING COSTS OF CARE. WHICH IN TURN SUGGEST THAT INVESTMENTS IN THESE MORE BROAD BASED POLICY RELATED INTERSECTIONS OR INVESTMENTS IN COMMUNITY STRATEGIES TO IMPROVE DIET, IMPROVE LEVELS OF PHYSICAL ACTIVITY, SUSTAINED WEIGHT REDUCTION, MAYBE A REIMBURSABLE OR MAYBE A STRATEGY WHICH INCREASES THE REIMBURSEMENT FOR PROVIDERS OF THE SYSTEM. THAT'S -- THAT IS SPECULATIVE. BUT WHEN I TALK TO PEOPLE WHO ARE INTIMATELY FAMILIAR WITH THE AFFORDABLE CARE ACT, THAT'S THE PROMISE. THE OTHER PROMISE IS THIS NOTION OF BUNDLING SERVICES AROUND -- FOR -- THAT CAN BE REIMBURSED SIMULTANEOUSLY IS AL MANDATE OR SUGGESTION WITHIN THE CARE ACT. AND THOSE SERVICES THAT ARE BUNDLED ARE SUPPORTED BY EVIDENCE BASED REVIEWS, CLINICAL PREVENTIVE SERVICES TASK FORCE. THERE ARE RECOMMENDATIONS FOR INTENSIVE INTERVENTIONS RELATED TO OBESITY IN CHILDREN AND ADULTS. I'M NOT AWARE OF EXCHANGES THAT ARE DRAFTING THOSE REGULATIONS ARE INCLUDING THIS BUT I KNOW THERE ARE EFFORTS UNDERWAY TO TRY TO DO SO. THAT'S ABOUT AS MUCH AS I KNOW. SORRY. THANK YOU VERY MUCH. GOOD MORNING, IT'S KEVIN CONCANNON FOR FOOD AND KNEW TRIG SERVICE. THANK YOU FOR YOUR KIND WORDS ABOUT THE WIC PROGRAM. AS YOU'RE REFERENCING INTEGRATION OF RECENT VISIT THAT I MADE IN IOWA, TO SUPERMARKET CHAIN THAT IS HEAD QUARTERED THERE THAT OPERATES IN 8 STATES IN THE MIDWEST, FOLLOWED UP MEETING OF THE IOM COMMITTEE ON OBESITY THAT TOOK PLACE HERE ABOUT SIX OR SEVEN WEEKS AGO. THIS PARTICULAR SUPERMARKET CHAIN HAS 235 SUPERMARKETS ACROSS THE MIDWEST BUT THEY NOW EMPLOY MOSTLY FULL TIME DIETITIANS, 206 OF THEM. IN THIS PARTICULAR STORE THIS WAS THE FLAGSHIP STORE, THEY HAVE TWO FULL TIME DIETITIANS. THEY WORK WITH AND ENCOURAGE THE PRIMARY CARE PRACTICES IN THIS CASE INTEGRATED DES MOINES AREA, TO REFER PATIENTS, GO OUT AND TALK TO FULL TIME DIETITIANS AVAILABLE IN THE SUPERMARKET AND THAT WILL TAKE YOU THROUGH THE STORE F. YOU'RE A PRACTITIONER RECOMMENDED SOMETHING THEY WILL ACCOMMODATE YOU THROUGH THE STORE AND TALK YOU DOWN THE AISLE OF SERIALS OR WHATEVER IT -- CEREALS IN AN EFFORT TO SUPPORT PATIENT CHOICE. BUT HELP YOU MAKE THE BETTER CHOICE SO WONDERING WHETHER YOU'RE SEEING THAT IN OTHER PLACES BECAUSE THIS WAS THE MOST EXTENSIVE -- 206 MOSTLY FULL TIME NUTRITIONISTS IN THE SUPERMARKET, I HAD NOT SEEN THAT ANYWHERE ELSE IN THE COUNTRY. INCREASINGLY SUPER MARKETS ARE HIRING NUTRITIONISTS, YOUR FAVORITE SUPERMARKET IN MAINE IS ONE OF THE LEADERS OF THAT. IT'S WORTH -- I THINK I'M GOING TO MANGLE THIS QUOTE FROM STEVEN BIRD WHO IS THE PRIOR CEO OF SAFEWAY WHO YEAR OR TWO AGO SAID AT THE MOMENT WE OTHER A GROCERY STORE THAT PROMOTES HEALTH THROUGH OUR PHARMACY AND ELSEWHERE. BUT IN TEN YEARS WE'RE GOING TO BECOME A STORE PROMOTING HEALTH AND SELLING GROCERIES ON THE SIDE. WHICH IF HE'S CORRECT, THAT'S A PLACE WHERE WE SHOULD BE PUSHING THE DIETARY GUIDELINES. THANK YOU VERY MUCH. [APPLAUSE] I'M GOING TO ASK MY COLLEAGUE RAFAEL PEREZ-ESCAMILLA TO INTRODUCE OUR NEXT SPEAKER. GOOD MORNING, EVERYONE. MY NAME IS RAFAEL PEREZ-ESCAMILLA FROM THE YALE SCHOOL OF PUBLIC HEALTH. I'M CHAIR OF SUBCOMITTEE 3 THAT DEALS WITH BEHAVIOR CHANGE. SO I AM REALLY, REALLY DELIGHTED TO WELCOME AND INTRODUCE DR. DEBORAH TATE, ASSOCIATE PROFESSOR IN THE SCHOOL OF PUBLIC GILLINGS SCHOOL OF GLOBAL PUBLIC HEALTH AT UNIVERSITY OF NORTH CAROLINA CHAPEL HILL, APPOINTED IN DEPARTMENT OF HEALTH BEHAVIOR, DEPARTMENT OF NUTRITION AND COMPREHENSIVE CANCER CENTER. DR. TATE HAS A Ph.D. IN CLINICAL PSYCHOLOGY AND SPECIALIZES IN BEHAVIORAL PREVENTION AND TREATMENT OF OBESITY ACROSS THE LIFE SPAN. RESEARCH PROGRAM FOCUSES ON TWO MAIN AREAS. FIRST, STRATEGIES FOR IMPROVING BOTH SHORT AND LONG TERM WEIGHT LOSS WITH INTERVENTIONS AND SECOND, THAT TRANSLATION OF OBESITY TREATMENT PROGRAMS USING ALTERNATIVES TO CLINIC BASED CARE WITH A PARTICULAR FOCUS ON USING INFORMATION TECHNOLOGY. SHE HAS DEVELOPED AND EVALUATED IN SEVERAL FIRST RANDOMIZED TRIAL METHODS FOR DELIVERING COMPREHENSIVE BEHAVIOR CHANGE PROGRAMS USING THE INTERNET AND OTHER TECHNOLOGIES TO DELIVER BEHAVIORAL TREATMENTS FOR OBESITY. SHE HAS ALSO EVALUATED ALTERNATIVE METHODS FOR PROVIDING PROFESSIONAL GUIDANCE IN INTERNET PROGRAMS INCLUDING CHATS WEBINARS AND AUTOMATED COUNSELORS HUMAN INTERVENTION TO PRODUCE SUSTAINABLE BEHAVIOR CHANGE. RECENT CURRENT NIH FUNDED RESEARCH IS EXAMINING DELIVERY OF OBESITY TREATMENT PROGRAMS IN A STEPPED CURVE FASHION RESERVING MORE INTENSIVE EXPENSIVE APPROACHES FOR DEMONSTRATED FAILURE WITH LOWER COST OPTIONS. WEB-BASED AND INCENTIVE BASED APPROACHES FOR WORK SITES. PREVENTION USING FACE TO FACE WEB AND MOBILE TECHNOLOGY FOR YOUNG ADULTS, TRANSLATING INTERNET OBESITY TREATMENT INTERVENTIONS WITH LOW INCOME POST PARTUM IN WICC INCLUDING A SPANISH VERSION AND EFFECT ACTIVENESS TRIALS FOR TAILORED INTERNET WEIGHT CONTROL IN PRIMARY HEALTHCARE PRACTICES. YOU CAN IMAGINE SHE IS HIGHLY RECOGNIZED SCHOLAR, VERY MUCH -- BY NIH AS SHE SERVES LEADERSHIP POSITIONS IN SEVERAL SCIENTIFIC COMMITTEES. SHE TEACHES ADVANCE DOCTORAL COURSE ON APPLICATION OF BEHAVIORAL THEORY IN DEVELOPING AND EVALUATING INNOVATIVE HEALTH PROMOTION AND DISEASE PREVENTION INTERVENTIONS. A COURSE ON ADVANCE NUTRITION INTERVENTION RESEARCH METHODS AND SERVES AS STANDING MEMBER OF THE NIH PRDP STUDY SECTION. SO PLEASE JOIN ME IN WELCOMING DEBORAH TATE FOR HER PRESENTATION TITLED EFFECTIVE STRATEGIES AND DELIVERY APPROACHES TO CHANGING THE DIET AND ACTIVITY FOR WEIGHT CONTROL. [APPLAUSE] THANK YOU VERY MUCH. I'M PLEASED TO BE HERE TODAY. I'M ALSO VERY HAPPY THAT MY COLLEAGUE DR. DIETZ HAS ALREADY TALKED A BIT ABOUT THE NEWLY PUBLISHED AHA AND A,C GUIDELINES FOR MANAGEMENT OF OBESITY. I WANT TO CALL ATTENTION TO THE SUMMARY STATEMENT THAT COMPREHENSIVE LIFESTYLE INTERVENTIONS CONSISTING OF DIET PHYSICAL ACTIVITY AND BEHAVIOR THERAPY PRODUCE 8-KILOGRAMS OF WEIGHT LOSS IN SIX MONTHS WITH FREQUENT IN PERSON TREATMENT. SO I WAS ASKED TO TALK ABOUT SOME OF THE THINGS THAT UNDERLIE THAT STATEMENT SO WE CAN UNDERSTAND MORE ABOUT WHAT IS COMPREHENSIVE LIFESTYLE INTERVENTION IN TERMS OF COMPONENTS FROM THE BEHAVIORAL OR BEHAVIOR CHANGE SIDE. AND TO TALK A LITTLE BIT ABOUT THEORETICAL MODELS THAT UNDERLIE THESE INTERVENTIONS WHAT FACTORS MIGHT IMPACT THE EFFICACY OF FACE TO FACE MANAGEMENT INTERVENTION, THAT IN PERSON CONTACT THAT WAS MENTIONED IN THE GUIDELINES, AS WELL AS WHAT ALTERNATIVES EXIST TO DELIVER SOMETHING THAT'S STILL COMPREHENSIVE THAT MIGHT BE A BIT MORE SUSTAINABLE AND PRODUCE EFFICACY. EFFICACIOUS INTERVENTION. SO START WITH DISCUSSION OF THEORETICAL MODELS THAT ARE FOUNDATION FOR BEHAVIOR CHANGE INTERVENTIONS IN THE WEIGHT MANAGEMENT FIELD. I PUT UP FAMILIAR SOCIO ECOLOGICAL MODEL BECAUSE I WILL TALK TODAY ABOUT THEORIES THAT APPLY TO INTERVENTIONS THAT ARE AIMED AT CHANGING INDIVIDUALS THAT IN SOME CASES FAMILIES OR SMALL GROUPS INDIVIDUALS WITHIN THOSE UNITS. SO OTHER THEORIES WOULD APPLY TO CHANGING OTHER LEVELS OF SOCIAL ECOLOGICAL MODEL. SYSTEMATIC REVIEW FASHION OR HAVE A NUMBER OF STUDIES BEHIND THEM ARE BEHAVIOR MODIFICATION, WHICH REALLY COMES FROM OUR UNDERSTANDING OF MORE BASIC PSYCHOLOGY WITH CLASSICAL CONDITIONING AND THERE'S A VERY LARGE EMPHASIS WITHIN THE MANAGEMENT OF OBESITY ON BEHAVIOR MODIFICATION WHICH COMES FROM THESE THEORIES. ALSO COGNITIVE BEHAVIORAL THERAPY MODEL WHICH IS TALK COGNITIVE THEORY AND STEM FROM WORK OF ALBERT VAN DUR NEXT SOCIAL COGNITIVE THEORY. THE TRANSTHEORETICAL MODEL WHICH IS FAMILIAR TO SOME STAGES OF CHANGE FOCUS ON STAGE BASED APPROACHES, SOME SELF-DETERMINATION THEORY ARE MOTIVATION FOCUSED. IF WE LOOK AT WHAT THE EVIDENCE SUGGESTS, THE MOST COMMONLY USED APPROACHES ARE REALLY A COMBINATION OF BEHAVIORAL AND COGNITIVE BEHAVIORAL APPROACHES. THEY -- THESE FORM THE FOUNDATION OF THE DIABETES PREVENTION PROGRAM AND LOOK AHEAD THERE ARE SEVERAL REVIEWS, CAN COCHRAN REVIEW AND ANOTHER SYSTEM MA IT CAN REVIEW THAT FOCUSES FOCUSES ON NUTRITION COUNSELING BUT SUGGEST THAT STUDIES THAT HAVE THIS TYPE OF FOUNDATION HAVE GREATER EFFICACY FOR DEVELOPING WEIGHT CONTROL INTERVENTIONS. THERE WAS A COCHRAN REVIEW ABOUT THE TRANSTHEORETICAL MODEL AND SUGGESTIONS EVIDENCE SO NOT ENOUGH STUDIES THAT HAVE USED THE TRANSTHEORETICAL MODEL AS BASIS FOR DEVELOPING WEIGH CONTROL INTERVENTIONS TO RECOMMEND UTILIZATION AS UNDERLYING THEORY. RARELY ALONE. THERE DOES APER TO BE EVIDENCE FOR -- APPEAR TO BE EVIDENCE FOR COMBINEDDED EFFECTS OF MOTIVATION FOCUSED APPROACHES WITH BEHAVIOR MODIFICATION, COMPARED TO CONTROL CONDITIONS, BUT FEW COMPARISON OF ADDITIVE VALUE THOUGH (INDISCERNIBLE) PUBLISHED A PAPER SHOWING BMOD WITH MOTIVATION FOCUSED APPROACH IS MORE EFFICACIOUS THAN BMOD ALONE. SO THE PRIMARY UNDERPINNING IS A BEHAVIORAL APPROACH WITH FOCUS ON COGNITION AN THOSE PATTERNS OF THINKING THAT MIGHT EFFECT OUR ABILITY TO CHANGE DIET AND PHYSICAL ACTIVITY. SO THE BEHAVIORAL COGNITIVE BEHAVIORAL APPROACH EFFECTED USES A STRUCTURED CURRICULUM VARIETY OF COGNITIVE BEHAVIORAL TECHNIQUES. A DIETARY MODIFICATION TO PRODUCE CALORIC REDUCTION, EXERCISE GOALS AND HALLMARK SELF-MONITORING AS A TECHNIQUE, WITH A PACKAGE OF OTHER TECHNIQUES, INCLUDING STIMULUS CONTROL, GOAL SETTING, PROBLEM SOLVING, RELAPSE PREVENTION, COGNITIVE RESTRUCTURING AN MOTIVATION ENHANCEMENT. ALL THESE TECHNIQUES ARE DELIVERED WITHIN THE CONTEXT OF WEIGHT MANAGEMENT COUNSELING SUPPORT TO HELP A PARTICIPANT IMPLEMENT THE BEHAVIOR CHANGES FOR DIET AND PHYSICAL ACTIVITY. THERE'S A NEWER FOCUS IN THE FIELD TO TRY TO UNDERSTAND BEHAVIOR CHANGE TECHNIQUE. THIS WORK BEING LED BY SUSAN MICEY IN THE UK AND RESEARCHERS ACROSS THE GLOBE ACTUALLY ARE VERY INTERESTED IN TRYING TO UNPACK AT THE TECHNIQUE LEVEL AS OPPOSED TO NECESSARILY THEORETICAL LEVEL. I'LL EXPLAIN MORE ABOUT THIS. BUT BEHAVIOR CHANGE TECHNIQUE IS AN OPERATIONALLY DEFINED ASPECT OF THE CONTENT. SO STARTING TO UNPACK THE BLACK BOX OF WHAT EXACTLY ARE WE ASKING OR ARE WE IMPLEMENTING WITHIN THE INTERVENTION TO PRODUCE BEHAVIOR CHANGE. EACH OF THESE TECHNIQUES IS LINKED TO THEORY. THOUGH SOME OF THE TECHNIQUES ARE LINKED TO MULTIPLE THEORIES. SO THEORIES OVERLAP IN TERMS OF CONSTRUCTS AND HOW WE MIGHT SEEK TO CHANGE THOSE CONSTRUCTS IN TERMS OF THE TECHNIQUES THAT WE USE. SO THESE ARE SOME EXAMPLES OF MORE SPECIFIC TECHNIQUES. SO PROVIDING INFORMATION ON THE BEHAVIOR HEALTH LINK SPECIFICALLY AS OPPOSED TO PROVIDING INFORMATION ON THE CONSEQUENCES SO THERE'S DIFFERENCE AND OFTENTIMES INFORMATION OR EDUCATION IS DESCRIBED IN TERMS OF INTERVENTION BUT NOT NECESSARILY MORE SPECIFICALLY WHAT HAS BEEN DONE. WE'RE FOLLOW-UP PROPS USED. DID YOU PROMPT IDENTIFICATION OF ROLE MODEL WITHIN THE INTERVENTION. SO MUCH MORE SPECIFICALLY THE TECHNIQUES THAT ARING BEING USED TO CHANGE BEHAVIOR. THERE IS A BIT OF EVIDENCE NOW OPT ROLE OF SOME OF THESE TECHNIQUES FEW RCTs BECAUSE IT'S VERY DIFFICULT TO PERFORM AN RCT TO STUDY ONE TECHNIQUE AND IMPACT ON BEHAVIOR CHANGE. THIS APPROACH TRYING TO UNDERSTAND TECHNIQUES ACROSS THE LITERATURE IS A BIT MORE OPPORTUNITY TO ADVANCE AND GENERATE HYPOTHESES ABOUT THESE TECHNIQUES. SO OFTENTIMES WE KNOW FROM RCT IS PACKAGE OF TECHNIQUES WORKS MANY THAT COMPREHENSIVE PACKAGE THAT WAS MENTIONED EARLIER. WHAT WE THINK OF AS SUCCESSFUL WEIGHT MANAGEMENT INTERVENTION. SO RECENTLY (INAUDIBLE) ACROSS 122 STUDIES, AND FOUND THAT THE AVERAGE NUMBER OF TECHNIQUES THAT IS USED WITHIN BEHAVIORAL TREATMENT PACKAGE IS SIX. AND THAT THEY WERE ABLE TO UNCOVER INTERVENTION FOCUSED ON SELF-MONITORING ARE MORE EFFECTIVE AND OFTENTIMES THAT MONITORING IS COUPLED WITH PROMPTING INTENTION FORMATION, PROMPTING SPECIFIC GOAL SETTING, PROVIDING FEEDBACK ON PERFORMANCE, AND PROMPTING REVIEW OF BEHAVIORAL GOALS. AND IF YOU THINK ABOUT THIS, THESE TECHNIQUES ARE OFTEN WHAT'S THE COUNSELORS IN WEIGH MANAGEMENT INTERVENTION ARE SUPPORTING. THEY'RE SUPPORTING THE PATIENTS AND PROMPTING THEM TO SET THEIR GOALS PROVIDING FEEDBACK ON PERFORMANCE AND REVIEWING NEGOTIATING. ING THE THING NOT HERE ALSO DOES OCCUR AND HAS EVIDENCE BASE LITERATURE FROM MYHEAL PERRY AND OTHERS IS PROBLEM SOLVES SO IF WE FOUND PROMPTING BARRIER IDENTIFICATION OR OTHER TECHNIQUE FROM THIS REVIEW I WOULD THINK THAT MAYBE A LOT OF WHAT WE -- WEIGH MANAGEMENT COUNSELORS ARE DOING IN THAT TREATMENT PACKAGE WOULD HAVE ALSO BEEN IDENTIFIED FROM THIS LARGE REGRESSION. SO EXCITING OPPORTUNITY TO UNPACK THE BLACK BOX AND WE WILL LEARN MORE ABOUT WHAT SPECIFICALLY WE SHOULD BEEN COURAGING COUNSELORS TO DO FROM THIS WORK. SO SWITCHING GEARS TO FACTORS IMPACTING EFFICACY OF FACE TO FACE WEIGHT MANAGEMENT INTERVENTION AND I'LL REVIEW PAPER BY DR. WADDEN IN 2012 THAT WE IN ADDITION TO FOCUS ON DIET AND ACTIVITY PRESCRIPTIONS, WEEKLY CONTACT IN PERSON OR BY TELEPHONE FOR 20 TO 26 WEEKS RECOGNIZING THAT OTHER MODALITIES MAY PRODUCE LESS EFFECTS, THIS CONTACT OCCURS IN GROUPS OR INDIVIDUALS, DAILY MONITORING OF FOOD INTAKE OR PHYSICAL ACTIVITY WITH FOOD INTAKE OR DIARIES, THERE'S EVIDENCE THAT EITHER APPROACH IS EFFECTIVE THE. WEEKLY MONITORING OF WEIGHT. STRUCTURED CURRICULUM OF BEHAVIOR CHANGE. I WILL COME BACK TO THE STRUCTURED CURRICULUM IN A MOMENT. WITH REGULAR FEEDBACK FROM AN INTERVENTIONIST. IF WE THINK ABOUT THE FORMAT THE INDIVIDUAL VERSUS GROUP FACE TO FACE QUESTION MR. HABERSKI: USED AND STRONG EVIDENCE FROM DPP WHICH IS AN INDIVIDUAL BASED COUNSELING APPROACH AND LOOK AHEAD USED A COMBINATION OF GROUP WITH INDIVIDUAL. SO THREE GROUP SESSIONS PER MONTH WITH ONE INDIVIDUAL SESSION. THERE'S ALSO BEEN RCT COMPARING INDIVIDUAL VERSUS GROUP AND THEY FOUND THAT GROUP TREATMENT WAS MORE EFFECTIVE FOR WEIGHT LOSS AND THEY ACTUALLY EXAMINED PATIENT PREFERENCE SO IT WAS A TWO BY TWO FACTORIAL COMPARING YOUR PREFERRED METHOD AND A MATCHING OR MISMATCHING IF YOU WILL ON PREFERENCE. AND DESPITE I THINK LONG STANDING BELIEF IF WE CAN BETTER MATCH PREFERENCES WE MIGHT HAVE BETTER OUTCOMES THEY DID NOT SEE A DIFFERENCE IN TERMS OF BETTER EFFECTS IF YOU GOT YOUR MATCHED PREFERENCE FOR GROUP OR INDIVIDUAL SO THOSE APPEAR TO BE EFFECTIVE APPROACHES. THIS ALSO APPEARS TO BE THE CASE WITH CONFERENCE CALLS. A RECENT STUDY DONE DELIVERING CARE OVER GROUP BASED CONFERENCE CALLS, APPEAR AS EFFECTIVE ADS GROUP FACE TO FACE TREATMENT IN THIS STUDY BY JOE DONLY AT SIX MONTHS AND 18 MONTHS THOUGH YOU SEE WEIGHT REGAIN WITH BOTH APPROACHES. IN THE GUIDELINES THE RECOMMENDATION IS FOR MORE THAN 14 SESSIONS IN SIX MONTHS AND THAT GREATER WEIGHT LOSS WILL OCCUR WITH THIS FREQUENCY SESSION COMPARED TO LOW OR MODERATE INTENSE INTENSITY INTERVENTIONS. MODERATE INTENTIONTY IS DEFINED ONE TO TWO -- INTENSITY IS ONE TO TWO SESSIONS PER MONTH AND THEY RECOGNIZE THAT THAT DOES APPEAR BETTER THAN USUAL CARE BUT WEIGHT LOSS OF 2 TO 4 KILOGRAMS OPPOSED TO 8-KILOGRAMS ACHIEVED WITH THE MORE INTENSIVE CONTACT. AND LOW INTENSITY INTERVENTIONS FEWER THAN MONTHLY ARE NOT WITH GENERAL CARE. I WANT TO PUBLISH A BIT OF DATA WE CONDUCTED LOOKING AT THE PURPOSE OF THIS STUDY IS TO STEPPED CARE INTERVENTION BUT FROM THE FIRST THREE MONTHS, THERE IS BEFORE PATIENTS ARE STEPPED UP BASED ON THEIR INABILITY TO ACHIEVE A CERTAIN AMOUNT OF WEIGHT LOSS IN THE STEP CARE ARM THE TREATMENT IS THREE MONTHLY GROUP SESSIONS WITH MATERIALS MAILED THROUGH REGULAR SNAMIL MAIL ON A WEEKLY BASIS BETWEEN MONTHS 1 TO 3. VERSUS STANDARD BEHAVIOR, WHERE WE CONDUCTED 12 GROUP SESSIONS DURING THAT SAME THREE MONTH PERIOD. THE WEIGHT LOSSES WERE 6.9-KILOGRAMS IN STANDARD WITH 12 SESSIONS AND 5.5 IN STEPPED CARE. A .06 THE MORE SESSIONS PRODUCES SLIGHTLY MORE WEIGHT LOSS BUT WITH 3 VERSUS 12 THERE MAYBE AN OPPORTUNITY TO DELIVER INTENSIVE CARE BUT FEWER SESSIONS IN A GROUP BASED FORMAT. SO I WAS ALSO ASKED TO THINK ABOUT THE RESULTS MIGHT LOOK LIKE IN MORE COMMUNITY SETTINGS VERSUS THE MORE CLINICAL UNIVERSITY BASED SETTINGS FOR OUR RCTs AN WHAT'S EFFECTIVE IN BEHAVIORAL WEIGHT CONTROL OCCURRED. IT DOES APPEAR THEY'RE SOMEWHAT ATTENUATED EFFECTS VERSUS CLINICAL TRIAL RESULTS. THERE WAS A REVIEW OF 28 US-BASED STUDIES TRANSLATING THE DPP INTO COMMUNITY OR REAL WORLD SETTINGS. THE AVERAGE WEIGHT LOSS WAS 4 TO 5%. SO THINK BACK TO DPP, THAT IS SIMILAR TO WHAT WAS ACHIEVED LONGER TERM. I DON'T THINK THESE STUDIES WERE AS LONG AS THE RESULTS OF DPP BUT SOMEWHAT ATTENUATED COMPARED TO THAT 8 KILOGRAMS OR WHAT IS 8 TO 10% IN THE GUIDELINES ACHIEVEED WITH INTENSIVE CARE. THESE DIFFERENCES IN WHAT WE MIGHT FIND IN IMMUNITY SETTINGS ARE HARD TO UNDERSTAND BECAUSE THEY MAY REFLECT A VARIETY OF CHANGES. OFTENTIMES WE RECRUIT DIFFERENT MOTIVATIONS, DIFFERENT CHARACTERISTICS TO GO OUT TO MORE TRANSLATIONAL SETTINGS. WE OFTEN CONTACT BECAUSE IT'S MORE FEASIBLE. AND IT'S MORE ACCESSIBLE TO SETTING CONSTRAINTS THAT MIGHT BE MORE COST EFFICIENT. BUT THERE'S ALSO A QUESTION OF WHETHER OR NOT WE HAVE A LOSS OF FIDELITY SO MOVING INTO COMMUNITY SETTINGS ALSO TRANSLATES OFTENTIMES TO CHANGING INTERVENTIONISTS OR POTENTIALLY THE TRAINING. SO OFTEN THERE ARE MULTIPLE DIFFERENCES THAT WE SEE WHEN WE TRY TO EVALUATE AND LOOK AT THE RESULTS FROM COMMUNITY TRIALS. I WILL TELL YOU THE STUDY CONDUCTED BY MICHAEL PERRY AND COLLEAGUES BY TRANSLATING STRUCTURED DELIVERED BY COOPERATIVE EXTENSION AGENTS WITH BACHELOR'S LEVEL OF TRAINING. IN RURAL COMMUNITIES WITH ECONOMICALLY DISADVANTAGED PARTICIPANTS SO A NUMBER OF CHANGES, DIFFERENT PARTICIPANTS, MORE DIVERSE, USING EXTENSION S RATHER THAN HIGHLY TRAINED INTERVENTIONISTS IN THE CLINICS BUT FACTORS RELATED TO THIS ACCEPT IN THIS STUDY ARE EXTENSIVE CONTACT, 50 CONTACTS OVER 18 MONTHS. A HIGH DEGREE OF TRAINING OF COOPERATIVE EXTENSION AGENTS AND ON GOING SUPERVISION BY THE PROFESSIONALS AT THE UNIVERSITY CLINIC. SO THEY WERE ABLE TO ACHIEVE TEN P KILOGRAMS WEIGH LOSS AT SIX MONTHS AT THE END OF THE INITIAL TREATMENT IN A VERY DIFFERENT POPULATION THAT MIGHT BE STUDIED IN SOME OF OUR CLINIC BASED RCTs. SO I ALSO ASKED TO SPEAK ABOUT THE EVIDENCE FOR ALTERNATIVE TO FACE TO FACE DELIVERY, A LOT OF WORK IS FOCUSED ON INTERNET AND TECHNOLOGY BASED INTERVENTIONS FOR THE REASON THAT WE HAVE AN OPPORTUNITY BECAUSE TECHNOLOGY IS PERVASIVE. WHEN I STARTEDDED DOING A LOT OF WORK, ONE OF THE CHALLENGES WAS THAT WE DIDN'T HAVE BROADBAND ADOPTION AS PERVASIVELY AS WE DO NOW. SO WHAT WE WANTED TO DELIVER IS CHALLENGING IN TERMS OF ABILITY FOR STUDY PARTICIPANTS TO ACCESS QUICKLY AN EASILY AND THAT HAS CHANGED DRAMATICALLY. WE ALSO HAVE ADOPTION OF MOBILE PHONES AND ALSO SMART PHONE ADOPTION IS ON THE RISE. THIS DATA IS MORE EXPONENTIALLY EXPANDED THE PAST YEARS SINCE THIS SLIDE WAS PRODUCED. NOT ONLY THE PERVASIVENESS BUT THE OPPORTUNITY TO THINK ABOUT CONCEPTS FROM REAIM THAT DR. GLAXO AN COLLEAGUES HAVE BEEN TALKING FOR MANY YEARS, BUT THIS SLIDE IS PARTICULARLY INTERESTING AND SPEAKS IN CERTAIN WAYS BECAUSE WE MIGHT THINK ABOUT THOSE TRADE OFFS THAT WE WOULD FIND WHEN WE THINK ABOUT ALTERNATIVES TO DELIVERY AS NATURALLY OCCURRING, BECAUSE THERE MIGHT BE A LOSS OF SOME EFFICACY BUT THE OPPORTUNITY TO ACHIEVE GREATER REACH MAY OFFSET THOSE DIFFERENCES WE THINK ABOUT REACH TIME EFFICACY AS REALLY OUR ABILITY TO IMPACT CHANGE. WE ARE STARTING TO SEE THOUGH THAT WITH COMPREHENSIVE INTERNET TREATMENT WE DON'T HAVE A HUGE LOSS OF EFFICACY. THIS STUDY BY GENE HARVEY BARINO AND DELIA WEST SHOW INTERNET DELIVERED INTERVENTION WAS AS GOOD AS IN PERSON INTERVENTION BUT ACHIEVED 5.5-KILOGRAMS OF WEIGHT LOSS AT 6 MONTHS COMPARED TO 7.6. SO SOME LOSS OF EFFICACY, TWO KILOGRAMS. HEALTH BENEFICIAL OF WEIGH LOSS. WE HAVE DONE WORK ON TRYING TO UNDERSTAND ENTER NET BEHAVIORAL TREATMENT AND WHAT COMPONENTS MIGHT MAKE THEM MORE OR LESS EFFECTIVE. TWO RCTs OF ENTERIN THE DELIVERED WEIGHT CONTROL SUGGESTED THAT WHAT YOU DO ON THE INTERNET IS REALLY IMPORTANT. SO HAVING INTERNET INTERVENTION PER SE IS NOT NECESSARILY GOING TO BE EFFICACIOUS. IT SOUNDS OBVIOUS BUT SOMETIMES WHAT IS PRODUCED ON THE INTERNET IS SOMEWHAT MORE INTERNET EDUCATION SO LOOK AT THE FIRST GRAPH, INTERNET EDUCATION PRODUCES LESS WEIGHT LOSS YELLOW BAR COMPARED TO COMPREHENSIVE INTERNET BEHAVIOR THERAPY PROGRAM THOUGH TRANSLATED FOR DELIVERY OVER THE INTERNET. SECOND STUDY TO UNDERSTAND WHETHER IT WAS HAVING THE STRUCTURE, HAVING THE SELF-MONITORING, HAVING OTHER THINGS THAT ARE PART OF THAT INTERNET BEHAVIOR THERAPY WHICH CONTRIBUTED TO THE SUCCESS, I'M SORRY, I MISSPOKE, THE YELLOW BAR WAS BEHAVIOR THERAPY AND THE PURPLE BAR WAS INTERNET EDUCATION. SO WE CONDUCT AD SECOND STUDY ISOLATING THE PROCEDURES AND LOOKED AT THAT WEEKLY COUNSELING SUPPORT DELIVERED OVER EMAIL AND WE FOUND THAT IF YOU PROVIDE ALL THE OTHER ASPECTS OF THE BEHAVIORAL TREATMENT OF OBESITY ON THE THE BEAR INTERNET ABSENT WEEKLY EMAIL FROM COUNSELOR, THE EFFECTS ARE ABOUT HALF OR LESS AND NOT SUSTAINED LOOKING AT THAT TIME SECOND GRAPH. THE PURPLE BAR REPRESENTS ALL THE PROCEDURES OF INTERNET BEHAVIOR THERAPY CONDUCTED IN STUDY ONE, EXCEPT THE WEEKLY EMAIL FOLLOW-UP FROM A COUNSEL ALREADY. THE RED BAR REPRESENTS WHAT WE CALLED IBT PLUS WEEKLY EMAIL COUNSELING FOLLOW-UP SO WE HAD SIGNIFICANTLY BETTER WEIGHT LOSS UP TO ONE YEAR. WE WONDERD WHETHER OR NOT THIS ACHIEVED WITHOUT INVOLVEMENT SO WE CONDUCTED A THIRD STUDY WEBSITE INTERVENTION VERSUS A WEB INTERVENTION WHERE ALL THE COUNSELING WAS AUTOMATED. SO A TAILORED MESSAGE WAS CREATED FROM THE INFORMATION THAT WAS SUBMITTED BY STUDY PARTICIPANT ABOUT THEIR SELF-MOPTORRING AND THEIR WEIGHT LOSS. AND A MESSAGE WAS DELIVERED WITH RECOMMENDATIONS FOR THE FOLLOWING WEEK WITHOUT ANY HUMAN INTERACTION. IT WAS A COMPLETELY AUTOMATED EMAIL EXCHANGE VERSUS TRADITIONAL WEEKLY EMAIL COUNSELING I HAVE BEEN DESCRIBENING THE PRIOR TWO STUDIES. YOU SEE AT THREE MONTHS THE BLUE BAR PRODUCES ABOUT TEN POUNDS OF WEIGHT LOSS VERSUS 12 POUNDS IN THE HUMAN BLUE BAR BEING AUTOMATED. BOTH ARE SIGNIFICANTLY BETTER THAN WEBSITE PROGRAM ALONE WITHOUT ONGOING FOLLOW-UP AND RECOMMENDATION. SO BY SIX MONTHS THE COMPUTER TAILORED ARM DOESN'T CONTINUE TO LOSE WEIGHT. THAT IS NOT DIFFERENT THAN EITHER THE WEB ALONE OR THE HUMAN COUNSELOR, THOUGH HUMAN COUNSELOR IS BETTER THAN WEB ALONE. THERE'S SOME SUGGESTION SHORT TERM YOU CAN PRODUCE TAILORED AUTOMATED APPROACHES THAT CAN BE HELPFUL IN LOSING WEIGHT BUT LONGER TERM MAY REQUIRE HUMAN INTERACTION IN ORDER TO BE EFFECTIVE. SO THERE MAYBE REASONS TO THINK ABOUT EXPANDING OR IMPROVING UPON THIS APPROACH. THIS WAS REALLY AN EARLY STUDY SO A GREATER DEGREE OF TAILORING MIGHT BE IMPORTANT BUT IT MIGHT MEAN OVER TIME THERE MIGHT BE SOME AMOUNT OF HUMAN INTERACTION THAT COULD BE DELIVERED IN SOME AMOUNT OF THAT COUNSELING SUPPORT COULD BE DELIVERED IN A MORE AUTOMATED FASHION TO OFFSET COSTS. I WANT TO SAY AN INTERNET INTERVENTION I ALLUDED TO THIS, IS WHETHER IT'S DELIVERED ON MOBILE PHONE OR DELIVERED ON A COMPUTER, STAND ALONE COMPUTER IS NOT INTERNET EDUCATION, IT INVOLVES THINGS FROM BEHAVIOR BASED OR COGNITIVE BEHAVIORAL BASED TREATMENTS THAT HAVE BEEN OPERATIONALIZED FOR DELIVERY OVER THE INTERNET. THIS DEFINITION BY THE (INAUDIBLE) COLLEAGUES FROM UVA IS A NICE ONE TO DESCRIBE HOW IT IS A REALLY COMPREHENSIVE PACKAGE THAT'S BEING DELIVERED ON THE INTERNET IS WHAT WE THINK OF AS A TRUE INTERVENTION. AND FOR THE MOST PART ACROSS THIS LITERATURE THIS HAD BEEN EFFECTIVE. WEB-BASED EDUCATION HAS NOT. WHAT MATTERS IN INTERNET INTERSECTIONS IS NOT WHAT -- INTERVENTIONS IS WHAT ALSO MATTERS IN FACE TO FACE INTERVENTIONS, WE HAD A TAPERED SCHEDULE OF CONTACT IN A STUDY LOOKING AT WEEKLY, MONTHLY AND NO CONTACT AT THE END. AND WE FOUND THAT WE REGAINED OCCURS JUST LIKE IN FACE TO FACE INTERVENTION. SO USING TECHNOLOGY IS NOT A PANACEA AN REQUIRES THE SAME CAREFUL ONGOINGING MAINTENANCE THAT HUMAN FACE TO FACE INTERVENTIONS INVOLVE. IF WE LOOK AT THIS AS EXPLORATORY ANALYSIS FROM TWO STUDIES I HAVE ALREADY SHOWN, THE STUDY WHERE WEEKLY CONTACT CONTINUES THE RED LINE, WEIGHT LOSSES ARE MAINTAINED AND WHEN THAT CONTACT IS TAPERED OR REMOVED, WEIGHT REGAIN STARTS TO OCCUR MORE PROXIMALLY. BUT WE DON'T KNOW FROM THESE OTHER STUDIES WHAT HAS WORKED. WAS IT STRUCTURED LESSONS, ACCOUNTABILITY, WAS IT GENERIC WEEKLY PROMPTING OR MESSAGE BOARDS OR THAT PROBLEM SOLVING AN REINFORCEMENT FROM THE COUNSELOR? THE STUDIES ISOLATING THE ROLE OF THE COUNSELOR IS UNIQUE THAT WE HAVE A TREATMENT PACKAGE OVER THE INTERNET AND WE CAN ISOLATE ONE FACTOR. SO WE BELIEVE THAT MANY SAME TECHNIQUES THAT NEED TO BE DELIVERED FACE TO FACE ARE ACTIVE INGREDIENTS DELIVERED IN INTERNET BEHAVIOR THERAPY AS WELL. WE RECENTLY HAVE THOUGHT ABOUT HOW WE CAN MAKE SELF-MONITORING A BIT EASIER FOR STUDY PARTICIPANTS BECAUSE IT IS THE HALLMARK, IF YOU WILL, BUT ALSO THE MOST BURDENSOME AND MOST DIFFICULT FOR PEOPLE TO ACHIEVE. SO WE CONDUCT AD STUDY WITH SCALES THAT WERE CONNECTED TO THE INTERNET. AND ASKED PARTICIPANTS TO MOPTOR THEIR WEIGHT EVERY DAY. OPPOSED TO MONITORING ALL THEIR CALORIES, ALL THEIR FOODS AND PHYSICAL ACTIVITY. AND USE WEIGHT AS THEIR MONITORING TOOL TO UNDERSTAND WHETHER THEY WERE IN OR NOT IN ENERGY BALANCE LOOKING AT DAILY FLUCTUATIONS. SO WE HAD THEM WEIGH EVERY DAY AND PROVIDED EMAIL FEEDBACK ON A WEEKLY BASIS VERSUS A WEIGHLESS CONTROL. WE FOUND THAT THE AVERAGE WEIGHING FREQUENCY WAS ONE DAY PER WEEK IN THE CONTROL GROUP. THEY ALSO HAD THE INTERNET CONNECTED SCALE SO OBJECTIVELY SEE THEIR WEIGHING FREQUENCY. IN THE INTERVENTION GROUP ABOUT 6 DAYS PER WEEK. SO THEY WERE SELF-REGULATING BY WEIGHING EVERY DAY. AND THE WEIGHT LOSSES WERE REMARKABLY GOOD FOR WEEKLY EMAIL FEEDBACK AND DAILY WEIGHING, 6% WEIGH LOSS AT SIX MONTHS. HYBRID COMBINATION APPROACHES, ONE STUDY CONDUCTED IN PRIMARY CARE WITH WAS EFFECTIVENESS TRIAL THAT DR. APPLE CONDUCTED LOOKED AT USING A WEB WITH IN PERSON SUPPORT OR TELEPHONE SUPPORT AS AN ADJUNCT TO THE INTERVENTION. YOU CAN SEE WITH A WEB PROGRAM AND REMOTE SUPPORT WHICH WAS DELIVERED OVER TELEPHONE THEY ACHIEVED QUITE GOOD WEIGHT ALSO OVER TIME. AND ONE OF THE OTHER PROGRAMS THAT DR. DIETZ REFERRED TO WAS CONDUCTED BY TRICIA LAHE AND COLLEAGUES LOOKING AT HYBRID OF FACE TO FACE AND EMAIL COACHING, THIS SPEAKS TO TWO THINGS THE COMMITTEE IS CONSIDERING, ONE THEY DELIVER 12 FACE TO FACE GROUP MEETINGS OVER SIX MONTHS OPPOSED TO WHAT WITH WE THINK OF AS 24 OR EVEN 14 RECOMMENDED BY THE COMMITTEE. THEN PROFESSIONAL COACHES, PEER TO PEER COACHES, OR MENTOR PREVIOUSLY SUCCESSFUL WEIGH LOSER. THE PROFESSIONAL BLUE BAR AND THE PEER PRODUCED EXCELLENT WEIGHT LOSS, 9.6 AND 9.1% WITH THAT ONGOING EMAIL FOLLOW-UP FROM A PEER BEING EQUAL TO THAT OF THE PROFESSIONAL SO WE MAYBE ABLE TO USE MORE LAY OR OTHER TYPES OF ON GOING COUNSELING SUPPORT IF WE COUPLE WITH FACE TO FACE. WE DON'T HAVE AN ANALYSIS OF THIS WITH INTERNET ONLY WITHOUT FACE TO FACE TO SEE WHETHER PEERS OR LAY PROFESSIONALS DO THAT WEEKLY COACHING THOUGH THE FACE TO FACE LITERATURE WITH TRAINING WOULD SUGGESTION THAT IT COULD. I WANT TO GO BACK TO STUDY THAT I MENTIONED FROM DR. HARVEY MORINO TO SHOW THEY ALSO HAD A HYBRID CONDITION ON THE FAR RIGHT AND THEIR HYBRID DID NOT PRODUCE BETTER WEIGHT LOSSES THAN THE INTERNET ALONE. THE HYBRID WAS INTERNET COACHING PROGRAM THAT INVOLVED ONCE A MONTH FACE TO FACE MEETINGS FROM A LOCAL INTERVENTIONIST. THERE WAS GROUP COUNSELING GOING ON ON THE INTERNET SO IN A COMPREHENSIVE PROGRAM THAT IS VERY INTENSE, THAT ADDITIONAL FACE TO FACE CONTACT MAY NOT BE NECESSARY. WE CAN DO THINGS WITH MOBILE USING PODCASTS, INTERNET, APPS, TEXT MESSAGES HYBRID. WHAT I WOULD LIKE TO SAY IS THAT THE INTERVENTIONS STUDIED USING THE INTERNET IS ADAPTED AND APPLIED TO MOBILE DELIVERY. WE DON'T NEED TO REPEAT THE STUDIES THAT HAVE BEEN DONE BECAUSE IT'S THE FUNCTION OF WHAT WE HAVE BEEN DOING THAT'S IMPORTANT, NOT NECESSARILY WHETHER THE DEVICE IS WITH SOMEONE OR DONE OVER THE INTERNET. SO A LOT OF THINGS WE HAVE BEEN LEARNING WILL APPLY RAPIDLY TO THIS EMERGING AREA. BUT EVEN WITH THIS TEXT MESSAGING THERE ARE DIFFERENCE TYPES OF APPROACHES THAT CAN BE DONE. REPORTING VIA TEXT MESSAGE, GETTING FEEDBACK VIA TEXT MESSAGE OR RECEIVING AUTOMATED MESSAGES AN REMINDERS. SO THINKING ABOUT TEXT MESSAGING INTERVENTIONS WE'RE GOING TO NEED TO FOCUS ON THE FUNCTION OF WHAT'S BEEN DONE. JUST LIKE WITH OTHER TYPES OF TECHNOLOGY DELIVERED INTERVENTIONS. BUT THERE HAS BEEN A REVIEW AND I WOULD LIKE TO REPORT THAT SO FAR THE WEIGHT LOSS IS WITH MOBILE TECHNOLOGIES ARE SEEMS TO ME SOMEWHAT SMALLER THAN COMPREHENSIVE INTERNET DELIVER BECAUSE THEY'RE RELYING ON TEXT MESSAGEING OR SINGLE TYPE DELIVERY BUT THERE IS INTEREST IN HOW THESE COULD BE COMBINED WITH COMPREHENSIVE INTERNET OR FACE TO FACE APPROACHES. SO I WOULD LIKE TO SUMMARIZE SAYING BEHAVIORAL AND COGNITIVE BEHAVIORAL APPROACHES HAVE THE MOST EVIDENCE FOR EFFICACY. IT'S THE PACKAGE WE KNOW EFFECTIVE. THERE'S LESS EVIDENCE FOR INDIVIDUAL TECHNIQUES THOUGH THE MOST STUDIES HAVE BEEN DONE ON SELF-MONITORING FEEDBACK AND COUNSELOR SUPPORT. CRITICAL FOR ADVANCING THE EFFECTS. THERE IS POTENTIAL OF DELIVERY FOR FACE TO FACE TREATMENT TO BE REDUCE IN TERMS OF INTENSITY. WITH INTENSIVE TREATMENT BEING DELIVERED VIA PHONE CALLS, EMAIL OR MAIL STRUCTURE MATERIALS SO MAINTAINING THE INTENSITY OF THE CONTACT BUT DECREASING THE INTENSITY OF FACE TO FACE CONTACT REQUIRED. COMMUNITY DELIVERED ACQUIRED INTERVENTIONS BASED ON THE EFFECTIVE MODEL THAT ARE TRUE BEHAVIORAL INTERVENTION PACKAGES. HAVE BEEN BETTER THAN CONTROLS. THOUGH TWO KILOGRAMS LESS THAN GOLD STANDARD FACE TO FACE INTERVENTIONS. THANK YOU. [APPLAUSE] NICE PRESENTATION. AS WE CONTINUE TO HAVE MORE TECHNOLOGY IN THIS FIELD, AND WE HOW DO YOU THINK THE INTERVENTIONS ARE GOING TO HELP ACROSS CULTURES, DIFFERENT ETHNIC GROUPS? BECAUSE MORE FACE TO FACE, MORE LABOR INTENSIVE. WE ARE ALL PRETTY MUCH AWARE IS NEEDED IN UNDERSERVED COMMUNITIES AND WITH THE INTERNET AN MORE TECHNOLOGY, WE REALLY WIDENING THE GAP OR INCREASING DISPARITIES MORE SO BECAUSE I THINK PEOPLE MAYBE LESS (INAUDIBLE) AND THE SECOND QUESTION IS I SAW THEORIES PRESENTED. WHAT ABOUT THEORY OF PLANNED BEHAVIOR, DOES THAT PLAY A ROLE? I DIDN'T HEAR ANYTHING ABOUT THAT. I'LL ADDRESS THE FIRST QUESTION, IN THAT YOU HAVE BROUGHT UP AN EXCELLENT POINT THAT MANY OF THE INTERVENTIONS THAT HAVE BEEN DONE WITH TECHNOLOGY HAVE BEEN EFFICACY TRIALS. AND SO MORE EFFECTIVENESS TRIALS ARE NOW BEING CONDUCTED THAT WILL UNCOLLUDE MORE DIVERSE POPULATIONS SO WE CAN SEE WHETHER OR NOT THERE ARE EQUIVALENT EFFECTS OR WE CAN DEVELOP INTERVENTIONS THAT ARE MORE WIDE REACHING. AS FAR AS THE DISPARITY GAP ONE THING WE DO KNOW IS THAT THE ACCESS TO TECHNOLOGY, THE GAP HAS BEEN CLOSING. AND IN FACT IN SOME POPULATIONS MOBILE PHONE ACCESS IS ACTUALLY HIGHER IN SOME OF OUR TRADITIONALLY UNDERSERVED POPULATIONS. SO WE HAVE AN OPPORTUNITY THERE I THINK TO CAPITALIZE ON THAT. BUT WE'RE JUST GOING TO BE LEARNING FOR EXAMPLE IN ONE OF THE STUDIES WE HAVE WHETHER OR NOT ADAPTING ONE OF THESE INTERVENTIONS IN TO SPANISH AND USING ALL SPANISH MATERIALS HAVING SPANISH ACTORS AND MODELS AND OTHER PEOPLE, WILL BE AS EFFECTIVE AS AS TRADITIONAL INTERVENTION SO THOSE STUDIES ARE BEING CONDUCTED BUT WE DOPE HAVE ENOUGH EVIDENCE. AS FAR AS THE THEORY OF PLANNED BEHAVIOR, THERE ARE SOME THEORIES THAT HAVE BEEN MORE STUDIED ABOUT THE NOT BEHAVIOR CHANGE BUT BEHAVIOR AND PREDICTING WHAT SOMEONE IS CURRENTLY DOING OPPOSED TO HELPING SOMEONE TO CHANGE THEIR BEHAVIOR. SO THE THEORY OF PLANNED BEHAVIOR HAS BEEN TO USE SOMEWHAT THOUGH NOT IN THESE LARGE INTERVENTION STUDIES AND A FOCUS ON SIMILAR CONSTRUCTS TO THOSE THAT ARE INCLUDED IN OTHER THEORY LIKE SELF-EFFICACY AN THINKING ABOUT PERCEIVED BEHAVIORAL CONTROL IN THAT WAY HAS BEEN SIMILARLY PREDICTIVE TO SELF-EFFICACY O I DID NOT REVIEW THAT BECAUSE THERE HAVEN'T BEEN ANY LARGE SYSTEM MA IT CAN REVIEWS PERHAPS BECAUSE THERE MAY NOT BE AS MANY INTERVENTIONS THAT WERE DEVELOPED WITH THAT THEORY FOR WEIGHT LOSS. YOUR PRESENTATION, I'M SORRY. OKAY. YOUR PRESENTATION IS LARGELY FOCUSED ON STRATEGIES IN ADULTS AND I'M CURIOUS ABOUT SMALL CHILDREN, IN PARTICULAR WHETHER OR NOT THERE STRATEGIES WHICH SOME OF THESE TECHNIQUES ARE USED CAN BE APPLIED TO MOTHERS FOR EXAMPLE MONITORING THE WEIGHT CHANGES IN SMALL CHILDREN. I AM NOT AWARE IF ANALYSIS OF BEHAVIOR CHANGE TECHNIQUE HAS BEEN LOOKED AT YET WITH CHILDHOOD OBESITY THOUGH I BELIEVE PERHAPS THERE IS A REVIEW. I THINK IT MAKES SENSE THAT WE CAN THINK ABOUT WHAT BEHAVIOR CHANGE TECHNIQUES WORK TO CHANGE ADULT BEHAVIOR IF YOU'RE THINKING ABOUT A MOTHER PERHAPS CHANGING THE BEHAVIOR OF HER CHILD. BUT I'M IN THE AWARE OF LARGE INTERVENTIONS THAT HAVE EXAMINED THOSE TECHNIQUES OR THE COMPONENTS OF THOSE TO TELL WHAT WE NEED TO BE FOCUSING ON. I THINK WE CAN EXTRAPOLATE FROM THISK TO THINK ABOUT MONITORING BEHAVIOR AND GETTING FEEDBACK ON WHETHER OR NOT WHAT THEY'RE TRYING TO DO TO HELP THEIR CHILD IS WORKING BUT FEEDBACK IMPORTANT FOR CHANGING ONE'S OWN BEHAVIOR, IT WOULD BE IMPORTANT FOR THE MOTHER TO RECEIVE FEEDBACK WHETHER OR NOT WHAT SHE'S TRYING IS HELPING. WE THINK ABOUT PROBLEM SOLVING IN ADULT INTERVENTIONS AN HELPING MOTHERS TO PROBLEM SOLVE, THINGS THAT ARE WORKING OR NOT WORKING WHEN THEY'RE TRYING TO HELP THEIR CHILD. I THINK IT WOULD MAKE SENSE BUT I'M NOT AWARE OF DATA. ALICE (INAUDIBLE) THANK YOU FOR PULLING TOGETHER A LARGE BODY OF DATA. MY QUESTION HAS TO DO WITH WHETHER THERE'S A TIPPING POINT IN TERMS OF GIVING FEEDBACK TO INDIVIDUALS. WE'RE ALL ON EMAIL LISTS, WE GET LOTS OF EMAILS, AFTER A WHILE SOMETIMES WE AUTOMATICALLY DELETE THEM. I SEEM/YOU SEE THEM AS EFFICACIOUS BUT DO YOU THINK THERE COMES A POINT SO MUCH FEEDBACK IS GIVEN THAT PEOPLE START TUNING OUT? PERHAPS. WE WORRIED ABOUT THIS IN A WORK SITE STUDY THAT WE DID AND ACTUALLY WE WEREN'T THINKING ABOUT THE FEEDBACK BUT PROMPTING. SO THINGS THAT ARE AUTOMATED LIKE REMEMBER TO DO THIS, YOU GET THE AUTOMATED EMAIL. SO WE HAD DONE FOCUS GROUPS AND WE DECIDED NOT TO PROMPT, BECAUSE THAT WAS WHAT WAS LEARNED IN THE FOCUS GROUPS. AND WE HAVE LOWER ADHERENCE IN THAT STUDY PROVIDING MORE OPPORTUNITIES FOR PEOPLE TO DO THE SAME BEHAVIOR, SUBMITTING THEIR WEIGHT, VIA TEXT MESSAGING AUTOMATED EMAIL, VIA STANDARD WEBSITE, INCREASE ADHERENCE AND WHEN WE INSTITUTED ADDITIONAL METHODS WE THOUGHT WELL PERHAPS THAT'S JUST GIVING THEM WAY TOO MUCH OPTIONS, WE FOUND BY INTRODUCING ANOTHER MORE CONVENIENT OPTION PEOPLE USE TWO AND THEY -- WE DID INCREASE ADHERENCE. BUT WHAT WE DID THE SAME TIME WAS PROMPT. SO I THINK THERE'S SOME AMOUNT OF PROMPTING AND REMINDING WITH INTERVENTIONS THAT NEEDS TO OCCUR TO KEEP PEOPLE ON TRACK. AS FAR AS FEEDBACK, WE ONLY REALLY STUDIED GIVING THAT FEEDBACK MORE OFTEN THAN ONCE A WEEK IN ONE STUDY. IT WAS NOT RANDOMIZED SO I DON'T KNOW WHETHER MORE OFTEN IS BETTER THAN LESS OFTEN. BUT I THINK JUST GENERAL COMMON SENSE HOW MUCH TO GIVE PROBABLY PREVAILS, I GUESS FROM FEEDBACK LITERATURE IT ALSO HAS TO BE USEFUL SO SUGGESTING THAT IF YOU PROVIDE FEEDBACK IT HAS TO BE SOMETHING THE PERSON MAY OR MAY NOT KNOW THEMSELVES SO THINGS THAT ARE SORT OF NOT SOPHISTICATED MAYBE DELETED IF NOT PROVIDING USEFUL INFORMATION TO SOMEONE. THANK YOU FOR VERY INFORMATIVE PRESENTATION, THIS IS FRANK HUE FROM HARVARD SCHOOL PUBLIC HEALTH. TWO QUICK QUESTIONS, FIRST, WHETHER YOU CAN DISTINGUISH WEIGH LOSS SHORT TERM WEIGHT LOSS FROM HONGER TERM WEIGH MANAGEMENT IN TERMS OF EFFECTIVE BEHAVIOR APPROACHES AS YOU KNOW SHORT TERM WEIGH LOSS IS RELATIVELY EASY BUT MOST REGAIN THEIR WEIGHT AFTER SIX MONTHS SO I THINK WEIGH LOSS MAINTENANCE IS EXTREMELY IMPORTANT FOR MAKING RECOMMENDATIONS. SECOND QUESTION, WHETHER YOU HAVE DONE COST EFFECTIVENESS ANALYSIS TO SEE WHETHER -- WHAT KIND OF HYBRID APPROPRIATE VERSUS MORE TRADITIONAL APPROACH MORE COST EFFECTIVE SO WE WANT INTERVENTIONS EFFICACIOUS BUT ALSO COST EFFECTIVE. WEIGHT LOSS MAINTENANCE IS CRITICAL. THERE HAVE BEEN FEWER INTERNET STUDY WEIGHT LOSS MAINTENANCE. WE CONDUCTED ONE TRIAL CALLED STOP REGAIN THAT INVESTIGATED WEIGHT LOSS MAINTENANCE INTERVENTION WHERE WE RECRUITED PEOPLE AFTER THEY LOST SIGNIFICANT WEIGHT AND WE BASE ON SELF-REGULATION THEORY. SO THERE IS A BELIEF THAT PERHAPS ADDITIONAL THEORIES MAYBE NEEDED FOR MAINTENANCE THOUGH THE STUDY OF WHAT THOSE THEORIES OR CONSTRUCTS MIGHT BE HAS NOT BEEN AS FRUITFUL. WE DON'T KNOW YET. WE DO THINK THAT LONG TERM TRACKING OF WEIGHT IS IMPORTANT AND PREVENTING SMALL REGAINS ARE IMPORTANT SO IN OUR STUDY WE FOUND THAT IN THE GROUPS WHERE THEY WERE TAUGHT TO QUICKLY RESPOND TO ANY REGAIN, AND THEY WERE WEIGHING DAILY, THAT THAT WAS MORE EFFECTIVE THAN A GROUP OBSERVED OVER TIME SO NEWS LETTER CONTROL GROUP FOR EXAMPLE THOUGH THE BEST RESULTS WERE ACHIEVED IN OUR FACE TO FACE INTERVENTION WHERE WE INTERVENED WITH PEOPLE IF THEY REGAIN THROUGH FACE TO FACE COUNSELING. THE INTERNET PROGRAM WAS ONLY EFFECTIVE IN PRIMARY PREVENTION OF REGAIN SO PEOPLE STRUGGLING IT LOOKED FACE THE FACE WAS NEEDED. SO I THINK AS FAR AS WHAT YOU'RE TALKING ABOUT WITH COST EFFECTIVENESS, INTERVENTIONS THAT ARE DELIVERED OVER THE INTERNET THAT INVOLVE HUMAN COUNSELORS ARE NOT NECESSARILY MORE COST EFFECTIVE THAN HAVING A GROUP FOR PROVISION OF THE CARE. YOU'RE LIMITED IN TERMS OF THE PANEL THAT YOU CAN INTERVENE WITH. OUR OPPORTUNITIES FOR COST EFFECTIVENESS ARE WITH SOME OF THE MORE AUTOMATED OR HYBRID APPROACHES WHERE WE RESERVE THE HUMAN FOR MORE PERHAPS CHALLENGING CASES. WE DID A STUDY OF A STEP CARE MODEL BUT IT WAS A FACE TO FACE DELIBERATIVE INTERVENTION AN FOUND THAT BY LOOKING WHETHER PEOPLE ARE SUCCESSFUL OR NOT AND GIVING MORE CARE TO THOSE THAT ARE STRUGGLING, WE CAN REDUCE COST OF STANDARD FACE TO FACE TREATMENT. TIME IS UP, GREAT PRESENTATION. EEL ASK MY COLLEAGUE TO INTRODUCE OUR NEXT SPEAKER, SONIA ANGELL. IT'S A PLEASURE TO INTRODUCE DR. SONIA ANGELL, SHE'S ONE OF MY PROFESSIONAL HEROES. DR. ANGELL WAS AT THE NEW YORK CITY HEALTH DEPARTMENT. SHE SHEPHERDED A NUMBER OF PROGRAMS, REALLY TOOK NUTRITION SCIENCE AN TRANSLATED IT INTO PUBLIC HEALTH POLICY THAT HAD AN ENVIRONMENTAL CHANGE. SO IN SOME CASES FOR INDIVIDUALS WHO THEY HAVE HAD LOW HEALTH LITERACY OR MOTIVATION OR NUTRITION MOTIVATION, THE DEFAULT OPTION HE WANTED UP BEING THE HEALTHIER OPTION AND THEY HAD TO GO OUT OF THEIR WAY FOR THE LESS HEALTHY OPTION AND FOR INDIVIDUALS WITH HIGH HEALTH AND NUTRITION MOTIVATION, MORE INFORMATION WAS AVAILABLE FOR THEM TO MAKE INFORMED CHOICES SO DR. ANGELL IS CURRENTLY CHIEF OF NON-COMMUNICABLE DISEASE UNIT AND SENIOR ADVISER IN THE DIVISION OF GLOBAL HEALTH PROTECTION AT THE CENTER OF GLOBAL HEALTH, CDC. SHE PROVIDES LEADERSHIP IN GLOBAL NON-COMMUNICABLE DISEASE AND POLICY AND PROGRAM DEVELOPMENT. AND SHE'S PARTICULAR EXPERTISE IN HEALTH POLICY PROGRAMMING EVALUATION AND CLINICAL SYSTEMS IMPROVEMENT. PRIOR TO JOINING THE CDC IN 2011, DR. ANGELL DIRECTED THE CARDIOVASCULAR NUTRITION PREVENTION -- CARDIOVASCULAR DISEASE PREVENTION CONTROL PROGRAM IN NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE. SOME KEY PROGRAMS ACCOMPLISHMENTS INCLUDE REGULATING THE USE OF PARTIALLY HYDROGENATED FAT AND NEW YORK CITY RESTAURANTS, LEADING THE NATIONAL SALT REDUCTION INITIATIVE, ESTABLISHING NUTRITION STANDARDS FOR FOOD PROCUREMENT FOR NEW YORK CITY GOVERNMENT AGENCIES, AND CLINICAL QUALITY IMPROVEMENT INITIATIVES TO IMPROVE BLOOD PRESSURE AND CHOLESTEROL CONTROL. DR. ANGELL IS MEMBER OF THE INSTITUTE OF MEDICINES PANEL ON STRATEGIES FOR REDUCTION OFFICED UPINTAKE IN THE UNITED STATES AND IS CURRENTLY A MEMBER OF THE PAN AMERICAN HEALTH ORGANIZATION TECHNICAL ADVISORY GROUP. ADDITIONALLY PROVIDES CONSULTATION TO THE WORLD HEALTH ORGANIZATION IN A WIDE RANGE OF AREAS. DR. ANGELL IS A BOARD CERTIFIED INTERNAL MEDICINE, SHE RECEIVED HER MEDICAL DEGREE FROM THE UNIVERSITY OF CALIFORNIA SAN FRANCISCO. SHE THEN COMPLETED RESIDENCY IN INTERNAL MEDICINE BRIGHAM BOSTON. SHE HAS A DIPLOMA IN TROPICAL MEDICINE AND HYGIENE FROM LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE AND MASTERS IN PUBLIC HEALTH EPIDEMIOLOGY FROM UNIVERSITY OF MICHIGAN. SHE'S A FORMER ROBERT WOOD JOHNSON CLINICAL SCHOLAR AND FELLOW OF AMERICAN COLLEGE OF PHYSICIANS. PLEASE JOIN ME IN WELCOMING DR. ANGELL. [APPLAUSE] THANK YOU SO MUCH FOR THAT AMAZING INTRODUCTION. I'M TOUCHED TO THINK I COULD BE ANYTHING CLOSE TO YOUR HERO, ALICE BUT TO COME BACK AND HAVE AN OPPORTUNITY TO TALK ABOUT THESE AREAS IS A GREAT PLEASURE TO ME. I'M HERE TODAY NOT REPRESENTING OR ON BEHALF OF THE NEW YORK CITY HEALTH DEPARTMENT BUT RATHER HAVING WORKED IN THIS CAPACITY TO SHARE WITH YOU REFLECTIONS AND EXPERIENCES AND THE EVIDENCE THAT CAME OUT OF THAT PROCESS THAT MIGHT BE RELEVANT TO THE DECISIONS THAT Y'ALL WILL BE MAKING OVER THE NEXT MONTHS TO COME. SO WHEN I WAS APPROACHED TO DISCUSS THIS IT CAME TO ME AS REQUEST TO TALK ABOUT TRANSFAT ON THE PHONE TO UNDERSTAND IT A LITTLE BIT MORE AND IT MORPHED ALMOST INTO ALL OF OUR PROGRAMS. SO WHAT I'M GOING TO DO HERE IS SYNTHESIZE STARTING WITH THE TRANSFAT PROGRAM AS REQUESTED BUT SORT OF TALK A FEW DIFFERENT PROGRAMS THAT HOPEFULLY THEMES OF INTEREST THAT I HEARD ABOUT DURING THE PRELIMINARY DISCUSSIONS MAY COME OUT AND THEN OF COURSE I CAN ANSWER ADDITIONAL QUESTIONS AT THE END. I'M GOING THE START FIRST WITH AN OVERVIEW ABOUT HOW ONE MAKES HEALTHIER CHOICES, EASIER CHOICES AND SPECTRUM OF OPPORTUNITIES, THIS IS FAMILIAR LANGUAGE BUT HELPS TO STEP BACK AND UNDERSTAND WHERE THE CONVERSATION THAT I'M GOING TO HAVE WITH YOU FITS INTO ALL THE DIFFERENT OPPORTUNITIES. WE HAVE TWO FABULOUS PREGNANT THIS IS MORNING. BUT I THINK REALLY SIT ON ONE END AND I'M GOING TO PERHAPS BRING THE OTHER END, MAYBE ROUNDING OUT DISCUSSIONS HERE. EXAMPLES OF NEW YORK CITY SYSTEMS LEVEL APPROACHES TO IMPROVE POPULATION NUTRITION WITH FOCUS ON TRANSFAT BUT NOT EXCLUE SUVLY ON FRANCE FAT TALKING ABOUT WHAT WE DID IN NEW YORK CITY RESTAURANTS AROUND TRANSFAT, TALKING ABOUT FOOD PROCUREMENT AND RELEVANCE TO THOSE EFFORTS. AND THEN EXPANNING THE REACH THROUGH AN EXAMPLE OF HOW WE'RE TRYING TO THINK ABOUT REDUCING SODIUM INTAKE. WITHIN THE CONVERSATION I'M GOING TO WEAVE IN HOW WE USE THE DIETARY GUIDELINES AN DEVELOPMENT HOW THEY MAY HAVE BEEN RELEVANT OR IN SOME CASES NOT ADS RELEVANT AND PERHAPS SERVE AS A TOUCH STONE FOR FURTHER DEVELOPMENT IN THE ACTIVITIES GIVE YOU CONCLUSIONNARY THOUGHTS. SO THIS DIAGRAM WAS GIVEN BY ONE OF MY COLLEAGUES AT THE CENTERS FOR DISEASE CONTROL, REALLY I THINK EXPRESSING THE TWO EXTREMES OF THE WAY WE THINK ABOUT TRYING TO IMPROVE AND CHANGE BEHAVIORS. MANY INFLUENCES ARE AT THE INDIVIDUAL LEVEL, CULTURAL ADDITIVE BELIEF, SKILL, KNOWLEDGE, THE TIME SOMEBODY HAS AND THE AFFORDABILITY OF MAKING SPECIFIC DECISION. THE OTHER END OF THE SPECTRUM ENVIRONMENT AND SYSTEMS THAT INFLUENCE THE WAY THE INDIVIDUAL MAKES DECISIONS INCLUDING PHYSICAL ACCESS AND AVAILABILITY, PRICING, ECONOMIC CONDITIONS COMMUNICATIONS THE WAY IN WHICH THE MEDIA IS INFLUENCING US, WHAT HAPPENS AT THE POINT OF DECISION. AND THEN THE EDUCATION AND THE PROMOTION AROUND SPECIFIC ISSUES. ALL ARE ENVIRONMENTAL ISSUES THAT THEN INFLUENCE HOW AN INDIVIDUAL CAN MAKE A DECISION. AND I THINK THE CRUX OF ALL OF THIS IS REALLY TRYING TO THINK ABOUT HOW CAN WE REDUCE THOSE BARRIERS THAT THE ENVIRONMENTAL -- AT THE ENVIRONMENTAL TRAVEL MAKE ROLLING THAT BALL UP A HILL. LESS STEEP HILL AND RESOLVE IN US HAVING HEALTHIER EATING PATTERNS, EATING BEING THE TOPIC OF INTEREST AT THIS MOMENT FOR THIS PRESENTATION. IS HOW DO WE DO THAT? THIS IS A PYRAMID IN MANY PRESENTATIONS BECAUSE IT HELPS US SEPARATE OUT OR UNDERSTAND WHAT'S HAPPENING IN THE MIDDLE AS WE TRY TO MOVE THINGS ALONG THAT SLOPE. BY DR. FREEDEN, DIRECTOR OF THE CENTERS FOR DISEASE CONTROL. AND WHILE I THINK ALL OF US CAN DEBATE HOW THIS FALLS IN THE PYRAMID, IN GENERAL WE THINK OF THOSE AT THE TOP OF THIS PYRAMID HAVING THE SMALLEST IMPACT OR AT LEAST THE SMALLEST IMPACT GIVEN THE AMOUNT OF RESOURCES PRACTICALLY SPEAKING WE HAVE IN SOCIETY TO INVEST IN THE TOP OF THE PYRAMID. ALL THE WAY DOWN TO THOSE THAT HAVE THE GREATEST IMPACT. SO THOSE THAT ONE MAY ARGUE POPULATION LEVEL NOT INDIVIDUAL LEVEL BUT POPULATION LEVEL HAVING PERHAPS SMALLEST IMPACT WOULD BE COUNSELING AND EDUCATION, HEALTHY EATING, BEING FIZZILY ACTIVE, WE HEARD THIS MORNING ABOUT DIFFERENT WAYS THAT WE CAN MOVE SOME OF THOSE. A LITTLE BIT FURTHER DOWN BY USING INNOVATIVE APPROACHES TO DELIVER THEM BUT GENERAL THEY CAN BE PRETTY EXPENSIVE TO DELIVER. CLINICAL INTERVENTIONS, MOVING ON UP LONG ACTING PROTECTIVE INTERVENTIONS SUCH AS IMMUNIZATIONS, ET CETERA, CAN CERTAINLY HAVE IMPACT. WITH I'M GOING TO SPEND TIME IS TALKING ABOUT CHANGING THE CONTEXT TO MAKE THE INDIVIDUAL DECEMBER FAULT DECISION, THE HEALTHY DECISION THAT ALICE INTRODUCED. I WANT TO PAY -- GIVE NOTE TO THE WHOLE ISSUE OF SOCIO ECONOMIC FACTORS BECAUSE AS WE WORK IN PUBLIC HEALTH AS EPITEAMOLOGIST WHEN YOU ANALYZE THE DATA THERE'S NO QUESTION THAT AGAIN AND AGAIN AN AGAIN ONE OF THE MOST IMPORTANT FACTORS ARE THE SOCIO ECONOMIC CONDITIONS OF THE INDIVIDUAL. FRUSTRATINGLY WE DON'T SPEND TIME IN THAT SPACE IN PUBLIC HEALTH FOR MANY DIFFERENT REASONS. I DON'T WANT THAT THE FALL OUT OF THE DISCUSSION AS YOU THINK PARTICULARLY ABOUT HEALTHY EATING HABITS AN ACCESS INDIVIDUALS HAVE. SO FOLLOWING THAT PYRAMID THAT I SHARED WITH YOU, I JUST PUT TOGETHER HERE A LIST OF ALL THE KINDS OF INTERVENTIONS WE CAN THINK ABOUT AS SORT OF SPECTRUM OF OPPORTUNITIES. CERTAINLY THERE ARE MANY MORE THAT ONE COULD ADD HERE BUT BUILDING FROM THE TOP OF THAT PYRAMID ALL THE WAY DOWN. SO WHEN IT COMES TO FOOD, THE SPECTRUM OF OPPORTUNITIES THAT WE HAVE TO REALLY CHANGE AN INDIVIDUAL'S EATING PATTERNS INCLUDES STARTING AT THE INDIVIDUAL LEVEL, THINKING ABOUT THE INGREDIENTS THAT THEY ARE SELECTING EVERY DAY FOR WHAT THEY'RE PREPARING AT HOME OR IMPORTANTLY HELPING THEM CHANGE WHAT THEY'RE ORDERRENING RESTAURANTS BECAUSE WE KNOW INCREASINGLY A GREATER PROPORTION OF OUR CALORIES ARE BEING CONSUMED BASED UPON FOODS THAT ARE ARE PURCHASED AND PREPAREDDED OUTSIDE THE HOME. THEN MOVING ON UP ONE CAN THINK ABOUT LABELING, THAT GIVES PEOPLE UNDERSTANDING WHEN THEY'RE PURCHASING. MARKET AND PRICING PRACTICES, MEDIA AND AWARENESS CAMPAIGNS REACH LOTS OF PEOPLE BUT DON'T NECESSARILY CHANGE BEHAVIOR UNLESS THERE IS ACTUALLY SOMETHING ACTIONABLE AT THE END OF THE MESSAGE. FEEDING PROGRAMS, SO STARTING TO FOCUS ON SPECIFIC POPULATIONS OF INTEREST, CHANGING THE TYPES OF FOODS THAT THEY GET. AND THEN THINKING A LITTLE BY MORE PROCUREMENT POLICY, HOW ARE HUGE INSTITUTIONS AN GOVERNMENTS MAKING DECISIONS ABOUT THE FOODS THEY'RE PURCHASING AND PASSING ON EITHER TO THEIR CLIENTS OR THAT TO THEIR POPULATION AT LARGE. THEN I THINK FINALLY, THIS SORT OF QUESTION OF INDUSTRY-WIDE REFORMULATION IN RESTAURANTS AN PACKAGED FOODS THAT REALLY REACH EVERYBODY NO MATTER WHERE YOU ARE. SO LET'S TALK ABOUT TRANSFAT. SO WHEN WE -- FIRST STARTED THIS DISCUSSION IN NEW YORK CITY TO THINK ABOUT HOW WE MIGHT REDUCE CARDIOVASCULAR DISEASE MORBIDITY AND MORTALITY, IT WAS QUITE COMPLICATED. WE HAVE 8 MILLION PEOPLE IN NEW YORK CITY. WE HAVE VAST RACIAL ETHNIC DISPARITIES AND RATES OF DISEASE SO NOT ONLY DID WE NEED THE REACH THE POPULATION BUT WE NEED TO REACH EVERY DIFFERENT GROUP OF POPULATION IN NEW YORK CITY AND NEW YORK CITY IS A VERY DIVERSE POPULATION WITH RESPECT TO INCOME, RACE ETHNICITY. NEIGHBORHOODS, IT'S A PRETTY INCREDIBLE PLACE TO WORK BUT IT ALSO REQUIRES MAKING SURE AND THINKING CONSTANTLY ABOUT WHAT YOU'RE DOING AND MAKING SURE THAT WHAT YOU'RE DOING GETS TO THE POPULATION AT LARGE AND TO THE SMALLER POPULATIONS OF CONCERN. SO AS WE STARTED THINKING ABOUT NUTRITION ISSUES, THINKING ABOUT THE DIFFERENT OPPORTUNITIES, THIS SPECIFIC REPORT, THIS WAS IN 2004 WHEN I ARRIVED AT THE HEALTH DEPARTMENT, THIS REPORT LEFT STRONG IMPRESSION NOT ONLY ON ME BUT OUR COLLEAGUES IN THE HEALTH DEPARTMENT. RELATED TO TRANSFAT IN THE DIET AND INSTITUTE OF MEDICINE IN 2002, SUMMARY REPORT CONCLUDED THERE'S A POSITIVE LINEAR TREND BETWEEN TRANSFATTY ACID INTAKE AND TOTAL LDL CONCENTRATION AND THEREFORE INCREASE RISK OF CORONARY HEART DISEASE. WHAT THEY ALSO CONCLUDED WAS IN ORDER TO REDUCE DIETARY TRANSFAT PEOPLE HAVE TO MAKE EXTRAORDINARY CHANGES SUCH THAT IT RESULTS IN TRADITIONALLY INCOMPLETE DIET SO ULTIMATELY THE CONCLUSION WAS KEEP TRANS FAT AS LOW AS YOU CAN. SO IF YOU SEE THIS AND YOU THINK HERE IS SOMETHING BAD FOR YOU AND ALL THAT WE CAN RECOMMEND IS KEEP IT DOWN BECAUSE THERE'S REALLY NOTHING YOU CAN DO ABOUT IT, THAT MAKES YOU THINK, OKAY, THIS MIGHT BE SOMETHING WE CAN REMEDY IF WE LOOK AT THE SYSTEM. SO THAT'S WHAT WE DID. SO IF YOU THINK ABOUT IT THE NEXT QUESTION IS FINE, WE KNOW IT'S FAT FREE BUT WHERE IS IT IN THE DIET? THE VAST MAJORITY OF TRANSFAT IN THE DIET AT THIS TIME WAS ARTIFICIALLY PRODUCED THROUGH A PROCESS PARTIALLY HYDROGENATING VEGETABLE OIL AND PUTTING THEM INTO THE FOOD SUPPLY. 79%. ONLY 21% NATURALLY OCCURRING AND ONE ARGUES THAT NATURALLY OCCURRING TRANSFAT WAS SOMETHING THAT IS IN TRADITIONAL DIET BUT 79% ISN'T NECESSARILY IN TRADITIONAL DIET THE IT WAS ADDED TO THE FOOD SUPPLY AT SOME POINT. SO WHAT CAN WE DO TO UNADD THAT FROM THE FOOD SUPPLY? VERY QUICKLY, TRANSFAT -- ARTIFICIAL TRANSFAT BECAUSE WORKING IN PUBLIC HEALTH DEPARTMENT TRANSLATED TERMS POPULATION BUZZ YOUR CLIENT POPULATION AT LARGE SO TRANSFATTY ACID, THOSE PRODUCED THROUGH INDUSTRIAL PROCESSES RESULT AS A PROCESS OF HYDROGENATION OF THE OIL WHERE BASICALLY YOU'RE ADDING HYDROGEN ACROSS BREAKING THE BONDS, AND WHEN THEY REFORM YOU END UP WITH SINGLE BONDS. THAT IS FULL HYDROGENATION THAT'S NOT AS BAD WHEN WE PARTIALLY HYDROGENATED OIL, PUT IT T THROUGH THIS PROCESS, ADD HYDROGEN, BREAK THE BONDS, THE BONDS REFORM, WHEN THEY REFORM IN THE TRANSEXON FIGURATION SO HYDROGEN IS ACROSS FROM EACH OTHER YOU END UP WITH A VERY STRAIGHT MOLECULE. AND THAT'S THE ONE WE'RE WORRIED ABOUT. THE TRANSFATTY ACIDS SO IT DOESN'T GET TOTALLY HYDROGENATED, BUT IT END UP WITH THIS DOUBLE BOND IN THERE BUT STRAIGHT MOLECULE. THAT IS PARTIALLY HYDROGENATED VEGETABLE OIL. WHERE ARE THE ARTIFICIAL TRANSFAT? BY AND LARGE THE MAJOR SOURCES DIETARY ENVIRONMENT IS CHANGING, BUT BASICALLY DEFINITELY CRIBBED TO MAJORITY, MARJORIE WAS A HUGE CONTRIBUTOR AT THAT TIME. FRIED POTATOES WHEN YOU THINK RESTAURANT INSTITUTES THOUGH WERE PROBLEMATIC AS WELL AS OTHER PRODUCTS BUT WHAT YOU SEE IS PRETTY MUCH EVERYWHERE, SO AS A CONSUMER IT'S QUITE DIFFICULT TO AVOID ONE OR THE OTHER. SO WE LOOKED AT THE DIETARY GUIDELINES SO THIS IS WHAT THE DIED TEAR GUIDELINES IN 2005 SAID AROUND TRANSFAT. TWO KEY RECOMMENDATION AREAS UNDER ADEQUATE NUTRIENTS WITHIN CALORIC NEEDS AND BASICALLY IT SAYS TO KEEP IT LIMITING THE INTAKE OF SATURATED AND TRANSFAT SO CONSISTENT WITH THE IOM REPORT AND UNDER FATS, KEEP TRANSFATTY ACID CONSUMPTION AS LOW AS POSSIBLE. IT ALSO ADVISED PEOPLE BY LOOKING AT FOOD LABELS CONSUMERS CAN SELECT PRODUCTS THAT ARE LOWEST IN TRANSFAT, SATURATE FAT, TRANSFAT AND CHOLESTEROL SO HERE IS A CALL TO ACTION FOR THE INDIVIDUAL TO LOOK AT PACKAGES. IN 2003 THERE WAS REGULATION PASSED THAT BY 2006 ALL PACKAGED PRODUCTS SHOULD HAVE TRANSFAT LISTED ON THE BACK AS WE SEE ON THIS LABEL SO PRIOR TO 2006 IF YOU WANTED TO AVOID TRANSFATTY AD IS YOU HAD TO LOOK -- ACID YOU HAT TO LOOK AT THE INGREDIENT LIST TO KNOW TRANSFATTY ACID WAS IN PARTIALLY HYDROGENATED VEGETABLE OIL AND TEMPERATURE YOU KNEW THAT YOU DIDN'T KNOW WHAT LEVEL OF CONTRIBUTION OF TRANSFAT YOU GET BECAUSE THERE WAS NOT THAT INFORMATION SO IT'S FABULOUS THAT IN 2006 IF YOU'RE A CONSUMER IN THE STORE YOU CAN SEE THIS INFORMATION AND MAKE A DECISION. SO PEOPLE ARE EATING OUT A LOT MORE. THIS DATA I'M KEEPING HERE, WE CAN -- WE HAVE MORE DATA MORE TO CURRENT YEARS BUT THIS IS WHETHER WE WERE WORKING WITH AT THE TIME THINKING ABOUT THE STRATEGY, ABOUT ONE-THIRD OF CALORIES WERE BEING CONSUMED AT FOODS PURCHASED AWAY FROM HOME. IN THIS ENVIRONMENT CONSUMERS ARE PRETTY MUCH IN POSITION, THERE WAS NOT MUCH THEY COULD DO. BECAUSE IN RESTAURANTS YOU DON'T HAVE A FAT LABEL TO LOOK AT. SO IF YOU'RE A RESTAURANT OWNER, YOU HAVE TO KNOW TRANSFAT IS IN PARTIALLY HYDROGENAT VEGETABLE OIL. YOU HAVE TO LOOK AT LABELS AND MAKE A VOLUNTARY DECISION THAT YOU CARE ENOUGH OR THIS IS IMPORTANT ENOUGH AS A BUSINESS DECISION AT THE MOMENT TO AVOID THESE PRODUCTS. SO CONSUMERS IN THIS VERY IMPORTANT FOOD ENVIRONMENT OF RESTAURANTS IN NEW YORK CITY AT DISTINCT DISADVANTAGE. SO THIS IS THE RATIONALE TO THINK ABOUT THIS. NEW YORK CITY WE REGULATE MOST HEALTH DEPARTMENTS DO REGULATE THE RESTAURANT ENVIRONMENT SO IT IS WITHIN OUR AREA OF PURVIEW. SO AS WE BUILT TO A POSITION OF ACTION, CARDIO CARDIOVASCULAR DISEASE IS LEADING CAUSE OF DEATH IN NEW YORK CITY. SO TRANSFAT IN THE DIET INCREASES RISK OF CORONARY HART DISEASE. KEY PUBLIC HEALTH SCIENTIFIC AUTHORITY AS IN DIETARY GUIDELINES RECOMMENDED REDUCING TRANSFAT INTAKE ON PACKAGED FOODS PEOPLE HAD A WAY TO DO THAT BUT THROUGH FOOD NUTRITION LABELING REQUIREMENT GOING INTO EFFECT BUT IN RESTAURANTS THERE WAS NO PRACTICAL WAY FOR CONSUMERS TO AVOID IT. SO WE CAME TO A DECISION NEW YORK CITY DEPARTMENT OF HEALTH RECOMMEND AS POLICY NEW YORK CITY RESTAURANTS SHOULD VOLUNTARILY ELIMINATE USE OF TRANSFAT IN FOODS. THIS SEEMED HIKE A LOGICAL PROCESS WE WENT THROUGH. SO WE DEVELOPED AMAZING PROGRAM CALLED THE TRANSFAT EDUCATION CAMPAIGN, WE THOUGHT STRATEGICALLY ABOUT EVERY AREA HOW WAS TRANSFAT GETTING TO RESTAURANTNESS AND HOW TO MOTIVATE A VOLUNTARY CHANGE. SO WE REACHED OUT TO RESTAURANTS BUT WE ALSO KNEW SUPPLIERS HAD TO PROVIDE TO RESTAURANTS AND CONSUMERS NEEDED TO TO DEMAND CHANGES TOO. RESTAURANTS RESPOND TO CONSUMER REQUESTS SO GREAT CAMPAIGN. WE DID A PRE-POST SURVEILLANCE TO FIND OUT WHAT LEVELS WERE AT THE BEGINNING AND THE END. WE DISTRIBUTED EDUCATIONAL TEAMS TO CONSUMERS OVER 200,000, 30,000 RESTAURANTS RECEIVED DIRECT INFORMATIONSFROM. WITH SENT OUT LETTERS TO SUPPLIERS ACROSS THE UNITED STATES. 15,000 LETTERS GOING OUT TELLING THEM LOOK NEW YORK CITY USED SUPPLY FOOD TO SOME OF THE RESTAURANTS, WE'RE GOING TO ASK THEM TO REDUCE TRANSFAT IN THEIR FOOD, CAN YOU GIVE OTHER FOODS AND OPTIONS. COVERED ALL THE SPECTRUM. WE ALSO INCLUDED IN OUR FOOD PROTECTION COURSES TRANSFAT MODULE THE ON TRANSFAT, EVERYBODY THAT WORKED IN RESTAURANT HAD TO SEND SOMEBODY TO THE TRAINING. WE PRINTED INFORMATION, WE HAD A PRESS LAUNCH AND EVALUATED A YEAR LATER, AND THIS WAS THE IMPACT. SO BEFORE THE CAMPAIGN ABOUT 50% KNOWN TO BE USING PARTIALLY HYDROGENATED VEGETABLE OIL AN AFTERWARDS, 51% SO ONE CAN ARGUE THAT WASN'T SUCCESSFUL SO WE WERE IN A SITUATION WE REALIZED WE PUT OUR INVESTMENT IN THIS CAMPAIGN TO CHANGE AN CREATE A VOLUNTARY CHANGE AND WE HAD NOT EVEN INKLING OF SUGGESTION THAT EVEN IF WE TWEAKED IT THAT WE COULD GET DIFFERENT OUTCOMES. AT THAT POINT IT WAS CLEAR WE HAD NOT AN ETHICAL RESPONSIBILITY CERTAINLY A PUBLIC HEALTH RESPONSIBILITY TO TAKE ACTION BECAUSE WE KNEW THERE WAS A PROBLEM. WE HAD AUTHORITY OVER THE ENVIRONMENT. AND WE KNEW A VOLUNTARY CAMPAIGN WOULDN'T WORK SO WE DEVELOPED, DRAFTED AND PRESENTED TO BOARD OF HEALTH AMENDMENT OF HEALTH CODE, REGULATION TO RESTRICT TRANSFAT. WE HAD CONVERSATIONS WITH INDUSTRY TO UNDERSTAND WHAT TECHNICAL CHALLENGES WOULD BE, WHAT THE TIME LINE SHOULD BE AN INTRODUCED IN 2006 IN DECEMBER AN WENT INTO EFFECT IN TWO PHASES. IT APPLIEDED TO NEW YORK CITY RESTAURANTS AND CITY COUNCIL ACTUALLY PASSED LEGISLATION THAT WAS SIMILAR IN ACTION. THIS IS WHAT WE SAW. THIS WAS WITH RESPECT TO USE OF IT. YOU SAW THE 50 AND 51% ALREADY. THEN WE DID ONE MORE SURVEY, RIGHT BEFORE IT WENT INTO FULL EFFECT TO SEE THAT IF PEOPLE WERE ACTUALLY CHANGING THEIR BEHAVIORS AND WHEN IT WAS IN FULL EFFECT BASICALLY INFECTION COMPLIANCE WAS CLOSE TO 100%. SO THROUGH THIS MEASUREMENT NOW WE UNDERSTOOD THEY WERE TAKING TRANSFAT OUT. WE THEN LOOKED AT WHAT WAS GOING ON IN RESTAURANTS AND THE MAJOR SOURCE WOULD BE FAST FOOD RESTAURANTS TO UNDERSTAND BECAUSE NUTRITIONAL INFORMATION IS AVAILABLE THERE. TO SEE WHAT IMPACT IT MIGHT HAVE HAD ON FAT, THIS IS AN EXAMPLE OF LOOKING AT IMPACT ON FATS IN FRIES. OF COURSE WE EXPECT THE TRANSFAT CONTENT TO DECREASE SO IN FRIES DECREASED BY 97.9%. WHAT ALSO HAPPENED IS DECREASE IN SATURATED FAT TOO SO A DOUBLE BONUS SO FRIES WERE HEALTHIER NOT JUST FROM TRANSFAT BUT SATURATED FAT PERSPECTIVE AND THERE WAS OVERALL REDUCTION, 54% IN THE PERCENTAGE OF SATURATED FAT AND TRANSFAT IN THE FRIES SO THAT WAS A GREAT OUTCOME. THEN WE DID A FURTHER ANALYSIS AFTER THE -- AFTER IT WEPT INTO EFFECT LOOKING AT WHAT PEOPLE WERE PURCHASING BASED UPON RECEIPT, PEOPLE LEAVING RESTAURANTS. WE FOUND THAT BEFORE THE REGULATIONS WENT INTO PLACE, ONLY 30% OF MEALS PURCHASED IN NEW YORK CITY FAST FOOD RESTAURANTS CONTAIN ZERO GRAM TRANSFAT BY END OF 200960% DID. THE DIFFERENCE IS THAT THE REGULATION ONLY COVERS THOSE PARTIALLY HYDROGENATED VEGETABLE OIL CONTAINING PRODUCTS SO SOME IS NATURALLY OCCURRING TRANSFAT THAT WILL ALWAYS BE THERE IF NOT COVERED. THE OTHER THING WE DID IS LOOK AT IMPACT BY STORE LOCATION AN NEIGHBORHOOD INCOME TO SEE IF WE WERE CREATING A GAP, WHICH IS A REALLY IMPORTANT PIECE OF THE INFORMATION FOR US. WE FOUND THERE TO BE NO DIFFERENCE. SO IT EQUALLY BENEFITED PEOPLE PURCHASING FOODS IN LOW INCOME AND HIGH INCOME RESTAURANTS. BASED UPON THIS ANALYSIS, WE HAD LIMITATION OF ONLY BEING THOSE THAT ARE CHAIN RESTAURANTS. SO QUICKLY UPTAKE WITHIN TWO YEARS REGULATION, ADDITIONAL 12 CITIES ABOUT STATES HAD ADOPTED IT AND THIS IS A MAP OF THE REGULATIONS AS OF JUNE 2012. SO WHAT ONE SEES IS SORT OF SPREADING OUT BUT I WANT TO POINT OUT THERE ARE MANY GAPS, MANY -- MUCH REGULATION SNOT COVERED BY -- POPULATION IS NOT COVERED BY REGULATION THAT RESTRICT USE OF TRANSFAT. AND THEN QUITE EXCITING IN NOVEMBER OF 2013, THE FDA RELEASED ITS CONCLUSION THAT TRANSFAT IS NOT GENERALLY RECOGNIZED AS SAFE, IT'S A PRELIMINARY DECISION AND IT'S OPEN FOR PUBLIC COMMENT WHICH ENDED ON THE 8TH OF THE MONTH SO NOW ALL COMMENTS ARE BEING REVIEWED BUT I THINK THIS IS AN INTERESTING EVOLUTION AN OPPORTUNITY TO THINK ABOUT REALLY PROTECTING THE POPULATION AT LARGE AND CHANGING THE ENTIRE FOOD SUPPLY TO A DEFAULT IT IS A HEALTHIERER DEFALL, NOT INDIVIDUAL DECISION MAKING ANY MORE THAT'S TAKEN OUT BECAUSE THE OPPORTUNITY HERE IS TO REMOVE IT FROM THE FOOD SUPPLY. SO NOW I WANT TO TALK FOOD PROCUREMENT. THE OPPORTUNITY HERE WAS REALLY IN THINKING ABOUT ALIGNING OUR CITY GOVERNMENT ACTION IN THE WAY WE OTHER PURCHASING THINGS TO MAKE IT CONSISTENT WITH WHAT WE'RE TELLING PEOPLE TO DO. NEW YORK CITY 260 MILLION MEALS AN SNACK ANNUALLY, THAT IS A LOT OF FOOD. THAT'S A LOT OF FOOD PURCHASE, IT'S PURCHASED THROUGH 12 AGENCIES AND THE SITES WHERE THESE FOODS ARE SERVED INCLUDE SCHOOLS, AFTER SCHOOL PROGRAMS, SENIOR CENTERS, HOMELESS SHELTERS, PARKS, PUBLIC HOSPITALS, EMERGENCY FOOD CENTERS, THERE'S A WHOLE VARIETY OF TYPES AN PLACES WHERE PEOPLE ARE EITHER PURCHASING OR RECEIVING FOOD. SO THE STRATEGY AND OPPORTUNITY HERE IS TO CREATE AND IMPLEMENT KNEW TRIG STANDARDS FOR ALL FOODS PURCHASED AND SERVED BY NEW YORK CITY AGENCIES. SOME ALREADY HAVE FOOD POLICIES BUT MANY ARE PURCHASING AND PUTTING THEM IN FOR EXAMPLE IN PATIENTS PROGRAM AS IS PART OF THE SOMETHING THEY OFFER AS PART OF THE PROGRAM BUT NOT NECESSARILY WITH NUTRITION IN MIND. IN 2006, THEN MAYOR BLOOMBERG CREATED THE FOOD POLICY TASK FORCE AN INTRODUCE AD FOOD POLICY COORDINATOR, AND THEN THERE WAS A WORK GROUP TO FOCUS ON PURCHASING NUTRITION FOR THIS VERY REASON BECAUSE OF IMPACT IT COULD HAVE. THE BIG CHALLENGE CAME DEPARTMENT OF HEALTH TECHNICAL ADVISERS FUNCTIONENING THE WORKSHOP WORK GROUP BUT HOW DO YOU ACTUALLY MAKE CRITERIA FOR PURCHASING WHEN YOU HAVE AN ENVIRONMENT LIKE THIS? SO WE LOOKED AT WAYS DUMP FOODS WERE BEING PURCHASED. IT'S INCREDIBLY COMPLICATED. WHILE ONE STARTS WITH A RECOMMENDATION THAT COMES FROM THE DIETARY GUIDELINES HOW MUCH AND TYPES OF FOODS INDIVIDUALS SHOULD BE CONSUMING TO OPERATIONALLIZE THAT IT'S COMPLICATED. WE HAVE AGENCIES THAT ARE PURCHASING FOOD AND CENTRALIZED LEVEL CONTRACTING AND OR FOR AGENCY ITSELF IS PRODUCING FOOD. SO THE FIRST EXAMPLE, AGENCY SCHOOL SYSTEM IS PURCHASING THE FOOD AND OBSERVING THROUGH THEIR OWN ACTIVITIES. ANOTHER VERSION OF IT IS WHAT WE SEE AT SENIOR CENTER COMMONLY IN NEW YORK CITY WHICH IS WHERE THE AGENCY CONTRACTS TO OTHER PEOPLE AND SERVE FOOD. THEN THERE'S THE MIXTURES THAT OCCUR, IN SOME AGENCIES THEY PROVIDED THEMSELVES AND THEN CONTRACT AND THE FINAL ONE IS SOMETHING LIKE HOMELESS OR EMERGENCY FOOD WHERE THEY JUST PURCHASE THE FOOD AND THEY GIVE IT OUT. IT'S NOT EVEN PROCESSED. THESE CRITERIA ARE INCREDIBLY COMPLICATED. YOU CAN IMAGINE WHEN YOU PURCHASE FOOD WHETHER OR NOT A SINGLE MEAL IS SUPPOSED TO HAVE X AMOUNT OF SODIUM BECOMES IRRELEVANT WHEN BUYING AN ENTIRE BOX OF FOOD TO GIVE TO AN INDIVIDUAL. SO WE CREATED THREE SECS FOR FOOD STANDARDS, PURCHASED FOODS SPECIFICALLY, MEALS AND SNACKS SERVED, AGENCY AND SPECIFIC STANDARD TO TRANSLATE THIS TO FOLKS SENIOR POPULATIONS WITH DIFFERENT NUTRITIONAL REQUIREMENTS REFLECTING OUR UNDERSTANDING OF THE NUTRITION GUIDELINES. IT COVERS SPECIFIC REQUIREMENTS AND INCLUDES THE NO ARTIFICIAL TRANSFAT AS WELL AS OTHER SPECIFIC LIMITATIONS ON NUTRITION. AND THEN MULTIITALY AS WE -- ULTIMATELY AS WE REFLECT UPON HOW THESE WERE PUT TOGETHER THE DIETARY GUIDELINES FOR AMERICANS AS I MENTIONED WERE AN IMPORTANT PIECE, WE LISTED THE IOM REPORTS, FOOD AND DRUG ADMINISTRATION, RELEVANT PUBLISHED RESEARCH BUT WHEN IT CAME DOWN TO IT WHAT WE HAD TO DO WAS LOOK AT ACTUALLY WHAT WAS AVAILABLE IN THE MARKETPLACE AND TRY TO FIND SOME HARMONIZATION BETWEEN WHERE WE WANT TO BE AND WHERE WE ARE NOW. SO THE REGULATIONS THEMSELVES DON'T NECESSARILY REFLECT ANY SPECIFIC GUIDELINE EXCEPT FOR MOVING ON THAT CONTINUE ONE TOWARDS HEALTHIER PURCHASING AT LARGE. FINALLY I WANT TO TALK QUICKLY ABOUT SALT REDUCTION EFFORTS. SO SALT IS A PROBLEM IN OUR DIET, WE TALK ABOUT THIS FREAKILY. THE DIETARY GUIDELINES AGAIN, THIS DATA IS UP TO 2006 BECAUSE THIS IS WHEN WE WERE DEVELOPING THE PROGRAM. WHAT WAS IMPORTANT, IS UNDERSTANDING WHERE WE WERE, BASED UPON THE RECOMMENDATIONS FOR DIETARY GUIDELINE WHICH IS SERVES AS A CALL TO ACTION BUT WASN'T NECESSARILY SOMETHING THAT GUIDED US INTO UNDERSTANDING HOW TO DEVELOP A RESPONSE. SO MOST OF THIS COMES FROM PROCESS RESTAURANT FOODS IN OUR DIET. THREE QUARTERS. AGAIN THIS IS SIMILAR TO THE ISSUE WE HAD WITH TRANSFAT. IT MAKES IT UM POSSIBLE FOR AN INDIVIDUAL YOU HAVE DIETARY RECOMMENDATIONS TO BE ABLE TO TAKE ACTION ON THEIR OWN UNLESS YOU'RE CHANGING THE ENVIRONMENT TO ENABLE THEM TO ACTUALLY BE ABLE TO ACHIEVE WHAT YOU'RE ASKING THEM TO DO. SO THE QUESTION IS HOW DO WE CHANGE THAT ENVIRONMENT TO ALLOW THEM TO ACHIEVE WHAT WE'RE TRYING TO DO OR WHAT WE'RE TELLING THEM TO DO. THIS WAS AN INTERESTING MODEL THAT CAME OUT OF THE UNITED KINGDOM WHICH WAS COLLABORATION BETWEEN INDUSTRY AND GOVERNMENT AND WE DECIDED TO FOLLOW THE SAME. ESSENTIALLY THIS APPROACH ESTABLISHES VOLUNTARY INDUSTRY SODIUM CONTENT TARGETS AND FOODS THAT ARE SUBSTANTIVE, TARGETS ARE ACHIEVEABLE. THEY BRING SODIUM DOWN GRADUAL WAY, VOLUNTARY AN MEASURABLE. THOSE ARE CRITERIA THAT SEEM TO CREATE AN ENVIRONMENT WHERE INDUSTRY AND GOVERNMENT WORK TOGETHER IN A VOLUNTARY FASHION TO CHANGE THE FOOD SUPPLY AT LARGE. IF ONE CAN CHANGE THE FOOD SUPPLY BRINGING IT DOWN ACROSS ALL SPECTRUMS PEOPLE WILL BE IN A POSITION MORE LIKELY THE ACHIEVE THE RECOMMENDATIONS. SO THE GOAL OF THE NATIONAL SALT REDUCTION INITIATIVE WHICH BECAME -- COORDINATED BY NEW YORK CITY BUT IN ORDER TO CHANGE THE FOOD ENVIRONMENT AT LARGE REALLY REQUIRES FOLKS ACROSS THE UNITED STATES WORKING TOGETHER BECAUSE THE FOOD SUPPLY PRODUCED NOT JUST NEW YORK CITY BUT EVERY CITY AND STATE. SO THE NATIONAL SALT REDUCTION FORMS WITH PARTNERSHIP NOW OF 90 CITIES STATE AND NATIONAL HEALTH ORGANIZATIONS. WITH THE GOAL OF REDUCING SODIUM INTAKE BY 20% OVER FIVE YEARS, 25% REDUCTION IN CONTENT OF OUR PROCESS PACKAGED FOODS AS WELL AS RESTAURANT FOODS. IN ORDER THE TO SET GUIDELINES THE BIG PICTURE GOAL WAS GETTING IT DOWN TO POPULATION BEING ABLE TO CONSUME WITH WHAT WAS RECOMMENDED DIETARY GUIDELINES BUT WE OOHER SO FAR FROM THAT, HAVING THAT NUMBER IS NOT A HELPFUL ITEM AND NOT OPERATIONALLIZABLE. SO WHAT WE NEEDED TO DO FOLLOWING THE UK MODEL WAS CREATE CATEGORIES OF FOOD PRODUCTS AND SUPPLIES SO WE CREATED TWO DATABASES ONE FOR PACKAGED FOODS, ONE FOREST, LOOKED THROUGH EACH SINGLE FOOD CATEGORY TO UNDERSTAND WHAT THE CURRENT LEVEL OF SODIUM PER HUNDRED GRAMS OF PRODUCT WAS, POTENTIAL FOR WHERE WAS OUTLIER ON BPO SIDES, WHAT WAS POTENTIAL FOR REDUCTION IN THAT AND THROUGH AND ITERATIVE PROCESS WITH INDUSTRY WE PROPOSED AND REVISED AND SET TARGETS BASED UPON WHAT IS POSSIBLE AND ACHIEVABLE FOR GRADUAL REDUCTIONS. YOU CAN GO OPT WEBSITE TO SEE ALL THE TARGETS BUT I PUT THIS HERE AGAIN, ANOTHER ITERATION TO UNDERSTAND CRITERIA TO HELP CHANGE OUR FOOD ENVIRONMENT. OBSERVATION AND CONCLUSION, POPULATION INTERVENTIONS TO MAKE HEALTHY CHOICES EASY CHOICES. I WANT TO KNOW BECAUSE THE GLOBAL COMMUNITY AND I THINK A QUESTION CAME UP BEFORE INCREASINGLY SIMILAR, I THINK THAT WHILE WE DO NEED THE LOOK AT MODELS THAT WORK IN OUR POPULATION, WE DO NEED TO LOOK OUTSIDE. SO WITH RESPECT TO DIETARY PATTERNS, LESSONS LEARNED IN ANY COUNTRY COULD BE IMPORTANT TO EVERY COUNTRY AND WE SHOULD CREATE A GLOBAL LEARNING COMMUNITY, IT'S ESSENTIAL AND OBVIOUSLY FROM WHERE I SID NOW AT THE CDC WORKING GLOBAL NON-COMMUNICABLE DISEASES I SEE SO MANY OPPORTUNITIES AND AS SUCH NEED FOR US TO THINK MORING TO ABOUT THESE ISSUES. SCALABLE IS KEY. AND THEY NEED TO BE EVIDENCE BASED AND SO AS YOU LOOK FOR YOUR EVIDENCE BASE, THIS ISSUE OF EVALUATION BECOMES KEY. BUT I ALSO THINK THAT WE NEED TO BE THOUGHTFUL ABOUT CHALLENGES RESOURCES NEEDED TO EVALUATE PROGRAMS AND THIS NEEDS TO BECOME A PRIORITY AS WE THINK ABOUT INTRODUCINGING THESE IN ANY SETTING. IN CONCLUSION, THE PRIOR U.S. DIETARY GUIDELINES WERE IN ALL THESE A VERY IMPORTANT REFERENCE POINT IN THE DEVELOPMENT OF NEW YORK CITY PROGRAMS THAT I DESCRIBED. BUT THE CREATION OF POPULATION LEVEL INTERVENTIONS REALLY REQUIRE THE USE OF ADDITIONAL RESOURCES SO SHAPE NUTRIENT RELATED CRITERIA. AS YOU THINK ALSO I UNDERSTAND THE EVOLUTION TRYING TO THINK ABOUT SYSTEMS LEVEL, THESE CRITERIA FOR INDIVIDUALS LOOK DIFFERENT WHEN YOU TRANSLATE AND THINK ABOUT THEM APPLYING THEM A POPULATION LEVEL. SO THANK YOU. [APPLAUSE] THANK YOU, SONIA, BARBARA MILLEN CHAIR OF THE DIETARY GUIDELINES ADVISORY COMMITTEE. THIS WAS A WONDERFUL PRESENTATION. AND I WANT TO THANK YOU FORGIVING ACKNOWLEDGEMENT TO THE WORK OF PREVIOUS COMMITTEES BUT ALSO TO POINT OUT HOW COMPLEX AN ISSUE IT IS TO CHANGE THE ENVIRONMENT OF AN ENTIRE CITY TOWARDS A HEALTHIER DIET. I WONDER IN THAT THE REGARD IF YOU CAN TALK MORE ABOUT STANDARDS YOU CREATED. THAT'S INCREDIBLY AMBITIOUS AND IT'S AN EXAMPLE OF HOW YOU HAD TO DIG DEEP AND DEVELOP THREE IF NOT FOUR MODELS OR LEVELS FOR THAT. AND I WONDER HOW YOU'RE GOING TO MANAGE THAT AND HOW THIS CITY IS GOING TO AND DO THEY HAVE ANY INFORMATION ON IMPACT YET. IN TERMS OF THAT. I WASN'T SURE IF THAT WAS VOLUNTARY OR MANDATORY. BECAUSE YOU SHOWED HOW EFFECTIVE MANDATORYING ARELATION IS. SO THE FOOD STANDARDS ARE -- THEY WERE ITERATIVE BY EXECUTIVE ORDER BY THE MAJOR. THEY ARE MANDATORY. COMPLIANCE IS ASSESSED ANNUALLY AND THE REPORTS ARE GIVEN TO CITY COUNCIL THROUGH THEIR PUBLIC AND ON LINE. AND THEY LOOK AT ALL OF THE CITY AGENCIES REVIEWED TO SEE WHERE THEY ARE WITH RESPECT TO EVERY SINGLE SPECIFIC STANDARD. I THINK -- SO -- THIS QUESTION IS MANDATORY VERSUS VOLUNTARY, IT IS A REALLY IMPORTANT ONE TO CONSIDER. I'M NOT SURE ONE IS BETTER THAN THE OTHER IN EVERY SITUATION. I THINK THAT REALLY ONE NEEDS TO THINK ABOUT THE CONTEXT OF EACH ONE. BECAUSE IN SOME SITUATIONS VOLUNTARY APPROACH MAYBE BETTER ON MANY LEVELS. THE QUESTION OF SUSTAINABILITY ONE GRAMS WITH NO MATTER HOW FAR ALONG YOU GET BUT THAT DOESN'T NECESSARILY MEAN REGULATION IS A GIVEN AS A NECESSITY. WHAT I THINK WAS REALLY IMPORTANT PROCESS ILLUSTRATED HERE, ESPECIAL HUH THROUGH THE TRANSFAT INITIATIVE, IS GOING THROUGH THE PROCESS OF UNDERSTANDING WHAT THE OPPORTUNITIES ARE AND WHAT POINT VOLUNTARY REACHED ITS INABILITY TO WORK ANY MORE. LOTS OF MODELS ARE USED IN OTHER COUNTRIES AS WELL, SOME VOLUNTARY AND SOME MANDATORY. I'M NOT SURE IF SOMETHING IS MANDATORY IF IT'S NOT SOMETHING SOMEBODY TO COMPLY WITH, IT'S NOT SUCCESSFUL SO IT'S A COMPLICATED PROCESS IN DECIDING THAT. THEN YOU ASKED SPECIFICALLY ABOUT THE FOOD STANDARDS AND HOW WE DEVELOP THOSE. I CAN GIVE A COUPLE OF EXAMPLES AND THEN I WOULD CERTAINLY ENCOURAGE YOU, THESE ARE ONLINE AND THEY'RE DOCUMENTS TO READ THROUGH, THEY'RE VERY SIMPLE AND STRAIGHT FORWARD BECAUSE THEY'RE DESIGNED FOR PEOPLE TO BE ABLE TO COMPLY WITH THEM. SO I WOULD CREDIT THE HEALTH DEPARTMENT HAVING DONE A REALLY NICE JOB, A KEY COMPONENT TO COMPLIANCE. TO GIVE AN EXAMPLE OF FOODS PURCHASED, THE PRODUCTS WOULD -- A DESCRIPTION WOULD BE FOR EXAMPLE, THERE -- YOU CANNOT PURCHASE SUGAR SWEETENED DRINKS WITH OVER 25-CALORIES PER 8-OUNCES SO THERE WOULD BE A SPECIFIC CRITERIA. THEN THOSE -- ALL THOSE CRITERIA WERE PUT IN CITY CONTRACTS SO THEN WHEN THEY WENT OUT TO BE CONTRACTED PEOPLE WOULDN'T QUALIFY TO BID UNLESS THEY WERE PROVIDING SPECIFIC FOODS THAT MET THESE SOME THAT WAS ANOTHER LAYER THAT MADE IT EASY TO OPERATIONALLIZE IT. WHEN IT COMES TO SEARCHING IT BECOMES MORE COME -- SERVING IT'S COMPLICATED BECAUSE PEOPLE SERVE DIFFERENT WAYS. IN SOME ENVIRONMENTS, PEOPLE RECEIVE ALL THEIR MEALS ALL DAY FROM THE SAME INSTITUTION. IN SENIOR CENTERS IT MIGHT BE BREAKFAST AN LUNCH SO YOU HAVE TO BREAK OUT EVERY MEAL AND UNDERSTANDING WHAT PERCENTAGE OF CALORIES SHOULD BE SERVED, ET CETERA. WHAT WE ALSO FOUND VERY IMPORTANT IS NUTRIENT BASED WAS HELPFUL BUT FOOD-BASED APPROACHES WERE PERHAPS EVEN MORE REASONABLE TO BE IMPLEMENTED. SO FOOD BASE SAYING YOU HAVE TO HAVE THREE PIECES OF FRUIT. OR THEY SHOULD BE WHOLE GRAIN ONLY OR THINGS THAT ARE CLEAR AND EASY TO IMPLEMENT. WE FOUND SPECIFICALLY BECAUSE YOU HAVE A DIVERSITY OF CONTRACTORS THAT SOME ENVIRONMENTS SOME WERE MUCH EASIER THAN OTHERS AND WE ALSO NEEDED TO INTRODUCE NUTRITIONISTS TO HELP MANY COME INTO COMPLIANCE AND DEVELOP THEIR PURCHASING DIFFERENTLY. THANK YOU SO MUCH. THIS IS MIN NELSON, TUFTS UNIVERSITY. GREAT WORK. SO I WONDER, YOU TALK ABOUT ADDED SUGAR AND IT'S SORT OF LIKE NEXT OPT LIST IN A SENSE BUT WHAT DO YOU -- IT'S TRICKY, THE SODIUM, THE TRANSFAT, WE MORE HAVE LEVELS WHERE WE KNOW IT'S UNHEALTHY, THE ADDED SUGARS IS COMPLICATED BECAUSE IT'S RELATED TO CALORIE. BUT I -- YOU PROBABLY I WOULD ASSUME YOU HAVE DONE QUITE A BIT OF THINKING ABOUT ADDED SUGAR. WHAT DO YOU THINK IT'S GOING TO TAKE IN ORDER FOR THERE TO BE ABLE TO HAVE SOME OF THE SAME LEVEL OF ATTENTION FOR -- RIGHT NOW IT'S HARD FOREPERSONS ALSO NOT TO GET LOT OF ADDED SUGAR BECAUSE SIMILAR TO TRANSFAT AND SODIUM, IT'S IN THE FOOD SUPPLY, SO WHAT DO YOU THINK IT WILL TAKE IN ORDER TO HAVE THOSE ELEMENTS IN PLACE TO BE ABLE TO HAVE SOME OF THE SAME ACTION ON THE FOOD SUPPLY? I'M VERY HAPPY THAT IT LOOKS LIKE THE NEXT LABEL WILL HAVE ADDED SUGAR, WHICH IS HELPFUL BUT I WONDER ABOUT OTHER THINGS. I THINK ONE OF THE BIGGEST CHALLENGES, FOR PROGRAM DEVELOP DEVELOPMENT SPECIFICALLY IS HAVING AN UNDERSTANDING WHERE YOU ARE AT YOUR BASELINE, SO YOU CAN COMMUNICATE CLEARLY TO WHATEVER POPULATION YOU'RE WORKING WITHIN AND FOR YOUR OWN NEEDS SO YOU CAN IDENTIFY WHAT THE APPROPRIATE INTERSECTION SHOULD BE. SO FOR EXAMPLE, TRANSFAT, THE BASELINE PREVALENCE, WHAT'S IMPORTANT TO UNDERSTAND 50% OF RESTAURANTS WE'RE USING AN HELPS US UNDERSTAND THE 50% NOT USING TRANSFAT COULD BE MODELS SO WE CAN GO TO THEM TO TRY AND UNDERSTAND HOW THEY'RE PURCHASING, WHY AREN'T THEY USING, WHAT ARE THEY USING INSTEAD. SO MY COMMENT WOULD BE ONE OF THE QUESTIONS WOULD BE IF YOU'RE DEVELOPING A PROGRAM IT WOULD BE TO UNDERSTAND WHERE THE ADDED SUGARERS, WHERE IS THE SWEET SPOT AND THE OPPORTUNITY FOR INTERVENTION. ONE WOULD -- I DON'T KNOW WHAT THAT IS. BUT I DON'T KNOW THAT IT WOULD BE THE SAME IN RESTAURANTS. THAT'S CERTAINLY BEEN ACTION AROUND SODA, THAT'S OBVIOUS. BEYOND THAT IT TAKES REAL CAREFUL THOUGHT. ONE CHALLENGE THAT YOU HAVE JUST DESCRIBED IS THAT IF YOU DON'T HAVE INFORMATION ON THE LABEL SOMEWHERE, THEN IT BECOMES AN IMPOSSIBLE TASK BECAUSE TO GO OUT AND TEST ALL OF THE FOODS IN EVERY RESTAURANT IS NOT FEASIBLE, DOESN'T MAKE SENSE TO I THINK ONE OF THE FIRST IMPORTANT STEPS IS LABELING. BASED UPON THAT YOU CAN DO THE INVESTMENT, AND DEVELOP A STRATEGIC APPROACH TO LOOK WHERE MAJOR CONTRIBUTORS ARE, I WOULD SUSPECT IN THE END IT WOULD PROBABLY NEED TO BE SORT OF A MULTI-LEVEL APPROACH LOOKING AT THE FOOD SUPPLY AT LARGE BUT ALSO THINKING PURCHASING PATTERNS HOW THOSE CAN BE CHANGED. THE NEAT THICK ABOUT PROCAR. YOU BID ON CONTRACTS TO CHANGE THE FOOD THEY PRODUCE. ONCE THEY CHANGE THE FORMULATIONS THEY'RE AVAILABLE OTHER PLACES SO IT'S LOOKING AT THIS RIPPLING EFFECT OF OPPORTUNITY ALONG THE WAY TOO. THANK YOU VERY MUCH FOR YOUR WONDERFUL PRESENTATION. JUST WANT THE FOLLOW-UP WHAT THE MAIN JUST ASK ABOUT ADDED SUGAR, AS YOU KNOW, SUGAR SWEETENED BEVERAGES CONTRIBUTE TO ALMOST 50% OF ADDED SUGAR IN OUR DIET. SO I THINK THIS GREAT IDEA TO FOCUS ON THE REDUCTION OF SODA IN SUGAR SWEET BEVERAGES, TRANSFAT AN SALT SINCE SOME OF THE POLICIES INITIATED BY DEPARTMENT OF PUBLIC HEALTH, HAD A LOT OF RESISTANCE ESPECIALLY BIG SODA RESTRICTION AND SODA TAX AND SO FORTH SO CAN YOU TALK ABOUT THE DIFFERENCES AND THE SIMILARITIES BETWEEN THE SODA RELATED POLICIES WITH TRANSFAT AND SODIUM RELATED POLICIES AND WHAT CAN WE LEARN FROM THOSE EXAMPLES. I'M NOT IN AS GOOD A POSITION TO DISCUSS THAT BECAUSE I THINK ONE OF THE REASONS I'M IN A GOOD POSITION TO TALK ABOUT THESE IS THAT I WAS ACTUALLY AT THE HEALTH DEPARTMENT. SO PART OF THAT PROCESS AND THAT RASH THINKING THROUGH RATIONALIZATION POLICIES AND WHEN TO GO ONE DIRECTION OR OTHER DIRECTION, I THINK YOU BRING UP A VERY IMPORTANT QUESTION ABOUT WHY SOME POLICIES SUCCEED AND OTHER ONES DON'T. AND I'M NOT IN A GOOD POSITION TO COMMENT ON THAT IN NEW YORK CITY. Q. (INAUDIBLE) SCHOOL OF PUBLIC HE FELT. SON I CAN'T RECOLLECT THANK YOU SO MUCH FOR ILLUMINATING US WITH TWO IMPORTANT DISEASE APPROACH TO IMPROVE THE DIETS OF AMERICANS. IN YOUR ROLE AS A LEADER IN GLOBAL HEALTH AN CHRONIC DISEASES SPECIFICALLY VERY PROMINENT ADVISER TO THE PAN AMERICAN HEALTH ORGANIZATION ON STRATEGIES TO REDUCE SODIUM INTAKE. ARE THERE ANY LESSONS WE CAN LEARN FROM WHAT IS HAPPENING IN CANADA OR OTHER COUNTRIES IN LATIN AMERICA AND CARIBBEAN, WE LIVE IN INCREDIBLY GLOBALIZED WORLD. SOME IDEA HAS IMNATED WERE BORN IN NEW YORK ABOUT IN TAXES FOR SODA, THEY'RE NOW IMPLEMENTED IN MEXICO. AS YOU KNOW. SO I THINK IT'S REALLY IMPORTANT IF WE CAN LEARN FROM WHAT IS HAPPENING ELSEWHERE THAT MAY HAVE BEEN UNSPIRED BY WORK DONE IN NEW YORK CITY. THERE ARE -- MAYBE THESE IDEAS -- MANY IDEA COME UP IN OTHER PLACES, SOME YOU CAN ENACT AND SOME ENVIRONMENTS YOU CAN'T. AND TO SEE MEXICO TAKE THE LEAD AND INTRODUCING THIS TAX SUGAR SWEETENED DRINKS AN JUNK FOOD AT LEVELS ONE WOULD ANTICIPATE SHOULD HAVE IMPACT ON CONSUMPTION PATTERNS WOULD BE FASCINATING TO SEE. ONE IMPORTANT THING YOU PRIA UP ALSO, IS AS THESE POLICY AN PROGRAMMING INTERVENTIONS GET INTRODUCED EVALUATIONS BECOMES REALLY IMPORTANT AN ILLUSTRATES THE DOMESTIC IMPORTANCE OF UNDERSTANDING WHAT'S HAPPENING IN THE GLOBAL COMMUNITY. AND THAT WE REALLY HAVE INVESTED INTEREST IN UNDERSTANDING HOW SOME OF THOSE INITIATIVES MAY OR MAY NOT WORK. BECAUSE IT CAN HELP US AVOID INTRODUCING THINGS THAT WOULDN'T HAVE WORKED ANYWAY AND WE CAN FOCUS MORE ON EFFECTIVE MEASURES SO WE DON'T KNOW WHAT'S GOING TO HAPPEN IN MEXICO YET. WHAT I HAVE SEEN AROUND SODIUM REDUCTION IS A LOT OF ACTION OF THINKING PROCESSED FOODS AND SETTING TARGET AN INDICATORS, MANY OF THE CHALLENGES HAVE TO DO AROUND DATABASES TO UNDERSTAND WHERE BASELINE IS, SO ONE CAN MONITOR OVER TIME. I THINK EVEN IN THE UNITED STATES NEW DATABASES FOR THE NEW YORK CITY INITIATIVE HAD TO BE CREATED, SIMILAR DATABASES NOW EXIST AT THE FEDERAL LEVEL TO UNDERSTAND SODIUM BY INDIVIDUAL BRAND PRODUCTS AND SALES WEIGHT. BUT THAT DATA IS NOT READILY AVAILABLE PARTICULARLY IN LOW AND MIDDLE INCOME COUNTRIES SO DIFFERENT INNOVATIONS NEED TO COME UP IN DATA AND EVALUATION TO UNDERSTAND WHERE THE PRODUCT IS TO GO AFTER IT. SO ULTIMATELY IT'S A MULTI-LEVEL APPROACH THE ALL THESE FOOD CHANGES THAT WE'RE SEEING, THE EPIDEMIOLOGIC TRANSITION, THE FOOD TRANSITIONS THAT ARE OCCURRING ARE INCREDIBLY RAPID. AND WHAT EXISTS IN LOW AND MIDDLE INCOME COUNTRIES IS THE OPPORTUNITY TO INTRODUCE POLICIES THAT WILL PREVENT THEM FROM FOLLOWING THE SAME TRAJECTORY, NOW WE'RE TRYING TO RETROFIT OUR FOOD SUPPLY TO MAKE IT REFLECT WHAT WE SHOULD BE EATING IN LOW AND MIDDLE INCOME COUNTRIES, MAYBE BE EARLY ENOUGH IF THEY PUT POLICIES IN PLACE THE TRANSITION OCCURS WITH THE HEALTHIER MULTIMITT SUPPLY. WE'LL TAKE WHERE YOU KNOW ONE MORE QUESTION. EXCUSE ME, TOM BRENNON, CORNELL UNIVERSITY. THANKS FOR THAT PRESENTATION. WONDER IF YOU CAN COMMENT A BIT ON THE IMPACT OF INTRODUCTION OR RAMP UP OF LOW OMEGA 3 SOYBEAN OIL, AROUND 2006 TIME FRAME AND WHETHER THAT IS HELPFUL OR PLAY AD ROLE AT ALL IN THE RAPID CHANGES IN TRANSCONTENT IN NEW YORK CITY. OR -- THAT YOU DISCUSSED. IN A LOT OF TECHNOLOGY IF YOU TALK TO OIL COMPANIES THEY WERE -- THEY WERE READY AND HAVE KNOWLEDGE HOW TO THINK ABOUT DIFFERENT OIL PRODUCTION BUT REALLY THE DEMAND NEEDS TO BE THERE. THAT HADN'T OCCURRED YET FOR ANY HOST OF REASONS, I THINK THE LABELING EFFECTS IS REALLY IMPORTANT. IT'S A CALL TO SAY THERE'S AN OPPORTUNITY HERE. THAT'S WHEN BUSINESS AN GOVERNMENT WORKS WELL TOGETHER. WHEN QUEUES HOW TO SHIFT PRODUCTION IN A WAY THAT ENDS UP PROFITABLE AND ECONOMICALLY MEANINGFUL FOR INDUSTRY BUT ALSO MEANINGFUL FOR OUR POPULATION HEALTH AT LARGE SO THESE POLICIES STAKE OUT AND PROVIDE DIRECTION FOR RING UP OR DECREASING THE TOTAL ITEMS. AGAIN, THANK YOU, SONIA FOR A WONDERFUL PRESENTATION. [APPLAUSE] WE'RE SCHEDULED FOR A BREAK, WE'LL CONVENE BACK IN 15 MINUTES. AND -- AT 10:45. JOHN IS CURRENTLY IMMEDIATE PAST PRESIDENT OF THE INSTITUTE OF FOOD TECHNOLOGISTS, HE RETIRED IN 2008 AS SENIOR VICE PRESIDENT OF GLOBAL QUALITY SCIENTIFIC AFFAIRS AND NUTRITION FOR CRAFT FOODS, TO JOINING CRAFT HE WAS THE BRAND MANAGER FOR PROCTER & GAMBLE IN ENGLAND. DURING HIS 36 WITH CRAFT AND FORMER GENERAL FOODS HE WORKS IN SIX COUNTRIES AND GAINED EXPERIENCE IN PRODUCT AND PROCESS DEVELOPMENT FOR BEVERAGE, COFFEE, CONFECTIONARY DESSERTS AN MEALS. HE LED MAJOR RESEARCH PROGRAMS IN SUGAR AN SAL SUBSTITUTES, FOOD SAFETY INITIATIVES, AND GREENFIELD SITE STARTUPS. HE HAD RESEARCH DEVELOPMENT GROUPS FOR CRAFT INTERNATIONAL AND NORTH AMERICAN BUSINESSES WHERE HE SUCCESSFULLY INTEGRATED THE TECHNICAL OPERATIONS NUMEROUS ACQUISITIONS ESTABLISH GLOBAL CENTERS OF EXPERTISE, AND LED A WORLDWIDE ADVISORY COUNCIL CONSISTING OF EXTERNAL EXPERTS WHO HELPED GUIDE CRAFTS HEALTH AND WELLNESS INITIATIVES. JOHN SERVED ON THE INSTITUTE OF MEDICINE COMMITTEE ON STRATEGIES TO REDUCE SODIUM INTAKE, HE'S PAST PRESIDENT OF THE INTERNATIONAL LIFE SCIENCES INSTITUTE AND HELD MANY OTHER PROFESSIONAL POSITIONS RELATED TO FOOD SCIENCE AND TECHNOLOGY. I THINK HIS BACKGROUND, HIS WEALTH OF EXPERIENCE ARE PARTICULARLY APPROPRIATE FOR THE TOPIC WE ASKED HIM TO ADDRESS THE 2006S IN FOOD SCIENCE, TO HELPING AMERICANS ACHIEVE DIETARY GUIDELINES FUTURE OPPORTUNITIES AND CHALLENGES. JOHN. THANK YOU, BAR PROGRAM I'M VERY PLEASED TO BE HERE TODAY TO ADDRESS YOU ON CONTRIBUTIONS OF FOOD SCIENCE TO HELPING AMERICANS ACHIEVE DIETARY GOALS. I ALSO WANT TO PUBLICLY THANK THE BROAD SPECTRUM OF FOOD SCIENTISTS MEMBERS WHO PROVIDE CONTRIBUTIONS AND PARTICULARLY TO THE IFT STAFF WHO HELPED TO CONSOLIDATE THAT HOPEFULLY INTO A COHERENT UNDERSTANDABLE PRESENTATION. IFT INSTITUTE FOR TECHNOLOGISTS WAS FOUNDED IN 1939, WE'RE GOING TO CELEBRATE 75TH ANNIVERSARY IN NEW ORLEANS, I HOPE TO SEE YOU THERE. WE'RE DEDICATED TO WORKING TOGETHER TO ADVANCE THE SCIENCE OF FOOD TO THE ULTIMATE GOAL TO ENSURE A SAFE NUTRITIOUS AFFORDABLE AND ABUNDANCE FOOD SUPPLY AROUND THE WORLD. WE'RE A NON-PROFIT SOCIETY WITH 18,000 MEMBERS FROM MORE THAN 100 COUNTRIES AN WE BRING THE FOOD SCIENTIST AND TECHNOLOGISTS AND RELATED PROFESSIONALS FROM ACADEMIC, GOVERNMENT AND INDUSTRY AREAS. TODAY I WANT TO START OFF BY TALKING A LITTLE BIT BRIEFLY ABOUT THE ROLE OF FOOD SCIENCE AN TECHNOLOGY. AND THEN I WANT TO ADDRESS THE QUESTIONS THAT YOU SPECIFICALLY ASK ME ABOUT WHICH ARE IN THE AREA -- THREE AREAS OF SODIUM SUGAR AND FAT. THE FUNCTIONS THE OPPORTUNITIES AND CHALLENGES TO MANAGE AND REDUCE THOSE NUTRIENTS. BEFORE CLOSE, I WANT TO TOUCH ON THE POTENTIAL UNINTENDED CONSEQUENCES OF ACTIONS AS WELL AS THE NUTRIENT CONTRIBUTIONS FROM PROCESS FOODS AS PART OF OUR SOLUTION. THEN I WILL HOPEFULLY BE ABLE THE ANSWER YOUR QUESTIONS. I HAVE A LOT OF MATERIALS BECAUSE YOU ASKED ME A LOT OF QUESTIONS, I WON'T GO THROUGH EVERY SLIDE AND LINE, YOU HAVE THOSE IN FRONT OF YOU AND YOU CAN ASK ME QUESTIONS AT THE END. SO FOOD SCIENCE AND TECHNOLOGY. FOOD PROCESSING, SOME TALK 200 YEARS OLD,. SOME GO BACK 10,000 YEARS AND TALK ABOUT USE OF SALT AS PRESERVATIVE, THE FIRST USE. I GO BACK HALF A MILLION YEARS TO OUR ANCIENT CAVE MAN WHEN HE FIRST FOUND THAT IF YOU PUT A PIECE OF MEAT ON THE FIRE FROM THAT ANIMAL, IT WAS SAFER, MORE NUTRITIOUS AN EASIER TO DIGEST, THERE FOOD PROCESSING STARTED SO ANY FAT FOR MANY YEARS WE USE THIS TO PRESERVE FOOD TO IMPROVE THE QUALITY IMPROVE THE TASTE OF HEALTH AND WELLNESS. TODAY WE UNDERSTAND MORE ABOUT THE SCIENCE, I DON'T THINK I UNDERSTAND WHAT HE WAS DOING TO SOME DEGREE MOST PEOPLE 10,000 YEARS AGO PLANNED CROPS AND PRESERVE FOODS DIDN'T UNDERSTAND THE SCIENCE, TODAY WE DO SO WE FOCUS ON TRANSFORMING MATERIALS AND INGREDIENTS, CONSUMED ALL AROUND THE YEAR. IT SPANS THE SPECTRUM FROM FARM THROUGH TO THE MANUFACTURING THROUGH TO RETAILING. MANY USES. NOT GOING TO TO GO THROUGH EVERY ONE, A LOT RELATE TO SUBJECTS WE TALK TODAY TO ENHANCE THE NUTRITIONAL QUALITY OF THE FOOD. IT ISN'T JUST PUTTING INGREDIENTS IN, IT'S HOW DO YOU GET A NUTRIENT DELIVERY SYSTEM TO MAKE THEM EFFECTIVE. HOW TO ENSURE THEY ARE BIOAVAILABLE BUT IT ALSO INCLUDES FOOD SAFETY, ENSURING OUR FOOD IS SAFE, AND GOES ALL THE WAY THROUGH TO LOOKING AT HOW TO REDUCE LOSSES SO THAT HE CAN HAVE MORE FOOD TO EAT, INCREASE SHELF LIFE AND TRANSPORTABILITY OF FOOD. LET ME TURN TO FIRST OF OUR NUTRIENTS AND THAT'S SODIUM. YOU HEARD SOMETHING FROM DR. ANGELL ABOUT SODIUM, MY COMMENTS WILL ADD TO THAT. SODIUM IS AN ESSENTIAL NUTRIENT THAT OCCURS NATURALLY IN OUR FOODS SUCH AS MILK, BEATS AND CELERY. THE MOST COMMON USE IS SODIUM CHLORIDE AND IT IS THE PRIMARY SOURCE WE OFTEN USE SODIUM AND SALT INTERCHANGEABLY, WE NEED TO BE CAREFUL AND KNOW WE'RE TALKING ABOUT BUT CERTAINLY SODIUM AND SALT ARE THE KEY ISSUE. IT WAS ONE OF OUR EARLIEST FOOD PROCESSING TECHNOLOGIES FOR THE USE OF PRESERVING FOODS. AS WE GOT TO MORE SCIENTIFIC METHODS IN MORE RESEN TIME WE FOUND WAYS TO RELEASE IT SO THE AMOUNT OF SODIUM WAS REDUCED ONE CAN LOOK AT DATA BACK 2, 300 YEARS AGO, TECHNOLOGY PRESS VAGUE CAME INTO PLACE SUCH AS CANNING OR FREEZING RIDGE -- FRIDGE RATING. IT PROVIDES AN OPPORTUNITY TO LOOK AT REDUCING SODIUM. SODIUM AS I THINK YOU ALREADY HEARD HAS MANY DIFFERENT ROLES RANGING FROM THE MICROBIOLOGICAL SAFETY, THE KEY CRITICAL CHALLENGES IN A MINUTE IS PALATABILITY, THE BUT THE FLAVOR SALT ISN'T JUST SALTYNESS THAT MANY LIKE. IT ALLOWS YOU TO USE LESS SUGARS, YOU CAN REDUCE BITTERNESS, PLAY AS KEEL ROW IN TEXTURE MODIFYING PROTEINS IN CATEGORIES LIKE MEAT AND CHEESE. KEY ROLE IN THE STRUCTURE SO THAT MANY BAKED GOODS REQUIRE THAT SODIUM FOR STRUCTURE. AS SAID BEFORE THE FIRST USE OF PRESERVATION. SO I'M PUTTING THIS SLIDE UP FROM THE IOM REPORT THAT I SERVED ON REALLY JUST TO ILLUSTRATE THE BROAD RANGE OF FUNCTIONS THAT SODIUM PLAYS IN FOOD, FROM FLAVOR ENHANCING TO TEXTURE AS WELL AS SODIUM COMPOUNDS IN THE FOOD INDUSTRY. MORE THAN SODIUM CHLORIDE THOUGH IT IS IN SALT THE NUMBER ONE SOURCE. SOURCES OF SODIUM, ALREADY TOUCHED ON, THE BIGGEST TAKE AWAY FROM THIS SLIDE IS LOOK HOW BROAD THOSE USES ARE. I THINK THE COMMENTS ALREADY BEEN MADE, I USE THE WORD UBIQUITOUS, SODIUM IS UBIQUITOUS IN OUR FOOD SUPPLY, HAS BEEN FOR VERY LONG TIME, IT IS VERY OFTEN THEREFORE HARD FOR ANYBODY WHETHER CONSUMERS MANUFACTURERS, FOOD AWAY FROM HOME TO MAKE MAJOR REDUCTIONS BECAUSE OF UBIQUITOUS NATURE, THE OTHER THING THAT IS WORTH STRESSING IS NUMBER ONE SOURCE AN NUMBER TEN SOURCE, IF YOU ASK THE QUMES THEY REVERSE THEM. MOST TELL YOU THE NUMBER ONE SOURCE IS IN POTATO CHIP OR SALTY SNACK. THEY DON'T THINK OF BREAD, IN KNOW IT'S THE OPPOSITE WAY AROUND. A CHALLENGE BECAUSE SOURCES OF SODIUM ARE PRODUCTS THAT OTHERWISE WE MAY WANT PEOPLE TO CONSUME IN SIGNIFICANT QUANTITIES. HAVING SAID THAT THERE ARE OPPORTUNITIES, LARGEST IS MEDICINE STRAND INJURIES WAS THIS STEP WISE REDUCTION TO REDUCE SODIUM SLOWLY OVER OVER TIME, NOT NOTICED BY CONSUMERS AND DO THAT CONSISTENTLY ACROSS A BROAD RANGE OF PRODUCTS. THERE ARE SALT SUBSTITUTES THAT CAN BE USED AND AVAILABLE, THAT ARE PHYSICAL CHEMICAL METHODS OF CHANGING SALT SO IT IS MORE EFFECTIVE SO LESS SODIUM AND SALT WILL HAVE A BIGGER UP PACT. WHETHER THEY BE CRYSTAL STRUCTURES OR MICROSPHERES. I WANT TO TOUCH THE LAST TWO AREAS HERE. ONE IS THE INCREASING POTASSIUM CONTENT TO BALANCE SODIUM. THE MOST WIDELY USE SALT REPLACEMENT IS POTASSIUM CHLORIDE. AS MOST KNOW UP TO 10, 20, 30 PEST DEPENDING ON FOOD CATEGORY CAN REPLACE SODIUM CHLORIDE EFFECTIVELY. ABOVE BECOME BITTER AND UNACCEPTABLE TO PEOPLE. THE BEAUTY OF THAT IS NOT ONLY ARE YOU REDUCING SODIUM YOU'RE INCREASING POTASSIUM. AS THIS COMMITTEE IS WELL IS A MICRONUTRIENT TO MAJOR WHICH MOST HAVE A MAJOR SHORT FALL. , IF YOU CHANGE THAT RATIO YOU GET A DOUBLE BENEFIT. THAT IS A STRATEGY I HOPE YOU ENCOURAGE, ONE I ENCOURAGE DURING MY TIME IN THE INDUSTRY AND I WILL TELL YOU PERSONALLY, DON'T THINK IS WIDELY USED ENOUGH BECAUSE IT'S NOT EMPHASIZED AN PUSHED THE DOUBLE BENEFIT THAT IT CAN BE USED SO THAT'S AN AREA TO BRING TO YOUR ATTENTION. SECOND LESS OBVIOUS IS PORTION. INTERESTING STATISTIC THAT IS IN THE IOM SODIUM REPORT, THAT'S WHERE I FIRST LEARN THE DATA IS CORRELATION AMONG U.S. CONSUMERS BETWEEN SODIUM CONSUMPTION AND CALORIES IS .8, BY FAR THE LARGEST FACTOR SO IF UP TO TO RESODIUM, THE EASIEST WAY TO DO IS CONSUME LESS FOOD. BECAUSE IT'S UBIQUITOUS, IT'S NOT SURPRISING, THE OBVIOUS WHEN YOU THINK ABOUT IT BUT NOT OBVIOUS UNTIL I SAW IT MAYBE NOT TO YOU. SO WHAT DOES THAT MEAN? IN TERMS OF ITS COMPANIES, IT'S MORE PORTION SIZE, IF FOOD AWAY FROM HOME DIETARY GUIDANCE IS CALORIES. IF THE SAME THEME OF DOUBLE BENEFIT SINCE THE NUMBER BUN CONCERN GENERALLY FOR HIGH -- ONE CONCERN IS EFFECT ON BLOOD PRESSURE AND IN FACT ONE MAJOR WAY IF NOT MORE EFFECTIVE WAY IS TO REDUCE WEIGHT. THE COMBINATION OF LESS CALORIES, ANALOGOUS TO SODIUM POTASSIUM, PALATABILITY OF TASTE IS THE LARGEST. THERE IS REALLY NO SALT REPLACEMENT, THERE'S SWEETENERS THAT DO APPROXIMATE GOD JOB ABOUT CAN BE USED THERE IS NO REPLACEMENT IN SODIUM AND SALT AND MANY SCIENTISTS ME INCLUDED DON'T BELIEVE WE'LL FIND ONE THAT WILL DO THAT JOB. SO IT'S PARTIAL REPLACEMENT WITH DIFFERENT MATERIALS. THE OTHER ISSUE, THE OTHER FUNCTION SO MICROBIOLOGICAL INSTABILITY. THE FACT THAT PERHAPS THE LAST ONE WHICH IS THE POTENTIAL FOR REJECTION BY CONSUMERS. THERE ARE CASES, MANY CASES OVER 20, 30, 40 YEARS WHERE COMPANIES AND ORGANIZATIONS REDUCE SODIUM INTRODUCED LOW SODIUM PRODUCTS OR LOWER SODIUM PRODUCTS, PUBLICLY MARKETD, BASICALLY REJECTED BY CONSUMERS AND CERTAINLY IF THAT HAS BEENS, CONSUMERS DON'T BY THEIR PRODUCT AND BUY ANOTHER ONE WITH MORE SODIUM, NOT ONLY IS THAT COMPANY LOSING OUT BUT THE -- WE OTHER CERTAINLY NOT HELPING THE HEALTH OF AMERICAN CONSUMERS. DESPITE THAT, AS YOU HEARD BEFORE, FROM DR. ANGELL, FOOD MANUFACTURERS HAVE RESPONDED. AND WHETHER IT'S THROUGH THE VOLUNTARY EFFORT INITIATED BY NEW YORK STATE I REFER TO HERE, 21 COMPANIES REDUCE THE SODIUM OR IN OTHER AREAS. SO REDUCTION IN BREAKFAST CEREALS ACROSS THE BOARD 11% SO THERE ARE EFFORTS BUT IT REMAIN AS CHALLENGE. THE FINAL SODIUM IS IN TERMS OF THE BACK TO THE POINT I MADE ABOUT THE INTRODUCTION OF LOW OR NO SODIUM FOOD. BETWEEN 2005 AND 8, MORE THAN DOUBLING NUMBER OF PRODUCTS WITH CLAIMS OF SODIUM REDUCTION, SO FORTH. IN THE LAST FEW YEARS THAT DECLINED SIGNIFICANTLY. SOME I REFERRED TO BEFORE THE FACT THIS THE SALES OF THOSE DO NOT MEET EXPECTATION, THEY WERE DECLINING, LOSING SHARE TO THE ALTERNATIVES. THE OTHER THING WE SEE NOW IS THE STEALTH APPROACH, SOUNDS A LITTLE UNDERHANDED THE WORD STEALTH BUT YOU MAKE THOSE CHANGES AND YOU DON'T ADVERTISE THEM ON YOUR PACKING OR -- TASTE -- SO THAT IS GOING ON AND THAT HAS CERTAINLY BEEN PARTIALLY SUCCESSFUL BUT AGAIN RE-EMPHASIZES THAT NEED TO DO THIS, A STEP AT A TIME GRADUALLY. AND PROBABLY FIND A WAY DOING IT IN MORE UNISON BY VOLUNTARY APPROACHES OR BY MORE REGULATORY APPROACHES. SUGAR. IN SUGARS CERTAINLY IN -- OCCUR INTRINSICALLY IN FOOD, FRUCTOSE AND SUCROSE IN FRUITS, LACTOSE MANY TYPES ARE ADDED IN FOOD, FROM AGAVE TO MOLASSES. THE FUNCTIONAL PROPERTIES USUALLY DEPEND ON THE COMPOSITION OF THE INTACT SWEETENER. THE DISACCHARIDE, MONOSACCHARIDE, IN THE PRODUCT. THE MET BOLL UK PROPERTIES, THEREFORE HEALTH PROPERTIES ARE USUALLY DRIVEN BY PROPORTIONS OF THE MONOSACCHARIDE THAT REACH THE BLOODSTREAM AFTER DIGESTION. IN INTRINSIC AN ADDED SUGAR, MANY ARE SIMILAR IN TERMS OF RATIO, GLUCOSE, SWEETENERS, SO VERY OFTEN WHEN WE REFORMULATE TAKE A SUGAR OUT AND REPLACE BY ANOTHER WE MAY NOT BE DOING -- TO FOOD THAT'S SOMETHING TO BE CONSCIOUS OF. I TOUCHED ON THE POTENTIAL FOR INTENSE SWEETENERS TO REPLACE SUGAR CALORIES, CLEARLY THE FACT THEY USE LOW LEVELS MEANS EFFECTIVELY HAVE A DE FACTO ZERO CALORIES IN THE PRODUCT SO THAT IS AN EFFECTIVE WAY OF REDUCING SUGAR CONSUMPTION. SUGARS LIKE SALT ALSO HAVE A BROAD RANGE, NOT JUST A SWEET, THEY REASON THE GAMUT FROM PHYSICAL, TO MICROBIOLOGICAL TO CHEMICAL. SO FOR INSTANCE THEY USE IN FOOD FOR MANY PURPOSES INTERESTINGLY ISN'T JUST TO MAKE SOMETHING SWEET, IT'S ALSO USED FROM A TASTE POINT OF VIEW TO BALANCE THE TARTNESS AND FLAVOR ENHANCE. BUT THEY HAVE OTHER FUNCTIONAL USE, PROBABLY ONE IMPORTANT ONE IS SAFETY, AVAILABLE CONTROL, MAJOR AREA OF SCIENCE AND USE. USE FOR DEPRESSING A FREEZING POINT. FOR INSTANCE INIZE CREAM, IN MOISTURE MANAGEMENT, TO AVOID MOISTURE MIGRATION BETWEEN THEM SO SUGARS WITH THE KEY COMPONENT IN TERMS OF MANAGING THAT. PROVIDING VOLUME AND STRUCTURE IN BAKED GOODS SO BROAD RANGE USED FOR SUGARS. THE PRIMARY USES ALREADY COMMENTED OR PRIMARY OCCURRENCE OF SUGARS IN THE DIET, FROM N HAYNES IS IN THE CATEGORY CALLED SWEETS AND WITHIN THAT SWEETS, BEVERAGES, SODAS IN PARTICULAR ARE HIGHEST NUMBER HOW FAR THERE IS A SIGNIFICANT AMOUNT OF SUGARS IN THE GRAIN AND DAIRY AREA. THE OPPORTUNITIES HERE, FIRST THE SUGAR SUBSTITUTES I TALKED ABOUT, SWEETENERS TO EXPAND FOOD CHOICES HELP YOU MANAGE YOUR WEIGHT, CAN HELP BLOOD SUGAR CONTROL, CERTAINLY ALSO RELEASE POTENTIAL FOR CARRIERS. THE CHALLENGES ON SUGAR, CONSUMER ACCEPTABILITY IS CLEARLY A KEY CHALLENGE AND WHILE THERE IS AN OPPORTUNITY TO LOOK AT REDUCING SWEETENERS OVER TIME, THE STUDIES THAT HAVE BEEN DONE ON SODIUM AN SUGAR SHOW IT APPEARS MORE ACHIEVABLE IN SODIUM AND SALT REDUCTION THAN SUGAR REDUCTION PERHAPS BECAUSE AS YOU KNOW WE'RE BORN WITH INNATE DESIRE FOR SUGAR DATING BACK TO DAYS WHEN SOMETHING WAS SWEET WAS SAFE. WE'RE BORN NEITHER LIKE OUR DISLIKE OF SALT SO ABILITY TO MODIFY SALT TASTE APPEARS TO BE WORK DONE MORE MODIFIABLE BUT CERTAINLY IT IS ONE OPPORTUNITY. THE OTHER CHALLENGES REALLY RELATE TO THE OTHER FUNCTIONAL ROLES SO YOU HAVE TO CONSIDER THE SAFETY AND SHELF LIFE. LOSING MOUTH FEEL, YOU HAVE TO DO MORE THAN JUST REPLACEMENT ONE FOR ONE, LAST ONE WE'RE STRESSING CONCERNING VERY OFTEN IF YOU'RE GOING TO PLACE SUGARS WITH SOMETHING ELSE APPROXIMATE YOU HAVE TO REPLACE IT WITH PERHAPS SOMETHING FOR SWEETNESS AND BULLING AND SOMETHING FOR SOME FUNCTION, NOW YOU HAVE THREE, FOUR, FIVE SIX THINGS ON THE INGREDIENT LINE. ONE THING WE HAD TODAY IS ENVIRONMENT IN THE UNITED STATES, IF IT'S GOT SOMETHING THEY DON'T RECOGNIZE SO THE UP FAMILIARITY IS A CHALLENGE TO BOTH FOOD SCIENTIST AND INDUSTRY. TO YOU AS GROUP IN TERMS OF HELPING CONSUMERS WITH THEIR DIET. AGAIN DESPITE THIS, THERE HAS BEEN SUCCESS, IN FACT THIS IS PROBABLY ONE OF THE MOST INTERESTING ASPECTS IS THAT OVER EIGHT YEARS ALMOST A QUARTER OF ADDED SUGAR REDUCTION FROM 100-GRAMS TO 76-GRAMS, A LOT HAS BEEN DRIVEN BY THE TREND RECENTLY TO AWAY FROM SODAS, CERTAINLY THE TREND AWAY FROM SUGAR SWEETENED BEVERAGES BROADLY BUT IT IS NOT SOLERY DUE TO THAT. CERTAINLY AS I REFER HERE, THERE'S REFERENCES TO REDUCTION IN READY TO EAT CEREALS AN SUGAR REDUCTION, IT IS NOT THERE BUT CERTAINLY THAT'S A FACTOR. THERE ARE AREA, THERE IS SOME SUCCESS -- SIGNIFICANT SUCCESS I WOULD ARGUE IN TERMS OF REDUCTION THAT IS ACHIEVED. THIRD AREA, FATTY ACIDS. I THINK EVERYBODY HERE KNOWS THERE ARE SOURCE OF ENERGY AN ESSENTIAL FATTY ACID THAT AIDS IN ABSORPTION OF METABOLISM, FAT SOLUBLE VITAMINS THAT ACT AS CARRIER FOR NUTRIENTS AND DO CONTRIBUTE TO SAY TIETY IN ADDITION TO THE PROTEIN FIBER MENTIONED EARLIER TODAY. FATS AN FATTY ACIDS WE HAVE A LONG EVOLVING HISTORY OF DIETARY GUIDANCE AND INTERVENTION. IN FACT, I WOULD PROBABLY SUGGEST THAT THIS IS ONE AREA, MORE THAN ANY OTHER, WHERE FOOD SCIENTISTS AN TECHNOLOGISTS HAVE RESPONDED VERY SIGNIFICANTLY TO EVOLVING GUIDANCE. SOMETIMES HOW FAR NOT WITH THE EFFECT WE WANT TO HAVE WHICH IS A MESSAGE I WANT TO LEAVE YOU WITH, SO BACK 50 YEARS NOW, BACK TO THE SHIFT WHEN WE MOVEDDED AWAY FROM ANIMAL FAT, IT WAS INITIALLY BECAUSE OF THE CHOLESTEROL CONCERN MORE THAN ANYTHING ELSE, SO WE SHIFTED AWAY AND REFORMULATED FROM ANIMAL FATS, TO VEGETABLE FATS. THE VEGETABLE FATS WE USED PARTICULARLY WHEN WE WANTED SOLID FAT STRUCTURE THAT I'LL COME TO, WERE OFTEN CALLED TROPICAL OILS, SOME IN THE ROOM MAY REMEMBER AN INDIVIDUAL CALLED PHIL (INDISCERNIBLE) LIKE THE RALPH NADER OF THE FOOD INDUSTRY WHO SINGLE HANDEDLY RAN A CAMPAIGN BUT LED THE FOOD INDUSTRY IN THE '80s TO REFORMULATE TAKE OUT OILS SATURATED FAT BECAUSE OF CONCERN OF SATURATED FAT. I THINK Y'ALL KNOW THE ANSWER THAT THAT WAS -- THEY WERE REFORMULATED WITH THE PARTIALLY HYDROGENATD VEGETABLE OILS WHICH AT THE TIME THE SCIENTIFIC INDICATED NO EFFECT ON CHOLESTEROL. SO SOME DEGREE WE MOVED -- A LARGE DEGREE WE MOVEED FROM THE FRYING PAN INTO THE FIRE IN THAT RESPECT. AS YOU KNOW AND HEARD FROM DR. ANGELL BEFORE, THERE HAS BEEN NOW, I'LL COMPLIMENT THAT A SIGNIFICANT EFFORT TO NOW REPLACE THOSE TRANSFATTY ACIDS FROM PARTIALLY HYDROGENATED VEGETABLE OIL. CAUTION HERE IS OFTEN THEY'RE REPLACED WITH SATURATED FAT. THE DATA DR. ANGELL SHARED FROM NEW YORK WAS ENCOURAGING, NOT SEEN THAT. I DON'T HAVE THE DATA ACROSS THE FOOD INDUSTRY BUT I KNOW AND YOU CAN TELL BY LOOKING AT INGREDIENT LIST IN MANY CASES THE REPLACEMENT WAS TO REPLACE TRANSFATTY ACID WITH SIGNIFICANT SATURATED FAT WHICH MAY OR MAY NOT DEPENDING O LEVEL HAVING THE EFFECT WE WE WANTTOR PUBLIC HEALTH SO CAUTION IN TERMS OF SHIFTING OF ADVICE AND THE SORT OF UNINTENDED CONSEQUENCES I'LL COME BACK TO. ONE OTHER THING I MENTION HERE IS SHIFT MORE RERECENTLY ENHANCED BY AVAILABILITY OF NEWER OILS THAT I WILL TOUCH ON IS FROM TROPICAL OIL TO FATS MONOSATURATED. A NUMBER OF MOVEMENTS IN RESPONSE TO DIETARY GUY LINES. THE FOLKS -- FAT LOOK SALT, LIKE ARE VERY BROAD, ACROSS FOR STABLE TEXTURE AND STABILITY. THE CHEMISTRY OF THE FATTY ACID COMPOSITION IS WHAT CREATES THE DISTINCTIVE FUNCTIONAL ROLE. UNFORTUNATELY THAT SAME CHEMISTRY IN FATTY ACIDS IS THAT WHICH WE BELIEVE AFFECTS NUTRITION AND HEALTH OUTCOMES SO TO SOME DEGREE SOME OF THE NOVEL INNOVATIONS THAT I'LL TOUCH ON ON FATS AN OILS ARE HELPING US NO QUESTION THEY ARE, THEY DONE TOTALLY SOLVE THE PROBLEM BECAUSE OFTEN IT'S THE FATTY ACID COMPOSITION, WE'RE LOOKING FOR MONOSATURATED AND POLYUNSATURATED FATS AND THEY DON'T HAVE THE FUNCTIONS WE WANT SO YOU CAN'T DISENGAGE THE HEALTH BENEFIT FROM THE FUNCTION. HAVING SAID THAT, THERE ARE CERTAINLY OPPORTUNITIES IN THIS AREA. AND ADVANCES TAKEN IN FOOD SCIENCE AND AGRICULTURE SIGNIFICANT PROVIDING ALTERNATE OIL SOURCES SUCH AS SUNFLOWER, CANOLA AND SOYBEAN AND CHANGEED THAT FATTY ACID COMPOSITION, AS TOUCHED ON, WE HAVE FATS THAT ARE LOW IN SATURATED FATTY ACIDS AND THOSE HIGH IN MONOUNSATURATED OMEGA 3 AND SO FORTH, THESE ARE DONE AND MADE A BENEFIT TO IMPROVE FLAVOR STABILITY THAT YOU NEED AND USED TO IMPROVE THE HEAT AND OXIDATIVE STABILITY AND PROVIDE STORAGE. THERE ARE SERIES OF INNOVATIONS, THESE ARE THE SLIDES I'M GOING TO HEADLINE AND GO THROUGH, (INDISCERNIBLE) IS ONE OF THOSE USED TO REMOVE TRANSFATTY ACIDS. GENERAL IT CANNILY ENHANCED SOYBEAN OIL, HIGH OLAY CANOLA OIL AS WELL AS SUNFLOWER AND SOYBEAN AND AT THE BOTTOM FROM, THE HIGH OILS. I THINK THE QUESTION WAS A QUESTION EARLIER IN TERMS OF THE HIGH LA SOYBEAN WHICH IS CERTAINLY MAJOR PORTION TO INCREASE THAT TO BE OVER A THIRD CRUSH BY 2023 AS WELL AS OTHER TODAY MUCH SMALLER OILS SUCH AS FLAXSEED, WORK ON SATISFY FLOWER AND SO FORTH. SIGNIFICANT INCREASE IN THE USE OF OMEGA 3. VALUES OF THOSE. AS WELL AS -- BECAUSE OF HIGH OIL CONTENT, SO MANY DIFFERENT AREAS OF INN INVESTIGATION GOING ON ACROSS THE WHOLE SUPPLY CHAIN OIL WHICH AS I HAVE SAID DO PROVIDE A BENCH BUT DON'T NECESSARILY TAKE THE CHALLENGES AWAY. THAT RE-EMPHASIZE IT IS POINT I MAKE, THE HEALTHY OILS ARE LESS STABLE BECAUSE OF THE UNSATURATED FAT CONTENT SO YOU HAVE THE ISSUE OF STABILITY WHETHER COOKING OR PROCESSING AND YOU HAVE THE STABILITY FOR PRODUCTS PACKAGE FOODS, WHETHER THEY BE REFRIGERATED OVER WEEKS AND MONTHS. THE SECOND ONE IS THAT MANY OF THE USES THAT WERE ORIGINALLY USED ANIMAL FATS, TROPICAL OILS WHICH ARE REQUIRED FOR SOLID FAT, THE SOLID FAT IS THERE BECAUSE YOU NEED STRUCTURE. SO FOR INSTANCE IN THINGS LIKE COOKIES YOU NEED THAT STRUCTURE SO TO ABLE TO REMOVE ALL THOSE FATS IS NOT THERE. YOU CAN REDUCE WITH SOME OF THE TECHNOLOGIES. THERE ARE CHALLENGES, I'M CONFIDENT WE WILL MAKE PROGRESS THERE BUT ENCOUNTER TASTE CHALLENGES BECAUSE OF THE INHERENT INSTABILITY. THE LAST POINT THERE IS OF ALL THE REFORMULATIONS THAT I HAVE BEEN TOUCHING ON, WHETHER IT BE SODIUM, WHETHER IT BE SUGARS, OR THIS IN THE FATS AND OIL, THE FAT AN OIL ONE IS FREQUENTLY MOST COMPLICATED HIGHEST COST, AN EXAMPLE IN A MINUTE. AGAIN AN EXAMPLE OF THE EFFORTS THAT HAVE GONE ON, FOOD COMPANIES CERTAINLY RESPONDED TO THE DIETARY GUIDELINES AND IN PARTICULAR SINCE 2003, REGULATIONS ON LABELING HAVE HAD APPROXIMATE IMPACT, YOU HAVE A THREE QUARTER REDUCTION OF THE TRANSFAT SO THAT IS VERY, VERY SIGNIFICANT EFFORT. AS I SAID BEFORE IN SOME WAYS CASES THE SATURATED FAT IS ABOUT AS MUCH AS REMOVED IN SOME CASES MORE, IN SOME IT'S LESS. I THINK ONE OF THE THINGS THE DATA DR. ANGELL WAS SHOWING WOULD BE INTERESTING TO LOOK AT THAT MORE BROADLY. I TOUCHED BEFORE ABOUT COST, THIS IS ONE EXAMPLE, WE PROVIDE REFERENCES TO VIRTUALLY EVERYTHING, THIS IS FROM MY FORMER COMPANY SOY KNOW IT PERSONALLY THOUGH THE QUOTE WAS NOT ME, IT WAS MY SUCCESSOR BUT THE PRODUCTS MY FORMER COMPANY REFORMULATED OVER A TWO YEAR PERIOD TOOK 100,000 MAN HOURS. AT THE TIMEK TELL YOU THAT WAS ABOUT $12 MILLION OF MAN POWER TIME. THAT EXCLUDED CONSUMER TESTING, LABEL CHANGES, SO FORTH THAT'S ONE COMPANY, ONE REFORMULATION. SO SOMETIMES WHEN YOU HEAR THIS IS EASY TO DO, COMPANIES AREN'T TRYING, COMPANIES ARE TRYING, REMEMBER THAT NUMBER BUZZ BECAUSE THAT ILLUSTRATES THE EFFORT THAT HAVE GONE INTO THAT. WAS A VERY SIGNIFICANT PART OF THE R&D BUDGET OF THAT COMPANY OVER A COUPLE OF YEARS TIME. SO CERTAINLY EFFORTS ARE CONTINUING TO REDUCE FAT AND TRENDS WHICH IS WHAT WE WANT TO DO IN COMBINATION. BEFORE I FINISH, I DID WANT TO SORT OF FOCUS OR JUST MAKE A COUPLE OF COMMENTS, ONE IS ON WHAT I CALL THE UNINTENDED CONSEQUENCES OF FOCUSING ON A SINGLE NUTRIENT. WHAT YOU CAN TALKING ABOUT AND RESPONDING TO, WHAT'S GONE ON IN SUGAR, SODIUM AN FAT. EVERYONE HAS GIVEN YOU EXAMPLES OF THAT. BUT ANOTHER EXAMPLE GO BACK PROBABLY 30 YEARS IS WHEN THE EFFORTS STARTED TO REDUCE THE FAT IN THE DIET WHEN PEOPLE PRODUCE LOW PHAT DIET, LOW FAT PRODUCTS, ONE OF THE PRODUCTS IS A PRODUCT CALLED SNACK WELLS BY NABISCO AND GAVE RISE TO A PHRASE THAT'S OFTEN USED, THE SNACK WELL EFFECTS AND THE THEORY GOES THAT BECAUSE PEOPLE HAVE THIS LOW FAT SNACK WELLS THEY ARE ATE MORE OF THOSE OR MR. CXFC LIKELY ATE MORE FOOD IN GENERAL. CERTAINLY IT WOULD APPEAR, THAT THE INTRODUCTION OF LOW FAT PRODUCTS IS -- IN THEORY AND PRACTICE THE CALORIES ARE LESS BUT NOT LESS IF YOU EAT MORE. THAT IS ONE OF THE UNINTENDED CONSEQUENCES ONE HAS TO THINK ABOUT WHEN YOU MAKE A CHANGE. I HAVE TOUCHED BEFORE REFORMULATION FROM SATURATED FATS TO TROPICAL OILS TO PARTIALLY HYDROGENAT AND BACK AGAIN AND SO FORTH. SOME DEGREE I LIKEN THIS TO -- YOU WHACK -- TO WHACK A MOLE. YOU WHACK ONE ON THE HEAD AND UP COMES ANOTHER ONE. SOME DEGREE WE COLLECTIVELY THOSE IN THE ROOM AND RESPONDING HAVE BEEN GUILTY OF THAT SO WE HAVE TO THINK CAREFULLY ABOUT THAT. IN THE CASE OF SODIUM, COUPLE OF OBSERVATIONS, ONE AS YOU HEARD BEFORE THE UK WAS PROBABLY THE MOST AGGRESSIVE COMPANY, FINLAND TOO BUT UK IS ONE OF THE MOST AGGRESSIVE COMPANIES IN THE -- COUNTRIES IN THE WORLD ON REDUCTION, TO A POINT WHERE WHILE OUR EFFORT IS VOLUNTARY, I CAN TELL YOU AS A BRITT AND HAVING BEEN INVOLVED IN THAT IS FROM A FOOD INDUSTRY POINT OF VIEW, IT WAS ALMOST NOT VOLUNTARY. IF YOU DIDN'T BEHAVE YOU WERE IN THE NEWSPAPER IN A WAY YOU TIN WANT TO BE. THAT ALLOWED SOME COMPANIES TO OVERREACH. WHILE COMPANIES HERE IN THE UNITED STATES OVERREACH BY GOING TOO LOW IN SODIUM AND HAVING TO BACK OFF, AT LEAST AT LEAST IN SOME CASES I'M AWARE OF COMPANIES GOT O A POINT THEY SAID BOY, WE NEED TO PUT MORE SODIUM BACK IN BECAUSE OF SAFETY. SO AGAIN, HAVE TO BE CAREFUL. THE BIG CHALLENGE IN THE SODIUM REDUCTION IS WHEN ONE COMPANY REDUCE IT IS SODIUM, THERE ARE MANY CASES I WON'T, WHERE THEY'RE PUBLIC PRODUCED LOW SODIUM VARIANTS OR REDUCED SODIUM AND WHAT HAPPENED IS THEIR CELLS DECLINED, COMPETITORS HAVE GONE UP AND ASIDE FROM THE IMPACT ON THEIR BUSINESS WE CERTAINLY DONE NO HELP TO THE HEALTH OF CONSUMERS AN MAYBE MAKING IT WORSE BY CHOICESTHEY EAR MAKING. SUGARS AGAIN, PROBABLY LONG LIST HERE BECAUSE OF THE NATURE OF THE SUGARS WHEN YOU MAKE A PRERE PLACEMENT YOU HAVE INGREDIENT SUBSTITUTION IF BY OTHER CARBOHYDRATES IT WILL HAVE THE SAME NUMBER OF CALORIES BUT THERE ARE INSTANCES WHERE IT MAY HAVE HIGHER CALORIES IN THE SAME WAY WHEN THERE WAS A PUSH TO LOW FAT THERE WAS NO CAR CARBOHYDRATE. WHEN YOU TAKE CARBOHYDRATE IS WHERE THE FAT COMES OUT SO YOU MAY END UP WITH MORE CALORIE, YOU NEED TO BE CONSCIOUS THE THAT. THAT RELATES TO THE SECOND BULLET. THE THIRD BULLET RELATES TO THE FACT THAT WE NEED TO THINK HARD BE CAREFUL TO THE PALATABILITY WHICH MAY LEAD ROW CONSUMPTION OF FOODS WE DO WAN THEM TO EAT MORE OF. SOME MAY HAVE THE WILL POWER TO EAT THINGS THAT HAVE NO SWEETNESS OR SUGAR. I DON'T. I THINK MOST CONSUMER ALSO GO AWAY AND NOT CONSUME THE PRODUCT UNLESS IT HAS THAT INNATE SWEETNESS. IN FACT THE NEXT EXAMPLE IS ONE OF THOSE POPULATION WE'RE CONCERNED ABOUT. OUR KIDS TODAY DON'T DRINK PLAIN MILK, THEY DRINK FLAVORED MILK, WE HAVE TO HAVE SUGAR OR ARTIFICIAL SWEETENERS IN IT. THE WELL INTENTIONED I KNOW EFFORTS OF LOCAL SCHOOL AUTHORITIES TRIED TO REMOVE THAT, LESS CONSUMPTION OF MILK SO CAUGHTS OF UNINTENDED CONSEQUENCES. FINALLY, THE CHALLENGE OF ADDED SUGAR, I KNOW THERE'S A QUESTION EARLIER, I WILL WILL ADDRESS THAT, AS A SCIENTIST I STRUCK WITH THE CONCEPT THERE'S DIFFERENCE BETWEEN SUGAR I ADD AND SUGAR THAT CAME SOMEWHERE ELSE. WE CAN GO INTO THAT IF WE NEED TO LATER. BUT WHAT I WILL TELL YOU IS THAT WE NEED TO BE CAREFUL, WE DON'T WANT TO ADD TO INCREDIBLE CONFUSION WE HAVE TODAY WITH CONSUMERS. CONSUMERS TODAY'S LABEL WE NEED TO FIGURE OUT HOW THE MAKE OUT SIMPLER, NOT MORE COMPLICATED. WE NEED TO FIND WAYS TO COMBAT MANY MESSAGES CONSUMERS ARE READING AND HEARING TODAY, WHETHER INTERNET FOOD SHOWS OR TV. ADVICE THAT IS BEST ILL INTENTIONED AND SOMETIMES PLAIN WRONG. AND ONE THING IF WE'RE NOT CAREFUL WILL LEAD PEOPLE TO CONCLUSION THERE'S SOMETHING BAD ABOUT SUGAR PER SE, WHICH I THINK AS WE ALL KNOW IS NOT TRUE, THERE ARE CONCERNS ABOUT LEVEL OF CONSUMPTION. BEFORE I CLOSE A COUPLE OF SLIDES ABOUT PACKAGED AND PROCESSED FOODS. I DO MISS PERHAPS BUILDING ON THE LAST COMMENT AS WELL AS COMMENTS BEFORE ABOUT CONFUSION OF CONSUMERS AND COMMENTS, HE'S VERY MUCH IN VOGUE AND I SAW AS I WAS SCANNING PUBLIC COMMENTS THAT YOU RECEIVE FOR THIS COMMITTEE, SOME FAIRLY I DON'T THINK THEY HAVE SCIENTIFIC CREDIBILITY BUT FAIR THROUGH AGGRESSIVE STATEMENTS, I HATE TO -- IN THE MEDIA YOU NEVER REPEAT SOMETHING NEGATIVE SO I'LL BREAK THAT RULE BUT PEOPLE TALK THE BEST WAY TO EAT BETTER IS AVOID PROCESSED FOODS. PROCESSED FOODS ARE BAD FOR YOU. THEY USE JUNK FOOD AND THEN IMMEDIATELY MEAN ALL PROCESSED FOODS. THE FACT IS, THAT IS JUST PLAIN WRONG. UP UNTIL RECENTLY I DON'T THINK WE HAVE HAD MUCH SCIENCE TO PROVE THAT. THESE THREE ARE STUDIES I HAVE BEEN INVOLVED WITH OTHER ORGANIZE, MANY DIETARY GROUPS. PROBABLY THE MOST IMPORTANT IS THE FIRST ONE, THE ONE THAT I USED IN MEETINGS QUITE OFTEN, WHAT THIS GROUP DID IS TOOK CONTRIBUTIONS FROM N HAYNES, TO THE AMERICAN DIET AND DID A CORRELATION OF THAT AGAINST THE LEVEL OF PROCESSING. HOW DO YOU DEFINE LEVEL OF PROSETSING BUT WHAT THEY DID WAS REASONABLE CONCLUSION. WAS A REASONABLE ASSESSMENT AND THE CONCLUSION WAS THAT IT WAS A DETERRENT, MINOR DETERRENT, VIRTUALLY NOT A FACTOR. THAT SURPRISED MANY PEOPLE, I SUSPECT PRICE MANY IN THIS ROOM, IT DIDN'T SURPRISE ME, I KNOW MANY COLLEAGUES NEED SCIENCE AND INDUSTRY, HAVE THEMSELVES FELT THAT THAT WAS PROBABLY TRUE. IT'S EASY TO GET CAUGHT UP WITH THAT BECAUSE YOU LOOK AT THE EXAMPLE THAT WE LOVE TO PICK. THOSE BAD EXAMPLES OF THINGS WE SHOULDN'T EAT TOO MUCH OF OR TOO OFTEN BUT IT DOESN'T BARE OUT AND THE OTHER TWO PAPERS I THINK ADD TO THIS IN TERMS OF CONTRIBUTIONS IN TERMS OF VITAMINS MINERALS AND OTHER THINGS TO FOCUS ON. ONE LAST SLIDE BEFORE SUMMARY. THIS ONE THERE AREN'T REFERENCES FOR BECAUSE I HAVE HEADED UP ADDITIONAL THOUGHTS FROM MY HEAD SO THE REFERENCE IS MY EXPERIENCE T. FIRST ONE MAY SOUND CHALLENGING BUT I THINK IT'S -- IT'S SOBERING, IT'S SAD BUT SOBERING TO THINK THAT 30 YEARS OF DIETARY ADVICE MINIMAL EFFECT ON OBESITY AND FOOD RELATED DISEASE IN THE UNITED STATES. SO WE HAVE A MAJOR CHALLENGE SO WE HAVE TO THINK VERY HARD ABOUT WHAT WE'RE SAYING, HOW WE SAY IT AN WHO WE'RE SAYING IT TO BECAUSE WE WANT TO MAKE A DIFFERENCE. THE AREA I WOULD SUGGESTION TO BE CAUTIOUS OF, THAT WAS PART OF MY COMMENTS UNINTENDD CONSEQUENCES IS FOCUS OPTION THE SINGLE NUTRIENT, THE WHACK A MOLE EXAMPLE. ALSO AVOIDING X. I THINK THE PROBLEM IS WHEN WE SAY AVOID X THAT'S FINE BUT IF WE GO TO Y WHICH IS BAD OR WORSE WE'LL HAVE BIGGER PROBLEM SO IT LEADS TO CONSUMPTION OF MACRO KNEW TREATMENTS OR MICRONUTRIENTS OF CONCERN. CERTAINLY ONE EXPERIENCE THAT I HAD OVER MANY YEARS IS CONSUMERS RESPOND BETTER TO POSITIVE MESSAGES SO THE MESSAGES ALREADY IN THE EXISTING DIETARY GUIDELINES, BUT APPEAR IN THE LATER CHAPTER, IT'S LESS CALORIES, ABSOLUTELY. THAT IS AVOID X, Y, Z, AND THEY EAT MORE A, B, C. AND ONE SUGGESTION I WOULD HUMBLY SUGGEST IS THINK MORE ABOUT SWITCHING THAT AROUND AND TALK ABOUT THE NEED TO EAT MORE COMPLEX CARBOHYDRATES. WHOLE GRAINS, FIBER VERSUS SUGARS. I DON'T SAY ADDED SUGARS, I SAY SUGARS. PERHAPS CONTROVERSIAL TO SOME BUT I WILL ARGUE IF YOU WANT TO MAKE OR CONTINUE TO MAKE DIFFERENCES IN OUR SUGAR CONSUMPTION, PARTICULARLY IN THE AREA OF BEVERAGES, DIET BEVERAGES IS ONE VERY PALATABLE, VERY -- WHAT I USE A LOT -- A LOT DO BUT IT'S GOT MIXED PERCEPTIONS. THERE'S CONSUMERS OUT THERE WHO WORRY ABOUT THE SAFETY, IT'S INTENDED AS MUCH AS IT SHOULD SO THERE'S ANOTHER THING TO CONSIDER. I TALKED IN THE AREA OF SODIUM ABOUT THE DOUBLE WIN OF MORE POTASSIUM VERSUS SODIUM. THAT'S A HARD MESSAGE THE TO CONVEY BUT IF YOU CAN GET PEOPLE TO THINK ABOUT CONSUMING MORE TOES THAT YUM AS WELL AS LESS SODIUM I THINK WE WILL BE MORE SUCCESSFUL. AND IN THE FACTS I RAISE AS CAN. IN SUMMARY, FOOD SCIENCE OPERATES ACROSS A COMPLEX FARM TO FORK SYSTEM. FOOD TECHNOLOGISTS CERTAINLY HAVE STRIVEN OVER YEARS CONTINUE TO STRIVE TO HELP AMERICANS ACHIEVE THE DIETARY GUIDELINES AND THE DIETARY RECOMMENDATION TO IMPROVE HEALTH. FOOD INDUSTRY ASPECTS HAVE BEEN SUCCESSFUL IN ALL THE AREAS WE TALKED ABOUT, CALORIES, SODIUM, SUGAR, SATURATED FAT AN TRANSFAT. YES, NOT AS SUCCESSFUL AS SOME WOULD LIKE, NOT AS FAST AS -- SUCCESSFUL AND WE'LL CONTINUE TO BE SUCCESSFUL I THINK IF WE CONTINUE TO FOCUS IN THAT AREA. FINALLY, MY LAST POINT, IT MAY BE MORE PRODUCTIVE TO TALK CONSUMERS, THE NUTRIENT CONTRIBUTIONS IN FOOD. OPPOSED TO MAKING COMMENTS OR CHOICES ON SORT OF LIMITING PROCESS FOODS OR LIMITING X AND Y. WITH THAT I WOULD BE HAPPY TO ANSWER YOUR QUESTIONS. [APPLAUSE] THANK YOU FOR THAT QUITE ILLUMINATING TALK. THIS IS ALAN (INAUDIBLE) TUFTS UNIVERSITY. COMMENT MORE ABOUT THE FUNCTIONAL CHARACTERISTICS OF SALT SUBSTITUTE? I THINK WE UNDERSTAND SODIUM CHLORIDE HAS IN VARIOUS FOODS BUT FOR SOMETHING SAY PROTEIN STRUCTURE, POTASSIUM CHLORIDE, DO THEY HAVE THE SAME CHEMICAL PROPERTY? THERE IS ALWAYS ALMOST ALWAYS A SUBSTITUTE THAT CAN BE USED FOR THOSE OTHER FUNCTIONAL PROPERTIES BUT AGAIN, YOU RUN INTO THE SAME PROBLEM PARTICULARLY WHEN POTASSIUM IS ONE, PROBABLY THE FIRST PEOPLE REACH FOR OFF THE BENCH OR SHELF. TO ELIMINATE BITTERNESS SO IF YOU HAVE A PRODUCT LIKE A CURED MEAT WHERE YOU HAVE SODIUM CHLORIDE AND SODIUM NITRITE AND SODIUM LACTATE WHICH USED TO BE VERY COMMON, IF IF YOU TRY AND REPLACE ALL THREE OF THOSE WITH THE POTASSIUM SALT, IT WILL BE TOTAL HI UNACCEPTABLE SO YOU GET TO THE SAME CHALLENGES, BUT CERTAINLY WHETHER POTASSIUM AMMONIUM SALT, SOME CASES THERE ARE -- I DIDN'T INCLUDE IT BUT SOME CASES THEY ARE GOING TO BE PROBABLY SOME -- NEED SOME NEED FOR NEW APPROVALS FOR ADDITIVES FOR USES OF ADDITIVES BECAUSE THERE ARE SOME SALTS WHICH I THINK IN OTHER APPLICATIONS ARE SAFE, AREN'T -- THERE ARE CHOICES BUT COMPLEXITY DIFFERENT FUNCTIONS LIMIT THE ABILITY TO MAKE THE MAJOR REDUCTION. THE SODIUM CHLORIDE IS STILL, SALT IS BY FAR LARGEST SO YOU FACE WITH TASTE CHALLENGES THAT I ALLUDED TO. CHERYL. CHERYL ANDERSON. JOHN, THANK YOU FOR YOUR PRESENTATION. YOU MENTIONED THE UNINTENDED CONSEQUENCES THAT MIGHT BE ASSOCIATED WITH THAT. WOULD YOU COMMENT ON STRATEGIES WILL CONSIDER AT THE COMMITTEE TO FOCUS ON GUIDING PRINCIPLE OF WHAT WORKS, PRINCIPLES AROUND CONSUMING HEALTHY PATTERNS AND HOW WE COMMUNICATE WITH FOOD TECHNOLOGISTS AND INDUSTRY PARTNERS AROUND HEALTHY PATTERN APPROACH OPPOSED TO HERE NEEDING TO FOCUS ON X NUTRIENT OR X I DO TEAR COMPONENT, EVEN THOUGH WE HAVE IDENTIFIED WHAT THOSE COMPONENTS ARE. I MEAN, I THINK YOUR QUESTION IS A GREAT ONE, AND IN FACT I WAS ALMOST GOING TO SORT OF INCLUDE IT BUT AS YOU CAN SEE I HAVE MORE MATERIALS THAT I EVEN COULD MANAGE TO GET THROUGH IN THE TIME I ACTUALLY THINK YOU ALMOST ANSWER THE QUESTION YOURSELF. I DO THINK THERE IS AN OPPORTUNITY, I WILL CERTAINLY ENCOURAGE THIS PANEL, THIS COMMITTEE TO REACH OUT TO PERHAPS THE APPROPRIATE SORT OF EXPERTISE IN FOOD PROCESSING BECAUSE THERE IS A LOT OF EXPERIENCE WHAT CONSUMERS RESPOND TO. CLEARLY PART -- KEY PART OF THIS COMMITTEE'S JOB ISN'T JUST TO SAY GUIDELINES RIGHT BUT HOW DO WE HAVE SOME GUIDELINES THAT AFFECT CHANGE, HOW DO WE COMMUNICATE THE GUIDELINES AND THERE'S A REAL OPPORTUNITY THE GET COUNSEL ADVICE FROM EXPERTS WHO SPENT THEIR CAREERS FIGURING OUT HOW TO GET MESSAGING OUT. I THINK IT IS DONE IN THE RIGHT WAY AND CONSTRUCTIVE WAY, I THINK IT WILL BE POSITIVE. I THINK THERE IS A TENDENCY VERY OFTEN FOR THIS TO BE A LESS THAN POSITIVE RELATIONSHIP. THERE IS A TENDENCY TO BE A -- I THINK IF THAT APPROACH IS DONE TO THE RIGHT PEOPLE IN THE RIGHT WAY YOU FIND RESPONSIVENESS AND YOU CAN HAVE BROADER BENEFITS ALONG THE LINES YOU ALLUDE TO. SO I WOULD CERTAINLY REACH OUT THERE. MY MESSAGE TODAY WOULD BE A, REACH OUT AND TWO, LOOK AT THOSE WAYS TO TALK THE POSITIVES, TALK THE DO THIS RATHER THAN THAT, TALK IN TERMS OF FOODS THAT PEOPLE REGULARLY EAT. I OBVIOUSLY -- NOT OBVIOUSLY BUT I READ THE WHOLE -- THE PUBLIC GUIDELINE ABOUT A WEEK AFTER COUPLE OF DAYS AFTER I WAS IS ASKED TO SPEAK, I WANT TO READ AND REMIND MYSELF, I READ IT. DONE DISAGREE WITH ANYTHING, I MEAN, IT'S ALL -- BUT THEN I LOOKED AT THE ADVICE, IT WAS PROBABLY GOOD THE WAY PEOPLE ATE 20 YEARS AGO BUT IT'S NOT THE WAY -- SOME OF THAT ADVICE ISN'T THE WAY PEOPLE EAT TODAY. THEY -- PEOPLE GO EAT, THEY BUY THINGS FROM A VENDING MACHINE OR 7 ELEVEN OR FROM A RESTAURANT OR GRAB SOMETHING AND PUT IT TOGETHER BECAUSE MOST DON'T SPEND MUCH TIME BUYING THE FOOD PUTTING THE MEAL TOGETHER AND COOKING, WITH BUYING PRE-MADE COMPONENTS. SOMETIMES I THOUGHT THE ACTUAL WAY WHICH THE FOODS WERE EXPRESSED WOULD ALWAYS IN THE WAY WHICH COULD BE HELPFUL TO CONSUMERS SO I THINK LOOKING HARD AT HOW WE CAN COMMUNICATE THAT MESSAGE, ISN'T JUST THE MESSAGE I THINK YOU ALL RECOGNIZE HOW IT'S COMMUNICATED. IT'S REAL OPPORTUNITY THERE. OUR TIME IS REALLY LIMITED AND WE HAVE GOT A PACKED AFTERNOON SO I'M GOING TO STOP THE QUESTIONS THERE AND ENCOURAGE PANEL MEMBERS WHO MAY HAVE QUESTIONS TO SEE IF JUST AFTER WE DISMISS YOU MIGHT TALK WITH JOHN ABOUT THOSE QUESTIONS. BUT AGAIN, THANK YOU VERY MUCH. [APPLAUSE] SO THIS ENDS OUR MORNING SESSION. THANK YOU, AGAIN, TO OUR SPEAKERS WHO HAVE PROVIDED WONDERFUL ADDITIONAL BACKGROUND INFORMATION TO THE GROUP. WE ARE DISMISSING FOR LUNCH, WE WILL BE BACK HERE AT 12:15 SHARP. THANKS VERY MUCH. WELCOME BACK, EVERYONE. MY NAME IS BARBARA MILLEN, CHAIR OF THE DIETARY GUIDELINES COMMITTEE, 2015 MY PLEASURE TO WELCOME EVERYONE BACK O THE AFTERNOON SESSION. THE FIRST OPPORTUNITY FOR THE COMMITTEE TO HEAR THE PROGRESS MADE SINCE OUR LAST PUBLIC HEARING WILL BE HEARING REPORTS FROM EACH OF THE FIVE SUBCOMITTEES OF THE ADVISORY COMMITTEE. I WILL BEGIN WITH A FEW CONTEXTUAL COMMENTS FOR THE WORK THAT HAS BEEN ONGOING. THEN I'LL ALSO PRESENT A BIT OF BACKGROUND INFORMATION COMMON TO EACH OF THE SUBCOMITTEES APPROACH AND PROCESS TO THEIR RESEARCH QUESTIONS. FIRST LET ME BEGIN WITH BY REITERATING THAT THE 2015 DIETARY GUIDELINES ADVISORY COMMITTEE PROVIDES SCIENCE BASED RECOMMENDATIONS FEDERAL GOVERNMENT HOW FOOD NUTRITION AND PHYSICAL ACTIVITY CAN PROMOTE THE HEALTH OF THE U.S. POPULATION. AND REDUCE BURDEN FOR MAJOR CHRONIC DISEASES AND OTHER LIFESTYLE RELATED HEALTH PROBLEMS. WE'RE MANDATED BY CONGRESS TO PRODUCE A SCIENCE-BASED EVIDENCE BASED REPORT CONSIDERING UPDATES THAT MAYBE NEEDED FROM THE 2010 GUIDELINES AND THEN EXPLORING NEW AREAS BASED ON EXPERT EVIDENCE. WE WILL REPORT BACK TO SECTIONS OF HEALTH AND HUMAN SERVICES AND U.S. DEPARTMENT OF AGRICULTURE IN OUR 2015 REPORT WHICH SERVES AS THE FOUNDATION FOR PUBLIC POLICY IN FOOD NUTRITION PHYSICAL ACTIVITY IN HEALTH RELATED AREAS. WE WERE CHALLENGE AND ENCOURAGED BY DR. MICHAEL MCGIN IN THIS FROM THE INSTITUTE OF MEDICINE IN JANUARY MEETING TO CONSIDER THE U.S. DIETARY GUIDELINES FOR AMERICANS SHOULD OFFER THE REFERENCE POINT FOR ALL FOOD AND NUTRITION POLICY ACTIVITIES. THE ANCHOR FROM WHICH ALL POLICY SHOULD EMANATE. WE SHOULD BE THE BEACON, THE CAR THE ADVOCATE FOR PROGRAMS THAT ARE STRONGLY EVIDENCE BASE AND INNOVATIVE AS POSSIBLE. AND POTENTIAL IMPACT IS VAST WHEN WE CONSIDER THE PROGRAMS, SERVICES AND ACTIVITIES AND RESEARCH THAT ARE SUPPORTED BY THE U.S. DEPARTMENT OF AGRICULTURE, FROM OUR FOOD PROGRAMS WIC SNAP AND SO FORTH, AND SERVICES THAT ARE UNDER THE JURISDICTION OF HEALTH AND HUMAN SERVICES INCLUDING THE CENTER FOR DISEASE CONTROL, THE NATIONAL INSTITUTES OF HEALTH, THE U.S. HEALTHCARE SYSTEM AS WELL AS THE PUBLIC HEALTH SYSTEM, POTENTIAL IMPACT OF POLICY RECOMMENDATIONS THAT EMANATE FROM OUR REPORT, ARE CONSIDERABLE. IN ADDITION TO THE IMPACT ON PROGRAMS AND SERVICES WITHIN THE FEDERAL AGENCIES AND THEIR COUNTER PARTS THAT THE STATE AND LOCAL LEVEL, WE ALSO HAVE THE OPPORTUNITY TO INFLUENCE THE PUBLIC PRIVATE PARTNERSHIPS IN DIVERSE SETTING AND NOT ONLY THOSE THAT INFLUENCE CHILDREN BUT IN INFLUENCE MIDDLE AGED AND OLDER ADULTS AND ALSO MANY, MANY DISADVANTAGED INDIVIDUALS. THEY ALSO HAVE THE OPPORTUNITY TO IMPACT PUBLIC SECTOR INITIATIVES LIKE THOSE THAT ARE OPERATING IN CORPORATE HEALTH AND WELLNESS ACTIVITIES. AND AS WE HEARD THIS MORNING, IN SPEAKERS COMMENTS, WE CAN SEE THE IMPACT ALREADY THAT THE PRIOR DIETARY GUIDELINES HAVE HAD IN MANY, MANY AREAS. I THINK WE ALL WHAT'S AT STAKE BUT DESPITE THE FACT WE HAVE THE MORE MOST SOPHISTICATED HEALTHCARE SYSTEM IN THE WORLD WE HAVE RATES, MORTALITY RATES, PREVENTABLE LIFESTYLE PARTICULARLY DIET RELATED HALF THE DISEASE BURDEN IN OUR COUNTRY RELATES TO PREVENTABLE DISEASESES INCLUDING CARDIOVASCULAR DISEASE, HYPERTENSION STROKE CORONARY HEART DISEASE, DIABETES AND CERTAIN FORMS OF CANCER. AS WE HEARD BEFORE AND DISCUSSED PREVIOUS MEETINGS WE HAVE AN OVERWEIGHT AND OBESITY EPIDEMIC AND WE'LL HEAR MORE ABOUT THAT FROM VARIOUS ANGLES IN THE SUBCOMITTEE REPORTS. THERE ARE ALSO WIDE HEALTH DISPARITIES ACROSS COMMUNITIES WITHIN SUBGROUPS OF OUR POPULATION THAT ARE UNNECESSARY WITH CLOSE ATTENTION TO WHY THESE CONDITIONS EXIST AND WHAT WORKS IN TERMS OF RESOLVING THE PROBLEMS. IF WE LOOK NOT ONLY MAJOR CAUSES IN DISABILITY AND COSTS IN THE HEALTHCARE SYSTEM THEY ARE ALSO MAJOR CAUSES OF PREMATURE MORTALITY IN OUR POPULATIONEN THOSE HERE IN RED ARE THE SIGNIFICANT DIET RELATED CONDITIONS THAT ARE ACCOUNTING FOR UPWARDS OF 60% MORTALITY IN OUR COUNTRY, HEART DISEASE, CANCER, SO FORTH THAT I MENTIONED BEFORE. WE KNOW FROM A VARIETY OF EXPERT REPORTS SOME MENTIONED BY SPEAKERS TODAY, AMERICAN HEART ASSOCIATION, NHLBI, AMERICAN COLLEGE OF CARDIOLOGY, WHAT WORKS IN TERMS OF REDUCING THE BURDEN OF THESE DISEASES AND YOU CAN SEE THAT MANY OF THESE THINGS AS HIGHLIGHTED IN THESE SLIDES HERE INCLUDING DIET AND PHYSICAL ACTIVITY PATTERN, REDUCING OBESITY RATES, LOWERING RISK MODERATING ALCOHOL USE, METABOLIC RISK FACTORS AND INDIVIDUAL LIFESTYLE RECOMMENDATIONS ARE ALL WITHIN THE PURVIEW OF THE DIETARY GUIDELINES ADVISORY COMMITTEE. OUR PROBLEMS ARE SUBSTANTIAL, AND THE PURVIEW OF THIS COMMITTEE ENCOMPASSES MANY THINGS THAT WE CAN DO SOMETHING ABOUT. IT IS OUR JOB TO LOOK OBJECTIVELY AT THE MOST CURRENT EVIDENCE TO SUMMARIZE IT AS THE BASIS FOR THE RECOMMENDATIONS THAT WE PUT FORWARD FOR USDA AND DHHS CONSIDERATION AS IT FORMULATES POLICIES THE ADDRESS THESE IMPORTANT PROBLEMS AND CONCERNS. WE'RE TESTING WITH A NEW SOFTWARE SYSTEM SO A LITTLE BIT OF ASSISTANCE HERE LOADING A CONCEPTUAL MODEL. I PRESENTED IT EARLIER MEETINGS THAT OUR FRAMEWORK FOR THE WORK OF THE DIETARY GUIDELINES COMMITTEE IS A SOCIAL ECOLOGICAL MODEL. BUT WE WANTED TO SEE IF WE CAN IT RATE THE MODEL SOMEWHAT TO REFLECT THE COMPLEX AND DYNAMIC AND PERHAPS EVEN THE POROSITY THAT DR. DIETZ WAS TALKING ABOUT THIS MORNING THAT ARE IMPORTANT IN TERMS OF DEVELOPING EFFECTIVE STRATEGIES TO ADDRESS THE IMPORTANT LIFESTYLE RELATED PROBLEMS. SO WHAT THE SOCIAL ECOLOGICAL MOLD SUGGESTIONS IS THERE ARE COMPLEX INFLUENCES DETERMINANTS THAT INFLUENCE THE LIFESTYLE BEHAVE PHYSICAL ACTIVITY WE'RE FOCUSING ON. YOU WILL HEAR MUCH MORE ABOUT EACH DIMENSIONS THAT ARE IMPORTANT TO REALLY DELVE DEEPLY INTO AS WE TRY TO UNDERSTAND THE IMPORTANT INFLUENCES AND DETERMINANTS OF DIET AND FIZZ AL ACTIVITY. THE ENTERPERSONAL CHARACTERISTICS SOCIAL ECONOMIC AND DEMOGRAPHIC FACTORS, THE BIOLOGICAL DETERMINANTS, OF DIET, PHYSICAL ACTIVITY, PREFERENCES AND SO FORTH. THE SOCIAL CHARACTERISTICS OF THE COMMUNITY AND INDIVIDUALS FRAMEWORKS THAT INFLUENCE BEHAVIORS AS WELL AS ENVIRONMENTAL, PHYSICAL AND BUILD, SECTORS OF INFLUENCE, THE SETTINGS OF INFLUENCE LIKE WORK SITE EDUCATIONAL SETTINGS, SO FORTH. EXCUSE ME. AND ALSO THE SYSTEMS OF INFLUENCE. WE HAD QUITE AN INTERESTING CONVERSATION THIS MORNING ABOUT HEALTHCARE EDUCATION AND THE SYSTEMS WITHIN A URBAN SETTING TRYING TO INFLUENCE CHANGE IN DIET AND PHYSICAL ACTIVITY BEHAVIOR. CERTAINLY CORE TO OUR WORK AS A COMMITTEE ARE THE LIFESTYLE FACTORS DIET AND PHYSICAL ACTIVITY AND WE'RE REALLY LOOKING AT VERY DIFFERENT DIMENSIONS OF DIET. THE OVERALL DIETARY PATTERNS AN NUTRIENT QUALITY OF THAT DIET. FOOD BEVERAGE NUTRIENT INTAKES NUTRACEUTICALS, FOOD SECURITYND SAFETY AS WELL AS FOOD SUSTAINABILITY. THAT IS NOT ONLY CONSIDERING WHAT INDIVIDUALS CONSUME THE OVERALL QUALITY OF THAT DIET BUT LOOKING FORWARD THE SUSTAINABILITY OF THAT DIET INTO FUTURE GENERATIONS. SO PHYSICAL ACTIVITY EXAMINING DIMENSIONS THE PATTERNS OF LEISURE AND WORK ACTIVITY, SCREEN AND SUDDEN TEAR TIMES, SLEEP, EXERCISE INCLUDING AEROBIC AND STRENGTH TRAINING. EXAMINING THE INFLUENCES AND DETERMINANTS ON THAT BEHAVIOR AND LINKING ALL OF THESE TO IMPORTANT HEALTH OUTCOMES. INCLUDING NUTRITIONAL STATUS OF THE POPULATION INDICATORS LIKE WEIGHT, WASTE CIRCUMFERENCE, OBESITY, AN APPROACH THAT IS LIFESTYLE ORIENTED LOOKING AT THE DIMENSIONS OF GROWTH AND DEVELOPMENT AND ADIPOSITY IN CHILDREN, IMPORTANT ISSUES IN TERMS OF MATERNAL NUTRITIONAL STATUS. AND WELL BEING AS WELL. IN TERMS OF HEALTH OUTCOMES THERE ARE NOW STRONG LITERATURE LINKING DIET TO A WIDE VARIETY OF MAJOR CAUSES OF MORBIDITY AND MORTALITY AS I MENTIONED BEFORE, WE AS A COMMITTEE LOCK TO THE LINKS THE RELATION SHIPS BETWEEN DIET AND HEART DISEASE, HYPERTENSION STROKE, DIABETES, HEART RELATED CANCERS BUT EXTENDING OUR WORK INTO THE GI EFFECTS OF DIET, EXAMINING WHERE WE STAND IN TERMS OF OUR UNDERSTANDING OF DIET AND LIFESTYLE AND RELATIONSHIP TO THE MICROBIOME, MUSCULOSKELETAL AND BONE HEALTH, PHYSICAL AND MENTAL WELL BEING WHICH IS A NEW DIMENSION FOR THE DIETARY GUIDELINES COMMITTEE. NOT ONLY LOOK AT MORBIDITY AS WELL AS HEART END POINTS BUT ALSO INTERMEDIATE MARKERS IMPORTANT MEASURES NOT ONLY OF HEALTH BUT ALSO AREAS IN TERMS OF EFFECT OF OUR INTERVENTION DIET AND PHYSICAL ACTIVITY PROMOTING HEALTH. YOU CAN SEE IN THE MODEL AS WELL, IN CONSIDERING THESE OUTCOMES SETTINGS WHICH INTERVENTIONS TAKE PLACE, HEALTHCARE PUBLIC HEALTH PUBLIC PRIVATE PARTNERSHIPS AS I MENTION BEFORE, KEY THEMES ABOUT 2015 GUIDELINES NOT ONLY UNDERSTANDING THE COMPLEXITY OF INFLUENCES ON DIET AND PHYSICAL ACTIVITY. IN THESE HEALTH OUTCOMES BUT WHAT WORKS FROM AN EVIDENCE BASED STANDPOINT IN TERMS OF CHANGING LIFESTYLE BEHAVIOR TO MOST EFFECTIVELY IMPACT OVERALL HEALTH AN WELL BEING. THANK YOU. SO I WANT TO UNDERSCORE NEW DIRECTIONS FOR COMMITTEE. CERTAINLY CORE IS LOOKING AT FOOD, NUTRITION AND HEALTH RELATED RECOMMENDATIONS. BUT KNEW THEMES IN THIS GO AROUND COMMITTEE ACTIVITY ARE EXPLORATION OF TOTAL DIET DIETARY PATTERNS AN HEALTH OUTCOMES NOT SIMPLY IN TERMS OF RELATIONSHIPS BUT UNDERSTANDING HOW WE CAN BEST IMPACT DIET AND PHYSICAL ACTIVITY TO PROMOTE INTERMEDIATE AND LONG TERM HEALTH OUTCOMES TO CONSIDER A SYSTEMS APPROACH TO CONSIDER SOCIO ECOLOGICAL MODEL COMPLETELY AS POSSIBLE AS WE LOOK AT WIDE VARIETY OF LEVELS OF INFLUENCE DIET AND PHYSICAL ACTIVITY AND RELATIONSHIP TO HEALTH AND ALSO TRY TO QUANTIFY AS BEST WE CAN THE EFFECTS THAT WE CAN EXPECT FROM INTERVENTIONS ON DIET AND PHYSICAL ACTIVITY. BUT ALSO THE METHODS OF BEHAVIORAL INTERVENTION THAT AFFECT THE INDIVIDUAL AND GROUPS BUT ALSO BEST PRACTICES IN LARGER SETTINGS SUCH AS THE COMMUNITY EDUCATIONAL HEALTHCARE AND OTHER SETTINGS THAT PROVIDE INFLUENCE AT POPULATION LEVEL IN TERMS OF OVERALL DIETARY PATTERNS AND HEALTH AND WELL BEING. AS WELL AS MENTIONING BEFORE THE ISSUES OF FOOD SECURITY BECAUSE OF THE DISPARITIES THAT WE SEE IN THE POPULATION BUT SUSTAINABILITY OF THE DIET SO WE THINK ABOUT NOT ONLY HEALTHY AFFORDABLE AND AVAILABLE FOOD BUT ALSO A DIETARY PATTERN AND FOOD SYSTEM THAT IS SUSTAINABLE IN TO THE FUTURE. TO CONDUCT THIS WORK AS MENTIONED BEFORE WE STARTED WITH THREE WORKING GROUPS AND EXPANDED TO FIVE SUBCOMITTEES EXAMINING THE FOLLOWING FIVE THEMES SUBCOMITTEE 1 LOOKING AT FOOD AND NUTRIENT INTAKE ABOUT HEALTH, CURRENT STATUS IN TRENDS, WHERE THE WORK ON NUTRIENTS OF CONCERN AS WELL AS FOOD GROUP INTAKE COMPARED TO RECOMMENDATIONS IS BEING DONE. SUBCOMITTEE 2 DIETARY PATTERNS FOODS AND NUTRIENTS AND HEALTH OUTCOMES IS WHERE WE'RE LOOKING AT THE RELATIONSHIPS IN TERMS OF CURRENT LITERATURE BETWEEN DIET -- DIETARY PA TERMS AND THE DRIVERS OF THOSE DIETARY PATTERNS IN VARIOUS HEALTH OUTCOMES NOT ONLY THE CHRONIC NON-COMMUNICABLE DISEASES BUT ALSO NEW AREAS SUCH AS BONE AND MENTAL HEALTH AS MENTIONED BEFORE. WE'RE ALSO LOOKING AT THE IMPACT OF DIETARY CHANGES AND PHYSICAL ACTIVITY INTERVENTION, SO AGAIN WE CAN QUANTIFY AS BEST WE CAN WHAT WE CAN EXPECT FROM INTERVENTIONS ON DIET AND PHYSICAL ACTIVITY. SUBCOMITTEE THREE BEHAVIOR CHANGE LOOKING AT THE LEVEL OF THE INDIVIDUAL AND SMALL GROUP TO EXAMINE METHODS OF BEHAVIOR CHANGE, EXPLORING INNOVATIONS DISCUSSED THIS MORNING IN TERMS OF MOBILE HEALTH BUT ALSO LOOKING AT ISSUES SUCH AS ACCULTURATION BECAUSE OF IMPORTANCE OF BEING CULTURALLY SENSITIVE IN DEVELOPING EFFECTIVE INTERVENTIONS. WE'RE LOOKING HERE ALSO AT THE HOME, FOOD ENVIRONMENT AS INFLUENCES INDIVIDUAL AND SMALL GROUP AND FAMILY DIETARY BEHAVIOR AND LOOKING ALSO AT SCREEN TIME AS AN IMPORTANT INFLUENCE ON THE DIETARY BEHAVIOR OF -- AND ALSO ACTIVITY LEVELS OF INDIVIDUALS. IN FC-4 FOOD AND PHYSICAL ACTIVITY ENVIRONMENTS WERE REALLY EXPANDING TO THE EXPLORATION OF THE BEST WAYS AND -- OF INFLUENCING THE DIET PHYSICAL ACTIVITY OF POPULATIONS AND HERE WE'RE LOOKING AT FOOD ACCESS A VARIETY OF SETTINGS RESEARCH IS REASONABLY WELL DEVELOPED. SCHOOL, CHILD CARE AND WORK SITE SETTINGS AGAIN TO IDENTIFY MODELS FOR EFFECTIVE POPULATION BEHAVIOR CHANGE AND ALSO THE TOPIC OF FOOD MARKETING AND HOW THAT MAY PLAY IN TERMS OF POPULATION BEHAVIOR CHANGE, FINALLY IN SUBCOMITTEE 5, FOOD SUSTAINABILITY AND SAFETY. HOAR NOT ONLY ISSUES OF FOOD SAFETY SPECIFIC TOPICS SUCH AS CAFFEINE, NON-CALORIC SWEETENERS BUT ALSO AS I WAS MENTIONING SUSTAINABILITY OF OUR FOOD SUPPLY AND IN THE CONTEXT OF THAT, DOING SOME MODELING AROUND DIETARY GUIDELINE AND PATTERN TO EXPLORE THE SUSTAINABILITY OF THAT PATTERN OVER TIME. WE WILL HEAR MUCH MORE IN OUR CONVERSATIONS THIS AFTERNOON ABOUT WHERE THE SUBCOMITTEES STAND IN TERMS OF THE VARIOUS ACTIVITIES TO DATE. THERE'S ALSO CROSS CUTTING TOPICS THAT REALLY RESULTED IN RESEARCH QUESTIONS ACROSS THE SUBCOMITTEES, THESE INCLUDE SODIUM AND WE'LL BE HEARING THIS AFTERNOON FROM THE CHAIRMAN OF THAT WORKING GROUP EATING OUT, BEHAVIORS IN THE FOOD ENVIRONMENT, HEALTH IMPACT, MODES AND METHODS OF BEHAVIOR CHANGE AS I WAS MENTIONING BEFORE THE THEME OF WHAT WORKS. AND ALSO PHYSICAL ACTIVITY. THE LAST TOPIC THERE CUT ACROSS AT LEAST FOUR SUBCOMITTEES AND SO WE FORM SEPARATE WORKING GROUPS TO REALLY LOOK AT THAT IN GREATER DETAIL. I HAVE BEEN ASKED TO TALK A LITTLE BIT MORE ABOUT THE PHYSICAL ACTIVITY WORK GROUP AND HOW THAT WORK HAS PROGRESSED AND ALSO AS I MENTIONED SOME OF THE COMMON ASPECTS OF THE APPROACH THAT THE SUBCOMITTEES HAVE TAKEN IN THEIR WORK. WITH PHYSICAL ACTIVITY, THIS GROUP IS LED BY MIM NELSON WHO IS CHAIRING OUR SUBCOMITTEE FIVE, THERE ARE SIX MAJOR STEPS THAT HAVE BEEN USED, WE AGREED FIRST OFF THAT WE WERE GOING TO USE SYSTEM MA IT CAN REVIEWS AND EXISTING REPORTS TO ADDRESS THIS TOPIC BECAUSE OF THE AVAILABILITY OF A SIGNIFICANT NUMBER OF RECENT EXPERT REVIEWS AND REPORTS ON PHYSICAL ACTIVITY. WE IDENTIFIED THOSE REPORTS AS PRIMARY SOURCES OF EVIDENCE, WE REVIEWED THE KEY FINDINGS RELATIVE TO TOPICS THAT DGAC IS INTERESTED IN, EXTRACTED THOSE FINDINGS, CONSIDERING METHOD LOGIC DESIGN FEATURES AND WHERE THEY EXISTED ANY LIMITATIONS IN THE RESEARCH METHODOLOGIES, WE THEN DELVE INTO RESEARCH QUESTIONS OF THE SUBCOMITTEES AND IDENTIFIED KEY FINDINGS SUMMARIZED FOR EACH OF THE REPORTS. AND THIS IS THE LIST OF THE REPORTS WE HAVE EXAMINED INCLUDING THE RECENT AHACC GUIDELINES ON LIFESTYLE RECENTLY PUBLISHED. THE PHYSICAL ACTIVITY GUIDELINES FROM THE MID COURSE REVIEW, THE APOP STUDY, DIETARY GUIDELINES REPORT FROM 210, AND SO FORTH. SO IT'S A 'WILL I RICH EXISTING SOURCE OF REPORTING THAT WE USED AS THE PRIMARY WAY OF EXAMINING PHYSICAL ACTIVITY FOR THE 2015 GUIDELINES. NEXT STEPS HERE WILL BE TO DISCUSS FINDINGS AND THAT DISCUSSION BEGAN YESTERDAY WITHIN THE SUBCOMITTEES AND AS A RESULT OF THOSE DISCUSSIONS, WITHIN THE COMMITTEE TO DEVELOP CONCLUDING STATEMENTS FOR EACH QUESTION BASED UPON THE FINDINGS OF RESEARCH EXTRACTED FROM THOSE REPORTS. WE WILL ALSO BRING THOSE TO THE JULY MEETING FOR PUBLIC PRESENTATION AND FURTHER DISCUSSION. IN ADDITION TO SUMMING UP THE PROCESS FOR PHYSICAL ACTIVITY I WANT TO TOUCH ON THE NOTION THIS EACH OF THE PHYSICAL ACTIVITIES WERE GIVEN -- SORRY SUBCOMITTEES WERE GIVEN THE OPTION TO INVITE EXPERTS AND I WOULD SAY THE SUBCOMITTEES HAVE MADE VERY GOD USE OF VARIETY OF EXPERTS IN THE FIELD BUT TYPICALLY ONE TIME BASIS. AND THIS MAYBE AS THE GROUP INITIATES DISCUSSION OF THE TOPIC OR FURTHER ON WHEN THE COMMITTEE BEGINS TO FORMULATE ITS SUMMARY OF EVIDENCE TO GET FURTHER IMPACT INPUT FROM EXPERTS. THEY'RE INVITED TO PARTICIPATE BUT DON'T ACTUALLY PARTICIPATE IN VOTING OR DECISION MAKING AT THE SUBCOMITTEE LEVEL. WE HAVE ALSO INVITED A VARIETY OF CONSULTANTS TO BECOME SUBCOMITTEE MEMBERS THEY WERE SOUGHT BECAUSE OF THEIR EXPERTISE, THEY ARE NOT MEMBERS OF THE FULL DGAC COMMITTEE BUT WILL BE UTILIZED THROUGHOUT THE REMAINING PROCESS TO GIVE INPUT TO THE FINDINGS OF OUR REPORT. LIKE THE REST OF THE MEMBERS THEY COMPLETED TRAINING TRAINING AN BEEN CLEARED THROW A FOR MILLION PROCESS IN FEDERAL GOVERNMENT FOR PARTICIPATION HERE. SO ACROSS ALL OF THIS SUBCOMITTEES AS WE EXAMINE THE EVIDENCE, THIS COMMITTEE TAKES SERIOUSLY THE TASK AT HAND UX WE ALL UNDERSTAND CLEARLY THE IMPORTANCE OF THIS WORK. BUT I WANT TO REASSURE EVERYONE THAT WE ARE APPROACHING THINGS IN THE MOST OBJECTIVE PROCESS AND BEING VERY CAREFUL ABOUT HOW WE REVIEW AND SUMMARIZE THE EVIDENCE. WE HAVE A VARIETY OF STRATEGIES OUTLOINED HERE THAT WE CAN USE. ONE, NUTRITION EVIDENCE LIBRARY SYSTEMATIC ARE REVIEW PROCESS. I'LL EXPLAIN THAT IN A LITTLE BIT FURTHER DETAIL. ORIGINAL DATA ANALYSES WE CAN DO WITH N HAYNES DATA SETS AND OTHER DATA SOURCES. WITH THE HEM OF COLLEAGUES AT HHS AND U SDA AND ELSEWHERE. EXISTING HIGH QUALITY EVIDENCE BASED REPORTS REPORTING FOR PHYSICAL ACTIVITY, ORIGINAL FOOD PATTERN MODELING ANALYSES SUPPORTED BY THE COLLEAGUES AT USDA AND WE ALSO HAVE SOLICITED SPECIAL COMMENTS FROM THE PUBLIC AND HAVE AN OPEN PROCESS OF PUBLIC COMMENT THAT WE ARE REVIEWING AND IN OUR DELIBERATIONS AS WELL. DIETARY GUIDELINES PROCESS, IT'S A NUTRITION LIBRARY AT NEL.GOV MANAGED BY THE U.S. DEPARTMENT OFFING AGRICULTURE UNDER THE INCREDIBLY CAPABLE LEADERSHIP OF OUR COLLEAGUE JOANNE SPAWN. BASICALLY WHAT THEY DO IN SUPPORTING OUR ORIGINAL REVIEW OF EVIDENCE IS A SIX STEP PROCESS. JOANNE PRESENTED THIS AT OUR FIRST MEETING BUT I WAS ASKED TO QUICKLY RECAP THAT HERE. BECAUSE IT'S BEING USED BY EACH OF THE SUBCOMITTEES FOR ONE OR ANOTHER OF THEIR QUESTIONS AS APPROPRIATE. FIRST IS TOPIC IDENTIFICATION AND SYSTEMATIC REYOU QUESTION DEVELOPMENT SO ARTICULATING AS CLEARLY AS POSSIBLE WHAT THE IMPORTANT RESEARCH QUESTION IS. SECOND, TO DO THE LITERATURE SEARCH SCREENING AND SELECTION. WITH A RATHER ELABORATE IDENTIFICATION INCLUSION EXCLUSION CRITERIAS, CONFOUNDING VARIABLES AND SO FORTH SOMETHING IN THE NEW PRESENTATIONS ONCE THE LITERATURE IS IDENTIFIED, AND APPROPRIATELY SCREENED AND BODY OF LITERATURE MOST APPROPRIATELY SERVES THE ANSWER OUR QUESTIONS AS IDENTIFIED, THE DATA FROM THOSE STUDIES ARE EXTRACTED, AND RISK OF BIAS ASSESSMENT IS DONE TO UNDERSTAND THE QUALITY OF THE EVIDENCE THAT WE'RE DEALING WITH. THEN THAT SUMMARY DATA GOES BACK TO THE COMMITTEE, SUBCOMITTEE AND THE EVIDENCE IS SYNTHESIZED FOR DISCUSSION BY THE DIETARY GUIDELINES COMMITTEE. CONCLUSION STATEMENTS ARE THEN DRAFTED AND THE EVIDENCE FROM THIS PROCESS IS GRADED IN TERMS OF QUALITY AND SERVES AS THE BASIS FOR RESEARCH RECOMMENDATIONS AND SO FORTH. SO AS YOU CAN SEE IT'S AN LAB RATE OBJECTIVE AND SYSTEMATIC PROCESS THAT WE FOLLOW WHEN DOING THE SYSTEMATIC REVIEWS USING THE NOW PROCESS, TODAY DEPENDING UPON SUBCOMITTEE PRESENTATIONS YOU'LL SEE ONE OR ANOTHER BUT PERHAPS NOT COMPLETE PROCESS FORGIVEN QUESTION. I WANT TO SHOW YOU HERE THAT THE EVIDENCE STATEMENTS THAT ARE CREATED AND RECOMMENDED AND SUM RIDED BY THE COMMITTEE WILL BE RATED STRONG, MODERATE, LIMITED OR GRADING NOT POSSIBLE BASED UPON THE QUALITY OF THE EVIDENCE AND THIS WILL SERVE TO GUIDE THE COMMITTEE IN TERMS OF ITS SUMMARY RECOMMENDATIONS. SO AT THIS POINT IN TIME I'M GOING TO TURN THE MICS OVER IF YOU WILL TO THE SUBCOMITTEES. WE'RE GOING TO REVERSE ORDER A LITTLE BIT AND BEGIN FIRST WITH SUBCOMITTEE 1. THANK YOU. IT'S 1, 5, 4, 3, 2. THANK YOU, GOOD AFTERNOON. I WOULD LIKE TO THANK THE MEMBERS OF SUBCOMITTEE 1 AND ALSO THANK BARBARA MILLEN FOR HER PARTICIPATION IN MOST CONFERENCE CALLS. THE SCOPE FOR SUBCOMITTEE ONE IS TO EXAMINE CURRENT STATUS IN TREND IN FOOD GROUPS FOOD AND NUTRIENT INTAKE, EATING BEHAVIORS, DIETARY PATTERNS, DIET RELATED CHRONIC DISEASE, WEIGHT, PHYSICAL ACTIVITY. THE REASON THAT'S IMPORTANT TO EXAMINE CURRENT STATUS AN TRENDS IS WE NEED TO KNOW WHERE THE POPULATION IS CURRENTLY AT IN ORDER TO FORMULATE APPROPRIATE RECOMMENDATIONS SO WE BELIEVE THIS VIEW OF CURRENT TREND WILL FORM THE FOUNDATION FOR THE REST OF THE COMMITTEE REPORT. WE HAVE HAD FOUR INVITED EXPERTS WHO HELPED US ALONG THE WAY IN THE LAST FEW MONTHS AND THEY HAVE REALLY HELPED OUR GROUP QUITE A BIT. THE QUEST ARE LESTED HERE. NUTRIENTS OF PUBLIC HEALTH CONCERN, EATING BEHAVIOR STATUS AN TRENDS, FOOD CATEGORY INTAKES AN SOURCES OF ENERGY, PREVALENCE OF HEALTH CONCERNS AN TRENDS AND POTENTIAL ISSUES OF OVERCONSUMPTION. SO LET'S START WITH THE FIRST TWO QUESTIONS. WHAT CURRENT CONSUMPTION PATTERNS OF NUTRIENTS AND FRUITS AND BEVERAGES IN THE U.S. POPULATION? SECONDLY, OF THE NUTRIENTS THAT ARE OVER OR UNDER CONSUMED, WHICH PRESENT A SUBSTANTIAL PUBLIC HEALTH CONCERN INCLUDING CONSUMPTION OVER THE UPPER LIMIT OF INTAKE. OUR COMMITTEE HAS TAKEN THREE PRONGED APPROACH TO EVALUATING NUTRIENT AND FOOD INTAKE. THE FIRST IS TO USE OUR NATIONAL NUTRITION MONITORING SYSTEM WHICH IS THE NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEYND DIETARY SURVEY PORTION OF N HAYNES IS CALLED WWEIA FOR WHAT WE EAT IN AMERICA. WE HAVE CONCENTRATED ON SURVEY YEARS 2007 TO 2010. WE HAVE EXAMINED NUTRIENT INTAKE DISTRIBUTION FROM FOOD AND BEVERAGE INTAKE BY AGE AN SEX GROUPS, WE HAVE NOT YET EXAMINED SUPPLEMENTAL INTAKE FROM DIETARY SUPPLEMENTS BUT WE DO PLAN TO DO THAT IN THE FUTURE SO FOR TODAY YOU'LL JUST SEE RESULTS FROM FOOD AND BEVERAGE INTAKE. THREE PRONGEDD APPROACH USES DATA FROM N HAYNES CDC BIOMARKER DATA WHERE AVAILABLE. AS MANY OF YOU KNOW THERE ARE BLOOD DRAWS FROM SUBSET OF N HAYNES PARTICIPANTS AND NUTRITIONAL BIOMARKERS SUCH AS IRON MEASURES TO ASSESS VITAMIN D FOR STATUS AND SO FORTH ARE AVAILABLE SO WHEN WE USE THOSE DATA, REVIEW AN ADDITIONAL PIECE OF INFORMATION THAT IN SOME WAYS OFFER AS DIFFERENT VIEW BECAUSE THE SURVEY DATA IS ONE DAY OF INTAKE OVER THE POPULATION WHERE THE BIOMARKER CAN REFLECT LONGER FROM STATUS AND SOME WAYS MORE OBJECTIVE. THE THIRD PART OF THREE PRONGED APPROACH IS TO FUNCTIONAL STATUS INDICATORS. WE LOOK AT CHRONIC DISEASE OUTCOMES SO IF A NUTRIENT HAS A KNOWN RELATIONSHIP TO A CHRONIC DISEASE OUTCOME, THEN WE USE THAT INFORMATION WHETHER OR NOT IT'S A SHORT FALL NUTRIENT, I.E. UNDERCONSUMED OR WHETHER IT'S ONE OF PUBLIC HEALTH CONCERNS. SO WE IDENTIFIED SHORT FALL AND OVERCONSUMED NUTRIENTS AND WE GET THESE FROM THE ANALYSIS OF USUAL INTAKE DISTRIBUTION FROM WHAT WE EAT IN AMERICA DATA AND IDENTIFIED NUTRIENTS OF PUB LOOK HEALTH CONCERNS FROM THE USUAL INTAKE -- PUBLIC HEALTH CONCERNS FUNCTIONAL INDICATORS AN RELATED HEALTH CONCERNS. BECAUSE NUTRIENTS HAVE A LITTLE BIT MORE WEIGHT ATTACHED TO THEM, IN TERMS OF PROGRAMMATIC CONCERN, WE FEEL WE MUST USE MORE THAN ONE PIECE OF INFORMATION TO IDENTIFY THOSE NUTRIENTS OF PUBLIC HEALTH CONCERN. HERE WE SHOW PERCENT OF POPULATION TWO AND OVER THE USUAL INTAKE BELOW THE EAR OR ESTIMATED AVERAGE REQUIREMENT. THE ONES WITH GREATEST PROPORTION BELOW THE EAR ARE LISTED AT THE TOP SUCH AS VITAMIN D, VITAMIN E MAGNESIUM, CALCIUM AND SO FORTH. THERE'S ONLY A SMALL FRACTION OF THE POPULATION THAT DOES NOT HAVE THE USUAL INTAKE BELOW THE EAR. HERE I'M GIVING ONE EXAMPLE OF ONE OF THE NUTRIENTS WE HAVE IDENTIFIED WHERE THERE ARE SUBSTANTIAL FRACTIONS OF POPULATION ACROSS VARIOUS AGE AN SEX GROUPS THAT MIGHT BE SOMETHING TO CONSIDER AS WE FORMULATE OUR GUIDANCE. SO YOU CAN SEE THAT FOR MALES, AGE 9 TO 13, OVER 50% OF THE POPULATION IN THAT GROUP HAS A USUAL UNTAKE OF CALCIUM BELOW THE EAR. MALES AGE 71 AND OVER, LIGHTLY OVER 70% IN THAT AGE GROUP HAS A USUAL INTAKE OF CALCIUM THAT'S BELOW THE EAR. FOR YOUNG ADOLESCENT AND ADOLESCENT FEMALES SLIGHTLY OVER 70 AND NEARLY 80% OF THOSE FEMALES ADOLESCENT FEMALES HAVE USUAL INTAKES OF CALCIUM THAT ARE BELOW THE EAR AND FOR MIDDLE AGE AND OLDER WOMEN LIKEWISE OVER 70% AND OVER 80% RESPECTIVELY HAVE CALCIUM INTAKES THAT ARE BELOW THE EAR. HER ARE SOME NUTRIENTS THAT SHOW PERCENT OF THE POPULATION AMONG AGE 2 AND OVER. THIS IS ALL THE POPULATION NOT AGE AN SEX GROUPS WITH USUAL INTAKES ABOVE THE AI. WE HAVE SOME NUTRIENTS ASSIGNED AN EAR WHERE WE HAVE MORE INFORMATION ABOUT THE DISTRIBUTION OF REQUIREMENTS. THERE ARE CERTAIN NUTRIENTS WE DON'T HAVE ENOUGH INFORMATION ABOUT THE DISTRIBUTION REQUIREMENT SO FOR THOSE NUTRIENTS THE INSTITUTE OF MEDICINE HAS ASSIGNED A CATEGORY CALLED AI. SO YOU CAN SEE HERE THAT WE HAVE LISTED FOUR NUTRIENTS, VITAMIN K, CHOLINE, DIETARY AND FIBER WHERE IT SHOWS A PERCENT OF POPULATION THAT IS WHERE USUAL INTAKE IS ABOVE THE AI. WE LISTED A NUTRIENT WE HEARD ABOUT THIS MORNING, THAT IS SODIUM. THE USUAL INTAKE IS ABOVE THE UL OR ABOVE UPPER LIMIT. FOR EACH AGE AND SEX GROUP THERE'S A SUBSTANTIAL PROPORTION OF THE POPULATION THAT IS CONSUMING SODIUM ON A DAILY BASIS THAT'S FAR ABOVE THE UL, IT'S SLIGHTLY MORE FOR MALES OF ALL AGE GROUPS BUT EACH AGE AND SEX GROUP HAS A DAILY SODIUM INTAKE ESTIMATED ABOVE TOLERABLE UPPER LIMIT OF INTAKE. FROM THESE DATA WE HAVE IDENTIFIEDED THE FOLLOWING NUTRIENTS OF PUBLIC HEALTH CONCERN. THIS IS BASED ON OUR EXAMINATION BOTH OF THE DISTRIBUTION OF INTAKE A WELL AS BIOMARKERS. VITAMIN D HAS INDICATOR RELATED TO BONE HEALTH, CALCIUM RELATED TO BONE HEALTH, POTASSIUM THIS MORN, HEALTH CONCERN BLOOD PRESSURE. SODIUM, THE USUAL UNTAKE EXCESSIVE, AGAIN RELATED TO BLOOD PRESSURE AS DISCUSSED THIS MORNING, GASTROINTESTINAL HEALTH AND FOR IRON WE IDENTIFIED SUBGROUPS IN THE POPULATION, CHILDREN, PRE-MENOPAUSAL FEMALES AND PREGNANCY WHERE THERE'S SHORT FALLS AN INDICATORS OF PUBLIC HEALTH CONCERN RELATED TO IRON DEFICIENCY. NUTRIENTS OF PUBLIC HEALTH CONCERN POPULATION AGES 2 AND OVER ARE VITAMIN D FOR SOME GROUP INCLUDES IRON OVERCONSUMPTIONEN COLLUDE SODIUM. AT THIS POINT WE ROLL TAKE ONE OR TWO BURNING QUESTIONS AT THE END OF THESE SECTIONS WE'LL ASK ONE OR TWO BURNING QUESTIONS AND THEN WE'LL HAVE TIME AT THENT OF THE ENTIRE SUBCOMITTEE PRESENTATION FOR CONTINUED DISCUSSION. SO ARE THERE ONE OR TWO BURNING QUESTIONS? MIRIAM, YOU DIDN'T SHOW THE DATA RELATED TO IRON. SO I WAS WONDERING WHAT THE PRE-LENS IS OF IRON -- PREVALENCE OF IRON DEFICIENCY IN THE SUBGROUPS. SPECIFICALLY RELATED TO PREGNANT WOMEN GIVEN THE FACT THERE WAS A SYSTEMATIC RERUE THAT CAME OUT 2009 THAT SAID MILD MODERATE ANEMIA DURING PREGNANCY IS NOT BENEFITED BY IRON SUPPLEMENTATION SO I'M CURIOUS TO KNOW WHAT PERCENTAGES WERE AND WHAT YOUR CUT OFF POINTS AND WHEN. HOW ABOUT WE HOLD THAT QUESTION UNTIL THEN SO YOU CAN PUP UP THE NUMBERS. SO WE'LL MOVE TO THE NEXT PRESENTER WHO IS MARY STORY. I'LL BE PRESENTING THE FINDINGS FROM OUR SUBCOMITTEE ON EATING BEHAVIORS,. TODAY WE'LL BE PRESENTING ON THE CURRENT STATUS FOR THE NUMBER OF DAILY EATING OCCASIONS, THE FREQUENCY OF MEAL SKIPPING AND DIET QUALITY BY MEAL AND SNACKS. I JUST WANTED TO POINT OUT THAT WE WILL BE LOOKING AT TRENDS OVER TIME FROM THE HAYNES DATA AND ALSO LOOKING AT ADDITIONAL SUBPOPULATIONS. FOR ALL THIS IS QUESTIONS KEEP IN MIND WE'LL BE LOOK AT TRENDS AND THEN ALSO BY SES AS WELL AS OTHER INDICATORS, SO FOR APPROACH, WE WILL BE DOING DATA ANALYSIS, USING DATA FROM N HAYNES 20092010, EEL BE PRESENTING THAT TODAY AND TREND DATA WILL LOOK AT HAYNES DATA FROM 2003, 2004 FOR THE YEARS 2005, 2006. AND 2007, 2008 SO THE JULY MEETING WE'LL PRESENT DATA ON TRENDS AND SUBPOPULATION ANALYSES. SO I WANT TO POINT OUT THIS IS THE NUMBER OF MEALS REPORTED PER DAY BY AGE AND GENDER FROM N HAYNES 2009, 10 THE MOST CURRENT DATA. BLUE IS PERCENT OF POPULATION 2 AND OLDER DIVIDED BY LOOKING THROUGH THE LIFE CYCLE FOR MALES ON THE LEFT AND THEN FEMALES. THOSE THAT REPORT ON THE 24 HOUR RECALL THREE MEALS A DAY, THOSE IN RED CONSUMING TWO A DAY AND IN GREEN ONE MALE A DAY SO BASED ON SELF-REPORT SO IF YOU LOOK AT THE BLUE LINE YOU SEE A U SHAPED CURVE FOR MALES AN FEMALES. THOSE THAT CONSUME THREE MEALS A DAY ARE HIGHEST FOR YOUNGER CHILDREN AND ELEMENTARY SCHOOL IT DIPS DOWN TO CONSUMING FEWER THAN THREE MEALS A DAY AND THEN INCREASES IN THE LATER YEARS. YOU CAN SEE OVERALL THREE MEAL AS DAY IS NORM FOR AMERICANS AGE 2 AND OLDER. 63% REPORT EATING BREAKFAST, LUNCH AND DINNER. YOUNG CHILDREN ARE MOST LIKELY TO EAT THREE MEALS A DAY AND LEAST LIKELY ARE ADOLESCENTS AND YOUNG ADULTS. EATING ONE MEAL A DAY WHICH IS IN THE GREEN IS MOST LIKELY FOR MALES 20 TO 29 YEARS OF AGE AND FEMALES THAT ARE 12 TO 19. BUT IN THIS SLIDE SNACKS IS NOT INCLUDED. WE FOUND THAT AMONG THOSE THAT REPORT CONSUMING ONE MEAL A DAY, MOST REPORT AT LEAST HAVING TWO TO THREE SNACKS A DAY. WE FOUND ONLY 1% OF THOSE THAT REPORT CONSUMING ONE MEAL A DAY, ONLY ONE PERCENT REPORT NOT HAVING ANY SNACKS. THE MODE IS ABOUT 2 TO 3 SNACKS PER DAY. WE WERE ALSO INTERESTED IN LOOKING AT PERCENT OF AMERICANS THAT REPORT SKIPPING MEALS AND SKIPPING MEALS WERE BREAKFAST LUNCH AND DINNER BY AGE AND GENDER GROUP. WE FIND DINNER WHICH IS IN THE GREEN, IS REPORTED ONLY 5 TO 10% OF MOST AGE GROUPS. REPORT SKIPPING DINNER. BREAKFAST IN BLUE LINE IS SKIPPED BY 20 TO 25% OF YOUNG ADULTS AND SKIPPING, THAT'S 20 TO 25% OF LUNCH. I WILL GO THROUGH THE NEXT SLIDES QUICKLY BUT I WANT TO POINT OUT THIS SLIDE SHOWS THE PERCENT OF TOTAL ENERGY INTAKE AND PERCENT OF TOTAL NUTRIENT INTAKE FOR SPECIFIC NUTRIENTS. THE NUTRIENTS WE CHOSE ARE POTENTIAL NUTRIENT OF CONCERN AS WELL AS PROTEIN, SO LOOK AT THE THICK BLACK LINE THAT IS THE ENERGY LINE SO ANY ABOVE INDICATE LARGER PERCENT OF THAT NUTRIENT RELATIVE TO ENERGY INTAKE NUTRIENTS BELOW THE ENERGY LINE REPRESENT A LOWER PERCENT OF NUTRIENT COMPARISON TO ENERGY. SO FROM THIS SLIDE YOU CAN SEE THAT ABOUT -- AMERICANS ARE GETTING THROUGHOUT THE LIFE CYCLE ABOUT 15 TO 20% OF THE TOTAL ENERGY INTAKE AT BREAKFAST BUT LOOK AT ALL THE NUTRIENTS THAT ARE ABOVE ENERGY LINE WHICH INDICATE BREAKFAST IS CONTRIBUTING A LARGE AMOUNT POSITIVE NUTRIENTS AND BREAKFAST HAVE HIGHER QUALITY THAN OTHER MEALS AN SNACKS SO LOOK AT FOR EXAMPLE LUNCH, IT IS NEUTRAL DIETARY QUALITY WITH SIMILAR PERCENT OF TOTAL KNEW TREATMENTS AND ENERGY INTAKE FOR MOST NUTRIENTS. REPRESENT AS NEUTRAL TO LOWER OVERALL NEUTRAL QUALITY COMPARED TO OTHER MEALS AND SNACKS. DINNER IS HIGHER PERCENT OF SODIUM SHOWN HERE AS WELL AS SATURATED FAT IN COMPARISON TO ENERGY. I WANTED TO HAVE YOU LOOK AT THE SNACKS BECAUSE YOU CAN SEE SNACKS ARE LOWER IN POSITIVE NUTRIENTS RELATIVE TO THEIR ENERGY. YOU CAN SEE LIKE FOR YOUNG CHILDREN 2 TO 5 YEARS OF AGE, 28% OF TOTAL ENERGY INTAKE IS COMING FROM SNACK FOODS ACROSS THE LIFE CYCLE THOSE CALORIES TEND TO BE LOWER IN QUALITY COMPARED TO OTHER MALES. OR OTHER OCCASIONS SO KEY FINDINGS IS EATING THREE MEALS ARE DAY ARE THE NORM, TEENS AN YOUNG ADULTS ARE MOST LIKELY TO SKIP ONE OR MORE MEALS USUALLY BREAKFAST OR LUNCH. BREAKFAST IS MORE NUTRIENT DENSE COMPAREDDED TO LUNCH OR DINNER AND SNACKS PROVIDE THE LOWEST PERCENT SOFT KEY NUTRIENTS COMPARED TO PERCENT OF ENERGY. I THINK NOW IF THERE'S A FEW ONE OR TWO -- ONE BURNING QUESTION, THAT CAN'T WAIT UNTIL DISCUSSION. AS MENTIONED EARLIER ONE CHARGE THIS SUBCOMITTEE IS LOOK AT FOOD GROUP INTAKE AND AS SUCH I'M GOING TO PROVIDE AN UPDATE OF WHAT WE HAVE BEEN DOING TO ANSWER TWO QUESTIONS ON THIS SLIDE WHAT ARE TOP FOODS CONTRIBUTING TO ENERGY INTAKE IN THE U.S. POPULATION AND WHAT ARE THE CURRENT CONSUMPTION PATTERN BUSINESS FOOD CATEGORIES. BUT LOOK AT FOODS CONSUMED IN THE U.S. POPULATION AND OUR APPROACH HAS BEEN TO USE DATA FROM THE NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY UP TO THE 20092010 WHAT WE EAT IN AMERICA AND WE'RE USING THE FOOD CATEGORIES AT THE BASE. THERE ARE 150 OF THEM SO IN ORDER TO IMPROVE APPLICABILITY TO THIS PROCESS AND MANAGEABILITY WE CONDENSED DOWN INTO NINE MAJOR FOOD CATEGORIES WITH 32 SUBCATEGORIES. IT'S IMPORTANT TO NOTE HERE THAT THESE ARE ADAPTED FROM THE APPROACH THAT WAS USED IN THE 2010 GUIDELINES AND SO WE WILL PUBLISH A DETAILED METHODOLOGY ASSOCIATED WITH THAT. WE ALSO ANALYZED PERCENT OF TOTAL INTAKE OF ENERGY AND NUTRIENTS. THERE ARE ONLY A FEW PRESENTED TODAY ALSO GLOBALLY FOR THE POPULATION IN FUTURE COMMITTEE GATHERINGS WE WILL PRESENT INFORMATION ON ADDITIONAL NUTRIENTS ABOUT SUBPOPULATION DATA. FIRST FOOD SOURCES OF ENERGY, WE HAVE TOP SOURCE AS PERCENT OF TOTAL CON SUP SUM SHUN, I WOULD LIKE TO DRAW YOUR ATTENTION TO THE BOTTOM RIGHT HAND CORNER OF THE SLIDE. THE CUMULATIVE PERCENTAGE THAT'S REPRESENTED BY THE FOODS LISTED HERE ABOUT 75%. THE TOP THREE CONTRIBUTORS ARE BURGERS AND SANDWICHES, DESSERTS APPROXIMATE SWEET SNACKS AND THEN SUGAR SWEETENED BEVERAGES THOSE MAKE UP 29% TOTAL ENERGY IN THE FOODS LISTED ON THIS SLIDE. I WILL SET UP THE STAGE FOR THE NEXT FOUR SLIDES U I'LL SHOW DATA ABOUT ENERGY AS WELL AS THREE NUTRIENTS, IT'S A PIE CHART DISPLAYING FOOD SOURCES OF ENERGY PERCENT FROM THE NINE CATEGORIES THAT I MENTION WE'RE USED IN THIS SUBCOMITTEE. THIS SLIDE AS RELATES TO ENERGY THE GREATEST CONTRIBUTOR TO ENERGY IS MIX DISHES AS HERE WE'LL DO FOR THE OTHER NUTRIENTS AS WELL. THE MAJOR CONTRIBUTOR IS BROKEN TO SUBCATEGORIES UX YOU CAN SEW WHAT INDIVIDUAL CATEGORIES ARE ALSO ARE MAKING UP THE LARGER CATEGORY OR SUBCATEGORIES MAKING UP THE LARGER CATEGORY. AND THE MAJOR CONTRIBUTOR HERE WOULD BE BURGERS AND SANDWICHES COMING IN AT 14% OF ENERGY. HERE ARE DATA FOR FOOD SOURCES OF SODIUM. WHAT WE HEARD EARLIER PRESENTATIONS UBIQUITOUS NATURE IN FOOD SUPPLY REFLECTED HERE, MANY CATEGORY HOPPING OUT, LARGEST SOURCE HERE, WHEN WE LOOK AT THE BREAK OUT BY SUBCATEGORY YOU SEE BURGERS AND SANDWICHES BEING IMPORTANT CONTRIBUTORS. THESE ARE DATE FOR ADDED SUGAR, HERE WE SEE TWO LARGE PIECES OF CHART BEVERAGES THAT ARE NOT 100 PERCENT FRUIT JUICE BEING A LARGE PROPORTION OF THE CHART, ANOTHER 3% FROM SNACKS AND SWEETS. WE LOOK AT THE SUBCATEGORIES FOR BEVERAGES, WE SEE THAT 25% COMES FROM SOFT DRINKS BUT THE SUGAR SWEETENED BEVERAGES IF YOU DRAW YOUR EYES TO THE RIGHT SIDE OF THE SCREEN COMPRISE 39% OF THE THAT PART OF THE PIE. LASTLY, SATURATED FAT, MIXED DISHES BEING AT 35%, 15% SNACKS AN SWEETS, PROTEIN FOODS AN DAIRY, WHEN WE LOOK AT SUBCATEGORIES WE SEE BURGERS AND SANDWICHES ARE KEY CONTRIBUTORS IN SOURCES OF SATURATED FOOD S. WE PROVIDED IN THE BACK OF BRIEFING BOOKLET FOODS THAT GO INTO THE MAJOR CATEGORIES IF YOU HAVE QUESTIONS ABOUT THAT. SO LET ME TIE EVERYTHING TOGETHER. WHEN WE THINK FOODS, THAT'S PART OF THE QUESTION, THOSE HIGHEST CONTRIBUTION TO INTAKE ARE BURGERS SANDWICHES DESSERTS AND SWEET SNACKS AND SUGAR SWEETENED BEVERAGES. WHEN WE THINK ABOUT THE MAJOR FOOD CATEGORIES NINE WE USE IN LOOKING AT THESE DATA WE SEE THAT MIXED DISHES ARE CONTRIBUTING THE MOST IN TERMS OF ENERGY SODIUM AND SATURATED FAT. AND WHEN IT COMES TO ADDED SUGAR, BEVERAGES ARE CONTRIBUTING. THESE ARE PRELIMINARY ANALYSES SO THE WAY WE HAVE DONE THE CATEGORIZATION HELPFUL UP TO THIS POINT, HOWEVER THAT IS SUBJECT TO CHANGE SO I'M GOING TO PAUSE HERE AND TAKE ONE OR TWO BURNING QUESTIONS BEFORE WE MOVE TO THE NEXT PRESENTATION. IN THAT CASE, HEARING NO QUESTIONS REGARDING FOOD CATEGORY UNTAKE I WOULD LIKE TO MOVE TO TALK ABOUT OUR -- ANOTHER AIM OF OUR SUBCOMITTEE 1 WHICH IS THAT ASSOCIATED WITH PREVALENCE AND TRENDS RELATED TO DIET HEALTH CONCERNS AND THE TWO QUESTIONS THAT WE'RE GOING TO TALK ABOUT TODAY IS WHETHER IS CURRENT PREVALENCE OF O OBESITY AN OVERWEIGH IN THE U.S. POPULATION AS WELL AS TRENDS AND PREVALENCE OF OVER WEIGHT AND OBESITY IN THE U.S. POPULATION. WE HAVE NUMEROUS HEALTH CONCERNS THAT THE SUBCOMMITTEE WILL ADDRESS. WE'RE JUST -- SUBCOMITTEE WILL ADDRESS, WE'RE STARTING A PRESENTATION AROUND OVERWEIGH AND OBESITY. THE APPROACH WE'RE TAKING HERE IS TO SUMMARIZE NATIONAL HEALTH AND NUTRITION EXAM NEIGHBOR DATA TABLES FOR CENTERS FOR DISEASE CONTROL WEBSITE IN CONJUNCTION WITH PUBLISHED PEER REVIEW ARTICLES BY CDC AUTHORS. WE ARE FORTUNATE ENOUGH TO HAVE DATA UP TO 2011, 12, FOR CURRENT STATUS OVERWEIGH AND OBESITY, WE'RE ALSO LOOKING AT TREND DATA, VARIOUS SURVEY YEARS, WE CAN GO BACK TO 1998 '94 SURVEY PERIOD UP TO 2011, 2012. HERE IT'S WORTH NOTING AS THE OTHER ONES ARE, WE ARE KEEPING THAT IN CONSIDERATION OF THE INTERPRET THE DATA. SO FIRST LET'S LOOK BY GENDER OR SEX AT WHAT'S HAPPENING IN TERMS OF TRENDS IN YES, SIR WEIGHT AN OBESITY, THIS SLIDE SHOWS DATA FOR MALES AGED 20 YEARS OR OLDER. WE SEE AN AREA GRAPH THAT SHOWS OVERWEIGH CATEGORY WHICH DOES NOT INCLUDE OBESE INDIVIDUALS AND THE VARIOUS CLASSIFY CASES OF OBESITY HERE GRADE 1, 2, AND 3 ARE REPRESENTED. THIS AREA GRAPH IS THE FORMAT FOR THE NEXT FOUR SLIDES SO ONCE OR YENNED TO IT HOPEFULLY THE OTHER SLIDES WILL BE EASIER TO DIGEST. Y AXIS WE HAVE PERCENT OF THE POPULATION AND ALONG X AXIS THE VARIOUS TIME FRAMES WE HAVE DATA. SO ESSENTIALLY IN MEALS 20 AND OLDER WE SEE PREVALENCE OF OVERWEIGHT REMAINED STABLE WHILE THERE HAVE BEEN INCREASES IN GRADES 1, 2 AND 3 OBESITY. IN TERMS OF FEMALES, WE SEE SIMILAR PICTURE THOUGH YOU SORT OF DO THE QUICK TRANSFER OF INFORMATION, THE OVERALL PERCENT OF THE POPULATION OF FEMALE POPULATION THAT IS OVERWEIGH OR OBESE IS LIGHTLY LOWER THAN IT IS FOR MEN. WHEN WE LOOK AT THE BMI DATA BUT STABILITY IN TERMS OF OVER WEIGH BUT NOT OBESE AN SLIGHT INCREASES OVER TIME IN GRADES 1, 2, 3 OBESITY. NOW I WOULD LIKE TO LOOK AT DATA BY BOYS AND GIRLS. BEING DEFINED AGE 2 TO 19, AND HERE WE HAVE OVERWEIGHT AND OBESE, RELATIVE STABILITY IN TERMS OF NUMBERS OVER TIME, THE DATA HERE START IN THE YEARS 1999 TO 2000. A SIMILAR TREND IS SEEN WHEN WE LOOK AT DATA FOR OVERWEIGHT AND OBESITY IN GIRLS AGE 2 TO 19. HOWEVER, THERE'S A LITTLE BIT MORE INFORMATION THAT CAN BE GLEANED WHEN WE BREAK THE DATA DOWN BY AGE CATEGORY AND WE SEE HERE THERE'S A GREATER SEPARATION IF YOU LOOK ACROSS TIME IN 2011, 2012, DATA PRESENTATIONS THAN WHAT WE SEE BACK IN 1998 TO 1994 AND PA TERMS OVER TIME ARE DIFFERENT FOR -- PATTERNS ARE DIFFERENT OVER THREE AGE GROUPS. IN THE AGE GROUP 2 TO 5 YEARS OLD WE SEE A DOWNTURN FROM THE LAST DATA POINT, 20092010. UP TO 2011, 2012. YOU HEARD EARLIER REASONS WHY THAT MIGHT BE WE'RE CAUTIOUSLY OPTIMISTIC BUT NEED TO UNDERSTAND THE DATA MOVING FORWARD BEFORE WE CAN INTERPRET THAT FULLY. BECAUSE OF IMPORTANCE OF CONSIDERING FATNESS THAT MAY NOT BE WELL REPRESENTED WHEN WE LOOK AT BMI DATA ALONE, WE ARE ALSO GOING TO BE THINKING THROUGH NOT JUST FACTS BUT OTHER METABOLIC PARAMETERS. HERE WE SHOW DATA FOR TRENDS ABOUT NOMINAL OBESITY BY AGE SEX CATEGORIES. I'LL DRAW YOUR ATTENTION TO THE TOP LINE, VERY DARK BLACK LINE FOR MALES AGE 60 AND OLDER, HAVING THE HIGHEST PREVALENCE WITH MALES, 20 TO 39 BEING LOWEST AND LATER ON WE CAN TALK ABOUT HOW THAT PROVIDES A LITTLE BIT MORE INFORMATION WHAT WE SAW WITH BMI WHERE WOMEN DIDN'T APPEAR AS OVERWEIGH OR OBESE AS MEN. TO SUMMARIZE OUR KEY FINDINGS AT THIS POINT IN ADULTS THE PREVALENCE OF OVERWEIGHT BUT NOT OBESE REMAINED STABLE OVER THE YEARS THAT WE HAVE DATA FOR. PREVALENCE OF ABDOMINAL OBESITY IS DIFFERENCE BY AGE SEX WITH HIGHEST PREVALENCE IN FEMALES OVER AGE 60. AND IN CHILDREN WE HAVE PREVALENCE OF OVERWEIGH OBESITY AGAIN, APPEARING STABLE FROM 1999 TO CURRENT EXAMINATION POINT WITH DIFFERENT PA TERMS WHEN WE LOOK BY AGE CATEGORIES EMERGING. SO TO THIS POINT YOU'LL PAUSE. IF THERE'S ANY EMERGENT QUESTIONS OR A QUESTION WE'LL TAKE IT HERE. WAYNE CAMPBELL, JUST ON THOSE GRAPHS THE TRENDS, I'M CURIOUS ABOUT THE PRESENTATION OF THE X AXIS IN AGE OR TIME CATEGORY OPPOSED TO CHRONOLOGICAL. DOES THAT CHANGE WHAT THE PATTERNS LOOK LIKE IF YOU -- IF THE DATA ARE PRESENTED IN CHRONOLOGICAL ORDER OR IN REAL TIME AS OPPOSED TO IN BLOCK TIME? THAT'S A GREAT QUESTION TO TRIAGE UNTIL THE END BECAUSE WE'LL NEED TIME TO TALK ABOUT THAT. TOPIC RELATED TO OVERCONSUMPTION I'M GOING TO PRESENT INFORMATION ABOUT CAFFEINE. SUBCOMITTEE 5 WE'LL TALK MORE IN A FEW MINUTES WHAT INTERPRETATIONS MIGHT BE OF CAFFEINE INTAKE. I WOULD LIKE TO PRESENT SOME OF THE CONSUMPTION DATA. OUR APPROACH IS TO USE THE N HAYNES DATA TO LOOK AT THE DISTRIBUTION FROM 2007 TO 2010 AND THEN THE SOURCES FOR 2009 AND 2010. THIS SLIDE SHOWS 10% TILE, 50 PERCENTILE AND 90 PERCENT ISLE AND BLACK BAR MEAN INTAKES WITH ADULTS YOU SEE TYPICAL INTAKE FROM 12-OUNCE SERVING OF SODA OR COFFEE. LOOK AT THE BLACK BAR, THE 90th PERCENTILE INTAKE YOU SEE THAT IN ADULTS OVER 30 TO 70 IS AROUND 400-MILLIGRAMS PER DAY, THE VALUE USED BY SOME INDICATING MODERATE CAFFEINE INTAKE LEVEL. THESE HAVE BEEN WHY AXIS THE LOWER AND THEY SHOW A FAIRLY SIGNIFICANT INCREASE BOTH IN THE MEAN AND 90th PER TILE VALUE AN ADOLESCENT WHEN YOU LOOK AT THE SOURCES LIKELY PRIMARILY TO INCREASE IN COFFEE, TEE AND SODA CONSUMPTION DURING THE ADOLESCENTS. WE WANT TO LOOK AT PREGNANT VERSUS NON-PREGNANT INTAKES, LOOK AT THE VALUES ON THE LEFT HAND SIDE, RELATED TO PREGNANCY, AGAIN, THE 10, 50 AND 90th PERCENTILE BARS AND THEN LINE WHICH REPRESENTS THE MEANS OF PREGNANT, NON--- PREGNANCY VALUES ARE CONSIDERABLY LOWER SOME LEVEL OF 150 TO 200-MILLIGRAMS PER DAY AS REPRESENTING A SAFE LIMIT AND YOU SEE OVERALL THE PREGNANT POPULATION DOESN'T MOSTLY SEE THAT LEVEL. SOURCE TO SUMMARIZE POPULATION 2 AND ABOVE. MOSTLY INTAKE BEGINNING IN ADOLESCENTS IS COFFEE, TEE, SOFT DRINKS, DIET AND REGULAR. SUMMARIZE KEY ISSUES INCREASE CAFFEINE INTAKE BEGINNING IN ADOLESCENTS ASSOCIATED WITH COFFEE TEA AND SODA. SOME ADULTS OVER AGE 30 HAVE INTAKES GREATER THAN 400-MILLIGRAMS PER DAY. 'S IMPORTANT TO NOTE THE DATA OF ANALYZING NOW DO NOT REFLECT CAFFEINE CONTAINING SUPPLEMENTS. MAY NOT REFLECT INCREASE IN THE USE OF ENERGY DRINKS. WE'LL DEFER DISCUSSION ON CAFFEINE UNTIL WE HAVE A CHANCE TO PRESENT TO THE SUBCOMITTEE 5. OUR NEXT STEP FOR SUBCOMITTEE 1 ARE LISTED HERE, FOOD AND SUPPLEMENTS FOR 3 NUTRIENT, CALCIUM, IRON AND VITAMIN D WE'LL DO SUBGROUP ANALYSES OF NUTRIENT INTAKE MEANS AND SOME DISTRIBUTION BY RACE ETHNICITY, ACCULTURATION AND PREGNANCY AND ADDITIONAL NUTRIENTS SUCH AS SATURATED FAT AND OVERALL ENERGY SO THAT'S IN OUR PLANS FOR THE NEXT FEW MONTHS. WE ALSO PLAN TO LOOK AT FOOD GROUPS INTAKE PATTERNS APPROXIMATE TRENDS USING THE FOOD GROUP METHOD, WHICH IS A LITTLE BIT DIFFERENT THAN FOOD CATEGORY. FOODS AS CONSUMED AND IN THE FOOD CATEGORY AS CHERYL MENTIONED SUBGROUP ANALYSES. FOOD SOURCE AN LOCATION, IN OTHER WORDS WHERE ARE PEOPLE EATING WHAT KIND OF FOODS, DELVE MORE INTO PATTERNS OF BEVERAGE INTAKE. DIETARY PATTERNS, ADHERENCE AND TRENDS, CHRONIC DISEASE INDICATORS PREVALENCE AN TRENDS AND POTENTIAL YEAR CONSUMPTION MICRONUTRIENTS FROM FRUITS PLUS SUPPLEMENTS FOR THOSE WHO ARE LISTED HERE, CALCIUM, IRON AND FOLATE. WE WILL EXAMINE THE USDA FOOD PATTERNS, ADEQUACY AND IMPACT OF POTENTIAL CHANGES AN RECOMMENDATIONS AND ALSO EXAMINE CURRENT LEVEL OF PHYSICAL ACTIVITY IN YOUTH, ADULTS AND OTHER ADULTS AS WAS MENTIONED IN BARBARA'S PRESENTATION AT THE BEGINNING. SO WE'LL OPEN TO QUESTIONS NOW STARTING WITH ANNA MARIA'S QUESTIONS WHICH HAD TO DO WITH WHAT WERE OR SOURCES OF DATA TO THINK ABOUT IRON AND WHETHER IRON SHOULD BE NUTRIENT OF PUBLIC HEALTH CONCERN. LET ME MENTION OUTSET WE CALL THESE KEY FINDINGS AT THIS POINT, IT'S AN IT RA RATIVE PROCESS, WE'RE NOT -- ITERATIVE PROCESS. WE'RE NOT READY FOR RECOMMENDATIONS OR CONCLUSIONS SO THESE ARE KEY FINDINGS. THE DATA COME FROM USING THE BIOMARKER DATA AS WELL AS PERCENT OF POPULATION IN THESE SUBGROUPS THAT MIGHT BE BELOW EAR. SO WE FIND AMONG ADOLESCENT YOUNG ADULT AND MIDDLE ADULT WOMEN WHO WERE UP TO THE MENOPAUSAL POINT, ABOUT 15 TO 16% ARE BELOW THE ESTIMATED AVERAGE EAR FOR IRON. NANOGRAMS PER ML AN 14 1/2 PERCENT HAVE INADEQUATE BODY IRON. ESTIMATE 7.2 TO 11.6 MILLION WOMEN HAVE LOW BODY STORES AND 3.8 MILLION HAVE IRON DEFICIENCY ANEMIA, BASED ON THOSE FIGURES WE FELL IT IMPORTANT NOT TO IGNORE. WE WOULD WELCOME ADDITIONAL INPUT FROM YOU AND OTHERS ANNA MARIA TO HELP US THINKN'T THIS NUTRIENT MORE. CORRECTION, NOT THAT I DON'T NECESSARILY THINK IT SHOULD BE NUTRIENT OF CONCERN I WAS ASKING FOR MORE INFORMATION ABOUT THE PREGNANCY GIVEN THE FACT IF YOU THINK ABOUT INTERVENING PREGNANCY, THE INTERVENTIONS OF PROVIDING IRON SUPPLEMENTATION HAVE NOT BEEN EFFECTIVE FOR MILD AND MODERATE ANEMIA DURING THE PREGNANCY. THAT WAS MY QUESTION. AS YOU NOTED WE HAVEN'T EXAMINED THE PREGNANCY STATUS YET, WE'LL DO THAT IN THE UPCOMING MONTHS SO WE COME YOUR INPUT AT THAT POINT. QUESTION. SO THE OTHER SIDE OF THE COIN (INAUDIBLE) DIABETES AN CARDIOVASCULAR DISEASE AND CANCERS. OVERLOAD OVER CONSUMPTION IRON SOURCES OF SUPPLEMENT HAS BECOME MORE PERMANENT POST MENOPAUSAL AND OLDER MEN SO THE QUESTION IS HOW TO BALANCE, TWO SIDES OF THE SAME COUNT. THAT'S AN IMPORTANT POINT FOR INTAKE DISTRIBUTIONS WE DO NOT FIND ANY AGE OR SEX SUBGROUPS THAT APPROACH TOLERABLE UPPER LIMIT OF INTAKE. WE HAVE YET TO DO THE FOOD PLUS SUPPLEMENTS SO THAT MIGHT FURTHER INFORM THE WAY WE'RE THINKINGN'T THIS SO YOU'RE RIGHT THAT WE WILL CONSIDER THESE IMPORTANT POINTS. CAN YOU COMMENT ON HOW YOU HI THE ROLE OF THE LACTOSE INTOLERANT ARE PLAYING IN THAT OR HOW WE SHOULD THINK IN TERMS OF RECOMMENDATIONS AND INTERVENTIONS, THINGS OF THAT SORT KNOWING THAT CERTAIN SUBPOPULATIONS MAY HAVE A HIGHER RATE OF LACTOSE INTOLERANCE THAN RESULTING INs THIS FININGS THAT YOU SEE? -- FINDINGS THAT YOU SEE? VERY GOOD QUESTION. I'LL ASK STEVE TO ADDRESS THAT QUESTION. HE'S THE EXPERT ON THE COMMITTEE AND VITAMIN D. SPEAKING OF SOURCES OF CALCIUM VITAMIN D RIGHT NOW THE CURRENT PRIMARY SOURCE IN THE UNITED STATES DIET IS DAIRY PRODUCTS FOR BOTH OF THOSE BEING ABOUT 50 TO 60% AS I RECALL OFFHAND, THERE ARE OTHER GOOD SOURCES INCLUDING INDIVIDUAL TABLES WHICH ARE GOOD SOURCES THOUGH INTAKE IS RELATIVELY HIGH SO IT'S IMPORTANT TO FOCUS ON FOOD, WE ALL NEED TO LOOK WHETHER OR NOT THE FOOD AS WE CURRENTLY HAVE IN THE UNITED STATES THE DISTRIBUTION CAN MEET REQUIREMENTS FOR THE HIGHEST RISK POPULATION. MINM NELSON, IN TERMS OF ADDED SUGAR, SORRY TO KEEP COMING BACK, ARE YOU GOING TO PRESENT TOTAL ADDED SUGAR AS WELL AS WHERE THEY'RE COMING FROM? YES WE CAN DO THAT. IT WOULD BE HELPFUL TO KNOW ACROSS AGE AN GENDER TOTAL. OKAY. THAT'S GREAT. THANKS. SO BACK TO THE VITAMIN D BECAUSE I THINK WE HAVE SEEN THAT THE VITAMIN D INTAKES HAVE BEEN LOW AND THERE HAS BEEN A LOT OF PRESS IN RELATION SHIP TO VITAMIN D DEFICIENCY IN THE POPULATION SO WONDERING IF YOU'RE INCLUDING THAT AS BIOMARKER TO LOOK AT CONGRUENCY BETWEEN WHAT DIETARY DATA TELLS US AND LITERALLY WHAT THE PREVALENCE OF VITAMIN D DEFICIENCY IS. AGAIN TO STEVE FOR THAT QUESTION. THE INSTITUTE OF MEDICINE REPORT DID IDENTIFY THE MAJORITY OF VITAMIN D COMES FROM SUNSHINE EXPOSURE OVERALL BUT THERE'S SIGNIFICANT LIMITATIONS BASED ON LATITUDE, RACIAL AND SKIN COLOR AND THE LIKE 20 NANOGRAMS AS THE INSUFFICIENT THAT THERE WAS NOT AS MUCH DEFICIENCY AS SEEN FROM INTAKE DATA. SO I THINK THAT THAT DOES NEED TO BE INTEGRATED TOGETHER IN TERMS OF MAKING RECOMMENDATIONS. STEVE, A FOLLOW-UP QUESTION ON VITAMIN D AN CALCIUM. MY IMPRESSION IS THAT IOM IS COMING IN NEW IOM COMMITTEE TO REVISE VITAMIN D ABOUT CALCIUM DRI. I DON'T KNOW THE DETAILS BUT -- SO THAT COMMITTEE ACTUALLY HAPPENED AND THOSE REPORTS CAME OUT IN 2010. THERE WERE INCLUDED VERY END OF THE 2010 REPORT BUT NOT MUCH MORE DETAIL SO I THINK WE'LL HAVE MORE OPPORTUNITY TO LOOK AT THAT INFORMATION AND HOW IT MIGHT AFFECT POLICY FOR THIS COMMITTEE. ALLEY. I ASSUME THE RECOMMENDATION OUT OF PUBLIC HEALTH SERVICE REGARDING POTENTIAL ADVERSE EFFECT OF CALCIUM SUPPLEMENTATION NEEDS TO BE TAKEN INTO CONSIDERATION ALSO. VERY GOOD POINT. OKAY. THANK YOU VERY MUCH. SO THIS IS OUR REPORT OUT ON OUR PROGRESS TO DATE WITH SUBCOMITTEE FIVE. MARY NELSON ON OUR SUBCOMITTEE STEVE ABRAMS, TOM BRENNA FRANK HU AND BARBARA MILLEN AND ACKNOWLEDGE ALICE HAS BEEN A ACTIVE PARTICIPANT IN OUR SUBCOMITTEE AS WELL SO VERY GOOD TEAM. THANK YOU. SO WE ARE FOCUSING ON TWO AREAS BARBARA MENTIONED, ONE ON FOOD SAFETY AND WE'RE SYSTEMATICALLY REVIEWING THE EVIDENCE FOR TARGETED FOOD SAFETY CONCERNS BOTH THE INDIVIDUAL LEVEL AND POPULATION SCALE, I'LL COME BACK TO THAT IN A LITTLE BIT. THEN IN TERMS OF SUSTAINABILITY WE'RE REALLY THIS IS A NEW AREA THAT PEOPLE KNOW AND WE'RE REALLY LOOKING AT AND TRYING TO UNTHE LINK BETWEEN FOOD INTAKE SUSTAINABILITY AND FOOD SECURITY. THIS ONE ABLE TO PROVIDE EVIDENCE TO INFORM DIETARY GUIDANCE SUSTAINABLE FOOD SYSTEM TO ENSURE LONG TERM FOOD SECURITY, EEL COME BACK IN MORE DETAIL ON OUR RATIONALE FOR THAT. WE HAVE HAD A NUMBER OF EXPERTS AND CONSULTANT THIS IS A LIST OF EXPERT WHEN WE WERE A WORKING GROUP ALL THE WAY ADS RECENT AS PAST TUESDAY, OUTSIDE AND WITHIN THE FEDERAL GOVERNMENT. WE HAVE GONE THROUGH RIGOROUS CLEARANCE, WE HAVE TWO SUBCOMITTEE CONSULTANTS, MIKE HAM FROM MICHIGAN STATE UNIVERSITY, HE SPOKE TO THE 2010 DIETARY GUIDELINES AND TIM GRIFFIN FROM TUFTS UNIVERSITY BOTH EXPERTS AROUND SUSTAINABILITY. TERMS OF FOOD SAFETY, THE AREAS WE LOOK AT, NUMBER ONE, WE HAVE A CAREFUL REVIEW OF THE 2010 DGAC TECHNICAL REPORT RELATED TO INDIVIDUAL BEHAVIOR. WE LOCKED AT THAT TIME WHOLE FOOD SAFETY SECTION AND IT WAS PRIMARILY FOCUSED ON INDIVIDUAL FOOD SATISFITY BEHAVIOR, TALK ABOUT THAT IN SECOND. THE OTHER AREAS WE'RE LOOKING AT ARE USUAL COFFEE, CAFFEINE CONSUMPTION AND HIGH DOSE WE WILL BE LOOKING AT HIGH DOSE CAFFEINE CONSUMPTION AND ASPARTAME IN PARTICULAR. IN TERMS OF THE 2010 DIETARY GUIDELINES TECHNICAL REPORT, WE HAVE BEEN GET ADVICE AND HIGHLY COORDINATING THIS WITH OTHER FEDERAL AGENCIES AND WE ARE PRIMARILY LOOKING AT AREAS WHERE THERE IS UPDATED INFORMATION OUR RECOMMENDATION IS THAT WE WILL BE BRINGING QUESTIONS 1 THROUGH 6 FROM PART B SECTION 8 IN THE 2010 TECHNICAL REPORT FORWARD BUT WE ARE GOING TO BE UPDATING, THERE ARE A COUPLE OF AREAS WE'RE GOING TO BE UPDATING WITH NEW TEMPERATURES FOR COOKING. AND WE WILL NOT BE BRINGING FORWARD BECAUSE THEY'RE IN THE TECHNICAL REPORT, THEY DON'T NEED TO BE BROUGHT FORWARD. THERE'S SOME AREAS THERE AROUND ACTUAL FOOD SAFETY BEHAVIORS. AND SORT OF USE OF SOME TECHNOLOGY. SO WE WON'T BRING THOSE FORWARD. AND WE ARE WORKING CLOSELY WITH OTHERS AT USDA TO REFLECT THE CURRENT GUIDANCE. I'M GOING TO HAND OVER NOW TO FRANK. TO TALK ABOUT NEW AREA AROUND FOOD SAFETY AND THIS IS REALLY LOOKING AT COFFEE AND CAFFEINE CONSUMPTION, IT'S BEEN VERY INTERESTING. THANK YOU. A LITTLE BIT OF BACKGROUND, AS STEVE MENTIONED COFFEE IS ONE OF THE MOST WIDELY CONSUMED BEVERAGES AMONG AMERICANS AND RESPECTS MAJOR SOURCE OF CAFFEINE. THE FACTS OF CAFFEINE CONSUMPTION ON HEALTH OUTCOMES HAVEN'T BEEN EVALUATED BY ANY PRIOR DGAC. SO THIS SUBCOMITTEE HAS RECENTLY REVIEWED SYSTEMATIC REVIEW ANALYSIS PUBLISHED THINGS ON COFFEE AND CAFFEINE INTAKE AND VARIOUS HEALTH OUTCOMES. SO I CAN TELL YOU THERE IS A LOT OF BUZZ IN THE CAFFEINE LITERATURE. IT'S AMAZING TO SAY HOW MANY META ANALYSIS SYSTEM MA TECH REVIEWS HAVE BEEN PUBLISHED COFFEE AND CAFFEINE CONSUMPTION ABOUT RANGE OF HEALTH OUTCOMES. MOST OF THE STUDIES WERE PUBLISHED IN THE PAST FIVE YEARS. SO FOR THIS OVERVIEW WE REVIEWED 52 SYSTEMATIC REVIEWS ON MAJOR HEALTH OUTCOMES, MORTALITY, 15 META ANALYSIS ON CARDIOVASCULAR OUTCOME, STROKE, CORONARY ARTERY DISEASE, ATRIAL FIBRILLATION, BLOOD PRESSURE, LIPIDS, FIVE META ANALYSIS ON TYPE 2 DIABETES, 22 META ANALYSIS TOTAL IN DIFFERENT CANCER SITE, SIX SYSTEM MA IT CAN REVIEW OR META ANALYSIS ON COGNITION AND PARKINSON DISEASE AND TWO META ANALYSIS ON PREGNANCY RELATED OUTCOMES. THESE ARE THE KEY FINDINGS FROM META ANALYSIS ON CARDIOVASCULAR DISEASE AND TYPE 2 DIABETES. THERE IS CONSISTENT EVIDENCE THAT MODERATE COFFEE CONSUMPTION FROM ONE TO 6 CUP TODAY WAS MOSTLY ASSOCIATED WITH LOWER RISK OF TOTAL MORTALITY, ESPECIALLY (INAUDIBLE) MORTALITY. MODERATE COFFEE CONSUMPTION WAS ASSOCIATED WITH I'M SORRY DENSE OF CARDIOVASCULAR DISEASE INCLUDING CORONARY HEART DISEASE AND STROKE. THE LOWEST RISK WAS OBSERVED AT THREE TO FIVE CUPS PER DAY. AND THIS ASSOCIATION WAS INDEPENDENT OF SMOKING AND WIDE RANGE OF CARDIOVASCULAR RISK FACTORS. THERE IS NO EVIDENCE OF INCREASE BLOOD PRESSURE OR RISK OF (INAUDIBLE) WITH LONG TERM COFFEE CONSUMPTION, RANDOMIZED CLINICAL TRIALS HAD FOUND UNFILTERED COFFEE BUT NOT FILTERED COFFEE INCREASE INCREASE TOTAL CHOLESTEROL AND LDL CHOLESTEROL. THERE'S CONSISTENT EVIDENCE THAT COFFEE CONSUMPTION WAS ASSOCIATED WITH RISK OF TYPE 2 DIABETES IN DOSE RESPONSE MANNER. INDEPENDENT OF WIDE RANGE OF LIFESTYLE AND DIETARY FACTORS ESPECIALLY OBESITY. BASED ON THERE'S A 7% REDUCTION IN TYPE 2 DIABETES RISK FOR EACH ONE CUP COFFEE A DAY CONSUMPTION AND NO THRESHOLD EFFECTS FOR TYPE 2 DIABETES IN THE DATA FOR CDD. REGULAR COFFEE CONFER SIMILAR BENEFITS SO SUGGESTS THE BENEFITS ON TYPE 2 DIABETES ENACTED TO BE CAFFEINE AND WE KNOW THAT COFFEE CONTAINS NUMEROUS BIOACTIVE COMPOUNDS IN ADDITION TO CAFFEINE. RELATIVELY SMALL SHORT TERM TRIALS INGEST OF 200 TO 500-MILLIGRAM CAFFEINE INCREASE BLOOD SUGAR AMONG PEOPLE WITH TYPE 2 DIABETES BUT WE DON'T KNOW THE LONG TERM EFFECTS OF THIS LEVEL OF CAFFEINE CONSUMPTION. FOR CANCER COFFEE CONSUMPTION ASSOCIATED WITH LOWER RISK OF LIVER CANCER END MEET TRIAL CANCER, POST MENOPAUSAL CANCER, BRAIN CANCER, PARTLY ASSOCIATION BETWEEN COFFEE AND LUNG CANCER AND BLOOD CANCER BUT THIS WAS PRIMARILY CONFOUNDED BY SMOKINGING. SO IN TERMS OF DRAFT CONCLUSION PREPONDERANCE OF EVIDENCE SHOW MODERATE COFFEE CONSUMPTION WAS ASSOCIATED WITH LOWER RISK OF DIABETES IN HEALTHY DOGS NO EVIDENCE OF HIGHER COFFEE CONSUMPTION WITH INCREASED RISK. THERE WAS CONSISTENT EVIDENCE REGULAR CONSUMPTION OF COFFEE WITH LOWER RISK OF LIVER AND ENDMETRIAL CANCER, NO ASSOCIATION OBSERVED FOR OTHER CANCER SITES. IN TERMS OF COGNITIVE FUNCTION, PROTECTIVE EFFECTS OF CAFFEINE FROM DIFFERENT SOURCES AN IMPAIRMENT HIGHER ASSOCIATED WITH 16% HOER RISK OF VARIOUS MEASURES OF COGNITIVE DECLINE OR IMPAIRMENT CONSISTENT ASSOCIATION BETWEEN HIGH ERICA PHONE CONSUMPTION AND LOWER RISK PARKINSON DISEASE AFTER ADJUSTMENT FOR SMOKING. 200-MILLIGRAM PER DAY INCREMENT CAFFEINE INTAKE ASSOCIATED WITH 17% LOWER RISK OF PARKINSON DISEASE. SO FOR NEURODEGENERATIVE AND DISEASE AND COGNITIVE FUNCTION LIMITED EVIDENCE INDICATED CAFFEINE CONSUMPTION WAS ASSOCIATED WITH MODERATE LOWER RISK OF COGNITIVE DECLINE OR IMPAIRMENT AND LOWER RISK ALZHEIMER'S DISEASE. THERE WAS CONSISTENT EVIDENCE OF PROTECTIVE ASSOCIATION BETWEEN CAFFEINE INTAKE AND PARKINSON DISEASE. TWO META ANALYSIS AT PREGNANCY OUTCOMES IN A RECENT META ANALYSIS, THERE'S NO ASSOCIATION BETWEEN CAFFEINE INTAKE DURING PREGNANCY AND PRE-TERM BIRTH IN EITHER COHORT OR CASE CONTROL STUDIES, THERE'S SUGGESTION OF SLIGHT INCREASE RISK FOR HIGH INTAKE DURING THE SECOND TRIMESTER IN COHORT STUDIES ONE EARLIER META ANALYSIS SUGGESTS A POSITIVE ASSOCIATION BETWEEN CAFFEINE CONSUMPTION MORE THAN 150-MILLIGRAM PER DAY AND INCREASE RISK OF SPONTANEOUS MISCARRIAGE AND LOW BIRTH WEIGHT BUT THOSE STUDIES DIDN'T (INAUDIBLE) IMPORTANT COP FOUNDERS SUCH AS SMOKING AND (INAUDIBLE) USE. SO THERE IS LIMITED EVIDENCE ON RELATIONSHIP BETWEEN CAFFEINE CONSUMPTION AN PREGNANCY RELATED OUTCOMES. IN TERMS OF HEALTH IMPLICATIONS CONSUMPTION OF COFFEE CAFFEINE IN THE USUAL RANGE IS NOT ASSOCIATED WITH INCREASE RISK OF CHRONIC DISEASE IN HEALTHY ADULTS BUT INSTEAD MAY CONFER BENEFITS MULTIPLE HEALTH OUTCOMES IN TYPE 2 DIABETES, SEVERAL CANCERS IN MARCH KIN SON'S DISEASE. MODERATE CAFFEINE CONSUMPTION INCORPORATED INTO HEALTHY LIFESTYLE WHEN ENGAGE IN OTHER HEALTHY BEHAVIORS SUCH AS NOT SMOKING, CONSUMING A HEALTHY DIET AND PHYSICALLY ACTIVE BUT CAUTION IS NEEDED FOR VULNERABLE POPULATIONS SUCH AS PREGNANT WOMEN AND (INAUDIBLE). WE SEVERAL RESEARCH GAPS MORE DATA NEEDED FOR COFFEE CONSUMPTION AN CANCER AT DIFFERENT SITES, WE NEED MORE DATA EFFECTS OF COFFEE, CAFFEINE ON COGNITIVE FUNCTION, NEURODEGENERATIVE DISEASE AN DEPRESSION. WE NEED TO STUDY THE BIOLOGICAL MECHANISMS UNDERLYING THE PROTECTING EFFECTS OF COFFEE OR CAFFEINE ON DIABETES AND CARDIOVASCULAR DISEASE, WE NEED MORE DATA, POPULATIONS ESPECIALLY PREGNANT WOMEN AND WE NEED TO STUDY EFFECTS OF COFFEE OR CAFFEINE LONG TERM HEALTH OUTCOMES AMONG PEOPLE WITH EXISTING CHRONIC DISEASES SUCH AS DIABETES, CANCER, CARDIOVASCULAR DISEASE, NEURODEGENERATIVE DISEASE AND THOSE WITH DEPRESSIVE SYMPTOMS FINALLY, MORE DATA ON THE EFFECT OF CAFFEINE ENTAKE OF SLEEP PATTERN, QUALITY OF LIFE, DEPENDENCY AND ADDICTION. THANK YOU. [APPLAUSE] I THINK WE HAVE GOT TIME, ARE THERE ANY BURNING -- I LIKE THE IDEA OF THE BURNING OR BUZZING QUESTIONS. RAFAEL. FRANK, DID YOU MENTION THE STUDY PERSPECTIVE COHORT VERSUS RCTs? FOR HEART OUTCOMES SUCH AS TYPE 2 DIE BOW TEASE, CANCER, NEURODEGENERATIVE DISEASE, THE VAST MAJORITY WERE PERSPECTIVE COHORT STUDIES. FOR INTERMEDIATE OUTCOMES SUCH AS BLOOD GLUCOSE, BLOOD LIPIDS AND PRESSURE, SHORT TERM RCTs. ANY OTHER BURNING QUESTIONS? ON CAFFEINE? OKAY. WE HAVE BEEN LOOKING INTO ASPARTAME, AND ONE CRITERIA REVIEWING FOOD SAFETY QUESTIONS, WHICH REALLY, ARE THERE ANY NEW DATA FOR THIS THE EUROPEAN FOOD SECURITY OFFICERTY AUTHORITY, I AM TOLD, I'M SIMILAR BUT NOT EXACTLY THE SAME AS FDA. IT'S A NON-GOVERNMENTAL ORGANIZATION BUT SUPPORTED BY EUROPEAN UNION THAT DID A DEEP REVIEW OF RE-EVALUATION OF THE SAFETY OF ASPARTAME AS A FOOD ADDITIVE. SO WE HAVE BEEN LOOKING AT THAT SUPPORT, EXPERT OPINION FROM FDA ON THIS REPORT AS WELL. AND IN LOOKING AT THIS, STEVE ABRAMS IS REVIEWING THIS IN DETAIL BUT OVERALL INTAKE OF AS PARTAKE TAME ARE NOT ASSOCIATED WITH INCREASE RISK OF ADVERSE OUTCOMES IN POPULATION WHOSE DON'T HAVE KU. THERE ARE SOME STUDIES THOUGH THIS IS NOT THE OVERALL FINDING BY THE REPORT BUT WE'RE LOOKING MORE DEEPLY INTO THIS, SOME CONCERN REQUIRING FURTHER INVESTIGATION THAT EXISTS FOR SOME CANCERS ESPECIALLY HEMATOPOIETIC ONES BUT THE DATA DO NOT CLEARLY IDENTIFY A RELATIONSHIP. THE POSSIBILITY THAT INTAKES AMONG THE HIGHER EXPOSURE GROUPS DURING PREGNANCY COULD BE ASSOCIATED WITH PRE-TERM DELIVERY REQUIRES FURTHER EVALUATION OF RESEARCH. OVERALL EXPOSURES UP TO 40 MGs PER KILOGRAMS A DAY, THE EUROPEAN ARE 40, U.S. IS 50. DO NOT POSE SAFETY CONCERNS BASED ON MODELING OF EVIDENCE BASED ON SAFE BLOOD LEVELS AND DOSE RESPONSE MODEL. INTAKE EXCEEDING THIS ARE UNCOMMON IN THE U.S. POPULATION AND WE DECIDE THESE FINDINGS DO NOT APPLY TO INDIVIDUALS BKU WITH DEFECT. WE ARE IN THE EARLY STAGES BUT IF THERE'S QUESTIONS I WILL PASS IT TO STEVE BUT ARE THERE ANY BURNS QUESTIONS? OKAY. THEN WE WILL MOVE FORWARD. ANY OTHER COMMENTS? SO NEXT FOR FOOD SAFETY? WE ARE CONTINUING TO FINALIZE THE REVIEW AND UPDATE OF THE 20101 THROUGH 6 QUESTIONS, WORKING ON THE NORMAL NOMENCLATURE TO FINALIZE WORK ON COFFEE AND CAFFEINE AND WE'RE MOVING INTO HIGH DOSES OF CAFFEINE INTAKE ESPECIALLY WE ARE LIKELY TO FOCUS ON VULNERABLE POPULATIONS CHILDREN ADOLESCENTS AND POTENTIALLY OLDER ADULTS, THIS IS A HOT TOP UK GIVEN YOU WILL YOU HAVE TO DO IS GO TO THE STORE AND SEE HOW MUCH CAFFEINE IS AVAILABLE. SO IT'S A FASCINATING TOPIC. THAT'S -- DON'T HAVE ANY FINDINGS YET. SO SHIFTING GEARS. AND THIS IS A NEW AREA FOR THE DIETARY GUIDELINES TO LOOK AT I BRING BACK COMMENTS MADE THIS MORNING, BILL DIETZ SPOKE INTEGRATING HEALTHCARE IN THE ENVIRONMENTS WE LIVE. I WOULD POSIT IT'S IMPORTANT WE'RE CONNECTING THE FOODS THAT ARE GROWN AND HEALTH AND WELLNESS AND LONG TERM SECURITY. THIS IS A CRITICAL THING BECAUSE NOT ONLY WANT TO EAT WELL BUT WE ALSO WANT TOWER CHILDREN TO EAT FOR GENERATIONS TO COME. WE SEE THIS A THREE PRONGED PART FOOD PATTERNS AN UNTAKE RELATED TO FOOD SECURITY, DEFINITION WE USE IS WHEN ALL PEOPLE AT ALL TIMES HAVE ACCESS TO SUFFICIENT SAFE NUTRITIOUS FOOD TO MAINTAIN HEALTHY AND ACTIVE LIFE AND RELATING IT TO HAVING SUSTAINABLE FOOD SYSTEM. OUR WORK AND YOU WILL HERE IN SUBCOMITTEE FOUR, WE ARE DEFINITELY THESE TWO ARE LOOKING MORE AT SYSTEMS WIDE APPROACHES AND I THINK DR. ANGELL HAS LEFT BUT THINKING ALONG THOSE LINES, THE OTHER THING FROM DR. ANGELL, WE SHOULD BE ANALYZING LOOKING AT OTHER COUNTRIES THAT HAVE FORGED AHEAD OF THIS MORE QUICKLY THAN WE HAVE AND GET SOME LEARNINGS AND TO THAT ENTHERE'S INTERESTING WORK AROUND TIE TEAR GUIDANCE AND FOOD SUSTAINABILITY THAT'S BEING DONE IN HIGHLY OTHER SOME HIGHLY DEVELOPED COUNTRIES AND WE'RE LOOKING AT THAT IN DETAIL TO LOOK AT HOW THEY FORGED WITH THIS AREA. FINALLY, I WILL SAY BEFORE I MARCH AHEAD, I WANT TO THANK PUBLIC COMMENT THAT CAME FROM THE PUBLIC AND PRIVATE SECTOR. THIS IS HELPFUL TO INFORM OUR WORK. A WE CONTEMPLATED THIS WORK SO I REALLY THANK ALL OF THOSE OF YOU THAT ARE OUT THERE LISTENING. THANK YOU FOR YOUR PUBLIC COMMENT. SO THE QUESTIONS WE'RE SPENDING TIME ON NOW IS WHAT IS THE RELATIONSHIP BETWEEN POPULATION LEVEL DIETARY PATTERNS AS A WHOLE AND LONG TERM FOOD SUSTAINABILITY AN RELATED FOOD SECURITY IN WE'RE DOING THIS THROW A SYSTEMATIC MEL REVIEW. WE WERE NOT EXACTLY SURE IF WE'D SEEN ANYTHING AND WE HAVE SEEN A GOOD ROBUST AMOUNT OF EVIDENCE TO LOOK AT THIS. OUR MODEL IS DIFFERENT HELPING WITH THE FRAMEWORK AN THIS ONE HAS SOME IF YOU WILL PARALLEL SIDES. WE ARE LOOKING AT DIETARY PATTERNS DIFFERENT TYPES OF PATTERNS, BOTH MODELING, HEALTH OUTCOMES AN THINKING OF SORT OF THE SUSTAINABILITY OUTCOMES, THIS IS TRICKY BECAUSE THERE'S MANY TYPES OF OUTCOMES SO WE'RE LOOKING AT QUITE A FEW. THIS IS THE MODEL HELPING TO GUIDE THIS WORK. THE ORIGINAL FIRST PASS IDENTIFIEDD 1685 PAPERS, WE HAD RIGOROUS EXCLUSION DRYERIA THROUGH DIFFERENCE AVENUES, MANY WERE EXCLUDED IN THE END WE HAVE ENDED UP WITH 15 SYSTEMATIC REVIEWS, THESE ARE ORIGINAL PAPERS, ORIGINAL RESEARCH REPORTS. STUDIES WERE CONDUCTED IN THE U.S., THE UK GERMANS NETHERLANDS FRANCE SPAIN ITALY NEW ZEALAND, BRAZIL, THERE WAS A REGIONAL STUDY DONE IN NEW YORK STATE AND ONE GLOBAL. THEY WERE CARRIED BETWEEN 2003 AND 2014 AND MANY USED A PRIMARILY A MODELING APPROACH. DIETARY EXPOSURES, THERE'S A DIFFERENT STUDY USED WERE REALLY A RANGE FROM THE AVERAGE RESPECTED COUNTRY DIETARY GUIDELINE WITNESS THOSE COUNTRIES, DIFFERENT DIET SCENARIOS BASED ON MEAT FOODS AN PLANT FOODS AND ONE IN NEW YORK LOOKED AT 42 MODELS OF DIETARY PATTERNS. HEALTH OUTCOMES PRIMARILY RELATED TO A STATED DIETARY PATTERN AND THE EXISTING LITERATURE ON THE HEALTH OUTCOMES OF THESE. SO FROM MEDITERRANEAN, DIFFERENT VEGETARIAN ONES, INDICT QUALITY AS IN HEALTHY EATING UNDEX OR WHO INDEX AND MODELED ONES. AS YOU SEE HERE. SUSTAINABILITY OUTCOMES AROUND TWO MAJOR AREAS LIFESTYLE ASSESSMENT WHICH IS A METHODOLOGICAL FRAMEWORK TO LOOK AT ENVIRONMENTAL IMPACTS AND ENVIRONMENTAL FOOD PRINTS, AS WE HAVE BEEN LEARNING AS WE DO OUR WORK, THERE IS A MYRIAD OF DIFFERENT OUTCOMES AND IT'S IMPORTANT NOT TO HANG OUR HAT ON ANY ONE OF THESE IN PARTICULAR. FOOD SECURITIED YOU COMES, AVERAGE DAILY PATTERN AN SUSTAINABLE DIETARY PATTERN. ONE LOOK AT FOOD CONSTRUCT. AND THE FOOD BASKET ALSO DEVELOP ACCORDING TO PRINCIPLES OF DIETARY GUIDANCE WITHIN THE RESPECTED COUNTRIES SEVERAL, NOT JUST ONE. SO I'M GOING TO JUST COUPLE OF COMMENTS. I DON'T HAVE ANY DRAFT FINDINGS FOR THIS, I WILL TELL YOU IN REVIEWING THESE STUDIES WHAT I THINK IS REMARKABLE IS THERE ARE CONSISTENT FINDINGS FROM ALL THE STUDIES, IT'S NOT LIKE IT'S ALL OVER THE PLACE, IT'S TELLING A SIMILAR STORY. IT'S NOT JUST A VEGETARIAN DIET, THERE'S A VARIETY OF PATTERNS. THEY EMPHASIZE MORE PLAN BASE BUT NOT STRICTLY VEGETARIAN DIET. GOOD NEWS HERE IS THERE IS ALSO SEEMS TO BE PRELIMINARY BUT REMARKABLE ALIGNMENT WITH THE CURRENT DIETARY GUIDELINES, NOT SAYING THE AMERICANS EAT THE CURRENT DIETARY GUIDELINES BUT THE ACTUAL GUIDANCE. SO REALLY INTERRING WORK. NOW THAT WE HAVE OUR CONSULTANTS ON BOARD, WE ARE DOING A LOT OF WORK AROUND BACKGROUND BECAUSE ONE OF OUR KEY GOAL IS TO DEVELOP FRAMEWORK FOUNDATION SIMILAR TO 2010 WHEN WE INTRODUCED THE FOOD ENVIRONMENT AND NOW WE'RE DIG FURTHER TO THAT, THIS IS REALLY AN EMERGING TOPIC. WE HAVE PUBLIC COMMENT IN THAT AREA. IT'S A FASCINATING CONSTRUCT AROUND HEALTH AND SUSTAINABILITY FOR INFORMING FOOD SECURITY DIETARY GUIDANCE AS WE MOVE FORWARD. I'M NOT GOING TO SAY WE WON'T DO ANY OTHER AREAS. BUT THESE ARE AREAS BETWEEN NOW AND JULY WE'RE GOING TO BE LOOKING AT. SUBCOMITTEE MEMBERS ANYTHING ELSE I SHOULD ADD THAT I MISSED IN TERMS OF OUR WORK? OKAY. HAPPY TO TAKE QUESTIONS. THANK YOU. ANNA MARIE. I WANT TO GO BACK TO CAFFEINE RESULTS. MY UNDERSTANDING WORKING IN THE FIELD OF REPRICKTIVE HEALTH IS THE FACT THAT PREGNANCY OUTCOMES ARE HETEROGENEOUS SO YOUR CONCLUSION THAT SAY THERE'S LIMITEDDED INCONSISTENT EVIDENCE ON THE RELATIONSHIP BETWEEN CAFFEINE CONSUMPTION AND PREGNANCY OUTCOMES KIND OF BOTHERS ME BECAUSE I DON'T EXPECT THAT THE EFFECTS OF CAFFEINE NEGATIVE OR POSITIVE ARE THE SAME ACROSS THE DIFFERENT OUTCOMES SO I WOULD LIKE TO KNOW FROM YOUR REVIEW OF THE SYSTEMATIC REVIEWS, HOW MANY WERE INCLUDED FOR THE OUTCOME PRETERM BIRTH BECAUSE YOU'RE BASICALLY SAID THOSE WERE FROM CASE CONTROL STUDIES AS WELL AS COHORT STUDIES. THERE WAS NO ASSOCIATION BUT THERE WAS A SLIGHT ELEVATED RISK I WOULD LIKE THE KNOW WHAT THAT ELEVATED RISK WAS. THE MISCARRIAGES, THAT IS A TOTALLY DIFFERENT OUTCOME. SO ONCE AGAIN, WHAT WAS THE NUMBER OF STUDIES BECAUSE THERE ARE AT LEAST FROM TALKING TO MY COLLEAGUES, CAFFEINE IS NOT AS EXCITING ANY MORE TO STUDY IN PREGNANCY, YET YOU'RE CALLING FOR MORE RESEARCH SO JUST TRYING TO UNDERSTAND THAT. THE AMOUNT PREGNANCY RELATED OUTCOMES IS MUCH, MUCH LESS COMPARED TO OTHER HEALTH OUTCOMES AND THERE ARE ONLY TWO META ANALYSIS PREGNANCY RELATED OUTCOMES ONE PUBLISHED IN 2010 LOOKING AT PRE-TERM BIRTH, LOW BIRTH WEIGHT AND SO ON, SO FORTH. THAT META ANALYSIS SUMMARIZE COHORT AND CASE CONTROL STUDIES. THE VAST MAJORITY OF THE RESULTS WERE PRETTY NULL. THERE WAS ONLY ONE POSITIVE ASSOCIATION, RELATIVE RISK WAS PRETTY MODEST, 1.18 OR SOMETHING. SO IT IS KIND OF MARGINALLY SIGNIFICANT BUT OF COURSE WE CANNOT IGNORE THAT. BUT THE MAIN CONCLUSION FROM THAT META ANALYSIS THAT CAFFEINE COMES FROM WITHIN THE NORMAL RANGE OF -- AMONG PREGNANT WOMAN WAS NOT ASSOCIATED WITH ANY OUTCOMES. AND THEN THE OTHER META ANALYSIS PUBLISHED AD WHILE AGO, 15, 20 YEARS AGO WAS BASED ON LIMITED AND WAS POORLY DESIGNED STUDY, AS I MENTION, MANY OF THE STUDIES DIDN'T CONTROL FOR SMOKING WHICH IS THE MOST IMPORTANT CONFOUNDING FACTOR AND THEY FOUND A POSITIVE ASSOCIATION WITH RESPOND TANIOUS ABORTION AND OTHER OUTCOMES. AND THEN I REMEMBER THERE WAS A SUBSEQUENT MORE RIGOROUS DESIGN STUDY NO ASSOCIATION AT ALL. SO I DON'T KNOW WHY ALL THOSE HAVEN'T BEEN FOLLOWED UP FURTHER NOT INTERESTING BUT MY QUESTION IS WHY THIS -- CAFFEINE IS LESS INTEREST, I GUESS FOR PREGNANT WOMAN IS STILL IMPORTANT QUESTION IS STILL A CONCERN BECAUSE CAFFEINE METABOLISM IS SUBSTANTIALLY REDUCED DURING PREGNANCY. THERE IS A LONGER HALF LIFE FOR CAFFEINE AMONG THE INVENTORY POPULATION. THE REASON I WANTED YOU TO GO THROUGH THE EVIDENCE, I APPRECIATE THAT, IS THE FACT THAT THEN I THINK THE CONCLUSION STATEMENT NEEDS TO BE DIFFERENT. IN FACT, THE CONCLUSION STATEMENT NEEDS THE OUTCOME OF PRE-TERM BIRTH, I WOULDN'T NECESSARILY SAY THERE'S INCONSISTENT OR THERE'S LIMITED. BUT THERE IS NO ASSOCIATION FOUND. HOWEVER FOR MISCARRIAGES WHICH ARE MORE DIFFICULT TO STUDY, THAT'S THE ISSUE WITH IT. YOU WOULD THINK NOWADAYS WITH OUR ABILITY TO BE ABLE TO DETECT A PREGNANCY SO MUCH QUICKER WITH ALL THE HOME PREGNANCY TESTS, IT'S HARD TO CAPTURE CAFFEINE CONSUMPTION IN THE MOST APPROPRIATE TIME PERIOD. SEEMS TO ME THAT'S THE ONE WHERE THERE'S LIMITED EVIDENCE. AND MAYBE INSUFFICIENT EVIDENCE TO SAY IF THERE'S ANY KIND OF ASSOCIATION SO THAT WAS MY CONCERN, IT NODES TO BE BROKEN DOWN. THESE ARE JUST DRAFTS. OBVIOUSLY. AND WHAT I WOULD SAY, I THINK THEN WE SHOULD MAKE SURE TO COORDINATE WITH YOU, YOU UNDERSTAND COMPLEXITIES OF THIS TYPE OF OUTCOME WITH PREGNANT WOMEN WE CAN MAKE SURE WE COORDINATE AND MAKE SURE WE'RE RESPECTIVE TO THE SCIENCE AND APPROPRIATELY CAUTIOUS. RIGHT. RAFAEL. RAFAEL PEREZ-ESCAMILLA. THANK YOU SO MUCH TO YOU AND SUBCOMITTEE FOR CONCEPTUALIZING AND LAYING DOWN THE GROUND SO NICELY TO EXAMINE AN INCREDIBLY IMPORTANT QUESTION OF DIETARY PATTERNS AND SUSTAINABILITY. I AM EXTREMELY EXCITED THAT 15 STUDIES WERE IDENTIFIED. I HAVE NO IDEA, THEY WERE GOING TO BE ENOUGH STUDIES OUT THERE. WE ANTICIPATEDDED YOUR REPORT IN MOST STUDIES USE MODELING APPROACH. THE VALIDITY OF FINDINGS IS VERY MUCH RELATED TO THE VALIDITY OF ASSUMPTIONS MADE IN THOSE MODELS. ADDRESSING REAL U.S.IC OUTCOMES, HOW SENSITIVE FINDINGS ARE TO SMALL DISEASE YEAR AGOS IN ASSUMPTIONS SO MY QUESTION, HOW ARE YOU -- HOW IS YOUR SUBCOMITTEE PLANNING TO ASSESS THAT QUALITY OF ASSUMPTIONS OF THIS EVIDENCE? OUR TWO CONSULTANTS WERE JUST APPROVED THIS WEEK AND THEY COME -- THEY WERE ABLE TO JOIN OUR SUBCOMITTEE WORK ON WEDNESDAY. THIS IS WHY WE'RE NOT -- WE HAVEN'T PRESENTED ANY OF THE FINDINGS BECAUSE WE WANT TO GO MORE DEEPLY AND UNDERSTAND THE QUALITY OF THESE PAPERS. SO I DON'T HAVE A GREAT ANSWER THEY ALL ARE HIGH QUALITY AT THE MOMENT. BUT NEXT STEP IS LOOKING AT THAT. IN THIS AREA IF WE WANT -- YOU CAN'T JUST LOOK AT -- YOU HAVE TO BLEND BOTH DIETARY GUIDANCE PATTERNS WITH THE SUSTAINABILITY, IT'S NOTS ONE OR THE OTHER. HIGHLY THE BLEND AND HAVING THEM BE COMPLIMENTARY. I'M FASCINATED BY IT AND JUST GLUED TO THE PRESENTATION. MY QUESTION HAS TO DO WITHIN THE EVIDENCE THAT YOU REVIEWED SO FAR HAS ATTENTION BEEN PAID TO FARMERS MARKETS? WITH REGARD TO CARBON FOOTPRINT AND SUSTAINABILITY? REASON I'M ASKING THE QUESTION IS INCREASINGLY CITIES LARGE AND SMALL DEVOTE RESOURCES TO ENABLE FARMERS MARKETS OFTEN IN MULTIPLE LOCATIONS THROUGHOUT A CITY SO IF THERE IS AN EVIDENCE THAT SUPPORT THAT, IT MIGHT HELP THOSE ACTIVITIES. IT'S A VERY INTERESTING LANDSCAPE. I THINK SOME OF THAT WE WILL BE LOOKING AT IN SUBCOMITTEE FOUR IN TERMS OF ACCESS, THESE -- MANY OF THESE STUDIES WHEN YOU DO THEM, WHEN YOU DO THE MODELING, AROUND SUSTAINABILITY AND FOOTPRINT YOU HAVE THE LOOK AT THAT TIME WHOLE FOOTPRINT FROM THE TIME THE FARM TO FORK SO TO SPEAK IT ISN'T ALWAYS THE CASE THE MOST LOCAL WILL HAVE -- SO THAT IS -- BECAUSE OF SOME OF THE WAY USDA LOOK AT INPUTS AND FOOTPRINT YOU CAN DO THAT ASSESS,MENT. WE'RE NOT FAR ENOUGH ALONG. I'M NOT SURE WE'RE GOING TO LOOK AT FARMERS MARKETS BUT THE WHOLE FOOD SYSTEM PEACE. WAYNE. Q. WAYNE CAMPBELL, THANK YOU VERY MUCH. I'M REVIEWING THE INFORMATION YOU PRESENTED ON COFFEE AND CAFFEINE, AS I'M READING THROUGH IT SEEMS THOUGH YOU'RE USING THOSE TERMS SYNONYMOUSLY. YET THERE'S A BACK AND FORTH BETWEEN COFFEE CONSUMPTION AND ITS INFLUENCE -- INTENTIONAL. I APPRECIATE PERSPECTIVE HOW THE COMMITTEE IS APPROACHING THE ENTITIES DIFFERENTLY. Q. IT'S'S A GREAT QUESTION. I'LL HAVE FRANK ANSWER IT. ONE WE HAVE BEEN TALKING ABOUT A LOT. AS STEVE SHOWED CAFFEINE IN DIET COME FROM COFFEE. SO IT IT'S DIFFICULT TO SEPARATE THE EFFECTS OF COFFEE AN CAFFEINE EPIDEMIOLOGICAL STUDIES. HOWEVER, FOR SOME DISEASE OUTCOMES, COFFEE IS -- BEVERAGE IS MORE RELEVANT CAFFEINE MAYBE THE ACTIVE SUBSTANCE, SO EXAMPLE, TYPE 2 DIABETES WHICH HAS THE LARGEST AMOUNT OF PUBLISHED LITERATURE IN THAT AREA RESERGERS HAVE BEEN ABLE TO REGULAR COFFEE AND DECALF AND SEPARATED IT AND THE RESULTS ARE SIMILAR SO IT MEANS THAT TO PENIAL BENEFICIAL COMPOUND IN COFFEE, I'M NOT -- TO BE CAFFEINE COFFEE HAS THE SUM BENEFIT AS REGULAR COFFEE. ANOTHER NEURODEGENERATIVE DISEASE FOR PARKINSON'S DISEASE IT HAS BEEN SHOWN CAFFEINE CAN STIMULATE IN THE BRAIN AND PROTECT DOPAMINE PRODUCING NEURONS AND THAT MAY EXPLAIN BENEFICIAL EFFECTS OF CAFFEINE WITH OUTCOMES. FOR PREGNANCY RELATED OUT COMES, CAFFEINE IS SUBSTANTIALLY REDUCED DURING PREGNANCY AND IT CAN ALSO ENTER PLACENTA AND MAY GET INTO THE BLOODSTREAM OF THE FETUS. SO MORE PUT ON CAFFEINE I THINK IS DEPENDENT ON THE BIOLOGY OF DISEASE MECHANISMS. WE PLAN TO HAVE DISCUSSION ABOUT THAT BECAUSE IT IS CONFUSING SO IT WILL BE SET UP WITH THE CHAPTER. SO PEOPLE WILL UNDERSTAND THAT. ALICE A QUESTION. THIS IS A QUICK COMMENT. IT'S RELATED TO FARMERS MARKETS AND CARBON FOOTPRINT ARE VERY IMPORTANT AND I HOPE YOU WILL TAKE INTO CONSIDERATION THINGS LIKE AVAILABILITY, AFFORDABILITY, FROZEN FRUIT -- FROZEN VEGETABLES AN THOSE THINGS THAT IMPACT PRODDER SEGMENT OF POPULATION. AFFORDABILITY AND ACCESS IS A KEY PIECE. AND OLDER ADULTS THAT DON'T GET OUT AS MUCH AND INCLEMENT WEATHER AND ARTHRITIS AND CHOPPING AND CUTTING THINGS. THANK YOU VERY MUCH. THANK YOU. SUBCOMITTEE FOUR IS ON FOOD AND PHYSICAL ACTIVITY ENVIRONMENTS. AND COMMITTEE MEMBERS ARE MYSELF, MARY STORY AND LUCILLE ADAMS CAMPBELL, WAYNE CAMPBELL, MIM NELSON AN BARBARA MILLEN ON MOST OF OUR WEEKLY CALLS. ALSO ALICE JOINS INFREQUENTLY. SO THERE'S INCREASING RECOGNITION THAT INDIVIDUAL BEHAVIOR CHANGE CAN ONLY OCCUR IN SUPPORTIVE ENVIRONMENT. WITH ACCESSIBLE AND AFFORDABLE HEALTHY FOOD CHOICES AN OPPORTUNITIES FOR REGULAR PHYSICAL ACTIVITY. SO WE'RE INTERESTED IN COMMUNITY AND POPULATION BASED PUBLIC HEALTH APPROACHES FOR IMPROVING DIET AS WELL AS REDUCING OBESITY AND OTHER CHRONIC DISEASES. WE DIVIDE THE ENVIRONMENT INTO INTERESTED IN LOOKING IN THE PHYSICAL ENVIRONMENT SETTINGS WHERE FOOD IS PURCHASED AND CONSUMED AS WELL AS THE BROADER MACRO ENVIRONMENT WHICH CONSISTS OF LIKE THE HEALTHCARE SYSTEM AND FOOD MARKETING. WE HAVE THREE PRIMARY GOALS. WE WANT TO CAM EXAMINE, WE WANT TO UNDERSTAND AN ASSESS ROLE OF FOOD ENVIRONMENT PROMOTING OR HINDERING HEALTHY EATING IN KEY SETTINGS AN SUBPOPULATIONS. WE WANT TO IDENTIFY THE MOST EFFECTIVE EVIDENCE BASED DIET RELATED PROGRAMS PRACTICES AS WELL AS ENVIRONMENTAL AND POLICY APPROACHES USED TO IMPROVE HEALTH AND REDUCE DISPARITIES SO WHAT WE'RE INTERESTED IN WHAT BARBARA WAS SAYING EARLIER, IN IDENTIFYING WHAT REALLY WORKS. OUR THIRD GOAL WE WANT TO REVIEW EVIDENCE ON EFFECT OF FOOD AND PHYSICAL ENVIRONMENTS LOOKING AT OUTCOMES SUCH AS DIETARY INTAKE, BEHAVIOR AND HEALTH OUTCOMES SUCH AS WEIGHT STATUS. THE TOPIC AREAS THAT WE'LL BE LOOK AT INCLUDE FOOD ACCESS SCHOOLS CHILD CARE EDUCATION SETTINGS, THOSE ARE ALL UNDERWAY SO THOSE ARE IN ITALICS, ALSO BE LOOKING AT OTHER KEY SETTINGS. NOW TODAY WE DON'T HAVE ANY OF OUR FINDINGS YET BUT I WANT TO INTRODUCE AN EXPLAIN PROCESS SO WE CAN LET YOU KNOW WHERE WE ARE AND GET INPUT FROM YOU. SO WE HAVE NOT AT THIS POINT IN TIME DEALING WITH THREE TOPICS UNDERWAY, WE HAVE NOT INVITED ANY EXPERTS ON OUR CALLS OR HAVE CONSULTED MEMBERS BUT WE ARE LOOKING AT OTHER EXPERTS IN SOME OF THE OTHER AREAS THAT WE'RE GOING TO BE DEALING WITH. SO IN THE AREA OF WE STARTED LOOKING A AT FOOD ACCESS AND REFINING OUR RESEARCH QUESTIONS AND FOR THE DATA FOR THIS WHOLE APPROACH WE'LL USE THE NULL SYSTEM SO WE'LL BE LOOKING -- WE WON'T DO OUR OWN DATA ANALYSIS, WE'RE REALLY DOING SYSTEMATIC REVIEWS WITH THE NELL SYSTEM SO WE'RE LOOKING AT THE RELATIONSHIP BETWEEN THE NEIGHBORHOOD AND COMMUNITY FOOD ACCESS SPECIFICALLY AVAILABILITY AND AFFORDABILITY IN VARIOUS FOOD RETAIL SETTINGS SUCH AS SUPERMARKETS, GROCERY STORES, CORNER STORES AND OTHER FOOD RETAIL SETTINGS, LOOKING AT THE RELATIONSHIP BETWEEN FOOD ACCESS IN THE NEIGHBOR COMMUNITY ON INDIVIDUALS DIETARY INTAKE CALL AND WEIGHT STATUS. WE'LL LOOK AT FOOD ACCESS IN LOW INCOME AND MINORITY AREAS BECAUSE THAT'S WHERE WE'RE SEEING THE DISPARITIES IN FOOD ACCESS. WE WILL ALSO BE LOOKING AT AND HAVE THE SEARCH UNDERWAY LOOKING AT EARLY CHILDHOOD MOST CHILDREN IN AMERICA ARE IN SOME TYPE OF EARLY CARE AND EDUCATION PROGRAM SO WE'LL BE LOOKING AT WHAT EARLY CARE AND EDUCATION PROGRAMS AS WELL AS POLICIES AND PRACTICES HAVE POSITIVE INTAKE ON DIETARY AND EATING BEHAVIOR, WHAT'S THE EFFECT OF DIETARY INTERVENTIONS AND ENVIRONMENTAL INTERVENTIONS ON DIETARY INTAKE AND QUALITY AND BEHAVIOR IN EARLY CARE AND EDUCATION SETTINGS. AND WHAT'S THE EFFECT OF OBESITY PREVENTION INTERVENTIONS IN EARLY CARE EDUCATION SETTINGS ON WEIGHT OUTCOMES IN WOMEN AND CHILDREN. BECAUSE SCHOOLS ARE SUCH AN IMPORTANT VENUE WHERE CHILDREN SPEND THEIR TIME WE'LL LOOK AT WHAT SCHOOL BASED APPROACHES HAD POSITIVE IMPACT ON DIET IN SCHOOL AGE CHILDREN SO WHAT WORKS. IN A VARIETY OF SCHOOL BASED APPROACHES SUCH AS SCHOOL GAD GARDENS, FRESH FRUITS AND VEGETABLES, POLICY FOR VENDING MACHINES AN COMPETITIVE FOODS AND BECAUSE WE'RE REALLY LOOKING AT THE SCHOOL ENVIRONMENT. WE'LL ALSO BE LOOKING AT SCHOOL BASED NUTRITION EDUCATION AS WELL AS THE MULTI-COMPONENT INTERVENTION SUCH AS COMBINING DIET AND PHYSICAL ACTIVITY. WHAT IS EFFECT OF SCHOOL BASED INTERVENTIONS SUCH AS A ON DIETARY INTAKE, QUALITY, DIETARY QUALITY AND BEHAVIOR, AND SCHOOL AGE CHILDREN. SO CHILDREN IN ELEMENTARY SCHOOL, MIDDLE SCHOOL AND HIGH SCHOOL. AND THERE HAVE BEEN SEVERAL OBESITY PREVENTION PROGRAMS, IN SCHOOLS AND REALLY EXAMINING THE EVIDENCE ON EFFECTIVE SCHOOL BASED INTERVENTIONS ON WEIGHT AND SCHOOL AGE CHILDREN. NOW WITH FOOD ACCESS WE STARTED OUR UNDERWAY WITH THE PROCESS WITH FOOD ACCESS. WE'RE LOOKING AT FOOD ACCESS KEY CHARACTERISTICS TO FOOD ACCESSIBILITY WHICH INCLUDES ACCESSIBILITY TO HEALTHY FOODS MEASURED BY DISTANCE TO STORE OR NUMBER OF STORES IN AN AREA, INDIVIDUAL LEVEL RESOURCES AS WELL AS NEIGHBORHOOD LEVEL INDICATORS OF RESOURCES. SO WITH FOOD ACCESS RIGHT NOW, WE WILL BE USING THE SYSTEMATIC REVIEW AND BARBARA MENTIONED THIS IN HER COMMENTS USING THE WE DEVELOP ANALYTICAL FRAMEWORK FOR EACH TOPIC LOOKING AT THE TOPIC POPULATION INTERVENTION AND EXPOSURE, WHAT HEALTH OUTCOMES WE WANT TO LOOK AT BOTH FOR INTERMEDIATE HEALTH OUTCOMES AS WELL AS OUR HEALTH OUTCOMES. AND THEN REALLY IDENTIFY POTENTIAL COP FOUNDERS SO FOR EVERY TOPIC AREA TO AID IN THE NEL SEARCH. SO WE LOOKED AT HOW WE WANT TO -- WHAT TYPES OF STUDY DESIGNS AND RIGHT NOW IN PUBLIC HEALTH INTERVENTIONS HAVE BEEN SEVERAL ADVANCES IN DEVELOPMENT AND ANALYSIS OF DESIGNS OTHER THAN THAT OF RANDOMIZED CLINICAL TRIALS WHICH ARE DIFFICULT IN DOING PUBLIC HEALTH COMMUNITY BASED STUDIES. SO WE HAVE LOOKED AT INCLUDING A RANGE OF ALTERNATIVE DESIGNS OTHER THAN RANDOMIZED CONTROL TRIALS SUCH AS INTERRUPTED TIME SERIES OR MULTIPLE BASELINE CONTROL PRE, POST STUDIES BUT EACH OF THESE WERE REALLY WILL UNDERGO A VERY I THINK IN DEPTH ANALYSIS TO DESIGN AND QUALITY OF STUDIES. FOR THE FOOD ACCESS WE WERE LOOKING AT PEER REVIEW JOURNALS THAT AD ARTICLES BETWEEN 2004, 2013 AND WE'RE LOOKING AT AVAILABILITY AND AFFORDABILITY TO HEALTHY AS WELL AS UNHEALTHY FOODS IN THESE SETTINGS AND AGAIN LOOKING AT THE WEIGHT AND DIET OUTCOMES. SO SO FAR, WE HAVE DONE THE NEL SEARCH, WE IDENTIFIED 547 ARTICLES SO GREAT INCREASE IN NUMBER OF ARTICLES OF STUDIES THAT HAVE COME OUT. LOOK AT FOOD ACCESS ISSUES. THOSE WERE SCREENED DOWN TO WHEN -- ONCE YOU EXCLUDED ARTICLES BASED ON OUR EXCLUSIONARY CRITERIA, WE FOUND 56 ARTICLES REVIEWED FOR ELIGIBILITY AND WE FOUND 40 SYSTEMATIC OR 40 INDIVIDUAL STUDIES WE WILL BE EXAMINING, SIX OF 40 ARE LONGITUDINAL STUDIES AND THE LONGITUDINAL STUDIES HAVE BEEN ABSTRACTED AND WE ARE LOOKING AT DATA BUT OTHERS WILL BE DONE FAIRLY SOON. FOR EARLY CHILDHOOD, WE HAVE RESEARCH QUESTIONS AND WE WILL DECIDE THAT WE'LL BE -- AND I'LL GO THROUGH THE PROSETS THAT FOR THE EARLY CHILDHOOD QUESTIONS, WE WON'T BE DOING THE NEL SYSTEMATIC REVIEWS OF INDIVIDUAL ARTICLES, RATHER WE'LL LOOK AT REVIEWING EXISTING SYSTEMATIC REVIEWS. WE DID OUR CONCEPTUAL FRAMEWORK OF WHAT WE WANTED TO LOOK AT. EXPOSURES, OUTCOMES, STUDY DESIGNS. WE WERE LOOKING INITIALLY AT STUDIES THAT HAD BEEN DONE BETWEEN OR SYSTEM MA TUCK REVIEWS THAT HAD BEEN DONE BETWEEN 2010 AND PRESENT. SO THIS IS ONLY LOOKING AT THIS POINT SYSTEMATIC REVIEWS DONE THAT INCLUDED RESEARCH QUESTIONS. SO WE FOUND 149 ARTICLES THAT WERE IDENTIFIED THROUGH THE DATABASES. WE FOUND AFTER EXCLUDING ARTICLES USING OUR EXCLUSION CRITERIA THERE WERE 29 FULL TEXT SYSTEMATIC REVIEWS AND WE DID A DUPLICATION ASSESSMENT REALLY LOOKING AT THE STRENGTH OF THOSE SYSTEMATIC REVIEWS AND WE WERE USING THE STARS TOOL TO LOOK AT THE STRENGTH OF SYSTEMATIC REVIEWS SO WE FOUND THREE RECENT STRONG SYSTEMATIC REVIEWS SO WHAT WE DECIDED THAT WE'D LIKE TO DO IS USE THOSE SYSTEMATIC REVIEWS AND THEN SINCE MOST I THINK WE'LL DO -- WE'LL DO A LITERATURE SEARCH TO LOOK AT INDIVIDUAL STUDIES DONE SINCE THE LAST REVIEW, ABOUT ONE OR TWO YEARS AGO SO FOR ADDITIONAL ARTICLES. WITH SCHOOLS WE DECIDE ON APPROACH WHETHER TO DO A SYSTEMATIC REVIEW OF INDIVIDUAL ARTICLES WITH REVIEWS. INTERVENTIONAL FRAMEWORK INTERVENTION EXPOSURES AS WELL AS OUTCOME POTENTIAL CONFOUNDERS TO LOOK AT. AND THEN I THINK THAT -- I WAS GOING TO SAY THAT WITH SCHOOLS WE FOUND OVER 150 SYSTEMATIC REVIEWS OF INTERVENTIONS AND STUDIES THAT REALLY -- THAT WILL BE FOR THE SCHOOLS SO RIGHT NOW WE'RE DECIDING ONCE WE SEE THOSE SYSTEMATIC REVIEW ABSTRACTED THAT WILL SEE -- WE'LL USE THOSE SYSTEMATIC REVIEWS OR ELSE INDIVIDUAL PROCESS OR SUPPLEMENTING THE LAST SYSTEMATIC REVIEW IN SUPPLEMENTING WITH INDIVIDUAL ARTICLES. THE PHYSICAL ACTIVITY DISCUSSED BY BARBARA, THE NEXT STEPS ON THE TOPICS AGAIN THAT WE'LL CONSIDER THAT WE'LL BE NEXT MOVING TO LOOKING AT WORK SITE AND POLICY AND WE'LL MOVE ON TO OTHER TOPICS TO CONSIDER. SO I THINK NOW WE CAN OPEN UP TO QUESTIONS FROM ALL OF THE SUBCOMITTEE MEMBERS. OR ANY COMMENTS. BY ANY OF THE COMMITTEE MEMBERS. WE'RE EXCITED ABOUT THIS AREA BECAUSE IT HOLES SO MUCH POTENTIAL TRYING TO APPROACHES WHERE PEOPLE ARE GETTING FOOD AND WHAT INTERVENTIONS WOULD WORK TO FOSTERS BEHAVIOR CHANGES IN OTHER AREAS. MARY YOU IDENTIFIED THE AREAS CLEARLY SOMETHING YOU'RE BREAKING NEW GROUND IN ARE A A SENSE AND IT WILL BE VERY INTERESTING TO SEE WHAT YOU COME UP WITH. CHERYL ANDERSON, THINKING ABOUT FOOD ACCESS AND THE WAY YOU'RE GOING TO INCORPORATE DATA, SEEMS LIKE THERE'S NEW DATA ON THE SCENE LATELY AND YOU'LL NEED TO LIKELY CAPTURE SOME OF THAT FROM THE CLOSURE OF IN SOME CASES USING SYSTEMATIC REVIEW. SO THAT WILL BE A BIG JOB. FOOD ACCESS WE OTHER NOT USING SYSTEMATIC REVIEW. WE'LL USE NEL TO EVALUATE EACH PARTICULAR STUDY. THE OTHER QUESTION I HAVE, HOW ARE YOU THINKING ABOUT THE DEVELOPING CONCEPTS AROUND FOOD DESSERTS, FOOD SWAMPS, IN TERMS OF HOW YOU LOOK AT FOOD ACCESS? WONDERING JUST ABOUT THE VARIOUS DEFINITIONS THAT ARE OUT THERE, TRYING TO APPROACH THAT IN SOME SORT OF STANDARDIZED SYSTEMATIC WAY, MIGHT BE CHALLENGING. WHEN THEY DO THE DATA EXTRACTION WE'RE LOOKING AT VARIOUS DEFINITIONS AND NOTING THAT BECAUSE RIGHT NOW SO MANY DEFINITIONS. MEASURES ARE DIFFICULT. PEOPLE ARE USING SO MANY WAYS TO CATEGORIZE FOODS. OUT BRINGS TO QUESTION WHETHER OR NOT BEING DRIVEN BY INABILITY TO MEASURE THE CONTANT OR IF THERE'S SOME REAL TRUTH BEHIND LOOK OF ASSOCIATION BETWEEN THESE CONCEPTS AND VARIOUS OUTCOMES. I'M ALSO WONDERING WHETHER OR NOT YOU'RE THINKING ABOUT STUDIES USING GPS AND CENSUS LEVEL DATA TO TRY AND UNDERSTAND WHAT'S HAPPENING IN THESE -- WE WERE GOING OVER THAT YESTERDAY. THE DIFFERENT MEASURES USED IS REALLY ALL OVER THE BOARD. SO I THINK THAT IN MAKING ANY TYPE OF GRADING THE EVIDENCE AND MAKING ANY TYPE OF CONCLUSIONS WE HAVEN'T DONE THAT. BUT THAT CAN BE REALLY DIFFICULT IF EVERYONE IS USING DIFFERENT MEASURES. AND DEFINITIONS FOR FOOD DESSERTS OR WHATEVER. MARY, ARE YOU GOING TO BE WHEN YOU'RE LOOKING AT FOOD ACCESS, WILL YOU BE UNCORP RATING ALL THE STUDIES THAT MIGHT HAVE DONE IT IN INVOLVED INDIVIDUALS FROM ACROSS AGE GROUPS AS WELL ASETH MISTIES AND TEASE OUT HOW RELATIONSHIPS MIGHT DIFFER DEPENDING RACIAL ETHNIC MAKE UP WHERE THE STUDY SETTING WAS OCCURRING AS WELL AS OVER THE LIFE COURSE? YES. THE CHARTS ARE SO LONG BECAUSE WHEN THEY ABSTRACT IT'S NOT JUST STUDY DESIGN, DURATION, AGE GROUP, RURAL OR URBAN AREAS SO TRYING TO ABSTRACT ALL OF THAT IS JUST BEGINNING. MARY, RELATED TO THAT, I WAS SO STRUCK AT SOME COMMON THEMES IN THE EXPERT PRESENTATIONS THIS MORNING. AROUND USE OF MULTI-FACTORAL APPROACHES PARTNERSHIPS BETWEEN INDUSTRY AND PUBLIC SETTINGS AND SO FORTH. I'M WONDERING THE EXTENT TO WHICH THE LITERATURE AS YOU UNDERSTAND IT REALLY ABOUT ASPECT OF THE INTERVENTION, IF I LOOK AT PARALLEL LITERATURE ON INDIVIDUAL AND SMALL GROUP BEHAVIOR CHANGE OFTEN TIMES THE KEY COMPONENTS OF THE BEHAVIORAL STRATEGY AND SO FORTH THAT'S SO IMPORTANT ARE QUESTIONS ABOUT WHAT WORKS IS NOT VERY WELL DETAILED WITH ONE OF THE THINGS THAT WAS WONDERFUL ABOUT DEBORAH'S PRESENTATION TODAY BECAUSE SHE LAID THAT OUT SO CLEARLY. BUT IN THE LIT THATTURE -- LITERATURE, DOES IT LAY OUT HOW EFFECTIVE PARTNERSHIPS HAVE COME TOGETHER TO AFFECT SCHOOL BASED INITIATIVES IN YOUR REVIEW OF THE LITERATURE? DO YOU THINK YOU CAN SUCCESSFULLY CAPTURE THAT IN THE DATA EXTRACT -- EXTRACTION PROCESS? I THINK THAT'S OFTENTIMES HARD TO MEASURE HOW EFFECTIVE THOSE ARE. BUT CERTAINLY WHETHER WE CAN CERTAINLY LOOK AT NUMBER OF PUBLIC PRIVATE PARTNERSHIPS WHAT THAT CONSISTS OF. AND THOSE THAT DID WORK TOGETHER WITH OTHER COMMUNITY PARTNERS. WE COULD AT LEAST SEE IF THAT'S MENTIONED. I THEY'S SCENARIO WHERE I THINK THERE'S CERTAINLY GROWING ATTENTION ON THAT AREA. SO WE CAN SEE IF IT'S BEING DONE. FOLLOW-UP TO THAT QUESTION, BILL USED THE TERM POROSITY WHEN TALKING ABOUT A NEW THINKING ABOUT THE DIFFERENT ASPECTS OF INFLUENCE OR THE DIFFERENT INFLUENCES ON DIETARY AND PHYSICAL ACTIVITY BEHAVIOR. I THINK HE WAS URGING THAT WE NOT THINK OF SAY THE SECTOR AS SEPARATE FROM THE SOCIAL INFLUENCES SEPARATE FROM THE INDIVIDUAL INFLUENCES AND TRY TO SEE MORE INTEGRATION WAS THE OTHER TERMINOLOGY USED AND I WONDER IF THAT'S ALTERED YOUR THINKING HOW SC-4 MIGHT LOOK AT THINGS OR IF THAT'S REALLY PART OF THE APPROACH THAT'S BEING TAKEN. WE HAVE WEEKLY CALLS SO -- LOST AUDIO) SO ONE OTHER ISSUE IN TERMS OF SOME OF THE VARIOUS EXPOSURES THAT YOU'RE INTERESTED IN IS WILL YOU BE LOOKING ACROSS THE VERY ENVIRONMENT WHERE PEOPLE SORT OF LIVE, WORK, PLAY, PRAY, BECAUSE I THINK AN IMPORTANT ISSUE HERE COULD BE IF YOU HAVE ACCESS IN THE PLACE WHERE YOU WORK, BUT NO ACCESS IN THE PLACE YOU LIVE, YOU MIGHT SEE THE LACK OF ASSOCIATION BETWEEN HOME ENVIRONMENT AND OUTCOME BECAUSE THE PERSON IS SPENDING GOOD CHUCK OF TIME AT WORK AND UTILIZING THAT ENVIRONMENT FOR THEIR FOODS. SO ARE YOU GOING TO BE ABLE TO HAVE SUFFICIENT (LOST AUDIO) INTERESTING QUESTION, WE CERTAIN BUT I DON'T KNOW IF THE FIELDS EVOLVED THAT MUCH AND I DON'T KNOW IF WAYNE OR LUCILLE, IF YOU WANT TO COMMENT WHERE WE ARE IN THE PROCESS IS IDENTIFYING MUCH AS WE CAN TO GET TO MAIN TOPIC OF THAT WAS PRESENTED. THE DEVIL IS IN THE DETAILS ARE YET TO COME. THE OPPORTUNITIES TO CHARACTERIZE AND DESCRIBE THE IMPORTANT SECOND LAYER OF ENVIRONMENTS IS ONE THAT FROM A CURSORY LOOK AT THE LITERATURE IS BEGINNING TO BE TOLD BUT WHETHER OR NOT THERE'S SUFFICIENT INFORMATION TO MAKE COMMENTS, POLICY WORTHY OR CAN BE RANKED BASED ON OUR CRITERIA OF STRENGTH TO WEAKNESS OF THE LITERATURE IS TO BE DETERMINED YET. I WAS GOING TO ADD I THINK THAT THAT QUESTION IS GOING TO REALLY DEPEND HEAVILY ON LOOKING AT VERY CLOSELY AT THE METHODOLOGY USED IN THE STUDIES. JUST TO BE ABLE TO GO FROM THE DIFFERENT ENVIRONMENTS, FOR ANYBODY AT ANY GIVEN TIME I THINK WE WILL BE REALLY SURPRISED IF WE FIND STUDIES THAT REALLY SUCCESSFULLY WILL BE SUFFICIENT DATA AT THE CURRENT TIME. ONE OTHER POINT I WOULD MAKE, WE'RE VERY THE FEDERAL STAFF THAT ARE HELPING US BE ABLE TO NAVIGATE ALL THESE QUESTIONS ARE JUST PHENOMENAL BEING ABLE TO HELP US APPRECIATE THE ENORMITY OF THE WORK. EACH TIME THAT COMES UP YOU IN ESSENCE ARE ASKING A SEPARATE QUESTION WITH SEPARATE ANALSIS AN SEPARATE SYSTEMATIC REVIEW OR ASSESSMENT OF THE LITERATURE. SO WHILE THE IMPORTANCE OF THESE IS FANTASTIC, ABILITY TO ANSWER ANY ONE PARTICULAR NUANCE OF BROAD QUESTION IS GOING TO HAVE TO BE PRIORITIZED VERY CAREFULLY. BUT A FOLLOW-UP TO THAT, THIS LITERATURE HAS BEEN GROWING AND THIS IS AN AREA WE'LL SEE MORE ENORMOUS GROWTH WITH THE POTENTIAL FOR USING BIG DATA FROM PHONES ABOUT ALL THE OTHER TYPES OF TECHNOLOGY THAT WE'RE USING, THAT GPS, WHERE WE ARE, WHERE WE WORK, WHERE WE EAT. SO IN FACT, WHILE WHAT WE'LL SEE IS THE LIMITATIONS OF INSTRUMENTS AND ABILITY TO CAPTURE THIS INFORMATION FOR THE LAST TEN YEARS, WHICH HAS REALLY BEEN RELATED TO JEO CODING -- GE CODING HOMES AND CONVENIENCE STORES IN THE NEIGHBORHOOD BY THE TIME 2020 COMES FOR THE NEXT COMMITTEE THAT WE'LL BE ABLE TO SEE GROWTH IN THIS AREA TO ANSWER THAT QUESTION BECAUSE IT'S A VALID QUESTION. WE HOPE TO BE ABLE TO THROUGH OUR EVIDENCE REVIEW TO MAKE RECOMMENDATIONS FOR RESEARCH. I THINK BACK TO SHARON'S POINT IT'S AN INTERESTING WAY OF LOOKING AT IT. THAT'S WHAT HAPPENS WHEN THERE'S ACCESSING ONE ENVIRONMENT VERSUS ANOTHER. I THINK ANOTHER WAY TO LOOK AT IT IS DOES CHANGING ONE ENVIRONMENT CHANGING THE OTHER ENVIRONMENT SO WHEN WE THINK ABOUT KIDS IN SCHOOL, WHAT WE DO, WE WANT TO ENGAGE THE PARENTS AND WE'RE HOPING THAT WHATEVER THE KIDS ARE LEARNING AND EXPOSED TO IN SCHOOL WILL TRANSLATE INTO CHANGES IN THE HOMES. I'M NOT SURE IF THERE IS ANY RESEARCH OUT THERE TO EMPIRICALLY LOOK FOR THE ANSWER BUT IT'S ANOTHER WAY OF LOOKING AT THAT QUESTION. THANK YOU VERY MUCH. I THINK WE'LL MOVE ON TO SC 3 AND RAFAEL. SO SUBCOMITTEE 3 IS LOOKING AT FACILITATORS AND BARRIERS FOR PHYSICAL ACTIVITY AND DIETARY RECOMMENDATIONS, IMPLEMENTATION OF THOSE RECOMMENDATIONS, AND IS ALSO VERY INTERESTED IN EXAMINING BEHAVIORAL INTERVENTIONS AND THE CHARACTERISTICS OF THE MOST EFFECTIVE ONE IN TERMS O OF ELICITING BEHAVIOR CHANGE. WE ARE TO FOCUSING ON TWO CONTEXTUAL FACTORS, FIVE BEHAVIORS AND IN RELATIONSHIP TO THE LAST TIME WE PRESENTED THIS INFORMATION WE HAVE NOW ADDED THE EATING OUT BOX BECAUSE THAT COMMITTEE AS WHOLE MADE A DECISION TO ALSO LOOK AT IT AS A CROSS CUTTING THEME SO WE'RE GOING TO BE EXAMINING THAT QUESTION INDIVIDUAL LEVEL HOW IT AFFECTS DIETARY AND BODY FAT OUTCOMES. IN TERMS OF THE BEHAVIORAL CHANGE INTERVENTIONS, WE HELD SUBSTANTIAL DISCUSSIONS NOW, WE ARE VERY MUCH LEANING TOWARDS FOCUSING ON SELF-MONITORING, ACTUALLY BE ABLE TO HAVE SUCCESSFUL BEHAVIOR CHANGE HEALTHY LIFESTYLE INTERVENTIONS AN UNDERSTAND HOW THE DIFFERENT WAYS OF DELIVERING THIS TYPE OF SELF-MONITORING INTERVENTION CAN INFLUENCE THE OUTCOMES THE WAY WE RECOMMEND THEM. WORK OF THE SUBCOMITTEE FALLS NICELY WITHIN THE ECOLOGICAL MODEL THAT HAS BEEN SO ELOQUENTLY PRESENTED BEFORE BY BARBARA. TODAY WE'RE GOING TO PRESENT PRELIMINARY CONCLUSIONS ON THE SEDENTARY BEHAVIOR SCREEN TIME, THAT'S ONE WE HAVE MOVED FURTHEST ALONG BUT WE'RE ALSO CONTINUING THE WORK UNDERWAY FOR TOPICS WE'LL NOT BE PRESENTING TODAY. BEFORE TURNING THE MIC TO WAYNE, I WOULD TO ACKNOWLEDGE MICHAEL PERRY IS BEHAVIOR CHANGE CONSULTANT GROUP AND HE HAS ALREADY MADE VERY IMPORTANT CONTRIBUTIONS TO OUR UNDERSTANDING AN ABILITY TO FRAME BETTER OUR BEHAVIORAL CHANGE QUESTIONS. SO WAYNE, FLOOR IS YOURS. THANK YOU, RAFAEL. WHAT I WOULD LIKE TO DO IS TAKE US THROUGH SORT OF THE THOUGHT PROCESS AN APPROACH WE HAVE BEEN USING SPECIFICALLY TO EVALUATE SEDENTARY BEHAVIORS INCLUDING SCREEN TIME AND JUST FOR CONTEXT AT THE MOMENT THE INFORMATION I'LL BE PRESENTING IS SPECIFICALLY ON ADULT SEDENTARY BEHAVIORS, WORK WITH RESPECT TO CHILDHOOD SEDENTARY BEHAVIORS IS STILL ONGOING. SO WE THOUGHT IT WOULD BE -- SO OUR QUESTION OF INTEREST IS WHAT IS THE RELATIONSHIP BETWEEN SEDENTARY BEHAVIORS INCLUDING RECREATIONAL OCCUPATIONAL AND SCREEN TIME, AND DIETARY UPTAKE AND BODY WEIGHT. AND WHEN POSSIBLE BODY WEIGHT CHANGES AS ARE DEPENDENT OUTCOMES OF INTEREST. WE'VE BEEN WORKING WITH THE N,L STAFF TO COME UP WITH A FRAMEWORK WHICH FOR OUR ANALYTICAL FRAMEWORK I'LL SHOW YOU IN JUST A MOMENT TO LOOK THROUGH THE LITERATURE WHICH WE HAVE DETERMINED IS BEST SUITED FOR A NEL IN DEPTH SYSTEMATIC REVIEW. FOR DEFINITION WE THOUGHT SEDENTARY BEHAVIOR MEAN AS LOT OF THINGS TO A LOT OF DIFFERENT PEOPLE. SO FOR OUR PURPOSES WE'RE USE USING A DEFINITION STANDARDIZED USE, ANY WAKING ACTIVITY CHARACTER RIDESSED BY ENERGY EXPENDITURE LESS THAN OR EQUAL TO 1.5 META BOLLIC EQUIVALENTS WHICH IS ONE AND A HALF TIMES RESTING ENERGY EXPENDITURE. WHEN YOU ARE EITHER SITTING OR RECLINING, THIS MEANS ANY TIME A PERSON IS SITTING OR LYING DOWN THEY'RE ENGAGED IN A SEDENTARY BEHAVIOR. KIND OF LUKE ME RIGHT NOW. OUR ANALYTICAL FRAMEWORK IS VERY PRESENTED IN THE SAME TYPES OF FORMAT AS OTHER SUBCOMITTEES TARGET POPULATION FOR THIS PARTICULAR QUESTION HEALTHY ADULTS AGE 19 YEARS AND OLDER. AND THE INTERVENTION EXPOSURES OR EXPOSURES ARE SEDENTARY BEHAVIORS AT RECREATIONAL OCCUPATIONAL SETTINGS. SCREEN TIME IS A VERY WIDESPREAD INVESTIGATED ONE, TELEVISION VIEWING IS THE MOST OUTCOME ASSESSED IN THE LITERATURE. WE ARE CERTAINLY MINDFUL THAT SEDENTARY BEHAVIORS WITH RESPECT TO ELECTRONICS GOES WELL BEYOND JUST TELEVISION. AND WE HAVE AS OUR -- YOU CAN READ DOWN THROUGH FOR COMPARETORS BASICALLY COMES DOWN TO DIFFERENT LEVELS OF BEHAVIOR. INTERMEDIATE OUTCOME, AGAIN, ALL FOCUS ON DIET AND BODY WEIGHT CONTROL. AND WE HAVE POTENTIAL CONFOUNDERS IN ULTIMATELY OUR END POINT OF HEALTH IS REGARDING BODY WEIGH. THIS IS A LAUNDRY LIST OF INCLUSION EXCLUSION CRITERIA, NOT TO GO THROUGH THIS IN DEPTH BUT JUST AS REMINDER AS ALL OF US REVIEWS ARE AD WITH SET CAREFULLY DESCRIBED ESTABLISHD CRITERIA FOR THE TYPES OF TO ADDRESS THOSE GIVEN QUESTIONS OUTCOMES OF INTEREST RELATED TO DIET CAN BE NOT ONLY DIETARY INTAKE BUT QUALITY FOOD GROUPS MACRO NUTRIENT PORTIONS AND THE LIKE AND WHEN YOU TALK BODY WEIGHT STATUS, THERE MAYBE DIFFERENT OUTCOMES OF INTEREST THAT ARE PRESENTED IN THE LITERATURE. THE LITERATURE SEARCH CONDUCTED, STARTED OFF WITH 1412 ARTICLES NARROWED DOWN BASED ON TITLE AND ABSTRACT WITH REVIEW DOWN TO A TOTAL OF 43 ARTICLES, THESE ARE PIE PRIMARY RESEARCH ARTICLESES NOT SYSTEMATIC REVIEWS. AND THE NELISH SAY HAVE BEEN ALSO SCRUTINIZED, THOSE ARTICLES AND BASED ON QUALITY CRITERIA HAVE COME DOWN TO 21 ARTICLES THAT ARE GOING TO BE UNCOLLUDED IN THE SYSTEM MA TUCK REVIEW. THESE INCLUDE 20 PROSPECTIVE COHORT STUDIES ONE RETROSPECTIVE AND OF THESE 15 ARE IN -- LOOK AT SEDENTARY BEHAVIORS IN ADULTS AND VERY INTERESTING, YOU'LL SEE IN PRELIMINARY CONCLUSIONS VERY IMPORTANT SIX LONGITUDINAL STUDIES THAT WHILE WE'RE FOCUSED ON ADULTHOOD, THE IMPACT OF WEIGHT OR WEIGHT STATUS IN ADULTHOOD THESE STUDIES ALLOWED US TO ASSESS TRANSITION FROM CHILDHOOD TO ADULTHOOD, LONGITUDINALLY WHICH IS VERY NICE. THE LONGITUDINAL STUDIES YOU CAN SEE DURATIONS VARY FROM ONE YEAR OF INTERVENTION -- OF ASSESSMENT ALL THE WAY TO 33 YEARS. MOST OF THE STUDIES OR EXCUSE ME FIVE WERE IN U.S., WE DO HAVE -- WE DID MAKE DECISION WE WOULD EXPAND BEYOND US-BASED LITERATURE TO INCLUDE OTHER WESTERN SOCIETIES THAT HAVE COMPARABLE TYPES OF DATA TO PRESENT. AND THE SAMPLE SIZES FROM EPIDEMIOLOGIC STANDPOINT RANGED FROM 170 UP TO OVER 18,000 INDIVIDUALS. AND AS YOU CAN SEE, THE LONGITUDINAL STUDIES WHEN THEY STARTED IN CHILDHOOD, THE AGE OF THE CHILDREN WAS SOMEWHERE BETWEEN 5 AND 16 YEARS AND WENT ALL THE WAY OUT TO FOLLOW-UP HIGH OUT TO WHEN THEY WERE 45 YEARS OF AGE. THESE ARE OUR DRAFT KEY FINDINGS. THAT INCREASING LEVELS OF TELEVISION VIEWING DURING CHILDHOOD AND ADOLESCENT ARE PREDICTIVE OF HIGHER BODY MASS INDICES IN ADULTS, THAT THERE'S NO CRITICAL MASS OF EVIDENCE EXAMINING POTENTIAL MEDIATORS SUCH AS DIET. THIS IS SOMETHING THAT KIM OUT VERY STRIKING AND SOMEWHAT SURPRISING BUT STRIKING IN THE LITERATURE THAT THERE REALLY HASN'T BEEN A FOCUS ON LOOKING AT DIETARY BEHAVIORS THAT INFLUENCE OR INTEGRATE WITH THE SEDENTARY BEHAVIORS. SO WHAT WE'RE LOOKING AT FROM LITERATURE STANDPOINT IS THE IMPACT OF SEDENTARY BEHAVIOR ON BODY WEIGHT. AND DESPITE METHODOLOGICAL DIFFERENCES, IN MEASUREMENT OF SEDENTARY BEHAVIOR THERE IS AN APPARENT LACK OF ASSOCIATION BETWEEN TV VIEWING AND BODY FAT OUTCOMES IN ADOLESCENT ADULT TO ADULT TIME FRAMES. FOR REASONS WE ARE STILL EVALUATING, AWE PEER IT IS STRONGEST RELATIONSHIPS ARE KIDS AND EVOLVE OVER TIME INTO ADULT HOOD AND THERE IS DEFINITELY A NEED FOR MORE RESEARCH IN DIVERSE SETTING, RACIAL ETHNIC AND OTHERWISE. IS DRAFT CONCLUSION STATEMENTS ARE THERE'S CONSISTENT EVIDENCE THAT EXISTS ASSOCIATING INCREASED TELEVISION VIEWING AND KEEP IN MIND FOR THE DATA AVAILABLE AND WHERE THEY STARTED ASSESSING DOING ASSESSMENTMENTS WITH PARTICIPANTS WHO ARE CHILDREN'S TV VIEWING, THERE'S NOT OTHER SEDENTARY BEHAVIORS CONSISTENTLY OR ROBUSTLY ASSESSED. BUT THAT HOW MUCH TV TIME THE KIDS HAVE IS POSITIVELY ASSOCIATED WITH ADULT EVENTUALLY HAVING HIGHER ADULT BODY WEIGH. THERE ARE NO -- THERE IS APPARENTLY NO PROSPECTIVE ASSOCIATION BETWEEN SEDENTARY BEHAVIOR IN ADULTHOOD AND BODY WEIGHT, BODY WEIGHT CHANGES OVER TIME, MOST OF THESE STUDIES HAVE FOLLOW-UPS IN PEOPLE RANGING FROM 4 TO 7 YEARS. AND INSUFFICIENT DATA EXIST TO ADDRESS ASSOCIATION BETWEEN BEHAVIORS SEDENTARY BEHAVIORS AND DIETARY INTAKE IN ADULTS. SO THIS IS JUST REFRESH MEMORIES OF THE QUESTIONS WE WERE ADDRESSING AND WE'LL BE GLAD TO ANSWER ANY QUESTIONS AND TURN IT BACK TO RAFAEL AFTER WORD. SO THE FLOOR IS OPEN FOR DISCUSSION. WAYNE, CAN I ASK A QUICK QUESTION REGARDING THE STUDY DESIGN. SO PERSPECTIVE COHORT STUDIES SO THE STUDY BASE KLINE LIPOHAS TO START -- BASELINE HAS TO START AT CHILDHOOD AND FOLLOW PARTICIPANTS INTO ADULT HOOD? THAT HAPPENED IN SIX STUDIES. THE REST OF THE STUDIES STARTED IN ADULTHOOD AND THEN CHRONOLOGICALLY FOLLOWED UP ON THEM ON AN AVERAGE OF 4 TO 7 YEARS LATER AND ASSESSED -- DID BASELINE ASSESSMENTS OF THEIR SEDENTARY BEHAVIOR AND THEN LOOKED FOR CHANGES IN BODY WEIGHT OVER TIME. SO ONE QUESTION I HAVE IS WHY YOU LIMIT THE SYSTEMATIC REVIEWS BODY WEIGHT OUTCOME, CARDIOVASCULAR DISEASE AND TOTAL MORTALITY AS YOU COMES. THOSE OUTCOMES WERE DEEMED SECOND TIER OUTCOMES BECAUSE OF THE CALL. NOT NECESSARILY THE QUALITY OF THE DATA BUT THIS IS THE BEGINNING OF WHAT WE'RE DOING. THE -- I BELIEVE PLEASE CORRECT ME IF I'M WRONG THOSE OUTCOMES ARE CAPTURED BUT WOULD HAVE REQUIRED ADDITIONAL QUESTIONS AND SEPARATE SYSTEMATIC REVIEWS. AND THIS IS WHERE WE ARE IN THE PROCESS RIGHT NOW. THE RESEARCH COVERED LAST TEN YEARS FROM 2004 TO 2014. RIGHT? CORRECT. THAT'S THE RANGE OF LITERATURE. I KNOW MANY OTHER STUDIES HAVE BEEN PUBLISHED PRIOR TO 2004. SO I GUESS THOSE STUDIES WILL BE EXCLUDED AUTOMATICALLY BECAUSE OF THE TIME FRAME. WE WANTED TO FOCUS -- DO YOU WANT TO ADDRESS? THAT DECISION WAS BASED ON THE FACT THAT THIS QUESTION WAS ADDRESSED IN 2010 DIETARY GUIDELINES BASED ON A SYSTEM MA IT CAN REVIEW PUBLISHED IN 2004. O LESS CONCEPT OF UPDATING AND TAKING FROM WHERE WE WERE AND AT THAT POINT MOST STUDY WERE CROSS SECTIONAL. SO THERE IS -- THESE ARE THE REALLY MOST IMPORTANT PIECES OF EVIDENCE PROSPECTIVE STUDIES BECOME AVAILABLE. I ALSO THINK THE EARLIER STUDIES MIGHT NOT REFLECT CONTEMPORARY BEHAVIORS IN TERMS OF SCREEN TIME AND DEVICES AVAILABLE IMPACTED ON PHYSICAL ACTIVITY MANY DIDN'T EXIST BACK THEN. BUT THE LITERATURE THAT WE'RE PRESENTING HERE WITH THE CHILDREN, THE FOCUS REALLY HAS BEEN ON TELEVISION VIEWING. CHERYL ANDERSON, I WAS STRUCK BY AMOUNT OF DATA YOU HAVE IN YEARS OF DURATION FOLLOW-UP AND ALSO BY THE FACT THAT FIVE STUDIES WERE IN THE U.S. AND OTHERS WERE IN COMPARABLE COUNTRIES CAN YOU TALK A LITTLE BIT MORE ABOUT THE PLACE WHERE IS THESE STUDIES WERE BEING CONDUCTED? AND HOW YOU AND THE TEAM ASSESS COMPARABILITY TO U.S. PATTERNS AS WELL AS DURATION AND FOLLOW-UP? SURE, BE GLAD AS MUCH AS -- INFORMATION I HAVE, THIS IS REGARDING LOCATION, SIX OF THE STUDIES WERE AUSTRALIAN. SIX WERE FROM THE UNITED KING TO. AS I MENTIONED FIVE FROM THE UNITED STATES, TWO NEW ZEALAND. ONE CANADIAN AND ONE SPAIN. SO THEY WERE ALL INDUSTRIALIZED COUNTRIES AND FELT GIVEN THE OUTCOME THAT THEY WERE APPROPRIATE FOR US TO BE ABLE TO ENHANCE THE OVERALL BODY OF LITERATURE THAT WE CAN LOOK AT. ALSO CHERYL WE BELIEVE THAT SOME COUNTRIES WERE FURTHER AHEAD AND WE WANT TO USE WHAT THEY DID AND EXAMINE THEIR DATA BECAUSE THEY WERE ALREADY DOING THINGS AND PROBABLY FOR LONGER PERIOD OF TIME, CLEARLY THE IMBALANCE IN TERMS OF THE YEARS OF FOLLOW-UP, AS YOU LOOK FROM ONE TO 33. SO WE HAVE TO CAREFUL HOW WE WEIGHT THAT AND OUTCOME. DID YOU WEIGHT THAT IN OUTCOME IN YOUR PRELIMINARY CONCLUSIONS? WE'RE PRELIMINARY. HAVE YOU IN CHILDREN THEY HAVE FOUND ASSOCIATION BETWEEN SEDENTARY BEHAVIORS SPECIFICALLY INCREASE TV WATCHING? DIETARY INTAKE AND OBESITY, SO YOU DIDN'T FIND RELATIONSHIP BETWEEN INCREASED TV WATCHING WHICH AS SEDENTARY BEHAVIOR WOULD BE PROXY FOR TV WATCHING. TV WATCHING AN SNACKS. ONE OR TWO PAPERS TALKED DIETARY INTAKE AND SEDENTARY BEHAVIOR SUCH AS TV WATCHING BUT INSUFFICIENT DATA TO FOCUS BECAUSE THERE'S LITTLE DATA AVAILABLE. WITH FOUR ADULTS, ONE OTHER CONSIDERATION IN THE STRENGTH OF THE LITERATURE IS THAT FOR MOST OF THE STUDIES, THE REPORTS OR DATA COLLECTED WERE SELF-REPORTS, THERE WAS ONLY ONE STUDY WHERE THEY ACTUALLY HAD SPECIFIC VERIFIABLE OR ACTUAL MEASUREMENT OF THE AMOUNT OF SEDENTARY BEHAVIOR THE PEOPLE WERE EXPOSING THEMSELVES TO, I GUESS. COW ALSO WANT TO ADD MARY -- COULD I ASK THAT YOU REPEAT YOUR NAMES? THANK YOU. RAFAEL PEREZ-ESCAMILLA. MARIE, A NUMBER OF THE STUDIES I'M AWARE OF ARE CROSS SECTIONAL IN TERMS OF CHILDREN VIEWING AND DIETARY BEHAVIORS BESTILL HAVE TIME TO REFINE IT. SO IN TERMS OF NEXT STEPS WE ARE NOW ANALYZING THE INFORMATION FROM THE NEL SEARCH RELATED TO YOUTH SEDENTARY BEHAVIORS INCLUDING SCREEN TIME AND PHYSICAL -- AND WEIGHT OUTCOMES. AND WE HAVE COMPLETED REDUNDANCY ANALYSIS FOR THE ACCULTURATION QUESTIONS, THERE WERE A NUMBER OF SYSTEM MA TUCK REVIEWS THAT WERE CONDUCTED IN BOTH MARIA AND MYSELF CONDUCT INDEPENDENT ANALYSIS TOGETHER WITH NEL STAFF, WE DETERMINED THAT WE CANNOT USE EXISTING SYSTEMATIC REVIEWS, IT JUST DIDN'T MAKE -- MEET THE QUALITY WE NEEDED SO ANY RESEARCH IS UNWAY TO LOOK AT ACCULTURATION AND DIVERSE DIET AND WEIGHT OUTCOMES. AND I'M VERY HAPPY TO REPORT THAT THERE APPEARS WE WILL HAVE ENOUGH EVIDENCE TO UNDERSTAND BEYOND HISPANICS OR MOST RESEARCH DONE IN THE PAST, THERE IS A CRITICAL MASS OF LITERATURE REPRESENT ASIAN COMMUNITIES AND THIS IS A POOL OF LITERATURE THAT CAPTURES MIXEDth IN THISTIES AND -- ETHNICITIES AN COUNTRIES OF ORIGIN SO WE'RE LOOKING FORWARD TO THAT. WE HAVE NOW MADE SUBSTANTIAL PROGRESS TOGETHER WITH OUR CONSULTANT, DR. MICHAEL PERRY REFINING OUR MOBILE HEALTH QUESTION. WE HAD A WONDERFUL PRESENTATION FROM DEBORAH TATE TODAY, WE'RE VERY EXCITED WE'RE INCLUDING THIS AS PART OF THE IT IS SO CENTRAL FOR SUCK SETS OF HEALTHY LIFESTYLE INTERVENTIONS AND AS IT WAS DISCUSSED TODAY THERE ARE DIFFERENT TECHNOLOGIES VERSUS MONITORING DIFFERENT METHODOLOGIES HOW TO COMMUNICATE THESE TO DIVERSE AUDIENCES AND THE ABILITY FOR THEM TO AWE PEER SO IT'S TOKING TO BE ALSO -- I THINK WE HAVE BEEN ABLE TO REFINE THAT QUESTION TO A LEVEL THE NEL STAFF IS COMFORTABLE STARTING WITH AN EXPLORATORY SEARCH. THAT FREQUENCY OF EATING OUT QUESTION IS STILL UNDER DEVELOPMENT, A QUESTION I THINK IS REALLY GOING TO BE VERY SIMILAR TO 2010 FREQUENCY OF EATING OUT, AS WE HAD ADDITIONAL FEEDBACK FROM THAT COMMITTEE. FREQUENCY OF EATING OUT AND DIETARY AND WEIGHT OUTCOME. QUESTION RELATED TO HOUSEHOLD SECURITY AND FAMILY AND MEALS AND ASLEEP, WE HAVE DEVELOPED ANALYTICAL FRAMEWORKS BUT RESEARCH HAS NOT BEEN CONDUCTED YET. WITH REGARDS TO SLEEP WHEN LUCILLE HA EXAMINED THE EXPARTICULARTORY SEARCH THAT WAS DONE, THERE IS A LOT OF LITERATURE ON SLEEP AND OBESITY BUT NOT SO MUCH ON SLEEP AND DIET. SO THAT IS PROBABLY THE DIRECTION THAT THAT QUESTION IS GOING TO TAKE. BUT EARLY ON IN THE GAME FOR THAT LAST BUT NOT LEAST FOOD AND MENU LABEL USE IS GOING TO BE INCLUDED WE'RE STILL DEBATING WHICH ARE THE MOST IMPORTANT ASPECTS TO ASK REGARDING THESE QUESTIONS BECAUSE ESPECIALLY THE FOOD LABEL QUESTION IS HUGE. FEEDBACK FROM THE WHOLE COMMITTEE ON YOUR IDEA WHICH ASPECTS SHOULD IT BE SODIUM, SO YOU WOULD SHOULD IT BE SUGAR SWEETEND BEVERAGES, OVERALL DIETARY CALL AND HOW THAT'S IMPACTED BY FOOD LABEL USE AND THE USE OF FOOD MENUS IS VERY IMPORTANT FOR US TO RECEIVE YOUR FEEDBACK. THANK YOU. IF THERE ARE NO OTHER QUESTIONS SC 2, ANNA MARIA. I HAVE TWO COMMENTS RELATED TO THE LAST SC 3. SO ONE, I THINK I SAID IN A BRIEFIUS SUBCOMITTEE MEETING IT WOULD BE HELPFUL TO UPS HOW THE FOOD LABEL IS ACTUAL HI CHANGING. BECAUSE I THINK THAT WILL HELP US INFORM WHEN WE START THINKING ABOUT WRITING UP THE SECTION ON FOOD LABELING AN MENU USE. AND MAKING RECOMMENDATIONS FOR THE FUTURE. AND THEN THE SECOND WHILE WE PRESENTED THE RESULTS OF SEDENTARY BEHAVIOR, THE ONE THING THAT GOT LEFT OUT IS THE FACT THAT WHILE A LOT OF STUDIES TELEVISION VIEWING, THEY ALSO LOOKED AT SITTING BEHAVIOR IN ADULTS AND THERE WAS NO ASSOCIATION IN THE RELATIONSHIP SITTING BEHAVIOR AND WEIGHT STATUS. SO I THINK THAT'S IMPORTANT TO BRING OUT BECAUSE THERE'S BEEN A LOT OF WORK EMPHASIS ON FIDGETING BEHAVIORS FROM OPPOSITE OF SEDENTARY BEHAVIOR, HOW WE ARE, THAT'S NICE THE MAKE SURE WITH KNOW THAT AS WELL. CAN I MAKE A SUGGESTION RAFAEL? YOU SAID YOU'RE GOING TO ASK CROSS SECTIONAL STUDIES TO BE WATCHING IN DIETARY INTAKES PERHAPS SLEEP AND DIETARY INTAKES. I THINK THOSE KIND OF STUDIES ARE ACTUALLY VERY IMPORTANT TO ADDRESS YOUR QUESTION BECAUSE YOU ARE -- YOUR DIET IS MEDIATED. YOU'RE NOT LOOKING AT THE QUESTION WHY THE CHANGES IS LEAD TO CHANGES IN DIET. THAT'S KIND OF INTERVENTION QUESTION HERE YOU'RE ASKING PRETTY STRAIGHT FORWARD QUESTION WHETHER TO BE WATCHING IS ASSOCIATED WITH CERTAIN DIETARY BEHAVIORS CALORIC INTAKE AND WHETHER THE DIETARY FACTORS MEDIATE THE ASSOCIATION BETWEEN SUBSEQUENT RISK OF OBESITY. I THINK THAT'S KIND OF VERY USEFUL TO SUMMARIZE THE DATA EVEN FROM CROSS SECTIONAL STUDIES. THANK YOU. SO WE HAVE REALLY PONDERED THIS A LOT. ONE FINDING WITH THE ADULT LITERATURE PERSPECTIVE STUDIES IS THREE OF THE STUDIES THAT LOOKED AT REVERSE CAUSALITY THEY FOUND IT BUT THEY FOUND THAT A MORE OBESE PEOPLE ARE MORE LIKELY TO WATCH MORE TELEVISION AND NOT THE OTHER WAY AROUND SO THE ISSUE OF REVERSE CAUSALITY IS WE WOULDN'T BE ABLE TO SORT OUT BUT IN TERMS OF ANSWERING A QUESTION THERE IS AN ASSOCIATION, IF THERE ARE NO PERSPECTIVE STUDIES ON TELEVISION VIEWING AND DIET, WE SHOULD RECONSIDER THE REST OF THE SUBCOMITTEE. YES. QUICK QUESTION. ARE YOU LOOKING AT ALL IN YOUR SUBCOMITTEE WITH ANY OF THE -- ANY OF YOUR TOPIC AREAS NOT ONLY RELATIONSHIPS BUT WHAT WORKS INTERVENTIONS THAT REALLY MIGHT IMPROVE DIET OR REDUCE SEDENTARY BEHAVIOR? WELL, CAN YOU SUM SUMMARIZE THE LACK OF RCTs THAT WE WERE VERY SURPRISED ABOUT IN TERMS OF TELEVISION VIEWING WHAT -- BECAUSE WE DID TRY TO IDENTIFY RCTs. WHAT HE SAID. THE STRENGTH OF THE LITERATURE AND THE AVAILABILITY OF THE LITERATURE TO LOOK AT WHERE IT WAS A CHANGE IN AN ENVIRONMENT OR CHANGE IN PRACTICE OF -- AND THEN TO BE ABLE TO THEN EQUATE THAT IN A RANDOMIZED CONTROLLED WAY WITH CHANGE IN WEIGHT OR CHANGE IN EATING BEHAVIOR, THOSE DATA JUST DIDN'T POP UP IN THE ASSESSMENTS OR REVIEWS THAT HAVE BEEN DONE. WE WILL CERTAINLY CONSIDER TO LOOK FOR THAT BUT THAT'S SEEMS TO BE A NEED FOR NEW INFORMATION OPPOSED TO PREGNANT ABLE TO DRAW CURRENT INFORMATION. FRANK HU. TOM ROBINSON FROM STANFORD PUBLISHED SEVERAL RCTs REDUCINGING TV WATCHING AND REDUCTION IN PREVALENCE OR TENSE OF CHILDHOOD OBESITY. RIGHT. BUT WE'RE FOCUSED RIGHT NOW ON ADULTHOOD. I REMEMBER THERE WAS A PAPER PUBLISHED IN ARCHIVE INTERNAL MEDICINE THREE OR FOUR YEARS AGO LOOKING AT REDUCING TV WATCHING AMONG ADULTS AND CHANGES IN DIETARY INTAKE AND BODY WEIGH. THAT WAS I THINK FOUR OR FIVE YEARS AGO PUBLISHED IN INTERNAL MEDICINE BASED ON RANDOMIZED SMALL SAMPLE. WE ARE HEARING A RELATIONSHIP BETWEEN DIETARY PATTERNS. WE ARE GOING AFTER DIETARY PATTERNS HOLISTICALLY FIRST AND THEN WE ARE GOING TO TRY TO IDENTIFY THE DRIVERS OF THESE I DO TEAR PATTERNS BY LOOKING AT FOODS, FOODS GROUPS AN NUTRIENTS. AND HOW THEY'RE RELATED TO PREVENTIBLE DIETARY RELATED DISEASES OBESITY AND MORTALITY. SO WHAT WE HAVE BEEN ABLE TO DO TO DATE IS HIGHLIGHT HERE IN THE ORANGE COLOR, YOU CAN SEE THE SCOPE OF OUR WORK SO IT IS RATHER HUGE AND TODAY WE'RE GOING TO BE PRESENTING WHAT WE HAVE BEEN ABLE TO ACCOMPLISH IN OUR SUBMY MEETINGS RELATED TO CARDIOVASCULAR DISEASE, TYPE 2 DIABETES, BODY WEIGHT OBESITY CANCER AND FOR THAT I'M GOING TO LET MY COLLEAGUES ACTUALLY TAKE OVER THE PRESENTATION. WAIT A SECOND. ONE THING. WE HAD SOME EXPERTS, THEY ARE LISTED HERE, ALL THE COMMITTEES HEARD FROM THE AUTHORS OF THE AMERICAN HEART ASSOCIATION, THE AMERICAN COLLEGE OF CARDIOLOGY AND THE TOX REPORTS THAT WE HAVE BEEN TALKING ABOUT. WE ALSO ASKED CONNIE WEAVER AND STEVEN ABRAMS TO GIVE SOME INFORMATION RELATED TO BONE HEALTH AND THEN WE ASK LORRAINE GUNS,ERETH TO GIVE A PRESENTATION ABOUT ALCOHOL AND DIETARY PA TERMS AN HEALTH OUTCOMES SO VERY GRATEFUL FOR THEIR INPUT THUS FAR. SO THE QUESTION WE WANT TO ADDRESS, WHAT'S THE RELATIONSHIP BETWEEN DIETARY PATTERNS AND THE RISK OF CARDIOVASCULAR DISEASE BODY WEIGH AND TYPE 2 DIABETES. IN THE PAST MONTHS WE HAVE MADE GOOD PROGRESS ADDRESSING THIS QUESTION. THE MAIN REASON IS THAT WE HAVE TWO OUTSTANDING EXISTING REPORTS WHICH BECAME AVAILABLE RECENTLY SO OUR REVIEW OF THE EVIDENCE IS PRIMARILY BASED ON THE DATA FROM THOSE TWO EXISTING REPORTS. THE FIRST IS DIETARY PATTERNS SYSTEMATIC REVIEW PROJECT. IT WAS JUST COMPLETED ORIGINALLY AND IS NOW AVAILABLE ON LINE. THE SECOND EXISTING REPORT IS THE 2013 ACC GUIDELINE LIFESTYLE MANAGEMENT TO REDUCE CARDIOVASCULAR RISK PUBLISHED IN THE GACC. YESTERDAY IN OUR DISCUSSION WITH THE SUBCOMITTEE WE CONDUCTED ADDITIONAL RESEARCH TO IDENTIFY SYSTEMATIC REVIEWS OR META ANALYSIS ON DIETARY PATTERNS AND DIABETES AND BODY WEIGHT TO AUGMENT THE EXISTING REPORTS BECAUSE AFTER COMPLETION OF THE RESEARCH BY THOSE TWO REPORTS, ADDITIONAL META ANALYSIS AND SYSTEMATIC REVIEWS HAVE BEEN PUBLISHED SO WE WANT TO DO A COMPREHENSIVE SYSTEMATIC RESEARCH TO IDENTIFY THOSE META ANALYSIS TO SUPPLEMENT THE EVIDENCE FROM THOSE TWO EXISTING REPORTS. SO THIS IS THE ANALYTICAL FRAMEWORK FOR THE NOW DIETARY PATTERN SYSTEMATIC REVIEW PROJECT. I WANT TO SAY THAT THIS PROJECT WAS ACTUALLY INITIATED AT 2010 DIETARY GUIDELINES ADVISORY COMMITTEE IN THE PAST COUPLE OF YEARS PATTERN OF INTERNATIONAL EXPERTS -- PANEL OF EXPERTS DIETARY PATTERNS AN CHRONIC DISEASE HAVE BEEN WORKING CLOSELY THE STAFF TO CONDUCT THIS PROJECT, THIS IS A HUGE UNDERTAKING, I WILL SHOW YOU HOW MANY PAPERS THEY HAVE REVIEWED IN ONE MINUTE. THE MAIN FOCUS OF THE REVIEW IS TO LOCATE DIETARY PATTERNS DERIVED THROUGH SEVERAL DIFFERENT MASTOLOGIES AND THE RISK OF TYPE 2 DIABETES AN BODY WEIGH. IN THE LITERATURE, THERE ARE DIFFERENT METHODOLOGIES THAT HAVE BEEN WIDELY USED TO DERIVE DIETARY PATTERNS OR LOOK AT THE WHOLE DIET INDICES OR SCORES BASED ON TRADITIONAL PATTERNS BASED ON THE USDA DIETARY RECOMMENDATIONS OR HA RECOMMENDATIONS, CLUSTER ANALYSIS, REDUCE RECREATION ANALYSIS AND THE OTHER METHODS SO THE OUTCOMES INCLUDE OBESITY OR BODY WEIGHT, UNDENSE OF CVD AN INCIDENCE OF TYPE 2 DIABETES. THIS REVIEW INITIAL DIETARY PATTERNS AND SOME OF THE INTERMEDIATE OUTCOMES ESPECIALLY BLOOD PRESSURE AND BLOOD LIPIDS. THIS IS ENORMOUS UNDERSTOOD TAKING BY THE OUTSTANDING INTERNATIONAL PANEL. THE PROJECT REVIEWED 176 PAPERS. AND MOST MAJORITY OF STUDIES FROM PROSPECTIVE COHORT STUDIES, AND REVIEW RCTs INTERMEDIATE OUTCOMES SUCH AS BLOOD PRESSURE AND LIPIDS. MOST OF THE STUDIES WERE CONDUCTED IN CARDIOVASCULAR OUTCOMES SUCH AS MYOCARDIAL INFARCTION, BLOOD LIPIDS AND BLOOD PRESSURE. AND 52 OF THOSE STUDIES USED A WIDE RANGE OF DIETARY INDICES OR DIETARY SCORES 22 STUDIES USE FACTOR ANALYSIS OR CLUSTER ANALYSIS, VERY FEW STUDIES USE REDUCE RECREATION APPROACH. FOR BODY WEIGHT AND TYPE 2, THERE ARE FEWER STUDIES USE FACTOR OR CLUSTER ANALYSIS. MOST IS CONCENTRATED IN AREA OF CARDIOVASCULAR DISEASE AT THIS PIPE. THIS IS THE DIETARY PATTERNS PROJECT ASSOCIATED WITH DECREASE RISK OF CARDIOVASCULAR DISEASE CHARACTERIZED BY REGULAR CONSUMPTION OF FRUITS, VEGETABLES WHOLE GRAINS LOW FAT DAIRY AND FISH. LOW IN RED AND PROCESSED MEATS AND SUGARS SWEETS IN FOODS AND DRINKS. MOST STUDIES REGULAR CONSUMPTION OF NUTS AN LEGUMES WERE ALSO SHOWN BENEFICIAL. ADDITIONALLY, RESEARCH THAT INCLUDED SPECIFIC NUTRIENTS INDICATED THAT PATTERNS THAT WERE LOW IN SATURATED FAT AND SODIUM AND RICH IN FIBER AND POTASSIUM MAYBE BENEFICIAL FOR REDUCINGING RISK. STRONG EVIDENCE COME FROM COHORT STUDIES USING INDICES OR SCORES INCLUDING (INDISCERNIBLE) DIETARY GUIDANCE RELATED AN DASH DIETS. AND ALSO COMES FROM RCTs OF DASH DIET USING FACTOR OR CLUSTER ANALYSIS. THERE'S INSUFFICIENT EVIDENCE IN STUDIES USING REDUCE RECREATIONS BECAUSE THERE ARE FEW STUDIES USING THIS RELATIVELY NOVEL STATISTICAL APPROACH. AND METHODOLOGY FOR THIS APPROACH IS NOT STANDARDIZED. THOSE ARE THE RECOMMENDATIONS BROUGHT FORWARD DIRECTLY FROM THE ACCHA GUIDELINES. THE ADULT BENEFIT FROM CLUSTER OR BLOOD PRESSURE TO CONSUME A DIETARY PATTERN THAT EMPHASIZES INTAKES OF VEGETABLES, FRUITS AND WHOLE GRAINS. LOW FAT DAIRY PRODUCTS FISH LEGUMES, NON-TROPICAL VEGETABLE OILS AN NUTS AND LIMBS INTAKE OF SWEETS, SUGAR SWEETENED BEVERAGES AN RED MEAT. TO APPROPRIATE CALORIE REQUIREMENTS PERSONAL CULTURAL FOOD PREFERENCES AN NUTRITION THERAPY FOR OTHER MEDICAL CONDITIONS SUCH AS DIABETES. ACHIEVE THIS PATTERN THE U S--A FOOD PATTERN AND DIET. THE STRENGTH OF THIS EVIDENCE WAS RATED STRONG FOR BODY WEIGHT WE RELY ON THESE TWO EXISTING REPORTS. THE DIETARY PATTERN SYSTEMATIC REVIEW PROJECT, AND 2013 OBESITY SOCIETY GUIDELINE FOR MANAGEMENT OF OVERWEIGHT AND OBESITY IN ADULTS. THESE ARE THE CONCLUSIONS FROM THE SYSTEMATIC REVIEW PROJECT THERE IS MODERATE EVIDENCE THAT IN ADULTS INCREASE ADHERENCE TO DIETARY PATTERNS SCORING HIGH IN FRUITS VEGETABLES LEGUMES, AND FISH, LOW IN TOTAL MEAT, SATURATED FAT, FOODS ANDRES AN SODIUM, AND MODERATE DAIRY PRODUCTS. IS ASSOCIATED WITH MORE FAVORABLE OUTCOMES RELATED TO BODY WEIGHT OR RISK OF OBESITY WITH SOME REPORT OF VARIATION BASED ON GENDER RISK OR BODY WEIGHT STATUS. SO THIS CONCLUSION IS DERIVED FROM PERSPECTIVE COHORT STUDIES USING DIETARY INDICES APPROXIMATE SCORES. MODERATE EVIDENCE THAT ADHERENCE EMPHASIZES VEGETABLES FRUITS AN WHOLE GRAINS IS ASSOCIATED WITH MODEST BENEFITS FROM PREVENTING PROMOTING WEIGHT LOSS IN ADULTS. LIMITED AND INCONSISTENT EVIDENCE FROM EPIDEMIOLOGICAL STUDIES EXAMINE DIETARY PATTERNS DERIVEDDED USING FACTOR OR CLUSTER ANALYSIS IN ADULTS, THAT CONSUMPTION OF DIETARY PATTERN CHARACTERIZE BY INTAKES OF VEGETABLES FRUITS WHOLE GRAINS AN REDUCED FAT DAIRY PRODUCT AS OPPOSED TO RED MEAT PROCESSED MEAT SUGARS SWEETS FOODS BEVERAGES ASSOCIATED WITH MORE FAVORABLE BODY WEIGHT STATUS OVER TIME. SO THIS CONCLUSION WAS PRIMARILY DERIVED FROM COHORT STUDIES USING FACTOR OR CLUSTER ANALYSIS. I WANT TO MENTION THAT THE METHODOLOGIES FOR USING FACTOR OR CLUSTER ANALYSIS IN PROSPECTIVE COHORT STUDIES ARE HETERO GENIUS SO THE DIFFERENT STUDIES USING SOMEWHAT DIFFERENT GROUPINGS OF FOODS USING SOMEWHAT DIFFERENT STATISTICAL APPROACHES. THERE IS INSUFFICIENT EVIDENCE USED IN STUDIES USED IN REDUCED REGRESSION, AGAIN, THERE WERE FEW STUDIES USING THIS NOVEL STATISTICAL APPROACH TO DERIVE DIETARY PATTERNS. THOSE ARE THE RECOMMENDATIONS TAKEN FROM THE ACC GUIDELINE PRESS SCRIBE A DIET TO ACHIEVE REDUCE CALORIE INTAKE FOR OBESE OR OVERWEIGHT INDIVIDUALS WHO BENEFIT FROM WEIGHT LOSS AS PART OF COMPREHENSIVE LIFESTYLE INTERVENTION. ANY ONE OF THE FOLLOWING METHODS CAN BE USED TO REDUCE FOOD AND CALORIE INTAKE. PRESCRIBE 1200 TO 1500-CALORIES PER DAY FOR WOMAN AND 1500 TO 1800-CALORIES PER DAY FOR MEN. PRESCRIBE 500-CALORIES PER DAY OR 750-CALORIES PER DAY ENERGY DEFICIT OR ONE EVIDENCE BASED DIETS THAT RESTRICTS CERTAIN FOOD TYPES IN ORDER TO CREATE ENERGY DEFICIT BY REDUCED FOOD INTAKE. STRENGTH OF THE EVIDENCE WAS RATEDDED STRONG. OBESE OVERWEIGH INDIVIDUALS WHO BENEFIT FROM WEIGHT LOSS BASED ON THE PATIENTS PREFERENCES AND STATUS AN PREFERABLY REFER TO NUTRITION PROFESSIONAL FOR COUNSELING. A VARIETY OF DIETARY APPROACHES CAN PRODUCE WEIGHT LOSS IN OVERWEIGHT AND OBESE ADULTS. FOR TYPE 2 I DO BEE TEASE, WE USE EVIDENCE FROM TWO EXISTING REPORTS THE BODIES OF EVIDENCE EXAMINE THE RELATIONSHIP BETWEEN DIETARY PATTERNS AND THE RISK OF TYPE 2 DIABETES ARE LIMITED OR INSUFFICIENT SO WE DIDN'T MAKE CONCLUSION STATEMENT REGARDING TYPE 2 DIABETES AT THIS POINT. NEXT STEPS AS I MENTIONED EARLIER WE WILL CONDUCT SEARCHES TO IDENTIFY SYSTEMATIC REVIEWS AND ME THE ANALYSIS PUBLISHED SINCE THE SEARCHES WERE COMPLETED BEFORE EXISTING REVIEWS. AS SOME OF YOU KNOW, EVEN THOUGH THE ACC REPORT WAS JUST PUBLISHED RECENTLY, THE LITERATURE SEARCH FOR THAT REPORT WAS ACTUALLY PLEATED AT END OF 2009 SO IN THE PAST SEVERAL YEARS A NUMBER OF PAPERS AND META ANALYSIS AND SYSTEMATIC REVIEWS HAVE BEEN PUBLISHED DIETARY PATTERNS DIET QUALITY AND CARDIOVASCULAR OUTCOMES. WE IDENTIFY META ANALYSIS AND SYSTEMATIC REVIEWS AN COME BACK TO OVERVIEW OF THIS EVIDENCE TO AUGMENT THE EVIDENCE FROM THE TWO EXISTING REPORTS. SO THIS IS WHERE WE ARE. DIETARY PATTERNS AND CAD OWE VASCULAR DISEASE BODY WEIGH AN TYPE 2 DIABETES. Q. I WAS STRUCK WHEN YOU WERE SHOWING DATA SYSTEMATIC REVIEW FOOD COMPONENTS WERE LISTED GO TO THE NEXT ONE. SO HERE FOR INSTANCE THAT FIRST BOLED ONE SAYS DIE HIGH IN FRUITS VEGETABLES WHOLE GRAINS LEGUMES UNSATURATED FATS OILS AN FISH AND NEXT ONE USES AND INSTEAD OF OR. SO THAT KIND OF STRUCK ME ONE OF THE ADVANTAGES OF EXAMINING DIETARY PATTERNS IS THAT WE REALLY CAN LOOK AT THE WHOLE DIET THE. IT'S POSSIBLE THAT THE WHOLE IS GREATER THAN THE SUM OF ITS PARTS SO I'M HOPING AS OUR SUBCOMITTEE MOVES FORWARD ANNA MARIA SAID FURTHER WORK WILL UNCOLLUDE IDENTIFYING THE DRIVERS BOTH FRUITS AND NUTRIENTS AND I HOPE THAT WILL HAVE A VERY THOUGHTFUL DISCUSSION ABOUT THAT, SO WE DONE GET TOO REDUCTIONIST IN THINKING AND LOSE THE BENEFIT OF THE AND IN THESE CHARACTERIZATIONS, I HOPE THAT MAKES SENSE. WE'LL BE CAUTIOUS AN THOUGHTFUL AS WITH PROCEED. YOUR POINT IS WELL TAKEN. I THINK RIGHT NOW WE LOOK AT BIG PICTURE. GOOD NEWS IS THAT THE PATTERNS, THE QUOTE UNQUOTE PATTERNS IDENTIFIEDED FROM THE REPORT AND A,C HA AND REPORT IS BROADLY CONSISTENT SO WE'RE NOT IDENTIFYING PATTERNS THAT GOOD FOR ONE CONDITION AND BAD FOR ANOTHER ONE OR VICE VERSA. THE QUOTE UNQUOTE HEALTHY PA TERMS IS BENEFICIAL FOR WIDE RANGE OF CONDITIONS. THERE IS A HUGE NUMBER IN CHILDREN FOR DEVELOPING TYPE 2 DIABETES, FATTY LIVER AN SEVERE COMPLICATIONS FROM PROFOUND OBESITY. DOILYNY LOOK AT SPECIFIC INTERVENTIONS RELATED TO THAT GROUP? NO, AT THIS POINT WE DIDN'T KNOW DIETARY PATTERNS AND OUTCOMES AMONG CHILDREN. MANY CLINICAL OUTCOMES. BUT I THINK THAT'S SOMETHING MAYBE WE SHOULD LOOK INTO. MORE PEOPLE LOOK AT FATTY LIVER TYPE 2 DIABETES, WHICH AREZOAL OUTCOMES AMONG YOUNG AD LESSENS SO YOU MIGHT BE ABLE TO LOOK AT THAT. ACC GUIDELINES WERE LIMITED TO ADULTS, AGE 16 AND OLDER. 18 AND OLDER. FRANK YOU WERE CLEAR IN PRESENTATION OF THIS BUT APROPOS OF MARY ANN'S QUESTION I THINK IT'S IMPORTANT TO REITERATE THAT THE CONCLUSIONS WE HAVE GOT STATED HERE ARE FROM THE EXISTING REPORTS. AND THERE ARE A VARIETY OF NEXT STEPS INCLUDING AUGMENTING THIS LITERATURE, THESE REVIEWS WITH INTERIM LITERATURE OR ARE VIEWS COMPLETED. -- REVIEWS COMPLETED. ABSOLUTELY. I THINK WE STILL HAVE WORK TO DO THESE ARE NOT OUR CONCLUSIONS. YES. OUR NEXT QUESTION IS WHAT IS THE RELATIONSHIP BETWEEN DIETARY PATTERNS AND RISK OF CANCER AND WE HAVE USED THE SAME APPROACH USING THE SYSTEMATIC REVIEW. THOUGH YOUR SLIDE SAYS STEVEN CLINTON THE OHIO STATE UNIVERSITY I'LL BE PRESENTING INSTEAD OF STEVEN. I'M MARY ANN NEUHOUSER. SO THIS IS A NEWS SLIDE THAT TALKS ABOUT WHAT CANCER IS, AND APPROACH. I OUR CANCER REPRESENTS OVER 100 DIFFERENT DISEASES, DIFFERENT HISTOPATHOLOGICAL TYPES, MOST WITH GENETIC BIOLOGICAL SUBTYPES APPROXIMATE EACH WILL EXHIBIT UNIQUE RISK FACTORS, THIS IS ACTIVE AREA OF RESEARCH TO TEASE OUT THE PHENOTYPES THIS DISEASE ENCOMPASSES. YOU CAN SEE ON THE RIGHT HAND PANEL, MOST COMMON KARENS AMONG MEN AND WOMEN IN THE UNITED STATES FOR MEN PROSTATE, LUNG, COLON AN RECTUM AND FOR FEMALES IT'S BREAST, LUNG UX AN COLON AND RECTUM SO WE ARE EMPHASIZING THESE FOUR CANCERS LUNG, PROSTATE, COHOP AN BREAST WHICH ACCOUNT FOR OVER 50% OF ALL CANCERS IN ALL AMERICAN, DOESN'T MEAN WE WON'T EXAMINE OTHERS WE PLAN TO DO THAT BUT OUR FIRST LOOK IS TO FOCUS UPON THESE FOUR COMMON CANCERS AND FOCUS ON DIETARY PATTERNS FOR SUPPORT FROM EXPERT REVIEW AND EMERGING DATA ON INDIVIDUAL COMPONENTS. SO THIS IS OUR ANALYTIC FRAMEWORK THAT'S BEEN SIMILAR TO WHAT'S PRESENTED FOR SOME OF THE OTHER TYPE 2 DIABETES OF BODY WEIGHT AND SO FORTH, SHOWS OUR TARGET POPULATION HOW WE'RE DOING LITERATURE SEARCH, INTERVENTION OR EXPOSURES WILL BE -- WILL EXAMINE ADHERENCE TO DIETARY PATTERN. SAME AS WITH THAT FRANK JUST PRESENTED WE EXAMINE APRY YOUR YES PATTERNS SUP AS INDICES AND SCORES DATA DRIVEN CLUES eANALYSIS REDUCE REGRESSION OR PATTERNS FROM OTHER METHODS SUCH AS SELF-IDENTIFIED VEGETARIAN. THE COMPARE TON IS DIFFERENT LEVELS OF ADHERENCE TO THESE DIETARY PATTERNS. OR ADHERENCE TO A DIFFERENT DIETARY PATTERN. THEN OUR END POINTS ARE INCIDENCE BREAST COLORECTAL, PROSTATE AND LUNG CANCER. WE HAVE NOT EXAMINE SECONDARY CANCER RECURRENCE SO THIS ALL REFERS TO INCIDENCE OF FIRST PRIMARY CARE TUMORS. IN THE OVAL RIGHT HAND SIDE THERE ARE A NUMBER OF CONFOUNDERS THAT ARE IMPORTANT TO CONSIDER IN THESE ANALYSES INCLUDING TOTAL ENERGY INTAKE. BMI, SEX, AGE, SMOKING, ALCOHOL INTAKE, PHYSICAL ACTIVITY, SOCIO ECONOMIC STATUS, RACE ETHNICITY, FAMILY HISTORY, GENETICS, HORMONE REPLACEMENT THERAPIES AND OF COURSE, CANCER SCREENING SUCH AS MAMMOGRAPHY COLORECTAL CANCER SCREENING, PSA TESTS AND SO FORTH. SO WE HAVE BEGUN THE DIETARY PATTERNS CANCER LITTURE SEARCH, THIS LISTS EXCLUSION AN INCLUSION CRITERIA, THE DATA RANGE INCLUDE JANUARY 2000 TO JANUARY 2014. WE REQUIRE THAT PAPERS BE IN ENGLISH AN PEER REVIEW JOURNAL WE INCLUDED RANDOMIZED OR NON-RANDOMIZED CONTROL TRIAL, PROSPECTIVE CONTROL STUDIES OR CASE CONTROL STUDIES NESTED WITHIN THE PERSPECTIVE STUDIES. WE INCLUDED CHILDREN ADOLESCENTS AN ADULTS AGE 2 AND OVER. FROM COUNTRIES WITH HIGHER OR VERY HIGH HUMAN DEVELOPMENT. THEN EXPOSURES AS I DESCRIBED AND OUTCOMES ARE AS I PREVIOUSLY DESCRIBED. SO INITIAL SEARCH FOUND 1,871 ARTICLES SCREENS AND EXCLUE CRITERIA, DONE SO FULL TEXT ARTICLES REVIEW FOR ELIGIBILITY NUMBER 82 AND YOU CAN SEE IN THE BLUE BOX INCLUDED IN SYSTEMATIC REVIEW, THERE ARE MORE FOR BREAST AN COLORECTAL CANCER, RELATIVELY FEW FOR LUNG AND PROSTATE CANCER. SO FOR PROSTATE CANCER AS SHOWN ON THE PREVIOUS SLIDE SEVEN PROSPECTIVE COHORT STUDIES, THAT WERE PUBLISHED. AND THAT WAS FROM SIX COHORTS SO ONE HAD TWO PUBLICATIONS. THEY INCLUDED UNITED STATES, INDUSTRIAL SWEDEN AND THE UK. RISK WAS LOW ACCORDING TO THE CRITERIA AN STUDY PARTICIPANTS WERE HEALTHY ADULT MEN AGE 40 TO 60 YEARS OLD WITHOUT PREVIOUS DIAGNOSIS OF PROSTATE CANCER. YOU CAN SEE THE SAMPLE SLIDES RANGING FROM A LITTLE OVER A THOUSAND TO 300,000 PARTICIPANTS AND THE PROSTATE CANCER CASE SIMILARLY ARE SHOWN RANGING FROM 132 TO AND FOLLOW-UP TIMES VARIED FROM 7 1/2 YEARS TO LIGHTLY MORE THAN 23 YEARS OLE. MEDITERRANEAN SCORE HEALTHY EATING INDEX AND SO FORTH. THREE USED FACTOR ANALYSIS, ONE HAD DERIVED PATTERN BASED ON AN MA'AM PRODUCT CONSUMPTION. FOR PROSTATE CANCER, WE DON'T HAVE A FIRM DRAFT CONCLUSION STATEMENT YET BUT THERE'S LIMITED EVIDENCE FROM SMALL NUMBER OF STUDIES WITH WIDE VARIATION IN METHODOLOGY SO THE SUBCOMMITTEE FEELS THAT WE REALLY NEED MORE TIME TO THINK ABOUT THE EVIDENCE, EXAMINE THE EVIDENCE AND SO FORTH. BEFORE DEFINITIVE CONCLUSION STATEMENT. SO FOR LUNG CANCER, AS NOTED PREVIOUSLY WE ONLY HAVE FOUR STUDIES, THREE PROSPECTIVE COHORTS WERE USED AND ONE NESTED CASE COHORT STUDY. SIMILAR TYPES OF LOCATIONS, FROM U.S. AN EUROPE. LOW RISK OF BIAS AND PARTICIPANTS WERE HEALTHY ADULTS WITHOUT PREVIOUS DIAGNOSIS OF CANCER. THERE WAS VARIATION IN SMOKING STATUS OF PARTICIPANTS, RA WHETHER CURRENT SMOKERS OR CURRENT HEAVY SMOKERS AND HOW THAT WAS CONTROLLED FOR AND YOU CAN SEE THE SAMPLE SIZE RANGE FROM 4,000 TO NEARLY 53 THOUSANDS. LUNG CANCER CASES RANGE FROM 117 TO A LITTLE OVER 1400 CASES. SEVERAL PROSTATE CANCER, THERE WAS VARIATION IN DESIGN, TWO STUDIES USE INDICES OR SCORES, ONE USED FACTOR ANALYSIS AND ONE SIMILAR TO PROSTATE STUDIES, USE DERIVED PATTERN BASED ON ANIMAL PRODUCT CONSUMPTION. SINCE THERE WERE ONLY FOUR STUDIES SO FAR ON DIETARY PATTERNS AN LUNG CANCER LIMITED EVIDENCE FROM SMALL NUMBERS OF STUDIES WITH WIDEIATION SO THE SUBCOMITTEE FEELS WE NEED TIME TO THINK ABOUT THE EVIDENCE AND REALLY GIVE THOUGHT BEFORE WE COME UP WITH MORE DEFINITIVE CONCLUSIONS ABOUT DIETARY PATTERNS AND LUNG CANCER. THERE WERE MORE STUDIES FOR BREAST CANCER, 25 THAT INCLUDED ONE RAP DOCUMENTIZED CONTROL TRIAL AND 24 PERSPECTIVE COHORT STUDIES. IN THESE 24 PERSPECTIVE COHORT STUDIES FROM 15 ACTUAL COHORTS SO FOR SEVERAL OF THE STUDIES IT WAS THE SAME COHORT BUT DIFFERENT PUBLICATIONS. AND AGAIN, MOST ARE FROM FOR BREAST CANCER IT WAS GENERAL ADULT WOMEN WITHOUT PREVIOUS DIG KNOWSIS OF BREAST CANCER SO FIRST PRIMARY INCIDENT CANCER, SIMILAR SAMPLE SIZE TO THE OTHER STUDIES THAT WE HAVE ALREADY EXAMINED. AGAIN, A VARIETY OF METHODS, AGO STUDIES USE THESE INDICES OR SCORES, 13 USE THE DATA DRIVEN APPROACH FROM FACTOR OR CLUSTER ANALYSIS. TWO USE REDUCED RANK REGRESSION, TWO USE THE DERIVED PATTERNS FROM THE ANIMAL PRODUCTS CONSUMPTION AND ONE STUDY, RANDOMIZED CONTROL TRIAL ROW FAT DIETARY PATTERN. FOR COLORECTAL CANCER, A SIMILAR NUMBER OF STUDY FOR BREAST KAREN, ONE RANDOMIZED CONTROL TRIAL, 21 PERSPECTIVE COHORT STUDIES FROM 11 COHORTS SO SEVERAL AD MORE THAN ONE PUBLICATION, IN HERE ARE A FEW STUDIES FROM ASIAN POPULATIONS, JAPAN AND SINGAPORE IN ADDITION TO THE U.S. AND YOUR PEEP COHORTS THAT HAVE BEEN MENTIONED PREVIOUSLY. COLORECTAL CANCER STUDIES INCLUDED MEN AND WOMEN AN THESE ARE FIRST PRIMARY CANCERS, SIMILAR SAMPLE SIZES AN SIMILAR FOLLOW-UP TIMES. AND FOR THE DIETARY PATTERNS, AGAIN, A VARIETY OF APPROACHES THAT USE INDICES AN SCORES IN ADDITION TO DATA DRIVEN APPROACHES USING FACTOR OR CLUSTER ANALYSIS. REDUCED RANK REGRESSION, THE ANIMAL PRODUCT CONSUMPTION AND THEN THE RCT THAT TESTED THE LOW FAT DIETARY PA TERM. -- PATTERN. RIGHT NOW THE EVIDENCE IS UNDER REVIEW FOR BREAST AND COLORECTAL CANCER, SO AT THIS TIME I'LL SEE IF THERE'S BURNING QUESTIONS RELATED TO RELATIONSHIP BETWEEN DIETARY PATTERNS AND RISK OF COLORECTAL BREAST PROSTATE AND LUNG CANCER. WHEN YOU LOOK AT BREAST CANCER ARE YOU ABLE TO LOOK BY MENOPAUSAL STATUS THE PRE-MENOPAUSAL AND POST MENOPAUSAL THAT'S ONE QUESTION, THE OTHER IS PROSTATE CANCER, NOT MUCH EVIDENCE BUT WHEN YOU LOOK AT THE DATA COLLECTED FROM, UK, ITALY, AND KNOWING IN THE U.S. HIGHEST PROSTATE CANCER RATES SEEMS LIKE A HUGE LIMITATION IN WEAKNESS AN DATA AVAILABLE. TWO EXCELLENT QUESTIONS AND FIRST I'LL ANSWER YOUR QUESTION ABOUT BREAST CANCER, THERE WAS A VARIETY OF DESIGNS SO SOME ONLY INCLUDED POST MENOPAUSAL WOMEN, SOME INCLUDED PRE-AND POST MENOPAUSAL AND DIRECTIONS OF ASSOCIATION BETWEEN PRE-MENOPAUSAL AN POST MENOPAUSAL WERE NOT ALL THE SAME. SO THIS IS ONE REASON THE COMMITTEE FEELS WITH NEED MORE TIME TO EVALUATE THE RESULTS FROM THESE STUDIES. BECAUSE IT WASN'T ALWAYS CONSISTENT. AND THERE WAS A LACK OF CONSISTENCY WITHIN THE STUDIES ABOUT WHETHER OR NOT IT INCLUDED OR INCLUDED PRE-AND POST AND SO FORTH: YOUR QUESTION ABOUT PROSTATE CANCER IS AN SLEPT ONE, MANY COHORTS THAT WE EXAMINED HAD BUT NOT ALL, HAD A LOW ENROLLMENT OF AFRICAN AMERICAN MEN AND I AGREE THIS IS A LIMITATION OF THE STUDIES THAT WE HAVE. POWER WAS LIMITED FOR SUBGROUP ANALYSES BY RACE. SO I CAN'T SAY AT THIS TIME BUT IT'S POSSIBLE WE WOULD IDENTIFY THIS AS A FUTURE RESEARCH RECOMMENDATION BECAUSE STUDIES WERE LIMITED WITH REGARDS TO SUBGROUP ANALYSES BY RACE ETHNICITY. Q. SO AT THIS TIME WE'RE GOING TO TALK ABOUT SILL YUM AND BEING ADDRESSED AS PRESIDENT OF THE CONVERSATION ABOUT SUBCOMITTEE TWO'S WORK. HOWEVER THERE HAS BEEN AN ACROSS SUBCOMITTEES WORKING GROUP PUT TOGETHER WITH REPRESENTATION FROM FOUR OF FIVE SUBCOMITTEES TO TRY TO ADDRESS THESE QUESTIONS AROUND SODIUM. SO THE TWO QUESTIONS ARE LISTED ON THE SCREEN RIGHT NOW, WHAT'S THE RELATIONSHIP BETWEEN DIETARY SODIUM INTAKE AND BLOOD PRESSURE. AND DIETARY AND CARDIOVASCULAR OUT COMES. THE APPROACH WE USE TO ANSWER THE QUESTIONS PRETTY MUCH RELIES ON EXISTING REPORTS. THIS IS A TOPIC AREA THAT'S BEEN A LOT OF INTEREST IN SCIENTIFIC LITERATURE. WE HAVE PUBLIC HEALTH EFFORT, SCIENTIFIC EFFORT, MEDICAL COMMITTEE EFFORTS, A LOT OF AUTHORITATIVE BODIES HAVE COME TOGETHER RECENTLY TO EXAMINE THE ISSUES THAT WE MAYBE GRAPPLING WITH AROUND SODIUM SO WE'RE GOING TO CAPITALIZE ON THE EXISTING OF THOSE PIECES OF INFORMATION. THEY INCLUDE THE FOLLOWING. RECENTLY PUBLISHED 2013 AHACC GUIDELINE ON LIFE TILE MANAGEMENT TO REDUCING CARDIOVASCULAR RISK, WE TALKED ABOUT EARLIER IN THE DAY. WE HAVE TWO REPORTS FROM INSTITUTE OF MEDICINE, ONE IS QUITE RECENT PUBLISHED IN EARLY 2013. THAT'S THE REPORT SODIUM INTAKE AND POPULATIONS AN ASSESSMENT OF THE EVIDENCE PRIMARY QUESTION BEING EVALUATED THERE IS WHAT'S THE RELATIONSHIP BETWEEN DIETARY SODIUM INTAKE AND CARDIOVASCULAR OUTCOMES. NOT LOOKING AT ANY SORT OF INTERMEDIATE OR SURROGATE MARKERS. THE OTHER IOM REPORT WAS PUB ESTABLISHED IN 2010, THAT OUTLINES POPULATION STRATEGIES THAT CAN BE USED TO REDUCE DIETARY SODIUM INTAKE. WE WILL ALSO PULL FROM DIETARY REFERENCE INTAKE FOR WATER POTASSIUM SODIUM CHLORIDE AN SULFATE. GIVEN AS MU COLLEAGUE DR. HU MENTIONED EARLIER AHACC REPORT CLOSE ENTRY FOR DATA UP TO 2009 AND THE IOM REPORT 2013 AT THE BEGINNING OF THE YEAR SO MAKE SURE WE HAVE A HANDLE ON ANY PUBLICATIONS SO FIRST I WOULD LIKE TO SHOW GUIDELINES THAT ADDRESS SODIUM INTAKE FROM AHACC REPORT GIVEN USING THOSE GUIDELINES OR CONSIDERING USING THOSE GUIDELINES IN OUR 2015 RECOMMENDATIONS. THESE ARE TAKEN BY TIM FROM THE HAACC REPORT. THE FIRST ADDRESSING DIETARY PATTERNS AND FOR ADULTS WHO BENEFIT FROM BLOOD PRESSURE LOWERING, THE RECOMMENDATION IS TO CONSUME A PATTERN THAT EMPHASIZES VEGETABLES FRUITS, WHOLE GRAINS, INCLUDES LOW FAT DAIRY PRODUCTS LEGUMES, NONTROPICAL VEGETABLE OILS APPROXIMATE NUTS, LIMB INTAKE OF SLEEP, SUGAR SWEETENED BEVERAGES AND RED MEAT AND AS MARY ANN POINTED OUT EARLIER THE AND HERE IS IMPORTANT IN PA TERMS APPROACH AND SO WE WILL BE TRYING TO REALLY THINK ABOUT MORE NUTRIENT. ALSO LOOKING TO ADAPT THE PATTERN TO APPROPRIATE CALORIE REQUIREMENTS INCLUSION OF PERSONAL CULTURE FOOD PREFERENCES IS NOTED. DIABETES BEING CONSIDERED HOW THE PATTERN IS ADAPTED. THERE IS NOTES ABOUT HOW TO ACHIEVE A PATTERN BY FOLLOWING THE DASH PATTERN, THE U SDA FOOD PATTERN OR AMERICAN HEART ASSOCIATION DIET. THE EVIDENCE WAS GRADED AS STRONG, IT'S THE FIRST RECOMMENDATION GIVEN IN THE REPORT AROUND BLOOD PRESSURE AND SODIUM. IT ADDRESS SEW YUM INTAKE WITH GRADE A OR VERY STRONG STRENGTH OF EVIDENCE RATING. SPECIFIC AMOUNTS INDIVIDUALS BENEFIT FROM BLOOD PRESSURE LOWING MIGHT TO CONSUME SODIUM AT AND THERE'S NO MORE THAN 2400-MILLIGRAMS PER DAY OF SODIUM RECOMMENDATION WITH FURTHER REDUCTION 1500-MILLIGRAMS PER DAY FOR INDIVIDUALS BECAUSE THEY GET GREATER REDUCTIONS IN BLOOD PRESSURE, THE THIRD POINT IS BOLDED THAT READS WITHOUT ACHIEVING THE TWO EARLIER BULLETS REDUCING SODIUM INTAKE BY 1,000-MILLIGRAM PER DAY LOWERS BLOOD PRESSURE. AND IN OUR WORKING GROUP, WE REALLY SAW THIS PART OF THE RECOMMENDATION AS AN OPPORTUNITY TO PULL IN GUIDE PRINCIPLES FOR THE 2015 REPORT DIETARY GUIDELINES REPORT IN THAT WILL BE THINKING A LOT AROUND HOW WE ACCOMPLISH SODIUM REDUCTION. SO THE NOTION OF TRYING TO GET EXCESSIVE INTAKE DOWN IS CAPTURED NICELY IN THIS BULLET AND WILL BE GETTING ADDITIONAL CONSIDERATIONS FROM OUR WORKING GROUP. LASTLY, THERE IS LANGUAGE ABOUT COMBINING THE DASH DIETARY PATTERN WITH LOWER SODIUM INTAKE. FOR ADULTS THAT GET A BENEFIT FROM BLOOD PRESSURE LOWERING. SO WE ARE EARLY IN OUR EXAMINATION OF SODIUM, WE AS A WORKING GROUP HAVE SEVERAL CONSIDERATIONS ON THE TABLE. AS I MENTION, WE ARE LIKELY TO USE THAT LIST OF REPORTS THAT WE -- I SHOW AD FEW SLIDES BACK. AND IN DOING SO WE WILL BE ABLE TO COMMENT ON NOT JUST LEVEL OF INTAKE THAT'S BEING CURRENTLY RECOMMENDED HOW WE MIGHT ACCOMPLISH REDUCTIONS IN SODIUM INTAKE. AND WE WILL NEED TO BE THINKING ABOUT INTERRELATIONSHIPS WITH OTHER COMPONENTS OF THE DIET THAT CAME UP EARLIER IN JOHN RUFF'S TALK THIS MORNING. RELATED TO SODIUM BEING CONNECTED TO POTASSIUM AND CALORIC INTAKE. AS WE THINK ABOUT RECOMMENDATIONS AROUND SODIUM WE NEED TO FOCUS ON DIETARY PATTERN AS A WHOLE AND THINKING ABOUT THOSE SPECIAL RELATIONSHIPS WITH POTASSIUM AND CALORIES. LASTLY, WE WANT TO IDENTIFY ACHIEVABLE AFFORDABLE PRACTICAL STRATEGIES CONSISTENT WITH THE MODEL WE SAW EARLIER AND ACKNOWLEDGING THE PERFORMANCE OF PARTNERING WITH OUR FOOD INDUSTRY AS WELL AS OTHER COMMUNITY PARTNERS IN ORDER TO GET MOVEMENT ON SODIUM REDUCTION. AT THIS POINT I WILL TAKE A QUESTION OR TWO. MACK SURE THE RECORD IS CORRECT REGARDING ARCCC ARCHA RECOMMENDATION, THE RECOMMENDATION MAIN RECOMMENDATION IS DIETARY PATTERN, INDIVIDUAL NEEDS AS SUBRECOMMENDATION AS THE ONE FOLLOWING DIETARY PATTERN SO WE SHOULD PROBABLY CORRECT THAT FOR THE RECORD. THANKS. THERE F THERE'S NO OTHER QUESTIONS WE'LL GO TO THE NEXT SLIDE WHICH IS LETTING YOU KNOW WHAT OUR NEXT STEPS ARE. SO WE HAVE MORE WORK TO DO IN RELATIONSHIP TO EXAMINING A DIETARY PATTERN IN SOME OTHER KAREN OUTCOMES. SO WE'LL BE LOOKING AT THE LITERATURE TO SEE WHERE IN FACT THERE IS SUFFICIENT LITERATURE TO REVIEW AND IDENTIFY THOSE WHICH THERE'S NOT FOR DIETARY PATTERNS WE TALK INCLUSION EXCLUSION CRITERIA SO THE NEL IS POISED TO GET STARTED WITH THAT. FOR THE DIETARY PATTERNS DURING PRECONCEPTION AN BIRTH DEFECTS, WE STILL IN THE PROCESS OF DOGGING INCLUSION EXCLUSION SO THAT IS NOT READY YET. AND THEN WE WILL MOVE TOWARDS LOOKING AT DIETARY PATTERNS IN BONE HEALTH AND THEN WITH SOME EXISTING REPORTS LOOK AT CHOLESTEROL AND ALCOHOL AND USE OUR EXPERTS THAT WE HAVE ACTUALLY BROUGHT IN TO HELP US LOOK AT THESE PARTICULAR TOPICS. WE STILL HAVE WORK, YOU CAN TELL THAT WE ARE IN THE THICKED OF THINGS, BUT WE LOOK FORWARD TO HEARING ANY KINDS OF COMMENTS AN RECOMMENDATIONS FROM THE REST OF OUR GROUP. WHAT IS GOING ON SUBGROUP IS IMPRESS SAN FRANCISCO BECAUSE AREAS ARE VERY COMPLEX. ONE OF THE THOUGHTS I HAD WHICH ECHOS SOMETHING MARY ANN BROUGHT UP PREVIOUSLY IS THAT THE ISSUE RELATED TO CHOLESTEROL AND ALCOHOL WILL HAVE TO BE GIVEN SOME THOUGHTS AND FITS WITHIN THE CONTEXT OF DIETARY PATTERNS SO IT'S O -- IF YOU'RE CONSUMEING A LOT OF ALCOHOL YOU'RE PROBABLY NOT CONSUMING CERTAIN AMOUNT OF FOOD, AND I' BOTH ISSUE OF ALCOHOL AND THEN WHAT ENDS UP GETTING DISPLACEDDED AND OBVIOUSLY OTHER BEHAVIORS AND THE ISSUE OF CHOLESTEROL IS AGAIN, IMPORTANT BUT WILL BE CHALLENGING BECAUSE IT'S FOODS THAT HIGH IN LEST CHOLESTEROL AND IF YOU'RE CONSUMING EGGS FOR BREAKFAST AND NOT OTHER THINGS, SO IT WILL BE INTERESTK TO SEW HOW THAT ADDRESSED. I THINK THERE'S RATIONALE WHY THIS IS LISTED LAST IN THE SENSE WE WANT TO LOOK AT DIETARY PATTERNS IN THE DRIVERS OF DIETARY PATTERNS AND THEN SEE WHAT IS MISSING. THE ALCOHOL ISSUE IS CHALLENGING BECAUSE DIETARY PATTERN INDICES INCLUDE ALCOHOL SOME INCLUDE LOW POINTS FOR CONSUMPTION FOR A CERTAIN NUMBER OF ALCOHOLIC BEVERAGES SO TO TEASE IT OUT IS A CHALLENGE SO IT WILL NEED SOME THOUGHT. I ASSUME THERE ARE ALSO BEHAVIORS ASSOCIATED WITH ALCOHOL LIFESTYLE BEHAVIORS THAT CORRELARY. I THINK THE SUBCOMITTEE IS UP TO IT. GREAT. THANK YOU. THINK WE ARE DONE. SO -- THERE'S ONLY ONE SLIDE SO I DON'T NEED TO ADVANCE. SO IT BRINGS IT BACK TO ME AND NEXT STEPS. I THINK I WANT TO BEGIN FIRST OF ALL BY THANKING THE CHAIRS OF OUR SUBCOMITTEES, OUR WORK GROUPS, SUBCOMITTEE STAFF LEADS RICK COLETTE KELLY, THE USDA AND DHHS, DNPP FNS, NEL, THERE'S SO MANY PEOPLE WHO HELPED US AND I WANT TO THANK EVERYBODY ON BEHALF OF THE COMMITTEE, AND MAYBE JUST GIVE THEM OF APPLAUSE. [APPLAUSE] I THINK IT MUST BE APPARENT TO ALL OF THE DGAC MEMBERS NOT ON THE COMMITTEES WHO SPOKE TODAY AND TO THOSE PARTICIPATING IN THE CONFERENCE THAT THE SCOPE OF THIS WORK, THE SCOPE HAS BEEN TACKLED BY THIS COMMITTEE WITH THE HELP OF THE FEDERAL STAFF IS TREMENDOUS. REFLECTS NOT ONLY COMMITMENT OF THE MEMBERS OF THE COMMITTEE AND THERE WILLINGNESS TO TACKLE WHAT I DESCRIBED IN MY OPENING COMMENT AS AN EXTREMELY COMPLEX SET OF RELATIONSHIPS AS WE UTILIZE A SOCIO ECOLOGIC MODEL TO TRY TO ADDRESS NOT ONLY THE DETERMINANTS AND INFLUENCES ON DIETARY BEHAVIOR PHYSICAL ACTIVITY BUT ALSO THE RELATION SHIPS BETWEEN THOSE BEHAVIORS AND THE WIDE RANGING OUTCOMES THAT WERE EXAMINING BECAUSE OF THE ROBUSTNESS CERTAIN LITERATURE THAT DOES DEMONSTRATE IMPORTANT RELATIONSHIPS THAT WE WANT TO TRY TO DELVE INTO AND TACKLE IN OUR REVIEWS OF THE LITERATURE. AND IF POSSIBLE, THE RECOMMENDATIONS THAT WE PUT FORWARD. SO AGAIN I SAID THIS FROM THE BEGINNING, I'M SO IMPRESSED WITH THE LEVEL OF COMMITMENT OF THIS GROUP AND NOW THE COMMITMENTMENT OF THE CONSULTANTS WHO HAVE COME ON BOAR AND THE EXPERTS WHO ADVISED US ALONG THE WAY AND THAT LIST IS ALREADY FAIRLY EXTENSIVE AND I THINK WE WILL CONTINUE TO ADD IN THAT REGARD. I ALSO WANTED TO COMMENT ON THE FACT THAT OUT HAS TO BE CLEAR TO EVERYONE AND DEMONSTRATED CLEARLY IN THE SUBCOMITTEE REMARKS HOW OBJECTIVE, HOW THOUGHTFUL, HOW SYSTEMATIC AND HOW VERY, VERY SERIOUS THE APPROACHES ARE THAT WE'RE TAKING, REGARDLESS OF THE METHODS THAT HAVE BEEN CHOSEN WITH THE NEL, WITH THE UTILIZATION OF EXISTING REPORTS, SO FORTH. IT IS JUST AN EXTRAORDINARILY COMPLEX AND VERY, VERY THOUGHTFUL PROCESS THE GROUP IS UTILIZING AND THAT SHOULD BE ACKNOWLEDGED. NEXT STEP IT IS COMMITTEES SUMMED IT UP, THERE'S A LOT OF WORK AHEAD OF US, WE HAVE ADDED AS RICK SAID IN HIS INITIAL REMARKS ADDITIONAL MEETING TO OUR SCHEDULE WE REPORT OUT AS WE DO TODAY ON THE -- NOT ONLY THE DATA BUT OTHER INTERPRETATION OF THE DATA, OUR CONCLUSIONS AND ULTIMATELY OUR RECOMMENDATIONS ALL IN PREPARATION FOR THE REPORT THAT I TALKED ABOUT WHICH AS RICK MENTIONED WILL BE HOPEFULLY READY TO SUBMIT AT THE END OF THE YEAR. SO JUST IN CONCLUDING TODAY'S REMARKS, THERE IS NO DOUBT BASED ON THESE PRESENTATIONS AND WHAT I SAID EARLIER WHAT ENORMOUS THINGS ARE AT STAKE HERE. TREMENDOUS PROBLEMS YOU ARTICULATED THEM WELL IN YOUR PRESENTATION YOU HAVE INTERESTING RELATIONSHIPS TO CAPTURE IN OUR USE OF THE DATA. ALSO EVIDENCE ON NOT ONLY EFFECTIVE INTERVENTIONS THAT INDIVIDUAL AND MALL GROUP LEVELS BUT NOW TOO AT COMMUNITY LEVELS AND BEYOND THAT REFLECT VERY INTERESTING PUBLIC PRIVATE PARTNERSHIPS THAT HAVE BEGUN TO BE BROUGHT TO BARE ON SOLVING THESE PROBLEMS SO I THINK OUR CHOICE OF ECOLOGICAL APPROACH IS A GOOD ONE, IT'S A SOUND ONE, AND I THINK THAT THE LITERATURE AS WE'RE BEGINNING TO SEE EMERGE FROM THE SUBCOMITTEES WILL SUPPORT WIDE RANGING AND IMPORTANT SET OF CONCLUSIONS AND HOPEFULLY A EVIDENCE BASE THAT WILL SUPPORT RECOMMENDATIONS LOOKING AT EFFECTIVE STRATEGIES FOR CHANGE THAT WE CAN INCORPORATE INTO OUR RECOMMENDATIONS THAT WILL THEN IN TURN BE IMPORTANT IN TRANSLATION TO PUBLIC POLICY FOR BOTH THE DEPARTMENTS USDA AND DHHS THAT ARE COLLABORATING ON THIS EFFORT. WE AS GROUP, AS A COMMITTEE ARE COMMITTED TO THIS ONTIVE AND DEEPER VIEW OF THE EVIDENCE AND THE ESTABLISHMENT OF RECOMMENDATIONS THAT CAN GUIDE MOST INFORMED FEDERAL POLICIES AS WE AS INNOVATIVE AND SOPHISTICATED APPROACHES AND INITIATIVES. I THINK WE'RE UP TO THE CHALLENGE MIKE MCGINNI SIXTH PUT FORTH TO US. WE ARE SEEKING NOT ONLY SOUND EVIDENCE BASED APPROACH BUS ALSO TO THE EXTENT WE CAN RECOMMENDATIONS APPROACHES AND THEIR TRANSLATION TO POLICY THAT CAN BE AS INNOVATIVE AS POSSIBLE. AS WE SAID AT THE BEGINNING, CAPTURE THE IMAGINE NEIGHS OF THE SCIENTIFIC COMMUNITY AND PUBLIC PRIVATE SECTORS ALL THOSE AREAS OF INFLUENCE AND CONSUMERS ALIKE I BELIEVE WE ARE INTENDING AS A RESULT OF THIS PROCESS TO IN THE END RESULT PROVIDE THE SAFEST SECURE AFFORDABLE SUSTAINABLE AND HEALTHY FOOD SUPPLY IN EACH OF THOSE PARTICULAR ADJECTIVES, THEY'RE SO IMPORTANT AS REFLECTED IN THE MODEL AND THE WORK SUBCOMITTEES PRESENTED HERE, THAT WERE ABOUT WITH OUR REVIEWS AND OUR RECOMMENDATIONS PROMOTING THE HEALTHIEST DIET PHYSICAL ACTIVITY PATTERNS, FOOD AND BEVERAGE AND NUTRIENT INTAKE PROFILES IN INDIVIDUALS OF ALL AGES AN SEGMENTS OF THE POPULATION SO WE INTEND TO BE BROUGHT TO THE EXTENT POSSIBLE DELVE DEEP INTO THE COMMUNITIES OF CULTURE AND DIVERSE POPULATIONS THAT REFLECT COMMUNITIES THAT WE SERVE. OUR RECOMMENDATION SHOULD SERVE TO PREVENT LIFESTYLE-RELATED DISEASES, CHRONIC PHYSICAL AND MENTAL HEALTH PROBLEMS, AND PROMOTE PHYSICAL AND MENTAL WELL BEING, SOME EXPANSION INTO AREAS THAT ARE NOVEL FOR THE DGAC VERY IMPORTANT. IN ADDITION, WE'RE HOPING TO SHIFT HEALTHCARE TOWARDS GREATER FOCUS ON LIFESTYLE PREVENTION STRATEGIES. INCLUDING SOUND APPROACHES TO PREVENTIVE DIET AND LIFESTYLE BEHAVIORS FOR INDIVIDUALS AND FAMILIES AN GUIDE INNOVATIONS IN IMMUNITY, SCHOOLS, WORK SITES, PUBLIC HEALTH AND OTHER SETTINGS TO PROMOTE SOUND NUTRITION APPROXIMATE PHYSICAL ACTIVITY ENVIRONMENTS TO PROMOTE THE HEALTH OF THE PUBLIC. FINALLY TO MOAT INVESTIGATE MULTI-FACTORIAL COLLABORATIONS AND PUBLIC/PRIVATE INITIATIVES TO CHANGE THE DIET AND PHYSICAL ACTIVITY PATTERNS AN NORMS. OF OUR POPULATIONS TOWARD HEALTH OUTYOU COMETS AND PRODUCTIVITY, NOT TO LOSE THE NOTION OF PRODUCTIVE THINK BECAUSE I THINK THAT'S OOH AN IMPORTANT POTENTIAL AS A RESULT OF -- THAT'S AN IMPORTANT POTENTIAL AS A RESULT OF THIS. SO THE SCOPE IS VAST, IT'S SO IMPORTANT. THE COMMITTEE CLEARLY, AND IS EVIDENT FROM EVERYTHING WE HAVE SEEN THIS AFTERNOON IS NOT DAUNTED BY THE TASK AT ALL. QUITE THE CONTRARY. THEY'RE REALLY AMBITIOUS AND IN TERMS OF GOING FORWARD, I'LL CERTAIN KEEP ONE THE WEEKLY OR BIWEEKLY MEETINGS THAT ARE ON GOINGND SUPPLEMENTAL AS NEEDED WHEN WE DRAW EXPERTS TO WORK WAS. OUR COMMITTEE IS EXPERT. WE'LL SEEK INPUT FROM OTHER EXPERTS AS NOTED BEFORE AND AS WELL THE PUBLIC IN THEIR COMMENTS IN ATTEMPTING TO ACCOMPLISH OUR MANDATE. WE'RE GOING TO TAKE THE MOST RIGOROUS OBJECTIVE APPROACHES TO THE EVIDENCE AND PROVIDE THE SOUNDEST RECOMMENDATIONS WE CAN TO THE SECRETARY OF BOTH USDA AND HHS. WE HAVE GOT IS MUCH AS STAKE AS I BEGAN BUT WE WILL BE SUCCESSFUL IF WE COLLABORATE AND USE THE BEST AVAILABLE SCIENCE AND INNOVATIONS IN RESPONDING TO THESE CHALLENGES. AND SO WITH THAT, WOULD ANYONE ELSE LIKE TO MAKE ANY OTHER COMMENTS? THANK YOU, EVERYBODY, IT'S A PLEASURE, IT'S REAL JOY, IT'S GREAT FUN, SO THANK YOU. [APPLAUSE] MEETING IS ADJOURNED. THANK YOU.