>> GOOD MORNING, THIS IS IS RICK OLSON FROM THE OFFICE OF DISEASE PREVENTION HEALTH PROMOTION AT HHS. I WOULD LIKE TO BEGIN THE 6TH MEETING OF THE DIETARY GUIDELINES ADVISORY COMMITTEE, AS FOLKS ON THE LINE MAY HAVE NOTED ON THE AGENDA, WE POSTED ON OUR WEBSITE, THE COMMITTEE MEMBERS ARE NOT MEETING IN PERSON FOR THIS MEETING SO THAT THE FORMAT WILL BE VERY DIFFERENT THAN WHAT YOU HAVE SEEN BEFORE. WE'LL BE HAVING VIRTUAL MEETING VIA WEBINAR. THE PUBLIC WILL SEE THE COMMITTEE'S SLIDES AND HEAR THE COMMITTEE MEMBERS DISCUSS ISSUES BUT YOU WON'T SEE THEM LIVE ON THE WEBCAST AS YOU HAVE FOR THE PREVIOUS MEETINGS. I'LL PROBABLY MAKE THIS ANNOUNCEMENT LATER IN THE MORNING PROBABLY AFTER OUR BREAK JUST IN CASE THE PUBLIC GETS ON SOME OF THE PUBLIC GETS ON LATER IN THE MEETING AND DON'T REALIZE THAT THINGS ARE DIFFERENT. ON THE NEXT SLIDE IT I SHOW YOU THE FEDERAL OFFICIALS OVERSEEING THE ADVISORY COMMITTEE. YOU HAVE SEEN THESE FOLKS BEFORE AT OUR PREVIOUS MEETINGS. NOW I WOULD LIKE TO SHOW YOU THE COMMITTEE MEMBERS BARBARA MILLEN IS OUR CHAIR. ALICE LICHTENSTEIN IS OUR VICE CHAIR. STEVE ABRAMS, LUCILE ADAMS-CAMPBELL, CHERYL ANDERSON, TOM BRENNA, WAYNE CAMPBELL, STEVE CLINTON, FRANK HU, MIRIAM NELSON, MARIAN NEUHOUSER, RA FEMALE PEREZ-ESCAMILLA, ANNA MARIA SIEGA-RIZ AND MARY STORY. ALL 14 MEMBERS OF THE COMMITTEE ARE ON THE CALL TODAY, ALTHOUGH MIN NELSON WILL BE ABSENT FROM THE CALL FOR APPROXIMATELY 10:15 TO 11:45 EASTERN TIME SO SHE WILL JOIN US BACK WITH US ABOUT 11:45 OR SO. FOR THE PUBLIC SAKE, I JUST WANTED TO REVIEW AGAIN THE ROLE AND RESPONSIBILITIES OF THE COMMITTEE. YOU CAN SEE THE CHARGE THERE THAT WE TALKED ABOUT AT OUR PREVIOUS MEETINGS. THE PRODUCT OF THE ADVISORY COMMITTEE IS THEIR REPORT TO THE TWO SECRETARIES, SECRETARY OF HHS AND USDA, WE'RE STILL ON TRACK TO FINALIZE THAT ABOUT THE END OF THIS CALENDAR YEAR OR FIRST PART OF JANUARY. THE COMMITTEE WILL THEN SUBMIT ITS REPORT TO THE SECRETARY AND DISBAND. THE ROLE OF THE FEDERAL AGENCY, HHS AND USDA TO DEVELOP THE DIETARY GUIDELINES FOR 2015, WE'LL BASE THAT ON THE COMMITTEE'S REPORT WITH CONSIDERATION OF COMMENTS FROM THE PUBLIC AND FROM SEVERAL FEDERAL AGENCIES AND DOE NUTRITION AND THE RELEASE TIME FOR DGA 2015 END OF CALENDAR YEAR 2015. I WOULD LIKE TO REVIEW THE AGENDA FOR TODAY'S MEETING. AS SOON AS I FINISH, BARBARA MILLEN, CHAIR OF THE COMMITTEE, WILL PROVIDE AN INTRODUCTION TO THE SUBCOMMITTEE AND WORK GROUP REPORTS THAT WILL BE GIVEN TODAY. FIRST WE WILL HAVE SUBCOMMITTEE 1 WHICH IS CHAIRED BY MIRIAM NEUHOUSER AND SUBCOMMITTEE TWO CHAIRED BY ANNA MARIA SIEGA-RIZ. WE'LL HAVE A LUNCH BREAK AT APPROXIMATELY ONE O'CLOCK BUT AS FOLKS ARE AWARE, THE TIMING WILL DEPEND ON HOW MUCH DISCUSSION WE HAVE BY THE COMMITTEE MEMBERS SO ONE A CLOCK IS NOT A FIRM TIME AT ALL. NOTICE AT THE BOTTOM OF THAT SLIDE, SUBCOMMITTEE 5 ON FOOD SUSTAINABILITY AND SAFETY WILL NOT HAVE A REPORT AT THIS MEETING BECAUSE THEY HAVE ALREADY PRESENTED ALL OF THEIR CONCLUSIONS AND IMPLICATION STATEMENTS AT PREVIOUS MEETINGS. THEN AFTER LUNCH WE'LL HAVE A REPORT FROM SUBCOMMITTEE THREE CHAIRED BY RAFAEL PEREZ-ESCAMILLA AND THEN SUBCOMMITTEE 4 CHAIRED BY MARY STORY. AS FOLKS ARE PROBABLY AWARE, THE COMMITTEE HAS DEVELOPED SOME CROSS-CUTTING TOPIC WORKING GROUPS, THESE ARE ISSUES THAT CUT ACROSS SEVERAL OF THE COMMITTEE'S SUBCOMMITTEES. SO WE'LL HAVE REPORTS FROM THOSE THREE THIS AFTERNOON. THE FIRST IS THE SODIUM WORKING GROUP LED BY CHERYL ANDERSON, THEN WE'LL HAVE A REPORT FROM THE ADDED SUGARS WORKING GROUP CO-CHAIRED BY MARY STORY AND MIM NELSON AND FINALLY THE SATURATED FAT WORKING GROUP REPORT, THAT'S CHAIRED BY FRANK HU. THEN WE'LL END UP, THE AGENDA OR THE MEETING THIS EVENING, BARBARA MILLEN WILL BE TALKING ABOUT HOW THE COMMITTEE IS THINKING ABOUT INTEGRATING ITS FINDINGS INTO THE REPORT AND TALK ABOUT THE NEXT STEPS. SO WE'LL ADJOURN APPROXIMATELY 5:30 BUT ONCE AGAIN, THAT DEPENDS ON HOW MUCH DISCUSSION WE HAVE. SO THIS IS MY LAST SLIDE, JUST REMIND FOLKS THAT THE MEETING 7 IS ALREADY PLANNED FOR DECEMBER THE 15th, THAT'S BEEN UP ON OUR WEBSITE FOR A COUPLE OF WEEKS AND WE'LL BE GETTING OUT A FEDERAL REGISTER NOTICE ON THAT IN THE NEXT COUPLE OF WEEKS OR SO WITH TIME AND AGENDA AND THINGS LIKE THAT. SO THAT DATE IS FIRM ON DECEMBER THE 15th. WE HAVE HAD SOME REQUESTS TO MAKE THE SLIDES THAT WE PRESENT AT PUBLIC MEETINGS LIKE THIS FROM THE COMMITTEE AVAILABLE ONLINE BEFORE THE MEETING STARTS. UNFORTUNATELY WE'RE NOT ABLE TO DO THAT, ONE IS AT THE COMMITTEE'S CAN BE WORKING ON THEIR SLIDES UP UNTIL THE MEETING STARTS BUT ALSO WE HAVE TO COMPLY WITH THE 508 REQUIREMENTS, EVERYTHING THAT WE POST ON OUR WEBSITE HAS TO BE 508 COMPLIANT. OTHERWISE WE CAN'T POST THAT, THAT GENERALLY TAKES US A COUPLE OF WEEKS TO GET DONE. SO WE ARE NOT ABLE TO POST THE SUBCOMMITTEE SLIDES PRIOR TO THE MEETING. THOSE OF Y'ALL WHO HAVE INDICATED ON THE REGISTRATION PROCESS THAT YOU WOULD LIKE A COPY OF THE SLIDES, WE'LL GET THOSE TO YOU PROBABLY IN THE MIDDLE OF NEXT WEEK OR SO. THE COMMITTEE WILL BE SUBMITTING THIS REPORT LIKE I SAID, PROBABLY THE FIRST PART OF JANUARY TO THE SECRETARIES AND DISBANNED. WE'LL BE CLOSING THE PUBLIC COMMENT DATABASE WHICH IS BASICALLY COMMENTS TO THE COMMITTEE SINCE THE COMMITTEE WON'T BE IN EXISTENCE ANY MORE. BUT THEN WE WILL REOPEN THAT UP LATER SO THAT THE PUBLIC CAN COMMENT ON THE COMMITTEE'S REPORT. SO WE'LL GET OUT A FEDERAL REGISTER NOTICE THAT TALKS ABOUT THOSE THINGS. THE REPORT WILL PROBABLY TAKE SEVERAL WEEKS TO BE MADE 508 COMPLIANT BEFORE WE CAN POST-IT ON OUR WEBSITE BUT WE WILL HAVE A WRITTEN PUBLIC COMMENT PERIOD AS WELL AS A PUBLIC COMMENT MEETING FOR ORAL PUBLIC COMMENTS MUCH LIKE THE MEETING WE HAD IN JANUARY OF THIS YEAR. BUT THOSE COMMENTS ARE DIRECTED TOWARDS FEDERAL OFFICIALS AS THE COMMITTEE WILL NO LONGER BE IN EXISTENCE. SO WITH THAT I'LL TURN THINGS OVER TO BARBARA MILLEN, THE CHAIR OF THE COMMITTEE. BEFORE I DO THAT THOUGH, JUST TO REMIND THE COMMITTEE MEMBERS TO PLEASE STATE YOUR NAME BEFORE YOU SPEAK SO THAT THE PUBLIC IS AWARE OF WHO IS SPEAKING. SO TURN THINGS OVER TO BARBARA. >> THANK YOU, RICK. GOOD MORNING, EVERYONE, THANK YOU FOR JOINING US AT THIS 6TH PUBLIC MEETING. IN THE NEXT SLIDE I'LL START BY REVIEWING THE TASK OF THE DGAC. AS RICK WAS NOTING WE'RE APPOINTED BY THE SECRETARIES OF HEALTH AND HUMAN SERVICES IN THE DEPARTMENT OF AGRICULTURE TO PROVIDE TECHNICAL RECOMMENDATIONS ON HOW FOOD, NUTRITION AND PHYSICAL ACTIVITY CAN PROMOTE THE HEALTH OF THE iPOPULATION AND HELP REDUCE THE BURDEN OF MAJOR CHRONIC DISEASES AND OTHER LIFESTYLE-RELATED HEALTH PROBLEMS, AS WELL AS TO DETERMINE THE BEST METHODS AND PRACTICES TO ACCOMPLISH THESE GOALS AT INDIVIDUAL AS WELL AS POPULATION LEVELS. OUR WORK IS GOING TO CULMINATE IN A SCIENTIFIC REPORT THAT WE WILL BE SUBMITTING RELATIVELY SHORTLY TO THE SECRETARIES OF THE TWO DEPARTMENTS. IN OUR REPORT IS THEN USED TO INFORM THE DEVELOPMENT OF THE DIETARY GUIDELINES FOR 2015, A POLICY DOCUMENT THAT IS PREPARED BY THE FEDERAL GOVERNMENT, AGAIN AS PREVIOUSLY NOTED OUR RECOMMENDATIONS ARE ADVISORY IN NATURE, NOT POLICY IN AND OF THEMSELVES. CENTRAL TO OUR CHARGE IN THE NEXT SLIDE THE DGAC WILL CONSIDER THE EVIDENCE AND MAKE FOOD NUTRIENT AND HEALTH RELATED RECOMMENDATIONS THAT SUPPORT THE DEVELOPMENT OF THE 2015 GUIDELINES POLICY DOCUMENT AND HELP FRAME THESE. THE COMMITTEE HAS LAID OUT SEVERAL THEMES THAT WE HOPE WILL INFORM IF NOT INSPIRE, DIFFERENT ASPECTS OF OUR REPORT. WE'RE FOCUSING ON DIETARY PATTERNS, A CONCEPT THAT CAPTURE IT IS OVERALL NUTRIENT CONTENT AND FOOD CONTENT AND QUALITY OF THE DIET. THIS IS AS OPPOSED TO THE APPROACH USED IN PREVIOUS REPORTS THAT FOCUS ON INDIVIDUAL FOODS OR NUTRIENTS. WE WILL THEN EXAMINE THE DIETARY PATTERNS IN RELATION TO MEETING FOOD, THE EXPERT AND NUTRIENT RECOMMENDATIONS AND SC 1 IS ACTUALLY CONDUCTING MODELING ANALYSES TO LOOK HOW TO OPTIMIZE DIETARY PATTERNS TO PROMOTE HEALTH. WE'RE LOOKING AT DIETARY PATTERNS IN RELATION TO HEALTH OUTCOMES. PARTICULARLY CBD, OVERWEIGHT OBESITY, DIABETES AND DIET RELATED CANCERS AS WELL AS OTHER LESS COMMON HEALTH CONDITIONS INCLUDING BONE HEALTH NEUROPSYCH DISORDERS AND SELECTED ADVERSE OUTCOMES OF PREGNANCY. THIS IS REALLY THE FOCUS OF OUR LARGEST SUBCOMMITTEE, SUBCOMMITTEE 2. WE'RE ALSO LOOKING AT DIETARY PATTERNS IN RELATIONSHIP TO SUSTAINABILITY AND MODELING HOW DIETARY PATTERNS CAN BE FORMULATED TO PROMOTE THE HEALTH TO HAVE PUBLIC, NOT ONLY NOW BUT ALSO IN THE FUTURE GENERATIONS AND REDUCE FOOD INSECURITY IN OUR POPULATION. WE LOOK AT WHAT WORKS IN AN INDIVIDUAL AND POPULATION LEVELS TO HELP AMERICANS MAKE BETTER EATING AND PHYSICAL ACTIVITY CHOICES, AND THIS IS THE WORK NOT ONLY OF SUBCOMMITTEE 2 BUT ALSO THE FOCUS OF 3 AND 4. THE COMMITTEE IS ALSO TAKING A SYSTEMS APPROACH WHICH WE'RE CONSIDERING MULTIPLE SPEARS AND SYSTEMS THAT INFLUENCE ON DIETARY PATTERNS, PHYSICAL ACTIVITY AND HEALTH, INCLUDING FACTORS THAT DETERMINE WHAT, WHERE AND HOW MUCH WE EAT AND EXERCISE. TO THIS END, WE'RE ALSO DEVELOPING A CONCEPTUAL MODEL. THE PURPOSE OF THE MODEL IS TO REALLY ATTEMPT TO CHARGE RISE THE -- CHARACTERIZE THE MULTIPLE INTERRELATED DETERMINANTS OF WIDE-RANGING NUTRITION AND LIFESTYLE BEHAVIORS AS WELL AS HEALTH OUTCOMES AT INDIVIDUAL AND POPULATION LEVELS. THE MODEL SHOULD HIGHLIGHT THOSE AREAS WITHIN LARGE SYSTEMS RELATED CONCEPTUAL FRAMEWORK AREAS. THAT ARE SPECIFICALLY BEING ADDRESSED BY THE 2015 COMMITTEE AND THE MODEL LAYS THE GROUND WORK FOR INTEGRATION OF THE RESEARCH RECOMMENDATIONS OF THE REPORT. THE MODEL THAT WE'RE WORKING ON AT THE MOMENT KEYS OFF THE MODEL OF THE SOCIO ECOLOGICAL MODEL OF THE 2010 COMMITTEE BUT WILL HAVE UNIQUE ASPECTS TO IT AS IT RELATES TO SOME OF THE REALLY NEW DIMENSIONS OF THE 2015 REPORT. BUT IN GENERAL OUR MODEL FOCUSES ON DIET, HEALTH PROMOTION AND DISEASE PREVENTION AT INDIVIDUAL AND POPULATION LEVELS ACROSS THE LIFE COURSE SO WE'RE TAKING A LIFE COURSE APPROACH, A PUBLIC HEALTH APPROACH BY FOCUSING ON INDIVIDUAL AND POPULATION LEVELS AND WE'RE LOOKING NOT ONLY AT DETERMINANTS OF DIET PHYSICAL ACTIVITY BEHAVIOR BUT ALSO THEIR RELATIONSHIP TO WIDE RANGING HEALTH OUTCOMES. AS WE REPORTED IN PREVIOUS MEETING WE HAVE A SCIENCE REVIEW SUBCOMMITTEE THAT PROVIDES GUIDANCE ON THE OVERALL PROCESS THAT WE UNDERTAKE, WE HAVE FIVE TOPIC SPECIFIC SUBCOMMITTEES AND THEY HAVE BEEN MEETING REGULARLY AND WITH SOME INTENSITY THIS WEEK TO PREPARE THEIR PRESENTATIONS FOR TODAY. WE'RE SUBCOMMITTEES 1 THROUGH 4, AS RICK NOTED, WILL PROVIDE A REVIEW OF THE REMAINING EVIDENCE. SUBCOMMITTEE 5 AS NOTED HAS ALREADY PRESENTED, WE WILL HEAR A HIGH LEVEL VIEW FROM THEM LATER ON IN THE MEETING WHEN WE TALK AT 5 O'CLOCK ABOUT INTEGRATION OF FINDINGS. BUT TO REVIEW IN BRIEF, SUBCOMMITTEE ONE IS GATHERING DATA AND TRENDS TO ANSWER THE QUESTION ON CURRENT ADEQUACY AND QUALITY OF THE AMERICAN POPULATIONS FOOD AND NUTRIENT INTAKE, OUR DIETARY PATTERNS, AND HEALTH. THESE FINDINGS WILL PROVIDE IMPORTANT PERSPECTIVES AND CONTEXT FOR OTHER SUBCOMMITTEES IN OUR RECOMMENDATIONS. THE SUBCOMMITTEES DATA COMPRISES A VERY TRADITIONAL AREA OF OUR FOCUS BUT THE COMMITTEE'S WORK IS EXPANDING ON NUTRITION-RELATED HEALTH OUTCOMES AND LOOKING AT DIETARY PATTERNS IN NOVEL WAYS. SUBCOMMITTEE 2 ARE LARGEST, IS ALSO FOCUSED ON MORE TRADITIONAL DGAC ISSUES, THAT IS THE RELATIONSHIP OF DIET TO THE MAJOR AS WELL AS LESS COMMON HEALTH OUTCOMES. HOWEVER, ITS APPROACH DIFFERS IN KEY MAJOR WAYS BECAUSE THE FOCUS AS I MENTION ON DIETARY PATTERNS. WHICH ARE BEING EXAMINED IN OUR WORK IN RELATIONSHIP TO APRIORI ADHERENCE SCORES AS WELL AS THE RELATIVE POPULATION SUBGROUPS OF OVERALL FOOD AND NUTRIENT CONSUMPTION. AMONG THE DIETARY PATTERNS THAT WE'RE LOOKING AT IS USDA PATTERN USING THE HEI OR ALTERNATIVE TYPES OF SCORING SYSTEMS, THE MEDITERRANEAN STYLE DIET USING SCORES AND PATTERNS, DASH STYLE DIETARY RECOMMENDATIONS AS WE AS VEGETARIAN DIET. OUR DGAC HAS TAKEN THIS TACT BECAUSE OF THE ABUNDANT NEW RESEARCH ON THE RELATIONSHIP BETWEEN THIS OVERALL DIETARY PATTERN CONCEPT AS WELL AS HEALTH OUTCOMES. AND ALSO CURRENT RESEARCH ON BEST METHODS MODES AND SETTINGS TO TRY TO ACHIEVE DIETARY PATTERN BEHAVIOR CHANGE FOR IMPROVED HEALTH AT INDIVIDUAL AND POPULATION LEVELS. SC 3 IS EXAMINING WHAT WORKS TO HELP AMERICANS MAKE BETTER EATING AND PHYSICAL ACTIVITY CHOICES AT INDIVIDUALS, FAMILIES, SMALL GROUP LEVELS, THEY'RE LOOKING AT BARRIERS AND MOTIVATORS IN DIET AND PHYSICAL ACTIVITY CHANGE AND THROUGH THIS WORK THE DGAC HOPES TO REALLY HELP INFORM THE PUBLIC TO ADOPT HEALTHY LIFESTYLES AND NOT JUST TO PROVIDE RECOMMENDATIONS ON WHAT SHOULD BE DONE BUT TO ACTUALLY PRESENT ON EFFECTIVE METHODS OF ACHIEVING NOT ONLY SHORT TERM BUT LONG TERM DIETARY AND PHYSICAL ACTIVITY BEHAVIOR CHANGE. SUBCOMMITTEE 4 IS EVALUATING DETERMINANTS OF DIET, PHYSICAL ACTIVITY, BEHAVIOR, AND ALSO METHODS OF INTERVENTION FROM AN ENVIRONMENTAL PERSPECTIVE. THE EXAMINATION OF THIS AREA WILL ALLOW THEM TO EXPLORE THINGS LIKE THE CHARACTERISTICS OF NEIGHBORHOODS THAT PROMOTE DIET AND PHYSICAL ACTIVITY BEHAVIOR AS WELL AS ENVIRONMENTS SUCH AS EARLY CHILD CARE SETTINGS, SCHOOL SETTINGS, WORK SITES AND OTHER LOCATIONS OR FRAMEWORKS SUCH AS OUR FEDERAL FOOD NUTRITION ASSISTANCE PROGRAMS THAT MIGHT HAVE MAJOR INFLUENCES ON DIET AND PHYSICAL ACTIVITY BEHAVIOR. LOOKING AT HOW THESE AND OTHER ENVIRONMENTS PROVIDE ACCESS TO QUALITY FOODS, INCREASE POPULATIONS UNDERSTANDING OF HEALTHY BEHAVIORS AND HOW THESE SETTINGS CAN PROMOTE ADOPTION AND MAINTENANCE OF HEALTHY CHOICES. THAT RELATE TO DISEASE PREVENTION AND HEALTH PROMOTION. FINALLY OUR SUBCOMMITTEE 5 IS UPDATING THE EVIDENCE ON FOOD SAFETY, BEHAVIORS FOR PREVENTION OF FOOD BORN ILLNESS AND ALSO ADDRESSING SOME SPECIFIC FOOD SAFETY TOPICS SUCH AS HIGH DOSE AND USUAL LEVELS OF CAFFEINE INTAKE AND ASPARTAME AND EVALUATING ALSO RELATIONSHIPS BETWEEN DIE I TEAR PATTERNS AND SUSTAINABILITY OF A HELL -- DIETARY PATTERNS AND SUSTAINABILITY OF HEALTHY DIET AND REDUCING POPULATION RISKS FOR FOOD INSECURITY NOW AS WELL AS IN FUTURE GENERATIONS. THEY HAVE ALREADY PRESENTED ON THEIR EXCITING FOOD MODELING WORK IN THIS REGARD. IN ADDITION TO THE SUBCOMMITTEES, WE HAVE GOT THE WORKING GROUPS AND WRITING COMMITTEES THAT ARE ADDRESSING ADDED SUGARS, SODIUM, SATURATED FAT, AND PHYSICAL ACTIVITY. WE HAVE HEARD IN DEPTH AT PREVIOUS MEETINGS ABOUT PHYSICAL ACTIVITY BUT WE'LL HEAR A HIGH LEVEL PERSPECTIVE LATER IN THE MEETING TODAY. JUST TO TOUCH BRIEFLY ON OUR PROCESS, WE CAN INCLUDE INVITED EXPERTS AND CONSULTANTS. AND THE EXPERTS ARE USUALLY BROUGHT IN ON A ONE TIME BASIS TO INFORM OUR COMMITTEE'S PROCESS, WHEREAS CONSULTANTS PARTICIPATE IN DISCUSSIONS AND DECISIONS ON ONGOING BASIS. THEY'RE NOT MEMBERS OF THE COMMITTEE, NOR DO THEY VOTE BUT THEY DO PARTICIPATE THROUGHOUT THE PROCESS AND LIKE MEMBERS OF THE COMMITTEE CONSULTS COMPLETE TRAINING AND HAVE BEEN REVIEW AND CLEARED FORMALLY BY THE FEDERAL GOVERNMENT. AND OUR SUBCOMMITTEES WORK GROUPS WILL KNOW WHEN THEY HAVE UTILIZED THE EXPERT CONSULTANTS OR ADVISERS. ALONG THE WAY. IN TERMS OF EXAMINING THE EVIDENCE, WE HAVE GOT MANY APPROACHES THAT YOU HAVE HEARD REPORTED ON AND THAT YOU WILL HEAR MORE ABOUT TODAY INCLUDING NEL SYSTEMATIC REVIEWS, WHICH IS SUPPORTED BY THE USDA NUTRITION EVIDENCE LIBRARY. THE USE OF EXISTING REPORTS, HIGH QUALITY EVIDENCE BASED REPORTS, SYSTEMATIC REVIEWS OR META ANALYSES, DATA ANALYSES, FOOD PATTERN MODELING ANALYSES, AS WELL AS PUBLIC COMMENTS. I WANT TO REMIND YOU THAT YOU CAN SEE MORE ABOUT ALL OF THESE IN THE DIETARYGUIDELINES.GOV WEBSITE. JUST TO REMIND QUICKLY IN OUR NEL PROCESS, THIS IS A SIX-STEP PROCESS THAT THE COMMITTEE USES FIRST TOPIC IDENTIFICATION, LITERATURE RESEARCH, DATA EXTRACTION AND RISK OF BIAS ASSESSMENT, EVIDENCE SYNTHESIS, THE DEVELOPMENT OF CONCLUSION STATEMENTS WITH GRADES, AND ALSO THEN THE PREPARATION OF RESEARCH RECOMMENDATIONS AND TECHNICAL ABSTRACTS. IN TERMS OF OUR SYSTEMATIC REVIEWS, JUST TO ALSO HIGHLIGHT AGAIN AS PART OF THE PROCESS, WE DO USE FORMAL ANALYTIC FRAMEWORKS THAT THE DGAC PUTS TOGETHER RELATING TO EACH SPECIFIC RESEARCH QUESTION. AS PART OF THAT PROCESS WE WILL ALSO IDENTIFY INCLUSION AND EXCLUSION CRITERIA. WE WILL PREPARE AND THEN EXAMINE THE LITERATURE RESULTS, WE WILL PREPARE A DESCRIPTION OF THE EVIDENCE AND KEY FINDINGS AND CONCLUSION STATEMENTS WITH GRADES AND IMPLICATION STATEMENTS. THE CONCLUSION STATEMENTS STATE CONCISE ANSWERS TO THE QUESTIONS THAT OUR COMMITTEES POSE AND GRADES -- THE COMMITTEES THEN GRADE THE EVIDENCE AND IN SO DOING CONSIDER A VARIETY OF DIMENSIONS OF QUALITY OF THAT BODY OF EVIDENCE. THE GRADING CRITERIA ARE QUITE FORMAL, THE DEFINITIONS HAVE BEEN PRESENTED EARLIER IN OUR REPORTED HERE, THEY CAN BE STRONG, MODERATE, LIMITED OR GRADE NOT ASSIGNABLE. WE USE PRE-DETERMINED SYSTEMATIC CRITERIA TO ASSIGN GRADES, FOR EXAMPLE STRONG EVIDENCE INDICATES THAT OUR CONCLUSION STATEMENT IS SUPPORTED BY A LARGE HIGH QUALITY CONSISTENT BODY OF EVIDENCE THAT DIRECTLY ANSWERS THE QUESTION. AND THERE'S HIGH CERTAINTY IN THAT CONCLUSION STATEMENT. BUT BEYOND THE CONCLUSION STATEMENTS YOU HEARD AND WILL HEAR MORE ABOUT IMPLICATION STATEMENTS. THEY BUILD ON THE CONCLUSION STATEMENT BUT OF NECESSITY PUT IT IN A BROADER CONTEXT. THEY MAKE THE CONCLUSION STATEMENTS ACTIONABLE AND THEY DESCRIBE WHAT THE COMMITTEE IS ADVISING GOVERNMENT AND INDIVIDUALS TO DO IN ORDER TO IMPLEMENT THE DIETARY GUIDELINES. AND BEFORE I TURN IT OVER TO THE INDIVIDUAL SUBCOMMITTEES, REMEMBER THAT OUR RECOMMENDATIONS AGAIN ARE ADVISORY, THEY'RE NOT IN ITSELF FEDERAL POLICY. OUR REPORT WILL BE USED BY HHS AND USDA AS THE SCIENTIFIC BASE TO DEVELOP POLICY DOCUMENT, DIETARY GUIDELINES FOR AMERICANS, 2015. TODAY WE'RE GOING TO BE HEARING FROM OUR SUBCOMMITTEES IN ORDER AS I MENTIONED AND RICK MENTIONED, SUBCOMMITTEE 5 SINCE THEY PRESENTED ALL OF THEIR CONCLUSIONS AND IMPLICATIONS IN EARLIER MEETINGS. BUT AS I MENTIONEDS ALSO, THEY WILL PARTICIPATE IN A HIGH LEVEL DISCUSSION OF THE INTEGRATION PROCESS THAT WILL START AT FIVE O'CLOCK THIS AFTERNOON. WITHOUT FURTHER ADIEU I'LL TURN THE FLOOR TO MARIAN NEUHOUSER, THE CHAIR OF SUBCOMMITTEE 1. >> GOOD MORNING, THANK YOU, BAR PROGRAM THIS IS MARIAN NEUHOUSER, CHAIR OF SUBCOMMITTEE ONE. THE TITLE OF OUR SUBCOMMITTEE, FOOD AND NUTRIENT INTAKE FOR HEALTH, CURRENT STATS AND TRENDS. NEXT. I WOULD LIKE TO ACKNOWLEDGE AND THANK THE OTHER MEMBER OF SUBCOMMITTEE, STEVE ABRAMS, CHERYL ANDERSON AND MARY STORY AND ALICE LICHTENSTEIN, THE DGAC VICE CHAIR. NEXT. NEXT. THE SCOPE OF SUBCOMMITTEE ONE TO EXAMINE CURRENT STATUS AN TREND FOOD GROUPS FOODS NUTRIENT INTAKES, EATING BEHAVIORS, THAT CAUSES DISEASES AND WEIGHT STATUS AND DIETARY PATTERN COMPOSITION. NEXT. AS BARBARA MENTIONED THERE HAVE BEEN MANY INVITED EXPERTS. HOWEVER WE DID NOT HAVE ANY INVITED EXPERTS OR CONSULTANTS IN THE TIME PERIOD COME SEPTEMBER UNTIL THIS MEETING TODAY. NEXT. THE TOPICS THAT WE WILL ADDRESS TODAY ARE UNDER THREE GENERAL CATEGORIES. NUTRIENTS OF PUBLIC HEALTH CONCERNS AND MYSELF AND STEVE ABRAMS HAVE BEEN WORKING ON THAT AREA. DIETARY PATTERN COMPOSITION, MYSELF AND CHERYL ANDERSON HAVE BEEN WORKING ON THAT AREA. AND HEALTH CONDITIONS PREVALENCE AND TRENDS LED BY CHERYL ANDERSON AND BARBARA MILLEN. NEXT. MOST OF THE QUESTIONS AND THE DRAFT CONCLUSION STATEMENTS FOR OUR COMMITTEE HAVE BEEN PRESENTED IN PAST MEETINGS. BUT ONE QUESTION REMAINS FOR PRESENTATION TODAY IN THE AREA OF THE NUTRIENTS OF PUBLIC HEALTH CONCERN. AND THAT QUESTION IS, HOW WELL DO THE USDA FOOD PATTERNS MEET NUTRITIONAL NEEDS OF CHILDREN 2 TO 5 YEARS OF AGE AND HOW DOES THE RECOMMENDED AMOUNTS COMPARE TO THEIR CURRENT INTAKE? GIVEN THE RELATIVELY SMALL EMPTY CALORIE LIMIT FOR THIS AGE GROUP, HOW MUCH FLEXIBILITY IS POSSIBLE IN FOOD CHOICES? AND WE ANSWERED THIS QUESTION USING FOOD PATTERN MODELING. NEXT. HERE IS A REVIEW OF THE EVIDENCE. AGAIN, THIS WAS CONDUCTED WITH FOOD PATTERN MODELING. FIRST THE NUTRITIONAL NEEDS AND DIET OF YOUNG CHILDREN DIFFER FROM THOSE OF ADULTS AND OLDER CHILDREN. SO PATTERNS FOR CHILDREN 2 TO 5 YEARS OF AGE. AS A REMINDER AS YOU HAVE HEARD THE FOOD PATTERN MODELING REPORTS PREVIOUSLY, THE FOOD PATTERN MODELING IS DESIGNED TO PROVIDE FOOD GROUP INTAKE SUCH THAT THE RDA IS MET. SO IN DOING SO, THE NUTRIENT PROFILES FOR DAIRY AND FRUIT GROUPS FOR MODIFIED TO REPRESENT THE INTAKES OF YOUNG CHILDREN. AND IN PREVIOUS ISSUANCES OF THE FOOD PATTERN MODELING AND DIETARY GUIDELINES THERE'S NOT BEEN SPECIFIC MODIFICATIONS MADE FOR YOUNG CHILDREN. SO THIS IS A NEW APPROACH SO IN THE FOOD PATTERN MODELING, COMPARED TO THE STANDARD ADULT AND OLDER CHILDREN PATTERN THE FOOD GROUPS INCREASE FROM 33 TO 42% OF THE TOTAL FRUIT INTAKE, SO JUST A SLIGHT INCREASE AND MILK INTAKE INCREASED FROM 54% TO 71% TOTAL DAIRY INTAKE. THIS INCLUDES FLUID, MILK, CHEESE, YOGURT, SOY MILK SO FORTH. ANOTHER CHANGE WAS REPRESENTED BY LOW FAT OR 1% MILK RATHER THAN FAT FREE MILK AND THESE RESULTING PATTERNS WERE COMPARED TO NUTRITIONAL GOALS AND THE CURRENT INTAKE. AND WE ALSO IDENTIFIED POTENTIAL FOR ANY FLEXIBILITY. NEXT. SO KEY FINDINGS IS THAT THE MODIFIED USDA FOOD PATTERNS MEET NUTRIENT NEEDS OF YOUNG CHILDREN T. NUTRIENTS WHICH RDAs ARE NOT MET IS SAME FOR OLDER CHILDREN AND ADULTS, MAINLY VITAMIN E AND VITAMIN B. RECOMMENDED FOOD GROUP AMOUNTS FALL WITHIN THE RANGE OF USUAL INTAKE, 95TH TO -- 5 TO 95 PERCENTILE, AGE GROUP AND SUBGROUPS SO IN OTHER WORDS IT'S A MEANINGFUL WAY TO PROVIDE GUIDANCE FOR YOUNG CHILDREN BECAUSE IT'S ACHIEVABLE. IT'S VERY SIMILAR TO WHAT YOUNG CHILDREN ARE. THE PATTERNS DO HAVE LIMITED FLEXIBILITY TO ALLOW CALORIES FROM SOLID FAT THROUGH ADDED SUGARS WHICH WE CALL EMPTY CALORIES. SO OPTIONS TO INCREASE FLEXIBILITY IN FOOD CHOICES INCLUDE A SMALL REDUCTION IN THE AMOUNT OF PROTEIN FOODS OR CHANGE FROM 1% MILK TO FAT FREE MILK AT FOUR YEARS OF AGE. NEXT. SO OUR DRAFT SUMMARY STATEMENT IS THAT THE USDA FOOD PATTERNS PROVIDES SUITABLE GUIDANCE FOR PROVIDING YOUNG CHILDREN 2 TO 5 YEARS OF AGE, THE PATTERN ASSUMES USE OF 1% RATHER THAN FAT FREE MILK AND THE ALLOWANCE FOR EMPTY CALORIES IS LIMITED, SINCE TOTAL CALORIES CONSUMED ARE LOWER AMONG YOUNG CHILDREN. NEXT. SO TO CIRCLE BACK TO OUR QUESTION, HOW WELL DO USDA FOOD PA TERMS MEET NUTRITIONAL NEEDS OF CHILDREN 2 TO 5 YEARS OF AGE AND HOW DO THE RECOMMENDED AMOUNTS COMPARE TO THE CURRENT INTAKE. GIVEN THE RELATIVELY SMALL EMPTY CALORIE LIMIT FOR THIS AGE GROUP, HOW MUCH FLEXIBILITY IS POSSIBLE IN FOOD CHOICES? SO LET ME OPEN IT UP FIRST TO OTHER SUBCOMMITTEE 1 MEMBERS FOR QUESTIONS OR COMMENTS. AND THEN WE CAN OPEN UP TO THE REST OF THE DGAC. SO SUBCOMMITTEE 1, QUESTIONS OR COMMENTS? HEARING NONE LET ME OPEN IT UP TO THE REST OF THE DGAC FOR QUESTIONS OR COMMENTS. >> THIS IS ANNA MARIA SIEGA-RIZ. I WAS WONDERING IF YOU CAN EXPLAIN A BIT MORE ABOUT THE RECOMMENDATION WHICH TO 1% MILK (INAUDIBLE) OF AGE? FROM WHOLE MILK TO 1%? >> LET ME HAVE STEVE ABRAMS ANSWER THAT QUESTION FOR YOU. >> SURE. THE SITUATION IS FOR MOST CHILDREN THE RECOMMENDATION IS THAT WE CONTINUE WHOLE MILK UNTIL TWO YEARS OF AGE THEN GRADUALLY TRANSITION DOWNWARD. ULTIMATELY ENDING UP AT VERY LOW FAT OR SKIM MILK. THE PROBABLE IS IT'S -- PROBLEM IS IT'S DIFFICULT TO MAKE THE TRANSITION SUDDENLY AND MANY FAMILIES DO IT OVER A PERIOD OF TIME. SOME MILK FAT MAYBE BENEFICIAL FOR SMALL CHILDREN. SO FOR THE PURPOSE OF MODELING WHAT WE CHOSE TO DO RATHER THAN USE SKIM MILK WHICH IS -- WOULD BE A BIG CHANGE FROM TWO YEARS TO RIGHT AFTERWARDS, TO USE 1% THAT'S SLIGHTLY A OVERALL CALORIES IN THE PATTERN BUT OVERALL DOESN'T CHANGE A LOT. >> THANK YOU, STEVE, SO THAT CLARIFICATION MEANS THAT YOU BASICALLY DIDN'T USE FAT FREE MILK FROM 2 TO 4 YEARS. YOU'RE USING 1% NOT WHOLE MILK. >> THAT'S CORRECT. >> OKAY. THANK YOU. >> THIS IS FRANK HU, I HAVE A QUICK QUESTION REGARDING JUICES SO YOU SAID THERE IS A SLIGHT INCREASE IN THE JUICES. CAN YOU GIVE QUANTIFICATION OF THE INCREASE IN HOW MUCH JUICES INCLUDED IN THE MODELING? >> YES, AS YOU SAW FROM THE SLIDE FRUIT JUICE INCREASED FROM 33% TO 42% OF THE TOTAL FRUIT INTAKE AND THIS WAS CHANGED BECAUSE WE HAVE NOTICED IN THE INTAKE OF YOUNG CHILDREN THIS IS ABOUT WHAT THEY'RE EATING AND THE NUTRIENT PROFILES, PROVIDE NUTRIENTS PER CUP EQUIVALENT OF THE GROUP AND FOR YOUNG CHILDREN WHO HAPPEN TO MAKE UP A LARGER PERCENTAGE, IT DOESN'T NECESSARILY MEAN THAT MORE JUICE IS RECOMMENDED, JUST ACKNOWLEDGING THAT MORE JUICE IS CONSUMED AND SO THE PATTERN DO REFLECT THAT. >> IN TERMS OF THE AMOUNT, TALKING ABOUT ONE CUP OR TWO CUPS A DAY? >> THE AMOUNTS RECOMMENDED IN THE FOOD PATTERN MODELING IS IDENTICAL TO THE AAP, AMERICAN ACADEMY OF PEDIATRICS RECOMMENDATIONS WHICH I BELIEVE IS FOR NO MORE THAN FOUR TO SIX OUNCES PER DAY. IF TRISH IS ON THE LINE SHE CAN MAKE A COMMENT AS WELL. >> HI, THIS IS TRISH BRITTON. MARIAN IS ABSOLUTELY RIGHT. THE TOTAL AMOUNT OF FRUIT INCLUDING JUICE GOES FROM ONE TO ONE 1/2 CUPS FOR CHILDREN BETWEEN TWO AND FIVE. AND 42% OF THAT WOULD BE REFLECTED IN OUR PATTERNS BY FRUIT JUICE BECAUSE THAT'S WHAT CHILDREN NOW CONSUME. SO THAT TOTAL AMOUNT OF JUICE FOR THAT AGE GROUP IS WITHIN THE AAP RECOMMENDATIONS OF 4 TO 6 OR ONE-HALF TO THREE FOURTHS CUP OF FRUIT JUICE A DAY. >> THANK YOU. >> ANY OTHER QUESTIONS FROM THE DGAC? AT THIS POINT I WILL TURN THE PODIUM OVER TO CHERYL ANDERSON FOR THE NEXT SET OF SLIDES. >> THANKS, MARIAN. SO I WOULD LIKE TO TALK WITH YOU ABOUT WHAT WE HAVE BEEN DOING IN TERMS OF THE DIETARY PATTERNS COMPOSITION WORK. ON THIS SLIDE YOU SEE A FEW POINTS ABOUT THE BACKGROUND AND RATIONALE FOR THIS WORK. SO IN SUBCOMMITTEE 2 A PRIMARY FOCUS HAS BEEN TO EXAMINE THE ASSOCIATION OF DIETARY PATTERNS, RATHER THAN SOME OF THE SINGLE NUTRIENT ANALYSES THAT WE GOT IN PREVIOUS REPORTS WITH RISK OF OBESITY, CARDIOVASCULAR DISEASE, TYPE 2 DIABETES AND CANCER. DIETARY PATTERNs MERGE HAVING HEALTHFUL BENEFITS AND WHAT WE'RE DOING IN THIS WORK IS COMPLIMENTING THE WORK BY OUR COLLEAGUES BY REALLY TRYING TO DETERMINE WHETHER OR NOT THEY ARE SPECIFIC TYPES AND QUANTITIES OF FOOD GROUPS THAT APPEARED MORE CONSISTENTLY IN THE STUDIES THAT WERE EXAMINING IN SUBCOMMITTEE TWO. SO THERE ARE THREE QUESTIONS RELATED TO DIETARY PATTERNS SO MUCH SESSION THAT WE'RE GOING TO ADDRESS TODAY. FIRST LISTED HERE, THE FIRST I WILL COVER AND THE SECOND TWO WILL BE COVERED BY MARIAN AND WE'LL HAVE DISCUSSION AT THE END. SO THE FIRST QUESTION IS WHAT IS THE COMPOSITION OF DIETARY PATTERNS WITH EVIDENCE OF POSITIVE HEALTH OUTCOMES AND A PATTERNS COMMONLY CONSUMED IN THE UNITED STATES. WHAT ARE THE SIMILARITIES AND DIFFERENCES WITHIN PATTERNS AN AMONG PATTERNS WITH EVIDENCE OF POSITIVE HEALTH OUTCOMES AND COMMONLY CONSUMED DIETARY PATTERN. SO THIS SLIDE PROVIDES AN OVERVIEW OF OUR METHODS. SO WE REVIEWED ARTICLES EXAMINED BY SUBCOMMITTEE 2 TO IDENTIFY THOSE STUDIES THAT REPORTED QUANTIFIED DATA ON FOOD GROUP INTAKES IN THE POPULATION OR INTERVENTION GROUPS THAT WERE SHOWN TO HAVE POSITIVE HEALTH OUTCOMES. WE HAD TO EXCLUDE ARTICLES THAT DIDN'T HAVE SUFFICIENT QUANTITATIVE INFORMATION. WHEN WE HAD QUANTIFIED FOOD GROUP INTAKES, WE CONVERTED THEM TO GRAMS, IF THEY WERE PRESENTED IN SERVING, AND WE USE SERVING TO GRAM CONVERSION FROM THE STUDY OR FROM DOCUMENTS RELATED TO THE STUDY THAT ALLOWED US TO DO THE CONVERSION. WE DID THE CONVERSIONS FROM GRAMS PER DAY TO GRAMS PER THOUSAND CALORIES TO ENSURE THAT WE CAN MAKE COMPARISONS ACROSS THE VARIOUS STUDIES. WHEN WE SHOW THESE DATA AND LOOK AT WHAT'S SEEN IN THE STUDIES COMPARED TO USUAL INTAKES, THOSE USUAL INTAKES ARE COMING FROM DATA FROM THE NATIONAL HEALTH NUTRITION EXAMINATION SURVEY, 2010 -- 2007 TO 2010 PERIOD, IT'S FOR ADULTS, CONVERTED TO GRAMS PER THOUSAND CALORIES FOR THE VARIOUS AGE, SEX GROUPS. WE USE THE RANGE OF INTAKES FOR USUAL U.S. INTAKE AS THE COMPARATOR. WHEN WE DO THE COMPARISONS TO THE USDA FOOD PATTERNS WE USE HEALTHY U.S. BELL PATTERNS THAT THOSE ANALYSES COMPRISE AND THE RECOMMENDED AMOUNTS OF EACH FOOD GROUP IN THE PATTERN FROM THE 800 TO 2400-KILO CALORIE GROUPS ARE CONVERTED TO GRAMS PER THOUSAND CALORIES AND THAT'S WHAT WE'RE USING AS THE COMPARATOR. SO THIS IS THE FIRST IN SERIES OF SLIDES THAT I'M GOING TO SHOW THAT ESSENTIALLY HAVE THE SAME SET UP. SO WHAT I WOULD LIKE TO DO IS PROVIDE A BRIEF ORIENTATION TO THE SLIDE. SO ALONG THE X AXIS HERE, WE HAVE THE VARIOUS CATEGORIES OF DIETARY PATTERNS, SO ON THE FAR LEFT YOU SEE THE DASH OMNI STYLE PATTERNS AND EACH DOT ON THE FIGURE SHOWS THAT DATA IS COMING FROM THAT PARTICULAR STUDY. IF YOU MOVE ACROSS TO THE FAR RIGHT OF THAT X AXIS YOU SEE STUDIES THAT DETERMINE DIETARY PATTERNS USING FACTOR OR CLUSTER ANALYSES. YOU HAVE THREE OTHER TYPES IN BETWEEN. ON THE Y AXIS WE SHOW THE GRAMS PER THOUSAND KILO CALORIE INTAKE AND EQUIVALENT CONVERSIONS IN CUPS OR SOMETIMES YOU'LL SEE IT ANNOUNCED DEPENDING ON WHAT'S RELEVANT FOR THE NUTRIENT OR FOOD GROUP BEING SHOWN. IN THIS PARTICULAR SLIDE, WE'RE SHOWING THE VEGETABLE INTAKE FOR HEALTHY DIETARY PATTERNS. AND THIS EXTENDS WHAT WAS SHOWN BACK IN THE SEPTEMBER MEETING IN THAT NOW WE ALSO HAVE THE RANGE OF INTAKE FROM THE USDA FOOD PATTERNS SHOWN BY THAT BLUE BAND THAT GOES ACROSS THE SLIDE OR ACROSS THE FIGURE, AND WE ALSO ALLOW FOR COMPARISON TO WHAT'S USUALLY INTAKE IN THE US POPULATION AND THAT'S SHOWN IN THAT PINK BAND THAT GOES ACROSS THE SCREEN. HOPEFULLY I DESCRIBE WHAT'S GOING ON IN THESE FIVE SLIDES, THINGS WILL BECOME EASIER TO INTERPRET ONCE WE GO THROUGH THIS FIRST SLIDE. SO HERE WE'RE LOOKING AT AS I MENTIONED, VEGETABLE INTAKE. YOU CAN SEE FOR THE VARIOUS STUDIES THAT HAD QUANTIFIABLE DIETARY PATTERNS INFORMATION, THERE IS INDEED A RANGE IN INTAKE ACROSS THE STUDIES. YOU SEE HOW THEY COMPARE TO THE USDA FOOD PATTERNS AND NOT MOST OF THESE STUDIES ARE FALLING EITHER WITHIN THE PATTERN OR ABOVE IT AND YOU CAN SEE A FEW THERE FALLING INTO THAT PINK RANGE WHICH REPRESENTS THE RANGE OF USUAL INTAKES FOR THE ADULT POPULATION. THIS SLIDE SHOWS DATA FOR FRUIT INTAKE FOOD GROUPS. IN THE HEALTHY DIETARY PATTERNS. AGAIN, YOU SEE THE RANGE HERE FOR STUDIES THAT ARE NOT CLASSIFIED IN THE DASH OMNI SECTION OF THE FIGURE, IT'S A BIT TIGHTER AND FOLLOWS CLUSTERS AROUND THE RANGE IN THE USDA FOOD PATTERNS. WHEN WE LOOK TO THE LEFT SIDE OF THE FIGURE AT THE DASH OMNI PATTERN, THESE ARE EFFICACY STUDIES WHERE THE INTERVENTION IS DONE THROUGH A FEEDING PROTOCOL WE SEE THAT THE FRUIT INTAKE FOR THOSE STUDIES ARE ABOVE WHAT WE SEE IN THE RANGE OF USDA FOOD PATTERNS. THIS SLIDE WE SEE DATA FOR DAIRY INTAKE IN THE HEALTHFUL DIETARY PATTERNS. I JUST WANT TO DRAW YOUR ATTENTION TO THE RANGE SEEN IN THE DASH OMNI FEEDING STUDIES THAT FALL SQUARELY WITHIN THE RANGE OF USDA FOOD PATTERNS, WE SEE TWO OTHER STUDIES FROM THE MEDITERRANEAN DIET STYLE PATTERNS AND THOSE WITH OTHER SCORING MECHANISMS IN THAT RANGE AS WELL. THE OTHER STUDIES TEND TO FALL EITHER WITHIN THE RANGE OF TYPICAL INTAKE FOR THE U.S. OR BETWEEN THE RANGE FROM THE USDA FOOD PATTERNS AND WHAT'S TYPICAL. WHEN WE LOOK AT SEAFOOD INTAKE IN THE HEALTHFUL PATTERNS, THANK YOU. WHEN WE LOOK AT THE RED AND PROCESSED MEAT INTAKE IN THE HEALTHFUL PATTERNS, WE SEE THE DASH OMNI STYLE STUDY INFORMATION AROUND INTAKES AS WELL AS TWO OTHERS FALL BELOW THE RANGE IN THE USDA FOOD PATTERNS. AND THE OTHER STUDIES SHOW DATA WHERE INTAKES ARE FALLING ABOVE USDA FOOD PATTERNS. AND ABOVE U.S. TYPICAL INTAKE AS WELL. FOR SEAFOOD INTAKE WE SEE THERE'S SIMILARITY IN THE RANGE OF USDA FOOD PA TERMS AND WHAT YOU SEE IN THE DASH STYLE OR OMNI STYLED DIETARY PATTERNS DATA. THE MAJORITY OF THE OTHER STUDIES ARE EITHER FALLING ABOVE THE RANGE OF INTAKE FOR THE USDA FOOD PATTERNS OR JUST SORT OF RIGHT IN THERE. SO TERMS OF OUR CONCLUSIONS, OMNI DIETARY PATTERNS COMPOSITION ANALYSES, WE SEE THAT THE PATTERNS WITH VARIANCE FOOD GROUP COMPOSITION, THEY HAVE CERTAIN COMMON ELEMENTS. THEY'RE OBSERVED ACROSS VARIOUS STUDIES TO HAVE HEALTH BENEFITS, IT OFFERS OPTIONS IN TERMS OF ACHIEVING A HEALTHY DIET. IN GENERAL RANGES OF INTAKE OF THESE PATTERNS WITH POSITIVE HEALTH BENEFITS COME CLOSE TO WHAT'S RECOMMENDED BY THE U SDA FOOD PATTERNS AND THOSE WERE SHOWN AGAIN, WITHIN THOSE BLUE BARS OR JUST ABOVE. THE AMOUNTS OF SOME SPECIFIC FOOD GROUPS VARY ACROSS THE VARIOUS DIET PATTERN TYPES. FOR EXAMPLE, THE DASH STYLE DIETS IN THE MEDITERRANEAN STYLE DIETS ARE SIMILAR WITH RESPECT TO THE AMOUNTS OF DAILY FRUIT AND VEGETABLE QUANTITIES, AND THEY'RE HIGHER THAN THE AMOUNTS RECOMMENDED IN THE USDA FAD PATTERNS. WHEN WE LOOK AT DAIRY WE SAW THE INTAKE WAS COMPARABLE BETWEEN DASH STYLE DIETS AND THE USDA FOOD PATTERNS RECOMMENDATIONS BUT DAIRY WAS LOWER FOR THE MEDITERRANEAN STYLE DIETS. WHEN WE LOOKED AT THE RED AND PROCESSED MEAT DATA, WE SAW IT WAS HIGHER IN THE MEDITERRANEAN STYLE DIET THAN RECOMMENDED IN THE USDA FOOD PATTERN BALLOWER IN THE DASH AND OMNI STYLE DIET AND WHAT'S RECOMMENDED IN THE USDA FOOD PATTERNS. A SEAFOOD INTAKE WAS SIMILAR IN THE DASH STYLE DIETS AND HIGHER IN THE MEDITERRANEAN STYLE KEITHS THAN THE USDA FOOD PATTERNS. THE DATA FROM THE VARIOUS STUDYS WE LOOK AD PROVIDE EMPIRICAL DATA -- LOOKED AT PROVIDE SOME EMPIRICAL DATA, CONSISTENT WITH THE EVIDENCE BASE WE'RE SEEING AROUND DIETARY PATTERNS AND PROVIDE REAL EVIDENCE BASED GUIDE TO FOOD COMPOSITION. IN TERMS OF IMPLICATION FOR PART OF DIETARY PATTERNS QUESTION, THE QUALITY OF CURRENT DIET U.S. POPULATION IS SUBOPTIMAL OVERALL, WE PRESENTED THOSE DATA IN PREVIOUS DIETARY GUIDELINES COMMITTEE MEETINGS, THIS HAS MAJOR ADVERSE HEALTH CONSEQUENCES. SO TO IMPROVE THE POPULATION DIET THESE ANALYSES SUGGEST THERE'S SEVERAL EATING PATTERNS THAT CAN BE ADOPTED. THE APPROACHES THAT CAN BE TAKEN ARE VARIED, AS WE SAW, THERE WERE FIVE DIFFERENT STYLES, CATEGORIZED IN THE DATA WE SHOWED, THEY CAN BE ADOPTED TO PERSONAL PREFERENCES AND CULTURAL PREFERENCES, AND THE OPPORTUNITY TO CONSUME THIS VARIED TYPE OF DIETARY PATTERNS, MAY ACTUALLY HELP TO PROMOTE MORE SUSTAINED DIETARY INTAKE AND CHANGES THAT COULD LEAD TO IMPROVED HEALTH OF THE U.S. POPULATION. I'M GOING TO TURN THE SLIDE DECK NOW OVER TO MARIAN AND ASK HER TO CONTINUE WITH OUR SECOND QUESTION THAT'S RELATED TO OUR DIETARY PATTERNS COMPOSITION. >> THANK YOU, CHERYL. SO OUR SECOND QUESTION IS WHAT EXTENT DOES THE US POPULATION CONSUME A DIETARY PATTERN SIMILAR TO THOSE OBSERVED TO HAVE POSITIVE HEALTH BENEFITS SUCH AS MEDITERRANEAN AND DASH STYLE DIETS. YOU SAW A LITTLE BIT OF THAT IN SOME OF THE LOWER BANDS ON THE SLIDES THAT CHERYL PRESENTED, YOU MAY REMEMBER THERE WAS A BAND THAT SHOWED WHAT THE U.S. POPULATION IS MORE OR LESS CONSUMING. SO WE WANT TO TAKE A CLOSER LOOK AT THAT. SO TO DO SO, WE COMPARED THE HEALTHY EATING INDEX 2010 SCORES AND THEIR SUBSCORES. FOR AGE AND SEX GROUPS USING THE NHANES TWINE TO 2010 DATA AND COMPARED THAT TO IDEAL SCORES. SO AN IDEAL SCORE ON THE HEALTHY TEATING INDEX OR ATI IS 100 POINTS, WHAT WE'RE SHOWING HERE ARE SUBSCALE AND TOTAL SCORES FOR ALL AMERICANS TWO YEARS OF AGE AND OLDER, IN ORANGE, AND THEN ALSO SPLIT OUT BY MALES AND FEMALES, WITH MALES IN THE RED AND FEMALES IN THE GRAY GREEN COLOR. SO HERE ON THE BOTTOM YOU SEE ALL THE COMPONENTS THAT MAKE UP HEALTHY EATING INDEX WHICH IS TOTAL FRUIT, WHOLE FRUIT, TOTAL VEGETABLES, GREENS AND BEANS, WHOLE GRAINS, DAIRY, TOTAL PROTEIN, SEAFOOD AND PLANT PROTEIN, FATTY ACIDS, REFINED GRAINS, SODIUM, EMPTY CALORIES, THEN THE TOTAL ATI SCORE. SO IF YOU LOOK OVER AT THE FAR RIGHT HANDSET OF COLUMNS ON THE SLIDE, YOU WILL SEE A BOX AROUND THE TOTAL ATI SCORE. YOU CAN SEE THAT MOST AMERICANS HOVER AROUND A LITTLE BIT LESS THAN 60 POINTS. REMEMBER, THERE'S A TOTAL OF 100. THERE'S CERTAINLY ROOM FOR WHITE A BIT OF IMPROVEMENT. AS WE LOOK ACROSS THE COMPONENT SCORES YOU CAN SEE THAT THERE IS SOME VARIATION BY MALE AND FEMALE INTAKE WITH FEMALES DOING A BETTER FOR MANY OF THE SUBCOMPONENT SCORES SUCH AS TOTAL FRUIT, VEGETABLES, GREENS, AND SO FORTH WE ALSO HAVE ATI SCORES BROKEN DOWN A LITTLE BIT FURTHER, MORE FINE TUNING BY THE AGE GROUP. SO YOU CAN SEE ACROSS THE TOP THE VARIOUS COLOR DESIGNATION FOR THE AGE GROUPS FOR YOUNG CHILDREN TWO TO THREE, FOUR TO EIGHT, NINE TO 13 AND SO FORTH. SO HERE WE CAN SEE THAT THERE'S A U SHAPE FOR MANY OF THE FOOD COMPONENTS. FOR INSTANCE, TOTAL FRUIT, YOUNG CHILDREN AND MIDDLE AGE AND OLDER ADULTS ARE DOING VERY WELL IN THE TOTAL FRUIT CATEGORIES AS WELL AS WHOLE FRUITS. DOING WELL WITH VEGETABLES, ESPECIALLY AMONG THE OLDER AGE GROUPS. WE ALSO SEE DAIRY CONSUMPTION IS VERY GOOD AMONG YOUNG CHILDREN THEN IT TENDS TO FALL OFF LITTLE BIT. AND SO FORTH AS WE GO ACROSS THE SLIDES. THEN AGAIN WE CAN SEE THE TOTAL ATI SCORES AT THE FAR RIGHT SET OF COLUMNS WHERE AGAIN THERE'S A SLIGHT U SHAPE WITH BETTER DIET AMONG YOUNG CHILDREN AMONG MIDDLE AGE AND OLDER ADULTS WITH POORER DIETS AMONG PRE-ADOLESCENT AND ADOLESCENT. CERTAINLY AMONG ALL GROUPS THERE'S MUCH ROOM FOR IMPROVEMENT FOR THESE ATI SCORES. SO OUR KEY FINDINGS ARE THAT THE ATI COMPONENT SCORES VARIED IN WHAT WE EAT IN AMERICA OR NHANES DATA. FEMALES, YOUNG CHILDREN, AND MIDDLE AGE AND OLDER ADULT VERSUS BETTER COMPONENT SCORES WHILE PRE-ADOLESCENT AND ADOLESCENT CHILDREN HAD THE POOREST SCORES. IT'S IMPORTANT TO NOTE THAT DATA ARE NOT AVAILABLE TO EXAMINE DASH STYLE OR MEDITERRANEAN STYLE DIETS IN WHAT WE EAT IN AMERICA. WE HAD READILY AVAILABLE THE ABILITY TO EXAMINE THE ATI SCORES AND SOMETHING THAT WE CERTAINLY LIKE TO DO IN THE FUTURE, FUTURE RESEARCH NEEDS IS TO EXAMINE THE EXTENT TO WHICH AMERICANS ALREADY FOLLOW A DASH STYLE DIET OR MEDITERRANEAN STYLE DIET. SO OUR DRAFT CONCLUSION STATEMENT IS AS FOLLOWS: DATA FROM WHAT WE EAT IN AMERICA SHOWS THE AVERAGE ATI SCORE IN THE U.S. POPULATION IS 57 POINTS, OUT OF A TOTAL OF 100 POINTS. THE BEST SCORES WERE OBSERVED FOR THE FOLLOWING COMPONENT SCORES. TOTAL PROTEIN FOODS, SEAFOOD AND PLANT PROTEIN AND DAIRY, WHILE THE POOREST SCORES WERE OBSERVED WHOLE GRAINS SODIUM, MEANING TOO MUCH SODIUM, FATTY ACID, GREENS AND BEANS AND EMPTY CALORIES. IN ADDITION YOUNG CHILDREN AGES TWO TO THREE YEARS AND MIDDLE AGE AND OLDER ADULTS HAVE THE BEST ATI SCORES WHILE PRE-ADOLESCENT AND ADOLESCENT VERSUS THE POOREST ATI SCORES. ADOLESCENTS HAVE THE POOREST ATI SCORES. SO NOW I'LL MOVE ON TO OUR THIRD DIETARY PATTERNS QUESTION AND THAT'S -- IT IS AS FOLLOWS, USING THE FOOD PATTERN MODELING PROCESS AND HEALTHY EATING PATTERNS FOR VEGETARIAN AND FOR THOSE WHO WANT TO FOLLOW A MED TERRAINIAN STYLE DIET BE DEVELOPED. HOW DO THESE PATTERNS DIFFER FROM THE USDA FOOD PATTERN PREVIOUSLY UPDATED FOR THE 2015 DGA. THE REASON WE WANT TO DO THIS WAS TO PROVIDE A LITTLE BIT OF VARIETY FOR AMERICANS IN TERMS OF POSSIBLE EATING CHOICES. SO OUR METHODS ARE AS FOLLOWS. TO TRY TO UNDERSTAND WHAT TO PUT IN THE VEGETARIAN STYLE FOOD PATTERN MODELING. WE FIRST REVIEW DATA ON PRE-GROUP ANALYSIS FROM SELF-IDENTIFIED VEGETARIAN DIET IN THE NHANES DATA BECAUSE THERE IS A QUESTION IN NHANES ASKING THE RESPONDENTS TO SELF-IDENTIFY AS VEGETARIANS. SO WE TOOK THOSE YES RESPONDENTS YES, I AM A VEGETARIAN AND EXAMINE THEIR FOOD INTAKE AS REPORTED IN WHAT WE EAT IN AMERICA DIETARY INTERVIEW DATA. BASED ON THESE DATA WE CHOSE TO MODEL A LACTO OVO VEGETARIAN PATTERN, WE WERE NOT ABLE TO MODEL A VEGAN BECAUSE NO VEGANS WERE IDENTIFIED. NEXT IS TO FILL OUT TYPES AN AMOUNTS BASED ON AVERAGE AMOUNTS CONSUMED FOR EACH FOOD GROUP OR SUBGROUP BY VEGETARIANS AND NON-VEGETARIANS IN THE NHANES STANDPOINT. NEXT WE DETERMINE THE AMOUNTS OF EACH GROUP CATEGORY, THERE COULD BE INCLUDED TO MEET NUTRIENT GOALS IN THE PATTERN AT 12-CALORIE LEVELS BASED ON VEGETARIAN CHOICES USING AN AN ITERATIVE PROCESS. THEY'RE DESIGNED TO MEET THE RDA AND CALORIE LEVELS ARE PROVIDED BECAUSE OF THE WIDE RANGE OF ENERGY NEEDS ACROSS THE POPULATION. THE CALORIES ADJUST AMOUNT OF OIL, SOLID FAT AND ADDED SUGAR AS APPROPRIATE AND THEN WE ASSESS THE NUTRIENT ADEQUACY OF THE VEGETARIAN PATTERN IN COMPARISON TO THE DIETARY INTAKE AND DIETARY GUIDELINES RECOMMENDATION. THE METHODS FOR THE MEDITERRANEAN STYLE PATTERN WERE DIFFERENT BECAUSE WE DON'T HAVE A QUESTION FOR NHANES ASKING ABOUT MEDITERRANEAN STYLE DIETS SO WHAT WE HAD TO DO FOR THESE METHODS WAS TO REVIEW THE DATA, FROM THE TIE TEAR PATTERNS COMPOSITION -- DIETARY PATTERNS COMPOSITION PROJECT CHERYL PRESENT AD FEW MINUTES AGO AND WE EXAMINE THE FOOD GROUP INTAKE FOR THE CITIES THAT ASSESS DIET FOR THE MEDITERRANEAN STYLE DIET INDEX. YOU SAW SOME OF THOSE STUDIES A FEW MOMENTS AGO. WE COMPARED THE RANGE OF THE FOOD GROUP INTAKES TO THE FOOD GROUP AMOUNTS IN THE HEALTHY U.S. STYLE FOOD PATTERN. WE THEN SELECTED FOOD GROUPS FOR MODIFICATION AND THE RANGE OF AMOUNTS OF EACH FOOD GROUP INCLUDED IN THE INITIAL ANALYSIS. AGAIN USING AN ITERATIVE PROCESS, WE ADJUST AMOUNTS TO PROVIDE SMOOTH TRANSITIONS ACROSS THE CALORIE LEVEL. REMEMBER THERE ARE 12-CALORIE LEVEL. AND AS WITH THE OTHERS THE CALORIES ARE ADJUSTED AND BALANCED BY ADDING OIL, ADDED SUGAR AS APPROPRIATE. FINALLY WE COMPARE THE NUTRIENTS IN THE MEDITERRANEAN STYLE DIETARY PATTERN TO THE REFERENCE INTAKES IN THE 2010 DIETARY GUIDELINES. WITH THE DGAC WE WANT TO DETERMINE TO WHAT EXTENT THE NUTRIENT EXTENDS FOR THE PATTERN MIGHT BE MODIFIED FOR MEDITERRANEAN STYLE PATTERN FOR THE AMERICANS WHO WANT TO USE SUCH A PATTERN. THIS SLIDE SHOWS THE INTAKE FROM PROTEIN FOODS BY SUBGROUP AND THE SUBGROUPS ARE THE SELF-IDENTIFIED VEGETARIANS THE NON-VEGETARIANS AND THE AMOUNTS IN THE CURRENT USDA FOOD PATTERN. SO YOU CAN SEE THAT THERE IS A RANGE AND EVEN AMONG SELF-IDENTIFIED VEGETARIANS THERE'S SOME CONSUMPTION OF MEAT, POULTRY AND OTHER TYPES OF PROTEIN FOODS. YOU CAN SEE IN THE MEAT COLUMN THAT THE NON-VEGETARIANS CONSUME MORE MEAT THAN THE SELF-IDENTIFIED VEGETARIANS AND ALSO CONSUME MORE MEAT THAN IS RECOMMENDED IN THE USDA 2000-CALORIE PATTERN. POULTRY, NON-VEGETARIANS CONSUME CLOSE TO WHAT IS IN THE PATTERN AND SELF-IDENTIFIED VEGETARIANS CONSUME MUCH LESS. SEAFOOD IS HIGHER IN THE PATTERNS THAN IS CURRENTLY CONSUMED BY SELF-IDENTIFIED VEGETARIAN TO NON-VEGETARIAN. EGGS ARE COMPARABLE ACROSS SELF-IDENTIFIED VEGETARIANS CONSUME MORE SOY, LEGUMES AND NUTS ARE COMPARABLE ACROSS ALL THREE GROUPS. THINKING BACK TO THE SLIDES CHERYL PRESENT AD FEW MOMENTS AGO, YOU SAW MANY OF THE STUDIES USING MEDITERRANEAN STYLE INDEX HAVE A RANGE OF INTAKE OF VARIOUS FOOD GROUPS. HERE WE HAVE ALL THE FOOD GROUPS IN ONE SLIDE, WHERE HE PRESENTED SEPARATE SLIDES FOR VEGETABLES, FRUITS, RED AND PROCESSED MEATS AND SO ON. WHAT WE'RE TRYING TO SHOW IN THIS SLIDE, LEFT HAND COLUMN YOU SEE THE VARIOUS FOOD GROUPS THAT WERE DESCRIBED IN THE STUDIES THAT USED A MEDITERRANEAN STYLE INDEX, THE SECOND COLUMN IS A RANGE OF THOSE INTAKES AND RECALL ON MANY OF THOSE SLIDES YOU SAW QUITE A RANGE, THE NEXT COLUMN IS MEDIAN INTAKE IN GRAMS PER 1,000-CALORIES AND FAR RIGHT COLUMN IS THE AMOUNTS IN THE USDA FOOD PATTERN. SO WHAT WE'RE TRYING TO COMMUNICATE IN THIS SLIDE IS WHAT THE DIFFERENCE IS SOME OF THE FOOD GROUPS MIGHT BE IN A MED TERRAIN RAN STYLE DIET COMPARED TO THE USDA FOOD PATTERNS. THE ROWS HIGHLIGHTED ARE ONE WHERE WE SEE RELATIVELY LARGE DIFFERENCES BETWEEN THE MEDITERRANEAN DIET ADS PUBLISHED -- AS PUBLISHED COMPARED TO THE USDA FOOD PATTERN. THE FIRST ROW HIGHLIGHTED IS FRUIT AND THE MEDIAN INTAKE OF 156-GRAMS PER 1,000-CALORIES IS HIGHER IN THE MEDITERRANEAN STYLE DIET AS PUBLISHED COMPARED TO THE USDA FOOD PATTERNS FOR THE RANGE OF 96 TO 125-GRAMS. THE NEXT ROW WE SEE SOME DIFFERENCES IS IN THE SEAFOOD. FOR MEDIAN INTAKE OF 32-GRAMS IS HIGHER THAN THE CURRENT USDA FOOD PATTERNS FOR THE RANGE OF 16 TO 20-GRAMS. THEN THE THIRD PLACE WE SAW DIFFERENCES BETWEEN MEDITERRANEAN STYLE DIET AND THE CURRENT USDA FOOD PATTERN IS IN THE DAIRY. WHERE IN THE PUBLISHED STUDY IT IS MEDIAN INTAKE WAS 152-GRAMS PER 1,000-CALORIES AND THE AMOUNTS IN THE USDA FOOD PATTERNS RANGE FROM 194 TO 258-GRAMS PER 1,000-CALORIES. THOSE ARE THE THREE FOOD GROUPS WHERE WE SAW DIFFERENCES WHEN DIGGING OUT THE DETAILS OF THOSE PUBLISHED STUDIES USING A MEDITERRANEAN STYLE DIET AND WHAT THE DIFFERENCES WERE COMPARED TO THE USDA FOOD PATTERNS. THIS INFORMED THE NEXT STEP OF THE FOOD PATTERN MODEL. HERE WE HAVE OUR COMPARISON OF THE THREE USDA FOOD PATTERNS AT THE 2000-CALORIE LEVEL. REMEMBER THAT WE DO HAVE 12-CALORIE LEVELS BUT THE 2000-CALORIE LEVEL WAS SELECTED JUST FOR ILLUSTRATION PURPOSES. AND THE LEFT HAND COLUMN SHOWS THE FOOD GROUPS, FRUITS, VEGETABLES, SUBGROUP LEGUME, WHOLE GRAIN, DAIRY, PROTEIN FOODS, MEAT, POULTRY, SEAFOOD EGGS, NUTS AND SEEDS, PROCESS SOY AND OIL. YOU CAN SEE LOOKING ACROSS THAT THERE ARE MANY SIMILARITIES IN FACT YOU MIGHT REMEMBER CHERYL POINTED OUT THERE'S MANY COMMON ELEMENTS ACROSS THESE DIETARY PATTERNS, THE FIRST ONE, THE FRUIT IS A LITTLE BIT HIGHER IN THE MEDITERRANEAN STYLE DIET, VEGETABLES ARE QUITE COMPARABLE, LEGUMES ARE HIGHER FOR THE HEALTHY VEGETARIAN AND FOR THE OTHER TWO TYPES, WHOLE GRAINS ARE THE SAME DAIRY IS LOWER IN THE MEDITERRANEAN STYLE DIET, TWO CUPS INSTEAD OF THREE CUPS. PROTEIN FOODS ARE LOWEST IN THE VEGETARIAN AND OF COURSE MEAT POULTRY AND SEAFOOD ARE ABSENT FROM VEGETARIAN. NOTABLY SEAFOOD IS ALMOST TWICE AS HIGH IN THE HEALTHY MEDITERRANEAN STYLE DIET AS IT IS IN THE HEALTHY U.S. STYLE DIET. EGGS ARE COMPARABLE, NUTS AND SEEDS ARE HIGHER IN THE HEALTHY VEGETARIAN AND EQUIVALENT IN THE U.S. STYLE AND THE HEALTHY MEDITERRANEAN STYLE AND PROCESSED SOY IS HIGHER IN THE HEALTHY VEGETARIAN. NOW, WHEN WE LOOK AT THE NUTRIENTS IN THE PATTERN, AS YOU REMEMBER, ONE OF THE GOALS IN THE FOOD PATTERN MODELING IS TO TRY TO MEET THE ADD. THIS SLIDES -- RDA. THIS SLIDE SHOW IT IS SELECTED NUTRIENTS AND THE PERCENT OF THE GOAL OR THE LIMIT AND WE PICKED 19 TO 30-YEAR-OLD WOMAN JUST AS AN EXAMPLE. IT GIVES THE THREE EATING STYLES THAT WE HAVE DONE THE WORK ON, THE HEALTHY U.S. STYLE OR THE CURRENT USDA FOOD PATTERNS, HEALTHY VEGETARIAN AND HEALTHY MEDITERRANEAN. YOU CAN SEE THAT FOR THE MOST PART MANY PERCENT OF GOALS ARE QUITE SIMILAR ACROSS THE THREE -- THERE'S SOME SLIGHT DIFFERENCES ACROSS THE THREE, FOUR, VITAMIN D AND SODIUM AND SOME DIFFERENCES FOR FIBER AND CALCIUM THAT BY AND LARGE THEY'RE QUITE SIMILAR IN MANY WAYS AS WELL. ONE NUTRIENT WE WANTED TO EXAMINE IN PARTICULAR WAS THE CALCIUM SINCE THE MEDITERRANEAN STEIN DIET HAS TWO CUPS OF BERRY INSTEAD OF THREE. SO HERE WE'RE JUST SHOWING THE RANGE OF CALCIUM INTAKE IN THE PATTERN BY AGE AND SEX GROUP FOR THE THREE TYPES OF DIET. YOU CAN SEE FOR MOST OF THESE THE CALCIUM IS NEXT FOR THE HEALTHY U.S. AND HEALTHY VEGETARIANS, IT'S A LITTLE BIT LOWER FOR THE HEALTHY MEDITERRANEAN FOR THE PRE-ADOLESCENTS AND THE ADOLESCENTS. AS WELL AS FOR THE MIDDLE AGE AND OLDER FEMALES 51 TO 87. FOR DRAFT CONCLUSION STATEMENT FOR THIS QUESTION IS FOOD PATTERN MODELING DEMONSTRATES THAT HEALTHY EATING PATTERNS CAN BE ACHIEVE FORD A VARIETY OF EATING STYLES INCLUDING HEALTHY U.S. STYLE, HEALTHY MEDITERRANEAN STYLE AND HEALTHY VEGETARIAN STYLE EATING PATTERNS. ALTHOUGH THERE ARE DIFFERENCES ACROSS THREE EATING PATTERNS, COMPARABLE AMOUNTS OF NUTRIENTS CAN BE OBTAINED USING NUTRIENT FOODS MAINTAINING ENERGY BALANCE. OUR DRAFT IMPLICATIONS FOR THIS SECTION ARE AS FOLLOWS. THERE ARE A VARIETY OF OPTIONS AVAILABLE TO HELP AMERICANS ACCOMPLISH HEALTHFUL EATING PATTERNS THAT MAINTAIN ENERGY BALANCE AND MEET DIETARY GUIDELINES. THESE INCLUDE A HEALTHY U.S. STYLE, MEDITERRANEAN STYLE OR VEGETARIAN EATING PATTERN. THESE DIETS MEET NUTRITIONAL GOALS AND USE A VARIETY OF FOODS. IMPORTANTLY, THESE DIETS REFLECT RANGE OF FOODS USED TO ACCOMPLISH A HEALTHFUL EATING PATTERN AND THEY SUPPORT THE INCLUSION OF DIVERSE FOODS THAT ARE CONSISTENT WITH INDIVIDUAL CULTURAL OR RELIGIOUS PRACTICES. THAT CAN BE TRANSLATED TO A VARIETY OF STUDIES INCLUDING HOMES, SCHOOLSES, WORK SITES, HEALTHCARE FACILITIES AND PLACES OF WORSHIP. >> THANK YOU, MARIAN. I WOULD LIKE TO NOW OPEN THE FLOOR FOR DISCUSSION BY THE COMMITTEE AND IF YOU HAVE A QUESTION WOULD YOU PLEASE STATE YOUR NAME BEFORE SPEAKING. AND PERHAPS AS CHAIR, I'LL -- THIS IS BARBARA MILLEN AND I'LL POSE THE FIRST QUESTION TO MARIAN AND CHERYL. FIRST, THANKS FOR THAT GREAT PRESENTATION AND TO REMIND THOSE HERE AT THE CONFERENCE THAT THIS IS REALLY PART OF THE GROUND-BREAKING WORK OF THE 2015 COMMITTEE. I WANTED TO GO BACK TO THE COMPARISON OF THE DIETARY PATTERNS WITH THE CURRENT AMERICAN EATING PATTERN. THERE IS NO DOUBT AS YOU PRESENTED BEFORE, THAT WE ARE NOT AS CLOSE AS WE MIGHT LIKE US TO BE IN TERMS OF THE USDA OR A HEALTHY U.S. DIETARY PATTERN. BUT CERTAINLY ACROSS THE AGE GROUPS OR EVEN LOOKING AT THE GENDER COMPARISONS YOU SEE FOR THE DIFFERENT COMPONENTS OF THESE HEALTHY EATING PATTERNS THAT AMERICANS ARE APPROACHING THE LEVELS OF INTAKE THAT MIGHT BE RECOMMENDED AND ARE BEING RECOMMENDED. CAN YOU COMMENT A LITTLE BIT ON WHAT THIS MEANS IN TERMS OF LIKELIHOOD OF MOVING THE AMERICAN PUBLIC TO A HEALTHIER EATING PATTERN. THAT IS REALLY THE CHALLENGE AHEAD, AND TO GET US CLOSER TO WHERE WE NEED TO BE IN TERMS OF HEALTHY EATING PATTERNS. CAN YOU COMMENT ON WHERE WE ARE RELATIVE -- SPEAKING RELATIVE TO THE HEALTHY PATTERN AND THEN WHAT THE SIGNIFICANCE IS PROVIDING THESE ALTERNATIVE OPTIONS. THANK YOU. >> CERTAINLY. I CAN START THE CONVERSATION AND I'M HOPING THAT OTHER SUBCOMMITTEE MEMBERS CAN ALSO JOIN THE CONVERSATION. YOU SAW FROM THE TOTAL SCORES THAT AMERICANS ARE A LITTLE BIT HALFWAY THERE, THEY DO BETTER ON SOME SUBCOMPONENT SCORES INCLUDING FRUIT AND DAIRY AND FEW OF THE OTHERS. AS WE HAVE BEEN DISCUSSING ACROSS THE ENTIRE DIETARY GUIDELINES, THERE'S STILL TREMENDOUS AMOUNT OF ROOM FOR IMPROVEMENT BECAUSE THE SODIUM IS TOO HIGH, ADDED SUGARS ARE TOO HIGH AND SODIUM IS INCLUDED IN THE ATI BUT SOME OF THE OTHER THINGS ARE A LITTLE BIT MORE CHALLENGING FOR AMERICANS TO CHANGE NOW SO WE NEED CONCERTED EFFORT THROUGH THE FOOD SUPPLY, FOOD PROVIDED AT SCHOOLS, WORKPLACES, B ABILITY TO OBTAIN FOOD, AND SO FORTH. SO WE CAN ACKNOWLEDGE SOME OF THESE POSITIVE COMPONENTS FOR AMERICANS SEEM TO BE DOING WELL BUT THERE'S TREMENDOUS ROOM FOR IMPROVEMENT. >> THIS IS CHERYL. >> SUBCOMMITTEE MEMBERS NOW. >> THIS IS CHERYL. I WILL ADD TO THAT IN TERMS OF HOW THIS MIGHT BE ENCOURAGING FOR THE POPULATION IS THIS SORT OF EXAMINATION OF THE PATTERNS GIVES THE SENSE THAT THERE ARE MANY PATHS TO ROAM. IT SUGGESTS TO ME THAT IT MIGHT OPEN UP SOME VARIOUS OPTIONS FOR PEOPLE TO REALLY TAYLOR, TAYLOR THE AMERICAN DIETS THAT WE'RE ALREADY PRACTICING TOWARD A MORE HEALTHFUL PATTERN WITH OUR INDIVIDUAL PREFERENCES, WE MAYBE ABLE TO AS WE LOOK AT FOOD COMPONENTS THINK ABOUT THINGS THAT ARE CULTURALLY RELEVANT TO INCLUDE IN THE VARIOUS APPROACHES THAT WE TAKE AND MAYBE THAT WILL GIVE US MORE FLEXIBILITY IN TRYING TO GET THERE. >> THANK YOU. >> THIS IS WAYNE CAMPBELL. >> I THINK WHAT THE PROGRESS THAT'S BEEN MADE IS ABSOLUTELY EXTRAORDINARY AND I THINK THE ISSUE OF HAVING MANY DIETARY PATTERNS THAT WILL GET US TO THE SAME END IS VERY HELPFUL AND WILL HAVE MAJOR IMPLICATIONS IN TERMS OF IMPLEMENTATION. THE ONE THING I THINK WE ALSO NEED TO INCORPORATE IN TO THE DISCUSSION IS ABSOLUTE QUANTITIES BECAUSE AN INDIVIDUAL CAN BE CONSUMING THE HEALTHIEST QUALITY DIET BUT IF IT'S IN EXCESS OF ENERGY NEEDS, THE BENEFITS ARE NOT GOING TO BE REALIZED SO ULTIMATELY I THINK WE HAVE TO MARRY THOSE TWO CONCEPTS. >> THANK YOU, ALICE. I THINK WAYNE HAD A COMMENT. >> YES. THIS IS WAYNE CAMPBELL. TWO QUESTIONS. FROM Z THE FIRST IS, YOU HAVE DONE A VERY NICE JOB OF COMPARING THE FEATURES OF THE DIFFERENT PATTERNS WITH RESPECT TO FRUITS, VEGETABLES AND THE LIKE. I'M WONDERING ABOUT THE UTILITY OR THE MESSAGEING OF -- TO CONSUMERS OF ALSO DOING A SIMILAR TYPE OF COMPARISON OF WHAT THESE DIFFERENT PATTERNS DO NOT CONTAIN. RELATIVE TO USUAL AMERICAN DIET. IT'S NOT INCREASING CONSUMPTION OF SOME THINGS BUT WITH RESPECT TO ENERGY BALANCE WEIGHT CONTROL ALSO DECREASING INTAKES OF OTHER THINGS TO ACHIEVE ENERGY BALANCE OR SLIGHT ENERGY DEFICIT. >> THAT'S A GOOD QUESTION. SOMEONE FROM SUBCOMMITTEE ONE LIKE TO ANSWER WAYNE'S QUESTION? >> LET ME CLARIFY, PERHAPS YOU'RE ASKING ABOUT ONE PATTERN -- DOES ONE PATTERN HAVE LOWER INTAKE OF REFINED GRAINS OR ADDED SUGARS, IN TERMS OF NOT CONSUMING? >> YES. THAT'S IT -- I MEAN, OR TO SET THE RECOMMENDED INTAKE OF THOSE -- OR NOT RECOMMENDED, BUT THE UPPER THRESHOLDS OF HOW THOSE PARTS OF A TYPICAL PERSON'S DIET FIT INTO THESE. SO IT'S NOT A MESSAGE OF EXCLUSION, BUT A MESSAGE OF CONSIDERABLE MODERATION. >> WAYNE, THIS IS CHERYL ANDERSON, YOU'RE MAKING AN IMPORTANT COMMENT HERE. WE IN OUR ATTEMPTS TO REALLY DO THESE ANALYSES SELECTED FIVE COMPONENTS THAT WERE SHARED ACROSS THE HEALTHFUL PATTERNS THAT WE CHOSE TO PRESENT TODAY. BUT TO YOUR POINT, THERE ARE OTHER ASPECTS OF EATING THAT AREN'T CAPTURED IN THE FIVE EXAMPLES THAT WE SHOWED HERE. AND I DO THINK IT WOULD ROUND OUT THE CONVERSATION AND THE PRESENTATION IN THE REPORT QUITE NICELY, ADDRESS THINGS LIKE ALICE JUST SAID, HOW IMPORTANT IT IS TO KEEP THESE THINGS IN ENERGY BALANCE. HOW IMPORTANT IT IS TO REMEMBER WHY WE WILL ENCOURAGE OR WHY THESE DATA ENCOURAGE CONSUMPTION IN HIGH QUANTITIES OF CERTAIN COMPONENTS. THERE ARE OTHERS THAT ARE NOT BEING ENCOURAGED OR BEING REDUCED. FOR EXAMPLE, WHEN I SHOWED THE INFORMATION FROM THE FIRST PART OF OUR QUESTION, YOU SAW FOR EXAMPLE THAT RED AND PROCESSED MEATS, THEY WERE HIGHER IN THE MEDITERRANEAN STYLE PATTERNS BUT LOWER IN THE DASH AND OMNI STYLE PATTERNS. SOME CONVERSATION AROUND WHAT THAT MIGHT ACTUALLY LOOK LIKE AS PEOPLE TRY TO CREATE HEALTHFUL PATTERNS ON THEIR OWN AND IN WHAT OUR MODELING DATA SHOW, I THINK WILL NEED TO BE CLARIFIED IN THE REPORT. >> THANK YOU VERY MUCH. >> NOT SURE BUT I THINK ONE OF THE THINGS WAYNE MAYBE GETTING ON -- AT, IS THE -- THAT WE NOT ONLY NEED TO EMPHASIZE WHAT PEOPLE ARE MEETING THE GOALS THEY'RE MEETING IN TERMS OF THE POSITIVE FOOD GROUPS BUT ALSO ULTIMATELY THE NEGATIVE. AND IT'S GETTING AT THE CONCEPT OF EXCHANGING, THAT IT'S NOT THAT WE WANT PEOPLE TO INCREASE FRUITS AND VEGETABLES BUT FOR THOSE WHO AREN'T CONSUMING ADEQUATE AMOUNT BUT IF NOT CONSUMING ADEQUATE AMOUNT OF FRUITS AND VEGETABLE WHAT IS HOW WOULD SHOULD THEY TAKE OUT OF THE DIET. >> HI. SO THIS IS ANNA MARIA SIEGA-RIZ. I THINK SOME OF THAT IS GOING TO COME THROUGH IN SUBCOMMITTEE 2'S WORK. SO STAY TUNED. >> THIS IS RAFAEL PEREZ-ESCAMILLA. I WANT TO THANK MARIAN AND CHERYL FOR THE WONDERFUL WORK THEY HAVE DONE. THE QUESTION THAT I HAVE FOR YOU YOUR HEALTHY EATING INDEX 2010 SCORES PRESENT SEAFOOD AND PLANT PROTEIN. WHEN PRESENTED THAT WAY IT COMES OUT RELATIVELY HIGH. FOR SEE FOOD THAT'S NOT AT ALL THE CASE. WILL IT BE POSSIBLE TO SEPARATE SEAFOOD FROM PLANT PROTEIN WHEN PRESENTING THE HAI DATA? >> EXCELLENT QUESTION, RAFAEL. WE'LL TAKE THAT BACK TO THE STAFF. WORKING ON THIS AND SEE WHAT'S POSSIBLE. EXCELLENT SUGGESTION. THANK YOU. >> THIS IS WAYNE CAMPBELL. THE TERM HEALTHY WAS USED IN DESCRIBING EACH OF THE THREE DIFFERENT PATTERNS. I'M JUST CURIOUS IF THE HEALTH BENEFITS ARE COMMON AMONG THESE PATTERNS OR THERE'S VARIABILITY IN TERMS OF WHAT THE HEALTH BENEFITS MAY BE. I ASK THAT QUESTION BECAUSE OF THE EMPHASIS ON THAT THESE PATTERNS CAN ADD IN VARIETY AND -- IN THE VARIETY OF FOODS THAT ARE AVAILABLE TO PEOPLE TO WITH HEALTH IN MIND. BUT IF SOMEBODY IS TRYING TO DO A PARTICULAR HEALTH OUTCOME, WOULD ANY OF THESE WORK? >> WAYNE THAT'S A GREAT QUESTION. THIS IS CHERYL, THAT IS THE CHARGE OF OUR SUBCOMMITTEE 2. SO I WOULD SAY JUST LIKE ANNA MARIA SAID, STAY TUNED BECAUSE THEY WILL BE TALKING ABOUT HOW THESE PATTERNS RELATE TO VARIOUS HEALTH OUTCOMETS. >> THIS IS FRED HU. TWO -- FRANK HU. I HAVE TWO QUESTIONS. THE FIRST IN MARIAN'S PRESENTATION IN THE FOOD PATTERN MODELING YOU HAVE DATA THREE PATTERNS BUT IN CHERYL'S PRESENTATION SHE SHE WAS ALSO MENTIONED OTHER HEALTHY PATTERNS SUCH AS DASH, OMNI PATTERN AND PERHAPS THE PROTEIN PATTERN. I WAS WONDERING WHY THE FOOD PATTERN MODELING WORK DIDN'T LOOK AT OTHER HEALTHY PATTERNS. MY SECOND QUESTION IS REGARDING THE DIFFERENCES IN BIOQUALITY ACROSS DIFFERENT AGE GROUPS, ACROSS DIFFERENT GENDER, BUT THE LARGEST DIFFERENCE IN TERMS OF DIET QUALITY IS ACROSS DIFFERENT SOCIO ECONOMICAL GROUPS. A RECENT PAPER SHOWED THAT FOR THE HIGH SES GROUP, THE DIET QUALITY INDEX HGI HAS IMPROVED OVERTIME BUT FOR THE LOWER GROUP THE HAI HAS DECREASED OVER TIME SO THE GAP BETWEEN THE POOR AND THE RICH, IN TERMS OF THE DIET QUALITY WIDENED IN THE PAST TEN YEARS OR SO IN THE U.S. POPULATION. SO I THINK THIS WILL HAVE HUGE RAMIFICATIONS IN TERMS OF OVERALL STRATEGIES TO IMPROVE THE DIET QUALITY IN THE U.S. POPULATION. >> THIS IS MARIAN, THANK YOU, FRANK. FOR FUTURE QUESTIONS LET'S TRY TO HAVE ONE QUESTION AT A TIME BECAUSE IN THIS FORMAT IT'S HARD TO DO MULTIPLE QUESTIONS. THE FIRST QUESTION YOU ASKED WHY WE DID NOT ALSO MODEL DASH, OMNI AND OTHER, THAT PURELY HAD TO DO WITH A BANDWIDTH ISSUE. WE WOULD LIKE TO DO THIS IN THE FUTURE MODELING THE MEDITERRANEAN STYLE DIET WAS THE FIRST TIME THAT STAFF HAVE EVER DONE THIS FOOD PATTERN MODELING. IT REALLY IS A TREMENDOUS AMOUNT OF WORK AND WE'RE GRATEFUL FOR THAT WORK THAT COULD BE COMPLETED AND PRESENTED TODAY. WE'RE HOPEFUL THAT IN THE FUTURE, SOME OF THE OTHER TYPES OF PATTERNS CAN BE DELINEATED FROM THE DIETARY PATTERN COMPOSITION WORK BECAUSE THAT WORK IS STILL A WORK IN PROGRESS. THEN ADDITIONAL FOOD PATTERN MODELING WILL BE ABLE TO BE REPRESENTED SO WE'RE CERTAINLY DESIRING TO DO THAT. IT'S ON THE LIST. AS FAR AS YOUR SECOND QUESTION GOES, I THINK MANY OF US ARE AWARE OF THAT RECENT PUBLICATION SO WE WILL KEEP THAT IN MIND. THANK YOU FOR MENTIONING IT. >> THANK YOU. >> OTHER QUESTIONS FROM SUBCOMMITTEE MEMBERS OR THE REST OF THE DGAC ON THIS SET OF QUESTIONS, THE DIETARY PATTERNS COMPOSITION? >> THIS IS BARBARA MILLEN, I WANT TO MAKE A COUPLE OF COMMENTS THEN ONE FINAL QUESTION. I THINK IT'S EXTREMELY POSITIVE THAT WHAT IS PRESENTED HERE IS SUGGESTING THAT THERE ISN'T -- I THINK CHERYL WAS ALLUDING TO, THERE ISN'T A SINGULAR -- SINGLE FORMULA OR SINGLE PRESCRIPTION FOR DIETARY PATTERN THAT WOULD LEAD TO A HEALTHY EATING PATTERN. THERE'S ACTUALLY MULTIPLE APPROACHES. I THINK ACTUALLY THE DASH STYLE WAS PRESENTED IN THE 2010 REPORT SO WE DO HAVE INFORMATION ABOUT THAT. BUT THAT'S JUST A SIDE BAR. SECOND POINT THAT YOU EMPHASIZE, MARIAN, IS THE AMERICAN PUBLIC IS HALF THE WAY THERE. IT'S NOT PERFECT. BUT IT'S HALF THE WAY THERE, AND I THINK THAT POINT THAT YOU MADE IS REALLY A POSITIVE MESSAGE THAT WE HAVEN'T NECESSARILY MADE BEFORE. THAT DOES NOT MEAN OF COURSE THAT WE AREN'T GOING TO EMPHASIZE THE NUTRIENTS OF CONCERN OR PUBLIC HEALTH CONCERN OR THE GAP THAT EXISTS BUT A POPULATION UNDERSTANDING THAT THEY ARE A SUBSTANTIAL PART OF THE WAY TO GOAL I THINK CAN BE VERY MOTIVATING. MY QUESTION IS WITH THE MODEL -- WITH THE MODELING AND THE PATTERNS THAT YOU PRESENTED, IT STRIKES ME SINCE THERE'S SIMILAR LEVELS OF QUALITY IN THE PATTERNS, THEN DAY ONE THE CONSUMER MIGHT THINK MORE VEGETARIAN, DAY TWO MORE MEDITERRANEAN, AND DAY 3 MORE TYPICALLY U.S. HEALTHY AND USE COMBINATIONS OF THE PATTERNS DEPENDING UPON WHAT THEIR PREFERENCES MIGHT BE, EVEN ON A DAY-TO-DAY BASIS. CAN YOU JUST COMMENT ON THAT, PLEASE? >> THAT'S CERTAINLY AN INTERESTING CONCEPT AND I THINK IT'S VERY POSSIBLE. SINCE WE'RE PROVIDING THREE TYPES OF HEALTHY EATING PATTERNS AND IN THE FUTURE HOPEFULLY WE'LL PROVIDE MORE THEN THAT'S CERTAINLY ROOM FOR VARIATION IN THE DIET. AS CHERYL MENTIONED, MANY PATHS TO ROAM. SO I THINK THE ANSWER IS THAT THAT IS HIGHLY POSSIBLE. >> THANK YOU. >> THIS IS ALICE LICHTENSTEIN, FOLLOWING UP ON THAT, AND THE CURRENT QUALITY OF THE DIET, PERHAPS THE TRENDS THAT ARE REALLY IMPORTANT IS A TREND IN INCREASING FRUITS AND VEGETABLES, DECREASING SUGAR, SOMETHING LIKE THAT, I THINK THAT'S WHAT SHOULD BE EMPHASIZED MORE THE TRAJECTORY THAN WHERE WE ARE RIGHT NOW. >> AND NOT TO LOSE FRANK'S EARLIER POINT, WE'D LIKE TO SEE THESE SUCCESSES ACROSS THE BOARD. WE WOULD LIKE TO HAVE EQUITY IN SUCCESS WE SEE AND ARE POOR IS HAVING A VERY APPARENT GAP BASED ON THESE NEW DATA FRANK HIGHLIGHTED. SO ACKNOWLEDGING THAT IN THE REPORT AND THINKING ABOUT WAYS TO CLOSE THE GAPS WILL BE IMPORTANT. >> ALICE LICHTENSTEIN AGAIN. I AGREE AND I UNDERSTAND WHAT THE GENESIS OF IT IS. IS IT AVAILABILITY, IS IT AFFORDABILITY, ARE THERE OTHER ISSUES. >> SOME OF THAT LINKS IN TO SUBCOMMITTEE 3 I BELIEVE. YOU CAN STAY TUNED FOR THAT. IF THERE'S NO OTHER QUESTIONS ON THE DIETARY PATTERNS COMPOSITION, THEN I'M GOING TO TURN THE PODIUM BACK OVER TO CHERYL ANDERSON. >> THANK YOU MARIAN. AT THIS TIME I WOULD LIKE TO BEGIN OUR CONVERSATION AROUND HEALTH CONDITION, PREVALENCE AN TRENDS, AS YOU MAY RECALL, PART OF THE SCOPE OF THE SUBCOMMITTEE 1 IS TO EVALUATE THE PREVALENCE AND TRENDS OF NUTRITION RELATED HEALTH CONDITIONS. MUCH OF THE DATA AROUND OUR WORK HERE AND OUR CONCLUSION STATEMENTS AND OUR IMPLICATIONS STATEMENT WERE PRESENTED AT EARLIER MEETINGS. HOWEVER WE EDITED SOME OF THOSE CONCLUSIONS AND IMPLICATIONS BETWEEN OUR SEPTEMBER MEETING AND NOW AND WANTED TO REPRESENT THIS TO THE FULL COMMITTEE FOR THEIR -- TO HEAR THEIR DELIBERATIONS ON IT, IN TERMS OF THE WAY THIS IS PRESENTED, THE CONCLUSION SLIDES ARE PRETTY MUCH PRESENTED WORD FOR WORD IN TERMS OF WHAT YOU HAVE SEEN BEFORE AND HOW WE MIGHT MOVE THOSE FORWARD. OUR IMPLICATIONS SLIDES HOWEVER, ARE BULLETED REALLY FOR EASE IN PRESENTATION. SO I WOULD ASK ON THE COMMITTEE TO HONE IN AS I EXPAND UPON THOSE BULLETED POINTS ON THE IMPLICATION SLIDES AND REALLY DELIBERATE ON WHAT I'M SAYING IN FULL CONTEXT VERSUS JUST THE BULLETED POINTS THAT YOU SEE ON THE SCREEN. AS A REMINDER, FIRST QUESTION AROUND HEALTH CONDITIONS EXAMINE IT IS PREVALENCE OF OVERWEIGH AND OBESITY AND DISTRIBUTION OF BODY WEIGHT, BODY MASS INDEX AND WAIST CIRCUMFERENCE IN THE POPULATION, WE LOOK AT THESE PREVALENCES BY AGE GENDER AN RACE ETHNIC AND INCOME GROUPS AND TRY TO ALSO EVALUATE THE TRENDS IN PREVALENCE. SO OUR DRAFT CONCLUSION STATEMENT AROUND THIS FIRST QUESTION INCLUDES THE FOLLOWING POINTS. THE CURRENT RATES OF OVERWEIGH AND OBESITY ARE EXTREMELY HIGH AMONG CHILDREN, AMONG ADULTS AN AMONG ADOLESCENTS. THESE HIGH RATES OF HAVE PERSISTED MORE THAN 25 YEARS. OVERALL, WE FOUND 65% OF ADULT FEMALES AN 70% OF ADULT MALES ARE OVERWEIGHT OR OBESE AND THE RATES HIGHEST IN THE MIDDLE AGED AND OLDER ADULT POPULATION. THE RATES OF OVERWEIGHT AND OBESITY IN ADULTS VARY BY AGE AND ETHNICITY. IN TERMS OF AGE, OVERWEIGHT IS MOST PREVALENT IN THOSE THAT ARE 40 YEARS OF AGE OR OLDER. AND IN TERMS OF RACE AND ETHNICITY, OVERWEIGH IS MOST PREVALENT IN HISPANIC AMERICAN ADULTS. OBESITY, IS MOST PREVALENT IN AFRICAN AMERICAN ADULTS, AND LEAST PREVALENT IN ADULTS WITH THE HIGHEST INCOME IN THIS COUNTRY. WHEN WE EXAMINE ABDOMINAL OBESITY DATA WE SAW IT PRESENT IN U.S. ADULTS OF ALL AGES BUT INCREASES WITH AGE AND VARIES BY GENDER AS WELL AS BY RACE ETHNICITY. RATES OF ABDOMINAL OBESITY ARE HIGHEST IN THOSE AGED 60 YEARS OR OLDER AND HIGHER THAN WOMEN -- IN WOMEN THAN IN MEN WHEN WE LOOK AT ALL AGE CATEGORIES. IN TERMS OF ABDOMINAL OBESITY IN MEN, WITH SEE THE RATES ARE LIGHTLY HIGHER AMONG WHITES THAN AMONG MEXICAN AMERICAN OR AFRICAN AMERICAN MEN. AGAIN WHEN WE LOOK AT RACE ETHNIC CATEGORIES WE SEE IN WOMEN ABDOMINAL OBESITY RATES ARE LOWER IN WHITES THAN THEY ARE IN MEXICAN AMERICAN OR AFRICAN AMERICAN WOMEN. A FEW ADDITIONAL CONCLUSIONS. RELATED TO OUR YOUTH. NEARLY ONE IN THREE YOUTH AGED 2 TO 19 YEARS OLD ARE NOW OVERWEIGHT. THAT'S CHARACTERIZED BY BEING BETWEEN THE 85TH AND 95TH PERCENTILE ON WEIGHT. OR OBESE. THAT'S CHARACTERIZED BY BEING GREATER THAN OR EQUAL TO THE 95TH PERCENTILE, THESE RATES IN YOUTH VARY BY AGE AND RACE ETHNICITY. IN TERMS OF AGE, IN THOSE 2 TO 19 YEARS OF AGE, OBESITY PREVALENCE INCREASES AS AGE GETS -- AS THEY GET OLDER AND THE AGE CATEGORY WITH THE HIGHEST PREVENIENCE ARE THOSE AGED 12 TO THE 19 YEARS. IN TERMS OF WHAT WE SEE WHEN WE LOOK BY RACE ETHNICITY IN OUR YOUTH, THE RACE ETHNICITY CATEGORIES THAT HAVE THE HIGHEST PREVALENCE OF OBESITY, ARE AMONG AFRICAN AMERICANS AND HISPANIC. SO BASED ON THOSE CONCLUSIONS, THE IMPLICATIONS THAT WE HAVE DRAFTED INCLUDE THE FACT THAT THE LONG STANDING HIGH LEVELS OF OVERWEIGHT AND OBESITY REQUIRE URGENT POPULATION AS WELL AS INDIVIDUAL LEVEL STRATEGIES THAT ARE GOING TO WORK IN MULTIPLE SETTINGS WHICH INCLUDE A CLINICAL SETTING AS WELL AS COMMUNITY SETTING. A COMPREHENSIVE LIFESTYLE INTERVENTION AND EVIDENCE BASED DIETARY INTERVENTIONS WEIGHT MANAGEMENT WHETHER IN INDIVIDUALS OR SMALL GROUPS, SHOULD BE DEVELOPED AND IMPLEMENTED BY TRAINED INTERVENTIONISTS AND BY PROFESSIONAL NUTRITION SERVICE PROVIDERS, IN MULTIPLE SETTINGS, THAT INCLUDES THE HEALTHCARE SETTING, IT INCLUDES COMMUNITY LOCATION, PUBLIC HEALTH FACILITIES, AND WORK SITES. QUALITY OF CARE STANDARDS IN THE HEALTHCARE SETTINGS NEED TO INCLUDE IMPACT OF PREVENTATIVE NUTRITION SERVICES AND THESE ARE PROVIDED BY MULTI-DISCIPLINARY TEAMS THAT INCLUDE TRAINED INTERVENTIONISTS AND WHERE APPROPRIATE TRAINED NUTRITION PROFESSIONALS. INCENTIVES NEED TO BE OFFERED TO PROVIDERS AS WELL AS HEALTHCARE SYSTEMS TO DEVELOP PREVENTIVE STRATEGIES AND THAT THE PUBLIC SHOULD MONITOR BODY WEIGHT, AND ENGAGE WITH PROVIDERS USING EVIDENCE BASED APPROACHES THAT ARE GEARED TOWARD ACHIEVING AND MAINTAINING A HEALTHY BODY WEIGHT. I WOULD LIKE TO MOVE ON NOW TO OUR SECOND QUESTION WHICH LOOKS AT THE RELATIVE PREVALENCE OF METABOLIC AND CARDIOVASCULAR RISK FACTORS. THAT INCLUDES BLOOD PRESSURE, BLOOD LIPIDS AND DIABETES. BY WEIGHT, BODY MASS INDEX AND WAIST CIRCUMFERENCE IN THE CATEGORIES IN THE GENERAL U.S. POPULATION AS WELL AS IN SUBGROUPS. SO JUST TO REVIEW THE CONCLUSIONS STATEMENTS THAT WE PRESENTED BACK IN SEPTEMBER BUT WE HAVE EXPAND AD LITTLE BIT HERE, APPROXIMATELY 50% OF INDIVIDUALS WHO ARE NORMAL WEIGHT HAVE AT LEAST ONE CARDIO METABOLIC RISK FACTOR. FURTHER APPROXIMATELY 70% OF INDIVIDUAL WHOSE ARE OVERWEIGHT AND APPROXIMATELY 75% OF THOSE WHO ARE OBESE, HAVE ONE OR MORE CARDIO METABOLIC RISK FACTORS. THE RATES OF ELEVATED BLOOD PRESSURE -- THE RATES OF ADVERSE BLOOD LIPID PROFILES INCLUDED HAVING LOW HDL CHOLESTEROL, HAVE A HIGH LDL CHOLESTEROL AND HIGH TRIGLYCERIDES AS WELL AS RATES OF DIABETES ARE HIGHEST IN INDIVIDUALS WHO HAVE ABDOMINAL OBESITY WHICH IS DEFINED AS A WAIST CIRCUMFERENCE GREATER THAN 1 # 2-CENTIMETERS IN MEN AND 88-CENTIMETERS IN WOMEN. IN TERMS OF DATA IN CHILDREN AGE 3 TO 19 YEARS OLD, THOSE WITH TYPE 2 BUY DYE BEE TEASE, PREVALENCE OF OBESITY IS HIGHER IN AFRICAN AMERICANS FOLLOWED BY AMERICAN INDIANS HISPANICS COMPARED TO WHITES COMPARED TO ASIAN PACIFIC ISLANDERS BETWEEN AGE 3 AND 19. WHEN WE EXAMINE DATA AROUND LIPID ABNORMALITIES AND RATES OF BORDERLINE HIGH BLOOD PRESSURE, WE SAW THAT THOSE RATES VIRRY BY WEIGHT STATUS IN OUR BOYS AND GIRLS AND THE RATES ARE PARTICULARLY HIGH IN BOYS WHO ARE OBESE. GOING BACK TO ADULTS IN ADULT WHOSE HAVE TYPE 2 DIABETES OR HYPERTENSION OR ADVERSE BLOOD LIPID PROFILES THE PREVALENCE OF OBESITY VARIES BY RACE AND ETHNICITY. WE HAVE NEARLY THREE FOURTHS OF THE OVER WEIGHT OR OBESE POPULATION HAVING AT LEAST ONE CARDIO METABOLIC RISK FACTOR INDICATING THAT THEY QUALIFY FOR PREVENTIVE LIFESTYLE AND NUTRITION INTERVENTIONS FOR WEIGHT MANAGEMENT, AGAIN, THAT BEING DONE BY TRAINED PROFESSIONALS AND NUTRITIONISTS. SO BASED ON THOSE CONCLUSIONS, WE HAVE SOME IMPLICATION STATEMENTS THAT WE HAVE DRAFTED. SO RATES OF CARDIO METABOLIC RISK FACTORS IN ADULT AMERICANS ARE EXTREMELY HIGH AND THEY REFLECT HIGH RATES OF POPULATION OVERWEIGHT AND OBESITY. MANY ADULTS HAVE PERSONAL HEALTH PROFILES IN WHICH MULTIPLE METABOLIC RISK FACTORS CO-EXIST AND SUBSTANTIALLY INCREASE RISK FOR CORONARY HEART DISEASE, HYPERTENSION AND STROKE, DIABETES AND OTHER OBESITY RELATED COMORBIDITIES. WE CAN TELL FROM OTHER DATA THAT THESE ARE COSTLY HEALTH PROBLEMS IN OUR NATION, AND THEY'RE PREVENTABLE AND THEY CAN BE MANAGED WITH INTENSIVE COMPREHENSIVE AND EVIDENCE BASED LIFESTYLE INTERVENTIONS THAT ARE IMPLEMENTED BY MULTI-DISCIPLINARY TEAMS OF TRAINED PROFESSIONALS OR MEDICAL NUTRITION THERAPY PROVIDED BY REGISTERED DIETITIANS OR NUTRITIONISTS. WE DRAFTED IMPLICATIONS AGAIN THAT REQUIRE BOLD ACTION TO CONFRONT OUR NATION'S OBESITY EPIDEMIC. AND IT'S DEVASTATING METABOLIC CONSEQUENCES. OUR HEALTHCARE PUBLIC HEALTH SYSTEM SHOULD BE REVAMPED AND INTEGRATE PREVENTIVE NUTRITION AND LIFESTYLE SERVICES FOR OBESITY PREVENTION AND WEIGHT MANAGEMENT. A SHIFT IN THE HEALTHCARE PARADIGM TOWARDS PREVENTION IS SERIOUSLY WARRANTED. AND AS PART OF THIS APPROACH THE QUALITY OF CARE GUIDELINES NEED TO BE REVISED INCENTIVIZE PROVISION OF PERSONALIZED LIFESTYLE AND NUTRITION INTERVENTIONS THAT HELP COMBAT OBESITY AND OBESITY RELATED CHRONIC DISEASE AND METABOLIC RISK FACTORS AND COMORBIDITIES. I EMPHASIZE OTHER PARTS OF THE REPORT THE MOST EFFECTIVE APPROACH TO PREVENTION AND TREATMENT OF OVERWEIGH AND OBESITY IN OUR P PUBLIC ACROSS THE LIFE SPAN IS GOING TO REQUIRE BOTH INDIVIDUAL AND POPULATION BASED ENVIRONMENTAL STRATEGIES. INITIATIVES IN HEALTHCARE AND PUBLIC HEALTH SECTORS NEED TO BE COMPLIMENTED WITH COLLABORATIVE PROGRAMMING AND AGRICULTURE IN RETAIL, IN EDUCATIONAL AND SOCIAL SERVICE SETTINGS IN ORDER TO MAKE THE LONG TERM ADOPTION OF HEALTH AND NUTRITION IN OUR LIFESTYLE BEHAVIORS NOT ONLY FEASIBLE BUT REALLY NORMATIVE. IN OUR YOUTH THE HIGH RATES OF OVERWEIGHT AND OBESITY IN THOSE AGED 18, 17 YEARS AND CONCOMITANT CARDIO METABOLIC RISK FACTORS REQUIRE EARLY EFFECTIVE INTERVENTION AT THE INDIVIDUAL AND POPULATION LEVELS. EVIDENCE BASED STRATEGIES ARE NEEDED, THEY'RE NEEDED IN OUR HEALTHCARE SETTINGS, OUR PUBLIC HEALTH SETTINGS, AND THEY SHOULD BE COMPLIMENTED BY ENVIRONMENTAL APPROACHES ACROSS WIDE RANGING SECTORS TRY AND REVERSE HIGH PRIORITY HEALTH PROBLEMS. I WOULD LIKE TO WRAP UP OUR HEALTH CONDITIONS SECTION WITH A LOOK AT OUR THIRD QUESTION WHICH IS WHAT ARE THE CURRENT RATES OF NUTRITION RELATED HEALTH OUTCOMES, INCIDENCE OF AND MORTALITY FROM BREAST, LUNG, COLORECTAL AND PROSTATE CANCER. AS WELL AS WHAT ARE THE CURRENT RATES AND PREVALENCE OF HIGH BLOOD PRESSURE CARDIOVASCULAR DISEASE AND TYPE 2 DIABETES. WHAT ARE THE RATES OF BIRTH DEFECTS IN CONGENITAL ABNORMALITIES. NEUROLOGICAL AND PSYCHOLOGICAL ILLNESSES AND BONE HEALTH IN THE OVERALL U.S. POPULATION. >> SO OR CONCLUSION STATEMENTS THAT HAVE BEEN MODIFIED SLIGHTLY FROM THE SEPTEMBER PRESENTATION, THEY INCLUDE ADULTS HAVE HIGH RATES OF NUTRITION RELATED CHRONIC DISEASES, AND INCLUDING HIGH BLOOD PRESSURE, CARDIOVASCULAR DISEASE, TYPE 2 DIABETES AN VARIOUS FORMS OF CANCER, CHILDREN AND ADOLESCENTS ALSO HAVE NUTRITION RELATED CHRONIC DISEASE INCLUDING BORDERLINE HIGH BLOOD PRESSURE AND TYPE 2 DIABETES. ALL AGES THE RATES OF CHRONIC DISEASE RISK ARE LINKED TO OVERWEIGHT AND OBESITY. AND THE RATES OF THESE CHRONIC DISEASES VARY BY RACE ETHNICITY GROUPS AS WELL AS BY INCOME STATUS. THE PREVALENCE OF OSTEOPOROSIS AND LOW BONE MASS INCREASES WITH AGE PARTICULARLY IN POST MENOPAUSAL WOMEN. AMONG OUR LESS COMMON HEALTH OUTCOMES, WE SEE THAT CONGENITAL ABNORMALITIES ARE RELATIVELY RARE PREGNANCY OUTCOME BUT IMPORTANT AND NUTRITION-RELATED NEUROLOGICAL AND PSYCHOLOGICAL CONDITIONS ARE GROWING CONCERN. THE IMPLICATIONS THAT WE HAVE DRAFTED TO GO WITH THOSE CONCLUSION STATEMENTS, THAT GIVEN THE HIGH RATES OF NUTRITION RELATED CHRONIC DISEASES IN THE ADULT POPULATION, AND THE RISING RATES THAT WE SEE IN YOUTH, IT'S IMPERATIVE THAT WE DEVELOP PREVENTION POLICIES FOR ALL AGE GROUPS AND THIS SHOULD ADDRESS NUTRITION AND LIFESTYLE ISSUES WITH EVIDENCE BASED INTERVENTIONS THAT ARE APPROPRIATE FOR THE DELIVERY IN MULTIPLE SETTINGS. QUALIFIED PROFESSIONALS SHOULD BE DELIVERING MULTI-DISCIPLINARY INTERVENTIONS THAT ARE EFFECTIVE IN REDUCING NUTRITION RELATED CHRONIC DISEASES THAT WE HAVE REVIEWED. AND MORE DATA NEEDED TO UNDERSTAND COMPLEX ETIOLOGY OF CONGENITAL ABNORMALITIES, MORE DATA NEEDED TO UNDERSTAND IN THE COMPLEX ETIOLOGY OF NEUROLOGICAL AND PSYCHOLOGICAL CONDITIONS. THE FACTORS INFLUENCING BONE HEALTH TO INFORM POTENTIAL DIETARY CHOICES BY THE U.S. POPULATION. THAT BRING MESS TO THE END OF OUR SUBCOMMITTEE PRESENTATION ON HEALTH CONDITIONS. YOU SEE A REVIEW OF THE QUESTIONS ON THE SCREEN AND I WOULD LIKE TO OPEN UP THE FLOOR RIGHT NOW FOR FIRST COMMENT BY OTHER SUBCOMMITTEE 1 MEMBERS AND QUESTIONS OR COMMENTS FROM FULL COMMITTEE. >> SC 1 OR COMMITTEE MEMBERS, MY QUESTIONS OR COMMENTS? >> RAFAEL PEREZ-ESCAMILLA. CHERYL THANK YOU SO MUCH FOR THE THOUGHTFUL SET OF IMPLICATIONS REGARDING THE SNAP SHOT OF DIETARY QUALITY AND THE HEALTH OF AMERICANS. I WOULD LOVE TO SEE A CLEAR SPECIFIC IMPLICATION CALLING FOR STRENGTHENING THE LINKS BETWEEN LOW HEALTHCARE AND LOW FOOD SYSTEMS. THAT IS SOMETHING THAT HAS TO BE ADDRESSED FROM BOTH ANGLES, FROM THE LOCAL HEALTH SECTOR AS WELL AS THE LOCAL FOOD SYSTEM SECTORS WORKING IN UNISON IN GOOD COORDINATION FOR THESE PROGRAMS THAT ARE SEEKING TO PROMOTE HEALTH OR TROUGH TREAT INDIVIDUAL WHOSE HAVE CHRONIC TYPE 2 DIABETES, THAT THEY CAN SUCCEED. >> THANK YOU, RAFAEL. I THINK THAT'S A GREAT POINT. WE WOULD CERTAINLY BE ABLE TO INCLUDE THAT. , ADD TO OUR IMPLICATION STATEMENT. OTHER SUBCOMMITTEE MEMBERS IN LINE WITH MY THINKING ON THAT? ARE THERE ANY ADDITIONAL COMMENTS AROUND WHAT RAFAEL JUST MENTIONED? >> THAT RESONATES VERY MUCH -- >> I VERY MUCH SUPPORT THAT. >> THIS IS BE BRA MILLEN, IT RESONATES VERY MUCH WITH THE RECOMMENDATIONS AND IMPLICATIONS FROM SOME OF THE OTHER COMMITTEES, SUBCOMMITTEES, ON PUBLIC PRIVATE PARTNERSHIPS. BUT IT'S PRETTY CLEAR IN A PUBLIC HEALTH MODEL WITH FOCUS ON THE INDIVIDUAL AS WELL AS THE POPULATION THAT ALL THIS CANNOT BE ACCOMPLISHED IN A HEALTHCARE SETTING OR PUBLIC HEALTH SETTING. IT REALLY WILL TAKE A BROAD STRATEGY ACROSS THE SECTORS IN ENVIRONMENTS OF POTENTIAL INFLUENCE. NOT ONLY TRADITIONAL HEALTHCARE BUT WHAT WE HAVE HEARD ABOUT IN TERMS OF COMMUNITY SETTINGS AND THESE CAN'T BE SILOED APPROACH BUT RATHER CROSS SECTOR TO BE MOST EFFECTIVE. THANK YOU, RAFAEL. >> MARIAN NEUHOUSER, IT ALSO FEEDS VERY WELL INTO THE SOCIAL ECOLOGICAL MODEL THAT WE HAVE BEEN DISCUSSING THROUGHOUT OUR COMMITTEE WORK. THIS IS SOMETHING THAT CAN ALSO CUT ACROSS MANY OF THE SUBCOMMITTEES, ESPECIALLY SUBCOMMITTEES 3, 4, 5, THERE'S COMMON THEMES THAT CAN BE DRAWN OUT FROM RAFAEL'S SUGGESTION. >> THIS IS BARBARA MILLEN, ONE OTHER COMMENT IN THIS REGARD. THAT IS THAT A LARGE PROPORTION OF A FAMILY'S INCOME IS SPENT ON HEALTHCARE. THE EMPHASIS PLACED IN THE COMMENTS MADE ON REALLY TRYING TO NOT ONLY ENCOURAGE BUT TO INCENTIVIZE THE ADDRESSING PREVENTATIVE LIFESTYLE STRATEGIES WITHIN THESE SETTINGS WHICH WERE ALREADY INVESTING SO MUCH IN, I THINK IS REALLY PARAMOUNT. I FULLY ENDORSE THAT. >> I THINK ONE OF THE AREAS WHERE PERHAPS LESS ATTENTION HAS BEEN GIVEN IS TO ISSUES RELATED TO ENVIRONMENTAL CHANGES THAT PROMOTE HEALTHY LIFESTYLES IN THE COMMITTEE, MAKING SIGNIFICANT IN ROADS IN THAT DIRECTION SO IN A SENSE THE DEFAULT OPTION THE HEALTHIER OPTION WHETHER BEING ABLE TO WALK IN NEIGHBORHOODS AND SAFETY CROSS STREETS OR TO WHAT YOU AUTOMATICALLY GET WITH FOOD NOT PREPARED BY -- FOOD NOT PREPARED BY YOURSELF. >> THIS IS ANNA MARIA SIEGA-RIZ, I WOULD LIKE TO ADD ON TO THIS CONVERSATION. I WAS PRETTY MUCH STUNNED THOUGH I'M QUITE WELL AWARE OF THE CHRONIC NUTRITION RELATED HEALTH OUTCOMES FOR YOUNG ADULTS IN PRE-ADOLESCENTS, AND I JUST THINK THAT THE MORE WE CAN DO TO CALL REALLY BOLD ACTION FOR THAT GROUP, THE BETTER OFF WE'LL BE BECAUSE WE KNOW THAT OBESITY IN A LOT OF THESE CHRONIC DISEASES START EARLY ON AND THEY TRACK. SO BEING ABLE TO FOCUS ON A VERY MEANINGFUL WAY OF TRYING TO COMBAT THIS AND NOT JUST GOING WITH SCHOOLS BUT WE THINK ABOUT THE HEALTHCARE SYSTEM AND HOW THERE IS VERY LITTLE CHECK UPS REQUIRED FOR CHILDREN IN THAT AGE SPAN BEYOND JUST IMMUNIZATIONS WHEN THEY GO TO HIGH SCHOOL OR COLLEGE, I THINK THIS IS REALLY A POINT WE CAN MAKE A STRONG CALL FOR THE MORMONTORING AND HELP FOR THIS POPULATION BEFORE THEY ACTUALLY CARRY THESE RISKS ONWARD FOR THE REST OF THEIR LIFE. >> THIS IS MARIAN NEUHOUSER, EXCELLENT POINT ANNA MARIA, IF YOU REMEMBER BACK NOT ONLY HEALTH CONDITIONS BUT ALSO THE ATI SCORES, THEY WERE LOWEST IN THE PRE-ADOLESCENT AND ADOLESCENT. I AGREE WITH YOU COMPLETELY THIS MIGHT BE -- IT'S NOT MIGHT BE, IT IS A VERY IMPORTANT TARGET GROUP TO IMPROVE HEALTH DECREASE THE PREVALENCE OF OBESITY, IMPROVE DIETARY INTAKE, IMPROVE PHYSICAL ACTIVITY. IT'S REALLY CRITICAL. >> THIS IS BARBARA MILLEN, IT'S SORT OF RAISES IN MY MIND ANOTHER POTENTIAL RESEARCH AREA AND THAT IS TO UNDERSTAND ACROSS THE AGE SPAN IN THIS -- IN THIS MOMENT IN THIS CONVERSATION, WHAT MOTIVATES THE ADOLESCENT TO EITHER REVERT FROM THE HEALTHIER EATING HABITS OF YOUNGER AGE, MORE IMPORTANTLY WHAT WOULD MOTIVATE THEM TO ADOPT HEALTHIER BEHAVIORS AT A TIME IN LIFE WHEN WE KNOW THEY'RE NOT NECESSARILY THINKING IN THE -- WITH THE PERSPECTIVE OF THE NEXT 30 OR 40 YEARS OF THEIR LIFE. SO JUST TO UNDERSCORE AN IMPORTANT RESEARCH NEED. >> IN THAT VEIN AS THEY BECOME INDEPENDENT ADULTS AND SPEND MORE TIME AWAY FROM HOME, IS DETERMINANT OF THEIR CHOICES, TO AVAILABILITY WHETHER IT'S AVAILABLE WHEN THEY GET A JOB OR COLLEGE CAFETERIA, OR IN THEIR LOCAL NEIGHBORHOOD. >> THIS IS LUCILE ADAMS-CAMPBELL, ALSO WE HAVE TO BE COGNIZANT OF THE FACT THERE ARE CULTURAL ISSUES INTO THE HEALTH -- UNHEALTHY PRACTICES. WE WOULD BE REMISIF WE DON'T REALIZE CULTURES OBESITY AND OVERWEIGHT IS NOT THE BIGGEST ISSUE. THAT'S -- I WOULD LIKE TO POINT SOMETHING OUT. >> THANK YOU FOR MENTIONING THAT. >> OKAY. IN THAT CASE MAYBE WE SHOULD HAVE ASKED FOR THE NEXT SLIDE, EEL PASS THE SLIDE DECK OVER TO MARIAN. >> THANK YOU, CHERYL. THE NEXT STEPS FOR SUBCOMMITTEE 1 ARE TO COMPLETE THE CHAPTER WRITING AND DRAFT OUR RESEARCH RECOMMENDATIONS. SO WE ARE WELL ON OUR WAY TO COMPLETING OUR WORK. AND I WANT TO GIVE GREAT THANKS TO SUBCOMMITTEE 1 MEMBERS AS WELL AS THE FEDERAL STAFF WHO HAVE BEEN WORKING SO CLOSELY WITH US AND WITHOUT WHOM WE COULD NOT GET OUR WORK DONE. SO THANKS TO EVERYONE AND WE CONTINUE TO WELCOME COMMENTS FROM THE PUBLIC AS RICK MENTIONED AT THE BEGINNING OF THE WEBINAR TODAY. WE'LL MOVE FORWARD. THANK YOU VERY MUCH. >> THANK YOU, MARIAN. I WANT TO ALSO EMPHASIZE THAT LAST POINT. WE WOULD NOT BE AT THIS AMAZING STAGE IN OUR PROCESS WHERE IT NOT FOR THE EXTRAORDINARY LEVEL OF SUPPORT AND COLLEGIALITY OF ALL OF THE FEDERAL STAFF. IT'S VERY MUCH APPRECIATED ACROSS THE COMMITTEE AND ACROSS THE BOARD. THANKS VERY MUCH. WHAT I WOULD LIKE TO DO NOW THEN IS TO TURN THE MIC OVER TO ANNA MARIA SIEGA-RIZ, THE CHAIR OF SUBCOMMITTEE 2. >> THANK YOU, BARBARA. SO THIS IS WHEN I THINK OUR COMMITTEE MEMBERS AS WELL AS PUBLIC ARE GOING TO BEGIN TO SEE HOW THE WORK FROM EACH OF THE SUBCOMMITTEES ARE ACTUALLY COMPLIMENTING ONE ANOTHER. SO I AM THE CHAIR FOR SUBCOMMITTEE 2 AND ON THIS SLIDE YOU WILL SEE OUR OTHER COMMITTEE MEMBERS, I WANT TO APPRECIATE THE WORK THAT'S BEEN DONE BY ALICE LICHTENSTEIN, OUR VICE CHAIR, CHERYL ANDERSON, TOM BRENNA, STEVE CLINTON, FRANK HU, RAFAEL PEREZ-ESCAMILLA, AND MARIAN NEUHOUSER. AS BARBARA REMINDED THE COMMITTEE, THE SCOPE OF SUBCOMMITTEE 2 IS TO EXAMINE THE RELATIONSHIP BETWEEN DIETARY PATTERN, FOODS AND NUTRIENTS AND PREVENTABLE DIET RELATED DISEASES, OBESITY AND MORTALITY. OUR PRIMARY FOCUS IS TO CONSIDER FOODS AND NUTRIENTS IN THE CONTEXT OF DIETARY PATTERNS AS BARBARA SO ELOQUENTLY DESCRIBED PREVIOUSLY. CONSIDERING EVIDENCE ON SPECIFIC FOODS AND NUTRIENTS AS NEEDED, SPECIFICALLY WHEN OUR BODY OF EVIDENCE WAS GRADED OUTSIDE OF THE STRONG MODERATE RANGE. INP SITED EXPERTS AND CONSULTANTS YOU HEARD THE COMMITTEES ARE ALLOWED TO DO THAT, FOR THE TIME PERIOD SINCE THE LAST PUBLIC MEETING, SUBCOMMITTEE 2 HAS NOT CONSULTED ANY INVITED EXPERTS. SO WHAT WE WOULD LIKE TO DO IS TO PROVIDE YOU WITH AN UPDATE, TO REVIEW WHAT OUR WORK HAS BEEN ON DIETARY PATTERNS RELATED TO DVD, BODY WEIGHT, TYPE 2 DIABETES, CANCER, CONGENITAL ANOMALIES, NEUROLOGICAL AND PSYCHOLOGICAL ILLNESSES AN BONE HEALTH. WE HAVE PRESENTED OUR DRAFT CONCLUSIONS AND MOST IMPLICATION STATEMENTS IN PUBLIC MEETINGS FOUR AND FIVE AND THERE HAVE BEEN NO SUBSTANTIAL CHANGES. WHAT OUR SUBCOMMITTEE HAS BEEN BUSY DOING IN ADDITION TO WRITING THE CHAPTERS, THE SECTIONS OF THE CHAPTER, WE HAVE ACTUALLY BEEN ABLE TO LOOK ACROSS THE DIETARY PATTERNS TO BE ABLE TO DESCRIBE SOME COMMON CHARACTERISTICS OR COMPONENTS OF THE DIET THAT APPEAR TO BE ASSOCIATED WITH HEALTH. SO TODAY WE'RE GOING TO SHARE WITH YOU THOSE COMMON CHARACTERISTICS OR COMPONENTS AS WELL AS PROVIDE YOU WITH OUR OVERALL DRAFT IMPLICATIONS FOR THE CHAPTER. SO AS YOU REVIEW WE FOUND STRONG EVIDENCE FOR THE RELATIONSHIP BETWEEN DVD WEIGH LOSS AMONG OVER WEIGHT AND OBESE ADULTS. THERE WAS MODERATE EVIDENCE FOR TYPE 2 DIABETES, COLORECTAL CANCER, POST MENOPAUSAL BREAST CANCER, AND BODY WEIGH, OR WEIGHT GAIN AS WELL AS INCIDENCE OF OVERWEIGH AND OBESITY IN ADULTS. WE FOUND LIMITED EVIDENCE FOR THE RELATIONSHIP BETWEEN DIETARY PATTERNS AND PREMENOPAUSAL BREAST CANCER, LUNG CANCER, NEURAL TUBE DEPECK IF HE CAN, DEPRESSION IN ADULTS, -- DEFECTS. DEPRESSION IN ADULTS, AGE RELATED COGNITIVE IMPAIRMENT, BONE HEALTH AND BODY WEIGHT IN CHILDREN. THE COMMITTEE THOUGHT THAT THE BODY OF EVIDENCE WAS UNASSIGNASSIGNABLE OR FOR PROSTATE CANCER, DEPRESSION, DEPRESSION IN POSTPARTUM WOMEN AND CHILDREN, CONGENITAL HEART DEFECTS, CLEF LIP AND CLEFT PALATE IN CHILDREN. SO WHEN WE LOOK ACROSS THE DIFFERENT DIETARY PATTERNS, STUDIES THAT LOOK AT WE FOUND VEGETABLES AN FRUITS WERE CONSISTENTLY IDENTIFIED AS A BENEFICIAL COMPONENT OF THE DIET AND EVERY CONCLUSION STATEMENT ACROSS ALL THE HEALTH OUTCOMES. WHOLE GRAINS WERE IDE IFED LESS CONSISTENTLY IDENTIFIED IN EVERY CONCLUSION WITH MODERIL RATH TO STRONG BODY OF EVIDENCE. FOR STUDIES WITH LIMITED EVIDENCE GRABS WERE NOT CONSISTENTLY DEFINED AND/OR THEY WERE NOT IDENTIFIED AS ACUTE CHARACTERISTIC OF THE DIETARY PATTERN. LOW FAT DAIRY WAS IDENTIFIED AS A BENEFICIAL COMPONENT OF THE DIET, FOR MOST OUTCOME WITH THE MODERATE TO STRONG EVIDENCE. AND WAS LESS CONSISTENTLY IDENTIFIED FOR THOSE OUTCOMES, WITH LIMITED EVIDENCE. FISH, SEAFOOD, LEGUMES, LEAN MEATS AND NUTS WERE IDENTIFIED AS BENEFICIAL COMPONENTS OF THE DIET, FOR ALL CONCLUSIONS WITH MODERATE TO STRONG EVIDENCE, HIGHER INTAKE OF RED AND PROCESSED MEATS WAS IDENTIFIED AS BEING A DETRIMENTAL COMPONENT OF THE DIET. MODERATE INTAKE OF ALCOHOL WAS IDENTIFIED AS A BENEFICIAL COMPONENT OF THE DIETARY PATTERN FOR CONCLUSIONS WITH MODERATE TO STRONG EVIDENCE, HIGHER CONSUMPTION OF SUGAR SWEETENED FOODS AND BEVERAGES AS WELL AS REFINED GRAINS WERE IDENTIFIED AS DETRIMENTAL IN ALMOST ALL CONCLUSION STATEMENTS WITH MODERATE TO STRONG EVIDENCE. IN SUMMARY WHAT WE FOUND WAS THAT THE COMMON COMPONENTS OF DIETARY PATTERNS, ASSOCIATED WITH POSITIVE HEALTH OUTCOMES INCLUDE HIGHER INTAKE OF VEGETABLES, FRUITS, WHOLE GRAINS, LOW FAT DAIRY, FISH, SEAFOOD, LEGUMES, AND NUTS. MODERATE INTAKE OF ALCOHOL, LOWER CONSUMPTION OF RED AND PROCESSED MEATS, AND LOW INTAKE OF SUGAR SWEETENED FOODS AND DRINKS AS WELL AS REFINED GRAINS. SPECIFICALLY WITH ALCOHOL WHILE MODERATE ALCOHOL INTAKE WAS IDENTIFIED AS COMPONENT OF A HEALTHY DIETARY PATTERN ASSOCIATED WITH HEALTH OUTCOMES, THIS WILL AFFIRM CONCLUSIONS RELATED MODERATE ALCOHOL CONSUMPTION BY THE 2010 DGACs. IT'S ALSO IMPORTANT TO KEEP IN MIND THAT THE IMPACT OF ALCOHOL ON SPECIFIC CANCERS WAS BASED ON 2007, AICR, WCRF REPORT IN 2010. AND THE COMMITTEE IN 2015 ALSO USED AN UPDATED VERSION OF THAT REPORT TO EVALUATE THE IMPACT OF ALCOHOL ON CANCER OUTCOME. THE 2010 DGAC ADDITIONALLY CONSIDERED ALCOHOL INTAKE AND UNINTENTIONAL INJURY AS WELL AS LACTATION. BECAUSE THE 2015 SUBCOMMITTEE 2 DID NOT LOOK AT THESE TWO OUTCOMES, WE'RE BRINGING FORWARD THE CONCLUSION STATEMENTS FROM 2010 AS THEY STAND. THEY'RE PRESENTED HERE AS REMINDER OF WHAT'S THE RELATIONSHIP WAS BETWEEN UNINTENTIONAL INJURY AND ALCOHOL AS WELL AS LACTATION AND ALCOHOL. SO THE COMMITTEE WILL BRING FORWARD THESE CONCLUSION STATEMENTS IN OUR REPORT. SO THE DRAFT IMPLICATIONS THAT WE WOULD LIKE TO PRESENT THAT ARE CROSS CUTTING IN OUR CHAPTER, IS THAT THE U.S. POPULATION SHOULD CONSUME DIETARY PATTERN THAT ARE RICH IN VEGETABLES AND FRUITS, WHOLE GRAINS, LOW FAT DAIRY, FISH, SEAFOOD, LEGUMES, LEAN MEAT AND NUTS. AND THEY SHOULD BE THEIR ALCOHOL CONSUMPTION SHOULD BE MODERATE. AND LOWER IN RED AND PROCESSED MEATS. AS WELL AS THE LOW AND SUGAR SWEETENED FOODS, BEVERAGES, REFINED GRAINS. THESE ARE IMPORTANT FOR MAINTAIN ING HEALTH WHEN COUPLED WITH AN ENERGY DEFICIT FOR ACHIEVING A HEALTHY WEIGHT. SO I THINK YOU CAN BEGIN TO SEE THE RELATIONSHIP BETWEEN SUBCOMMITTEE 2'S WORK AND SUBCOMMITTEE 1'S WORK WHICH I JUST HEARD. FROM CHERYL ANDERSON. THESE DIETARY PATTERNS CAN BE ACHIEVED IN MANY WAYS. AND SHOULD BE TAYLORED TO THE INDIVIDUAL BIOLOGICAL NEEDS AS WELL AS SOCIAL CULTURAL PREFERENCES. WE RECOGNIZE A MULTI-LEVEL PROCESS AT BOTH THE INDIVIDUAL AND POPULATION LEVEL IS REQUIRED TO HELP ACHIEVE A HEALTHY WEIGHT AND OTHER LIFESTYLE BEHAVIORS SO AS TO ACHIEVE CHRONIC DISEASE RISK REDUCTION AND OVERALL WELL BEING. WE RECOMMEND THE DEVELOPMENT OF PROGRAMS AND SERVICES THAT FACILITATE THE IMPROVEMENT IN EATING BEHAVIORS. CONSISTENT WITH HEALTHY DIETARY PATTERNS IN RAREIOUS SETTINGS. I THINK YOU HEARD IN SUBCOMMITTEE 1 REPORT OF ALL THESE DIFFERENT SETTINGS THAT WILL BE -- CONTINUE TO BE PRESENTED IN SUBCOMMITTEE 4 WORK AS WELL. THEN WE WANT TO PROPOSE THAT THE BRING FORWARD THE 2010 DGAC RECOMMENDATION THAT IF ALCOHOL IS CONSUMED, IT SHOULD BE CONSUMED IN MODERATION AND ONLY BY ADULTS THAT MODERATE ALCOHOL CONDITION SUM SHUN IS DEFINED AS AN AVERAGE DAILY CONSUMPTION ONE DRINK PER DAY FOR WOMEN AND UP TO TWO DAY DRINKS PER DAY FOR MEN AND NO MORE THAN THREE DRINKS IN ANY SINGLE DAY FOR WOMEN AND NO MORE THAN FOUR DRINKS IN ANY SINGLE DAY FOR MEN. WE ALSO WANT TO FURTHER RECOGNIZE THAT WHILE IT IS NOT RECOMMENDED THAT ANYONE BEGIN DRINKING OR DRINK MORE FREQUENTLY ON THE BASIS OF POTENTIAL TOX BENEFIT BECAUSE MODERATE ALCOHOL INTAKE IS ALSO ASSOCIATED WITH INCREASE RISK OF BREAST CANCER, VIOLENCE, DROWNING, AND INJURIES FROM FALLS IN MOTOR VEHICLE CRASHES. FURTHERMORE THERE MIGHT BE MANY CIRCUMSTANCES MANY WHICH PEOPLE SHOULD NOT DRINKING, THESE INCLUDES INDIVIDUAL WHOSE CANNOT RESTRICT TO MODERATE LEVEL AND YOUNGER THAN THE LEGAL DRINKING AGE, WOMEN WHO ARE PREGNANT OR MAYBE PREGNANT, INDIVIDUALS TAKING PRESCRIPTION OR OVER THE COUNTER MEDICATIONS THAT CAN INTERACT WITH ALCOHOL. INDIVIDUALS WITH CERTAIN SPECIFIC MEDICAL CONDITIONS SUCH AS LIVER DISEASE, HYPOTRY -- AND PAN KEY EYE AT THIS, INDIVIDUALS THAT DRIVE OR OPERATE MACHINERY OR TAKE PART IN OTHER ACTIVITIES THAT REQUIRE ATTENTION OR COORDINATION OR IN SITUATION WHERE IS IMPAIRED JUDGMENT CAN CAUSE INJURY OR DEATH. LASTLY, WE WANT TO SHOW THAT THE MAJORITY EVIDENCE CONSIDERED FOCUS ON DIETARY PATTERNS CONSUMED IN ADULTS ON HEALTH RISK. THESE RECOMMENDATIONS WHILE THEY WERE NOT ANY STUDIES AT ALL IN CHILDREN ALSO CAN BE APPLIED WITH CHILDREN. IT'S IMPORTANT TO KNOW THAT THE DIETARY PATTERN RESEARCH REVIEWED BY SUBCOMMITTEE 2 BOTH SUPPORTS AND EXTENDS THE FOOD GROUP RESEARCH THAT WAS REVIEWED BY THE 2010 DGAC COMMITTEE. WHILE BOTH COMMITTEES APPROACHED THE QUESTION SLIGHTLY DIFFERENTLY, IT IS VERY INTERESTING TO NOTE THAT IN FACT WE'RE COMING UP WITH THE SAME OVERALL CONCLUSION IN TERMS OF WHAT CONSTITUTES A HEALTHY DIETARY PATTERN. FOR AMERICANS. SO NOW I WILL OPEN THIS UP TO DISCUSSION AN I WOULD LIKE TO INVITE SUBCOMMITTEE 2 MEMBERS TO SEE IF THEY HAVE ANY COMMENTS THAT THEY WOULD LIKE TO MAKE BEFORE WE OPEN IT UP TO THE FULL COMMITTEE. NOT HEARING ANY COMMITTEE MEMBERS FROM SUBCOMMITTEE 2, ANY COMMENTS OR QUESTIONS FROM THE FULL COMMITTEE? >> ANNA MARIA, THANK YOU, THIS IS MARY STORY. I WAS WONDERING IN YOUR ALCOHOL IMPLICATIONS WHICH I'M REALLY GLAD THAT YOU DEFINE MODERATE AND THAT YOU SAY -- YOU GIVE RESTRICTIONS, BUT WHY DIDN'T YOU INCLUDE LACTATION AT ALL IN THOSE THAT SHOULD BE LIMITING ALCOHOL ENTIRELY? >> WE'RE NOT -- I MEAN, WE'RE BRINGING FORWARD THE 2010 DGAC AND SO THE CONCLUSION STATEMENTS FOR THE QUESTION FROM THE 2010 REPORT STATE THAT MODERATE OR CONSISTENT EVIDENCE SHOWED THAT WHEN A LACTATING MOTHER CONSUMED ALCOHOL, ALCOHOL DOES ENTER BREAST MILK IN QUANTITY MILK PRODUCED IS REDUCED LEADING TO REDUCED MILK CONSUMPTION BY THE INFANT. ALTHOUGH LIMITED EVIDENCE SUGGESTS THAT ALCOHOL CONSUMPTION DURING LACTATION IS ASSOCIATED WITH ALTERED POSTNATAL GROWTH SLEEP PATTERNS AND CYCLE MOTOR PATTERNS ARE THE OFFSPRING. WHILE THERE IS A RELATIONSHIP, THERE IS SOME STANDARD RECOMMENDATIONS FOR WOMEN WHO ARE BREAST FEEDING THAT IF THEY DO CONSUME ALCOHOL THAT THEY ACTUALLY DO NOT FEED THE BABY RIGHT AFTER THE CONSUMPTION OF ALCOHOL, AND THAT THEY EXPRESS THE BREAST MILK AND GET RID OF IT. WHILE THERE IS SOME RECOMMENDATIONS FOR WOMEN WHO BAR BREAST FEEDING HOW TO DEAL WITH THAT SO THEY DON'T NECESSARILY POSE A THREAT TO THEIR CHILD. LACTATION WASN'T CONSIDERED IN 2010 TO CALL OUT BUT I'M OPEN TO OTHER PEOPLE'S REVIEWPOINT ON THAT, I'M GOING TO REFER TO OUR COLLEAGUE RAFAEL PEREZ-ESCAMILLA, WHO IS PROBABLY DONE THE MOST RESEARCH ON BREAST FEED TO SEE IF'S ANYTHING ELSE. >> I THINK IF WE CAN BRING IT BACK TO YOUR SUBCOMMITTEE BECAUSE THE LIST IS PRETTY LONG AND COMPREHENSIVE TO WHO SAID AVOID IT. OR BE CAREFUL, SO YOU JUST -- IT JUST SEEMS GIVEN YOU BRING UP SO MANY CONDITIONS BY NOT HAVING ANYTHING REGARDING LACTATION, IT MIGHT LOOK LIKE BREAST FEEDING MOTHERS CONSUME AS MUCH -- I MEAN, MODERATE AMOUNTS. AND GIVEN THAT BREAST FEEDING RATES ARE PRETTY MUCH AT AND ALL TIME HIGH, I THINK IT'S IMPORTANT TO RECONSIDER ADDING SOMETHING. >> WE LOOKED THROUGH THAT, THANK YOU. >> I ALSO WONDERED, WE'RE GOING TO DEFINE AT ALL IN YOUR SECTION WHAT LOWER AMOUNTS OF RED AND PROCESSED MEATS MEAN? >> SO THAT'S -- WE HAD THIS CONVERSATION IN THE SUBCOMMITTEE AND IT'S -- WHILE WE WISH THAT WE COULD BE ABLE TO DEFINE IT, THIS IS WHY THERE'S BEEN SOME SORT OF COMPLIMENTARY WORK WITH SUBCOMMITTEE ONE AND THE REASON WHY CHERYL PRESENTED WHAT THE RANGES WERE FOR THE DIFFERENT TYPES OF DIETARY PATTERNS REVIEWED IN OUR SUBCOMMITTEE AND THE RANGE FOR ALL THE DIFFERENT FOODS THAT WERE ASSOCIATED WITH THE HEALTHY DIETARY PATTERN. SO GETTING TO MORE SPECIFICITY ON THAT WOULD REQUIRE OUR TOOLS FOR WHICH WE ASSESS DIET TO ACTUALLY BE ABLE TO PROVIDE US WITH THAT. THAT'S AN AREA WE WOULD LOVE MORE FUTURE RESEARCH ON. YOU CAN GO BACK WITH SUBCOMMITTEE ONE BUT MY UNDERSTANDING, CHERYL YOU CAN CHIME IN HERE, WE REALLY DON'T HAVE BEYOND BEING ABLE TO PRESENT WHAT THOSE RANGES WERE ACROSS THE STUDIES TO BE ABLE TO REALLY DEFINE THESE AMOUNTS IN GREATER DEPTH. >> WE HAVEN'T DONE THAT AT THIS TIME, THAT WOULD HAVE TO BE A CONVERSATION WITH STAFF. IN TERMS OF BOTH TECHNICAL AND PRACTICAL ISSUES. >> THIS IS ALICE LICHTENSTEIN. I THINK AS AN IMPORTANT THING TO CLARIFY, PROBABLY WE DON'T HAVE THE DATA NOW, WE ALSO HAVE TO UNDERSTAND WHETHER WE NEED TO SEPARATE PROCESS MEAT FROM RED MEAT BECAUSE COMPOSITIONALLY THEY'RE DIFFERENT. THEN HAVE MORE SPECIFICITY AND DEFINITION OF RED MEAT BECAUSE OF THE HUGE RANGE IN CONTENT OF PROTEIN FAT ACROSS THE DIFFERENT CUTS. >> I THINK THIS IS -- I -- >> THIS IS MARY. IF YOU CAN AT LEAST NOT BRING THAT BACK TO THE COMMITTEES, BECAUSE I THINK SAYING LOWER AMOUNTS OF RED AND PROCESSED MEATS MIGHT NOT REALLY HELP AMERICANS KNOW EXACTLY HOW MUCH OR WHAT LOWER MEANS. >> I AGREE WITH THAT, MARY. I THINK SOME OF THE LIMITATIONS THAT WE ARE RECOGNIZING IS HOW THE DATA WAS ACTUALLY COLLECTED. SO MOST OF THESE STUDIES ARE EITHER USING FOOD FREQUENCY QUESTIONNAIRES, SOME OF THE OTHER ONES MIGHT BE USING 24 HOUR RECALLS AND IN THE REPORTS THEMSELVES THEY DON'T NECESSARILY CLARIFY IN GREATER DEPTH WHAT'S INCLUDED IN THOSE PARTICULAR FOOD GROUPS. >> THIS IS WAYNE CAMPBELL. I WOULD LIKE TO ECHO THE CONCERNS ABOUT THIS TOPIC AND I JUST FIND THE RESPONSE YOU JUST MADE WITH RESPECT TO THE INADEQUACIES OF THE PREVIOUS LITERATURE DISTURBING WITH RESPECT TO CARRYING FORWARD THE MESSAGE THAT'S BEING PRESENTED HERE. IF THERE'S REALLY INADEQUACIES IN IDENTIFYING THE RED MEAT VERSUS LEAN RED MEAT VERSUS PROCESSED MEAT VERSUS PROCESSED NON-RED MEATS, FOR EXAMPLE, THEN THIS MESSAGE IS EXTREMELY VAGUE AND ILL SERVED. WHAT THEY CAN THE MOST -- THE VARIETY OF VARIOUS LEAN MEATS THAT CAN BE CONSUMED IN A HEALTHY DIET. >> THIS IS MARIAN NEUHOUSER, THANK YOU, WAYNE FOR MENTIONING THAT, ISLE RESPOND IN TWO WAYS. FIRST IS THIS WHOLE TOPIC WHICH IS QUITE IMPORTANT IS WHAT MOTIVATED THE DIETARY PATTERN TO COMPOSITION WORK IN SUBCOMMITTEE ONE. THIS IS THE FIRST TIME THE DIETARY GUIDELINES HAS DELVED INTO THIS KIND OF WORK. SO WE THINK WE JUST AT THE TIP OF THE ICEBERG, THERE'S CERTAINLY A LOT MORE WORK TO DO. BUT ONE OF THE GOALS WAS TO TRY TO GET A HANDLE ON SOME OF THE QUANTIFICATION INSTEAD OF HIGHER VERSUS LOWER AND SO FORTH. THE SECOND QUESTION WHICH RELATES DIRECTLY TO WHAT WAYNE MENTIONED, OR THE SECOND COMMENT, THIS IS A TREMENDOUS RESEARCH NEED. PARTICULARLY FOR DIETARY ASSESSMENT METHODOLOGY. WE REALLY, REALLY NEED BETTER AND MORE IMPROVED WAYS TO ASSESS THE DIET IN OUR POPULATION AND ACROSS POPULATIONS WE NEED BETTER WAYS TO QUANTIFY FOODS AND IDENTIFY WHAT PEOPLE ARE REALLY EATING, AND WHAT AMOUNT AND WHAT BRANDS BECAUSE THINGS DO VARY. CUTS OF MEAT VARY. EVEN LOOKING ACROSS DIFFERENT TYPES OF PREPARED FOOD, THE SODIUM VARIES THE ADDED SUGAR VARIES. SO WE HAVE TREMENDOUS RESEARCH NEEDS TO IMPROVE DIETARY ASSESSMENT. >> THIS IS FRANK HU. I AGREE WITH MARIAN THAT THIS IS DIETARY PATTERN ANALYSIS. THAT'S THE REASON MOST OF THE STUDIES DID NOT GET INTO DETAILS IN TERMS OF WHETHER FOR EXAMPLE PROCESSED MEATS ARE WORSE THAN UNPROCESSED RED MEATS. MOST OF THE STUDIES LUMP RED MEAT AND PROCESS MEATS TOGETHER. SOME STUDIES ACTUALLY IN THE FFQs, 24 HOUR RECOURSE, COMBINE RED MEAT BOTH PROCESS AND PROCESSED RED MEAT. SO IT'S DIFFICULT TO SEPARATE OUT PROCESS RED MEAT AND UNPROCESS RED MEAT IN THIS TYPE OF DIETARY PATTERN ANALYSIS. HAVING SAID THAT, THERE ARE A LARGE BODY OF -- THERE IS A LARGE BODY OF LITERATURE ON DIFFERENT TYPE OF RED MEAT. AND VARIOUS HEALTH OUTCOMES INCLUDING CARDIOVASCULAR DISEASE, TYPE 2 DIABETES, COLORECTAL CANCER AND SO FORTH. I THINK IF WE WANT TO GET MORE DETAILED INFORMATION REGARDING THE HEALTHY DIFFERENT TYPE OF RED MEAT ESPECIALLY PROCESSED VERSUS UNPROCESSED RED MEAT, WE HAVE TO SUPPLEMENT DIET PATTERN ANALYSIS WITH SYSTEMATIC REVIEW, META ANALYSIS, DIFFERENT TYPE RED MEAT AND VARIOUS HEALTH OUTCOMES. FROM THOSE STUDIES WE MAYBE ABLE TO GET A GOOD HANDLE ON THE QUANTITY THAT SHOULD BE RECOMMENDED, FOR EXAMPLE, WHAT'S THE AMOUNT OF PROCESSED RED MEAT VERSUS UNPROCESSED RED MEAT IN RELATION TO VARIOUS DISEASE OUTCOMES. >> THIS IS MARIAN, GOOD POINTS, FRANK BUT DOING A SYSTEMATIC REVIEW WILL NOT GET AT THE PROBLEM OF TRYING TO IMPROVE DIETARY ASSESSMENT. IF YOU DO A SYSTEMATIC REVIEW USING THE SAME INSTRUMENTS THAT GROUP EVERYTHING TOGETHER THAT DOESN'T ADVANCE TRYING TO UNDERSTAND WHAT PEOPLE ARE EATING. >> PUTTING ASSESSMENT ISSUE I THINK IS MANY -- EVIDENCE BASE HAS ALREADY EXISTED FOR DIFFERENT TYPE OF RED MEAT IN RELATION TO HEALTH OUTCOMES WHICH WAS NOT COVERED BY DIETARY PATTERN REVIEW. IN THOSE STUDIES, IN PROCESS RED MEAT TYPICALLY INCLUDE BACON, SAUSAGE, HOT DOGS AND SO FORTH, AND UNPROCESSED RED MEAT INCLUDE STEAKS, FOR EXAMPLE, PORK, AND HAM BURGERS AND SO FORTH. SO OF COURSE THEY'RE GOING TO BE LARGE AMOUNT OF MANAGEMENT ERRORS IN ANY OF THOSE ITEMS. BUT IN MOST OF THOSE STUDIES OF THE CLASSIFICATION OF PROCESSED RED MEAT SEARCH AND SEIZURE UNPROCESSED RED MEAT, IS RELATIVELY GOOD AND I THINK THE HEALTH OUTCOMES THAT WAS VERY DIFFERENT BETWEEN THOSE TWO TYPE OF MEATS. >> THIS IS WAYNE. I APPRECIATE THE COMMENTS. IN THE FIRST STATEMENT REGARDING FOODS PATTERN INTAKES THAT WERE DEEMED HEALTHY, IN THE TERM LEAN MEAT IS INCLUDED. WOULD IS THAT BROAD ENOUGH THAT YOU'RE INCLUDING LEAN RED MEATS? >> WAYNE, ARE YOU DIRECTING THAT QUESTION TO A PARTICULAR PERSON? >> NO. THERE'S -- IT SEEMS IT IS EATER VAGUE OR INCONSISTENT, ESPECIALLY INCONSISTENT TO HAVE A RECOMMENDATION FOR LEAN MEAT AS A HEALTHY THING THEN TO SAY RED MEAT IS BAD WHEN THERE ARE LEAN CUTS OF RED MEAT. >> EXACTLY. THIS IS BARBARA, JUST TO JUMP IN ON THIS, THOSE WHO ARE LISTENING IN -- LET YOU THINK THAT THE RECOMMENDATIONS ARE NOT SPECIFIC, THE WORK THAT I THINK -- THE ELEGANT WORK THAT MARIAN AND CHERYL PRESENTED ON THE ASSESSMENT OF HEALTHY DIETARY PATTERNS AND MODELING MULTIPLE ALTERNATIVES THAT AMERICANS CAN CONSIDER EATING HAVE VERY SPECIFIC CALORIE-LEVEL SPECIFIC RECOMMENDATIONS FOR THE FOOD GROUPS. ALSO WITHIN THAT MODELING ACTIVITY RED AND OTHER LEAN MEATS WERE CERTAINLY CONSIDERED AND TRISH MAY WANT TO ADD FURTHER COMMENT ON THAT BUT THERE ARE SPECIFIC PORTION SIZES THAT ARE CONSIDERED RELEVANT TO AGE AND CALORIE LEVEL NEEDS OF THE INDIVIDUAL. >> THIS IS ALICE LICHTENSTEIN. WE WILL NEED TO MAKE A LITTLE MORE AND PERHAPS UNDERSTANDING IN TERMS OF HOW THAT MODELING WAS DONE, CONSIDERED THINGS LIKE LEAN. >> I CAN ANSWER THAT QUESTION A LITTLE BIT AND THEN IF TRISH, THIS IS MARIAN, IF TRISH BRITTON WANTS TO EXPAND WE WELCOME HER COMMENTS AS WELL. IN THE USDA FOOD PATTERN MODELING NUTRIENT DENSE LEAN CUTS ARE ALWAYS CHOSEN BECAUSE AS YOU KNOW IN THE USCA STANDARD REFERENCE FOOD DATABASE, THERE'S MANY VARIETIES OF MEAT THAT HAVE FAT ON THE FAT OFF, THE VISIBLE FAT TRIMMED ON OR OFF EVEN AMONG THE GROUND BEEF THERE'S CHUCK, WHICH HAS HIGHER FAT CONTENT AND THEN OTHER TYPES. SO THE EXPERTISE OF THE PEOPLE AT USDA, SENT FOR NUTRITION POLICY AND PROMOTION ARE VERY FAMILIAR WITH THAT FOOD DATABASE AND THEY SELECT THE LEAN CUTS FOR THE FOOD PATTERN MODELING BECAUSE THEY CAN SEE IN THE DATABASE WHICH CUTS HAVE LESS MEAT OR LESS FAT RELATIVE TO OTHER CUTS OF MEAT. SO THAT'S CONSIDERED FOR THE FOOD PATTERN MODELING. FOR SOMEONE WHO IS CREATING A NUTRIENT DATABASE TO BACK UP THEIR FOOD FREQUENCY QUESTIONNAIRE, I CAN ONLY SPEAK FOR THE ONE THAT I WORK WITH. BUT OTHER FOOD FREQUENCY QUESTIONNAIRES, WHOEVER IS CREATING THAT NUTRIENT DATABASE, TO PROCESS THE FOOD FREQUENCY QUESTIONNAIRES HAS THE ABILITY TO SELECT OUT LEAN CUTS OR NON-LEAN CUTS. SO ON MANY FOOD FREQUENCY QUESTIONNAIRES, WHEN IT ASKS RESPONDENTS TO COMPLETE QUESTIONS ON TYPES OF MEATS THEN DEPENDING ON WHAT TYPE OF MEAT IS SELECTED, IN THE NUTRIENT DATABASE, THAT INFLUENCE FOR A CUT IS LEAN OR NOT. TRISH, WHEN YOU LIKE TO ADD ANYTHING TO THOSE COMMENTS? >> THIS IS TRISH BRITON FROM THE USDA. MARIAN, YOU DID A SUPER JOB DESCRIBING THE WAY WE SELECT FOODS FROM THE NUTRIENT DATABASE TO PUT IN TO OUR FOOD PATTERNS AND OUR MODELING EXERCISES, SO WE TAKE A PREMISE OF NUTRIENT DENSE FOODS FOR THE PATTERNS, AND THOSE ARE THE LEANEST CUTS OF MEAT. IN ADDITION TO THE LEANEST VERSIONS OF ALL THE OTHER FOODS OR THE LOW FAT OR THE NO ADDED SUGAR OR LOWER SODIUM VERSIONS OF ALL FOODS. SO WE DO HAVE THAT. WE DO HAVE THE ISSUE OF COURSE THAT RED MEAT AND PROCESSED MEAT AND THE POWELLTRY ARE ALL GROUPED, AND SOMETIMES SPLIT OUT AND WE DO NOT KNOW WITH PROCESSED MEAT AND PEOPLE WHO DO THE NUTRIENT DATABASES UNLESS THEY GO TO ONE PARTICULAR FOOD THEY DON'T ALWAYS KNOW WHETHER OR NOT A PROCESSED MEAT IS MADE FROM POULTRY OR WHETHER IT'S MADE FROM RED MEAT OR COMBINATION THEREOF. SO THERE'S THE DEFINITIONS ARE DIFFICULT TO DEAL WITH WHEN YOU GET DOWN TO THAT GRANULARITY. THAT'S HOW WE DO IT, WE PICK THE LEANEST. >> I UNDERSTAND THAT, THAT WAS VERY HELPFUL, I UNDERSTAND THAT AS FAR AS MODELING GOES BUT WHEN YOU RECONCILE THE MODELING WITH WHAT IS BEING REPORTED BY INDIVIDUALS, I THINK THAT'S WHERE WE MAYBE RUNNING INTO PROBLEMS BECAUSE WHAT ONE PERSON CONSIDERS AS LEAN ANOTHER PERSON MAY NOT. THE PERCENT FAT FOR LEAN FOR CERTAIN CUTS OF MEAT, THE PERCENT OF FAT AND CERTAIN CUTS OF MEAT, THE LEAN OPTION IS DIFFERENT THAN THE AMOUNT OF FAT IN ANOTHER CUT OF MEAT. >> THAT'S ABSOLUTELY CORRECT. EVEN FOR MANY FOOD FREQUENCY QUESTIONNAIRES, FROM WHICH THESE DATA ARE DERIVED, ON MANY OF THESE QUESTIONNAIRE, A LOT OF FOODS ARE GROUPED TOGETHER. SO FOR EXAMPLE, THERE MIGHT BE A LINE ITEM FOR LUNCH MEAT. THE THEN P PERSON MARK IT IS FREQUENCY AND THE PORTION SIZE OF LUNCH MEAT THEY CONSUME BUT IT CAN INCLUDE BOLONEY, TURKEY, HAM, CHICKEN, A WHOLE VARIETY OF TYPES OF LUNCH MEAT. SO EVEN WITHIN THAT, THERE'S A WIDE RANGE. AGAIN, DEPENDING WHO IS CREATING THE NUTRIENT DATABASE TO BACK THAT UP, THE ONE THAT I WORK WITH, WE WEIGHT THE LUNCH MEATS DEPENDING ON THE CONSUMPTION, WE COMPARE TO NHANES TO SEE FREQUENCY OF CONSUMPTION OF THOSE TYPES. BUT AGAIN, THERE'S SOME GUESS WORK INVOLVED SCIENTIFIC EXPERTISE, ET CETERA, NOT AS PRECISE AS ONE WOULD LINE IT. SO THIS IS AN EXAMPLE WHERE WE NEED BETTER DIETARY ASSESSMENT TOOLS TO BE ABLE TO REALLY UNDERSTAND AND FOR PEOPLE TO ACCURATELY REPORT AS WELL. BECAUSE SOMEONE'S PERCEPTION OF WHAT THEY EAT, AND MARK ON QUESTIONNAIRE MAYBE DIFFERENT FROM WHAT THEY ACTUALLY EAT. Q. THAT'S WHAT I WAS GETTING AT. >> WE REALLY NEED BETTER METHODS. >> SO ALL THESE THINGS SAID, THIS IS BARBARA AGAIN, THERE'S NO DOUBT THAT GOING FORWARD GIVEN THE IMPORTANT LIGHT THAT THIS APPROACH WITH DIETARY PATTERN SHEDS ON DIET HEALTH RELATIONSHIP, WE KNOW THERE ARE LEVELS OF RESEARCH NEED OF A METHOD LOGIC NATURE AND ALSO HELPING REFINE OUR UNDERSTANDING OF WHAT THESE RELATIONSHIPS ARE AND HOW THEY VARY IN DIFFERENT POPULATION SUBGROUPS AND SO FORTH. BUT IN ADDITION TO THE IMPORTANT RESEARCH NEEDS THAT I THINK THIS APPROACH HAS ALLOWED US TO BEGIN TO IDENTIFY, I THINK IT'S IMPORTANT AS A TAKE HOME TO ALSO UNDERSTAND JUST HOW CRITICAL IT WAS TO BETTER DEFINE THESE RELATIONSHIPS BECAUSE IT DOES -- IT HAS NOT ONLY HELPED INFORM THE MODELING WORK WHICH IS NOVEL AND INNOVATIVE IN SC 1 BY USDA, BUT IT'S REALLY GOING TO BE THE STRONG EVIDENCE BASIS FOR A NEW APPROACH REALLY ON -- TO COMMUNICATING WITH THE AMERICAN PUBLIC ABOUT DIFFERENT ALTERNATIVE STRATEGIES THAT THEY CAN USE TO IMPROVE THE -- THEIR EATING PRACTICES TO TRY TO ACHIEVE A HEALTHIER DIET. I THINK THAT WE WILL TAKE UNDER ADVISEMENT THE NOTION OF REALLY TRYING TO REFINE AS MUCH AS POSSIBLE THE SPECIFICITY OF THOSE MESSAGES SO WE CAN BE AS CLEAR AND CONCISE AS POSSIBLE IN THE RECOMMENDATIONS THAT WE PUT FORTH TO THE FOLKS AT HHS AND USDA. >> ANY OTHER COMMENTS OR COMMENTS? >> BARBARA, I WANT TO ECHO WHAT YOU JUST SAID ABOUT THIS CROSS CUTTING INTEGRATION IN DIFFERENT AREAS OF WORK. THE DIETARY PATTERN ANALYSIS TO A LARGE DEGREE I THINK IS QUALITATIVE AND SEMIQUANTITATIVE TO GET MORE PRECISE INFORMATION, I THINK THE MODELING CAN HELP A LOT. IN TERMS OF DIFFERENTIATION DIFFERENT TYPE OF RED MEAT AND PROCESS MEAT, THIS CANNOT BE DONE AT DIETARY PATTERN TYPE ANALYSIS BUT DIETARY PATTERN ANAL US IS REALLY -- ANALYSIS, IN TERMS OF DEFINING OR IDENTIFYING THE COMMON ELEMENTS OF HEALTHY DIETARY PATTERN OR MULTIPLE HEALTH DIETARY PATTERN, THAT HAS BEEN DEMONSTRATED BECAUSE THE COMMON ELEMENTS CUTTING ACROSS DIETARY PATTERN, DASH PATTERN, USDA PATTERN. AND THE WORK IN DIFFERENT WORKING GROUPS, CAN BE HELPFUL FOR THE DIETARY WORKING GROUP WE ARE LOOKING AT AMOUNT OF SATURATED FAT IN OUR DIET AND HOW THAT'S RELATED TO RAREIOUS HEALTH OUTCOMES. IF WE RECOMMEND LEVELS OF SATURATED FAT AND WE CAN LOOK AT HOW MUCH OF THE SATURATED FAT COME FROM MEATS, HOW MUCH COME FROM OILS, HOW MUCH -- WHAT'S THE BEST STRATEGY AT INDIVIDUAL LEVEL AND POPULATION LEVEL, TO LIMIT THE TOTAL AMOUNT OF SATURATED FAT CON SOME SHUN, INTEGRATION OF THE WORK ACROSS DIFFERENT WORKS GROUPS, DIFFERENT SUBCOMMITTEES CAN BE EXPREMIUM TREATMENTLY HELPFUL IN MAKING MORE SPECIFIC RECOMMENDATIONS FOR THE GENERAL PUBLIC. >> ABSOLUTELY. I CONCUR COMPLETELY. THANK YOU FOR THAT. >> THIS IS WAYNE CAMPBELL. I'M CURIOUS ABOUT IF THERE'S A SOMEWHAT COMPARABLE TYPE OF A DISCUSSION WITH REGARD TO THE RECOMMENDATIONS FOR FRUITS AND VEGETABLES. THEY ARE LISTED AS AN UNDERCON SUM PSALMED HEALTHY COMPONENT OF A DIET. I'M WONDERING IF THERE'S MORE SPECIFICITY ABOUT WHETHER OR NOT STARCHY VEGETABLES VERSUS DARKER COLORED VEGETABLES, THE -- VERSUS SOLID FORMS OF VEGETABLES, WHOLE FOODS VERSUS BEVERAGES, I THINK -- I'M CURIOUS HOW IF AND HOW THE DELIBERATIONS HAVE BEEN HANDLED WITH REGARD TO VEGETABLES AND FRUITS. SO ONCE AGAIN, WAYNE, THOSE ARE ALL INTERESTING AND GOOD POINTS TO RAISE. THE FRUITS AND VEGETABLES ARE VERY SIMILAR AS WELL AS WHOLE GRAINS, AND ALL OF THESE FOOD GROUPS FOR WHAT YOU JUST HEARD FRANK AND MARIAN PRESENT IS THAT THE FACT THAT THE DEPENDING ON HOW MUCH EACH OF THE STUDIES DESCRIBED WHAT IS INCLUDED AS VEGETABLE OR FRUIT AND SOME STUDIES EITHER INCLUDED 100% FRUIT JUICE IN THOSE ITEMS, OR FOR THE MOST PART THEY DID. NOT AWARE OF ONE THAT DO NOT INCLUDE 100% FRUIT JUICE OR VEGETABLE JUICE IN THOSE PARTICULAR ITEMS. AS OPPOSED TO FRUIT DRINKS. SAME THING ABOUT ANY ONE OF THESE FOOD COMPONENTS EXACTLY WHAT ARE THEY. SO THE DIETARY PATTERNS WERE PICKED UP WHAT THE SIMILARITIES WERE AND ALL OF THESE STUDIES WITH A DIFFERENT TYPE OF INSTRUMENTS THAT WERE USED AND SOME OF THE STUDIES MIND YOU WERE RANDOMIZED CONTROL TRIALS. THOSE WERE STUDIES WERE FOODS WERE GIVEN TO THE INDIVIDUALS AND WHILE WE MIGHT BE ABLE TO FIND SOME SUBSEQUENT PAPERS THAT WENT IN DEPTH WHAT FOODS WERE GIVEN, WHAT THE COMPONENTS OF THE FOODS WERE, I THINK IT'S REALLY THE COMBINATION OF SUBCOMMITTEE 1 AND SUBCOMMITTEE 2'S WORK THAT WILL HELP COME UP WITH OVERALL GUIDANCE TO THE AMERICAN PUBLIC AS TO THE DEFINITIONS OF THESE DIFFERENT PARTICULAR FOODS. >> ANNA MARIA, COULD YOU EXPAND ON THAT? DID YOU LOOK AT ANYTHING SPECIFICALLY REGARDING POTATOES? SINCE THAT HAS BEEN CONTROVERSIAL LATELY? >> I'M SORRY, IN REGARD TO POTATOES? YOU KNOW, MARY, THAT REALLY DRIVES DOWN TO THE INDIVIDUAL STUDIES NOW. I'M GOING TO NEED HELP FROM CHERYL AND FRANK BECAUSE YOU'RE TALKING ABOUT A FEW HUNDRED STUDIES HERE. THAT WE EVALUATED ACROSS ALL THE DIFFERENT HEALTH OUTCOMES. SOME OF THESE COMPONENTS DON'T INCLUDE FRIED POTATOES AND SOME OF THEM DO. SO IT COULD BE A LITTLE BIT OF A MIX BUT CHERYL DID YOU SEE THAT WHEN YOU WERE LOOKING AT YOUR TABLE PREPARING THE AMOUNTS OF VEGETABLES ACROSS THE DIFFERENT STUDIES AS TO WHETHER OR NOT THERE IS VERY MUCH A DIFFERENCE IN THE POTATOES BEING INCLUDED? >> THAT IS A REALLY INTERESTING QUESTION. I AM LOOKING AT ONE OF THE TABLES RIGHT NOW, WE DON'T HAVE -- I DON'T HAVE IT RIGHT AT HAND. THE SCOPE OF WHERE WE CAN FIND THAT SPECIFIC LEVEL OF BREAK DOWN. SO IT DOES VARY, IT VARIES ACROSS THE HUNDRED OR SO THAT ARE OUT THERE IN THE LITERATURE. WE HAVE TO GO BACK AND CAREFULLY LOOK AT THAT, MARY, IF WE WANTED TO COMMENT. >> I THINK THIS MIGHT BE WORTH -- >> I JUST THINK IT MIGHT BE WORTH IT BECAUSE THERE'S BEEN SO MUCH ATTENTION LATELY ABOUT THE ROLE OF POTATOES IN THE AMERICAN DIET. >> THIS IS FRANK, I AGREE WITH ANNA MARIA, IT'S AGAIN, THIS IS A LEVEL TYPE OF QUESTION, IT'S NOT DIETARY PATTERN QUESTION. BUT AS FAR AS I KNOW, MOST COHORT STUDIES IN THE U.S. DID NOT INCLUDE POTATOES AN FRENCH FRIES IN THE DEFINITION OF VEGETABLES, SOME OF THE COHORTS I'M FAMILIAR WITH HAVE EXCLUDED POTATOES AND FRENCH FRIES IN THE TOTAL VEGETABLE GROUP. SOME EUROPEAN STUDIES, MIGHT HAVE INCLUDED POTATOES IN THE VEGETABLE GROUP DEFINITION BUT I'M NOT ENTIRELY SURE. THE U.S. STUDIES TEND TO EXCLUDE POTATOES FROM VEGETABLE GROUP DEFINITION AND THERE ARE INDIVIDUAL STUDIES LOOKING AT POTATOES AND WEIGHT GAIN POTATOES AN TYPE 2 DIABETES, BUT THAT LEVEL OF EVIDENCE HAS NOT BEEN INCORPORATED IN TO OUR REVIEW OF THE DIETARY PATTERN STUDIES. >> LET ME JUMP IN HERE AND SHOUT OUT TO OUR STAFF WHO ACTUALLY MADE A LITTLE NOTE HERE ON THE VARIOUS STUDIES THAT INCLUDE OR EXCLUDE POTATOES IN THE CHARACTERIZATION OF VEGETABLES AND BY -- I CAN SEE FOR ONLY WOMEN'S HEALTH INITIATIVE IT APPEARS IN A 2014 PUBLICATION HAS POTATOES INCLUDED IN THE VEGETABLE QUANTIFICATION. >> THIS IS TRISH WITH FCA. I THINK WE NEED TO GO BACK AND RELOOK AT THOSE, BECAUSE IN A LOT OF CASES WHAT WE HAD WAS SILENT ON THE MANNER SO WE STILL ARE UNCERTAIN ON IT, AND WE DIG FURTHER INTO THEY WERE INCLUDED OR EXCLUDED. >> AGREE. >> THANKS. >> ALSO REGARDING WAYNE'S QUESTION ABOUT HOW MUCH FRUITS AND VEGETABLES WE SHOULD RECOMMEND AND WHAT TYPE OF FRUITS AND VEGETABLES WE RECOMMEND, THE DIETARY PATTERN ANALYSIS IS SPECIFICALLY -- NOT SPECIFIC ENOUGH FOR US TO ADDRESS THOSE QUESTIONS. WE MAY -- I THINK WE PERHAPS SHOULD LOOK AT THE 2010 EVIDENCE SUMMARY FOR FRUITS AND VEGETABLES TO SEE WHETHER THERE IS -- THERE WAS SEPARATE ANALYSIS OF FRUITS AND VEGETABLES VERSUS TOTAL AMOUNT OF FRUITS AND VEGETABLES IN RELATION TO CARDIOVASCULAR OUTCOMES AND OTHER OUTCOMES. >> I THINK THIS IS BARBARA AGAIN, IT ALSO I THINK WILL BE IMPORTANT FOR US TO CLARIFY IN THE DEFINITION OF THE HEALTHY DIETARY PATTERNS AS WE HAVE EXAMINED THEM AND IN THE 25th ROUND, A 2015 ROUND TO REALLY EXPLAIN IN MUCH GREATER DETAIL WHAT WE MEAN BY THE NUTRIENT DENSE FOODS THAT WERE INCORPORATED IN THE DIFFERENT CATEGORIES FRUITS AND VEGETABLE VEGETABLES, AND PROTEIN FOODS AND SO FORTH FOR THE BENEFIT OF THE FOLKS WHO WERE GOING TO BE TRANSLATING THIS INTO PUBLIC POLICY. >> BARBARA, THIS IS ANNA MARIA, I THINK WE'RE ABLE TO DO THAT MORE WITH THE FOOD MODELING THAT WE'RE DOING IN SUBCOMMITTEE 1'S WORK BECAUSE ONCE AGAIN SOME OF THE INFORMATION ON THE STUDIES ON FOOD FREQUENCY QUESTIONNAIRES AND THEY BROADLY GROUP PEOPLE AND ONCE AGAIN THE COMMENTS MADE MOST INDIVIDUALS DONE REALLY UNDERSTAND EXACTLY WHAT IT IS THAT THEY'RE CONSUMING SOMETIMES. WE JUST HAVE TO BE CAREFUL WITH THE AMOUNT OF SPECIFICITY BEING ASKED HERE. >> THAT'S EXACTLY WHAT I WAS REFERRING TO, THAT WE KNOW THAT ALTHOUGH THERE ARE LIMITATIONS, THAT EVERYONE HAS BEEN DISCUSSING WITH THE DIETARY ASSESSMENT METHODOLOGY AND THE WORK ON DIETARY PATTERNS NONETHELESS WE HAVE A MODERATE TO STRONG BODY OF EVIDENCE ON DIETARY PATTERN AND HEALTH OUTCOME RELATIONSHIPS. THAT'S THE BOTTOM LINE, THAT'S IMPORTANT FOR EVERYONE LISTENING TO UNDERSTAND AND WHAT IT HAS ENABLED IS THE MODELING WORK THAT MARIAN AND CHERYL HAVE PRESENTED AND WHAT I WAS REFERRING TO IS THAT WE REALLY SHOULD TAKE IT UPON OURSELVES TO BE VERY CLEAR IN DEFINING THE FOODS THAT WERE INCORPORATED INTO THE MODELING ANALYSES AN INTO THOSE HEALTHY DIETARY PATTERNS AS WE'RE PRESENTING THEM SO THAT THAT CLARITY AND SPECIFITY CAN BE BROUGHT FORWARD AS THE POLICY DELIBERATIONS TAKE PLACE. SO YOU'RE ABSOLUTELY RIGHT. WE DON'T GET AT THAT SPECIFICITY FROM THE DIETARY PATTERN LITERATURE PER SE BUT IT INFORMS OUR MODELING AND WE GET GREATER SPECIFICITY THERE. >> I THINK THE WORK CHERYL PRESENTED SHOWED CLEARLY THAT THE AMERICAN DIET IS SUBOPTIMAL COMPARED TO THE HEALTHY DIETARY PATTERNS IDENTIFIED BY SC 2 IN TERMS OF HEALTHY MEDITERRANEAN DIET PATTERN, DASH OR OMNI PATTERN, AND HAI PATTERN. IN THE FIGURES YOU CAN SEE THERE IS BIG GAP BETWEEN THE CURRENT AMERICAN DIET AND MORE HEALTHY DIETARY PATTERNS WITH FRUITS VEGETABLES, RED MEAT, PROCESSED MEAT INTAKE AND SOME OTHER FOOD GROUPS. SO THAT GAP IS VERY IMPORTANT FOR US TO LOOK AT IN TERMS OF WHAT CAN WE DO TO FILL THE GAP, WHAT KIND OF FRUITS AND VEGETABLES, HOW MUCH FRUITS AND VEGETABLES WE CAN CONSUME AND HOW MUCH OF THE CURRENT CONSUMPTION OF RED MEAT, PROCESSED MEAT SHOULD BE REDUCED. WE MEET THE 2010 DIETARY GUIDELINES OR TO MEET THE HEALTHY DIETARY PATTERNS DEFINED NUTRIENT AND FOOD PROFILES. >> THIS IS MARIAN. I WOULD LIKE TO ALSO MAKE A CLARIFICATION FOR THE COMMITTEE AS WELL AS PUBLIC WHO MAYBE WATCHING THE WEBCAST. WE HAVE BEEN TALKING IN THIS DISCUSSION ABOUT SOME OF THE CHALLENGES IN GETTING SPECIFICITY ON THE LEANNESS OF MEATS THAT ARE CONSUMED, VARIATION IN TYPES OF FOODS THAT ARE CONSUMED AND WHERE NUTRIENT CONTENT MAY DIFFER WHAT WE'RE REFERRING TO MOSTLY IS STUDIES THAT USE THE FSQS TO CONDUCT DIETARY ASSESSMENT. I WANT TO MAKE A VERY CLEAR POINT THAT THE DATA PRESENTED IN SUBCOMMITTEE 1 THAT IDENTIFIES THE CURRENT PATTERNS AND TRENDS, IN FOOD INTAKE, USES OUR NATIONAL MUTATION MONITORING SYSTEM WHICH IS CALLED WHAT WE EAT IN AMERICA WHICH IS PART OF THE NHANES SURVEY. WHAT WE EAT IN AMERICA SURVEY THE 24 HOUR RECALL METHOD WHICH IS A DETAILED INTERVIEW FOR THAT LEVEL OF SPECIFICITY IS ABLE TO BE OBTAINED. IF SOMEONE REPORTS THEY HAD SAY A ROAST BEEF DINNER, THEN TREMENDOUS DETAIL IS ASKED ABOUT WHAT WAS THE TYPE OF CUT, WAS THE FAT ON, WAS THERE FAT ADDED IN COOKING, WAS THERE SALT ADDED. SO WE CAN GET THAT TYPE OF GRANULAR DETAIL THAT WAYNE WAS ASKING ABOUT THAT STIMULATED THIS CONVERSATION. FOR OUR NATIONAL NUTRITION MONITORING SYSTEM. I WANT TO MAKE THAT CLEAR DIFFERENTIATION THAT WHAT WE PRESENTED IN SUBCOMMITTEE 1 ABOUT WHAT AMERICANS ARE EATING IN TERMS OF THESE FOOD GROUPS COMES FROM A MUCH MORE DETAILED ASSESSMENT THAN THE CHALLENGES THAT WE HAVE BEEN TALKING ABOUT THE LAST SEVERAL MINUTES. >> THANK YOU, MARIAN. >> ARE THERE ANY OTHER QUESTIONS OR COMMENTS FOR SC 2? >> YES, THIS IS WAYNE. I'M CURIOUS ABOUT, REFRESH MY MEMORY PLEASE ON MAYBE FROM SC 2 OR 1, WHEN PEOPLE ARE CONSUMING, PEOPLE THAT WOULD CONSUME HEALTHY DIETS ARE THERE ANY SHORT FALL NUTRIENTS THAT STILL EXIST? >> THIS IS MARIAN, I CAN ANSWER THAT QUESTION, YOU MAY REMEMBER THE SLIDE THAT WE PRESENTED. COMPARING THE FOOD PATTERN MODELING AND ARE A COUPLE OF NUTRIENTS THAT FALL SHORT, ONE OF WHICH IS VITAMIN D ACROSS THE TYPES OF PATTERNS AND FOR THE MEDITERRANEAN STYLE PATTERN CALCIUM FALLS SHORT. >> SO WITH THAT -- THOSE POSSIBILITIES EXISTING, IS THERE -- CAN THEY BE REASONABLY OVERCOME FROM A DIETARY APPROACH? OR CONSUMING HEALTHY PATTERNS NECESSITATE SUPPLEMENTATION? >> WE DO HAVE SOME COMMENTS ON THAT IN OUR REPORT. STEVE ABRAMS, WOULD YOU WANT TO ADD TO THAT A LITTLE BIT THIS CONVERSATION? >> CAN YOU BE SPECIFIC? >> IF THE SHORT FALL NUTRIENTS WE MENTION, THE CALCIUM AND VITAMIN D WHICH THERE MAYBE FROM FOOD PATTERN MODELING SUGGESTED THAT IT'S VERY DIFFICULT TO GET THOSE FROM THE DIET AS -- REACH THE RDA AS MODELED. >> THAT'S PARTICULARLY TRUE OF VITAMIN D WE GET RDA 600 UNITS PER DAY MODELING PATTERN. IS EXTREMELY DIFFICULT. CALCIUM DEPENDS UPON THE AGE GROUP TO SOME DEGREE WHERE AS THE INTAKE RECOMMENDATION REMARKSDA GETS HIGH AD LESS ISN'TS IT BECOMES A LITTLE MORE DIFFICULT. >> SO THE QUESTION IS WHETHER OR NOT THOSE SHORT FALL NUTRIENTS CAN BE OVERCOME BY MODIFICATIONS OR ENCOURAGEMENTS TO CONSUME CERTAIN FOODS, VERSUS WHETHER OR NOT SUPPLEMENTATION IS INCORPORATED INTO A RECOMMENDATION FOR SUPPLEMENTATION NEED TO BE INCORPORATED INTO THE PATTERNING RECOMMENDATION. >> THIS IS ANNA MARIA. I THINK WHAT YOU HAVE TO KEEP IN MIND IS THESE DIETARY PATTERNS HAVE BEEN ASSOCIATED WITH POSITIVE HEALTH OUTCOMES. >> I UNDERSTAND THAT COMPLETELY. BUT THERE'S ALSO SOME -- THERE'S ALSO RECOMMENDATIONS FOR CONTINUED CONCERN REGARDING BONE. THAT TIES IN WITH THE CALCIUM AND VITAMIN D SO I'M ASKING A QUESTION ABOUT IF WE'RE TRYING TO ENSURE WITH HEALTHY PATTERNS -- HEALTHY DIET PATTERNING ENSURE NUTRIENT ADEQUACY, WHETHER OR NOT TO SUPPLEMENT IN ORDER TO FULLY GAIN THAT IN A POPULATION. >> ? SUBCOMMITTEE 1 WORKING ON WORDING RELATED SPECIFICALLY TO VITAMIN D BECAUSE THE INDIVIDUAL -- THE IDEA REPRESENTS NEEDS 97% IS NOT THE AVERAGE REQUIREMENT SO INDIVIDUALS HAVE TO BE DECIDE BASED ON AN OVERALL HEALTH PICTURE WHETHER OR NOT SUPPLEMENT PATIENT IS APPROACH THEY WOULD LIKE THE TAKE. HOWEVER, THIS IS CERTAINLY TRUE THE REACH 600 UNITS PER DAY OF VITAMIN B INTAKE IS EXTREMELY DIFFICULT TO DO, THEREFORE PEOPLE MIGHT CHOOSE SUPPLEMENTATION AS AN APPROACH TO DOING THAT. >> OTHER COMMENTS OR QUESTIONS? OKAY. WELL, THANK YOU, EVERYONE. ALSO FOR THE REALLY WONDERFUL TUNE MIC BETWEEN SC--- DYNAMIC BETWEEN SC 1 AND 2, DEMONSTRATING HOW COMPLIMENTARY THE WORK IS AND ALSO IN RESPONDING TO THESE GREAT QUESTIONS. I'M GOING TO TURN IT BACK TO RICK. >> OKAY. WE'RE A FEW MINUTES AHEAD OF SCHEDULE SO I THINK WHAT WE WANT TO DO, IT'S EAST COAST TIME IT'S 12:50 ALMOST. WE CAN COME BACK AT 1:40 SO WE'LL START AGAIN BACK AT 1:40. IF THE COMMITTEE MEMBERS CAN GET BACK ON THE PHONE AT 1:35, JUST SO WE CAN TOUCH BASE AND CHECK IN. SO WE'LL START BECOME AT 1:40 EASTERN TIME. THANKS. >> THANK YOU. >> WELCOME BACK FROM LUNCH, WE'LL RESUME OUR DIETARY GUIDELINES COMMITTEE MEETING. ALL THE DGAC MEMBERS HAVE RETURNED FROM THEIR LUNCH BREAK AND ARE OPT LINE SO I'LL TURN THE FLOOR OVER TO RAFAEL PEREZ-ESCAMILLA FOR THE SUBCOMMITTEE 3 PRESENTATION. >> THANK YOU VERY MUCH. I WANT TO WELCOME EVERYONE WHO IS LISTENING IN TO THIS COMMITTEE MEETING. IT IS MY GREAT PLEASURE TO ACKNOWLEDGE THE GREAT WORK FROM MY SUBCOMMITTEE MEMBERS, THAT INCLUDE WAYNE CAMPBELL, (INDISCERNIBLE) ANNA MARIA SIEGA-RIZ AND I WANT TO ACKNOWLEDGE THE GREAT CONTRIBUTIONS FROM MICHAEL PERRI WHO HAS BEEN ACTING AS A CONSULTANT TO OUR SUBCOMMITTEE. THE WORK OF OUR SUBCOMMITTEE WHICH FOCUSES ON THE INDIVIDUAL'S BEHAVIOR CHANGE LIES RIGHT AT THE INNER CORE OF THE SOCIAL ECOLOGICAL MODEL SPECIFICALLY THE SCOPE OF OUR SUBCOMMITTEE WORK FOCUSES ON IDENTIFYING MOTIVATORS FACILITATORS OR BARRIERS FOR INDIVIDUALS LIVING IN THE U.S. TO BE ABLE TO IMPLEMENT RECOMMENDED DIETARY AND PHYSICAL ACTIVITY BEHAVIORS. ALSO OUR SUBCOMMITTEE IS WORKING ON IDENTIFYING INTERVENTIONS THAT ARE LIKELY TO WORK TO HELP PEOPLE WITH DIETARY AND PHYSICAL ACTIVITY RECOMMENDATIONS. OUR SUBCOMMITTEE HAS BEEN FOCUSING ON SPECIFIC BEHAVIORS THAT YOU CAN NOW SEE ON YOUR SCREEN. FAMILY SHARED MEALS, EATING OUT, FOOD AND MINUTIA MANTORRING, SLEEP BEHAVIOR AND SLEEP PATTERNS AND TAKE INTO ACCOUNT TWO CONTEXTUAL FACTORS THAT GREATLY AFFECT THE ABILITY OF VULNERABLE POPULATIONS IN OUR COUNTRY TO BE ABLE TO ENACT THESE BEHAVIORS, THOSE ARE (INAUDIBLE) INSECURITY AND ACCULTURATION. BOTH CONTEXTUAL FACTORS AND BEHAVIORS OF INTEREST HAVE BEEN EXAMINED IN RELATIONSHIP TO THEIR IMPACT ON DIET PHYSICAL ACTIVITY WEIGHT AND YEAR OUTCOMES AS WELL AS CHRONIC DISEASE RISK FACTORS, BIOMARKERS AND END POINTS. IT HAS BEEN SHOWN BEFORE WE HAVE PRETTY MUCH COMPLETED ALL THE WORK THAT OUR SUBCOMMITTEE DECIDED TO UNDERTAKE AT THE BEGINNING OF THE DIETARY GUIDELINES ADVISORY COMMITTEE WAS CONVENED. IF SO, IN JULY WE PRESENTED THE FINDINGS WITH RELATIONSHIP TO ACCULTURATION AND MOBILE HEALTH WHICH LATER WAS MERGED TOGETHER, WITH SELF-MONITORING. IN SEPTEMBER WE CALLED IT THE TOPICS OF HOUSEHOLD INSECURITY, FAMILY SHARED MEALS, EATING OUT, SEDENTARY BEHAVIOR, SELF-MONITORING AND SLEEP PAPA ATTORNEYS SO THE FOCUS OF -- PATTERNS. SO THE FOCUS OF THE -- WILL BE ON THE REMAINING QUESTION RELATED TO FOOD AND MENU LABELING. AS IT HAS BEEN SHARED BEFORE BY OTHER SUBCOMMITTEES WE WERE GIVEN THE OPTION TO BE ABLE TO INVITE EXPERTS AND/OR CONSULTANTS TO HELP US WITH THE WORK ON OUR SUBCOMMITTEE. WE HAVE BENEFITED IN BOTH INSTANCES FROM THESE OPPORTUNITIES. SPECIFICALLY SINCE THE LAST DIETARY GUIDELINES ADVISORY COMMITTEE MEETING THAT TOOK PLACE IN SEPTEMBER, WE INVITED PROFESSOR -- ASSISTANT PROFESSOR MARY PIERCE FROM NEW YORK OBESITY RESEARCH CENTER AT COLUMBIA UNIVERSITY TO ELIMINATE US ON THE -- ILLUMINATE ON SLEEP PATTERNS DIETARY OUTCOMES AN RISK. SHE DID A VERY GOOD PRESENTATION TO THE SUBCOMMITTEE FIRST HOW SLEEP PATTERNS AFFECT OBESITY RISK AND THEY WENT ON TO PRESENT US WITH EVIDENCE IN RELATIONSHIP TO SLEEP DEPRIVATION DIETARY BEHAVIOR, SLEEP DEPRIVATION AND PHYSICAL ACTIVITY BEHAVIORS AND ALSO HIGHLIGHTED THE FACT THERE'S LITTLE EVIDENCE TO UNDERSTAND THE RELATIONSHIP BETWEEN DIETARY PATTERNS AND SLEEP QUALITY. SHE'S THE INVITED EXPERT WE BENEFITTED FROM SINCE OUR LAST MEETING, AND MIKE PERRI, DEAN OF COLLEGE OF PUBLIC HEALTH PROFESSIONALS AT THAT TIME UNIVERSITY OF FLORIDA, HAS CONTINUED WITH HIS GREAT CONTRIBUTIONS ADVISING US ON THE EVIDENCE AND INTERPRETATION OF THE EVIDENCE EXAMINING ASSOCIATION BETWEEN BEHAVIORAL STRATEGIES INCLUDING SELF-MONITORING, DIETARY AND WEIGHT OUTCOMES. TODAY I'M NOW GOING TO TURN THE MIC TO MY COLLEAGUE TO TELL US ABOUT WHAT WE KNOW ABOUT THE EFFECT OF USE OF FOOD AND MENU LABELS ON FOOD SELECTION AND DIETARY INTAKE IN THE U.S. POPULATION. >> ALL RIGHT. THANK YOU. WHY DON'T WE MOVE FORWARD WITH THESE TWO QUESTIONS THAT YOU CAN SEE ON THIS SLIDE THE FIRST QUESTION FOCUS ON BODY WEIGHT OUTCOMES. FOOD AND MENU LABELS PROVIDE INFORMATION THAT IMPROVES AN INDIVIDUAL'S FOOD SELECTION POTENTIALLY IMPROVE BODY WEIGHT OUTCOMES. SECOND FOCUS ON FOOD SELECTION AND INTAKEOUT OUTCOMES. STATED AS FOLLOWS. PROVIDING FEUD NUTRITION INFORMATION MAY IMPACT FOOD SELECTION AND DIETARY INTAKE. CONSISTENT WITH MUCH OF THE WORK OUR COMMITTEE HAS BEEN DOING TODAY WE FOCUS ON ENERGY INTAKE. CAN WE NOVEMBER SLIDES PLEASE. HERE IS THE ANALYTICAL FRAMEWORK. FOR FOOD LABELING. THERE'S A POPULATION I HAVE ADULTS AT RISK FOR DISEASE. EXPOSURE OF INTEREST MENU AND FOOD PACKAGE BACK PANEL LABEL, THE COMPARATOR IS DIFFERENT OF DIFFERENT TYPES OF LABELS OR ABSENCE OF LABELS. AND RAREIOUS INTERMEDIATE OUTCOMES WERE OF INTEREST, CONSUMER BEHAVIOR, DIETARY INTAKE, DIET QUALITY INDICES, FOODS, FOOD GROUPS MACRO NUTRIENT INTAKE, AND PROPORTION, SODIUM INTAKE, BMI WEIGHT CHANGE, CHILD GROWTH INDICES, ALL POTENTIALLY OF INTEREST. KEY CONFOUNDERS INCLUDE DEMOGRAPHIC SOCIAL ECONOMIC STATUS, CULTURE ETHNICITY, FOOD AVAILABILITY. NEXT SLIDE. THE FOOD MENU LABELING LITERATURE RESEARCH, INCLUSION AND EXCLUSION CRITERIA ARE SHOWN HERE. PEER REVIEWED ARTICLES PUBLISHED IN ENGLISH BETWEEN JANUARY 2004 AND SEPTEMBER 2014. THE FOCUS HUMANS ADOLESCENTS AND ADULTS. HEALTHY OR THOSE WITH CHRONIC DISEASE RISK FACTORS BUT THOSE NOT IN DISEASE GROUPS WERE THE TARGET. STUDIES CONDUCTED IN THE UNITED STATES PARTICULARLY FOCUSING OR LIMITED TO RANDOMIZED CONTROL TRIALS OF SUFFICIENT POWER, GREAT THAN 30 SUBJECTS PER ARM, WHERE WITH A LOW DROP OUT RATE LESS THAN 20%. THE INTERVENTION WOULD BE SOME TYPE OF MENU OR NUTRITION FACT PANEL LABEL. AND OUTCOMES AS I STATED FOCUS PRIMARILY CALORIC INTAKE AND BODY WEIGHT. THIS SLIDE SHOWS THE LITERATURE RESEARCH RESULTS WITH 1,274 POTENTIAL ARTICLES INITIALLY SCREENED, ULTIMATELY WITH ABSTRACTS BEING REVIEWED WE HAVE 207 FULL TEXT ARTICLES REVIEWED IN DETAIL TO MEET ELIGIBILITY CRITERIA. 25 ULTIMATELY WE FOUND THAT ONLY 7 STUDIES ARE INCLUDED IN OUR SYSTEMATIC REVIEW AT THIS TIME. THE DESCRIPTION OF THE EVIDENCE IS SHOWN HERE, THERE ARE SEVEN RANDOMIZED CONTROL TRIALS, THAT ASSESSED THE EFFECT OF A RESTAURANT MENU CALORIE LABELING ON FOOD SELECTION THESE WERE TYPICALLY CONDUCTED IN ONE TEST SESSION FOUR WHICH MEASURED MENU SELECTION THAT DID NOT PROVIDE FOOD, THREE ASSESS MENU ORDER CALORIC CONSUMPTION, TWO MEASURED CALORIC INTAKE FOR THE REMINDER OF THE DAY THE NUMBER OF PARTICIPANTS RANGE FROM 99 TO 802 SUBJECTS, THESE ARE PREDOMINANTLY CAUCASIAN. ATENDENCY FOR STUDIES THAT ARE WEIGHTED TOWARDS FEMALES. AND COLLEGE EDUCATED. KEY FINDINGS BEGIN ON THE NEXT SLIDE. SEVEN WERE INCLUDED IN THIS BODY OF EVIDENCE THAT COMPARED MENU CALORIE LABELING ON FOOD SELECTION. THREE OF THE SEVEN DID MEASURE CALORIC CONSUMPTION. ONE STUDY FOUND CALORIE LABEL RECOMMENDED WITH CALORIC INTAKE WITH SELECTION AND CONSUMPTION OF VIEWER CALORIES AT A TEST MEAL. TWO, STUDIES EXAMINED PHYSICAL ACTIVITY EQUIVALENT AND I THINK THIS IS AN IMPORTANT POINT AS A COMPONENT OF CALORICALLY LABELING AND FOUND DECREASE IN CALORIC CONTENT OF SELECTED FOOD ITEMS. I WANT TO HIGHLIGHT MY READING OF THE BULK OF THE LITERATURE DOES SUGGEST PHYSICAL ACTIVITY EQUIVALENT IS THE VALUABLE APPROACH FOR THESE TYPES OF STUDIES. ON THE NEXT SLIDE, TWO STUDIES REPORTED NO ASSOCIATION WITH CALORIC INFORMATION AS FOOD SELECTION, ONE THAT EXAMINED THE EFFECT OF CALORIE LABELING AND PRICING WHICH IS DEFINED AS STRUCTURED PRODUCT, PRICE, SUCH THAT THE PER UNIT COST DECREASES AS THE PORTION SIZE INCREASES. SHOWED NO ASSOCIATION BETWEEN CALORIE LABELING AND FOOD SELECTION OR CONSUMPTION. VERY CRITICALLY METHOD LOGIC COMPLEXITIES LABORATORY STUDIES LIMIT GENERALIZABILITY TO FREE LIVING POPULATIONS. ON THE NEXT SLIDE WE TALK ABOUT SOME OF THE LIMITATIONS. NO STUDIES WERE CONDUCTED IN ACTUAL RESTAURANT SETTINGS. WHICH LIMITS THE EXTERNAL VALIDITY OF THE FINDINGS. ONLY THREE STUDIES MEASURED ACTUAL FOOD INTAKE AS OPPOSED TO MERELY RESPONDING TO QUESTIONNAIRES. SOME STUDIES INCLUDED PRICING BUT THE MAJORITY DO NOT. THE SHORT STUDY DURATION OFTEN ONE TEST SETTING REALLY LIMIT OUR ABILITY TO INTERPRET THIS DATA. NO STUDIES ADEQUATELY ADDRESSED WEIGHT PUBLICATION OR OUTCOMES. OUR CONCLUDING STATEMENT FROM THIS VERY LIMITED -- I THINK THE WAY I LOOK AT IT IS A RATHER IMMATURE LITERATURE, CONCLUSION IS THAT LIMITED AND INCONSISTENT EVIDENCE DOES NOT SUPPORT ASSOCIATION BETWEEN MENU CALORIE LABEL AND FOOD SELECTION OR CONSUMPTION, UNDER LABORATORY TESTING CIRCUMSTANCES. SO OUR GRADE AT THIS POINT WILL BE LIMITED. ON THE NEXT SLIDE WE TALK ABOUT RESEARCH RECOMMENDATIONS WHICH ARE OBVIOUSLY IN GREAT NEED. CRITICALLY WE WANT TO SUGGEST CONDUCTING RANDOMIZED CLINICAL TRIALS IN FREE LIVING POPULATIONS ON TYPES OF MENU LABELING SPECIFIC TO VARIOUS FOOD OUTLETS. WE SUGGEST TESTING THE EFFECTS OF DIFFERENT COMBINATIONS OF INFORMATION ON MENU LABELS, ON DIET AND WEIGHT RELATED OUTCOMES. DESIGN STUDIES TO CONTROL FOR CRITICAL CONFOUNDERS SUCH AS THE PRICE OF LABELED MEALS AND STUDY PARTICIPANTS CHARACTERISTICS WHEN TESTING THE EFFECTIVENESS OF FOOD AND MENU LABELS. TO CONDUCT STUDIES WITH LONGITUDINAL FOLLOW-UP TO ASSESS IMPACT OF LABELING ON CALORIC INTAKE AND ENERGY EXPENDITURE DIET QUALITY AND WEIGHT RELATED OUTCOMES. TO DETERMINE HOW CURRENT FOOD LABELING STRATEGIES USED IN FREE LIVING POPULATIONS CAN BE TESTED AND VALIDATED IN LABORATORY SETTINGS. FINALLY WHAT IS THE EFFECT OF USE OF FOOD AND MENU LABELS ON MEASURES OF FOOD SELECTION AND DIETARY INTAKE IN U.S. POPULATIONS GROUPS. AND WHAT THE EFFECT OF USE OF FOOD AND MENU LABELS ON BODY WEIGHT ACROSS POPULATIONS GROUPS. THESE QUESTIONS ARE NOW OPEN FOR DISCUSSION >> SO I WOULD LIKE TO FIRST ASK OTHER MEMBERS OF SUBCOMMITTEE 3 IF THEY HAVE ANYTHING TO ADD. IF NOT, THE FLOOR IS OPEN FOR ANY MEMBERS OF THE DIETARY GUIDELINES ADVISORY COMMITTEE FOR QUESTIONS. >> THIS IS MARY STORY. I WAS WONDERING WHY IN THIS QUESTION THERE WERE ONLY SEVEN STUDIES ALL OF THEM WERE LABORATORIES THAT STUDIES THERE WERE SEVERAL LIMITATIONS WHY YOU DIDN'T JUST GIVE THIS AN INSUFFICIENT EVIDENCE INSTEAD OF LIMITED BECAUSE IT SEEMS TO ME THAT LOOKING AT THISH -- WHAT YOU'RE LOOKING AT UNDER LAB TORE CONDITIONS WHERE PEOPLE MIGHT HAVE JUST GONE TO THE LABORATORY ONE POINT IN TIME THAT THESE LABORATORY STUDIES WERE REALLY FLAT SO I'M SURPRISED THAT YOU REACHED YOU GRADED THIS LIMITED INSTEAD OF INSUFFICIENT EVIDENCE TO EVEN GRADE IT. >> I THINK THAT POINT IS WELL TAKEN AND AT THIS POINT IN OUR DRAFT CON COLLUSION, WE KIND OF LEANED IN THIS DIRECTION BUT THAT'S OPEN FOR DISCUSSION. LET ME TAKE THE OPPORTUNITY TO HIGHLIGHT ONE OTHER PAPER THAT CAME OUT THIS WEEK HOWEVER. I WANT TO POINT OUT THIS ONE BY NIKOLAOU IN OBESITY, NOVEMBER 5TH. THIS STUDY ACTUALLY MET SOME OF THE RECOMMENDATIONS THAT WE ACTUALLY WERE SUGGESTING, IT COMPARED A GROUP OF STUDENTS IN COLLEGE IN AN AREA IS TO GET FOOD FROM DIFFERENT RESOURCES. IN ONE YEAR THERE WERE NO FOOD LABELS THE NEXT YEAR THEY USED THE FOOD LABELS. INDEED THERE WAS AN AVERAGE 3.5 PLUS KILO GRAM GAIN IN THE YEAR WITH NO FOOD LABELS AND ACTUALLY A MINOR LOSS IN THE YEARS WITH THE CALORIE LABEL SO THESE WERE MEETING MANY OF THE CRITERIA, THIS STUDY WILL SERVE A MODEL FOR FUTURE RECOMMENDATIONS. >> IT WOULD BE POSSIBLE FOR YOU GROUP TO GO BACK, YOUR SUBCOMMITTEE AND RECONSIDER AND DISCUSS THE EVIDENCE, THE GRADING? OF THIS QUESTION AS MUCH >> I BELIEVE SO. I REMEMBER THE NEW YORK DEPARTMENT OF PUBLIC HEALTH HAD PUBLISHED A COUPLE OF PAPERS OF THE MENU LABELING FOOD PURCHASE IN FAST FOOD RESTAURANTS AND OTHER SETTINGS. I REMEMBER THERE WAS A PAPER A FEW YEARS AGO THAT WAS NOT IN THE LABORATORY SETTING, (INDISCERNIBLE). >> I THINK THERE IS A LITERATURE OUT THERE OF OBSERVATIONAL DATA, THIS LITERATURE SEARCH WAS LOOKING FOR RANDOMIZED TRIALS. SO I THINK THERE IS A LARGER CONTEXT OF INFORMATION THERE BUT WE WERE TRULY LOOKING FOR THE RANDOMIZED TRIALS HERE TO GIVE US THE STRONGEST DATA IN ORDER TO MAKE RECOMMENDATIONS. >> BUT GIVEN THE MAJOR LIMITATIONS THAT YOU MENTIONED IN TERMS OF LABORATORY STUDIES, I THINK THIS TYPE -- NOT PURE -- QUASI EXPERIMENTAL STUDY MAYBE MORE RELEVANT IN TERMS OF THE IMPACT OF FOOD LABELING OR MENU LABELING, BEHAVIOR IN THE FAST FOOD RESTAURANT SITING (INAUDIBLE) THE STUDIES I REMEMBER LOOK AT RECEIPTS FROM THOSE RESTAURANTS BEFORE THE MANUAL LABEL -- MENU LABELING WAS IMPLEMENTED AND COMPARED THE RECEIPTS FROM THE SAME RESTAURANT AFTER IT WAS PASSED AND THE IMPLEMENTED, I THINK IT'S REALLY A USEFUL COMPARISON QUASI EXPERIMENTAL TYPE OF STUDIES. >> I DON'T DISAGREE THOSE STUDIES WERE THE IMPETUS FOR THIS PARTICULAR LITERATURE REVIEW, HOWEVER THE DEFINITION OF CRITERIA FOR THIS REVIEW WAS A RANDOMIZED CONTROL TRIAL SO I TOTALLY AGREE WITH YOU, THAT THAT TYPE OF INFORMATION NEEDS TO BE PUT IN CONTEXT WITH OUR SYSTEMATIC REVIEW. >> I THINK THIS IS BARBARA, THAT IF WE GO BACK TO THE DGAC RESPONSIBILITY IT'S TO TRY TO IDENTIFY THE BEST OF THE AVAILABLE EVIDENCE. SO THE CRITERION USED BY THE COMMITTEE ARE STRONG, UNFORTUNATELY THE RESEARCH IS LIMITED AND IS REALLY DONE IN THE ARTIFICIAL SETTING. I THINK AT LEAST AS I DESIRE THE CONVERSATION WITHIN THE SUBCOMMITTEE THE CONCLUSION WAS CRAFTED TO FOCUS ON THE LAB SETTING. AND BECAUSE THERE IS A LITERATURE, IT'S RCT IN NATURE AND WAS -- THE BASIS FOR THE CONCLUSION THEY DECIDED TO GRADE IT LIMITED IN THIS NARROW SETTING THAT WAS ALL -- THEY WERE ABLE TO EXAMINE. I THINK THE POINTS ARE WELL TAKEN BUT IN THIS SETTING AND THIS LITERATURE THE GRADE AT LEAST IN TERMS OF DISCUSSION THAT WENT ON THEMED APPROPRIATE -- SEEMED APPROPRIATE. >> FOR THIS QUESTION, I THINK -- I THINK RCT MAY NOT BE THE MOST RELEVANT MOST INFORMATIVE STUDY DESIGN especially in a laboratory setting. BECAUSE REAL LIFE DECISIONS ARE MADE VERY DIFFERENTLY FROM LABORATORY SETTING GIVEN THAT THERE IS PRETTY LARGE BODY OF LITERATURE IN LIVING POPULATIONS PRE-MENU LABELING LOWER IMPLEMENTATION, MANUAL LABELING IMPLEMENTATION, THAT LITERATURE CAN BE MORE INFORMATIVE. >> WE NEED TO KEEP IN MIND WITH LAB LITERATURE IS QUITE MIXED SO WERE WE TO ASSESS THAT LITERATURE WE HAVE TO BE A VERY CAREFUL SYSTEMATIC REVIEW OF WHAT'S AVAILABLE. >> AN ALTERNATIVE STRATEGY THAT THE COMMITTEE HAS DISCUSSED IS TO LOOK AT THE RANDOMIZED TRIAL OR MORE CAREFULLY CONTROLLED DEMONSTRATIONS FROM OTHER TYPES OF SETTINGS. LIKE WORK SITES AS AN EXAMPLE WHERE WE KNOW MENU LABELING IS USED AS PART OF A MULTI-DIMENSIONAL INTERVENTION AND TO SEE WHETHER OR NOT THE INTERVENTION IS CLEARLY DEFINED ENOUGH SO THAT ONE COULD EXTEND THE WORK ACCORDINGLY. TO OTHER KINDS OF SETTINGS THAT MAY ACTUALLY BE USING RESEARCH DESIGNS THAT ARE STRONGER. >> I THINK SO. I THINK THIS IS SUCH IMPORTANT QUESTION WHICH DOES REQUIRE ASSESSMENT OF AVAILABLE EVIDENCE WHETHER -- EXPERIMENTAL ANALYSIS WOULD PURCHASING BEHAVIORS IN CERTAIN SITINGS BEFORE AND AFTER THE MANUAL LABELING -- MENU LABELING LAW. >> THIS IS MIM. I GUESS I WOULD AGREE I THINK THAT THIS SEEMS LIKE THIS IS INTERESTING BUT IT'S QUITE NARROW AND I TOO AM NOT SURE THIS IS THE RIGHT EXACT DESIGN THAT WOULD BE STRONGEST. I WONDER TO AL LESS'S POINT, IT MIGHT TELL US EVEN THOUGH IT MAY NOT BE STRAIGHT FORWARD ANSWER BUT IT WOULD TELL A MORE COMPLETE STORY IF WE ADD IN THE PRETTY RICH EXPERIENCE OF NATURAL EXPERIMENTS AND QUASI DESIGNS, QUASI EXPERIMENTAL DESIGNS. >> THIS IS CHERYL. I WOULD ALSO LIKE THE ADD SOMETHING THAT OCCURRED TO ME WHILE THIS WAS BEING PRESENTED. SO WE HAVE BEEN TALKING ABOUT DIETARY PATTERNS AND WHAT'S EMPHASIZED AND DE-EMPHASIZED IN THOSE PAPA TERMS. WE ALSO HAVE A WORKING GROUP FOCUSEDD ON SODIUM THAT CUTS ACROSS THE VARIOUS SUBCOMMITTEES SODIUM STRIKES ME AS PARTICULARLY INTERESTING IN THIS CONTEXT BECAUSE SOME OF THE LITERATURE AROUND WHAT INFLUENCES SODIUM SELECTION IN TERMS OF PEOPLE'S BEHAVIORS AROUND FOOD THAT SELECT THAT HAVE LOWER OR HIGHER AMOUNTS OF SODIUM IN THEM ARE FLAVOR AND TASTE. WHEN LABELING IS PRESENT AROUND LOWER SODIUM PRODUCTS, THERE'S THIS EQUATION OR EQUATING OF THAT LABEL WITH THINGS THAT AREN'T GOING TO TASTE VERY GOOD. SO I WONDER IF WE MIGHT CONSIDER BACK TO MENTION IN THE RESEARCH RECOMMENDATIONS IN TERMS OF SOME OF THOSE THINGS THAT WE'RE LOOKING AT IN THE CROSS CUTTING THEMES, ARE THERE SPECIFIC ISSUES GUIDING LABELING THAT WOULD BE WORTH HIGHLIGHTING. SO HERE I WOULD SAY SOMETHING ALONG THE LINES OF THERE'S EMERGING LITERATURE AROUND REPLACING WITH SPICES AND HERBS AND HOW WE CAN COMMUNICATE BEST TO CONSUMERS THAT SENSE OF JUST BECAUSE YOU MAY SEE A LABEL THAT INDICATES PRODUCT LOWER IN SODIUM ISN'T NECESSARILY GOING TO COMPROMISE ON FLAVOR. >> THIS IS STEVE. I THINK I CAN COME UP WITH A LIST OF PROBABLY 50 QUESTIONS RELATING TO FOOD LABELING THAT I THINK ARE RELEVANT TO HELPING AMERICANS CONSUME A BETTER DIET. I THINK WHAT WE HAVE TO DO GIVEN THIS DATA WE LOOKED AT, WE JUST COMPLETED THIS LITERATURE REVIEW AND I THINK -- I FEEL MYSELF AND OTHERS B WE'RE UNDERWHELMED BY THE AMOUNT OF QUALITY STUDIES THAT WERE PICKED UP IN THIS NARROW REVIEW. AND I THINK WE ALSO RESPECT YOUR COMMENT ABOUT OTHER LABELING TOPICS AND CERTAINLY FRANK AND EVERYONE ELSE'S CONCERNS ABOUT THE LARGER BODY OF DATA THAT ARE NATURAL EXPERIMENTS. SO I THINK THIS IS WHERE WE ARE TODAY. I THINK AT OUR NEXT COMMITTEE MEETING WE WILL BRING ALL THIS UP TO SEE WHAT OPPORTUNITIES WE HAVE TO TAKE ADVANTAGE OF IN THE SHORT RUN. >> GREAT. THANK YOU. ARE THERE OTHER QUESTIONS FOR STEVE OR THE COMMITTEE? OKAY. THEN IF NOT WHAT I WOULD LIKE TO DO IS TURN THE FLOOR OVER TO MARY STORY WHO WILL BE REPORTING ON SUBCOMMITTEE 4. >> CAN YOU HEAR ME? HELLO? >> WE CAN HEAR YOU, MARY. >> I'M SORRY BEFORE I KEPT TRYING TO TALK AND I THINK I WASN'T ON MUTE SO LET ME KNOW IF ANYTHING HAPPENS IF YOU CAN'T HEAR ME. >> THIS IS SUBCOMMITTEE 4, THE FOOD AND PHYSICAL ACTIVITY ENVIRONMENT. NEXT SLIDE JUST ONE SECOND MARY, WE'RE UP LOADING THE PROGRAM. >> COULD OUR COMMITTEE >> OKAY. MARY, YOU SHOULD BE ABLE TO GO FORWARD. >> NEXT SLIDE. >> I'LL GET MY SLIDES UP HERE. OUR SUBCOMMITTEE CONSISTS OF LUCILE ADAMS-CAMPBELL, WAYNE CAMPBELL AND MIRIAM NELSON AND BARBARA MILLEN IS ALSO ON OUR CALL. OUR FOCUS ON THE ENVIRONMENT SUBCOMMITTEE HAS BEEN TO FOCUS IN ON THE PHYSICAL ENVIRONMENT AND THESE ARE THE KEY SETTINGS WHERE FOOD IS PURCHASED AND CONSUMED. SO WE'RE LOOKING AT NEIGHBORHOOD AND COMMUNITY FOOD ACCESS, EARLY CARE AND EDUCATION. EARLY CHILDHOOD SETTINGS. SCHOOLS AND WORK SITES. WE ALSO LOOKED AT -- WE'RE TRYING TO BETTER UNDERSTAND AND ASSESS THE ROLE OF THE FOOD ENVIRONMENT IN PROMOTING HEALTHY EATING IN THESE KEY SETTINGS. AND A KEY OBJECTIVE WAS TO IDENTIFY THE MOST EFFECTIVE EVIDENCE BASED DIET RELATED PROGRAMS PRACTICES AND ENVIRONMENTAL AND POLICY APPROACHES. SO WE WERE REALLY LOOKING TO SEE WHAT WORKS TO IMPROVE OVERALL HEALTH AND REDUCE DIET RELATED DISPARITIES. TODAY WE'RE GOING TO BE REPORTING ON THE CONCLUSION STATEMENTS AND FOR SCHOOLS AND ALSO THE KEY FINDINGS AND THE CONCLUSIONS AND IMPLICATIONS FOR WORK SITE PROGRAMS. SINCE THE LAST MEETING WE HAVE NOT HAD ANY INVITED EXPERTS OR CONSULTANT MEMBERS TO OUR SUBCOMMITTEE. NOW WAYNE CAMPBELL WHO IS THE LEAD FOR SCHOOLS WILL TALK ABOUT THE MAJOR -- THE SCHOOL RELATED QUESTION. >> THANK YOU, MARY. YOU WILL NOTICE THAT THERE ARE FOUR QUESTIONS WE ADDRESS ON THIS TOPIC. AND THEY HAVE EACH BEEN PRESENTED PREVIOUS DIETARY GUIDELINES COMMITTEE PUBLIC MEETING. PURPOSE OF TODAY IS TO PROVIDE ADDITIONAL FOCUS AND INFORMATION WITH REGARD TO THE SECOND QUESTION WHICH IS AS REED'S -- WHAT IS THE IMPACT OF SCHOOL BASED POLICIES ON THE DIETARY INTAKE QUALITY BEHAVIOR PREFERENCES OF SCHOOL AGE CHILDREN. YOU WILL NOTICE AT THE BOTTOM THAT WE CONDUCTED OUR EVIDENCE BASED FOR ALL THESE QUESTIONS INCLUDING THE ONE WE'RE TALKING ABOUT TODAY WERE EXISTING SYSTEMATIC REVIEWS. OUR KEY FINDINGS FOR SCHOOL BASED POLICIES AND DIETARY INTAKE ARE AS FOLLOWS. THE IMPLEMENTATION OF SCHOOL POLICY TO CHANGE COMPETITIVE FOOD AND BEVERAGE AVAILABILITY AND ACCESSIBILITY, IT IS ASSOCIATED WITH A REDUCTION IN THE AVAILABILITY ACCESSIBILITY AND CONSUMPTION OF SUGAR SWEETENED BEVERAGES CANDY, UNHEALTHY SNACKS AND DESSERT FOODS. THAT REPLACEMENT OF REGULAR SUGAR ADDED SUGAR CONTAINING SODAS WITH -- TO HEALTH OPTIONS IN VENDING MACHINES AND SNACK BARS, IS EFFECTIVE WITH APPROPRIATE PROBLEMS. SECONDLY, THERE ARE STRONG INCONSISTENT ENFORCEMENT COMPETITIVE POLICY -- COMPREHENSIVE, COMPREHENSIVE POLICIES WAS ASSOCIATED WITH GREATER CHANGES OF SCHOOL -- IN SCHOOL CONSUMPTION INTAKE AND OR PURCHASING OF HEALTHIER FOODS. AND THAT WHEN YOU LOOK AT DISTRICT OR COMBINED DISTRICT AND STATE BASED POLICIES RESTRICTING USE OF FOOD IS A REWARD FOR ACADEMIC PERFORMANCE OR AS A FUND RAZOR, THAT THIS -- FUND RAISER. THAT THIS POLICIES AGAINST THOSE -- THAT LIMITED OR PREVENTED THOSE HAPPENINGS ASSOCIATED WITH REDUCTION IN USE OF FOODS AND BEVERAGES FOR THOSE PURPOSES. THE FINAL CONCLUSION STATEMENT WE HAVE IS STRONG EVIDENCE DEMONSTRATES THAT IMPLEMENTATION OF SCHOOL POLICIES FOR NUTRITION STANDARDS CHANGE THE AVAILABILITY ACCESSIBILITY AND CONSUMPTION OF FOODS AND BEVERAGES SOLE OUTSIDE THE SCHOOL MEAL PROGRAMS AKA COMPETITIVE FOODS AND BEVERAGES ASSOCIATED WITH HIGHER QUALITY PURCHASING BEHAVIOR, AND DIETARY INTAKE AMONG THE AD -- THE CHILDREN AND ADOLESCENTS WHILE THEY'RE AT SCHOOL, OUR GRADING WAS STRONG. SO WE'LL TRANSITION NOW TO THE WORK SITE QUESTIONS LED BY LUCILE ADAMS-CAMPBELL. >> THANKS, WAYNE. TODAY I'M GOING TO FOCUS ON FOUR QUESTIONS FOR THE WORK SITE SETTING. WHAT IS THE IMPACT OF WORK SITE BASED APPROACHES ON DIETARY INTAKE AND QUALITY AND BEHAVIOR OF EMPLOYEES, WHAT IS THE IMPACT OF THE WORK SITE BASED POLICIES ON DIETARY QUALITY AND BEHAVIOR? OF EMPLOYEES, THE WORK SITE ON WEIGHT STATUS OF EMPLOYEES AND THE IMPACT OF WORK SITE POLICIES ON THE WEIGHT STATUS OF EMPLOYEES. WE TOO ARE USING EXISTING SYSTEMATIC REVIEWS TO CONDUCT THE ASSESSMENT. QUESTION ONE FOCUS ON WORK SITE BASED APPROACHES AN DIETARY INTAKES, THIS INCLUDED TWO SYSTEMATIC REVIEWS META ANALYSIS PUBLICKED IN 2013 AND 2014, TOTAL OF 35 STUDIES PUBLISHED AND AMSTAR SCORE RATING WAS HIGH, 8 OUT OF 11 OUT OF 9 OUT OF 11. THE STUDY WERE RANDOMIZED CLINICAL TRIALS, NON-RANDOMIZED CONTROL TRIALS AN PRE-AN POST STUDY, SUBJECTS WERE WORKERS, SAMPLE SIZE VARIED GREATLY AS YOU CAN SEE FROM 65 TO 4,000 -- AND THE OUTCOMES WERE PRIMARY DIETARY INTAKE AND VARIOUS HEALTH OUTCOMES. THE KEY FINDINGS FOR QUESTION ONE ON WORK SITE APPROACHES IN INTAKE, IT INCREASES FRUIT AND VEGETABLE INTAKE OF EMPLOYEES AND REPORTED ONE QUARTER TO ONE HALF SERVING PER DAY. MULTI-COMPONENT PROGRAMS TARGETING BEHAVIOR MODIFICATION FOUND TO BE MORE EFFECTIVE THAN SINGLE COMPONENT PROGRAM, EFFICIENT EDUCATION PROGRAMS IN COMBINATION WITH DIETARY MODIFICATION INTERVENTIONS SHOWN TO BE EFFECTIVE. APPEAR TO BE PROMISING METHOD TO IMPROVE DIETARY INTAKE, AND ENVIRONMENTAL MODIFICATIONS IN COMBINATION WITH PHYSICAL CONTACT, THAT IS FACE TO FACE MEETINGS, ALSO ENHANCES EFFECTIVENESS. THE DRAFT CONCLUSION STATEMENT WAS MODERATE EVIDENCE INDICATES THAT MULTI-COMPONENT WORK SITE APPROACHES CAN INCREASE FRUIT AND VEGETABLE CONSUMPTION EMPLOYEES. A GRADE OF MODERATE. QUESTION 2, THIS IS THE WORK SITE BASED POLICIES IN DIETARY INTAKE THIS INCLUDED ONE SYSTEMATIC REVIEW PUBLISHED IN 2012 AND THE AMSTAR SCORE WAS 8 OUT OF 11, THIS IS IS 27 STUDIES DESIGN RANDOMIZED CLINICAL TRIALS QUASI EMPERIMENTAL STUDIES WITHOUT EXPERIMENTAL DESIGN AND SUBJECTS WERE WORKERS MORE DIVERSE, 145 TO OVER 26,000 INDIVIDUALS. OUTCOMES WERE DIETARY BEHAVIORS INDICES OF WEIGH STATUS AND VARIOUS HEALTH OUTCOMES. THE KEY FINDINGS FOR THE POLICIES IN DIETARY INTAKE ARE AS FOLLOWS. THE VARIETY OF WORK SITE POLICIES TARGETING DIETARY -- EXAMPLE POINT OF PURCHASE INFORMATION CATERING POLICIES AN MENU LABELING ARE EFFECTIVE. WORK SITE POLICIES TARGETING DIETARY INTAKE ARE MORE LIKELY TO ASSESS HEALTH OUTCOMES SUCH AS BODY MASS INDEX WHEN COMBINED WITH INTERVENTIONS TARGETING INDIVIDUALS AND WORK SITE POLICIES TARGETING DIETARY BEHAVIOR ALONE AND IN COMBINATION WITH INDIVIDUAL LEVEL STRATEGIES, SIGNIFICANTLY IMPROVE DIETARY OUTCOMES. AND THAT IS INCREASE CONSUMPTION OF FRUITS AND VEGETABLES IN PARTICULAR. THE CONCLUSION STATEMENT WAS MODERATE CONSISTENT EVIDENCE INDICATES THAT WORK SITE NUTRITION POLICIES ALONE AND IN COMBINATION WITH INDIVIDUALS OF STRATEGIES CAN IMPROVE DIETARY INTAKE OF EMPLOYEES. MULTI-COMPONENT STRATEGIES APPEAR MORE EFFECTIVE THAN SINGLE COMPONENT STRATEGIES. THE GRADE WAS MODERATE. QUESTION 3 ADDRESSING WORK SITE BASED APPROACHES AND WEIGHT STATUS, THIS INCLUDED TWO SYSTEMATIC REVIEW, ONE INCLUDED A META ANALYSIS. ONE IN 2011, 2014, TOTAL OF 70 STUDIES PUBLISHED PRIOR TO NOVEMBER OF 2012. THERE WAS OVERLAP OF TWO STUDIES ONLY, THE STUDY DESIGNS RANDOMIZED IN CLINICAL TRIALS, 59, AND PRE-AND POTTS STUDIES, 11. -- POST STUDIES 116789 SUBJECTS ARE WORKERS AND SAMPLE SIZE IS 33 TO OVER 10,000. THE OUTCOME IS INDICES OF WEIGHT STATUS. OUR KEY FINDINGS WERE INTERNET BASED APPROACHES DEMONSTRATE THESE RESULTS IN WEIGHT RELATED OUTCOMES. RANDOMIZE CONTROL TRIAL IS ASSESSING THE IMPACT OF WORK SITE INTERVENTIONS TARGETING DIET AND PHYSICAL ACTIVITY SIGNIFICANTLY IMPROVE WEIGHT RELATED OUTCOMES AN META ANALYSIS FININGS SHOWN HERE, SHOWS IN THE RIGHT DIRECTION DECREASES WITH THE INTERVENTION. BODY WEIGHT BODY MASS BODY FAT PERCENTAGE BY SKIN FOLDS. IN CONCLUSION STATEMENTS QUESTION 3, WORK SITE APPROACHES IN WEIGHT STATUS, MODERATE CONSISTENT EVIDENCE INDICATES THAT MULTI-COMPONENT WORK SITES APPROACHES TARGETING PHYSICAL ACTIVITY AND DIETARY BEHAVIORS FAVORABLY IMPACT OUTCOMES AND THE GRADE IS MODERATE. LAST QUESTION 4. FOCUSES ON WORK SITE BASED SPOILS AND WEIGHT STATUS. ONE SYSTEMATIC REVIEW, INCLUDE ONE SYSTEMATIC REVIEW. 27 STUDIES PUBLISHED. STUDY DESIGNS THROUGH RANDOMIZED CONTROL TRIAL, QUASI EXPERIMENTAL AND WITHOUT EXPERIMENTAL DESIGN AND WORKERS 145 TO OVER 26,000 AND THE OUTCOMES WERE DIETARY BEHAVIORS INDICES OF WEIGHT STATUS AND HEALTH OUTCOMETS. -- OUTCOMES. KEY FINDINGS ARE FEW STUDIES ASSESS THE IMPACT OF WORK SITE POLICIES AN WEIGHT RELATED OUTCOMES, MOST FOCUS ON BEHAVIORS AN DESPITE IMPROVING DIETARY INTAKE WORK SITE POLICIES FOR HEALTH PROMOTION TARGETING DIETARY PHYSICAL ACTIVITY BEHAVIORS ALONE AND IN COMBINATION STRATEGIES DO NOT IMPACT WEIGHT RELATED OUTCOMES. THE BODY OF EVIDENCE ASSESSING IMPACT OF GROUP POLICY ON WEIGHT STATUS EMPLOYEES IS VERY LIMITED. WE GRADE IT NOT ASSIGNABLE. IMPLICATIONS ARE AS FOLLOW, EXISTING EVIDENCE INDICATES WORK SITE APPROACHES FOCUSED ON DIETARY INTAKE CAN INCREASE FRUIT AND VEGETABLE INTAKE OF EMPLOYEES, MULTI-COMPONENT PROGRAMS TARGETING NUTRITION IN COMBINATION WITH DIETARY MODIFICATION INTERVENTIONS ARE FOUND TO BE EFFECTIVE. ALSO ENVIRONMENTAL MODIFICATIONS IN CONJUNCTION WITH WORK SITE POLICIES TARGETING DIETARY MODIFICATION INCLUSIVE OF PURCHASE INFORMATION CATERING POLICIES AN MENU LABELING ARE ALSO EFFECTIVE. GIVEN THAT APPROXIMATELY 64% OF ADULTS ARE EMPLOYED AND SPEND AVERAGE 34 HOURS PER WEEK AT WORK THE WORKPLACE REMAINS AN IMPORTANT SETTING FOR ENVIRONMENTAL INTERVENTIONS, HEALTH PROMOTION AND DISEASE PREVENTION. QUESTIONS AT THIS TIME? FROM THE COMMITTEE? >> ARE WE -- CAN WE ASK QUESTIONS ON WHAT WAYNE PRESENTED? OR IS THIS RESTRICTED TO THE INFORMATION THAT LUCILE PRESENTED IF >> WE CAN NOW OPEN IT UP FOR BOTH SCHOOL AS WELL AS THE WORK SITE COMMENTS AND QUESTIONS. >> THIS IS MARIAN, I WOULD LIKE TO ADDRESS A COUPLE OF QUESTIONS TO WAYNE. WAYNE IN THE MATERIAL THAT YOU PRESENTED MOST OF THE STUDIES SEEM TO EMPHASIZE RESTRICTIONS ON FOOD, FOR INSTANCE RESTRICTIONS ON COMPETITIVE FOODS AND SO FORTH AND WERE THERE ANY STUDIES THAT EXAMINE WHAT WAS PROVIDED. SO IF THERE WERE CHANGES, IMPROVING WHOLE GRAINS SWAPPING OUT WHITE BREAD FOR WHOLE GRAIN BREAD OR THINGS LIKE THAT. DOES THAT MAKE SENSE? >> THIS IS WAYNE, QUESTION IS CLEAR. THE SYSTEMATIC REVIEWS THAT WE WERE UTILIZING FOR THIS QUESTION DID NOT INCLUDE INFORMATION REGARDING EXPERIMENTAL DESIGNS LIKE YOUR DESCRIBING. THEY WERE FOCUSED REALLY ON SPECIFICALLY ON COMPETITIVE FOODS, THAT WAS THE TOPIC OF THE REVIEW. SO WE'RE LIMITED WITH RESPECT TO THAT. NOW THERE WERE SEVERAL STUDIES NOT NECESSARILY ON A POLICY BASIS BUT MORE ON APPROACHES BASIS, THOSE WERE DIFFERENT QUESTIONS, THOSE WERE OTHER ASPECTS OF THE SCHOOL TOPIC THAT WERE IMBEDDED IN THE OTHER QUESTIONS WHICH I REVIEWED BACK IN SEPTEMBER THAT DO REGARD SUBSTITUTIONS OF WHOLE MILK -- SKIM MILK FOR WHOLE MILK OR DIFFERENT WAYS OF MANIPULATING THE FOOD OFFERINGS OF CHILDREN. THOSE WERE SHOWN TO BE EFFECTIVE OF ALTERING DIETARY INTAKE, THERE WAS NOT MUCH INFORMATION REGARDING CHRONIC BODY WEIGHT OR OTHER OUTCOMES LIKE THAT. >> OKAY. THANK YOU. >> THEN I ALSO HAVE A COMMENT, I FEEL THIS IS A CRITICALLY IMPORTANT AREA TO PROVIDE STRONG IMPLICATIONS ON -- AS EVERYONE SAW, EARLIER TODAY THE DATA THAT WE PRESENTED FROM SC 1, YOUNG CHILDREN DO QUITE WELL IN MUCH OF THEIR DIETARY INTAKE AND THE POOREST DIETARY INTAKE IS AMONG PRE-ADOLESCENTS 9 TO 11, 12 YEARS OLD AND ADOLESCENT, 13 TO 17 OR SO. BECAUSE CHILDREN EAT AT LEAST ONE MEAL IN THE DAY AT SCHOOL, THIS IS REALLY A TREMENDOUS OPPORTUNITY, IMPERATIVE OPPORTUNITY TO DO SOMETHING TO IMPROVE THEIR DIET. I HAVE SEEN THOSE DATA FOR JUST REALLY SHARPLY DROPPED OFF WAS QUITE STRIKING TO ME. SO I THINK WE NEED TO MAKE SOME CRITICAL CHANGES. >> THANK YOU. I REALLY -- I CONCUR COMPLETELY AND WE'LL DEFINITELY CONSIDER THAT STRONG EF FASIS AS WE CRAFT IMPLICATION STATEMENT THAT ENCOMPASSES ALL FOUR OF THE QUESTION. >> THANK YOU. >> RAFAEL PEREZ-ESCAMILLA. I TOTALLY AGREE WITH MARIA IN THAT THESE ARE ISSUES THAT HAVE ENORMOUS RELEVANCE FOR POLICY IMPLICATIONS. I WANT TO RECOMMEND, I'M SURE YOU HAVE CONSIDERED EXPLICITLY STATING SO, THAT IS VERY IMPORTANT WHEN THESE POLICY RECOMMENDATIONS ARE MADE THAT THEY INCLUDE EQUITY COMPONENTS, THE QUALITY OF THE FOOD SERVED IN THE SCHOOL AND ISSUES RELATED TO THE WORKPLACE, ARE NOT A FUNCTION OF HOW MUCH BUDGETS THE SCHOOL HAS OR THE INCOME OF THE PEOPLE THAT ARE BENEFITING FROM THEM. >> RAFAEL, AGAIN, I COMPLETELY AGREE, INDEED WITH RESPECT TO THE SCHOOL PROGRAM AND DIETARY INTAKE SOME OF THE MOST EFFECTIVE AND MOST ROBUST IMPROVEMENTS WERE INDEED SHOWN IN STUDIES TARGETED IN LOWER INCOME SCHOOLS OR SCHOOLS THAT SERVE LOWER INCOME -- DISADVANTAGED POPULATIONS IN THAT THEME DEFINITELY RESONATES. >> THANK YOU. >> THIS IS ANNA MARIA. I HAVE A QUESTION FOR LUCILE. LUCILE, I WAS -- I THINK WE SPOKE A LITTLE BIT MORE ABOUT THIS AT THE LAST PUBLIC MEETING AND THE CONSISTENCY OF SUBCOMMITTEES IN GRADING THE BODY OF EVIDENCE. SO I WAS CURIOUS AS TO -- FOR THE LAST OUTCOME THAT YOU PRESENTED WHILE THERE WERE NO ONLY 27 STUDIES, THE SAMPLE SIZE WAS FROM 145 TO 26,000. YET YOU'RE GRADING THAT BODY OF EVIDENCE AS NOT ASSIGNABLE. >> THE REASON IS, OUT OF ALL THAT THERE WAS REALLY ONLY ONE STUDY THAT FOCUSED ON THE WEIGHT STATUS. THAT'S WHY WE GRADED IT NON-ASSIGNABLE, ALL THE STUDIES WEIGHT STATUS WAS NOT CLEAR CUT. SO WE COULDN'T GRADE IT, ALL THOSE STUDIES ADDRESSING THE ISSUE. ONE STUDY ADDRESSED THE ENTIRE ISSUE. >> DOES THAT MEAN MORE STUDIES SHOULD HAVE BEEN EXCLUDED OR THIS IS SYSTEMATIC REVIEW YOU USE WAS NOT NECESSARILY APPROPRIATE? >> I DON'T KNOW IF IT SAYS NOT APPROPRIATE P MIGHT HAVE BEEN PERFECT. A LOT OF STUDIES ARE DONE IN THE WORK SITE FORCE, THERE'S NO QUESTION ABOUT THAT. BUT IN TERMS OF HOW THEY GET REPORTED, AND WHETHER THEY -- IN THE SYSTEMATIC REVIEW THAT'S A DIFFERENT STORY. >> THIS IS BARBARA. IT LOOKS LIKE THE WORK SITE LITERATURE IN PARTICULAR IS SOMETHING THAT RECENT YEARS HAS REALLY EXPANDED. IT SEEMS TO ME THAT YOU HAVE GOT MODERATE EVIDENCE AS YOU STATED ON NOT ONLY CHANGES IN DIETARY BEHAVIOR BUT WEIGHT RELATED OUTCOMES AND EMPLOYEES WHICH IS REALLY AS OTHERS HAVE SAID VERY IMPORTANT. AND I KNOW THAT THIS OPPORTUNITY MIGHT BE LIMITED IN THE REVIEWS THAT YOU EXAMINE BUT WOULD YOU BE ABLE TO PULL OUT THE INFORMATION ON WHAT ASPECTS OF THE INTERVENTIONS WORKED. OR AT LEAST WITHIN THOSE MULTI-COMPONENT INTERVENTIONS, WHAT THE DIMENSIONS THOSE INTERVENTIONS WERE. IT SEEMED AS THOUGH YOU WERE EMPHASIZING IN THE MOST EFFECTIVE CASES, IT INVOLVES A DIRECT INTERACTION WITH EMPLOYEES AROUND NUTRITION EDUCATION OR PROVISION OF RESOURCES FOR PHYSICAL ACTIVITY OR THESE SORTS OF THINGS, WOULD IT BE POSSIBLE TO DEFINE THOSE BETTER SO THAT WE CAN PERHAPS INCORPORATE THAT INTO THE IMPLICATION STATEMENTS. >> SURE. I THINK WE WILL GO BACK AND LOOK AT IT. THAT'S APPROPRIATE. >> GREAT. THANK YOU. >> ARE THERE ANY OTHER QUESTIONS? THANK YOU. >> MARY, I'M SORRY I WASN'T ABLE TO PRESS THE MUTE BUTTON QUICK ENOUGH. THIS IS ANNA MARIA I HAVE ANOTHER QUESTION FOR WEIGHING PERHAPS COMBINING WHAT WE LEARNED FOR SUBCOMMITTEE ONEs WORK AND MIRIAM STATING HOW ADOLESCENTS REALLY HAD THE WORST SCORES IN THE HEI AND GIVEN HOW MUCH THEY NEED TO MOVE FORWARD IN ORDER TO IMPROVE THEIR DIETARY INTAKES, I WAS WONDERING WHETHER OR NOT WE FELT THAT THE SCHOOL INTERVENTIONS WERE ENOUGH. BECAUSE MY PREVIOUS WORK ON HAVING DONE ONE OF THOSE INTERVENTIONS BEING PART OF IT WHILE WE WERE ABLE TO INCREASE VEGETABLE INTAKE BETWEEN A QUARTER AND A HALF WONDERING WHETHER OR NOT IT REALLY CALLS -- WE NEED TO HAVE A CALL TO ACTION THAT ACTUALLY REINFORCES THIS STRONGER. >> THIS IS WAYNE VERY GOOD POINT. ONE OF THE CHALLENGES THAT THESE STUDIES THAT WE REVIEWED OR FEATURE WAS THEY -- VERY POOR DIETARY DATA IN GENERAL ACROSS THE LITERATURE. SO THEY MAY -- A PARTICULAR STUDY MAY HAVE FOCUSED ON A PARTICULAR INTERVENTION STYLE LIKE GARDENING OR COMPETITIVE FOODS IN VENDING MACHINES BUT THEY DIDN'T NECESSARILY THE CALL TO ACTION FROM A RESEARCH STANDPOINT IS REALLY THAT WE NEED NEW RESEARCH ACCURATELY DOCUMENTS THE INTAKES OF NOT ONLY THE FOODS THAT ARE SERVED OR CONSUMED IN THE SCHOOL SETTING BUT ALSO ON A 24 HOUR DAILY BASIS. THE OTHER THING THAT IS A CHALLENGE FOR THESE STUDIES IS THE LENGTHS OF THE INTERVENTIONS. AND WHETHER OR NOT WE CAN GET PAST A QUARTER CUP OR HALF A CUP A SERVING OF THIS THAT WHEN UP OR DOWN BUT WHETHER OR NOT YOU ALSO HAVE -- HOW THAT HABITUALIZATION SUSTAINS ITSELF, THOSE ARE UNBELIEVABLY IMPORTANT FROM A POLICY STANDPOINT, BUT UNFORTUNATELY THE LITERATURE DOESN'T -- THAT WE REVIEWED DID NOT INDICATE THAT THERE'S A LOT OF HIGH QUALITY EVIDENCE TO BE ABLE TO SUPPORT OR REFUTE THEIR USE. >> THANK YOU. >> ARE THERE OTHER QUESTIONS FOR SC 4, ANY FURTHER DISCUSSION? ACCORDING TO THE SCHEDULE WE HAVE A BREAK IN -- A 15-MINUTE BREAK BUT I HAVE HAD AN EXCHANGE WITH THE RICK OLSON AND WE RECOMMEND THAT WE GO AHEAD AND MOVE ON SINCE WE REALLY HAVE JUST RECENTLY GOTTEN BACK FROM OUR LUNCH. SO IF -- WHAT I WOULD LIKE TO DO NOW IS TURN TO THE NEXT TOPIC WHICH ARE THE CROSS CUTTING TOP ICS AND SINCE WE HAVE HEARD AT THIS POINT FROM EACH -- FOUR OF THESE SUBCOMMITTEES, AND SC 5 PRESENTED IN PAST MEETINGS, I REALLY WANT TO TAKE THE TIME TO INTRODUCE THE CROSS CUTTING TOPICS. SO AS WE POINTED OUT IN PREVIOUS MEETINGS, THERE WERE ACTUALLY FOUR TOPICS, SODIUM, ADDED SUGAR, SATURATED FAT AND PHYSICAL ACTIVITY, THAT HAD ASPECTS OF THEIR WORK THAT WERE IDENTIFIED BY THE SUBCOMMITTEES FAIRLY EARLY ON AS BEING SORT OF BIGGER THAN WHAT SIMPLY THEIR GROUP WAS FOCUSING ON, THAT IT ACTUALLY RELATED TO THE WORK OF A NUMBER OF DIFFERENT SUBCOMMITTEES IN DIFFERENT WAYS. SO FOR EXAMPLE, A TOPIC LIKE SODIUM MIGHT BE IDENTIFIED AS THE PUBLIC HEALTH CONCERN BUT ALSO HAVING RELATIONSHIPS WITH ONE OR MORE MAJOR HEALTH PROBLEMS OR LESS COMMON HEALTH PROBLEMS. SUCH AS CARDIOVASCULAR DISEASE, HYPERTENSION AND STROKE. ALTERNATIVELY IT MAY HAVE BEEN IDENTIFIED AS IMPORTANT TO ADDRESS WITH INDIVIDUAL OR ENVIRONMENTAL INTERVENTION STRATEGIES. INCLUDING FOOD PRODUCT FORMULATION. SO THE NOTION OF INDIVIDUAL LEVEL CHANGE AS RAFAEL POINTED OUT, OR ENVIRONMENTAL CHANGE AS MARY POINTED OUT, MIGHT BE A TOPIC RELEVANT TO A PARTICULAR ISSUE. THE AREA MAY ALSO BE RELEVANT TO THE WORK OF SUBCOMMITTEE 5 ON SUSTAINABILITY OF THE HEALTHY DIET NOW AND IN THE FUTURE. AS A METHOD FOR REDUCING FOOD INSECURITY IN THE POPULATION SO THE TOPICS OF SODIUM, ADDED SUGAR SATURATED FAT IN ONE WAY OAR ANOTHER, MET TWO OR MORE OF THESE CRITERIAS, WE FORM WORKING GROUPS AND IN THE CASE OF PHYSICAL ACTIVITY WRITING GROUP TO FOCUS DOWN ON THEM. FOR THESE THE COMMITTEE IDENTIFIED A NUMBER OF QUESTIONS TO ADDRESS AND BROUGHT THEM TOGETHER IN A SMALLER WORKING GROUP WHICH THEN ALLOWED US TO BE MORE THOUGHTFUL AND COMPREHENSIVE IN ADDRESSING THE CROSS CUTTING AREAS OF RELEVANCE TO THE TOPIC. , WE HAVE MEMBERS FROM ACROSS THE DGAC WITHIN THE SUBCOMMITTEES SO WE COULD COORDINATE SOME OF THE WORK THAT THE WORK GROUP WAS DOING AND PROVIDE FEEDBACK TO AN FROM THE LARGER SUBCOMMITTEE STRUCTURE. SO WHAT WE'RE GOING TO DO NOW IS HEAR FROM THREE OF THE FOUR GROUPS ADDED SUGAR SODIUM AND SATURATED FAT AND AS I MENTIONED IN MY COMMENTS THIS MORNING WE'LL HEAR FURTHER FROM PHYSICAL ACTIVITY WHEN WE TALK HIGH LEVEL THEMES AND INTEGRATION OF OUR WORK. SO NOW I'M GOING TO TURN THE MIKE TO CHERYL ANDERSON, LEAD ON OUR SODIUM WORKING GROUP. CHERYL. >> THANK YOU, BARBARA. SO I WOULD LIKE TO REVIEW WHAT THE SODIUM WORKING GROUP IS DICESSIS CUSSING SINCE THE SEPTEMBER MEETING, SOME WILL INCLUDE A BIT OF SLIDES THAT YOU HAVE SEEN BEFORE, BUT NOW WILL ALSO SHOW YOU HOW THOSE EARLY SLIDES FIT INTO OUR LATER WORK. SO I WOULD LIKE TO FIRST ACKNOWLEDGE THE OTHER MEMBERS OF THE WORKING GROUP, THEY INCLUDE WAYNE CAMPBELL, STEVE CLINTON AND ALICE LICHTENSTEIN ARE DIETARY GUIDELINES VICE CHAIR. THE SCOPE OF OUR WORK INCLUDES DESCRIBING THE RELATIONSHIP BETWEEN SODIUM INTAKE BLOOD PRESSURE AND CARDIO VASCULAR DISEASE AND RECOMMENDATIONS MAYBE INFLUENCED BY INTERACTION OF SODIUM AND POTASSIUM. AND DESCRIBE STRATEGIES THAT MAY PROMOTE RECOMMENDED INTAKE OF SODIUM. WE DID NOT HAVE ANY EXPERTS INVITED TO COME IN OR ANY CONSULTANTS FROM THE LAST TIME WE MET UNTIL NOW. THE QUESTIONS TO ADDRESS TODAY ARE AS FOLLOWS, WHAT'S THE RELATIONSHIP BETWEEN SODIUM INTAKE AND BLOOD PRESSURE IN CHILDREN. WHAT'S THE RELATIONSHIP BETWEEN SODIUM INTAKE AND BLOOD PRESSURE IN ADULTS. WHAT'S THE RELATIONSHIP BETWEEN SODIUM INTAKE AND CARDIOVASCULAR DISEASE, WHAT'S THE INTERRELATIONSHIP OF SODIUM AND POTASSIUM ON BLOOD PRESSURE AND CARDIOVASCULAR DISEASE OUTCOMES. AS PART OF OUR IMPLICATIONS STATEMENT WE WILL ADDRESS THE TWO QUESTIONS WE HAVE ABOUT STRATEGIES WHICH ARE WHAT INDIVIDUAL STRATEGIES ARE USED TO PROPROMOTE RECOMMENDED INTAKE OF SODIUM AND WHAT POLICIES AND ENVIRONMENTAL STRATEGIES CAN BE USED TO PROMOTE RECOMMENDED INTAKE OF SODIUM. SO STARTING WITH SODIUM INTAKE AND BLOOD PRESSURE IN CHILDREN QUESTION. HERE OUR SOURCES OF EVIDENCE INCLUDED THE 2010 DIETARY GUIDELINES REPORT WHERE THEY CONDUCT AD SYSTEMATIC REVIEW ON THE RELATIONSHIP BETWEEN SODIUM INTAKE AND BLOOD PRESSURE IN CHILDREN FROM BIRTH TO AGE 18 YEARS OLD. AND THAT REVIEW INCLUDED STUDIES THAT HAD BEEN PUBLISHED FROM 1970 THROUGH MAY OF 2009. THE 2015 COMMITTEE UPDATEED THAT SYSTEMATIC REVIEW WITH TWO NEWLY PUBLISHED STUDIES. WE REVIEWED THE BODY OF EVIDENCE IN THE SEPTEMBER -- SEPTEMBER MEETING AND THE CONCLUSION STATEMENT THAT WE DRAFTED FROM THOSE FINDINGS WERE MODERATE BODY OF EVIDENCE DOCUMENTED THAT AS SODIUM INTAKE DECREASES SO DOES BLOOD PRESSURE IN CHILDREN AGEED FROM BIRTH TO 18 YEARS. IN TERMS OF SODIUM AND BLOOD PRESSURE IN ADULTS WE USE EXISTING REPORTS TO IDENTIFY OR ANSWER THAT QUESTION AND THOSE EVIDENCE INCLUDES 2013 AMERICAN HEART ASSOCIATION AND AMERICAN COLLEGE OF CARDIOLOGY GUIDELINE ON LIFESTYLE MANAGEMENT TO REDUCE CARDIOVASCULAR RISK. THE CONCLUSION STATEMENTS THAT WE DREW FROM THAT EXISTING REPORT ARE AS FOLLOWS. WE PRESENTED THESE AT THE SEPTEMBER MEETING, SO THIS IS JUST A REVIEW. THE COMMITTEE CONCURS WITH THE 2013 H ACC LIFESTYLE REPORT, WHICH BENEFITS BLOOD PRESSURE TO LOWER THE SODIUM INTAKE AND THE CREATIVE FIND TO THIS CONCLUSION IS STRONG. THE COMMITTEE ALSO CONCURS CON CURSE THE HACC LIFESTYLE REPORT BENEFITING FROM BROOD PRESSURE LOWERING TO CONSUME MORE THAN 2400-MILLIGRAMS SODIUM PER DAY AND FURTHER REAREDUCTION TO 1500-MILLIGRAMS PER DAY RESULT IN EVEN GREATER REDUCTION IN BLOOD PRESSURE. EVEN WITHOUT ACHIEVING THE TWO AFORE MENTIONED GOALS, REDUCING SODIUM INTAKE BY 1,000-MILLIGRAMS PER DAY WOULD LOWER BLOOD PRESSURE. AND THE GRADE ASSIGNED TO THE EVIDENCE INFLUENCING THOSE CONCLUSION STATEMENTS IS MODERATE. LASTLY THE COMMITTEE CONCURS WITH 2013 HACC LIFESTYLE REPORT WHICH ADVISES ADULTS WHO BENEFIT BENEFIT FROM BLOOD PRESSURE LOWERING TO COMBINE THE DASH DIETARY PATTERN WITH LOWER SODIUM INTAKE. AND THAT IS STRONG. IN TERMS OF IMPLICATIONS NEWLY DRAFTED THAT RELATE TO THOSE CONCLUSIONS, FOR BLOOD PRESSURE LOWERING HIGH LEVELS OF SODIUM INTAKE SHOULD BE REDUCED AND HEALTHFUL U.S. DIETARY PATTERNS SHOULD BE COMBINED WITH LOWER SODIUM INTAKE IF NECESSARY. IN ACHIEVING THE RECOMMENDATIONS, FOR REDUCE SODIUM INTAKE, THERE IS REQUIRED EMPHASIS ON POLICIES AND POPULATION BASED STRATEGIES. AND THESE INCLUDE FDA TAKING ACTION TO MODIFY THE GENERALLY REGARDED AS SAFE OR THE GRASS STATUS OF SODIUM, INCLUDES FOOD FORMULATION TO ACHIEVE PROGRESSIVE REDUCTION IN SODIUM CONTENT OF FOODS, IT INCLUDES INCENTIVES TO ENCOURAGE HEALTH SYSTEMS TO PROVIDE PREVENTATIVE NUTRITION SERVICES THAT ENCOURAGE HEALTHFUL DIETARY PATTERNS. AS WELL AS PUBLIC PRIVATE COMMUNITY LEVEL PARTNERSHIPS THAT WILL HELP IN THE ACHIEVEMENT OF THE RECOMMENDATION OF THE SODIUM INTAKE REQUIREMENT. FURTHERMORE STRATEGIES THAT COMPLIMENT POLLSIS AN SUPPORT CONSUMERS TO MAKE DIETARY BEHAVIOR CHANGES ARE ALSO NEEDED. THESE INCLUDE NUTRITION SERVICES AND COMPREHENSIVE LIFESTYLE INTERVENTIONS BY MULTI-DISCIPLINARY TEAMS AS EMPHASIZED IN THE AHACC REPORT AND AS YOU HAVE HEARD DISCUSSED EARLIER WHEN WE TALKED ABOUT NUTRITION RELATED HEALTH CONDITIONS AND THE APPROACHES THAT WE MIGHT TAKE THERE. ADDITIONALLY, ENHANCED NUTRITION LABELING AND POINT OF PURCHASE SODIUM INFORMATION THAT WAS DISCUSS AS PART OF THE SUBCOMMITTEE 4'S WORK AS WELL. AND DIET PLANNING TOOLS INCLUDING SODIUM AS AREA OF FOCUS. LASTLY, ALTHOUGH THE EVIDENCE ON POTASSIUM AND BLOOD PRESSURE IS LIMITED, POTASSIUM INTAKE IS SUBOPTIMAL, WE DISCUSSED IN PREVIOUS DGAC MEETINGS THE THE REPORT ON POTASSIUM AND NUTRIENT OF CONCERN SO WE WANTED TO BRING THAT FORWARD IN IMPLICATION AROUND SODIUM AND BLOOD PRESSURE. IN A FEW MINUTES YOU'LL HEAR ME DESCRIBE THE EXISTING REPORTS AND THEIR STANCE ON INTERRELATIONSHIP BETWEEN SODIUM AND POTASSIUM. IN TERMS OF THE NEXT QUESTION, WHAT IS THE RELATIONSHIP BETWEEN SODIUM INTAKE AND CARDIOVASCULAR DISEASE, THE ANALYTIC FRAMEWORK THAT WE USE TO EXAMINE THE LITERATURE FOR SYSTEMATIC REVIEW FOCUSED ON THE QUESTION OF WHAT'S THE RELATIONSHIP WITH SODIUM AND CVD INCLUDE AD TARGET POPULATION, OF CHILDREN AND ADULTS AGED 2 YEARS AND OLDER, THE INTERVENTION OR EXPOSURE THAT WE FOCUSED ON WITH SODIUM INTAKE WITH A COMPARATOR OF DIFFERENT LEVELS OF SODIUM INTAKE. THE END POINT OR HEALTH OUTCOMES INCLUDED IN THE REVIEW MYOCARDIAL INFARCTION, STROKE, CORONARY HEART DISEASE, CVD RELATED MORTALITY, INCIDENT HYPERTENSION, AND CONGESTIVE HEART FAILURE. THIS REVIEW ALSO TOOK INTO ACCOUNT POTENTIAL CONFOUNDERS YOU CAN SEE CIRCLED ON THE RIGHT SIDE OF THE SCREEN. THE INCLUSION EXCLUSION CRITERIA ARE OUTLINED ON THIS SLIDE. THE RANGE AS I MENTIONED EARLIER, OF STUDIES INCLUDED WERE THOSE PUBLISHED BETWEEN JANUARY 2013 AND SEPTEMBER 2014 AND THAT ENCOMPASSES LITERATURE THAT WAS NOT INCLUDED IN THE EXISTING REPORTS BEING USED WHICH I MIGHT REMIND EVERYONE ARE THE IOM 2013 REPORT AND THE AHACC REPORT PUBLISHED IN EARLY 2014. WE LOOK AD STUDY DESIGNS RANDOMIZED OR NON-RANDOMIZED CONTROL TRIALS AS WELL AS PERSPECTIVE COHORT STUDIES, INCLUDED CHILDREN AND ADULTS AGE TWO OR OLDER. PARTICIPANTS CAME FROM HIGH OR HIGH HUMAN DEVELOPMENT FOR THE 2012 HUMAN DEVELOPMENT INDEX AND IF A STUDY INCLUDED PARTICIPANTS FROM MULTIPLE COUNTRIES WITH DIFFERENT HUMAN DEVELOPMENT INDEX RATINGS, THE STUDY WAS INCLUDED. STUDY PARTICIPANTS WERE HEALTHY OR ELEVATED CHRONIC DISEASE RISK. INTERVENTION OR EXPOSURE WITH SODIUM INTAKE, AND THE OUTCOMES ARE LISTED AGAIN AT THE BOTTOM OF THAT SLIDE. OUR LITERATURE RESULTS WERE SUMMARIZED HERE. WE PICKED UP THROUGH THE DATABASE 1100 STUDIES, AFTER SCREENING WE EXCLUDED 1,056 WAYED ON TITLES, ANOTHER 48 BASED ON ABSTRACTS WITH THE FINAL REVIEW IN FULL TEXT OF THREE ARTICLES AROUND THIS QUESTION. IN DESCRIBING THE EVIDENCE WE IDENTIFIED PROSPECTIVE COHORT STUDIES DONE IN ADULTS FROM THE U.S. AND NETHERLANDS, UK AND 17 COUNTRIES AROUND THE WORLD, TWO STUDIES USED MULTIPLE 24 URINARY SODIUM EXCRETION SAMPLES, AS THE MEANS OF DETERMINING SODIUM INTAKE, TWO STUDIES USE SINGLE URINE SAMPLES AND TWO FOUND THAT HIGHER SILL YUM INTAKE WAS ASSOCIATED WITH HIGHER CARDIOVASCULAR DISEASE RISK AND TWO STUDIES FOUND EITHER BEING NO ASSOCIATION OR INVERSE ASSOCIATION WITH INTAKE AND CARDIOVASCULAR DISEASE, WE HAD LIMITATIONS THAT MADE INTERPRETATION CHALLENGING AND THE RISK OF BIAS SCORE ON ONE STUDY WAS PARTICULARLY HIGH. WE CONSIDER FINDINGS FROM THESE STUDIES AND DETERMINED CHANGES WERE NOT WARRANTED TO THE CONCLUSIONS OF EXISTING REPORTS OF THE IOM AND AHANCC OR NHLBI SYSTEMATIC REVIEW. HERE ARE CONCLUSION STATEMENTS SUMMARIZED FOR YOU. FIRST THE 2015 COMMITTEE CONCURS WITH THE INSTITUTE OF MEDICINE, WHICH CONCLUDED THAT THOUGH REVIEWED EVIDENCE ON ASSOCIATIONS BETWEEN SODIUM INTAKE AND DIRECT HEALTH OUTCOMES AS METHODOLOGICAL FLAWS AND LIMITATIONS, WHEN CONSIDERED COLLECTIVELY IT INDICATES A POSITIVE RELATIONSHIP BETWEEN HIGHER LEVELS SODIUM INTAKE AND RISK OF CARDIOVASCULAR DISEASE EXISTS. THIS EVIDENCE IS CONSISTENT WITH EXISTING EVIDENCE ON BLOOD PRESSURE AS A SURROGATE INDICATOR OF CARDIOVASCULAR DISEASE RISK. THE IOM COMMITTEE DIDN'T DETERMINE A GRADE, IT WAS OUTSIDE THE STATEMENT OF TASK FOR THAT COMMITTEE. HOWEVER THE DGAC COMMITTEE GRADE THE BODY OF EVIDENCE THAT WAS INCLUDED IN THAT REPORT AS MODERATE. SECONDLY, THE COMMITTEE CONCURS WITH THE IOM CONCLUSION THE EVIDENCE FROM STUDIES ON DIRECT HEALTH OUTCOMES IS INCONSISTENT AND INSUFFICIENT TO CONCLUDE LOWERING SODIUM INTAKE BELOW 2300-MILLIGRAMS PER DAY INCREASES CVD RISK OR DECREASES CVD RISK. WE CONCUR THE EVIDENCE IS INCONSISTENT AND INSUFFICIENT IN ITS RELATIONSHIP OF SODIUM TO ALL CAUSE MORTALITY IN THE GENERAL U.S. POPULATION. THE IOM COMMITTEE PRODUCED THE 2013 REPORT DID NOT GRADE THE EVIDENCE, IT WAS OUTSIDE THE STATEMENT OF TASK FOR THAT COMMITTEE AND EVIDENCE RELATED TO THIS CONCLUSION, THE DGAC DECIDED IT'S NOT ASSIGNABLE. IN TERMS OF OUR NEXT CONCLUSION STATEMENT, DGAC CONCURS WITH THE NATIONAL HEART LUNG AND BLOOD INSTITUTE, WHICH CONCLUDED THAT A REDUCTION OF SODIUM INTAKE BY 1,000 MILLIGRAMS PER DAY REDUCE CARDIOVASCULAR DISEASE EVENTS BY 30% AND HIGHER DIETARY SODIUM INTAKE IS ASSOCIATED WITH THE GREATER RISK FOR FATAL AND NON-FATAL STROKE IN CARDIOVASCULAR DISEASE, THE NHLBI SYSTEMATIC REVIEWS STRENGTH OF EVIDENCE GRADE HERE IS LOW. AND EQUIVALENT GRADE FROM DGAC HAS BEEN ASSIGNED AS LIMITED. 2015 COMMITTEE CONCURS THAT THE EVIDENCE IS NOT SUFFICIENT TO DETERMINE ACERTAINIATION BETWEEN SODIUM INTAKE AND DEVELOPMENT OF HEART FAILURE. THE NHLBI SYSTEMATIC REVIEW DID NOT PROVIDE A GRADE, IT WAS NOT ASSIGNED DUE TO INSUFFICIENT EVIDENCE AND IN OUR ASSESSMENT IN TERMS OF THE DGAC GRADE WE HAVE DEEMED IT NOT ASSIGNABLE. SO IMPLICATIONS RELATED TO SODIUM AND CARDIOVASCULAR DISEASE. TO REDUCE RISK FOR CARDIOVASCULAR DISEASE, HIGH LEVEL SODIUM INTAKE SHOULD BE REDUCED AND HEALTHFUL U.S. DIETARY PATTERNS SHOULD BE COMBINED WITH LOWER SODIUM INTAKE IF NECESSARY. FURTHERMORE BECAUSE THERE'S A STRONG LINK BETWEEN BLOOD PRESSURE AND CARDIOVASCULAR DISEASE, AND HERE I MIGHT DRAW THE COMMITTEE'S ATTENTION TO WHAT WE DISCUSSED EARLIER IN THE NUTRITION RELATED HEALTH CONCERNS PART OF OUR PRESENTATION WHERE PREVALENCE OF HYPERTENSION IS HIGH, 30% AMONG U.S. ADULTS, IT'S PARTICULARLY HIGH IN OLDER ADULTS, THOSE AGE 60 OR OLDER. WHO HAVE A PREVALENCE OF 66%. THE PREVALENCE OF HYPERTENSION IN AFRICAN AMERICANS IS 42%. WE SAW DATA FOR YOUTH AGED 8 TO 17-YEAR-OLDS WHERE BORDERLINE HYPERTENSION BEING THE DEFINED AS BEING IN THE 90th -- 95TH PERCENTILE BEING AT 8.3% AND THERE'S ALSO AN ESTIMATED LIFETIME RISK DEVELOPING HYPERTENSION IN THE UNITED STATES HAVING BEEN PUBLISHED AT 90%. SO BECAUSE OF THAT STRONG LINK BETWEEN -- BECAUSE OF THE PREVALENCE AND PUBLIC HEALTH CONCERNS AROUND HIGH BLOOD PRESSURE AND THE LINK BETWEEN HIGH BLOOD PRESSURE AND CARDIOVASCULAR DISEASE, WE HAVE IMPLICATIONS HERE TO SUGGEST IF WE'RE GOING TO ACHIEVE RECOMMENDATIONS TO REDUCE SODIUM INTAKE AGAIN, THAT EMPHASIS ON POLICY AND POPULATION BASE IS NEEDED. IT INCLUDES WHAT WE EMPHASIZED EARLIER, THE FTA TACKING ACTION TO MODIFY -- FDA MODIFYING -- LOOKING AT FOOD PRODUCT FORMULATION AND SODIUM CONTENT OF FOODS, PROVIDING INCENTIVES TO ENCOURAGE OUR HEALTH SYSTEMS TO HAVE PREVENTIVE NUTRITION SERVICES THAT ADDRESS HEALTHFUL DIETARY PATTERNS WHICH WOULD CONCOMITANTLY ADDRESS SODIUM INTAKE AND PUBLIC PRIVATE COMMUNITY PARTNERSHIPS. HERE WE ALSO INCLUDE IN THE IMPLICATION STATEMENTS THE NEED FOR COMPLIMENTARY STRATEGIES TO THE POLICIES THAT ARE GOING TO SUPPORT CONSUMERS IN MAKING POSITIVE DIETARY BEHAVIOR CHANGES AGAIN, NUTRITION LIFESTYLE SERVICES WHICH MULTI-DISCIPLINARY TEAMS, POINT OF THE PURCHASE LABELING INFORMATION WITH SODIUM, INFORMATION USED BY CONSUMERS AND BY CONSUMERS WITH DIET PLANNING TOOLS. SO THOUGH THE EVIDENCE ON POTASSIUM AN CVD IS LIMITED, I'LL GO THROUGH THAT IN THE NEXT SET OF SLIDES, WE DO ACKNOWLEDGE THE POTASSIUM IS ON OUR NUTRIENT OF CONCERN LIST AND IT SHOULD BE INCLUDED WHEN THINKING ABOUT THE RISK BETWEEN SODIUM AND CARDIOVASCULAR DISEASE. SO LET ME BRING THE SECTION OF THE PRESENTATION TO A CLOSE BY REVIEWING WHAT WE HAVE FILED IN EXISTING REPORTS ABOUT THE INTERRELATIONSHIP OF SODIUM AND POTASSIUM ON CARDIOVASCULAR -- WE USE THE STYLE TO REDUCE RISK SYSTEMATIC EVIDENCE REVIEW, AND THE DGAC CONCURS WITH THE NHLBI LIFESTYLE WORK GROUP THAT FIRST THE EVIDENCE IS NOT SUFFICIENT AROUND POTASSIUM TO DETERMINE WHETHER INCREASING DIETARY POTASSIUM INTAKE WOULD LOWER BLOOD PRESSURE. THERE WAS NO GRADE ASSIGNED BECAUSE OF INSUFFICIENT EVIDENCE AND OUR COMMITTEE AND WORK GROUP HAS ELECTED TO CONCUR AND ASSIGN A NOT ASSIGNABLE GRADE HERE AS WELL. OBSERVATIONAL STUDIES WITH APPROPRIATE ADJUSTMENTS, THAT IS FOR BLOOD PRESSURE SODIUM INTAKE OR OTHER FACTORS KNOWN TO BE ASSOCIATED WITH POTASSIUM AND OUTCOMES. HIGHER DIETARY POTASSIUM INTAKE IS ASSOCIATED WITH LOWER RISK FOR STROKE. HOWEVER STRENGTH OF THE EVIDENCE AS ASSIGNED IS LOW AND THE DGAC GRADE HERE WILL BE LIMITED. THE EVIDENCE IS NOT SUFFICIENT TO DETERMINE ASSOCIATION OF DIETARY POTASSIUMEN TAKE AND CORONARY HEART DISEASE, HEART FAILURE AND CARDIOVASCULAR MORTALITY, STRENGTH OF THE EVIDENCE IS ASSIGNED BY THE NHLBI WORK GROUP IS NOT ASSIGNED BECAUSE THEY -- IT WAS INSUFFICIENT AND DGAC GRADE HERE WOULD BE NOT ASSIGNABLE. THAT BRINGS ME TO THE CLOSE OF WHAT WE HAVE BEEN DISCUSSING IN THE SODIUM WORKING GROUP AND BEFORE I OPEN UP THE FLOOR FOR THE FULL COMMITTEE TO COMMENT, I WOULD LIKE TO ASK MEMBERS OF THE WORKING GROUP, ALICE WAYNE AND STEVE TO CHIME IN IF YOU HAVE ANY CONTRIBUTIONS OR IF I MAY HAVE MISSED ANYTHING IN THE PRESENTATION. >> YOU DID EXTREMELY GOOD COMPREHENSIVE JOB, THIS IS ALICE LICHTENSTEIN, NOTHING TO ADD. >> THANKS, ALICE. HEARING NOTHING FROM WAYNE OR STEVE, I WILL OPEN THE FLOOR FOR COMMENTS FROM MEMBERS. >> THIS IS REALLY VERY COMPREHENSIVE, TWO RELATED QUESTIONS, ONE IS THAT YOU HAVE TWO IMPLICATIONS SLIDES OF THE ALMOST IDENTICAL. >> YES, THEY ARE, FRANK. THEY ARE ALMOST IDENTICAL AND WE -- THE PROCESS HERE WAS THAT WE ELECTED TO KEEP THEM SEPARATE BECAUSE WE THOUGHT IT WAS IMPORTANT TO REALLY UNDERSTAND WHY THEY WOULD OR WOULD NOT BE DIFFERENT AND COMBED THROUGH THE EVIDENCE ON CARDIOVASCULAR DISEASE, THE WORKING GROUP FELT STRONGLY THE RELATIONSHIP BETWEEN BLOOD PRESSURE AND CARDIOVASCULAR DISEASE IS SUCH THAT IF WE ARE GOING TO AIM FOR CARDIOVASCULAR DISEASE REDUCTION AND FOR BLOOD PRESSURE REDUCTION STRATEGIES AND IMPLICATIONS WOULD BE SIMILAR. >> SECOND QUESTION IS FOR CVD OUTCOMES. SINCE YOU HAVE TWO CONCLUSION STATEMENTS, ONE I THINK IT WAS BASED ON IOM, EVIDENCE SUMMARY, ANOTHER ONE BASED ON NHLBI REPORT. AND THEN FOR THE FIRST CVD CONCLUSION STATEMENT YOU ASSIGNED EVIDENCE GRADE MODERATE. THE OTHER ONE WHICH IS RELATED TO NHLBI REPORT YOU ASSIGN LIMITED, SO I WANT TO MAKE SURE THAT I DIDN'T MISUNDERSTOOD THE DISTINCTIONS BETWEEN THE TWO STATEMENTS. >> THAT'S A GREAT QUESTION. SO LET ME CLARIFY WHAT'S HAPPENING THERE. WHEN THE IOM CONCLUSION STATEMENT IT IS RELATED TO THE FIND OF A POSITIVE RELATIONSHIP BETWEEN HIGHER LEVELS OF SODIUM INTAKE AND RISK OF CVD. AND FOR THE NHLBI SYSTEMATIC REVIEW, THAT IS RELATED TO THE EVIDENCE THAT A REDUCTION BY APPROXIMATELY 1,000 MILLIGRAMS PER DAY REDUCES CVD EVENTS BY 30%. >> IS THIS BASED ON THE RCTs? >> IT'S BASED ON RCT AND PROSPECTIVE COHORTS. >> FOR BOTH CONCLUSION STATEMENTS? >> FOR BOTH CONCLUSION STATEMENTS, YES. THE ISSUE IS -- THE ISSUE IS THAT THAT SPECIFICATION OF 1,000-MILLIGRAMS PER DAY REDUCTION, REDUCTION IN EVENTS BY 30% IS WHERE -- IS WHAT'S DIFFERENT BETWEEN THE TWO. >> BIT CONFUSING TO ME BECAUSE SEEMS THAT OVERALL CONCLUSION IS THAT THERE IS POSITIVE RELATIONSHIP BETWEEN SODIUM, HIGH SODIUM CONSUMPTION AND CVD INCIDENCE AND THEN IF YOU READ THE NHLBI SUMMARY, AND YOU MAY CONCLUDE THAT THERE IS NOT MUCH RELATIONSHIP BETWEEN HIGH SODIUM AND CVD SO IT'S A BIT CONTRADICTORY BASED ON THE -- >> FRANK, THIS IS ALICE LICHTENSTEIN, WHICH OF THE SUMMARIES ARE YOU READING THE -- THE AHACC SUMMARY THAT APPEARED IN CIRCULATION OR THE AHAACC SUMMARY THAT WERE -- APPEARED IN JAG? >> THIS ONE, RIGHT. THIS IS THE -- 1,000-MILLIGRAM PER DAY -- >> JUST BECAUSE THE REASON I'M BRINGING THAT UP IS BECAUSE THERE'S SLIGHT DIFFERENCES IN THE TWO REPORTS. SO WE'RE RELYING ON THE -- AND CHERYL, CORRECT ME IF I'M WRONG. THE NHLBI EVIDENCE REVIEW AND THEN WE ALSO RELY ON ONE OF THE ACCHA REPORTS? >> YES, I'M LOOKING -- YES WE ARE. SO I'M -- >> THE JACK ONE. >> JACK ONE, YEAH. >> THERE'S SLIGHT DIFFERENCES IN SODIUM, THAT'S THE ONLY REPORT AREA WHICH THEY DIFFER. >> THESE TWO STATEMENTS GAVE SOMEWHAT DIFFERENT IMPRESSIONS, THE RELATIONSHIP BETWEEN HIGH SODIUM AND CARDIOVASCULAR DISEASE AND YOU ASSIGN DIFFERENT EVIDENCE GRADE. I GUESS THAT'S THE REASON I'M CONFUSED. SO FRANK, I AGREE WITH YOU. WE ACTUALLY HAD A CLARIFICATION ON THIS FOR OUR WORKING GROUP. SO IT TURNS OUT WE WENT BACK TO THE NHLBI SYSTEMATIC REVIEW. AND LOOKED WITHIN THAT REVIEW CAREFULLY AT WHAT THE STRENGTH OF THE EVIDENCE WAS FOR THAT PARTICULAR 1,000-MILLIGRAMS PER DAY REDUCTION IN CDV BY 30%. THE ASSIGNMENT THERE WAS LOW. HOWEVER WHEN THEY MAKE THE FULL RECOMMENDATION IN TERMS OF CONSUMING NO MORE THAN 2400-MILLIGRAMS FURTHER REDUCTION 1500, AND REDUCTION BY 1,000-MILLIGRAMS PER DAY, IN THE JACK PUBLICATION, THAT IS GRADED IN ITS TOTALITY AS MODERATE. TO YOUR POINT DEPENDS WHETHER OR NOT YOU TEASE OUT ONE SPECIFIC ASPECT OF THAT RECOMMENDATION OR IF YOU LOOK AT THE RECOMMENDATION IN ITS FULL FORM. IN ITS FULL FORM THE EVIDENCE GRADE IS HIRE THAN IF YOU LOOK AT JUST ONE COMPONENT OF IT. >> THAT ONE COMPONENT I THINK IS TOO SPECIFIC. IT'S DIFFICULT FOR ANY OBSERVATIONAL STUDY OR TRIALS TO QUANTIFY 1,000-MILLIGRAM REDUCTION IN SODIUM LEAD TO 30% REDUCTION IN CVD. >> I AGREE YOUR POINT IS WELL TAKEN. OTHER MEMBERS OF THE WORKING GROUP I WOULD ENCOURAGE US TO GO BACK AND RETHINK ABOUT TEASING OUT AND GRADING THAT SPECIFIC ASPECT OF THE CONCLUSION. I ALSO WOULD LOVE TO HEAR OTHER COMMITTEE MEMBERS AS PERSPECTIVE ON THIS AS WELL. >> THIS IS WAYNE, I CONCUR WITH US REVISITING IT. >> THIS IS STEVE. THAT'S FINE. I THINK WE HAVE HAD A LOT OF KIND OF DISCUSSION ABOUT HOW TO BRING FORWARD THESE VARIOUS REPORTS AND MAKE SURE WE'RE CONSISTENT. >> THIS IS MARIAN, I HAVE A QUESTION IF WE'RE DONE DISCUSSING THAT PARTICULAR TOPIC. >> LET'S PAUSE FOR A SECOND AND SEE IF THERE'S ANYBODY ELSE TO CHIME IN. >> GO AHEAD, MARIAN. >> I HAVE TWO QUESTIONS, I'LL ASK ONE AT A TIME. THE FIRST IS ON THE IMPLICATIONS AND FRANK IMPLICATIONS ON A COUPLE OF SLIDES, THERE WAS A LOT OF INFORMATION ABOUT THE FOOD PROCESSING AND PRODUCTION LINES SO LABELLY FOOD PRODUCT FORMULATION AND SO FORTH. I THINK IT MIGHT BE USEFUL TO ALSO THINK ABOUT OUR SOCIO ECOLOGICAL MODEL ABOUT HOW THERE'S SEVERAL LAYERS THAT GO INTO FOOD CHOICE AND DIETARY PRACTICES, BECAUSE I DON'T SEE ANYTHING IN THERE EXCEPT ONE BULLET ABOUT DIET PLANNING TOOLS. I DON'T SEE ANYTHING IN THERE ABOUT ENCOURAGING HOME COOKING. HOME COOKING IS ONE OF THE WAYS WHERE WITHDRAW INGREDIENTS IS ONE WAY PEOPLE CAN MAIM AN IMPACT FOR THE SODIUM. A LOT OF THE INFORMATION ABOUT FDA AND FOOD PRODUCT FORMULATIONS AND SO FORTH, THAT ASSUMES USE OF A LOT OF PACKAGED FOODS. WHEN PEOPLE DO HOME COOKING FROM RAW INGREDIENTS, THEY CAN REALLY CONTROL THE AMOUNT OF SODIUM THAT IS IN THEIR DIET. BECAUSE WE HAVE BEEN THINKING ABOUT THE SOCIO ECOLOGICAL MODEL THAT'S INDIVIDUAL, THE FAMILY, THE IMMUNITY AND SO FORTH, I THINK THAT THAT MIGHT BE A REALLY USEFUL THING TO INCLUDE, TO TEACH COOKING AND TO ENCOURAGE PEOPLE TO COOK AND NOT RELY ON PURCHASING A LOT OF PRE-PREPARED MEALS AND PRE-PACKAGED FOODS, WHERE THERE IS A LOT OF SODIUM. >> THANK YOU, MIRIAM. IMPORTANT POINT, IT REMINDS ME OF SOME OF THE DATA MARY STORY PRESENTED IN ONE OF OUR EARLIER MEETINGS AROUND THE EATING BEHAVIORS OF AMERICANS. ALTHOUGH AMERICANS ARE NOT CURRENTLY PREPARING THEIR FOODS OR COOKING AT HOME IN THE PATTERNS THAT MIGHT LEAD TO US ACCOMPLISHING THE RECOMMENDED AMOUNT OF INTAKE, I THINK YOU'RE ABSOLUTELY IN LINE IN TERMS OF THE RECOMMENDATION TO SUGGEST THAT WE DO MORE OF THAT. >> THIS IS RAFAEL PEREZ-ESCAMILLA, I STRONGLY ENDORSE THE RECOMMENDATION MADE BY MARIAN AND I WANT TO ADD YOU DO MENTION BRIEFLY THE TOPIC OF IMPROVING INFORMATION THROUGH FOOD LABELS. BUT I THINK YOU REFER TO IT AS COMPLIMENTING A POLICY RECOMMENDATION. I THINK THAT FOOD LABEL RECOMMENDATIONS SHOULD BE AT THE LEVEL OF POLICY. I THINK FOOD LABEL LEGISLATION IS ONE OF THE MOST POWERFUL TOOLS THAT WE MAY HAVE IN OUR HANDS TO HELP THE U.S. POPULATION IMPROVE THEIR FOOD CHOICES AND IN THIS INSTANCE UNDERSTAND DIFFERENT LEVELS OF SODIUM THAT PROCESS FOODS HAVE. THAT'S NOT ALWAYS UNDERSTANDING FROM THE CURRENT LABEL AND WE KNOW THE FDA HAS BEEN WORKING ON THIS FOR A WHILE BUT THERE'S QUITE A BIT OF CONSUMERS RESEARCH THAT IS NEEDED TO BETTER UNDERSTAND WHICH IS THE BEST WAY OF THIS INFORMATION -- COMPARING THIS INFORMATION. SO MY SPECIFIC RECOMMENDATION IS FOR HOPEFULLY YOUR WORKING GROUP TO ELEVATE THE FOOD LABEL RECOMMENDATION TO POLICY LEVEL. NOT JUST AS AN ADJUNCT TO POLICY. >> THANK YOU, RAFAEL. I APPRECIATE I THINK OUR WORKING GROUP MEMBERS BASED ON SOME OF THE DISCUSSIONS THAT I HAVE HEARD OVER THE WEEKS WILL APPRECIATE WHAT BOTH YOU AND MARIAN SAID ABOUT ENCOURAGING HOME COOKING, WE RECENTLY HAD WERE MADE AWARE OF DATA AROUND INNOVATIVE THINGS HAPPENING IN TERMS OF TEACHING CONSUMERS HOW TO COOK, TAKING OUT SODIUM, PUTTING IN HERBS, SPICES, FLAVORING FOODS AND IN NEW AND DIFFERENT WAYS SO THAT FLAVOR ISN'T COMPROMISED AND THAT WE HAVE GREATER CONTROL OVER THE AMOUNT OF SODIUM THAT'S IN THE FOODS WE CONSUME. THANK YOU. WE WILL BRING THAT INFORMATION FORWARD. IN THE SECTION. >> THIS IS ALICE LICHTENSTEIN, GOING ALONG WITH THAT IF WE'RE GOING POTOMAC RECOMMENDATIONS ABOUT HOME COOKING WHICH I CERTAINLY SUPPORT, I THINK WE SHOULD ALSO BE COMMENTING ON THE VALUE OF TEACHING BASIC COOKING SCHOOLS AND SKILLS IN SCHOOLS. >> FROM K TO 12 AS AGE APPROPRIATE. >> THANK YOU, AGAIN, AND THE SOCIO ECOLOGIC MODEL, RIGHT? THAT'S GREAT. >> CONSISTENT. >> THIS IS BARBARA. I WANTED TO ALSO ADD THE DIMENSION GOING BACK TO THE SC 1 PRESENTATION ON METABOLIC DISEASE AND CO-OCCURRENCE OF MULTIPLE RISK FACTORS, BLOOD PRESSURE, OVERWEIGHT OBESITY, DISLIPIDEMIA AND SO FORTH IN INDIVIDUALS. WITH THE TRACKING OF BLOOD PRESSURE WITH AGE, AND GIVEN THE HIGH PREVALENCE OF OVERWEIGHT AND OBESITY, THE PRESENTATION AT THE INDIVIDUAL LEVEL IS LIKELY TO BE FAIRLY COMPLICATED. THE INDIVIDUAL PRESENTING NOT ONLY WITH ELEVATED BLOOD PRESSURE BUT ALSO WITH OTHER THINGS NOT THE AT LEAST LEAST OF WHICH MIGHT BE IN EXCESS BODY WEIGHT. I THINK THE NHLBI COROLLARY REPORTS EMPHASIZE LIFESTYLE AND WAIT MANAGEMENT THE IMPORTANCE OF MAKING THE AVAILABLE PREVENTIVE NUTRITION SERVICES OR MEDICAL NUTRITION THERAPY WHICH IS APPROPRIATE IN THE CASE OF MANY OF THESE INDIVIDUALS. I'M NOT ARGUING AT ALL AGAINST THE ENVIRONMENTAL APPROACHES WHICH ARE IMPORTANT GIVEN HOW UBIQUITOUS SODIUM IS IN OUR FOOD SUPPLY, I THINK THAT THAT -- THAT POINT IS MADE VERY WELL IN THE REPORT BUT I DO THINK THAT WE NEED TO COMPLIMENT THE ENVIRONMENTAL STRATEGIES WITH THE -- WITH THE APPROPRIATE ONE ON ONE AND SMALL GROUP INTERVENTIONS WHICH WE'VE HEARD A FAIR AMOUNT ABOUT AS BEING EFFECTIVE, SO I WOULD URGE YOU TO ALSO CALL OUT THE RECOMMENDATIONS FROM LIFESTYLE ON THE PREVENTIVE INTERVENTIONS AS WELL. >> THANKS, BARBARA. I THIS THEY ALSO FITS SQUARELY WITHIN THE FRAMEWORK OF THE SOCIO ECOLOGIC MODEL AS WELL. APPRECIATE THAT COMMENT. >> GREAT. THANK YOU. >> NO FURTHER DISCUSSION ON THAT. THIS IS RICK OLSON, LET'S TAKE A 15 MINUTE BREAK AND WE'LL RECONVENE AT 3:30 EASTERN TIME. >> RICK, CAN I ASK A QUESTION? I GOT FOR SOME REASON MY PHONE GOT CUT OFF. >> SURE. GO AHEAD. >> I GUESS WE'RE ALREADY IN BREAK BUT I HAD ANOTHER QUESTION FOR CHERYL. >> GO AHEAD. >> CHERYL, ARE YOU STILL ON THE LINE? >> YES, I AM. >> YOU KIND OF WENT QUICKLY OVER THE TWO STUDIES THAT YOU -- THE BIOMARKERS OR THE THREE STUDIES, I DON'T WANT TO SAY THAT THE WORK WAS DISMUSSED BUT IT WAS -- IT WAS ESSENTIALLY NOT USED. BECAUSE THOSE STUDIES IF I'M THINKING OF THE RIGHT STUDIES THAT YOU'RE REFERRING TO GOT A LOT OF PUBLICITY AND A LOT OF VISIBILITY I THINK IT DESERVES A LITTLE BIT MORE ATTENTION AS TO WHY THE FINDINGS FROM THOSE STUDIES ARE NOT BEING CONSIDERED. >> ACTUALLY, I APOLOGIZE IF I GAVE THE IMPRESSION THAT THEY ARE NOT BEING CONSIDERED. THEY WERE CONSIDERED QUITE HEAVILY. SO WE REVIEWED THE EVIDENCE PORTFOLIO, FOR THOSE STUDIES. AMONG OUR WORKING GROUPS RAN THROUGH THE STUDIES LOOKED AT THE EVIDENCE TABLE CAREFULLY AND WHAT WE CONCLUDED WAS THAT THEY WERE NOT OF -- THEY WOULD NOT CHANGE THE CONCLUSIONS THAT HAVE BEEN -- THAT HAD BEEN MADE BY THE PRIOR REPORT. BUT WE DID HOWEVER GO THROUGH THEM IN GREAT DETAIL. WE WILL ALSO BE WRITING ABOUT THEM IN THE SECTION OF THE REPORT BECAUSE YOU'RE ABSOLUTELY RIGHT. NOT ONLY DID THEY GET A LOT OF PUBLICITY BUT THEY REPRESENT A GOOD BIT OF HARD WORK. SO THEIR FINDINGS ARE INCONSISTENT WITH EACH OTHER, WITH EACH OTHER, THEY WERE NOT IN ANY WAY GOING TO CHANGE WHAT HAD BEEN CONCLUDED BY THE OTHER TWO REPORTS. >> THAT'S A HELPFUL CLARIFICATION. THANK YOU. >> SO YOU MEAN THE TWO PAPERS PUBLISHED IN NEW ENGLAND JURY ROOM OF MEDICINE THIS YEAR? >> THEY ARE ACTUALLY WHAT -- ONE IS -- ONE IS FROM THE PEER STUDY, YES. HAVING BEEN PUBLISHED IN THE NEW ENGLAND JOURNAL OF MEDICINE, THE OTHER IS EPIC NORFOLK COHORT, ANOTHER IS FROM TRIAL OF HYPERTENSION PREVENTION. ONE PREVENT STUDY, PREVENT RENAL VASCULAR END STAGE DISEASE. >> THANK YOU. >> YOU'RE WELCOME. >> ARE THERE ANY OTHER QUESTIONS? RICK, THEN WE'RE BACK TO YOU. >> LET'S TAKE A 15-MINUTE BREAK. WE'LL RESUME AT 3:35 EASTERN TIME ABOUT 16 MINUTES. THANKS. >> THANK YOU. >> I'LL TURN THINGS OVER TO MARY STORY, WHO WILL INTRODUCE THE ADDED SUGAR WORKING GROUP REPORT. >> THANK YOU, RICK. WELCOME BACKS, EVERYONE. THIS IS WE WILL TALK ABOUT, DISCUSS THE WORK OF THE ADDED SUGAR WORKING GROUP. THE ADDED SUGARS WORKING GROUP IS LED BY MIM NELSON AND MYSELF WITH ACTIVE MEMBERS OF CHERYL ANDERSON, MARIAN NEUHOUSER, WAYNE CAMPBELL, FRANK HU AND ALICE LICHTENSTEIN. THE SCOPE OF THE ADDED SUGARS WORKING GROUP WAS WE CAN'TED TO INFORM POTENTIAL RECOMMENDATIONS FOR ADDED SUGARS BY EXAMINING THE RELATIONSHIP BETWEEN INTAKE OF ADDED SUGAR AND HEALTH, EVALUATING THE AMOUNT OF ADDED SUGARS THAT CAN BE CONSUMED WHILE MEETING FOOD GROUP AND NUTRIENT NEEDS WITHIN THE USDA FOOD PATTERN. AND WE WANTED TO CONSIDER THE EVIDENCE ON LOCALRY SWEETNERS USED TO REPLACE ADDED SUGAR IN SOME FOODS AND BEVERAGES. THIS WAS SHOWN ON THE LAST -- AT LAST PUBLIC MEETING BUT DEFINITION WE'RE USING FOR ADSED SUGAR IS PROPOSED FDA DEFINITION. AND THIS IS SUGARS THAT ARE EITHER ADDED DURING THE PROCESSING OF FOODS OR ARE PACKAGED AS SUCH AND INCLUDES SUGARS, MONOAND DISACCHARIDES, SYRUPS, NATURALLY OCCURRING SUGARS ISOLATEED FROM A WHOLE FOOD AND SON CONCENTRATE SOD THAT SUGAR IS THE PRIMARY CONULE POINT, FOR EXAMPLE, FRUIT JUICE CONCENTRATE. AND OTHER CALORIC SWEETNERS. WE HAD NO INVITED EXPERTS OR CONSULTANT MEMBERS SINCE THE LAST PUBLIC MEETING. AND TODAY WE'RE GOING TO LOOK AT THE QUESTIONS AND THE FINDINGS FROM VARIOUS TOPICS. MIM NELSON WILL LOOK AT BODY WEIGHT AND OBESITY, THEN WAYNE CAMPBELL WILL TALK TYPE 2 DIABETES, FRANK HU WILL TALK CARDIOVASCULAR DISEASE AND ADD PSEUDOGARS, EEL DISCUSS DENTAL T MARIAN NEUHOUSER WILL TALK FOOD GROUP AND NUTRIENT ADEQUACY AND WAYNE CAMPBELL WILL COVER EVIDENCE ON LOCALRY SWEETNERS. THEN WE WILL GO OVER THE IMPLICATIONS AND THE CONCLUSIONS STATEMENTS. MIM WILL START AND LOOK AT THE RELATIONSHIP BETWEEN THE INTAKE OF ADDED SUGARS AND BODY WEIGHT. >> THANK YOU, MARY, IT'S A PLEASURE TO BE HERE AND PRESENT THIS. NEXT SLIDE, PLEASE. SO IN TERMS OF THE QUESTION AROUND BODY WEIGHT AND ADDED SUGARS, WE USE THE -- WE USE SYSTEMATIC REVIEWS, THE WHO COMMISSIONED A SYSTEMATIC REVIEW META ANALYSIS WHICH IS PUBLISHED IN 2013. WE SUPPLEMENTED THAT WITH TWO OTHER SYSTEMATIC META ANALYSES PUBLISHED SINCE THAT TIME. IN TERMS OF ADDED SUGARS, THAT WERE INCLUDED IN THE REVIEWS, WHO EXAMINED FREE SUGAR, I'M NOT GOING TO GET OFF TOPIC HERE AND DO A DEFINITION OF FREE SUGARS BUT IT IS VERY CLOSE TO ADDED SUGARS, WE CAN GO INTO THIS MORE AT THE END. THEN THE OTHER TWO REVIEWS FOCUSED ON SUGAR SWEETENED BEVERAGES PRIMARILY. IN TOTAL 92 ARTICLES WERE CONSIDERED IN THESE INTERVIEWS INCLUDING A SIMILAR NUMBER OF RCTs AND PERSPECTIVE COHORT STUDIES INCLUDING CHILDREN AND ADULTS. KEY FINDINGS CONSUMING INTAKE OF ADDED SUGARS OR SUGAR SWEETENED BENCHES IS ASSOCIATED WITH UNFAVORABLE WEIGHT STATUS IN CHILDREN AND ADULTS. THERE'S A CLEAR BENEFIT OF WEIGHT REDUCTION WITH SUGAR SWEETENED BEVERAGE REDUCTION OVERWEIGH CHILDREN AND ADULTS. OUR DRAFT CONCLUSION FOR THIS QUESTION IS THAT STRONG AND CONSISTENT EVIDENCE INDICATES THAT INTAKE OF ADDED SUGARS FROM FOOD AND/OR SUGAR SWEETENED BEVERAGES ARE ASSOCIATED WITH UNFAVORABLE BODY WEIGHT IN CHILDREN AND ADULT T. THE REDUCTION OF ADDED SUGARS AND SUGAR SWEETENED BEVERAGES IN THE DIET REDUCES BMI IN CHILDREN AND ADULTS. COMPARISON GROUPS WITHIN THE HIGH VERSUS LOWEST INTAKE OF ADDED SUGARS IN COHORT STUDIES, WERE COMPATIBLE WITH THE RECOMMENDATION TO KEEP ADDED SUGAR INTAKE BELOW 10% OF ENERGY INTAKE. LOOKING AT THESE REPORTS WE FELT THAT THERE WAS CONSISTENT EVIDENCE, THERE WAS A LARGE BODY OF EVIDENCE, AND THE QUALITY OF THE STUDIES WERE OF THE REVIEWS WAS VERY HIGH, WE GIVE THE EVIDENCE CONCLUSION STATEMENT A STRONG GRADE WE'RE GOING GO THROUGH EACH QUESTION NOW AND WE WILL OPEN IT UP FOR QUESTIONS AFTERWARDS. MOVING TO WAYNE IN TERMS OF TYPE 2 DIABETES AND ADDED SUGARS. >> THANK YOU, MIM. THE QUESTION IN HAND IS WHAT IS THE RELATIONSHIP BETWEEN INTAKE OF ADDED SUGARS AND TYPE 2 DIABETES AND THIS WAS THIS WAS ACCOMPLISHED BY THIS REVIEW WAS ACCOMPLISHED BY USING EXISTING REPORTS. THERE WERE FIVE SYSTEMATIC REVIEWS IN META ANALYSIS PUBLISHED THE LAST FIVE YEARS THAT WE USE AS BODY OF EVIDENCE, FOUR REVIEWS SUGAR SWEETENED BEVERAGES ONE EXAMINED SUGAR INTAKE MORE BROADLY. IN TOTAL THERE WERE 17 ARTICLES FROM THESE REVIEWS WHICH JUST UNDER HALF WERE INCLUDED IN TWO OR MORE REVIEWS. AND ALL THESE PROSPECTIVE COHORT STUDIES IN THESE REVIEWS WERE WITH ADULTS SO THIS INFORMATION, THE KEY FINDINGS AND CONCLUSIONS THAT WE ARE PRESENTING HERE ON THE NEXT SLIDE ARE SPECIFIC TO ADULTS. FIRST KEY FINDING IS INCREASED CONSUMPTION OF SUGAR SWEETENED BEVERAGES IS CONSISTENTLY ASSOCIATED WITH INCREASED RISK OF TYPE 2 DIABETES. THESE -- THIS POSITIVE ASSOCIATION BETWEEN SUGAR SWEETENED BENCHES AND TYPE 2 DIABETES IS ATTENUATE BUD EXISTS AFTER ADJUSTMENT FOR BODY MASS INDEX. AND THE REASON FOR THAT LAST PART IS BECAUSE OF THE WELL KNOWN ASSOCIATION BETWEEN BODY WEIGHT AND THE RISK FOR TYPE 2 DIABETES. SO IN CONCLUSION, HIGHER CONSUMPTION OF ADDED SUGARS ESPECIALLY SUGAR SWEETENED BEVERAGES INCREASE RISK OF TYPE 2 DIABETES AMONG ADULTS AND THIS RELATIONSHIP IS NOT EXPLAINED BY BODY WEIGHT AND OUR GRADE IS THE EVIDENCE WAS CONSISTENT AND STRONG. SO WE'LL MOVE ON TO CARDIOVASCULAR DISEASE WITH FRANK HU. >> THANK YOU. THE QUESTION WE WANT TO ADDRESS WHAT IS THE RELATIONSHIP BETWEEN THE INTAKE OF ADDED SUGAR AND CARDIOVASCULAR DISEASE. WE CONDUCTED SYSTEMATIC REVIEW BECAUSE THERE'S NO EXISTING META ANALYSIS OR SYSTEMATIC REVIEWS ADDED SUGAR IN THE CARD SLOW OWE VASCULAR OUTCOMES. THIS IS HOW AN UNIQUE FRAMEWORK, TARGET POPULATION IS HEALTHY ADULTS, THERE WERE FEW STUDIES CONDUCTED AMONG CHILDREN FOR 93 STUDIES OR INTERVENTION STUDIES REVIEW WAS FOCUSED ON ADULTS. THE INTERVENTION OR EXPOSURE WAS ADDED SUGARS INCLUDING SUGAR SWEETENED BEVERAGES IN FACT MOST OF THE OBSERVATIONAL STUDIES EVALUATED SUGAR SWEETENED BEVERAGES IN RELATION TO HEALTH OUTCOMES. INTERMEDIATE OUTCOMES INCLUDE BLOOD LIPIDS, INCLUDING LDL, HDL TRIGLYCERIDE AND BLOOD PRESSURE. AND INCIDENCE OF HYPERTENSION. THE HEALTH OUTCOMES INCLUDE INCIDENCE MYOCARDIAL INFARCTION INCIDENCE OF STROKE, INCIDENT OF SAFETY, AND CVD RELATED MORTALITY. >> THIS LITERATURE SEARCH WAS CONDUCTED ON THE PUBLICATION PUBLICATIONS BETWEEN JANUARY 2000 AND AUGUST 2014. IN PEER REVIEWED JOURNALS. THE STUDY DESIGNS OF PUBLICATIONS INCLUDED RANDOMIZED OR NON-RANDOMIZED CONTROL TRIALS PERSPECTIVE COHORT STUDIES, CASE CONTROL STUDIES. SIEGA-RIZ THE INTERVENTION OR EXPOSURE AGAINST ADDED SUGAR AT DIFFERENT LEVELS, BOTH PERSPECTIVE COHORT STUDIES SUGAR SWEETENED BEVERAGES AS PRIMARY EXCLUSION VARIABLE. SAGA RAISE THERE ARE INITIAL LITERATURE RESEARCH IDENTIFIED MORE THAN 5,000 ARTICLES SIEGA-RIZ FROM SEVERAL DATABASES AND AFTER EXCLUDING THOSE ARTICLES THAT WERE -- DID NOT MEET INCLUSION EXCLUSION CRITERIA, WE LAYER IT DOWN TO 23 STUDIES AND THOSE STUDIES WERE INCLUDED IN THE SUSPECT REVIEW. AMONG THE 23 STUDIES 11 OF THEM WERE INTERVENTION STUDIES, TRIALS, PERSPECTIVE COHORT STUDIES. MAJORITY OF THE STUDIES PROVIDED SOME EVIDENCE POSITIVE RELATIONSHIP BETWEEN HIGHER ADDED SUGAR ESPECIALLY IN THE FORM OF SUGAR SWEETENED BEVERAGES AND THE RISK OF CARDIOVASCULAR DISEASE. WE FOUND MORE CONSISTENT ASSOCIATIONS BETWEEN ADDED SUGAR AND ELEVATED SERUM TRIGLYCERIDE BLOOD PRESSURE AND INCREASE INCIDENCE HYPERTENSION STROKE OR CORONARY HEART DISEASE. THE EVIDENCE FOR ASSOCIATION BETWEEN ADDED SUGAR AND DISLIPIDEMIA INCLUDING REDUCED HDL AND INCREASED TOTAL LDL CHOLESTEROL WAS NOT CONSISTENT ESPECIALLY AMONG INTERVENTIONS STUDY. Z WE IDENTIFIED SEVERAL MAJOR LIMITATIONS IN THE TRIGLYCERIDE STUDIES THAT WE REVIEWED. IN THE INTERVENTION STUDIES THERE WAS EXTENSIVE HETEROGENEITY IN THE TYPES AND FORMS OF SUGAR USED, SOME STUDIES LOCAL I -- FRUCTOSE GLUCOSE OTHER STUDIES FRUCTOSE VERSUS ANOTHER TYPE OF SUGAR. SEVERAL STUDIES EVALUATED THE EFFECT OF SUGAR SWEETENED BEVERAGES OR SWEETENED MILK. IN THE INTERVENTION STUDIES THE TYPE OF CONTROL AND THE CALORIC CONDITIONS DIFFERED SUBSTANTIALLY ACROSS THE STUDIES. AND MOST OF THE INTERVENTION STUDIES HAD SMALL SAMPLE SIZE AND HAD SHORT DURATION OF INTERVENTION. MOST OBSERVATIONAL STUDIES ONLY ASSESSED DIETARY INTAKE AT BASELINE. AND DID NOT TAKE ASSESSMENTS DURGANUP. -- FOLLOW-UP. THIS IS A DRAFT CONCLUSION STATEMENT, ADDED SUGAR AND CARDIOVASCULAR DISEASE, EVIDENCE FROM PERSPECTIVE COHORT STUDIES INDICATES THAT HIGH INTAKE OF ADDED SUGAR ESPECIALLY IN THE FORM OF SUGAR SWEETENED BEVERAGES IS CONSISTENTLY ASSOCIATED WITH INCREASE RISK OF HYPERTENSION, CORONARY HEART DISEASE IN ADULTS. OBSERVATIONAL INTERVENTION STUDIES INDICATE HIGHER -- >> I'M GOING TO INTERJECT. THIS IS KELLIE FROM HHS. WE WEREN'T ABLE TO HAIR THE SECOND HALF OF YOUR CONCLUSION STATEMENT. IF YOU COULD START AGAIN WITH THE CONCLUSION STATEMENT ON THE SLIDE, THAT WOULD BE GREAT. AND IF WE'RE UNABLE TO HEAR EWE, WE WILL LET YOU KNOW. >> OKAY. THIS IS OUR DRAFT CONCLUSION STATEMENT. EVIDENCE FROM PERSPECTIVE COHORT STUDIES INDICATES THAT HIGH INTAKE OF ADDED SUGARS ESPECIALLY IN THE FORM OF SUGAR SWEETENED BEVERAGES IS CONSISTENTLY ASSOCIATED WITH INCREASE RISK OF HYPERTENSION, STROKE CORONARY HEART DISEASE IN ADULTS, OBSERVATIONAL AND INTERVENTION STUDIES INDICATE CONSISTENT RELATIONSHIP BETWEEN HIGHER ADDED SUGAR INTAKE AND HIGHER BLOOD PRESSURE IN SERUM TRIGLYCERIDES THE EVIDENCE GRADE IS MODERATE. >> I'LL DISCUSS NOW THE RELATIONSHIP BETWEEN THE INTAKE OF ADDED SUGAR AND DENTAL CARRIES AND FOR THIS WE USE A SYSTEMATIC REVIEW. WE LOOKED AT THE WHO COMMISSION SYSTEMATIC REVIEW THAT WAS PUBLISHED RECENTLY IN 2014, THIS WAS LOOKING AT THE EFFECT OF CARRIES OF RESTRICTING SUGAR INTAKE AND IT WAS A SYSTEMATIC REVIEW TO INFORM WHO GUIDELINES. HERE THEY EXAMINED TOTAL SUGARS, FREE SUGARS, ADDED SUGARS, AND ADDED -- FREE AND ADDED SUGARS ARE SIMILAR AND I CAN TALK ABOUT THE DIFFERENCE DURING THE DISCUSSION. SUCROSE, NON-MILK EXTRINSIC SUGARS BUT THE MAJORITY OF THE STUDIES REALLY LOOKED AT FREE SUGARS. THERE WERE 65 PAPERS AND WE LOOKED AT INCLUDED IN THE REVIEW ARE 55 STUDIES FROM 1950 TO 2011. THE VAST MAJORITY WERE IN CHILDREN AND ADOLESCENTS, ONLY FOUR IN ADULTS. OF THE 55 STUDIES THERE WERE THREE INTERVENTION STUDIES, EIGHT PERSPECTIVE COHORT STUDIES, 20 POPULATION STUDIES, AND 24 CROSS SECTIONAL STUDIES. THERE WERE NOT ANY RANDOMIZED CONTROL STUDIES. THE KEY FINDINGS ARE THAT THE LARGELY CONSISTENT EVIDENCE SUPPORTS THE RELATIONSHIP BETWEEN THE AMOUNT OF SUGAR INTAKE AND THE DEVELOPMENT OF DENTAL CARRIES ACROSS ALL THE AGE GROUP STUDY -- AGE GROUPS THAT WERE STUDIED. THE DENTAL CARRIES OUTCOME INCLUDED CARRIES, PREVALENCE, INCIDENCE, AND/OR SEVERITY OF CARRIES. THE FINDINGS WERE THAT 42 OUT OF THE 50 STUDIES IN CHILDREN AND FIVE OUT OF FIVE STUDIES IN ADULTS REPORTED AT LEAST ONE POSITIVE ASSOCIATION BETWEEN SUGARS AND CARIES. OUR DRAFT CONCLUSION STATEMENT WAS THAT THE DTA -- DGAC CONCURS WITH THE WORLD HEALTH ORGANIZATION, COMMISSION SYSTEMATIC REVIEW, THAT THERE IS MODERATE CONSISTENT EVIDENCE SUPPORTING A RELATIONSHIP BETWEEN AMOUNT OF SUGARS INTAKE AND THE DEVELOPMENT OF DENTAL CARIES AMONG CHILDREN AND ADULT. THERE'S ALSO EVIDENCE OF MODERATE QUALITY SHOWING THAT CARRIES ARE LOWER WHEN SUGAR INTAKE IS LESS THAN 10% OF ENERGY INTAKE. THE GRADE EVIDENCE GRADE WAS MODERATE. >> THIS IS MARIAN NEUHOUSER, I WILL BE TALKING ABOUT ADDED SUGARS AND FOOD GROUP AND NUTRIENT ADEQUACY WITH THE FOLLOWING QUESTION. HOW MANY CALORIES ARE AVAILABLE IN THE USDA FOOD INTAKE PATTERNS AFTER THE FOOD GROUP AND NUTRIENT RECOMMENDATIONS THAT COULD BE CONSUMED AS ADDED SUGARS. THIS QUESTION WAS ADDRESSED IN CONJUNCTION WITH FOOD PATTERN MODELING, WE HAVE COMPLETED AS PART OF SC 1 ACTIVITY. SO FROM OUR EARLIER SLIDES YOU MAY REMEMBER WE HAVE THREE HEALTHY EATING PATTERNS RIGHT NOW THAT WE PRESENTED EARLIER TODAY. THE HEALTHY U.S. STYLE PATTERN HEALTHY MEDITERRANEAN STYLE PATTERN AND HEALTHY VEGETARIAN PATTERN. WE HAVE 12-CALORIE LEVELS. YOU MAY REMEMBER THAT ONE OF THE GOALS OF THE FOOD PATTERN MODELING IS TO SELECT FOODS THAT ARE NUTRIENT DENSE AND PROVIDE THE RDA FOR ALL IMPORTANT VITAMINS AND MINERALS WHILE MAINTAINING ENERGY BALANCE NOT EXCEEDING CALORIC INTAKE. AFTER WE COMPLETE THAT EXERCISE FOR -- WE COME UP WITH DRAFT SUGGESTIONS FOR THE FOOD GROUP INTAKE AS YOU SAW FROM THE SLIDES EARLIER TODAY, THIS IS MORE OR LESS WHAT WE CAN THINK ABOUT IS LEFT FOR EMPTY CALORIES THAT WOULD BE AVAILABLE SO THAT ONE DOES NOT EXCEED CALORIES THAT THEY NEED FOR EACH DAY. SO CALLED EMPTY CALORIES ASSUMED ABOUT 55% OF THOSE COMES FROM SOLID FAT AND 45% COMES FROM ADDED SUGARS. THE FIRST SET OF ROWS THAT YOU SEE IS THE NUMBER OF CALORIES FROM ADDED SUGARS THAT WOULD BE AVAILABLE FROM EACH ONE OF THOSE PATTERNS, ACROSS THE DIFFERENT CALORIE LEVELS. AND BOTTOM ROW FOR THE AVERAGE, THAT SHOWS ON AVERAGE HOW MANY CALORIES WOULD BE AVAILABLE FOR SOMEONE OF ADDED SUGAR. AS CAN EXAMPLE IF YOU LOOK AT THE 2000-CALORIE LEVEL WE USED EARLIER TODAY AS A BALLPARK EXAMPLE, 123-CALORIES ARE AVAILABLE TO CONSUME AS ADDED SUGARS. THE SECOND SET OF ROWS AT THE BOTTOM, LISTS THE HEALTHY EATING PATTERNS AGAIN AND AGAIN AN AVERAGE AND THIS SHOW IT IS CALORIE LEVELS AS A PERCENT OF THE TOTAL CALORIES. SO YOU SEE FROM THE BOTTOM ROW THE PERCENT OF CALORIES OF TOTAL CALORIES AVAILABLE AS ADDED SUGARS RANGES FROM 4% OF TOTAL CALORIES UP TO 8% OF TOTAL CALORIES. SOME OF THIS VARIES DEPENDING UPON THE CALORIE LEVEL. SO ON AVERAGE TO SUMMARIZE BETWEEN 4 AND 8% OF CALORIES, COULD BE AVAILABLE AS ADDED SUGARS FROM ANY HEALTHY EAT EATING PATTERNS. >> OKAY. MARIAN, THANK YOU VERY MUCH. THIS IS WAYNE CAMPBELL. THE LAST TOPIC THAT WE'RE GOING TO DISCUSS BEFORE WE OPEN UP FOR DISCUSSIONS OR PRESENT BEFORE WE OPEN FOR DISCUSSIONS ARE FOCUS ON LOCALRY SWEETNERS WE HAD FOUR TOPICS THAT WE WERE CONSIDERING, THE INFLUENCES OF LOCALRY SWEETNERS ON BODY WEIGHT, CARDIOVASCULAR DISEASE, TYPE 2 DIABETES AND DENTAL CARIES, PLAN TOO USE EXISTING REPORTS SYSTEMATIC REVIEWS META ANALYSES, THOSE REPORTS AND MANUSCRIPTS ONLY EXIST FOR BODY WEIGHT AND FOR TYPE 2 DEE BEE TEASE. -- DIABETES. SO WE WILL NOT BE PRESENTING ANY INFORMATION ON CARDIOVASCULAR DISEASE OR DENTAL CARIES. NOT THAT WE DIDN'T CONSIDER THEM BUT THE REPORTS AVAILABLE TO ADDRESS THE ISSUES WERE NOT FOUND. WHEN WE START WITH THE EVIDENCE ON SPECIFIC TO BODY WEIGHT THERE WERE THREE SYSTEMATIC REVIEWS IN META ANALYSES PUBLISHED IN THE LAST FIVE YEARS THAT WE RELIED ON, ALL THESE -- THE PAPERS THAT WERE PART OF THESE REVIEWS COMBINED AND ASSESSED A VARIETY OF LOCALRY SWEETNERS, SO THERE'S NO INFORMATION REVIEWS ON SPECIFIC COMPOUNDS AS A LOCALRY SWEETENER. FINDINGS ARE BASED ON THE GENERAL TOPIC OR CATEGORY OF LOCALRY SWEETENERS. THERE WERE 39 ARTICLES, IN THE REVIEW OF WHICH SIX WERE INCLUDED IN BOTH REVIEWS. IN AT LEAST TWO OF THE REVIEWS. AND THE RESEARCH THAT EXPERIMENTAL DESIGNS THAT WERE USED WERE BOTH RANDOMIZED CONTROL TRIALS AS WELL AS PROSPECTIVE COHORT STUDIES. AND I'LL COME BACK TO THAT AND THE EXPERIMENTAL DESIGNS HAVE AN INFLUENCE ON HOW WE MIGHT INTERPRET THE FINDINGS. OUR KEY FINDINGS WERE EVIDENCE SPECIFICALLY FROM RANDOMIZED CONTROL TRIALS CONSISTENTLY INDICATES THAT LOCALRY SWEETNERS IN COMPARISON TO SUGAR CONTAINING FOODS AND BEVERAGES MODESTLY REDUCES BODY WEIGHT IN ADULTS. THERE IS ALSO EVIDENCE FROM ADULTS AND FROM CHILDREN THAT THAT SWEETENERS REDUCE BODY INDEX FAT MASS AND WASTE CIRCUMFERENCE, SO SO OUR DRAFT CONCLUSION STATEMENT IS THAT MODERATE AND GENERALLY CONSISTENT EVIDENCE FROM SHORT TERM RANDOMIZED CONTROL TRIALS CONDUCTED IN ADULTS AN CHILDREN SUPPORT THAT REPLACING SUGAR CONTAINING SWEETNERS WITH LOCALRY SWEETNERS REDUCES ENERGY INTAKE, BODY WEIGH AND ADIPOSITY AND WE GRADE THIS AS MODERATE EVIDENCE. THE SECOND CONCLUSION IS THAT LONG TERM OBSERVATIONAL STUDIES CONDUCTED IN CHILDREN AND ADULTS PROVIDE INCONSISTENT EVIDENCE OF ASSOCIATION BETWEEN LOCALRY SWEETNERS AND BODY WEIGHT AS COMPARED TO SUGAR CONTAINING SWEETNERS. THIS IS GRADED AS LIMITED. OUR -- THE OTHER QUESTION WE WERE ABLE TO FIND EXISTING REPORTS TO ADDRESS WAS THE ASSESSMENT OF ASSOCIATIONS BETWEEN LOCALRY SWEETNERS AND TYPE 2 DIABETES. FOR THIS QUESTION WE USE TWO SYSTEMATIC REVIEWS IN META ANALYSES PUBLISHED IN THE LAST FIVE YEARS. DATA FROM ONE REVIEW IS REPRESENTED IN THE SECOND REVIEW. THESE REVIEWS EXAMINED ARTIFICIALLY SWEETENED SOFT DRINKS, THAT WAS THE TERMINOLOGY THAT THEY USED OPPOSED TO ARTIFICIALLY SWEETENED BENCHES, THEY USED IT SPECIFICALLY ON SOFT DRINKS. WHAT WE FOUND IS BOTH STUDIES BOTH REVIEWS, I SHOULD SAY, REPORT POSITIVE ASSOCIATION BETWEEN ARTIFICIALLY SWEETENED SOFT DRINKS AND TYPE TWO DIABETES RISK. THAT WAS CONFOUNDED BY WEIGHT STATUS. IF YOU'LL RECALL BACK TO SUGAR SWEETENED BEVERAGE AND TYPE 2 DIABETES REVIEW OF EVIDENCE A POSITIVE ASSOCIATION BETWEEN THOSE TWO WAS ALSO ESTABLISHED THAT REMAINED AFTER CORRECTING FOR BODY MASS INDEX. IN THIS CASE CORRECTIONS FOR ACCOUNTING FOR BODY MASS INDEX WAS NEGATED OR ELIMINATED VIA PARENT ASSOCIATION. EXPERIMENTAL DESIGNS OF THESE STUDIES PRECLUDES THE ASSESSMENT OF CAUSE AND EFFECT RELATIONSHIPS. DISPARATE FINDINGS BODY MASS INDEX IS VERSUS IS NOT INCLUDED IN THE STATISTICAL MODEL ADDS COMPLEXITY TO THE ISSUE. BY THAT WE MEAN THERE SEEMS TO BE PROFOUND CONFOUND PROFOUND CONFOUNDING OF BODY WEIGHT IN THE PARENT ASSOCIATION FROM THE PROSPECTIVE STUDIES AND WHEN YOU ACCOUNT FOR BODY MASS INDEX, THERE IS -- DOES NOT SEEM TO BE ANY RELATIONSHIP BETWEEN ARTIFICIALLY SWEETENED SOFT DRINKS AND TYPE 2 DIABETES. SO OUR CONCLUSION IS LONG TERM OBSERVATIONAL STUDIES CONDUCTED IN ADULTS PROVIDE INCONSISTENT EVIDENCE OF AN ASSOCIATION BETWEEN LOCALRY SWEETNERS AND RISK FOR TYPE 2 DIABETES, GRADE OF LIMITED. AT THIS POINT I WILL TURN TO MIM NELSON FOR ADDED SUGARS. >> THANK YOU, WAYNE. FOR ADDED SUGARS OUR WORKING GROUP FELT IT WAS IMPORTANT TO HAVE ONLY ONE IMPLICATION STATEMENT THAT REALLY INTEGRATED ALL OF OUR CONCLUSIONS THIS IS OUR IMPLICATION, DRAFT IMPLICATION STATEMENT. OBESITY TYPE 2 DIABETES, CARDIOVASCULAR DISEASE AND DENTAL CARIE, ARE MEN IT WILL HEALTH CONCERN, ADD PSEUDOTOWARD HAS NEGATIVE IMPACT ON ALL THESE CONDITIONS AN STRONG EVIDENCE SUPPORTS REDUCING ADDED SUGAR INTAKE TO REDUCE HEALTH RISK. ADDED SUGARS ARE USED IN FOOD BEVERAGE PROCESSING AND PROVIDE ENERGY BUT NO OTHER NUTRIENTS. IN ORDER TO ENSURE HIGH QUALITY NUTRIENT DENSE DIETARY PATTERN BALANCED IN CALORIES, THE U.S. POPULATION SHOULD MINIMIZE INTAKE OF ADDED SUGARS. THIS RECOMMENDATION IS SUPPORTED BY THE FOOD PATTERN MODELING ANALYSIS CONDUCTED BY THE DGAC, THIS ANALYSIS BASED ON THE HEALTHY US STYLE PATTERN, THE HEALTHY VEGETARIAN PATTERN AND THE HEALTHY MEDITERRANEAN STYLE PATTERN DEMONSTRATES THAT BETWEEN 3 TO 9% OF TOTAL CALORIES DEPENDING UPON CALORIE LEVEL FROM ADDED SUGARS IN FOODS AND BEVERAGES CAN BE INCLUDED IN A HEALTHY DIETARY PATTERN AND MARIAN SHOWED THIS. THE COMMITTEE RECOMMENDS LIMITING ADDED SUGARS TO NO MORE THAN 10% OF TOTAL DAILY CALORIE INTAKE. THE SCIENTIFIC EVIDENCE ON ADDED SUGARS ON CHRONIC DISEASE RISK COUPLED WITH THE FOOD PATTERN MODELING SUPPORTS THIS LIMIT. GIVEN THE AVERAGE CURRENT INTAKE OF THE U.S. POPULATION IS 13.4% THIS 10 PRESIDENT OF REASONABLE GOAL. WHEN LOCALRY SWEETNERS ARE USED TO REPLACE SUGAR IT IS REDUCTION IN CALORIES RETRIEVE SHORT TERM WEIGHT LOSS. THERE'S INSUFFICIENT EVIDENCE TO RECOMMEND THE USE OF LOCALRY SWEETENERS AS A STRATEGY FOR LONG TERM WEIGHT LOSS AND WEIGHT MAINTENANCE. NEXT SLIDE. THE RECOMMENDATION TO LIMIT ADDED SUGARS ESPECIALLY SUGAR SWEETENED BEVERAGES IS IN LINE WITH RECOMMENDATIONS FROM NATIONAL AND INTERNATIONAL ORGANIZATIONS INCLUDING THE AMERICAN ACADEMY OF PETTED PEDIATRICS. WHO, CDC AHA AND ADA. POLICIES AND PROGRAMS A LOCAL STATE AND NATIONAL LEVEL IN BOTH PRIVATE SECTOR AND PUBLIC SECTOR ARE NECESSARY TO SUPPORT EFFORTS TO LOWER ADDED SUGARS IN FOODS AND BEVERAGES AND LIMIT AVAILABILITY OF SUGAR SWEETENED BEVERAGES, AND WE BELIEVE THESE PROGRAMS POLICIES AND PROGRAMS SHOULD HELP TO BENEFIT INDIVIDUAL BEHAVIOR AS WELL AS THE PRIVATE SECTOR. THE NUTRITION FAX PANEL WE BELIEVE SHOULD INCLUDE ADDED SUGARS IN GRAMS AND TEASPOONS AND INCLUDE A PERCENT DAILY VALUE IN ORDER TO ASSIST CONSUMERS IN IDENTIFYING THE AMOUNT OF ADDED SUGAR IN FOODS AND BEVERAGES TO HELP MAKE INFORMED DECISIONS. THIS IS NOW OPEN FOR DISCUSSION AND MARY I WILL LET YOU MODERATE DISCUSSIONS. I'M SURE THAT OUR WORKING GROUP WILL PIPE IN TO SUPPORT YOU. >> DOES ANYONE FROM THE WORKING GROUP WANT TO MAKE ANY COMMENTS BEFORE WE OPEN IT UP? >> I MIGHT MAKE AN OVERALL COMMENT, THIS IS MIM NELSON, IT COMES OUT IN THE IMPLICATION STATEMENT, BUT IT WAS REMARKABLE HOW STRONG THE EVIDENCE WAS HERE AND THAT THE -- IF YOU WILL, THE TRIANGULATION BETWEEN THE FOOD MODEL, THE FOOD PATTERN MODELING, AS WELL AS THE EVIDENCE AROUND ELEVATED RISK OF MANY CHRONIC DISEASES WITH ADDED SUGARS, IT'S SORT OF WAS REMARKABLE HOW WELL IT ALL CAME TOGETHER AND HOW STRONG THE EVIDENCE WAS. >> THIS IS BARBARA. I WOULD CONCUR WITH THAT, I THINK THE GROUP IS REALLY TO BE CONGRATULATED ON NOT ONLY IDENTIFYING AND REVIEWING THESE EXCELLENT REVIEWS BUT ALSO DOING DE NOVO ANALYTICAL WORK AS WELL, WHICH IS JUST GREAT BECAUSE I THINK THE STORY IS REALLY VERY COHERENT. I MIGHT JUST RECOMMEND THAT THE APROPOS OF YOUR OWN RECOMMENDATIONS ABOUT FORMATTING THE INFORMATION WITH GRAMS AND THE HOUSEHOLD MEASURE TEASPOON, TO ADD THAT TO YOUR GRAPH AS WELL WHERE YOU HAVE GOT THE CALORIE LEVELS AND THE PERCENT IN THE GRAMS, WHY NOT THE HOUSEHOLD EQUIVALENT AS CLOSE AS YOU CAN GET IT. SO -- >> THAT'S A VERY GOOD IDEA. THANK YOU. >> WHAT WE HAVE DONE IN SOME OF THE OTHER SC 1 TABLES TO REALLY MAKE IT AS READABLE AS POSSIBLE, I THINK THAT WOULD BE GREAT. >> I CAN DO THAT, THANK YOU. >> DULY NOTED. >> THIS IS ALICE. IT'S REALLY NICE TO SEE ALL OF IT, ALL THE DATA BEING PULLED TOGETHER. ONE THING THAT STRUCK ME, THOUGH, A LOT OF THE INFORMATION WE HAVE HAS TO DO WITH LIQUID CALORIES. SO ESSENTIALLY SUGAR SWEETENED BEVERAGES. I'M WONDERING, THE WHOLE AREA OF ADDED SUGAR AND SUGAR ENDS UP IN COMMERCIALLY PREPARED FOODS THAT FREQUENTLY IS NOT PARTICULARLY OBVIOUS, IS ANOTHER ISSUE. BUT I'M WONDERING WHETHER WE SHOULD CONSIDER BEING A LITTLE MORE SPECIFIC. AND PRESENTING SOME OF THE RESULTS ON THE BASIS OF LIQUID SUGAR VERSUS SOLID. >> ALICE, THIS IS FRANK. >> YEP. >> GO AHEAD, FRANK. >> I THINK HIS PHONE BATTERY MAYBE GOING OUT. >> ONE OF THE THINGS BEFORE FRANK GETS ON -- AT LEAST FROM THE DENTAL CARIES REVIEW, THEY DID NOT CLASSIFY IT LIKE THAT, ALICE SO I'M NOT SURE IN EACH OF THE LOOKING AT THE VARIOUS HEALTH OUTCOMES, HOW MANY WERE ABLE TO DISTINGUISH BETWEEN THE LIQUID AND OTHER FORMS OF FOOD. >> MAYBE FOR THOSE THAT THERE WAS A DISTINCTION, MIGHT BE USEFUL, I THINK FROM A -- A COMMUNICATION PERSPECTIVE. A RELATIVELY HIGH PROPORTION OF ADDED SUGAR IS COMING FROM SUGAR SWEETENED BEVERAGES. BY HAVING A LITTLE MORE SPECIFICITY IT MIGHT USEFUL IN THE LONG RUN AS FAR AS TRYING TO RAISE AWARENESS HOW MUCH SUGAR IS IN A GLASS ACCOMPANYING A MEAL VERSUS THE MEAL ITSELF WHERE THERE'S -- MAYBE ADDED SUGAR THAT'S NOT PARTICULARLY OBVIOUS. >> SOMETHING TO THINK ABOUT. >> THIS IS MARIAN. THAT'S AN INTERESTING POINT, ALICE. I THINK IT MAY VARY DEPENDING ON WHAT AN INDIVIDUAL IS CONSUMING. IF YOU REMEMBER BACK TO FOOD PATTERN MODELING THAT I SHOWED, SAY FOR THE 2000-CALORIE DIET, THERE'S 123-GRAMS OF SUGAR AVAILABLE. SO SOMEONE CAN GET THAT THROUGH SMALL FREQUENT INTAKES OF SAY A LITTLE SUGAR IN THE COFFEE IN THE MORNING OR THE TEA, MAYBE A SNACK OF A COOKIE, OTHER PLACES WHERE SUGAR MAY COME IN, EVEN IN SMALL AMOUNTS, PLACES WHERE PEOPLE MIGHT NOT THINK ABOUT IT LIKE SOME OF THE FLAVORED YOGURTS THAT HAVE ADDED SUGARS, SOME OF THE PLANT BASE MILK LIKE ALMOND MILK THAT HAS ADDED SUGAR. >> SALAD DRESSING. >> SALAD DRESSING, SMALL PLACES ADD UP FREQUENTLY BUT SOME PEOPLE MAY GET IT ALL IN ONE FELL SWOOP IN A BEVERAGE. SO IT'S PROBABLY WORTHWHILE THINKING ABOUT THAT AND FORMULATING GUIDANCE AROUND THAT. BECAUSE SOME OF THE VERY SMALL PLACES PEOPLE MAY NOT REALIZE AT ALL THAT THEY'RE GETTING THESE ADDED SUGARS BUT THEY ADD UP. >> GIVEESS THAT'S MY POINT THAT I AGREE WITH YOU 100%, I'M JUST THINKING FROM THE PERSPECTIVE OF COMMUNICATION WE HAVE TO APPROACH A DIFFERENT WAY, THE SAME MAY HAVE BEEN YOU OR SOMEONE ELSE WHO ADDRESSED THE ISSUE WHERE DIFFERENT FORMS THINGS LIKE CONCENTRATED FRUIT JUICE SOME MAY NOT I HAVE TO AS ADDED SUGAR SO FROM A MESSAGING PERSPECTIVE, A LITTLE BIT MORE. >> THIS IS MIM, TO THAT POINT ALSO I THINK WE FELT STRONGLY ABOUT SUPPORTING THE ADDITION OF ADDED SUGARS TO THE NUTRITION FACTS BECAUSE A PERSON COULD SEE IT'S? SALAD DRESSING, IN THEIR COOKIES OR IN THEIR YOGURT AS WELL AS THEIR SUGAR SWEETENED BEVERAGE. >> THIS IS WAYNE. FOLLOWING UP ON ALICE'S COMMENT ABOUT BEVERAGES SPECIFICALLY, WHAT YOU DESCRIBE IS VERY CONSISTENT WITH THE LITERATURE SHOWING WHEN PEOPLE ADD -- CONSUME BEVERAGES WITH SUGAR IN THEM WITH THE MEAL, THEY DON'T COMPENSATE FOR THOSE CALORIES. SO IT'S ACTUALLY SORT OF A AT THIS TIME'S A DOUBLE NEGATIVE TO CONSUME NOT ONLY ADDED SUGAR WHICH DATA SUPPORT LEADS TO POSITIVE WEIGHT AND ADVERSE HEALTH RISK, BUT IT ALSO IS THAT CONTRIBUTING TO EXCESS CALORIE INTAKE EVEN MORE BECAUSE OF COMPETITIVE RESPONSES TO BEVERAGES IS NOT -- IS NOT AS STRONG AS FOR SOLID FOODS. >> THIS IS ALICE, I AGREE WITH THAT BUT I THINK THAT WE NEED A MULTI-PRONGED APPROACH. PUTTING -- HAVING IT ON THE LABEL, IN HOUSEHOLD MEASURES IS ONE APPROACH BUT WE KNOW HIGH PERCENTAGE OF THE POPULATION DON'T USE LABELS, THOSE MOTOR GRATE INVESTIGATED DO, AND WILL WORK FOR THEM, MAYBE OTHER APPROACHES WE NEED TO THINK ABOUT TO RAISE AWARENESS AMONG THOSE PEOPLE THAT DON'T RELY ON A LABEL SO WE HAVE TO THINK BROADLY PERHAPS CREATIVELY. >> RAFAEL PEREZ-ESCAMILLA HERE. IT SEEMS IT TAKES PREFERENCES GET DEVELOPED VERY,VERY EARLY ON IN LIFE. I THINK IT WOULD BE PRUDENT TO EMPHASIZE THE NEED FOR POLICIES THAT PREVENT EXCESSIVE EXPOSURE OF YOUNG CHILDREN TO SUGAR SWEETENED BEVERAGES OR OTHER FOODS WITH ADDED SUGARS. >> RAFAEL, THANK YOU. I THINK WE COULD DO A LITTLE BIT MORE EMPHASIS ON CHILDREN HERE. WE DO EMPHASIZE IN THE IMPLICATION STATEMENT THAT POLICIES AS WELL AS VARIED APPROACHES FROM THE INDIVIDUAL ALL THE WAY THROUGH PRIVATE SECTOR CHANGES HAVE TO HAPPEN. >> WE CAN BRING IT BACK TO THE COMMITTEE AND SEE IF WE SHALL FLESH OUT MORE SPECIFIC POLICIES, PROGRAMS. >> THANK YOU. >> YES. >> THIS IS BARBARA. I WONDERED WHETHER OR NOT IN THE REVIEW OF EVIDENCE IF YOU FOUND COHERENT PRESENTATION OF THE DIFFERENT MECHANISMS OF ACTION. IT SEEMS PRETTY CLEAR IN THE AREA OF SAY DENTAL CARIES. I WONDER WHETHER OR NOT IT'S -- IT IS REALLY WELL WORKED OUT IN TERMS OF THE OTHER OUTCOMES AND IF THAT WOULD BE -- COULD BE BRIEFLY SUMMARIZED IN YOUR REVIEW. >> WE CAN DO THAT WHERE IT IS. THE MAIN DRIVER IS THROUGH EXCESS CALORIES. >> THIS IS WAYNE T. REVIEWS WE CONSIDERED FOR A LOT OF THESE QUESTIONS OTHER THAN NECESSARILY BRIEF INTRODUCTORY STATEMENTS, THEY REALLY WERE ADDRESSING THE OUTCOME NOT THE MECHANISM. >> I SUSPECTED THAT BUT I THOUGHT IT WOULD BE USEFUL IF IT'S PRESENTED IN A COHERENT WAY. IT DOESN'T SURPRISE ME, THE LINK WITH EXCESS INTAKE AND OVERWEIGHT AND OBESITY PARTICULARLY BECAUSE YOU PRESENTED SOME OF THE CONFOUNDING IN ONE OF THE AREAS IN THAT REGARD. >> CAN YOU HEAR ME NOW? >> YES. >> SORRY, FOR SOME REASON I WAS CUT OFF >> WE HEAR YOU. >> JUST WANT TO MENTION THAT THE EVIDENCE FOR SUGAR SWEETENED BEVERAGES IS MUCH STRONGER THAN ADDED SUGAR PER SE BECAUSE BOTH STUDIES OBSERVATIONAL SAW STUDIES OR TRIALS LOOK AT SUGAR SWEETENED BEVERAGES AS THE MAIN EXPOSURE. AND SUGAR SWEETENED BEVERAGES ACCOUNT FOR 50% TO 55% OF ALL ADDED SUGARS. >> RIGHT. I THINK -- I DO THINK THIS IS MEANT TO ALL THOSE POINTS AND IT MAYBE MARIAN IN SUBCOMMITTEE ONE BUT IF IT'S NOT, WE SHOULD MAKE SURE WE ALSO LETTING THAT WE'RE REPORTING WHAT PERCENT IN EITHER A PIE CHART OR SOME OTHER WAY, WHAT PERCENT IS COMING OF ADDED SUGARS COMING FROM SUGAR SWEETENED BEVERAGES AND FOOD. IT ISN'T JUST FROM SUGAR SWEETENED BEVERAGES BUT ALSO FROM FOOD. >> THIS IS MARIAN. THANK YOU FOR BRINGING THAT UP. SOME OF THE INFORMATION WE HAVE PRESENTED IN PREVIOUS MEETINGS ON THE FOOD COMPONENTS, FOODS AS CONSUMED, WE HAVE THAT DATA. >> THANK YOU. >> THAT'S CORRECT. WE DO SHOW IT IN THE FOOD CATEGORIES DATA. >> ANY OTHER COMMENTS OR QUESTIONS? >> MIM, QUESTION REGARDING REGARDING ARTIFICIAL SWEETNERS. HERE WHEN EXCELLENT JOB SUMMARIZING THE EVIDENCE I WAS WONDERING HOW THIS INFORMATION CAN BE INTEGRATED WITH THE WORK IN ESSAY FIVE WHICH WAS A LOOK AT THE FOOD SAFETY ISSUES RELATED TO ARTIFICIAL SWEETNERS. >> SO THIS IS MIM, FRANK, I WAS THINKING ABOUT THAT AS WAYNE WAS PRESENTING AND I'M NOT SURE BECAUSE WAYNE CORRECT ME IF I'M WRONG BUT WITH THE LOCALRY SWEETNERS, WITHIN THIS WORKING GROUP, WE DID NOT ASK ABOUT SAFETY AND THEN SUBCOMMITTEE FIVE AS PEOPLE REMEMBER IN PREVIOUS MEETING WE ONLY LOOK AT ASARTAME AND SAFETY, WE DIDN'T LOOK AT EFFICACY AROUND WEIGHT REDUCTION. SO THEY'RE QUITE DIFFERENT APPROACHES. AND THEY WERE DONE FOR SPECIFIC REASONS. SO WE -- I THINK MAYBE WE CAN GO BACK TO EACH SUBCOMMITTEE AND SEE WHERE WE CAN AT LEAST CROSS REFERENCE AS MANY WILL BE CROSS REFERENCING, AND CONSIDER HOW WE INTEGRATE THE TWO. >> I AGREE. THE INFORMATION WE WERE LOOKING AT FROM A SAFETY STANDPOINT IS REFLECT IN THE OUTCOME OF BODY WEIGHT AND DIABETES, NOT OTHER INDICES OF ORGAN FUNCTION OR OTHERWISE. >> THANK YOU. >> IT SOUNDS LIKE THAT MAY WRAP IT UP. ARE THERE ANY OTHER FINAL QUESTIONS OR COMMENTS? >> THANK YOU, EVERYBODY. >> THANK YOU. >> I'M GOING TO TURN IT OVER TO FRANK TO TALK ABOUT THE FINDINGS OF THE SATURATED FAT WORKING GROUP. >> THANK YOU, BARBARA. SO I PRESENTED THE FRAMEWORK EVIDENCE BASE AND PRELIMINARY DRAFT CONCLUSION STATEMENT AT THE LAST PUBLIC MEETING, SO TODAY I'M NOT GOING TO GET INTO THE DETAILS, ESPECIALLY THE EVIDENCE BASE INSTEAD I'M GOING TO REVIEW THESE SUMMARY STATEMENTS AND IMPLICATIONS. BEFORE I DO THAT I WANT TO ACKNOWLEDGE THE OTHER MEMBERS OF THIS WORKING GROUP, TOM BRENNA AND BARBARA AND VICE CHAIR ALICE. >> THE SCOPE OF OUR WORK WAS TO EXAMINE THE RELATIONSHIP BETWEEN THE INTAKE OF SATURATED FAT AND THE RISK OF CARDIOVASCULAR DISEASE. WE DIDN'T HAVE ANY INVITED EXPERTS OR CONSULTANTS FOR THIS WORKING GROUP. SO AGAIN, THE QUESTION WE WANT TO ADDRESS IS THE RELATIONSHIP BETWEEN SATURATED FAT INTAKE AND RISK OF CARDIOVASCULAR DISEASE AND OUR WORK IS PRIMARILY BASED ON EXISTING REPORTS. FOR REVIEW OF THE EVIDENCE WE INCLUDED TWO SYSTEMATIC REVIEWS AND SIX META ANALYSIS PUBLISHED IN THE PAST FIVE YEARS. WE INCLUDED THE ANNULS INTERNAL MEDICINE META ANALYSIS PUBLISHED EARLIER THIS YEAR. AND MORE RECENT META ANALYSIS PUBLISHED IN CIRCULATION. , WE PUT PARTICULAR EMPHASIS ON THE REVIEWS THAT EXAMINED THE MICRONUTRIENT REPLACEMENT FOR SATURATED FAT. SO OUR DRAFT CONCLUSION STATEMENT, STRONG CONSISTENT EVIDENCE FROM RANDOMIZE CLINICAL TRIALS SHOWS THAT REPLACING SATURATED FAT WITH POLYUNSATURATED FAT OR MONOUNSATURATED FAT SIGNIFICANTLY REDUCE TOTAL AND LDL CHOLESTEROL, REPLACING SATURATED FAT WITH CARBOHYDRATE, ALSO REDUCE TOTAL LDL CHOLESTEROL, BUT SIGNIFICANTLY INCREASES TRIGLYCERIDES AND REDUCES HDL CHOLESTEROL. STRONG AND CONSISTENT EVIDENCE FROM RANDOMIZED CLINICAL TRIALS IN THE STATISTICAL MODELING INPUT OF ACTIVE COHORT STUDIES SHOWS REPLACEMENT OF SATURATED FAT WAS POLYUNSATURATED FAT REDUCES THE RISK OF CARDIOVASCULAR DISEASE AND CORONARY MORTALITY. FOR EVERY ONE PERCENT OF ENERGY INTAKE FROM SATURATED FAT REPLACED WITH POLYUNSATURATED FAT, THE INCIDENCE OF CORONARY HEART DISEASE IS REDUCED BY TWO TO THREE PERCENT. STRONG CONSISTENT EVIDENCE FROM RANDOMIZED CLINICAL TRIALS, AND PERSPECTIVE COHORT STUDIES SHOWS THAT REDUCING TOTAL FAT MEANING REPLACING TOTAL FAT WITH ANY TYPE OF CARBOHYDRATE, THAT'S NOT LOWER -- DOES NOT LOWER RISK. STRONG EVIDENCE FROM PERSPECTIVE COHORT STUDIES SHOWS THAT HIGHER SATURATED FAT INTAKE AS COMPARED TO TOTAL CARBOHYDRATE IS NOT ASSOCIATED WITH RISK. IN SOME STUDIES THEY THE COMPARISON OR REPLACEMENT MICRONUTRIENT WAS NOT SPECIFIED, BUT WAS LARGELY CARBOHYDRATES THE SOURCES WERE NOT DEFINED. AND IN THOSE STUDIES THIS REPLACEMENT OR THIS COMPARISON WAS NOT ASSOCIATED WITH DIFFERENCES IN RISK OF -- THE EVIDENCE GRADE IS STRONG. REGARDING MONOUNSATURATED FAT OUR CONCLUSION STATEMENT IS THE FOLLOWING. THERE IS LIMITED EVIDENCE REGARDING WHETHER REPLACING SATURATED FAT WITH MONOUNSATURATED FAT COME FIRST OVERALL SEE ANY BENEFITS. ONE REASON IS THE MAIN SOURCE OF MONOUNSATURATED FAT IN WESTERN DIETARY PATTERNS OF ANIMAL FATS, HOWEVER, EVIDENCE FROM RANDOMIZED CLINICAL TRIALS IN THE PROSPECTIVE COHORT STUDIES AS DEMONSTRATED BENEFITS OF PLANT BASED MONOUNSATURATED FATS, SUCH AS OLIVE OIL AND NUTS, RISK. EVIDENCE GRADE FOR MONOUNSATURATED FAT IS LIMITED. THOSE ARE OUR DRAFT IMPLICATIONS STATEMENT. RECOMMENDATIONS UNSATURATED FAT INTAKE SHOULD SPECIFY REPLACEMENT MICRONUTRIENTS AND EMPHASIZE POLYUNSATURATED FAT AND SHOULD BE BASED ON FOODS AND OVERALL DIETARY PATTERNS. CONSUME DIETARY PATTERN THAT IS RELATIVELY LOW IN SATURATED FAT, AND SHOULD EMPHASIZE INTAKES OF VEGETABLES FRUITS, WHOLE GRAINS, INCLUDE LOW FAT DAIRY PRODUCTS, POULTRY, FISH, LEGUMES, TROPICAL VEGETABLE OILS AND NUTS AND LIMIT INTAKES OF SUGAR SWEETENED BEVERAGES AND RED AND PROCESSED MEATS. NON-HYDROGENATED VEGETABLE OILS THAT ARE HIGH IN UNSATURATED FATS AND RELATIVELY LOW IN SATURATED FAT SHOULD INSTEAD OF ANIMAL FATS ALREADY TROPICAL OILS RICH IN SATURATED FAT RECOMMENDED ADS PRIMARY SOURCE OF CULINARY FAT. THOUGH HEALTHY DIETARY PATTERN IS RELATIVELY LOW IN SATURATED FAT, IT CAN ALSO INCLUDE LEAN MEAT AND LOW -- AND LOW FAT DAIRY PRODUCTS WHICH ARE CONSISTENT WITH THE USDA DIETARY PATTERNS OR OTHER HEALTHY DIETARY PATTERNS, SIMPLY REDUCING FAT TOTAL FAT IN A DIET BY REPLACING WITH ANY TYPE OF CARBOHYDRATE IS NOT A FACTOR REDUCING RISK OF CVD. THEREFORE, DIETARY (INDISCERNIBLE) SHOULD BE MORE EMPHASIS ON (INAUDIBLE) FAT HA RATHER THAN -- TYPE OF FAT RATHER THAN TOTAL AMOUNT OF FAT. FINALLY THE CARBOHYDRATE SOURCES IN THE DIETARY PATTERN SHOULD BE PRIMARILY FIBER RICH WHOLE GRAINS LEGUMES FRUITS VEGETABLES, AND SHOULD MINIMIZE CONSUMPTION OF REFINED GRAINS AND ADDED SUGARS, THE CONSUMPTION OF LOW FAT OR -- PRODUCTS WITH HIGHER REFINED GRAINS AND ADDED SUGARS SHOULD BE DISCOURAGE. THAT'S ALL I HAVE. WANT TO SAY WHETHER -- ARE THERE MEMBERS OF THE WORKING GROUP HAVE ANYTHING TO ADD? IF NOT, OPEN THIS UP FOR QUESTIONS AND DISCUSSIONS. >> FRANK, THIS IS MARY STORY,. IS THERE ANY EVIDENCE THAT THE FAT IN WHOLE MILK IS ANY DIFFERENT THAN THE SATURATED FAT IN OTHER FOODS? AND THEIR EFFECT ON LIPIDS? >> I DON'T THINK SO. IT'S VERY COMPLICATED QUESTION BECAUSE FATS IN WHOLE MILK OF COURSE SATURATED FAT (INDISCERNIBLE) ACIDS --. >> THANK YOU. >> FRANK, THIS IS WAYNE CAMPBELL -- >> THE ISSUE HAS BEEN RAISED BUT THE DATA ARE QUITE THIN AT THIS POINT. >> RIGHT. AGREE WITH THAT. >> FRANK, THIS IS WAYNE CAMPBELL, JUST A POINT OF REFERENCE TO NOT TO REVISIT THE DISCUSSION BUT LIKE WE DISCUSSED EARLIER REGARDING READ MEAT VERSUS THE PROCESSED MEATS. I PRESUME WE NEED TO CLARIFY THE WORDING IN THE IMPLICATIONS FOR THE STATEMENTS THAT YOU MADE IN YOUR IMPLICATION STATEMENT AS WELL. I THINK WE NEED SOME COORDINATIONS AND INTEGRATIONS ACROSS ESSAY 1, ASSAY 2 AND SATURATED FAT WORKING GROUP TO MAKE SURE THAT WE USE THE SAME LANGUAGE AND THE SAME TERMINOLOGIES IN TERMS OF CONCLUSION STATEMENTS AND IMPLICATIONS. >> THANK YOU. >> FRANK, THIS IS MARIAN, I HAVE ONE SMALL REQUEST, IT HAS TO DO WITH THE DRAFT CONCLUSION STATEMENT. IN THE FIRST BULLET OF THE DRAFT CONCLUSION STATEMENT IT JUST MENTIONED CARBOHYDRATE. IT WAS EITHER THE THIRD OR THE FOURTH BULLET, THERE IS A PARENTHESES AFTER CARBOHYDRATE THAT SAID TYPE NOT SPECIFIED SOURCE NOT DEFINED. I'M WONDERING IF THAT PHRASE IN THE PARENTHESES CAN ALSO BE ADDED TO THE FIRST BULLET, THE LAST SENTENCE FIRST BULLET WHERE IT SAYS REPLACING SATURATED FAT WITH CARBOHYDRATE SAY SOURCES NOT IDENTIFIED >> BECAUSE OF THE IMPLICATIONS THERE'S VERY HELPFUL INFORMATION COMMUNICATING THAT NOT ALL CARBOHYDRATES ARE CREATED EQUALLY AND WHOLE GRAINS SHOULD BE THE SOURCE OF CARBOHYDRATES SO UNLESS WE SPECIFY IN THE STUDIES IT DID NOT DEFINE IT, THEN THERE COULD BE SOME MISCOMMUNICATION >> THAT'S REALLY A GOOD POINT. >> THANK YOU. >> FRANK, COULD YOU ALSO IN THE IMPLICATION STATEMENT GIVE US SOME EXAMPLES OF THE TYPE OF OILS AMERICANS SHOULD BE CONSUMING? >> FOR CARDIOVASCULAR DISEASE ONLY. >> ALICE, DO YOU THINK WE SHOULD BE THAT SPECIFIC? >> I DON'T SEE ANY REASON WHY NOT. -- >> RIGHT. SOME VEGETABLE OILS SUCH AS CORN OIL IS A FLOWER OIL CONTAIN MOSTLY (INAUDIBLE) BUT OTHER VEGETABLE OILS CANOLA OIL SOYBEAN OIL CONTAINS BOTH POLYUNSATURATED FAT AND MONOUNSATURATED FAT. AND SOME FOODS SUCH AS NOT CONTAINED ALSO MOSTLY MONOUNSATURATED FAT, SOME CONTAIN POLYUNSATURATED FAT. >> SPECIFICALLY FRANK WHAT YOU COULD DO IS GIVE EXAMPLES TOP TROPICAL OILS. YOU CAN SAY INSTEAD OF CONSUMING VEGETABLE OILS, ARE LOW IN SATURATED FAT INSTEAD OF ANIMAL FATS TROPICAL OILS. MAYBE YOU CAN GIVE A COUPLE OF EXAMPLES OF TROPICAL OILS. BECAUSE I DON'T KNOW IF A LOT OF AMERICANS WOULD NECESSARILY KNOW WHAT -- >> PALM OIL IS WIDELY USED WORLDWIDE. >> WE SPENT TIME ON TROPICAL OILS AND THAT IS A EVOLVING ISSUE. THE ISSUE OF VIRGIN COCONUT OIL VERSUS CONVENTIONAL COCONUT OIL AND SO FORTH. I DON'T KNOW THAT THIS IS SPECIFIC ENOUGH TO BE ABLE TO DISTINGUISH BETWEEN THOSE. SO I WOULD -- I WOULD HAVE TO TAKE A LOOK IN MUCH MORE DETAIL WHAT WE HAVE GONE HERE TO BE ABLE TO SAY SOMETHING LIKE THAT. I DON'T THINK IT'S SUPPORTED. >> THIS IS MIM. REMEMBER WE'RE NOT NECESSARILY COMING UP WITH A MESSAGING FOR THE GUIDELINES. WE'RE JUST GUIDING THE POLICY PROCESS. >> FRANK, THIS IS WAYNE. I HAVE A QUESTION REGARDING MONOUNIS IT RATED FAT. COULD WE GO TO THE DRAFT CONCLUSIONS -- CONCLUSION STATEMENTS PUT THERE? MY QUESTION IS IT SEEMED AS THOUGH THERE WAS LIMITED EVIDENCE FOR THE QUOTE UNQUOTE BENEFITS OF MONOUNSATURATED FAT, I'M WONDERING WHAT -- HOW THIS -- THE LIMITED -- HOW THIS INFORMATION FITS INTO THE HEALTHY EATING PATTERNS AND SPECIFICALLY DIET PATTERN LIKE MEDITERRANEAN DIETS WHICH I RECALL INCLUDES AN EMPHASIS ON OLIVE OIL. DOES THIS SUGGEST THAT ONE OF THE QUOTE UNQUOTE HEALTHY EATING PATTERNS WOULD BE BETTER THAN ANOTHER BASED ON THE FATTY ACID PROFILE, OILS ARE CONSUMED IN >> FOR MONOUNSATURATED FAT IF YOU LOOK AT THE STUDIES PUBLISHED IN THE U.S. PERHAPS IN WESTERN EUROPEAN COUNTRIES TYPICALLY THERE IS EITHER NO ASSOCIATION BETWEEN HIGHER INTAKE OF MONOUNSTAT RATED -- SATURATED FAT AND SAFETY, FOUNDED POSITIVE ASSOCIATION. BECAUSE IN THE TYPICAL WESTERN DIET -- DIETARY PATTERN MONOUNSATURATED FAT COME FROM THE SAME SOURCES OF SATURATED FAT WHICH ARE DAIRY AND MEATS. SO THERE IS A HUGE CONFOUNDING ISSUE WHEN YOU TRY TO TEASE OUT EFFECTS OF MONOSATURATED FROM SATURATED FAT IN THIS KIND OF DIET. HOWEVER, IN INTERVENTIONS MORE INTERVENTION STUDIES USING OLIVE OIL, OR IN MEDITERRANEAN COUNTRIES WHERE OLIVE OIL IS THE PRIMARY CULINARY FAT, THERE IS MORE EVIDENCE OF BENEFITS IN TERMS OF BLOOD LIPIDS AND THE CARDIOVASCULAR OUTCOMES. SO THERE IS A DIVERGENCE OF OF THE EVIDENCE AND THERE WAS DIRER CONSENSUS OF SOURCES OF MONOUNSATURATED FAT. EVEN THOUGH WE HAVE IDENTIFIED MEDITERRANEAN DIETARY PATTERN AS HEALTHY DIETARY PATTERN, OLIVE OIL IS JUST ONE COMPONENT OF DIETARY PATTERN. SO WE CANNOT USE THIS KIND OF DIETARY PATTERN EVIDENCE TO INFER MONOUNSATURATED FAT IS SOLELY RESPONSIBLE FOR THE BENEFIT OF MEDITERRANEAN DIET ON CARDIOVASCULAR OUTCOMES. >> THIS IS ALICE. I AGREE TOTALLY WITH WHAT FRANK SAID. I THINK WE ALSO HAVE TO REMEMBER THAT THESE ARE U.S. DIETARY GUIDELINES. SO WE REALLY NEED TO THINK ABOUT CONCOMITANT TYPES OF DIETARY BEHAVIORS THAT THE GENERAL U.S. POPULATION ADHERES TO CURRENTLY. AND ALSO LIFESTYLE BEHAVIORS. SO WE CAN'T SUPER IMPOSE WHAT'S OBSERVED IN OTHER CULTURES AT THIS STAGE. >> OKAY. ANY OTHER QUESTIONS? >> THIS IS ANNA MARIA, I WANT TO RESPOND TO ALICE'S COMMENT THERE. >> I'M SORRY. THIS IS BARBARA. CAN I BE HEARD? >> WE HEAR YOU. >> I HAD A QUESTION, COULD WE PUT THE CONCLUSION SLIDE BACK UP? I WONDERED ABOUT THE SECOND PHRASE THAT REFERS TO YOUR POINT ABOUT THE CONFOUNDING REALLY, IN THE WESTERN DIET OF SATURATED FAT BY MONO. SO HERE YOU'RE SAYING ONE REASON FOR THE INABILITY TO REALLY DEMONSTRATE THE RELATIONSHIP IS BECAUSE OF THE TRAVELING, IF YOU WILL OF MONOS AN SATURATED FAT. SO THERE REALLY ISN'T A SUBSTITUTION GOING ON BECAUSE AS YOU -- WITH THE WESTERN PATTERN AS YOU INCREASE MONO, YOU'RE ALSO INCREASING SATURATED FAT. I THINK THAT'S YOUR POINT, RIGHT? >> YEAH. SO THAT'S THAT'S THE EXACT -- BUT YOU'RE NOT -- >> THAT'S WHAT I'M TRYING TO SAY ALSO. YOU'RE NOT MAKING A DISTINCTION BETWEEN SOMETHING UNUSUAL ABOUT THE MONO UNSATURATED FAT IN A MEAT VERSUS OR DAIRY VERSUS OLIVE OIL, OR ARE YOU? >> NO. YEAH. BUT THAT'S NOT RIGHT WHAT I WANTED YOU TO SAY. >> SO MAYBE CLARIFY THAT THE CONFOUNDING ISSUE A LITTLE BIT MORE BECAUSE IT SOUNDS LIKE YOU'RE MAKING A DISTINCTION ABOUT SOMETHING UNUSUAL OR SO ABOUT MONOUNSATURATED FAT AND ANIMAL PRODUCT. ISSUE IS REALLY THAT THEY'RE TRAVELING TOGETHER. AND SO THE MORE YOU EAT OF MEAT OR DAIRY, THE MORE BOTH YOU'RE GETTING -- UNLESS YOU'RE SUBSTITUTING A VERY LEAN OR FAT -- FAT FREE PRODUCT OF COURSE TAKES BOTH OF THEM OUT. >> THERE IS INCREASING CONSUMPTION OF PLANT BASED MONOUNSATURATED FAT FROM OLIVE AND CANOLA OIL AND ALSO PERHAPS FROM AVENUE CASTRO DOES BUT THE AMOUNT IS -- AVOCADOS BUT IT'S SMALL COMPARED TO MONOSATURATED FAT. >> INCREASING THOSE IN THE DIET WOULD BE A TRUE SUBSTITUTION. >> THAT WOULD BE A TRUE SUBSTITUTION. RIGHT. >> IT STRUCK ME THAT PHRASE COULD BE FINE TUNE AD LITTLE BIT TO RAISE THE POINT OF CONFOUNDING. BY THE CO-OCCURRENCE OF BOTH OF THOSE FATTY ACIDS AND THE FOODS. >> THIS CONCLUSION STATEMENT. >> OKAY. THANK YOU. >> WERE THERE OTHER QUESTIONS OR COMMENTS FOR SATURATED FAT GROUP? >> I HAVE A COMMENT THAT SOUNDED LIKE ANNA MARIA HAD A COMMENT FIRST. >> OKAY. >> THANK YOU. I WAS JUST GOING TO EMPHASIZE A POINT OR COUNTER IT ON WHAT ALICE SAID IN RELATIONSHIP TO THE AMERICAN EATING PATTERNS BECAUSE I THINK WE NEED TO KEEP IN MIND THAT ONE OF THE RECOMMENDATIONS OR IMPLICATIONS THAT OUR WORK IS SHOWING BOTH IN SUBCOMMITTEE ONE AS WELL AS SUBCOMMITTEE 2, IS THE FACT THAT THESE DIETARY PATTERNS THAT WE ARE RECOGNIZING AS BEING BENEFICIAL HAS THE OPPORTUNITY TO BE ABLE TO BE TAILORED TO INDIVIDUAL PREFERENCES AND CULTURES. SO I JUST WANT TO MAKE SURE WE KEEP THAT POINT IN MIND GIVEN HOW DIVERSE AMERICANS ARE THESE DAYS. >> POINT WELL TAKEN. >> SAME POINT TO THE HEALTH RISKS PROFILE AND NEEDS OF THE INDIVIDUALS AS HAS BEEN POINTED OUT WHEN WE TALK ABOUT SUBSTITUTIONS OF SATURATED FAT, THE END POINT THAT WAS EXAMINED HERE WAS LARGELY CARDIOVASCULAR DISEASE AND THERE'S A RANGE OF ISSUES WHEN WE LOOK AT THE FATTY ACID PROFILE OF THE DIET IN CANCER RISK. >> ARE WE ADDRESSING THAT? I DON'T REMEMBER ADDRESSING THAT. >> WE'RE NOT ADDRESSING THAT BUT I THINK THE RECOMMENDATION HAS BEEN MADE IN OTHER OF THE DGAC CONVERSATIONS THAT WE CAN CLARIFY THE EMPHASIS HERE IS CVD. >> RIGHT. FROM >> I HAVE A COMMENT TO MAKE AS WELL THIS IS MARIAN. BACK TO MARY STORY'S SUGGESTION ABOUT LISTING SOME OF THE TYPES OF OILS TO USE AND I THINK IT WOULD BE HELPFUL TO DEFINE IN THIS WRITE UP WHAT THE TROPICAL OILS ARE, WHAT ARE THE TROPICAL OILS THAT PEOPLE CAN PURCHASE IN THE GROCERY STORE, BECAUSE THEY HAVE REALLY ESCALATED IN POPULARITY. TO THE DEGREE THEY'RE VIEWED AS HEALTH FOODS. >> THEY'RE VIEWED AS HEALTH FOODS SOY THINK IT'S REALLY IMPORTANT TO COMMUNICATE AND LIST OUT THE TROPICAL OILS THAT ARE KIND OF VERY POPULAR NOW IN CERTAIN GROUPS OF PEOPLE. >> WE HAVE TO BE CAREFUL ABOUT THAT, BECAUSE TROPICAL OILS THAT ARE AVAILABLE NOW VIRGIN COCONUT OIL, PROBABLY THE BEST EXAMPLE, REALLY VERY DIFFERENT THAN THE ONES STUDIED IN THE 1980s AND TROPICAL OILS, THEY'RE REPUTATION IN THE DATA FROM STUDIES IN THAT ERA AND SINCE THEN, WE HAVE TO BE CAREFUL ABOUT -- >> WAS THAT EXAMINED, WAS THAT PRESENTED HERE AT ALL? DO YOU HAVE DATA ON THE DIFFERENCES IN THOSE OILS? >> WE DIDN'T LOOK AT THAT SPECIFIC. WE THOUGHT THERE'S AT LEAST PRE-CLINICAL EVIDENCE THAT ISN'T JUST THE FATTY ACID PROFILE THAT MATTERS AND WE ARE LOOKING AT FOOD PATTERNS AND IN FOODS IN GENERAL SO THERE'S A -- THE RECOMMENDATIONS HERE ARE ROBUST IF WE GET TOO GRANULAR WE GO BEYOND THE DATA JUST LIKE WE DISCUSSED IN OTHER CONTEXT. >> PER MAPS THE ASSAY 1 THE USDA COLLEAGUES CAN HELP US PULL SOME DATA ON TROPICAL OILS IN TERMS OF FATTY ACIDS PROFILE. >> WE CAN TRY TO DO THAT. , WE'LL TRY TO FOLLOW-UP ON THAT IN SC 1. >> MARIAN WERE YOU SUGGESTING THAT IMPLICATIONS MIGHT NEED TO HAVE SOMETHING ADDED? IN THAT REGARD? >> I JUST NOTICE THAT IN DRAFT CONCLUSION STATEMENTS, MAYBE IT WAS IN IMPLICATIONS, SINCE WE DON'T HAVE IT UP ANY MORE, THERE WAS A STATEMENT ABOUT THE TROPICAL OILS. I WONDERED IF THERE SHOULD BE MORE SPECIFICITY, THE PUBLIC MAY NOT KNOW WHAT'S REFERRED TO WHEN IT SAYS TROPICAL OILS AND A LOT OF TROPICAL OILS ARE EXTREMELY POPULAR WITH THE PUBLIC. FOR CULINARY USE. SO I THINK WE JUST NEED TO BE CLEAR BUT THEN TOM MENTIONED MAYBE THEY'RE NOT ALL CREATED EQUALLY. IT MAYBE MORE COMPLICATED THAN WE REALIZED AT THIS MOMENT. SAME TOP CONTROL OILS MAY NOT BE CLEAR TO CONSUMERS. WHAT THAT MEANS. >> I HEAR THE RECOMMENDATION TO THE WORK GROUP THE TAKE A LOOK AT HOW THE PHRASING AROUND TROPICAL OILS AND TO CONSIDER IN THE REPORT WHETHER OR NOT IT'S FEASIBLE BOTH ACROSS THE WORKING GROUP AND SC 1 TO PROVIDE FURTHER INFORMATION ON DECOMPOSITION OF AVAILABLE PRODUCTS. PARTICULARLY THE TROPICAL OILS. >> SOUNDS GOOD. I THINK THAT'S A GOOD SUGGESTION. >> ANYTHING ELSE FOR THIS GROUP? ALL RIGHT. THEN LET'S GO AHEAD AND MOVE ON. WE HAVE GOT A COUPLE OF TOPICS THAT WE WENT TO PRESENT. ONE IS THE INTEGRATION OF FINDINGS AND THEN A FINAL SUMMARY OF THE NEXT STEPS BY THE COMMITTEE. I'M GOING TO MOVE QUICKLY THROUGH A SERIES OF SLIDES THAT THE FEDERAL STAFF ASKED ME TO BRIEFLY PRESENT AT THIS END OF THE MEETING BEFORE WE HEAR FROM VARIOUS SCs AND WORK GROUPS. ON INTEGRATION PIECE OF IT. BUT IF WE COULD GO QUICKLY LIEU THE NEXT FIVE OR SIX SLIDES SINCE SOME ON THE CALL AT THIS POINT MAY NOT HAVE HEARD THE COMMENTS AT THE BEGINNING OF THE MEETING, REMEMBER WE ARE PROVIDING SCIENCE-BASED RECOMMENDATIONS TO THE GOVERNMENT ON HOW FOOD NUTRITION AND PHYSICAL ACTIVITY CAN HELP PROMOTE THE HEALTH OF THE POPULATION AND REDUCE BURDEN OF DISEASE. WE ARE ADVISORY, WE DO NOT CREATE POLICY, NEXT SLIDE. WE HAVE TRIED TO TAKE RATHER NOVEL APPROACH IN A NUMBER OF WAYS, WE'RE CLEARLY FOCUSING ON TRADITIONAL AREAS OF FOCUS, BUT WE'RE ALSO TRYING TO CARVE OUT NEW THEMES AND TERRITORY TO COVER IN THE REPORT, NEXT SLIDE. WE'RE NOT ONLY FOCUSING, LET ME SEE. WE'RE FOCUSING ON THE ISSUES OF DIETARY PATTERNS. SUSTAINABILITY WHAT WORKS AND WE'RE USING A SYSTEMS APPROACH. WE'RE IN THE PROCESS OF CREATING THE CONCEPTUAL MODEL WE PRESENTED DRAFTS AT AN EARLIER MEATING BUT A MODEL THAT ADVANCES BEYOND THE 2010 SOCIO ECOLOGICAL MODEL AND CHARACTERIZE THE MULTIPLE INTERRELATED DETERMINANTS OF DIET AND LIFESTYLE BEHAVIORS. KEY ELEMENTS OF THE MODEL ARE THE DETERMINANTS OF DIET PHYSICAL ACTIVITY AND HEALTH AND OUTCOMES THAT ARE REALLY REALLY QUITE DIVERSE IN TERMS OF THE SCOPE THAT WE HAVE COVERED. WE HAVE GOT THE FIVE SUBCOMMITTEES, WE HEARD FROM ALL BUT SUBCOMMITTEE 5 BECAUSE ITS WORK IS COMPLETED, THEY'RE DRAFTING REPORTS NOW AND THEN WE HAVE FOUR WORK GROUPS ONE OF WHICH IS A WRITING GROUP THAT WE HAVE HEARD FROM TODAY. ADDED SUGARS AND SO FORTH. OVER ARCHING ALL OF WHAT WE DO, A A MAJOR THEME IS TRYING TO UNDERSTAND THE HEALTH IMPACT OF CHANGES IN DIET PHYSICAL ACTIVITY AND PARTICULARLY HOW WE ACCOMPLISH THOSE CHANGES WITH KNOWN EFFECTIVE METHODS, MODES OF INTERVENTION, METHODS OF INTERVENTION AND SETTINGS OF INTERVENTION AS WE HEARD A LOT ABOUT IN TODAY'S MEETING AND PREVIOUS MEETINGS. IN TERMS OF INTEGRATION AT THIS STAGE IN PROCESS WE WANT TO TAKE HIGHER LEVEL VIEWS ACROSS THE WORK GROUPS AND SUBCOMMITTEES IDENTIFY MAJOR THEMES THAT REFLECT MODERATE STRONG CONCLUSION IT IS COMMITTEES COME TO BUT ALSO THEMES THAT RESONATE ACROSS THE COMMITTEE YOU HEARD THAT TODAY PARTICULARLY TODAY AS IT BECOMES CLEARER THERE ARE CROSS CUTTING NOT ONLY TOPICS BUT THEMES ACROSS SUBGROUPS. WITH THAT IN MIND, THIS IS BEING OUR SIX AND NEXT TO FINAL MEETING I ASK THE SUBCOMMITTEES TO CONSIDER WHAT MIGHT BE ONE OR TWO MAJOR CROSS CUTTING THEMES TO TAKE A MINUTE OR TWO IN ORDER OF SUBCOMMITTEES TO COMMENT ON THEM SO THAT WE CAN HIGHLIGHT OF COURSE EVERYTHING THAT WE HAVE PRESENTED WHERE WE THINK WE ARE IN TERMS OF THEMES THAT BEGIN TO GIVE US A BETTER SENSE OF INTEGRATION ACROSS THE SUBCOMMITTEES AND WORK GROUPS. SO WITH THAT, MARIAN, I'LL ASK YOU TO TAKE A MINUTE OR TWO OF COMMENT AND THEN WE'LL HEAR FROM THE OTHERS. >> CERTAINLY. THANK YOU, BARBARA. THIS IS MARIAN NEUHOUSER FOR THOSE LISTENING. THE DATA FOR SUBCOMMITTEE 1 COME FROM OUR NATIONAL NUTRITION MONITORING SYSTEM, SURVEILLANCE SYSTEM CALLED WHAT WE EAT IN AMERICA, WHICH IS PART OF THE NATIONAL HEALTH NUTRITION EXAMINATION SURVEY. WHAT WE FOUND ARE A NUMBER OF NUTRIENTS THAT ARE UNDERCONSUME. WE CALL THESE SHORT FALL NUTRIENTS, AS WELL AS NUMBER OF NUTRIENTS THAT ARE OVERCONSUMED, ACROSS THE POPULATION. SOME OF THE NUTRIENTS UNDERCONSUME REDIRECT EXAMINATION SHORT FALL NUTRIENTS INCLUDING CALCIUM, VITAMIN D, MAGNESIUM, POTASSIUM, FIBER AND SOME OF THE NUTRIENTS THAT ARE OVERCONSUME INCLUDE SODIUM, SATURATED FAT. WE HAVE NUTRITION RELATED HEALTH CUPS IN THIS COUNTRY AND WE OBTAIN THOSE DATA IN PARTNERSHIP WITH THE CENTERS FOR DISEASE CONTROL. SOME OF THOSE NUTRIENT RELATED HEALTH CONDITIONS INCLUDE OVERWEIGHT AND OBESITY, CARDIOVASCULAR DISEASE, MANY CANCERS, KYE BEE TEASE, AND SO FORTH. -- DIABETES AND SO FORTH. MANY ARE PREVALENT AT HIGH ATENABLE LEVELS PUTTING A LARGE STRESS ON THE HEALTHCARE SYSTEM. GROUP INTAKE WHICH INCLUDE WHOLE GRAINS VEGETABLES FRUIT, LOW FAT DAIRY, MANY OF THESE FOOD GROUP INTAKES ARE POOR FOR THE MAJORITY OF THE U.S. POPULATION. AND TREND DATA AGAIN LOOKING AT USING OUR WHAT WE EAT IN AMERICA SURVEILLANCE DATA SHOW LITTLE IMPROVEMENT OVER TIME. HOW FAR, THERE'S SOME OPTIMISM THAT YOUNG CHILDREN HAVE GOOD INTAKE OF FRUIT AND DAIRY AND EVEN WHOLE GRAIN SO WE NEED TO MAINTAIN THESE POSITIVE HABITS, WE NEED TO IDENTIFY WHY PRE-ADOLESCENT AND ADOLESCENT CHILDREN HAVE SUCH A SHARP DROP OFF IN THEIR DIET QUALITY, WHAT CAN WE DO TO MAINTAIN THE GOOD HABITS STARTED IN EARLY CHILDHOOD TO MAINTAIN A POSITIVE TRAJECTORY. >> WE FOUND INTAKE OF SODIUM, ADDED SUGAR AND SATURATED FAT, REFINED GRAINS AT VERY HIGH UNHEALTHY LEVELS AND NEED TO BE REDUCED. FOODS IDENTIFIED AS SOURCES OF THESE NUTRIENTS INCLUDE MIXED DISHES, DESSERTS AND SUGAR CEDE SWEETENED BEVERAGES. DIET QUALITY IS POOR IN ALL EATING ENVIRONMENTS, INCLUDING ALL TYPE T OF RESTAURANTS, HOME AND SCHOOLS. MEAL SKIPPING ESPECIALLY BREAKFAST IS COMMON. FINALLY THE COMPOSITION OF DIETARY PATTERNS POSITIVE HEALTH OUTCOMES HAS BEEN IDENTIFIED IN THREE VERSIONS OF THE USDA FOOD PATTERNS WERE CREATED. THIS IS ARE CONSISTENT WITH HEALTHY PATTERNS, THESE FOOD PATTERNS PROVIDE PRACTICAL GUIDANCE FOR HEALTHY FOOD CONSUMPTION THAT CAN BE USED BY ALL RESIDENTS OF THE UNITED STATES. SO I THINK THOSE ARE THE MAJOR THEMES THAT WE HAVE COVERED IN SUBCOMMITTEE ONE. >> THANK YOU, MIRIAM. ANNA MARIA. >> THANK YOU, THIS IS ANNA MARIA SIEGA-RIZ. SO FOR CHAPTER TWO WE WERE TASKED WITH LOOKING AT THE ASSOCIATION BETWEEN DIETARY PATTERN AND VARIOUS HEALTH OUTCOMES. AND IN DOING SO FOR THE DIFFERENT HEALTH OUTCOMES WE LOOK AT WHICH INCLUDED DVD TYPE TWO DIABETES, OBESITY AND WEIGHT STATUS, KARENS NEUROLOGICAL PSYCHOLOGICAL ILLNESSES, CONGENITAL ANOMALIES. AND BONE HEALTH, WE WERE ABLE TO SEE ACROSS DIETARY PATTERNS COMMON CHARACTERISTICS ASSOCIATED WITH POSITIVE HEALTH OUTCOMES AN THOSE COMMON CHARACTERISTICS INCLUDED HIGHER INTAKE OF VEGETABLE, FRUITS, WHOLE GRAINS, LOW FAT DAIRY, FISH, SEAFOOD, LEGUMES, LEAN MEAT AND NUTS WHILE THEY INCLUDED A MODERATE INTAKE OF ALCOHOL. LOWER CONSUMPTION OF RED PROCESSED MEATS AN LOW SUGAR SWEETENED FOODS DRINKS AN REFINED GRAIN. WHEN WE LOOK AT THE DIETARY PATTERNS EVIDENCE RELATED TO OUTCOMES RATED AS STRONG AND MODERATE WHICH IS PREDOMINANTLY CVD TYPE 2 DIABETES AND BODY WEIGHT THE MAJORITY OF THAT EVIDENCE DOES COME FROM RANDOMIZED TRIALS SO IT'S NOT JUST OBSERVATIONAL COHORT STUDIES THAT WERE BASING THESE FINDINGS ON. SO COMMON CHARACTERISTIC OF THE CONCLUSION STATION -- STATEMENTS IMPLY BY FOLLOWING A DIETARY PATTERN THAT'S ASSOCIATED WITH REDUCE RISK OF CVD OVERWEIGHT OBESITY WHICH WERE BOTH RATED AS STRONG IN TYPE 2 DIABETES WHICH IS MODERATE, WILL HAVE HEALTH POSITIVE BENEFITS BEYOND CATEGORY OF THESE PARTICULAR HEALTH OUTCOMES. THAT'S ALL AMERICAN SHOULD TRY TO CONSUME DIETARY PATTERNS THAT ARE RICH IN FOODS THAT WE IDENTIFIED, MOTH MODERATE AND ALCOHOL AND LOW RED AND PROCESSED MEAT AND SUGAR SWEETENED BEVERAGES REFINED GRAINS. I THINK WHAT'S STRIKING HERE IS THE FACT THAT IT'S NOT JUST ONE SUBCOMMITTEE WORK IT'S GOING TO INFORM POLICY BUT IT'S THE COMPLIMENTARY ASPECTS OF ALL THE SUBCOMMITTEES WORK THAT ARE GOING TO LEAD TO THESE INTEGRATION OF FINDINGS THAT REINFORCES WHAT HAS BEEN FOUND HERE. FOR EXAMPLE, IT IS SUBCOMMITTEE ONE WORK WITH THE FOOD PATTERN MODELING, THAT WILL ALLOW US TO DETERMINE MORE -- GREATER SPECIFICITY THE DIFFERENT AMOUNT OF FOODS FOR EACH OF THESE GROUP FOOD GROUPS WE HAVE BEEN TALKING ABOUT AND IT IS SUBCOMMITTEE 3 AND 4'S WORK AS WELL AS PARTS OF SUBCOMMITTEE 5'S WORK. THAT ACTUALLY WILL SPEAK TO HOW WE NEED TO INTERVENE IN ORDER TO INCREASE INTAKES OF THESE PARTICULAR FOODS THAT WE HAVE FOUND OR FOODS ASSOCIATED WITH DIETARY PATTERNS THAT LEAD TO POSITIVE BENEFITS. SO I WILL END WITH THAT. >> THANK YOU, ANNA MARIA. RAFAEL. >> THANK YOU. CAN YOU HEAR ME, BARBARA? >> YES. >> OKAY. SO I'M RAFAEL PEREZ-ESCAMILLA THE CHAIR OF SUBCOMMITTEE 3 THAT FOCUSES ON INDIVIDUAL LEVEL KYE TEAR AND PHYSICAL ACTIVITY BEHAVIORAL CHANGE. AS WE ALL KNOW INDIVIDUAL IS AT THE INNER CORE OF THE SOCIAL ECOLOGICAL MODEL. AT THE END OF THE DAY PROPER IMPLEMENTATION OF THE DIETARY GUIDELINES FOR AMERICANS REQUIRES MOTIVATING FACILITATING BEHAVIORAL CHANGE AT THE INDIVIDUAL LEVEL. ON THE ONE HAND, THE COLLECTIVE WORK FROM SUBCOMMITTEE 3 INDICATES THERE ARE A NUMBER OF PROMISING BEHAVIORAL CHANGE STRATEGIES TO PREVENT SEDENTARY BEHAVIORS, IMPROVE DIETARY BEHAVIORS AND IMPROVE WEIGHT OUTCOMES. THESE INCLUDE AVOIDING EATING OUT AT FAST FOOD RESTAURANTS, EATING MORE OFTEN FAMILY SHARED MEALS AND SELF-MONITORING BOTH OF CALORIES, BEING CONSUMED AS WELL AS OF WEIGHT. THESE NEEDS TO BE COMBINED WITH TIMELY FEEDBACK FROM DIETITIANS AND OTHER QUALIFIED HEALTH PROFESSIONALS. ON THE OTHER HAND THE WORK OF SUBCOMMITTEE 3 INDICATES THAT THE SOCIAL ECONOMIC AND CULTURAL CONTEXT IN WHICH INDIVIDUALS LIVE HAVE STRONG INFLUENCE FACILITATING OR HINGERING THE ABILITY OF INDIVIDUALS TO CHOOSE AND CONSUME DIETARY PATTERNS THAT ARE CONSISTENT WITH DIETARY GUIDELINES. AND HAVE BEEN SO ELEGANTLY IDENTIFIED BY SUBCOMMITTEE 1 AND SUBCOMMITTEE 2. SPECIFICALLY HOUSEHOLD FOOD INSECURITY IS A CONDITION THAT HINDERS THE ACCESS TO HEALTHY DIET FOR MILLIONS OF AMERICANS. ALSO RECENT IMMIGRANTS ARE HIGH RISK OF LOSING THE HEALTHY DIETARY PATTERNS THEY ARRIVE WITH AS THEY ACULTURE RATE INTO MAINSTREAM AMERICA. TO SUM UP THE WORK OF SUBCOMMITTEE 3 COLLECTIVELY INDICATES STRONGER POLICIES ARE NEEDED TO PREVENT HOUSEHOLD INSECURITY FROM HAPPENING OR TO HELP FAMILIES TO COPE WITH -- HELP FAMILIES COPE WITH IT ONCE DEVELOPS. LIKEWISE, FOOD AND NUTRITION ASSISTED PROGRAMS AND THE HEALTHCARE SYSTEM, AT ALL LEVELS, FROM THE LOCAL NEED TO TAKE INTO ACCOUNT THE RISK THAT RECENT IMMIGRANTS HAVE OF GIVING UP HEALTHY DIETARY HABITS SOON AFTER ARRIVING IN THE US. AT THE END OF THE DAY, THINKING LOCAL HEALTH SYSTEMS WITH LOCAL FOOD SYSTEMS IS A MUST TO FACILITATE ACCESS TO HEALTHY DIETARY PATTERNS TO ALL INDIVIDUALS LIVING IN THE U.S. AS SUBCOMMITTEE 4 AND SUBCOMMITTEE 5 HAVE BEEN ILLUSTRATING WITH THEIR WORK. THANK YOU. >> THANK YOU SO MUCH, RAFAEL. MARY. >> THIS IS MARY STORY, THIS IS REPRESENTING SUBCOMMITTEE 4 ON THE FOOD ENVIRONMENT. THE COMMITTEE FOUND THAT EVIDENCE INDICATES THAT THE FOOD ENVIRONMENT AND THE KEY SETTINGS THAT WE LOOKED AT COMMUNITIES AND FOOD ACCESS, SCHOOLS, EARLY PARENT EDUCATION AND WORK SITES THAT THESE SETTINGS IMPACT DECISIONS ABOUT WHAT AND HOW MUCH PEOPLE EAT AND THEY ALSO CAN INFLUENCE BODY WEIGHT, WE NEED STRATEGIES TO IMPROVE DIETARY INTAKE AND REDUCE INCIDENCE AND PREVALENCE OF OBESITY. THAT NEED TO BE IN PLACE TO HAVE THE GREATEST IMPACT. IT'S REALLY IMPORTANT TO NOTE THAT GIVEN THE MAJOR PUBLIC HEALTH CONCERNS OF OBESITY IN THIS COUNTRY AND IT STARTS EARLY WHERE YOUNG CHILDREN THAT WE FOUND PROMISING MODERATE AND STRONG EVIDENCE DEMONSTRATING THAT MULTI-COMPONENT, EARLY CHILD CARE AND SCHOOL BASED APPROACHES CAN HAVE BENEFICIAL EFFECTS ON WEIGHT STATUS. WE FOUND THAT THE MULTI-COMPONENT APPROACHES PARTICULARLY ONES THAT COMBINED NUTRITION AND PHYSICAL ACTIVITY, WERE MOST EFFECTIVE AND ALSO THOSE THAT WERE IN SCHOOLS AND IN CHILD CARE, THOSE THAT HAD A FAMILY ENGAGEMENT OR FAMILY OUTREACH COMPONENT, AT THE MOST IMPACT. THE FOOD ENVIRONMENT REALLY IN ORDER FOR AMERICANS ALL AMERICANS TO MEET THE DIETARY GUIDELINES RECOMMENDATIONS ACTION IS REALLY NEEDED TO ENSURE THAT EVERYONE IN THE UNITED STATES HAS ACCESS TO HEALTHY FOODS. FOR AMERICANS TO IMPROVE DIET THEY NEED TO HAVE ACCESS TO NUTRITION TRISHAWS HIGH QUALITY AND AFFORDABLE FOODS. IN THE COMMUNITIES THEY LIVE AS WELL AS SETTINGS AS WELL AS THEY SPEND THEIR TIME. THANK YOU. >> THANK YOU, MARY. >> MIM. >> HI, THANKS. THIS IS MIM NELSON. REPRESENTING SUBCOMMITTEE 5. OUR WORK WAS REALLY AROUND SUSTAINABLE DIETS AND FOOD SAFETY. THE SCOPE OF OUR SUBCOMMITTEE WAS TO ADDRESS FOOD AND NUTRITION ISSUES THAT WILL INFORM PUB LINK HEALTH ACTION AND POLICY TO PROMOTE THE HEALTH OF THE POPULATION THROUGH SUSTAINABLE DIET AND FOOD SAFETY AND THE PURPOSE OF ADDRESSING SUSTAINABLE DIET IN NEW AREA FOR THE DGAC TO CONSIDER IS DIRECTLY RELATED TO FOOD SECURITY IN ORDER TO UNDERSTAND HOW DIETARY GUIDANCE AND FOOD INTAKE INFLUENCE OUR CAPACITY TO MEET THE NUTRITIONAL NEEDS OF POPULATION NOW AND IN THE FUTURE. WHEN I REALLY LOOK AT OUR SUBCOMMITTEE AND I LOOK AT THE WHAT I WOULD CALL INTEGRATED FINDINGS, WHAT WE SEE IS THAT ONE OF THE MAJOR AREAS WE LOOKED AT WAS AROUND DIETARY PATTERNS AND SUSTAINABILITY. IN FACT WHAT THE EVIDENCE FOUND THROUGH MODELING LOOKING AT BOTH HEALTH AS WELL AS SUSTAINABLE DIET IS THAT THERE WAS VERY CONSISTENT EVIDENCE THAT DIETARY PATTERNS HIGHER IN PLANT BASED FOODS SUCH AS VEGETABLES FRUITS, WHOLE GRAINS NUTS AND SEEDS AND LOWER IN ANIMAL BASED FOODS AS WELL AS CALORIES IS BOTH HELP PROMOTING AND ASSOCIATED WITH A LESSER ENVIRONMENTAL IMPACT. SO I THINK THIS REALLY DIRECTLY RELATES TO SUBCOMMITTEE 1 AND SUBCOMMITTEE 2, AND CERTAINLY ALSO SUBCOMMITTEE 3 AROUND FOOD SECURITY BUT HAVING A VERY LONGER VIEW AROUND FOOD SECURITY AND MAKING SURE WE HAVE THE FOODS WE NEED FOR THE LONG RUN. INTEGRATED WITHIN THAT, WITH STRONG EVIDENCE WAS AROUND -- SEAFOOD WHICH IS FORMED AND WILD CAUGHT IS BOTH SAFE AND WHAT WE FOUND IS THAT -- WITH HEALTHTHY APPROPRIATE STEWARDSHIP THIS SHOULD BE ABLE TO -- SEAFOOD SHOULD BE AVAILABLE IN AMOUNTS THAT WE NEED TO PROMOTE HEALTH FOR YEARS TO COME. SEAFOOD WAS A PIECE OF THAT. THE ONLY OTHER THING THAT I WOULD SAY IS -- IS IMPORTANT TO NOTE THERE WERE STRONG EVIDENCE AROUND SOME ASSOCIATED HEALTH BENEFITS WITH COFFEE INTAKE. AT NORMAL LEVELS, NOT AT HIGH LEVELS. THERE WAS NO CAUSE FOR ALARM WITH ANY ADVERSE EFFECTS OF COFFEE CONSUMPTION AT NORMAL LEVELS OUR MAIN THEME WAS AROUND SECURITY AND THE SYNERGY IN FACT OUR SUBCOMMITTEE HAS NOTHING TO DO WITH THE DEVELOPMENT OF PATTERNS PRESENTED EARLIER. NOSE PATTERNS WE WOULD CONSIDER COMPARED TO THE TAPECAL INTAKE RIGHT NOW TO BE SUSTAINABLE. >> THANK YOU, MIM. >> WHY DON'T WE TURN NOW TO THE WORK GROUPS AND I'LL ASK CHERYL TO PRESENT ON BEHALF OF SODIUM. S FROM >> SURE. THANKS, BARBARA. THE SODIUM WAS REALLY IN OUR EXPERIENCE FROM THE WORK GROUP PERSPECTIVE A CROSS CUTTING TOPIC IN EVERY WAY. IT'S A GREAT EXAMPLE REALLY OF THE NEED FOR INTEGRATED APPROACH TO PROVIDING THE GUIDELINES REPORT. SUBCOMMITTEE 1 ACTIVITY SODIUM WAS IDENTIFIED A NUTRIENT OF CONCERN FOR OVERCONSUMPTION THE EVIDENCE SHOWS IT'S STRONGLY ASSOCIATED WITH TWO HEALTH CONDITIONS WE EVALUATED FROM PREVALENCE IN TRENDS, THAT BEING BLOOD PRESSURE AS WELL AS CARDIOVASCULAR DISEASE. IN SUBCOMMITTEE 2 WORK IT CAME UP IN THE DIETARY PATTERNS WHERE THEY SHOWED THAT HEALTHFUL DIETARY PATTERNS ARE DEE USED IN SODIUM, PARTICULARLY WE LOOKED AT THE USDA FOOD PATTERNS AT THAT TIME 2000-KILO CALORIE LEVEL, WE SAW BEING FEASIBLE IN A MODELING APPROACH IS 1700-MILLIGRAM PER DAY SODIUM INTAKE LEVEL. SOME PATTERNS THAT ARE HIGHER IN SODIUM, WE AS WORKING GROUP HAVE BEEN ABLE TO MAKE IMPLICATIONS AROUND REDUCING THOSE PATTERNS IF NECESSARY TO CONFER HEALTH BENEFIT. AS WE HEARD DURING THE DISCUSSION EARLIER SUBCOMMITTEES 3 WORK AND 4 WORK AND WAYNE AND STEVE, REPRESENTED THOSE COMMITTEES ON THE WORKING GROUP REALLY CONTRIBUTED TO OUR IMPLICATION STATEMENT AROUND WHAT STRATEGIES ACROSS WHAT SETTINGS WOULD WE NEED TO BE TAKING ACTION IN ORDER TO GET ADHERENCE TO CURRENT RECOMMENDED SODIUM INTAKE. AND JUST TODAY IT WAS A WONDERFUL DISCUSSION AND HIGHLIGHT OF HOW SODIUM IS AMENABLE TO THE APPLICATION OF U SOCIO ECOLOGIC MODEL THAT WE HAVE ALL BEEN THINKING ABOUT ACROSS THE VARIOUS SUBCOMMITTEES AN WORKING GROUPS. WHERE AT THE INDIVIDUAL LEVEL WE CAN AIM TO GET EQUITY IN OVERALL DIET QUALITY WHICH WE KNOW SODIUM IS A BIG COMPONENT. WE TALK ABOUT ADDRESSING INDIVIDUAL BEHAVIOR SUCH AS HOME COOKING STRATEGIES EMPHASIZE NOT JUST TECHNICAL ASPECTS BUT FLAVOR ASPECTS RELATED TO SODIUM, AT THE RELATIONSHIP LEVEL, ENGAGING PEOPLE'S FAMILIES AND OTHER SOCIAL NETWORKS FLOUT THROUGHOUT THE VARIOUS IMPLICATION STATEMENTS WE HAVE HEARD ACROSS THE REPORT, THERE'S MENTION OF PEOPLE OF SOCIAL NETWORK AND RELIGIOUS GROUPS AND THE VARIOUS SETTINGS IN WHICH WE OPERATE. FINALLY AT THAT TIME COMMUNITY LEVEL, JUST TODAY AGAIN YOU HEARD MENTION OF OUR IMPLICATIONS FOCUSING ON TEACHING COOKING IN SCHOOL WE WANT INDIVIDUALS TO BE ABLE TO COOK MORE AT HOME TO MEET RECOMMENDATIONS, SOCIETAL FACTORS SUCH AS POLICY, POPULATION BASED STRATEGIES, PUBLIC PRIVATE PARTNERSHIP, EFFORTS TO CHANGE OUR FOOD SUPPLY, FOODS ARE REFORMULATED MOVEMENT TOWARD REDUCING SODIUM INTAKE IS ALSO PART OF THE DISCUSSION THAT WE HAD IN THE WORKING GROUP LEVEL. AND WILL HELP THE AMERICAN PUBLIC PREPARING THEMSELVES FROM ACCESSIBILITY AND AFFORDABILITY OF PREVENTION PERSPECTIVE TO MEET THE RECOMMENDED SODIUM INTAKE. SO THANK YOU FOR THE OPPORTUNITY TO THINK THROUGH THAT. AND PULL IT TOGETHER FOR OUR MEETING TODAY. >> THANK YOU, CHERYL. FRANK, WOULD YOU TALK TO THE SATURATED FAT WORK GROUP? >> AS MENTIONED EARLIER WE HAVE STRONG EVIDENCE TO SUPPORT CURRENT RECOMMENDATIONS TO REPLACE SATURATED FAT WITH POLYUNSATURATED FAT FOR THE PREVENTION OF CARDIOVASCULAR DISEASE DEBATE ABOUT THE ROLE OF SATURATED FAT MISSED A VERY IMPORTANT POINT WHICH REPLACEMENT MACRO KNEW TREATMENT EVIDENCE FROM TRIALS AN OBSERVATIONAL STUDIES DEMONSTRATED CLEARLY SATURATED FAT IS REPLACED BY ANY CARBOHYDRATE ESPECIALLY REFINED CARBOHYDRATE AND ADDED SUGAR THERE'S NO BENEFIT ON HEART DISEASE, I THINK THIS IS WHY MANY EPIDEMIOLOGY STUDIES AND TRIALS FAILED TO OBSERVE ASSOCIATION BETWEEN SATURATED FAT INTAKE AND RISK OF CSD BECAUSE CARBOHYDRATES WERE USE AS A COMPARE TON. HOWEVER IF SATURATED FAT IS REPLACED BY UNSATURATED FAT ESPECIALLY POLYUNSATURATED FAT THERE A CLEAR BENEFIT FOR HEART DISEASE PREVENTION. I THINK THIS LINE OF EVIDENCE IS CONSISTENT WITH THE DIETARY PATTERNING -- DIETARY PATTERN MODELING WORK AT (INAUDIBLE) WOULD SHOW FOR DIET -- HEALTHY DIETARY PATTERNS, THE AMOUNT OF UNSATURATED FAT IS LESS THAN 10% OF CALORIES. SATURATED FAT EVIDENCE IS CONSISTENT WITH DIETARY PATTERN WORK ASSAY 2 BECAUSE DIETARY PATTERN RELATIVELY LOW IN SATURATED FAT BUT HIGHER IN UNSATURATED FAT IS CONSISTENT WITH NUTRIENT AND FOOD PROFILES OF THE HEALTHY USDA PATTERN THE PA TERM MEDITERRANEAN DIET PATTERN AND HEALTHY EVENTUAL TEARIAN PATTERN. AND THE SATURATED FAT WAS I THINK REINFORCED THE IMPORTANCE OF MAKING RECOMMENDATIONS BASED ON FOODS. AND DIETARY PATTERNS INSTEAD OF SINGLE NUTRIENTS, AND ALSO REINFORCED THE MESSAGE THAT BOTH TYPE OF FAT AND TYPE OF CARBOHYDRATES ARE VERY IMPORTANT, HEALTHY DIETARY PATTERN SHOULD BE LOW IN BOTH SATURATED FAT AND THE REFINED CARBOHYDRATES AN ADDED SUGAR. AND ALSO IT'S VERY IMPORTANT ISSUE FOR PUBLIC HEALTH MESSAGING, A LOT OF PEOPLE ENTERPOE LATE A INDICT LOW IN SATURATED FAT IS THE SAME AS LOW FAT HIGH CARBOHYDRATE DIET. WE DISTINGUISH HEALTHY DIETARY PATTERN RELATIVELY LOW IN SATURATED FAT FROM COMBINATION OF LOW FAT HIGH CARBOHYDRATE DIET SO THE MESSAGE SHOULD BE THAT LOW SATURATED FAT DIETARY PATTERN IS NOT EQUIVALENT TO A LOW FAT HIGH CARBOHYDRATE DIET. FINALLY THE DIETARY RECOMMENDATIONS SHOULD BE FOOD BASED AND DIETARY PATTERN BASED, EMPHASIZING REPLACEMENT RATHER THAN JUST SIMPLY INCREASE OR DECREASE. THANK YOU. >> THANK YOU, FRANK. LET'S TURN NOW TO ADDED SUGARS AND WILL LET MARY, I DON'T KNOW IF YOU WILL TAKE THE LEAD ON THAT OR MIM OR BOTH. >> GO, MARY. >> THE WORKING GROUP LOOKED SYSTEMATICALLY AND ALREADY CAREFULLY AT MAJOR PUBLIC HEALTH CONCERNS OF OBESITY TYPE 2 DIABETES CARDIOVASCULAR DISEASE AND DEN TAP TALL CARIES AND WE FOUND THE ADD PSEUDOGARISH TAKE HAS IMPACT ON ALL THESE CONDITIONS. AND I THINK THE EVIDENCE CLEARLY SUPPORTS THAT REDUCING ADDED SUGAR IS REALLY NEEDED AMONG AMERICANS TO REDUCE HEALTH RISKS. I THINK WE ALSO -- I THINK WHAT WAS DONE IN LOOKING AT THE FOOD PATTERN MODELING ANALYSIS, SHOWS THAT THREE TO 9% OF TOTAL CALORIES CAN BE NON-CALORIE LEVELS FROM ADDED SUGARS CAN BE INCLUDED IN A HEALTHY DIETARY PATTERN. THIS WILL BE WHAT WE'RE RECOMMENDING IS THERE WILL BE AN UPPER LIMIT OF 10% FOR ADDED SUGARS AND IT WILL HELP AMERICANS TO EAT BETTER IF WE CAN HAVE CHANGES ON NUTRITION FACTS PANEL THAT WOULD INCLUDE ADDED SUGARS IN GRAMS AN TEASPOONS. AND FOR THE FIRST TIME INCLUDE A PERCENT DAILY VALUE. TO HELP CONSUMERS BE ABLE TO IDENTIFY THE AMOUNT OF ADDED SUGARS IN THE FOODS THEY EAT. AND ALSO I THINK IT SHOWS YOU WON'T NEED TO HAVE POLICIES AND PROGRAMS IN PLACE AT THE VARIOUS LEVELS. INCLUDING THE REFORMULATING FOODS HAVE LOWER LEVELS OF ADDED SUGAR, MIM, DO YOU WANT TO ADD ANYTHING? >> I DID THINK YOU DID IT PERFECTLY. THANK YOU. >> MI HAD BEEN, PHYSICAL ACTIVITY. -- MIM, PHYSICAL ACTIVITY. >> THIS IS MIM NELSON, WE HADN'T PRESENTED FOR A WHILE BECAUSE WE PRESENTED EARLY ON, I WOULD SAY THE MAJOR THEME HERE WITH STRONG EVIDENCE AND WE USED REPORTS THAT THE COMBINATION OF WHOLESOME NUTRITION COMBINED WITH REGULAR PHYSICAL ACTIVITY IS ESSENTIAL TO PROMOTING OTHERALL HEALTH AND PREVENTING CHRONIC DISEASE AND PHYSICALLY ACTIVE PEOPLE HAVE IMPROVED GROWTH AND DEVELOPMENT, HIGHER LEVELS OF HEALTH RELATED FITNESS AND LOWER RISK PROFILE FOR A NUMBER OF DISABLELING CONDITIONS AN LOWER RATES OF VARIOUS CHRONIC DISEASES THAT PEOPLE WHO ARE LESS SEDENTARY. SO I THINK THE BIG MESSAGE IS THAT GIVEN THE STRONG EVIDENCE FOR BENEFIT OF PHYSICAL ACTIVITY EVERY EFFORT SHOULD BE MADE TO ENCOURAGE FACILITY AT A TIME PROGRAMS AT MULTIPLE LEVELS SO CHILDREN AND ADULT AN OLD E OAR ADULTS MEET THE 2008 GUIDELINES. WHEN I LOOK AT THE INTEGRATION ACROSS THE SUBCOMMITTEES HERE, THERE'S A COUPLE OF THINGS TO MIND, ONE, THAT THERE IS A ENORMOUS GAP BETWEEN THE KNOWLEDGE OF THE BENEFIT OF PHYSICAL ACTIVITY, WHAT THE GUIDELINES ARE AND WHAT PRACTICE IS, SIMILAR WITH MANY OF THE GUIDELINES AROUND NUTRITION AND THE GAP IN TERMS OF WHAT PEOPLE ARE EATING, I THINK THERE'S A GAP ISSUE, WHEN YOU'RE TALKING ABOUT CREATING ACTUAL PUBLIC HEALTH CHANGE WE NEED TO THINK OF THE INDIVIDUAL LEVEL THE SYSTEMS LEVEL AND THE POLICY LEVEL AND I THINK THOSE ARE THE MAJOR THEMES. THANK YOU. >> THANKS VERY MUCH TO ALL OF YOU. I ASKED FOR VERY SHORT AND COHERENT SUMMARIES FROM THE GROUPS THAT I REALLY JUST THINK EACH OF THE LEADS HAVE DONE A WONDERFUL JOB. BOTTOM LINES HERE -- THERE'S NO DOUBT CHALLENGES ARE GREAT WE FACE IN TERMS OF IMPROVING THE HEALTH PROFILE AND THE DIETARY PATTERNS OF AMERICANS, WE HEARD A LOT ABOUT THAT, I DON'T THINK ANYONE NEEDS ANY MORE CONVINCING OF THOSE POINTS, THESE ARE ISSUES ACROSS THE LIFE SPAN BUT I THINK THAT IT'S IMPORTANT TO UNDERSTAND THAT WHAT WE'RE RECOMMENDING OVERLAPS AT LEAST TO SOME EXTENT WHERE AMERICANS ARE THESE DAYS. FC 1 MADE THE POINT THAT PERHAPS A MESSAGE TO AMERICANS IS THAT WE'RE HALF THE WAY THERE, WE HAVE QUITE A WAYS TO GO LET'S START THE FOUNDATION, A SOLID FOUNDATION AND MOVE FORWARD. WITH THAT IN MIND I THINK THE WORK OF THE DGAC HAS BEEN VERY SUCCESSFUL IN TERMS OF THE THEMES PUT FORTH INITIALLY AND WHERE WE ARE RIGHT NOW. THE DIETARY PATTERN WORK I THINK AS WE HAVE ALL SEEN HAS BEEN VERY SUCCESSFUL. WE HAVE BEEN ABLE TO DEMONSTRATE THAT THE HEALTH BENEFITS OF MANY DIFFERENT DIETARY PATTERNS AS THEY RELATE TO MAJOR HEALTH OUTCOMES, IN FACT THE MOST COSTLY HEALTH OUTCOMES WE CONFRONT TODAY, IT TURNS OUT AS THE GROUPS WORKING INDEPENDENTLY CAME TOGETHER IN SC-2 AND 5, WE REALIZE THAT NOT ONLY ARE THE HEALTHY DIETARY PATTERNS THAT WE HAVE IDENTIFIED ARE BENEFICIAL IN TERMS OF HEALTH OUTCOMES BUT IN FACT THEY ARE SUSTAINABLE AS WELL. AND I WOULD PUT FORTH IN THAT REGARD THE HEALTH AS WELL AS SUSTAINABILITY AND FOOD SECURITY MESSAGING FOR IN TERMS OF THE SHORE LONG TERM ARE PROBABLY GOING TO BE STRONG MOTIVATING AND PERHAPS NOVEL MESSAGES AS WE WRAP UP OUR REPORT AND BEGIN TO GET THE WORD OUT. THE OTHER POINT I GUESS BOTTOM LINE THAT I WOULD MAKE IS THAT THE HEALTHY PATTERNS THAT ARE BEING MODELED FOR PRESENTATION IN THE REPORT ARE STRONGLY EVIDENCE BASED. SHOWING THAT THESE STRONG TIES NOT ONLY BETWEEN SC 1s WORK AND SC 2s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th. ONCE WE SUBMIT OUR REPORT TO THE SECRETARIES OF HEALTH AND HUMAN SERVICES AND THE U.S. DEPARTMENT OF AGRICULTURE WE WILL DISBAND, BUT THE FEDERAL GOVERNMENT WILL ACCEPT PUBLIC COMMENTS ON OUR REPORT BUT THESE WILL BE REVIEWED BY THE FEDERAL AGENCIES AS THEY REALLY POUR OVER OUR FINDINGS AND CONCLUSIONS AND RECOMMENDATIONS AND WORK ON THE POLICY STATEMENTS. AND IT IS THE TASK AFTER WE WRAP UP OUR REPORT THAT OF THE AGENCIES TO ACTUALLY CREATE THE 2015 DIETARY GUIDELINES FOR AMERICANS. AS WE TAKE THOSE NEXT STEPS, LET'S REMEMBER WE HAVE MAJOR BUT PREVENTABLE DIET AND LIFESTYLE RELATED HEALTH OUTCOMES. WE HAVE GOT HEALTH DISPARITIES THAT WE HAVE MORE METHODS TO ATTEMPT TO DEAL WITH AND WORK WITH. WE HAVE THE EPIDEMICS OF OVERWEIGHT AND OBESITY THAT REALLY UNDERPIN THE MAJOR PROBLEMS THAT WE CONFRONT IN TERMS OF CHRONIC DISEASES AND WE ALSO HEARD COMPELLING EVIDENCE ABOUT THEIR RELATIONSHIPS TO OTHER LESSER -- LESS COMMON BUT IMPORTANT HEALTH PROBLEMS IN OUR COUNTRY AND CERTAINLY ALL THESE -- THE EVIDENCE EVIDENCE WE HAVE SEEN SHOWS IN MANY CASES MODERATE TO STRONG EVIDENCE -- EVIDENCEIAL LINKS WITH DIET AND PHYSICAL ACTIVITY AND LIFESTYLE BEHAVIORS. WE HAVE AS I SAID AT OUR VERY FIRST MEETING THE ADVANCED PUBLIC HEALTHCARE PUBLIC HEALTH SYSTEMS IN THE WORLD. WE GOT THE MOST ADVANCED ABUNDANT AGRICULTURE, WE HAVE ADVANCED TECHNOLOGIES ACROSS ALL THE SECTORS, THAT WOULD ENABLE US TO REALLY NOT ONLY CONSIDER THINGS LIKE FOOD PRODUCT REFORMULATION THAT HAS BEEN CALLED FOR PARTICULARLY WITHIN SOME OF OUR WORK GROUP ACTIVITIES, WE HAVE TECHNOLOGIES THAT ENABLE US IN WAYS WE PROBABLY NEVER THOUGHT OF BEFORE. TO GET MESSAGES OUT AND THAT HAVE NOW BEEN DEMONSTRATED TO SHOW CONSIDERABLE PROMISE NOT ONLY IN INDIVIDUAL BASED INTERVENTIONS STRATEGIES BUT IN STRATEGIES THAT COULD IMPACT ENTIRE COMMUNITIES, WORK SITES, SCHOOLS, AND SO FORTH. WE WANT TO REALLY REMEMBER THE RIVETING EVIDENCE THAT WE HAVE HEARD IN OUR MEETINGS ABOUT THE IMPORTANCE OF -- AND THE BENEFITS OF IMPROVED DIET QUALITY AND HEALTH OUTCOMES. AND THE MESSAGES THAT WORKS. BOTH AT INDIVIDUAL AND POPULATION LEVELS, THE IMPORTANCE OF POLICIES TO BE IN PLACE THAT CAN IMPACT THE QUALITY OF OUR FOOD SUPPLY THAT CAN MAKE THE SETTINGS MUCH STRONGER IN TERMS OF SUPPORTING HEALTHY EATING AND PHYSICAL ACTIVITY AND TO BE SUPPORTIVE AND COMPLIMENTARY OF EDUCATIONAL AND COUNSELING AND EFFORTS THAT WOULD ALSO MAKE ALL THE IMPLEMENTATION OF THE RECOMMENDATIONS IN OUR REPORT MUCH MORE FEASIBLE. THAT SAID, WE HAVE THE RESOURCES, WE HAVE THE KNOWLEDGE AND WE HAVE THE CAPACITY WITHIN THIS COUNTRY TO MAKE PROFOUND CHANGES FOR HEALTH OF OUR PUBLIC. THE QUESTION BECOMES DO WE HAVE THE WILL AND THE LEADERSHIP TO DO SO. AS MANY OF THE LEADS HAVE SAID, WE NEED BOLD ACTION, WE NEED SYSTEMS WIDE APPROACHES. WE NEED ATTENTION INDIVIDUAL COMMUNITY AND BROADER LEVELS SO WE ADDRESS THE PREVENTIBLE HEALTH PROBLEMS OF OUR NATION AND MOVE TO IMPROVED DIET AND PHYSICAL ACTIVITY. SO OUR RECOMMENDATIONS SHOULD AND TRUST WILL BE BOLD, CERTAINLY SOUND AND WILL BE RESEARCH DRIVEN. IN SO DOING WE HOPE TO MOTIVATE INDIVIDUALS IN COMMUNITIES TO NOT ADOPT HEALTHY LIFESTYLE BUT PROMOTE AS MANY SAID THEY'RE BECOMING NORMATIVE IN OUR COMMUNITIES. WE WANT TO TRY TO STIMULATE COLLABORATIONS ACROSS PUBLIC AND PRIVATE SECTORS OF INFLUENCE ON THE BEHAVIORS. AND TO SEEK PARADIGM SHIFTS PARTICULARLY IN HEALTHCARE BUT OTHER SETTINGS TOO, WORK SITES, SCHOOLS, EARLY CHILD CARE SETTINGS AND SO FORTH SO WE CAN HAVE A MUCH GREATER EMPHASIS ON HEALTHY EATING AND FISCAL ACTIVITY AND PREVENTION IN GENERAL. WE SHOULD TRY COLLECTIVELY TO SEEK TO TRANSFORM OUR NATION IN AS MANY WAYS AS POSSIBLE TOWARDS A CULTURE OF HEALTH. AGAIN I WANT TO THANK THE COMMITTEE FOR ITS SERVICE, I WANT TO JUST CHEER AND EXPRESS THE GRATITUDE OF EVERYONE ON THE COMMITTEE FOR OUR COLLABORATING COLLEAGUES AND GOVERNMENT. I WANT TO THANK THE PUBLIC FOR BEING NOT ONLY SO ATTENTIVE AND SUPPORTIVE OF THIS WORK BUT SO PROLIFIC AND RESPONSIVE IN YOUR COMMENTS WHICH WE HAVE TAKEN VERY SERIOUS AND I WOULD ENCOURAGE THEM TO CONTINUE, PARTICULARLY AS YOU THINK ABOUT THE THINGS THAT YOU HAVE HEARD ABOUT IN THE MEETING TODAY. WITH THAT I WOULD JUST ASK IF THERE ARE ANY FURTHER COMMENTS THAT MY VICE CHAIR ALICE LICHTENSTEIN WOULD LIKE TO MAKE OR OTHER MEMBERS OF THE COMMITTEE. FIST YOU, ALICE. HELLO? DO WE HAVE ANY OTHER COMMENTS? IF NOT I'M GOING TO TURN IT OVER TO RICK, TO ADJOURN THE MEETING AND AGAIN, THANK YOU, EVERYONE, FOR YOUR ATTENTION AND YOUR PARTICIPATION. >> THANK YOU. VERY PRODUCTIVE DAY. THE NEXT MEETING WE HAVE ANNOUNCED IS DECEMBER THE 15th. SO SIXTH MEETING TODAY IS ADJOURNED. THANK YOU. >> THANK YOU.