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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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Redesigning the Process for Establishing the
Dietary Guidelines for Americans

Committee to Review the Process to Update the
Dietary Guidelines for Americans

Food and Nutrition Board

Health and Medicine Division

A Consensus Study Report of

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THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by Contract No. AG-3198-C-16-0004 from the U.S. Department of Agriculture. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-46482-6
International Standard Book Number-10: 0-309-46482-X
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the process for establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24883.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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images

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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COMMITTEE TO REVIEW THE PROCESS TO UPDATE THE DIETARY GUIDELINES FOR AMERICANS

ROBERT M. RUSSELL (Chair), Professor Emeritus, Nutrition and Medicine, Tufts University School of Medicine, Boston, Massachusetts

JAMY ARD, Professor, Department of Epidemiology and Prevention; Co-Director, Wake Forest Baptist Health Weight Management Center, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina

STEPHANIE A. ATKINSON, Professor, Pediatrics, McMaster University, Hamilton, Ontario

CAROL J. BOUSHEY, Associate Researcher, Professor, Cancer Epidemiology Program; Director, Nutrition Support Shared Resource, University of Hawaii Cancer Center, Honolulu

SUSAN M. KREBS-SMITH, Chief, Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland

JOSEPH LAU, Professor Emeritus, Center for Evidence Synthesis in Health, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island

BRUCE Y. LEE, Director, Operations Research, International Vaccine Access Center; Executive Director, Global Obesity Prevention Center; Associate Professor, International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

JOANNE R. LUPTON, Distinguished Professor Emerita, Texas A&M University, College Station

SALLY C. MORTON, Dean, College of Science, Virginia Tech, Blacksburg

NICOLAAS P. PRONK, President, HealthPartners Institute; Chief Science Officer, HealthPartners, Minneapolis, Minnesota

SUSAN B. ROBERTS, Director, Energy Metabolism Laboratory and Professor of Nutrition, U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University; Professor of Psychiatry and Staff Member in Pediatrics, Tufts Medical School, Boston, Massachusetts

A. CATHARINE ROSS, Professor, Nutrition and Physiology; Dorothy Foehr Chair and Professor, Department of Nutritional Sciences, The Pennsylvania State University, University Park

___________________

NOTE: See Appendix G, Disclosure of Conflicts of Interest.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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BARBARA O. SCHNEEMAN, Emeritus Professor of Nutrition, Department of Nutrition and Department of Food Science and Technology, University of California, Davis

MARTÍN J. SEPÚLVEDA, IBM Fellow, Retired IBM Vice President of Health Systems and Policy Research, Watson Research Laboratory, IBM Corporation, St. Augustine, Florida

Health and Medicine Division Study Staff

SAMANTHA M. CHAO, Study Director

MEGHAN E. QUIRK, Senior Program Officer

MEREDITH J. YOUNG, Senior Program Assistant

ANNA BURY, Research Associate

ANN L. YAKTINE, Director, Food and Nutrition Board

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

CHERYL ACHTERBERG, The Ohio State University

ALICIA CARRIQUIRY, Iowa State University

WILLIAM H. DIETZ, The George Washington University

CHRISTINA ECONOMOS, Tufts University

JOHN W. ERDMAN, JR., University of Illinois at Urbana-Champaign

PETER BARTON HUTT, Covington & Burling LLP

RONALD M. KRAUSS, Children’s Hospital Oakland Research Institute and University of California, San Francisco

PENNY KRIS-ETHERTON, The Pennsylvania State University

SUZANNE P. MURPHY, Emeritus, University of Hawaii Cancer Center

ESTHER F. MYERS, EF Myers Consulting, Inc.

DEBORAH L. O’CONNOR, University of Toronto

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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ROBERT C. POST, Chobani Nutrition Center, Chobani, LLC, and formerly with the U.S. Department of Agriculture Center for Nutrition Policy and Promotion

HOLGER J. SCHÜNEMANN, McMaster University

PAUL SHEKELLE, RAND Corporation

PATRICK J. STOVER, Cornell University

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by SUE CURRY, University of Iowa, and JOHANNA T. DWYER, Tufts Medical Center. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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Preface

This is the second and final installment of a report that examines and then suggests improvements for the entire process used for establishing the Dietary Guidelines for Americans (DGA). This report is a consensus product of a committee of the National Academies of Sciences, Engineering, and Medicine as mandated by Congress in the Consolidated Appropriations Act of 2016. The first report was released in February 2017 and suggested changes to be made in the selection process of members of the Dietary Guidelines Advisory Committee (DGAC). In this report, the DGAC is called the DGSAC to stand for the Dietary Guidelines Scientific Advisory Committee. This second report focuses on a process redesign in developing and updating the guidelines, beyond just the selection of members for the DGSAC. This National Academies committee was specifically asked to evaluate the process, but not to evaluate the content, recommendations, or scientific justifications used in the current or past editions of the DGA.

Over time, the role of the DGA has become two-fold: (1) they provide the public with science-based dietary advice on eating patterns that can help to reduce the risk of developing a chronic disease, and (2) they provide food-based guidance (types and composition of foods to be used) in federal nutrition programs, such as the National School Lunch Program, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program, and many others. Despite the huge amount of effort that goes into establishing the DGA, less than 10 percent of Americans actually follow the guidelines. Congress has suggested that the low

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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level of adherence could be the result of a lack of confidence, in part because of how the DGA have been developed and hence a low level of trust in the ultimate recommendations. Congress thus directed the U.S. Department of Agriculture (USDA) to engage the National Academies to establish this ad hoc committee to conduct a comprehensive evaluation of the processes used to establish the DGA. (The Statement of Task can be found in the Introduction in Box 1-3.)

A principal finding of this National Academies committee is that an inefficiency of effort and a lack of continuity exists between successive 5-year DGA cycles. Within a 5-year cycle, the current process allots 2 years for evaluation of the science and for making conclusions by the DGAC, and 1 year for developing the DGA Policy Report by the government. The remaining 2 years of the 5-year cycle are a period of relative inactivity. This National Academies committee believes that using the entire 5 years for work on the DGA will not only provide the opportunity for a more thorough evaluation of the science, but also allow the DGA process to become more agile, flexible, and effective—and will address more topics of interest to the general public.

Currently, topic identification, gathering of scientific data, and the synthesis and interpretation of the science all fall on the shoulders of a single DGAC to be completed within a 2-year time frame. A central recommendation of this National Academies committee is to allow for more focused and tailored groups of experts to undertake each of the functions by dividing them among several groups during the 5-year cycle. The division of functions and the use of the entire 5-year time period for work on the DGA would provide many more opportunities for stakeholder and public participation, and thus serve to insert greater transparency into the process. If the DGA omits or only accepts parts of the conclusions in the DGSAC report, a clear explanation has to be given as to why. We believe these steps would all contribute to a higher degree of integrity and thus enhance the trustworthiness of the process to develop the DGA (see Recommendations 1 and 2).

Our National Academies committee also believes it is critical that the methods used to inform the DGA be validated and appropriate to the questions being asked. After extensive evaluation, we found that the current methods being used in the DGA process—original systematic reviews; existing systematic reviews, meta-analyses, and reports; food pattern modeling; and descriptive data analysis—are indeed appropriate. However, the vetting and updating of methods could be greatly strengthened by putting out the systematic reviews done at USDA’s Nutritional Evidence Library (NEL) for external peer review before handing them over to the DGSAC (see Recommendation 3). Moreover, there should be ongoing evaluation of NEL methods and ongoing training of NEL staff

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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by external expert groups with greater investment made in supportive, technological infrastructure (see Recommendation 4).

The final three recommendations made by this National Academies committee (see Recommendations 5, 6, and 7) are for strengthening and adopting appropriate and strategic methodologies so as always to align with current best practices. Scientific methods are continually evolving as new ones are emerging. Food pattern modeling has been used by previous DGACs, and it was found to be very useful in elucidating food grouping nutrient profiles, for example. In the future such modeling will help to make much more sense out of the complex system of exposure that is diet, which influences health. Moreover, systems approaches (now in their infancy in the nutrition field) will help us to more clearly define the roles and limitations of diet in reducing chronic disease risk. A concentrated effort will be needed to help the DGA achieve its promise, particularly as its scope becomes broadened to include all Americans—not just healthy Americans—as well as children under 24 months and pregnant women.

As chair of the committee, I would like to thank members of the committee for their time, effort, and willingness to engage in these discussions. This National Academies Committee to Review the Process to Update the Dietary Guidelines for Americans wishes to sincerely thank the many experts who helped us with this report by giving presentations, writing comments, and reviewing our drafts. The review of this report was done by individuals chosen for their diverse perspectives as well as technical expertise, and we have greatly appreciated their input. The committee hopes actions that follow the release of this report will lead to a more transparent process, resulting in more trustworthy DGA.

Robert M. Russell, Chair
Committee to Review the Process to Update the
Dietary Guidelines for Americans

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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Acknowledgments

The committee and staff would like to thank those who made presentations and statements at the public workshop held on January 10, 2017, in Washington, DC, as well as those who submitted written comments for consideration during that meeting:

Angela Amico, Center for Science in the Public Interest, on behalf of Lorrene Ritchie, University of California Nutrition Policy Institute

Tejas Bhatt, Institute of Food Technologists

Darlena Birch, National Women, Infants, and Children Association

Patricia Britten, Center for Nutrition Policy and Promotion, U.S. Department of Agriculture (retired)

Cara Brumfield, 1,000 Days

Robert Burns, Grocery Manufacturers Association

Stephanie Chang, Agency for Healthcare Research and Quality

Jeannette Crenshaw, United States Breastfeeding Committee

Janet de Jesus, National Institutes of Health

Becky Domokos-Bays, Supervisor of School Nutrition, Loudoun County, VA

Eve Essery-Stoody, U.S. Department of Agriculture

Emma Gregory, American Frozen Food Institute

Colette Heimowitz, Atkins Nutritionals, Inc.

Guy Johnson, McCormick Science Institute

Casey Keller, Global Wrigley

Mark Kennedy, Physicians Committee for Responsible Medicine

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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Clara Lau, National Cattlemen’s Beef Association

Susan Levin, Physicians Committee for Responsible Medicine

Sean Lucan, Albert Einstein College of Medicine

Richard Lucas, Food and Nutrition Service, U.S. Department of Agriculture

Patricia Mabry, Indiana University

David Meltzer, University of Chicago

Shawna Mercer, Centers for Disease Control and Prevention

Barbara Millen, Chair, 2015 Dietary Guidelines Advisory Committee

Suzanne Murphy, University of Hawaii Cancer Center

Julie Obbagy, U.S. Department of Agriculture

Jim O’Hara, Center for Science in the Public Interest

Sarah Ohlhorst, American Society for Nutrition

Mary Pat Raimondi, Academy of Nutrition and Dietetics

Tia Rains, Egg Nutrition Center

Kathleen Rasmussen, Cornell University

Pauline Sakamoto, Human Milk Banking Association of North America

Lee Sanders, American Bakers Association

Holger Schunemann, McMaster University

Kristen Strader, Public Citizen

Cathie Woteki, U.S. Department of Agriculture

Joan Younger, American Academy of Pediatrics Section on Breastfeeding

Tracey Ziener, Wrigley

We would like to thank those who provided written public comment to the committee. We would also like to recognize the General Services Administration for its helpful background information. In addition, there are many National Academies of Sciences, Engineering, and Medicine staff members who helped throughout the study process. The staff would like to thank Sylara Marie Cruz, Faye Hillman, Sarah Kelley, Tina Ritter, and Julie Wiltshire. Finally, we would like to thank and recognize the U.S. Department of Agriculture for sponsoring this study and for its helpful background information.

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Acronyms and Abbreviations

AHA

American Heart Association

AHRQ EPC

Agency for Healthcare Research and Quality Evidence-based Practice Centers Program

AI

adequate intake

AMDR

Acceptable Macronutrient Distribution Range

AMSTAR

A Measurement Tool to Assess Systematic Reviews

ARS

U.S. Department of Agriculture Agricultural Research Service

ARS NND

Agricultural Research Service National Nutrient Database for Standard Reference

B–24

children from birth to 24 months

CDC

Centers for Disease Control and Prevention

COI

conflict of interest

CSFII

Continuing Survey of Food Intakes by Individuals

DASH

Dietary Approaches to Stop Hypertension

DAT

data analysis team

DGA

Dietary Guidelines for Americans

DGAC

Dietary Guidelines Advisory Committee

DGPCG

Dietary Guidelines Planning and Continuity Group

DGSAC

Dietary Guidelines Scientific Advisory Committee

DRI

Dietary Reference Intake

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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EAR

Estimated Average Requirement

EER

Estimated Energy Requirement

FDA

U.S. Food and Drug Administration

FTE

full-time equivalent

HHS

U.S. Department of Health and Human Services

IOM

Institute of Medicine

NEL

Nutrition Evidence Library

NEL BAT

Nutrition Evidence Library Bias Assessment Tool

NHANES

National Health and Nutrition Examination Survey

NHIS

National Health Interview Survey

NIH

National Institutes of Health

P/B–24

pregnant women and children from birth to 24 months

PICO

population, intervention/exposure, comparator, and outcome of interest

RDA

Recommended Dietary Allowance

SEER

National Cancer Institute’s Surveillance, Epidemiology, and End Results

TEP

technical expert panel

UL

Tolerable Upper Intake Level

USDA

U.S. Department of Agriculture

WHO

World Health Organization

WIC

Special Supplemental Nutrition Program for Women, Infants, and Children

WWEIA

What We Eat in America

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Redesigning the Process for Establishing the Dietary Guidelines for Americans. Washington, DC: The National Academies Press. doi: 10.17226/24883.
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What foods should Americans eat to promote their health, and in what amounts? What is the scientific evidence that supports specific recommendations for dietary intake to reduce the risk of multifactorial chronic disease? These questions are critically important because dietary intake has been recognized to have a role as a key determinant of health.

As the primary federal source of consistent, evidence-based information on dietary practices for optimal nutrition, the Dietary Guidelines for Americans (DGA) have the promise to empower Americans to make informed decisions about what and how much they eat to improve health and reduce the risk of chronic disease. The adoption and widespread translation of the DGA requires that they be universally viewed as valid, evidence-based, and free of bias and conflicts of interest to the extent possible. However, this has not routinely been the case.

A first short report meant to inform the 2020 review cycle explored how the advisory committee selection process can be improved to provide more transparency, eliminate bias, and include committee members with a range of viewpoints. This second and final report recommends changes to the DGA process to reduce and manage sources of bias and conflicts of interest, improve timely opportunities for engagement by all interested parties, enhance transparency, and strengthen the science base of the process.

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