May 8, U.S. Department of Health and Human Services 1101 Wootton Parkway, Suite LL100 Tower Building Rockville, MD 20852

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1 May 8, 2015 Richard D. Olson, M.D., M.P.H. Designated Federal Officer, 2015 Dietary Guidelines Advisory Committee Office of Disease Prevention and Health Promotion Office of the Assistant Secretary for Health U.S. Department of Health and Human Services 1101 Wootton Parkway, Suite LL100 Tower Building Rockville, MD Kellie Casavale, Ph.D., R.D. Deputy Designated Federal Officer, 2015 Dietary Guidelines Advisory Committee Nutrition Advisor; Office of Disease Prevention and Health Promotion Office of the Assistant Secretary for Health U.S. Department of Health and Human Services 1101 Wootton Parkway, Suite LL100 Tower Building Rockville, MD Colette I. Rihane, M.S., R.D. Lead USDA Co-Executive Secretary, 2015 Dietary Guidelines Advisory Committee Director, Office of Nutrition Guidance and Analysis Center for Nutrition Policy and Promotion U.S. Department of Agriculture 3101 Park Center Drive, Room 1034 Alexandria, VA Shanthy A. Bowman, Ph.D. USDA Co-Executive Secretary Nutritionist, Food Surveys Research Group Beltsville Human Nutrition Research Center Agricultural Research Service U.S. Department of Agriculture Baltimore Avenue BARC-West Bldg 005, Room 125 Beltsville, MD Re: The Dietary Guidelines for Americans, 2015 Dear Dr. Olson, Dr. Casavale, Ms. Rihane, and Dr. Bowman: The Society for Nutrition Education and Behavior (SNEB) thanks the United States Department of Agriculture and the Department of Health and Human Services for the opportunity to provide comments on the Scientific Report of the 2015 Dietary Guidelines

2 Advisory Committee (DGAC) during the process of developing the eighth edition of the Dietary Guidelines for Americans. SNEB represents the unique professional interests of nutrition educators in the United States and worldwide. SNEB is dedicated to promoting effective nutrition education and healthy behavior through research, policy and practice with a vision of healthy communities, food systems and behaviors. Our members educate individuals, families, fellow professionals, and students, and influence policymakers about nutrition, food, and health. Their work takes place in colleges, universities and schools, government agencies, cooperative extension, communications and public relations firms, the food industry, voluntary and service organizations and within other reliable places of nutrition and health education information. We commend the committee for their work on this report. The recommendations contained within it are informed by a solid scientific evidence base, address the most critical diet-related public health issues at present, and largely align with views of the Society of Nutrition Education and Behavior. SNEB recognizes the unique role the Dietary Guidelines for Americans (DGA) play in shaping the diets of everyday consumers. There are a multitude of factors that may influence diet and physical activity behaviors, from the individual, household, social, cultural, environmental, political and systemic. It is for this reason that attempts to achieve and maintain healthy dietary patterns must take into account all of the above aspects, simultaneously and consistently. Moreover, we want to underscore the significance of the report s recommendations for policies and environments that support and improve public health. We particularly commend and agree with the Committee s call to achieve a culture of health, which emphasizes the bold, concerted actions that are necessary on the part of all stakeholders. The comments we share today are grounded in the belief that creating healthful dietary patterns requires cooperation from individuals, families, communities, industry and government. The Society for Nutrition Education and Behavior (SNEB) respectfully addresses the following proposed recommendations within the scientific report of the DGAC: Recommendation #1: Include more vegetables, fruits, whole grains, seafood, nuts, legumes, low/non-fat dairy or dairy alternatives and reduce consumption of red and processed meat, refined grains, added sugars, sodium, and saturated fat.

3 There is a strong body of scientific evidence highlighted in the Committee s report indicating that dietary patterns that include less meat, added sugars, sodium and saturated fat and more plant-based foods are better for health. This finding has persisted from the 2010 DGAs and has been echoed by other professional organizations, including the American Heart Association and the American Institute for Cancer Research. But, because consumers may have difficulty piecing together individual aspects of dietary recommendations, especially those that are focused only on nutrients, the new guidelines should include clear food-based messaging. A focus only on nutrients is insufficient for Americans at this time, given the preponderance of diet-based chronic disease and the confusion many consumers express with regard to dietary choices. We encourage the USDA and DHHS to recognize that overall dietary pattern is largely more important than any specific food or nutrient. A variety of dietary patterns are explored in the Committee s report, which allow consumers to meet their nutrient needs through a variety of foods tailored to their preferences. These patterns share the similar features of more vegetables, fruits, nuts, whole grains, healthy oils, and less red and processed meats, sugar-sweetened foods and beverages, and refined grains. The committee s findings lend themselves to unequivocal food-based and consumer-friendly messaging and the final Dietary Guidelines should continue to emphasize them as well as make specific recommendations with respect to less red and processed meats etc., and more vegetables, fruits, nuts, whole grains, etc. Recommendation #2: Reduce the consumption of added sugars We fully support the DGAC s recommendations to reduce consumption of added sugars, including the need for a line on added sugars on the Nutrition Facts label that includes a percentage of a Daily Value based on 10 percent of calories or less in a 2,000-calorie diet, and for amounts expressed in teaspoons as well as grams to maximize consumer understanding. First, we concur that the scientific evidence underscoring concerns with added sugars in the diet is strong. With regard to high consumption of added sugars, the DGAC concluded that there was strong evidence for an increased risk of excess body weight, obesity, and type 2 diabetes and moderate evidence for an increased risk of hypertension, stroke, coronary heart disease, high blood pressure, serum triglycerides, and dental caries. After reviewing the evidence, the Committee found that strong evidence supports reducing added sugars intake to reduce health risks and that a limit on added sugars to a maximum of 10 percent of total daily caloric intake

4 was supported by the food pattern modeling analysis and the scientific evidence review on added sugar and chronic disease risk. A quantitative recommendation for added sugars must be included in the main body (and not just an appendix) of the DGA, as it has important implications for national programs and policies, including school meals, snacks and drinks in schools, and food labeling. Recommendation #3: Achieve and maintain a healthy weight. We support the Committee on their efforts to include achieving and maintaining healthy weight in their recommendations. The committee has recognized that about half of all American adults 117 million individuals (i.e. more than two-thirds of adults), have one or more preventable, chronic diseases that are related to obesity that includes cardiovascular disease, hypertension, type 2 diabetes and diet related cancers. Nearly one-third of children and youth are overweight or obese. Their review of evidence has suggested moderate to strong links that obesity is related to poor quality dietary patterns and physical inactivity, and it exacerbates poor health profiles and increases risks for chronic diseases and their co-morbidities. In addition, the annual medical cost of obesity is enormous. More than 5% of the national health expenditure in the United States is directed at medical costs associated with obesity. Hence, inclusion of healthy weight in the dietary guidelines should be undebated. The committee has also reviewed the literature that suggests how we may achieve and maintain healthy weight and prevent excessive weight gain. The evidence suggests moderate to strong links demonstrating that dietary interventions implemented by nutrition professionals and individual or small-group comprehensive lifestyle interventions that target diet and physical activity and are led by multidisciplinary professional teams provide optimal results in chronic disease risk reduction, weight loss, and weight loss maintenance. Individuals can be helped in their intentions to implement healthy lifestyles by targeting specific eating and physical activity behaviors (e.g., meal patterns, cooking and preparation techniques, family/household meal experiences, reducing sedentary behaviors in adults and youth, reducing screen time in children). Sound behavioral interventions can engage individuals actively in the behavior change process, using traditional face-to-face or small group strategies and new technological approaches such as websites and mobile/telephone technology, by providing intensive, long-term professional interventions as appropriate, and by monitoring and offering feedback on sustainable behavioral change and maintenance strategies over time.

5 As nutrition educators we commend the committee for considering the healthy weight issue as a priority and making clear recommendations about the how it can be achieved. Recommendation #4: The Dietary Guidelines for Americans should highlight the distinct dietary needs of older adults. As the fastest growing demographic, the final report should underscore both the nutrition and physical activity differences among this population. The Committee noted that overweight and obesity are highest in adults 40 years and older, particularly among Hispanic Americans and African Americans. In addition, abdominal obesity is highest in individuals 60 years and older and that more than half of women ages 60 to 69 years have low bone mass, with approximately 12 percent meeting the criteria for osteoporosis. The prevalence of osteoporosis increases with age; about one-quarter of women ages 70 to 79 years and about one-third of women older than age 80 years have osteoporosis. As the committee noted, poor bone health and osteoporotic fractures are a major cause of morbidity and mortality in the elderly and account for significant health care costs. The Committee found that shortfall nutrients are distinct among this population, falling short of the estimated average intakes of both calcium and vitamin D, nutrients that are crucial for bone health. Fiber, protein, and potassium were also identified as shortfall nutrients for older adults. High sodium intake and significant rates of high blood pressure are also of note for older adults. Thus, the final guidelines should pay strong attention to guidance and messaging specific for older adults. As nutrition educators, we commend the Committee for recognizing the need for additional data on the dietary intake of older adults given the small sample sized used for the Committee s analyses. We also support the Committee s recommendation that more research is needed on whether older adults can shop, cook and whether co-morbidities affect one s ability to establish and maintain proper nutritional status. In sum, the Dietary Guidelines should address the unique concerns of this population and take a lifecycle approach when issuing the final report and related nutrition guidance. Recommendation #5: Promote water as the beverage of choice. We support the development of policies to promote water as the primary beverage of choice. We also support public education and policy changes to encourage access to clean water,

6 including a symbol for water as part of the graphics for MyPlate. Recent research shows that substituting drinking water for sugar drinks (sodas, juice drinks, pre-sweetened tea and coffee drinks, sports drinks, and energy drinks) can help reduce intake of calories from added sugars among both children and adults and reduce the risk of dental caries. Science-based organizations, such as the Institute of Medicine s Committee on Accelerating Progress in Obesity Prevention, Centers for Disease Control and Prevention, and the American Heart Association s Voices for Healthy Kids embrace the importance of water in chronic disease prevention and have called for improvements in community-wide drinking water access. The American Academy of Pediatrics encourages water as the best source of hydration for young people. We recommend that HHS and USDA promote plain tap water as the primary beverage of choice. That recommendation would build on that provided in the 2010 DGA ( To limit excess calories and maintain healthy weight, individuals are encouraged to drink water and other beverages with few or no calories... ) and the strengthened recommendations for drinking water made in the 2015 DGAC report. Encouraging water consumption would build demand for improved access to clean and safe tap water, needed in many homes, schools, and other sites across the country, as recommended by the DGAC. Adding water to the MyPlate graphic would support effective implementation of the provisions of the Healthy, Hunger-Free Kids Act of 2010 requiring ready access to water in childcare and in schools, also recommended by the DGAC. Recommendation #6: Recognize and place priority on moving toward a more sustainable diet consistent with the healthy dietary pattern options described in this DGAC report. The system that produces, distributes, and processes the food that sustains and nourishes us is intricate, and SNEB applauds the DGAC for addressing sustainability in this report. There is growing recognition that the way in which foods are produced can undermine other aspects of public health by eroding the wellbeing of the broader environment in which we all live. The Committee s rigorous and comprehensive assessment of the evidence has concluded that the average U.S. diet has a larger environmental impact contributing to greater greenhouse gas emissions, land use, water use, and energy use, than the recommended dietary patterns. Its prioritization of sustainability is consistent with a range of scientific consensus organizations, including the National Research Council, a committee of the Institute of Medicine, the United Nation s Food and Agriculture Organization and the Academy of Nutrition and Dietetics.

7 It is imperative that our nation s dietary guidance considers the sustainability of the overall food system when crafting recommendations. Less resource-intensive dietary patterns support nutrition and reduce greenhouse-gas emissions, land, water, and energy use, and ecosystem harm. Our nation s ability to meet future food needs will depend on those environmental outcomes, particularly in the context of a changing climate, with more extremes in weather such as drought, resource shortages, changes in global dietary patterns, and population growth. In the DGAC report, there is an incredible opportunity for harmony on the issues of personal health and environmental sustainability. The dietary patterns that contribute to lower risk of chronic diseases such as diabetes, cardiovascular disease, and some cancers, are also associated with less environmental impact. Including a focus on healthy, sustainable dietary patterns can also provide new themes for consumer education and communication, and may help individuals adopt healthy behaviors for reasons beyond personal health. Therefore, we are asking the United States Department of Agriculture (USDA) and Health and Human Services (HHS) to show a strong commitment to keeping Americans, and our shared environment, healthier by developing clear dietary recommendations on the need for reduced consumption of animal products and more plant-based foods. Recommendation #7: Policy and environmental approaches to support a healthy dietary pattern As explored in the Committee s report, a wealth of evidence converges a dietary pattern that promotes health, yet many Americans fail to achieve this pattern. We strongly support the DGAC s focus on the broad range of factors, including policy and environmental approaches that influence people s diet and weight-related behaviors. We agree with the Committee s recommendation that developing, implementing and sustaining programs in schools, communities and other settings is key to achieving healthy diet patterns. Doing so requires action on the part of Federal, state, and local governments, in concert with public-private partnerships and businesses. The final DGA report should continue to reflect these sensible and science-based changes to our food environment and public policies to support and facilitate Americans making healthier food and beverage choices across the lifespan. The following are specific approaches that SNEB supports:

8 a) Implementing comprehensive school meal guidelines The Committee highlights the 49.6 million school-aged children in the nation that would likely benefit from a comprehensive approach to nutrition in schools. In particular, school meal programs play a significant role in safeguarding the health and wellbeing of American children. When combined with other approaches such as wellness policies and/or nutrition education, strong nutrition standards for school meals and snacks result in a higher quality diet for our children. Recent research has shown that revised nutrition standards are working as intended, both to promote children s intake of fruits and vegetables and reduce waste. Reversing or repealing school nutrition standards at this point would prove detrimental to children s health and would make future changes improbable. It is for this reason that the Dietary Guidelines must include mention of this approach as a means for American schoolchildren to adhere to healthy diet patterns. b) Maintaining strong support for Federal food and nutrition programs and aligning food assistance programs such as WIC and SNAP with Dietary Guidelines In our country today, over 49 million people, including nearly 9 million children, live in food insecure households. These households struggle with limited or uncertain availability of foods and the anxiety and distress that accompany it. The Committee has found household food insecurity to be an independent risk factor for several health outcomes, both physical and mental, across the lifespan. Being food insecure is likely to promote the development of many chronic diseases, as the Committee notes, because the cycle of having enough food followed by inadequate amounts has been associated with stress, poor diet quality, poor glycemic control, and in some studies, a higher body weight. Because of its intimate relationship with future health outcomes, the Committee recommends a focus on food security in the final dietary guidelines. Because individual dietary changes are near impossible when food availability is uncertain, federal nutrition programs play a key role in reducing food insecurity and improving nutritional health. Today, 62% of food insecure households in America participate in one of the federally funded nutrition programs, including SNAP, WIC and the National School Lunch Program. Thus, the potential reach and impact of these programs to promote food security while simultaneously promoting healthy dietary patterns is broad, particularly when they include strong nutrition education and promotion components. But efforts to promote healthy dietary patterns need to be seamlessly integrated with food assistance programs, such as food banks, soup

9 kitchens, and the Federal nutrition assistance programs. A focus on reducing consumption of, calorie-dense, nutrient-poor foods and sugar-sweetened beverages and increasing access to whole plant-based foods like fruits, vegetables, nuts and whole grains, has the potential to double-down on the positive effects of already beneficial federal nutrition programs. Furthermore, creating a shift in demand for healthy food products through altered institutional purchasing, federal nutrition programs are likely to influence changes in the overall food system and shift the supply of healthy foods across the nation. The final dietary guidelines must make explicit the positive potential of these programs. c) Considering alternative policy options that were recommended by the Committee Establishing healthy food environments can happen through other policy actions as well. Today, nearly one third of all calories consumed by Americans are consumed outside of the home, mainly from full service and fast food restaurants. The Committee found that, independent of where the food is prepared or obtained, the diet quality of the U.S. population does not meet recommendations for fruit, vegetables, dairy, or whole grains, and exceeds recommendations for the nutrients sodium and saturated fat, and the food components refined grains, solid fats, and added sugars. There are several effective and evidence-based policy options mentioned in the Committee s report to address our nation s poor dietary quality. For example, the Committee recommends: Improving, standardizing and implementing Nutrition Facts labels and Front of Package labels Implementing economic and pricing approaches to promote the purchase of healthy foods and beverages Price incentives on vegetables and fruits could be used to promote consumption and public health benefits. Mounting public education campaigns to increase the public s awareness of the health effects of excess added sugars, sodium, saturated fat, and calories Implementing policies that limit exposure and marketing of foods and beverages high in added sugars and sodium to all age groups, particularly children and adolescents. We agree that the Dietary Guidelines should mention several of these policy options to be utilized where possible. These policy options constitute a tool kit from which governments and

10 communities can select from and tailor to their unique needs. Noting these policy options is warranted given the state of Americans dietary quality and preponderance of diet-related chronic disease. Furthermore, it is becoming abundantly clear that individual dietary change is hard when not supported by a healthy food environment. There is no one magic bullet that will improve American s dietary patterns overnight, but instead a series of steps that ultimately create a culture of health. Such steps will include a combination of individual dietary changes, community actions, public-private partnerships, and governmental policy to support changes to the food environment that can help individuals make healthy choices. Those and other sectors all have a role to play in promoting healthy behaviors and creating environments that promote a healthy way of life. The key stakeholders must become champions for a healthy diet and lifestyle and work in partnership across sectors to change policies and environments that make eating healthy foods and beverages and maintaining a healthy weight not just easier, but the cultural norm. Many of the recommended population-level strategies involve changes in federal policies, and the federal government must move forward with making evidence-based changes in policies and practices. The federal government should also encourage and incentivize policy changes at other levels of government and in the private sector that promote healthy environments and behaviors. Thank you for your efforts to grapple with these complex issues and for your consideration of our recommendations. We welcome the opportunity to provide further evidence in support of our recommendations if needed. Sincerely, Kendra Kattelmann, PhD, RD, LD, FAND President Society for Nutrition Education and Behavior