Dietary Patterns, and Effect on Population Health, Get Attention from Advisory Panel

Back in 1977, when a committee convened by then-US Senator George McGovern, D-SD, took the first official look at the American diet, the big concern was nutrient deficiency: In other words, what’s missing that might make people sick?¹

How times have changed.

On January 13-14, 2014, when the 2015 Dietary Guidelines Advisory Committee (DGAC) met in Bethesda, Maryland, the worries were generally not about too little but too much: Americans are making themselves sick alright, but most of the evidence concerns what we’re putting in our diets, not what we’re leaving out.

Rates of diabetes and obesity are soaring, especially in the Southeast, and at least part of this difference is attributed to the regional diet.² Institute of Medicine (IOM) Senior Scholar J. Michael McGinnis, MD, MA, MPP, opened the session with an historical overview of the Dietary Guidelines process, and noted that 500,000 Americans now die each year due to poor diet and exercise habits — more than die from smoking.^1,3

But as McGinnis and DGAC Chairwoman Barbara E. Millen, DrPH, RD, made clear, the 2015 guidelines cycle is not happening in a vacuum: the process, which occurs every 5 years and rotates between the US Departments of Agriculture (USDA) and Health and Human Services (HHS), will unfold within HHS as the Affordable Care Act (ACA) takes hold across the country. And language heard throughout the 2 days of hearings was strikingly similar at times to that of healthcare reform itself.

Looking to Improve Population Health

McGinnis, when asked how the guidelines could engage primary healthcare providers, said he was encouraged with the creation of accountable care organizations, as envisioned in the ACA. McGinnis noted that the ACA not only calls for the improvement of population health but for primary and specialty care providers to “look beyond the clinic doors” and speak to a “broad set of factors” that affect the health of every American, and require primary care physicians to be engaged.

The next day, after public testimony had concluded, Millen opened reports of the subcommittees with a clear link to healthcare reform. The 2015 guidelines, she said, have the potential to affect “the implementation of the Affordable Care Act, the accountable care organizations,” national prevention strategy, as well as grant funding within the National Institutes of Health and the Centers for Disease Control and Prevention. She then outlined what is good and bad about both the food and the healthcare systems.

The US population, she said, has the finest healthcare innovations in the world, including the best cancer care, but access to care is “variable.” The nation needs to shift its attentions from a preoccupation with treatment to a system based on prevention. Despite what employers and families spend on healthcare, there are wide healthcare disparities, Millen said. “We have preventable disease morbidity and chronic disabilities, and they account for half of the nation’s health burden.”

Is there a link between these facts and what Americans eat? Millen seemed to suggest so. “One in 6 households are food insecure, and two-thirds of the population is overweight or obese…we suffer from poor dietary patterns,” she said. “Foodborne illnesses have reached 76 million annually, accounting for 325,000 hospitalizations and 5000 deaths each year.”

Despite the many strengths of the agriculture and food distribution systems, Millen said, many experts believe that the committee must find solutions to these problems, and it must act aggressively to tackle diabetes and obesity, to do something about healthcare disparities among certain groups, to moderate alcohol use, and to lower metabolic risk factors. “These are the questions that are on the minds of the DGAC,” Millen said.

A “Systems” Approach

Millen, DGAC Vice Chair Alice Lichenstein, DSc, and the 2 returning members from 2010, Miriam Nelson, PhD, and Rafael Perez-Escamilla, PhD, have formed a science review subcommittee that is ensuring that the committee takes a “systems approach,” and examines dietary patterns and best practices, rather than just go food by food, or ingredient by ingredient. In fact, the third presenter at the January 13 session, Susan Krebs-Smith, gave the panel an overview of how to evaluate diets based on different systems approaches. Millen called for looking at “what works” at both a population level and at an individual level. The 2015 committee will continue its predecessor’s work in examining the effects of the places where people eat, cultural factors, and access to quality food, but it will dig deeper to examine the connection with health outcomes, Millen said.

This approach is more novel than it might seem. Past DGAC reviews have been criticized for being captive to corporate food groups; indeed, those interests gave it their best during the morning session of January 14. A literal smorgasbord of professionals paraded to the microphone, representing sugar, salt, potatoes, California walnuts, the American Meat Institute, nonalcoholic beverages, Ocean Spray cranberries, McDonald’s, juice products, Dannon yogurt, food technologists, egg farmers, the Tea Council, the National Cattlemen’s Beef Association, candy and gum, pistachio growers, and the United Fresh Produce Association, among others. Most interests came armed with a registered dietician, and everyone had studies to support giving their product a place at the table.

How food-specific the DGAC’s recommendations will be remains to be seen. Anna Maria Siega-Riz, PhD, RD, who chairs the largest and most critical subcommittee on “Dietary Patterns, Foods and Nutrients, and Health Outcomes,” explained in the afternoon session January 14 that her panel will first examine dietary patterns, and from those results will take its work into specific foods. She did not directly answer a question from Nelson on how the subcommittee would tackle thorny topics such as sugar-sweetened beverages, which has been the subject of important research since 2010, as well as high-profile public policy initiatives in New York City, Mexico, and the United Kingdom; and dairy, which dominated testimony in the public hearing January 14.

The Importance of Sustainability

Some topics of the January 13-14 meeting were anticipated: Given the public flap over a May IOM study that did not per day, it was hardly surprising when a Salt Institute lobbyist asked the committee to take the “courageous step” of calling for more salt in American diets.⁴

Comments received in the fall from Johns Hopkins’ Center for a Livable Future⁵ presaged the presentation from its visiting scholar, Kate Clancy, PhD, who spoke January 13 about food sustainability and food security; essentially, the idea that it’s best for the sources of food to be as close to the people that consume them as possible, to protect both population health and the environment.

As the Hopkins center did last fall, Clancy addressed the beef industry’s effects on the climate; she did not, however call for diets “bereft” of meat, but said “low-meat” diets produce many of the same benefits.

When it came to seafood, however, Clancy was clear: overfishing is a “wicked” problem, and the current dietary recommendations of 2 servings per week simply don’t square with supplies of popular fish. The public needs better, more specific advice on what species to eat; the fish “conundrum,” as Clancy called it, is part of a broader problem of food diversity. “There is biodiversity available to people, but when we look at what people eat, the message is not getting through,” she said. “Just like anything else, a better diet would have more species in it.”

Clancy said efforts to improve biodiversity and reduce portion size in school lunches in the largest districts and in college cafeterias have made some headway, but there’s more to be done. The public has a huge role to play in food sustainability and food security through the choices it makes, she said.

Dueling Over Dairy

Opponents of meat and especially dairy were out in force January 14; 13 of 54 favored plantbased diets in some form,⁶ and they ran the gamut: from the vegan mother who shared a typical daily menu, to the African American doctor who showed up in scrubs after an overnight hospital shift, to the actress Marilu Henner. Mona Sigal, MD, the former emergency room chief at North Shore Medical Center in Massachusetts who today educates the public about healthy eating, used her 3 minutes to lambaste the USDA’s publicly funded promotion of cheese, which left the audience laughing when the moderator announced that the next speaker was from the National Dairy Council. But Sigal’s message was serious: like other speakers, she cited studies that link dairy consumption with cancer.

The African American physician, Martin Mills, MD, is a graduate of Stanford University School of Medicine and has led a suit by the Physicians’ Committee for Responsible Medicine against the dairy industry, seeking warning labels on milk.⁷ Mills did not mention those credentials; instead, he cited statistics that unlike Americans of Northern European origin, most ethnic minorities are naturally lactose intolerant, including 70% of African Americans, 90% of Asian Americans, and 55% of Mexican Americans.

Moreover, Mills said, connections between milk and cancer are emerging, and the troubling disparities of prostate cancer among African American men⁸ demands that the committee, “stop holding Americans hostage to the marketing interests of the dairy industry.”

While percentages in studies have varied, Mills’ overall assertion that lactose intolerance is higher among minorities than persons of Northern European heritage is supported in the literature,^9-11 and his assertions about cancer links are supported as well.^12,13

Thus, Mills likened the government’s ongoing inclusion of recommended daily allowances of dairy in American diets to a form of “institutional government racism.”

“Yes, I played the race card,” he said.

Various dairy groups brought up past recommendations about “nutrients of concern,” specifically calcium, potassium, and vitamin D, and cited studies showing that consuming dairy would contribute to meeting daily requirements.

Controversies over dairy recommendations are not new. The inclusion of a separate dairy cup to the side of the My-Plate graphic was a key criticism of the 2010 edition of Dietary Guidelines for Americans; Harvard’s School of Public Health replaced the dairy cup with a glass of water in its “Healthy Plate” alternative, citing dairy links to prostate cancer as a reason.¹⁴

Next Steps

In opening the subcommittee sessions, Millen reminded the committee that its work is advisory in nature, and the final guidelines are set by the federal departments that oversee the group. Still, the committee has a significant role in shaping guidelines that Millen said shape massive federal programs and touch virtually “every American, every day.”

EBDM

References

1. 2015 Dietary Guidelines Advisory Committee. DGAC Meeting 2 Materials and Presentations. http://www.health.gov/dietaryguidelines/2015-binder/meeting2/index.aspx. Published January 13-14, 2014. Accessed February 12, 2014.

2. Kiage JN, Merill PD, Robinson CJ, et al. Intake of trans fat and all-cause mortality in the Reasons for Geographical and Racial Differences in Stroke (REGARDS) cohort. Am J Clin Nutr. 2013;97(5):1121-1128.

3. Campaign for Tobacco Free Kids website. https://www.tobaccofreekids.org/facts_issues/toll_us/. Accessed February 20, 2014.

4. Center for Science in the Public Interest. Institute of Medicine chief knocks press coverage of salt report. https://www.cspinet.org/new/201306171.html. Published June 17, 2013. Accessed January 1, 2014.

5. Fry JP, Love DC, Nachman KE, Lawrence RS. Letter to 2015 Dietary Guidelines Advisory Committee. Center for Livable Future website. http://www.jhsph.edu/research/centers-andinstitutes/ johns-hopkins-center-for-a-livable-future/_pdf/projects/ffp/farm_bill/CLF-publiccommentseafood-DGAC_2013.pdf.

6. Oldways: Health through Heritage website. Sneak Peak at the 2015 Dietary Guidelines. http://oldwayspt.org/community/blog/sneakpeek-2015-dietary-guidelines. Published January 23, 2014. Accessed February 20, 2014.

7. Physician Profile, Milton Mills, MD: Prescribing Change. Physicians’ Committee for Responsible Medicine website. http://www.pcrm.org/search/?cid=855. Accessed February 20, 2014.

8. American Cancer Society. Cancer Facts & Figures for African Americans, 2011-2012. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc 027765.pdf. Accessed February 20, 2014.

9. Swagerty DL Jr, Walling AD, Klein RM. Lactose intolerance. Am Fam Physician. 2002;65(9):1845-1850.

10. Scrimshaw NS, Murray EB. The acceptabilityof milk and milk products in populations with a high prevalence of lactose intolerance. Am J Clin Nutr. 1988;48(4 Suppl);1079-1159.

11. Mattar R, Mazo DF. Lactose intolerance: changing paradigms due to molecular biology. Rev Assoc Med Bras. 2010;56(2):2360236.

12. Chan JM, Gann PH, Giovannucci EL. Role of diet in prostate cancer development and progression. J Clin Oncol. 2005;23(32):8152-8160.

13. Leitzmann MF, Rohrmann S. Risk factors for the onset of prostatic cancer: age, location, and behavioral correlates. Clin Epidemiol. 2012;4:1-11.

14. Healthy Eating Plate vs. USDA’s MyPlate. Harvard School of Public Health website. http://www.hsph.harvard.edu/nutritionsource/healthyeating-plate-vs-usda-myplate/. Accessed January 1, 2014.

The committee’s work, she said, “must be thoughtful, it must be science driven, and it must be very careful.” Millen noted that the committee would consider online comments, in addition to those given in person at the hearing. The next committee meeting is set for March 14, 2014.

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