Academy Comments to USDA and HHS re DGA Topics and Questions

March 30, 2018

Dr. Donald Wright
Deputy Assistant Secretary for Health
Office of Disease Prevention and Health Promotion
Office of the Assistant Secretary for Health
United States Department of Health and Human Services
11001 Wootton Parkway, Suite LL 100
Rockville, MD 20852

Mr. Brandon Lipps
Food and Nutrition Service
United States Department of Agriculture
3101 Park Center Drive
Alexandria, VA 22302

Kristin Koegel
Food and Nutrition Service
Center for Nutrition Policy and Promotion
United States Department of Agriculture
3101 Park Center Drive, Suite 1034
Alexandria, VA 22302

Re: Dietary Guidelines for Americans: Request for Comments on Topics and Questions (Docket No. FNS-2018-0005)

Dear Dr. Wright, Mr. Lipps, and Ms. Koegel:

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the U.S. Department of Agriculture and the U.S. Department of Health and Human Services (collectively, the "agencies") related to the published item "Dietary Guidelines for Americans: Request for Comments on Topics and Questions (Docket No. FNS-2018-0005)" (the "request for comments") published in the Federal Register on February 28, 2018. Representing over 100,000 registered dietitian nutritionists,1 nutrition and dietetic technicians, registered, and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to accelerating improvements in global health and well-being through food and nutrition. Our members have helped conduct, review, and translate nutrition research for previous editions of Dietary Guidelines for Americans (the "Guidelines" or DGA), served on the advisory committees for the DGAs, and will work to help consumers, industry, schools, and food assistance programs choose meal patterns in accordance with the finalized recommendations of the 2020-2025 DGA.

The Academy supports the agencies' efforts implementing recommendations to improve the processes by which the quinquennial Guidelines are developed, enhance transparency, and increase opportunities for public participation at various stages of development. We respectfully submit these comments to further improve the DGA and help ensure the research framework is designed to elicit findings that will inform and help build scientifically sound Guidelines for helping Americans create healthy eating patterns to help people achieve and maintain health and reduce the risk of disease throughout the lifespan.

A. Adopting Recommendations of the National Academies

The National Academies of Science, Engineering, and Medicine(the "National Academies") drafted two reports evaluating the processes used to establish the DGA and outlining their recommendations for improvement. The Academy supports the agencies' consideration and implementation of several of those recommendations in the request for comments, and encourages the agencies to specifically detail all of the recommendations for improving the DGA process it intends to implement as soon as practicable. Changes to the DGA process cannot be viewed in isolation; they need to be evaluated in the context of all other forthcoming changes yet to be announced.

The Academy strongly supports efforts to enhance transparency throughout the DGA process. We are honored to participate in the selection and prioritization of topics through this request for comment, and we eagerly anticipate the agencies' additional efforts to enhance transparency throughout the entire DGA development process.  The request for comments suggests the agencies are removing the authority to determine topics and questions from independent scientific experts and are granting it to the agencies themselves. Given this new, powerful role in dictating the scope of the research inquiry at the beginning of the DGA process, we agree with the National Academies that novel, substantial transparency will be especially critical at the final stage of the process, when the agencies take the Dietary Guidelines Advisory Committee (DGAC) Scientific Report and transform it into the official Guidelines: "The federal writing team ought not be exempted from adhering to explicit and transparent standards for developing clinical practice guidelines."2 The public must have confidence that the Guidelines are indeed "based on the preponderance of the scientific and medical knowledge which is current at the time the report is prepared"3 that has not been "influenced by politics or other factors" noted by the National Academies.4 Accordingly, we suggest that the agencies should provide the public with a detailed rationale for material deviations from the DGAC recommendations to the final DGA.

The request for comments indicates the agencies adopted the National Academies' recommendation to shift responsibility for topic identification, selection, and prioritization away from the DGAC and make it the first stage of the process. We agree with the National Academies that selecting topics at the outset will "influence the DGAC's composition,"5 "allow for more focused and tailored groups of experts"6 and free up significant time for the DGAC to engage in additional duties over its limited two-year existence. We seek clarification as to who will make the final selection of topics and questions; if that responsibility falls to the agencies, we encourage them to transparently make the selection on a scientific basis, with objective criteria, by providing an explanation of why certain topics were selected while others were not.

In the past, DGACs were charged with reviewing the preceding Guidelines, after which they would "determine topics for which new scientific evidence is likely to be available that may inform revisions to the current guidance or suggest new guidance."7 The charge for the 2020-2025 DGAC has not been issued and it is uncertain whether this DGAC will retain an authority to add, remove, or refine topics and questions. The Academy respectfully suggests that the DGAC retain some measure of flexibility in this regard, at minimum the ability to timely amend the scientific questions, if necessary.  Notably, we emphasize that the DGAC would need to make any amendments or changes prior to any examination of the literature to avoid weakening the methodology.

We encourage the agencies to eliminate the ambiguity around the present and future status of certain 2015 DGA recommendations based upon evidence reviewed for a topic chosen for review in 2015 but not for the 2020-2025 Guidelines (e.g., sodium).  The Academy supports the National Academies' recommendation that certain topics need not be reviewed anew if strong evidence exists supporting their continuance and significant new data on the topic have not been added in the five-year interval.8 This willingness to forgo re-reviewing a fairly settled topic under certain circumstances differs in substance from the agencies' proffered criterion of "importance" stating that there might need to be "new, relevant data" to warrant a new review of the evidence. We thus seek clarification from the agencies on the standard for reviewing topics anew. In addition, we seek confirmation that recommendations in the 2015-2020 DGA will be carried forward to the 2020-2025 DGA even if the associated topics of the recommendations are not reviewed anew.9 The Academy strongly urges the agencies to carry forward all existing recommendations unless they have been affirmatively rescinded in order to provide continuity, manifest the consistency of the DGAs over time, and remove confusion among consumers and other stakeholders.


The Academy's concerns with the "duplication" criterion are similar to those noted with "importance." Even if a topic is addressed through existing evidence-based federal guidance other than the DGA, we believe it should be included in the DGA if it can help guide individual consumers or institutional policies towards healthier diets. If key topics are omitted at this stage of the process, it is unclear how they would be addressed in the 2020 DGA, potentially leaving significant gaps in evidence-based federal guidance for food and nutrition. Therefore, the 2020-2025 DGA should encompass all of the federal government's evidence-based recommendations on dietary practices for optimal nutrition, rather than an abridged subset focusing on topics with changing science or newfound popular interest.

B. DGAs Remain Critically Necessary

The DGAs for 35 years have provided life-saving advice to consumers seeking to reduce their risk of diet-related disease. This advice has never been more critical. Two out of three American adults10 and one out of three children11 are overweight or have obesity. Nearly half of adults have diabetes or prediabetes,12 and roughly half of adults have high blood pressure,13 a major risk factor for heart disease and stroke. Furthermore, 13 cancers, including breast, colorectal, esophageal, and uterine, are linked to overweight or obesity.14

However, the DGA offer more than advice for individual consumers; they are used as the scientific basis for the benefit design and certain programmatic elements of the National School Lunch and School Breakfast Programs, the Child and Adult Care Food Program and senior meals through the Older Americans Act. They also are used by state and local governments and health departments across the country as the basis for many of their nutrition policies and programs, including to establish guidelines for healthier food that is sold or served on public property. The 2015-2020 DGA newly focused on dietary patterns instead of individual nutrients, consistent with the way in which we typically eat.

C. Review Additional Topics Not Suggested by the Agencies for All Age Groups

1. Sodium

It is curious that the agencies propose no questions on the topic of sodium when expert guidelines15 classify roughly one out of two adults as hypertensive, and new data from the CDC indicate that the average American adult consumes 4,000 mg of sodium per day, well above the 2,300 mg per day recommended by the National Academy of Medicine.16 We understand that the NAM is in the process of revising the Dietary Reference Intakes for sodium and anticipate that the DGAC would defer to the substantive outputs of that process, if available. In short, the DGA should either include the DRI committee's advice or—if the DRIs are not available before the 2020 Guidelines must be finalized—include advice on sodium from the 2015 Guidelines. Ignoring the salient and important issue of sodium entirely puts public health at risk.

As we noted in our comments to the 2015-2020 DGAC Scientific Report, there is a distinct and growing lack of scientific consensus on merits of a single sodium consumption recommendation for all Americans. The Academy encourages the DGAC to undertake a review of evidence that could potentially support sodium recommendations related to a) physical activity and/or body weight; b) height, weight and gender, which may also offer methodology for fine tuning recommendations; and c) the relationship of sodium recommendations to daily caloric needs related to points a) and b), above. The Academy also encourages the agencies to help facilitate the convening of stakeholders to agree upon an acceptable consensus marker of sodium intake and the acceptability of a methodology.

2. Effective Implementation of DGAs

The National Academies estimates that "less than 10% of Americans actually follow the Guidelines."7 Despite the strength of the recommendations and the evidence underlying them, the Guidelines cannot meet their promise without substantially more widespread and effective implementation. Implementation science is relatively new but shows significant promise in its value, and thus we encourage the DGAC to add a new topic for improving strategies for implementation of the Guidelines in the 2020-2025 iteration.

Effective implementation likely includes tailoring of the implementation strategies to the contextual needs of a particular change effort. The Academy encourages the DGAC to assess the ability of various subgroups of the population to effectively implement the Guidelines in their own lives, including those with chronic illness, struggles with hunger and food insecurity, and other impediments. Effective implementation of the DGAs require that the Guidelines themselves recognize the functional reality that the socio-economic status and environmental conditions of many Americans greatly limits their opportunities to incorporate the DGAs into their lifestyle.

The Academy welcomes a scientific review of strategies to help best facilitate the adoption or selection of healthy dietary patterns among Americans. We encourage the DGAC to review the extent to which successful implementation of dietary recommendations depends upon how referenced dietary patterns are interpreted by various subpopulations and the referenced diets or eating styles those subpopulations adopt. One very large such subpopulation that the Guidelines are not intended for is the millions of Americans with a chronic disease. Given the preponderance of overweight, obesity and chronic disease in the U.S., how can the Guidelines be designed to address the nutritional needs, across all life stages, of both those who are 'healthy' and those with diet-related chronic disease(s)?

3. Sustainability

The Academy is familiar with the growing body of evidence around the importance of sustainable practices in food and water systems, including the alarming amount of food wasted daily in the United States, which the USDA's Agricultural Research Service estimates per capita at 1,249 calories per day.18 Registered dietitian nutritionists recognize the opportunity and responsibility, as food and nutrition professionals, to integrate sustainable, resilient, and healthy (SRH) food and water systems into our respective practice areas as a means to secure, preserve, and strengthen these systems now and for the future. Therefore, the Academy continues to develop and implement standards of practice for SRH Food and Water Systems to ensure that we can better serve tomorrow's practitioners and their customers, clients, and community.19


We respectfully request that sustainability be included as a topic for the Guidelines and that the agencies consider the propriety of its inclusion de novo. In fact, none of the three reasons cited by the National Academies as potentially justifying sustainability being excluded from the 2015-2020 DGA remain valid concerns.  First, the National Academies stated that "Congress raised questions about the scope of the 2015 DGAC, stating that the DGAC did not have the expertise, evidence, or charter to comment on topics such as sustainable diets[,]"20 but this concern is actually ameliorated by the improvements in this request for comments: the charter has yet to be issued, the evidence base can be expanded, and the agencies could ensure that the DGAC for this iteration of Guidelines includes members with expertise in sustainability.  The second justification was that various people "raised questions regarding the evidence used and the comprehensiveness of the literature reviewed,"21 which could be an appropriate reason for rejecting the DGAC's recommendation or even excluding the topic at the last stage of development, but cannot rationally be used to prevent the DGAC from using the evidence or reviewing the literature to begin with.  Finally, the National Academies referenced the agencies' conclusion that sustainability was outside the scope.  The Academy asserts that sustainability is no less firmly within the scope of the DGA's mandate to provide "nutritional and dietary information and guidelines"22 than the topic of physical activity, which is presently included in the Guidelines.

The Academy encourages the DGAC to review several scientific questions for the proposed sustainability topic, recognizing the questions are also relevant to food insecurity and other cross-cutting issues.

  • What is our nation's capacity to supply, consistently and equitably across regions, the foods recommended by the proposed dietary pattern(s), and if that supply is insufficient or inequitably distributed, what (if any) shifts in agricultural production (i.e. what is produced and how) and policy would be needed to ensure sufficient supply of the recommended foods or food groups.
  • Whether U.S. households are able to afford the proposed dietary patterns and the likelihood of long-term adherence to the proposed dietary pattern(s)? In addition, the DGAC should assess what, if any, geographic or demographic disparities exist in households' ability to afford adherence to such a pattern.
  • If financial or geographic access to and intake of such foods is inequitable, what evidence-based programs and policies (e.g. based on experiences and experiments at the local, state and regional levels) could be tested or scaled nationally to reduce such disparities and bolster implementation of and adherence to the Guidelines.
  • Evaluate the estimated economic impact (e.g. on our agricultural economy) and ecological impact of collective adherence to the Guidelines and of any shifts in production needed to better support the proposed dietary pattern(s).

4. Oral Health

The Academy joins partner organizations in advocating for inclusion of oral health preventive practices in the DGA, recognizing these practices had appeared in the 2005-2010 DGA and 2010-2015 DGA. We support the agencies' new approach to evaluate the diet by life stages and believe that oral health is essential to a healthy diet at all life stages. There is a strong body of evidence connecting oral health to a healthy diet and overall health, which should aid the DGAC in answering the proposed scientific question querying the relationship between dental caries and nutrient intake during each life stage.

Dental caries is the most prevalent disease in the U.S. and it is completely preventable through routine dietary and oral health practices that include brushing teeth twice daily with a fluoridated toothpaste, flossing, adopting actions to increase saliva (e.g., chewing sugar free gum), drinking fluoridated water, not smoking or using other tobacco products, and limiting intake frequency of dietary fermentable23 carbohydrates.

Table 1 – Prevalence of Dental Caries in the U.S. Population
United States, National Health and Nutrition Examination Survey, 1999-2004


Percent with dental caries
(primary teeth)

Percent with untreated dental caries
(primary teeth)

Percent with dental caries
(permanent teeth)

Percent with untreated dental caries
(permanent teeth)














































*Includes missing or filled permanent teeth.

a. Relevance

As Table 1 shows, the prevalence of dental caries is high for all age groups. Dental caries can begin with the primary teeth in infancy and continue for permanent teeth.  For Americans who do not or are unable to seek treatment due to lack of access or funds, untreated dental caries worsen over time and may lead to pain and tooth loss which can decrease desire and ability to chew. Dental caries often result in poor intake of nutrient-dense foods25; infection; speech impairment; lost days of work or school; and in rare cases death.26,27,28 Black non-Hispanics, individuals of lower socioeconomic status, and individuals with less education bare a disproportionate share of this burden.

b. Importance

Oral health preventive practices allow for intake of nutrient dense foods at all life stages. Dental caries can affect nutrient intakes of individuals throughout the lifespan, most notably for children and seniors. The consequences of dental caries include pain and infection, often leading to reduced consumption of fruits, vegetables, and proteins recommended in the DGA.29,30,31 When the consumption of these food groups is limited, important nutrients such as fiber, iron, and calcium are decreased in the diet.  In lieu of difficult to chew nutrient-dense foods, consumers often turn to higher calorie options that often lack key micronutrients. Since the relationship between diet and oral health is symbiotic, diet can affect oral health.32 Prevention is shown to be the most cost-effective way of addressing oral health.33,34

Most U.S. oral care organizations stress that infants should begin oral health preventive practices and have their first dentist visit soon after the eruption of the first tooth and/or before one year of age. Dental caries formation can begin in infancy and lead to disrupted nutrient intake in children and adolescents.35,36 Without a full set of teeth, children and adolescents may limit food choices and compromise their nutrient intakes.37 Furthermore, children may experience other detrimental effects on cognition, school performance, attention and performance of complex tasks, and behavior, due to nutritional deficiencies.38

Oral health is essential to overall health in the prenatal period.39 Increased maternal salivary bacteria level is associated with oral infection among children and predicts increased early childhood caries rate occurrence.40

Many individuals assume that tooth loss is a part of aging, when in fact; it does not need to be a part of aging at all. For those over 65 years, the prevalence of dental caries exceeds that of hypertension and arthritis.  Edentulism, or loss of teeth, is declining as adults take better care of their teeth.41,42 For individuals with partial or full dentures, their intakes of twenty key nutrients including vitamin A, vitamin C, vitamin B6, folic acid, calcium, iron, fiber and protein can be inadequate.43,44 Involuntary weight loss and frailty also plaque older individuals with dentures; demonstrated by an inverse association with number of natural teeth and BMI, waist circumference, blood pressure, and fasting blood glucose.35 Tooth loss has been significantly associated with increased rates of metabolic syndrome even when adjusting for age, race/ethnicity, gender, income, physical activity, smoking, and energy intake.46

c. Federal Implications

Since a daily routine of oral health practices is an integral part of overall health and a healthy diet, recommendations of oral health preventive practices could be integrated into all federal nutrition education and assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children, Supplemental Nutrition Assistance Program Education, School Lunch and Breakfast, Child and Adult Care Programs and Senior Nutrition Programs.

d. Avoiding Duplication

We are not aware of any other federal policy that sets forth guidance on routine oral health preventive practices.

D. Amend Certain Proposed Topics and Questions for All Age Groups

1. Beverages

The Academy encourages the 2020 DGAC to examine the evidence on added sugars and sugar-sweetened beverages (SSB) together, because SSBs are the largest source of added sugars in the average American's diet.

2. Added Sugars

The 2015-2020 DGA recommends that people consume less than 10 percent of calories from added sugars to meet their food group and nutrient needs. In addition, the Guidelines noted that an eating pattern that reduces the risk of chronic disease is low in added sugars. The 2015-2020 DGAC examined the evidence on added sugars and SSBs together in part because SSBs are the greatest source of added sugars in the average American's diet (contributing almost half of intake) and in part because SSBs are easier to use in randomized controlled trials and easier to examine in observational studies than are added sugars. The Academy encourages the 2020-2025 DGAC to similarly evaluate added sugars and SSBs together.

3. Saturated Fats

The agencies proposed that the DGAC would examine the relationship between saturated fats and risk of cardiovascular disease for adults aged 19–64. To effectively do this, the 2020 DGAC should examine the effect of replacing saturated fatty acids with polyunsaturated fatty acids (and monounsaturated fatty acids) on the risk of CVD for children aged 2–18 and adults aged 19 and older. As the Guidelines focus on healthier eating patterns, it is important to review the literature examining the nature and impact of replacing food items within a food category. The 2015 DGA recommends that "intake of saturated fats should be limited to less than 10 percent of calories per day by replacing them with unsaturated fats." Furthermore, the DGAC should examine the evidence on saturated fats and CVD for everyone aged 2 or older, not merely for adults 19–64, because atherosclerosis begins in childhood and continues beyond age 64. Lastly, the DGAC should compare the effects of replacing saturated fatty acids with polyunsaturated fatty acids (and monounsaturated fatty acids) on the risk of CVD with the effects of replacing carbohydrates with polyunsaturated fatty acids (and monounsaturated fatty acids) on the risk of CVD.

We encourage the DGAC to assess whether saturated fats have a different relationship to risk of CVD or other disease states based on the food source of the saturated fats (e.g., dairy, eggs, beef, palm, coconut, etc.) based upon empirical evidence of the health effects of the actual foods. We also encourage a review of the benefits of low-fat dairy foods as compared to regular-fat dairy foods among varying food categories (i.e., cheese, yogurt, milk).

Finally, we note that the term "saturated fat," while familiar to consumers, is a highly imperfect manner of categorization given that the fatty acids in dairy foods do not appear to give rise to the health concerns implicated by the fatty acids in processed meat.  We encourage the agencies to consider shifting away from the term and category "saturated fat" and instead consider effective ways of categorizing in a different manner, such as food groups.

E. Infants and Toddlers: Topics and Questions

Good nutrition throughout the first two years of life helps lay the foundation for a child's future health well into adulthood. New research in the fields of neuroscience and the early origins of adult health is shedding light on how infants' brains develop, how children and adults become susceptible to diseases, and how capacities and skills are either nourished or thwarted, beginning during pregnancy and through the first two years of life.47

A growing body of scientific research indicates that the foundations for lifelong health—including predispositions to obesity and certain chronic diseases—are largely determined during pregnancy and the first two years.48 Emerging research also indicates that the effects of poor nutrition early in life impact not only a child's health but also potentially that of the child's offspring.49 The damaging effects caused by poor nutrition in early life could have the potential to cascade down through generations of children and lock families into a cycle of poor health, making comprehensive, actionable recommendations for infants and children essential.

1. Distinct Age Groupings

There are many differences in the nutritional and dietary needs of infants younger than six months and children who are six months to two years old. In particular, infants younger than six months should ideally be exclusively fed breastmilk. Infants who are not fed complementary foods may also have different supplementation needs than do older infants fed complementary foods. For this reason, the DGA topics should be considered separately for infants zero to six months than for those aged seven to 24 months.

2. Feeding Styles

The period of time from birth to age two represents a highly sensitive period of time for children to learn to accept and like healthy food.50 The DGAC should examine as a new topic the impact of feeding patterns and responsive feeding practices on cognitive development, short- and long-term health, growth, size, and body composition, and future obesity risk.

3. Food Insecurity

The DGAC should consider as a new topic the relationship between food insecurity and a) dietary intake; b) nutritional risk or deficiency; c) cognitive development; d) short- and long-term health; e) obesity risk; and f) growth, size, and body composition. Food insecurity during pregnancy and the critical first years of a child's life can impair child development in both the short- and long-term, hindering adult achievement, health, and productivity. Adequate prenatal nutrition is critical to ensure normal development of children's bodies and brains.51 Inadequate dietary intake during pregnancy and early childhood—which may be a consequence of food insecurity—can increase the risk of birth defects, anemia, low birth weight, preterm birth, and developmental problems.52,53,54

4. Duration of Exclusive Human Milk or Infant Formula Feeding

In addition to the agencies' suggested questions, the DGAC should also consider the short- and long-term health and developmental outcomes of exclusive human milk feeding on neurocognitive development, taste preference formation, self-regulation, childhood origins of adult disease and obesity, infection risk, and immunity. The DGAC should also consider recommending when mothers should discontinue exclusive breastfeeding or infant formula feeding. Lastly, the Academy suggests that the DGAC should evaluate the relationship between the duration of exclusive human milk consumption of the child, and the health outcomes of the mother.

5. Dietary Supplements

Guidance on the topic of dietary supplements during pregnancy, lactation and infancy would guide nutrition education provided by federal food and nutrition policies and programs, like WIC, the Supplemental Nutrition Assistance Program, and the Child and Adult Care Food Program. It may also be used to inform nutrition education materials provided by the USDA's Center for Nutrition Policy and Promotion.

6. Complementary Foods and Beverages

In a 2013 study, nearly 40 percent of mothers in the U.S. first gave their babies solid foods before their babies were 4 months of age.55 There is confusion regarding recommendations of when babies should be introduced to solid foods, as parents face conflicting messages from doctors, infant and toddler food companies, and others.  If breast milk or formula is replaced by complementary foods too early, babies are at risk for poorer nutrition. The Academy encourages the DGAC to review whether and how the method for introducing complementary foods (i.e., traditional spoon-feeding vs. baby led weaning) impacts the timing, introduction, types, and amounts. The relationship between complementary feeding and short- and long-term health outcomes, neurocognitive development, self-regulation, and taste preference formation should also be considered by the DGAC.

The DGAC also should address beverages, including fruit juice and sugar-sweetened beverage consumption, for children and toddlers. In addition, the DGAC should consider impacts on short- and long-term growth, obesity risk and excessive weight gain; diet quality; micronutrient status; short- and long-term health outcomes; taste preference formation; growth, size and body composition; and self-regulation. Lastly, we note that the Academy has undertaken the responsibility for scoping research on the introduction of complementary foods, and welcomes the opportunity to share this information with the agencies or the DGAC as needed.

F. Children and Adolescents: Topics and Questions

1. Distinct Age Groupings

There are many differences in the nutritional and dietary needs of young children and adolescents. The health needs, eating habits, physical activity levels, hormones, energy metabolism, and other characteristics differ significantly among children and maturing adolescents. For this reason, the DGA topics should be considered separately for young children and adolescents using the Tanner stages or other sufficiently helpful scale.

2. Beverages

The Academy encourages the DGAC to review an additional question of the relationship between beverage consumption during childhood and adolescence and growth, size, and body composition.

G. Adults: Topics and Questions

1. Dietary Patterns

The Academy encourages the DGAC to examine more long term health outcomes, requiring the inclusion of prospective and retrospective studies. In addition, we recommend asking whether there is a relationship between the frequency of feeding and a) meeting nutrient recommendations for adults, b) body weight or obesity, and c) risk for diet-related chronic disease. We also encourage review of a relationship between intermittent fasting and x) meeting nutrient recommendations for adults, y) body weight or obesity, and z) risk for diet-related chronic disease. To align with increasingly preferred terminology, we suggest continuing to use the term "plant based diet" rather than "vegetarian diet," to the extent consumer research shows the latter may not appeal to individuals resistant to a completely meatless diet.

We encourage the DGAC to review the literature to evaluate the extent to which vitamin D deficiency or low vitamin D levels (i.e., levels are below 30) are correlated with health issues, such as osteoporosis, hypertension, mental health, and immune dysfunction, and evaluate any relationship between supplementing with Vitamin D for adults whose levels are below 30 and improved health outcomes on the aforementioned health conditions. When considering possible changes to food patterns, we suggest reviewing whether the current fiber recommendation for women can be increased for optimal heart health and weight maintenance.

H. Pregnancy and Lactation: Topics and Questions

1. Distinct Groupings

The DGAC should consider evaluating some topics separately for pregnant and postpartum women. The nutritional and dietary needs and patterns of pregnant women differ from those of lactating and non-lactating postpartum women.56 For example, for food safety reasons, pregnant women are advised against consuming some types of cheese or processed meats, but those foods are acceptable for postpartum women, even if they are breastfeeding. Further, pregnant women need different nutrient supplements than postpartum lactating women or non-lactating women.57

2. Diet Quality

It is clear that diet plays a critical role in the health and well-being of women, both during and after pregnancy, and the Academy encourages the addition of diet quality as a new topic for this group. Diet quality is related to the micronutrient status and weight of women, factors that are intrinsically linked to birth outcomes and the health of mothers. Among U.S. women giving birth in 2014, half are overweight or have obesity before becoming pregnant.58 Having overweight or obesity can create or exacerbate complications, such as preeclampsia and gestational diabetes, which lead to higher-risk pregnancies.59 Similarly, key nutrients play important roles in women's health during and after pregnancy.

Specifically, the DGAC should evaluate the relationship between diet quality during pregnancy and a) risk of gestational diabetes; b) risk of hypertensive disorders during pregnancy; c) gestational age at birth; and d) birth weight standardized for gestational age and sex; e) the risk of excessive weight gain during pregnancy; f) the micronutrient status of the mother and infant; g) the long-term health of both mothers and infants; and h) the infant's predisposition to chronic disease later in life.  In addition, the DGAC should consider the relationships between diet quality of postpartum women and x) excessive weight gain; y) the short- and long-term health of mothers; and z) micronutrient status.

Food InsecurityThe DGAC should consider as a new topic the relationship between food insecurity and a) dietary intake; b) pregnancy outcomes (e.g., pregnancy weight gain); and c) breastfeeding initiation and duration. Of particular concern is the risk for food-insecure mothers who enter pregnancy with insufficient iron stores and with low-folate diets. Poor iron and folate status are linked to preterm births and fetal growth retardation, respectively.60,61 Prematurity and intrauterine growth retardation are critical indicators of medical and developmental risks that affect not only children's short-term well-being, but also extend into adulthood.62


Children born to mothers who were food-insecure during pregnancy may also be at increased risk of birth defects.63 Finally, research suggests that women who were marginally food insecure and had restricted their eating in an unhealthy way prior to becoming pregnant are more likely to gain excessive weight during pregnancy, which puts the mother at risk for gestational diabetes and obesity postpartum, and can predispose the baby to chronic disease through prenatal nutritional programming.64

4. Dietary Patterns and Maternal Health

The DGAC should not only consider the relationship between dietary patterns during pregnancy and risk of gestational diabetes, risk of hypertensive disorders during pregnancy; gestational age at birth; and birth weight, but also the relationship of dietary patterns during pregnancy and lactation to maternal health. In addition, we encourage review of the relationship between dietary patterns and exercise to maternal and infant outcomes (e.g., incidence of C-section, pregnancy induced hypertension, gestational diabetes, low birth weight, preterm birth, or macrosomia) in pregnant women with obesity. We also suggest including a review of the average calorie intake in pregnant women with obesity, an assessment of the amount of weight lost among pregnant women with obesity who intentionally lose weight, the trimester in which weight is lost, and whether there are negative outcomes from the weight loss, such as low birth weight or preterm birth.

5. Dietary Supplements

The DGAC should consider not only the impact of micronutrient status on infants and the composition and quantity of breastmilk, but also the impact on the short- and long-term health and micronutrient status of the mother.

6. Beverages

As mentioned above, the DGAC should consider added sugars and sugar-sweetened beverages together. Specific to this group, the DGAC should consider the relationship between the consumption of added sugars and sugar-sweetened beverages by postpartum women and a) maternal health; b) weight gain; and c) micronutrient status. For pregnant women, the DGAC should review the relationship between sugar-sweetened beverages and added sugars and excessive weight gain.

7. Alcoholic Beverages

As addressed above, the Academy believes the DGAC should consider the impact of alcoholic beverages on birth outcomes and maternal health for women who are pregnant or lactating.

I. Older Adults

Dietary Patterns

When considering modifications to dietary patterns for older adults, we suggest the DGAC consider other modifications due to aging metabolic changes, such as decreased taste, immunity, vitamin B12 and vitamin D status.

J. Conclusion

The Academy sincerely appreciates the opportunity to respond to the agencies' request for comments on topics and scientific questions, and we would welcome the opportunity to discuss the above issues and suggestions with the agencies in the future. Please contact either Jeanne Blankenship by telephone at 312/899-1730 or by email at or Pepin Tuma by telephone at 202/775-8277, ext. 6001 or by email at with any questions or requests for additional information.


Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics

1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts.  The RD and RDN credentials have identical meanings and legal trademark definitions.

2 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: (NASEM 2) at 129.

3 National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101-445 - Oct. 22, 1990).

4 NASEM 2 at 129.

5 National Academies of Sciences, Engineering, and Medicine. 2017. Optimizing the process for establishing the Dietary Guidelines for Americans: The selection process. Washington, DC: The National Academies Press. doi: (NASEM1) at x.

6 NASEM 2 at xi.

7 Millen BE, Abrams S, Adams-campbell L, et al. The 2015 Dietary Guidelines Advisory Committee Scientific Report: Development and Major Conclusions. Adv Nutr. 2016;7(3):438-44.

8 NASEM 2 at 8 ("The breadth and content of each required report could vary such that not all topics may require a detailed review every 5 years; only those topics with enough new data to generate a full review would be considered for in-depth evaluation in the next DGA cycle.")

9 For the purposes of this request for comments, a non-exhaustive list of recommendations to be carried forward would include whole grains, vegetables and fruits, alcohol, and processed meats and poultry.

10 Fryar CD, Carroll MD, Ogden CL. Prevalence of overweight, obesity, and extreme obesity among adults aged 20 and over. National Center for Health Statistics. 2016 July. Available at

11 Fryar CD, Carroll MD, Ogden. Prevalence of overweight and obesity among children and adolescents aged 2–19: United States, 1963–1965 through 2013–2014. National Center for Health Statistics. 2016 July. Available at

12 Centers for Disease Control and Prevention. A Snapshot: Diabetes in the United States. 2017 November.  Available at

13 Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Nov 7. pii: S0735-1097(17)41519-1. doi: 10.1016/j.jacc.2017.11.006.

14 Centers for Disease Control and Prevention. Cancers associated with overweight and obesity make up 40 percent of cancers diagnosed in the United States. 2017 October. Available at

15 American Heart Association. High blood pressure redefined for first time in 14 years: 130 is the new high. 2017 November. Available at

16 Cogswell ME, Loria CM, Terry AL, et al. Estimated 24-hour urinary sodium and potassium excretion in U.S. adults. JAMA. 2018 Mar 7; doi: 10.1001/jama.2018.1156.

17 NASEM 2 at ix.

18 Buzby, Jean C., Hodan F. Wells, and Jeffrey Hyman. The Estimated Amount, Value, and Calories of Postharvest Food Losses at the Retail and Consumer Levels in the United States, EIB-121, U.S. Department of Agriculture, Economic Research Service, February 2014.

19 Tagtow A, Robien K, Bergquist E, et al. Academy of Nutrition and Dietetics: Standards of professional performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems. J Acad Nutr Diet. 2014;114(3):475-488.e24.

20 NASEM 2 at 23, citing (Conaway, 2015; Hartzler et al., 2015).

21 NASEM 2 at 23, citing (Dabrowska, 2016; Heimowitz, 2016; Hentges, 2016; Mozzaffarian, 2016; Teicholz, 2015).

22 National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101-445 - Oct. 22, 1990).

23 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2005 – 2010 Dietary Guidelines for Americans. 6th Edition. December 2015. Available at

24 National Institute of Dental and Craniofacial Research. Dental Caries (Tooth Decay). Accessed May 26, 2017.

25 Beaudette J, Fritz P, Sullivan P, Ward W. Oral Health, Nutritional Choices, and Dental Fear and Anxiety. Dentistry Journal. 2017;5(1):8. doi:10.3390/dj5010008.

26 Norris, L. J. 2007. Testimony of the Public Justice Center on May 2, 2007 to the Subcommittee on Domestic Policy Committee on Oversight and Government Reform, U.S. House of Representatives (110th Congress), on the story of Deamonte Driver and ensuring oral health for children enrolled in Medicaid.

27 Otto, M. 2007. For want of a dentist. Washington Post, February 28, P. B01.

28 Casamassimo, P. S., S. Thikkurissy, B. L. Edelstein, and E. Maiorini. 2009. Beyond the DMFT: The human and economic cost of early childhood caries. Journal of the American Dental Association 140(6):650-657.

29 Acs G, Lodolini G, Kaminski S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatric Dentistry 1992;14:302-5.

30 Nowjack_Raymer R, Sheiham A. Association of Edentulism and Diet and Nutrition in US Adults. Journal of Dental Research. 2003. Accessed March 5, 2018.

31 Savoca M et al. Impact of Denture Usage Patterns on Dietary Quality and Food Avoidance amount Older Adults. J Nutr Gerontol Geriatr. 2011; 30(1): 86–102. Accessed on March 5, 2018.

32 Touger-Decker R, Mobley C et al. Academy of Nutrition and Dietetics. 2013. Position of the Academy of Nutrition and Dietetics: Oral health and nutrition. Journal of the Academy Of Nutrition and Dietetics 113(5):693–701.

33 Sharon SC, Connolly IM, Murphree KR. A review of the literature: the economic impact of preventive dental hygiene services. J Dent Hyg. 2005; 79(1): 11.

34 Stearns SC et al. Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees. Arch Pediatr Adolesc Med. 2012 Oct; 166(10): 945-51.

35 Rainchuso L. 2013. Improving oral health outcomes from pregnancy through infancyJournal of Dental Hygiene. 87(6):330–335.

36 Divaris K, Vann WF, Baker AD, Lee JY. 2012. Examining the accuracy of caregivers' assessments of young children's oral health statusJournal of the American Dental Association 143(11):1237–1247.

37 Ervin RB, Kit BK, Carroll MD, Ogden CL. 2012. Consumption of Added Sugar among U.S. Children and Adolescents, 2005–2008. Hyattsville, MD: National Center for Health Statistics. briefs/db87.htm.

38 Tufts University, Center on Hunger, Poverty and Nutrition Policy. 1994. Statement on the Link between Nutrition and Cognitive Development in Children. Medford, MA: Tufts University, Center on Hunger, Poverty and Nutrition Policy. PDFS/ED374903.pdf.

39 Rainchuso L. 2013. Improving oral health outcomes from pregnancy through infancy. Journal of Dental Hygiene. 87(6):330–335.

40 Chaffee BW, Gansky SA, Weintraub JA, Featherstone JD, Ramos-Gomez FJ. 2014. Maternal oral bacterial levels predict early childhood caries development. Journal of Dental Research 93(3):238–244.

41 QuickStats: Prevalence of Edentualism in Adults Aged ≥65 Years, by Age Group and Race/Hispanic Origin — National Health and Nutrition Examination Survey, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:94. DOI:

42 Dye BA, Li X, Beltrán-Aguilar ED. Selected oral health indicators in the United States, 2005–2008. NCHS data brief, no 96. Hyattsville, MD: National Center for Health Statistics. 2012.

43 Nowjack-Raymer R, Sheiham A. Association of Edentulism and Diet and Nutrition in US Adults. Journal of Dental Research. 2003. Accessed March 5, 2018.

44 Savoca M et al. Impact of Denture Usage Patterns on Dietary Quality and Food Avoidance amount Older Adults. J Nutr Gerontol Geriatr. 2011; 30(1): 86–102. Accessed on March 5, 2018.

45 Kamdem B. et al. Relationship between oral health and Fried's frailty criteria in community-dwelling older persons. BMC Geriatric. 2017; 17: 174. Accessed March 5, 2018.

46 Zhu and Hollis. Associations between the number of natural teeth and metabolic syndrome in adults. J Clin. Perio. 2015. Accessed March 2, 2018.

47 See, e.g., Center on the Developing Child at Harvard University (2010). The Foundations of Lifelong Health Are Built in Early Childhood.

48 Mcmillen IC, Adam CL, Mühlhäusler BS. Early origins of obesity: programming the appetite regulatory system. J Physiol (Lond). 2005;565(Pt 1):9-17.

49 Borja JB. The impact of early nutrition on health: key findings from the Cebu Longitudinal Health and Nutrition Survey (CLHNS). Malays J Nutr. 2013;19(1):1-8.

50 Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the RWJF HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Toddlers from Birth to 24 Months. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Durham, NC: Healthy Eating Research, 2017. Available at

51 Kind K. Diet around conception and during pregnancy – effects on fetal and neonatal outcomes. Reproductive BioMedicine Online. 2006;12(5): 532-541.

52 Black, MM, Quigg AM, Hurley KM, Pepper MR. Iron deficiency and iron-deficiency anemia in the first two years of life: strategies to prevent loss of developmental potential. Nutrition Reviews. 2011;69 (Supplement 1), S64-S70.

53 Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Washington, DC: U.S. Department of Agriculture & U.S. Department of Health and Human Services. 2015.

54 Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi W W; Nutrition Impact Model Study Group (anemia). Anemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. BMJ. 2013;346, f3443.

55 Clayton HB, Li R, Perrine CG, Scanlon KS. Prevalence and reasons for introducing infants early to solid foods: Variations by milk feeding type. Pediatrics. 2013;131:1108–14.

56 Marangoni F, Cetin I, Verduci E, et al. Maternal Diet and Nutrient Requirements in Pregnancy and Breastfeeding. An Italian Consensus Document. Nutrients. 2016;8(10).

57 Micronutrient Needs During Pregnancy and Lactation.  Linus Pauling Institute at Oregon State University.  Available at  Accessed March 28, 2018.

58 Branum AM, Kirmeyer SE, Gregory EC. Pre-pregnancy Body Mass Index by Maternal Characteristics and State: Data From the Birth Certificate, 2014. National Vital Statistics Reports. 2016;65:1–11.

59 Persson M, Cnattingius S, Wikström AK, Johansson S. Maternal overweight and obesity and risk of pre-eclampsia in women with type 1 diabetes or type 2 diabetes. Diabetologia. 2016;59(10):2099-105.

60 Scholl TO, Johnson WG. Folic acid: influence on the outcome of pregnancy. American Journal of Clinical Nutrition. 2000;71 Suppl 5, 1295S–1303S.

61 Haider, op. cit.

62 Abu-Saad K, Fraser D. Maternal nutrition and birth outcomes. Epidemiological Reviews. 2010;32(1):5–25.

63 Carmichael SL, Yang W, Herring A, Abrams B, Shaw GM. Maternal food insecurity is associated with increased risk of certain birth defects. Journal of Nutrition. 2007; 137(9): 2087-2092.

64 Laraia B, Epel E, Siega-Riz AM. Food insecurity with past experience of restrained eating is a recipe for increased gestational weight gain. Appetite. 2013;65, 178-184.

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