This final chapter presents workshop planning committee chair Stephanie Atkinson’s closing summary and her three strategic messages to send to the consensus committee.1
In her closing summary, Stephanie Atkinson summarized what she described as a “very generous sharing of experiences,” both good as well as challenging ones. She observed a great enthusiasm and collaborative spirit for harmonizing and was struck by the honesty with which different people talked about their own experiences. In her opinion, the next steps will be “to make things happen.” Very briefly, she highlighted what she heard in each of the sessions that pertain to this.
In the first session on harmonization frameworks, summarized in Chapters 3 and 4, several participants provided some excellent examples of what has worked, but with challenges remaining. These challenges include the need for transparency, lack of standardization among endpoints, the difficulties of setting requirements based on chronic disease, the need for a central repository for evidence, and variation in terminology. She remarked
1 As previously mentioned, this workshop will help to inform a separate consensus effort to review and assess methodological approaches to developing nutrient intake recommendations: http://nationalacademies.org/hmd/Activities/Nutrition/NutrientIntakeRecommendations.aspx (accessed April 25, 2018).
that these same issues were mentioned or discussed throughout the workshop and will need to be addressed up front.
In session 2, on approaches to evaluating the evidence and summarized in Chapter 5, Atkinson perceived great hope that the field is on the brink of new, nutrition-specific methodology such that nutrition scientists will not have to think about how to apply their work to pharmaceutical trials. She especially liked Joseph Lau’s quote, “Evidence is global, decision is local.” In these days of open access and big data, she said, “Sharing is what it’s about.”
As summarized in Chapter 6, the discussion became more country specific in session 3, she observed, when contextual factors were addressed, although probably not for genetics or physiology. “We just need to recognize where [genetics and physiology] may be important factors,” she said. For example, with respect to physiology, she referred to Anura Kurpad’s discussion of the importance of understanding and accounting for adaptation when conducting randomized clinical trials. Atkinson referred to what she described as the two wonderful examples of health status indicators that vary among countries or regions: aging and infection. Aging is a global issue, affecting every country. Infection is more of a regional issue, she observed. Nonetheless, she suggested that perhaps there can be a global approach to recognizing the effects of infection on setting nutrient recommendations. Like infection, bioavailability has very different effects depending on the region. In her opinion, Rosalind Gibson and Umi Fahmida provided hope that new and more universal approaches are becoming available for assessing bioavailability.
Regarding the session 4 breakout discussions summarized in Chapter 7, Atkinson referred workshop participants to Lindsay Allen’s summary at the end of that session. “We heard time and time again that the greatest advantage we can have is a central repository of evidence,” she said. Yet, she added, there are still some needs that are more of an issue in some countries than in others, such as the need for good composition tables and dietary assessments at the population level. One of the greatest challenges is the disparate availability of resources among countries, she remarked. By sharing resources, such disparities could be alleviated.
Finally, in session 5 and summarized in Chapter 8, when representatives from different parts of the world shared their different experiences, the lack of a consistent approach to assessing the literature emerged as a major issue, with different systematic reviews following different protocols and different committees using different tools. Consistency will require standardizing these critical elements of the process, Atkinson said.
Atkinson identified three strategic messages to send to the consensus committee:
- Develop a standardized methodological approach: “We would value a standardized methodological approach with rigorous scientific review of the literature,” Atkinson said. Preferably, she added, this would be a centralized collaborative open for all countries to access. She referred to King’s concept of a global consultative group on nutrient recommendations, as summarized at the end of Chapter 8, and suggested that perhaps the United Nations’ Food and Agriculture Organization (FAO) or the World Health Organization (WHO) consider organizing such a group. She added that nutrition-specific tools, such as for risk of bias, and acceptance of standardized terminology would also be of great advantage. Regarding terminology, she acknowledged that different countries may not want to stop using their own terms, as reeducating the public would be difficult. She suggested, however, that at least the definitions be standardized such that regardless of what a value is called, all of its names have the same meaning.
- Recognize the special needs of geographic regions or countries: Atkinson called for recognition of the special needs of geographic regions, or countries, related to food composition, dietary surveys, bioavailability, and health status.
- Fill knowledge gaps: There is a desperate need to fill knowledge gaps and improve the science upon which to derive nutritional requirements that include phenotypic differences across the world, Atkinson stated. In her opinion, this is an area where the nutrition field needs to approach funding agencies. She expressed uncertainty around how to make an impact on funders, at least at the federal levels (e.g., National Institutes of Health, Canadian Institutes of Health Research), but said, “Let’s not stop trying.”
Finally, Atkinson suggested, as a first next step, a scoping of already completed work, such as the methodological work in process at WHO and available work on systematic reviews and other protocols, perhaps through the aforementioned global consultative group. She wondered if all of the knowledge accrued thus far could be combined under one tent, from which next steps could then be decided. “I do feel this isn’t the end,” she said. “It’s only the beginning.”
The workshop’s parting words were provided by Francesco Branca, director of the WHO Department of Nutrition for Health and Develop-
ment, who expressed gratitude to the National Academies for highlighting the challenge and persuading WHO and FAO to take it on. It is a “big gap area,” he said, and it is not acceptable that such an important element, nutrient intake recommendations, which has both research and public health implications, has so many divergences not grounded in real biological or dietary differences, rather differences in interpretation, methodology, and terminology. His hope was that the understanding, or scoping, of the issues made possible by this workshop would help to move this field forward, although he also expressed caution given the complexity and magnitude of the challenge. We are “humbly here,” he said, and will build on “what you have started to construct today.”