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Introduction

The Food and Nutrition Board (FNB) of the National Academies of Sciences, Engineering, and Medicine, in partnership with the Department of Nutrition for Health and Development of the World Health Organization (WHO) and the Nutrition Division of the Food and Agriculture Organization (FAO), convened an open public workshop that was available in person and on the web to explore the evidence for achieving global harmonization of methodological approaches to establishing nutrient intake recommendations.¹ The workshop was held at the FAO headquarters in Rome, Italy, September 21–22, 2017. The workshop objectives, guided by the Statement of Task (see Box 1-1) and identified by the workshop planning committee, were the following:

• Describe potential frameworks to enable global harmonization of methodologies to establish nutrient intake recommendations.
• Explore approaches for evaluating the evidence to facilitate global harmonization of methodologies to establish nutrient intake recommendations.
• Examine the potential for addressing contextual factors from different population subgroups, regions, and countries that may or may not be conducive to harmonization.

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¹ Throughout this publication, unless otherwise indicated, harmonization refers to the harmonization of methodological approaches to establishing nutrient intake values, not the harmonization of actual values.

• Consider approaches to facilitate global sharing of resources to maintain quality and support cost-effectiveness to develop methodologies for nutrient intake recommendations.
• Identify the advantages, barriers, and challenges to global harmonization of methodologies to establish nutrient intake recommendations.

In his welcoming remarks, Kostas Stamoulis, assistant director-general of FAO’s Economic and Social Development Department, described nutrition as a fundamental pillar of FAO work. “The nutrition community has been sounding the alarm for a long time,” he said. Now, with one in three people on earth suffering from some form of malnutrition (i.e., under-nutrition, critical nutrition deficiency, overweight, or obesity) and caught in a vicious cycle of malnutrition and poverty, the international community has taken notice. In 2014, United Nations (UN) member states gathered

at the Second International Conference on Nutrition (ICN2) and committed to eradicate hunger and prevent all forms of malnutrition. The 2030 Agenda for Sustainable Development reiterated the need to end malnutrition in all its forms, with Goal 2 being to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture. Then, the UN General Assembly declared, in April 2016, the period between 2016 through 2025 the “UN decade of nutrition.” Together, these three actions, along with numerous regional declarations to promote nutrition “have placed nutrition firmly at the heart of the development debate,” Stamoulis said. The development agenda recognizes firmly that transformed food systems, not just agriculture, have a fundamental role to play in promoting healthy diets and improving nutrition.

The challenge for FAO as an organization, as Stamoulis suspected was true for many organizations, is how to turn this political commitment into

action at the country level. Over its first 50 years, FAO worked very closely in collaboration with WHO to continuously support the provision of scientific advice on nutrient requirements to member countries and international bodies. However, despite all of this work, there is little consistency in the approaches used to set country-level nutrient intake recommendations. Moreover, there are few processes in place to ensure that these recommendations are properly updated and remain relevant to target population groups. In this regard, Stamoulis concluded, FAO looked forward to the outcomes of this workshop.

For Stephanie Atkinson, McMaster University professor of pediatrics and chair of the workshop planning committee, this workshop has been an outcome of a nearly 25-year journey. In 1995, Atkinson was the Canadian representative to the oversight committee for the first harmonization of Dietary Reference Intakes (DRIs) between Canada and the United States. In 1997, Canada hosted the International Union of Nutritional Sciences (IUNS) International Congress in Montreal, where an informal luncheon was held to talk about harmonization of the Canadian and U.S. DRIs. Atkinson noted that several people in attendance at the workshop had also attended that 1997 luncheon. People were interested, but a little apprehensive, Atkinson recalled. But they did develop, over the next 10 years, harmonized DRIs for the two countries. Then, in 2005, the UN University’s Food and Nutrition Programme, in collaboration with FAO, WHO, and the UN Children’s Fund (UNICEF), sponsored an international harmonization initiative, led by Janet King and Cutberto Garza. “That was, we thought, the next big step,” Atkinson said. She noted that King would be describing the work later during the workshop (a summary of King’s presentation is provided in Chapter 2). Her hope was that it would not be another 10 years before reaching consensus and realizing a globally implementable plan for harmonization of methodological approaches to setting nutrient-based recommendations.

DEFINING THE PROBLEM: PARTNER PANEL

Following Stamoulis’s and Atkinson’s welcoming remarks, representatives from WHO and FAO were invited to offer further opening remarks in the first panel of the workshop: “Defining the Problem: Partner Panel.” Atkinson spoke on the behalf of Ken Brown of the Bill & Melinda Gates Foundation.

WHO

Like Atkinson, Chizuru Nishida, WHO coordinator of the Nutrition Policy and Scientific Advice Unit in the Department of Nutrition for Health

and Development, viewed this workshop as an opportunity to build on the 2005–2007 initiative, including the 10 commissioned background review papers, each on a specific aspect of the process for harmonizing nutrient intake values (NIVs). She repeated that the focus of that initiative was not on the values themselves (i.e., NIVs) but on how to harmonize the concepts and approaches for developing them.

At around that same time, Nishida recalled, as requested by WHO’s World Health Assembly, some transformations were being implemented in the way WHO guidelines were developed. Specifically, in 2007, the Guidelines Review Committee was set up to harmonize guidelines across all WHO program areas, including in diet and nutrition, and to ensure that WHO guidelines were consistent with internationally accepted best practices, based on evidence through systematic reviews where appropriate, and based on a transparent process for evaluating the quality of evidence and strength of recommendations. WHO began implementing this new harmonized approach for guideline development throughout its organization in January 2009, with mandatory implementation initiated in January 2010.

Additionally, as part of its efforts to strengthen its scientific advice on nutrition, WHO proposed to establish a global network of institutions for scientific advice on nutrition, initially by bringing together public institutions involved in developing national diet- and nutrition-related guidelines to explore the possibility of facilitating synergy and avoiding replication of work. In March 2010, WHO held the first face-to-face meeting of this global network in Geneva (WHO, 2010). The objective of the meeting was to share information and to learn about each other’s ongoing and planned work. Through this network, Nishida explained, WHO hopes to explore whether there is a way to harmonize how evidence is extracted so it can be shared and used collectively among public institutions, including international, normative agencies like WHO and FAO. The outcome of the 2010 meeting indicated, according to Nishida, that although everyone was willing to collaborate and harmonize, they viewed implementation as difficult. Thus, there was hesitation to move forward.

Since then, however, nearly 10 years have passed. She expressed hope that this work will not just further the discussion,² but will provide a road map of possible next steps for facilitating global harmonization, including the identification of priority nutrients or areas where proposed approaches can be tested. Additionally, she expressed WHO’s interest in the possibility of applying or incorporating existing processes and methodologies already

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² This workshop will help to inform a larger, consensus effort to review and assess methodological approaches to developing nutrient intake recommendations, as described at http://nationalacademies.org/hmd/Activities/Nutrition/NutrientIntakeRecommendations.aspx (accessed April 25, 2018).

in use by different agencies and institutions, such as those being implemented by WHO (e.g., the organization-wide effort to harmonize guideline development).

Food and Agriculture Organization (FAO) of the United Nations

Anna Lartey, FAO director of nutrition, began her remarks by mentioning that she attended the 1997 IUNS International Congress in Montreal, which Atkinson had mentioned. At the time, she was a graduate student at the University of California, Davis, unaware that one day she would become president of IUNS. Her term would end in October 2017, she noted. Also in October, FAO would turn 72 years old. Yet, the mandates that resulted in establishment of FAO remain, she said, and remain to be relevant. This includes raising the level of nutrition of the people under FAO’s jurisdiction.

Lartey then described some of FAO’s ongoing programs in nutrition that are relevant to work on the harmonization of methodological approaches to developing nutrient intake recommendations, noting FAO’s emphasis over the past 5 years on reforming food systems to deliver healthy diets. “We believe that if we want to address all forms of malnutrition as we currently have it,” she said, “we really have to look at sustainable food systems.”

First, she mentioned FAO’s collaboration with WHO to develop the Global Individual Food consumption data Tool (GIFT), a dynamic platform for capturing individual food consumption data (FAO/WHO, 2017). By providing age and sex disaggregated data on individual food consumption, GIFT will help to answer the question, what are people eating? She explained that when individual or household food consumption data and food composition data are converted into energy and nutrients, they can be compared to recommended nutrient intake references. Another relevant FAO activity is its work over the past year to organize trainings for over 24 Anglophone and Francophone countries to support these countries in developing and implementing national food-based dietary guidelines. Also relevant, in 2014, FAO and partners developed a minimum dietary diversity score for women to use as a global indicator for assessing women’s diet quality. Now, with the support of the European Union, FAO is supporting countries to include this indicator in their country-monitoring frameworks.

One of the inefficiencies in food systems, Lartey continued, is the huge loss and waste of food. FAO estimates that about one-third of the food produced for human consumption becomes food waste or is lost somewhere along the value chain. To address this, FAO, as custodian of Sustainable Development Goal 2, which Stamoulis described previously, has agreed to

develop a global indicator against which countries can report on their food loss and waste using a common methodology.

FAO is interested not only in what people are eating, but also in whether they are meeting their nutrient requirements for optimal health and nutrition. However, many member states, especially those in the developing world, do not have the resources and technical capacity to develop their own national recommended nutrient intakes and, as such, they depend on WHO and FAO for guidance. Lartey expects this work to be very useful in continuing to guide other countries in the development of nutrient intake tables. She concluded by echoing calls to put harmonization “into action,” particularly as the UN has declared this next decade the decade of action on nutrition. “Let’s give [countries that do not have nutrient intake tables] some basis around which they can determine some of these figures for their own countries,” she said.

Bill & Melinda Gates Foundation

To conclude this opening Partner Panel, Atkinson spoke on the behalf of Ken Brown of the Bill & Melinda Gates Foundation, which provided a generous grant for the workshop. According to Brown, as conveyed by Atkinson, the Gates Foundation will judge this effort as being successful if the consensus group,³ not this workshop, is able to develop recommendations for a preferred method to approach global harmonization and apply this method to the derivation of nutrient intakes for one or more nutrients as an example. Brown also remarked, again, as conveyed by Atkinson, that the Gates Foundation recognizes that the process of global harmonization will require not only technical considerations, but political consensus on how best to apply the recommended approach and which organization or organizations should take the lead on implementing the consensus committee’s recommendations.

ORGANIZATION OF THIS PROCEEDINGS

The organization of this Proceedings of a Workshop parallels the organization of the workshop (see Appendix A for the workshop agenda). This introductory chapter summarizes the statement of task, welcoming remarks, and the first panel of the workshop. Chapter 2 summarizes the

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³ The consensus group, separate from the planning committee for this workshop, will be using the evidence presented and the discussions that took place here to review and assess methodological approaches to developing nutrient intake recommendations. Information on the consensus study, including other relevant meetings, is available at http://nationalacademies.org/hmd/Activities/Nutrition/NutrientIntakeRecommendations.aspx (accessed April 25, 2018).

“Background for the Workshop” section of the workshop agenda, which included two presentations, one by Janet King, the second by Suzanne Murphy. Chapter 3 summarizes the first part of session 1, “Harmonization Frameworks,” which included a presentation on harmonization efforts in Australia and two presentations on the harmonized U.S.–Canadian approach to setting nutrient reference values for chronic disease. The remainder of session 1, which was a panel discussion, “Current Models for Establishing Intake Recommendations,” with four panelists from different regions of the world discussing opportunities for and challenges of harmonization, is summarized in Chapter 4. Chapter 5 summarizes the session 2 presentations on “Approaches to Evaluating the Evidence,” with three presentations on quality assessment instruments, systematic reviews, and risk–benefit analysis. Chapter 6 summarizes session 3, “Contextual Factors: Host, Diet/Environment, and Health Status,” with a total of six presentations covering genetic variation, host physiology, infection, aging, and bioavailability, and their effects on nutrient intake values. Chapter 7 summarizes the session 4 breakout discussions on “Applications, Facilitating Quality, and Cost-Effectiveness.” The workshop was split into six smaller breakout sessions, with each group assigned one of three questions to consider. Chapter 8 summarizes the session 5 panel discussion on “Advantages, Barriers, and Challenges to Global Harmonization of Methodologies for Nutrient Intake Recommendations.” Five panelists, again from different regions of the world, shared their experiences and insights. Finally, Chapter 9 summarizes Atkinson’s summary of the workshop and discussion of next steps.

It is important to note that this Proceedings of a Workshop summarizes information presented and discussed at the workshop and is not intended to serve as a comprehensive overview of the subject. Nor are the citations herein intended to serve as a comprehensive set of references for any topic; only references cited on speaker slides or in the workshop briefing notebook are included. Additionally, the information presented here reflects the knowledge and opinions of individual workshop participants and should not be construed as consensus on the part of the workshop planning committee, the FNB, or the National Academies.