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New Challenges in Nutrition, Food Science, and Policy

OVERVIEW

The second session, moderated by Robert M. Russell, Professor Emeritus at Tufts University and former Chair of the Food and Nutrition Board (FNB), provided a range of perspectives on current and emerging challenges facing the FNB in the areas of nutrition, food science and technology, and food and nutrition public policy. Russell introduced the session speakers. The first presentation by Patrick Stover addressed a range of new and emerging challenges to nutrition science, including a perspective on genetic and genomic influences on personalized nutrition and the importance of maintaining the public’s trust in nutrition science. The second speaker, Eric Decker, presented an array of new food products entering the marketplace, and how these products respond to the nutritional needs as well as preferences of consumers. In the final presentation, David M. Klurfeld, Susan Taylor Mayne, and Alanna Moshfegh each reviewed how their respective agencies are working to respond to current and emerging challenges in food and nutrition policy.

NEW CHALLENGES IN NUTRITION SCIENCE

Stover, Vice Chancellor and Dean for Agriculture and Life Sciences at Texas A&M AgriLife Research, opened the session. He began by stating that his presentation would focus on three areas: systems science, population versus individual, and harmonization in the context of public trust.

Stover opened with the announcement by the Secretary of Agriculture that week that he wanted to see an increase in agriculture production by 40 percent and a 50 percent reduction of the agricultural footprint on the environment by 2050. “This, of course, is a very ambitious agenda,” Stover said. He then described ways to achieve that agenda, noting opportunities for progress in four areas: understanding food systems; people, including the systems biology of individual- and population-level nutrition needs; economic systems; and environmental systems. “We have to understand how they interact, where there are opportunities to leverage each of these systems, and where there are tradeoffs across these systems,” he said.

Stover remarked that by 2050 population growth would be greatest in South Asia and Africa, and this would create both opportunities and challenges, specifically the loss of farmland to development and urban expansion. Stover described the advantage of controlled environmental agriculture as using one-tenth the amount of land and requiring 95 percent fewer chemicals compared to conventional agriculture. The United States overproduces food to assure accessibility, which gives very thin profit margins across the food and agriculture value chain and makes agriculture vulnerable economically. Sustainability is important for these systems to remain viable. Stover commented on innovations to lower the environmental footprint. New technologies are coming to capture agricultural emissions and sell them to the energy sector. He added that there is a need to reduce fertilizer runoff and eutrophication. Animal and plant agriculture are a system, and there is a need to look at regenerative approaches, he said.

Stover then addressed the issue of climate change and concerns about uncertainty in temperature. He remarked that there is a need to think about resiliency because of the need to produce food in a changing climate. Stover mentioned several National Academies publications that address this issue, for example, the workshop summary Exploring Health and Environmental Costs of Food (IOM and NRC, 2012). The publication called for looking at the overall economy when thinking about food systems policy. That publication, he added, led to another study chaired by Malden Nesheim titled A Framework for Assessing Effects of the Food System (IOM and NRC, 2015). The study brought together agronomists, nutritionists, economists, and social scientists to develop a framework for making comprehensive, science-informed decisions across the entire food system. Stover remarked that there are now new expectations for the food system—support human health, limit environmental damage, promote social welfare, and promote a strong economy. “And, importantly, we have to think about data,” he added. Rigorous data assessments are needed to drive decisions and make sure that metrics, methods, and standards of evidence are similar across all domains, he said.

Stover then discussed the issue of chronic diseases as complex traits. He pointed out that chronic diseases involve entire metabolic systems, but

also include modifiers such as age, environmental exposures, exercise, and sleep. All of these factors contribute to chronic disease, and nutrition is one of them. Stover then recounted biological and metabolic networks, noting that they work as a whole, which then relates to health and disease processes. Nutrients, he added, interact within these networks. He remarked on the need for sensitivity analyses to see the dynamic range of effect of a nutrient as an input affecting network function, adding that there is a need to think about system readouts as biomarkers that talk across metabolic pathways and the Dietary Reference Intakes (DRIs) as ranges of input to affect those networks. “How does nutrition delay that system decay that is related to chronic disease, and how do nutrient needs change as systems naturally decay?” he asked.

The issue of chronic disease, said Stover, was also reflected in the National Nutrition Research Roadmap 2016–2021 (Interagency Committee on Human Nutrition Research, 2016), which asked: How do we enhance understanding of the role of nutrition in disease prevention and treatment?, and How do we understand the individual status and variability in response to diet? “You are going to have responders and non-responders and everything in between, and how do we deal with that in terms of setting DRIs or DGA [Dietary Guidelines for Americans]?” he asked. Stover remarked that nutrients are involved in processes from absorption to storage and bio-activation, but there are modifiers and sensitizers specific to an individual’s disease or genetic state, including those related to how individuals differ in their responses to nutrients and diet. Furthermore, he added, nutrition has played a key role not only in determining human genotypes, but also in how people react to food in modern society. Chronic disease affects the way we metabolize nutrients as well as our nutrient requirements.

Stover recollected a paper published in 1972 by Victor Herbert that showed there were certain disease-related etiologies, such as inflammation, that disrupt normal physiologic processes related to food, including whole body and tissue-specific deficiencies that can create new conditionally essential nutrient needs, but can also cause new nutrient toxicities. He noted that while the DRIs and the DGA are developed for healthy populations, 50 percent of adults in the United States fall into the chronic disease category, raising the question of whether they even apply to half of the population. There is a need, he said, to understand more about special nutritional requirements. We need to understand the effect of disease on tissue-specific requirements, and the role of nutrition on restoration of function in disease and tissue regeneration, for example, in the use of endogenous stem cells in restoring tissue regeneration in disease states.

In returning to the topic of food systems, Stover said there is evidence that food systems are global, yet nutrition may be individual (see Figure 5-1). What this means is that in the area of precision and personalized nutrition,

we are seeing real-world experiments; that is, N of 1 studies on how a single individual reacts with food in an environment where they can make free choices. You can ask the question, he remarked, whether people having their personal information on a cell phone in real time reinforces positive health behaviors better than population-based recommendations. You see evidence of individual efficacy and higher adherence in behavior change.

Stover concluded by mentioning the concept of harmonization that was presented earlier by Janet King. He noted the need for up-to-date science as well as collaboration. As an example, two National Academies reports recommended the Grading of Recommendations Assessment, Development and Evaluation system for evidence reviews, but not everyone agrees on that approach, he said, adding that getting agreement on methodologies is important for public trust. Stover mentioned that during his time as President of the American Society for Nutrition he put together a blue-ribbon panel to look at ways to earn and keep the public trust. He showed on a slide seven domains that were absolutely critical in ensuring public trust (see Figure 5-2). In closing, Stover encouraged the FNB to look at the next generation of data, analytics, devices, and research methods and to make sure they are rigorous and advance public health. “We need harmonized approaches to evidence synthesis and standards of evidence; otherwise we will not have the public trust.”

NEW CHALLENGES IN FOOD SCIENCE AND TECHNOLOGY

Decker, Professor and Department Head of Food Science at the University of Massachusetts Amherst, explained that his presentation would combine food science and nutrition challenges for the future. He began by asking: What it is that drives an individual’s decision about what to buy in the grocery store? Although we would like to think that nutrition is the reason for food choices, other factors like convenience become greater drivers, he said. Value is another driver, he added, which could also mean

brand loyalty or shelf life, as a means of getting the true value from the food. Decker described sustainability as a new area for the food industry, and an important factor for making food choices. However, taste is the real reason that people buy certain foods, adding that taste is really key to the success of dietary interventions, because if a food does not taste good, it will not be part of the diet, regardless of how healthy it is (see Figure 5-3).

Decker then turned to fruits and vegetables, and their role in health outcomes. He noted a number of reasons why the plant-based side of supermarkets and food services will continue to grow. Decker identified three health-related reasons: fruits and vegetables are nutrient-dense, they contain bioactive compounds linked to better health outcomes, and they offer a more sustainable approach to the food supply. He pointed out that Americans have failed to meet the 5-a-day recommendation—in fact, there has been no increase in fruit and vegetable consumption from 2003 to 2016, and it is important to figure out why. Decker showed a graph depicting the type of vegetables consumed and the form in which they are consumed the most (see Figure 5-4). He noted that the most consumed starchy vegetable is potatoes, and that he was surprised by the amount of fruits and vegetables consumed in sandwiches. “The third highest intake of fruits and vegetables comes from the lettuce and tomato that is on your hamburger,” he said.

The explanation was that potatoes are tasty, inexpensive, and versatile, while tomatoes taste good and are versatile, even though they are more expensive. Decker added that people are willing to spend based largely on taste and convenience.

Decker then described “stealth nutrition” as one way of increasing vegetable intake. The example he gave was a study in which 45 percent of the beef in a taco mixture was replaced with mushrooms. Because of the umami flavor from the mushrooms, the study subjects were unable to detect the substitution. The mushroom displacement of meat also decreased the total amount of fat in the recipe, he added. Another part of the sustainability issue is the replacement of animal-based with plant-based foods. Among the nutrition advantages that he noted were lower fat and cholesterol content, lower lactose, and higher fiber. A disadvantage he mentioned was the loss of calcium from plant-based dairy products.

Decker then described some challenges to making plant-based meat. Getting a plant protein to take the shape of an animal protein is one, he said. Another is the bad taste of extruded plant fibers. Adding flavor enhancers and moisture requires a lot of other ingredients, such as sodium, starches, and fat. After that, he said, the nutritional advantages go away, and people look at the ingredient list and see an ultra-processed food. Decker added that such food classification can become a scare tactic based on concerns about foods being made from individual components, and not

the science. Examples of some commonly consumed foods that are also processed by various means include carbonated drinks, ice cream, breads, and breakfast cereals. “The term ultra-processed is somewhat misleading,” he said.

Decker talked about a National Institutes of Health diet study on ultra-processed foods. He recounted that subjects who consumed the ultra-processed foods experienced an increased caloric intake and weight gain. Among the posited reasons were food volume preference and satiety; the subjects who consumed ultra-processed foods ate more calories and ate a greater volume faster because it was much more dense. “Are you just eating food so quickly that the satiety triggers do not kick in and tell you that you are full?” he asked, adding that studies like this should be considered in diet design. Unprocessed foods are more expensive, take longer to prepare, and generate more waste, both on the industrial and consumer sides. Another aspect, he said, was that making foods in a controlled environment reduces the safety risk. Lifestyle factors are another consideration that Decker mentioned. He compared the number of men and women who cook, noting that today 50 percent of men and 66 percent of women cook, whereas in 1965, 92 percent of women cooked.

Decker concluded by reminding the audience of the need for a healthy food supply. In his opinion, processed foods are a very important part of the modern food supply because they are convenient, affordable, nourishing, sustainable, and taste great as well. He added that there is no doubt about the need to improve on the health and wellness of the food supply, but the nutrition message today is confusing to consumers. “Can we brand single, simple nutritional messages that the food industry can get behind and have incentives to improve towards that goal?” he asked. Decker closed by remarking that there is a real need to consider our nutritional recommendations in terms of whether they are accessible to everyone.

NEW CHALLENGES IN FOOD AND NUTRITION TO INFORM POLICY

Klurfeld, National Program Leader at the U.S. Department of Agriculture’s (USDA’s) Agricultural Research Service (ARS), opened the session by describing recent research efforts under way at ARS, and the agency’s plans for the next decade. He reported that over the next decade, ARS plans to continue research support for dietary guidance, which includes the DRIs, the DGA, and the effects of nutrients versus foods versus dietary patterns. It is a fundamental question today that those who are making policy decisions must grapple with, he added. Klurfeld remarked that research in new technologies will be needed to better measure food intake, assess physical activity and the gut microbiome, and support genomic and epigenomic

discovery, in particular small micro ribonucleic acids that communicate through endocrine and autocrine pathways. He noted that an area of critical importance that was previously neglected is the differentiation between the biological basis for nutrient and energy requirements and behavior choices that are not necessarily driven by biology.

Klurfeld then described the ARS 5-year Action Plan, which is comprised of five overarching components. The first component is to link agricultural practices to health outcomes and environmental change. This includes management practices as well as the genetics of plants or animals produced for food, he said, adding that the largest part of the ARS human nutrition program is dedicated to building the scientific basis for dietary guidance. Another component is obesity-focused research, which has gone from 10 to 30 percent of the research effort in the past decade. Klurfeld predicted that in another 10 years, there would be at least 10 more best-selling diet books. He went on to say that there would also be two new sets of Dietary Guidelines, as well as a continuation in both intentional and unintentional misinformation.

To illustrate some of ARS’s research, Klurfeld shared the results of an ARS scientist, Tara McHugh, who developed several new technologies. One example is a technology that casts 100 percent of fruit and vegetable trimmings into edible films. These products are now available in grocery stores and represent recovery of previously wasted food product. A second example, observed Klurfeld, is no-added-sugar fruit bars, a much healthier alternative to the typical snack bar. Finally, said Klurfeld, there is an ultraviolet light process to promote vitamin D content in mushrooms, a product that is now available nationwide. In a follow up study, the USDA Western Human Nutrition Research Center in Davis, California, showed an increase in vitamin D2 levels among subjects fed the enhanced mushrooms.

Klurfeld turned to ARS’s efforts to revamp the food composition databases, called FoodData Central (see Figure 5-5). The underlying architecture was changed to account for variations in crops. For a given crop, a mean value is shown with the standard deviation for the nutrients, which, Klurfeld explained, reflects the substantial variation in the nutrient composition of foods. He added that the branded foods in the database account for an overwhelming number of foods, which is important to know when doing a search. Klurfeld noted that there are now 280,000 branded foods in the database and no way for ARS staff to verify the information for the more than 1 million nutrient components.

Klurfeld talked about ARS’s research support for the DGA. He described a study, done at the USDA Western Human Nutrition Research Center, which tested the guidelines. He showed that a typical American diet has a Healthy Eating Index (HEI) of 62, which is better than that of the average American’s score of 58 or 59. By comparison, he said, the DGA

study diet had an HEI of 98 out of a maximum of 100. For the primary endpoint of plasma glucose, there was no improvement from following the healthier diet. The key point, noted Klurfeld, was that the diets were designed to maintain body weight. The USDA Western Human Nutrition Research Center is now conducting a follow up study where intentional weight loss is built in. The study found systolic blood pressure went down by 9 millimeters; a substantial change, Klurfeld remarked. He added that for total and high-density lipoprotein cholesterol, although the change was modest, it was still statistically significant. Klurfeld described another study under way at the Jean Mayer USDA Human Nutrition Research Center on Aging, which is substituting entirely refined grains for whole grains, up to five or six servings per day. He said that subjects on the whole grain diet experienced a significant reduction in energy balance, a difference of about 92 calories per day that was excreted in the stool. That translates into a 9-pound weight differential over 1 year, so maybe there is a good reason to have whole grains in the Dietary Guidelines, he said.

Klurfeld concluded his talk with descriptions of some state-of-the-art products in development. One of these was “glucose-sensing tattoos” to detect instantly any changes in blood glucose. Another was the Sun eButton to detect physical activity and energy expenditure, which has a camera that takes a photo every 8 seconds. It also has a Geospatial Positioning System, an accelerometer, and an ultraviolet monitor to detect indoors versus outdoors. Klurfeld remarked that we have to get the cost of reading the genome down to $99.00 so that a physician can order it. “The way all these other -omic markers can be made sense from is an improvement in artificial intelligence and machine learning,” he said.

Mayne, Director of the Center for Food Safety and Applied Nutrition (CFSAN) at the U.S. Food and Drug Administration (FDA) described her presentation as centering on the importance of the FNB’s work to FDA. Our job is to translate science involving food and nutrition to protect and promote public health, she said. Mayne gave an overview of several activities under way at FDA related to the work of the FNB. She said that FDA is working hard to reduce the amount of sodium in the U.S. food supply, noting that the DRI review of sodium and potassium (NASEM, 2019) was critically important in confirming the need to reduce sodium consumption. Similarly, with the Nutrition Facts Label (NFL), she added that “several key things have been updated in important ways,” she said, for example, the way dietary fiber is calculated for declaration on the NFL, which was in large part informed by recommendations from the previous DRI report (IOM, 2005). Mayne noted that companies have been using synthetic fibers and adding them to products. She stated that FDA is now asking for scientific data to substantiate that these dietary fibers have benefits on human health, as do those naturally occurring in the plant products that we eat.

Mayne turned to a discussion of challenges affecting food and nutrition going forward. The discussion, she said, would focus on innovation, noting that the U.S. food supply is undergoing unprecedented innovation right now, which has ramifications for food safety, labeling, and nutrition. Mayne identified five main areas where innovation is impacting the work of FDA. These include innovations to improve nutrition and better health; innovations in novel foods and ingredients; biotechnology; innovations in analytical science; and genomic innovations impacting foodborne outbreak investigations. In the area of innovations for nutrition and better health, Mayne began with changes in the food supply to produce more nutritious products, citing the high vitamin D mushrooms described previously by Klurfeld as an example. She described FDA’s Nutrition Innovation Strategy in two main parts (see Figure 5-6).

On the right side of the slide, she said, is the agency’s work as regulators to facilitate industry innovation in the food supply toward healthier foods. The left side represents FDA’s work to empower consumers with information so they can make more informed decisions. Mayne then described the perimeter of the figure that showed six different “buckets” of activity. Some, she said, are very familiar, such as the NFL, which has both components. “It is empowering the consumer with information, but it also facilitates innovation, such as product reformulation” she said.

Mayne then discussed product claims and ways to modernize them to help drive people toward healthier dietary choices. She noted modernizing ingredient lists, standards of identification, and menu labeling as other activities FDA is working on under its Nutrition Innovation Strategy. “Having information available in retail food establishments, which came along with menu labelling, is a really important achievement,” she said, adding that in the near future, there will be a major education campaign around the launch of the updated NFL. Another area of innovation identified by Mayne was plant-based proteins, noting it as one of the fastest growing areas in food technology today. Mayne gave as an example an ingredient called soy leghemoglobin that has been used in a plant-based burger to impart flavor, appearance, and aromas similar to beef. This plant hemoglobin, produced in a microorganism, has iron and browns when it is cooked. However, she said, it has not been in human diets before, so FDA worked with the company to make sure the ingredient is safe. “One of our jobs is to make sure that as people are developing these, we have to make sure that they are safe as well as appropriately labeled,” she said. Insect proteins, she noted, could potentially trigger an allergic response in someone with a shellfish allergy because of similarities in the exoskeleton. In another example of innovation, Mayne noted interest in cell-cultured food products, derived from cells of meat, poultry, and seafood that are now under development, and, she added, are areas in which the agency is deeply engaged.

Mayne’s next topic was biotechnology. “We know that genetic engineering and genome editing are two very important tools to feeding a global world population,” she said. FDA has been regulating genetically engineered crops for almost 30 years, she said, adding that it is important to make sure the products are safe, which also helps maintain the public’s confidence in the technology. Mayne gave as an example the genome-edited high-oleic acid soybean product, the first FDA-completed consultation, which was important because, when media stories described the launch of the product, there were no questions or concerns from consumers about its safety. Mayne added that consumer confidence is critically important as new technologies continue to evolve. “We will soon be releasing a whole host of materials to really explain what these new technologies are and how they are used in our food supply.”¹

On the topic of analytical sciences, one of Mayne’s concerns was the ability to measure substances at increasingly lower levels of detection, because consumers then become less trusting of foods. Detecting low levels of toxic substances such as mercury or pesticides in foods causes people to be afraid of foods like fruits and vegetables—this is a risk communication challenge, she remarked.

Mayne concluded her presentation with the topic of foodborne outbreaks and the identification of pathogens. She stated that FDA, along with the Centers for Disease Control and Prevention, can now make molecular links between a pathogen and a food, and clinical illness, which would never have been possible in the past. She said that the faster the outbreak investigation team at CFSAN can identify the source of contamination, the faster the harmful product can be removed from the food supply. Being able to more quickly detect the source of the foodborne contamination has implications for consumer confidence. Mayne added that identifying pathogens is important, not only from a food safety perspective, but also from a nutrition point of view. She shared a concern that outbreaks with fresh produce may lead consumers to turn to other food options less consistent with the DGA. In summing up Mayne remarked, “Just as industry is innovating, FDA is also trying to innovate.” The FNB is clearly a trusted partner, she said.

The final presentation in the session was by Moshfegh, Research Leader at the USDA ARS. She described her task as “new challenges in monitoring and assessing dietary intake of the population.” She divided the challenges into four broad areas: technology innovations, changes in society, accurate assessment, and food composition. Moshfegh began with the number of

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¹ This information has subsequently been released and is available at https://www.fda.gov/food/agricultural-biotechnology/agricultural-biotechnology-education-and-outreach-initiative (accessed June 14, 2020).

national surveys conducted in the United States since the 1930s. From that time until the 1950s, she said, the federal government was doing about one national survey per decade. Between the 1960s and the 1990s up to the 2000s, we moved to about two to three surveys per decade, she said, adding that the mobile exam center was introduced through the National Health and Nutrition Examination Survey (NHANES). Beginning with 2000 through today, we have a continuous collection, she said.

Moshfegh described the national dietary data as useful for informing nutrition and public health policy. Examples she gave included dietary assessment, the adequacy of diets, and food safety of additives and pesticides. She then turned to discussing the four challenge areas. First is technology innovation. The capture of data, Moshfegh noted, can be improved with new technologies; particularly data review and release, and analysis. The challenge is in development and maintenance of the technology, particularly given the pace of change in the food supply as well as in eating behaviors. Foods have a lot of detail, although they look similar when captured in a picture—a number of foods have different nutrient profiles, she said. Additional information is demanded with this data, she added, including information about the eating occasion including time of eating, additions to a food, and other foods consumed but not reported.

Moshfegh then talked about the instrument used to collect national dietary data, the USDA Automated Multiple-Pass Method (see Figure 5-7). This method, she said, is used to collect information from dietary recalls reported in the NHANES, adding that there are five standardized steps for collecting the data. It is a very large instrument, containing at least 30,000 questions about foods and their response options, divided into 130 categories. She noted that standardized questions and responses for 15–20 food categories are updated every 2 years to keep up with changes in the food supply. Moshfegh described the interview, which takes about 20–30 minutes, with an additional 30–45 minutes to code the data. Although FDA has automated coding, she said, the agency cannot code every food or beverage because of the number of new items added to the market each day as well as the creative food combinations reported by interviewees.

Another challenge was the food system, which is more than just agricultural production, Moshfegh said, noting that the food system must be linked to the consumer. She reminded the audience of Decker’s presentation on the drivers of food choice, adding that those drivers are exactly what is seen through the Food and Health Survey conducted by the International Food Information Council. Moshfegh shared data from the Economic Research Service that shows a shift in food behavior (see Figure 5-8). For the first time in 2010, she said, expenditures of “away from home” food surpassed those from “food at home,” noting that the additional demand was likely for more convenience foods. In addition to consuming more food

away from home, Moshfegh added, one-third of the mean daily caloric intake is now coming from the total amount of food consumed away from home. Another shift noted by Moshfegh was the change in eating behavior, particularly snacks, across time. In contrast to the 1970s, when most Americans reported no snack consumption on a given day, today it is only 7 percent who report not having a daily snack.

A concern expressed by Moshfegh was the decline in the NHANES response rate, which has dropped from 85 percent 20 years ago to 49 percent in the latest survey covering 2017–2018. “This is clearly an area that needs answers from the Food and Nutrition Board,” she said. Moshfegh added that accurate assessment of self-report data is important but can be influenced by a number of factors. These include the availability of biomarkers for select compounds in foods, use of dietary supplements, and day-to-day variability that can reflect reporting bias. Moshfegh concluded her presentation by commenting on the importance of up-to-date data on food composition. Other components in foods and the food supply will impact the whole system, she noted, adding that the USDA FoodData Central database presented earlier by Klurfeld provides information on nutrient variability in the food supply as well other measures of food that will contribute to a more complete picture of the composition of foods. In closing, Moshfegh reminded the audience about the importance of dietary data. She remarked, “We know we need strong technology innovations, better assessment methods … and improvements in composition. But, as we have heard, with everything, the evidence-based research for all these changes is paramount while balancing dietary data needs with today’s society.”

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