HHS FOIA Response Part 1

Casavale, Kellie (OS/OASH)
From: Lichtenstein, Alice <Alice.Lichtenstein@tufts.edu>

Sent: Friday, September 20, 2013 10:39 AM
To: Nelson, Miriam; Casavale, Kellie (OS/OASH); Goodwin, Stephanie (HHS/OASH); 'Millen,
Barbara E'; 'Perez-Escamilla, Rafael'; 'Rihane, Colette - CNPP'
Subject: RE: Subgroup naming
Ditto about the call. I like the subcommittee names as suggested although would
propose being a bit more general for the first, perhaps;
Foods and Nutrients to Promote
Positive message and gives us enough flexibility to address challenges, a.k.a.,

nutrients of concern, under consumed food groups, and quality within foods groups
(refined vs whole grains).
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Alice H. Lichtenstein, D.Sc.
Gershoff Professor of Nutrition Science and Policy
Director and Senior Scientist, Cardiovascular Nutrition Laboratory
Tufts University
JM USDA Human Nutrition Research Center on Aging
711 Washington Street
Boston, MA 02111

phone: 617 556 3127
e‐mail: Alice.Lichtenstein@Tufts.edu
From: Nelson, Miriam

To: Casavale, Kellie (OS/OASH); Goodwin, Stephanie (HHS/OASH); 'Millen, Barbara E'; 'Perez-Escamilla, Rafael';
Lichtenstein, Alice; 'Rihane, Colette - CNPP'
Cc: Nelson, Miriam
Subject: Subgroup naming

Barbara, Alice, and Kellie,

Good call today. Here is what I am thinking for a title for the fifth subcommittee:
1. Food Groups, Nutrients of Concern & Health
2. Dietary Patterns & Health
1
PSC-HHS-000001
3. Behavior Change
4. Food & Physical Activity Environment
5. Food Consumption Status, Sustainability & Food Safety
Many thanks! Best, Mim
Miriam E. Nelson, PhD

Professor, Friedman School of Nutrition Science and Policy
Tufts University
150 Harrison Avenue, RM 249
Boston, MA 02111
phone: 617-636-3735
fax: 617-636-3727
www.StrongWomen.org
www.ChildObesity180.org
www.facebook.com/StrongWomenwithMiriamNelson
Twitter: @DrMiriamNelson
From: Casavale, Kellie (OS/OASH) [Kellie.Casavale@hhs.gov]

Sent: Thursday, September 19, 2013 5:36 PM
To: Casavale, Kellie (OS/OASH); Olson, Richard (HHS/OASH); Nelson, Miriam; McPeak, Holly (HHS/OASH); Goodwin,
Stephanie (HHS/OASH); Thelusma, Joann; 'Spahn, Joanne - CNPP'; 'Millen, Barbara E'; 'Donna Blum-Kemelor'; 'Molly
McGrane'; Sehlke, Mackenzie M; 'Obbagy, Julie - CNPP'; Trish Britten; 'Adrianna Mironick'; Cole, Susan - CNPP
(Contractor); 'Perez-Escamilla, Rafael'; Essery, Eve - CNPP; Bowman, Shanthy; Lichtenstein, Alice; 'Rihane, Colette -
CNPP'
Cc: Post, Robert - CNPP; Anne Rodgers
Subject: Agenda and Attachments: Science Review Subcommittee Meeting, Friday, Sept. 20th, 8:30-10:00 am
SRSC (and support staff),

On behalf of Barbara, Please find the agenda for tomorrow mornings SRSC call and attachments. These include a
compilation of your preliminary thoughts on subcommittees, which are the focus for discussion for tomorrow’s call.
Currently SRSC meetings are only scheduled through the October public meeting. Tomorrow, we also need to touch base
quickly to determine if you want to continue with every other Friday 9:30‐10:30 am after the October meeting or some
other time.

Science Review Subcommittee Meeting
Friday, September 20, 2013 8:30 am – 10:00 am EDT
Conference Call: (b) (6)
Passcode: (b) (6)

Agenda

Attachments

September 6th SRSC Meeting Minutes

Starting Proposals for Subcommittee Organization

3 Work Group Topic Tables
2
PSC-HHS-000002

NEL Methodology, Defining Inclusion/Exclusion Criteria

Inclusion/Exclusion Criteria Template (same as was used for NEL training)

Thanks,

Kellie

Kellie O. Casavale, PhD, RD
Nutrition Advisor, Division of Prevention Science
Co‐Executive Secretary, 2015 Dietary Guidelines Advisory Committee
HHS, Office of Disease Prevention and Health Promotion

-----Original Appointment-----
From: Casavale, Kellie (OS/OASH)
Sent: Tuesday, June 25, 2013 12:27 PM
To: Olson, Richard (HHS/OASH); 'Nelson, Miriam'; McPeak, Holly (HHS/OASH); Goodwin, Stephanie (HHS/OASH); 'Joann
Thelusma'; 'Spahn, Joanne - CNPP'; 'Millen, Barbara E'; 'Donna Blum-Kemelor'; 'Molly McGrane'; Sehlke, Mackenzie M;
'Obbagy, Julie - CNPP'; Trish Britten; 'Adrianna Mironick'; Cole, Susan - CNPP (Contractor); 'Perez-Escamilla, Rafael';
Essery, Eve - CNPP; Bowman, Shanthy; 'Lichtenstein, Alice'; 'Rihane, Colette - CNPP'
Cc: Post, Robert - CNPP; Anne Rodgers
Subject: Science Review Subcommittee Meeting
When: Friday, September 20, 2013 8:30 AM-10:00 AM (GMT-05:00) Eastern Time (US & Canada).
Where: (b) (6)

This is an update to the time for the Sept. 20th SRSC call. It is now earlier and 30 minutes longer. Rafael will not be able to
be on this call as he will be traveling back from Spain.

Thanks,

Kellie

3
PSC-HHS-000003
From: Millen, Barbara E <bmillen@bu.edu>

Sent: Thursday, October 17, 2013 2:19 PM
To: Casavale, Kellie (OS/OASH)
Cc: Olson, Richard (HHS/OASH)
Subject: RE: Minutes Meeting 1
Kellie and Rick,

Welcome back. I can’t imagine how difficult the shutdown has been for everyone there. We have all been thinking
about you and hoping for the best of outcomes.

(b) (6)
We will manage but hope you can stay on as long as you’re
completely comfortable.

According to my schedule, we have a SRSC call on Monday. Do you think that will still happen? I leave for Houston early
tomorrow morning and will be at FNCE until late on Tuesday. While you were out, Alice and I have worked on WG3 as
planned and devised a plan. I circulated our thoughts separately to Mim and Raphael (consistent with our protocol) and
spoke with Raphael yesterday. Alice and I wanted to confirm that he was in agreement on a strategy to streamline the
food group questions and reduce the overall number of ideas from WG3. Basically, we propose that when food groups
are examined in relationship to health outcomes, that they be treated as part of the dietary pattern questions. The idea
here would be to determine whether there are food group ‘drivers’ of the pattern’s relationship to health outcomes
(such as breast cancer risk). This would also allow to control for confounding that often occurs when food group
analyses don’t control for the overall dietary pattern. Raphael suggested that there was a considerable amount of
attention paid to cross‐sectional and prospective studies of food groups and health outcomes in 2010 and that study
design weaknesses (such as confounding by dietary pattern) limited the conclusions that could be made or weakened
the strength of evidence. We thought that literature focusing on food groups and health outcomes [without control for
dietary patterns] could be limited to existing systematic reviews rather than a review of original research. That would
probably work except for relatively new health outcomes of interest (for example, perhaps mental health). We did all
agree that food groups and intermediate markers would still be considered and that controlled feeding trials should
provide this evidence. Mim also has the summary Alice and I did and is still reviewing it.

Would you like me to forward it to you or wait until our next call?

All best,

Barbara
Dr. Barbara E. Millen
bmillen@bu.edu

From: Casavale, Kellie (OS/OASH) [mailto:Kellie.Casavale@hhs.gov]
Sent: Thursday, October 17, 2013 11:08 AM
To: Millen, Barbara E

4
PSC-HHS-000004
Thanks, Barbara! We are back to work today. (b) (6)
Just wanted to give you a heads up.

We will be pulling together any edits we have on the meeting minutes and can update them online. Our new web
contractor mentioned it would be a costly step, so we will only want to do it once. So, we may wait until we have any
others we’ve found in the interim as well.

Thanks!

Kellie


From: Millen, Barbara E [mailto:bmillen@bu.edu]
Sent: Wednesday, October 02, 2013 10:47 AM
Subject: Minutes Meeting 1

Hi Kellie,

I know that you are restricted from answering but I thought I would send along my edits to the minutes from Public
Meeting 1. I thought you did a great job and that they read well. I had only minor comments on the material you
prepared and offer suggestions below. Attached is a summary of my comments. I hope you consider including them
too.

All best,

Barbara

Page 7 para 3, last 2 lines Change “….challenging to grab” to “challenging to attract”.
Page 25 What works for individuals to adhere to healthy dietary patterns (i.e. I would suggest that this be edited to say
“sound evidence‐based methods for promoting behavior change at individual and population levels). This including both
traditional counseling and communications methods as well as new and innovative technologies that can be applied in
various settings.

I think WG 2 is intending that the Subcommittee examines both traditional behavioral methods (what providers,
approaches, settings and modes are known to be effective) as well as the evidence on web/mobile/telephonic
approaches.

Page 27 Dr. Millen noted that important descriptive information on behavioral methods from clinical trials has not been
mined sufficiently. She encouraged paying attention to dietary pattern protocols and methods/modes of intervention
(including provider/team characteristics and settings) used to achieve and sustain improved dietary behavior.
5
PSC-HHS-000005

Attachments: AL BEM WG Priority Topics SRSC 10.17.2013.docx
Hi Kellie,

Alice and I began the task of streamlining WG3 by summarizing the top (1) priority areas from each work group and
reviewing them for scope and overlap. As part of this discussion we tried to think carefully about whether the most
important topics would be covered if we were only able to answer questions in this tier. Then we talked about how to
handle WG3 specifically since we had agreed in our last SRSC call that the list of questions had to be streamlined. This
let us to the recommendation to incorporate food groups into WG2 questions to the extent possible.

Attached is the working draft we developed and circulated. Let’s add it to the Monday agenda if you think it’s
reasonable and we can see whether we can reach consensus on a reorganization of the questions and our analytical
strategies.

All best,

Barbara

Perfect timing, Barbara. Rick, Colette, and I just touched base and I am about to send out a message noting that we are
still on for the SRSC call on Monday. A discussion of what you described below would be great. If there is a document for
me to include for the meeting related to WG3 and that discussion, please send it my way and I can include it. We also
have several other items for discussion. I will work on an agenda tomorrow.

Thanks!

Kellie



Kellie and Rick,
6
PSC-HHS-000006

Welcome back. I can’t imagine how difficult the shutdown has been for everyone there. We have all been thinking
about you and hoping for the best of outcomes.

(b) (6)
We will manage but hope you can stay on as long as you’re
completely comfortable.

According to my schedule, we have a SRSC call on Monday. Do you think that will still happen? I leave for Houston early
tomorrow morning and will be at FNCE until late on Tuesday. While you were out, Alice and I have worked on WG3 as
planned and devised a plan. I circulated our thoughts separately to Mim and Raphael (consistent with our protocol) and
spoke with Raphael yesterday. Alice and I wanted to confirm that he was in agreement on a strategy to streamline the
food group questions and reduce the overall number of ideas from WG3. Basically, we propose that when food groups
are examined in relationship to health outcomes, that they be treated as part of the dietary pattern questions. The idea
here would be to determine whether there are food group ‘drivers’ of the pattern’s relationship to health outcomes
(such as breast cancer risk). This would also allow to control for confounding that often occurs when food group
analyses don’t control for the overall dietary pattern. Raphael suggested that there was a considerable amount of
attention paid to cross‐sectional and prospective studies of food groups and health outcomes in 2010 and that study
design weaknesses (such as confounding by dietary pattern) limited the conclusions that could be made or weakened
the strength of evidence. We thought that literature focusing on food groups and health outcomes [without control for
dietary patterns] could be limited to existing systematic reviews rather than a review of original research. That would
probably work except for relatively new health outcomes of interest (for example, perhaps mental health). We did all
agree that food groups and intermediate markers would still be considered and that controlled feeding trials should
provide this evidence. Mim also has the summary Alice and I did and is still reviewing it.

Would you like me to forward it to you or wait until our next call?

All best,

Barbara
bmillen@bu.edu


Thanks, Barbara! We are back to work today. (b) (6)
Just wanted to give you a heads up.

We will be pulling together any edits we have on the meeting minutes and can update them online. Our new web
contractor mentioned it would be a costly step, so we will only want to do it once. So, we may wait until we have any
others we’ve found in the interim as well.

Thanks!

Kellie

7
PSC-HHS-000007

Subject: Minutes Meeting 1

Hi Kellie,

I know that you are restricted from answering but I thought I would send along my edits to the minutes from Public
Meeting 1. I thought you did a great job and that they read well. I had only minor comments on the material you
prepared and offer suggestions below. Attached is a summary of my comments. I hope you consider including them
too.

All best,

Barbara

Page 7 para 3, last 2 lines Change “….challenging to grab” to “challenging to attract”.
Page 25 What works for individuals to adhere to healthy dietary patterns (i.e. I would suggest that this be edited to say
“sound evidence‐based methods for promoting behavior change at individual and population levels). This including both
traditional counseling and communications methods as well as new and innovative technologies that can be applied in
various settings.

I think WG 2 is intending that the Subcommittee examines both traditional behavioral methods (what providers,
approaches, settings and modes are known to be effective) as well as the evidence on web/mobile/telephonic
approaches.

Page 27 Dr. Millen noted that important descriptive information on behavioral methods from clinical trials has not been
mined sufficiently. She encouraged paying attention to dietary pattern protocols and methods/modes of intervention
(including provider/team characteristics and settings) used to achieve and sustain improved dietary behavior.
8
PSC-HHS-000008

Sent: Sunday, March 30, 2014 2:02 PM
To: Essery, Eve - CNPP; Frank Hu; Siega-Riz, Anna Maria; c1anderson@ucsd.edu
Cc: Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP
Subject: RE: DGAC SC2: Dietary patterns & CVD, BW, & T2D
Hi Eve,

This is very helpful. I wonder if we might discuss the data abstraction. Work has begun in SC4 with a review of
systematic reviews and meta analyses and the data abstraction might be quite different that with the NEL and what was
done with caffeine. The SC might be interested in having more discussion in an upcoming call if possible. Also, I
wondered if we might consider a few of the excluded studies: 32 might provide information on food ‘drivers’ of the
patterns, 35 is examining inflammatory markers that may be of interest relating to PUFAs. Also, along with our theme of
what works, if the following reviews were of RCTs, we might consider them: 31,36,37,41,45. And, 44 is the only one I
saw addressing the issue of dietary variety which may be of interest or worth a bit of SC discussion.
When abstracting these studies, a careful definition of the patterns is important, particularly ‘Mediterranean’ since it
varies so much and the dietary patterns may not be identifiable from the ‘label’.

All best,

barbara

bmillen@bu.edu

From: Essery, Eve - CNPP [mailto:Eve.Essery@fns.usda.gov]
Sent: Friday, March 28, 2014 6:07 PM
To: Frank Hu; Siega-Riz, Anna Maria; c1anderson@ucsd.edu; Millen, Barbara E
Cc: 'Casavale, Kellie (OS/OASH)'; Obbagy, Julie - CNPP
Subject: DGAC SC2: Dietary patterns & CVD, BW, & T2D

Hi Frank, Anna Maria, Cheryl, and Barbara,
I just wanted to give you a quick update on the dietary patterns and CVD, BW, and T2D questions. As requested at the
public meeting, Yat Ping conducted a search for existing systematic reviews/ meta-analyses published since 2008. Her
search identified 47 articles. I just finished an abstract review of the articles, and 30 are potentially relevant (with most
articles addressing CVD, but a handful each for body weight and T2D). The next step will be for staff to review the full text
of these articles. It is likely that some of the articles will drop off the list following full text review.
I’ve attached the results of the abstract review in case you are interested. I’ll send an updated list after the full text review.
From there, the staff will look at reference overlap between the reviews (and the NEL and AHA/ACC reviews), and you
can discuss how best to include these existing systematic reviews/ meta-analyses in your review of the evidence.
I just wanted to let you know that things are moving… More soon!
Eve
Eve Essery Stoody, PhD

Nutritionist | Center for Nutrition Policy and Promotion | USDA
3101 Park Center Drive, Room 1034 | Alexandria, VA 22302
Eve.Essery@cnpp.usda.gov | Office: 703-305-2563 | Fax: 703-305-3300
9
PSC-HHS-000009
www.DietaryGuidelines.gov | www.ChooseMyPlate.gov | www.NEL.gov
This electronic message contains information generated by the USDA solely for the intended recipients. Any
unauthorized interception of this message or the use or disclosure of the information it contains may violate the
law and subject the violator to civil or criminal penalties. If you believe you have received this message in error,
please notify the sender and delete the email immediately.
10
PSC-HHS-000010

Sent: Friday, May 02, 2014 4:40 PM
To: Lichtenstein, Alice; Anne Rodgers
Cc: Casavale, Kellie (OS/OASH); Olson, Richard (HHS/OASH); 'Rihane, Colette - CNPP'
Subject: RE: Notes from last night -- notes on integration chapter
Thank you Alice. I do agree; dietary guidelines that are based upon our best understanding of nutritional needs of the
population should be the basis of our guidance and the framework of our programs. However, I would add that an
improved understanding of the determinants of nutritional risk (including food insecurity and other factors) and their
relationship to health outcomes may help us better design programs and interventions to reach vulnerable population
or improve program/service effectiveness. Agreed? Thought I would add these further thoughts.

Barbara

bmillen@bu.edu

From: Lichtenstein, Alice [mailto:Alice.Lichtenstein@tufts.edu]
To: Anne Rodgers; Millen, Barbara E
Cc: 'Casavale, Kellie (OS/OASH)'; 'Olson, Richard (HHS/OASH)'; 'Rihane, Colette - CNPP'
Very useful call today. I think I figured out what I was trying to suggest at the end of
the call, in an inarticulate way.
Dietary Guidelines should drive programs aimed at addressing issues of household

food insecurity, household food insecurity should not drive formulation of dietary
guidelines. The issue of diet quality and food insecurity is not new and is embedded in
current federal assistance programs. Isn’t that why federal feeding programs are tied
to the DG and food assistance programs are either tied to the DG (e.g., WIC) or SNAP
configured in a way to maximize their purchasing power (e.g., restrictions on
purchasing prepared foods)?
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
11
PSC-HHS-000011
From: Anne Rodgers (b) (6)
To: 'Millen, Barbara E'; Lichtenstein, Alice
Subject: FW: Notes from last night -- notes on integration chapter

Anne Brown Rodgers
Science Writer
(b) (6)

Sent: Wednesday, March 19, 2014 3:21 PM
To: Anne Rodgers
Subject: FW: Notes from last night
This is the follow‐up e‐mail (below) with Mim’s notes that I mentioned on the phone yesterday. Several Committee
members have also asked for the updated version of chapter guidance. What’s the status of that document? Are you
also getting the input you need to move the examples of conclusion statements forward?

Kellie


From: Nelson, Miriam [mailto:Miriam.Nelson@tufts.edu]
Sent: Friday, March 14, 2014 6:14 AM
To: 'bmillen@bu.edu'; mary.story@duke.edu
Cc: Casavale, Kellie (OS/OASH); Lichtenstein, Alice
Subject: Notes from last night
Hi Barbara and Mary,

Great discussion last night late in the dinner about the "synthesis" chapter.
Because I am apt to forget things, I thought I would send along notes on the ideas. I am including Alice on the email
because she prompted the conversation!
Here you go (without word-smithing or considering order):
There is the most evidence for healthy food and nutrition from the following:
1. Activate health care sector in nutrition/food health promotion

2. Place matters: improve food environment where you live, work, learn, and play
3. Respect culture
4. Calories matter
5. Eat more: vegetables, fruits, legumes, nuts, and seeds
7. Eat Less: Added sugars, refined grains, saturated fat, sodium, meats
8. Move more!
12
PSC-HHS-000012
(I will work on a sustainability one...)
Just didn't want to forget them.

Thanks. Mim
PS: here is the section from 2010 - I know we can do better:
Excerpted verbatim:
Four Main Integrated Findings to be Used in Developing the 2010 Dietary Guidelines for Americans:
1. Reduce the incidence and prevalence of overweight and obesity of the US population by reducing overall calorie in take
and increasing physical activity.
2. Shift food intake patterns to a more plant-based diet that

emphasizes vegetables, cooked dry beans and peas, fruits, whole
grains,
nuts, and seeds. In addition, increase the intake of seafood and
fat-free and low-fat milk and milk products, and consume only
moderate amounts of lean meats, poultry, and eggs.
3. Significantly reduce intake of foods containing added sugars and

solid fats because these dietary components contribute excess
calories and few, if any,nutrients. In addition, reduce sodium intake
and lower intake of refined grains, especially refined grains that are
coupled with added sugar, solid fat, and sodium.
4. Meet the 2008 Physical Activity Guidelines for Americans.

Tufts University
Boston, MA 02111
phone: 617-636-3735
fax: 617-636-3727
www.StrongWomen.org
13
PSC-HHS-000013

Cc: Casavale, Kellie (OS/OASH); Olson, Richard (HHS/OASH); 'Rihane, Colette - CNPP'
I agree that this is not our task to design programs or services since that is part of the policy development
process. However, we are looking at ‘what works’ and are trying to cull out the dietary patterns, food and nutrient
‘drivers’ of the patterns, and features of interventions (self‐monitoring, comprehensive lifestyle intervention, school‐
based and other community programs, etc.) that have proven effectiveness and efficacy or present as ‘best practices’
which we can summarize. Hope that helps clarify.

Barbara

bmillen@bu.edu

To: Millen, Barbara E; Anne Rodgers
I agree with your reasoning, however, I do not agree that this committee is tasked to
“design programs and interventions to reach vulnerable populations or improve
program/service effectiveness”. Were that the case we would have individuals with
different types of expertise on the committee. That task sounds like an IOM
project. We have a huge job just with the nutrition science/food intake aspect and as I
keep saying, probably too many times in on any one day, I am concerned that as we
keep expanding our scope we will scrimp on our main goal.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

14
PSC-HHS-000014
Thank you Alice. I do agree; dietary guidelines that are based upon our best understanding of nutritional needs of the
population should be the basis of our guidance and the framework of our programs. However, I would add that an
improved understanding of the determinants of nutritional risk (including food insecurity and other factors) and their
relationship to health outcomes may help us better design programs and interventions to reach vulnerable population
or improve program/service effectiveness. Agreed? Thought I would add these further thoughts.

Barbara

bmillen@bu.edu

To: Anne Rodgers; Millen, Barbara E
Very useful call today. I think I figured out what I was trying to suggest at the end of
the call, in an inarticulate way.
Dietary Guidelines should drive programs aimed at addressing issues of household

food insecurity, household food insecurity should not drive formulation of dietary
guidelines. The issue of diet quality and food insecurity is not new and is embedded in
current federal assistance programs. Isn’t that why federal feeding programs are tied
to the DG and food assistance programs are either tied to the DG (e.g., WIC) or SNAP
configured in a way to maximize their purchasing power (e.g., restrictions on
purchasing prepared foods)?
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: 'Millen, Barbara E'; Lichtenstein, Alice
Subject: FW: Notes from last night -- notes on integration chapter
15
PSC-HHS-000015

Anne Brown Rodgers
Science Writer
(b) (6)

Sent: Wednesday, March 19, 2014 3:21 PM
To: Anne Rodgers
Subject: FW: Notes from last night
This is the follow‐up e‐mail (below) with Mim’s notes that I mentioned on the phone yesterday. Several Committee
members have also asked for the updated version of chapter guidance. What’s the status of that document? Are you
also getting the input you need to move the examples of conclusion statements forward?

Kellie


From: Nelson, Miriam [mailto:Miriam.Nelson@tufts.edu]
Sent: Friday, March 14, 2014 6:14 AM
To: 'bmillen@bu.edu'; mary.story@duke.edu
Cc: Casavale, Kellie (OS/OASH); Lichtenstein, Alice
Subject: Notes from last night
Hi Barbara and Mary,

Great discussion last night late in the dinner about the "synthesis" chapter.
Because I am apt to forget things, I thought I would send along notes on the ideas. I am including Alice on the email
because she prompted the conversation!
Here you go (without word-smithing or considering order):
There is the most evidence for healthy food and nutrition from the following:
1. Activate health care sector in nutrition/food health promotion

2. Place matters: improve food environment where you live, work, learn, and play
3. Respect culture
4. Calories matter
5. Eat more: vegetables, fruits, legumes, nuts, and seeds
7. Eat Less: Added sugars, refined grains, saturated fat, sodium, meats
8. Move more!
(I will work on a sustainability one...)
Just didn't want to forget them.

Thanks. Mim
PS: here is the section from 2010 - I know we can do better:
Excerpted verbatim:
16
PSC-HHS-000016
Four Main Integrated Findings to be Used in Developing the 2010 Dietary Guidelines for Americans:
1. Reduce the incidence and prevalence of overweight and obesity of the US population by reducing overall calorie in take
and increasing physical activity.
2. Shift food intake patterns to a more plant-based diet that

emphasizes vegetables, cooked dry beans and peas, fruits, whole
grains,
nuts, and seeds. In addition, increase the intake of seafood and
fat-free and low-fat milk and milk products, and consume only
moderate amounts of lean meats, poultry, and eggs.
3. Significantly reduce intake of foods containing added sugars and

solid fats because these dietary components contribute excess
calories and few, if any,nutrients. In addition, reduce sodium intake
and lower intake of refined grains, especially refined grains that are
coupled with added sugar, solid fat, and sodium.
4. Meet the 2008 Physical Activity Guidelines for Americans.

Tufts University
Boston, MA 02111
phone: 617-636-3735
fax: 617-636-3727
www.StrongWomen.org
17
PSC-HHS-000017

Sent: Saturday, May 03, 2014 7:06 AM
To: Siega-Riz, Anna Maria; Frank Hu; Essery, Eve - CNPP
Cc: Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP; Anne Rodgers
(b) (6)
Subject: RE: DGAC SC2: Dietary patterns and CVD, T2D, and BW
Attachments: CVD.dietary.patterns.Chapter2.4.30.14 bem edits 5 3 2014.docx
Thank you Anna Maria,

I want to say first that I think the CVD summary, as mentioned in my attached ‘comments’, is elegant, informative and
quite thorough. It is the first and will be the model for the others so I would like to be sure we have been as rigorous as
possible. I like the format I reviewed rather than the others.
You will see that I went back and extracted the definitions of DASH and MED‐style diets from the ACC/AHA publications.
It think we ought to do this for the ‘scores’ as well and be certain that we agree with the component foods and nutrients
that we use in our summary conclusion statements. We ought to be a bit more specific on the exposure definitions in
our summaries statements. I have comments in my review. Please accept these in the most constructive way. This is so
important and we want to get it right. While I would like to be as inclusive of the dietary pattern food and nutrient
components, this needs to be data driven. Right now, I fear it is a bit selective of the views (that we may collectively
hold) but may not be truly supported by the data.

Interested in your thoughts. I added Alice to the review list since I know she has deep expertise and strong views on
these areas.

Barbara
bmillen@bu.edu

From: Siega-Riz, Anna Maria [mailto:am_siegariz@unc.edu]
To: Frank Hu; Essery, Eve - CNPP
Cc: Millen, Barbara E; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP; Anne Rodgers
(b) (6)
Dear Eve, Frank and Barbara;
I made some edits to the T2D and BW conclusions and evidence. I also had just a few edits on Frank’s. Given the
differences in the amount of details provided in these two drafts and the style of writing, it would be very helpfully to all
committee members if the SRC can provide input as to which is preferred. I am happy to go with either.
Thank you and have a great weekend.
AMSR

Anna Maria Siega-Riz, PhD, RD
Professor of Epidemiology and Nutrition
and
Associate Dean for Academic Affairs
Gillings School of Global Public Health
2105‐A McGavran‐Greenberg Hall, CB 7435
18
PSC-HHS-000018
Chapel Hill, NC 27599
Phone:919‐962‐8410 (CPC); 919‐966‐5984 (Epi)
Email: am siegariz@unc.edu

From: Frank Hu [mailto:nhbfh@channing.harvard.edu]
Sent: Thursday, May 01, 2014 9:24 AM
To: Essery, Eve - CNPP
Cc: Siega-Riz, Anna Maria; Millen, Barbara E; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP;
Figueroa, Angelica M; PBROWN@hsph.harvard.edu
Subject: Re: DGAC SC2: Dietary patterns and CVD, T2D, and BW
Dear All,
attached is a draft of the section on dietary patterns and CVD by integrating the evidence reviews from the NEL
report, AHA/ACC guidelines, and additional meta-analyses/systematic reviews. In addition to CVD outcomes,
evidence on hypertension and dyslipidemia is also included. The review of evidence section is a bit detailed
because there are so much data, but it can be consolidated later on if necessary.
I look forward to your comments.
Frank
On Thu, Mar 6, 2014 at 3:10 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi Anna Maria, Frank, Barbara, and Cheryl,
In preparation for tomorrow’s call, I have pulled together a variety of documents so that you have everything in one place.
You have seen all of these materials previously except for the summary table for dietary patterns and T2D. Otherwise,
everything is exactly the same as the documents you have received previously. Below is a summary of the attachments:
1. Excel summary tables of existing reports for (1) CVD, (2) BW, and (3) T2D. (All three spreadsheets are included in
this file.)
2. Draft chapter content from Anna Maria
3. Email correspondence from Barbara, Frank, and Anna Maria after receiving Anna Maria’s chapter content
4. The pre-pub draft of the NEL report (zip file)
5. The lifestyle guidelines (zip file)
6. The obesity guidelines (zip file)
Also, I have asked staff from the NEL and NHLBI who were involved in these reviews to join the call in case you have any
questions about the specific reports.
19
PSC-HHS-000019
Talk to you tomorrow at noon ET (9am PT)!
Call-in number: (b) (6)
Access code: (b) (6)
Webinar: (b) (6)
Thanks,
Eve
--
*******************************************************
Frank B. Hu, MD, PhD
Professor of Nutrition and Epidemiology
Harvard School of Public Health
Professor of Medicine
Harvard Medical School
20
PSC-HHS-000020
665 Huntington ave, Boston, MA 02115
tel: 617 432 0113 fax: 617 432 2435
<http://www.hsph.harvard.edu/faculty/frank-hu/>
http://www.hsph.harvard.edu/faculty/frank-hu/
******************************************************
21
PSC-HHS-000021

Sent: Sunday, May 04, 2014 10:01 PM
To: Siega-Riz, Anna Maria; Frank Hu
Cc: Essery, Eve - CNPP; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie -
CNPP; Anne Rodgers (b) (6)
Subject: RE: DGAC SC2: Dietary patternse and CVD, T2D, and BW
Hi,

I also think the chapter introduction ought to set the stage for the major themes and approaches, including method of
exposure and outcome assessment, patterns and pattern scoring. The definition and interpretation of the exposures
probably need some particular explanation since we think of ‘risk’ associated with a category (for example, quartile or
quintile) and the ‘score’ may capture only part of the pattern and may not reflect complete compliance with the pattern
components.

All best,

Barbara

bmillen@bu.edu

From: Siega-Riz, Anna Maria [mailto:am_siegariz@unc.edu]
Sent: Sunday, May 04, 2014 8:23 PM
To: Frank Hu; Millen, Barbara E
Cc: Essery, Eve - CNPP; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP; Anne Rodgers
(b) (6)
Barbara and Frank,
I agree that we need to come to a consensus before revising. It seems as if in the introduction of this chapter we should
define the dietary patterns and then for each outcome we can say whether the studies reviewed fit the standard
definition or explain briefly how they deviated. If this is not done upfront, each of these sections are going to get pretty
long rather quickly.
SC#2 has a call on Thursday‐I believe this is important for all of our subcommittee members to participate in.
Eve, as soon as Steve writes up his section can you send that to us review?
AMSR

Sent: Saturday, May 03, 2014 11:07 AM
Cc: Siega-Riz, Anna Maria; Essery, Eve - CNPP; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP;
Anne Rodgers (b) (6)
Hi Barbara,
22
PSC-HHS-000022
Thank VERY MUCH for your detailed and thoughtful comments on the dietary pattern - CVD section. Overall,
I agree with your rigorous, specific, and integrated approach. Before revising this section, I'd like to clarify with
you and the subcommittee on several issues:
1. How detailed information do we need to provide on methods to define dietary patterns (e.g. data-driven
approaches vs. dietary indices vs. trials). Within each of the method, there is a large amount of heterogeneity
across different studies in defining DASH-style diets, Mediterranean-style diets, vs. vegetarian-type diets. It can
easily take a couple of pages to explain the variability in different methodologies and interpretations. Shall we
need a separate section to describe the methodology because the same issue will apply to other endpoints as
well (obesity, diabetes, cancer, etc.)? Would this conform to the chapter template provided by Ann?
2. We need to integrate the evidence from 3 main sources: NEL report, AHA/ACC report, and a review of
additional meta-analyses/systematic reviews. Of note, the exact patterns and components of the patterns are not
identical because these reports/reviews focus on different types of studies and methodologies. For example,
AHA/ACC report reviewed only RCTs on intermediate endpoints through 2009, while NEL report is most
focused on large prospective cohort studies on CVD endpoints. I think it is important to identify "common"
elements of the patterns, but also to be inclusive in defining broad dietary patterns that can be beneficial for a
wide range of endpoints (i.e. intermediate endpoints, CVD outcomes) and in different populations (US,
European, vegetarians etc.). In other words, we need to define both "common denominators" and potentially
unique elements (e.g., extra virgin olive oil in the Med-diet used in the PREDIMED) of the patterns.
3. You suggest that we should pay attention to key nutrients in certain dietary patterns. Among various patterns
that have been derived, only DASH has a clear characterization of nutrient intakes and other patterns are mostly
focused on foods/food groups.
In the RCTs, the DASH dietary pattern is low in saturated fat, total fat, and cholesterol. It is rich in potassium,
magnesium, and calcium, as well as protein and fiber. But most of these nutrients were not used in calculating
DASH scores in observational studies. The calculation of Med-score and HEI scores are mainly based on
foods/food groups. I'm not sure how much we can say about the role of nutrients based on pattern
analyses. Shall we delve into specific nutrients in separate sections? I think saturated/total fats, cholesterol,
protein, fiber, and some minerals deserve separate reviews of evidence.
4. PREDIMED trial is the only primary prevention trial of dietary pattern interventions on CVD endpoints (a
separate paper was published on diabetes in Ann Intern Med). Although the trial is not perfect, it is large (>6000
patients in >10 clinical centers), long-duration, and sufficiently powered, with excellent compliance (using
plasma and urinary biomarkers for nuts and extra virgin olive oil) and follow-up rates during 4 years. In
contrast, DASH is a small, short-tern, feeding study on intermediate endpoints. Thus, we need to put these
trials in perspectives in terms of methodologies and outcomes. Fortunately, the results from these trials are
largely consistent, supporting broadly defined healthy dietary patterns that are beneficial in reducing risk of a
wide range of CVD risk factors and endpoints. I think we need to look at the big picture when integrating the
evidence from different sources.
Can we set up a call to discuss these issues and your other comments? I think it is important to get a consensus
from the subcommittee before the revision.
23
PSC-HHS-000023
Best regards
Frank
On Sat, May 3, 2014 at 7:06 AM, Millen, Barbara E <bmillen@bu.edu> wrote:
Thank you Anna Maria,
I want to say first that I think the CVD summary, as mentioned in my attached ‘comments’, is elegant, informative and
quite thorough. It is the first and will be the model for the others so I would like to be sure we have been as rigorous as
possible. I like the format I reviewed rather than the others.
You will see that I went back and extracted the definitions of DASH and MED‐style diets from the ACC/AHA publications.
It think we ought to do this for the ‘scores’ as well and be certain that we agree with the component foods and nutrients
that we use in our summary conclusion statements. We ought to be a bit more specific on the exposure definitions in
our summaries statements. I have comments in my review. Please accept these in the most constructive way. This is so
important and we want to get it right. While I would like to be as inclusive of the dietary pattern food and nutrient
components, this needs to be data driven. Right now, I fear it is a bit selective of the views (that we may collectively
hold) but may not be truly supported by the data.
Interested in your thoughts. I added Alice to the review list since I know she has deep expertise and strong views on
these areas.
Barbara
bmillen@bu.edu
From: Siega-Riz, Anna Maria [mailto:am siegariz@unc.edu]

Cc: Millen, Barbara E; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP; Anne Rodgers
(b) (6)
24
PSC-HHS-000024
Dear Eve, Frank and Barbara;
I made some edits to the T2D and BW conclusions and evidence. I also had just a few edits on Frank’s. Given the
differences in the amount of details provided in these two drafts and the style of writing, it would be very helpfully to all
committee members if the SRC can provide input as to which is preferred. I am happy to go with either.
Thank you and have a great weekend.
AMSR
Anna Maria Siega-Riz, PhD, RD
and
Phone:919‐962‐8410 (CPC); 919‐966‐5984 (Epi)

Sent: Thursday, May 01, 2014 9:24 AM
Cc: Siega-Riz, Anna Maria; Millen, Barbara E; Anderson, Cheryl; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP;
Figueroa, Angelica M; PBROWN@hsph.harvard.edu
Dear All,
attached is a draft of the section on dietary patterns and CVD by integrating the evidence reviews from the NEL
report, AHA/ACC guidelines, and additional meta-analyses/systematic reviews. In addition to CVD outcomes,
25
PSC-HHS-000025
evidence on hypertension and dyslipidemia is also included. The review of evidence section is a bit detailed
because there are so much data, but it can be consolidated later on if necessary.
I look forward to your comments.
Frank
On Thu, Mar 6, 2014 at 3:10 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi Anna Maria, Frank, Barbara, and Cheryl,
In preparation for tomorrow’s call, I have pulled together a variety of documents so that you have everything in one place.
You have seen all of these materials previously except for the summary table for dietary patterns and T2D. Otherwise,
everything is exactly the same as the documents you have received previously. Below is a summary of the attachments:
1. Excel summary tables of existing reports for (1) CVD, (2) BW, and (3) T2D. (All three spreadsheets are included in
this file.)
2. Draft chapter content from Anna Maria
3. Email correspondence from Barbara, Frank, and Anna Maria after receiving Anna Maria’s chapter content
4. The pre-pub draft of the NEL report (zip file)
5. The lifestyle guidelines (zip file)
6. The obesity guidelines (zip file)
Also, I have asked staff from the NEL and NHLBI who were involved in these reviews to join the call in case you have any
questions about the specific reports.
Talk to you tomorrow at noon ET (9am PT)!
Webinar: (b) (6)
26
PSC-HHS-000026
Thanks,
Eve
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
27
PSC-HHS-000027
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
28
PSC-HHS-000028

Sent: Wednesday, May 07, 2014 11:58 AM
To: Frank Hu; Essery, Eve - CNPP; bmillen@bu.edu; Tom Brenna
Cc: Anderson, Cheryl; Anna Maria Siega-Riz, PhD, MS, RD (am_siegariz@unc.edu); Casavale,
Kellie (OS/OASH); Obbagy, Julie - CNPP; McDowell, Margaret (NIH/NIDDK) [E]; Fisher,
Rachel (NIH/NIDDK) [E]
Subject: RE: FW: DGAC SC 2: Pre-read for Thurs call
I agree with Frank. Link to the ‘teach-in’;
http://www.hsph.harvard.edu/news/features/saturated-or-not-does-type-of-fat-matter/
The front part is just set up, move the bar until you see the first speaker.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Essery, Eve - CNPP; Lichtenstein, Alice; bmillen@bu.edu; Tom Brenna
Cc: Anderson, Cheryl; Anna Maria Siega-Riz, PhD, MS, RD (am_siegariz@unc.edu); Casavale, Kellie (OS/OASH); Obbagy,
Julie - CNPP; McDowell, Margaret (NIH/NIDDK) [E]; rachel.fisher@nih.hhs.gov
Subject: Re: FW: DGAC SC 2: Pre-read for Thurs call
thanks, Tom, for your comments on the Annals meta-analysis. Since it is focused on individual macronutrients
rather than dietary patterns, I'm not sure whether it fits in this section on patterns and CVD. I think we probably
need to do a separate evidence-based review on saturated fat and other macronutrients, although this will take
significant time and efforts.
It is well recognized that the Annals paper contains multiple errors/omissions including data abstraction errors, omission of
PUFA studies, lack of comparator (saturated fat vs. carbs)... Overall I think the data and interpretation of this meta-
analysis are seriously flawed. The authors tried to correct some of the errors but the corrections are incomplete. We did a
teach-in symposium about this study to clarify some of the confusions; both Alice and I presented our viewpoints and
interpretation of the existing evidence.
Attached please see my slides for your information.

29
PSC-HHS-000029
Regarding the WSJ article, it was written by a reporter who does not seem to understand nutrition or epidemiology. She
has a book on the same topic coming out next week. The article is not peer-reviewed and makes many nonsense
viewpoints without any references or real data to support them.
I think we should discuss these issues tomorrow to see what's the best way to proceed.
Frank
On Wed, May 7, 2014 at 8:25 AM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi Frank and Cheryl,
Tom sent the comments below related to the dietary patterns and CVD, T2D, and body weight reviews.
Eve
From: (b) (6) gmail.com [mailto:(b) (6) gmail.com] On Behalf Of Tom Brenna
Sent: Tuesday, May 06, 2014 9:41 PM
To: Siega-Riz, Anna Maria
Cc: Essery, Eve - CNPP; alice.lichtenstein@tufts.edu; Millen, Barbara E
Subject: Re: DGAC SC 2: Pre-read for Thurs call
Here are a few comments.
Comments on "CVD.dietary.patterns.Chapter2.4.30.14"
(1) Q1: Japanese DP? 100+ papers on Pubmed.
(2) Definitions. I concur with note B7 about definitions. The added paragraph ("AHA/ACC/...") uses many
relative adjectives ("higher", "moderate", relatively low"). Compared to what? The usual answer is "Western"
but what's that? Same comment for DASH. My anecdotal survey of dietitians is that they don't know where
MED begins and ends (apart from wine and olive oil), let along Western.
General comments on CVD.
30
PSC-HHS-000030
Two issues relevant to the CVD story that are probably better considered in solitude.
1) Do we intend to do anything with the (attached) Chowdhury paper, not DP but still reelvant, which has
numerous data analyses that contradict the AHA conclusions?
a) No harm from sat fat (RCT (Fig 1, Intake) and PCS (Fig 2, Biomarker, which can be linked to intake and are
objectively measured)). RCT has non-sig signal for benefit.
b) Benefit from the odd and branched chain FA 15:0 and 17:0, markers of dairy/beef fat (PCS, Figure 2)
c) Benefit from EPA+DHA = "Total long-chain w-3" (RCT & PCS) and from EPA alone (PCS) and DHA alone
(PCS).
d) No benefit from w6 PUFA (RCT & PCS) and no benefit from linoleic acid (PCS)
e) Benefit from circulating arachidonic acid, a marker of meat (and not veg oil) intake (PCS)
While the embargoed version of this paper released to the press was apparently riddled with errors (copy on
request), I think it should be addressed at least among ourselves now or later.
2) The WSJ article from 6 May 2014 (link below) about an upcoming book rehashes many familiar concerns
with the saturated fat story. Whether or not the current DGAC includes or rejects this evidence, it is out there
and to my eyes is increasingly prominent in the public mind. DGAC should make non-political
recommendations but I reckon it helpful to policy makers if we are especially solid on those matters that may be
attacked.
The Questionable Link Between Saturated Fat and Heart Disease
Are butter, cheese and steak really bad for you? The dubious science behind the anti-fat crusade
<http://online.wsj.com/news/articles/SB10001424052702303678404579533760760481486?tesla=y>
Comment on "Question T2D&BW_summary_5_2_14"
Comment on the sentence highlighted by SAM2: "An unhealthy dietary pattern...sweets." Is this not a circular
observation? Consumption of meats, high-fat dairy, and refined grains and sweets scores low on HEI, and then
we look at a low score and conclude that it is due to these factors. What other ways might HEI be low?
31
PSC-HHS-000031
I generally concur and have no questions at this time about Q3 conclusions.
Tom
On Tue, May 6, 2014 at 8:49 AM, Siega-Riz, Anna Maria <am_siegariz@unc.edu> wrote:
Thank you Tom. Weighing in here is important for how we will proceed with writing up our conclusions. Safe travels.
AMSR
Sent: Monday, May 05, 2014 7:38 PM
To: Essery, Eve - CNPP; Siega-Riz, Anna Maria
Cc: alice.lichtenstein@tufts.edu; Millen, Barbara E
Anna Maria, Eve,
I am just realizing that I'm scheduled to fly on Thursday and land in LA mid-call. I'll call in if there is a change
in schedule or I can somehow get connected.
I'll have a look at the attachments and comment in writing if I think useful.
Apologies.
Tom
On Mon, May 5, 2014 at 5:26 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi SC2 members,
32
PSC-HHS-000032
On behalf of the Dietary Patterns and CVD, T2D, and body weight work group (Frank, Anna Maria, Barbara, and Cheryl),
attached are the current versions of their draft conclusions and report sections for your review prior to Thursday’s SC2
call. Also attached are the summary tables for these questions.
Thursday’s agenda is coming soon…
Best,
Eve
--
*******************************************************
33
PSC-HHS-000033
tel: 617 432 0113 fax: 617 432 2435
******************************************************
34
PSC-HHS-000034

Sent: Wednesday, May 07, 2014 4:55 PM
To: Tom Brenna; Frank Hu
Cc: Essery, Eve - CNPP; bmillen@bu.edu; Anderson, Cheryl; Anna Maria Siega-Riz, PhD, MS,
RD (am_siegariz@unc.edu); Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP;
McDowell, Margaret (NIH/NIDDK) [E]; Fisher, Rachel (NIH/NIDDK) [E]
Subject: RE: FW: DGAC SC 2: Pre-read for Thurs call
There is another point. I thought we had a cut-off on publication date prior to

Chowdhury. If we extend it for Chowdhury, we would have to extend it for all topics.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
To: Frank Hu
Cc: Essery, Eve - CNPP; Lichtenstein, Alice; bmillen@bu.edu; Anderson, Cheryl; Anna Maria Siega-Riz, PhD, MS, RD
(am_siegariz@unc.edu); Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP; McDowell, Margaret (NIH/NIDDK) [E];
rachel.fisher@nih.hhs.gov
Subject: Re: FW: DGAC SC 2: Pre-read for Thurs call
Thanks Frank. I'm afraid I don't expect to be on the call tomorrow.
Of course the Chowdhury paper is not about DP but I thought I would raise it while we are looking at DP and
arriving at apparently different conclusions.
As I mentioned, I recognize that the Chowdhury paper has many problems as outlined by your ppt, as was
outlined by Walter W on the Annals website the day after release, and was addressed, at least in part, by the
final release of that paper. That said, it appears your ppt is on the embargoed paper and not the final published
(corrected) one that I sent along (e.g. slide 2, "N-3 polyunsat (long chain)" is listed as 0.84-1.02 but in the final
is 0.78-0.97). I don't think they corrected everything.
I was familiar with Jakobsen and will avoid debating its merits here.
More importantly, the issue of omissions and missed references really should be settled by a systematic review
that gets at the actual source of the differences, as you say, and I'm all for that whatever time it takes.
The WSJ article is indeed a review of the book.

35
PSC-HHS-000035
The "teach-in" is a 3 hour long video; I would prefer the written word.
Tom
On Wed, May 7, 2014 at 10:06 AM, Frank Hu <nhbfh@channing.harvard.edu> wrote:

thanks, Tom, for your comments on the Annals meta-analysis. Since it is focused on individual macronutrients
rather than dietary patterns, I'm not sure whether it fits in this section on patterns and CVD. I think we probably
need to do a separate evidence-based review on saturated fat and other macronutrients, although this will take
significant time and efforts.
It is well recognized that the Annals paper contains multiple errors/omissions including data abstraction errors, omission of
PUFA studies, lack of comparator (saturated fat vs. carbs)... Overall I think the data and interpretation of this meta-
analysis are seriously flawed. The authors tried to correct some of the errors but the corrections are incomplete. We did a
teach-in symposium about this study to clarify some of the confusions; both Alice and I presented our viewpoints and
interpretation of the existing evidence.
Attached please see my slides for your information.
Regarding the WSJ article, it was written by a reporter who does not seem to understand nutrition or epidemiology. She
has a book on the same topic coming out next week. The article is not peer-reviewed and makes many nonsense
viewpoints without any references or real data to support them.
I think we should discuss these issues tomorrow to see what's the best way to proceed.
Frank
On Wed, May 7, 2014 at 8:25 AM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi Frank and Cheryl,
Tom sent the comments below related to the dietary patterns and CVD, T2D, and body weight reviews.
Eve
Cc: Essery, Eve - CNPP; alice.lichtenstein@tufts.edu; Millen, Barbara E
Here are a few comments.
36
PSC-HHS-000036
Comments on "CVD.dietary.patterns.Chapter2.4.30.14"
(1) Q1: Japanese DP? 100+ papers on Pubmed.
(2) Definitions. I concur with note B7 about definitions. The added paragraph ("AHA/ACC/...") uses many
relative adjectives ("higher", "moderate", relatively low"). Compared to what? The usual answer is "Western"
but what's that? Same comment for DASH. My anecdotal survey of dietitians is that they don't know where
MED begins and ends (apart from wine and olive oil), let along Western.
General comments on CVD.
Two issues relevant to the CVD story that are probably better considered in solitude.
1) Do we intend to do anything with the (attached) Chowdhury paper, not DP but still reelvant, which has
numerous data analyses that contradict the AHA conclusions?
a) No harm from sat fat (RCT (Fig 1, Intake) and PCS (Fig 2, Biomarker, which can be linked to intake and are
objectively measured)). RCT has non-sig signal for benefit.
b) Benefit from the odd and branched chain FA 15:0 and 17:0, markers of dairy/beef fat (PCS, Figure 2)
c) Benefit from EPA+DHA = "Total long-chain w-3" (RCT & PCS) and from EPA alone (PCS) and DHA alone
(PCS).
d) No benefit from w6 PUFA (RCT & PCS) and no benefit from linoleic acid (PCS)
e) Benefit from circulating arachidonic acid, a marker of meat (and not veg oil) intake (PCS)
While the embargoed version of this paper released to the press was apparently riddled with errors (copy on
request), I think it should be addressed at least among ourselves now or later.
2) The WSJ article from 6 May 2014 (link below) about an upcoming book rehashes many familiar concerns
with the saturated fat story. Whether or not the current DGAC includes or rejects this evidence, it is out there
and to my eyes is increasingly prominent in the public mind. DGAC should make non-political
recommendations but I reckon it helpful to policy makers if we are especially solid on those matters that may be
attacked.
37
PSC-HHS-000037
The Questionable Link Between Saturated Fat and Heart Disease
Are butter, cheese and steak really bad for you? The dubious science behind the anti-fat crusade
<http://online.wsj.com/news/articles/SB10001424052702303678404579533760760481486?tesla=y>
Comment on "Question T2D&BW_summary_5_2_14"
Comment on the sentence highlighted by SAM2: "An unhealthy dietary pattern...sweets." Is this not a circular
observation? Consumption of meats, high-fat dairy, and refined grains and sweets scores low on HEI, and then
we look at a low score and conclude that it is due to these factors. What other ways might HEI be low?
I generally concur and have no questions at this time about Q3 conclusions.
Tom
On Tue, May 6, 2014 at 8:49 AM, Siega-Riz, Anna Maria <am_siegariz@unc.edu> wrote:
Thank you Tom. Weighing in here is important for how we will proceed with writing up our conclusions. Safe travels.
AMSR
Cc: alice.lichtenstein@tufts.edu; Millen, Barbara E
Anna Maria, Eve,
38
PSC-HHS-000038
I am just realizing that I'm scheduled to fly on Thursday and land in LA mid-call. I'll call in if there is a change
in schedule or I can somehow get connected.
I'll have a look at the attachments and comment in writing if I think useful.
Apologies.
Tom
On Mon, May 5, 2014 at 5:26 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi SC2 members,
On behalf of the Dietary Patterns and CVD, T2D, and body weight work group (Frank, Anna Maria, Barbara, and Cheryl),
attached are the current versions of their draft conclusions and report sections for your review prior to Thursday’s SC2
call. Also attached are the summary tables for these questions.
Thursday’s agenda is coming soon…
Best,
Eve
39
PSC-HHS-000039
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tel: 617 432 0113 fax: 617 432 2435
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40
PSC-HHS-000040

Sent: Friday, May 09, 2014 11:36 AM
To: Mosher, Amber (OS/OASH); Nelson, Miriam (Miriam.Nelson@tufts.edu);
'campbellw@purdue.edu' (campbellw@purdue.edu); Alice Lichtenstein
(alice.lichtenstein@tufts.edu); Liz Rahavi (Elizabeth.rahavi@cnpp.usda.gov); Casavale,
Kellie (OS/OASH); (b) (6) Psota, Tricia - FNS (Contractor)
Subject: RE: MEETING PREP: Materials for PAWG call on 5/9 @ 2:30
Attachments: Copy of DGAC_PA questions evidence_MN edit_5 7 14 bem edits 5 9 2014.xlsx
Thanks for the superb summary table. I went through and added comments and made questions in certain places. In
the overall conclusion and Implications statement, it would seem important to consider specifying subgroups for which
there are consistent data (age and sex) and for the recommended types of interventions, those for which evidence is
strongest. I wasn’t sure from the summaries whether some of the conclusions were supported by data or not. Things
for thought and discussion.

Barbara

bmillen@bu.edu

From: Mosher, Amber (OS/OASH) [mailto:Amber.Mosher@hhs.gov]
To: Nelson, Miriam (Miriam.Nelson@tufts.edu); 'campbellw@purdue.edu' (campbellw@purdue.edu); Alice Lichtenstein
(alice.lichtenstein@tufts.edu); Liz Rahavi (Elizabeth.rahavi@cnpp.usda.gov); Casavale, Kellie (OS/OASH);
(b) (6) Millen, Barbara E; Psota, Tricia - FNS (Contractor)
Subject: MEETING PREP: Materials for PAWG call on 5/9 @ 2:30
Importance: High

All,

On behalf of Mim, please find meeting materials attached for the next Physical Activity Writing Group (PAWG) call. As a
reminder, this meeting is scheduled for Friday, May 9, 2014 from 2:30 – 3:30 p.m.

You will find the following documents attached:
Meeting agenda (Word)
Updated PA questions and evidence (Excel, dated 5.7.14)
Proposed guidance for developing 2015 DGAC evidence reviews (Word, dated 4.15.14)

When reviewing the Excel workbook prior to the call, note that the purple tab represents the PAWG’s list of questions
and corresponding evidence from the three PAG reports. This includes 15 questions in three physical activity subtopic
areas (i.e., health outcomes = 11; behavioral interventions = 1; environmental interventions = 3). The focus of Friday’s
discussion will only include the questions and evidence in the purple tab. Also note that Mim has provided initial
examples of conclusion and implication statements for questions #1 and #1a for discussion.

Regarding the Proposed guidance for developing 2015 DGAC evidence reviews, note that the PAWG will use scenario 2
(i.e., using existing reports or systematic reviews/meta‐analyses) to address physical activity questions; see pages 4 – 6
for specific guidance.

41
PSC-HHS-000041
Finally, we plan to use webcast capabilities to review the Excel workbook during the call on Friday. Conference line and
webcast information is provided in the meeting agenda and Outlook calendar invite. Please let me know if you have any
questions.

Many thanks, ALM

Amber L. Mosher, MPH, RD | Prevention Science Fellow
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
1101 Wootton Parkway, LL-100
Rockville, MD 20852
O: 240 - 453 - 8261 | C: 202 - 815 - 3618
Amber.Mosher@hhs.gov
Dietary Guidelines for Americans | Physical Activity Guidelines for Americans

42
PSC-HHS-000042

Subject: FW: Comments open until June 9 on draft USPSTF recommendation on diet/ physical
activity counseling
Probably should keep track of this. I sent it on to SC2 and SC3 leads. Barbara

bmillen@bu.edu

From: Millen, Barbara E
To: Anna Maria Siega-Riz, PhD, MS, RD (am_siegariz@unc.edu); 'Perez-Escamilla, Rafael' (rafael.perez-
escamilla@yale.edu)
Subject: FW: Comments open until June 9 on draft USPSTF recommendation on diet/ physical activity counseling

Thought you both might be interested in this recent recommendation. Doesn’t go so far as to mention “who is qualified
to provide the intensive behavioral recommendation” but they are encouraging it. I think we can do and have done a bit
better in our wording.

Barbara

bmillen@bu.edu

From: McMurry, Kathryn (NIH/NHLBI) [E] [mailto:kathryn.mcmurry@nih.gov]
To: 'Donna Ryan'; 'Alison Beale'; 'Anthony G. Comuzzie'; Millen, Barbara E; 'Bruce Wolfe'; Apovian, Caroline; Loria,
Catherine (NIH/NHLBI) [E]; 'Cathy Nonas'; 'F. Xavier Pi-Sunyer'; 'Frank Hu'; Hubbard, Van (NIH/NIDDK) [E]; 'John M.
Jakicic'; 'June Stevens'; 'Michael Jensen'; 'Robert Kushner'; Yanovski, Susan (NIH/NIDDK) [E]; 'Thomas A. Wadden';
'Victor J. Stevens'
Cc: De Jesus, Janet M (NIH/NHLBI) [E]; (b) (6)
Subject: Comments open until June 9 on draft USPSTF recommendation on diet/ physical activity counseling

Hello all –

I thought you would be interested to know about, and possibly comment on, the recent draft recommendation from the
USPSTF:

Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease
Prevention in Adults with Known Risk Factors: U.S. Preventive Services Task Force Recommendation
Statement
DRAFT
Summary of Recommendation and Evidence
The U.S. Preventive Services Task Force (USPSTF) recommends offering or referring overweight and obese adults who have
additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthy diet and
physical activity for CVD prevention.
This is a Grade B recommendation.
43
PSC-HHS-000043

More detailed information on the evidence report and commenting can be accessed at this link:
http://www.uspreventiveservicestaskforce.org/tfcomment.htm

Best,

Kathryn

Kathryn Y. McMurry, M.S.
NHLBI Nutrition Coordinator
301‐594‐2094 (direct)
301‐480‐4907 (fax)
Kathryn.McMurry@nih.gov

From: Donna Ryan [mailto:Donna.Ryan@pbrc.edu]
To: Alison Beale; Anthony G. Comuzzie; Barbara Millen; Bruce Wolfe; Caroline M. Apovian; Loria, Catherine (NIH/NHLBI)
[E]; Cathy Nonas; F. Xavier Pi-Sunyer; Frank Hu; Hubbard, Van (NIH/NIDDK) [E]; Jamy Ard; John M. Jakicic; June
Stevens; Karen Donato; McMurry, Kathryn (NIH/NHLBI) [E]; Kelley, Melinda (NIH/NIA/ERP) [E]; Michael Jensen; Robert
Kushner; Yanovski, Susan (NIH/NIDDK) [E]; Thomas A. Wadden; Victor J. Stevens
Cc: Lisa Bradfield; Ezaldeen Ramadhan; Halperin, Jonathan; JeffreyL.Anderson@imail.org; Marco Dibuono (AHA); Adbul
Abdullah (AHA)
Subject: RE: RESPONSE REQUESTED: 2014 LBCT Voting; Obesity - Due Friday, May 23rd

The only study on the attached list that seems relevant to the Obesity Guidelines is STAMPEDE (50 subjects per group
randomized to sleeve, bypass or medical intervention with glycemic and weight endpoints). Given that it is only 50
subjects with sleeve gastrectomy, I don't think that it rises to the level of changing our CQ 5 recommendation. The other
study that we should at least talk about is LABS II (three year data on surgical outcomes; it's authoritative on the amount
of weight loss that could be expected with the various procedures. Its a good study, but I don' t think it changes our
recommendations and we would not change our evidence statements based on this sort of methodology (a casual one of
remembering studies)..
I don't think we should change the evidence statements; they had rigorous methodology which we wouldn't want to
weaken with this sort of approach.
As for other studies that address CQ 1-5, nothing else comes to mind that would likely change our recommendations for
those 5 CQs.
My vote is that I see nothing to add and nothing to change.
Donna
Donna H. Ryan MD
Professor Emerita,
Pennington Biomedical Research Center
Baton Rouge, LA 70808
225 229 3909
donna.ryan@pbrc.edu
New Orleans address: :

(b) (6)
Colorado addresses:
(b) (6)
44
PSC-HHS-000044
From: Alison Beale [mailto:abeale@acc.org]
Sent: Tue 5/13/2014 1:36 PM
To: Anthony G. Comuzzie; Barbara Millen; Bruce Wolfe; Caroline M. Apovian; Catherine Loria; Cathy Nonas; Donna Ryan;
F. Xavier Pi-Sunyer; Frank Hu; Hubbard Van; Jamy Ard; John M. Jakicic; June Stevens; Karen Donato; Kathryn McMurry;
Melinda Kelley; Michael Jensen; Robert Kushner; Susan Yanoviski; Thomas A. Wadden; Victor J. Stevens
Cc: Lisa Bradfield; Ezaldeen Ramadhan; Alison Beale; 'Halperin, Jonathan'; JeffreyL.Anderson@imail.org; Marco Dibuono
(AHA); Adbul Abdullah (AHA)
Subject: RESPONSE REQUESTED: 2014 LBCT Voting; Obesity - Due Friday, May 23rd
URGENT: Timely Response Requested
We would appreciate your immediate attention to this request

Dear ACC/AHA Obesity Writing Committee Member,

As part of our ongoing guideline review process, we are asking you to vote on late‐breaking clinical trials (LBCTs)
presented at the 2013 and 2014 ACC, AHA, ESC, and TCT meetings to determine whether they might lead to an update
or revision of the ACC/AHA Obesity Guideline. This process will assist in providing timely updates of the guidelines.

ACTIONS: Votes are due by Friday, May 23rd.

1. Please cast your votes using the attached 2014 LBCT Review document.
a. We have indicated which trials are relevant to which guidelines, so please make your votes accordingly.
2. If you feel that some of the trials not listed as relevant to your guideline are in fact relevant, please feel free to
also vote on those trials.

3. Lastly, your input/suggestions are requested regarding any additional studies/data that are not already included.
a. Your expertise in the clinical area specific to your guideline will add tremendous value and will be a
primary consideration when the Task Force decides which guidelines to update. The end goal is to
identify the most important trials that could potentially lead to a change in existing or new
recommendations.

Each trial listed in the 2014 LBCT Review document has a link to the Cardiosource summary sheet or other link as
appropriate. If the study has been published, there will be a link to the PubMed abstract or full article if available.
Unpublished trials will not be incorporated into guidelines until they publish but we would still like your feedback about
the trial. Note: To view the Cardiosource summaries, please be sure you are logged into www.cardiosource.org first. If
you need assistance accessing the website, please contact the ACC Resource Center for technical assistance at 1‐800‐
253‐4636, ext. 5603.

Next Steps:
After collecting input from writing committee members, the ratings will be presented to the ACC/AHA Task Force on
Practice Guidelines on June 9th, 2014, and the members will decide which writing committees should convene a
conference call to decide if an update is necessary. If a focused update is commissioned, we will reconvene the writing
committee or a portion of it, pending review of the composition of the relationships with industry of all members. If you
have any questions about the process, or about your role, please do not hesitate to contact ACC/AHA staff.

The review criteria follow (not listed in order of importance):

Publication in a peer reviewed journal (this element assures time for the evidence to “simmer” in the clinical
community, which helps protect against being too reactionary);
Large, randomized, placebo‐controlled trial(s);
45
PSC-HHS-000045
Nonrandomized data deemed important on the basis of results affecting current safety and efficacy
assumptions, including observational studies and meta‐analyses;
Strength/weakness of research methodology and findings;
Likelihood of additional studies influencing current findings;
Impact on current and/or likelihood of need to develop new performance measure(s);
Request(s) and requirement(s) for review and update from the practice community, key stakeholders, and other
sources free of relationships with industry or other potential bias;
Number of previous trials showing consistent results; and
Need for consistency with a new guideline or guideline updates or revisions.

As always, thank you for your dedication and time allocated for this review process.

Best Regards,

Jeffrey L. Anderson, M.D., F.A.C.C., F.A.H.A.
Chair, ACCF/AHA Task Force on Practice Guidelines

Cc: Lisa Bradfield, Marco Di Buono

46
PSC-HHS-000046

Sent: Sunday, May 25, 2014 8:59 AM
Cc: Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu; jtb4
@cornell.edu; steven.clinton@osumc.edu; frank.hu@channing.harvard.edu;
mneuhous@fhcrc.org; rafael.perez-escamilla@yale.edu; Olson, Richard (HHS/OASH);
Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel
(NIH/NIDDK) [E]; McDowell, Margaret (NIH/NIDDK) [E]; Wong, Yatping - CNPP; Anne
Rodgers; Casavale, Kellie (OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu;
Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica
Figueroa
Subject: RE: DGAC SC2: Call THURS @ 1pm ET (10 am PT)
Attachments: CVD dietary patterns Chapter2 5 20 14 bem edits 5 25 2014.docx
Hi Frank et al,

This revision is a wonderful summary. I think it is getting very close but I am hoping with my edits to fine tune it a bit
more. This is intended in the most constructive way and I hope the comments help. I wondered whether we should
consider including one other category of foods (lean/lower fat proteins) and certain other macro‐ and micronutrients
(saturated fat in particular but also possibly total fat, cholesterol and fiber, potassium, magnesium and calcium) as
reflected in the summary of evidence. I realize that it makes the summary statement more complicated but it is also
perhaps more complete. This will depend, of course, on whether we have consensus opinion on this additional food
group and the other nutrients. I went ahead and also edited the wording on the prospective cohort literature to reflect
the nature of the research (associations not effects). I wasn’t sure if it makes sense to capture other prospective cohort
literature relating to use of factor/cluster approaches where ‘empty calorie’ and ‘Western’ patterns are associated with
adverse CVD outcomes and ‘heart healthier’ patterns are beneficial.

Hope your holiday weekend is safe and restful.

Barbara

bmillen@bu.edu

Cc: Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu; jtb4@cornell.edu;
steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; rafael.perez-escamilla@yale.edu;
Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher,
Rachel (NIH/NIDDK) [E]; margaret.mcdowell@nih.gov; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie
(OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.;
Knight, Brianna; Angelica Figueroa
Subject: Re: DGAC SC2: Call THURS @ 1pm ET (10 am PT)
Dear All,
attached is a revised draft of the section on dietary patterns and CVD. To address your comments, the revised
version included more detailed information on methods used to derive the patterns, components of the patterns
47
PSC-HHS-000047
that may drive the associations, and variations in the patterns across different studies and populations. Despite
the heterogeneity in study designs, populations, and methodologies, several heart-healthy patterns were
identified with strong evidence from both observational studies RCTs and these patterns share most
components. The implication is that individuals can adopt these patterns according to their personal needs and
preferences.
We can discuss this further at tomorrow's call.
Frank
On Wed, May 21, 2014 at 5:25 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi SC2 members,
On behalf of Anna Maria, attached are materials for tomorrow's SC2 call at 1pm ET (10am PT). Please let me know if you
will not be able to join the call. (Alice, Steve, Marian, and Rafael – I have you as “unavailable,” but let me know if that’s
incorrect.) Thanks!

Web conference: (b) (6)
AGENDA
1. Science Review SC follow-up [Barbara and Eve]
Timeline goal: Complete draft chapter by end of September
Conception framework: SC feedback requested (attachment)
Implications: Examples from 2010 DGAC (attachment)
2. Updates
SC1 and SC2 crossover – dietary patterns composition project (attachment) [Cheryl and Eve]
Sodium [Cheryl]
Dietary patterns and CVD [Frank]
Dietary patterns and T2D and BW [Anna Maria]
48
PSC-HHS-000048
Dietary patterns and cancer [Steve, Marian, or Rafael, if available, or Julie]
Upcoming NEL reviews [Julie]
Next call: Thursday, June 5 from 1:00 to 2:00 pm ET (10:00 to 11:00 am PT)
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49
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tel: 617 432 0113 fax: 617 432 2435
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50
PSC-HHS-000050

Sent: Monday, May 26, 2014 10:14 AM
To: Frank Hu
Cc: Essery, Eve - CNPP; Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu;
c1anderson@ucsd.edu; jtb4@cornell.edu; steven.clinton@osumc.edu;
frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; rafael.perez-
escamilla@yale.edu; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman,
Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E]; McDowell, Margaret
(NIH/NIDDK) [E]; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH);
Eric E Calloway; PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org;
Bailey, Lauren A.; Knight, Brianna; Angelica Figueroa
Thank you Frank. I recommended considering the additional nutrients because polyunsaturated fat was included in the
statement. I think including it as well as sodium makes sense and it would sure we nice if we reached consensus on
saturated if not total fat. Let’s see how others might feel about that particularly saturated fat since I believe many of the
patterns are relatively low in it. In terms of the factor and cluster patterns, I don’t recall what the NEL review concluded.
Was it that there wasn’t enough consensus to make further statements about not ‘scoring[ methods?

All best,

Barbara

bmillen@bu.edu

Cc: Essery, Eve - CNPP; Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu; jtb4@cornell.edu;
Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel
(NIH/NIDDK) [E]; margaret.mcdowell@nih.gov; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH); Eric E
Calloway; PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna;
Angelica Figueroa
Thanks, Barbara, for your helpful suggestions.
Since our evidence-based reviews are focused on overall dietary patterns rather than individual nutrients, I
would be hesitate to add those nutrients (except for sodium) to the conclusion statement. I think a statement on
individual nutrients (such as saturated fat, total fat, calcium, potassium, mg, fiber etc.) would warrant separate
systematic reviews if evidence-based statements were to be made about them (I know we don't have time to do
that). Somewhere in the text, we can describe the nutrient profiles of certain dietary patterns, although we need
to be cognizant that some nutrients (e.g., the amount of total fat and saturated fat) are likely to differ according
to different dietary patterns (e.g., Med, DASH, Omni-Heart higher mono or higher protein, vegetarian, AHEI
etc). Clearly, one size does not fit all, but these patterns do share many food components (e.g., fruits, vegs,
legumes, whole grains, nuts, etc). Of note, none of the patterns reviewed here have clearly distinguished
"lean/lower fat proteins" from "high fat proteins", which are fairly vague terms. Instead, red meats and
51
PSC-HHS-000051
processed meats are often lumped together and poultry and fish are recommended to replace red and processed
meats in these diets (e.g., Med, DASH, AHEI etc). Therefore, I think the conclusion statements and
implications should stick to foods and food patterns (except for sodium, PUFA in vegetable oils) instead of
using the terms like "low fat" or "low carbo", which are not evidence-based and have continued to cause much
controversy and confusions in the general public and recommendations.
I'm not exactly sure your question regarding "other prospective cohort literature relating to use of factor/cluster

approaches where ‘empty calorie’ and ‘Western’ patterns are associated with adverse CVD outcomes and ‘heart
healthier’ patterns are beneficial." I thought the NEL has already done this.
Frank
On Sun, May 25, 2014 at 8:58 AM, Millen, Barbara E <bmillen@bu.edu> wrote:
Hi Frank et al,
Barbara
bmillen@bu.edu

52
PSC-HHS-000052
steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; rafael.perez-
escamilla@yale.edu; Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman,
Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E]; margaret.mcdowell@nih.gov; Wong,
Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH); Eric E Calloway;
PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna;
Angelica Figueroa
Dear All,
preferences.
Frank
Hi SC2 members,
incorrect.) Thanks!

53
PSC-HHS-000053
AGENDA
2. Updates
Sodium [Cheryl]
54
PSC-HHS-000054

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55
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******************************************************
56
PSC-HHS-000056

To: Tom Brenna; Frank Hu
Cc: Millen, Barbara E; Essery, Eve - CNPP; Siega-Riz, Anna Maria; c1anderson@ucsd.edu;
steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org;
rafael.perez-escamilla@yale.edu; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP;
Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E]; McDowell,
Margaret (NIH/NIDDK) [E]; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie
(OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu; Mironick, Adrianna;
jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica Figueroa
I would suggest keeping in mind, if SFA intake changes, so does either unsaturated fat
or carbohydrate, and the impact can be different. We need to be careful about
focusing on single energy containing nutrients.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
To: Frank Hu
Cc: Millen, Barbara E; Essery, Eve - CNPP; Siega-Riz, Anna Maria; Lichtenstein, Alice; c1anderson@ucsd.edu;
Angelica Figueroa
Comment on this string:
I support a saturated fat NEL review, perhaps in combination with cholesterol. I agree with many of Frank's
comments about evidence insofar as they urge caution in extrapolating DP reviews to food groups or nutrients.
I'm not sure where the sodium committee stands and reserve judgement until I see how that group will take the
totality of evidence into account.
Tom
57
PSC-HHS-000057
On Mon, May 26, 2014 at 10:44 AM, Frank Hu <nhbfh@channing.harvard.edu> wrote:
Thanks, Barbara, I agree that most of the "healthy" patterns are relatively low in saturated fat and high in
unsaturated fats (from olive oil, nuts, and other plant oils). AHA/ACC reviewed the evidence on substituting
vegetable oils rich in PUFA for saturated fat in lowering total and LDL cholesterol, but patterns from the NEL
review and newly identified meta-analyses are not very specific about the amount of PUFA. Instead of
describing MUFA or PUFA, we can include plant-based oils as part of the conclusion statement.
After the publication of the Annals of Intern Medicine meta-analyses, saturated fat has become the center of
dietary controversy again. Now many people feel that saturated fat is exonerated, largely based on faulty meta-
analyses/interpretations as well as media headlines. However, although most of the dietary patterns we reviewed
contain relatively low saturated fat (typically at the expenses of higher unsaturated fats), this does not directly
address or resolve the saturated fat controversy. Perhaps the committee is content with the pattern review that
makes inference about saturated fat. Otherwise we have to delve into the saturated fat issue directly by doing a
review of meta-analyses/systematic reviews on saturated fat. If this were to be done, it has to be done after the
pattern reviews are completed. One possibility is to combine saturated fat and cholesterol reviews together as
they mainly come from the same food sources.
Frank
On Mon, May 26, 2014 at 10:13 AM, Millen, Barbara E <bmillen@bu.edu> wrote:
Thank you Frank. I recommended considering the additional nutrients because polyunsaturated fat was included in the
statement. I think including it as well as sodium makes sense and it would sure we nice if we reached consensus on
saturated if not total fat. Let’s see how others might feel about that particularly saturated fat since I believe many of the
patterns are relatively low in it. In terms of the factor and cluster patterns, I don’t recall what the NEL review concluded.
Was it that there wasn’t enough consensus to make further statements about not ‘scoring[ methods?
All best,
Barbara
bmillen@bu.edu

Cc: Essery, Eve - CNPP; Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu; jtb4@cornell.edu;
58
PSC-HHS-000058
Angelica Figueroa
Since our evidence-based reviews are focused on overall dietary patterns rather than individual nutrients, I
would be hesitate to add those nutrients (except for sodium) to the conclusion statement. I think a statement on
individual nutrients (such as saturated fat, total fat, calcium, potassium, mg, fiber etc.) would warrant separate
systematic reviews if evidence-based statements were to be made about them (I know we don't have time to do
that). Somewhere in the text, we can describe the nutrient profiles of certain dietary patterns, although we need
to be cognizant that some nutrients (e.g., the amount of total fat and saturated fat) are likely to differ according
to different dietary patterns (e.g., Med, DASH, Omni-Heart higher mono or higher protein, vegetarian, AHEI
etc). Clearly, one size does not fit all, but these patterns do share many food components (e.g., fruits, vegs,
legumes, whole grains, nuts, etc). Of note, none of the patterns reviewed here have clearly distinguished
"lean/lower fat proteins" from "high fat proteins", which are fairly vague terms. Instead, red meats and
processed meats are often lumped together and poultry and fish are recommended to replace red and processed
meats in these diets (e.g., Med, DASH, AHEI etc). Therefore, I think the conclusion statements and
implications should stick to foods and food patterns (except for sodium, PUFA in vegetable oils) instead of
using the terms like "low fat" or "low carbo", which are not evidence-based and have continued to cause much
controversy and confusions in the general public and recommendations.
I'm not exactly sure your question regarding "other prospective cohort literature relating to use of factor/cluster

approaches where ‘empty calorie’ and ‘Western’ patterns are associated with adverse CVD outcomes and ‘heart
healthier’ patterns are beneficial." I thought the NEL has already done this.
Frank
Hi Frank et al,
59
PSC-HHS-000059
Barbara
bmillen@bu.edu


steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; rafael.perez-
escamilla@yale.edu; Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman,
Angelica Figueroa
Dear All,
60
PSC-HHS-000060
preferences.
Frank
Hi SC2 members,
incorrect.) Thanks!

AGENDA
2. Updates
61
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Sodium [Cheryl]
62
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64
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Subject: FW: Bias
You might as well keep this on file since he refers to the 2015 AHA guidelines but he means the DGAC guidelines since
there are no 2015 AHA guidelines.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Gershoff Professor of Nutrition Science and Policy Director and Senior Scientist, Cardiovascular Nutrition Laboratory
Tufts University JM USDA Human Nutrition Research Center on Aging
Boston, MA 02111

phone: 617 556 3127

‐‐‐‐‐Original Message‐‐‐‐‐
From: Joshua Schwerstfeger [mailto (b) (6) @me.com]
To: Lichtenstein, Alice
Subject: Bias

Dear Alice,
I'm saddened to see someone of your stature having such deeply held biases with regard to saturated fats. You would
do our nation more good by retiring. Good luck in picking and choosing only the science that supports your bias in
chairing the 2015 AHA guidelines. I and my family have learned that your recommendations are actually the source of
our current epidemic.

Josh Schwerdtfeger

(b) (6)
65
PSC-HHS-000065

Sent: Tuesday, May 27, 2014 7:35 AM
To: Perez-Escamilla, Rafael; Lichtenstein, Alice
Cc: Tom Brenna; Frank Hu; Essery, Eve - CNPP; Siega-Riz, Anna Maria;
c1anderson@ucsd.edu; steven.clinton@osumc.edu; frank.hu@channing.harvard.edu;
mneuhous@fhcrc.org; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman,
Hi everyone,

While I agree with the comments, we agreed to identify the food and nutrient ‘drivers’ of the patterns to the extent
possible. The evidence base we reviewed attempts to do so (See the summary Excel table) and the fine tuning of our
summary, conclusions and implications are aimed this. Anna Maria, I might recommend the smaller CVD group have a
call as early as possible this week to finalize the revisions and then present them to the SC2 group. I will try to be as
available as possible. I would also like to be mindful of staffing resources and our timetable. We may/may not be able
to do additional evidence‐based reviews and we might not desire to do a nutrient‐based NEL at this point.

All the best,

Barbara

bmillen@bu.edu

From: Perez-Escamilla, Rafael [mailto:rafael.perez-escamilla@yale.edu]
Sent: Tuesday, May 27, 2014 6:56 AM
Cc: Tom Brenna; Frank Hu; Millen, Barbara E; Essery, Eve - CNPP; Siega-Riz, Anna Maria; c1anderson@ucsd.edu;
steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Olson, Richard (HHS/OASH); Rihane,
Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E]; margaret.mcdowell@nih.gov;
Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu;
Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica Figueroa
Based on my 2010 DGAC experience I strongly agree with Alice's comment. As we had previously agreed I
think that for CVD we should keep our focus on DP's.
Rafael Perez-Escamilla, PhD
Professor of Epidemiology and Public Health

Director, Office of Public Health Practice
Director, Global Health Concentration
Yale School of Public Health
135 College St. (Suite 200)
New Haven CT
66
PSC-HHS-000066
IOM Food and Nutrition Board member
Chair, Global Nutrition Council, American Society for Nutrition
President, International Society for Research in Human Milk and Lactation (ISRHML)
Sent from my iPad
On May 26, 2014, at 5:00 PM, "Lichtenstein, Alice" <Alice.Lichtenstein@tufts.edu> wrote:
I would suggest keeping in mind, if SFA intake changes, so does either

unsaturated fat or carbohydrate, and the impact can be different. We need
to be careful about focusing on single energy containing nutrients.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
To: Frank Hu
Cc: Millen, Barbara E; Essery, Eve - CNPP; Siega-Riz, Anna Maria; Lichtenstein, Alice;
mneuhous@fhcrc.org; rafael.perez-escamilla@yale.edu; Olson, Richard (HHS/OASH); Rihane, Colette -
CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E];
margaret.mcdowell@nih.gov; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH); Eric E
Calloway; PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight,
Brianna; Angelica Figueroa
Comment on this string:
I support a saturated fat NEL review, perhaps in combination with cholesterol. I agree with
many of Frank's comments about evidence insofar as they urge caution in extrapolating DP
reviews to food groups or nutrients.
I'm not sure where the sodium committee stands and reserve judgement until I see how that
group will take the totality of evidence into account.
Tom
On Mon, May 26, 2014 at 10:44 AM, Frank Hu <nhbfh@channing.harvard.edu> wrote:
67
PSC-HHS-000067
Thanks, Barbara, I agree that most of the "healthy" patterns are relatively low in saturated fat and
high in unsaturated fats (from olive oil, nuts, and other plant oils). AHA/ACC reviewed the
evidence on substituting vegetable oils rich in PUFA for saturated fat in lowering total and LDL
cholesterol, but patterns from the NEL review and newly identified meta-analyses are not very
specific about the amount of PUFA. Instead of describing MUFA or PUFA, we can include
plant-based oils as part of the conclusion statement.
After the publication of the Annals of Intern Medicine meta-analyses, saturated fat has become
the center of dietary controversy again. Now many people feel that saturated fat is exonerated,
largely based on faulty meta-analyses/interpretations as well as media headlines. However,
although most of the dietary patterns we reviewed contain relatively low saturated fat (typically
at the expenses of higher unsaturated fats), this does not directly address or resolve the saturated
fat controversy. Perhaps the committee is content with the pattern review that makes inference
about saturated fat. Otherwise we have to delve into the saturated fat issue directly by doing a
review of meta-analyses/systematic reviews on saturated fat. If this were to be done, it has to be
done after the pattern reviews are completed. One possibility is to combine saturated fat and
cholesterol reviews together as they mainly come from the same food sources.
Frank
On Mon, May 26, 2014 at 10:13 AM, Millen, Barbara E <bmillen@bu.edu> wrote:
Thank you Frank. I recommended considering the additional nutrients because polyunsaturated fat was
included in the statement. I think including it as well as sodium makes sense and it would sure we nice if
we reached consensus on saturated if not total fat. Let’s see how others might feel about that
particularly saturated fat since I believe many of the patterns are relatively low in it. In terms of the
factor and cluster patterns, I don’t recall what the NEL review concluded. Was it that there wasn’t
enough consensus to make further statements about not ‘scoring[ methods?
All best,
Barbara
bmillen@bu.edu

Cc: Essery, Eve - CNPP; Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu;
jtb4@cornell.edu; steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org;
68
PSC-HHS-000068
rafael.perez-escamilla@yale.edu; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman,
Angelica Figueroa
Since our evidence-based reviews are focused on overall dietary patterns rather than individual
nutrients, I would be hesitate to add those nutrients (except for sodium) to the conclusion
statement. I think a statement on individual nutrients (such as saturated fat, total fat, calcium,
potassium, mg, fiber etc.) would warrant separate systematic reviews if evidence-based
statements were to be made about them (I know we don't have time to do that). Somewhere in
the text, we can describe the nutrient profiles of certain dietary patterns, although we need to be
cognizant that some nutrients (e.g., the amount of total fat and saturated fat) are likely to differ
according to different dietary patterns (e.g., Med, DASH, Omni-Heart higher mono or higher
protein, vegetarian, AHEI etc). Clearly, one size does not fit all, but these patterns do share many
food components (e.g., fruits, vegs, legumes, whole grains, nuts, etc). Of note, none of the
patterns reviewed here have clearly distinguished "lean/lower fat proteins" from "high fat
proteins", which are fairly vague terms. Instead, red meats and processed meats are often lumped
together and poultry and fish are recommended to replace red and processed meats in these diets
(e.g., Med, DASH, AHEI etc). Therefore, I think the conclusion statements and implications
should stick to foods and food patterns (except for sodium, PUFA in vegetable oils) instead of
using the terms like "low fat" or "low carbo", which are not evidence-based and have continued
to cause much controversy and confusions in the general public and recommendations.
I'm not exactly sure your question regarding "other prospective cohort literature relating to use of

factor/cluster approaches where ‘empty calorie’ and ‘Western’ patterns are associated with
adverse CVD outcomes and ‘heart healthier’ patterns are beneficial." I thought the NEL has already
done this.
Frank
Hi Frank et al,
69
PSC-HHS-000069
This revision is a wonderful summary. I think it is getting very close but I am hoping with my edits to fine
tune it a bit more. This is intended in the most constructive way and I hope the comments help. I
wondered whether we should consider including one other category of foods (lean/lower fat proteins)
and certain other macro‐ and micronutrients (saturated fat in particular but also possibly total fat,
cholesterol and fiber, potassium, magnesium and calcium) as reflected in the summary of evidence. I
realize that it makes the summary statement more complicated but it is also perhaps more
complete. This will depend, of course, on whether we have consensus opinion on this additional food
group and the other nutrients. I went ahead and also edited the wording on the prospective cohort
literature to reflect the nature of the research (associations not effects). I wasn’t sure if it makes sense
to capture other prospective cohort literature relating to use of factor/cluster approaches where ‘empty
calorie’ and ‘Western’ patterns are associated with adverse CVD outcomes and ‘heart healthier’ patterns
are beneficial.
Barbara
bmillen@bu.edu

Cc: Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu;

jtb4@cornell.edu; steven.clinton@osumc.edu; frank.hu@channing.harvard.edu;
mneuhous@fhcrc.org; rafael.perez-escamilla@yale.edu; Millen, Barbara E; Olson, Richard
(HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher,
Rachel (NIH/NIDDK) [E]; margaret.mcdowell@nih.gov; Wong, Yatping - CNPP; Anne
Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica Figueroa
Dear All,
70
PSC-HHS-000070
attached is a revised draft of the section on dietary patterns and CVD. To address your
comments, the revised version included more detailed information on methods used to derive the
patterns, components of the patterns that may drive the associations, and variations in the
patterns across different studies and populations. Despite the heterogeneity in study designs,
populations, and methodologies, several heart-healthy patterns were identified with strong
evidence from both observational studies RCTs and these patterns share most components. The
implication is that individuals can adopt these patterns according to their personal needs and
preferences.
Frank
Hi SC2 members,
On behalf of Anna Maria, attached are materials for tomorrow's SC2 call at 1pm ET (10am PT). Please let
me know if you will not be able to join the call. (Alice, Steve, Marian, and Rafael – I have you as
“unavailable,” but let me know if that’s incorrect.) Thanks!
AGENDA
71
PSC-HHS-000071
2. Updates
SC1 and SC2 crossover – dietary patterns composition project (attachment) [Cheryl and
Eve]
Sodium [Cheryl]
This electronic message contains information generated by the USDA solely for the intended
recipients. Any unauthorized interception of this message or the use or disclosure of the
72
PSC-HHS-000072
information it contains may violate the law and subject the violator to civil or criminal penalties.
If you believe you have received this message in error, please notify the sender and delete the
email immediately.
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74
PSC-HHS-000074

Sent: Thursday, June 05, 2014 3:48 PM
To: Essery, Eve - CNPP; Frank Hu
Cc: Casavale, Kellie (OS/OASH)
Frank, you can take the lead, I am exhausted with the SFA/chol issue. I agree with the
limitations of the ACC/AHA document. Would this be something one of your post-doc’s
could take on? It would be a major contribution.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Frank Hu; Lichtenstein, Alice
Subject: FW: DGAC SC2: Call THURS @ 1pm ET (10 am PT)
Hi Frank and Alice,
As discussed today, Anna Maria asked the two of you to come up with potential strategies to address (1) saturated fat
and (2) cholesterol that could be brought to the Science Review SC. Anna Maria is not on the next SC2 call on June 19th.
Are the two of you available? Would you like to use that time to really flesh out these topics with the SC? If so, let me
know if there’s anything you’d like the staff to pull together to support your discussion.
Thanks!
Eve

Correct, I am not on the call June 19th. I am fine with them discussing the potential strategies with the others during that
call.
AMSR

75
PSC-HHS-000075
Yes, that’s great, thank you. Do you want the topics to go through the SC before going to SRSC? You are not on the call in
two weeks, correct? Perhaps we could use that time for Frank and Alice to discuss potential strategies…?

I asked Frank and Alice to come up with a couple of strategies that we can then present to SRC. The strategies may
involve more time and effort by staff so I think it is important to first have their input. Is that okay?
aMSR

Glad you were able to get that in! What a packed call!!

I’m not sure I followed the discussion around saturated fat and cholesterol. Did you task Frank and Alice (and Tom?) to
provide options for how to deal with those two topics that would be brought back to the full group? I’m happy to help
facilitate that request. I just wanted to make sure I understood the next steps. THANKS!

Eve, if for by some miracle we end up with free time, I have rewritten the conclusion and implication statements for T2D
and BW to share with the group.
They are attached.
AMSR

Sent: Wednesday, June 04, 2014 4:54 PM
To: Siega-Riz, Anna Maria; 'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu'; 'jtb4@cornell.edu';
'steven.clinton@osumc.edu'; 'frank.hu@channing.harvard.edu'; 'mneuhous@fhcrc.org'; 'rafael.perez-escamilla@yale.edu';
'Millen, Barbara E'
Cc: 'Olson, Richard (HHS/OASH)'; Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; 'Fisher, Rachel
(NIH/NIDDK) [E]'; 'margaret.mcdowell@nih.gov'; Wong, Yatping - CNPP; 'Anne Rodgers'; Casavale, Kellie (OS/OASH);
'Eric E Calloway'; 'PBROWN@hsph.harvard.edu'; Mironick, Adrianna; 'jconnor@fhcrc.org'; 'Bailey, Lauren A.'; Knight,
Brianna; Figueroa, Angelica M
Subject: DGAC SC2: Call THURS @ 1pm ET (10 am PT)
Hi SC2 members,
will not be able to join the call. (Cheryl and Barbara – I have you as “unavailable”.) Thanks!

76
PSC-HHS-000076
AGENDA
1. [10 min] Next round of NEL reviews – Brief introduction and action items (Julie) [attachment 2]
Dietary patterns and neuro-psych illnesses (Topic team: Tom, Steve, Alice)
Dietary patterns during preconception and birth defects (Topic team: Anna Maria, Rafael, Tom)
2. [30 min] Review of draft conclusions
Dietary patterns and cancer (lung, prostate, breast, colorectal) (Topic team: Steve, Marian, Rafael) [attachments 3
and 4]
3. [20 min] Other items
Saturated fat and cholesterol
Conceptual framework [attachment 5]
Microbiom e presentation
Talk soon!
Eve

77
PSC-HHS-000077

To: Frank Hu
Cc: Essery, Eve - CNPP; Casavale, Kellie (OS/OASH)
I am not suggesting you go at it alone, I want to be involved and I think we are on the
same page. I just can’t think to straight about how to approach the topic at the moment
so that the nuances don’t confound the ultimate outcome.
Were we successful in completing this task it would be wonderful. I am happy to

brainstorm with you and anyone else you think should be involved go come up with an
approach.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Alice,
I'd be happy to take a lead on this. Of course I will need your and other committee members' input. I will try to
put together some strategies together in the next day or two.
Frank
On Thu, Jun 5, 2014 at 3:47 PM, Lichtenstein, Alice <Alice.Lichtenstein@tufts.edu> wrote:
Frank, you can take the lead, I am exhausted with the SFA/chol issue. I agree with the
limitations of the ACC/AHA document. Would this be something one of your post-doc’s
could take on? It would be a major contribution.
78
PSC-HHS-000078
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111
phone: 617 556 3127

To: Frank Hu; Lichtenstein, Alice
Subject: FW: DGAC SC2: Call THURS @ 1pm ET (10 am PT)
Hi Frank and Alice,
As discussed today, Anna Maria asked the two of you to come up with potential strategies to address (1) saturated fat
and (2) cholesterol that could be brought to the Science Review SC. Anna Maria is not on the next SC2 call on June 19th.
Are the two of you available? Would you like to use that time to really flesh out these topics with the SC? If so, let me
know if there’s anything you’d like the staff to pull together to support your discussion.
Thanks!
Eve

79
PSC-HHS-000079
Correct, I am not on the call June 19th. I am fine with them discussing the potential strategies with the others during that
call.
AMSR

Yes, that’s great, thank you. Do you want the topics to go through the SC before going to SRSC? You are not on the call in
two weeks, correct? Perhaps we could use that time for Frank and Alice to discuss potential strategies…?

I asked Frank and Alice to come up with a couple of strategies that we can then present to SRC. The strategies may
involve more time and effort by staff so I think it is important to first have their input. Is that okay?
aMSR

Glad you were able to get that in! What a packed call!!
I’m not sure I followed the discussion around saturated fat and cholesterol. Did you task Frank and Alice (and Tom?) to
provide options for how to deal with those two topics that would be brought back to the full group? I’m happy to help
facilitate that request. I just wanted to make sure I understood the next steps. THANKS!
80
PSC-HHS-000080
Eve, if for by some miracle we end up with free time, I have rewritten the conclusion and implication statements for T2D
and BW to share with the group.
They are attached.
AMSR

Sent: Wednesday, June 04, 2014 4:54 PM
To: Siega-Riz, Anna Maria; 'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu'; 'jtb4@cornell.edu';
'Millen, Barbara E'
(NIH/NIDDK) [E]'; 'margaret.mcdowell@nih.gov'; Wong, Yatping - CNPP; 'Anne Rodgers'; Casavale, Kellie (OS/OASH);
'Eric E Calloway'; 'PBROWN@hsph.harvard.edu'; Mironick, Adrianna; 'jconnor@fhcrc.org'; 'Bailey, Lauren A.'; Knight,
Brianna; Figueroa, Angelica M
Subject: DGAC SC2: Call THURS @ 1pm ET (10 am PT)
Hi SC2 members,
will not be able to join the call. (Cheryl and Barbara – I have you as “unavailable”.) Thanks!
AGENDA
1. [10 min] Next round of NEL reviews – Brief introduction and action items (Julie) [attachment 2]
Dietary patterns and neuro-psych illnesses (Topic team: Tom, Steve, Alice)
Dietary patterns during preconception and birth defects (Topic team: Anna Maria, Rafael, Tom)
81
PSC-HHS-000081
2. [30 min] Review of draft conclusions
Dietary patterns and cancer (lung, prostate, breast, colorectal) (Topic team: Steve, Marian, Rafael)
[attachments 3 and 4]
3. [20 min] Other items
Saturated fat and cholesterol
Conceptual framework [attachment 5]
Microbiome presentation
Talk soon!
Eve
82
PSC-HHS-000082
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tel: 617 432 0113 fax: 617 432 2435
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83
PSC-HHS-000083

Sent: Sunday, June 15, 2014 8:59 AM
mneuhous@fhcrc.org; rafael.perez-escamilla@yale.edu; Olson, Richard (HHS/OASH);
Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel
(NIH/NIDDK) [E]; McDowell, Margaret (NIH/NIDDK) [E]; Wong, Yatping - CNPP; Anne
Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica
Figueroa
Hi Frank,

This is excellent. I had but a few comments where clarification might be helpful. I made a comment about the
mode/method of intervention. The ACC/AHA/NHLBI reports also define the interventionists who carried our these
evidence based RCTs. We will have to decide where to put this information on ‘what methods work’ to implement the
dietary pattern strategies. It might bear a separate conclusion/implication or could be incorporated perhaps into the
existing one.

Many thanks.

Barbara

bmillen@bu.edu

Sent: Saturday, June 14, 2014 4:27 PM
Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher,
Rachel (NIH/NIDDK) [E]; margaret.mcdowell@nih.gov; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie
(OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.;
Knight, Brianna; Angelica Figueroa
Dear All,
Attached please find the revised section on dietary patterns and CVD based on comments from the group. The
Conclusion statement and Implications have been revised according to the discussions at our conference call. In
particular, the wordings are more consistent with those from the NEL report, but also taking into account the
conclusions from the AHA/ACC report. In addition, the phrases "Mediterranean-style dietary patterns" "DASH
or DASH-style dietary patterns", and "Vegetarian-style dietary patterns" are now used throughout the text to
reflect the fact that these diets are not a single unique diet. They do share most of healthy components.
I think this section is pretty close to be finalized. Of course, your additional comments/suggestions would be
greatly appreciated.
84
PSC-HHS-000084
I'd also like to have Anne Roger's help in polishing and formatting the text.
Eve, as discussed yesterday at the Science Review Subcommittee call, we will move ahead with an updated
review of the literature on saturated fat intake and CVD outcomes (incidence or mortality). Similar to dietary
patterns and CVD, this would entail a literature search of meta-analysis/systematic reviews on saturated fat
intake and CVD outcomes published in the past 5 years. This updated review will be synthesized with the
AHA/ACC report (on LDL cholesterol) to provide the evidence base for saturated fat recommendations (using
DGAC 2010 as the basis). I know Tom has expressed interest on this topic. I wonder if anyone else would be
interested in this.
Thanks
Frank
Hi SC2 members,
incorrect.) Thanks!
AGENDA
85
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2. Updates
Sodium [Cheryl]
86
PSC-HHS-000086
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87
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Sent: Sunday, June 15, 2014 3:37 PM
To: Perez-Escamilla, Rafael; Frank Hu; Essery, Eve - CNPP
Good thoughts. I also wondered if it would make sense to note that the healthy patterns contained relatively low to
moderate fat intake (with range specified). I realize that this might be somewhat controversial but it is consistent with
our dietary pattern approach and the reported ranges for DASH and the others.

Barbara
bmillen@bu.edu

steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Millen, Barbara E; Olson, Richard
(HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E];
margaret.mcdowell@nih.gov; Wong, Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH); Eric E Calloway;
PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica
Figueroa
Dear Frank and colleagues,
Given that you indicate at conference call that "healthy" dietary patterns include saturated fat
consumption ranging from <7% to > 10% of calories should we be thinking about recommending a
range as a function of dietary pattern vs. trying once again to identify a single cut
point? This approach would be analogous to the evolution of % calories from fat recommendation
and consistent with the strong emphasis of the 2015 DGAC on dietary patterns driven
recommendations.
Best,

Professor of Epidemiology & Public Health
Department of Chronic Disease Epidemiology
135 College Street, Suite 200 (room 216)
88
PSC-HHS-000088
New Haven CT 06510
email: rafael.perez-escamilla@yale.edu
phone: (203) 737-5882
fax: (203) 737-4591
From: Frank Hu [nhbfh@channing.harvard.edu]

steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Perez-Escamilla, Rafael; Millen,
Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel
Angelica Figueroa
Dear All,
interested in this.
Thanks
Frank
89
PSC-HHS-000089
Hi SC2 members,
incorrect.) Thanks!
AGENDA
2. Updates
Sodium [Cheryl]

90
PSC-HHS-000090
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
91
PSC-HHS-000091

To: Tom Brenna; Millen, Barbara E
Cc: Casavale, Kellie (OS/OASH); Frank Hu, MD, PhD MPH; Bowman, Shanthy; Siega-Riz,
Anna Maria; Rihane, Colette - CNPP; Perez-Escamilla, Rafael; Angelica Figueroa;
c1anderson@ucsd.edu; PBROWN@hsph.harvard.edu; Essery, Eve - CNPP; Obbagy, Julie
- CNPP; Frank Hu; Wong, Yatping - CNPP; Knight, Brianna; mneuhous@fhcrc.org; Eric E
Calloway; steven.clinton@osumc.edu; jconnor@fhcrc.org; Mironick, Adrianna; Anne
Rodgers; Olson, Richard (HHS/OASH); Bailey, Lauren A.; McDowell, Margaret
(NIH/NIDDK) [E]; Fisher, Rachel (NIH/NIDDK) [E]
If you can get a copy of this week’s Time magazine it would be worth it. The cover
story is saturated fat.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
Cc: Casavale, Kellie (OS/OASH); Frank Hu, MD, PhD MPH; Bowman, Shanthy; Siega-Riz, Anna Maria; Rihane, Colette -
CNPP; Perez-Escamilla, Rafael; Angelica Figueroa; c1anderson@ucsd.edu; PBROWN@hsph.harvard.edu; Lichtenstein,
Alice; Essery, Eve - CNPP; Obbagy, Julie - CNPP; Frank Hu; Wong, Yatping - CNPP; Knight, Brianna;
mneuhous@fhcrc.org; Eric E Calloway; steven.clinton@osumc.edu; jconnor@fhcrc.org; Mironick, Adrianna; Anne
Rodgers; Olson, Richard (HHS/OASH); Bailey, Lauren A.; margaret.mcdowell@nih.gov; Fisher, Rachel (NIH/NIDDK) [E]
Just a quick note to confirm Frank's comment that I'm interested in the saturated fat story. I'm a little behind the
eight ball since I've not been in on all these conversations, and I received three NEL reviews in the last two
weeks that I'm plowing through, but I'll hope to find time.
Tom
On Jun 15, 2014 3:38 PM, "Millen, Barbara E" <bmillen@bu.edu> wrote:
92
PSC-HHS-000092
Good thoughts. I also wondered if it would make sense to note that the healthy patterns contained relatively low to
moderate fat intake (with range specified). I realize that this might be somewhat controversial but it is consistent with
our dietary pattern approach and the reported ranges for DASH and the others.
Barbara
bmillen@bu.edu

Figueroa
Dear Frank and colleagues,
Given that you indicate at conference call that "healthy" dietary patterns include saturated fat
consumption ranging from <7% to > 10% of calories should we be thinking about recommending a
range as a function of dietary pattern vs. trying once again to identify a single cut
point? This approach would be analogous to the evolution of % calories from fat recommendation
and consistent with the strong emphasis of the 2015 DGAC on dietary patterns driven
recommendations.
Best,

New Haven CT 06510
93
PSC-HHS-000093
phone: (203) 737-5882
fax: (203) 737-4591

steven.clinton@osumc.edu; frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Perez-Escamilla, Rafael; Millen,
Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel
Angelica Figueroa
Dear All,
interested in this.
Thanks
Frank
94
PSC-HHS-000094
Hi SC2 members,
incorrect.) Thanks!
AGENDA
2. Updates
95
PSC-HHS-000095
Sodium [Cheryl]
96
PSC-HHS-000096
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
97
PSC-HHS-000097

Sent: Monday, June 16, 2014 8:07 AM
Cc: Siega-Riz, Anna Maria; c1anderson@ucsd.edu; jtb4@cornell.edu;
rafael.perez-escamilla@yale.edu; Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane,
Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK)
[E]; McDowell, Margaret (NIH/NIDDK) [E]; Wong, Yatping - CNPP; Anne Rodgers;
Casavale, Kellie (OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu; Mironick,
Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Angelica Figueroa
Attachments: 5 Usual intake distributions for cholesterol NHANES 2007-10 SFA AHL.docx
Thanks Frank. Looks good to me. Made some comments.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Cc: Siega-Riz, Anna Maria; Lichtenstein, Alice; c1anderson@ucsd.edu; jtb4@cornell.edu; steven.clinton@osumc.edu;
frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; rafael.perez-escamilla@yale.edu; Millen, Barbara E; Olson,
Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E];
Figueroa
Dear All,
98
PSC-HHS-000098
interested in this.
Thanks
Frank
Hi SC2 members,
incorrect.) Thanks!
AGENDA
99
PSC-HHS-000099
2. Updates
Sodium [Cheryl]
100
PSC-HHS-000100
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
101
PSC-HHS-000101

Sent: Friday, June 20, 2014 7:36 AM
To: Essery, Eve - CNPP; 'Frank Hu'; 'Millen, Barbara E'; jtb4@cornell.edu
Subject: RE: DGAC SC2: Saturated fat (response requested)
Attachments: image001.emz
I would suggest tweaking one component of the framework.

Intervention/Exposure
Saturated fat intake
Comparator
Replacement macronutrient (PUFA, MUFA, carb [specifying type],
protein)
Regarding the question, “What is the relationship between saturated fat intake and risk
of cardiovascular disease?” I think the questions needs to be modified with a series of
questions;
What is the relationship between saturated fat intake when replaced by PUFA and risk
of cardiovascular disease?
What is the relationship between saturated fat intake when replaced by MUFA and risk
What is the relationship between saturated fat intake when replaced by carbohydrate
(capturing type) and risk of cardiovascular disease?
What is the relationship between saturated fat intake when replaced by protein and risk
of cardiovascular disease? (unlikely to find much if anything here)
If we take this approach then the accompanying document would need to be modified
to put as much emphasis on the change in dietary SFA as the change in the other
dietary component(s).
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

102
PSC-HHS-000102
phone: 617 556 3127

To: 'Frank Hu'; Lichtenstein, Alice; 'Millen, Barbara E'; jtb4@cornell.edu
Subject: DGAC SC2: Saturated fat (response requested)

Hi Frank, Alice, Barbara, and Tom,
Please review the attached documents related to saturated fat and CVD, and let us know if they accurately reflect your
proposed question and approach for answering the question. If possible, please provide your comments and edits by
Wednesday, June 25th. Once we hear from you, we will work on the “next steps” as described in the attached.
Thank you,
Eve

103
PSC-HHS-000103

To: Frank Hu; Tom Brenna
Cc: Essery, Eve - CNPP; Millen, Barbara E; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP
Subject: RE: DGAC SC2: Saturated fat (response requested)
Given there is so much attention these days on the Mediterranean diet pattern/MUFA,
perhaps when the data are available we distinguish between MUFA coming from meat
fat vs canola oil (source). I think canola oil is the second most prevalent vegetable oil
in the US diet, after soybean oil (albeit not a close second).
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Tom Brenna
Cc: Lichtenstein, Alice; Essery, Eve - CNPP; Millen, Barbara E; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP
Subject: Re: DGAC SC2: Saturated fat (response requested)
It is a good idea to spell out the "comparators", especially in prospective cohort studies. Since 85% of PUFA
are linoleic acid, the results for the comparison of PUFA vs. saturated or LA vs. saturated are typically
similar. As far as I know, no study has specifically compared ALA or EPA/DHA with saturated fat. However,
studies have compared high saturated fat food sources such as red and processed meats with foods high in
omega-3 fatty acids, such as marine fish.
Since most MUFA in Western diets share the same food sources as saturated fat (meats and dairy), the
comparison with saturated fat will be difficult to interpret.
Frank
On Fri, Jun 20, 2014 at 8:05 AM, Tom Brenna <jtb4@cornell.edu> wrote:
Alice and all,
Thanks - this is right about where we were in one of the working groups last summer after considerable
discussion and with which I agreed.
104
PSC-HHS-000104
I would add (as I think I did last summer) that PUFA should not be added together. I would have specific
questions for linoleic acid, alpha-linolenic acid, and long chain omega-3. I'm not sure if this is workable with
our resources or the presentations of the papers; someone decide, I'm on board either way and can comment as
appropriate later, and let's get on with it.
Tom
On Fri, Jun 20, 2014 at 7:36 AM, Lichtenstein, Alice <Alice.Lichtenstein@tufts.edu> wrote:
I would suggest tweaking one component of the framework.
Regarding the question, “What is the relationship between saturated fat intake and risk
of cardiovascular disease?” I think the questions needs to be modified with a series of
questions;
What is the relationship between saturated fat intake when replaced by PUFA and risk
What is the relationship between saturated fat intake when replaced by MUFA and risk
105
PSC-HHS-000105
What is the relationship between saturated fat intake when replaced by carbohydrate
(capturing type) and risk of cardiovascular disease?
What is the relationship between saturated fat intake when replaced by protein and risk
of cardiovascular disease? (unlikely to find much if anything here)
If we take this approach then the accompanying document would need to be modified
to put as much emphasis on the change in dietary SFA as the change in the other
dietary component(s).
-------------------------------------------------------------------------------
Tufts University
Boston, MA 02111
phone: 617 556 3127
e-mail: Alice.Lichtenstein@Tufts.edu

To: 'Frank Hu'; Lichtenstein, Alice; 'Millen, Barbara E'; jtb4@cornell.edu
Subject: DGAC SC2: Saturated fat (response requested)
106
PSC-HHS-000106
Hi Frank, Alice, Barbara, and Tom,
Please review the attached documents related to saturated fat and CVD, and let us know if they accurately reflect your
proposed question and approach for answering the question. If possible, please provide your comments and edits by
Wednesday, June 25th. Once we hear from you, we will work on the “next steps” as described in the attached.
Thank you,
Eve
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
107
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******************************************************
108
PSC-HHS-000108

Sent: Wednesday, July 02, 2014 4:17 PM
To: Rahavi, Elizabeth - CNPP; Mary Story, Ph.D.
Subject: RE: SC 4 Follow Up - Policy Related Questions
Attachments: DRAFT SC4 - ECE Weight - Key Trends Document 07 01 14 + MS AHL.docx
Sorry, I seem to have lost track of the e-mail to which the attached document
arrived. Have some comments. More in line with serving as devil’s advocate.
Mary, I defer to you on all of my suggested changes and comments. You have been in
the weeds on this.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Rahavi, Elizabeth - CNPP [mailto:Elizabeth.Rahavi@cnpp.usda.gov]

Sent: Wednesday, July 02, 2014 1:39 PM
To: Lichtenstein, Alice; Barbara Millen; Lucile Adams-Campbell; Mary Story; Nelson, Miriam; Wayne Campbell; Amber
Mosher; Anne Rodgers; Blum, Donna - CNPP; Bowman, Shanthy; Joan Lyon; Kellie Casavale; Nancy Terry; Psota, Tricia -
FNS (Contractor); Rihane, Colette - CNPP; Stephanie Goodwin
Subject: SC 4 Follow Up - Policy Related Questions

Hi All,

This email is to follow up on the SC conversation this morning related to questions that would look at the impact of
Federal nutrition assistance programs. The following points were identified during that call as areas for further
consideration:
Need to develop specific questions to determine if any issues exist related to the scope of the DGAC’s work and
general applicability to the Dietary Guidelines for Americans.
Need to consider how these new questions might be prioritized against remaining topic areas, mainly food
marketing and other food access questions.
Need to ensure that a systematic approach is utilized to identify the literature base and review the evidence
(i.e., NEL systematic review, systematic reviews, or existing reports).

The SC decided that to work through some of these points via a smaller working group (MS, BM, AHL), although all SC
members are welcome to attend this meeting. Here are some potential meeting times:

109
PSC-HHS-000109
Monday, July 7th 10:00‐12:00
Tuesday, July 8th 9:30‐2:00

If you are interested in attending this call, please provide your availability to Liz Rahavi ASAP, and we’ll get a meeting
scheduled. In the meantime, here are some resources that have been provided to Federal staff related to this topic area:
“Effects of Food Assistance and Nutrition Programs on Nutrition and Health” (multiple volumes) developed by
ERS: http://www.ers.usda.gov/publications/fanrr‐food‐assistance‐nutrition‐research‐program/fanrr19‐1.aspx
FNS‐sponsored WIC literature review: “Effects of the Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC): A Review of Recent Research.” http://www.fns.usda.gov/effects‐special‐
supplemental‐nutrition‐program‐women‐infants‐and‐children‐wic‐review‐recent‐research. This is an update of
the systematic review that was conducted by ERS in 2004 (link provided above).
There is another report from FNS “Nutrient and MyPyramid Analysis of USDA Foods in Five of its Food and
Nutrition Programs.” This report provides HEI‐2005 scores for USDA Foods provided to FDPIR, TEFAP, CSFP, NSLP
and CACFP. http://www.fns.usda.gov/nutrient‐and‐mypyramid‐analysis‐usda‐foods‐five‐its‐food‐and‐nutrition‐
programs‐0.

SC staff will also reach out to colleagues at FNS to see if other resources can be identified. If you are aware of other
reports related to this topic, please feel free to share them with the group.

Thanks,

Liz

Elizabeth Rahavi, RD
Nutritionist
Center for Nutrition Policy and Promotion
US Department of Agriculture
3101 Park Center Drive, Rm 1034
Alexandria, VA 22302
(703) 305‐2441

110
PSC-HHS-000110

Sent: Monday, July 07, 2014 7:20 AM
To: Tom Brenna; Siega-Riz, Anna Maria
Cc: Perez-Escamilla, Rafael; Essery, Eve - CNPP; alice.lichtenstein@tufts.edu;
Bailey, Lauren A.; Knight, Brianna; Figueroa, Angelica M; Joan Lyon
Attachments: DP and Birth Defects - Evidence Portfolio 7 3 14 (1) RPE_amsr jtb bem 7 7 2014.docx
Here are a few additional thoughts relating primarily to wording given the nature of the study designs. Barbara

bmillen@bu.edu

Sent: Sunday, July 06, 2014 8:58 PM
Cc: Perez-Escamilla, Rafael; Essery, Eve - CNPP; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu;
PBROWN@hsph.harvard.edu; Mironick, Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Figueroa,
Angelica M; Joan Lyon
I added a couple of points and comments.
Tom
On Sat, Jul 5, 2014 at 11:33 AM, Siega-Riz, Anna Maria <am_siegariz@unc.edu> wrote:
Here are my edits. Thank you Rafael for taking the lead.
AMSR

Sent: Friday, July 04, 2014 11:30 AM
To: Siega-Riz, Anna Maria; Tom Brenna
Cc: Essery, Eve - CNPP; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu; steven.clinton@osumc.edu;
frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette -
CNPP; Bowman, Shanthy; Obbagy, Julie - CNPP; Fisher, Rachel (NIH/NIDDK) [E]; margaret.mcdowell@nih.gov; Wong,
Yatping - CNPP; Anne Rodgers; Casavale, Kellie (OS/OASH); Eric E Calloway; PBROWN@hsph.harvard.edu; Mironick,
111
PSC-HHS-000111
Adrianna; jconnor@fhcrc.org; Bailey, Lauren A.; Knight, Brianna; Figueroa, Angelica M; Joan Lyon
Please see attached. I took the liberty to draft an initial set of graded conclusions.
I'll be offline until Monday but I'm looking forward to our next round of discussions on these
questions.
Best,

New Haven CT 06510
phone: (203) 737-5882
fax: (203) 737-4591
From: Siega-Riz, Anna Maria [am siegariz@unc.edu]

To: Tom Brenna
frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Perez-Escamilla, Rafael; Millen, Barbara E; Olson, Richard
Tom
We have noted the difference and once Rafael has had time to review the studies we will discuss.
Thanks
112
PSC-HHS-000112
AMSR
Sent from my iPhone
On Jul 4, 2014, at 6:29 AM, "Tom Brenna" <jtb4@cornell.edu> wrote:
Dear all,
Slide comment:
Since the last meeting much time was spent on the first set of reviews. Because the reviews on
DP connected to Neuro and to Depression were in the second wave of reviews, little time has
been available to discuss conclusions. In our upcoming meeting, I (Tom) can describe the
studies identified in general terms as a sort of promise for more in the next meeting, which would
leave time for the main material on cancer, etc.
The DP and birth defects appears to be nearly done. Prior, I would like to discuss this with
others focused on this topic because it seems my take away may be a bit different. Folate/one-
carbon nutrients were the focus of all five studies and emerged as pivotal in at least one study. I
think this should be mentioned.
Overall comment. Differences in methodology are mentioned as making studies difficult to

compare. In some ways yes, but diet is the independent variable assessed in whatever way, so
when no conclusion emerges I would see that as an effect smaller than the method can
detect. Planes, trains, or automobiles,the destination is the same.
I could speak with the DP-birth defects group most any day next week.
Tom
On Wed, Jul 2, 2014 at 5:54 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi SC2 members,
On behalf of Anna Maria, attached are materials for tomorrow's SC2 call at 1pm ET (10am PT). Talk
soon!
113
PSC-HHS-000113
AGENDA
1. [45 min] Review draft slides for public meeting (attached)
1 hr 45 min for presentation on Thursday, July 17 (first SC report)
Identify areas to be completed
2. [15 min] Updates
Saturated fat (Topic team: FH, AMSR, AHL, BM)
o Librarian conducting search for existing systematic reviews/meta-analyses on saturated fat

and CVD outcomes published from 2009 to present
o Focus on (1) quantitative recommendation and (2) macronutrient replacement
Added sugars (Topic team: MS/MNel, FH, AHL, BM, WC)
o Staff pulling together background information related to added sugars in the 2010 DGAC
report, 2010 DGA, food pattern modeling reports, and recent WHO proposed guidelines
Other topic updates
SC2 In-Person Meeting: Wednesday, July 16 from 1:00 to 3:30 pm ET
114
PSC-HHS-000114
email immediately.
115
PSC-HHS-000115

Sent: Monday, July 07, 2014 7:26 AM
To: Tom Brenna; Siega-Riz, Anna Maria
Cc: Perez-Escamilla, Rafael; Essery, Eve - CNPP; c1anderson@ucsd.edu;
Millen, Barbara E; Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman,
Bailey, Lauren A.; Knight, Brianna; Figueroa, Angelica M; Joan Lyon
Attachments: DP and Birth Defects - Evidence Portfolio 7 3 14 (1) RPE_amsr jtb AHL.docx
Looks very good. I made a few suggested changes.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
Sent: Sunday, July 06, 2014 8:58 PM
Cc: Perez-Escamilla, Rafael; Essery, Eve - CNPP; Lichtenstein, Alice; c1anderson@ucsd.edu; steven.clinton@osumc.edu;
I added a couple of points and comments.
Tom
On Sat, Jul 5, 2014 at 11:33 AM, Siega-Riz, Anna Maria <am_siegariz@unc.edu> wrote:
Here are my edits. Thank you Rafael for taking the lead.
AMSR
116
PSC-HHS-000116


To: Siega-Riz, Anna Maria; Tom Brenna
Please see attached. I took the liberty to draft an initial set of graded conclusions.
I'll be offline until Monday but I'm looking forward to our next round of discussions on these
questions.
Best,

New Haven CT 06510
phone: (203) 737-5882
fax: (203) 737-4591
From: Siega-Riz, Anna Maria [am siegariz@unc.edu]

To: Tom Brenna
frank.hu@channing.harvard.edu; mneuhous@fhcrc.org; Perez-Escamilla, Rafael; Millen, Barbara E; Olson, Richard
117
PSC-HHS-000117
Tom
We have noted the difference and once Rafael has had time to review the studies we will discuss.
Thanks
AMSR
Sent from my iPhone
On Jul 4, 2014, at 6:29 AM, "Tom Brenna" <jtb4@cornell.edu> wrote:
Dear all,
Slide comment:
Since the last meeting much time was spent on the first set of reviews. Because the reviews on
DP connected to Neuro and to Depression were in the second wave of reviews, little time has
been available to discuss conclusions. In our upcoming meeting, I (Tom) can describe the
studies identified in general terms as a sort of promise for more in the next meeting, which would
leave time for the main material on cancer, etc.
The DP and birth defects appears to be nearly done. Prior, I would like to discuss this with
others focused on this topic because it seems my take away may be a bit different. Folate/one-
carbon nutrients were the focus of all five studies and emerged as pivotal in at least one study. I
think this should be mentioned.
Overall comment. Differences in methodology are mentioned as making studies difficult to

compare. In some ways yes, but diet is the independent variable assessed in whatever way, so
when no conclusion emerges I would see that as an effect smaller than the method can
detect. Planes, trains, or automobiles,the destination is the same.
I could speak with the DP-birth defects group most any day next week.
Tom
118
PSC-HHS-000118
On Wed, Jul 2, 2014 at 5:54 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi SC2 members,
On behalf of Anna Maria, attached are materials for tomorrow's SC2 call at 1pm ET (10am PT). Talk
soon!
AGENDA
1. [45 min] Review draft slides for public meeting (attached)
1 hr 45 min for presentation on Thursday, July 17 (first SC report)
Identify areas to be completed
2. [15 min] Updates
Saturated fat (Topic team: FH, AMSR, AHL, BM)
o Librarian conducting search for existing systematic reviews/meta-analyses on saturated fat

and CVD outcomes published from 2009 to present
o Focus on (1) quantitative recommendation and (2) macronutrient replacement
Added sugars (Topic team: MS/MNel, FH, AHL, BM, WC)
o Staff pulling together background information related to added sugars in the 2010 DGAC
report, 2010 DGA, food pattern modeling reports, and recent WHO proposed guidelines
Other topic updates
SC2 In-Person Meeting: Wednesday, July 16 from 1:00 to 3:30 pm ET
119
PSC-HHS-000119
email immediately.
120
PSC-HHS-000120

Sent: Wednesday, July 16, 2014 9:27 AM
Subject: RE: Updated Slide Decks: Intro to SC Reports and CM/Next Steps
Attachments: Intro to SCs Millen DRAFT 7.15.14 for BEM editing 7 16 2015.pptx
Hi Kelly,

Late night last night. Didn’t make it in until nearly 2a.m. I looked at the Intro slides and I think the attached document is
good to go. Many thanks to you and the rest of our colleagues/staff who reviewed them and provided input.

I will take a bit of time later to get the conceptual model slides finalized.

See you in a bit.

Barbara

bmillen@bu.edu

Sent: Tuesday, July 15, 2014 2:22 PM
Subject: Updated Slide Decks: Intro to SC Reports and CM/Next Steps
Importance: High

Barbara,

A few staff had a couple of good comments. The actual edits to the presentations are minor though, and can be seen in
red text on the slide and bold text in the commentary (as noted below) for the two files attach titled “SHOWS EDITS.”
The last two files are the versions that do not highlight the changes, titled “for BEM editing.” Work from these.
I need your Intro slides no later than tomorrow night at 7:30 pm so that I can get them to the printer for
Thursday.
Your Conceptual Model/Next Steps slides are needed no later than Thursday at 7:30 pm.)

Presentation: Introduction to SC Reports

Slide 3 (In file “SHOWS EDITS” see red text on slide and bold text in the commentary section)
1. Added “Meeting nutrient recommendations” under the dietary patterns bullet. The DGAC is looking at dietary
patterns and (1) health outcomes and (2) sustainability, but the food pattern modeling is also important and
gets at how dietary patterns help us meet nutrient recommendations. Now reads

Focus on dietary patterns related to:
Meeting nutrient recommendations
Health outcomes
Sustainability

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2. Reworded the sentence below to be consistent with the language used on slide 8. This addresses the sensitivity
we have heard that some people view “behavior change” as “governmental control” (as silly as that sounds to
us).
From: "We are also identifying “what works” to change the diet and physical activity behaviors of individuals
and populations to better inform our healthcare and public health systems and reach individuals and
populations of all ages. "
To: “We are also identifying “what works” to help individuals and populations in the US make better eating and
physical activity choices to better inform our healthcare and public health systems and reach individuals and
populations of all ages. “

3. Changed “determine” to “influence” in the sentence below. It was thought this was “softer.”
"The Committee is also taking a “systems approach” to consider the multiple spheres and systems of influence
on dietary patterns, physical activity and health and the factors that determine what, where, and how much we
eat and exercise."

Slides 13 and 14
Slides adjusted to be a tad more general and less NEL‐focused because all of the questions will actually have
conclusion statements, grades, etc… not just the NEL questions.

1. On slide 13‐ Deleted “NEL” to read “Materials presented today may include” (rather than “NEL material…”)
2. On slide 14‐ Deleted “systematic review” so this applies to all the approaches:
Conclusion statements: Brief overall summary statement worded as an answer to the systematic review
question; tightly associated with the evidence

3. The grading criteria have now been tweaked so that they would also apply to non‐NEL questions. The table on
slide 14 was replaced with this one below. And slide 14 was split to two slides (14 and 15) because this table is a
tad larger.

The conclusion statement is substantiated by a large, high quality, and/or consistent body of evidence
Strong that directly addresses the question. There is a high level of certainty that the conclusion is generalizable
to the population of interest, and it is unlikely to change if new evidence emerges.
The conclusion statement is substantiated by sufficient evidence, but the level of certainty is restricted
by limitations in the evidence, such as the amount of evidence available, inconsistencies in findings, or
Moderate
methodological or generalizability concerns. If new evidence emerges, there could be modifications to
the conclusion statement.
The conclusion statement is substantiated by insufficient evidence, and the level of certainty is seriously
restricted by limitations in the evidence, such as the amount of evidence available, inconsistencies in
Limited
findings, or methodological or generalizabilty concerns. If new evidence emerges, there could likely be
modifications to the conclusion statement.
Grade not A conclusion statement cannot be drawn due to a lack of evidence, or the availability of evidence that
assignable has serious methodological concerns.

Presentation: Conceptual Model and Next Steps (Note: You would want to make changes to the slides to
the actual outline as well on its next iteration.)
General‐ Would you like to group the factors on the slides so that those addressed by the DGAC appear together
followed by those not addressed by the DGAC? This would take some reworking of the commentary as well, but could
be done if you felt it was less awkward to review that way.

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Slide 13‐ “Dietary product and nutrient supplements” is italicized as an outcome, indicating that the DGAC is doing
evidence reviews on the topic. (In the notes, it says, “Dietary product and nutrient supplement use, including
nutraceuticals.”)
Staff don’t think the DGAC has any questions supplements/nutraceuticals as an outcome. (And this
might open a can of worms as worded.) Did you mean that the recommendations of the DGAC might
include those related to recommending supplements for certain groups (like iron or folic acid
supplements women)?
Staff also questioned what a “dietary product” includes. That may need some clarification.
EDIT: In the current draft, the italics were removed (see red text on slide)

Slide 16‐
1. “Urinary sodium” was highlighted as a clinical indicator the DGAC is considering, but staff did not think this was
the case. EDIT: Took off blue and italics
2. “Peri‐ and post‐menopause” weren’t clear since they are usually population groups. I believe you meant
“related outcomes.” Also, the first “pregnancy” should also have been “fertility” to match the edit from Anna
Maria. EDIT: “Fertility‐, peri‐ and post‐menopause‐, pregnancy‐related outcomes”
3. Added cancer outcomes in parentheses “(breast, colorectal, prostate, lung)” to the “Diet‐related cancers” bullet
so it matches the others that have specific outcomes in parens.
4. Added “depression” to the parens after Neuro‐psych conditions

Let me know if you have any questions, issues with these edits, or anything else you would like me to work on with
them. I am available tomorrow before 10 am, but in transit and then at the meeting with you after that. I will also
send you and Alice the agendas for the breakout sessions as soon as I have them so you can plan your attendance.

Thanks,

Kellie

1101 Wootton Pkwy, LL117
Rockville, MD 20852
(240) 453‐8252
www.DietaryGuidelines.gov

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Sent: Wednesday, August 13, 2014 8:16 AM
To: Nelson, Miriam; Campbell, Wayne W; 'campbellw@purdue.edu'
(campbellw@purdue.edu)
Cc: Mosher, Amber (OS/OASH); Liz Rahavi (Elizabeth.rahavi@cnpp.usda.gov);
(b) (6) Psota, Tricia - FNS (Contractor); Casavale, Kellie (OS/OASH)
Subject: RE: PAWG Chapter - next steps?
Happy to discuss the issue. My concern is the following; if we are reiterating the 2008
PA guidelines so be it and clearly state as such. Reproduce verbatim to avoid
confusion. From what I remember, because PA guidelines is a standalone document
and was slated for updating in the future that is what we decided. As written, I don’t
think our approach is clear.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Nelson, Miriam

Sent: Wednesday, August 13, 2014 8:04 AM
To: Lichtenstein, Alice; Campbell, Wayne W; 'campbellw@purdue.edu' (campbellw@purdue.edu)
Cc: Mosher, Amber (OS/OASH); Liz Rahavi (Elizabeth.rahavi@cnpp.usda.gov); (b) (6) Psota, Tricia -
FNS (Contractor)
Subject: PAWG Chapter - next steps?

Hi Alice and Wayne,

Thank you for your thorough review of the draft physical activity chapter content. You address several areas that when
refined will significantly improve the overall chapter, particularly the use of more consistent and standardized language.
That said, I am concerned with the volume of comments related to the physical activity questions and conclusion
statements, which have been reviewed a number of times, revised as requested, and presented at the recent public
meeting.

As you recall, the group agreed to address this topic area using evidence available in the Physical Activity Guidelines for
Americans reports, which was extracted and incorporated into conclusion statements virtually verbatim, without
significant changes to the language or descriptions of evidence. While I generally agree with the rationale presented in
your feedback, I am worried the group is losing sight of the settled approach to the physical activity topic by proposing
changes that would inevitably change the course we’ve taken thus far. I am concerned that if we start editing the
language from the 2008 and Midcourse reports, we will start to unravel and it will become impossible to contain. It is
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also important to remember that the 2018 PA guidelines are moving forward. Most critical in this report is that we
stress the importance of combining PA and good nutrition ‐ that they work together; that Americans are not even close
to meeting the 2008 PA guidelines and that we need to take action.

I would like to schedule a call to discuss the group’s next steps. My hope is that we can continue as planned and begin
the chapter writing as soon as possible, including finalizing the overall implications statement as well as drafting the
introduction and methodology sections. However, we must resolve any reservations regarding our approach to
addressing this topic before moving forward. Amber will send a doodle poll to the group to identify a date/time for this
call. Please feel free to contact me with any questions and concerns, and many thanks for your time and thoughtfulness.

Best, Mim


Chair, Affiliated Faculty, Tisch College of Citizenship and Public Service
Lincoln Filene Hall
10 Upper Campus Road
Tufts University
phone: 617-627-4178
www.StrongWomen.org
125
PSC-HHS-000125

Sent: Thursday, August 21, 2014 9:14 AM
Subject: RE: Dietary Guidelines Panel to Mull New Sodium Research
One good thing, it did not come up on the Tufts PR daily search, which means it did
not get wide attention. I will certainly not alert them about it.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Cc: Mosher, Amber (OS/OASH)
Subject: FW: Dietary Guidelines Panel to Mull New Sodium Research
Alice,

It was good to chat. The article is below. To follow‐up on your request, Amber will touch base with you with some
guidance on how to approach a correction if you decide to pursue that. I think this provides a great example of how an
interview with the best intentions and careful disclaimers can result in something unintended and unexpected. We know
you well, and know you did not speak on behalf of the DGAC even though the reported made it seem that way.

Have a great day!

Kellie

126
PSC-HHS-000126
MORNING
TAKE Dietary Guidelines Panel to Mull New Sodium
6 a.m.
Research
By Philip Brasher, CQ Roll Call
Aug. 18, 2014
» Blog Home In today’s Morning Take:
Panel’s Vice Chairwoman Says Salt Research Merits Study

Farm Bill Subsidies in Line with CBO Estimate, for Now
Score One for Rice Growers
Note to Readers: Due to the August recess, CQ on Agriculture & Food will publish a Morning Take
every Monday until Sept. 8, when our regular publishing schedule will resume.
That new study on sodium is likely to get a long look next month from the Dietary Guidelines
Advisory Committee. The study, which tracked 100,000 people across 17 countries, has focused new
attention on the scientific debate about what’s a safe level of sodium intake and how far Americans
should try to lower theirs.
Alice Lichtenstein, a nutritionist at Tufts University and vice chairwoman of the advisory committee,
tells CQ Roll Call’s Georgina Gustin that the study is critically important given its scope, but that
other factors, such as disease or lifestyle, might affect the study’s findings. She said that the advisory
panel will look at the latest science on the issue but isn’t planning to recommend changes to the
current guidance on sodium.
127
PSC-HHS-000127
Study may not change government sodium advice. (Philip Brasher)
The 2010 guidelines generally recommend a limit of 2,300 milligrams a day, but say that individuals
with hypertension, blacks, and middle-aged and older adults should aim for no more than 1,500
milligrams. The new study, published in the New England Journal of Medicine, found that people
who consume less than the 2,300 milligrams have a higher risk of heart attack or stroke. The average
American consumes 3,400 milligrams a day. The study was the largest of its kind taking a look at the
impact of lower sodium consumption.
“It’s a huge study, because they took all the data from all these disparate places, and in the most
conservative way, combined it,” Lichtenstein said. “But we know there are a huge number of factors
that bear on cardiovascular health. We’ll never be able to disentangle those from a l festyle
perspective.”
Lichtenstein added, “Taking this out of context is probably not something on which we should
develop policy.”
Farm Bill Numbers on Target, for Now. So far, the bean counters at the Congressional Budget
Office are looking like geniuses when it comes to estimating the cost of the new farm bill, at least as
far as the main new subsidy programs go. Scoring farm bills is notoriously hard, given it means
estimating commodity prices years in advance and getting into the minds of farmers to forecast what
decisions to make.
Economists Carl Zulauf of The Ohio State University and Gary Schnitkey at the University of Illinois
have run numbers based on the price forecast the Department of Agriculture released last week and
found that payments under the new Agricultural Risk Coverage and Price Loss Coverage programs
could actually fall a little below the CBO estimate.
128
PSC-HHS-000128
CBO projected that the programs would pay out $3.8 billion on this year’s crops, $2.1 billion for ARC
and $1.7 billion for PLC. Based on the midpoint of the price forecasts issued by USDA last week, the
programs would pay farmers $3.5 billion to $2.9 billion for ARC and $600 million for PLC.
Most of the ARC payments would go to corn growers, while the PLC subsidies would be dominated by
producers of long grain rice, the variety grown in Arkansas and other Southern states. (The
economists’ numbers are based on prices being at the midpoint of the ranges estimated by USDA.) “If
all of my forecasts were that good, I would be happy,” Zulauf says of the CBO score. “But as we talk
the forecast is subject to incredible change.”
Possible 2014 payments per acre under new farm bill programs. (Source: University of
Illinois)
Forecast Vindicates Rice Growers. According to Zulauf and Schnitkey, Southern rice growers
could receive about $90 an acre in PLC payments, which is roughly what they were receiving annually
in the direct annual payments that were abolished by the farm bill (PL 113-79). The forecast would
appear to be a vindication for the rice lobby, which fought hard not only to enact PLC but to make
sure that the price guarantee, or reference price, was so close to the market price that it was likely to
trigger payments.
A key to the rice growers’ win was Mississippi Sen. Thad Cochran’s successful move to oust Pat
Roberts of Kansas as ranking Republican on the Agriculture Committee.
Considerable Uncertainty Yet on Prices, Payments. The economists based their estimates off
the midpoint of the price range USDA projects for each commodity. The actual cost of the two
programs for this year’s crop could range from negligible to as much as $9 billion, depending on
where prices actually fall within those ranges. USDA, for example, estimates that the average price
129
PSC-HHS-000129
paid to farmers for corn could be anywhere from $3.55 to $4.25 a bushel. At the low end of the price
ranges, the ARC payment could reach $79 an acre, and the PLC payment for long rice could hit $120
an acre, the economists say.
At CQ on Ag and Food:
Lawmakers Push OMB on Menu Labeling
CQ on Agriculture & Food is a paid-subscription newsletter and website published by CQ Roll Call. Routine or systematic forwarding or
photocopying of this publication or portions thereof is a violation of federal copyright laws. To ensure compliance or to inquire about a
site license, contact CQ Roll Call Sales at 800-432-2250 x 6599 or sales@cqrollcall.com. If you are having technica issues accessing
this publication, contact CQ Roll Call Customer Service at 800-432-2250 x 6621 or customerservice@cqrollcall.com. Request a free trial.
An Economist Group Business. Copyright 2014 © CQ Roll Call. All rights reserved.
You are subscribed as scott.carter@fns.usda.gov

To stop or change your subscription, please visit My Subscriptions.
Issue-Id: 33011794:execbriefagriculturefood:1297
130
PSC-HHS-000130

To: Mosher, Amber (OS/OASH); Casavale, Kellie (OS/OASH)
Thanks for your help. Modified slightly, decided to get it scanned, your advice, rather
than sending a pdf directly. Will copy you when it goes out.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Mosher, Amber (OS/OASH) [mailto:Amber.Mosher@hhs.gov]

To: Casavale, Kellie (OS/OASH); Lichtenstein, Alice
Importance: High
Alice,

After reviewing the article closely, I believe it is appropriate for you to send the editor a letter of correction. I’ve drafted
a potential letter for your review and use – please see attached. Notice that I highlighted a placeholder for the date you
provided comments to CQ Roll Call’s reporter. If you decide to move forward with the letter, I would suggest printing
and signing a copy and emailing a scanned PDF of the original to the editorial staff. I could not locate individual email
addresses on their website, but assume you can reach Mr. Brasher directly at phillipbrasher@cqrollcall.com. Finally,
note that because CQ on Agriculture & Food is a paid‐subscription service, (b) (5)
(b) (5)

Please let me know if you have any questions or would like additional guidance.

Hope this helps! ALM

Amber L. Mosher, MPH, RD
O: 240 - 453 – 8261
C: 202 – 815 – 3618
E: Amber.Mosher@hhs.gov

131
PSC-HHS-000131
Cc: Mosher, Amber (OS/OASH)
Subject: FW: Dietary Guidelines Panel to Mull New Sodium Research
Alice,

It was good to chat. The article is below. To follow‐up on your request, Amber will touch base with you with some
guidance on how to approach a correction if you decide to pursue that. I think this provides a great example of how an
interview with the best intentions and careful disclaimers can result in something unintended and unexpected. We know
you well, and know you did not speak on behalf of the DGAC even though the reported made it seem that way.

Have a great day!

Kellie

MORNING
TAKE Dietary Guidelines Panel to Mull New Sodium
6 a.m.
Research
By Philip Brasher, CQ Roll Call
Aug. 18, 2014
» Blog Home In today’s Morning Take:
Panel’s Vice Chairwoman Says Salt Research Merits Study

Farm Bill Subsidies in Line with CBO Estimate, for Now
Score One for Rice Growers
Note to Readers: Due to the August recess, CQ on Agriculture & Food will publish a Morning Take
every Monday until Sept. 8, when our regular publishing schedule will resume.
That new study on sodium is likely to get a long look next month from the Dietary Guidelines
Advisory Committee. The study, which tracked 100,000 people across 17 countries, has focused new
attention on the scientific debate about what’s a safe level of sodium intake and how far Americans
should try to lower theirs.
132
PSC-HHS-000132
Alice Lichtenstein, a nutritionist at Tufts University and vice chairwoman of the advisory committee,
tells CQ Roll Call’s Georgina Gustin that the study is critically important given its scope, but that
other factors, such as disease or lifestyle, might affect the study’s findings. She said that the advisory
panel will look at the latest science on the issue but isn’t planning to recommend changes to the
current guidance on sodium.
Study may not change government sodium advice. (Philip Brasher)
The 2010 guidelines generally recommend a limit of 2,300 milligrams a day, but say that individuals
with hypertension, blacks, and middle-aged and older adults should aim for no more than 1,500
milligrams. The new study, published in the New England Journal of Medicine, found that people
who consume less than the 2,300 milligrams have a higher risk of heart attack or stroke. The average
American consumes 3,400 milligrams a day. The study was the largest of its kind taking a look at the
impact of lower sodium consumption.
“It’s a huge study, because they took all the data from all these disparate places, and in the most
conservative way, combined it,” Lichtenstein said. “But we know there are a huge number of factors
that bear on cardiovascular health. We’ll never be able to disentangle those from a l festyle
perspective.”
Lichtenstein added, “Taking this out of context is probably not something on which we should
develop policy.”
Farm Bill Numbers on Target, for Now. So far, the bean counters at the Congressional Budget
Office are looking like geniuses when it comes to estimating the cost of the new farm bill, at least as
far as the main new subsidy programs go. Scoring farm bills is notoriously hard, given it means
estimating commodity prices years in advance and getting into the minds of farmers to forecast what
133
PSC-HHS-000133
decisions to make.
Economists Carl Zulauf of The Ohio State University and Gary Schnitkey at the University of Illinois
have run numbers based on the price forecast the Department of Agriculture released last week and
found that payments under the new Agricultural Risk Coverage and Price Loss Coverage programs
could actually fall a little below the CBO estimate.
CBO projected that the programs would pay out $3.8 billion on this year’s crops, $2.1 billion for ARC
and $1.7 billion for PLC. Based on the midpoint of the price forecasts issued by USDA last week, the
programs would pay farmers $3.5 billion to $2.9 billion for ARC and $600 million for PLC.
Most of the ARC payments would go to corn growers, while the PLC subsidies would be dominated by
producers of long grain rice, the variety grown in Arkansas and other Southern states. (The
economists’ numbers are based on prices being at the midpoint of the ranges estimated by USDA.) “If
all of my forecasts were that good, I would be happy,” Zulauf says of the CBO score. “But as we talk
the forecast is subject to incredible change.”
Possible 2014 payments per acre under new farm bill programs. (Source: University of
Illinois)
Forecast Vindicates Rice Growers. According to Zulauf and Schnitkey, Southern rice growers
could receive about $90 an acre in PLC payments, which is roughly what they were receiving annually
in the direct annual payments that were abolished by the farm bill (PL 113-79). The forecast would
appear to be a vindication for the rice lobby, which fought hard not only to enact PLC but to make
sure that the price guarantee, or reference price, was so close to the market price that it was likely to
trigger payments.
134
PSC-HHS-000134
A key to the rice growers’ win was Mississippi Sen. Thad Cochran’s successful move to oust Pat
Roberts of Kansas as ranking Republican on the Agriculture Committee.
Considerable Uncertainty Yet on Prices, Payments. The economists based their estimates off
the midpoint of the price range USDA projects for each commodity. The actual cost of the two
programs for this year’s crop could range from negligible to as much as $9 billion, depending on
where prices actually fall within those ranges. USDA, for example, estimates that the average price
paid to farmers for corn could be anywhere from $3.55 to $4.25 a bushel. At the low end of the price
ranges, the ARC payment could reach $79 an acre, and the PLC payment for long rice could hit $120
an acre, the economists say.
At CQ on Ag and Food:
Lawmakers Push OMB on Menu Labeling
CQ on Agriculture & Food is a paid-subscription newsletter and website published by CQ Roll Call. Routine or systematic forwarding or
photocopying of this publication or portions thereof is a violation of federal copyright laws. To ensure compliance or to inquire about a
site license, contact CQ Roll Call Sales at 800-432-2250 x 6599 or sales@cqrollcall.com. If you are having technica issues accessing
this publication, contact CQ Roll Call Customer Service at 800-432-2250 x 6621 or customerservice@cqrollcall.com. Request a free trial.
An Economist Group Business. Copyright 2014 © CQ Roll Call. All rights reserved.
You are subscribed as scott.carter@fns.usda.gov

To stop or change your subscription, please visit My Subscriptions.
Issue-Id: 33011794:execbriefagriculturefood:1297
135
PSC-HHS-000135

Subject: RE: recommendatgions. Call this Friday
Hi Eve,

Frank and I are talking next Tuesday and I will review his latest CVD summary (I am also happy to review Anna Maria's
Overweight and Obesity summary when she is ready.). BTW, Joanne and Katrina just presented to SC3 an evidence
summary table that they have compiled which summarizes data on interventions for weight management, CVD risk
reduction, and other selected endpoints. I believe Anna Maria she is going to consider it when doing her summary of
evidence on overweight and obesity since it includes information on effect sizes from behavioral intervention for obesity
management (and other outcomes, CVD and DM) as reported in the AHA ACC report. Katrina is going to send the tab le
to you and they are going back to extract the graded recommendations. The summary they have done also captures
information on the mode and method of behavioral intervention. We are discussing where best to report on that
information in the report and SC3 will continue its discussion.

Can you send me the latest version of the CVD summary and the full data tables? Anne Rodgers sent me some but
noted that I may not have the latest versions. When Anna Maria is done, please send me her summary and the data
tables too.

We will have determine whether we're going to add Katrina and Joanne's evidence table to our tables (at least the part
from AHA ACC) and perhaps where to locate the rest of it. Hope that's clear and make sense. Let me know if you have
any questions.

Many thanks.

Barbara
bmillen@bu.edu

From: Essery, Eve ‐ CNPP [mailto:Eve.Essery@fns.usda.gov]
To: Millen, Barbara E; Siega‐Riz, Anna Maria
Cc: Kellie Casavale (OS/OASH)

Hi Barbara,
Anna Maria and I had emailed about potentially including this as an agenda item on the SC2 call next Thursday. Would
you be willing to take one of the write‐ups and make comments throughout to highlight the aspects of "what works" you
think might be missing? That way, everyone is on the same page, and groups that have reviewed the individual
questions can speak to if/how that information may be available for each outcome. As has been stated, it might be that
CVD and BW are the main areas where this information can be elucidated, but this would give everyone concrete
136
PSC-HHS-000136
examples of the information that is being requested. Frank's assistant just confirmed that Frank will be on the SC2 call
next week.

Anna Maria ‐ Apologies, I've been busy getting some saturated fat and added sugars materials out. I'll review your
section ASAP ‐‐ likely early next week.

Best,
Eve

To: Siega‐Riz, Anna Maria
Cc: Essery, Eve ‐ CNPP; Kellie Casavale (OS/OASH)

Many thanks.

bmillen@bu.edu

From: Siega‐Riz, Anna Maria [mailto:am_siegariz@unc.edu]
Cc: Eve ‐ CNPP Essery; Kellie Casavale (OS/OASH)

Hi Barbara,
Thank you for this note and I am happy for you to review the sections written to see if we have or can further bring out
the points that you have mentioned below. I have completed my second draft of the T2D conclusions, implications and
key findings. I hope to tackle the obesity one next‐over the weekend if possible since this does take long hours of
focused effort. I sent Eve and Kellie the T2D draft at the beginning of the week. Not sure if they had any edits as of yet (
I am sure there will be) but here it is for you to begin to review.
The conclusion and implication statements for obesity are the latest version we have from the July meeting.

Best regards,
Anna Maria

To: Siega‐Riz, Anna Maria
Cc: Eve ‐ CNPP Essery; Kellie Casavale (OS/OASH)
Subject: RE:recommendatgions. Call this Friday

Dear Anna Maria,

137
PSC-HHS-000137
I spoke with Kellie this morning to go over a variety of topics that seem important to discuss before we move into the
review of the SC work beyond the subcommittee level. Since Frank has not been on the most recent SC2 calls when the
'what works' topic was raised, I would like to propose that I talk with Frank directly about the CVD summary. When
you're done with your edits to Obesity and Diabetes, it would also be helpful to have a short conversation after I've had
a chance to review it. My hope is to work with the existing summaries of evidence and the tables to assess if we've
made the strongest case possible for the relationships between and 'impact' of dietary patterns on health outcomes
(end points and intermediate markers, where appropriate). I think we have covered the prospective cohort findings
very well. So, I'm most interested in looking closely at how the RCT information is being brought forward (in the case of
the existing reports) and summarized and what conclusions we draw. This is well within the scope of the existing priority
questions. In examining 'relationships' between dietary patterns and health outcomes, we have identified and analyzed
evidence on 'associations' as well as the 'efficacy' and 'effectiveness' of interventions. If we can draw reasonably strong
conclusions about both relationship between dietary patterns and the development of disease as well as the efficacy
and impact of dietary patterns and health outcomes, it will be extremely important to our DGAC work. Our summaries
and conclusions will also influence our implications statements and recommendations, so it is important that they are as
complete as possible.

It is not my intent to add major work at this point. We are all well aware that we need to be careful with staff and
committee member activities. However, it is at this juncture that we make the necessary edits to answer our priority
questions as completely as possible. If we have to draw further from existing reports or the papers we have already
summarized, I hope it doesn't add much burden. If there is any indication that it will, we should definitely discuss it with
the SC but hopefully it won't.

I hope you agree and will work with me to accomplish this as quickly as possible.

Let me know your writing timetable for obesity and diabetes and when you might have a half hour at most to talk early
next week. I will reach out to Frank. If you want to talk before I do, let me know.

Best regards,

Barbara

bmillen@bu.edu

From: Siega‐Riz, Anna Maria [mailto:am_siegariz@unc.edu]
Sent: Wednesday, September 03, 2014 6:57 PM
To: Eve ‐ CNPP Essery; Kellie Casavale (OS/OASH); Millen, Barbara E
Subject: Call this Friday

Hi, I have a dissertation defense to attend from 10‐12 on Friday and thus unable to make the call.
My plan is to complete the key findings for dietary patterns and obesity over the weekend.
Anna Maria

Sent from my iPhone

unauthorized interception of this message or the use or disclosure of the information it contains may violate the law and
138
PSC-HHS-000138
subject the violator to civil or criminal penalties. If you believe you have received this message in error, please notify the
sender and delete the email immediately.
139
PSC-HHS-000139

Sent: Sunday, September 07, 2014 12:40 PM
To: Campbell, Wayne W; Psota, Tricia - CNPP; Alice H. Lichtenstein; Lucile Adams-Campbell;
Mary Story; Mim Nelson; Wayne Campbell
Cc: Lauren Bailey; Goyette-Blankenship, Jessica S; Mosher, Amber (OS/OASH); Casavale,
Kellie (OS/OASH); Rihane, Colette - CNPP; Rahavi, Elizabeth - CNPP
Subject: RE: RESPONSE REQUESTED: DGAC SC4 Worksite Topic Area
I agree with the rewording of the questions and it seems that the Archer provides suitable contextual information. I
wasn’t sure why the Groeneveld was omitted. While the results summarized on impact on most CVD risk factors seemed
inconclusive, the summary seems to note that that effects on body fat were observed for lifestyle interventions. The
quality rating seemed reasonable despite the limitations noted. Since I was not on the call, I defer to others for the
nuance relating to the decision.

Best,

Barbara
bmillen@bu.edu

From: Campbell, Wayne W [mailto:campbeww@purdue.edu]
Sent: Sunday, September 07, 2014 10:29 AM
To: Psota, Tricia - CNPP; Alice H. Lichtenstein; Millen, Barbara E; Lucile Adams-Campbell; Mary Story; Mim Nelson;
Wayne Campbell
Cc: Lauren Bailey; Goyette-Blankenship, Jessica S; Mosher, Amber (OS/OASH); Casavale, Kellie (OS/OASH); Rihane,
Colette - CNPP; Rahavi, Elizabeth - CNPP
Subject: RE: RESPONSE REQUESTED: DGAC SC4 Worksite Topic Area

My responses to the questions are below.
Wayne
From: Psota, Tricia - CNPP [tricia.psota@cnpp.usda.gov]

Sent: Friday, September 05, 2014 1:32 PM
To: Alice H. Lichtenstein; Barbara Millen; Lucile Adams-Campbell; Mary Story; Mim Nelson; Wayne Campbell
Cc: Lauren Bailey; Goyette-Blankenship, Jessica S; Mosher, Amber (OS/OASH); Casavale, Kellie (OS/OASH); Rihane,
Colette - CNPP; Rahavi, Elizabeth - CNPP
Subject: RESPONSE REQUESTED: DGAC SC4 Worksite Topic Area
Hi all,

As a follow‐up action item to today’s SC4 call, please review the attachments and answer the following questions by
Tues 9/9:
1. Do you approve the edits to the 3 original worksite questions and the addition of another question?
WWC ‐ yes.

2. Do you support removing the Groeneveld paper from the evidence base?
WWC‐ yes. It is important to note that insufficient evidence exists to assess of the impact of diet‐only work site
programs. The results from Verweij et al. show that diet+exercise programs work, but not exercise‐only
140
PSC-HHS-000140
programs. An important area for research might be whether the apparent effectiveness of diet+exercise
programs is synergistic (between the two components), or if the diet component is driving the effect?

3. Should the Archer paper be used for contextual purposes only?
WWC‐Yes. The inclusion of findings from experimentally 'weaker' studies in this review is not consistent with the
rigorous DGAC criteria for inclusion.

Attachments:
Questions for the worksite topic area (Word)
Worksite Duplication Assessment (Excel)
6 articles of interest (PDFs)

Note that the Word document with the original and revised questions indicates which articles would be used to answer
each question. Also, removal of the Groeneveld article is under consideration due to the overlap with the Verweij article,
which is a systematic review and meta‐analysis including most of the studies in the Groeneveld paper and encompasses
a wider date range.

Please let me know if you have any questions.

Best,
Tricia

Tricia L. Psota, PhD, RDN
Nutritionist
USDA Center for Nutrition Policy and Promotion

Web: Dietary Guidelines | Nutrition Evidence Library | MyPlate
Twitter: @MyPlate | @NutriciaPsota
Facebook: MyPlate
Phone: 703.305.2568

As America’s children head back to school this Fall,
they’ll find that The School Day Just Got Healthier!
Click below to find out how and why.

141
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Sent: Tuesday, September 09, 2014 5:16 PM
To: Casavale, Kellie (OS/OASH); Millen, Barbara E
Cc: Olson, Richard (HHS/OASH); Colette Rihane; Shanthy Bowman; Anne Rodgers
Subject: RE: Response Needed: DGAC Meeting 6
I support the change. This report is very large. To give adequate time to the details it
would be helpful to move the date. This is particularly true for anyone on an academic
schedule. Courses are usually over early Dec.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Millen, Barbara E; Lichtenstein, Alice
Subject: Response Needed: DGAC Meeting 6
Importance: High

Barbara and Alice,

The Co‐executive Secretaries and staff have done some thinking about the timeline for completing the report. We
wanted to touch base with you to get your thoughts on potentially moving the date of the final DGAC public meeting
from November 5‐7th to early December (or early January if December isn’t possible), which would give the Committee
an additional month for writing and review.

There were 8 weeks between the January and March and the July and September meetings. From those experiences,
Committee members and staff have a good feel for what work can get done in that time frame. There are only 7 weeks
between the September and November meeting dates. This is likely enough time to get the remaining evidence reviews
completed. However, it is likely not enough time for the Committee to complete the science base chapter writing, run
those pieces through a thorough cross‐review and editing, soundly develop and review your synthesis sections, and
complete the other sections and appendices that will require attention (e.g., glossary of terms, methodology).

We think the additional time would give you the time you need for thorough cross‐review and synthesis and would
result in a better final product. However, even if we moved the meeting back to early December, the goal of the
Committee would still be to complete its report by the end of the calendar year. This would mean retaining the
aggressive timelines and drafting goal dates the SCs have established and not addressing any additional questions
beyond those already underway.
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PSC-HHS-000142

If you are open to this idea, we need to contact NIH immediately; the availability of meeting space is crucial. Then, we
would need to query the DGAC schedules for potential dates, another challenging task. Because the report would be in a
more complete state if it were presented in early December than it would be in November, it may be possible that a
December meeting would be 1‐2 days rather than 3, which could help with scheduling a date. There are some strategies
we also could employ for vetting the remaining recommendations (following FACA) so that there aren’t any surprises at
the last meeting. We welcome your thoughts!

Thanks,

Kellie

Rockville, MD 20852
(240) 453‐8252

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Sent: Wednesday, September 10, 2014 8:55 AM
See notes after each week. I don’t know how many members will have teaching
responsibilities in the spring. For me, I don’t.


Thanks, Alice. Since you are very in tune with the academic schedule. Do you have any feedback on what date range in
early Dec (and early Jan) might work best for members? The work weeks look like this:

DEC
1st week: Dec 1‐5 – end of classes
2nd week: Dec 8‐12 – reading period, final exams – possibility good for meeting, personally I don’t need to be at Tufts
3rd week: Dec 15‐19 – likely good for meeting
(4th week is the week of Christmas)
(5th week/ 1st of Jan not good)

JAN
1st week: Jan 5‐9 – I am out all week
2nd week: Jan 12‐16 – first part of week likely good, sometimes classes start in the later part of the week, some don’t
start until following week
(We wouldn’t want to go any later, so there is time to get the report submitted before the charter ends Feb 19th)

Kellie


To: Casavale, Kellie (OS/OASH); Millen, Barbara E

I support the change. This report is very large. To give adequate time to the details it
would be helpful to move the date. This is particularly true for anyone on an academic
schedule. Courses are usually over early Dec.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
144
PSC-HHS-000144
Tufts University
Boston, MA 02111

phone: 617 556 3127

Importance: High

Barbara and Alice,





Thanks,

Kellie

145
PSC-HHS-000145
Rockville, MD 20852
(240) 453‐8252

146
PSC-HHS-000146

To: Casavale, Kellie (OS/OASH); Lichtenstein, Alice
Hello all,

Thank you for the very thoughtful consideration of the timetable. Sorry that I didn’t respond right away but my
schedule is really tight.

We all know how very hard everyone is working and that we have a common interest in producing a deep and
informative report with on time submission. I also favor pushing our next meeting out. As you know, I will be
presenting at the Royal Swedish Academy of Sciences in Stockholm on November 25, just before Thanksgiving. The
holiday will probably affect most of us. So, as long as we can work around it, early December or January work for
me. Let’s see how the Committee feels. Our academic schedule typically went well into mid‐December with thesis and
doctoral defenses until just before the December break. So, December might get tricky for some but let’s move ahead
and see how it works out.

Best,

Barbara

bmillen@bu.edu

Importance: High

Barbara and Alice,



147
PSC-HHS-000147


Thanks,

Kellie

Rockville, MD 20852
(240) 453‐8252

148
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Cc: alice.lichtenstein@tufts.edu; jtb4@cornell.edu; Casavale, Kellie (OS/OASH); Obbagy,
Julie - CNPP
Subject: RE: DGAC: Sat Fat and CVD
Attachments: 5 Sat Fat and CVD - Key Trends - 9 9 14 bem edits 9 11 2014.docx
Here you go. Very nice summary with strong quantifiable outcomes. I would advocate a couple of things as noted in my
comments, in particular some clarification on methods and modes of intervention that are successful in achieve these
results, what level of PUFA and SFA are realistic to achieve (based on the trial evidence and possibly PCs) s and whether
there are any added benefits of total fat reduction with PUFA substitution for SFA and/or weight loss.

Many thanks Eve and Frank for this great work so quickly.

Barbara

bmillen@bu.edu

Cc: alice.lichtenstein@tufts.edu; Millen, Barbara E; jtb4@cornell.edu; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP
Subject: Re: DGAC: Sat Fat and CVD
Dear All,
attached is a draft key trend document. I'd appreciate your comments and suggestions.
Frank
On Tue, Sep 9, 2014 at 12:43 PM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
Hi Alice, Frank, Tom, and Barbara,
Attached are the materials we reviewed on Thursday’s call for your question on saturated fat and CVD. Per your request,
we have added Jakobsen, which was not identified in the original search because it was not tagged as a meta-analysis.
We also added Skeaff, 2009 per Tom’s request. Skeaff was also not identified in the original search because it did not
include “saturated” in the title or abstract (no abstract available).
Please see the following attached:
1. Include/exclude list – Please review and let us know if you think something was incorrectly excluded or is missing.
2. Evidence table
149
PSC-HHS-000149
3. Reference overlap
4. PDFs of included articles
5. Key trends document – Please provide brief responses to the questions to help inform your synthesis and
development of conclusions.
Does one of you want to take the lead and do a first pass and then do a round robin with the group?
Let me know if you need anything else.
Eve
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
150
PSC-HHS-000150
******************************************************
151
PSC-HHS-000151

To: Millen, Barbara E; Frank Hu; Essery, Eve - CNPP
Cc: jtb4@cornell.edu; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP
Attachments: 5 Sat Fat and CVD - Key Trends - 9 9 14 bem edits 9 11 2014 AHL.docx
Very nice job Frank. I added my comments to Barbara’s.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Cc: Lichtenstein, Alice; jtb4@cornell.edu; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP


Barbara

bmillen@bu.edu

Dear All,
152
PSC-HHS-000152
Frank
2. Evidence table
Eve
153
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--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
154
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To: Tom Brenna
Cc: Frank Hu; Essery, Eve - CNPP; alice.lichtenstein@tufts.edu; Casavale, Kellie (OS/OASH);
Obbagy, Julie - CNPP
Thank you Tom,

I would only add that while we’re focusing on the healthy population, our evidence certainly does include high‐risk
individuals. We’re not looking at rehab or interventions in those post‐event but certainly those with varying degrees of
risk. Just an additional thought. Hopefully, that helps clarify things.

Barbara

bmillen@bu.edu

Cc: Frank Hu; Essery, Eve - CNPP; alice.lichtenstein@tufts.edu; Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP
To all,
I now see Ramsden BMJ 2013 is on the EXCLUDE list because it focuses on secondary prevention. The
Sydney Diet and Heart Study is secondary, not 100% sure of the meta-analysis; I'm looking and will advise if I
disagree.
The Sat Fat and CVD Approach document says the question is "What is the relationship between saturated fat
intake and risk of cardiovascular disease?" I don't see the words primary or secondary in the
document. Implicitly we're discussing healthy people so I suppose exclusion on those criteria are acceptable.
My opinion on research recommendation is unchanged.
Tom
On Fri, Sep 12, 2014 at 7:36 AM, Tom Brenna <jtb4@cornell.edu> wrote:
Dear all.
I added an important typo fix (a missing "not" in 2a) and two proposed research recommendations.
It may be too late but there is another meta-analysis that we've not covered, buried in the back of the attached
paper. It separates omega-3 and omega-6 and while not significant (95% CL = 0.98 to 1.65) shows only signal
of harm from LA predominant ("selective") interventions (all RCT).
155
PSC-HHS-000155
I presume the decision to include the paper turns on formal inclusion criteria. Whether or not it is included, I
think at least we should make the research recommendation to monitor LA and ALA separately.
Tom
On Fri, Sep 12, 2014 at 5:42 AM, Millen, Barbara E <bmillen@bu.edu> wrote:
Barbara
bmillen@bu.edu

Dear All,
Frank
156
PSC-HHS-000156
2. Evidence table
Eve
157
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--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
158
PSC-HHS-000158

Sent: Tuesday, September 16, 2014 5:52 AM
Subject: FW: DGAC SC2: Mtg tomr @ 12:30 pm ET
Attachments: DGAC Meeting 5 SC2 9 12 14 bem edits 9 16 2014.pptx
Good morning! See my note below. B

bmillen@bu.edu

Sent: Tuesday, September 16, 2014 5:51 AM
To: 'Essery, Eve - CNPP'; Anna Maria Siega-Riz, PhD, MS, RD (am_siegariz@unc.edu)
Cc: 'Neuhouser, Marian L'; 'steven.clinton@osumc.edu'
Subject: RE: DGAC SC2: Mtg tomr @ 12:30 pm ET
HI there,

I reviewed the bone health slides and did a few tweaks. I hope this is consistent on where we came out on the
implications yesterday. I didn’t see any in the slide deck I had so I added a couple of lines to reflect the dietary pattern
evidence summary and to note that we acknowledge the roles of vitamin D and calcium in bone health across all
ages. Hope this makes sense. I believe we will have the hard copy of slides in our binder today. Perhaps these pages
can be updated.

Many thanks.

Barbara

bmillen@bu.edu

Sent: Sunday, September 14, 2014 8:14 PM
To: 'Siega-Riz, Anna Maria'; 'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu'; 'jtb4@cornell.edu';
Millen, Barbara E
(NIH/NIDDK) [E]'; 'margaret.mcdowell@nih.gov'; Wong, Yatping - CNPP; 'Anne Rodgers'; 'Casavale, Kellie (OS/OASH)';
'PBROWN@hsph.harvard.edu'; 'jconnor@fhcrc.org'; 'Bailey, Lauren A.'; 'Knight, Brianna'; 'Angelica Figueroa'; Psota, Tricia
- CNPP;(b) (6) @gmail.com; Julie Obbagy
Subject: DGAC SC2: Mtg tomr @ 12:30 pm ET
Hi SC2 members,
Attached are materials for tomorrow’s SC2 meeting in the Orange Skybox from 12:30 to 4:30 pm ET. Frank and Rafael –
please see the webinar and conference line information.
2015 Dietary Guidelines Advisory Committee

Subcommittee 2: Dietary Patterns, Foods and Nutrients, and Health Outcomes
159
PSC-HHS-000159
Monday, September 15 from 12:30 to 4:30 pm ET
Orange Skybox-1G600 of Building 35, Porter Building

AGENDA
1. Review and finalize materials to be presented at public meeting (presentation is Tuesday from 2:45 to 4:30 pm ET)
a) Dietary patterns and neuro-pysch illnesses (attachments 2-3)
b) Dietary patterns and birth defects (attachment 4)
c) Dietary patterns and bone health (attachment 5)
d) Saturated fat and CVD (*new* draft conclusions) (attachments 6-7)
e) Alcohol (approach)
2. Dietary patterns and CVD, T2D, and BW – “what works” (attachments 8-10)
Thanks and see you tomorrow!
Eve

160
PSC-HHS-000160

To: Neuhouser, Marian L; Essery, Eve - CNPP; 'Siega-Riz, Anna Maria';
'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu'; 'jtb4@cornell.edu';
'steven.clinton@osumc.edu'; 'frank.hu@channing.harvard.edu'; 'rafael.perez-
escamilla@yale.edu'
Cc: Olson, Richard (HHS/OASH); Rihane, Colette - CNPP; Bowman, Shanthy; Obbagy, Julie -
CNPP; Fisher, Rachel (NIH/NIDDK) [E]; McDowell, Margaret (NIH/NIDDK) [E]; Wong,
Yatping - CNPP; 'Anne Rodgers'; Casavale, Kellie (OS/OASH);
'PBROWN@hsph.harvard.edu'; Connor, Jennifer N; 'Bailey, Lauren A.'; 'Knight, Brianna';
'Angelica Figueroa'; Fu, Stephenie - CNPP; Psota, Tricia - CNPP; anjuli.bodyk@yale.edu
Subject: RE: DGAC SC2: Call TOMR @ 11am ET (8am PT) - DRAFT chapter for review!
Sorry Marian. My comment on methodological limitations was that the range of limitations in these methods may bias
towards the null. I agree with your very precise explanation. I was concerned though that if we dwell on their
limitations in the introduction without some stronger statement of their advantages, it would weaken NOT strengthen
the interpretation of our conclusions. My comment wasn’t terribly clear so I hope this helps. Hopefully my edits seem
reasonable.

Many thanks,

Barbara

bmillen@bu.edu

From: Neuhouser, Marian L [mailto:mneuhous@fredhutch.org]
To: Millen, Barbara E; Essery, Eve - CNPP; 'Siega-Riz, Anna Maria'; 'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu';
'jtb4@cornell.edu'; 'steven.clinton@osumc.edu'; 'frank.hu@channing.harvard.edu'; 'rafael.perez-escamilla@yale.edu'
'PBROWN@hsph.harvard.edu'; Connor, Jennifer N; 'Bailey, Lauren A.'; 'Knight, Brianna'; 'Angelica Figueroa'; Fu,
Stephenie - CNPP; Psota, Tricia - CNPP; anjuli.bodyk@yale.edu
RE: some of the comments below about measurement error . We should not state that measurement error will bias
towards the null and “make our conclusions stronger” because this is not true. Confounding typically biases towards the
null, but not measurement error. Measurement error distorts relationships (so can artificially increase or decrease the
observed associations), particularly when it is systematic measurement error.

Marian

To: Essery, Eve - CNPP; 'Siega-Riz, Anna Maria'; 'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu';
'jtb4@cornell.edu'; 'steven.clinton@osumc.edu'; 'frank.hu@channing.harvard.edu'; Neuhouser, Marian L; 'rafael.perez-
escamilla@yale.edu'
161
PSC-HHS-000161
'PBROWN@hsph.harvard.edu'; Connor, Jennifer N; 'Bailey, Lauren A.'; 'Knight, Brianna'; 'Angelica Figueroa'; Fu,
Hi all,

Congratulations on the chapter! It is coming together very well. I took quite a bit of time to review it in somewhat
greater detail. Hopefully this will make the next level of review easier. A few overall points….It will be important to
review the consistency across SC chapters in the wording of and emphasis in the dietary pattern statements. For this
review, I suggested wording that we discussed in the last SC2 call. Your wording is very close but you will note that I am
recommending some slight editing. Also, the ‘what works’ could come through a bit stronger based on the evidence,
particularly as related to weight management. I am suggesting that the AHA/ACC review of RCTs precede the
prospective cohort literature in that section of the chapter. It think this may better reflect the high level of concern over
ingrained, very high rates of overweight and obesity in our population and the moderate to strong evidence on how
best to manage it. Also, I noticed that the Look Ahead Diabetes trial was not addressed and think we can use the
AHA/ACC reports for that purpose. Those in the field consider it pretty definitive so I think the conclusions and evidence
summary on DM from the existing reports need to be drawn upon to add to our DM section. It was not until the cancer
section that there was mention that the cohort literature often only defines dietary exposures (or other exposures) at
baseline and may not consider all relevant potential confounders. You may wish to include this in the brief discussion of
limitations in the dietary assessment methods in your introduction. I did though soften the wording here a bit. I don’t
think we want to be so strong in our critique of these methods that we take away from our conclusions. The key thing is
that the limitations will add to the bias towards the ‘null’ and may thereby make our moderate to strong conclusions
where we see them that much more important.

If you have any questions, please let me know.

Best,

Barbara

bmillen@bu.edu

Sent: Monday, October 27, 2014 5:46 PM
Millen, Barbara E
'PBROWN@hsph.harvard.edu'; 'jconnor@fhcrc.org'; 'Bailey, Lauren A.'; 'Knight, Brianna'; 'Angelica Figueroa'; Fu,
Subject: DGAC SC2: Call TOMR @ 11am ET (8am PT) - DRAFT chapter for review!
Attached is the DRAFT compiled SC2 chapter (congrats!!). Anna Maria has requested that for tomorrow’s discussion, you
focus your review on the Chapter Introduction, Methodology, and Summary and come prepared to discuss your
comments, particularly related to any potential gaps in those sections. We will also talk about next steps for the chapter
review. Thanks and talk soon!
Eve
2015 Dietary Guidelines Advisory Committee

Subcommittee 2: Dietary Patterns, Foods and Nutrients, and Health Outcomes
162
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Tuesday, October 28 from 11:00am to 12:00 pm ET (8:00 to 9:00 am PT)


163
PSC-HHS-000163

Sent: Wednesday, November 05, 2014 9:48 AM
To: Campbell, Wayne W; Obbagy, Julie - CNPP; 'Clinton, Steven'; Anderson, Cheryl;
campbellw@purdue. edu
Subject: RE: DGAC: Sodium Working Group -- Na-CVD systematic review - input needed!
Attachments: Sodium and CVD - Evidence Portfolio 11 3 14 WC 11-5-14 AHL.docx
Added to Wayne’s comments/additions

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Obbagy, Julie - CNPP; 'Clinton, Steven'; Anderson, Cheryl; Lichtenstein, Alice; campbellw@purdue. edu

Good morning,
Here are a few edits and draft grading scores for consideration.
Wayne
From: Obbagy, Julie - CNPP [Julie.Obbagy@cnpp.usda.gov]

Sent: Tuesday, November 04, 2014 1:51 PM
To: 'Clinton, Steven'; Campbell, Wayne W; Anderson, Cheryl; 'Lichtenstein, Alice'; campbellw@purdue. edu
Subject: DGAC: Sodium Working Group -- Na-CVD systematic review - input needed!
Hi Alice, Cheryl, Steve, and Wayne

I’ve taken your input (from the key trends, and the emails below), and summarized/synthesized it in the attached
document. Prior to our meetings on Thurs‐Fri, please review the attached document, focusing on these sections:
Conclusion Statement
Grade (please indicate which DGAC grade you would assign this conclusion)
Evidence Synthesis
Research Recommendations

If you have proposed edits or comments, please circulate to the full working group, and we can make sure that they are
discussed on Thursday, and that materials are ready for presentation publically on Friday.
164
PSC-HHS-000164

Thanks!

Julie

From: Clinton, Steven [mailto:Steven.Clinton@osumc.edu]
Sent: Tuesday, November 04, 2014 8:54 AM
To: Campbell, Wayne W; Anderson, Cheryl; Obbagy, Julie - CNPP; 'Lichtenstein, Alice'
Cc: Essery, Eve - CNPP; campbellw@purdue. edu

1. Agree with concept that we use verbatim conclusions. That is the only option unless we do an additional
evaluation of data.
2. In response to Wayne, BP is a surrogate marker for risk of cardiovascular/stroke events and indicator of ongoing
cardiovascular disease (a process).
3. Nothing else to add prior to discussion on Thursday.

Sent: Monday, November 03, 2014 9:49 AM
To: Anderson, Cheryl; Obbagy, Julie - CNPP; 'Lichtenstein, Alice'; Clinton, Steven

Good morning everyone,
While I do not think omitting the second sentence of conclusion 1 markedly diminishes the message contained in the first
sentence, I suggest we bring the entire statement forward as written. As described in the 'implications' section of the IOM
summary, the second sentence seems to be contextually related to the DRI report that includes sodium, not specifically
the IOM report. Thus, the statement about using BP as a surrogate marker of CVD may be based on evidence beyond the
IOM report. Also, I recall a similar discussion regarding carrying forward conclusions from reports used for the physical
activity chapter. If memory serves, we decided conclusions from existing reports needed to be carried forward word-for-
word, otherwise the DGAC would be obligated to conduct an independent assessment of the topic.
Thanks
Wayne
From: Anderson, Cheryl [c1anderson@ucsd.edu]

To: Obbagy, Julie - CNPP; Campbell, Wayne W; 'Lichtenstein, Alice'; 'Clinton, Steven'
Julie: thanks.
Members: please reconsider whether knowing that the text was pulled verbatim from those reports influences your
thinking on conclusion 1.
Looking forward to our meeting on Thursday.

Cheryl

To: 'Campbell, Wayne W'; Anderson, Cheryl; 'Lichtenstein, Alice'; 'Clinton, Steven'
Thanks Alice, Cheryl, and Wayne for sending your input!
165
PSC-HHS-000165

Yes, the conclusions were all pulled verbatim from the IOM and AHA/ACC reports (for example, the conclusion Alice
inquired about is found on page 4 of the attached PDF).

I compiled your input into a single document (Attached), and will work on writing it up for the Evidence Portfolio and for
your presentation later this week. However, there is some inconsistency around whether or not to carry forward
Conclusion 1 of the IOM report. The Sodium Working Group has a breakout session on Thursday from 1‐3pm EST, and
this issue can be discussed then. However, if you have some time to review prior to that and discuss via email, we can
capture your decisions and finalize before Thursday.

Thanks!

Julie

Sent: Saturday, November 01, 2014 9:48 AM
To: Anderson, Cheryl; Obbagy, Julie - CNPP; 'Lichtenstein, Alice'; 'Clinton, Steven'

Hi Julie,
I have added my comments to those from Alice and Cheryl.
Wayne
From: Anderson, Cheryl [c1anderson@ucsd.edu]

Sent: Friday, October 31, 2014 2:10 PM
To: Obbagy, Julie - CNPP; 'Lichtenstein, Alice'; 'Clinton, Steven'; Campbell, Wayne W
Cc: Essery, Eve - CNPP
Hi Julie. Here is mine and Alice's.
Would you please clarify whether the IOM conclusions are taken verbatim from the report. Alice's comment re conclusion
#1 prompted me to ask this.
Thanks,
Cheryl

Sent: Friday, October 31, 2014 10:46 AM
To: Obbagy, Julie - CNPP; Anderson, Cheryl; 'Lichtenstein, Alice'; 'Clinton, Steven'; 'Campbell, Wayne W'
Hi All,

Just a reminder to send any input you have on the sodium‐CVD review via the Key Trends document.

Have a nice weekend,

Julie

From: Obbagy, Julie - CNPP
To: Obbagy, Julie - CNPP; 'Anderson, Cheryl'; 'Lichtenstein, Alice'; 'Clinton, Steven'; 'Campbell, Wayne W'
166
PSC-HHS-000166

Hi Sodium Working Group,
Just a reminder that your input on the materials described below is needed to finish the question on Sodium and CVD
risk.
Attached are materials for your review of evidence on the relationship between sodium and cardiovascular disease.
Below is a summary of the attached materials, with “action steps” highlighted in yellow. Since this is an update of the
systematic review done by the IOM and ACC/AHA, the Key Trends document should be done considering the 4 newly
published studies, along with the conclusions from the previous reviews. The goal is to review the new research, and
determine what your Conclusion Statement and Grade are based on the totality of evidence.
1. Sodium and CVD ‐ Search Plan and Results: This document provides a detailed description of the search
strategy (databases, search terms) and results (# of articles screened, list of included references, table list the
articles that were excluded with rationale). Please review and let us know whether you think we have missed
anything (search terms, key references, etc).
2. Sodium and CVD Evidence Portfolio (for the 2015 update)
a. Evidence Grid: Excel spreadsheet that includes all data extracted from the included articles
b. Description of Evidence: Overview of the included articles (e.g., subject characteristics, the
interventions/exposures and outcomes examined and methodology used). The information provided is
purely descriptive in nature, and does not compare and contrast the studies or their results.
c. PDFs of the articles
3. Sodium and CVD – Key Trends Document: Questions designed to facilitate evidence synthesis, and
development of a conclusion statement and grade, by identifying key trend/ themes among the studies,
including similarities and differences in results, and factors that may impact the relationships being
examined. Please review the 2015 Evidence Portfolio, and IOM and AHA/CC conclusions and provide us with
responses to this document ASAP.
4. PDF of the summary of the IOM Report (summary, let us know if you want the full report)
5. PDF of the AHA/ACC report (summary, let us know if you want the full report)
If you begin reviewing the evidence and working on the Key Trends document, and have questions, please email. We’ll
be in touch soon to set‐up a meeting to discuss this, and your other work related to sodium.
Thank you,
Julie

Julie E. Obbagy, PhD, RD
Center for Nutrition Policy and Promotion
U.S. Department of Agriculture
julie.obbagy@cnpp.usda.gov
703‐305‐2327

As America’s children head back to school this Fall,
they’ll find that The School Day Just Got Healthier!
Click below to find out how and why.

167
PSC-HHS-000167
168
PSC-HHS-000168

Sent: Friday, November 07, 2014 8:07 AM
Subject: RE: Public Meeting Slides and Reminders: DGAC Meeting 6
That’s what I have. It doesn’t have any comments for me. I will state: The SRSC has been discussing the process for
integrating the conclusions and recommendations across all Subcommittees and Cross‐Cutting Topic Work and Writing
groups. I recently asked the SC and WG chairs to reflect with their teams including staff to identify the most salient
themes that have emerged. Look for major and common themes. From these, high‐level perspectives my Co‐Chair, Alice
Lichtenstein and I , will prepare a summary of the overall major and cross‐cutting themes to discuss further with the
DGAC. After these deliberations, we will finalize our overall conclusions and recommendations in an integrating chapter
for the final report.

I will now call upon the SC chairs in order and then our Cross‐Cutting Workgroup/Writing Group Chairs to to take literally
only a minute or two to describe the themes across the Research Questions they addressed.

Hope this makes sense.

Barbara
bmillen@bu.edu


No they haven’t as long as you printed the ones where I added the names and pictures of the SC/Wg chairs for the
Integration presentation. That was the last change I made to any of them Going to load them on the computer now….

Kellie



Kellie, Have mine changed at all from last night? I printed those already and wonder if I should do so again? Barbara

bmillen@bu.edu

169
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To: Alice Lichtenstein, DSc, MS; Anna Maria Siega-Riz, PhD, MS, RD; Millen, Barbara E; Cheryl Anderson, PhD, MS, MPH;
Frank Hu, MD, PhD, MPH; J. Thomas Brenna, PhD, MS; Lucile Adams-Campbell, PhD, MS; Marian Neuhouser, PhD, RD;
Mary Story, PhD, MS, RD; Miriam (Mim) E. Nelson, PhD, MS; Rafael Pérez-Escamilla, PhD, MS; Steven Abrams, MD;
Steven Clinton, MD, PhD; Wayne Campbell, PhD, MS
Cc: Angelica Figueroa; Bailey, Lauren A.; Brianna.Knight@osumc.edu; Jennifer Connor; Ms. Lejuana Himes; Patrice
Brown ; Tidings Chan ; anjuli.bodyk@yale.edu; jgoyett@purdue.edu; Olson, Richard (HHS/OASH); Colette Rihane;
McPeak, Holly (HHS/OASH); Mosher, Amber (OS/OASH); Britten, Patricia - CNPP; Essery, Eve - CNPP; Piercy, Katrina
(HHS/OASH); Rahavi, Elizabeth - CNPP; De Jesus, Janet M (NIH/NHLBI) [E]
Subject: Public Meeting Slides and Reminders: DGAC Meeting 6

DGAC Members,

The current versions of your slides for today are attached. If you have not done so already, please prepare your work
space:

Phone line: Dialing in through a landline is preferred over a cell phone or through a computer. A headset connected to a
phone provides the best sound quality.
Computer: You will be watching through the NIH webcast (the same view as the public), but dialing in through your
phone. Test your computer with the links below:
Test your browser using this test page at http://videocast.nih.gov/browsertest/
(There are no live webcasts until ours this morning if you were unable to test watch a live event before today.)

Join the meeting at 9:30 am ET (6:30 am PT) for a sound check and review of procedures. The live webcast begins at 10
am ET (7 am PT). We will do an alphabetical roll call to check the quality of your phone sound at 9:30 am.

Webcast Link: videocast.nih.gov
*Turn the sound off of your computer speakers. Your sound will come from your phone.
Call in: (b) (6)
Leader Passcode: (b) (6)
*After entering the passcode, a recording will prompt you to press *0.
Press *0 for the operator to join you to the call.

Attachments
Agenda
Introduction to Subcommittee Reports (Millen)
SC 1
SC 2
SC 3
SC 4
(SC 5 is not presenting; no slides)
Introduction to the Cross‐cutting Topics of Dietary Guidance and Public Health Importance (Millen)
Sodium WG
Added Sugars WG
Saturated Fat WG
Integration of Findings (Millen, SC/WG Chairs/Leads)

Please let us know if you have any questions. Thanks!

Kellie
170
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Subject: FW: cross reviews of DGAC chapters and timeline for completing report
Attachments: Part_D_Ch6__PA 11-17-14_FINAL FOR CROSS-REVIEW AHL.docx
Should have copied you on this, sorry about that.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Lichtenstein, Alice

To: 'Anne Rodgers'; Nelson, Miriam; Millen, Barbara E (bmillen@bu.edu)
Subject: RE: cross reviews of DGAC chapters and timeline for completing report

Hit at the right time for me to review today. Very exciting to see things come together.
Mim, embedded a few questions for you.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Lichtenstein, Alice; am siegariz@unc.edu; bmillen@bu.edu; c1anderson@ucsd.edu; frank.hu@channing.harvard.edu;
jtb4@cornell.edu; lla9@georgetown.edu; mneuhous@fhcrc.org; mary.story@duke.edu; Nelson, Miriam; rafael.perez-
escamilla@yale.edu; sabrams@bcm.edu; steven.clinton@osumc.edu; campbellw@purdue.edu
Cc: amfiguer@email.unc.edu; Bailey, Lauren A.; Brianna.Knight@osumc.edu; jconnor@fhcrc.org; lhimes@bcm.edu;
PBROWN@hsph.harvard.edu; tc268@georgetown.edu; anjuli.bodyk@yale.edu; jgoyett@purdue.edu;
Richard.Olson@hhs.gov; colette.rihane@cnpp.usda.gov; Amber.Mosher@hhs.gov; Patricia.Britten@cnpp.usda.gov;
171
PSC-HHS-000171
Eve.Essery@cnpp.usda.gov; Katrina.Piercy@hhs.gov; elizabeth.Rahavi@cnpp.usda.gov; dejesusjm@nhlbi.nih.gov;
kellie.casavale@hhs.gov
Subject: cross reviews of DGAC chapters and timeline for completing report
Importance: High

Dear DGAC members,

Some weeks ago, we described that all of the Science Base chapters and several other sections of the report would go
through a cross‐review process. Each of the Science Base chapters will be reviewed by two members; the other sections
will be reviewed by all members. These other sections include the Introduction, the Integration chapter, the overall
Methods chapter, the Glossary, and Needs for Future Research (a complication of all the SCs’ research
recommendations).

Now that the Science Base chapters are nearly completed, I wanted to remind you about the cross‐review process and
explain how it will work. This process will take place over the next 3 weeks.
When a Science Base chapter or other section is ready, I will send it to the reviewers and to Barbara and
Alice. When you review, please focus only on substantive issues (e.g., major omissions or differences with other
chapters), not on editorial issues. The attached guidance provides some things you may want to consider as you
review. Please use the track changes function and marginal notes for your comments.
Reviewers will return the section to me, and I will send it back to the SC and staff for revisions.
When you have completed your review, please return the draft with your comments to me and Kellie. I will
transmit your comments to Barbara, Alice, pertinent members and staff, and the other reviewer.

Here is a table that summarizes the reviewers and projected timeline for cross‐reviews.
SCIENCE BASE CHAPTERS
Reviewers Projected date you will Draft due back to
receive draft Anne and Kellie
Subcommittee 1 Anna Maria, Wayne Monday 11/24 Tuesday 12/1
Subcommittee 2 Steve A, Mim Friday 11/21 Wednesday 12/3
Subcommittee 3 Mary, Frank Wednesday 11/19 Tuesday 11/25
Subcommittee 4 Tom, Steve C Friday 11/21 (all but Monday 12/1 (all but
worksites); Worksites worksites); Worksites
will be sent Monday due 12/2
12/1)
Subcommittee 5 Marian, Rafael Tuesday 11/25 Tuesday 12/2
Physical Activity Cheryl, Lucile Monday 11/17 Monday 11/24
Cross‐cutting Topics (sodium, Rafael, Steve A TBD
added sugars, low‐calorie
sweeteners, saturated fat)
OTHER SECTIONS
Section Reviewers Date you will receive Draft due back to
draft Anne and Kellie
Executive Summary All DGAC members TBD
Report Introduction All DGAC members TBD
Integration chapter All DGAC members TBD
Research Recommendations All DGAC members TBD (discussed by SRSC
11/21)
Methods Marian, Anna Maria, Thursday 11/21 Tuesday 12/2
Wayne

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All of the report’s sections (Front Matter; Introduction, Integration; Methods, Science Base chapters;
Appendices) must be finalized (meaning that reviewers comments are incorporated and final edits completed)
by Friday, December 5. At that time the report will be compiled and sent to you by Tuesday, December 9. This
will allow you several days to review the report in preparation for the final DGAC meeting on Monday,
December 15.
We recognize the very tight deadlines and that you have many other demands on your time. We very much appreciate
all that you are doing to complete the DGAC report on time. If there are any details of your availability or approaches
most convenient for you for cross‐review, please feel free to share those details with me and Kellie so that we can take
them into consideration to make the process as smooth as possible for you.

Thanks,
Anne

Anne Brown Rodgers
Science Writer
(b) (6)
173
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Sent: Thursday, November 20, 2014 5:03 PM
Subject: FW: CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid
Caffeine, Coffee
You should have been copied on this and the string of e-mails. Sorry, I am very behind, got slide
lined yesterday afternoon unexpectedly.
Mike should have gone through different channels to submit his comments.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Mike Jacobson [mailto:mjacobson@cspinet.org]

Sent: Wednesday, November 19, 2014 10:10 PM
To: Frank Hu
Cc: Lichtenstein, Alice; Anna Maria Siega-Riz; Mary Story; Nelson, Miriam
Subject: Re: CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid Caffeine, Coffee
Frank,
Thanks for considering our concerns.
I'm glad to learn that you reviewed those studies. I certainly wouldn't argue that the case-control and cohort studies (and
meta-analyses that include them) can provide definitive evidence. They have inherent limitations, especially for identifying
relatively rare events. But I don't know that sensitive, accurate studies will ever be conducted, so what should women do
in the meantime?
In cases such as this where there's moderate evidence that higher dosages (>200 or 300 mg/d) pose a risk and there's no
evidence for a threshold, I think that the committee should adopt a precautionary stance. The committee could do what
toxicologists do all the time and recommend that, in light of the uncertainty, a safety factor should be applied...and
recommend that women who are (or are trying to become) pregnant "should avoid caffeine-containing foods and drugs, if
possible, or consume them only sparingly," as the FDA wrote about 30 years ago. Why risk such serious outcomes as
miscarriages and stillbirths (and possibly childhood leukemia)? Caffeine and the beverages that contain it are totally
unnecessary in a diet and have caffeine-free counterparts.
Best wishes,
Mike
174
PSC-HHS-000174
Michael F. Jacobson, Ph.D.
Executive Director
Center for Science in the Public Interest
1220 L Street, NW, Suite 300
Washington, DC 20005
(o) 202-777-8328
(f) 202-265-4954
CSPI web site: www.cspinet.org
Make your voice heard on important health and nutrition issues! Join CSPI's online action network at
http://my.cspinet.org
CONFIDENTIALITY NOTICE: This message is intended only for the use of the individual or entity to which it
is addressed and may contain confidential information. If the reader of this message is not the intended
recipient, please be aware that any dissemination, distribution, or copying of this communication or other use of
a transmission received in error is strictly prohibited. If you have received this transmission in error, please
immediately notify me at (202) 777-8328.
Frank Hu <nhbfh@channing.harvard.edu> To Mike Jacobson <mjacobson@cspinet.org>,

cc Frank Hu <frank.hu@channing.harvard.edu>, Mary Story <mary.story@duke.edu>,
11/19/2014 06:20 PM "Nelson, Miriam" <miriam.nelson@tufts.edu>, Alice Lichtenstein
<Alice.Lichtenstein@tufts.edu>, Anna Maria Siega-Riz <am_siegariz@unc.edu>
Subject Re: CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women
Avoid Caffeine, Coffee
thanks, Mike, for your comments.
We actually reviewed this meta-analysis and its methodological issues as well as conclusion carefully. The
study did not identify 100 g caffeine as a risk threshold because it analyzed caffeine as a continuous variable.
Based on their data from the dose-response continuous analysis, the linear positive association was mainly
driven by the higher categories of intake (>300 g/day). One problem is that the meta-analysis mixed cohort
studies with case-control studies, which are prone to recall bias. The authors concluded "There is therefore
insufficient evidence to support further reductions in the maximum recommended intake of caffeine, but
maintenance of current recommendations is a wise precaution."
Based on the data from this and other meta-analyses, our conclusion is pretty cautious:
"Overall, the evidence provides support for current recommendations to limit caffeine intake during pregnancy
as a precaution. Based on existing evidence, pregnant women, or women planning to become pregnant, should
be cautious and adhere to current recommendations of the American Congress of Obstetricians and
Gynecologists regarding caffeine consumption, and not consume more than 200 mg caffeine per day."
Of note, 200 m/d includes non-coffee sources of caffeine, which is not trivial.
175
PSC-HHS-000175
I'm concerned about the methodology of the acute leukemia meta-analysis because it was based on several small
case-control studies, in which the association could be easily be explained by recall bias. In earlier case-control
studies of coffee and heart disease or some cancers, recall bias and confounding by smoking were major
problems because subsequent cohort studies did not substantiated these associations.
Frank
Meta-analyses included 60 unique publications from 53 cohort and case–control studies. An increment of 100 g caffeine
was associated with a 14 % (95 % CI 10–19 %) increase in risk of spontaneous abortion, 19 % (5–35 %) stillbirth, 2 % (-2
to 6 %) preterm delivery, 7 % (1–12 %) low birth weight, and 10 % (95 % CI 6–14 %) SGA. There was substantial
heterogeneity in all models, partly explained by adjustment for smoking and previous obstetric history, but not by
prospective assessment of caffeine intake. There was evidence of small-study effects such as publication bias. Greater
caffeine intake is associated with an increase in spontaneous abortion, stillbirth, low birth weight, and SGA, but not
preterm delivery. There is no identifiable threshold below which the associations are not apparent, but the size of the
associations are generally modest within the range of usual intake and are potentially explained by bias in study design or
publication. There is therefore insufficient evidence to support further reductions in the maximum recommended
intake of caffeine, but maintenance of current recommendations is a wise precaution.
On Wed, Nov 19, 2014 at 1:05 PM, Mike Jacobson <mjacobson@cspinet.org> wrote:
Dear Frank, Mary, Mim, Alice, and Anna Maria,
CSPI submitted this additional comment to the DGAC, but I wanted to make sure you saw it. I think
that the subcommittee's review of the possible risks of caffeine in pregnancy misread the scientific
research and deferred excessively to ACOG's opinion.
Thanks for reading this comment.
Best,
Mike

Executive Director
(o) 202-777-8328
(f) 202-265-4954
176
PSC-HHS-000176
----- Forwarded by M ke Jacobson/Program/CSPI on 11/19/2014 01:00 PM -----
News from CSPI/Program/CSPI
To News from CSPI/Program/CSPI@CSPI,

11/19/2014 10:20 AM
cc
Subject CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid Caffeine, Coffee
For Immediate Release:

Wednesday, November 19, 2014
Contact: Jeff Cronin, 202-777-8370 or Ariana Stone, 202-777-8355
CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid

Caffeine, Coffee
Group Cites Increased Risk of Miscarriage, Childhood Leukemia
WASHINGTON—The federal government may be poised to give women who are or might become
pregnant bad advice on how much caffeine is safe to consume during pregnancy, according to the
Center for Science in the Public Interest. Draft advice from the government’s Dietary Guidelines
Advisory Committee indicates that pregnant women should be sure to limit their caffeine consumption
to 200 milligrams per day. But CSPI says following that advice could increase the risk of adverse
pregnancy outcomes, including spontaneous abortion, stillbirth, preterm delivery, and childhood
leukemia.
The nonprofit group says that the Dietary Guidelines Advisory Committee, which every five years
crafts the government’s official nutrition advice, should instead advise pregnant women to avoid
caffeine-containing foods and beverages. In comments filed today CSPI pointed to a recent meta-
analysis published in the European Journal of Epidemiology which found that a dose as low as 100
mg per day of caffeine was associated with a 14 percent increase in risk of miscarriage, and a 19
percent increase in the risk of stillbirth. Consumption of 100 mg of caffeine per day was also
associated with increased risks of small-for-gestational-age fetuses and low birth weight. Risks
177
PSC-HHS-000177
increase as caffeine dosages increase, according to the study.
To put 100 mg of caffeine into context, a 16-ounce Grande Starbucks coffee has 330 mg of
caffeine. Coffee you brew at home has between 60-150 mg per 5-ounce cup, depending on how it is
brewed. A 20-ounce bottle of Diet Coke has 78 mg.
“Pregnant women deserve accurate advice about the risks caffeine poses to their healthy pregnancy
and have been badly misinformed,” said CSPI chief regulatory affairs attorney Laura
MacCleery. “The Dietary Guidelines for Americans shouldn’t compound this problem by conveying
an impression that 200 milligrams per day is some kind of red line below which caffeine is safe and
above which caffeine is dangerous. Instead, the science indicates that even lower levels of caffeine
can increase the risk of serious problems, including for only a cup or two of regular coffee per day.”
CSPI’s comments indicate flaws in the advice given to pregnant women by the respected American
College of Obstetricians and Gynecologists, which the Dietary Guidelines Advisory Committee cites in
its draft recommendation. ACOG’s analysis of the risk of miscarriage posed by caffeine is thin and
outdated, the group says. While the recent meta-analysis considers 25 separate studies, ACOG
considered only two of those, including the lone study that found no link to an increased risk of
miscarriage.
The Food and Drug Administration used to recommend that pregnant women avoid caffeinated drinks
altogether, or consume them only sparingly. “As a general rule, pregnant women should avoid
substances that have drug-like effects and can cross the placenta,” the agency wrote in a 1981
brochure.
CSPI’s comments also call on the DGAC to consider the risk of childhood leukemia related to drinking
coffee during pregnancy. A 2014 meta-analysis published in the American Journal of Obstetrics and
Gynecology found a dose-related increased risk of childhood acute leukemia associated with
maternal coffee consumption. In comments to the DGAC, epidemiologist Peter Infante called the
evidence linking maternal coffee consumption during pregnancy and childhood acute leukemia
“strong.” In the U.S., lifetime probability of childhood acute leukemia in children aged 0 to 14 is
approximately 73 per 100,000. According to a risk analysis submitted to the DGAC by biostatistician
Steven Bayard, 19 of those cases might be attributable to coffee consumption of one to two cups per
day during pregnancy.
The Dietary Guidelines Advisory Committee meets next on December 15.

###
View this release online.
The Center for Science in the Public Interest is a nonprofit health advocacy group based in Washington, DC,
that focuses on nutrition and food safety policies. CSPI is supported by the 900,000 U.S. and Canadian
subscribers to its Nutrition Action Healthletter and by foundation grants.
Like us on Facebook at http://www.facebook.com/cspinet

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178
PSC-HHS-000178
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179
PSC-HHS-000179

Sent: Thursday, November 20, 2014 5:04 PM
Subject: FW: CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid
Caffeine, Coffee
more
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Sent: Thursday, November 20, 2014 7:31 AM
To: Mike Jacobson
Cc: Lichtenstein, Alice; Anna Maria Siega-Riz; Mary Story; Nelson, Miriam
Subject: CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid Caffeine, Coffee
Mike,
We will discuss your comments in the next conference call. A few further points:
1. I agree that our recommendations need to be cautious, but they should not be overly restrictive without good
data. Besides coffee, tea and chocolate are important sources of caffeine. There is no evidence to exclude these
items from the diets during pregnancy.
2. When it comes to coffee/caffeine, the study design (case-control vs. prospective cohort) does make a big
difference. Many case-control studies in the 1980's and 1990's showed a strong and significant association
between coffee and MI. It is for sure this association was mainly driven by recall bias and confounding by
smoking as numerous prospective studies have now demonstrated that higher coffee consumption is actually
protective against diabetes, CVD, and other outcomes.
3. The only RCT conducted in Denmark showed no effects of caffeine reduction during pregnancy on birth
weight and length of gestation.
BMJ. 2007 Feb 24;334(7590):409. Epub 2007 Jan 26.
Effect of reducing caffeine intake on birth weight and length of gestation:

randomised controlled trial.
Bech BH1, Obel C, Henriksen TB, Olsen J.
180
PSC-HHS-000180
Frank,
Thanks for considering our concerns.
I'm glad to learn that you reviewed those studies. I certainly wouldn't argue that the case-control and
cohort studies (and meta-analyses that include them) can provide definitive evidence. They have
inherent limitations, especially for identifying relatively rare events. But I don't know that sensitive,
accurate studies will ever be conducted, so what should women do in the meantime?
In cases such as this where there's moderate evidence that higher dosages (>200 or 300 mg/d) pose
a risk and there's no evidence for a threshold, I think that the committee should adopt a precautionary
stance. The committee could do what toxicologists do all the time and recommend that, in light of the
uncertainty, a safety factor should be applied...and recommend that women who are (or are trying to
become) pregnant "should avoid caffeine-containing foods and drugs, if possible, or consume them
only sparingly," as the FDA wrote about 30 years ago. Why risk such serious outcomes as
miscarriages and stillbirths (and possibly childhood leukemia)? Caffeine and the beverages that
contain it are totally unnecessary in a diet and have caffeine-free counterparts.
Best wishes,
Mike

Executive Director
(o) 202-777-8328
(f) 202-265-4954
Frank Hu <nhbfh@channing.harvard.edu> To Mike Jacobson <mjacobson@cspinet.org>,
181
PSC-HHS-000181
cc Frank Hu <frank.hu@channing.harvard.edu>, Mary Story <mary.story@duke.edu>,
"Nelson, Miriam" <miriam.nelson@tufts.edu>, Alice Lichtenstein
11/19/2014 06:20 PM
<Alice.Lichtenstein@tufts.edu>, Anna Maria Siega-Riz <am siegariz@unc.edu>
Subject Re: CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women
Avoid Caffeine, Coffee
thanks, Mike, for your comments.
We actually reviewed this meta-analysis and its methodological issues as well as conclusion carefully. The
study did not identify 100 g caffeine as a risk threshold because it analyzed caffeine as a continuous variable.
Based on their data from the dose-response continuous analysis, the linear positive association was mainly
driven by the higher categories of intake (>300 g/day). One problem is that the meta-analysis mixed cohort
studies with case-control studies, which are prone to recall bias. The authors concluded "There is therefore
insufficient evidence to support further reductions in the maximum recommended intake of
caffeine, but maintenance of current recommendations is a wise precaution."
Based on the data from this and other meta-analyses, our conclusion is pretty cautious:
"Overall, the evidence provides support for current recommendations to limit caffeine intake during pregnancy
as a precaution. Based on existing evidence, pregnant women, or women planning to become pregnant, should
be cautious and adhere to current recommendations of the American Congress of Obstetricians and
Gynecologists regarding caffeine consumption, and not consume more than 200 mg caffeine per day."
Of note, 200 m/d includes non-coffee sources of caffeine, which is not trivial.
I'm concerned about the methodology of the acute leukemia meta-analysis because it was based on several small
case-control studies, in which the association could be easily be explained by recall bias. In earlier case-control
studies of coffee and heart disease or some cancers, recall bias and confounding by smoking were major
problems because subsequent cohort studies did not substantiated these associations.
Frank
Meta-analyses included 60 unique publications from 53 cohort and case–control studies. An

increment of 100 g caffeine was associated with a 14 % (95 % CI 10–19 %) increase in risk of
spontaneous abortion, 19 % (5–35 %) stillbirth, 2 % (-2 to 6 %) preterm delivery, 7 % (1–12 %) low
birth weight, and 10 % (95 % CI 6–14 %) SGA. There was substantial heterogeneity in all models,
partly explained by adjustment for smoking and previous obstetric history, but not by prospective
assessment of caffeine intake. There was evidence of small-study effects such as publication bias.
Greater caffeine intake is associated with an increase in spontaneous abortion, stillbirth, low birth
weight, and SGA, but not preterm delivery. There is no identifiable threshold below which the
associations are not apparent, but the size of the associations are generally modest within the range
of usual intake and are potentially explained by bias in study design or publication. There is
therefore insufficient evidence to support further reductions in the maximum recommended
intake of caffeine, but maintenance of current recommendations is a wise precaution.
182
PSC-HHS-000182
Dear Frank, Mary, Mim, Alice, and Anna Maria,
CSPI submitted this additional comment to the DGAC, but I wanted to make sure you saw it. I think
that the subcommittee's review of the possible risks of caffeine in pregnancy misread the scientific
research and deferred excessively to ACOG's opinion.
Thanks for reading this comment.
Best,
Mike

Executive Director
(o) 202-777-8328
(f) 202-265-4954
----- Forwarded by M ke Jacobson/Program/CSPI on 11/19/2014 01:00 PM -----
News from CSPI/Program/CSPI
To News from CSPI/Program/CSPI@CSPI,

11/19/2014 10:20 AM
cc
Subject CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid Caffeine, Coffee
183
PSC-HHS-000183
For Immediate Release:
Wednesday, November 19, 2014
Contact: Jeff Cronin, 202-777-8370 or Ariana Stone, 202-777-8355
CSPI Urges Dietary Guidelines Committee to Recommend Pregnant Women Avoid

Caffeine, Coffee
Group Cites Increased Risk of Miscarriage, Childhood Leukemia
WASHINGTON—The federal government may be poised to give women who are or might become
pregnant bad advice on how much caffeine is safe to consume during pregnancy, according to the
Center for Science in the Public Interest. Draft advice from the government’s Dietary Guidelines
Advisory Committee indicates that pregnant women should be sure to limit their caffeine consumption
to 200 milligrams per day. But CSPI says following that advice could increase the risk of adverse
pregnancy outcomes, including spontaneous abortion, stillbirth, preterm delivery, and childhood
leukemia.
The nonprofit group says that the Dietary Guidelines Advisory Committee, which every five years
crafts the government’s official nutrition advice, should instead advise pregnant women to avoid
caffeine-containing foods and beverages. In comments filed today CSPI pointed to a recent meta-
analysis published in the European Journal of Epidemiology which found that a dose as low as 100
mg per day of caffeine was associated with a 14 percent increase in risk of miscarriage, and a 19
percent increase in the risk of stillbirth. Consumption of 100 mg of caffeine per day was also
associated with increased risks of small-for-gestational-age fetuses and low birth weight. Risks
increase as caffeine dosages increase, according to the study.
To put 100 mg of caffeine into context, a 16-ounce Grande Starbucks coffee has 330 mg of
caffeine. Coffee you brew at home has between 60-150 mg per 5-ounce cup, depending on how it is
brewed. A 20-ounce bottle of Diet Coke has 78 mg.
“Pregnant women deserve accurate advice about the risks caffeine poses to their healthy pregnancy
and have been badly misinformed,” said CSPI chief regulatory affairs attorney Laura
MacCleery. “The Dietary Guidelines for Americans shouldn’t compound this problem by conveying
an impression that 200 milligrams per day is some kind of red line below which caffeine is safe and
above which caffeine is dangerous. Instead, the science indicates that even lower levels of caffeine
can increase the risk of serious problems, including for only a cup or two of regular coffee per day.”
CSPI’s comments indicate flaws in the advice given to pregnant women by the respected American
College of Obstetricians and Gynecologists, which the Dietary Guidelines Advisory Committee cites in
its draft recommendation. ACOG’s analysis of the risk of miscarriage posed by caffeine is thin and
outdated, the group says. While the recent meta-analysis considers 25 separate studies, ACOG
considered only two of those, including the lone study that found no link to an increased risk of
miscarriage.
The Food and Drug Administration used to recommend that pregnant women avoid caffeinated drinks
altogether, or consume them only sparingly. “As a general rule, pregnant women should avoid
184
PSC-HHS-000184
substances that have drug-like effects and can cross the placenta,” the agency wrote in a 1981
brochure.
CSPI’s comments also call on the DGAC to consider the risk of childhood leukemia related to drinking
coffee during pregnancy. A 2014 meta-analysis published in the American Journal of Obstetrics and
Gynecology found a dose-related increased risk of childhood acute leukemia associated with
maternal coffee consumption. In comments to the DGAC, epidemiologist Peter Infante called the
evidence linking maternal coffee consumption during pregnancy and childhood acute leukemia
“strong.” In the U.S., lifetime probability of childhood acute leukemia in children aged 0 to 14 is
approximately 73 per 100,000. According to a risk analysis submitted to the DGAC by biostatistician
Steven Bayard, 19 of those cases might be attributable to coffee consumption of one to two cups per
day during pregnancy.
The Dietary Guidelines Advisory Committee meets next on December 15.

###
View this release online.
The Center for Science in the Public Interest is a nonprofit health advocacy group based in Washington, DC,
that focuses on nutrition and food safety policies. CSPI is supported by the 900,000 U.S. and Canadian
subscribers to its Nutrition Action Healthletter and by foundation grants.
Like us on Facebook at http://www.facebook.com/cspinet

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185
PSC-HHS-000185
tel: 617 432 0113 fax: 617 432 2435
******************************************************
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
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*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
186
PSC-HHS-000186

Sent: Sunday, November 23, 2014 10:51 AM
To: Essery, Eve - CNPP; Campbell, Wayne W; Clinton, Steven
Cc: Casavale, Kellie (OS/OASH); Obbagy, Julie - CNPP; Millen, Barbara E (bmillen@bu.edu)
Subject: RE: DGAC: For review - Sodium chapter content
Commented extensively. In some cases playing the devil’s advocate. This is our last time to think
about certain issues.
We need to give some thought to redundancy through the whole document. Perhaps general
recommendations that are repeated in multiple chapters and sections within chapters can be moved
to the integration chapter. Otherwise, there seems to be a considerable amount of repetition that can
dilute the message.
Having said that it is my personal impression, I understand if others don’t agree. Including Barbara
on this response because I have invoked the “integration” word.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: Lichtenstein, Alice; Campbell, Wayne W; Clinton, Steven
Subject: FW: DGAC: For review - Sodium chapter content

I just renamed the email subject so that everyone sees this is draft chapter content ready for review. See email below
and the attachment… Thanks!

From: Essery, Eve - CNPP
To: 'Anderson, Cheryl'; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'
Subject: RE: DGAC: Cheryl - Sodium chapter content

Hi Cheryl and Sodium Working Group,

Actually, please use the version attached to make comments. This version has all formatting changes accepted, and I’ve
accepted the addition of the major sections (e.g., Introduction and Review of Evidence sections) just so that they are
187
PSC-HHS-000187
easier to read. I kept all tracked changes to the conclusions and implications, since these sections have been discussed
by the group previously.

Working Group – Please review and provide comments on this document by end of day on Monday, Nov 24. Please
review the document in full, since much of the content is new, but place particular emphasis on the conclusions and
implications. Please also review the Needs for Future Research at the end of the document, since these have not been
discussed by the group.

Thanks!!!
Eve

From: Anderson, Cheryl [mailto:c1anderson@ucsd.edu]
To: Essery, Eve - CNPP; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'

Dear SWG: Here is a clean version and a marked up version of the sodium chapter.
Eve: Please let everyone know which one they should mark-up.
All: I have two questions embedded. Both are related to whether we need a conclusion statement about articles
published since Jan 2013? One article is in the blood pressure section, the others are in the CVD section.
Best,
Cheryl
From: Essery, Eve - CNPP [Eve.Essery@fns.usda.gov]

To: Anderson, Cheryl; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'
Subject: DGAC: Cheryl - Sodium chapter content
Hi Cheryl,
As promised, Julie has provided a summary from your NEL evidence portfolio for the (1) sodium and BP in children and
(2) sodium and CVD questions. I have dropped these pieces into the chapter section attached. (This is the same
document I sent you on Saturday. If you have started working on other sections, I’m happy to combine the documents.)

Can you please reply with your estimated date for completion of the draft of this section? It will need to go through
Working Group review before it can be placed into the Cross-Cutting chapter for editing and cross-review. Can you give
me a sense for your timeline so that we can plan accordingly?
Thank you!
Eve

Sent: Saturday, November 15, 2014 8:56 PM
To: Anderson, Cheryl
Cc: Lichtenstein, Alice; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'; Casavale, Kellie (OS/OASH); Obbagy, Julie -
CNPP
Subject: DGAC: Sodium chapter content

Hi Cheryl,
As lead of the Sodium Working Group, as well as the three questions within this section, attached is the chapter template
for the sodium section of the Cross-Cutting chapter. I’ve included the content you presented at the public meeting and
provided comments highlighting areas for you to draft content. Once drafted, the content will go through Working Group
review and then be placed into the larger Cross-Cutting chapter with added sugars and saturated fat. In addition to what
you see here, staff will draft the Methodology section of this chapter describing your approach to answering the individual
188
PSC-HHS-000188
questions. As you know, we are now working on a tight timeline. Can you provide the draft content by Thursday, Nov 20
for Working Group review? If that is not possible, please let me know what is so that I can follow-up with Anne on the
timeline for this section.
Please let me know if you need anything or if you have any questions.
Thank you,
Eve


189
PSC-HHS-000189

Sent: Monday, November 24, 2014 2:34 PM
To: Essery, Eve - CNPP; Campbell, Wayne W; Clinton, Steven; Anderson, Cheryl
Subject: RE: DGAC: Alice - Sodium
Attachments: DGAC Sodium section 11-18-14-1_ca edits for comments AHL.docx
Now I know why no one was throwing eggs at me.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Sent: Monday, November 24, 2014 2:15 PM
To: Lichtenstein, Alice; Campbell, Wayne W; Clinton, Steven; Anderson, Cheryl
Subject: DGAC: Alice - Sodium

Hi Alice,
We did not receive the attachment with your comments to the sodium section that you emailed on Sunday. Can you
resend them? Thank you!
Eve

To: Essery, Eve - CNPP; Campbell, Wayne W; Clinton, Steven

Commented extensively. In some cases playing the devil’s advocate. This is our last time to think
about certain issues.
We need to give some thought to redundancy through the whole document. Perhaps general
recommendations that are repeated in multiple chapters and sections within chapters can be moved
to the integration chapter. Otherwise, there seems to be a considerable amount of repetition that can
dilute the message.
Having said that it is my personal impression, I understand if others don’t agree. Including Barbara
on this response because I have invoked the “integration” word.
190
PSC-HHS-000190
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127


I just renamed the email subject so that everyone sees this is draft chapter content ready for review. See email below
and the attachment… Thanks!

To: 'Anderson, Cheryl'; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'


Actually, please use the version attached to make comments. This version has all formatting changes accepted, and I’ve
accepted the addition of the major sections (e.g., Introduction and Review of Evidence sections) just so that they are
easier to read. I kept all tracked changes to the conclusions and implications, since these sections have been discussed
by the group previously.

Working Group – Please review and provide comments on this document by end of day on Monday, Nov 24. Please
review the document in full, since much of the content is new, but place particular emphasis on the conclusions and
implications. Please also review the Needs for Future Research at the end of the document, since these have not been
discussed by the group.

Thanks!!!
Eve

To: Essery, Eve - CNPP; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'

Dear SWG: Here is a clean version and a marked up version of the sodium chapter.
191
PSC-HHS-000191
All: I have two questions embedded. Both are related to whether we need a conclusion statement about articles
published since Jan 2013? One article is in the blood pressure section, the others are in the CVD section.
Best,
Cheryl

To: Anderson, Cheryl; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'
Hi Cheryl,
As promised, Julie has provided a summary from your NEL evidence portfolio for the (1) sodium and BP in children and
(2) sodium and CVD questions. I have dropped these pieces into the chapter section attached. (This is the same
document I sent you on Saturday. If you have started working on other sections, I’m happy to combine the documents.)

Can you please reply with your estimated date for completion of the draft of this section? It will need to go through
Working Group review before it can be placed into the Cross-Cutting chapter for editing and cross-review. Can you give
me a sense for your timeline so that we can plan accordingly?
Thank you!
Eve

Cc: Lichtenstein, Alice; 'Campbell, Wayne W'; 'steven.clinton@osumc.edu'; Casavale, Kellie (OS/OASH); Obbagy, Julie -
CNPP

Hi Cheryl,
As lead of the Sodium Working Group, as well as the three questions within this section, attached is the chapter template
for the sodium section of the Cross-Cutting chapter. I’ve included the content you presented at the public meeting and
provided comments highlighting areas for you to draft content. Once drafted, the content will go through Working Group
review and then be placed into the larger Cross-Cutting chapter with added sugars and saturated fat. In addition to what
you see here, staff will draft the Methodology section of this chapter describing your approach to answering the individual
questions. As you know, we are now working on a tight timeline. Can you provide the draft content by Thursday, Nov 20
for Working Group review? If that is not possible, please let me know what is so that I can follow-up with Anne on the
Thank you,
Eve


192
PSC-HHS-000192

To: Clinton, Steven; 'Anderson, Cheryl'; Essery, Eve - CNPP
Cc: Wayne W Campbell; Barbara E Millen; Casavale, Kellie (OS/OASH); Obbagy, Julie -
CNPP
Attachments: CLINTON DGAC Sodium section 11-18-14-1_ca edits for comments AHL.docx
Added a few more comments.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

To: 'Anderson, Cheryl'; Essery, Eve - CNPP
Cc: Lichtenstein, Alice; Wayne W Campbell; Barbara E Millen; Kellie Casavale; Obbagy, Julie - CNPP

Here are my comments, want to be very specific and clear, also I favor stronger statement about the need for definitive
studies.
Considering the billions spent on DRUG studies, and even more on HEALTH CARE, we should be able to do a few good
studies!

Sent: Sunday, November 23, 2014 3:49 PM
Cc: Alice.Lichtenstein@tufts.edu; Wayne W Campbell; Clinton, Steven; Barbara E Millen; Kellie Casavale; Obbagy, Julie -
CNPP
Subject: Re: DGAC: For review - Sodium chapter content

Great to have Alice's input (even if playing devil's advocate). It will make the section stronger ‐‐ the next draft will
hopefully be easier.
Cheryl

On Nov 23, 2014, at 8:46 AM, "Essery, Eve ‐ CNPP" <Eve.Essery@fns.usda.gov> wrote:
Just including Cheryl on this email string as well. (Cheryl, Alice, & Wayne ‐ Sorry I just sent you a blank
email. I hit "send" on my phone by accident.) Alice ‐ thx for your quick review!
193
PSC-HHS-000193

Sent from my iPhone

Begin forwarded message:
From: "Essery, Eve ‐ CNPP" <Eve.Essery@fns.usda.gov>
Date: November 23, 2014 at 10:43:34 AM CST
To: "Alice.Lichtenstein@tufts.edu" <Alice.Lichtenstein@tufts.edu>, Cheryl Anderson
<c1anderson@ucsd.edu>, Wayne W Campbell <campbeww@purdue.edu>
Subject: Fwd: DGAC: For review ‐ Sodium chapter content

Sent from my iPhone

From: "Lichtenstein, Alice" <Alice.Lichtenstein@tufts.edu>
To: "Essery, Eve ‐ CNPP" <Eve.Essery@fns.usda.gov>, "Campbell, Wayne
W" <campbeww@purdue.edu>, "Clinton, Steven"
<Steven.Clinton@osumc.edu>
Cc: "Casavale, Kellie (OS/OASH)" <Kellie.Casavale@hhs.gov>, "Obbagy,
Julie ‐ CNPP" <Julie.Obbagy@cnpp.usda.gov>, "Millen, Barbara E
(bmillen@bu.edu)" <bmillen@bu.edu>
Subject: RE: DGAC: For review ‐ Sodium chapter content
Commented extensively. In some cases playing the devil’s

advocate. This is our last time to think about certain issues.

We need to give some thought to redundancy through the
whole document. Perhaps general recommendations that
are repeated in multiple chapters and sections within
chapters can be moved to the integration
chapter. Otherwise, there seems to be a considerable
amount of repetition that can dilute the message.

Having said that it is my personal impression, I understand if
others don’t agree. Including Barbara on this response
because I have invoked the “integration” word.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
194
PSC-HHS-000194


I just renamed the email subject so that everyone sees this is draft
chapter content ready for review. See email below and the
attachment… Thanks!

To: 'Anderson, Cheryl'; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne
W'; 'steven.clinton@osumc.edu'


Actually, please use the version attached to make comments. This
version has all formatting changes accepted, and I’ve accepted the
addition of the major sections (e.g., Introduction and Review of
Evidence sections) just so that they are easier to read. I kept all tracked
changes to the conclusions and implications, since these sections have
been discussed by the group previously.

Working Group – Please review and provide comments on this
document by end of day on Monday, Nov 24. Please review the
document in full, since much of the content is new, but place particular
emphasis on the conclusions and implications. Please also review the
Needs for Future Research at the end of the document, since these have
not been discussed by the group.

Thanks!!!
Eve

To: Essery, Eve - CNPP; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne

Dear SWG: Here is a clean version and a marked up version of the
sodium chapter.
All: I have two questions embedded. Both are related to whether we

need a conclusion statement about articles published since Jan 2013?
One article is in the blood pressure section, the others are in the CVD
section.
195
PSC-HHS-000195
Best,
Cheryl

To: Anderson, Cheryl; 'alice.lichtenstein@tufts.edu'; 'Campbell, Wayne
Hi Cheryl,
As promised, Julie has provided a summary from your NEL evidence
portfolio for the (1) sodium and BP in children and (2) sodium and CVD
questions. I have dropped these pieces into the chapter section
attached. (This is the same document I sent you on Saturday. If you
have started working on other sections, I’m happy to combine the
documents.)

Can you please reply with your estimated date for completion of the draft
of this section? It will need to go through Working Group review before it
can be placed into the Cross-Cutting chapter for editing and cross-
review. Can you give me a sense for your timeline so that we can plan
accordingly?
Thank you!
Eve

Cc: Lichtenstein, Alice; 'Campbell, Wayne W';
'steven.clinton@osumc.edu'; Casavale, Kellie (OS/OASH); Obbagy, Julie -
CNPP

Hi Cheryl,
As lead of the Sodium Working Group, as well as the three questions
within this section, attached is the chapter template for the sodium
section of the Cross-Cutting chapter. I’ve included the content you
presented at the public meeting and provided comments highlighting
areas for you to draft content. Once drafted, the content will go through
Working Group review and then be placed into the larger Cross-Cutting
chapter with added sugars and saturated fat. In addition to what you see
here, staff will draft the Methodology section of this chapter describing
your approach to answering the individual questions. As you know, we
are now working on a tight timeline. Can you provide the draft content by
Thursday, Nov 20 for Working Group review? If that is not possible,
please let me know what is so that I can follow-up with Anne on the
Thank you,
Eve


196
PSC-HHS-000196
This electronic message contains information generated by the
USDA solely for the intended recipients. Any unauthorized
interception of this message or the use or disclosure of the
information it contains may violate the law and subject the violator
to civil or criminal penalties. If you believe you have received this
message in error, please notify the sender and delete the email
immediately.
197
PSC-HHS-000197

Subject: RE: DGAC: Cheryl - Sodium is ready for round 2
Sorry, do not remember discussing. Clearly, it did not gain traction from the 2010 report. It is
technically impossible. Wouldn’t we be better offer recommending changes we know are feasible? I
think it is bad idea to recommend for this report.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Subject: Re: DGAC: Cheryl - Sodium is ready for round 2

Good morning. Yes, it is. It is a carry forward from the 2010 IOM report.

On Nov 26, 2014, at 3:58 AM, "Lichtenstein, Alice" <Alice.Lichtenstein@tufts.edu> wrote:
Does this have to do with the GRAS list issue?

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

198
PSC-HHS-000198
To: Essery, Eve - CNPP; Campbell, Wayne W; Lichtenstein, Alice; Clinton, Steven
Cc: Barbara E Millen; Kellie Casavale; Obbagy, Julie - CNPP
Subject: RE: DGAC: Cheryl - Sodium is ready for round 2

Thanks everyone for your edits. I just took a quick look and it seems that Alice has a significant concern
which would delay our being able to send this forward. I was under the impression that, before the 6th
meeting, the working group agreed with the approach described. Since that is not the case, I will call Eve
to discuss how best to proceed. I have to drive all day tomorrow, but will call Eve on the drive for
advice/instructions, then revise the text tomorrow night (PST).
Best,
Cheryl

To: Campbell, Wayne W; Lichtenstein, Alice; Clinton, Steven; Anderson, Cheryl
Subject: DGAC: Cheryl - Sodium is ready for round 2
Hi Cheryl,
Attached is the latest sodium section with all comments combined from Alice (both sets of her
comments), Steve, and Wayne. When do you think you can have an updated version of the section
ready?
Thanks!
Eve and Julie

To: Lichtenstein, Alice; Clinton, Steven; 'Anderson, Cheryl'; Essery, Eve - CNPP

Here is my 2 cents-worth.
Wayne
From: Lichtenstein, Alice [Alice.Lichtenstein@tufts.edu]

To: Clinton, Steven; 'Anderson, Cheryl'; Essery, Eve - CNPP
Cc: Campbell, Wayne W; Barbara E Millen; Kellie Casavale; Obbagy, Julie - CNPP
Added a few more comments.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
199
PSC-HHS-000199

To: 'Anderson, Cheryl'; Essery, Eve - CNPP
Cc: Lichtenstein, Alice; Wayne W Campbell; Barbara E Millen; Kellie Casavale; Obbagy, Julie - CNPP

Here are my comments, want to be very specific and clear, also I favor stronger statement about the
need for definitive studies.
Considering the billions spent on DRUG studies, and even more on HEALTH CARE, we should be able to
do a few good studies!

Cc: Alice.Lichtenstein@tufts.edu; Wayne W Campbell; Clinton, Steven; Barbara E Millen; Kellie Casavale;
Obbagy, Julie - CNPP
Subject: Re: DGAC: For review - Sodium chapter content

Great to have Alice's input (even if playing devil's advocate). It will make the section stronger ‐‐ the next
draft will hopefully be easier.
Cheryl

On Nov 23, 2014, at 8:46 AM, "Essery, Eve ‐ CNPP" <Eve.Essery@fns.usda.gov> wrote:
Just including Cheryl on this email string as well. (Cheryl, Alice, & Wayne ‐ Sorry I just
sent you a blank email. I hit "send" on my phone by accident.) Alice ‐ thx for your quick
review!

Sent from my iPhone

From: "Essery, Eve ‐ CNPP" <Eve.Essery@fns.usda.gov>
To: "Alice.Lichtenstein@tufts.edu" <Alice.Lichtenstein@tufts.edu>,
Cheryl Anderson <c1anderson@ucsd.edu>, Wayne W Campbell
<campbeww@purdue.edu>
Subject: Fwd: DGAC: For review ‐ Sodium chapter content

Sent from my iPhone

From: "Lichtenstein, Alice"
<Alice.Lichtenstein@tufts.edu>
To: "Essery, Eve ‐ CNPP" <Eve.Essery@fns.usda.gov>,
"Campbell, Wayne W" <campbeww@purdue.edu>,
200
PSC-HHS-000200
"Clinton, Steven" <Steven.Clinton@osumc.edu>
Cc: "Casavale, Kellie (OS/OASH)"
<Kellie.Casavale@hhs.gov>, "Obbagy, Julie ‐ CNPP"
<Julie.Obbagy@cnpp.usda.gov>, "Millen, Barbara E
(bmillen@bu.edu)" <bmillen@bu.edu>
Subject: RE: DGAC: For review ‐ Sodium chapter
content
Commented extensively. In some cases

playing the devil’s advocate. This is our last
time to think about certain issues.

We need to give some thought to redundancy
through the whole document. Perhaps general
recommendations that are repeated in multiple
chapters and sections within chapters can be
moved to the integration chapter. Otherwise,
there seems to be a considerable amount of
repetition that can dilute the message.

Having said that it is my personal impression, I
understand if others don’t agree. Including
Barbara on this response because I have
invoked the “integration” word.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐
Director and Senior Scientist, Cardiovascular Nutrition
Laboratory
Tufts University
Boston, MA 02111

phone: 617 556 3127

[mailto:Eve.Essery@fns.usda.gov]
To: Lichtenstein, Alice; Campbell, Wayne W; Clinton,
Steven
Subject: FW: DGAC: For review - Sodium chapter
content

I just renamed the email subject so that everyone sees
this is draft chapter content ready for review. See email
below and the attachment… Thanks!

201
PSC-HHS-000201
To: 'Anderson, Cheryl'; 'alice.lichtenstein@tufts.edu';
'Campbell, Wayne W'; 'steven.clinton@osumc.edu'


Actually, please use the version attached to make
comments. This version has all formatting changes
accepted, and I’ve accepted the addition of the major
sections (e.g., Introduction and Review of Evidence
sections) just so that they are easier to read. I kept all
tracked changes to the conclusions and implications,
since these sections have been discussed by the group
previously.

Working Group – Please review and provide comments
on this document by end of day on Monday, Nov 24.
Please review the document in full, since much of the
content is new, but place particular emphasis on the
conclusions and implications. Please also review the
Needs for Future Research at the end of the document,
since these have not been discussed by the group.

Thanks!!!
Eve

To: Essery, Eve - CNPP; 'alice.lichtenstein@tufts.edu';

Dear SWG: Here is a clean version and a marked up
version of the sodium chapter.
Eve: Please let everyone know which one they should

mark-up.
All: I have two questions embedded. Both are related to

whether we need a conclusion statement about articles
published since Jan 2013? One article is in the blood
pressure section, the others are in the CVD section.
Best,
Cheryl

To: Anderson, Cheryl; 'alice.lichtenstein@tufts.edu';
202
PSC-HHS-000202
Hi Cheryl,
As promised, Julie has provided a summary from your
NEL evidence portfolio for the (1) sodium and BP in
children and (2) sodium and CVD questions. I have
dropped these pieces into the chapter section attached.
(This is the same document I sent you on Saturday. If
you have started working on other sections, I’m happy to
combine the documents.)

Can you please reply with your estimated date for
completion of the draft of this section? It will need to go
through Working Group review before it can be placed
into the Cross-Cutting chapter for editing and cross-
review. Can you give me a sense for your timeline so
that we can plan accordingly?
Thank you!
Eve

[mailto:Eve.Essery@fns.usda.gov]
Cc: Lichtenstein, Alice; 'Campbell, Wayne W';
'steven.clinton@osumc.edu'; Casavale, Kellie
(OS/OASH); Obbagy, Julie - CNPP

Hi Cheryl,
As lead of the Sodium Working Group, as well as the
three questions within this section, attached is the
chapter template for the sodium section of the Cross-
Cutting chapter. I’ve included the content you presented
at the public meeting and provided comments
highlighting areas for you to draft content. Once drafted,
the content will go through Working Group review and
then be placed into the larger Cross-Cutting chapter with
added sugars and saturated fat. In addition to what you
see here, staff will draft the Methodology section of this
chapter describing your approach to answering the
individual questions. As you know, we are now working
on a tight timeline. Can you provide the draft content by
Thursday, Nov 20 for Working Group review? If that is
not possible, please let me know what is so that I can
follow-up with Anne on the timeline for this section.
Please let me know if you need anything or if you have
any questions.
Thank you,
Eve

Nutritionist | Center for Nutrition Policy and Promotion |
USDA
3101 Park Center Drive, Room 1034 | Alexandria, VA
22302
Eve.Essery@cnpp.usda.gov | Office: 703-305-2563 |
Fax: 703-305-3300
203
PSC-HHS-000203
www.DietaryGuidelines.gov | www.ChooseMyPlate.gov |
www.NEL.gov

This electronic message contains information

generated by the USDA solely for the intended
recipients. Any unauthorized interception of this
message or the use or disclosure of the information
it contains may violate the law and subject the
violator to civil or criminal penalties. If you believe
you have received this message in error, please
notify the sender and delete the email immediately.
204
PSC-HHS-000204

To: Essery, Eve - CNPP; 'Siega-Riz, Anna Maria'; 'alice.lichtenstein@tufts.edu';
'c1anderson@ucsd.edu'; 'jtb4@cornell.edu'; 'steven.clinton@osumc.edu'; 'rafael.perez-
escamilla@yale.edu'; 'Frank Hu'; 'Neuhouser, Marian L'
Cc: Obbagy, Julie - CNPP; Casavale, Kellie (OS/OASH)
Subject: RE: DGAC SC2: Chapter follow-up
Well done summary. I also agree with Frank that perhaps we ought to mention in the discussion of future research or
the rationale. Perhaps we could include something like the following:

Emerging research is exploring alternative dietary pattern approaches to the Low‐carbohydrate, higher protein/fat
dietary pattern. In some approaches (such as Atkins), the dietary pattern which emphasizes animal proteins may
achieve a macronutrient composition that is higher in total and saturated fat. Others may emphasize plant‐based
proteins and fats and may achieve a lower saturated fat content and may be higher in polyunsatured fats. Research is
needed to determine the impact of these alternative approaches, and perhaps others, on CVD risk profiles and other
health outcomes.

Many thanks.

B arbara
bmillen@bu.edu

'steven.clinton@osumc.edu'; 'rafael.perez-escamilla@yale.edu'; Millen, Barbara E; 'Frank Hu'; 'Neuhouser, Marian L'
Subject: DGAC SC2: Chapter follow-up

Hi SC2 members,
As you all know, there has been a continued, and perhaps growing, interest in low-carbohydrate diets, and we have been
asked on numerous occasions why the Dietary Guidelines do not recommend low-carbohydrate diets as the dietary
pattern of choice to the general public. As a result, we met with Anna Maria and Barbara to ask if it would be possible to
include a more direct statement on low-carbohydrate diets in the Subcommittee 2 chapter. In response, Anna Maria has
drafted the following content, which has been added to the SC2 chapter (1) Methodology and (2) Needs for Future
Research. The sections are excerpted below. To support these statements, Anna Maria reviewed search results from
Julie on low-carb diets and the health outcomes considered by SC2. If you’d like more information, please let us know. As
this is just added to the methodology, it’s not a formal recommendation of the DGAC and supports the statements from
the AHA/ACC/TOS Guidelines that were considered for the dietary patterns and body weight question. Please let us know
if you have any questions, comments, or concerns. Your report is instrumental in informing the 2015 Dietary Guidelines,
but it is also extremely helpful to us in addressing these types of questions – now and over the next five years. Happy
Thanksgiving!!
Eve
Excerpt from the SC2 Chapter Methodology

There are a number of studies available in the scientific literature that describe diets based on macronutrient proportion or
only test a specific food group or nutrient in the diet. For example, a low-carbohydrate diet fits this description and has
been of public interest. The 2015 DGAC reviewed the body of evidence related to this type of diet as part of Question 2.
205
PSC-HHS-000205
Additionally, the Committee examined the results of exploratory searches on low-carbohydrate diets (defined as <45% of
calories from carbohydrate) and all of the health outcomes considered by the subcommittee published since 2000.
Overall, it appears that there is limited evidence available to address the relationship between low-carbohydrate diets
(<45% energy from carbohydrate) and health, particularly evidence derived from U.S.-based populations. The most
evidence available focused on low-carbohydrate diets and body weight. The 2010 DGAC examined the relationship
between macronutrient proportion and various body weight outcomes concluding that:
“1) There is strong and consistent evidence that when calorie intake is controlled, macronutrient proportion of the diet
is not related to losing weight; 2) A moderate body of evidence provides no data to suggest that any one
macronutrient is more effective than any other for avoiding weight re-gain in weight reduced persons; 3) A moderate
body of evidence demonstrates that diets with less than 45% of calories as carbohydrates are not more successful for
long-term weight loss (12 months). There is also some evidence that they may be less safe. In shorter-term studies,
low-calorie, high-protein diets may result in greater weight loss, but these differences are not sustained over time; and
4) A moderate amount of evidence demonstrates that intake of dietary patterns with less than 45% calories from
carbohydrate or more than 35% calories from protein are not more effective than other diets for weight loss or weight
maintenance, are difficult to maintain over the long term, and may be less safe.”
The published literature since that review does not provide sufficient evidence to change these conclusions. Thus in
summary, while these studies that examine macronutrient proportion or only test a specific food group or nutrient are
important, they answer different questions related to diet and health and generally did not meet the DGAC’s definition of a
dietary pattern study unless a full description of the dietary pattern consumed was provided and appropriate methods
were used to adjust for the confounding of foods and nutrients.
Needs for Future Research

More research is warranted to examine the long-term cardiometabolic effects of the various dietary patterns identified in
the AHA/ACC/TOS Guidelines for the Management of Overweight and Obesity in Adults capable of resulting in short-term
weight loss (see Question 2). Rationale: While the research to date demonstrates that to lose weight, a variety of dietary
pattern approaches can be used if a reduction in caloric intake is achieved, the long-term effects of these diets on
cardiometabolic health are unknown. As mentioned in the review of the literature associated with saturated fat and
cardiovascular disease in Chapter 6: Cross-Cutting Topics of Dietary Guidance and Public Health Importance, there may
be unintended consequences of substituting one macronutrient for another. Careful consideration to the types of foods
that are used in these diets and in particular the type of fat and amount of added sugars should be taken into account.


206
PSC-HHS-000206

To: Anderson, Cheryl; Perez-Escamilla, Rafael
Cc: Neuhouser, Marian L; Frank Hu; Essery, Eve - CNPP; Siega-Riz, Anna Maria;
alice.lichtenstein@tufts.edu; jtb4@cornell.edu; steven.clinton@osumc.edu; Obbagy,
Julie - CNPP; Casavale, Kellie (OS/OASH)
Very thoughtful comments. Not sure if my earlier comment was circulated in the recent conversation. I agreed with
Anna Maria’s summary and thought a brief explanation of the nuances might be presented (I thought perhaps in future
research since the research on the relative merits of alternative types of carbohydrates, holding other things constant, is
not definitive at this point. It should also be recognized that fat composition may change depending upon the food
sources chosen to increase plant‐based carbohydrates. Happy Thanksgiving! Barbara

From 11.26.2014 8:41 am
Well done summary. I also agree with Frank that perhaps we ought to mention in the discussion of future
research or the rationale. Perhaps we could include something like the following:
Emerging research is exploring alternative dietary pattern approaches to the Low-carbohydrate, higher
protein/fat dietary pattern. In some approaches (such as Atkins), the dietary pattern which emphasizes animal
proteins may achieve a macronutrient composition that is higher in total and saturated fat. Others may
emphasize plant-based proteins and fats and may achieve a lower saturated fat content and may be higher in
polyunsaturated fats. Research is needed to determine the impact of these alternative approaches, and perhaps
others, on CVD risk profiles and other health outcomes.
Many thanks.
B arbara
bmillen@bu.edu

bmillen@bu.edu

To: Perez-Escamilla, Rafael
Cc: Neuhouser, Marian L; Frank Hu; Essery, Eve - CNPP; Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu;
jtb4@cornell.edu; steven.clinton@osumc.edu; Millen, Barbara E; Obbagy, Julie - CNPP; Casavale, Kellie (OS/OASH)
Subject: Re: DGAC SC2: Chapter follow-up
I like what Anna Maria drafted and agree -- thanks for summarizing it so beautifully.
Frank's point about the effects on weight loss is well taken and, from what I can tell, it depends on the outcome.
I was a co-investigator on a recent, moderately sized isocaloric feeding study of 5 weeks duration, testing type
207
PSC-HHS-000207
and amount of carb (OmniCarb). I know some of you saw the abstract and presentation at AHA last spring.
There was no effect of type or amount on CVD risk factors (weight was held stable). This paper is in press.
Consistent with Marian and Rafael's comments, I would like to address it in the implications.
Happy Thanksgiving,
Cheryl
On Nov 26, 2014, at 4:32 PM, "Perez-Escamilla, Rafael" <rafael.perez-escamilla@yale.edu> wrote:
I agree with Anna Maria's recommendation to carry forward 2010 DGAC's work on low carb
diets (with the qualifications that she indicates) and Marian's recommendations below to stick to
evidence reviewed. For example I'm not aware that there is evidence out there to imply that say a
"low carb Mediterranean like diet" is healthier than a "regular carb" Mediterranean diet. I also
think that there are other sections in report that provide the opportunity to recommend dietary
patterns that include healthy fats, and limit saturated fat and refined sugars. So perhaps the
integrative chapter could help bring all of this together without having to over reach beyond the
evidence reviewed.
Best,
Professor of Epidemiology and Public Health

135 College St. (Suite 200)
New Haven CT

Chair, Global Nutrition Council, American Society for Nutrition
Sent from my iPad
On Nov 26, 2014, at 6:35 PM, Neuhouser, Marian L <mneuhous@fredhutch.org> wrote:
I think that what Anna Maria wrote is good and probably sufficient.
Frank - what you mention below is not a research need, but seems more like an
implication but since we did not review these data, not sure we can make this leap. Also
, as you note , not all CHO are created equal but substituting others fats and protein (vs,
say substituting whole grains) has not been sufficiently tested.
My 2 cents
Marian

Cc: Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu;
208
PSC-HHS-000208
jtb4@cornell.edu; steven.clinton@osumc.edu; rafael.perez-escamilla@yale.edu; Millen,
Barbara E; Neuhouser, Marian L; Obbagy, Julie - CNPP; Casavale, Kellie (OS/OASH)
Eve,
I think it is important to acknowledge that not all low carbohydrate diets are
created equal. For example, the original Atkins-type low carb diets are high in
saturated fat, cholesterol, and low in fiber, but plant-based low-carb diets (Eco-
Atkins as David Jenkins called) are high nuts, seeds, legumes, fiber-rich whole
grains, but very low in refined carbs/sugars. These two types of low carb diets
have very different effects on blood lipids in short-term trials and different
associations with risk of type 2 diabetes and CVD in long-term prospective cohort
studies. A Med-type of low carb diets high in healthy sources of protein and fat
was shown to have benefits on blood glucose, body weight, and blood lipids
within 2 years (Shai et al. NEJM 2008).
I wish that the committee has more time to summarize and update the RCT and
cohort evidence on low-carb DIETS and various health outcomes. In any event,
we should not simply dismiss the role of low-carb diets in weight control and
improving overall health outcomes. Instead, we should say that when individuals
cut back on refined carbs/added sugar, they should use healthy sources of fat and
protein as replacement instead of saturated fat-rich food sources.
Frank
On Wed, Nov 26, 2014 at 8:50 AM, Essery, Eve - CNPP

<Eve.Essery@fns.usda.gov> wrote:
Hi SC2 members,
As you all know, there has been a continued, and perhaps growing, interest in low-
carbohydrate diets, and we have been asked on numerous occasions why the Dietary
Guidelines do not recommend low-carbohydrate diets as the dietary pattern of choice to
the general public. As a result, we met with Anna Maria and Barbara to ask if it would be
possible to include a more direct statement on low-carbohydrate diets in the
Subcommittee 2 chapter. In response, Anna Maria has drafted the following content,
which has been added to the SC2 chapter (1) Methodology and (2) Needs for Future
Research. The sections are excerpted below. To support these statements, Anna Maria
reviewed search results from Julie on low-carb diets and the health outcomes considered
by SC2. If you’d like more information, please let us know. As this is just added to the
methodology, it’s not a formal recommendation of the DGAC and supports the
statements from the AHA/ACC/TOS Guidelines that were considered for the dietary
patterns and body weight question. Please let us know if you have any questions,
comments, or concerns. Your report is instrumental in informing the 2015 Dietary
Guidelines, but it is also extremely helpful to us in addressing these types of questions –
now and over the next five years. Happy Thanksgiving!!
209
PSC-HHS-000209
Eve
There are a number of studies available in the scientific literature that describe diets
based on macronutrient proportion or only test a specific food group or nutrient in the
diet. For example, a low-carbohydrate diet fits this description and has been of public
interest. The 2015 DGAC reviewed the body of evidence related to this type of diet as
part of Question 2. Additionally, the Committee examined the results of exploratory
searches on low-carbohydrate diets (defined as <45% of calories from carbohydrate) and
all of the health outcomes considered by the subcommittee published since 2000.
Overall, it appears that there is limited evidence available to address the relationship
between low-carbohydrate diets (<45% energy from carbohydrate) and health,
particularly evidence derived from U.S.-based populations. The most evidence available
focused on low-carbohydrate diets and body weight. The 2010 DGAC examined the
relationship between macronutrient proportion and various body weight outcomes
concluding that:
“1) There is strong and consistent evidence that when calorie intake is controlled,
macronutrient proportion of the diet is not related to losing weight; 2) A moderate
body of evidence provides no data to suggest that any one macronutrient is more
effective than any other for avoiding weight re-gain in weight reduced persons; 3) A
moderate body of evidence demonstrates that diets with less than 45% of calories as
carbohydrates are not more successful for long-term weight loss (12 months). There
is also some evidence that they may be less safe. In shorter-term studies, low-
calorie, high-protein diets may result in greater weight loss, but these differences are
not sustained over time; and 4) A moderate amount of evidence demonstrates that
intake of dietary patterns with less than 45% calories from carbohydrate or more than
35% calories from protein are not more effective than other diets for weight loss or
weight maintenance, are difficult to maintain over the long term, and may be less
safe.”
The published literature since that review does not provide sufficient evidence to change
these conclusions. Thus in summary, while these studies that examine macronutrient
proportion or only test a specific food group or nutrient are important, they answer
different questions related to diet and health and generally did not meet the DGAC’s
definition of a dietary pattern study unless a full description of the dietary pattern
consumed was provided and appropriate methods were used to adjust for the
confounding of foods and nutrients.
More research is warranted to examine the long-term cardiometabolic effects of the

various dietary patterns identified in the AHA/ACC/TOS Guidelines for the Management
of Overweight and Obesity in Adults capable of resulting in short-term weight loss (see
Question 2). Rationale: While the research to date demonstrates that to lose weight, a
variety of dietary pattern approaches can be used if a reduction in caloric intake is
achieved, the long-term effects of these diets on cardiometabolic health are unknown. As
mentioned in the review of the literature associated with saturated fat and cardiovascular
disease in Chapter 6: Cross-Cutting Topics of Dietary Guidance and Public Health
Importance, there may be unintended consequences of substituting one macronutrient for
another. Careful consideration to the types of foods that are used in these diets and in
particular the type of fat and amount of added sugars should be taken into account.
210
PSC-HHS-000210
This electronic message contains information generated by the USDA solely for
the intended recipients. Any unauthorized interception of this message or the use
or disclosure of the information it contains may violate the law and subject the
violator to civil or criminal penalties. If you believe you have received this
message in error, please notify the sender and delete the email immediately.
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
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211
PSC-HHS-000211

To: Siega-riz, Anna Maria; Neuhouser, Marian L; Frank Hu; Essery, Eve - CNPP
Cc: Millen, Barbara E; c1anderson@ucsd.edu; jtb4@cornell.edu; steven.clinton@osumc.edu;
rafael.perez-escamilla@yale.edu; Obbagy, Julie - CNPP; Casavale, Kellie (OS/OASH)
I have been keeping up with all the back and forth about low-carb diets. I too am concern about
entering into a nonsystematic review at this point and clearly there is no time for a SR. I am also
concerned about carrying forward the 2010 material because so much has been published since
then. Hindsight is always helpful. However, we did not think to include a question on low-carb diets.
I think Anna Maria hit the right balance, notwithstanding a few tweaks as suggested.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Siega-riz, Anna Maria [mailto:am_siegariz@unc.edu]

To: Neuhouser, Marian L; Frank Hu; Essery, Eve - CNPP
Cc: Millen, Barbara E; Lichtenstein, Alice; c1anderson@ucsd.edu; jtb4@cornell.edu; steven.clinton@osumc.edu;
rafael.perez-escamilla@yale.edu; Obbagy, Julie - CNPP; Casavale, Kellie (OS/OASH)
Folks,
Julie and the NEL did conduct a review on low carb for us though we are not adding it as a formal question for reasons that we
mention in the methodology section. Overall, the totality of the evidence does not support us saying very much at all. It is
attached for your review and we can discuss further on the call this week.
Anna Maria Siega-Riz, PhD
and
Phone: 919‐966‐5984 (Epi) or 919‐962‐6120 (CPC) new as of 6/18/14;

212
PSC-HHS-000212
From: <Neuhouser>, Marian L <mneuhous@fredhutch.org>
Date: Saturday, November 29, 2014 at 3:02 PM
To: Frank Hu <nhbfh@channing.harvard.edu>, Eve Essery <Eve.Essery@fns.usda.gov>
Cc: DrPH Barbara Millen <bmillen@bu.edu>, Anna Siega‐Riz <am siegariz@unc.edu>, Alice Lichtenstein
<Alice.Lichtenstein@tufts.edu>, "c1anderson@ucsd.edu" <c1anderson@ucsd.edu>, "'jtb4@cornell. edu'"
<jtb4@cornell.edu>, Steven Clinton <steven.clinton@osumc.edu>, Rafael Perez‐Escamilla <rafael.perez‐
escamilla@yale.edu>, Julie Obbagy <Julie.Obbagy@cnpp.usda.gov>, Kellie Casavale <Kellie.Casavale@hhs.gov>
Subject: RE: DGAC SC2: Chapter follow‐up

I am a little concerned about the timeline and feeling that we don't have time to add a new question on low CARB diets -
even a narrative non-systematic review would not be consistent with methods we have done for all the other dietary
patterns.
Marian

Cc: Millen, Barbara E; Siega-Riz, Anna Maria; alice.lichtenstein@tufts.edu; c1anderson@ucsd.edu; jtb4@cornell.edu;
steven.clinton@osumc.edu; rafael.perez-escamilla@yale.edu; Neuhouser, Marian L; Obbagy, Julie - CNPP; Casavale, Kellie
(OS/OASH)
Happy Thanksgiving to everyone!
Hi Eve, Anna Maria, Barbara,
Thanks for the summary of low-carb pattern, which looks very good overall. Attached please find some
comments/edits. Given the popularity of such pattern and enormous amount of research that has been generated
in the past several years, I was wondering if we should have a separate section on low-carb diets rather than
burying it in the Methodology section. People who are familiar with the field may complain that we gloss over
recent evidence and don’t give low-carb diets (under many different names: Atkins, eco-Atkins, South Beach,
Paleo, Zone et al.) sufficient attention that they deserve.
If we decide to do a separate section on low-carb diets, we can still carry forward the 2010 DGAC conclusions,
but provide more background and contextual information, and also be more specific about the long-term safety
issues of such diets. A narrative non-systematic update of the literature, especially on the emerging evidence on
healthy versions of low-carb diets, can be useful given that NEL review is probably not feasible given the time
constraint. Since low-carb diets are recommended as one of the options for weight loss, i think it is important for
the committee to consider clinical and public health implications of such diet and its healthy variations. As
suggested by several committee members, this should be considered in conjunction with the sections on
saturated fat and added sugars.
Thanks for considering this idea.
Best regards
213
PSC-HHS-000213
Frank
On Wed, Nov 26, 2014 at 10:29 AM, Essery, Eve - CNPP <Eve.Essery@fns.usda.gov> wrote:
There is certainly still time to make revisions to what is included in your report. To help facilitate that, I’ve dropped this
content into the attached Word document and added Barbara’s suggestion below. Please edit, add, revise the statements
as you’d like, and we can drop the final content into the chapter early next week. Thank you!

To: Essery, Eve - CNPP; 'Siega-Riz, Anna Maria'; 'alice.lichtenstein@tufts.edu'; 'c1anderson@ucsd.edu';
'jtb4@cornell.edu'; 'steven.clinton@osumc.edu'; 'rafael.perez-escamilla@yale.edu'; 'Frank Hu'; 'Neuhouser, Marian L'
Well done summary. I also agree with Frank that perhaps we ought to mention in the discussion of future
research or the rationale. Perhaps we could include something like the following:
Emerging research is exploring alternative dietary pattern approaches to the Low-carbohydrate, higher
protein/fat dietary pattern. In some approaches (such as Atkins), the dietary pattern which emphasizes animal
proteins may achieve a macronutrient composition that is higher in total and saturated fat. Others may
emphasize plant-based proteins and fats and may achieve a lower saturated fat content and may be higher in
polyunsatured fats. Research is needed to determine the impact of these alternative approaches, and perhaps
others, on CVD risk profiles and other health outcomes.
Many thanks.
B arbara
bmillen@bu.edu

214
PSC-HHS-000214
'steven.clinton@osumc.edu'; 'rafael.perez-escamilla@yale.edu'; Millen, Barbara E; 'Frank Hu'; 'Neuhouser, Marian L'
Subject: DGAC SC2: Chapter follow-up
Hi SC2 members,
As you all know, there has been a continued, and perhaps growing, interest in low-carbohydrate diets, and we have been
asked on numerous occasions why the Dietary Guidelines do not recommend low-carbohydrate diets as the dietary
pattern of choice to the general public. As a result, we met with Anna Maria and Barbara to ask if it would be possible to
include a more direct statement on low-carbohydrate diets in the Subcommittee 2 chapter. In response, Anna Maria has
drafted the following content, which has been added to the SC2 chapter (1) Methodology and (2) Needs for Future
Research. The sections are excerpted below. To support these statements, Anna Maria reviewed search results from
Julie on low-carb diets and the health outcomes considered by SC2. If you’d like more information, please let us know. As
this is just added to the methodology, it’s not a formal recommendation of the DGAC and supports the statements from
the AHA/ACC/TOS Guidelines that were considered for the dietary patterns and body weight question. Please let us know
if you have any questions, comments, or concerns. Your report is instrumental in informing the 2015 Dietary Guidelines,
but it is also extremely helpful to us in addressing these types of questions – now and over the next five years. Happy
Thanksgiving!!
Eve
There are a number of studies available in the scientific literature that describe diets based on macronutrient proportion or
only test a specific food group or nutrient in the diet. For example, a low-carbohydrate diet fits this description and has
been of public interest. The 2015 DGAC reviewed the body of evidence related to this type of diet as part of Question 2.
Additionally, the Committee examined the results of exploratory searches on low-carbohydrate diets (defined as <45% of
calories from carbohydrate) and all of the health outcomes considered by the subcommittee published since 2000.
Overall, it appears that there is limited evidence available to address the relationship between low-carbohydrate diets
(<45% energy from carbohydrate) and health, particularly evidence derived from U.S.-based populations. The most
evidence available focused on low-carbohydrate diets and body weight. The 2010 DGAC examined the relationship
between macronutrient proportion and various body weight outcomes concluding that:
“1) There is strong and consistent evidence that when calorie intake is controlled, macronutrient proportion of the diet
is not related to losing weight; 2) A moderate body of evidence provides no data to suggest that any one
macronutrient is more effective than any other for avoiding weight re-gain in weight reduced persons; 3) A moderate
body of evidence demonstrates that diets with less than 45% of calories as carbohydrates are not more successful for
long-term weight loss (12 months). There is also some evidence that they may be less safe. In shorter-term studies,
low-calorie, high-protein diets may result in greater weight loss, but these differences are not sustained over time; and
4) A moderate amount of evidence demonstrates that intake of dietary patterns with less than 45% calories from
carbohydrate or more than 35% calories from protein are not more effective than other diets for weight loss or weight
maintenance, are difficult to maintain over the long term, and may be less safe.”
The published literature since that review does not provide sufficient evidence to change these conclusions. Thus in
summary, while these studies that examine macronutrient proportion or only test a specific food group or nutrient are
important, they answer different questions related to diet and health and generally did not meet the DGAC’s definition of a
dietary pattern study unless a full description of the dietary pattern consumed was provided and appropriate methods
were used to adjust for the confounding of foods and nutrients.
More research is warranted to examine the long-term cardiometabolic effects of the various dietary patterns identified in
the AHA/ACC/TOS Guidelines for the Management of Overweight and Obesity in Adults capable of resulting in short-term
215
PSC-HHS-000215
weight loss (see Question 2). Rationale: While the research to date demonstrates that to lose weight, a variety of dietary
pattern approaches can be used if a reduction in caloric intake is achieved, the long-term effects of these diets on
cardiometabolic health are unknown. As mentioned in the review of the literature associated with saturated fat and
cardiovascular disease in Chapter 6: Cross-Cutting Topics of Dietary Guidance and Public Health Importance, there may
be unintended consequences of substituting one macronutrient for another. Careful consideration to the types of foods
that are used in these diets and in particular the type of fat and amount of added sugars should be taken into account.
www.DietaryGuidelines.gov|www.ChooseMyPlate.gov| www.NEL.gov
--
*******************************************************
tel: 617 432 0113 fax: 617 432 2435
******************************************************
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To: Mary Story, Ph.D.; Nelson, Miriam
Subject: RE: added sugar implication statement
Mary, tried to follow the e-mail trail but not clear what is the FDA’s response. I am okay leaving
things as they are written, however, as indicated previously, given the experience with TFA, expecting
a DV any time soon is unrealistic. The impact of listing TFA on the Nutrient Facts label without a DV
was enormous.
Having said that, you are more knowledgeable about this than I am.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Mary Story, Ph.D. [mailto:mary.story@duke.edu]

To: Nelson, Miriam; Lichtenstein, Alice
Subject: Re: added sugar implication statement
Mim and Alice,
I think we should leave the Implications stateemnt as we had it and not make any changes based o nthe FDA
response. Please see the short string of emails below. Can you let me know if you agree.
After I hear your thoguhts I can talk with Marian.
Mary

From: <Essery>, Eve ‐ CNPP <Eve.Essery@fns.usda.gov>
Date: Wednesday, November 26, 2014 11:09 AM
To: Mary Story <mary.story@duke.edu>, "Miriam (Mim) E. Nelson, PhD, MS" <miriam.nelson@tufts.edu>,
"alice.lichtenstein@tufts.edu" <alice.lichtenstein@tufts.edu>
Cc: "Britten, Patricia ‐ CNPP" <Patricia.Britten@cnpp.usda.gov>

Hi Mary – This was just FYI based on your and Marian’s request to touch base with Essie. You can certainly leave them in,
as is. You are correct that you can provide such advice. I will include a statement about consumer research for FOP that
you can review and edit when I send the chapter to you – hopefully soon! Thank you.

217
PSC-HHS-000217
To: Essery, Eve - CNPP; Miriam (Mim) E. Nelson, PhD, MS; alice.lichtenstein@tufts.edu
Cc: Britten, Patricia - CNPP
Thanks you Eve for sending us the FDA comments. I would like to leave the Implications statement as we have
written and only make the recommendation in the research section that we need more consumer research on the
FoP. The IOM report which we cite clearly recommened a standardized FoP label and support for such a lable. We
do not mention FDA at all in either of the statements. Also it sounds from Esse's message that the committee can
provide such advice.

So I would like to leave everything in the Implications statement as is and only add a research recommendation
that consumer research be done for FoP.
Also I think the process is that the committee decides and should not be influenced by a government agency.

Alice and Mim please weigh in.
Mary

From: <Essery>, Eve ‐ CNPP <Eve.Essery@fns.usda.gov>
Date: Wednesday, November 26, 2014 10:44 AM
To: Mary Story <mary.story@duke.edu>, "Britten, Patricia ‐ CNPP" <Patricia.Britten@cnpp.usda.gov>
Cc: "Miriam (Mim) E. Nelson, PhD, MS" <miriam.nelson@tufts.edu>, "alice.lichtenstein@tufts.edu"
<alice.lichtenstein@tufts.edu>

Hi Mary – Yes, I will add this statement to the final.

Also, as requested, I emailed Essie about the bullets pertaining to FDA. Please see her responses below.

DGAC implication: The Nutrition Facts Panel (NFP) should include added sugars (in grams and teaspoons) and
include a percent daily value, to assist consumers in making informed dietary decisions by identifying the
amount of added sugar in foods and beverages.

FDA response: While such advice may be provided by the DGAC, there are a number of issues that FDA must
consider as a regulatory agency before forming a decision in the rule making process. We have issued a
proposed rule on the NFL and currently are in the process of reviewing the public comments.

DGAC implication: Consumers would benefit from a standardized, easily understood front‐of‐package (FOP)
label on all food and beverage products to give clear guidance about a food’s healthfulness. An example is the
FOP label recommended by the Institute of Medicine (ref), which included calories, and 0 to 3 “nutritional”
points for added sugar, saturated fat, and sodium. This would be integrated with the NFP, allowing consumers
to quickly and easily identify nutrients of concern for over‐consumption, in order to make healthier choices

FDA response: Such advice may be provided by the DGAC, but as mentioned above, there are a number of
issues that FDA must consider as a regulatory agency. We are wondering whether this suggestion is based on
a review of consumer research that has shown that “Consumer would benefit from a standardized, easily
understood front of package……“. Currently, there are many questions in regard to establishing an FOP and
FDA is evaluating all of the issues. What would help FDA the most in coming to any determination on FOP
labeling is more consumer research.

218
PSC-HHS-000218

To: Britten, Patricia - CNPP
Cc: Essery, Eve - CNPP; Miriam (Mim) E. Nelson, PhD, MS; alice.lichtenstein@tufts.edu
Thanks Trish for doing this.

My preference is the first choice.
Eve, could you make this change please
Sent from my iPhone
On Nov 26, 2014, at 8:15 AM, "Britten, Patricia - CNPP" <Patricia.Britten@cnpp.usda.gov> wrote:
Hi Mary,
I sent the table below to Eve yesterday in anticipation of your request. Alice’s suggested addition
was: “Currently, the mean intake of added sugars in the U.S. population is 13%, and x%, y%, and
z % in children, adolescents and young adults.”

However, looking at the table, It is really children 9 and older who would fit into this higher
intake group. Because we also have separate data for males and females, I would suggest using
a range and modifying the groups so that young children are not included.
Two suggestions:
“Currently, the mean intake of added sugars in the U.S. population is 13%, and from 15% to
17% in children 9 and older, adolescents and young adults.”
OR
“Currently, the mean intake of added sugars in the U.S. population is 13%, and 15% to 17% in
pre‐adolescents, adolescents and young adults.”

Trish

Mean Intake Mean energy Percent of
2007‐10 intake 2007‐10 caloaries from
(from NCI) added sugars
Males
150 1426
1 to 3 10.5%
252 1771
4 to 8 14.2%
341 2033
9 to 13 16.8%
394 2374
14-18 16.6%
376 2517
19-30 14.9%
328 2551
31-50 12.9%
264 2256
51-70 11.7%
224 1881
71+ 11.9%
Females
135 1330
1 to 3 10.2%
219
PSC-HHS-000219
229 1657
4 to 8 13.8%
282 1827
9 to 13 15.4%
281 1751
14-18 16.0%
267 1820
19-30 14.7%
242 1797
31-50 13.5%
200 1715
51-70 11.7%
174 1520
71+ 11.4%
268 1996
ALL 1+ 13.4%

To: Essery, Eve - CNPP; Britten, Patricia - CNPP; 'Miriam (Mim) E. Nelson, PhD, MS'
Cc: 'alice.lichtenstein@tufts.edu'
Subject: added sugar implication statement
Hi Eve, Trish and Mim,

I just sent Eve the final draft which has received input from the Added Sugars working group. Alice
had some good edits that I incorporated int othis near final draft. Trish please look at the draft.
Alice suggested a change to add the mean percent intake of added sugars for children, adolescents
and young adolescents. Can you add that info in the text?

Mim, the first paragraph has changed slightly because of Alice's edits and so if you please look at it.

I think it is looking good.

Eve, sending it to you now for the next steps.
Mary
email immediately.
220
PSC-HHS-000220

Sent: Wednesday, December 03, 2014 8:54 AM
Subject: RE: DGAC: For Alice
On a call now. Overwhelmed with all the reviewing and calls. I have to get back to my
responsibilities at Tufts. Someone else will have to do this.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

Sent: Monday, December 01, 2014 10:12 AM
Subject: DGAC: For Alice

Hi Alice,
I believe that you volunteered (or were volunteered?) to lead the cross-cutting chapter. As I think you’ve seen, over the
past two weeks, there has been a lot of back and forth on sodium, added sugars, and saturated fat. There’s still more fine
tuning to come (e.g., the sodium section); however, attached is the current draft chapter.
Can you review the chapter Introduction (pg 1) and Summary (pg 24) and let me know if you have any edits, additions,
re-writes? Since each of the topic sections provide their own introductions and the implications almost serve as the topic
summaries, I really just pulled together a basic intro and summary for the chapter. I’m attaching the complete draft
chapter, but it’s really here just to give you the basic framework. A lot of pieces are still under review; so, please don’t do a
full review of the chapter just yet!
Thanks!
Eve


221
PSC-HHS-000221
222
PSC-HHS-000222

Sent: Friday, December 05, 2014 5:14 AM
Subject: RE: For review: 12.5.14 SRSC Meeting 59 Agenda.docx
Attachments: 11 21 14 SRSC Meeting 58 draft notes bem edits 12 5 2014.docx; 12 5 14 SRSC
Meeting 59 Agenda bem edits 12 4 2014.docx
Hi Kelly,

Here are the documents for today’s call. See my notes and edits from the minutes of our last call. Let’s put healthcare
onto the agenda for today’s call (just an update on what came of the final reviews on the recommendation that we try
to frame our evidence so as to help those in HHS and healthcare‐related position to consider the report and use it in
policy/program development. This would particularly entail the evidence on population health risks and disparities, links
between dietary patterns and health outcomes, and evidence on what works at individual and population levels to
change behavior for health promotion and disease prevention).

I have not had any feedback on the revised theme or individual recommendations that I circulated since our call. I think
Alice is very busy keeping track of the iterations on saturated fat and the cross‐cutting topics and may not have had a
chance to iterate. I’m feeling that it is premature to circulate anything to the full DGAC and we may not have anything
until EOB Monday and then, only if Alice, SRSC and others can provide feedback. Timing is very tight and I think we may
also need to sandwich in another SRSC call mid week to review the model, the integration chapter and the
introduction. Your thoughts?

Barbara

bmillen@bu.edu

Sent: Thursday, December 04, 2014 7:59 PM
Subject: FW: For review: 12.5.14 SRSC Meeting 59 Agenda.docx
Importance: High

Barbara‐ I don’t see that I have heard back on this agenda for SRSC tomorrow. I can send it in the morning. But do have a
few questions in it for you before I can get it out the door. Thanks!

Kellie


Sent: Wednesday, December 03, 2014 5:11 PM
To: bmillen@bu.edu
Subject: For review: 12.5.14 SRSC Meeting 59 Agenda.docx
Importance: High
223
PSC-HHS-000223

Barbara‐ A draft agenda is attached for SRSC Friday for your review. A few questions for you in it. I have an all‐day
meeting tomorrow‐ so I will send this after COB/5:30 pm. Draft notes are attached as well.

Thanks,

Kellie
224
PSC-HHS-000224

Sent: Friday, December 05, 2014 5:55 PM
Cc: Casavale, Kellie (OS/OASH); Anne Rodgers; Braunstein, Nadine (OS/OASH)
Subject: introduction and Integration
Attachments: Integrated OVERARCHING THEMES and Recommendations with popultion added bem
12 5 2014 (2).docx; Part B Chapter 1_Introduction_v1_12-5-14.doc
HI Alice,

The big outstanding items from the morning SRSC call are the completion of the introduction and integration chapters
and the conceptual model. It was proposed that you and I work over the weekend with Kellie and Anne to prepare the
chapters in draft and then circulate them on Monday to the DGAC with a very short turnaround deadline so they can go
out on Tuesday to the DGAC with the rest of the report. We want to be sure we have covered the overarching themes
and recommendations and resolved outstanding issues from the previous reviews. I will work with Nadine if she’s
available to review things that remain on the conceptual model. Not sure if you have had the time to review the
revisions I did on the integration chapter but your input would be very much appreciated.

Is there a time over the weekend that you have up to an hour to review the current draft of the integration chapter and
introduction. Both are attached for your review. The only time I am definitely not available is noon or about 3
tomorrow.

Nadine, can you let me know your availability too?

Many thanks.

Barbara

bmillen@bu.edu

To: Anne Rodgers; 'Perez-Escamilla, Rafael'; 'Abrams, Steven A'; Millen, Barbara E; frank.hu@channing.harvard.edu;
Eve.Essery@cnpp.usda.gov
Cc: 'Casavale, Kellie (OS/OASH)'; Richard.Olson@hhs.gov; colette.rihane@cnpp.usda.gov; 'Bodyk, Anjuli';
lhimes@bcm.edu; Bailey, Lauren A.; PBROWN@hsph.harvard.edu
Subject: RE: REVISED SATURATED FAT IMPLICATION FOR YOUR REVIEW

Looks fine to me, just one word change.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111
225
PSC-HHS-000225

phone: 617 556 3127
From: Anne Rodgers [mailto:abrodgers@verizon.net]

To: 'Perez-Escamilla, Rafael'; 'Abrams, Steven A'; 'Millen, Barbara E'; Lichtenstein, Alice; frank.hu@channing.harvard.edu;
Subject: REVISED SATURATED FAT IMPLICATION FOR YOUR REVIEW

All,

Based on very recent comments from Barbara and Alice, Frank has revised the saturated fat implications
statement. Please review this and send any comments to me and Kellie by Friday, December 5.

Thanks very much,
Anne

Anne Brown Rodgers
Science Writer
(b) (6)

226
PSC-HHS-000226

Sent: Saturday, December 06, 2014 7:39 AM
Subject: RE: introduction and Integration
Attachments: Part B Chapter 1_Introduction_v1_12-5-14 bem edits 12 6 2015.doc
An iteration on Anne’s edits to the introduction. Barbara

bmillen@bu.edu

To: 'Lichtenstein, Alice'
Cc: 'Casavale, Kellie (OS/OASH)'; Anne Rodgers; Braunstein, Nadine (OS/OASH) (Nadine.Braunstein@hhs.gov)

HI Alice,


tomorrow.


Many thanks.

Barbara

bmillen@bu.edu


227
PSC-HHS-000227
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127
From: Anne Rodgers [mailto:abrodgers@verizon.net]


All,


Thanks very much,
Anne

Anne Brown Rodgers
Science Writer
(b) (6)

228
PSC-HHS-000228

12 6 2014 (3).docx
Hi Alice,

Another iteration on the Integration chapter. I think the formatting is much better now and hopefully the themes and
recommendations are clearer, bolder and as specific as possible. I would recommend that you review it in the ‘final’
review format so the edits are not so overwhelming.

Let me know what you think and if a call would be helpful.

Barbara
bmillen@bu.edu


About to leave for a flight back to return to Boston. Will review then.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127


HI Alice,

229
PSC-HHS-000229

tomorrow.


Many thanks.

Barbara

bmillen@bu.edu


‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127


All,

230
PSC-HHS-000230

Thanks very much,
Anne

Anne Brown Rodgers
Science Writer
(b) (6)
231
PSC-HHS-000231

12 5 2014 (2) AHL.docx
Incredible job of pulling this together so quickly, particularly given my abandonment of the task.
I apologize for my grumpiness on the call yesterday. I have a critical grant that has a submission
date of Jan 2 and delayed writing it until I finished working on all the DGCA sections. This has really
hurt the people in my group and collaborators who are involved with the grant. I now need to work on
it in overdrive and deal with all the final papers in my Nutritional Biochem course in order to submit
the grades. Having said that I will respond to DGAC issues. Please convey my apology to others.
Regarding comments on the attached file, thy are numerous, as usual from me. Don’t panic. Some
are comments/questions. Some highlight concerns about repetition with the section. Instead of
working on my grant and grading I have spent quite a few hours on this document. I absolutely have
to drop out for the rest of the weekend.
There is only one issue of semi-major concern. As stated in the excellent opening section our biggest
challenge in the US is BW and chronic disease. We have identified nutrients of concern, both over
and under consumption. The ones associated with overconsumption are the ones associated most
closely with chronic disease risk. Hence, increases in the nutrient density of diets, as it repeatedly
mentioned, although laudable, is only tangentially related to the major health problem in the US. This
concern about the text is reflected in my comments. I am not downgrading nutrient dense diets but
increasing nutrient density of the diets can mean adding a highly fortified breakfast cereal rich in
sugar and refined carbs. I don’t think we would predict this would benefit a large proportion of the US
population.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

232
PSC-HHS-000232

HI Alice,


tomorrow.


Many thanks.

Barbara

bmillen@bu.edu


‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Tufts University
Boston, MA 02111

phone: 617 556 3127

233
PSC-HHS-000233

All,


Thanks very much,
Anne

Anne Brown Rodgers
Science Writer
(b) (6)
234
PSC-HHS-000234

HHS FOIA Response Part 1

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Casavale, Kellie (OS/OASH)

From: Lichtenstein, Alice <Alice.Lichtenstein@tufts.edu>

Foods and Nutrients to Promote

Positive message and gives us enough flexibility to address challenges, a.k.a.,

From: Nelson, Miriam

Barbara, Alice, and Kellie,

1. Food Groups, Nutrients of Concern & Health

2. Dietary Patterns & Health

4. Food & Physical Activity Environment

5. Food Consumption Status, Sustainability & Food Safety

Many thanks! Best, Mim

Miriam E. Nelson, PhD

From: Casavale, Kellie (OS/OASH) [Kellie.Casavale@hhs.gov]

From: Millen, Barbara E <bmillen@bu.edu>

From: Millen, Barbara E <bmillen@bu.edu>

From: Millen, Barbara E <bmillen@bu.edu>

Eve Essery Stoody, PhD

From: Millen, Barbara E <bmillen@bu.edu>

Dietary Guidelines should drive programs aimed at addressing issues of household

Hi Barbara and Mary,

Here you go (without word-smithing or considering order):

1. Activate health care sector in nutrition/food health promotion

Just didn't want to forget them.

PS: here is the section from 2010 - I know we can do better:

2. Shift food intake patterns to a more plant-based diet that

3. Significantly reduce intake of foods containing added sugars and

4. Meet the 2008 Physical Activity Guidelines for Americans.

Miriam E. Nelson, PhD

From: Millen, Barbara E <bmillen@bu.edu>

From: Millen, Barbara E [mailto:bmillen@bu.edu]

Dietary Guidelines should drive programs aimed at addressing issues of household

From: Anne Rodgers (b) (6)

Hi Barbara and Mary,

Here you go (without word-smithing or considering order):

1. Activate health care sector in nutrition/food health promotion

(I will work on a sustainability one...)

Just didn't want to forget them.

PS: here is the section from 2010 - I know we can do better:

2. Shift food intake patterns to a more plant-based diet that

3. Significantly reduce intake of foods containing added sugars and

4. Meet the 2008 Physical Activity Guidelines for Americans.

Miriam E. Nelson, PhD

From: Millen, Barbara E <bmillen@bu.edu>

I look forward to your comments.

Hi Anna Maria, Frank, Barbara, and Cheryl,

2. Draft chapter content from Anna Maria

4. The pre-pub draft of the NEL report (zip file)

5. The lifestyle guidelines (zip file)

6. The obesity guidelines (zip file)

Call-in number: (b) (6)

Access code: (b) (6)

Webinar: (b) (6)

Eve Essery Stoody, PhD

Nutritionist | Center for Nutrition Policy and Promotion | USDA

3101 Park Center Drive, Room 1034 | Alexandria, VA 22302

Eve.Essery@cnpp.usda.gov | Office: 703-305-2563 | Fax: 703-305-3300

www.DietaryGuidelines.gov | www.ChooseMyPlate.gov | www.NEL.gov

From: Millen, Barbara E <bmillen@bu.edu>

On Sat, May 3, 2014 at 7:06 AM, Millen, Barbara E <bmillen@bu.edu> wrote:

From: Siega-Riz, Anna Maria [mailto:am siegariz@unc.edu]

Anna Maria Siega-Riz, PhD, RD

From: Frank Hu [mailto:nhbfh@channing.harvard.edu]

I look forward to your comments.

Hi Anna Maria, Frank, Barbara, and Cheryl,