Nutrition and Your Health:
Dietary Guidelines for Americans

Summary	Recommend you revise the definition of "moderate" to the equivalent of 3 or 4 beers per week. This sends a much better signal to people on what is "healthy."
Comments	By defining "moderation" as the equivalent of 2 beers per day, you are endorsing this quantity as acceptable. Inclusion of the words "or less" does not change this endorsement. Two beers a day may be what many Americans consume, but it is clear that the effects of this much alcohol for most people is just plain unhealthy.
Submission Date	9/23/2004 10:19:00 PM
Author	from Canal Winchester, OH

Summary	The Committee report states: One drink is defined as 12 oz of regular beer, 5 oz. of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits. It would be more useful to consumers if it included the information that defined each drink in terms of 0.6 fluid ounces of alcohol.
Comments	Clearly written consumer guidance on ethanol, with a comprehendible and consistent definition of a standard drink will assist dietitians and other health professionals in giving guidance about moderate and responsible consumption of alcohol for those adults who choose to drink. Given the importance of the definition of a drink in giving guidance for following the ethanol guideline, I propose two recommendations to make this statement more clear. First, the addition of the percent alcohol for wine that was added in the 2005 draft is extremely helpful, but propose that the percent alcohol should be stated for each type of beverage. Second, an additional important piece of information is that each of these standard drinks contains 0.6 fl oz of alcohol. There is a wide variety of alcohol beverages that have different percents of alcohol. Knowing that a ¡§standard drink¡¨ contains 0.6 fl oz of alcohol would allow the individual who consumes alcohol drinks to easily determine the amount of alcohol they are consuming so that they can follow the moderation guideline.
Submission Date	9/24/2004 4:05:00 PM
Author	from boston, ma

Summary	Standard drink definition should include amount of alcohol in each drink (0.6 fl ounces). Suggestion: 12 fl ounces of regular beer (5% alcohol); 5 fl ounces of wine (12% alcohol); 1.5 fl ounces of 80-proof distilled spirits (40% alcohol). Each standard drink contains 0.6 fl ounces of alcohol.
Comments	September 24, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science STE LL100 1101 Wootton Parkway Rockville, MD 20852 FR Docket No. 04-19563, Department of Health and Human Services, Announcement of the Availability of the Final Report of the Dietary Guidelines Advisory Committee, a Public Comment Period, and a Public Meeting Dear Ms. McMurry: Thank you for providing the opportunity to comment on the Advisory Committee’s draft report of the 2005 Dietary Guidelines for Americans. These Guidelines are an important tool for consumers and the dietitians and other health professionals who advise them. As a professor in the Department of Family Medicine in the Graduate School of Medicine at the University of Tennessee, and past-president of the American Dietetic Association, I would like to thank the Committee for its efforts to provide useful and clear guidance on alcohol consumption. In general, the alcohol guideline provides evidence based information that will be helpful to dietitians and all health professionals in providing guidance to their patients. In counseling with patients, I am often asked, “What does moderation mean?” and “How much is a drink?” To effectively explain moderation, I need to be able to clearly communicate the meaning of a standard drink. The current definition in the proposed guideline is helpful. However, a clearer and more complete definition would better assist the dietitian in communicating the guidance on moderate and responsible consumption as defined in the alcohol guideline to their adult patients who choose to drink. The proposed 2005 guideline defines a standard drink as: One drink is defined as 12 oz of regular beer, 5 oz. of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits. The addition in the current draft of the percent alcohol for a serving of wine is an excellent revision to past Guidelines. However, to make this definition more complete and consistent, information on percent of alcohol by volume for each type of alcohol beverage (beer, wine and distilled spirits) should be included. Additionally, in counseling patients, dietitians address the fact that the alcohol content in different types of alcohol drinks may vary. Thus, the drink definition should also include information on the amount of alcohol in each standard drink (0.6 fl ounces). This information will provide a benchmark for quantification and assist consumers to better determine the number of standard drinks they are consuming. The additional clarifications I have suggested, as illustrated below, will provide consumers with the necessary information to most easily follow the recommendations set forth in the alcohol guideline. A standard drink is defined as: • 12 fluid ounces of regular beer (5 percent alcohol) • 5 fluid ounces of wine (12 percent alcohol) • 1.5 fluid ounces of 80-proof distilled spirits (40 percent alcohol). Each standard drink contains 0.6 fl ounces of alcohol. Once again I appreciate the opportunity to comment on the proposed 2005 Dietary Guideline’s guideline on alcohol. As a dietitian, I am committed to providing accurate and meaningful information to my patients regarding their diet and lifestyle. I think the suggested revisions will provide useful information to all health professionals in communicating their messages to their patients. Sincerely, Jane White, PhD, RD, FADA Professor, Department of Family Medicine Graduate School of Medicine University of Tennessee – Knoxville Knoxville, TN
Submission Date	9/24/2004 6:00:00 PM
Author	University of Tennessee – Knoxville

Summary
Comments	Alcohol risks listed do not include women with risk factors for breast cancer. The best studies are absolutely conclusive regarding the link, with the curve of risk never reaching zero even with only a very, very small alcohol intake.
Submission Date	9/27/2004 11:25:00 AM
Author	American College of Preventive Medicine

Summary	Health Professionals wishing to have the Dietary Guidelines provide additional information for patients so that they can more easily calculate the amount of alcohol they are consuming when they drink alcohol. This can be for patient self-education or in the context of working with a physician.
Comments	Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science STE LL100 1101 Wootton Parkway Rockville, MD 20852 RE: Federal Register Docket No. 04-19563, Department of Health and Human Services, Announcement of the Availability of the Final Report of the Dietary Guidelines Advisory Committee, a Public Comment Period, and a Public Meeting. Dear Ms. McMurry: Thank you for the opportunity to provide comments on the alcohol guideline in the proposed 2005 Dietary Guidelines for Americans. As physicians we regularly see patients who have various questions regarding drinking alcohol. We find that the alcohol guideline provides very informative, evidenced based information that will be helpful in providing guidance. We do wish to bring attention to one area where we believe the Dietary Guidelines can be improved even further. One scenario that repeatedly arises in patient interactions is, “Can I figure out how much I am drinking when I drink?” We are asking whether it could be possible to make a few changes that could provide even more useful information for physicians to communicate the guidance provided on consumption of alcohol? The current definition of a drink in the 2005 proposed Guideline is: “One drink is defined as 12 oz of regular beer, 5 oz. of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits.” To make this definition most clear, percent of alcohol by volume should be included for each type of alcohol drink. This would assist in helping patients calculate their total alcohol intake. Furthermore, the definition should also include a statement regarding the amount of alcohol in each drink. This additional information would provide the individual all necessary information to determine the amount of alcohol he or she is consuming so that they may follow the recommendations for moderation set forth in the proposed 2005 alcohol guideline. In addition and we believe of even greater importance, the guidelines could then be used to demonstrate to patients who are not drinking in a healthy manner, the amount by wish they might be misjudging their own alcohol intake due to lack of knowledge concerning equivalence of alcohol across types of drinks consumed. Some patients are uncomfortable discussing their drinking patterns with physicians and we believe that with the following changes, the dietary guidelines could be brought home from the physicians visit and used for self-education concerning this and many other topics of nutrition and health. We suggest the following drink definition: A standard drink contains 0.6 fluid ounces of alcohol. A standard drink is defined as: 12 ounces of regular beer (5 percent alcohol) 5 ounces of wine (12 percent alcohol) 1.5 ounces of 80-proof distilled spirits (40 percent alcohol). In discussions with patients we point out that there is a range of alcohol content in drinks and that they must therefore be aware of alcohol content they are consuming when they choose to drink. The Standard Drink is a helpful and easy way to help educate patients concerning total alcohol consumption. This is why we think it is important to include the amount of alcohol per standard serving in the 2005 Dietary Guidelines definition of a standard drink. Providing this information makes it straightforward for the health-conscious consumer to calculate the amount of alcohol they are consuming. This knowledge is key to making responsible decisions about drinking and following the Dietary Guidelines recommendations on moderation. We appreciate the opportunity to comment on the alcohol guideline in the proposed 2005 Dietary Guidelines. As physicians we are committed to providing patients with the most accurate and useful information for making prudent choices in their diet and lifestyle. We feel that our suggested revisions to the alcohol guideline will assist physicians and all health professionals in communicating to patients who choose to drink alcohol, the information most accurate and useful for making responsible decisions about drinking moderately. Please contact Howard Forman at hforman@aecom.yu.edu if you have any questions or would like more information. Sincerely, Stephen M. Kreitzer M.D. Internal Medicine, Pulmonary Medicine, Sleep Medicine Nava Bak M.D. Emergency Medicine Howard Forman Co-Chair, American Medical Association Action Team on Alcohol and Health
Submission Date	9/27/2004 11:33:00 AM
Author	from Bronx, NY

Summary	Supporting text should include alcohol consumption as a risk factor for breast cancer, as well as for high blood pressure and congestive heart failure if drinking is prolonged.
Comments
Submission Date	9/27/2004 1:18:00 PM
Author	ACS, ADA, AHA

Summary	Drink definition should include alcohol % for each type & add each drink contains 0.6 oz. The calorie table for alcohol is misleading & has inaccurate information. The recommendation to reduce alcohol consumption as a good weight loss strategy is not supported by the scientific literature.
Comments	September 27, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science 1101 Wootton Parkway, Suite LL100 Rockville, Maryland 20852 Regarding: Federal Register Docket No. 04-19563; Department of Health and Human Services, Announcement of the Availability of the Final Report of the Dietary Guidelines Advisory Committee, a Public Comment Period, and a Public Meeting. Dear Ms. McMurry: The Distilled Spirits Council of the United States, Inc. (DISCUS) is a national trade association representing producers and marketers of distilled spirits and importers of wine sold in this country. We appreciate the opportunity to provide comments concerning the 2005 Committee report for the Dietary Guidelines for Americans that will be published by the Departments of Agriculture and Health and Human Services. These Guidelines provide an important public service to Americans and provide the basis for Federal nutrition policy and nutrition education activities. DISCUS and its members stand second to none in our concern about the abuse of beverage alcohol products. Throughout the decades, DISCUS and its members have developed, disseminated and supported numerous programs to reduce drunk driving; illegal underage drinking; and all forms of alcohol abuse. Many of these programs include the Dietary Guidelines alcohol guideline as a key message. DISCUS disseminates several thousand copies of the Dietary Guidelines at various venues throughout the year. Our commitment to combating alcohol abuse is longstanding and steadfast. Alcohol guideline We commend the Dietary Guidelines Advisory Committee’s commitment to provide evidenced based dietary guidance to consumers regarding beverage alcohol consumption. We strongly agree with the beverage alcohol guideline’s primary message concerning beverage alcohol consumption—“If you drink alcoholic beverages, do so in moderation.” This message has been the centerpiece of all editions of the Dietary Guidelines and of many education programs and efforts undertaken and supported by DISCUS and its members over the decades. In that regard, we will continue to incorporate the Dietary Guidelines into our programs and offer any help or assistance to the Department of Agriculture in its mandate to provide these guidelines to health professionals who provide nutrition and lifestyle advice to consumers. Standard drink definition It is essential that the evidence-based guidance on ethanol is supplemented with a complete and consistent definition of a standard drink. A clear understanding of a standard drink will assist the individual in following the alcohol guideline. We propose two recommendations to improve the clarity and completeness of the definition of a standard drink proposed in the 2005 Committee report. First, while the addition of the percent alcohol for wine that was added in the 2005 Committee report is extremely helpful towards a clearer definition, a further improvement would be that the percent alcohol should be stated for each type of beverage alcohol product. Second, an additional important piece of information is that each of these standard drinks contains 0.6 fl oz of alcohol. There is a wide variety of alcohol beverages that have different percents of alcohol. Knowing that a “standard drink” contains 0.6 fl oz of alcohol would provide an individual with necessary information to determine the amount of alcohol he or she is consuming, which is all about making responsible decisions about drinking moderately. The Committee report states: “One drink is defined as 12 ounces of regular beer, 5 ounces of wine (12% alcohol), or 1.5 ounces of 80-proof distilled spirits.” We suggest that the following definition would provide the most accurate and useful information to help consumers make responsible choices about beverage alcohol consumption: A standard drink contains 0.6 fluid ounces of alcohol. A standard drink is defined as: • 12 fluid ounces of regular beer (5 percent alcohol) • 5 fluid ounces of wine (12 percent alcohol); or • 1.5 fluid ounces of 80-proof distilled spirits (40 percent alcohol). The U.S. Department of Education’s Higher Education Center for Alcohol and Other Drug Abuse and Violence uses a similar definition (Please see Appendix 1). There can be a range of alcohol content in drinks. This is precisely why we think it is important to include the amount of alcohol per standard serving in the 2005 Dietary Guidelines definition of a standard drink. Providing this information makes it straightforward for the consumer to calculate the amount of alcohol they are consuming. This knowledge is key to enabling consumers to make responsible decisions about drinking in following the Dietary Guidelines recommendations on moderation. A guideline on moderate drinking Since the overwhelming majority of adult Americans who choose to drink do so responsibly and are at low risk for developing problems (NIH publication, 2000), a balanced discussion regarding moderate beverage alcohol consumption is of critical importance in formulating our nation’s nutrition and dietary policy, which is a stated goal of the Dietary Guidelines. Furthermore, the point has been made by the Committee that the Dietary Guidelines are intended for “healthy” Americans. “Healthy” adult Americans are those who either drink in moderation or choose to abstain. Therefore, the beverage alcohol guideline should start out with a statement that the overwhelming majority of adult Americans drink moderately or abstain. This statement emphasizes normative behavior and the expectations in our society for those adults that choose to drink (NIH publication, 2000). This also incorporates the Committee’s recommendation that language be added to state that abstention is an appropriate personal choice. DISCUS fully supports the right of an adult to abstain. Finally, the Departments of HHS and Agriculture should consider adding to the Dietary Guidelines NIAAA’s conclusion in its submission to the Committee: “Except for those individuals at particular risk (as are described in the current guidelines), consumption of 2 drinks a day for men and 1 for women is unlikely to increase health risks. As risks for some conditions and diseases do increase at higher levels of consumption, men should be cautioned to not exceed 4 drinks on any day and women to not exceed 3 on any day." (NIAAA, 2003, page 30) Calories Table E-3: Estimated Caloric Content of Alcoholic Beverages, is in some instances misleading to the consumer and in other cases incorrect. Although the majority of distilled spirits contain 100 calories, wine 100 calories and regular beer 150 calories per standard drink, there is certainly some variability in calories. Therefore, a general statement that some beers, wines and distilled spirits may have higher or lower calories may be helpful. The Dietary Guidelines, however, is not an appropriate vehicle to attempt to present an exhaustive list of drinks with associated calories. First, recipes for ingredients other than alcohol differ greatly depending on the individual making the drink, for example, regular soda vs. diet soda. Even though the Table states that calorie content may differ by recipe, recipes for many drinks are so varied that calories in a mixed drink could differ by 100 %. For this reason, it is not helpful to provide calorie estimates for mixed drinks, which include ingredients other than beverage alcohol. Second, the drink by drink approach is not only unhelpful, but unnecessary. We are not aware of any literature supporting the proposition that consumers are unaware that adding a mixer (such as juice) to beverage alcohol adds additional calories or, conversely, that adding a mixer (such as a no calorie soda) does not add extra calories. Finally, the Table lists “dark beer” as 165 calories. “Dark" beer is a category that contains many types of beer with different calories. For example, Guinness, which accounts for 95% of the Stout consumed in the United States, is probably among the best known of the “dark" beers. Guinness Stout has only 125 calories per serving. Obesity According to several studies over the past two decades, (For example see, Jequier, 1999; Cordain et al., 1997; Kahn et al., 1997; Mannisto et al., 1997; Istvan et al., 1995; Prentice, 1995; Liu et al., 1994; Colditz et al, 1991; Hellerstedt et al., 1990), the relationship between moderate alcohol consumption and obesity is unclear. For example, Lands (1995), in a review article concluded that the cumulative evidence of 31 separate studies does not support the concept that reduced alcohol consumption would help maintain a lower body weight. This conclusion was echoed in the NIAAA review of the literature submitted to the Committee (NIAAA, 2003), which stated that, “Thus far, the evidence on the relationship between moderate alcohol consumption and obesity remains inconclusive.” The NIAAA report goes on to state that “…there appears to be some protective effect of moderate consumption on two of the major sequelae of obesity, i.e., metabolic syndrome and diabetes.” The draft report states “The healthiest way to reduce calorie intake is to reduce one’s intake of saturated fat, added sugars and alcohol—they all provide calories, but don’t provide essential nutrients.” This may be misleading to those consumers who moderately consume beverage alcohol products and are interested in losing weight. First, much of the data shows that the extra calories from one or two drinks a day does not result in weight gain. Therefore, it is unclear whether calorie reduction by simply not consuming beverage alcohol will actually result in weight loss to the individual who has been moderately consuming. Certainly, given the ambiguities in the existing research literature, a clinical trial should be completed before the government recommends to the moderate consumer of beverage alcohol that they will lose weight by reducing their beverage alcohol consumption. Second, the literature shows that there may be some protective effect of moderate consumption of beverage alcohol on two major sequelae of obesity; metabolic syndrome and Type II Diabetes; particularly in overweight individuals (NIAAA, 2003). Thus, the recommendation to the moderate consumer of beverage alcohol to reduce alcohol consumption to reduce weight may not result in weight loss and may eliminate a potential protective effect for Type II diabetes and metabolic syndrome. Again, we urge that clinical trials be concluded before a recommendation is made that may be at best misleading to the individual attempting to lose weight, and at worst result in a potential increased risk of disease for some individuals. “Question 1: Among persons who consume four or fewer alcoholic beverages per day, what is the dose-response relationship between alcohol intake and health?” Conclusion 4. states, “Relationships of alcohol consumption with major causes of death do not differ for middle-aged and elderly Americans. Among younger people, however, alcohol consumption appears to provide little, if any, health benefit; alcohol use among young adults is associated with a higher risk of traumatic injury or death.” First, while mortality data indicate that there are few coronary deaths under the ages of 45 for men and 55 for women (NIAAA, 2003), there is a lack of scientific data to show whether or not potential benefits may accrue from exposure at an earlier age. In fact, most of the epidemiological data on risk reductions are from populations who have been drinking over several decades, not just at a point in time in their fourth or fifth decade. Thus, there does not appear to be scientific justification for the statement that moderate consumption provides little, if any, potential health benefit for younger adults (NIAAA, 2003, page 8). Second, we are aware of no data that support the statement that alcohol use among “young adults” is associated with a higher risk of traumatic injury or death and, certainly, none is provided in the draft. Furthermore, this statement is vague with respect to both age and alcohol consumption. The term young adult can refer to anyone from age 18-40. In addition, there is no qualification of the amount of beverage alcohol consumed. Taken to an extreme example, the individual can interpret that sentence to mean a 39 year old woman who consumes one drink per week is at increased risk for traumatic injury and death. Again, there is certainly no scientific data to support this statement. Meals versus Food We would like to again comment on the suggestion made by several Committee members over the past few editions of the Dietary Guidelines to consider changing consuming beverage alcohol with “meals” to “food.” Food is often consumed outside of what traditionally is considered a meal. Consumers may find themselves in social situations outside of regularly scheduled meal times where they may wish to consume a beverage alcohol product, such as having a cocktail at a reception or party where food is served, before dinner at home with a snack or hors d’oeuvres, or as an after dinner drink. The language in the 2000 Dietary Guidelines’ beverage alcohol guideline may create confusion among consumers inasmuch as the guideline suggests only consuming beverage alcohol with a meal. Moreover, there is no scientific evidence to suggest that consuming beverage alcohol only with meals is a more healthy choice. For example, in a study by Mukamal et al. (2003), the association of beverage alcohol consumption and cardiovascular disease was examined with consumption during meals as an independent variable. There were no differences in reduced risk of cardiovascular disease risk when beverage alcohol was consumed with meals versus not with meals. Clearly, the intent of the 2005 edition of the Dietary Guidelines is to encourage individuals to consume food when they are consuming a beverage alcohol product in order to slow down absorption. The food consumed with beverage alcohol, however, need not and should not be limited to food consumed only as part of a formal meal. Illegal underage consumption Research recommendation # 23 is: “Investigate the impact of banning alcohol advertising when and where it might increase underage drinking (e.g., during college sports events).” As stated earlier, the Distilled Spirits Council of the United States and its sister organization, The Century Council, have developed and implemented numerous programs over the decades aimed at reducing illegal, underage drinking. We all agree that underage drinking is unacceptable and is a complex societal problem that requires a sustained, collaborative commitment. The National Academy of Sciences (NAS) recently reviewed the scientific literature to develop a strategy to reduce underage drinking. The number one recommendation was a media campaign directed at parents. In reviewing the literature on advertising, NAS concluded that accumulated evidence does not demonstrate that advertising causes underage persons to consume beverage alcohol. The Department of Health and Human Services reached the same conclusion in their 1990 and 2000 Report to Congress (U.S. HHS, and NIAAA, 1990, 2000). It seems prudent to focus research recommendations on evidenced based factors. Finally, the data are clear that the majority of beverage alcohol consumed by underage persons is obtained through parents and other adults (NAS, 2003; FTC, 2003). A statement reminding adults not to provide beverage alcohol to underage consumers would appear to be warranted. Food Guide Pyramid There has been discussion about including beverage alcohol in the revised Food Guide Graphic that has been known as the Food Guide Pyramid for decades. The current preamble states: What's in this booklet for me? This booklet introduces you to The Food Guide Pyramid. The Pyramid illustrates the research-based food guidance system developed by USDA and supported by the Department of Health and Human Services (HHS). It goes beyond the "basic four food groups" to help you put the Dietary Guidelines into action. The Pyramid is based on USDA's research on what foods Americans eat, what nutrients are in these foods, and how to make the best food choices for you. The Pyramid and this booklet will help you choose what and how much to eat from each food group to get the nutrients you need and not too many calories, or too much fat, saturated fat, cholesterol, sugar, sodium, or alcohol. Indeed, the assumption would be that the Food Guide Graphic would offer guidance on all areas mentioned in the Dietary Guidelines. Many individuals only see the Food Guide Graphic and do not read the entire Dietary Guidelines and therefore, at this point in time, are left without the Guidelines’ message on beverage alcohol consumption. Additionally, this is a missed opportunity to reinforce messages on moderate and responsible consumption. Concern was raised by the Committee that the Food Guide Graphic is for all individuals greater than two years of age and that including alcohol in the Graphic may result in mixed messages for the underage. As the Food Guide Graphic will be revised to reflect the 2005 Dietary Guidelines, we think that it will be important to include beverage alcohol consumption so that a greater number of individuals will be exposed to the government’s guideline on beverage alcohol consumption. It has been mentioned repeatedly that one graphic may not be appropriate for all consumers and that there is a need for flexibility. Thus, there can be, as one suggestion, a version of the Food Guide Graphic for adults over the age of 21 so that they can benefit from a visual representation of the Dietary Guideline advice on how to make choices about beverage alcohol consumption in the context of an overall adult healthy diet. Conclusion The beverage alcohol guideline in the 2005 edition of the Dietary Guidelines for Americans will continue to assist adult Americans in making informed decisions for a healthy diet and lifestyle. For this reason, it is important that the statements in the alcohol guideline, as in all other guidelines in the Dietary Guidelines, are based on sound science. Furthermore, we feel that the revisions we have suggested to make the standard drink definition more complete and consistent will assist individuals in following the guidance for moderate beverage alcohol consumption as set forth in the 2005 Committee report. We thank you in advance for consideration of our comments. If you have any questions concerning our comments or if we can be of any assistance, please contact Monica Gourovitch, Ph.D. at Distilled Spirits Council of the U.S. (202.682.8837; mgourovitch@discus.org). Sincerely, Monica L. Gourovitch, Ph.D. Sr. VP, Office of Scientific Affairs Distilled Spirits Council of the United States CC: The Honorable Tommy Thompson The Honorable Ann Veneman Ms. Carole Davis References Colditz, G. A., Giovannucci, E., Rimm, E., Stampfer, M. J., Speizer, F. E., Gordis, E., Willett, W. Alcohol intake in relation to diet and obesity in women and men. (1991). American Journal of Clinical Nutrition, 54, 49-55. Cordain, L., Bryan, E. D., Melby, C. L., Smith, M. J. Influence of moderate daily wine consumption upon body weight regulation and metabolism in healthy free living males. (1997). Journal of the American College of Nutrition, 16(2), 134-139. Federal Trade Commission. (September 2003). Alcohol Marketing and Advertising, A Report to Congress. Hellerstedt, W. L., Jeffery, R. W., Murray, D. M. The association between alcohol intake and adiposity in the general population. (1990). American Journal of Epidemiology, 132(4), 594-611. Institute of Medicine, National Research Council of the National Academies. (September 2003). Reducing Underage Drinking A Collective Responsibility. The National Academies Press Washington, D.C. Istvan, J., Murray, R., Voelker, H. The relationship between patterns of alcohol consumption and body weight. (1995). International Journal of Epidemiology, 24(3), 543-546. Jequier, E. Alcohol intake and body weight: a paradox. (1999). American Journal of Clinical Nutrition, 69, 173-174. Kahn, H. S., Tatham, L. M., Rodriguez, C., Calle, E. E., Thun, M. J., Heath, C. W. Stable behaviors associated with adults' 10-year change in body mass index and the likelihood of gain at the waist. (1997). American Journal of Public Health, 87(5), 747-754. Lands, M. Alcohol and energy intake. (1995). American Journal of Clinical Nutrition, 62(5-suppl), 1101S-1106S. Liu, S., Serdula, M. K., Williamson, D. F., Mokdad, A. H., Byers, T. A prospective study of alcohol intake and change in body weight among US adults. (1994). American Journal of Epidemiology, 140(10), 912-920. Mannisto, S., Uusitalo, K., Roos, E., Fogelholm, M., Pietinen, P. Alcohol beverage drinking, diet and body mass index in a cross-national survey. (1997). European Journal of Clinical Nutrition, 151, 326-332. Mukamal, K. J., Conigrave, K, M., Mittleman, M. A., Camargo, C. A., Stampfer, M. J., Willett, W. C., Rimm, E. B. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. (2003). The New England Journal of Medicine, 348, (2), 109-118. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism and Department of Health & Human Services. (2003). State of the Science Report on the Effects of Moderate Drinking. Prentice, A. M. Alcohol and obesity. (1995). International Journal of Obesity, 19(5), S44-S50. U.S. Department of Health & Human Services, Public Health Service Alcohol, Drug Abuse, and Mental Health Administration, National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism. (1990). Seventh Special Report to the U.S. Congress: Alcohol and Health (DHHS Publication No. (ADM) 90-1656). U.S. Department of Health & Human Services, Public Health Service, National Institute of Health and National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism. (2000). 10th Special Report to the U.S. Congress: Alcohol and Health (DHHS Publication No. (ADM) 90-1656). U.S. Department of Health & Human Services, National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism. (2000). The Physicians guide to helping patients with alcohol problems (NIH Publication No. 95-3769).
Submission Date	9/27/2004 4:58:00 PM
Author	Distilled Spirits Council of the U.S.

Summary	We recommend the definition of one drink of wine be retained as stated in the 2000 version of the Guidelines in Box 26 – What is Drinking in Moderation? Any changes made to the current definition would lead to inaccurate and misleading representations of the Guidelines’ moderation message.
Comments	September 27, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science Suite LL100 1101 Wootton Parkway Rockville, MD 20852 Dear Ms. McMurry: Wine Institute is the public policy association of California wineries representing over 800 California wineries and affiliated businesses. These companies are responsible for 80 percent of the nation’s wine production. On behalf or our members, we are pleased to submit comments in response to the request for public input on the 2005 Dietary Guidelines Advisory Committee Report to the Departments of Health and Human Services and Agriculture. We agree that the 2005 Dietary Guidelines for Americans should represent a balanced approach to recommendations on the full range of nutrition, lifestyle and health issues. In particular, we support the Ethanol Subcommittee’s continued recommended advice to discourage excessive consumption and indicate that, even in moderation, there are individuals who should not drink. We are pleased that the main alcohol message has been maintained from the 2000 Dietary Guidelines: “If you drink alcoholic beverages, do so in moderation” and that the Committee has maintained the recommendation (advice) that, “For those who choose to drink an alcoholic beverage, it is advisable to consume it with meals to slow absorption. Data suggest that the presence of food in the stomach can slow the absorption of alcohol and thereby mitigate the associated rise in blood alcohol concentration.” While we support the majority of the findings in the Committee Report, we would like to provide additional comment in two important areas: • There should be no changes to the Drinking In Moderation Definition, especially with the “Count as a Drink” language regarding expressions of alcohol content for wine, because there will be extensive rulemaking by the Treasury Department’s Tax and Trade Bureau (TTB) in 2005 that will address several significant issues that are based on the language of the Dietary Guidelines. Language in the Dietary Guidelines should not be misused or misconstrued in any future regulatory action or rulemaking. • Messages relating to moderate drinking and weight gain and obesity for the public should clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. I. MODERATE DRINKING DEFINITION In the 2000 version of the Dietary Guidelines for Americans, drinking in moderation is defined in Box 26 on page 36 - What is Drinking in Moderation?: The Advice For Today on page 37 goes one step further and recommends “Limit intake to one drink per day for women and two per day for men, and take with meals to slow alcohol absorption.” The Advisory Committee found this definition of moderate drinking as optimal for adults who choose to drink as a means to provide both beneficial effects on heart disease and all-cause mortality as well as reduce risks caused by heavy drinking. However, the Advisory Committee also states that, “The definition of moderation, including the size of one drink, requires emphasis. (Some investigators and apparently many individuals interpret ‘moderate drinking’ to cover higher levels of intake than shown in Table E-25. Many mixed drinks actually provide several servings of alcohol per drink.” (DG Advisory Committee Report, Part D, Section 8, page 3). In an apparent response to further define a moderate serving of each beverage, the Advisory Committee has added a “12 percent alcohol” qualifier to the definition of a serving of wine. Throughout the text of the Advisory Committee Report, one serving of wine is defined as “a 5-ounce glass of 12 percent alcohol.” (See Table E-25, below). Wine Institute believes that providing the public a frame of reference by including serving size information in ounces will assist wine, beer, and distilled spirits consumers in their awareness of alcohol consumption levels. We believe that direct serving size information in ounces about the product being consumed is relevant and, if truthful, accurate and specific, should be able to be included. However, within each category of drinks (wine, beer and distilled spirits) there is a range of products with different alcohol percent values. Unlike distilled spirits, wine is not a “mixed” drink. Consumers discriminate among the various wine products more by their broad product categories, and producers of wine do not target a particular alcohol level but a sensory style and taste. Even from a regulatory standpoint, the standards of identity for wine differ significantly from distilled spirits product standards. Table wine, for example, is defined as still wine between 7 and 14 percent alcohol by volume. While from a scientific or clinical standpoint it may make sense to qualify wine with a specific alcohol content, we do not believe that assigning an arbitrary value of 12 percent alcohol to wine provides the consumer with any additional useful information from which to make an informed decision. As the alcohol percent value of table wine varies between 7 percent and 14 percent and that for dessert wine is 14 percent and above, such a listing would not necessarily be truthful or accurate and could be misleading. We believe that the addition of a “12% alcohol” qualifier in the “Count as a Drink” language will be misinterpreted by some as the establishment of a “standard drink” size, which will eventually lead to a distortion and/or omission of the important moderation message. The Guidelines represent great efforts to explain moderate consumption to U.S. consumers, but they have also been misunderstood. We are seeing the moderation message giving way to a much broader interpretation that the Guidelines themselves have established the size of a “standard drink,” and there have been several regulatory actions that have been based on this contention. We have seen the “count as a drink” language stripped of its accompanying moderation context, with what remains being repackaged as a definition for a “standard drink.” We do not believe that this is what was intended by the authors of the Guidelines, and we are concerned that this misinterpretation and misuse, all pending the safeguards of future rulemaking, will raise serious social as well as political implications. While adding a “12% alcohol” qualifier to wine may appear to be minor and consistent with the “80 proof distilled spirits” language, we are concerned that such changes will result in an argument that these sizes equate to “standard drink” sizes and will become the basis for untruthful and misleading information on wine, beer, and spirits labels. Changes such as this will tend to bolster an argument that all alcoholic beverages are “equal,” a notion that Wine Institute disagrees with. It is an oversimplification to single out the ethyl alcohol property that all alcoholic beverages have in common, and then to conveniently boot strap this commonality into a graphic equation that all alcoholic beverages are equal but only in specific but differing quantities. There are three separate regulatory actions that are pending administrative rulemaking, all based in large part on the contention that the U.S. Dietary Guidelines have established standard serving sizes. Carbohydrate Labeling of Alcoholic Beverages Awaits Rulemaking On April 7, 2004, without the benefit and safeguards of the rulemaking process, the TTB published an Industry Circular that authorized the voluntary labeling of carbohydrate information for wine, beer, and distilled spirits . Citing the 2000 Dietary Guidelines , TTB in its Industry Circular uses the Dietary Guidelines “Count as a drink” language as a measure of a serving size: Accordingly, this ruling holds that the statement of average analysis must apply to a serving of the product, and that the serving must be 12 fl. oz. for malt beverages, 5 fl. oz. for wine, and 1.5 fl. oz. for distilled spirits. TTB indicates in this ruling that it will conduct a rulemaking on this issue in the future. To date, almost six months since the publication of this interim policy, Wine Institute still awaits the promised publication of a Notice of Proposed Rulemaking by TTB on this matter. The significance of this action, however, should not be lost. This is an instance where an administrative agency has taken information from the Dietary Guidelines, eliminated the notion of moderate consumption, and concludes that the “Count as a drink” volumes for alcoholic beverages are “standard drink” sizes. “Serving Facts Panel” Labeling of Alcoholic Beverages Awaits Rulemaking The issue of whether the Dietary Guidelines established a definition of a “standard drink” came to light again with TTB in early August, 2004. On August 5, 2004, and again without the benefit of rulemaking, TTB released what it referred to as a “Serving Facts White Paper” where the identical drink volume values were being used by TTB to permit not simply additional nutritional information, but a comparative “equivalency” graphic” showing illustrations of a beer, wine and spirits container: The beer and wine sectors of the alcoholic beverage industry, strenuously objected to both the process and the content of the “White Paper.” Wine Institute opposed the “White Paper” for many reasons, but we point out that the term “standard drink” used by TTB and attributed to the Dietary Guidelines does not appear anywhere within the 2000 version of the Dietary Guidelines. It should be noted that TTB did not move ahead on this version of the “Serving Facts Panel” white paper, but revised and reissued a second white paper on September 21, 2004. While this white paper removes the more onerous provisions embodied in the first version and is careful not to use the term “standard drink,” this second white paper maintains, without benefit of rulemaking, serving size information that is identical to the Guidelines’ “Count as a Drink” sizes. TTB states in this version of the white paper that it will be conducting a rulemaking in the future. National Consumer League / Center for Science in the Public Interest Rulemaking Petition Awaits Rulemaking Submitted to TTB in December of 2003, the rulemaking petition of the National Consumer League and the Center for Science in the Public Interest calls for uniform information on several label items: • Alcohol content • Standard serving size • Amount of alcohol in ounces and number of calories per serving • Number of standard drinks per container • Ingredient declaration • U.S. Dietary Guideline recommendations for moderate drinking The petitioners contend that more uniform alcohol information should be conveyed to consumers in a context where consumers can more easily understand how much alcohol they are consuming. They suggest that the serving sizes “prescribed” by the U.S. Dietary Guidelines should be used as the “standard serving size.” Additionally, the petitioners suggest that a consistent graphic, such as a beer mug or a glass of wine, be used to alert consumers to the statement. The sample label proposed in that petition looks like this: We urge the authors of the Dietary Guidelines 2005 version to allow for the completion of rulemaking before considering any changes to that portion of the Guidelines. II. CALORIES AND WEIGHT The issue of caloric content and association of alcohol with added sugar and solid fats in relation to discretionary calories and maintaining a healthy weight/weight gain is addressed both in Part A: Executive Summary and Part E: Translating the Science into Dietary Guidance. In the section “Control Calorie Intake to Manage Body Weight” (Part E page 7), the Advisory Committee states that, “Calories come from fat, carbohydrate, protein, and alcohol. The healthiest way to reduce calorie intake is to reduce one’s intake of added sugars, solid fat, and alcohol – they all provide calories, but they do not provide essential nutrients.” … “Table E-3 gives examples of how calories can be decreased by decreasing alcoholic beverage intake.” As we stated in our May 2003 submission to the Advisory Committee, “Given the current lack of consensus on the issue of moderate wine, beer and spirits consumption and its relationship to weight gain, Wine Institute recommends that the Committee provide more detailed discussion on the issue of moderate consumption of wine, beer and distilled spirits and its relationship to weight gain.” (WI Comment 2003, pages 6-7) The NIAAA review, State of the Science Report on the Effects of Moderate Drinking, concluded that the current scientific literature suggests that, “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.” (NIAAA 2003, page 29) An independent review commissioned by Wine Institute to review wine and alcohol and its effects on calories and body weight control since 1985 stated that, “At least 90 papers were published that have dealt directly or indirectly with alcohol consumption and body weight regulation. This renewed interest in how alcohol influences body weight stems, in part, from concern over dietary elements that may underlie the world-wide obesity epidemic. Although no universal consensus has been reached, a number of lines of evidence increasingly suggest that moderate alcohol consumption does not represent a dietary risk for developing obesity and may in fact promote certain metabolic changes which reduce the risk for overweight and obesity.” (Cordain 2003, page 2) In response to the scientific evidence presented, the Ethanol Subcommittee concluded that the relationship between consuming four or fewer alcoholic beverages daily and obesity was an “Unresolved Issue.” They state that, “The available data on the relationship between alcohol consumption and weight gain/obesity are sparse and inconclusive. There are contradictory findings at the higher end of the spectrum (i.e. 3 to 4 drinks per day) that may relate to fundamental limitations of the cross-sectional study design. At moderate drinking levels (i.e. up to one drink per day for women, up to one (sic?) drink per day for men), there is no apparent association between alcohol intake and obesity.” The Subcommittee concludes, “In summary, although prospective data are limited, there is no apparent association between consuming one or two alcoholic beverages daily and obesity.” Dietary Guidelines Advisory Committee Report, (Part 6, Section 8, page 6) Based on the Ethanol Subcommittee conclusion, we would like to recommend the statement made in Part E: Translating the Science into Dietary Guidelines be revised to read: “Calories come from fat, carbohydrate, protein, and alcohol. The healthiest way to reduce calorie intake is to reduce one’s intake of added sugars and solid fats. The findings on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive, however, it may be prudent to monitor consumption as it relates to the intake of discretionary calories.” CLOSING STATEMENTS We would like to commend the members of the Advisory Committee for their thorough review of the scientific literature and overall balanced recommendations on moderate alcohol consumption by healthy adults. On the issue of the Drinking In Moderation Definition, we strongly support the current definition of moderation (no more than 1 drink per day for women and no more than 2 drinks per day for men). We recommend the definition of one drink of wine be retained as stated in the 2000 version of the Guidelines in Box 26 – What is Drinking in Moderation? We believe that any changes made to the current definition would lead to inaccurate and misleading representations of the Guidelines’ moderation message to the public. Therefore, we recommend the addition of a clear and unambiguous statement in the guidelines that the “Count as a Drink” statements should not be interpreted as the establishment of a “standard drink,” and that the information is being provided to further explain the moderation message. As stated, there will be full and extensive industry and regulatory agency review accompanied by public comment for both serving size and serving facts labeling at the start of 2005. We would ask that any messages relating to moderate drinking and weight gain and obesity for the public clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. We thank you for the opportunity to present additional information and recommendations on the Dietary Guidelines Advisory Committee Report. Sincerely, Robert P. Koch President and CEO cc: Secretary Tommy Thompson, HHS Secretary Ann Veneman, USDA
Submission Date	9/27/2004 5:30:00 PM
Author	Wine Institute

Summary	AIM appreciates the Committee's continued emphasis on moderation for those adults who choose to drink. However, recent research conclusions reveal that the wording on alcohol and calories needs further clarifications. We also suggest that moderate consumption with food should be emphasized.
Comments	This submission is made on behalf of Peter Duff, Chairman of AIM-Alcohol in Moderation. We would like DHHS and USDA to consider our earlier comments when reviewing the Dietary Guidelines Advisory Committee's report. Specifically, AIM would like the agencies to review and further consider AIM's original research submission, especially as it pertains to the question on alcohol and calories. Towards this end, we would like to underscore that the science to date does not support any message that implies that alcohol in moderation would lead to excess weight gain. May 18, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Room 738-G, 200 Independence Ave, SW Washington, DC 20201 Email: dietaryguidelines@osophs.dhhs.gov RE: Year 2005 Draft Edition of Dietary Guidelines for Americans Dear Ms. McMurry: The following comments are submitted on behalf of AIM (Alcohol in Moderation), an international non-profit education group dedicated to science and social responsibility related initiatives. Specifically, AIM is devoted to increase socially responsible behavior with respect to alcohol consumption by bringing scientifically based education messages to the public via websites and other programs. Our efforts are centered on governmental and public health messages from around the world. We work with a Social, Scientific and Medical Council of physicians, scientists, and experts in social policy in preparing and presenting information related to an ongoing debate on alcohol use and abuse. We appreciate the opportunity to make comments on the recommended wording of the 2005 Dietary Guidelines that will be published by the Departments of Agriculture and Health and Human Services. AIM has long acknowledged that these Guidelines represent an important foundation for nutrition education activities. In fact, the Dietary Guidelines for Americans have served as an important consumer education tool as part of AIM’s outreach efforts. These programs advocate moderate consumption as the only responsible option for those who choose to enjoy wine, beer and spirits as a component of a well-balanced diet and lifestyle. Towards this end, we are committed to continuing and expanding our educational outreach efforts with the upcoming 2005 Dietary Guidelines for Americans edition. First and foremost, we applaud the Advisory Committee’s effort and express our strong support for expanded wording intended to discourage abuse while indicating that moderate and responsible use of alcohol is an acceptable lifestyle choice, and encouraging the consumption of alcoholic beverages with food (which markedly decreases the risk of abuse). In our view, however, the Guidelines should more fully take into account the research facts presented by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) in their December, 2003, submission. In particular, we agree that the Guidelines should be based on the “preponderance of scientific and medical knowledge current at the time of publication”. (1, 2) In light of the developing research consensus on moderate consumption, reflected in both published scientific research studies and official nutrition and public policy positions, we would like to respectfully ask you to consider the following additional points when finalizing the alcohol guideline wording: I. Provide a more positive opening of the guideline, underscoring that responsible consumption is the only acceptable choice for those adults who choose to drink In line with the emerging evidence on moderate versus abusive drinking, the Guidelines should give more weight to positive messages about moderation as part of a healthy diet and lifestyle. In fact, we believe that the currently proposed wording disproportionately focuses on reported risks of abusive consumption while not adequately addressing scientific findings with respect to moderation. This is especially warranted as the overwhelming majority of those who choose to drink consume alcohol moderately and responsibly. This is not only reflected on page 20 in the recent NIAAA submission (1) and in the NIH 2000 physician’s guide (3) but also in earlier reports by NIAAA on alcohol and health to the US Congress.( 4) Along those lines the recent NIAAA submission emphasizes that “the consequences of alcohol use must be evaluated in conjunction with its potential benefits.” It is stressed that alcohol’s apparent protective effect against coronary heart disease and other atherosclerotic diseases are significant, as these are the most common cause of death in the US. The submission also cites a 1994 study predicting that abstention among current drinkers would lead to significant increases in coronary heart disease death rates. Another recent review article by Dr. Arthur Klatsky from Kaiser Permanente, who has published dozens of scientific studies over the last two decades, also cautions that while non drinkers should not necessarily be encouraged to drink, current moderate drinkers with no health contraindications should not be discouraged from drinking.(5) These and other statements underscore the importance of a more balanced discussion on moderation and abuse when formulating the US nutrition and dietary policy, which is also a stated goal for the Dietary guidelines 2005 ( Fed. Reg., Vol.68, no 171. Sept 4, 2003). With these and other research and public health facts in mind, we firmly believe that it is important to open the Guidelines with an additional message that underscores the acceptable behavior of moderation while also stressing the consequences of abuse. In sum, we recommend the addition of a sentence before the current lead sentence that would underscore, “The moderate and responsible consumption of wine, beer and spirits as part of a well-balanced diet and lifestyle is the only acceptable option for adults who choose to enjoy consumption of alcoholic beverages. The overwhelming majority of adult Americans drinks moderately or abstains, depending on their lifestyle choice.” This could lead the reader directly to the definition of moderation, underscoring that heavy drinking and binge drinking are irresponsible, which would also be underscored by the next sentence of the guideline reading, “Alcoholic beverages are harmful when consumed in excess.” II Further expand discussions on moderation and stress both the consumption with food and/or meals to foster responsible drinking behavior even outside the traditional mealtime consumption. We fully endorse the emphasis on eating and meals and would suggest including an expanded wording that would underscore that consumption should “preferably occur with food and/or with meals to slow alcohol absorption.” You may also wish to point out that alcohol should be consumed slowly, preferably over several hours. Such messages would encompass a wider range of drinking occasions and would also address NIAAA’s statement that people should be given more detailed advice on what encompasses “moderation.” Along those lines, we would also like to recommend that the following NIAAA statement be included, “Except for those individuals at particular risk ( as described in the current guidelines), consumption of 2 drinks a day for men and 1 drink a day for women is unlikely to increase health risks. As risks for some conditions and diseases do increase at higher levels of consumption, men should be cautioned to not exceed 4 drinks on any day and women to not exceed 3 on any day.” This represents an important caution intended to prevent serious binge drinking behaviors. Furthermore, this more detailed approach is also in line with other governmental guidelines such as those of the UK and Australia that provide more specific guidance for the consumer. (6, 7) In fact, official guidelines such as the UK Sensible Drinking Guidelines and the Australian Alcohol Guideline are taking a more positive approach (as reflected in our recommendations I. and II). In addition, social scientists have underscored that such education messages emphasizing positive cultural norms reinforce and initiate the most responsible drinking behaviors in a given society. In fact, these points are directly and indirectly addressed in a Rutgers University monograph entitled, “Society, Culture, and Drinking Patterns Reexamined,” as well as the International Handbook on Alcohol and Culture published by Brown University Professor Dwight Heath. ( 8,9) III. Address scientific findings with respect to moderation and other aspects of health, including overall mortality and stroke (in line with the recent NIAAA submission). As the NIAAA submission attests, since 2000 scientific support of moderate consumption’s role as part of a healthy lifestyle has gotten stronger. Large-scale studies from the US and around the world have found moderate drinkers not only have a reduced rate of cardiovascular disease, but also have a reduced overall mortality rate. The largest study on alcohol consumption to date by Thun et al(add ref), based on nearly 500,000 Americans, reports that overall death rates were lowest among men and women reporting about one drink daily (approximately 20% lower than abstainers for both men and women). (10) The American Heart Association concluded in 1996, “The lowest mortality occurs in those who consume one or two drinks a day.” (11)These findings were also acknowledged in the NIAAA submission along with many other research findings including a 2003 meta-analysis based on more than 50 studies on the subject. (1) Therefore, we urge the Committee to consider expanding the discussions on the health effects of moderation by including the NIAAA statement:” The lowest total all-cause mortality occurs at the level of 1 - 2 drinks per day.” Along those lines we also suggest including a statement acknowledging the potential positive affects with respect to ischemic stroke and Type II diabetes, in line with the research findings presented by NIAAA in its appendix 2.(1) The suggested mentioning of potential stroke risk reductions is also in line with the National Stroke Association’s official statement, which states:” Current scientific data continue to show that moderate levels of alcohol consumption do not increase risk for heart failure, myocardial infarction or ischemic stroke, and in fact provide protective effects along a J-shaped curve.”(12) A meta-analysis published recently in the Journal of the American Medical Association by Reynolds, et al concluded, “Heavy alcohol consumption increases the risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.” Another study suggested that alcohol may protect against reoccurring strokes, and others have confirmed these findings. (13,14) The inclusion of discussions on diabetes is also appropriate as recent studies continue to reveal a reduced risk of diabetes among moderate drinkers. These include a study by Davies, et al in 2003 and a recent study by Wannamethee, et al, which reported that light drinking cuts diabetes risk in women. (15-18) IV. Discussions on calories and obesity should not be misleading. While we agree that the guidelines should provide a general benchmark for outlining average calories for wine, beer and spirits, we would like to caution against a more detailed statement on moderate drinking and obesity. Numerous studies, as outlined in the NIAAA submission, suggest no clear association between alcohol and weight gain for men, and some studies indicate a slight reduction in weight gain for women. Specifically, we would like to urge you to fully consider NIAAA’s conclusion on the subject, which is as follows: “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.”(1) Experimental studies have suggested that alcohol calories are not efficiently utilized and therefore generally do not lead to weight gain. For example, a 1997 study published in the European Journal of Clinical Nutrition concluded, “Alcohol consumers were leaner than abstainers,” and this is a common finding in most epidemiologic studies everywhere. Furthermore, a 1998 study published in the American Journal of Clinical Nutrition suggests that alcohol’s consumption with food slows not only the absorption process, keeping alcohol blood levels low, but may also have a favorable effect on lipid profiles during the postprandial period. (19, 20) In line with many studies over the last two decades,, the relationship between moderate alcohol consumption and obesity is unclear. In line with the 2003 NIAAA conclusion, for example, Lands wrote in a 1995 review article, “Thus, alcohol seemed unable to contribute to the overall body mass of either men or women. In fact, the cumulative evidence of 31 separate studies does not support the concept that reduced alcohol consumption would help maintain a lower body weight. Also the National Health and Nutrition Examination Survey (NHANES) showed that moderate drinkers gained less weight, on average, than abstainers over a ten year follow up period (21-27) In light of these and other findings, we believe an overall cautionary and even warning message on alcohol’s calories would be misleading and is therefore unwarranted, especially if it would suggest in any way that individuals should reduce moderate consumption of beverage alcohol to decrease weight; scientific data are not present to support such a statement. V. The “Who should not drink section” should also be evidence-based and supported by science. In all of AIM’s education efforts, we stress the unacceptability of underage drinking and emphasize adherence to the laws regarding the purchase and possession age limitations in the US. Therefore, we support the Dietary Guideline’s Committee’s focus to reduce underage drinking problems. We are concerned, however, that the statement, “Risk of alcohol abuse increases when drinking starts at an early age,” is scientifically and culturally unwarranted. The issue is still a matter of debate, and indeed alcohol abuse rates are actually lower in many countries (such as Italy) where wine consumption begins early in life. It does appear that early abusers of alcohol and drugs may be more likely to be adult abusers, but studies have reported that it was drinking problems, rather than any drinking, that show the ability to predict later-life alcohol problems.(28,29)Other studies have shown that the age of first use of alcohol (as recalled at age 18) did not predict alcohol or drug use at either 20 or 30 years of age.(30) Another study concluded, “These results suggest the association between drinking onset and diagnosis is no causal, and attempts to prevent the development of alcohol dependence by delaying drinking onset are unlikely to be successful.”(31) More recent studies also conclude that much of the association can be accounted for by genetic vulnerability.(32,33) Recent reports by the Federal Trade Commission and the National Academy of Sciences point out that most alcohol beverages are obtained by underage persons through their parents and other adults.(34,35) Therefore, we strongly suggest to the Committee that it include wording that cautions parents to discourage their children from drinking and to discuss the subject of alcohol in detail with them. VI. The Food Guide Pyramid Graphics should include alcohol to help put the Dietary Guidelines into action, reinforcing the importance of moderation as the only choice. As the Food Guide Graphic will be revised to mirror the 2005 Dietary Guidelines, we would like to strongly recommend that alcoholic beverages will be included as an option for adults. We firmly believe that this would provide increased exposure to the government’s moderation message and the overall Guideline cautioning about abuse and the importance of only moderate consumption as part of an overall healthy and well-balanced lifestyle. The pyramid and accompanying booklet will help Americans get the needed guidance to choose a balanced diet and responsible decision-making skills as outlined in the Guidelines. This approach would provide an important venue to reinforce socially responsible behavior with respect to wine, beer, and spirits consumption. This approach is also in line with other dietary models and accompanying graphics. Specifically, we would like you to review and consider approaches presented in the Mediterranean, Latin-American, Asian, and Vegetarian Diet Pyramids. These concepts have been developed by leading experts from Harvard University of Public Health and other leading institutions. (36-40) In conclusion, we would like to reiterate that the developing research consensus on moderate versus abusive consumption should be fully reflected in the upcoming 2005 Dietary Guidelines for Americans. While we support the admonition against abusive behavior, and agree that for certain groups of individuals any consumption is inadvisable, we respectfully recommend through this submission that you re-examine the impressive and credible evidence suggesting that, for most people, moderate drinking is consistent with a healthy and well-balanced lifestyle. We are confident that the upcoming Guidelines will continue to assist Americans and other consumers around the world in making informed healthy diet and lifestyle choices. Towards this end, AIM will be committed to widely disseminating the 2005 Dietary Guidelines as a basis of our ongoing and expanded education initiatives. Thank you for your time and consideration. If you have any questions concerning our sub mission or if we can be of any assistance, please contact Elisabeth Holmgren, at our US office at (925) 934-3226 or at em-h@pacbell.net . Sincerely, Peter Duff Chairman AIM-Alcohol in Moderation Attachment I: References: 1. National Institute on Alcohol Abuse and Alcoholism, State of the Science Report on the Effects of Moderate Drinking, Submission to the Dietary Guidelines Advisory Committee, December 2003. 2. Dietary Guidelines Advisory Committee Meeting Announcement, September 4, 2003, Federal Register, 68 (171). 3. U.S. Department of Health & Human Services, National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism 2000, The Physician’s Guide to Helping patients with Alcohol Problems, NIH Publication No. 95- 3796. 4. National Institute of Alcohol Abuse and Alcoholism, Ninth and Tenth Special Report to US Congress on Alcohol and Health, DHHS, 1997, 2000. 5. Klatsky A., Alcohol and Health: How Much is Good for You? Scientific American, February 2003. 6. United Kingdom Department of Health, Sensible Drinking, Report, 1995 at http://www.dh.gov.uk/AboutUs/fs/en 7. National Health and Medical Research Council, Australian Drinking Guidelines, 2000 at http://www.alcoholguidelines.gov.au/ 8. Pittman D J et al, Society, Culture, and Drinking Patterns Reexamined, Rutgers Center of Alcohol Studies, 1991. 9. Heath D, International Handbook on Alcohol and Culture, Greenwood Press: Westport, 1995. 10. Thun M. et al, Alcohol Consumption and Mortality among Middle-Aged and Elderly Adults, The New England Journal of Medicine, 1997; 337. 11. Pearson T and Nutrition Committee of the American Heart Association, Alcohol and Heart Disease, Circulation, 94 (11), 1996. 12. Gorelick P. et al, Prevention of first Stroke: A Review of Guidelines from the National Stroke Association, Journal of the American Medical Association, 1999; 281. 13. Sacco, R. et al, The Protective Effect of Moderate Alcohol Consumption on Ischemic Stroke, Journal of the American Medical Association, 281, 53-60, 19999. 14. Reynolds K, et al, Alcohol Consumption and Risk of Stroke: A Meta-Analysis, Journal of the American Medical Association, 289, 579- 588, 2003. 15. Davies MJ et al, Effects of Moderate Alcohol Intake on Fasting Insulin and Glucose Concentrations and Insulin Sensitivity in Postmenopausal Women, Journal of the American Medical Association, 287, 2003. 16. Wannamethee SG et al, Alcohol Consumption and the Incidence of Type 2 diabetes, Journal of Epidemiology and Community Health, Vol 56, 2002. 17. Wannamethee SG et al, Alcohol Drinking Patterns and Risk of Type 2 Diabetes Mellitus among Younger Women, Archives of Internal Medicine, 163, 2003. 18. Howard A et al, Effect of Alcohol Consumption on Diabetes Mellitus – A Systematic Review, Annals of Internal Medicine, Vol 140, No 3, 2004. 19. Howard A et al,, Effect of Alcohol Consumption on Diabetes Mellitus – A Systematic Review”, Annals of Internal Medicine, Vol 140, No 3, 2004.18. Mannisto S et al, Alcohol Beverage Drinking, Diet, and Body Mass Index in a Cross-Sectional Survey, European Journal of Clinical Nutrition, Vol 51, 1997. 20. Locher R et al, Ethanol Suppresses Smooth Muscle Cell Profileration in the Postprandial Stage: A New Antiathereosclerotic Mechanism of Ethanol? American Journal of Clinical Nutrition, Vol 67, 1998. 21. Liu S.et al, A Prospective Study of Alcohol Intake and Change in Body Weight among US Adults, American Journal of Clinical Nutrition, Vol 140, 1994. 22. Coldwitz G et al, Alcohol Intake in Relation to Diet and Obesity in Women and Men, American Journal of Clinical Nutrition, Vol 54, 1991. 23. Istvan, The relationship between patterns of alcohol consumption and body weight. International Journal of Epidemiology, 24 (3), 1995. 24. Jequier, E. Alcohol Intake and Body Weight: a Paradox, American Journal of Clinical Nutrition, 59, 1999. 25. Kahn, H.S., Stable behaviors Associated with Adults’ 10-year Change in Body Mass Index and the Likelihood of Gain at the Waist, American Journal of Public Health, 87, 1997. 26. Mannisto S, Alcohol Beverage Drinking, Diet, and Body Mass Index in a Cross- National Survey, European Journal of Clinical Nutrition, 1997 27. Lands, M. Alcohol and energy intake. American Journal of Clinical Nutrition, 26, 1995. 28. Fillmore F, Relationship between Specific Drinking Problems in Early Adulthood and Middle Age, Journal of Studies on Alcohol, 1975; 36:882-907 29. Labouvie, E et al, Age of First Use: Its Reliability and Predictive Utility. Journal of Studies on Alcohol, 58, 1997. 30. Grant, F et al, Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: A 12-year follow-up. Journal of Substance Abuse, 12, 2001. 31. Guo, J et al, Developmental Pathways to Alcohol Abuse and Dependence in Young Adulthood, Journal of Studies on Alcohol, 61, 2000. 32. Mc Gue M et al, Origins and Consequences of first Drink, Alcoholism: Clinical and Experimental Research, 25 (7, 8), 2001. 33. Harford, T. Early Onset of Alcohol Use and Health Problems: Spurious Associations and Prevention. Addiction, Vol 98, 2003. 33. Anderson A et al, tracking Drinking Behavior from Age 15- 19 years, Addiction, 2003. 34. Federal Trade Commission: Alcohol Marketing and Advertising, A Report to Congress, 2003. 35. Institute of Medicine, National Research Council of the National Academies. Reducing Underage Drinking a Collective Responsibility, The National Academies Press 2003. 36. The Eat Wise Pyramid, released at the 2003 International Conference on the Mediterranean Diet, Boston, Oldways Preservation & Exchange Trust, 2003 37. The Healthy Traditional Mediterranean Diet Pyramid, released at the Intern. Conference on the Diets of the Mediterranean, San Francisco, Oldways, 1994. 38. The Healthy Traditional Asian Diet Pyramid, released at the International Conference on the Diets of Asia, San Francisco, Oldways PT, 1995. 39. 39. The Healthy Traditional Latin America Diet Pyramid, released at the Intern. Conference on the Diets of Latin America, El Paso, Texas, Oldways PT, 1996. 39.40. The Vegetarian Diet Pyramid, released at the International Conference on Vegetarian Diets, Austin, Texas, Oldways Preservation & Exchange Trust, 1997. AIMUS, 2004 May 18, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Room 738-G, 200 Independence Ave, SW Washington, DC 20201 Email: dietaryguidelines@osophs.dhhs.gov RE: Year 2005 Draft Edition of Dietary Guidelines for Americans Dear Ms. McMurry: The following comments are submitted on behalf of AIM (Alcohol in Moderation), an international non-profit education group dedicated to science and social responsibility related initiatives. Specifically, AIM is devoted to increase socially responsible behavior with respect to alcohol consumption by bringing scientifically based education messages to the public via websites and other programs. Our efforts are centered on governmental and public health messages from around the world. We work with a Social, Scientific and Medical Council of physicians, scientists, and experts in social policy in preparing and presenting information related to an ongoing debate on alcohol use and abuse. We appreciate the opportunity to make comments on the recommended wording of the 2005 Dietary Guidelines that will be published by the Departments of Agriculture and Health and Human Services. AIM has long acknowledged that these Guidelines represent an important foundation for nutrition education activities. In fact, the Dietary Guidelines for Americans have served as an important consumer education tool as part of AIM’s outreach efforts. These programs advocate moderate consumption as the only responsible option for those who choose to enjoy wine, beer and spirits as a component of a well-balanced diet and lifestyle. Towards this end, we are committed to continuing and expanding our educational outreach efforts with the upcoming 2005 Dietary Guidelines for Americans edition. First and foremost, we applaud the Advisory Committee’s effort and express our strong support for expanded wording intended to discourage abuse while indicating that moderate and responsible use of alcohol is an acceptable lifestyle choice, and encouraging the consumption of alcoholic beverages with food (which markedly decreases the risk of abuse). In our view, however, the Guidelines should more fully take into account the research facts presented by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) in their December, 2003, submission. In particular, we agree that the Guidelines should be based on the “preponderance of scientific and medical knowledge current at the time of publication”. (1, 2) In light of the developing research consensus on moderate consumption, reflected in both published scientific research studies and official nutrition and public policy positions, we would like to respectfully ask you to consider the following additional points when finalizing the alcohol guideline wording: I. Provide a more positive opening of the guideline, underscoring that responsible consumption is the only acceptable choice for those adults who choose to drink In line with the emerging evidence on moderate versus abusive drinking, the Guidelines should give more weight to positive messages about moderation as part of a healthy diet and lifestyle. In fact, we believe that the currently proposed wording disproportionately focuses on reported risks of abusive consumption while not adequately addressing scientific findings with respect to moderation. This is especially warranted as the overwhelming majority of those who choose to drink consume alcohol moderately and responsibly. This is not only reflected on page 20 in the recent NIAAA submission (1) and in the NIH 2000 physician’s guide (3) but also in earlier reports by NIAAA on alcohol and health to the US Congress.( 4) Along those lines the recent NIAAA submission emphasizes that “the consequences of alcohol use must be evaluated in conjunction with its potential benefits.” It is stressed that alcohol’s apparent protective effect against coronary heart disease and other atherosclerotic diseases are significant, as these are the most common cause of death in the US. The submission also cites a 1994 study predicting that abstention among current drinkers would lead to significant increases in coronary heart disease death rates. Another recent review article by Dr. Arthur Klatsky from Kaiser Permanente, who has published dozens of scientific studies over the last two decades, also cautions that while non drinkers should not necessarily be encouraged to drink, current moderate drinkers with no health contraindications should not be discouraged from drinking.(5) These and other statements underscore the importance of a more balanced discussion on moderation and abuse when formulating the US nutrition and dietary policy, which is also a stated goal for the Dietary guidelines 2005 ( Fed. Reg., Vol.68, no 171. Sept 4, 2003). With these and other research and public health facts in mind, we firmly believe that it is important to open the Guidelines with an additional message that underscores the acceptable behavior of moderation while also stressing the consequences of abuse. In sum, we recommend the addition of a sentence before the current lead sentence that would underscore, “The moderate and responsible consumption of wine, beer and spirits as part of a well-balanced diet and lifestyle is the only acceptable option for adults who choose to enjoy consumption of alcoholic beverages. The overwhelming majority of adult Americans drinks moderately or abstains, depending on their lifestyle choice.” This could lead the reader directly to the definition of moderation, underscoring that heavy drinking and binge drinking are irresponsible, which would also be underscored by the next sentence of the guideline reading, “Alcoholic beverages are harmful when consumed in excess.” II Further expand discussions on moderation and stress both the consumption with food and/or meals to foster responsible drinking behavior even outside the traditional mealtime consumption. We fully endorse the emphasis on eating and meals and would suggest including an expanded wording that would underscore that consumption should “preferably occur with food and/or with meals to slow alcohol absorption.” You may also wish to point out that alcohol should be consumed slowly, preferably over several hours. Such messages would encompass a wider range of drinking occasions and would also address NIAAA’s statement that people should be given more detailed advice on what encompasses “moderation.” Along those lines, we would also like to recommend that the following NIAAA statement be included, “Except for those individuals at particular risk ( as described in the current guidelines), consumption of 2 drinks a day for men and 1 drink a day for women is unlikely to increase health risks. As risks for some conditions and diseases do increase at higher levels of consumption, men should be cautioned to not exceed 4 drinks on any day and women to not exceed 3 on any day.” This represents an important caution intended to prevent serious binge drinking behaviors. Furthermore, this more detailed approach is also in line with other governmental guidelines such as those of the UK and Australia that provide more specific guidance for the consumer. (6, 7) In fact, official guidelines such as the UK Sensible Drinking Guidelines and the Australian Alcohol Guideline are taking a more positive approach (as reflected in our recommendations I. and II). In addition, social scientists have underscored that such education messages emphasizing positive cultural norms reinforce and initiate the most responsible drinking behaviors in a given society. In fact, these points are directly and indirectly addressed in a Rutgers University monograph entitled, “Society, Culture, and Drinking Patterns Reexamined,” as well as the International Handbook on Alcohol and Culture published by Brown University Professor Dwight Heath. ( 8,9) III. Address scientific findings with respect to moderation and other aspects of health, including overall mortality and stroke (in line with the recent NIAAA submission). As the NIAAA submission attests, since 2000 scientific support of moderate consumption’s role as part of a healthy lifestyle has gotten stronger. Large-scale studies from the US and around the world have found moderate drinkers not only have a reduced rate of cardiovascular disease, but also have a reduced overall mortality rate. The largest study on alcohol consumption to date by Thun et al(add ref), based on nearly 500,000 Americans, reports that overall death rates were lowest among men and women reporting about one drink daily (approximately 20% lower than abstainers for both men and women). (10) The American Heart Association concluded in 1996, “The lowest mortality occurs in those who consume one or two drinks a day.” (11)These findings were also acknowledged in the NIAAA submission along with many other research findings including a 2003 meta-analysis based on more than 50 studies on the subject. (1) Therefore, we urge the Committee to consider expanding the discussions on the health effects of moderation by including the NIAAA statement:” The lowest total all-cause mortality occurs at the level of 1 - 2 drinks per day.” Along those lines we also suggest including a statement acknowledging the potential positive affects with respect to ischemic stroke and Type II diabetes, in line with the research findings presented by NIAAA in its appendix 2.(1) The suggested mentioning of potential stroke risk reductions is also in line with the National Stroke Association’s official statement, which states:” Current scientific data continue to show that moderate levels of alcohol consumption do not increase risk for heart failure, myocardial infarction or ischemic stroke, and in fact provide protective effects along a J-shaped curve.”(12) A meta-analysis published recently in the Journal of the American Medical Association by Reynolds, et al concluded, “Heavy alcohol consumption increases the risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.” Another study suggested that alcohol may protect against reoccurring strokes, and others have confirmed these findings. (13,14) The inclusion of discussions on diabetes is also appropriate as recent studies continue to reveal a reduced risk of diabetes among moderate drinkers. These include a study by Davies, et al in 2003 and a recent study by Wannamethee, et al, which reported that light drinking cuts diabetes risk in women. (15-18) IV. Discussions on calories and obesity should not be misleading. While we agree that the guidelines should provide a general benchmark for outlining average calories for wine, beer and spirits, we would like to caution against a more detailed statement on moderate drinking and obesity. Numerous studies, as outlined in the NIAAA submission, suggest no clear association between alcohol and weight gain for men, and some studies indicate a slight reduction in weight gain for women. Specifically, we would like to urge you to fully consider NIAAA’s conclusion on the subject, which is as follows: “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.”(1) Experimental studies have suggested that alcohol calories are not efficiently utilized and therefore generally do not lead to weight gain. For example, a 1997 study published in the European Journal of Clinical Nutrition concluded, “Alcohol consumers were leaner than abstainers,” and this is a common finding in most epidemiologic studies everywhere. Furthermore, a 1998 study published in the American Journal of Clinical Nutrition suggests that alcohol’s consumption with food slows not only the absorption process, keeping alcohol blood levels low, but may also have a favorable effect on lipid profiles during the postprandial period. (19, 20) In line with many studies over the last two decades,, the relationship between moderate alcohol consumption and obesity is unclear. In line with the 2003 NIAAA conclusion, for example, Lands wrote in a 1995 review article, “Thus, alcohol seemed unable to contribute to the overall body mass of either men or women. In fact, the cumulative evidence of 31 separate studies does not support the concept that reduced alcohol consumption would help maintain a lower body weight. Also the National Health and Nutrition Examination Survey (NHANES) showed that moderate drinkers gained less weight, on average, than abstainers over a ten year follow up period (21-27) In light of these and other findings, we believe an overall cautionary and even warning message on alcohol’s calories would be misleading and is therefore unwarranted, especially if it would suggest in any way that individuals should reduce moderate consumption of beverage alcohol to decrease weight; scientific data are not present to support such a statement. V. The “Who should not drink section” should also be evidence-based and supported by science. In all of AIM’s education efforts, we stress the unacceptability of underage drinking and emphasize adherence to the laws regarding the purchase and possession age limitations in the US. Therefore, we support the Dietary Guideline’s Committee’s focus to reduce underage drinking problems. We are concerned, however, that the statement, “Risk of alcohol abuse increases when drinking starts at an early age,” is scientifically and culturally unwarranted. The issue is still a matter of debate, and indeed alcohol abuse rates are actually lower in many countries (such as Italy) where wine consumption begins early in life. It does appear that early abusers of alcohol and drugs may be more likely to be adult abusers, but studies have reported that it was drinking problems, rather than any drinking, that show the ability to predict later-life alcohol problems.(28,29)Other studies have shown that the age of first use of alcohol (as recalled at age 18) did not predict alcohol or drug use at either 20 or 30 years of age.(30) Another study concluded, “These results suggest the association between drinking onset and diagnosis is no causal, and attempts to prevent the development of alcohol dependence by delaying drinking onset are unlikely to be successful.”(31) More recent studies also conclude that much of the association can be accounted for by genetic vulnerability.(32,33) Recent reports by the Federal Trade Commission and the National Academy of Sciences point out that most alcohol beverages are obtained by underage persons through their parents and other adults.(34,35) Therefore, we strongly suggest to the Committee that it include wording that cautions parents to discourage their children from drinking and to discuss the subject of alcohol in detail with them. VI. The Food Guide Pyramid Graphics should include alcohol to help put the Dietary Guidelines into action, reinforcing the importance of moderation as the only choice. As the Food Guide Graphic will be revised to mirror the 2005 Dietary Guidelines, we would like to strongly recommend that alcoholic beverages will be included as an option for adults. We firmly believe that this would provide increased exposure to the government’s moderation message and the overall Guideline cautioning about abuse and the importance of only moderate consumption as part of an overall healthy and well-balanced lifestyle. The pyramid and accompanying booklet will help Americans get the needed guidance to choose a balanced diet and responsible decision-making skills as outlined in the Guidelines. This approach would provide an important venue to reinforce socially responsible behavior with respect to wine, beer, and spirits consumption. This approach is also in line with other dietary models and accompanying graphics. Specifically, we would like you to review and consider approaches presented in the Mediterranean, Latin-American, Asian, and Vegetarian Diet Pyramids. These concepts have been developed by leading experts from Harvard University of Public Health and other leading institutions. (36-40) In conclusion, we would like to reiterate that the developing research consensus on moderate versus abusive consumption should be fully reflected in the upcoming 2005 Dietary Guidelines for Americans. While we support the admonition against abusive behavior, and agree that for certain groups of individuals any consumption is inadvisable, we respectfully recommend through this submission that you re-examine the impressive and credible evidence suggesting that, for most people, moderate drinking is consistent with a healthy and well-balanced lifestyle. We are confident that the upcoming Guidelines will continue to assist Americans and other consumers around the world in making informed healthy diet and lifestyle choices. Towards this end, AIM will be committed to widely disseminating the 2005 Dietary Guidelines as a basis of our ongoing and expanded education initiatives. Thank you for your time and consideration. If you have any questions concerning our sub mission or if we can be of any assistance, please contact Elisabeth Holmgren, at our US office at (925) 934-3226 or at em-h@pacbell.net . Sincerely, Peter Duff Chairman AIM-Alcohol in Moderation
Submission Date	9/27/2004 7:38:00 PM
Author	AIM-Alcohol in Moderation

Summary	Keep alcoholic drinks to the bar/tavern in draft form, and encourage unpasteurized traditional soft drinks, herbal teas. Help eliminate alcoholism by encouraging complete hot meals first for all first.
Comments	Some of the Native American tribes made their own fermented drinks, mostly sour, with any alcohol being counteracted by the high quantity of B-vitamins in these indegenous drinks (example, pulque is undistilled, also unfermented in its traditional state, and not able to be transported very far - by distilling something similar to make Tequila, you develop the problems of severe intoxication). The Cherokees fermented a sour corn drink for visitors, releasing its nutrients to the highest advantage. Alcoholism is a plague killing many, and disabling many others. By returning even to the traditions of unpasteurized beer on the tap, we would have at least maintained the B-vitamins and kept the drunkenness to the taverns, minimizing its presence behind the wheels. Traditional drinks, including traditionally fermented ginger ale and native herbal flavored teas contain nutrients that strengthen constitution and also provide much less sugar than do the soft drinks of the convenience store.
Submission Date	9/27/2004 10:28:00 PM
Author	from Poplar, Montana

Summary	While we support the majority of the findings in the Committee Report, we would like to provide additional comment in two important areas: • There should be no changes to the Drinking In Moderation Definition, especially with the “Count as a Drink” language regarding expressions of alcohol content f
Comments	Wine Institute is the public policy association of California wineries representing over 800 California wineries and affiliated businesses. These companies are responsible for 80 percent of the nation’s wine production. On behalf or our members, we are pleased to submit comments in response to the request for public input on the 2005 Dietary Guidelines Advisory Committee Report to the Departments of Health and Human Services and Agriculture. We agree that the 2005 Dietary Guidelines for Americans should represent a balanced approach to recommendations on the full range of nutrition, lifestyle and health issues. In particular, we support the Ethanol Subcommittee’s continued recommended advice to discourage excessive consumption and indicate that, even in moderation, there are individuals who should not drink. We are pleased that the main alcohol message has been maintained from the 2000 Dietary Guidelines: “If you drink alcoholic beverages, do so in moderation” and that the Committee has maintained the recommendation (advice) that, “For those who choose to drink an alcoholic beverage, it is advisable to consume it with meals to slow absorption. Data suggest that the presence of food in the stomach can slow the absorption of alcohol and thereby mitigate the associated rise in blood alcohol concentration.” While we support the majority of the findings in the Committee Report, we would like to provide additional comment in two important areas: • There should be no changes to the Drinking In Moderation Definition, especially with the “Count as a Drink” language regarding expressions of alcohol content for wine, because there will be extensive rulemaking by the Treasury Department’s Tax and Trade Bureau (TTB) in 2005 that will address several significant issues that are based on the language of the Dietary Guidelines. Language in the Dietary Guidelines should not be misused or misconstrued in any future regulatory action or rulemaking. • Messages relating to moderate drinking and weight gain and obesity for the public should clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. I. MODERATE DRINKING DEFINITION In the 2000 version of the Dietary Guidelines for Americans, drinking in moderation is defined in Box 26 on page 36 - What is Drinking in Moderation?: The Advice For Today on page 37 goes one step further and recommends “Limit intake to one drink per day for women and two per day for men, and take with meals to slow alcohol absorption.” The Advisory Committee found this definition of moderate drinking as optimal for adults who choose to drink as a means to provide both beneficial effects on heart disease and allcause mortality as well as reduce risks caused by heavy drinking. However, the Advisory Committee also states that, “The definition of moderation, including the size of one drink, requires emphasis. (Some investigators and apparently many individuals interpret ‘moderate drinking’ to cover higher levels of intake than shown in Table E-25. Many mixed drinks actually provide several servings of alcohol per drink.” (DG Advisory Committee Report, Part D, Section 8, page 3). In an apparent response to further define a moderate serving of each beverage, the Advisory Committee has added a “12 percent alcohol” qualifier to the definition of a serving of wine. Throughout the text of the Advisory Committee Report, one serving of wine is defined as “a 5-ounce glass of 12 percent alcohol.” (See Table E-25, below). Wine Institute believes that providing the public a frame of reference by including serving size information in ounces will assist wine, beer, and distilled spirits consumers in their awareness of alcohol consumption levels. We believe that direct serving size information in ounces about the product being consumed is relevant and, if truthful, accurate and specific, should be able to be included. However, within each category of drinks (wine, beer and distilled spirits) there is a range of products with different alcohol percent values. Unlike distilled spirits, wine is not a “mixed” drink. Consumers discriminate among the various wine products more by their broad product categories, and producers of wine do not target a particular alcohol level but a sensory style and taste. Even from a regulatory standpoint, the standards of identity for wine differ significantly from distilled spirits product standards. Table wine, for example, is defined as still wine between 7 and 14 percent alcohol by volume.1 While from a scientific or clinical standpoint it may make 1 27 USC 5041 states, in part, as follows: (a) Imposition There is hereby imposed on all wines (including imitation, substandard, or artificial wine, and compounds sold as wine) having not in excess of 24 percent of alcohol by volume, in bond in, produced in, or imported into, the United States, taxes at the rates shown in subsection (b), such taxes to be determined as of the time of removal for consumption or sale. All wines containing more than 24 percent of alcohol by volume shall be classed as distilled spirits and taxed accordingly. Still wines shall include those wines containing not more than 0.392 gram of carbon dioxide per hundred milliliters of wine; except that the Secretary may by regulations prescribe such tolerances to this maximum limitation as may be reasonably necessary in good commercial practice. (b) Rates of tax (1) On still wines containing not more than 14 percent of alcohol by volume, $1.07 per wine gallon; (2) On still wines containing more than 14 percent and not exceeding 21 percent of alcohol by volume, $1.57 per wine gallon; (3) On still wines containing more than 21 percent and not exceeding 24 percent of alcohol by volume, $3.15 per wine gallon; (4) On champagne and other sparkling wines, $3.40 per wine gallon; (5) On artificially carbonated wines, $3.30 per wine gallon; and (6) On hard cider which is a still wine derived primarily from apples or apple concentrate and water, containing no other fruit product, and containing at least one-half of 1 percent and less than 7 percent alcohol by volume, 22.6 cents per wine gallon. sense to qualify wine with a specific alcohol content, we do not believe that assigning an arbitrary value of 12 percent alcohol to wine provides the consumer with any additional useful information from which to make an informed decision. As the alcohol percent value of table wine varies between 7 percent and 14 percent and that for dessert wine is 14 percent and above, such a listing would not necessarily be truthful or accurate and could be misleading. We believe that the addition of a “12% alcohol” qualifier in the “Count as a Drink” language will be misinterpreted by some as the establishment of a “standard drink” size, which will eventually lead to a distortion and/or omission of the important moderation message. The Guidelines represent great efforts to explain moderate consumption to U.S. consumers, but they have also been misunderstood. We are seeing the moderation message giving way to a much broader interpretation that the Guidelines themselves have established the size of a “standard drink,” and there have been several regulatory actions that have been based on this contention. We have seen the “count as a drink” language stripped of its accompanying moderation context, with what remains being repackaged as a definition for a “standard drink.” We do not believe that this is what was intended by the authors of the Guidelines, and we are concerned that this misinterpretation and misuse, all pending the safeguards of future rulemaking, will raise serious social as well as political implications. While adding a “12% alcohol” qualifier to wine may appear to be minor and consistent with the “80 proof distilled spirits” language, we are concerned that such changes will result in an argument that these sizes equate to “standard drink” sizes and will become the basis for untruthful and misleading information on wine, beer, and spirits labels. Changes such as this will tend to bolster an argument that all alcoholic beverages are “equal,” a notion that Wine Institute disagrees with. It is an oversimplification to single out the ethyl alcohol property that all alcoholic beverages have in common, and then to conveniently boot strap this commonality into a graphic equation that all alcoholic beverages are equal but only in specific but differing quantities. There are three separate regulatory actions that are pending administrative rulemaking, all based in large part on the contention that the U.S. Dietary Guidelines have established standard serving sizes. Carbohydrate Labeling of Alcoholic Beverages Awaits Rulemaking On April 7, 2004, without the benefit and safeguards of the rulemaking process, the TTB published an Industry Circular that authorized the voluntary labeling of carbohydrate information for wine, beer, and distilled spirits2. Citing the 2000 Dietary Guidelines3, TTB in its Industry Circular uses the Dietary Guidelines “Count as a drink” language as a measure of a serving size: 2 TTB Ruling Number 2004-1, dated April 7, 2004, entitled “Caloric and Carbohydrate Representations in the Labeling and Advertising of Wine, Distilled Spirits and Malt Beverages, is currently available on the TTB web site at http://www.ttb.gov/alcohol/info/revrule/rules/2004-1.pdf Accordingly, this ruling holds that the statement of average analysis must apply to a serving of the product, and that the serving must be 12 fl. oz. for malt beverages, 5 fl. oz. for wine, and 1.5 fl. oz. for distilled spirits. TTB indicates in this ruling that it will conduct a rulemaking on this issue in the future.4 To date, almost six months since the publication of this interim policy, Wine Institute still awaits the promised publication of a Notice of Proposed Rulemaking by TTB on this matter. The significance of this action, however, should not be lost. This is an instance where an administrative agency has taken information from the Dietary Guidelines, eliminated the notion of moderate consumption, and concludes that the “Count as a drink” volumes for alcoholic beverages are “standard drink” sizes. “Serving Facts Panel” Labeling of Alcoholic Beverages Awaits Rulemaking The issue of whether the Dietary Guidelines established a definition of a “standard drink” came to light again with TTB in early August, 2004. On August 5, 2004, and again without the benefit of rulemaking, TTB released what it referred to as a “Serving Facts White Paper” where the identical drink volume values were being used by TTB to permit not simply additional nutritional information, but a comparative “equivalency” graphic” showing illustrations of a beer, wine and spirits container: 3 In TTB Ruling Number 2004-1, it is stated: It should be noted that we are setting serving sizes for these products in ounces, even though existing regulations require the use of metric terms in labeling the net contents of wine and distilled spirits containers. It is our belief that consumers are used to seeing serving sizes set forth in ounces, in the U.S. "Dietary Guidelines" and elsewhere. 4 In TTB Ruling Number 2004-1, it is stated that “TTB plans to engage in rulemaking, in the near future, on the issue of labeling and advertising statements regarding calorie and carbohydrate content. We believe that public comment on these issues will be useful in developing a more comprehensive policy on the mandatory or voluntary use of nutritional information on alcohol beverage labels.” The beer and wine sectors of the alcoholic beverage industry, strenuously objected to both the process and the content of the “White Paper.” Wine Institute opposed the “White Paper” for many reasons, but we point out that the term “standard drink” used by TTB and attributed to the Dietary Guidelines does not appear anywhere within the 2000 version of the Dietary Guidelines. It should be noted that TTB did not move ahead on this version of the “Serving Facts Panel” white paper, but revised and reissued a second white paper on September 21, 2004. While this white paper removes the more onerous provisions embodied in the first version and is careful not to use the term “standard drink,” this second white paper maintains, without benefit of rulemaking, serving size information that is identical to the Guidelines’ “Count as a Drink” sizes. TTB states in this version of the white paper that it will be conducting a rulemaking in the future.5 National Consumer League / Center for Science in the Public Interest Rulemaking Petition Awaits Rulemaking Submitted to TTB in December of 2003, the rulemaking petition of the National Consumer League and the Center for Science in the Public Interest calls for uniform information on several label items: • Alcohol content • Standard serving size • Amount of alcohol in ounces and number of calories per serving • Number of standard drinks per container • Ingredient declaration • U.S. Dietary Guideline recommendations for moderate drinking 5 TTB states in its document entitled: “Nutrient Claims in the Labeling and Advertising of Wine, Distilled Spirits and Malt Beverages – “Serving Facts” Panel” as follows: “The ruling would provide guidance to industry members on what TTB will allow as optional serving facts information on labels and in advertising until we develop final regulations concerning such panels. It is possible that the results of the rulemaking will differ from the guidance in the ruling.” The petitioners contend that more uniform alcohol information should be conveyed to consumers in a context where consumers can more easily understand how much alcohol they are consuming. They suggest that the serving sizes “prescribed” by the U.S. Dietary Guidelines should be used as the “standard serving size.” Additionally, the petitioners suggest that a consistent graphic, such as a beer mug or a glass of wine, be used to alert consumers to the statement. The sample label proposed in that petition looks like this: We urge the authors of the Dietary Guidelines 2005 version to allow for the completion of rulemaking before considering any changes to that portion of the Guidelines. II. CALORIES AND WEIGHT The issue of caloric content and association of alcohol with added sugar and solid fats in relation to discretionary calories and maintaining a healthy weight/weight gain is addressed both in Part A: Executive Summary and Part E: Translating the Science into Dietary Guidance. In the section “Control Calorie Intake to Manage Body Weight” (Part E page 7), the Advisory Committee states that, “Calories come from fat, carbohydrate, protein, and alcohol. The healthiest way to reduce calorie intake is to reduce one’s intake of added sugars, solid fat, and alcohol – they all provide calories, but they do not provide essential nutrients.” … “Table E-3 gives examples of how calories can be decreased by decreasing alcoholic beverage intake.” As we stated in our May 2003 submission to the Advisory Committee, “Given the current lack of consensus on the issue of moderate wine, beer and spirits consumption and its relationship to weight gain, Wine Institute recommends that the Committee provide more detailed discussion on the issue of moderate consumption of wine, beer and distilled spirits and its relationship to weight gain.” (WI Comment 2003, pages 6-7) The NIAAA review, State of the Science Report on the Effects of Moderate Drinking, concluded that the current scientific literature suggests that, “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.” (NIAAA 2003, page 29) An independent review commissioned by Wine Institute to review wine and alcohol and its effects on calories and body weight control since 1985 stated that, “At least 90 papers were published that have dealt directly or indirectly with alcohol consumption and body weight regulation. This renewed interest in how alcohol influences body weight stems, in part, from concern over dietary elements that may underlie the world-wide obesity epidemic. Although no universal consensus has been reached, a number of lines of evidence increasingly suggest that moderate alcohol consumption does not represent a dietary risk for developing obesity and may in fact promote certain metabolic changes which reduce the risk for overweight and obesity.” (Cordain 2003, page 2) In response to the scientific evidence presented, the Ethanol Subcommittee concluded that the relationship between consuming four or fewer alcoholic beverages daily and obesity was an “Unresolved Issue.” They state that, “The available data on the relationship between alcohol consumption and weight gain/obesity are sparse and inconclusive. There are contradictory findings at the higher end of the spectrum (i.e. 3 to 4 drinks per day) that may relate to fundamental limitations of the cross-sectional study design. At moderate drinking levels (i.e. up to one drink per day for women, up to one (sic?) drink per day for men), there is no apparent association between alcohol intake and obesity.” The Subcommittee concludes, “In summary, although prospective data are limited, there is no apparent association between consuming one or two alcoholic beverages daily and obesity.” Dietary Guidelines Advisory Committee Report, (Part 6, Section 8, page 6) Based on the Ethanol Subcommittee conclusion, we would like to recommend the statement made in Part E: Translating the Science into Dietary Guidelines be revised to read: “Calories come from fat, carbohydrate, protein, and alcohol. The healthiest way to reduce calorie intake is to reduce one’s intake of added sugars and solid fats. The findings on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive, however, it may be prudent to monitor consumption as it relates to the intake of discretionary calories.” CLOSING STATEMENTS We would like to commend the members of the Advisory Committee for their thorough review of the scientific literature and overall balanced recommendations on moderate alcohol consumption by healthy adults. On the issue of the Drinking In Moderation Definition, we strongly support the current definition of moderation (no more than 1 drink per day for women and no more than 2 drinks per day for men). We recommend the definition of one drink of wine be retained as stated in the 2000 version of the Guidelines in Box 26 – What is Drinking in Moderation? We believe that any changes made to the current definition would lead to inaccurate and misleading representations of the Guidelines’ moderation message to the public. Therefore, we recommend the addition of a clear and unambiguous statement in the guidelines that the “Count as a Drink” statements should not be interpreted as the establishment of a “standard drink,” and that the information is being provided to further explain the moderation message. As stated, there will be full and extensive industry and regulatory agency review accompanied by public comment for both serving size and serving facts labeling at the start of 2005. We would ask that any messages relating to moderate drinking and weight gain and obesity for the public clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. We thank you for the opportunity to present additional information and recommendations on the Dietary Guidelines Advisory Committee Report.
Submission Date	9/27/2004
Author	Wine Institute

Summary	If you drink alcoholic beverages, do so in moderation. • Supporting text should include alcohol consumption as a risk factor for breast cancer, as well as for high blood pressure and congestive heart failure if drinking is prolonged. Written by: Ralph B. Vance, Karmeen Kulkarni, Alice K. Jacobs
Comments	If you drink alcoholic beverages, do so in moderation. • Supporting text should include alcohol consumption as a risk factor for breast cancer, as well as for high blood pressure and congestive heart failure if drinking is prolonged.
Submission Date	9/27/2004
Author	American Cancer Society, American Diabetes Association, American Heart Association

Carbohydrates

Sugars

Summary	Include the recommendation: Reduce added sugars.
Comments	These guidelines will be considered a travesty unless you address the problem of added sugars that is a main cause of obesity in America.
Submission Date	9/1/2004 7:14:00 AM
Author	Anonymous

Summary	Sugar is an addictive substance and the public should be told this in a clear fashion. This report does not address this issue strongly enough. Please revise these recommendations to reflect what scientists, health advocates and the public now know about the dangers of sugar.
Comments	Sugar is an addictive substance and the public should be told this in a clear fashion. This report does not address this issue strongly enough. For the sake of the health of this country, please revise these recommendations to reflect what scientists, health advocates and the public now know about the dangers of sugar.
Submission Date	9/1/2004 7:16:00 AM
Author	Anonymous

Summary	Your correct intent to limit added sugars is not reflected clearly in your theme to "Choose CHO wisely." Please don't confuse the average American.
Comments	Reading the fine print of your document, I can see your wise emphasis on decreasing added sugars within total calorie intake. I fear that the average American will not get this message clearly with your overarching theme - to choose carbohydrates carefully. Please be clear, and urge Americans to reduce addes refined sugars in the same way that you urge them to resude salt.
Submission Date	9/1/2004 7:17:00 AM
Author	from Swarthmore, PA

Summary	Be unambiguous about limiting sugar consumption.
Comments	It is crucial that unambiguous advice about sugar consumption be in the final guidelines in early 2005. With the growing obesity epidemic this hardly seems to be the time to be any less specific about limiting sugar in the diet of every person. This seems to be clearly indicated by scientific reports.
Submission Date	9/1/2004 7:53:00 AM
Author	from Blooming Grove, New York

Summary	The Dietary Guidelines Committee should make explicit recommendations about added sugars in its advisory reporet. Recent studies clearly show a link between simple sugars and adverse health, such as obesity and diabetes. The committee must take responsibility to clearly advise our nation.
Comments	The Dietary Guidelines Advisory Committee should make explicit recommendations about added sugars in its advisory report on dietary guidelines. Results from recent studies clearly show a link between simple sugars, such as high fructose corn syrup, and adverse health, such as obesity and diabetes. Our nation needs such detailed advice to live healthier lives. This, in turn, should help to reduce the burden of chronic, preventable health problems on our health care system.
Submission Date	9/1/2004 8:21:00 AM
Author	from Madison, WI

Summary	Your "nine tips for healthy eating" must include a clear, unambiguous statement about the harmful effects of added sugars in the diet. "Reduce added sugars" is what we need to hear. You will be failing your mission if you neglect to include a clear unequivocal warning about sugar.
Comments	I am appalled that the new guidelines eliminate a direct mention of the harmful effect of refined sugars in the diet. As a parent, educator, and activist with extensive knowledge of good nutrition, I expect clear and unequivocal advice in the nutritional pyramid. A simple statement such as "reduce added sugars" is essential. Most people do not have the time, as I did, to read the summary report. I am appalled at the appearance your agency has capitulated to the food, drug, and dietary supplement industries' pressure to removed the statment "Avoid too much sugar" from the food pyramid guidelines. The statement "Choose carbohydrates wisely for good health" is blatantly unhelpful for the millions of obese Americans who haven't the time to read the fine print. Your mission is to provide clear unambiguous information for the citizenry regarding the best health choices we can make. As teacher since the late 1970's, I have witnessed first-hand the dramatic rise in childhood obesity, Attention Deficit Disorder, food allergies, and other diet-related illnesses. I have witnessed the rise in marketing highly processed foods to children. I despair to think that your revised guidelines will encourage school lunches to be further degraded and the health of the citizenry to further erode. Do not capitulate to industry pressure. Revise your statement to read "Reduce added sugars." People need to know this. It is no less than your mission to be clear, consise,and, above all, truthful to the American public.
Submission Date	9/1/2004 8:34:00 AM
Author	from Topsham, Maine

Summary	I URGE you to reconsider and issue REAL advice and guidleines concerning the consumption of artificial/processed sugar. Please do your job.
Comments	I am astounded that you would remove any negative or restrictive comments regarding artificial/processed sugars in your new food pyramid guidelines, e.g., "choose carbohydrates wisely"?!? Did the fact that 7 members of that panel are connected to the food processing industry have anything to do with it? Can we say "conflict of interest?" Have you no regard for public health at all? Shame on you!
Submission Date	9/1/2004 10:40:00 AM
Author	Anonymous

Summary
Comments	This is for the public comment period for the new nutritional guidelines. Please include a caution specific to the need to limit sugar in diet. These guidelines will be used in classrooms everywhere and our children need to know that too much sugar is actually bad for their health.
Submission Date	9/1/2004 11:03:00 AM
Author	Organization Name not Specified

Summary	Limit sugars in guidelines
Comments	This is for the public comment period for the new nutritional guidelines. Please include a caution specific to the need to limit sugar in diet. These guidelines will be used in classrooms everywhere and our children need to know that too much sugar is actually bad for their health.
Submission Date	9/1/2004 11:04:00 AM
Author	from Hydesville, CA

Summary	As a physician, I am disturbed by the guideline "Choose carbohydrates wisely for good health," apparently a result of sugar industry pressure. This should be replaced with clear, health-based advice: "Avoid sugar and foods with added sugars."
Comments	As both a family physician and head of a growing household, I appreciate the importance of sound expert advice on nutrition in face of conflicting messages about health and nutrition in the media. While I generally agree with the recommendations of the advisory committee, I was taken aback by the recommendations on sugars and carbohydrates. I am a bit dumbfounded by the committee's decision to break with past sound advice about added sugar, such as "Avoid too much sugar." The proposed guideline "Choose carbohydrates wisely for good health" is vague and essentially abdicates responsibility for providing sound, easy-to-follow advice about the importance of limiting added sugars. Strong evidence, much of it cited in the committee's report, supports the link between added sugar and obesity. Added sugar, which has no nutritional value, also replaces comsumption of other foods with nutritional value, leading to a general decline in nutritional status. As a parent constantly bombarded with media advertising promoting processed, sweetened food products, I appreciate the importance of strong, unbiased nutritional guidance. The committees vague unhelpful guidance on sugars is disturbing. The only likely explanation is that the committee has yielded to pressure from the sugar and processed food industry. I urge you to rewrite the guideline on sugar, replacing the draft statement with a statement such as "Avoid sugar and foods with added sugars."
Submission Date	9/1/2004 11:13:00 AM
Author	from Elizabeth, NJ

Summary
Comments	What happened to saying we should limit the amount of sugar we eat? If 1980 guidelines said to avoid too much sugar why shouldn't we still say that rather than the mealy-mouthed "Choose your carbohydrates wisely." What a cop-out. You know what sugar does to our teeth & how fat too much sugar, especially in soft drinks, has made too many people. I'm skinny & am tired of all the costs fat people are adding to our health care. If you don't hit people over the head with plain nutrition advice they won't do the research necessary to make the wisest decisions. I eat a lot of junk, but I eat a LOT of fruit & vegetables too. Bravo for emphasizing fruits & vegetables. Now if we could just shift subisdies from sugar & corn to apples, cherries, asparagus, etc. it would be great.
Submission Date	9/1/2004 12:45:00 PM
Author	from Montgomery, AL

Summary	Reduce added sugars
Comments	Your use of sugars is a bit vague. You should be more specific about limiting added sugars in one's diet. Maybe something along the lines of "reduce added sugars." There is too much research out there that addresses the harms of eating added sugars to ignore it.
Submission Date	9/1/2004 1:34:00 PM
Author	from Seattle, WA

Summary	Be more specific on dangers of too much sugar.
Comments	"Choose carbohydrates wisely for good health" is too general. The growing evidence regarding the bad effects of added sugars(soft drinks)necessitates more specific guidelines. Do not let the sugar industry influence the report.
Submission Date	9/1/2004 1:41:00 PM
Author	from Bronx, NY

Summary	Recommend "Reduce added sugars"
Comments	As someone who attempts to eat healthfully, I feel that issuing a recommendation to the public like "Choose carbohydrates wisely" is useless for the average reader. To provide valuable assistance to the public, we should be told which types of carbohydrates should be chosen and which should be avoided. As the New York Times editorial suggests, "Reduce added sugars" would be far more helpful, unless it is true that the committee is unduly unfluenced by the sugars industry.
Submission Date	9/1/2004 2:14:00 PM
Author	from Newark, DE

Summary	A more exact definition of healty carbohydrates is essential - people do not look at the ingredients in what they are eating - they think it is sufficient to look at nutritional facts.
Comments	Sugar is a highly addictive substance - it should be limited in intake to only natural foods. A strong suggestion should be made to stay away from foods w/ added sugar (in all forms.)
Submission Date	9/1/2004 3:06:00 PM
Author	from Brooklyn, New York

Summary	Change “dental caries” to “caries” (all caries are dental caries) Use “potentially cariogenic” rather than “cariogenic,” which is an inaccurate term Change “sugar” to “sugars” to more accurately reflect the range of sugars that are potentially cariogenic (more detailed comments being mailed)
Comments	September 7, 2004 TO: 2005 USDA Dietary Guidelines Advisory Committee FROM: Stephen J. Moss, DDS, MS Professor Emeritus, New York University College of Dentistry RE: 2005 USDA Dietary Guidelines Advisory Committee Report (Part D, Section 5, Question 1: Carbohydrates and Caries) As a lifelong oral health professional who has focused on caries prevention, particularly in children, I want to commend the Dietary Guidelines Advisory Committee on an enlightened and well-written report. Your sophisticated explanation of the relationship between intake of carbohydrates and caries (Part D, Section 5, Question 1) is of great service to the American public, as it clearly and concisely describes the multifactorial nature of the caries process. The following comments pertain to terminology. 1. Page 4, line 23 Change: “contributes to dental caries” To: “contributes to caries” (There are a variety of caries, e.g. active, buccal, compound, distal, fissure, incipient, etc., but all are dental caries.) _______________________________________________________ 2. Page 4, line 25 Change: “reduce the risk of dental caries” To: “reduce the risk of caries” _______________________________________________________ 3. Page 4, line 26 Change: “A combined approach of reducing the frequency and duration of exposure to fermentable carbohydrate intake” To: “Reducing the frequency of fermentable carbohydrate intake and optimizing…” 4. Page 4, line 27 Change: “most effective way to reduce caries incidence” To: “most effective way to reduce development of caries” 5. Page 4, line 32 Change: “of substrate by cariogenic bacteria in the mouth” To: “of substrate by plaque bacteria in the mouth to produce acid and subsequent demineralization of the enamel surface by the acid.” (Used alone, the terms “cariogenic” and/or “cariogenicity” are meaningless. The concept began as a prediction of how a particular food or group of foods would impact on the caries process. It is, at best, an educated guess and refers to the food rather than the bacteria. More meaningful terms in conveying the concept include “potential cariogenicity,” a prediction of how the author believes the fermentable carbohydrates in particular foods will impact the future development of caries. It takes in the multi-factorial nature of caries development. A second useful term is “relative cariogenicity,” which generally refers to a comparison test among a group of foods. They are tested against criteria such as oral retention, oral clearance, ability to demineralize enamel, ability to stimulate salivary flow, etc. Rat feeding studies are a good example of attempts to determine relative cariogenicity among a group of foods, but they are fraught with problems such as consistency of the food, the preference for certain foods by the animals and the fact that humans are not giant rats. For those reasons, those studies are seldom referenced today. There is actually no one test or group of tests that enable scientists, with any degree of certainty, to predict the potential cariogenicity of a food in humans.) 6. Page 4, line 35 Change: “available to the bacteria, and the susceptibility…” To: “available to the bacteria, salivary flow and the susceptibility…” 7. Page 5, line 1 Change: “much less cariogenic than other carbohydrates…” To: “are not as readily fermentable as other carbohydrates 8. Page 5, line 2 Change: “whether or not substituting sucrose with sugar substitutes…” To: “whether or not substituting sugar with sugar substitutes…” (Sugar substitutes can replace a range of sugars, not just sucrose, which is commonly known as “refined” or “table” sugar. _____________________________________________________ 9. Page 5, line 10 Change: “The longer a cariogenic substance remains in the oral cavity…” To: “The longer a fermentable carbohydrate remains in the oral cavity…” _______________________________________________________ 10. Page 5, line 22 Change: “Dental hygiene may have a greater role in the development of dental caries…” To: “Dental hygiene may have a greater role in the development of caries…” _______________________________________________________ 11. Page 6, line 6 Change: “The impact of sugar intakes on dental caries…” To: “The impact of sugars intake on caries…” (Colloquially, “sugar” typically refers to sucrose; all sugars have an impact on caries formation. 12. Page 6, line 33 Change: “had a higher score for dental caries…” To: “had a higher score for caries…”
Submission Date	9/17/2004 4:52:00 PM
Author	Organization Name not Specified

Fiber

Summary	Avocados are a natural source of eight vitamins, two minerals and at least three phytochemicals. Avocados are included in dietary programs from many of the world’s leading nutrition organizations and can make a significant contribution to the health of Americans.
Comments	One of the nine key messages is: Choose carbohydrates wisely for good health. Including avocados in the diet helps meet the recommended intake of dietary fiber of 14 grams per 1000 calories. One-fifth of a medium avocado provides 3 grams of dietary fiber.
Submission Date	9/17/2004 5:53:00 PM
Author	California Avocado Commission

Sugars

Summary	The guidelines should specifically advise against substantial consumption of refined sugar and urge the food industry to reduce the sugar content of beverages and other foods. For people to take the guidelines seriously, the guidelines are to be based on facts, not commercial interests.
Comments	Based on the available data from research, both long term average BMI and specific studies on refined carbohydrates such as sugars, I believe that the guidelines should be much more foreceful in stating that sugars should be reduced from present consumption. The dietary guidelines run the risk of being ignored if they do not address clear current dietary problems or appear to pander to commercial interests. The committee is to be applauded for finally stating what has been obvious for at least a dozen years about the adverse health effects of trans-fats. While I can understand that the Government did not want to adversely affect commercial interests, the slow reaction to such a clear problem food gave the users of the guidelines little confidence that the guidelines were constituted with their best interests in mind. Please, don't make the same mistake with sugars. While it may not be absolutely clear that high carbohydrate consumption is entirely responsible for the BMI bloat, there is no doubt that high sugar consumptions is at least partially, and probably mostly, responsible.
Submission Date	9/20/2004 12:22:00 PM
Author	Carleton University (retired)

Fiber

Summary
Comments	Regarding: Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2005 to the Secretaries of Health and Human Services and Agriculture It is with great interest, we read the Dietary Guidelines Advisory Committee report, which was certainly very thoughtful and comprehensive. We thoroughly reviewed the discussion around the importance of carbohydrates in the American diets. As a producer of a carbohydrate rich product, we were generally in agreement with the committee’s report. Our only concern is the ability to communicate to consumers the fact that all carbohydrates are not equal and how to choose carbohydrates wisely. To that end, we would like to offer the following reasons why we believe that “Pasta is a Good Carb” and should be a food promoted to Americans in the 2005 Dietary Guideline. Choose Carbohydrates Wisely Choose Pasta · Pasta is relatively low in calories Calories 1 Cup Spaghetti (cooked) 200 1 Med. Baked Potato (plain) 220 1 Cup Brown Rice 232 3 oz. Bagel 240 1 Cup Mashed Potato 248 2 oz. Snickers Bar 282 1 slice chocolate cake (iced) 320 4 oz. French Fries (McDonald’s) 515 · A pasta meal consisting of 1 cup cooked spaghetti, ½ cup spaghetti sauce, 2 oz. lean ground beef, ¼ cup chopped onion and ½ cup green bell pepper is below 500 calories. For a diet of 2500 calories, this is less than 20% of the daily caloric intake. · Pasta is a good source of thiamin, folic acid, iron, riboflavin and niacin. Pasta is also a low fat; very low sodium and cholesterol-free food. · Pasta is even more valuable nutritiously when accompanied by healthy partners like: vegetables, beans, tomato sauce, olive oil, fish, lean poultry or beef and low-fat cheese. When combined these ingredients can result in a delicious meal that is nutrient rich and low fat. · Pasta, like other complex carbohydrates, is an excellent source of energy. This is very different than other carbohydrates such as: cakes, cookies, candy, donuts, potato chips and corn chips, to name a few, that have relatively little nutritional value and unlike pasta have a high Glycemic Index resulting in a fast blood sugar response. · An article published in the Journal of The American Medical Association supports using the Glycemic Index to help choose healthy foods. “Clinical use of Glycemic index as a qualitative guide to food selection would seem prudent in view of the preponderance of evidence suggesting benefit and absence of adverse effects.” JAMA – May 8, 2002 · The Glycemic Research Institute (GRI), a nonprofit organization based in Washington, DC, gives the following reasons why low Glycemic foods are beneficial to health: - Low Glycemic foods do not stimulate food-cravings or human-food-craving-mechanism - Low Glycemic foods are not based on starvation or deprivation - Low Glycemic foods do not promote fat storage - Low Glycemic food plans have been proven to reduce incidence of Type II diabetes and to help control Type I and Type II diabetes - Low Glycemic foods do not elevate insulin and blood glucose - Low Glycemic foods do not exacerbate hyperactivity - Low Glycemic foods do not reduce sports performance GRI – Copyright 1999-2003 · Based on the facts that Pasta has excellent nutritional value, provides diverse meal options and is low on the Glycemic Index, it should be considered “A Good Carbohydrate” and promoted as part of a healthful diet in the upcoming sixth edition of the Dietary Guidelines for Americans. We hope you will agree that Pasta is indeed a good carb and therefore is worthy of specific mention as a carbohydrate, which consumers should consider favorably when planning a healthful meal. Sincerely, Drew Lericos Director of Marketing American Italian Pasta Company 4100 N. Mulberry Drive Kansas City, MO 64116
Submission Date	9/20/2004 6:48:00 PM
Author	American Italian Pasta Company

Glycemic Response

Summary	Utilizing the clinically proven glycemic index of a food and/or raw material is mandatory in identifying "Net Carb" and "Low Carb" foods, as well as any claims for Diabetic-Friendly foods.
Comments	RE: Food Labeling and the Glycemic Index. Low Carb labeling and Sugar Alcohols. Dear Sirs; Our research organization has been conducting clinical studies of the Glycemic Index and human biochemistry for over 20 years. We possess the largest database of glycemic research of any organization in the world. We recently completed clinical for Hershey Foods to identify the biochemical pathway utilized by chocolate in the body. Our clinical studies are conducted at the University of Florida, and include glycemic index, glycemic load, and fat-storing mechanisms in humans, such as Leptin, Lipoprotein Lipase, and Neuropeptide Y. We are submitting our comments to provide scientific evidence that: 1) sugar alcohols can elevate blood glucose and insulin levels, and and stimulate fat-storage in humans, and this needs to be reflected in FDA labeling guidelines. 2) Determination of the glycemic response of foods, Nutraceuticals, and all consumables, is mandatory in the determination of labeling information. 3) Identifying "Low Carb" foods and "Net Carb" foods requires knowledge of the biochemical properties of the food. We concur with the FDA position that the term "Low Carb" should not be allowed until a competent definition on "Low Carb" is established. If the glycemic index of a low carb product is not known, how can that product claim not to elevate blood glucose, insulin levels, and stimulate fat-storing mechanisms in humans? Sugar alcohols can elevate blood glucose, insulin levels, and fat-storage in adipose tissue fat cells, despite what manufacturers claim. Food manufacturers should not be allowed to use the terms "Low Carb" or "Net Carb" foods until there is definitive data showing the clinical response of all raw materials used in food manufacturing, such as sugar alcohols. Only specific laboratory and definitve clinical studies can quantify these terms. If manufacturers are allowed to state "Net Carbs" without clinical evidence of the biochemical properties of foods and raw materials, there will be mis-labeling, misuse, and outright fraud against the public. All carbs and sugars and sugar alcohols present caloric value, as well as blood glucose, insulin, and fat-storage properties. It is our position that all carbohydrates and sugars should be claimed under Carbohydrates, and not allowed to be placed under the guise of "Low Carb" or "Net Carb." Sincerely, Dr. Ann de Wees Allen Chief of Biomedical Research Glycemic Research Institute Washington, D.C. www.glycemic.com
Submission Date	9/21/2004 6:10:00 PM
Author	Glycemic Research Institute

Fiber

Summary	The guideline should be modified to increased specificity. Suggested guideline; Choose foods made with whole grains and little added sugar.
Comments	If the intent of the proposed general carboydrate guideline is to reinforce the guideline “Increase daily intake of fruits and vegetables, whole grains, and nonfat or low-fat milk and milk products” and address the issue of increasing whole grains and reducing sugar intakes a more actionable guideline would read; “Choose foods made with whole grains and little added sugar”.
Submission Date	9/22/2004 2:23:00 PM
Author	from Boston, MA

Sugars

Summary	The guideline should be modified to increase specificity. Suggested guideline; Choose foods made with whole grains and little added sugar.
Comments	If the intent is to reinforce the guideline “Increase daily intake of fruits and vegetables, whole grains, and nonfat or low-fat milk and milk products” and address the issue of increasing whole grain and reducing sugar intakes a more actionable guideline would read; “Choose foods made with whole grains and little added sugar”.
Submission Date	9/22/2004 2:28:00 PM
Author	from Boston, MA

Summary	It is urgent that you distinguish between simple and complex carbs in the new dietary guidelines for the nation. Urge that people eat complex carbs, and leave simple carbs for on occasional, RARE, treat. We need to lower the rate of obesity in this country or we will be a nation of sick people.
Comments	In the new Dietary Guidelines you are working on, it is essential that you explain the difference between COMPLEX carbohydrates and SIMPLE carbohydrates, and the way that difference relates to good health vs. poor health, AND to weight loss opportunities. All carbs are NOT created equal. Other than honey, only complex carbohydrates occur in nature. They contain a great deal of fiber. When the fiber is removed from these naturally-occuring complex carbohydrates--by food processing--the complex carbs become simple carbs (read "sugars")and are then ready to be rapidly digested by the body. Keeping the fiber in the naturally-occurring carbohydrates by using only minimal processing that does not remove fiber results in slow digestion, whereby the calories are released SLOWLY into the bloodstream, which does not result in a rapid rise in blood sugar level. Eating carbohydrates that have had all the fiber removed by food processing releases a cascade of simple sugars (read "calories") into the bloodstream rapidly, causing a rise in insulin, which is called the "insulin response." That is NOT a good thing, as it causes quick calorie storage in the fat cells, followed by a quick blood sugar drop, making us even fatter than we already are, and wanting more of what we just ate. Repeating this cycle frequently can significantly raise the risk of diabetes. Furthermore, I have personally observed over the years (I'm now 62)that simple sugars DULL my tastebuds, and my desire for complex carbohydrates and other health-promoting foods, and give me instead a craving for simple carbs(cakes, candy, cookies, chips, etc, ad infinitum), resulting in the "One is not enough" syndrome. It's really, really easy to want to binge on simple-carb foods. This doesn't happen with complex-carb foods. Simple-sugar foods cause cravings, a result of the rapid rise and fall in blood sugar levels. With complex carb intake, cravings go away and blood sugar stabilizes. I have repeated this unfortunate "learning cycle" more times than I care to admit over my 62 years. It is always the same. At the end of the cycle, I need to lose the weight I gained during the "learning" part! All my acquaintances say the same is true for them. When you are eating simple carbs, you simply don't want good, health-promoting food. You will choose "junk" food, instead, and the more the better! It is imperative that the important difference between types of carbohydrate (unrefined vs refined) be spelled out for our citizens. Many don't know how important the difference is to their overall health, or to their waistines. Please, please do the right thing and tell the truth. We depend heavily on your work, so you need to do it right. You are charged with EDUCATION FOR GOOD HEALTH for all Americans. Fulfill your charge. Please.
Submission Date	9/23/2004 9:52:00 AM
Author	from Cary, NC

Summary	Omit the word “carbohydrate” from the guidelines. Suggest changing to "Choose sugar containing foods and drinks wisely for good health."
Comments	Omit the word “carbohydrate” from the guidelines. Suggest changing to "Choose sugar containing foods and drinks wisely for good health." Many people don’t realize that sugar falls under the carbohydrate group- they only relate carbohydrate to breads/grains.
Submission Date	9/23/2004 12:16:00 PM
Author	OSU Extension Program- Cleveland, OH

Summary	Suggest removing the term "carbohydrate."
Comments	Suggest removing the term "carbohydrate." Carbohydrate is such a “popular” term these days that many people don’t know what to think when they hear the term. They are bombarded with "high carb, low carb, no carb, net carb"…how are they to know what is truly a wise carbohydrate choice? Carbohydrates are not the enemy- over consumption is the issue. Over-consumption of carbohydrates, fats & protein- not just carbs!
Submission Date	9/23/2004 12:20:00 PM
Author	OSU Extension Program- Cleveland, OH

Summary	The DGA could reword its message to distinguish between healthy and not-so-healthy carbohydrate choices. For example "Choose carbohydrates from unrefined grains and sugars" makes a distinction between whole and processed sources.
Comments	Given the current "low-carb" climate, "Choose Carbohydrates Wisely" taken without its supporting message may lead to more confusion over which sources of carbohydrates are the healthiest choices.
Submission Date	9/24/2004 1:04:00 PM
Author	from Salem, MA

Summary	Stress lower daily carbohydrate intake. Stress importance of WHOLE grains, not refiled grains of any kind.
Comments
Submission Date	9/24/2004 2:15:00 PM
Author	from Holland, MI

Glycemic Response

Summary	glycemic responses depend on food not considered in isolation...
Comments	Please emphasize that the glycemic response of a food is not fixed. A potato eaten with nourishing sour cream has a much lower glycemic index than a plain potato. Foods are not isolated chemicals. They are parts of a meal.
Submission Date	9/24/2004 4:47:00 PM
Author	from Beaverton, OR

Fiber

Summary	Leading health organizations promote the benefits of citrus, including the American Heart Association, American Cancer Society, the National Cancer Institute and the Produce for Better Health Foundation.
Comments	One of the key messages is: Choose carbohydrates wisely for good health. Including citrus fruits in the diet helps meet the recommended intake of dietary fiber of 14 grams per 1,000 calories. Oranges and grapefruit rank #1 and #2 in fiber out of the top 20 most consumed fruits and vegetables . One medium-sized orange is an excellent source of fiber, providing 7 grams, or 28 percent of the Recommended Daily Value. Half a grapefruit is also an excellent source of fiber providing 6 grams and 24 percent of the Recommended Daily Value.
Submission Date	9/24/2004 5:21:00 PM
Author	Sunkist Nutrition Bureau

Sugars

Summary	Thank you again for the opportunity to express my opinion on this topic. Thank you for taking the time to sort through all of the comments that people will no doubt contribute.
Comments	Thank you for the opportunity to be able to provide my own individual input on such important matters as the Dietary Guidelines. It is so wonderful to know that you care about individual’s nutrition and health. It is comforting to felt that there is hope in making this country healthy once again. I wanted to comment on the carbohydrate sugars that can increase dental caries. I am in agreement that sugars, over time, can contribute to children having dental caries. This has been a concern of mine for a long time. I work in a hospital and see so many very young children coming in to get multiple crowns and pulpotimies. I think that the most contributing factor to this is negligent hygiene of the parents. Young children can not be responsible for their dental care at such a young age. I think it should be a recommendation that parents help their children brush up until at least age five. This would hopefully instill that habit in to the children for life. Also, I fully believe that parents should carefully watch how much carbohydrates and sugar their child consumes. When parents let the child eat candy this can also contribute to dental caries because of the length of time the sugars remain in the mouth. I completely agree with the studies that were found on this topic in the report. Again, I think it should be recommended that parents keep track of or prevent their very young children from consuming certain sugars and the amounts of the sugars eaten.
Submission Date	9/26/2004 9:28:00 PM
Author	Anonymous

Fiber

Summary	I thank you for the opportunity to provide my input on the revised dietary guidelines. I applaud you for caring about the individual’s nutrition and raising the awareness of these issues.
Comments	I read over the carbohydrates section of the dietary guidelines and I was very encouraged by all of the research that had been conducted about the role of carbohydrates in our bodies. Because of low-carb diets, carbohydrates have received such bad publicity that people don’t care to hear about or look at a food that contains any sort of carbohydrate in it. The fact is, carbohydrates are essential in our daily diets because they give us the energy we need. My concern is that this information is necessary for the public to hear. How are you going to reach the public? Another concern I have regarding this information is about how to make people understand that this information is truthful and not just dietary propaganda. It has been my experience that people want a quick and easy way to lose weight. The low-carb diets do offer extreme weight loss in a very short amount of time. People want a quick fix and these low-carb diets are offering that. So how are you going to distinguish between the truth and fallacy?
Submission Date	9/27/2004 12:09:00 AM
Author	Anonymous

Summary	In summary I am glad that carbohydrates such as fiber and its importance were addressed. I think this may help more people in the United States turn away from the Fad Diets that restrict carbohydrates.
Comments	Dear Secretaries Veneman and Thompson: Thank you for giving me the opportunity to provide some input in the dietary guidelines. I would also like to thank you for caring about individual's nutrition in the United States. I strongly agree with Choose Carbohydrates Wisely for Good Heatlth. In a world that is consumed with Fad Diets, such as the Atkins Diet or South Beach Diet, where little or no carbohydrates are allowed this lets people know how important it is to consume carbohydrates for energy and overall nutrition. It also allows people to to know that there are bad carbohydrates like sugars and starches that can cause dental caries and unwanted weight gain, so chose good carbohydrates like fruits, vegetables, and grains to help maintain a healthy weight.
Submission Date	9/27/2004 8:53:00 AM
Author	Anonymous

Sugars

Summary	In discussions and observation of seniors on a regular basis, many of them that are diabetic assume they cannot eat carbohydrates because of the sugar breakdown.
Comments	Specific guidance should be provided on food types that "contain sugar" or breaks down to sugars and the effect this may produce for diabetic individuals.
Submission Date	9/27/2004 10:51:00 AM
Author	Northwest Indiana Community Action Corp.

Summary	The recommendation to limit calories through reductions in sugars, saturated fats, and alcohol should be retained, even if there are political pressures against such a recommendation.
Comments
Submission Date	9/27/2004 12:05:00 PM
Author	from Lincoln, Nebraska

Glycemic Response

Summary	Consumers today (including my 900 college students per year) are so inundated with the low-carb message they think all are bad. The "choose carbohydrates wisely" message must become a major message in the USA.
Comments
Submission Date	9/27/2004 12:40:00 PM
Author	University of Nebraska-Lincoln

Sugars

Summary	Page 4 of the Backgrounder notes the recommendation of 45% to 65% CHO, but notes the IOM allowance of 130 g in the same paragraph. These should be separated and 130 g explained perhaps.
Comments
Submission Date	9/27/2004 12:43:00 PM
Author	University of Nebraska-Lincoln

Fiber

Summary
Comments	Emphasize healthy carbohydrates, such as whole grains, fruits, and vegetables. Emphasize whole grains instead of refined carbohydrates
Submission Date	9/27/2004 1:21:00 PM
Author	Volunteers of America

Summary	It is essential that consumers understand the concept of choosing carbohydrates with the most “bang for the carb.” Everyone who communicates these guidelines to consumers should note the distinction about fruits and vegetables as an important dietary choice for maximum health and nutrition.
Comments	Given the current attention to low-carbohydrate diets, it is important for consumers to understand the issues surrounding carbohydrates in their diets. The committee writes: “Since the RDA for carbohydrate is relatively easy to meet, and carbohydrates (sugars and starches) supply calories, it is important to choose food sources of carbohydrates carefully to maximize nutrient value per calorie. Also, since fiber has known health benefits (e.g., promoting a healthy laxation and decreasing the risk of CHD and diabetes) it is advisable to select high-fiber foods where possible. For example, fruits provide sugars, usually at a relatively low calorie cost, and they are important sources of fiber and at least eight additional nutrients. Some vegetables are high in starch and some are very low in both starch and sugar, but they all are important sources of fiber. They also are important sources of 19 or more nutrients, including vitamins A, E, and folate and potassium, and, in general, do not supply many calories.” It is essential that consumers understand the concept of choosing carbohydrates with the most “bang for the carb” when choosing the components of their daily diets. Everyone who communicates these guidelines to consumers should note the distinction the committee made about fruits and vegetables as an important dietary choice for maximum health and nutrition.
Submission Date	9/27/2004 4:28:00 PM
Author	Produce Marketing Association

Sugars

Summary	-
Comments	- The latter part of the first message “while staying within energy needs” is more closely related to the second message “Control Calorie Intake To Manage Body Weight”. The second message is an important one and needs to emphasize the importance of energy balance. According to NHANES data, almost 65% of adults are overweight or obese and over 15% of youth are overweight. As indicated in this message, obesity is caused by over consumption of calories relative to energy expenditure, and therefore the general public needs to have a clearer understanding of this issue. Including this discussion with other key messages, and not as a separate message, does not give the importance to this issue that is needed.
Submission Date	9/27/2004 4:46:00 PM
Author	Missouri Department of Health and Senior Services

Summary
Comments	- There is an overlap between the fourth message, Increase Daily Intake of Fruits and Vegetables, Whole Grains and Non-fat or Low-fat Milk and Milk Products and the sixth message, Choose Carbohydrates Wisely for Good Health. The information in these two messages is similar and neither message puts strong emphasis on the importance of reducing added sugar and foods high in sugar content. Though the Executive Summary of the Report states that the Committee provides strong rationale for limiting one’s intake of added sugars, the key message does not carry the weight of this recommendation. It is recommended that the message Choose Carbohydrates Wisely for Good Health, be changed to Decrease/Reduce Foods High in Sugar. Carbohydrates are not food components that are necessarily added to foods, as are fat, salt and sugar. The word carbohydrate is too broad, and the general public does not fully understand this term.
Submission Date	9/27/2004 4:48:00 PM
Author	Missouri Department of Health and Senior Services

Fiber

Summary
Comments	First, we congratulate the 13-member panel of scientists who devised the above recommendations. We support the majority of recommendations, especially the emphasis on fruits, vegetables, unrefined carbohydrates, and seafood – all of which mirror the Pritikin Eating Plan. We also applaud the conclusion that total calories – and the calorie density of foods – are more important than food components when trying to maintain or lose weight. Finally, we agree that the glycemic index is not a viable weight loss tool. Below is our first (of three) key corrections to the panel’s recommendations: 1. In real-world settings, low-fat, high-carbohydrate diets do not lead to increased levels of triglycerides. In their proposed guidelines, the panel states that a negative consequence of a low-fat diet is that “it is usually a high-carbohydrate diet, which can lead to increased levels of triglycerides.” The data supporting this statement, however, come from controlled laboratory settings; researchers directed subjects to eat the same number of calories on high-carbohydrate diets as they had eaten on high-fat diets. Never did the subjects have the opportunity to evaluate how full they were – and how much of the foods on the differing diets they preferred to eat. In studies that mimicked real-life setting – those in which the subjects themselves were allowed to determine their daily total intake from food – low-fat diets rich in unrefined carbohydrates led to reductions in body weight and improved blood lipids, including triglycerides. Results from two long-term trials in subjects with impaired glucose tolerance found that a diet higher in carbohydrates combined with exercise led to weight loss and about a 60% reduced risk of developing diabetes. Two studies in normal subjects showed that the adverse changes seen in blood lipids do not occur if the subjects – rather than the researchers – determined how much they ate of the high-carbohydrate diets. Finally, recent research demonstrated that type 2 diabetics who were allowed to eat as much as they wanted from either a high-carbohydrate or high-monounsaturated-fat diet did not suffer adverse impacts on blood lipids from the high-carbohydrate diet. The authors concluded: “Contrary to expectations, the ad libitum, low-fat, high-fiber diet promoted weight loss in patients with type 2 diabetes without causing unfavorable alterations in plasma lipids or glycemic control.” Certainly, as the 2005 guidelines elaborate, the type of carbohydrate Americans eat is critical. Refined carbohydrates are not the answer. Because they are rapidly absorbed and are often low in satiety, people may eat nearly as many calories as if they were on a high-fat diet. But a diet with plenty of unrefined carbohydrates like fruits, vegetables, and whole grains is rich in fiber and volume yet low in calories, and is therefore more likely to promote satiety, weight loss, and improved blood lipids.
Submission Date	9/27/2004 5:40:00 PM
Author	Pritikin Longevity Center

Summary
Comments	Earlier today I submitted comments under the heading "In real-world settings, low-fat, high-carbohydrate diets do not lead to increased levels of triglycerides." I do not believe, however, that the footnotes "traveled" into this comment field. So below are the footnotes for this topic. 1) N Engl J Med, 2002; 346: 393. 2) N Engl J Med, 2001, 334: 1343. 3) JAMA, 1995; 274: 1450. 4) Arterioscler Thromb, 1994; 14: 1751. 5) Am J Clin Nutr, 2004; 80: 668.
Submission Date	9/27/2004 5:57:00 PM
Author	Pritikin Longevity Center

Glycemic Response

Summary	Encourage traditional, local processing, minimizing preservatives. Use the whole wild or pasture raised animal (organs, bones, AND fat), and gathered or locally raised fruits, vegetables, and grains. Improve family dinner-time by preparing God-given foods together and eating to satisfaction.
Comments	Corrected version - original version I stated that fermenting decreases nutrients such as iron, which was a typographical error, please note, iron availability increases with slow fermentation of grains! Thank you for allowing input. I would like to see a return to a circle of foods, as done in the Native American symbols with the 4 directions with buffalo (or animals) from the north, gathered ones (fruits, berries, vegetables, herbs) from the east, traded ones (squashes, corn, beans, starchy vegetables) from the south, and water from the west,if I remember right! Here on the reservation those who eat more traditional foods, with hunting and fishing do much better with their health. Our children need whole foods, including all parts of the animal, using the fat for its strength and the bones for their soup. We need the fruits and berries, plants and roots for their healthful properties. We do not need the sugar drinks and alcohol from the supermarket. Even the lard from pigs and tallow from beef has high nutrients when raised as nature meant, without hormones, without additives, out in the sun, and on the range - much better than vegetable oils and margarines and crisco that are little better than plastic to our bodies. Please encourage the use of traditional foods from whatever culture they may come from, as additive free as possible, without the dyes and preservatives that harm our sensitive members. Encourage artisan breads and cheeses, without the current requisite pasteurization. We want clean food from clean facilities, not sterilized food from unknown sources. If it comes from overseas, let it be from quality sources. Above all, healthy wild food being the best, and healthy homegrown or locally grown without the many flavorings and other additives needed to cover the sterile taste of sterile food. Were commodities to change the crisco to the original lard, tallow, butter of the healthy animal or even the organic coconut and palm oil of early shortenings, and deliver the cow on the hoof again, we would have made a profound start in alleviating the burden of diabetes. God delivered the bounty for our use in carefulness, and not in waste. Even the mediterraneans ate boiled eggs, cheese, olives, tomatoes and cucumbers as a breakfast - traditional foods wherever we are should be remembered. We can only do that by emphasizing the whole animal and allowing small craftmanship to be retailed, as in tiny three-cow dairies, ten-pig farms, and makers of traditional foods using real kidney fat for the pemmican, lard for native tortillas, unpasteurized milk for cheeses, and real intestine and bones for the native soups. Please emphasize the use of traditional, home, and small-crafted foods. Even some of the Native American tribes made their own fermented drinks, mostly sour, with any alcohol being counteracted by the high quantity of B-vitamins in these indegenous drinks (example, pulque is undistilled, also unfermented in its traditional state, and not able to be transported very far - by distilling something similar to make Tequila, you develop the problems of severe intoxication). The Cherokees fermented a sour corn drink for visitors, releasing its nutrients to the highest advantage. Alcoholism is a plague killing many, and disabling many others. By returning even to the traditions of unpasteurized beer on the tap, we would have at least maintained the B-vitamins and kept the drunkenness to the taverns, minimizing its presence behind the wheels. Traditional drinks, including traditionally fermented ginger ale and native herbal flavored teas contain nutrients that strengthen constitution and also provide much less sugar than do the soft drinks of the convenience store. One last item that may be of interest - our main diabetes did not start until after the second world war. Part can be attributed to the employment in factories to build armament reducing physical activity, but remember also that dried yeast was transmitted to us after Germany was defeated. Before that, bread in all countries was made by a slow-rise, equivalent to what we call sour-doughs today, even though many slow-rise breads are not sour. The grandmas here call them Gabubu bread. You start by mixing flour and water and over a few days it starts to rise, and that is used as a start for whatever bread you may make. 24-hour plus fermentations allow the bacteria to eat starch and make the goo that allows even rye breads to rise. The bacteria also decrease the glycemic index, increasing many nutrients such as iron that originally had been bound by phytic acid, and make it a healthy food for diabetics. In international aid, private foundations have started to send prefermented grains, knowing that to save children on limited protein and fats, they must have the maximum available nutrition from the limited food they do receive, which necesitates fermentations of grains. Native americans consuming the flour delivered in bags in the first commodities didn't get diabetes partly because they had to ferment the flour in order to make some breads taught to them by the whites, except for times when soda ash and baking soda were used, and even then they were often used with soured milk/buttermilk from the cows delivered to them. When frying started, they used real beef tallow, which is absorbed less into the fried substance than vegetable oils do. The Mennonite colonies here in NE Montana also cook sourdough breads for themselves, although they bake quick yeast leavened breads for the outside farmers markets. They have broad straight jaws and teeth, and healthy trim but strong figures. The homemade, homegrown diet includes garden items, chicken eggs, milk products, and meat all from their own colony. The health of the traditional foods, although quite different from the Native American tribal foods, is still very evident. Although a colony existence is not the mainstream, we can encourage local neighborhood artisanship. In the larger community nationwide, we can start by encouraging traditional, lesser processed foods with natural preservation techniques such as salting, natural pickling, drying, and sour fermenting. We can also require the use of strong labeling for any chemical preservatives. Bright labeling of hydrogenated and partially hydrogenated fats would be helpful. An encouragement of organic, animal or tropical natural fats in place of vegetable oils, especially in frying, would also be appreciated. Again, an emphasis on the traditional foods, homegrown or healthily grown and prepared would be appreciated. When we tell people that fats are bad, especially the ones with the vitamins A and D, and the CLA that is so beneficial to the body, we set them up to eat carbohydrates using quick leavens and vegetable oils that leaves them unsatisfied, thus driving them towards sodas and alcohol. Kibbe Conti, a dietician from the Rosebud reservation, taught the 4 winds concept, a circle of nutrition. Other than the fact she thought that the traditional diet is low fat, she was right on. She forgot that 'taneega' (intestines soup saved for the elders of tribe first)and 'was-na'(8 parts pounded dried meat and berries to one part melted fat from above the kidneys)are just prime examples of how traditional native american foods valued the whole animal. I am a newcomer, having only been on the reservation for two years, but in that time have been priveleged to learn how valuable the Native American traditional foods are, as well as the traditional foods from the American, Mexican, and middle-eastern traditions I grew up with. Sincerely, Julene McCurry
Submission Date	9/27/2004 10:20:00 PM
Author	from Poplar, Montana

Sugars

Summary	Simply and directly state to clearly limit consumption of processed sugars, which includes things like high fructose corn syrup, white sugar, etc... Don't make people guess at what you mean.
Comments	the new guidelines do not directly comment on the criticality of reducing/significantly minimizing consumption of PROCESSED SUGAR. The more DIRECTLY you state this the more likely your AUDIENCE will get the message. Consider your audience and using plain, simple language that is easily understood at 1st glance.
Submission Date	9/28/2004 11:45:00 AM
Author

Summary
Comments	I am very dismayed at the new guidelines for the new food pyramid. It is absolutely unconscionalble that you would remove all references to excess sugar as a negative quality in a normal diet. This is the worst kind of pandering to industry I have seen for a while. Please reconsider the diservice to the American Public you are considering and do your duty to the PUBLIC.
Submission Date	9/29/2004 10:52:00 AM
Author	Anonymous

Summary	as requested by sandy saunders, DGAC, i am submitting my mailed comments via email. thank you.
Comments	September 7, 2004 TO: 2005 USDA Dietary Guidelines Advisory Committee FROM: Stephen J. Moss, DDS, MS Professor Emeritus, New York University College of Dentistry RE: 2005 USDA Dietary Guidelines Advisory Committee Report (Part D, Section 5, Question 1: Carbohydrates and Caries) As a lifelong oral health professional who has focused on caries prevention, particularly in children, I want to commend the Dietary Guidelines Advisory Committee on an enlightened and well-written report. Your sophisticated explanation of the relationship between intake of carbohydrates and caries (Part D, Section 5, Question 1) is of great service to the American public, as it clearly and concisely describes the multifactorial nature of the caries process. The following comments pertain to terminology. 1. Page 4, line 23 Change: “contributes to dental caries” To: “contributes to caries” (There are a variety of caries, e.g. active, buccal, compound, distal, fissure, incipient, etc., but all are dental caries.) _______________________________________________________ 2. Page 4, line 25 Change: “reduce the risk of dental caries” To: “reduce the risk of caries” _______________________________________________________ 3. Page 4, line 26 Change: “A combined approach of reducing the frequency and duration of exposure to fermentable carbohydrate intake” To: “Reducing the frequency of fermentable carbohydrate intake and optimizing…” 4. Page 4, line 27 Change: “most effective way to reduce caries incidence” To: “most effective way to reduce development of caries” 5. Page 4, line 32 Change: “of substrate by cariogenic bacteria in the mouth” To: “of substrate by plaque bacteria in the mouth to produce acid and subsequent demineralization of the enamel surface by the acid.” (Used alone, the terms “cariogenic” and/or “cariogenicity” are meaningless. The concept began as a prediction of how a particular food or group of foods would impact on the caries process. It is, at best, an educated guess and refers to the food rather than the bacteria. More meaningful terms in conveying the concept include “potential cariogenicity,” a prediction of how the author believes the fermentable carbohydrates in particular foods will impact the future development of caries. It takes in the multi-factorial nature of caries development. A second useful term is “relative cariogenicity,” which generally refers to a comparison test among a group of foods. They are tested against criteria such as oral retention, oral clearance, ability to demineralize enamel, ability to stimulate salivary flow, etc. Rat feeding studies are a good example of attempts to determine relative cariogenicity among a group of foods, but they are fraught with problems such as consistency of the food, the preference for certain foods by the animals and the fact that humans are not giant rats. For those reasons, those studies are seldom referenced today. There is actually no one test or group of tests that enable scientists, with any degree of certainty, to predict the potential cariogenicity of a food in humans.) 6. Page 4, line 35 Change: “available to the bacteria, and the susceptibility…” To: “available to the bacteria, salivary flow and the susceptibility…” 7. Page 5, line 1 Change: “much less cariogenic than other carbohydrates…” To: “are not as readily fermentable as other carbohydrates 8. Page 5, line 2 Change: “whether or not substituting sucrose with sugar substitutes…” To: “whether or not substituting sugar with sugar substitutes…” (Sugar substitutes can replace a range of sugars, not just sucrose, which is commonly known as “refined” or “table” sugar. _____________________________________________________ 9. Page 5, line 10 Change: “The longer a cariogenic substance remains in the oral cavity…” To: “The longer a fermentable carbohydrate remains in the oral cavity…” _______________________________________________________ 10. Page 5, line 22 Change: “Dental hygiene may have a greater role in the development of dental caries…” To: “Dental hygiene may have a greater role in the development of caries…” _______________________________________________________ 11. Page 6, line 6 Change: “The impact of sugar intakes on dental caries…” To: “The impact of sugars intake on caries…” (Colloquially, “sugar” typically refers to sucrose; all sugars have an impact on caries formation. 12. Page 6, line 33 Change: “had a higher score for dental caries…” To: “had a higher score for caries…”
Submission Date	9/29/2004 11:04:00 AM
Author	Organization Name not Specified

Glycemic Response

Summary	The section on low carbohydrate diets is out-of-date.
Comments	September 22, 2004 To the Guideline Panel: I have reviewed the Guideline sections below regarding low carbohydrate diets, solicited input from other low carbohydrate diet researchers, and urge you to make changes to this section to reflect the science that has been recently performed. This response is organized into A) Comments to Sections B) Sections Reviewed. A) COMMENTS TO SECTIONS 1) Reference #14 (Westman, 2002) was NOT a randomized trial as mentioned in the text. The randomized controlled trial from that group was: Yancy, W.S., Jr., Olsen, M.K., Guyton, J.R., et al., A Low-Carbohydrate, Ketogenic Diet Versus a Low-Fat Diet to Treat Obesity and Hyperlipidemia: A Randomized, Controlled Trial. Annals of Internal Medicine 2004;140(10):769-777. 2) In the sentence: “…diet compared with 3.2 percent below baseline for those on the control diet. At 18 months, however, there was no statistically significant difference in weight loss. Some of the early weight...” 18 should be changed to 12 months.1) It is not customary to promote a particular lay press popular diet book, so the reference to a diet book should be deleted. 3) Many studies involving very low carbohydrate diets have been published since the reviews by Freedman and Bravata, which makes these reviews out-of-date. Either delete these references, or mention that many studies have been published since these reviews were performed. 4) There is no mention of the low carbohydrate randomized trials (in which half the subjects were eating fewer than 50 grams CHO/day) in the section that states that "the Recommended Dietary Allowance for carbohydrate...is 130 grams/daily." How are the positive findings from the low carbohydrate randomized trials consistent with these statements? 5) The reference to Fleming, 2002 should be deleted because the science was terribly flawed. (e.g. The authors state that subjects were randomly assigned, but the text reads "Patients...were randomly assigned to one of the four dietary regimens based upon dietary preferences." There was no objective documentation that patients instructed in a diet were actually following it. Moreover, there was no reduction in serum triglycerides in the low carbohydrate group, a finding seen in every other clinical trial involving this diet.) 6) The reference to Larosa, 1980 should be deleted because the clinical trials published since 2003 have given much more detail, use contemporary laboratory measures, and the Larosa study was not a randomized controlled trial. 7) There is no definition of "healthy" -- is it weight loss, blood levels of cholesterol, mental health, etc. 8) For an example of how to word recent data in a non-judgmental way, please see the following excerpt from: Klein S, Sheard NF, Pi-Sunyer X, Daly A, Wylie-Rosett J, Kulkarni K, Clark NG. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies. A statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition1–3. Am J Clin Nutr 2004;80:257– 63. “Recently, there has been increased interest in the use of low carbohydrate diets as potential therapy for obesity. The results of 5 randomized controlled trials in adults (65–69) found that subjects randomly assigned to a low-carbohydrate, high-protein, high-fat diet (25–40%of calories from carbohydrate) achieved greater short-term (6 mo) (65–67), but not long-term (12 mo) (65, 68), weight loss than did those randomly assigned to a low-fat diet (25–30% of calories from fat and 55–60% of calories from carbohydrate). The data from these studies also found greater improvements in serum triglycerides and HDL cholesterol concentrations but not in serum LDL-cholesterol concentrations in the low-carbohydrate group than in the low-fat group. In addition, glycemic control was better with low carbohydrate than with low-fat diet therapy in subjects with type 2 diabetes (66, 68). Data from a study conducted in overweight adolescents found that altering the dietary glycemic load by reducing the total carbohydrate content (45–50% of energy intake) and consuming foods with a low glycemic index resulted in greater weight loss than did a conventional low-fat diet (25–30%) (70). Additional research is needed to clarify the long-term efficacy and safety of low-carbohydrate diets, particularly in patients with diabetes. It is unlikely that one diet is optimal for all overweight and obese persons.” References found in the Klein excerpt: 65. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a lowcarbohydrate diet for obesity. N Engl J Med 2003;348:2082–90. 66. Samaha FF, Iqbal N, Seshadri P,et al.Alow-carbohydrate as compared with a low-fat diet in severe obesity.NEngl J Med 2003;348:2074–81. 67. Brehm BJ, Seeley RJ, Daniels SR, D’Alessio DA. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab 2003;88:1617–23. 68. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med 2004;140:778–85. 69. Yancy WS Jr, Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med 2004;140:769–77. 70. Ebbeling CB, Leidig MM, Sinclair KB, Hangen JP, Ludwig DS. A reduced-glycemic load diet in the treatment of adolescent obesity. Arch Pediatr Adolesc Med 2003;157:773–9. PERTINENT REFERENCES NOT MENTIONED IN THE GUIDELINE: 1. Full bibliographic reference details of research Bailes, J.R.J., Strow, M.T., Werthammer, J., et al., "Effect of Low-Carbohydrate, Unlimited Calorie Diet on the Treatment of Childhood Obesity: A Prospective Controlled Study. Metabolic Syndrome and Related Disorders, 1(3), 2003, pages 221-225. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Use of low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<30 grams/day) to low calorie diet for obesity in clinical practice 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects Obese children from a Pediatrics Endocrinology (n=37) 11. Outcome Measures Weight change at 2 months 12. Results/Main Findings Children instructed in the low carbohydrate diet lost more weight than the children on the low calorie diet. Compliance was also better with the low carbohydrate approach 13. Further comments 1. Full bibliographic reference details of research Brehm, B.J., Seeley, R.J., Daniels, S.R., et al., "A Randomized Trial Comparing a Very Low Carbohydrate Diet and a Calorie-Restricted Low Fat Diet on Body Weight and Cardiovascular Risk Factors in Healthy Women. Journal of Clinical Endocrinology and Metabolism, 88(4), 2003, pages 1617-1623. 2. Funding body American Heart AssociationNational Institutes of Health 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<50 grams/day) to 30% fat low calorie diet for obesity 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 53 healthy, obese female volunteers 11. Outcome Measures Anthropometric and metabolic measures at baseline, 3 and 6 mos 12. Results/Main Findings The very low carbohydrate group lost more weight and more body fat than the low fat diet group. Blood pressure, lipids, fasting glucose, and insulin improved in both groups. 13. Further comments 1. Full bibliographic reference details of research Foster, G.D., Wyatt, H.R., Hill, J.O., et al., "A Randomized Trial of a Low-Carbohydrate Diet for Obesity. New England Journal of Medicine 348(21), 2003, pages 2082-2090. 2. Funding body National Institutes of Health 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<20 grams/day) to 30% fat low calorie diet for obesity 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 63 healthy, obese volunteers 11. Outcome Measures Weight change, serum lipids, glucose tolerance at 3 and 6 mos 12. Results/Main Findings Subjects on the low carbohydrate diet had lost more weight than subjects on the conventional diet at 3 months and 6 months, but the difference at 12 months was not significant. Blood pressure, lipids, and the glucose response to an oral glucose load were improved in both groups. 13. Further comments 1. Full bibliographic reference details of research Gannon, M.C., Nuttall, F.Q., "Effect of a High-Protein, Low-Carbohydrate Diet on Blood Glucose Control in People with Type 2 Diabetes. Diabetes 53(9), 2004, pages 2375-2382. 2. Funding body American Diabetes AssociationMinnesota Beef CouncilColorado and Nebraska Beef Councils 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity-related Type 2 diabetes 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on Type 2 Diabetes 8. Principal question that research is designed to answer Comparison of 20% carbohydrate to a 55% carbohydrate diet for Type 2 Diabetes 9. Type of research (please tick) Cross-over trial 10. Population/subjects 8 male volunteers 11. Outcome Measures Serum glucose, insulin at 5 weeks 12. Results/Main Findings Subjects on the 20% carbohydrate diet had a greater reduction in serum glucose, insulin, and glycohemoglobin. 13. Further comments 1. Full bibliographic reference details of research Hays, J.H., DiSabatino, A., Gorman, R.T., et al., "Effect of a High Saturated Fat and No-Starch Diet on Serum Lipid Subfractions in Patients with Documented Atherosclerotic Cardiovascular Disease Mayo Clinic Proceedings 1 , 78(11), 2003, pages 1331-1336. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To determine whether a diet of high saturated fat and avoidance of starch results in weight loss without adverse effects on serum lipids in obese nondiabetic patients 8. Principal question that research is designed to answer Noncomparative description of effect of diet in a clinical practice 9. Type of research (please tick) Observational study in clinical practice 10. Population/subjects 23 patients with atherosclerotic cardiovascular disease 11. Outcome Measures Weight change, body fat, lipoprotein profiles by NMR analysis 12. Results/Main Findings Patients instructed on the high saturated fat, no starch diet lost weight. 13. Further comments 1. Full bibliographic reference details of research Hays, J.H., Gorman, R.T., Shakir, K.M., "Results of Use of Metformin and Replacement of Starch with Saturated Fat in Diets of Patients with Type 2 Diabetes. Endocrine Practice 8(3), 2002, pages 177-183. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity, and obesity-related type 2 diabetes 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity and type 2 diabetes 8. Principal question that research is designed to answer Comparison of high saturated fat, low starch diet to historical controls 9. Type of research (please tick) Retrospective chart review with historical controls 10. Population/subjects 283 patients from a clinical endocrinological practice 11. Outcome Measures Weight change, hemoglobin A1C, serum lipids over 1 year 12. Results/Main Findings Patients on the high saturated fat, low starch diet had improved glycemic control without adverse effects on serum lipids. 13. Further comments 1. Full bibliographic reference details of research Hickey, J.T., Hickey, L., Yancy, W.S.J., et al., "Clinical Use of a Carbohydrate-Restricted Diet to Treat the Dyslipidemia of the Metabolic Syndrome. Metabolic Syndrome and Related Disorders 1(3), 2003, pages 227-232. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity and hyperlipidemia 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet (<20 grams/day) on weight and serum lipids 8. Principal question that research is designed to answer Description of effects of the diet in a clinical practice 9. Type of research (please tick) Retrospective chart review with two clinical groups using a low carbohydrate diet 10. Population/subjects 80 patients 11. Outcome Measures Weight change, serum lipids using NMR lipoprotein analysis over 240 days 12. Results/Main Findings Patients instructed in a low carbohydrate diet with or without pre-existing statin therapy had improvements in total cholesterol, triglycerides, HDL cholesterol and LDL cholesterol. The LDL particle concentration was reduced similarly in both groups compared to baseline. 13. Further comments 1. Full bibliographic reference details of research Husain, A.M., Yancy, W.S., Jr., Carwile, S.T., et al., "Diet Therapy for Narcolepsy. Neurology, 62(12), 2004, pages 2300-2302. 2. Funding body Narcolepsy Network. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity and obesity-related narcolepsy 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To monitor the effects of a low carbohydrate diet (<20 grams/day) in obese patients with narcolepsy 8. Principal question that research is designed to answer Description of effects of the diet in a clinical practice 9. Type of research (please tick) Observational study 10. Population/subjects 9 patients with narcolepsy 11. Outcome Measures Weight, narcolepsy questionnaire 12. Results/Main Findings Patients with narcolepsy experienced modest improvements in daytime sleepiness on a low carbohydrate diet. 13. Further comments 1. Full bibliographic reference details of research Kossoff, E.H., Krauss, G.L., McGrogan, J.R., et al., "Efficacy of the Atkins Diet as Therapy for Intractable Epilepsy. Neurology, 61(12), 2003, pages 1789-1791. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity with a low carbohydrate diet-safety and use in children with epilepsy 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To monitor the effects of a low carbohydrate diet (<20 grams/day) in patients with refractory epilepsy 8. Principal question that research is designed to answer Description of effects of the diet in a clinical practice 9. Type of research (please tick) Observational study 10. Population/subjects 6 patients with seizure disorder 11. Outcome Measures Seizure frequency 12. Results/Main Findings 5 patients maintained moderate to large ketosis for periods of 6 weeks to 24 months; three patients had seizure reduction and were able to reduce antiepileptic medications. 13. Further comments 1. Full bibliographic reference details of research Meckling, K.A., O'Sullivan, C., Saari, D., "Comparison of a Low-Fat Diet to a Low-Carbohydrate Diet on Weight Loss, Body Composition, and Risk Factors for Diabetes and Cardiovascular Disease in Free-Living, Overweight Men and Women. Journal of Clinical Endocrinology and Metabolism, 89(6), 2004, pages 2717-2723. 2. Funding body Natural Sciences Engineering Research Council of Canada 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of a 15% carbohydrate diet to a low fat, 50% carbohydrate diet for obesity 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 40 healthy, obese volunteers 11. Outcome Measures Weight, body composition, serum insulin, blood pressure, serum ketones over 10 weeks 12. Results/Main Findings There was similar weight loss and blood pressure reduction in both groups. Only the 15% carbohydrate diet group had a reduction in fasting serum insulin. The 15% carbohydrate diet group had an increase in HDL cholesterol. 13. Further comments 1. Full bibliographic reference details of research Samaha, F.F., Iqbal, N., Seshadri, P., et al., "A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity. New England Journal of Medicine 1, 348(21), 2003, pages 2074-2081. 2. Funding body Veterans Affairs Healthcare Network Competitive Pilot Project Grant 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<30 grams/day) to 30% fat low calorie diet for obesity 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 132 healthy, obese volunteers 11. Outcome Measures Weight change, serum lipids, glucose tolerance at 3 and 6 mos 12. Results/Main Findings Severely obese subjects with a high prevalence of diabetes or the metabolic syndrome lost more weight during six months on a carbohydrate-restricted diet than on a calorie and fat-restricted die, with a relative improvement in insulin sensitivity and triglyceride levels. 13. Further comments 1. Full bibliographic reference details of research Sharman, M.J., Gomez, A.L., Kraemer, W.J., et al., "Very Low-Carbohydrate and Low-Fat Diets Affect Fasting Lipids and Postprandial Lipemia Differently in Overweight Men. Journal of Nutrition 1 , 134(4), 2004, pages 880-885. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used for obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on cardiovascular risk factors 8. Principal question that research is designed to answer Comparison of 8% carbohydrate to a 47% fat diet 9. Type of research (please tick) Controlled trial 10. Population/subjects 20 normal weight, male volunteers 11. Outcome Measures Serum lipids, serum insulin, LDL particle size 12. Results/Main Findings The 8% carbohydrate diet was associated with a greater reduction in serum triglycerides, postprandial lipemia, and fasting serum insulin. In subjects with a predominance of small LDL particles pattern B, there were significant increases in mean and peak LDL particle diameter and the percentage of LDL-1 after the 8% carbohydrate diet.. 13. Further comments 1. Full bibliographic reference details of research Sharman, M.J., Kraemer, W.J., Love, D.M., et al., "A Ketogenic Diet Favorably Affects Serum Biomarkers for Cardiovascular Disease in Normal-Weight Men. Journal of Nutrition 1, 132(7), 2002, pages 1879-1885. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used for obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on cardiovascular risk factors 8. Principal question that research is designed to answer Comparison of 10% carbohydrate to a 30% fat diet 9. Type of research (please tick) Balanced, randomised, cross-over trial 10. Population/subjects 15 overweight, male volunteers 11. Outcome Measures Serum lipids, serum insulin, LDL particle size 12. Results/Main Findings The hypoenergetic low-fat diet was more effective at lowering serum LDL-C, but the very low-carbohydrate diet was more effective at improving characteristics of the metabolic syndrome: a reduction in fasting serum triglycerides, TG/HDL ratio, postprandial lipemia, serum glucose, an increase in LDL particle size and also greater weight loss. 13. Further comments 1. Full bibliographic reference details of research Sondike, S.B., Copperman, N., Jacobson, M.S., "Effects of a Low-Carbohydrate Diet on Weight Loss and Cardiovascular Risk Factors in Overweight Adolescents. Journal of Pediatrics 1, 142(3), 2003, pages 253-258. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used for obesity in adolescents 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of very low carbohydrate (<20grams/day) to a 30% fat diet calorie restricted diet 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 30 obese adolescents 11. Outcome Measures Weight, serum lipids 12. Results/Main Findings The very low carbohydrate group lost more weight and had improvements in non-HDL cholesterol levels. There was improvement in LDL cholesterol in the 30% fat diet group, but not the very low carbohydrate diet group. 13. Further comments 1. Full bibliographic reference details of research Stern, L., Iqbal, N., Seshadri, P., et al., "The Effects of Low-Carbohydrate Versus Conventional Weight Loss Diets in Severely Obese Adults: One-Year Follow-up of a Randomized Trial. Annals of Internal Medicine, 140(10), 2004, pages 778-785. 2. Funding body Veterans Affairs Healthcare Network Competitive Pilot Project Grant 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<30 grams/day) to 30% fat low calorie diet for obesity 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 132 healthy, obese volunteers 11. Outcome Measures Weight change, serum lipids, glucose tolerance at 12 months. (extension of previous study by Samaha NEJM 2003) 12. Results/Main Findings Participants in both groups had significant weight loss over a one year period, but there were no between-group differences. Persons following the low-carbohydrate diet had greater reductions in serum triglyceride, and hemoglobin A1c. 13. Further comments 1. Full bibliographic reference details of research Vernon, M.C., Mavropoulos, J., Transue, M., et al., "Clinical Experience of a Carbohydrate-Restricted Diet: Effect on Diabetes Mellitus. Metabolic Syndrome and Related Disorders 1(3), 2003, pages 233-237. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity and type 2 diabetes 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet (<20 grams/day) on weight and diabetes mellitus 8. Principal question that research is designed to answer Description of effects of the diet in a clinical practice 9. Type of research (please tick) Retrospective chart review 10. Population/subjects 14 patients with diabetes with a median follow-up of 8 months 11. Outcome Measures Weight change, hemoglobin A1c, fasting serum lipids 12. Results/Main Findings Patients instructed in a low carbohydrate diet had an average weight loss of 9.7% and a reduction in hemoglobin A1c from 10.0% to 5.9%. 13. Further comments 1. Full bibliographic reference details of research Volek, J.S., Gomez, A.L., Kraemer, W.J., "Fasting Lipoprotein and Postprandial Triacylglycerol Responses to a Low-Carbohydrate Diet Supplemented with N-3 Fatty Acids. Journal of the American College of Nutrition, 19(3), 2000, pages 383-391. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet on serum lipoproteins and postprandial triacylglycerol response 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on cardiovascular risk factors 8. Principal question that research is designed to answer What are the effects of a low carbohydrate diet 9. Type of research (please tick) Observational study 10. Population/subjects 10 normal weight, male volunteers 11. Outcome Measures Serum lipids, postprandial lipemia over an 8 week period 12. Results/Main Findings Compared to baseline, the low carbohydrate diet led to a reduction in body weight, fasting serum triglycerides, and peak postprandial triglyceride. 13. Further comments 1. Full bibliographic reference details of research Volek, J.S., Sharman, M.J., Gomez, A.L., et al., "Comparison of a Very Low-Carbohydrate and Low-Fat Diet on Fasting Lipids, LDL Subclasses, Insulin Resistance, and Postprandial Lipemic Responses in Overweight Women. Journal of the American College of Nutrition, 23(2), 2004, pages 177-184. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet on cardiovascular risk factors 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on cardiovascular risk factors 8. Principal question that research is designed to answer A comparison of a very low carbohydrate (<10%) diet to a low-fat (<30%) diet 9. Type of research (please tick) Randomised, cross-over study 10. Population/subjects 13 overweight, female volunteers 11. Outcome Measures Weight, serum lipids, fasting glucose and insulin, oxidized LDL and LDL subclass distribution over a 4 week period 12. Results/Main Findings Both diets led to a reduction in postprandial lipemia, fasting triglycerides, oxidized LDL, and LDL subclass distribution. The <10% carbohydrate diet led to improved insulin sensitivity. 13. Further comments 1. Full bibliographic reference details of research Volek, J.S., Sharman, M.J., Gomez, A.L., et al., "An Isoenergetic Very Low Carbohydrate Diet Improves Serum HDL Cholesterol and Triacylglycerol Concentrations, the Total Cholesterol to HDL Cholesterol Ratio and Postprandial Lipemic Responses Compared with a Low Fat Diet in Normal Weight, Normolipidemic Women. Journal of Nutrition, 133(9), 2003, pages 2756-2761. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet on cardiovascular risk factors 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on cardiovascular risk factors in women 8. Principal question that research is designed to answer A comparison of a very low carbohydrate (<10%) diet to a low-fat (<30%) diet 9. Type of research (please tick) Randomised, cross-over study 10. Population/subjects 10 overweight, female volunteers 11. Outcome Measures Weight, serum lipids, oral fat tolerance test, C-reactive protein, interleukin-6, tumor necrosis factor, over a 4 week period 12. Results/Main Findings The <10% carbohydrate diet led to a increase in fasting serum total cholesterol, LDL cholesterol, HDL cholesterol, decreased serum triacylglycerols, and decreased postprandial triacylglycerols. There were no significant changes in LDL size or markers of inflammation. 13. Further comments 1. Full bibliographic reference details of research Volek, J.S., Sharman, M.J., Love, D.M., et al., "Body Composition and Hormonal Responses to a Carbohydrate-Restricted Diet. Metabolism, 51(7), 2002, pages 864-870. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet for obesity on body composition and selected hormones 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet on body composition 8. Principal question that research is designed to answer A comparison of a very low carbohydrate (8%) diet to controls eating their normal diet 9. Type of research (please tick) Controlled study 10. Population/subjects 12 normal weight, male volunteers 11. Outcome Measures Weight, body composition, serum insulin, thyroid hormones over a 6 week period 12. Results/Main Findings The 8% carbohydrate diet led to a decrease in fat mass, and an increase in lean body mass. There was a decrease in serum insulin and ain increase in thyroid hormone levels. There were no significant changes in glucagons, total or free testosterone, sex hormone-binding globulin, insulin-like growth factor, cortisol, or T3 uptake. 13. Further comments 1. Full bibliographic reference details of research Westman, E.C., Mavropoulos, J., Yancy, W.S., et al., "A Review of Low-Carbohydrate Ketogenic Diets. Current Atherosclerosis Reports, 5(6), 2003, pages 476-483. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To review the randomized controlled trials of a low carbohydrate ketogenic (<20 grams/day) diet for obesity 8. Principal question that research is designed to answer What is the evidence supporting the use of these diets? 9. Type of research (please tick) Systematic Review 10. Population/subjects N/A 11. Outcome Measures Weight, serum lipids 12. Results/Main Findings Several recent randomised, controlled efficacy and effectiveness trials have shown that a low carbohydrate ketogenic diet is superior to a reduced calorie 30% fat diet for weight loss over a 6 month period. 13. Further comments 1. Full bibliographic reference details of research Westman, E.C., Yancy, W.S., Edman, J.S., et al., "Effect of 6-Month Adherence to a Very Low Carbohydrate Diet Program. American Journal of Medicine 113(1), 2002, pages 30-36. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used for obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer What are the effects of a very low carbohydrate (<20grams/day) diet over a 6 month period? 9. Type of research (please tick) Observational study 10. Population/subjects 51 overweight and obese healthy volunteers 11. Outcome Measures Weight, serum lipids, electrolytes, urinary function 12. Results/Main Findings Subjects lost weight and had improvements in serum lipid profiles over a 6 month period. 13. Further comments 1. Full bibliographic reference details of research Yancy, W.S., Jr., Olsen, M.K., Guyton, J.R., et al., "A Low-Carbohydrate, Ketogenic Diet Versus a Low-Fat Diet to Treat Obesity and Hyperlipidemia: A Randomized, Controlled Trial. Annals of Internal Medicine 140(10), 2004, pages 769-777. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<20 grams/day) to 30% fat low calorie diet for obesity and hyperlipidemia 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 119 healthy, obese volunteers 11. Outcome Measures Weight change, body composition, fasting serum lipids, and tolerability after 6 months 12. Results/Main Findings The low carbohydrate diet had better participant retention and greater weight loss. During active weight loss, serum triglyceride levels decreased more and high-density lipoprotein cholesterol level increased more with the low-carbohydrate diet than with the low-fat diet. 13. Further comments 1. Full bibliographic reference details of research Yancy, W.S., Jr., Provenzale, D., Westman, E.C., "Improvement of Gastroesophageal Reflux Disease after Initiation of a Low-Carbohydrate Diet: Five Brief Case Reports. Alternative Therapies in Health and Medicine, 7(6), 2001, pages 120, 116-129. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity using a low carbohydrate diet 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To describe cases of reflux symptoms improving on a low carbohydrate diet 8. Principal question that research is designed to answer Description of effects of the diet 9. Type of research (please tick) Case series 10. Population/subjects 5 subjects with reflux symptoms 11. Outcome Measures Weight, narcolepsy questionnaire 12. Results/Main Findings These patients with reflux symptoms noted prompt relief of symptoms after starting a very low carbohydrate diet. 13. Further comments 1. Full bibliographic reference details of research Yancy, W.S., Vernon, M.C., Westman, E.C., "A Pilot Trial of a Low-Carbohydrate, Ketogenic Diet in Patients with Type 2 Diabetes. Metabolic Syndrome and Related Disorders, 1(3), 2003, pages 239-243. 2. Funding body The Robert C. Atkins Foundation 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity and type 2 diabetes 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet (<20 grams/day) on weight and diabetes mellitus over a 16 week period 8. Principal question that research is designed to answer Description of effects of the diet in a clinical practice 9. Type of research (please tick) Prospective pilot study 10. Population/subjects 7 patients with Type 2 diabetes 11. Outcome Measures Weight change, hemoglobin A1c, fasting serum lipids 12. Results/Main Findings Patients instructed in a low carbohydrate diet had an average weight loss of 10% and a reduction in hemoglobin A1c from 7.4% to 5.9%. 13. Further comments 1. Full bibliographic reference details of research Larosa JC, Fry AG, Muesing R, Rosing DR. Effects of high-protein, low-carbohydrate dieting on plasma lipoproteins and body weight. J Am Dietetic Assoc 77, 1980, pages 264-270. 2. Funding body Washington Heart Association 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used for obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer What are the effects of a very low carbohydrate (<20grams/day) diet over an 8 week period? 9. Type of research (please tick) Observational study 10. Population/subjects 24 obese, normolipidemic, healthy volunteers 11. Outcome Measures Weight, serum lipids, electrolytes 12. Results/Main Findings Subjects lost weight and had a reduction in fasting triglycerides by the end the study period. Women had a significant rise in LDL cholesterol. 13. Further comments 1. Full bibliographic reference details of research Goldberg JM, O’Mara K. Metabolic and anthropomorphic changes in obese subjects form an unrestricted calorie, high monounsaturated fat, very low carbohydrate diet. Journal of Clinical Ligand Assay, 23(2), 2000; pages 97-103. 2. Funding body Not noted. 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used in the management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a high monounsaturated fat, very low carbohydrate diet for obesity 8. Principal question that research is designed to answer What are the effects of a very low carbohydrate (10%) diet over an 12 week period? 9. Type of research (please tick) Observational study 10. Population/subjects 30 obese, normolipidemic, healthy volunteers 11. Outcome Measures Weight, serum lipids, electrolytes 12. Results/Main Findings The average weight loss was 9.1 kg. There was a reduction in total cholesterol and triglycerides. HDL was not affected. 13. Further comments 1. Full bibliographic reference details of research Landers P, Wolfe MM, Glore S, Build R, Phillips L. Effect of Weight Loss Plans on Body Composition and Diet Duration. J Okla State Med Assoc, 95(5), 2002. 2. Funding body Not noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of several diets for obesity 8. Principal question that research is designed to answer Comparison of low carbohydrate (<20 grams/day), the Zone diet and a conventional diet. 9. Type of research (please tick) Randomised controlled trial (RCT) 10. Population/subjects 91 healthy, obese volunteers 11. Outcome Measures Weight change, body composition, fasting serum lipids, and tolerability after 12 weeks 12. Results/Main Findings The mean weight loss was 5.1 kg, and the weight loss was similar among the treatment groups. There were no differences among the groups for total weight, fat or lean body mass loss. 13. Further comments 1. Full bibliographic reference details of research Bishop HL, Morse WI. Influence of percentage of fat prescribed in reduction diets on rate of weight loss. Journal De L’Association Canadienne des Dietetistes 1965. 2. Funding body Not noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research Assess the effects of several diets for obesity 8. Principal question that research is designed to answer Comparison of two diets with a carbohydrate / fat gram ratio of ½ and 2/1. 9. Type of research (please tick) Controlled trial 10. Population/subjects 19 healthy community volunteers 11. Outcome Measures Weight change after 12 weeks 12. Results/Main Findings Weight loss was similar between the treatment groups. 13. Further comments 1. Full bibliographic reference details of research Meckling KA, Gauthier M, Grubb R, Sanford J. Effects of a hypocaloric, low-carbohydrate diet on weight loss, blood lipids, blood pressure, glucose tolerance, and body composition in free-living overweight women. Can J Physiol Pharmacol, 80, 2002, pages 1095-1105. 2. Funding body Canadian Institutes of Health Research 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer What are the effects of a very low carbohydrate (70 grams/day) diet over an 8 week period? 9. Type of research (please tick) Observational study 10. Population/subjects 20 overweight female volunteers 11. Outcome Measures Weight, serum lipids, electrolytes, blood pressure, body composition 12. Results/Main Findings Subjects lost an average of 5.0 kg over 8 weeks. There were reductions in total cholesterol, triacylglycerol, LDL cholesterol. 13. Further comments 1. Full bibliographic reference details of research Miyashita Y, Koide N, Ohtsuka M et al. Beneficial effect of low carbohydrate in low calorie diets on visceral fat reduction in type 2 diabetic patients with obesity. Diabetes Research and Clinical Practice, 65, 2004, pages 235-241. 2. Funding body Meeting of Obesity and Nutritional Disturbance 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of low calorie diets of different carbohydrate content for obesity 8. Principal question that research is designed to answer Comparison of 1000 kcal 40% carbohydrate to 1000 kcal 65% carbohydrate diet 9. Type of research (please tick) Randomised, controlled trial 10. Population/subjects 22 obese type 2 diabetic patients 11. Outcome Measures Weight, serum glucose and insulin, lipids, visceral fat measured by computed tomography 12. Results/Main Findings Similar decreases in body weight and serum glucose levels were seen. Fasting serum insulin levels were reduced, and HDL levels increased on the 40% carbohydrate diet. There was a larger reduction in visceral fat area for the 40% carbohydrate group. 13. Further comments 1. Full bibliographic reference details of research Alnasir FA, Fateha BE. Low carbohydrate diet. Its effects on selected body parameters of obese patients. Saudi Med J, 24(9), 2003, pages 949-952. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a very low carbohydrate diet for obesity 8. Principal question that research is designed to answer To describe the effects of the diet over a 6 week period 9. Type of research (please tick) Observational study 10. Population/subjects 13 obese type 2 diabetic patients 11. Outcome Measures Weight, serum lipids 12. Results/Main Findings The mean weight loss was 6.6 kg over the 6 week period. Total cholesterol and serum glucose were reduced, but there were no other significant changes from baseline. 13. Further comments 1. Full bibliographic reference details of research Westman, E.C.. A Review of Very Low Carbohydrate Diets for Weight Loss. Journal of Clinical Outcomes Management 6(7), 1999, pages 36-40. 2. Funding body Atkins Center for Complementary Medicine 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To summarize the published literature regarding very low carbohydrate (<40 grams/day) diets 8. Principal question that research is designed to answer What is the evidence supporting the use of these diets? 9. Type of research (please tick) Systematic Review 10. Population/subjects N/A 11. Outcome Measures Weight, serum lipids, serum insulin and glucose levels 12. Results/Main Findings The literature search yielded 329 citations; 32 contained primary data. Based on several small, short-term observational studies, very low carbohydrate diets can lead to ketosis, weight loss, and changes in carbohydrate and lipid metabolism. Most of these studies also included caloric restriction. The long-term risks are not documented. 13. Further comments 1. Full bibliographic reference details of research O’Neill DF, Westman EC, Bernstein RK. The effects of a low-carbohydrate regimen on glycemic control and serum lipids in diabetes mellitus. Metabolic Syndrome and Related Disorders, 1(4), 2003, pages 291-298. 2. Funding body None noted. 3. Relevance to the guideline (refer to the scope where relevant) Management of obesity and diabetes mellitus. Documents use of very low carbohydrate diet. 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a regimen using a low carbohydrate diet (~30 grams/day) on weight and diabetes mellitus 8. Principal question that research is designed to answer Description of effects of the diet in a clinical practice 9. Type of research (please tick) Retrospective chart review 10. Population/subjects 30 patients diabetes 11. Outcome Measures Weight change, hemoglobin A1c, fasting serum lipids over an average of 13.8 years 12. Results/Main Findings Patients instructed in a low carbohydrate diet had an average weight loss of 5.5 kg and a reduction in hemoglobin A1c from 7.9% to 5.7%. There were favorable effects on the fasting lipid profiles. 13. Further comments 1. Full bibliographic reference details of research Miller III, BV, Bertino Jr, JS, Reed RG et al. An evaluation of the Atkins Diet. Metabolic Syndrome and Related Disorders, 1(4), 2003, pages 299-309. 2. Funding body The E. Donnall Thomas Resident Research ProgramStephen C. Clark Research Fund 3. Relevance to the guideline (refer to the scope where relevant) Effect of a very low-carbohydrate diet when used for obesity 4. This article primarily relates to the prevention of overweight and obesity NO 5. This article primarily relates to the identification, assessment and management of overweight and obesity? YES 6. Status (please tick) Complete 7. Objectives/aims of research To assess the effects of a low carbohydrate diet for obesity 8. Principal question that research is designed to answer What are the effects of a very low carbohydrate (<20grams/day) diet over a 4 week period? 9. Type of research (please tick) Observational study 10. Population/subjects 18 overweight and obese healthy volunteers 11. Outcome Measures Weight, serum glucose, insulin, lipids, electrolytes, NPY, leptin 12. Results/Main Findings Subjects lost weight and had significant reductions in serum total cholesterol, triglycerides, and fasting insulin. Weight loss could be explained by the self-selected lower caloric intake. 13. Further comments B) SECTIONS REVIEWED Low-Carbohydrate, High-Fat Diets. The propounded theory behind low carbohydrate, high-fat diets is that a drastically reduced carbohydrate intake will lower insulin levels, allow uninhibited lipolysis, increase fat oxidation, initiate ketone production, and decrease appetite (Atkins, 1999). Another expectation of diets with an extremely low ratio of carbohydrate to fat is that they will facilitate compliance and increase water losses. Five randomized controlled trials (Brehm et al., 2003; Fleming, 2002; Foster et al., 2003; Samaha et al., 2003; Westman et al., 2002) recently have compared weight loss after 6 months to a year on diets that have low carbohydrate-to-fat ratios with weight loss on more balanced diets. The low-carbohydrate diets initially provided less than 20 to 30 g of carbohydrate per day (followed by 40 to 60 g of carbohydrate per day after the first 2 weeks in both Brehm et al. (2003) and Foster et al. (2003)). Control diets provided 60 percent of calories from carbohydrate, 25 to 30 percent of calories from fat, and 15 percent of calories from protein (Brehm et al., 2003; Fleming, 2002; Foster et al., 2003; Samaha et al., 2003; Westman et al., 2002). All studies found that the low-carbohydrate diets produced greater initial weight loss, but the difference was modest. For example, Foster and colleagues (2003) reported that mean weight loss at 6 months was 7.0 percent below baseline for those on the low-carbohydrate diet compared with 3.2 percent below baseline for those on the control diet. At 18 months, however, there was no statistically significant difference in weight loss. Some of the early weight loss on a low-carbohydrate diet is due to water loss (Yang and Van Itallie, 1976; Bortz et al., 1967). Whether the remaining difference in initial weight loss is due to a lower energy intake, a larger energy expenditure, or a combination of the two is not known. In any case, differences in weight loss tend to diminish, and by 12 to 18 months no real difference remains. The long-term safety of any diet needs to be considered. Unfortunately, only short-term data (6 to 12 months) are available for these diets. Within this period of follow up, no evidence of serious adverse effects has been published. However, the diets require that 10 dietary supplements be taken regularly because the diets are low in vitamins E, A, thiamin, B6, and folate; calcium; magnesium; iron; potassium; and dietary fiber (Freedman et al., 2001). Very-low-carbohydrate diets often include a high percentage of protein along with the high percentage of fat. Usually, this includes large amounts of animal protein, which adds substantially to the saturated fat and cholesterol intake. A recent study has cautioned that such diets also can lead to a high urinary calcium loss and kidney stones (Reddy et al., 2002). Uric acid production is increased and may lead to elevated blood uric acid concentrations. There are very few long-term trials of high protein weight loss diets. Skov et al. (1999) showed a greater weight loss with a higher protein diet (25 percent of total energy) than with a lower protein diet (12 percent of total energy) (loss of 8.9 kg and 5.1 kg, respectively) over 6 months. Another study, 10 weeks long, showed no difference in the body composition, cholesterol, triglycerides, uric acid, percent body fat, or nutrient intake in sedentary, overweight women following 1,200 calorie diets with varying macronutrient distributions (Alford et al., 1990). Interestingly, blood lipid values in the various studies of high-fat diets were found to have improved at least as much as in the lower-fat control diets (Foster et al., 2003; Samaha et al., 2003). LaRosa et al. (1980), however, reported an increase in serum low-density lipoprotein (LDL) cholesterol on a high-protein/high-fat diet. The concern regarding the long-term safety of high-fat, low-carbohydrate diets is warranted given that (1) they have a high saturated fat, high cholesterol, and low fiber content; (2) they result in a very low intake of fruits, vegetables, and grains (which could lead to deficiencies in essential vitamins, minerals, and fibers over the long-term); and (3) they originally were designed for short-term use during a weight loss period and have not been evaluated long-term. High-Carbohydrate, Low-Fat Diets. A diet with a high-carbohydrate/fat ratio (that is, a very low-fat diet) has been popularized by Ornish (1990) and Pritikin (1988). This diet suggests decreasing fat intake to about 10 percent of calories, keeping protein at 15 percent of calories, and eating about 75 percent of calories as carbohydrates. The high carbohydrate content is compatible with achieving more than the recommended intake of fruits, vegetables, and fiber. However, the very-low fat content may increase the risk of essential fatty acid deficiency (IOM, 2002) and may reduce the bioavailability of some fat-soluble vitamins (IOM, 2002; Roodenburg et al., 2000). In a weight-loss study Mueller-Cunningham et al. (2003) prescribed a diet with less than 15 percent of total calories from fat and reported a decrease in the intakes of vitamin E (as á-tocopherol) and of n-3 fatty acids. Freedman et al. (2001) described these high-carbohydrate/low-fat diets as being low not only in vitamin E, but also in vitamin B12 and zinc. The other negative consequence of a low-fat diet is that it usually is a high-carbohydrate diet, which can lead to increased levels of triglycerides (see Part D, Section 4, “Fats”). Weight Maintenance For weight maintenance, the desirable diet is one that prevents weight gain, meets nutrient needs, and can be consumed for a long time without adverse effects. One of the questions is how much fat should be in such a diet. The majority of observational studies and surveys support an association between dietary fat intake and BMI. Bray and Popkin (1998) summarized data from a variety of populations in more than 20 countries and reported an association between greater fat intake and higher BMI. However, Willett (1998) points out that this relationship is not consistent across countries and that the effect of fat intake on BMI is rather minor. For adults, the Acceptable Macronutrient Distribution Ranges (AMDRs) for fat, protein, and carbohydrate are estimated to be 20 to 35 percent, 10 to 35 percent, and 45 to 65 percent of energy, respectively (IOM, 2002). The upper range for fat, 35 percent of total calories, is based on the increased risk of overconsuming calories and of obesity with fat intakes above that range (Astrup et al., 2000; Saris et al., 2000; Shepard et al., 2001; Tremblay et al., 1991). Thus, diets with very-low carbohydrate to fat ratios (i.e., diets high in fat) may not be desirable for weight maintenance. The lower limit of fat recommended 20 percent of calories and aims at avoiding (1) fatty acid deficiency when fat intake is too low (Mueller-Cunningham et al., 2003), and (2) excess carbohydrate intake, which may have adverse effects on the blood lipid profile (see Part D, Section 4, “Fats”). Both the low-carbohydrate diet and the low-fat diet limit the variety of foods that can be eaten and, therefore, may be difficult to follow long-term (Foster et al., 2003). This probably explains the extremely high dropout rates in studies of these diets. There is insufficient evidence to make recommendations for or against the use of these diets for weight loss, but there is great concern about their long-term use for weight maintenance (Bravata et al., 2003). Although both low-fat diets and low-carbohydrate diets have been shown to result in weight reduction if followed, the maintenance of a reduced weight ultimately will depend on a change in lifestyle from the one that resulted in the need for weight reduction to one that meets nutrient needs while maintaining a balance between energy consumption and energy expenditure (Freedman et al., 2001). REFERENCES 1. Atkins C. Dr. Atkins’ New Diet Revolution. New York, NY: Avon Books, 1999. 2. Bravata DM, Sanders L, Huang J, Krumholz HM, Olkin I, Gardner CD, Bravata DM. Efficacy and safety of low-carbohydrate diets. JAMA 289:1837-1850, 2003. 3. Bray GA, Popkin BM. Dietary fat intake does affect obesity! Am J Clin Nutr 68(6):1157-1173, 1998. 4. Brehm BJ, Seeley RJ, Daniels SR, D’Allessio DA. A randomized trial comparing a very low carbohydrate diet and a calorie restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrin Metab 88:1617-1623, 2003. 5. Fleming, RM. The effect of high-, moderate-, and low-fat diets on weight loss and cardiovascular disease risk factors. Prev Cardiol 5:110-118, 2002. 6. Foster GD, Wyatt HR, Hill JO, McGucken BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman I, Klein S. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 348:2082-2090, 2003. 7. Freedman MR, King J, Kennedy, E. Popular diets: a scientific review. Obes Res 9 suppl 1:1S-40S, 2001. 8. Institute of Medicine (IOM). Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington DC: National Academies Press, 2002. 9. Larosa JC, Gordon A, Muesing R, Rosing DR. Effects of high-protein, low-carbohydrate dieting on plasma lipoproteins and body weight. J Am Diet Assoc 77: 264-270, 1980. 10. Samaha F, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 348:2074-2081, 2003. 11. Skov AR, Toubro S, Ronn B, Holm L, Astrup A. Randomized trial on protein vs carbohydrate in ad libitum fat reduced diet for the treatment of obesity. Int J Obes Relat Metab Disord 23:528-536, 1999. 12. St. Jeor ST, Howard BV, Prewitt TE, Bovee V, Bazzarre T, Eckel RH. Dietary protein and weight reduction: a statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation. 2001; 104: 1869-1874. 13. Westman EC, Yancy WS, Edman JS, et al. Effect of 6-month adherence to a very low carbohydrate diet program. Am J Med 113:30-36, 2002. 14. Willett WC. Is dietary fat a major determinant of body fat? Am J Clin Nutr 67:556S-62S, 1998. 15. Yang MU, Van Itallie TB. Composition of weight lost during short-term weight reduction. Metabolic responses of obese subjects to starvation and low-calorie ketogenic and nonketogenic diets. J Clin Invest 58(3):722-730, 1976. RECOMMENDATIONS FOR THE INTAKE OF SUGARS AND STARCHES The Institute of Medicine report Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (IOM, 2002) established a Recommended Dietary Allowance (RDA) for carbohydrate of 130 g per day for adults and children. This value is based upon the amount of carbohydrate (sugars and starches) required to provide the brain with an adequate supply of glucose. Glucose is the only energy source for red blood cells and the preferred energy source for the brain, central nervous system, placenta, and fetus. When muscle cells operate anaerobically (without oxygen), they rely 100 percent on glucose. If glucose is not provided in the diet and the body’s storage form of glucose (glycogen) is depleted, the body will break down protein in muscles to maintain glucose blood levels and supply glucose to the brain (IOM, 2002). The Institute of Medicine (IOM) also set an Acceptable Macronutrient Distribution Range (AMDR) for carbohydrate of 45 to 65 percent of total calories. At the low end of this range it is very difficult to meet the recommendations for fiber intake, and at the high end of the range overconsumption of carbohydrates may result in high blood triglyceride values. A comparison of the RDA to the AMDR shows that the recommended range of carbohydrate intake is higher than the RDA. For example, if an individual with a caloric intake of 2,000 kcal per day were to consume 55 percent of calories as carbohydrate (the mid-range of the AMDR) that would mean that 1,100 kcal would be from carbohydrate. This equates to 275 g carbohydrate (1 g carbohydrate = 4 kcal), well above the RDA of 130 g per day. In summary, the primary beneficial physiological effect of sugars and starches, and the basis for setting an RDA for carbohydrate, is the contribution of glucose as an energy source for the brain. However, the amount of glucose needed by the brain is lower than the AMDR for carbohydrate (45 to 65 percent of total calories). REFERENCES 1. FAO/WHO (Food and Agriculture Organization/World Health Organization). Carbohydrates in Human Nutrition. Rome: FAO, 1998. 2. Institute of Medicine (IOM). Dietary carbohydrates: sugars and starches. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press, 2002.
Submission Date	9/29/2004 4:49:00 PM
Author	from Durham, NC

Sugars

Summary
Comments	AARP urges HHS and USDA to reexamine the guideline “Choose carbohydrates wisely for good health.” The Committee decided to address a number of points under the umbrella of “carbohydrates.” We are concerned that this approach, and the elimination of a specific guideline on sugar, significantly dilutes the important message that people should limit their intake of added sugars.
Submission Date	10/1/2004 4:37:00 PM
Author	AARP

Glycemic Response

Summary	We concur with the Committee's statement “The glycemic index and/or glycemic load are of little utility for providing dietary guidance for Americans.”
Comments	We concur with the Committee's statement “The glycemic index and/or glycemic load are of little utility for providing dietary guidance for Americans.”
Submission Date	9/21/2004
Author	North American Miller's Association

Sugars

Summary	In whole form, carbohydrates support life, but refined carbohydrates are inimical to life because they are devoid of bodybuilding elements.
Comments	Only during the last century has man’s diet included a high percentage of refined carbohydrates. Our ancestors ate fruits, vegetables and grains in their whole, unrefined state. In nature, sugars and carbohydrates—the energy providers—are linked together with vitamins, minerals, enzymes, protein, fat and fiber—the bodybuilding and digestion-regulating components of the diet. In whole form, carbohydrates support life, but refined carbohydrates are inimical to life because they are devoid of bodybuilding elements.
Submission Date	9/21/2004
Author	Weston A Price Foundation

Summary	NFPA recommends that the Dietary Guidelines for Americans acknowledge that there are numerous food products that deliver essential nutrients and contain added sugars, and that these foods can be part of a healthful diet, balanced with physical activity.
Comments	NFPA notes that the Dietary Guidelines Advisory Committee focused on added sugars that deliver calories but no essential nutrients. NFPA recommends that the Dietary Guidelines for Americans acknowledge that there are numerous food products that deliver essential nutrients and contain added sugars, and that these foods can be part of a healthful diet, balanced with physical activity.
Submission Date	9/21/2004
Author	National Food Processors Association

Summary	I would add to this that including meat, dairy, and refined sugars in one’s diet is in fact detrimental to one’s health.
Comments	I would add to this that including meat, dairy, and refined sugars in one’s diet is in fact detrimental to one’s health.
Submission Date	9/21/2004
Author	Anonymous

Summary	The advice to choose carbohydrates wisely doesn’t provide clear enough advice.
Comments	The advice to choose carbohydrates wisely doesn’t provide clear enough advice. The two main messages in that section are about increasing whole grains and reducing the consumption of refined sugars. And since the whole grain recommendation is in this section of increasing daily intake of fruits and vegetables, whole grains, and low-fat and nonfat milk products, this section should avoid redundancy and convey the important dietary advice about refined sugars in a way that is easier for the public to understand and more available, and read, drink fewer soft drinks and limit cakes, cookies, and other foods rich in refined sugars
Submission Date	9/21/2004
Author	Center for Science in the Public Interest

Summary	We support the science-based conclusions on dental caries, diabetes, glycemic index and load and dietary fiber. There are, however, two areas related to the Added Sugars conclusive statements that require further consideration of the evidence. We are concerned that the Report suggests that a high
Comments	The Committee’s conclusions concerning carbohydrates closely align with the DRI Macronutrient Report (Institute of Medicine, 2003). We support the science-based conclusions on dental caries, diabetes, glycemic index and load and dietary fiber. There are, however, two areas related to the Added Sugars conclusive statements that require further consideration of the evidence. • Added Sugars We are pleased that the Committee recognized the important nutrient contributions made by sweetened, flavored milks and presweetened cereals. We are concerned that the Report suggests that a high intake of added sugars is associated with reduced nutrient intakes. The DRI Macronutrient Report, however, indicates that association is not significant until added sugars intake reaches 25% or more of caloric intake. It is not clear why the Dietary Guidelines Report fails to use this number to more specifically describe the level at which this shift occurs. In fact, the Dietary Guidelines Report indicates that individuals with moderate intakes of added sugars (5-10% of calories) have better nutrient status than those at higher or lower intake levels. The Advisory Report lists that 10% of added sugars intake comes from breakfast cereals and other grains such as breakfast bars. We recommend that this category be split due to the different usage and consumption patterns of cereals (predominantly breakfast occasions) versus the bar category (snacks and sometimes breakfast occasions). We would also like to clarify that ready to eat cereals contribute approximately 4% of added sugars intake.
Submission Date	9/27/2004
Author	General Mills

Glycemic Response

Summary	We concur with the committee’s finding that the glycemic index and/or glycemic load are of little utility for providing dietary guidance for Americans.
Comments	We concur with the committee’s finding that the glycemic index and/or glycemic load are of little utility for providing dietary guidance for Americans.
Submission Date	9/27/2004
Author	U.S. Rice Federal

Sugars

Summary	Overview of the Sugar Association position on sugars • People eat foods, not individual nutrients. • Sugar is valued as a food ingredient not only for its flavor enhancement but also for its uniqueness to meet the myriad of fundamental and essential functional requirements, particularly safety. •
Comments	The Sugar Association, Inc. (Association) is pleased to provide comments to the Department of Health and Human Services and the United States Department of Agriculture (Agencies) relating to sugars intake advice in the final report of the Dietary Guidelines Advisory Committee (Committee.) The Association acknowledges the dedication of those in the Federal Government working hard to provide the best possible advice to assist the American public in making choices that will improve overall health and well being. The Association believes today’s public health challenges require innovative strategies and contemporary initiatives when educating the American public about healthful eating and active lifestyles. The Association was founded in 1943 by the US sugar industry to monitor nutrition science and educate consumers about sugar’s role in a healthy diet. We ask the Agencies to consider the Association’s scientific expertise and years of experience in consumer education when evaluating these comments as part of the process of establishing federal nutrition advice about sugar. While the Association submitted written comments to the Dietary Guidelines Advisory Committee throughout its deliberative process, the Association would like to provide the Agencies with the following bulleted overview of specific issues provided to the Committee regarding sugars and a detailed response on the issues: discretionary calories, added sugars and nutrient displacement, and terminology. Overview of the Sugar Association position on sugars • People eat foods, not individual nutrients. • Sugar is valued as a food ingredient not only for its flavor enhancement but also for its uniqueness to meet the myriad of fundamental and essential functional requirements, particularly safety. • There is no scientifically verifiable body of evidence persistently documenting negative health impacts ascribable to sugar intake, including obesity and nutrient displacement, at current consumption levels. • Every major scientific review completely exonerates the direct involvement of sugars in the etiology of lifestyle diseases. , , , • The National Academy of Sciences, Institute of Medicine Macronutrient Report (IOM Report) concludes that current scientific data are insufficient to support evidence of any major health impact from sugars intake, including obesity. • The IOM Report did not establish a UL (Upper Level) for total or added sugars intake, only a suggested threshold for added sugars. • In the matter of added sugars and nutrient displacement, the IOM Report stated unequivocally that the suggested intake threshold applied to only some micronutrients within some subpopulation groups. The suggested intake threshold is well above the current average consumption level of sugars in the US population. • The US Food and Drug Administration has ruled that “added” and “naturally occurring” sugars are indistinguishable, and therefore concludes that consumers could be misled into believing that food containing no refined sugar is superior to food containing refined sugar. • Inordinate emphasis on added sugars could create a public health outcome similar to the one resulting from the simplistic focus on low-fat. The importance of energy balance is obscured by such one-dimensional approaches. • We ask the Agencies to consider the potential long-term repercussions the current trend of increasing use of sugar replacers may exert on satiety, metabolism and taste preference, especially among children.Recommended daily nutrient intake values are established to meet the dietary needs of healthy individuals. Micronutrient intake recommendations are established such that 98% of a normally distributed population receives adequate micronutrients. Consequently, micronutrient intake values provide a tool to evaluate the dietary adequacy of the general population. Although a single study might show that the intake of one or more selected vitamins or minerals is less than 100% of its established intake recommendation, this observation has little to do with a single food or a particular food ingredient. In any given short-term dietary sampling, it is highly unusual if the recorded intake of every micronutrient equals its recommended intake value.xi In fact, dietary intake expert committees “tend to err on the side of generosity.”xi There are always sectors that lie beyond the lower and upper boundaries of a normal distribution. It is no different with micronutrient intakes. Accordingly, small fractions of a population exhibiting dietary habits and eating patterns outside the norm are to be expected. Unless micronutrient intakes consistently fall below two-thirds of the recommended intake level, there is no long-term harm to health.xi Dietary guidance must be focused on the foods and beverages not consumed by a minority of individuals, not on a dietary component like added sugars. It is indefensible to construct dietary guidance systems, intended for 98% of the population, on the micronutrient intakes of the select few individuals requiring highly specialized dietary advice. There is no validated body of irrefutable evidence that corroborates the popular theory that added sugars reduce the nutrient adequacy of the American diet. Thorough examination of the data in the stable of articles cited repeatedly as substantiating this theory points out the fallacy of this hypothesis. For example, the data in the article emphasized by the Committee as supporting the added sugars and nutrient displacement hypothesis say the opposite. As listed in Table 3 of the cited article, micronutrient intakes range between 78% (zinc) and 237% (vitamin B12) of dietary recommendations for those Americans consuming more than 18% of their daily energy as added sugars. These intake levels are not nutritionally inadequate. While it is true that added sugars can be mathematically associated with the intake of a micronutrient like calcium, , critical analysis points out the ineffectiveness of using the nutrient displacement theory to explain low calcium intakes.xiv, However, the Committee continued to perpetuate the flawed nutrient displacement hypothesis by its treatment of the recently published IOM Report data of the comparative added sugars and calcium intake levels. As seen in Figure 1, the ‘inverted U-shaped’ response between the comparative calcium and added sugars intakes argue against the nutrient displacement hypothesis. Legitimate nutrient displacement requires that highest calcium intakes occur at the lowest level of added sugars intake. The fact that genuine nutrient displacement is obviously absent is underscored by the Figure-1 arrow labeled “This level represents the best with respect to micronutrient intake.”xix Not only has this statement been so generalized as to imply that it is true for all micronutrients, it disregards the fact that Figure 1 pertains only to calcium intakes for children ages 4 to 8. The arrowed statement of Figure 1 further ignores the fact that the second added sugars category (5 – 10%) is not always reflective of highest calcium intakes reported in the IoM added sugars dataset.xviii For example, males ages 19 to 50 have higher calcium intakes in the third added sugars category (10 – 15%) than in the second added sugars category. Second, inclusion of age-specific recommended intake values further weakens the relevance of unilaterally applying the nutrient displacement theory to added sugars and calcium intake comparisons. The dashed line in Figure 2 readily demonstrates that children’s calcium intakes uniformly exceed the recommended 800-mg/day level at added sugars levels as high as 25% of daily calories (fifth category). In fact when the reported statistical errorsxv are included (data not shown), some children within the 25 – 30% added sugars group (sixth category) achieve their daily 800-mg/day intake level established for calcium.Finally, Figure D5–1 should have been labeled with the terminology “added sugars,” not “added sugar.”xix Terminology - Sugar-sweetened drinks The Food and Drug Administration has defined sugar to mean sucrose for the purpose of ingredient labeling, 21 C.F.R. 101.4(b)(20). For the purposes of ingredient labeling, the term sugar shall refer to sucrose, which is obtained from sugar cane and sugar beets in accordance with the provisions of 184.1854. The terms sugars (plural) is used to designate all mono- and disaccharides. Therefore, The Association takes strong issue with the use of the term “sugar-sweetened drinks” to denote caloric beverages throughout the Committee’s final recommendations and asks that the Agencies not allow this terminology in the messages developed to communicate dietary guidance to the American public. Very few beverages, and all major soft drinks, have not contained sugar since the mid 1980s. High fructose corn syrup (HFCS) is the major sweetener in nearly all caloric beverages and to use the term “sugar-sweetened drinks” is not only inaccurate but misleads the consuming public. Today’s foods and food ingredients are not the same as those of our grandmothers. No longer is a jelly or jam, for example, simply made with fruit, sugar (sucrose) and pectin. While consumers can read a detailed list of ingredients on many food products, many of today’s foods contain ingredients that consumers cannot pronounce, let alone have any idea of what the ingredient is and its function in the food. This is particularly true regarding sweetening ingredients used in today’s foods. As verified in Figure 3, the sucrose share of the US caloric sweetener market has fallen from nearly 86% in 1970 to 43% in 2003. While Figure 3 was updated specifically for these comments, an earlier edition was published recently in the peer-reviewed literature.xx The Association recently conducted eight focus groups across the country. In an exercise where participants were asked to list ingredients now used to sweeten foods, not one participant identified high fructose corn syrup as a sweetening ingredient even though HFCS is a major sweetener used in today’s food supply. Nor did these consumers have any knowledge of sugar alcohols or fillers, such as maltodextrins, used today to replace fats and sugar in foods. However, consumers do understand the term “sugar” to mean pure, white granulated sugar that their mothers and grandmothers used and trusted. Although there are conflicting points of view as to whether or not individual caloric sweeteners are equivalent, the Association firmly believes the public interest is not served when consumers continue to be misled by the improper use of the term “sugar” to describe the myriad of sweeteners used in today’s food and beverage products. In closing, the Association would like to restate a part of its oral comments presented on September 21, 2004 to representatives of the Agencies. Sugar is an important food ingredient that has provided safety and important functional properties to our food supply for thousands of years, and is an essential component in many nutrient-rich foods. We are encouraged that the Committee has emphasized the central importance for individuals to balance their energy intake with their activity level for weight control. If one eats more food and thus calories – no matter the source - than one burns, weight gain is inevitable. We agree emphasis should be placed on helping Americans understand the importance of having nutrient-rich diets, and are confident the Agencies will develop science-based, credible messages to help Americans achieve their individual energy balance goals for improved health.
Submission Date	9/27/2004
Author	Sugar Association

Summary	Executive Summary Should Reflect the Order of Priority of the Guidelines Written by: Maureen Storey & Richard Forshee
Comments	The Center for Food and Nutrition Policy (“Center” or CFNP) at Virginia Tech—National Capital Region located in Alexandria is an independent, non-profit research and education organization that is dedicated to advancing rational, science-based food and nutrition policy. It is recognized as a Center of Excellence on such matters by the Food and Agriculture Organization of the United Nations (FAO). The Center uniquely operates like an independent “think-tank,” while maintaining its academic affiliation with Virginia Tech, a major land-grant university. The research, education, outreach, and communications activities of the faculty are conducted in a relevant, time-sensitive manner that helps inform the public policy process on food and nutrition issues. Encompassed in the Center’s activities on nutrition policy are its interests in policy and regulatory issues involving dietary guidance. The Center respectfully submits the following comments in response to the solicitation for written comments regarding the proposed 2005 Dietary Guidelines for Americans as published in the Federal Register.1 The comments contained herein urge the final guidelines to 1) reflect the priorities or order of importance in producing desirable health outcomes; 2) delete the section on the role of the environment as speculative rather than substantive; and 3) re-draft certain segments of the carbohydrates chapter to accurately reflect the results of publications used to justify the recommendations of the DGAC. Choose Carbohydrates Wisely for Good Health The following comments pertain to Part D Science Base, Section 5 Carbohydrates. The Center agrees that the message to “choose carbohydrates wisely for good health” is scientifically sound advice. Yet the language of the Conclusion and the Rationale of the guideline suggesting that added sugars may uniquely contribute to certain undesirable health outcomes such as poorer nutrient intake, unhealthy body weight, and increased risk of dental caries, is overstated. What is the relationship between intake of carbohydrates and dental health? The DGAC draft report suggests a possible relationship between added sugars and dental health. Question 1 asked: “What is the relationship between intake of carbohydrates and dental health?” Enclosed is a recent paper published by Forshee and Storey examining the association between dental caries and soft drink consumption.4 The study showed that for most age groups, soft drink consumption was not linked to an increase in dental caries. Our examination generally agrees with the findings of Heller and coworkers, but our interpretation of the policy implications of the results differs from theirs.5 The Center agrees that good dental hygiene, drinking fluoridated water, and using fluoridated dentifrices are the most effective ways to reduce dental caries. A secondary consideration is intake of fermentable carbohydrates that stick to the teeth and are not removed by brushing or rinsing the mouth. The Center therefore urges the draft report to reflect the priority of behaviors that will lead to better oral health by re-stating the final sentence in the conclusion to read: “A combined approach of optimizing oral hygiene practices and reducing the frequency and duration of exposure to fermentable carbohydrate intake is the most effective way to reduce caries incidence.” 4 Forshee RA, Storey ML. Evaluation of the association of demographics and beverage consumption with dental caries. Food Chem Toxicol. 2004; 42:1805-1816. 5 Heller KE, Burt BA, Eklund SA. Sugared soda consumption and dental caries in the United States. Journal of Dental Research 2001; 80: 1949-1953. 4 Does intake of added sugars have a negative impact on achieving recommended nutrient intake? The sentence in the Conclusion—“A reduced intake of added sugars (especially sugarsweetened beverages) may be helpful in achieving recommended intakes of nutrients and in weight control”—overstates the evidence presented. The evidence in fact shows that focusing on added sugars intake as a way to control or lose weight or improve micronutrient intake is unlikely to have any effect on these outcomes. The Center is pleased that the DGAC considered our research during its deliberations, however, we object to the manner in which our research is characterized in the draft report. For example, the draft report notes that most cross-sectional studies have found that “an increased intake of added sugars is associated with increased total energy intake” and the study by Storey et al, 20036 is cited as support for this statement. Our study in fact showed that less than 10% of children’s BMI and less than 15% of adolescents’ BMI could be explained by the parameters of our models. Of the variance that was explained by the models we developed, the largest predictors of BMI among children and adolescents were factors that can not be modified, such as age, gender, and race-ethnicity. Of the lifestyle factors that can be modified, sedentary behavior was far more predictive of BMI than was dietary intake; and within dietary intake, added sugars did not predict BMI. The conclusions we reached therefore do not support the statement made in the draft DGAC report. The Center also objects to how another one of our studies is represented in the draft report. The DGAC asked the sub-question: “Does intake of added sugars have a negative impact on achieving recommended nutrient intake?” The sentence in the draft report—“each of these papers shows a decreased intake of at least one micronutrient with higher levels of added sugar intake”—is true on its face, but it misrepresents the intent and overall conclusion of at least the study conducted by the Center. While again the Center is pleased that the DGAC cited our study (Forshee and Storey, 2001),7 we in fact showed that added sugars intake had an inconsistent association with micronutrient intake and that the association was always small. In addition, whether the association was positive or negative, it was probably small enough to be biologically insignificant. The DGAC also relied heavily on the Institute of Medicine of the National Academies draft report—specifically Appendix J—that examined the relationship between added sugars intake and micronutrient intake. Unfortunately, the NAS report used a ratio variable (percent energy from added sugars [%EAS]) that introduced a statistical and mathematical complexity that certainly affected the results of the study. In a study to be published by Forshee and Storey and that was provided to the DGAC carbohydrate subcommittee, we found that the relationship between total energy intake and 6 Storey ML, Forshee RA, Weaver AR, Sansalone WR. Demographic and lifestyle factors associated with BMI among children and adolescents. International Journal of Food Science and Nutrition 2003; 54: 491- 503. 7 Forshee RA, Storey ML. The role of added sugars in the diet quality of children and adolescents. Journal of the American College of Nutrition 2001; 20: 32-43. 5 micronutrient intake is far stronger than the one between energy from added sugars and micronutrients.8 Does intake of added sugars contribute to excess intake of energy? This question is irrelevant because one could just as easily ask if intake of any macronutrient contributes to excess intake of energy. Of course, the answer is yes; intake of any macronutrient, including added sugars, can contribute to excess intake of energy. In addition, the first two sentences in this section should be deleted because the statements address a different scientific question of underreporting food intake.9 The language in the draft report alludes to “prospective studies” that suggest a positive association between consumption of sugar-sweetened beverages and weight gain. At least one DGAC member argued that prospective studies are more important than cross-sectional studies in providing evidence regarding relationships between health behaviors and health outcomes. The Center agrees that prospective studies allow the testing of certain hypotheses that cannot be tested in cross-sectional studies. We therefore encourage the principal investigators of existing prospective studies to make the data widely available so that the scientific and policy communities can benefit from the work of many independent research teams. In order to better understand the importance of these studies, we critically reviewed five of the prospective studies cited by the DGAC 10, 11, 12, 13, 14 and one prospective study published since the release of the draft report.15 8 Forshee RA, Storey ML. Controversy and statistical issues in the use of nutrient density in assessing diet quality. Journal of Nutrition 2004; in press. 9 “The analysis of dietary data on added sugars may underestimate intake because of the underreporting of food intake, which is more pervasive among obese adolescents and adults than among their lean counterparts (Johnson, 2000). It appears that foods high in added sugars are selectively underreported (Krebs-Smith et al., 2000).” 10 Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. The Lancet 2001; 357: 505-508. 11 Berkey CS, Rockett HR, Field AE, Gillman MW, Colditz GA. Sugar-added beverages and adolescent weight change. Obesity Research 2004; 12: 778-788. 12 Newby PK, Peterson KE, Berkey CS, Leppert J, Willett WC, Colditz GA. Beverage consumption is not associated with changes in weight and body mass index among low-income preschool children in North Dakota. J Am Diet Assoc. 2004; 104: 1086-94. 13 James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing the consumption of carbonated soft drinks: cluster randomised controlled trial. British Medical Journal 2004; 328:1237-1242. 14 Schulze MB, Manson JE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, Hu FB. Sugarsweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. Journal of the American Medical Association 2004; 292: 927-934. 15 Field AE, Austin SB, Gillman MW, Rosner B, Rockett HR, Colditz GA. Snack food intake does not predict weight change among children and adolescents. Int J Obes Relat Metab Disord. 2004; 28:1210- 1216. 6 Each of these studies was conducted with the primary purpose of linking sweetened beverages with weight gain in children, adolescents, or adults. We believe the studies, as a body of evidence, show inconsistent results. The relationship between sugarsweetened beverages and BMI ranges from not statistically significant to a weak relationship affecting a small percentage of the population. A critique of each study is shown below. Ludwig et al., Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. The Lancet 2001; 357: 505-508. This 19-month prospective observational study examined dietary habits and weight gain among 548 11-12 year old school children living in Massachusetts. Separate multivariate regression analyses were performed to estimate BMI and the probability of a child becoming overweight as a result of consuming calorie-containing carbonated soft drinks. At the end of the study, the authors found that only 6.8% of the study population of growing children, or 37 previously normal-weight, growing children, moved to the overweight category. At the same time, 35 (6.4% of the study population) previously overweight, growing children moved to the normal-weight category. Therefore, a net of two more children out of 548 (or 0.36% of the population) were classified as overweight at the end of the study. The regression analysis in Table 2 reports a relation of 0.24 kg/m2 increase in BMI for a one serving per day increase in sugar-sweetened drink consumption (controlling for other covariates). According to Table 1, baseline sugar-sweetened drink consumption was 1.22 servings per day and increased by 0.22 to 1.44 servings per day at followup. Therefore, the model predicts that for the average participant sugar-sweetened drink consumption contributed to a 0.05 kg/m2 increase in BMI over 19 months. While statistically significant, it does not appear that sugar-sweetened drinks made a large contribution to BMI for the average child in this study. Moreover, the authors did not report the coefficients of the other independent variables in the regression analyses. This prevents readers from determining the relative strength of the evidence upon which the authors made their conclusions regarding any possible unique contribution of soft drink consumption and weight gain among growing children. Berkey et al., Sugar-added beverages and adolescent weight gain. Obes Res 2004; 12: 778-788. This prospective, observational study (U.S. Growing Up Today Study) uses a powerful dataset, and the statistical modeling is generally good. However, the interpretation of the results does not appear to reflect the findings. Many of the reported p-values for the sweetened beverage variables were greater than (not statistically significant) or barely below 0.05. This is particularly surprising for such a large sample (>10,000 after exclusion criteria). 7 For example, in this sample of more than 10,000 boys and girls ages 9-14 years (y), the largest increase in BMI was 0.14 kg/m2 for boys who increased their consumption of caloric beverages by more than two servings per day. This small increase in BMI was attributed to a very large increase in calorically sweetened beverages. On average, there was an increase of 0.03 kg/m2 per serving/day for males, which was significant at p = 0.04. For females, there was a non-significant increase of 0.02 kg/m2 per serving/day (p = 0.096). Sugar-added beverages were defined as soda pop, sweetened iced tea, and non-carbonated fruit drinks. For boys, the average soda pop consumption in this study ranged form 0.34 (for 9 y) to 0.77 (for 14 y); iced tea ranged from 0.69 (for 9 y) to 0.20 (for 14 y), and non-carbonated fruit drinks ranged from 0.69 (for 9 y) to 0.78 (for 14 y). An increase of two servings per day is very large relative to the average consumer; indeed it is larger than the mean servings for the highest consuming age group. Even if we reduced consumption by more than the mean of the highest consumers, we would reduce average BMI by 0.14 kg/m2 at most. The coefficients and p-values for milk, sweetened beverages, and fruit juices are all very similar. Furthermore, the coefficients are much smaller and not statistically significant once total energy is introduced as a control variable. This suggests, as the authors report, that energy explains the relationships observed rather than any special property of sweetened beverages. Given the small magnitude of the reported relationships and the borderline p-values, the impact of sweetened beverages on BMI appears to be small. The authors also collected data on physical activity and sedentary behavior. Although these variables were included in the analysis, the authors did not report the results. Other research has shown that these variables have a stronger relationship with BMI than does added sugars. Since the results for physical activity and sedentary behavior were not reported, there is no context or basis for comparison in the interpretation of the reported relationship between sugar-added beverages and BMI. Despite these weak relationships and the lack of context, the authors still call for limiting the consumption of soft drinks and claim that this approach may prevent excessive weight gain. However, their results do not support the claim that limiting consumption of soft drinks may play a meaningful role in preventing weight gain. Based on these results, it is difficult to see how discouraging sweetened drink consumption could have a meaningful impact on average adolescent BMI. 8 James et al., Preventing childhood obesity by reducing the consumption of carbonated soft drinks: cluster randomised controlled trial. BMJ 2004; 328:1237-1242. This cluster, randomized controlled trial was designed to discourage consumption of “fizzy” drinks among 7-11 year old British school children. The so-called “Ditch the Fizz” campaign told the children that reducing calorie-containing soft drink consumption would improve well-being and dental health. The original published version of the paper noted that consumption of carbonated drinks decreased by 0.6 glasses per day. It was amended to show that consumption decreased by 0.6 servings over three days, or 0.2 servings per day. These results indicated that few children changed their dietary habits as a result of the campaign. The results also showed that consumption of carbonated drinks with sugar was unchanged in the control group and decreased by 0.3 of a (250ml) serving over a 3-day period in the intervention group. Neither change was statistically significant, and there was no statistically significant difference between the control and intervention groups. Furthermore, the mean change in BMI was 0.8 kg/m2 for the control group and 0.7 kg/m2 for the intervention group. This difference was not statistically significant. Newby et al. Beverage consumption is not associated with changes in weight and body mass index among low-income preschool children in North Dakota. J Am Diet Assoc. 2004; 104:1086-94. Newby et al. analyzed data from a prospective cohort study of 1,345 children 2-5y who were participating in the North Dakota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Their models found no statistically significant association between beverage consumption and change in either weight or BMI. Specifically with regard to soda consumption, the estimated coefficient in the multivariate adjusted model for weight was -0.00 ± 0.04 (p=.95) and for BMI was -0.01 ± 0.02 (p=.58). Moreover, zero was in the middle of the confidence interval and the estimate was negative, not positive, which was the hypothesis being tested. As the authors note, average consumption of soda in this study is only a little over one ounce per day, but this is very close to the national average of 1.75 oz/day for children under 5y as reported by the CSFII 1994-96, 1998 Table Set 17, Table 15A.16 This prospective study of a group of young, low-income children consuming nearly the national average of 16 U.S. Department of Agriculture, Agricultural Research Service. 1999. Food and Nutrient Intakes by Children 1994-96, 1998. Online. ARS Food Surveys Research Group, available on the "Products" page at [accessed September 23, 2004]. 9 soda showed no association between soda consumption and either weight or BMI. Schulze et al., Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA 2004; 292: 927- 934. This article addresses important nutrition, public health, and public policy issues using an extraordinarily rich and important dataset. Unfortunately, some of the commentary in the study does not accurately reflect the data presented. This prospective cohort analysis used data from the Nurses’ Health Study II. This non-representative sample of women had a full sample of 116,671 women, but the authors excluded nearly half of the respondents (n=51,603). It is important to note that the average weight increased in all sugar-sweetened beverage consumption categories during the four-year periods 1991-1995 and 1995-1999. Even the category that sharply reduced consumption of sugar-sweetened beverages had an average weight gain of 1.34 kg from 1991-1995. Percent of Population Affected by Sugar-sweetened Beverage Consumption 1991-1995 Consumption Category Percentage of the Population ?kg/4years ?lb/year Consistent =1/wk 75 3.21 1.8 Consistent =1/day 5 3.12 1.7 =1/wk to =1/day 2 4.69 2.6 =1/day to =1/wk 2 1.34 0.7 Other 16 3.04 1.7 Source: Adapted from data presented in Schulze et al. As shown in the table above, 75% of the participants were already in the lowest category of sweetened beverage consumption, consistently drinking one or fewer soft drinks per week (Consistent =1/wk). Only 2% of the participants increased sweetened beverage consumption from =1/wk to =1/day, and these participants gained about 1.5 kg more than those in the lowest consumption category. Similarly, only 2% of the participants reduced their sweetened beverage from =1/day to =1/wk, and those 10 participants gained 1.9 kg less than participants in the lowest consumption category. Percent of Population Affected by Sugar-sweetened Beverage Consumption 1995-1999 Consumption Category Percentage of the Population1 ?kg/4years ?lb/year Consistent =1/wk 76 2.04 1.1 Consistent =1/day 5 2.21 1.2 =1/wk to =1/day 1.5 4.20 2.3 =1/day to =1/wk 2 0.15 0.1 Other 16 2.10 1.2 Source: Adapted from data presented in Schulze et al. 1 Does not sum to 100 due to rounding. Slightly more than 96% of the women in this study had the same average weight gain between 1995 and 1999. Three out of four women in this study already consumed soft drinks once a week or less and can not be expected to reduce their consumption much further. Of the four percent of women who went from one extreme category to another (i.e., dramatically decreased or increased consumption), their weight gain changed by about one pound per year compared with the 96% of the rest of the population. This association was somewhat smaller after controlling for total energy. If less than a two kilogram change over a four-year period for less than four percent of the population is the best single opportunity we have to curb the obesity epidemic, then we have a serious challenge ahead for all of us, including the 96 percent of the population who are low or very modest consumers of sweetened beverages. Field et al. Snack food intake does not predict weight change among children and adolescents. Int J Obes Relat Metab Disord. 2004;28:1210- 1216. Using the same prospective, observational study as Berkey et al. (U.S. Growing Up Today Study), Field et al. report no association between consumption of snack foods and annual change in BMI z-score among the nearly 15,000 girls and boys who were 9-14y in 1996. The estimated coefficients were negative, small, and not significant for both boys and 11 girls. Adding sugar-sweetened beverages to the snack food category “did not meaningfully change the results” (p. 1214). Body of Evidence Does Not Support a Public Health Strategy Targeting Sweetened Beverages Overall risk from any substance depends on the level of exposure and the degree to which the substance is considered a hazard. The table below illustrates that seven studies using a variety of designs show a very slight difference in BMI that is often not significant. “Hazard” estimates in this set of data range from not significant to about 0.20 (kg/m2)/year per serving/day. It is therefore difficult to justify public health strategies that would focus on reducing sweetened beverages as a unique risk for obesity and Type 2 diabetes. Summary of Findings from Selected Major Papers Study Magnitude ?BMI/year/(serving/day) Significance Forshee & Storey17 (cross-sectional) 0.11 (males) 0.26 (females) Not Significant Not Significant Ludwig et al. (prospective) 0.15 (0.24 over 19 months) p=0.03 Berkey et al. (prospective) 0.03 (boys) 0.02 (girls) p=0.04 p=0.096 Not Significant James et al. (intervention) 0.1 difference between treatment and control Not Significant Newby et al. (prospective) -0.01 (children) Not Significant Schulze et al. (prospective) 0.20 (women) (applies to 4% of participants) p<0.05 Field et al. (prospective) ~0 (not directly reported) Not Significant Source: Compiled by CFNP from data presented in published studies. Several approaches have been developed to evaluate the overall strength of a body of scientific evidence. One recent example is the U.S. Food and Drug Administration’s Interim Evidence-based Ranking System for Scientific Data18 that is part of the Interim 17 Forshee RA, Anderson PA, Storey ML. The role of beverage consumption, physical activity, sedentary behavior, and demographics on body mass index of adolescents. Int J Food Sci Nutr. In press. 18 U.S. Department of Health and Human Services, Food and Drug Administration, Center for Food Safety and Applied Nutrition. Interim Evidence-based Ranking System for Scientific Data. July 2003. last accessed September 21, 2004. 12 Procedures for Qualified Health Claims in the Labeling of Conventional Human Food and Human Dietary Supplements.19 The guidance describes an approach to evaluate how strongly the totality of scientific evidence supports a claim in the form of “consuming more X reduces the risk of Y,” with its counterpart claim being, “consuming less X reduces the risk of Y.” Based on the type and quality of the evidence, a proposed claim will be placed in one of four categories (First-level is the existing standard of Significant Scientific Agreement): Scientific Ranking FDA Category Appropriate Qualifying Language Second Level B ... "although there is scientific evidence supporting the claim, the evidence is not conclusive." Third Level C "Some scientific evidence suggests ... however, FDA has determined that this evidence is limited and not conclusive." Fourth Level D "Very limited and preliminary scientific research suggests... FDA concludes that there is little scientific evidence supporting this claim." Source: FDA Interim Procedures for Qualified Health Claims Using this approach, we believe that the claim “Consuming less sugar-sweetened beverages may reduce body mass index” would be a Third-level or Fourth-Level claim. There are no large clinical trials testing this claim. One small randomized control trial (James et al.) showed no difference in the change in BMI between treatment and control groups. The evidence from prospective observational studies is inconsistent. The Newby et al. and Field et al. studies found no relationship between sugarsweetened beverages and BMI. The Berkey et al. study found only a weak relationship between sugar-sweetened beverages and BMI, and that relationship disappeared after controlling for total energy. Ludwig et al. found a statistically significant relationship (p=0.03) that predicted an increase of 0.05 kg/m2 over 19 months for the average respondent in their study. Schulze et al. found statistically significant differences of about one pound/year that affected the approximately four percent of the participants who went from one extreme consumption category to the opposite extreme category. The other ninety-six percent of the participants had indistinguishable weight gains regardless of their sugar-sweetened beverage consumption. The prospective studies therefore have not confirmed a relationship between calorically sweetened beverages and BMI and cross-sectional studies generally have not found a relationship between sugar-sweetened beverage consumption and BMI either. 19 U.S. Department of Health and Human Services, Food and Drug Administration, Center for Food Safety and Applied Nutrition. Interim Procedures for Qualified Health Claims in the Labeling of Conventional Human Food and Human Dietary Supplements. July 2003. last accessed September 21, 2004. 13 Broad policies promoting the reduction of caloric-sweetened beverage consumption in order to decrease overweight/obesity in the U.S. population are not supported by the existing evidence. Summary of Comments In summary, the Center for Food and Nutrition Policy urges the following: 1) Prioritize the executive summary of the report to reflect the order of priority of the guidelines; 2) Delete the section on the role of the environment in implementing the guidelines as speculative and not supported by a science base; 3) Re-write the sentence on dental health as shown in these comments, which reflect the priority and relative importance of the factors that contribute the most to dental caries. 4) Re-write the section on added sugars and micronutrient intake to reflect the inconsistency and size of the relationship; 5) Re-write the section on added sugars and weight gain to reflect the actual findings in the scientific literature; that is, the relationship is small, weak, or not statistically significant. Furthermore, only a small percentage of the population appears to be affected by excessive intake of added sugars and/or sweetened beverages. Respectfully submitted, Maureen Storey, PhD Richard A. Forshee, PhD Director, CFNP Associate Director, CFNP Director, Research
Submission Date	9/27/2004
Author	Center for Food and Nutrition Policy

Summary	Choose carbohydrates wisely for good health. • Suggest changing key message to “Choose carbohydrates wisely for good health, including to help manage body weight”. • Supporting text should provide explicit recommendations on those carbohydrate-rich food and beverage sources that should be limited an
Comments	Choose carbohydrates wisely for good health. • Suggest changing key message to “Choose carbohydrates wisely for good health, including to help manage body weight”. • Supporting text should provide explicit recommendations on those carbohydrate-rich food and beverage sources that should be limited and which should be consumed more frequently as part of a healthy diet.
Submission Date	9/27/2004
Author	American Cancer Society, American Diabetes Association, American Heart Association

Summary
Comments
Submission Date	12/1/2004 12:20:00 PM
Author	Anonymous

Fiber

Summary	Why is it Americans fall for the low carb advertising. We need carbs, chldren to thrive. Over carbs over weight Exercise America. You do youve funds to launch a massive advertising campaign.
Comments	We learned in 4th grade, in 1958 that calories turn into fat if we don't burn the calories through exercise. I remember my teacher to this day.
Submission Date	1/12/2005 10:04:00 AM
Author	from Springfield,`, MA

Discretionary Calories

General

Summary	2005 Dietary Guidelines for Americans looks great! I am extremely excited for this report to impact the individuals of America. Good luck sorting through all the comments!
Comments	Dear Secretaries Veneman and Thompson: First of all, I just want to thank you for the opportunity to provide input for the 2005 Dietary Guidelines for Americans. I am currently a senior at Ball State University majoring in elementary education. As a future educator I feel individuals nutrition is imperative for classroom success! Thank you for caring for the people of America. I have always been a huge advocate of fat grams and proportion sizes in food. As I was reading this report, the section on Control Calorie Intake to Mange Body Weight grabbed my attention. This section comments on how calories control weight. Then it goes on to state how the proportion sizes of carbohydrate, fat, and protein in diets don’t matter. I agree with the statement on how calories control weight. But I disagree with how proportion sizes don’t matter. So is this saying an individual’s diet can consist of fatty foods, as long as they keep within there recommended calorie intake? The same goes for carbohydrate and protein. This would not be healthy for an individual. I feel a healthy diet consists of all areas of the food guide pyramid. My concern with this statement is that people will start focusing in on how many calories they consume, and not variety in their diet. This could be a problem. The right variety in a diet is crucial. Our society can become vulnerable to different trends that are diet related. I have seen it happen, for example the Atkins diet. My advice to you would be to take out the statement on how the proportions of carbohydrate, fat, and protein in diets don’t matter. Instead, I would include a statement on how people should control calorie intake by making smart choices within the food guide pyramid. The overall report looks great, and I am really excited! Again, I just want to thank you for the opportunity to here out my comment. Good luck! Sincerely,
Submission Date	9/21/2004 8:18:00 AM
Author	from Anderson, Indiana

Summary	recommendations to be in real food specifications sugar must be addressed with specifics as to decreased quantity
Comments	I concur with letter sent to Ms McMurry Sept 21 signed by numerous professionals beginning with Garry Auld of Colorado State University. Information to the public must be in usable, specific information - not generalities. Sugar must be addressed as well as corn syrup, high fructose syrup, etc as the amount is being consumed in exageraged quantities
Submission Date	9/23/2004 4:31:00 PM
Author	from Durango, Colorado

Summary	Discretionary calories is a correct concept scientifically, but difficult educationally. This concept will undoubtedly be preferentially used against the obese while giving thin people the license to eat whatever they want, whether or not the nutritional value of their selected foods is adequate.
Comments	Discretionary calories were implicit in all dietary advice before the Food Guide Pyramid. The assumption was that one would eat at least the recommend amounts of each food group. If more calories were needed the person would include some sugar or fat or simply eat more foods from the recommended groups. However, in the pasts 30 years the consumption of added sugars has increased, particularly sweetened beverage consumption [Haines, 2000, Putnam, et al., 2002]. The studies cited by the Committee indicate that practically everyone is eating more fat and sugar than recommended, not just those who are overweight or obese. Although it is a scientific fact that very few discretionary calories are available if one is sedentary, educationally it is a concept that is very difficult to handle. Sedentary and active people are found among those that have a normal BMI, as well as those who are considered overweight or obese [Farrell, et al., 2002, Lee, et al., 1999]. Therefore, there is no good way to tell if a person is sedentary based on whether they are thin or fat. Because of the ignorance of the public as to the true nature of obesity and the difficulty of permanently reducing weight [Stern et al., 1995], this concept will undoubtedly be preferentially used against the obese while giving thin people the license to eat whatever they want, whether or not the nutritional value of their selected foods is adequate. I can best sum up the problem with an incident that occurred about 40 years ago. Dr. Charlotte Young was my major professor for my Master’s studies and a very large woman. She did not own a car, and walked everywhere. One day there was a departmental birthday party. As people were leaving the room she was eating a ½” wedge of birthday cake, the only piece of cake she had eaten during the celebration. One very thin person remarked in a loud voice as she walked out: “Imagine someone that fat eating cake”. Dr. Young was obviously hurt by the remark. She said to me: “You know, I am 5’ 10” tall and weigh 250 lbs. However, all my brothers and sisters weigh over 300 lbs.” Dr. Young’s area of expertise was obesity and she did everything we have always taught to control her weight. She was successful compared with other members of her family. Please do not turn in a report that foments the kind of ignorance and cruelty to which she was subjected. Farrell SW, Braun L, Barlow CE, Cheng YJ, Blair SN. 2002. The relation for body mass index, cardiorespiratory fitness, and all-cause mortality in women. Obes. Res. 10(6): 417-423. Haines PS. 2000. Consumer trends in fats and sweets: Policy options for dietary change. J. Food Distribution Res. 31(1): 32-38. Lee CD, Blair SN, Jackson AS. 1999. Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men. Am. J. Clin. Nutr. 69(3):373-80 Putnam J, Allshouse J, Kanter LS. 2002. U.S. Per Capita Food Supply Trends: More Calories, Refined Carbohydrates and Fats. Food Review 25(3): 2-15. (Economic Research Service). Stern JS, Hirsch J, Blair SN, Foreyt JP, Frank A, Kumanika SK, Madans JH, Marlatt GA, St.Jeor ST, Stunkard AJ. Weighing the options: criteria for evaluating weight-management programs. The Committee to Develop Criteria for Evaluatin the Outcomes of Approaches to Prevent and Treat Obesity. Obes. Res. 3(6): 591-604.
Submission Date	9/26/2004 7:02:00 PM
Author	from Mayagüez, ¨PR

Summary	This letter on Discretionary Calories will include how low caloric intake will not only give you a good body image, but it will help you feel better about yourself and have a good mental state. It also agrees with what you already have in the dietary guidelines.
Comments	Dear Secretaries Veneman and Thompson, Thank you for providing the opportunity for me to provide my suggestions about the Revised Dietary Guidelines for Americans. I find it very inspiring that you are revising these guidelines to better individual's personal nutrition. The next topic I believe goes hand in hand with physical activity and body maintiance; it is Control Calorie Intake To Manage Body Weight. I find this section very important, especially with our overweight epidemic. I believe portion sizes and caloric intake cannot be talked about enough. In this section, I would consider informing Americans that a low caloric intake diet will help you feel better about yourself, while maintaining a good body image. Other than this comment, I feel you inform individual's exactly what they need to do to manage body weight. Thank you very much for taking suggestion and giving careful consideration on how you might improve the Revised Dietary Guidlines for Americans. It is a very good idea to take suggestion from individuals who actually will read and have to follow these guidelines, the public. Good luck with your journey and sorting through the many suggestion. Sincerely, Kendra Chestnut 1012 Ashland Ave. Muncie, In 47303
Submission Date	9/27/2004 12:47:00 AM
Author	from Muncie, Indiana

Summary	This entire section should be deleted because it is both unnecessary and a wasteful distraction from the important basics of nutrient intake.
Comments	This section is unnecessary according to the 2005 guideline itself, “…most Americans have used up discretionary calories even before meeting recommendations for nutrient intakes.” The American people, approximately half of whom are overweight, do not need information on discretionary calories. They need help (desperately) on moderation, wise choices, and nutrients. This section distracts from the primary aim of this important document. If this section is released, it will unleash a torrent of wasteful discussion and debate, energy that would be better spent helping people understand portion control and nutrient intake. People already reference the overwhelming explosion of “new information, new fads” as excuses for not using common sense (and clear basics) in dietary choices. Please do not contribute to the “confusion.” Please, please, please, delete this entire section, and focus on the basics. This entire section should be deleted because it is both unnecessary and a wasteful distraction from the important basics of nutrient intake.
Submission Date	9/27/2004 10:40:00 AM
Author	from Okemos, MI

Summary	I agree with the comments and suggestions posted in the guidlines for this section on discretionary calories.
Comments	September 27, 2004 HHS Office of Disease Prevention and Health Promotion %Kathryn McMurry Office of Public Health and Science Suite LL 100 1101 Wootton Parkway Rockville, MD 20852 Dear Secretaries Veneman and Thompson: Thank you for this opportunity to provide my own opinion about the Revised Guidelines for Americans. I appreciate your concern and desire to gain feedback from the people whom the guidelines will apply to. I hope others will take the time to read through and comment on the guidelines as well. Most of the information provided in the document seemed to be an affirmation of what many people who visit a doctor already know or at least have heard about before. There was one section in particular that caught my attention, the section titled "Control Calorie Intake to Manage Body Weight." In it, you state "When it comes to weight control, calories do count- not the proportions of carbohydrate, fat, and protein in the diet. Calories expended must equal energy consumed to stay at the same weight. A deficit could be achieve by eating less, being more active physically, or combing the two." I completely agree with this statement. This, however, is a fact that many people who are dieting tend to overlook. People see "Low Fat" or "Low Carb" on a lable and automatically think that it is good for them and they may eat large portions because it is light or low fat. Calories definitely do count! A person must take in fewer calories than they expend in order to lose weight. Portion control is a big problem in the lives of many people, which partly comes for the thinking that low fat or low carb gives them free reign to eat however much they want, regardless of calories, which simply is not the case. In order to successfully lose and maintain weight loss, a person must carefully watch calories and exercise daily, both of which are stated in this document. I would like to thank you again for asking for feedback. I appreciate the opportunity to share my thoughts. I wish you luck with your project and hope that everything goes well. Thank you again. Sincerely, Amy VanDeWielle 224 N. Meeks Ave. Muncie, IN 47303
Submission Date	9/27/2004 11:47:00 AM
Author

Summary	NFPA recommends that the Departments approach the concept of “discretionary calories” cautiously.
Comments	NFPA recommends that the Departments approach the concept of “discretionary calories” cautiously. We note that the report reflects some contradictory recommendations on this subject – the physical activity recommendations encourage increased activity, yet the “discretionary calorie” recommendations reflect only needs of sedentary individuals. This concept must be evaluated carefully with consumers to avoid interpretation as calorie permissiveness. “Discretionary calories” must be communicated with great care, if at all.
Submission Date	9/21/2004
Author	National Food Processors Association

Summary	The issue of discretionary calories and how to effectively communicate it to consumers will be a difficult problem to deal with when composing the Dietary Guidelines, and in the future, the food Guide Pyramid.
Comments	The issue of discretionary calories and how to effectively communicate it to consumers will be a difficult problem to deal with when composing the Dietary Guidelines, and in the future, the food Guide Pyramid. We are concerned that the concept will be confusing to consumers, especially when it seems to restrict foods that provide many nutrients, such as whole milk. If this seen as a punishment for an individual’s weight or inactivity, consumers could tune out this detail, along with the entire positive message of the Dietary Guidelines.
Submission Date	9/21/2004
Author	International Dairy Foods Association

Summary	The upcoming edition of the Dietary Guidelines should emphasize the Committee’s conclusion that calorie intake, not macronutrient composition, is the critical factor for managing weight. We believe the concepts of discretionary and essential calories will be difficult to communicate to consumers. T
Comments	General Mills appreciates the Committee’s focus on weight management throughout the report and commends the committee for promoting science-based approaches such as increasing intake of whole grains, fruits and vegetables. The scientific evidence supporting these strategies will continue to grow as more emphasis is placed on the health benefits of these foods. The upcoming edition of the Dietary Guidelines should also emphasize the Advisory Committee’s conclusion that calorie intake, not macronutrient composition, is the critical factor for weight maintenance/weight loss. This message enables consumers to select foods from all food groups, thus contributing to a more balanced intake of nutrients. We believe that consumer testing will be critical to determine how best to communicate and motivate consumers about the importance of calories. General Mills is concerned about the consumer appropriateness of the concepts of discretionary and essential calories. We believe that it will be difficult to communicate these concepts to consumers without stigmatizing foods that have been part of the American diet for many years. The strong emphasis on limiting foods with fat and added sugar reduces flexibility in diet planning and may not lead to improved nutrient intakes. As mentioned in the report, research shows that individuals who consume a moderate amount of added sugar (5-10% of calories) have higher intakes of certain micronutrients than those who consume fewer calories from added sugar. This may be because added sugar (and fat) can improve the palatability of many nutrient-rich foods. The Dietary Guidelines should aim to communicate that all foods can fit into a diet rather than reinforcing “good food/bad food” messages. This is an ideal opportunity to educate consumers about the importance of portion size and calorie content when making food choices. General Mills commends the Advisory Committee for reviewing relevant scientific literature and developing physical activity recommendations for adults and children. We strongly believe that a guideline for physical activity should be included in the upcoming Dietary Guidelines. Scientific studies show that physical activity and appropriate food choices form the foundation of a healthy lifestyle. Balancing energy intake and energy expenditure is increasingly important given the high prevalence of overweight/obesity and other associated health conditions and chronic diseases in the US. Developing consumer messages related to energy balance, however, will likely be a significant challenge. Nevertheless, we encourage the Communications Committee to commit to this endeavor since meaningful, motivational messages about the relationship between “calories in” and “calories out” have great potential to improve the health of Americans.
Submission Date	9/27/2004
Author	General Mills

Summary	The Association acknowledges that advising the American public on the importance of achieving nutrient adequate diets is a very central consideration for Federal nutrition policy recommendations. We agree wholeheartedly that individuals should strive to meet their nutritional requirements within the
Comments	The Association acknowledges that advising the American public on the importance of achieving nutrient adequate diets is a very central consideration for Federal nutrition policy recommendations. We agree wholeheartedly that individuals should strive to meet their nutritional requirements within their particular energy needs. We disagree, however, that nutrient adequacy can be achieved by following extremely restrictive and complicated meal patterns that fundamentally require individuals to exclude calories from individual macronutrients. The concept of discretionary calories is impractical because people don’t eat individual nutrients or calories, they eat foods. While certain foods could be considered “discretionary foods” whose intakes depend on an individual’s energy needs, the premise that all sugars are simply discretionary calories is flawed. For example, a candy bar may have fewer grams of sugars than a nutrient-rich yogurt. To eat within the discretionary calorie intake limits for sugars proposed by the Committee appears to be based totally on the supposition that sugars are an expendable ingredient in all foods. In order to meet this stringent advice for sugars intake, one would have to almost exclusively consume many nutrient-rich foods, such as cereals, yogurt and even peanut butter, that are sweetened only with artificial sweeteners. This could have unforeseen consequences, especially for children. Suggestions to designate added sugars as discretionary calories does not help average consumers make informed food choices, and may direct them to foods that may have fewer sugars but not fewer calories. The meal patterns developed by the USDA Center for Nutrition Policy and Promotion for revising the Food Guide Pyramid (Pyramid) are the mathematical calculations the Committee used for its suggested intake levels of discretionary calories for sugars. It is critical to reiterate that these meal patterns are based on mathematical formulas, not on scientific consensus of negative health impact from sugars intake. The mathematical model used to develop these meal patterns is established on attaining only the highest recommended micronutrient intakes (detailed explanation in section on added sugars and micronutrient displacement) without the benefits of our fortified and enriched food supply. Therefore, in order to consume the required upper levels of micronutrients, caloric intake is unnecessarily inflated. One consequence is sugars calories are artificially restricted. Furthermore, the Association would like to suggest that the current undue emphasis on upper intake amounts as the standard for defining micronutrient adequacy is inadequate for nutrition advice, and such food guidance policy may not achieve the primary goal of better overall health for the US public. In a recent review article, Dr. Cutberto Garza wrote about the importance of considering micronutrient toxicity in the development of revised dietary reference intakes. “It was clear that scientific, healthcare practitioners and consumer communities had moved beyond focused interest in the prevention of classical nutrient deficiencies.” “Related to this consideration was an appreciation of the unprecedented ability to manipulate nutrient intakes over wide ranges by increasingly common voluntary fortification of foods, increasing and expanding uses of nutrient supplements and nutrient-related botanicals, and the growing likelihood of expanded capabilities to alter the nutritional characteristics of food crops and animals by genetic modification. These on-going and anticipated changes in food supply raised concerns regarding the evidence base justifying the putative benefits of intake levels higher than necessary to prevent classical deficiency diseases and to possibilities of more easily reaching toxic levels of nutrients in diets easily accessible to the public.” (Emphasis Added) The Association would like to emphasize its strongly held position. The Pyramid’s mathematical model lacks the scientific underpinning to be used as the basis to make official or unofficial quantitative recommendations for levels of added sugars intake. This is also the conclusion of the American Dietetic Association (ADA) in its revised position paper on nutritive and non-nutritive sweeteners. After providing a detailed description of the paradigm of the Pyramid, ADA concluded, “Thus, the suggestion of 6% to 10% of energy from added sugars was not based on any scientific evidence regarding health impacts but was calculated using the Food Guide Pyramid.” Therefore, we ask the Agencies to re-evaluate the practical implications, as well as the scientific basis, for promoting the concept of discretionary calories based solely on the Pyramid’s proposed meal patterns in issuing guidelines for sugars intake.
Submission Date	9/27/2004
Author	Sugar Association

Energy Balance/Weight Management

Weight loss

Summary	How does one determine an accurate daily calorie need based on their height, weight, age, activity and metabolic rate?
Comments	How does one determine an accurate daily calorie need based on height, weight, age, activity and metabolic rate? If one knows exactly what their need is then they can decrease calories and increase activity according to the guidelines.
Submission Date	8/27/2004 1:18:00 PM
Author	Anonymous

Weight maintenance

Summary	The USDA and the Dietary Guidelines Advisory Committee only need to confirm the Mayo Clinic food pyramid.
Comments	The Mayo Clinic's Weight Pyramid is already the best food pyramid design.
Submission Date	8/29/2004 1:54:00 PM
Author	from Albuquerque, NM

Summary	Based on about five years' of personal experience, I recommend that your panel consider the blood type diet developed by Dr. Peter D'Adamo and described in his book, "Eat Right 4 Your Type."
Comments	Based on about five years' of personal experience, I recommend that your panel consider the blood type diet developed by Dr. Peter D'Adamo and described in his book, "Eat Right 4 Your Type." I have found his system, which keys dietary recommendations to one's blood type, to be instrumental in strengthening my immune system and maintaining a healthy weight and cholesterol levels. Since going on the diet, my productivity at work is much higher, I recover from minor illnesses more rapidly, and sick days are almost nonexistent. Dr D'Adamo has summarized extensive clinical and research experience that conclusively demonstrates the efficacy of this system.
Submission Date	9/1/2004 9:32:00 AM
Author	Anonymous

Energy density

Summary	In closing, we would like to point out that avocados are included in dietary programs from many of the world’s leading nutrition organizations including.
Comments	Control calorie intake to manage body weight. As a nutrient-rich food, substituting avocados for nutrient-poor foods helps achieve recommended nutrient intake without excess calories.
Submission Date	9/17/2004 5:25:00 PM
Author	California Avocado Commission

Summary	Avocados are a natural source of eight vitamins, two minerals and at least three phytochemicals. Avocados are included in dietary programs from many of the world’s leading nutrition organizations and can make a significant contribution to the health of Americans.
Comments	One of the 9 key messages is: Consume a variety of foods within and among the basic food groups while staying within energy needs. Avocados are a naturally nutrient-dense fruit that can help Americans increase their intake of carotenoids, vitamins E and C, magnesium, potassium, and fiber. As the top-ranking fruit source for folate, avocados can help adolescent females and women of childbearing age meet their needs for folic acid.
Submission Date	9/17/2004 5:48:00 PM
Author	California Avocado Commission

Summary	In closing, we would like to point out that avocados are included in dietary programs from many of the world’s leading nutrition organizations including.
Comments	Control calorie intake to manage body weight. As a nutrient-rich food, substituting avocados for nutrient-poor foods helps achieve recommended nutrient intake without excess calories.
Submission Date	9/17/2004 6:07:00 PM
Author	California Avocado Commission

Portion Sizes

Summary	Simpler portion measurement.
Comments	Portion size should be described in a simpler format, other than use of measuring tools. Example: A serving size of protein is equal to the size of your palm.
Submission Date	9/19/2004 12:01:00 PM
Author	Seton Hill University

Summary	Simpler portion measurement.
Comments	Portion size should be described in a simpler format, other than use of measuring tools. Example: A serving size of protein is equal to the size of your palm.
Submission Date	9/19/2004 12:03:00 PM
Author	from Greensburg, PA

Weight maintenance

Summary	Please consider revising the Nutrition Facts label to reflect any decreases in recommended total calories for the day. 1800 might be a better level for the daily values to reflect. Thank you.
Comments	Recommended calories and other nutrients are listed in table format by age and gender. Just wondering if the Nutrition Facts Label will reflect different total calories. (Currently labels lists 2000 and 2500 calories; and % daily value is based on 2000 calories a day)
Submission Date	9/21/2004 3:58:00 PM
Author	Anonymous

Summary
Comments	I submit the following 2005 Dietary Guidelines concerns for consideration by the expert committee. It has been my experience when working with patients as well as their care providers that little is understood about the recommended energy requirements. Physicians refer patient to Weight Watchers simply because of availability and it seems any prgram is preferred to no program. I realize you are well aware of the pit falls of weight cycling. Please consider stressing the importance of adequate calories to address those who cut below recommendations in the hope for a rapid weight loss. All the guidelines about adequate carbs but not too many, and the restrictions on fat etc. are great but we skip over education and recommendation on adequate caloreis. I believe the studies by Ancel Keyes from the U of Minnesota should alert us to the probelm with undernutirion and starvation effects. We see so much that addressed overeating and I beleive we can create a positive psychological effect by stressing the importance of getting enough calories. I still see recommendations for 500- 1200 calories orderd by physician. Thank you for your consideration and all the work you do on behalf of the guidelines.
Submission Date	9/22/2004 10:43:00 AM
Author	from Fargo , ND

Summary	Suggest retuning to "aim for a healthy weight" and omit the use of the word "control." It carries too many negative connotations if the "control intake" guidleline is not met.
Comments	Suggest not using the word “control.” The word “control” tends to set people up for failure- uncontrolled. Suggest changing back to “aim for a healthy weight” & not use “control intake-” when people loose weight, but are unable to reach/maintain a specific weight- adding in the term control will set them up for continued failure. It denotes that they are unable to “gain control” of their lives (out of control) and thus, they must deal with the consequences.
Submission Date	9/23/2004 11:59:00 AM
Author	OSU Extension Program- Cleveland, OH

Summary	PBH supports the emphasis on nutrient density and the unique role of fruits and vegetables in weight management. We hope that this important concept will be better communicated to consumers.
Comments	PBH supports the emphasis on nutrient density and the unique role of fruits and vegetables in weight management. We hope that this important concept will be better communicated to consumers and that more specific examples of substituting fruits and vegetable for energy dense-nutrient poor food choices are provided. PBH would welcome the opportunity to help expand Table E-9: Ways to Increase Consumption of Fruits and Vegetables, by providing actionable ways that consumers can increase the variety of fruits and vegetables especially dark green and orange ones, such as through the successful PBH Color Way Campaign and hope it can be included in the consumer document. Simple, positive and specific examples of how to incorporate more fruits and vegetables into the diet will be welcome by consumers who are constantly reminded of what they should NOT eat. Emphasizing a more positive message including the need for consumers to “SWITCH” to more nutrient-rich, and low calorie fruits and vegetables, will also help consumers meet the higher fruit and vegetable recommendations.
Submission Date	9/24/2004 1:23:00 PM
Author	Produce for Better Health Foundation

Summary	The Council urges HHS to include statements in the 2005 Dietary Guidelines acknowledging that intense sweeteners are low in calories and the usefulness of reduced calorie products containing them, as well as fat-free and low-fat products that are also reduced in calories.
Comments	September 24, 2004 Kathryn McMurray HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science Suite LL100 1101 Wootton Parkway Rockville, MD 20852 RE: 2005 Dietary Guidelines for Americans Dear Ms. McMurray: The Calorie Control Council (the “Council”) is an international association of manufacturers of low-calorie, light, and special dietary foods and beverages, including the manufacturers of a variety of sweeteners, fat replacers and other low-calorie ingredients used in these foods. The Council commends the 2005 Dietary Guidelines Advisory Committee for its diligence and comprehensive report. The Council, is concerned, however, that the report made no mention of the safe and appropriate use of sugar substitutes and fat replacers. The Council urges HHS to include statements in the 2005 Dietary Guidelines acknowledging that intense sweeteners are low in calories and the usefulness of reduced calorie products containing them, as well as fat-free and low-fat products that are also reduced in calories. For example, the 2000 Dietary Guidelines did acknowledge the role of sugar substitutes stating: “Sugar substitutes, such as saccharin, aspartame, acesulfame potassium, and sucralose are extremely low in calories. Some people find them useful if they want a sweet taste without the calories. Some foods that contain sugar substitutes, however, still have calories. Unless you reduce the total calories you eat or increase your physical activity, using sugar substitutes will not cause you to lose weight.” The consumer, as well as the food and beverage industry, is fortunate to now have five low-calorie sweeteners (the four mentioned above plus neotame) and several reduced calorie sweeteners and fat replacers from which to choose. This variety of low-calorie ingredients allows the calorie control industry to use the ingredient, or combination of ingredients, best suited for a given product. According to the Council’s 2004 Light Products Survey, 198 million adult Americans use light products, i.e., low-calorie, sugar free and/or reduced fat products. More than eight out of ten of these consumers say they want additional light products from which to choose. Low-calorie sweeteners, fat replacers and the reduced-calorie products containing them provide good taste without the calories of their full calorie counterparts. Studies demonstrate, for example, that when sucrose is covertly replaced with low-calorie sweeteners non-dieting obese and normal weight individuals incompletely compensate for the calorie reduction. In other words, they eat fewer calories. Importantly, it has been demonstrated that multidisciplinary weight control programs that include the use of reduced-calorie foods and beverages may facilitate weight loss and weight maintenance. The Advisory Committee cites one (Raben et al., 2002) of the number of studies, which demonstrate that reduced calorie products may be useful in weight control and weight maintenance. In its 2004 updated position paper, “Use of Nutritive and Nonnutritive Sweeteners,” the American Dietetic Association concludes that “High-intensity sweeteners can offer consumers a way to enjoy the taste of sweetness with little or no energy and or glycemic response. Nonnutritive sweeteners may assist in weight management, control of blood glucose, and prevention of dental caries.” The Calorie Control Council urges HHS to reconfirm the safe and appropriate use of FDA approved low-calorie sweeteners and fat replacers and state that the use of reduced-calorie foods in place of their full calorie counterparts can assist in weight management efforts. The Council would be pleased to provide additional information upon request. Respectfully submitted, Lyn O’Brien Nabors Lyn O’Brien Nabors Executive Vice President
Submission Date	9/24/2004 4:27:00 PM
Author	Calorie Control Council

Weight loss

Summary	Leading health organizations promote the benefits of citrus, including the American Heart Association, American Cancer Society, the National Cancer Institute and the Produce for Better Health Foundation.
Comments	One of the key messages is: Control calorie intake to manage body weight. As a nutrient-rich food, substituting citrus fruits for nutrient-poor foods helps achieve recommended nutrient intake without excess calories. One medium-size orange contains just 80 calories and has been shown to suppress hunger levels for up to four hours after eating . New research from the Nutrition and Metabolic Research Center at Scripps Clinic shows that consuming half of a fresh grapefruit before meals can result in significant weight loss.
Submission Date	9/24/2004 5:18:00 PM
Author	Sunkist Nutrition Bureau

Energy density

Summary	In summray, I think the term "low fat soups" should be omitted. Soups provide the consumer with a higher sodium content and a low satiety value. I would replace that area and sugges the consumer choose, whole raw fruits and vegetables, dairy products, or whole grains.
Comments	I would like to comment, however, on the area in the executive summary titled: Control Calorie Intake to Manage Body Weight. In the summary it states, “consuming large portions of raw vegetables or low fat soups may help limit one’s intake of other foods that are more energy dense.” I feel that this is strongly misleading, contradictory to other sections of the document, and most notably, false. Indeed, the part about consuming raw vegetables is true and important. However, I do not agree with the “low fat soup” comment. For an average American, the word soup immediately causes the consumer to think of a can of soup. Canned goods are generally higher in sodium content, and a simple can of condensed chicken noodle soup contains 175 calories, 4.5 g of fat and 890mg of sodium. While the soup is low-fat, it is not low sodium. Throughout the summary, there is consistent talk of reducing sodium in the diet, and this is surely not the best advice on limiting sodium or controlling caloric intake. The soup is a made up mostly of liquid content. This is not effective in providing a high satiety value. The consumer will most likely eat the soup and be hungry within an hour due to the lack of satiety. I recommend altering this section of the document and offer consumption of raw fruits and vegetables or a serving of a dairy product or whole grain product. By stating these choices instead, the consumer will ingest more essential vitamins and minerals and they will be eating foods that certainly provide a higher satiety value than a can of condensed soup. In turn, the consumer’s caloric intake will be lowered due to consuming foods that keep one fuller for a longer period of time and avoid excessive snacking or excessive portions at meal time.
Submission Date	9/26/2004 11:49:00 PM
Author	from Muncie , IN

Weight maintenance

Summary	We feel that people need to adjust to be at the appropriate body weight.
Comments	We recommend that you change "Control Calorie Intake to Manage Body Weight" to "Adjust Calorie Intake to Manage Appropriate Body Weight."
Submission Date	9/27/2004 1:19:00 PM
Author	Volunteers of America

Summary	Please try to provide in the final draft specific exercise guidelines in 1. minutes/session 2. times/week 3. intensity for both children and adults.
Comments	Please try to provide in the final draft specific exercise guidelines in 1. minutes/session 2. times/week 3. intensity for both children and adults. There is conflicting information available to the public. I understand it is hard to provide a global recommendation for various needs such as weight maintenance, weight loss, and fitness. In CA we have an employees fitness program for WIC employees. I work with employees to keep the program going. I have found, the more specific the message the easier it is for folks to use. If anything, I find many people under exercise, both in time and intensity, and assume they are doing enough. There are many reasons for this, but time constraints and a culture of inactivity seem to influence many people's perception of adequate activity. I know this is not scientific, but it is what I see 'on the streets' out here working with people. Thank you.
Submission Date	9/27/2004 1:56:00 PM
Author	CA WIC Assn

Energy density