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Inside Peek Into the Making of the Dietary Guidelines for Americans
By Jessica Levings, MS, RDN

Have you even wondered what goes on behind the scenes in developing the Dietary Guidelines for Americans (DGA)? Today's Dietitian (TD) sits down with Kellie O. Casavale, PhD, RD, nutrition advisor in the office of disease prevention and health promotion at the US Department of Health and Human Services (HHS), to get a behind-the-scenes look into the development and future of the DGA.

TD: What was your involvement with the 2015–2020 DGA?

Casavale:
I was one of four coexecutive secretaries who led the process for the 2015 Dietary Guidelines Advisory Committee, and I supported HHS during the process and content development of the 2015–2020 Dietary Guidelines for Americans.

TD: How are the Dietary Guidelines developed?

Casavale: First, HHS and the US Department of Agriculture (USDA) release a Federal Register announcement seeking public nominations for advisory committee members. The advisory committee, after appointment by the HHS and USDA secretaries, develops research questions using the previous edition of the DGA as a starting point and then conducts a rigorous, systematic review of the current evidence on nutrition and medical science. From this evidence, they draw the recommendations comprising the Dietary Guidelines Advisory Report submitted to HHS and USDA. After the advisory report is submitted, HHS and USDA open a comment period for the public to weigh in on the advisory committee's findings. Finally, HHS and USDA consider the scientific evidence from the advisory report, public comments, and input from federal agency experts to develop the dietary guidelines policy document. Throughout the process, the emphasis is placed on science-based recommendations representing the total body of evidence.

TD: How has the dietary guidelines development process changed over the years?

Casavale:
The first few editions—1980, 1985, and 1990—were voluntary educational brochures intended for consumer use. The 1990 National Nutrition Monitoring and Related Research Act required HHS and USDA to jointly release an evidence-based report outlining nutrition and dietary information, and guidelines every five years. The act also charged an advisory committee with preparing technical reports advising the federal government on the status of the evidence on nutrition and health. The 1995 edition was the first edition that was a mandated policy document rather than a voluntary educational brochure, shifting the Dietary Guidelines' audience from consumers to health professionals and policy makers, who then use the recommendations to inform nutrition programs.

TD: How do topics that weren't in previous editions of the DGA, sustainability for example, end up as advisory committee research questions and subsequently, themes and recommendations in the advisory report?

Casavale: When the advisory committee is developing research questions, the members use their collective expertise to decide whether new topics should be included. Typically, these are topics in which the evidence has grown since the release of the last report.

TD: Since USDA and HHS jointly develop the guidelines, how are disagreements reconciled between the agencies about what should and shouldn't be included?  

Casavale: USDA and HHS go through great lengths to ensure that the final DGA represent a consensus from all of the federal agencies that work on food and nutrition. The process of reaching this consensus involves extensive review by federal subject matter experts and culminates in the review and approval of each edition by the secretaries of USDA and HHS.

TD: How is the advisory committee involved in changes that are made when the advisory committee's report is submitted to HHS and USDA and when the dietary guidelines policy document is published?

Casavale: Under the Federal Advisory Committee Act, advisory committees are not permitted to write policy documents. After the advisory committee submits the advisory report to the federal government, the work of the advisory committee is complete.

TD: Sustainability and the recommendation to eat less red and processed meat were both themes of the advisory committee report yet absent from the final DGA recommendations. Why?

Casavale:
HHS and USDA determined that sustainability fell outside the scope of the dietary guidelines mandate to provide "nutritional and dietary information and guidelines." The recommended amounts and types of foods that are included in the 2015–2020 edition of the dietary guidelines are the same as what the advisory committee recommended. There was a lot of media coverage that inaccurately stated that the dietary guidelines didn't carry forward some of the advisory committee's recommendations, especially around meat consumption. In fact, the dietary guidelines included the advisory committee's evidence statements about meat and included the three eating patterns from the advisory committee's report. All the eating patterns in the dietary guidelines recommend lower amounts of meat, poultry, and eggs than what is currently consumed on average by most Americans. This inaccuracy in the media coverage reflects a common misunderstanding about the difference between the advisory report summarizing the evidence and the dietary guidelines, which translate that evidence into actionable recommendations.

TD: What is different about these guidelines compared with years past?

Casavale:
We now know more about how the components of a healthful eating pattern fit together into overall healthful eating patterns. This was the first edition that really took a comprehensive look at the evidence linking healthful eating patterns to health outcomes because the evidence base for healthful eating patterns had grown to the point where it was possible to do systematic reviews of the literature. What we know now is that a healthful eating pattern is more than the sum of its parts and may be more predictive of overall health and disease risk than individual foods or nutrients.

TD: What new things might we expect in the next version of the guidelines?

Casavale:
A federal law was passed in 2014 specifying that comprehensive guidance for infants and toddlers from birth to 24 months and pregnant women now be included. By 2020, the dietary guidelines also will provide guidance for these important populations.

TD: HHS recently released several tools and resources for public health practitioners. How can dietitians use these tools and resources to better educate their clients about the dietary guidelines?

Casavale:
We have great resources designed to meet the needs of busy professionals that dietitians can use to help start conversations about how to follow a healthful eating pattern. Dietaryguidelines.gov has patient handouts explaining how to make healthful shifts and cut down on added sugars, and tips to help consumers make small changes over time. Also, the dietary guidelines and related materials are in the public domain so anyone can adapt the information for their own use, including use of the images. For more information, including a turn-key Dietary Guidelines Presentation for Professionals, visit: https://health.gov/dietaryguidelines/2015/resources.asp.

TD: For dietitians who have limited time with clients, what are the key messages they should be sharing about the dietary guidelines?

Casavale:
If there's one thing that I would recommend dietitians focus on when working with clients, it would be to help clients understand how to follow a healthful eating pattern. Dietitians can work with clients to develop recommendations for following a healthful eating pattern that works for their personal tastes and cultural preferences. Dietitians also can help clients understand that healthful eating is about making healthful choices over time and that every meal is an opportunity to make a healthful choice. People can work toward a healthful eating pattern by making healthful choices whenever they can.

— Jessica Levings, MS, RDN, is a freelance writer and owns Balanced Pantry, a consulting business helping companies develop and modify food labels, conduct recipe analyses, and create nutrition communications materials. Learn more at www.balancedpantry.com, on Twitter @balancedpantry, and Facebook.com/Balancedpantry1.

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