Barbara Schneeman

An emerging paradigm in public health focuses on enhancing nutrition in existing food staples to reduce chronic disease at the population scale, rather than relying on individuals to change their behavior. This paradigm leverages plant and animal breeding, production practices, and processing to enhance nutrition, whereby foods consumed by millions can be improved at low incremental cost. This article supports and operationalizes this paradigm, illustrating the potential to improve diets through a case study that increases the arabinoxylan fiber content of commodity wheat through classical plant breeding (a non-GMO technology). The approach described in this article proposes to link agricultural and food science with health system implementation to deliver equitable access, improved healthcare outcomes and cost savings, and improved community health. Based on published dose–response relationships, comparative risk modeling indicates that modest fiber increases achieved by the commodity wheat breeding led to reduced population-level risks of 1–3% for cardiovascular disease, 3–4.5% for type 2 diabetes, and 1–3.5% for colorectal cancer, translating into substantial healthcare cost savings when implemented at a national scale. This article outlines possible low-risk pathways for implementing these nutrition increases at the population scale through commodity supply chains and community-level nutrition improvement efforts and evaluates the ranges of potential population-level impacts.

The National Academy of Sciences, Engineering, and Medicine (NASEM) recommended steps to redesign the process of developing the Dietary Guidelines for Americans (DGA) are based on 5 guiding principles (enhance transparency; promote diversity of expertise and experience; support a deliberative process; manage biases and conflicts of interest; and adopt state-of-the-art processes and methods). Using these principles and recommendations, the USDA and HHS updated the process for developing the 2020-2025 Dietary Guidelines, including the process for appointing members and managing the work of the 2020 Dietary Guidelines Advisory Committee. Modifications included having public comment on the topics and questions to be addressed by the Federal Advisory Committee, reviewing professional and financial activities on potential appointees to the committee prior to their appointment, redesigning the website to provide status updates on the work of the committee as analytical frameworks and draft conclusions were developed, strengthening the approaches for conducting systematic reviews, and adding a public meeting for discussion of the final report before its submission to the Secretaries of the USDA and HHS. Because the DGA is reviewed and updated every 5 y, it is possible to learn from each cycle what works well and where improvements in the process can be implemented. The current article illustrates, from the perspective of the advisory committee, the impact of the NASEM report on the development of the scientific report by examining changes in the process consistent with the 5 principles.

Nutrition labeling encompasses nutrient declaration, supplemental nutrient information such as interpretative nutrition information on the principal display panel or front-of-pack labeling, and nutrition-related claims used to promote the nutritional properties of packaged foods. These types of labeling are inter-related. In many countries, nutrient declaration is mandatory for most packaged foods and used to inform consumers at the point of purchase to help them make more informed food choices. Supplemental nutrition information on the principal display panel is designed to assist consumers in the interpretation of nutrition information. The use of nutrition-related claims should be regulated to have consistency in what is allowed and avoid claims from being false or misleading. Nutrition labeling should be based on public health priorities and be designed to enable consumers to compare products and judge if a product is high or low in a declared nutrient in the context of the daily diet. Supplemental nutrition labeling can have various purposes and research is needed to validate that it is effective for the intended purpose with the target audience. The presence of standardized nutrition labeling on packaged foods enables the development of education strategies for consumer use of the information. Education is a key component for labeling strategies to be effective.

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Dietary Fats and Seafood Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between seafood consumption during childhood and adolescence (up to 18 years of age) and neurocognitive development? Developmental domains: Cognitive development: Insufficient evidence is available to determine whether there is a favorable relationship between seafood intake during childhood and adolescence and measures of cognitive development in children and adolescents. However, no unfavorable relationships were found between seafood consumption during childhood and adolescence and measures of cognitive development. (Grade: Grade not assignable). Language and communication development: Insufficient evidence is available to determine whether there is a favorable relationship between seafood intake during childhood and adolescence and measures of language and communication development in children and adolescents. However, no unfavorable relationships were found between seafood consumption during childhood and adolescence and measures of language and communication development. (Grade: Grade not assignable). Movement and physical development: Insufficient evidence is available to determine the relationship between seafood intake during childhood and movement and physical development in children. (Grade: Grade not assignable). Social-emotional and behavioral development: Insufficient evidence is available to determine the relationship between seafood intake during childhood and adolescence and social-emotional and behavioral development in children and adolescents. (Grade: Grade not assignable). Attention deficit disorder and Attention-deficit/hyperactivity disorder: Insufficient evidence is available to determine the relationship between seafood consumption during childhood and adolescence and attention deficit disorder or attention-deficit/hyperactivity disorder-like traits or behaviors. (Grade: Grade not assignable). Autism spectrum disorder: No evidence is available to determine the relationship between seafood intake during childhood and adolescence and autism spectrum disorder-like traits or behaviors or autism spectrum disorder diagnosis. (Grade: Grade not assignable). Academic performance: Insufficient evidence is available to determine the relationship between seafood intake during adolescence and academic performance in adolescents. (Grade: Grade not assignable). Anxiety and Depression: Insufficient evidence is available to determine the relationship between seafood consumption during childhood and adolescence and anxiety and depression. (Grade: Grade not assignable). A literature search was conducted using four databases (i.e., PubMed, Cochrane, Embase, and CINAHL) to identify published literature that evaluated the intervention or exposure of seafood consumption during childhood and adolescence and the outcome of neurocognitive development. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two NESR analysts independently for inclusion based on pre-determined criteria. Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The Committee qualitatively synthesized the body of evidence to inform development of conclusion statements, and graded the strength of evidence using pre-established criteria for risk of bias, consistency, directness, precision, and generalizability. This review includes 13 articles, six articles from three randomized controlled trials (RCTs) and seven articles from six prospective cohort studies (PCSs), published between January 2000 and October 2019. The 2020 Dietary Guidelines Advisory Committee used the following seafood definition: marine animals that live in the sea and in freshwater lakes and rivers. Seafood includes fish (e.g., salmon, tuna, trout, and tilapia) and shellfish (e.g., shrimp, crab, and oysters). The majority of studies addressed developmental domains – cognitive development (seven articles), language and communication development (five articles), movement and physical development (two articles), and social-emotional and behavioral development (three articles). No conclusion regarding the relationship between seafood intake during childhood and adolescence and developmental domains could be drawn due to an inadequate number of studies, inconsistency in results, risk of bias in classification of exposures, and heterogeneity of outcome assessments. ○. Seafood intake during childhood and adolescence had a predominantly beneficial or null relationship across all domains, and had a few detrimental relationships, primarily in social-emotional and behavioral development. ■. Results from three RCTs found that three fatty fish meals per week (~50-80 grams per meal) compared to meat meals for 12 weeks in adolescents or 16 weeks in children had a predominantly null effect on developmental domain outcomes. ■. Results from three PCSs generally found a beneficial association between fish intake in children and adolescents and developmental domains. ○. The vast majority of analyses showed no detrimental relationship between seafood intake during childhood and adolescence and cognitive, language and communication, and movement and physical development. No conclusion regarding the relationship between seafood consumption during childhood and adolescence and academic performance, attention deficit disorder (ADD) or attention-deficit/hyperactivity disorder...

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Dietary Fats and Seafood Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between seafood consumption during pregnancy and lactation and neurocognitive development in the child? Seafood intake during pregnancy Developmental domains: Moderate evidence indicates that seafood intake during pregnancy is associated favorably with measures of cognitive development in young children. (Grade: Moderate). Limited evidence suggests that seafood intake during pregnancy may be associated favorably with measures of language and communication development in the child. (Grade: Limited). Insufficient evidence is available to determine the relationship between seafood intake during pregnancy and movement and physical development in the child. (Grade: Grade not assignable). Insufficient evidence is available to determine the relationship between seafood intake during pregnancy and social-emotional and behavioral development in the child. (Grade: Grade not assignable). Attention deficit disorder or attention-deficit/hyperactivity disorder-like traits or behaviors: Insufficient evidence is available to determine the relationship between seafood consumption during pregnancy and attention deficit disorder or attention-deficit/hyperactivity disorder-like traits or behaviors in the child. (Grade: Grade not assignable). Attention deficit disorder or attention-deficit/hyperactivity disorder diagnosis: No evidence is available to determine the relationship between seafood consumption during pregnancy and diagnosis of attention deficit disorder or attention-deficit/hyperactivity disorder in the child. (Grade: Grade not assignable). Autism spectrum disorder: Insufficient evidence is available to determine the relationship between seafood consumption during pregnancy and autism spectrum disorder-like traits or behaviors or autism spectrum disorder diagnosis in the child. (Grade: Grade not assignable). Academic performance: No evidence is available to determine the relationship between seafood intake during pregnancy and academic performance in the child. (Grade: Grade not assignable). Anxiety: No evidence is available to determine the relationship between seafood intake during pregnancy and anxiety in the child. (Grade: Grade not assignable). Depression: No evidence is available to determine the relationship between seafood intake during pregnancy and depression in the child. (Grade: Grade not assignable). Seafood intake during lactation: No evidence is available to determine the relationship between maternal seafood intake during lactation and neurocognitive development in the child. (Grade: Grade not assignable). A literature search was conducted using 4 databases (PubMed, Cochrane, Embase and CINAHL) to identify articles that evaluated the intervention or exposure of seafood consumption during pregnancy and lactation and the outcomes of neurocognitive development. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two NESR analysts independently for inclusion based on pre-determined criteria. Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The Committee qualitatively synthesized the body of evidence to inform development of conclusion statements, and graded the strength of evidence using pre-established criteria for risk of bias, consistency, directness, precision, and generalizability. Seafood intake during pregnancy: This review included 26 articles from 18 prospective cohort studies (PCSs) published between January 2000 and October 2019. The 2020 Dietary Guidelines Advisory Committee used the following seafood definition: marine animals that live in the sea and in freshwater lakes and rivers. Seafood includes fish (e.g., salmon, tuna, trout, and tilapia) and shellfish (e.g., shrimp, crab, and oysters). Developmental domains: ○. Evidence from 21 articles from 15 PCSs indicated predominantly beneficial associations between seafood intake during pregnancy and measures of cognitive development, including milestone achievement and intelligence, particularly in young children. ○. Evidence from 15 articles from 12 PCSs suggested beneficial associations between seafood intake during pregnancy and measures of language and communication development. However, results were less consistent than for cognitive development. Furthermore, 8 articles assessed measures of verbal intelligence or verbal intelligence quotient (IQ), which may be less specific assessments of language and communication development. ○. Few detrimental associations between seafood intake during pregnancy and measures of child cognitive or language development were found. ○. Heterogeneity in exposure and assessment methods, and ages of children at follow-up, made it difficult to determine a relationship between seafood intake during pregnancy and movement and physical development or social-emotional and behavioral development. Four articles, from 3 PCSs, found inconsistent results when examining the relationship between seafood intake during pregnancy and attention deficit disorder (ADD)-like or attention-deficit/hyperactivity disorder (ADHD)-like traits or behaviors in the child, with studies reporting either null or protective associations. Three PCSs assessed autism spectrum disorder (ASD)-like traits or behaviors or ASD diagnosis but heterogeneity in outcome assessment methods and child age across the 3 PCSs made it difficult to...

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Beverages and Added Sugars Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between alcohol consumption and all-cause mortality? Primary comparisons (among those who currently drink alcohol): ○. Moderate evidence indicates that higher average alcohol consumption is associated with an increased risk of all-cause mortality compared with lower average alcohol consumption among those who drink. (Grade: Moderate). ○. Moderate evidence indicates that binge drinking (consuming 5 or more drinks for men or 4 or more drinks for women during a drinking occasion) is associated with increased risk of all-cause mortality, and that more frequent binge drinking is associated with increased risk of all-cause mortality compared with less frequent or no binge drinking among those who drink. (Grade: Moderate). Secondary comparison (between those who currently drink alcohol and those who have never consumed alcohol): ○. Limited evidence suggests that low average alcohol consumption, particularly without binge drinking, is associated with a lower risk of all-cause mortality compared with never drinking alcohol. However, in light of the many scientific and public health issues associated with alcoholic beverages, any conclusions about low average consumption compared to never drinking alcohol require careful consideration. (Grade: Limited). A literature search was conducted using 3 databases (PubMed, Cochrane, and Embase) to identify articles that evaluated the intervention or exposure of alcohol consumption and the outcome of all-cause mortality. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two NESR analysts independently for inclusion based on pre-determined criteria. Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The Committee qualitatively synthesized the body of evidence to inform development of a conclusion statement(s), and graded the strength of evidence using pre-established criteria for risk of bias, consistency, directness, precision, and generalizability. Sixty studies that met the inclusion criteria for this systematic review addressing alcohol consumption and all-cause mortality were identified through the literature search from January 2010 to March 2020. ○. The body of evidence included one Mendelian randomization study, one retrospective cohort study, and 58 prospective cohort studies. The evidence included no RCTs. Consistent evidence reported increased all-cause mortality among those with higher average volume of alcohol consumption compared to lower average alcohol consumption. Although consumption categories varied, among those who drank alcohol most studies found lower risk among men consuming within ranges up to 2 drinks per day and women consuming within ranges up to 1 drink per day compared to those consuming higher average amounts. Among studies assessing continuous distributions or based on dose-response relationships among narrower consumption ranges among men who drink, the lowest levels of risk were generally up to 1 or 1.5 drinks on average (depending on how consumption was categorized). Relatively few studies among women examined risk based on categories within the range of up to 1 drink per day on average. Consistent evidence among those who drink alcohol reported higher all-cause mortality with more frequent binge drinking (consuming 5 or more drinks for men or 4 or more drinks for women during a drinking occasion) compared with less frequent or no binge drinking. For the secondary comparison between current drinkers and never drinkers, the limited available evidence suggested that low average consumption was associated with lower risk of mortality compared with never drinking status. Included studies were a subset of the 60 studies above that were used to assess the primary comparisons of interest. Twenty-five studies compared those who consumed alcohol with never drinkers. Approximately half of the studies reported significant findings that low average alcohol consumption (particularly without binge drinking) was associated with reduced risk of all-cause mortality compared with never drinking alcohol, approximately half of the studies indicated no significant relationship, and two studies reported that low alcohol consumption was significantly associated with greater all-cause mortality compared to never drinking alcohol. Generally, the evidence was limited by inadequate adjustment for confounders, selection bias and limited generalizability (studies often included only middle- and older-aged adults), and potential misclassification or bias from an exposure assessment based on single-time measurements of alcohol consumption. Low average volume was classified variably. Because the studies provided no consistent definition or categorization of higher average or lower average consumption, these terms are used in a descriptive sense in the conclusion statement. However, across most studies definitions of binge drinking or levels that corresponded to binge drinking were generally consistent; thus binge drinking is defined based on a set number of drinks in the conclusion statement.

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Dietary Fats and Seafood Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between types of dietary fat consumed and risk of cardiovascular disease?

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Beverage and Added Sugars Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between beverage consumption and growth, size, body composition, and risk of overweight and obesity? Milk: ○. Limited evidence suggests that milk intake is not associated with adiposity in children. (Grade: Limited). ○. Insufficient evidence is available to draw a conclusion about the relationship between the type of milk (i.e., milk fat content, flavor) and adiposity in children. (Grade: Grade not assignable). ○. Limited evidence suggests that higher milk intake is associated with a greater increase in height compared to lower intake in children. (Grade: Limited). ○. Limited evidence suggests that milk intake is not associated with adiposity in adults. (Grade: Limited). 100% Juice: ○. Limited evidence suggests 100% juice intake in children is not associated with adiposity or height in children. (Grade: Limited). ○. Limited evidence suggests 100% juice consumption is not associated with measures of adiposity in adults. (Grade: Limited). Sugar-sweetened beverages: ○. Moderate evidence suggests that higher sugar-sweetened beverage intake is associated with greater adiposity in children. (Grade: Moderate). ○. Limited evidence suggests that higher sugar-sweetened beverage intake is associated with greater adiposity in adults. (Grade: Limited). ○. Insufficient evidence is available to determine the relationship between sugar-sweetened beverages compared with low- and no- calorie sweetened beverages on adiposity in children. (Grade: Grade not assignable). ○. Limited evidence suggests no association between sugar-sweetened beverages compared with low- and no- calorie sweetened beverages on adiposity in adults. (Grade: Limited). Low and no-calorie sweetened beverages: ○. Limited evidence suggests no association between low- and no-calorie sweetened beverage consumption and adiposity in children. (Grade: Limited). ○. Limited evidence suggests that low- and no- calorie sweetened beverage consumption is associated with reduced adiposity in adults. (Grade: Limited). A literature search was conducted using 3 databases (PubMed, Cochrane, Embase) to identify articles that evaluated the intervention or exposure of non-alcoholic beverage consumption and the outcomes of growth, size, body composition, and risk of overweight and obesity. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two NESR analysts independently for inclusion based on pre-determined criteria. Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The Committee qualitatively synthesized the body of evidence to inform development of a conclusion statement(s), and graded the strength of evidence using pre-established criteria for risk of bias, consistency, directness, precision, and generalizability. Milk: The body of evidence includes 62 papers: 30 papers on children and 32 papers on adults. Of the evidence on children, there were 4 papers from randomized controlled trials (RCTs) and 26 papers from longitudinal cohort studies. Of the evidence on adults, there were 7 papers from RCTs; 24 papers from prospective cohort studies; and 1 paper using a Mendelian Randomization design. To discern healthy growth from excessive growth in children, weight status (i.e., prevalence or incidence of overweight or obesity), BMI and BMI z-scores, and body composition measures (e.g., waist circumference and body fat), were considered to reflect “adiposity.”: ○. The majority of the findings for these outcomes were not significant. The few findings that were significant were not consistent in direction. To assess healthy growth in children, outcomes such as height and lean mass were considered. Four studies reported height as an outcome: 3 cohort studies reported a significant positive association between milk intake and height in children, and 1 RCT found no effect of milk intake on height compared to drinking water though this study’s duration was only 12 weeks. Seven cohort studies specifically examined types of milk (i.e. milk fat levels, flavored milk) and adiposity outcomes in children; however, the results were not consistent. The majority of the studies in adults found no significant association between milk intake and adiposity; there were some significant associations; however, these were inconsistent in direction. The body of evidence from children and adults has several significant limitations including lack of specificity and consistency in definition of the exposure, the use of non-validated methods for assessing beverage intake, uncontrolled confounding, and inconsistencies in findings. More research is needed to address these issues. 100% Juice: 42 papers examining the relationship between 100% juice intake and outcomes related to growth, size, body composition, and risk of overweight or obesity were included in this body of evidence. Studies published between January 2000 and June 2019 were synthesized by age group: ○. Children: 23 studies, including 1 RCT and 22 prospective cohort studies. ○. Adults: 19 studies, including 4 RCTs, 1 NRCT, and 14 prospective cohort studies. Evidence in children: ○. The 1 RCT and the majority of the higher quality prospective cohort studies found no statistically significant relationship between 100% juice intake and adiposity. ○. The few studies that were significant were not consistent in direction. ○. The evidence in children was limited by lack of clarity in defining the juice exposure; inconsistent quantification of juice consumption, inconsistent measures of adiposity, lack of evidence from stronger study designs, and inadequate adjustment for confounders. Evidence in adults: ○. The 4 RCTs and 1 NRCT found no statistically significant relationship between 100% juice intake and adiposity. ○. The prospective cohort studies found inconsistent evidence depending on the specific measure of adiposity. For example, roughly half of the studies (n=4) found that greater consumption of 100% juice intake was related to a greater increase in weight, while the others (n=3) found no significant relationship. Studies examining waist circumference were more consistent, with 5 of the 6 studies finding no significant association with 100% juice intake. Further, all studies (n=3) examining body fat or prevalence of (abdominal) obesity found no significant associations with 100% juice intake. ○. The evidence from the RCTs and NRCT were limited by the short durations small sample sizes. ○. The evidence from the prospect cohort studies were limited by the single measurement of the exposure, reliance on self-reported outcome data, inadequate adjustment for confounders, and limited generalizability of the experimental data. Sugar-sweetened beverages: 76 studies identified via a literature search from June 2012 to June 2019 were included in this systematic review. Studies were synthesized based on comparator (no/different amount of sugar-sweetened beverage or low/no-calorie sweetened beverage) and age of participants (children or adults). ○. Sugar-sweetened beverage (SSB) consumption compared to different amounts or water: ■. Children: 46 articles: RCTs: 2 articles. NRCTs: 1 article. Prospective cohort studies: 43 articles. ■. Adults: 27 articles: RCTs: 3 articles. NRCTs: 1 article. Prospective cohort studies: 23 articles. ○. Sugar-sweetened beverage consumption compared to low- or no-calorie sweetened beverages (LNCSB): ■. Children: 2 articles: RCTs: 2 articles. ■. Adults: 6 articles: RCTs: 5 articles. Prospective cohort studies: 1 article. In studies examining SSB intake in children, the majority of studies (~80%) reported a significant effect or association between SSB intake and adiposity, however this was not always consistent within studies that reported multiple outcome measures. There were additional concerns related to risk of bias and generalizability. In studies examining SSB intake in adults, the majority of studies (~70%) reported a significant effect or association between SSB intake and adiposity; however, this was not always consistent within studies that reported multiple outcome measures. The 3 included RCTs had significant risk of bias concerns related to the methodology, particularly around the comparator, and concerns with generalizability. Two articles from one RCT addressed the relationship between SSB compared to LNCSB intake in children and there was insufficient evidence to draw a conclusion. In studies comparing intake of SSBs and LNCSB in adults, there was inconsistency in findings and in methodology. Of the 5 RCTs, 3 did not find a significant difference between groups, however 2 of these studies had small sample sizes and may have been underpowered. Of the 2 studies that did report a significant effect, there was not a significant effect across all reported outcomes. For example, one study reported differences based on the type of sweetener within LNCSB and the other did not find a difference in weight or BMI between groups, but did report that those who consumed LNCSB were more likely to achieve 5% weight loss. Low and no-calorie sweetened beverages: There were 37 studies identified via literature search from January 2000 to June 2019 included in this systematic review that examined the relationship between LNCSB and outcomes related to growth, size, body composition, and risk of overweight and obesity. ○. Of the 17 papers in children, all were prospective cohort studies. ○. Of the 20 papers in adults, 6 were from RCTs and 14 were from prospective cohort studies. In studies examining LNCSB intake in children, the majority of studies (~75%) reported no association for the main outcome measure(s) of adiposity among the study populations. The remaining studies had mixed associations and methodologic concerns. ○. 3 papers with findings of increased adiposity measures. ○. 1 paper with findings of decreased adiposity measures. ○. 1 paper only reported height-related outcomes. The body of evidence from children had several limitations: ○. Inadequate adjustment for confounders. ○. Inconsistency in methods for assessing beverage intake. ○. Short study duration. ○. High attrition. In studies examining LNCSB intake in adults, the majority of studies (72%) reported a significant effect or association between LNCSB intake and adiposity; however, this was not always consistent within studies that reported multiple outcome measures. ○. One well-designed RCT and two large prospective cohort studies reported an association between LNCSB and reduced adiposity. The body of evidence from adults had several limitations: ○. Experimental studies: short study duration, no assessment of compliance, and difference in comparators. ○. Cohort studies: confounding, difference in assessment methods, poor generalizability, and high attrition.

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Beverages and Added Sugars Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between beverage consumption during pregnancy and birth weight standardized for gestational age and sex? Insufficient evidence is available to determine the relationship between consumption of milk during pregnancy and birth weight outcomes. (Grade: Grade not assignable). Insufficient evidence is available to determine the relationship between consumption of tea during pregnancy and birth weight outcomes. (Grade: Grade not assignable). Insufficient evidence is available to determine the relationship between consumption of coffee during pregnancy and birth weight outcomes. (Grade: Grade not assignable). Insufficient evidence is available to determine the relationship between consumption of sugar-sweetened beverages or low- or no-calorie sweetened beverages during pregnancy and birth weight outcomes. (Grade: Grade not assignable). Insufficient evidence is available to determine the relationship between consumption of water during pregnancy and birth weight outcomes. (Grade: Grade not assignable). A literature search was conducted using four databases (PubMed, Embase, Cochrane, and CINAHL) to identify articles that evaluated the intervention or exposure of beverage consumption during pregnancy and the outcome of birth weight standardized for gestational age and sex. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two NESR analysts independently for inclusion based on pre-determined criteria. Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The Committee qualitatively synthesized the body of evidence to inform development of a conclusion statements, and graded the strength of evidence using pre-established criteria for risk of bias, consistency, directness, precision, and generalizability. Nineteen studies published between January 2000 and June 2019 met the criteria for inclusion in this systematic review, including 1 randomized controlled trial (RCT) and 18 prospective cohort studies (PCS). Many studies examined intake of multiple beverages. Evidence is summarized below by beverage type. Six studies examined the relationship between dairy milk consumption and birth weight outcomes. The body of evidence included 1 RCT and 5 PCS. The search strategy focused on dairy milk, which included commercially available cow’s milk and soy beverages with varying fat and sweetener content. However, no studies examining soy beverages met the inclusion criteria. The body of evidence showed little consistency in the timing of exposure assessment (ranging from first through third trimesters) and the period of intake it represented (ranging from the previous 24 hours to average intake for the first half of pregnancy), which limited comparability across studies. Both continuous and categorical birth weight outcomes were examined, and some studies examined both: ○. Five studies assessed continuous birth weight. ○. Three studies assessed categorical birth weight outcomes. The 5 studies examining continuous birth weight found significant associations with milk intake, but in different directions. Four studies suggested greater milk intake was related to higher birth weight, but 1 study found the opposite. The 3 studies examining categorical birth weight outcomes had limited consistency in the outcomes measured and in findings: ○. Two of the 3 studies examined risk of SGA; 1 found greater milk intake was associated with lower risk, while the other did not find a significant relationship. One of those studies also evaluated risk of LGA and did not find a relationship with milk intake. ○. One study (the RCT) examined risk of LBW and found milk was related to lower risk. Overall, findings were inconsistent in both direction and statistical significance, limiting the ability to draw conclusions. This body of evidence had several limitations: ○. SES differed by geographic location, with the 2 studies conducted in Asia enrolling populations with substantially lower SES than did the European and Canadian studies, potentially limiting generalizability of those findings. ○. Two studies, including the RCT, had attrition rates of more than 25 percent, and neither provided information on the potential for selective attrition across intervention or exposure groups. ○. Outcomes examined, definitions used, and adjustment techniques varied across studies. ○. Many studies did not adjust for birth weight for gestational age and sex. ○. All studies failed to adjust for at least one key confounder. Eight PCS examined the relationship between tea consumption and birth weight outcomes. Studies varied in the type of tea examined: ○. Three studies reported on overall tea intake. ○. Three studies reported on caffeinated tea only. ○. Three studies reported on specific types of tea (e.g., green, black, dark, oolong). Most studies examined tea intake in early pregnancy. Continuous birth weight was examined in 6 studies, and categorical birth weight outcomes were examined in 8. The 6 studies examining continuous birth weight reported mixed findings: ○. Three studies found tea intake at the highest amount related to lower birth weight. ○. Three studies found the relationship was not significant. The 8 studies examining categorical birth weight reported similarly mixed findings:...

This important public health question was identified by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) to be examined by the 2020 Dietary Guidelines Advisory Committee. The 2020 Dietary Guidelines Advisory Committee, Dietary Fats and Seafood Subcommittee conducted a systematic review to answer this question with support from the Nutrition Evidence Systematic Review (NESR) team. The goal of this systematic review was to examine the following question: What is the relationship between seafood consumption during childhood and adolescence (up to 18 years of age) and risk of cardiovascular disease? Insufficient evidence is currently available to accurately determine the relationship between seafood consumption during childhood and adolescence and risk of developing cardiovascular disease. (Grade: Grade not assignable). A literature search was conducted using four databases (i.e., PubMed, Cochrane, Embase, and CINAHL) to identify articles that evaluated the intervention or exposure of seafood consumption during childhood and adolescence and the outcomes of cardiovascular disease. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two NESR analysts independently for inclusion based on pre-determined criteria. Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The Committee qualitatively synthesized the body of evidence to inform development of a conclusion statement, and graded the strength of evidence using pre-established criteria for risk of bias, consistency, directness, precision, and generalizability. Four articles, two randomized controlled trials and two prospective cohort studies, met inclusion criteria for this systematic review. The 2020 Dietary Guidelines Advisory Committee used the following seafood definition: marine animals that live in the sea and in freshwater lakes and rivers. Seafood includes fish (e.g., salmon, tuna, trout, and tilapia) and shellfish (e.g., shrimp, crab, and oysters). Few articles were identified that examined the relationship between seafood intake during childhood and adolescence and blood pressure, lipid levels, and cardiovascular-related mortality, and no articles examined the relationship with incidence of cardiovascular disease. Two of four included articles had serious methodological limitations that made interpretation of the results difficult. Evidence was insufficient and no conclusion could be drawn.