Part D. Chapter 6: Cross-Cutting Topics of Public Health Importance - Continued
Needs for Future Research
- Design and conduct studies with sufficient power to define the impact of improving dietary quality, including the lowering of dietary sodium intake, on hypertension and relevant disease outcomes, including cardiovascular disease, stroke, peripheral vascular disease, kidney disease, and others. The interactions with patterns of therapeutic medication use (e.g., diuretics, antihypertensives, and lipid-lowering) should be considered.
Rationale: The current literature is incomplete, limited in power and durations, and often compromised by methodological challenges that must be addressed in well-designed studies with relevant clinical outcomes.
- Assess the accuracy of 24-hour urine collections for sodium assessment in populations with different health conditions (e.g., diabetes, chronic kidney disease, heart failure, cardiovascular disease) and interactions with different patterns of medication use (e.g., diuretics, antihypertensives).
Rationale: If there is systematic error in sodium assessment because individuals with various co-morbidities who are taking medications systematically do not provide accurate urine collections, paradoxical findings between sodium and health outcomes may be observed.
- Examine the effect of behavioral interventions, with novel approaches (e.g., flavorful recipes, cooking techniques) on adherence to dietary sodium recommendations.
Rationale: For decades, the population has exceeded dietary sodium intake recommendations. A public health approach that results in reformulation of commercially processed foods to lower sodium content should be the primary strategy for decreasing sodium intake in the U.S. population. However, individual support for public health policies will be needed to further document demand for changes in the sodium food environment. To this end, interventions that modify individual knowledge, attitudes, and behaviors around sodium intake should be evaluated.
- Examine the effect of low sodium intake on taste preferences for sodium and healthy dietary patterns.
Rationale: It has been argued that populations desire higher levels of sodium intake and will inevitably revert to higher levels of sodium intakes after acute reductions in sodium intake. It has also been argued that after six weeks of reduced sodium intake, taste preferences are modified such that higher sodium is no longer desirable. Studies are needed to elucidate the effects of lowering sodium intake on diet preferences.
- Document the relationship between portion size and sodium intake.
Rationale: These data are needed to inform whether dietary recommendations for sodium should be adjusted for caloric intake. It is known that the absolute amount of sodium intake is highly correlated with caloric intake. As a result, the absolute recommended amount of sodium is harder to achieve for a larger, high energy consuming person than for a smaller, low energy consuming person. The science to inform whether sodium density confers different risk than absolute intake of sodium is limited because of methodologic limitations in surveys where both calories and sodium intake can be calculated. Furthermore, the existing correlation between sodium and calories may be an artifact of the current food supply.
- Determine the effects of replacement of saturated fat with different types of carbohydrates (e.g., refined vs. whole grains) on cardiovascular disease risk.
Rationale: Most randomized controlled trials and prospective cohort studies compared saturated fat with total carbohydrates. It is important to distinguish different types of carbohydrates (e.g. refined vs. whole grains) in future studies.
- Examine the effects that replacement of saturated fat with polyunsaturated fat vs. monounsaturated fat has on cardiovascular disease risk.
Rationale: Most existing studies have examined the effects of substituting PUFA for saturated fat on cardiovascular disease risk. Future studies should also examine the potential benefits of substituting monounsaturated fat from plant sources such as olive oil and nuts/seeds for saturated fat on cardiovascular disease risk.
- Examine lipid and metabolic effects of specific oils modified to have different fatty acid profiles (e.g. commodity soy oil [high linoleic acid] vs. high oleic soy oil).
Rationale: As more modified vegetables oils become commercially available, it is important to assess their long-term health effects. In addition, future studies should examine lipid and metabolic effects of plant oils that contain a mix of n-9, n-6, and n-3 fatty acids, as a replacement for animal fat, on cardiovascular disease risk factors.
- Examine the effects of saturated fat from different sources, including animal products (e.g. butter, lard), plant (e.g., palm vs. coconut oils), and production systems (e.g. refined deodorized bleached vs. virgin coconut oil) on blood lipids and cardiovascular disease risk.
Rationale: Different sources of saturated fat contain different fatty acid profiles and thus, may result in different lipid and metabolic effects. In addition, virgin and refined coconut oils have different effects in animal models, but human data are lacking.
- Conduct gene-nutrient interaction studies by measuring genetic variations in relevant genes that will enable evaluation of effects of specific diets for individualized nutrition recommendations.
Rationale: Individuals with different genetic background may respond to the same dietary intervention differently in terms of blood lipids and other cardiovascular disease risk factors. Future studies should explore the potential role of genetic factors in modulating the effects of fat type modification on health outcomes.
- Identify sources and names of added sugars and low-calorie sweeteners used in the food supply and quantify their consumption levels and trends in the U.S. diet.
Rationale: It is unclear whether all food and nutrient databases capture all added sugars because: 1) added sugars have varied and inconsistent nomenclature and may not be recognized as added sugars in nutrient analyses; and 2) many foods with added sugars have formulations considered proprietary by the manufacturers and for this reason actual added sugars content is difficult to obtain. Accurate assessment of added sugars in the U.S. diet is needed to quantify the population level exposure and subsequent health risks from added sugars. The lack of information on the various added sugars in the food supply hinders efforts to make policy about consumption.
- Conduct prospective research with strong experimental designs and multiple measurements of the consumption of added sugars and low-calorie sweeteners on health outcomes, such as body weight, adiposity, and clinical markers of type 2 diabetes and cardiovascular disease.
Rationale: High heterogeneity exists among published research with regard to the types and forms of added sugars and low-calorie sweeteners-containing foods/beverages used for interventions, which precludes assessing the effects of specific added sugars and low-calorie sweeteners on body weight, adiposity, and cardio-metabolic health in adults and children. Many studies use single baseline measurements of diet to reflect usual patterns and quantities of intake over time. New research should emphasize assessments within the context of usual dietary intakes and patterns of food and beverage consumption in free-living populations, along with specific added sugars and low-calorie sweeteners, especially those that are currently understudied. Large prospective studies with repeated measurements of low-calorie sweeteners are needed to monitor their long-term effects on cancer and other health outcomes.
- Design studies that emphasize assessments of relationships between the intakes of added sugars and low-calorie sweeteners and body weight, adiposity, and cardio-metabolic health in diverse sub-populations who are at high risk of obesity and related morbidities.
Rationale: Insufficient evidence exists to assess the impact of added sugars and low-calorie sweeteners contained in foods and beverages on individuals from diverse populations who have high risk for adverse health outcomes. These include (but not limited to) different race/ethnicity groups; low income groups, especially those with food insecurity; groups who live in specific geographic locations with high prevalence of obesity (e.g. inner city, rural, and Southern regions of the United States); and age and sex groups (women, children, and elderly adults).
- Assess and improve approaches and policies to reduce the amount of added sugars in the food and beverage supply as well as in school and community settings.
Rationale: Results from this research would assist policy makers and the private sector in establishing sustainable approaches and policies to limit the availability and consumption of added sugars. These approaches and policies would also be important for multi-component strategies to improve weight control and health among people living in the United States.
- Conduct consumer research to identify and test elements of a standardized, easily understood front-of-package label.
Rationale: Research is needed to provide an evidence base to support the need and identify critical elements of a front of package label. This is particularly important to support the Food and Drug Administration in implementing a front-of-package labeling system.