News from NHLBI: Nutrition Research at the National Heart, Lung, and Blood Institute and Future Opportunities.

BACKGROUND: Nutrition plays a major role in the prevention and treatment of cardiovascular and other chronic diseases; hence, nutrition research is a priority for the National Heart, Lung, and Blood Institute (NHLBI). The purpose of this analysis is to describe the scope of NHLBI-funded extramural nutrition research grants over the past decade and offer insights into future opportunities for nutrition research relevant to NHLBI's mission. METHODS: Data were extracted using the Research, Condition, and Disease Categorization spending categories from the publicly available NIH Research Portfolio Online Reporting Tool Expenditures and Results. New 2018 and 2019 grants were coded into categories and mapped to the 2016 NHLBI Strategic Vision priorities. RESULTS: Approximately 90% of nutrition research funds supported extramural grants, particularly through investigator-initiated R series grants (69.6%). Of these, 19.8% were classified as clinical trials. Consistent nutrition-related topics, including physical activity, weight loss, fatty acids, metabolic syndrome, childhood obesity, and other topics such as gut microbiota, arterial stiffness, sleep duration, and meal timing, emerged in 2014-2019.  Mapping of the NHLBI Strategic Vision objectives revealed that 32% of newly funded grants focused on pathobiological mechanisms important to the onset and progression of heart, lung, blood, and sleep disorders, with opportunities including developing novel diagnostic and therapeutic strategies and clinical and implementation science research. DISCUSSION: The findings show the breadth of NHLBI-funded nutrition research and highlight potential research opportunities for nutrition scientists.

A Diet for Healthy Weight: Why Reaching a Consensus Seems Difficult.

Overweight and obesity are global health problems that contribute to the rising prevalence of non-communicable diseases, such as type 2 diabetes, heart disease, and certain cancers. The World Health Organization recognizes obesity as a primarily diet-induced, preventable condition, yet losing weight or keeping weight loss permanent is a universal challenge. In the U.S., formal dietary guidelines have existed since 1980. Over the same time-period, the incidence of obesity has skyrocketed. Here, we present our perspective on why current dietary guidelines are not always supported by a robust body of scientific data and emphasize the critical need for accelerated nutrition research funding. A clear understanding of the interaction of dietary patterns with system-level biological changes in a precise, response-specific manner can help inform evidence-based nutrition education, policy, and practice.

Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit.

BACKGROUND: Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development's Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a "Food Assistance for Nutrition Evidence Summit" to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps. OBJECTIVE: This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit. METHODS: Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature. RESULTS: Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem. CONCLUSIONS: These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

Setting research priorities on multiple micronutrient supplementation in pregnancy.

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

Why Food System Transformation Is Essential and How Nutrition Scientists Can Contribute.

BACKGROUND: The International Union of Nutritional Sciences held its 21st International Congress of Nutrition in October 2017 in Buenos Aires, Argentina under the theme - From Sciences to Nutrition Security. In addition to multiple sessions on food systems and their links to diet, nutrition and health, the Congress closing lecture focused on the need to transform food systems so as to increase their capacity to provide healthy diets, making a call for greater involvement of nutrition scientists. SUMMARY: This article presents the main messages of that lecture, providing (i) an overview of global nutrition trends and their links to diets, food environments and food systems, (ii) a synopsis of the current global momentum for food system transformation and (iii) the need for nutrition scientists to leverage this momentum in terms of increased evidence generation and policy advocacy. Key Messages: Poor quality diets are increasingly leading to the compromising of human health as never before; the prevalence of undernutrition persists and remains acute in vulnerable regions, and hunger is increasing concomitantly with an unprecedented rise in overweight, obesity and nutrition-related non-communicable diseases. Increasing access to healthy diets through faster, stronger implementation of supply and demand-side strategies that address the underlying drivers of today's faulty food systems is imperative to solve these problems, as well as to address related environmental and economic costs. The global momentum for such action is increasing, but the evidence base needed to galvanize governments and hold stakeholders accountable remains yet a fledgling. To date, inputs from nutrition scientists to this reform agenda have been weak, especially given the unique contributions the field can make in terms of rigorous analysis and technical advice. Strengthened participation will require innovations in metrics and methodologies, combined with new thinking on what constitutes viable evidence and a greater willingness to engage with private sector agri-food actors.

21st century toolkit for optimizing population health through precision nutrition.

Scientific, technological, and economic progress over the last 100 years all but eradicated problems of widespread food shortage and nutrient deficiency in developed nations. But now society is faced with a new set of nutrition problems related to energy imbalance and metabolic disease, which require new kinds of solutions. Recent developments in the area of new analytical tools enable us to systematically study large quantities of detailed and multidimensional metabolic and health data, providing the opportunity to address current nutrition problems through an approach called Precision Nutrition. This approach integrates different kinds of "big data" to expand our understanding of the complexity and diversity of human metabolism in response to diet. With these tools, we can more fully elucidate each individual's unique phenotype, or the current state of health, as determined by the interactions among biology, environment, and behavior. The tools of precision nutrition include genomics, metabolomics, microbiomics, phenotyping, high-throughput analytical chemistry techniques, longitudinal tracking with body sensors, informatics, data science, and sophisticated educational and behavioral interventions. These tools are enabling the development of more personalized and predictive dietary guidance and interventions that have the potential to transform how the public makes food choices and greatly improve population health.

Nutrient profiling for front of pack labelling: how to align logical consumer choice with improvement of products?

The primary goal of front of pack (FOP) labelling is to help consumers make healthier choices through communication. A secondary goal is to encourage producers to improve the nutritional composition of their products. Evidence has shown that (FOP) labelling can help consumers to make healthier food choices and has been an incentive for producers to improve product composition. As FOP labelling is seen as an important tool to improve food environments for public health purposes, the WHO supports initiatives of governments to implement an FOP labelling system. Based on the experiences of a wide range of countries over many years, possible success factors for such an FOP system have been defined, six of which are discussed in the present paper and used to evaluate the Dutch Choices Programme that was started in 2006. In the course of time a large number of producers joined the programme and the logo was recognised by more than 90 % of the consumers, but by 2016 the Dutch consumer organisation argued on the basis of their own research that a quarter of the consumers did not understand the colour coding of the logo and as a result the Dutch government decided to no longer support this logo and to introduce a nutrition app. The challenge that remains is to find a system that consumers understand well and that still encourages manufacturers of food to improve product composition. New technology-based data collecting initiatives might provide the right tools to develop such a system.

Nutrient profiling for regulatory purposes.

In this paper, I first provide definitions of nutrient profiling and of a nutrient profile model. I set out the purposes of nutrient profiling: both general and specific. I give two examples of nutrient profile models that have been developed for regulatory purposes by the Food Standards Agency (FSA) in the UK and the WHO for its European Region - the UK FSA/Ofcom and the WHO-Euro models - and compare the way the models are constructed and function, how they have been developed, the extent to which they have been tested and validated and their use in regulation. Finally I draw some conclusions about the future use of nutrient profiling for regulatory purposes. I argue that its full potential has yet to be realised and give some reasons why. I pose some urgent research questions with respect to nutrient profiling.

Uses of nutrient profiling to address public health needs: from regulation to reformulation.

Nutrient profiling (NP) models rate the nutritional quality of individual foods, based on their nutrient composition. Their goal is to identify nutrient-rich foods, generally defined as those that contain more nutrients than calories and are low in fat, sugar and salt. NP models have provided the scientific basis for evaluating nutrition and health claims and regulating marketing and advertising to children. The food industry has used NP methods to reformulate product portfolios. To help define what we mean by healthy foods, NP models need to be based on published nutrition standards, mandated serving sizes and open-source nutrient composition databases. Specifically, the development and testing of NP models for public health should follow the seven decision steps outlined by the European Food Safety Authority. Consistent with this scheme, the nutrient-rich food (NRF) family of indices was based on a variable number of qualifying nutrients (from six to fifteen) and on three disqualifying nutrients (saturated fat, added sugar, sodium). The selection of nutrients and daily reference amounts followed nutrient standards for the USA. The base of calculation was 418·4 kJ (100 kcal), in preference to 100 g, or serving sizes. The NRF algorithms, based on unweighted sums of percent daily values, subtracted negative (LIM) from positive (NRn) subscores (NRn - LIM). NRF model performance was tested with respect to energy density and independent measures of a healthy diet. Whereas past uses of NP modelling have been regulatory or educational, voluntary product reformulation by the food industry may have most impact on public health.

From the SAIN,LIM system to the SENS algorithm: a review of a French approach of nutrient profiling.

Nutrient profiling aims to classify or rank foods according to their nutritional composition to assist policies aimed at improving the nutritional quality of foods and diets. The present paper reviews a French approach of nutrient profiling by describing the SAIN,LIM system and its evolution from its early draft to the simplified nutrition labelling system (SENS) algorithm. Considered in 2010 by WHO as the 'French model' of nutrient profiling, SAIN,LIM classifies foods into four classes based on two scores: a nutrient density score (NDS) called SAIN and a score of nutrients to limit called LIM, and one threshold on each score. The system was first developed by the French Food Standard Agency in 2008 in response to the European regulation on nutrition and health claims (European Commission (EC) 1924/2006) to determine foods that may be eligible for bearing claims. Recently, the European regulation (EC 1169/2011) on the provision of food information to consumers allowed simplified nutrition labelling to facilitate consumer information and help them make fully informed choices. In that context, the SAIN,LIM was adapted to obtain the SENS algorithm, a system able to rank foods for simplified nutrition labelling. The implementation of the algorithm followed a step-by-step, systematic, transparent and logical process where shortcomings of the SAIN,LIM were addressed by integrating specificities of food categories in the SENS, reducing the number of nutrients, ordering the four classes and introducing European reference intakes. Through the French example, this review shows how an existing nutrient profiling system can be specifically adapted to support public health nutrition policies.

Nutrition Society of New Zealand Annual Conference Held in Christchurch, New Zealand, 8-9 December 2016.

Background: Economic(structural)factors,includingincomeandfoodprice,maypartiallyexplain socioeconomic inequalities in diet quality, obesity and health outcomes. Internationally, healthy foods and dietary patterns tend to cost more than less healthy options. Calories from energy-dense foods (refined grains, fats/oils, added sugars) are relatively low cost; whereas, calories from nutrient-rich foods(freshfruits/vegetables,leanmeats/chicken)arerelativelyhighcost. Greatervarietyandcultural acceptability also increases food costs. The NZ Food Cost Survey has been monitoring retail food prices for a weekly basket of healthy food in New Zealand since 1972. In 2014 methodological updates ensured food types and amounts were culturally acceptable and achieved both dietary guidelines and nutrient requirements. Methods: The availability and retail price (ignoring 'specials') of 161 foods in four large supermarketsinAuckland,Wellington,ChristchurchandDunedinwererecordedannually. Theweekly estimated food costs for individuals following a basic (cooked from scratch), moderate and liberal diet were calculated by city. Results: Auckland 'basic' healthy food costs ranged from $27 (1 year old) to $67 (adolescent male) per week in 2016. For example, an Auckland household of four, basic healthy food costs were $233 per week (man $64, woman $55, adolescent boy $67, 10 years old $47), which is 41% of a full-time (pre-tax) income on the minimum wage. Most of this cost came from fruits/vegetables (30%), meats/proteins (27%) and dairy (17%). While food prices in New Zealand fell slightly in 2016, food costs have been rising over time. Full results are reported elsewhere (http://www.otago.ac.nz/humannutrition/ research/food-cost-survey). Conclusions: Threatstohealthyfoodaffordabilityincludeinadequateincomes(risingunemployment, declining real wages/benefits due to rising housing and other costs), reduced food supply (global climate change impacts), and increased food demand (global food security, population growth, bio-fuels). These threats can be managed with sustainable environmental, agricultural/food chain, economic and social welfare policies [added].

Nutrient profiling for product reformulation: public health impact and benefits for the consumer.

The food industry holds great potential for driving consumers to adopt healthy food choices as (re)formulation of foods can improve the nutritional quality of these foods. Reformulation has been identified as a cost-effective intervention in addressing non-communicable diseases as it does not require significant alterations of consumer behaviour and dietary habits. Nutrient profiling (NP), the science of categorizing foods based on their nutrient composition, has emerged as an essential tool and is implemented through many different profiling systems to guide reformulation and other nutrition policies. NP systems should be adapted to their specific purposes as it is not possible to design one system that can equally address all policies and purposes, e.g. reformulation and labelling. The present paper discusses some of the key principles and specificities that underlie a NP system designed for reformulation with the example of the Nestlé nutritional profiling system. Furthermore, the impact of reformulation at the level of the food product, dietary intakes and public health are reviewed. Several studies showed that food and beverage reformulation, guided by a NP system, may be effective in improving population nutritional intakes and thereby its health status. In order to achieve its maximum potential and modify the food environment in a beneficial manner, reformulation should be implemented by the entire food sector. Multi-stakeholder partnerships including governments, food industry, retailers and consumer associations that will state concrete time-bound objectives accompanied by an independent monitoring system are the potential solution.

Providing evidence to support the development of whole grain dietary recommendations in the United Kingdom.

Observational evidence suggests that increased whole grain (WG) intake reduces the risks of many non-communicable diseases, such as CVD, type 2 diabetes, obesity and certain cancers. More recently, studies have shown that WG intake lowers all-cause and cause-specific mortality. Much of the reported evidence on risk reduction is from US and Scandinavian populations, where there are tangible WG dietary recommendations. At present there is no quantity-specific WG dietary recommendation in the UK, instead we are advised to choose WG or higher fibre versions. Despite recognition of WG as an important component of a healthy diet, monitoring of WG intake in the UK has been poor, with the latest intake assessment from data collected in 2000-2001 for adults and in 1997 for children. To update this information we examined WG intake in the National Diet and Nutrition Survey rolling programme 2008-2011 after developing our database of WG food composition, a key resource in determining WG intake accurately. The results showed median WG intakes remain low in both adults and children and below that of countries with quantity-specific guidance. We also found a reduction in C-reactive protein concentrations and leucocyte counts with increased WG intake, although no association with other markers of cardio-metabolic health. The recent recommendations by the UK Scientific Advisory Committee on Nutrition to increase dietary fibre intake will require a greater emphasis on consuming more WG. Specific recommendations on WG intake in the UK are warranted as is the development of public health policy to promote consumption of these important foods.

New mobile methods for dietary assessment: review of image-assisted and image-based dietary assessment methods.

For nutrition practitioners and researchers, assessing dietary intake of children and adults with a high level of accuracy continues to be a challenge. Developments in mobile technologies have created a role for images in the assessment of dietary intake. The objective of this review was to examine peer-reviewed published papers covering development, evaluation and/or validation of image-assisted or image-based dietary assessment methods from December 2013 to January 2016. Images taken with handheld devices or wearable cameras have been used to assist traditional dietary assessment methods for portion size estimations made by dietitians (image-assisted methods). Image-assisted approaches can supplement either dietary records or 24-h dietary recalls. In recent years, image-based approaches integrating application technology for mobile devices have been developed (image-based methods). Image-based approaches aim at capturing all eating occasions by images as the primary record of dietary intake, and therefore follow the methodology of food records. The present paper reviews several image-assisted and image-based methods, their benefits and challenges; followed by details on an image-based mobile food record. Mobile technology offers a wide range of feasible options for dietary assessment, which are easier to incorporate into daily routines. The presented studies illustrate that image-assisted methods can improve the accuracy of conventional dietary assessment methods by adding eating occasion detail via pictures captured by an individual (dynamic images). All of the studies reduced underreporting with the help of images compared with results with traditional assessment methods. Studies with larger sample sizes are needed to better delineate attributes with regards to age of user, degree of error and cost.

Developments in clinical food and nutrition science in Indonesia.

Indonesia, as a major population in the Asia Pacific region, threatened with food and health insecurity through climate change and rapid economic development, faces the challenge to build capacity among its science-based food and health professionals and institutions. The nutrition research agenda is now being more actively set within the region, rather than by external imposition. A series of papers emanating from a new generation of public health and clinical nutrition scientists is reported in this issue of APJCN. It draws attention to the importance of food patterns and background culture as contributors to the failure of the nutrient rather than a food, food system and socio-ecological approach to solve the region's intransigent nutritionally-related health problems. New understandings of human eco-social biology are providing opportunities to accelerate the resolution of these problems. The challenge is to transform the food-health construct from one which is not sufficiently concerned about the precarious state of ecologically dysfunctional health and its nutrient market drivers to one which strives for more sustainable and affordable solutions. The present reports address a range of options to these ends.

Driving Along the Zinc Road.

After having written hundreds of research articles, reviews, and book chapters, I find it awkward to pen an autobiography. I still do use a pen. As stated by others in the nutrition field who have written of their own experiences in a perspective article for the Annual Review of Nutrition, my course through this field of science has been serendipitous. My interest in nutrition developed during my experiences with horses and then Angus cattle and entry into an animal science degree program. As the age of molecular biology was unfolding, I pursued a PhD in nutritional biochemistry with Hamilton Eaton at the University of Connecticut followed by postdoctoral work with Hector DeLuca at the University of Wisconsin, working on vitamins A and D, respectively. At Rutgers University, one of the two institutions where I have served on the faculty, I started my research program on trace elements with a focus on cadmium toxicity but soon thereafter began my research on zinc metabolism and function. I moved to the University of Florida in 1982 for an endowed position and have been a Florida Gator ever since. At the University of Florida, research expanded to include identification of zinc-responsive genes and physiological outcomes of zinc transport influencing health and disease, particularly as related to inflammation. I had the opportunity to contribute national science policy as president of both the Federation of American Societies for Experimental Biology and the American Society for Nutrition. As the time of this writing, I maintain an active laboratory.