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{"project":"LitCovid-PD-GO-BP","denotations":[{"id":"T8","span":{"begin":3438,"end":3443},"obj":"http://purl.obolibrary.org/obo/GO_0007568"},{"id":"T9","span":{"begin":3715,"end":3721},"obj":"http://purl.obolibrary.org/obo/GO_0007631"},{"id":"T10","span":{"begin":7333,"end":7339},"obj":"http://purl.obolibrary.org/obo/GO_0007601"},{"id":"T11","span":{"begin":7879,"end":7888},"obj":"http://purl.obolibrary.org/obo/GO_0007610"},{"id":"T12","span":{"begin":8583,"end":8595},"obj":"http://purl.obolibrary.org/obo/GO_0006113"},{"id":"T13","span":{"begin":11121,"end":11127},"obj":"http://purl.obolibrary.org/obo/GO_0040007"},{"id":"T14","span":{"begin":11576,"end":11582},"obj":"http://purl.obolibrary.org/obo/GO_0007631"},{"id":"T15","span":{"begin":13750,"end":13763},"obj":"http://purl.obolibrary.org/obo/GO_0006412"},{"id":"T16","span":{"begin":16996,"end":17007},"obj":"http://purl.obolibrary.org/obo/GO_0009056"}],"text":"The Burden\nPoor nutrition is contributing to major increases in diet-related obesity and type 2 diabetes, as well as continuing high rates of other chronic diet-related diseases such as cardiovascular diseases, cancers, and other conditions (1). Since the 1970s, Americans’ diets have changed significantly. For example, both portion sizes and frequency of snacking have increased, with each linked to greater calorie intake (14, 15). Among US children, substantial increases in daily calories since the 1970s are entirely attributable to increased foods eaten outside from home, mostly from fast food (16). Consistent with prior health messaging to reduce total fat, the percentage of energy from carbohydrates increased from 42% to 48% of calories in men and 45% to 51% in women between 1971 and 2004, primarily due to higher consumption of starches, grains, and caloric beverages (17, 18). Between 1977 and 1994, intake of processed breakfast cereals increased by 60%, intake of pizza by 115%, and intakes of snack foods like crackers, popcorn, pretzels, and corn chips by 200% (19). Between 1965 and 2002, the intake of caloric beverages increased from 12% to 21% of all calories, representing an average increase of 222 calories/d per person (20). This change was due to increased intake of sweetened fruit drinks, alcohol, and especially soda. Over this time, the average portion size of a sugar-sweetened beverage increased by \u003e50% (21).\nIn more recent years, with growing public awareness of the critical role of nutrition in overall health, some aspects of US diet quality have modestly improved, such as reductions in soda and small increases in whole grains, fruits, and nuts/seeds (22, 23). Nevertheless, intakes of these and other healthful components remain far below dietary guidelines, with 45.6% of adults and 56.1% of children continuing to have poor-quality diets overall, and most of the remainder having intermediate-quality diets, with very few Americans having ideal diets (22, 23). While less well documented by national surveillance data, the levels and types of food processing have substantially changed in the past 50 y. Ultra-processed foods now contribute ∼60% of all calories in the US food supply (24). These changes in our nutrition and corresponding diet-related illnesses are associated with rising health care costs, widening diet-related health disparities, and weakened national security and military readiness (25).\nBetween 1980 and 2018, the percentage of US children with obesity increased from 5.5% to 19.3%, whereas the percentage of adults with obesity increased from 15% to 42.4% (26–30). Nearly 3 in 4 American adults are now either overweight or obese (26, 31, 32). Across all preventable risk factors for disease in the US, poor diet is now the leading cause of poor health, associated with more than half a million deaths per year—or more than 40,000 deaths each month (1). Along with suboptimal diet, adiposity and physical inactivity are shared risk factors for illness and death (33–37). Over the last 20 y, the number of adults with diabetes has more than doubled (38), and today, \u003e100 million Americans—nearly half of all adults—suffer from diabetes or prediabetes (39). Cardiovascular disease afflicts ∼122 million Americans and causes ∼840,000 deaths each year (40). Many of these diseases disproportionately affect older Americans, and as our nation's demographics shift toward an aging population, the burden of diet-related ailments on society will accelerate (41, 42). In short, more Americans are sick or suffer from major medical conditions than are healthy, and much of this is related to diet-related illness.\nAlthough the general contours of healthy eating patterns have been outlined by important advances in nutrition science, many questions remain unanswered (10). Modern nutrition science is still evolving, with a rapidly growing but still relatively nascent repertoire of research methods, foundational science, and large-scale interventions to investigate and address diet-related diseases. For most of the 20th century, the focus of nutrition research was on isolated vitamins and minerals and their role in clinical nutrient deficiency diseases. This effort led to major accomplishments, such as documenting the role of individual nutrients in diseases such as pellagra (vitamin B-3 deficiency), rickets (vitamin D deficiency), and scurvy (vitamin C deficiency), among others, and then quickly mobilizing innovative technology such as fortification of staple foods, along with well-coordinated policy and programmatic responses, to address these conditions. In comparison, the shift of nutrition science to focus more meaningfully on diet-related chronic diseases, such as heart disease, strokes, cancer, diabetes, obesity, brain health, and autoimmune and inflammatory diseases, is much more recent, largely begun only since the 1980s. In this short period, important knowledge has been gained. Yet, the investment and pace of progress have been insufficient to address the burgeoning rates of diet-related illness and the associated societal and economic consequences.\nFor example, in detailed reviews of available research by the 2015 Dietary Guidelines Advisory Committee (DGAC), numerous areas were identified as having only moderate, limited, or insufficient (not assignable) scientific evidence for making dietary recommendations (Supplemental Table 1). These include, for instance, evidence that healthier dietary patterns favorably influence body weight or obesity in adults (moderate evidence) or children or adolescents (limited); reduce the risk of type 2 diabetes in adults (limited) or children (not assignable); or are associated with lower risk of colorectal (moderate), breast (moderate to limited), lung (limited), or prostate (not assignable) cancer; age-related cognitive impairment, dementia, or Alzheimer disease (limited); depression in adults (limited) or children, adolescents, or postpartum mothers (not assignable); or bone health in adults (limited) or children and adolescents (not assignable). Considering specific individual foods and nutrients, the 2015 DGAC concluded that evidence is only moderate that coffee consumption is associated with reduced risk of type 2 diabetes, cardiovascular disease, or certain cancers and is limited for caffeine intake and lower risk of cognitive decline and Alzheimer disease or increased risk of miscarriage, stillbirth, or low birth weight. The 2015 DGAC found limited evidence to address additives, such as aspartame and risk of cancers or preterm delivery. Evidence was considered moderate for any specific sodium target (e.g., 2400 mg/d) for blood pressure control or risk of cardiovascular outcomes; limited or not assignable for potassium intake and these outcomes; moderate or limited for low-calorie sweeteners and body weight or diabetes; and limited for replacing saturated fat with monounsaturated fat for reducing cardiovascular risk.\nThe 2015 DGAC identified multiple specific areas of research needs (Supplemental Table 2). Examples include the need to conduct research on 1) the dietary needs and intakes of older adults, whether polypharmacy plays a role in nutritional adequacy, and whether comorbidities, such as poor dentition, musculoskeletal difficulties, arthralgias, vision loss, and other age-related symptoms, affect their ability to establish and maintain proper nutritional status; 2) nutrition transitions from early childhood to adolescence to identify how and why diets change so rapidly during this period, the driving forces behind these changes, and effective programs to maintain positive nutrition habits established in young children; 3) the validity, reliability, and reproducibility of new biomarkers of nutritional status; 4) the effects of fortification strategies and supplement use on consumer behaviors and diets related to calcium, vitamin D, potassium, iron, and fiber; and 5) design approaches to quantify diets in large population-based studies.\nOverall, advances in science have identified numerous new opportunities for research and pressing scientific questions that must be addressed (Figure 2). These topics, discussed further in “The Opportunity” section below, include fundamental questions about foods and diet quality in relation to obesity, insulin resistance, diabetes, cancers, and other conditions; the interactions between diet, physical activity, the microbiome, and immunity and other key health defenses; and the health effects of various forms of food processing, additives, fermentation, and probiotics. Other topics include personalization of nutrition based on each person's background, habits, genes, microbiome, medications, and existing diseases; how hunger and food security influence wellness and key approaches to address this interaction; the intersections of plant and animal breeding and farming practices with nutrition and sustainability; and many other questions. Thus, we have learned much, but the present state of science remains far from offering a sufficient understanding of many crucial facets of food and nutrition fundamental to human health (43–47). Scientific progress is being made, but at the current pace it may take many decades to meaningfully understand and reduce the prevalence and impact of the broad range of diet-related chronic diseases that we face.\nThe economic costs of nutrition-related diseases are staggering and ever rising. As a share of our economy, total US health care expenditures have nearly tripled since 1970, from 6.9% to 17.9% of Gross Domestic Product (GDP) (48, 49). These increases are harming government budgets, competitiveness of US businesses, workers’ wages, and livelihoods of families. Federal health care spending has increased from 5% of the total federal budget in 1970 to 28% in 2018, reducing available funds for other priorities. Similarly, average state government spending on health care has increased from 11.3% of state budgets in 1989 to 28.7% in 2016. For US businesses, health care expenditures have increased 15-fold in 50 y, from $79 billion in 1970 to $1180 billion in 2017 (in constant 2017 dollars) (49). Over this same period, annual per capita health care spending in the US has increased from $1797 to $10,739 (in constant 2017 dollars) (49). And, ∼85% of total US health care expenditures are related to management of diet-related chronic diseases (50). For example, the total direct health care and indirect economic costs of cardiovascular diseases are estimated at $316 billion/y; of diabetes, at $327 billion/y; and of all obesity-related conditions, at $1.72 trillion/y (51, 52). These economic costs exceed the annual budget appropriations of most federal departments and agencies, such as (for fiscal year 2020) the budgets of the USDA ($150 billion) (53), DoE ($72 billion) (54), DHS ($51 billion) (55), DoJ ($33 billion) (56), NIH ($42 billion) (57), CDC ($12.7 billion) (58), EPA ($9.5 billion) (59), and FDA ($5.9 billion) (59).\nRising health care expenditures are straining government budgets and private business growth; limiting the ability to support other national, state, and business priorities; contributing to stagnating wages; and bankrupting individuals, families, and small businesses (60, 61). Improving what Americans eat would have a significant impact on reducing diet-related chronic diseases, lowering health care spending, and creating new opportunities for innovation and jobs. Although advancing science has elucidated the broad outlines of healthy eating patterns for making many general dietary and policy recommendations, numerous critical questions remain unanswered, with corresponding scientific debate and public confusion. There is a large and growing appetite among American citizens for credible, rigorous nutritional science information, both for general health but also for treating many specific diseases and ailments. Consumers are inundated with often conflicting information from multiple sources, including the internet, social media, television, marketing, and food and menu labeling, among others, making it difficult to discern trusted information for making informed choices (62). Many American adults remain unaware of foundational federal guidance on nutrition (63, 64), and use the internet or other sources for seeking guidance on what to eat (65).\nPoor nutrition also contributes to profound disparities. Prior to COVID-19, food insecurity was a significant challenge for 1 in 8 Americans (66, 67), and is expected to more than double this year. A total of 37 million Americans, including 11 million children, experienced food insecurity in 2018 (68, 69). The dramatic increase in unemployment with COVID-19 is expected to cause food insecurity for an additional 18 million US children, bringing the total to 40% of all US youth (70). Americans are also experiencing ever-widening disparities in diet quality and diet-related chronic diseases by race/ethnicity, education, and income (22, 71–75). While social and economic factors such as lower education, poverty, bias, and reduced opportunities are major contributors to population disparities, they are likewise major barriers to healthy food access and proper nutrition. Poor diets lead to a harsh cycle of lower academic achievement in school, lost productivity at work, increased chronic disease risk, increased out-of-pocket health costs, and poverty for the most vulnerable Americans (76). Addressing these profound diet-related disparities experienced by rural, low-income, and minority populations requires a better understanding of their multilevel and interrelated individual, social, and environmental determinants, and corresponding translational solutions (77–80). As one example, the 2015 DGAC concluded that the current body of evidence on the links between access to retail food outlets and dietary intake was limited and inconsistent (81).\nOur national nutrition challenges also diminish military readiness (82). For much of human history, governments have prioritized nutrition to enable a high-performing, able military. During World War II, for example, recognition of the national security threat of undernutrition produced strong federal actions, such as creation of the first RDAs by President Franklin D Roosevelt in 1941 and of the National School Lunch Program by Congress in 1945 (83). Today, we face very different nutritional challenges: 71% of young people between the ages of 17 and 24 do not qualify for military service, with obesity being the leading medical disqualifier (25). Since 2010, Mission: Readiness—a group of \u003e750 retired US generals, admirals and other top military leaders—has produced several reports documenting the national security threat of childhood obesity (25, 84, 85). In addition, obesity and other diet-related chronic diseases are common among veterans, with more than one-third of veterans seen at the Veterans Health Administration (VHA) being obese (86). Food insecurity is common among veterans seen at the VHA and is associated with suboptimal control of medical conditions (87–89). Both obesity and food insecurity are common and often coexist in active-duty military families (90, 91). Overall, diet-related illnesses are harming the readiness of US military forces and the budgets of the DoD and VA (86, 92, 93). A more robust understanding of nutrition is a top DoD priority to maximize the performance of active-duty forces and their recovery from physical and psychologic injuries (11).\nOur food systems are creating challenges to our climate and natural resources with widespread related health consequences (94). Emerging science is advancing the understanding of how nutrition security—access to affordable, sufficient, safe, and nutritious food—is interrelated with challenges and opportunities in use of natural resources (11, 94). While federal nutrition research and coordination is the focus of this white paper, we recognize that nutrition research and agricultural and food systems research are mutually interdependent (95). Ongoing market forces, food production, and consumption patterns, among other factors, are creating not only poor health but large and unsustainable environmental impacts (96). On a global scale, one-quarter of greenhouse gases, 70% of water use, and 90% of tropical deforestation are related to food production. Climate change is warming the planet, contributing to lower crop yields and new economic risks for farmers. These issues and corresponding potential solutions are complex: for example, greenhouse gas emissions have global impact, while water use has more regional impact (97–101). Food waste worsens resource losses, with at least one-third of food produced in the US wasted during post-harvest, and consumer losses (102). The future productivity of US agriculture faces additional growing environmental challenges such as resource scarcity, loss of biodiversity, and soil degradation (96). These sustainability issues have direct relevance for human health, increasing the risk of infectious diseases, respiratory illness, allergies, cardiovascular diseases, food- and waterborne illness, undernutrition, and mental illness (103, 104).\nAddressing all of these nutrition-related health, equity, societal, and economic burdens requires advancing science to better understand their biological, individual, social, and environmental drivers. Current scientific knowledge, however, remains insufficient to address the mechanistic determinants and solutions of these complex challenges."}

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