IFPA Submits Comments to Inform 2025-2030 Dietary Guidelines

Dear Dr. Stoody and Ms. de Jesus,

On behalf of the International Fresh Produce Association, we respectfully submit the following comments to the U.S. Departments of Agriculture and Health and Human Services (the Departments) on the proposed scientific questions that will help inform the expertise needed for the 2025 Dietary Guidelines Advisory Committee and the development of the 2025-2030 Dietary Guidelines for Americans (DGA).

The International Fresh Produce Association (IFPA) was founded in 2022 on the deep-seated history of leadership of the United Fresh Produce Association (UFPA) and the Produce Marketing Association (PMA). IFPA is the largest and most diverse association serving the entire global fresh produce and floral supply chain, and the only to seamlessly integrate world-facing advocacy and industry-facing support. A core component of the association’s work has been increasing fruit and vegetable consumption through federal policy and programs guided by DGA recommendations. IFPA looks forward to working with the Departments on the development of the 2025-2030 DGA.

Although fruits and vegetables are core elements of previous editions of the DGA and the 2020-2025 Dietary Guidelines for Americans, an overwhelming amount of the population do not meet the recommendations related to fruits and vegetables. According to the Centers for Disease Control and Prevention (CDC), only 1 in 10 adults consume enough fruits and vegetables. ⁱ An eating pattern rich in fruits and vegetables can lower blood pressure and reduce or prevent the risk of chronic conditions like cardiovascular disease or stroke, certain types of cancer, type 2 diabetes, and more. Furthermore, research has shown that replacing high energy density foods with lower energy density foods, like fruits and vegetables, can be an effective weight management tool. ⁱⁱ

While the DGA are intended for a generally healthy population, the Departments should identify how the DGA can apply to those with chronic conditions. A staggering 6 in 10 adults have a chronic condition and 4 in 10 have more than one. Many of these chronic conditions are nutrition-related, including heart disease, some cancers, stroke, and diabetes. ⁱⁱⁱ Unhealthy eating patterns are also costly. One study published in 2019 found that unhealthy diets account for almost 20%, or $50 billion, of the U.S. healthcare costs annually from diabetes, heart disease, and stroke alone. ^iv Related to COVID-19, the CDC found that having obesity and other nutrition-related chronic conditions, like type 2 diabetes, increases the risk of severe illness from COVID-19 and may triple the risk of hospitalizations. ^{v vi} Additionally, a study that examined COVID-19 cases as of November 2020 found that 63.5% of the COVID-19 hospitalizations could be attributed to obesity, hypertension or heart failure, or diabetes meaning the hospitalizations may have been preventable if the individuals did not have these chronic conditions. ^vii

More than 40% of US adults ^viii have obesity, and almost 20% of children ^ix and adolescents aged 2-19 years have obesity. Because of these statistics, we are pleased to see the additional emphasis on weight loss and weight maintenance; however, we urge the Departments to develop guidelines that minimize the risk of overweight and obesity to begin with. Prevention strategies, including policy, systems, and environmental change should be taken into consideration throughout the DGA development process. The Departments should also recognize overweight and obesity disparities among population groups and develop DGA that address these disparities.

IFPA also welcomes the expansion of questions to address ultra-processed foods. The consumption of ultra-processed foods has increased over the last 20 years, growing from 53.5% of calories in 2001- 2002 to 57% of calories in 2017-2018. A recently published study showed that the U.S. diet has shifted to consuming a more processed diet that results in poor diet quality and a higher risk of nutrition related chronic conditions like obesity and heart disease. ^x Through the DGA development process, we urge the Departments to define ultra-processed foods and determine how the consumption of such foods can be minimized to improve health and reduce and prevent nutrition-related chronic conditions.

Dietary Patterns during Pregnancy and Lactation

A healthy dietary pattern before and during pregnancy as well as during lactation is critical to the short and long-term health of a child. A growing body of evidence has focused on the importance of nutrition prior to conception, including adolescence. We encourage the Departments to emphasize the impact of dietary patterns prior to pregnancy and the health and developmental status of a child. Additionally, the components of dietary patterns, like fruits and vegetables, should be examined to determine how they can meet nutritional needs before and during pregnancy and during lactation. The Departments could include a question that examines nutritional status before and during pregnancy and during lactation to the long-term health of a child, including risk of chronic conditions, to better understand nutrition and health status across the lifespan.

Dietary Patterns during Birth to 24 Months

Research shows the importance of consumption of fruits and vegetables during birth to 24 months. One study examined the intake of fruit and vegetables at 6 years of age compared to intake during late infancy. The results showed that the infrequent intake of fruits and vegetables during late infancy was associated with infrequent intake of fruits and vegetables at age 6 which highlights the importance of frequent and consistent offerings of fruits and vegetables and the impact of longer-term eating patterns. ^xi IFPA commends the 2020-2025 DGA for recommending that infants should be introduced to nutrient-dense complementary foods, including fruits and vegetables. The American Academy of Pediatrics recommends offering a variety of healthy foods rich in nutrients that the child needs to assist in forming good eating habits. ^xii Proposed questions and recommendations that address the scientific questions related to this age group should be clear, consistent, and easy for all parents and caregivers to understand and achieve. Furthermore, consideration should be given for how nutrient-dense foods, like fruits and vegetables, can be developmentally appropriate throughout the various windows of 6-24 months. We also encourage the Departments to make clear the importance of whole fruits and vegetables that are free from additives, like salt or sugar, as we know the negative implications of sodium and added sugars. Similarly, to the pregnancy and lactation population, we urge the Departments to examine the impact of eating patterns during birth to 24 months and long-term health and risk of nutrition-related chronic conditions.

Children and Adolescents

The COVID-19 pandemic has had detrimental impacts on children’s physical and mental health. According to USDA estimates from 2020, among households with children, 14.8% experienced food insecurity, compared to 14.6% of households with children in 2019.^{xiii xiv} Unfortunately, even more common than food insecurity among children is childhood obesity which impacts about one in five children and adolescents ages 2-19 years of age. ^xv Research that examined body mass index among children and adolescents in Southern California during COVID-19 found that youths gained more weight during the pandemic than before, and that most of the increase in obesity was among those ages 5-11 and 12-15. ^xvi

Throughout the development of the 2025-2030 DGA, the Departments should recognize the importance the guidelines will have as they inform federal nutrition programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children, (WIC), school nutrition programs, and the nation’s largest nutrition program, the Supplemental Nutrition Assistance Program (SNAP). In 2021, over 6 million individuals participated in the WIC program and prior to the COVID-19 pandemic, 29.6 million children participated in the school meal programs daily, showing the magnitude of the guidelines and their influence on children’s health and nutrition. ^xvii We request that the proposed questions further address how dietary patterns during childhood and adolescence can impact health and nutrition across the lifespan. We also ask that the proposed questions allow for recommendations that address the current health status of children and adolescents and aim to improve nutrition and health to prevent and reduce the risk of nutrition-related chronic conditions.

Specific Dietary Components

Complementary Foods & Beverages

The types and frequency of foods introduced in infancy can influence eating habits throughout childhood and longer. Because fruits and vegetables are under consumed across the lifespan, the introduction of these foods during this life stage is imperative. Research questions should examine how introducing fruits and vegetables as a first food can impact health and nutrition not only during this timeframe, but across the lifespan. They should also explore the differences in initial acceptance of foods like fruits and vegetables to better understand food preferences. The Departments should recommend that complementary foods with added salt be avoided in the first year of life and limited thereafter to prevent children from developing preferences for salty foods and this should be extended to vegetable recommendations for this age group. ^xviii Additionally, parents and caregivers should be provided with guidance on evidence-based feeding strategies for developmentally-appropriate complementary foods and beverages which includes the number of exposures it may take for a child to accept a food, that introducing fruits before vegetables does not cause a preference for sweet foods, and specific nutrient needs during this timeframe along with which foods contain those.

Beverages

We continue to support the 2020-2025 DGA recommendation that stated that before 12 months of age, 100% fruit or vegetable juices should not be given to infants, that between 12-24 months, fruit juice is not necessary and most fruit intake should come from eating whole fruit (including fresh-cut), and no more than 4 oz. of 100% fruit juice should be given per day. We also support the recommendation that juices with added sugars should be avoided. We urge the Departments to continue to encourage whole fruits as sources of fruit instead of fruit juices as whole fruits are more nutrient dense.

Food-Based Strategies

Food Exposures: It is important that the Departments not only recommend what kinds of foods to consume, but how and when. This is particularly important for the birth to 24 months and childhood and adolescence age groups. Providing guidance on exposure to different types of nutrient-dense foods, like fruits and vegetables, and flavors and textures is key to developing a nutritious eating pattern. Peer and parental role modeling is also important for child acceptance of healthy foods. Research has shown that children are aware of parents’ eating behaviors which makes them an influential role model during meal and snack times. ^xix

Snacking: The increase in snacking has increased over the years signaling a change in a three meal per day eating pattern. A market research firm, NPD Group, found that over the past five years, including during the COVID-19 pandemic, U.S. consumers added 25 between-meal snacking occasions per capita in its annual “Eating Patterns in America” study. Additionally, consumption of snack foods at meals increased from 21% of eating occasions in 2010 to 26% in 2020. ^xx The Departments should examine this increase in snacking and provide nutritious snack recommendations like fruits and vegetables free from added sugars or salt.

USDA Dietary Patterns

As the Departments are utilizing food pattern modeling to examine established USDA Dietary Patterns (Healthy U.S.-style, Healthy Mediterranean-Style, and/or Healthy Vegetarian), we ask that dietary patterns be easy to understand and interpret to ensure more Americans can adhere to healthy eating patterns. We also encourage the Departments to consider several factors when developing the updated eating patterns such as cultural preferences, access, affordability, and skill and time to prepare healthy foods. Established and recommended dietary patterns should be flexible to fit a variety of lifestyles and preferences and attainable for all households.

Research Approaches

The Departments should determine how best to use outside, unbiased research to assist in answering the proposed scientific research questions. Utilizing nutrition evidence systematic reviews (NESR), food pattern modeling, and data analysis conducted by the Departments is a good, initial approach, however, if sufficient data are not included in these methods, the DGAC should be permitted to utilize additional unbiased and strong research and resources.

Cross-Cutting Recommendations & Implications

We commend the Departments for their commitment to including equity throughout the 2025- 2030 DGA process, including selection of the DGAC, in the process of addressing the proposed scientific research questions, and in the eventual recommendations and guidelines. A USDA study conducted in 2018 found that nearly nine out of 10 SNAP participants face barriers to achieving a healthy diet with the number one barrier reported being the cost of healthy food followed by time to prepare meals from scratch. Other barriers included distance to the grocery store, physical disability or limitations, storage for fresh or cooked foods, kitchen equipment, knowledge about healthy foods, and cooking skills. ^xxi It is imperative that the Departments recognize that nutrition and health can be vastly different among population groups due to disparities as well as cultural or traditional preferences. We applaud the Departments for ensuring that socioeconomic status, race, ethnicity, and culture are examined at each point in the process and are considered when reviewing scientific literature and data.

We also urge the Departments to focus on food and nutrition security and ensure that all Americans can achieve both when meeting the DGA. Nutrition-related chronic conditions impact communities with high rates of food insecurity the most. With the USDA announcement in March regarding the administration’s focus on nutrition security, the DGA process should strive to examine how diet quality can help reduce nutrition-related chronic conditions while emphasizing equity and health disparities. The Departments and the DGAC have a responsibility to work towards achieving nutrition security through the 2025-2030 DGA

Policy Systems & Environmental Change

The DGA have a profound impact on families across the country as they determine nutrition standards for school meals, the WIC food package, the SNAP-Ed program curriculum, and more. Although the DGA inform multiple federal nutrition programs, unfortunately, not all federal programs align with DGA recommendations and Americans still do not meet DGA recommendations, including for fruits and vegetables. The Departments should take additional proactive and bold steps in the implementation and dissemination of the DGA. Department and private sector collaboration is required to foster systemic change in eating patterns.

Initiatives that can be supported to assist Americans in meeting the DGA include increased funding for nutrition research, improved and transparent nutrition labeling, promotion of foods and food groups outlined in the DGA recommendations, insurance coverage and incentives for nutritious foods and medically tailored meals, and increased dedicated access to fruits and vegetables in feeding programs. A multi-faceted and collaborative approach is necessary to improve dietary patterns and reduce and prevent nutrition-related chronic conditions.

When the DGA are followed, we know that eating patterns improve. Research found that poor nutritional quality food consumed at schools decreased from 55% to 24%, with the decrease mainly occurring after 2010, ^xxii aligning with when the Healthy, Hunger-Free Kids Act was passed which was based on the DGA. Additionally, research found that obesity rates were decreasing among 2-4 year olds participating in WIC after the food package was updated to better align with DGA. ^xxiii With the increased cash value benefit (CVB) for fruits and vegetables in the WIC program, preliminary data has shown that WIC participants increased their purchasing of fruits and vegetables and were able to purchase more varieties of fruits and vegetables – a win-win for participants, retailers, and farmers or producers. ^xxiv

Increased access to fruits and vegetables through these programs has played a pivotal role in the progress of these federal nutrition programs and government agencies as well as Congress should strive to promote the DGA through federal nutrition programs and policies. There is no better way to improve the diet quality of Americans than increasing access and consumption of fruits and vegetables and we stand ready and willing to serve as an ally to the Departments throughout the 2025-2030 DGA process. We look forward to being a part of the process and to making the eventual recommendations a reality for every American.

Sincerely,

Mollie Van Lieu
Vice President, Nutrition and Health
International Fresh Produce Association