<b>Bijsluiter</b>. De hyperlink naar het originele document werkt niet meer. Daarom laat Woogle de tekst zien die in dat document stond. Deze tekst kan vreemde foutieve woorden of zinnen bevatten en de opmaak kan verdwenen of veranderd zijn. Dit komt door het zwartlakken van vertrouwelijke informatie of doordat de tekst niet digitaal beschikbaar was en dus ingescand en vervolgens via OCR weer ingelezen is. Voor het originele document, neem contact op met de Woo-contactpersoon van het bestuursorgaan.<br><br>====================================================================== Pagina 1 ======================================================================

<pre>Ingezonden commentaren op het openbare concept van het
achtergronddocument Granen en graanproducten
De volgende personen/organisaties hebben commentaar ingestuurd:
    Federatie Nederlandse Levensmiddelen Industrie
    Rijksinstituut voor Volksgezondheid en Milieu
    Drs. B. Spoorenberg, Maastricht
    Unilever
    De Vries Nutrition Solutions / Healthgrain Forum & TNO Food and
     Nutrition
</pre>

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<pre>Van: Christine Grit
Verzonden: dinsdag 10 februari 2015 16:36
Aan: GR_RGV2O15
Onderwerp: Respons op eerste serie achtergronddocumenten Gezondheidsraad RGV
Geachte heer/mevrouw,
Bijgaand doe ik u toekomen een reactie namens de Federatie Nederlandse
Levensmiddelen Industrie (FNLI) op de eerste 8 achtergronddocumenten waarvoor een
publieke consultatieronde was ingesteld in het licht van de nieuwe Richtlijnen Goede
Voeding van de Gezondheidsraad. De opmerkingen over alle documenten zijn gebundeld
in één document dat bij deze e-mail is gevoegd.
Uiteraard kunt u bij eventuele vragen, bij mij terecht.
Met vriendelijke groet,
Christine Grit
Manager Voeding & Gezondheid
FN LI
</pre>

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<pre>                    Consultatie respons eerste ronde achtergrond documenten Gezondheicisraad
                    EGV       15  004      A
                    Notitie
                    Consultatierespons op 8 achtergronddocumenten
                    Onderwerp           Achtergronddocumenten Aardappelen, Granen en Graanproducten,
                                        Koffie, Thee, Vetten en Oliën, Vitamine- en Mineralensupplementen,
                                        Voedingsvezel, Water.
                    Datum               10 februari 2015
                    Inleiding
                    Als eerste willen we de Commissie bedanken voor het kunnen inzien van de Werkwijze
                    en de achtergronddocumenten voor de Richtlijnen Goede Voeding (RGV) 2015. Als
                    tweede willen we ook graag de Commissie complimenteren met het vele werk dat hiertoe
                    moet zijn uitgevoerd. Er is sprake van stuk voor stuk zeer grondig uitgewerkte
                     documenten en dat is wat ons betreft zeker een compliment waard. Voor de goede orde
                    willen we daarbij ook vermelden dat juist de grondigheid het voor de lezers en
                    belanghebbenden relatief eenvoudig heeft gemaakt om er op- en aanmerkingen bij te
                     plaatsen. Een zeer transparante werkwijze die ons bijzonder aanspreekt.
                     Vervolgens willen we uiteraard wel graag van de gelegenheid gebruik maken om te
                     reageren op de verschillende achtergronddocumenten die hij deze eerste ronde zijn
                     verspreid voor consultatie. Alle 8 achtergrond documenten zijn in onze achterban
                     doorgenomen waarbij uiteraard de door de Commissie gestelde vragen zoveel mogelijk
                     centraal hebben gestaan. De reacties op de verschillende documenten volgen vanaf
                     pagina 4 van deze consultatierespons. De documenten worden in alfabetische volgorde
                     behandeld, te beginnen bij ‘aardappelen’ en eindigend bij ‘water’.
                      We willen wel graag een algemeen punt naar voren brengen naar aanleiding van de
                      gekozen thema’s voor de achtergronddocumenten. De gedachte dat er zowel naar
                      voedingsmiddelen en dranken als naar voedingsstoffen en voedingspatronen zal worden
                      gekeken, onderschrijven wij uiteraard van harte. Het is de laatste jaren duidelijk
                      geworden dat het uitsluitend evalueren van voedingsstoffen tekort schiet in het duiden
                      van alle mogelijke relaties tussen voeding en gezondheid. Uit de Werkwijze komt naar
                      voren dat er achtergrond documenten zijn opgesteld over verschillende
                      basisvoedingsmiddelen en dat één categorie uit de zogenaamde “extra” categorie of niet
                      basisvoedingsmiddelen zal worden uitgelicht. De motivering achter de keuze voor de
                      groepen voedingsmiddelen die zijn uitgekozen, is ons onduidelijk gebleven. De meeste
                      basisvoedingsmiddelen lijken te zijn meegenomen maar er lijkt niet gekeken te zijn naar
                      samengestelde voedingsmiddelen en de meeste niet-basisvoedingsmiddelen (die wel een
           F N II                                                            Respons consultatie eerste ronde achtergronddocumenten 1 1
FEDERATiE NEDERLANDSE
LEVENSMIDDELEN_INOUILJ
</pre>

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<pre>                       Consultatie respons eerste ronde achtergrond documenten Gezondheidsraad
                       bijdrage aan de totaal voeding leveren) zijn evenmin opgenomen. De drankenkeuze roept
                       eveneens enkele vragen op. Zo vragen wij ons af of er niet naast dranken met toegevoegd
                       suiker er niet nog anderen zijn om te bespreken.
                       Werkwijze
                       De Werkwijze is niet ter consultatie aangeboden, doch ter inzage verstrekt. Hier hebben
                       wij uiteraard begrip voor. Voorop zij gesteld dat het ons verheugt dat er sprake is van
                       een systematische en uitgebreide werkwijze die bovendien heel inzichtelijk is gemaakt.
                       Desalniettemin roept dit document wel enige vragen en opmerkingen op. Deze vragen en
                       opmerkingen willen wij u hieronder graag voorleggen. We zijn ons ervan bewust dat u
                       deze niet mee behoeft te nemen in uw algemene reactie op de verschillende
                       consultatierondes. We hopen echter wel dat u er kennis van wilt nemen, en indien
                       mogelijk, er rekening mee wilt houden.
                       Werkwijze
                       1.       Het baart ons enige zorgen dat er nauwelijks recht wordt gedaan aan de
                       complexe functie en werking van voedsel en voeding maar uitsluitend naar de relatie
                       tussen voedselirmame, voeding en chronische ziekten wordt gekeken. Bovendien via een
                       tamelijk klinische benadering die naar onze mening slechts beperkt recht doet aan de
                       volledige betekenis van voeding en voedsel in de mens en de samenleving (indirecte
                       effecten die eveneens van betekenis zijn voor een goede gezondheid komen niet aan bod).
                       Hiermee wordt enerzijds mogelijkerwijs een negatieve associatie opgeroepen tussen
                       voedsel en voeding en anderzijds worden meer indirecte aspecten van voedsel, zoals met
                       plezier eten en sociaal eetgedrag buiten beschouwing gelaten. Onzes inziens zijn de
                       navolgende factoren eveneens van belang voor de gezondheid en deze zouden eigenlijk
                       ook moeten worden meegenomen.
                        • Timing van consumptie en de hoeveelheden ervan. In de Richtlijnen Goede Voeding
                            1986 en 2006 was er ook aandacht voor frequentie van consumptie van bepaalde
                            producten/voedingsstoffen. Wordt dit aspect ook meegenomen in de algehele
                            uiteindelijke analyse
                        •   Chronische effecten van voedsel of voeding kunnen niet gekoppeld worden aan de
                            eenmalige consumptie van één product maar ook niet aan kortdurende
                            voedselpatronen. Wordt de tijdsduur van het gebruikte voedingspatroon ook
                            meegenomen?
                          •  Wij zijn heel benieuwd naar de afweging tussen voedingsmiddelen en
                             voedingsstoffen en ook wellicht de interacties tussen voedingsmiddelen en
                             voedingsstoffen en de effecten daarvan op de gezondheid.
                        2.       Deze kanttekening vloeit eigenlijk voort uit de eerste. Naar ons idee zijn de
                        achtergronddocumenten wel erg op zichzelfstaand en is het lastig om inzicht te krijgen in
                        de context. Als bijvoorbeeld een effect wordt gevonden van een bepaald voedingsmiddel
                        op het voorkomen van een bepaalde aandoening, is het erg onduidelijk hoe dat dan
                        beoordeeld moet worden in het licht van de rest van de voeding, om welke hoeveelheden
                        het gaat in die bepaalde context, wordt er gekeken naar de wenseljke consumptie in een
                        voedingspatroon of de gebruikelijke consumptie, en zo verder. Wij hopen dat er nog wel
            F Ii II                                                             Respons consultatie eerste ronde achtergronddocunienten 2
FEDERATIE NEDERLANDSE
LEVE NSOIDDLSLE4 INOLISERIE
</pre>

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<pre>                Consultatie respons eerste ronde achtergrond documenten Gezondheidsraad
                enig inzicht zal worden geboden in deze materie voordat de nieuwe Richtlijnen Goede
                Voeding verschijnen. Het is wat ons betreft ook onduidelijk wanneer er precies sprake is
                van een voedingspatroon en hoe deze wordt gedefinieerd.
                3.       Het buiten het bestek vallen van dit document van suppiementen met andere
                bioactieve stoffen lijkt eveneens een aandachtspunt. We concluderen hieruit dat noch
                 suppiernenten, noch levensmiddelen verrijkt met deze stoffen aan bod zullen komen in
                 de nieuwe RGV terwijl ze wel een onderdeel uit kunnen maken van de geconsumeerde
                 voeding. Hierdoor zou een vertekend beeld kunnen ontstaan. Wij hopen dat u op een of
                 andere wijze téch aan deze stoffen recht wilt doen.
                 4.       Bij ons wordt ook de vraag opgeroepen wat de consequentie is van het niet
                 opnemen van de verhoudingen tussen de verschillende cholesteroifracties in het bloed
                 maar uitsluitend naar LDL-cholesterol te kijken (alleen deze is als intermediair eindpunt
                 opgenomen). Dat dit voor de conclusies van het achtergronddocument over oliën en
                 vetten weinig uitmaakt, wil nog niet zeggen dat het voor andere documenten die de
                 relatie met hart- en vaatziekten in kaart brengen, ook het geval zal zijn. Wij hopen dat u
                 hier nog naar wilt kijken en indien enigszins mogelijk antwoord wilt/kunt geven.
                                               -
                                                                           -
                  5.      De keuze om alleen PubMed publicaties over de relatie tussen voedsel en/of
                  voeding en chronische ziekten te onderzoeken, levert een incompleet beeld op. Uiteraard
                  begrijpen we dat er op een of andere manier een afbakening moet plaatsvinden omdat er
                  anders wel een hele grote reeks publicaties meegenomen moet worden, zelfs met het in
                  acht nemen van de gestelde criteria aan het onderzoeksdesign. Desalniettemin zouden er
                  belangrijke publicaties kunnen ontbreken. Daarom willen we u vriendelijk verzoeken dit
                  punt te heroverwegen.
           F I1 II                                                       Respons consultatie eerste ronde achtergronddocurnenten 1 3
ED[RaU[ NEDERLAND5E
L[V JS.1IOOttN
</pre>

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<pre>                      Consultatie respons eerste ronde achtergrond documenten Gezondheidsraad
                      Granen en Graanproducten
                      Opinerkingen vooraf
                      Het valt ons op dat het recentelijk verschenen ontwerp rapport van de Britse SACN met
                      een uitgebreide systematische review met betrekking tot koolhydraten inclusief granen
                                                                                                      —
                      en graanproducten niet is meegenomen bij de beoordeling. De onderliggende
                                              -
                      methodologie is een andere dan die welke is gebruikt door de commissie, terwijl ook
                      andere intermediaire eindpunten zijn meegenomen. Wij vermoeden dat het SACN
                      rapport (ook al is het op dit moment nog een ontwerpversie) zeer complementair kan zijn
                      voor dit specifieke achtergronddocument.
                       Referentie:
                      The Scientific Advisory Committee on Nutrition (SACN), Draft Carbohydrates and
                       Health report, scientific consultation: 26 june to 1 september 2014. Note: This is a draft
                       report and does not necessarily represent the final views of the Scientific Advisory
                       Committee on Nutrition, or the advice/policy of Public Health England and Health
                       Departments.
                       Regels 53 77 -
                       Heeft de Commissie bij alle beschikbare onderzoek kunnen nagaan dat de 25% minimum
                       hoeveelheid volkorenmeel ook daadwerkelijk gehanteerd werd?
                       Verder is naar onze mening onderzoek gebruikt waarin zowel volkoren producten (min
                       25% volkoren), hoog vezel ontbijtgranen en zemelen worden meegenomen onder de
                       noemer ‘volkoren’. Wetenschappelijk gezien lijkt het erop dat deze verschillende groepen
                       dezelfde gezondheidseffecten bewerkstelligen en daarom zeker bij elkaar bi de analyse
                       gebruikt kunnen worden. in de publicatie van De Moura et al (2009) bijgevoegd—                —
                       wordt duidelijk dat bij gebruik van publicaties met de huidige volkoren definitie er te
                       weinig onderzoek is om relaties vast te stellen, terwijl als de bredere definitie van
                       volkoren wordt gebruikt, deze wel kunnen worden vastgesteld. Zij concluderen dan ook:
                        When considering only whole gram studies that met the FDA definitjon, we found
                        irisufficient scientific evidence to support a claim that whole gram intake reduces the risk
                        of CVD. However, a whole gram and reduced risk of CVD health claim is supported
                        when using a broader concept of whole gram to inciude studies that considered intake of
                        fiber-rich bran and germ als well as whole gram.
                        Het is in onze ogen zeer belangrijk om bij de conclusies steeds ‘volkoren, hoog vezel
                        producten en zemelen’ te schrijven en niet te volstaan met ‘volkoren’ (een andere optie is
                        om de type voedingsmiddelen die in de studies zijn gebruikt in relatie tot de uitkomst
                        maat te gebruiken). Officieel zijn zemelen en hoog vezel producten niet ‘volkoren’ en dan
                        kan er al gauw verwarring ontstaan. Dat laatste is niet in het belang van de consument.
              F î’1 II                                                            Respons consultatie eerste ronde achtergronddocumenten 1 7
1L5IDDE1[N
  FEDERATIE NEDERLANDSE
                  INDUStRIE
</pre>

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<pre>                    Consultatie respons eerste ronde achtergrond documenten Gezondheidsraad
                    Bovenstaand punt geldt voor veel meer plaatsen in het document. De GR vermeldt dit op
                    verschillende plaatsen ook maar in de conclusies wordt vervolgens volstaan met
                    uitsluitend het woord volkoren. Wij zouden willen voorstellen dit aan te passen.
                    Wij denken dat het ook belangrijk is om een definitie of omschrijving van ‘geraffineerde’
                    granen’ te hebben. Zijn dat graanproducten waarvan het aandeel volkoren minder dan
                    25% is? En hoe zit het dan met hoog vezel producten en zemelen?
                    Graanzemelen worden op zichzelf niet als volkoren aangemerkt omdat zij een onderdeel
                    vormen van de graankorrel. Wij zouden daarom willen suggereren dat het wellicht
                    zinvol is om ook nader in te gaan op de mogelijke bijdrage aan de gezondheid van
                    graanzemelen en bioactieve stoffen die in graanzemelen en volkoren producten aanwezig
                    zijn.
                    Het lijkt ons zinvol als de navolgende publicaties eveneens in de analyse worden
                     betrokken.
                     Referenties:
                     Consumption of cereal fiber, mixtures of whole grairis and bran, and whole grains and
                     risk reduction in type 2 diabetes, obesity, and cardiovascular deseases, American Journal
                     of Clinical Nutrition 2013, Aug. 98 (2): pp. 594-619.
                     Additionele studie volkoren versus geraffineerde tarweproducten en systolische
                     bloeddruk:
                     Bodinham CL, Hitchen KL, Youngman PJ, Frost GS, Robertson MD. Short-term effects of
                     whole-grain wheat on appetite and food intake in healthy aduits: a pilot study. Br J Nutr.
                     2011 Aug; 106(3):327-30.
                     Additionele studie volkoren versus geraffineerde tarweproducten en LDL cholesterol:
                     Tighe P, Duthie G, Vaughan N, Brittenden J, Simpson WG, Duthie S e.a. Effect of
                     increased consumption of whole-grain foods on blood pressure and other cardiovascular
                     risk markers in healthy middle-aged persons: a randomized controlled trial. Am J Cm
                     Nutr 2010; 92(4): 733-740.
                      Additionele systematische review volkorenproducten en diabetes mellitus type 2:
                      Priebe MG, van Binsbergen JJ, de Vos R, Vonk RJ, Whole grairi foods for the prevention
                      of type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2008, Issue 1. Art.
                      No.: CD006061. DOl: 10.1002/14651858.CD006061.
                      De Moura F.F., Lewis K.D., and Falk M.C., Applying the FDA defirution of Whole Grains
                      to the Evidence for Cardiovascular Disease Health claims, The Journal of Nutrition,
                      Suppiement, doi 1 0.3945/jn.1 09112383. (bijgevoegd)
            F F1 II                                                          Respons consultatie eerste ronde achtergronddocumenten 1 8
FWAT5 NEOERLAND5,E
1E’I[NSMIDOEIEN INDUSISIF
</pre>

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<pre>                    Consultatie respons eerste ronde achtergrond documenten Gezondheidsraad
                    Ferruzzi M.G., et al, Developing a Standard definition of Whole-Grain foods for dietary
                    Reconunendations: Summary Report of a Multidisciplinary Expert Roundtable
                    discussion, Adv. Nutr. 5: pp. 164-176, 2014. (bijgevoegd).
                    Tot slot vragen wij ons bij deze sectie af of producten als koek en banket ook tot de groep
                    graanproducten worden gerekend. Het zijn wel producten waarvan het belangrijkste
                    irigrediënt veelal de granen is.
                    Regels 78 85 -
                    Ontbijtgranen worden wel als voorbeeld meegenomen in regels 76-77 maar zijn niet in de
                    tabel opgenomen. Volgens onze gegevens is de gemiddelde per capita inname in
                    Nederland van ontbijtgranen ongeveer 7 gram per dag. Dat is vergelijkbaar met witte
                    rijst, maar veel meer dan roggebrood, haver en gerst. Het lijkt zinvol om ook de groep
                    ontbijtgranen toe te voegen.
                     Regel 201
                     Volgens ons is de literatuurverwijzing incorrect, dit zou 9 moeten zijn.
                     Regels 869 877-
                     In de tabel worden de volkoreneffecten beschreven als ‘volkoren versus geraffineerde
                     graanproducten’. Klopt dit wel? Het was behalve bij haver nergens uit de tekst te halen.
                     In regels 611/612 lijkt naar een vergelijking te worden verwezen. Maar bij de overige
                     publicaties lijkt er uitsluitend naar de effecten van volkoren te zijn gekeken, niet in
                     vergelijking met geraffineerde graan(producten).
                     Regels 931-933
                     Is de publicatie van Kyro over de biomarker alkylresorcinols wel gebruikt in het
                     document?
                     Referen ties:
                     Hauner H, et al. Evidence-Based Guideline of the German Nutrition Society:
                     Carbohydrate Intake and Prevention of Nutrition-Related Diseases. Ann Nutr Metab
                      2012;60(suppl 1):1-58.
                      Cho et al. Consumption of cereal fiber, mixtures of whole grains and bran, and whole
                      grains and risk reduction in type 2 diabetes, obesity, and cardiovascular disease. Am J
                      Clin Nutr. 2013 Aug;98(2) :594-619.
                      En de zeer recente, Wu H, et al. Association Between Dietary Whole Grairi Intake and
                      Risk of Mortality. JAMA 2015, E1-E13.
                      Regels 982-983
                      In de tabel ontbreekt de eenheid van de Follow-up duur: 6-40
             F N II                                                           Respons consultatie eerste ronde achtergronddocumenten 1 9
FEDERATIE NFDERAtID5E
LEVI 1150105E EEN_iNûus_J
</pre>

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<pre>The Journal of Nutrition. First published ahead of print September 23, 2009 as doi: 10.3945/jn.109.112383.
                                                                                                                                       The Journal of Nutrition
                                                                                                                                                      Suppiement
     Applying the FDA Definition of Whole
     Grains to the Evidence for Cardiovascular
     Disease Health 1                                  Claims
                                                       2
                                                       ’
     Fahiana F. De Moura, Kara D. Lewis, and Michael C. Falk»
     Life Sciences Research Office, Bethesda, MD 20814
     Abstract
                                                                                                                                             principal
     The U.S. FDA defines whole grains as consisting of the intact, ground, cracked, or flaked fruit of the grains whose
                                       endosperm,      germ,   and  bran,  are present   in the same    relative  proportions  as  they  exist  in the
     components, the starchy
                                                    of applying   the FDA   definition of whole   grains  to the strength  of scientific evidence    in
     intact gram. We evaluated the effect
                                                                                                                                               whole
     support of claims for risk reduction of cardiovascular disease (CVDI. We concluded that using the FDA definition for
                                                                                                          often  use a broader   meaning    to define
     grains as a selection criterion is limiting, because the majority of existmng studjes
     whole grains. When considering only whole gram studies that met the FDA definition, we found insufficient scientific
     evidence to support a claim that whole gram               intake reduces the risk of CVD. However, a whole gram and reduced risk of
     CVD health claim is supported            when    using  a broader concept of whole gram to include studies that considered intake of
     fiber-rich bran and germ as well as whole             gram.  This type of analysis is complicated by diversity in nutrients and bioactive
     components among different types of whole grains.                    J. Nutr. doi: 1O.3945/jn.109.112383.
      Introduction
                                                                                                U.S. whole gram health claim regulations
      In the US, food laws and regulations are generally supported hy                           One means to disseminate nutritional information is through
      sound scienti& evidence and aim to promote health and well                                label claims, in particular health claims, for foods and dietary
      being by providing the public with the basis to make inforrned                            supplements. These claims are regulated by the U.S. FDA onder
      nutritional choices. At times, food laws and regulations become                           the Federal Food, Drug and Cosmetic Act. Health claims for
      asynchronous. Either new evidence is discovered that contra                                food labels are authorized in the US by 2 amendments to the
      dicts the previous scientifc consensus or new policies are                                Federal Food, Drug and Cosmetic Act: the Nutrition Laheling
      introduced that may have the unintended consequence of                                     and Education Act (NLEA)  3 of 1990 and the Food and Drug
      misdirecting the public from goud nutritional choices. Thus, it                            Administrati     on  Modernizatio     n Act (FDAMA) of 1997. Under
      is necessary to periodically review the scientific evidence and                            the NLEA, a health claim is a food label statenient that
      update public policy to provide optimal nutritional guidance.                              characterizes a relationship between a food ingredient or specific
                                                                                                 food and a disease. Health claims must be aurhorized and
                                                                                                 published as regulations by the FDA to be used in food labels (1).
                                                                                                 To be approved as an NLEA health claim, the FDA must
       1
          This review summarizes the findings of a recent Life Sciences Research Office          evaluate the supporting evidence to ascertain it meets the
       (LSRO) report, “Whole Gram Intake and Cardiovascular Disease and Whole Gram               standard of significant scientific agreement, a level that bas heen
       Intake and Diabetes—A Revew” l8ethesda, MD: Life Sciences Research                        described as well after the state of emerging science but before
       Office, 20081. The suppiement coordinator for this suppiement is Michael C.
       Falk, LSRO. Publication costs for this suppiement were defrayed in part by the
                                                                                                 unanimous agreement. Such claims are also known as unqual
       payment of page charges. This publicatiori must therefore be hereby marked                ified health claims. In response to a series of court rulings, the
       ‘advertsement’ in accordance with 18 USC section 1734 soiely to indicate this              FDA has exercised enforcement discretion to also allow claims
       tact. The LSR0 report was developed under a contract between the Kellogg                   based on a lesser standard of evidence if the)’ contain language
       Company and LSRO. An independent Expert Panel appointed by LSR0 on the                     qualifying the strength of the claim. These are known as
        basis of their qualifications and freedom from conflict of interest provided
        scieritific oversight and direction for the study. The Kellogg Company provided a         qualified health claims. FDAMA health claims are based on an
        limited review of the report to assure contractual conformance, Supplement
        Coordinator disclosure; Michael C. Falk: no conflicts to disclose Catherine Ross
        handled the manuscript revew process, and had no Confl!ct of Interest. The
        opinions expressed in this publication are those of the authors and are not
                                                                                                  °
                                                                                                    Abbreviations used: AACC, American Association for Cereal Chemists; CHD,
        attributable to the sponsors or the publisher, Editor, or Editorial Board of The          coronary heart disease; CVD, cardiovascular disease; DBP, diastolic blood
         Journa/ of Nutrition.                                                                    pressure; EDAMA, Food and Drug Administration Modernization Act; LDL-C,
        2
           Author dsclosures’ F. F. De Moura, K D. Lewis, and M. C. Falk, no confl cts of         LDL cholesterol; LSRO, Life Sciences Research Office; Ml, myocardial infarc
         Interest.                                                                                tion; ND, not detected; NLEA, Nutrition Labeling ard Educaton Act; SBP,
           To whom all correspondence should be sddressed E-mail: falkm@LSRO.org.                 systolic blood pressure; TC, total cholesterol.
                                                                                                                                                                   iS of 7S
         0022-3166/08 $8.00 © 2009 Amerjcan Society for Nutrition
         doi: 10.3945[jn.109.1 12383.
                                                  Copyright (C) 2009 by the American Society for Nutrition
</pre>

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<pre>authoritative statement from an appropriate federal agency or                                       macronutrients, micronutrients, and bioactive components,
the National Academy of Sciences (2). Distributors or manu                                          including components thought to have a role in disease
facturers may submit to FDA a notification of a FDAMA health                                        prevention such as fiber, folate, phenolic compounds, lignan,
claim and ifFDA does not prohibit or modify it withïn 120 d of                                      and sterols (Tables 1 and 2).
receipt of the notification, the claim may be used. Therefore, the                                      Although working definitions of whole grains were in
health claim provisions in FDAMA were intended to expedite                                           common use, it was not until 1999 that a standardized definition
the process by which the use of food label health claims are                                         of whole grains was recommended on the basis of a consensus
aurhorized (3).                                                                                      among an ad hoc committee of experts from the American
                                                                                                     Association for Cereal Chemists (AACC). In 2006, the AACC
Corn position and definition of whole grains                                                         whole grains deflnition was adopted by the FDA in the
A whole cereal gram is the fruit (also known as the seed,                                            document “Whole Gram Label Statements” (4) to provide
caryopsis, or kernel) of plants belonging to the Poaceae (or                                         guidance to the industry about what the agency considers to be
 Gramineae) family also known as grasses. Some exaniples of                                          whole gram and to assist manufacturers in labeling their
 cereal grains are wheat, rice, barley, corn, rye, oats, millet,                                     products. The FDA defines whole grains as consisting of the
 sorghum, teff, triticale, canary seed, Job’s tears, fonio, and wild                                 “intact, ground, cracked or flakeci fruit of the grains whose
 nee. The seed is composed of 3 parts: the endosperm; the bran,                                      principal components—the starchy endosperm, germ and bran
 which is the outer layer of the whole gram; and the germ or                                         —are present in the same relative proportions as they exist in the
 embryo, which is located at the base of the gram. There is great                                    intact gram.” For purposes of this review, we will refer to the
 variability among the various whole grains in their content of                                      whole grains definition as the FDA definition of whole grains.
 TABLE 1            Nutrient concentrations of a variety of grains      t
                                      Barley            Brown                                Corn
                                     (hulled)
                                     3                   rice            Bulgur            (yellow)           Oats            Rye             Sorghum           Whet              Wild rico
 2
 Nutrient
                                                                                                            un/t/WO g
 Proximates
                                       1481              1548             1431               1627             1628            1402              1418              1389               1494
    Energy, kJ
                                      12.48              7.50            12.29               9.42            1689            14.76             11.30             1261               14.73
    Protein, g
                                        230              2.68              1.33              474              6.90            2.50              330                154                1.08
    Total lipid, g
                                      7348              76.17            75.87              74.26            66.27           69.76             74.63             71.18              74.90
    Carbohydrate, g
    4
                                      17.3               3.4             18.3                7.3             10.6            14.6                63              12.2                 6.2
    Ether, total dietary, g
 Minerals
                                                             33               36                  7              54               33               28                 29                 21
    Calcium, mg                            33
                                        3.60              1.80             2.46               2.71            472              2.67              4.40              3.19               1.96
    Iran, mg
                                         133               143              164                127              177             121                                 126                177
    Magnesium, mg                                                                                                                                 —
                                         264               264              300                210              523             374               287               288                433
    Phosphorus, mg
                                         452               268              410                281              429             264               350               363                 427
    Putassium, mg
                                           12                  4              17                 35                2                6                6                  2                  7
    Sodiurn, mg
                                                          202              1.93               2.21             3.97            373                                 2.65               5.96
    Zinc, ing                           2.77                                                                                                      —
                                        0.498             0.277            0.335              0.314            0.626           0.450                               0434               0.524
    Copper, mg                                                                                                                                    —
                                        1 943             3.743            3.048              0.485            4.916           2.680                               3.985              1.329
    Manganesa, mg                                                                                                                                 —
                                       377                —
                                                                           2.3               15.5                            353                                 70.7                 28
    Seleniurn, .ag                                                                                              —
                                                                                                                                                  —
  6
  Vitarnins
                                        0.646             0.413            0.232              0.385            0.763           0.316             0.237             0.383              0.116
    Thianrin, mg
                                        0.285             0.043            0.115              0.201            0.139           0.251             0.142             0.115              0.262
     Riboflavin, mg
                                        4 604             4 308             5.114             3.627            0.961           4 270             2.927             5.464               6 733
     Niacin, mg
                                        0.282              1.493            1.045             0.424            1.349           1.456                               0 954               1.074
     Pa9tothenic acid, mg                                                                                                                         —
                                        0318              0.509             0.342              0.622           0.1 19           0.294                               0.300              0.391
     Vitamin B-6, ing                                                                                                                             —
                                            19                20               27                19               56               60                                 38                  95
     Folate, pg                                                                                                                                   —
                                                                          28.1                                                30.4                                31.2               35.0
     Choline, total, mg                   —
                                                                                                —
                                                                                                                —
                                                                                                                                                  —
                                                                0               0                 11                0                1                0                  0                  1
     Viiamin A, 1 ig_HAE                     1
                                         0.57                               0.06               0.49                             1.28                                1.01               0.82
     Vitamin E’ mg                                          —
                                                                                                                —
                                                                            1.9                0.3                              5.9                                 1.6                1.9
     Vitamin K, g                        2.2                —
                                                                                                                —
                                                                                                                                                   —
  Other
                                            13                                  5                 97                                 7                                   5                11
     -Carotene, ig                                          —
                                                                                                                —
                                                                                                                                                   —
                                          160                                220               1355                              210                                 220                 220
     Lutein + zeaxanthin, pg                                —
                                                                                                                 —
                                                                                                                                                   —
   Adapted from (11), wjth permission.
    Nutrieni values and weights are for edible parten,
                                                                                                                                                                               bulgur (Tnlicum)
    Scieniific namen and specificaiions of grains (top row, trom left to rightl: barley, hulled lHordeum vu/gure L.l; rico (Oryza SatiVa L.), brown and medium-gram raw;
  dry, corn, yellow (Zee mays Lj; oats (Avena sariva L.); rye lSeca/e cereale L.), sorghum (Sorghum sppj; wheat (Triticum aestivum L.(.
                                                                                                                                                  hard red winier, wild rico, ram (Zizani spp).
    The sum of availabla ard nonavailable caroonydrate.
    Dash repr050nts the nutrients not listod in the USDA daiabase for the reapective grains
    The values lor vitamin C and viiamin 012 for all the grains listed above ware 0.0 mg/100 g.
    Vitamin E values are lor a-t000pherol.
  2S of 7S Supplement
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<pre>TABLE 2             Phytochemical content of cereal grains and brans         1
                                                                                Whole cereal gram                                                    Bran
Phytochemicals                               Reference            Rarley         Dat            Rye          Wheat            Rarley           Dat          8
                                                                                                                                                            y e            Wheat
Lignan, cg/1OOg dry weight                     (12,13)
     Total                                                          58           13.]           112            35.5             63             179           299             110
     Matairesinol                                                     0           0.3             65             26              0             155           167               0
     Secoisolariciresinol                                           58           13.4             4]           32.9             63              24           132             110
Isotlavonaids, pg/1OOg dryweight               (12)
     Total                                                         21.7            0                0              0           22.7              0              3           104
     Daidzein                                                        14            0                0              0            64               0             0             3.5
     Genistein                                                      7.]            0                0              0           16.3              0             0             6.9
Phenolic acids, ycg/g dry we/gist              (14—18)
     Total                                                         478            9.4          1210             640                            360          3360            5655
     Ferulic                                                       478            2.1          1035°            640             —              360          2780            5410
      Sinapic                                                       —
                                                                                                 1202           —               —
                                                                                                                                                —            390              75
                                                                                  ]3              552           —               —
                                                                                                                                               —             1902            170
     p-coumaric                                                     —
Phenolic lipids, jig/g dry weight               (19,20)
     Akylresorcinols                                                 45           —              734            583             —              ND           2758            2211
      Sterols, mg/100g Wet weight              (21)
     Total sterols                                                 67.8          33.5           88.7           66.4             —               —            —
      Carnpesterol                                                   17             4              17             12            —               —            —               —
      Campestanol                                                   0.8          Trace            8.3            65             —               —            —               —
      Stigmasterol                                                     3           1.6            3.4            1.9            —               —            —               —
      Sitosterol                                                     46           27              48              36            —               —            —               —
      Sitostanol                                                       1           0.9             12             10            —               —            —               —
 1
    This is an Ilustrative tab!e comparing the dietarv tiber and phytochemical content ot 4 coreal grains and their respective bran. It is not meant to be repr000ntative.
 2
     Mean values ot difteront cultivars.
     Dash represents data not found, it doos not necossanly mean that data are unavailable.
        The FDA has approved health claims relating to the effect of                          relevant articles: (whole gram OR whole grains) AND (cardio
 diet and reduction of risk of cardiovascular disease (CVD) (5).                              vascular disease OR heart OR coronary heart disease OR stroke
 Three NLEA health claims have been approved for gram products                                OR blood pressure OR myocardial infarction OR health OR
   (not whole grains), 1 related to cancer (6) and 2 related to                               diabetes). The MEDLONE searches returned 634 potentially
 coronary heart disease (CHD) (7,8). All health claims for gram                               relevant articles. Additional articles were identified from a Web
  products refer to a specifc subsrance, 1 to total dierarv fher,                             of Science darahase search using the same kevwords used for the
  the others to soluble dietary fiber, and a disease coiriponent. The                         MEDLINF. search. Other studies were identified by biblio
   FDAMA healrh claim addressing whole grains is based on the                                 graphic searches of relevant reviews and articles.
  following authoritative statement: “diets high in plant foods—                                     The Life Sciences Research Office (LSRO) report was guided
   i.e., fruits, vegetables, legumes, and whole gram cereals—are                              by an independent expert panel composed of Julie Mares, Ph.D.,
   associated with lower occurrence of CHD and cancers of the lung,                           Judith Marlett, Ph.D., Harry Sapirstein, Ph.D., and James
  colon, esophagus, and stomach” extracted froni the NRC report                               Hoadley, PIi.D., whose fields of expertise are in epidemiology,
   (9). The scientific research upon which these claims were based                            nutrition, cereal chemistry, and federal food regulations, respec
   was largely conducted prior to the 2006 release of the FDA                                 tively. Two scientists independently reviesved each article for
   guidance document on the definition of whole grains. In this                               inclusion and to ensure the information was accurately ab
   context, we conducted an independent review of the scientific                              stracted from the article. Further details about methodology
   literature to evaluate the effect of applying the FDA deflnition of                        may be found in the LSRO report.
   whole grains on the strength of scientific evidence in support of
   whole-grain health claims for risk reduction of CVD and diabetes                           Inciusion criteria
   (10). Here, we restrict the results and conclusions of that review                         The inclusion criteria were derived from the specifications of the
   regarding the outcomes for CVD only and expand beyond the                                  FDA guidelines for studies eligible to establish a health claim
   report to elaborate public health implications. It is important to                         under the NLEA (22). Therefore, reviews, editorials, and meta
   note that the FDA has not conducted such a review, because the                              analysis studies (n = 200) were excluded, as were studies not
   only health claim petitions related to whole grains were submit                             written in English (n = 28). Although the FDA may use animal
   ted under FDAMA and based on the conclusions of the NRC                                     and in vitro studies as background information, only human
    rather than an independent FDA review of the literature.                                   intervention and observational studies were considered for the
                                                                                               purpose of this study. According to the FDA, only these studies
                                                                                               can provide evidence from which scientiflc conclusions can be
    Methodology                                                                                drawn about substance and disease relarionships in humans.
    Literature search                                                                          Consequently, animal and in Vitro studies were also excluded
    We conducted a comprehensive search of the scientific literature                           (n = 79). A total of 327 articles remained. After reading titles
    by searching MEDLINE for articles published through February                               and abstracts, 204 articles were evaluated further. Studies were
    2008. The following search strategy was used to identify                                   considered if they measured a validated endpoint [i.e. CHD,
                                                      Who)e gram      intake and cardiovascular disease and who)e gram              intake and diabetes: a review          3S of 7S
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<pre>myocardial infarction (Ml), ischemic heart disease, and strokej                        control. Although the 2 observational studies observed a signif
or surrogate endpoints [i.e. blood pressure, total cholesterol                         icant reduction of CVD-related surrogate endpoints, the absence
concentration (TC), and serum LDL cholesterol (LDL-C)                                  of support from intervention studies leads to the conclusion that
concentrationi for CVD in a healthy U.S population and                                 the evidence does not support a health claim for the reduced risk
populations representative of the US. Two scientists indepen                           of CVD.
dently reviewed each article for inclusion and to ensure the
information was accurately abstracted from the article.                                Expanded analysis
     LSRO first analyzed only studies that explicitly described or                     The expanded approach included additional human studies for a
defined whole grains according to the FDA definition of whole                          total of 29 (15 intervention and 14 observational) studies for the
grains to evaluate the effect of applying the FDA definition of                        association between whole gram consumption and CVD.
whole grains on the strength of the scientific evidence. Later,                             Most of the observational studies in the expanded definition
LSRO expanded the analysis to include studies with a broader                           analysis (Table 3) were excluded from the FDA definition
definition of whole grains, including studies that added bran                          because thev considered the intake of bran, germ, or fiber along
and/or germ along with whole grains or studies that did not                            with whole gram foods. Twelve additional observational studies
explicitly use the term whole grains but were in fact conducted                        were included in the evaluation when considering an expanded
with individual whole grains (e.g. oats or barley). Other sources                      definition of whole grains. Of these 12 studies, 10 defined whole
of dietary fiber not derived from whole grains or typically found                      grains as described by Jacobs Jr. et al. (27), who included
in whole gram foods (e.g. psyllium seed husk, inulin) were not                         individual bran and germ as whole gram: Esmaillzadeh et al.
included.                                                                               (28), Jacobs Jr. et al. (27), Jacobs Jr. et al. (29), Liu et al. (30), Liu
                                                                                       et al. (31), Liu et al. (32), McKeown et al. (33), Newby et al.
                                                                                        (34), Steffen et al. (35), and \Vang et al. (36); 1 study assessed
Resuits                                                                                intake of vhole gram bread (37,38); and 1 study evaluated the
Restricted analysis (FDA definition only)                                              effect of oats (39). Results of all 14 observational studies
Only 4 studies conformed to the EDA definition of whole grains.                         included in the expanded definition, regardless of their whole
Two were observational studies, including a prospective cohort                         gram source, suggested a protective association between whole
study (23) and a cross-sectional study (24). jensen et al. (23)                        gram intake and risk of CVD (Table 3).
observed a reduced relative risk of CHD comparing the highest                               Most of the intervention studies in the expanded definition
to the lowest quintile of whole gram intake (P-trend = 0.01).                           analysis (Table 4) were excluded from the FDA definition
Jensen et al. (24) observed a decrease in total cholesterol of                          analysis because the authors had not explicitly stated that the
0.16 mmol/L comparing the highest to the lowest quintile of                             endosperm, bran, and germ are present in the same proportion
 whole gram intake (P-trend = 0.02). Two were randomized,                               as required hy the FDA definition. Although the intervention
crossover design intervention studies (25,26). Notably, both of                         study by Andersson et al. (25) that met the FDA definition
 these were published after the FDA definirion of whole grains                          reported no effect on CVD outconles, other inrervention studies
 was publicly released. Neither study evaluated health outcomes                         in the expanded definition generally reported a beneficial effect.
 per se but both evaluated surrogate endpoints such as TC, LDL-C,                       A beneficial effect of oats was reported in 6 studies (40—45),
 systolic blood pressure (SBP), and diastolic blood pressure                            whereas only 1 study showed no effect (46). Studies of oats that
 (DBP). Neither study observed any significant clifferences from                        reported a positive effect were conducted for 6—S wk compared
 TABLE 3            Observational studies on the association of whole gram              intake and incidence of CVD
 Author, publication year,                        Study             Whole gram                        Length,        (Surrogate)
 and reference                     Population     design                intake         Sex       n        y           endpoint                     Outcome
 Restricted analysis
   Jensen ei al,, 2004 (23)          OS       Cohort          3.5 vs. 42.4 servings/d  M     40,850       2   CHD                      RR = 0.82, P-trend = 0.01
   Jensen et al., 2006 (24)          OS       Cross-sectional 82 vs. 43.8 g/d          F/M        938   NA    TC and LDL-C             Lowered IC, P-trend = 0.02
 Expanded analysis
    Fraser ei al,, 1992 (37);        OS       Cohort          Bread. whole             F/M   26,473     6—8   Fatal MI                 Whole 8H = 0 45, P < 0.01
    Fraser et al, 1999 (38)                                      wheat vs wnite                               Nonfatal Ml              Nonsignificant
   Jacobs et al., 1998 (27)          OS       Co’rort         02 VS. 3.2 servings/d    F      31,284       9  Ischemic heart disease   RR = 0.70, P-trend = 0.02
    Jacobs et al., 1999 (29)         US       Cohort          0.2 ‘is. 3.2 servings/d  F      31 .284      9  CHD                      AH = 0.82, P-trend = 0.03
    Liu et al., 1999 (30)            US       Cohort          0.13 ‘is. 2.7 servings/d F      76,521     10   CHO                      RR = 0.67. P-trend < 0.01
    Liu et al., 2000 (32)            IJS      Cohort          0.13 no. 2.7 serVings/d  F      75,521     10   Ischemic stroke          RR = 0.64, P-trend = 0.04
    Steffen et al., 2003 (35)        OS       Cobort          0.1 xs. 3.0 servings/d    F/M   15,792     11   Incident coronary        AH = 0.52, P-trend = 0.001
                                                                                                                 artery disease
    Liu es al., 2003 (31)             OS      Cohart          rare vs. 1.0 serxings/d   M     75,521     6.6  CVD mortality            89 = 0.80, P-trend = 0.08
    Wang et al,, 2007 (36)           OS       Cohen           <0.5 xs. >4 servings/d    F     28,926     10   HypertenSion             98 0.77, P-trend 0.607
    He ei al, 1995 (39)              China    Cross-sectional 0 VS. 90 g oats/d         F/M       850    NA   TC, LDL-C, SBP, and UBP  Decreased all )P < 0.05)
    McKeow9 et al., 2002 (33)         US      Cross-seciional 0.1 VS. 2.91 serVings/d   F/M     2941     NA   TC, LOL-C, SBP, and DBP  Decreased TC (P-trend = 0.02)
                                                                                                                                          and LDL-C (P-trend = 0 006)
    Esmaillzadeh et al., 2005 (28)    Iran    Cross-sectional 6 ns. 229 g/d             F/M       827    NA   TC, LDL-C, SBP, and DBP AH = 0.84, P-trend = 0.03
    Newby ei al., 2007 (34)           US      Croos-sectisnal 0.63 VS. 45.6 g/d         F/M      1516    NA   IC, I.DL-C, SBP, and DBP Decreased TC (Pfor trend = 0.02)
                                                                                                                                          and LDL-C (Pfor trend = 0.04)
  4S of 7S Supplement
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<pre>TABLE 4             Intervention studies on the association of whole gram               intake and incidence of CVD
Author, publication,                                                                                                            Length,
year, and reference       Populatian     Study design             Cereal gram                    Guantity         Sex       n     eik                  Outcome
Restricted analysis
Anderssnn et al.,          Sweden    Randomized crossover Whnle gram                     112 g/d                  PIM    22/8       6   No nignificant changos in iC,
   2007 25)                                                                                                                                LD[-C, SBP,  and DBP
Reve at al.,               Gersnany  Rendnmized cronsover Wheie whnat’                   200 g/d                  F/M    18/13      4   Na nigeificant changns in TO,
   2007 (26)                                                                                                                               [DL-C, SBP,  and DOP
Expanded anolysin
JJ44 et ei.,               England   Randnmized cr0550vvr Rnlled nasa                    125 g/d                  F/M      4/5      3   No nignificani ctsango in TO
    1981 (45)
Van Hem nO al.,            US        Rondomized parallel  Oet bres and oatrneal          60 g/d                   F/M    99/109     6   Decreased TC with oatmoa[ enly
    1985(45)                                                                                                                               (P<005)
Van Hem et al.,            US        Randomized parallel  Ootmoal                        60 g/d                   PIM  1 50/86      8   No significant change in TC
    1988 43)
Van Hem er al.,            US        Rxndsmizcd parallel  Oxtmaal                        56 g/d                   F/M    40/40      8   No signilicant changen in TC,
    1991 (44)                                                                                                                              LDL-C, SBP, and DBP
Davidnnn al al.,           GO        Hendemized parallel  Dat bron and eatrneal          28, 56, er 84 g/d        P/M    60/80      6   Decreased TC and [DID (P < 0 05)
    1991 (40)                                                                                                                              with eet bran (56 and 84 g/d) and
                                                                                                                                           oatmeal (84 9/di
Saltzrrren et al  ,        US        Randsmized parallel  Oets                           45 g/d                   PIM    23/20      8   Decreasnd TC, [01-0, and SBP
    2001 142)                                                                                                                              (P< 005)
Kennen ot al.,             US        Randomzed parallel   Gat cemeal                     552 g/d p glecan         F/M      9/9      6   Dato decrcased TO, LDL-C, SBP,
    2002 (41)                                                                                                                              and DOP IP < 0 05)
 Da as al..                 IJS      Randornized parallel Oat cereel                     Oatrneal: 60 gld and     PIM    18/18     12   Ns’ significant changos ie SBP and Dop
    2002 151)                                                                                set bran 76 g/d
 Hallfrisch et al.,         US       [atin square         BerIep, bmown rico, and whcat  0, 3, er 6 g/d 13-glucan   M       16       5  Decreasnd SBP (P= 0 0004)
    2003 (52)                                                                                                                               and DOP )P= 0.015)
 Onheil et al.,             US       [atin sqaare         Barley, brown rica, end whoot  0, 3, or 6 g/d /3glucen    M       16       S  Decreased TO and
    2004 148)                                                                                                                               [D[-C )P < 0.0001)
 BohalI at al..             US       [etn oquare          BerIep, brnwn rica, and whear  0.3, er 6 g!d [3-glucen   F/M    18/7       5  Decrcaacd TO end [D[-C (P< 0.0031)
    2004 (471                                                                                                                               nnly whcn berIep wan incladod
 Behall et al.,             US       [atin sqaaro         Beriep, b’own rico, and wheet   0, 3, cr6 g/d /3-gljcan  PIM    18/7       5  Decmeased DBP IP < 0.0093) wth alt
    2006 (49)                                                                                                                               grainn, end SBP (P < 0993) with all
                                                                                                                                            graino accept with 100% barloy
 liet al., 2003 (50)        Japan    Randomized crossover Berley                          1.8 97kg body weight       t      10       4   Decreased TO and LD[-C (P< 0.05)
   Starch-reduced whole gram dorived trom doublo-fermentod whest.
 with fewer than 3 wk for rhose studies that reported no                                     intake of bran and germ to evaluate the health effect of whole
 benefkial effect. Four interventiors studies with harley showed a                           grains, and a great number of intervention studies that use
 reduction in plasma TC and LDL-C levels. Three of these barley                              individual grains, because they do not explicitly state that the
 studies were published by the same research group in the US (47—                            endosperm, bran, and germ are present in the same proportion.
 49) and the other was conducted by a research group in Japan                                    The scientific evidence on the relationship between whole
 (50). Two of these studies had a similar study design, sample                               gram consunaption and CVD can be evaluated 2 ways (Table 5).
 size, and study duration. One studied a diverse population of                               First, there is no consistent scientific evidence to support a whole
 American men with hypercholesterolemia (48) and the other                                   gram and CVD risk health claim if only whole gram studies that
 studied healthy Japanese women (50), but they reported similar                              explicitly conform to the FDA whole gram deflnition (using the
 reductions in TC (20—15%) and LDL-C (21%) levels. The                                       “native” proportion of endosperm, bran, and germ) are consid
 positive effect of barley reported across population, gender, and                           ered. To date, only 4 studies conform to the FDA definition. In
 health status adds strength to the evidence for a beneficial health                         contrast, a whole gram and CVD health claim is supported using
 effect of barley on plasma TC and LDL-C levels.                                             a broader concept of whole gram typically used in the scientific
       A consistent definstion of whole grains has not been applied                          literature that includes whole gram foods containing principal
  in existing research that investigates the health benefits of                              components such as bran. A health claim for the relationship
  consuming whole grains. As such, drawing specific conclusions                              between soluble fiber from oats and barley and risk of CHD has
  about healrh benefits of whole grairis in general from the body of                         been approved by the FDA (53).
  scientific literature is confounded, typically with bran/dietary                                The results also suggest that the health beneflts observed from
  fiber. Using the FDA definition for whole grains as a selection                            consumption of 1 whole gram do not necessarily reflect the same
  criterion is limiting, because the vast majority of studies often                           benefit or the same magnitude of beneflt from other whole
  have used a broader meaning to categorize a gram product as                                 grains. For example, intake of oat and barley producos for 5—6
  whole gram. Restricting the analysis of the literature about                                wk had a beneficial effect on reducing TC and LDL-C plasma
  health benefits of whole grains to studies explicitly using the                             levels, whereas intake of whole wheat products elicited no
  FDA definition of whole grains results in the exclusion of                                  significant change in those variables when consumed for the
  the majority of observational studies, because they include the                             same length of time (Table 4). This may be doe to the diversity
                                                  Whole gram     intake and cardiovascular disease and whole gram intake and diabetes: a review                        5S of 7S
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<pre>TABLE 5         Comparing the FDA definition with the                           health benefirs of whole grams other than oats and barley, and
                expended definition                                             on the relative contribution to health benefit of the individual
                                                                                gram components such as bron, germ, flber, and phvtochemicals.
                        FDA definition Expanded
Outcome       Design         only       definition    Expanded analysis
GVD        Intervention       2             15     Beneficial effect            Literature Cited
           Observation&       2             14     Consistent protective effect
                                                                                1.    Nutrition Labeling and Education Act of 1990, Pub. L No. 101—535,
                                                                                      DS. Congress (Nov 8 1990).
                                                                                2. DS. Congress. Pub. L. No. 105—115. Lood and Drug Administration
                                                                                      Modernization Act of 1997. FDA; 1997 [cited 2008 Jun 20]. Available
among whole grains in terms of macronutrient, micronutrient,                          from: http://www.fda.gov/CDER/guidance/ 105—11 5.htrn.
lber, and bioactive components. For example, the total fiber                    3. DS. FDA. Guidance to industry: notiOcation of a health claim or
content of bulgur and barley is —5-fold higher than that of hrown                     nutrient content claim based ori an authoritative statement of a scientiOc
rice (Table 1). Rye contains the highest amount of lignan and                         hody. FDA; 1998 lcitcd 2008 jun 5]. Availahic from: http://www.cfsan.
                                                                                      fda.govl-.dms/hclmguid.htnsl.
sterols (other than phenolic acids and phenolic lipids) compared
                                                                                4. U.S. FDA. Guidance for industry and FDA staff: whole gram label
with wheat, oats, and barley (Table 2). Furthermore, some                             statements [draft guidance]. LDA; 2006 (cited 2008 May 30]. Available
nutrients are absent in some grains but present in high amounts                       from: http://www.cfsan.fda.gov/-.dms/flgragui.html.
in other grains as in the case of vitamin A, /3-carotene, lutein, and           5. U.S. LDA. Qualifled health claims. FDA; 2006 citcd 2009 Mar 20).
zeaxanthin that are present in high levels in corn but absent in                      Available from: http://www.cfsan.fda.gov/—dms/lah-qhc.html.
brown rice, oats, and sorghurn (Table 1). Therefore, the                         6. DS. Code of Fcderal Regulations. 21 CLR § 101.76 llealth claims:
variation in constituents among types of whole grains should                          fiber-containing gram products, fruits, and vegetables and cancer. 2001
be considered when associating whole grains with a health                             [cited 2008 jun 16]. Available from: http://edocket.access.gpo.gov/
                                                                                      cfrZOOi/aprqtr/pdf/21 cfrlOl .76.pdf.
henefit. Among the intervention studies included in the ex
                                                                                 7. DS. Code of Lederal Regulations. 2) CFR § 101.81 Jlealth claims:
panded defirtition, only the studies conducted with oats and                          soluble Ober from certain fonds and risk of coronary heart diseasc
barley (44,48) reported reduced cholesterol levels. Milled wheat                      (Cl ID). 2001 Icited 2008 inn 16]. As’ailable from: http://edocker.access.
did not lower serum cholesterol levels (25). Therefore, studying                      gpo.gov/cfr.200i/aprqtr/pdfl2 1 cfrl 01.81 .pdf.
the association of individual grains, rather than an entire                      8. DS. Code of Federal Regufations. 21 CLR §101.77 I-lcalth claims:
category of whole grains, with a particular health benefit would                      fruits, vegetablcs, and gram products that contain Ober, particularly
                                                                                       solublc Ober, and risk of coronary heart disease. 2001 [cited 2008 Jun
provide additional evidence about the possible benecial corn
                                                                                       16]. Available from: hctp://cdocker.acccss.gpo.gov/cfr.2001/aprqcr/pdf/
 ponents of whole grains.                                                             2lcfrlOl.77.pdf.
                                                                                 9. NRC. Dier and health: innplications for reducing chronic disease risk.
 Beyond the LSRO report: implications for public health                                Washington, DC: Nationaf Academies l’ress; 1989.
 Because the majority of scientific evidence supporting the CVD                  10. life Sciences Research Office. Whole gram intake and cardiovascular
 health beneflts of whole grains is confounded, typically with                         disease and whole gram intake and diabetes. A reviesv. Bethesda (MD):
 bran, gerrn, or fiber, it is difficult to dissociate the effect of whole              Life Sciences Research Offlcc; 2008.
 grains from that of their major components. Restricting the                     11. USDA. Composirion of foods raw, processed, prepared USDi\ national
                                                                                       nurrient database for standard refercnce, release 20. 2008 Icited 2008
 scienrific evidence to onlv that which expresslv and clearly
                                                                                       jun 21. Available from: lrttp://svwns.nal.usda.gov/mnic/foodcomp/Data/
 addresses whole grains is an artificial construct and obscures the                    SR2O/SR2Odoc.pdf
 potential benefits of whole gram components. The scientific                      12. Adlercreutz 1-1, Mazur W. Phyto-oestrogens and Western diseases. Ann
 evidence supporting the CVI) health benefits of fiber are well                        Mcd. 1997;29:95—120.
 documented in approved health claims. Public health policy and                   13. Nilsson M, Ânian P, l-larkönen II. 1 lallrnans G, Knudsen KEB, Ma,ur
 dietary recommendations on carbohydrate intake should clearly                          cç Adlercrcutz F1. Content of nutrients and lignans in roller milled
 communicate the value of whole grains, gram foods, and cereal                          fractions of rye. j Sci Food Agric. 1997;73:143—8.
 fiber by broadening recommendations to any gram that is a good                   14. Adoni KK, Liu R1-l. Antioxidant activity of grains. j Agric Lood Chem.
                                                                                        2002;50:6 182—7.
 source of fiber. Moreover, because the FDA definition does not
                                                                                  15. Andreasen MF, Christenscn LP, Meyer AS, 1 lansen A. Content of
 include an assessment of fiber, the label “whole grains” can be                        phenolic acids and ferulic acid dehydrodimers in 17 rye (Secale cereaie
 mistakenly understood as a goud or excellent source of fiber,                          L.) varicties. j Agric Lood Chem. 2000;48:2837—42.
 although that is not necessarily the case. This may have the                     16. Andreasen ML, Kroon PA, Williamson G, Garcia-Conesa Ml. Esterase
 negative effect of limiting fiber intake rather than increasing it.                    accivity able to hydrolyze dietary antioxidant hydroxycinnamaces is
 Broadening recommendations to include bran and including an                            distributed along the intestine of mammals. J Agric lood Chem.
                                                                                        2001;49:5679—84.
 assessment for fiber may be warranted to signiflcantly increase
                                                                                  17. Zupfer jM, Churchill KE, Rasmusson DC, Fulcher RG. Variation in
 Americans’ fiber intake.                                                               ferulic acid concentration among diverse barley cultivars nieasured by
     Although whole grains share enough similarities to be                              1 IPLC and microspectrophotometry. j Agric Lood Chem. 1998;46:
 thought of as a class, there are significant differences among                          1350—4.
 the individual grains not only in the fiber content (Table 1) or                 18. Bryngefsson S, Dimberg LII, Kamal-Eldin A. Effects of commercial
  bran but also in the content of putative bioactive compounds                          processing on levels of antioxidants in oats (Avena sativa L.(. J Agric
                                                                                         l:ood Chem. 2002;50:1890—6.
  (Table 2), such that products of the various grains may have
 substantially different health benefits. The majority of the                      19. Ross AB,, Shepherd MJ. Schupphaus M, Sinclair V, Alfaro B, Kamal
                                                                                         Eldin A, t.man P. Alkylresorcmnols in cereals and cereal products. J Agric
  intervention studies on whole gram and CVD were conducted                              Lood Chern. 2003;51:4111—S.
  with oats and barley (Table 3). Potenrially, claims of whole gram               20. Chen Y, Ross AB, Âmari P, Kamal-Eldin A. Alkylresorcinols as markers
  health benefits could be restricted to only those grains for which                     of whole gram whcat and rye in cereal products. J Agric Lood Chem.
  adequate scientiflc support can be demonstrated to avoid                               2004;52:8242—6.
  generalizing conciusions based on evidence developed on a                        21. Piironen V, Toivo j, Lampi A-M. Plant sterols in cereals and cereal
  specific gram. Additional research is required to identify the                         products. Cereal Chem. 2002;79: 148—54.
  6S of 7S Supp(ement
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<pre>22. US. FDA. Guidance for industry: evidence-based review system for the           37. Fraser GE, Sahate J, Beeson WL, Strahan TM. A possible protective
     scientific evaluatton of hcalth claims [draft guidance]. 2007 [cited 2008          effect of nut consumption on risk of coronary heart disease: ‘the
     Mar 3j. Availabic from: htrp://www.cfsan.fda.gov/..dms/hclmguii.html.              Adventist ilealth Study. Arch intern Mcd. 1992;152:14l6—24.
23. Jcnscn MK, Koh-Banerjcc P, Hu EB, Franz M, Sampson L, Gronhack M,              38. l:raser GE. Associations between dier and cancer, ischemic heart disease,
     Rimm EB. intakes of whole grains, bran, and gerni and the risk of                  and alI-cause moriality in non-I-lispanic white California Seventh-day
     coronary heart disease in men. Ani J Clin Nurr. 2004;80:1492—9.                    Advcntists. Am J Clin Nutr. 1999;70:S532—S.
24. Jcnscn MK, Koh-Bancrjee P, Eranz M, Sanapson L, Gronbaek M, Rimm               39. 1-1e J, Klag MJ, Whelton PK, Mo JP, Chen JY, Qian MC, Mo ES, 11e GQ.
     EB. Whole grains, bran, and germ in relation to honiocysteine and                  Oats and huckwhcat intakes and cardiovascular disease risk factors in
     naarkers of glycemic control, lipids, and inflammation. Am J Clin Nutr.            an ethnic minority of China. Arn J Clin Ntitr. 1995;61:366—72.
     2006;83:275—83.                                                               40. Davidson MII, Dugan LD, Burns JIl, Bova J, Story K, Drennan KB. The
25. Andersson A, Tengblad S, Karlstroni B, Kamal-Eldin A, Landherg R,                   hypocholcsteroleniir effects of beta.glucan in oatrneal and oat bran: a
     Basu S, Aman P, Vessbv B. Whole.grain foods do not affect insulin                  dose.cnntrolled siudy. JAMA. 1991 ;265:1 833—9.
     sensitivity or markers of lipid peroxidation and inflammation in hcalthy,     41. Keenan JM, Pins JJ, Frazel C, Moran A, Turnquist L. Dat ingesrion
     moderately overweight subjects. J t’utr. 2007;137:1401—7.                          reduces systolic and diastolic blood pressure in patients svith mild or
26. Rave K, Roggen K, Dellweg S, 1 Icisc T, Tom DII. Improvement of                     bordcrline hypertcnsion: a pilot trial. J Fam Pract. 2002;51:369.
     insulin resistance after diet with a whole.grain based dietary product:       42. Salteman E, Das SK, Lichtenstein All, Dallal GE, Corrales A,
     rcsulrs of a randomized, controlled cross-over study in obesc stibjccts            Schaefcr Ej, Greenberg AS, Roberts 5E. An oat-containing hypo
     with elevated fasting blond glucose. Er J Nutr. 2007;98:l—8.                       caloric diet reduces systolic blond prcssure and improves lipid profile
27. Jacobs DRJr, Meyer KA, Kushi LII, lolsom AR. Whole-grain intake may                 bcyond cffects of weight loss in men and women. J Nurr. 2001;131:
     reduce the risk of ischemic heart discase death in postmenopausal womcn:           1465—70.
     the lowa Women’s Health Study. Am J Clin Nutr. 1998;68:248—57.                43. Van Horn L, Emidy LA, Liu KA, Liao YL, Ballew C, King J, Staniler J.
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     nietaholic syndrome: a favorable associarion in Tehranian adulis. EurJ             Mcd. 19S8;17:377—b’6.
     Clin Nutr. 2005;59:353—62.                                                    44. Van 1-lom L, Moag-Stahlberg A, i.iu KA, Ballew C, Ruth K, 1 lughes R,
29. Jacobs DR Jr, Meyer KA, Kushi LII, Folsom AR. Is whole gram intake                  Stamler J. Effeets no serum lipids of adding instant nats to usual
     associated witli reduccd total and cause.speciflc death rates in older womcn?      American diets. Am J Public I-Iealth. 1991;81:183—8.
     The losva Wonien’s 1 lealth Study. Ani J Public 1 lealth. 1999;S9:322—9.      45. Van Ibm IV, Liu K, Parker t), Eniidy L, l.iao YL, Pan Wil, Giumetti
30. Liu S, Stampfcr MJ, 1 lu EB, Giovannucci E, Rinim E, Manson JE,                     1), 1 lewitt J, Stamler J. Seruni lipid rcsponsc to nat product intake with
     1 Iennckcns CII, WiHett WC. Whole-grain consurnption and risk of                   a fat.rnodificd diet. J Am Dict Assoc. 1986;86:759—64.
     coronary heart discasc: results from the nurses’ hcalrh study. Am J Clin      46. Judd PA, Truswell AS. The effect of rolled oats on blood lipids and fecal
     Nutr. 1 999;70:41 2—9.                                                             steroid excretion in man. Am J Clin Nutr. 1981;34:2061—7.
31. Hu S, Sesso III), Manson JE, Willctt WC, Buring JE. is intake of               47. BelialI KM, Scholfield DJ, 1 lallfrisch J. Dicts containing barlcy
     hreakfast cercals related to total and cause-specific mortality in nico?            signiflcantly rcducc lipids in mildly hypercholesterolrmic men and
     Ani J Clin Nutr. 2003;77:594—9.                                                    women. Am J Clin Nutr. 2004;80:I185—93.
32. Liii S, Manson JE, Stampfer MJ, Rcxrndc KM, Ilu EB, Rinim EB,                  48. BehalI KM, Scholfield DJ, iiallfrisch J. Lipids signiflcantly reduced by
      Willett WC. Wholc gram consuiription and risk of ischemic stroke in
                                                                                         diets containing barlcy in nioderatcly hypercholesterolemic men. J Ani
     women: a prospective study. JAMA. 2000;284:1534—40.
                                                                                         Coli Nutr. 2004;23:55—62.
33. McKeown NM, Meigs JB, Liii S, Wilson EW, Jacques PL Whole-grain
                                                                                   49. Behall KM, Scholfield DJ, 1 lalifrisch J. Whole-grain diets reducc blond
      intake is favorably associated with metabolic risk factors for type 2
                                                                                         pressure in rnildly hypercholesterolemic men and wornen. J Am Diet
     diabetes and cardiovasctilar diseasc in the Framingham Offspring Study.
                                                                                         Assoc. 2006;106:1445—9.
      Ani J Clin Nutr. 2002;76:390—8.
                                                                                    50. Li J, Kaneko T, Qin i.Q, Wang J, Wang Y. Effects of barley intake on
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                                                                                         glurosc tolerance, 1 ipid metabo! 1 sni, and bowcl function in svoinen.
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      records and associatinns with risk factors for chronic disease. Am J Clin
      Nutr. 2007;86:1745—53.                                                        51. Davv EM, Melby Ci., Beske SD, 1 lo RC, Davrath LR. Davy KI’. Oat
                                                                                         consumption dnes not affect rcsting casual and anihulatory 24.h arterial
35. Steffen LM, Jacobs DR Jr, Stevens J, Shahar E, Carithers T, Folsom AR.
                                                                                         blond pressure in men with high-norrnal blond prcssure to stage 1
      Associations of svhole-grain, refined-grain, and fruit and vegetable
                                                                                         hypertensmon. J Nutr. 2002;132:394—8.
      consumption with risks of all-catise mortality and incident coronary
      artery disease and ischeniic stroke: the Atheroaclerosis Risk in              52. 1 lalifrisch J, Scholfield DJ, Behall KM. Blond pressure reduced by whole
      Comtnunitics (ARIC) Study. Am J Clin Nutr. 2003;78:383—90.                         gram diet containing barlcy om whole whcat and bmown rice in
                                                                                         moderately hypercholestemolemic toen. Nutr Bes. 2003;23:1631—42.
 36. Wang L, Gaziano JM, Liu S, Manson JE, Buring JE, Sesso iii). Whole’
      and reflned.grain intakes and the risk of hypertension in women. Am J         53. ES. FDA. Food labeling: hcalth claims. Souluble fiber from ccrtain
      Clin Nutr. 2007;86:472—9.                                                          fonds and risk of cornnary heart disease. Eed Regist. 2008;73:47828—9.
                                                Whole qiain intake and cardiovascular disease and whole gram intake and diabetes: a review                 7S of 7S
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<pre>REVIEW
Developing a Standard Definition of Whole-Grain
Foods for Dietary Recommendations: Summary
Report of a Multidisciplinary Expert Roundtable
Discussion
2
’
1
Mario G. 3      Ferruzzi, Satya S. 5
                4
                ’                                 Jonnaiagadda, Simin Liu,
                                                  *                                7 Len Marquart,
                                                                                   ’
                                                                                   6              8 Nicola McKeown,         9 Maria Reicks,               °
                                                                                                                                                          1
Gabrieie        11
                Riccardi,           Chris     12
                                              Sea!,    Joanne     °
                                                                  1
                                                                  Siavin,      Frank     13
                                                                                         Thieiecke,     Jan-Wiiiem        van     der   14
                                                                                                                                        Kamp,          and    Densie Webbt5
3
D epartment of Food Science, and 4                Department of Nutrition Science, Purdue University, West Lafayette, IN; 5           Kerry lngredients and Flavaurs, Beloit,
WI; 6Department af Epidemialogy, and 7                 Department of Medicine, Brawn University, Pro vidence, RI; 8           Department af Faod Science and Nutrition,
University af Min nesata, St. Paul, MN; 9             iean Mayer USDA Human Nutrition Research Center an Aging at Tufts University, Baston, MA;
 °Department af Food Science and Nutrition, University af Minnesota, St. Paul, MN; ‘                       Department af Clinical Medicine and Surgery, Federica II
                                                                                                           t
University, Nuava Paliclinica, Napoli, Italy; ‘            Human Nutrition Research Centre, School of Agriculture, Faad and Rural Develapment, Newcastle
                                                           2
University, Newcastle upon Tyne, UK; ‘               Cereal Partners Worldwide, Innovatian Centre, Orbe, Switzerland; ‘
                                                     3                                                                                 TNO Food and Nutrition, Zeist,
                                                                                                                                       4
The Netherlands; and ‘            Cansultant, Austin, TX
                                  5
Although the term “whole gram’ is well defined, there has been no universal standard of what constitutes a “whole gram food,’ creating chal!enges
for researchers, the food industry, regulatory authorities, and consumers around the world. As part of the 2010 Dietary Guidelines for Americans, the
U.S. Dietary Guidelines Technical Advisory Committee issued a calI to action to develop defmnitions for whole-grain foods that could be universally
accepted and applied to dietary recommendations and planning. The Committee’s calI to action, and the lack of a global whole-grain food
definition, was the impetus for the Whole Gram Roundtable held 3—5 December 2012 in Chicago, lllinois.The objective was to develop a whole-grain
food definition :hat is consistent with the quartet of needs of science, food product formulation, consumer behavior, and label education. The
roundtable’s expert panel represented a broad ra’sge of expertise from the United States and Europe, including epidemiology and dietary
intervention researchers, consumer educators, government policy makers, and food and nutrition scientists from academia and the gram food
industry. Taking into account the totality, quality, and consistency of available scientific evidence, the expert panel recommended that 8 g of whole
grain/30 g serving (27 g/100 g), without a fiber requirement, be considered a minimum content of whole grains that is nutritionally meaningful and
that a food providing at least 8 g of whole grains/30g serving be defined as a whole-grain food. Having an established whole gram food definiton
will encourage manufacturers to oroduce foods with meaningfu( amounts of whole gram, allow consistent product labeling and messaging, and
empower consumers to readily dentify wholegrain foods and achieve whole-grain dietary recommendations. Adv Njtr. 5: 164—176, 2014.
 Introduction                                                                                    a whole-grain food was in place at the time of the roundtable,
 Definition of a whole-grain food is lacking                                                     creating challenges for researchers, industry, regulatory author
 Although a working definition exists for what constitutes a                                     ities, and consumers alike. Developing a deftnition for a who]e
 whole gram (1), no standard definition for what constitutes                                     gram food will be a critical first step to help consurners meet
                                                                                                 their whole-grain dietary intake recommendations and ulti
                                                                                                  mately contribute to the irnprovement of their hea]th.
  Supporred by General MuIs mc. IS L, N M and iS) and Cereal Partners Worldwide lC S.l.
 2
 A vthor disciosures. St Jonnalagadda was errployed by General Muis, mc; F. rhiemeckc                 The need for a standard definition for whole-grain foods
  is employed by cereal Partners Woridwide, D. Webb is a paid consultant of General               is evidenced by the fact that:
  MuIs, mc. M G. Ferru7zu, S. S. Jonnalagadda, S. Liu, L Msrquart, N. Mcfeown, M. Reicks,
  G. Ruccardu, C. Seal, 1. Slavin, F. Thuelecke, 3W van der Kamp, and 0. Webb, no conflucts of       • whole-grain foods are not consistently defined,
  interest. This is a free access arsicle, distributed under serms lhttp://www.nutrition.org/        • whole-grain qualification standards, where they exist, vary
  publications/guidelines-and.poiicies/license/) that permis unmestricted noncommercial                among countries, government and regulatory agencies, and
  ure, dustribution, and reproduction in any medium, provided the original work is
  properly cited.
                                                                                                       private bodies,
   o whom correspondence should be addressed E-rrai[ SatyaJonnaIaeadda@keny.com.                     • wholc-grain foods and package labeling lack standardization,
 164                                                                                           ©2014 Amerucan Society for Nutrition. Adv. Ni.Sr. 5: 164—176, 2014, dci 103945/an,113 005223
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<pre>    • due to myriad labeling inconsistencies, consumers are often                           Health benefits of whole grains: A brief summary of
       confused when shopping for whole-grain foods, and,                                   the evidence
    • wholc-grain and fiber contents of foods are often incorrcctly                         Although this is not a comprehensive review of the whole
       used interchangeably.                                                                gram science literature, the expert panel at the roundtable
                                                                                            engaged in a review of the evidence relevant to the objec
      The roundtable experts agreed to assess 4 criteria for the
                                                                                            tives. The evidence linking whole-grain intake to reduced
establishment of a whole-grain food definition: scientific
                                                                                            risk of cardiovascular disease (CVD), diabetes, and excess
basis (rationale), food forniulation (feasibility), consurner
                                                                                            weight is briefly summarized in Tabie 1. Consumption of
acceptance, and ease of label education (application). Stan
                                                                                            whole grains also has been associated with greater nutrient
dardizing a definition for whole-grain foods would en
                                                                                            intakes and enhanced diet quality (3—6).
courage manufacturers and governmental and regulatory
                                                                                                   Findings from large, population-based, prospective, ob
authorities to develop and label foods with meaningful
                                                                                            servational studies have consistentlyobserved a dose-response
amounts of whole gram, provide researchers with a consis
                                                                                             relation between whole-grain intake and disease risk, with
tent approach to quantify whole-grain intake, and help ad
                                                                                             health benefits proportional to the amount of whole gram
vance science related to the effects of whole gram on
                                                                                             consumed (7—17). Consumption of 2—3 servings/d (—48 g)
health outcornes.
      The currentiackofa dear definition for whole-grain foods                               of whole grains, an amount that is readily achievable, may
                                                                                             reduce risk of CVD, type 2 diabetes mellitus (T2DM), and
may be contributing to the widespread failure of consumers
                                                                                             overweight and obesity. Generally, the current evidence
to meet current whole-grain dietary recommendations.
                                                                                             shows that consuming between 3 and 5 servings of whole
      A eau to action to develop a definition for whole-grain
                                                                                             grains per day reduce not only the risk of ischemic heart dis
foods that could be universally accepted and applied to die
                                                                                             ease and CVD events but also risk factors associated with
tary recommendations and planning was issued by the U.S.
                                                                                             CVD (15, 18—20). Evidence also suggests that those who con
Dietary Guidelines Technical Advisory Committee (DGTAC)’                  6
                                                                                             sume an average of 3—5 daiiy servings ofwhole grains have a
as part of the 2010 Dietary Guidelines for Americans (DGA).
                                                                                             21—30% reduction in risk of T2DM compared with those
The committee stated, “Without dear definitions, it is difficult
                                                                                             who rarely or never consume whole grains (14,16,17,21,22).
 to compare studies examifling the effectiveness of various
                                                                                              Potential mechanisms for whole gram health benefits inciude
 whole grains on biomarkers of interest in disease. Clear def
                                                                                              aiding in the niaintenance of glucose and insulin homeostasis,
 initions would also help consumers identify foods that can
                                                                                              lowering of serum cholesterol and LDL-cholesterol concen
 help them meet the Dietary Guidelines recommendation
                                                                                              trations, and reducing infiammation and oxidative stress (7).
 (2).”
                                                                                                   These observational data have been supported to some
       The ongoing lack of a globally accepted whole-grain food
                                                                                              extent by small-scale intervention studies of at-risk popula
 definition, along with the DGTAC cail to action, was the im
                                                                                              tions, i.e., participants with T2DM, hypertension, and/or
 petus to organize the “Whole Gram Roundtable” held 3—5
                                                                                              high cholesterol, but findings have not always been consis
 December 2012, in Chicago, Illinois. The purpose of the
                                                                                              tent (23—27).
 meeting was to discuss and agree upon a definition for a
                                                                                                    In addition, there may be as-yet—-unidentified genetic and
 whole-grain food that could be used both in the United
                                                                                              other lifestyle influences that interact with the inciusion of
  States and internationally. The roundtable, jointly sponsored
                                                                                               whole grains in the diet as well as inherent metabolic differ
 by the General Milis Beu Institute of Health and Nutrition
                                                                                               ences among populations and between men and women that
  (United States) and Cereal Partners ‘Vorldwide (Switzerland),
                                                                                               affect study outcomes. Proving a cause and effect relation
  hosted experts from the United States and Europe in multi
                                                                                               with one aspect of the diet, even in intervention trials, can
  ple disciplines, inciuding epidemiology, public health nutrit
                                                                                               be challenging because of the inherent complexity of the
  ion, dietetics, clinical medicine, consunier education, policy
                                                                                               food/dietary matrix and the general lack of large changes
  and law, food science, and technology, inciuding gram food
                                                                                               in targeted biomarkers in apparently healthy populations
  processing. The panel of experts recognized that establishing
                                                                                               as a result of short-term dietary interventions.
  a whole-grain food definition is critical to move the field for
                                                                                                    Another factor contributing to inconsistent flndings is
  ward, not only to improve dietary guidance but to provide a
                                                                                               that the diets of free-living populations typically contain a
  standard for the food industry to translate dietary recom
                                                                                               variety of grains, with different phytonutrients (e.g., pheno
  mendations for consumers. The primary objectives of the
                                                                                               lie acids, polyphenols, inositol, alkylresorcinol, phytoste
  ‘vVhole Gram Roundtable were to: 1) present and discuss rel
  evant scientific evidence to confirm that the benefits of                                    rols), fibers (e.g., /3-glucans in oats and barley, arabinoxylans
                                                                                               in wheat and rye), micronutrients, and macronutrients
  whole gram are attributable to many of its components;
                                                                                               that may play important roles in whole-grain health bene
   and 2) review relevant evidence and develop a standard def
                                                                                                fits. Interactions among these whole gram co-passengers
   inition for whole-grain foods.
                                                                                                may contribute to the observed differences in health bene
                                                                                                fits, but because they exist together as part of the whole-grain
                                                                                                package, delineating which compound(s) is (are) responsible
    6
      Abbreviations used AACCI, American Association of Cereal Chemi5ts International; CVD,     for observed health benefits or whether specific synergies ex
      cardiovascular disease, DGA, uetary Guidelines for Americans; DGTAC, US Dietary
      Guidelines Technical Advinory Comrnirtee; T2DM, type 2 diabetes.                          ist remains a challenge not yet addressed (28—30).
                                                                                                                                   Whole-grain food de6nition 165
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<pre>TABLE 1        Summary of the potential whole-grain health benefits evidence      t2
   Outcome                                              Benefits                                              USDA evidence analysis conciusion (6)
CVD                              Associated with      2 % lower risk of CVD                         A moderate body of evidence from large p’ospective cobort
                                                                                                       studies shows that whole-grain intake, which inciudes
                                                                                                       cereal tibet, protects against cVD.
12DM                              Associated with   - 26% lower risk of T2DM                        Limited evidence shows that consumption of whole grains is
                                                                                                       associated with a reduced incidence of 12DM in large
                                                                                                       prospective cohort studies.
Weighi management                 Associated with lower BMI, Iess weight gain during                Moderate evidence shows that intake of whole grains and
                                    8—13 y (1.27 kg). and lower central adiposity                      gram tiber is associated with ower body weight.
                                                                                    o
   Conciusions ae drawn from a smet of me:a-anaiyses and c’tlcal sys:ema:Ic revews wbole grains in —ela:ion to health outcomes. Compared witn never/rare consumers of
   whoie grains, t9.DSe co9suming 2-3 se’vngs/d o wboie grains have ower risk of D.’D, 12DM ano weight gain cVD, cardovasculm dsease: T2DM, :ype 2 diabetes.
                                                                                                                                                                     with
2
   The most up-to-date systematic review and meta-analysis assessing the role of whole-graîn intake in developirrg health outcomes of Interne indicate that compared
   never/rare consumers of whole grains, those consuming 48 g/d of whole grains have a ower risk of CVD, T2DM, and body weight gairi.
      Although the understanding of the mechanisms behind                              grains/ounce-equivalent (—30 g) were identified as foods
whole-grain health benefits is limited, relying on random                              that provided a substantial amount of whole grains (47).
ized controlled trials that focus on intermediate outcomes                                  Whole-grain recommendations in some countries have
alone may not be the best approach for setting dietary rec                              recently become more speciuic. In Mexico, e.g., the recom
ommendations. In evaluating studies for the 2010 Dietary                               mendation from the Official Mexican Norm of Nutrition/
 Guidelines, the DGTAC gave more weight to experirnental                                Food Education was recently altered from “Wholegrains
 studies than to observational studies, more weight to meta                             should be recommended                ..“ to “Include wholegrain cereals
 analysis of randomized controlled trials than to individual                            in each meal              (41). Many recornmendations stress the
 randomized controlled trials, and more weight to cohort                                importance of the co-passengers in whole gram, incjuding
studies than to case-control studies (6). Overall, the panel                            fiber and phytochemicals, but without specifying quantities
 supported the view that the totality of the evidence for                               or defining what constitutes a whole-grain food.
 health benefits of whole-grain consumption is convincing                                   Historically, increasing whole-grain intake was recom
 and serves as the basis of dietary recommendations globally                            mended primarily because it increased fiber intalce, as whole
 to inciude and/or choose whole grains more frequentlv in                               gram foods make an important contribution to dietary fiber
 the diet (31—48) (Tabic 2).                                                            intake. Choosing whole grains that are higher in fiber has
                                                                                        additional health benefits; hosvever, high fiber does not al
 Recommendations to increase consumptiori of whole                                      ways equate with whole gram, just as whole gram does not
 grains are global                                                                      always equate with high fiber (2,54) (Tabic 3). Dietary recom
 Woridwide, dietary recommendations for consuming whole                                 mendations in some countries have slowly shifted over time
 grains range from the generic, e.g., eat more fruits, vegetables,                       from being nutrient based to being food based (55—59). Inipor
  and whole-grain products (49), and intermediate, e.g., eat at                         tantly, although countries may vary in their food vs. nutrient
  least 30 g of dietary fiber daily, especially from whole-grain                        approaches to dietary guidelines, many include a recom
  products (50), to the more speciflc, e.g. consurne at least one                       mendation to increase consumption ofwhole grains (60,61).
  half of aU grains as whole grains and increase whole-grain in
  take by replacing refined grains with whole grains (2).                                Whole grains are defined but whole-grain
       Several countries recommend consumption of whole                                 foods are not
  grains, inciuding Australia, Canada, Chile, China, Colombia,                           In 1999, a whole-grain ingredient definition was developed
  Denmark, France, Germany, Greece, Iceland, India, Latvia,                              by the Whole Grains Working Group of the American Asso
  Mexico, Oman, Singapore, Switzerland, the United Kingdom,                              ciation of Cereal Chemists International (AACCI) (1). The
  and the United States. Tahie 2 provides a summary of some                              AACCI established this working group as a source of accu
  existing global dietary whole-grain guidelines. However, the                           rate scientific information on whole grains and charged
  specific quantities of whole grains recommended to be con                              the group with discussing and establishing criteria to define
  sumed per day vary considerably. The first specific advice in                          a whole gram. The AACCI definition states that whole grains
  the United States to inciude whole-grain servings was a part                           are “intact, ground, cracked or flaked fruit of the gram whose
   of the 2005 DGA (51). This change from a more general                                 principal components, the starchy endosperm, germ and bran,
   gram recommendation to a specific whole-grain recommen                                are present in the same relative proportions as they exist in
   dation was deve]oped from and supported by a body of                                  the intact gram” (1). This definition was adopted and issued
   epidemiological (52) and mechanistic experimental (53)                                by the U.S. FDA in its Draft Whole Gram Label Guidance in
   studies linking whole-grain intake to an array of beneficial                           2006 (62,63). Some countries use an adapted AACCI/FDA
   outcomes. The 2010 DGA recommends 6—11 servings/d of                                  whole-grain definition and/or DGA whole-grain dietary rec
   grains based on an individual’s energy needs, with at least                            ommeridation (1). The European HEALTKGRAIN Forum,
   one-half of those servings (at least 3 servings) as whole                              a European Union consortium of scientists, industry repre
   grains. In these guidelines, foods with at least 51% of the to                         sentatives, and policy makers advocating for whole grains
   tal weight as whole-grain ingredients or at least 8 g of whole                         and grain-based foods also agreed and published a whole-grain
   166    Ferruzzi et al,
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<pre>   TABLE 2                                          1
                Global dietary whole-grain guidelines
                                                                                                            Specific recommendation                                                                    Reference
     Country/organization
                                                                              and  Guide to Healthy  Eating recommend 3—8 1/2 servings (dependent upon age, sex, or caloric requirements) of gram         31
   Australia                               The Australian Dietary Guidelines
                                              (cereal) foods, mostly whole gram, such as breads cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa, and barley.
                                                                                                                                                                                                          32
   Austria                                 The Austrian Food Pyramid (Die österreichische Ernâhrungspyremide) recommends consuming 4 servings/d of cereals, bread, pasta, rice, or potatoes (5
                                              servings for active aduits and children), preferably whole gram.
                                           The Canadian Food Guide recommends 3—8 seivings/d (age and sex dependent) of gram products and advises making at least one-half of the gram                     33
   Canada
                                              product choices whole gram each day. Further recommendations state to eat a variety of whole grains such as barley, brown rice, oats, qumnoa, and
                                              wild rice.
                                                                                                                                                                                                           34
   Chile                                   Group of pediatricians in Chile from Chilean Pediatric Society recommends that one-half of grains should be whole gram to reach recommended amount
                                              of Ober.
                                                                                                                                                                                                           35
   China                                   The Chinese Dietary Guidelines and the Diet Pagoda recommend aduits consume 300—500 g/d (dependent upon energy requirements) of total gramns,
                                              cereals, and legumes, among them, al least 50 g/d of coarse gramns, including whole grains.
                                           Denmarks Food Administration uses the Diet Compass (Ko5tkompasset) and the Dietary 8(8 kostr3d) to recommend consuming 75 g/d whole grains (for                 36
   Denmark
                                              energy requiremenis of 10 MJ/d). Bread, grains, rice, and pasta should be an essential part of the diet and for older children and aduits, 500 g/d is
                                               recommended.
                                                                                                                                                                                                           37
   trance                                  France’s Guido of the National Health and Nutrition Program (Guides alimentaires du program national nutrition-santé) recommends consumption of
                                              breads, cereals, and starchy foods at each meal, especially whole-grain foods that provide considerable amounts of fiber.
                                                                                                                                                                                                           38
   Greece                                  The Dietary Guidelines for aduits in Greece suggest consuming 8 servings of nonreOned cereals and products, preferably whole-grain varieties (whole
                                              gram bread, whole-gramn pasta, brown rice, etc.).
                                                                                                                                                                                                           39
   India                                   The Dietary Guidelines for Indians recommends increasing consumption of whole grains, legumes, and nuts to maintain body weight and body
                                               composition.
                                                                                                                                                                                                           40
    Latvia                                 The Latvian Health Ministry recommends consumption of 4—6 servings/d of cereals, especially whole grains such as fiber-rich whole-grain products
                                               (bread, pasta, oatmeal porridge) to reduce the risk of diseases.
                                                                                                                                                                                                           41
    Mexico                                  Mexico’s Department of Nutrition and Health Promotion recommends consumption of cereals should be recommended, preferably whole grains without
                                               added sugar. Their Ober and nutrients should be hghlighted. Whole grains should be eaten with every meal, with legume seeds.
                                                                                                                                                                                                           42
    Norway                                 The Health Directorate of Norway’s Key Advice for a Healthy Diet (Nøkkelrâd for er sunt kosthold) suggests ncreasing intake of whole-grain products and
                                               cereals each day. The whole-gramn products should together provide 70—90 g/d of whole-meal four or whole gram.
                                                                                                                                                                                                           43
    Oman                                    The Omani Guide to Healthy Eating recommends choosing whole grains and cereals and consuming potatoes, with their skin. For an average diet of 2000
                                               kcal, 2—3 servings/d of whole gra!ns is advised.
                                                                                                                                                                                                           44
    Singapore                               The Dietary Guidelines for Adult Singaporeans and Healthy Diet Pyramid recommend eating sufficient amounts of grains especially whole grains. Out of
                                               the 5—7 servings of rice and alternatives, adults shculd consume 2—3 servings/d of whole-grain food.
                                                                                                                                                                                                           45
    Switzerland                             The Swiss Society for Nutrition recommends that each main meal should be ser-ved with 1 starch-rich side dish [ie., 3 portions/d, 1 portion = 75—1 25 g of
                                                                                                                                                                                              r
                                                bread or 60—100 g of pulses (raw weight)]; for instance, lentils/chick peas or 180—300 g of potatoes or 45—75 g of pasta/rice/flakes/corn/othe grains
                                                (raw weight), including at bast 2 portions of whole-grain products.
                                                                                                                                                                                                            46
    United Kingdom                          The National Health Service’s Eatwell Plate recommerds eating plenty of bread, rice, potatoes, pasta, and other starchy foods (shown as one-third of a
0
(p                                              plate) and choosing whole-gramn varieties whenever possible.
                                                                                                                                                                                                            47
w   United States                           The 2010 DGA suqgests consuming 3 or more ounce-equivalents of whole-grain products per day, with the rest of the recommended grains coming
D                                               from enriched or whole-grain products (al the 2000 kcal intake level). Consume at least one-half of all grains as whole gramns. lncrease whole-grain
0                                               mntake by replacing refined grains with whole gramns.
0
0                                                                                                                                                                                                           48
    WHO                                     The WHO and the FAO of the United Nations recommend increasing consumplion of whole gramns as a strategy to prevent diet-related chronic diseases.
0
ro                                             The WHO/FAO rate the strength of evidence for whole-grain consumption and decreased risk of CVD and diabetes as probable.
D
0
     CVD, cardiovascular disease; DGA, Dietary Gumdeimnes for Americans.
D
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<pre>TABLE 3        Fiber content of a variety of grains
                                             1                       Some have argued for quantifying whole-grain content of
   Gram                                    Fiber content             foods based on fber content, e.g., as a compliance marker
                             gIS g gram                 g/IOO g gram for the FDA whole-grain health claim. However, fiber con
Brown rice                        0.3                          3.5   tent of whole grains varies widely (lable 3), considerably
Wild rice                         0.5                          6.2   limiting its reliability as a whole-grain indicator for all
Corn, yellow                      0.6                          7.3
                                                             10.6
                                                                     whole-grain foods. Furthermore, the content and type of
Cats                              0.9
Wheat                             1.0                        12.2    fiber in a whole-gramn food depends not only on the gram
Amaranth                          1.2                        15.0    but also on the density of the product, moisture content,
Rye                               1.2                        15.1    amount of bran, and other ingredients. For example, a gram
Barley                            1.4                        1 7.3   food made with 100% whole-grain corn will naturally
   Data from reerence 54.                                            contain —1 g fiber/30-g serving but still provide all of the
                                                                     beneficial compounds found in that whole gram. An inter
definition. This defines whole grains as “consisting of              nationally accepted definition for whole-grain foods could
the intact, ground, cracked or flaked kernel after the removal       help in the development of dear regulatory standards and
of inedible parts such as the huil and husk. The principle           food package labeling, differentiate between whole grains
anatomical components—the endosperm, germ and bran—                  and fiber, promote easier identification of whole-grain foods
are to be present in the same relative proportions as they exist     by consurners, and contribute to improved quantification of
in the intact kernel. Small losses of components, i.e., <2% of       whole-grain intake.
the germ or <10% of the bran, which may occur through                     The 2010 DGA recommends that consumers make one-
processing methods consistent with safety and quality, are al-.       half of their grains whole, which approxirnates to a mini
lowed” (64). The definition differs from that of the AACCI           mum of 48 gld whole grains (47). 1f whole-gramn foods are
in that it allows for small losses during initial processing?         defined as providing 8 g whole grains/30 g (27 g/l00 g),
cleaning of the gram. It has been suggested that the effects         then consumers could meet the whole-grain recomnienda
of further processing (baking, malting, and fermentation)             tion of 48 g/d with six 30-g servings of such foods, the cur
should be determined before a whole-grain food definition             rent minimum amount of gram foods the DGA recommend
 is developed (65). However, available research suggests that         to inciude in the diet each day (2). For foods with 100%
the frequency of consumption and amount of whole gram                 whole-grain content, the target could be met with 3 servings
 eaten, rather than the type of processing, are the most impor        (each of 16 g whole grains).
 tant considerations when selecting a healthful diet (66). As
new scientific evidence emerges, dietary recommendations              Whole-grain food definition would support whole
 and guidelmnes should be reexamined and further consider             gram research efforts
 ation of defining whole-grain foods may be warranted.                Whole-grain information in nutrient databases varies.
      Although definitions exist for vhole grains and relevant        Whole-grain research, both ohservational and intervention
 whole-gramn ingredients, a consistent delinition for what            trials, largely relies upon the completeness and accuracy of
 constitutes a whole-grain food has not been developed and            nutrient databases to capture whole-grain intakes of study
 adopted for use by the FDA, the USDA, or the European                participants. A substantial increase in the availability of
 Commission. Researchers have defined criteria for quantify           whole-grain products during the past decade has made accu
 ing whole-grain foods based on the available information              rate assessment of whole-grain intake increasingly challeng
 and marketpiace of whole-grain products, but in the absence           ing. Dietarv intakes in most observatiorial studies reflect
 of an accepted deflnition of a vhole-grain food, an array of          intakes before the introduction of a wider variety of whole
 packaged food products provides diverse arnounts of whole             gram foods, with whole-gramn intakes being represented
  gram per serving. Given the different regulatory standards           mainly by whole-gramn breads and whole-gramn ready-to-eat
  and requirements across the globe, for the purpose of this           breakfast cereals. Existing whole-grain food composition
  roundtable meeting and discussions, the United States was            data are limited, as are the number of whole-gramn food items
  considered as the starting point for defining whole-grain            listed on some FFQs. Up-to-date nutrient databases are
  foods. In the United States, a standard gram food serving            needed to better assess whole-grain intake and capture the
  size is estimated to be 1 ounce-equivalent by the USDA               changing whole-grain food supply.
  (39) or 30 g by the FDA (67), a definition for whole-grain
  foods that incorporates a specific amount of whole grains            Lack of a whole-grain food definition slows research
  per 3 O-g serving is needed.                                         progress. The significant heterogeneity among studies is
                                                                       in part the result of differing whole-grain classifications
  Multiple whole gram policies and regulations                          (73) used such as: 1) foods that list a whole gram as the first
  Though no universally accepted definition has existed for             ingredient on the food label (13); 2) fiber-rich, whole-grain
  whole-gramn foods, several government agencies in the United          cereals providing specific amounts of total, insoluble, and
  States and elsewhere have established whole-grain food def            soluble fiber per serving (74); 3) whole-gramn items with
  initions for a wide range of purposes (31,35,41,47,48,62,63,          added bran, germ, and fiber (9); 4) products with 25% or
  65, 68—72), which has added to the confusion (Table 4).               more of whole-grain or bran weight (9); 5) whole gram
   168    Ferruzzi et al.
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<pre>                  Multiple whole-grain dietary guidance, policies, and regulations in the United States and international         1              ly
   TABLE 4
      Agency/organization (reference)                                                                                                                         Definition/dassification
   United States
       2010 DGA (47)                                                                                           Make one-half of your grains whole grains, Eat as east 3-oz equivalents ofwhole grains daily (1 ounce equivalent is
                                                                                                                  about 1 slice bread; 1 oz ready-to-eat cereal; or 1/2 cup cooked rice, pasta, or cereal; 1 ounce equivalent •—30 g).
                                                                                                                  51% whole gram is a significant amount. Foods with at east 8 g whole grains per ounce-equivalent. Whole
                                                                                                                  grains provide benefits beyond Ober.
       EDA Whole Gram     Health Claim (1999, 2003, 2008) (62)                                                 Poods must be 51% whole gram by weight per RACC. Dietary Ober used as marker for compliance. Exceptions
                                                                                                                  include single ingredient whole-gramn food, ie., first gram ingredient and no Ober marker.
       EDA Draft Guidance en Whole Gram          Label Statement (2006) (63)                                   Allows factual statements about whole-grain content of products, eg., 100% whole grains, 109 of whole grains, 1/2
                                                                                                                  oz whole grains. Restates the FDA whole-grain health claim as a permitted statement: product must meet the
                                                                                                                  requirements outlined in the health claim. Doet not characterize a signAcant amount of w’nole gram (no
                                                                                                                  minimal standard). No Ilnal guidance.
       USDA School Meals Regulations (2012) (68)                                                               Whole gram rich detned as 50% whole gram by weigbt or first ingredient is whole gram er 8 g whole gramn/
                                                                                                                  serving.
       USDA WIC Food Package Regulations (2013) (69)                                                           Bread: Standard of identity for whole-grain bread and contain a minimum of 51% whole gram by weight (using
                                                                                                                  dietarv Ober as the indicator) and Orst ingredient whole gram and meet FDA labeling requirement for making a
                                                                                                                  whole-grain health claim and meet regulatory detnitions for “low saturated fat” and “10w cholesterol” and bear
                                                                                                                  quantitative trans fat labeling and contain 6.5 g total fat/RACC and 0.5 g trons fat/RACC. Cereal: Same re
                                                                                                                   quirements as whole-gramn bread plus no more than 21 g sugars/100 9.
       USD4 Food Safety and Inspection Service Statement of Interim Policy                                     Only applicable to products containing meat or poultry, Foods can be considered whole gram that meet 51% of
          Guidance (2005) (70)                                                                                     the gram as whole gram or 51% of the product by weight er contain at bast 1/2-oz equivalent or 89 dry whole
                                                                                                                   gram ingredient. Products that meet EDA standards of identity er that contain at least 1/2-oz equivalent er 8 g
                                                                                                                   whole gram can be described as “made with whole grains.”
       Whole Gram Council Stamp (71)                                                                            100% Stamp: all gram ingredients are whole grains. Minimum requirement of 169 of whole gram per labeled
                                                                                                                   serving. Basic Stamp: contains at least 8 g of whole gram. Even if a product contains large amounts of whole
                                                                                                                   gram (23 g, 37 g, 41 g, etc), t will use the Basic Stamp if it also contains extra bran, germ, er retned flour.
    Other countries/organizations
        Australia (31)                                                                                         Whole-grain food must provide a minimum of 8 g/serving.
        China (35)                                                                                             The Chinese Dietary Guidelines and the Diet Pagoda recommend adults consume 300—500 g/d (dependent upon
                                                                                                                   energy requirements) of total grains, cereal, and legumes, among them, at least 50 g/d of coarse grains, in
                                                                                                                   cluding whole grains.
        Germany (72)                                                                                            Whole-grain bread must be 90% whole gram.
        Mexico (41)                                                                                             Mexico’s Department of Nutrition and Health Promotion recommends consumption of cereals, preferably whole
                                                                                                                   grains without added sugar. Their fiber and nutrients should be highlighted. Wbole grains should be eaten with
                                                                                                                   every meal, with legume seeds.
        Sweden Code of Practice (65)                                                                            Conditions for the use of the whole-grain claim according to the Code are that flours, grains, and flakes must be
                                                                                                                    100% whole gram and other products, including breakfast cereals and bread, must have at least 50% whole gram
                                                                                                                    based on the dry matter. Dietary Ober content must beat least 4.5 g/l000 kJ and conditions regarding fat, sugar,
                                                                                                                    and salt content for the keyhole must be fulfilbed.
8                                                                                                               The WHO and FAO of the United Nation recommend increasing consumption of whole grains as a strategy to
        WHO (48)
                                                                                                                    prevent diet-related chronic diseases.
    1                                     11
                                          a  relevant guîdance, regulations, er policies. DGA, Deta GuiOelines for Arnericans; RACC, Reference Amount Customarily Consumed.
      This is not a comprehensive list of
0’
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<pre>from “dark” breads (9); and 6) products with 51% of whole-grain intakes in populations and ultimately in evalu
whole gram by weight (9—11). Products made with whole ating the strength of the evidence for issuing population
grains that fail to meet a study’s unique criteria for what specific dietary guidance internationallv.
constitutes a whole-grain food may stil! contribute to an in
dividual’s whole-grain intake. Failure to account for these Educating consumers on how to incorporate whole
foods may lead to substantial misclassification of whole grains into their diets
gram intake and have an impact on study outcomes.                                A dear deflnition for whole-grain foods would help health
     Previous epidemiological studies have categorized whole professionals and consumers to accurately identify foods
gram intakes into discrete groups (>50%, 25—50%, or < 25% that provmde a meaningful amount of whole grains. For ex
whole gram by weight) or “servirigs,” in order to rank in ample, although continued public education efforts in the
takes and compare them with health outcomes of interest. United States encourage the consumption of one-half of
However, such a ranking strategy cannot completely quan the recommended 6 servings of grain-based foods per day
tify the content of whole grains within foods, making the as whole grains (48 g/d), the mediari intake of U.S. aduits
comparison of findirigs across studies difficult, particularly based on current classifications is about one-half serving
among diverse populations.                                                       or 8 g/d (2). Less than 1% of the U.S. population consumes
     Comparisons          of study  findings   are also  hampered      by  the   the recommended intake and 20% of individuals report
diversity     and  characteristic   s within    whole  grains   (oats  vs. rye   consuming no whole-gramn products (3). A USDA analysis
vs. wheat). For example, according to the USDA database, found that Americans choose refined grains over whole
which bases the serving size recommendations on the grains by a ratio of 5:1 (80). In the UK, the average daily
DGA and FDA guidelines (54) and many FFQs, 1/2 cup whole gram intake is 14—16 g, with one-third of the adult
 (97 g) ofcooked brown nee and 1/2 cup (117 g) cooked oat population never eating whole grains (81). The average
 meal are both considered a single serving of a whole-grain whole-grain consumption in France is only 7.3 g/d. In con
 food, yet the actual amount of whole gram they provide dif trast, adult populations in Sweden and Denmark consume
 fers signiflcantly; brown rice provides 26 g of whole gram                      much higher amounts, a mean of 42 g/d whole grains in
 per serving, whereas oatrneal provides 17 g, because of the Sweden and 36 g/d in Denmark (82—84).
 different dry matter content of each food. They also differ                          Motivators and barriers to increasing consumption of
 substantially in the amounts and              Spectrum    of  the  bioactive    whole-grain      foods are sometimes similar, depending on
 components (such as dietary            flber,  micronutrien    ts, and  phy     consumer      perceptions   of taste; familiarity with whole-grain
 tochemicals)       each     serving   provides    due   to  differences     in   foods,  especially   for children;  cost; identification skills; and
 composition        of  the   2 cereal  grains.  The   lack   of  a standard      knowledge     of the  associated  health benefits (85,86). The fol
 measurement for a whole-grain food could also affect the lowing are strategies found to be effective in increasing
 observed association between biomarkers and health out whole-grain consumption (87,88):
 comes. Unless a who!e-grain food definition is developed                            • Direct substitution (i.e., brown nee for white rice)
 that a!lows researchers to capture the whole-grain con tribu                        • Replacement of refined-grain foods with whole-grain foods,
 tion of lower fiber whole grains as well as products with dif                         wherc the 2 foods differ (ie., who!c-grain pretzels instead of
 ferent whole-grain content, determining health effects will                           refined-grain crackers)
 continue to be challenging, particularly if whole grains are                        • Adding new whole-grain foods in the diet (ie., who!c-grain ce
 consumed in combination with refined grains.                                          reals or whole wheat pasta that were not previously consumed)
                                                                                     • Structural changes in meal patterns (i.e., cating brcakfast that
  Whole-grains research needs for the future. There is a                               contains whole grains when brcakfast was not previously
                                                                                       consumed)
 dear need for large, controlled, dietary intervention studies
                                                                                     • Stealth approach (ie., whole-grain ingredients are gradually
  in diverse ethnic populatioris that examine the potential                            substituted for refined grains)
  health effects of speciflc and weil-characterized who!e grains
  alone and in combination, as a prerequisite to demonstrat                           Inconsistencies in labeling and wide variations in the
  ing   sustained   health    effects over  time.  Overall,   observationa     l  amounts     of whole gram found in foods labeled as whole
  research suggests that health benefits are dose dependent, gram make it difficult for educators to provide advice to
  i.e., the more vhole grains that are consumed, the greater consumers on what to look for in a whole-grain food pro
  the likelihood of a protective effect (14,75—8 1). However, in duct. Because whole gram is an ingredient, and not a nutri
  tervention studies are needed to better identify the amount ent, it does not appean on the Nutrition Facts Panel, the very
  of whole grains likely to confer the most health benefits.                       place where consumers are instructed to look for important
       In tandem, standardized methods for identifying and nutrition information. Consumers often equate fiber, which
  classifying whole grains and their biomarkers are needed is available on the Nutrition Facts Panels of food products,
  to help distinguish whole-grain intake from fiber intake with whole gram (89), mistakenly believing that a food
  and intact grains from processed flours, and to accurately must be high in fiber to provide whole grains. In the United
  identify and precisely quantify whole-grain foods. Gaining States, many health professionals, in fact, instruct their cli
   consensus on a definition of what constitutes a whole-grain ents to look for fiber as a proxy for whole grains and recom
   food can help overcome current challenges in determining mendations exist to choose whole-grain foods that provide
   170    Ferruzzi et al.
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<pre>at least 3 g fiber/serving (90). However, rnost nutrient-rich        for consumers. Consumer taste preferences often present
whole grains provide fewer than 3 g fiber/16 g whole gram,           the greatest challenge in the development of whole-grain
inciuding amaranth, barley, brown rice, oats, wheat, wild            food products. The variety of the gram, the cultivar, and
rice, and quinoa (91) (Table 3).                                     the processing technique employed all affect flavor, appear
      Barriers to increasing the consumption of whole grains         ance, texture, shelf life, and the flnal cost of a product. A va
should be addressed in part by focusing on identification            riety of other factors affect the formulation and processing
skills (86,90,91). Unlike fruits and vegetables, which are available of whole-grain foods, including serving size; stability of
in distinct, recognizable units, making it easy for consumers to     the food matrix; moisture content; presence of other ingre
know if they are meeting recommendations, whole grains are           dients such as yeast, spices, sugar, fats, and oils; and total
often consumed as an ingredient in a packaged food and are           gram content. For example, a food with a larger portion
not easily identified. A standard whole-grain food definition        size can accommodate more whole grains in its formulation
would identify whole-grain foods for consumers. Multicompo           without introducing considerable changes in taste, appear
 nent educational strategies in schools, including classroom cur      ance, or texture, i.e., the amount of whole grains that can
 ricula, farnily newsietters, and supermarket and bakery tours        be incorporated into a food with a 1 5-g serving size without
 coupled with daily exposure in school cafeterias, have increased     substantially affecting sensory characteristics would be less
 the knowledge and whole-grain product identification skills of       than the amount that can be incorporated into a food
 children, parents, and school food service personnel and in          with a 30-g serving size. Eight grams of whole gram per
 creased intake among children (85,92).                               30-g serving (27 gil00 g) assures an achievable and mean
       Guidance for choosing whole-grain foods should be in           ingful minimum amount of whole gram relative to serving
 the context of the overall healthful diet and inciude specific       size and simplifies for consurners the identification of
 information on how to identify and limit whole-grain foods           whole-grain foods. This would encourage manufacturers
 that are high in calories, sugar, sodiurn, saturated fats, or        to prornote ‘hole-grain foods with smaller serving sizes
  trrnis fats. In the United States, this would be in accordance      and potentially increase whole-grain intake while gaining
 with the FDAs defïnitions for acceptable levels of negative          wider consumer acceptance.
  nutrients (93). The ongoing obesity and diabetes epidemics                Although new processing opportunities exist for the fu
  cali for the gram community to provide leadership by mak             ture, the industry is faced with processing challenges now.
  ing more nutrient-dense, lower energy, whole-grain options           Most manufacturing facilities are designed to accommodate
  available. Additionally, to ensure nutrient adequacy, especially     large volumes of refined grains, not whole grains. New cost
  for folate, individuals, especially women of child-bearing           effective manufacturing lines and processes that can work
  age, who consume all of their grains as whole grains should          with large volumes of whole grains would be able to accom
  include some enriched grains that have been fortified with           modate any resulting increase in demand for whole-grain
   folic acid (2). There must also be whole-grain educational          foods. A coordinated effort to implement comprehensive
   efforts within the food industry itself. Currently, littie effort   change across the entire food industry is needed, yet food
   focuses on industry-wide recommendations for food pro               companies may be hesitant to initiate such widespread for
   duct formulation that would increase availability of more            mulation and processing changes without dear consumer
   healthful whole-grain foods in the rnarketplace (94).               demand and preferences for whole-grain foods. A consistent
       Au environment in which supermarkets, restaurants,               definition for who]e-grains foods would not only enable
   homes, and other venues support current dietary guidance             clearer identification of whole-grain foods but can also in
   on whole grains will require small and gradual modifications         crease their availability and consumer acceptance of whole
   to gram food staples, combined with aggressive consumer              gram foods. In the United States, grains and gramn-based
   education and awareness building. A universally accepted             foods constitute a considerable portion of the packaged
    definition for whole-grain foods outlining a meaningful             foods consumed (66). New products can serve as the pri
   minimum amount of whole grains would ease the transition             mary vehicles to carry beneflcial whole grains while reducing
    for the food industry as its members develop new whole              fat, sugar, sodium, calories, and portion size, in keeping with
    gram food products and for consurners as they learn to              dietary guidance. Packaged foods represent a unique oppor
    more easily identify and incorporate whole-grain foods              tunity to increase whole-grain consumption.
    into their daily dietary intake. Although such a whole-grain            The limitations and gaps that currently exist in whole
    definition is important, the message to consumers should            gram research provide future research opportunities, includ
    continue to be that “more is better’ within the scope of cal        ing the identification of biomarkers for individual whole
    ories and negative nutrients, and they should be encouraged         grains, the role that each of the components of whole grains
    to consume whole-grain--dense foods and make more                    plays in health and disease prevention, and the unique con
    healthful whole-grain food choices.                                  tributions of each whole gram to health.
    Challenges, considerations, and future opportunities                 Coordinated approach to increasing whole-grain
    for formulating whole-grain foods                                    intake
     To increase consumption in populations, whole-grain foods           A dear whole-grain food definition, coupled with the coop
     must be formulated to be practical, affordable, and desirable       eration of various sectors and disciplines, could provide an
                                                                                                          Whole-grain food definition 171
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<pre>organized process for gradually shifting the arnount of whole        that are found in much greater amounts in whole grains
gram incorporated into the food supply and increasing the            than in their refined-gramn counterparts (30). All of these
availability of desirable, affordable, and healthful whole           components are present in different proportions in the
gram foods for consurners. Partnerships of industry, govern          bran, germ, and endosperm fractions of the whole gram
ment, academia, and food and nutrition organizations to              and vary in concentration based on the type of whole gram.
develop a supply chain infrastructure and help support               Whole grains contribute to a phytochemical-rich dietary
the gradual introduction of more whole-grain foods into              pattern. However, research has been unable to identify
the diet are needed. Such an effort has been underway                how much of the reduced risk associated with consumption
in the United States with the recent stealth introduction of         of whole grains is due to fiber alone or to the combination of
whole-grain foods into school meals. These interventions             the compounds found in whole grains. Whole-gramn phyto
have been effective in increasing whole-gramn intake arnong          chemicals and macro- and micronutrients may work syner
children in school cafeterias and afterschool programs, in           gistically to contribute to the observed whole-grain health
cluding substituting whole-grain foods for refined-grain             benefits (30). More research is needed to better understand
menu items (95,96), reformulating products to gradually in           the effects of these individual components on heaith outcomes.
crease whole-gramn content (88), and distributing novel                    Participants in the roundtable discussed whether the def
whole-grain commodity food products (97). In a study of               inition of a whole-grain food should include products with
 fifth and sixth grade students in a large suburban school dis       partially refined gram, or products which contain other
 trict, whole-grain consumption was increased by nearly a             gram components, like “added bran” and “added germ.”
 full serving when white whole wheat tlour was partially              The AACCI and HEALTHGRAIN definitions of whole gram
 substituted for refined wheat four in pizza crust (98). Find         clearly state that a whole-grain four must contain all the
 ings were simiiar for 10 schools in Minnesota and 7 schools          constituent parts of the gram and in the same proportions
 in Texas in which refined-grain pancakes and tortillas ‘ere          as the original gram. The 2010 U.S. DGA also specifically
 replaced with whole-gramn versions (99). Current supply              states that bran is not a whole gram (2). Thus, a food
 chain technologies, processes, and infrastructure developed          made from refined four with bran or germ as an additional
 through the delivery of whole grains into school cafeterias          ingredient alone does not qualify as a whole-grain food and
 can be effectively applied to restaurant and other food ser          should not be described as such. Both observational and in
 vice settings as well.                                               tervention studies that have examined the effects of the con
       Dietary modeling exercises of U.S. children ages 9—18 y        surnption of specific whole grains and whole-grain foods on
 indicate the feasibility of increasing intake via substitution       biomarkers, surrogate endpoints, and incidence of disease
 of whole-grain ingredients in commonly consumed foods                have found that when intakes of added bran and germ
  (99). Substituting whole-gramn products for refined-grain            were controlled for, the beneficial association with whole
  products, particularly yeast breads, pizza, and grain-based          gram remained (14,15,105). Although the majority of phy
  desserts, which together account for almost one-half of the          tochemicals in whole grains are indeed found in the bran
  refined grains in the American diet (100), could be one ef           and germ, in some cases, a substantial proportion can be
  fective strategy to increase whole-grain consumption.                found elsewhere: in whole wheat, the starchy endosperm
       To increase the availability of whole-grain foods in food       contributes >50% of the /3-crypotxanthmn, almost 50% of
  service as well as retail and home environments, dietary             the lutein, 21% of the flavonoid content, and 17% of the to
  guidance should be aligned with food formulation and                 tal phenolic content (106). Furthermore, evidence for bene
  new product development.                                             ficial metabolic effects is stronger for consuming a variety of
                                                                       whole grains than for a single moiety in isolation (14).
  Expert Panel Recommendation for Adopting a                                In practice, recombining or reconstitution of whole-gramn
  Standard Definition of a Whole-Grain Food                            components is the most common way in which whole-grain
  Benefits of ivhole-grain coinponents. An accumulating                flours are produced. The roller miii process involves dividing
  body of evidence now shows that diets rich in whole grains           the germ, bran, and endosperm during processing of the
  impart health benefits (8—15). Dietary fiber greatly contrib         gram and then recombining or reconstituting them back
  utes to these benefits but does not explain them all. For ex         to their origmnal proportions during processing. The major
  arnple, some, but not all, studies suggest that consuming             ity of products fourid on retail store shelves would be con
   brown rice, which is a whole gram that is relatively low in          sidered recombined or reconstituted whole-grain products.
   fiber (3.5% by weight), can impart heaith benefits (101—             Not only do recombined or reconstituted whole gramns corn
   103). In contrast, a recent meta-analysis by Hu et al. (104)         prise most of the whole grains in the food supply, but most
   indicated that higher consurnption ofwhite rice is associated        studies showing health benefits of whole grains have used re
   with a significantly increased risk of 2TDM, especially in           combined or reconstituted whole grains (107).
   Asian (Chinese and Japanese) populations. Although fiber
   is the most extensively studied, it is only one of a complex          Whole-grain food definition. Dietary guidance from sev
   array of beneficial bioactive components, including vitamjns,        eral countries currently recommends increased consump
   minerals, dietary fiber, lignans, j3-glucan, inulin, and phenolic     tion of whole grains (Table 2). The observational research
   and polyphenolic constituents, phytosterols, and sphingolipids       data published to date clearly demonstrate an association
    1 72  Ferruzzi et al.
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<pre>between intake of whole grains and a reduced risk of disease.   McKeown (Tufts University, USDA-Humarl Nutrition Center
From a practical standpoint, many food products already on      on Aging); Robert Post (USDA-Center for Nutrition Policy
the market provide at least 8 g of whole grains per serving     and Promotion); MarIa Reicks (University of Minnesota);
and can contribute to achieving the dietary recommenda          Gabriele Riccardi (Federico II University); Sarah Roller
tion of 48 gld (1). Therefore, it is recommended that 8 g       (Kelley Drye); Chris Seal (Newcastle University); Joanne
ofwhole gram per 30 g (27 g/100 g), without a fiber require     Slavin (University of Minnesota); Jan-Willem van der
ment, be considered a minimum content that is substantial       Kamp (HEALTHGRAIN Forum); Laura Hansen (General
and meaningful to aid consurners toward achieving their         Mills Inc.); Satya Jonnalagadda (General Mills Beu Institute
whole-grain dietary recommendation and that a food pro          of Health and Nutrition); Maha Tahiri (General MuIs BeIl
viding at least 8 g of whole grains per 30 g (27 gIlOO g) be    Institute of Health and Nutrition); Frank Thielecke (Cereal
recognized as a whole-grain food. This aligns with both         Partners Woridwide); Greg Thompson (General Milis mc.);
the 2010 DGA and the newly approved AACCI whole-grain           Densie Webb (consultant; science writer); and Kathy Weimer
characterization, which states that a whole-grain food pro      (General Mills BeIl Institute of Health and Nutrition). All au
duct must contain at least 8 g whole grain/30 g of product.     thors read and approved the final manuscript.
On 21 May 2013, the AACCI Board of Directors indepen
dently approved the Whole Grains Working Group’s charac         Literature Cited
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<pre> 98. Chan H, Burgess-Champoux T, Rcicks M, Vickers Z, Marquart L.                  doesn’t substanlially affect metabolic risk in rniddle-aged Chinese men
     White whole wheat four is partially substituted for refined wheat             and women with diabetes or a high risk for diabetes. T Nutr. 2011;
     four in pizza crust in school meals. 1 Child Nutr Manag. 2008 ]cited          141: 168 5—90.
     2013 July 71;32. Available from: http://docs.schoolnutrition.org/news    104. Hu E, Pan A, Malik T, Sun Q. White nee consumption and risk of type
     roorn/jcnm/O8springlchan/index.asp.                                           2 diabetes: meta-analysis and systensatic review. Br Mcd 1. 20l2;15;
 99. Keast DR, Rosen RA, Arndt LA, Marquart LE Dietary modeling shows              344:c 1454.
     that substitution of whole gram for refined gram ingredients of foods    105. Jensen MR, Koh-Banerjcc P, Franz M, Sampson L, Gronbaek M,
     commonly consumed by US children and teens can increase intake of             Rimm EB. Whole grains, bran, and gerns in relation to homocysteine
     whole grains. JAm Did Assoc. 2011;ll 1:1322—8.                                and markers of glycemic control, lipids, and infiammation. Am 1 Clin
 00. Nationa] Cancer Institute. Sources of refined grains in the diets of the      Nutr. 2006;83:275—83.
     U.S. population ages 2 years and older. NHANILS 2003—2004. Risk          106. Adorn KK, SorreUs 51, Liu R. Phytochemicals and antioxidant activity
     Factor Monitoring and Methods. Cancer Control and Population Sci              of milled fractions of different whcat varieties. J Agric Food Chem.
     ences [cited 2013 Jul 7]. Available from: httplJriskfactor.cancer.gov/        2005;53:2297—306.
     diet/foodsources/food_groups/table3.htmI.                                107. International Association for Cereal Science and Technology. Whole
101. Tantamango YM, Knutsen S, Beeson W, Fraser G, Sabate J. Foods and             grains task force. Whole grains-issues and deliberations from the
     food groups associated with the incidence of colorectal polyps: the           Whole Grains Task Forcc. 2008 [cited 2013 Jan 29]. Available from:
     Adventist Health Study. Nutr Cancer. 2011;63:565—72.                          www.icc.or.at/working-groups/whole._ gram.
102. Sun Q, Spicgclman D, van Dam R, Holmes M, Malik V, Vil1ett W, Hu         108. The American Association of Cercal Chemists International (AACCI)
     F. White nee, brown nee, and risk of type 2 diabetes in US men and            Board of Directors approved the Wholc Grains Working Group’s char
     wornen. Arch Intern Mcd. 2010;170:961—9.                                      acterization [cited 2013 Aug 20]. Available from: hltp://www.aaccnet.
103. Zhang G, Pan A, Zong G, Yu Z, Wu H, Chen X, lang 1., Feng Y, Zhou             org/about/newsreleases/Pages/WholeGrain ProductCharactcrization.
     H, Chen X, et al. Substituting white rice with brown rice for 16 weeks        aspx.
 176    Ferruzzi et al.
</pre>

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<pre>Van: Caroline van Rossum
Verzonden: maandag 9 februari 2015 22:35
Aan: Javanmardi, M. (Mitra)
CC: Spaaij, C.J.K. (Caroline); Weggemans, R.M. (Rianne)
Onderwerp: Re: Commentaarronde Richtlijnen goede voeding         .
Beste collegas van de GR,
Hierbij stuur ik jullie de reacties vanuit het RIVM op de documenten in de eerste commentaarronde
Succes met de wijzigingen.
Groetjes Caroline
Caroline van Rossum, PhD
Centre for Nutrition, Prevention and Health Services
National Institute for Public Health and the Environment
POBoxi
3720 BA Bilthoven
The Netherlands
See httn ://www.voedselconsurnrtiepeiling nl for information on the Dutch food consumption surveys
See http://wwwrivm.nl/nevo for information on the Dutch food composition database
</pre>

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<pre>  Reactie RIVM op concept
  achtergrondrapporten RGV
  dd 2februari 2015
Granen
- Aardappelen
  Regel 426; Er worden veel aannames gemaakt in de kwantificering van de sterkte van het
  effect;
          Verwijzen
  Dit is een
      -
              algemene      NEVO vooralsbron
                      naaropmerking           van nutriënten?
                                           er kwantitatieve relaties worden beschreven op basis van
  cohortonderzoek
      -               datonderwerpen
          Bij de andere    met voedselfrequentievragenlijsten     gebeurt.het
                                         is het niet uitgewerkt waarvoor   Deze  vragenlijsten
                                                                              belangrijke  bron zijn
                                                                                                is.
  niet goed
      -
              in staat om  het absolute   niveau  van  inname  goed  te schatten.
          Dit stuk lijkt qua opbouw niet consistent met andere deelrapporten.
      -   In dit stuk worden geen VCP-data over de consumptie weergegeven.
  Granen
      -   Regel 426; Er worden veel aannames gemaakt in de kwantificering van de sterkte van het
          effect;
          Dit is een algemene opmerking als er kwantitatieve relaties worden beschreven op basis van
          cohortonderzoek dat met voedselfrequentievragenlijsten gebeurt. Deze vragenlijsten zijn
          niet goed in staat om het absolute niveau van inname goed te schatten.
  Koffie
      -   De toelichting over wat wel/niet gefilterde koffie is, kan beter.
      -   Het zou goed zijn om explicieter aan te geven hoe de term koffie wordt bedoeld als daar niet
          bij staat of deze wel/niet gefilterd is. Bijvoorbeeld bij de conclusie duidelijk maken welke
          koffie bedoeld is.
  Thee
       -   De consumptiecijfers betreft thee inclusief specifieke theesoorten; Het zou goed zijn om
           hierover een voetnoot bij de tabel op te nemen.
  Vetten en oliën
       -   Klopt het dat er geen bewijs is voor het margarine versus olie?
       -   Dat boter en margarines een belangrijke bron zijn voor vitamine A en D komt niet aan bod.
       -   Bij consumptiecijfers vermelden dat het gemiddelde van 2 dagen is.
       -   In regel 629 2e “concludeert” kan weg.
  Voedingssu pplernen ten
        -  Zijn dit de relevante eindpunten? De reden dat mensen supplementen slikken zijn vaak
           anders dan de hier geselecteerde eindpunten.
        -  Voor wat betreft vitamine D en colonkanker. De conclusie is consequent volgens GR
           systematiek; Een aantal RIVM-ers hebben hierover een andere mening. Dit komt door de
           gevolgde systematiek.
</pre>

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<pre>         Commentaar ontvangen per email 9 februari 2015
         Goedenmiddag,
         Graag wilde ik uw aandacht vragen voor de publicatie:
         Fasano et al
         Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to
         Inflammation, Autoimmunity, and Cancer
         http://physrev.physiology.org/content/91/1/151
         welke naar mijn mening aannemelijk maakt dat graanproducten (in elk geval in de
         huidige densiteit) voor gezonde volwassenen bedreigend is voor hun gezondheid. Ook
         in de populaire media is er afgelopen jaar erg veel aandacht geweest voor de voor- en
         nadelen van het eten van granen en naar mijn mening is het eerlijker om te vermelden
         dat we niet weten of het consumeren van granen op harde eindpunten significante
         verschillen laat zien met voedingspatronen zonder graan, maar dat dat zeer wel
         aannemelijk is.
         Ik ben werkzaam als docent op een instituut waar huisartsen worden opgeleid en zie
         zelf hoeveel gezondheidsproblemen deze artsen aan hun eigen lijf ervaren. En hoe ze
         het vertrouwen in de oa het voedingscentrum (en daarmee de GR) verliezen.
         Granen, suikers, omega 6:omega 3 en toevoegingen zijn m.i. hoofdverdachten.
         Ik ben erg benieuwd naar uw reactie op bovenstaand artikel en zou het ten zeerste
         waarderen om te vernemen in hoeverre deze informatie wordt meegenomen in het
         ontwikkelen van de nieuwe voedingsrichtlijnen.
         Met betrekking tot de adviezen omtrent vetconsumptie zou ik u willen verzoeken het
         volgende artikel te lezen:
          Are some diets “mass murder”?
         BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g7654 (Published 15 December
         2014)
         Cite this as: BMJ 2014;349:g7654
         Tevens interessant, m.n. met het oog op de metabool-syndroom-golf die de wereld
         meer en meer overspoelt:
pagina 1
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<pre>         http://youtu.be/D0GSSSE4l8U
         Professor Tim Noakes on the topic: "The Great Diet Controversy: UCT taught me to
         Challenge Beliefs."
         Wat denkt u?
         Hartelijke groet,
         drs Birgit Spoorenberg
         huisarts
         tevens werkzaam als docent bij de huisartsopleiding Maastricht
pagina 2
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<pre>Van: Elk, Kathelijn-van
Verzonden: maandag 9 februari 2015 18:28
Aan: GR_Webmaster; Javanmardi, M. (Mitra)
Onderwerp: Commentaar Unilever achtergronddocumenten Richtlijnen goede voeding 2015
Beste commissie van de Gezondheidsraad, beste Mitra,
Wij danken de commissie voor de inzage in de werkwijze en achtergronddocumenten voor de
Richtlijnen Goede Voeding 2015. Bij dezen maken wij graag gebruik van de gelegenheid tot het geven
van commentaar op verschillende achtergronddocumenten.
In de bijlage vindt u het Unilever commentaar op de volgende achtergronddocumenten:
     -    ‘Granen en graanproducten’, gecombineerd met ‘Voedingsvezel’
     -    ‘Thee’
     -    ‘Vetten en oliën’
Daarnaast hebben we nog een vraag gerelateerd aan het achtergronddocument over supplementen.
Regel 80-81:
Suppiementen met andere bioactieve stoffen zoals flavonoiden, fytosterolen, terpenen en probiotica,
vallen buiten het bestek van dit document.
Graag zouden we van de commissie vernemen in welk achtergrond document supplementen of
voedingsmiddelen verrijkt met deze genoemde bioactieve stoffen, wel zullen worden behandeld.
Wij wensen de commissie veel succes met de komende fases van dit belangrijke werk, en kijken met
belangstelling uit naar de volgende achtergronddocumenten.
 Mocht u van de genoemde referenties de abstract of de volledige publicatie ontvangen, dan verneem
 ik dat graag, ook indien er overige vragen zijn.
 Met vriendelijke groet,
 Kathelijn van Elk
         ..-
  UQwe
  ’
  4     -
  Kathelijn van Elk Nutrition and Health Manager
</pre>

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<pre>                                            COMMENTAAR ACHTERGRONDDOCUMENTEN GRANEN EN
                 February 9, 2015           GRAANPRODUCTEN EN VOEDINGSVEZEL
INTRODUCTIE:
Wij danken de commissie voor de inzage in de werkwijze en achtergronddocumenten voor de Richtlijnen
Goede Voeding 2015. Bij dezen maken wij graag gebruik van de gelegenheid tot het geven van commentaar op
het achtergronddocument Granen en graanproducten en het achtergronddocument Voedingsvezel.
We complimenteren de commissie met de systematische en uitgebreide werkwijze voor de nieuwe richtlijnen.
Wij verwelkomen de afstemming van de conclusies met internationale richtlijnen. Het is in onze ogen erg
belangrijk dat voedingsadviezen breed worden gedragen. Internationale eenduidigheid in adviezen voor de
bevolking verschaft ook de voedingsmiddelenindustrie duidelijke richtingen voor het verbeteren van
producten.
Wij waarderen ook de grondige evaluatie en weging van verschenen literatuur tot juli 2014. Toch zouden we
graag meegeven dat de Britse SACN onlangs een draft rapport heeft gepubliceerd met een uitgebreide
systematische review met betrekking tot koolhydraten inclusief graanproducten en voedingsvezel voor een
brede reeks aan uitkomsten. Zij komen op meerdere punten tot andere conclusies (bv. effect van vezels op
bloeddruk, LDL-cholesterol en lichaamsgewicht) dan de commissie. Dit door het gebruik van een andere
onderliggende methodologie, waardoor het SACN rapport ook andere intermediaire uitkomstmaten includeert.
Dit rapport willen we graag onder de aandacht brengen, zodat de commissie zich bewust is van het bestaan
van deze publicatie en de nieuwe Nederlandse voedingsrichtlijnen gebaseerd zullen zijn op de meest recente
wetenschappelijke inzichten.
GEDETAILEERD COMMENTAAR:
         Achtergrond document Granen en graanproducten: regel 54 77                         -
         Er staan momenteel definities in voor Volkoren, Graansoorten en Graanproducten. Wij stellen voor ook
         een definitie toe te voegen omtrent ‘geraffineerde granen’.
         Referentie:
              1. The Scientific Advisory Committee on Nutrition (SACN), Draft Carbohydrates and Health report,
                  scientific consultation: 26 june to 1 september 2014. Note: This is a draft report and does not necessarily
                  represent the fïnal views of the Scientific Advisory Committee on Nutrition, or the advice/policy of Public Health England and
                  Health Departments.
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<pre>Verzonden: ma 9-2-2015 11:38
Geachte heer/mevrouw,
De concept-achtergronddocurnenten Richtlijnen goede voeding 2015 Granen en
graanproducten en Voedingsvezel geven een gedegen overzicht van de stand van zaken op
deze terreinen. Desondanks willen wij voor het opstellen van de definitieve documenten
hierbij nog enkele zaken ter overweging geven voor aanpassingen en completering.
Onze opmerkingen treft u aan in de bijlage.
Met vriendelijke groet,
Jan de Vries,                         Jan Willem van der Kamp
                                      Board member van Healthgrain Forum
(www.hea lthgrain.or)
Jan Willem van der Kamp
Senior Officer International Projects
TNO Food and Nutrition
                                                                            Innovaticiri
                                                                            for liie
</pre>

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<pre>Geachte heer/mevrouw,
De concept-achtergronddocumenten Richtlijnen goede voeding 2015 Granen en
graanproducten en Voedingsvezel geven een gedegen overzicht van de stand van zaken
op deze terreinen. Desondanks willen wij voor het opstellen van de definitieve documenten
hierbij nog enkele zaken ter overweging geven voor aanpassingen en completering.
Concept document granen en graanproducten
In navolging van onderzoek uit de Verenigde Staten gebruikt de commissie in dit document
de term volkorenproducten voor graanproducten die voor ten minste 25 procent uit
volkorenmeel bestaan, en voor graanzemelen. Daarom is het wenselijk om nader in te gaan
op de mogelijke bijdrage van graanzemelen en bioactieve stoffen aanwezig in graanzemelen
en volkorenproducten op gezondheid.
Het is wellicht zinvol om de publicatie Cho et al. met een Scientific Statement van de
American Society for Nutrition bij uw analyse te betrekken. Consumption of cereal fiber,
mixtures of whole grains and bran, and whole grains and risk reduction in type 2 diabetes,
obesity, and cardiovascular disease van Am J Clin Nutr. 2013 Aug;98(2):594-619. doi:
10.3945/ajcn.1 13.067629. Epub 2013 Jun 26. Dit statement sluit aan bij de
voedingsaanbeveling van de USDA (2010): “Choosing whole grains that are higher in dietaryfiber
has additional health benefits”.
Concept document Voedingsvezel
Constipatie
In de Richtlijnen Goede Voeding van 2006 en in de Richtlijn voor de vezelconsumptie 2006
wordt aangegeven dat voedingsvezel de snelheid waarmee voedsel het maagdarmkanaal
passeert verhoogt (Richtlijnen Goede Voeding 2006, pg 66; Richtlijn voor de
vezelconsumptie 2006, pg 12 en hoofdstuk 2 Obstipatie). In beide richtlijnen wordt dit
gekoppeld aan een risico vermindering op obstipatie. In de Richtlijn voor de vezelconsumptie
wordt dit zelfs getalsmatig uitgewerkt: Voor volwassenen ligt de optimale vezelconsumptie in
verband met de darmpassagesne!heid bij een gemengde voeding rond de 32 tot 45 gram per
dag. Daarbij is essentieel dat men voldoende vocht gebruikt en voldoende
lichaamsbe weging heeft.
</pre>

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<pre>Daarnaast heeft EFSA een positief oordeel uitgesproken over de dossiers van een aantal
voedingsvezels waarin de claim ‘increase in fecal bulk” is ingediend. In de literatuur variëren
prevalentie cijfers voor constipatie (conform de meest recente Rome Criteria       ) tussen de 2%
                                                                                   1
en   27%2   welke in de VS een geschat laxantia gebruik van ca $800 miljoen dollar met zich
       . Het mag algemeen bekend worden geacht dat obstipatie, of constipatie, een
mee brengt
       2
veel voorkomend ongemak is dat in veel gevallen door middel van een hogere inneming van
bepaalde voedingsvezels kan worden verholpen, een goedkopere oplossing dan het gebruik
van laxatieve geneesmiddelen.. Daarom geven we u in overweging om, in navolging van de
adviezen uitgegeven in 2006, dit onderwerp in uw advisering te betrekken.
 1
   Drossman DA, Dumitrascu DL, Rome III: New standard for functiona gastrointestinal disorders. J Gastrointestin
Liver Dis 2006; 15: 237-41
2
   MI Pinto Sanchez, P Bercik. Epidemiology and burden of chronic constipation. Can J Gastroenterol
2011;25(Suppl B):11B-15B.
Definitie van voedingsvezel
Het huidige sub-hoofdstuk 1.1 stelt dat er geen internationale consensus is. Echter, een
publicatie    ( CODEX-aligned dietary fiber definitions help to bridge the ‘fibergap’, Julie Miller
Jones, Nutrition Journal 2014, 13:34 doi:10. 1186/1475-2891-13-34) laat zien dat de CODEX
definitie, met inciusie van niet-verteerbare koolhydraten vanaf polymerisatiegraad 3
wereldwijd breed wordt overgenomen. Zie ook hieronder voor het overzicht in Table 3 van
 deze publicatie. Ook het in ontwikkeling zijnde voorstel van de FDA gaat deze kant op, zoals
 blijkt in diverse mededelingen en presentaties van deze organisatie. Zie bijvoorbeeld
 FDA: Proposed Dietary Fiber Definition (in presentatie: Nutrition & Suppiement Facts Label
 Proposed Rule Paula R. Trumbo, PhD www.fdaqov/downloads/Food/.../UCM403514.pdf)
</pre>

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<br><br>====================================================================== Pagina 38 ======================================================================

<pre>http:Ilwww. nutr[tionj.com/content/1 3/1/34
http://www.nutriton .corn/content/13/1/34/table/T3
Table 3
Countries adopting the CODEX with DP >3 dietarv fiber definition
     Authorities/Countries accepting the         Countries not accepting the     Countries awaiting a
            definitions with DP3                      definition with DP3             decision
             EFSA/European Union                           South Africa                US FDA
   Food Standards Australia and New Zealand
                    (FSANZ)
                       Brazil
                Health Canada
              Chile  —  for labeling               Chile - not for health claims
                      China
                   Indonesia
                      Korea
                    Malaysia
                     Mexico
                    Thailand
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                    Reactie op commentaren
Reactie van de commissie Richtlijnen goede voeding 2015
op het achtergronddocument Granen en graanproducten
De commissie heeft op het achtergronddocument over granen en graanproducten
reacties ontvangen van de Federatie Nederlandse Levensmiddelen Industrie (FNLI),
Unilever, De Vries Nutrition Solutions / Health grain forum & TNO Food and Nutrition,
drs. B. Spoorenberg en het Rijksinstituut voor Volksgezondheid en Milieu (RIVM). De
commissie heeft de inhoudelijke reacties betrokken bij het opstellen van het definitieve
achtergronddocument en over het algemeen de tekstuele suggesties overgenomen.
Geen van de commentaren heeft geresulteerd in wijzigingen van conclusies.
Op de volgende pagina’s beschrijft de commissie in een tabel alle inhoudelijke
commentaren en wat zij daarmee heeft gedaan.
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                          Reactie op commentaren
Tabel Overzicht ontvangen inhoudelijke commentaren op achtergronddocument over granen en graanproducten en reactie van de commissie.
 Commentatoren      Commentaar                                                                 Reactie commissie
                                                                                      1
 FNLI en            Het valt ons op dat het recentelijk verschenen ontwerp rapport van de      Niet verwerkt
 Unilever           Britse SACN met een uitgebreide systematische review met betrekking        Het rapport van het Scientific Advisory Committee on Nutrition
                                                                                                         1
                    tot koolhydraten - inclusief granen en graanproducten - niet is            (SANC) was ten tijde van het opstellen van de
                    meegenomen bij de beoordeling. Zij komen op meerdere punten tot            achtergronddocumenten alleen beschikbaar als concept. In het
                    andere conclusies dan de commissie (bv. effect van vezels op               concept was vermeld dat het niet noodzakelijkerwijs een
                    bloeddruk, LDL-cholesterol en lichaamsgewicht). Dit door het gebruik       weergave was van het uiteindelijke standpunt van SANC.
                    van een andere onderliggende methodologie, waardoor het SACN ook           Daarom is het niet aangehaald in het achtergronddocument. De
                    andere intermediaire eindpunten includeert.                                commissie baseert zich op peer-reviewed publicaties die binnen
                                                                                                                         2
                                                                                               haar werkwijze passen.
 FNLI               Heeft de Commissie bij alle beschikbare onderzoek kunnen nagaan dat        Niet verwerkt
                    de 25% minimum hoeveelheid volkorenmeel ook daadwerkelijk                  De commissie heeft niet bij ieder onderzoek kunnen nagaan hoe
                    gehanteerd werd?                                                           de term volkoren gedefinieerd was.
 FNLI               Verder is naar onze mening onderzoek gebruikt waarin zowel volkoren        Niet verwerkt
                    producten (min 25% volkoren), hoog vezel ontbijtgranen en zemelen          De commissie geeft aan dat de term volkoren niet goed is
                    worden meegenomen onder de noemer ‘volkoren’. Wetenschappelijk             gedefinieerd en dat zij de term volkorenproducten hanteert voor
                    gezien lijkt het erop dat deze verschillende groepen dezelfde              graanproducten die voor ten minste 25 procent uit volkorenmeel
                    gezondheidseffecten bewerkstelligen en daarom zeker bij elkaar in de       bestaan en voor graanzemelen (paragraaf 1.1), hetgeen aansluit
                    analyse gebruikt kunnen worden. In de publicatie van De Moura et al        aan bij het beschikbare cohortonderzoek (paragraaf 3.1). De
                    (2009) - bijgevoegd - wordt duidelijk dat bij gebruik van publicaties met  definitie is herhaald in hoofdstuk 4 (conclusies relevant voor de
                    de huidige volkoren definitie er te weinig onderzoek is om relaties vast   richtlijnen).
                    te stellen, terwijl als de bredere definitie van volkoren wordt gebruikt,
                    deze wel kunnen worden vastgesteld. Zij concluderen dan ook: “When         Verwerkt
                    considering only whole grain studies that met the FDA definition, we       Om verwarring te voorkomen is de definitie ook toegevoegd in
                    found insufficient scientific evidence to support a claim that whole grain paragraaf 3.7 (alle conclusies uit het cohortonderzoek).
                    intake reduces the risk of CVD. However, a whole grain and reduced
                    risk of CVD health claim is supported when using a broader concept of
Pagina 2
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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                    Reactie op commentaren
 Commentatoren    Commentaar                                                               Reactie commissie
                  whole grain to include studies that considered intake of fiber-rich bran Niet verwerkt
                  and germ as well as whole grain.”                                        De commissie vindt het niet wenselijk om hoog-vezelproducten
                  Het is in onze ogen zeer belangrijk om bij de conclusies steeds          en graanzemelen in de formulering van conclusies op te nemen.
                  ‘volkoren, hoog vezel producten en zemelen’ te schrijven en niet te      De formulering ‘hoog-vezelproducten’ is niet specifiek voor
                  volstaan met ‘volkoren’ (een andere optie is om de type                  graanvezel en graanproducten. De stand van wetenschap die
                  voedingsmiddelen die in de studies zijn gebruikt in relatie tot de       door de commissie is beschreven gaat niet specifiek over
                  uitkomstmaat te gebruiken). Officieel zijn zemelen en hoog vezel         graanzemelen, maar over producten die voor ten minste 25
                  producten niet ‘volkoren’ en dan kan er al gauw verwarring ontstaan.     procent uit volkorenmeel bestaan en graanzemelen
                  Dat laatste is niet in het belang van de consument.                      samengenomen.
                  En hoe zit het dan met hoog vezel producten en zemelen?
                  Graanzemelen worden op zichzelf niet als volkoren aangemerkt omdat       Niet verwerkt
                  zij een onderdeel vormen van de graankorrel. Wij zouden daarom willen    Het beschrijven van onderzoek naar bioactieve stoffen die in de
                  suggereren dat het wellicht zinvol is om ook nader in te gaan op de      graanzemel voorkomen past niet in de werkwijze van de
                                                                                                       2
                  mogelijke bijdrage aan de gezondheid van graanzemelen en bioactieve      commissie.
                  stoffen die in graanzemelen en volkoren producten aanwezig zijn.
                  Bovenstaand punt geldt voor veel meer plaatsen in het document. De
                  GR vermeldt dit op verschillende plaatsen ook maar in de conclusies
                  wordt vervolgens volstaan met uitsluitend het woord volkoren. Wij
                  zouden willen voorstellen dit aan te passen.
 FNLI en          Wij denken dat het ook belangrijk is om een definitie of omschrijving    Niet verwerkt
 Unilever         van ‘geraffineerde’ granen te hebben. Zijn dat graanproducten waarvan    Het geven van een definitie van geraffineerde graanproducten
                                                             1                                                                        2
                  het aandeel volkoren minder dan 25% is?                                  zou binnen de werkwijze van de commissie passen, als die
                                                                                           definitie was beschreven en toegepast in de publicaties over het
                                                                                           cohortonderzoek. Dat is niet het geval.
                                                                                           NB: De innamegegevens van geraffineerde graanproducten in
                                                                                           Tabel 1 hebben uitsluitend betrekking op producten waarin geen
                                                                                           volkorenmeel is verwerkt, zoals witbrood, witte pasta en bloem.
Pagina 3
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                  Reactie op commentaren
 Commentatoren    Commentaar                                                         Reactie commissie
 FNLI             Het lijkt ons zinvol als de navolgende publicaties eveneens in de  Verwerkt
                                                                                     
                                                                                                                          3
                  analyse worden betrokken:                                               Een verwijzing naar Cho e.a. is toegevoegd in paragraaf
                  
                                                          3
                       Cho e.a. (Am J Clin Nutr 2013)                                     1.1 (definities) en in de inleidende alinea van de paragraaf
                  
                                                                 4
                       De Moura e.a. (J Nutr Supplement 2008)                             3.5.1 (cohortonderzoek naar het verband tussen
                  
                                                        5
                       Ferruzzi e.a. (Adv Nutr 2014)                                      volkorenproducten en het risico op diabetes). Deze
                                                                                          systematische review bevat ten opzichte van de meta-
                                                                                                                    6
                                                                                          analyse van Aune e.a. geen aanvullende publicaties en
                                                                                          beschrijft een deel van de cohortonderzoeken op basis
                                                                                          oudere publicaties met een kortere follow-up duur. Daarom
                                                                                          blijft de publicatie verder buiten beschouwing. De
                                                                                          literatuurlijst levert geen aanvullende onderzoeken op.
                                                                                     Niet verwerkt
                                                                                     
                                                                                                            4
                                                                                          De Moura e.a. is niet toegevoegd, omdat het geïncludeerde
                                                                                          observationele onderzoek deels cross-sectioneel onderzoek
                                                                                                                                                       2
                                                                                          betreft dat niet aansluit bij de werkwijze van de commissie.
                                                                                     
                                                                                                          5
                                                                                          Ferruzzi e.a. is niet toegevoegd, omdat het geen
                                                                                          systematische review betreft en daarom niet aansluit bij de
                                                                                                                          2
                                                                                          werkwijze van de commissie.
 FNLI             Additionele studie volkoren versus geraffineerde tarweproducten en Verwerkt
                  systolische bloeddruk:                                                 De referentie is toegevoegd. Dit leidt niet tot aanpassing
                  
                                                    7
                       Bodinham (Br J Nutr 2011)                                          van de conclusie.
 FNLI             Additionele studie volkoren versus geraffineerde tarweproducten en Niet verwerkt
                  LDL cholesterol:                                                       Deze referentie was al aangehaald in Tabel 8. De
                  
                                                      8                                                                        8         9
                       Tighe (Am J Clin Nutr 2010)                                        publicaties van Tighe e.a. uit 2010 en 2013 hebben
                                                                                          betrekking op dezelfde RCT.
Pagina 4
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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                       Reactie op commentaren
 Commentatoren    Commentaar                                                                Reactie commissie
 FNLI             Additionele systematische review volkorenproducten en diabetes            Niet verwerkt
                                                                                            
                                                                                                                                 10
                  mellitus type 2:                                                               Een verwijzing naar Priebe e.a.    is toegevoegd in de
                  
                                                                                        10
                       Priebe e.a. (Cochrane Database of Systematic Reviews 2008)                inleidende alinea van de paragraaf 3.5.1 (cohortonderzoek
                                                                                                 naar het verband tussen volkorenproducten en het risico op
                                                                                                                                                      10
                                                                                                 diabetes). De systematische review van Priebe e.a.      is
                                                                                                 gedateerd ten opzichte van de beide meta-analyses (2008
                                                                                                 versus 2012 en 2013). In de publicatie is niet gespecificeerd
                                                                                                 welke referenties in de specifieke meta-analyses zijn
                                                                                                 opgenomen. De literatuurlijst van deze publicatie levert
                                                                                                 geen aanvullende onderzoeken op.
 FNLI             Tabel 1: Tot slot vragen wij ons bij deze sectie af of producten als koek Niet verwerkt
                  en banket ook tot de groep graanproducten worden gerekend. Het zijn       In de Nederlandse consumptiegegevens die in Tabel 1
                  wel producten waarvan het belangrijkste ingrediënt veelal de granen is.   gepresenteerd worden, zijn koek en banket niet meegerekend.
 FNLI             Tabel 1: Ontbijtgranen worden wel als voorbeeld meegenomen in de          Niet verwerkt
                  tekst maar zijn niet in de tabel opgenomen. Volgens onze gegevens is      In Tabel 1 zijn ontbijtgranen geïncludeerd in de gegevens over
                  de gemiddelde per capita inname in Nederland van ontbijtgranen            de consumptie van granen en graanproducten (totaal,
                  ongeveer 7 gram per dag. Dat is vergelijkbaar met witte rijst, maar veel  geraffineerd en ongeraffineerd). De consumptie van
                  meer dan roggebrood, haver en gerst. Het lijkt zinvol om ook de groep     ontbijtgranen is niet apart berekend, omdat geen van de
                  ontbijtgranen toe te voegen.                                              conclusies in het achtergronddocument specifiek betrekking
                                                                                            hebben op ontbijtgranen.
 FNLI             In de tabel van hoofdstuk 4 (Conclusies relevant voor de richtlijnen)     Verwerkt
                                                                                                              a
                  worden de volkoreneffecten beschreven als ‘volkoren versus                De kop ‘Volkoren versus geraffineerde graan(producten)’ is
                                                                                                                                 a
                  geraffineerde graanproducten’. Klopt dit wel?                             vervangen door ‘Volkorenproducten ’. Deze kolom betreft
                                                                                            bevindingen uit cohortonderzoek waarbij het gaat om de
                                                                                            vergelijking van verschillende consumptieniveaus van
                                                                                            volkorenproducten.
Pagina 5
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                           Reactie op commentaren
 Commentatoren    Commentaar                                                               Reactie commissie
 FNLI             Is de publicatie van Kyro over de biomarker alkylresorcinols gebruikt in Niet verwerkt
                                                                                                                            11
                  het document?                                                            De publicatie van Kyro e.a.         is niet gebruikt, omdat de
                                                                                           commissie zich in het achtergronddocument richt op onderzoek
                                                                                           waarin de inname direct is geschat.
 FNLI             Additionele referenties:                                                 Verwerkt:
                      Hauner e.a. (Ann Nutr Metab 2012)
                                                          12
                                                                                           
                                                                                                                                    3
                                                                                                Een verwijzing naar Cho e.a. is toegevoegd in paragraaf
                      Cho e.a. (Am J Clin Nutr 2013)
                                                      3
                                                                                                1.1 (definities) en in de inleidende alinea van de paragraaf
                      Wu e.a. (JAMA 2015)
                                             13
                                                                                                3.5.1 (cohortonderzoek naar het verband tussen
                                                                                                volkorenproducten en het risico op diabetes). Deze
                                                                                                systematische review bevat ten opzichte van de meta-
                                                                                                                            6
                                                                                                analyse van Aune e.a. geen aanvullende publicaties en
                                                                                                beschrijft een deel van de cohortonderzoeken op basis
                                                                                                oudere publicaties met een kortere follow-up duur. Daarom
                                                                                                blijft de publicatie verder buiten beschouwing. De
                                                                                                literatuurlijst levert geen aanvullende onderzoeken op.
                                                                                           Niet verwerkt:
                                                                                               Hauner e.a.
                                                                                                               12
                                                                                                                  is niet toegevoegd. In deze systematische
                                                                                                review zijn de oorspronkelijke cohortonderzoeken
                                                                                                beschreven, maar niet samengevat in meta-analyses.
                                                                                           
                                                                                                          13
                                                                                                Wu e.a.      is gepubliceerd na juli 2014, terwijl het
                                                                                                literatuuronderzoek voor de achtergronddocumenten de
                                                                                                periode tot juli 2014 betreft, en de bevindingen zijn in lijn
                                                                                                met de conclusies van de commissie. De publicatie is niet
                                                                                                toegevoegd.
Pagina 6
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                       Reactie op commentaren
 Commentatoren    Commentaar                                                               Reactie commissie
 De Vries         In navolging van onderzoek uit de Verenigde Staten gebruikt de           Niet verwerkt
                                                                                                                                             2
 Nutrition        commissie in dit document de term volkorenproducten voor                 Dit past niet in de werkwijze van de commissie.
 Solutions /      graanproducten die voor ten minste 25 procent uit volkorenmeel
 Health grain     bestaan, en voor graanzemelen. Daarom is het wenselijk om nader in te
 forum & TNO      gaan op de mogelijke bijdrage van graanzemelen en bioactieve stoffen
 Food and         aanwezig in graanzemelen en volkorenproducten op gezondheid.
 Nutrition
 De Vries         Het is wellicht zinvol om de publicatie Consumption of cereal fiber,     Verwerkt
                                                                                           
                                                                                                                                3
 Nutrition        mixtures of whole grains and bran, and whole grains and risk reduction        Een verwijzing naar Cho e.a. is toegevoegd in paragraaf
                                                                                         3
 Solutions /      in type 2 diabetes, obesity, and cardiovascular disease van Cho et al.        1.1 (definities) en in de inleidende alinea van de paragraaf
 Health grain     met een Scientific Statement van de American Society for Nutrition bij        3.5.1 (cohortonderzoek naar het verband tussen
 forum & TNO      uw analyse te betrekken. Dit statement sluit aan bij de                       volkorenproducten en het risico op diabetes). Deze
 Food and         voedingsaanbeveling van de USDA (2010): “Choosing whole grains that           systematische review bevat ten opzichte van de meta-
                                                                                                                          6
 Nutrition        are higher in dietary fiber has additional health benefits”.                  analyse van Aune e.a. geen aanvullende publicaties en
                                                                                                beschrijft een deel van de cohortonderzoeken op basis
                                                                                                oudere publicaties met een kortere follow-up duur. Daarom
                                                                                                blijft de publicatie verder buiten beschouwing. De
                                                                                                literatuurlijst levert geen aanvullende onderzoeken op.
 Drs. B.          Graag wilde ik uw aandacht vragen voor de publicatie van Fasano et al    Niet verwerkt
                           14                                                                                                                2
 Spoorenberg      uit 2011    welke naar mijn mening aannemelijk maakt dat                 Dit past niet in de werkwijze van de commissie.
                  graanproducten (in elk geval in de huidige densiteit) voor gezonde
                  volwassenen bedreigend is voor hun gezondheid. Ook in de populaire
                  media is er afgelopen jaar erg veel aandacht geweest voor de voor- en
                  nadelen van het eten van granen en naar mijn mening is het eerlijker
                  om te vermelden dat we niet weten of het consumeren van granen op
                  harde eindpunten significante verschillen laat zien met
                  voedingspatronen zonder graan, maar dat dat zeer wel aannemelijk is.
Pagina 7
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                                                                 Reactie op commentaren
 Commentatoren    Commentaar                                                           Reactie commissie
 RIVM             Er worden veel aannames gemaakt in de kwantificering van de sterkte  Niet verwerkt
                  van het effect. Dit is een algemene opmerking als er kwantitatieve   De commissie beschrijft in paragraaf 3.1 de methodologische
                  relaties worden beschreven op basis van cohortonderzoek dat met      kanttekeningen bij cohortonderzoek; daarin is aangegeven dat
                  voedselfrequentievragenlijsten gebeurt. Deze vragenlijsten zijn niet sprake kan zijn van schattingsfouten. Het achtergronddocument
                  goed in staat om het absolute niveau van inname goed te schatten.    beschrijft de kwantificeringen zoals gerapporteerd in het
                                                                                       gepubliceerde onderzoek.
Pagina 8
</pre>

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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                     Reactie op commentaren
Literatuur
1     The Scientific Advisory Committee on Nutrition (SACN). Draft Carbohydrates and Health report,
      scientific consultation: 26 june to 1 september 2014 - Note: This is a draft report and does not
      necessarily represent the final views of the Scientific Advisory Committee on Nutrition, or the
      advice/policy of Public Health England and Health Departments. 2015.
2     Gezondheidsraad. Werkwijze van de commissie Richtlijnen goede voeding 2015 -
      Achtergronddocument bij Richtlijnen goede voeding 2015. Den Haag: Gezondheidsraad; 2015:
      publicatienr. A15/03.
3     Cho SS, Qi L, Fahey GC, Jr., Klurfeld DM. Consumption of cereal fiber, mixtures of whole grains
      and bran, and whole grains and risk reduction in type 2 diabetes, obesity, and cardiovascular
      disease. Am J Clin Nutr 2013; 98(2): 594-619.
4     De Moura FF, Lewis KD, Falk MC. Applying the FDA definition of whole grains to the evidence for
      cardiovascular disease health claims. J Nutr 2009; 139(11): 2220S-2226S.
5     Ferruzzi MG, Jonnalagadda SS, Liu S, Marquart L, McKeown N, Reicks M e.a. Developing a
      standard definition of whole-grain foods for dietary recommendations: summary report of a
      multidisciplinary expert roundtable discussion. Adv Nutr 2014; 5(2): 164-176.
6     Aune D, Norat T, Romundstad P, Vatten LJ. Whole grain and refined grain consumption and the
      risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Eur
      J Epidemiol 2013; 28(11): 845-858.
7     Bodinham CL, Hitchen KL, Youngman PJ, Frost GS, Robertson MD. Short-term effects of whole-
      grain wheat on appetite and food intake in healthy adults: a pilot study. Br J Nutr 2011; 106(3): 327-
      330.
8     Tighe P, Duthie G, Vaughan N, Brittenden J, Simpson WG, Duthie S e.a. Effect of increased
      consumption of whole-grain foods on blood pressure and other cardiovascular risk markers in
      healthy middle-aged persons: a randomized controlled trial. Am J Clin Nutr 2010; 92(4): 733-740.
9     Tighe P, Duthie G, Brittenden J, Vaughan N, Mutch W, Simpson WG e.a. Effects of wheat and oat-
      based whole grain foods on serum lipoprotein size and distribution in overweight middle aged
      people: a randomised controlled trial. PLoS One 2013; 8(8): e70436.
10    Priebe MG, van Binsbergen JJ, de VR, Vonk RJ. Whole grain foods for the prevention of type 2
      diabetes mellitus. Cochrane Database Syst Rev 2008;(1): CD006061.
Pagina 9
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<pre>Granen en graanproducten
GEZONDHEIDSRAAD                                                                      Reactie op commentaren
11    Kyro C, Olsen A, Landberg R, Skeie G, Loft S, Aman P e.a. Plasma alkylresorcinols, biomarkers of
      whole-grain wheat and rye intake, and incidence of colorectal cancer. J Natl Cancer Inst 2014;
      106(1): djt352.
12    Hauner H, Bechthold A, Boeing H, Bronstrup A, Buyken A, Leschik-Bonnet E e.a. Evidence-based
      guideline of the German Nutrition Society: carbohydrate intake and prevention of nutrition-related
      diseases. Ann Nutr Metab 2012; 60 Suppl 1: 1-58.
13    Wu H, Flint AJ, Qi Q, van Dam RM, Sampson LA, Rimm EB e.a. Association between dietary whole
      grain intake and risk of mortality: two large prospective studies in US men and women. JAMA Intern
      Med 2015; 175(3): 373-384.
14    Fasano A. Zonulin and its regulation of intestinal barrier function: the biological door to
      inflammation, autoimmunity, and cancer. Physiol Rev 2011; 91(1): 151-175.
Pagina 10
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<br><br>