DWRF Submissions (#1 & #2) to the 2015 Dietary Guidelines Advisory Committee

Submission #1

 

September 25, 2013

Barbara Millen, Dr.PH, R.D.
Chair, 2015 Dietary Guidelines Advisory Committee, U.S. Department of Agriculture / U.S. Department of Health and Human Services

Alice H. Lichtenstein, D.Sc.
Vice-chair, 2015 Dietary Guidelines Advisory Committee, U.S. Department of Agriculture / U.S. Department of Health and Human Services

 

RE: The Importance of Water Consumption as a Part of a Healthful Diet

 

Dear Drs. Millen and Lichtenstein:

The Drinking Water Research Foundation (DWRF) is an independent not-for-profit 501(C)3 foundation that sponsors peer-reviewed scientific research that addresses the production of safe and affordable drinking water, including bottled water, tap water, and filtered water. We appreciate the opportunity to provide the following comments on maintaining a healthful diet—one that includes beverages that help achieve and maintain a healthy weight, promote health, and positively influence body functions.

Daily water consumption supports a nutritious, healthful and well-balanced diet. We therefore request that the Dietary Guidelines Advisory Committee recognize the importance of water consumption in its recommendations for the 2015 Dietary Guidelines.

Water consumption contributes to optimum physiologic and mental functions.

  • Water makes up 75% of body weight in infants and 55% in the elderly, and is essential for cellular homeostasis and life. (7) The average value for water’s contribution to body weight is 60%. (1) Optimum water intake can positively influence gastrointestinal function (including decreasing the incidence of constipation), kidney function, heart function, regulation of blood volume, and skin elasticity and resilience. (9)
  • Our brain is 83% water and many studies have demonstrated the positive influence of water consumption and the negative impacts of dehydration on cognitive functions, mood, and motor function. Dehydration can negatively affect fatigue levels, mood, choice-reaction time, short- and long-term memory, and attention span. (4, 5)
  • Water is an essential compound that supports numerous metabolic reactions, including many cellular processes and the, formation of urine, sweat and blood. (1, 6, 9) In addition, as the main component of blood, water carries nutrients, hormones, and other compounds to, and metabolic waste products away from, all cells in the body. (6)
  • Lack of adequate hydration will impair physical performance activities that require endurance, such as playing sports, getting daily exercise, and maintaining stamina for the school/work day. Drinking water and staying hydrated contributes to the support of muscle function and body temperature regulation. (6, 9)

Water’s role in preventing health issues (including obesity, metabolic syndrome, diabetes and kidney stones)

  • Two thirds of American adults are overweight, with one-third of those individuals being obese. (8) Over the last 30 years, children’s obesity rates have climbed from 5% to 17%. According to the World Health Organization (WHO), combined, being overweight and obese are now the fifth leading risks for global deaths. (12) An overconsumption of calories is a primary contributor to obesity. Opting for zero-calorie beverages, such as water, can cut calorie consumption significantly. Cutting calories positively influences weight management.As stated in the Nutrition Reviews’ paper (2010 August; 68(8): 439–458), Water, Hydration and Health, “Water’s importance for prevention of nutrition-related noncommunicable diseases has emerged more recently because of the shift toward large proportions of fluids coming from caloric beverages.” (9) Drinking zero-calorie beverages, such as water, instead of sugar-sweetened drinks is often noted as a key component of a more healthful lifestyle. Studies have suggested that excessive consumption of sugar-sweetened beverages increases the risk of type 2 diabetes (10) and it has also been shown that in adults, high consumption of sugar-sweetened beverages is associated with the prevalence of metabolic syndrome. (15)
  • Another notable disease that can be alleviated by increased water consumption is kidney stones (also called Nephrolithiasis). Various studies (10, 11) indicate that increased water consumption can alleviate the incidence of kidney stones. This is very important since Nephrolithiasis affects about 10% of the population of Western countries (2), and the prevalence of kidney stones has been increasing during the past decades. (11) Adequate fluid intake helps to decrease concentrations of substances involved in stone formation.

DWRF Recommendations to the DGAC:

Living a healthy lifestyle— a combination of eating a healthful diet and physical activity—is a key component of keeping our bodies performing at their optimal level. A major part of this includes adopting healthy hydration habits. This involves both the quality and quantity of our beverage intake. (9) Water consumption is an integral part of staying healthy. DWRF asks that the Committee keep this in mind as it makes its recommendations concerning the 2015 Dietary Guidelines. This includes encouraging Americans to focus on eating a healthful diet, maintaining a healthy weight, promoting health, and preventing disease.

Scientific evidence has demonstrated that people need to drink more water. DWRF recognizes and commends USDA’s current recommendations for water as a healthy and smart choice for proper hydration. We encourage messaging like those in the USDA’s “Make Better Beverage Choices” document (13) and the “MyPlate on Campus Toolkit,” (14)—both promote water consumption over sugary beverages and the consistent daily intake of water. DWRF believes this messaging is important and we request that the Committee include this information in its recommendations for the 2015 Dietary Guidelines. Although water consumption is not currently included in the USDA “MyPlate” nutrition guide, water should have a prominent place in any promotional tool used to advocate for healthy diets. Depicting water’s important role in healthy hydration would be a step in the right direction. Many countries already include water in their nutrition guides. For example, the Chinese Pagoda, France’s Food Stairs, the Japanese Spinning Top, Spain’s Food Pyramid, the Australian Guide to Health Eating, Irish Food Pyramid, Swiss Food Pyramid, Belgian Food Pyramid, Latvian Food Pyramid, Austrian Food Pyramid, and the Bulgarian Food Pyramid all include water. (3, 15)

Thank you for considering these comments. If we can provide any additional information, please let contact me.

Sincerely,

Jack West
DWRF Chairman

In addition to the references cited in these comments, CLICK HERE for a list of studies and research papers that further support the importance of water consumption in a healthful diet.

Endnotes:

1. Armstrong LE, “Hydration assessment techniques.” Nutr Rev. 2005; 63:S40-54.

2. Daudon M, “Epidemiology of nephrolithiasis in France.” Paris, Ann Urol 2005; 39:209-31.

3. European Food Information Council (EUFIC), “Food-Based Dietary Guidelines in Europe.” EUFIC Review, 2009.

4. European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition, and Allergies (NDA); Scientific Opinion on Dietary reference values for water. EFSA Journal. 2010; 8:1459-507.

5. Institute of Medicine (IOM), “Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate.” Washington, DC: National Academies Press, 2004.

6. Kleiner SM, “Water: an essential but overlooked nutrient.” J Am Diet Assoc. 1999; 99:200-6.

7. Nicolaidis S, “Physiology of Water Intake,” Ann Nutr Aliment. 1976; 30(2-3):349-68.

8. Ogden et al, “Prevalence of Obesity in the United States,” 2009–2010.

9. Popkin B, “Water, Hydration and Health,” Nutr Rev. 2010 August; 68(8): 439–458.

10. Schulze MB, Manson JE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, Hu FB.“Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women,” JAMA.

11. Stamatelou KK, Francis ME, Jones CA, et al. “Time trends in reported prevalence of kidney stones in the United States: 1976-1994.” Kidney Int 2003; 63:1817-23.

12. World Health Organization. “Obesity and Overweight. Fact sheet n°311.”Updated March 2013.

13. USDA 2012 Nutrition Education Series, “Make Better beverage Choices.”

14. USDA “2013 My Plate Campus Toolkit.”

15. West E. “Food Pyramids of The World: 10 nutrition guideline charts from around the globe.” The Food Republic. Jun 2011.

16. Yoo K, “Comparison of dietary intakes associated with metabolic syndrome risk factors in young adults”, Am J Clin Nutr 2004Oct; 80(4):841-8.

 

Submission #2

 

March 3, 2014

Alice H. Lichtenstein, D.Sc.
Subcommittee 2 Chair/Vice Chair Rep, 2015 Dietary Guidelines Advisory Committee, U.S. Department of Agriculture / U.S. Department of Health and Human Services

Anna Maria Siega-Riz , PhD, RD
Chair, 2015 Dietary Guidelines Advisory Committee, U.S. Department of Agriculture / U.S. Department of Health and Human Services

 

RE: Water is Essential to a Healthful Diet/Addressing the Focus of Subcommittee 2: Dietary Patterns, Foods and Nutrients, and Health Outcomes

 

Dear Drs. Lichtenstein and Siega-Riz:

The Drinking Water Research Foundation (DWRF) is an independent, not-for-profit, 501(C)(3) foundation that sponsors scientific research that addresses the production of safe and affordable drinking water, including bottled water, tap water, and filtered water. We appreciate the opportunity to provide the following additional comments on the importance of water in maintaining a healthful diet. Zero calorie beverages such as water can help achieve and maintain a healthy weight, promote health, and positively influence body functions.

Water –whether tap, filtered or bottled –when consumed daily can help support a balanced and nutritious diet. The 2010 Dietary Guidelines for Americans recognized this fact when it noted that, “Sweetened foods and beverages can be replaced with those that have no or are low in added sugars. For example, sweetened beverages can be replaced with water and unsweetened beverages.” (18) We recommend more messaging on water consumption be incorporated into the 2015 Guidelines and related supplemental documents, including adding water to the “My Plate” nutrition guide. Moreover, we suggest the Dietary Guidelines Advisory Committee specifically acknowledge the importance of bottled water since it is the healthiest option among packaged beverages, which in today’s on-the-go society is the primary way most people consume liquids in their diets.

On September 25, 2013, DWRF submitted comments to the DGAC highlighting various aspects of how daily water consumption supports a nutritious, healthful and well-balanced diet. We outlined multiple health concerns that are linked to poor water consumption, such as obesity, metabolic syndrome, diabetes and kidney stones. Attached is a copy of those comments for your review and further consideration. However, for your convenience, we would like to reiterate the following key points made in our earlier comments.

Water consumption contributes to optimum physiologic and mental functions

  • Water makes up 75% of body weight in infants and 55% in the elderly, and is essential for cellular homeostasis and life. (10) Optimum water intake can positively influence gastrointestinal function (including decreasing the incidence of constipation), kidney function, heart function, regulation of blood volume, and skin elasticity and resilience. (12)
  • Dehydration can negatively affect fatigue levels, mood, choice-reaction time, short- and long-term memory, and attention span. (4, 5)
  • Water is an essential compound that supports numerous metabolic reactions, including many cellular processes and the, formation of urine, sweat and blood. (1, 7, 12)
  • Drinking water and staying hydrated contributes to the support of muscle function and body temperature regulation. (7, 12)

Water’s role in preventing health issues (including obesity, metabolic syndrome, diabetes and kidney stones)

  • One third of American adults are overweight, and one-third of American Adults are obese. (9) Drinking zero-calorie beverages, such as water, instead of sugar-sweetened drinks is often noted as a key component of a more healthful lifestyle. As stated in the Nutrition Reviews’ paper (2010 August; 68(8): 439–458), Water, Hydration and Health, “Water’s importance for prevention of nutrition-related noncommunicable diseases has emerged more recently because of the shift toward large proportions of fluids coming from caloric beverages.” (12)
  • Drinking zero-calorie beverages, such as water, instead of sugar-sweetened drinks is often noted as a key component of a more healthful lifestyle. Studies have suggested that excessive consumption of sugar-sweetened beverages increases the risk of type 2 diabetes and it has also been shown that in adults, high consumption of sugar-sweetened beverages is associated with the prevalence of metabolic syndrome. (13)
  • Another disease that can be alleviated by increased water consumption is kidney stones (also called nephrolithiasis). Various studies (13, 16) indicate that increased water consumption can alleviate the incidence of kidney stones. This is very important since nephrolithiasis affects about 10% of the population of Western countries (2), and the prevalence of kidney stones has been increasing during the past decades. (16)

 

Provided below are additional data (not included in our earlier comments) that support the importance of water consumption in a healthy diet.

National Health and Nutrition Examination Survey studies indicates a call for increased water consumption in the United States:

  • The National Health and Nutrition Examination Survey (NHANES) data reported on recently in the Biomed Central Public Health journal, indicates that water consumption rates among adults are below Institute of Medicine (IOM) recommended levels and may be a cause for concern, especially for older adults. (3) The study, “Water and beverage consumption among adults in the United States: cross-sectional study using data from NHANES 2005–2010,” also referenced research that indicated that drinking plain water was an effective way to gain sufficient water intake in the diet without calories consumption, which is pertinent for health and weight management. The study noted, “Drinking plain water, tap or bottled, instead of caloric beverages, helps to reduce dietary energy density and may contribute to the management of body weight.” (3)
  • The “Association between Water Intake, Chronic Kidney Disease (CKD), and Cardiovascular Disease: A Cross-Sectional Analysis of NHANES Data,” published in the American Journal of Nephrology in 2013 examined the associations between low total water intake and chronic kidney disease and self-reported cardiovascular disease. The study found the prevalence of stage III CKD was highest among those with the lowest water intake and this decreased with increased water intake. Additionally, individuals who had lower water intake reported a history of coronary heart disease, myocardial infarction, stroke, congestive heart failure and angina pectoris although the study noted a less clear correlation between water intake and cardiovascular disease. (14)

National Health and Nutrition Examination Survey studies indicates increased sugar intake contributes to death rates related to heart disease.

    • Recently-published research based on National Health and Nutrition Examination Survey data analysis has shown a relationship between added sugar in the diet and the incidence of cardiovascular disease (CVD). (19) Specifically, the sugar originating from sugar-sweetened beverages was noted to contribute the most to added sugar and increased calories consumption (by an average of close to 100 extra calories per day) in the diet for individuals aged 2 years old and into adulthood. The study, “Added Sugar Intake and Cardiovascular Diseases Mortality among US Adults,” referenced data that showed major sources of added sugar in American adults’ diet included sugar-sweetened beverages (37.1%), grain-based desserts (13.7%), fruit drinks (8.9%), dairy desserts (6.1%), and candy (5.8%). (13) This study’s analysis specifically found that the regular consumption of sugar-sweetened beverages (≥7 servings/wk) was linked with increased risk of CVD mortality. (19)

 

    This research, concluded, “Most US adults consume more added sugar than is recommended for a healthy diet… In addition, regular consumption of sugar-sweetened beverages is associated with elevated CVD mortality.” (19) While this study does not demonstrate a causal relationship between sugar-sweetened beverages and CVD mortality, it certainly establishes a strong association. This further underscores the importance of water consumption as being integral to healthy dietary patterns.

The above-noted research highlights the importance of water consumption in order for Americans to establish and maintain a healthy lifestyle. Dietary practices that support physiological functions, such as drinking water, are important to consider. But, consumption trends, how people come into contact with the foods and beverages they ultimately consume, are also important. That is why it is critical to stress the central role bottled water plays in today’s healthy American’s lifestyle.

All water consumption, including bottled water, can help Americans be healthier, reduce calorie intake and reduce sugar consumption:

  • One of the simplest changes a person can make when seeking to lead a healthier lifestyle is to switch to drinking water instead of other beverages that contain added sugar and an excess in calories. Bottled water is the best option when choosing a packaged beverage and helps lead consumers to choosing water – whatever the type – as their drink of choice. Packaged beverages are frequently the primary way people consume liquids.
    Making water one’s beverage of choice is also impactful to overall health and lifestyle choices. In fact, a November 2013 U.S. Centers for Disease Control and Prevention (CDC) report, Obesity — United States, 1999–2010, found that, while increases in obesity prevalence have slowed or even stopped in recent years for some groups, it is still a pressing concern for the U.S. population as whole. The CDC report noted that this is particularly true for households without regular access to effective nutritional and wellness education and healthier food options. (9)
    Further, the CDC’s findings note that one important way to help reduce rates of obesity includes making healthy choices, such as healthy eating and active living opportunities, easily accessible and available to everyone. Drinking water, whether bottled, tap, or filtered continues to be one of the easiest choices people can make to have an immediate impact on caloric intake. For those who want to eliminate or moderate calories, sugar, caffeine, artificial flavors or colors, and other ingredients from their diet, choosing water is the right choice.
  • The data in this CDC study also support similar research released in 2012 by the Institute of Medicine and the American Journal of Preventative Medicine, further reinforcing the importance of water, showing that one-third of American adults are overweight and another one-third is obese. And, over the last 30 years, children’s obesity rates have climbed from 5% to 17%. (5, 6)

Dietary patterns suggest consumption of packaged beverages are a part of Americans’ lifestyle:

    • In today’s on-the-go society, most of what we drink comes in a package. Therefore, encouraging specific, smart, healthy dietary choices – like bottled water instead of sugary beverages – can help encourage individuals to lead more active and healthful lives. Conversely, research shows that if bottled water isn’t available, 63% of people will choose soda or another sugared drink – not tap water.

 

      To determine changes in consumption habits, the marketing research firm FRC (www.frcresearch.com) collected information for an IBWA member company (FRC Bottled Water General Market Tracking Study, Q4 2010 – Q3 2011). 13,350 consumers were surveyed online and asked what beverage they might switch to if unable to access their first choice of bottled water.

 

      When asked what alternative beverage, if any, they would choose if their preferred choice of bottled water were not available, 63% of the identified alternative preferences were the sweetened beverages identified in the following table.

      * Note:

The total percentage of consumer responses that chose a sweetened beverage when unable to select their first choice of bottled water was slightly less than 64%. However, to be conservative in our statement, we rounded the figure down to 63%.

 

Consumers are making healthy choices, including choosing bottled water over sugar-sweetened beverages:

  • Consumers choose bottled water for several reasons, including its refreshing taste, reliable quality, zero calories and additives, and convenience. In fact, since 1998, approximately 73% of the growth in bottled water consumption has come from people switching from carbonated soft drinks, juices, and milk to bottled water.
    The 73% figure refers to shifts in per capita consumption – from carbonated soft drinks, fruit juices, and milk, to bottled water – and is based on data from the Beverage Marketing Corporation (BMC). The BMC data reflect consumer beverage preference trends. The BMC chart below shows the per-capita consumption figures for non-alcoholic liquid refreshment beverages (LRBs) for the period 1998-2011. It lists all non-alcoholic LRBs and shows which products increased their per-capita consumption (and by how much) and which products lost per-capita consumption (and by how much) during this period. It also shows each product’s percentage of the total gains or total losses.
    There were six categories of beverages that gained per-capita consumption, totaling 20 gallons. Of that total gain, bottled water comprised 14.6 gallons, or 72.9%. There were three categories of beverages that lost per-capita consumption, totaling 18.9 gallons. They were carbonated soft drinks, fruit beverages, and milk. This per-capita consumption loss reflects a change in consumer beverage preferences that favors bottled water, which accounts for 72.9% of the per-capita market share gain.
    * Note: “Bottled Water” includes retail PET plastic individual bottles; 1, 2 and 5 gallons bulk; domestic sparkling; imported water; as well as home and office delivery and vending. “Fruit Beverages” includes liquid fruit juice and fruit drinks and excludes powdered fruit drinks and vegetable juices.
  • Bottled water’s continued popularity can be attributed to a “shift-in-consumption” trend, with the soft drink category experiencing its eighth consecutive year of volume loss. Beverage Marketing Corporation (BMC) CEO Michael Bellas predicts that bottled water could overtake soda as America’s most popular packaged beverage within the next decade. Bottled water is currently the number two beverage product. According to BMC’s Gary Hemphill, Senior Vice President Information Services, “All signs point to U.S. consumers’ already displayed thirst for bottled water continuing in the years ahead. Changes in per capita consumption indicate persistent interest in a product that consumers embrace as a healthful alternative to other beverages.”

The Drinking Water Research Foundation (DWRF) believes that the revised Dietary Guidelines should encourage specific, smart, healthy dietary choices – like water instead of sugary beverages – and put emphasis on this being a key component of a more healthful lifestyle. DWRF also believes that specifically including consumption of bottled water in recommendations to drink more water is a realistic and practical way to support the efforts of people striving for a healthier lifestyle.

Thank you for considering these comments. If we can provide any additional information, please contact me.

Sincerely,

Jack West
DWRF Chairman

In addition to the references cited in these comments, CLICK HERE for a list of studies and research papers that further support the importance of water consumption in a healthful diet.

Endnotes:

1. Armstrong LE, “Hydration assessment techniques.” Nutr Rev. 2005; 63:S40-54.

2. Daudon M, “Epidemiology of nephrolithiasis in France.” Paris, Ann Urol 2005; 39:209-31.

3. Drenowski A et al, “Water and beverage consumption among adults in the United States: cross-sectional study using data from NHANES 2005–2010,” BMC Public Health 2013, 13:1068.

4. European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition, and Allergies (NDA); Scientific Opinion on Dietary reference values for water. EFSA Journal. 2010; 8:1459-507.

5. Finkelstein, EA, Khavjou, OA, Thompson, H, Trogdon, JG, Pan, L, Sherry, B Dietz, W, “Obesity and Severe Obesity Forecasts Through 2030.” American Journal of Preventative Medicine , 2012; 42(6):563–570

6. Institute of Medicine (IOM), “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.” Washington DC: The National Academies Press, 2012.

7. Institute of Medicine (IOM), “Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate.” Washington, DC: National Academies Press, 2004.

8. Kleiner SM, “Water: an essential but overlooked nutrient.” J Am Diet Assoc. 1999; 99:200-6.

9. May AL et al, Obesity — United States, 1999–2010.

10. Nicolaidis S, “Physiology of Water Intake,” Ann Nutr Aliment. 1976; 30(2-3):349-68.

11. Ogden et al, “Prevalence of Obesity in the United States,” 2009–2010

12. Popkin B, “Water, Hydration and Health,” Nutr Rev. 2010 August; 68(8): 439–458.

13. Schulze MB, Manson JE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, Hu FB.“Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women”JAMA.

14. Sontrop JM, Dixon SN, Garg AX, Buendia-Jimenez I, Dohein O, Huang SS, Clark WF, “Association between Water Intake, Chronic Kidney Disease, and Cardiovascular Disease: A Cross-Sectional Analysis of NHANES Data,” Am J Nephrol 2013;37:434–442.

15. Sources of Calories from Added Sugars among the US Population, 2005–06.Applied Research Program Web site. National Cancer Institute. Updated October 18, 2013. Accessed February 18, 2014

16. Stamatelou KK, Francis ME, Jones CA, et al. “Time trends in reported prevalence of kidney stones in the United States: 1976-1994.” Kidney Int 2003; 63:1817-23.

17. World Health Organization. “Obesity and Overweight. Fact sheet n°311.”Updated March 2013.

18. U.S. Department of Agriculture and U.S. Department of Health and Human Services; “2010 Dietary Guidelines for Americans.”

19. Yang Q, Zhang Z, Gregg EW, Flanders D, Merritt R, Hu FB, “Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults,” JAMA Intern Med doi:10.1001.